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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5500
}
|
Medical Text: Admission Date: [**2149-12-27**] Discharge Date: [**2150-1-2**]
Date of Birth: [**2088-4-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement (Right)
History of Present Illness:
61 yo male with hx AML, s/p 7+3 induction chemo with idarubicin
and cytarabine (Day 1=[**2149-11-23**]), complicated aspergillus
pneumonia tx with voriconazole. Also, pt found to have a newly
depressed EF to 30-40% with focal hypokinesis. He had a left
heart cath that found 3VD and had 3 BMS placed to LAD, 1
proximal and 2 to the mid LAD on [**2149-12-24**]. The pt was discharged
on [**2149-12-26**] on aspirin and plavix. He now presents with a chief
complaint of chest pain starting this morning.
.
This morning he felt "cold and clammy" and he had suddent onset
of chest pain. He describes the pain as dull/pressure, focused
in the center of his chest, [**7-7**]. It was non-radiating and
associated with diaphoresis and shortness of breath, but no
dizziness, palpitations, nausea or vomiting. Of note, he had
similar chest pain several months ago while raking leaves (pain
resolved on its own at that time). He called 911 and was taken
by the ambulance to the [**Hospital6 **]. CP resolved at OSH
with nitro and morphine. Trop T was elevated to 0.12 and EKG
showed no ischemic changes. He had a CTA showing no PE. He was
transferred to [**Hospital1 18**] for further management. In our ED, initial
vitals were T 96.2 HR 99 BP 105/73 RR14 SaO2 97%. He was given
vancomycin and zosyn, and blood cultures were sent. Also given
tylenol 650mg x 1. CEs were trending up.
.
Per nursing report prior to transfer the patient became
hypotensive and tachycardic when standing up. He was bolused
500cc and placed in a supine position. On arrival to the floor
his vitals were T 100.7, HR 114, BP 108/65, SaO2 99% on 2L. He
denied any chest pain or pressure but did report feeling unable
to take a deep breath and feeling intermittent chills/rigors
throughout the afternoon. Additionally, he reported dysuria
starting this morning. He denied GI sx or productive cough. He
was given 1 liter NS, then given demerol for the rigors and his
BP dropped to 90s. He was started on a 3rd liter and his BP
improved. His temp increased to 102. His EKG showed some mild
STE vs J point elevation changes in the anterior leads,
cardiology felt it was not consistent with a instent thormbosis.
He was transfered to the unit for sepsis.
.
REVIEW OF SYSTEMS:
He denies GI sx, no hematuria or prior dsyuria other than today,
no cough, no vision changes, no neck stiffness. Had a mild HA
today. Has a tender right wrist (where cath was done).
Past Medical History:
-3VD (see HPI), BMS x 3 to LAD [**2149-12-24**]
-AML s/p induction chemo starting [**2149-11-23**]
Social History:
Married here with wife. [**Name (NI) **] daughter & son. both married & live
an hour away.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
Brother with AML s/p transplant here at [**Hospital1 18**] in [**2145**]. Father
with a history of "multiple small heart attacks," but died in
his 80s.
Physical Exam:
On admission:
VS: temp- T- 101.4 HR- 130 BP 106/60 RR-15 Sat- 99% 2 liters
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Eyes closed
during most of the exam
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with no LAD
CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. 2+ pulses
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c/e.
SKIN: No rashs, skin warm and moist
NEURO: altert, cn 2-12 grossly intact, gait not assessed, moving
all limbs appropriately
Pertinent Results:
EKG: sinus tach at 135, STE vs j point elevations in V2-V4,
qwave in III (ST changes are new from ER EKG)
.
TTE [**2149-12-23**]: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 30-40 %) secondary to hypokinesis of the
anterior septum, inferior septum, anterior free wall, lateral
wall, and apex. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2149-11-19**], the left ventricular ejection fraction is
further reduced.
.
CARDIAC CATH [**2149-12-24**]:
1. Selective coronary angiography of this right dominant system
demonstrated three vessel coronary artery disease. The LMCA was
not
present. There were separate ostia for the LAD and LCx. The LAD
had a 60-70% proximal eccentric lesion, a total occlusion of the
mid-LAD and a 50-60% lesion of the diagonal branch. The LCs had
a 40% stenosis in a large OM and a 60-70% stenosis in the
smaller distal LCx into the OM2. There was a large patent ramus.
The RCA was 100% occluded proximally. The PDA and PL filled by
left to left collaterals.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressure of 96/73 mmHg.
3. Successful PTCA and placement of a 3.0x12mm Vision bare-metal
stent in the proximal LAD and overlapping 2.5x23mm and 2.5x12mm
Mini Vision bare-metal stents in the mid LAD were performed.
Final angiography showed normal flow, no apparent dissection,
and no residual stenoses. IVUS showed good stent apposition.
(See PTCA comments.)
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Placement of bare-metal stents in the LAD.
.
CK: 175 MB: 21 MBI: 12.0 Trop-T: 0.61 (9pm)
CK: 95 MB: 12 MBI: 12.6 Trop-T: 0.20 (2pm)
UA: yellow, Clear, SpecGr 1.023, pH 5.0, Urobil neg, Bili Neg,
Leuk
Neg, Bld Sm , Nitr neg, Prot Tr, Glu Neg, Ket Neg, RBC 0-2, WBC
[**1-30**], bact Few, Yeast None, Epi 0-2
Lactate:1.1
.
139 106 13 AGap=14
------------<113
4.6 24 0.7
.
wbc 11.6, plt 680, hct 31.3
N:69.3 L:16.6 M:13.0 E:0.1 Bas:1.1
PT: 12.7 PTT: 27.0 INR: 1.1
.
OSH labs:
Trop T: 0.12, CK 47
WBC 11.1, Hct 32, plt 584
.
CT abd/pelvis w/ and w/o contrast:
1. No evidence of retroperitoneal hematoma. No focal abscess or
overt
infection in the abdomen or pelvis.
2. Interval development of bilateral moderate pleural effusions
with
compressive atelectasis, left greater than right. Area of focal
consolidation vs mass in the left upper lobe as previously
identified is not encompassed by today's study, however, is
evident on scout radiograph.
3. Multiple bilateral sub-4 mm pulmonary nodules are better
demonstrated on prior CT from [**2149-12-13**].
4. 9-mm hypodense liver lesion is too small to fully
characterize but likely represents a cyst. Focal fatty
infiltration in anterior left lobe of liver.
5. Trace pelvic fluid, a non-specific finding.
Brief Hospital Course:
61 yo m with hx of AML, s/p 7+3 induction chemo c/b presumed
fungal pneumonia treated with voriconazole, and reduced EF
(30-40%), CAD s/p PCI with BMS x3 in LAD([**2149-12-24**]) who now
presents with chest pain and fevers/tachycardia.
.
# Fever/Leukocytosis/tachycardia: Pt had SIRS criteria, new
leukocytosis and rigors on admission. Pt has known lingular
opacity seen on prior imaging last week, as well as OSH imaging
that confirmed this finding that in the past was thought to be a
Aspergillus infection, since the Ag was positive and B-glucan
was present. He denies GI sx, however, did have C. diff
infection on [**2149-12-2**], and just completed flagyl 2 days prior to
infection. Also had mild hypotension concerning for sepsis at
the time of admission. OSH CTA was negative for PE. He
initially required an ICU stay for management of his hypotension
and sepsis, he was treated with vancomycin and cefepime for a
hospital acquired pneumonia and also continued on prior
voriconazole. He was also continued on treatment for C.diff
with po vancomycin. Infectious disease was consulted and felt
that he should complete a 14 day course of vancomycin/cefepime
for a hospital acquired pneumonia, a PICC was placed for him to
complete his antibiotic course as an outpatient.
.
# CAD, chest pain: As above, patient s/p PCI with BMS to LAD
several days prior to admission, now with chest pain and
elevated troponin. Patient was seen by cardiology who felt that
the bump in enzymes was related to demand ischemia in the
setting of hypotension, and as a result did not feel that he
needed to have a repeat catheterization. GIven his three vessel
disease he was evaluated by CT surgery, who felt that he was not
a candidate for a CABG, so he was continued with medical
management. He was continued on his aspirin, plavix and statin.
.
# Atrial Fibrillation: during this hospitalization patient was
found to be in atrial fibrillation with rapid ventricular
response. He was started on amiodarone and converted back to
normal sinus rhythm. He was continued on metoprolol for rate
control, and at the time of discharge was sent home on an
amiodarone taper, with EP follow up to determine the duration of
amiodarone therapy.
.
# Heart Failure: Pt with chronic systolic heart failure with
recent TTE showing EF worsened to 30-40%. He did not have any
signs of decompensated heart failure during his admission. He
was continued on his beta blocker and ACE inhibitor during his
admission.
.
# Acute AML s/p induction chemotherapy: patient had a bone
marrow biopsy during his stay that was to be followed up with
Dr. [**Last Name (STitle) **] as an outpatient. He was continued on
voriconazole during his stay and at the time of discharge had
outpatient follow up to determine the next step in his treatment
plan.
Medications on Admission:
MEDICATIONS at home:
1. Clopidogrel 75 mg daily
2. Aspirin 325 mg daily
3. Voriconazole 200 mg Q12H
4. Lisinopril 5 mg daily
5. Toprol 37.5 mg daily
6. Atorvastatin 40 mg daily
.
Transfer Medications:
- Meperidine 12.5 mg IV ONCE
- Metoprolol Succinate XL 37.5 mg PO DAILY
- Oseltamivir 75 mg PO DAILY
- Acetaminophen [**Telephone/Fax (1) 1999**] mg PO/NG Q6H:PRN pain or fever
- Piperacillin-Tazobactam 4.5 g IV Q8H
- Aspirin 325 mg PO/NG DAILY
- Atorvastatin 80 mg PO/NG DAILY
- Clopidogrel 75 mg PO/NG DAILY
- Vancomycin 1000 mg IV Q 12H
- Heparin IV Sliding Scale
- Voriconazole 200 mg PO Q12H
- Lisinopril 5 mg PO/NG DAILY
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary:
Pneumonia
NSTEMI
Atrial Fibrillation
AML s/p induction chemotherapy
Secondary:
AML
Discharge Condition:
Vitals stable
Ambulating
Alert and Oriented to person, place, time and purpose
Discharge Instructions:
You were admitted to the hospital with chest pain and came to
the ICU for low blood blood pressure and concern for infection.
You are being treated with iv antibiotics for pneumonia and you
had a PICC line placed. You will received the iv antibiotics at
home for an additional 3 days.
You should continue taking the Plavix 75 mg once a day (a
medication for the stents placed in the blood vessels in your
heart). You will need to take this for at least one month. Dr.
[**First Name (STitle) 437**] will determine if you need to take this longer.
Additionally, you must continue to take a full strength aspirin
indefinitely.
The following medications were added:
- Cefepime 2g iv twice a day through [**2150-1-3**]
- Vancomycin 1g iv twice a day through [**2150-1-3**]
- Oral Vancomycin 250mg four times a day, you will continue
taking this through [**2150-1-11**]
- Amiodarone 400mg twice a day for one week, then 200mg once a
day for another 3 weeks. This is for your abnormal heart rhythm
(atrial fibrillation). Dr. [**Last Name (STitle) **] will determine if you need
to take this for a longer period of time.
Appointments have been made for you for cardiology (Dr. [**First Name (STitle) 437**]
and Dr. [**Last Name (STitle) **], infectious disease (Dr. [**Last Name (STitle) 724**], Oncology (Dr.
[**Last Name (STitle) **]. If you need to change them, please call the
numbers listed below.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
PICC Line Removal:
7 [**Hospital Ward Name 1826**] Outpatient Clinic
[**2150-1-5**] at 1pm (you can come over after your cardiology
appointment)
Hematology/Oncology:
Dr. [**Last Name (STitle) **]
[**2150-1-6**] at 1pm
7 [**Hospital Ward Name 1826**] Outpatient Clinic
CARDIOLOGY:
Dr. [**First Name (STitle) 437**]: Phone:[**Telephone/Fax (1) 62**] [**2150-1-5**] 4:00pm [**Hospital Ward Name 23**] [**Location (un) 436**]
Dr. [**Last Name (STitle) **]: Phone:[**Telephone/Fax (1) 62**] [**2150-1-15**] 11:00am [**Hospital Ward Name 23**] [**Location (un) **]
Please follow up with your primary care doctor within one month
of discharge.
ICD9 Codes: 0389, 486, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5501
}
|
Medical Text: Admission Date: [**2168-6-21**] Discharge Date: [**2168-6-27**]
Date of Birth: [**2120-5-23**] Sex: M
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 48-year-old male with
a known history of a thoracoabdominal aneurysm who had been
followed by his primary care physician. [**Name10 (NameIs) **] was decided upon
consultation with Dr. [**Last Name (Prefixes) **] that this patient would
ultimately need repair of this aneurysm, and therefore it was
decided that the patient would undergo surgery.
PAST MEDICAL HISTORY: Hypertension. High cholesterol.
Seizure disorder. Left thumb neuropathy.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Aspirin 325 p.o. q.d., Zantac 150
p.o. b.i.d., Keppra 1000 mg p.o. b.i.d., Glucophage 500 mg
p.o. q.a.m., 1000 mg p.o. q.p.m., Lisinopril 20 mg p.o. q.d.
PHYSICAL EXAMINATION: Vital signs: He was afebrile with
stable vital signs. General: He was in no apparent
distress. Lungs: Clear. Heart: Regular. Abdomen: Soft,
nontender, nondistended. Bowel sounds positive.
Extremities: Warm and well perfused.
LABORATORY DATA: All within normal limits.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2168-6-21**], for a thoracic aneurysm repair. Please see
the operative report for further details.
The patient was transferred to the CSIU postoperatively and
did well. He was weaned from the ventilator and extubated.
He was given cardiac pressors in order to enhance his blood
pressure which was slowly weaned off, and the patient's blood
pressure was stabilized. He was started back on all of his
preoperative blood pressure medications.
The patient continued to do well and was ultimately
transferred out of the CS RU and was transferred to the
floor.
The patient had an epidural placed for the operation which
was removed postoperatively. After removal of the epidural
catheter, the patient had episodes of bradycardia and
headache. The patient was reconsulted, and it was decided
that the patient had a small CSF leak. He was offered a
patch for treatment of this; however, his headache resolved,
and the leak resolved as well, and it was decided that the
patient would not need further treatment.
His beta-blocker was stopped at that time for reason of his
bradycardia. Physical Therapy was consulted, and it was
deemed that the patient could go home. By that time, he was
medically stable. The patient continued to do well from a
medical standpoint and was cleared by Physical Therapy.
The patient also underwent an MRA of the aorta in order to
evaluate for further dilatation. These results are still
pending at the time of discharge. The patient was discharged
on postoperative day 6 after his chest tubes and wires were
removed, as well as his Foley catheter. The patient was
discharged in stable condition.
DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., Aspirin
325 p.o. q.d., Zantac 150 p.o. b.i.d., Keppra 1000 mg p.o.
b.i.d., Glucophage 500 mg p.o. q.a.m., 1000 mg p.o. q.p.m.,
Lisinopril 20 mg p.o. q.d., he was given pain medications [**2-12**]
tab p.o. q.4 hours p.r.n., as well as Oxycodone.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE DIAGNOSIS:
1. Thoracic aneurysm status post thoracic aortic aneurysm
repair.
2. Hypertension.
3. High cholesterol.
4. Seizures.
5. Left thumb neuropathy.
FO[**Last Name (STitle) 996**]P: He was instructed to follow-up with his primary
care physician [**Last Name (NamePattern4) **] [**2-12**] weeks, his cardiologist in [**3-16**] weeks,
and with Dr. [**Last Name (Prefixes) **] in [**5-17**] weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], MD 2351
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2168-6-27**] 14:31:53
T: [**2168-6-27**] 15:02:39
Job#: [**Job Number 20130**]
ICD9 Codes: 2720, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5502
}
|
Medical Text: Admission Date: [**2170-4-3**] Discharge Date: [**2170-4-16**]
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:
[**2170-4-15**] Right Thoracentesis
[**2170-4-4**] Emergernt coronary artery bypass graft x 3 with left
internal mammary artery to left anterior descending coronary
artery; reversed saphenous vein single graft from the aorta to
the first diagonal coronary artery; and reversed saphenous vein
single graft from the aorta to the first obtuse marginal
coronary artery. Mitral valve replacement with 31mm St. [**Male First Name (un) 923**]
epic porcine valve
[**2170-4-4**] Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 23**] is an 89 year old male who presented with shortness
of breath for a few days. He noticed it started Sunday evening,
over the next two days it progressed to at rest. Family noted
him to have dyspnea and he was brought to emergency for
evaluation.
Past Medical History:
Coronary artery disease
History of Myocardial Infarction in [**2146**]
Hypertension
Peripheral neuropathy of [**Last Name (un) 5487**] etiology
Chronic renal insufficiency
Hiatal hernia
PTSD after war
s/p TURP > 10 years ago
History of Osteomyelitis right heel > 5 years ago
Social History:
Lives at an [**Hospital3 **] facility. Has a girlfriend. [**Name (NI) **]
drinks wine occasionally. No current tobacco but has a [**6-4**] pack
year history remotely. He was a [**Location (un) 7349**] cab driver in the past. He
moved to the [**Location (un) 86**] area 1 year ago. All his medical care is in
[**State 108**].
Family History:
Noncontributory
Physical Exam:
Pulse: 85 SR Resp: 24 O2 sat: 90% 100% NRB
B/P 117/68 on nipride 0.3mg/kg/min
Height: 5'[**71**]" Weight: 88.5
General: respiratory distress on 100% NRB unable to complete
sentences with use of excessory muscles
Skin: Dry [x] intact [x]
Neck: Supple [x] Full ROM [x]
Chest: Diminished throughout
Heart: RRR [x] Irregular [] Murmur [**3-31**] holosystolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema + 1
Neuro: alert and oriented x3 non focal - limited activity
tolerance due to shortness of breath
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
PREOP WORKUP:
[**2170-4-3**] WBC-15.9* RBC-4.66 Hgb-14.9 Hct-43.2 RDW-14.0 Plt
Ct-234
[**2170-4-3**] PT-13.5* PTT-23.8 INR(PT)-1.2*
[**2170-4-3**] UreaN-39* Creat-1.7*
[**2170-4-4**] Cardiac Catheterization:
1. Coronary angiography in this right dominant system
demonstrated two
vessel disease. The LMCA had a distal 60% stenosis. The LAD was
subtotally occluded in the proximal segment with TIMI 2 flow.
The LCx
had an 80% proximal stenosis. The RCA had mild disease.
2. Resting hemodynamics revealed elevated right and left heart
filling
pressures with RVEDP 15 mmHg and PCWP 25 mmHg. There were
accentuated V
waves in the PCW pressure tracing. The pulmonary artery systolic
pressure was elevated at 50 mmHg. The cardiac index was
preserved at 2.5
L/min/m2. The systemic vascular resistance was normal. The
pulmonary
vascular resistance was elevated at 323 dyn-sec/cm5. There was
systemic
arterial normotension.
[**2170-4-4**] Intraop Echocardiogram:
PRE Bypass: Image quality is very poor. No transgastric views
could be obtained. The left atrium is moderately dilated.
Overall left ventricular systolic function is grossly normal
(LVEF>55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. There are complex (>4mm) atheroma in the
[**Month/Day/Year 8813**] arch. The study is inadequate to exclude significant
[**Month/Day/Year 8813**] valve stenosis. No [**Month/Day/Year 8813**] regurgitation is seen. The
mitral valve leaflets are moderately thickened. An eccentric,
anteriorly directed jet of Moderate to severe (3+) mitral
regurgitation is seen. There is P2 flail of the posterior mitral
leaflet with a torn chordae visible.
POST Bypass: Patient is a-paced on phenylepherine and
epinepheine infusions. Image quality remains poor. No
transgastric views could be obtained. Biventircular appears
unchanged. There is a tissue valve in the mitral position. There
is no perivalvular leaks, no MR [**First Name (Titles) **] [**Last Name (Titles) **]. [**First Name (Titles) **] [**Last Name (Titles) 86554**] intact.
Remaining exam is limited, but appears unchanged.
POSTOP LABS:
[**2170-4-16**] WBC-11.8* RBC-3.49* Hgb-11.0* Hct-33.2* RDW-14.3 Plt
Ct-566*#
[**2170-4-12**] WBC-11.0 RBC-3.76* Hgb-11.5* Hct-34.6* RDW-14.6 Plt
Ct-339
[**2170-4-11**] WBC-11.1* RBC-3.65* Hgb-10.9* Hct-33.4* RDW-14.5 Plt
Ct-261
[**2170-4-10**] WBC-12.1* RBC-3.60* Hgb-11.1* Hct-33.1* RDW-14.7 Plt
Ct-201
[**2170-4-16**] PT-20.5* INR(PT)-1.9*
[**2170-4-15**] PT-18.5* PTT-26.2 INR(PT)-1.7*
[**2170-4-14**] PT-18.4* PTT-26.4 INR(PT)-1.7*
[**2170-4-13**] PT-18.9* PTT-29.1 INR(PT)-1.7*
[**2170-4-12**] PT-23.4* PTT-33.3 INR(PT)-2.2*
[**2170-4-16**] Glucose-128* UreaN-64* Creat-2.6* Na-141 K-4.1 Cl-101
HCO3-26
[**2170-4-15**] UreaN-70* Creat-2.8*
[**2170-4-14**] Glucose-107* UreaN-83* Creat-3.1* Na-142 K-3.7 Cl-104
HCO3-27
[**2170-4-13**] Glucose-129* UreaN-93* Creat-3.4* Na-143 K-3.5 Cl-104
HCO3-29
[**2170-4-12**] Glucose-114* UreaN-106* Creat-4.0* Na-143 K-3.6 Cl-103
HCO3-26
[**2170-4-11**] Glucose-112* UreaN-105* Creat-4.6* Na-139 K-3.5 Cl-99
HCO3-27
[**2170-4-10**] UreaN-106* Creat-4.7* Na-139 K-3.5 Cl-99 HCO3-26
AnGap-18
[**2170-4-10**] UreaN-106* Creat-4.7* Na-139 K-3.5 Cl-99 HCO3-26
AnGap-18
[**2170-4-10**] Glucose-93 UreaN-107* Creat-5.2* Na-138 K-3.5 Cl-97
HCO3-25
[**2170-4-9**] Glucose-257* UreaN-91* Creat-5.0* Na-132* K-3.9 Cl-94*
HCO3-25
[**2170-4-8**] Glucose-101* UreaN-73* Creat-4.3* Na-135 K-4.1 Cl-101
HCO3-20*
[**2170-4-7**] Glucose-91 UreaN-54* Creat-3.3* Na-136 K-3.7 Cl-101
HCO3-21*
[**2170-4-16**] 05:45AM BLOOD Mg-2.0
[**2170-4-15**] Discharge Chest X-ray:
As compared to the previous examination, there is status post
thoracocentesis on the right. There is marked decrease in extent
of the right pleural effusion. No pneumothorax can be seen on
the right. On the left, a basal air-fluid level suggests the
presence of minimal intrapleural air, despite the absence of
visibility of a left pneumothorax. No newly appeared focal
parenchymal opacities. Unchanged large hiatal hernia. Mild
cardiomegaly.
Brief Hospital Course:
Presented with shortness of breath and found to be hypoxic in
the setting of heart failure. He was rapidly worked up where an
echo revealed severe mitral valve regurgitation with partial
flail leaflet and torn chordae. He was then brought for a
cardiac catheterization which also revealed severe mitral
regurgitation along with coronary artery disease. In the setting
of respiratory failure and hemodynamic instability, it was
decided to bring him emergently to the operating room where he
underwent a mitral valve replacement with coronary artery bypass
graft. Please see operative report for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring. Remained on inotropes and pressors that were weaned
off over the first few days postoperatively, additionally had
episodes of atrial fibrillation and flutter treated with
coumadin and amiodarone. On post operative day two he was
successfully weaned from the ventilator and extubated.
Additionally renal was consulted due to acute kidney injury post
operatively. He remained in the intensive care unit an
extended stay for hemodynamic management, pulmonary monitoring,
and renal management. He progressively improved and was weaned
down to nasal cannula and hemodynamically stable off all
vasoactive medications. Coumadin was held due to increased INR
and allowed to correct back on its own. Renal function slowly
improved and he was transferred to the floor for the remainder
of his care. His renal function continued to improve. On
postoperative day 11, he underwent successful right sided
thoracentesis of approximately 400cc of fluid. He tolerated the
procedure well, and followup chest x-ray showing improvement
with no signs of pneumothorax. He continued make clinical
improvements and was eventually discharged to rehab on
postoperative day 12. Following thoracentesis, Coumadin was
resumed for atrial fibrillation and should be adjusted for goal
INR between 2.0 - 2.5. Following discharge, his renal function
should be monitored weekly to ensure recovery back to baseline.
Medications on Admission:
ASA 325mg daily
Atenolol 25mg po bid
Allopurinol
Zantac 150mg po bid
Xanax 0.25mg po bid prn
Neurontin 300mg po bid
Norvasc 5mg dialy
Zocor 20mg po daily
Omega 3
MVI daily
Triamterene 37.5 / HCTZ 25 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please hold Warfarin today [**4-16**] - please check INR [**4-17**] prior to
giving dose - titrate for goal INR between 2.0 - 2.5.
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold if HR less than 60.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute Congestive Heart Failure
Coronary artery disease, Mitral regurgitation - s/p MVR/CABG
Atrial fibrillation
Acute on Chronic Renal Insufficiency
Postop Pleural Effusions
Acute respiratory failure
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon -[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2170-5-8**] 1:30
Cardiologist - [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2170-5-1**] 3:20
Please call to schedule appointments
Primary Care Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7730**] [**Last Name (un) **] in [**1-27**] weeks
[**Telephone/Fax (1) 27593**]
Completed by:[**2170-4-16**]
ICD9 Codes: 4240, 5845, 9971, 412, 4280, 5859, 496, 4168, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5503
}
|
Medical Text: Admission Date: [**2131-2-6**] Discharge Date: [**2131-2-9**]
Date of Birth: [**2071-12-12**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old man
with no significant past medical history who presented on the
day of operation for a mitral valve repair. His presenting
symptoms were shortness of breath approximately six months
ago for which he visited his primary care physician, [**Name10 (NameIs) 1023**]
found him to have a heart murmur and atrial fibrillation. He
had been cardioverted and placed on aspirin, atenolol and
Prinivil and then he was referred to his cardiologist, Dr.
[**Last Name (STitle) 5310**], who referred him to Dr. [**Last Name (STitle) 1537**] for surgery. On
presentation, the patient was in good health and felt well.
PAST MEDICAL HISTORY: The past medical history was
significant for an appendectomy in [**2079**], Achilles surgery in
[**2116**], a fractured leg in [**2115**] and atrial fibrillation.
MEDICATIONS ON ADMISSION:
Atenolol 25 mg q.d.
Prinivil 2.5 mg q.d.
Aspirin 325 mg q.d., discontinued one week prior to surgery.
ALLERGIES: There were no known drug allergies.
PHYSICAL EXAMINATION: The patient had a heart rate of 80 and
a blood pressure of 113/77. In general, he was a well
appearing, middle aged man. On head, eyes, ears, nose and
throat examination, the pupils were equal, round and reactive
to light and accommodation. The neck was supple with no
lymphadenopathy and no jugular venous distention. The chest
examination was clear to auscultation. The heart examination
revealed an irregular rhythm with a III/VI murmur heard best
at the apex, radiating to the axilla. The abdomen was soft.
The extremities had no edema. Neurologically, the patient
was alert and oriented times three.
LABORATORY: The patient had a white blood cell count of
8,300 with a hematocrit of 32 and a platelet count of
118,000. Chemistries revealed a sodium of 137, potassium of
4.3, chloride of 104, bicarbonate of 25, BUN of 18,
creatinine of 0.9 and glucose of 108.
CARDIAC CATHETERIZATION REPORT:
1. Arteriography demonstrated normal coronary arteries in a
right dominant system.
2. Hemodynamics demonstrated normal right and left sided
pressures.
3. Left ventriculography demonstrated normal systolic
function with an ejection fraction of 60%. There was no
regional wall motion abnormality. There was severe 4+ mitral
regurgitation.
SUMMARY OF HOSPITAL COURSE: The patient was admitted on the
day of operation for mitral valve repair. His presenting
symptoms were shortness of breath, which led to a cardiac
catheterization that, in summary, showed normal coronary
arteries, normal ventricular function and 4+ severe mitral
regurgitation. He received his Operating Room on [**2131-2-6**],
during which he received a mitral valve repair with
neocortical [**Doctor Last Name 4726**]-Tex x 4 to antrum leaflet.
The patient was transferred to the Cardiothoracic Intensive
Care Unit for his postoperative care. His postoperative care
was excellent and unremarkable. He was found to be in atrial
fibrillation, as he was prior to the operation. As before,
the patient continued to refuse Coumadin for anticoagulation
and was therefore allowed to continue on aspirin for his
anticoagulation. He was also started on amiodarone for a
better rhythm control.
The patient is being discharged in good health and good
condition, feeling well and tolerating a regular diet and
pain medications p.o. He will follow up with Dr. [**Last Name (STitle) 1537**] and
his cardiologist.
DISCHARGE MEDICATIONS
1. Aspirin 325 mg p.o. q.d.
2. Atenolol 25 mg p.o. q.d.
3. Ibuprofen 600 mg p.o. every six hours p.r.n.
4. Colace 100 mg p.o. b.i.d.
5. Zantac 150 mg p.o. b.i.d.
6. Amiodarone 400 mg p.o. t.i.d. times ten days, then 400 mg
p.o. b.i.d. times one month, then 400 mg p.o. q.d. with
further evaluation per his cardiologist.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with [**Hospital6 407**]
services.
DISCHARGE DIAGNOSES:
Mitral valve repair--[**Doctor Last Name 4726**]-Tex.
[**Known firstname 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 180**]
MEDQUIST36
D: [**2131-2-12**] 11:00
T: [**2131-2-12**] 14:01
JOB#: [**Job Number 34069**]
ICD9 Codes: 4240, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5504
}
|
Medical Text: Admission Date: [**2156-12-27**] Discharge Date: [**2157-2-10**]
Date of Birth: [**2103-7-6**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Intracranial hemorrhage
Major Surgical or Invasive Procedure:
Intubation->Tracheostomy
[**First Name3 (LF) 5041**] placement->VP shunt
PEG placement
Temporary tarsorrhaphy OS
History of Present Illness:
53 year-old man with a possible history of hypertension presents
as a transfer to [**Hospital1 18**] for management of intracranial
hemorrhage. The patient apparently presented to [**Hospital3 **]
late this morning with a left-sided headache associated with
dysarthria and right hemiparesis. He reportedly had asked his
mother to call emergency services. CBC revealed hyperchromia
and macrocytosis without anemia. INR was reportedly normal
(thoough not included in transfer documentation). EKG showed
sinus tachycardia perhaps with peaked T waves in V2 and V3. CT
at [**Hospital1 **] revealed a pontine hemorrhage with spread into the 4th
ventricle. There was one report that his left pupils was
"blown." There was also report of a possible left lower lobe
opacity on CXR. He was intubated for "airway protection" then
and received an additional dose of versed for some agitation on
the ventilator. He also received 5 mg lopressor for blood
pressure control.
Review of Systems: Unable to provide, given intubation
Past Medical History:
-Possible hypertension
Social History:
Lives at home with his mother, for whom he is her primary care
giver.
Family History:
Unknown
Physical Exam:
Vitals: T 100.5 F BP 166/91 P 64 RR 14 SaO2 100 on vent
FIO2 100%
General: NAD, not on standing sedation
HEENT: NC/AT, sclerae anicteric, orally intubated, NGT in place
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear ventilated breath sounds
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated, onychomycosis
Skin: severely dry skin on feet
Neurologic Examination:
Mental Status: Appears awake, able to follow basic verbal
commands, including squeezing of hands and effort at tongue
protrusion
Cranial Nerves: Fundoscopy limited; no blink to threat
bilaterally. Pupils equally round and reactive to light, 2.5 to
2 mm bilaterally. On Doll's maneuver, eyes just able to cross
midline bilaterally. Nasal tickle and corneals absent
bilaterally. Hearing intact to loud verbal commands. Make a
weak effort to protrude tongue. Brisk gag reflex.
Sensorimotor: Normal bulk and tone throughout. No tremor or
adventitious movement noted. Squeezes hands bilaterally, more
strongly on the left. Able to bend left knee, just lifting it
off the bed. He is not moving the right voluntarily. He
withdraws in all four extremities, left side more briskly than
right.
Reflexes: B T Br Pa Pl
Right 2 2 2 2 0
Left 2 2 2 3 0
Left toe is upgoing and the right is mute.
Coordination and gait could not be assessed
Brief Hospital Course:
1. Pontine/medullary hemorrhage: The patient is a 53 year-old
man with a possible history of hypertension who presented as a
transfer to [**Hospital1 18**] for management of intracranial hemorrhage. The
patient apparently presented to [**Hospital3 **] with a
left-sided headache followed by right hemiparesis. On general
examination on admission, he had a low-grade fever (rectal) and
was hypertensive. On neurologic examination on admission, off
standing sedation, he was able to follow basic appendicular and
midline commands, nasal tickle and corneals were difficult to
elicit; otherwise brainstem reflexes, including pupillary
reflex, appeared preserved. He was not moving the right
voluntarily. CTA Head on admission showed hemorrhage in the
medulla and pons, subarachnoid hemorrhage in the prepontine and
premedullary cisterns, small amount of intraventricular
hemorrhage in the posterior [**Doctor Last Name 534**] of the left lateral ventricle,
and slightly dilated lateral ventricles bilaterally. He received
Nimodipine for vasospasm x14 days starting on the day of
admission. Serum tox showed 78 EtOH, urine tox positive for BZD.
Neurosurgery was consulted on admission, and placed an [**Doctor Last Name 5041**] on
[**12-27**] in the right lateral ventricle. Given that the [**Month/Year (2) 5041**] was in
place, he was started on Dilantin 100 mg TID. Was later stopped
prior to transfer and had no seizures. MRI head on admission
showed multiple small enhancing foci in the area of hemorrhage
in the left side of the pons; extensive left pontine and
medullary hemorrhage, intraventricular and subarachnoid
hemorrhage; moderate dilatation of the supratentorial
ventricular system; and small 1-2 mm infundibulum at the
junction of the right distal vertebral artery and the basilar
artery. Cerebral angiography was performed on [**1-3**], which
showed possible acute right vertebral artery occlusion, but no
AVM or aneurysm. Regardless, this occlusion would not explain
his symptoms and he could not be anticoagulated anyway. The
patient failed multiple attempts to clamp his [**Last Name (LF) 5041**], [**First Name3 (LF) **] a VP shunt
was placed. Neurological course over the hospitalization was
stable to slowly improving. He is alert and follows some
commands. Near full strength extremities, and minimal movement
on right. Also profound left facial weakness.
2. Hypertension: The patient has an unknown past medical
history, but possible history of hypertension. He was started on
Labetalol 200 PO tid and Lasix 20 mg daily. TTE showed no
cardiac source of embolism, hyperdynamic left ventricular
systolic function with LVEF >75%.
3. SIADH vs. cerebral salt wasting: His Na was 130 on admission,
then normal from [**Date range (1) 81836**]. However, on [**1-6**] his Na dropped
from 132->125, and nadired at 121. His serum osm was initially
262, and nadired at 256. Renal was consulted who determined that
he most likely had SIADH. He received 3% hypertonic saline at 20
cc/hr and initially started Lasix 20 PO bid to decrease urine
osms with improvement in his Na to normal.
4. ATN: His Cr increased from 0.8 to 1.4 on [**1-8**], and peaked at
1.7. Renal determined that this was possibly due to a
hypotensive episode along with his Hct drop (see below) causing
some ATN. FeNa was 2.3% supporting this. His Lasix and Enalapril
were discontinued at that time. Renal ultrasound was a limited
portable exam without hydronephrosis or upper abdominal ascites.
His Cr slowly improved.
5. ID: The patient continued to spike fevers during the
hospitalization, which were thought to be central fevers from
his hemorrhage. He was initially on Ancef IV while the [**Month/Day (4) 5041**] was
in place, then changed to Vanc/Cefazolin on [**1-4**] for WBC (40)
out of proportion to RBC (5250) in CSF, which was changed to
Vanc/Zosyn which was subsequently discontinued. CSF cultures
showed no growth, and eventually the WBC in his CSF was thought
to be reactive to the [**Month/Year (2) 5041**]. He also recevied Fluconazole 200 IV
q24 hr for sparse growth yeast in his sputum. Bilateral LENIs
showed no DVT of the lower extremities, and CT Torso showed
emphysematous changes in the lungs, minimal bronchiolitis in the
lingula and bilateral lower lobes, 1.4-cm enhancing lesion in
the left lobe of the liver may represent a hemangioma,
cholelithiasis. Head CT showed left mastoid opacification.
6. Respiratory: The patient was intubated upon admission, and
extubated [**12-28**] but then required re-intubation. Tracheostomy
was placed on [**1-4**]. Continues to be vented.
7. Hematology: He received 2 U PRBCs on [**1-8**] for a Hct drop to
23.7. His stool was guaiac negative.
8. Left corneal abrasion/ulceration: Ophthalomology was
consulted for his left eye chemosis, and the patient was found
to have a left corneal abrasion and ulceration. He is s/p
temporary tarsorrhaphy [**1-7**]. He was placed on
Bacitracin/Polymyxin ointment and artificial tears. Eye culture
showed no growth. Impriving with ointment and drops.
9. GI/FEN: The patient is s/p PEG placement on [**1-4**] for tube
feeds. He was placed on MVI/thiamine/folate on admission given
the positive EtOH on his tox screen.
Medications on Admission:
-Flonase
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain or fever.
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
10. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q6H (every 6 hours).
11. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic Q2H EXCEPT AT TIMES WHEN POLYSPORIN OINTMENT
IS GIVEN ().
12. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
13. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed.
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
16. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
18. Insulin Regular Human 100 unit/mL Cartridge Sig: per sliding
scale Injection four times a day.
19. Metoclopramide 5 mg IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Pontine hemorrhage
Discharge Condition:
Fair
Discharge Instructions:
Patient being transferred to vent unit. Follow up as below.
Meds as below. Please call or bring pt to ED if any acute
neurological changes.
Followup Instructions:
Patient should follow up with Dr. [**Last Name (STitle) 78537**]/[**Doctor Last Name **] ([**Telephone/Fax (1) 15319**]
on [**4-20**] 1:30 PM. [**Hospital1 **] [**Last Name (Titles) 516**],
[**Hospital Ward Name 23**] Building [**Location (un) **].
Should also follow up with PCP [**Name Initial (PRE) 6164**] [**Telephone/Fax (1) 4475**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 5845, 0389, 5990, 5180, 5119, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5505
}
|
Medical Text: Admission Date: [**2168-5-6**] Discharge Date: [**2168-5-9**]
Date of Birth: [**2101-2-24**] Sex: M
Service: SURGERY
Allergies:
Chromium
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
thoracic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2168-5-6**]
Endovascular Stent graft exclusion of thoracic aortic aneurysm
with [**Doctor Last Name **] TAG device
History of Present Illness:
The patient is a 67-year-old
gentleman who previously had an abdominal aortic aneurysm
repair. He has a known thoracic aortic aneurysm that is
enlarging. It is now the size that warrants repair. Given
these findings, the patient was consented for endovascular
stent graft exclusion of his thoracic aortic aneurysm.
Past Medical History:
PAST MEDICAL HISTORY:
1. CAD RISK FACTORS: DM2, HTN, dyslipidemia, CAD, smoking
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- 50+ pack year history of smoking
- CRI
- RAS s/p L stenting 07, right kidney atretic
- severe COPD
- obesity
- back surgery
- abdominal aneurysm - CT angiogram performed in [**2167-9-20**]
showed the size to be 8 cm. His descending thoracic aort is also
enlarged (less than 5 cm), and the right common iliac artery was
aneurysmal (5 cm) with left common iliac smaller (3 cm)
aneurysm. Of note, the
abdominal aortic aneurysm is pararenal and extends to the left
renal artery (which had been stented in [**2165-2-17**]).
Social History:
The patient in married and lives with his wife. [**Name (NI) **] is retired.
Smokes 1 ppd and has done so for over 50 years. He denies
alcohol or recreational drugs. He does not exercise and has no
dietary restrictions.
Family History:
significant for heart disease. Negative for stroke and diabetes
Physical Exam:
afebrile
VSS
Gen: wdwn, alert and oriented
Neck: supple, no adenopathy, no jvd
Card: RRR no m/r/g
Lungs: CTA bilat
Abd: Soft +bs, no m/t/o
Neuro: sensation of LE intact bilat
Extremities: warm, well perfused, Full ROM LE bilat
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2168-5-9**] 02:29AM BLOOD WBC-8.7 RBC-4.23* Hgb-12.7* Hct-36.8*
MCV-87 MCH-30.0 MCHC-34.5 RDW-15.3 Plt Ct-204
[**2168-5-9**] 02:29AM BLOOD Glucose-123* UreaN-18 Creat-1.2 Na-138
K-3.8 Cl-99 HCO3-29 AnGap-14
[**2168-5-9**] 02:29AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
[**2168-5-6**] 11:11 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2168-5-8**]**
MRSA SCREEN (Final [**2168-5-8**]): No MRSA isolated.
Cardiology Report ECG Study Date of [**2168-5-6**] 10:43:40 AM
Sinus bradycardia. Since the previous tracing of [**2168-4-22**] the rate
is slower.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 158 100 432/425 34 4 14
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2168-5-6**] and taken to the endosuite with
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 17356**] both being present. General
anesthesia was initiated and a spinal drian was placed. The
underwent and Endovascular Repair of his thoracic aortic
aneurysm with [**Doctor Last Name **] tag stent. He tolerated the procedure well,
was extubated and taken to the PACU for recovery. He remained
hemodynamically stale, and his systolic BPs were kept a bit on
the higher side, 120-160, for spinal perfusion. He maintained
good neuro-vascular function of the lower extremities throughout
his stay. He was later transfered to the CV ICU where he was
montiored closely. He remaiend hemodynamically stable with good
BPs and neuro-motor function. He tolerated a regular diet and
once his spinal drain was removed, he ambulated and voided
without difficulty. His pain remained under good control
throughout his stay. Given his need for slightly elevated BPs,
his lisinopril was not restarted post operatively. On POD 3 he
was doing quite well and was deemed stable for discharge to
home. He will follow up with Dr. [**Last Name (STitle) **] as well as his
PCP.
Medications on Admission:
atenolol 25', furosemide 80', lisinopril 10', lorazepam 1',
Paroxetine 20', Crestor 20'
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day: while on lasix - pcp
to check potassium level.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
thoracic aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? STOP taking your lisinopril 10mg daily. Your blood pressure
needs to be kept a bit higher than usual after your stent.
Systolic BP (the top number) should be 120-160 for now. You may
continue all other medications you were taking before surgery,
?????? You make take Tylenol and prescribed oxycodone 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 [**12-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
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
3 weeks. After that no lifting more than 60-70lbs for life.
?????? After 2 weeks, you may resume sexual activity
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-6-8**] 11:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2168-6-8**] 1:00
call PCP for appt in 2 weeks
Completed by:[**2168-5-9**]
ICD9 Codes: 4019, 2720, 3051, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5506
}
|
Medical Text: Admission Date: [**2177-12-9**] Discharge Date: [**2177-12-30**]
Date of Birth: [**2121-12-28**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2177-12-9**] INCISION + DRAINAGE OF PERINEUM WITH EXTENSIVE SOFT
TISSUE DEBRIDEMENT [**Doctor Last Name **]
[**2177-12-10**] WASHOUT & DEBRIDEMENT PERINEUM [**Doctor Last Name **]
[**2177-12-11**] Incision, drainage and washout of infected rectum and
perineum, laparotomy with diverting sigmoid colostomy. [**Doctor Last Name **]
[**2177-12-12**] RESETTING OF TESTICLES & PLACEMENT OF WOUND VAC [**Doctor Last Name **]
[**2177-12-18**] percutaneous tracheostomy, flexible bronchoscopy,
debridement and washout of perineal / buttock wound [**Doctor Last Name **]
[**2177-12-19**] I&D PERINEUM, WOUND VAC DRESSING PLACEMENT
History of Present Illness:
55yM with h/o DM2 and gastroparesis, here with abdominal
pain. Pain is chronic and he was going to see a
Gastroenterologist this week. However, he developed more acute
LLQ pain and N/V this past few days. Also noted some right
buttock and scrotal pain. Was initially admitted to the medical
service
with surgical consultation for concern of perirectal infection
vs. Fourniers Gangrene. He had an unremarkable CT scan at
admission, but he was mildly septic with a HR in the 120s and BP
in the 90s which both responded to fluid challenge.
Past Medical History:
PMH: DM2, gastroparesis, MRSA infections, kidney stones, HTN,
Hyperchol.
.
PSH: left knee replacement
Family History:
Noncontributory
Physical Exam:
On presentation:
VS: T: 98.0 BP: 104/61 P: 96 R: 18 O2: 100% on 2L
PE:
Gen: mild distress, warm, AAOx3
HEENT: anicteric
CV: RRR
Pulm: CTA b/l
Abd: soft, LLQ mild TTP, no rebound or guarding, nondistended
Rectal: unable to perform rectal. Entire right buttock very
indurated with some spreading erythema. Posterior scrotum firm
as well and painful. No crepitus palpated. No spontaneous
drainage.
Pertinent Results:
IMAGING:
[**12-8**] CXR: No acute cardiopulmonary process. No evidence of free
air
beneath the diaphragms.
[**12-8**] KUB: pending
[**12-8**] CT ABD/PELVIS: 1. Bilateral small pleural effusions. 2. No
small-bowel obstruction. 3. Non-specific fat stranding about the
kidneys. Delayed contrast excretion. 4. Foley catheter and air
within the urinary bladder could be from placement of Foley;
correlate clinically. 5. Non obstructive 2mm stone at the lower
pole of left kidney.
[**12-9**] SCROTAL U/S: Extensive hyperechoic foci tracking to the
floor of the perineum concerning for gas w/in the scrotal cavity
and Fournier's. No fluid collection to suggest an abscess.
[**12-10**]: CXR:New right IJ catheter tip is in the upper-to-mid SVC
and there is no evidence of pneumothorax. ET tube tip is 6.6 cm
above the carina. NG tube tip is out of view below the
diaphragm, difficult to visualize. Cardiac silhouette is
unchanged. Mild pulmonary edema has worsened. Left lower lobe
retrocardiac opacity has worsened, consistent with worsening
atelectasis. Bilateral pleural effusions are small.
[**12-10**]:abd Xray:Motion artifact, unable to visualize nasogastric
tube. Recommend repeat imaging to further assess.
[**12-11**] ECHO:LA severely increased,RA is moderately dilated, mild
symm LVH with normal cavity size, moderate regional left
ventricular sys dysfunction with hypokinesis of the basal
anterior, anteroseptal and lateral walls and of the inferior
septum. increased left ventricular filling pressure
(PCWP>18mmHg). RV dilated.Aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mitral valve
leaflets are mildly thickened. Mild (1+) MR, moderate pulmonary
artery systolic hypertension, small to moderate sized
pericardial effusion
[**12-11**]: CXR: Persistent retrocardiac opacity, can't exclude
infectious process
[**12-11**]: ABD: G tube in gastric antrum
[**12-12**] CXR: Continued evidence of increased pulmonary venous
pressure with substantial enlargement of the cardiac silhouette.
There is continued opacification in the retrocardiac region
incompletely silhouetting the hemidiaphragm. Again this is
consistent with some combination of atelectasis, pneumonia, and
pleural effusion.
[**12-14**]: CXR: Mild pulmonary edema, most readily visible in the
right lung has improved. Moderate cardiomegaly and mediastinal
vascular engorgement have decreased slightly. Left lower lobe is
still collapsed.
[**12-15**]: CXR: cardiomegaly unchanged, diffuse b/l alveolar
opacities likely representing pulmonary edema worsening, LLL
atelectasis
[**12-15**]: KUB: tip of OGT in antrum of stomach
[**12-16**] CXR:e/o elevated pulmonary venous pressure. Extensive
opacification at the left base is consistent with volume loss in
the left lower lobe and pleural effusion
[**12-17**] CXR:enlarged cardiac shadow, decreased lung vol, LL
collapsed, minimal left pleural eff.
[**12-18**] CXR:enlarged cardiac shadow, decreased lung vol, LL
collapsed, minimal left pleural eff.
11/25CXR:As compared to the previous radiograph, the
endotracheal tube has been removed and replaced by a
tracheostomy tube. The tip of the tube is projecting 4.8 cm
above the carina. Unchanged course and position of the
nasogastric tube and of the right-sided central venous access
line. There is no evidence of complications, notably no
pneumothorax. Unchanged severe cardiomegaly with a small left
pleural effusion and left lower lobe atelectasis. No newly
appeared focal parenchymal opacities suggesting pneumonia.
[**12-20**]: CXR: No acute changes.
[**12-21**]: CXR: New large RLL consolidation consistent with
aspiration.
[**12-21**]: KUB: NG tube tip is in the proximal stomach
[**12-22**] CXR: Consolidation RML RLL, pulmonary edema periphery
right lung as well as the left has improved. Mod cardiomegaly
improved. Trach tube abuts right tracheal wall. RIJ line can be
traced junction of brachiocephalic veins. feeding tube w/ wire
stylet in place passes into stomach and out of view.
[**2177-12-29**] Chest
FINDINGS: In comparison with the study of [**12-23**], the monitoring
and support devices remain in place. There is continued
enlargement of the cardiac silhouette with elevation of
pulmonary venous pressure and bilateral pleural effusions more
prominent on the left. The more focal opacification in the right
mid zone is not appreciated at this time
[**2177-12-9**] 06:50PM GLUCOSE-154* UREA N-59* CREAT-2.9* SODIUM-133
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-23 ANION GAP-12
[**2177-12-9**] 06:50PM CALCIUM-7.9* PHOSPHATE-4.4 MAGNESIUM-1.7
[**2177-12-9**] 06:50PM WBC-18.9* RBC-2.77* HGB-8.4* HCT-25.0* MCV-90
MCH-30.2 MCHC-33.6 RDW-14.2
[**2177-12-9**] 06:50PM NEUTS-80* BANDS-11* LYMPHS-1* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2177-12-9**] 06:50PM PLT SMR-NORMAL PLT COUNT-249
[**2177-12-9**] 06:50PM PT-13.1 PTT-22.5 INR(PT)-1.1
[**2177-12-9**] 04:55AM %HbA1c-8.1* eAG-186*
[**2177-12-8**] 09:30PM GLUCOSE-549* UREA N-57* CREAT-2.0*
SODIUM-131* POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-27 ANION GAP-14
[**2177-12-8**] 09:30PM ALT(SGPT)-13 AST(SGOT)-37 ALK PHOS-110 TOT
BILI-0.5
Brief Hospital Course:
Patient seen by acute care surgical team and was admitted for
ICU management and aggressive debridement.
ICU Course as follows per dictation of Dr. [**First Name8 (NamePattern2) 7656**] [**Name (STitle) **]:
[**12-9**]: admission to TSICU. R IJ CVL placed. Transfused 2U
overnight.
[**12-10**]: s/p further debridement in OR, upon transfer back to ICU
pt was hypotensive- received Calcium, neo, ephedrine by
anesthesia
[**12-11**]: Went to OR for debridement and colostomy. Plan to return
to the OR tomorrow. Tissue culture is growing coag negative
staph. Echo today showed EF of 35-40%. Post op he did well, but
Hct dropped to 25 from 30 and he was started back on Neo to
maintain MAPs>65. As a result, he received 1 unit PRBCs.
[**12-12**]: went to OR for further debridement. started TFs postop.
started NPH [**8-31**] in addition to insulin gtt.
[**12-13**]:[**Last Name (un) **] consulted,erythromycin started for high TF
residuals in pt with h/o gastroparesis
[**12-14**]: Started on statin and Lopressor, ASA increased to 325.
IVF and albumin were DC'd and he was started on Lasix 20 [**Hospital1 **].
required 2 additional doses of Lasix, but still did not diurese
well. He was down 1L as of midnight. He was somewhat
uncomfortable overnight but increasing the propofol/fentanyl
resulted in respiratory depression. As a result, he was put back
on a rate with improved ABG.
[**12-15**]: Lasix held. bedside VAC changed by ASC team. Aline
replaced.
[**12-16**]: CPAP, Started on Clonidine, ACS repaired vac leakage, TF
at goal
[**12-17**]: VAC taken down at bedside by ACS.
[**12-18**]: went to OR for repeat debridement, did not reapply VAC
given plans to return to OR again [**12-19**].
[**12-19**]: hct 20.5, transfused 2units, increased clonidine to
0.3TID, went to OR for debridement, all Abx dc'ed per ACS
[**12-20**]: 1U PRBC, did have periods of hypertension and tachycardia
at first thought to be related to pain. His fentanyl drip was
maximized, but he still was uncomfortable. Per discussion with
Dr. [**Last Name (STitle) 35981**], we decided to start on methadone, continued
clonidine, and due to some abdominal distention, started
relistor. He passed gas, but not much increase in stool via
ostomy. Was more calm after the methadone. Pulled out NGT
partially, it was replaced and CXR obtained
[**12-21**]: pt had several episodes of emesis with increased
abdominal distention and minimal ostomy output. TFs were held
and meds were switched to IV. pt continued to have projectile
vomiting despite NGT sumping well. Erythro changed to Reglan.
given another dose of methylnaltrexone in the evening.
[**12-22**]: Bedside VAC change. Methadone increased. D/c Dilaudid.
Diuresis.
[**12-23**]: NGT clamped for 4 hrs;XR KUB- unchanged position of NGT;
restarted TF.
_
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________________________________________________________________
He was transferred to the regular nursing unit on [**2177-12-23**]:
His course as follows by systems per dictation by [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**],
NP:
Neuro-he was noted to be delirious felt to be multifactorial.
His physical exam, meds and labs were reviewed carefully. The
decision was made to stop the methadone IV that was started
while in the ICU for control of his acute pain issues. He
actually had minimal pain issues once transferred to the floor
requiring only in rare occasion oral Dilaudid. He remains on a
Clonidine patch which was also started during his ICU stay for
helping to control agitation; this should be weaned once he is
at rehab. His mental status over the course of his stay on the
floor has improved significantly. He is very alert and oriented
x2-3 and cooperative with his care.
Cardiac-his blood pressure and heart rate have been relatively
stable with SBP 140's-150's, DBP 70's-80's, he continues on his
Norvasc and Lisinopril. There are currently no acute issues at
time of this dictation.
Respiratory-he continues with a trach and receives humidified
air, his saturations have been stable ranging 95-99%. he wears a
Passy-Muir valve for speaking. He should continue on his prn
nebulizer treatments.
Gastrointestinal-patient self removed his Dobbhoff. it was
decided that he be evaluated by Speech given that his mental
status improved. He was placed on a dysphagia diet of soft
solids with thin liquids. He has required 1:1 supervision for
meals. His colostomy care was followed closely by the Wound Care
Ostomy Nurse during his stay.
Genitourinary-he is currently being treated for a UTI with a
total of 5 days of oral Cipro. His Foley catheter was replaced
on [**12-29**] and is being recommended to remain in place because of
his extensive perineal wound.
Musculoskeletal-there are no active issues. He was evaluated and
seen regularly by Physical and Occupational therapy and is being
recommended for acute rehab.
Integumentary-he has an extensive wound that has required VAC
dressing since his surgery. For transfer to rehab he has a wet
to dry, but this should be changed back to the VAC @125 once at
rehab.
Endocrine-he intermittently had elevated blood sugars requiring
adjustment of his standing and insulin sliding scales.
Heme-his hematocrits have been low but stable with a recent Hct
of 25.4 on [**12-29**] which is up from 24.9 on [**12-28**]. He is not showing
any signs of active bleeding.
Prophylaxis-he is receiving Heparin for DVT prophylaxis.
Medications on Admission:
[**Last Name (un) 1724**]:Norvasc 10', Lasix 40', Neurontin 300'', Amaryl 4', Levsin
0.5''' prn, Lantus 38U'', Lisinopril 5', Reglan 10'''',
Lopressor
50'',Zocor 40'.
.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. hyoscyamine sulfate 0.125 mg Tablet Sig: 2-3 Tablets PO TID
(3 times a day) as needed for GI spasm .
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
16. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
18. NPH Sig: Twelve (12) units Injection at breakfast.
19. NPH Sig: Sixteen (16) units Injection at supper.
20. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous
four times a day as needed for per sliding scale: see attached
sliding scale.
21. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-29**]
hours as needed for pain .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Fournier's gangrene
Respiratory failure
Urinary tract infection
Acute blood loss anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized with a severe infection in your
scrotal/perineal region requiring an operation. As a result you
have an extensive wound that requires specialized dressing
changes and care.
It is important that you not sit for long periods of time
because of the location of your wounds.
Followup Instructions:
Follow up in [**Hospital 2536**] clinic in 2 weeks for evaluation of your wound;
call [**Telephone/Fax (1) 600**] for an appointment.
Completed by:[**2178-1-7**]
ICD9 Codes: 0389, 2851, 5849, 2930, 5990, 5859, 2720, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5507
}
|
Medical Text: Admission Date: [**2192-1-7**] Discharge Date: [**2192-1-11**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 86 year old male with
history of advanced hormone-refractory prostate cancer,
elevated PSA and possible bone mets who presented with fever
and substernal chest pain on [**2192-1-7**]. The patient was a
poor historian on admission and the details of his history
were not clear. The patient had a recent bone scan due to an
elevated PSA and since then has been complaining of increased
fatigue. On the day of admission, the patient had increased
lethargy and he was found to be febrile at his [**Hospital3 12272**].
The patient did not note fevers, chills or chest pain but
does not chest pain of unclear characterization. The patient
reports it to be right shoulder pain without elaboration.
The patient's wife reports shaking and mild abdominal pain
yesterday. The patient denies dysuria, headache, shortness
of breath, cough, nausea, vomiting, diarrhea.
In the ER, the patient was found to be hypoxic. He was given
IV Lasix when his chest x-ray showed flash pulmonary edema.
He was also hypertensive and had received some Nitropaste.
He then became hypotensive and required a 500 cc normal
saline bolus and then was transferred to the MICU.
The patient was aggressively volume resuscitated prior to
transfer with three liters as his systolic blood pressures
were not being maintained. He was also given 2 grams of
Ceftriaxone IV times one.
PAST MEDICAL HISTORY:
1. Advanced prostate cancer status post XRT and
chemotherapy, last PSA 55. He has been treated with Lupron,
Casodex and Ketoconazole.
2. Hypercholesterolemia.
3. Cataracts.
4. Dementia.
5. Glaucoma.
6. Gout.
7. History of cholestasis and jaundice.
8. Hypertension.
MEDICATIONS: Flomax 0.4 qd, Protonix 40 po qd, Celexa 10 po
qd, TUMS 500 po qd, Nitroglycerin prn, Cosopt 1 gtt each eye.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married times 56 years and
lives with his wife at [**Hospital3 **] called [**Location (un) 5481**].
He does not smoke, quit 50 years ago and has approximately
one drink per day but recently quit.
FAMILY HISTORY: His father died of stomach cancer.
PHYSICAL EXAMINATION: Vital signs show temperature of 102.9,
pulse 83, blood pressure 119/39, breaths 19, satting 98% on
room air. In general he is an elderly, somewhat confused
male, agitated, moves frequently in bed. HEENT: PERRL,
EOMI. Sclera nonicteric, mildly dry mucous membranes. Neck
is supple, difficult to appreciate JVP. Cardiovascular:
Regular rate and rhythm, no murmurs, rubs or gallops.
Pulmonary: Upper airway transmitted sounds with some
wheezing, slightly tachypneic, otherwise clear. Abdomen:
Positive bowel sounds, soft, nontender. Extremities: No
cyanosis, clubbing or edema, 1+ pedal pulses. Neurologic:
Oriented to hospital, self, [**5-23**] motor and lower extremities.
HOSPITAL COURSE:
1. Sepsis: On admission the patient's blood cultures were
positive for gram-negative rods in [**2-22**] bottles which later
grew out to be E. coli which where pansensitive. The
patient's urine culture also grew E. coli. The patient was
found to have sepsis secondary to a UTI. The patient
required Dopamine transiently on admission to the MICU due to
low blood pressures but then improved and his Dopa was weaned
on day two of his MICU stay. The patient was treated with
Levo and Ceftriaxone initially on [**1-10**] after his cultures
and sensitivities as being sensitive to quinolones. His
Ceftriaxone was discontinued. The patient will be treated
with a three week course of Levaquin.
On admission the patient had been complaining of chest pain
and his troponins showed him to have an acute non Q wave MI
though his CKs were not elevated. His cardiac ischemia was
thought to be secondary to demand. He was started on a
Heparin drip times 48 hours as per Cardiology's
recommendations. He was also continued on aspirin, beta
blocker and on the day of discharge the patient was also
started on an ACE. The patient was noted to have ST
elevations on day two of his MICU stay. While he denied
further chest pain, the patient was continued on the Heparin
drip. This was discontinued on [**2192-1-10**].
The patient had a subsequent echocardiogram which
demonstrated a depressed EF of 25% to 30% with severe left
ventricular dysfunction and a marked anterior akinesis. On
discussing with the patient's attending, Dr. [**Last Name (STitle) **], it was
decided that given the patient's advanced metastatic disease,
anticoagulation would not be started on the patient such as
Coumadin.
2. Pulmonary: The patient was desatting on admission and
required some oxygen due to aggressive volume repletion for
hypotension. On discharge, the patient's room air stats were
96%.
3. Hypoglycemia: The patient had some episodes of
hypoglycemia in the MICU which was attributed to sepsis. The
patient has no history of diabetes so the patient was placed
on an sliding scale of insulin. This will be stopped as the
patient is going to rehab and we are recommending that his
blood sugars are checked while fasting to prevent
hypoglycemia.
4. Prostate cancer: The patient likely had bone mets from a
recent bone scan. The plan was for the patient to have
continued hormonal therapy or chemo but this will be decided
by his outpatient oncologist, Dr. [**Last Name (STitle) **]. The patient had
some episodes of hematuria after his Foley was discontinued.
The Foley was replaced when the patient failed a voiding
trial and then discontinued again and the patient had no
further hematuria but this should be followed up after the
patient is discharged.
5. Dementia: The patient had some episodes of sundowning
while in the hospital however this was not worse than his
baseline and not surprising considering his recent sepsis.
6. Code status: The patient was DNR/DNI while in the
hospital however the patient did accept pressors and required
them during his MICU stay.
DISCHARGE CONDITION: The patient's condition is stable.
DISCHARGE DIAGNOSES: Sepsis secondary to UTI, bacteremia,
acute MI.
FOLLOW UP PLAN: The patient is to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2192-2-21**] at 10:30 in the Heme [**Hospital **] Clinic.
DISCHARGE MEDICATIONS: ASA 325 one po qd, Calcium carbonate
500 mg one po qd, Protonix 40 mg one po qd, Metoprolol 25 mg
po bid, Tamsulosin 0.4 one po qd, Dorzolamide - Timolol 2.5%
one drop ophthalmic qd, Citalopram 20 mg one po qd,
Levofloxacin 500 mg po qd continued for a total of two week
course.
[**Name6 (MD) 177**] [**Name8 (MD) **], M.D. [**MD Number(1) 9267**]
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2192-1-11**] 12:27
T: [**2192-1-11**] 15:10
JOB#: [**Job Number 103856**]
ICD9 Codes: 4280, 5990, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5508
}
|
Medical Text: Admission Date: [**2141-6-14**] Discharge Date: [**2141-7-6**]
Date of Birth: [**2070-6-26**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Transfer from [**Hospital1 **] with necrotizing pancreatitis and ARDS
Major Surgical or Invasive Procedure:
Mechanical ventilation/ intubation x2
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE
Date: [**2141-7-3**]
Time: 04:13
The patient is a Pt is a 70F with PMH of HTN, PVD and [**Hospital **]
transferred from outside hospital with severe pancreatitis and
respiratory failure requiring intubation. History was obtained
from family and the medical record.
Two days prior to admission, pt began experiencing sharp RUQ
pain, nausea, nonbloody, nonbilious vomitus and diarrhea. The
family denies any fevers, cough or chills and states she was in
her normal state of health prior to developing pain. She did not
want to go see her MD, but one day prior to transfer her pain
worsened and she finally went to [**Hospital6 **]. At
LGH intital labs were notable for a lipase of 2254 which trended
upward to 8117, normal Cr and WBC of 22. Initial BUN was 22 but
subsequently trended upward to 30. RUQ US revealed common bile
duct dilitation and an abnormal appearance of her pancreas. She
was given metronidazole and levofloxacin and admitted to the
general medical floor where she was kept NPO and given IVF. CT
scan of her abdomen and pelvis was performed and was concerning
for necrosis, therefore were was transferred to the ICU where
aggressive fluid repletion was initiated (at the time of
transfer she has recieved 7 L. HCT demonstrated
hemoconcentration (54) which remained stable despite fluids.
Antitbiotics were broadened to imipenem. She remained
hemodynamically stable, afebrile, with UOP of 60 cc/hr
overnight.
Initial plan was for ERCP however the afternoon of transfer the
patient developed an acute desaturation event to 88% on 5L NC.
Saturations improved to 96% with 50% FiO2 via a venti mask. ABG
at that time was 7.17/46.2/81.7 bicarb of 17. She was intubated
prior to transfer to [**Hospital1 18**]. On transport she was noted to be
transiently hypotensive to the 80s requiring peripheral levophed
which was weaned off on arrival to the [**Hospital Unit Name 153**]. No ROS was obtained
due to the patient being unconcious.
Of note [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] records the patient has a history
of chronic nausea and intolerance of greasy food, however the
family denies any previous diagnosis of gallbladder disease. The
patient does not drink alcohol, has no new medication but does
have HL for which she has been on pravastatin.
On arrival to the MICU on [**2141-6-14**], patient's VS 157/79 105 18 95%
on CMV with RR 16, Vt 400, FiO2 60%. The patient was intubated
and sedated due to ARDS. LIJ central venous catheter was placed
given access issues. She was extubated on [**2141-6-20**] and was
transfered to the medicine floor and was treated for VAP from
[**Date range (3) 112125**] with zosyn and vancomycin (cipro was started
initially, but subsequently discontinued). On [**2141-6-23**], she was
transfered back to the ICU, re-intubated for hypoxia thought to
be due to atelectasis, bilateral pleural effusions and a
questionable infarct in the [**Date Range **] without thrombus, which was not
anticoagulated. On [**2141-6-24**], she was noted to have ARF with rare
eos (AIN), which was thought to be due to medications/contrast
dye exposure. Several potential offending agents were
discontinued. On ECHO on [**6-26**] was wnl. Her initial tachycardia
later improved with verapamil. A LUQ u/s showed no gallstones
and minimal sludge.
Past Medical History:
Type II DM
HTN
HL
PVD
Chronic low back pain
Social History:
Patient is married, former smoker, but not currently. She does
not drink and does not do drugs. She lives with her husband and
has three children.
Family History:
Skin cancer in a grandfather
Physical Exam:
VS: 98.6 132/68 107 22 95% RA; 0/10 pain
GEN: No apparent distress, somnolent
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert to person and situation; CN II-XII grossly intact,
global muscle weakness
DERM: no lesions appreciated
Pertinent Results:
[**2141-6-14**]
Na 146 K 4.6 Cl 116 C02 20 BUN 30 Cr 0.7
Alb 2.6 Alk Phos 91 Bilirubin 0.7 (direct 0.1) AST 171 ALT 286
Tpro 6.3 Lipase 8117
[**6-14**] 1434
WBC 20.7 HgB 17.2 HCT 53.7 PLT 168
ABG BiPAP (PEEP 5, PS 5)7.20/41/85
Venti mask 10L 7.17/47/82
Micro: urine cx [**Hospital1 487**] [**2141-6-13**] > 100,000 colonies of beta
hemolytic group B strep
[**Hospital3 **] Imaging
CT Abdomen Pelvis with contrast
Severe acute pancreatitis with suggestion of early pancreatic
necrosis
Mildly distended gallbladder containing sludge and stones no
definite CBD stone identified
US Gallbladder: Markedly abnormal appearance of the pancreas and
gallbladder with prominent common bile duct.
CT Abdomen/Pelvis
CXR [**Hospital1 487**]: Bilateral lower lobe infiltrates R > L No
effusions, No pneumothroax
CXR ([**Hospital1 18**] my read) Bilateral pleural effusions, some vasular
prominence no focal consolidations
EKG: sinus at 137 Bpm LAD, isolated Q in V1
Admission labs:
[**2141-6-15**] 12:05AM BLOOD WBC-16.8* RBC-5.27 Hgb-15.1 Hct-48.1*
MCV-91 MCH-28.6 MCHC-31.3 RDW-14.4 Plt Ct-214
[**2141-6-15**] 12:05AM BLOOD Neuts-75* Bands-10* Lymphs-3* Monos-8
Eos-0 Baso-0 Atyps-1* Metas-3* Myelos-0
[**2141-6-15**] 12:05AM BLOOD PT-14.4* PTT-64.8* INR(PT)-1.3*
[**2141-6-15**] 12:05AM BLOOD Glucose-229* UreaN-35* Creat-0.7 Na-141
K-3.8 Cl-112* HCO3-17* AnGap-16
[**2141-6-15**] 12:05AM BLOOD ALT-176* AST-87* AlkPhos-68 TotBili-0.7
[**2141-6-15**] 04:55AM BLOOD ALT-154* AST-71* LD(LDH)-793* AlkPhos-65
TotBili-0.7
[**2141-6-15**] 12:05AM BLOOD Lipase-980*
[**2141-6-15**] 12:05AM BLOOD Albumin-2.7* Calcium-6.7* Phos-2.6*
Mg-1.5*
[**2141-6-15**] 01:23AM BLOOD Type-ART Temp-37.4 Rates-/16 Tidal V-400
PEEP-5 FiO2-60 pO2-96 pCO2-41 pH-7.23* calTCO2-18* Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2141-6-14**] 11:23PM TYPE-ART TEMP-37.4
[**2141-6-14**] 11:23PM LACTATE-1.5
[**2141-6-14**]
CT abdomen/pelvis
IMPRESSION:
1. Extensive necrotizing pancreatitis without gas formation.
2. Peripancreatic inflammatory fat stranding and free fluid in
the
retroperitoneum, pelvis and perihepatic locations. Distended
gallbladder with
sludge and possibly stones, though no ductal dilatation is seen.
3. Patent portal venous system, though the splenic artery is
attenuated.
RUQ U/S
[**2141-6-15**]
IMPRESSION:
1. Gallbladder filled with sludge and gallstones. No evidence
of
choledocholithiasis or definite cholecystitis at this time.
2. Rounded heterogeneous segment II liver lesion without
correlation to CT two days prior. This could be focal fatty
sparing but other lesions such as FNH could be missed on CT in
equilibrium phase. When the patient's condition improves, a
repeat ultrasound should be obtained.
3. Echogenic liver is most consistent with fatty deposition.
More advanced liver disease such as fibrosis or cirrhosis can
not be excluded on this study.
CT abdomen and pelvis [**2141-6-18**]
IMPRESSION:
1. Redemonstration of necrotizing pancreatitis with unchanged
distribution of pancreatic necrosis. Interval increase in
peripancreatic fluid around on the tail of the pancreas and
gastric greater curvature, but fluid collections do not appear
organized.
2. Moderate nonhemorrhagic pleural effusions with associated
atelectasis.
Echo [**2141-6-26**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Doppler parameters are
indeterminate for left ventricular diastolic function. 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 aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
LENIs [**6-26**]
The visualized vessels are patent and compressible with normal
flow
and augmentation. No thrombus is identified. There is normal
phasicity
within the common femoral veins bilaterally.
IMPRESSION: No evidence of bilateral lower extremity DVT.
[**2141-6-27**]: renal US:
IMPRESSION: No hydronephrosis.
CT chest from [**6-25**]
Pulmonary nodules measuring up to 7 mm, for which a followup CT
in three to six months is recommended if the patient is high
risk for malignancy and 6 to 12 months if low risk for
malignancy based on [**Last Name (un) 8773**] study guidance.
Brief Hospital Course:
#. Severe, necrotizing gallstone pancreatitis: Resolved. Most
likely gallstone pancreatitis though LFT pattern not c/w
prolonged obstruction. Imaging at outside hospital demonstrated
the presence of stones in addition to common bile duct
dilitation. She was initially treated with meropenem which was
discontinued after several days. Surgery and ERCP services were
consulted and suggested supportive medical management of
pancreatitis. ERCP was deferred during acute disease state given
that no obstructing stones were identified on CT and RUQ U/S.
After acute disease state resolves, she will require lap
cholecystectomy or ERCP with sphincterotomy (in 2-3months).
#. Hypoxemic/hypercarbic Respiratory Failure: Resolved. Initial
episode of respiratory failure was thought to be due to ARDS, as
well as bilateral effusions and some vascular congestion,
suggesting volume overload in the setting of aggressive volume
resuscitation. After pt's pancreatitis started to improve, she
was aggressively diuresed and weaned off of sedation and the
ventilator. She did not have a cuff [**Last Name (LF) 3564**], [**First Name3 (LF) **] she was given
steroids for 24hrs and was ultimately extubated.
After extubation, pt was called out to general medical floor on
[**6-23**]. Within 24hrs, she developed worsening mental status and
increased work of breathing. She was found to be hypercarbic on
ABG. Despite aggressive diuresis and a trial of bipap, pt's CO2
did not improve, so she was re-intubated in the [**Hospital Unit Name 153**]. After
intubation, a bronchoscopy was performed that did not reveal any
evidence of lobar infiltrate consistent with aspiration or pna.
BAL cx was negative. A CTA was performed that revealed relative
[**Name (NI) 20534**] of [**Name (NI) **] consistent with ischemic changes, but no
thrombus was identified. LENIs were performed and did not
demonstrate any evidence of clot and echo did not show right
heart strain. She was also noted to have persistent bilateral
pleural effusions. Due to the fact that no definitive clot was
found and she clinically improved, a decision was made to not
anticoagulate. She was extubated on [**2141-6-28**], and approximately
15min after, she developed stridor and increased wob. She was
treated with steroids, racemic epinephrine and heliox for
presumed laryngeal edema. After several hours her respiratory
status improved and within 24 hrs she was weaned to nasal
cannula. Chest X-ray showed improvement in bilateral effusion
despite persistent ataelectasis. On discharge she was
comfortable at rest and with ambulation on room air.
#. Ventilator associated pneumonia: On [**2141-6-20**], she developed
worsening fevers and increased sputum production. Other sources
of infection were investigated (normal U/A, abdomen imaging
unchanged, no diarrhea), so she was empirically treated for VAP
with vancomycin, zosyn and ciprofloxicin. Pt completed a 8 day
treatment course for VAP. No current evidence of infectious
process
#. Acute renal failure: Thought to be AIN after being exposed to
cipro and zosyn, both of which can cause AIN. Renal U/S was
performed and did not reveal any signs of hydronephrosis. Pt's
cr continued to improve (last 1.2) and she continued to have
good urine output.
#. Tachycardia: Improved with treatment of acute disease and
with restarting her home verapamil and metoprolol (PCP confirmed
that both are for hypertension).
#. Insomnia/delerium: Was previously on olanzapine for steroid
vs. ICU induced delerium. She responded well however complained
of increased insomnia. Olanzapine was discontinued and Trazodone
was ordered.
#. Diabetes: She has had fluctuating blood sugars. Initial
hyperglycemia treated with SSI and lantus resulted in next day
hypoglycemia. Resolution of hypoglycemia achieved with D5W and
holding insulin. Hyperglycemic again on [**2141-7-2**] with glucose in
400s. She was continued on gentle HISS while NPO. She was
ultimately transition back to glargine and HISS. The diabetes
service saw the patient and also adjusted her insulin dosing.
#. Hypertension, benign: Held home amlodpine, lisinopril and
verapamil initially on admission. She was restarted on verapamil
and metoprolol.
#. Peripheral Vascular Disease:
- Continue home dose of ASA
# Anemia: Hct on admission in the 40's, now 23. Improved from
yesterday. Iron studies c/w anemia of CD with ferritin of 859.
Normocytic. LDH is elevated, but bili is normal and coags are
normal so hemolysis and DIC seem less likely causes.
-consider transfusion if hct <21
# Leukocytosis, thrombocytosis: Peaked on [**6-30**]. UA negative.
Afebrile. Suspect that this may have been related to aspiration
as her WBC and platelets are now improving.
. Access: PIV
. Prophylaxis: Heparin sub-Q 5000 Units TID for VTE prophylaxis.
. Precautions: None
. Communication: Patient, daughter [**Name (NI) 1787**] and Husband [**Name (NI) 24039**]
. Dispo: Pending clinical improvement
. CODE: Full (confirmed on this admission)
Transitional:
- cholecystectomy or ERCP with sphincterotomy in the future
- aspiration: on a dysphagia diet of ground solids and
nectar-thick liquids
- nutrition: continue tube feeds pending re-eval by nutritionist
- CT chest: Pulmonary nodules measuring up to 7 mm, for which a
followup CT in three to six months is recommended if the patient
is high risk for malignancy and 6 to 12 months if low risk for
malignancy based on [**Last Name (un) 8773**] study guidance.
- please uptitrate metoprolol to home dose (100mg)
- uptitrate lisinopril to 40mg as tolerated
- once diet is stable (and off TF) restart pt's outpatient
diabetes regimen (actos and metformin)
Medications on Admission:
Actos 15 mg daily
Amlodipine 2.5 mg daily
Aspirin 81 mg daily
Galantamine 8 mg daily with food
Lasix 20 mg PO daily
lisinopril 40 mg daily
Loratadine 10 mg daily
metformin 500 mg [**Hospital1 **]
Metoprolol tartrate 100 mg daily
omeprazole 40 mg daily
Pravastain 40 mg daily
Verapamil 240 mg daily
Medications on Transfer
Acetaminophen 650 PR q 4 PRN
Calcium gluconate 1,000 q 6 PRN
Heparin subQ
insulin aspart
meropenam 1 gram q 8 day 1 =[**6-14**]
levofloxacin 750 mg IV daily day 1 = [**2141-6-14**]
metoprolol 25 mg [**Hospital1 **]
morphine 4 mg q 4 hr PRN pain
ondansetron 4 mf q 8 PRN nausea
Pantoprazole 40 mg IV daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. galantamine 8 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
9. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
12. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day) as needed for constipation.
13. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
14. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
u Subcutaneous once a day.
17. insulin lispro 100 unit/mL Solution Sig: see attached
sliding scale Subcutaneous four times a day.
18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
19. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please administer until patient
is ambulation tid .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Pancreatitis
Cholelithiasis
Aspiration pneumonitis
Pneumonia, ventilator associated
Diabetes mellitus, type II
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with severe pancreatitis from gallstones. You
were treated supportively during this and you improved. You
required intubation (breathing tube) twice to support your
breathing. You were treated for pneumonia, acute kidney failure
and aspiration. You are now improving and being sent to an acute
rehabilitation facility.
In the future it will be important for you to have a
cholecystectomy (gall bladder removal) in [**2-10**] months, once you
have completely recovered from this hospitalization.
You will also need to have follow up imaging (CT scan) of your
lungs in 6 months given the pulmonary nodules found during this
admission.
Some of your medications have changed:
We have stopped actos and metformin. These were changed to
insulin while you were sick. Once you go home you can restart
these.
We have stopped amlodipine.
We have halved your lisinopril.
We have started trazodone, simethicone, senna, colace,
bisacodyl, insulin and lidocaine patch.
Followup Instructions:
Please schedule a follow up appointment with your primary care
doctor within 2 weeks of leaving rehab.
ICD9 Codes: 2724, 4439, 2768, 5070, 5845, 2760, 5119, 5180
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5509
}
|
Medical Text: Admission Date: [**2165-4-24**] Discharge Date: [**2165-4-30**]
Date of Birth: [**2165-4-24**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This is a 2185-gram infant
female, dichorionic-diamniotic, intrauterine insemination,
twin B, delivered by cesarean section to a 33-year-old
gravida 2, para 1 (now 3) mother.
PRENATAL SCREENS: B positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B surface antigen
negative, group B strep unknown.
Maternal history of hypothyroidism, nephrocalcinosis,
hypercholesterolemia. Medications: Ranitidine and Levoxyl.
DELIVERY ROOM COURSE: Cesarean section for increasing
discordance in growth between two infants. History of
oligohydramnios in twin one. This infant, twin B, in breech
position, transferred to warmer, blow-by oxygen given for
central cyanosis. Apgar scores were 7 at 1 minute and 8 at 5
minutes. The infant was transferred to Neonatal Intensive
Care Unit for management of prematurity.
PHYSICAL EXAMINATION ON PRESENTATION: Birth weight was 2185
grams (50th percentile), length was 46 cm (50th percentile),
and head circumference was 31 cm (50th percentile). Anterior
fontanel open, soft, and flat. Positive red reflex in both
eyes. A regular rate and rhythm. No murmurs. Bilateral
breath sounds were clear and equal. Grunting. The abdomen
was soft with positive bowel sounds. No hepatosplenomegaly.
A nonfocal neurologic examination.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The infant was initially placed on
continuous positive airway pressure of 6; requiring 30% to
40% oxygen. A chest x-ray was significant for hyalin membrane
disease, and the infant was intubated and received one dose of
surfactant. Maximal ventilator settings of 25/5 with a rate
of 22. The infant weaned significantly after surfactant was
given and was decreased to 21% FIO2. The infant was
extubated to room air on day of life two. The infant has
remained on room air throughout the rest of the
hospitalization with oxygen saturations of greater than 94%
and respiratory rates of 30s to 40s. The infant has not had
any apnea or bradycardia this hospitalization.
2. CARDIOVASCULAR SYSTEM: The infant has remained
hemodynamically stable this hospitalization. No murmurs.
Heart rate was 120 to 140.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant was
nothing by mouth and was receiving 80 cc/kg per day of D-10-W
until day of life two. The infant was started on enteral
feedings of breast milk, 20 calories per ounce at 30 cc/kg
per day, and advanced to full volume feedings by day of life
four. The infant has been receiving breast milk 20 calories
per ounce at a minimal of 120 cc/kg per day, plus breast
feeding and receiving all feedings orally. The infant
tolerated feeding advancement without difficulties.
The infant's most current weight was [**2187**] grams, head
circumference was 31 cm, and length was 47 cm.
Most recent electrolytes on day of life three revealed sodium
was 143, potassium was 4.2, chloride was 109, PCO2 was 25.
4. GASTROINTESTINAL ISSUES: Single phototherapy was
started on day of life three for a bilirubin of 9.5/0.3.
Phototherapy was discontinued on day of life four, and a
rebound bilirubin on [**4-30**] was 11.4/0.3. Another bilirubin
was recommended on day of life seven.
5. HEMATOLOGIC ISSUES: The infant did not receive any
blood transfusions during this hospitalization. The infant's
most recent hematocrit on day of life three was 56.9%.
Hematocrit on admission was 65%.
6. INFECTIOUS DISEASE ISSUES: Due to respiratory distress,
the infant was started on ampicillin and gentamicin on the
day of delivery. A complete blood count and blood culture
were also drawn at that time. The white blood cell count was
11.3, hematocrit was 65%, and platelets were 413,000 (with
different of 31 polys and 0 bands).
The infant received 48 hours of ampicillin and gentamicin.
Blood cultures remained negative to date.
7. NEUROLOGIC ISSUES: Normal neurologic examination.
8. SENSORY ISSUES: Hearing screening was recommended prior
to discharge.
9. OPHTHALMOLOGIC ISSUES: The infant did not meet criteria
for eye examination.
10. PSYCHOSOCIAL ISSUES: [**Hospital1 188**] Social Work involved with the family. The contact
social worker can be reached at telephone number
[**Telephone/Fax (1) 8717**]. The parents were involved.
CONDITION AT DISCHARGE: A former 34-3/7 week infant; now
35-2/7 week corrected, stable on room air.
DISCHARGE STATUS: Transferred to [**Hospital3 **] level
II nursery.
PRIMARY PEDIATRICIAN: Name of primary pediatrician is Dr.
[**Last Name (STitle) **] ([**Location (un) 2274**]).
CARE RECOMMENDATIONS:
1. Feedings at discharge: Breast milk 20 calories per
ounce, minimum 120 cc/kg per day orally.
2. Medications: None.
3. Car seat position screening recommended prior to
discharge.
4. State newborn screens were sent on day of life two; the
results were pending.
IMMUNIZATIONS RECEIVED: The infant has not received any
immunizations during this hospitalization.
DISCHARGE INSTRUCTIONS/FOLLOWUP: A hip ultrasound is
recommended (per AAP guidelines) after discharge.
DISCHARGE DIAGNOSES:
1. Prematurity; twin II, 34-3/7 weeks.
2. Status post respiratory distress.
3. Status post rule out sepsis.
4. Status post hyperbilirubinemia.
DR.[**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2165-4-30**] 09:23
T: [**2165-4-30**] 10:24
JOB#: [**Job Number 48761**]
ICD9 Codes: 769, 7742, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5510
}
|
Medical Text: Unit No: [**Numeric Identifier 63001**]
Admission Date: [**2101-12-5**]
Discharge Date: [**2101-12-28**]
Date of Birth: [**2101-12-5**]
Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] twin [**Known lastname **] II was born at 32-3/7 weeks
gestational age to 37-year-old G1, P0-2 mother. [**Name (NI) **] prenatal
screens were blood type O-positive, antibody screen negative,
hepatitis B negative, RPR nonreactive, rubella immune, GBS
unknown. Her pregnancy was notable for IVF, di-di twin
gestation, and advanced maternal age. Mother was admitted to
[**Hospital1 69**] for premature rupture of
membranes and preterm labor.
Dexamethasone was given 48 hours prior to delivery. Mother
was treated with ampicillin and erythromycin through the
delivery. Twins were delivered by cesarean section on [**2101-12-5**]. Baby boy twin [**Name2 (NI) **] was in breech presentation. He
emerged with weak cry. He was brought to warmer, dry,
suctioned, and stimulated. His Apgars were 7 at 1 minute and
8 at 5 minutes. He remained with mild-to-moderate respiratory
distress in delivery room. He was transported on blow-by
oxygen to the neonatal intensive care unit.
PHYSICAL EXAM ON ADMISSION TO NEONATAL INTENSIVE CARE UNIT:
Weight is 1,660 grams, head circumference 31 cm, length is 43
cm. Temperature on admission 97.5, heart rate 150, blood
pressure 58/34 with mean of 43, respiratory rate 64, oxygen
saturation is 92% on blow-by oxygen. His physical exam on
admission was remarkable for premature infant in mild-to-
moderate respiratory distress.
HOSPITAL COURSE BY SYSTEMS: Respiratory: On admission,
infant with mild-to-moderate respiratory distress. He was
placed on CPAP with good response. Chest x-ray consistent
with mild hyaline membrane disease. He remained on CPAP for
the 1st 48 hours. He weaned to room air on day of life 2. He
remained on room air since then. Baby [**Name (NI) **] [**Known lastname **] was observed
for signs of apnea of prematurity. He had no significant
spells through his hospital stay.
Cardiovascularly: Baby [**Name (NI) **] [**Known lastname **] remained clinically stable
with normal cardiac exam through his hospital stay.
FEN/GI: On admission, Baby [**Name (NI) **] [**Known lastname **] was made NPO. His
initial IV fluids were at 80 cc per kilogram. Feeds were
introduced on day of life 2. He quickly advanced to full
feeds by day of life 4. He was fed predominantly per NG tube
through his 1st week of life. He was able to switch to full
p.o. feeds on [**2101-12-25**].
At the moment of discharge, he is taking full p.o. feeds with
the minimum of 150 cc per kilogram. He is receiving breast
milk, Enfamil supplemented with Enfamil powder to 24 calories
per ounce. He demonstrated stable weight gain through his
hospital stay. His discharge weight is 2,110 grams. He was
observed for signs of hyperbilirubinemia during his hospital
stay. His bilirubin peaked at 6.9/0.3 on day of life 4. No
phototherapy was started.
Hematology: His initial CBC was reassuring with 11.9 thousand
white blood cells, 51 polys, 1 band. His hematocrit was 45.6
and platelets were 283,000. No blood transfusions were given.
Infectious disease: Due to maternal history, Baby [**Name (NI) **] [**Known lastname **]
[**Name2 (NI) **] was started on antibiotics on admission to the NICU. His
blood cultures remained negative, and ampicillin and
gentamicin were discontinued at 48 hours. He remained without
any signs of infection through his hospital stay.
Neurology: His exam remains stable through his hospital stay.
Sensory: Hearing screen was done on [**2101-12-27**], and it
was referred bilaterally. The follow-up hearing screen
scheduled for [**2101-12-28**] and pending.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home. Patient's primary
care doctor is at [**Hospital 1426**] Pediatrics.
FEEDS AT DISCHARGE: Breast milk, Enfamil supplemented to 24
calories per ounce with Enfamil powder.
MEDICATIONS: Ferrous sulfate 0.15 cc p.o. once a day.
CAR SEAT POSITION SCREENING: Car seat test was done on
[**12-27**], and the patient passed car seat test.
STATE NEWBORN SCREEN: Normal.
VACCINATIONS: Hepatitis B vaccine was given on [**2101-12-27**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following criteria: 1. Born at less than 32 weeks;
2. Born between 32 and 35 weeks with 2 of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-age
siblings; or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS: Recommended with primary care
doctors [**Last Name (NamePattern4) **] 7 days after discharge.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Hyaline membrane disease resolved.
3. Sepsis ruled out resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Last Name (STitle) 62635**]
MEDQUIST36
D: [**2101-12-28**] 08:19:44
T: [**2101-12-28**] 08:50:51
Job#: [**Job Number 63002**]
ICD9 Codes: 769, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5511
}
|
Medical Text: Admission Date: [**2103-8-10**] Discharge Date: [**2103-9-26**]
Date of Birth: [**2063-11-9**] Sex: F
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8841**]
Chief Complaint:
Confusion, nausea, vomiting, headache
Major Surgical or Invasive Procedure:
Ventriculostomy
Ventriculoperitoneal shunt placement
Intrathecal Vancomycin
History of Present Illness:
39F transferred from [**Hospital **] Hospital for evaluation of multiple
brain lesions. Pt had been well until approx 1 month prior to
admission when she travelled to [**Country 651**] via [**Location (un) 6847**] and [**State 8842**].
Patient states that she first noticed problem when "it felt odd
when my children touched my left leg". Denied pain, pins and
needles, loss of bladder/bowel control. Following one week in
[**State 8842**], the pt began to have LBP (no prior hx). Pain was over
the spine at L3-4 level w/o radiation. Several days later the pt
developed severe headache w/ nausea and vomiting. On return to
the U.S., she noted confusion mostly in regards to getting lost
and forgetting what she was doing. Presented to [**Hospital **]
hospital where she was noted to have multiple brain lesions on
CT, lung mass, liver mass, bony lesions, transferred for further
eval. Denies F/C/visual changes/or weakness.
Past Medical History:
[**Last Name (un) **] diabetes
Social History:
Denies smoke/drink/drugs
Married, two children
Trained as M.D., microbiologist at [**Hospital1 2025**].
Family History:
Non-contributory
Physical Exam:
97.1 99/60 71 18 98% RA
General: No acute distress
HEENT: PERRLA. EOMI. no nystagmus. anicteric oropharynx clear.
Neck: no cervical/sm/sc la noted
Cardiovascular: Regular S1, S2. no m/r/g
Lungs: Clear to auscultation bilaterally
Breast: Negative for masses/nodules
Abdomen: Bowel sounds present, soft, nontender nondistended,
hepatomegaly (~9cm) No splenomegaly.
Extremities: No c/c/e. No palmar erythema noted.
Neuro: CN III-XII intact
2+DTR's b/l
[**5-30**] ue, [**4-30**] le b/l
Mild past pointing on finger
Mentating clearly, able to do days of the week backwards
Pertinent Results:
At [**Hospital **] Hospital:
WBCC 10..1, hct 37.0, plt 186, mcv88
diff n76, l15,
inr 1.1, ptt 26.3
alb 3.5 tbili 0.8, ld 584, ap 219, ast 36, alt 52, cea 17.8
CXr: rounded density in LUL and L hilar enlargement
CT chest: soft tissue mass in L apex extending to hilum abutting
L main PA and L main bronchus. L hilar adenopathy. three mm r
lung nodule.
CT abd/pelvis: Lobulated mass in L hepatic lobe 7.5x3.2cm,
suspicious for mets, no splenomegaly, no adrenal mets.
CT head: numerous cerebral and cerebellar mass lesions c/w mets.
MRI head: innumerable ring enhancing lesions, largest on R
2.8x2.2 cm, largest on L is 2.5x1.8. In cerebellum, 2.8x2.4cm.
Midline shift to L. Some lesions demonstate surrounding
vasogenic edema.
----
[**Hospital1 18**]
ECG: Sinus at 84 w/ L axis deviation. Nl intervals. No st-tw
abnormalities.
[**2103-8-10**] 09:30AM GLUCOSE-334* UREA N-15 CREAT-0.6 SODIUM-135
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18
[**2103-8-10**] 09:30AM ALT(SGPT)-68* AST(SGOT)-38 LD(LDH)-762* ALK
PHOS-286* TOT BILI-0.3
[**2103-8-10**] 09:30AM ALBUMIN-4.1 CALCIUM-8.5 PHOSPHATE-2.8
MAGNESIUM-2.1
[**2103-8-10**] 09:30AM WBC-16.6* RBC-4.25 HGB-12.8 HCT-37.4 MCV-88
MCH-30.0 MCHC-34.2 RDW-12.5
[**2103-8-10**] 09:30AM PLT COUNT-253
[**2103-8-10**] 09:30AM PT-13.4* PTT-26.6 INR(PT)-1.2
---
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2103-8-13**] 3:27 PM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Evaluate lesions
[**Hospital 93**] MEDICAL CONDITION:
39 year old woman with no PMH found to have multiple enhancing
lesions on MR at outside hospital.
REASON FOR THIS EXAMINATION:
Evaluate lesions
INDICATIONS: Enhancing lesions on outside MRI. Left upper lobe
mass, liver mass and lytic lesions of the spine.
MRI OF THE BRAIN WITHOUT CONTRAST:
TECHNIQUE: Multiplanar pre and post contrast T1W images, axial
T2W, susceptibility, and FLAIR images were obtained.
FINDINGS: There are innumerable areas of susceptibility effect
in the cerebellum and cerebrum, many associated with T1
hyperintensity. The lesions enhance peripherally. Many are
located at the [**Doctor Last Name 352**]/white matter junction. Others lie in the
right lentiform nucleus on thalamus. There is a lesion in the
dorsal left mid brain on the lateral claviculi. Given the
history, they are most likely hemorrhagic metastases.
Largest lesion is in the left cerebellar hemisphere measuring
approximately 2.6 cm in maximum dimension. There are 2.3 cm
lesions in the lateral left frontal lobe, the medial right
parietal lobe and the right lentiform nucleus. There is
vasogenic edema, particularly prominent in the parietal white
matter, the right posterior temporal region and the right
cerebellar hemisphere. There is some shift of septum pellucidum
towards the right left. There is minimal right sided mass effect
in the fourth ventricle. There is no hydrocephalus. Some of the
sulci are effaced. The right cerebellar tonsils displace
slightly inferiorly into the foramen magnum.
There is also a 16 mm peripherally enhancing pineal mass,
probably also a metastases in an unusual location.
IMPRESSION: There are innumerable lesions in the brain
parenchyma with associated blood break down products and
enhancement most consistent with multiple metastases. The
largest are on the order of 2.5 cm in size. There is some shift
of the septum pellucidum towards the left but no dilatation of
the ventricular system. There is a large right cerebellar lesion
with some edema but only minimal mass effect on the fourth
ventricle. An unusual peripherally enhancing pineal mass is
noted, probably also a metastases. The outside study is not
available for comparison.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2103-8-21**] 9:44 PM
---
CT ABD W&W/O C [**2103-8-11**] 5:08 PM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: Possibility for tissue sample, either via bronchoscopy
or li
Field of view: 30 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
39 year old woman with multiple cerebral lesions, l lung lesion,
and large liver mass.
REASON FOR THIS EXAMINATION:
Possibility for tissue sample, either via bronchoscopy or liver
biopsy.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Multiple cerebral lesions, left lung lesion, large
liver mass.
COMPARISON: Outside CT from [**2103-8-9**].
TECHNIQUE: Helically aquired contiguous axial images were
obtained from the lung apices through pubic symphysis following
the administration of 150 cc of IV Optiray. Nonionic contrast
was used secondary to patient debilitation. Multiphasic images
of the liver were also obtained.
CT CHEST WITH IV CONTRAST: Within the apex of the left upper
lobe, there is an ill defined mass present, measuring 2.4 x 3.2
cm. Contiguous with this mass and just inferior to it are
several, smaller, ill defined nodules within the left upper lobe
and left hilar region, the largest of which measures 1.5 x 1.2
cm. Additionally within the right middle and right lower lobes,
there are at least four, 1-2 mm, noncalcified pulmonary nodules
identified. There is narrowing of the left upper lobe bronchus
by the left hilar mass. Otherwise, the airways are patent to the
level of the segmental bronchi bilaterally. An enlarged
prevascular lymph node is identified adjacent to the aorta
measuring approximately 11 mm. An ill defined left hilar mass is
identified which appears to consist of a conglomeration of
smaller pulmonary parenchymal nodules and left hilar lymph
nodes, which narrows the left upper lobe bronchus. No other
pathologically enlarged axillary lymphadenopathy is seen. The
heart, pericardium and great vessels are unremarkable. No
pleural or pericardial effusion is present.
CT ABDOMEN W/O&W IV CONTRAST: Within the left lateral segment of
the liver, there is a large, heterogeneously enhancing mass
present which measures approximately 4.0 x 7.7 cm. Within the
dome of the right lobe of the liver, there is a second,
enhancing, low attenuation lesion present measuring 2.1 x 1.3
cm. Multiple, smaller, heterogeneously enhancing, low
attenuation lesions appear to be present throughout the liver,
findings suggestive of innumerable metastatic lesions. There is
no intrahepatic biliary duct dilatation. The portal vein is
patent. The gallbladder, pancreas, spleen, adrenal glands,
kidneys, ureters, stomach, and loops of large and small bowel
are all within normal limits. There is no free air or free
fluid. There is no significant mesenteric or retroperitoneal
lymphadenopathy.
CT PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, uterus,
adnexa, distal ureters, and bladder are all within normal
limits. There is no free fluid. There is no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: Multiple lytic lesions are noted within the T6,
T12, L2, and L4 vertebral bodies with the most destructive
changes noted within the L4 vertebral body. No definite
extension into the spinal canal is present. Additionally a lytic
lucency is identified within the posterior right iliac [**Doctor First Name 362**].
IMPRESSION:
Large ill defined mass within the left upper lobe of the lung
concerning for a primary neoplastic process. Heterogeneously
enhancing low attenuation lesions within the liver as well as
lytic lesions within the bones are concerning for hepatic and
osseous metastases. The large mass within the left lateral
segment of the liver would be amenable to ultrasound guided
biopsy.
The findings have been discussed with Dr. [**Last Name (STitle) **] on [**2103-8-11**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**First Name8 (NamePattern2) 8843**] [**Location (un) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: MON [**2103-8-13**] 2:17 PM
---
SPECIMEN RECEIVED: [**2103-9-21**] [**-4/3309**] SPINAL FLUID
SPECIMEN DESCRIPTION: Received 1ml cloudy fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: None provided.
PREVIOUS BIOPSIES:
[**2103-8-13**] [**-4/2774**] LIVER MASS
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DIAGNOSIS: POSITIVE FOR MALIGNANT CELLS.
Rare atypical cells present, consistent with metastatic
carcinoma.
Note:
Previous cytology slides of liver FNA (C04-[**Numeric Identifier 8844**]) were
reviewed. Cytologic features of rare malignant cells seen
in CSF specimen are similar to that of liver FNA specimen.
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] notified of the diagnosis by Dr. [**Last Name (STitle) **]. [**Doctor Last Name 8845**] via
e-mail on [**2103-9-24**].
DIAGNOSED BY:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8846**], CT(ASCP)
[**Name6 (MD) 8847**] [**Name8 (MD) **], M.D.
[**First Name11 (Name Pattern1) 2127**] [**Last Name (NamePattern1) **], M.D.
---
[**Last Name (NamePattern1) **]
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2103-9-26**] 09:35AM 3.4* 3.07* 9.9* 29.8* 97 32.4* 33.4 17.9*
98*
[**2103-9-25**] 08:00AM 3.1* 3.15* 10.1* 30.1* 95 31.9 33.4 17.6*
102*
BASIC COAGULATION PT PTT Plt Ct INR(PT)
[**2103-9-26**] 09:35AM 98*
[**2103-9-25**] 08:00AM 102*
[**2103-9-25**] 08:00AM 12.01 25.8 0.9
1 NOTE NEW NORMAL RANGE AS OF 12AM OF [**2103-9-4**]
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2103-9-26**] 09:35AM 111* 13 0.4 140 3.8 103 26 15
[**2103-9-25**] 08:00AM 109* 16 0.4 140 3.2* 103 26 14
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2103-9-26**] 09:35AM 8.3* 3.6 1.8
[**2103-9-25**] 08:00AM 8.3* 5.1* 1.9
---
CT HEAD W/O CONTRAST [**2103-9-22**] 10:31 PM
Reason: Any hydrocephalus or indication of shunt malfunction?
[**Hospital 93**] MEDICAL CONDITION:
39 year old woman with nsclc mets to brain, s/p VP shunt 2 days
ago now with fairly severe HA for several hours.
REASON FOR THIS EXAMINATION:
Any hydrocephalus or indication of shunt malfunction?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Severe headache for several hours, status-post VP
shunt two days ago, metastatic non-small cell lung cancer to
brain.
Comparison is made to the prior CT scan dated [**2103-9-17**].
TECHNIQUE: Noncontrast head CT.
FINDINGS: There is again demonstrated a small amount of residual
intraventricular hemorrhage in the left occipital [**Doctor Last Name 534**] of the
lateral ventricle. There has been interval removal of the
right-sided intraventricular drain with a small amount of
hemorrhagic products along the course of the prior drain. There
has been interval placement of a left-sided intraventricular
drain with the tip in the frontal [**Doctor Last Name 534**] of the left lateral
ventricle. There are again demonstrated innumerable metastatic
brain lesions. The ventricles, sulci and cisterns are unchanged
in configuration. There is no shift of normally midline
structures or hydrocephalus. The visualized paranasal sinuses
and osseous structures are unremarkable. Skin staples are seen
overlying the course of the VP shunt.
IMPRESSION:
1. Interval placement of VP shunt with removal of prior right
intraventricular drainage. A small amount of hemorrhage products
are noted along the course of the prior drainage catheter.
2. Otherwise stable appearance of the brain with innumerable
brain metastases.
Brief Hospital Course:
39F recent onset of paresthesias, low back pain, headache
accompanied by nausea and vomiting, and confusion, transferred
from outside hospital, with multiple intracranial, pulmonary,
bony, and hepatic masses.
1) Altered mental status associated with multiple intracranial
masses:
Patient was transferred to [**Hospital1 18**] on [**8-10**]. Diagnosis of
metastatic large cell lung cancer was made by ultrasound guided
liver biopsy, and multiple metases noted throughout spine and
brain by MRI (L spine metases, loss of L4 disc space, foraminal
narrowing; multiple enhancing lesions in brain, largest of 2.5
cm with hemorrhage).
Carboplatin/Taxol chemotherapy was administered, however, over
several days, patient began to have decreased level of
consciousness, increased headache, nausea, and vomiting with no
relief from narcotics or acetaminophen. On day 4 following
chemotherapy, patient became unresponsive to verbal stimuli and
somnolent with decreased tone; this was thought to be possibly a
non-convulsive status event. CT head at the time indicated new
metastases, effacement of sulci and herniation into the foramen
magnum.
Patient was given a bolus of 10mg decadron q6hours, and
transferred to the ICU for q1hour neuro checks. Patient was
administered whole brain radiation therapy (total dose 2,000
cGy). A right frontal EVD was placed, and mannitol and decadron
were administered to reduce edema and increased intracranial
pressure. Mental status/neurolic function slowly improved with
increased response to commands and increased amount of
communication. However, over the next several days, it was
determined that the EVD was infected with coagulase negative
staphylococcus, which was treated with both intravenous and
intraventricular Vancomycin until cultures from CSF were
negative for seven consecutive days. The EVD was then removed
and a ventriculoperitoneal shunt was placed without
complication.
The patient's mental status continued to improve and at the time
of discharge, decadron had been weaned to 4mg QD. The patient
was placed on a regiment of Keppra 750 [**Hospital1 **] to maintain seizure
prophylaxis.
2) Metastatic lung cancer: Although it was felt that the patient
had an overall poor prognosis, it was felt that she may still
benefit from a palliative standpoint from aggressive treatment.
Completed one cycle of [**Doctor Last Name **]/Taxol (as above). Was scheduled
for repeated chemotherapy but delayed due to EVD infection. The
patient was started on Iressa (EGFR inhibitor) 250mg qd, since
shown to have some benefit in metastatic lung Ca to brain as 2nd
line [**Doctor Last Name 360**] to chemo/XRT.
3) Non-sustained ventricular tachycardia: Had multiple runs of
NSVT and was started on amiodarone infusion. Evaluated by
Cardiology who felt that the rhythm was polymorphic, and likely
catecholamine mediated VT which would be best treated with a
beta-blocker. Amiodarone was discontinued. Felt to be NOT a
candidate for ICD given her metastatic disease. Also felt to
have some component of Brugada syndrome (but does not strictly
meet criteria for this). At the time of discharge, patient's
blood pressure and heart rate were stable without ectopy, and
patient was discharged on 25mg Metoprolol [**Hospital1 **].
4) Hyperglycemia: Likely steroid-induced. Diabetic diet
initiated with good glucose control. Sliding scale insulin
administered while on daily decadron to good effect.
5) Pain control: Patient was continuing to have headaches
despite recovery of her mental status. Repeat head CT showed
residual blood in the ventricles, likely from removal of the
EVD. It was felt that her headaches were likely due to this
residual blood, and that the VP shunt was still patent and
functioning. Patient's pain was fairly well controlled with
morphine PCA, then converted to Oxycontin with oxycodone for
breakthrough pain.
6) Patient will follow up with Neurosurgery the day after
discharge.
Medications on Admission:
Meds at Home:
OCP
Meds on Transfer:
Decadron 4mg po q6
Protonix 40mg po qd
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 QD (once a day) as needed.
3. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. IRESSA 250 mg Tablet Sig: One (1) Tablet PO once a day ().
5. Kaolin-Pectin 5.85-0.13 g/30 mL Suspension Sig: 30-60 MLs PO
PRN (as needed) as needed for give with stools.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Psyllium 58.6 % Packet Sig: One (1) Packet PO TID (3 times a
day) as needed.
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
11. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Ondansetron HCl 2 mg/mL Solution Sig: [**1-26**] Intravenous Q6H
(every 6 hours) as needed for nausea.
14. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
15. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Units Injection ASDIR (AS DIRECTED).
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for RR<10, SBP<110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Metastatic non Small Cell Lung Cancer
(Liver, Brain, and Bone metastases)
Central Nervous System Infection
Discharge Condition:
Good
Discharge Instructions:
1) Follow up with your neurosurgeon tomorrow as directed.
2) Continue taking your medications as directed.
3) If you have fever, chills, extreme headache, weakness,
seizures, or confusion, call your doctor who will decide if you
should come to the emergency room. Some headache is to be
expected, and you should take your pain medication. However, if
it associated with mental status changes or weakness, you should
call your doctor immediately ([**Telephone/Fax (1) 1669**]).
4) Continue to follow up with your primary care physician,
[**Name10 (NameIs) 5564**], and neurosurgeon as directed.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] (Neurosurgery) [**Last Name (NamePattern1) **].
Date/Time:[**2103-9-27**] 11:00 AM. [**Telephone/Fax (1) 1669**]
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2103-10-4**] 8:30
Provider: [**Name10 (NameIs) 8848**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9 Where: [**Hospital 4054**] [**Hospital **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2103-10-4**] 8:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 8849**]
ICD9 Codes: 431, 4271
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5512
}
|
Medical Text: Admission Date: [**2157-2-23**] Discharge Date: [**2157-3-4**]
Date of Birth: [**2157-2-23**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 35227**] was born at 32
and 1/7 weeks gestation. She was born to a 41-year-old G5,
P2, now 3 woman with past OB history notable for full term
normal vaginal delivery x2, in [**2138**] and [**2139**]. Both babies
alive and well. A TAB for trisomy 21 in [**2154**] and an SAB in
[**2155**].
PAST MEDICAL HISTORY: Notable for a LEEP procedure in [**2154**]
for HSV (on Valtrex suppressive therapy with no active
lesions during pregnancy).
Prenatal screens: blood type A negative, status post RhoGAM,
DAT negative, HBSAG negative, RPR nonreactive, rubella
immune, GBS unknown.
Antenatal history: The [**Last Name (un) **] was [**2157-4-19**] for an estimated
gestational age of 32 and 1/7 weeks at delivery. This
pregnancy was complicated by cervical incompetence with
cerclage placement at 16 weeks gestation, and premature
prolonged rupture of membranes approximately 12 hours prior
to delivery. Quadruple screen, full fetal survey, and
amniocentesis were both normal. Cerclage was removed on the
day of delivery and a cesarean section was performed for
footling breech presentation. There was no interpartum fever
or other clinical evidence of chorioamnionitis, but the
antibiotics were administered for latency.
Neonatal course: The infant was vigorous at delivery. She was
orally and nasally bulb suctioned, dried and received brief
supplemental free flow oxygen. Apgars were 7 at 1 minute, and
8 at 5 minutes.
PHYSICAL EXAMINATION: A well appearing moderately preterm
infant. Birth weight of 1790 grams which is 50th percentile;
length of 42 cm which is 50th percentile; head circumference
of 30 cm which is 50th percentile. HEENT: Anterior fontanel
soft and flat. Nondysmorphic, intact palate, neck and mouth
normal. Normocephalic. No nasal flaring. CHEST: No
retractions. Good breath sounds bilaterally. No adventitious
sounds. CARDIOVASCULAR SYSTEM: Well perfused. Normal rate and
rhythm. Femoral pulses normal. Normal S1 and S2 without
murmurs. ABDOMEN: Soft, nondistended. No organomegaly. No
masses. Bowel sounds active. Patent anus. GENITOURINARY:
Normal female genitalia. CNS: Active, alert, responsive to
stimulus. Tone is appropriate for gestational age and
symmetric. Normal suck, gag and root reflexes.
INTEGUMENTARY: Normal. MUSCULOSKELETAL: Normal spine, limbs,
hips and clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The
infant came to the NICU having mild retractions, was on room
air and has remained on room air for entire stay in the NICU.
She has had occasional spells. She has not been started on
any methylxanthine therapy and has approximately 3 to 4
spells per day. All are mild, quick self resolved, not
requiring any intervention.
CARDIOVASCULAR: On day of life the infant had an abnormal
vascular event which while at rest the infant presented with
left sided pallor and no palpable femoral pulse or pedal
pulse at that time. This episode was while at rest and some
pallor and cyanosis across the midline on the abdomen and
back of the infant and buttocks. The infant has never had any
central line. The infant was treated with a normal saline
bolus for this episode presuming some hypovolemia at the time
and it did resolve within 15 to 20 minutes of time. Due to
this episode an EKG ws done which was found to be normal and
that was on day of life 2 also. An echocardiogram with
cardiac consult was done. The echocardiogram showed an
aneurysmal septum primum with left to right patent foramen
ovale. No significant valvar dysfunction. No patent ductus
arteriosus. Qualitatively mildly depressed left ventricular
systolic function. The infant has presented with no further
such episodes. There is no audible murmur and nor has there
been one. There is normal heart rate and rhythm and blood
pressures consistently. There was also no blood clot noted on
the echocardiogram.
FLUIDS, ELECTROLYTES AND NUTRITION: IV fluids were initiated
on admission to the NICU. The infant received a total of 2
boluses of normal saline shortly after admission for
decreased perfusion at the vascular event. Enteral feedings
were initiated on day 3 of life. The infant received full
volume feedings on day of life 6. He is presently all PG
feeds of breast milk 24 calorie per ounce at 150 ml per kg
per day. His most recent weight is 1660 grams on [**2157-3-3**]. His most recent set of electrolytes was on [**2157-2-26**], with sodium of 143, K of 4.2, chloride 109, CO2 of 21.
GASTROINTESTINAL: The infant has ongoing issues of
hyperbilirubinemia and is presently under phototherapy and
has received a total of 3 days of phototherapy, initially a 2-
day course of phototherapy. The bilirubin level continued to
climb after the rebound. The most recent bilirubin level on
[**2157-3-3**], was 12.1/0.3 and phototherapy was restarted
at that time. Follow up bilirubin level was drawn on [**2157-3-4**], and the result is 10.3/0.3. There have been no
further GI issues.
HEMATOLOGY: CBC was screened on admission to the NICU.
Hematocrit was 54.2, platelet count of 225,000, no further
hematocrits have been measured. Follow up platelet count was
done on day of life 2 looking for hemolytic issue related to
the vascular event. PT was 16.6, PTT was 57.3. The fibrinogen
was 174. No further hematologic tests have been done. The
infant has a blood type of O positive and Coombs negative.
INFECTIOUS DISEASE: CBC and blood culture were screened on
admission due to the premature rupture of membranes. CBC
showed a white blood cell count of 7.9000 with 19 poly's, 0
bands and 54 lymphs. The infant received 48 hours of
ampicillin and gentamycin which were subsequently
discontinued when the blood culture remained negative at 48
hours and the clinical status improved.
Also due to mother's history of HSV, although latent during
this pregnancy, HSV surface cultures were done on this infant
and found to be normal.
NEUROLOGY: The infant has maintained a normal neurological
examination for gestational age and has had no cranial
imaging done.
AUDIOLOGY: A hearing screen has not been performed thus far
but will need to be done prior to discharge from the
hospital.
PSYCHOSOCIAL: A [**Hospital1 18**] social worker has been involved with
the family. There are no active ongoing issues at this time.
If there are any concerns she can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to [**Hospital 1474**] Hospital level
II nursery.
NAME OF PRIMARY PEDIATRICIAN: Undecided.
CARE RECOMMENDATIONS:
1. Feeds at 150 ml per kg per day PG, to start PO when ready
and advance calories beyond 24 cal/oz as needed.
2. Medications: None at this time but will need iron and
multivitamins should be initiated soon.
3. Car seat position screening has not been done on this
infant thus far.
4. State newborn screen was sent on [**2157-2-27**], and
results are pending.
5. Immunizations received: The infant has received no
immunization thus far.
6. Immunizations Recommended:
7. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the
following:
daycare during the RSV season,
a smoker in the household,
neuromuscular disease,
airway abnormalities,
or school age siblings
3. with chronic lung disease.
11. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
The infant was in breech position and will need followup hip
ultrasound as an outpatient.
DISCHARGE DIAGNOSES:
1. Prematurity, born at 32 and 1/7 weeks gestation, now
adjusted age of 33 and 3/7 weeks gestation.
2. Apnea of prematurity, ongoing.
3. Sepsis, ruled out.
4. Cardiac abnormality, ruled out.
5. Breech.
6. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2157-3-3**] 23:29:54
T: [**2157-3-4**] 00:25:13
Job#: [**Job Number 72447**]
ICD9 Codes: 7742, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5513
}
|
Medical Text: Admission Date: [**2201-2-14**] Discharge Date: [**2201-2-23**]
Date of Birth: [**2146-4-3**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Aspirin / Codeine / Lipitor
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
1. Right Femoral Line
History of Present Illness:
54F w/HTN, CAD s/p CABG, MV repair, AVR on coumadin, hemolytic
anemia [**12-31**] valve s/p mechanical fall with trauma to leg and
chest in setting of elevated INR 6.7 (checked at PCPs office)
admitted 2 days after fall with persistent L knee pain and
hematoma on head/L chest wall. On admission, patient's INR had
fallen to 2.7; however, given fall in setting of elevated INR,
but had a trauma evaluation including CT head, spine, Abd/pelvis
and LLE without evidence of bleed or fracture. At the time, she
was admitted for pain control and monitoring of hematocrit
(34.6-->31.9). Of note, patient has a h/o HTN; on admission was
noted to have low BPs (usual SBP 140-160s, on admission SBP
100), but was asymptomatic (no LH/dizziness/CP/SOB/fatigue).
Past Medical History:
CAD LVEF > 50% s/p CABG '[**95**] and stents
AVR '[**95**]; MV ring-annuloplasty
HTN
Hyperlipidemia
Hypothyroidism [**12-31**] iodine tx for [**Doctor Last Name 933**] dz
Depression with psychosis
Discoid lupus
PTSD
H/o carcinoid s/p resection in '[**73**]
COPD
TAH b/l SBO
Hemolytic anemia [**12-31**] AVR
Migraine
T9-T10 disk herniation
Social History:
no ETOH, smokes 1ppd.
Family History:
Father, healthy, in his 80s. Mother, 73, deceased, had DM HTN.
Sister died at age 47 from MI. Brother died from liver
cirrhosis.
Physical Exam:
96.1, 103, 95-117/66-80, 18, 100%RA
GENL; mildly uncomfortable
HEENT: CN II-XII grossly in tact, OP clear, no thyromegaly
CV: RRR +click, +systolic murmur
Lungs: CTA
ADB: obese, nt, nd, +bs
EXT: tender R knee and R lower leg. Most tender in popliteal
fossa. Able to minimally bend knee to 20 degress lmtd by pain.
Also has pain with passive motion. 2+ distal pulses. Non
erythematous.
Pertinent Results:
Admission Labs:
[**2201-2-14**]: 1:15pm Hct 34.6
[**2201-2-15**]: 07:00am Hct 31.9, INR 2.9, PTT 42.1
[**2201-2-15**]: 6:00pm Hct 30.0
*
Chemistries: GLUCOSE-94 UREA N-21* CREAT-1.4* SODIUM-134
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
*
Radiologic Studies-
CT left knee: No evidence of hemarthrosis or fracture of the
left knee.
*
CT head: No acute hemorrhage or mass effect.
*
C-Spine: 1) No fracture or malalignment 2) Multilevel
degenerative changes.
*
CT abd/Pelvis: No evidence of acute traumatic injury on limited
noncontrast evaluation.
*
Femur/Tib Fib Plain Films: Negative for fracture
*
CXR PA/LAT [**2-17**]: Bilateral plate-like atelectasis at the lung
bases, left greater than right. Underlying pneumonia within
atelectatic lung cannot be excluded.
*
CXR PA/LAT [**2-19**]: No signs of acute or chronic parenchymal
infiltrates are present and the lateral and posterior pleural
sinuses are free. The on previous examination, ([**2-17**]) identified
bilateral plate atelectasis have resolved completely.
*
ECHO: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. LVEF>50%. mechanical aortic valve
prosthesis is present. The transaortic gradient is normal for
this prosthesis. Trace aortic regurgitation is seen. [The amount
of regurgitation present is normal for this prosthetic aortic
valve.] The mitral valve leaflets are mildly thickened. A mitral
valve annuloplasty ring is present. There is a minimally
increased gradient consistent with trivial MS. [**Name13 (STitle) **] MR. Moderate
[2+] TR. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion
Brief Hospital Course:
54 y/o female with CAD, mechanical AVR, MVannuloplasty, on
coumadin, who was admitted for pain control s/p fall with
hospital course c/b hypotension and hematocrit drop of unclear
etiology requiring [**Name (NI) 153**] overnight observation. Subsequently
remained hemodynamically stable.
1. Hypotension: On admission the patient was found to have a
blood pressure in 100's systolic. She was otherwise asymptomatic
(no lightheadedness, dizziness, dyspnea or chest pain). However,
of concern is that she normally has poorly controlled
hypertension and she remained with low systolic BP's off all
anti-hypertensives. Aggressive work up was performed to rule out
bleed given her recent fall. She was guaiac negative on exam. CT
scan of the thigh and pelvis were performed which showed no
evidence of bleed. CT head on admission was also negative for
bleed. It was suspected that her hypotension might be secondary
to opiate analgesics she recieved on admission, therefore opioid
analgesics were discontinued. However BP's remained low. SBP
decreased to the 80's-90's and she was given NS prn boluses to
maintain BP >100. She initially responded well to boluses, but
SBP then fell to 70's systolic. During her hospitalization, her
BPs remained on the low side and required prn NS boluses. Her
hematocrits were also being followed. Afternoon of [**2-17**], patient
was found to have a SBP 70s. Patient awake/alert but diaphoretic
and given 250cc NS bolus. Had an EKG which showed a new RBBB.
Right femoral line placed and given 2L NS but SBP remained in
the 80s with good UOP (1000cc after foley placed). Given her
history of significant cardiac disease and new RBBB, cardiology
was consulted and a stat bedside echo was performed to r/o
cardiogenic shock, which was unchanged from prior echo. Pt was
transferred to the [**Hospital Unit Name 153**] for hemodynamic monitoring.
In the [**Hospital Unit Name 153**], hematocrit that was checked showed drop 29.7 to
25.9. Etiology of hematocrit drop was unclear as on admission
patient had full work up which was negative for hematoma. [**Hospital Unit Name 153**]
team wanted to perform an NG lavage to r/o GI bleed, but patient
did not want this done. She was transfused 1 upRBC. (Of note,
she developed T 103 mid-transfusion; blood was sent for
transfusion reaction. She was later transfused a full unit of
RBCs). Despite low BPs, patient continued to mentate and have
brisk UOP, suggesting adequate end organ perfusion. She had a
[**Last Name (un) 104**] stim test to r/o adrenal insufficiency as cause for her
hypotension, which was normal. Pt did have a mild temperature
and sepsis was entertained as possible etiology of hypotension.
CXR showed vague RLL infiltrate, and she was started on empiric
vancomycin/levofloxacin pending culture data. She remained
stable overnight, with stable blood pressure and hematocrit and
was transferred back to the medicine service.
On return to the medicine service her blood pressures gradually
normally, trending upwards to 120's systolic of
anti-hypertensives. Her blood pressure meds may be re-started as
outpatient as her BP/HR tolerates. She subsequently remained
afebrile and HD stable, with cultures negative, suggesting
against infectious etiology of her hypotension. In addition,
repeat CXR PA and Lat showed resolution of vague RLL infiltrate.
Vancomycin was discontinued and she will complete a seven day
course of levofloxacin on [**2-24**].
2. Anemia- The patient has a noted history of hemolysis
secondary to mechanical valve. Her LDH on admission was mildly
elevated w/ Haptoglobin less than 20. However, her levels were
not significantly elevated from baseline to suggest this as the
cause of her acute hematocrit drop. As mentioned she had no
evidence of bleed by multiple CT studies. Her hct drop may have
been dilutional secondary to recieving aggressive IVF repletion
with her hypotension. Following her transfusion in the ICU, her
hematocrit remained stable at 30 and she required no further
transfusions.
3. Mechanical AVR-Given her risk of thrombosis, in setting of no
obvious bleeding, she was re-started on anti-coagulation. She
was started on IV heparin since her INR was sub-therapeutic and
she was continued on this until her INR was greater than 2 on
coumadin.
4. CAD- Known CAD s/p CABG with recent Cath in [**9-1**] with stents
X 4 to RCA/RPDA. She had a new RBBB seen on EKG but stat ECHO
showed no new changes from previous and she was not felt to have
acute MI or cardiogenic shock. She remained chest pain free
throughout her course. Continued on plavix, lipitor. Plan to
re-start atenolol once blood pressure tolerates.
5. Left Leg Pain s/p Fall: No evidence of fracture or hematoma.
Given reported history of multiple falls recently, she was
evaluated by physical therapy service who felt inpatient rehab
was necessary for physical conditioning. She was set up for
placement to rehab center upon discharge. Pain was controlled
with tylenol and low-dose oxycodone prn. Avoided long-acting
opioids given her hypotensive episodes.
6. LLL pneumonia: Initial evidence of pneumonia by CXR vs
atelectasis. She was started empirically on Levo/Vanco. However
subsequent CXR 2 days later showed no evidence of pneumonia. She
was taken off vancomycin at that point and should complete her
7th day of levofloxacin on [**2-24**].
Medications on Admission:
Imdur
COumadin 3 mg
Albuterol IH
Ambien 5 mg QHS
Atenolol 25 mg daily
Clonazepam 2mg PRN
Lipitor 10 mg QD
Plavix 75
Percocet
Oxycontin 20 mg [**Hospital1 **]
HCTZ 25 mg QD
syntroid 125 mcg QD
Protonix 40 mg QD
Lisinopril 40 mg QD
Folate 5 mg daily
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Left leg pain
Secondary Diagnoses:
1. [**Name (NI) **] unclear etiology
2. Chronic Hemolytic Anemia
3. Mechanical Aortic Valve
4. Hypothyroidism
5. Multiple falls
Discharge Condition:
Good. Hemodynamically stable. Needs continued physical therapy
rehabilitation.
Discharge Instructions:
You are being discharged to Rehab. Report any medical complaints
to your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**] following discharge.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 665**] in [**11-30**] weeks after discharge
from rehab. Call to make an appointment at [**Telephone/Fax (1) 250**].
*
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 11216**] Date/Time:[**2201-4-17**] 1:00
ICD9 Codes: 2765, 2851, 496, 4589, 4168, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5514
}
|
Medical Text: Admission Date: [**2166-10-6**] Discharge Date: [**2166-10-19**]
Date of Birth: [**2166-10-6**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] is Twin B, 2555
gm product of a 33 [**1-16**] week twin gestation to a healthy 32
year old gravida 2, para 2 mother whose pregnancy was notable
for pre-term labor with cerclage placement. She was treated
with Terbutaline at 29 weeks forward. Antenatal ultrasound
was notable for ventricular asymmetry and dilation in this
child. No sepsis risk factors. Prenatal screen is complete
and unremarkable. Mother's blood type is 0 positive,
antibody negative, Rubella immune, RPR nonreactive, hepatitis
B surface antigen negative and Group B Streptococcus status
unknown. Mom was delivered via cesarean section for breech
positioning of this twin. At delivery decreased tone and
respiratory effort prompted several bag mask ventilations,
with a good response. Heartrate was always greater than 100.
Apgar scores 6 at one minute and 8 at five minutes of age.
Baby was having mild grunting, flaring and retracting in the
delivery room and was brought to the Neonatal Intensive Care
Unit after visiting with parents. Of note, Mom was beta
complete.
PHYSICAL EXAMINATION: Birthweight 2,555 gm (90th
percentile), length 48 cm (90th percentile), head
circumference 33 cm (90th percentile). On examination,
infant was well perfused and saturated in room air. Pink,
active, nondysmorphic infant. Skin without lesions. Head,
eyes, ears, nose and throat within normal limits except for
head circumference in the 90th percentile for gestational
age. Sutures split. Heart normal S1 and S2, without
murmurs. Lungs, coarse, equal breathsounds bilaterally.
Abdomen benign. Genitalia, normal male, testes descended
bilaterally. Neurological nonfocal and age appropriate.
Spine intact. Hips normal. Clavicles intact. Anus patent.
HOSPITAL COURSE: Respiratory - The infant was intubated
shortly after admission to the Neonatal Intensive Care Unit.
He received one dose of Surfactant and was weaned to room air
by 24 hours of age. He has not had issues with apnea of
prematurity and has not required any treatment with
Methylxanthine.
Cardiovascular - The infant's has been stable throughout his
hospitalization. No fluid boluses or pressors were required.
Fluids, electrolytes and nutrition - Upon admission to the
Newborn Intensive Care Unit intravenous fluids of D10/W were
initiated at 80 cc/kg/day. The infant was started on enteral
feeds on day of life #2 at 30 cc/kg. He advanced to full
volume feeds without difficulty by day of life #7. Caloric
density was advanced to a maximum of 24 calorie breastmilk.
He is currently bottling feeds without difficulty. Weight at
the time of discharge is 2,545 gm. The last set of
electrolytes on day of life #1, sodium 140, potassium 6.7
which was hemolyzed, chloride 109 and total carbon dioxide of
18.
Gastrointestinal - The infant was started on single
phototherapy on day of life #3 for a bilirubin of 12.2 with a
direct of 0.3. Phototherapy was discontinued on day of life
#7 with rebound on day of life #8 of 10.2/0.3.
Hematology - Hematocrit at birth was 54. This infant did not
receive any blood products during his hospitalization.
Infectious disease - Upon admission to the Neonatal Intensive
Care Unit we obtained a complete blood count with
differential and blood cultures. Complete blood count had a
white count of 13,000, hematocrit 54, platelet count of
307,000 with 24% polys and 0% bands. The blood culture was
negative. The infant received 48 hours of ampicillin and
gentamicin. There have been no other issues of infection
during his hospitalization.
Neurology - IN light of the findings of ventricular asymmetry
on antenatal ultrasound a post nasal ultrasound was performed
on [**10-7**] which did show ventricular asymmetry with the
left ventricle being slightly larger than the right. A
follow up ultrasound was performed on [**10-17**] which was
read as normal. Neurology Service at [**Hospital3 1810**] are
aware of the findings and feel that no further follow up is
necessary.
Sensory - Hearing screen was performed with automated
auditory brain stem responses and he passed in both ears.
Ophthalmology, eye examination not indicated for this 33 [**2-21**]
weeker.
Genitourinary - Circumcision was done on the day of
discharge, no abnormal bleeding or discharge noted at the
circumcision site.
Psychosocial - [**Hospital6 256**] Social
Work has been involved with the family and a contact social
worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Stable. Infant with stable
temperature in open crib, taking p.o. feeds without
difficulty, no evidence of apnea of prematurity.
DISCHARGE DISPOSITION: To home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27098**] in [**State 2748**],
Willows Group Pediatrics, phone [**Telephone/Fax (1) 50907**].
CARE/RECOMMENDATIONS:
Feeds at discharge - Adlib demand feeds of breastmilk
enriched to 24 calories with Enfamil powder.
Medications - Iron supplement and Poly-Vi-[**Male First Name (un) **].
Carseat position screening - Infant had a carseat test just
prior to discharge which he passed.
State newborn screen - Last state newborn screen sent on
[**10-16**], no abnormal results have been reported.
Immunizations received - The infant received his first
hepatitis B vaccine prior to discharge. The infant did
receive Synagis vaccine just prior to discharge. 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.
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.
FOLLOW UP: A follow up appointment has been scheduled with
Dr. [**Last Name (STitle) 27098**] for [**10-20**].
DISCHARGE DIAGNOSIS:
1. Prematurity at 33 2/7 weeks
2. Respiratory distress syndrome
3. Rule out sepsis
4. Ventricular asymmetry, now resolved as evidenced by head
ultrasound
5. Physiologic jaundice.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Name8 (MD) 37391**]
MEDQUIST36
D: [**2166-10-19**] 18:22
T: [**2166-10-19**] 19:09
JOB#: [**Job Number 50908**]
ICD9 Codes: 769, 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5515
}
|
Medical Text: Admission Date: [**2141-5-18**] Discharge Date: [**2141-6-1**]
Date of Birth: [**2071-3-17**] Sex: F
Service: VSU
CHIEF COMPLAINT: Bilateral toe gangrene.
HISTORY OF PRESENT ILLNESS: This is a 70-year old female
with a complicated medical history including peripheral
vascular disease and insulin-dependent type 2 diabetes. She
has recently moved from [**State 4565**] to [**State 350**]. She
states she has had multiple surgeries and stent placements on
the lower extremities bilaterally. She does not remember the
details. She has requested further information from the
hospital in [**State 4565**] ([**First Name8 (NamePattern2) **] [**Hospital **] Hospital). She was first
seen at our institution, [**Hospital1 18**], on [**2141-4-4**] for
necrotic toes. She was seen in the emergency room and
referred to the [**Hospital **] Clinic for podiatry consult. She was
then referred to Dr. [**Last Name (STitle) 1391**] for a vascular evaluation. She
is now admitted to our service for IV antibiotics and
evaluation.
REVIEW OF SYSTEMS: Positive for a history of chest pain and
pressure, dyspnea on exertion (relieved with rest), history
of hemorrhoids with bright red blood per rectum, and urinary
frequency.
PAST MEDICAL HISTORY: Includes insulin-dependent type 2
diabetes, coronary artery disease (with a history of a
myocardial infarction), a history of congestive heart failure
(compensated), seasonal allergies, history of GI bleed
secondary to hemorrhoids.
PAST SURGICAL HISTORY: Includes a cholecystectomy, total
abdominal hysterectomy with bilateral salpingo-oophorectomy
in [**2105**], right carpal tunnel repair, and trigger finger
surgery.
ALLERGIES: ZOCOR and LIPITOR (cramps and joint pain), SULFA
(caused hives and angioedema), DEMEROL (caused skin
blisters), IVP DYE (caused hives and blisters), and TAPE
(caused blisters).
MEDICATIONS ON ADMISSION: Lasix 40 mg b.i.d., Mavik 4 mg
daily, omeprazole 20 mg daily, Lantus insulin 35 units at
bedtime with a Humalog insulin sliding scale.
FAMILY HISTORY: Positive for father dying at 79 with
prostate carcinoma, diabetes, Parkinson's, and emphysema.
Mother was 83 and died of renal failure.
SOCIAL HISTORY: She has 3 children, all living, 2 with renal
disease and 1 with hypercholesterolemia. The patient denies
tobacco or alcohol use and is independent in ADLs.
PHYSICAL EXAMINATION ON ADMISSION: The patient is alert and
oriented. Obese. Teary eyed but pleasant. HEENT exam is
unremarkable. The lungs are clear to auscultation
bilaterally. Heart has a regular rate and rhythm with a 2/6
systolic ejection murmur at the base. Abdominal exam is
obese, nontender, nondistended. Bowel sounds are present. No
masses noted. The extremities show minimal edema with
palpable femoral's at 2+ bilaterally with dopplerable DP and
PT signals bilaterally. The left 1st toe is with gangrenous
changes, dry. The right 1st toe and 2nd toe are with
gangrenous changes, dry.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
vascular service. She was begun on vancomycin and
levofloxacin. Admitting white count was 5.4, hematocrit was
42.5, platelets were 343,000. Coag's were normal. Urinalysis
was negative. BUN was 37, creatinine was 1.5, with a K of
5.2. Liver enzymes revealed an ALT of 19, AST of 23, alkaline
phosphatase of 176, amylase of 71, total bilirubin of 0.4,
and lipase of 25. Albumin of 3.9. Cholesterol of 191.
Triglycerides of 178. Hemoglobin A1C was 8.
The patient's stress test on [**2141-5-9**] showed moderate
reversible medium-size lateral wall perfusion defect with an
ejection fraction of 68%. Foot films done on [**2141-4-4**]
demonstrated osteomyelitis of the right 1st and 2nd digits,
ulceration of the distal left 1st digit with diffusely
demineralized bone. An echocardiogram on [**2141-4-21**]
demonstrated a left atrial dilatation with mild symmetrical
left ventricular hypertrophy with an ejection fraction
calculated at 55%. The mitral valves were mildly thickened.
She had physiological mitral regurgitation with mild
pulmonary systolic hypertension. EKG was a sinus rhythm with
no acute changes.
The patient was continued on her preadmission medications.
Renal function was monitored. IV hydration was begun in
anticipation for arteriogram. Podiatry was consulted
regarding the necrotic toes and recommendations regarding
management and antibiotic therapy.
On [**2141-5-18**] the patient underwent an abdominal aortic and
pelvic vessel arteriogram with bilateral lower extremity
angiograms. The study demonstrated patent abdominal aorta,
although diffusely and mildly narrowed in the infrarenal
portion. There was single renal arteries present bilaterally.
There was mild post ostial stenosis of the left renal artery.
There was calcification along the infrarenal aorta and iliac
arteries. The right side runoff showed significant segmental
stenosis at the level of the mid to upper right superficial
femoral artery. A patent right above-the-knee popliteal stent
was noted. A focal short narrowing of the distal right below-
the-knee popliteal artery was seen. There was involvement of
the proximal right anterior tibial as well. More distally,
the anterior tibial, peroneal, and posterior tibial arteries
were patent. The right DP and plantar arteries were widely
patent, although there was noted of calcification of the
right DP artery. The left side runoff showed a short moderate
narrowing of the proximal left common iliac with segmental
disease of the left external iliac with areas of moderate
stenosis. There were 2 overlying metallic stents visualized
in the mid left superficial femoral artery with mild
restenosis. There was approximately a 5- to 6-cm length area
of significant stenosis just proximal to the stent within the
proximal left superficial femoral artery. The popliteal,
anterior tibial, peroneal, and posterior tibial arteries were
widely patent. The left DP is widely patent as well. The left
plantar arteries are small but remained patent.
Cardiology was requested to see the patient preoperatively
given her significant cardiac history. Their recommendations
were the patient was a high risk for surgery given prior
stress test, history of MI, and decompensated failure.
Recommendations were to cover her perioperatively with IV
beta blockade, starting aspirin, postoperative EKG and
enzymes, continue her H2 blockers, and monitor her hematocrit
and transfuse to maintain a hematocrit of greater than 30,
and defer the use of heparin given history of GI bleeds in
the past.
The [**Last Name (un) **] service followed the patient during her
hospitalization and managed her glycemia control. The patient
was seen by social service for emotional support given her
hospitalization and also for a reported difficult domestic
situation. The patient did require adjustments in her sliding
scale during her perioperatively period to maintain adequate
glucose control.
The patient proceeded to surgery on [**2141-5-24**] and
underwent a right femoral/dorsalis pedis bypass graft with in
situ saphenous vein. The patient had a palpable graft and
triphasic DP and PT at the end of the procedure. She was
transferred to the PACU in stable condition. Postoperatively,
she remained hemodynamically stable. Her hematocrit remained
stable at 31.3. BUN and creatinine were stable at 15 and 1.0.
Her magnesium, phosphate, and potassium were repleted. The
chest x-ray was without pneumothorax, and the line was in
appropriate position. The EKG was without ischemic changes.
The patient continued to do well and was transferred to the
VICU for continued monitoring and care.
On postoperative day 1, there were no overnight events. She
remained hemodynamically stable. Her hematocrit remained
stable. Her BUN and creatinine remained stable. The patient's
pulse exam remained unchanged. The foot showed stable dry
gangrene. The patient was begun on Percocet for analgesic
control. Her diet was advanced as tolerated. Her IV fluids
were hep-locked. She was maintained on bedrest and remained
in the VICU for continued hemodynamic monitoring.
On postoperative day 2, the patient had low urinary output
overnight with a poor response to fluid boluses. Her
hematocrit dropped from 30.4 to 28.7. Swan was continued. The
JP's remained in place and were monitored for drainage. The
patient received a Lasix challenge with good urinary output.
On postoperative day 3, hematocrit was 27.3. The patient's
Cordis was converted to triple lumen catheter. Ambulation
with touchdown weightbearing essential distances only was
begun. Physical therapy was requested to see the patient. The
patient was transferred to the floor on telemetry.
Postoperative CK and troponin levels were flat. EKG was
without ischemic changes.
On postoperative day 4, the patient had episodes of
bradycardia to rates in the 40s without symptoms. The
bradycardia resolved spontaneously. Her hematocrit remained
stable at 27.7. Otherwise, the patient continued to progress.
Her glycemic control was excellent. She was evaluated by
physical therapy who felt they would recommend rehab prior to
discharge to home when medically stable.
The patient returned to surgery on [**2141-5-30**] for a right
1st and 2nd toe amputation and left 1st toe amputation. She
tolerated the procedure well. The patient tolerated the toe
amputations. Hematocrit continued to show some drifting to
26. The recommendations were to consider a transfusion by
cardiology. The patient remained in a sinus rhythm with
bradycardia which was asymptomatic. The initial dressings
were removed on postoperative day 1. The amputation sites
were clean, dry, and intact with well approximated skin
edges. There was no ecchymosis or erythema. Glycemic control
continued to remain stable. The patient continued to be
monitored. Her hematocrit continued to show a mild drifting.
On [**6-1**], in the morning, her hematocrit was 25.6. A repeat
hematocrit was to be followed up on. Rectal exam was guaiac-
negative stool. Her BUN and creatinine were stable at 22 and
1.4.
DISCHARGE STATUS: The patient was transferred to rehab in
stable condition. All wounds were clean, dry, and intact
without erythema. She had a working graft.
DISCHARGE FOLLOWUP: She should follow up with Dr. [**Last Name (STitle) 1391**]
in 2 weeks' time.
DISCHARGE INSTRUCTIONS: She may ambulate essential
distances, full weightbearing with Humin sandals. She should
keep the legs elevated when sitting in a chair or in bed. The
skin clips should remain in place until seen in followup, and
the amputation sutures to remain in place until seen by Dr.
[**Last Name (STitle) 1391**] who will then decide on followup when to discontinue
the amputation site sutures.
MEDICATIONS ON DISCHARGE: Include levofloxacin 500 mg q.24h.
(for a total of 2 weeks post discharge), Protonix 40 mg
daily, alprazolam 1 mg b.i.d. p.r.n. (for anxiety),
hydromorphone 2 mg 1 to 2 tablets q.4h. p.r.n. (for
breakthrough pain), Colace 100 mg b.i.d. (hold for loose
stools), bisacodyl 5-mg tablets 2 daily as needed, aspirin 81
mg daily, oxycodone/acetaminophen 5/325 tablets 1 to 2 q.4-
6h. p.r.n. (for pain). Her trandolapril 4 mg daily has been
held secondary to her low urinary output postoperatively and
low systolic blood pressures. Her blood pressure should
continue to be monitored at rehabilitation and restart if
indicated. Lasix 40 mg b.i.d. has also been held because of
low blood pressure. Recommendations were to monitor blood
pressure and restart if indicated. Insulin regimen is
Glargine 35 units at bedtime with a Humalog sliding scale
before meals and at bedtime. Senna tablets 1 b.i.d. p.r.n.
DISCHARGE DIAGNOSES: Bilateral ischemic toe gangrene, status
post bilateral lower extremity arteriograms, right
femoral/dorsalis pedis bypass with in situ saphenous vein,
and right toe amputation (toes 1 and 2), and left 1st toe
amputation, insulin-dependent type 2 diabetes (controlled),
coronary artery disease with a history of myocardial
infarction and congestive heart failure (stable), history of
gastrointestinal bleed with postoperative low hematocrit and
negative guaiac.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2141-6-1**] 10:27:25
T: [**2141-6-1**] 12:11:08
Job#: [**Job Number 61389**]
ICD9 Codes: 4280, 412, 3572
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5516
}
|
Medical Text: Admission Date: [**2187-9-8**] Discharge Date:
Date of Birth: [**2130-3-24**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
morbidly obese female who has been immobile at home who
presents to the Emergency Department with a five day history
of shortness of breath. At home she had been on 4 liters of
increasing amount of oxygen secondary to shortness of breath.
She denies any fevers, chills, cough or chest pain. She does
admit to some diarrhea at home. In the Emergency Department
she became grossly more short of breath. She was given
nebulizer treatment and nasal cannula was increased to 10
liters. The arterial blood gases was 7.28, 82, and 42. Her
baseline carbon dioxide from [**2187-3-15**] is 48. Because
Department.
PAST MEDICAL HISTORY:
1. Congestive heart failure with normal left ventricular
ejection fraction.
2. Cardiomyopathy.
3. COR pulmonale.
4. Osteoarthritis.
5. Rheumatoid arthritis.
6. Hypertension.
7. Peptic ulcer disease.
8. Chronic obstructive pulmonary disease.
9. Obesity.
10. History of acute renal failure.
MEDICATIONS:
1. Combivent 2 puffs four times a day
2. Lasix 100 mg q.d.
3. Vioxx 25 mg q.d.
4. Aspirin 325 mg q.d.
5. Prozac 20 mg q.d.
6. Trazodone 50 mg q.h.s.
7. Detrol 5 mg b.i.d.
8. Milk of magnesia 38 ml prn
9. Prevacid 30 mg b.i.d.
10. Iron 325 mg t.i.d.
11. Lovenox
12. 25 mg every Tuesday and Saturday
13. Plaquenil 200 mg q.d.
14. Ambien prn
15. Neurontin 30 mg q.h.s.
16. Elocon 80 mg b.i.d.
17. Glucosamine 100 mg q.d.
18. Triple antibiotic cream to buttocks
ALLERGIES: Demerol and cashew nuts, to the nuts she develops
an anaphylactic reaction.
FAMILY HISTORY: Father died of an myocardial infarction.
SOCIAL HISTORY: The patient lives with friend. She has 72
pack year history of smoking. She denies any alcohol use.
PHYSICAL EXAMINATION: In the Emergency Department
temperature was 96.5, heartrate 68, blood pressure 90/44,
respiratory rate 18, 90% oxygen saturation. In general the
patient is an obese female who was intubated. Head, eyes,
ears, nose and throat: Pupils are equal, round, and reactive
to light and accommodation. Neck was supple. Chest with
bilateral wheezes diffusely. Cardiac: Distant heartsounds,
S1 and S2 normal. Abdomen soft, nontender, nondistended with
positive bowel sounds.
LABORATORY DATA: On admission white count was 8.7,
hematocrit 30.4, platelets 183. Neutrophils 79.9, 0 bands,
PT 14.3, INR 1.3, PTT 30.6, sodium 135, potassium 5.8,
chloride 93, bicarbonate 24, BUN 78, creatinine 2.1, glucose
96. Chest x-ray showed several opacities in the right lung
base. Electrocardiogram showed normal sinus rhythm and old
right bundle branch block. There were no ST or T wave
changes.
HOSPITAL COURSE:
1. Pulmonary - The patient had been intubated on initial
settings of title volume 100, positive end-expiratory
pressure 5, respiratory set at 14 and FIO2 of 50%. Periodic
arterial blood gases were taken. The patient was started on
Solu-Medrol and then converted to Prednisone, starting at 30
mg q.d. She was also given nebulizer treatment with
Albuterol and Atrovent. Because of the chest x-ray she was
also started on Levofloxacin 500 mg intravenously q.d. She
had lower extremity ultrasound done. It was negative for
deep vein thrombosis. She was started on pressor support.
She had apnea, however, she was able to spontaneous about
every q. 12 seconds. She gradually improved in her
respirations. On [**9-21**], the patient was extubated. She
was able to maintain decent oxygenation on shovel mask. She
was transferred to the floor on [**9-22**], where she was
placed on nasal cannula and was able to tolerate it. She was
continued on her nebulizer treatments and her puffs of
Serevent and Atrovent. She was also started on Flovent. Her
Prednisone was started to taper from 30 to 20 mg.
2. Infectious disease - The patient was noted to have
pneumonia, based on chest x-ray as a finding. Sputum for
sent for culture and Gram stain and came back positive for
Methicillin-resistant Staphylococcus aureus. She was started
on Vancomycin along with the Levaquin. Eventually the
Vancomycin was continued for a total of 14 days. Her urine
was positive for Enterococcus. Because it was sensitive to
Vancomycin, she was not started on any other antibiotics.
She also had a rash on her gluteal region. She had initially
been given triple antibiotic ointment, however, Nystatin was
then added. Her lesions then became clear for vesicular
eruptions. She was then started on Acyclovir 800 mg p.o.
five times a day for a total of ten days planned. She has
diarrhea, however, all Clostridium difficile screens were
negative.
3. Renal - Her initial creatinine was elevated, however,
with hydration her creatinine came down towards baseline.
4. Gastrointestinal - The patient had developed diarrhea.
She also had Clostridium difficile screen sent, which all
returned negative. She had been started on tube feedings
when the diarrhea had developed. The diarrhea was felt
secondary to these tube feedings. The tube feedings were
stopped, and she had improved bowel movements. They
decreased in frequency and watery quality.
CONDITION ON DISCHARGE: The patient will be going to
rehabilitation center to become more functional.
DISCHARGE STATUS: Stable.
DIAGNOSES:
Chronic obstructive pulmonary disease exacerbation
MRSA Pneumonia
Shingles
Prerenal Azotemia
DISCHARGE MEDICATIONS:
1. Acyclovir 800 mg p.o. five times a day for ten days
2. Prednisone 20 mg p.o. q.d. for a total of five days and
then a 10 mg p.o. q.d. for another five days
3. Flovent 6 to 8 puffs b.i.d.
4. Serevent 2 puffs b.i.d.
5. Atrovent 2 puffs q.i.d.
6. Aspirin 325 mg p.o. q.d.
7. Prozac 20 mg p.o. q.d.
8. Imipenem 300 mg p.o. q.d.
9. Plaquenil 20 mg p.o. q.d.
10. Protonix 30 mg p.o. q.d.
11. 25 mg subcutaneously two times a week
12. Furosemide 12 mg p.o. q.d.
13. Iron Sulfate 325 mg p.o. t.i.d.
14. Heparin 700 units subcutaneously b.i.d.
15. Albuterol 2 puffs every 4 hours as needed for dyspnea
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2187-9-25**] 16:49
T: [**2187-9-25**] 18:03
JOB#: [**Job Number 34721**]
cc:[**Hospital3 34722**]
ICD9 Codes: 5990, 4280, 4254, 4019
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5517
}
|
Medical Text: Admission Date: [**2109-10-5**] Discharge Date: [**2109-10-12**]
Date of Birth: [**2109-10-5**] Sex: F
Service: NBB
HISTORY: Baby Girl [**Known lastname 75373**] was admitted from the delivery room
for perinatal depression requiring resuscitation. Her birth
weight was 2665 grams which was within 25th and 50th
percentile. Her length was 47 cm, 25th to 50th percentile,
and her head circumference was 32.5 cm which was within the
25th to 50th percentile. She was the 2665 gram product of a
38-6/7 weeks gestation, born by spontaneous vaginal delivery
to a 34-year-old gravida 1, para 0-1 mother. Prenatal
screens revealed blood type O negative, antibody negative,
hepatitis B antigen negative, RPR nonreactive, rubella immune
and GBS positive. Mother was treated with RhoGAM prior to
delivery. Pregnancy was uncomplicated. There was a normal fetal
survey. Her membranes ruptured with bloody fluid about two
hours prior to delivery. There was no maternal fever. Mom
received one dose of intrapartum antibiotics about 3.5 hours
prior to delivery.
Infant emerged limp and apneic. Because neonatology was not
present at delivery, resuscitation was initiated by the labor
and delivery nurses. Neonatology arrived at about two minutes of
life. At that time, this infant was still pale and apneic
despite getting positive pressure ventilation. The heart rate
was initially greater than 60 but fell becasue of ineffective
positive pressure ventilation. Chest compressions were
initiated. She was bulb suctioned several time for small amounts
of bloody mucus and a large bloody mucus plug. Then, she was
intubated with a 3.5 Fr endotracheal tube. There was resultant
effective ventilation and improvement of heart rate. Chest
compressions were stopped after approximately five minutes. No
recuscitation medications were required. Apgars were 2 at one
minute, 2 at five minutes and 5 at ten minutes of age. She was
transferred to the NICU for further management.
PHYSICAL EXAMINATION AT DISCHARGE: Her current weight was
2500 grams. Head circumference was 33cm. Length was 47.5 cm.
Neurologic exam was awake and alert on exam. She had a
positive grasp, positive suck, positive root and positive
Moro and positive truncal incurvation reflux. Her tone was
AGA. HEENT: Anterior fontanelles open and soft, positive
bilateral red reflex, normal appearing nose, normal appearing
ears and palate intact. Respiratory: Breath sounds equal
and clear. Chest was symmetric. Cardiovascular: No murmur,
regular rate and rhythm, and pulses were palpable and equal
+2. Gastrointestinal: Abdomen was soft and round. Positive
bowel sounds and no hepatosplenomegaly. Patent anus. GU:
Normal female genitalia. Extremities: Clavicles intact,
hips intact, no click or clunk on exam, and spine was
straight.
SUMMARY HOSPITAL COURSE:
1. Respiratory: Infant intubated in delivery room for
perinatal depression. Placed on conventional ventilator
upon admission to the NICU. Her initial ABG was 7.09 PCO2
31 PaO2 63 HCO3 10 and Base excess -19, for which she was
given a sodium bicarb bolus of 2 mEq/kg/dose. Repeat ABG was
ABG was 7.23 PCO2 37 PaO2 58 HCO3 16 and Base excess -11. A
second sodium bicarb bolus of 2 mEq/kg/dose was given.
Infant's initial chest x-ray revealed bilateral diffuse
streaky lung opacities. On the day of life #1, the infant
was extubated to nasal cannula O2 and on day of life #4,
the infant transitioned to room air.
1. Cardiovascular: UVC was successfully placed on
admission to NICU. Infant received two normal saline
boluses for poor perfusion. Two sodium bicarb boluses
for metabolic acidosis. Infant did not require
vasopressor support. Infant had been hemodynamically
stable for the rest of the NICU admission.
1. Fluids, electrolytes and nutrition:
A UVC was placed for IV fluids on admission to
the NICU and the infant was made NPO at that time. The
infant was hypoglycemic on admission to the NICU
requiring two D10 boluses of 2 mL/kg/dose with IV fluids
of D12.5 at 60 mL/kg/day. Electrolytes obtained on day
of life one showed a sodium of 134, potassium 3.2,
chloride of 94, a CO2 of 27, her BUN was 16 and her
creatinine was 0.7, and her ionized calcium was 0.92.
Enteral feeds began of E20 or breast milk at 30
mL/kg/day on day of life #2. Full ad lib enteral feeds
on day of life #3 of E20 or breast milk. Her
electrolytes on day of life #3 showed her sodium was
139, her potassium was 3.6, chloride was 101, and her
CO2 was 31. Her serum calcium level on day of life 4
was 8.8.
1. Gastrointestinal: Liver functions were performed on day
of life #1. Her AST was 133, her ALT was 113, her alk
phos was 119. Repeat liver functions performed on day
of life 4 revealed an AST of 38, an ALT of 127, an alk
phos of 135. Her maximum bilirubin level was on day of
life 4 which was 10/0.5 and her repeat bilirubin on day
of life 5 was 7/0.4. The infant did not require photo
therapy.
1. Hematology: Infant's blood type is A positive, DAT
negative. Initial hematocrit on admission to the NICU
was 47.5 with platelet count of 142. Repeat platelet
count obtained on day of life one revealed 72,000 with a
hematocrit of 51.2. Platelet count followed daily which
revealed a platelet count on day of life 5 of 60,000
requiring a platelet transfusion at 10 mL/kg/dose.
Infant had normal PT 13.7 PTT 33.4 Fib 438 on day of life 2.
Infant did not require a blood transfusion and most
current hematocrit obtained on day of life 5 of 42.9.
Her platelet count was not repeated after the transfusion.
1. Infectious disease: A CBC and blood culture screen were
obtained on admission to the NICU. Initial white count
was 11,100 with 9 polys and 19 bands on admission to the
NICU. Repeat white count was 15,800 with 69 polys and
10 bands on day of life 1. The infant received a 7-day
course of ampicillin and gentamicin for presumed pneumonia
(mother's placenta had acute chorioamnionitis). Blood
culture remained negative and LP culture remained negative.
1. Neurology: CFM performed on admission to the NICU and
was read as normal. Head ultrasound was performed on
day of life 2 that was as normal. [**Hospital1 **]
Neurology was consulted on day of life 2. Their exam
revealed mild hypertonia without other focal findings.
Neurology examined the infant again on day of life 3
which was found to be entirely normal. No further studies
performed as per recommendation of Neurology. Infant
will be followed up with Neurology at three months of
age after discharge.
1. Audiology screening was performed with automated auditory
brain stem responses and the infant passed.
1. Ophthalmology: Infant did not meet the criteria for
exam.
1. Psychosocial: [**Hospital1 18**] social worker involved in family.
The contact social worker can be reached at [**Telephone/Fax (1) **].
1. Name of primary pediatrician is [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 75374**].
The phone number is ([**Telephone/Fax (1) 75375**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge were ad lib breast milk or Enfamil 20
calories.
2. Medications: Tri-Vi-[**Male First Name (un) **] 1 mL p.o. daily; ferrous
sulfate (25 mg/1 mL) 0.2 mL p.o. daily which is 2
mg/kg/dose; iron and vitamin D supplementation. Iron
supplementation is recommended for pre-term and low
birth weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units
(may be provided as a multivitamin preparation) daily
until 12 months corrected age.
3. Car seat position screening: Infant does not meet
criteria.
4. State newborn screening: Status sent per protocol and
results are pending.
5. Immunizations received: Infant has received the
hepatitis B vaccination on [**2109-10-5**].
6. Immunizations recommended: Synergis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following four criteria:
(1) Born at less than 32 weeks; born between 32 and 35
weeks with two of the following: Daycare during RSV
season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings.
(3) Chronic lung disease; (4) Hemodynamically
significant congenital heart disease. Influenza
immunization is recommended annually in the fall for all
infants once they reach six months of age. Before this
age (for the first 24 months of the child's life)
immunization against influenza is recommended for
household contacts and out of home caregivers. This
infant has not received the Rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of pre-term infant at or following discharge
from the hospital if they are clinically stable and at
least six weeks or fewer than 12 weeks of age.
FOLLOW UP APPOINTMENTS SCHEDULED AND RECOMMENDED:
1. Follow up with pediatrician, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 75374**], on
Monday, [**2109-10-14**].
2. [**Hospital **] [**Hospital 878**] Clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] three
months after discharge. The referral has been send from the
NICU. The program will contact the family with an
appointment. In case the family needs to call the clinic,
The phone number where Dr. [**Last Name (STitle) **] can be reached is
([**Telephone/Fax (1) 56746**].
DISCHARGE DIAGNOSIS: Term infant, perinatal depression,
respiratory distress, presumed blood aspiration
pneumonia, thrombocytopenia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 71091**]
MEDQUIST36
D: [**2109-10-11**] 23:54:47
T: [**2109-10-12**] 13:34:42
Job#: [**Job Number 75376**]
ICD9 Codes: V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5518
}
|
Medical Text: Admission Date: [**2152-5-25**] Discharge Date: [**2152-5-29**]
Date of Birth: [**2127-1-27**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8250**]
Chief Complaint:
scheduled c/s for complete posterior placenta previa
Major Surgical or Invasive Procedure:
Primary lower transverse c-section for posterior previa, ICU
admission, transfusion blood products.
History of Present Illness:
Ms. [**Known lastname 1255**] is a 25yo G1P0 at 37+2WGA by LMP ([**2151-9-7**]) presents to
L&D for a scheduled c/s for complete posterior placenta previa.
Patient trnsferred her care from [**Country 651**] at 24 weeks. Prior to
that she reported a normal pregnancy.
Pregnancy review:
Dating: [**Last Name (un) **] [**2152-6-13**] by LMP ([**2151-9-7**]) c/w 2nd tri US
Prepregnancy weight: 128
Exposures: No TB exposures. No pets. No sick contacts.
*) [**Name2 (NI) **]
- AB+/Abs-/RI/RPRNR/VZI/HBsAg-/HCV-/HIV-/GC-/CT- / GBS positive
- normal 2h GTT
*) Ultrasound
- FFS 25wks nl anatomy, complete previa 4cm over os
- [**4-12**]: 1676g 46th% BPP [**9-4**], AFI 9.7cm, cephalic; complete
previa
- [**5-9**]: [**11-6**] BPP
- [**5-16**] ATU EFW: 2918g, 55%
*) Screening
- Normal hemoglobin electrophoresis
*) Issues
1. Previa
- Growth/placenta scans in ATU q3 weeks
- [**5-16**]: placenta is 1.3cm away from the os
- [**5-23**]: complete previa
2. Anemia - iron/colace rx, on PNV as well
3. Transfer of care from [**Country 651**]
- Do not have records, probably not necessary at this point (pt
says they were faxed from [**Country 651**] by her husband)
Genetic risk factors/ethnicity:
- Born in [**Country 651**] of Chinese background; no known chromosomal
problems/birth defects in family
- FOB's family Chinese, no known chromosomal problems/birth
defects
Past Medical History:
-Obstetrical History:
G1 current
-Gynecological History:
LMP [**2151-9-7**]. No abnormal Paps. No STIs. No known fibroids.
Regular menses, q 30-31 days
[**Hospital 87972**] Medical History: denies
-Past Surgical History: denies
Social History:
Lives with her father. Graduated from BU law school. Husband in
[**Name2 (NI) 651**], coming to US and buying [**Last Name (un) **] nearby.
Family History:
Pt denied family hx of Down syndrome, neural tube defects,
thalassemias, Huntingtons dz, mental retardation.
Physical Exam:
Physical Exam:
A&O, NAD
RRR, CTAB
No thyromegaly or neck mass
Abd soft, NT, gravid
Ext NT NE
Pertinent Results:
[**2152-5-27**] 07:15AM BLOOD WBC-9.3 RBC-2.66* Hgb-8.7* Hct-24.7*
MCV-93 MCH-32.9* MCHC-35.4* RDW-14.3 Plt Ct-218
[**2152-5-26**] 03:29PM BLOOD WBC-17.5* RBC-2.89* Hgb-9.5* Hct-26.7*
MCV-92 MCH-32.8* MCHC-35.6* RDW-14.3 Plt Ct-219
[**2152-5-26**] 04:50AM BLOOD WBC-14.7* RBC-2.79* Hgb-9.1* Hct-25.2*
MCV-90 MCH-32.6* MCHC-36.1* RDW-14.2 Plt Ct-186
[**2152-5-25**] 02:01PM BLOOD WBC-14.2* RBC-2.04* Hgb-6.9* Hct-19.4*
MCV-95 MCH-33.8* MCHC-35.6* RDW-13.1 Plt Ct-198
[**2152-5-25**] 11:17AM BLOOD WBC-19.6*# RBC-2.47* Hgb-8.3* Hct-23.7*
MCV-96 MCH-33.4* MCHC-34.9 RDW-13.0 Plt Ct-240#
[**2152-5-25**] 10:00AM BLOOD WBC-9.1 RBC-3.13* Hgb-10.6* Hct-29.8*
MCV-95 MCH-33.8* MCHC-35.5* RDW-12.7 Plt Ct-159
[**2152-5-25**] 06:21AM BLOOD WBC-9.9 RBC-3.75* Hgb-12.3 Hct-35.0*
MCV-93 MCH-32.8* MCHC-35.2* RDW-13.0 Plt Ct-251
.
[**2152-5-26**] 04:50AM BLOOD PT-12.5 PTT-25.5 INR(PT)-1.1
[**2152-5-25**] 09:54PM BLOOD PT-12.4 PTT-23.3 INR(PT)-1.0
[**2152-5-25**] 02:01PM BLOOD PT-12.7 PTT-24.8 INR(PT)-1.1
[**2152-5-25**] 11:17AM BLOOD PT-13.3 PTT-31.8 INR(PT)-1.1
[**2152-5-25**] 10:00AM BLOOD PT-12.4 PTT-31.0 INR(PT)-1.0
.
[**2152-5-26**] 04:50AM BLOOD Fibrino-412*
[**2152-5-25**] 09:54PM BLOOD Fibrino-384
[**2152-5-25**] 02:01PM BLOOD Fibrino-280#
[**2152-5-25**] 11:17AM BLOOD Fibrino-173
[**2152-5-25**] 10:00AM BLOOD Fibrino-220
.
[**2152-5-26**] 04:50AM BLOOD Glucose-68* UreaN-10 Creat-0.7 Na-136
K-3.7 Cl-105 HCO3-23 AnGap-12
[**2152-5-25**] 09:54PM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-139
K-3.3 Cl-104 HCO3-27 AnGap-11
[**2152-5-25**] 02:01PM BLOOD Glucose-94 UreaN-9 Creat-0.5 Na-141 K-3.5
Cl-107 HCO3-28 AnGap-10
[**2152-5-25**] 11:22AM BLOOD Na-139 K-4.3 Cl-109*
.
[**2152-5-25**] 02:01PM BLOOD LD(LDH)-429* TotBili-0.3
.
[**2152-5-26**] 04:50AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.9
[**2152-5-25**] 09:54PM BLOOD Mg-2.1
[**2152-5-25**] 02:01PM BLOOD Calcium-7.7* Phos-4.0 Mg-1.6
[**2152-5-25**] 11:22AM BLOOD Albumin-2.6* Calcium-7.1* Mg-1.5*
[**2152-5-25**] 02:01PM BLOOD Hapto-48
.
[**2152-5-25**] 02:13PM BLOOD Type-ART Temp-36.6 pO2-148* pCO2-52*
pH-7.32* calTCO2-28 Base XS-0
[**2152-5-25**] 02:13PM BLOOD Lactate-1.7
Brief Hospital Course:
Ms.[**Known lastname 1255**] presented for L&D at 37 weeks and 2 days gestational
age for a planned cesarean delivery given complete posterior
placenta previa. The patient had previously been counseled
about risk of potential accreta as well as the risk of
hemorrhage. She also understood the risk of prematurity, which
was outweighed by the risk of labor/hemorhage. The patient was
typed and crossed for 2 units, and the blood was available on
labor and delivery at the time of the cesarean section. Her
surgery was complicated by uterine atony after delivery and
hemorrhage, EBL for the surgery was approximately [**2141**] cc. Pt
received uterotonics and was transfused 2 units of PRBC, 4 units
FFP, 2 units of PLT, and 2 units of cryo. [**Year (4 digits) **] were trended to
ensure pt's stability. Please see Dr[**Doctor Last Name 87973**] operative for
details of the surgery. Pt was then transferred to the ICU after
the surgery for intense monitoring given fluid shifts. Pt was
extubated on the evening of post-op day#0. Pt was transferred
out of the ICU on POD#1 and received routine post-op/postpartum
care. Pt spiked a fever, and was likely due to endometritis. She
was treated with Ampicillin/gentamicin/Clindamycin for 48 hrs
afebrile. Pt was started on iron supplement for post-op anemia.
Pt recovered well and was discharged on post-operative day #4
in stable condition: afebrile, able to eat regular food, under
adequate pain control with oral medications, and ambulating and
urinating without difficulty.
Medications on Admission:
Calcium + vit D, PNV, Iron
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
Disp:*60 Capsule(s)* Refills:*2*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain: take medication with food.
Disp:*60 Tablet(s)* Refills:*0*
3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary cesarean section
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Nothing in the vagina for 6 weeks (No sex, douching, tampons)
No heavy lifting for 6 weeks
No driving while taking narcotics
Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
Do not take more than 2400mg ibuprofen in 24 hrs
Please call if you develop shortness of breath, dizziness,
palpitations, fever of 101 or above, abdominal pain, increased
redness or drainage from your incision, nausea/vomiting, heavy
vaginal bleeding, or any other concerns.
Followup Instructions:
-Postpartum appointment: Dr.[**Last Name (STitle) **] [**2152-7-4**] at 10:15 AM. If you
need to change this appointment, please call [**Telephone/Fax (1) 2664**].
Completed by:[**2152-5-31**]
ICD9 Codes: 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5519
}
|
Medical Text: Admission Date: [**2190-5-10**] Discharge Date: [**2190-5-16**]
Date of Birth: [**2130-11-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABG x 3 [**2190-5-11**] (LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
59 yo Caucasian male with back and shoulder chest pain with +
ETT. Referred for cath which showed 80% LM, 60% LAD, 60% OM1 ,
99% RCA. Transferred in from [**Hospital3 1443**] for CABG with Dr.
[**Last Name (STitle) **].
Past Medical History:
HTN
obesity
tonsillectomy
Social History:
pathologist
lives alone
no tobacco use
no ETOH use
Family History:
non-contributory
Physical Exam:
HR 53 RR 17 170/74 left
5'[**93**]" 121.6 kg
NAD
skin/HEENT unremarkable
neck supple with full ROM, no carotid bruits
CTAB
RRR, no murmurs
abd soft, NT, ND
trace peripheral edema with no varicosities
neurologically grossly intact
2+ bilat. fem/DP/PT/radial pulses
Pertinent Results:
[**2190-5-14**] 08:15AM BLOOD WBC-9.4 RBC-3.23* Hgb-9.8* Hct-27.4*
MCV-85 MCH-30.4 MCHC-35.9* RDW-14.0 Plt Ct-173
[**2190-5-16**] 05:00AM BLOOD Hct-27.4*
[**2190-5-10**] 04:10PM BLOOD Neuts-78.5* Lymphs-15.7* Monos-4.1
Eos-1.4 Baso-0.3
[**2190-5-14**] 08:15AM BLOOD Plt Ct-173
[**2190-5-10**] 04:10PM BLOOD PT-13.1 PTT-30.7 INR(PT)-1.1
[**2190-5-15**] 05:25AM BLOOD Glucose-134* UreaN-19 Creat-1.1 Na-135
K-3.7 Cl-99 HCO3-27 AnGap-13
[**2190-5-16**] 05:00AM BLOOD K-4.0
[**2190-5-10**] 04:10PM BLOOD ALT-23 AST-23 AlkPhos-50 TotBili-0.6
[**2190-5-14**] 08:15AM BLOOD Mg-2.1
[**2190-5-10**] 04:10PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
[**2190-5-10**] 04:10PM BLOOD Triglyc-120 HDL-35 CHOL/HD-4.6
LDLcalc-102
Brief Hospital Course:
Admitted on [**5-10**] to cardiology service and underwent CABG x3
with Dr. [**Last Name (STitle) **] on [**5-11**]. Transferred to the CSRU in stable
condition on neo and propofol drips. Extubated and off all drips
on POD #1. Swan removed. Chest tubes removed and transferred to
the floor on POD #2 to begin increasing his activity level.
[**Last Name (un) **] consult obtained for newly diagnosed DM and oral agents
started. Gentle diuresis and beta blockade continued. Pacing
wires removed on POD #3. Short burst of AFib on POD #4 that
spontaneously converted to SR. Cleared for discharge to home
with VNA on POD #5.
Medications on Admission:
plavix 300 mg (LD [**5-10**])
lovenox 120 mg SC
ASA 325 mg daily
atenolol 100 mg daily
lipitor 80 mg daily
lisinopril 10 mg daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 4
days.
Disp:*16 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary artery disease
CABG x3 [**5-11**]
HTN
NIDDM
obesity
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed. Seek medical
attention if fever, chills, nausea, vomiting, shortness of
breath, or increased pain occurs.
Take all medications as prescribed.
No driving or heavy lifting (> 10 lbs) for 6 weeks.
Followup Instructions:
Please call Dr.[**Name (NI) 5572**] office at [**Telephone/Fax (1) 170**] within the next
few weeks to schedule a follow-up appointment.
Please call Dr. [**Last Name (STitle) **] within the first few days after
discharge to schedule a follow-up appointment.
Please call Dr. [**Last Name (STitle) 67060**] within the first few days following
discharge to schedule a follow-up appointment.
Please follow-up with the [**Hospital **] [**Hospital 982**] clinic within the
first day after discharge.
Completed by:[**2190-5-18**]
ICD9 Codes: 4280, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5520
}
|
Medical Text: Admission Date: [**2169-4-14**] Discharge Date: [**2169-4-21**]
Date of Birth: [**2088-5-12**] Sex: M
Service: SURGERY
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Speech difficulty
Major Surgical or Invasive Procedure:
Left CEA per Dr. [**Last Name (STitle) 1391**] on [**2169-4-19**]
History of Present Illness:
Mr. [**Known lastname 105691**] (previous spelling incorrect as Rhineharist and a
new [**Hospital **] medical record was created) is an 80 year old right
handed male with complex medical history including prior TIA,
possible seizure disorder, now presenting with difficulty
speaking. The patient is unable to provide a complete history as
a result of his language deficit. He lives alone and cannot
provide a proxy at the moment. [**Name2 (NI) **] report intermittent difficulty
with balancing his checkbook over the last few days prior to
admission. He reported something was wrong on the day of
admission with sudden intermittent difficulty speaking
associated with right hand numbness and clumsiness. He was
brought to [**Hospital1 18**] ED where a head CT revealed question of a left
frontal lobe mass.
He was evaluated by neurosurgery and admitted for MRI. Two days
following his initial admission, MRI reveals subacute infarcts
in the inferior division of the L MCA. Neurology was then
consulted to evaluate the patient.
Upon my comparison of the patient's license in his wallet to his
current ID band there is a discrepancy in the spelling of his
last name. Revealing that the patient has an extensive previous
medical history here at this institution. The patient is able to
tell me that his PCP his here at [**Hospital1 18**].
MRI is without any vessel imaging. The patient was taking plavix
for coronary and carotid stents and this is currently being held
for unclear reasons. The patient is unable to offer any further
HPI. At present he denies any headache. He is well aware of his
difficulty in speech production. He reports difficulty with
handwriting, he is unable to hold a pen in his right hand
despite normal strength. He reports right hand diminished
sensation. No bowel or bladder
incontinence. He reports his gait has been unsteady for ? amount
of time.
ROS: denies any F/C/NS, + chronic cough and singultus, no chest
pain. no abdominal pain. no N/V, no diarrhea, no constipation.
Past Medical History:
-Hypertension
-Peripheral [**Hospital1 1106**] disease, s/p distal aortic stenting
-Chronic renal insufficiency
-Multiple TIAs in [**2161**]. Then with right hand weakness in [**2164**]
and
now s/p L ICA stent in [**11-25**]
-Autonomic neuropathy, with evidence of both sympathetic and
parasympathetic dysfunction on autonomic testing
-Prostate cancer s/p brachytherapy
-Hyperlipidemia
-Gout
-Enhancing lesion, thought to be a meningioma in the anterior
cranial fossa
-? h/o Clivus lesion on MRI, bone scan negative
Social History:
He lives alone in [**Location 1268**]. Widowed from his second
marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**]. He
has a sig other [**Doctor Last Name 636**] "[**Doctor First Name 7019**]" [**Location (un) **]. He is retired from a
medical supplier shipping business. He has an 80-pack-year
smoking history; he quit 18 years ago. He denies any ETOH or
illicit drug use.
Family History:
No history of neurologic disease.
Physical Exam:
T 98.3, HR 64, BP 114/36, 16, 100% 2L NC
Gen- well appearing, comfortable, upright in bed, cooperative
with obvious speech deficit, NAD
HEENT: NCAT, OP clear, MMM, Anicteric sclera
Neck- no carotid bruits bilat. Left sided neck incision is c/d/i
with steri-strips in place
CV- RRR, no MRG
Pulm- diffuse, prominent expiratory wheezes
Abd- protuberant, soft, nd, nt, BS+
Extrem- no CCE
Neurologic Exam:
MS- alert, arouses easily to voice, attentive to examination,
speech is of variable fluency, largely nonfluent, his naming is
intact to high and low frequency objects, he makes some frequent
paraphasic errors with spontaneous speech, repitition is
impaired. He is able to read some simple phrases, but then
perseverates and does not read more complex sentences. He is
unable to write. No difficulty with praxis for combing hair,
brushing teeth. No neglect.
CN- PERRL 3-->2mm bilat, EOMI, no nystagmus, VFF to
confrontation, his facial musculature appears symmetric, full
facial strength, facial sensation diminished to pinprick R
V2,V3. hearing intact to FR, palate elevates symm, SCM and trap
are [**4-25**], tongue at midline.
Motor- increased tone in all extremities, no cogwheeling. no
adventitious movements. R pronator drift. Strength is full in
all muscles tested including delt, tri, [**Hospital1 **], WE, FE, FF, IP, Q,
H, TA, PF, [**Last Name (un) 938**].
Sensory- diminished PP, LT, temperature, prop on right hemibody
(face, arm, trunk, leg).
Reflexes- Absent [**Hospital1 **], tri, brachioradialis, 1+ patellars, absent
ankle jerks.
Coordination- intact FNF, slightly slowed [**Doctor First Name 6361**] bilaterally
(symmetrically).
Gait- poor initiation, shortened stride, unsteady.
Pertinent Results:
CT Head [**4-14**]:
IMPRESSION: 1.6 x 1.3 cm left frontal hyperdense brain mass. MRI
is
recommended for further evaluation.
MR [**Name13 (STitle) 430**] [**4-15**]:
IMPRESSION: Multiple foci of slow diffusion consistent with
acute infarction in the left MCA [**Month/Year (2) 1106**] distribution,
involving the subcortical white matter, likely consistent with
embolic disease. No mass lesion or abnormal enhancement is
identified at the site of hyperdensity seen on recent CT.
Multiple scattered FLAIR hyperintensity areas likely consistent
with chronic microvascular ischemic changes in the subcortical
white matter.
CTA Head and Neck [**4-16**]:
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or major
territorial
infarction. Small regions of embolic infarction within the left
MCA territory are better appreciated on the DWI sequence of
recent MRI.
2. Severe luminal stenosis involving the right internal carotid
artery just distal to its bifurcation, of at least 80%.
Significant stenosis is present involving the left internal
carotid artery at the cranial aspect of the [**Month/Year (2) 1106**] stent and a
short segment beyond with at least 60% stenosis.
3. Mild paraseptal emphysematous changes within the lung apices.
4. Moderate irregularly ulcerated plaque within the aortic arch
incidentally noted.
Carotid Series Complete [**4-17**]
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is significant heterogeneous plaque
in the carotid bulb/ICA. on the left there is a patent LT
ICA/CCA stent with some mild to moderate narrowing distal to
stent .
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are141/33, 160/43, 55/15,
cm/sec. CCA peak systolic velocity is 83 cm/sec. ECA peak
systolic velocity is 107 cm/sec. The ICA/CCA ratio is 1.9. These
findings are consistent with 60-69% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 70/26, 119/43, 102/31, cm/sec. CCA peak
systolic
velocity is 72 cm/sec. ECA peak systolic velocity is 123 cm/sec.
The ICA/CCA ratio is 1.6. These findings are consistent with
40-59% stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA stenosis 60-69
Left ICA stenosis 40-59
Brief Hospital Course:
Patient is a 80 year old man admitted to Neurosurgery service on
[**4-14**] with difficulty speaking and now transferred to Neurology
for stroke workup. He has hx of TIA in [**2161**], two admissions for
TIA in [**2164**], first with aphasia and then subsequently for right
hand weakness, received left ICA stent in [**2164**]. He has been on
aspirin, Plavix, and Lipitor since the ICA stenting. He has
history of two amnestic episodes and multiple episodes of
left-sided weakness. He is being evaluated for possible simple
partial seizures and complex partial seizures. He has been on
Keppra since [**2167**]. Also hx of autonomic instability both
sympathetic and parasympathetic. Hyperlipidemia. PVD.
On [**4-14**], he had difficulty speaking. Also noted right hand
numbness and clumsiness. Patient was taken to [**Hospital1 18**] ED where
Head CT showed question of left frontal mass.
Admitted to Neurosurgery. MRI brain on [**4-15**] showed multiple
subacute infarcts in the inferior division of the left MCA. No
hemorrhages seen.
On exam, he has non-fluent aphasia, with alexia and agraphia,
right pronator drift, and mild sensory deficits on the right.
Etiology could be embolic due to possible restenosis of the left
ICA stent, intracranial embolus, or possibly cardioembolic
source. CTA showed critical stenosis of the L ICA just distal to
the prior stenting hence he was started on heparin gtt and
[**Month/Year (2) 1106**] consult was obtained. Given the symptomatic and
critical stenosis, patient was taken for L CEA per Dr. [**Last Name (STitle) 1391**].
He tolerated the procedure well and was taken to the [**Last Name (STitle) 1106**]
ICU overnight. He was on a nitro drip to keep his systolic
pressures below 140 mmHg. This was discontinued on the same
night as surgery.
On POD 1 his staples were removed from his neck and steri-strips
were placed. He was seen and evaluated by PT and OT who
recommended rehab.
POD#2 stable. rehab screening in progress.
POD#3 d/c to rehab.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs(s) by mouth every four (4) to six (6) hours as needed
ALLOPURINOL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
ASA - 325 MG - ONE BY MOUTH EVERY DAY
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth every day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
CHLORPROMAZINE - 10 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **] prn
hiccups
CITALOPRAM [CELEXA] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a day
DARIFENACIN [ENABLEX] - 7.5 mg Tablet Sustained Release 24 hr -
1
Tablet(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) both nares
every day
LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth
twice a day
OMEPRAZOLE - 20 mg Capsule daily
DOCUSATE SODIUM 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
FERROUS GLUCONATE - (Prescribed by Other Provider) - 325 mg
Tablet - 1 Tablet(s) by mouth once a day
SODIUM CHLORIDE - 1,000 mg Tablet, Soluble - one tab po three
times a day for orthostatic hypotension
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Recurrent left carotid stenosis
history of HTn
history of aortic- descending stenosis, s/p thoracic stenting
history of chronic renal disease
history of recurrent TIA's, stroke-aphasic
history of carotid disease s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stenting [**11-25**]
history of prostatic Ca s/p brachythearphy
history of rt. ueretal stenting
history of autonomic neuropathy
history of dyslipdemia
history of gout
Discharge Condition:
Stable. Steri-strips over left neck incision.
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 pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1391**] in 4 weeks. Call his office
at [**Telephone/Fax (1) 1393**] to schedule that appointment.
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2169-4-25**]
1:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-4-25**]
2:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-4-25**]
2:30
followup Dr. [**Last Name (STitle) **] [**2169-5-10**] @ 1pm Neuro/stroke , if need to
change appointment call [**Telephone/Fax (1) 2574**]
Completed by:[**2169-4-21**]
ICD9 Codes: 5859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5521
}
|
Medical Text: Admission Date: [**2104-6-23**] Discharge Date: [**2104-7-2**]
Service: CSU
HISTORY OF PRESENT ILLNESS: This is an 84-year-old man
admitted [**2104-6-23**] being discharged today, [**2104-7-2**], who
has a past medical history significant for coronary artery
disease, hypertension, hypercholesterolemia, prostate cancer,
status post a radical prostatectomy ten years ago, with
chronic urinary tract infections, status post hernia repair
times two and status post bilateral knee repairs.
PREOPERATIVE MEDICATIONS:
1. Procardia XL 60 mg p.o. q d.
2. Imdur 60 mg p.o. q d.
3. Lescol 80 mg p.o. q d.
4. Aspirin 81 mg p.o. q d.
5. Ditropan 5 mg p.o. q d.
6. Macrobid 50 mg p.o. q h.s.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: History of a 20 pack per year history of
smoking quitting 40 years ago denying alcohol use.
HOSPITAL COURSE: The patient had a known history of coronary
artery disease with a history of percutaneous transluminal
coronary angioplasty to his left circumflex coronary artery
in 199. He presented to an outside hospital with complaints
of chest pain and was found to have an elevated troponin. He
was then transferred to [**Hospital6 256**]
on [**2104-6-23**] for cardiac catheterization at which time, he
continued to complain of intermittent mild chest pain.
Cardiac catheterization was performed that day, [**2104-6-23**],
which revealed severe two-vessel coronary artery disease with
a fifty percent distal stenosis of his left main coronary
artery, 80-90 percent stenosis of his left anterior
descending coronary artery, 80 percent stenosis of his left
circumflex coronary artery with moderate left ventricle
dysfunction with an ejection fraction of 40-45 percent.
The patient underwent coronary artery bypass grafting times
two with the left internal mammary artery to left anterior
descending coronary artery and saphenous vein graft to the
obtuse marginal on [**2104-6-25**]. Total cardiopulmonary bypass
time was 48 minutes. Total cross-clamp time was 37 minutes.
The patient was discharged in stable condition to the Cardiac
Surgery Recovery Unit on propofol and phenylephrine. The
patient was extubated the evening of surgery without
complication. The patient continued to be constipated during
his course, however, stating that he had been constipated
four days prior to his admission to the hospital. He was
transferred to [**Hospital Ward Name 121**] two [**2104-6-27**] in stable condition. The
patient went into atrial fibrillation on postoperative day
three with a heart rate in the 90s. He was administered
Lopressor with good effect and he was converted back to sinus
rhythm with a heart rate in the 50s. The patient's Foley
catheter was discontinued on postoperative day two and his
own condom catheter was placed secondary to incontinence,
which he had been wearing at home prior to admission. The
patient was found to have a urinary tract infection. Urine
cultures were sent out which grew out E. Coli for which he
was treated with ceftriaxone 1 gm intravenously b.i.d. On
postoperative day four, he was also found to have a
hematocrit of 25.3 for which he was transfused one unit of
packed red blood cells. The patient continued to remain in
normal sinus rhythm. His heart rate was in the 50s to 70s
progressing to level five for physical therapy on
postoperative day six and was ready to be discharged to a
rehabilitation facility on [**2104-7-2**].
PHYSICAL EXAMINATION: The patient's examination on discharge
revealed the patient to be neurologically intact. The chest
was clear to auscultation bilaterally with no wheezing,
rhonchi or rales. The sternum was stable. The incision was
clean, dry and intact. His heart was regular with no murmurs,
rubs or gallops. Abdomen was soft, nontender and
nondistended. Extremities were warm with 1+ pedal edema
bilaterally. Vital signs 98.7 was his current temperature,
blood pressure 107/59, heart rate 58, respirations 20,
saturation 94 percent on room air.
Chest x-ray performed [**2104-7-1**] revealed a small left
pleural effusion, otherwise, unremarkable.
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 mEq p.o. q d for two weeks.
2. Lasix 20 mg p.o. q d for two weeks.
3. Colace 100 mg p.o. b.i.d.
4. Protonix 40 mg p.o. q d.
5. Aspirin 325 mg p.o. q d.
6. Acetaminophen 325 mg, two tablets p.o. q four hours p.r.n.
7. Plavix 75 mg p.o. q d for three months.
8. Ditropan 5 mg p.o. q d.
9. Lipitor 40 mg p.o. q d.
10. Multivitamin p.o. q d.
11. Ascorbic acid 500 mg p.o. b.i.d.
12. Iron complex 150 mg p.o. q d.
13. Metoprolol 25 mg p.o. b.i.d.
14. Ceftriaxone 1 gm intravenously b.i.d. for ten days.
15. Darvon for pain 100-650 mg p.o. q six hours p.r.n.
DISPOSITION: The patient was discharged in good condition to
a rehabilitation facility with discharge instructions to
follow-up with Dr. [**Last Name (STitle) 1295**] in [**1-29**] weeks and Dr. [**Last Name (STitle) 70**] in
[**4-1**] weeks.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass grafting times two.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 28488**]
MEDQUIST36
D: [**2104-7-2**] 11:04:42
T: [**2104-7-2**] 11:46:55
Job#: [**Job Number **]
ICD9 Codes: 5990, 9971, 2875, 412
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5522
}
|
Medical Text: Admission Date: [**2145-10-23**] Discharge Date: [**2145-10-23**]
Date of Birth: [**2111-6-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Alcohol intoxication, concern for withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 y/o M with PMH of AVR [**1-30**] endocarditis, HCV, HBV p/w seizure.
The patient reports having seized twice today. He states that he
felt dizzy, fell and then woke up. He states that he felt "out
of it" and had very stiff arms after each event. He reports
still feeling "loopy" now. He also feels agitated and shaky. He
denies any SOB, no CP, no palpatations prior to the events. He
denies any eye pain. Endorses left chest wall tenderness [**1-30**] old
rib fx.
In the ED, the patient was afebrile, tachycardic to 120's with
BP 130/80. He was mildly tremulous on arrival. He noted chest
pain at site of rib fx. EKG nl. CXR w/o pathology. He received a
total of 5mg Ativan on CIWA scale.
Notably, the patient was recently discharged to [**Hospital 1680**] Hospital
after admission for ROMI and abusing inhalants. Pt was ruled
out. Received a CIWA scale but refused nursing assessement. He
was evaluated by psychiatry who did not feel that he had a
mental illness but would from inpatient psych stay.
Past Medical History:
1) s/p aortic mechanical valve replacement in [**2139**] for
endocarditis secondary to IVDU.
- Patient has a cardiologist at [**Hospital1 2177**], but he infrequently follows
care; INR range is supposed to be between 2.5-3.5 but patient is
noncompliant with coumadin. In the past, he has been a patient
of the [**Hospital1 2177**] coumadin clinic.
2) +Hepatitis B and C
- Serology determined during patient's last admission to [**Hospital1 18**]
during which he left AMA after 1 day.
3) H/o EtOH withdrawal seizures
- Denies history of DTs
Social History:
Smokes cig - 1 ppd
-Etoh - onset of problem drinking 15 y/o, ~10 detox, h/o w/d
seizures, denies h/o DTs, longest period of sobriety was 6
months
in '[**31**] (? if in jail during this time), regarding his interest
to
stop drinking states "I don't know...I don't really care...I
want
to leave and have a drink".
-Marijuana - as a kid, none recently.
-Cocaine - "a couple of times/week", smoked or IV, last use was
2
days ago.
-Heroin - past use, denies any recent use.
-Denies any other illicit substance use or prescription med
misuse.
-Homeless
Family History:
From OMR in d/c summary from [**2143-10-13**], DM in mom and sister.
Denies CAD, stroke. Grandparents died of lung CA. Patient denies
family medical history of mental illness.
Physical Exam:
VS: afebrile HR 105 BP 144/90 RR 17 Sa02 95%
Gen: NAD
HEENT: OP clear, EOMI, periorbital bruising, no TTP
Neck: No JVD, no LAD
CVS: RRR, [**3-4**] murmur with systolic click
Pulm: CTAB; + TTP to left chest wall but no bruising
Abd: +BS, NTND, No HSM
Extrem: no c/c/e, mild tremor bilaterally, no clonus, moving all
ext easily, no rigidity
Skin: no rashes
Neuro: non-focal
Pertinent Results:
[**2145-10-23**] 12:17AM WBC-10.9# RBC-4.36* HGB-13.4* HCT-38.6*
MCV-89 MCH-30.8 MCHC-34.8 RDW-13.8
[**2145-10-23**] 12:17AM NEUTS-83.7* LYMPHS-10.2* MONOS-4.9 EOS-0.9
BASOS-0.2
[**2145-10-23**] 12:17AM GLUCOSE-91 UREA N-18 CREAT-1.1 SODIUM-136
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13
[**2145-10-23**] 12:17AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2145-10-23**] 07:16AM WBC-8.2 RBC-4.13* HGB-12.6* HCT-36.7* MCV-89
MCH-30.5 MCHC-34.4 RDW-13.9
[**2145-10-23**] 07:16AM ALBUMIN-3.5 CALCIUM-8.0* PHOSPHATE-2.5*
MAGNESIUM-2.3
[**2145-10-23**] 07:16AM ALT(SGPT)-19 AST(SGOT)-40 ALK PHOS-60 TOT
BILI-0.9
[**2145-10-23**] 07:16AM GLUCOSE-118* UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
CT HEAD W/O CONTRAST Study Date of [**2145-10-23**] 12:19 AM
1. No acute intracranial abnormality.
2. Bilateral maxillary sinus disease.
CHEST (PA & LAT) Study Date of [**2145-10-23**] 2:06 AM
There is minimal left basilar atelectasis. The lungs are
otherwise clear. No pneumothorax is identified. Changes of
median sternotomy are stable. Cardiac and mediastinal
silhouettes are unchanged. No fracture is identified.
IMPRESSION: No acute process.
Brief Hospital Course:
43 y/o M with PMH of AVR [**1-30**] endocarditis, HCV, HBV with
possible alcohol withdrawal and seizure.
# Seizures: question if these were indeed seizures as syncope
may also be c/w this presentation. it is possible that the pt
was hypovolemic or anemic particularly given a slight drop in
HCT. in addition, the patient has recently been increased on
zyprexa which could explain stiffness although he does not
exhibit other signs of NMS w/o fever, AMS or residual rigidity.
In the setting of possible alcohol withdrawal, seizures would be
concerning for DT's. head CT neg. Kept on CIWA scale but did
not require additional benzo dosing while in ICU. Once
clinically sober, patient left against medical advice (AMA).
# Alcohol withdrawal: Patient reported feeling tremulous and
having had seizures in the past with withdrawal. His last
drink was 12-24hrs prior to admission. While inpatient was on
CIWA valium, MVI, thiamine, fluids. Patient then left AMA.
# AVR: subtherapeutic. Initially held heparin gtt bridge to
coumadin until next HCT confirmed stable. When this was
confirmed, patient left AMA. Tried to stress importance of
medical compliance on this issue.
# Slightly lower HCT: baseline 45, 38 on admission. No sign of
HD instability or overt bleeding. No melena, no hematemasis,
guaiac neg. Likely [**1-30**] hemodilution.
# Subclinical Hypothyroidism: TSH 14, may benefit from
levothyroxine but it is doubtful that he would take it and
titration would require followup. Given concern for
noncompliance, will defer to outpatient follow-up.
ONCE CLINICALLY SOBER, PATIENT LEFT AGAINST MEDICAL ADVICE
(AMA).
Medications on Admission:
1. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for mouth pain.
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Alcohol intoxication, withdrawal
Secondary: History of AVR
Discharge Condition:
Stable.
YOU HAVE LEFT AGAINST MEDICAL ADVICE.
Discharge Instructions:
You were admitted for alcohol intoxication, confusion and
concern for seizure. You were monitored and recommended to stay
in the hospital for further medical care. You signed out
against medical advice.
YOU HAVE LEFT AGAINST MEDICAL ADVICE.
Keep all doctor's appointments.
Take all medicatoin as prescribed. You MUST take your
Coumadin/Warfarin as prescribed given your mechanical valve.
Return to ED for headache, chest pain or any other symptom that
is conerning to you.
Followup Instructions:
Please see your PCP this week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 3051, 2449
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5523
}
|
Medical Text: Admission Date: [**2165-6-24**] Discharge Date: [**2165-7-4**]
Date of Birth: [**2086-5-7**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 16590**] had undergone a
coronary artery bypass graft on [**2165-6-14**] and was
subsequently discharged to rehabilitation on [**2165-6-23**].
She was readmitted after being in rehabilitation for
approximately 36 hours on the evening of [**6-24**] with
complaints of the acute onset of shaking chills, rigors, a
fever to 103 at the rehabilitation facility, as well as
hypotension to the 70s systolic.
In the Emergency Department, she was found to be hypotensive
with a systolic blood pressure to the 70s. She had
complications of feeling very cold. She was febrile - I
believe - to 101.6 in the Emergency Department. The patient
had been pan-cultured at that time and was admitted to the
Cardiac Surgery Recovery Unit/Intensive Care Unit for
intravenous Neo-Synephrine to manage her hypotension.
PAST MEDICAL HISTORY: Significant for chronic lymphocytic
leukemia as well as a previous coronary artery bypass graft
(as previously stated), hypertension, hypercholesterolemia,
idiopathic pulmonary fibrosis, and a previous history of
esophageal dilatations. Please see previous Discharge
Summary for details of previous hospitalization during her
coronary artery bypass graft.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg by mouth once per day.
2. Pravastatin 40 mg by mouth once per day.
3. Colace 100 mg by mouth twice per day.
4. Metoprolol XL 25 mg by mouth once per day.
5. Prednisone 20 mg by mouth once per day.
6. Multivitamin.
7. Folic acid.
PHYSICAL EXAMINATION ON ADMISSION: The patient's temperature
was 101.6, her heart rate was 74 (in a normal sinus rhythm),
and her blood pressure was 83/44.
LABORATORY DATA ON ADMISSION: Urinalysis performed in the
Emergency Department was positive for leukocyte esterase as
well as nitrites.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Cardiac Surgery Recovery Unit with a presumed diagnosis of
urosepsis. The patient was placed on an intravenous Neo-
Synephrine drip. The patient was immediately started on
vancomycin and levofloxacin intravenously while waiting
bacteria. She was also given a stress dose of steroids in
the Cardiac Surgery Recovery Unit. She was placed on
intravenous hydrocortisone. She ultimately required
approximately 3 mcg/kilogram per minute of Neo-Synephrine and
had a brief period during the first night of hospitalization
where she was also requiring Levophed in addition for
hypotension into the 70s.
The patient had a central line placed. The patient had an
arterial line placed and was seen by the Critical Care staff
- Dr. [**First Name (STitle) **] [**Name (STitle) **] - who agreed with aggressive hydration and
pressors to support her blood pressure. The patient was also
transfused to a hematocrit of 30. She came in with a
hematocrit of 23.
Also of note, upon admission to the hospital, she did have a
white blood cell count in the 70s; and previously - because
of her leukemia - had been running 30s to 50s. We obtained
an Infectious Disease consultation, and it was at their
recommendation that we continue quinolone as well as
vancomycin initially. The levofloxacin was switched to
ciprofloxacin while we were waiting for the final cultures
because of the interaction with sotalol which she had been
placed on during her previous admission for atrial
fibrillation and a combination of prolongation of the Q-T
interval less likely to occur with the combination of
ciprofloxacin than it was with levofloxacin.
The patient subsequently had gram-negative rods in her blood
as well as in her urine, and this has turned out to all be
the same bacteria which was a resistant Escherichia coli
sensitive to meropenem - which she was ultimately placed on.
A Hematology/Oncology consultation was also obtained due to a
significantly elevated white blood cell count. It was their
recommendation to increase the steroids to 60 mg once per
day, and this was continued for a number of days.
Hemodynamically, over the next few days, the patient
considerably improved. In addition, at the request of the
family, a Urology consultation was obtained due to a history
of recurrent urinary tract infections - approximately three
in the past year. They did not have any significant
recommendations. They did recommend, however, that we could
obtain a CT urogram to evaluate for any source of a
mechanical cause of infection.
A computed tomography was obtained a couple days later, and
this did show air in the bladder which was felt by the
radiologist to be either as a result of a recent Foley
catheterization or bacteria. She was also noted to have
diverticular disease, although no active diverticulitis. She
did have diverticulosis. A General Surgery consultation was
obtained. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] did see the patient and
recommended that Urology follow up probably as an outpatient
to perform a cystoscopy at a later date. The patient was
also followed by the Electrophysiology Service because she
had some bradycardia into the 50s with her hypotension. The
sotalol was discontinued for a couple of days but was
ultimately resumed as her heart rate and blood pressure
improved. It was also the recommendation of the Urology
Service as well as the Infectious Disease Service to continue
suppressive antibiotic treatment due to her recurrent urinary
tract infections.
The patient continued to improve significantly from a
hemodynamic standpoint and was ultimately transferred out of
the Cardiac Surgery Recovery Unit to the Telemetry floor on
hospital day five where she continued to improve. The
patient ultimately had a PICC catheter placed. It was the
recommendation of the Infectious Disease Service to continue
meropenem intravenously for a total of a 2-week course and
then to convert her to Macrodantin by mouth for six months
for chronic suppression of urinary tract infections.
The patient has remained hemodynamically stable, ambulatory,
and ready to be discharged to a rehabilitation facility to
continue to progress with mobility and postoperative recovery
with physical therapy.
Today, the patient's condition is as follows. She remained
in a normal sinus rhythm with a pulse of 60. Her temperature
was 98.4, her respiratory rate was 18, her blood pressure was
112/66, and her oxygen saturation was 98 percent on room air.
Her weight today was 69 kilograms. The patient was alert and
oriented. The lungs were clear to auscultation bilaterally.
Her cardiovascular examination revealed a regular rate and
rhythm. No rubs or murmurs. Her abdomen was benign. Her
extremities were warm with no peripheral edema noted.
Most recent laboratory values included a white blood cell
count of [**Numeric Identifier 20597**], hematocrit was 32, and her platelets were
251. Sodium was 140, potassium was 3.9, chloride was 106,
bicarbonate was 28, blood urea nitrogen was 20, creatinine
was 0.4, and blood glucose was 77. Her INR was 2.1.
MEDICATIONS ON DISCHARGE:
1. Enteric coated aspirin 81 mg by mouth once per day.
2. Colace 100 mg by mouth twice per day.
3. Protonix 40 mg by mouth once per day.
4. Multivitamin one tablet by mouth once per day.
5. Folic acid 5 mg by mouth once per day.
6. Vitamin A 25,000 units one by mouth every day.
7. Sotalol 40 mg by mouth once per day.
8. Tylenol one to two tablets as needed (for pain).
9. Coumadin 2 mg by mouth once per day (this is to be
followed with INR checks at least twice per week and
titrated accordingly for a target INR of 2 to 2.5).
10. Bactrim double strength 150/800 one by mouth three
times per week (this is to continue as long as the patient
remains on greater than 40 mg or greater of prednisone per
day).
11. Prednisone 50 mg once per day (which was just
decreased today - [**7-3**]). The prednisone dose is to
be decreased by 10 mg once per week and ultimately tapered
off. She is to have complete blood counts followed during
this weaning period to be followed by her primary care
physician to aid in the weaning of the prednisone.
12. Meropenem 1 gram intravenously q.8h. (for five more
days after discharge; and this should conclude with her
last dose on [**7-7**]).
DISCHARGE FOLLOWUP: The patient was instructed to follow up
with her primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4281**]). The
patient was to call for an appointment as soon as she is
discharged from rehabilitation. She was also to follow up
with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] (telephone number [**Telephone/Fax (1) 170**])
upon discharge from rehabilitation. She was also to follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] upon discharge from
rehabilitation (telephone number [**Telephone/Fax (1) 285**]). The patient
was to follow up with Dr. [**First Name8 (NamePattern2) 189**] [**Last Name (NamePattern1) **] from the
Hematology/Oncology Service here (office telephone number is
[**0-0-**]). She has an appointment with Dr. [**Last Name (STitle) **] on
[**8-5**] at 1:00 p.m. in the [**Last Name (un) 469**] Clinical Center on
the [**Hospital Ward Name **] of [**Hospital1 69**] on
the ninth floor. She was also to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 365**] from the Urology Service here (telephone number [**Telephone/Fax (1) 58565**]) on [**7-24**] at 11:40 a.m., and his office is located
at [**Hospital1 9384**] on the [**Location (un) 448**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Urosepsis.
2. Status post coronary artery bypass graft.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2165-7-3**] 17:24:51
T: [**2165-7-3**] 18:07:10
Job#: [**Job Number 58566**]
ICD9 Codes: 5990, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5524
}
|
Medical Text: Admission Date: [**2140-3-9**] Discharge Date: [**2140-3-16**]
Date of Birth: [**2071-10-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68 m with hx of 5mm proximal right ureter stone s/p stent
placement [**2140-2-19**], who presented with n,v x 3 days who was
hypotensive to the 70's in the ED with Cr to 3.3 (baseline 0.9)
and leukopenia and thrombocytopenia. He was admitted to the ICU
for sepsis. He had 2/2 bottles of GNR from ED blood cultures
and a grossly positive UA, cx still pending. He was treated
with vanc and zosyn for sepsis and received a total of 7L IVF.
CT showed stent in correct placement and ultrasound was without
hydronephritis. Of note, he has recently been treated with an
increased dose of atenolol for post-surgical AVNRT and increased
terazosin for urinary obstruction.
He is being transferred out of the ICU with urology consult. He
reports that he is feeling much better, still has some mild
nausea and decreased appetite but no vomiting and has been
taking po's. He reports he has not had a BM in 3 days.
ROS: Currently, denies CP, SOB, cough, hematuria, abd pain, or
diarrhea, vision changes, numbness, palpitations.
Past Medical History:
Obstructing ureteral stone, s/p R ureteral stent placement
[**2-/2140**]
HTN
HLD
BPH
Arthritis
s/p CCY
Social History:
Is a musician. No tobacco use. Glass of wine 4 times a week, 3
cocktails per week. No drug use.
Family History:
No h/o urinary problems.
Physical Exam:
On transfer:
Vitals: 98 123/76 78 18 97%RA
GEN: Well-appearing M in NAD
HEENT: EOMI, PERRL, sclera anicteric, dry MM, OP Clear
NECK: No JVD, no cervical lymphadenopathy
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: scattered crackles that clear with cough
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, warm well perfused
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
GU: Foley in place draining dark yellow urine; foley d/c'd
prior to discharge
Pertinent Results:
MICRO:
Blood: [**2140-3-9**]: E.coli 3/4 bottles, sensitive to Cipro
Urine: [**2140-3-9**]: E.coli, sensitive to Cipro
Blood: [**2140-3-10**]: E.coli 1/4 bottles, sensitive to Cipro
UA:
BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-MOD RBC->50 WBC->50
BACTERIA-FEW YEAST-NONE EPI-0
BLOOD:
- CBC: WBC-8.9 RBC-3.60* Hgb-10.3* Hct-30.4* MCV-85 MCH-28.7
MCHC-34.0 RDW-14.5 Plt Ct-83*
- DIFF: Neuts-88.1* Lymphs-6.4* Monos-4.5 Eos-0.6 Baso-0.3
- CHEM 10: Glucose-172* UreaN-50* Creat-1.9* Na-142 K-3.5
Cl-116* HCO3-16* AnGap-14 Calcium-8.4 Phos-2.3* Mg-2.4
IMAGING:
[**3-9**] CT A/P: IMPRESSION: Right ureteral double-J stent in
standard position.
Non-obstructing right lower pole renal stones. No
hydronephrosis.
.
[**3-9**] CXR: IMPRESSION: No acute cardiopulmonary process.
.
[**3-9**] Renal U/S: FINDINGS: The right kidney appears normal by
ultrasound without evidence of hydronephrosis or masses. No
stones are seen. The right kidney measures 12.4 cm. The left
kidney measures 12.3 cm and contains a 4.0 x 2.9 x 2.3 simple
cyst in the lower pole and parapelvic region. No hydronephrosis,
masses or stones are seen. The bladder is collapsed around a
Foley catheter.
.
TTE:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral and trivial aortic regurgitation.
Brief Hospital Course:
This is a 68 year-old male with a history of recent right ureter
stent placement for nephrolithiasis who presents with sepsis
from a urinary source.
.
# UTI with sepsis - he was initially admitted with hypotension
and leukopenia to the ICU, where he received aggressive IVF and
broad-spectrum antibiotics. Blood and urine cultures
subsequently grew out E.coli, sensitive to Ciprofloxacin. He
was transitioned to po cipro (given 100% bioavailability) for a
planned 14-day course from the day following the last positive
cultures ([**2140-3-10**]) - last day of abx is [**2140-3-24**]. Abd CT and
renal u/s showed no obstruction or hydronephrosis; his sepsis
was attributed to BPH and recent rght ureteral stenting. He was
seen by urology in-house, and he will follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2140-3-21**] for removal of the non-obstructing stone. The
patient was voiding comfortably without a foley and with good
UOP for several days prior to discharge.
.
# ARF - initially admitted with a Cr of 3.3, secondary to
pre-renal azotemia +/- ATN. This resolved to a baseline of 1.2
prior to discharge. NSAIDs were avoided.
.
# AVNRT - history of AVNRT during his last admission, which
recurred during this admission in the setting of BB
discontinuation (while in the ICU), stress, and illness. He
responsed to vagal manuvers, adenosine prn, and initiation of
dilitazem. He was seen by Cardiology who recommended transition
back to Atenolol, which he was restarted on prior to discharge
(on original home dose of 100 mg daily). He also underwent a
TTE, which was essentially normal. At rest and with normal
activity, his HR ranges between 60-110; however with voiding and
stress his HR does jump to 140s-160s with AVNRT. He is
asymptomatic, which is reassuring. He is recommended to have an
outpatient Holter for further monitoring and cardiology
follow-up, as scheduled, as ablation may need to be considered
if this is persistent. While inpatient, he should be kept on
tele and vagal manuvers and/or adenosise can be used to break
the rhythm.
.
# BPH - transitioned to tamsulosin 0.4 mg qhs, passed voiding
trial successfully.
.
# Thrombocytopenia: Was low at 121 on admission (baseline 160)
with decrease to 80s. Likely from sepsis vs. med effect with
PPI and has been on Zosyn both known to cause thrombocytopenia.
HIT Ab was negative. Platelet count normalized on its own to
214K prior to discharge.
Medications on Admission:
Medications on Transfer:
Piperacillin-Tazobactam 2.25 g IV Q6H
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain or fever
Heparin 5000 UNIT SC TID
Morphine Sulfate 2 mg IV Q4H:PRN pain
Multivitamins 1 TAB PO/NG DAILY
Omeprazole 40 mg PO DAILY
Terazosin 2 mg PO BID
Ondansetron 4 mg IV Q8H:PRN nausea
Vancomycin 1000 mg IV Q 24H
Home Medications:
Pravastatin 20mg qday
Atenolol 100mg qday
Treazosin 5mg [**Hospital1 **]
Ibuprofen 400mg TID-QID for last 2 weeks
MV
Selenium
Prilosec 40mg qam
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. 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*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days: Last dose to be on [**2140-3-24**]. .
Disp:*16 Tablet(s)* Refills:*0*
6. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for anxiety: This medication can cause
sedation; do NOT drink or drive while taking this medication. .
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
UTI with sepsis
Tachycardia, AVNRT
HTN
BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a urinary tract infection (e.coli)
resulting in sepsis (bloodstream infection). You were treated
initially with IV antibiotics and IV fluids, and switched to
oral antibiotics once your symptoms improved. You will need to
complete this course over the next 8 days (last day [**2140-3-24**]).
Your course was complicated by fast heart rates, for which you
were started on atenolol. you were seen by cardiology, who
agreed with the plan. Your echo was unremarkable.
you are scheduled for a lithotripsy with Dr.[**Name (NI) 24219**] office on
Monday, [**3-21**].
.
MEDICATION RECONCILIATION:
1. Start Ciprofloxacin 750 mg twice daily for 8 more days (last
day [**2140-3-24**])
2. Start Atenolol 100 mg daily
3. Start Tamsulosin 0.4 mg at night
4. Continue pravastatin, prilosec
5. Take ativan as needed for anxiety, please note this
medication can cause sedation and you should not drink or drive
while taking this medication.
Followup Instructions:
Urology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for Ureteroscopy on [**3-21**] at 2:15
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: Internal Medicine
Address: [**Apartment Address(1) 108209**], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 8960**]
Appointment: Thursday [**3-24**] at 9:30AM
Name: [**Doctor Last Name **]-[**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital6 **]
Address: [**Location (un) **], 3rd FL [**Location (un) **],[**Numeric Identifier 13108**]
Phone: [**Telephone/Fax (1) 47675**]
Appointment: Wednesday [**4-6**] at 9AM
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2140-3-16**]
ICD9 Codes: 5845, 2762, 2875, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5525
}
|
Medical Text: Admission Date: [**2137-8-8**] Discharge Date: [**2137-8-13**]
Date of Birth: [**2063-1-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Fever/Hypoxia
.
Reason for MICU transfer: Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 10523**] is a 74 y/o M with a h/o IPF, bullous emphysema
normally on home oxygen for exercise and a recent
hospitalization at [**Hospital1 18**] from [**Date range (1) 10525**] for pneumonia, where he
was discharged on levofloxacin, cefpodoxime and flagyl and at
the time of discharge had an increased oxygen requirement to 1L
at rest and 3L with activity who presents from his
pulmonologists office with continued fever and hypoxia. He went
to his regularly scheduled pulmonology follow up appointment
today, where he was found to be hypoxic to 75% on 4LNC after
walking in from the car. After resting his oxygen saturation
improved to the high 80's, however when he walked around the
room he continued to desaturate to the 80's on 3-4LNC. A CXR
was done that showed the known RUL PNA, and he continued to
complain that he felt "hot" at night, so he was sent to the ER
for further evaluation as his physician was concerned that he
could have an infected bullous.
.
In the ED, initial VS were: 99.4, 84, 138/74, 20, 89% 4L. In
the ER since he was desaturating with ambulation, a CTA of his
chest was done that showed multiple small pulmonary emboli,
worsening of the RUL pneumonia and fluid in the fluid in the
right upper lobe in bullae of unclear etiology. He was given
vancomycin and zosyn (has a pcn allergy, although reportedly
tolerated ok), and started on a heparin gtt. His labs were
notable for a white count of 13.3 with 78%N, no bands. During
his ER course he continued to desaturate on 4LNC, and eventually
required a NRB to keep his oxygen saturation in the 93-96%
range, although he did not have any increased work of breathing
or any signs of respiratory distress. VS on transfer were: 81,
131/70, 20, 93-96% on NRB.
.
On arrival to the MICU his initial VS were: 97.8, 80, 149/68,
16, 97% on 5LNC and 100% shovel mask. He says that he has not
been coughing much, but every morning says that he does cough to
"clear his airways." He currently feels well, denies any chest
pain, shortness of breath, n/v/d, abdominal pain, orthopnea or
LE edema.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Pulmonary fibrosis -- on home oxygen 2LNC when he excercises and
sleeps
bullous emphysema, h/o hemoptysis
Lung nodules
Osteoarthritis of Hip s/p right hip replacement [**2135**]
Glucose Intolerance
COPD
diverticulosis
OSA
HTN
colonic polyp
h/o squamous cell carcinoma - SKIN-L clavicular area, SCC in
situ
hyprecholesterolemia
nephrolithiasis
BPH and prostatic nodule
Social History:
Lives in a house in [**Location (un) 745**] with his wife. Heavy cigarette
smoker prior to [**2116**], none since. 2ounces of bourbon regularly.
NO MJ, IVDU. Exercises almost daily for about one hour on
either a stationary bike or nordic track, also participates in a
softball league, does wear oxygen when he exercises and at
night.
Family History:
Father - CVA, Mother MI, CVA. Uncle - DM.
Physical Exam:
On Admission to MICU
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, oropharynx clear
Lymphatic: Cervical WNL, Supraclavicular WNL, No Cervical
adenopathy
Cardiovascular: RRR, Nl S1,S2 no M/G/R
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: Crackles : in the right upper lobe area
around his scapula and along his spine, no wheezes or rhonchi
Abdominal: Soft, Non-tender, Bowel sounds present, Not Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No Cyanosis, No Clubbing
Skin: Warm, No Rash: , No Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Tone: Normal
.
Discharge Exam:
VS: 97.9 (99.6), 131/76 73 18 93%on 3L NC
Gen: Pt is a very pleasant gentleman in NAD
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, MMM, OP clear
Neck: Supple, no LAD, no thyromegaly
CV: RRR, NL S1 & S2, no MRG
Chest: Good respiratory effort, unlabored. Few rales in RLL.
+egophony diffusely at lung bases. decreased tactile fremitus
bilaterally.
Abd: +BS. soft/nt/nd. no HSM. no guarding/rebound.
Ext: No C/C/E. 2+ radial, DP, PT pulses.
Skin: No rashes or lesions. Numerous seborrheic keratoses,
dermal and junctional moles throughout.
Neuro: Awake, alert, and oriented to [**Hospital1 **] and date. CNs II-XII
intact. Strength 5/5 in delts, biceps, triceps, and IPs on motor
exam.
Psych: Normal mood and affect.
Pertinent Results:
LABORATORY DATA
CBC
[**2137-8-8**] 04:40PM BLOOD WBC-13.3* RBC-3.96* Hgb-12.6* Hct-36.6*
MCV-93 MCH-31.8 MCHC-34.4 RDW-12.2 Plt Ct-419
[**2137-8-8**] 04:40PM BLOOD Neuts-78.2* Lymphs-11.8* Monos-6.1
Eos-3.4 Baso-0.5
[**2137-8-10**] 05:53AM BLOOD WBC-10.1 RBC-3.74* Hgb-12.0* Hct-36.1*
MCV-96 MCH-31.9 MCHC-33.1 RDW-12.4 Plt Ct-431
.
CHEMISTRY
[**2137-8-8**] 04:40PM BLOOD Glucose-97 UreaN-21* Creat-0.9 Na-136
K-4.6 Cl-99 HCO3-28 AnGap-14
[**2137-8-11**] 08:25AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-140
K-4.0 Cl-105 HCO3-24 AnGap-15
.
LFTs
[**2137-8-8**] 04:40PM BLOOD ALT-99* AST-52* LD(LDH)-238 CK(CPK)-57
AlkPhos-95 TotBili-0.4
.
IRON STUDIES
[**2137-8-11**] 08:25AM BLOOD calTIBC-189* Ferritn-591* TRF-145*
.
MICROBIOLOGY
Legionella Urinary Antigen (Final [**2137-8-11**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
.
Blood cultures- pending
.
IMAGING
CTA [**2137-8-8**]:
1. Multiple small pulmonary emboli involving the segmental and
subsegmental
arteries of the right lower lobe and lobar arteries of the left
lower lobe and
lingula. No evidence of right heart strain on this study.
2. Worsening pneumonia in the right upper lobe on a background
of severe
emphysema and known IPF. Fluid within bullae in the right upper
lobe is
thought most likely to reflect normal sequela from pneumonia,
but a
necrotizing component cannot be excluded.
.
Brief Hospital Course:
Mr. [**Known lastname 10523**] is a 74-year-old man with a history of IPF, bullous
emphysema and recent admission for presumed CAP, discharged on a
regimen of cefpodoxime, levofloxacin and metronidazole who now
re-presents with worsening RUL pneumonia complicated by possible
infected bulla and multiple small pulmonary emboli in the
setting of significantly worsened hypoxemia.
.
#) Pneumonia and possible infected bullae: The patient was
recently hospitalized for a presumed CAP but failed treatment
and re-presented with worsening hypoxia, continued fever and CT
findings of possible infected bullae vs. necrotizing pneumonia.
He was admitted to the MICU for close monitoring. For the HCAP
and infected bullous/functional lung abscess he needed coverage
for MRSA, pseudomonas and bacteroides and was placed on
Vancomycin, Meropenem, and levofloxacin. Multiple induced sputum
cultures were sent however all were contaminated with saliva.
Patients oxygen saturations were noted to improve, he remained
afebrile with a down trending WBC; therefore, he was transferred
to the floor. On the floor he was maintained on supplemental
oxygen as needed to keep oxygen saturations above 92%. Given his
umimpressive history of a penicillin allergy, and his recent
failure of cefpodoxime, levofloxacin, and metronidazole, the
patient was switched to Augmentin 875mg PO Q8H on [**8-12**] and
monitored for allergic reaction. He did not exhibit any signs
of drug allergy after starting Augmentin.
.
Given patient's clinical improvement the utility of bronchoscopy
has lessened. Additionally the patient has underlying lung
disease that increases risk that bronchoscopy could result in
him requiring intubation. Therefore decision was made to hold
off on bronschoscopy. This was discussed with his outpatient
pulmonologist, Dr. [**Last Name (STitle) 9303**]. Patient improved throughout
admission and remained afebrile. He was discharged on Augmentin
[**2125**] mg [**Hospital1 **] for 14 days. He will discuss continuing the course
of antibitoics with his pulmonologist and his PCP.
.
#) Multiple Pulmonary Emboli: Multiple PEs were seen on CTA
chest, likely contributing to his significant hypoxia, but he
was otherwise asymptomatic (no chest pain, tachycardia.). Of
note, he was on DVT prophylaxis with SQ heparin during his
recent hospitalization. Heparin gtt was started, and coumadin
was started on [**8-12**]. Mr. [**Known lastname 10523**] was discharged on coumadin
with lovenox bridge.
Dosing of coumadin:
[**8-12**]: 7.5 mg
[**8-13**]: 5 mg
[**8-14**]: 5 mg
[**Location (un) 2274**] anti-coagulation nurses are aware that patient is starting
coumadin and will contact patient regarding anti-coagulation
follow-up.
.
#) Transaminitis: Patient with elevation of his AST and ALT
during hospitalization. Initially statin was held, but this is
unlikely [**12-19**] to statin as he had normal LFTs at outpatient
appointment this month and the statin is not a new medication.
Possibly secondary to meropenem. Patient needs outpatient
work-up for transaminitis.
.
#) Mild Normocytic Anemia: baseline HCT as an outpatient is in
the low 40's, during his last hospital stay HCT was between 34
and 37, has remained stable since that time, likely due to the
inflammation from his current illness. Iron studies were
consistent with anemia of chronic disease.
.
#) Obstructive Sleep Apnea: Continue CPAP at night with
supplemental oxygen with goal to keep oxygen sat > 92%,
.
#) Hypertension: Patient was continued on home diltiazem XR
120mg daily with good blood pressure control
.
#) Hypercholesterolemia: Initially held statin given elevation
in LFTs. Restarted statin at discharge.
.
TRANSITIONAL ISSUES:
# Beta-glucan and galactomannan pending at discharge - will be
followed up by primary team
# Outpatient work-up for elevated AST/ALT
# Code: Full (confirmed with patient)
Medications on Admission:
1. pravastatin 40 mg DAILY
2. diltiazem HCl 120 mg ER DAILY
3. cefpodoxime 200 mg twice a day for 6 days.
4. levofloxacin 750 mg DAILY for 6 days.
5. metronidazole 500 mg Q8H for 6 days.
6. Home Oxygen Therapy - 1 liter/minute at rest and increase to
3
liters/minute with ambulation or activity.
Discharge Medications:
1. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB,
wheezing.
3. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. amoxicillin-pot clavulanate 1,000-62.5 mg Tablet Extended
Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO
twice a day for 14 days.
Disp:*56 Tablet Extended Release 12 hr(s)* Refills:*0*
5. warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO As directed: Take
5 mg on [**8-14**] and [**8-15**]. Then take as directed by the
anti-coagulation nurses at [**Location (un) 2274**]. .
Disp:*60 Tablet(s)* Refills:*2*
6. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q12H (every 12 hours) for 7 days: You must take this medication
until you have a therapeutic "INR" for 2 days. [**Hospital **] will direct you. .
Disp:*QS mL* Refills:*0*
7. Oxygen
Oxygen 2 - 4 L/minute to maintain oxygen saturation of 90 - 93%.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Pulmonary embolsim
Pneumonia
COPD
SECONDARY:
Pulmonary fibrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 10523**],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you were noted to have very poor
oxygen saturations while at your pulmonologist's office. A chest
xray and CT both showed worsening of your pneumonia and
pulmonary embolism. You were admitted to the MICU where you
were started on antibiotics with improvement in your oxygen
saturations. You will need to continue antibiotics for another
14 days until you follow-up with your primary care doctor or
pulmonary doctor.
We also started you on a blood thinner for the pulmonary
embolism (blood clot in your lung). You will start on coumadin.
The anti-coagulation nurses at [**Location (un) 2274**] will contact you to
schedule an appointment for you this week regarding the coumadin
dosing.
We made the following changes to your medications
1. START Augmentin [**2125**] mg (twice a day) for 14 days - you may
continue this medication for longer. Please discuss with your
PCP at your next appointment.
2. START coumadin 5 mg daily for the next two days ([**8-14**] and
[**8-15**]). You will should continue taking as directed by the
[**Hospital 2786**] clinic at [**Location (un) 2274**].
3. START lovenox 90 mg SC twice a day. You will take this for
the next 5 days OR until you have been therapeutic on coumadin
for 48 hours (whichever is longer).
Please see below for your follow-up appointments.
Followup Instructions:
Name: CAMAC-[**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
When: Tuesday, [**8-20**], 1:30PM
*You will also receive a call from [**Last Name (un) 10526**] [**Hospital1 **] to get set up
in the [**Hospital **] Clinic this week.
Name: [**Last Name (LF) 9303**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
When: Tuesday, [**10-1**], 10AM
*Dr. [**Last Name (STitle) 9303**] is trying to get you in sooner. You will receive
a call from his office if they can fit you in before [**Month (only) **].
ICD9 Codes: 486, 4019, 2720, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5526
}
|
Medical Text: Admission Date: [**2101-10-18**] Discharge Date: [**2101-10-25**]
Date of Birth: [**2041-10-12**] Sex: F
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yo F with RA (only on plaquenil), HTN, pulm fibrosis, PVD,
OA, tobacco use presents to ED with 2-3 wk h/o malaise, dry
cough, and progressive SOB. Denies any F/C/NS. Nearly
intubated in the ED for hypoxic respiratory failure (O2 sats
80s, RR 40s), with significant wheeze. However, with IV
steroids and continuous albuterol nebs, improved and
stablilized, though still tachypnic with wheeze. CTA
demonstrated no PE, though large mass (taking up much of RUL,
some of RML that compresses the RUL and RML bronchi, with
?extension into the pretrachial/subcarinial space vs associated
lymphadenopathy, innumerable bilateral nodules and thick
interstitial markings. In addition, hypodensities were
visualized in the liver. Started on empiric levo/azithro in the
ED.
ED course also notable for MAT as high as 170 bpm, in part
exacerbated by albuterol, with rate-related lateral ischemic
changes (st dep V3-V6, lateral TWI). ruling out for MI with
serial neg cardiac enzymes.
Past Medical History:
RA
pulmonary fibrosis
PVD
tobacco use (>20 years)
OA
HTN
prior Cardiomyopathy, with EF now 55% (was 30-40% [**2095**], etiology
unknown)
Recent p-mibi, with no perfusion defects, no [**Last Name (LF) **], [**First Name3 (LF) **] 58%
s/p appy
s/p cervical fusion [**2095**]
s/p lumbar fusion
OA
Social History:
Very relgious, former heavy smoker.
Family History:
N.C.
Physical Exam:
T 97.9 HR 127 BP 138/63 RR 25 98% NRB
Gen: Female, sitting up, tachypnic, w/ acc muscle use
HEENT/Neck: +JVD, +cervical LAD, EOMI, MM dry,
CV: irregular, tachy, no m/r/g
Pul: diffuse wheezes, poor a/m b/l
abd: soft, nt, nd.
Ext: no edema, from
Pertinent Results:
[**2101-10-18**] 02:22PM TYPE-ART TEMP-37.0 RATES-/30 O2-60 PO2-118*
PCO2-40 PH-7.36 TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA
[**2101-10-25**] 03:02AM BLOOD WBC-17.2* RBC-3.61* Hgb-9.9* Hct-31.9*
MCV-88 MCH-27.5 MCHC-31.1 RDW-15.0 Plt Ct-95*
[**2101-10-25**] 03:02AM BLOOD Glucose-150* UreaN-56* Creat-1.2* Na-145
K-4.5 Cl-111* HCO3-25 AnGap-14
[**2101-10-25**] 09:40AM BLOOD Type-ART Temp-36.4 O2 Flow-4 pO2-70*
pCO2-51* pH-7.26* calHCO3-24 Base XS--4 Intubat-NOT INTUBA
Brief Hospital Course:
Pt was admitted to the [**Hospital Unit Name 153**] in respiratory distress.
CT/angiogram results showed a large right lung mass, likely to
be lung cancer, with metastasis to the left lung and liver. The
prognosis of this cancer was discussed with the patient and her
sister, [**Name (NI) **], her healthcare proxy. [**Name (NI) **] the patient's
respiratory distress seemed to improve, her blood gases
demonstrated that she was tiring out. On [**10-24**] and [**10-25**] family
meetings were held to discuss the patient's progress and dismal
prognosis. At this time the patient was made DNR/DNI but
treatment was continued. Later on in the night, the patient
became hypotensive and increasingly short of breath. After
speaking with [**Doctor Last Name **], her healthcare proxy, comfort measures
were started with morphine. Shortly thereafter, she became more
hypoxic and bradycardic. The patient had no corneal reflexes,
and had no heart sounds or breath sounds for one minute. Time
of death was 7:10pm. The family was present. Autopsy consent
was granted.
Medications on Admission:
lopressor
oxycontin
vioxx
plaquenil
fosamax
mvi
Discharge Medications:
expired
Discharge Disposition:
Home
Facility:
expired
Discharge Diagnosis:
pneumonia
metastatic lung cancer
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
ICD9 Codes: 4254, 4280, 5849, 4019, 4439
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5527
}
|
Medical Text: Admission Date: [**2180-3-10**] Discharge Date: [**2180-3-18**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
swan ganz catheter placement
History of Present Illness:
Mr. [**Known lastname 51298**] is a 84 year old male with a history of type A
aortic dissection repair in [**7-26**] complicated by embolic stroke
that was admitted from an OSH on [**3-10**] with w/ type B aortic
dissection for medical management.
The patient is a caregiver for his blind and disabled wife with
diabetes, and has not been taking medications for 1 month due to
being too busy with his wife and possibly not comprehending
importance. He presented to an outside hospital complaining of
low back pain. A CT scan obtained at the outside showed: type B
dissection to L external iliac a. Patent celiac/SMA/[**Female First Name (un) 899**]/renals,
4 cm ascending AAA. Pt started on esmolol+nipride, transferred
to [**Hospital1 18**].
During CCU stay, patient cardioverted from Aflutter/Afib. Team
had some difficulty with controlling labile blood pressures in
setting of post cardioversion sinus bradycardia- has been
controlled with Hydralazine and Labetalol IV and is now being
switched to PO meds. Also found to have newly decreased EF (see
echo report) and new ARF.
On ROS: the patient denies chest pain, shortness of breath,
abdominal pain, dysuria, fever/chills.
Past Medical History:
1.Type A aortic dissection-repair [**7-26**]
2. HTN noncompliant w/ meds
3. Depression
Social History:
Lives in [**Location 4310**] with his wife - blind and disabled from [**Name (NI) 1568**]
patient is her primary caregiver. [**Name (NI) **] also lives with him- ? if
helpful. No tobacco, no EtOH, no recreatinoal drugs
Family History:
non-contributory
Physical Exam:
98.7, 60, 114/58, 20, 94%RA, 100/70 i/o since mdn, 73.7kg
NAD, AAOx3, resting comfortably, no concerns
MMM, OP-clear
RRR
bibasilar crackles
Soft, NT/ND, +BS
trace LE edema, warm, radial 2+ bilat, DP- not palpable at
marked area.
Pertinent Results:
Echo: The left atrium is elongated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is moderate global left ventricular
hypokinesis. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
are mildly thickened but no aortic stenosis is present. Mild
(1+) aortic regurgitation is seen. Mild to moderate ([**12-26**]+)
mitral regurgitation is seen. There is moderate [2+] tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
Global biventricular hypokinesis c/w diffuse process
(toxin,metabolic, multivessel CAD, etc.). Mild-moderate mitral
regurgitation. Mild arotic regurgitation.
Abdominal MRI:
1) Aortic dissection extending at least as high as the
descending thoracic aorta, its proximal extent is not included
on this study, which extends distally at least as far as the
left common iliac artery. Mural thrombus at the level of the
diaphragmatic hiatus within the abdominal aorta.
2) Single widely patent renal arteries on each side. Extrinsic
compression of the left renal artery by the false lumen during
the cardiac cycle is not excluded on the basis of this study.
Cine imaging of the renal artery can be performed to assess for
that possibility. The patient shall be brought back for these
additional images at no additional cost. Both kidneys however
perfuse symmetrically with contrast.
3) Bibasilar atelectasis.
[**2180-3-10**] 05:23PM GLUCOSE-186* UREA N-18 CREAT-1.7* SODIUM-139
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-16* ANION GAP-17
[**2180-3-10**] 05:23PM CK-MB-4 cTropnT-0.02*
[**2180-3-10**] 05:23PM FERRITIN-94
[**2180-3-10**] 05:23PM TSH-1.6
[**2180-3-10**] 05:23PM CRP-5.45*
[**2180-3-10**] 05:23PM WBC-9.8 RBC-4.95 HGB-14.9 HCT-43.4 MCV-88
MCH-30.2 MCHC-34.4 RDW-14.5
[**2180-3-10**] 06:00AM ALT(SGPT)-72* AST(SGOT)-30 CK(CPK)-106 ALK
PHOS-146* TOT BILI-1.7*
[**2180-3-10**] 06:00AM GGT-60
[**2180-3-10**] 06:00AM TRIGLYCER-83 HDL CHOL-46 CHOL/HDL-3.0
LDL(CALC)-76
Brief Hospital Course:
Mr. [**Known lastname 51298**] was admitted with an Aortic Dissection Type B, from
thoracic aorta to level of external iliacs. There was mural
thrombus in the new dissecting Type B aorta but he was not
anticoagulated with heparin secondary to dissection per vascular
surgery recomendations. His blood pressure control goal was SBP
100-120 and to facilitate this he was switched from PO
medications to labetalol, hydralazine, and isosorbide
mononitrate. This controled him well, although he had been
labile in the CCU and with sinus bradycardia.
Mr. [**Known lastname 51298**] had irregularities with his rhythm. He was DC
cardioverted from atrial flutter/atrial fibrillation to
borderline sinus bradycardia. He was also loaded with amiodarone
400 QD however he was not anticoagulated because of dissection.
Following conversion to NSR, Mr. [**Known lastname 51300**] pressure dropped,
requiring use of pressors. He was eventually weaned off without
further complications. Once stable, he was restarted on oral
agents.
From the standpoint of his pump function, the echo showed EF of
35 % and Mr. [**Known lastname 51300**] old EF was normal. The etiology for this
change was unclear as it could be from either hypertension or
from CAD or from both. Since the creatinine bumped from a
previous contrast [**Last Name (LF) 1868**], [**First Name3 (LF) **] outpatient catheterization was
suggested once the creatnine goes back to baseline. His aspirin
and plavix were continued. He was initially not on a statin but
it was not clear as his total cholesterol was 130 and LDL 78.
Even so, it was started since antiinflammatory effects may help
with the ulcerating plaques in the aortic intima.
Mr. [**Name14 (STitle) 51301**] was found to have acute renal failure with stable Cr
at 2.1. This was not thought to be secondary to extension of the
dissection because the MR showed that the renal arteries come
off the true lumen. Instead, it was thought likely from
contrast [**Name14 (STitle) 1868**]. His renal function and cardiac catheterization
should be followed as an outpatient. He was transferred to the
floor for further management once his acute issues were stable.
Patient had an unremarkable floor course and discharged home on
[**2180-3-18**] for cardiology followup as an outpatient.
Medications on Admission:
patient noncompliant
Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): will need to increase dose as tolerated as oupatient in
3weeks by discussing with Dr. [**First Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*2*
9. Labetalol HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Hydralazine HCl 10 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All CAre
Discharge Diagnosis:
aortic dissection
hypertension
congestive heart failure
Discharge Condition:
fair- able to walk and carry out ADLs.
Discharge Instructions:
-avoid vigorous activity
-take all medications as prescribed, they are ESSENTIAL to your
health and life with this aortic dissection.
-heart healthy diet
-call your doctor or return to the emergency department with any
chest pain, shortness of breath, back pain, high blood pressure,
or any other concerns
Followup Instructions:
Followup with your primary care doctor in [**12-26**] weeks for followup
on your blood pressure (VERY IMPORTANT WITH THIS DISSECTION) and
your renal function. Call for an appointment.
Followup with Dr [**First Name (STitle) **] your cardiologist in [**12-26**] months, first
available appointment, to follow this aortic dissection and to
discuss need for futher cardiac catheterization because of your
decreased heart function.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
ICD9 Codes: 5849, 4254, 2875, 4019, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5528
}
|
Medical Text: Admission Date: [**2206-8-24**] Discharge Date: [**2206-9-3**]
Date of Birth: [**2132-5-30**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Fall, Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 1007**] is a 74 y/o F with a h/o COPD on 4L O2 during day and
6L O2 at night, pulmonary hypertension, obesity hypoventilation,
dCHF (EF > 55% in [**8-/2205**]), anxiety and multiple recent
hospitalizations for dyspnea, thought to be due to her
underlying untreated OSA and obesity hypoventilation syndrome,
who presented from home s/p a "fall". She was working with two
health aides when she felt weak and was lowered to the floor and
was unable to get up so EMS was called. She initially
complained of two days of productive cough, worsening shortness
of breath and subjective fever/chills.
In the ED, initial vs were: 97, 70, 144/61, 14, 94% on her home
4L nasal cannula. There was initial concern that she was
somewhat somnolent so she was given narcan 0.4mg x 1 with some
improvement in her MS. She refused to undergo a head CT and the
ER physicians felt she understood the risk of her refusal. She
had a CXR that was read as improved mild pulmonary vascular
congestion, no focal consolidation or infiltrate. Her EKG was
A.flutter at 73, consistent with prior. Labs were notable for a
PCO2 of 56, [**Known lastname **] count of 4.1, which is down from 6.1 two days
ago, lactate of 2.2. Despite her negative CXR and normal [**Known lastname **]
count, there was concern for PNA so she was given cefepime,
levofloxacin, with plans to give vancomycin as well and admitted
to the ICU since she has baseline poor respiratory status. At
the time of transfer her VS were: 88, 137/79, 24, 94% on 4LNC,
per report with no increased work of breathing.
.
On arrival to the MICU her initial VS were: 96.5, 86, 126/69,
22, 92% on 6LNC. Her current weight is 257lbs and weight on
discharge was recorded to be 263.5lbs. She complained of
shortness of breath that is unchanged from her baseline and
feeling tired. As there did not appear to be any acute process,
she was transferred to the floor.
Prior to transfer, she had a panic attack and on further
discussion notes that she has had progressive anxiety.
Pallitaive care had recommended morphine prn which was just
recently started. The patient's anxiety worsens her breathing.
She is however, amenable to pulmonary rehab and further
treatment of her anxiety.
ROS: see hpi She denied any associated n/v/d, abdominal pain,
chest pain, palpitations, HA, changes in her vision. She does
endorse continued orthopnea, PND multiple times per week and
possibly an increase in her LE edema. She says that her cough
is the same as it has been since her recent discharge from [**Hospital1 18**]
on [**2206-8-20**] with a presumed viral URI. 10 point ROS otherwise
negative.
Past Medical History:
- COPD
- obesity
- unspecified hypoxemia
- CNS lymphoma c/b CVAs x3 (posterior circulation) and seizure
d/o
- history of SAH while on coumadin
- diastolic heart failure
- coronary artery disease
- atrial fibrillation
- hypertension
- hyperlipidemia
- severe OSA (did not tolerate CPAP in the past)
- primary hyperparathyroidism/25-vit D deficiency c/b
nephrolithiasis
- toxic multinodular goiter with subclinical hyperthyroidism
- neovascular glaucoma c/b right eye blindness
Social History:
- Smoking: Denies current smoking. Heavy smoker in the past quit
in [**2175**]. About 3 ppd for 30 years
- EtOH: Denies.
- Illicits: Denies.
- Home: Lives at [**Hospital3 **] facility and recently enrolled
in home hospice. At baseline, able to
transfer to and from chair without support; able to bath self;
able to feed and dress self. Cooking/food provided at [**Hospital **]. Uses a wheelchair to get around.
- Work: Not working. Retired ob/gyn nurse.
Family History:
Father - Esophageal problems (unsure of the specifics),
[**Name (NI) 5895**]
Mother - Bradycardia, AAA
3 brothers all passed away: -Diabetes and heart attacks
Sister: healthy
Physical Exam:
Admisssion Physical Exam:
VS 35.8 86 126/69 22 92% NC 6L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
Admission Labs:
[**2206-8-24**] 09:46PM WBC-4.1 RBC-4.90 HGB-13.1 HCT-42.8 MCV-87
MCH-26.7* MCHC-30.6* RDW-18.8*
[**2206-8-24**] 09:46PM NEUTS-66.0 LYMPHS-23.7 MONOS-5.4 EOS-3.7
BASOS-1.2
[**2206-8-24**] 09:46PM PLT COUNT-320
[**2206-8-24**] 09:46PM GLUCOSE-96 UREA N-17 CREAT-1.0 SODIUM-139
POTASSIUM->10 CHLORIDE-102 TOTAL CO2-31
[**2206-8-24**] 09:46PM CK(CPK)-233*
[**2206-8-24**] 09:46PM cTropnT-<0.01
[**2206-8-24**] 09:46PM CK-MB-4
[**2206-8-24**] 09:57PM LACTATE-2.2* K+-8.9*
[**2206-8-24**] 11:12PM K+-3.5
[**2206-8-24**] 09:57PM TYPE-[**Last Name (un) **] PO2-33* PCO2-56* PH-7.36 TOTAL
CO2-33* BASE XS-3
.
Microbiology:
blood cultures ([**8-24**]): [**1-14**] bottle coag neg staph
[**8-26**] cultures no growth.
Imaging:
CXR ([**8-24**]): UPRIGHT AP VIEW OF THE CHEST: There is continued
moderate cardiomegaly. Lung volumes remain low. The mediastinal
and hilar contours are stable. Mild pulmonary vascular
congestion persists, but may be mildly improved when compared to
the prior study. Linear atelectasis in the right lung base is
unchanged. No large pleural effusion or pneumothorax is
identified. IMPRESSION: Persistent mild pulmonary vascular
congestion, perhaps slightly improved compared to the prior
study. No new focal consolidation.
.
CXR ([**8-25**]): FINDINGS: In comparison with study of [**8-24**], there
is continued mild pulmonary vascular congestion. Poor definition
of the hemidiaphragms suggests possible small effusions and
atelectasis in a patient with low lung volumes.
.
Head CT [**8-25**]: FINDINGS: Again noted is encephalomalacia in the
left cerebellum (image 3:3)
and right occipital lobe (image 3:8), unchanged. There is no
acute
intracranial hemorrhage, edema or mass effect. There is no
evidence of
enhancing intraaxial or extraaxial lesions. The ventricles and
sulci remain
prominent, compatible with age-related global atrophy.
No lytic or sclerotic bone lesions suspicious for malignancy are
seen.
Thickening of the right maxillary sinus walls is again seen,
likely sequela of
prior chronic sinusitis.
IMPRESSION:
No evidence of new intracranial abnormalities. MRI would be more
sensitive
for evaluating the status of intracranial malignancy and for
detecting a
seizure source, if clinically warranted.
Brief Hospital Course:
Ms. [**Known lastname 1007**] is a 74 y/o F with a complicated PMH that includes
chronic hypoxemia on home oxygen (4L during the day and 6L at
night), untreated OSA, obesity hypoventilation syndrome,
pulmonary hypertension and multiple recent admissions who
presents after an episode of weakness at home with anxiety and
shortness of breath
.
#Dyspnea
# Chronic hypoxemia
#Obstructive sleep apnea
#Obesity hypoventilation syndrome
#Pulmonary hypertension
It is unclear if this is a true change from her baseline, as
most of her complaints seem to be chronic and she has frequent
dyspneic attacks which are closely correlated with anxiety
attacks as well. Her cough is unchanged from a recent
admission and she is afebrile, with no leukocytosis or CXR
findings that would support a pneumonia as the cause of her
dyspnea. Her current weight is 257lbs, which is 6lbs less than
her recent discharge weight ([**8-20**]) which also makes a component
of HF and volume overload less likely. No wheezing on exam.
Some notes indicate that she has COPD but pulmonary notes show
FEV1/FVC of 70% without significant obstruction. She was
continued on albuterol/atrovent nebs. She has baseline severe
OSA but does not tolerate CPAP.
She has seen palliative care on a prior admission and also has
recently enrolled in home hospice. She was continued on liquid
morphine prn and benzodiazepine for anxiety. (is on Xanax as an
outpt, and we increased its availability prn).
#) Anxiety: Based on prior admissions, anxiety appears to play a
substantial role in her sensation of dyspnea. She was continued
on xanax prn (increased availability to tid prn) and we
communicated with her outpatient psychiatrist and PCP regarding
her care. Her psychiatrist was ok with starting a long acting
benzodiazepine if needed but the pt did not require this. We
were also cautious about doing this because as her pulmonary
physician has noted, she has substantial sleep apnea and is
prone to CO2 retention. Her psychiatrist also mentioned that if
needed in the future, her seroquel could be titrated up for
anxiety. She advised against starting an SSRI because the pt
reportedly had some manic symptoms many years on SSRI.
.
#) CAD: Given her acute presentation, cardiac enzymes were sent
and negative. Continue home ASA, statin. ACEi was changed to
[**Last Name (un) **]. She does not appear to be on b-blocker at baseline/home.
.
#) Atrial fibrillation: Not on anticoagulation, only on ASA
despite CHADS>2, currently well rate controlled.
.
#)Hypertension: Currently normotensive on home regimen, continue
home amlodipine. ACEi was changed to [**Last Name (un) **] while in the ICU for
?dry cough.
.
#)Hyperlipidemia: Continue home simvastatin
.
#)Severe OSA: Continues to refuse CPAP, so will continued on
supplemental oxygen overnight.
.
#)Primary hyperparathyroidism: Continue home sensipar
.
#)Neovascular glaucoma c/b right eye blindness: Continue home
eye drops
#) Thrush: [**Month (only) 116**] be related to steroid inhaler use. Given
Nystatin swish and swallow and now appears resolved
.
#) Pannus fungal infection: Per prior documentation is stable,
continue miconazole powder QID.
.
#) Neuro: The patient has a known seizure disorder (complication
from CNS lymphoma). She was continued on lamictal 225mg daily.
Head CT was re-ordered as the patient does not remember the
events prior to admission, results showed no acute changes.
.
Disposition: her assisted facility has expressed significant
concerns about her safety at home, and she was evaluated by
physical therapy who recommended rehab stay. She is being
discharged to skilled nursing facility for rehab but will need
to be reassessed while there. It is possible she will not be
able to return to independent living.
.
Medications on Admission:
1. morphine 15 mg: 0.5 Tablet Q4H as needed for dyspnea,
anxiety.
2. alprazolam 0.25 mg QHS prn insomnia.
3. ipratropium bromide 0.02 % every six (6) hours as needed for
shortness of breath or wheezing.
4. amlodipine 10mg Daily
5. atropine 1 % Drops: One drop twice a day Right eye.
6. cinacalcet 30 mg [**Hospital1 **]
7. fluticasone 50 mcg: One Spray Nasal [**Hospital1 **]
8. furosemide 60 mg [**Hospital1 **]
9. lisinopril 5 mg DAILY
10. omeprazole 20 mg DAILY
11. simvastatin 40 mg at bedtime.
12. brimonidine 0.15 %: One Drop Ophthalmic [**Hospital1 **]
13. timolol maleate 0.5 %: One drop Ophthalmic twice a day.
14. aspirin 81 mg DAILY
15. docusate sodium 100 mg [**Hospital1 **]
16. miconazole nitrate 2 % Cream: twice a day as needed for as
needed for rash
17. guaifenesin 100 mg/5 mL Liquid Sig: 5-10 mLs every six hours
as needed for cough.
18. lamotrigine 200 mg once a day, take with 200mg for total of
225.
19. lamotrigine 25 mg once a day take with 200mg for total of
225.
20. quetiapine 25 mg: 1.5 Tablets HS
21. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
22. Cepacol Sig: One tab every four hours as needed for sore
throat.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNITS Injection TID (3 times a day).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. atropine 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
4. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
8. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
12. lamotrigine 200 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily): total 225 mg daily.
13. lamotrigine 25 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: total 225 mg daily.
14. quetiapine 25 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
15. Senna Concentrate 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2
times a day) as needed for constipation.
16. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) as needed for anxiety.
19. Cepacol Sig: One (1) LOZENGE Mucous membrane every [**6-18**]
hours as needed for cough.
20. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
21. morphine 10 mg/5 mL Solution Sig: 5-10 MG PO Q4H (every 4
hours) as needed for shortness of breath or pain.
22. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for dyspnea.
23. ipratropium bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for dyspnea.
24. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
25. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Hypoxemia
Acute on chronic dyspnea
Obstructive sleep apnea
Obesity hypoventilation syndrome
Pulmonary hypertension
Anxiety disorder
Secondary:
Chronic diastolic CHF
Coronary artery disease
Hypertension
Discharge Condition:
condition: stable
mental status: alert, lucid
ambulatory status: wheelchair bound
Discharge Instructions:
You were admitted with shortness of breath, anxiety, cough, and
somnolence (now resolved). Your evaluation did not show any
signs of pneumonia or new [**Last Name **] problem. Your shortness of
breath was treated with nebulizers, morphine as needed, and anti
anxiety medications.
Please continue to take your medications as prescribed,
including the morphine as needed for shortness of breath.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2206-9-12**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PSYCHIATRY
When: TUESDAY [**2206-9-23**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5750**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: PULMONARY FUNCTION LAB
When: FRIDAY [**2206-10-24**] at 11:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2760, 4168, 4280, 496, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5529
}
|
Medical Text: Admission Date: [**2128-11-17**] Discharge Date: [**2128-11-20**]
Date of Birth: [**2072-11-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with Drug Eluting stents to Left
anterior Descending Artery. 80% left Cirumflex artery was not
intervened on.
History of Present Illness:
Patient is a 56 year old male with no significant past medical
history presents with substernal chest pain radiating to back
since 11 am this morning. Patient was doing work on his cottage
in [**Location (un) 945**] and began to feel some "intense heart burn" and took
several tums with no improvement. He describes the pain as
substernal chest pressure ranging from [**2130-5-10**] throughout the day
with intermittent nausea, vomiting and radiation to the back.
Denies associated shortness of breath or dizziness. Patient also
describes fatigue, malaise and anxiety. He was feeling not well,
drove home and then to [**Hospital3 4107**] as the pressure worsened
to [**8-12**]. Patient states he has not seen his primary care doctor
in > 1 year.
.
At [**Hospital3 **] ED BP 136/84, P 82, RR 20, 99% RA. EKG
demonstrated ST elevation V2, V3 and a reported troponin level
of 8.24 (no documentation). Started on Heparin drip, Nitro drip,
Integrillin bolus and drip, lopressor and aspirin. After
receiving nitro SBP decreased to 76, responded to IVF bolus.
Patient directly transferred to [**Hospital1 18**] cath [**Hospital1 **].
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
On review of systems, denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
All of the other review of systems were negative.
Past Medical History:
PAST MEDICAL HISTORY: Dirverticulatis.
1. CARDIAC RISK FACTORS:: Denies: Diabetes, Dyslipidemia,
Hypertension.
2. CARDIAC HISTORY: None prior
Social History:
-Tobacco history: 2 ppd for > 30 years.
-ETOH: Quit drinking 5 years ago. Reports drinking several beers
a day prior.
-Illicit drugs: Denies.
Family History:
No family history of early MI. Mother age 86 secondary severe
arthritis. Brother with CAD. Denies history of DM, HTN,
hyperlipidemia.
.
Physical Exam:
VS: T= 98.6 BP= 119/69 HR= 81 RR= 14 O2 sat= 99% RA
GENERAL: 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: JVP not appreciated above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Physical Exam at discharge unchanged from admission. Systolic
blood pressure in the 100-110 range
Pertinent Results:
[**2128-11-17**] 04:17AM BLOOD WBC-14.6* RBC-4.91 Hgb-15.1 Hct-41.6
MCV-85 MCH-30.7 MCHC-36.3* RDW-13.5 Plt Ct-198
[**2128-11-18**] 04:26AM BLOOD WBC-12.8* RBC-4.51* Hgb-13.8* Hct-38.4*
MCV-85 MCH-30.6 MCHC-35.8* RDW-13.4 Plt Ct-173
[**2128-11-19**] 06:50AM BLOOD WBC-12.1* RBC-4.54* Hgb-13.6* Hct-38.7*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.4 Plt Ct-206
[**2128-11-20**] 06:08AM BLOOD WBC-10.3 RBC-4.55* Hgb-14.1 Hct-38.9*
MCV-86 MCH-31.0 MCHC-36.2* RDW-13.5 Plt Ct-205
[**2128-11-17**] 04:17AM BLOOD PT-13.5* INR(PT)-1.2*
[**2128-11-20**] 06:08AM BLOOD PT-19.9* INR(PT)-1.9*
[**2128-11-17**] 04:17AM BLOOD Glucose-95 UreaN-11 Creat-0.6 Na-137
K-4.2 Cl-103 HCO3-24 AnGap-14
[**2128-11-20**] 06:08AM BLOOD Glucose-91 UreaN-13 Creat-0.8 Na-139
K-4.6 Cl-104 HCO3-27 AnGap-13
[**2128-11-17**] 04:17AM BLOOD ALT-48* AST-167* LD(LDH)-673*
CK(CPK)-2725* AlkPhos-67 TotBili-0.8
[**2128-11-17**] 12:51PM BLOOD CK(CPK)-2135*
[**2128-11-17**] 09:04PM BLOOD CK(CPK)-1474*
[**2128-11-18**] 04:26AM BLOOD ALT-38 AST-79* LD(LDH)-685* CK(CPK)-900*
AlkPhos-56 TotBili-0.6
[**2128-11-17**] 04:17AM BLOOD CK-MB-349* MB Indx-12.8* cTropnT-6.05*
[**2128-11-17**] 12:51PM BLOOD CK-MB-153* MB Indx-7.2* cTropnT-3.28*
[**2128-11-17**] 09:04PM BLOOD CK-MB-74* MB Indx-5.0 cTropnT-2.18*
[**2128-11-18**] 04:26AM BLOOD CK-MB-40* MB Indx-4.4
[**2128-11-17**] 04:17AM BLOOD Triglyc-122 HDL-44 CHOL/HD-3.9
LDLcalc-105
[**2128-11-17**] 04:17AM BLOOD %HbA1c-5.5
Cath Report:
LMCA: 40% ostial
LAD: 99% mid
LCX: 60% ostial, 70% OM1, 80% mid circumflex
RCA: no significant disease
2 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] placed in LAD.
.
EKG: [**Hospital1 **]: ST elevation V2-V3 with Q waves. [**Hospital1 18**]: ST
elevation V2-V6.
Echo ([**11-17**])
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
moderate hypokinesis of the mid to distal anterior and
anteroseptal segments and the apex. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric LVH with moderate regional LV
systolic dysfunction consistent with CAD of the LAD. No
significant valvular pathology seen.
Brief Hospital Course:
ASSESSMENT AND PLAN: 56 year old male transferred to BIMDC for
anterolateral STEMI s/p 2 DES to the LAD. Requiring 3-6 months
coumadin for akinetic wall.
.
# CORONARIES: Patient presented with anterolateral MI, s/p 2 DES
to the LAD (99% occlusion). Patient with circumflex lesions (60%
ostial, 70% OM1, 80% mid circumflex).
- Discharged on ASA, Plavix
- Atorvastatin 80 mg (despite elevated AST--needs to be
followed)
- Beta blocker, ACE inhibitor as pressure tolerates.
- Stress test with MIBI in 6 weeks to assess burden of
circumflex dz and f/u with Dr. [**Last Name (STitle) **] after.
.
# PUMP: No signs of heart failure on exam (no crackles, JVD,
edema). Significantly depressed EF with hypokinetic wall on
echo.
- Pt will require 3-6 months of anticoagulation with coumadin to
prevent LV thrombus. INR=1.9 at time of discharge, pt discharged
with Rx for 5mg dose, he will have his INR checked two days
post-discharge and sent to his PCP who will follow his INR
thereafter.
- [**Name (NI) 8863**] [**Name (NI) 8864**]
- Pt instructed to discuss with his PCP [**Last Name (NamePattern4) **]: cardiac rehab
available through his insurance network in the area
.
# RHYTHM: Normal sinus rhythm with occasional accelerated
idioventricular rhythm (6 beat max). Re-perfusion rhythm.
.
# Tobacco use: Pt given Rx for Chantix and given material re:
smoking cessation
Medications on Admission:
none
Discharge Medications:
1. Outpatient [**Name (NI) **] Work
PT/INR and chem-10 to be drawn on Monday, [**11-22**].
Please have results called to Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 18323**] in [**Hospital1 **], phone
([**Telephone/Fax (1) 79920**]
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take every day for one year, do not stop taking unless
Dr. [**Last Name (STitle) **] tells you to. .
Disp:*30 Tablet(s)* Refills:*11*
4. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*100 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes x3 total as needed for chest pain.
Disp:*1 bottle* Refills:*1*
8. Chantix 0.5(11)-1(3X14) mg Tablets, Dose Pack Sig: One (1)
Package PO as directed: For dosing, please follow directions in
packet.
Disp:*1 Dose Pack* Refills:*2*
9. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Anterior Myocardial Infarction
Accelerated Idioventricular Rhythm
Compendsated Left Ventricular Systolic Dysfunction: EF 35-40%
Discharge Condition:
stable.
Hct 38.7
creat 0.7
WBC 12.8
CK 257
Discharge Instructions:
You had a heart attack and your heart function is weak. We think
that your heart function may improve over the next few weeks. A
stress test has been scheduled for you before you see Dr.
[**Last Name (STitle) **]. it is very important that you go to cardiac
rehabilitation and take all of your medicines as prescribed.
New medicines:
1. Plavix: to prevent blood clots and future heart attacks. This
keeps your stents open. Take this every day for one year, do not
miss a dose.
2. [**Last Name (STitle) 8863**] XL: a beta blocker which rests your heart and promotes
healing. Slows your heart rate.
3. Lisinopril: lowers blood pressure and rests your heart.
4. Aspirin: prevents blood clots and another heart attack.
5. Atorvastatin: to lower your cholesterol and prevent another
heart attack.
6. Warfarin: to prevent blood clots because your heart is not
pumping well. You will take this every day but the drug level in
your blood needs to be monitored. The goal warfarin level (INR)
is 2.0-3.0. You will get your INR checked on Monday--you must
make sure that Dr. [**Last Name (STitle) 18323**] gets the result and you must discuss
how much coumadin you should take with him.
.
Please stop smoking. This is the single most important thing you
can do for your health. Information was given to you on
admission regarding smoking cessation.
.
Please call Dr. [**Last Name (STitle) **] if you have any chest pain, trouble
breathing, nausea, vomiting, groin pain or tenderness.
.
If you have chest pain:
1. sit down
2. take 1 sublingual nitroglycerin every 5 minutes for total of
3 doses. If you have chest pain after 3 doses, call 911.
Followup Instructions:
Please get your blood work done on Monday [**11-22**]. You
should contact your Primary care physician about the results.
Also, call your PCP on MONDAY [**2128-11-22**] to discuss your blood
test results and to set up a convenient way for you to get your
INR checked regularly. Make a follow up appointment within 1
week of your discharge from the hospital.
You have the following appoitment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 3942**] from Cardiology on [**1-5**] at 1 p.m. in [**Hospital Ward Name 23**]
building [**Location (un) 436**].
You have a stress test planned for [**12-31**] at 10 a.m., no
eating or drinking for 2 hours prior to the stress test. No
caffeine for 12 hours prior to stress test. This is located in
the [**Hospital Ward Name 23**] Building at the [**Hospital3 **] on the [**Location (un) **].
Completed by:[**2128-11-21**]
ICD9 Codes: 4280, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5530
}
|
Medical Text: Admission Date: [**2131-9-28**] Discharge Date: [**2131-10-9**]
Date of Birth: [**2087-10-15**] Sex: F
Service: MED
Allergies:
Codeine
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
Dyspnea and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 year old obese woman with history of smoking (20 pack year),
asthma, bronchitis with multiple admissions since [**2130-9-18**]
for asthma flares. She has required hospitalization and steroids
in the past, but no intubations. She has been on Prednisone 20
mg PO for the past year. On [**9-28**], she presented with one day of
wheezing and cough, peak flows of 120 mL (baseline 250-300 mL).
In the ED, she was unresponsive to nebulizers, heliox, oral
prednisone and was hypoxemic to 87% on 6L NC. She was admitted
to the [**Hospital Unit Name 153**] for nebs q1hr, IV steroids and continuous
monitoring. Empiric CPAP at night was started in [**Hospital Unit Name 153**]. Of note,
pt was seen by Dermatology for rash x 2weeks and a biopsy was
negative for mites. She was discharged from the [**Hospital Unit Name 153**] with
improved oxygenation and ventilation with decreased frequency of
nebs to q3 hour.
ROS: Gained 60 pounds since [**9-21**] (when started steroids).
Endorses fatigue. No rhinorrhea, fever, chills. No N/V or
diarrhea. No chest pain, PND or palpitations. 2 pillow
orthopnea. Denies daytime sleepiness. Frequent bloody stools
with abdominal pain (missed several colonoscopy appointments
because of fatigue).
Past Medical History:
Asthma
Recurrent HAs
Hyperlipidemia
Depression
Obesity
Bronchitis
GERD/hiatal hernia
Anxiety
Rectal bleeding
Social History:
Lives adjacent to a pet store. Noticed that rash developed after
moving into new apartment. Has a dog and is going through
divorce. Lives with 13 and 27 yo sons. 1ppd x 2yrs after
quitting for 11yrs. No EtOH or IVDU.
Family History:
No IBD or early CAD.
Mom – died ovarian CA at 63
Dad- died of ?brain CA at 27
Physical Exam:
Vitals T 97 P 74 BP 114/54 Resp 22
O2 97% on 5L NC
Gen A+Ox3.Slight resp distress. Not toxic.
HEENT No JVD. OP clear w/o exudates. No LAD. EOMI.
Neck Thyroid difficult to assess, but no discrete nodules
palpated. No carotid bruits.
Thorax Diffuse I & E wheezes throughout both lungs. Coarse
rhonchi throughout.
CV Distant heart sounds. NSR. No m/r/g.
Abd Obese. Normoactive BS. No tenderness. No ascites,
masses.
Skin Diffuse macular rash with varying sized lesions on abdomen,
arms and quadriceps.
Ext 1+ pitting edema. Warm. Radial and PT 2+ bilaterally. DP 1+
bilat.
Neuro CN II-XII intact. Strength 5/5 in UE & LE. Sensation to
touch intact. Babinski-upgoing toes bilat.
Pertinent Results:
[**2131-9-28**] 08:06PM TYPE-ART PO2-115* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-1
[**2131-9-28**] 08:06PM O2 SAT-97
[**2131-9-28**] 11:15AM WBC-12.4* RBC-4.64 HGB-12.7 HCT-38.3 MCV-83
MCH-27.5 MCHC-33.3 RDW-15.7*
[**2131-9-28**] 11:15AM NEUTS-82* BANDS-1 LYMPHS-12* MONOS-3 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2131-9-28**] 11:15AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
STIPPLED-OCCASIONAL
[**2131-9-28**] 11:15AM PLT COUNT-303
CXRs:
([**2131-9-28**]) - IMPRESSION: No evidence of an acute cardiopulmonary
abnormality.
([**2131-9-30**]) - IMPRESSION: There is no evidence of active disease
in the lungs or heart. No significant changes since the prior
study.
([**2131-10-1**]) - IMPRESSION: Improving left heart failure.
Sputum Culture ([**2131-9-30**]): GRAM STAIN - <10 PMNs and >10
epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE
ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.
CXR:
[**10-3**] Bilateral lungs are clear. No evidence of active lung
disease. There is minimal plate-like atelectasis in the left
lower lobe (prelim report)
[**10-1**] Cephalization of pulmonary vasculature persists, although
improved since the last exam.
[**9-30**] No cardiomegaly. The lungs are clear of an active
congestion or infiltration. No evidence of pleural effusion or
pneumothorax.
Abdominal Skin Biopsy ([**2131-9-30**]): The presence of acanthosis and
subepidermal fibrin is most consistentwith irritation or trauma
to the site (as would be seen with excoriations). The typical
histologic findings of dermatitis herpetiformis or pemphigus
foliaceous are not seen.
Axillary biopsy ([**2131-10-6**]): Right upper arm. Dermal
hypersensitivity reaction
Note: Sections show an unremarkable epidermis. The dermis
demonstrates a superficial and deep perivascular lymphocytic
infiltrate with eosinophils. The findings are consistent with a
dermal hypersensitivity reaction, such as to an arthropod
assault.
Brief Hospital Course:
43 year old obese woman with history of asthma, 20 pack year
smoking, bronchitis with multiple admissions since [**9-21**] for
asthma flares requiring hospitalization and steroids. Her
hospital course is discussed by problem.
1) Asthma-
On transfer to the medical floor, she was placed on q3:prn nebs
with albuterol and ipratropium. She also received combivent q4
standing, prednisone 60 mg PO, serevent, flovent and singulair.
During her hospital course, she tolerated the weaning frequency
of neb treatment to q3-q4:prn, as well as a decrease in her O2
requirement from an initial 5 L/ min to room air. During this
transition from O2 via nasal cannula to room air, her O2
saturation was between 92-97%. Also, her daily peak flows
gradually increased to 250-300, which is at the patient's
baseline. Notably, the patient's O2 on ambulation was 97% on
her discharge date. Smoking cessation was encouraged during her
hospital stay. She was sent home on Wellbutrin and a nicotine
patch.
2) Rash - Patient reported rash on torso, upper thigh and arms
was pruritic and developed when she moved into her apartment,
which is adjacent to a pet store. She was given clobetasol,
benadryl and hydroxyzine with some relief. Initial biopsy
demonstrated nonspecific inflammation (see results sections).
After her discharge, it was noted that the rebiopsy of new
axillary lesion demonstrated many eosinophil consistent with
arthropod infestation.
3) Obstructive sleep apnea (OSA)
Patient complained of difficulty sleep and apneic episodes. She
noted a decreased in her symptomatology once she started using
CPAP. Patient's obesity, reported symptoms and improvement on
empiric CPAP was thought to be suggestive of OSA. Patient will
follow up with sleep lab for a sleep study.
4) Bronchitis
Patient completed 5 day course on empiric Levaquin for atypical
coverage and a cough characterized by scant white/yellow sputum.
5)Metabolic alkalosis-
Patient's HCO3 was persistently 34 fro a few days, and then
decreased to 29 on her discharge date. This elevated HCO3 was
thought to be due to large consumption of Diet Pepsi (>6 jugs 24
oz/day).
6) Leukocytosis
WBC count between 19 and 25. This was thought to be due to
steroids(chronically on prednisone 20 for over a year, and now
on prednisone 60 mg PO). However, because patient was on
steroids, it was not felt that she would mount a febrile
response if infected, thus, to rule out an infection cultures
were sent. Urine cultures and analysis were negative. Blood
cultures pending upon discharge.
7) Diabetes mellitus
Patient was managed on insulin sliding scale and glucose was
checked qid.
8) Anxiety
Celexa and Klonopin were continued, per outpatient regimen.
9) GERD-
Patient complained of emesis while asleep. CT scan demonstrated
a large hiatal hernia, which was thought to contribute to her
symptoms of GERD and worsening asthma from aspiration. She was
started on a proton pump inhibitor. Also, an appointment with
Dr. [**Last Name (STitle) 57300**] from General Surgery was scheduled for the
patient.
Patient was stable upon discharge to home. She has transferred
all of her medical care to the [**Hospital1 18**].
Medications on Admission:
Transfer Meds:
Ipratropium Bromide MDI 2 PUFF IH QID
Ipratropium Bromide Neb [**1-19**] NEB IH Q3H
Albuterol Neb Soln [**1-19**] NEB IH Q3H
Albuterol 2 PUFF IH Q6H
Albuterol Neb Soln 15 NEB IH EVERY TWO HOURS
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Methylprednisolone Na Succ 125 mg IV Q8H
Montelukast Sodium 10 mg PO QD
Guaifenesin-Dextromethorphan 5 ml PO Q6H:PRN
Diphenhydramine HCl 25 mg PO Q6H:PRN
Levofloxacin 500 mg PO Q24H Duration: 5 Days (d1=[**2131-10-2**])
Atorvastatin 10 mg PO QD
Clonazepam 1 mg PO BID
Citalopram Hydrobromide 60 mg PO
Nicotine 14 mg TD QD
Pantoprazole 40 mg PO Q24H
Calcium Carbonate 500 mg PO TID W/MEALS
Vitamin D 400 UNIT PO QD
Sarna Lotion 1 Appl TP QID:PRN
Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
Heparin 5000 UNIT SC TID
Insulin SC (per Insulin Flowsheet)
Acetaminophen 325-650 mg PO Q4-6H:PRN
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal QD (once a day).
Disp:*30 Patch 24HR(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days: Stop on [**10-11**].
Disp:*9 Tablet(s)* Refills:*0*
3. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day for
6 days: Start [**10-12**]; stop [**10-17**].
Disp:*6 Tablet(s)* Refills:*0*
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
6 days: Start [**10-18**]; stop [**10-23**].
Disp:*12 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 6 days: start [**10-24**]; stop [**10-29**].
Disp:*18 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
6 days: start [**10-30**]; stop [**11-4**].
Disp:*6 Tablet(s)* Refills:*0*
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
start [**11-5**] and continue every day.
Disp:*30 Tablet(s)* Refills:*2*
8. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning))
for 1 days.
Disp:*1 Tablet Sustained Release(s)* Refills:*0*
9. Wellbutrin XL 300 mg Tablet Sustained Release 24HR Sig: One
(1) Tablet Sustained Release 24HR PO once a day.
Disp:*21 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*42 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*21 Tablet(s)* Refills:*2*
12. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*21 Tablet(s)* Refills:*2*
13. Fluticasone Propionate 220 mcg/Actuation Aerosol Sig: 4
puffs Inhalation twice a day.
Disp:*3 * Refills:*2*
14. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet
PO QD (once a day).
Disp:*63 Tablet(s)* Refills:*2*
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H () as needed for shortness of breath or wheezing.
Disp:*3 units* Refills:*0*
16. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: [**1-19**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*21 amps* Refills:*0*
17. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*42 Disk with Device(s)* Refills:*2*
18. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for itching.
Disp:*100 Tablet(s)* Refills:*0*
19. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
Disp:*100 Capsule(s)* Refills:*0*
20. Clobetasol Propionate 0.05 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for itching: Avoid on
face. .
Disp:*2 tube* Refills:*0*
21. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*2 tube* Refills:*0*
22. Spacer
Please obtain spacer at pharmacy.
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma
Obstructive sleep apnea
Obesity
Rash
Hypoxemia
Hypoventilation
Metabolic alkalosis
Bronchitis
Hyperlipidemia
Gastroesophageal reflux disese
Anxiety
Depression
Discharge Condition:
Stable
Discharge Instructions:
* Call your primary care physician if you develop chest pain,
worsening shortness of breath, lightheadedness or any other
concerning symptoms.
* Take all medications as prescribed.
* Follow up with all appointments.
* Taper prednisone slowly to 10 mg/day over one month. Started
50 mg PO on [**2131-10-10**]. Will take 50 mg PO for 6 days, and then
take 40 mg PO for 6 days, etc.
* Per Dermatology, please request that PCP check tissue
transglutaminase (TTG) for celiac sprue.
* Remind PCP to call insurance company to request a reclining
chair.
* Speak with PCP about home environment evaluation.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-10-18**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/DR. [**First Name (STitle) **] Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2131-10-12**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Where: LM [**Hospital Unit Name 41726**] ASSOCIATES Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2131-10-22**] 2:30
Provider: [**First Name11 (Name Pattern1) 306**] [**Last Name (NamePattern4) 7907**], MD Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2131-11-19**] 11:00
Completed by:[**2131-10-10**]
ICD9 Codes: 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5531
}
|
Medical Text: Admission Date: [**2167-7-20**] Discharge Date: [**2167-7-23**]
Date of Birth: [**2130-2-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Struck by car
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37 year-old man transferred from outside hospital after being
struck by car while intoxicated with alcohol and traveling on a
bicycle. He denied loss of consciousness.
Past Medical History:
None
Social History:
Works as a chef. Married and his lives with his wife. Reports
occasional alcohol use.
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: HR 102 BP: 154/P RR: 16 O2: 95% RA
General: Alert and oriented. Responding appropriately.
HEENT: Hematoma over left superior lid. Pupils equal and
reactive bilaterally.
Neck: Trachea midline.
Chest: No crepitus.
CV: RRR.
Chest: Clear to auscultation bilaterally.
Abdomen: Soft. NT/ND.
Rectal: Normal tone. No gross blood. Normal prostate.
Musculoskeletal: Pelvis stable. Left shoulder tender to
palpation. No gross deformities.
Neuro: GCS 15. Cranial nerves intact grossly. Moving all
extremities.
Pertinent Results:
Non-contrast CT head [**2167-7-20**]- IMPRESSION: Limited study due to
artifact. Small subdural hematoma along the left temporal lobe.
Hyperdense fluid in paranasal sinuses in bilateral maxillary and
sphenoid sinuses, and mucosal thickening. The finding can be due
to chronic sinus disease, however, please correlate with
physical examination for the possibility of facial fractures.The
referring resident was informed in person.
ATTENDING NOTE: A linear lucency in left temporal bone could be
due to vascular groove and adjacent suture line.
.
MRI Left Shoulder [**2167-7-22**]
1. Extensive edema within the deep subcutaneous soft tissues
overlying the distal clavicle, associated with a slightly
displaced comminuted distal clavicular fracture (as demonstrated
on recent plain radiography); this appears to spare the A/C
joint, which is otherwise unremarkable.
2. Other acute fracture.
3. Evidence of underlying distal supra- and infra-spinatus
tendinopathy without discrete tear, with associated subchondral
cystic change.
4. Grossly unremarkable glenoid labrum and biceps tendon.
.
Left Shoulder, scapular, humerus x-ray [**2167-7-21**]- Comminuted
fracture of the distal left clavicle without significant
displacement. No evidence of humeral fracture.
.
Chest and pelvis X-ray [**2167-7-20**]- Oblique fracture of the distal
left clavicle. Non-displaced fracture of the left first and
second ribs. The referring resident was informed in person.
.
CT C-spine [**2167-7-20**]-No evidence of subluxation or fracture in the
cervical spine. Non-displaced fracture of the left second rib as
seen on the plain radiograph. Hyperdense fluid in the maxillary
sinuses as described in the head CT. The wet read was provided
to ED dashboard.
.
[**2167-7-20**] 07:24AM PH-7.35 COMMENTS-GREEN
[**2167-7-20**] 07:24AM GLUCOSE-107* LACTATE-2.2* NA+-140 K+-3.4*
CL--105 TCO2-23
[**2167-7-20**] 07:24AM HGB-14.3 calcHCT-43 O2 SAT-87
[**2167-7-20**] 07:15AM GLUCOSE-110* UREA N-9 CREAT-0.8 SODIUM-137
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-22 ANION GAP-20
[**2167-7-20**] 07:15AM estGFR-Using this
[**2167-7-20**] 07:15AM ALT(SGPT)-21 AST(SGOT)-33 ALK PHOS-46
AMYLASE-38 TOT BILI-0.7
[**2167-7-20**] 07:15AM ALBUMIN-4.7
[**2167-7-20**] 07:15AM ASA-NEG ETHANOL-217* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2167-7-20**] 07:15AM URINE HOURS-RANDOM
[**2167-7-20**] 07:15AM URINE HOURS-RANDOM
[**2167-7-20**] 07:15AM URINE GR HOLD-HOLD
[**2167-7-20**] 07:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2167-7-20**] 07:15AM WBC-16.7* RBC-4.71 HGB-14.8 HCT-42.6 MCV-90
MCH-31.3 MCHC-34.7 RDW-13.9
[**2167-7-20**] 07:15AM NEUTS-89.6* BANDS-0 LYMPHS-8.4* MONOS-1.8*
EOS-0.1 BASOS-0.1
[**2167-7-20**] 07:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2167-7-20**] 07:15AM PLT SMR-NORMAL PLT COUNT-229
[**2167-7-20**] 07:15AM PT-11.9 PTT-20.0* INR(PT)-1.0
[**2167-7-20**] 07:15AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2167-7-20**] 07:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
Mr. [**Known lastname **] was found to have a 7mm left subdural hematoma,
fractures of the left distal clavicle as well as non-displaced
fractures of the left first and second ribs. He was admitted to
trauma surgery and neurosurgery and orthopedics were consulted.
.
1) Left Subdural Hematoma- Neurosurgery was consulted and
recommended starting dilantin and titrating systolic blood
pressure to <140, hourly neuro checks and a repeat head CT. He
continued to be awake, alert and oriented. Repeat head CT
revealed no change in the subdural hematoma. He was discharged
with instruction to continue Dilantin until follow-up with
Neurosurgery. He will see his primary care doctor to follow his
Dilantin levels. He was instructed to follow-up four weeks after
discharge with a Dr. [**Last Name (STitle) 75130**] after a repeat head CT.
.
2) Distal Clavicle Fracture- Orthopedics was consulted for
distal left clavicle fracture. Non-operative treatment was
recommended and a sling was provided for comfort.
.
3) Left Shoulder Pain- Mr. [**Known lastname **] continued to have left shoulder
pain for which orthopedics recommended an MRI to evaluate for
rotator cuff injury. MRI revealed 1. Extensive edema within the
deep subcutaneous soft tissues overlying the distal clavicle
sparing the acromioclavicular joint as well as distal supra- and
infra-spinatus tendinopathy without discrete tear. He was
discharged home with follow-up with Dr. [**First Name (STitle) **].
Discharge Disposition:
Home
Discharge Diagnosis:
s/p collision with car while riding bicycle
Subdural hematoma
Distal left clavicular fracture
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital after being hit by a car while
on your bicycle. A CT scan of your brain was done and showed a
small area of bleeding in your brain known as a subdural
hematoma. You were started on an anti-seizure medication known
as Dilantin. You should continue taking this medication until
otherwise directed by neurosurgeon Dr. [**Last Name (STitle) 75130**] your follow-up
appointment. You should see your primary care doctor to monitor
the level of Dilantin in your blood.
Also, an X-ray showed a fracture of your left clavicle
(collarbone). You were seen by the orthopedic surgery service
who did not think any surgery was required at this time. They
recommended an MRI of your shoulder which showed a rotator cuff
tendinopathy (damage to the tendon in your shoulder) but no
obvious tear. You should follow-up in orthopedics clinic with
Dr. [**First Name (STitle) **] in [**12-20**] weeks. Continue to use your arm sling for
comfort as needed.
Please call your doctor or return to the hospital for:
* Worsening headache
* Increasing drowsiness
* Loss of Consciousness
* Nausea or vomiting
* Worsening weakness
* Any other concerning symptoms
* Abdominal pain
* Any other symptoms that concern you
Followup Instructions:
Please follow-up in trauma surgery clinic with Dr. [**Last Name (STitle) **] in two
weeks. Call ([**Telephone/Fax (1) 376**] to make an appointment.
.
Call Neurosurgery to set up an appointment for a CT scan in 4
weeks and for a follow-up appointment with Dr. [**Last Name (STitle) 75130**]
([**Telephone/Fax (1) 1669**].
.
Please see your primary care doctor as soon as possible to
monitor your Dilantin levels. Also, talk to your primary care
doctor about your facial numbness.
Please call [**Hospital 5498**] clinic to make an appointment with Dr.
[**First Name (STitle) **] in [**12-20**] weeks. Call ([**Telephone/Fax (1) 2007**] to make an appointment.
ICD9 Codes: 2720, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5532
}
|
Medical Text: Admission Date: [**2146-5-24**] Discharge Date: [**2146-6-2**]
Date of Birth: [**2077-10-17**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Zometa / Keflex / Tetracycline / erythromycin /
Iodine Containing Agents Classifier / nuts / fish derived /
lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
syncopal episode
Major Surgical or Invasive Procedure:
pacer setting adjustment
History of Present Illness:
68-year-old female with nonischemic cardiomyopathy(EF 10-15%),
NYHA class III heart failure s/p BiV ICD placement, PAF s/p
ablation, severe asthma, recently discharged from [**Hospital1 18**] on
[**2146-5-9**] on milrinone for decompensated heart failure,
transferred from the ED of [**Hospital1 1774**] for VT/VF requiring multiple
ICD shocks.
She reports a few day history of severe generalized weakness and
nausea. She had one episode of syncope, which was witnessed by
her husband while she was sitting in bed. She went to an OSH and
was found to have polymorphic VT requiring ICD shocks. She was
tranferred to [**Hospital1 18**] because her cardiac issues are managed here.
Of note, on arrival she was off milrinone and had a 2:1 AV block
at a rate of 60 beats per minute with QTc 555ms.
On systems review, patient has had nausea, loose stools that
were green today, containing mucous. No fever, headache, head
injury, chest pain, SOB. No abdomional pain. Otherwise systems
review normal.
She has been followed by Dr. [**Last Name (STitle) **] and Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]. She
received cardiac resynchronization therapy in [**2141**] which
resulted in a transient marked improvement in her functional
status. However, during the past year or so, there has been a
progressive and severe decline in her functional status,
accompanied by the development of significant mitral
regurgitation, pulmonary hypertension, and tricuspid
regurgitation. She was hospitalized from [**5-2**] through [**5-9**],
during which time milrinone IV therapy was initiated.The patient
was noted to have a considerable clinical response with
considerable improvement in functional capacity going from
having difficulty just speaking and holding up her head in bed
to being able to walk around her home where she lives on a [**Doctor Last Name **]
and participated most if not all of her activities of daily
living.
Past Medical History:
1. Severe nonischemic cardiomyopathy with LVEF of 10% s/p BiVICD
placment
2. Severe mitral regurgitation, severe tricuspid regurgitation
and moderate pulmonary hypertension.
3. PAF status post ablation.
4. Severe asthma.
5. Old compression fractions of T8 and T10.
6. Venous stasis disease.
7. Anxiety, depression.
8. Restless legs syndrome.
9. Recent septic bursitis of the right knee.
Social History:
The patient used to work as a jeweler and makes jewelry. She
lives with her husband. Remote smoking history, quit over 40
years ago, occasional ETOH and no illicit drug use
Family History:
Father may have had a heart attack, but died from a blood clot
to the brain. Mother had diabetes and cirrhosis. Son with
[**Name2 (NI) 14595**]-1 antitrypsin deficiency.
Physical Exam:
Physical Exam on Admission:
Vital signs- BP- 94/61, HR 120, SpO2 96% on 6L via nasal
cannula, RR 24. A-sense V-Paced rhythm on telemetry.
GENERAL: Lethargic, in distress.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP raised to angle of the jaw.
CARDIAC: PMI displaced laterally, RR, normal S1, S2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles bilaterally
half- way up the lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema to the level of the mid-shin. No
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Physical Exam on Discharge:
VS 97.3, 100/70, 94, 18, 96% RA
exam unchanged except:
JVD is not elevated
Pertinent Results:
Labs on Admission:
[**2146-5-24**] 04:13PM WBC-12.9* RBC-3.96* HGB-12.1 HCT-38.7 MCV-98
MCH-30.5 MCHC-31.1 RDW-14.7
[**2146-5-24**] 04:13PM NEUTS-80.9* LYMPHS-12.5* MONOS-5.0 EOS-1.2
BASOS-0.4
[**2146-5-24**] 04:13PM PT-30.5* PTT-41.4* INR(PT)-3.0*
[**2146-5-24**] 04:13PM DIGOXIN-1.1
[**2146-5-24**] 04:13PM TSH-6.0*
[**2146-5-24**] 04:13PM CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-1.7
[**2146-5-24**] 04:13PM CK-MB-2 cTropnT-<0.01
[**2146-5-24**] 04:13PM ALT(SGPT)-17 AST(SGOT)-28 CK(CPK)-64 ALK
PHOS-90 TOT BILI-1.2
[**2146-5-24**] 04:13PM GLUCOSE-153* UREA N-11 CREAT-1.1 SODIUM-141
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-17
[**2146-5-24**] 09:32PM LACTATE-0.9
.
MICRO:
Urine cx [**5-24**]: negative
blood cx [**5-24**]: negative
c. diff [**5-25**]: negative
.
Imaging:
Chest x-ray [**5-24**]
Comparison is made with prior study [**5-16**].
Moderate-to-severe cardiomegaly is unchanged. Pacemaker leads
are in standard position. Right PICC tip is in the lower SVC.
There are low lung volumes. There has been interval worsening
of moderate
pulmonary edema and bibasilar opacities. Bibasilar opacities
could be due to a combination of atelectasis and small pleural
effusions, larger on the left side, though superimposed
pneumonia cannot be totally excluded. Asymmetric opacity at the
periphery of the right upper lobe, is also worrisome for
pneumonia.
.
Echocardiogram [**2146-5-4**]:
The left atrium is mildly dilated. The left atrium is elongated.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed
(quantitative biplane LVEF= 20 % ) secondary to severe global
hypokinesis with the basal infero-lateral and antero-lateral
segments contracting best. A left ventricular mass/thrombus
cannot be excluded. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis. There is abnormal septal motion/position. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. The mitral valve leaflets do not fully
coapt. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study dated [**2146-5-2**] (images reviewed),
LVEF has improved slightly, mainly due to more vigorous
contraction of the basal lateral segments. Other findings are
similar.
.
[**5-3**] Cardiac Catherization:
1. Limited resting hemodynamics revealed modereately elevated
right and left sided filling pressures with an RVEDP of 24mmHg
and LVEDP of 29mmHg. There was severely elevated pulmonary
artery systolic pressure at rest of 78mmHg. At rest there was
severely depressed cardiac index of 1.39L/min/m2. Patient was
infused with Milrinone, first bolused with 50mcg/kg over 3
minutes then 0.375mcg/kg/min over 15 minutes. With milrinone
infusion there was a significant improvement in cardiac index
from 1.39 to 2.22L/min/m2. There was a significant reduction in
PASP from 78 to 58mmHg.
.
Echo [**2146-5-26**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 0-5 mmHg.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is severely depressed (LVEF= [**10-17**] %). No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is dilated with
severe global free wall hypokinesis. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The mitral valve leaflets
do not fully coapt. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severely dilated, globally hypokinetic left
ventricle. Increased left ventricular filling pressure. Dilated,
hypokinetic right ventricle. Moderate mitral regurgitation.
Tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension. Left pleural effusion.
Compared with the prior study (images reviewed) of [**2146-5-4**], the
left ventricle has increased in size (from 6.2 to 6.5
centimeters). Global left ventricular systolic has further
declined from 20% to 10-15%.
.
ECHO [**5-27**]: echocardiographic optimization of LV-to-RV offset
LV-RV offset = 0 msec: LVOT VTI = 14.5 cm
LV-RV offset = 40 msec: LVOT VTI = 17.0 cm
LV-RV offset = 50 msec: LVOT VTI = 19.5 cm
LV-RV offset left at 50 msec
.
CXR ([**5-27**]):
As compared to the previous radiograph, a left pectoral
pacemaker
and the right PICC line are unchanged. Lung volumes have
increased, likely reflecting improved ventilation. The
pre-existing signs of fluid overload have decreased in severity.
However, there is unchanged moderate cardiomegaly with signs of
retrocardiac atelectasis. No newly appeared focal parenchymal
opacities.
.
CXR ([**5-28**]):
The pacemaker and right-sided PICC line are unchanged. There is
unchanged
cardiomegaly. There is improved aeration at the left lung base.
There is
persistent mild pulmonary edema, stable.
.
CTA CORONARIES [**2146-6-1**]:
1. Global cardiomegaly. Conventional anatomy of the pulmonary
veins, no
evidence of stenosis or thrombosis in left atrium or left atrial
appendage.
2. Biventricular pacemaker leads with left ventricular lead
coursing through the coronary sinus into one of the epicardial
vein up to the epicardial surface.
3. Mild diffuse pulmonary edema.
4. The study was not targeted for evaluation of coronary veins.
If repeated study is nessesary, it would be obtained with no
charge
Brief Hospital Course:
BRIEF CLINICAL SUMMARY
Ms. [**Known lastname 71175**] is a 68-year-old female with nonischemic
cardiomyopathy(EF 10-15%), NYHA class III heart failure s/p BiV
ICD placement, paroxsymal atrial fibrillation (PAF) s/p ablation
on milrinone for decompensated heart failure, transferred from
the ED of [**Hospital1 1774**] for VT.
ACTIVE ISSUES:
# Polymorphic VT: She had 5 episodes of polymorphic VT which
required ICD shock. There is likely multifactorial etiology
including 2:1 AV block due to BiV pacemaker settings, fever due
to pneumonia, and milrinone. BiV pacer interrogated and we
decreased her refractory time allowing her to be paced 1:1 AV.
She was also given magnesium. She was given tylenol for the
fever and her pneumonia was treated (see below). Milrinone
turned down initially, but then it was titrated back to her home
dose. Review of her med list revealed particularly high dose of
sertraline at 200mg daily so this was titrated down to 100mg
daily due to the arrythmogenic risk caused by sertraline. Her
digoxin was stopped. She was monitored on tele and had no
further episodes of VT.
# Acute on chronic systolic heart failure: She has a history of
heart failure with an LVEF of 20%. On exam she appeared to have
hypervolemia with crackles, peripheral edema and an elevated
JVD. Diuresed with a lasix drip. Stopped digoxin. Held
valsartan and spironolactone initially, restarted
spironolactone at half of home dose due to hypotension during
admission. started metoprolol tartrate 12.5mg po BID because HR
elevated in low 100s. Increased home torsemide to 50mg daily.
Discharge regimen was: torsemide 60 mg daily, spironolactone
12.5 mg daily, metoprolol succinate 50 mg daily, aspirin 162 mg
daily, milrinone drip.
We continued with the 1:1 BiV settings initially but echo on
[**2146-5-26**] was read "Compared with the prior study of [**2146-5-4**], the
left ventricle has increased in size (from 6.2 to 6.5
centimeters). Global left ventricular systolic has further
declined from 20% to 10-15%." repeat echo revealed somewhat
dyssynchronous A-V function. Thus, she underwent a CTA of the
coronary veins to assess the placement of her BiV leads. It
turns out that the left ventricle lead is located very
anteriorly and so is stimulating not far from the septum. The
CTA did show other coronary veins accessible for lead
replacement. She was scheduled to return to the hospital for
Dr. [**Last Name (STitle) **] to replace the left lead more posterio-laterally
which will allow for better ventricle stimulation and improved
BiV synchrony. She will return on Tuesday or Wednesday, [**6-7**].
# Sinus tachycardia: Unclear whether from fever or heart
failure. Did improve during admission and was discharged on
metoprolol 50 mg daily.
# Pneumonia: Pt febrile on admission. Blood cx and urine cx
showed no growth. CXR showed pulm edema initially but also
showed findings concerning for LLL and RUL PNA. She was started
on empiric antibiotics with vanc, aztreonam and tobramycin for
HCAP coverage due to her multiple drug allergies. She was
treated with an 8 day course (last dose [**2146-5-31**]).
# Paroxysmal Atrial fibrillation: Continued warfarin.
# Depression: on very large dose of sertraline which can be
arrythmogenic. Weaned to 100mg sertraline.
TRANSITIONAL ISSUES:
- Continue Milrinone infusion at home
- Return to the hospital on [**6-7**] or 6th for repositioning of
left ventricle BiV pacer lead with Dr [**Last Name (STitle) **]
Medications on Admission:
1. milrinone in D5W 200 mcg/mL Piggyback Sig: 0.38 mcg/kg/min
Intravenous INFUSION (continuous infusion).
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please continue to taper your Prednisone dose as previously
directed. -- patient unsure if she is taking this medication
4. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY.
10. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1)
tablet, Chewable PO once a day.
11. valsartan 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY.
17. warfarin 2.5 mg Tablet Sig: as directed by the coumadin
clinic Tablet PO once a day.
18. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
19. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
20. montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
21. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
22. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. magnesium oxide 400 mg Capsule Sig: One (1) Capsule PO once a
day.
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every six (6) hours as needed for SOB.
7. montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
10. Milrinone
0.5mg/1ml @ 0.38mcg/kg/min via continuous infusion; weight 160
pounds
Disp# 30
Refills: 6
11. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended
Release Sig: One (1) Capsule, Extended Release PO once a day.
12. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for shortness of breath or wheezing: start taper if
having asthma attack.
14. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO once a day.
15. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
16. torsemide 20 mg Tablet Sig: 2.5 Tablets PO once a day: if
you gain 3 lbs in 1 day: take 60mg.
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
18. Coumadin 5 mg Tablet Sig: 0.5 Tablet PO once a day.
19. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours as needed for shortness of breath or wheezing.
20. loratadine 10 mg Capsule Sig: One (1) Capsule PO once a day.
21. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
22. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
23. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
VT/VF s/p multiple shocks
nonischemic cardiomyopathy(EF 10-15%)
NYHA class III heart failure s/p BiV ICD placement
PAF
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 71175**],
You were admitted to the hospital after multiple ICD shocks.
The settings on your pacemaker were adjusted and you were not
shocked again.
We have made the following changes to your medications:
STOP your Digoxin
STOP your Gabapentin
STOP your Valsartan (Diovan)
START Potassium 20 MEQ daily (this is a potassium supplement)
RESUME your Coumadin at 2.5mg daily until you hear from Dr. [**Name (NI) 71181**] office about stopping it pre procedure
You should have your INR checked tomorrow (VNA can check it at
home).
Dr.[**Name (NI) 29750**] office will call you with instructions for next
week.
For your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 62**]) the office will call you to schedule
your lead revision either next Tuesday or Wednesday. They will
give you instructions about eating and taking your medications.
You will need to hold your Coumadin for 2 days pre procedure.
ICD9 Codes: 4271, 486, 4254, 4240, 4168, 311, 4280
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5533
}
|
Medical Text: Admission Date: [**2123-1-15**] Discharge Date: [**2123-1-16**]
Date of Birth: [**2074-11-21**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Gabapentin / Lamotrigine
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Source: Patient and telephone conversation with Dr. [**Last Name (STitle) 11435**]
48-year-old male with past medical history significant for
alcoholism with prior DTs, multiple psychiatric diagnosis,
ulcerative colitis, and ? NASH that presents with alcohol
withdrawal.
He presented to [**Hospital3 8063**] from [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **] for
voluntarily detox. Given severe tremors refractory to large
amounts of benzos (lorazepam and Librium), he was sent to [**Hospital1 18**]
for further management. Also with epigastric pain.
[**Hospital3 8063**] reports 150 mg Librium, 4 mg ativan and
still with tremors and anxiety. He reports drinking 2 gallons of
vodka for 12 days with last drink 3 days ago. Alcohol level 515
on [**1-14**] in [**Hospital3 **]. He had attempted detox x 2 days but
details are "fuzzy."
The patient started drinking at age 23 with intermittent periods
of sobriety lasting 1-2 years. He has been detoxed before with
valium/librium working the best. He denies any history of
seizure but does have vivid hallucinations and tremors. He
denies any history of pancreatitis or liver disease. The patient
has increased drinking notably over the past 3-4 weeks
consisting of 2 gallons of "whatever vodka is on sale." He
endorses depression and sense of abandonment. He denies other
recent ingestions, but he has drank Scope mouthwash in the past
due to restrictive [**State 350**] alcohol laws on Sunday. He
denies ever drinking anti-freeze. He has drank rubbing alcohol
in the past mixed with gatorade. He denies any recent other
substances including opiates, marijuana, and IVDU. He denies
recent trauma.
Per his PCP, [**Name10 (NameIs) **] has a history of alcohol abuse with DTs at
[**Hospital6 **] in [**Month (only) 956**]. Also previously in AA x 6
years with current relapse.
He endorses a primary pain generator consisting of his left hip,
which has necrosis. He uses percocet and MS Contin to control
his pain.
In regards to his UC, his symptoms have been stable for the past
few weeks. He has scant BRBPR per normal baseline and denies
coffee-grind like stool. He endorses a history of GIB from his
UC, but details are "fuzzy."
He feel and hit head 5 week ago with no LOC and evaluation.
.
In the [**Hospital1 18**] ED, initial VS were: 99.7 122 141/101 18 96%.
He was placed on diazepam CIWA 5mg IV q10-15 min, received at
least 100mg IV in the ED. Given banana bag and Mg. EKG with NSR,
borderline right bundle. CXR no acute process. Also given PPI,
Maalox, banana bag, magnesium. Initial CIWA in ED was 20
Access is 1 PIV. Mental status intact, still tremulous but calm.
.
On the floor, patient has visble tremors and diaphoretic
requesting more pain medications and valium.
.
Review of systems:
(+) Per HPI , 5-week history of night sweats, shortness of
breath on exertion yesterday. Mild HA. Nausea, vomiting
(non-bloody).
(-) Denies fever, chills, recent weight loss or gain.sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
.
Past Medical History:
- Alcoholism
- ? history per patient of recent MI (no cath, medical
management)
-History of pneumonia with sepsis (? CAC vs. aspiration [**2116**]).
- Hypogonadism on testosterone ([**Hospital1 2177**] endocrine clinic)
- Chronic left pain on narcotics
- necrotic hip with planned repair (left)
- Hypercholesteremia
- GERD
- History of ulcerative colitis
Quiescient recently.
- Hypertension
- NASH - no known cirrhosis, no prior EGD
- Psychiatric diagnosis (multiple diagnoses)
- Mood disorder NOS
ADHD combined type
anxiety disorder with panic attacks
alcohol dependence
Bipolar
Past surgical history:
- Laceration of neurovascular bundles of left index finger ([**2107**]
per [**Hospital1 18**] records)
Social History:
Smokes tobacco since age 15. 1 ppd.
History of alcohol abuse
Homeless at one time, has housing now and lives alone. No job.
Taking medical classes.
He currently lives in [**Hospital1 392**]
Family History:
History of sudden cardiac death in relatives.
[**Name (NI) **] has pancreatic cancer. Mom had MI at age 49.
Physical Exam:
Vitals: HR 92 BP 146/85 RR 18 Sat 98 T 98.8 weight 88.5 kg
General: Alert, oriented, tremors/sweating
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, epigastric tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Rectal: hemoccult negative. Stool in vault.
Neuro: AAOx3. Can say days of week backwards. Motor and sensory
exam grossly intact. CN III-XII intact. No nystagus. Obvious
tremors in all extremities. No asterixis. Gait not assessed
secondary to instability.
Skin: No apparent rash, palmar erythema, spiders
Pertinent Results:
[**2123-1-16**] 03:27AM BLOOD WBC-5.8 RBC-4.41* Hgb-13.5* Hct-38.6*
MCV-88 MCH-30.6 MCHC-34.9 RDW-15.2 Plt Ct-137*
[**2123-1-15**] 09:54AM BLOOD WBC-11.0 RBC-4.33* Hgb-13.3* Hct-37.1*
MCV-86 MCH-30.7 MCHC-35.8* RDW-15.4 Plt Ct-176
[**2123-1-15**] 09:54AM BLOOD PT-11.8 PTT-21.5* INR(PT)-1.0
[**2123-1-15**] 09:54AM BLOOD Glucose-84 UreaN-12 Creat-0.7 Na-137
K-3.6 Cl-97 HCO3-23 AnGap-21*
[**2123-1-16**] 03:27AM BLOOD Glucose-66* UreaN-7 Creat-0.6 Na-137
K-3.4 Cl-97 HCO3-27 AnGap-16
[**2123-1-15**] 09:54AM BLOOD ALT-92* AST-162* CK(CPK)-749* AlkPhos-96
Amylase-79 TotBili-1.3
[**2123-1-16**] 03:27AM BLOOD ALT-87* AST-141* LD(LDH)-420*
CK(CPK)-787* AlkPhos-103 TotBili-1.2
[**2123-1-15**] 09:54AM BLOOD Albumin-3.9 Calcium-8.6 Phos-1.2* Mg-2.1
[**2123-1-16**] 03:27AM BLOOD Albumin-4.0 Calcium-8.6 Phos-1.9* Mg-2.0
[**2123-1-15**] 09:54AM BLOOD Lipase-49
[**2123-1-15**] 09:54AM BLOOD cTropnT-<0.01
[**2123-1-15**] 09:54AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2123-1-15**] 11:00AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CXR [**1-15**]: No acute intrathoracic process.
# Pending studies
- [**2123-1-16**] 03:27AM BLOOD HBsAg-PND HBsAb-PND
- [**2123-1-16**] 03:27AM BLOOD HCV Ab-PND
- MRSA screen
Brief Hospital Course:
Hospital course: 48-year-old male with past medical history
significant for alcoholism with prior DTs, multiple psychiatric
diagnosis, ulcerative colitis, and ? NASH that is transferred
from an OSH given severe tremors refractory to large amounts of
BZD sent to [**Hospital1 18**] for further management of alcohol withdrawal.
# Alcohol abuse with withdrawal
Patient displayed tremors, diaphoresis, tachycardia, and
hypertension on admission, now resolved. He did not have fever,
altered mental status, seizures or other symptoms suggesting
mimics such as meningitis.
Patient was placed on CIWA scale every 1 hour with diazepam 10
mg PO or IV with average CIWA ~ 20. Labs significant for
elevated CK (800), normal renal function, hypophosphatemia,
hypokalemia with appropriate repletion (HCTZ held in this
setting). Labs showing no evidence of other substance abuse or
osmolol gap. Patient transitioned to regular diet without
difficulties. In the am, patient wanted to leave hospital and go
back to [**Hospital1 **]. His CIWA was decreased to q4h at that time
given overall improvement. Given large amount of diazepam
requirement (~200mg over hospitalization of <24 hrs), he would
benefit from a monitored environment where further care can be
given, including prn diazepam.
Started thiamine and folate in addition to multivitamin given
history of alcohol abuse.
# Transaminitis
Patient has history of uncharacterized liver disease per reports
with baseline normal LFTs per PCP. [**Name10 (NameIs) **] admission, AST/ALT ~ 2
suggesting acute rise with alcohol. Hepatitis panel pending at
discharge and NEEDS TO BE FOLLOWED UP. He was told to hold
statin at discharge until liver issue resolved.
# Ulcerative colitis
Continued asacol
# Chronic left hip pain
Continued oxycodone and MSContin, although urine opiates
negative so unclear if these are being actively prescribed (PCP
not prescribing them) and they were removed from his d/c med
list.
Medications on Admission:
Asacol 1200 mg PO TID
Rowasa enemas prn UC flare
ASA 81 mg PO qD
MVI
Simvastatin 40 mg PO qD
HCTZ 12.5 mg PO qD
Loraditine 10 mg PO qD
Buproprion 150 mg PO BID (psych)
Zolpidem 5-10 mg PO qHS
Testosterone 100 mg INJ weekly
Percocet 10/325 mg PO 1 tab qID prn (last filled [**2122-10-26**])
MSContin 30 mg PO BID (unclear if being actively prescribed)
Discharge Medications:
1. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Rowasa 4 gram/60 mL Kit Sig: One (1) Rectal as directed as
needed for ulcerative colitis.
3. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
6. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
7. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
8. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Valium 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for CIWA>10: please administer for benzodiazepine
withdrawal as patient scores on CIWA>10.
10. testosterone cypionate 100 mg/mL Oil Sig: One Hundred (100)
mg Intramuscular once a week.
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Alcohol abuse
Secondary: GERD, ulcerative colitis, hypertension, mood disorder
NOS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were treated for alcohol withdrawal in the hospital.
** Please do not drink alcohol. Alcohol is affecting your health
poorly and you are at risk for serious medical complications and
even DEATH.***
Medication changes:
- Stopped simvastatin until you see your primary care doctor, as
your muscle enzyme level was high.
- Removed MS Contin and Percocet from your med list as it is not
clear that these are being actively prescribed.
- Start thiamine and folate (which are vitamins).
Followup Instructions:
Please follow-up with your primary care doctor
([**Last Name (LF) **],[**First Name3 (LF) **]) [**Telephone/Fax (1) 11436**] within 1 week of being
discharged from the hospital. It is a weekend, so we cannot make
this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 2720, 4019
|
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|
Medical Text: Admission Date: [**2124-5-17**] Discharge Date: [**2124-5-23**]
Date of Birth: [**2041-8-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
pulmonary intubation
History of Present Illness:
Ms. [**Known lastname 74813**] is an 82 year-old woman with a history of CAD s/p
CAD s/p MI with CABG in [**2110**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 of OM/LCx and DES of LM in
[**2118**], severe ischemic cardiomyopathy with EF 18%, s/p placement
of dual chamber ICD/PPM, who presents with acute onset shortness
of breath. History is obtained from her daughter.
.
One month prior to admission had been contact[**Name (NI) **] by PCP who
relayed lab abnl that were consistent with dehydration and
encouraged PO hydration as well as liberalization of
salt-restricted diet.
.
Per report patient has been experiencing gradual onset malaise
for the past 2-3 days. At baseline she is able to ambulate
around the house without shortness of breath, and she has been
unable to do this for several days. Yesterday she had
intermittent palpitations and shortness of breath daughter
attributed to anxiety. She awoke today acutely short of breath.
EMS was activated.
Her daughter denies any recent fevers or chills, cough, chest
pain, lower extremity edema, pain with urination. She does
endorse chronic constipation and mild abdominal discomfort for
the past few days (last bowel movement two days prior to
admission).
.
In the ED, initial VS 120 146/80 36 95% on facemask. EKG with
LBBB which was consistent with prior. CXR notable for pulmonary
vascular congestion and bilateral effusions. Her O2 Sat fell and
Bipap was started. She was given 40 mg of IV lasix, 4 mg IV
morphine, nitro SL. ABG at that time 7.11/71/81 on Bipap. She
was intubated with succ/etomidate for mixed hypoxic/hypercarbic
respiratory failure, then started on fentanyl/midazolam.
Peri-intubation her blood pressure fell to 60s (despite only 5
of PEEP). R IJ CVL was placed. and levophed was started. On the
levophed, her BP initially rose and stabilized however dropped
prior to transfer necessitating dopamine initiation. She
diuresised ~800cc in ED to the 40mg IV Lasix.
Repeat ABG prior to transfer, 7.28/41/69 on 500/15, 100% FiOx,
PEEP 8
.
On arrival to the CCU her MAPs>60 on combination levophed and
dopamine; O2 saturations 100% on FiO2 100 Vt: 500 24/8. ABG on
arrival 7.35 CO2: 35 O2 204. Levophed downtitrated and lasix gtt
initiated for treatment fo CHF exacerbation.
.
ROS: unable to attain
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)HTN
2. CARDIAC HISTORY:
# CAD s/p MI with CABG in [**2110**] (in [**Location (un) 74814**], [**State **])
# PERCUTANEOUS CORONARY INTERVENTIONS:
DES X2 in OM/Cx placed in
[**2118**]. DES in LM in [**2118**]. ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 54752**] Hospital in [**Location (un) 6482**])
# PACING/ICD: placement of PPM/ICD in [**2116**] (Guidant ICD placed
on
[**7-2**])
# Ischemic CMP;
-- TTE: [**5-17**]
EF: 20-25%; Severe regional left ventricular dysfunction with an
aneurysm of the anterior/anteroapical wall. Mild to moderate
mitral regurgitation
# Atrial Fibrillation per OSH records
.
OTHER PAST MEDICAL HISTORY:
# CKD. Baseline creatinine 1.6-2.0. Multifactorial origin
thought to be secondary to atrophic right kidney, longstanding
hypertension, and prior cardiac events.
# Solitary Kidney (due to nephrolithiasis/pyelonephritis)
# Pituitary Adenoma
# Thyroid Nodule
# Chronic Pain
# Right Sided Bell's Palsy
.
Social History:
From [**Country 9362**], has been in the United States for 13 years.
Widowed. Lives with daughter, her husband and 2 children. Walks
with cane at baseline, requires assistance with some ADLs.
No history of tobacco/alcohol/drugs
.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
.
Physical Exam:
On CCU admission:
.
.
GENERAL: Sedated, intubated. Withdrawls to pain; opens eyes to
command
HEENT: NCAT, PERRLA, Sclera anicteric. Conjunctiva were pink; OG
tube and ET tube in place
NECK: Supple with JVP elevated 10 cm.
CARDIAC: RRR; hard to discern murmur in setting of rhonchorous
bs anteriorly.
LUNGS: Breath sounds b/l; Rhonchorus bs anteriorly
ABDOMEN: Soft, NT, ND. No HSM or tenderness.
EXTREMITIES: No pedal edema appreciated. 1+ DPs and PTs.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: Sedated; withdraws to pain, responds to voice when
sedation lessened
.
Pertinent Results:
.
admission labs:
[**2124-5-17**] 10:48PM GLUCOSE-126* UREA N-28* CREAT-1.3* SODIUM-140
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14
[**2124-5-17**] 10:48PM CK(CPK)-122
[**2124-5-17**] 10:48PM CK-MB-5 cTropnT-0.04*
[**2124-5-17**] 10:48PM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-1.8
[**2124-5-17**] 10:48PM WBC-12.5* RBC-3.76* HGB-11.9* HCT-34.5*
MCV-92 MCH-31.7 MCHC-34.5 RDW-13.9
[**2124-5-17**] 10:48PM NEUTS-77* BANDS-5 LYMPHS-8* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2124-5-17**] 10:48PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2124-5-17**] 10:48PM PLT SMR-NORMAL PLT COUNT-229
[**2124-5-17**] 07:19PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2124-5-17**] 07:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-5-17**] 07:19PM URINE RBC-7* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2124-5-17**] 07:19PM URINE RBC-7* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2124-5-17**] 07:19PM URINE GRANULAR-1* HYALINE-18*
[**2124-5-17**] 07:19PM URINE MUCOUS-OCC
[**2124-5-17**] 04:26PM TYPE-ART TEMP-36.3 RATES-24/ TIDAL VOL-500
PEEP-8 O2-100 PO2-204* PCO2-35 PH-7.36 TOTAL CO2-21 BASE XS--4
AADO2-474 REQ O2-81 -ASSIST/CON INTUBATED-INTUBATED
[**2124-5-17**] 04:26PM LACTATE-1.3
[**2124-5-17**] 04:26PM freeCa-1.21
[**2124-5-17**] 03:47PM GLUCOSE-146* UREA N-27* CREAT-1.3* SODIUM-141
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-21* ANION GAP-14
[**2124-5-17**] 03:47PM ALT(SGPT)-11 AST(SGOT)-20 LD(LDH)-262* ALK
PHOS-51 TOT BILI-0.5
[**2124-5-17**] 03:47PM LIPASE-58
[**2124-5-17**] 03:47PM ALBUMIN-3.7 CALCIUM-8.3* PHOSPHATE-3.8
MAGNESIUM-1.8 IRON-88
[**2124-5-17**] 03:47PM WBC-11.6* RBC-3.90* HGB-12.2 HCT-37.1 MCV-95
MCH-31.3 MCHC-32.8 RDW-14.0
[**2124-5-17**] 03:47PM NEUTS-88* BANDS-8* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2124-5-17**] 03:47PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2124-5-17**] 03:47PM PLT SMR-NORMAL PLT COUNT-290
[**2124-5-17**] 03:47PM PT-37.1* PTT-31.1 INR(PT)-3.7*
[**2124-5-17**] 11:34AM TYPE-ART TIDAL VOL-500 PEEP-8 O2-100 O2
FLOW-24 PO2-69* PCO2-41 PH-7.28* TOTAL CO2-20* BASE XS--6
AADO2-603 REQ O2-99 -ASSIST/CON INTUBATED-INTUBATED
VENT-CONTROLLED
[**2124-5-17**] 11:11AM URINE HOURS-RANDOM
[**2124-5-17**] 11:11AM URINE UHOLD-HOLD
[**2124-5-17**] 11:11AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2124-5-17**] 10:10AM LACTATE-1.5
[**2124-5-17**] 10:04AM COMMENTS-GREEN TOP
[**2124-5-17**] 10:04AM GLUCOSE-146* LACTATE-1.8 NA+-142 K+-5.3
CL--111 TCO2-19*
[**2124-5-17**] 09:50AM GLUCOSE-166* UREA N-28* CREAT-1.4* SODIUM-137
POTASSIUM-5.3* CHLORIDE-107 TOTAL CO2-18* ANION GAP-17
[**2124-5-17**] 09:50AM estGFR-Using this
[**2124-5-17**] 09:50AM cTropnT-<0.01
[**2124-5-17**] 09:50AM CK-MB-4
[**2124-5-17**] 09:50AM WBC-13.7*# RBC-4.34# HGB-13.5# HCT-41.6#
MCV-96 MCH-31.2 MCHC-32.5 RDW-13.9
[**2124-5-17**] 09:50AM NEUTS-55.0 LYMPHS-39.5 MONOS-4.1 EOS-0.9
BASOS-0.6
[**2124-5-17**] 09:50AM PLT COUNT-280
[**2124-5-17**] 09:50AM PT-29.8* PTT-27.7 INR(PT)-2.9*
.
discharge labs:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2124-5-23**] 06:05 11.0 3.50* 10.7* 32.9* 94 30.7 32.6 13.7
290
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2124-5-23**] 06:81.0* 13.1* 4.6 0.6 0.7
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2124-5-23**] 06:05 290
[**2124-5-23**] 06:05 22.0* 2.0*
LAB USE ONLY
[**2124-5-22**] 06:05
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2124-5-23**] 06:05 111*1 49* 1.5* 144 3.7 105 29 14
.
Imaging on this admission:
.
ECG [**5-17**]: Sinus rhythm with borderline sinus tachycardia and
ventricular premature beat.
Probable atypical left bundle-branch block with left axis
deviation. Since the
previous tracing of the same date sinus tachycardia rate is
slower and
ventricular ectopy is present. Otherwise, probably no
significant change.
TTE [**5-17**]:
The left ventricular cavity size is top normal/borderline
dilated. There is severe regional left ventricular systolic
dysfunction with akinesis of almost all segments apart from the
inferior and inferolateral walls which are mildly hypokinetic.
There is an anteroapical left ventricular aneurysm. Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-2**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is borderline pulmonary artery systolic
hypertension.
IMPRESSION: Severe regional left ventricular dysfunction with an
aneurysm of the anterior/anteroapical wall. Mild to moderate
mitral regurgitation.
Compared with the prior study (images not available for review)
of [**2121-8-30**], the degree of mitral regurgitation has probably
increased. LV systolic
Historical imaging:
The left ventricular cavity size is top normal/borderline
dilated. There is severe regional left ventricular systolic
dysfunction with akinesis of almost all segments apart from the
inferior and inferolateral walls which are mildly hypokinetic.
There is an anteroapical left ventricular aneurysm. Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-2**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is borderline pulmonary artery systolic
hypertension.
IMPRESSION: Severe regional left ventricular dysfunction with an
aneurysm of the anterior/anteroapical wall. Mild to moderate
mitral regurgitation
.
2D-ECHOCARDIOGRAM: ([**2121-3-8**]):
The left atrium is normal in size. There is a very large
antero-apical left ventricular aneurysm. There is severe
regional left ventricular systolic dysfunction with akinesis of
almost all segments apart from the inferior and inferolateral
walls which are mildly hypokinetic. A left ventricular
mass/thrombus cannot be excluded - the apex is not well seen.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
no pericardial effusion.
.
IMPRESSION: Severe regional left ventricular dysfunction with a
large aneurysm of the anterior wall. Mild mitral regurgitation
and trace aortic regurgitation. Pulmonary artery systolic
pressure could not be estimated.
.
CXR: [**5-17**]
IMPRESSION: Bibasilar opacities and cardiomegaly may relate to
CHF in the appropriate clinical setting, with bibasilar
opacities relating to pleural effusions and overlying
atelectasis, underlying consolidation cannot be excluded.
.
PERSANTINE MIBI: ([**2121-3-10**])
SUMMARY OF DATA FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142 mg/kg/min.
INTERPRETATION:
Left ventricular cavity size is severely enlarged.
Rest and stress perfusion images reveal multiple fixed perfusion
defects including a severe anterior and apical defect as well as
moderate anterolateral and distal inferolateral defects. Gated
images reveal global hypokinesis. The calculated left
ventricular ejection fraction is 18%. There is no prior for
comparison.
IMPRESSION: 1) Multiple fixed perfusion defects including a
severe anterior and apical defect as well as moderate
anterolateral and distal inferolateral defects. 2) Severe left
ventricular enlargement with global hypokinesis and an LVEF of
18%.
.
CARDIAC CATH: Per prior discharge summary: OSH records for cath
performed in [**3-4**]. "Cath done with balloon pump support, OM and
LCx dilation, DES X2 in OM/Cx, LM dilated, DES in LM crossing
intermediate artery. The Cx was considered as a non-jeopardized
side branch and the origin was stented across. Long term plavix
recommended."
.
TTE [**2120**]:
The left ventricular cavity size is top normal/borderline
dilated. There is severe regional left ventricular systolic
dysfunction with akinesis of almost all segments apart from the
inferior and inferolateral walls which are mildly hypokinetic.
There is an anteroapical left ventricular aneurysm. Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-2**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is borderline pulmonary artery systolic
hypertension.
.
Brief Hospital Course:
Ms [**Known lastname 74813**] is a 82 year-old woman with severe ischemic
cardiomyopathy EF 20-25% admitted to the CCU with acute on
chronic CHF exacerbation resulting in respiratory failure.
.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE: On admission to the
ED clinical picture was consistent with pulmonary edema, CXR
notable for pulmonary vascular congestion and bilateral
effusions. Her O2 Sat fell and Bipap was started. She was given
40 mg of IV lasix, 4 mg IV morphine, nitro SL. ABG at that time
7.11/71/81 on Bipap. She was intubated with succ/etomidate for
mixed hypoxic/hypercarbic respiratory failure, then started on
fentanyl/midazolam. Peri-intubation her blood pressure fell to
60s (despite only 5 of PEEP). R IJ CVL was placed. and levophed
was started. On the levophed, her BP initially rose and
stabilized however dropped prior to transfer necessitating
dopamine initiation. She diuresised ~800cc in ED to the 40mg IV
Lasix. Repeat ABG prior to transfer, 7.28/41/69 on 500/15, 100%
FiOx, PEEP 8
On arrival to the CCU her MAPs>60 on combination levophed and
dopamine; O2 saturations 100% on FiO2 100 Vt: 500 24/8. ABG on
arrival 7.35 CO2: 35 O2 204. Levophed and Dopamin were
subsequently weaned and patient was treated with lasix gtt for
duresis with good response. She was extubated on day 2 and
remained respiratorily stable. LOS at discharge from CCU was
-5L.
.
As for etiology for her CHF exacerbation this is attributable to
excess fluid intake and dietary indiscretion on the days
preceeding her admission. Other potential causes are thought
unlikely: she had no signs or symptoms of infection, Ucx and Bcx
were negative; her clinical complaints, EKG, TTE and biomarkers
were not suggestive of an ischemic event.
.
The Patient was transfered to the cardiology floor where home
meds were restarted. She is discharged with torsemide,
metoprolol, digoxin, atacand and warfarine as outlined below.
.
.
# AF w/ RVR: this developed with concurrent hypotension on [**5-19**].
Ventricular rate was as high as 170 and in this setting patient
got shocked by her ICD 7 times without conversion. Amiodarone +
digoxin were IV loaded with subsequent return to sinus rythm. EP
were consulted, ICD was interrogated and data was c/w Afib with
RVR. ICD was reset appropriately. Patient was subsequently well
rate controlled with metoprolol, digoxin and amiodarone. She is
discharged on the same as outlined below.
.
# CORONARY ARTERY DISEASE: EKG currently difficult to interpret
for ischemia given LBBB which is old. TTE unchanged from prior
with no evidence of new WMA. Biomarkers peaked at trop 0.04, MB
5. Continued on statin and BB. Was started on ASA 81.
.
# CHRONIC KIDNEY DISEASE. Multifactorial in setting of atrophic
right kidney, longstanding hypertension, and prior cardiac
events. Baseline creatinine 1.3-1.8. Cr was 1.5 on dsicharge.
.
# Abdominal Pain. Patient with long history of chronic
constipation. Was treated with laxatives with consequent BM and
resolution of abdominal pain.
.
# HYPERTENSION: Had some episodes of hypotension during this
admission first in the setting of intubation then in the setting
of AF/RVR. Subsequently stabilized and currently normotensive on
low doses of BB and [**Last Name (un) **].
.
# Code: Full during this admission; confirmed, HCP: daughter
.
# Dispo: patient is discharged to rehabilitation facility.
.
.
Post discharge issues:
- follow I/O daily weights and fluid status.
- adjust duretic and BP medication as needed.
- Aldosterone antagonist may be added on in the out patient
setting after [**First Name9 (NamePattern2) 74815**] [**Last Name (un) **] and BB therapy.
- contionue Coumadin for anticoagulation of LV aneurysm; Adjust
dosage as needed for goal INR = [**2-3**].
- f/u Bcx result from [**5-19**] which is still pending at discharge
Medications on Admission:
Medications (reconciled with daughter)
Coumadin 2.5mg PO QD
Crestor 20mg QD
Atacand 16mg PO QD
Meclizine 25mg PO TID
Omeprazole 20mg PO
Imdur 60mg PO QD
Torsemide 20mg PO QD
Calcitriol 0.25mg 1 tab QOD
Prunelax 15mg prn
Nitroglycerin prn chest pain
Colace 100mg PO BID
Dulcolax 5mg prn QD
Lactulose 30ml prn constipation
.
Discharge Medications:
1. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: please check INR daily until stable.
2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atacand 16 mg Tablet Sig: One (1) Tablet PO once a day: Hols
SBP < 100.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. torsemide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks: then decrease to 200 mg daily.
12. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO every
other day.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] [**Location (un) 1821**]
Discharge Diagnosis:
Primary diagnosis:
Ventricular tachycardia
Acute on chronic systolic congestive heart failure
Secondary diagnosis:
Ischemic cardiomyopathy
Dyslipidemia
Hypertension
Chronic kidney disease
Coronary artery disease
constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had an acute exacerbation of your systolic congestive heart
failure and needed increased amounts of diuretics to get rid of
the fluid. You required intubation to help you breathe. You also
had ventricular tachycardia, a dangerous rhythm that was
controlled by starting amiodarone and metoprolol. You have not
had any of this rhythm for the last 48 hours. You were confused
but this is improving as you are getting better.
We made the following changes to your medicines:
1. Decrease coumadin to 1mg daily as amiodarone can increase
coumadin level
2. Decrease torsemide to 5 mg daily
3. Start colace, senna and mirilax to treat your constipation
4. stop taking prunelax, lactulose, bisacodyl and dulcolax
5. Stop taking meclizine and Imdur
6. STart taking metoprolol to slow your heart rate
7. Start taking amiodarone to keep you in a normal rhythm
8. Start taking Digoxin to help your heart beat more effectively
Weigh yourself every morning, call Dr. [**Last Name (STitle) 3357**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 4606**]
The office will call you with an appt in [**1-2**] weeks. Please call
them if you have not received an appt.
Completed by:[**2124-5-23**]
ICD9 Codes: 4280, 4589, 5859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5535
}
|
Medical Text: Admission Date: [**2143-11-2**] Discharge Date: [**2143-11-4**]
Date of Birth: [**2087-12-26**] Sex: F
Service: CICU
CHIEF COMPLAINT: Non ST elevation MI.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 98237**] is a 55-year-old
female with a history of coronary artery disease status post
MI times three, last in [**2136**] that was treated with a PTCA to
the right coronary and left circumflex. She was brought in
from an outside hospital where the patient had presented with
left sided chest pressure. The patient had described the
pressure as [**7-30**] and radiation to the back and to both arms.
It was associated with diaphoresis and nausea. The patient
described the pain as exactly the same as her previous MI and
that took her to the ED at the outside hospital.
At the outside hospital, she was given aspirin, Nitroglycerin
and Morphine without relief of the pain. EKG read at the
outside hospital as no acute changes and her CK at the
outside hospital was negative. However, the chest pain
persisted. The patient was started on anticoagulation and
her second CK came back at 1100 with positivity for
myocardial infarction. The patient was then started on AV
heparin and Integrilin. She continued to have chest pain
[**3-29**], but her EKG continued to be read as normal. She was
transferred to [**Hospital1 69**] for
cardiac catheterization.
At cardiac catheterization, the patient was shown to have
left anterior descending lesion 90% which was stented. The
patient then became chest pain free post catheterization for
the first time and remained chest pain free and without
shortness of breath for the remainder of her hospitalization.
At baseline, of note, the patient has minimal exercise
capacity limited by back pain. Her last stress test was two
years ago which was within normal limits per the patient.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post stents to the
proximal left circumflex and right coronary artery in [**2135**]
and three previous myocardial infarctions.
2. Hypertension.
3. Insulin dependent diabetes mellitus.
4. Hypercholesterolemia.
5. Obesity.
6. Chronic obstructive pulmonary disease.
7. Hypothyroidism.
8. Gastroesophageal reflux disease.
9. Peptic ulcer disease.
10. Status post cholecystectomy.
MEDICATIONS: Her home medications are as follows.
1. Zantac 150 mg p.o. b.i.d.
2. Lipitor 10 mg p.o. q. day.
3. Glucophage 1000 mg p.o. b.i.d.
4. Glyburide 10 mg p.o. b.i.d.
5. Isordil 20 mg p.o. t.i.d.
6. Lopressor 125 mg p.o. b.i.d.
7. Captopril 25 mg p.o. t.i.d.
8. Premarin 0.625 mg p.o. q. day.
9. Provera 0.5 mg.
10. Humalog 75/25 14 units q. AM, 14 units q. PM.
11. Levoxyl 200 mcg p.o. q.d.
12. Celexa 20 mg p.o. q.d.
13. Ativan 0.5 mg b.i.d.
14. Albuterol MDI p.r.n.
15. Albuterol nebs q.i.d.
16. Vicodin 5/500 b.i.d. p.r.n. pain.
ALLERGIES: Patient has no known drug allergies.
SOCIAL HISTORY: Patient lives with her husband and four
kids. She has a 30 pack year history of smoking, quit four
years ago. Denies any alcohol or drug use.
PHYSICAL EXAMINATION: On presentation at which time she was
on Integrilin drips and Nitrodrip include the following, a
temperature of 96.6 F, pulse 103, blood pressure 140/58,
breathing 17, saturating at 94% on two liters. She weighed
137 kilograms. General: She was a pleasant, obese woman in
no acute distress. Head, eyes, ears, nose and throat:
Pupils are equal, round and reactive to light. Oropharynx
clear. Mucous membranes dry. Neck was full, but there was
no jugular venous distention visualized. Chest: Distant
breath sounds with faint wheezes. Cardiovascular: Chest and
heart sounds, no murmurs, rubs, or gallops. Abdomen: Bowel
sounds normal, obese, soft, nontender, nondistended.
Extremities: Trace edema. Positive erythema with a raised
margin and satellite lesions in her bilateral groins. She
had 2+ distal lower extremity pulses. Neurologically: Alert
and oriented. Moving all extremities symmetrically.
LABORATORY DATA: Labs at the outside hospital showed an ABG
of 7.32, 54 and 102, no ventilator settings or oxygenation
information is available.
The first set of labs available from [**Hospital3 **] were on the
15th which showed a CBC with a white blood cell count of
10.7, hematocrit 41.1, platelets 206.
CK of 6, CK MB of 30. She had a PT of 12.4, PTT of 20.4 and
an INR of 1.0. She had a potassium of 4.1, BUN 9, creatinine
0.6. Total cholesterol 174, HDL 51, LDL 68, triglycerides
276.
The patient underwent cardiac catheterization which
demonstrated the following: Markedly elevated left sided
filling pressures and left ventricular ejection fraction of
25%, anterolateral apical and distal inferior akinesis, no
mitral regurgitation.
Coronary angiography determined the following: She was right
dominant. Her left main coronary artery was normal. Her
left anterior descending artery was 95% mid stenosed with
moderate calcium. Her D1 was 70% occluded and the origin of
D2 was 60% occluded. Left circumflex showed minimal luminal
irregularities and proximal stent widely patent. Her RCA
showed a mid RCA stent mildly patent, minimal luminal
irregularities throughout.
In addition, the day of discharge the patient had the
following laboratory values. CBC: White blood cell count
8.3, hemoglobin 13.7, hematocrit 40.8, platelets 175. PT
13.3, PTT 71.1 and INR of 1.2. Her Chemistry 7 was as
follows with a sodium of 137, potassium 3.4, chloride 94,
bicarbonate 30, BUN 8, creatinine 0.5. CK was 168.
HOSPITAL COURSE:
1. CARDIOVASCULAR: The patient was found to have a 90%
occluded left anterior descending artery which was stented
with good success and with subsequent relief of her chest
pain. She had initially been continued on 48 hours total of
Integrilin and anticoagulated with IV heparin. Her pump
function was noted to be roughly 25% left ventricular
ejection fraction with akinesis throughout. She was gently
diuresed and she was treated with Captopril and Isordil, beta
blocker for pressure control after Nitrodrip had been weaned
off.
She remained chest pain free and free of shortness of breath
and palpitations throughout her hospital course. The patient
was noted throughout hospital to have significant
biventricular ectopy and was continued on her beta blocker.
2. HEMATOLOGIC: The patient had been on Integrilin for
lysis of her thrombotic left anterior distending artery. She
received 48 hours total of Integrilin. She then was started
on Plavix and aspirin. After cardiac catheterization, she
was also started on Coumadin and continued on her heparin.
The day of discharge, the heparin was turned off and Coumadin
was maintained at 7.5. Her INR was 1.2. The Plavix was
continued as was the aspirin.
The patient is to receive a total of 30 days of Plavix and to
go home on baby aspirin 81 mg p.o. q.d. in the setting of
receiving Plavix as well. She is to have her INR checked two
days after discharge and indicates that she will do so. The
primary care physician will check for her INR goal which is
2.0 to 3.0.
3. ENDOCRINOLOGY: Patient has a history of insulin
dependent diabetes mellitus. Her blood sugars remained
roughly 150 to 200 throughout her hospital stay. She was
initially treated with an insulin drip then transferred to
Humalog 75/25 q. AM and q. PM and covered with a regular
insulin sliding scale. She is to resume taking her Metformin
and her Glyburide when she gets home at the previous doses.
Her Metformin was held for 48 hours following post
catheterization. She is also to continue on her Levoxyl 200
mcg p.o. q. day.
4. DERMATOLOGY: The patient was noted to have a likely
tinea infection of her bilateral groin. She was treated with
Nystatin cream.
5. CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The patient was
noted to have some wheezing on admission. She was treated
with Albuterol and Atrovent metered dose inhaler and
nebulizers p.r.n.
CONDITION ON DISCHARGE: Patient was in good condition at
discharge.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Status post non ST elevation myocardial infarction of the
anterior wall with 90% left anterior descending occlusion
status post stent to that lesion.
2. Congestive heart failure with a left ventricular ejection
fraction of 25%.
3. Ventricular ectopy.
4. Insulin dependent diabetes mellitus.
5. Hypothyroidism.
6. Tinea infection of the groin.
7. Chronic obstructive pulmonary disease.
8. Left shoulder pain.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d. times 30 days.
3. Lopressor 75 mg p.o. b.i.d.
4. Lisinopril 20 mg p.o. q.d.
5. Warfarin 70.5 mg p.o. q.h.s. to be adjusted after two
days by primary care physician to goal INR of 2 to 3.
6. Insulin 75/25 14 units in the morning and 14 units in the
evening.
7. Zantac 150 mg p.o. q. day.
8. Lipitor 10 mg p.o. q.d.
9. Synthroid 200 mcg p.o. q.d.
10. Celexa 20 mg p.o. q.d.
11. Albuterol MDI p.r.n. shortness of breath.
12. Ativan 25 mg p.o. b.i.d.
13. Premarin 0.625 mg p.o. q.d.
14. Isordil 20 mg p.o. t.i.d.
15. Glucophage 1000 mg p.o. b.i.d.
16. Glyburide 10 mg p.o. b.i.d.
17. Lovenox 100 mg p.o. subcu until her INR is at goal of 1.8
to 2.
FOLLOW UP PLANS: The patient is to follow up with her
primary care physician in two days following discharge for
check of her INR.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2143-11-4**] 14:56
T: [**2143-11-7**] 10:34
JOB#: [**Job Number **]
ICD9 Codes: 496, 2724, 2449, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5536
}
|
Medical Text: Admission Date: [**2176-10-29**] Discharge Date: [**2176-11-5**]
Date of Birth: [**2136-3-10**] Sex: F
Service: SURGERY
Allergies:
nsaids
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Morbid obesity
Major Surgical or Invasive Procedure:
1. Laparoscopic repair of paraesophageal hernia.
2. Placement of laparoscopic adjustable band and port device.
History of Present Illness:
[**Known firstname 45779**] has class III morbid obesity with weight of 276.2
pounds as of [**2176-9-10**] (her initial screen weight on [**2176-8-8**] was
280 pounds), height of 64 inches and BMI of 47.4. Her previous
weight loss efforts have included Weight Watchers, the Salad
Diet, the South Beach diet, the [**Doctor Last Name 1729**] diet, over-the-counter
ephedra-containing Ma [**Doctor Last Name **], Slim-Fast, prescription weight loss
medication and pancreatic lipase inhibitor orlistat (Xenical),
and [**First Name8 (NamePattern2) 1446**] [**Last Name (NamePattern1) **]. Her weight and age 21 was 140-145 pounds with
her lowest adult weight 130 pounds at age 20 and her highest
weight 281.7 pounds on [**2176-8-19**]. She weighed 140-145 pounds 10
years ago and 165 pounds 5 years ago. She states she developed
significant [**Last Name 4977**] problem in childhood and cites as factors
contributing to her excess weight genetics, large portions,
grazing, late night eating, too many carbohydrates in saturated
fats, stress, compulsive eating and emotional eating as well as
lack of exercise regimen. Her current activity includes
swimming 30 minutes 2-3 times per week and walking 10-15 minutes
twice per week. She denied anorexia, bulimia, diuretic or
laxative abuse but stated she does have binge eating without
purging. She has significant psychological history of
depression/bipolar disorder/anxiety and suicide attempts
admitted to [**Hospital 1191**] Hospital in [**Location (un) 10059**] x 2 in [**2171**] for drug
overdose and lithium toxicity with auditory hallucinations,
followed by psychiatrist and a therapist and is currently on
psychotropic medications (paroxetine, Abilify and lorazepam).
Past Medical History:
PMH: COPD, Fatty liver, HTN, HL, hypothyroidism,GERD, bipolar
disorder, iron deficiency anemia, renal insufficiency,
nephrogenic diabetes insipidus
PSH: wisdom teeth, breast implants, precervical cancer surgery
Social History:
She smoked one pack per day of cigarettes for 25 years quit
[**2176-7-29**], no
recreational drugs, no alcohol and does drink both carbonated
and caffeinated beverages. Two daughters age 20 and age 21 who
had been in DSS group homes and in [**Doctor Last Name **] homes. She is
divorced and is on disability, used to work in cosmetic sales,
lives alone but does have supportive friends.
Family History:
Her family history is noted for both parents living father with
history of stroke, mother with heart disease, hyperlipidemia,
asthma, thyroid disorder; sister living with heart disease and
thyroid disorder; multiple family members with mental illness
Physical Exam:
VS: T 98 HR 80 BP 120/78 RR 20 O2 99%RA
Constitutional: NAD
Neuro: Alert and oriented to person, place and time; affect flat
Cardiac: RRR, NL S1,S2, No MRG
Lungs: CTA B
Abdomen: Soft, non-tender, non-distended, no rebound tenderness
or guarding
Wounds: Abdominal lap sites with steri-strips, no periwound
erythema/ induration, mild periwound ecchymosis
Ext: 2+ DP pulses
Pertinent Results:
LABS:
[**2176-11-5**] 10:09AM BLOOD WBC-8.4 RBC-3.77* Hgb-9.7* Hct-30.8*
MCV-82 MCH-25.7* MCHC-31.5 RDW-16.0* Plt Ct-207
[**2176-11-5**] 06:27AM BLOOD Glucose-90 UreaN-24* Creat-1.5* Na-146*
K-3.7 Cl-108 HCO3-26 AnGap-16
[**2176-11-5**] 10:09AM BLOOD Glucose-124* UreaN-22* Creat-1.5* Na-143
K-4.1 Cl-106 HCO3-27 AnGap-14
[**2176-11-5**] 10:09AM BLOOD Calcium-9.7 Phos-3.3 Mg-2.2
[**2176-11-4**] 02:05AM BLOOD Glucose-100 UreaN-21* Creat-1.4* Na-143
K-4.0 Cl-107 HCO3-23 AnGap-17
[**2176-11-4**] 04:05PM BLOOD Na-139 K-3.9 Cl-103
[**2176-11-4**] 08:39PM BLOOD Na-141 K-3.7 Cl-105
[**2176-11-3**] 04:04AM BLOOD Glucose-102* UreaN-19 Creat-1.6* Na-149*
K-3.9 Cl-112* HCO3-26 AnGap-15
[**2176-11-2**] 12:31AM BLOOD Glucose-102* UreaN-15 Creat-1.7* Na-155*
K-4.1 Cl-119* HCO3-23 AnGap-17
[**2176-11-2**] 04:44AM BLOOD Na-158* K-4.0 Cl-121*
[**2176-11-2**] 12:31AM BLOOD Glucose-102* UreaN-15 Creat-1.7* Na-155*
K-4.1 Cl-119* HCO3-23 AnGap-17
[**2176-11-2**] 04:44AM BLOOD Na-158* K-4.0 Cl-121*
[**2176-11-2**] 07:58AM BLOOD Glucose-147* UreaN-17 Creat-1.8* Na-159*
K-4.4 Cl-122* HCO3-28 AnGap-13
[**2176-11-2**] 12:28PM BLOOD Glucose-95 UreaN-19 Creat-1.8* Na-154*
K-4.5 Cl-117* HCO3-26 AnGap-16
[**2176-11-2**] 04:15PM BLOOD Glucose-101* UreaN-18 Creat-1.6* Na-149*
K-4.0 Cl-113* HCO3-25 AnGap-15
[**2176-11-2**] 08:25PM BLOOD Glucose-105* UreaN-19 Creat-1.6* Na-150*
K-4.2 Cl-114* HCO3-26 AnGap-14
[**2176-11-1**] 09:27AM BLOOD Na-159* Cl-122*
[**2176-11-1**] 09:48AM BLOOD Glucose-139* UreaN-15 Creat-2.0* Na-159*
K-3.9 Cl-123* HCO3-26 AnGap-14
[**2176-11-1**] 12:05PM BLOOD Na-156* K-3.5 Cl-120*
[**2176-11-1**] 02:10PM BLOOD Na-154* K-3.9 Cl-120*
[**2176-11-1**] 10:10PM BLOOD Na-152* K-3.5 Cl-116*
[**2176-11-1**] 01:25AM BLOOD Glucose-128* UreaN-15 Creat-2.1* Na-168*
K-3.9 Cl-131* HCO3-26 AnGap-15
[**2176-10-31**] 08:50AM BLOOD Glucose-136* UreaN-15 Creat-1.9* Na-167*
K-3.7 Cl-129* HCO3-27 AnGap-15
[**2176-10-31**] 10:50AM BLOOD Glucose-100 UreaN-15 Creat-1.9* Na-167*
K-4.5 Cl-132* HCO3-23 AnGap-17
[**2176-10-31**] 04:02PM BLOOD Na-164* K-3.6 Cl-128*
[**2176-10-31**] 08:50AM BLOOD Calcium-10.7* Phos-2.5*# Mg-2.6
[**2176-10-31**] 10:50AM BLOOD Osmolal-346*
[**2176-11-4**] 02:05AM BLOOD Osmolal-304
[**2176-10-31**] 10:50AM BLOOD TSH-0.71
[**2176-10-31**] 10:50AM BLOOD T4-13.1*
[**2176-10-31**] 05:31PM BLOOD Na-163*
[**2176-10-31**] 08:36PM BLOOD Na-159*
[**2176-10-31**] 11:32PM BLOOD Na-163*
[**2176-11-1**] 04:50AM BLOOD Na-163*
[**2176-11-1**] 04:12PM BLOOD Na-154*
[**2176-11-1**] 06:40PM BLOOD Na-154*
[**2176-11-1**] 08:48PM BLOOD Na-153*
[**2176-11-3**] 12:29AM BLOOD Na-148*
[**2176-11-3**] 09:08AM BLOOD Na-145
[**2176-11-3**] 12:32PM BLOOD Na-146*
[**2176-11-3**] 04:38PM BLOOD Na-143 K-4.4
[**2176-11-3**] 08:36PM BLOOD Na-144
[**2176-11-4**] 06:33AM BLOOD Na-144
[**2176-11-4**] 11:58AM BLOOD Na-144
Imaging:
[**2176-10-30**]: UGI SGL CONTRAST W/ KUB:
IMPRESSION: Appropriate lap band position, patent stoma, no
evidence of leak.
[**2176-10-31**] ECG:
Sinus tachycardia. Low precordial lead voltage. ST-T wave
changes in the
anterolateral leads which raise the question of active
anterolateral ischemic process. Followup and clinical
correlation are suggested. No previous tracing available for
comparison
[**2176-11-1**]: CHEST (PORTABLE AP):
IMPRESSION: No pneumothorax, hematoma, or other sequela of
procedural
complication identified. Bibasilar atelectasis.
[**2176-11-1**]:
CHEST PORT. LINE PLACEMENT:
IMPRESSION: New right PICC terminating within the right atrium,
4.5-5.0 cm
beyond the cavoatrial junction.
Brief Hospital Course:
The patient presented to pre-op on [**2175-10-30**]. Pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic adjustable gastric band placement. There were no
adverse events in the operating room; please see the operative
note for details. Pt was extubated, taken to the PACU until
stable, then transferred to the [**Hospital1 **] for observation.
Neuro: The patient became intermittently agitated beginning on
POD1, pulling at her NGT, IV lines and threatening to leave
against medical advice and complaining of thirst. Psychiatry
was consulted, however, the patient declined visitation; the
patient's home psychiatric medication regimen was resumed at
this time. Overnight on POD2, the pt became progressively
disoriented, again attempting to leave against medical advice
and lacked insight into all aspects of her hospitalization and
expected post-operative recovery. Psychiatry was re-consulted
as the patient appeared to lack any capacity for decision
making. At this time, electrolytes had been checked and the
serum sodium was noted to be 167 making a metabolic cause for
the patient's disorientation more likely; upon reviewing the
sodium level, psychiatry felt her mental status changes were
more likely the result hypernatremia induced delerium related to
diabetes insipidus. After normalization of serum sodium levels,
the patient remained alert and oriented x 3 without any further
issues regarding agitation or insight into her care.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Of note, the
patient's InnoPran XL was changed to regular release propranolol
as all medications must be crushed.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: She was initially on bariatric stage 1 diet, which
was well tolerated despite patient consuming more liquid than
ordered. An upper GI study was performed on POD 1 which
revealed appropriate band position without evidence of
obstruction. Her diet was further advanced to stage 2 and then
3 due to the patient's extreme thirst and dietary
non-compliance; the patient tolerated this level of intake well.
Additionally, on POD2, the patient was noted to be
hypernatremic with a serum sodium level of 167. Renal was
consulted and felt this was due to diabetes insipidus related to
prior lithium use; [**Name8 (MD) **] RN at the patient's PCP's office confirmed
this was a known diagnosis. The patient was identified as
having a free water deficit of approximately 10 liters; LR was
discontinued, D5W initiated, fluid intake liberalized and the
patient was transferred to the TSICU for q 3-4 hour serum sodium
monitoring. While in the TSICU, the patient's hypernatremia
gradually resolved over the course of 4 days with resolution of
her delerium; she was transferred back to the general surgical
[**Hospital1 **] on POD6. Her serum sodium remained between 141-146; Renal
felt it was safe for discharge to home with liberal fluid
intake, a stage 3 diet and a repeat serum sodium level within 1
week. Both the patient's PCP and nephrologist were contact[**Name (NI) **]
and follow-up appointments were made for the patient.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a
liberalized stage 3 diet, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan including
follow-up with her PCP tomorrow and her nephrologist on [**11-25**], [**2175**].
Medications on Admission:
Aripiprazole 15 mg daily
Paroxetine 10 mg daily
Perphenazine 32 mg q HS
Propranolol XL 160 mg daily
Levothyroxine 88 mcg daily
Zolpidem 10 mg daily
Omeprazole 40 mg [**Hospital1 **]
Lorazepam 1 mg QID
Diphenhydramine 25 mg daily
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day as needed for constipation.
Disp:*250 ml* Refills:*0*
2. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for Pain.
Disp:*100 ML(s)* Refills:*0*
3. aripiprazole 15 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
4. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a
day: Please crush.
5. perphenazine 8 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
6. propranolol 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
Please crush.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: Open capsule,
sprinkle contents onto applesauce, swallow whole. Do not chew
beads.
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO four times a
day: Please crush.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Gastroesophageal reflux with paraesophageal hernia.
2. Obesity.
3. Fatty liver.
4. Diabetes Insipidus
5. Hypernatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, nausea or vomiting,
difficulty drinking fluids, severe abdominal bloating, inability
to eat or drink, foul smelling or colorful drainage from your
incisions, redness or swelling around your incisions, confusion,
headache, weakness, increased thirst or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance diet, do not drink out of a straw or chew
gum. Please drink fluids freely and contact Dr. [**Last Name (STitle) 15645**] office
or report to the Emergency Department immediately if you are
unable to tolerate liquids.
Medication Instructions:
Resume your home medications except for the following changes:
1. Please stop InnoPran XL (propranolol) as this medication
CANNOT be crushed. A new prescription for propranolol (regular
release) has been provided to you as you may crush this
medication. Please notify your primary care provider of this
change.
2. Please stop amiloride per our Nephrologist.
CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**10-12**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Completed by:[**2176-11-5**]
ICD9 Codes: 2760, 2930, 496, 2449, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5537
}
|
Medical Text: Admission Date: [**2162-7-13**] Discharge Date: [**2162-7-15**]
Date of Birth: [**2109-3-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Flagyl / Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Severe, sudden onset of headache
Major Surgical or Invasive Procedure:
Cerebral Angiogram
History of Present Illness:
HPI: 53yo female with onset of severe headache this morning.
Patient awoke with no symptoms and developed symptoms overnight.
Was seen at OSH where SAH was noted on CT and patient
transferred
to [**Hospital1 18**] for evaluation and treatment. Notably, patient
reported
to have previous SAH w/clipping and placement of shunt at
unknown
medical center and unknown time. She denies other symptoms
including loss of motor or sensory function and incontinence.
Past Medical History:
PMHx: PKD, HTN, presumed previous SAH w/clipping and shunt
placement
Social History:
Social Hx: non-contributory
Family History:
Family Hx: non-contributory
Physical Exam:
PHYSICAL EXAM:
Gen: uncomfortable, agitated, NAD.
HEENT: previous incision noted on left scalp
Pupils: 4>3.5 reactive bilaterally EOMs full and intact
Neck: Supple.
Lungs: not examined
Cardiac: not examined
Abd: not examined
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam,
agitatated
affect due to discomfort.
Orientation: Oriented to person, place only
Language: Speech fluent with good comprehension and repetition
with slight occasional slurring.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to 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 [**4-13**] throughout.
Sensation: Intact to light touch.
Reflexes: B T Br Pa Ac
Right 3+ all
Left 3+ all
Toes downgoing bilaterally, no clonus
Coordination: patient not compliant
Upon discharge: Pt is intubated and sedated, Pupils 3.5->3
bilat. Complete exam deferred at this time due to high risk of
rupture due to SBP spikes to 200mmHg when sedation stopped.
Pertinent Results:
Head CT [**7-13**] 1449
IMPRESSION:
1. Diffuse subarachnoid hemorrhage centered in the right
suprasellar cistern
extending to the right sylvian fissure and right ambient
cistern.
2. Slit-like ventricles with tip of right-sided shunt in the
head of the
right caudate. Trace hemorrhage in the left lateral ventricle.
3. There is no herniation.
4. There are left-sided aneurysm coils in the region of the left
suprasellar
cistern.
5. Chronic right frontal infarct with encephalomalacia.
Head CT [**7-13**] 2140
IMPRESSION: No significant interval change. Diffuse subarachnoid
hemorrhage centered in the right suprasellar cistern extending
into the right sylvian fissure and right ambient cistern.
Slit-like ventricles with tip of the right-sided shunt in the
head of the right caudate. Trace hemorrhage in the left lateral
ventricle. Left-sided aneurysm clip in the region of the left
suprasellar cistern. Chronic right frontal infarct with
encephalomalacia.
[**2162-7-13**] 02:30PM BLOOD WBC-7.7# RBC-4.95# Hgb-16.7*# Hct-49.7*#
MCV-101*# MCH-33.7*# MCHC-33.5 RDW-13.1 Plt Ct-128*
[**2162-7-13**] 10:47PM BLOOD WBC-7.3 RBC-4.45 Hgb-15.2 Hct-43.7 MCV-98
MCH-34.0* MCHC-34.7 RDW-13.2 Plt Ct-105*
[**2162-7-14**] 04:04AM BLOOD WBC-7.5 RBC-4.80 Hgb-15.8 Hct-47.7
MCV-100* MCH-32.9* MCHC-33.1 RDW-13.0 Plt Ct-114*
[**2162-7-14**] 04:04AM BLOOD PT-11.7 PTT-23.5 INR(PT)-1.0
[**2162-7-13**] 02:30PM BLOOD Glucose-146* UreaN-36* Creat-1.7*# Na-145
K-4.2 Cl-114* HCO3-18* AnGap-17
[**2162-7-13**] 10:47PM BLOOD Glucose-152* UreaN-30* Creat-1.5* Na-147*
K-3.2* Cl-116* HCO3-21* AnGap-13
[**2162-7-14**] 04:04AM BLOOD Glucose-156* UreaN-32* Creat-1.8* Na-145
K-4.2 Cl-112* HCO3-20* AnGap-17
[**2162-7-14**] 04:19AM BLOOD Lactate-3.7*
Brief Hospital Course:
53F was intubated and brought for cerebral angiogram for coiling
of aneurysm. Coiling was unsuccesful due to a compromised L ICA
and inabilty to assess region of aneurysm. It is suspected that
the L Pcom Aneurysm bled and she has a L MCA and Basilar tip
anuerysm. No intervention done at that time. She was admitted to
SICU, where she remained intubated and sedated on Propofol. She
was on Nimodipine, q1hr neuro checks, HOB >30, CVL, IVF,
Nicardipine for goal SBP <120, Dil 100mg TID. SHe was to be kept
sedated and only pupils were to be examined. When sedation was
held for exam pt would spike SBP to 200's placing patient at
risk for rupture. Dr. [**First Name (STitle) **] then arranged for transfer of care
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1128**] at [**Hospital1 2025**] to resume pt care.
Medications on Admission:
unknown per pt
Discharge Medications:
1. Propofol 10 mg/mL Emulsion Sig: 10mg/ml Intravenous TITRATE
TO (titrate to desired clinical effect (please specify)):
Titrate to sedation.
2. Famotidine 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
3. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours).
4. Nicardipine 25 mg/10 mL Solution Sig: 1-3 mcg/kg/min
Intravenous INFUSION (continuous infusion): Please titrate to
SBP <120.
5. Phenytoin Sodium 50 mg/mL Solution Sig: Two (2) ml
Intravenous Q8H (every 8 hours).
6. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Five (5) mg
Intravenous Q4H (every 4 hours) as needed for HTN: Hold for SBP
<100, HR<60.
7. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for temp>100.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
L MCA Aneurysm
Basilar tip Aneurysm
L PCom Aneurysm
L ICA occlusion
Discharge Condition:
Critical Condition
Discharge Instructions:
Instructions will be dictated by [**Hospital1 2025**] upon discharge.
Followup Instructions:
Follow-Up Appointment Instructions
Your care is being transferred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14361**] a
Neurosurgeon at [**Hospital6 1129**] .
Completed by:[**2162-7-14**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5538
}
|
Medical Text: Admission Date: [**2135-10-10**] Discharge Date: [**2135-10-18**]
Date of Birth: [**2076-2-14**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Prednisone
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior lumbar inerbody fusion with instrumentaiton L2-S1
Posterior lumbar fusion with instrumentation L2-S1
History of Present Illness:
Ms. [**Known lastname 69478**] has a long history of back and leg pain from her
lumbar scoliosis. She has attempted conservative therapy
including physical therapy and has failed. She now presents for
surgical intervetion.
Past Medical History:
HTN
Lumbar scoliosis
Social History:
Denies
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes intact at quads and achilles
Pertinent Results:
[**2135-10-14**] 06:00AM BLOOD Hct-32.0*
[**2135-10-13**] 02:30AM BLOOD WBC-8.6 RBC-3.52* Hgb-11.1* Hct-31.0*
MCV-88 MCH-31.5 MCHC-35.8* RDW-15.4 Plt Ct-201#
[**2135-10-12**] 01:34AM BLOOD WBC-6.9 RBC-3.75* Hgb-11.9* Hct-33.0*
MCV-88 MCH-31.8 MCHC-36.1* RDW-15.6* Plt Ct-121*
[**2135-10-11**] 08:30PM BLOOD Hct-35.1*#
[**2135-10-11**] 01:45PM BLOOD Hct-25.5*
[**2135-10-11**] 05:40AM BLOOD Hct-27.2*
[**2135-10-13**] 02:30AM BLOOD Plt Ct-201#
[**2135-10-13**] 02:30AM BLOOD PT-12.7 PTT-35.5* INR(PT)-1.1
[**2135-10-11**] 03:45PM BLOOD PT-14.0* PTT-27.6 INR(PT)-1.2*
[**2135-10-11**] 10:18AM BLOOD PT-13.3* PTT-29.2 INR(PT)-1.2*
[**2135-10-14**] 06:00AM BLOOD Glucose-118* UreaN-9 Creat-0.5 Na-138
K-3.7 Cl-102 HCO3-29 AnGap-11
[**2135-10-13**] 02:30AM BLOOD Glucose-112* UreaN-11 Creat-0.5 Na-142
K-3.3 Cl-107 HCO3-26 AnGap-12
[**2135-10-12**] 02:17PM BLOOD K-4.3
[**2135-10-12**] 01:34AM BLOOD Glucose-132* UreaN-14 Creat-0.6 Na-142
K-3.4 Cl-109* HCO3-27 AnGap-9
[**2135-10-11**] 03:45PM BLOOD Glucose-114* UreaN-12 Creat-0.5 Na-142
K-3.8 Cl-109* HCO3-24 AnGap-13
[**2135-10-14**] 06:00AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.9
[**2135-10-13**] 02:30AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.9
[**2135-10-12**] 02:17PM BLOOD Calcium-7.9* Phos-2.0* Mg-2.1
[**2135-10-12**] 01:34AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8
[**2135-10-11**] 03:45PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.6
Brief Hospital Course:
Ms. [**Known lastname 69478**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for
an anterior/posterior lumbar fusion with instrumentation for her
lumbar scoliosis. She was informed and consented of the risks
and benefits and agreed to proceed. Please see Operative Note
for procdure in detail.
Post-operatively she was transferred to the T/SICU because of
her large blood loss. She required multiple units of packed
cells intraoperatively and postoperatively. Her drains and
epidural were removed POD2 and she was transferred out of the
T/SICU POD3.
On the floor she remained hemodynamically stable. She was
fitted for a lumbar corset and was able to work with physical
therapy. She tolerated PO's well and her pain was controlled.
She was discharged in good condition and will follow up in the
Orthopaedic Spine Clinic during her previously scheduled
appointments.
Medications on Admission:
Triamterene-HCTZ
Diazepam
Protonix
Beconaze
Hydrocodone
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar degenerative scoliosis L2-S1
Post-operative anemia
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Activity as tolerated
Lumbar corset for ambulation. [**Month (only) 116**] be out of bed to chair
without.
Treatments Frequency:
Site: Anterior/Posterior midline
Type: Surgical
Please change daily with dry, sterile gauze.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
Completed by:[**2135-10-18**]
ICD9 Codes: 2859, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5539
}
|
Medical Text: Admission Date: [**2151-4-4**] Discharge Date: [**2151-4-19**]
Date of Birth: [**2151-4-4**] Sex: F
Service: Neonatology
HISTORY: [**Known lastname **] [**Known lastname **], girl #1 was born at 34-2/7 weeks
gestation to a 40-year-old gravida 3, para 2 now 4 woman by
spontaneous vaginal delivery. The mother's prenatal screens
were blood type O+, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, and group B
Strep unknown. This was a pregnancy achieved with in-[**Last Name (un) 5153**]
fertilization with dichorionic-diamniotic twins. The mother
received betamethasone at 23 weeks gestation for cervical
shortening. The pregnancy was also complicated with
hypertension and urinary tract infection x2 with unknown
organism, and mother did [**Name2 (NI) **] throughout the pregnancy.
This twin had spontaneous rupture of membranes 12 hours prior
to delivery and onset of preterm labor. The infant emerged
vigorous. Apgars were nine at one and nine at five minutes.
ADMISSION PHYSICAL EXAMINATION: Reveals a preterm infant.
Anterior fontanel open and flat. Positive red reflex
bilaterally. Respirations comfortable. Lungs sounds clear
and equal. Heart was regular, rate, and rhythm, no murmur.
Abdomen is soft with positive bowel sounds. Normal preterm
female genitalia. Stable examination and a nonfocal
neurological examination.
The birth weight was 1,665 grams. The birth length was 43.5
cm and the birth head circumference was 29.5 cm.
HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The infant has remained in room air throughout
her NICU stay. She has had no apnea, bradycardia, or
desaturations. On examination, her respirations are
comfortable. Lung sounds are clear and equal.
CARDIOVASCULAR: The infant has remained normotensive
throughout her NICU stay. There are no cardiovascular
issues.
FLUIDS, ELECTROLYTES, NUTRITION: At the time of
discharge, the weight is 1,860 grams, the length is 45 cm,
and the head circumference is 30 cm. Enteral feeds were
begun on day of life one and advanced without difficulty to
full volume feedings by day of life #2. At the time of
discharge, she is eating on an adlib schedule breast milk or
Enfamil 24 calories/ounce made with Enfamil powder.
GASTROINTESTINAL: Infant had a bilirubin level on day
of life #3, total bilirubin of 1.6 and direct bilirubin 0.6.
She never required phototherapy.
HEMATOLOGY: The hematocrit at the time of admission was
48.6. Infant has never received any blood product
transfusions during the NICU stay. She is receiving
supplemental iron 2 mg/kg/day of elemental iron.
INFECTIOUS DISEASE: [**Known lastname **] was started on antibiotics at
the time of admission for sepsis risk factors. The
antibiotics were ampicillin and gentamicin. The antibiotics
were discontinued after 48 hours after the blood cultures
were negative, and the infant was clinically well.
NEUROLOGY: No issues.
AUDIOLOGY: Hearing screening was performed with automated
auditory brain stem responses and the infant passed in both
ears.
Psychosocial: The parents have been very involved in the
infant's care throughout the NICU stay.
CONDITION ON DISCHARGE: The infant is discharged in good
condition.
The infant is discharged home with her parents.
PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **]
of [**Hospital1 1562**], telephone #[**Telephone/Fax (1) 49156**].
CARE AND RECOMMENDATIONS AFTER DISCHARGE:
Feedings of 24 calorie/ounce of breast milk or Enfamil 24 or
breast feeding to maintain weight gain.
MEDICATIONS: Iron sulfate (25 mg/ml of elemental iron)
0.15 cc po q day.
The infant has passed her car seat position screening test.
State newborn screens were sent on [**4-8**] and [**2151-4-18**]. The
infant has not yet received any immunizations due to her
weight gain less than 2 kg, the minimum for the first
hepatitis B vaccine.
RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: 1) Born at less than 32 weeks, 2) born between 32
and 35 weeks with plans for daycare during RSV season, with a
smoker in the household, or with preschool siblings, or 3)
with chronic lung disease.
2. 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.
FOLLOW-UP APPOINTMENTS:
1. The [**Hospital6 407**] of [**Hospital3 **], telephone
number of 1-[**Telephone/Fax (1) 46331**].
2. Hepatitis B vaccine when she receives 2 kg in weight.
DISCHARGE DIAGNOSES:
1. Prematurity 34-2/7 weeks gestation.
2. Twin #1.
3. Sepsis ruled out.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2151-4-19**] 02:48
T: [**2151-4-19**] 06:23
JOB#: [**Job Number 49157**]
ICD9 Codes: 7742, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5540
}
|
Medical Text: Admission Date: [**2147-12-31**] Discharge Date: [**2148-1-1**]
Date of Birth: [**2126-2-2**] Sex: M
Service: NEUROLOGY
Allergies:
Vancomycin / Levaquin / Erythromycin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Seizure in the setting of apparent head trauma
Major Surgical or Invasive Procedure:
* Pt arrived intubated
History of Present Illness:
Per Admitting Resident:
Patient is a 21 yo man (handedness unknown) s/p renal
transplant currently on Prograf, prednisone and mycophenolate,
who is incarcerated for battery and assault who fell off the top
bunk and was found seizing per guard this morning. Per guard,
patient was stiff and having shaking of all limbs with eyes open
but deviated upwards. This shaking abated on its own in less
than 1 minute but upon transfer to [**Hospital6 302**], patient
had more generalized seizures requiring Ativan IV total of 10mg
and Versed 4mg IV x2. In the midst of all this, he was intubated
and was loaded with Dilantin. Given that patient has no hx of
prior seizures, patient underwent LP (WBC 6, RBC 1356, Glucose
121 and Protein of 40) and given empiric ABX including
ceftriaxone and ampicillin plus Decadron for unclear reason then
transferred here for further care.
Patient remains intubated but upon turning off sedation, patient
awoke soon and appeared to move all limbs with good resistance.
ROS unknown.
Patient normally treated at [**Hospital1 3278**] but brought here because there
is no bed at [**Hospital1 3278**] per report. No details known about his renal
transplant hx.
Past Medical History:
Polycystic Kidney Disease, s/p renal transplant ([**2138**])
HTN
Depression
Social History:
- currently in a correcctional facility for assault and battery
Family History:
- unkown
Physical Exam:
ON ADMISSION:
T 99 BP 164/113 HR 76 RR 13 O2Sat 98% intubated
Gen: Lying in bed, intubated.
HEENT: Hard cervical collar.
CV: RRR, no murmurs/gallops/rubs
Lung: Clear
Abd: +BS, soft - well healed kidney transplant scars and bulge
present.
Ext: No edema
.
Neurologic examination:
Mental status: Intubated - initially did not open eyes to verbal
or sternal rub but then began moving both arms purposefully as
sedation turned off. Does not follow commands.
.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Positive Doll's eyes and corneal's present in both
eyes. Face appears symmetric.
.
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. Moves all extremities well with resistance. Although
unable to test individual muscle groups, appear full strength
and
without lateralization.
.
Sensory: Intact to noxious stim.
.
Reflexes: +2 and symmetric throughout. Toes downgoing
bilaterally
Pertinent Results:
[**2147-12-31**] WBC-15.5* RBC-3.02* HGB-8.7* HCT-26.3* MCV-87 PLT- 182
[**2147-12-31**] UREA N-47* CREAT-3.3*
[**2147-12-31**] GLUCOSE-147* LACTATE-1.5 NA+-139 K+-4.3 CL--107 TCO2-25
[**2147-12-31**] ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
.
[**2147-12-31**] URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2147-12-31**] URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
.
[**2147-12-31**] tacroFK-5.0
.
[**2147-12-31**] 12:40PM PHENYTOIN-8.4*
[**2147-12-31**] 08:53PM PHENYTOIN-10.3
.
CT C-Spine without Contrast ([**2147-12-31**]):
FINDINGS: There is no fracture. Loss of cervical lordosis is
presumed
related to the hard cervical collar. There is no prevertebral
hemorrhage or edema, though the evaluation may be limited by the
presence of nasogastric and endotracheal tubes. The limited
included lung apices are unremarkable. Regional soft tissue
structures of the neck are unremarkable, and intracranial
contents are better characterized on the concurrent dedicated
head CT.
IMPRESSION: No fracture or traumatic malalignment.
.
CT Head without Contrast ([**2147-12-31**]):
FINDINGS: There is no intracranial hemorrhage, edema, mass
effect, or
vascular territorial infarction. The ventricles and sulci are
normal in size and configuration. There is no fracture.
Paranasal sinuses and mastoid air cells are clear. Small amount
of secretions layering dependently in the nasopharynx and the
posterior nasal cavity are presumed secondary to intubation.
IMPRESSION: No acute intracranial abnormality.
.
MRI Head without Contrast ([**2147-12-31**]):
formal interpretation is pending at discharge (please see brief
summary of hospital course for our interpretation)
.
Chest X-ray ([**2147-12-31**]):
IMPRESSION: ETT tip at 4.0 cm above the carina. No acute
intrathoracic
process.
.
Echocardiogram ([**2148-1-1**]):
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The estimated cardiac index is normal (>=2.5L/min/m2).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. The estimated
pulmonary artery systolic pressure is normal. There is a small
circumferential pericardial effusion without echocardiographic
signs of tamponade.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No valvular pathology or pathologic flow identified. Small
circumferential pericardial effusion without evidence of
hemodynamic compromise.
Brief Hospital Course:
Mr. [**Known lastname **] is a 21 year-old (handedness unknown) man with a
past medical history including PCKD, s/p renal transplant, and
hypertension who initially presented to [**Hospital3 **] [**2147-12-31**]
following an apparent GTC in the setting of head trauma.
Following the administration of ativan, versed, a dilantin load,
and decadron, the performance of an LP, treatment with empiric
antibiotics, and the process of intubation, the patient was
transferred to the [**Hospital1 18**] for further evaluation and care. He
was admitted to the Neurology/ICU Service from [**2147-12-31**] to
[**2148-1-1**].
.
NEURO:
To evaluate for hemorrhage and other contributory abnormalities,
a non-contrast CT of the head was performed. The study was
negative for intracranial pathology. An MRI was also done to
look for evidence of PRES in the context of hypertension and the
use of prograf. The MRI revealed bioccipito-parietal (edema)
and right > left frontal cortically-based T2 lesions. The
findings could be consistent with PRES. Alternatively, the
results could reflect contusions sustained during the patient's
reported fall from a top bunk bed.
.
To provide seizure prophylaxis, dilantin 100 mg IV q 8h was
initiated. Following admission, the patient was thought to
experience an additional GTC lasting approximately five minutes.
In addition to ativan 2 mg IV, he was given phenytoin 1 gram IV
x 1. In the course of the evening, the patient's nurse thought
she witnessed approximately four further episodes lasting less
than one minute; the events were described as bilateral upper
and lower extremity shaking without clear head or gaze
deviation. In the setting of persistent events, ativan 1 mg IV
q 8h was started. The patient had one more event at about 6am;
the neurology resident who witnessed the event was uncertain as
to whether it represented epileptic activity; however, the
patient received ativan 2 mg IV x 1. There were no further
clinical events.
.
The most recent dilantin level was found to be 14.3 (corrected
to 23 with albumin of 2.7). As the level was considered
supratherapeitic, the 12 pm dose of dilantin was held [**2148-1-1**].
.
RESP
The patient arrived intubated; he remained intubated at
discharge.
.
CVS
The patient was monitored by telemetry. Nifedipine, clonidine,
and atenolol were continued.
.
FEK
The renal transplant surgical team was consulted. At their
recommendation, Mr. [**Known lastname **]' outpatient tacrolimus dosing was
continued and a morning level was drawn (7.5).
.
ID
The ampicillin and ceftriaxone started at [**Hospital3 **] were
continued at the time of admission to the [**Hospital1 18**]. The
ceftriaxone was ultimately transitioned to ceftazidime for
partial nocardia coverage. Acyclovir was initiated to
empirically treat HSV. Pyramethamine, clindamycin, and folinic
acid were started in case of a toxo infection. At the [**Hospital1 18**],
blood and fungal cultures were drawn (results pending at the
time of discharge). The team also called the lab at [**Hospital3 **]
([**Telephone/Fax (1) 84205**]; [**Telephone/Fax (1) 84206**] [**Doctor First Name **]) to ask the lab to
add on CMV, HSV, cryptococcus, nocardia, toxo, and fungal
assays. The urinalysis and chest x-ray were unrevealing.
.
PPX:
For prophylaxis, famotidine and sc heparin were adminsitered.
.
CODE: Full presumed.
Medications on Admission:
MEDICATIONS ON ADMISSION
Prograf 3mg [**Hospital1 **]
Trazodone 100mg bedtime
Venlafaxine 75mg daily
Atenolol 100mg daily
Clonidine 0.1mg [**Hospital1 **]
Nifedipine SR 90 daily
Mycophenolate 500mg
Prednisone 2mg [**Hospital1 **]
.
ALLERGIES: reaction unknown
Vancomycin
Levaquin
E-Mycin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for T>100.4 or pain.
2. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours).
3. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
Sig: One (1) PO BID (2 times a day): total of 500 mg.
4. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO DAILY (Daily).
5. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO daily ().
8. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
12. Propofol 10 mg/mL Emulsion Sig: One (1) Intravenous TITRATE
TO (titrate to desired clinical effect (please specify)).
13. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP>160.
14. Dextrose 50% in Water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
15. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours).
16. Acyclovir Sodium 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours): total of 700 mg .
17. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours).
18. Phenytoin Sodium 50 mg/mL Solution Sig: One (1) Intravenous
Q8H (every 8 hours).
19. Lorazepam 2 mg/mL Syringe Sig: [**12-23**] Injection Q2H (every 2
hours) as needed for seizures > 5 minutes.
20. Ceftazidime 1 gram Recon Soln Sig: One (1) Intravenous Q12H
(every 12 hours).
21. Lorazepam 2 mg/mL Syringe Sig: 0.5 Injection Q8H (every 8
hours).
22. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) for 1 days: total of 600 mg.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Seizure secondary to PRES vs Head Trauma
Discharge Condition:
On Day of Discharge:
Tmax 96.3; Tc 95.6; bp 1teens-140s/60-105; hr 70s-80s; O2 sat
100% on CPAP/PSV Fio2 40%, [**4-24**].
GEN: intubated, sedated
HEENT: apparent soft tissue swelling in lateral aspects of head
bilaterally
PULM: CTAB anteriorly
CVS: Regular rate, normal S1 and S2
ABD: round, + bs, soft, nt, nd
EXT: RLE more externally rotated than LLE
NEUROLOGICAL EXAMINATION:
Mental Status: sedated
CN: PERRL, + corneals bilaterally, + nasal tickle response
Motor: increased tone in LE, withdraws UE, LE to noxious
bilaterally, sustained clonus in LE bilaterally
Reflexes: brisk at biceps, patella bilaterally; plantar
responses flexor bilaterally
Discharge Instructions:
FOR THE NEXT CARE TEAM:
NEURO
* Please perform an EEG
* Please follow the corrected dilantin level (last corrected
level was 23 on [**2147-12-31**]); a free level had not yet been drawn at
the [**Hospital1 18**].
* Please follow the formal interpretation of the MRI
FEK
* Please connect with the patient's nephrologist
ID
* Please consider an infectious disease consult
* Please follow the results of pending CSF cultures ([**Hospital3 15402**]
drawn [**2147-12-31**])
* Please follow the results of blood cultures ([**Hospital1 18**] drawn
[**2147-12-31**])
FOR THE PATIENT:
You were initially brought to [**Hospital3 **] following a seizure in
the setting of head trauma. You were given medication to help
prevent further seizures. A procedure called a lumbar puncture
was done to look for evidence of infections. You were then
given antibiotics to treat potential infections pending the
results of the assays. You were then transferred to the [**Hospital1 18**]
for further evaluation and care. A CT of the head showed no
evidence of bleeding. An MRI of the brain did show some
abnormalities that likely represent swelling or bruising. The
seizures are thought to be related to the head trauma (from
falling out of your bunk bed) or a condition referred to as PRES
which can be associated with high blood pressures and some of
the medications you take.
Followup Instructions:
* Please coordinate follow-up care per your physicians at [**Hospital1 3278**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 4019, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5541
}
|
Medical Text: Admission Date: [**2108-3-20**] Discharge Date: [**2108-3-27**]
Date of Birth: [**2025-1-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
femur fracture
Major Surgical or Invasive Procedure:
ORIF of left femur
History of Present Illness:
Mrs. [**Known lastname 109174**] is an 83yoF with a history of advanced Alzheimer's
dementia, atrial fibrillation with RVR, diastolic dysfunction,
CAD s/p previous PCI, HTN, hypertrophic cardiomyopathy, PVD,
breast cancer s/p lumpectomy and radiation in [**2095**] who presented
from rehab s/p likely mechanical fall with subsequent left
femoral fracture.
.
She had just been transferred to [**Hospital3 **] for
advancing dementia, though had been known to have significant
sundowning nightly with agitation. At baseline, she is AAOx0,
she speaks though is incoherent. She had been wandering without
a walker and sustained a fall. Admission imaging showed a
severely displaced left metadiaphyseal femur fx with severe
foreshortening. CT head and cervical spine showed no acute
fracture or displacement.
.
Her hospital course had been complicated by atrial fibrillation
in RVR with rates to the 130s that has responded well to PO
metoprolol 100mg q6hr. Of note, she has a history of apical-form
hypertrophic cardiomyopathy and has outflow physiology at
elevated rates- she had HF symptoms with this recent RVR that
responded to beta blockade. She has also experienced
intermittent agitation on the medicine floor that seems to have
responded better to seroquel 25mg than haldol, per medicine
attending report.
.
She underwent operative fixation of her left femoral fracture
this afternoon without significant peri or intraoperative
complications. She tolerated extubation initially but then
became agitated with ABG demonstrating 7.2/77/87 on room air.
She was placed on BiPAP with improvement of her gas to
7.37/54/122. Her pain did not respond to fentanyl, but was
controlled with dilaudid PO 6mg. She was hypoxic on 3L 02 via
nasal cannula, though p02 improved to 94 on 70% shovel mask with
Sats 98%. She was felt to require ICU level care related to the
delicate balance between adequate analgesia and hypoventilation.
Of note, she was admitted with DNR/DNI status which was
reversed for her surgery. Per her son, the HCP, she will remain
full code for this immediate peri-operative interval, and can be
intubated if necessary.
.
On arrival to the ICU T98.4 P107 BP137/88 R14 Sat98% 70%Shovel
mask. She is groaning though cannot articulate her discomfort.
She cannot answer questions. She is moving all extremities.
.
ROS: Unable to obtain due to dementia
Past Medical History:
1. Hypertension.
2. Left ventricular hypertrophy; EF 70% in [**2100**]
3. Prior history of breast cancer (per OMR)
4. Hepatitis C.
5. Osteoporosis.
6. s/p proximal humerus fracture & rib fx's.
7. Afib
Social History:
She lives with her husband, who is very sick from cancer. Does
not smoke, rarely drinks.
Family History:
nc
Physical Exam:
VS: T98.4 P107 BP137/88 R14 Sat98% 70%Shovel mask
GENERAL: groaning, mild agitation
HEENT: will not open eyes, MMM
NECK: Supple, no JVD
LUNGS: CTA bilat, no r/rh/wh, poor effort, resp unlabored.
HEART: tachycardic, nl S1, variable S2, no MRG
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. LLE splinted
and wrapped
SKIN: No rashes or lesions.
NEURO: does not respond to quesitioning, moving all extremities.
Pertinent Results:
[**2108-3-20**] 08:20PM WBC-8.9 RBC-2.97* HGB-9.7* HCT-28.4* MCV-96
MCH-32.6* MCHC-34.1 RDW-15.4
[**2108-3-20**] 08:20PM PLT COUNT-213
[**2108-3-20**] 03:45PM WBC-7.2 RBC-3.05* HGB-10.1* HCT-29.2* MCV-96
MCH-33.0* MCHC-34.4 RDW-15.5
[**2108-3-20**] 09:20AM CK(CPK)-237*
[**2108-3-20**] 09:20AM CK-MB-9 cTropnT-<0.01
[**2108-3-20**] 12:30AM PT-19.6* PTT-29.5 INR(PT)-1.8*
[**2108-3-20**] 12:30AM WBC-6.2 RBC-3.64* HGB-12.0 HCT-34.8* MCV-96
MCH-32.8* MCHC-34.3 RDW-15.6*
Brief Hospital Course:
83 yo woman with dementia, afib with RVR, cardiomyopathy, CAD
s/p stenting, and recent femoral fracture transferred to ICU
with hypoxia/hypercarbia following extubation requiring BiPAP,
now on room air.
.
# POST-EXTUBATION HYPERCARBIA/HYPOXIA: She began retaining C02
after extubation with an acute respiratory acidosis and hypoxia
to the 50s. Her hypercarbia may be narcotic-induced
hypoventilation from the preceding surgery, however this should
not cause significant AA gradient unless the hypoventilation was
profound. Her hypoxia may also have been related to a
post-operative atelectasis or even mild congestion each with
subsequent V/Q mismatch. She came to MICU [**3-21**]. From a
respiratory standpoint she continued to require oxygen
alternating between nasal cannula and oxygen face mask. [**3-25**] she
was noted to have a new infiltrate on CXR likely to due
aspiration and subsequently had increasing 02 requirement,
antibiotics started. [**3-26**] she was made CMO after extensive
family meeting with MICU team and palliative care and patient
passed away [**3-27**].
# LEFT FEMORAL FRACTURE S/P OPERATIVE FIXATION: Surgery went
without incident, but patient required BIPAP post extubation and
was transfered to the intensive care unit. Pain controlled with
IV hydromorphone.
# ATRIAL FIBRILLATION WITH RVR: She has intermittently been in
RVR during this hospitalization with rates to the 160 that were
difficult to control despite fluid bolus, lopressor, diluadid.
Her blood pressures held well throughout these episodes.
Attempts at pain control, anxiety control and rate control
including esmolol gtt were mostly unsuccessful, though she did
seem to improve slightly with IV metoprolol Q4H.
.
# ADVANCED ALZHEIMER'S DEMENTIA: She has been frequently
agitated with significant sundowning. Has received both haldol
and seroquel. Her likely aspiration event showing the pneumonia
[**3-25**] was likely due to her altered mental status.
.
# DIASTOLIC DYSFUNCTION: Patient became volume overloaded and
had increasing oxygen requirements with increasing Cr and was
not able to be effectively diuresed.
.
# CORONARY ARTERY DISEASE: S/P LAD PCI in past. Unable to
continue home cardiac meds due to NPO status.
.
# HYPOTHYROIDISM: continued levothyroxine.
.
# ANEMIA: down from recent baseline of 38.8. Likely 2/2 blood
loss due to fracture and correction of hemoconcentration. Iron
studies and b12/folate unrevealing. No grossly bloody stools.
.
# HEPATITIS C: followed by Dr. [**Last Name (STitle) **]. Due to chronicity
and her age, never underwent treatment.
Medications on Admission:
-tylenol 975 TID
-simvastatin 20 q d
-aspirin 81 q day
-maalox 30 q 4
-ca/vit d
-celexa 30 q day
-B12 inj montly
-digoxin 0.125 q day
-colace 100 mg q day
-lasix 80 [**Hospital1 **]
-neurontin 200 at 1800, 100 at [**2096**]
-haldol 0.5 [**Hospital1 **]
-synthroid 75 mcg daily
-lidocaine patch to anterior lower ribs
-MOM daily PRN
-MV
-SLNTG prn
-prilosec 20 BBID
-Miralax q day
-KCL 20 meq q day
-metamucil daily
-senokot hs
-seroquel 25 q hs
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
1. Femoral fracture, displaced
2. Delirium
3. Hypotension
4. Atrial fibrillation with rapid ventricular response
5. Healthcare-associated pneumonia
Secondary:
1. Dementia
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
ICD9 Codes: 486, 5185, 5180, 5849, 4254, 4280, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5542
}
|
Medical Text: Admission Date: [**2170-10-29**] Discharge Date: [**2170-11-2**]
Date of Birth: [**2128-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42yo M PMH of IDDM, alcohol abuse, and question of seizure
disorder (in setting of hypoglycemia) who presented today to
[**Hospital **] hospital with substernal chest burning. He was found to
have hyperglycemia to 1008, HCO3 10, CK 45, troponin-I 0.03 (5
am) and ARF with creatinine 3.2. His ABG at that time was
7.36/29/97. At [**Location (un) **], he was given 10 units of regular insulin
and started on an insulin drip at 6 units/hr and received 2
liters of crystalloid. He was transferred to [**Hospital1 18**] ED.
He denies any recent infections, URI symptoms, diarrhea,
dysuria, skin infections. He denies SOB or back pain. He reports
persistent heartburn symptoms for which he takes Alka-Seltzer
regularly. He states that he takes his Lantus nightly and checks
his BG up to 4 times daily which runs around 200-300. He states
that he takes his Novolag "as needed," usually only if his blood
sugar is "out of control" or over 300. Last night he reports
that his heartburn symptoms were worse than usual and it was the
pain that prompted him to go to the hospital. He denies
shortness of breath but states that he doesn't want to take a
deep breath due to pain. He denies radiation of the pain or
associated nausea or diaphoresis. He does have acidic tasting
reflux into his mouth which he spits out. He also describes
upper abdominal pain that is nonradiating.
Of note, pt has had multiple visits to [**Hospital **] hospital for
hyperglycemia and recent [**Hospital1 18**] admission [**2170-5-10**] with similar
presentation.
.
In the ED, his VS were T 99.1, HR 100, BP 105/72, RR 18, O2 100%
on 3L, initial BG was 420 and he was continued on an insulin
drip (increased to 7 units/hr) with IVFs (NS). Chest X-ray on
preliminary read showed no acute abnormalities and EKG showed
sinus tachycardia and T wave inversions compared to prior
(though these appear to have normalized from [**5-17**]). His labs
were significant for a leukocytosis to 13.9, anion gap of 31
(+urine ketones), lipase of 1373.
Past Medical History:
Type I DM - poorly controlled
Seizure disorder, secondary to hypoglycemia or alcohol
withdrawal
.
Past surgical hx: inguinal hernia repair and appendectomy
Social History:
Previously incarcerated at [**Location (un) 912**] Jail. Works nights at Stop &
Shop, though hasn't been in 1+ weeks (unclear reason). Smokes
1.5ppd for many years. Drinks alcohol once per week (Tuesday's)
until he is drunk. Per PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] heavy drinking problem.
Endorses marijuana use. Past cocaine use, no IV drug use.
Family History:
Father died of lung cancer, mother died at 66.
Physical Exam:
Tmax: 36.6 ??????C (97.9 ??????F)
Tcurrent: 36.5 ??????C (97.7 ??????F)
HR: 79 (77 - 103) bpm
BP: 122/74(85) {105/51(63) - 138/77(88)} mmHg
RR: 15 (8 - 26) insp/min
SpO2: 96%
Height: 62 Inch
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Tachycardic, regular, systolic murmur [**3-15**] > apex, radial
pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, tender to palpation over epigastrium, +BS, no
HSM, no masses, no guarding or rebound tenderness
EXT: No C/C/E
NEURO: Alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
No ulcers or wounds
Pertinent Results:
[**2170-10-29**] 09:35AM BLOOD WBC-13.9*# RBC-4.23* Hgb-12.2* Hct-34.4*
MCV-81*# MCH-29.0 MCHC-35.6* RDW-13.8 Plt Ct-313#
[**2170-10-30**] 05:58AM BLOOD Glucose-244* UreaN-19 Creat-1.2 Na-133
K-3.8 Cl-95* HCO3-26 AnGap-16
[**2170-10-29**] 01:53PM BLOOD Glucose-177* UreaN-43* Creat-1.9* Na-137
K-3.4 Cl-93* HCO3-30 AnGap-17
[**2170-10-29**] 09:35AM BLOOD Glucose-535* UreaN-52* Creat-2.4*#
Na-132* K-4.1 Cl-83* HCO3-18* AnGap-35*
[**2170-10-30**] 05:58AM BLOOD Amylase-280*
[**2170-10-30**] 05:58AM BLOOD Lipase-84*
[**2170-10-29**] 09:35AM BLOOD Lipase-1373*
[**2170-10-29**] 01:53PM BLOOD CK-MB-7 cTropnT-<0.01
[**2170-10-29**] 01:53PM BLOOD Osmolal-306
[**2170-10-29**] 09:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-10-29**] 02:29PM BLOOD Type-[**Last Name (un) **] pH-7.48*
U/A: 150 ketones, 1000 glucose, tr protein, negative LE, nitr,
WBC, RBC, few bacteria
CXR [**10-29**]
IMPRESSION:
1. No acute intrathoracic process.
2. Mid thoracic vertebral compression, chronicity uncertain.
Brief Hospital Course:
This is a 42 year-old male with a history of Type I DM, ?seizure
d/o, and longstanding h/o alcohol abuse admitted with DKA, acute
renal failure and pancreatitis.
.
# Diabetic ketoacidosis: Pt with known Type I DM with multiple
hospitalizations both at [**Hospital **] hospital and [**Hospital1 18**]. The
possible precipitating factors include medicaiton
non-compliance, alcohol abuse, and/or pancreatitis. This was
unlikey an infectious process given the patient is afebrile, no
leukocytosis and no localizing symptoms. Pt was r/o for MI by
enzymes and no EKG changes. The anion gap at presentation was 31
with +ketones in urine. The patient was started on an insulin
gtt, given IVF and repleted lytes. His insulin regimen was
changed to his home lantus dose (34U) & ISS when his FS were
<100. The patient refused lab draws during the evening. The
patient's gap had closed by the morning AM (AG:12).
Addtionally, the patient's last pH was venous 7.48. The
diabetes endocrinology service was consulted, and patient was
placed on Lantus 25 units at night, with humalog sliding scale.
An appointment was made for him in the endocrinology clinic for
follow up. The patient was started on regular/diabetic diet and
tolerated this well.
.
# Acute renal failure: The patient's creatine was 3.2 at [**Location (un) **]
and 2.4 on presentation here. His creatine improved with fluids.
This is most likely a prerenal etiology given dehydration and
ketoacidosis. Pt denies any other medication use except for
antacids. On prior hospitalizations had similar bump in
creatinine.
.
# Alcohol abuse: The patient denies regular use (once weekly)
and denies ever having withdrawal symptoms but his history at
times is conflicting. He does take Valium 5 mg daily at home for
questionalbe anxiety. The patient was monitored on a CIWA
scale. Additionally the patient was given thiamine, folic acid,
and MVI. He did not require prn Valium.
.
# Pancreatitis: On admission the patient had elevated lipase to
>1000 with mild sx of upper abdominal pain. The patient's other
LFTs were otherwise unremarkable and no known hx of
pancreatitis. The pancreatic enzymes were trending down and the
patient tolerated regular diabetic diet.
.
# Chest pain: Pt describes chronic "burning" chest pain that
improves with antacids. He denies worsening with activity or
associated sx. The patient was ROMI. There were no ST-T
elevations or depressions on EKG, though does have T wave
inversions in lateral leads (now concordant). First set of CEs
at [**Hospital **] hospital wnl. CE here have been negative. The
patient was started on a PPI.
.
# Diabetes mellitus, Type I: As above. On history it appears
that the patient has very poor insight into his medical illness
and is not taking short-acting insulin as prescribed. He has
been refered to [**Last Name (un) **] in the past but does not keep regular
appointments. He was again seen by the inpatient service, and
again advised to follow up with [**Last Name (un) **] as an outpatient.
.
#. Dispo. He was discharged to home with services.
Medications on Admission:
- Insulin Glargine 34 units at bedtime.
- Insulin Aspart sliding scale qid
- Phenytoin 200mg po bid
- Valium 5mg po daily
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) dose
Subcutaneous four times a day: Per sliding scale.
5. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous QHS.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
1. Acute pancreatitis
2. Alcohol use/withdrawal
3. Diabetic ketoacidosis
4. Diabetes mellitus type I with complications
5. Polysubstance abuse
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with pancreatitis with associated diabetic
ketoacidosis. In the setting of drinking alcohol, you developed
inflammation of your pancreas.
.
This led to poor control of your blood sugars.
Followup Instructions:
An appointment was made for you with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 89459**]y [**11-8**] at 10am.
.
An appointment was made for you at the [**Hospital **] [**Hospital 982**] clinic on
Monday [**11-2**] at 4:30pm. Please keep this appointment as it is
important to keep good control of your blood sugars.
ICD9 Codes: 5849
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5543
}
|
Medical Text: Admission Date: [**2186-8-26**] Discharge Date: [**2186-9-5**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Furosemide
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Right ankle pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]M with history of sCHF, non-ischemic cardiomyopathy (EF
15-20%), severe pulmonary HTN and right sided heart failure,
recent worsening of lower extremity edema, presenting now with
1-1.5 week history of purplish toes and acute onset right medial
ankle pain. Patient has had recent worsening of bilateral lower
extremity edema, with associated weeping. Is followed by Dr.
[**Last Name (STitle) 911**] in Cardiology, and plan was for him to see an advanced
heart failure specialist. Outpatient diuretic regimen of
ethacrynic acid recently increased to 150 mg daily. Last night
around 6pm, developed [**9-20**] pain in the medial aspect of his
right ankle. Pain came on suddenly and was sharp/cramping in
nature, extending mid-way up his calf. He denies any preceding
injury or history of gout. Given severe pain, called EMS and
was brought to ED for evaluation.
In the ED, initial VS were 98.7 67 100/61 18 100% RA. On exam,
his bilateral hands were cool, bluish w/blue discoloration of
the nails. Had [**2-12**]+ lower ext edema with blue discoloration of
distal aspects of toes; [**3-16**] sec cap refill with dopplerable
PT/DPs bilaterally (L>R). Noted to have of erythema over the
right medial malleolus tracking upwards to the mid calf, no
crepitus noted. Labs notable for WBC 7.3 (N:71.7), INR 3.1, Cr
1.9. K 5.5, lactate 2.7. While in ED, BP dropped to
70s/40s-50s (baseline SBP in 80s). Received 250cc NS, R IJ
placed, and he was started on norepinephrine. CVP was 12. No
alteration in mental status. Also received broad antibiotic
coverage with vanc/[**Last Name (un) 2830**]/clindamycin and pain control with
morphine. X-ray of right tib/fib negative for subcutaneous air
per prelim report. Was concern for septic joint vs. cellulitis
vs. nec fasciitis. ED deferred Vascular consult or CTA of aorta
with runoff due to [**Last Name (un) **] and bilateral distribution with
dopplerable pulses.
On arrival to the MICU, patient reports pain has improved to
[**2184-2-12**]. VS on arrival 98.3 117/ 71/56 11 97% RA.
Review of systems:
(+) Per HPI. Reports recent chills, "sweating" in his legs.
Has chronic dyspnea with minimal exertion (<30 seconds of
activity). Has intermittent nausea and diarrhea. No recent
antibiotic use. Reports purplish discoloration of digits is not
new.
(-) Denies fever, headache, cough, wheezing, chest pain, chest
pressure, palpitations, orthopnea, PND. Denies constipation,
abdominal pain, dark or bloody stools. Denies dysuria,
frequency, or hematuria. Denies arthralgias or myalgias other
than in RLE.
Past Medical History:
Atrial flutter on anticoagulation
Hyperlipidemia
Aortic stenosis
Nonischemic cardiomyopathy, EF 25% w/symmetric hypertrophy
CHF
Pulmonary arterial hypertension
LBBB w/prolonged QRS duration s/p CRT placement [**3-/2186**]
TIA, remote
Colon polyps
Cataracts s/p bilateral surgery
s/p prostatectomy
s/p tonsillectomy
Social History:
Lives alone. Wife recently passed away. Son lives in [**State 2690**],
nephew lives in the area. Former smoker, quit in [**2159**]. Denies
any significant EtOH use. No recreational drugs
- Plans to move to [**Location (un) 11270**] TX to be closer with family
Family History:
Father had MI in his 60s.
Physical Exam:
Admission Exam:
Vitals: 98.3 117/ 71/56 11 97% RA
General: awake, alert, oriented x3, no acute distress
HEENT: pupils constricted and minimally reactive to light, EOMI,
sclera anicteric, MMM, oropharynx clear
Neck: supple, R IJ in place, JVD to mandible
CV: tachycardic, irregular, normal S1 + S2, possible systolic
murmur, distant heart sounds
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley draining clear yellow urine
Ext: cool, dopplerable PTs bilaterally, [**2-12**]+ pitting [**Last Name (un) **]
extending beyond knees bilaterally
Skin: bilateral lower extremities with serous weeping from skin
and scattered excoriations/abrasions, erythema overlying medial
aspect of right ankle/calf without warmth, induration,
fluctuance, or crepitus, exquisitely tender to light touch,
digits with deeper erythematous-purplish tint
Msk: passive and active ROM right ankle limited secondary to
pain, though patient is able to minimally dorsiflex right ankle.
Tender to palpation over right medial malleolus. Difficult to
appreciate if joint effusion present in right ankle given degree
of lower extremity edema, but no warmth
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
.
DISCHARGE:
Vitals: 97.8 83/51 70 16 93% RA
General: awake, alert, oriented x3, no acute distress
HEENT: pupils constricted and minimally reactive to light, EOMI,
sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat
CV: irregular rhythm, normal S1 + S2, III/VI holosystolic murmur
best heard at apex
Lungs: CTAB, trace bibasilar rales, no wheezes or rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: with compression stockings, 3+ pitting edema to knees
bilaterally, much improved sincea admission
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
Pertinent Results:
Admission:
[**2186-8-25**] 11:41PM BLOOD WBC-7.3 RBC-4.68 Hgb-15.2 Hct-46.2
MCV-99* MCH-32.4* MCHC-32.8 RDW-14.5 Plt Ct-183
[**2186-8-25**] 11:41PM BLOOD Neuts-71.7* Lymphs-22.3 Monos-2.9 Eos-2.6
Baso-0.4
[**2186-8-25**] 11:41PM BLOOD PT-31.9* PTT-44.6* INR(PT)-3.1*
[**2186-8-25**] 11:41PM BLOOD Glucose-109* UreaN-66* Creat-1.9* Na-131*
K-9.2* Cl-98 HCO3-23 AnGap-19
[**2186-8-25**] 11:41PM BLOOD ALT-35 AST-102* AlkPhos-46 TotBili-0.9
[**2186-8-25**] 11:41PM BLOOD Albumin-4.1 Calcium-9.1 UricAcd-14.5*
[**2186-8-25**] 11:48PM BLOOD Lactate-2.7* K-5.5*
Discharge:
[**2186-9-5**] 04:00AM BLOOD WBC-7.0 RBC-4.29* Hgb-13.9* Hct-42.8
MCV-100* MCH-32.4* MCHC-32.5 RDW-14.1 Plt Ct-139*
[**2186-9-5**] 04:00AM BLOOD PT-27.7* PTT-41.9* INR(PT)-2.7*
[**2186-9-5**] 07:10AM BLOOD Glucose-111* UreaN-27* Creat-1.1 Na-139
K-4.5 Cl-99 HCO3-32 AnGap-13
[**2186-9-5**] 07:10AM BLOOD CK(CPK)-40*
[**2186-9-5**] 07:10AM BLOOD Calcium-9.2 Phos-2.5* Mg-2.0
Micro:
[**8-25**] Blood cultures no growth
Imaging:
[**8-26**] Right tib/fib x-ray:
No evidence of soft tissue gas. No suspicious bony lesions. No
fracture.
Calcification of the anterior tibial artery and the superficial
femoral artery are seen.
[**8-26**] Right ankle x-ray:
Three views of the right ankle demonstrate medial soft tissue
swelling; however, the alignment is normal and there is no
fracture or
dislocation.
[**8-26**] CXR:
Moderate cardiomegaly and vascular congestion. Left pleural
effusion has
improved compared to [**2186-4-11**]. The right IJ central line ends
at the mid SVC. No pneumothorax.
[**8-28**] Echo:
IMPRESSION: Moderately dilated left ventricle with severe global
hypokinesis. Markedly dilated right ventricle with moderate
hypokinesis. Calcified aortic valve with probable moderate
aortic stenosis - the gradient is relatively low due to poor
systolic function. Mild aortic regurgitation directed towards
the anterior leaflet of the mitral valve. Mild mitral
regurgitation. Moderate tricuspid regurgitation with moderate
pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2186-1-23**],
left ventricular systolic function has worsened. The other
findings are similar.
.
([**8-30**]) R. Heart Cath:
FINAL DIAGNOSIS:
1. Mild elevation in right sided and severe elevation in left
sided
filling pressures.
2. Severe pulmonary hypertension with a moderately elevated PVR.
3. Severely reduced cardiac output/index.
4. PA catheter secured in place for continued hemodynamic
monitoring in
the CCU. The PA catheter balloon should not be inflated without
fluroscopic guidance as the catheter tip may migrate.
Brief Hospital Course:
Brief Course:
[**Age over 90 **]M with history of sCHF, non-ischemic cardiomyopathy (EF
15-20%), severe pulmonary HTN, right sided heart failure, recent
worsening of lower extremity edema, presenting now with acute
onset right medial ankle pain.
.
# Acute on Chronic sCHF exacerbation (EF 10-15%) - etiology is
non ischemic cardiomyopathy, likely idiopathic, Echo from this
admission shows worsening EF of [**9-25**]% with dilated left and
right ventricles with global hypokinesis. Current clinical
picture most c/w right sided heart failure, given JVD and lower
extremity edema, with minimal evidence of left-sided heart
failure at present (lungs CTAB, CXR w/o effusions or pulm
edema). We held metoprolol given hypotension and lisinopril
given [**Last Name (un) **]. We restarted his home ethacrynic acid given net
positive fluid status.
Cath in [**2181**] showed NORMAL coronoaries at age [**Age over 90 **]. On exam
pitting edema appreciated to right and left knee, and lungs with
crackles b/l. Pt required inotropes on admission to maintain
SBPs, weaned off. Lactate improved to 1.8 from 2.7, and patient
mentating well with good UOP during entire admission. In CCU we
initiated diuresis which significantly decreased oxygen
requirement back to baseline of room air. Swelling in legs
improved. CHF team consulted and recommended Swan Ganz with
Milrinone trial, which was done and showed significant
improvement (Decreased RA, RV, PA pressures, Increased CO/CI)
with Milrinone. Swan removed, PICC placed and plan is for
patient to have Milrinone pump as an outpatient to provide
better cardiac output. Patient plans to move to [**Location (un) 11270**], [**State 2690**]
where he will have all future cardiology care. On D/C pt was on
0.25 mcg/kg/min of Milrinone via PICC and ethacrynic acid 75mg
qdaily. In addition, we recommended pt have supplemental oxygen
during long plane ride to [**State 2690**].
Pre-Milrinone Hemodynamic Measurements:
RA: 9
RV: 65/11
PA: 65/31/42
PCWP: 30
CO: 3.15
CI: 1.62
Hemodynamic Measurements with Milrinone at 0.25mcg/kg/min:
CVP: 2
PAP: 34/10/18
CI: 2.6
.
#Atrial Fibrillation: HR was well controlled in the 60s-80s
during this admission. Pacer firing irregularly initially, EP
interrogated pacer yesterday. Atrial lead was not properly
sensing afib, so Pt was only being intermittently paced.
Increased sensitivity of lead and now Pt is paced every beat
while in afib. Working properly. Given loading doses of
amiodarone and digoxin which helped to control his tachycardia.
We continued both digoxin and amiodarone initially but stopped
Amio on [**9-2**]. Pt was initially on heparin gtt without problems,
then switched to home regimen of Warfarin alone when INR > 2.
INR on discharge was 2.4. Cardioversion considered and TEE done
which, unfortunately, showed a left atrial thrombus so
cardioversion was not pursued. Discharged on Dig 0.125, Warfarin
2.5 mg, and milrinone as mentioned above.
.
#R ankle pain/erythema: Differential diagnosis includes
cellulitis, gout, septic arthritis, DVT; much less likely septic
arthritis given his ROM now without pain and per rheumatology
and ortho will not pursue tap given low likelihood and also
overlying cellulitis with fear for introducing infection from
skin. Less likely gout given he did not receive the steroids as
rec??????d by rheum and is doing much better. Most likely
cellulitis. Given concern for possible cellulitis, we continued
vancomycin day 1=[**8-26**], completed full 8 day course. Holding
colchicine for now given lower suspicion of gout and clinical
improvement with abx. Blood cx were negative, pt was afebrile
and WBC remained wnl and stable. Pt was also seen by dr. [**Last Name (STitle) 96682**]
who recommend specific wraps to the patient. On day of discharge
the patient legs were significantly improved as compared to his
admission. Pt was discharged with instructions to use special
support stockings.
.
#[**Last Name (un) **]: Cr on admission 1.8, Cr on discharge 1.1. Baseline of
1.3-1.4. DDx includes pre-renal azotemia in setting of sepsis,
ATN secondary to hypotension, poor forward flow in setting of
CHF, overdiuresis. We trended Cr, electrolytes, renally dose
meds, and held lisinopril. His kidney function improved and his
Cr was 1.0 on discharge.
.
.
## TRANSITIONAL
- Left Atrial Thrombus, continue Warfarin monitoring with goal
INR [**1-13**]
- Cont PICC Line Care and Milrinone monitoring
- Lisinopril was held and not restarted during this admission
due to [**Last Name (un) **] and softer [**Name (NI) 96683**] Pt needs to address with next
provider whether to restart in order to optimize CHF regimen.
- Metoprolol also held during admission due to softer pressures-
Pt is to readdress with next provider regarding when to restart
to optimize CHF regimen
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Ethacrynic Acid 150 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >
5. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
6. Simvastatin 10 mg PO DAILY
7. Warfarin 2.5 mg PO DAILY16
2.5mg S/T/T, 1.25mg other days
8. Vitamin D 1000 UNIT PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Milrinone 0.25 mcg/kg/min IV INFUSION
2. Ferrous Sulfate 325 mg PO DAILY
3. Outpatient Lab Work
Please check chem-7 and INR on thursday [**9-7**] with results to Dr.
[**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 24396**]
Fax: [**Telephone/Fax (1) 96684**] and Dr. [**Last Name (STitle) **] [**Name (STitle) **] at fax [**Telephone/Fax (1) 32656**] or
phone [**Telephone/Fax (1) 96685**]
ICD-9 427
4. Simvastatin 10 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Warfarin 2.5 mg PO DAILY16
2.5mg S/T/T, 1.25mg other days
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg one tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
8. Ethacrynic Acid 75 mg PO DAILY
RX *ethacrynic acid [Edecrin] 25 mg 3 tablet(s) by mouth daily
Disp #*90 Tablet Refills:*2
9. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
Home Solutions Infusion Therapy
Discharge Diagnosis:
Right lower leg cellulitis
Acute on Chronic CHF exacerbation (EF 10 = 15%)
Atrial fibrillation
Aortic stenosis
Severe pulmonary hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 96686**],
You were admitted to [**Hospital1 18**] for right ankle pain and hypotension.
The right ankle pain was likely due an infection of the skin
called cellulitis, which we treated with a full course of
antibiotics. You were also found to be fluid overloaded causing
shortness of breath, likely due to your congestive heart
failure. The extra fluid was removed using diuretics (water
pill). Due to the progressive worsening of your congestive heart
failure, you were started on a medication called Milrinone,
which is given into your vein using your PICC Line. Your
symptoms improved and swelling decreased.
We have made appointments for you with cardiologist who will
follow your response to the Milrinone, see appointment
information below.
Followup Instructions:
IF YOU ARE NOT STILL IN THE [**Location (un) **] AREA FOR THESE APPOINTMENTS
PLEASE CALL AND CANCEL SO THAT ANOTHER PATIENT CAN HAVE YOUR
APPOINTMENT TIME.
Department: CARDIAC SERVICES
When: Tuesday [**9-12**] at 3:00pm
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2186-10-11**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2186-10-11**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4254, 5849, 4280, 2724, 4240
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5544
}
|
Medical Text: Admission Date: [**2115-7-24**] Discharge Date: [**2115-7-27**]
Date of Birth: [**2082-9-13**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
head and neck pain
Major Surgical or Invasive Procedure:
[**2115-7-24**] Suboccipital craniotomy for decompression of chiari
malformatoin
History of Present Illness:
32 yr old left handed female who has had tussive headaches and
progressive neck pain for approximately 2.5 months. The pain
was initially head and neck and recently radiates to her
shoulders, left arm to elbow, right arm to deltoid, numbness
tingling hands. The head and shoulder pain are constant with
occasional sharp shooting pain if she moves her head. She also
complains of bilateral hand clumsiness such as trouble picking
up a pen or separating paper.
She states of late she has occasional trouble swallowing due to
a sensation of someone or something pressing on her trachea.
She mentions long term symptoms of slight dizziness, faintness
ongoing and rare ringing or buzzing in her ears.
Past Medical History:
none
Social History:
Patient lives with husband in [**Name (NI) **]. She works as a
legal secretary. She smokes [**12-31**] pack per day ongoing 15 years
and drinks approximately 12 drinks a week. No ilicits
Family History:
Mother - CAD
Father - alive and well
Maternal grandparents CAD
Paternal grandfather: prostate cancer, CVA
Paternal aunts: breast cancer, CAD
Maternal uncles diabetes and lung cancer
Paternal uncle: stomach cancer
No known hypertension
Physical Exam:
AF VSS
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-4**] throughout. No pronator drift
Sensation: Intact to light touch and proprioception
Reflexes: B T Br Pa Ac
Right 2+2+2+2+2+
Left 2+2+2+2+2+
Coordination: normal on finger-nose-finger
Handedness Left
Discharge exam:
non focal, dissolvable sutures
Pertinent Results:
CT head [**7-24**] - Status post suboccipital decompression and C1
laminectomy with expected post-procedure changes. No concerning
post-procedure hemorrhage.
[**7-25**] MRI Brain- IMPRESSION: Expected post-surgical appearance
related to suboccipital decompression for patient's known
underlying Chiari type 1 malformation, as described above.
Apparent compression at the cervicomedullary junction is not
significantly changed since pre-operative exam of [**2115-7-8**],
presumably due to small amount of post-operative fluid/edema.
Attention on follow-up exams is recommended.
Brief Hospital Course:
Patient was admitted to Neurosurgery on [**2115-7-24**] and underwent
the above stated procedure. Please review dictated operative
report for details. Patient was extubated without incident and
transferred to ICU in stable condition. Post op CT head shows
no acute hemorrhage and post op changes. Foley was removed in
routine fashion and pt voided without incident. She was
transferred to floor in stable condition on [**7-25**]. She was
encouraged to ambulate and use incentive spirometry. She was
given a collar to wear for comfort.
She was cleared for discharge on [**7-26**] but she requested an
additional day.
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 intact
without evidence of infection. Patient is ambulating without
issues. She is set for discharge home in stable condition and
will follow-up accordingly.
Medications on Admission:
Fe [**1-18**] daily, Propecia, Vitamin D 50,000 unit, Naproxen
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain/ fever
2. Bisacodyl 10 mg PO DAILY
3. Tizanidine 4 mg PO Q8H:PRN neck pain
4. Docusate Sodium 100 mg PO BID
5. Propecia *NF* (finasteride) 1 mg Oral DAILY
* Patient Taking Own Meds *
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN Pain
7. Nicotine Patch 14 mg TD DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chiari Malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? **You have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? **Your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office in [**7-9**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Physician Assistant or [**Name9 (PRE) **] 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 3 months with an MRI Brain.
Completed by:[**2115-7-27**]
ICD9 Codes: 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5545
}
|
Medical Text: Admission Date: [**2188-4-13**] Discharge Date: [**2188-4-18**]
Date of Birth: [**2118-2-8**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 70-year-old male
with a history of chronic obstructive pulmonary disease with
most recent exacerbation in [**2-/2188**], who was admitted to the
MICU after he passed out early yesterday morning in the lobby
of his apartment complex. The patient woke up in the early
morning with shortness of breath and went to the window to
catch some fresh air. He continued to be dyspneic and
subsequently went down to get some water and he passed out.
He remembers feeling that he was going to lose consciousness.
He was then intubated and brought to the MICU. Blood gas was
7.07/74/381. He was tachycardiac to the 140s. In the MICU,
he was started on Solu-Medrol and Levofloxacin. After an
overnight stay in the MICU, he was extubated successfully and
transferred to the floor for further management. He reports
that over the past one week he has had progressively
worsening shortness of breath and a nonproductive cough. He
has had several episodes of chronic obstructive pulmonary
disease exacerbation in the past, which culminated in
hospitalizations. He denied any chest pain, fevers, chills,
nausea, vomiting, diarrhea, or bright red blood per rectum.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease. The patient had
bronchitis as a child. Most recent pulmonary function tests
were in [**4-/2187**], which showed FEV1 of 1.62 or 60%; FVC of 3.46
or 87%; FEV1/FVC ratio of 69%; DLCO 77%; and total lung
capacity of 13.2.
2. Hypothyroidism.
3. Depression.
4. Echocardiogram recently showing 1+ MR. EKG with
incomplete right bundle branch block.
MEDICATIONS ON ADMISSION:
1. Serevent 2 puffs b.i.d.
2. Flovent 110 mcg two puffs b.i.d.
3. Levoxyl 125 mcg p.o.q.d.
4. Paxil 20 mg p.o.
5. Folate 1 mg p.o.q.d.
6. Atrovent MDI with spacer two puffs q.i.d.p.r.n.
7. Albuterol MDI with spacer two puffs q.i.d.p.r.n.
8. Protonix 40 mg p.o.q.d.
ALLERGIES: The patient is allergic to PENICILLIN, WHICH
CAUSES SWELLING.
SOCIAL HISTORY: The patient works at [**Company **]in the
food services section. He has a history of smoking one pack
per day for 40 years, but quit greater than one year ago. He
denies alcohol use. He denies having pets in the house. He
recently had pneumovacs approximately one year ago, but he
has never had influenza vaccine.
FAMILY HISTORY: History is unknown.
PHYSICAL EXAMINATION: Temperature 98.7, pulse 106, blood
pressure 112/66, respiratory rate 24, saturations 97% on room
air. GENERAL: The patient is alert and oriented times three
in no apparent distress. HEENT: Pupils equal, round, and
reactive to light, extraocular muscles are intact. No
lymphadenopathy, supple. NECK: Mucous membranes moist,
oropharynx clear. CARDIOVASCULAR: S1 and S2 tachycardiac,
regular. PULMONARY: Mild expiratory wheezing, otherwise,
clear to auscultation. ABDOMEN: Nontender, nondistended,
soft, positive bowel sounds. EXTREMITIES: No cyanosis,
erythema, or edema; pulses 2+ bilaterally. NEUROLOGICAL:
Cranial nerves II through XII intact.
LABORATORY DATA: When transferred to the [**Hospital1 139**] Service,
white blood cell count was 19.3, hematocrit 32.5, platelet
count 179,000, sodium 141, potassium 4.7, chloride 111,
bicarbonate 20, BUN 18, creatinine 0.6, glucose 122. EKG:
Sinus tachycardia at 138, left axis deviation, right bundle
branch block. Radiographic data: CT angiogram showed no
evidence of PE, three nodules noted in the right apex, and
some colonic diverticulosis.
HOSPITAL COURSE:
#1. PULMONARY: Trigger for patient's COPD exacerbations
unclear (environmental versus upper respiratory tract
infection). The clinical picture is most consistent with
chronic bronchitis. After transfer from the MICU, the
patient was continued on metered dose inhalers and Prednisone
taper. The Levofloxacin was discontinued. The patient's
white blood cell count was elevated likely secondary to
Prednisone. He remained afebrile throughout the course of
his stay in the hospital. He also remained stable from a
respiratory standpoint throughout the course of his stay in
the hospital. The patient is to followup with the Pulmonary
Clinic for further management and workup of his chronic
obstructive pulmonary disease.
#2. CARDIOVASCULAR: The patient had elevated CKs, however,
they were though to be secondary to muscle injury from his
fall. The patient was stable from a respiratory standpoint
post extubation. It seemed that the respiratory
decompression could not fully explained by pleurisy or COPD.
The sequence of his exacerbations were unusual and it was
thought that there might be a cardiac component to his
respiratory distress, which included tachycardiac from
Albuterol that may have lead to pulmonary edema in the
setting of diastolic dysfunction.
Additionally, the patient's EKG showed T-wave inversions in
V1 through V6. Cardiology consult was obtained and it was
decided for the patient to have stress echocardiogram. The
stress echocardiogram showed anterior abnormalities (please
see stress report for further details). Due to this atrial
abnormality, the patient had cardiac catheterization, which
showed mild-to-moderate CAD with no flow-limiting lesions;
normal filling pressures, left ventricular ejection fraction
of 55%. The patient was started on aspirin, however, beta
blockers were held due to the patient's respiratory disease.
The patient was also started on folic acid.
CONDITION ON DISCHARGE: Stable. The patient was discharged
to home.
DISCHARGE DIAGNOSES: Chronic obstructive pulmonary disease
exacerbation in the setting of URI.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o.b.i.d.
2. Levoxyl 100 mcg p.o.q.d.
3. Folate 1 mg p.o.q.d.
4. Prednisone taper.
5. Protonix 40 mg p.o.q.d.
6. Albuterol p.r.n.
7. Atrovent p.r.n..
8. Serevent two puffs b.i.d.
9. Flovent two puffs b.i.d.
The patient was discharged to home. The patient will
followup with his primary care physician next week and with
the pulmonary clinic.
DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2188-5-19**] 14:42
T: [**2188-5-19**] 15:02
JOB#: [**Job Number 96128**]
ICD9 Codes: 2762, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5546
}
|
Medical Text: Admission Date: [**2126-4-30**] Discharge Date: [**2126-5-9**]
Date of Birth: [**2044-10-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy
CT guided lung biopsy
Embolization of right bronchial artery
Centran Venous Line Placement
Intubation and Mechanical Ventilation
History of Present Illness:
81 year old man with GERD, HTN, who presented on [**4-30**] with
hemoptysis. For a more complete HPI please see the NF admission
H&P. The pt reported that at 7pm on [**4-29**] he had sudden onset
hemoptysis - bright red blood with some clots which he estimated
at 2 tbsp. The hemoptysis continued about 4-5 times per hour,
and when it did not stop the patient presented to [**Hospital1 18**] ED. The
pt denied any prior episodes of hemoptysis, epistaxis or GIB. He
endorsed [**Hospital1 **] aspirin for a recent URI.
.
In the ED, initial VS were: T98.4, HR 112, 141/96, R21, 94% on
RA. Nasogastric lavage showed scant red blood thought likely due
to swallowing coughed up blood. Cleared after 60 cc. CTA showed
RUL spiculated mass. Since the pt's hemoptysis began to slow,
and he did not develop hypoxia or an O2 requirement, the pt was
admitted to the floor at 2am [**4-30**].
.
Initially on the floor the patient appeared comfortable, denied
CP, shortness of breath and reported no hemoptysis for [**4-4**]
hours. At approximately 7am the pt developed hemoptysis again,
and produced 100+cc of bright red blood over the course of the
hour. The pt was also noted to be tachycardic in the 120's and
was bolused with 1L NS. Blood pressures on the floor were
notably elevated in the 180's systolic and the patient's O2 sats
remained normal on room air.
.
Interventional pulmonology was consulted and the pt was taken
for urgent rigid bronchoscopy on [**2126-4-30**]. Bronchoscopy showed a
large clot in the right bronchus intermedius, but no active
bleeding was visualized. A dual-lumen ET tube was placed to
occlude blood from R lung from entering L lung, and the patient
was transferred to the TSICU for further monitoring.
.
In the TSICU the pt is intubated and sedated on propofol and
paralyzed with rocuronium. Blood pressures had begun to drift
down in the OR, and peripheral neosynephrine was at 1mcg/hr.
.
Review of systems: (Per NF note and brief discussion with pt
this am)
(+) Per HPI
(-) Denied fever, chills, headache, shortness of breath. Denied
chest pain or tightness, palpitations, lightheadedness. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
* Denied weight loss, night sweats
Past Medical History:
- HTN
- GERD
- BPH
- Colon polyp on colonoscopy [**10/2125**]
Social History:
(Per NF note) Widowed. Has 2 sons, lives with one of them. Had a
daughter as well who passed away. Retired engineer. Travelled
during working life around US and various countries ([**Country 4754**],
middle east, [**Country 5142**]). Born in [**Location (un) 86**]. No TB contacts. [**Name (NI) **] current
smoking history, reports smoking for a short time during WWII
only. Father did [**Name2 (NI) **] while he was growing up. No etoh.
Family History:
Per NF note) One son with psoriasis, other with asthma. Daughter
died at age 37 of liver cancer. Mother died at 85 of head and
neck cancer and father died in 40s of brain tumor.
Physical Exam:
Afebrile, BP's 110-120/60, P 50-60, RR 12, 100% on AC
500/12/5/100%
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, ET tube in place
Neck: supple, JVP not elevated, ? anterior cervical LAD.
Lungs: Decreased breath sounds at right base, rhonchi present on
right side, clear ventilated breath sounds on left
CV: Regular rate and rhythm, no murmurs
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Intubated, responds to noxious stimuli
Lymph: No supraclavicular, axillary or inguinal LAD
Pertinent Results:
Labs on admission:
[**2126-4-29**] 10:45PM PT-10.7 PTT-26.5 INR(PT)-0.9
[**2126-4-29**] 10:45PM PLT COUNT-285
[**2126-4-29**] 10:45PM NEUTS-62.1 LYMPHS-27.7 MONOS-6.3 EOS-3.4
BASOS-0.6
[**2126-4-29**] 10:45PM WBC-8.4 RBC-4.92 HGB-14.2 HCT-42.7 MCV-87
MCH-28.9 MCHC-33.3 RDW-12.6
[**2126-4-29**] 10:45PM ALBUMIN-4.2 CALCIUM-9.5 PHOSPHATE-3.9
MAGNESIUM-2.2
[**2126-4-29**] 10:45PM ALT(SGPT)-31 AST(SGOT)-85* ALK PHOS-87 TOT
BILI-0.5
[**2126-4-29**] 10:45PM estGFR-Using this
[**2126-4-29**] 10:45PM GLUCOSE-111* UREA N-14 CREAT-1.0 SODIUM-137
POTASSIUM-6.0* CHLORIDE-101 TOTAL CO2-23 ANION GAP-19
[**2126-4-29**] 10:46PM HGB-15.5 calcHCT-47
[**2126-4-29**] 10:46PM LACTATE-3.3* K+-4.6
[**2126-4-29**] 10:46PM COMMENTS-GREEN TOP
[**2126-4-30**] 06:40AM PLT COUNT-296
[**2126-4-30**] 06:40AM WBC-7.0 RBC-4.08* HGB-12.2* HCT-35.9* MCV-88
MCH-30.0 MCHC-34.1 RDW-12.5
[**2126-4-30**] 06:40AM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-2.2
[**2126-4-30**] 06:40AM ALT(SGPT)-19 AST(SGOT)-19 ALK PHOS-69 TOT
BILI-0.4
[**2126-4-30**] 06:40AM GLUCOSE-109* UREA N-12 CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-24 ANION GAP-12
[**2126-4-30**] 12:38PM PT-12.2 PTT-30.9 INR(PT)-1.0
[**2126-4-30**] 12:38PM PLT COUNT-248
[**2126-4-30**] 12:38PM WBC-10.5 RBC-4.43* HGB-13.5* HCT-39.1* MCV-88
MCH-30.6 MCHC-34.6 RDW-13.4
[**2126-4-30**] 12:38PM CALCIUM-7.3* PHOSPHATE-4.1 MAGNESIUM-2.0
[**2126-4-30**] 04:09PM O2 SAT-97
[**2126-4-30**] 04:09PM TYPE-ART PEEP-5 O2-50 PO2-161* PCO2-39
PH-7.36 TOTAL CO2-23 BASE XS--2 INTUBATED-INTUBATED
VENT-SPONTANEOU
[**2126-4-30**] 07:45PM HCT-39.4*
STUDIES/IMAGES:
ECG [**2126-4-29**]: TRACING #1 Sinus tachycardia. Right bundle-branch
block. Modest inferior lead ST-T wave changes may be primary and
are non-specific but baseline artifact makes assessment
difficult. No previous tracing available for comparison.
Portable CXR [**2126-4-29**]: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST:
The heart size is upper limits of normal, with a possible left
ventricular configuration, which can be seen with hypertension.
The right upper lobe demonstrates a spiculated mass measuring
approximately 4 cm. There is also right hilar lymphadenopathy. A
small amount of air projecting in the left paraspinal region
through the medial lung base may represent a small hiatal
hernia. The bony thorax is unremarkable. IMPRESSION: Right upper
lobe mass and right hilar lymphadenopathy, for which CT is
recommended for further evaluation.
Bronchial washings [**2126-4-30**]: (From RUL) Atypical epithelial
cells, favor reactive bronchial cells.
Bronchial brushings [**2126-4-30**]: (From RUL) NEGATIVE FOR MALIGNANT
CELLS. Reactive bronchial cells and pulmonary macrophages.
.
ECG [**2126-4-30**]: TRACING #2 Sinus rhythm. Right bundle-branch block.
Right precordial lead ST-T wave configuration may be primary and
is non-specific but cannot exclude possible ischemia. Prolonged
QTc interval is non-specific. Clinical correlation is suggested.
Since the previous tracing of [**2126-4-29**] sinus tachycardia is
absent, further precordial lead ST-T wave changes are seen and
the QTc interval appears longer.
.
CTA chest [**2126-4-30**]: IMPRESSION: 1. No evidence segmental/larger
PE; limited for eval of small/subsegmental PE. 2. Spiculated 3.7
x 2.9 cm mass in the right upper lobe causing obliteration of
the anterior segmental bronchus, with associated right hilar
lymphadenopathy. 3. Significant tracheal/right bronchial
secretions. 4. Moderate hiatal hernia.
.
CXR [**2126-4-30**]:
IMPRESSION:
1. Double-lumen ETT in left main bronchus.
2. NGT in proximal duodenum.
3. Right upper lobe mass and lymphadenopathy.
.
Trans cath embo therapy [**2126-5-1**]: IMPRESSION:
1. Right bronchial arteriogram demonstrating origin of the right
bronchial artery from a right intercostal artery. An area of
hypervascular blush was noted in the right upper lobe which is
suspicious for neoplasm. This area corresponds to the lesion
seen on CTA from [**9-30**]. Multiple attempts were made to selectively cannulate the
right bronchial artery but were unsuccessful because of a very
acute angle of takeoff from the intercostal artery; no spinal
artery was visualized.
3. Embolization was performed by placing multiple Hilal coils in
the intercostal artery beyond the origin of the right bronchial
artery and then using 500-700 micron Embospheres to embolize the
right bronchial artery with successful angiographic result.
.
CT abdomen/pelvis [**2126-5-2**]: IMPRESSION: No evidence of hematoma in
the abdomen or pelvis; bilateral pleural effusions with
atelectasis.
.
CXR [**2126-5-3**]: FINDINGS: In comparison with the study of [**5-2**], the
left PICC line has been extended so that the tip lies in the mid
portion of the SVC. The other monitoring and support devices are
unchanged. Bibasilar atelectasis persists, more prominent on the
left. Apparent prominence of the transverse diameter of the
heart may well reflect relatively low lung volumes. Spiculated
right upper lobe mass and hilar adenopathy are stable.
.
CT HEAD W/WOUT CONTRAST [**2126-5-8**] - FINDINGS:
There is no evidence of intracranial, bony, or soft tissue
masses.
Specifically, there is no evidence of enhancing parenchymal
lesions. No
hemorrhage, edema, mass effect, or infarction is identified. The
paranasal sinuses and mastoid air cells are clear and well
aerated. No fractures, suspicious lytic, sclerotic, or soft
tissue abnormalities are identified.
IMPRESSION:
No evidence of metastases. However, MRI is more sensitive in
detection of
intracranial metastases.
Brief Hospital Course:
81M with history of minimal past medical history presenting with
hemoptysis, found to have a spiculated mass in right upper lobe
on bronchoscopy.
.
# Hemoptysis: The patient was transferred to the trauma SICU
post bronchoscopy with placement of double lumen ETT tube. His
hospital course in the SICU was complicated by an episode of
submassive hemoptysis. He underwent pulmonary angiogram with
coil embolization of the right bronchial artery without further
epidodes of significant hemoptysis. The thoracic surgery service
was consulted for possible urgent lobectomy but given
stabalization in his clinical status this was deferred.
Post-procedure his hematocrit dropped to thirty and a CT
abdomen/pelvis was performed to evaluate for retroperitoneal
bleed, which was negative. Repeat hematocrit check was at
baseline. He was successfully extubated after four days. His
hematocrit remained stable throught the remainder of his
hospital course with no further evidence of hemoptysis.
.
# RUL mass: A broad differential was maintained although the
suspicion for malignancy was high. He was admitted to a
respiratory isolation room pending three negative AFB smears.
Bronchial washings were obtained during the initial bronchscopy
with intiail pathology demonstrating reactive bronchial cells.
All microbiologic studies were negative. The patient was taken
for repeat bronchoscopy for planned EBUS on [**5-7**]. However no
biopsy was able to be obtained secondary to poor visualization.
The patient was taken for CT guided biopsy of the RUL lesion on
[**5-8**] with pathology results pending at the time of discharge. He
underwent CT Head for staging as MRI was unable to be obtained
secondary to hardware, which was negative for evidence of
metastasis. CT A/P also negative. He is scheduled to follow up
with Dr. [**Last Name (STitle) **] in Thoracic Surgery for further evaluation
and management of suspected lung cancer.
.
# Hypertension: His antihypertensives were initially held given
concern for hemodynamic instability but were restarted as the
patient's clinical status improved. His home dose of amlodipine
was increased to 10mg daily prior to discharge.
.
# BPH: Finasteride and flomax were continued
Medications on Admission:
finasteride 5 mg daily
flomax 0.4 mg daily
amlodipine ?5 mg daily
captopril ?dose TID
omeprazole 20 mg QOD
multivitamin daily
calcium daily
recent ASA - 2 tabs daily of unknown strength
robitussin prn
no other NSAIDs
Discharge Medications:
1. Captopril 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hemoptysis
2. Right Upper Lobe Lung Mass
.
Secondary:
1. Hypertension
2. Benign Prostatic Hypertrophy
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 hemoptysis (coughing up
blood) and were found to have a mass in your lung that was the
source of bleeding. Your bleeding was treated with an
interventional radiology procedure called coiling to stop the
bleeding from one of the blood vessels in your lung. You have
undergone a biopsy of the lesion in your lung, the results of
which are pending at this time. You will follow up in clinic
with Thoracic Surgery and your primary care physician for
further evaluation and management of the mass in your lung.
.
The following changes have been made to your medications:
Your blood pressure medication amlodipine has been increased to
10 mg daily.
Your Aspirin has been stopped to decrease your risk of bleeding.
.
Please maintain your scheduled follow up listed below:
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
When: Wednesday, [**5-15**], 2:20pm
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2126-5-14**] at 9:00 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2126-5-23**] at 3:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 5185
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5547
}
|
Medical Text: Admission Date: [**2172-9-20**] Discharge Date: [**2172-9-25**]
Date of Birth: [**2150-1-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Vicodin / Morphine
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
altered mental status, respiratory failure, hypotension
Major Surgical or Invasive Procedure:
Endotracheal intubation, mechanical ventilation
Left internal jugular triple lumen catheter
L knee arthrocentesis
History of Present Illness:
Ms. [**Known lastname 80115**] is a 22yo woman with h/o poorly controlled IDDM and
repeated admissions for DKA who was transferred from St Lukes'
with DKA.
.
She was found unresponsive on the couch by friends and EMS was
called. According to notes from [**Hospital3 17162**] she had been c/o
abdominal pain. Per report, BP was 60/40 in the field with HR in
160s in bigeminy. She was intubated in the field and started on
lidocaine bolus then gtt.
.
She was brought to the St Lukes' ED and found to have a blood
sugar of 1490. She was afebrile and tachycardic to 200 (?
whether EKG misinterpreted T waves as QRSs). Initial blood gas
revealed pH 6.8/38/479. Potassim was 8.9 and EKG showed peaked T
waves. She was given 30g x 2 and insulin/calcium. Her WBC was 53
and her lactate was 4.4. Cr of 2.1 and initial AG of 43. A left
IJ was placed and she received 5.5L of IV fluids as well as
vanc/flagyl/levo. The lidocaine gtt was DC'd when review of EKGs
showed she was most likely in sinus. UTox was negative. She was
transferred to [**Hospital1 **] as there were no MICU beds available at [**Hospital3 80116**].
.
In the [**Hospital1 18**] ED, initial VS were: 101.2 132 146/94 17 99%. She
was noted to have facial edema. She received regular insulin gtt
at 3 units/hr, versed 5mg IV x 2, tylenol PR 650mg, and fentanyl
gtt. Nursing staff recorded that a total of 7L of IV fluid had
been given. Repeat ABG showed 7.18/28/393. CT Head was done
given poor mental status, and she was sent to the MICU.
Past Medical History:
DM c/b gastroparesis
Dyslipidemia
Thyroid disease
h/o pancreatitis
GERD
Bipolar disorder
? Personality disorder
? Dilaudid abuse
Social History:
apparently frequently leaves AMA from [**Hospital 15405**]. Denies EtOH,
illicits, IVDA. Has 3 year old son who was recently adopted by
aunt. [**Name (NI) **] pt, her son is what she "lives for."
Family History:
non-contributory
Physical Exam:
99.5 122 126/51 22 100% on PS 5/5
Intubated, sedated.
Pupils small but equal and reactive.
+Scleral and facial edema. No blood behind TM b/l.
MMM.
Neck supple. No thyroid nodule palpated. Left IJ in place, site
appears clean.
S1, S2, tachy and regular, +II/VI systolic murmur at base.
Lungs: thick secretions suctioned from ET tube. Coarse BS b/l.
Abd: soft, does not flinch to palpation, ND. +BS
Ext: Peripheral pulses +2 b/l.
Large amount of dilute urine in bag.
Pertinent Results:
LABS ON ADMISSION:
[**2172-9-20**] 07:06PM WBC-27.7* RBC-3.35* HGB-10.0* HCT-31.0*
MCV-93 MCH-29.8 MCHC-32.1 RDW-13.6
[**2172-9-20**] 07:06PM NEUTS-70 BANDS-5 LYMPHS-13* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-5* MYELOS-0
[**2172-9-20**] 07:06PM PLT SMR-NORMAL PLT COUNT-399
[**2172-9-20**] 07:06PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2172-9-20**] 07:06PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2172-9-20**] 07:06PM URINE RBC-0-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2172-9-20**] 07:06PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2172-9-20**] 07:06PM CALCIUM-7.6* PHOSPHATE-3.9 MAGNESIUM-2.2
[**2172-9-20**] 07:06PM GLUCOSE-341* UREA N-30* CREAT-1.3*
SODIUM-151* POTASSIUM-4.6 CHLORIDE-119* TOTAL CO2-11* ANION
GAP-26*
[**2172-9-20**] 07:18PM freeCa-1.13
[**2172-9-20**] 11:09PM PT-13.6* PTT-25.7 INR(PT)-1.2*
[**2172-9-20**] 11:09PM ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-385* ALK
PHOS-101 AMYLASE-139* TOT BILI-0.1
[**2172-9-20**] 11:09PM LIPASE-75*
[**2172-9-20**] 11:09PM ALBUMIN-3.1* CALCIUM-7.4* PHOSPHATE-2.6*
MAGNESIUM-2.0
[**2172-9-20**] 11:40PM TYPE-ART PO2-177* PCO2-37 PH-7.23* TOTAL
CO2-16* BASE XS--11
STUDIES:
EKG: Sinus tach at 126 with normal axis and intervals, TWI in
III, good R wave progression, no ischemic ST/T changes.
.
CXR [**9-20**]:
The ET tube is low lying its tip approximately 9 mm from the
carina.
The tip of the NG tube is projected over the stomach. There is
right
perihilar haze, which could represent infection versus
aspiration. The cardiomediastinal silhouette is unremarkable.
The left lung is clear. Left IJ approach CVL tip is at the
cavoatrial junction.
CONCLUSION: The endotracheal tube needs reassessment and
repositioning, this was put in the wet read. Right perihilar
haze could represent infection or aspiration given the patient's
history of diabetic ketoacidosis.
.
CT Head [**9-20**]: No acute intracranial process. Cerebral atrophy.
.
L knee x-ray [**9-22**]: No comparison. No acute fractures or
dislocations are noted. No lucent or sclerotic lesion is seen.
There is a small left knee joint effusion. Soft tissues are
otherwise unremarkable.
Small left knee joint effusion.
.
CT abd/pelvis with contrast [**9-22**]: 1. No evidence of ischemic
bowel.
2. Normal appendix.
3. Small air bubble in the nondependent position of bladder.
Please
correlate with clinical history if patient has recent
instrumentation.
Otherwise, this could suggest UTI.
.
CXR [**9-22**]: 1. Interval extubation and removal of nasogastric
tube.
2. Right perihilar opacity, may be a focus of aspiration or
possible early focus of infection.
Brief Hospital Course:
1) DKA, poorly controlled type 1 diabetes - AG resolved within
12 hours on arrival to MICU on insulin gtt. Lytes were repleted
and IVFs were given aggressively. She was able to be extubated
the following day without difficulty and was transitioned over
to SQ insulin once she was tolerating pos. [**Last Name (un) **] was consulted
who helped manage her transition to a SQ insulin regimen. The
patient was also provided extensive diabetic teaching and was
informed of how important it is to remain compliant on her
diabetic regimen at home. She was also seen by a social worker
who reinforced the issue of compliance as well. As the pt wished
to transfer her diabetes care to the [**Last Name (LF) **], [**First Name3 (LF) **] appointment was
made for the patient to follow-up at the [**Last Name (un) **] on [**10-6**] for
further care, diabetic teaching, and counseling.
2) L knee pain: Patient began to complain of worsening pain in
her L knee almost immediately upon extubation. Intraosseous
access by the L knee that was obtained in the field was removed
upon arrival. Knee exam significant for mild erythema and
moderate effusion with pain with both passive and active ROM.
Knee x-ray revealed effusion but no other abnormalities. Given
persistent low grade fevers to 99.5 and concern for L knee pain,
a left arthocentesis was performed that revealed only 12 WBC,
thus being negative for a septic or otherwise infected joint.
Knee fluid studies from arthocentesis negative for
infected/septic joint. Cultures were negative as well. She was
treated with standing ibuprofen, po dilaudid prn, and IV
dilaudid prn. Pain improved upon discharge and pt was able to
ambulate independently without difficulty.
3) Low grade fever: Fever to 101 upon arrival to [**Hospital1 18**] and had
Tm to 99.5 while in MICU. Most likely with aspiration PNA.
Treated by MICU team with 5 day course of levofloxacin. There
was also a concern for a septic L knee, work-up negative as
above. The patient was without fevers upon callout to the
medical floor. All culture data remained negative.
4) Abd pain: Concern for possible ischemic bowel while in MICU
given lactate of 4 and diffuse abdominal tenderness. CT
abd/pelvis with contrast without evidence of ischemic bowel.
Patient then began to complain of gassy abdominal pain, which
resolved with simethicone prn.
5) Altered mental status/Agitation/Psych: Began to have
intermittent episodes of agitation on hospital day 3 and
demanded to intermittently sign out AMA. Most of the episodes of
agitation were provoked by the pt asking for IV dilaudid and
being told that she would need to try po dilaudid first.
Psychiatry consulted who felt that given the pt's poor insight
and judgement as well as the severity of her presentation, that
she could not sign out AMA. She was continued on her home
regimen of xanax prn, abilify, and celexa as well as written for
IV/IM haldol and ativan prn, which was never required. Social
work was consulted as well and the patient usually would
deescalate upon offering her prn xanax or dilaudid. Did code
purple the night prior to discharge, which resolved without
chemical or physical restraints. At the time of discharge, the
pt was exhibiting fair insight into her medical situation and
was cleared by psychiatry to d/c home with f/u with her outpt
psychiatrist and therapist.
6) ARF: Cr 2.1 on presentation, resolved by discharge. ARF most
likely [**1-25**] to prerenal causes such as hypotension/dehydration
vs. ATN from hypotension. Never oliguric.
7) Anemia: Hct stable at discharge. Likely [**1-25**] dilution effect
from large amounts of IVFs while being hospitalized.
8) Hypothyroidism: TSH on check in MICU in setting of acute
illness. Continued levothyroxine at current dose.
Medications on Admission:
Xanax 0.5mg TID
Levemir (long acting insulin) 50 units QAM and QPM
Humalog 12 units TID with sliding scale
Reglan 10mg TID
Levothyroxine 112 mcg daily
Prilosec 20mg daily
Crestor 10mg daily
Recently started on "psych meds"--celexa
Discharge Medications:
1. Alprazolam 1 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day)
as needed.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gassy abdominal
pain.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
8. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day.
9. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous qlunch.
Disp:*5 bottles* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous before breakfast, lunch, dinner.
Disp:*3 bottles* Refills:*2*
11. Humalog 100 unit/mL Solution Sig: per attached sliding scale
sheet units Subcutaneous qachs.
Disp:*3 bottles* Refills:*2*
12. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
13. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Diabetic Ketoacidosis
L knee pain
Secondary Diagnosis:
Poorly controlled type 1 diabetes mellitus with gastroparesis
Bipolar disorder
Hyperlipidemia
GERD
Discharge Condition:
Stable, anion-gap closed, FS improved. Afebrile. Ambulating
independently.
Discharge Instructions:
You were admitted with a coma that was induced by very, very
high blood sugars. This was life threatening and you required a
breathing tube and machine initially. You were treated in the
ICU before you were well enough to be transferred to the medical
floor. The [**Last Name (un) **] doctors saw [**Name5 (PTitle) **] [**Name5 (PTitle) 1028**] you were in the hospital
and you have follow-up with them as an outpatient. You had fluid
sampled from your left knee which did not show an infection.
You were also treated for a possible aspiration pneumonia with a
course of antibiotics. You were also seen by a social worker and
psychiatrists.
It is very, very important for you to take your insulin as
prescribed and monitor your blood sugars. Diabetes is a serious
condition and you can potentially die from the complications if
it is not carefully managed.
The following changes were made to your medications while you
were in the hospital:
1) You are now on a new insulin regimen per the [**Last Name (un) **] doctors.
You will take 35 units of lantus at lunch and 8 units of humalog
prior to each meal. You will also take an additional humalog
sliding scale depending on what your blood sugars are prior to
eating.
2) You were started on a medication called simethicone for gassy
abdominal pain. You may take this up to four times a day as
needed.
3) The amount of your usual dilaudid dose was increased to [**3-31**]
mg every 4 hours as needed for your left knee pain.
4) You were also started on ibuprofen 800 mg three times a day
for left knee pain. Please continue to take this for 5-7 days
and take the medication with food.
Call your doctor or return to the emergency room if you
experience any of the following: fever > 101, worsening left
knee pain, blood sugar greater than 450, increasing confusion or
sleepiness.
Followup Instructions:
We have set up an appointment for you to establish care at the
[**Hospital **] Clinic on [**10-6**] at 9am. Your PCP will need to make an
official referral to the [**Last Name (un) **] for insurance reasons. Please
call [**Telephone/Fax (1) 2384**] if you have any further questions or need to
change the appointment.
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], within 1 week.
Please keep your previously scheduled appt with your
psychiatrist/therapist.
Completed by:[**2172-9-25**]
ICD9 Codes: 5070, 5849, 2760
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5548
}
|
Medical Text: Admission Date: [**2124-9-16**] Discharge Date: [**2124-9-27**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
right hemiparesis, neglect, aphasia
Major Surgical or Invasive Procedure:
PEG tube placement
History of Present Illness:
81yo man with PMH significant for MI, prostate cancer, [**Hospital 11491**]
transferred from an OSH after presentation with right
hemiparesis, neglect, and aphasia, and treatment with tPA. Per
previous reports, he was in his USOH until the day of admission,
when he acutely slumped over to the right and stopped speaking.
He was taken to an OSH, where he had L gaze preference, global
aphasia, and right hemiplegia, and a head CT showed a hyperdense
L MCA. He was given IV tPA and transferred to the [**Hospital1 18**] ICU.
Past Medical History:
prostate ca [**2119**]
s/p MI [**2112**] with medical management
asthma/COPD
lower back problems
Social History:
lives in [**Location **] with his wife, uses some assistance to walk. No
tobacco or alcohol use.
Family History:
not elicited
Physical Exam:
P/E on admission
Afebrile (temp not taken yet) 95 175-187/83 28 95%
Gen elderly man lying in bed
CV rrr
Pulm ctab
Abd soft nt/nd
Ext no edema
NEURO
MS Awake, eyes open. Turns his head to the left when his son
called out "Dad!" Does not do so to my voice on the right.
Reaches to left to grab a hat with his left hand. Does not
follow
commands. No verbal output.
CN optic discs clear. Blinks to threat on the right, not the
left. Pupils 3->2 b/l. Gaze conjugate in primary position and
looking to the left (does not look to the right). Unable to
doll's eye. R facial droop includes upper face as well as lower
face.
Motor decreased tone in R arm, increased in R leg. Normal on
left. Allows R arm to fall onto his chest; when his left arm is
lifted, he moves it back to his side. Unable to cooperate with
exam. Withdraws L leg to noxious stimuli purposefully; does not
do so with right.
Sensory: withdraws L arm/leg to noxious stimuli. None on right.
Coordination: unable to assess
Gait: unable to assess
Reflexes: unable to obtain on left due to inability to get the
patient to relax his arm. 2+ on the right. Toes down b/l.
Pertinent Results:
Admission labs:
WBC-13.9* RBC-4.87 Hgb-15.1 Hct-42.3 MCV-87 MCH-31.1 MCHC-35.8*
RDW-13.4 Plt Ct-246
Neuts-92.5* Bands-0 Lymphs-5.5* Monos-1.5* Eos-0.3 Baso-0.1
PT-11.5 PTT-22.6 INR(PT)-1.0
Glucose-129* UreaN-14 Creat-0.8 Na-137 K-4.2 Cl-103 HCO3-22
Calcium-9.4 Phos-3.1 Mg-2.0
ALT-13 AST-17 CK(CPK)-77 AlkPhos-69 TotBili-0.7 Albumin-4.3
Cardiac enzymes (r/o)- negative x 3, on tele
Lipids LDL 154
HbA1C 5.4
Imaging:
- MRI/A - Acute left middle cerebral artery infarct with
possible thrombus within the left middle cerebral artery. No
evidence of hemorrhage. MRA w/ L M1 occlusion.
- TTE - "extensive regional LV systolic dysfunction c/w CAD"
Brief Hospital Course:
81yo man with CAD, prostate cancer, presented with right
hemiparesis, gaze deviation, and aphasia, and transferred here
after CT with L MCA sign and treatment with IV tPA. Exam notable
for right sided weakness, left gaze preference, and global
aphasia, MRI confirms acute L MCA infarct with occlusion at L
M1.
While in the ICU, he was monitored frequently. An MRI/A was
perfromed showing an acute L MCA infarct with occlusion at M1. A
TTE showed LV systolic dysfunction. Labs were drawn. He failed a
swallow evaluation and had an NGT placed, which he removed. He
was then transferred to the floor. He was stable s/p tPA and
remained minimally interactive, though not following commands.
Stroke workup included MRI/A, showing acute left middle cerebral
artery infarct with possible thrombus within the left middle
cerebral artery, MRA w/ L M1 occlusion, TTE with "extensive
regional LV systolic dysfunction c/w CAD", negative cardiac
enzymes, lipid panel that was elevated with resulting initiation
of a statin once taking po, and a normal HbA1c. He was started
on a daily ASA, and aggrenox was started after G-tube was
placed. It was felt that his stroke was cardioembolic secondary
to significant wall motion abnormalities. We did not start
anticoagulation given the large size of his infarct. Coumadin
will be discussed at first clinic visit..
Incidentally, he was noted to have a PNA, likely aspiration
secondary to the stroke. He was started on levofloxacin on [**9-19**],
and to complete a 10 day course.
He failed multiple swallow evaluations and had placement of an
NGT. He pulled this and it was replaced. After he pulled it
again, it was unable to be replaced. He went for PEG by
interventional radiology but this was unsuccessful as his colon
was anterior to his stomach. Surgery was called for G tube
placement, and recommended GI placement with endoscopy. PEG was
placed by EGD [**9-25**] without complications, and was confirmed in
place the following morning. Test bolus of TF was given and
tube feeds were started.
Medications on Admission:
ASA 81mg daily
mucinase 600mg [**Hospital1 **]
theophylline ER 200mg [**Hospital1 **]
flovent 2puffs [**Hospital1 **]
duoneb qid
ambien 10mg qhs
vicodin 5/500 1-2tabs q4h prn
colace 100mg [**Hospital1 **]
flomax 0.4mg every other day
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: per RISS
Injection ASDIR (AS DIRECTED).
Disp:*1 1* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*1 1* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*60 Tablet(s)* Refills:*2*
6. Aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
Disp:*30 Suppository(s)* Refills:*2*
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*90 1* Refills:*2*
8. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ONCE (Once) for 1 doses.
Disp:*1 1* Refills:*0*
9. Pantoprazole 40 mg IV Q24H
10. ChlorproMAZINE 12.5 mg IV Q4H:PRN hiccups
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH
Discharge Diagnosis:
Right MCA infarct
Discharge Condition:
Good. Making progress but still with deficits of aphasia, left
sided neglect and paresis.
Discharge Instructions:
Return to [**Hospital1 18**] or contact EMS if any acute changes in mental
status or new deficits. Please follow up with appointments as
listed below.
Followup Instructions:
Follow up with [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD: Phone:[**Telephone/Fax (1) 657**]
Date/Time:[**2124-10-24**] 3:00 .
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 5070
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5549
}
|
Medical Text: Admission Date: [**2139-8-2**] Discharge Date: [**2139-8-8**]
Date of Birth: [**2071-3-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Transfer for treatment of CHF and possible cardiac catherization
Major Surgical or Invasive Procedure:
Cardiac Catheterization s/p stent to LCX
Tunneled catheter placement
History of Present Illness:
Pt is a 68 yo male with CAD s/p MI in [**2119**], CHF, renal failure,
DM, hypertension, hyperlipidemia, multiple myeloma presenting
with sudden onset of SOB and chest pressure starting this
afternoon. He denies recent dyspnea on exertion or chest pain.
He does report about 2 weeks ago that he had some SOB, but it
resolved. Denies orthopnea or PND and reports that he has been
taking all of his medications. He has had hospital admissions
in the past for CHF exacerbations for which he was intubated.
He first went to [**Hospital3 417**] Hospital and was transfered for
potential cath and/or CHF therapy as he continued to have chest
pain and had EKG changes. At [**Hospital3 417**] he was started om
heparin drip, aspirin, nitro drip and was tranfered on 100%
non-rebreather. His CK 1156, MB 46.3, index 4.0, Trop I 4.4
from OSH and his creatinine was 10.9. He became CP free on the
ambulance ride to [**Hospital1 18**]. Denied CP on admission, but did have
signiifcant SOB. Does not make very much urine at baseline and
said that he was getting set up for dialysis.
Past Medical History:
1. Coronary artery disease, status post small myocardial
infarction in [**2119**], status post catheterization in [**2134**] for
congestive heart failure with no intervention,
status post Persantine MIBI in [**2131**] with a reversible defect
in the inferior wall.
2. Non-insulin-dependent diabetes mellitus.
3. Congestive heart failure.
4. Chronic renal insufficiency with a ? baseline creatinine
of ? 1.5, thought due to diabetic nephrosclerosis.
5. Chronic anemia with a baseline in the
high 20s.
6. Multiple myeloma.
7. Hypertension, difficult to control.
8. Hyperlipidemia.
9. Gout.
Social History:
Quit smoking in [**2115**], 35-pack-year history.
Denies recent alcohol.
Family History:
Mother died at 64 from renal cell carcinoma.
Father died in his 30s of unknown causes. Three siblings
with elevated cholesterol, diabetes, and hypertension.
Physical Exam:
Vitals: afeb, 95% NRB
General: Elderly male breathing using accessory muscles with
non-rebreather
HEENT: Could not appreciate JVP or carotid bruits
CV: RRR, nl S1S2, could not appreciate murmur, b/l femoral
bruits
Pulm: crackles throughout the lung fields bilaterally
Abd: normal BS, soft, NT/ND
Ext: warm, 2 +DP pulses and trace LE edema
Neuro: AAOx3
Pertinent Results:
[**2139-8-2**] 01:39AM BLOOD WBC-10.0 RBC-3.48* Hgb-9.3* Hct-29.4*
MCV-84 MCH-26.9* MCHC-31.8 RDW-20.4* Plt Ct-350
[**2139-8-8**] 06:55AM BLOOD WBC-7.8 RBC-3.31* Hgb-8.9* Hct-28.9*
MCV-87 MCH-26.8* MCHC-30.7* RDW-19.7* Plt Ct-236
[**2139-8-2**] 01:39AM BLOOD PT-14.1* PTT-39.1* INR(PT)-1.3
[**2139-8-8**] 06:55AM BLOOD Plt Ct-236
[**2139-8-2**] 01:39AM BLOOD Ret Aut-1.6
[**2139-8-2**] 01:39AM BLOOD Glucose-147* UreaN-131* Creat-10.3*#
Na-133 K-4.0 Cl-94* HCO3-17* AnGap-26*
[**2139-8-8**] 06:55AM BLOOD Glucose-142* UreaN-50* Creat-4.5* Na-140
K-3.0* Cl-100 HCO3-29 AnGap-14
Hematology
CK(CPK)
[**2139-8-5**] 05:46AM 106
[**2139-8-4**] 04:00PM 135
[**2139-8-4**] 05:50AM 163
[**2139-8-2**] 10:28AM 840*
[**2139-8-2**] 01:39AM 1117*
.
CPK ISOENZYMES CK-MB MBIndx cTropnT
[**2139-8-5**] 05:46AM 8 5.26*
[**2139-8-4**] 04:00PM 12 8.9* 5.37
[**2139-8-4**] 05:50AM 13 8.0* 3.48
[**2139-8-2**] 10:28AM 53 6.3* 1.73
[**2139-8-2**] 01:39AM 43* 3.8 1.07
[**2139-8-2**] 01:39AM BLOOD Albumin-4.2 Calcium-10.6* Phos-7.7*#
Mg-1.9 Iron-21*
[**2139-8-2**] 01:39AM BLOOD Ferritn-62
[**2139-8-6**] 02:30PM BLOOD calTIBC-196* Ferritn-150 TRF-151*
[**2139-8-3**] 07:11PM BLOOD TSH-0.41
[**2139-8-3**] 11:39AM BLOOD PTH-39
[**2139-8-4**] 05:50AM BLOOD PTH-46
[**2139-8-6**] 02:30PM BLOOD PTH-66*
[**2139-8-5**] 02:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
.
[**2139-8-2**] CXR: Congestive failure with pulmonary edema.
Pneumonitis at the bases cannot be excluded.
.
[**2139-8-4**] Cardiac catheterization: 1. Selective coronary
angiography revealed a right dominant system with three vessel
coronary artery disease. The LMCA had a 40% stenosis. The LAD
had diffuse 40 to 50% disease with 50% lesions in the upper and
lower poles of a large bifurcating diagonal branch. The LCX had
a hazy ostial 90% lesion with diffuse 50% disease in the mid to
dital vessel. The RCA had diffuse 60% stenoses with distal
occlusion of the PDA and PL that filled via left collaterals.
2. Resting hemodynamics demonstrated normal right sided
pressures
(mean RA 7 mmHg), severely elevated pulmonary (mean PA 45 mmHg),
and
mildly elevated left sided pressures (LVEDP 15 mmHg) with no
gradient
upon movement of the catheter from the ventricle back to the
aorta and a
normal cardiac index (4.8 l/min/m2).
3. Left ventriculography was deferred.
4. Successful placement of a Cypher drug-eluting stent in the
ostium
of the LCX.
.
[**2139-8-4**] Echocardiogram: The left atrium is mildly dilated. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50%) secondary to
hypokinesis of the inferior and posterior walls. 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 aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-14**]+) mitral regurgitation is seen. The mitral regurgitation
jet is eccentric. There is no pericardial effusion.
Compared with the findings of the prior report (tape unavailable
for review) of [**2135-4-27**], left ventricular contractile
function is reduced.
Brief Hospital Course:
68 yo M a/w SOB and CP, found to have pulmonary edema and
NSTEMI.
.
1. NSTEMI: On admission patient extremely SOB on 89% on 100%
NRB. He was placed on heparin gtt, Nitro, ASA, BB and ReoPro.
Patient underwent cardiac catheterization with stenting of his
LCX which was uncomplicated. After catheterization he was on
ASA, metoprolol, Lipitor, ReoPro for antiplatelet activity, and
Plavix. He was CP free throughout his admission and remained
hemodynamically stable. He was continued on ASA, metoprolol,
Plavix, Lipitor, Imdur and hydralazine.
.
2. CHF/pulmonary edema: On admission patient was had significant
pulmonary edema initially satting 89% on 100% NRB then briefly
on BIPAP with 100% O2 sat. He was diuresed with Lasix drip and
Diuril to which he was able to put out significant amounts of
urine (up to 2 liters over 24 hours). However, he soon required
HD after tunneled line placement on [**2139-8-3**]. He was afterload
reduced with hydralazine and Imdur. He had significant
improvement in his respiratory status within 24 hours with
improvement in pulmonary edema on chest x-ray and was satting 95
% on RA by discharge.
.
3. Renal: On admission creatinine was 10.3 indicative of ARF on
CRF likely secondary to myeloma. He was able to make urine on
Lasix drip however. A tunneled HD catheter was placed on [**2139-8-3**]
which he tolerated well. He was started on HD with significant
improvement in his pulmonary status as mentioned above. His
creatinine was 4.5 at discharge. He will follow up for dialysis
at the [**Last Name (un) **] dialysis center.
.
4. Myeloma: It was unclear what work up and treatment has been
done. Free calcium levels ranged from 1.19-1.30. This will be
follow up as an outpatient.
.
5. DM II: Fingersticks well controlled on RISS. Restarted on
Prandin as an outpatient.
.
6. Gout: Allopurinol was originally held, but was restarted and
continued at discharge.
.
7. Hypercholesterolemia: Started on high dose Lipitor. LFTs will
be monitored as an outpatient.
Medications on Admission:
Hydralazine 20 mg [**Hospital1 **]
Postassium Cl ER Micro 20 meq QD
Toprol-XL 200 mg p.o. q.d.
Clonidine 0.1 mg QD
Lasix 120 mg QD
Minoxidil 10 mg [**Hospital1 **]
Lipitor 20 mg p.o. q.d
allopurinol 100 mg p.o. q.d.
Prandin 2 mg at dinner only
Procrit 40k/60K as directed
Metolazone 2.5 mg 1 tab [**Hospital1 **]
aspirin 81 mg p.o. q.d.,
Cartia XT 180 mg 1 capsule [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
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).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
12. Prandin 2 mg Tablet Sig: One (1) Tablet PO at dinner time.
13. Procrit Injection
14. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD now on hemodialysis
CAD s/p stent to LCX, EF50%
Diabetes Mellitus Type II
Chronic anemia
Multiple Myeloma
Hypertension
Hyperlipidemia
Gout
Discharge Condition:
chest pain free, no shortness of breath, hemodynamically stable
Discharge Instructions:
If you have any chest pain, shortness of breath, palpitations or
any other concerning symptoms call you doctor or go to the
emergency room.
Your next scheduled dialysis is on Tuesday at [**Last Name (un) **] Dialysis
Center.
The following changes have been made to you medications:
1. Your lipitor has been increased to 80 mg per day
2. DO NOT TAKE YOUR Clonidine, metolazone, minoxidil, lasix or
cartia XT. These can be added back by Dr. [**Last Name (STitle) 7047**] as your blood
pressure dictates.
3. Continue your hydralazine 20 mg twice per day and toprol XL
200 mg once per day
4. Take the other medications on the attached medication list as
directed and follow up with Dr. [**Last Name (STitle) 7047**] and you primary doctor
for titration of medications.
Followup Instructions:
You will need to follow up with a nephrologist Dr. [**Last Name (STitle) **] at the
dialysis center. You will need dialysis at the [**Last Name (un) **] Dialysis
Center on Tuesday. These arrangments ahve already been made.
Please make a follow up appointment with Dr. [**Last Name (STitle) 7047**] within the
next week to follow up your blood pressure medications as you
need close monitoring.
Please make a follow up appointment with Dr. [**Last Name (STitle) **] within 1
month.
ICD9 Codes: 5849, 4280, 2749, 2724, 4168
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5550
}
|
Medical Text: Admission Date: [**2176-9-4**] Discharge Date: [**2176-9-7**]
Date of Birth: [**2107-11-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Nausea, vomiting, distended abdomen
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
68 yo M with a history of metastatic pancreatic ca s/p recent
duodenal stenting in [**7-/2176**], and recent hospital admission for
abd pain in [**2176-8-31**] s/p celiac plexus block for pain control,
who is transfered from OSH for KUB that was concerning for
obstruction vs ileus. His cancer has been unresponsive to
chemotherapy, and he has been speaking with palliative care
about transitioning to hospice.
The morning of admission, the patient presented to the OSH with
nausea, vomiting, and a distended abdomen. KUB was suggestive of
obstructive. NG tube was placed and drained 1L of fluid. He was
given levofloxacin 750mg x1, zofran, and sent to the [**Hospital1 18**] ER.
In the ED, initial VS were 97.7 112 107/76 16 96%. He was
hypotensive to the 80s-90s, and tachycardic to the 120s. He was
given a total of 6L normal saline. Labs were notable for a WBC
of 40.7. Daughter stated that he was full code. CXR was without
free air under the diaphragm. CT abdomen showed marked interval
progression of pancreatic mass 18.9 x 14.9 cm, (9.1 x 8.8 cm
previous), with concerns for obstruction of duodenum and
stomach. No SBO or large bowel obstruction. Ddx included
contained perforation vs necrotic mass vs less likely air in
collapsed bowel. He also had new large amt of ascites. Increased
+ new hepatic mets.
He was given 1g IV Vancomycin, and 500mg IV Flagyl, and 2mg IV
dilaudid.
ERCP was consulted who recommended Zosyn, Vanc, Fluconazole
given leukocytosis. They were not interested on intervening
currently. Surgery was also consulted, who contemplated
performing laparoscopic PEG placement for decompression. However
after speaking with palliative care and the family, the decision
was made not to perform surgery tonight. Vitals prior to
transfer were T98.2 104/67 110 97% on RA.
Currently, the patient has abdominal pain and back pain. His
abdomen feels tight. Denies fevers or chills. Can't remember
when his last meal was. Believes he had a BM one day prior to
admission.
Past Medical History:
ONCOLOGIC HISTORY: The patient presented with 2 months of
abdominal pain and was admitted to [**Hospital1 1170**] from [**2176-3-19**] through [**2176-3-22**] after initial
evaluation at [**Hospital3 417**] Hospital where he was found to have
a large pancreatic mass on CT scan. During his hospitalization,
he underwent EGD, EUS with FNA of the pancreatic mass on [**3-21**]
which is consistent with adenocarcinoma. FNA of the
peripancreatic lymph node was negative for malignant cells. His
imaging from outside details a 7.7 cm pancreatic body and tail
mass extending into the spleen, stomach, left adrenal gland, and
small bowel. His pain was treated with MS Contin, MSIR, and he
was discharged in stable condition. The patient has since
initiated palliative chemotherapy with gemcitabine. In total,
he has completed 4 cycles.
Abdominal CT on [**2176-7-17**] showed interval progression of the
pancreatic adenocarcinoma involving the distal body and tail, as
compared to the [**2176-5-22**] examination. There was noted new
rightward mass effect and loss of fat plane against the SMA,
worsening encasement of the splenic artery, aggressive invasion
into the adjacent duodenum and greater curvature of the stomach,
and obscuration of the fat plane against the spleen posteriorly.
There was also an unchanged segment [**Doctor First Name 690**] liver lesion,
concerning for metastatic focus. On [**2176-7-24**], he started
treatment with Xeloda as well as oxaliplatin.
Other Medical History:
Hypertension
Type 2 Diabetes [**Name (NI) **]
PTSD
Depression
Insomnia
Headaches related to head trauma
Social History:
[**Country 3992**] War veteran with PTSD and h/o multiple head injuries
from parachuting. Divorced with four children. Daughter and son
both work here at [**Hospital1 18**], other two live in the area. Denies
tobacco, alcohol, or other drug use.
Family History:
No h/o GI malignancy or other CA. No family history of DM or
CAD. Mother died at age 85 of MI.
Physical Exam:
GEN: NAD
VS: T 98 HR 113 BP 100/65 RR 18 94% on
HEENT: MMM, no OP lesions, neck is supple, no cervical,
supraclavicular, or axillary LAD
CV: RRR. No murmurs.
PULM: CTAB. No wheezes or crackles.
ABD: Markedly distended. No rebound or guarding. No palpable
masses.
LIMBS: 3+ LE edema, no tremors or asterixis, no clubbing
SKIN: No rashes or skin breakdown
NEURO: A+O x3. CNII-XII nonfocal, reflexes 1+ of the upper and
lower extremities
Pertinent Results:
Admission Labs:
[**2176-9-4**] 08:20AM WBC-40.7*# RBC-3.34* HGB-9.3* HCT-28.4*
MCV-85 MCH-27.8 MCHC-32.7 RDW-17.8*
[**2176-9-4**] 08:20AM NEUTS-90* BANDS-5 LYMPHS-2* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2176-9-4**] 08:20AM PLT SMR-NORMAL PLT COUNT-432
[**2176-9-4**] 08:20AM PT-19.6* PTT-23.3 INR(PT)-1.8*
[**2176-9-4**] 08:20AM ALT(SGPT)-39 AST(SGOT)-84* ALK PHOS-211* TOT
BILI-4.9*
[**2176-9-4**] 08:20AM LIPASE-93*
[**2176-9-4**] 08:20AM GLUCOSE-115* UREA N-45* CREAT-1.4* SODIUM-133
POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-27 ANION GAP-16
.
Imaging:
.
[**2176-9-4**] CXR: 1. Interval placement of nasogastric tube, with
distal tip in the expected location of the stomach, but with
side port at the GE junction. Recommend advancement so that it
is well into the stomach. 2. Low lung volumes without focal
consolidation or pulmonary edema seen. 3. Lucency under the left
hemidiaphragm seen on the prior radiograph at
outside hospital is no longer appreciated, status post NG
placement and most likely represented distended gastric bubble.
.
[**2176-9-4**] CT Abdomen/Pelvis:
.
1. Marked interval disease progression, including substantial
interval
increase in size of pancreatic mass, as above, which invades the
stomach,
duodenum, left adrenal gland, and likely the splenic flexure,
encases at least
the splenic, hepatic, and distal celiac arteries, the splenic
vein and SMV,
and at least abuts and likely invades the left renal vein.
Increased
retroperitoneal lymphadenopathy. Peritoneal/omental thickening
and
nodularity. Worsened hepatic metastases, enlarged in size and
increased in
number.
.
2. Contrast seen in the stomach and duodenum, possibly to the
level of the
duodenal stent without contrast seen more distally. While the
stomach is not
frankly dilated, a nasogastric tube is in place, likely causing
decompression.
Findings are highly concerning for obstruction, possibly at the
level of the
duodenum due to the large pancreatic mass. No evidence of large
bowel
obstruction or obstruction of the small bowel distal to the
duodenal stent.
.
3. Small foci of gas adjacent to the duodenal stent amongst the
large
pancreatic mass. Differential diagnosis includes bowel
perforation versus
necrotic mass versus much less likely air within collapsed loops
of bowel
amongst the pancreatic mass. Interval development of large
amount of
abdominal/pelvic ascites, which can be seen in metastatic
disease and in bowel
perforation.
.
4. Delayed left nephrogram. Left periureteral stranding.
.
Discharge Labs:
[**2176-9-7**] 06:00AM BLOOD WBC-46.5* RBC-3.40* Hgb-9.1* Hct-29.6*
MCV-87 MCH-26.9* MCHC-30.9* RDW-18.6* Plt Ct-395
[**2176-9-7**] 06:00AM BLOOD Neuts-95* Bands-1 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2176-9-6**] 03:37AM BLOOD PT-22.9* PTT-24.4 INR(PT)-2.2*
[**2176-9-7**] 06:00AM BLOOD ALT-49* AST-92* AlkPhos-207* TotBili-6.4*
[**2176-9-7**] 06:00AM BLOOD Calcium-12.5* Mg-2.4
Brief Hospital Course:
68 year old gentleman with advanced pancreatic cancer who
presented with nausea, vomiting, and abdominal distension.
.
1. Duodenal and Gastric Obstruction: The patient was admitted
with several days of nausea and vomiting. A KUB performed at an
OSH was concerning for obstruction and the patient was
transferred to [**Hospital1 18**] for further evaluation. A CT scan on
admission was concerning for marked interval progression of
pancreatic mass obstructing his duodenum and stomach. An NG tube
was placed for decompression. The patient was initially
transferred to the ICU with plans for possible intervention by
Surgery or the ERCP team but neither felt intervention was
appropriate. The patient was initially treated with antibiotics
due to concern for perforation. These were eventually stopped as
discussions with the family led to changes in the patient's
goals of care and he was being prepared to go home with hospice
services. Palliative care become the primary goal for the
patient and he was ultimately transferred home with hospice
care.
.
2. Pain control: Per above, palliative measures became the
primary concern for this patient. The patient was transferred
from the ICU to the OMED service on a Dilaudid drip. The patient
was discharged home on a Dilaudid PCA.
.
3. Acute renal failure: Creatinine on admission was increased to
1.4 from a a baseline of 0.6 which improved with intravenous
hydration.
.
4. Normocytic Anemia: Hematocrit was 28.4 on admission which was
at the patient's recent baseline. No further evaluation was
sought and the patient received no transfusions.
.
5. Coagulopathy: INR 1.8 was elevated on admission which was
likely due to hepatic metastases as well as nutritional
deficiencies. No further evaluation or treatment was sought.
Medications on Admission:
1. Fluoxetine 20 mg po daily
2. Lorazepam 0.5-1 mg po q6h PRN anxiety
3. Zofran 4-8mg po q4h PRN nausea
4. Prochlorperazine 5-10mg po q6h PRN nausea
5. Trazodone 100 mg po qhs PRN insomnia
6. Docusate 100 mg po bid
7. Methylphenidate 2.5 mg po qAM
8. Senna 17mg po qhs
9. Omeprazole 20 mg po daily
10. Miralax 17 gram po PRN constipation
11. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO 8:00 AM, 4:00 PM, 9:00 PM.
12. Morphine 15 mg Tablet Sig: 1-3 Tablets PO Q3H as needed for
pain.
Discharge Medications:
1. Dilaudid 5 mg/mL Solution Sig: ASDIR ASDIR: Please give
continuous infusion at 0.5 to 5 mg/hr. Please bolus at 2 to 5 mg
every 30 minutes as needed for pain.
Disp:*200 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Primary Diagnosis:
Metastatic pancreatic cancer
Small bowel obstruction
Secondary Diagnosis:
Hypertension
Type 2 Diabetes [**Hospital **]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 1001**]:
.
You were admitted to the hospital with abdominal pain, nausea
and vomiting. It was found that your tumor has grown, and is
causing an obstruction in your stomach and small bowel. A
nasogastric tube was placed to decompress your stomach. Your
pain medications were increased as well.
While you were in the hospital, your care was focused on
treating your symptoms and making you comfortable. You were set
up with hospice at home in order to continue this care at home.
Followup Instructions:
You are being discharged with hospice at home. Please call the
hospice nurses if your symptoms worsen or new problems arise.
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
Completed by:[**2176-9-8**]
ICD9 Codes: 5849, 311, 2859, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5551
}
|
Medical Text: Admission Date: [**2199-9-13**] Discharge Date: [**2199-9-23**]
Date of Birth: [**2117-5-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Gastric cancer
Major Surgical or Invasive Procedure:
Total gastrectomy of the Roux-en-Y reconstruction and feeding
jejunostomy
History of Present Illness:
Pt is an 82yo M with gastric cancer who initially presented with
dysphagia, dyspepsia, weight loss (15 pounds over the last
several months) and early satiety accompanied by a general
decline in overall appetite. He denies any change in his bowel
habits including diarrhea or constipation. He had a workup on
[**2199-8-8**] with UGI AIR W/O KUB and tissue path on [**2199-8-21**] which
showed a well differentiated adenocarcinoma of the stomach
specimen.
Past Medical History:
HTN
Osteoarthritis of L knee and R shoulder - s/p TKR [**2196-2-9**]
Tonsillectomy
Appendectomy
Bilateral cataract excision.
Social History:
50-year smoking history but stopped over 25 years ago. He is
retired.
Family History:
Family history is notable for a son who died of lung cancer.
Physical Exam:
Vitals: T 97.1 P 83 BP 108/70 RR 18 SaO2 95% 3L NC
General: Well-developed, appears much younger than his stated
age
HEENT: NCAT, PERRL, EOMI, VFFTC, TMs clear, no oral lesions,
nares patent
Neck: Supple, no thyromegaly
Chest: CTAB
Heart: RRR, no M/R/G
Abdomen: +BS, soft NT/ND, no masses or organomegaly
Ext: no C/C/E, old scar from TKR
Neuro: AOx3, motor/sensation intact, unsteady gait
Pertinent Results:
[**2199-9-14**] 06:10AM BLOOD WBC-16.9*# RBC-3.66* Hgb-11.5* Hct-32.9*
MCV-90 MCH-31.4 MCHC-35.0 RDW-14.2 Plt Ct-239
[**2199-9-14**] 06:10AM BLOOD Plt Ct-239
[**2199-9-14**] 06:10AM BLOOD Glucose-137* UreaN-29* Creat-1.1 Na-135
K-4.7 Cl-100 HCO3-28 AnGap-12
[**2199-9-14**] 06:10AM BLOOD Calcium-8.6 Phos-4.8*# Mg-1.9
Pathology [**2199-9-13**]
Stomach, resection (A-AJ):
Poorly differentiated adenocarcinoma, see synoptic report.
Jejunal donut (AJ-[**Doctor Last Name **]):
Small bowel with no malignancy identified.
Esophageal donut (AK):
Esophagus with no malignancy identified.
[**2199-9-15**] CTA CHEST W&W/O C&RECONS, NON-CORONARY
1. No evidence of aortic dissection or pulmonary embolism. No
pneumonia.
Small-to-moderate bilateral simple pleural effusions and
adjacent compression
atelectasis within the lower lobes.
2. Post-surgical changes status post subtotal gastrectomy
including moderate
amount of pneumoperitoneum, extension of air superiorly
resulting in mild
pneumomediastinum, and small free fluid collections within the
visualized
upper abdomen.
3. Emphysema. New 3 mm nodule along the right minor fissure
likely
represents a benign intraparenchymal lymph node. Given
underlying emphysema,
would consider a one-year followup CT to document stability.
4. Mildly dilated main pulmonary artery likely related to
underlying
pulmonary arterial hypertension.
[**2199-9-15**] CT HEAD W/O CONTRAST
No evidence of infarction or hemorrhage.
[**2199-9-17**] BAS/UGI W/KUB
1. No evidence of anastomotic leak.
2. Aspiration with thin barium, this can be further evaluated
with dedicated video fluoroscopic swallowing study as clinically
indicated.
[**2199-9-18**] VIDEO OROPHARYNGEAL SWALLOW
Aspiration with thin liquids, with mild-to-moderate dysphagia.
Brief Hospital Course:
Pt is an 82yo M with gastric cancer who initially presented with
dysphagia, dyspepsia, weight loss (15 pounds over the last
several months) and early satiety accompanied by a general
decline in overall appetite. He had a workup on [**2199-8-8**] with
UGI AIR W/O KUB and tissue path on [**2199-8-21**] which showed a well
differentiated adenocarcinoma of the stomach. Pt had a total
gastrectomy of the Roux-en-Y reconstruction and a feeding
jejunostomy performed on [**2199-9-13**] without complication. On [**2199-9-14**]
the pt triggered on the floor for hypoxia (SaO2 low 80's) and
was transferred to the TSICU. Pt had post-procedure epidural in
place and both the primary team and pain service felt that it
should be left in place. CTA on [**9-15**] did not show any evidence
of pulmonary embolism, aortic dissection or pneumonia. On [**9-15**]
pt developed dysarthria and hoarseness. Neuro and ENT consults
did not reveal an acute cause; there were no laryngeal injuries
seen on laryngoscopy. CT head on [**9-16**] was negative for acute
processes. Tube feeds were initiated and tolerated, epidural
was discontinued on [**9-18**]. Pt attempted to tolerate nectar
thickened liquids but experienced severe epigastric pain. Pain
improved on viscous lidocaine but pt declined oral feeding in
favor of tube feeds. Pt was discharged on [**9-23**] with home
services for home PT and continued tube feeds.
Medications on Admission:
ATENOLOL - 25 mg Tablet - one Tablet(s) by mouth daily Start
with
one tab daily
RANITIDINE HCL [ZANTAC] - 150 mg Tablet - one Tablet(s) by mouth
Twice daily
Medications - OTC
ASPIRIN - 81 mg Tablet - one Tablet(s) by mouth daily
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
Disp:*180 Tablet(s)* Refills:*0*
3. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q4H (every 4
hours) as needed for 4 weeks.
Disp:*600 mL* Refills:*0*
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) as needed for epigastric discomfort.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane QID (4 times a day) for 4 weeks.
Disp:*2240 ML(s)* Refills:*0*
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) for 4 weeks.
Disp:*560 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Gastric adenocarcinoma
Post- operative hypoxemia
Discharge Condition:
Stable
Discharge Instructions:
You were treated for stomach cancer with surgery and had a tube
placed to help you feed. You will need to go home with your
tube to continue your feedings. You will also go home with
oxygen to help you breath better. You should continue to take
your home medications. In addition you will be given medication
to help with your pain. These medications will make you drowsy.
You should call your doctor or return to the ED for worsening
pain, fever, chills, chest pain, shortness of breath, nausea,
vomiting or any other concerning symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] to schedule a follow-up appointment
within a couple of weeks. You should also keep your appointment
with Dr. [**Last Name (STitle) **].
Completed by:[**2199-9-25**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5552
}
|
Medical Text: Admission Date: [**2180-12-26**] Discharge Date: [**2180-12-28**]
Date of Birth: [**2111-9-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
ST Elevation Myocardial Infarction
Major Surgical or Invasive Procedure:
Cardiac Catheterization and Percutaneous Intervention
History of Present Illness:
69 y/o Female with h/o who presents with 2-3 days of Jaw pain,
DOE found to have ST elevation in II, III and AVF.
.
She reports 3 days of chest pain. On sunday, she developed jaw
pain. Her pain was intermittent. No chest pain associated with
it but + nausea. It will last minutes. It would come at rest or
while exercising. On Monday, she had this discomfort again, took
ASA obtaining some relieve. On Monday night, she noted more
shortness of breath. Today, she went to see her PCP. [**Name10 (NameIs) **] the
office, and EKG was performed that showed ST elevation in the
inferior leads.she was referred to the emergency department.
.
In the ED, VS 194/81 Hr 77, RR 12 sats 97% on RA. Given EKG
findings, cath lab was activated. IN the cath lab, a cypher
stent was placed to RCA.
.
Currently, patient feels well, no chest pain or shortness of
breath.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
*** Cardiac review of systems is notable for absence of dyspnea
on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope.
Past Medical History:
Anxiety
Social History:
Lives with her husband. smoking (-), [**Name2 (NI) **] - [**12-20**] glass of wine
daily.
Family History:
Has 2 children - healthy
Physical Exam:
VS: T 98 , BP121/66 , HR 79 , RR 15 , O2 % 97%
Gen: non apparent distress, very pleasant.
HEENT: PEERLA, EOM preserved.
Neck: Supple, no JVP
CV: RRR: s1-s2 normal, no murmurs
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were
Lungs: clear to auscultation.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: no edema
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Groin: R - no hematoma, no bruit\
Pertinent Results:
1/8/8 17:13 --> NSR< HR 60, sinus rhythm, left axis deviation.
st elevation II, III and avf III>II, st depresions I, avl, and
v2.
[**2180-12-26**] 06:00PM WBC-10.1 RBC-4.49 HGB-13.7 HCT-40.6 MCV-91
MCH-30.4 MCHC-33.6 RDW-14.0
[**2180-12-26**] 06:00PM PLT COUNT-552*
[**2180-12-26**] 07:39PM WBC-9.5 RBC-4.24 HGB-12.9 HCT-37.3 MCV-88
MCH-30.4 MCHC-34.6 RDW-13.3
[**2180-12-26**] 07:39PM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-2.2
[**2180-12-26**] 07:39PM GLUCOSE-123* UREA N-18 CREAT-0.7 SODIUM-139
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
[**2180-12-27**] 04:11AM BLOOD CK(CPK)-67
[**2180-12-27**] 04:11AM BLOOD cTropnT-0.01
[**2180-12-27**] 04:11AM BLOOD Triglyc-89 HDL-41 CHOL/HD-3.8 LDLcalc-95
Cath [**2180-12-26**]:
COMMENTS:
1. Selective coronary angiograohy of this right dominant system
revealed two vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting stenoses. The LAD was
angiographically normal with a proximal 80% D1 lesion and
diffuse
calcification. The LCX was angiographically without critical
lesions.
The RCA was a dominant vessel with a 90% distal eccentric
lesion.
2. Limited resting hemodynamics revealed moderate to severe
systemic
arterial hypertension of 178/82 mm Hg.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate to severe systemic arterial hypertension.
TTE: [**2180-12-27**]
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+)
MR. Normal LV inflow pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with focal hypokinesis of
the basal inferior and inferolateral segments. 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 aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Mild regional LV dysfunction with inferior and
inferolateral hypokinesis. Mild mitral regurgitation. Boderline
pulmonary artery systolic hypertension.
Brief Hospital Course:
# STEMI: The patient was taken to the cath lab emergently where
she was found to have a 90% stenosis of the RCA and 80% stenosis
of D1. Given her inferior ST changes a cypher stent was placed
in the RCA. Heparin and integrillin were administered for
anticoagulation. She was continued on integrillin 18 hours post
cath as well as plavix. Her CK post cath was 65 consistent with
her late presentation to her PCP following her symptoms. Post
cath the patient had a brief drop in her BP and presyncopal
symptoms while her sheath was being pulled from her R groin,
consistent with her past history of vasovagal syncope. She had
no further episoded during her hospitalization. The patient
remained pain free throughout her hospitalization. She was
started on metoprolol 12.5mg [**Hospital1 **] and catopril 6.25mg TID, this
was transitioned to atenolol 25mg daily and lisinopril 5 mg
daily prior to discharge. She was also started on atorvastatin
80mg daily. She was continued on Plavix as directed and aspirin
325mg. Given her d1 stenosis which was not fixed, she should
undergo a submaximal stress test in [**5-27**] weeks to further
evaluate this lesion. Echo performed on [**12-27**] demonstrated an EF
of 50-55% with mild regional LV dysfunction with inferior and
inferolateral hypokinesis. She was scheduled to follow up with
Cardiology on [**1-19**].
Medications on Admission:
Lexapro 10mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. ST Elevation Myocardial Infarction
Discharge Condition:
Good
Discharge Instructions:
You were admitted with chest discomfort and were found to have a
blockage of one of your coronary arteries. You underwent a
cardiac catheterization and had a stent placed to open your
right coronary artery.
.
You are now taking Plavix to prevent a blot clot formation in
your cardiac stent. It is extremely important that you take this
medication every day. You should never stop taking your Plavix
unless instructed to stop by your Cardiologist. You should also
continue to take an aspirin daily.
.
You have also started the medication Atorvastatin to lower your
cholesterol level after your heart attack. Please continue to
take this medication as directed.
.
You have started the medications Metoprolol and lisinopril to
control your blood pressure. Please continue to take these
medications as directed.
.
Please maintain your scheduled follow up appointments listed
below.
.
You should return or call your PCP if you experience chest pain
or discomfort, shortness of breath or begin to feel unwell.
Followup Instructions:
Please maintain your scheduled follow up with Dr. [**Last Name (STitle) 410**] on
Monday [**2181-1-1**] at 10:30am.
.
You should follow up with your Cardiologist Dr. [**First Name (STitle) **] on [**2181-1-19**]
at 11am. Your appointment is in the [**Hospital Ward Name 23**] Building [**Location (un) 436**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2181-1-19**] 11:00.
.
You were found to have an additional blockage of one of your
coronary arteries during your catheterization. You should
discuss undergoing a submaximal stress test in [**5-27**] weeks for
further evaluation of this blockage.
.
Please maintain your scheduled follow up appointments listed
below:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 24672**], MD Phone:[**Telephone/Fax (1) 24673**]
Date/Time:[**2181-4-24**] 10:10
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2182-2-4**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2182-2-4**] 11:30
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5553
}
|
Medical Text: Admission Date: [**2102-9-23**] Discharge Date: [**2102-9-28**]
Date of Birth: [**2081-5-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Traumatic injury to abdomen
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy
2. Chest tube placement
History of Present Illness:
21 yo female who was the restrained passenger in MVC.
Transferred to [**Hospital1 18**] as a trauma patient.
Past Medical History:
None
Social History:
College student. Non-smoker. No EtOH. No drug use.
Family History:
Non-contributory
Physical Exam:
On discharge:
Gen: NAD, resting comfortably
HEENT: NC/AT, PERRL, IOMs intact
Chest: CTAB
CV: RRR, s1 s2, no murmurs
Abd: incision CDI, soft, mildly tender, non-distended
Ext: WWP, 2+ pulses, no edema
Pertinent Results:
[**2102-9-23**] 08:10PM HCT-57.2*
[**2102-9-23**] 06:25PM TYPE-ART PO2-154* PCO2-31* PH-7.41 TOTAL
CO2-20* BASE XS--3
[**2102-9-23**] 04:23PM GLUCOSE-92 UREA N-11 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-19* ANION GAP-13
[**2102-9-23**] 04:23PM ALT(SGPT)-139* AST(SGOT)-186* ALK PHOS-38*
AMYLASE-291* TOT BILI-3.4*
[**2102-9-23**] 04:23PM LIPASE-597*
[**2102-9-23**] 04:23PM CALCIUM-8.0* PHOSPHATE-2.3* MAGNESIUM-2.4
[**2102-9-23**] 04:23PM WBC-12.3* RBC-6.63* HGB-20.6* HCT-58.0*
MCV-88 MCH-31.0 MCHC-35.5* RDW-14.5
[**2102-9-23**] 04:23PM PLT COUNT-167
[**2102-9-23**] 04:23PM FIBRINOGE-242
[**2102-9-23**] 01:55PM LACTATE-2.6*
[**2102-9-23**] 05:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2102-9-23**] 05:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2102-9-23**] 08:10PM BLOOD Hct-57.2*
[**2102-9-24**] 12:37AM BLOOD Hct-53.9*
[**2102-9-24**] 03:47AM BLOOD WBC-13.5* RBC-6.09* Hgb-19.6* Hct-53.6*
MCV-88 MCH-32.2* MCHC-36.6* RDW-14.5 Plt Ct-138*
[**2102-9-24**] 08:04PM BLOOD Hct-50.5*
[**2102-9-25**] 05:43AM BLOOD WBC-14.0* RBC-5.64* Hgb-17.8* Hct-51.5*
MCV-91 MCH-31.5 MCHC-34.5 RDW-14.0 Plt Ct-149*
[**2102-9-25**] 01:07PM BLOOD Hct-52.9*
[**2102-9-27**] 08:50AM BLOOD WBC-9.1 RBC-4.94 Hgb-15.5 Hct-44.7 Plt
Ct-134
.
CXR ([**9-23**]): IMPRESSION:
1. Satisfactory position of the endotracheal and nasogastric
tubes.
2. Diffuse pulmonary contusions and possible right aspiration.
3. Increased density in the lower right neck raising concern for
underlying hematoma.
.
[**9-24**]: LUMBAR SPINE.
IMPRESSION: Eight views of the thoracic and lumbar spine are
submitted. The alignment and heights of the vertebral bodies and
intervertebral discs in the lumbar spine are normal. The pelvic
ring is intact. The posterior alignment of the lower thoracic
vertebral bodies are partially obscured by external material.
The frontal view is entirely normal. Pedicles are aligned and
the vertebral bodies and disc spaces are normal in height.
.
CT head ([**9-23**])
IMPRESSION:
1. No hemorrhage, mass effect, or edema.
2. Ethmoid and right maxillary sinus mucosal thickening.
.
CT c-spine ([**9-23**])
IMPRESSION:
1. No fracture or malalignment of cervical spine. Loss of normal
cervical
lordosis, presumably due to positioning.
2. No significant canal stenosis or neural foraminal narrowing.
.
CXR ([**9-26**]):
REASON FOR EXAMINATION: Discontinuation of right chest tube.
Portable AP chest radiograph compared to [**2102-9-26**].
The right chest tube was removed in the meantime interval. There
is no change in relatively small right basal atelectasis. The
left retrocardiac
atelectasis is unchanged as well accompanied by pleural
effusion. The upper lungs are unremarkable. There is no increase
in bilateral pleural effusions and there is also no
pneumothorax.
Brief Hospital Course:
Pt is a 21 yo female who was the restrained passenger in MVC vs
tree and suffered blunt abdominal trauma. Her and her boyfriend
were driving home from concert and her boyfriend fell asleep at
the wheel. Transferred to [**Hospital1 18**] as a trauma patient from [**Hospital 8641**]
hospital by helicopter, en route she developed respiratory
distress and was intubated. She arrived at [**Hospital1 18**] approximately
5 hours out from MVC.
.
According to referring hospital records, the patient was
conscious and complaining of abdominal pain at the scene of the
accident. She was transferred to [**Hospital 8641**] hospital where she was
noted to be hypotensive with a HCT of 38.4. Crystalloid and 5
units of PRBCs in addition to crystalloid replacement for
hypotension were administered and she was transferred to [**Hospital1 18**].
Upon arriveal to [**Hospital1 18**] she was Intubated, sedated, and had a
collar and back board.
Pertinent exam findings include blood in her left ear, pupils
were equal and reactive, trachea midline, lungs were coarse, her
abdomen was tense/distended, with seat belt sign. At CT Torso
was positive for fluid in abdomen, and Left sided liver
laceraction. She was taken to the operating room for an
exploratory laparotomy and repair of mesenteric injury.
Hematology-Oncology was consulted because her labs demonstreted
a Hct
of 57.4 and a mild coagulopathy following aggressive
transfusion. They stated the patient's coagulopathy is likely
secondary to dilution of her
coagulation factors following aggressive blood transfusion which
will correct over time. She was monitored with serial PT/PTT
q6-8 hrs while in hospital and her HCT did become stable.
On [**9-26**] she was extubated, her PCA was removed and she was
transferred from the ICU to the floor. She became tachycardic
and desaturated while on the floor requiring transfer back to
the ICU that same day. A cest Xray demonstrated a right sided
pleural effusion for which a chest tube was placed on [**9-26**].
After chest tube drainage of the effusion her breathing
improved. She was again transferred to the floor where she did
well. Prior to disharge she was hemodynamically stable and her
pain was controlled with PO pain meds.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) liver laceration
2) zone 2 RP bleed
Discharge Condition:
Good. Stable to home.
Discharge Instructions:
Please seek medical attention if you experience increasing
abdominal pain, nausea or vomiting. Please return to the
hospital if you experience fevers greater then 101.4, chills, or
other signs of infection. Also return to the hospital if you
experience chest pain, shortness of breath, redness, swelling,
or purulent discharge from the incision site. Return if you
experience worsening pain or any other concerning symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
Restart taking all your regular medications once you arrive at
home.
Please follow-up as directed.
Followup Instructions:
Please follow-up with the trauma surgery service. Please call
to make an appointment. [**Telephone/Fax (1) 6429**]
ICD9 Codes: 5119, 5070
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5554
}
|
Medical Text: Admission Date: [**2119-8-10**] Discharge Date: [**2119-8-19**]
Date of Birth: [**2064-5-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Exertional chest discomfort
Major Surgical or Invasive Procedure:
[**2119-8-15**] Two vessel coronary artery bypass grafting - left
internal mammary to left anterior descending and vein graft to
diagonal
History of Present Illness:
This is a 55 year old female with multiple cardiac risk factors
and known coronary disease. She has undergone multiple
percutaneous interventions to her left anterior descending
artery in [**2116**] and [**2117**].
She was in her USOH until the end of [**Month (only) 216**] when she began to
experience exertional chest discomfort. She admitted to
occasional rest symptoms. Her angina does respond to Nitro. She
denies claudication, orthopnea, edema, PND, syncope, presyncope
and palpitations. Given her history, she was admitted for
cardiac catheterization.
Past Medical History:
Coronary artery disease - s/p multiple LAD PCI/stenting,
Hypertension, Diabetes mellitus, Hyperlipidemia, GERD, Obesity,
Hepatosplenomegaly, History of pancreatitis due to elevated
triglycerides, s/p Hysterectomy, s/p Lumpectomy, s/p Hemorrhoid
surgery
Social History:
Married, lives in [**Location 5110**]. She has one daughter. She is an
office manager at Building 19. Prior light smoker, quit 5 years
ago.
Family History:
Aunt diagnosed with CAD in her 60's.
Physical Exam:
Vitals: BP 140/74, P 75
General: Well developed, obese female in NAD
HEENT: Unremarkable
Neck: Supple, no JVD
Lungs: Clear bilaterally
Heart: RRR, normal s1s2, no murmur or rub
Abdomen: soft, nontender, nondistended, normoactive bowel sounds
Ext: warm, no edema
Pulses: 2+ distally, no carotid or femoral bruits noted
Neuro: Nonfocal, MAE
Pertinent Results:
[**2119-8-17**] 03:24AM BLOOD WBC-7.0 RBC-2.95* Hgb-8.5* Hct-24.8*
MCV-84 MCH-28.7 MCHC-34.3 RDW-15.5 Plt Ct-212
[**2119-8-17**] 03:24AM BLOOD Glucose-152* UreaN-15 Creat-0.6 Na-139
K-3.6 Cl-102 HCO3-27 AnGap-14
[**2119-8-10**] 03:58PM BLOOD %HbA1c-7.7* [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
Mrs. [**Known lastname 1313**] was admitted and underwent cardiac catheterization.
Angiography was notable for 90% proximal and mid LAD in-stent
restenoses. The second diagonal also had a 80% lesion. The left
main, circumflex and right coronary arteries had no significant
disease. Based on the above findings, cardiac surgery was
consulted and further evaluation was performed as the patient
preferred to proceed with surgical revascularization. A carotid
ultrasound was normal. An echocardiogram revealed a LVEF of 70%
with only trivial mitral regurgitation. The ascending aorta was
mildly dilated, measuring 3.9 centimeters. The rest of her
evaluation was unremarkable and she was cleared for surgery.
On [**2119-8-15**], Dr. [**Last Name (STitle) **] performed two vessel coronary artery
bypass grafting. The operation was complicated by a mild
coagulopathy. A postoperative TEE showed normal LV function and
no mitral regurgitation. Following surgery, she was brought to
the CSRU. Her coagulopathy improved with multiple blood
products. No further intervention was required. Within 24 hours
she was extubated and awoke neurologically intact. She
maintained stable hemodynamics and remained in a normal sinus
rhythm. On POD#1, she transferred to the SDU. Beta blockade was
resumed and advanced as tolerated. She remained fluid overloaded
and required further diuresis. She responded well to Lasix and
by discharge, had room air oxygen saturations of *******. She
made steady progress and worked daily with PT. All tubes and
wires were removed without incident. Medical therapy was
optimized and she was discharged to home on POD#4.
Medications on Admission:
ASA 325 qd, Plavix 75 qd, Toprol XL 25 qd, Lopid 600 [**Hospital1 **],
Glucophage 1000 [**Hospital1 **], Imdur 30 qd, Pravachol 20 qd, Lisinopril 10
qd, Actos 45 qd, Glipizide 10 qd, Ativan prn, Omeprazole 20 qd
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. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO DAILY (Daily).
4. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 2 weeks.
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease - s/p CABG x 2, Hypertension, Diabetes
mellitus, Hyperlipidemia, GERD, Obesity, Hepatosplenomegaly,
History of pancreatitis
Discharge Condition:
Good
Discharge Instructions:
Patient may shower. No baths. No lotions or creams to incisions.
No lifting no more than 10 lbs for 10 weeks. No driving for one
month. Monitor wounds for signs of infection.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **](PCP) in [**1-12**] weeks
Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **](cardiologist) in [**1-12**] weeks
Completed by:[**2119-8-18**]
ICD9 Codes: 4111, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5555
}
|
Medical Text: Admission Date: [**2134-4-16**] Discharge Date: [**2134-4-17**]
Date of Birth: [**2055-1-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
CC:[**CC Contact Info 65907**]
Major Surgical or Invasive Procedure:
Femoral catheterization and successful recanalization, PTA,
cryoplasty and stenting of the left
SFA
History of Present Illness:
HPI: 71 yo F with h/o porcine AVR, CABG (LIMA->LAD), PVD
presenting for elective angioplasty of Left SFA lesion.
Previously, she was found by her cardiologist, to have a R ABI
of 0.59 and a left ABI of 0.5 after complaining of BL
claudication. She presented for elective angiography and PCI of
the left and was to return in 2 weeks for treatment of the R.
This AM, angiography revealed a Left distal SFA lesion with
diffuse disease to the proximal popliteal and proximal occlusion
of the AT and PT with reconstitution distally from collaterals.
She received angioplasty, cryoplasty and stenting of the left
SFA lesion from Right femoral artery access. Her sheath was
subsequently removed at 11 AM with minor oozing at the site of
the wound. An ACT at the time was found to be 220, an EKG
showed NSR with frequent PACs but no acute changes from prior to
procedure. Pressure was held for 30 minutes by the
interventional fellow with attainment of hemostasis. 30 minutes
later, the patient felt wet, and noticed bleeding at the site of
the wound. Pressure was again held at the site of the wound for
30 minutes. While holding pressure, she became persistently
hypotensive HR 40s, SBP 60s. 1 amp of atropine was given and
dopamine was given transiently. She became tachycardic to the
130s and developed [**11-23**] sharp pain below her breasts R>L
without radiation associated with nausea (no SOB, diaphoresis).
She denied having felt this pain before. She was given wide
open fluids x 2 L, a hct was checked and found to be 33 (from
her baseline of 40), and she was given a bolus of 1 unit of
blood. Her BP stabilized at 103/49 and her HR decreased to 104.
Her temp was 94, likely due to the IVF, and she was given warm
blankets. Her RUQ abdominal/chest pain gradually resolved and
she was subsequently transferred to the CCU. In the CCU, she
reported resolution of her CP. No back pain.
Past Medical History:
[**2123-3-4**] AVR porcine, LIMA-LAD
[**2107**] colon Ca remote
high cholesterol
right hernia
Social History:
Widowed 2 years ago, lives alone. Has no help at home. Her
son-in-law and daughter are close. Remote occasional smoking
history (40 years ago). No EtOH.
Family History:
no hx of CAD
Physical Exam:
PE:T 97.3 HR 79 RR 19 100% RA BP 108/52
Gen: WDWN woman lying flat in NAD
HEENT: PERRL, OP clear, MM dry
Neck: no carotid bruits
CV: RRR, nl s1, s2, 2/6 systolic murmur best heard at LUSB
without radiation to apex or carotids
Lungs: CTAB from chest
Abd: BS+, soft, NT, ND, no organomegaly
Ext: R femoral hematoma within marked space (~10x10 cm), 1+ R
femoral pulse, dressing C/D/I, no bruit, L femoral pulse 2+,
dopplerable DP and PT pulses bilaterally, DP>PT, no edema,
warmth or swelling
Pertinent Results:
[**10-18**] TTE
LVEF 60%, LA mild dilation, bioprosthetic aortic valve with
normal function and mean gradient of 15 mm Hg and peak of 27 mm
Hg with 1+ AR, severe mitral annular calcification with 2+ MR,
2+ TR , estimated PAP of 29 mm Hg. Doppler evidence of
diastolic dysfunction.
.
EKG pre-cath [**4-16**] 0731
SR with PACs at 72, left anterior fascicular block, LVH, TWI in
I and aVL, borderline LBBB with QRS 118
.
EKG 14:22
NSR at 76, LAFB, LVH, TWI in I and aVL, borderline LBBB with QRS
116
Femoral Cath Report [**2134-4-16**]
PROCEDURE:
Peripheral Catheter placement was performed.
Peripheral Imaging was performed.
Peripheral PTA was performed.
Peripheral Stenting was performed.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: m2
HEMOGLOBIN: gms %
FICK
**PRESSURES
AORTA {s/d/m} 144/60/90
**PTCA RESULTS
PTCA COMMENTS: Initial angiography showed a distally
occluded left
SFA. We planned to recanalize the vessel. Heparin was used for
anticoagulation. A 7 French [**Last Name (un) 12297**] sheath was advanced around the
[**Doctor Last Name 534**]
into the left SFA. The lesion was crossed with an angled
GlideWire which
was then exchanged for a FilterWire. The lesion was dilated with
a
4.0x80 mm Amphirion balloon at 2-4 atm. Next, the lesion was
treated
with Cryoplasty using a 5.0x60 mm Polar catheter for multiple
inflations. Angiography showed a residual dissection which was
covered
with a 6.0x56 mm Dynalink stent, post-dilated with a 5.0x40 mm
Submarine
balloon at 8 atm. Final angiography showed a 20% residual
stenosis, no
dissection and normal flow. The patient left the lab in stable
condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 31 minutes.
Arterial time = 1 hour 31 minutes.
Fluoro time = 20 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 175
ml, Indications - Hemodynamic
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 2500 units IV
Other medication:
Benadryl 25 mg iv
Fentanyl 25 mcg IV
Midazolam 0.5 mg IV
Cardiac Cath Supplies Used:
7F COOK, [**Last Name (un) 28712**], 55
200CC MALLINCRODT, OPTIRAY 200CC
150CC MALLINCRODT, OPTIRAY 150CC
4 EV3, AMPHIRION, 80
5 EV3, SUBMARINE PLUS, 40
6 GUIDANT, DYNALINK .018, 100
- [**Company **], FILTER WIRE EZ 300 CM
5 [**Company **], POLARCATH BALLOON .014, 20
- [**Company **], POLARCATH INFLATION UNIT
COMMENTS:
1. Access was obtained via the right CFA in a retrograde
fashion.
2. Resting hemodynamics showed mild central aortic
hypertension.
3. Abdominal aorta: Diffuse moderate disease.
4. Renal arteries: Single bilaterally without lesions.
5. Right lower extremity: The CIA, EIA, IIA and CFA were widely
patent.
6. Left lower extremity: The CIA, EIA, IIA and CFA were widely
patent.
The distal SFA had diffuse disease and was occluded at [**Doctor Last Name 26971**]
canal up
to the proximal popliteal. The PA was the principle vessel to
the foot
with the AT and PT proximally occluded and reconstitution
distally via
collaterals.
7. Successful recanalization, PTA, cryoplasty and stenting of
the left
SFA with a 6.0 mm Dynalink stent, post-dilated to 5.0 mm.
[**2134-4-16**] Femoral Vascular Ultrasound
REPORT: There is normal flow on color flow from the right common
femoral vein and artery. No evidence of hematoma, pseudoaneurysm
or AV fistula is identified.
Brief Hospital Course:
71 yo F with h/o porcine AVR, CABG (LIMA->LAD), PVD s/p PCI of
Left distal SFA lesion complicated by R groin bleed/hematoma
with hct drop of 7.
.
#. Hct drop with groin bleed - Patient with rapid hct drop of 7
from 40 to 33 in the setting of R groin bleed and development of
hematoma. Received 2 L of NS and 2 units of blood, and was
hemodynamically stable on transfer to the MICU. Her metoprolol
and digoxin were held. No evidence of RP bleed. A right
femoral ultrasound showed no evidence of hematoma,
pseudoaneurysm or AV fistula. Her hematocrit remained stable
and there was no evidence of repeat bleeding with serial exams.
She was restarted on her metoprolol XL 25 mg QD and tolerated it
well. Her digoxin was held as her heart rate was well
controlled and she had no evidence of heart failure.
.
#. Chest/RUQ and epigastric Abdominal pain (burning) with
nausea- this was in the setting of the dopamine drip and hct
drop and may have been demand ischemia, though her cardiac
enzymes were flat x 3 and there were no EKG changes. She was
given protonix, maalox, anzemet and tums, and the pain resolved.
- start on omeprazole 40 QD
.
#. PVD - Following her intervention, her distal pulses remained
dopplerable bilaterally. She is scheduled to return in [**3-20**]
weeks for angiography and possible intervention in her RLE.
- continue ASA and plavix indefinitely
.
#. Ischemia - patient s/p CABG (LIMA-> LAD 10 years ago). No
recent cath. No EKG changes with her chest/abdominal pain. Her
cardiac enzymes were cycled and were flat x 3.
- continue ASA and plavix indefinitely
- restart metoprolol XL 25 mg QD
.
#. Pump - last TTE in [**10-18**] showed LVEF 60%, 1+ AR with porcine
valve, 2+ MR and 2+ TR, and evidence of diastolic dysfunction.
- continue metoprolol 25 mg PO QD
- hold digoxin with no evidence of failure and well-controlled
heart rate
.
#. Rhythm - SR, occasional PACs on telemetry
Medications on Admission:
Admission meds:
metoprolol XL 25 mg QD
digoxin 125 mcg QD
ECASA 325 mg QD
MVI
Lipitor 10 mg QD
Plavix 75 mg QD
.
Transfer meds:
Toprol XL 25 QD
Dig 125 mcg QD
ECASA 325 mg QD
Plavix 75 mg QD
MVI
Lipitor 10 mg QD
Tylenol PRN
NTG SL PRN
Simethicone PRN
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
5. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral vascular disease s/p revascularization and stenting
of Left SFA/popliteal lesion
Right femoral bleed
Discharge Condition:
Patient is doing well, hemodynamically stable, no chest pain,
ambulating without difficulty
Discharge Instructions:
1. Please take all medications as prescribed. You MUST take
your Aspirin and Plavix EVERY DAY.
2. Please keep all follow-up appointments.
3. Please seek medical attention if you develop chest pain,
shortness of breath, abdominal pain, recurrent or worsened
claudication of the left foot, a larger hematoma, bleeding,
lightheadedness or have any other concerning symptoms.
4. Please refrain from heavy lifting or vigorous activity for 2
weeks.
5. Please refrain from driving until at least 3 days after
discharge from the hospital (after Wednesday, [**4-21**]).
Followup Instructions:
Return in [**3-20**] weeks for angiography and intervention on the
right leg.
Please follow-up with Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 16005**] in [**2-15**]
weeks.
Please follow-up with Dr. [**Last Name (STitle) 911**] at ([**Telephone/Fax (1) 7236**] in [**7-22**] weeks.
Completed by:[**2134-4-18**]
ICD9 Codes: 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5556
}
|
Medical Text: Admission Date: [**2198-5-22**] Discharge Date: [**2198-5-27**]
Date of Birth: [**2149-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2198-5-22**] - CABGx4 (Left internal mammary ->Left anterior
descending artery, Vein->Diagonal artery, Vein->obtuse marginal,
Vein->Posterior descending artery)
History of Present Illness:
48 year old gentleman with known coronar artery disease who
recently presented with exertional angina. A stress MIBI was
performed which showed a moderate perfusion deficit in the mid
lateral wall. A cardiac catheterization was performed which
showed severe three vessel disease. Given the severity of his
disease, he was referred for surgical revascularization.
Past Medical History:
CAD s/p BMS x 2 '[**83**]
HTN
DM
Hypercholesterolemia
OSA - uses cpap
Social History:
Patient works as a printing press repair man. He quit smoking
15 years ago, but recently started again 8 months ago, smoking
[**6-12**] cigarettes per day. He is married, and lives in [**Location **].
Social drinker and no IVDU
Family History:
Father with CABG at 59
Sister with multiple stents at 58
Physical Exam:
66 148/87 72" 230lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM.
LUNGS: CTA bilaterally
HEART: RRR, No M/R/G
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, no varicosities,no
peripheral edema
NEURO: No focal deficits.
Pertinent Results:
[**2198-5-22**] ECHO
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 6. Trivial
mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient is being A
paced intermittently and is in sinus rhythm when not paced.
1. Bi ventricular function is preserved.
2. Aorta is intact post decannulation
3. Other findings are unchanged
[**2198-5-23**] CXR
In comparison with the study of [**5-22**], the patient has taken a
much poorer inspiration. The endotracheal and nasogastric tubes
have been removed. Swan-Ganz catheter has been pulled back and
only a right IJ sheath remains. Specifically, no evidence of
pneumothorax. Blunting of the costophrenic angle on the left
persists. Probable bibasilar atelectatic changes.
Brief Hospital Course:
Mr. [**Known lastname 6877**] was admitted to the [**Hospital1 18**] on [**2198-5-22**] for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to four vessels. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. By
postoperative day one, Mr. [**Known lastname 6877**] had awoke neurologically intact
and was extubated. Beta blockade, aspirin and a statin were
resumed. He was later transferred to the step down unit for
further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for asistance with his postoperative strength and mobility. Mr.
[**Known lastname 6877**] continued to make steady progress and was discharged home
on postoperative day four. He will follow-up with Dr. [**Last Name (STitle) **],
his cardiologist and his primary care physician as an
outpatient.
To note pt potassium was 6.1 / kayexalate given time one / on DC
k is stable. Pt will not be given potassium supplements on dc.
Medications on Admission:
Lopressor 25mg [**Hospital1 **]
Metformin 500mg [**Hospital1 **]
Aspirin 325mg QD
Lipitor 80mg QD
Lisinopril 20mg QD
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABG
PTCA/Stenting [**3-/2184**] and [**5-/2184**]
HTN
Diabetes
Hyperlipidemia
hyperkalemia
Obstructive sleep apnea
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) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) **] in [**1-3**] weeks. [**0-0-**]
Please call all providers for appointments.
Completed by:[**2198-5-27**]
ICD9 Codes: 486, 5180, 2767, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5557
}
|
Medical Text: Admission Date: [**2189-8-3**] Discharge Date: [**2189-8-17**]
Date of Birth: [**2106-12-24**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP [**2189-8-3**]
Laparoscopic cholecystectomy [**2189-8-9**]
History of Present Illness:
82M transfer with reported cholecystitis. He is not the
best historian. He notes abdominal pain that started 3 days
ago.
He denies fevers/chills, nausea/vomiting. He has not eaten in a
day or so. He reports [**Location (un) 2452**] colored urine over the past few
days, but no [**Male First Name (un) 1658**] colored stools. He denies any recent weight
loss. He is unable to tell me his last colonoscopy.
Past Medical History:
PMH:
HTN
glaucoma
HTN
gout
hypothyroidism
Social History:
Lives with his son.
Longstanding tobacco use: quit [**2183**]
No ETOH or IVDA
Family History:
non contributory
Physical Exam:
PE
Tc 98.6, HR 76, BP 178/85, RR 16, O2sat 99%
Genl: NAD, scleral icterus
CV: RRR
Resp: expiratory wheezing
Abd: s/nt/nd; no visible scars
Extr: no c/c/e
DRE: nl rectal tone; guaiac negative
Pertinent Results:
[**2189-8-3**] 05:30AM WBC-21.4* RBC-4.70 HGB-15.0 HCT-44.4 MCV-95
MCH-32.0 MCHC-33.9 RDW-13.3
[**2189-8-3**] 05:30AM PLT COUNT-284
[**2189-8-3**] 05:30AM PT-11.5 PTT-25.9 INR(PT)-1.0
[**2189-8-3**] 05:30AM GLUCOSE-109* UREA N-42* CREAT-2.1* SODIUM-140
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-19
[**2189-8-3**] 05:30AM ALT(SGPT)-300* AST(SGOT)-95* LD(LDH)-285* ALK
PHOS-286* TOT BILI-9.4* DIR BILI-7.4* INDIR BIL-2.0
[**2189-8-14**] 07:07AM BLOOD WBC-15.3* RBC-3.35* Hgb-9.9* Hct-31.6*
MCV-94 MCH-29.6 MCHC-31.4 RDW-14.5 Plt Ct-501*
[**2189-8-14**] 07:07AM BLOOD Plt Ct-501*
[**2189-8-11**] 02:14AM BLOOD Fibrino-488*
[**2189-8-14**] 07:07AM BLOOD Glucose-88 UreaN-30* Creat-2.2* Na-142
K-3.7 Cl-106 HCO3-25 AnGap-15
[**2189-8-14**] 07:07AM BLOOD Glucose-88 UreaN-30* Creat-2.2* Na-142
K-3.7 Cl-106 HCO3-25 AnGap-15
[**2189-8-14**] 07:07AM BLOOD LD(LDH)-268*
[**2189-8-12**] 09:41PM BLOOD Lipase-68*
[**2189-8-13**] 02:24AM BLOOD CK-MB-5 cTropnT-0.04*
[**2189-8-14**] 07:07AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2
[**2189-8-11**] 02:14AM BLOOD TSH-37*
[**2189-8-13**] 03:00AM BLOOD Comment-GREEN TOP
[**2189-8-13**] 03:00AM BLOOD Lactate-1.8
Echo: [**2189-8-13**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a mild resting left ventricular
outflow tract obstruction. 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 aortic
regurgitation is seen. 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. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2189-8-4**],
the LV walls are better seen. The inferolateral wall thickness
is normal. There is discrete upper septal hypertrophy - coupled
with the hyperdynamic LV systolic function, there is functional
LVOT obstruction with a small gradient. Hypertrophic
cardiomyopathy cannot be excluded. The degree of mitral
regurgitation has increased slightly. The estimated pulmonary
artery systolic pressures have increased.
CXR: [**2189-8-13**]
COMPARISON: [**2189-8-12**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Unchanged retrocardiac atelectasis, unchanged right
suprabasal
atelectasis. Unchanged mild enlargement of the right hilar
structures,
presumably due to vascular crowding. No newly appeared focal
parenchymal
opacity, no evidence of overhydration, no pneumothorax.
RUQ US [**2189-8-3**] : IMPRESSION:
1. The sum of son[**Name (NI) 493**] and CT findings are concerning for
acute
cholecystitis. No biliary dilatation.
2. Pancreas not visualized
[**2189-8-3**] Abd CT :IMPRESSIONS:
1. Together with same-day son[**Name (NI) 493**] findings, CT findings are
concerning for acute cholecystitis.
2. Pancreatic cyst and vague hypodense area are likely
incidental findings.
These are incompletely evaluated and may be further assessed
with IV contrast
after resolution of acute symptoms.
2. Small hiatal hernia. Bilateral fat-containing inguinal
hernias.
3. Atherosclerotic disease with coronary artery disease.
[**2189-8-3**] ERCP : Impression: Stone and sludge in biliary tree on
cholangiography.
Successful biliary sphincterotomy performed.
One stone and sludge with a small amount of pus was retrieved
from the biliary tree using a 12mm balloon
(sphincterotomy, stone extraction)
Otherwise normal ercp to third part of the duodenum
[**2189-8-4**] Cardiac echo: Conclusions
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is a mild resting left ventricular outflow
tract obstruction. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
The left ventricular inflow pattern suggests impaired
relaxation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**8-5**] /09 Abdominal CT: IMPRESSION:
1. Mild pancreatitis with likely beginning pseudocyst formation
posterior to
the body of the pancreas
2. Cystic lesions in the head of the pancreas are likely
incidental and may represent IPMN. Follow- up in 6 months is
recommended to ensure stability.
this could be performed with MRI.
3. Acute cholecystitis with hyperemia of the adjacent liver
parenchyma
Brief Hospital Course:
1. Gallstone pancreatitis and Choledocholithiasis: Patient
initially transferred from OSH with symptoms of biliary
obstruction (elevated LFTs and total bilirubin of 9.4) and
pancreatitis. Patient was placed on Unasyn, made NPO and
hydrated with IVF. Patient underwent ERCP with spincterectomy
and extraction of multiple stones on [**8-3**]. Abdominal pain
improved and patient placed on clear diet which he tolerated
well. WBC count decreased from 21.4 on admission to 12.9
following ERCP. On [**8-9**], patient was taken back to the
operating room for laproscopic cholecystectomy. Surgery was
reportedly technically difficult and significant venous oozing
of the liver bed was observed. He was transferred back to the
general surgery floor [**8-11**]. Postoperative course with numberous
complications including acute on chronic renal failure, acute
anemia, acute respiratory distress and rising WBC count (all
outlined below). By time of discharge, biliary obstruction had
subjectively and objectively improved. LFTs had trended down,
total bilirubin was 1.4 and patient was tolerating oral intake.
His port sites were dry and healing well.
Of note, on his initial abdominal CT a pancreatic cyst/mass was
noted at the junction of the head and the body thus prompting a
repeat abdominal CT with pancreatic protocol. His repeat CT
scan noted that the cyst was an incidenental finding and should
be followed in 6 months with a repeat scan or MRI.
2. Labile HTN: Throughout hospital course, patient had labile
HTN with systolic BP rising to as high as 180s- 200s, prompting
multiple changes in BP management. Initially, patient was
continued on his home verapamil SR 240mg daily although his ACEI
was held secondary to creatinine of 2.1 (see below). Labetolol
was added temporarily prior to lap cholecystectomy.
Postoperatively, patient was on verapamil only and had markedly
elevated blood pressure to 170-180s on [**8-12**]. At this point,
patient developed acute respiratory distress most likely
secondary to flash pulmonary edema and was transferred to
medical ICU. Blood pressure was initially controlled with
hydralazine. Lisinopril was started at home dose on [**8-13**] of
MICU stay. Labetolol was also added to blood pressure regimen,
and pressures became more well controlled and stable, with SBP
ranging mostly in 120's - 130's.
3. Acute Respiratory Distress: On [**8-12**], patient was transferred
from general surgery floor to MICU for worsening respiratory
distress. Patient was tachypnic to 40s with prominent wheeze
and a new O2 requirement of 6L NC. ABG on transfer was
7.44/23/102, with a HCO3 of 16. Initially, patient was started
on vancomycin and zosyn secondary to concern of VAP. CXR
showed increased interstitial pattern consistent with early
pulmonary edema. While patient has an extensive smoking
history, he has no known history of COPD and labs were not
consistent with chronic CO2 retention. PE was considered to be
unlikely given quick resolution of symptoms with treatment, and
prior negative LENIs. Cardiac enzymes were cycled, with
troponins .02, .04 and negative CK-MB. Nebulizer treatments
were continued for symptomatic relief. Dyspnea was thought to
be secondary to flash pulmonary edema in the setting of poorly
controlled HTN and all antibiotics were stopped. Overall
respiratory status improved, with fluid balance of -2.5 liters
during 2 days of MICU stay. Patient was weaned off oxygen
requirement. On [**8-15**], the patient did have an episode of
dyspnea on the floor. O2 sats were 94% on RA, and he responded
to albuterol nebs. His CXR also showed increased fluid, and he
was given IV lasix. By time of discharge he was saturating 97%
on room air.
4. Leukocytosis: Upon transfer to [**Hospital1 18**], patient had WBC of 24.5
with a neutrophil predominance of 92% secondary to cholecystitis
and gallstone pancreatitis. Following initial ERCP, WBC fell
to 12.9. After laproscopic cholecystectomy on [**8-9**], WBC count
again rose to the 20s although patient remained afebrile and
without focal symptoms of infection. Abdominal exam was
unremarkable, giving low suspicion for a surgical deep space
infection. Leukocytosis was felt to be an acute response to
recent stress. When patient transferred to MICU on [**8-12**] for
respiratory distress, there was initial concern for PNA given
prolonged hospital course and recent intubation. Antibiotics
were started empirically on [**8-12**], but discontinued on [**8-13**] due
to rapid resolution of symptoms. Urine culture from [**8-11**] was
negative. The positive urine culture on [**8-14**] was attributed to
bladder trauma from the previous evening (see
dementia/agitation). He remained afebrile with WBC 9.6 at
discharge.
5. AMS: Throughout hospital stay, patient exhibited waxing and
[**Doctor Last Name 688**] mental status, with predominant sun downing features.
Patient became agitated multiple nights, pulling at IV and foley
(causing foley trauma with [**Known firstname **] hematuria), requiring halidol
for behavioral control. At baseline, patient exhibited marked
cognitive impairment as indicated by mini-mental exam and his
AMS may have represented features of his dementia. Other
sources of delerium including toxic- metabolic syndrome (med
effects, electrolyte imbalance, myxedema, etc), recent surgery,
ICU psychosis. Infection as etiology was also considered esp in
setting of leukocytosis and patient had multiple blood cultures,
urine cultures, CXR, etc. At time of discharge the pt was alert
and oriented x 2 and was at baseline per son.
6. Diastolic CHF: Patient with history of diastolic CHF that
contributed to complications of postoperative course, chiefly
acute respiratory distress from pulmonary edema. Cardiac
enzymes were cycled several times during postoperative course,
and always remained negative, indicating no acute coronary
syndrome. Echo was performed on [**8-13**], showing function LVOT
with a small gradient, slightly increased mitral regurgitation,
and increased pulmonary artery systolic pressures.
7. chronic kidney disease: Creatinine has been stably elevated
during admission, with baseline ~2.0, and consistent proteinuria
on urinalysis. Creatinine did increase to 2.4 on [**8-7**] likely
from CT scan with acute dye load, but returned quickly to
baseline with hydration. Chemistries were checked daily to
monitor renal function, and he maintained good urine output.
Lisinopril was initially held on hospitalization, but restarted
on [**8-13**] without incident. After his foley catheter was removed,
the patient did have some elevated post-void residuals.
However, with encouragement, he was able to further empty his
bladder. By the time of discharge, his post-void residuals was
58 ml.
8. Hypothyroidism: While on the floor, the patient was showing
some psychomotor slowing. His TSH was found to be 37 (50 on
recheck). His free T4 was also decreased at 0.31. His
levothyroxine was increased to 112 mcg (his reported home dose)
mg daily. He should have his thryroid rechecked in 4 weeks and
adjust meds as needed at that time.
9. Glaucoma: Home eye drop treatments were continued.
10. History of gout: Allopurinol was held given recent acute
rise in creatinine above baseline elevation. Will plan to
restart if creatinine remains stable, or resume as outpatient.
Prior to his follow up visit with Dr. [**Last Name (STitle) **] he will have an
abdominal CT to evaluate the pancreas.
Medications on Admission:
Allopurinol 100mg daily
.Cosopt [**Hospital1 **]
.HCTZ 25mg daily
.Lisinopril 40mg daily
.Verapamil SR 240mg daily
.Xalatan 0.005%
.Synthroid 12.5mcg daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
gallstone pancreatitis
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-26**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1231**])
Call Dr. [**First Name (STitle) **] for a follow up appointment in 2 weeks
ICD9 Codes: 5849, 5859, 4280, 2749, 2449
|
{
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|
Medical Text: Admission Date: [**2173-8-20**] Discharge Date: [**2173-8-26**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 86-year-old female
with a history of congestive heart failure, type 2 diabetes,
complicated by end stage renal disease and hypertension who
presented with acute onset of dyspnea. Patient reported
being in her usual state of health until the morning of
admission, when she awoke with severe dyspnea and
diaphoresis. She informed her niece who telephoned EMS. Per
EMS reports, the patient was found in profound respiratory
distress, diaphoretic with pale and cool skin. EMS also
noted jugular venous distention to her jaw, wheezing and
bibasilar rales half way up her lungs. Pulse of 95. Blood
pressure of 220/100. Respiratory rate of 36 and oxygen
saturation of 90%. Later, 100% on nonrebreather mask. She
was placed on a high flow of oxygen and given 0.04 mg of
sublingual nitroglycerin, ten times over the course of her
stay and with EMS and 100 mg of Lasix. Her blood pressure
improved to 164/doppler.
REVIEW OF SYSTEMS: The patient reported worsening lower
extremity edema and orthopnea over the past two
months,resulting in the need for two pillows and sleep at
times in a chair. Patient denied any cardiac symptoms
including angina, palpitations, lightheadedness, any cold
symptoms including fever, headaches, shakes, chills and
urinary symptoms including frequency, dysuria discharge and
any gastrointestinal symptoms including nausea, emesis.
PAST MEDICAL AND SURGICAL HISTORY:
1. Congestive heart failure. Diagnosed of congestive heart
failure with echocardiogram in [**2172-8-3**] showing an
ejection fraction of greater than 60%.
2. Type 2 diabetes, complicated by retinopathy, nephropathy,
and peripheral neuropathy.
3. Diverticulosis with multiple episodes of lower
gastrointestinal bleeding.
4. Hypertension.
5. Polymyalgia rheumatica.
6. Urinary frequency with hematuria and proteinuria.
7. Status post total abdominal hysterectomy in [**2134**] for
fibroids.
MEDICATIONS ON ADMISSION:
1. Allopurinol 100 mg q.d.
2. Norvasc 10 mg q.d.
3. Atenolol 100 mg q.d.
4. Lasix 60 mg b.i.d.
5. Insulin NPH 10 units subcutaneous q.a.m.
6. Tylenol 1-2 tablets q. 6 hours prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives with her niece. She is widowed
with five children. Uses a walker for ambulation. She
smokes 20-30 pack years and quit four years ago. No alcohol
use. She has a history of blood transfusions, the first one
being in [**2134**] during her total abdominal hysterectomy. Her
mother had coronary artery disease and diabetes.
EMERGENCY DEPARTMENT COURSE: At the Emergency Department,
her vitals were: Blood pressure of 180/doppler. Heart rate
of 90. Respiratory rate of 40 and oxygen saturation of 90%
on nonrebreather mask. The patient was oriented times three,
bilateral diffuse crackles were found on lung exam,
nitroglycerin was titrated to 100 mcg/hour. She was also
given Lasix 100 mg intravenously, morphine 2 mg intravenous
and aspirin 60 mg. She was placed on BiPAP. The patient
eventually demonstrated subjective improvement in breathing
with respiratory rate coming down to the 20s. There was no
urine output to an additional 100 mg of Lasix intravenously.
Her arterial blood gases were 7.26, 37 and 351. Natrecor was
started with a 2 mg/kg bolus followed by a drip at 0.01
mcg/kg/minute. She was given Diuril 50 mg intravenous for
urine output of only 200 cc.
MEDICAL INTENSIVE CARE UNIT COURSE: Due to the patient's
continued poor respiratory status, she was admitted to the
Medical Intensive Care Unit with a temperature of 96.6.
Heart rate of 74. Blood pressure of 132/58. Respiratory
rate of 19 and saturation of 92% on BiPAP. Her exam was
notable for jugular venous distention up to the jaw, [**4-8**]
holosystolic ejection murmur, heard diffusely over her
precordium, bibasilar crackles half way up her lungs with
anterior wheezing and 3+ pitting edema in her lower
extremities.
LABORATORIES: Her laboratories are notable only for a BUN of
68 and a creatinine of 6.8, phosphate of 6.7 and a PTH of
1448. Chest x-ray revealed alveolar edema. Abdominal CT,
which was taken for concern of retroperitoneal bleed causing
a low hematocrit was unconcerning. The electrocardiogram
revealed no changes from the previous electrocardiogram and
the patient ruled out for myocardial infarction by cardiac
enzymes.
The patient underwent Dialysis twice over the weekend via the
left femoral for her volume overload. Her edema and
respiratory distress resolved allowing the discontinuation of
BiPAP and she was transferred from the Medical Intensive Care
Unit in stable condition on the following po medications:
Aspirin 81 mg q.d., hydralazine 30 mg q. 6 hours, isosorbide
dinitrate 10 mg t.i.d., Toprol 100 mg q.d., and Sevelamer 800
mg t.i.d. She was also placed on an insulin sliding scale,
pneumonic boots and subcutaneous heparin.
COURSE ON THE WARDS: In summary, we accepted an 86-year-old
female with a history of congestive heart failure, type 2
diabetes, complicated by end stage renal disease and
hypertension who presented with acute or subacute dyspnea due
to pulmonary edema secondary to either acute ischemic event
or subacute worsening of renal failure. The patient's vitals
on acceptance were a temperature of 98, a heart rate of 88,
blood pressure of 160/99, respiratory rate of 24 and an
oxygen saturation of 96% on room air. Her exam was notable
only for her 3/6 systolic murmur and scattered
bibasilar crackles on lung exam. On Monday, the patient
refused a pharmacological stress test. She was, however,
followed by the Heart Failure Team and educated regarding
diet modification compliance and the signs and symptoms of
congestive heart failure. The patient underwent Dialysis on
Tuesday, the 22nd, and Thursday, without complications. On
Wednesday, a Permacath was placed in her right internal
jugular while an AV fistula was done in her left arm, both by
Transplant Surgery. Lisinopril was instituted in place of
hydralazine with good effect.
At the time of discharge, the patient's blood pressure was
138/60. Heart Failure Team has given instructions not to
lower her systolic blood pressure below the 130s for now to
give her system time to adapt. Of note, is an eye infection
that developed on Tuesday, for which the patient was given
tobramycin drops. The patient was discharged to
rehabilitation in good condition with instructions to
continue hemodialysis regimen. A follow-up appointment has
been arranged with Dr. [**Last Name (STitle) 2067**] of the Heart Failure Clinic.
DISCHARGE MEDICATIONS:
1. Toprol 100 mg po q.d.
2. Lisinopril 10 mg po q.d.
3. Isosorbide mononitrate 30 mg po q.d.
4. Aspirin 81 mg po q.d.
5. Insulin NPH 10 units subcutaneous q.a.m.
6. Calcium acetate 1334 mg t.i.d. with meals.
7. Acetaminophen 650 mg po q. 4-6 hours prn pain.
8. Protonix 40 mg po q.d.
9. Tobramycin 0.3% ophthalmic solution 1 drop q.i.d.
[**Last Name (un) **] DIAGNOSES:
1. Congestive heart failure/respiratory failure
2. Renal failure
3. Conjunctivis
4. Hypertension
5. Diabetes mellitus
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2173-9-6**] 03:54
T: [**2173-9-7**] 11:12
JOB#: [**Job Number 99428**]
ICD9 Codes: 4280, 2761, 2749, 3572
|
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"id": 5559
}
|
Medical Text: Admission Date: [**2111-3-19**] Discharge Date: [**2111-3-26**]
Date of Birth: [**2042-8-19**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Cholangitis, biliary obstruction
Major Surgical or Invasive Procedure:
[**2111-3-20**]: placement of Left external biliary drain
[**2111-3-24**]: placement of right internal/external biliary drain and
internalization of left biliary drain
History of Present Illness:
Ms.[**Known lastname 31624**] is a 68 year old female transferred from OSH w
persistent cholangitis/biliary obstruction s/p [**Known lastname **] stent x 3
for malignant biliary stricture at level of common hepatic duct
extending to hilum. She was in usual
state of health prior to [**2111-2-3**] when she noted gradual onset
nausea, abdominal discomfort and unintentional 10 pound weight
loss. This progressed to jaundice prompting admission to OSH
[**2111-2-12**] and diagnosis of stricture on RUQ US. On [**2-13**] she
[**Month/Year (2) 1834**] [**Month/Year (2) **] at OSH with sphincterotomy. She was transferred
to [**Hospital1 18**] on [**2111-2-17**] for repeat [**Date Range **] by Dr. [**Last Name (STitle) **] who replaced
stent for finding of 15mm common hepatic duct stent and obtained
brushings which ultimately revealed atypical cells. She was
discharged from the OSH on [**2111-2-19**] but returned to OSH ED
withchills, rigors and fever to 103.9 on [**3-15**]. CT scan was
obtained findings below) and transferred to [**Hospital1 18**] for repeat
[**Hospital1 **] [**2111-3-17**] which
found purulence at CBD orifice. At that time, the stent was
replaced for finding of worsening CHD stricture. Wire was
placed into the RH system after the stent placement. A second
wire placed into the left hepatic system, wire was unable to
reach the dominant branch. Following return to OSH, Ms. [**Known lastname 31624**]
was still febrile to 103.6 [**Hospital 92285**] transferred to the [**Hospital1 18**]
hepatobiliary service for management of her refractory
stricture.
Past Medical History:
Essential thrombocytosis, Hx L breast CA s/p lumpectomy,
axillary lymoh node dissection, chemoXRT ([**2095**]), R breast DCIS
s/p lumpectomy/XRT ([**2107**]), Fibromyalgia, DJD, HLD, depression,
anxiety, mitral valve prolapse
Social History:
Lives with husband. [**Name (NI) 1403**] as ophthalmology technician. Denies
tobacco, EtOH, and recreational drugs
Family History:
Mother: Breast CA (age 41); Father: Gastric CA (age 81);Four
sisters w breast CA, Siblings w/ melanoma
Physical Exam:
VS: T: 99.6 P: 85 BP: 132/99 RR: 20 O2sat: 95RA
GEN: NAD, AOX3, WN F in NAD
HEENT: EOMI
CV: RRR
PULM: CTA B/L, no respiratory distress
ABD: soft, mild RUQ tenderness to moderate palpation, ND, no
mass, no hernia, Right and left PTBD in place, capped.
Surrounding skin without erythema, dressings c/d/i
EXT: WWP, no CCE
NEURO: A&Ox3, no focal neurologic deficits
Pertinent Results:
[**2111-3-20**] Common bile duct brushings: NEGATIVE FOR MALIGNANT CELLS
[**2111-3-18**] Common bile duct stent: NEGATIVE FOR MALIGNANT CELLSS,
Rare groups of reactive and degenerated epithelial cells,
Numerous neutrophils, Bile pigment and bacteria.
[**2111-2-17**] Common bile duct, brushing: ATYPICAL, Rare group of
atypical epithelial cells in a background of benign appearing
ductal epithelial cells.
[**2111-3-25**] CXR:
IMPRESSION: PA and lateral chest compared to [**3-15**] through
19:
Small bilateral pleural effusions and severe bibasilar
atelectasis are
unchanged since [**3-22**]. Upper lungs are clear. Heart size
normal. No
pneumothorax.
[**2111-3-24**]:
IMPRESSION:
1. Successful uncomplicated internalization of the external
drain left in the left biliary system. An 8 French
internal-external percutaneous transhepatic biliary drain was
placed.
2. Successful uncomplicated placement of a new 8 French
percutaneous
transhepatic biliary drain through the right anterior system
with the pigtail locked in the duodenum.
[**2111-3-22**] CXR:
FINDINGS: In comparison with the study of [**3-21**], the endotracheal
and
nasogastric tubes have been removed. The patient has taken a
much better
inspiration. There is continued bibasilar opacification, most
likely
consistent with pleural fluid and compressive atelectasis, more
prominent on the right. The possibility of supervening pneumonia
would certainly have to be considered in the appropriate
clinical setting. No evidence of pulmonary edema.
[**2111-3-20**] biliary endoscopy:
IMPRESSION:
1. High-grade obstruction at the level of the hepatic
confluence.
2. Left moderate to severe biliary dilatation.
3. No right biliary dilatation (plastic stent in place).
4. Brushing of the hepatic confluence.
5. Placement of 8.5 French external drain in the left biliary
ductal system.
CT Abdomen with and without contrast [**2111-3-21**]:
Final Report
HISTORY: 68-year-old female with a history of biliary stricture
status post
[**Month/Day/Year **] and stent placement and persistent cholangitis now status
post left
external percutaneous biliary drain.
STUDY: CTA of the abdomen with and without contrast; MDCT images
were
generated through the abdomen without IV contrast. Subsequent
MDCT images
were generated through the abdomen after the uneventful IV
administration of
Omnipaque intravenous contrast in the arterial, venous and
three-minute
delayed phases. Coronal and sagittal reformatted images were
generated in the
arterial and venous phases.
COMPARISON: [**2111-3-16**] outside hospital CT of the
abdomen.
FINDINGS: Small bilateral pleural effusions consisting of
minimally complex
pleural fluid are present with associated compressive
atelectasis. These are
new compared to prior exam. An endogastric tube courses into the
stomach. A
CBD stent is in place. There has been interval placement of a
percutaneous
biliary drain from a left-sided approach. Its course
demonstrates either
possibly a kinked contour or a sharp bend around a drainage hole
(2; 15 and
400a; 32).
The liver demonstrates definite improvement of the intrahepatic
biliary
dilatation. Periportal edema is still present. The gallbladder
shows no
definite evidence of stones or wall edema. The spleen is normal
in size and
appearance. The pancreas shows no ductal dilatation,
peripancreatic
inflammation, or hypoenhancement. However, a small amount of
peripancreatic
fluid or hypodense tissue is present, and while is not
definitely organized,
it does not appear to have appreciable fat stranding associated
with it. The
visualized portion of the small and large bowel show no evidence
of
obstruction or wall edema. The kidneys enhance with and excrete
contrast
symmetrically without evidence of a mass or hydronephrosis. A
subtle area of
cortical thinning in the mid pole of the left kidney may
represent an area of
prior infection or infarct (400a; 55). Subtle perinephric fat
stranding is
present on the right, likely reactive in nature. There is no
free air or
lymphadenopathy.
CTA: The aorta is of a normal caliber along its course. The
celiac artery
demonstrates conventional branching pattern with a patent
hepatic artery
branching to both the right and left lobes. The renal arteries,
SMA, [**Female First Name (un) 899**] and
common iliac arterial branches are widely patent. There is no
evidence of a
pseudoaneurysm.
CTV: The hepatic veins are patent. The portal vein, splenic
vein, and SMV
are patent. The renal veins are patent bilaterally.
BONES: No aggressive-appearing lytic or sclerotic lesion is
present.
Mild-to-moderate degenerative changes are seen throughout the
visualized
portion of the spine, primarily in the form of endplate
sclerosis and small
osteophytes.
IMPRESSION:
1. Small bilateral pleural effusions with associated
atelectasis.
2. Status post left percutaneous biliary drain placement with
marked
improvement of intrahepatic biliary dilatation; questionable
area of kinking within its course as described above.
3. Patent hepatic arterial and venous vasculature.
4. Small amount of fluid or hypodense soft tissue around the
pancreas without appreciable surrounding inflammation may
represent sequela of prior pancreatitis, post-surgical change,
adenopathy, or mass; endoscopic ultrasound and biopsy may be
considered.
Brief Hospital Course:
Ms. [**Known lastname 31624**] was admitted to West 1 Surgery team on [**2111-3-19**]. She
[**Date Range 1834**] placement of a left side external biliary drain on
[**2111-3-20**]. This was complicated by difficult intubation,
aspiration event and subsequent admission to the ICU. She was
weaned off ventilation and repeat CXR on [**2111-3-25**] showed
resolution of her right side opacity. She was on room air
following her extubation and ICU stay. She had no further
respiratory issues during her hospital stay.
On [**2111-3-24**], Ms. [**Known lastname 31624**] [**Last Name (Titles) 1834**] placement of a right side
internal-external biliary drain and [**Last Name (Titles) 1834**] internalization of
her left side biliary drain. She tolerated this well. She was
afebrile with stable vital signs for the remainder of her
hospital stay. Her biliary drains were capped on [**2111-3-25**] which
she tolerated well. She was discharged home with VNA on [**2111-3-27**].
Medications on Admission:
Hydroxyurea 500 QOD, Fluoxetine 40 mg PO q day, ASA 81 mg q day
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain at drain sites: Do not drive while on
this medication. Use an over the counter stool softener such as
colace while on this medication.
Disp:*30 Tablet(s)* Refills:*0*
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*1*
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
VNA of Central & [**Hospital3 29991**] [**Hospital3 **]
Discharge Diagnosis:
Biliary stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You [**Hospital3 1834**] placement of an external left biliary drain on
[**2111-3-20**]. On [**2111-3-24**], you [**Date Range 1834**] placement of a right biliary
drain that has an internal and external component. At the same
time you also had internalization of the left drain. Your bile
is draining from your right and left liver into your small
bowel. Both drains should remain capped.
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have
temperature of 101 or greater, chills, nausea, vomiting,
jaundice, increased abdominal pain, drain sites appear red or
have drainage, constipation/diarrhea or drain sutures fall or
"stat lock" falls off.
[**Hospital3 **] Visiting Nurse services have been arranged
Followup Instructions:
-[**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator [**Numeric Identifier 92286**] for Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 673**] will call you on Monday with a follow up
appointment next week (appointment will likely be on Wednesday)
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2111-5-12**] 12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2111-5-12**] 12:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2111-3-29**]
ICD9 Codes: 2724, 311, 4240
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5560
}
|
Medical Text: Admission Date: [**2164-11-21**] Discharge Date: [**2164-11-23**]
Date of Birth: [**2096-9-8**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Central venous line placement
History of Present Illness:
68 year old female with metastatic renal cell carcinoma (lung,
lymph nodes, liver) presents with hypotension. The patent's son
reports that the patient has not been eating or drinking much
for the last few days. She has been having copious diarrhea and
vomiting for the last few weeks as well. The son had not noticed
any change in mental status or any other new issues other than
continued weakness.
In the ED, the patient's presenting vitals were T97 P113 BP63/39
R10 O293%RA. At the time of evaluation by the MICU team, her
vitals were T97.4 P106 BP76/54 R19. She received 5L of NS and 2
units PRBC and IV levofloxacin, as well as potassium and
magnesium repletion. A right IJ central line was placed.
Of note, the patient was reported to be enrolled [**Hospital 1121**]
Hospice. Discussions with the son suggested that the family was
not aware of the general goals of hospice care. After explaining
the various options of care, the patient and her son elected for
full medical care (including intubation and resuscitation as
needed) pending further discussion with oncology.
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]
Past Medical History:
1) Metastatic renal cell carcinoma
- s/p left nephrectomy with concurrent resection of an isolated
pulmonary nodule in 12/[**2160**].
- Adjuvant high-dose interleukin-2 therapy in [**1-/2161**]
- CCI/IFN trial terminated in [**11/2162**] because of cumulative side
effects and the lack of definitive measurable disease.
- Thalidomide d/c [**8-/2163**] due to side effects and disease
progression.
- Avastin off study terminated because of disease progression.
- Photodynamic therapy terminated because of hemoptysis and MI
during bronchoscopy.
- Mediastinal radiation therapy.
- Gemcitabine terminated because of disease progression.
- Currently enrolled in open-access sorafenib trial (started
[**2164-9-12**]
- [**2164-10-29**] Torso CT: unchanged thoracic inlet LAD, large
pretracheal LN, subcarinal LN, LLL mass (3.7 X 3.4 cm), multiple
hypodense liver masses.
2. Status post TAH, uterine prolapse repair
3. Hyperlipidemia
Social History:
SHx: Married. Lives with family. Denies tobacco or other alcohol
use
at home with hospice.
Family History:
FHx: noncontributory
Physical Exam:
On admission to MICU:
PE:
Temp 97.4 P113 BP 76/54 (pre-levophed) RR 19 O2 sat 96 NC
Gen - Alert, no acute distress, Russian-speaking elderly female,
cachectic
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - RIJ in place; nodules at base of left neck (tumors, per
patient)
Chest - Coarse breath sounds on right.
CV - Normal S1/S2, tachycardic, regular
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - Warm, with clubbing but no cyanosis. 2+ pitting edema
bilaterally. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-10**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Pertinent Results:
Studies:
CXR: 1. Multifocal airspace opacities, unchanged since the prior
study, concerning for post-obstructive atelectasis or pneumonia.
2. Small bilateral pleural effusions, left greater than right.
.
CT ([**2164-10-29**]):
CT OF THE CHEST WITHOUT CONTRAST: Examination for comparative
purposes is somewhat limited by the absence of IV contrast. In
the soft tissue windows, there is no axillary lymphadenopathy.
In the left thyroid lobe, there is a 4- mm calcification that is
unchanged. The lymphadenopathy in the thoracic inlet is
unchanged. There are multiple masses within the mediastinum that
are relatively unchanged. Lesion #3 is a pretracheal lymph node
measuring 23 x 18 mm and is unchanged. Target lesion #4 is a
subcarinal lymph node measuring 23 x 17 mm and is also
unchanged. There is also hilar lymphadenopathy that is
unchanged. In the lung windows, there is a mass in the left
lower lobe as target lesion #1 measuring 37 x 34 mm and is also
relatively unchanged. There are multiple areas of focal patchy
infiltrates bilaterally including geographic paramediastinal
consolidations (presumably patient had prior radiation therapy)
that are unchanged. Tiny noduleas are present at both lung bases
, unchanged. No new large pulmonary nodules are identified.
There are small bilateral pleural effusions that smaller than on
prior study. There is a pericardial effusion that is unchanged.
CT OF THE ABDOMEN WITHOUT CONTRAST: There are multiple hypodense
lesions in the liver that are unchanged. Specifically, these
include one 19-mm in the segment VII and another unchanged
lesion in segment VI. No new liver lesions are identified. There
is interval increase in a massive left nephrectomy bed lesion
that now measures 107 x 104 mm that is, allowing for absence of
IV contrast, increased from approximately 95 x 92 mm. This is
target lesion #2. A large left adrenal mass measuring 5.7 cm is
unchanged. The spleen and right kidney are normal. The large and
small bowel loops are of normal caliber. There is no free fluid
in the abdomen.
IMPRESSION: Widely metastatic disease with interval enlargement
of target lesion #2 in the left nephrectomy bed. Stable
mediastinal ,lung, liver and left adrenal disease.
.
Head CT: ([**8-31**]) no mets
.
CXR ([**11-22**]):
Comparison to a prior chest x-ray shows certainly no improvement
and possibly the increasing densities at both lung bases
consistent with increasing pleural effusions. Bilateral upper
lobe airspace disease is present. The heart is enlarged.
IMPRESSION: Increasing effusion since [**2164-11-20**].
Brief Hospital Course:
A/P: 68 year old female with metastatic renal cell carcinoma
admitted to MICU with hypotension.
1) Hypotension: Concern for infection and sepsis/SIRS
physiology. Potential sources of infection include
post-obstructive pneumonia, UTI (given positive U/A). Patient
also has known large left adrenal mass. Blood, sputum and urine
cultures were sent and had no growth, and a repeat urine was
negative for infection. The patient was started on antibiotics
in the emergency department. Steroids were also given, although
the results of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim test did not support the idea of
adrenal suppression. The patient was maintained on levophed and
fluids.
.
2) Respiratory distress: On HD 2 the patient developed
significant respiratory distress with bilateral wheezes/rales.
She had only a minimal response in UO to lasix with a BP drop,
and couldn't tolerate aggressive diuressis. Given end-of-life
discussions (see below), the patient was not intubated and was
only supported with non-invasive means. On HD3 she was tachypnic
all morning and was supported with O2 by face mask (which she
refused) and nasal canulla. In the early afternoon her nurse
found her not breathing; given her DNI/DNR status (see below)
she was not intubated and passed away. Her family was present at
the time, and her oncologist and PCP were notified.
.
3) Code status: the patient had metastatic renal cancer and, per
her oncologist, had always been resistant to discussions about
advanced directives. Although enrolled in hospice care at home,
per her family this was only for the home services and not
because she was declining further treatment. However, from her
arrival in the ED the patient refused most treatment, including
foley catheters and ECGs. There were multiple discussions with
her, her family, the MICU staff and her oncologist, with the
resultant conclusion that she was DNR/DNI. The Palliative Care
service (which already knew the patient) was also consulted.
.
3) F/E/N: House diet, but patient had poor appetite and refused
most food. She did somewhat better with Russian food her husband
brought. .
4) Anemia: HCT 26.5. Baseline HCT 27-31. Most likely ACD
secondary to malignancy.
Transfused 2u PRBC in ED, no active bleeding, Hct stable in
MICU.
.
5) Coagulopathy: INR>2, up from baseline; no active bleeding but
given PO vitamin K with resulting INR=1.5.
.
6) Prophylaxis: PPI, bowel regimen, heparin SC
.
7) Communication: [**Name (NI) 19989**] [**Name (NI) 19990**] (son) [**Telephone/Fax (1) 19991**] (cell)
Medications on Admission:
Sorafenib 400 mg daily
lorazepam 0.5 mg p.r.n.
Paxil
Robitussin Methadose
Ambien
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypotension
Respiratory arrest
Metastatic renal cell carcinoma
Discharge Condition:
Expired
ICD9 Codes: 0389, 5849, 5859, 5990, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5561
}
|
Medical Text: Admission Date: [**2165-4-21**] Discharge Date: [**2165-5-22**]
Date of Birth: [**2110-4-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
[**2165-4-21**] Intubation
[**2165-4-21**] Right IJ line placement
[**2165-4-24**] IR-guided lumbar puncture
[**2165-4-25**] TEE
[**2165-4-20**] Intubation
[**2165-4-23**] Attempted bedside lumbar puncture
[**2165-4-24**] IR-guided lumbar puncture
[**2165-4-26**] Hemodialysis line placement and hemodialysis initiation
[**2165-4-30**] Nasogastric tube placement
[**2165-4-30**] Extubation
[**2165-5-2**] IR-guided hemodialysis tunneled catheter placement
[**2165-5-6**] lumbar puncture
[**2165-5-13**] tunnelled HD cath placed
[**2165-5-15**] tunnelled HD cath placed
History of Present Illness:
55 y.o. male with PMHx of DM, HTN, CAD s/p IMI with 3 stents to
RCA and recently diagnosed RCC who is transferred from [**Hospital **]for ongoing work-up of acute renal failure and change in
mental status.
.
Patient was admitted to [**Hospital3 7571**]Hospital on [**2165-4-16**] for
chest and abdominal pain. He ruled out for an MI with cardiac
biomarkers and was felt to be constipated as was illustrated on
CT and thought to be due to chronic narcotic use for lower back
pain and right hip pain (awaiting hip replacement). His
constipation was treated aggressively with medications and
disimpaction with minimal effect. On day 4 of his
hospitalization, he was febrile to 104 with a leukocytosis to 14
and was pan-cultured while Vancomycin and Zosyn were started
empirically with specific concern for a PIV infection suggested
by surrounding erythema and edema. Blood cultures later grew
GPCs in [**2-23**] bottles and chronic foot ulcers were swabbed and
reportedly grew staph aureus with pending sensitivities. Zosyn
was thus discontinued. In the setting of infection, patient
became delirious, noted to be attempting to grab things from the
air and talking to people in the room. Of note, patient was
continued on narcotics, reportedly at the wife's insistence
given concern for narcotic withdrawal. Neurology was consulted
and recommended a head CT which was unremarkable, leaving them
to conclude that the mental status was toxic/metabolic in the
setting of infection and narcotic use. He was started on
Ceftriaxone 2 grams daily for CNS coverage though no LP was
performed. On day 5, patient was noted to develop acute renal
failure with a creatinine of 3, up from 1.3 and was also anuric.
CKs were checked to evaluate renal failure from rhabdomyolysis
and were not likely contributing at a level of 361. He was
transferred to [**Hospital1 18**] for concern of his renal failure
progressing to the point of needing HD, since [**Hospital3 77641**]
no HD facilities.
.
Upon arrival, patient was noted to vomit and had reportedly
vomited in route to [**Hospital1 18**]. He additionally started experiencing
low-amplitude, rhythmic clonus of his hands and legs, became
transiently hypoxic and was not verbally responsive. There was
concern for seizing and patient was urgently intubated to
protect his airway. Discussion with the patient's wife, [**Name8 (MD) **] RN,
revealed that the patient has never had a seizure disorder and
does not drink alcohol. Additionally, he had a CT scan with
contrast at [**Hospital1 2025**] 3 days prior to his admission to [**Hospital3 **]as a part of his RCC work-up and the wife expressed concern for
contrast-induced nephropathy. Patient was then ordered for a
stat head CT given the mental status and neurology was consulted
for further assistance with management.
Past Medical History:
CAD s/p IMI in '[**60**] with stents in RCA
DM
HTN
Morbid Obesity
OA - awaiting right hip replacement
Gout
Social History:
Per wife, no alcohol.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 98.5, BP: 139/110, P: 117, R: 16 O2: 93% AC
600/14/100%/5
General: Awake, but not able to follow commands, responding with
one word sentences, occasionally not responsive to sternal rub,
noted to have fasiculations of tongue and low-amplitude clonus
of hands and legs bilaterally
HEENT: NC/AT; PERRLA, EOMI; OP with dry mucous membranes
Neck: Obese neck, unable to appreciate JVD
Lungs: CTAB
CV: S1, S2 nl, no m/r/g appreciated
Abdomen: Markedly distended and tympanic to percussion, bowel
sounds not appreciated
Ext: No c/c/e; Left foot with 2 stage 3 ulcers without
surrounding cellulitis and amputation of 2 toes
Neuro: Patient largely unable to cooperate. Downgoing toes
bilaterally
Pertinent Results:
Discharge Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2165-5-22**] 05:07AM 8.6 2.76* 7.6* 23.1* 84 27.6 32.9 16.4*
368
PT PTT Plt Smr Plt Ct INR(PT)
[**2165-5-22**] 05:07AM 368
Source: Line-picc
[**2165-5-22**] 05:07AM 14.7* 26.0 1.3*
ESR
[**2165-5-14**] 06:30AM 150*
Source: Line-PICC
HEMOLYTIC WORKUP Ret Aut
[**2165-5-16**] 05:33AM 4.9*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2165-5-22**] 05:07AM 79 26* 2.2* 140 4.0 100 28 16
Calcium Phos Mg UricAcd Iron
[**2165-5-22**] 05:07AM 9.0 3.9 1.7
Source: Line-picc
HEMATOLOGIC calTIBC VitB12 Folate Hapto Ferritn TRF
[**2165-5-6**] 05:25AM 156* 587 9.4 336* 981* 120*
PITUITARY TSH
[**2165-4-21**] 07:47PM 4.0
ADDED [**Doctor Last Name **] AT 2040 ON [**2165-4-21**]
THYROID PTH
[**2165-5-21**] 07:30AM 26
[**2165-5-21**] 06:30AM 41
Source: Line-PICC
IMMUNOLOGY CRP
[**2165-5-14**] 06:30AM 112.5*1
[**2165-4-21**] through discharge -> no growth in blood cultures
[**2165-5-21**] cath tip swab -> no growth
For complete blood culture results, please call [**Telephone/Fax (1) 2756**] and
ask for microbiology.
[**2165-4-21**] CXR: ET tube tip at the thoracic inlet is approximately
45 mm from the carina, standard position. Lung volumes are low
and there are several areas of plate-like atelectasis. Heart
size borderline enlarged. Pleural effusion, if any, is minimal.
No pneumothorax.
[**2165-4-21**] Abd XR: Diffuse colonic dilatation without air within
the rectum. This may represent ileus. Close followup is
recommended.
[**2165-4-21**] Left foot XR: The patient is status post partial
amputation of the first through fifth metatarsals and resection
of multiple phalanges. Portions of the 1st distal phalanx, the
toe of the second (?) digit, and the fifth toe are present.
There is a focus of air overlying the surgical bed of the first
ray, representing either air within an area of ulceration or
subcutaneous emphysema. There is relative lucency of the
adjoining portion of the first metatarsal bony remnant
suspicious for osteomyelitis.
Correlation with any previous (outside) radiographs and history
of recent
debridement is recommended for full assessment. The posterior
calcaneus is obscured by overlying material and not fully
evaluated on this examination.
[**2165-4-22**] CT head: No intracranial hemorrhage or edema.
[**2165-4-22**] EEG: This is an abnormal portable EEG recording due to
the pattern of widespread alpha range activity alternating with
relative suppression of the background without reactivity which
is suggestive of an alpha coma pattern. This abnormality
suggests a severe encephalopathy. Medications and metabolic
disturbances may be causes but this pattern can also be seen in
post-anoxic patients. There were no lateralized or epileptiform
features seen and no electrographic seizures were seen in this
recording.
[**2165-4-22**] Renal U/S: No evidence of hydronephrosis.
[**2165-4-22**] TTE: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild cavity enlargement and
preserved global biventricular systolic function.
[**2165-4-25**] TEE: No intracardiac mass or vegetations. No significant
valvular regurgitation. Complex, mobile atheroma in descending
aorta, simple atheroma in the aortic arch.
[**2165-4-25**] MRI/MRV Head w/o Contrast: IMPRESSION:
1. No evidence of acute infarction.
2. Patent major dural venous sinuses. Decreased signal in the
posterior part of the superior sagittal sinus, including the
torcular herophili and the right sigmoid sinus, likely relates
to slow flow rather than thrombosis given the lack of increased
signal on the sagittal T1-weighted sequences. If there is
continued concern based on the clinical presentation, CTA and
CTV, if serum creatinine level is appropriate or a followup MR
venogram can be considered.
[**2165-4-30**] CT SPINE: IMPRESSION:
Limited study due to patient habitus and motion, and non-
myelographic technique, with:
1. No definite epidural or subdural abscess collection seen in
the thoracolumabr spine.
2. Apparent hyperdense focus in the ventral epidural space at
the T2 level, most likely artifactual.
If this remains of clinical concern, follow-up CT study,
dedicated CT-
myelography or MRI, when feasible, might be helpful for further
evaluation. N.B. The patient successfully underwent MRI of the
brain (at this institution) as recently as [**2165-4-25**].
3. No fracture or malalignment.
4. Mild spondylosis of the thoracolumbar spine, with no canal
compromise.
5. Small bilateral pleural effusions and moderate bibasilar
consolidations; differential diagnosis includes atelectasis,
aspiration and bacterial pneumonia.
[**2165-5-2**] Renal U/S: IMPRESSION: No hydronephrosis and no
perinephric collections seen in this very limited mobile renal
ultrasound study.
[**2165-5-9**]
IMPRESSION:
1. Definite abnormal focus of tracer accumulation in the left
foot correlating
with known sites of ulceration/infection.
2. Indeterminate foci in the right proximal thigh medially or
scrotum and the
soft-tissues of the left knee medially, for which clinical
correlation is
needed.
3. Possible nasal infection or ethmoid sinusitis.
[**2165-5-13**] EEG:
IMPRESSION: This is an abnormal routine EEG due to a slow and
poorly
modulated background indicative of a mild to moderate
encephalopathy.
Medications, metabolic disturbances, and infections are among
the most
common causes. There were no areas of prominent focal slowing
although
encephalopathies can obscure focal findings. There were no
epileptiform
discharges noted.
Brief Hospital Course:
55 year old male had prolonged hospital course complicated by
multiple infections, mental status changes, and renal failure
who requires long term antibiotic therapy.
# Sepsis/Meningitis: He was transferred from [**Location (un) **] in the
setting of high-grade MSSA bacterimia and mental status changes,
and intubated on arrival because of question seizures and
concern for airway protection. Before speciation returned, he
was initially managed with vancomycin and zosyn, and then
switched to nafcillin given MSSA. He also required pressors
intermittently on the day after presenting but this was
ultimately thought to represent a low-baseline blood pressure,
and pressors were subsequently discontinued, with MAPs that
remained greater than 65. The source of his infection was
unclear but thought to be secondary to left foot ulcers, which
also grew MSSA. This was evaluated by podiatry and vascular,
and he was found to have osteomyelitis of the first toe, and
would possibly need L BKA for definitive treatment. There was
also concern for encephalopathy given his worsening mental
status prior to and after transfer, and neurology was consulted.
An LP was initially deferred because of the unlikelihood of him
developing meningitis during his hospitalization at [**Location (un) **], as
he did not initially present with symptoms suggestive of this
condition. However, it was later performed and was consistent
with bacterial meningitis, and antibiotics were changed to
vancomycin, ceftriaxone, and acyclovir. ACV and CTX were then
discontinued as CSF culture returned negative and other cultures
continued to be MSSA. He was extubated after 10 days and
tolerate this well. Vancomycin was continued following transfer
to floor. A thorough work up for source of infection, including
LP and left foot imaging, did not yield a source. As patient
continued to improve clinically, the decision was made to treat
empirically with vancomycin until [**6-5**], dosing during HD.
# Altered mental status: After extubation, patient was
delirious, not responding to commands, and with jerking motions
of his head. An MRI/MRV was negative for structural abnormality
on [**2165-4-25**], after EEG showed possible alpha-coma waves. His
mental status cleared after 4 days extubation suggesting ICU
narcosis. He began to follow commands on [**2165-5-4**]. Following
transfer to floor, fentanyl patch was discontinued in favor of
morphine PO. The patient's mental status continued to improve
without further intervention. At time of discharge, patient was
oriented to time, person, and place.
# ? hypodense region in TT2 area of spinal cord: Intial concern
was for abscess with cord compression as patient was febrile
with MSSA infection and not moving his lower extremities for
several days pre-extubation [**2165-4-30**]. Neurosurgery was consulted
and recommended CT myelogram or MRI to better define this
lesion. Dr. [**Last Name (STitle) **] (radiology) stated CT myelogram was not
indicated and suggested MRI. Mr. [**Known lastname 77642**] was unable to fit in
the MRI scanner far enough to scan his spine so he was watched
clinically and improved. Consider f/u MRI in open MRI scanner as
an outpatient.
# Respiratory failure: He was intubated shortly after ariving
at [**Hospital1 18**] because of concern for airway protection in the setting
of question seizures, as he had low-amplitude clonic movements
of his hands and legs. His vent settings were weaned and plan
for extubation on [**5-1**] was moved up after he bit through the
tubing to inflate the cuff. He was extubated after 9 days and
his respiratory status continue to improve. EEG obtained showed
no epileptiform activity. Patient had stable respiratory for
the duration of his hospitalization following extubation.
# Acute Renal Failure: His creatinine began rising prior to
transfer from a baseline of 1.3, and he developed oliguric renal
failure. Renal was consulted and their analysis of his urine
was consistent with ATN secondary to sepsis, though there was no
clear documentation of hypotension from the OSH. He had to be
started on HD ([**2165-4-26**]) for volume overload and hyperkalemia. At
that point his creatinine was 9.8. He continued on HD and
eventually a temporary dialysis catheter was placed (on [**5-2**])and
the femoral HD catheter was pulled. His urine output improved,
although his need for HD continued. The patient had another
dialysis catheter placed on [**5-15**] for HD, with subsequent
self-removal secondary to agitation. A tunnelled catheter HD
line was placed on [**2165-5-17**] for resumption of HD. The patient
continued receiving HD 3 times weekly on the floor, and pt's
creatinine was 2.2 at time of discharge. The patient will
continue HD following discharge and will be followed by the
nephrology service.
# Hypertension: After septic picture resolved, patient was
hypertensive to 200s/80s. His losartan was held for renal
protection in hopes that his renal function would recover. He
was started on metoprolol and hydralizine with better control.
Pt's HTN was managed well on the floor following ICU transfer
with the current medication regimen at discharge.
# L foot ulcer: Likely seeding to blood causing sepsis. ESR and
CRP very high and will monitor with Abx treatment for
osteomyelitis.
- Podiatry and vascular surgery were consulted and stated they
would defer amputation and await stabilization/abx treatment of
patient prior to surgery.
- no intervention was pursued, as patient improved clinically on
floor on vancomycin
- pt will have ID follow up on [**6-5**]
# Right hip OA: significant source of pain and had required
large doses of narcotics prior to admission. Per family, the
plan was to replace his hip, but he was battling recurrent
infections from L toe delaying this. Morphine PO with scheduled
tylenol proved an effective regimen for his pain.
# Large bowel obstruction: A KUB demonstrated a distended
transverse colon concerning for ileus in the setting of large
narcotic use for R hip pain. General surgery was consulted and
felt that it was improving and did not require surgical
intervention. He eventually began stooling again after PO narcan
was started and with an aggressive bowel regimen. Following
transfer to floor, constipation resolved with bowel regimen and
change in opiate use.
# CAD s/p IMI: Ruled out for MI at OSH and was continued on
ASA/plavix. He was not on a beta blocker or statin at home for
unclear reasons.
# DM: Managed initially with an insulin drip because of
elevated finger sticks and converted to a sliding scale. [**Last Name (un) **]
consulted and placed patient on a basal bolus regimen with good
control at time of discharge. This regimen will be continued at
rehab.
# Renal Cell Carcinoma: Is seen at [**Hospital1 2025**]. Per family, he was
recently diagnosed ~2 cm mass, CT torso without mets. He was
scheduled for cryoablation prior to this hospitalization.
# Gout: Renally-dosed Allopurinol and then d/c'd given renal
failure.
# Communication: [**Name (NI) **] wife, [**Name (NI) **] [**Telephone/Fax (1) 77643**] - cell
# Patient was made DNR, but okay to re-intubate for respiratory
failure post-extubation.
Medications on Admission:
Medications on Transfer:
Allopurinol
Aspirin
Plavix
Colchicine
Lasix
Indomethacin
Insulin
Cozaar
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Morphine 15 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
13. line care
Heparin Flush (5000 Units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line
flush Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous as directed for 2 weeks: to be administered
after each dialysis session three times weekly, until [**6-5**].
15. Insulin Glargine 100 unit/mL Solution Sig: Forty Eight (48)
units Subcutaneous once a day.
16. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
QACHS: please see attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
- MSSA baceremia
- MSSA LLE osteomyelitis
- Ileus
- MRSA pneumonia
- MRSA meningitis
- Altered mental status
- Acute renal failure
- Osteoarthritis awaiting R hip replacement
Secondary
- Coronary artery disease
- Diabetes mellitus
- Hypertension
- Morbid obesity
- Gout
Discharge Condition:
Hemodynamically stable, afebrile, non-ambulatory, able to
tolerate PO
Discharge Instructions:
You were transferred from another hospital for management of
your acute kidney failure in the setting of a high-grade blood
infection with a bacteria called MSSA, thought to be introduced
from our infected left foot ulcer. You were intubated in the ICU
in order to protect your airways due to concern for seizure. You
also had an ileus thought to be precipitated by high doses of
narcotics; this has now resolved. You were initiated on
hemodialysis for your renal failure with improvement. Your ICU
course here was further complicated by MRSA bacteral meningitis
and pneumonia, for which you were treated with antibtioics. You
were able to be weaned off your ventilator. You were
transferred from the ICU to the floor. Your medical problems
contributed to confusion, which improved with time. Your kidney
function declined from your medical issues, and you were started
on dialysis for support. When you left the hospital, you still
required dialysis, but your kidney function has improved
greatly. Your chronic hip pain is being treated well with
medication. You are being dischaged to a rehab center, where
they will focus on getting you stronger as you continue to
recover from your long hospitalization.
There were multiple changes made to your medication, your rehab
providers will be responsible for your new regimen.
Please take all medications as prescribed.
Call your doctor or 911 if you develop chest pain, difficulty
breathing, fevers >101, dizziness, bleeding, or any other
concerning symptoms.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**], on discharge from
Rehab to schedule follow-up. His office number is [**Telephone/Fax (1) 22629**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 457**]
Date/Time:[**2165-6-5**] 1:30
ICD9 Codes: 5845, 5990, 2749, 412, 5859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5562
}
|
Medical Text: Admission Date: [**2103-7-26**] Discharge Date: [**2103-8-1**]
Date of Birth: [**2041-1-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
CP, EtOH withdrawal
Major Surgical or Invasive Procedure:
EGD - [**7-27**]
History of Present Illness:
62M with PMH significant for CAD and EtOH abuse ([**1-4**] vodka qD)
with h/o DTs and seizures, presenting with CP at home at 5pm
while walking down the street. He describes the pain as dull,
and admitted some mild dyspnea and associated diaphoresis. No
N/V or radiation of pain to arm, jaw, or back. He states that
the pain feels similar to previous occasions during which he was
experiencing EtOH withdrawal.
Past Medical History:
- EtOH abuse with h/o DTs with visual hallucinations and
withdrawal seizures.
- ?CAD: Was apparently cathed at [**Hospital1 2025**] 3 years ago and underwent
angioplasty. Does not know whether stent was placed. Was told he
showed evidence of a previous MI.
- HTN
Social History:
Parents deceased; remains close to two sisters, one in [**Name (NI) 21380**]
and the other in [**State 1727**]. Educated through high school. Ex-marine.
Worked 22 years at Digital Corp in film
reproduction/development. Has lost job at homeless shelter [**2-1**]
EtOH abuse. Twice married and divorced, no children
Family History:
"Mild" depression in sister
Physical Exam:
On admission:
PE: T: 99.8F BP: 192/92 HR: 127 RR: 19 SaO2: 99% 2L NC
Gen: Disheveled gentleman, slightly diaphoretic and tremulous,
interacting and in NAD
HEENT: PERRL, Large ecchymosis around L eye with subconjunctival
hemorrhage, OP somewhat dry.
Neck: Cleared C-spine, no pain on neck flexion/extension or
rotation. Supple, no LAD
CV: Tachycardic, regular rhythm. Loud S1 and S2, II/VI SEM LUSB
radiating to carotids
Chest: CTAB, no w/r/r
Abd: Soft, obese, NT/ND, no HSM, hypoactive BS
Ext: No LE edema, trace DPs bilaterally
Pertinent Results:
[**2103-7-26**] 10:50AM CK(CPK)-53
[**2103-7-26**] 10:50AM CK-MB-3 cTropnT-<0.01
[**2103-7-26**] 02:34AM GLUCOSE-123* UREA N-15 CREAT-0.8 SODIUM-137
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-21*
[**2103-7-26**] 02:34AM WBC-6.3 RBC-3.41*# HGB-10.1*# HCT-31.1*#
MCV-91 MCH-29.8 MCHC-32.6 RDW-17.3*
[**2103-7-26**] 12:35AM TYPE-[**Last Name (un) **] PO2-88 PCO2-37 PH-7.21* TOTAL
CO2-16* BASE XS--12
[**2103-7-25**] 11:58PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2103-7-25**] 11:58PM URINE RBC-0-2 WBC-[**3-4**] BACTERIA-MOD YEAST-NONE
EPI-[**3-4**]
[**2103-7-25**] 07:20PM D-DIMER-5207*
[**2103-7-25**] 07:00PM LD(LDH)-252* CK(CPK)-58
[**2103-7-25**] 07:00PM ASA-NEG ETHANOL-229* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
In the ED he was noted to be tachycardic, anxious and
diaphoretic. his VS were T 99.2F BP 187/107 HR 131 RR 16 SaO2
98% 2L NC. He had no ECG changes other than tachycardia. Ddimer
was positive at 5207, but chest CTA was negative for dissection
or PE. First set CEs negative at CK 58, trop <.01. Mr. [**Known lastname **]
stated that his last drink was 24h prior to admission. Serum
EtOH in ED was 229. Serum and urine tox was otherwise negative.
Initial labs were notable for a large AG metabolic acidosis,
with HCO3 13 and AG 32, delta-delta 1.7. Mg 1.6, Phos 5.1. VBG
was 7.21/37/88. Urine ketones were positive at 50, and urine was
negative under Wood's lamp for ethylene glycol, with one
amorphous crystal seen. Subsequent lytes drawn 4 hours later and
after 2L NS demonstrated closure of the AG to 13, with VBG
7.41/31/76. An addendum was added to CTA report, noting
thickening of the gastric mucosa c/w gastritis vs lymphoma vs
TB, and recommended an EGD to further evaluate. Mr. [**Known lastname **] was
given valium 10mg IV x 3, and was placed briefly on ativan drip
with little effect on his chest pain. He was transferred to the
[**Hospital Unit Name 153**] for further management.
.
In the [**Name (NI) 153**], pt was placed on CIWA scale and received PO Valium
for CIWA>10. First night received ~70 mg Valium o/n and second
night received ~30 mg. No significant withdrawal sxs and no
seizures. EGD performed [**7-27**] to further characterize abnormality
seen on CTA revealed ulcers in the antrum and pre-pyloric area.
Remained AF and VSS.
He was txed to the floor on [**7-28**]
1) ETOH abuse
social worker saw pt; all of us counseled him to quit use
he was alert and oriented without any w/d sxs at dc
2) GI
Had EGD on [**7-27**] which revealed multiple antral and pre-pyloric
ulcers. Pt had H. Pylori biopsies which are pending. Was started
on PPI therapy [**Hospital1 **] in the hospital; changed to QD therapy at
discharge.
3) Htn
Poor control; meds were titrated up
4) Acute gout
developed pain in ankles and knees requiring initiation of po
prednisone. Sxs markedly improved with prednisone. Plan is to
have him taper them down as an outpt.
5) Ileus
had ileus in ICU which improved on floor; tolerating a nl diet
on discharge without any abd pain
6) Hypomag and hypokalemia
pt's potassium and mag were replaced with improvement
7) UTI
had pansensitive e. coli
treated pt with cipro - advised him to stay out of sun given
risk of photosensitivity
blood cultures neg at time of discharge
Medications on Admission:
Atenolol - unknown dose (25mg PO qd in [**2097**] note)
Lisinopril - unknown dose
Discharge Medications:
1. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 10 days.
Disp:*20 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Ketosis due to ETOH abuse and dehydration
2) Peptic ulcer disease
3) Urinary tract infection
4) Ileus
5) htn
6) Acute gouty flare
Discharge Condition:
STable
Discharge Instructions:
seek medical attention if you are not feeling well
Followup Instructions:
Followup with your pcp, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 6164**] at the [**Location (un) 686**] House
ICD9 Codes: 2762, 5990, 4019, 2768
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5563
}
|
Medical Text: Admission Date: [**2162-2-11**] Discharge Date: [**2162-2-13**]
Date of Birth: [**2117-4-13**] Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
male with a history a seizure disorder who presented to
Northeast [**Hospital 3914**] [**Hospital 12018**] Hospital on [**2162-2-9**], with
several days of vomiting and vague abdominal pain. The
patient was found to have an increase in LFTs with an AST of
11,700; an ALT of 11,800. Coagulopathic INR of 14.8. The
patient was lethargic. Alert and oriented x 3 without
encephalopathy. Positive asterixis. The patient also
complained of right upper quadrant pain. Denies a history of
excessive EtOH. Denies a large amount of Tylenol ingestion.
Denies IV drug abuse, or blood transfusions, or recent
travel. The patient's Dilantin, Tegretol, and valproic acid
were all in a therapeutic range. The patient was transfused 4
units of FFP and vitamin K for an increased INR. The patient
was also noted to have hematemesis. Serial hematocrits were
obtained and monitored. The patient was intubated for
increased lethargy and agitation and transferred to [**Hospital1 18**] via
medical flight. He had positive epistaxis per report, and
there was an atraumatic intubation.
PAST MEDICAL HISTORY: Includes seizure disorder, GERD,
hypertension, and self gunshot wound to groin as a suicide
attempt in [**2157-12-5**].
PAST SURGICAL HISTORY: None.
MEDICATIONS AT HOME: Depakote 500 t.i.d., Tegretol 300
b.i.d., Dilantin 300 b.i.d., Nexium 40 daily, lisinopril 10
daily.
ALLERGIES: Vioxx, rash.
SOCIAL HISTORY: No tobacco. No ethanol. No IV drug abuse. On
Dilantin due to a seizure disorder.
PHYSICAL EXAMINATION ON ADMISSION: Vital's on admission were
95.9, 130/86, 82, 14, 100%. He was intubated on assist
control of 60%, respiratory rate 14 with a PEEP of 5. The
patient was intubated, sedated, and paralyzed. His heart was
regular in rate and rhythm without murmurs, rubs, or gallops.
The lungs were clear to auscultation bilaterally. The abdomen
was soft, and no palpable liver edge. Positive edema. Mild
distention on abdominal exam.
IMAGING: Imaging at the outside hospital showed an abdominal
ultrasound with gallbladder small. No gallstones. Chest x-ray
was unremarkable. KUB was unremarkable.
LABORATORY DATA: The patient had an ammonia of 202.
Admission labs with a white count of 8.9, hematocrit of 35,
platelets pending on admission. Coagulation studies of 23.5,
34.7, 3.5. Fibrinogen of 109. AST of 280, ALT 669, amylase
55, lipase of 105, LDH of 923, alkaline phosphatase of 127,
total bilirubin of 9.2, albumin of 3.3. Phenytoin was 7.6,
valproic acid of 4.5, carbamazepine of 7.6, and acetaminophen
was 5.8. Calcium of 7.5, magnesium of 2.0. Sodium of 150,
potassium of 4.1, chloride of 116, bicarbonate of 24, BUN of
49, creatinine of 3.5, with a glucose of 115. The patient had
a blood gas of 7.40, 38, 259, 25 and 0.
HOSPITAL COURSE: On hospital day 1 neurology was consulted.
On hospital days 0 and 1 neurology was consulted and
suggested checking levels of antiepileptic medications.
Suggested an EEG. Neurology also suggested on hospital day 2
start Versed for seizure control and overnight the patient
had 3 seizures requiring large doses of Ativan. A head CT
showed no evidence of acute intracranial pathology with sinus
opacification. Abdominal CT the same day showed ascites with
no focal collection, edematous appearing kidneys with no
evidence of hydronephrosis or hydroureter. The distal ureters
were not imaged. Somewhat large edematous appearing liver
with no focal lesion, parenchyma suggestive fatty
replacement. Gallbladder containing dense material consistent
with sludge may represent biliary excretion, contrast from
previous CT scan. Bilateral pleural effusion, bilateral
atelectasis. A liver ultrasound on hospital day 3 showed
patent hepatic artery, veins small, small amount of ascites,
with gallbladder sludge. The patient continued to receive
large amounts of transfusions of blood products throughout
hospital course, and by hospital day 3 had ALT of 3802 and
AST of 1300 with an INR of 2.75. Because the patient was in
status epilepticus, he currently was not transplantable and
was clinically comatose by [**2162-2-12**]. Progressively
deteriorated by [**2162-2-13**]. Over the course of the
evening and early morning and became progressively acidotic,
worsening lactate, progressive coagulopathy; unresponsive to
sodium bicarbonate infusion, IV fluids resuscitation, and
blood product infusion. On [**2162-2-13**], was on Levophed
0.5 mcg per kg per minute and Neo-Synephrine at 7.0 mcg per
kg per minute with the most recent ABG of 7.09/27/127/9/and -
20. He was on full life support measures at that time but was
appearing to be futile. The patient was made CMO at the
request of his wife.
The patient died at 4:15 a.m. on [**2162-2-13**], was
asystolic on telemetry. Organ bank was notified, and autopsy
report showed submassive hepatic necrosis with bowel stasis
most concentrated around zones 2 and 3 of the liver, soft
density mild vascular congestion, mild interval thickening of
the right coronary artery.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 3762**]
Dictated By:[**Doctor Last Name 9174**]
MEDQUIST36
D: [**2162-5-10**] 11:52:11
T: [**2162-5-11**] 15:39:36
Job#: [**Job Number 60689**]
ICD9 Codes: 5849, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5564
}
|
Medical Text: Admission Date: [**2154-8-12**] Discharge Date: [**2154-8-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Hypoxia, cyanosis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. [**Known lastname 12347**] is an 84F with a PMH of alzheimer's dementia, HTN,
paroxysmal atrial fibrillation who was admitted from NH when she
was noted to have cyanotic lips, grey coloring and hypoxia with
O2 saturation 73-76%. BP 151/82 HR 47, she was placed on O2 NC
at 4L with improvement in O2 sat to 98% on 4L NC, BP 107/83 P
80. According to her family she had seemed a bit off over the
past several days, no more specific symptoms than that were
noted.
.
Of note she was recently admitted [**7-21**] - [**7-23**] for shaking and
altered mental status. She was found to have a UTI and was
discharged on 7 day course of ciprofloxacin. On review of her
culture data it appears that her urine culture grew morganella
morgani resistant to cipro. She was also evaluated by neurology
during that admission for the shaking, felt to be a tremor, EEG
without evidence of seizure.
.
In addition, she was also admitted from [**2154-6-10**] -[**2154-7-5**] with
pneumonia and sepsis requiring intubation, complicated by acute
renal failure, suspected VAP, paroxysmal afib with RVR, NSTEMI,
and pulmonary edema.
.
In the ED T98.5 HR 92 BP 114/44 RR 26 98% 3L NC. She was given
Ceftriaxone 1g IV, Vancomycin 1g IV, levofloxacin 750mg IV,
combineb x1, solumedrol 125mg IV. She seemed to respond to neb
treatments intially however she was then noted to become
tachypnic and appeared to be in progressive respiratory
distress. She was given etomidate 20, succinylcholine 100mg,
versed 2mg IV and fentanyl 50mcg IV and intubated.
Past Medical History:
- dementia: alzheimer's disease
- hypertension
- recent NSTEMI
- recent Hypercarbic respiratory failure c/b VAP
- Paroxysmal Atrial fibrillation
- Chronic obstructive pulmonary disease
Social History:
Prior to a prolonged hospitalization in [**6-/2154**] for pneumosepsis
the patient had lived in an [**Hospital3 **] facility where she
had some assistance with ADLs, but was still very interactive.
She is currently living in [**Hospital **] [**Hospital **] nursing home.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 96.1, HR 101, BP 110/35, RR 17, 96% on VC 100%/600/14/5
Gen: intubated, sedated, generalized tremors with stimulation,
opens eyes
HEENT: NC, AT, EOMI, PERRL, endotracheal tube in place
Neck: supple, no LAD
CV: RRR, soft 1/6 systolic murmur
Lungs: vented breath sounds, basilar crackles at right
ABD: soft, NT, ND BS + no guarding
Ext: cool, no pedal edema or cyanosis
Pertinent Results:
Admission Labs:
WBC 10.9 23% bands, HCT 39.8, PLT 238
Na 148 K 4.5 Cl 106 HCO 35 BUN 20 Creat 0.8 Gluc 124
Lactate 2.6
UA: trace leuks, nitr pos, blood neg, [**12-26**] WBC, many bacteria
Micro:
[**8-12**] Blood Cx: P
[**8-12**] Urine Cx: P
Imaging:
[**2154-8-12**] CXR: Emphysema with small areas of opacity in the right
lung likely represent scarring or areas of bronchial wall
thickening, better seen on recent CT chest. No evidence of acute
intrathoracic process.
[**2154-8-12**] CXR post intubation (prelim):ETT terminates 5.3 cm above
carina, in satisfactory position. No change in emphysema and
parenchymal scarring since earlier same day.
[**2154-8-12**] EKG: NSR at 89 bpm, normal intervals, normal axis, no ST
segment or T wave changes, no significant change c/w prior
[**2154-7-21**].
Brief Hospital Course:
Mrs. [**Known lastname 12347**] is an 84 yo F with PMH of alzheimer's type
dementia, recent hospitalizations for PNA and UTI who was
admitted following episode of hypoxia and cyanosis.
.
#Hypoxic respiratory failure - unclear etiology. She developed
heavy secretions so PNA seemed most likely. Treated with vanco
/ piptazo / azithro and within 4d was extubated. She required
positive pressure vent for 6h postextubation but then remained
stable thereafter. Sputum cultures while intubated were
negative except for oropharyngeal flora. Her urine grew E. coli,
sensitive to Zosyn. She finished 5 days of azithro and continued
vanc and zosyn for at total of 14 days.
.
#Bandemia - She presented with a bandemia of 22, concerning for
acute infection and supportive of likely PNA. Treated broadly
as above. Ecoli grew out of the urine. This resolved with
antibiotic treatment.
.
#Hypotension - on arrival to ICU blood pressure decreased to SBP
80's - 90's, however she continued to have good urine output
with about 50-60cc's/hour after getting total of 4L IVF since
admission. She then was diuresed peri-extubation.
.
#Hypernatremia - most likely hypovolemic hypernatremia likely
with component of free water defecit as well. Improved with
free water bolusing
.
#Dementia/Delirium - she has had progressive decline since her
recent hospitalization in [**6-13**] with likely superimposed delirium
[**3-9**] acute medical illnesses. Namenda was held on admission and
restarted on [**8-17**]. Discontinuation of this medication should be
considered if [**Known firstname **] does not return to [**Hospital3 **]. Her
mental status after extubation was felt to be far below her
previous baseline. The geriatrics service was consulted and
discussed with the family that the patient's superimposed
delirium that has incurred likely to recurrent infections and
hospitalizations may take months to resolve, and that she may
never return to her previous level of functioning, and thus may
require a long-term facility that could provide full time care.
The family seemed to be in good understanding of this and will
make future plans accordingly. She will follow-up with her
behavioral neurologist Dr. [**Last Name (STitle) **] after discharge. If needed,
she can also be seen by the gerontology outpatient service at
[**Hospital1 18**].
#h/o Hypertension - hypotensive on admission with good urine
output. Metoprolol was held and then restarted slowly after
fluid resuscitation.
.
#Paroxysmal atrial fibrillation - in NSR on admission. She
converted to afib while in the ICU, and she was re-loaded with
amiodarone in the ICU. Upon arrival to the floor on [**8-17**] she
went into afib with RVR. She was asympomatic and converted back
to normal sinus rhythm after 5mg IV and 12.5mg po metoprolol.
Her metoprolol dose was increased slowly due to intermittent
bradycardia at night until she was discharged on metoprolol 50
t.i.d. with good rate control. Coumadin 4mg was started as CHADS
score was 3. The risks and benefits of intitiating
anticoagulation were discussed with her son. The plan is to
continue anticoagulation for now, and he will discuss the risks
and benefits with additional family members. [**Name (NI) 227**] her
concomitant ASA, she was started on a PPI.
#Tremor - evaluated by neurology during her last admission, felt
most likely essential tremor. No seizure activity on EEG.
#Code Status - DNR after speaking with her son and HCP as well
as her daughter. Family is okay with reintubation if necessary
but are considering DNI.
.
#Contacts: Son [**Name (NI) 382**] [**Name (NI) **] [**Name (NI) 12347**] [**Telephone/Fax (1) 17733**]; daughter [**Name (NI) **]
[**Telephone/Fax (1) 17737**]
Medications on Admission:
-Metoprolol Tartrate 100 mg Tablet PO BID
-Namenda 10mg [**Hospital1 **]
-EC Aspirin 81 mg Tablet daily
-Ipratropium Bromide nebs q6h prn
-Sennakot 1 [**Hospital1 **] prn
-colace 100mg [**Hospital1 **]
-tylenol 650mg q6prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clotrimazole 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
3. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
4. Memantine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO bid ().
5. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
6. Warfarin 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4
PM.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours).
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous
once a day for 4 days: Last day is [**8-25**].
10. Zosyn 2.25 gram Recon Soln [**Month/Year (2) **]: One (1) Intravenous every
six (6) hours for 4 days: **Last day is [**8-25**]**.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: **For prophylaxsis on
coumadin and ASA**.
12. Outpatient Lab Work
Please check INR on [**2154-8-23**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
1) Pneumonia
2) urinary tract infection
3) atrial fibrillation
4) dementia
5) delirium
Discharge Condition:
Stable; Good
Discharge Instructions:
Please return to the hospital with fevers or shortness of breath
ICD9 Codes: 486, 5990, 2761, 4280, 4019, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5565
}
|
Medical Text: Admission Date: [**2113-5-29**] Discharge Date: [**2113-6-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yo F with diastolic CHF (EF 60%), COPD, OSA, restrictive lung
disease [**3-2**] scoliosis, admitted with 5d h/o increased dyspnea on
exertion. She states she is normally quite inactive at home and
gets short of breath after ambulating 10 feet. For the past 5d,
she has been increasingly short of breath, even with moving
around in bed and trying to get dressed. She also reports
inreased fatigue. She has not had any chest pain with the
increased SOB. Her last episode of angina was about 2 weeks ago
after eating dinner, resolved with rest. She denies recent
headache, nausea, vomiting, diaphoresis, palpitations, or visual
changes. She denies recent dietary indiscretions. She states she
has had no recent med changes and has been adherent to her home
regimen. She has had no weight gain. She developed a mild,
minimally productive cough last night.
.
In the ED, her vitals on presentation were: T 98.9, HR 74, BP
140/68, RR 27, and O2sat 81% on RA. She received albuterol and
atrovent neb x 1 and Lasix 40mg IV.
.
Currently, she denies SOB at rest, but still experiences dyspnea
with minimal exertion such as moving around in bed. She denies
CP, N/V, palpitations.
Past Medical History:
1. Restrictive lung dz [**3-2**] scoliosis
2. Chronic hypercapnea pCO2 in 50s-100s
3. COPD
4. Diastolic dysfunction EF>55%
5. PAF
6. OSA: intolerant of BiPAP in past, uses nocturnal O2 2L NC
7. HTN
8. spinal stenosis
9. Grave's disease: s/p ablation, now on Synthroid
10. TAH [**3-2**] fibroids
11. PFO
12. Hx of lacunar infarct
13. L eye CVA: residual visual field defect, [**2101**], on coumadin
14. L cataract surgery
[**22**]. Right breast CA s/p radiation on [**2084**]
Social History:
Widow, 2 kids, lives w/ daughter, +tob 100 pk yr
Family History:
+ca, cva, 3 siblings.
Physical Exam:
vitals- T 99.3, HR 71, BP 120/48, RR 22, O2sat 85-90% 2L NC
General- elderly woman, sitting up in bed, no respiratory
distress at rest, mild tachypnea with minimal exertion
HEENT- NCAT, sclerae anicteric, poor dental hygiene
Neck- JVP flat with head at 90 deg., supple
Pulm- + rales 2/3 up, + expiratory wheeze, moderate air
movement, decreased breath sounds at both bases
CV- RRR, nl S1/S2, no m/r/g
Abd- obese, soft, NT, ND, NABS
Ext- no LE edema, DP pulses 2+ b/l
Neuro- A&Ox3, CNs III-XII intact, pt reports central visual
field defect in L eye, strength grossly intact and symmetrical
throughout, no pronator drift
Pertinent Results:
[**2113-5-29**] 12:15PM WBC-7.4 RBC-3.92* HGB-11.7* HCT-35.6* MCV-91
MCH-29.8 MCHC-32.8 RDW-15.1
[**2113-5-29**] 12:15PM NEUTS-77.7* LYMPHS-17.8* MONOS-3.5 EOS-0.8
BASOS-0.1
[**2113-5-29**] 12:15PM PLT COUNT-180
[**2113-5-29**] 12:15PM PT-38.2* PTT-35.7* INR(PT)-4.2*
[**2113-5-29**] 12:15PM CK(CPK)-42
[**2113-5-29**] 12:15PM CK-MB-2 cTropnT-0.01
[**2113-5-29**] 12:15PM CK-MB-NotDone cTropnT-<0.01 proBNP-1714*
[**2113-5-29**] 12:15PM GLUCOSE-139* UREA N-30* CREAT-1.0 SODIUM-143
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-34* ANION GAP-12
.
ECG: NSR at 70bpm, LAD and QRS 102-- LAFB, poor R wave
progression, TWI aVL, no change from prior study in [**5-3**]
.
CXR: vascular congestion, bilateral pleural effusions, no
infiltrate
.
TTE ([**4-2**]):
1. The right atrium is moderately dilated.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). E/A ratio 0.58.
3.Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6.There is borderline pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Brief Hospital Course:
.
# Dyspnea: She had several days of worsening dyspnea on exertion
at home, and was found to be hypoxic on admission. She has a
history of severe CO2 retention in the past with minimal
increase in O2 supplementation, thought secondary to CHF with
some contribution from restrictive lung disease. She has
required intubation for hypercarbic respiratory acidosis in the
past. She was ruled out for an acute MI. She had a LLL
infiltrate on chest x-ray. Although she did not have a very
convincing story or picture for pneumonia, she was started on
antibiotics for CAP due to her increased oxygen requirement.
Her bumetanide dose was increased in an effort to increased
diuresis as CHF exacerbation was thought partially responsible
for her increased O2 requirement. She has a questionable
diagnosis of COPD in the past. She was put on MDIs, steroids,
and her outpatient salmeterol for possible COPD exacerbation.
The day after admission, she was found to be hypoxic to 70s on
2L. She had normal mentation and no acute distress. She was
extremely resistant to increasing her oxygen as she is very
fearful that she will retain carbon dioxide. She went to the
MICU for a night to increase O2, and tolerated 6L well. She was
eventually weaned to 1.5-2L to keep sats >88%. However, she was
adamantly against the idea of continuous home O2 as she felt it
would significantly limit her movement and thus decreased her
quality of life. She was advised by both the housestaff and the
attending to wear her O2 as much as she possibly can at home.
She was discharged on the increased dose of bumetanide, her
outpatient salmeterol, and a prednisone taper. She will follow
up with her PCP.
.
# CHF: She has a history of diastolic CHF with EF 60% and E/A
ratio 0.58. Her bumetanide dose was increased as above. She
was maintained on her isosorbide dinitrate and nifedipine and
had good control of her blood pressure.
.
# PAF: She was initially maintained on her outpatient dose of
diltiazem. She had 2 runs of NSVT on the morning of [**6-2**], so a
third dose of diltiazem was added. She maintained sinus rhythm
and had no further NSVT. She was also maintained on Coumadin
and had a therapeutic INR.
.
# Supratherapeutic INR: She is on Coumadin for PAF and history
of CVA. Her INR was 4.2 on admission. She had no signs of
bleeding. Coumadin was held for 2 days, then started back at
her outpatient dose.
.
# FEN: Low salt diet. 1.5L fluid restriction.
.
# Code status: FULL CODE.
.
Medications on Admission:
Levothyroxine Sodium 100mcg qd, 200 mcg qSUN
Diltiazem HCl 30 mg [**Hospital1 **]
Isosorbide Dinitrate 20 mg TID
Albuterol 90 mcg/Actuation Aerosol 1-2 Puffs Q6H as needed
Folic Acid 1 mg QD
Salmeterol 50 mcg 1 Inhalation QPM
Docusate Sodium 100 mg [**Hospital1 **]
Sodium Chloride 0.65 % Aerosol TID
Bumetanide 2mg po QD
Discharge Medications:
1. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) inh
Inhalation DAILY (Daily).
9. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
10. Diltiazem HCl 30 mg Tablet Sig: 0.5-1 Tablet PO QHS (once a
day (at bedtime)): Take 1 tab in the morning and the afternoon,
then take 0.5 tab at bedtime.
Disp:*72 Tablet(s)* Refills:*2*
11. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
12. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
13. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) inh
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*2 inhalers* Refills:*0*
14. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 3 days: Please take 6 tabs on [**6-6**], then 5 tabs on [**6-7**],
then 4 tabs on [**6-8**].
Disp:*15 Tablet(s)* Refills:*0*
15. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day
for 7 days: Please take 7 tabs on [**6-9**] tabs on [**6-10**] tabs
on [**6-11**] tabs on [**6-12**] tabs on [**6-13**] tabs on [**6-14**], and 1
tab on [**6-15**].
Disp:*28 Tablet(s)* Refills:*0*
16. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
community-acquired pneumonia
CHF exacerbation
Discharge Condition:
good
Discharge Instructions:
Please take all of your medications as prescribed.
It is advised that you wear your oxygen at 2L at all times.
If you experience worsening shortness of breath, chest pain,
fever>101, or other concerning symptoms, please call your doctor
or go to the ER.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 102299**], to
schedule an appointment within the next 2 weeks.
Completed by:[**2113-6-6**]
ICD9 Codes: 486, 496, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5566
}
|
Medical Text: Admission Date: [**2141-3-3**] Discharge Date: [**2141-3-31**]
Date of Birth: [**2069-2-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ambien
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Transesophageal Echocardiogram
History of Present Illness:
Mr [**Known lastname **] is a 71-year-old man with a PMHx significant for
systolic HF (EF 20-25%), old anterior wall MI, paroxysmal AV
block, atrial fibrillation, ventricular tachycardia, history of
ventricular fibrillation in the past, status post eventual BiV
ICD implantation with subsequent revisions due to the presence
of malfunctioning Fidelis lead, who presented to the ED this
morning with a chief complaint of dyspnea. The patient reports
that he began having a cough productive of dark beige sputum for
the past week. He also had some low-grade temps at home (Tm
99.8) earlier this week. He called his cardiologist on [**2141-2-28**],
complaining of this cough and LE edema. He was told to increase
his lasix to 60mg TIW and 40 mg daily the rest of the week. He
then presented to gerontology clinic on [**2141-3-1**] with similar
complaints. CXR and CBC done that day were unremarkable. He then
developed dyspnea over the past 24-36 hours. He called
cardiology clinic this morning and was instructed to present to
the ED.
On arrival to the ED, the patient's VS were 97.1 80 100/60 22
96. He was noted to have crackles half-way up bilaterally. CXR
reportedly showed changes c/w pulmonary edema as well as a ? LLL
opacification. In the ED, he received Levofloxacin 750mg,
Vancomycin 1g, Ondansetron 4mg, and Furosemide 40mg. He was
admitted to the CCU for further management.
On arrival to the CCU, the patient's VS were T= 98.7 BP=
103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP. He reported that his
dyspnea was improved. He stated that the chest pressure that he
experienced earlier had resolved. He endorses recent worsening
DOE and PND. He also reports some chest pressure last night and
this morning, which was located across his chest, did not
radiate, and has since resolved. He reports recent 5-pound
weight gain. He also reports recent loose stools and stable
urinary frequency.
On review of systems, he denied any prior history of stroke.
He did report a questionable history of TIA. He denied any
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains, hemoptysis, black
stools or red stools. He denied recent chills or rigors. He
denied exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence of
palpitations or syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
- Anterior wall myocardial infarction in [**2126**] with ventricular
tachycardia and complete heart block requiring pacemaker
- Systolic heart failure (EF 20-25%)
- Atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Anemia.
4. Irritable bowel syndrome.
5. Constipation.
6. Obesity.
7. Hearing loss, requiring bilateral hearing aids.
8. Squamous cell carcinoma of the left lower eyelid.
9. Vitamin D deficiency.
10. Cerebral infarct.
11. Falls.
12. Compression fractures.
13. History of Whipple operation, with subsequent E. coli and
Klebsiella bacteremia
14. History of possible C3-C4 osteomyelitis
15. Abdominal hernia secondary to Whipple procedure
PAST SURGICAL HISTORY:
1. Placement of pacemaker and ICD.
2. Knee surgery.
3. Removal of squamous cell carcinoma of his left lower eyelid.
4. Recent Whipple's procedure for which he was diagnosed with
dysplasia.
Social History:
Teaches history at [**University/College 15559**]. Divorced, 2 children.
Lives in [**Location **], but is staying intermittently in [**Location (un) **] with his
[**Last Name (LF) 15560**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Former pipe and cigarette smoker (quit
>10 years ago). Used to smoke 1ppd X 30 yrs. Drinks [**12-24**] glasses
of wine/day. No drugs. Health Care Proxy: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Family History:
Strong family history of vascular disease with father deceased
of CVA at 59, Mother with MI at 70, Brother with MI and CABG in
50's. Also reports a family history of diabetes.
Physical Exam:
Admission Exam:
VS: T= 98.7 BP= 103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP
GENERAL: Alert, NAD. Oriented x3. Mood, affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.
NECK: Supple. Unable to appreciate JVP.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use. Pt with
high-flow neb O2 mask on. Crackles noted [**12-24**] to [**2-23**] of the way
up bilaterally. Scattered wheezes as well.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral
hernia present.
EXTREMITIES: No significant LE edema noted. No calf pain. DP
pulses palpable bilaterally.
Pertinent Results:
Admission Labs
[**2141-3-3**] 10:15AM BLOOD WBC-7.1 RBC-3.71* Hgb-11.9* Hct-35.3*
MCV-95# MCH-32.0 MCHC-33.7 RDW-14.4 Plt Ct-166
[**2141-3-3**] 10:15AM BLOOD Neuts-78.8* Lymphs-13.5* Monos-5.0
Eos-2.3 Baso-0.5
[**2141-3-3**] 10:15AM BLOOD PT-24.2* PTT-33.2 INR(PT)-2.3*
[**2141-3-3**] 10:15AM BLOOD Glucose-152* UreaN-28* Creat-1.1 Na-135
K-4.4 Cl-99 HCO3-25 AnGap-15
[**2141-3-3**] 10:15AM BLOOD ALT-27 AST-36 CK(CPK)-126 AlkPhos-139*
TotBili-0.6
[**2141-3-3**] 10:15AM BLOOD Lipase-64*
[**2141-3-3**] 10:15AM BLOOD cTropnT-<0.01
[**2141-3-3**] 10:15AM BLOOD CK-MB-4 proBNP-3057*
[**2141-3-3**] 10:15AM BLOOD Albumin-4.1
[**2141-3-3**] 10:25AM BLOOD Lactate-2.0
[**2141-3-3**] 11:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2141-3-3**] 11:10AM URINE Blood-NEG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-3-3**] 11:10AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
CXR ([**2141-3-3**]) - IMPRESSION: Increased pulmonary edema.
Superimposed infectious process in
the left lower lobe cannot be excluded. Recommend follow-up post
diuresis.
CT Chest ([**2141-3-7**]) - IMPRESSION:
1. No intrathoracic abscess. Bilateral non-hemorrhagic
small-to-moderate pleural effusions, minimally loculated, if at
all, on the right.
2. Severe lower lobe and moderate upper lobe atelectasis.
Minimal pneumonia cannot be excluded.
3. Mediastinal lymphadenopathy, likely reactive.
CT Head ([**2141-3-11**]) - IMPRESSION: No evidence of infectious or
other acute process.
CT Abd/Pelvis ([**2141-3-11**]) - IMPRESSION:
1. No evidence of infectious process in the abdomen or pelvis.
2. Ground-glass opacity in lung bases may partially be explained
by fluid overload, although an infectious component should be
considered.
3. Slightly increased bilateral small pleural effusions with
associated atelectasis.
4. Unchanged postoperative findings related to prior Whipple and
hepatojejunostomy, with soft tissue in the postoperative bed,
which appears stable, of unclear significance.
5. Apparently new rectus muscle herniation containing
non-obstructed bowel.
6. Unchanged compression fracture of L1.
TEE ([**2141-3-14**]) - No atrial septal defect is seen by 2D or color
Doppler. There is moderate to severe regional left ventricular
systolic dysfunction with septal, inferoseptal and inferior
hypokinesis. There are complex (>4mm) atheroma in the descending
thoracic aorta. 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. No mass or vegetation is seen on the
mitral valve. Moderate to severe (3+) mitral regurgitation is
seen. Moderate to severe [2+] tricuspid regurgitation is seen.
There is at least mild pulmonary artery systolic hypertension.
No vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No vegetations seen on the pacemaker/ICD leads (at
least 4 wires identified in the right atrium) or on the valves.
Depressed left ventricular systolic function. Moderate to severe
mitral regurgitation. At least mild pulmonary hypertension.
Complex atheroma in descending aorta.
Brief Hospital Course:
71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI
in '[**26**], paroxysmal AV block, atrial fibrillation, h/o v.tach and
v.fib s/p ICD implantation, who presented to the ED this morning
with a chief complaint of dyspnea, likely due to CHF
exacerbation.
Respiratory Failure
Pt's respiratory distress initially was thought to be related
to CHF exacerbation in the setting of possible dietary
indiscretion. He was given IV lasix initially with good urine
output. However, later on the evening of admission, he became
febrile and CXR was c/w possible PNA. Pt was started on
vanc/cefepime and was continued on azithromycin (started in ED)
as broad coverage for a possible PNA. On the following evening
([**2141-3-4**]), pt had worsening respiratory status and was
intubated. Thus, respiratory failure was attributed to both
decompensated congestive heart failure as well as pneumonia.
Despite being on broad spectrum abx, the patient continued to
spike fevers, and his abx were eventually switched to meropenem
monotherapy (see below). Bronch was performed but did not reveal
an obvious infective process. With diuresis and abx therapy,
pt's respiratory status improved. He was ultimately extubated on
[**2141-3-14**]. He was subsequently re-intubated for pacemaker
procedure on [**2141-3-23**] and extubated the following day on [**2141-3-24**].
He did not have any respiratory comlpications following this.
Fevers
As above, the patient began to spike fevers on the evening of
admission. At that time, he was started on
vanc/cefepime/azithromycin as broad coverage for a suspected
PNA. When he continued to spike fevers on this regimen, viral
screens were sent and his antibiotic regimen was changed to
meropenem. ID was consulted, as the patient has a complex
medical history involving chronic cefpodoxime for ongoing
suppression after high-grade viridans streptococcal bacteremia
as well as suspected Klebsiella pneumoniae ICD/pacer lead
endocarditis during a prior bacteremia. The patient's pacer was
interrogated, and it was found that his ICD was not functioning
properly. Despite recurrent fevers, even when he was on
meropenem, the patient did not have any positive culture data,
aside from yeast in the sputum and one positive blood culture
(which was a likely contaminant). TEE was performed and did not
show any evidence of vegetation. The patient's fevers ultimately
subsided. With no positive culture data to guide therapy, his
antibiotics were d/c'ed and he was placed back on his chronic
cefpodoxime regimen per his infectious disease physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 3197**] whom he will follow up with this month.
ICD Malfunction
As explained above, the patient's pacer was interrogated early
in his hospital course, and it was noted to not be working
properly. On the afternoon of [**2141-3-12**], he went into to VT and
was unable to be paced out of it by his pacer. He then went into
VF arrest, and his ICD did not shock him out of it.
Consequently, he received approximately 2 minutes of CPR and 1
external defibrillation with return of a perfusing rhythm. On
the morning of [**2141-3-17**], the patient had an additional episode of
VF, for which he required external defibrillation and CPR. After
this, his pacer was set at a higher rate to avoid fast-slow-fast
sequences that may have precipitated the episode of ventricular
tachycardia. Throughout all of this, the patient was followed by
the EP service. Plans were made to take the patient to the OR
for possible removal and replacement of his leads. The patient's
dose of amiodarone was also briefly increased in an attempt to
prevent episodes of VT; his metoprolol was also increased. On
[**2141-3-23**] the patient underwent two lead extractions (R ventricular
and R atrial) and ICD implant without complications. He was
extubated the following day. He was discharged with increased
doses with amiodarone and metoprolol.
Altered mental status
Patient exhibited aggitation consistent with ICU delerium
post-intubation. He was pan cultured, but did not have evidence
of infection. It was thought that he may have also sufferred
anoxic brain injury during his multiple v fib arrest/v tach.
However, over a few days his mental status dramatically
improved. He then went for his ICD lead revision and following
extubation became acutely aggitated again. He received ativan
.5 mg IV x 2, which worsened his delerium. Small doses of
haldol and zydis were tried, but did not have good effect
either. The patient was started on seroquel standing dose at
night plus PRNs and he had drastic improvement in his mental
status. His paxil was also weaned down to 20 mg a day and
should continue to be weaned off slowly over the next few weeks.
He is being discharged on 6.26 mg seroquel Q HS. He required
one extra PRN dose the night before discharge and was slightly
disoriented the morning of discharge. However, overall his
mental status has improved dramatically, and this is likely the
result of his prolonged ICU stay. All labs have remained normal
and there are no signs of infection or metabolic abnormalities.
Coronary Artery Disease
Pt with a history of an anterior wall MI in [**2126**]. Of note, the
patient did report some chest pressure prior to admission.
However, on arrival to the CCU, he denied any chest pain. He
ruled out for ACS with three sets of CE's. He was continued on
metoprolol and aspirin.
Atrial Fibrillation
Pt with a history of a.fib, for which he takes coumadin. In
anticipation for possible procedures regarding his ICD, the
patient was taken off of coumadin and placed on a heparin gtt in
the meantime. He was restarted on coumadin 3 mg once a day and
his INR was elevated to 3.4. His coumadin was subsequently
decreased to 2 mg a day. His INR will need to be checked daily
and his coumadin adjusted as needed for a goal [**1-25**]. He may
require a lower dose still given he is now on amiodarone which
can interact with INR.
Hypotension
Normotensive on presentation. On pressors (levophed) for a
short time after he was intubated. After he was weaned off of
pressors, his beta blocker was able to be restarted. On [**3-27**] -
[**3-28**] he was noted to have hypotension to the 70's systolic when
sitting/standing up. This was thought to be due to poor PO
intake and volume contraction. The patient continued to mentate
well despite the hypotension. He was given IV fluid boluses
with response in his blood pressure. As he continues to improve
his PO intake this is expected to resolve. He should continue
to have holding parameters on his beta blocker to prevent
hypotension in the meantime. He was not ressztarted on an ACE
inhibitor due to the low blood pressures. This may be restarted
at a later date by his PCP/cardiologist if his blood pressures
will tolerate it.
Congestive Heart Failure
As stated above the patient will continue on his regimen of
aspirin and metoprolol with holding parameters. His ACEi was
held as stated above due to hypotension and may be restarted at
low dose (2.5 mg) in the future as blood pressure tolerates it.
Nutrition and Dysphagia
The patient was on tube feeds while he was intubated and
sedated. Following each intubation he had profound aggitation
and delerium. He failed his swallow studies several times and
had to have a dobhoff tube placed. Due to his aggitation he
self-removed his dobhoff tube and his nutrition was interrupted
several times. On day 5 following his intubation, discussions
were held whether he should have a bridled NGT placed versus a
PEG tube. It was decided that he would get a PEG tube as this
was thought to be less disturbing to the patient versus a long
term bridled NGT that he might try to pull out, and it would
only be temporary until his dysphagia improved. However, that
morning he passed his swallow study. He was restarted on a
pureed diet with nectar thick liquids. It is anticipated that
his swallow function will continue to improve during rehab.
Increased CK
Pt was noted to have elevated CK, peaking at 2723. CK-MB and
troponin were unremarkable. His statin was held, and his CK's
were trended. They continued to improve.
Hypothyroidism
The patient's levothyroxine was continued at 50 mcg daily.
Anemia
Pt with a history of anemia, baseline Hct of approx. 33-35. Pt
currently near his baseline. He was continued on iron
supplementation.
S/p Whipple
Was continued initially on pancreatic enzyme repletion, which
were stopped when the patient was on tube feeds. These were
restarted when he was able to take PO again.
CODE: FULL CODE, confirmed with patient and his HCP
[**Name (NI) **]: HCP is [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 15561**])
Medications on Admission:
AMIODARONE - 200 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
CEFPODOXIME - 100 mg Tablet - 2 Tablet(s) by mouth twice daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth Tues/[**Last Name (un) **]/Sat/Sun and 1.2 tabs (60mg) on
M/W/F
LEVOTHYROXINE [LEVOXYL] - 50 mcg Tablet - 1 (One) Tablet(s) by
mouth once a day
LIPASE-PROTEASE-AMYLASE [PANCREASE MT 10] - 30,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth 3x/day
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth once a day
NYSTATIN - 100,000 unit/mL Suspension - 1 (One) tsp by mouth [**2-23**]
times/day swish in mouth and swallow
PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40 mg
Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth
DAILY
PAROXETINE HCL [PAXIL] - 30 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
SIMVASTATIN [ZOCOR] - 20 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime Start
with 1/2 pill. [**Month (only) 116**] increase to 1 pill if needed; may increase to
total of 2 pills as needed
WARFARIN - 1 mg Tablet - 1 (One)-3 Tablet(s) by mouth as
directed by MD
ACETAMINOPHEN - (OTC) - Dosage uncertain
ASCORBIC ACID - (Prescribed by Other Provider) - 250 mg Tablet -
1 Tablet(s) by mouth daily
ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) - 81
mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth
once a day
FERROUS SULFATE [SLOW FE] - 142 mg (45 mg Iron) Tablet Sustained
Release - 1 (One) Tablet(s) by mouth every other day
LACTOBACILLUS ACIDOPHILUS [ACIDOPHILUS] - (OTC) - Dosage
uncertain
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet
- 1 (One) Tablet(s) by mouth once a day
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pancrease MT 10 10,000-30,000 -30,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
TIDAC.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Slow Fe 142 mg (45 mg Iron) Tablet Sustained Release Sig:
One (1) Tablet Sustained Release PO once a day.
12. Lactobacillus Acidophilus Miscellaneous
13. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a
day.
14. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary
- Acute on Chronic Heart Failure
- Ventricular Fibrillation / Cardiac Arrest
- Hospital acquired pneumonia
- Delerium
Secondary:
- coronary artery disease
- hyperthyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the ICU with worsening of your heart
failure. Soon after admission, your respiratory status worsened,
and you were intubated. It was felt that you might also have a
pneumonia, so you were started on antibiotics. Additionally,
while you were in the hospital, you had 2 episodes of abnormal
heart rhythms for which you required CPR and electrical shocks.
Your internal defibrillator was interrogated and was felt to not
be functioning properly so it was replaced. You also developed
some delerium in the ICU and had trouble swallowing food. Your
mental status is now improving and you are able to take pureed
food.
CHANGES TO YOUR MEDICATIONS:
**Increase amiodarone to 200 mg once a day
**Increase metoprolol to 25 mg once a day
**Decrease Paxil to 20 mg once a day
**Decrease coumadin to 2 mg a day
**Stop lasix
**Stop simvastatin
**Stop trazodone
Please weigh yourself every morning and call your doctor if you
weight goes up more than 3 lbs.
Followup Instructions:
Please follow-up with:
Cardiology:
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-4-13**] 3:00
Infectious disease:
Provider: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD
Date/Time:[**2141-4-4**] 2:00
Primary care provider:
[**Name10 (NameIs) 357**] call your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to schedule
a follow up appointment after you leave rehab. The phone number
is: [**Telephone/Fax (1) 719**]
ICD9 Codes: 486, 4275, 4254, 2760, 4280, 412, 4019, 4589, 2449, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5567
}
|
Medical Text: Unit No: [**Numeric Identifier 69109**]
Admission Date: [**2188-9-6**]
Discharge Date: [**2188-9-16**]
Date of Birth: [**2188-9-6**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] [**Last Name (NamePattern1) **] is the
former 34 and [**3-11**] week gestational age twin who is discharged
home on day of life 10 with corrected gestational age of 35
and 6/7 weeks. She was born to a 36 year-old, Gravida VIII,
Para 1 to 3 woman with previous history notable for preterm
delivery. Prenatal screens were as follows: A positive, HBS
antigen negative, RPR nonreactive, Rubella immune, GBS
unknown. Estimated delivery date of [**2188-10-15**]. She
was delivered on [**2188-9-6**]. Pregnancy was complicated
by twin gestation and pregnancy induced hypertension. Repeat
Cesarean section for pre-eclampsia, twin gestation under
epidural and spinal anesthesia. There was no fever or other
clinical evidence of chorioamnionitis. Intrapartum
antibiotics prophylaxis was not administered. Rupture of
membranes occurred at delivery and yielded clear amniotic
fluid. Infant emerged vigorous, orally and nasally bulb
suctioned and dried. Subsequent mild grunting respirations
but pink in room air. Apgars at 1 minute was 7, 8 at 5
minutes. She was transported to the NICU on facial C-pap.
PHYSICAL EXAMINATION: Term infant on facial C-pap. Birth
weight is 2295 grams. Length 48.5 cm. Head circumference is
32.5 cm. Heart rate 158. Respiratory rate 60 to 70.
Temperature 97.2. blood pressure 56/40 with a mean of 48.
Anterior fontanel soft and flat, non dysmorphic infant,
palate intact. Neck and mouth normal. Normocephalic. Chest:
Mild intercostal retractions. Good breath sounds bilaterally.
No adventitial sounds. Cardiovascular: Well perfused,
regular rate and rhythm. Femoral pulses normal and
symmetrical. S1 and S2 normal. No murmur. Abdomen soft,
nondistended. No organomegaly. No masses. Breath sounds
active. Anus patent. Three vessel umbilical cord.
Appropriate tone for gestational age. Normal spine, limbs,
hips and clavicles.
D-stick on admission 36. Chest x-ray with 8th rib expansion,
diffuse ground glass opacities, consistent with surfactant
deficiency.
CBC with 9000 white blood cells, 24 polys, 0 bands, 67
lymphs. Hematocrit 56.9. Platelets 287.
HOSPITAL COURSE: Respiratory: Due to worsening respiratory
distress, infant was intubated shortly after admission. Two
doses of Surfactant were given in the first 24 hours with
significant improvement in ventilation. She was extubated to
C-pap on day of life #2 and weaned to room air by day of life
#3. She remained on room air since [**2188-9-8**]. She was
monitored for signs of apnea of prematurity but remained
spell free through her hospital course.
Cardiovascular: Remained stable through hospital course. No
murmur was appreciated.
FEN/GI: On admission, she was made n.p.o. and started on IV
fluids D-10-W. Feeds were introduced on day of life 2. She
quickly advanced to full feeds and was off IV fluids by day
of life #3. She remained at full p.o. feeds with breast milk,
Similac 24 calories since [**9-13**], day of life #7. She
was followed for hyperbilirubinemia. Her bilirubin peaked at
12.0 over 0.3 on day of life #3 and she was treated with
phototherapy. Phototherapy was discontinued on day of life 5
and rebound bilirubin was 8.2 over 0.3 on day of life #6. Her
discharge weight was 2290 grams.
Hematology: Initial CBC reassuring. Clinical course stable.
No blood products were given through hospital stay.
Infectious disease: Initial blood cultures were negative at
48 hours. She was treated for sepsis rule out with Ampicillin
and Gentamycin IV for 48 hours and they were discontinued on
day of life 3. She remained stable since then.
Neurology: Reassuring clinical exam. No head ultrasounds
were done since the infant was over 32 weeks gestational age.
Audiology: Hearing screen was done prior to discharge and
infant passed on both ears.
Ophthalmology: Infant over 32 weeks gestational age. No
ophthalmology exam warranted. Clinical course was reassuring.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Discharge home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43888**] from Wellesly
Pediatric Associates ([**Telephone/Fax (1) 69110**] .
FEEDS AT DISCHARGE: Full p.o. feeds with breast milk,
Similac supplemented to 24 calories with Similac powder.
MEDICATIONS: Nystatin ointment to diaper area.
CAR SEAT TEST: Passed prior to discharge.
STATE NEWBORN SCREEN: Sent on [**2188-9-16**].
IMMUNIZATIONS: Hepatitis B vaccine was given on [**2188-9-9**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 weeks and 35 weeks with two of
the following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP: Follow-up with primary care doctor [**First Name (Titles) **] [**2188-9-18**] at 11:20.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestational age, resolved.
2. Sepsis, ruled out, resolved.
3. Respiratory distress syndrome, resolved.
4. Hyperbilirubinemia, resolved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Doctor First Name 69111**]
MEDQUIST36
D: [**2188-9-16**] 07:51:16
T: [**2188-9-16**] 08:15:07
Job#: [**Job Number 69112**]
ICD9 Codes: 769, 7742, V053, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5568
}
|
Medical Text: Admission Date: [**2183-10-20**] Discharge Date: [**2183-10-20**]
Date of Birth: [**2124-6-6**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History very limited by patient's somnolence and largely
obtained by medical records and report from other caregivers. 59
[**Name2 (NI) **] with a history of polysubstance abuse, who was reportedly
recently discharged from [**Hospital 1474**] Hospital after a fall, later
found down and brought to the [**Hospital1 18**] ED. It is unclear if the
reported fall is different than the fall resulting in left-sided
rib fractures and pain noted in OMR occurring ~2 months ago. He
notes drinking 1 pint of vodka on day of presentation, followed
by vomiting and a syncopal episode that he relates as a seizure,
but denied loss of continence, tongue biting. Per ED report, he
also took morphine prior to admission, although he denies this
in the ICU.
.
In the [**Hospital1 18**] ED, initial vitals revealed: HR=89 BP=134/95 RR=18
SaO2=99%RA. He became unresponsive and had generalized tonic
clonic seizure x2. He received naloxone and lorazepam, with
improvement to A&Ox2 five minutes later. Also given 1L NS. Head
CT, CXR, and EKG were normal. He was afebrile with a normal
white count, tox screen positive for benzodiazepines, and EtOH
level of 56. He is admitted to the MICU with concern for EtOH
withdrawal. Prior to transfer, his vital signs were: 98.0 72
110/77 18 99%,2L.
.
On review of systems, he confirms left-sided chest wall pain,
although denies HA, blurry vision, fevers, chills, dyspnea.
Patient became agitated and continually repeated "no" with
further ROS.
Past Medical History:
Alcoholism, chronic - (active drinker)
Polysubstance abuse
Intravenous drug abuse.
Chronic HCV infection
Remote history of vertebral osteomyelitis
Low Back Pain / Degenerative disease
Vertebral compression fractures.
Diabetes mellitus type II
Pseudo-seizures
Hypertension
Depression
Left parietal bone lesion NOS - ?atypical hemangioma
Calf injury [**2175**] with left gluteal transplant to left calf
Social History:
(per OMR, patient uncooperative with confirming) He drinks 1/2-1
pint of vodka per day. Also uses cocaine. Positive tobacco with
one half of a pack per week. He used intravenous heroin 30 years
ago. He is unemployed, on disability. Emigrated from [**Male First Name (un) 1056**]
in [**2132**]. Pt is a veteran, homeless. He has a sister in [**Name (NI) 392**]
but does not know where she lives. Also one sister in [**Name2 (NI) **]
[**Name (NI) **]. Not in contact with his family. No friends. Wife died
last spring.
Family History:
(per OMR) Positive for diabetes
Physical Exam:
GENERAL: Somnolent male, NAD, awakens and responds to voice,
easily agitated
HEENT: No scleral icterus. PERRLA/EOMI. MM dry.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. No chest wall
tenderness.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema, WWP, 2+ radial and posterior tibial
pulses.
SKIN: No rashes.
NEURO: Somnolent, oriented x3. CN 2-12 grossly intact. [**4-29**]
strength throughout.
Pertinent Results:
Laboratory studies:
[**2183-10-20**] 12:44AM BLOOD WBC-8.2 RBC-4.23* Hgb-12.1* Hct-36.4*
MCV-86 MCH-28.5 MCHC-33.2 RDW-15.4 Plt Ct-296
[**2183-10-20**] 12:44AM BLOOD Neuts-57.9 Lymphs-31.3 Monos-6.4 Eos-3.8
Baso-0.7
[**2183-10-20**] 12:44AM BLOOD Glucose-80 UreaN-11 Creat-0.7 Na-143
K-3.4 Cl-104 HCO3-27 AnGap-15
[**2183-10-20**] 12:44AM BLOOD ASA-NEG Ethanol-56* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
Microbiology:
[**2183-10-20**] MRSA Screen: positive
.
Reports:
.
CT head [**2183-10-20**]: No acute intracranial process.
.
CXR [**2183-10-20**]: No acute intrathoracic process.
Brief Hospital Course:
1. Seizure/EtOH withdrawal: The patient had a witnessed seizure
in the [**Hospital1 18**] emergency department. This was thought to be due to
EtOH withdrawal. The patient was admitted to the ICU for close
monitoring. He was treated with diazepam per CIWA scale with
good clinical response. He also received IV thiamine, folate,
and multivitamin. No further evidence for seizures or DTs. The
morning after admission, the patient's left against medical
advice (AMA; see below).
.
2. Altered mental status: Thought to be related to polysubstance
abuse, EtOH withdrawal, post-ictal state. Head CT negative.
Patient left AMA before he could undergo further evaluation.
.
3. Leaving AMA: On the morning after admission to the ICU (the
patient was admitted overnight), the patient signed himself out
AMA. At the time, he was A+Ox3 and was able to state the risks
of leaving the hospital. The ICU, nurses, residents, fellow, and
attendings emphasized the dangers of leaving (including contined
risk for seizures, delirium tremens, and death) and tried to
convince the patient to stay. However, the patient decided to
sign himself out AMA. It was felt that the patient was compitant
had the capacity to make the decision to sigh out AMA, although
the ICU team did not agree with the patient's decision and
strongly advised the patient to remain in the hospital.
Medications on Admission:
(1,2 per OMR. 3-7 per rx found on patient dated "[**10-19**]")
1. Verapamil 180 mg daily
2. Citalopram 20 mg daily
3. Dilantin 50mg daily
4. Dilantin XL 400mg daily
5. Lisinopril 10mg [**Hospital1 **]
6. Thiamine 100mg daily
7. Metoprolol 50mg [**Hospital1 **]
Discharge Medications:
Patient signed out of hospital against medical advice (AMA)
Discharge Disposition:
Home
Facility:
left against medical advice
Discharge Diagnosis:
1. EtOH withdrawal seizures
2. EtOH abuse
Discharge Condition:
left against medical advice
Discharge Instructions:
The patient left against medical advice. He was advised to stay
at the hospital for further treatment. He was told that he could
return at any time.
Followup Instructions:
The patient was advised to stay at the hospital for further
treatment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 4019, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5569
}
|
Medical Text: Admission Date: [**2186-5-18**] Discharge Date: [**2186-6-9**]
Date of Birth: [**2117-6-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fevers, malaise
Major Surgical or Invasive Procedure:
right hepatectomy and small bowel resection of GIST [**2186-5-18**]
History of Present Illness:
The patient is a 68 year- old male who recently presented with
fever and malaise. A CT scan of the chest and abdomen
demonstrated 2 small left upper lobe pulmonary nodules of
uncertain etiology but concerning for malignancy. His abdominal
CT demonstrated a left lower quadrant mass that on biopsy was
demonstrated to be a GIST tumor that was C-kit positive. In
addition, this CT
demonstrated a large mass in the right lobe of the liver that
was initially thought to represent an abscess but an attempted
CT guided drainage demonstrated only a small amount of blood.
Biopsies demonstrated only granulation tissue. The patient had a
recent follow-up CT scan that demonstrated
rapid and significant enlargement of the right lobe mass. It was
uncertain whether this represented a liver abscess or a tumor
with necrosis and secondary infection. Because of the rapid
enlargement of the mass and inability to drain this
percutaneously along with continued fevers and malaise, the
patient is brought to the operating room after informed consent
was obtained for right hepatic lobectomy, cholecystectomy and
resection of the left lower quadrant GIST
tumor.
Past Medical History:
Hypertension
Hypercholesterolemia
Benign esophageal growth
h/o prostate CA s/p resection in [**2179**]
Social History:
Denies tobacco, drinks 2 glasses of wine after dinner, retired,
married
Family History:
NC
Pertinent Results:
ADMISSION LABS --->
[**2186-5-18**] 09:50PM BLOOD WBC-18.6* RBC-3.36* Hgb-9.3* Hct-28.1*
MCV-83 MCH-27.5 MCHC-33.0 RDW-15.6* Plt Ct-745*
[**2186-5-18**] 09:50PM BLOOD PT-15.3* PTT-33.5 INR(PT)-1.4*
[**2186-5-18**] 09:50PM BLOOD Glucose-100 UreaN-19 Creat-1.3* Na-132*
K-4.9 Cl-94* HCO3-26 AnGap-17
[**2186-5-18**] 09:50PM BLOOD ALT-51* AST-26 AlkPhos-321* Amylase-61
TotBili-0.6
[**2186-5-18**] 09:50PM BLOOD Lipase-32
[**2186-5-18**] 09:50PM BLOOD Albumin-3.2* Calcium-9.1 Phos-4.2 Mg-2.3
[**2186-5-19**] 04:43AM BLOOD calTIBC-198* Ferritn-264 TRF-152*
[**2186-5-31**] 05:00AM BLOOD Triglyc-50
[**2186-5-28**] 05:30AM BLOOD Triglyc-41
[**2186-5-26**] 06:45PM BLOOD Ammonia-31
[**2186-5-26**] 06:57PM BLOOD TSH-0.63
[**2186-5-26**] 06:57PM BLOOD Free T4-1.4
[**2186-5-26**] 06:57PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2186-5-26**] 06:57PM BLOOD CEA-1.8 PSA-<0.1 AFP-2.1
[**2186-5-21**] 03:30PM BLOOD AFP-1.1
[**2186-5-26**] 06:57PM BLOOD HIV Ab-NEGATIVE
CERULOPLASMIN 16 L 18-36 MG/DL
Alpha-1-Antitrypsin, S 167 100-190
mg/dL
HERPES I (IGG) ANTIBODY 4.16 A NEGATIVE
HERPES II (IGG) ANTIBODY NEGATIVE NEGATIVE
CA [**98**]-9 49 H 0-37 SEE NOTE
COCCIDIOIDES ANTIBODY, ID NEGATIVE NEGATIVE
.
DISCHARGE LABS --->
[**2186-6-9**] 05:45AM BLOOD WBC-6.9 RBC-2.90* Hgb-8.8* Hct-26.5*
MCV-91 MCH-30.4 MCHC-33.3 RDW-20.8* Plt Ct-192
[**2186-6-9**] 05:45AM BLOOD Plt Ct-192
[**2186-6-9**] 05:45AM BLOOD PT-14.9* PTT-33.2 INR(PT)-1.3*
[**2186-6-9**] 05:45AM BLOOD Glucose-76 UreaN-26* Creat-1.3* Na-128*
K-4.7 Cl-99 HCO3-23 AnGap-11
[**2186-6-9**] 05:45AM BLOOD ALT-86* AST-74* AlkPhos-210*
TotBili-11.9*
[**2186-6-8**] 05:00AM BLOOD Lipase-106*
[**2186-6-9**] 05:45AM BLOOD Albumin-2.3* Calcium-8.2* Phos-2.6*
Mg-2.3
[**2186-5-29**] 03:44AM BLOOD calTIBC-95* Ferritn-243 TRF-73*
.
IMAGING/STUDIES --->
.
[**5-19**] CT Abd/Pelvis:
IMPRESSION:
1. Unchanged left upper lobe ground-glass ill-defined nodules
may represent metastatic disease versus primary pulmonary
neoplasm.
2. Left lower quadrant mass as described consistent with biopsy
proven GI stromal tumor.
3. Large multiloculated low-density collection with enhancing
rim seen on prior examination, slightly increased in size and in
segment VI consistent with progression of hemorrhage/malignancy.
4. Diverticulosis without evidence of diverticulitis.
5. Stable lymph nodes in the gastrohepatic ligaments and in the
retroperitoneum.
6. New trace perihepatic fluid.
.
[**5-19**] CT Head:
IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. Maxillary sinusitis.
.
[**5-19**] Liver biopsy:
Liver core biopsy: Granulation tissue with a focally prominent
acute inflammatory component. Organizing fibrinous exudate.
The adjacent hepatic parenchyma shows acutely inflamed portal
triads; no malignancy identified.
.
[**5-23**] Duplex:
CONCLUSION: Status post right hepatic lobectomy with patent
portal, hepatic arterial and hepatic venous flow. Echogenic
material surrounding the remaining liver may represent areas of
surgical packing, omental plugs and/or Surgicel.
.
[**5-25**] KUB:
IMPRESSION:
1. Multiple dilated loops of small bowel and large bowel. This
appearance is suggestive of ileus.
2. Bilateral atelectatic changes are noted at lung bases, more
prominent on the right.
3. Small pneumoperitoneum, not unexpected after recent surgery.
.
[**5-26**] US:
IMPRESSION: Limited exam. The portal vein is patent with
antegrade flow. The appearance of the liver parenchyma and
adjacent small hematoma is not significantly changed from 3 days
earlier.
.
[**6-2**] KUB:
IMPRESSION: Non-obstructive bowel gas pattern.
.
[**6-4**] Duplex:
IMPRESSION: Patent portal veins, hepatic veins, and main hepatic
artery. Left and right branches of the hepatic artery are not
visualized on today's study, possibly secondary to technical
factors.
.
Brief Hospital Course:
This patient was admitted to the transplant surgical service on
[**5-18**] with the chief complaint of fevers and malaise. A CT head
and CT abd/pelvis were obtained (see reports above), and he was
started on his home medications. On admission, his temperature
was 102.1. A CXR showed no acute cardio-pulmonary process. On
[**5-19**], the pt was seen by Thoracic Surgery and had a liver biopsy
performed. He was also seen by GI and ID and nutrition labs were
sent. On [**5-21**], the pt was found to have a positive C.Diff (sent
for watery stools). On [**5-22**], the patient was seen by the urology
service, and in light of his urological history, he had a Foley
placed via cystoscopy during his surgery. Patient was taken to
the OR on [**5-22**] for his procedure (see operative note for
details). He was taken to the ICU after his procedure and
extubated the same day. He had a PA line in place, with a CVP
from [**2-11**] and making approx 10-15cc/hr of urine. Overnight of
POD0, he received 2 Litres in fluid bolus in total for low urine
output and SBP in the 80's. Overnight of POD0, the patient was
sleepy and not following commands. On POD1, the patient remained
very sleepy and was not responding to stimuli. He was then given
IV narcan by the ICU team, and was then noted to become more
awake. On [**5-23**] (POD1), he received 2 units of FFP (for an
elevated INR) with no correction of INR. He was then given Vit K
SC x 3 days and 1 unit of PRBC. On [**5-24**], the patient was
transfered from the SICU to the floor. On POD3 ([**5-25**]), patient's
respiratory saturations were noted to be approx 93%, most likely
due to atelectasis. He was encouraged to use IS. His diet was
advanced from sips to clears. On [**5-26**], he was noted to have
signs of hepatic decompensation with decreased mental status,
asterixis, decreased urine output, ascites and increased
bilirubin. He was transfered back to the SICU for closer
monitoring. On [**5-26**], the patient had an ultrasound of the liver
to exclude portal vein thrombosis; this was unchanged from the
prior study. On [**5-28**], a PICC was placed for hydration,
antibiotics and TPN. TPN was started the same day. He was
transfered from the SICU back to the floor on this day. The
patient had a voiding trial on [**5-30**], as reccomended by the
urology service. He was tolerating PO's by [**5-31**], and received
nutritional supplements. A bedside swallowing evaluation was
done on [**6-1**] during which he presented with mild oral dysphagia
and it was determined he could continue with a regular
consistency diet with thin liquids. TPN was stopped on [**6-3**].
The patient's LFT's were found to be elevating from [**6-3**] onwards.
Hence, an ERCP was performed on [**6-7**]. This showed a normal
appearing biliary tree with no evidence of obstruction or a
leak. LFT's continued to rise, and then remained stable on [**6-8**].
On [**6-8**], a suture was removed from the patient's abdomen, but
then re-sutured as ascitic fluid leaked from the incision. On
discharge, the patient's total bili had come down; he remained
jaundiced but was taking in good amount of PO's (approx [**2179**]
calories); he had 2 bowel movements and was ambulating. His
wound was clean, dry and intact, and only required a dry gauze
dressing over the area (no packing necessary). He will require
home physical therapy, and he should continue ciprofloxacin for
SBO prophylaxis.
Medications on Admission:
Aspirin 81', Fluticasone 50", HCTZ 25', Iron 325', Atorvastatin
10 '
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
colonic GIST with metastasis to liver
LUL nodules
c.diff
hepatic encephalopathy, resolved
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fevers, chills,
nausea, vomiting, increased jaundice (yellowing of skin),
increased abdominal pain, fluid retention, weight gain of 3
pounds in a day, increased size of abdomen or any questions.
Drink plenty of fluids.
.
You should aim to take in more than [**2179**] calories per day. You
should drink at least 3 cans of nutritional supplements each day
(these can be obtained from the pharmacy).
.
Keep your wound clean at all times. There is a small aspect of
your wound that is open, but this is not infected. You should
put a dry piece of gauze over this area and change it daily. If
you notice purulent drainage from this area, call your doctor
immediately.
.
Continue the antibiotic (ciprofloxacin) until furthur notice by
Dr [**Last Name (STitle) **]. You should not resume your hydrochlorthiazide
medication, but should begin those that we are now prescribing
to you. In terms of your other medications:
- Aspirin 81' - do not resume (discuss this with Dr [**Last Name (STitle) **] when
you see him in the clinic next week)
- Fluticasone 50" - you may resume this
- HCTZ 25' - do not resume, you have been given Lopressor as an
alternative
- Iron 325' - you may resume
- Atorvastatin 10 - you may resume.
.
You may take pain medications as you need them.
.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2186-6-14**] 9:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2186-6-9**]
ICD9 Codes: 2761, 5180, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5570
}
|
Medical Text: Admission Date: [**2178-4-24**] Discharge Date: [**2178-7-24**]
Date of Birth: [**2178-4-24**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 56158**] is the 884 gram product of a 26
week gestation, born to a 34 year old, Gravida III, Para I
Mom with [**Name2 (NI) **] type A positive, GBS unknown. Prenatal
screens not available at the time of delivery. Subsequently,
[**Name2 (NI) **] type was A positive, antibody negative, Rubella immune.
RPR nonreactive. Hepatitis B surface antigen negative.
Mother was admitted from [**Hospital3 **] with preterm
labor and received Magnesium sulfate and Betamethasone. She
became Betamethasone complete on [**2178-4-24**]. Mother also
received Clindamycin for GBS prophylaxis. In addition to
preterm labor, mother with history of intermittent vaginal
bleeding during pregnancy, which proceeded during this
admission. Due to persistent bleeding and unstoppable
preterm labor, the infant was delivered by spontaneous
vaginal delivery. Apgars of six and seven at one and five
minutes respectively. Infant emerged active, some
respiratory effort. Pink with heart rate greater than 100.
Intubated easily in the delivery room and brought to the
Neonatal Intensive Care Unit for further care.
PHYSICAL EXAMINATION: On admission, birth weight was 884;
50th percentile. Length 34 cm, 50th percentile. Significant
for five erythematous maculopapules on abdomen. Anterior
fontanel open and flat. Normal S1 and S2. No murmur.
Breath sounds: Coarse but equal. Mild intercostal and
subcostal retractions. Abdomen: Soft, nontender,
nondistended. Extremities: Warm, well perfused. Tone
appropriate for gestational age. Spine intact. Testes non
palpable; normal preemie male genitalia. Skin: Translucent,
no bruising or break down.
HOSPITAL COURSE: Respiratory: [**Known lastname **] was intubated in the
delivery room for management of airway and respiratory
distress syndrome. Maximum ventilator settings were PIP of
30, PEEP of 5 with a rate of 20. He remained intubated for a
total of 48 hours, at which time he was transitioned to C-
Pap. He received one dose of Surfactant for Surfactant
deficiency. He remains on C-Pap for a month and a half, at
which time he transitioned to room air. He remained stable
in room air at this time, with occasional desaturations
associated with feeding. He was treated with caffeine
citrate which was discontinued on [**2178-6-16**]. His last
episode of apnea and bradycardia was documented on [**2178-6-30**]. He does have episodes of desaturations associated with
enteral feedings.
Cardiovascular: Infant treated with Indomethacin on day of
life four for presumed patent ductus arteriosus by clinical
examination. Infant has been stable cardiovascular wise, with
a soft intermittent murmur, consistent with PPF. No further
cardiovascular issues.
Fluids, electrolytes and nutrition: Birth weight was 884
grams. He was originally started on 100 cc per kg per day of
D-10-W via UVC. Also had a UAC placed. Enteral feedings were
initiated on day of life six. Infant reached full enteral
feedings by day of life number 14. Maximum enteral intake
was 140 cc per kg per day of breast milk 32 calories or
Special Care 32 calorie with ProMod. He is currently
weighing 3,480 kg, taking ad lib feedings with Enfamil 20
calorie, taking in excess of 130 cc per kg per day.
Gastrointestinal/Genitourinary: Peak bilirubin was 3.9 on
day of life one; treated with phototherapy. The issue has
since resolved.
[**Known lastname **] has a right inguinal hernia, which is soft, easily
reduced. Surgery is planned for [**2178-7-24**].
Hematology: Hematocrit on admission was 48. Infant received
two [**Year (4 digits) **] transfusions during his hospital course. His most
recent hematocrit was . That was performed on [**2178-7-23**].
Infectious disease: CBC and [**Year (4 digits) **] culture obtained on
admission. CBC was benign. [**Year (4 digits) **] cultures remained negative
at 48 hours. Ampicillin and Gentamycin were discontinued at
that time. The infant had two subsequent sepsis evaluations
with negative [**Year (4 digits) **] cultures. Antibiotics were discontinued
after 48 hours.
Neurology: Head ultrasound was performed. Most recent was
performed on [**2178-7-8**] with left ventricular size
slightly larger than the right. Otherwise, no changes. This
has been a finding that has been seen since [**5-7**]. No
evidence of bleeding. Infant is appropriate for gestational
age.
Most recent eye examination was performed on [**7-20**].
Immature zone three in the left eye; stage one, zone three,
one clock hour in the right eye. Recommended follow-up in
two to three weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 1810**].
PRIMARY CARE PHYSICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43527**], [**Name Initial (NameIs) **].D. Telephone
number [**Telephone/Fax (1) 56159**].
CARE RECOMMENDATIONS: Continue ad lib feeding Enfamil 20
calorie.
MEDICATIONS: Continue Fer-in-[**Male First Name (un) **] supplementation.
Car seat passed.
Hearing screen has been performed with automated auditory
brain stem responses and the infant passed in both ears.
State newborn screens have been sent per protocol, most
recently on [**2178-6-10**], and have been within normal
limits.
IMMUNIZATIONS: Received: Infant received hepatitis B
vaccine on [**2178-5-26**] and [**2178-6-26**]. He received
PTAP, HIB, IPV and pneumococcal 7 value on [**2178-6-26**].
Recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) 359**] to
[**Month (only) 547**] for infants who meet any of the following three
criteria: 1. ) Born at less than 32 weeks. 2.) Born between
32 and 35 weeks with two of the following: Day care during
RSV season, a smoker in the household, neuromuscular disease,
airway abnormalities or school age siblings. Or, 3.) With
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES: Premature infant born at 26 weeks
gestation.
Mild respiratory distress syndrome.
Rule out sepsis with antibiotics.
Presumed patent ductus arteriosus.
Mild hyperbilirubinemia.
Apnea and bradycardia of prematurity.
Anemia of prematurity.
Retinopathy of prematurity.
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2178-7-24**] 01:37:23
T: [**2178-7-24**] 04:53:34
Job#: [**Job Number 56161**]
ICD9 Codes: 769, 7742
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5571
}
|
Medical Text: Admission Date: [**2197-6-17**] Discharge Date: [**2197-6-19**]
Date of Birth: [**2117-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
CC: SOB
Major Surgical or Invasive Procedure:
Cardiac catheterization on [**2197-6-17**]
Intubated [**2197-6-17**]
Extubated [**2197-6-19**]
History of Present Illness:
HPI: 79 yo Haitian female with h/o breast ca and possible lung
CA presents with sudden onset of SOB. Daughter states that she
thought her O2 (uses home o2) was not working, said she felt SOB
and called out for help. She did not note any chest pain at the
time. EMS was called and she was intubated in field. She was
hypotensive in the ER (btwn 1am -3 am bp 70-118/38-94 and HR
66-84). An R IJ line was attempted to be inserted at this time,
but caused a hematoma. Pt was still hypotensive so left sc line
was put in and caused a second hematoma. She was started on
dopamine in the ER and then changed to levophed b/c she got
tachycardic. An EKG showed ST elevations in leads I, II AVR and
V2-V6. Pt was taken to cath emergently d/t ST changes and
hypotension thought to be from cardiogenic shock.
Past Medical History:
PMH: unclear, daughter is a poor historian, has h/o breast ca
and possible pulmonary fibrosis, may also have dx of lung ca,
HTN
Social History:
Social hx: pt lives at home with daughter, has been noted to be
very depressed lately d/t the loss of two family members. Does
not drink or smoke.
Family History:
Fam hx: father had angina
Physical Exam:
PE:
Tm 97.7 Tc 97.3 BP assisted diastolic 123-145, mean arterial bp
73-87 P 64-76 R 18-26 O2 sat 98% I/O 1043/423
Gen: awakes to pain
HEENT: PERRL, hematoma on right neck covered by bandage, large
nodule present on left side of neck, feels somewhat soft
Pulm; coars rhonchorous breathe sounds bilaterally
Chest: right breast removed s/p mastectomy
Cardio; difficult to hear heart with loud breathe sounds
Abd: soft, ND, breathe sounds transmitted to abd
Ext: feet feel cold, pulses hard to palpate
Skin: Where left subclavian line placed there is a large
hematoma, that is soft to push on
Pertinent Results:
Cath showed:
LMCA, LCX: no significant disease
LAD: mild diffuse irregularirties
RCA: 50-60% ostial with catheter damping
LV: LVEF 20% with apical ballooning
--moderately elevated left sided and severely elevated right
sided filling pressures; severe pulm htn, severely depressed CO,
apical ballooning syndrom vs acute myocarditis.
co 2.6
ci 1.5
MAPs: RA 19 [**MD Number(3) 64077**] 22 AO 64
labs at admit:
pH
7.30 pCO2
44 pO2
229 HCO3
23 BaseXS
-4
na 132 cl 104 bun 14 gluc 89 AGap=11
k 4.4 hco3 21 cr 0.9
CK: 197 MB: 26 MBI: 13.2 Trop-*T*: 1.46
Ca: 7.3 Mg: 1.5 P: 3.7
wbc 19.3 (prev was 14.7) hgb 11.2 D plts 245
hct 35.6 (previous was 43.8)
PT: 14.5 PTT: 38.7 INR: 1.4
CXR: satisfactory ETT placement, diffuse bilateral alveolar
opacities. Differential includes multifolca PNA, ARDS, pulm
edema. Large left and probable right sided pleural effusion.
Massive gastric distension.
.
Echo [**6-19**]: Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Right
ventricular chamber size is normal. Right ventricular systolic
function appears depressed. There is a prominence of the
non-coronary sinus. The ascending aorta is moderately dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal.
.
[**2197-6-19**] 05:15AM BLOOD WBC-16.4* RBC-2.83* Hgb-8.2* Hct-23.8*
MCV-84 MCH-28.8 MCHC-34.3 RDW-14.7 Plt Ct-119*
[**2197-6-18**] 08:31PM BLOOD Hct-25.6*
[**2197-6-18**] 11:42AM BLOOD Hct-28.0*
[**2197-6-18**] 05:16AM BLOOD WBC-12.8* RBC-3.36* Hgb-9.4* Hct-27.8*
MCV-83 MCH-27.9 MCHC-33.7 RDW-14.5 Plt Ct-147*
[**2197-6-17**] 11:20PM BLOOD Hct-29.5*
[**2197-6-17**] 04:05PM BLOOD WBC-13.1* RBC-3.93* Hgb-10.8* Hct-32.9*
MCV-84 MCH-27.6 MCHC-32.9 RDW-14.3 Plt Ct-184
[**2197-6-17**] 04:11AM BLOOD WBC-19.3* RBC-4.15* Hgb-11.2*# Hct-35.6*
MCV-86 MCH-27.0 MCHC-31.5 RDW-13.9 Plt Ct-245
[**2197-6-17**] 12:10AM BLOOD WBC-14.7* RBC-5.07 Hgb-14.4 Hct-43.8
MCV-87 MCH-28.5 MCHC-32.9 RDW-13.6 Plt Ct-302
[**2197-6-19**] 05:15AM BLOOD Plt Ct-119*
[**2197-6-18**] 05:16AM BLOOD Plt Ct-147*
[**2197-6-17**] 12:10AM BLOOD Plt Ct-302
[**2197-6-19**] 05:15AM BLOOD Glucose-92 UreaN-20 Creat-1.0 Na-134
K-3.8 Cl-105 HCO3-22 AnGap-11
[**2197-6-18**] 05:16AM BLOOD Glucose-100 UreaN-17 Creat-1.0 Na-134
K-3.9 Cl-104 HCO3-21* AnGap-13
[**2197-6-17**] 12:10AM BLOOD UreaN-14 Creat-1.2*
[**2197-6-18**] 05:16AM BLOOD CK(CPK)-158*
[**2197-6-17**] 04:05PM BLOOD CK(CPK)-238*
[**2197-6-17**] 04:11AM BLOOD CK(CPK)-197*
[**2197-6-17**] 12:10AM BLOOD Amylase-157*
[**2197-6-18**] 05:16AM BLOOD CK-MB-9 cTropnT-0.51*
[**2197-6-17**] 04:05PM BLOOD CK-MB-20* MB Indx-8.4* cTropnT-0.86*
[**2197-6-17**] 04:11AM BLOOD CK-MB-26* MB Indx-13.2* cTropnT-1.46*
[**2197-6-17**] 12:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-13.1
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2197-6-19**] 12:22PM BLOOD Type-ART pO2-56* pCO2-47* pH-7.32*
calHCO3-25 Base XS--2
[**2197-6-19**] 05:19AM BLOOD Type-ART pO2-126* pCO2-40 pH-7.39
calHCO3-25 Base XS-0
[**2197-6-17**] 01:58AM BLOOD Type-ART Rates-/16 Tidal V-500 PEEP-5 O2
Flow-100 pO2-129* pCO2-55* pH-7.22* calHCO3-24 Base XS--5
Intubat-INTUBATED
[**2197-6-17**] 10:43AM BLOOD Lactate-1.5
[**2197-6-17**] 04:45AM BLOOD Lactate-1.9
Brief Hospital Course:
*SOB: This 79 yo Haitian female with h/o breast ca and possible
lung CA presented with sudden onset of SOB. EMS was called and
she was intubated in field. She was hypotensive in the ER (btwn
1am -3 am bp 70-118/38-94 and HR 66-84). An R IJ line was
attempted to be inserted at this time, but caused a hematoma. Pt
was still hypotensive so a left SC line was put in and caused a
second hematoma. She was started on dopamine in the ER and then
changed to levophed b/c she got tachycardic. An EKG showed ST
elevations in leads I, II AVR and V2-V6. Pt was taken to cath
emergently d/t ST changes and hypotension thought to be from
cardiogenic shock.
The cath showed:
LMCA, LCX: no significant disease
LAD: mild diffuse irregularirties
RCA: 50-60% ostial with catheter damping
LV: LVEF 20% with apical ballooning
--moderately elevated left sided and severely elevated right
sided filling pressures; severe pulm htn, severely depressed CO,
apical ballooning syndrom vs acute myocarditis.
co 2.6 ci 1.5
MAPs: RA 19 [**MD Number(3) 64077**] 22 AO 64
An echo was done during the cath that showed no evidence of a
pericardial effusion.
A balloon pump was also placed at the time of cath. Her groin
was oozing at the cath site. Pt was given protamine to reverse
the heparin. It was decided to hold her heparin drip until the
AM and then start at a low dose b/c of hematomas and bleeding.
It was thought that the patient had Takotsubo cardiomyopathy
secondary to the stress of watching the news related to
terrorist activity in [**Location (un) 311**]. ASA, plavix and beta-blocers were
not started because the patient had clean coronaries. One day
after admission the balloon pump was pulled. An echo was done
two days after admission and showed mild symmetric left
ventricular hypertrophy with preserved global systolic function.
Right ventricular free wall hypokinesis c/w possible ischemia
(given normal PA systolic pressure). Mild aortic regurgitation.
Pt's CXR at admission showed possible ARDS, pneumonia or
pulmonary edema. Pt could have had fluid overload in lungs
secondary to systolic dysfuction. [**Month (only) 116**] also have had PNA,
especially since WBC was elevated. Pt did not have fevers,
however. There was also a h/o pulmonary fibrosis, breast and
lung cancer. She received captopril 6.5 mg to diurese pt and
help her CHF. She was also given ipratropium inhalers. One day
after admission the family indicated to the social worker that
the patient had been dc'd to home hospice care two weeks prior
but the patient refused hospice and did not fill her narctoics
for pain. A palliative care consult was obtained. Patient was
still intubated but her respiratory status was not improving to
a great degree. Patient and patient's family made the decision
to extubate the patient knowing that she would most likely die
when extubated. This was per the family consistent with the
patient's previous expressed wishes. Of note patient's hct
dropped from 43 at admission to 23 on [**6-19**]. Family was informed
of the necessity of a transfusion but refused blood
transfusions. The patient was made comfort measures only and
extubated with family present consistent with the wishes of all.
The patient was extubated on [**2197-6-19**]. She was pronounced dead
at 7:0 pm on [**2197-6-19**] with the family at her side. Family
declined to have an autospys performed.
Acute blood loss anemia: Pt's hct has dropped significantly in
the past day. This can be explained by two hematomas and oozing
from the cath. It is possible that she is bleeding from
somewhere else.
-will re-check hct in pm to see if pt stable
-check stool guiacs
.
Medications on Admission:
MEDS: unknown, may include diovan
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
ICD9 Codes: 496, 4254, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5572
}
|
Medical Text: Admission Date: [**2140-3-28**] Discharge Date: [**2140-4-4**]
Date of Birth: [**2104-9-10**] Sex: F
Service: MEDICINE
Allergies:
Tape [**1-25**]"X10YD / Augmentin / Hydrocodone / Levofloxacin /
Ciprofloxacin / fentanyl / Keflex / ceftriaxone / Ativan
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
diabetic ketoacidosis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
35yo F with poorly controlled T1DM c/b retinopathy, nephropathy,
gastroparesis and distant h/o GI bleed from esophagitis p/w
nausea, vomiting, and melena since yesterday. Some (~2 cups)
coffee-ground emesis last night per ED, but pt's mother states
there was no coffee-ground emesis. Some lightheadedness; no
syncope or LOC. No abdominal pain or fevers. Pt says she just
woke up last night from sleep nauseous. Her BGs were in the
300s-400s overnight. Pt reports not taking her Lantus this AM.
Pt also reports nonproductive cough for several weeks and
non-bloody diarrhea x6 weeks. No dyspnea. No urinary symptoms.
In the ED inital vitals were 99.4, 130, 175/104, 16, 97% on 2L.
Pt had a gap metabolic acidosis and received 2L IVF and 8 un
insulin; she was then started on an insulin gtt, 5 un/hr. Her
N/V improved with zofran and ativan. She had guaiac-positive,
black stools but refused NG lavage. Pantoprazole drip was
started. GI consult ([**First Name8 (NamePattern2) 3095**] [**Last Name (NamePattern1) **]) saw the pt and plans to do
endoscopy.
.
On arrival to the ICU, pt was somnolent but arousable. She
reported some nausea but no pain.
Review of systems:
(+) Per HPI
(-) No fever, chills, night sweats. No headache. No shortness
of breath or wheezing. No chest pain. No dysuria, frequency, or
urgency.
Past Medical History:
Type 1 DM c/b retinopathy ("quiescent" proliferative on last eye
exam, [**4-/2136**]), nephropathy (nodular glomerulosclerosis on renal
bx [**2139-9-15**]; baseline Cr ~1.0-1.1 in [**12/2139**]), and
gastroparesis. Diagnosed at age 11, multiple hospitalizations
for DKA. HbA1c was 7.8 on [**2140-2-15**].
Barrett's esophagitis, GERD, gastritis, PUD (antral ulcer [**2132**])
HLD
HTN
dCHF LVEF >60% in [**8-/2139**]
normocytic anemia
acquired hemophilia (FVIII inhibitor in [**2132**]) treated w/steroids
and rituximab
anti-E and warm autoantibody (negative Coombs)
hydronephrosis
osteoporosis ([**2138-11-12**] T-score L spine -2.2, femoral neck -3.1)
migraines
depression
h/o avascular necrosis
h/o severe hyperemesis gravidarum requiring TPN
h/o PEA arrest during renal biopsy [**2139-9-15**] (on fentanyl and
versed)
s/p C-section at 33 weeks because of hyperemesis gravidarum
s/p repair for ruptured [**Last Name (un) 18863**] tendon
s/p ORIF of right distal radius
s/p appendectomy
Social History:
Re-married, lives at home with mother, husband, and 8-year-old
son from first marriage. Currently a homemaker. On disability
since [**2132**].
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
No h/o bleeding disorder. Kidney cancer and colitis in maternal
grandfather.
Physical Exam:
ON ADMISSION:
Vitals: T: 99.3, BP: 158/92, P: 113, R: 11, SpO2: 99% on RA
General: Eyes closed, arouses to voice but has trouble staying
awake to answer questions, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, neck veins flat, no LAD
Lungs: CTAB
CV: RRR, no m/r/g
Abdomen: soft, NDNT, bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CN2-12 intact, moving all extremities spontaneously
.
ON DISCHARGE:
Pertinent Results:
ON ADMISSION:
[**2140-3-28**] 03:00PM WBC-8.9 RBC-4.18* HGB-12.9 HCT-36.2 MCV-87
MCH-31.0 MCHC-35.7* RDW-15.4
[**2140-3-28**] 03:00PM NEUTS-90.1* LYMPHS-8.5* MONOS-0.7* EOS-0.4
BASOS-0.4
[**2140-3-28**] 03:00PM ALBUMIN-3.9 CALCIUM-9.8 PHOSPHATE-2.7
MAGNESIUM-3.2*
[**2140-3-28**] 03:00PM ALT(SGPT)-9 AST(SGOT)-13 ALK PHOS-102 TOT
BILI-0.5
[**2140-3-28**] 03:00PM GLUCOSE-420* UREA N-41* CREAT-1.5* SODIUM-143
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-22 ANION GAP-24*
[**2140-3-28**] 03:11PM LACTATE-2.2*
CXR: No acute cardiac or pulmonary process. No evidence of free
air under the hemidiaphragms.
ON DISCHARGE:
[**2140-4-3**] 08:10AM BLOOD WBC-7.8 RBC-3.04* Hgb-9.6* Hct-27.4*
MCV-90 MCH-31.6 MCHC-35.0 RDW-15.4 Plt Ct-249
[**2140-4-2**] 05:04AM BLOOD Glucose-86 UreaN-12 Creat-1.1 Na-135
K-4.3 Cl-108 HCO3-24 AnGap-7*
[**2140-4-2**] 05:04AM BLOOD Calcium-8.1* Phos-4.5 Mg-1.9
EGD ([**2140-4-4**])
Impression: Mucosa suggestive of Barrett's esophagus (biopsy)
Food in the stomach body and fundus
Friability and erythema in the whole stomach compatible with
gastritis
Polyps in the stomach
Otherwise normal EGD to third part of the duodenum
Recommendations: The likely source of bleeding was from a now
healed [**Doctor First Name 329**] [**Doctor Last Name **] tear.
fundic gland polyps related to PPI use
Likely Barrett's seen in distal esophagus. Will mail biopsy
results in [**2-26**] weeks.
Continue Omeprazole.
Brief Hospital Course:
Ms. [**Name13 (STitle) **] is a 35 year old woman with poorly controlled DM1,
requiring multiple admissions for DKA, usually triggered by
gastroparesis flares, who presented to MICU again with DKA in
the setting of nausea, vomiting, melena, and coffee-ground
emesis. She did well overall, but needs to set up followup with
[**Last Name (un) **] as well as gastroenterology for potential EGD.
GI was consulted in [**Hospital Unit Name 153**], thought about EGD once pt stable.
she was stable and transferred to floor [**Hospital Unit Name 2974**] night. took
several days in MICU for intractable nausea/vomiting to resolve.
now she is taking POs. Of note, she is on torsemide for dCHF,
which was restarted Saturday night. At baseline now. Abdominal
exam benign now and n/v/abdom pain resolved. Only 1 episode of
coffee ground emesis and melena with gastroparesis flare prior
to admission (melena x1 in ED), but no further symptoms; has had
coffee ground emesis with gastroparesis flares in the past. Has
had multiple EGDs in the past, though none recent.
# DKA: Blood glucose in 400s with anion gap of 20 on arrival to
ED. DKA precipitant thought to be dehydration secondary to
gastroenteritis given diarrhea x6 weeks and missed AM glargine
dose. No evidence of PNA on CXR, no urinary symptoms suggestive
of UTI, UA on presentation showing a few WBCs but
nitrite-negative and no bacteria. In the ED, the patient
received 2L IVF and 8 units of insulin bolus and was started on
an insulin drip at 5 un/hr. Given free water deficit of ~1.6L,
patient received 1L 1/2 NS D5W (with 80 mEq KCl) and was further
resuscitated with 1/2 NS. For nausea, patient had a trial of
PRN IV zofran, IV phenergan, and IV lorazepam without much
success. Patient stated that ativan works well for her at home,
was given 0.5 mg IV q6hrs PRN nausea made her very somnolent and
was therefore changed to 0.25 mg IV q3hrs with good effect. Pt
was also started on standing IV metoclopramide. Patient's anion
gap closed on insulin gtt, and D5W drip with KCl was started in
addition to insulin gartt once blood glucose was consistently
<250. Nausea resolved on [**2140-4-1**], at which time she was
transitioned from insulin drip to subcu insulin and transferred
to the floor. She is followed by [**Last Name (un) **] as an outpatient and
may be a candidate for an insulin [**Last Name (LF) 4581**], [**First Name3 (LF) **] she is carb counting
at home. Her glargine was increased to lantus 10units at
bedtime (rather than 4 units [**Hospital1 **]).
# UTI: Her initial UTI showed only few WBCs without
bacteria/nitrites, and repeat UA showed >182 WBC but 6
epithelial cells. Decision was made to treat, in setting of
intractable nausea/vomiting for days, in case this was a
contributing factor. Pt was started on 7-day course of PO
nitrofurantoin (pt unable to take PO Bactrim b/c of pill size)
on [**2140-3-31**] and tolerated it well. She should continue for 2 more
days post discharge.
# Question of Upper GI bleed: Pt reports coffee ground emesis x1
prior to admission, which she has had in the past with
gastroparesis flares, most likely secondary to [**Doctor First Name **]-[**Doctor Last Name **]
tear, but also in differential are gastritis, PUD, esophagitis.
Pt remained hemodynamically stable throughout hospitalization,
Hct stable in ED (hemoconcentrated), then 30 in ICU (baseline
~30-32). Pantoprazole drip was converted to IV bolus [**Hospital1 **], then
discontinued once pt back on home PO omeprazole. She underwent
EGD on [**4-4**], which demonstrated known Barrett's esophagus
(biopsies taken). Hemetemesis is thought to be due to a
now-healed [**Doctor First Name **]-[**Doctor Last Name **] tear. She was continued on omeprazole
on discharge.
# Chronic diastolic CHF: LVEF >60% in 8/[**2139**]. Patient on
torsemide 20mg [**Hospital1 **] at home. Metoprolol was held during fluid
resuscitation and restarted as IV form once BP became more
elevated. Patient developed overall puffy appearance,
particularly in face and hands on transfer from MICU. Home
torsemide was restarted day prior to discharge.
# Prerenal [**Last Name (un) **]: Cr 1.5 on admission from baseline of 1.0-1.1.
Thought to be prerenal given osmotic diuresis in the setting of
DKA. Cr normalized with IVF.
# Elevated BPs/HTN: Pt's BPs were occasionally elevated to SBP
180, and patient received IV hydralazine PRN in MICU while
unable to tolerate POs. Standing IV metoprolol was started on
hospital day 2 while still having intractable vomiting. Home PO
metoprolol and amlodipine were restarted once pt was tolerating
POs.
# HLD: home simvastatin was continued once pt tolerating POs.
# Normocytic anemia: Stable. Home iron was continued once pt
tolerating POs.
# Depression: home sertraline, buspirone, and zolpidem were
continued once pt tolerating POs.
# Neuropathy: home gabapentin was withheld due to patient's
somnolent mental status (with lorazepam administration). It was
restarted once pt tolerating POs.
# Prophylaxis: pneumoboots
# Communication: patient, patient's mother [**Name (NI) **] [**Name (NI) 51375**] (HCP;
[**Telephone/Fax (1) 51376**]), patient's husband [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 51377**])
# Code: full
Medications on Admission:
INSULIN GLARGINE [LANTUS] 4 units [**Hospital1 **]
INSULIN LISPRO [HUMALOG] sliding scale TID, max 60 units/day
METOPROLOL TARTRATE 37.5 PO BID
AMLODIPINE - 10 mg PO daily
TORSEMIDE - 20 mg PO BID
SIMVASTATIN - 20 mg PO QHS
OMEPRAZOLE (delayed release) - 40 mg PO daily
SERTRALINE - 50 mg PO daily
BUSPIRONE - 5 mg PO BID
GABAPENTIN - 800 mg Tablet PO QHS
ZOLPIDEM [AMBIEN] - 10 mg PO QHS PRN insomnia
CALCIUM CITRATE - 315MG-200 Tablet PO with food QID
FERROUS SULFATE - 325 mg PO daily
ERGOCALCIFEROL (VITAMIN D2) - 50,000 units PO weekly
Discharge Medications:
1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
10. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
11. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO Q12H (every 12 hours) for 2 days.
Disp:*5 Capsule(s)* Refills:*0*
12. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
13. calcium Oral
14. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
QACHS: pls take per carb counting and Humalog sliding scale
before meals and at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Gastroparesis
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. [**Last Name (Titles) **],
You were admitted to the hospital because you were having
another gastroparesis flare that led to diabetic ketoacidosis.
You were maintained on an insulin drip in the medical ICU for a
few days until you were able to eat and drink. You were also
started on an antibiotic for a urinary tract infection, which
you should continue to take for a few more days.
You will also need to be followed closely by [**Last Name (un) **] when you
leave the hospital.
You had some blood in your stool and in your vomit when you came
to the hospital. You underwent an upper endoscopy which showed
no change from prior endoscopy. The gastroenterologists took a
biopsy and will follow-up the results with you in [**2-26**] weeks.
The following changes have been made to your medications:
- Please INCREASE your lantus to 10 units at bedtime (rather
than 4 units at twice a day)
- Please use CARB COUNTING and the HUMALOG SLIDING SCALE
provided by [**Last Name (un) **] with meals and at bedtime
- Please START nitrofurantoin for your urinary tract infection
for 2 more days
Followup Instructions:
** Please be sure to make an appointment with your primary care
doctor or one of the nurse practitioners in Dr.[**Name (NI) 51374**]
office in the next 1-2 weeks.
[**Last Name (LF) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 2010**]
** Please be sure to make an appointment with the
Gastroenterology team for in the next 2-3 weeks. Your primary
care doctor can help set this up.
** Please be sure to also set up an appointment with your doctor
or nurse practitioner [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] in the next 1-2 weeks.
Please be sure to keep your other previously scheduled followup
appointments, as follows:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2140-4-27**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2140-6-22**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2140-4-5**]
ICD9 Codes: 5849, 5990, 2724, 4019, 4280, 311, 3572, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5573
}
|
Medical Text: Admission Date: [**2172-7-21**] Discharge Date: [**2172-8-5**]
Date of Birth: [**2128-10-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Trauma - Fall
Major Surgical or Invasive Procedure:
[**2172-7-22**]
Ortho:
- Intramedullary nail, right tibia.
- Closed treatment, left glenohumeral dislocation, with
manipulation.
- Washout and closure, right thigh wound, with debridement to
muscle.
ENT:
- Surgical preparation of the frontal area (area debrided and
irrigated 80 cm2)
- Cranialization of frontal sinus.
- Removal of nasal frontal duct mucosa bilaterally.
- Obliteration of nasal frontal duct bilateral.
- Anterior frontal sinus bony reconstruction.
- Complex wound closure of 15 cm
Neurosurgery:
- Elevation of depressed fractures of the left frontal sinus and
the left frontal area.
[**2172-7-30**]
Orthopedics:
- Open reduction internal fixation greater tuberosity fracture
- Repair rotator cuff
History of Present Illness:
This patient is a 43 year old male transferred for 20 foot fall
onto a pole that impaled his R thigh. Imaging at OSH (including
a CT pan scan) found a depressed skull fx, L humerus
fx/dislocation. Initial GCS 13. Then developed
projectile vomiting and became more somnolent, so he was
intubated by RSI. Received PTA 250 mcg fentanyl, 4 mg versed, 10
mg vecuronium (40 minutes prior to arrival), TD, and 2 g of
ancef.
Past Medical History:
PMH: none
PSH: none
Social History:
construction worker, lives with wife and one son
Family History:
non contributory
Physical Exam:
On Admission (per ED note)
Temp:96.7 HR:124 BP:186/75 Resp:12 O(2)Sat:100 normal
Constitutional: Intubated
HEENT: Pupils 2 mm NR, + facial laceration, bilateral
periorbital ecchymoses
C-collar, midline trachea
Chest: Equal bs with bagging
Cardiovascular: Regular Rate and Rhythm, tachycardic
Abdominal: Soft, stable pelvis
GU/Flank: No stepoffs on log roll
Extr/Back: Warm extremities, No palpable DP in RLE, +
palpable PT/femoral pulses in RLE and normal pulses in other
extremities
Skin: Very large laceration to medial R thigh oozing blood,
but no arterial bleeding, + abrasions
Neuro: Limited neuro exam, + spontaneous inspiratory effort
and extremity movement in UEs
Pertinent Results:
CT torso OSH [**7-21**]: Air tracking along right groin through
iliopsoas,
no active extrav from SFA or profunda. Left renal interpolar
hypodensity concerning for laceration. No
hematoma/extravasation.
SQ gas along the right thigh with sm gas to RP R iliopsoas. No
pneumoperitoneum. Minimally displaced left 11th and 10th rib
fractures. Left humeral head dislocation and Fx. Hepatic
steatosis.
Ct Head [**7-22**]: Depressed left anterior skull fracture, no
associated
hemmorhage. Skull fracture with extension to the L frontal
sinus.
Cspine [**7-22**]: Negative
Tib/ Fib Xray [**7-21**]: Right tibial fracture
Femur xray right [**7-21**]: No fx
[**2172-7-25**] head CT : 1. Evolving bifrontal edema related to known
parenchymal contusions. The volume of intracranial hemorrhage
has minimally decreased, and there is no new focus of
intracranial hemorrhage.
2. Mild increase in the size of a small extra-axial fluid and
gas collection overlying the left frontal lobe.
[**2172-7-30**] Left shoulder : ORIF of the left proximal comminuted
humerus fracture with interval placement of metallic fixation
devices
CT head [**8-2**]:
1. No new intracranial hemorrhage.
2. Interval mild decrease of parenchymal edema and its mass
effect in the left frontral lobe.
3. No definite new fracture. Unchanged comminuted frontal
calvarial fracture and left lateral orbital wall fx with
metallic clips.
Brief Hospital Course:
Trauma team evaluated the patient and after primary/secondary
surveys and imaging the following injuries were noted:
Injuries:
Depressed skull fx without associated hemorrhage
scalp lac
L shoulder dislocation
comminuted left humeral fracture
R thigh lac
R tib fx
Pt was admitted to the TSICU for further management.
[**7-22**] - admitted with multiple lesions/fractures, hypotensive.
Received 7L crystalloids and 1U pRBC. to OR for elevation of
depressed skull fracture ORIF right tibia fracture; closed
reduction left proximal humerus, lumbar drain
[**7-23**] - New right CVL placed; increased dilantin dosing and gave
one time additional dose of 500mg IV as level was
sub-therapeutic. Removed potentially dirty left groin trauma
line. Plan for OR on [**7-24**] for left humerus greater tuberousity
repair. NPO after midnight.
[**7-24**] - Restarted TFs goal 70. Changed right a.line to left
a.line. Discontinued vanc/ceftaz/flagyl and started only unasyn
per Nsurg and Plastics. Transfused 1U pRBC for Hct 22.0.
Extubated succesfully.
[**7-25**] - interval head CT with evolving bifrontal edema, MRI
L-spine done, C-spine clear
[**7-26**] - ordered arterial non-invasives bilateral lower
extremities. minimally improving neuro exam (patient now able to
say his name). Will likely require PEG on [**2172-7-27**].
[**7-27**] - Pt spiked to 101.9 at 8 am, then afebrile during the day.
Bcx and lumbar drain cx's were sent. CSF with 2575 RBC, 119
protein, gram stain negative, cx's pending. Neurosurgery to pull
the lumbar drain in am after clamp trial overnight to monitor
for CSF leak. Currently on cefazolin. No need for NIAS per
vascular, pt now with palpable pulses. Diuresed with lasix 20',
-3L for the day. [**Month (only) 116**] have PEG when availability if WBC going
down. Stopped standing lopressor, due to bradycardia episodes
during night
[**7-28**] - Continues to have elevated WBC of 13.6 with no obvious
source of infection. Lumbar drain pulled. Still waiting on PEG
given leukocytosis. Facial sutures dc'd by plastics.
[**7-29**] - Passed speech/swallow eval for diet of thin liquids and
pureed solids
[**7-30**] - Pt transferred to floor. Taken to OR with orthopedics for
ORIF L humerus greater tuberosity, rotator cuff repair.
[**8-2**] - Evaluated by ophthalmology, no acute issues. Pt can follow
up with outpatient ophthalmologist. In the evening, pt had
mechanical fall while attempting to move from commode to bed.
Struck right side of head on wall. No other injuries. No head
bleeding, neuro exam at baseline. CT head showed no acute bleed
or fracture.
[**8-4**] - Right thigh sutures and knee staples removed.
At the time of discharge, pt working with Physical Therapy to
increase mobility but still required a maximal assist. His
appetite was slowly improving but still on calorie counts. He
remained free of any pulmonary complications post op and
remained afebrile. he was transferred to rehab on [**2172-8-5**] with
the hopes of returning home independently.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day) as needed for constipation.
4. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**]
Discharge Diagnosis:
S/P [**2172**]0 ft.
1. Depressed skull fracture
2. Scalp laceration
3. Left shoulder proximal fracture and dislocation
4. Right thigh laceration
5. Right tibial fracture
6. Acute blood loss anemia
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 to the Acute Care Service after your
traumatic fall with multiple injuries requiring evaluation by
Plastic Surgery, Orthopedic Surgery, Neurosurgery< Opthamology
and Rehab Services.
* You have made great strides but you still have room to improve
thus necessitating this transfer to rehab.
* Your mental status is improving daily and should continue to
do so.
* Participation in physical therapy with gait training, balance
and range of motion will help you in your goal to return home.
* Continue to eat and stay hydrated to help with healing and
stamina.
Followup Instructions:
1. During business hours, please have patient call the office of
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 6742**] to schedule a follow-up
appointment for [**Last Name (LF) 2974**], [**8-7**]. ( Plastic Surgery)
2. Please call/or have the patient call ([**Telephone/Fax (1) 88**] to
schedule a follow- up appointment in 4 weeks with a Non-contrast
CT scan of the head. Our office is located in the [**Hospital **] Medical
Building, [**Hospital Unit Name 12193**]. ( Neurosurgery)
Call [**Telephone/Fax (1) 1228**] for a follow up appointment in 1 week at the
[**Hospital **] Clinic
Call your eye doctor for a follow up appointment when you return
home from from rehab.
Completed by:[**2172-8-5**]
ICD9 Codes: 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5574
}
|
Medical Text: Admission Date: [**2194-12-25**] Discharge Date: [**2194-12-30**]
Date of Birth: [**2162-6-27**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old
female who is approximately 18 pregnant with her second child
with a history of a transient ischemic attack in the past.
At the time of her workup for her transient ischemic attack a
patent foramen ovale was diagnosed, and she underwent patent
foramen ovale closure in [**2190**] by a CardioSeal device. This
was complicated by two subsequent neurologic events.
The patient presented to the Emergency Department on [**2194-12-24**]. An echocardiogram was performed in the Emergency
Department at that time which revealed a large left apical
thrombus.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Asthma.
2. She had a transient ischemic attack in [**2190**].
3. She had a patent foramen ovale with a device closure in
[**2190**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**].
4. The patient has had two recent neurologic events (as
previously described).
MEDICATIONS ON ADMISSION:
1. Prenatal vitamins.
2. Wellbutrin-SR 150 mg by mouth twice per day.
3. Colace 100 mg by mouth twice per day.
ALLERGIES: The patient states she has no known drug
allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
upon admission to the hospital was unremarkable.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory
values upon admission to the hospital were unremarkable.
CONCISE SUMMARY OF HOSPITAL COURSE: A Cardiac Surgery
consultation was obtained on [**2194-12-25**] by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. After a discussion with the patient's cardiologist
(Dr. [**Last Name (STitle) 28032**] [**Name (STitle) **]), and the patient, and her husband it
was felt appropriate to take the patient to the operating
room for removal of the left atrial clot.
The patient was taken to the operating room on [**2194-12-26**] where she underwent removal of a left atrial mass which
was felt to be a thrombotic in nature. Please see the
Operative Report for a full description of this surgery.
Postoperatively, the patient was transported from the
operating room to the Cardiothoracic Surgery Recovery Unit.
The Obstetrics Service and Fetal and Maternal Medicine
Service were consulted. Fetal heart tones were heard in the
immediate postoperative period with a rate of 130, and they
did fell that the pregnancy was progressing appropriately.
On postoperative day one, the patient remained in good
condition; although, she was having some difficulty with
nausea and pain control. Her medications were adjusted
according and she was transferred out of the Intensive Care
Unit to the Telemetry floor on [**2194-12-27**].
The patient continued to progress in an appropriate fashion.
She was beginning to get out of bed and ambulated. She was
requiring a little bit of assistance. The Obstetrics Service
continued to follow the patient. At 5 p.m. on [**12-27**],
there was another evaluation by the Obstetrics Service and
the patient did have an audible fetal heart tone by Doppler
which was felt to be appropriate.
Over the next two days, the patient continued to increase her
ambulation. A Pain Service consultation was obtained because
the patient was still having a lot of difficulty with pain
control. The patient was started on OxyContin with relief.
The recommendation was to order that twice per day and
Percocet for breakthrough pain. Since that time, the patient
remained with good control of her pain. She has been able to
be up and ambulating independently and was ready to be
discharged from the hospital on postoperative day four.
The patient's condition on [**12-30**] was as follows; the
patient's epicardial wires were discontinued. She was
started on Lovenox for anticoagulation 70 mg subcutaneously
twice per day.
Physical examination was as follows; the patient was alert
and oriented. Her cardiovascular examination revealed a
regular rate and rhythm. Her wound was clean, dry, and
intact. Her lungs were clear to auscultation bilaterally.
Her abdomen was soft and nontender. The patient was
complaining of intermittent right flank tenderness; however,
she had a negative urinalysis from yesterday. There was 1+
edema bilaterally.
DISCHARGE DISPOSITION: The patient was to be discharged
today in good condition.
DISCHARGE DIAGNOSES: Left atrial thrombus.
MEDICATIONS ON DISCHARGE: (The patient was given a
prescriptions for)
1. OxyContin 10 mg by mouth twice per day.
2. Percocet 5/325-mg tablets by mouth q.4-6h. as needed (for
breakthrough pain); the patient stated that she would not
need this, although she was given prescriptions for both.
3. Lovenox 70 mg subcutaneously twice per day; visiting
nurses were to draw a factor X(a) level on Friday morning
([**1-1**]) and was to call those results to the office of
her cardiologist Dr. [**Last Name (STitle) 28032**] [**Name (STitle) **] (telephone number
[**Telephone/Fax (1) 6197**]).
4. Wellbutrin 150 mg by mouth twice per day.
5. Zantac 150 mg by mouth twice per day.
6. Colace 100 mg by mouth twice per day.
7. Prenatal vitamins.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 12166**] in the Maternal Fetal Medicine Department. She had an
appointment for [**1-15**] at 10:45 a.m.
2. The patient was instructed to return to [**Hospital Ward Name 121**] Two for a
wound check in one to two weeks.
3. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in one month (telephone number [**Telephone/Fax (1) 170**]).
CONDITION AT DISCHARGE: Condition on discharge was good.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2194-12-30**] 15:31
T: [**2194-12-30**] 17:27
JOB#: [**Job Number 28033**]
(cclist)
ICD9 Codes: 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5575
}
|
Medical Text: Admission Date: [**2139-11-3**] Discharge Date: [**2139-11-12**]
Date of Birth: [**2083-6-22**] Sex: M
Service: [**Hospital1 **] Medicine
HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with
a history of severe peripheral vascular disease, diabetes
mellitus type 1, secondary to alcohol abuse and pancreatitis,
hypertension, end-stage renal disease status post kidney
transplant in [**2133**], failing, DVT in the right upper
extremity, GERD, MRSA, depression, chronic right leg ulcer
with external fixation on [**10-25**], who presented to the
Emergency Department in diabetic ketoacidosis and
hyperkalemia. He was admitted to the MICU for diabetic
ketoacidosis.
PAST MEDICAL HISTORY: As above per history of present
illness.
ALLERGIES: No known drug allergies.
MEDICATIONS UPON ADMISSION:
1. Folate 1 mg a day.
2. Multivitamin one a day.
3. Wellbutrin 100 mg 3x a day.
4. Protonix 40 mg once a day.
5. Neurontin 300 mg once a day.
6. Chlorhexidine 50 mg 3x a day.
7. Aspirin 81 mg once a day.
8. Vancomycin 1 gram q Monday and Friday.
9. Pancreatic enzymes.
10. Calcium carbonate 500 3x a day.
11. Amlodipine 5 mg two times a day.
12. Clonidine 0.3 mg 2x/day.
13. Lasix 60 mg 2x/day.
14. Hydralazine 75 mg 4x a day.
15. Lovenox 40 mg once a day.
16. Prednisone 5 mg once a day.
17. Celexa 20 mg once a day.
18. Metoprolol 100 mg twice a day.
19. OxyContin 40 mg twice a day.
20. Ceftaz 1 gram q.48h.
21. Insulin.
ALLERGIES: The patient reported a history of swelling with
codeine, however, has not had a problem during
hospitalization. Also reported an allergy to FK-506.
SOCIAL HISTORY: Twenty pack year smoker, quit six years ago.
No alcohol x11 years, formally heavy use.
PHYSICAL EXAMINATION: On admission, temperature is 96.9,
pulse 63, blood pressure 190/110, satting 98% on room air. A
thin male in no acute distress. Breathing comfortably.
Answering all questions appropriately. Extraocular movements
are intact. Anicteric sclerae. Moist mucous membranes.
Oropharynx is clear with supple neck. Lungs are clear to
auscultation bilaterally. Heart regular, rate, and rhythm
with normal S1, S2, no murmurs, rubs, or gallops. Belly is
soft, nontender, nondistended, positive bowel sounds. There
is a left lower quadrant renal allograft, nontender.
Extremities: No edema, cool. Left TMA, right toe
amputations with external fixation device on the right.
Neurologic: Alert and oriented times three. Cranial nerves
II through XII intact. No asterixis.
LABORATORIES UPON ADMISSION: Significant for a white count
of 9, hematocrit 43, potassium of 6.3, BUN and creatinine of
80 and 9.5, bicarb 13, glucose 647. Had a gas with pH of
7.28, CO2 36, O2 109. Calcium was 7.5, phosphorus 8.9,
magnesium 2.5. Urinalysis: Leukocyte esterase and nitrite
negative, 0-2 white blood cells and occult bacteria.
Chest x-ray showed no infiltrate and no CHF.
HOSPITAL COURSE:
1. Diabetic ketoacidosis: Patient was admitted to the MICU,
managed with IV insulin drip and IV fluids, which resolved.
Initial triggers unclear. [**Name2 (NI) **] has a history of poor
glycemic control and diabetic ketoacidosis with last
admission in [**2139-8-24**].
The [**Last Name (un) **] endocrinologists were consulted and over the
course of his hospitalization, had fine tuned his diabetes
regimen to Glargine 12 units at night standing dose with a
Humalog insulin-sliding scale.
2. Neurologic: This patient had a question of seizure-like
activity, twitching, and apnea when called out from the MICU
post hemodialysis on [**11-4**]. His electrolytes had
shown a low ionized calcium of 0.99. Was in the process of
getting repleted. Eventually normalized.
Neuro was following. LP was unrevealing. Normal EEG. Tox
screen negative. Unable to have a MRI due to metal in his
legs external fixator. He was originally started on
Dilantin, but then was felt that Dilantin was not needed as
this was probably not a seizure disorder likely metabolic.
Additionally, the patient's glucose was low during the time
of the twitching activity.
3. End-stage renal disease: Failing transplant. Patient is
on prednisone 5 mg a day and will be for life to prevent
transplant rejection. Patient has undergone several
hemodialysis sessions and should be continued 3x a week.
4. Chronic osteomyelitis: Patient completed his six week
course of Vancomycin and ceftaz from [**9-26**] to [**11-8**], and patient is to followup with Orthopedics for removal
of the external fixator. Pain control with OxyContin and prn
oxycodone. Additionally, this patient was found to have a
left rib fracture, ribs #9 and 10 pain control and calcium
supplementation.
5. Hypertension: Patient is hypertensive upon admission.
Now is running in the 130s. Patient was restarted on
amlodipine 5 mg two times a day and is stable. Next
medication to add if needed would be metoprolol.
6. Anemia chronic: Patient was on Epogen dosing, however,
has been D/C'd per Renal.
7. Depression: Patient was stable on his home medication of
Celexa.
8. Fluids, electrolytes, and nutrition: Patient is on a
renal diabetic diet, hemodialysis for repletion and
supplements.
Patient is full code. Patient is to be discharged to
[**Hospital1 **].
Important measures to followup at [**Hospital1 **] are:
1. Pain control: Patient has a history of drug seeking
behavior and has a narcotics contract with Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **].
Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] is to be paged upon this patient's discharge
at [**Telephone/Fax (1) **]. He will be discharged on 20 mg two times a day
of OxyContin and prn oxycodone.
2. Electrolytes each week for this patient's renal failure
and hemodialysis 3x a week.
3. Vital signs everyday. Patient's blood pressure is now
stable, however, if increases, the next drug to add would be
metoprolol.
4. Fingersticks: Patient is a very brittle diabetic and on a
good regimen [**First Name8 (NamePattern2) **] [**Last Name (un) **] evaluation.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Diabetes type 1.
2. Osteomyelitis.
3. Hypocalcemia.
4. End-stage renal disease failing transplant.
5. Hypertension.
6. Seizure-like activity secondary to metabolic
abnormalities.
RECOMMENDED FOLLOWUP:
1. Dr. [**First Name (STitle) 3636**] with [**Last Name (un) **] Diabetes Center, please call
[**Telephone/Fax (1) 2384**] for an appointment.
2. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the Transplant Center on [**2139-12-3**] 2 p.m. for dialysis access. Patient previously had vein
mapping done at his last admission.
3. [**Hospital 5498**] Clinic appointment with Dr. [**First Name (STitle) **],
[**Telephone/Fax (1) 1113**] at [**Hospital Ward Name 23**] [**Location (un) **] 10:45 a.m. on the [**11-24**]. Additionally, he has an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
RN, [**Hospital Ward Name 23**] Center, [**12-9**] at 11:20 a.m.,
[**Telephone/Fax (1) 250**].
5. Patient should follow up with his primary care doctor, Dr.
[**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **], and call for an appointment, [**Telephone/Fax (1) 250**]. She
has a narcotics contract with this patient.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg once a day.
2. Colace 100 mg 2x/day.
3. Folic acid 1 mg one time a day.
4. Atorvastatin 10 mg at night.
5. VG capsule one capsule every day.
6. Pantoprazole 40 mg delayed release EC q.24h.
7. Chlorhexidine 0.12% liquid solution to be used two times a
day swish mouth as needed.
8. Amylase, lipase, protease two tablets with meals.
9. Calcium carbonate 500 mg take two tablets 3x a day.
10. Prednisone 5 mg take one tablet once a day.
11. Oxycodone 5 mg tablets one tablet p.o. q.4-6h. as needed
for pain.
12. OxyContin 20 mg 2x/day.
13. Calcitriol 0.5 mcg one capsule p.o. once a day.
14. Tylenol 500 mg p.o. q.6h. as needed for pain.
15. Amlodipine 5 mg twice a day.
16. Patient will be D/C'd with insulin-sliding scale and
scheduled insulin as per the [**Last Name (un) **] recommendations.
Very important, when patient is discharged, please page Dr.
[**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) **] to let her know when this patient is
leaving so she can know when to prescribe his next narcotics
as they have a narcotic contract.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2139-11-12**] 11:27
T: [**2139-11-12**] 11:30
JOB#: [**Job Number 106443**]
ICD9 Codes: 2767, 496, 4019, 4439
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5576
}
|
Medical Text: Admission Date: [**2115-9-28**] Discharge Date: [**2115-10-20**]
Date of Birth: Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: Patient is an 83-year-old male
with past medical history significant for CAD status post
CABG, Class IV CHF with an EF of 35%, AFib status post ICD
pacer and chronic renal insufficiency, transferred to [**Hospital1 18**]
from nursing home facility due to increased respiratory rate
and lethargy on day of admission. Patient had a recent
hospital admission for pneumonia, and had just completed a
seven day course of Augmentin, which was finished on the day
of this current admission. Patient had been noticed to be
increasingly lethargic with decreased p.o. intake by the
nursing home staff. He also notes diffuse achiness and
feeling chilly. Patient is a poor historian.
Upon arrival to [**Hospital1 18**], his blood pressure was 167/68, heart
rate of 60, respiratory rate of 30, and satting 86% on 5
liters. He was placed on 100% nonrebreather with his sats
improving to the 90s. He received 80 mg of IV Lasix, and his
oxygen requirement then decreased to 4 liters. He also
received a dose of Levaquin and was started on a
nitroglycerin drip.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG x3 in [**2096**] with
redo in [**2108**]. P-MIBI in [**2115-4-16**] showing moderate
reversible inferior defect, status post dual lead pacer and
defibrillator placed in [**2114-8-16**], bilateral pleural
effusions.
2. Class IV CHF with EF of 35%.
3. AFib.
4. Chronic renal insufficiency with baseline creatinine of
2.2.
5. Hyperlipidemia.
6. Hypertension.
7. Monoclonal gammopathy.
8. Prostate cancer status post prostatectomy.
9. Tophaceous gout.
10. Cervical spondylosis.
11. Status post appendectomy.
12. GAVE syndrome.
13. Status post knee surgery.
14. Status post spinal cyst removal.
15. History of lower gastrointestinal bleed.
MEDICATIONS:
1. Protonix.
2. Digoxin.
3. Colace.
4. Isosorbide mononitrate.
5. Epogen.
6. Hydralazine.
7. Toprol XL.
8. Bumetanide.
9. Timoptic eyedrops.
10. Senna.
11. Allopurinol.
12. Remeron.
13. Multivitamin.
ALLERGIES: Morphine.
SOCIAL HISTORY: Currently residing at [**Hospital 33092**] Rehab.
Lives alone. Daughter in [**Name2 (NI) 4565**]. Quit tobacco 40 years
ago. No current alcohol use.
FAMILY HISTORY: Noncontributory.
LABORATORIES ON ADMISSION: White count 11.2, hematocrit
34.7. Sodium 154, potassium 4.9, chloride 116, bicarb 24,
BUN 106, creatinine 2.6. Urinalysis: 100 protein, 21-50
RBC, and few bacteria.
Chest x-ray: Cardiomegaly, bilateral basilar dense opacities
with air bronchograms in the right middle lobe and right
lower lobe consistent with pneumonia with superimposed
pulmonary edema.
EKG: Paced rhythm, left bundle branch block.
HOSPITAL COURSE:
1. Cardiovascular: Pump: Patient with Class IV CHF admitted
with acute CHF exacerbation. At initial presentation in the
ED, patient in acute respiratory distress, received Lasix
with good diuresis, and subsequent improved respiratory
status.
He initially went to the floor, where he was weaned down to 4
liters nasal cannula of oxygen. However, the day following
admission, patient developed worsening respiratory distress
and was markedly tachypneic with decreased urine output and
abdominal pain. He was then transferred to the MICU for
closer monitoring.
Upon arrival in the MICU, there was concern that patient
might be intervascularly dry given his hypernatremia, acute
renal failure, and free water deficit, and low CVPs. He
received several free water and normal saline boluses.
Although his chest x-ray did show bilateral pleural
effusions, these were thought to be chronic.
However, on [**10-4**], the patient continued to have
significant respiratory distress and difficulty weaning off
the ventilator. A CAT scan was obtained, which showed
bilateral layering effusions, pulmonary edema, and patient
was thought to be in CHF. At this point, he was then
diuresed with Zaroxolyn and Bumex for several days without
response. Cardiology was then consulted for evaluation of
his CHF at which point he was started on a Natrecor drip.
Initially, Bumex and Zaroxolyn were D/C'd. Patient had
minimal diuresis.
Review of the record showed patient has had multiple episodes
of CHF refractory to diuresis. Bumex and Zaroxolyn were
added back. In addition, patient was started on a Lasix
drip. He did have an adequate diuretic response on this
regimen. He also required the addition of dobutamine given
his poor cardiac function. A Swan was placed to monitor
patient's hemodynamics throughout this. Multiple attempts
were made to wean him off of his drips, which were
unsuccessful. After several days, his Lasix drip was
stopped, and he was maintained on Natrecor and dobutamine.
However, patient had significant ectopy with dobutamine, so
this was slowly weaned down. The CHF service was also
consulted, but no further progress was able to be made in the
management of patient's CHF.
Rhythm: Patient with biventricular pacer and defibrillator.
He was V paced throughout the hospitalization. He was seen
by EP and his pacer rate was increased to 95 in order to
optimize his cardiac function given his severe CHF. He had
marked ectopy on dobutamine drip, which had been added as per
his CHF.
Coronary: Patient had no active ischemia during the
hospitalization.
2. ID: Patient admitted having just completed treatment for
a pneumonia. He was started on Levaquin and Cipro on
admission to cover for community acquired and aspiration
pneumonia. When he was transferred to the MICU, his
antibiotic coverage was brought in to ceftaz, Flagyl, and
Vancomycin to cover for pneumonia. He was treated for seven
days.
Given his continued respiratory issues, patient was bronched
with BAL cultures obtained. These grew out only sparse MRSA
which was thought to be colonization. Patient remained off
antibiotics for many days. He then subsequently developed a
Pseudomonas UTI for which he was started on cefepime.
3. Pulmonary: Patient admitted with mild respiratory
distress thought to be CHF exacerbation and pneumonia.
Following diuresis, his respiratory status initially
improved, but then upon day of transfer to the MICU, he was
markedly tachypneic with abdominal pain and decreased urine
output. In this setting, he was electively intubated to
allow for better workup of his other issues.
Following this, multiple attempts to wean him off the
ventilator were unsuccessful. He was then started on an
aggressive diuresis regimen. He was finally extubated on
[**10-10**]. He had been intubated for a total of 12
days. He did well for several days following extubation, but
in the setting of his worsening CHF, developed progressive
respiratory distress.
Following lengthy discussions with the patient and the
family, decided that patient would not be reintubated. He
was briefly placed on BiPAP, which he did not tolerate well
and which had minimal effect on his respiratory distress.
4. Heme: Several days into admission, the patient developed
left lower upper edema. An ultrasound showed a new left
subclavian vein thrombus in addition to an old right IJ clot.
Patient was then started on Heparin. Given patient's history
of GAVE syndrome, GI was consulted prior to initiation of
Heparin. There was also concern given a recent EGD, which
showed gastritis and a few AVMs.
Following lengthy discussion with the GI team, it was decided
that the patient would benefit from Heparin. Serial
hematocrits were followed on this regimen. Patient with
baseline anemia due to chronic renal insufficiency, he was
maintained on Epogen and iron per his outpatient regimen.
5. Renal: Patient with chronic renal insufficiency and
baseline creatinine of approximately 2.2. His creatinine
remained essentially stable. His medications were renally
dosed. Patient did have symptoms with urinary obstruction.
The day following admission, he developed acute abdominal
pain. A CAT scan of the abdomen showed a distended bladder.
Following catheterization, his abdominal pain resolved.
Patient had multiple issues with Foley catheter placement
thought to be due to his prostatectomy and unusual anatomy.
Multiple episodes of Foley catheter clogging and with large
bladder residuals measuring 100 cc. Urology was consulted,
and several catheters were placed including finally a
catheter placed under cystoscopy. Patient then had multiple
blood clots and hematuria thought to be due to Foley catheter
trauma in the setting of Heparin.
He was briefly placed on continuous bowel irrigation and his
symptoms resolved.
6. GI: Patient with dysphagia. He had a PEG tube placed and
tube feeds were started, which he tolerated well. He has a
history of GAVE syndrome for which GI followed him. He had
no active exacerbations of this.
7. Fluids, electrolytes, and nutrition: Patient initially
dry on admission and rehydrated. He subsequently developed a
severe CHF exacerbation and was fluid restricted. His
electrolytes were followed throughout the hospitalization and
patient was started on tube feeds, which he tolerated well.
A PEG was placed for tube feed delivery.
8. Disposition: Patient continued to have progressive CHF
refractory to diuretic or other treatments. He developed
progressive respiratory distress, but did not wish to be
reintubated. Multiple discussions regarding codes and
interventions were discussed with patient and his daughter.
[**Name (NI) 227**] patient's extremely poor prognosis and medical futility
treatment, it was decided that he would not benefit from
intubation. Patient had progressive symptoms related to his
CHF. He was briefly placed on BiPAP, which he did not
tolerate. He was given Morphine to make him comfortable and
in an attempt to facilitate BiPAP.
Patient developed progressive respiratory distress and died
secondary to cardiopulmonary failure on [**2115-10-20**] at
4:10 p.m. Patient's daughter was [**Name (NI) 653**] and made aware.
She declined any postmortem examination.
The patient was actually transferred to the CCU service with
the attending, Dr. [**Last Name (STitle) **], although it is still listed in the
computer under MICU, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], just as to clarify
who the attending of record is to be.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-932
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2116-1-23**] 23:36
T: [**2116-1-24**] 12:10
JOB#: [**Job Number 96378**]
cc:[**Last Name (NamePattern4) 96379**]
ICD9 Codes: 4280, 2760, 5990
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5577
}
|
Medical Text: Admission Date: [**2103-12-30**] Discharge Date: [**2104-1-8**]
Date of Birth: [**2053-6-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Acute Appendicitis
Major Surgical or Invasive Procedure:
Open Appendectomy
History of Present Illness:
50-year-old man with progressive
signs and symptoms consistent with appendicitis and probable
small bowel involvement and/or abscess. He presents for
emergency appendectomy.
He reported right sided diffuse abdominal pain x 4-5 days. He
described sharp, constant, worsening RLQ pain. He had a fever to
100.9, chills, decreased appetite and poor PO intake.
Past Medical History:
HIV X 20 yrs (CD4 213,VL undetectable), h/o CMV hepatitis, h/o
PCP PNA, [**Name Initial (PRE) **]/o ? hep A in 70's, h/o penile kaposi sarcoma sp
excision/chemo tx X 13 yrs ago, HPV sp anal fulguration [**5-21**],
[**3-23**]. s/p R SCV port & removal
Social History:
He reports no Tobacco, or ETOH.
Physical Exam:
VS: 99.3, 77, 157/85, 20, 95% RA
Gen: Sick comfortable, tired
HEENT: Anicteric, dry mucosa, no LAD, supple
Chest: CTA bilat.
CV: RRR, no murmurs
GI/Abd: soft, +tenderness periumbilical and RLQ, +Rovsign's
sign, hypoactive BS, no flank tenderness.
Skin: diaphoretic, no rash
Neuro: A+O x 3, no focal deficits
Psych: Appropriate
Pertinent Results:
[**2104-1-5**] 04:42AM BLOOD WBC-4.6 RBC-3.98* Hgb-10.8* Hct-32.3*
MCV-81* MCH-27.2 MCHC-33.5 RDW-13.9 Plt Ct-260
[**2104-1-3**] 03:36AM BLOOD Neuts-55 Bands-4 Lymphs-23 Monos-16*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2104-1-1**] 11:24AM BLOOD WBC-8.5 Lymph-19 Abs [**Last Name (un) **]-1615 CD3%-85
Abs CD3-1370 CD4%-10 Abs CD4-156* CD8%-71 Abs CD8-1150*
CD4/CD8-0.1*
[**2104-1-6**] 05:00AM BLOOD Glucose-112* UreaN-5* Creat-0.6 Na-137
K-3.7 Cl-102 HCO3-27 AnGap-12
[**2104-1-6**] 05:00AM BLOOD ALT-21 AST-34 AlkPhos-101 Amylase-54
TotBili-1.9*
[**2104-1-1**] 09:30AM BLOOD ALT-34 AST-34 AlkPhos-159* Amylase-26
TotBili-5.5*
[**2104-1-6**] 05:00AM BLOOD Lipase-73*
[**2104-1-6**] 05:00AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9
[**2104-1-1**] 08:37PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2104-1-1**] 08:37PM BLOOD HCV Ab-NEGATIVE
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
INDICATION: Right lower quadrant pain.
IMPRESSION:
1. Markedly abnormal appendix with large amount of stranding
around the distal tip. Findings are more suggestive of acute
appendicitis, though other etiologies for appendiceal
inflammation including appendiceal carcinoma or mucocele should
be considered.
2. Inflamed small bowel, probably due to its proximity to the
inflamed appendix.
3. Right renal cyst.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2104-1-1**] 3:14 PM
Reason: JAUNDICE ,RUQ PAIN EVAL FOR GB STONES,OBSTRUCTIVE
JAUNDICE
IMPRESSION:
1. Gallbladder wall edema. Differential diagnosis includes
hypoproteinemia, hepatitis, pancreatitis, or CHF. Cholecystitis
seems unlikely, although this cannot be entirely excluded.
Further evaluation with HIDA scan could be considered.
2. No evidence for biliary obstruction.
Cardiology Report ECG Study Date of [**2104-1-1**] 10:53:48 PM
Sinus rhythm. No significant change compared to the previous
tracing
of [**2104-1-1**].
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 152 94 364/403.71 55 -4 6
ABDOMEN U.S. (COMPLETE STUDY) PORT [**2104-1-2**] 10:49 AM
[**Hospital 93**] MEDICAL CONDITION:
50 year old man HIV+, POD 3 s/p open appy, with rising bilrubin
and abdominal distension.
REASON FOR THIS EXAMINATION:
please evaluate for mesenteric venous thrombosis,
portal/hepatic/splenic vein thrombosis & ascites
IMPRESSION:
1. Normal hepatic vasculature, as clinically questioned.
2. Ascites.
3. Persistent diffuse gallbladder wall thickening. Gallbladder
sludge without evidence of gallstones.
4. Dilated small bowel loops in left lower quadrant,
postoperative ileus versus small bowel obstruction. SMV not
viisualized.
ABDOMEN (SUPINE & ERECT) [**2104-1-3**] 10:43 AM
Reason: interval change, ileus pattern vs. bowel obstruction
INDICATION: Abdominal pain after open appendectomy.
IMPRESSION: Continued appearance of gas filled bowel loops in a
pattern suggestive of ileus, though early or partial SBO cannot
be excluded. Continued followup recommended.
Brief Hospital Course:
He was admitted to [**Hospital1 18**] on [**2103-12-30**] for an Acute laparoscopic
to open Appendectomy. Post-operatively he was NPO, with IV
fluids and a PCA for pain control. He was Levo/Flagyl
antibiotics.
On POD 1, he was noted to be sweating and appearing
uncomfortable. An EKG and tropins were done and were negative.
Pain: He was slightly hypertensive post-operatively (BP 160/100)
with movement. His PCA was increased in order to help gain
better pain control.
Renal: He was noted to have a low urine output on POD 1. He
received 500 cc bolus x 2 and his fluid rate was increased to
150cc/hr. He continued to have low urine output, dark amber in
appearance.
GI/Abd: His abdomen was round and distended and he had
hypoactive bowel sounds.
The evening of POD 1, he was transferred to the ICU for +++
sweating, a very distended abdomen, abdominal pain, poor urine
output and a rapidly rising Bilirubin. An Ultrasound showed
gallbladder wall edema and no evidence for biliary obstruction.
GI: A NGT was placed and returned 1400cc immediately. This was
consistent with an Ileus. He reported + BM on POD 4. His abdomen
began to soften with less tenderness. The NGT was removed on
[**1-4**]. He was started back on his HIV meds once tolerating
clears on [**2104-1-4**]. He was having frequent watery stools. C.diff
was negative. He was tolerating a regular diet and pain was well
controlled.
Heme: He had a rising TBili and Hepatitis labs were drawn. He
was shown to have + hepatitis A and + HepBsAb. Blood cultures
and Urine cultures were negative. His WBC was trending down and
was 3.3 on [**1-4**]. His WBC stabilized at 4.6.
Wound: His abdominal wound was noted to be slightly red with
induration and he was still slightly distended. An US showed
normal hepatic vasculature, ascites, persistent diffuse
gallbladder wall thickening (Gallbladder sludge without evidence
of gallstones), dilated small bowel loops in left lower
quadrant, postoperative ileus versus small bowel obstruction.
SMV not visualized.
Some staples were removed from the inferior portion of the
incision and the wound opened slightly. The superior staples
remained in place. The wound was opened about 5 cm and the edges
were pink. A wound swab showed E.coli and he continued on Keflex
and Flagyl. He will continue with dressing changes at home.
Blood pressure: He continued to have elevated blood pressures.
He was started back on Atenolol 25 mg qd and his pressures were
150-160/80.
Medications on Admission:
trivata, norvir, 2 test drugs?, fuzeon injections", omeprazole
30', prozac', wellbutrin 150'
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Appendicitis
Small Bowel Ileus
Post-op Low Urine Output
Abdominal Distension
Wound Infection
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
Please resume all of your regular medications and take any new
meds as ordered.
Continue to ambulate several times per day.
You will have a visitng nurse assist you with dressing changes.
Change dressing [**Hospital1 **]. Pack lightly with wet to dry 4x4 gauze.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**3-23**] weeks.
Call ([**Telephone/Fax (1) 9058**] to schedule an appointment.
Completed by:[**2104-1-8**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5578
}
|
Medical Text: Admission Date: [**2109-6-30**] Discharge Date: [**2109-7-5**]
Date of Birth: [**2033-4-27**] Sex: F
Service: MEDICINE
Allergies:
Risperdal / Ace Inhibitors
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Fevers, altered mental status
Major Surgical or Invasive Procedure:
Right IJ CVC placement
History of Present Illness:
76 yo F with a history of dementia, schizophrenia, DM and T12
burst fracture complicated by lower extremity paralysis admitted
from a nursing home with fevers, hypotension and hypoxia.
.
The patient was found at her nursing home to be febrile to 101.4
104 140/90 tachypneic to RR 22, saturating at 85% on RA. She was
noted to have a cough and to be less interactive than normal. Of
note the patient was on Levofloxacin 250mg daily for 3 of a
total 7 day course for UTI. Reportedly the nursing home was
using a foley catheter more frequently in order to limit diaper
time as the patient had developed a diaper rash and this was
though to be exacerbating sacral decub. The patient is a poor
historian. She denies all symptoms.
.
On arrival to the ED, T 105 rectal HR 139-150 BP 102/76 RR 30
86% 3L improved to 100% on NRB. The patient's bp declined to
75/53. She had a right IJ placed, received Vancomycin, Zosyn and
5-6L of NS. She was started on levophed 0.06mcg/kg/min. MAP
ranged 66-89, CVP 10. She had 130cc of urine output over the
first 1 hour. Prior to transfer her reported vitals were 103
121/79 26 99% 6L
Past Medical History:
- Schizophrenia
- Dementia
- History of upper GI bleed with angioectasia in the stomach and
duodenum, electrocauterized. Distant GI bleed in past, declined
work-up.
- GERD
- COPD
- Hyptertension
- Diabetes Mellitus
- Osteoarthritis
- Neuropathy
- Urinary incontinence
- T12 burst fracture complicated by lower extremity paralysis
- Sacral decubitus ulcer, previously graded as stage 3
- S/p PEG placement in [**2107-7-9**]
Social History:
Longstanding mental illness, presently living in nursing home.
Is wheelchair bound at baseline.
Family History:
Has siblings with schizophrenia, otherwise noncontributory.
Physical Exam:
Vitals: T 105 rectal, HR 139-150, BP 102/76, RR 30, Sat 86% 3L
Gen: Comfortable, NAD.
HEENT: PERRL. Dry mucus membranes. Asymmetric facial appearance,
slight droop and less responsive on the left. EOMI with the
exception right upper field.
CV: Systolic ejection murmur at right sternal border.
Pulm: CTA bilaterally.
Abd: Soft, g-tube in place without drainage.
Ext: 1+ bilateral lower extremity edema.
Back: 8x5cm stage 1-2 sacral decub. No exudate or surrounding
erythema.
Neuro: A&O x2 (to place and current president). Difficult to
assess though appears to have left sided CN's deficits in VII
otherwise appears intact. Proximal left lower extremity [**5-13**]
strength, refusing and possibly unable to move the left lower
and distal right lower extremity. 5/5 strength in the bilateral
upper extremities.
Brief Hospital Course:
Patient was originally admitted to the [**Hospital Unit Name 153**] on [**2109-6-30**] due to
hypotension and hypoxia in the setting of fever and recent UTI.
As for the etiology of the sepsis, urologic was most likely
despite urine culture showing mixed flora (likely fecal
contaminate) at admission. All blood cultures from [**6-30**] to [**7-2**]
are still pending with no growth to date. Patient was originally
covered by pip/tazo alone and vancomycin was later added. Of
note, patient has a history of cipro resistant urologic
infections. To manage hypotension associated with sepsis,
patient was volume resuscitated with fluid boluses and then was
placed on norepinephrine which was D/C'ed due to 15 beats of
non-sustained ventricular tachycardia. Hypotension was then
managed by phenylephrine, from which the patient was liberated
on [**2109-7-3**]. The hypoxia at admission was originally thought to
be related to sepsis vs. silent aspiration; however, there was
never frank CXR evidence of pulmonary infiltrate to support
asipration. The patient was relieved of supplemental oxygen on
morning of [**2109-7-3**]. The patient's sacral decubitus pressure
ulcer is longstanding and appears to be better than previous
descriptions in recent outpatient notes. There was no evidence
of infection of her sacral decub per wound nurse [**First Name (Titles) **] [**Last Name (Titles) **]
[**Name Initial (PRE) **].
After transfer to the medical service, the patient was
clinically stable, alert and interactive. Since none of her
cultures grew anything and given pt's prior hx of MRSA urinary
infection and presumed bacteremia, the patient was discharged on
a total 14 day course of vanc and zosyn.
Medications on Admission:
Metoprolol Tartrate 25 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO twice a
day: via PEG tube
HOLD for SBP< 110 and HR<60.
Flovent HFA 110 mcg/Actuation Aerosol [**Name Initial (PRE) **]: Two (2) puffs
Inhalation twice a day.
Calcium Carbonate 500 mg (1,250 mg) Tablet [**Name Initial (PRE) **]: One (1) Tablet
PO three times a day: via PEG tube.
Heparin (Porcine) 5,000 unit/mL Solution [**Name Initial (PRE) **]: One (1) injection
Injection TID (3 times a day).
Combivent 18-103 mcg/Actuation Aerosol [**Name Initial (PRE) **]: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
Atorvastatin 20 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO once a day.
Olanzapine 2.5 mg Tablet [**Name Initial (PRE) **]: Three (3) Tablet PO HS (at
bedtime).
Ferrous Sulfate 300 mg/5 mL Liquid [**Name Initial (PRE) **]: Five (5) mL PO DAILY
(Daily).
Multivitamin Liquid [**Name Initial (PRE) **]: Five (5) mL PO once a day.
Senna 8.6 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO BID (2 times a day)
as needed for constipation.
Docusate Sodium 50 mg/5 mL Liquid [**Name Initial (PRE) **]: Five (5) mL PO twice a
day: Hold for diarrhea.
Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
Gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at
bedtime).
Mirtazapine 15 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime).
Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet
PO DAILY (Daily).
Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Three [**Age over 90 **]y
(320) mg PO Q6H (every 6 hours) as needed.
Bisacodyl 10 mg Suppository [**Age over 90 **]: One (1) supp Rectal once a day
as needed for constipation.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet [**Age over 90 **]: One (1) Tablet PO twice
a day: via PEG tube
HOLD for SBP< 110 and HR<60.
2. Flovent HFA 110 mcg/Actuation Aerosol [**Age over 90 **]: Two (2) puffs
Inhalation twice a day.
3. Calcium Carbonate 500 mg (1,250 mg) Tablet [**Age over 90 **]: One (1)
Tablet PO three times a day: via PEG tube.
4. Heparin (Porcine) 5,000 unit/mL Solution [**Age over 90 **]: One (1)
injection Injection TID (3 times a day).
5. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [**Age over 90 **]:
One (1) bag Intravenous Q6H (every 6 hours): Discontinue on [**7-14**].
6. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day (4) **]: One (1)
gram Intravenous Q 24H (Every 24 Hours): Discontinue on [**7-14**].
7. Combivent 18-103 mcg/Actuation Aerosol [**Month/Day (4) **]: 1-2 puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
8. Atorvastatin 20 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day.
9. Olanzapine 2.5 mg Tablet [**Month/Day (4) **]: Three (3) Tablet PO HS (at
bedtime).
10. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Day (4) **]: Five (5) mL PO DAILY
(Daily).
11. Multivitamin Liquid [**Month/Day (4) **]: Five (5) mL PO once a day.
12. Senna 8.6 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (4) **]: Five (5) mL PO twice
a day: Hold for diarrhea.
14. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One
(1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
15. Gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at
bedtime).
16. Mirtazapine 15 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime).
17. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
18. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Three [**Age over 90 **]y
(320) mg PO Q6H (every 6 hours) as needed.
19. Bisacodyl 10 mg Suppository [**Age over 90 **]: One (1) supp Rectal once a
day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**] Center
Discharge Diagnosis:
Sepsis, unknown source
Acute Renal Failure
Hypoxemia
Sacral Decubitus Ulcer stage 3
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to ED if having fevers, rigors, hypotension.
Followup Instructions:
Patient to f/u with PCP.
ICD9 Codes: 0389, 5849, 4271, 2762, 311, 3572, 4019, 2724, 496, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5579
}
|
Medical Text: Admission Date: [**2155-9-5**] Discharge Date: [**2155-9-5**]
Date of Birth: [**2073-2-3**] Sex: M
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Mechanical fall, unconscious, herniation
Major Surgical or Invasive Procedure:
Intubation from OSH
History of Present Illness:
82M fell while walking at 1400 on [**2155-9-4**] and was admitted to
[**Location (un) 8641**]. Initial CT showed SDH. Per reports, only c/o was
headache which subsided. No other neurological findings. He was
kept at the hospital for observation and a repeat scan later
that evening. He rapidly decompensated at 2100, becoming
unresponsive
with seizure, requiring emergent intubation. Head CT from OSH
showed progression of SDH with uncal herniation. He is
medflighted to [**Hospital1 18**] for further care and management.
He is moving lower extremities. No reports of posturing. Remains
intubated and minimal response while taken off sedation. He was
given mannitol at OSH en route to [**Hospital1 18**]. Per reports, there were
2 witnessed seizure events after his decompensation. All other
ROS unable to be obtained
Past Medical History:
PMHx: HTN, allergic rhinitis, AF, MR, colon polyps, neck pain,
lung nodules, venous insuff, BPH, RLS, OA
PSHx: gum repair, prostate [**Doctor First Name **], pericardiocentesis, SCCA
excision, deviated septum repair, variocele repair
Social History:
Social Hx: retired GE, former smoker, no EtOH use. Has HCP -
DNR/[**Name2 (NI) 835**]
Physical Exam:
PHYSICAL EXAM:
O: T: 97 BP: 154/87 HR: 100 R 35 O2Sats
CMV 100% 500 20 Peep 5
Gen: Intubated, moving lower extremities
HEENT: Pupils: fixed and dilated, no reaction to light
Neck: On C-collar
Lungs: intubated, coarse BS bilaterally
Cardiac: [**Last Name (un) 3526**] [**Last Name (un) 3526**]
Abd: Soft, NT, BS+
Extrem: Moving all extremities
Neuro: unable to assess, intubated
Cranial Nerves:
I: Not tested
II: No reaction to light, fixed pupils bilaterally
Motor: moves lower extremities to stimuli, no response to
sternal
rub. No movement to upper extremities elicited.
Toes upgoing bilaterally
Pertinent Results:
CT/MRI: Large acute left SDH along the left cerebral hemisphere
and falx with left cerebral edema, midline shift to the right by
2.1 cm and descending transtentorial herniation
Brief Hospital Course:
Pt was admitted to the NSICU under Dr. [**Last Name (STitle) 739**]. Given
clinical exam and radiological findings, pt with severe brain
damage unamenable to surgical intervention. Poor prognosis and
plan was thoroughly explained to pt's family (including HCP) and
they agreed to withdraw all care. Patient with be extubated and
made comfort measures only. He expired on 3:45 am on [**2155-9-5**].
Medications on Admission:
Medications prior to admission: colace, iron supp, lisinopril
10,
lopressor 25, clonazepam, oxybutynin 5, asa 325, terazosin 2,
finasteride 5, ropinirole 1, vit D
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
SDH w/ herniation
mechanical fall
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
ICD9 Codes: 4240, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5580
}
|
Medical Text: Admission Date: [**2198-2-15**] Discharge Date: [**2198-2-18**]
Date of Birth: [**2137-9-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22282**]
Chief Complaint:
SOB, dizziness
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
Briefly, this is a 60 year old Mandarin speaking man with
history of hypertension and emphysema complicated by pulmonary
fibrosis who was admitted with melena and ~20 point HCT drop
(baseline 40s, dropped to mid 20s). He was initially hypotensive
in the ED and was admitted to the ICU [**2198-2-15**] for resuscitation
and EGD.
In the ED, initial vitals were: T 99.8 P 72 BP 87/61 R 16 O2sat
100%RA. Patient was given 1.5L normal saline, and proton pump
inhibitor. Nasal gastric lavage was positive for some coffee
ground appearing fluid.
In the MICU, repeat nasogastric lavage was negative. He
initially received 2 units of blood. Hematocrit improved from
EGD today revealed 2 bleeding ulcers and gastritis. BP 86/56 HR
70 91%RA. EKG last night was w/o ischemic changes. Today he
complained of new chest pain, it resolved without treatment.
Felt like a numbness on his chest wall this morning per pt. No
problems breathing. One set of negative cardiac enzymes.
On the floor, he is getting unit #[**Unit Number **] of blood. No pain anywhere.
No chest pain or problems breathing. [**Name2 (NI) **] more melena. No new
issues.
Past Medical History:
Hypertesion
Emphysema (per CT)
Pulmonary Fibrosis (per CT)
FEV1/FVC 105%
Tobacco use
Motor vehicle collision requiring exploratory lap in [**2158**]
Low back pain, herniation of L4-L5 with compression of L5 nerve
root
Osteopenia
Lung nodule, found [**2193**]
Social History:
He works as Szechuan Chinese chef in [**Location (un) 3844**]. He lives
with his ex-wife and daughter. Originally he is from [**Country 5142**]. He
does smoke approximately ten cigarettes a day for the last 40
years. He does not drink alcohol now, but used to drink fairly
heavily.
Family History:
Significant for his mother who is 86 and has hypertesion. His
father died of "old age" at age 84.
Physical Exam:
ICU Admission Exam:
BP 86/56 HR 70 91%RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: well healed midline scar, 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
Exam on transfer to floor:
Vital signs: 98.9, 96/65, 72, 20, 98% RA BS 134, wt 172.6
General: Alert, oriented, no acute distress, speaks Mandarin
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur at
left sternal border, soft sounding
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
Pertinent Results:
labs-
[**2198-2-15**] 05:45PM BLOOD WBC-13.4*# RBC-2.99*# Hgb-9.3*#
Hct-26.6*# MCV-89 MCH-31.0 MCHC-34.8 RDW-13.2 Plt Ct-356
[**2198-2-15**] 09:20PM BLOOD WBC-12.1* RBC-2.45* Hgb-7.7* Hct-21.8*
MCV-89 MCH-31.5 MCHC-35.4* RDW-12.7 Plt Ct-320
[**2198-2-16**] 03:24AM BLOOD WBC-12.1* RBC-2.93* Hgb-9.0* Hct-25.8*
MCV-88 MCH-30.6 MCHC-34.8 RDW-13.2 Plt Ct-271
[**2198-2-17**] 07:40AM BLOOD WBC-9.4 RBC-3.47* Hgb-10.6* Hct-29.9*
MCV-86 MCH-30.5 MCHC-35.4* RDW-14.2 Plt Ct-253
[**2198-2-17**] 05:10PM BLOOD Hct-29.6*
[**2198-2-18**] 07:40AM BLOOD WBC-8.1 RBC-3.43* Hgb-10.8* Hct-30.0*
MCV-88 MCH-31.5 MCHC-35.9* RDW-13.9 Plt Ct-329
[**2198-2-15**] 05:45PM BLOOD Neuts-76.6* Lymphs-19.4 Monos-3.0 Eos-0.7
Baso-0.3
[**2198-2-15**] 09:20PM BLOOD PT-15.1* PTT-26.5 INR(PT)-1.3*
[**2198-2-18**] 07:40AM BLOOD PT-13.9* PTT-27.0 INR(PT)-1.2*
[**2198-2-15**] 05:45PM BLOOD Glucose-149* UreaN-43* Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-24 AnGap-14
[**2198-2-18**] 07:40AM BLOOD Glucose-111* UreaN-10 Creat-0.8 Na-140
K-3.5 Cl-105 HCO3-27 AnGap-12
[**2198-2-15**] 05:45PM BLOOD ALT-18 AST-12 CK(CPK)-23* AlkPhos-47
TotBili-0.2
[**2198-2-16**] 09:05PM BLOOD CK(CPK)-38
[**2198-2-15**] 05:45PM BLOOD cTropnT-<0.01
[**2198-2-16**] 09:05PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2198-2-15**] 05:45PM BLOOD Albumin-3.7 Calcium-8.1* Phos-2.2* Mg-2.2
[**2198-2-18**] 07:40AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
[**2198-2-15**] 05:50PM BLOOD Lactate-2.7*
[**2198-2-15**] 11:41PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2198-2-15**] 11:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2198-2-17**] 7:40 am SEROLOGY/BLOOD
HELICOBACTER PYLORI ANTIBODY TEST (Pending):
[**2198-2-15**] 9:20 pm MRSA SCREEN
**FINAL REPORT [**2198-2-18**]**
MRSA SCREEN (Final [**2198-2-18**]): No MRSA isolated.
[**2198-2-15**] 11:41 pm URINE Source: CVS.
**FINAL REPORT [**2198-2-17**]**
URINE CULTURE (Final [**2198-2-17**]): NO GROWTH.
Reports-
Cardiology Report ECG Study Date of [**2198-2-15**] 4:54:28 PM
Sinus rhythm. No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 144 84 348/398 73 18 52
CXR
HISTORY: 60-year-old male with emphysema/restrictive lung
disease with
leukocytosis and fever.
COMPARISON: Chest radiograph [**2194-1-16**].
FINDINGS: The nasogastric tube terminates within the stomach;
the distal tip is directed cephalad. The lungs are clear.
Relative mediastinal prominence may be due to low lung volumes
and magnification on frontal view. No airspace consolidation is
identified to suggest pneumonia. Interstitial prominence is
similar to [**2194-1-14**].
The study and the report were reviewed by the staff radiologist.
Endoscopy
-Esophagus: Normal esophagus.
-Stomach:
Contents: Bilious fluid was seen in the stomach body. There was
no red blood or melena in the stomach or duodenum.
Mucosa: Scattered erosions with erythema and congestion of the
mucosa with no bleeding were noted in the antrum, stomach body
and fundus. These findings are compatible with erosive
gastritis.
Excavated Lesions Two cratered non-bleeding ulcers ranging in
size from 4mm to 10mm were found in the antrum. In addition,
there was an area of nodular mucosa with erythema and congestion
adjacent to the 1 cm ulcer that is likely due to inflammation.
-Duodenum: Normal duodenum.
-Impression: Erosion, erythema and congestion in the antrum,
stomach body and fundus compatible with erosive gastritis
Ulcers in the antrum
Retained fluids in stomach
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
MICU Course:
The patient was admitted with melena, NG lavage positive for
coffee ground emesis, hypotension to 80s, and hematocrit drip
from 40s to 20s. He was transfused 3 units with improvement in
hematocrit to 28.5 and started on IV PPI. He underwent upper
endoscopy, which showed 2 non-bleeding ulcers in the gastric
antrum and gastritis. His blood pressure remained stable and
patient was transferred to the floor to continue with
transfusion of one more unit PRBCs for goal hematocrit of > 30.
The patient was also noted to have leukocytosis of 12.5. Blood
cultures were sent and were pending at the time of transfer. He
was also complaining of new right-sided chest discomfort, but
EKGs were stable and cardiac enzymes were negative.
Floor course:
On arrival to the floor pt was starting his 4th unit of red
blood cells. His blood pressures remained stable initially,then
increased and before discharge was restarted on his blood
pressure medications. His hematocrit was monitored, and was 29.9
after the transfusion. He was started on clears, but complained
of some abdominal discomfort. He was monitored for bleeding for
an additional day and remained stable and hematocrit was 30 at
discharge. He was started on treatment for h. pylori with
amoxicillin, clarithromycin, and PPI for a 2 week course. He has
a follow up appointment for a colonoscopy. He will also have a
repeat endoscopy in 6 weeks. H. pylori antigen was sent,
however, the patient already was positive in previous test,
therefore, it is expected to still be positive. Stool antigen
was not collected since pt did not have BM after test was
ordered. He was advised not to smoke. Blood cultures remained
with no growth at discharge. His anemia of blood loss may
require treatment with iron as out patient.
He was discharged home with GI and PCP follow up care. His
aspirin was stopped.
Medications on Admission:
ATENOLOL - 50 mg daily
ASPIRIN - 81 mg daily
Discharge Medications:
1. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a
day for 14 days: antibiotic for stomach.
Disp:*28 Capsule(s)* Refills:*0*
2. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days: antibiotic for stomach.
Disp:*28 Tablet(s)* Refills:*0*
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day: to protect the
stomach from bleeding.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
gastric ulcers
gastritis
acute blood loss anemia
Discharge Condition:
stable, afebrile, amubatory
Discharge Instructions:
You were admitted with blood in your stool. You were found to
have peptic ulcer disease and gastritis on your endoscopy
procedure. This may be from an infection with a bacteria called
H. pylori.
You were placed on 2 antibiotics for the infection, you will
need to take them for 14 days, complete this course even if you
feel better. You will also now be on a medication called protnix
to protect your stomach, take this twice a day. Do not take
aspirin, ibuprofen/motrin or other similar medications, as they
can increase your risk of abdominal bleeding. You may continue
to take atenolol although stop this medication and call your
doctor should you experience dizziness, unsteadiness or
confusion.
It is recommended that you avoid alcohol and tobacco, as these
can worsen the stomach. Also, at first eat bland foods, such as
bread, rice, eggs. Once your stomach feels better you can eat
normally.
Please keep your follow up appointments. It is important to have
the colonscopy on [**3-27**]. Please call Dr.[**Name (NI) 27118**] office for
instructions on how to prepare for the exam.
Please take your medications as instructed.
If you have blood in your stool, bad abdominal pain, faint,
vomit blood, or have other concerning symptoms please seek
medical attention or go to the ER.
Followup Instructions:
Please follow up with your primary care provider, [**Name Initial (NameIs) 2169**]:
[**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2198-3-29**] 1:40
Colonoscopy:
[**Last Name (NamePattern1) 11100**] with Dr. [**Last Name (STitle) **] for [**2198-3-27**] at
9:30am. Please call ([**Telephone/Fax (1) 2306**] with questions.
Completed by:[**2198-2-19**]
ICD9 Codes: 2851, 3051, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5581
}
|
Medical Text: Admission Date: [**2185-6-25**] Discharge Date: [**2185-6-30**]
Date of Birth: [**2117-2-27**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old
female with a past medical history of chronic renal
insufficiency, diabetes mellitus, paroxysmal atrial
fibrillation on Coumadin at home, who presents with 3 days of
dark red blood per rectum and episodes of lightheadedness.
She subsequently presented to the Emergency Department, where
she was found to have a hematocrit of 18. A NG lavage was
negative for active bleeding. She was sent to the ICU for
hemodynamic monitoring and transfusions and received 6 units
of red blood cells, vitamin K, 4 units of FFP and remained
hemodynamically stable. Her INR slowly trended down and she
was awaiting a colonoscopy and EGD to find the source of
bleeding.
PAST MEDICAL HISTORY:
1. CHF. History of diastolic dysfunction, echo from [**Month (only) 1096**]
[**2184**] with an EF of 60 percent.
2. Type II diabetes mellitus.
3. Chronic renal failure, baseline creatinine 2.2 to 3.3.
4. Paroxysmal atrial fibrillation status post pacer.
5. Hyperlipidemia.
6. Hypertension.
7. History of DVT.
8. Anemia.
9. Peripheral vascular disease, status post bypass.
10. Colonic polyps.
SOCIAL HISTORY: The patient lives alone, single, no tobacco,
or alcohol. She is supported by her sister who lives nearby.
ALLERGIES: SULFA CAUSES HIVES.
MEDICATIONS ON TRANSFER:
1. Imdur 20 mg 3 times a day.
2. Hydralazine 30 mg 4 times a day.
3. Lopressor 50 mg twice a day.
4. Percocet p.r.n.
5. Lipitor 10 mg once a day.
6. Protonix 40 IV q.12.
7. Vitamin K.
PHYSICAL EXAMINATION: Vital signs: Temperature is 98.8,
blood pressure 138/60 to 160/74, heart rate 60 to 72,
respirations 20, O2 saturation 96 to 97 percent on room air,
and fingersticks 93 to 102. General appearance: The patient
appears comfortable in no apparent distress. HEENT exam:
Nonicteric. Mucosa moist. Lungs are clear to auscultation
bilaterally. Cardiac exam: Regular rate and rhythm, 2/6
systolic ejection murmur. Abdomen: Soft, nontender,
nondistended with good bowel sounds, and obese. Extremities:
No lower extremity edema.
LABORATORIES ON TRANSFER: Notable for an initial hematocrit
of 18.2, which slowly trended up to the low 30s. At the time
of transfer, her hematocrit was 30.3. Her INR was initially
and 4.0 trended down to 1.5. Creatinine was initially 3.3
and trended down to 2.7. UA was negative. Chest x-ray
showed cardiomegaly with stable improvement of CHF.
HOSPITAL COURSE:
1. GI bleeding: Her GI bleeding was felt to likely be
related to her INR of 4 on Coumadin and was suspected that
it was related to her previously known colonic polyps as a
source of this bleeding. Her Coumadin was held and her
INR slowly drifted down and her hematocrit remained stable
for the rest her hospital course. She had a colonoscopy
on [**2185-6-28**] showing rectal polyps, ascending colonic
polyp, mid transverse polyp, which were all removed and
she had a biopsy of the distal transverse colon. She also
had an EGD showing mild gastritis. It was presumed that
her bleeding was related to the colonic polyps and her
Coumadin was held at the time of discharge.
1. Renal: Her BUN and creatinine are slightly elevated at
the time of admission, which improved to her baseline
prior to admission.
1. Cardiac: She did not have any episodes of congestive
heart failure during this admission. After discussion
with the attending, Dr. [**Last Name (STitle) **], instructed the patient
they have considered discontinuing Coumadin therapy in the
future because of the future risks of GI bleeding.
DISPOSITION: The patient was felt well for discharge and
Physical Therapy was consulting, felt the patient was safe
for discharge home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home with services.
DISCHARGE DIAGNOSES: Primary diagnosis: GI bleed.
Secondary diagnoses: Diastolic CHF, diabetes mellitus,
chronic renal failure, paroxysmal atrial fibrillation status
post pacer, hyperlipidemia, anemia, peripheral vascular
disease, and colonic polyps.
DISCHARGE MEDICATIONS:
1. Hydralazine 30 mg p.o. q.i.d.
2. Lasix 60 mg p.o. b.i.d.
3. Glipizide 5 mg p.o. q.d.
4. Isosorbide dinitrate 20 mg p.o. t.i.d.
5. Protonix 40 mg p.o. q.d.
6. Lipitor 10 mg p.o. q.d.
7. Ambien 5 mg p.r.n.
8. Sertraline 50 mg p.o. q.d.
9. PhosLo 667 mg p.o. t.i.d.
10. Lopressor 100 mg p.o. t.i.d.
FOLLOWUP PLANS: The patient was told to weigh herself every
morning and adhere to a low-sodium diet. She was told that
to take all medications as prescribed and to continue
stopping her aspirin for 3 weeks as well as her Coumadin as
discussed with Dr. [**Last Name (STitle) **]. She was told that if she
develops any bloody stools, black tarry stools,
lightheadedness, abdominal pain, chest pain, shortness of
breath, or any other concerning symptoms that she should
notify her PCP immediately and seek immediate medical
attention. She was told to followup with her primary care
doctor, Dr. [**Last Name (STitle) **] who will contact her about the date and
time of her followup appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 105322**], MD [**MD Number(2) 105323**]
Dictated By:[**Last Name (NamePattern1) 2366**]
MEDQUIST36
D: [**2185-12-1**] 11:35:03
T: [**2185-12-2**] 02:02:50
Job#: [**Job Number 105325**]
ICD9 Codes: 5789, 4280, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5582
}
|
Medical Text: Admission Date: [**2165-8-4**] Discharge Date: [**2165-8-15**]
Date of Birth: [**2105-7-16**] Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Biaxin / Penicillins / Aspirin / Flexeril /
clindamycin / doxycycline
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Bright Red Blood Per Rectum and Hemoptysis
Major Surgical or Invasive Procedure:
-Upper Endoscopy
-Mechanical Ventilation
History of Present Illness:
Ms. [**Known lastname **] is a 60 year old woman with morbid obesity, diastolic
CHF, and afib on coumadin who presents with hemoptysis x several
[**Known lastname **] and BRBPR x2 [**Known lastname **]. The patient describes a slip/fall
approximately 2 months ago after which she experienced worsening
abdominal and back pain. Since that time, the patient reports
having little to no appetite. Over the past week, she has been
unable to keep any food down and describes one episode of
vomiting after attempting to eat. Also endorses worsening of
her abdominal pain recently, especially over the RLQ. Pain is
described as sharp and non-radiating. Self-d/c'ed coumadin this
past friday after she noticed that she was excessively bleeding
following a small cut. The patient reports N/V with eating as
above, but otherwise denies CP, palp, SOB, diarrhea, fever or
recent illness.
.
In the ED, the patient's intial vitals were BP 142/47 and HR 134
(afib/rvr). She was triggered for tachycardia and GI bleed. NG
lavage performed with blood clots intially but cleared after
200ml. Stool is brownish-green in color and guaiac positive.
Initial labs revealed Hct 35 (baseline 40), lactate 3.3, INR
>19, PTT 150 which were verified with repeat labs. Got 1L NS
IVF, 10mg IV vitamin K, type & crossed x2 units, started on PPI
gtt, vancomycin and FFP. Admitted to MICU with vitals 100.8,
112, 116/73, 22-30, 100% 2L NC.
Past Medical History:
- Morbid obesity
- Chronic back, hip, and knee pain: Multilevel DJD on L-spine
x-ray in [**2164**], severe djd on knee x-ray in [**2164**]. On narcotics
agreement.
- Hypertension
- Dyslipidemia
- Pre-diabetes
- Diastolic CHF: on lasix.
- Atrial fibrillation: S/p DC cardioversion, on Coumadin. INR
variable in past as Coumadin frequently held in past for trigger
point injections.
- Dyspepsia
- Migraine headaches: Fioricet prn.
- Uterine fibroids
- Postmenopausal bleeding, as above
- Osteoarthritis
- Asthma: mild intermittent.
- Allergic rhinitis
Social History:
Social History: Lives with daughter in [**Name (NI) 392**]
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Family History: Endorses family Hx of cancer but does not know
type.
Physical Exam:
ON ADMISSION:
Physical Exam:
Vitals: T: 98.6 BP: 106/58 P:70 R: 17 O2: 100% on NC
General: Obese female. Alert, oriented, in mild distress [**2-20**]
abdominal pain
HEENT: PERRLA, sclera anicteric, MM dry, oropharynx clear, dried
blood on lip
Neck: supple, could not assess JVD due to body habitus
Lungs: Limited exam. Clear to auscultation bilaterally, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese. Tender diffusely but worse over the RLQ.
BSx4, no rebound tenderness. 3x3cm area of echymoses over LUQ.
Surgical scar from cholecystectomy.
GU: no foley
Ext: warm, 2+ pulses, significant swelling/lymphedema
ON DISCHARGE:
General: morbidly obese, lying in bed in NAD
HEENT: MMM, PERRL
Neck: impossible to assess JVD
CV: irregularly irreg, nl S1/s2, no m/r/g
RESP: Exam limited by body habitus, no r/r/w in anterior lung
fields
ABD: +BS, soft/morbidly obese/tender to palp in RLQ>RUQ. No
erythema of pannus, moist under folds.
EXT: 2+ Pitting edema of legs bilaterally, calves non-tender
Pertinent Results:
[**2165-8-4**] 11:00PM PT->150 PTT->150* INR(PT)->19.2
[**2165-8-4**] 11:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2165-8-4**] 11:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2165-8-4**] 09:05PM GLUCOSE-137* UREA N-27* CREAT-1.0 SODIUM-138
POTASSIUM-2.7* CHLORIDE-90* TOTAL CO2-27 ANION GAP-24*
[**2165-8-4**] 09:05PM LIPASE-10
[**2165-8-4**] 09:05PM WBC-16.6*# RBC-4.29 HGB-11.4* HCT-35.5*
MCV-83 MCH-26.5* MCHC-31.9 RDW-17.1*
[**2165-8-4**] 09:05PM NEUTS-81.4* LYMPHS-14.4* MONOS-3.5 EOS-0.1
BASOS-0.6
[**2165-8-4**] 09:05PM FIBRINOGE-1074*
CXR ([**2165-8-4**]): Low lung volumes, cardiomegaly, questionable
consolidation R base, no clear pneumonia or volume overload.
EKG ([**2165-8-4**]): Rate is 134, a fib with RVR
CT chest/abdomen ([**2165-8-5**]): Markedly degraded image quality due
to patient body habitus. Within these limits, note is made of
bibasilar consolidation and moderate volume left perihepatic and
perisplenic free fluid.
RUQ US ([**2165-8-8**]): Severely limited ultrasound due to the
patient's body habitus. No gross biliary dilatation or ascites
identified.
CTA Chest ([**2165-8-9**]): The technical quality of the exam is
severely limited and allows only for evaluation of the central
pulmonary arteries, and the current CT does not reveal any
evidence of central pulmonary embolism. The lobar, segmental and
subsegmental arteries could not be evaluated due to severe
artifacts and technically limited CT exam. Moderate
cardiomegaly with enlarged pulmonary artery suggestive of
pulmonary artery hypertension.
US of abdominal soft tissue ([**2165-8-9**]): Unremarkable ultrasound
examination of the superficial tissues in the right upper
quadrant.
US left upper extremity ([**2165-8-12**]): No left upper extremity deep
venous thrombosis.
.
TTE: The left atrium is mildly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is probably low normal (LVEF
50-55%) but views are suboptimal for assessment of this. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2161-11-5**],
the abnormal septal motion consistent with right ventricular
pressure/volume overload may be new but images are suboptimal
for comparison.
TVUS ([**2165-8-14**]): Enlarged uterus with multiple calcified
fibroids, at least one of which is in a submucosal location.
Direct comparison of fibroid size from previous ultrasound is
not possible due to limited visualization.
Discharge labs:
[**2165-8-15**] 05:38AM BLOOD WBC-9.1 RBC-3.42* Hgb-9.4* Hct-29.6*
MCV-87 MCH-27.5 MCHC-31.7 RDW-20.3* Plt Ct-397
[**2165-8-15**] 05:38AM BLOOD Plt Ct-397
[**2165-8-15**] 05:38AM BLOOD Glucose-111* UreaN-7 Creat-0.5 Na-135
K-3.5 Cl-95* HCO3-34* AnGap-10
[**2165-8-15**] 05:38AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.6
[**2165-8-14**] 05:50AM BLOOD ALT-15 AST-26 LD(LDH)-271* AlkPhos-107*
TotBili-0.9
Brief Hospital Course:
Assessment and Plan: Ms. [**Known lastname **] is a 60 y/o F with multiple
medical comorbidities presenting with hemoptysis and BRBPR in
the setting of elevated PT/PTT.
.
# Bleeding - Patient presented with an INR >19 and bleeding from
her mouth, rectum and vagina. An upper endoscopy was preformed
by GI which showed diffuse continuous atrophy of the mucosa with
no bleeding noted in the stomach. She subsequently had a CT
Torso with PO contrast which showed no acute intrabdominal
process but was limited by body habitus. She was given 2 units
PRBCs on [**2165-8-4**] and was admitted to the MICU. Her bleeding
slowed down as her INR was reversed with FFP and Vitamin K.
After her Hct was stable and bleeding was controlled, she
was transferred to the floor. She continued to have vaginal
bleeding despite a normal INR, although no further episodes of
hematemesis or hemoptysis were noted during her time on the
floor. She was briefly placed on a heparin drip to observe for
further evidence of bleeding, although this was stopped after
she had some continued vaginal bleeding. Her INR remained
somewhat elevated in the 1-1.5 range despite being off Coumadin.
CTA did not show evidence for a PE in the central pulmonary
arteries, although the report notes dilation of the pulmonary
arteries. The leading explaination for her bleeding and
coagulopathy is a congestive hepatopathy as mentioned below. At
the time of discharge, her Hct has been stable and she has not
had any further episodes of major bleeding.
Ob/gyn was consulted regarding the post-menopausal vaginal
bleeding, they had recently performed a very technically
challenging biopsy for the same issue which did not show
evidence of malignancy, but was a limited sample. A repeat
transvaginal US was obtained during this admission which was
unable to comment on uterine dimensions but again noted
calcified fibroids, including a submucosal fibroid. OB/Gyn
consult did not recommend any further inpatient procedures but
suggested that she will an MRI of her pelvis after the bleeding
has stopped. PCP was [**Name (NI) 653**] about the need for follow up and
pt is scheduled to be seen in ob/gyn clinic on [**2165-8-19**].
.
# Coagulopathy: The patient takes coumadin at home for afib, but
had stopped since 2 [**Known lastname **] prior to admission. Her INR had
previously been therapeutic. Initial labs in the ED revealed a
PTT of 150 and INR >19 without history of heparin containing
products. Pt received FFP and Vitamin K in the ED and her INR
corrected to 1.2 in the MICU. INR remained mildly elevated
around 1.2-1.5 despite being off of Coumadin for many [**Known lastname **].
The coagulopathy was thought likely worsened by congestive
hepatopathy.
.
# Abdominal Pain: Patient complained of RLQ abdominal pain that
had been present for a number of weeks prior to admission, worse
with palpation. CT abdomen was unrevealing for acute process,
she was seen by surgery which did not feel this was an acute
issue possibly related to calcified fibroids.
After arrival to the floor, her LFTs were elevated with
AST>ALT, a Tbili of [**2-20**].2 and high alk phos and LDH. RUQ US was
unremarkable, limited due to body habitus but showed normal
caliber common bile duct. LFTs trended down, but her LDH and
alk phos remained elevated. Her pain waxed and waned during the
admission, but at discharge she states it has improved since
when she was admitted. As discussed below, her abdominal pain
is thought to also be related to a congestive hepatopathy with
likely capsular stretch and possible ascites.
.
#Congestive hepatopathy - The unifying diagnosis that is
believed to be causing the above issues, coagulopathy, bleeding
and abdominal pain is congestive hepatopathy. A TTE obtained
prior to discharge showed evidence of elevated right-sided
pressure with evidence of pulmonary hypertension. Congestive
hepatopathy in the setting of pulmonary hypertension and right
heart failure would explain her coagulopathy and abdominal pain
from stretching of the liver capsule. It would also explain why
her INR never normalized despite stopping Coumadin.
.
# Afib: The patient has a h/o afib with RVR. Beta blockade was
initially held in the setting of her acute bleed. Once
stabilzied she was restared on her home dose of 50 mg
Metoporolol TID which was up titrated to 100mg q6h for better
rate control. Her HR remained below 100 with this increased
dose of metoprolol.
She has been off Coumadin given her ongoing bleeding. Her
CHADS2 score is 2 and she has an allergy to aspirin, so this is
not an option. We have informed her of the risk of stroke being
off Coumadin and the fact that there is no suitable alternative
given her continued vaginal bleeding. Both the patient and her
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**] were notified about the short term plan to hold
coumadin until the bleeding has resolved but she will need to
anti-coagulated again soon.
.
# Pneumonia: Patient had a temperature of 99.9 in the setting
of an elevated white count and sputum culture which grew E.
coli. This was believed to be caused by an aspiration event.
She was treated with Levaquin for 8 [**Known lastname **] given her history of
multiple antibiotic allergies.
.
# Elevated lactate: Her lactate was elevated to 3.3 on admission
with the administration of fluids this corrected to 1.3 along
with closure of her anion gap.
.
# Diastolic CHF and Right sided failure: The patient carries a
diagnosis of diastolic CHF (EF 50-55% on TTE this admission).
BNP at admission was 2342, no other recent BNPs for comparison.
She was diuresed, although we are unable to assess the response
as her volume status is impossible to determine given body
habitus. However, her LFTS did improve with diuresis and pt was
discharged on lasix 20mg daily.
.
#Insulin Insensitivity: Patient was admitted with diagnosis of
"pre-diabetes" was placed on insulin sliding scale which was not
utilized. Her blood glucose remained below 200 and she did not
regularly receive insulin.
.
#OSA - She continued to wear CPAP with oxygen at night during
her hospitalization.
.
Transitional Care:
-Has follow-up arranged with ob/gyn regarding fibroids and
vaginal bleeding
-Will need to have her metoprolol dose monitored, this was
increased during her hospitalization
-She has been discharged without anticoagulation for her AF, the
issue of anti-coagulation will need to be re-addressed after her
bleeding stops. Dabigatran may be an option for
anti-coagulation as she has been supratherapeutic with
significant bleeding on warfarin.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every 6 hours as needed for asthma
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 (One) Tablet(s) by
mouth once a [**Known lastname **]
BUTALBITAL-ACETAMINOPHEN-CAFF - 50 mg-325 mg-40 mg Tablet - 1
(One) Tablet(s) by mouth twice a [**Known lastname **] as needed for migraines.
This contains acetaminophen (Tylenol); do not exceed 4 grams
Tylenol daily.
CELECOXIB [CELEBREX] - 100 mg Capsule - 1 capsule by mouth twice
a [**Known lastname **] as needed for pain. Take the medication with food.
COMPRESSION STOCKINGS - - wear daily to decrease swelling in
legs, ankles, and feet
CROLOM - 4% Drops - 2 DROPS EACH EYE THREE TIMES A [**Known lastname **] AS NEEDED
DIVALPROEX [DEPAKOTE] - (Prescribed by Other Provider:
[**Name10 (NameIs) 96235**] at [**Hospital1 112**]; Dose adjustment - no new Rx) - 250 mg Tablet,
Delayed Release (E.C.) - As directed Tablet(s) by mouth 1 tab
qAM, 2 tabs at noon, 2 tabs qhs
FEXOFENADINE - 180 mg Tablet - 1 Tablet(s) by mouth once a [**Known lastname **]
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250-50 mcg/Dose Disk
with Device - one puff twice a [**Known lastname **]
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a
[**Known lastname **]
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by
mouth twice a [**Known lastname **] as needed for pain Per [**2165-4-30**] Narcotics
Agreement
HYDROXYZINE HCL - 25 mg Tablet - [**1-20**] Tablet(s) by mouth at
bedtime as needed for itching
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth qam
METHOCARBAMOL [ROBAXIN-750] - 750 mg Tablet - take [**1-20**] Tablet(s)
by mouth twice a [**Known lastname **] as needed for back pain
METOPROLOL TARTRATE [LOPRESSOR] - 50 mg Tablet - 1 Tablet(s) by
mouth three times a [**Known lastname **]
MOM[**Name (NI) **] [NASONEX] - 50 mcg Spray, Non-Aerosol - 1 SPRAY NASAL
DAILY
OLOPATADINE [PATANOL] - 0.1 % Drops - 1 DROP in each eye twice a
[**Known lastname **]
TOPIRAMATE [TOPAMAX] - 25 mg Tablet - 1 Tablet(s) by mouth in am
and 3 tabs at bedtime
WARFARIN [COUMADIN] - 2.5 mg Tablet - 3 to 4 Tablet(s) by mouth
once a [**Known lastname **] as directed by [**Hospital **] Clinic to maintain INR
ACETAMINOPHEN - (OTC) - 500 mg Tablet - as below Tablet(s) by
mouth max 2gm daily. takes 2 tabs [**Hospital1 **] prn
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth daily
MULTIVITAMIN WITHOUT VITAMIN K - (OTC) - Dosage uncertain
OMEPRAZOLE - 20 mg Tablet, Delayed Release (E.C.) - 1 (One)
Tablet, Delayed Release (E.C.)(s) by mouth once a [**Known lastname **]
SIMETHICONE - 166 mg Capsule - 1 Capsule(s) by mouth Q8:PRN as
needed for BLOATING
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO twice a
[**Known lastname **] as needed for migraines.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a [**Known lastname **].
5. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
every six (6) hours.
6. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a [**Known lastname **].
7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a [**Known lastname **].
8. simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
[**Known lastname **] as needed for gas.
9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a [**Known lastname **].
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. miconazole nitrate 2 % Powder Sig: One (1) application
Topical three times a [**Known lastname **] as needed for rash.
12. warfarin 2.5 mg Tablet Sig: 3-4 Tablets PO once a [**Known lastname **]:
Please do not take this until your bleeding has stopped and you
have talked with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**].
13. cromolyn 4 % Drops Sig: Two (2) drops Ophthalmic three times
a [**Known lastname **] as needed: both eyes.
14. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal once a [**Known lastname **].
15. olopatadine 0.1 % Drops Sig: One (1) once a [**Known lastname **] Ophthalmic
twice a [**Known lastname **].
16. cholecalciferol (vitamin D3) Oral
17. multivitamin Oral
18. simethicone Oral
Discharge Disposition:
Extended Care
Facility:
Tower [**Doctor Last Name **] - [**Location (un) 2624**]
Discharge Diagnosis:
Primary diagnoses:
Congestive hepatopathy
Gastrointestinal bleed
Pneumonia
Post-menopausal vaginal bleeding
Secondary diagnoses:
Atrial fibrillation
Diastolic heart failure
Obstructive sleep apnea
Uterine fibroids
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you while you were admitted. You
came in because you had bleeding from your rectum, vagina and
mouth and were found to have a very high INR, which means that
your blood was not able to clot properly. An upper endoscopy
did not show any source of the bleeding. You received blood
products and vitamin K to correct the clotting problem and your
bleeding improved. There was still some vaginal bleeding which
continued and you will follow-up with ob/gyn regarding this
issue.
You are not currently on anticoagulation for your atrial
fibrillation because you are still bleeding and are have an
allergy to aspirin. As soon as you have stopped bleeding,
please contact your PCP so that you can be restarted on Coumadin
as soon as possible.
Your abdominal pain is believed to have been caused by your
heart not pumping effectively, causing blood to back up into
your liver. This also explains why you had the clotting
disorder mentioned above, since the liver is responsible for
making many of your blood's clotting factors.
You were also found to have a pneumonia, which was treated with
levofloxacin (Levaquin) for 8 [**Known lastname **]. Your fevers and difficulty
breathing improved after treatment with antibiotics.
The following changes have been made to your medications:
CHANGE Metoprolol 100mg by mouth every 6 hours
CHANGE Lasix to 20mg by mouth daily
STOP Coumadin until your bleeding has stopped and you contact
your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**]
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2165-8-21**] at 1 PM
With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: OBSTETRICS AND GYNECOLOGY
When: MONDAY [**2165-9-16**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 71322**], MD [**Telephone/Fax (1) 2664**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5070, 2762, 2851, 4280, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5583
}
|
Medical Text: Admission Date: [**2104-12-14**] Discharge Date: [**2104-12-15**]
Date of Birth: [**2031-8-25**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 73-year-old female
with a history of CAD status post CABG and multiple stents
presenting following a witnessed cardiac arrest at home. The
patient was in the bathroom combing her hair when she called
out to her husband. The husband ran into the bathroom and
found the patient slowly sliding against the wall down to the
ground. She was then pulseless and apneic. The husband
initiated CPR. Seven to 10 minutes later, the police
arrived. The patient was shocked with an ACD 5x.
Approximately 10 minutes after the initial arrest, EMS
arrived. The patient was found to be pulseless electrical
activity and apneic. The patient was intubated, given
Epinephrine, atropine, and lidocaine. The pulse returned
approximately 12-15 minutes after the initiation of the
arrest.
The patient was taken to the outside hospital and was
transferred to [**Hospital1 69**]. In the
Emergency Department, the patient was hypothermic to 93.8.
She was nonresponsive and intubated without any need for
sedation. Patient was also on Neo-Synephrine for blood
pressure support and was on a lidocaine drip ever since the
arrest.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG and stent.
2. Status post carotid endarterectomy.
3. Diabetes mellitus type 2.
4. Status post hysterectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: Patient was on a long list of
medications at home, which were not available at time of
presentation to the ED.
PHYSICAL EXAMINATION ON ADMISSION TO THE ED: Patient was
hypothermic to a temperature of 93.8. Patient was intubated
and not on any sedation. She was nonresponsive to verbal or
painful stimuli. The patient withdrew from pain in the upper
extremities bilaterally, but not in the lower extremities.
Pupils are equal, round, and reactive to light, but there was
no corneal reflex and no doll's eyes. Face appeared
symmetric. There was a very weak gag reflex. Heart was
regular, rate, and rhythm with a [**2-21**] holosystolic murmur best
heard at the apex. Lungs were clear to auscultation
bilaterally. There was no lower extremity edema. Systolic
blood pressure was stable in the 100s while on Neo-Synephrine
drip.
LABORATORIES ON ADMISSION: Chemistries were within normal
limits. Hematocrit was stable.
Head CT showed no evidence for acute infarct or intracranial
bleed or mass effect.
Chest CTA showed no evidence for pneumothorax or pulmonary
embolism.
EKG showed sinus rhythm with ST depression in the anterior
leads, but no Q waves or ST elevations.
Echocardiogram performed in the Emergency Department showed a
very poor ejection fraction of 20-25% with significant mitral
regurgitation.
A CT of the neck was performed, which ruled out cervical
fracture or compromise of the cord.
Chest x-ray showed an endotracheal tube in the correct
position as well as a nasogastric tube mid esophagus. No
pulmonary infiltrates were identified.
HOSPITAL COURSE: Patient following stabilization in the
Emergency Department, was admitted to CCU for further
management. Due to the patient's extensive coronary artery
disease and ischemic cardiomyopathy, it was believed that the
cause of the cardiac arrest was most likely to be ventricular
tachycardia, which then worsened into ventricular
fibrillation.
On admission, there were no electrolytes to suggest an
electrolyte abnormality as the cause of her ventricular
fibrillation. There was no pericardial effusion on
echocardiogram to suggest tamponade. Chest CTA showed no
evidence of pulmonary embolism. EKG was not consistent with
an acute massive ST segment elevation MI. On admission,
there was an elevated white blood cell count to 23.3 as well
as hypothermia. There was no evidence of infection prior to
arrest according to the family that would suggest sepsis as a
cause for her ventricular fibrillation. Blood and urine
cultures were sent in the Emergency Department which are
still pending at the time of this dictation.
The patient was continued on a lidocaine drip to prevent
degeneration back into ventricular fibrillation. She also
required Neo-Synephrine for blood pressure support.
Neurologic examination showed no evidence of higher cortical
functioning as well as some loss of brain stem function. In
the Emergency Department, the patient developed rhythmic
whole body jerks occurring approximately every 2-4 minutes.
A Neurology consult was obtained. They felt that the jerks
represented either postanoxic myoclonus or status
epilepticus. The patient was started on Ativan as well as a
Dilantin load. The patient stopped moving, but never became
responsive.
Serial neurologic examinations showed no improvement in brain
stem function. An EEG was performed which showed the patient
to be in status epilepticus. She was again loaded on
Dilantin and continued on Ativan, but the medications were
unable to break her out of status. The patient was continued
on assist control mechanical ventilation throughout her stay
in the CCU. General Surgery consult was obtained in order to
place a brachial arterial line. ABG showed a pH of 7, pCO2
of 21, pO2 of 262, and a bicarbonate of 6, most consistent
with metabolic acidosis. Her lactate level was 7.0.
Considering the patient's extremely poor prognosis due to
worsening metabolic acidosis as well as poor neurologic
function and continued status epilepticus, a family
discussion was held.
The family was made aware of the patient's poor prognosis for
functional recovery. The family ultimately decided to
withdraw blood pressure support. Two hours later the patient
became asystolic. She died at approximately 9:50 p.m. The
family was at the bedside.
DISCHARGE DIAGNOSIS: Cardiac arrest (ventricular
fibrillation).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2104-12-17**] 15:53
T: [**2104-12-18**] 06:23
JOB#: [**Job Number 54133**]
ICD9 Codes: 4271, 4240, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5584
}
|
Medical Text: Admission Date: [**2167-2-15**] Discharge Date: [**2167-2-20**]
Service: MEDICINE
Allergies:
Norvasc
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Hypotension, nausea, vomiting.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The pt. is an 86 year-old male with history of
panhypopituitarism (s/p resection for pituitary adenoma in [**2158**])
who presented with hypotension, nausea and vomiting. He was
recently discharged from [**Hospital1 18**] to [**Hospital3 **] on two days
PTA after a two and a half week stay for an inferior STEMI on
[**2167-1-28**] complicated by cardiogenic shock, ventilator-associated
pneumonia, and a small retroperitoneal bleed. Per his daughter,
his [**Name2 (NI) **] pressure was in the 70s to 90s systolic while at
[**Hospital1 **]. He was transferred to [**Hospital1 18**] ED for evaluation of
hypotension.
On arrival, the pt. complained only of slight abdominal pain and
nausea, and said he had a poor appetite over the few days PTA.
He denied [**Hospital1 5162**], chills, respiratory problems, diarrhea. [**Name2 (NI) **] has
had constipation recently but no BRBPR.
In the ED, he had a nadir BP of 72/48 but averaged 90/60. He
received 3.5 liters of fluid. A CXR was performed which was not
suggestive of cardiac failure, an abdominal CT was normal. The
surgery service was consulted and recommended no intervention
for abdominal pain. He was given zosyn, vanco, dexamethasone,
and hydrocortisone. His troponins were elevated. He had ST
segment changes on an EKG, but cardiology was consulted and not
concerned. He was transferred to the MICU for hypotension.
During his one day MICU stay, the pt. was hydrated with 4 liters
of normal saline and placed on stress-dose steroids.
Past Medical History:
-inferior STEMI [**1-17**] with cath, stent placement x 4 (2LCMA,
1LCx, 1 -LAD), c/b cardiogenic shock. CK peak 4000, Tp peak 12
-ventilator associated pneumonia (serratia marascens) [**1-17**]
-CHF, EF 40-45% on echo [**1-17**]
-hyperlipidemia
-HTN
-Pan-hypopituitarism s/p pituitary adenoma resection [**2158**]
-H/O Tachy-Brady syndrome s/p pacemaker placement in [**2154**]
-SIADH
-gastroesophageal reflux disease
Social History:
The pt. lived at home with his wife before last admission in
[**Month (only) 956**] at which time he was discharged to rehab. He denied
h/o tobacco, alcohol or illicit drug use.
Family History:
Noncontributory.
Physical Exam:
Vitals: T: 97.8F BP: 130/70 (90/50-170/110) P: 80 R: 14 SaO2:
97% on 4L O2 NC
Gen: Lying in bed, NAD, talkative and cooperative
HEENT: PERRL, OP clear, MMM, small white areas on tongue, soft
palate
Neck: no JVD
CV: RRR, nl S1s2 distant, soft II/VI HSM at LSB without apparent
radiation
Resp: CTA bilaterally
Abd: slight tenderness to palpation in suprapubic area. No
rebound, no guarding. Nondistended. Normoactive bowel sounds. No
massess or HSM appreciated.
Ext: 2+ bilateral UE edema, 1+ bilateral LE edema, warm, well
perfused bilaterally
Skin: scattered ecchymoses over extremities and trunk
Pertinent Results:
[**2167-2-15**] Radiology CT ABDOMEN W/CONTRAST
IMPRESSION:
1) No definite reason for patient's pain identified.
2) Interval resolution of right pleural effusion and interval
decrease of the left pleural effusion.
3) Interval decrease of the intramuscular hematomas.
4) Duodenum diverticulum containing fecalized material is
unchanged when com compared to previous study.
[**2167-2-14**] Radiology CHEST (PORTABLE AP)
IMPRESSION: Left retrocardiac opacity was seen previously and
could represent atelectasis or pneumonia.
TTE [**2167-2-16**]:
Conclusions:
Technically difficult study.
1. The left atrium is normal in size. The left atrium is
elongated.
2.The right atrium is moderately dilated.
3.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction. Overall left ventricular
systolic function is mildly depressed (LVEF=45-50%). Resting
regional wall motion abnormalities include inferior and basal
inferolateral hypokinesis.
4.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
5.The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
6.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Mild (1+) aortic regurgitation is seen.
7.The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-14**]+)
mitral regurgitation is seen.
8.The estimated pulmonary artery systolic pressure is normal.
9.There is no pericardial effusion.
10. There is an echogenic density in the right ventricle
consistent with a central line.
Compared with the findings of the prior report (tape unavailable
for review) of [**2167-2-10**], by description in the limited views
obtained in this study, suspect the whole inferior wall is now
hypokinetic.
Labs on admission:
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] WBC-12.1* RBC-4.22* Hgb-12.7* Hct-37.4*
MCV-89 MCH-30.1 MCHC-34.0 RDW-14.0 Plt Ct-303
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] Neuts-92.2* Bands-0 Lymphs-5.5* Monos-2.3
Eos-0 Baso-0
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] PT-12.8 PTT-26.2 INR(PT)-1.0
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] Glucose-125* UreaN-35* Creat-1.0 Na-129*
K-4.8 Cl-95* HCO3-25 AnGap-14
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] ALT-37 AST-36 CK(CPK)-67 AlkPhos-63
Amylase-75 TotBili-1.5
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] Lipase-68*
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] cTropnT-1.16*
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] TotProt-6.0* Calcium-9.4 Phos-3.3 Mg-2.3
[**2167-2-16**] 06:38AM [**Year/Month/Day 3143**] TSH-1.3
Labs on discharge:
[**2167-2-20**] 05:25AM [**Year/Month/Day 3143**] WBC-13.2* RBC-3.79* Hgb-11.6* Hct-34.6*
MCV-91 MCH-30.6 MCHC-33.6 RDW-15.0 Plt Ct-265
[**2167-2-20**] 05:25AM [**Year/Month/Day 3143**] Glucose-78 UreaN-15 Creat-0.7 Na-127*
K-3.9 Cl-91* HCO3-29 AnGap-11
[**2167-2-20**] 05:25AM [**Year/Month/Day 3143**] Albumin-3.0* Calcium-8.6 Phos-1.9* Mg-1.8
Brief Hospital Course:
1. Hypotension: The cause of the pt's hypotension was felt to be
multifactorial and related to hypovolemia and a degree of
adrenal insufficiency. He was given approximately five liters
of normal saline over the course of the first 24 hours of
admission in the ED and MICU to which his [**Year/Month/Day **] pressure
responded to 110-120's. He was also started on IV
hydrocortisone and oral fludricortisone. This was eventually
changed to oral prednisone on hospital day three. As his [**Year/Month/Day **]
pressure had remained stable in the 110-130's systolic, his beta
blocker and [**Last Name (un) **] were re-introduced on the third hospital day.
He will be discharged on a prednisone taper, his maintainence
dose should remain 10mg daily once the taper is complete.
2. CHF: The pt. is known to have low EF 40-45% after his MI in
[**Month (only) 956**]. A repeat TTE was performed on hospital day two, the
results of which are noted in the "Pertinent Results" section of
this report.
As part of treatment for hypotension, the pt. was aggressively
hydrated. This resulted in the pt. becoming fluid over-loaded
both on physical exam and also evident with a serum sodium of
127. This was felt to reflect a hypervolemic hyponatremia and
chronic SIADH and was stable with gentle diuresis before
discharge. His [**Last Name (un) **] was re-introduced on hospital day four.
Furosemide was also re-introduced on hospital day five with
effective diuresis. Subsequently, the pt. was maintained on
20mg of oral furosemide daily.
3. Cardiac Rhythm/Pacemaker: The pt. is status-post pacemaker
placement for a history of tachy-brady syndrome. In the MICU, he
was noted to have episodes of wide and narrow compled paced
rhythm on telemetry. The pt remained asymptomatic. The
electrophysiology service was consulted and reprogrammed his
pacemaker. During his last admission in [**Month (only) 956**], he
experienced peri-myocardial infarction atrial fibrillation and
the pt. was continued on the month-long amiodarone taper during
this admission.
4. Hypopituitarism: The pt. was treated with levothyroxine and a
steroid regimen as above. He was also re-started on a
testosterone patch.
5. Thrush: This was felt to be due chronic prednisone
immunosuppression, and was treated with nystatin swish and
swallow.
6. CAD: The pt. had one episode of left shoulder pain while
working with physical therapy on hospital day four. This
spontaneously abated. He had no further episodes. He was
maintained on aspirin, plavix and atorvastatin. Once his [**Month (only) **]
pressure stabilized, metoprolol and atacand were reintroduced on
hospital day four.
7. Steroid-induced hyperglycemia: The pt was maintained on a
sliding scale of regular insulin while on steroids.
Medications on Admission:
Aspirin EC 325 mg PO DAILY
Clopidogrel Bisulfate 75 mg PO DAILY
Atorvastatin Calcium 80 PO DAILY
Levothyroxine Sodium 75 mcg PO DAILY
Senna 8.6 mg PO BID prn
Acetaminophen 325 mg Tablet PO Q4-6H
Docusate Sodium 100 mg PO BID
Milk of Magnesia 311 mg Tablet PO Q6H as needed for heartburn.
Atacand 4 mg PO QD
Spironolactone 25 mg PO DAILY
Lactulose 30 ML PO TID PRN constipation
Amiodarone HCl 300 mg PO DAILY for 9 days: then start 200 mg per
day for 3 more weeks, then off.
Toprol XL 12.5 mg PO DAILY
Prednisone 20 mg PO DAILY for 5 days: Then 10 mg for 7 days then
5 mg ongoing.
Potassium Chloride 30 mEq PO DAILY
Furosemide 40 mg PO DAILY
Guaifenesin 5-10 MLs PO Q6H as needed for cough for 7 days
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
10. Testosterone 2.5 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal Q24H (every 24 hours).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
12. Candesartan Cilexetil 4 mg Tablet Sig: One (1) Tablet PO
daily ().
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Amiodarone HCl 200 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily) for 2 days.
Disp:*3 Tablet(s)* Refills:*0*
16. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day for 21 days.
Disp:*21 Tablet(s)* Refills:*0*
17. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO daily () for
5 doses.
Disp:*20 Tablet(s)* Refills:*0*
18. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO daily () for
5 doses.
Disp:*10 Tablet(s)* Refills:*0*
19. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily (): To
continue as maintainence dose after taper.
Disp:*30 Tablet(s)* Refills:*2*
20. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 1 days: To be given on [**2-21**], followed by taper as
written.
Disp:*3 Tablet(s)* Refills:*0*
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
-hypotension related to dehydration
-congestive heart failure with EF 40-45%
-SIADH
-coronary artery disease
-pan-hypopituitarism s/p pituitary resection
-hypertension, by history
Discharge Condition:
Stable.
Discharge Instructions:
Please continue to take all medications as prescribed. If you
experience any chest pain, shoulder pain, shortness of breath,
nausea, vomiting or abdominal pain or any other symptom that is
concerning to you, please call your primary care doctor or come
to the emergency department for evaluation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2167-2-24**] 2:15
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up
appointment within the next week.
ICD9 Codes: 2765, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5585
}
|
Medical Text: Admission Date: [**2160-7-26**] Discharge Date: [**2160-7-30**]
Date of Birth: [**2094-1-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary catheterization with Percutaneous Coronary Intervetion
to proximal left anterior descending artery with placement of
Drug Eluding Stent in the middle left anterior descending
History of Present Illness:
66 y/o M hx of HPL, and MI [**2145**] with 90% stenosis of mid-RCA s/p
BMS and [**2149**] rheolytic thrombectomy and 90% mid-LAD stenosis s/p
DES to LAD who presented to the ED after sudden onset of chest
pressure this am while working in his yard. His symptoms were
typical of prior episodes when he was having a MI. He was
sweating profusely and have crushing, non-radiating chest pain.
He says that over the last few weeks he was getting more
fatigued with activities he was usually able to do with [**Last Name **]
problem. [**Name (NI) **] his wife, with the onset of the chest pressure, he
started sweating more than usual and they knew he was having a
heart attack. He stated that he tried a SL nitro with no
relief, but his prescription was 1 year old. Per his wife he
also appeared to lose consciousness for a few minutes while in
the car, but was arousable. He was taken by truck back to the
house and EMS was called, an EKG was notable for ST elevations
and a code STEMI was called.
He was taken directly to the cath lab where had systolic BPs
ranging from 80-96/50-60s, he recieved 210 cc contrast, was
loaded with Plavix 600mg, and started on heparin drip. LHC via
the right radial artery revealed 100% occlusion of the mid-LAD
within the prior stent. This was stented with a DES. In
addition, there was a 80% stenosis of the origin of the diagonal
branch within the LAD stent. There was a 3 mm segment of
intraluminal filling defect 15 mm distal to the stent likely
representing embolized thrombus and patient was started on
integrilin drip.
Vitals on transfer were 93/66 90 42 92% on 3L.
.
On arrival to the floor, patient stable, he had complaints of
residual chest discomfort with exhalation, but much improved.
He described is "when you just had a headache and it goes a way,
you know you had a headache not too long ago". Otherwise he had
no c/o SOB, cough, arm, neck or jaw pain. Denies f/c, n/v,
abdominal pain, LE edema.
Past Medical History:
- CAD s/p PCI to mRCA '[**45**], mLAD '[**49**], PTCA of mLAD and diag '[**50**],
- colon cancer s/p colectomy ([**2149**])
- nephrolithiasis
- s/p cholecystectomy
- HPL
Social History:
- Employed as an engineer, married with 3 sons
-[**Name (NI) 1139**] history: smokes [**11-26**] ppk per day off and on for over 30
years
-ETOH: less than 1 drink per week
-Illicit drugs: No
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION:
VS: T=98.2 BP=105/49 HR=107 RR=24 O2 sat=97%
GENERAL: WDWN 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: Flat neck veins.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE:
GENERAL: WDWN 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: Flat neck veins.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2160-7-26**] 12:23PM BLOOD WBC-9.5 RBC-4.60 Hgb-14.3 Hct-42.2 MCV-92
MCH-31.0 MCHC-33.8 RDW-13.0 Plt Ct-277
[**2160-7-26**] 06:44PM BLOOD Neuts-82.0* Lymphs-11.9* Monos-5.6
Eos-0.1 Baso-0.4
[**2160-7-26**] 12:23PM BLOOD PT-10.8 PTT-23.6* INR(PT)-1.0
[**2160-7-26**] 06:44PM BLOOD Glucose-134* UreaN-11 Creat-1.0 Na-141
K-4.0 Cl-108 HCO3-23 AnGap-14
[**2160-7-26**] 12:23PM BLOOD CK(CPK)-89
[**2160-7-26**] 12:23PM BLOOD CK-MB-2 cTropnT-<0.01
[**2160-7-26**] 06:44PM BLOOD Calcium-8.9 Phos-2.8 Mg-1.9
[**2160-7-27**] 01:40AM BLOOD HDL-32 CHOL/HD-3.8 LDLmeas-77
.
.
STUDIES:
([**2160-7-26**]) CXR: In comparison with the study of [**7-26**], there is
little overall change. Cardiac silhouette remains within normal
limits. Mild indistinctness of pulmonary vessels could reflect
some elevated pulmonary venous pressure. No acute focal
pneumonia or pleural effusion
.
.
([**2160-7-26**]) CATH: ASSESSMENT
Coronary angiography: right dominant
.
LMCA: Normal
.
LAD: 100% occlusion of the mid LAD within the prior stent.
There was a 80% stenosis of the origin of the diagonal branch
within the LAD stent. The distal LAD was a large disbtribution
vessel that supplied the apex. There were small 2nd and 3rd
diagonal branches that supplied the anterolateral wall.
.
LCX: The proximal and distal LCx had minimal lumen
irregularities. Threw was a large OMB that supplied the
posterolater wall. It was free of significant disease.
.
RCA: The RCA stent was widely patent. The was a 50% margin
stenosis distal to the stent that supplied a large PDA branch
and medium size posterolateral branches.
.
Interventional details
.
The indication for the procedure was an anterior STEMI.
.
The procedure was performed from the right radial artery without
complications
.
Unfractionated heparin was used to achieve an ACT > 250 seconds.
Eptifibatide was given as a double bolus.
.
Using a 6Fr XB3.5 guiding catheter and a 0.014 OTW BMW wire, the
LAD was dilated with a 2.5 mm balloon. There was lesion
rigidity in the distal portion of then stent and a 2.75 mm x 12
mm Apex NC balloon was used to fully expand the stent. A 2.0
mm balloon was used to dilated the diagonal branch prior to
additional stent implantation. A 2.75 mm x 14 mm Resolute
drug eluting stent was then deployed within the stent and was
post dilated with a 3.0 mm balloon to 22 atms pressure. This
resulted in no residual stenosis within the stent and TIMI 3
flow into the distal vessel.
.
There was a 50-60% stenosis of the origin of the diagonal branch
but TIMI 3 flow into the distal vessel.
.
There was a 3 mm segment of intraluminal filling defect 15 mm
distal to the stent that likely represented embolized thrombus.
It was laminar and seen in the [**Doctor Last Name **] but not the LAO projections.
It will be treated with continued antiplatelet therapy and
GPIIB-IIIa antagonists for 18 hours. Consideration for long
term anticoagulation with warfarin with evidence of an LV
aneurysm.
.
The patient was painfree at the end of the procedure, but the
EKG showed improved but persistent ST elevation in the anterior
precordial leads.
.
ASSESSMENT
1. Anterior ST elevation due to LAD stent occlusion
2. Successful drug-eluting stent of the mid LAD
PLAN
1. Aspirin 325 mg daily for one month then 81 mg daily
thereafter
2. Plavix 75 mg daily
3. Eptifibatide infusion x 18 hours
4. Echocardiogram for LV akinesis: consider anti-coagulation
Brief Hospital Course:
66-year-old man with CAD s/p PCI to mRCA '[**45**], mLAD '[**49**], PTCA of
mLAD ISR and diag '[**50**], and colon CA s/p colectomy '[**42**] presenting
with substernal chest pressure while working in the yard. This
is in the setting of increasing fatigue with daily activities.
He presented to the ED where his ECG was consistent with an
anterior STEMI and he was taken emergently to the cath lab.
.
## STEMI - Left heart cath showed an occlusion of the mid-LAD at
the site of a previous stent, 80% stenosis at the diag origin,
and a 50% margin stenosis distal to the RCA stent. A
drug-eluting stent was placed in the mid LAD with TIMI 3 flow
into the distal vessel following stent placement. The patient
had persistent ST elevations and Q-waves on post-procedure ECG
suspicious for LV dyskinesis. He was started on an Integrilin
gtt intraop x 18 hours total. Started on Heparin gtt after
Integrellin given risk of developing LV Mural thrombus. Pt had
an Echo on [**7-28**] that showed Mild symmetric left ventricular
hypertrophy with regional left ventricular dysfunction(akinesis)
c/w LAD territory MI. Preserved right ventricular function. No
pathologic valvular disease. Based on this finding the patient
was started on Warfarin with a Lovenox bridge. We continued the
patient on Plavix 75mg daily, ASA 81mg daily, Metoprolol XL
150mg daily, atorvastatin 80mg/day. Lisinopril was started on
[**2160-7-29**], 2.5mg daily. Given extensive CAD history, patient may
benefit from ICD to decrease risk of SCD, will need to consider
in > 90 days. His lisinopril could be uptitrated in the future
and spironolactone could be initiated if his BP allows these
medication changes.
.
## TRANSITIONAL
- Consider/discuss ICD placement > 90 days post PCI
- Start spironolactone and uptitrate ACEI if BP allows
- PCP to monitor INR and smoking cessation
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 325 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Lisinopril 2.5 mg PO DAILY
hold for SBP < 90
RX *lisinopril 2.5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Warfarin 5 mg PO DAILY16
please check with your PCP about specific dosing based on the
blood level INR
RX *warfarin 2 mg 2.5 tablet(s) by mouth daily Disp #*75 Tablet
Refills:*2
6. Outpatient Lab Work
Chem-7, INR on Thursday [**2160-7-31**] with result to Dr. [**Last Name (STitle) 7842**] at
Phone: [**Telephone/Fax (1) 8506**]
Fax: [**Telephone/Fax (1) 19406**]
ICD-9 428 CHF
7. Enoxaparin Sodium 100 mg SC BID
RX *enoxaparin 100 mg/mL one syringe twice a day Disp #*8
Syringe Refills:*2
8. Metoprolol Succinate XL 150 mg PO DAILY
hold for SBP<100, HR<60
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily
Disp #*45 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Acute on chronic systolic congestive heart failure
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 19407**],
You were admitted for chest pain, which was due to a heart
attack. You were evaluated by cardiologist and they performed a
procedure that involved opening the blocked vessel and placing a
drug eluting stent. After the procedure you had an
echocardiogram of the heart that showed the poor movement of the
left and lower side of the heart. This poor movement increases
your risk of developing a clot in that part of your heart. To
prevent clot formation, you will need to take a blood thinner
medicine called Warfarin. This is in addition to the Plavix and
Aspirin. You will need to have blood levels of the Warfarin
checked regularly and communicate with the [**Hospital 3052**] at [**Hospital 1411**] Medical about those results. You will need to
use the Lovenox injections until the blood level of Warfarin
(called INR) is between 2.0 - 3.0. You can stop Lovenox
injections at that time when the [**Hospital3 **] says it
is OK.
Please stop smoking. Continuing smoking will significantly
increase your risk for additional heart attacks, and strokes,
not to mention the risks of multiple cancers.
Because your heart is weak, please weigh yourself every day in
the morning before breakfast. Call Dr. [**Last Name (STitle) 7842**] if weight
increases more than 3 pounds in 1 day or 5 pounds in 3 days.
Watch for trouble breathing and your legs for signs of swelling.
Call Dr. [**Last Name (STitle) 7842**] if you notice any of those symptoms.
MEDICATIONS:
START Warfarin 5mg by mouth daily, change dose after discussion
with your PCP
START Clopidogrel(Plavix) 75mg/day and Aspirin 81mg/day, do not
miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking this medicine unless Dr. [**First Name (STitle) **] says
that it is OK.
START Lovenox 100mg injection twice daily
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Specialty: Primary Care
Location: [**Hospital **] MEDICAL ASSOCIATES-[**Location (un) **]
Address: [**Location (un) 11898**], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
Appointment: Tuesday [**2160-8-5**] 3:00pm
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Doctor Last Name 19408**] MD
Location: [**Hospital **] MEDICAL ASSOCIATES
Department: Cardiology
Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9311**]
Phone: [**Telephone/Fax (1) 8506**]
Appointment: Thursday [**2160-8-28**] 10:45am
ICD9 Codes: 4271, 4019, 2724, 3051, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5586
}
|
Medical Text: Admission Date: [**2119-4-19**] Discharge Date: [**2119-4-23**]
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Tegretol / Dilantin / Heparin Agents
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
severe tracheal stenosis
Major Surgical or Invasive Procedure:
bronchoscopy, debridement of granulation tissue, placement of
new tracheal stent
History of Present Illness:
This is an 83M who is well known to the IP service who comes
in with severe TBM and tracheal stenosis for a bronch tomorrow.
He was initially intubated on [**2115**] after a stroke. He had
difficulty weaning from the vent and underwent a tracheostomy on
[**3-28**]. He subsequently had a T-tube placed and then removed for
granulation tissue. He then had a Y-stent placed and then
removed and replaced. Most recently, he was admitted to an OSH
[**2119-4-8**] for LLL PNA and transferred here today. He has been on
Levaquin since [**4-8**], Flagyl since [**4-8**], and Aztreonam since [**4-11**]
for Pseudomonas and Stenotrophomonas sensitive to Levo and
Aztreonam. His antibiotics were discontinued prior to transfer.
He has been on trach mask during the day and on the vent at
night
at 30%, 400x 12, PEEP 5, having copious secretions.
Past Medical History:
1) Tracheomalacia, status post stent x 2 with failure secondary
to stent migration. Status post trach revision [**3-28**]. Status
post T-tube removal on [**2115-6-26**].
2) Status post stroke in [**2109**] with TIA; right upper extremity
weakness resulting.
3) Hypertension.
4) Seizure disorder.
5) History of MRSA.
6) Hemorrhoids.
7) Arthritis.
8) Depression.
9) History of CHF.
10) CRI
Social History:
Married and lives at home with wife with nursing care. Remote hx
of smoking, duration unknown. Rare Etoh.
Family History:
NC
Physical Exam:
Admission:
T 97.8, P 83, BP 130/67, RR 16, O2 96% on AC 40%, 400x 12, 5
Gen- NAD
heart- RRR
lungs- b/l coarse breath sounds
abd- PEG without signs of infection, soft, NT/ND, BS normal
ext- 1+ b/l edema
Discharge:
No change except improved breath sounds, less coarse and no
upper airway stridor
Pertinent Results:
[**2119-4-19**] 10:31PM WBC-12.1*# RBC-4.30*# HGB-12.9* HCT-38.8*#
MCV-90 MCH-30.0 MCHC-33.2 RDW-15.2
[**2119-4-19**] 10:31PM GLUCOSE-105 UREA N-25* CREAT-1.1 SODIUM-140
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-30 ANION GAP-13
[**2119-4-19**] 10:31PM CALCIUM-8.6 PHOSPHATE-2.7 MAGNESIUM-1.8
Brief Hospital Course:
Mr. [**Known lastname 34384**] was admitted to the TICU under the care of the
Interventional Pulmonary Team on [**2119-4-19**]. He had a CT trachea
done which showed TBM, with the stent in place but with moderate
to severe malacia distal to the stent in the main bronchi.
Compared to his previous CT, the stent demonstrated decreased
amount of stenosis. The next day he underwent bronchoscopy with
IP, and had some granulation tissue removed and sent to
pathology. The stent was then removed and replaced with a
longer stent. He had some mild post procedure bleeding, which
was evaluated with bronchoscopy that showed a clot behind the
stent. This was managed conservatively with close observation
(Hct remained stable, no transfusions were required), and he had
no more episodes of bleeding. He was rebronched on PPD#1 [**4-21**].
He continued to do well without any issues. By PPD#2 and 3, he
was weaned to trach mask for most of the day, with no
respiratory issues. On PPD#3, he is afebrile, AVSS, tolerating
tube feeds at goal, and he will be discharged to home with trach
mask during the day, ventilator at night, with f/u with Dr.
[**Last Name (STitle) **] in [**7-2**] weeks.
Medications on Admission:
insulin drip (2.5/h), KCl 20', simethicone
80''', HCTZ 12.5', lactinex QD, phenobarb 240 HS, nexium 40',
duonebs QID, solu-medrol 80', nystatin s/s, versed PRN, fentanyl
PRN
Discharge Medications:
1. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Phenobarbital 20 mg/5 mL Elixir Sig: Two [**Age over 90 8821**]y (240)
ml PO HS (at bedtime).
4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q2H (every 2 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q4H (every 4 hours) as needed.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 4-6 Puffs
Inhalation Q4H (every 4 hours).
10. Prednisone 20 mg Tablet Sig: 2 tablets x3 days, then 1
tablet x3 days, then stop Tablets PO DAILY (Daily) for 6 days:
Take 2 tablets on [**4-9**], [**4-25**]. Take 1 tablet on [**5-11**],
and [**4-28**], then stop prednisone.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
tracheobronchial malacia
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 14680**] office or go to the Emergency Room if
you have any shortness of breath, bleeding, fevers > 101,
nausea, vomiting, or any other questions or concerns.
Continue your Prednisone taper as instructed.
Followup Instructions:
please call Dr.[**Name (NI) 14680**] office at [**Telephone/Fax (1) 3020**] to schedule a
follow-up appointment for 6-8 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
ICD9 Codes: 486, 5859, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5587
}
|
Medical Text: Admission Date: [**2169-2-16**] Discharge Date: [**2169-3-8**]
Date of Birth: [**2091-6-16**] Sex: F
Service: MEDICINE
Allergies:
citalopram / Seroquel
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
History of Present Illness:
77 year old female with h/o COPD on 2L nc, hypercarbic resp
failure, HTN, pulmonary nodules who was found to be unresponsive
at her nursing home.
.
Per NH records and ED report, patient found to be at her normal
baseline status (A&Ox3) around 5pm. Approx 15-30min later, she
was found to be unresponsive, and EMS was called. Her VS at the
time were: BP 120/60, HR 100, RR 22, 82% on 15L, FS 190. Labs
from NH [**2-10**]: UA neg ket/nit/leuk/wbc/prot, Na 145, K 4.5, CO2
45, BUN 14, Cr 0.4, Ca 9.3, Glu 81, wbc 3.8, hgb 8.5. Of note,
per nursing home records, she is on xanax standing and trazadone
prn for anxiety.
.
In the ED, initial VS: 92.7 100 86/37 90% 10L. Her SBP ranged
70s-200s. Per ED report, dropped w/ propofol and fentanyl,
improved with holding of sedations. Her pupils were thought to
be minimally reactive with some weakness on the left, so a code
stroke was called. CTA head/neck prelim negative. CXR
hyperinflated w/o evidence of pna/effusions. She was intubated
in the ED given worsening AMS. There was question of jaw
[**Last Name (LF) 110199**], [**First Name3 (LF) **] she was given ativan for possible seizure. Her
labs in the ED were notable for Na 150, BUN/Cr 25/0.6, K 5, HCO2
>50, WBC 13.6 (85% PMN, 2% bands), trop < 0.01; UA neg
wbc/leuk/nit, pos prot, pos granular casts; lactate 2.2. On the
vent, her ABG was: 7.34/78/501. She has 2piv's, vent settings:
fio2 30%, tv 400, r18.
.
Currently, patient is awake and responsive; she denies pain,
history of cough, diarrhea, dysuria, fevers.
Past Medical History:
vitamin d 50,000 units qmonth
amlodipine 5mg daily
asa 81mg daily
mvi daily
alprazolam 0.25mg q6hr
trazadone 25mg qid prn anxiety
ventolin 90mcg q4hr
advair 250-500mcg [**Hospital1 **]
spiriva 18mcg cap daily
CloniDINE 0.5mg daily
omeprazole 20mg daily
tums [**Hospital1 **]
levaquin 500mg daily - since [**2-9**] (unclear why started)
colace
polyethylene glycol
Social History:
Currently at rehab since [**2166-12-28**], but did live in [**Location (un) 86**]. Has
several children, very involved.
Family History:
Unable to obtain on admission
Physical Exam:
Admission physical exam:
HEENT: Sclera anicteric, dry MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Able to elevate hands/feet off bed, [**4-8**] hand grip, down
going toes, EOMI, PERRL, alert, responding to commands
appropriatly, no rigidity, normal tone
.
Pertinent Results:
Admission labs:
[**2169-2-16**] 06:35PM WBC-13.7* RBC-3.49* HGB-10.7* HCT-36.5
MCV-105* MCH-30.7 MCHC-29.3* RDW-15.2
[**2169-2-16**] 06:35PM NEUTS-85* BANDS-2 LYMPHS-8* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2169-2-16**] 06:35PM CALCIUM-10.2 PHOSPHATE-6.4* MAGNESIUM-3.2*
[**2169-2-16**] 06:35PM GLUCOSE-208* UREA N-25* CREAT-0.6 SODIUM-150*
POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-GREATER TH
[**2169-2-16**] 07:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2169-2-16**] 07:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2169-2-16**] 07:15PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2169-2-16**] 07:15PM URINE GRANULAR-1* HYALINE-46*
[**2169-2-16**] 07:15PM URINE MUCOUS-RARE
[**2169-2-16**] 07:45PM LACTATE-2.2*
[**2169-2-16**] 07:51PM TYPE-ART PO2-501* PCO2-78* PH-7.34* TOTAL
CO2-44* BASE XS-12 INTUBATED-INTUBATED
[**2169-2-16**] 10:33PM freeCa-1.14
[**2169-2-16**] 11:45PM WBC-8.5 RBC-2.93* HGB-8.9* HCT-30.2* MCV-103*
MCH-30.5 MCHC-29.6* RDW-15.3
[**2169-2-16**] 11:45PM CALCIUM-8.4 PHOSPHATE-2.4* MAGNESIUM-2.4
[**2169-2-16**] 11:45PM GLUCOSE-118* UREA N-19 CREAT-0.5 SODIUM-147*
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-41* ANION GAP-8
Microbiology:
Blood culture [**2-16**]- no growth x 2
Urine culture [**2-17**]- no growth, NEGATIVE FOR LEGIONELLA SEROGROUP
1 ANTIGEN.
Sputum culture [**2-17**]-
GRAM STAIN (Final [**2169-2-17**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2169-2-19**]):
MODERATE GROWTH Commensal Respiratory Flora.
Sputum culture [**2-20**]-
GRAM STAIN (Final [**2169-2-20**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2169-2-22**]):
SPARSE GROWTH Commensal Respiratory Flora.
Urine culture [**2-26**]- no growth
Blood culture [**2-26**]- no growth x 2
Sputum culture [**2-26**]-
GRAM STAIN (Final [**2169-2-26**]):
[**9-28**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2169-2-28**]):
Commensal Respiratory Flora Absent.
YEAST. MODERATE GROWTH.
Imaging:
[**2169-2-16**] CXR- Endotracheal tube 2.5 cm from the carina. Linear
parenchymal
opacities in the right upper lung, potentially chronic; however,
followup of this region recommended on future exams.
.
[**2169-2-16**] CTA head and neck-
1. No acute intracranial abnormality.
2. Generalized parenchymal atrophy with changes of chronic small
vessel
ischemic disease.
3. Confluent hypodensity in the central pons likely represents
additional
sequelae of chronic small vessel ischemic disease, given the
such findings in other typical locations. However, possiblity of
osmotic myelinolysis ("central pontine myelinolysis") cannot be
excluded entirely, in the appropriate clinical context.
4. Tiny, 2 mm aneurysm arising from the proximal portion of the
right
posterior inferior cerebellar artery.
5. Unremarkable CTA of the neck.
6. Prominence of superior ophthalmic veins in both orbits,
likely varices.
7. Severe emphysematous changes in the visualized lung apices
with
ill-defined nodular opacities in the right upper lobe.
Comparison with
previous (outside) cross-sectional studies, if available, is
advised.
.
[**2169-2-17**] CTA chest-
1. No evidence for pulmonary embolus with suboptimal
opacification of the
left lower lobe subsegmental arteries where there is scarring;
therefore,
pulmonary embolus cannot be excluded in this region.
2. Severe emphysema.
3. Trace bilateral pleural effusions.
.
TTE [**2-21**]- The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF 65%). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
borderline normal free wall function. 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. Mild (1+) mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
The tricuspid valve leaflets are mildly thickened. Tricuspid
valve prolapse is present. Moderate [2+] tricuspid regurgitation
is seen. There is a small to moderate sized pericardial
effusion. There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
.
CXR [**3-2**]- As compared to the previous radiograph, there is no
relevant change. Large lung volumes, moderate cardiomegaly
without pulmonary edema. No evidence of pneumothorax or pleural
effusions. No newly appeared focal parenchymal opacities.
Brief Hospital Course:
77 year old female with h/o COPD on 2L nc, hypercarbic resp
failure, HTN, pulmonary nodules who was found to be unresponsive
at her nursing home, intubated for hypercarbic respiratory
distress, found to be hypothermic in ED, hyperNa, and w/
fluctuating BPs.
.
# Hypercarbic respiratory distress: Patient with COPD on 2L home
O2, w/ elevated bicarb from nursing home a week ago and likely
CO2 retainer. Her pH suggests compensated process and elevated
bicarb suggest that her respiratory status likely has
deteriorated over a chronic period of time due to worsening
COPD. Although CXR was not notable for PNA, CTA showed some
suggestion of retrocardiac opacities and sputum w/ Gram positive
cocci on gram stain. PE was ruled out w/ CTA. Patient was
treated for HCAP (vancomycin, levofloxacin and cefepime), along
with standing nebulizers. There was difficulty controlling her
anxiety with recurrent hyperventilation on pressure support.
Initial extubation attempt on [**2-20**] failed due to tachypnea, low
minute ventilation and eventually hypercarbic respiratory
failure. Patient was continued on HCAP coverage and started on
steroids for COPD exacerbation and marked bronchospasm on
examination. TTE showed a moderate pericardial effusion w/o
signs of tamponade with diastolic dysfunction. Patient
underwent IV diuresis.
A major barrier to her extubation was felt to be anxiety leading
to tachypnea, in addition to above factors. She was tried on
multiple sedative and antipsychotics and best regiment was felt
to be clonazepam 0.5mg [**Hospital1 **] (prior attempted medications w/o
significant improvement - xanax, ativan, zydis, seroquel).
Per [**Hospital1 2177**] records, baseline ABG was confirmed to be
7.33-37/70-80/39/80-100.
Patient was extubated on [**2-26**]. She tolerated this well, however
was noted to be very sensitive to hyperoxia (as during nebulizer
treatments or increased supplemental oxygen) with resultant
hypercarbia, resp. distress (requiring return to ICU though no
intubation). This improved w/ reduction of supplemental O2. She
was restarted on antibiotics with vancomycin, levofloxacin,
cefepime though there was no CXR evidence of recurrent
pneumonia. She was narrowed to levofloxacin and remained
afebrile and stable. Her goal O2 sat should be 88-92 to prevent
resultant hypercarbia and acidosis. Patient's Advair dosing was
increased to 500/50 and tiotropium was restarted w/ albuterol
inhalers. Nebulizers were discontinued seondary to hyperoxia as
above. Patient was stable on 1.5L NC at the time of discharge,
sat'ing 88-96%. Patient will continue levofloxacin through
[**2169-3-10**] for total 8 days treatment.
# Altered mental status: Patient recieved number of sedating
medications per nursing home records, which in addition to
hypercarbia could have contributed to her mental status changes.
Patient w/ leukocytosis and hypothermia on admission, though
infectious w/o negative. Labs also notable for hyperNa, and
appeared volume depleted by exam. CTA head/neck unremarkable,
and neuro exam in non-focal. Seizure seemed unlikely given the
above factors. No meningeal signs on exam. Urine and blood
cultures were negative; sputum culture positive as above. Sodium
was corrected. Much of this was felt to be due to transient
hypercarbia and benzodiazapines. At time of discharge, patient
was alert and oriented x 3. She was tolerated clonazepam 0.5mg
qAM and qHS.
# Bacterial pneumonia: Hypothermic in ED 92.5 and patient w/
leukocytosis. Lactate mildly elevated. Hypotensive in the ED,
but normotensive in ICU. See above for further discussion.
Patient completed vancomycin and zosyn course for HCAP. On
return to the ICU, concern for RLL pneumonia, so patient was
restarted on antibiotics, vancomycin and levofloxacin. Patient
was narrowed to levofloxacin and is now day [**5-12**], should be dosed
through [**2169-3-10**].
# COPD with exacerbation: Discontinued nebulizers secondary to
respiratory distress in setting of hyperoxia. Albuterol inhaler
as needed and daily tioptrium restarted per home regimen.
Patient is on a long steroid taper, currently 30mg po daily,
with plan to decrease weekly by 10mg (next decrease Saturday
[**2169-3-12**]).
# Pericardial effusion: Noted on prior OSH records. TTE here
showed moderate effusion that seemed unchanged on repeat TTE.
# HTN: Blood pressure controlled with home amlodipine and
addition of lisinopril 2.5mg po daily.
# Transitional issues:
- discontinue levofloxacin after [**2169-3-10**] (8 day course started
[**3-3**])
- goal O2 sat 88-92% (patient has been reaching this goal with
1.5L NC)
- avoid nebulizers as high flow oxygen has worsened respiratory
distress, patient is stable on albuterol inhalers and tiotropium
- patient was full code throughout admission; several family
meetings confirmed her wishes for cardiopulmonary resuscitation
if necessary
Medications on Admission:
vitamin d 50,000 units qmonth
amlodipine 5mg daily
asa 81mg daily
mvi daily
alprazolam 0.25mg q6hr
trazadone 25mg qid prn anxiety
ventolin 90mcg q4hr
advair 250-500mcg [**Hospital1 **]
spiriva 18mcg cap daily
CloniDINE 0.5mg daily
omeprazole 20mg daily
tums [**Hospital1 **]
levaquin 500mg daily - since [**2-9**] (unclear why started)
colace
polyethylene glycol
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days: ending [**2169-3-10**].
6. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days: then taper to 20mg x 1week, then 10mg x
1week, then 5mg x 1week, then stop.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: please hold for loose stools.
10. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day
as needed for constipation.
11. simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for gas.
12. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
13. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location 8391**]
Discharge Diagnosis:
Primary diagnosis:
# Hypercarbic respiratory failure
# Health care associated pneumonia
# Chronic obstructive pulmonary disease, exacerbation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**].
You were admitted with rspiratory distress likely due to an
exacerbation of your COPD. You were in the ICU and intubated
for a period of time, then stabilized and transferred to the
floor. You were treated for pneumonia.
The following changes were made to your medication regimen:
- START lisinopril for your blood pressure
- STOP clonidine
- START prednisone 30mg, continue this through [**2169-3-11**], then
decrease to 20mg for an one week, then decrease to 10mg for one
week, then decrease to 5mg for one week, then stop
- START bactrim every monday, wednesday and friday to prevent
infection while you are taking prednisone
- STOP trazodone for anxiety
- START clonazepam 0.5mg every morning and before bedtime for
anxiety
Followup Instructions:
Name: [**Name6 (MD) **] [**Name8 (MD) **], MD
Location: [**Hospital6 **] DEPT OF PULMONARY
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 55132**]
When: Thursday, [**3-16**], 2:00 PM
Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) **],
after discharge from the hospital.
Location: [**University/College **]GERIATRIC SERVICES
Address: [**Location (un) 11452**], ACC BLDG 3RD FL, [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 10238**]
Fax: [**Telephone/Fax (1) 102347**]
ICD9 Codes: 2760, 2875, 2762, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5588
}
|
Medical Text: Unit No: [**Numeric Identifier 64322**]
Admission Date: [**2157-5-19**]
Discharge Date: [**2157-5-19**]
Date of Birth: [**2157-5-19**]
Sex: F
Service: NB
Birth weight 2,240 grams, gestational age 37 weeks.
White female infant born to a 31-year-old G1, P0 mother who
had a normal pregnancy aside from note of 2 echogenic foci of
the fetal heart on [**12-29**]. Follow-up ultrasound was
normal and quadruple screen was normal. Parents elected to
have no amniocentesis. Remainder of pregnancy without any
notable medical issues. Upon delivery, the infant was noted
to have dysmorphic features and to have respiratory distress.
Neonatal team was called to the delivery room. Upon entering,
infant was indeed having respiratory distress with grunting,
flaring, and retracting. Color was dusky. Infant had obvious
dysmorphic features, slanting forehead, midfacial
abnormalities, low-set ears, hypoplastic nipples. Concern
upon seeing the facial features was that of genetic disorder,
possibly trisomy 13. Infant was examined. Was given facial
CPAP and oxygen. Discussed with the parents the respiratory
distress and the need to further evaluate the baby.
Infant was admitted to the intensive care nursery
approximately 18:30. In addition to the microcephaly, midface
abnormalities, sloping forehead, large metopic suture, low-set
ears, depressed nasal bridge, flat nose, that was overlapping of
thumb on index finger for each hand, overlapping 2nd toe on 3rd
toe of each foot, abnormal sacral dimple.
Breath sounds were diminished bilaterally. Because of respiratory
distress, infant was intubated. Prior to intubation, chest x-ray
showed opacification of the left chest with probable stomach
bubble on the left. Provisional diagnosis: L congenital
diaphragmatic hernia, probably accompanying trisomy 13. NG tube
placement showed position of stomach was in the left chest.
Infant was intubated for respiratory managment until further
assessment and decisions were made. Infant's oxygen saturation
was always low ranging from 47-80, usually in the 70s, even
after intubation on FiO2 = 100%.
Based on the physical features of the infant, I discussed with
the parents that we were very concerned about a major genetic
abnormality and suspected trisomy 13, but that this diagnosis
was not absolutely certain. We would need to have chromosome
and cytogenetics studies conducted. We requested an emergent
genetic consultation which was obtained. Dr. [**Last Name (STitle) 64323**] [**Name (STitle) 3532**]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] from genetics department [**Hospital3 18242**] consulted. They concurred that this child has
significant abnormalities, possible trisomy 13. Diagnosis of
diaphragmatic hernia was certain.
I discussed with the family the futility of continuing support
given the strong clinical diagnosis of severe genetic abnormality
(probable Trisomy 13) with CDH. Within this context, we do not
recommen further clinical evaluation of cardiac workup. The
decision was made to withdraw support. Support was
discontinued at approximately 10 p.m. on [**2157-5-19**].
Infant was pronounced dead by nurse practitioner, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], attending.
TIME OF DEATH: 23:25 on [**2157-5-19**].
The parents and their parents had been involved the entire
evening with the diagnosis and discussion about the future
prognosis, further intervention. Obtained parental permission for
chromosomes and skin biopsy to be done. The blood for
chromosomes was obtained after death by intracardiac puncture.
Skin biopsy was obtained postmortem along R back of thorax. I,
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], performed each of these procedures. Parents have
signed consent for postmortem evaluation. The autopsy medical
examiner's office declined jurisdiction of this case. Autopsy
will be conducted here at [**Hospital1 69**].
Admitting office has also been called.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 50-ABP
Dictated By:[**Last Name (NamePattern1) 56577**]
MEDQUIST36
D: [**2157-5-20**] 02:43:10
T: [**2157-5-20**] 06:28:22
Job#: [**Job Number 64324**]
cc:[**Location (un) 64325**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 64326**], MD
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD
ICD9 Codes: 769
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5589
}
|
Medical Text: Admission Date: [**2109-2-22**] Discharge Date: [**2109-2-25**]
Date of Birth: [**2059-2-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Geodon / immunoglobulin
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Mucus plugging and need for tracheostomy [**First Name3 (LF) **] upsizing
Major Surgical or Invasive Procedure:
REMOVAL OF TRACHEOSTOMY [**First Name3 (LF) **] WITH PLACEMENT OF A NEW PORTEX 7.0
TRACHEOSTOMY [**First Name3 (LF) **]
History of Present Illness:
50yo F PMHx schizoaffective disorder, trachea malacia w chronic
tracheostomy, recent [**Hospital 18**] hospital stay for CO2 laser treatment
of high tracheal stenosis, trach downsizing (Portex No 6), and
subsequent failing of red capping, discharged to [**Hospital1 **] State
[**Hospital **] Hospital [**2109-2-16**] with plan for outpatient IP follow-up,
who subsequently was admitted to [**Hospital3 20284**] Center [**2109-2-20**]
with hypoxia in the setting of trach plugging, with a hospital
course notable for attempts to pull out trach (something she has
done in the past), increased secretions / trach plugging, and
hypoxia to 50% w unsuccessfully intubation with a 9mm Shiley,
and subsequently repeat successful attempt with a 6mm Shiley,
labs significant for WBC 4.9 (N57, L15, Bands13) Trop I 0.144
without EKG changes, patient remaining afebrile and w/o focal
consolidation on CXR, but started on ceftazadine and vancomycin
(has previously grown Ecoli and MSSA from sputum, was MRSA
screen positive), now s/p extubation continuing to plug trach
and require frequent suctioning, being transferred to [**Hospital1 18**] for
evaluation for trach revision.
.
On arrival to the MICU, patient was pleasant, speaking minimal
English, with vital signs 98.5 81 113/78 15 98% trach mask 40%.
Past Medical History:
Tracheomalacia s/p tracheostomy
Hypoventilation syndrome
Obesity
Hypothyroidism
Bipolar disorder
Schizophrenia
Hypertension
morbid obesity
?Pneumonia (?Ventilator-associated)
Tracheostomy placement
Appendectomy
Social History:
Pt is a Russian speaking lady with some English ability, but
prefers to have a translator or daughter present to explain.
Usually lives at [**Hospital 91503**]. Has been
hospitalized at [**Hospital 58990**] Hospital (psychiatric facility) for
several Months. She will be living with her daughter [**Name (NI) **] once
the tracheostomy is closed. No history of alcohol or drug use.
Family History:
Patient states no chronic illnesses in family; confirmed by
daughter.
Physical Exam:
Admission Exam:
Vitals: 98.5 81 113/78 15 98% trach mask 40%
General: No acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present
GU: no foley
Ext: warm, well perfused, 2+ radial/DP, no c/c/e
Neuro: moving all extremities
.
Discharge Exam:
VS 97.3 135/71 84 24 96/RA
General: middle-aged woman walking around unit, labile mood
(alternatively jumping for joy and tearful, anxious, needing
consolation)
HEENT: NCAT MMM, EOMI, PERRL oropharynx clear, poor dentition
Neck: supple, JVP not elevated, trach collar in place
CV: RRR nl S1/S2, no murmurs, rubs, gallops
Lungs: coarse breath sounds obscurbed by trach collar gurgling,
no focal consolidations auscultated, no wheeze or rhonchi
Abdomen: soft obese NT ND NABS
Ext: WWP, 2+ radial/DP, no c/c/e
Neuro: communicating well with staff in English, gait stable
Pertinent Results:
Admission Labs:
[**2109-2-22**] 08:11PM BLOOD WBC-4.3 RBC-3.72* Hgb-10.6* Hct-32.9*
MCV-89 MCH-28.4 MCHC-32.1 RDW-12.0 Plt Ct-232
[**2109-2-22**] 08:11PM BLOOD Neuts-64.1 Lymphs-24.0 Monos-7.5 Eos-4.1*
Baso-0.4
[**2109-2-22**] 08:11PM BLOOD PT-12.6* PTT-30.1 INR(PT)-1.2*
[**2109-2-22**] 08:11PM BLOOD Glucose-93 UreaN-6 Creat-0.7 Na-142 K-4.2
Cl-103 HCO3-33* AnGap-10
[**2109-2-22**] 08:11PM BLOOD Calcium-9.5 Phos-3.2 Mg-2.1
.
Drug Monitoring:
[**2109-2-23**] 03:05AM BLOOD Valproa-39*
[**2109-2-22**] 08:11PM BLOOD Lithium-0.5
[**2109-2-23**] 03:05AM BLOOD TSH-0.79
.
DISCHARGE LABS
[**2109-2-24**] 06:40AM BLOOD WBC-3.3* RBC-4.35 Hgb-12.5 Hct-38.1
MCV-88 MCH-28.8 MCHC-32.8 RDW-12.2 Plt Ct-231
[**2109-2-24**] 06:40AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-143 K-4.1
Cl-103 HCO3-30 AnGap-14
[**2109-2-24**] 06:40AM BLOOD Calcium-9.9 Phos-3.7 Mg-2.3
.
MICROBIOLOGY
[**2109-2-23**] 4:16 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2109-2-23**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH.
.
IMAGING
.
Chest X-ray ([**2109-2-22**]):
Tracheostomy [**Month/Day/Year **] has been placed and is in standard position.
Right PICC terminates in lower superior vena cava. Heart is
enlarged,
accompanied by pulmonary vascular congestion and mild perihilar
edema.
Opacity at right lung base obscuring the medial right
hemidiaphragm probably reflects atelectasis, but pneumonia is
also possible in the appropriate clinical setting. Probable
small left pleural effusion.
Brief Hospital Course:
50F w/schizoaffective disorder, tracheomalacia s/p chronic
tracheostomy, recent [**Hospital 18**] hospital stay for trach downsizing
and treatment of high tracheal stenosis admitted from an outside
hospital for recurrent tracheostomy plugging and hypoxia to the
50s. Hospital course was notable for upsizing of trach [**Hospital **] with
resolution of mucous plugging and hypoxia.
.
# TRACH PLUGGING/HYPOXIA
Known hx trachea malacia s/p tracheostomy, recently undergoing
trach downsizing presented w recurrent plugging of tracheostomy
and hypoxia. Underwent trach upsizing intra-operatively by
interventional pulmonology, to size 7. Patient did well
thereafter, ambulatory w/O2 sats in the mid90s/RA. Some thin
mucous occasionally suctioned by nursing. Also received home
duonebs and mucinex.
.
#OSH CONCERN FOR PNEUMONIA
There was also concern for PNA at OSH prior to transfer because
sputum sample gathered (in setting of hypoxia and WBC 4.9 w 13%
bands) grew MSSA. Had been receiving vanco/ceftaz there - this
was stopped on MICU admission [**2-22**] when she was found to be
hemodynamically stable, breathing fine on trach mask, with
unremarkable pulm exam. Afebrile, WBC remained wnl, bandemia
already resolved on arrival.
.
# OSH TROPONIN ELEVATION
Trop I elevation to 0.144 at OSH, no ischemic changes noted on
TTE. Thought [**12-20**] strain in setting of hypoxia and recurrent
trach plugging before collar upsized. Very low suspicion for
ongoing cardiac process. Cardiac enzymes repeated in the MICU
were trop <0.01.
.
# SCHIZOAFFECTIVE DISORDER
Chronic condition which prompted initial inpatient psych
admission at [**Hospital1 **] State Hospital. Patient was initially
continued on her home medications of divalproex, benztropine,
trazodone, lithium, prn ativan. Psychiatry consulted for
agitation in the MICU, followed closely. They recommended
increasing valproate, decreasing benztropine, and dc'ing ativan.
Patient remained agitated and pleasant but difficult to manage
on the floor after MICU callout, requiring 2:1 nursing/MD
reassurance and assistance nearly continuously. She was
discharged back to her previous [**Hospital1 **] Psychiatric facility.
.
# Hypothyroidism. TSH 0.79 (wnl). Her levothyroxine was
continued.
.
TRANSITIONAL ISSUES
.
HALDOL DEPOT DOSING
Note: patient did not receive any of her 240 mg IV qmonth haldol
depot injections because last date of administration could not
be obtained from prior inpatient psych facility. [**Month (only) 116**] be due.
.
VALPROATE LEVEL MONITORING
Dose increased to 750 [**Hospital1 **] on [**2-23**] after level 39
(subtherapeutic). Needs repeat valproic acid level check on
[**2109-2-26**] and dose adjustment PRN for goal level 50-100.
.
RESPIRATORY RECOMMENDATIONS
Patient may need trach collar suctioning q2h or more frequently
PRN for mucous plugging and/or hypoxia/dyspnea.
Needs humifified air by trach collar qHS.
Recommend duonebs q6H and PRN for any respiratory distress.
Contact medical consult and alert outpatient pulmonologist with
any tracheostomy issues including hypoxia, difficulty
suctioning, excessive secretions.
NOTE: PATIENT MUST KEEP TRACH COLLAR IN AT ALL TIMES.
.
PSYCHIATRY CONSULT RECOMMENDATIONS [**2109-2-23**] (ENACTED):
1. Decrease benztropine to 0.5 mg po bid - could be contributing
to confusion and there are currently no signs of EPS - monitor
for dystonia or tremor.
2. Clarify schedule and dose for next haloperidol decanoate
injection.
3. Continue current lithium, valproate, trazodone.
4. Discontinue lorazepam - can worsen confusion and
disinhibition.
5. Haloperidol 5 mg po/iv/im q4h agitation or anxiety.
6. Monitor QTc and for dystonia (last QTc here 410).
9. Given lithium therapy, monitor renal function, especially
with any significant volume changes.
Medications on Admission:
OUTPATIENT MEDICATIONS
- Divalproex 500mg [**Hospital1 **]
- Haldol Decanoate 240mg IV q28days (uncertain when last given)
- Tylenol 650mg q4hrs prn
- bisacodyl 10mg daily prn
- milk mag 30ml prn
- oxycodone IR 10mg q12hrs prn
- duonebs
- mucinex 1200mg [**Hospital1 **]
- levothyroxine 50mcg daily
- benztropine 1mg [**Hospital1 **]
- trazodone 200mg qhs
- lithium 300mg q8hrs
- ASA 81mg daily
- ativan 0.25mg qhs prn
.
MEDICATIONS ON TRANSFER FROM OUTSIDE HOSPITAL
- Haldol 240mg IM q28d
- duonebs
- ceftaz 1g q8h
- ativan 1mg IV q4h prn
- zofran 4mg IV q6h prn
- vanco 1gram q12h
- tylenol 650mg q4h prn
- ASA 81mg daily
- benztropine 1mg [**Hospital1 **]
- bisacodyl 10mg daily prn
- divalproex 500mg daily
- pepcid 20mg [**Hospital1 **]
- mucinex 1200mg [**Hospital1 **]
- levothyroxine 50mcg daily
- lithiium 300mg q8h
- milk mag prn
- oxycodone IR 10mg q12hr prn
- trazadone 200mg qhs
- lovenox 40mg daily
Discharge Medications:
1. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Haldol Decanoate 100 mg/mL Solution Sig: Two [**Age over 90 8821**]y
(240) mg depot Intramuscular once a month: note: none given in
hospital because [**Hospital1 **] could not tell us last dose date.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for Pain.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for indigestion.
6. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed for pain.
7. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) neb Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
8. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1)
Tablet, ER Multiphase 12 hr PO twice a day.
9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. benztropine 1 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
11. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] state hospital
Discharge Diagnosis:
Chronic tracheomalacia
Need for tracheostomy adjustment
Schizoaffective disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs [**Known lastname 91501**],
You were admitted to the hospital for difficulty breathing and
low oxygen, which was solved by replacing your trach with a
larger sized trach.
.
You were seen by interventional pulmonology daily - they
arranged a follow-up appointment for you (see below for
details).
You were breathing comfortably with the new trach collar. You
did develop sudden breathing difficulty whenever you removed the
collar - your oxygen level improved once we cleaned it and
replaced it. You needed occasional mucous suctioning too.
We stopped antibiotics because we did not think you had
pneumonia.
You required multiple doses of IM and PO haldol to control
agitation.
We made the following changes to your medications:
INCREASED DIVALPROEX TO 750 MG TWICE DAILY
DECREASED BENZTROPINE TO 0.5 MG TWICE DAILY
DISCONTINUED ATIVAN
.
The psychiatrist who saw you in the hospital recommended you
have valproic acid levels rechecked on [**2109-2-26**] (you will have
received 4 doses of the new 750 mg dose by that date).
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2109-3-5**] at 10:30 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2109-3-5**] at 11:45 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 4019, 2449
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5590
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|
Medical Text: Admission Date: [**2108-8-12**] Discharge Date: [**2108-8-31**]
Date of Birth: [**2030-8-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3967**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
plasmapheresis
plasmapheresis catheter insertion
Chemotherapy
History of Present Illness:
Mr. [**Known lastname 40029**] is a 77 year old gentleman with a PMH significant for
prostate CA on lupron therapy, GERD, and past afib s/p
cardioversion admitted to the [**Hospital Unit Name 153**] for urgent plasmapheresis.
The patient states that he has had 10 days of progressive
fatigue and weakness such that today he was unable to climb a
flight of stairs. He denies any dyspnea, orthopnea, increased LE
edema, or PND. He reports an associated non-productive cough,
decreased PO intake, urine output, and nausea but no emesis. He
also reports chills and night sweats that have occurred since
starting lupron. Denies any bruising, hematochezia or melena,
dysuria, HA, palpitations, or chest pain. The patient presented
to an OSH today, and was noted to have a WBC of 144, creatinine
of 2.72, and a TnI of 0.8 with no CK. Of note, the patient had a
CBC drawn approximately 3 months ago after a colonoscopy which
was "normal." The patient received 162 mg ASA and 60 mg IV lasix
and was transferred to [**Hospital1 18**] for further management.
.
In the [**Hospital1 18**] ED, VS 97.9 116/73 62 95%2L nc. The patient was
again noted to have a WBC 160 with 74% other, Cr 2.8, UA 16, TnT
0.17, LDH of 2188, and BNP of [**Numeric Identifier 40030**]. The patient was evaluated
by oncology in the ED with a peripheral smear that was
consistent with AML. A bone marrow biopsy was also performed in
the ED, and the patient was then transferred to the [**Hospital Unit Name 153**] for
further monitoring and leukopheresis.
.
Review of Systems: Positive for acid reflux. As above, otherwise
negative. Denies visual changes, hearing changes, swollen
glands, sore throat, belly pain, n/v/d, constipation, dysuria,
bone pain, leg
swelling, orthopnea or PND.
Past Medical History:
GERD
Atrial fibrillation - s/p cardioversion 3+ years ago, not
currently anticoagulated
OA
sciatica - took naproxen a couple of years ago.
HTN
Hyperlipidemia
heart murmur ? AS
Social History:
Patient lives on [**Location (un) **] with his son, and in [**Name (NI) 108**] in the
winter; he is currently engaged. He is retired from the
wholesale meat industry, no occupational exposures. No tobacco,
etoh, IV, illicit, or herbal drugs.
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Gen: Age appropriate male in NAD
HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema.
CV: Irregular S1+S2, harsh IV/VI systolic murmur throughout the
precordium radiating to the carotids.
Pulm: CTAB
Abd: S/NT/ND +bs
Ext: No c/c/e, 1+ dp/pt bilaterally
Neuro: AOx3, CN II-XII intact
Discharg exam:
Gen: Age appropriate male in NAD
HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema.
CV: Irregular S1+S2, harsh IV/VI systolic murmur throughout the
precordium radiating to the carotids.
Pulm: CTAB
Abd: S/NT/ND +bs
Ext: No c/c/e, 1+ dp/pt bilaterally
Neuro: AOx3, CN II-XII intact
skin: petechial rash in dependent areas of body, including
buttocks and feet.
Pertinent Results:
Admission labs:
[**2108-8-12**] 03:05PM BLOOD WBC-160.6* RBC-4.04* Hgb-12.0* Hct-35.0*
MCV-87 MCH-29.8 MCHC-34.3 Plt Ct-218
Neuts-11* Bands-3 Lymphs-3* Monos-3 Eos-0 Baso-1 Atyps-0
Metas-3* Myelos-2* Promyel-0 Young-0 Blasts-0 Other-74*
[**2108-8-12**] 03:05PM BLOOD Glucose-139* UreaN-41* Creat-2.8* Na-141
K-3.8 Cl-108 HCO3-18* AnGap-19 Calcium-9.9 Phos-4.4 Mg-2.3
[**2108-8-12**] PT-16.2* PTT-31.1 INR(PT)-1.4*
[**2108-8-13**] PT-21.3* PTT-36.4* INR(PT)-2.0*
[**2108-8-12**] Fibrino-299, FDP->1280*, D-Dimer-8314*
[**2108-8-12**] ALT-33 AST-70* LD(LDH)-2188* CK(CPK)-52 AlkPhos-136*
TotBili-0.5 Albumin-3.9 UricAcd-16.0*
[**2108-8-12**] proBNP-[**Numeric Identifier 40030**]*
[**2108-8-14**] BLOOD PSA-11.0*
Cardiac enzymes:
[**2108-8-12**] 03:05PM BLOOD CK(CPK)-54 CK-MB-NotDone cTropnT-0.17*
[**2108-8-12**] 09:49PM BLOOD CK(CPK)-114 CK-MB-4 cTropnT-0.21*
[**2108-8-13**] 02:55AM BLOOD CK(CPK)-84 CK-MB-4 cTropnT-0.18*
Cultures:
Blood cultures ([**2108-8-13**]): negative to date
URINE CULTURE (Final [**2108-8-15**]): BETA STREPTOCOCCUS GROUP
B.10,000-100,000 ORGANISMS/ML..
Imaging/Studies:
EKG ([**2108-8-12**]): Atrial fibrillation with moderate ventricular
response. Left axis deviation with left anterior fascicular
block. Modest non-specific ST-T wave changes. No previous
tracing available for comparison.
Echo ([**2108-8-13**]): There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is moderately dilated. 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). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate aortic stenosis and symmetric LVH. Normal
regional and global biventricular systolic function. Mild
pulmonary artery systolic hypertension.
Flow cytometry ([**2108-8-12**]): Three color gating is performed (light
scatter vs. CD45) to optimize blast yield.
Cell marker analysis demonstrates that the majority of the cells
isolated from this bone marrow express immature antigens CD34,
HLA-DR, myelomonocytic antigens CD33, CD15, CD11c, CD64, CD56,
and CD4. They lack B and other T cell associated antigens, are
CD10 (cALLa) negative, and are negative for CD13, CD117, CD14,
CD41, and Glycophorin. Blast cells comprise 68% of total gated
events. In the lymphoid gated events. B cells are scant in
number. T cells comprise 77% of lymphoid gated events, express
mature lineage antigens, and have a helper-cytotoxic ratio of 2.
INTERPRETATION: Immunophenotypic findings consistent with
involvement by: Acute myeloid leukemia with monocytic
differentiation.
Bone marrow aspirate and biopsy ([**2108-8-12**]): DIAGNOSIS:
Markedly hypercellular bone marrow with involvement by acute
monoblastic leukemia (FAB, M5a). See note.
Note: Please correlate with cytogenetic findings.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are
normochromic and show very mild anisopoikilocytosis with
scattered burr cells. Scattered polychromatophils are also
seen. Rare nucleated RBCs (2 per 100 RBCs) are noted. The
white blood cell count appears markedly increased. Platelet
count appears normal; large forms are seen; giant forms are not
present.
Differential count shows 12% neutrophils, 6% bands, 1%
monocytes, 5% lymphocytes, 2% eosinophils, 0% basophils, 69%
monoblasts, 3% myelocytes, 2% metamyelocytes. The blasts are
large, have abundant vacuolated cytoplasm with fine granules,
high N/C ratio, round to irregular nuclear contours, open
chromatin, and prominent nucleoli.
Aspirate Smear: The aspirate material is adequate for
evaluation. The M:E ratio is 11:1. Erythroid precursors are
decreased and include occasional dyspoietic form. Myeloid
precursors appear increased and consist primarily of blasts.
Megakaryocytes are present in increased numbers; abnormal forms
are not seen, but focal clusters are seen.
Differential shows: 80% Blasts, <1% Promyelocytes, 2%
Myelocytes, <1% Metamyelocytes, 6% Bands/Neutrophils, 0% Plasma
cells, 4% Lymphocytes, 8% Erythroid.
Clot Section and Biopsy Slides: The biopsy material is adequate
for evaluation. Marrow cellularity is estimated at 90%. There
is an interstitial infiltrate of immature cells consistent with
blasts occurring in sheets occupying 90% of marrow cellularity.
There is scant remaining hematopoiesis. Scattered erythroid
precursors are noted including forms with dyspoietic maturation
with irregular nuclear contours and asymmetric nuclear budding.
Maturing myeloids are extremely scant. Megakaryocytes are
decreased and appear in focal tight clusters; naked nuclei and
hyperchromatic forms are seen. Marrow clot section is not
submitted. Touch prep is similar to the core.
Bone marrow cytogenetics ([**2108-8-13**]):
Specimen Type: BONE MARROW - CYTOGENETICS
Lab #: [**Numeric Identifier 40031**]
Date and Time Taken: [**2108-8-13**] 10:02 AM Date Processed: [**2108-8-13**]
Requesting Physician: [**Name (NI) **],[**Name11 (NameIs) 2295**] [**Name Initial (NameIs) **]. Location: INPATIENT
Cell culture was established to provide metaphase
cells for chromosome analysis. However, no metaphases were
available from this specimen, therefore the cytogenetic
analysis could not be performed.
Please see results of FISH analysis below.
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
FISH evaluation for a MLL rearrangement was performed on
nuclei with the LSI MLL Dual Color, Break Apart Probe
(Vysis) at 11q23 and is interpreted as ABNORMAL.
Rearrangement was observed in 78/100 nuclei, which exceeds
the range of a normal hybridization pattern (up to 1%)
established for this probe in our laboratory. A MLL
rearrangement is found in a subset of cases of ALL and AML,
and is associated with oncogenic fusions between MLL and
various partner genes.
nuc ish(MLLx2)(5'MLL [**9-27**]'MLLx1)[78/100]
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
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 NORMAL Two EGR1 hybridization signals
were observed in 99/100 nuclei examined, which is
within the normal range established for this probe in the
Cytogenetics Laboratory at [**Hospital1 18**]. Up to 3% of cells in
normal samples can show apparent 5q deletion using this
probe set. A normal EGR1 FISH finding can result from
absence of a 5q deletion, from a 5q deletion that does not
involve the region to which this probe hybridizes, or from
an insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 7q deletion was performed with the
Vysis 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
NORMAL. Two D7S522 hybridization signals were observed in
98/100 nuclei, which is within the normal range established
for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. Up
to 3% of cells in normal samples can show apparent 7q
deletion using this probe set. A normal D7S522 FISH
finding can result from the absence of a 7q deletion, from
a 7q deletion that does not involve the region to
which this probe hybridizes, 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.
nuc ish(D5S23,D5S721,EGR1,D7Z1,D7S522,D20S108)x2[100]
MLL 5' probe at 11q23
MLL 3' probe at 11q23
D5S23, D5S721 at 5p15.2
EGR1 at 5q31
D7Z1 at 7p11.1-q11.1
D7Z522 at 7q31
D20S108 at 20q12
Discharge labs:
[**2108-8-31**] 12:00AM
COMPLETE BLOOD COUNT
White Blood Cells 2.2* K/uL 4.0 - 11.0
Red Blood Cells 3.15* m/uL 4.6 - 6.2
Hemoglobin 9.3* g/dL 14.0 - 18.0
Hematocrit 26.4* % 40 - 52
MCV 84 fL 82 - 98
MCH 29.5 pg 27 - 32
MCHC 35.2* % 31 - 35
RDW 19.5* % 10.5 - 15.5
DIFFERENTIAL
Neutrophils 56.8 % 50 - 70
Lymphocytes 34.5 % 18 - 42
Monocytes 6.2 % 2 - 11
Eosinophils 2.0 % 0 - 4
Basophils 0.4 % 0 - 2
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 18* K/uL 150 - 440
GENERAL URINE INFORMATION
Urine Color Straw
Urine Appearance Clear
Specific Gravity 1.009 1.001 - 1.035
DIPSTICK URINALYSIS
Blood SM
Nitrite NEG
Protein 30 mg/dL
Glucose NEG mg/dL
Ketone NEG mg/dL
Bilirubin NEG mg/dL
Urobilinogen NEG mg/dL 0.2 - 1
pH 6.0 units 5 - 8
Leukocytes NEG
MICROSCOPIC URINE EXAMINATION
RBC 1 #/hpf 0 - 2
WBC 1 #/hpf 0 - 5
Bacteria NONE
Yeast NONE
Epithelial Cells 0 #/hpf
URINE CASTS
Urine Casts, Other 1* #/lpf 0 - 0
OTHER URINE FINDINGS
Urine Mucous RARE
[**2108-8-29**] 9:24 am URINE Source: CVS.
**FINAL REPORT [**2108-8-30**]**
URINE CULTURE (Final [**2108-8-30**]): NO GROWTH.
Brief Hospital Course:
A/P: 77M with 2-3 weeks of fatigue, found to have elevated white
count, diagnosed with AML s/p decitabine ([**8-18**]).
.
# AML - The patient presented with a leukocytosis of 160k on
[**8-12**] with 74% blasts. Bone marrow biopsy was performed and he
was found to have AML, moncytic subtype. The patient was having
symptoms concerning for leukostasis such as cardiac demand
ischemia with troponin leaks. The patient also received multiple
treatments of hydroxyurea. These treatments decreased his WBC
into normal range. The patient had symptoms concerning for DIC.
In the [**Hospital Unit Name 153**] the patient was transfused with 2 units of FFP and 1
unit of cryo. DIC labs were followed and slowly resolved. The
patient also had some symptoms of tumor lysis syndrome.
Allopurinol was started and the patient also received
Rasburicase, along with IVF with bicarb to a goal urine output
of 100 cc/hour. The patient was then transferred to 7 [**Hospital Ward Name 1826**]
to receive treatment. The patient's options were discussed and
he decided to pursue treatment with Decitabine which he received
his first infusion on [**2108-8-18**]. The patient tolerated this well.
He received 5 days of Decitabine with a resultant drop in all of
his cell lines. He was transfused a total of 5 units PRBCs, 2
units FFP, 2 units platelets and 1 unit of cryo. He received a
unit of platelets just prior to discharge and was instructed to
follow up in the [**Hospital Ward Name 1826**] 7 outpatient clinic on monday.
# Renal insufficiency - The patient had a history of renal
insufficiency. He presented with a Creatinine of 2.8 with a
baseline of 1.5. The likely etiology was pre-renal due to
decreased fluid intake versus tumor lysis syndrome. He was given
IVF and his creatinine slowly returned to baseline.
.
# Infectious disease - The patient spiked fevers when he was
undergoing pheresis in the [**Hospital Unit Name 153**]. He was treated with cefepime
and vancomycin for broad antibiotic coverage. The patient was
transferred to 7 [**Hospital Ward Name 1826**] and was afebrile. Vancomycin was
discontinued and Cefepime was continued. His urine from [**8-15**]
grew out Beta streptococcus group B. A repeat urine culture
from [**8-29**] showed no growth after treatment with cefipime.
.
# Superficial venous thrombosis - On [**8-20**] the patient noted a
tender nodule on his right leg. The patient underwent ultrasound
of his lower extremities and was found to have a superficial
thrombus with no deep vein thrombosis. The patient was treated
with warm compresses and the pain resolved. Pathology report of
the lesion showed no evidence of leukemia cutis or sweet's
syndrome.
.
# CV disease - Per past medical records the patient has
extensive coronary artery disease. The patient underwent an TTE
which showed an EF of 55 percent with moderate aortic stenosis
and mitral regurgitation with concentric LVH. The patient was
asymptomatic.
.
# Hypertension - The patient was continued on his home blood
pressure medications with good control. During his stay at
[**Hospital Ward Name 1826**] 7 however, his blood pressure remained low-normal. His
amlodipine and lisinopril was discontinued, and his bp remained
stable. He was therefore discharged home on only his
metoprolol.
.
# Petechial rash - the patient had a petechial rash which was
noticed on the day of his discharge. The rash was present only
in dependent areas of his body, including his feet and buttocks.
This rash was thought to be due to his low platelet count.
Medications on Admission:
Lupron
Lisinopril
Metoprolol
Pravastatin
Prilosec
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: 0.5 Tablet PO once a
day.
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute Myelogenous Leukemia
Discharge Condition:
Hemodynamically stable, good
Discharge Instructions:
You were admitted with acute myelogenous leukemia. You received
leucopheresis, which is where you have your blood filtered to
take out some of the white blood cells from your blood. You
also received decitabine, a type of chemotherapy for your
leukemia, which you tolerated well. During your admission, we
gave you some platelets because they became low because of your
chemotherapy. You were discharged home with plans to follow up
in the clinic on Monday.
.
Some medication changes have been made:
- Your Procardia has been stopped. Please do not take this until
you follow up with your PCP.
[**Name Initial (NameIs) **] Your lisinopril has been stopped as well.
- Do not take your aspirin, because your platelets are low and
taking aspirin can cause you to bleed.
.
Please take all medications as prescribed.
.
Please keep all of your follow up appointments.
.
If you develop shortness of breath, chest pain, bleeding from
your nose or mouth or rectum, or bleeding that does not stop
after 15 minutes, please call your primary care provider or go
to your nearest emergency room. You may also call ([**Telephone/Fax (1) 40032**] to reach the outpatient oncology nursing clinic.
Your primary oncologist here at [**Hospital1 **] will be
[**Last Name (LF) **],[**First Name3 (LF) **]. You can reach his office at ([**Telephone/Fax (1) 40033**]. When you come to your appointment on monday, please ask
the nurses to contact Dr. [**Last Name (STitle) **] to come and see you.
Followup Instructions:
Please come on monday to the [**Location (un) 436**] of the [**Hospital Ward Name 1826**] building
to have your blood counts checked at the date and time below.
.
Provider: [**Name Initial (NameIs) 455**] 2-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2108-9-3**] 12:00 telephone: ([**Telephone/Fax (1) 40034**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 3974**] MD, [**MD Number(3) 3975**]
Completed by:[**2108-9-2**]
ICD9 Codes: 5990, 4280, 4241, 5859, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5591
}
|
Medical Text: Admission Date: [**2191-9-7**] Discharge Date: [**2191-9-28**]
Date of Birth: [**2138-2-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Prednisone
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right bronchopleural fistula
Major Surgical or Invasive Procedure:
Dr. [**Last Name (STitle) **]:
[**2191-9-7**]
1. Bronchoscopy with aspiration of secretions.
2. Right thoracoplasty with closure of bronchopleural
fistula.
[**2191-9-16**]
Flexible bronchoscopy.
.
Dr. [**First Name (STitle) **]:
[**2191-9-7**]
Combined pectoralis major musculocutaneous flap
containing entire right breast, transferred into the fistula
area and split-thickness skin graft, 200 cm2.
.
Dr. [**Last Name (STitle) **]
[**2191-9-18**]
Flexible bronchoscopy
.
Dr. [**Name (NI) **]
[**2191-9-22**]
Flexible bronchoscopy
History of Present Illness:
Ms. [**Known lastname 4640**] is a 53-year-old former smoker with a prior history
of resected chest wall with invasive carcinoma of the lung
approximately 8 years ago. This was a right upper lobectomy with
en bloc chest wall resection, reconstructed with mesh. She also
had received postoperative radiotherapy. She presented several
months ago with a empyema necessitans draining through the low
right flank. This was traced up to a source arising from the
apical pleural space and mesh. I had previously reopened the
posterior aspect of her thoracotomy, removed the mesh, and
performed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 72968**] window to marsupialize this and place her
on dressing changes. At this time, she was still smoking and
severely malnourished. We placed a percutaneous gastrostomy for
nutritional supplements, and she has gained approximately 4 to 5
pounds. She has been successful in quitting smoking. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of plastic surgery has also placed a tissue expander
under the right breast as she has very little muscular tissue to
help close this flap. It is our hope that a de-epithelialized
flap including the right breast skin and breast tissue along
with the pectoralis, as well as remaining tissue above the
thoracotomy, would be adequate to help close the defect if I
could also collapse the chest using a thoracoplasty. It was our
hope, with this combined technique, that we could close the
bronchopleural fistula and eradicate the space. She understood
the risks involved, including that this would not work and she
would be left with a chronic wound. She agreed to proceed.
Past Medical History:
Squamous cell CA- Right lung
s/p Right lung upper lobectomy and right lower lobe wedge
resection with excision of ribs 5,6, and 7
s/p chemo, radiation
Social History:
Married. Works as waitress. Smokes [**1-7**] cigs/day (20+
pack-years). Recently quit smoking.
Family History:
Noncontributory
Physical Exam:
DISCHARGE PE:
Vitals: 98.4 94 131/57 18 96% room air
Gen: NAD
CVS: RRR
Resp: CTA bilaterally
Abd: soft, ND, NT, NABS
Incisions: clean, dry, intact
Ext: Pulses palpable distally in all extremities
Pertinent Results:
[**2191-9-28**] 04:57AM BLOOD WBC-12.5* RBC-3.24* Hgb-10.5* Hct-32.3*
MCV-100* MCH-32.4* MCHC-32.5 RDW-15.6* Plt Ct-543*
[**2191-9-28**] 04:57AM BLOOD Glucose-102 UreaN-21* Creat-0.4 Na-135
K-5.1 Cl-97 HCO3-34* AnGap-9
[**2191-9-28**] 04:57AM BLOOD Calcium-9.7 Phos-4.3 Mg-1.8
.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 98101**],[**Known firstname **] [**2138-2-2**] 53 Female [**-5/3940**]
[**Numeric Identifier 98102**]
SPECIMEN SUBMITTED: RIGHT NIPPLE, TISSUE EXPANDER RIGHT BREAST,
RIGHT 2ND, 3RD, AND 4TH RIB (5).
Procedure date Tissue received Report Date Diagnosed
by
[**2191-9-7**] [**2191-9-7**] [**2191-9-14**] DR. [**Last Name (STitle) **]. BROWN/vf
Previous biopsies: [**Numeric Identifier 98103**] CHEST WALL PROSTHESIS.
[**Numeric Identifier 98104**] CONSULT SLIDES REFERRED TO DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
DIAGNOSIS:
1. Nipple, right (A):
No evidence of malignancy.
2. Tissue expander, right breast.
Gross exam only.
3. Rib, right fourth (B):
Bone and marrow with no evidence of malignancy.
4. Rib, right third (C):
Bone and marrow with no evidence of malignancy.
5. Rib, right second (D):
Bone and marrow with no evidence of malignancy.
.
CHEST (PA & LAT) [**2191-9-27**] 8:05 AM
REASON FOR THIS EXAMINATION:
eval need for bronch
IMPRESSION: Continued improving aeration in the right mid and
lower lung regions status post right thoracoplasty.
Brief Hospital Course:
The patient is a 53 year-old female admitted to Dr.[**Doctor Last Name 4738**]
[**Name (STitle) 1092**] surgery service at the [**Hospital1 1170**] on [**2191-9-7**] for surgical management of [**Last Name (un) **] chest wall
reconstruction. She underwent a bronchoscopy with aspiration of
secretions, right thoracoplasty with closure of bronchopleural
fistula, and combined pectoralis major musculocutaneous flap
containing entire right breast, transferred into the fistula
area and split-thickness skin graft, 200 cm2 on [**2191-9-7**] by Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **]. For details operation, please refer to
the operative reports. Following the surgery, she was
transferred to the CSRU.
.
On POD 1, she was continued on levofloxacin and ancef. Her pain
was well-controlled with a dilaudid PCA, she was afebrile, had
good oxygenation, and adequate urine output. Her VAC was
functioning, CT was continued to wall suction, and her arm sling
was continued.
.
On POD 2, her pain was well-controlled, however, she was over
sedated from the narcotics and her PCA was discontinued. She
continued to remain afebrile with O2 saturation at 97% on 2L NC.
Her antibiotics were continued. Her VAC remained intact and
her CT was continued on wall suction.
.
On POD 3, she continued to remain afebrile and pain was
controlled with PO dilaudid. The [**Doctor Last Name 406**] drain was placed to bulb
suction. A CXR demonstrated almost complete opacification of
the right lung and a bronch was performed with removal of thick
brown/bloody secretions and mucus plugs from the right mainstem
bronchus, resulting in improved aeration of right lung.
.
On POD 4, her antibiotics was switched to cefepime to
pseudomonas cultured from BAL. She remained afebrile and pain
well-controlled with PO dilaudid. Again the patient required
another bronch following a chest x-ray with progressive
opacification of the right lung. Clear thick secretions were
removed from the right mainstem bronchus. The VAC continued to
be and continued on suction and her [**Doctor Last Name 406**] drain was continued to
bulb suction.
.
On POD 5, she was continued on the cefepime and remained
afebrile. The VAC was continued as well as her [**Doctor Last Name 406**] drain.
Her pain continued to be well controlled with PO dilaudid. No
bronch was required on this day.
.
From POD [**5-13**], the patient continued to remain afebrile in the
ICU, requiring a bronch on POD 7 and POD 9 for removal of thick
secretions. Her VAC was continued on suction and her [**Doctor Last Name 406**] was
continued on bulb suction. Pain continued to be well-controlled
with input from acute pain service.
.
On POD 10, she had a fever of 101.9 with increased WBC to 45.6
and a CT chest demonstrated severe PNA of the right lung. Her
antibiotics were broaden to include vancomycin, tobramycin,
flagyl, and the cefepime was continued. The decision was made
at this point to have daily bronchs for removal of purulent
secretions from the right mainstem bronchus. She also
complained of diarrhea and C.Diff cultures were sent. Her VAC
was continued on suction and her [**Doctor Last Name 406**] was continued on bulb
suction.
.
On POD 11, she continued to have low grade temperatures and her
antibiotics were continued. A CT chest/abdomen/pelvis was
performed showing thickening and pericolonic inflammatory change
of the cecum and ascending colon, consistent with colitis.
Bronch today demonstrated moderate thick prurlent secretions in
the right mainstem bronchus. Her VAC was continued on suction
and her [**Doctor Last Name 406**] was continued on bulb suction.
.
On POD 12, she was found to be C.Diff positive and was continued
on the flagyl, vancomycin, and cefepime. The tobramycin was
discontinued. Her VAC was continued on suction and her [**Doctor Last Name 406**]
was continued on bulb suction. She remained afebrile and
continued to oxygenate well, not requiring a bronch today.
.
On POD 13, she continued to remain afebrile and her diarrhea was
resolving. Her [**Doctor Last Name 406**] drain was discontinued. Bronch
demonstrated moderate secretions in right mainstem bronchus and
she was deemed stable to be tranferred to the floor. She
continued to oxygenate well on 2 liters nasal cannula. The
vancomycinwas discontinued and the flagyl and cefepime were
continued.
.
On POD 14, she was started on a clear liquid diet, which she
tolerated well, and TF were started at 30 cc/hr. She was
continued on the flagyl and cefepime. Her diarrhea continued to
resolve and she remained afebrile. She was advanced to a
regular diet, which she tolerated well.
.
On POD 15, she remained afebrile but continued to have copious
secretions requiring a bronch. Her wound continued to heal
wellwith the [**Doctor Last Name 406**] d/c'd and the VAC d/c'd. She continued to
tolerate her regular diet.
.
On POD 16, she was continued on the flagyl and cefepime without
fevers. Her pain was well-controlled, she was tolerating a
regular diet with increasing PO intake, and starting to ambulate
well. Her wound continued to be clean, dry, intact, and [**Last Name (un) 76914**]
well.
.
On POD 17-19, her TFs were cycled overnight, she remained
afebrile and continued to increase her PO intake. Her chest
x-ray continued to show improvement without a need for further
bronchs. Her antibiotics were continued as well as aggressive
pulmonary toilet and ambulation.
.
On POD 20-21, she continued to improve clinical and remain
afebrile. Her chest x-rays remain unchanged with no indication
for a bronch. She was deemed stable for discharge home. She
will be discharged home with VNA and will continue her cefepime
for 3 weeks and flagyl for 4 weeks. She has been been
instructed to follow-up with Dr. [**Last Name (STitle) **] next week and to
follow-up with Dr. [**First Name (STitle) **] in 1 week.
Medications on Admission:
Neurontin
Percocet
Ultram
Discharge Medications:
1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*30 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
7. Equipment
Peri-Trek-S portable nebulizer.
8. Cefepime 2 g Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 21 days.
Disp:*42 Recon Soln(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 28 days.
Disp:*84 Tablet(s)* Refills:*0*
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous DAILY (Daily): 5 mL (100units/mL) flush to
each lumen Daily.
Disp:*qs qs* Refills:*0*
11. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ML Injection
once a day: 10 mL NS flush to each lumen Daily.
Disp:*qs qs* Refills:*0*
12. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
14. Aquaphor Ointment Sig: One (1) Topical three times a
day as needed for dryness: Apply to skinas needed for dryness.
Disp:*2 2* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Right empyema with chronic bronchopleural fistula.
Discharge Condition:
Stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] / Thoracic Surgery office [**Telephone/Fax (1) 170**]) for:
fever, shortness of breath, chest pain, exscessive foul smelling
drainage from incision sites
.
Please follow-up with as instructed.
.
Continue medications as previous to surgery. Please take new
medications as directed.
.
You may leave incisions/wounds open to air. Apply aquaform
cream twice a day as instructed by plastic surgery. You may
shower, please pat incisions dry.
Followup Instructions:
Scheduled Appointments :
Provider [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**]
Date/Time:[**2191-10-6**] 3:30
.
Appointments to be made:
Please call Dr. [**First Name (STitle) **] / Plastic Surgery at [**Telephone/Fax (1) 1416**] to
schedule a follow-up appointment in 1 week.
ICD9 Codes: 486, 5180
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5592
}
|
Medical Text: Admission Date: [**2115-4-10**] Discharge Date: [**2115-4-18**]
Date of Birth: [**2075-8-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
39yM with alcoholic cirrhosis presents from outside hospital for
further management of upper GI bleed.
Presented to OSH on [**2115-4-9**] with nosebleed x 2 days and
requesting detox. Alcohol level 355 there. Put on thiamine,
folate, and ativan per detox protocol. Platelets of 15,
transfused 15 unit of platelets. On the medical floor, dry
heaving and retching, vomited x1 coffee grounds. Hct dropped
from 38.6 to 26.9 this AM. Today, transfused 2U and underwent
EGD, showing recently bleeding gastric varices but no active
bleeding, in addition to portal hypertension and small
esophageal varices. Remained on octeotride gtt and IV protonix.
Transferred to [**Hospital1 18**] for consideration of TIPS vs. fibrin glue.
Transfused 2 more additional units of platelets.
Drinks [**1-19**] pints of vodka daily. Last drink on morning of [**4-9**].
Has been taking 10-15mg Q8h of oxycodone for the past several
weeks. Of note, patient underwent right elbow fusion 3 weeks
prior to presentation after falling down stairs and hitting
forehead.
On transfer, vitals signs stable with BP 126/83, HR 94, RR 16
97% on 2L NC. + Midepigastric and periumbilical pain, constant
but sometimes sharp, radiates laterally. + [**7-27**] right elbow pain
s/p surgical fusion of R elbow after fall 3-4 weeks ago.
Past Medical History:
EtOH abuse--2 pints of vodka daily
Hx of alcohol withdrawal
Thrombocytopenia [**2-19**] liver cirrhosis
Cirrhosis x 2 years
Hx of biliary sludge
S/p fusion of right elbow 3-4 weeks ago
S/p remote jaw surgery
Social History:
Lives alone, recently feels lonely. States that family lives
close by. Drinks [**1-19**] pints of vodka daily. Currently does not
work, retired from department of corrections.
Family History:
Mother with hypertension and osteoporosis
Physical Exam:
T 97.3, HR 89, BP 126/83, 97% on 2L
Gen: Tired, alert, oriented, appropriate
HEENT: NCAT. Pupils 2mm, equal, round and reactive to light with
accommodation. + mild scleral icterus. Dried blood in right
nostril, no signs of active bleeding. Oral mucosa moist,
jaundice noted on tongue.
Neck: Thyroid symmetric, no nodules. Soft anterior cervical
lymph nodes, mobile and nontender. No other posterior cervical,
submental, supraclavicular lymphadenopathy.
CV: RRR. Mild I/VI systolic murmur at RUSB
Lungs: Poor inspiratory effort (difficult secondary to abdominal
pain), but clear to ausculation posteriorly and anteriorly.
Abdomen: soft, nondistended. Bowel sounds hyperactive.
Tenderness to palpation in epigastric region with some volumtary
guarding. No rebound. Liver percussed 4cm from costal margin. No
fluid wave or evidence of ascites.
R elbow: flexed, moderately tender to palpation. Restricted
range of motion.
Extremities: warm and well-perfused. 2+ DP pulses bilaterally.
No edema
Wrist tremor, but no asterixes.
Pertinent Results:
On admission:
[**2115-4-10**] 10:39PM BLOOD WBC-3.9* RBC-3.43* Hgb-11.0* Hct-31.2*
MCV-91 MCH-32.2* MCHC-35.4* RDW-15.3 Plt Ct-35*
[**2115-4-10**] 10:39PM BLOOD Neuts-58.1 Lymphs-35.1 Monos-5.7 Eos-0.8
Baso-0.4
[**2115-4-10**] 10:39PM BLOOD PT-14.7* PTT-29.0 INR(PT)-1.3*
[**2115-4-10**] 10:39PM BLOOD Glucose-117* UreaN-12 Creat-0.8 Na-137
K-4.2 Cl-100 HCO3-28 AnGap-13
[**2115-4-10**] 10:39PM BLOOD ALT-20 AST-146* LD(LDH)-178 AlkPhos-139*
TotBili-4.2*
[**2115-4-10**] 10:39PM BLOOD Albumin-3.4* Calcium-7.9* Phos-3.0
On discharge:
[**2115-4-17**] 03:40PM BLOOD Hct-27.8*
[**2115-4-17**] 06:30AM BLOOD WBC-5.9 RBC-2.77* Hgb-9.1* Hct-27.0*
MCV-98 MCH-32.8* MCHC-33.5 RDW-15.7* Plt Ct-74*
[**2115-4-17**] 06:30AM BLOOD PT-16.1* PTT-33.5 INR(PT)-1.4*
[**2115-4-17**] 06:30AM BLOOD Plt Ct-74*
[**2115-4-17**] 06:30AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-135
K-3.8 Cl-99 HCO3-29 AnGap-11
[**2115-4-17**] 06:30AM BLOOD ALT-13 AST-78* LD(LDH)-166 AlkPhos-155*
TotBili-2.7*
[**2115-4-17**] 06:30AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8
MICRO:
Blood cultures negative from [**4-11**]
Two cultures from [**4-14**] with no growth to date
RUQ ultrasound
1. Reversed flow direction in the portal system with varices.
2. Marked splenomegaly.
3. Cholelithiasis.
Elbow
Three views. Positioning is suboptimal. The patient is status
post open
reduction and internal fixation of fracture of the olecranon
process of the
ulna. Fracture fragments are transfixed by a screw and wire.
There is mild
diastasis at the fracture site. Cortices appear otherwise
intact. There is
no evidence of dislocation. Mineralization appears normal. Soft
tissue
swelling is present over the fracture site.
IMPRESSION: Status post ORIF
EGD [**4-12**]:
Varices at the lower third of the esophagus (ligation)
Small hiatal hernia
Schatzki's ring
Activate bleeding and an erosion in the gastroesophageal
junction compatible with [**Doctor First Name 329**] [**Doctor Last Name **] tear
Granularity, friability and mosaic appearance in the whole
stomach compatible with portal hypertensive gastropathy
Varices at the fundus (injection)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
39 year old man with alcoholic cirrhosis and EtOH abuse presents
with upper GI bleed.
#. Upper GI Bleed: Pt with one episode of coffee ground emesis
with associated Hct 12 point Hct drop at the OSH. Received 1U
pRBC and underwent EGD that showed stigmata of prior variceal
bleed and gastropathy. Hct has remained stable after transfer,
but an EGD performed [**4-12**] showed active bleeding from a
[**Doctor First Name **]-[**Doctor Last Name **] tear, bleeding portal gastropathy, and esophageal
varices were banded. He was started on carafateand pantoprazole.
He received five days of ceftriaxone. He is scheduled for repeat
EGD and hematocrt check as an outpatient.
#. EtOH Cirrhosis:
LFTs trended down over hospitalization. Nadolol and diuretics
were held.
Encouraed to drink boost supplements.
#. EtOH Abuse:
Pt reported 1 pint of vodka per day. He was monitored on a CIWA
scale and started on thiamine, folate and a multivitamin. He was
seen by social work.
- CIWA scale with Valium dosing for CIWA>10
- Thiamine, folate, MV
- SW Consult to develop plan to ensure sobriety on d/c
#. Thrombocytopenia:
s/p 15U plts at the other hospital. Likely secondary to
splenomegaly, and bone marrow suppression from alcohol.
#. Right elbow fracture s/p fall and ORIF - Patient pain
currently controlled, but with reduced range of motion. He was
seen by orthopedic surgery. THe fracture was felt to be slowly
healing and no intervention was neccessary during this
hospitalization. Lidocaine patch and oxycodone for pain.
# Conjuntivitis
Allergic versus viral. Started erythromycin ointment.
#. Code - Full Code
Medications on Admission:
Furosemide 20mg PO QD
Folic acid 1mg PO QD
Nadolol 20mg PO QD
Spironolactone 50mg PO BID
Omeprazole 20mg PO QD
Lactulose 15ml PO TID
Ativan 1mg Q4h prn alcohol withdrawal--takes 1mg QD
Oxycodone 5mg PO BID prn (taking 10-15mg Q8h for last several
weeks).
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to 3 BM per day.
Disp:*2700 ml* Refills:*2*
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*1*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Erythromycin 5 mg/g Ointment Sig: 0.5 in Ophthalmic QID (4
times a day).
Disp:*1 tube* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: do not drive or operate machinery.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastrointestinal bleed, esophageal varices, portal
hypertensive gastropathy, [**Doctor First Name 329**] [**Doctor Last Name **] tear, alcoholic
hepatitis
Secondary: alcohol abuse, status post right elbow fracture,
cirrhosis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted with bleeding from your esophagus and stomach.
You underwent endoscopy twice to repair the bleeding. You no
longer had any evidence of bleeding, but will need to have a
repeat EGD as an outpatient on [**2115-4-23**]. The bleeding occured as
a complication of your liver diease due to alcohol. It is
important that you no longer drink alcohol.
The following changes were made to your medications:
1) You were started on thiamine, folic acid and multivitamin
2) You were started on lactulose 30ml three times a day and
titrate to 3 bowel movements per day
3) You were started on a lidocaine patch that you should wear
for 12 hours and then take off for 12 hours.
4) You were started on sucralfate 1g four times a day
5) You were started on pantoprazole 40mg twice a day
6) You were started on erythromycin ointment to your eyes four
times a day
7) You were started on oxycodone 5mg every 6 hours as needed for
pain. You should avoid driving or operating machinery.
You should follow-up with the appointments below.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2115-4-23**]
3:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2115-4-23**] 3:00
Please follow-up with your outpatient [**Year/Month/Day 86055**] within the
next week. If you are unable to contact your [**Name2 (NI) 86055**] you
can schedule on appointment at [**Hospital1 18**]: Phone: ([**Telephone/Fax (1) 2007**]
ICD9 Codes: 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5593
}
|
Medical Text: Admission Date: [**2185-5-25**] Discharge Date: [**2185-5-27**]
Date of Birth: [**2118-8-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
cardiac catheterization with stent placement
History of Present Illness:
66 year old female with history of HTN, hyperlipidemia, family
history of hyperlipidemia, and no prior history of CAD, or DM,
presented to the ED with complaints of severe chest pain.
Symptoms began at approximately 5pm this evening and the patient
presented to the ED approximately half an hour later. Chest pain
was described to worsen with exertion, and were not associated
with symptoms of nausea/vomiting or diaphoresis. Of note, over
the weekend, the patient had experienced mild chest pain
associated with abdominal discomfort and bloating. Her symptoms
improved, but on Monday and Tuesday she experienced intermittent
fleeting sensations of chest discomfort which were mild. This
morning, the patient felt fine that thought nothing more of her
chest pain until she was walking home from work, approximately 4
blocks to her car, when she suddenly experienced the same chest
discomfort, only much more severe and concerning. The patient
then proceeded to drive her car directly to the [**Hospital1 18**] ED for
further evaluation.
.
Upon arrival to the ED, V/S were: P - 132, BP 187/101, RR-18, O2
99% RA. Chest pain had started to resolve, however a 12-lead EKG
showed ST segement elevations in the V1-V3 with reciprocal
changes in the inferior leads. The patient was given Aspirin,
600mg of plavix, a heparin bolus, as well as an integrillin
bolus and was brought immediately to the cath lab where she was
found to have two vessel disease (LAD 90% just past D1, LCx
60-70% at OM1 bifurcation) with a proximal LAD lesion which was
stented with one bare metal stent.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, dysuria, abdominal pain. S/he denies recent
fevers, chills or flu-like symptoms. Cardiac review of systems
is notable for absence of dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope. All of the other review of systems were negative.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- HTN
- Hyperlipidemia
- Urinary Incontinence
- Osteopenia
Social History:
Tobacco history: None
-ETOH: Few alcoholic drinks occasionally
-Illicit drugs: None
-Works here at the [**Hospital1 18**] as a PhD/chemist studying blood
coagulation and thrombosis. Husband is also a PhD here, working
as a hematologist. Son currently in medicine residency in
[**State 5887**].
-Very physically active, exercising in a pilates-like class
3x/week and gardening very frequently.
Family History:
Family history of early MI - father died at age 52, and
grandfather died at age 52 related to complications of MI. No
family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; Mother with history of Diabetes.
Physical Exam:
VS: T= BP= HR= RR= O2 sat=
GENERAL: Thin woman, appears younger than stated age. NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Mucous membranes
dry.
NECK: Supple without elevated JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Extra heart sounds. No murmurs. No
thrills, lifts.
LUNGS: No chest wall deformities. Unlabored breathing. Lung
fields CTAB without crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No abdominial bruits.
EXTREMITIES: Right groin cath site with good hemostasis, small
hematoma. No femoral bruits. No lower extremity edema. Foley
catheter in place.
SKIN: Warm without rash or bruises.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2185-5-25**] 06:10PM BLOOD WBC-11.9* RBC-4.95 Hgb-15.3 Hct-44.6
MCV-90 MCH-30.9 MCHC-34.3 RDW-13.0 Plt Ct-330
[**2185-5-25**] 06:10PM BLOOD Neuts-54.2 Lymphs-38.8 Monos-5.1 Eos-1.3
Baso-0.7
[**2185-5-25**] 06:10PM BLOOD PT-12.1 PTT-21.2* INR(PT)-1.0
[**2185-5-25**] 06:10PM BLOOD Glucose-172* UreaN-15 Creat-1.0 Na-136
K-3.1* Cl-96 HCO3-23 AnGap-20
[**2185-5-25**] 06:10PM BLOOD Calcium-10.2 Phos-3.2 Mg-1.9
.
[**2185-5-25**] 06:10PM BLOOD CK(CPK)-71 CK-MB-NotDone cTropnT-<0.01
[**2185-5-26**] 03:45AM BLOOD CK(CPK)-756* CK-MB-68* MB Indx-9.0*
[**2185-5-27**] 05:35AM BLOOD CK(CPK)-208* CK-MB-12* MB Indx-5.8
cTropnT-0.63*
.
.
ECG [**2185-5-25**]: Sinus tachycardia. ST segment depression in leads
II, III and aVF. ST segment elevation in leads I, aVL and V1-V3
with ST segment depression in leads V5-V6. These findings are
consistent with acute anterior, lateral and apical ischemic
process. Rule out myocardial infarction. Followup and clinical
correlation are suggested.
.
Cardiac catheterization [**2185-5-25**]:
1. Selective coronary angiography of this right dominant system
revealed two vessel coronary artery disease. The LMCA had no
angiographic apparent disease. The LAD had a 99% lesion just
after D1. The Lcx had a 60-70% bifurcation lesion at the level
of OM1 bifurcation. The RCA had mild luminal irregularities.
2. Resting hemodynamics revealed normal left sided filling
pressures with mean PCWP of 12 mmHg as well as normal right
sided filling pressure with RVEDP of 8mmHg. There was normal
cardiac index of 4.3 L/min/m2. Normal pulmonary pressures with
PA systolic of 26mmHg. There was mild systemic hypertension with
a central aortic pressure of 145/84 mmHg.
3. Successful PTCA and stenting of the LAD with a 2.5x18mm Mini
Vision stent. Final angiography revealed 30% stenoses proximal
and distal to the stent with 0% residual stenosis in the stent
portion, no angiographically apparent dissection and TIMI III
flow.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. ST elevation MI
3. Successful PCI of the LAD.
4. Normal left and right sided filling pressures
5. Mild systemic hypertension.
.
ECG [**2185-5-25**]: Sinus rhythm with slowing of the rate as compared
with previous tracing of [**2185-5-25**]. Anterior ST segment elevation
persists with now some evolution of the ST-T wave changes
recorded in lead V2. T waves are now biphasic in leads V2-V3.
The ST segment depression recorded in the inferolateral leads
has resolved somewhat. Followup and clinical correlation are
suggested. Rule out myocardial infarction.
.
ECG [**2185-5-25**]: Sinus tachycardia. Compared to the previous tracing
of [**2185-5-25**] there is further evolution of acute anteroseptal and
lateral myocardial infaction and an increase in rate. Clinical
correlation is suggested.
.
ECG [**2185-5-26**]: Sinus rhythm with slowing of the rate as compared
with previous tracing of [**2185-5-25**]. There is further evolution of
acute anteroseptal and lateral myocardial infarction. Clinical
correlation is suggested.
.
TTE [**2185-5-26**]: The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is 0-10mmHg.
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with mid to distal anteroseptal akinesis and distal anterior and
apex hypokinesis. The remaining segments are hyperdynamic. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is a trivial/physiologic
pericardial effusion. There is an anterior space which most
likely represents a fat pad. IMPRESSION: Mild focal left
ventricular systolic dysfunction (consistent with coronary
artery disease) with overall normal global function.
Brief Hospital Course:
ASSESSMENT AND PLAN: The patient is a 66 year old woman with
cardiac risk factors of hypertension and hyperlipidemia
presented with acute onset of chest pain and anterior ST segment
elevation on EKG. She was taken emergently to cardiac
catherization, which showed evidence of 2-vessel disease with a
99% LAD lesion and 60-70% LCx lesion. She received a bare-metal
stent to the LAD lesion.
.
CORONARIES: The patient suffered from an anterior STEMI and
underwent cardiac catheterization that revealed a mid-LAD
lesion, which was stented with a bare-metal stent. She was
treated with aspirin, palvix, heparin and integrillin gtts. Her
Lipitor dose was increased, and she was started on a
beta-blocker and continued on her home ACEi. Serial ECGs showed
evolution of the infarction, and serial cardiac enzymes were
followed that showed a peak CK of 756 and MB of 68.
.
PUMP: An echocardiogram was done on the day post-STEMI, which
showed mild focal left ventricular systolic dysfunction
consistent with coronary artery disease, with overall normal
global function. She was continued on her home ACEi and started
on a beta-blocker. Her HCTZ was discontinued.
.
RHYTHM: The patient was initially tachycardic, likely related to
stress, pain, and the recent STEMI, but she remained in sinus
rhythm throughout the hospitalization without any evidence of
arrhythmia or ectopy. She was started on a beta-blocker.
Medications on Admission:
Atorvastatin - 10 mg po daily
HCTZ - 12.5 mg po daily
Moexipril - 15MG po BID (increased 3 months ago)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ST elevation myocardial infarction
Secondary: Hypercholesterolemia, Hypertension
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with chest pain and determined
to be having a heart attack. You underwent cardiac
catheterization that demonstrated a blockage in one of the
arteries of the heart. A stent was placed during this procedure.
Because you now have a stent it is very important that you take
ASPIRIN and PLAVIX daily. You will discuss the duration of the
plavix when you see your cardiologist.
NEW MEDICATIONS:
ASPIRIN
PLAVIX
METOPROLOL TARTRATE
FAMOTIDINE
Medication CHANGES:
--STOP taking HCTZ: your blood pressure has been well controlled
in the hospital without this medication.
--Atorvastatin INCREASED from 10mg daily to 80 mg daily
--Moexipril now 15 mg ONCE DAILY rather than twice a day
If you experience chest pain, shortness of breath, fevers,
chills or any other concerning symptom please contact your
cardiologist or come to the emergency department for evaluation.
Followup Instructions:
You should make an appointment to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] (cardiologist) in 4 weeks. His office phone is ([**Telephone/Fax (1) 3942**].
You should also follow up with your primary care physician
within the next 2 weeks.
ICD9 Codes: 2724, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5594
}
|
Medical Text: Admission Date: [**2201-2-17**] Discharge Date: [**2201-2-19**]
Date of Birth: [**2124-5-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) /
Azithromycin / Iodine-Iodine Containing / Atenolol / Metoprolol
Tartrate / Lipitor / Clindamycin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms [**Known lastname 3646**] is a 76 y/o F with hx of CAD, sCHF (EF 45% in [**Month (only) 1096**]
[**2200**]), HTN, DVT on enoxaparin, and recent hospitalization in
[**Month (only) 1096**] for asthma exacerbation c/b resp failure requiring
mechanical ventilation, on home O2 2L NC, who came to the ED
today reporting 4-5 days of worsening SOB, accompanied by
substernal chest tightness and productive cough with sputum
production. Also endorses orthopnea, and recently increased her
pillows from 4 to 6 at night. No extremity swelling. No
pleuritic chest pain. No nausea or vomiting. She has had
worsening exertional dyspnea, though she is wheelchair bound and
only intermittently ambulates.
.
In the ED, initial VS were: 99.4, 78, 180/106, 99% 4L NC. Exam
initially unremarkable. Labs included hgb of 10.4, normal
WBC/plt/chem7. Cardiac biomarkers were negative. BNP was 318.
U/a was negative. CXR showed small bilateral pleural effusions,
but no pulmonary edema or consolidations. ECG showed no new
ischemic changes. BNP was normal and troponin was negative.
The ED team initially planned on having the patient undergo a
stress test, but she became acutely dyspneic with respiratory
rate in the 30s. ABG 7.41/44/193 on BiPap. She was treated
with methylprednisolone, magnesium, and nebulizers. She was
also given benadryl, famotidine, and an epipen out of concern
for possible anaphylactic reaction--the patient has had itching
after taking her lovenox (last taken this morning). The ED team
spoke with the patient's PCP, [**Name10 (NameIs) 1023**] reported that the patient has
been recommended to pursue [**Hospital3 **]. Prior to departing
the ED, her VS were 97.3, 80, 22, 128/71, 100% on Bipap.
.
On arrival to the MICU, the patient was agitated and repeatedly
requested to be transferred to [**Hospital **] Hospital. Her only
physical complaint was of heartburn, no worse than her usual
acid reflux symptoms.
Past Medical History:
1. Coronary artery disease.
2. Ischemic cardiomyopathy. EF 35-40% on ECHO in [**2198**].
3. Asthma, though no PFTs in system and no documented outside
PFTs. uses 2LNC at home
4. Lower extremity DVT that was diagnosed at [**Hospital1 2025**] at an unknown
time and was treated for an unknown length of time, but this was
many years ago.
5. Dyslipidemia.
6. Hypertension.
7. Normocytic anemia.
8. Chronic rhinosinusitis.
9. Depression.
10. Adenoid hyperplasia
Social History:
Home: Lives in [**Location 686**] with her daughter (40 y/o) and
grand-son (16 y/o). However, the patient also states that her
daughter frequently disappears from home for a few weeks at a
time because she is "mixed up in drugs." The patient does not
currently know where her daughter is or how to get in touch with
her. She is tearful and worried when talking about her home
situation.
- Exposures: The patient states that there are no pets at home.
There is no mold, dust, construction in or around the home.
- ADL: The patient is wheelchair-bound at baseline but uses a
cane to take a few steps. Her activity is limited due to
musculoskeltetal discomfort as well as dyspnea. She is able to
dress and shower by herself.
- Smoking: denies.
- EtOH: denies.
- Illicits: denies
Family History:
She has several members of family with coronary artery disease
and heart attacks, no diabetes, no cancer reported.
Physical Exam:
Physical exam
General: Awake, alert, agitated, oriented, redirectable
HEENT: No conjunctival icterus/pallor; mild conjunctival
injection. MMM. OP clear. No JVD or LAD
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: +moderate wheeze throughout, no crackles or rhonchi
Abdomen: soft, NT/ND, NABSx4, no organomegaly
Ext: warm, well perfused, 2+ pulses, trace edema to shins
bilaterally
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred
Discharge exam
pt left AMA
Pertinent Results:
Admission labs
[**2201-2-17**] 11:40AM BLOOD WBC-4.1 RBC-3.66* Hgb-10.4* Hct-31.6*
MCV-87 MCH-28.6 MCHC-33.0 RDW-13.7 Plt Ct-293
[**2201-2-17**] 11:40AM BLOOD Neuts-53.6 Lymphs-35.7 Monos-6.2 Eos-3.6
Baso-0.9
[**2201-2-17**] 11:40AM BLOOD Glucose-89 UreaN-18 Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-28 AnGap-14
[**2201-2-17**] 11:40AM BLOOD CK(CPK)-88
[**2201-2-17**] 11:40AM BLOOD CK-MB-3 proBNP-318
Cardiac enzymes
[**2201-2-17**] 11:40AM BLOOD cTropnT-<0.01
[**2201-2-17**] 08:18PM BLOOD cTropnT-<0.01
[**2201-2-18**] 04:45AM BLOOD cTropnT-<0.01
Discharge labs
[**2201-2-19**] 04:23AM BLOOD WBC-11.8*# RBC-3.39* Hgb-9.9* Hct-29.0*
MCV-86 MCH-29.1 MCHC-34.0 RDW-14.1 Plt Ct-284
[**2201-2-19**] 04:23AM BLOOD Neuts-77.6* Lymphs-15.1* Monos-6.9
Eos-0.2 Baso-0.1
[**2201-2-19**] 04:23AM BLOOD Glucose-98 UreaN-27* Creat-0.9 Na-137
K-4.0 Cl-100 HCO3-28 AnGap-13
[**2201-2-19**] 04:23AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.3
Studies
CXR [**2201-2-17**]: The heart is enlarged, stable. Aorta is
tortous. No focal opacities are seen. Previously seen right
middle lobe
opacity is no longer evident. No pneumothoraces are seen. Bones
are intact. IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
76 y/o F with hx CAD, CHF, DVT and recent hospitalizations for
asthma exacerbation, presenting with progressively worsening
cough, dyspnea, chest tightness, and sputum production, with
hypertensive crisis on arrival to MICU. Respiratory status
improved without major intervention, and she was briefly on a
nitro gtt, then pt left AMA before anything could be done.
.
# Respiratory distress: Unclear what patient's intrinsic
pulmonary dysfunction is due to, although prior documentation
suggests she wears nasal cannula at home and prior episodes of
respiratory distress have been attributed to asthma
exacerbations. Pt had no oxygen saturation measurements on room
air in ED, and pO2 only measured while on Bipap, so degree of
hypoxia is uncertain, if any. Symptoms of progressive
orthopnea, dyspnea on minimal exertion and leg edema suggestive
of CHF, although pt not grossly volume overloaded, CXR generally
clear, and BNP normal. Sudden onset of symptoms in ED in
absence of exposure to asthma precipitants or allergens is
atypical for true asthma exacerbation. No PFTs available in our
system. No widened mediastinum or hemodynamic instability to
suggest aortic dissection. Multiple reports of poor medication
compliance in OMR; pt may not be using home inhalers. We tried
to get PFT's but she left AMA prior to this. This was briefly
given prednisone but this seemed to make littler difference as
she was already at baseline after 12 hours in the MICU.
.
# Hypertensive urgency: likely [**3-12**] epinephrine she got in the
ED (for what was thought to be an allergic rxn). Improved with
nitro gtt. Generally normo/hypertensive in ED. on home meds
hctz and diltiazem
.
# CAD/Ischemic cardiomyopathy: No ischemic changes on ECG, trop
negative. No chest pain. Not on afterload reducing [**Doctor Last Name 360**].
Ruled out for MI
.
# Lower extremity DVT: Unclear if taking enoxaparin at home,
though she tolerated it well in house.
# Dyslipidemia: c/w statin
.
# Normocytic anemia: hgb/hct at baseline
.
The pt left AMA before further intervention could be made
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1
puff . Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for reflux.
9. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at
bedtime.
10. enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1
puff . Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for reflux.
9. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at
bedtime.
10. enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
transient resp distress, atypical, possibly asthma though has
had no PFTs
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
pt left AMA
Followup Instructions:
pt left AMA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 4280, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5595
}
|
Medical Text: Admission Date: [**2133-1-14**] Discharge Date: [**2133-1-30**]
Date of Birth: [**2062-5-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2133-1-23**]: Bedside placement of PEG
History of Present Illness:
This is a 70 y/o man who had a fall from a ladder after presumed
syncopal episode. Per OSH reports, Mr. [**Known lastname **] was working on a
ladder, complained of light headedness and fell approximately
[**4-24**] feet. He was alert and oriented initially, but vomited three
times en route to OSH, where he had a GCS of 10. He was then
intubated for airway protection, and prepared for [**Location (un) **] to
[**Hospital1 18**]. Upon arrival here, head CT was performed revealing a
significant right SDH and basilar skull fracture.
Past Medical History:
Hypertension, Dyslipidemia
Social History:
Married, resides at home.
Family History:
Non-contributory
Physical Exam:
On admission:
O: BP:148/108 HR:97 RR:18 O2Sats:100%CMV
Gen: WD/WN, comfortable, NAD.
HEENT: periorbital ecchymosis, there are air bubbles appreciated
behind the left ear; right TM appears to be intact
Pupils: PERRL EOMs: UTA
MOTOR: minimal spontaneous movement of the upper extremities,
withdrawal of the lower extremities to noxious nail bed
pressure.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm to 1.5mm
bilaterally.
III, IV, VI-XII: UTA.
Reflexes: +gag, +corneals
Toes upgoing bilaterally
Exam on Discharge:
A&Ox self, month, and year
PERRL 4-2mm bilaterally
EOMs: intact
follows commands intermittently
Face symmetrical
tongue midline
RUE: [**5-20**] biceps and triceps, [**4-20**] grip
LUE: [**4-19**] biceps and triceps, [**3-20**] grip
BLE: antigravity
PEG incision: c/d/i
Pertinent Results:
CT C-spine [**2133-1-14**]
1. No fracture or malalignment involving the cervical spine.
2. Multilevel degenerative change most prominent at the level of
C6-C7 with loss of intervertebral disc height, posterior
disc-osteophyte complex, facet arthrosis and uncovertebral
hypertrophy resulting in mild-to-moderate central canal stenosis
and neural foraminal narrowing. This predisposes the patient to
spinal cord injury with minimal trauma, and MRI of the cervical
spine should be considered for further evaluation of cord injury
if clinically indicated.
3. Basilar skull fracture involving the left occipital bone
extending to
involve the left occipital condyle and the left internal carotid
canal within the petrous portion of the left temporal bone.
Recommend CTA for further evaluation.
4. Partially imaged is pneumocephalus involving the right
temporal region as seen on concurrent CT examination.
CT Head [**2133-1-14**]:
1. Extensive intracranial hemorrhage as detailed above with
right cerebral
convexity subdural hemorrhage measuring up to 11 mm, a small
left frontal
subdural hemorrhage measuring up to 4 mm, extensive right-sided
cerebral
subarachnoid hemorrhage, and likely component of
intraparenchymal right
frontal contusion.
2. Multiple scalp hematomas involving the left occipital region,
the right
frontal region, and likely near the right frontal convexity.
3. Left basilar skull fracture involving the left occipital bone
with
extension into the left occipital condyle and petrous portion of
the left
temporal bone, with involvement of the left internal carotid
canal. Recommend CTA for further evaluation.
4. Sinus opacification likely related to recent intubation
ankle X-ray [**2133-1-14**]
Minimally displaced lateral malleolar fracture. Small well
corticated ossific density inferior to medial malleolus could
represent sequelae of old trauma.
CTA neck [**2133-1-14**]:
No evidence of vascular injury, thrombosis or aneurysm. The left
basilar
skull fracture involving the left occipital bone and extending
into the left carotid canal is redomenstrated. The left carotid
artery is suboptimally opacified in this region, however given
symmteric appearance a focal intimal dissection is felt
unlikely. ([**First Name8 (NamePattern2) 30217**] [**Doctor Last Name **] [**Numeric Identifier 83113**])
ECHO [**2133-1-15**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
CT Head [**2133-1-15**]
1. Increase in the right inferior frontal intraparenchymal
hemorrhage with
mild increase in the leftward shift of the midline structures.
2. Increase in the conspicuity of the subarachnoid hemorrhage in
the left
frontal and parietal lobes. Persistent mass effect on the right
lateral
ventricle with mild increase in the leftward shift of the
midline structures.
3. Other details as above. Please see the prior CT head study
for details
regarding the osseous structures.
4. Unchanged appearance of the scalp soft tissue swelling, on
the left side.
MRI C-spine [**2133-1-15**]:
IMPRESSION:
1. Multilevel neural foramen narrowing as above.
2. Posterior disc bulge at C6-C7 and C7-T1 levels without
impingement on the cord or central canal stenosis.
3. Incidental note is made of blood within the left cerebellar
cistern.
CT Head [**2133-1-18**]:
IMPRESSION: Re-demonstration of multifocal intracranial
subdural,
intraparenchymal, and subarachnoid hemorrhage. There is no new
hemorrhage
identified. Right subarachnoid hemorrhage is somewhat less
conspicuous than on prior study. There is continued mass effect
upon the right lateral
ventricle, and associated rightward shift of midline structures,
again
measuring approximately 1 cm. Small amount of intraventricular
blood is again identified in the occipital [**Doctor Last Name 534**] of the left
lateral ventricle. There is no new hemorrhage or increased mass
effect identified.
LENIS [**2133-1-20**]:
CONCLUSION: No evidence of DVT in the right or left lower
extremity.
CTA Chest [**2133-1-20**]:
IMPRESSION:
1. Right upper lobe pneumonia.
2. No central pulmonary embolism. Limited distal branch
evaluation due to
respiratory motion artifact. In a single posterior segment right
upper lobe pulmonary artery, there is suggestion of a filling
defect, although this opacity overlaps with adjacent airspace
disease, and may be artifactual.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] on [**1-15**]. He was intubated and
taken to the ICU with Q1hr neuro checks. CT imaging showed
worsening hemorrhage. Platelets were goiven for history of
aspirin use. e was on Dilantin for seizure prophylaxis. MRI
c-spine was performed on [**2133-1-15**]. He was see by Orthopedics who
recommended an air cast for his ankle. Serial CT's remained
stable. Dr. [**Last Name (STitle) **] cleared his cervical collar on [**2133-1-16**]. He was
weaned toward extubation. Repeat Head CT on [**2133-1-17**] was stable.
His Mannitol was held due to NA/OSM parameters. He failed Speech
and Swallow evaluation at the bedside and a Dobhoff was placed.
On [**1-19**] his Mannitol was discontinued. His Foley was
discontinued. He was transferred to the step down unit. His
dilantin dose was increased for a corrected level of 6.1.
The patient had tachypnea overnight but his oxygen saturation
remained within normal limits. His neuro exam remained stable.
During the day on [**1-20**] his tachypnea became worse and his ABG
showed respiratory alkalosis. He continued to oxygenate well.
Lenis were negative for DVT. His RR went up to the 40s and he
became more lethargic and stopped following commands. The repeat
head CT was stable. He also spiked a fever of 102. Due to
suspicion of a PE and the tachypnea, he was transferred to the
ICU and had a chest CTA on the way there.
The CTA was equivocal. The patient's head of bed was kept
elevated and he had nasotracheal suctioning and he several mucus
plugs were removed. He also had chest PT and his RR came down to
the 20s. By [**1-21**] his mental status improved and he was following
commands again with the right side.
Additionally ID was consulted to guide antibiotic managment for
his pneumonia. A repeat speach and swallow evaluation was
performed and unfortunately, he did not pass. Therefore a
general surgery consult was obtained. He was also transferred
to the stepdown unit, where vancomycin increased to Q8H. Urine
culture was negative from [**2133-1-20**]. Sputum culture found to have
normal flora. His dobhoff was replaced to restart tube feeds.
PEG was performed on [**2133-1-26**] to bridge his nutrition during his
recovery. Post-operatively, he was tachypneic and reintubated
for respiratory managment. He was then transferred back to the
ICU. After being placed on CPAP, his respiratory status
improved, as it was thought his tachypnea was due to atelactasis
and/or mucous plugs. A NCHCT was again performed; revealing
persistant right acute on chronic SDH and evolving right frontal
contusion. It was decided to take him to the operating room on
[**1-28**] to evacuate the right SDH to optimize his recovery.
However, it was noted on morning rounds on [**1-28**], that he has
much improved clinically(following commands, moving all
extremities); so the OR case was cancelled.
The patient's mental status remained stable and he was
successfully extubated on [**1-28**]. He continued to do well
neurologically and he was breathing on room air with no
difficulty. Therefore he was transferred back to the neuro step
down unit. He continued to work with PT and OT and was screened
for rehab. He is stable neurosurgically and respiratory wise and
will be discharged to rehab on [**2133-1-30**].
Medications on Admission:
Lopid
Magnesium
Calcium
ASA
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-17**] Inhalation Q6H (every 6 hours) as needed
for wheezing.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. HydrALAzine 10 mg IV Q4H:PRN sbp>160 , HR<100
hold for sbp<100
12. Metoclopramide 10 mg IV Q6H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
subdural hematoma
subarachnoid hemorrhage
skull fracture
cerebral contusion
Minimally displaced lateral malleolar fracture
Hospital Acquired Pneumonia
Respiratory Failure
Dysphagia
Hyponatremia
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen
etc. You have however, already been restarted on your home dose
of aspirin.
?????? You have been prescribed an anti-seizure medicine,Keppra. You
will not require any bloodwork to monitor this. You will
continue to take this until you are seen in follow up
??????
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
this appointment.
Completed by:[**2133-1-30**]
ICD9 Codes: 5070, 5180, 2761, 2762, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5596
}
|
Medical Text: Admission Date: [**2149-5-19**] Discharge Date: [**2149-5-27**]
Date of Birth: [**2081-1-9**] Sex: F
Service: SURGERY
Allergies:
Percocet / Aspirin / Tylenol / Morphine
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Acute cold left foot
Major Surgical or Invasive Procedure:
[**2149-5-19**]
Abdominal aortogram with unilateral extremity runoff, Perclose
of right groin, left groin exploration with common femoral and
profunda endarterectomy with bovine patch angioplasty, SFA
embolectomy, below-knee [**Doctor Last Name **] exploration with vein patch
angioplasty following embolectomy of anterior tibial and
posterior tibial arteries; four compartment fasciotomies through
2 incisions.
History of Present Illness:
This is a 68-year-old female who noted the acute onset of left
foot pain at 10 o'clock the prior evening and after a few hours
went to [**Hospital3 **] where she was then transferred to [**Hospital1 1535**]. Upon arrival she had a palpable
left femoral pulse but it was weaker than her right femoral
pulse. She had no dopplerable signals in her left foot and she
had mildly decreased motor and decreased sensation of the left
foot. Her foot was cold
and mottled at the forefoot. The decision was made for urgent
arteriography with decisions for possible embolectomy versus
bypass versus catheter based intervention.
Past Medical History:
ESRD from htn, partial
colectomy for colonic polyps, and thyroid resection for benign
disease, ventral hernia repair
Social History:
Lives with husband in home
Family History:
Noncontributory
Physical Exam:
98.9 P:76 BP: 125/70 RR:20 Spo2: 99%
NAD A&Ox4
CTAB
RRR
Abd soft, NT, ND
Ext: LLE 3cm skin open with serous stained packing. +CSM
Fem DP PT
R palp palp dop
L palp dop dop
Pertinent Results:
[**2149-5-27**] 06:15AM BLOOD WBC-12.0* RBC-2.94* Hgb-9.0* Hct-28.0*
MCV-95 MCH-30.5 MCHC-32.1 RDW-17.5* Plt Ct-483*
[**2149-5-27**] 06:15AM BLOOD Plt Ct-483*
[**2149-5-27**] 06:15AM BLOOD Glucose-112* UreaN-48* Creat-10.3* Na-140
K-4.0 Cl-98 HCO3-29 AnGap-17
[**2149-5-27**] 06:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) 251**] C.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 251**] on TUE [**2149-5-20**] 3:10 PM
Name: [**Known lastname 41311**], [**Known firstname **] Unit No: [**Numeric Identifier 41312**]
Service: Date:
Date of Birth: [**2081-1-9**] Sex: F
Surgeon: [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 41313**]
PREOPERATIVE DIAGNOSIS: Ischemic left leg.
POSTOPERATIVE DIAGNOSIS: Ischemic left leg.
PROCEDURE: Abdominal aortogram with unilateral extremity
runoff, Perclose of right groin, left groin exploration with
common femoral and profunda endarterectomy with bovine patch
angioplasty, SFA embolectomy, below-knee [**Doctor Last Name **] exploration with
vein patch angioplasty following embolectomy of anterior
tibial and posterior tibial arteries; four compartment
fasciotomies through 2 incisions.
ASSISTANT: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27576**], MD.
ANESTHESIA: General endotracheal anesthesia.
FLUIDS: 1.6 liters of crystalloid.
ESTIMATED BLOOD LOSS: 300 cc.
URINE OUTPUT: Zero as the patient was on peritoneal
dialysis.
COMPLICATIONS: There were no complications and the patient
tolerated the procedure well, was extubated and taken to the
cardiovascular intensive care unit in guarded condition.
A total of 128 cc of Visipaque were used and total fluoro
time was 22 minutes.
INDICATIONS: This is a 68-year-old female who noted the
acute onset of left foot pain at 10 o'clock the prior evening
and after a few hours went to [**Hospital3 **] where she was
then transferred to [**Hospital1 69**].
Upon arrival she had a palpable left femoral pulse but it was
weaker than her right femoral pulse. She had no dopplerable
signals in her left foot and she had mildly decreased motor
and decreased sensation of the left foot. Her foot was cold
and mottled at the forefoot. The decision was made for urgent
arteriography with decisions for possible embolectomy versus
bypass versus catheter based intervention.
PROCEDURE: The patient was taken to the operating room on
[**2149-5-19**], laid on the table in the supine position. The
patient's groins were prepped and draped in the sterile
fashion. Retrograde access was obtained to the right common
femoral artery using the micropuncture technique after
infiltration of local anesthesia. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was placed
in the abdominal aorta and a short 4-French sheath was
placed. An Omni Flush was placed at the level of L1 and
diagnostic abdominal aortogram was obtained. A 4-French
angled glide catheter was placed into the left external iliac
artery after this was accessed using the floppy angled
Glidewire and then serial images were obtained of the left
lower extremity down to and including the foot. At this
point, the decision was made to cut down the left groin so
the glide catheter was removed and the 4-French sheath was
sutured into place. The anesthesia team was called and they
promptly intubated the patient. She was given intravenous
antibiotics. A longitudinal incision was made in the left
groin and the common femoral artery was exposed. The SFA and
profunda were isolated with vessel loops as well as an Aldara
clamp placed on the distal external iliac artery. A
longitudinal arteriotomy was made in the common femoral
artery and there was a large amount of thrombus present. This
was pulled out using a snap and then a #3 and #4 embolectomy
catheter was passed down the superficial femoral artery with
a large amount of clot removed. A #3 embolectomy catheter was
passed down the profunda and there was excellent amount of
clot removed. There was good back bleeding from the SFA and
profunda. An endarterectomy was then performed of the common
femoral going into the SFA and a plaque was pulled out of the
origin of the profunda. A bovine pericardium patch was
created and sewn into place using a 6-0 Prolene. Attempts
were made to put a sheath through the side of the patch for
further arteriography. This was not feasible so the SFA and
funda were back bled and then there was good forward flow and
the sutures were tied and the patch was punctured with a
regular 0.018 needle and then [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was placed and a
long 6-French sheath was placed into this patch.
Arteriography was then performed of the left lower extremity
and there was still noted to be a large amount of clot at the
tibioperoneal trunk and despite multiple attempts with the
export catheter over a [**Name (NI) 41314**] PT wire which had been placed
into the posterior tibial artery and despite multiple passes
with the excisor vacuum assisted battery-operated
thrombectomy device, there was still a tremendous amount of
clot in the anterior tibial and the posterior tibial so these
were pulled out and the sheath was left in place. A cutdown
was performed of the below-knee popliteal artery and the
gastrocnemius and soleus muscle were taken off their
attachments to the tibia. The proximal below-knee popliteal
artery was isolated and vessel loops were placed around the
anterior tibial artery, posterior tibial artery and
tibioperoneal trunk. At this point a longitudinal arteriotomy
was made in the below-knee popliteal artery and a #2
embolectomy catheter was passed into the anterior tibial
artery all the way to approximately 60 cm and a large amount
of thrombus was removed after multiple passes and ultimately
there was excellent backbleeding. Attempts were made to pass
the #2 embolectomy catheter down the posterior tibial artery
but there was a clot lodged immediately distal to the
arteriotomy and this would no come out so the arteriotomy was
extended onto the posterior tibial and ultimately this clot
was removed. The #2 embolectomy catheter was passed easily
down into the foot and pulled back with a good amount of clot
removed and excellent backbleeding. There was excellent
backbleeding from the peroneal. At this point, a piece of
saphenous vein was harvested from this vein incision as there
had been a tremendous amount of tension put on the saphenous
vein with the exposure. A patch was created and sewn into
place using 6-0 Prolenes. Flow was restored and then a
completion arteriogram was shot through the same sheath in
the left groin patch. There was noted to be persistent
thrombus in the distal anterior tibial and distal posterior
tibial artery but the decision was made to stop at this
point. The fascia was then incised in a deep posterior and
superficial posterior compartment through the same incision
as the below-knee popliteal exposure. A fasciotomy was
performed of the anterior and lateral compartments through a
separate incision which was 1 cm anterior to the tibia. All
bleeding was checked and controlled. The skin was then closed
in the fasciotomy sites using 3-0 Vicryl and then staples for
the skin. The sheath was removed from the left groin and a U
stitch Prolene was placed. Surgicel was placed and then
hemostasis was checked for. The patient had been on heparin
throughout this case and was intermittently bolused to keep
her ACT's around 300. At this point 20 mg of protamine was
given and the left groin was closed in layers of 2-0, 3-0 and
staples for the skin. A Perclose device was deployed through
the right groin after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was placed back to the
abdominal aorta. Manual pressure was held and there was
excellent hemostasis from this. The dressings were applied
and a Kerlix was wrapped. The patient, at the completion of
the case had a dopplerable distal AT, peroneal, PT, but there
was no signals in the foot. The foot was still pale. The
decision was made to leave the patient on heparin as multiple
attempts had been made without success to remove all the clot
from the distal foot. The patient was extubated and taken to
the cardiovascular intensive care unit in guarded condition.
ANGIOGRAPHIC FINDINGS: Initial images of the abdominal aorta
revealed patent abdominal aorta and iliac arteries
bilaterally. There is patency of the external and internal
iliacs bilaterally. Initial image of the left lower extremity
reveal a clot sitting in the profunda which seems
superimposed on the SFA. There is flow through the
superficial femoral artery and then a clot sitting at the
tibioperoneal trunk. There is flow through the anterior
tibial but it is very sluggish and goes very slowly through
the mid leg. There is very minimal flow going through the
posterior tibial artery. The peroneal artery reconstitutes
and is patent down to the foot. There are then images taken
after there was a sheath placed through the left groin patch.
This revealed excellent flow through the SFA and profunda and
through the popliteal artery. There is patency of the below-
knee popliteal artery and the proximal anterior tibial artery
but clot sitting in the anterior tibial artery going down
towards the foot. The peroneal artery is patent but there is
a large clot sitting at the proximal posterior tibial artery.
There is multiple images revealing attempts at export
thrombectomy followed by excisor battery assisted
thrombectomy. The flow through the posterior tibial artery
was improved but there was still a hangup at the proximal
posterior tibial artery consistent with clot. There was then
the intervening portion of the operation where the below-knee
popliteal artery was isolated and the tibials were
thrombectomized. Completion run through the sheath shows flow
continuously through the peroneal into small collaterals into
the foot. There is very sluggish flow through the anterior
tibial artery in the mid leg and there is no flow into the DP
in the foot. There is cut-off of flow at the PT at the distal
area above the medial malleolus. There is small amount of
tarsal flow and collaterals into the foot from the peroneal.
There is injection of papaverine followed by one completion
run showing the same appearance with poor flow into the foot.
CONCLUSIONS:
1. Successful removal of clot from the common femoral
artery followed by bovine patch angioplasty.
2. Successful removal of clot from the tibioperoneal trunk,
but there is persistent thrombus at the distal PT going
into the foot as well as the very distal AT going into
the foot.
3. There is continuous flow through the peroneal artery
supplying collaterals to the foot.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 41315**]
Dictated By:[**Last Name (NamePattern4) 41316**]
Brief Hospital Course:
[**2149-5-19**]
Patient transferred from [**Hospital3 4107**] for cold left foot with
acute onset of [**8-29**] leg pain. Faint dopperable AT and PT and
foot mottled. Heparin gtt initiated. Radial a-line placed and
bear hugger applied for hypothermia. Nephrology consulted for
urgent PD. Taken to the OR for revascularization (see attached
Op note). Transferred to the CVICU post-op. Dopperable
peripheral signals throughout and right groin perclosed.
[**2149-5-20**]
ICU monitoring. Extubated and vitals stable. Continued on a
heparin gtt and diet advanced to regular. Continued on
peritoneal dialysis per nephrology recommendations. Nitropaste
to left foot for continued vasodilation. 2 units of PRBC given
for hct= 29 and symptomatic hypovolemia.
[**2149-5-21**]
ICU monitoring. VSS Home meds restarted. Frequent pulse checks.
Transferred to VICU.
PT/OT evaluation recommended home vs. rehab.
7/3/08-7/408
VSS. Tolerating regular diet. Continue heparin. Coumadin started
for anticoagulation with goal [**12-22**]. Continued on Q4 PD. OOB daily
with PT. CXR for pleuritic pain WNL. Several staples removed
from left leg incision for bleeding. Wound irrigated and packed
with wet-dry dressing and ace wrap twice daily. 2 units of PRBC
given for hct 24.3 which increased to 29.3 post-transfusion.
[**2149-5-24**]
Underwent CTA or torso. OOB with PT. Continue anticoagulation.
Renal continues to follow. Continue to monitor left leg incision
for bleeding and wound care.
[**2149-5-25**]
No acute events. VSS. Pain control with tylenol (not a true
allergy). Coumadin for anticoagulation. Rehab screen. Statin
started.
[**2148-5-25**]
VSS. Toprol DC'ed for 1st degree AV block per ECG. Continues
Coumadin dosing, PD and rehab screening.
[**2149-5-27**]
Cleared for Rehab and accepted placement. Will follow-up with
Dr. [**Last Name (STitle) **] for post-op check [**2149-6-4**].
Medications on Admission:
Fosamax 35 mg once a month, Lopressor 50', calcitriol 0.25 mcg
once a day, Sensipar 30', Epogen 20,000 qwk, fluoxetine 40',
metolazone 5', nifedipine 60', PhosLo one tab QID, potassium
chloride 20', Renagel 800''', and simvastatin 20'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO
QIDWMHS (4 times a day (with meals and at bedtime)).
7. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical TID (3
times a day).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for post surgery pain.
15. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM:
Goal PTT [**12-22**].
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Ischemic left leg.
PMH:
End Stage Renal Disease (on diaylisis)
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**12-22**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-9-23**] 10:50
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2149-6-4**] 9:00
Completed by:[**2149-5-27**]
ICD9 Codes: 5856, 2767
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5597
}
|
Medical Text: Admission Date: [**2149-11-25**] Discharge Date: [**2149-12-10**]
Date of Birth: [**2079-7-7**] Sex: F
Service: MED ICU
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known firstname 18404**] is a 70 year old
female with a past medical history of high cholesterol,
mitral valve prolapse, and recent history of falls and
unsteady gait. The patient's husband describes approximately
two to three months of ill health with symptoms mainly
consisting of some dyspnea on exertion, breathing trouble,
non-specific weakness and several falls. Today, Miss [**Known lastname **]
fell while on the toilet. The patient denies loss of
consciousness. Family reports loss of consciousness. The
patient was brought to the Emergency Room at an outside
hospital where she was alert and oriented times three and in
respiratory distress. She was treated for congestive heart
failure and transferred to [**Hospital1 188**].
Here in the Emergency Room, she was tachypneic and
hypertensive, and arterial blood gas revealed ventilatory
failure for which she was intubated. In the Emergency
Department, CT scan of the head revealed a question of left
frontal early ischemic lesion. Neurology was consulted. The
patient was treated with additional Lasix and triaged to
Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Mitral valve prolapse.
2. Right carotid stenosis.
3. Hypercholesterolemia.
4. Question of hypertension.
5. Breast CA, question Tamoxifen.
6. History of unsteady falls.
MEDICATIONS:
1. Atenolol 25 mg p.o. q. day.
2. Zocor 10 mg p.o. q. day.
3. Detrol.
4. Aspirin.
ALLERGIES: Tamoxifen leads to a rash.
SOCIAL HISTORY: The patient lives in [**State 531**], is married,
and was in the [**Location (un) 86**] area visiting family. No tobacco.
Son, whose name is [**Name (NI) **], has a phone number of [**Telephone/Fax (1) 37492**].
PHYSICAL EXAMINATION: On admission, temperature 98.1 F.;
heart rate 60 to 70; blood pressure 120/90; respiratory rate,
intubated. Generally, intubated and sedated. Pupils equally
round and reactive to light and accommodation. Face was
symmetrical. Neck was supple; increased jugular venous
distention to approximately 8 to 9 cm. Lungs with bibasilar
crackles. Cardiac regular with II/VI at left lower sternal
border. Abdomen was soft, nontender, nondistended. Positive
bowel sounds. Extremities: Warm with good pulses, positive
edema.
LABORATORY ON ADMISSION: White blood cell count of 6,800,
hematocrit of 42.8, platelets 199,000. Sodium 134, potassium
5.4, chloride 99, CO2 of 32, BUN 26, creatinine 1.1, glucose
105, ALT 188, AST 239, LDH 2137.
Urinalysis was nitrite positive, positive white blood cells,
positive bacteria.
CPK went from 138 to 252. Arterial blood gas revealed gas of
7.17/103/107.
EKG was normal sinus rhythm, normal axis, large P wave in II,
T's decreased in III, AVF and V2 through V5.
Chest [**Known lastname 37493**]: Moderate congestive heart failure, no
infiltrates.
CT scan of the head showed negative bleed, question left
frontal cortex, hypodense, question edema and infarction.
BRIEF SUMMARY OF HOSPITAL COURSE: This is a 70 year old
female with question of neurological history who presents
status post syncope with respiratory distress requiring
intubation, intermittent hypertension and evidence of
congestive heart failure. EKG and head CT scan was
suggestive of ischemic process of the brain. Also,
urinalysis is suggestive of urinary tract infection.
The patient had a right arterial line placed as well as right
internal jugular catheter centrally placed. This was done
without complications. On [**11-25**], the day of admission, the
patient was started on Nitroprusside GGT for unstable
systolic blood pressure. The patient was continued on a
Propofol drip, Lopressor, Zocor, Levaquin for urinalysis and
Zantac for GI prophylaxis.
The patient was not aggressively diuresed. Chest [**Known lastname 37493**] was
revealing of only mild congestive heart failure with oxygen
saturations stable. The patient underwent cardiac
echocardiogram on [**11-25**], which showed positive left
ventricular hypertrophy. No thrombus was seen and ejection
fraction estimated at 45% with apical lateral hypokinesis.
The patient had an episode in the evening of [**11-25**] to [**11-26**],
of bloody gastric drainage and was started on Protonix 40 mg
p.o. twice a day and subcutaneous heparin was discontinued in
favor of Venodyne. The patient's neurologic examination at
this time: The patient squeezes with left hand only and
wiggles left toes only. The patient opens eyes to command.
An MRI/MRA performed on [**11-26**], showed hemorrhage into the
left frontal infarction with midline shift; no significant
carotid stenosis was seen and right frontal area of apparent
hemorrhage, the patient's carotids appeared normal on MRA.
The patient had a transesophageal echocardiogram on [**11-27**],
which showed left atrium normal in size. No mass or thrombus
was seen in the left atrium or left atrial appendage. No
mass or thrombus was seen in the right atrium or right atrial
appendage. No ASD or patent foramen ovale was seen by 2D
color Doppler or saline contrast maneuvers. Moderate
symmetric left ventricular hypertrophy; left ventricle cavity
is unusually small. Left ventricular systolic function is
hyperdynamic with ejection fraction greater than 75%. The
right ventricular free wall is hypertrophied. Aortic
leaflets appear structurally normal; no aortic regurgitation.
Small pericardial effusion. No vegetations or thrombi were
identified compared to trans-thoracic study of [**11-25**]. Right
ventricular function was probably also depressed in the prior
study but the right ventricular free wall was less well seen
in the prior study.
The patient had a head CT scan done on [**2149-11-28**], which
showed two areas of hemorrhage: The first was located in the
left frontal lobe in the region of the infarction first seen
on [**11-25**]. The size of the hemorrhage and extensive
surrounding edema and mass effect is unchanged from the MRI
of [**11-26**]. The left lateral ventricle is mildly
compressed and shifted to the right. There is no
hydrocephalus.
A second area of hemorrhage is seen as a small 3 mm
hyperdense region, high in the sulcus of the parietal lobe.
Bone windows show fluid levels within the sphenoid sinus;
these are unchanged from MRI of [**11-26**]. No fractures
were identified.
On [**12-1**], the patient self extubated thought to be secondary
to a respiratory muscle weakness and shallow breaths with
respiratory rate into the fifties and delta MF. The patient
was reintubated and put on assist control.
The patient's blood pressure was labile throughout her
Intensive Care Unit stay. The patient would have episodes of
blood pressure 200 to 100 which would resolve either
spontaneously or with Lopressor. She would then drop down to
the 90s systolic. Lability of the blood pressure stabilized
throughout her Intensive Care Unit stay. The patient was put
on Atenolol 12.5 mg p.o. q. day and blood pressure ranged at
the end of the MICU stay was from 110 to 170 systolic. The
patient had no readily appreciated changes in mental status
during these episodes.
Neurology recommended an MR of the cervical spine which was
done on [**2149-12-5**], showed no evidence of cord compression or
neural impingement. Cord signal is normal. The etiology of
the patient's failure for extubation was thought to be
possibly centrally mediated. The patient had a tracheostomy
placed on [**2149-12-3**], without complications. A PEG tube was
successfully placed on [**12-4**], using standard techniques.
An esophagogastroduodenoscopy at the time showed normal EGD
to the stomach. The patient was started on tube feeds and
tolerated them well.
The patient's sedation was weaned off and the patient was
alert and responsive to questions and commands. The patient
had a CT scan of the chest on [**2149-12-5**], to assess for
possible primary pulmonary process, and to assess for
previous needs for intubation and prolonged ventilation.
This study revealed no gross evidence of interstitial lung
disease, bibasilar dependent opacities, more prominent on the
right lower lobe than the left; may represent atelectasis. A
small pericardial effusion and cardiomegaly.
On [**12-7**], the patient was changed to a tracheostomy mask with
50% of FIO2. The patient tolerated trache mask and was
briefly put on respiratory support on the evening of [**12-7**]
and was switched back to tracheostomy with face mask of FIO2
of 50. The patient had original respiratory rate of 40 to
50; this slowly came down into the 20s. Repeat arterial
blood gas on trache mask revealed no elevated hypercarbia
above normal. The patient's pH of 7.39, pCO2 of 54, and pO2
of 103. The patient's pCO2 was in line with previous pCO2
while intubated. Increased respiratory rate did not lead to
respiratory alkalosis and there was no failure of total
volume.
The patient was discharged to the Medical Floor on
[**2149-12-9**], in stable condition and awaiting placement.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Ischemic transformed into hemorrhagic stroke.
2. Hypercarbic respiratory failure.
DISCHARGE MEDICATIONS:
1. Zocor 10 mg p.o. q. day.
2. Atenolol 12.5 mg p.o. q. day.
3. Prevacid 15 mg p.o. q. day.
4. ProMod with five hour tube feeds at 65 cc per hour.
5. Oxygen through her tracheostomy mask to keep oxygen
saturation greater than 90%.
CODE STATUS: The patient is Full Code.
DISPOSITION: The patient was discharged to [**Hospital1 **]
Rehabilitation Facility at [**Hospital 4415**].
FOLLOW-UP INSTRUCTIONS:
1. The patient should follow-up with neurologist.
2. Follow-up with primary care physician.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 1324**]
MEDQUIST36
D: [**2149-12-10**] 14:52
T: [**2149-12-10**] 15:03
JOB#: [**Job Number 37494**]
ICD9 Codes: 431, 4280, 5990, 4240, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5598
}
|
Medical Text: Admission Date: [**2123-1-12**] Discharge Date: [**2123-1-19**]
Date of Birth: [**2047-9-27**] Sex: F
Service: MEDICINE
Allergies:
Tape [**12-14**]"X10YD / Morphine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
- Cardiac catheterization [**2123-1-14**]
History of Present Illness:
75 F with CAD s/p to stent to RCA [**2116**], COPD recently started on
home oxygen, HTN, PVD who inititally presented to [**Hospital 1474**]
Hospital after for ongoing SOB since the beginning of [**Month (only) 404**].
Pt states that since early [**Month (only) 404**], she has been experiencing
worsening shortness of breath that has occurred on exercise & at
rest. She has been unable to sleep or tolerate recumbency. She
has had an ongoing cough productive of clear-white sputum
without hemoptysis. She experienced one episode of chest
thightness/sharp chest pain roughly 3 weeks ago. This pain was
non-radiation; it was not associated with diaphoresis, nausea,
vomiting.
.
She was seen by her PCP and started on inhalers for concern
regarding possible URI. On Monday, she was started on
azithromycin yesterday as well as home oxygen with a plan to
increase her prednisone.
.
Early on the morning of admission, she had worsening SOB/DOE so
she called 911 & was brought to [**Hospital 1474**] Hospital. There was
iniital concern for a COPD exacerbation; she was given 250 mg
azithro, 1 gm cftx, albuterol/ipratropium nebs, IV solumedrol
125 mg IV. CXR showed bilateral effusions. CTA was negative for
PE.
.
Pt ruled in for NSTEMI (trop 2.76 -> 4.02). She was given 325
mg ASA, plavix 75 mg, & she was started on heparin gtt. She was
also given 40 mg IV lasix and subsequently transferred to [**Hospital1 18**]
for possible cath.
.
REVIEW OF SYSTEMS: As per HPI. No headache, dizziness, abdominal
pain, nausea, vomiting, diarrhea, constipation, melena,
hematochezia, dysuria, myalgias, or arthralgias. No history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery. No recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
PND, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis
Social History:
- Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits.
Family History:
No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T= 95.6 BP= 135/69 HR= 105 RR= 18 O2 sat= 95% RA
GENERAL: thin elderly female, resting comfortably but fatigued
appearing, NAD
HEENT: NCAT. Sclera anicteric. Pupils equal, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma. Slightly dry mucous membranes/
NECK: Supple with JVD to mandible.
CARDIAC: RRR, normal S1, S2. No m/r/g. Distant heart sounds.
LUNGS: Resp were unlabored, no accessory muscle use. Decreased
breath sounds with bibasilar crackles, no wheezing or rhonchi.
ABDOMEN: Bowel sounds present, soft, non-tender, non-distended,
no organomegaly, no guarding or rebound tenderness.
EXTREMITIES: Warm, DPs 2+ bilaterally, no edema
SKIN: No stasis dermatitis or other rashes.
NEURO: AAOx3, CN 2-12 grossly intact, strength 5/5 throughout,
sensation grossly intact to light touch
PSYCH: Calm, appropriate
DISCHARGE PHYSICAL EXAM:
Tm: 98.5 100(70-100) 97/50(80-120/40-80) 18 98/2L
24 I/O: 1170/1100
GEN: Appears frail.
HEENT: NCAT.
NECK: No JVD
COR: +S1S2, RRR, no m/g/r.
PULM: Crackles at bases, do not clear with cough.
[**Last Name (un) **]: +NABS in 4Q. Soft, NTND.
EXT: WWP, no leg edema. R groin with hematoma stable.
NEURO: MAEE, weak.
Pertinent Results:
ADMISSION LABS & STUDIES:
[**2123-1-13**] 06:55AM BLOOD PT-13.2* PTT-VERIFIED B INR(PT)-1.2*
[**2123-1-13**] 06:55AM BLOOD WBC-9.4 RBC-3.95* Hgb-11.8* Hct-33.9*
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.2 Plt Ct-290
[**2123-1-13**] 06:55AM BLOOD Glucose-100 UreaN-23* Creat-1.3* Na-140
K-3.6 Cl-100 HCO3-26 AnGap-18
[**2123-1-13**] 12:34AM BLOOD CK-MB-9 cTropnT-0.33*
[**2123-1-13**] 06:55AM BLOOD Calcium-8.8 Phos-5.8*# Mg-2.1
CXR ([**2123-1-14**]):
FINDINGS: Comparison is made with the most recent study at this
institution of [**2118-6-16**]. The cardiac silhouette remains somewhat
enlarged and there is increased opacification at the bases
consistent with small pleural effusions and associated
compressive atelectasis. There is engorgement of ill-defined
pulmonary vessels, consistent with elevated pulmonary venous
pressure, as suggested in the clinical history
CT ABDOMEN & PELVIS ([**2123-1-14**]):
IMPRESSION:
1. Left groin hematoma, deep to the left common femoral artery.
There is
mild stranding surrounding the right common femoral artery,
though no evidence of hematoma.
2. Diverticulosis.
3. New bilateral pleural effusions and smooth intralobular
septal thickening, likely indicating volume overload.
4. Extensive atherosclerosis.
5. Calcified granulomata in the liver and spleen.
DISCHARGE LABS & STUDIES:
[**2123-1-19**] 08:55AM BLOOD Glucose-104* UreaN-25* Creat-1.1 Na-139
K-4.2 Cl-100 HCO3-28 AnGap-15
[**2123-1-18**] 07:05AM BLOOD proBNP-9710*
[**2123-1-19**] 08:55AM BLOOD WBC-8.0 RBC-3.28* Hgb-9.9* Hct-29.1*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.4 Plt Ct-291
TTE ([**2123-1-13**]):The left atrium is mildly dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25-30
%) secondary to akinesis of the entire septum and apex, and
moderate global hypokinesis of the remaining segments. The
basal-mid lateral wall contracts best. Right ventricular chamber
size is normal. with focal hypokinesis of the apical free wall.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction
c/w multivessel CAD. Moderate mitral and tricuspid regurgitation
with moderate pulmonary artery systolic hypertension.
Brief Hospital Course:
REASON FOR HOSPITALIZATION:
75 F w CAD s/p RCA stent [**2116**], COPD, RA, seizure disorder, HTN,
PVD, p/w several weeks of worsening SOB. Ruled in for STEMI at
OSH & subsequently transferred to [**Hospital1 18**] for cath.
ACUTE DIAGNOSES:
# NSTEMI: Found to have peak troponin to 2.76 at OSH with T wave
changes in V2-V5.
Transferred on heparin gtt. Pt was continued on metoprolol,
statin, ASA. Loaded with plavix prior to cath on [**2123-1-14**] which
showed minimal in-stent restenosis of RCA stent, as well as a
tight ostial LAD on which PCI could not be performed (too
difficult). Pt had radial access for arterial cath; venous
access in groin difficult to obtain. Patient hypotensive during
case, requiring dopamine gtt temporarily (now off pressors).
Afterward, patient developed rapidly expanding left groin
hematoma. She was given protamine. Hematoma now stable,
hematocrit 29 on discharge (stable for days). Patient also
dyspnea, requiring O2 4L per NC, and appears somewhat volume
overloaded. Patient admitted to CCU for diuresis and observation
overnight. B/L LE US were negative for hematoma, non-contrast CT
abdomen and pelvis were negative for RP bleed. In the CCU,
patient was continued on ASA 325mg PO, Atorvastatin 80mg PO
daily, Metoprolol tartrate 50mg PO BID, plavix. Amlodipine was
discontinued and lisinopril was held due to hypotension/low
urine output. On the floor, patient started on diovan 40 mg,
which should be held if her blood pressure is less than 100.
Discharged on full ASA, plavix, metoprolol succinate 100 mg QD.
# LEFT GROIN HEMATOMA: Developed apparent right groin hematoma
which was treated with protamine. CT [**Last Name (un) 103**] showed pt actually had
left groin hematoma, none on right. No pseudoaneurysm/RP bleed.
Hematoma and hematocrit remained stable throughout CCU & floor
course. DPs dopplerable BL. Patient was maintained on
pneumoboots instead of heparin sq prophylaxis.
# Acute on Chronic Systolic CHF: CXR showed pulmonary
engorgement & bilateral effusions with compressive atelectasis.
Pt was given IV lasix prior to going to the cath lab. A TTE was
performed that showed severe global hypokinesis & akinesis of
entire septum & apex. LVEF 25-30%. Prior ECHO shows EF 40-45%
in [**2116**]. During catheterization, pt was hypotensive & required
dopamine gtt. She was transferred to the CCU for transient
hypotension requiring dopamine in the catheterization lab. Ms.
[**Known lastname 13143**] was normotensive on the floor. Diovan was started on
the floor as above. Lasix will not be reinitiated on discharge.
CHRONIC DIAGNOSES:
# COPD/Emphysema: Pt was continued on her course of
azithromycin. There was no concern for acute exacerbatin given
good air movement & lack of wheeze.
# PVD: continued on aspirin & plavix.
# Seizure disorder: Last seizure was on [**2120**]. He was continued
on home keppra 1500mg [**Hospital1 **], but pharmacy recommended switching
her dose based on her renal function. The recommended dose
(based on creatinine clearance) is 750 mg [**Hospital1 **]. This was
explained to the patient as she was nervous about the change in
dose.
# Rheumatoid arthritis: He was continued on prednisone 5mg PO
daily. Her celebrex was held due to NSTEMI.
# Osteopenia: He was continued on calcium, vitamin D.
TRANSITIONAL ISSUES:
# Follow-Up: Upon leaving rehab, the patient should schedule
follow up appointments with her cardiologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
and her primary care doctor.
# Code Status: DNR/DNI. Daughter is HCP: [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 28220**]
Medications on Admission:
Aspirin 81mg daily
Celebrex 100mg daily
Simvastatin 20mg nightly
Prednisone 5 mg daily
Metoprolol 25mg daily
Omeprazole 20mg daily
Amlodipine 5mg daily
Vitamin D 400 units daily
Calcium carbonate - 6 tabs daily
Keppra 1500mg [**Hospital1 **]
B12 injection once per month
Timolol 0.5% one drop to each eye daily in AM (not recently
taking)
Brimodidine 0.15% one drop left eye [**Hospital1 **] (not recently taking)
Optive dry eye solution, both eyes TID (not recently taking)
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-14**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Please hold for sBP < 100 or HR < 60.
7. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please hold for sBP < 100.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough for 2 weeks.
12. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous
membrane five times a day as needed for sore throat for 1 weeks.
13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. calcium citrate 200 mg (950 mg) Tablet Sig: One (1) Tablet
PO three times a day.
16. Medication
B12 injections one per month
17. timolol maleate (PF) 0.5 % Dropperette Sig: One (1) drop
Ophthalmic QAM.
18. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
19. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
20. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO HS
(at bedtime) as needed for cough for 1 weeks: Do not administer
this medication if patient sedated.
21. oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for congestion for 2 days.
22. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Inhalation Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 27838**] Rehabilitation & [**Hospital **] Care Center - [**Hospital1 1474**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Non-ST Elevation Myocardial Infarction
SECONDARY DIAGNOSES:
- Congestive Heart Failure
- Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 13143**], it was a pleasure to participate in your care
while you were at [**Hospital1 18**]. You came to the hospital for shortness
of breath over hte past month. You were transferred from
[**Hospital 1474**] Hospital after it was found that you had a small heart
attack. While you were here, you had a cardiac catheterization
which showed a blockage. We were unable to treat the blockage
because your blood pressure was low during the procedure and you
need to go to the cardiac intensive care unit. While you were
there, you were treated with some intravenous diuretics. Your
urine output temporarily dropped, but by the time you were
transferred back to the medical floor, your urine production
improved. You had an ultrasound of your heart that showed
slight worsening of your heart failure.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
MEDICATION INSTRUCTIONS:
- Medications STARTED:
---> Please start taking celexa 10 mg daily
---> Please start taking diovan 40 mg daily
---> Please start taking atorvastatin 80 mg daily
---> Please start taking plavix 75 mg daily
---> Please start taking nasal saline spray as needed for dry
nose
---> Please start taking calcium citrate (instead of calcium
carbonate)
---> Please start taking your inhaler as indicated
- Medications STOPPED:
---> Please stop taking lisinopril
---> Please stop taking amlodipine
---> Please stop taking simvastatin
---> Please stop taking calcium carbonate
- Medications CHANGED:
---> Please decrease your dose of Keppra from 1500 mg twice a
day to 750 mg twice a day (this medication is now dosed safely
according to your kidney function)
---> Please increase your dose of aspirin from 81 mg to 325 mg
daily
---> Please increase your dose of metoprolol from 25 mg daily to
100 mg daily
Followup Instructions:
After you leave rehab, please call Dr.[**Name (NI) 5452**] office to schedule
a follow-up appointment.
ICD9 Codes: 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5599
}
|
Medical Text: Admission Date: [**2156-6-24**] Discharge Date: [**2156-7-1**]
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
[**Age over 90 **] y.o. female with multiple medical problems, most pertinent
for a history of diverticulosis and diverticulitis, transferred
from [**Hospital3 7571**]Hospital with for further management of a
GIB. Patient was admitted to [**Hospital3 7571**]Hospital on [**6-22**]
with BRBPR and a Hct of 23, for which she received 4 units of
PRBCs. Her Hct increased to 30 with this intervention and she
remained stable for the remainder of [**6-22**] and [**6-23**]. During this
time, GI and surgery were consulted and plans from both
perspectives were supportive care/conservative management,
particularly as she was not felt to be a surgical candidate and
the patient refused. On [**6-24**], patient's Hct was noted to drop to
23 and she began to have continuous BRBPR. She remained
normotensive and was not tachycardic despite these intermittent
GI bleeds. She received one unit of PRBCS and an RBC scan was
performed, which reportedly showed bleeding at the splenic
flexure. Patient received an additional unit of PRBCs while in
route to [**Hospital1 18**] for further management.
Past Medical History:
CAD s/p PCI
Hypertension
Anemia
History of urinary retention and recurrent UTIs
Hypothyroidism
Depression
GERD
Osteoporosis
Glaucoma
TAH and bladder lift
Ataxia ([**1-31**] peripheral neuropathy)
Nephrolithiasis
History of C. diff colitis
CCY
Atrial fibrillation
Social History:
Denies history of tobacco, alcohol or illicit drug use
Family History:
NC
Physical Exam:
VS: T - 97.6, BP - 133/67, HR - 70, RR - 18, O2 - 96% RA
GEN: Awake, alert, well-related, NAD
HEENT: NC/AT; PERRLA, EOMI, conjuctival pallor; OP clear, dry
mucous membranes
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, inspiratory crackles at left base
ABD: soft, NT, ND, + BS, no HSM
Rectal: Maroon-colored, guaiac positive stool
EXT: warm, dry, +2 distal pulses BL
Pertinent Results:
EKG: Sinus at rate of 60 with prolonged PR, borderline QRS, nl
QT, LAD, poor R wave progression, TWF in V1, V2, V3, no STE, no
STD; Unchanged from prior
.
Brief Hospital Course:
[**Age over 90 **] y.o. female with multiple medical problems, transferred from
OSH with persistent GIB.
.
# GIB: Pt was initially admitted to the ICU for serial hct
monitoring and pending colonoscopy by GI. Colonoscopy was
performed which revealed 2 polyps and diverticulosis with old
blood, but no active bleeding was visualized. Patient remained
hemodynamically stable (with respect to heart rate and blood
pressure) despite several episodes of rebleed. Tagged RBC scan
was performed twice in the setting of active rebleed, however
they failed to reveal a clear source of bleed. Her hct was
monitored serially and she was transfused supportively with a
total of 5 units of pRBCs. Her last episode of BRBPR was on
[**2156-6-28**]. She will need daily CBC and if hematocrit drops below
25 or she has BRBPR she should be evaluated immediately and
transfused. She would need interventional radiology assessment
for possible embolization procedure.
.
# Leukocytosis: She presented with a leukocytosis of 17K with
only mild neutrophil predominance of 80%. It was thought to be
most likely from GI bleed/stress response as she had no history
of fever and no localizing signs/symptoms of infection. UA was
negative, CXR did not reveal any infiltrate. Urine culture was
negative.
.
# CAD: She had no chest pain and EKG was without ischemic
changes even in setting of her anemia and acute blood loss.
Cardiac enzymes were cycled on presentation, which were
negative. TTE on [**6-25**] showed preserved EF, mild LVH, and mild
pulm htn (27mmHg). Her aspirin was held in the setting of GI
bleed, this was restarted at 81mg daily upon discharge. She was
not on beta blocker, statin, nor ACEI on presentation. Fasting
lipids were checked, which were within normal limits.
.
# Urinary Retention: Patient was transferred without foley and
Urology was consulted for foley placement due to difficulty
identifying the urethral meatus.
.
# Hypothyroidism: She was continued on her outpatient synthroid
dose of 100mcg daily.
.
# Atrial fibrillation: She remained in NSR on amiodarone. Her
CHADS2 score was 2, with <3% yearly risk of stroke due to emboli
from A fib. She was not anticoagulated in the setting of
bleeding diathesis during her hospital stay, however,
anticoagulation should be considered as an outpatient, she was
discharged on 81mg of aspirin daily.
.
# Depression: She was continued on outpatient antidepressants.
.
# GERD: Continued on PPI.
.
# Glaucoma: Continued outpatient timolol and brimonidine eye
drops.
.
# Osteoporosis: Continue calcium carbonate and she received her
weekly vitamin D on [**2156-6-26**].
.
# CODE: DNR/DNI confirmed with patient on arrival.
Medications on Admission:
Timolol gtt QD
Levothyroxine 100 mcg PO QD
Amiodarone 100 mg PO QD
Aspirin 81 mg PO QD
Celexa 20 mg PO QD
MVI PO QD
Omeprazole 20 mg PO QD
Preservision 2 capsules PO QD
Vitamin D 50,000 TU PO Qmonth (on the 28th)
Vitamin B12 injection Qmonth (on the 16th)
Brimonidine 0.2% gtt [**Hospital1 **]
Calcium Carbonate 500 mg PO BID
Senna 2 tabs PO BID
Natural Balance Tear Drops 1 drop R eye QID
Sodium Chloride 5% solution 1 drop L eye QID
Desipramine 10 mg PO QHS
[**Doctor First Name **] 180 mg PO QHS
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Desipramine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-31**]
Drops Ophthalmic PRN (as needed).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
12. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
13. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO
Monthly on the 28th.
14. Natural Balance 0.4 % Drops Sig: One (1) Ophthalmic four
times a day: to Right eye.
15. Sodium Chloride 5 % 5 % Parenteral Solution Sig: One (1)
Intravenous four times a day: to Left eye.
16. [**Doctor First Name **] 180 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Xalatan 0.005 % Drops Sig: One (1) Ophthalmic at bedtime:
to BOTH eyes.
18. Milk of Magnesia 400 mg/5 mL Suspension Sig: 30 cc PO once
a day as needed for constipation.
19. Maalox 200-200-20 mg/5 mL Suspension Sig: 30 cc PO every
four (4) hours as needed for indigestion.
20. Acetaminophen 650 mg Suppository Sig: One (1) Rectal every
4-6 hours as needed for fever/ pain with nausea.
21. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**4-4**]
hours as needed for fever or pain.
22. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: 1 cc
Intramuscular monthly on 16th.
23. PreserVision 226-200-5 mg-unit-mg Capsule Sig: Two (2)
Capsule PO once a day.
24. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
25. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
26. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 25576**]
Discharge Diagnosis:
Primary:
GI bleeding
Secondary:
CAD s/p PCI
Hypertension
Anemia
History of urinary retention and recurrent UTIs
Hypothyroidism
Depression
GERD
Osteoporosis
Glaucoma
TAH and bladder lift
Ataxia ([**1-31**] peripheral neuropathy)
Nephrolithiasis
History of C. diff colitis
CCY
Atrial fibrillation
Discharge Condition:
fair, with stable Hct (~29-30), and stable vital signs.
Discharge Instructions:
You were transferred to [**Hospital1 69**] for
further management of your gastrointestinal bleeding. Studies we
performed failed to identify the source of bleeding. Because you
deemed not to be a candidate for surgery, and because you did
not want a surgery, you were treated supportively with fluids
and blood transfusions. Your blood pressure and heart rate
remained stable even with episodes of bleeding, and your last
episode of bleeding was on [**2156-6-28**].
.
If you experience bleeding again, have chest pain, shortness of
breath, fatigue, or ANY other worrisome symptoms, please contact
your primary care physician or go to the emergency room.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1159**], at
[**Telephone/Fax (1) 20587**] to make a follow-up appointment for sometime in the
next 1-2 weeks.
ICD9 Codes: 5789, 2761, 2851, 4019, 2449
|
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