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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5700
}
|
Medical Text: Admission Date: [**2181-6-8**] Discharge Date: [**2181-6-11**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 y/o M with h/o CABG, acute on chronic HF with EF 15-20%, AFib
on Coumadin, advanced dementia, DM on insulin, CKD stage III,
h/o colon ca s/p colectomy, recent R hip fx s/p repair who
presents from [**Hospital3 **] for 12 hour history of shortness
of breath with chest pain, found to have troponin elevation and
mild CHF exacerbation.
.
Pt has been in nursing home since [**6-1**] discharge and was sent
from nursing home today after 12 hour history of shortness of
breath with chest pain, found to have trop (I?) 4.9, s/p lovenox
40mg SC (in addition to morning 40mg), aspirin 325mg, lasix 80mg
IV, nitropaste (with relief of chest pain). At request of pt's
family he was transferred here for further evaluation.
.
Of note, pt was admitted [**5-25**] for R Hip fracture s/p Right
Dynamic Hip Screw on [**2181-5-29**]. Course was c/b post-op delirium,
UTI with pansensitive e.coli tx with cefpodoxime (last day [**6-7**]),
acute on chronic systolic heart failure. Pt was started on
lovenox post op and restarted on coumadin (INR 1.6), which had
been held in the perioperative period. On [**6-7**], he had, per
family, markedly improved mental status. He presented for f/u at
Dr.[**Name (NI) 7379**] clinic where hip xr was read as "Healing
intertrochanteric fracture. No evidence of hardware
complication."
.
In the ED, initial VS: 97.9 80 130/64 24 4L Nasal Cannula. EKG
showed a. fib, LBBB, TWI V3, concordant ST depression V4 (c/w
prior). Trop was elevated to 0.74, bnp [**Numeric Identifier 31597**], pCXR - c/w mild
CHF. Bedside ultrasound (by ED) demonstrated global hypokinesis,
no signs of right ventricular strain suggestive of PE.
Cardiology was consulted and felt pt did not need heparin, that
presentation was likely related to CHF exacerbation and cardiac
strain. Pt was admitted for diuresis with VS:77, 128/65, 17,
100on2L.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- CAD s/p CABG (remote)
- Chronic systolic heart failure with EF 25% in [**4-/2181**] echo
- AFib on Coumadin
- CKD stage III
- Per family h/o "small strokes" but no gross stroke per history
- HTN
- DM, on insulin
- Hip fracture
- Colon ca s/p colectomy, no chemo, last [**Last Name (un) **] 3 yrs ago per
family
- Dementia manifested by going back to previous years, thinking
his family is his mother or sister, not knowing where he is,
worsening for the past 5 yrs. Will recognize family and names
for the most part, but sometimes not
- Anemia chronic disease
- Ventral hernia
- Leg and back arthritis
Social History:
Demented. Not currently smoking or drinking EtOH. Used to live
with family but D/c'd to NH after recent admission. Very recent
difficulty with ambulating and uses a walker. Has 3 [**Last Name (un) 39184**].
[**Doctor First Name **] who is co-HCP, [**Name (NI) **] who is co-HCP [**Telephone/Fax (1) 39185**], [**Doctor First Name **]
[**Telephone/Fax (1) 39186**], c [**Telephone/Fax (1) 39187**], and son [**Name (NI) 39188**]; wife is still
alive and clear mental status.
Family History:
Non-Contributory
Physical Exam:
Admission Exam:
Initial VS: 97.9 80 130/64 24 4L Nasal [**Hospital 39189**]
Transfer to CCU: VS:77, 128/65, 17, 100on2L.
GENERAL: thin, inattentive, disoriented man in NAD. occ.
coughing.
HEENT: NCAT. slight temporal wasting. Sclera anicteric. PERRL,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
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. Rhonchorous upper
airway sounds that interfere with exam. Patient does not
cooperate. no crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Right hip incision is
c/d/i with healthy appearing staple line.
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 Exam:
Pertinent Results:
Admission Labs:
[**2181-6-8**] 06:40PM WBC-7.1 RBC-3.69* HGB-10.9* HCT-33.3* MCV-90
MCH-29.6 MCHC-32.8 RDW-19.2*
[**2181-6-8**] 06:40PM NEUTS-77.7* LYMPHS-15.7* MONOS-4.3 EOS-2.0
BASOS-0.3
[**2181-6-8**] 06:40PM PLT COUNT-298#
[**2181-6-8**] 06:40PM PT-17.5* PTT-31.6 INR(PT)-1.6*
[**2181-6-8**] 06:40PM CALCIUM-9.3 PHOSPHATE-4.2# MAGNESIUM-2.2
[**2181-6-8**] 06:40PM CK-MB-7 proBNP-[**Numeric Identifier 31597**]*
[**2181-6-8**] 06:40PM cTropnT-0.73*
.
Hip Films: ([**2181-6-7**])
FINDINGS: Three views of the right hip demonstrate a dynamic
compression
screw fixating a nondisplaced intertrochanteric fracture with
interlocking
screws. No evidence of hardware loosening or fracture. The
fracture line
remains barely visible along its inferior extent, less
conspicuous as compared to [**2181-5-25**]. Severe bone-on-bone hip
osteoarthritis is redemonstrated with joint space obliteration,
osteophytosis, and subchondral cystic formation. Extensive
vascular calcifications are also seen. Overlying skin staples
remain in place.
IMPRESSION: Healing intertrochanteric fracture. No evidence of
hardware
complication.
.
CXR: ([**2181-6-8**])
PORTABLE AP VIEW OF THE CHEST: Patient is status post median
sternotomy and CABG. Mild cardiomegaly is unchanged. There is
mild pulmonary edema, which appears similar when compared to the
prior study. The thoracic aorta is diffusely calcified and
mildly unfolded. Tiny right pleural effusion is
present. No pneumothorax is identified. No acute osseous
findings are seen. Ovoid opacity projecting over the left sixth
posterior rib is unchanged.
IMPRESSION: Mild congestive heart failure and tiny right pleural
effusion.
LENI [**2181-6-9**]: IMPRESSION: No bilateral lower extremity DVTs
TTECHO [**2181-6-9**]: The left atrium is mildly dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %) with severe global hypokinesis and regioanl
inferior/infero-lateral akinesis. There is no ventricular septal
defect. The right ventricular cavity is dilated with severe
global free wall hypokinesis. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
CARDIAC ENZYMES
[**2181-6-8**] 06:40PM CK-MB-7 pr
TROPONINS
[**2181-6-10**] 07:20 4 0.94*1 ADDED TNT,CPIS
[**2181-6-9**] 03:06 6 0.78*1
[**2181-6-8**] 18:40 0.73*
oBNP-[**Numeric Identifier 31597**]*
[**2181-6-8**] 06:40PM CK(CPK)-85
ABG
[**2181-6-8**] 09:23PM TYPE-[**Last Name (un) **] PO2-109* PCO2-39 PH-7.49* TOTAL
CO2-31* BASE XS-5
DISCHARGE LABS
[**2181-6-10**] 07:20AM BLOOD WBC-9.7 RBC-3.63* Hgb-11.2* Hct-33.0*
MCV-91 MCH-30.8 MCHC-33.8 RDW-18.9* Plt Ct-339
[**2181-6-10**] 07:20AM BLOOD PT-18.8* PTT-28.6 INR(PT)-1.7*
[**2181-6-10**] 07:20AM BLOOD Glucose-186* UreaN-28* Creat-1.4* Na-137
K-4.4 Cl-99 HCO3-27 AnGap-15
Brief Hospital Course:
88M h/o CABG, acute on chronic CHF EF 15-20%, AFib on Coumadin,
advanced dementia, DM on insulin, CKD III, h/o colon ca s/p
colectomy, recent R hip fx s/p repair that presented from OSH
with CP and SOB, here with mild CHF exacerbation.
ACTIVE ISSUES:
# Acute on Chronic Systolic CHF: No clear preciptant. EF 20% on
Lasix 20mg PO Daily presented with SOB with CP. At OSH was
mildly volume overloadedand given Lasix 80mg IV, and nitro paste
with resolution of symptoms. On [**Hospital1 18**], BNP [**Numeric Identifier 31597**], ECG unchanged
from prior, troponins slightly elevated. Given hx of recent hip
surgery PE was in the differential. Serial echos (bedside in ED,
formal on the floor) was without evidence or right sided strain.
ECG with unchanged axis. No evidence of DVT on LENIs. CTA was
avoided given CRI. The pt's Lovenox was increased from 40mcg
daily (PPx dosing) to 30mcg [**Hospital1 **] (Therapeutic dosing) and
Warfarin was increased given pts INR was 1.5 on admission and
lovenox was subsequently discontinued as INR rose. Placed back
on Metoprolol Succinate 25mg on discharge. Increased dose of
lasix to 40 mg PO with explicit instructions to rehab as
follows:
1. Monitor weights daily
2. If weight increases by one pound, increase PO lasix to 60 mg.
If weight still increases, raise dose of lasix by another 20 mg.
3. Check creatinine on the day following any increase of lasix
and monitor for increases.
4. Conisder IV lasix PRN for weight changes of 2 pounds or more
per day and be sure to increase PO dose
# Troponin Elevation: Patient with tenuous cardiac
vasculopathy, ischemic cardiomyopathy and significant CKD (GFR
30). Troponin is 0.3 at baseline, presented with trop T of 0.8
and trop I of 4.9. This is of unclear significance. He was
medically managed with aspirin and metoprolol. Since the
patient was already coumadin and aspirin, plavix was deferred at
this point. Statin was deferred for now. TTE with EF 20%.
SUMMARY
1. Patient has baseline elevated troponin
2. Patient has baseline elevated BNP (10K on this admission)
Follow up
1. Please follow patient's INR and adjust dose of coumadin
accordingly.
#. R Hip Fx s/p ORIF [**5-29**]: Wound appeared clean withtout signs
of erythema or drainage. Patient was on prophylactic dose of
lovenox prior to admission (40 mg) and while he was here, his
INR rose to 1.7. His lovenox was discontinued and his coumadin
continued.
FOLLOW UP
1. Follow INR and adjust coumadin accordingly
# AF: Was rate controlled while in house. Anticoagulation
(Lovenox and Coumadin detailed as above).
CHRONIC ISSUES:
# Dementia - No clinical signs of delerium according to family.
Infectious workup was unrevealing.
# CKD: Last admission cr ranged from 1.3- 1.6 (1.3 on
discharge). Creatinine 1.3 on admission. NOTE THAT HIS GFR IS
ACTUALLY 30. HIS CREATININE DOES NOT COMMUNICATE THE SEVERITY OF
HIS RENAL DISEASE.
#. Recent UTI: Recently completed 2wk course of cefpodoxime 400
mg po BID until [**2181-6-7**]. recently treated for UTI with
pansensitive e. coli UTI.
# Aspiration: Noted to have profuse audible upper airway
secretions and persistent cough without infiltrate on cxr. Prior
speech/swallow recommended dysphagia diet. Current
recommendations are:
DIET RECS: Soft solids, thin liquids, pills whole in puree and
1:1 supervision for meals.
TRANSITIONAL ISSUES:
CODE: DNR, ok to intubate (last admission DNR/DNI)
SUMMARY OF FOLLOW UPS
DIURESIS / CHF Management
1. Monitor weights daily
2. If weight increases by one pound, increase PO lasix to 60 mg.
If weight still increases, raise dose of lasix by another 20 mg.
3. Check creatinine on the day following any increase of lasix
and monitor for increases.
4. Conisder IV lasix PRN for weight changes of 2 pounds or more
per day and be sure to increase PO dose
5. Patient has baseline elevated troponin
6. Patient has baseline elevated BNP (10K on this admission)
Follow up
7. Please follow patient's INR and adjust dose of coumadin
accordingly.
8. DIET RECS: Soft solids, thin liquids, pills whole in puree
and 1:1 supervision for meals.
9. NOTE THAT HIS GFR IS ACTUALLY 30. HIS CREATININE DOES NOT
COMMUNICATE THE SEVERITY OF HIS RENAL DISEASE.
Medications on Admission:
1. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
2. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1)
PO once a day.
3. docusate sodium 100 mg Capsule [**Hospital1 **]
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for agitation .
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 7 days: CONTINUE UNTIL [**2181-6-8**] then give as
needed for pain .
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
12. insulin regular human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): PLEASE see sliding
scale .
14. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous once a day for 5 days: UNTIL INR> 1.5 for 2 days in
a row .
15. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust dose for INR between [**2-1**].
16. Outpatient Lab Work
Please check INR every day until INR >2.0 for two days and on
stable warfarin dose, then check once a week.
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob/
wheezing.
4. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1)
dose PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Hold for loose stools.
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Outpatient Lab Work
Please have INR checked on:
Thursday [**6-14**]
Monday [**6-18**]
.
Please fax results to Dr. [**First Name (STitle) 39190**] [**Telephone/Fax (1) 39191**]
16. insulin glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous at bedtime.
17. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous qACHS: Please see sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] [**Location (un) 701**]
Discharge Diagnosis:
mild sCHF exacerbation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure participating in your care. You were
admitted for chest pain and shortness of breath and found to
have a mild CHF exacerbation. You were given IV medications to
aid in diuresis and then your oral Lasix was increased to help
maintain good volume status. Your coumadin was also increased as
you continue to be subtherapeutic with your INR. You did not
have evidence of infection or heart attack. You also did not
have evidence of blood clots in your legs.
Please call or return to the hospital if you develop
increasing shortness of breath, chest pain, or any other
symptoms that concern you.
Please START the following medications:
- Aspirin 325mg daily
Please STOP the following medications:
- Lovenox (enoxaparin)
The following medications are CHANGED:
- warfarin has been increased to 4mg daily
- Lasix has been increased to 40mg daily
Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2181-6-28**] at 1:20 PM
With: [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 27264**], PA [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5701
}
|
Medical Text: Admission Date: [**2137-12-2**] Discharge Date: [**2137-12-6**]
Date of Birth: [**2089-4-25**] Sex: M
Service: MEDICINE
Allergies:
Ziagen / Crixivan / Pravastatin
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
Myalgias
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
48yoM with HIV on HAART, HTN, HL, polysubstance abuse,
depression p/w 8-10 days of worsening watery diarrhea, nausea,
anorexia, diffuse myalgia, and chills. The patient states that
he began feeling ill about 10 days ago and that his symptoms
progressive worsened and have not improved. He states that he
has diarrhea at baseline from HIV meds, but that the diarrhea
has been especially severe - profuse, watery, some blood in
stool (not unusual as pt is s/p chemo/radiation for anal
cancer). He has had severe nausea, dry heaves without vomiting
because he hasn't eaten much in the past 10 days. He has tried
to drink fluids. He also endorses diffuse myalgia from his legs
to his jaw. No fevers, + chills - temp at home has been 95-96.0.
No sick contacts. [**Name (NI) **] has continued to take his HIV meds normally
and has continued to take his BP meds except for HCTZ, which he
discontinued the past 2 days. No rashes, no CP or SOB. No
dysuria. He describes vision changes this AM and feels
lightheaded upon standing. He did have the flu shot this year.
Pt was seen at HCP office at [**Name (NI) 778**] Clinic and BP in 70s/40s
with associated lightheadedness upon standing and with visual
changes this morning. Guarding on abd exam but no focal
tenderness. Hypothermic to 95-96.7 in office. He has been taking
2 of 3 BP meds despite illness (has continued atenolol 25 mg
qday and moexipril 15 mg qday). Does report blood in stool but
has history of this from anal ca s/p radiation/chemo.
In the ED, triage vital signs were: 97.1 73 79/45 18 98% RA. Pt
found to have a CK of [**Numeric Identifier 6702**], Cr of 27, anion gap of 30 and phos
of 18.9. Triggered in ED for hypotension, but was mentating,
awake. Received 4L NS bolus and now 1L D5W with 3 amps bicarb.
Now SBPs in 100's. No tachycardia. UA and CXR unremarkable.
Given vanc and zosyn and nephrology was consulted in ED. VBG
initially with pH 7.07. 2 18g PIVs were placed.
Past Medical History:
HIV diagnosed in [**2118-7-14**], with a recent CD4 count 355
([**8-/2137**])
Stage I Squamous Carcinoma of the Rectum s/p 5FU and cisplatin
and XRT
Anal condylomata treated multiple times with cryotherapy
syphilis in [**2129**]
hypertension
depression with suicidal
ideation in [**2133-5-14**]
ETOH abuse
polysubstance abuse
Social History:
He lives in [**Location 2251**]. He currently lives alone.
He did not have a partner at this time. He works as a book
keeper for a scrapyard on Monday, Wednesday, and Friday. He has
smoked a pack and a half of cigarettes since he was 15 years old
and drinks alcohol moderately.
Family History:
H/O ? heart disease in father when his father was in his late
30s; htn runs in the family
Physical Exam:
VS: Temp: 96 BP:102/68 HR:87 RR:16 O2sat 99RA
GEN: pleasant, NAD, shivering
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules, occasional facial
muscle spasm
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: somewhat distended, tympanic, +b/s, nt, no masses or
hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps. No Chvosteks or
Trousseaus sign.
Pertinent Results:
ADMISSION LABS:
[**2137-12-2**] 04:45PM BLOOD WBC-5.6 RBC-3.11*# Hgb-11.0*# Hct-33.2*#
MCV-107* MCH-35.6* MCHC-33.3 RDW-13.7 Plt Ct-261
[**2137-12-2**] 04:45PM BLOOD Neuts-76.1* Lymphs-15.4* Monos-4.3
Eos-3.7 Baso-0.5
[**2137-12-2**] 04:45PM BLOOD PT-13.6* PTT-29.4 INR(PT)-1.2*
[**2137-12-2**] 04:45PM BLOOD Glucose-146* UreaN-208* Creat-27.7*#
Na-133 K-5.4* Cl-95* HCO3-8* AnGap-35*
[**2137-12-2**] 04:45PM BLOOD ALT-120* AST-206* CK(CPK)-[**Numeric Identifier 6702**]*
TotBili-0.8
[**2137-12-2**] 04:45PM BLOOD CK-MB-277* MB Indx-1.4 cTropnT-0.04*
[**2137-12-2**] 04:45PM BLOOD Calcium-6.5* Phos-18.9*# Mg-1.9
[**2137-12-2**] 05:17PM BLOOD Lactate-0.6 K-5.3
[**2137-12-2**] 05:17PM BLOOD freeCa-0.78*
URINE:
[**2137-12-2**] 07:44PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2137-12-2**] 07:44PM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2137-12-2**] 07:44PM URINE RBC-[**2-15**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2137-12-2**] 07:44PM URINE Hours-RANDOM UreaN-414 Creat-132 Na-43
K-36 Cl-44
[**2137-12-2**] 07:44PM URINE Myoglob-PRESUMPTIV
[**2137-12-2**] 07:44PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
OTHER PERTINENT LABS:
[**2137-12-3**] 12:53PM BLOOD Ret Aut-1.0*
[**2137-12-2**] 04:45PM BLOOD CK(CPK)-[**Numeric Identifier 6702**]*
[**2137-12-2**] 08:50PM BLOOD CK(CPK)-[**Numeric Identifier 6703**]*
[**2137-12-3**] 12:40AM BLOOD CK(CPK)-[**Numeric Identifier 6704**]*
[**2137-12-3**] 05:10AM BLOOD CK(CPK)-[**Numeric Identifier 6705**]*
[**2137-12-3**] 09:02PM BLOOD CK(CPK)-[**Numeric Identifier 6706**]*
[**2137-12-4**] 05:35PM BLOOD CK(CPK)-6975*
[**2137-12-5**] 01:59AM BLOOD CK(CPK)-5275*
[**2137-12-5**] 05:38AM BLOOD CK(CPK)-5077*
[**2137-12-5**] 11:21PM BLOOD CK(CPK)-4104*
[**2137-12-6**] 05:48AM BLOOD CK(CPK)-3328*
[**2137-12-2**] 04:45PM BLOOD CK-MB-277* MB Indx-1.4 cTropnT-0.04*
[**2137-12-2**] 08:50PM BLOOD cTropnT-0.03*
[**2137-12-3**] 12:40AM BLOOD CK-MB-220* MB Indx-1.3 cTropnT-0.03*
[**2137-12-3**] 05:10AM BLOOD CK-MB-178* MB Indx-1.2 cTropnT-0.03*
[**2137-12-5**] 05:38AM Iron-117 calTIBC-302 VitB12-347 Folate-4.8
Ferritn-828* TRF-232
[**2137-12-4**] 08:17AM BLOOD TSH-1.7
[**2137-12-5**] 05:38AM BLOOD IgA-95
[**2137-12-5**] 05:38AM BLOOD tTG-IgA-PND
MICRO:
[**2137-12-2**] BCx: NGTD
[**2137-12-3**] MRSA screen: negative
[**2137-12-3**] Stool studies:
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final [**2137-12-5**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2137-12-4**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
CHARCOT-[**Location (un) **] CRYSTALS PRESENT.
Cryptosporidium/Giardia (DFA) (Final [**2137-12-5**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-12-4**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2137-12-5**] 03:26PM STOOL FECAL FAT, QUALITATIVE, RANDOM-PND
STUDIES:
[**2137-12-2**] CXR:
No acute intrathoracic process.
[**2137-12-2**] CT head:
No acute intracranial hemorrhage or fractures identified.
[**2137-12-5**] Renal U/S:
Normal study
DISCHARGE LABS:
[**2137-12-6**] 05:48AM BLOOD WBC-5.6 RBC-2.35* Hgb-8.3* Hct-24.3*
MCV-104* MCH-35.3* MCHC-34.1 RDW-14.0 Plt Ct-301
[**2137-12-6**] 05:48AM BLOOD Glucose-98 UreaN-129* Creat-14.7* Na-143
K-3.4 Cl-109* HCO3-17* AnGap-20
[**2137-12-6**] 05:48AM BLOOD CK(CPK)-3328*
[**2137-12-6**] 05:48AM BLOOD Calcium-6.7* Phos-8.7* Mg-1.6
[**2137-12-6**] 06:10AM BLOOD freeCa-0.85*
Brief Hospital Course:
Mr. [**Known lastname 6707**] is a 48 year old man with h/o HIV, on HAART, rectal
SCC, HLD on statin, who was admitted with acute renal failure
and rhabdomyolysis.
# Acute renal failure: Differential includes prerenal renal
failure d/t N/V, decreased PO intake, ATN secondary to low BP's
at home (pt was taking antihypertensive meds at home) and
heme-pigment induced ATN in the setting of rhabdomyolysis due to
tenofovir or statin. Nephrology saw muddy brown casts on urine
sediment, so most likely ATN pigment nephropathy provoked by
HAART meds. Pt was profoundly acidemic (pH 7.07) and
hyperphosphatemic on admission, but potassium was only mildly
elevated. Nephrology was consulted in the ED. Cr on admission
was 27.7, which has trended down to 14.7 on discharge. The
patient did not need HD initiation. He was started on aluminum
hydroxide. Currently auto-diuresing well.
# Rhabdomyolysis: CK elevated to 20,000 on admission, but pt
denies recent red/brown urine. Potential etiologies of rhabdo in
this pt include statin-induced, tenofovir related, viral,
hypothyroid. CK has trended down to 3300 on discharge. Statin
and fibrate have been discontinued. HAART medications were held
- can be restarted as an outpatient.
# Diarrhea: Patient has had chronic diarrhea, which has recently
worsened. Stool studies are negative to date - Cdiff negative,
no O&P, no crypto/giardia/campylobacter. Fecal fat and stool
culture still pending on discharge.
# Anemia: Pt with macrocytic anemia, HCT in mid 20s. No evidence
of bleeding during hospitalization. Given low retic count, may
have degree of marrow suppression from prior chemo, xrt, and
ARVs.
# Hypocalcemia: Occasional muscle spasm of facial muscles
concerning for tetany early in hospitalization, which resolved.
To prevent complications of hypercalcemia in recovery phase,
avoided calcium repletion in the absense of hypocalcemic
symptoms or severe hyperkalemia. Goal ionized Ca 0.8-0.9.
# Hypotension: In clinic pt was in the 70's systolic but able to
relate a history. In [**Name (NI) **] pt was in the 80's for SBP, which
improved with 4L IVF. SBP 100-110s while hospitalized. Atenolol
and HCTZ were held.
# HIV: Well controlled on current regimen. Held HAART regimen
given ARF.
# Rectal SCC: S/p chemotherapy (5FU, cisplatin) and XRT.
Followed in oncology by Dr. [**Last Name (STitle) **]. Currently stable.
# Insomnia: Continued on home seroquel and klonopin.
Medications on Admission:
TRUVADA 200-300 MG TABS 1 TAB daily
REYATAZ 150 MG 2 CAPS daily
NORVIR 100 MG CAPS 1 CAP daily
ATENOLOL 25 MG daily
VENTOLIN HFA 2puff q4-6 HOURS
ACYCLOVIR 800 MG q8 prn herpes
REMERON 30 MG qhs
PRAVASTATIN 40 MG daily
SEROQUEL 100 MG 1-2 tabs PO QHS
FENOFIBRATE 160 daily
KLONOPIN 1 MG QHS
HCTZ 12.5MG daily
UNIVASC 15 MG TABS (MOEXIPRIL HCL) 1 TAB BY MOUTH EACH DAY
IMODIUM A-D 2 MG TABS (LOPERAMIDE HCL) TAKE 1 TAB BY MOUTH EVERY
8 HRS PRN DIARRHEA
Discharge Medications:
1. Outpatient Lab Work
Please draw CBC/diff, CHEM10, ionized calcium, CK once a week
starting [**2137-12-9**] at [**Hospital1 778**] Health.
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. aluminum hydroxide gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Rhabdomyolysis
Acute renal failure
Secondary Diagnosis:
HIV
Chronic diarrhea
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
fatigue, malaise, and diarrhea. You were found to have
rhabdomyolysis and acute renal failure. You were treated with
fluids and electrolyte replacements. Your kidney function is
improving.
The following changes were made to your medications:
#. HOLD Truvada, Reyataz, Norvir
#. HOLD Atenolol, Hydrochlorothiazide
#. DISCONTINUE Pravastatin, Fenofibrate
#. START Aluminum hydroxide 3 times a day with meals
Followup Instructions:
Please call [**Hospital1 778**] Health at [**Telephone/Fax (1) 798**] early Monday morning
for an appointment. They will make sure that somebody can see on
Monday. You also need to have your blood drawn next Monday
[**2137-12-9**] at [**Hospital1 778**].
The following appointments have been made for you:
Department: NEPHROLOGY
When: TUESDAY [**2137-12-24**] at 3:00 PM
With: [**Known firstname 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
ICD9 Codes: 5845, 4019, 3051, 2859, 4589, 2724, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5702
}
|
Medical Text: Admission Date: [**2182-10-25**] Discharge Date: [**2182-10-27**]
Service: MEDICINE
Allergies:
Mevacor / Iodine; Iodine Containing / Nizoral A-D
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Reason for admit: left ICA stent
.
Major Surgical or Invasive Procedure:
left internal carotid artery stenting
History of Present Illness:
HPI: 85 year-old male with PMH of CVA, AS s/p bovine AVR, CAD
s/p SVG to PDAin [**4-/2176**], trans-venous pacemaker for third degree
HB who presents for placement of left internal carotid artery
stent. Patient has had two recent possible TIAs, manifested as
aphasia, that resulted in a carotid ultrasound. The ultrasound
on [**2182-10-23**] revealed progression of the left ICA stenosis from
40-59% stenosis to now greater than 90% stenosis. The known
occluded right ICA was again documented. He was thus referred
for left ICA stenting. On the night of admission he was
premedicated with Prednisone, Zantac, and Benadryl given a
history of dye allergy.
Past Medical History:
PMH:
CVA [**93**] years ago
? TIA
Known right ICA occlusion
Depression
Anxiety, panic attacks
AS, s/p AVR and CABG x1 [**2176**]
s/p PM implant [**2176**]
Glaucoma
Previous falls
Progressive supranuclear palsy (PSP)
HTN
Hyperlipidemia
.
Social History:
Social History:
Married
Retired family care physician
[**Name9 (PRE) **] tobacco
.
.
Family History:
noncontributory
Physical Exam:
EXAM:
Temp 97.4
BP 124/60
Pulse 66
Resp 18
O2 sat 95% RA
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD, no cervical lymphadenopathy, no carotid bruits
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, 2/6 SEM at LUSB radiating to the L
carotid
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds Extr - No clubbing, cyanosis, or edema. 2+ DP pulses
bilaterally
Neuro - pt slightly confused, conversant with no dysphasia,
though circumferential in conversation; during hx he often
repeated elements of the hx; pt with left facial droop
Skin - No rash
Pertinent Results:
[**2182-10-25**] 07:26PM GLUCOSE-138* UREA N-29* CREAT-1.6* SODIUM-141
POTASSIUM-5.5* CHLORIDE-103 TOTAL CO2-25 ANION GAP-19
[**2182-10-25**] 07:26PM CALCIUM-9.8 PHOSPHATE-2.5* MAGNESIUM-2.3
[**2182-10-25**] 07:26PM WBC-9.2 RBC-4.53*# HGB-14.2# HCT-42.9 MCV-95
MCH-31.2 MCHC-33.0 RDW-13.2
[**2182-10-25**] 07:26PM PLT COUNT-250
MODERATELY HEMOLYZED
141 103 29 138 AGap=19
5.5 25 1.6
Ca: 9.8 Mg: 2.3 P: 2.5
14.2
9.2 250
42.9
.
DATA:
Carotid US ([**2182-10-22**]):
1. Progression of left ICA stenosis from 40-59% stenosis, now
greater than 90% stenosis.
2. Occluded right ICA again documented.
3. Antegrade flow in both vertebral arteries.
.
NCHCT ([**2181-3-16**]):
Chronic right superior division middle cerebral artery infarct.
[**2182-10-22**] CArotid series
IMPRESSION: Compared to the study of [**2179**]:
1. Progression of left ICA stenosis from 40-59% stenosis, now
greater than
90% stenosis. The referring physician was notified of this
result.
2. Occluded right ICA again documented.
3. Antegrade flow in both vertebral arteries.
[**2182-10-25**]
CTA head/neck
No acute intracranial hemorrhage. Stable encephalomalacia in
right MCA distribution from [**2181-3-16**]. NO CT evidence of acute
minor or major vascular territorial infarct.
Occlusion of right internal carotid artery from level of
bifurcation to cavernous portion, where there is reconstitution
of contrast opacification.
Brief Hospital Course:
A/P: 85 yo male with h/o CVA, AS s/p bovine AVR, CAD s/p SVG to
PDA, pacemaker placement and known complete right carotid artery
stenosis here for elective L carotid stenting following recent
carotid dopplers.
1) Left carotid stenosis-- On [**10-22**] an out-pt carotid series,
prompted by two episodes of aphasia demonstrated progression of
left ICA stenosis. The pt was admitted on [**10-25**]/o5 for elective
left ICA stenting. CTA head and neck were performed the night of
admission for further elucidation of carotid anatomy. On [**10-26**]
the pt received successful stenting of his left ICA. The pt was
medcically stable post-procedure. He was kept overnight for
observation post-op. He will f/u with Dr. [**First Name (STitle) **] in 2 weeks
2) CV:
CAD: The pt is s/p CABG in '[**76**]. Throughout his admission he was
contined on asa, plavix, and lipitor.
[**Name (NI) 101711**] pt was paced with a transvenous pacer.
pump: The pt's last ECHO in '[**76**] showed nml LV function. He
demonstrated no signs of failure clinically
3) [**Name (NI) 42398**] pt was placed back on his home dose of norvasc
post-op. His BP was well-controlled throughout the admission.
4) hyperlipidemia--The pt was placed on his home lipitor
throughout his admission.
5) depression/anxiety--The pt remained on his home lexapro and
alprazolam prn anxiety.
6) glauma--The pt continued on his home dose of trusopt,
latanoprost, betoptic S
7) [**Name (NI) 48980**] pt was NPO past midnight for procedure, and resumed
a low Na/cardiac healthy diet post procedure.
8) ppx: The pt was eating post-procedure, and kept on hep sc
throughout admit.
9) FULL CODE
Medications on Admission:
Allergies:
Parabin
Nizoral
contrast -> hives
.
Medications:
Plavix 75mg daily
Lexapro 10mg daily
Norvasc 10mg daily
Zocor 20mg daily
Xanax 0.25mg 1-3x/day p.r.n.
ASA 325mg daily
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO ONE TO THREE
TIMES PER DAY PRN () as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
left internal carotid artery stenosis
Discharge Condition:
Stable
Discharge Instructions:
Pt or pt's family should contact PCP or go to ED if pt has:
[**Name (NI) **] headaches
Changes in vision
Changes in mental status
Changes in speech
Changes in motor functioning
Chest pain
Changes in breathing
SBP >140, per VNA
Followup Instructions:
Pt should follow-up with Dr. [**First Name (STitle) **] in approximately 2 weeks.
Pt's family should contact Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 40086**]
to set-up appointment.
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5703
}
|
Medical Text: Admission Date: [**2112-3-30**] Discharge Date: [**2112-4-2**]
Service: MEDICINE
Allergies:
Ace Inhibitors / Gatifloxacin / Shellfish Derived /
Hydrocodone/Acetaminophen
Attending:[**First Name3 (LF) 13386**]
Chief Complaint:
Fall, Hypotension
Major Surgical or Invasive Procedure:
Surgiseal closure of head laceration
History of Present Illness:
87yM with hx of COPD, dCHF, heart block s/p PPM, DM, and CKD who
presented after a fall at nursing home. Patient was found down
on bathroom floor with copious bleeding from head and staff
called EMS. Patient denied LOC.
Recently hospitalized at [**Location 1268**] VA when found fallen in
the stairwell after an OP appointment at the VA. Discharged 4
days prior to current presentation with diagnosis of pneumonia.
Of note, patient had another fall one day after discharge from
VA.
In ED, vitals 99.2, HR 64, BP 108/82, 16, 100% RA. Labs showed
leukocytosis to 10.1, lactate to 2.4, Hct 28.5. SBP dropped to
80s which responded to 2L. Head CT, Abdomen/Pelvis CT, and FAST
negative for bleeding. Forehead laceration from fall bled
profusely and sealed with gel foam. On floor he received
ceftriaxone and flagyl for presumed pneumonia. Was then found to
be hypotensive to 80s despite numerous fluid boluses. Hct
dropped to 23.8.
Pt endorsed light-headedness, some difficulty breathing,
+productive cough x2 weeks (no blood). RofS negative for abd
pain, nausea, vomiting, diarrhea, chest pain, dysuria, weakness,
numbness, tingling, headache.
Past Medical History:
-Bladder cancer
--HGT1 w/ CIS, s/p BCG Therapy with subsequent BCG-osis - was
found to have suspicious etiology in [**8-2**] and subsequently has
had three atypical cytologies
-Heart Block s/p PPM
-Atrial Flutter
-Seborrheic keratosis
-Squamous Cell Carcinoma of Skin
-CKD 4
-Senile Cataract
-Hypertension
- COPD
- CHF (Diastolic)
- AAA (s/p endovascular repair) - with bleeding in small
intestine during capsule endoscopy - could not identify source.
-Hyperlipidemia
-DM type II
-Prostate Benign Hypertrophy
-Colonic Polyps
Social History:
Lives in [**Hospital 599**] nursing home x2 years. Two children in
[**State 4565**], one locally in [**State 350**], one in [**State 531**].
Family History:
Denies any family history of diseases including
blood/bleeding diseases and cancer.
Physical Exam:
General Appearance: Well nourished, No acute distress
Neuro: Alert, oriented, appropriate. Symmetric strength and
sensation in all 4 extremities. Symmetric smile.
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Dry oral mucosa, large
beefy tongue
Lymphatic: JVP at level of ears with double pulsation.
Cardiovascular: Normal S1 and S2. Grade III holosystolic murmur
at LLSB which increases on inspiration.
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : Course, Bilaterally at bases, L>R)
Abdominal: Non-tender, Bowel sounds present, No(t) Tender: ,
Somewhat firm, bruising diffuse at inferior aspect.
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent. Extremities warm and dry.
Skin: Warm
Neurologic: A&O x3Attentive, Follows simple commands, Responds
to: Not assessed, Oriented (to): Place, Date, Time, Movement:
symmetric in all 4 extremities.
Pertinent Results:
[**2112-3-30**] 08:16PM GLUCOSE-47* UREA N-73* CREAT-2.6* SODIUM-135
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-12
[**2112-3-30**] 08:50PM LACTATE-1.4
[**2112-3-30**] 08:16PM ALT(SGPT)-48* AST(SGOT)-24 LD(LDH)-195 ALK
PHOS-122 TOT BILI-0.5
[**2112-3-30**] 08:16PM LIPASE-268*
[**2112-3-30**] 08:16PM CK-MB-5 cTropnT-0.14*
[**2112-3-30**] 08:16PM WBC-14.4* RBC-2.17* HGB-7.4* HCT-23.6*
MCV-109* MCH-34.1* MCHC-31.5 RDW-17.2*
[**2112-3-30**] 08:16PM PT-12.3 PTT-31.1 INR(PT)-1.0
.
Discharge Labs:
[**2112-4-2**] 06:30AM BLOOD WBC-9.4 RBC-3.01* Hgb-10.0* Hct-30.4*
MCV-101* MCH-33.4* MCHC-33.0 RDW-19.7* Plt Ct-45*
[**2112-4-2**] 06:30AM BLOOD Glucose-149* UreaN-68* Creat-2.3* Na-136
K-4.9 Cl-106 HCO3-19* AnGap-16
[**2112-4-2**] 06:30AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.3
.
Studies:
[**2112-4-1**] CXR
REASON FOR EXAM: Heart failure, received fluids.
Comparison is made with prior study performed the same day in
the morning.
Cardiomediastinal contours are unchanged. Small bilateral
pleural effusions associated with adjacent atelectasis, left
greater than right, are minimally increased from prior. Pacer
leads remain in place, as is the right PICC. There is no
pulmonary edema.
.
[**2112-4-1**] R hand xray
FINDINGS: There is a comminuted fracture of the fifth proximal
phalanx.
.
[**2112-3-31**] Abd/pelvis CT
IMPRESSION:
1. No evidence of retroperitoneal bleed.
2. Stable 5.5 cm infrarenal abdominal aortic aneurysm sac,
status post
endovascular repair.
3. Slightly increased small bilateral pleural effusions and
slight increased free fluid in the pelvis.
4. Cholelithiasis.
.
[**2112-3-31**] Transthoracic Echo
The right atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %) with mid to distal septal and distal
inferior hypokinesis. There is no ventricular septal defect. The
RV appears dilated with preserved systolic function.The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-30**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2111-8-19**],
regional LV systolic dysfunction is now present and the severity
of TR has increased.
.
[**2112-3-29**] CT Head
IMPRESSION:
1. No acute intracranial abnormality.
2. Left frontal scalp laceration and subgaleal hematoma without
underlying
fracture.
3. Bilateral sinus disease with air-fluid levels may indicate
acute
sinusitis. Clinical correlation recommended.
.
[**2112-3-29**] CT spine
IMPRESSION:
1. No acute fracture or malalignment.
2. Multilevel degenerative change with mild-to-moderate canal
narrowing at
C3-4 and C4-5 as above may predispose the patient to cord injury
in the
setting of trauma. If there is clinical concern for cord injury
and there is no contraindication, MRI is recommended for further
evaluation.
3. Unchanged mild compression deformity of C7.
Brief Hospital Course:
87 M with MMP, presents s/p fall and hypovolemia admitted to the
ICU for hypotension.
.
# Hypotension: Dropped to 80s in setting of elevated Cr, Lactate
and compressable IVC. After 2L of NS in ED his blood pressure
increased to the 110s. [**Last Name (un) **] Stim was normal, so unlikely
adrenal insufficiency. No fever or leukocytosis so unlikely
sepsis/infection. TSH was normal so not hypothyroidism. Patient
had ECHO with worsening EF (45-50%) and LV systolic dysfunction
new since [**7-/2111**] so it was felt that his hypotension was likely
due to hypovolemia and poor forward flow in the setting of CHF.
Acute MI was ruled out with CE flat x3 (though troponin 0.14
0.12 in setting of ARF) He was not given any further fluid but
transfused 3 units of PRBCs. His blood pressure meds were held
and he remained normotensive in the ICU. Back on the floor his
pressures were stable but he was kept off of all
anti-hypertensives on discharge.
.
# Head laceration: Head lac not actively bleeding and surgiseal
was applied in the ED. General surgery was consulted in the ICU
and said that no further intervention is needed. The laceration
will heal and the surgiseal slough off.
.
# R 5th digit fracture - he was elgvaulated by hand surgery and
placed in a splint. Advised to keep RUE elevated. Has hand
clinic followup on [**2112-4-12**]. To continue PT and OT in rehab.
.
# Macrocytic Anemia: HCT 28 on arrival and dropped to 23 after
ICF resuscitation. After two units of PRBCs the patient's HCT
improved to 28 and after a 3rd unit his HCT was >30. His retic
was checked and was 5.8%.
.
# Heart Block s/p PPM, Atrial Fibrillation: Coumadin on med
list, but INR 1. Coumadin was not restarted given head
laceration and high risk of fall. His aspirin was also held per
Geriatrics recommendations (given chronic thrombocytopenia and
history of GI bleeding). He was in atrial fibrillation with a
paced rate of 60. His heart rate did not increase in the setting
of hypotension, remaining at 60bpm. The EP team interrogated
his pacer, finding that he is almost entirely in Afib and paced
at 60bpm. The pacer's responsiveness feature was activated and
the basal rate was raised to 70bpm to hopefully reduce future
hypotensive episodes.
.
# Acute on Chronic renal failure: Cr 3 from baseline 2.3-2.5.
After 2L IVF and 2 units PRBCs his creatinine 2.1 so likely
pre-renal azotemia. Creatinine was back at baseline 2.3.
.
# ? COPD: Unclear if patient has COPD or another underlying lung
process. He was continued on his home nebs.
.
# CHF (Diastolic): Lasix was held in the setting of hypotension.
.
# DM type II: Patient placed on a diabetic diet and his home
insulin regimen. However, serum glucose in the AM was 62 and he
was taking poor POs so his NPH was cut in half and he was
continued on SSI. He was returned to his usual insulin dose for
discharge.
.
# ? Health care associated Pneumonia - the patient was started
on antibiotics (vancomycin and cefepime) while in the ICU out of
concern for pneumonia. Course began on [**2112-3-30**]. These were then
taped to ceftriaxone on [**2112-4-1**], which was switched to
cefpodoxime on discharge to complete a 10 day course ending
[**2112-4-8**].
.
# Code - DNR/I, confirmed
Medications on Admission:
Advair 25/50 1 puff [**Hospital1 **]
Spiriva 18mcg inhaler
Forticort nasal spray
Zocor 10mg PO Qhs
Effexor 75mg PO QD
Remeron 50mg PO QD
Asa 81mg PO QD
Isordil 10mg TID
Lasix 100mg PO QD
Colace 200mg PO QD
Neurontin 200mg TID
Senna 1 tablet PO BID
Colace 200mg PO QD
Lactulose 10g/50ml??????20ml PO QD
Insulin NPH 15U Qam
Regular Insulin Sliding Scale qAC &HS
Calcitonin
Ambien 5mg Qpm
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation Q6H
(every 6 hours) as needed for SOB.
2. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Spray Nasal DAILY (Daily): Alternating nostrils.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
5. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO once
a day.
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: Two
(2) Capsule, Sust. Release 24 hr PO DAILY (Daily).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
13. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed for heartburn.
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous QAM.
19. Insulin Regular Human 100 unit/mL Solution Sig: As directed
units Injection QACHS: Please take per sliding scale.
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
21. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days: course to end on [**2112-4-8**].
22. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic
QID (4 times a day).
23. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnosis: Hypotension secondary to volume depletion,
bleeding and possible sepsis
Secondary diagnoses: Health-care associated pneumonia
Discharge Condition:
Mental Status: Subacute delirium
Level of Consciousness: Alert, oriented to person and place
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the hospital after falling and cutting your
head. The cut on your head was covered and your broke your
finger, requiring a splint. You lost a lot of blood, requiring a
total of 3 blood transfusions. Your blood pressure was low, and
you received several liters of fluid. You are now ready to go
back to rehab and work on getting strong.
.
Some changes were made to your medications:
- Your blood pressure medications (are being held to prevent
further hypotension or low blood pressure)
- your coumadin (blood thinner) is also being held
- you are being given a course of antibiotics to end on [**2112-4-8**]
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You will be seen by the doctors at your rehab facility.
.
Follow-up in hand clinic on Tuesday, [**2112-4-12**]. Call the hand
clinic at [**Telephone/Fax (1) 3009**] to make the appointment.
ICD9 Codes: 4589, 5849, 486, 4280, 5180, 2851, 496, 4240
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5704
}
|
Medical Text: Admission Date: [**2180-11-15**] Discharge Date: [**2180-11-21**]
Date of Birth: [**2129-7-12**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
right total knee arthroplasty
History of Present Illness:
51 yo woman complaining of right knee pain. Patient had
traumatic MCl tear to right knee 21 years ago. Patient has had
increasing pain in right knee since injury. Pain is now
affecting daily activities.
Past Medical History:
Osteoarthritis
Hypertension
Social History:
Etoh-occasional
TOB-denies
IVDA-denies
Physical Exam:
Gen-A&Ox,NAD
VS-HR-51 SpO2-100%RA
CV-RRR S1/S2
Lungs-CTA
Abd-Soft NT/ND
Ext-no club/cyanosis/edema, decreased ROM right knee secondary
to pain.
Pertinent Results:
CT angiogram: Tiny filling defect in a segmental right upper
lobe pulmonary
artery is most likely representative of streak artifact. No
evidence of
occlusive thrombus.
EEG: This is a mildly abnormal portable EEG due to the presence
of delta with mixed theta frequency slowing seen over the left
temporal
and parietal regions. This finding suggests subcortical
dysfunction in
these areas and is a relatively non-specific finding with regard
to an
evaluation for seizures. No epileptiform abnormalities were
seen.
brain MRI: heterogenous left temporal lobe mass with
calcification and/or blood products without distinct
enhancement. No significant surrounding edema. The differential
diagnosis includes cavernous malformation however given the
irregular distribution of the blood products, the appearance is
not typical.
CT R knee: Status post right total knee replacement with complex
postoperative flusion. Otherwise unremarkable examination.
[**2180-11-15**] 12:34PM GLUCOSE-94 UREA N-13 CREAT-0.8 SODIUM-145
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-30* ANION GAP-13
[**2180-11-15**] 12:34PM CALCIUM-8.9 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2180-11-15**] 12:34PM WBC-4.6 RBC-3.38* HGB-11.6* HCT-31.7* MCV-94
MCH-34.3* MCHC-36.5* RDW-12.7
[**2180-11-15**] 12:34PM PLT COUNT-201
[**2180-11-17**] 01:53AM BLOOD Glucose-178* UreaN-9 Creat-0.8 Na-123*
K-2.9* Cl-86* HCO3-22 AnGap-18
[**2180-11-17**] 06:05AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-120*
K-2.9* Cl-84* HCO3-30* AnGap-9
[**2180-11-17**] 11:22AM BLOOD UreaN-8 Creat-0.6 Na-127* K-3.0* Cl-91*
HCO3-28 AnGap-11
[**2180-11-17**] 03:45PM BLOOD UreaN-8 Creat-0.6 Na-136 K-3.7 Cl-99
HCO3-26 AnGap-15
[**2180-11-17**] 07:58PM BLOOD Na-138 K-3.7
[**2180-11-17**] 11:51PM BLOOD Creat-0.6 Na-140 K-4.0 Cl-105 HCO3-26
AnGap-13
[**2180-11-17**] 01:53AM BLOOD WBC-20.9*# RBC-2.38* Hgb-8.1* Hct-22.0*
MCV-93 MCH-34.2* MCHC-36.9* RDW-12.5 Plt Ct-195
[**2180-11-17**] 06:05AM BLOOD WBC-18.7* RBC-2.30* Hgb-8.0* Hct-20.8*
MCV-90 MCH-34.5* MCHC-37.4* RDW-12.5 Plt Ct-193
[**2180-11-21**] 07:15AM BLOOD WBC-8.3 RBC-3.09* Hgb-9.5* Hct-27.6*
MCV-89 MCH-30.7 MCHC-34.4 RDW-14.7 Plt Ct-290
Brief Hospital Course:
1. right total knee arthroplasty - patient had been followed by
Dr.[**Last Name (STitle) **] in [**Hospital 6669**] clinic prior to her admission for an
elective total knee arthroplasty. Consent was obtained in
clinic, medical clearance was also obtained prior to surgery.
Patient was admitted on [**2180-11-15**] for an elective right total knee
arthroplasty. Surgery was without complication, please see
op-note [**2180-11-15**]. On post-op check patient was doing well.
Patient was afebrile/vital signs stable. Dressing had moderate
amount of drainage, dressing was reinforced and ice applied to
incision. Pt developed a hematoma around the area of the joint
but there was no evidence of local infection, through to the day
of discharge. She was sent home with Percocet for pain relief,
and VNA was arranged to help with dressing changes and physical
therapy. She was given IV Ancef while in the hospital, and sent
out on a 5-day course of Keflex to prevent wound infection. She
will also remain on Lovenox for 4 weeks after discharge. She
will follow up with Dr. [**Last Name (STitle) **] in clinic.
2. postoperative seizure - Pt was stable immediately post op
until 2:30AM then she was noted to have generalized tonic-clonic
seizures witnessed by RN, followed by brief periof of post ictal
confusion. At the time, the eyes rolled back into head, arms
extended and shaking and mouth twitching. The episode lasted [**1-14**]
minutes, no tongue biting or incontinence. Pt became tachycardic
to 114 during the seizure but did not desat. Following seizure
event, the patient had a brief period where she was "speaking
non-sense" which subsequently resolved. Pt was transferred to
the [**Hospital Unit Name 153**]. Sodium dropped as low as 120 (down from 145 on
[**2180-11-15**]), Hct 22 (from 31.7 on [**2180-11-15**]), K was 2.9, and INR was
1.5. CT angio showed no PE. Head CT showed a small lesion with
calcifications in left inferior temporal lobe. Of note, pt has
been receiving continuous D5 1/2NS, poor PO intake except for
water and juice with significant pain in the postoperative
period. Pt did not have any recurrent seizures, and her
hyponatremia corrected overnight with hypertonic saline
initially, and then NS. It is thought that pain and
postoperative hypotonic fluids caused her hyponatremia.
However, due to the presence of the L temporal lobe lesion,
neurology consult was called. An EEG was performed to evaluate
for the likelihood that this mass was the etiology of the
seizure. There was some slowing over the L temporal and
parietal regions, but this was thought to be nonspecific and not
necessarily consistent with epileptiform abnormalities. Pt
transferred to the floor with a stable sodium.
3. left temporal lobe lesion - After the CT scan showed this
left temporal lobe mass, an MRI was done to further evaluate the
lesion. This showed a heterogenous left temporal lobe mass with
calcification and/or blood products without distinct
enhancement. No significant surrounding edema. The differential
diagnosis includes cavernous malformation however given the
irregular distribution of the blood products, the appearance is
not typical. Per neurology, this was likely a lesion that was
fairly stable and not extremely likely to bleed, and with
careful consideration, it was decided that the benefits of
anticoagulation would outweigh the risk of intracerebral
bleeding, given the appearance of this lesion on imaging
studies. An EEG was performed, which did not particularly point
to the lesion as the etiology of seizures. An LP was performed,
mainly for cytologic analysis. Pt will follow up with Dr.
[**Last Name (STitle) 4253**] in a few weeks, where she will receive the results of
the LP. The MRI reviewed by neurology and neuroradiology, and
it was recommended that pt also be followed up in neurosurgery
clinic, as there were some atypical features of this likely
cavernoma, and surgical intervention may be indicated if there
are multiple feeding vessels, which would increase her lifetime
risk of hemorrhage.
4. Anemia - most likely due to bleeding into leg. Pt was given
lovenox after recent surgery and developed a significant
hematoma with a tense thigh, but did not develop compartment
syndrome. CT scan showed edema with small hematoma (<100c),
which did not explain a large Hct drop. Pt was given 2 units
PRBC, 1 unit FFP, and hematocrit held steady.
5. Fevers - pt developed low grade temps the day prior to
discharge. As pt was also tachycardic, she underwent CXR, which
was negative for pneumonia, blood cultures, which are no growth
to date, a urine culture, which was negative, and a CT angiogram
to look for a PE. This, too, was negative. It is likely that
her fevers are from postoperative atelectasis, or perhaps
associated with the large hematoma at the site of her surgery.
Pt was clinically stable and feeling well, and was therefore
discharged the following day. Of note, the site of her incision
was not consistent with any local infectious process.
6. Hypertension - pt's HCTZ and lisionpril were initially held
when pt developed hypokalemia. They were restarted 2 days prior
to discharge, with good control of her blood pressure.
Medications on Admission:
Lisionpril 20
HCTZ 25
Protonix 40
Naproxen
MVI
Darvocet
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Lovenox 40 mg/0.4mL Syringe Sig: Forty (40) mg Subcutaneous
once a day for 4 weeks.
Disp:*QS * Refills:*0*
3. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every three
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
4. Keflex 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking percocet.
Disp:*60 Capsule(s)* Refills:*0*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): until pain resolves.
Disp:*240 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right knee osteoarthritis
hyponatremia
hypokalemia
Discharge Condition:
stable
Discharge Instructions:
Please cont with weight bearing as tolerated right leg. Lovenox
40mg once a day x4weeks for anti-coagulation. Oral pain
medication as needed. Please cont with physical therapy. Please
keep incision clean/dry. Please call/return if any
fevers/increased discharge from incision or trouble breating.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2180-11-27**] 2:40
Provider: [**Name10 (NameIs) 5005**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Where: [**Hospital6 29**]
NEUROLOGY - this is on the eighth floor Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2180-12-1**] 3:30
You will be contact[**Name (NI) **] in the next few days about a neurosurgery
appointment, likely with Dr. [**First Name (STitle) **]. If you do not hear from them,
call the neurosurgery clinic at ([**Telephone/Fax (1) 88**].
ICD9 Codes: 2761, 2768, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5705
}
|
Medical Text: Admission Date: [**2192-9-6**] Discharge Date: [**2192-9-16**]
Date of Birth: [**2192-9-6**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] was born at 35
weeks gestation by cesarean section for breech presentation
and oligohydramnios. The mother is a 44-year-old gravida
2/para 1 (now 2) woman. The mother's prenatal screens are
blood type O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, and group B
strep unknown. The pregnancy was uncomplicated until 3 weeks
prior to delivery when the mother was thought to have leaking
of urine. The week prior to delivery she was found to have a
significantly decreased amniotic fluid volume. She had a
normal amniocentesis. The infant emerged from cesarean
section in breech presentation; vigorous, Apgar's were 8 at
one minute and 8 at nine minutes. He was brought to the NICU
for respiratory distress.
Birth weight was 2430 grams, birth length was 47.5 cm, and
birth head circumference was 31.5 cm.
ADMISSION PHYSICAL EXAMINATION: Reveals a vigorous preterm
infant. Anterior fontanel soft and flat. Palate intact.
Breath sounds reduced on the left. Positive grunting and
retracting. Heart was regular in rate and rhythm. No murmur.
Good perfusion. Abdomen was soft, no organomegaly,
hypospadias, testes descended bilaterally, and age
appropriate tone.
NICU COURSE BY SYSTEM:
1. RESPIRATORY STATUS: The infant was initially on
nasopharyngeal continuous positive airway pressure. He was
found to have a left pneumothorax. He was then intubated.
He received 2 doses of Survanta and required a needle
thoracentesis on the left. On days of life #2 and #3, he
had recurrent bilateral pneumothorax resolved with needle
thoracentesis each time. He weaned from conventional
ventilation to nasal cannula oxygen on day of life #1, and
he remained on nasal cannula until day of life #5 when he
weaned successfully to room air. On exam, his respirations
are comfortable. Lung sounds are clear and equal. He has
had no apnea or bradycardia.
1. CARDIOVASCULAR: He has remained normotensive throughout
his NICU stay. His heart was regular in rate and rhythm.
No murmur.
1. FLUIDS, ELECTROLYTES, NUTRITION: At the time of discharge
his weight is 2280 grams. Enteral feeds were begun on day
of life #4 and advanced without difficulty to full volume
feedings by day of life #6. At the time of discharge, he
is breast feeding or supplementing with formula and breast
milk on an ad lib schedule.
Maximum bilirubin was 17.8 on DOL. Treated with
phototherapy. DOwn to 10.8 on [**9-15**]. Phototherapy dced and
rebound bili was 11.8 on [**9-16**]. Follow-up as outpatient is
suggested.
1. HEMATOLOGY: He has received no blood product transfusions
during his NICU stay. His hematocrit is 57.8 and platelets
are 264,000 at the time of admission.
1. INFECTIOUS DISEASE STATUS: He was started on ampicillin
and gentamicin at the time of admission. He completed 7
days of antibiotics for presumed sepsis. His blood
cultures remained negative.
1. SENSORY: Audiology screening was performed with automated
auditory brain stem responses, and the infant passed in
both ears.
1. PSYCHOSOCIAL: The parents have been very involved in the
infant's care throughout his NICU stay.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: He was discharged home with his
parents.
DISCHARGE STATUS:
1. He passed a car seat position screening test.
2. State newborn screen was sent on [**9-8**].
3. He received his first hepatitis B vaccine on [**9-14**].
4. He was discharged on 1 medication; Tri-Vi-[**Male First Name (un) **] 1 mL p.o.
daily.
DISCHARGE DIAGNOSES:
1. Status post prematurity at 35 weeks gestation.
2. Status post respiratory distress syndrome.
3. Status post bilateral pneumothorax with needle
thoracenteses.
4. Status post presumed sepsis.
5. Hypospadias.
DISCHARGE FOLLOWUP: Urology consult after discharge and
consideration of hip ultrasound recommended for breech
presentation.
Follow-up of hyperbilirubinemia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2192-9-16**] 04:03:15
T: [**2192-9-16**] 10:23:21
Job#: [**Job Number 63668**]
ICD9 Codes: 769, 7742, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5706
}
|
Medical Text: Admission Date: [**2196-9-25**] Discharge Date: [**2196-10-3**]
Date of Birth: [**2151-12-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
[**9-27**]: left parietal craniotomy
History of Present Illness:
44 right handed male with hx of melanoma metastatic to the brain
treated with surgical resection and CyberKnife, presented
originally with R arm numbness and weakness, now transferred
from an OSH after his wife noticed that he was acutely confused
around 1AM this morning. He was reportedly fine when she
returned from work, but 20 minutes later he was speaking
nonsensically and
agitated. 911 was called and he was brought to [**Hospital3 **], where a CT scan of the head revealed 1.7 cm R frontal
hemorrhage and 3.9 cm L fronto-parietal hemorrhage with
associated edema with local effacement of sulci without midline
shift. Other lab values were WNL. He received 10 mg of IV
dexamethasone and 250 mg of Phenytoin and was transferred to
[**Hospital1 18**] for further eval. Currently he attests to feeling
confused, but denies any dizziness, nausea, visual changes, or
headache.
Past Medical History:
Melanoma originally diagnosed in left axilla, metastatic to
brain. MRI [**2196-7-19**] showed 3 lesions - 2 in the left parietal and
1 in the right frontal regions. He underwent resection of the
larger parietal tumor on [**2196-7-20**] by Dr. [**First Name (STitle) **], and pathology
confirmed metastatic melanoma. He was treated with CyberKnife
on
[**2196-8-8**] to the resection cavity and to the remaining parietal
lesion. A repeat MRI on [**8-3**] showed slight increase in the size
of both tumors, and a third MRI [**9-5**] showed a new right parietal
metastasis. He underwent a second CyberKnife treatment to the
two right sided lesions on [**2196-9-9**].
Social History:
Married, resides at home with wife and children
Family History:
Non-contributory
Physical Exam:
Exam upon admission:
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Disoriented to person, place, time.
Recall: able to repeat, 0/3 objects at 5 min.
Language: Speech fluent but occasionally inappropriate, poor
naming. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light. Visual fields
are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-7**] throughout, except [**5-8**] on R
finger grip.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+
Left 2+ 2+ 2+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Exam upon discharge:
Alert, Oriented to person, place and date, with minimal
prompting. PERRL. Face is symmetric, tongue is midline. Full
strength and power throughout LUE, and bilateral LE. RUE with
4/5 weakness diffusely.
Pertinent Results:
MRI HEAD W & W/O CONTRAST [**2196-9-25**]:
FINDINGS: The study is compared with very recent enhanced MR
examination
(with tumor volumetry) of [**2196-9-5**]. Over the short interval, the
hemorrhagic
left temporoparietal lesion has substantially increased in size,
now measuring at least 4.0 cm (AP) x 2.6 cm (TRV), with
substantial hemorrhagic component and significant associated
vasogenic edema and increased mass effect upon the occipital
[**Doctor Last Name 534**] and atrium of the left lateral ventricle (4:15). Similarly,
the lesion in the right frontal lobe, which measured only 8 mm,
is significantly larger, now measuring 17 x 16 mm, and also
demonstrates significant hemorrhagic (and/or melanotic)
component with small zone of vasogenic edema which, too, has
substantially increased since the recent study. There has been
no significant interval growth in the small lesion in the
central aspect of the right parietal lobe, adjacent to the
occipital [**Doctor Last Name 534**] of that lateral ventricle, and no new enhancing
lesion is identified. Again demonstrated is thick, irregular rim
enhancement at the margins of the left frontovertex resection
cavity likely representing residual neoplasm (as suggested
previously). The cavity also demonstrates residual marginal and
internal blood products. There is no restricted diffusion to
indicate acute ischemia and the principal intracranial vascular
flow voids, including those of the dural venous sinuses, are
preserved and these structures enhance normally.
IMPRESSION: Marked short-interval progression of the hemorrhagic
and/or
melanotic dominant left temporoparietal and right frontal
metastases, now
measuring up to 4.0 and 1.7 cm, respectively. There is
corresponding
significant interval increase in associated vasogenic edema, but
no overall shift of midline structures or evident herniation.
CT Torso [**2196-9-26**]:
CT CHEST: Left axillary dissection changes are stable. 6 mm
right apical lung nodule is unchanged since [**2196-7-21**]. There are
no other lung nodules. Small bilateral effusions have resolved
since [**2196-7-21**]. The pulmonary arteries and airways are patent to
the subsegmental level. Heart size is mildly enlarged. There is
no pericardial effusion. Scattered central nodes do not meet CT
size criteria for enlargement.
CT ABDOMEN: A 1 cm liver lesion in segment VII (2:42) enhances
similar to the blood pool and are probably present since
[**2195-9-27**]. The gallbladder, pancreas, spleen, kidneys are
unremarkable. There is no intrahepatic or extrahepatic biliary
dilatation. The abdominal loops of bowel are unremarkable
without evidence of obstruction or free air. Well circumscribed
fluid density (20 [**Doctor Last Name **])3.4 X 1.9 cm and 2 x 1.7 cm lesions
adjacent to the left adrenal gland and superior to the pancreas,
respectively (2:54), are new since [**2196-7-21**].
CT PELVIS: The bladder, rectum, prostate, and seminal vesicles
are
unremarkable. There is no pelvic or inguinal lymphadenopathy.
Bone windows demonstrate no lesion concerning for metastasis or
infection.
IMPRESSION:
1. No new lesion concerning for metastasis.
2. Segment VII liver lesion likely represents flash filling
hemangioma given similar enhancement to blood pool, but is not
fully characterized. MRI suggested for more definitive
characterization given history of malignancy.
3. New fluid density collections near the pancreas likely
represent
pancreatic pseudocysts.
MRI Head [**9-28**](post-op):
FINDINGS: There is a new left parietal/temporal craniotomy, with
associated post-operative changes in the overlying scalp. The
previously noted left parietal/temporal mass has been resected.
There are blood products in the new resection bed, with high
signal on the pre-contrast T1-weighted images. This limits
evaluation for any residual enhancing tumor components on the
post-contrast T1-weighted images, though none definitively seen.
An apparent 5 mm focus of slow diffusion along the anterolateral
margin of the new resection cavity (image 12 of series 700 and
series 702), most likely represents an artifact related to the
post-operative blood products, although a small contusion or
infarction of adjacent tissue cannot be excluded. There is high
T2 signal surrounding the new resection cavity, likely
representing a combination of post-operative edema and
pre-existing tumor-related and therapy-related changes. There is
a minimal decrease in mass effect following the new resection.
The pre-existing left parietal resection cavity, superior to the
new cavity, appears stable, with linear enhancement along its
margins. The greatest thickness of the linear enhancement is
located medially, as before (image 9:19). The hemorrhagic lesion
in the right frontal lobe is unchanged in the interim (image
9:19). Enhancing and hemorrhagic lesions in the right parietal
lobe (image 9:17) and in the left frontal lobe (image 1000:50)
are unchanged.The ventricles are stable in size. The major
arterial flow voids are unremarkable.There is mild mucosal
thickening in the maxillary sinuses.
IMPRESSION:
1. Status post left parietal/temporal mass resection, with blood
products in the resection cavity limiting evaluation for any
residual enhancing
components. Continued follow-up is recommended.
2. The other previously noted hemorrhagic masses are unchanged
in the short interim.
MRI Abdomen [**9-29**]:
There is minimal dependent atelectasis at the right lung base.
There is a
subcapsular lesion measuring 10 x 10 mm in segment VIII of the
liver,
corresponding to the enhancing abnormality on prior CT, which
demonstrates
uniform high signal on T2- weighted images, low signal on T1-
weighted
sequences and arterial phase hyperenhancement with continued
enhancement on the dynamic series. The appearance is consistent
with a hemangioma (image 41, series 100). A 1.4-mm lesion in
segment II of the liver also shows features consistent with a
hemangioma. There are scattered up to 3 mm hepatic cysts which
demonstrate low signal on T1- weighted sequences and high signal
on T2-weighted sequences without enhancement (image 37, 41 and
56, series 300). There are again demonstrated peripancreatic
fluid collections which have high signal on T1-weighted
sequences, low signal on T2-weighted sequences and demonstrate
subtle rim enhancement suggestive of focal collections with
hemorrhagic or proteinaceous contents. The larger collection in
the region of the pancreatic tail measures 4.4 x 1.6 cm and the
smaller collection abutting the anterosuperior aspect of the
pancreatic body measures 1.8 x 1.2 cm (image 63 and 67, series
200). The spleen, gallbladder, adrenal glands, and kidneys
appear unremarkable. The
pancreatic parenchyma shows homogeneous enhancement. There is no
upper abdominal lymphadenopathy. The visualized loops of bowel
appear unremarkable. The visualized bones appear unremarkable.
IMPRESSION:
1. The lesion of interest in the right lobe of the liver
represents a
hemangioma. Additional simple hepatic cysts and hemangiomas as
described
above.
2. Hemorrhagic or proteinaceous peripancreatic collections which
may
represent sequelae of pancreatitis. The pancreatic parenchyma,
however,
enhances homogeneously.
Brief Hospital Course:
The patient was admitted to the Neurosurgical stepdown unit at
[**Hospital1 18**] through the Emergency Department. An MRI Scan performed
upon admission demonstrated 3 brain lesions, either hemorrhagic
or increased size of tumors. He was initially agitated secondary
to steroids, and IV ativan, seroquel, and haldol were started
and the steroids were subsequently stopped. His keppra was
increased to 1000mg, and a 1000mg bolus was given for a possible
focal seizure in his RUE.
The patient went to the operating room on Tuesday, [**9-27**] for a
resection of a L parietal mass. He tolerated the procedure well
and following a short stay in the ICU he was transferred to the
Neurosurgical Floor. An MRI of the Head and Abdomen were ordered
d/t concerning findings of a Segment VII liver lesion per CT
Scan. This MRI revealed mutliple small cysts that did not
required acute intervention per the GI team. The patient was
given instruction for these findings to be followed from an
outpaient standpoint.
He was seen and evaluated by PT and OT; after working with him
for several days; he was ultimatley improved enough to the point
of disposition to home with services. He was discharged as such
on [**2196-10-3**]. At the time of discharge, the patient continues to
experience mild sensory ataxia of his right hand (though the
ataxia had improved significantly post-resection)
Medications on Admission:
Keppra 500'', Decadron taper finished the day before admission.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Metronidazole 1 % Gel Sig: One (1) Appl Topical DAILY
(Daily).
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Metastatic melanoma to the brain
Discharge Condition:
Neurologically stable
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.
??????Your wound closure uses dissolvable sutures, you must keep that
area dry for 10 days.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????Make sure to continue to use your incentive spirometer while at
home.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**8-12**] days (from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2196-10-17**]
@11:30am . The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will need an MRI of the brain on [**2196-10-13**] 12:20
You also have an appointment with Dr. [**Last Name (STitle) 1729**] on [**2196-10-19**] at
9:45am
During your hospitalization and imaging performed; multiple
small cysts were identified on your liver. These do not require
intervention at this time; however should be monitored by your
PCP [**Name Initial (PRE) 78297**].
Completed by:[**2196-10-3**]
ICD9 Codes: 431, 5119
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5707
}
|
Medical Text: Admission Date: [**2105-3-30**] Discharge Date: [**2105-4-4**]
Date of Birth: [**2029-12-19**] Sex: F
Service: SURGERY
Allergies:
Allopurinol
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 year right handed woman with a history of "mini strokes on
ASA and Plavix, COPD, whom according to her son [**Name (NI) 122**], was
found by her husband on [**3-30**] some time around 5 pm, in a pool of
blood and vomitus outside her back steps. Mrs [**Known lastname 86767**] had gone
to Twin Rivers Casino, and had been in her usual state of
health, according to both the patient and her son, she was prone
to falls, however, her son mentioned that she was secretive
about her health issues. Her husband heard a thud outside the
back stairs, he was watching TV, he went to see what had
happened about 10 mins later. Initially he thought that it was a
UPS package because his wife got regular deliveries as she shops
on
line, so he did not get there right away. There are two steps to
the back door, she had tripped back and hit the back of her head
(according to the EMS face sheet she had fallen supine). She had
not lost consciousness, but looked dazed and she did not speak
(patient does not remember the event). She was covered in blood
(from her head) and vomit. He called 911 around 5:55 pm. She was
taken to [**Hospital3 3583**]. At the OSH a CT of the Head was
obtained which showed a 1.1cm acute on chronic right SDH with
associated mass effect on the adjacent sulci, and a large right
sided subgaleal hematoma. She was loaded with fosphenytoin,
given Zofran, 6 pack of platelets at the OSH and was sent by
helicopter to [**Hospital1 18**] for further evaluation. Upon arrival to the
[**Hospital1 18**] ER she
was awake and alert and did not remember falling. She has also
been transfused with PRBC (stool guaiac has not been done). She
was nauseous and had an episode of emesis in the trauma bay. At
the [**Hospital1 **], left arm twitching (shoulder twitching, spreading down
the arm) was noted by the neurosurgical and trauma ICU teams.
Past Medical History:
COPD
HTN
hypercholesterolemia
on Plavix and ASA for a history of a TIA in [**2095**] which involved
left hand, face and forearm numbness
Gout & hyperuricemia
Social History:
She lives with her husband, and has two adult children: [**Name (NI) 122**]
([**Telephone/Fax (1) 86768**]) and [**Doctor First Name 6480**] ([**Telephone/Fax (1) 86769**]) PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
([**Telephone/Fax (1) 13254**]) Ex-smoker, gave up 28 years ago (40 pack year
history, smoked 2 ppd for 20 y) Alcohol: occasional glasses of
wine and a "Captain [**Doctor Last Name 2031**] with a twist of lime." Retired
manager of a telephone company.
Family History:
She is adopted. Her son has HTN
Physical Exam:
In ED:
HR 102 BP 90/42 RR 18 SpO2 99% RA
GCS 15
large occipital scalp hematoma with laceration, stapled closed
CTAB
RRR
S/obese/ND, mild suprapubic tenderness
large R gluteal hematoma
CII-XII intact
motor, sensory exam and reflexes within normal limits
Pertinent Results:
[**2105-3-30**] 10:23PM PH-7.26* COMMENTS-GREEN TOP
[**2105-3-30**] 10:21PM WBC-25.0* RBC-3.42* HGB-9.7* HCT-28.9* MCV-85
MCH-28.3 MCHC-33.4 RDW-15.2
[**2105-3-30**] 10:21PM PLT COUNT-303
[**2105-3-30**] 10:21PM PT-12.7 PTT-21.1* INR(PT)-1.1
[**2105-3-30**] 10:21PM FIBRINOGE-308
[**2105-3-30**] 09:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2105-3-30**] 09:30PM URINE RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**2-20**]
[**2105-3-30**] 10:23PM GLUCOSE-176* LACTATE-4.0* NA+-145 K+-3.4*
CL--106 TCO2-24
[**2105-3-30**] 10:21PM UREA N-28* CREAT-1.2*
[**2105-3-30**] 10:23PM freeCa-1.09*
CT C-spine from [**Hospital3 3583**] [**2105-3-30**]: 1. No fracture or
traumatic malalignment involving the cervical spine. 2.
Mild-to-moderate multilevel degenerative change, most severe
from C5 through T1, without critical canal stenosis. 3. Small
osseous fragment well-corticated adjacent to the spinous process
of C7 likely represents sequelae of prior trauma. 4. Enlarged
heterogeneous thyroid should be further evaluated with
ultrasound non-emergently if not already performed.
CT head [**2105-3-30**]: 1. Unchanged diffuse subarachnoid hemorrhage,
small left frontal subdural hematoma, and moderate right
acute-on-chronic subdural hematoma. Persistent mass effect upon
the right cerebral sulci and right lateral ventricle, without
evidence for herniation. 2. Large right parietal subgaleal
hematoma, without underlying fracture.
CT abdomen/pelvis [**2105-3-30**]: 1. No evidence of acute visceral
injury in the abdomen or pelvis. 2. Scattered hypodense renal
lesions, too small to characterize. 3. Degenerative changes in
the lumbar spine. 4. Soft tissue contusion/hematoma over the
right gluteal region, incompletely visualized.
CT head [**2105-3-31**]: Slight redistribution but no substantial change
in right
frontoparietal, small left frontal hematoma, and bilateral
diffuse
subarachnoid hemorrhage. There is again no intraventricular
extension and no evidence for increased hematoma or resultant
mass effect. Ventricles remain prominent, though unchanged.
Carotid U/S: [**2105-3-31**]: Right ICA stenosis <40%. Left ICA with no
stenosis.
EEG [**2105-4-1**]: This is an abnormal portable EEG due to slowing and
disorganization of the background rhythm suggestive of a mild
encephalopathy. Medications, toxic/metabolic disturbances or
infections
are common causes. No areas of focal slowing, epilepitoform
discharges
or electrographic seizures were seen during this recording.
CT head [**2105-4-1**]: Stable subarachnoid, subdural and
intraventricular hemorrhage as compared to prior study, with no
new hemorrhage.
MRI head [**2105-4-1**]: 1. Unchanged subdural, subarachnoid and
intraventricular hemorrhage with no evidence of new sites of
hemorrhage, mass effect, or infarction. 2. No evidence of
hippocampal/medial temporal sclerosis or focal cortical
dysplasia.
N.B. There is ample post-traumatic injury which could act as
substrate for
seizures (e.g. the subdural hematoma), without invoking an
additional
underlying anatomic abnormality, such as HS or FCD, which would
only rarely present in a 75 year-old.
CT Abd/Pel [**2105-4-1**]: 1. No evidence intra-abdominal or
retroperitoneal hematoma. 2. Previously described right flank
hematoma incompletely visualized - if clinical concern for
expanding right flank hematoma, then rescanning in the wide-bore
CT scanner with dedicated imaging of the entire right flank
would be recommended.
Brief Hospital Course:
Mrs. [**Known lastname 86767**] was admitted to the Trauma Surgery service
following her fall which resulted in the following injuries:
bilateral subarachnoid hemorrhage, right acute on chronic
subdural hematoma, right gluteal hematoma, right subgaleal
hematoma, and left small subdural hematoma. She was admitted to
the Trauma Surgical ICU because of these injuries for close
monitoring of her mental status. Her ICU course and remaining
hospitalization can be summarized below by systems.
Neuro: At the OSH, she was loaded with fosphenytoin for seizure
prophylaxis which was switched to dilantin here at [**Hospital1 18**]. She
underwent serial head CTs for intermittent confusion which
showed no significant progression of her bleeds. On [**2105-4-1**], the
patient had two short (approx 1 minute) seizures, thought to be
a Jacksonian [**Month (only) **] by neuro consult who suggested an MRI and
switching to keppra. The patient was transitioned to Keppra po
and had no more seizures. She is being discharged on Keppra and
will follow up with Neurology and Neurosurgery in approximately
one month. During her stay, she experienced some dizziness on
standing which was thought to be related to her anemia. After
her hematocrit improved, so did her dizziness. Should this
continue in the future, CTA of her vertebrobasilar system is
recommended. She will follow up with both neurosurgery and
neurology in approximately four weeks.
Heme: The patient had both a head laceration and a right gluteal
hematoma on admission. She had previously been on aspirin and
plavix for a history of TIA. During her stay, she ultimately
required a total of three transfusions of RBCs and one platelet
transfusion. At neurology's and neurosurgery's request because
of the head bleeds, her aspirin and plavix are being held on
discharge for at least one month, especially as neurology felt
her history of a TIA was relatively soft. On [**2105-4-1**], the
patient's hematocrit continued to fall and so a repeat CT of the
abdomen and pelvis was performed and she was noted to still have
a large right gluteal hematoma. It is suspected that that is
where she was intermittently bleeding. Because of her large
size, following this hematoma was difficult. Thus she was
monitored with serial hematocrits and upon discharge had
stabilized at a hematocrit of 28-29.
CV/Resp: no issues
F/E/N: fluids and electrolytes were repleted as necessary. She
was tolerating a regular diet on discharge. No major issues.
Physical Therapy: she was evaluated by physical therapy who
recommended rehab placement. Of note, on the evening of [**4-3**],
the patient fell again while getting up from the commode,
appeared to be a mechanical fall. She did not hit her head or
lose consciousness. Her hematocrit was stable and this appeared
to have no sequelae. She will need to work extensively with PT
during rehab and should be considered to be at high risk of fall
given her recent history of falls and her overall habitus and
strength level.
Medications on Admission:
accupril 20 daily, HCTZ 50 daily, simvastatin 10 daily,
probenecid 500 [**Hospital1 **], albuterol 90 PRN, plavix 75 daily, ASA 81
daily, proair 90 qid PRN, spiriva qd
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q4H (every 4 hours) as
needed for SOB, wheezes.
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Four (4) Capsule PO
DAILY (Daily).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Probenecid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p fall
bilateral subarachnoid hemorrhage
right acute on chronic subdural hematoma
right gluteal hematoma
right subgaleal hematoma
left small subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after falling and bumping your
head, which caused bleeding inside your head and a laceration to
the back of your head which was stapled.
Call your doctoro or return to the Emergency Department for the
following:
confusion, nausea with vomiting, changes in mental status
fevers, chills, increasing pain
Also please see danger signs below.
Followup Instructions:
Please call Dr.[**Name (NI) 1482**] office at ([**Telephone/Fax (1) 1483**] on Tuesday
to schedule a follow up appointment in 2 weeks.
Please call Dr.[**Name (NI) 9399**] (Neurosurgery) office on Tuesday at
[**Telephone/Fax (1) 3231**] in order to schedule a follow up appointment in 4
weeks. You will need to have a non-contrast CT scan of the head
prior to this visit.
You have a follow up appointment with Neurology with DRS.
[**Name5 (PTitle) 43**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2105-5-7**] 4:00.
Please call for directions to their clinic.
ICD9 Codes: 5990, 2930, 2851, 4589, 496, 4019, 2720, 2749
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5708
}
|
Medical Text: Admission Date: [**2140-5-27**] Discharge Date: [**2140-6-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
[**2140-5-27**] [**Doctor Last Name 1352**] L3-5 PSIF Lami
History of Present Illness:
[**5-27**] [**Doctor Last Name 1352**]
[**5-27**] L3-5 PSIF Lami, 600 EBL
HPI: [**Age over 90 **] F L4-L5 spondylolisthesis with mild stenosis at
L3-4, L4-5, and L5-S1, R leg pain, amb with walker
PMH: Angina, HTN, Cholesterol, Skin Cancer, Insomnia, OA,
Restless leg syndrome, osteoperosis
MED: Fosamx 70, Atenlol 25, Aspirin 325, Nitro 0.6 mg SL,
lipitor 10, Gabapentin 100 [**Hospital1 **], Tramadol 50, Triamterene-HCTZ
37.5-25, Calcium 500-vitD, MVI
ALL: NKDA
Social History:
she lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has four
sons, two of whom live close by.
Family History:
No premature CAD, SCD
Physical Exam:
RLE pain
BLE fires L2-S1 motor
Repsonds to senstion throughout BLE
Vitals: TEMP 97.1 HR 83 BP 124/68 RR 23 SAT 96% 3L NC
Gen: Pleasant, well appearing elderly woman lying in bed in NAD
Eyes: No conjunctival pallor. No icterus.
ENT: MMM. OP clear.
CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th
intercostal space, mid clavicular line. RR. nl S1, S2. No
murmurs, rubs, clicks, or gallops. Full distal pulses
bilaterally. No femoral bruits.
LUNGS: L>R crackles. predominately basilar crackles on R, [**1-2**]
way up on the L. No wheezes or rales.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
Heme/Lymph/Immune: No CCE, no cervical lymphadenopathy.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Gait assessment deferred
PSYCH: Mood and affect were appropriate.
Pertinent Results:
[**2140-5-27**] 02:35PM BLOOD WBC-16.6*# RBC-2.98*# Hgb-9.5*#
Hct-29.1*# MCV-98 MCH-31.9 MCHC-32.7 RDW-14.5 Plt Ct-443*
[**2140-5-30**] 06:58AM BLOOD Neuts-85.1* Lymphs-7.6* Monos-6.6 Eos-0.5
Baso-0.2
[**2140-5-27**] 02:35PM BLOOD PT-13.4 PTT-27.6 INR(PT)-1.1
[**2140-5-27**] 02:35PM BLOOD Glucose-143* UreaN-11 Creat-0.7 Na-139
K-3.4 Cl-107 HCO3-25 AnGap-10
[**2140-5-29**] 09:20AM BLOOD CK(CPK)-508*
[**2140-5-30**] 06:58AM BLOOD CK-MB-23* MB Indx-10.7* cTropnT-1.17*
proBNP-[**Numeric Identifier 4978**]*
[**2140-5-30**] 09:02PM BLOOD CK-MB-13* MB Indx-9.6* cTropnT-1.30*
[**2140-5-31**] 03:23AM BLOOD CK-MB-10 MB Indx-9.8* cTropnT-1.26*
[**2140-6-1**] 05:30AM BLOOD Calcium-8.2* Phos-1.9* Mg-1.8
[**2140-5-30**] 06:58AM BLOOD TSH-2.4
[**2140-5-31**] 03:23AM BLOOD Cortsol-21.8*
[**2140-5-27**] 02:57PM BLOOD Type-ART Temp-36.3 Rates-/12 Tidal V-500
FiO2-50 pO2-84* pCO2-42 pH-7.36 calTCO2-25 Base XS--1
Intubat-INTUBATED
[**2140-5-29**] 05:18PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2140-5-29**] 05:18PM URINE Blood-MOD Nitrite-NEG Protein-75
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2140-5-29**] 05:18PM URINE RBC-[**6-9**]* WBC-[**3-4**] Bacteri-FEW Yeast-NONE
Epi-[**3-4**]
[**2140-5-29**] 05:18PM URINE CastGr-0-2 CastHy-[**3-4**]*
ECG [**2140-5-29**]: regular, narrow-complex tachycardia at 148 bpm,
left axis deviation, lateral ST-segment depression in V5-V6
compared with abseline ECG.
.
ECHO: The left atrium is mildly dilated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is severely depressed with septal and apical akinesis
(LVEF= 25 %). Cannot exclude apical thrombus. There is distal
right ventricular free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is mild functional mitral
stenosis (mean gradient 4mmHg) due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.There is moderate pulmonary artery systolic
hypertension.
.
OTHER TESTING:
CXR ([**2140-5-29**]): Single frontal view of the chest demonstrates
cardiomegaly. There is mild congestive failure with essential
prominence of the pulmonary vasculature. Aorta is somewhat
ectatic and the arch is calcified. There is left lower lobe
consolidation and a small left pleural effusion. The patient is
somewhat rotated.
.
CXR ([**2140-6-1**]): As compared to the previous radiograph, there is
unchanged moderate cardiomegaly and unchanged course and
position of the left-sided PICC line. Also unchanged is the
minimal left apical pneumothorax. The pre-existing opacity at
the left lung base is smaller and less dense than on the
previous examination. No newly occurred focal parenchymal
opacities.
Brief Hospital Course:
The patient underwent an uncomplicated procedure. She was
transfused 1 RBC. She was discharged to rehab about a routine
postop recovery. She was given written information and
precautionary guidance.
MICU Course- Patient admitted to the MICU after developing SVT,
delirium and leukocytosis on POD 3. Prior to transfer, EKG
obtained showed sinus rhythm with borderline left axis
deviation, borderline intraventricular conduction delay with TWF
in the inferolateral leads (all changes new since previous EKG
on record [**2123**]). CXR showed likely LLL infiltrate and increased
vascular markings suggestive of CHF. CE's trended with peak
troponin of 1.30, peak CK of 508 and peak MB of 37. Diagnosed
with NSTEMI vs demand ischemia. Cardiology consulted and
recommended medical management as patient could not be bolused
with heparin given recent spinal procedure. Therefore, she
could not undergo catheterization. She was started on aspirin
325mg, beta-blocker, high-dose statin. She underwent TTE on [**5-31**]
which showed EF of 25% with septal and apical akinesis.
After transferring to floor, she was taken off the heparin.
Questionable thrombus in left ventricle was evulated and thought
to be old with fibronsis over it, so patient was maintained on a
full dose of aspirin. She was not started on warfarin due to
her history of multiple falls. She remained afebrile
thoroughout her stay. Physical therapy evaluated her. It was
thought that her troponin leak is rate related and her poor EF
is due to an old MI. This post-op tachyarrhythmia revealed the
defect and cause her troponin to raise. She remained in sinus
on the floor and was discharged in stable condition. Her PICC
line was stopped and her foley was discharged. She does have a
residue small apical pneumothorax which we are following with
serial CXR. No intervention needed at this point but may need a
repeat CXR in about a week.
She has to follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2140-6-13**] 10:40. She also needs to
wear TLSO brace while she is up and out of bed for the next 4
weeks. She needs to follow up with her PCP for post
hospitalization followup. Please follow up with a cardiologist
at a location near your rehab regarding further titration of
your medications.
Medications on Admission:
MED: Fosamx 70, Atenlol 25, Aspirin 325, Nitro 0.6 mg SL,
lipitor 10, Gabapentin 100 [**Hospital1 **], Tramadol 50, Triamterene-HCTZ
37.5-25, Calcium 500-vitD, MVI
Discharge Medications:
1. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for GI upset.
3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nitroglycerin 0.6 mg Tablet, Sublingual Sig: [**1-2**] Sublingual
PRN (as needed) as needed for chest pain.
10. Gabapentin 100 mg Capsule Sig: [**1-4**] Capsules PO BID (2 times
a day): 200 in am, 100 in pm, 400 in evening.
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**]
Discharge Diagnosis:
L3-L5 Spinal Stenosis
SVT
h/o MI
CHF
low urine output
hypotension
AMS
anemia
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mrs. [**Known lastname 4643**], you came to the hospital for back surgery. After
surgery, you developed a very fast heart rate and arrythmia
called atrial flutter. We were able to control your heart rate
and you converted back to the regular rhythm. However,
evaluation of your heart showed that you had a previous silent
heart attack that caused a reduction in how effective your heart
pumps. We believe this is the reason for all the lab
abnormalities when your heart was beating very fast. You were
discharged in stable condition and was started on the following
new medications (see below).
Please follow up the following doctors.
Please note we made the following changes to your medications.
STOPPED:
Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
INCREASED:
1. Aspirin 81mg by mouth daily to Aspirin 325 mg Tablet Sig:
One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet PO DAILY to Atorvastatin 80 mg
Tablet Sig: One (1) Tablet PO DAILY (Daily).
STARTED:
Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Lasix 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig:
0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
It was a pleasure taking care of you. We wish you the best on
your road to recovery.
You have activity limitations:
No Bending
No Twisting
No Lifting
Please call your PCP if your weight increases >2lb in one day.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2140-6-13**] 10:40
Please follow up with your PCP and cardiologist near your rehab.
You need to have your medications titrated to appropriate
level, specifically with regard to your diuretics.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
ICD9 Codes: 486, 4280, 9971, 4019, 2859, 2720, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5709
}
|
Medical Text: Admission Date: [**2152-9-25**] Discharge Date: [**2152-10-2**]
Date of Birth: [**2086-5-8**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname 25121**] is a 66 year-old female on Coumadin for DVT/PE with
a history of colitis in [**11-4**] presenting with abdominal pain
that started yesterday morning at 7AM. Per her reports the
crampy pain occurred suddenly, localized to the bilateral lower
quadrants associated with nausea but no vomiting. The pain
continued to persists into today with increasing intensity.
Ofnote, she reports that she noticed a "[**Doctor Last Name **]" in her left lower
abdominal yesterday afternoon. Since that time, she has
continued to have flatus and had a last BM today at 10AM. She
reported that she thought it may have been constipation and took
some Ex-Lax this morning with relief. She has had mild low
grade fevers last night. Her last bowel movement was normal
without blood or diarrhea.
Her last colonoscopy with in [**2143**] which showed Grade 1 internal
hemorrhoids, diverticulosis of the sigmoid colon.
Past Medical History:
Past Medical History: Hypercholesterolemia, DVT/PE, [**Doctor Last Name 15532**]
esophagus, hiatal hernia, fibromyalgia
Past Surgical History: Left breast lumpectomy s/p chemo
radiation
6 years ago, right leg operation c/b DVT on Coumadin, bilateral
toe operations
Social History:
Social History: Lives in [**Location 2624**] with husband, has four children.
Works as a office assistant for her husband. Denies current
tobacco, recreational drugs. Reports social EtOH and history of
tobacco 1pack/week x 2 years remotely.
Family History:
Significant for her mother's side who had breast cancer at the
age of 70 and also a benign brain tumor. She has two cousins,
from the mother's side, who had breast cancer; one was diagnosed
at the age of 42 and the other was diagnosed at the age of 60.
Her maternal grandmother also had breast cancer but she is not
sure at what age she had. On her father's side, her father was a
love and only child, and she does not know anything about her
paternal grandparents.
Physical Exam:
Physical Exam:
Vitals:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mild TTP bilateral lower quadrants, no
rebound or guarding, normoactive bowel sounds, no palpable
masses, tympanic.
DRE: normal tone, no gross or occult blood
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2152-9-25**] 12:55PM WBC-14.7*# RBC-4.49 HGB-13.2 HCT-39.3 MCV-87
MCH-29.4 MCHC-33.7 RDW-13.5
[**2152-9-25**] CT abdomen/pelvis: Perforated sigmoid diverticulitis
with large amount of pneumoperitoneum. No abscess.
Brief Hospital Course:
Mrs. [**Known lastname 25121**] was admitted to the TSICU given [**Last Name (un) 17147**] III
diverticulitis. She was kept NPO, started on IVF. IV
cipro/flagyl was initiated. She continued to improve clinically
with conservative management, pain resolving, so a decision was
made to continue conservative management. She remained stable in
the ICU and was transferred to the floor. On hospital day 4 a
gastrograffin enema was obtained which showed a small leak. She
was managed nonoperatively. On HD 5 she was started on a
heparin drip for concern of her past medical history of DVT and
PE. Her pain improved and she was gradually restarted on clears
then advanced to a regular diet which she tolerated without
recrudescent pain. She was discharged on [**2152-10-2**] in good
condition. Per discussion with her primary care physician she
was to restart her home dose of coumadin without further
bridging as she had been stable on that regimen without
complications.
Medications on Admission:
Coumadin 3mg daily, Omeprazole 40mg daily,
Simvastatin 40mg daily, Alendronate, Femara 2.5mg daily
Discharge Medications:
1. warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Please see your PCP regarding INR checks.
2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated sigmoid diverticulitis
Secondary:
Hypercholesterolemia
H/o DVT/PE
[**Doctor Last Name 15532**] esophagus
hiatal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for a diverticulitis episode. This
was hadled conservatively, meaning you were allowed nothign to
eat and we waited for your bowel function to return, which it
did. You were advanced to a regualr diet, which you tolerated
well. You were sent home with minimal abdominal pain and
tolerating a regular diet. You also came in with a history of
known pulmonary embolisms that you were sent home on coumadin
for.
You may resume your own diet, but should make sure it is high
fiber. Please take your antibiotics as prescribed. You may
resume all your home medications on discharge.
Followup Instructions:
Please call for an Acute Care Service appointment at
[**Telephone/Fax (1) 600**]. You should schedule this appointment for 4 weeks
from discharge. You should make this appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Please also follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16258**], [**Numeric Identifier 32369**] next
Monday, [**2152-10-9**], to have your INR checked. You were discharged
on your home dose of coumadin to start tonight. You should also
discuss repeating your colonscopy with your PCP before your
follow up appointment with Dr. [**Last Name (STitle) **] in ACS.
Completed by:[**2152-10-2**]
ICD9 Codes: 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5710
}
|
Medical Text: Admission Date: [**2144-12-30**] Discharge Date: [**2145-1-5**]
Date of Birth: [**2082-8-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea, scrotal edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62M hx of CVA 7 yrs prior, CHF with reported EF 25% thought
secondary to EtOH, afib of unclear duration not on medications
due to compliance, asthma, going EtOH abuse who presented to
[**Hospital3 26615**] hospital with dyspnea and scrotal edema. States
that for the past few months he has had worsening dyspnea
without chest pain, first occurred with exertion but for the
past 2-3 weeks has been at rest. He has a history of asthma and
recently received a script for an albuterol inhaler, which he
has been taking 4-5 times per day for the past 2 weeks for his
dyspnea. He also noticed over the past 2 weeks progressive
lower extremity edema that began in his ankles and has spread to
his mid thorax, notably with a large amount of scrotal edema.
For the past 3 days, his scrotum has also become painful and
tender. Denies fevers/chills. States that he was drinking (~1
6pk per day) up until 2 weeks ago when his dyspnea at rest
began. He is not the best historian, however, as he exhibited
some word finding difficulties and some difficulty with recall.
.
He went to [**Hospital3 26615**] hospital where he was noted to be in afib
with RVR with rates to the 140s. He was given IV diltiazem
multiple times and eventually placed on a dilt drip, which
dropped his BP into the 80s. He was PO loaded with 50 metop and
was given 60mg IV lasix with ~500cc output. He was then
transferred to [**Hospital1 18**] for further management.
.
On arrival to the CCU, he was mildly dyspneic at rest but felt
comfortable. Denied chest pain, palpitations. States he had
pain in his scrotum exacerbated by the ambulance ride from the
OSH. Otherwise, ROS is negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Reported history of cardiomyopathy with EF
25%, no records sent. Also reported history of at least 2
months of atrial fibrillation.
3. OTHER PAST MEDICAL HISTORY:
-CVA 7 years prior with no residual deficits (patient does not
know which side his stroke affected)
-ETOH abuse
Social History:
- Tobacco history: 1ppd since age 17, with many years of [**1-22**]
ppd
- ETOH: drinking since [**49**], beer only, at peak ~24 beers per
day, now drinking only 6 beers per day. Last drink ~2 wks
prior. Has withdrawn in the past, never had seizures.
- Illicit drugs: Remote history of polysubstance abuse, +IVDU
with heroin, +crack cocaine use
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ON ADMISSION:
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Not in
respiratory distress.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with markedly elevated JVP to the angle of the
mandible, +HJR.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations mildly labored. Crackles bilaterally 1/2 up.
Decreased breath sounds at both bases. No wheeze/rhonchi.
ABDOMEN: Soft, NTND, +BS. No HSM or tenderness. +hepatojugular
reflex.
EXTREMITIES: No c/c. +3 pitting edema to the hips, [**12-21**]+ to the
mid thorax. Scrotum is tense, edematous, erythematous and
tender to palpation. No necrosis or focal area of erythema
noted. +penile edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. No
spider angiomata, palmar erythema noted.
AT DISCHARGE:
VS: AF Tm 98.4 122-140/80-90s HR >100 up to 120s this AM RR 18
96% RA
Scrotal edema almost gone, pt still with 2+ lower extremity
pitting edema (chronic) no crackles on auscultation of lungs.
Pertinent Results:
CBC
[**2144-12-30**] 10:47PM BLOOD WBC-13.5* RBC-5.01 Hgb-15.9 Hct-47.7
MCV-95 MCH-31.8 MCHC-33.4 RDW-13.0 Plt Ct-326
[**2145-1-5**] 06:20AM BLOOD WBC-8.1 RBC-4.46* Hgb-14.4 Hct-42.0
MCV-94 MCH-32.2* MCHC-34.2 RDW-12.9 Plt Ct-218
DIFF
[**2144-12-30**] 10:47PM BLOOD Neuts-84.7* Lymphs-9.1* Monos-5.0 Eos-0.6
Baso-0.7
[**2145-1-5**] 06:20AM BLOOD Neuts-65.9 Lymphs-22.3 Monos-7.6 Eos-3.5
Baso-0.8
COAGS
[**2144-12-30**] 10:47PM BLOOD PT-16.1* PTT-35.7 INR(PT)-1.5*
[**2145-1-5**] 06:20AM BLOOD PT-18.7* PTT-60.8* INR(PT)-1.8*
ELECTROLYTES
[**2144-12-30**] 10:47PM BLOOD Glucose-163* UreaN-28* Creat-1.8* Na-139
K-4.3 Cl-99 HCO3-23 AnGap-21*
[**2145-1-5**] 06:20AM BLOOD Glucose-134* UreaN-23* Creat-1.0 Na-142
K-3.2* Cl-97 HCO3-38* AnGap-10
LFTs
[**2144-12-30**] 10:47PM BLOOD ALT-63* AST-81* LD(LDH)-390* CK(CPK)-305
AlkPhos-108 TotBili-1.4
OTHER PERTINENET LABS
[**2144-12-30**] 10:47PM BLOOD GGT-231*
[**2144-12-30**] 10:47PM BLOOD CK-MB-12* MB Indx-3.9 cTropnT-0.07*
[**2144-12-30**] 10:57PM BLOOD %HbA1c-6.5* eAG-140*
[**2144-12-30**] 10:47PM BLOOD Triglyc-64 HDL-83 CHOL/HD-2.3 LDLcalc-98
[**2144-12-31**] 06:14AM BLOOD TSH-2.8
[**2144-12-30**] 10:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
STUDIES:
ECG on presentation [**2144-12-30**]
Atrial fibrillation with rapid ventricular response. RSR'
pattern in
leads V1 and V2. Anterolateral T wave inversion, possibly
related to ischemia. No previous tracing available for
comparison.
CXR [**2144-12-30**]
Moderate bilateral pleural effusions are associated with
adjacent bibasilar atelectasis. There is mild vascular
congestion. Cardiac size is obscured by the pleural parenchyma
abnormalities.
TTE [**2144-12-31**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is mildly dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 25%). Right
ventricular chamber size is normal with mild global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Biatrial enlargement. Mildly dilated left ventricle
with normal wall thickness and severely depressed global left
ventricular systolic function. Mild global right ventricular
free wall hypokinesis. Moderate mitral regurgitation. Mild to
moderate tricuspid regurgitation. Moderate pulmonary artery
systolic hypertension.
Brief Hospital Course:
62M hx of CVA, afib not compliant with medications, CHF with
reported EF of 25%, going EtOH abuse, who presents with multiple
months of progressive dyspnea now at rest and 2 weeks of lower
extremity edema, as well as atrial fibrillation with rapid
ventricular rate.
.
# Afib with RVR: unclear history of afib, per the patient, was
diagnosed 2 months prior at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He is supposed to be
taking medications at home, which he does not know the names,
and which is is not taking. He has been previously asymptomatic
from his rhythm/rate. Etiology likely secondary to CHF with
marked volume overload (caused by ETOH direct myocardial
toxicity). Ischemia was thought to be unlikely. Pt was rate
controlled on admission after receiving 50mg Po metoprolol at
OSH. Metoprolol was continued. Regarding anticoagulation, pt was
started on a heparin gtt and eventually bridged to coumadin
(CHADS2 score 4 - CHF, HTN, stroke). Pt was counseled at length
about the importance of anticoagulation and the importance of
abstaining from alcohol use while on coumadin.
.
# Systolic heart failure: unclear history, per patient has
cardiomyopathy diagnosed 2 months prior. Reportedly echo from
OSH with EF 25%, no report sent. Exam on admission revealed,
has evidence of marked right sided overload with anasarca and
JVD. Also has evidence of pulmonary edema with effusions,
suggesting a mixed left/right sided failure picture. Denies
chest pain. EKG without changes to suggest ischemic cause for
decompensation. CXR with bilateral effusions and mild pulmonary
edema. BNP [**Numeric Identifier 961**] at OSH. Is actively drinking, and likely is
the etiology for his cardiomyopathy (complicated by Afib, see
above). First set of enzymes suggestive of demand ischemia with
mild troponin leak not elevated past his set at the OSH. No
suspicion for CAD or acute ACS. Heart failure was treated as
below. Started aspirin 81 mg and lasix gtt with goal fo 3-4 L
out per day pending renal function. Pt put out over 10 L during
this hospital stay.
TTE [**2144-12-31**] showed biatrial enlargement. Mildly dilated left
ventricle with normal wall thickness and severely depressed
global left ventricular systolic function. Mild global right
ventricular free wall hypokinesis. Moderate mitral
regurgitation. Mild to moderate tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension. (LEVF = 25%)
.
# Scrotal pain: secondary to profound anasarca and significant
edema in the scrotum. There were no signs of infection, pt was
afebrile, and once foley inserted pt put out large quantities of
urine with rapid resolution of scrotal edema. UA was positive
for blood, felt secondary to foley insertion, but without
evidence of infection.
.
# [**Last Name (un) **]: unclear baseline, Cr 1.4 at OSH and down to 1.2 on
transfer to [**Hospital1 18**]. Likely in setting of poor forward flow due
to worsening volume status and heart failure. Pt diuresed well
(>10L out) over course of this hospitalization. Transitioned to
PO lasix and discharged with PO regimen.
.
# ETOH abuse: longstanding history. Reportedly last drink was 2
weeks prior, has history of withdrawal but no history of
seizures. Does not appear tremulous on exam. No obvious ascites
on exam to suggest portal hypertension, plus his marked JVD
speaks to cardiac etiology for his edema rather than liver. Pt
was given thiamine, folate, MVI, lytes repleted prn. Started on
CIWA scale but pt never scored and recieved no benzodiazepines
for this.
.
# HTN: history of HTN, reportedly was hypertensive at OSH prior
to initiation of dilt gtt, which then made him hypotensive. On
admission pt was hypertensive and was started on a nitro drip.
He was also started on an esmolol drip for rate control and
hypertension. Esmolol was unsuccessful and pt switched to
diltiazem drip which did lower his heart rate to the low 100s.
Dilt gtt was stopped and over the next several days BP rose to
pressures as high as 160/110, improved with beta blockade and
linsinopril (pt sent home with these medications).
.
PT was maintained as DNR/DNI throughout this hospitalization.
Medications on Admission:
albuterol prn. reportedly supposed to be taking warfarin but is
noncompliant.
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
3. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
4. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day.
Disp:*60 Tablet, ER Particles/Crystals(s)* Refills:*2*
5. warfarin 2 mg Tablet Sig: 2.5 Tablets PO Once Daily at 4 PM.
Disp:*90 Tablet(s)* Refills:*2*
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Health of [**Location (un) 5028**]
Discharge Diagnosis:
Acute systolic congestive heart failure
New Atrial fibrillation
Dyslipidemia
Hypertension
Tobacco abuse
Alcohol Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had fluid retention because your heart was not pumping well
which caused swelling in your scrotal area and in your legs. You
were given diuretics to get rid of the fluid and will need to
take your pills every day to stay out of the hospital and get
rid of the remaining fluid. Weigh yourself every morning, call
Dr. [**Last Name (STitle) 82705**] if weight goes up more than 3 lbs in 1 day or 5
pounds in 3 days. You have a heart rhythm problem called atrial
fibrillation which makes you much more likely to have another
stroke. You have been started on warfarin (coumadin) to prevent
a stroke and will need to get your INR (warfarin level) checked
regularly to make sure the warfarin level is not too high or too
low. We want your INR to be between 2.0 and 3.0.
You had some diarrhea but this was not due to an infection. Your
heart rate and blood pressure are still too high so you will
need to follow up with your doctors on a regular basis to
titrate the medicines up so your heart can get stronger. It is
extremely important that you stop smoking and drinking,
otherwise your heart will stay weak and you will need to come
back to the hospital repeatedly.
.
We have started the following medicines:
1. Warfarin to prevent a stroke
2. Lisinopril to lower your blood pressure and help your heart
pump better
3. Metoprolol to lower your heart rate and help your heart pump
better
4. Potassium to increase a low potassium level
5. Furosemide to help get rid of extra fluid.
6. Multivitamin to help your nutrition.
.
Please wear the tight white stockings daily to decrease fluid in
your legs.
Followup Instructions:
Cardiology:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A. MD
37 [**12-21**] [**Location (un) 5028**] [**Numeric Identifier 12023**]
([**Telephone/Fax (1) 91979**] Fax: [**Telephone/Fax (1) 91980**]
Thursday [**2145-1-14**] at 12:15PM
.
Primary Care:
Name: [**Last Name (un) **],[**Last Name (un) 75760**] A. MD
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 86648**], [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 75761**]
Fax: [**Telephone/Fax (1) 86319**]
Friday [**2145-1-8**] at 11:30 with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP
Fax: [**Telephone/Fax (1) 85734**]
ICD9 Codes: 5849, 4168, 4280, 2724, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5711
}
|
Medical Text: Admission Date: [**2199-1-25**] Discharge Date: [**2199-1-31**]
Service:
DATE OF DEATH: [**2199-1-31**]
The patient is an 83-year-old patient with multiple medical
problems who presented to [**Hospital1 188**] on [**2199-1-25**], with complaint of intermittent diarrhea,
nausea following a viral URI (treated with Zithromax). The
patient initially went to an outside hospital where she was
noted to have a K of 10. She transferred here for a possible
hemodialysis. At [**Hospital1 69**], the
patient was treated with Kayexalate, bicarbonate, calcium,
D50, insulin and Lasix. She was also noted to be in acute
renal failure, BUN and creatinine were 122 and 3.4
respectively with a K of 10 and bicarbonate of 9.
The patient is without history of renal insufficiency, it was
thought that the patient's metabolic acidosis was secondary
to severe diarrhea and acute renal failure, was prerenal in
etiology. In the MICU, K and acidemia improved with
hydration. The patient also underwent abdominal CT, which
was within normal limits. The patient was called out of the
MICU on [**2199-1-26**], noted to have improved renal function.
Spironolactone was restarted shortly thereafter on the floor.
The patient's systolic blood pressure was around 90-100 on
the afternoon of [**2199-1-29**], did spike a temperature to 101
associated with shortness of breath and rigors. Chest x-ray
showed no evidence of CHF or infiltrate. She was
pancultured. EKG showed increased rate with no other
changes. In the evening of [**2199-1-29**], she was noted to be
hypotensive with the BP in the 60s, given fluid boluses,
started on low-dose dopamine and transferred to the MICU.
EKG noted for new onset atrial fibrillation.
PAST MEDICAL HISTORY: CHF, EF of 30 percent on 3 liters of
home O2.
Bilateral CEA.
CAD status post CABG, [**2190**].
Dyslipidemia.
Pacemaker placement status post syncope.
AICD placement status post Vtach, [**2193**].
Hypertension.
OA.
Hypothyroidism.
Pulmonary hypertension.
ALLERGIES: No known drug allergies.
TRANSFER MEDICATIONS: Included Lipitor, sotalol, furosemide,
KCl, metoprolol, levothyroxine, docusate, ASA,
spironolactone, amlodipine, pantoprazole, and heparin.
PHYSICAL EXAMINATION: Elderly-appearing female,
uncomfortable. Temperature was 98.0 degrees, blood pressure
73/30, heart rate 109, respiratory rate 29, O2 saturation was
96 percent on room air and 100 percent on nonrebreather.
HEENT: Normocephalic, atraumatic, PERRL. Mucous membranes
were moist. Sclerae were anicteric. Neck was supple with no
lymphadenopathy, no carotid bruits, right subclavian line.
CARDIOVASCULAR: Tachy, irregular, S1, S2 with 2/6 systolic
ejection murmur. Lungs were clear to auscultation
anterolaterally. Abdomen was obese, soft and nontender,
nondistended with no hepatosplenomegaly. EXTREMITIES: No
CCE. NEUROLOGIC: Alert and oriented x3. Cranial nerves II
to XII are grossly intact, moved all extremities well.
LABORATORY FINDINGS: Relevant data on MICU transfer included
CBC which was essentially within normal limits with the
exception of a creatinine of 1.8. UA with moderate bacteria
with 42 white blood cells and urine and blood cultures were
pending. Etiology data was reviewed essentially above.
ASSESSMENT, PLAN AND HOSPITAL COURSE: An 83-year-old female
with history of cardiac disease admitted to MICU on [**2199-1-25**]
with hyperkalemia, acidemia, and acute renal failure, was
readmitted to the MICU with new onset of atrial fibrillation
with RVR and associated hypotension. Lab data notable for
UTI and leukocytosis.
Hypotension: Differential initially included sepsis,
hypovolemia, diuresis, poor forward flow in the setting of
adrenal insufficiency and MI. The patient was continued on
pressors, and she was originally placed on rule out sepsis.
Plan in addition, urine culture came back positive for fecal
contamination and blood cultures showed gram positive cocci
in clusters and pairs. Thus she was started on vancomycin
and Levaquin and Flagyl for ? C-difficile after Zithromax.
Left subclavian line was removed and a new line was inserted.
The patient was given a cortisol test, which was not in
keeping with adrenal insufficiency. No labs are going to be
drawn given family preference given the hypotension and poor
prognosis of this septic patient; this was in context of a
family meeting, [**2199-1-30**], to discuss the plan. The family
decided on yes antibiotics and supportive care; no lab draws,
no pressors; DNR/DNI. The patient had been kept on pressors
until this point.
Sepsis: The fever began to trend down with the treatment
with antibiotics. Blood cultures were positive in 5 out of 6
bottles. Levaquin was continued for ? UTI, Flagyl for ? C.
difficile and vancomycin was continued as well.
Atrial fibrillation: The patient was continued on
amiodarone. She had the pacer but the ICD was disabled per
family interest and patient's comfort and to avoid shocking
this very ill patient.
Coronary artery disease: The patient was continued on
aspirin and statin, followed on telemetry.
GI: Clostridium difficile assay was attempted although the
patient did not have a bowel movement in the final days of
her life and comfort was the main key here.
FEN: Ad lib given goal of patient comfort.
PPI: PPX, subcutaneous heparin, PPI.
Communication was with the patient and the daughter.
Respiratory failure: The patient was hypoxemic and kept on
face mask to keep comfortable. She did not tolerate BiPAP or
nonrebreather well. Given the better articulated family
goals and patient's goal, the patient was maintained on
facemask.
DISPOSITION: Plan was initially to transfer the patient to
the floor, but after a brief stay in the MICU and transfer of
antibiotics to oxacillin on the day of her death. The
patient was kept in the MICU just for the sake of comfort and
lack of disruption and she passed away on the night of
[**2199-1-31**] with her family and friends at the bedside.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25971**] [**Name8 (MD) **], MD
Dictated By:[**Last Name (NamePattern1) 25972**]
MEDQUIST36
D: [**2199-5-28**] 18:37:50
T: [**2199-5-29**] 23:37:53
Job#: [**Job Number 25973**]
ICD9 Codes: 5845, 5990, 2767, 2762, 4280, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5712
}
|
Medical Text: Admission Date: [**2121-6-2**] Discharge Date: [**2121-6-5**]
Service: MEDICINE
Allergies:
Cardizem / Lisinopril
Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 year old female with PMH CHF, Afib, CAD, DM2 chief complaint
of tachypnea, hypoxia. Family reports that over two weeks she
has had increased fatigue, lethargy as well as cough. Starting
one day prior to admission she was noted to have significantly
worsened dyspnea and tachypnea to 30's-40's. MD [**First Name (Titles) **] [**Last Name (Titles) 4382**] recomended she go to the ED however yesterday pt refused.
In clinic today she denied any pain or other concerns. She was
tachypnic with RR 34, BP 146/80 T98.4 91% on 2L NC at rest with
desat to 86% with moving to exam table and lying down for EKG.
She also was found to have diffuse wheezing and bilateral
crackles on lung ausculation, and be in Afib with RVR at
105-120. Per family ROS is negative for any fevers, vomiting,
diarrhea, chest pain, palpitations. Her weight is stable,
without lower extremity edema. In clinic she was suspected to
have CHF exacerbation due to worsened Left sided heart failure.
Past Medical History:
1. Atrial fibrillation anticoagulated on coumadin.
2. Coronary artery disease.
3. Congestive heart failure -diastolic.
4. Hypertension.
5. Dementia.
6. Hyperlipidemia.
Social History:
Pt lives with her son and daughter in law. Has 4 children.
Former smoker (20 pack year hx, quit 30 yrs ago). No EtOH.
Family History:
Noncontributory
Physical Exam:
VS: 99.5 139/77 HR 80 92% 3L w RR 26
Gen: elderly, fatigued, somnulent
HEENT: MM dry, sclera anicteric.
NECK: JVP at angle of jaw
CARDS: Irreg irreg. Prominent S1. Parasternal heave. II/VI LLSB
systolic murmur. No diastolic murmur.
LUNGS: Resp labored. Rales throughout with course crackles bilat
bases. Exp wheeze faint.
ABDOMEN: Soft, NTND. No HSM or tenderness. No rebound or
guarding.
EXTREMITIES: Warm well perfused. Trace LE edema.
SKIN: dry, No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
NEURO: AAO to person, place, [**2121-3-23**] but fatigues easily.
Motor [**5-27**] bilat distal upper/lower. [**Last Name (un) 36**] to light touch
Pertinent Results:
[**2121-6-2**] 03:30PM BLOOD WBC-5.5 RBC-4.81# Hgb-13.6# Hct-42.8#
MCV-89 MCH-28.3# MCHC-31.8 RDW-14.5 Plt Ct-179#
[**2121-6-5**] 04:20AM BLOOD WBC-8.1 RBC-3.92* Hgb-11.5* Hct-37.7
MCV-96 MCH-29.5 MCHC-30.6* RDW-15.2 Plt Ct-176
[**2121-6-5**] 06:15AM BLOOD PT-30.2* PTT-39.3* INR(PT)-3.1*
[**2121-6-3**] 06:35AM BLOOD PT-79.3* PTT-55.6* INR(PT)-10.0*
[**2121-6-2**] 03:30PM BLOOD PT-53.1* PTT-44.2* INR(PT)-6.1*
[**2121-6-2**] 03:30PM BLOOD Glucose-149* UreaN-33* Creat-1.2* Na-143
K-4.9 Cl-97 HCO3-35* AnGap-16
[**2121-6-5**] 04:20AM BLOOD Glucose-350* UreaN-78* Creat-2.2* Na-136
K-5.1 Cl-95* HCO3-33* AnGap-13
[**2121-6-2**] 03:30PM BLOOD CK(CPK)-97
[**2121-6-2**] 11:00PM BLOOD CK(CPK)-112
[**2121-6-3**] 06:35AM BLOOD CK(CPK)-93
[**2121-6-5**] 04:20AM BLOOD CK(CPK)-27
[**2121-6-2**] 03:30PM BLOOD CK-MB-NotDone proBNP-6976*
[**2121-6-2**] 03:30PM BLOOD cTropnT-0.05*
[**2121-6-2**] 11:00PM BLOOD CK-MB-7 cTropnT-0.05*
[**2121-6-3**] 06:35AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2121-6-5**] 04:20AM BLOOD CK-MB-NotDone cTropnT-0.06* proBNP-[**Numeric Identifier 26589**]*
[**2121-6-4**] 11:12AM BLOOD Digoxin-2.5*
[**2121-6-5**] 04:20AM BLOOD Digoxin-2.6*
[**2121-6-3**] 03:42PM BLOOD Type-ART pO2-97 pCO2-93* pH-7.27*
calTCO2-45* Base XS-11
[**2121-6-4**] 09:10AM BLOOD Type-ART pO2-61* pCO2-90* pH-7.30*
calTCO2-46* Base XS-13
[**2121-6-4**] 11:41AM BLOOD Type-ART pO2-104 pCO2-97* pH-7.27*
calTCO2-47* Base XS-13 Intubat-NOT INTUBA
[**2121-6-4**] 09:31PM BLOOD Type-ART O2 Flow-5 pO2-131* pCO2-89*
pH-7.30* calTCO2-46* Base XS-13 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2121-6-2**] 03:46PM BLOOD Lactate-1.7
[**2121-6-3**] 03:42PM BLOOD Hgb-14.5 calcHCT-44
[**2121-6-4**] 11:17PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2121-6-2**] 05:00PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2121-6-4**] 11:17PM URINE RBC->50 WBC-[**3-27**] Bacteri-NONE Yeast-NONE
Epi-0
[**2121-6-2**] 05:00PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0 TransE-0-2
[**2121-6-2**] 05:00PM URINE CastHy-21-50*
[**6-4**] C diff negative. Blood cultures x2 pending.
[**6-2**] Blood cultures x2 pending
Brief Hospital Course:
On the floor she was treated for presumed PNA with levaquin and
diuresed with torsemide (maintained even) given clinical exam
and elevated BNP (6900). She developed acute renal failure w Cr
bump to 1.7. Triggered on [**6-4**] at 9am for tachynpea and hypoxia.
O2 sat 87% 4L w RR 32-36. ABG 7.3/90/61 w HCO3 46. She was
transferred to the CCU.
.
In the CCU, the patient was started on an esmolol gtt for rate
control. ABG did not improve despite BiPap. She was diuresed
with a lasix drip. However her blood pressure dropped into the
80s -responsive to fluid bolus. [**6-5**] the CCU team had a family
meeting and it was agreed to make the patient CMO.
That evening at 9:30pm the patient died. No pupillary reflexes.
No pulse. Patient was warm. No breath sounds. Not arousable to
sternal rub. The family was notified, and declined autopsy.
Medications on Admission:
Atorvastatin 10mg po daily
Digoxin 125mcg po daily
Donepezil 10mg po qhs
Metoprolol 62.5mg po daily
Omeprazole 20mg po daily
Spironolactone 25mg po daily
Torsemide 20mg twice a week. 30mg the other days
Coumadin 1-1.5mg po daily
Calcium 500mg po daily
Ferrous gluconate 240mg po daily
Senna
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Acute on chronic diastolic congestive heart failure secondary
to mitral stenosis
Discharge Condition:
--
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]
Completed by:[**2121-6-6**]
ICD9 Codes: 486, 5849, 4280, 2724, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5713
}
|
Medical Text: Admission Date: [**2117-3-18**] Discharge Date: [**2117-3-26**]
Date of Birth: [**2035-1-22**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Left Auricular Mass
Major Surgical or Invasive Procedure:
[**2117-3-18**]: Left total auriculectomy. Left lateral temporal bone
resection. Left modified radical neck dissection. Left
parotidectomy. Left thyroid lobectomy. Left temporalis flap.
Temporoparietal fascial graft to middle ear. Placement of
split-thickness skin graft. (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**], Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1837**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
History of Present Illness:
82-year-old male with history of squamous cell carcinoma of his
left ear. He had previously undergone resection and skin graft
reconstruction which was complicated by poor wound healing and
MRSA infection. Due to persistence in poor wound healing he
underwent a second surgical procedure at which time it was found
that there was cartilage involvement. He was sent to [**Hospital 18**]
[**Hospital **] clinic for further evaluation and consideration
of resection. At the time of presentation the patient had
continued left ear pain.
After a review of the imaging the the extent of the malignancy
considered the patient was offered surgical excision and
reconstruction. The patient elected to proceed with this
procedure.
Past Medical History:
Hypertension.
Coronary artery disease status post MI.
Gastroesophageal reflux and history of peptic ulcers.
CLL.
Depression.
Arthritis.
Carbon monoxide poisoning.
Social History:
He smoked 15-20 years, but is not currently. He
does not drink alcohol. He is retired and used to be a
taxidermist. He is widowed.
Family History:
Cancer, diabetes, heart disease, and respiratory
disease.
Physical Exam:
General Appearance: He is a stable appearing male in some
degree
of pain from his ear, in no acute distress.
Airway: There are no signs of obstruction.
Facial Region: I found no evidence of any swelling, tenderness,
mass, or adenopathy. In particular, the parotids were free of
any masses or adenopathy. Postauricular region was free of any
adenopathy or masses.
Ears: The left auricle is densely involved with a granulomatous
mass which appears to extend up to but not through the skin of
the posterior surface of the auricle. The tumor does extend
down
towards the external auditory canal and blocks it to the point
where I cannot see the most distal portion of the tumor. It
fills the conchal bowl. There was no obvious extension off of
the auricle.
Neck: There was no palpable mass or adenopathy.
Transoral Exam: I found no evidence of any chronic inflammatory
or neoplastic changes affecting the oral cavity or the
oropharynx.
Pertinent Results:
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] Otolaryngology service
on [**2117-3-18**] to undergo Left total auriculectomy, Left lateral
temporal bone resection, Left modified radical neck dissection,
Left parotidectomy, Left thyroid lobectomy, Left temporalis
flap, Temporoparietal fascial graft to middle ear, and placement
of split-thickness skin graft with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**], Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1837**], and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please see the separate
operative notes for full details of the operation. The patient
was transferred to the SICU post-operatively for further
management and remained intubated due to his post-operative
volume status. He remained stable overnight and was extubated
without event on POD1. He was noted to have some increased
swelling around the temporalis flap and oozing along his
incision line and remained in the SICU for an additional night.
He was transferred to the floor on [**2117-3-20**]. His pain was
controlled on an oral regimen. Due to some evidence of dysphagia
post-operatively, the patient underwent a bedside fiberoptic
examination which demonstrated left hypopharyngeal ecchymosis
without significant edema. The patient was evaluated by Speech
and swallow and underwent video swallow which did not show
evidence of aspiration. His diet was slowly advanced to soft
diet with thin liquids. He had three drains placed
intraoperatively by both the Otolaryngology and Plastic Surgery
service. These were sequentially removed once meeting removal
criteria. The patient's wound was managed with gentle cleaning
and covered with xeroform changed twice daily. The patient had
difficulty with insomnia during his hospital course which slowly
resolved. Due to an episode of urinary retention post-op the
patient required replacement of a foley catheter which was
removed without event and no further voiding difficulty. On
[**2117-3-26**] the patient's pain was well controlled, he was
ambulating with assistance and wounds remained stable. He was
felt to be stable for discharge to home with VNA.
Medications on Admission:
Tamsulosin 0.4 mg p.o. at bedtime, omeprazole 40 mg
p.o. once daily, finasteride 5 mg p.o. daily, bupropion 150 mg
p.o. daily and bisoprolol/HCTZ 5/6.25 mg daily.
Discharge Medications:
1. bisoprolol-hydrochlorothiazide 5-6.25 mg Tablet Sig: One (1)
Tablet PO once a day.
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain.
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*300 mL* Refills:*2*
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for eye care.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] home health of [**Location (un) 5450**] and southern NH
Discharge Diagnosis:
Left Auricle Squamous Cell Carcinoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Please keep wounds clean and dry. Ok to gently clean incisions
with saline. Please Do not clean around the skin graft. Place
xeroform dressing to incision and skin graft at all times and
change twice daily.
No lifting >10 lbs x2 weeks
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 19848**] CUTANEOUS ONCOLOGY
Phone:[**Telephone/Fax (1) 19462**] Date/Time:[**2117-3-31**] 11:00
.
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**]
Date/Time: Friday [**2117-4-2**] 2:15
Dr.[**Name (NI) 27488**] office is located on the [**Hospital Ward Name **], [**Hospital Unit Name **],
[**Location (un) 442**], [**Hospital Unit Name 6333**].
ICD9 Codes: 4019, 412, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5714
}
|
Medical Text: Admission Date: [**2156-4-20**] Discharge Date: [**2156-4-22**]
Date of Birth: [**2099-9-21**] Sex: F
Service: CARDIOLOGY INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
female with coronary artery disease status post RCA stent as
well as left circumflex stent, as well as hyperlipidemia, and
tobacco use who was admitted for carotid artery stenting.
The patient was noted initially in [**3-22**] to have a left
carotid bruit on examination. Subsequent duplex ultrasound
in [**3-22**] revealed left carotid 70 to 79 percent stenosis as
well as a 40 percent stenosis of the right carotid. The
patient was initially managed with Plavix and Lipitor. The
repeat ultrasound revealed further stenosis on the left up to
90 percent. The patient is referred for elective stenting of
the left carotid artery.
REVIEW OF SYSTEMS: Negative for any headaches, changes in
vision, changes in hearing, shortness of breath, chest pain,
dyspnea on exertion, PND, diarrhea, melena, BRBPR, or
myalgia.
PAST MEDICAL HISTORY: Coronary artery disease status post
left circumflex stent (Cypher in [**3-22**]), status post RCA
stent in [**5-22**] to the proximal RCA. A subsequent coronary
catheterization in [**8-22**] showed that the stents were patent,
though there was moderate branch disease. Her estimated
ejection fraction was 59 percent.
Hyperlipidemia.
Urinary tract infection.
Fibromyalgia.
Tendinitis.
Arthritis.
Right hearing loss.
Irritable bowel syndrome.
Lactose intolerance.
Carotid artery disease as detailed in the history of present
illness.
ALLERGIES: Include sulfa, erythromycin, and possibly also
penicillins. The patient also reports GI upset with aspirin.
She states that sulfa drugs cause nausea and facial swelling.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg.
2. Plavix 75 mg.
3. Protonix 40 mg.
4. Lipitor 10 mg.
5. Clonazepam p.r.n.
6. Tramadol p.r.n.
7. Cyclobenzaprine p.r.n.
SOCIAL HISTORY: She is married, lives with her husband. She
has an approximately 80-pack-year history of smoking, though
currently smokes 2 cigarettes per day. Denies any
significant alcohol use (drinks less than 1 glass of alcohol
a week), and denies any IVDA.
FAMILY HISTORY: Notable for ischemic stroke and stomach
cancer in her mother who had the stroke in her 60s and an MI
in her father, passed away at age 48. A sister has MS, and
several family members also have diabetes.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.5 degrees,
pulse of 40, blood pressure 114/46, respirations 16, oxygen
saturation 98 percent on room air. The patient was found to
be sitting in a chair, breathing comfortably, in no acute
distress. She was normocephalic/atraumatic. Pupils were
equally round and reactive to light. Extraocular muscles
were intact. Mucous membranes were moist. There were no
sores or lesions in the oropharynx. There was no JVD.
Regular rate and rhythm. Normal S1 and S2. No murmurs,
rubs, or gallops. Chest was clear to auscultation
bilaterally. Abdomen was soft, nontender, and nondistended.
Positive bowel sounds. There was no edema or calf
tenderness. Mental status examination is normal. The
patient had 5 plus upper and lower extremity strength.
Cranial nerves II-XII were intact. She had a normal sensory
examination, normal cerebellar examination, and normal gait.
LABORATORY DATA ON ADMISSION: White count is 12, hematocrit
is 25.8, platelets are 224,000, sodium is 145, potassium is
4.0, chloride 112, bicarbonate 24, BUN 8, creatinine 0.8,
glucose 102, calcium 8.3, magnesium 1.8, phosphorus 4.0, and
glycated hemoglobin is 5.4.
HOSPITAL COURSE: The patient was taken for elective coronary
artery stenting. Angiography was limited to the [**Doctor First Name 3098**], showed
no change in lesion in comparison to prior angiography. A
resting mean gradient of 30 mmHg was noted from the left CFA
to the aorta. Iliac angiography showed a very long diffuse
lesion in the left CIA. The [**Doctor First Name 3098**] was stented using
a PRECISE stent. Final angiography showed normal flow and no
evidence of distal embolism. The patient remained incident-
free throughout the procedure. She was, however, briefly
hypotensive with accompanying bradycardia during post
dilation that resolved with atropine and IV phenylephrine.
The patient was transferred to the cardiac intensive care
unit for post procedure monitoring. The patient was noted to
have ongoing bradycardia as well as hypotension and required
initially phenylephrine and subsequently was switched to
dopamine for maintenance of adequate postprocedure blood
pressure (target range 110:130 mmHg). The patient also
required several liters of normal saline boluses to maintain
target blood pressure. The patient's dopamine was weaned off
on [**4-21**], and the patient did not require dopamine for
adequate blood pressure maintenance for approximately 24
hours prior to discharge. Neurological examination did not
reveal any focal deficits (other than the aforementioned mild
right-sided hearing loss that was noted prior to this
procedure).
Hyperlipidemia. The patient's cholesterol panel was checked,
and the patient was found to have a total cholesterol of 230
with HDL of 33, a total to HDL ratio of 7.0, LDL calculated
of 167, and triglycerides of 150. Given the result of this
fasting lipid panel, the patient's Lipitor was increased from
10 mg q.d. to 40 mg q.d.
Fibromyalgia. The patient was maintained on her outpatient
regimen of Tramadol and cyclobenzaprine p.r.n. The patient
is discharged in stable condition.
DISCHARGE DIAGNOSES: Coronary artery stenosis status post
left coronary artery stent, coronary artery disease, and
fibromyalgia, as well as hyperlipidemia. The patient will
follow up with Dr. [**First Name (STitle) **] as well as with her cardiologist,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], as well as with her primary care physician.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Plavix 75 mg q.d.
3. Cyclobenzaprine 10 mg h.s. p.r.n.
4. Clonazepam 0.5 mg h.s. p.r.n.
5. Tramadol 25 mg q.4-6h. p.o. p.r.n.
6. Lipitor 40 mg q.d.
[**First Name11 (Name Pattern1) 487**] [**Last Name (NamePattern4) **], [**MD Number(1) 32301**]
Dictated By:[**Last Name (NamePattern1) 8188**]
MEDQUIST36
D: [**2156-4-22**] 14:53:48
T: [**2156-4-23**] 09:40:33
Job#: [**Job Number 48137**]
ICD9 Codes: 9971, 2724, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5715
}
|
Medical Text: Admission Date: [**2144-2-18**] Discharge Date: [**2144-2-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
EGD- [**2144-2-20**]
Sigmoidoscopy - [**2144-2-20**]
History of Present Illness:
[**Age over 90 **]yoM with h/o MDS, CAD, CHF (preserved EF), cryptogenic
cirrhosis, unconfirmed h/o HBV, GAVE, esophageal, gastric, and
rectal varices, endocarditis, CKD, admitted [**2144-2-18**] with chief
complaint of "weakness,". Pt initially presented to [**Hospital1 18**] ED
with complaint of one day of weakness/dizziness and feeling
"wobbly" on his feet. Due to his MDS, pt usually requires a
PRBC transfusion when he feels weak. His last transfusion was
three weeks prior to admission, and he is usually transfused
every 2-4 weeks. On admission he denied having chest pain,
abdominal pain, fevers, dysuria, bloody or black stools.
Past Medical History:
1)CAD s/p PTCA [**2123**], negative stress test [**2141**]
2)Sick sinus syndrome, s/p pacemaker [**2139**] (now on 3rd pacemaker)
3)CHF (ECHO [**8-24**]: EF 30-35%, apical akinesis, severe hypokinesis
of anterior and anteroseptal wall, ECHO [**2144-2-19**] EF >55%, no wall
motion abnormalities, 1+MR)
4)Hx of gastric antral vascular ectasia (GAVE)
5)TIA [**2135**]
6)CRF, baseline Cr~2.0
7)Myelodysplastic syndrome, thrombocytopenia X 5-6 years
8)Hepatitis B history with "cryptogenic" cirrhosis listed in
[**Medical Record Number 68809**])hx of gastric, esopaphageal, and rectal varices
10)hx of enterococcal endocarditis [**2140**]
11)BPH
12)Gait disturbance
Social History:
Social hx:
- lives alone in apartment on [**Location (un) 448**] of daughter's home
- recently moved from [**Location (un) 9095**]
- Retired teacher who has traveled extensively to Europe as
[**Last Name (un) 68810**] Scholar
- non-smoker
- occasional EtOH
- no illicit drugs
Family History:
NC
Physical Exam:
PE: T 97.8 HR 67 BP 142/67 RR 18 99 2L NC
.
GEN: AAOx3, NAD, comfortable w/ head of bed elevated
HEENT: PERRL/EOMI, anicteric, conjunctiva clr, MMM
Neck: supple, no LAD, JVP nondistended
CV: RR, irreg rhythm, II/VI SEM at LLSB
Resp: coarse BS bil bases, otherwise clear
Abd: +BS, soft, NT, ND, no masses
Ext: trace BLE edema, R toe wound dressing C/D/I.
Neuro: A&Ox3, CN II-XII intact
Pertinent Results:
[**2144-2-18**] 07:40AM BLOOD WBC-7.6 RBC-3.36* Hgb-9.6* Hct-30.7*
MCV-91 MCH-28.5 MCHC-31.2 RDW-15.4 Plt Ct-48*
[**2144-2-20**] 06:50AM BLOOD WBC-7.1 RBC-2.62* Hgb-7.4* Hct-23.8*
MCV-91 MCH-28.2 MCHC-31.1 RDW-15.0 Plt Ct-32*
[**2144-2-24**] 05:00AM BLOOD WBC-5.1 RBC-3.46* Hgb-9.9* Hct-30.4*
MCV-88 MCH-28.7 MCHC-32.7 RDW-14.7 Plt Ct-33*
[**2144-2-19**] 06:30AM BLOOD Plt Smr-VERY LOW Plt Ct-31* LPlt-3+
[**2144-2-24**] 12:35PM BLOOD Plt Ct-54*#
[**2144-2-18**] 07:40AM BLOOD Glucose-192* UreaN-40* Creat-2.1* Na-135
K-4.0 Cl-97 HCO3-30 AnGap-12
[**2144-2-20**] 06:50AM BLOOD Glucose-137* UreaN-56* Creat-2.4* Na-132*
K-4.2 Cl-98 HCO3-24 AnGap-14
[**2144-2-24**] 05:00AM BLOOD Glucose-107* UreaN-33* Creat-1.5* Na-137
K-3.4 Cl-102 HCO3-24 AnGap-14
[**2144-2-25**] 05:30AM BLOOD WBC-4.8 RBC-3.60* Hgb-10.2* Hct-32.1*
MCV-89 MCH-28.4 MCHC-31.9 RDW-14.7 Plt Ct-58*
[**2144-2-25**] 05:30AM BLOOD Plt Ct-58* LPlt-1+
[**2144-2-25**] 05:30AM BLOOD PT-13.2* PTT-27.7 INR(PT)-1.1
Brief Hospital Course:
ED Course: On arrival to [**Hospital1 18**] ED, T 98.2 HR 92 BP 142/64 RR 20
99%RA. Pt was admitted for anemia and weakness.
.
[**Location (un) **]: Pt received transfusion to bolster his anemia.
Unfortunately, pt experienced a temperature increase during
blood transfusion to 100.9, and then fever up to 101.8. Pt
recieved full fever w/u, with one of four blood cultures with
GPC; he was treated with vancomycin x 1, but when CT max-facial
revealed acute sinusitis, vanc was replaced with Augmentin.
Also with CKD (creatinine 2.0 at baseline), rose to 2.4. On
[**2144-2-20**], pt spiked a fever to 101.8 and passed BRBPR, melanotic
stool, and clots; HR increased to 115 and BP dropped to 70s/40s.
Pt was transferred to the ICU for futher care.
.
MICU: Pt received 950cc NS and had another liter hanging on
initial ICU evaluation. He was being transfused two units PRBC,
was alert, mentating, denied chest pain, SOB, abdominal pain,
nausea. On MICU eval T 97.0 HR 80 BP 90/63 RR 18 100%2L. Pt
received protonix, octreotide, PRBCs, FFP, DDAVP, and GI
consultation. GI performed EGD and sigmoidoscopy on [**2144-2-20**],
which revealed that the likely source of the GIB was a gastric
polyp (which was resected). Hepatology was consulted given h/o
cirrhosis, and blood tests failed to reveal HBV infection;
hepatology continues to follow. Pt remained hemodynamically
stable and was called out to the floor on [**2144-2-22**]; he experienced
one episode of hemoptysis on [**2144-2-23**] w/o other issues. Pt.
underwent speech and swallow eval that showed no evidence of
aspiration.
.
[**Hospital1 1516**]: Upon arrival to the floor, pt was asymptomatic and without
complaint. He was tolerating a regular diet. On [**2144-2-24**] he was
transfused one unit of platelets. He c/o of loose stools and
had a Cdiff that was negative. Pt. continued to have guaic +
stool after his GI bleed, but his Hct remained upward trending.
He was evaluated by PT and felt to be a candidate for rehab. He
will require a 14 day total course of Unasyn IV for his Strep G
Bacteremia. On day of d/c, pt. had a midline placed for his IV
abx. He was d/c to rehab with PCP and GI [**Name9 (PRE) 702**]. He will
also follow-up with his hematologist as scheduled.
Medications on Admission:
Metolazone 1.25mg qday
Omeprazole 20mg [**Hospital1 **]
Nadolol 80mg qday
KCl 20mg [**Hospital1 **]
Fulbic
Iron 325mg qday
Flomax 0.4mg qhs
ASA 81mg qday
lasix 20mg qMWF
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for neck pain.
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD ().
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Unasyn 3 g Recon Soln Sig: Three (3) g Intravenous twice a
day for eight days.
7. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2
times a day).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
GI Bleeding
Bacteremia
Discharge Condition:
Good
Discharge Instructions:
See your own doctor right away or go to the ER if any problems
develop, including the following:
* Severe Bleeding from your rectum
* Markedly bloody stools
* Fever > 101
* Difficulty Breathing
* Your chest pain or chest discomfort lasts longer than 5
minutes.
* Your chest pain or chest discomfort gets worse in any
way.
* You have angina and your chest pain or chest discomfort
is worse, lasts longer than usual or comes on with less
activity than usual.
* You have angina and your chest pain or chest discomfort
is not relieved by your usual medicines.
* You develop any shortness of breath, sweats, dizziness,
throwing up or nausea with your chest pain or chest
discomfort.
* Your chest pain or chest discomfort moves into your
arm, neck, back, jaw or stomach.
* Dizziness
* Loss of Consciousness
* Anything else that worries you.
Even if you feel better and have no further chest pain or chest
discomfort, follow-up with your own doctor tomorrow.
The Emergency Department is open 24 hours a day for any
problems.
Followup Instructions:
You should follow-up with your primary care doctor as already
scheduled: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2144-3-2**] 12:00
You should call should you need to reschedule this appointment.
You should follow-up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] in [**7-28**] days. You
should call ([**Telephone/Fax (1) 16940**] and schedule an appointment.
You should follow-up with the below appointments as previously
scheduled.
Provider: [**Name10 (NameIs) 3242**] CHAIR 2 Date/Time:[**2144-2-27**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2144-2-27**] 10:00
Completed by:[**2144-2-25**]
ICD9 Codes: 7907, 5849, 4280, 5715, 5859, 5789
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5716
}
|
Medical Text: Admission Date: [**2115-8-17**] Discharge Date: [**2115-8-23**]
Date of Birth: [**2057-3-21**] Sex: F
Service: NEUROSURGERY
Allergies:
Cephalosporins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
SDH
Major Surgical or Invasive Procedure:
[**2115-8-17**]: Right Craniectomy and evacuation of SDH
History of Present Illness:
This is a 58 year old woman with history of ETOH and narcotic
abuse who was found after a fall down a flight of stais. EMS
arrived and took her to an OSH about 5pm. She was stuporous but
moving her legs. She was intubated for airway protection. She
was given Mannitol 25 g and Dilantin was started but stopped for
BP changes. She was given Fentanyl/3 and Versed/50 in the
[**Location (un) **].
Past Medical History:
CAD
[**Last Name (un) **] CA s/p colectomy
Depression/Anxiety
ETOH/Narcotic abuse
Elevated LFT's
Social History:
per her estranged sister, she [**Name2 (NI) 546**] in a single family home
with "transients" and abuses drugs and ETOH. No known
accupation. We contact[**Name (NI) **] her sister [**Name (NI) **] [**Name (NI) 111905**] [**Telephone/Fax (1) 111906**]
who is estranged from her sister and reports no other contacts
for her and does not wish to be her HCP.
Family History:
non-contributory
Physical Exam:
O: 130/84 HR:99 O2Sats 100%
Gen: Intubated, no corneal reflexes, no cough, no gag, Pupils:
Right 3 and MR [**First Name (Titles) **] [**Last Name (Titles) 2325**] 4 MR, Right periorbital hematoma, Collar
in place, No WD UE, TF LE.
Pertinent Results:
[**8-17**] Trauma Xray- IMPRESSION:
1. Acute left-sided rib fractures and acute right midclavicular
fracture. Old bilateral rib fractures are also seen, and likely
old left scapular fracture.
2. Standard positioning of endotracheal tube and orogastric
tube.
3. Widening of the mediastinum for which correlation with CTA
chest is
recommended.
4. Bilateral airspace opacities which could reflect atelectasis
but contusion or aspiration is not excluded.
5. No acute fracture or dislocation within the pelvis.
[**8-17**] CT Torso- IMPRESSION:
1. Multiple fractures including a distracted fracture of T7
involving the
posterior elements, right mid clavicular fracture, right
scapular fracture and left rib fractures (ribs 2, 6 and [**8-27**]).
An MRI of the thoracic spine is suggested to evaluate for cord
or ligamentous injury.
2. Opacities in the right upper lobe and both lung bases with
associated
tree-in-[**Male First Name (un) 239**] opacities suggest aspiration pneumonia.
3. Right-sided duplicated collecting system with mild to
moderate hydroureter of the ureter draining the upper pole
likely partially due to ectopic insertion of the ureter
inferiorly within the bladder.
4. Endotracheal and orogastric tubes in proper positions.
[**8-17**] CT Head- IMPRESSION:
1. Large right subdural hematoma causing midline shift and
obliteration of the right basal cisterns concerning for uncal
herniation.
2. Multiple hemorrhagic foci including subarachnoid blood in
the right
frontal lobe and bilaterally in the frontoparietal regions close
to the
vertex, intraparenchymal hemorrhage in the left inferior frontal
lobe, and a focus of hemorrhage in the left posterior fossa
associated with the left
occipital fracture and in the region of the transverse sinus
suggesting venous epidural hematoma.
3. Multiple fractures, including in the calvarium, cranial base
and facial bones as described above. A dedicated facial CT is
suggested for further assessment of the fractures.
4. Right orbital fracture involving the roof with subperiostial
hematoma
along the lateral aspect of the roof with mild thickening of the
superior
rectus muscle.
5. Large subgaleal hematoma overlying the left calvarium.
[**8-18**] MRI Spine: IMPRESSION:
1. Left occipital bone fracture and left posterior fossa
hemorrhage, better assessed on preceding head CT scans.
2. Minimally displaced C2 fracture, as described on the prior
neck CTA,
without evidence of associated ligamentous disruption. No
spinal canal
narrowing or cord impingement.
3. Chronic compression deformities of the C7 and T2 vertebral
bodies.
4. Burst fracture of T7 vertebral body with minimal
retropulsion. No
evidence of ligamentous disruption. No significant spinal canal
narrowing and no cord compression.
5. Nondisplaced spinous process fractures at T5, T6, and T7.
Interspinous ligament edema from T2-3 through T6-7.
6. Fracture parallel to the T8 superior endplate without loss
of height or retropulsion. No evidence of ligamentous
disruption.
7. The feeding tube is coiled in the pharynx prior to entering
the esophagus.
[**8-18**] CTA Neck- IMPRESSION:
1. Type 3 fracture of the C2 vertebral body with
intra-articular involvement, but no evidence of disruption of
the atlantoaxial articulation, in this limited imaging.
2. Though the fracture involves both foramina transversaria,
there is no
evidence of associated vertebral artery dissection or other
injury.
3. Normal cervical carotid arteries with no evidence of acute
injury.
4. Abnormal appearance to the left transverse sinus with
adjacent contrast collection suggesting acute injury with
contrast extravasation, related to known left lateral occipital
bone fracture. There is no evidence of dural venous sinus
thrombosis.
5. Unremarkable included intracranial arterial circulation,
with no
flow-limiting stenosis or occlusion.
6. Extensive particularly paramediastinal airspace opacity,
right more than left, which may represent atelectasis, contusion
or a combination of the two, associated with slightly displaced
rib fractures, better-delineated on the preceding torso CT.
[**8-18**] CT Head: IMPRESSION:
1. Status post evacuation of the right subdural hematoma, with
small residual subdural blood products.
2. Persistent leftward shift of normally midline structures and
right basilar cisternal effacement have improved, as described
above.
3. Subarachnoid and intraventricular hemorrhage, as described
above.
4. Multiple fractures, unchanged.
[**8-18**] CXR-FINDINGS: After power flush, the PICC line has been
re-directed so that the tip lies in the mid portion of the SVC.
Otherwise, little change.
[**8-18**] CXR- NG tube has been advanced, now the tip is in the
stomach. ET tube has been repositioned, now the tip is 3.2 cm
above the carina. Of note, the NG tube is coiled in the
hypopharynx. Left lower lobe retrocardiac opacity has worsened.
Right lower lobe opacity is unchanged. Right upper lobe opacity
is stable. Opacities are a combination of areas of atelectases
and aspiration. There is
no evident pneumothorax. Left PICC tip is in the lower SVC.
[**8-20**] EEG:
[**8-20**] CT Head- IMPRESSION:
1. Status post right craniotomy for subdural hemorrhage
evacuation with
residual blood products and brain parenchymal herniation through
the
craniectomy defect as described above.
2. Evolving right frontal hypodensity that may represent
infarction,
contusion, or both.
3. Stable appearance of multiple fractures as described above
[**8-20**] CT Max-Face: IMPRESSION: Fractures involving the medial and
lateral right orbital wall, orbital roof, nondisplaced and
without extraocular muscle entrapment although thickening of the
superior rectus muscles suggested as an injured. Left inferior
orbital wall blowout fracture. No fracture of the nasal bones,
maxilla, or mandible. Stable appearance of fracture adjacent to
left occipital condyle and clivus and right petrous apex and
sphenoid body.
[**8-20**] Chest Xray-
FINDINGS: As compared to the previous radiograph, the patient
has undergone spine stabilization surgery. According devices
project over the spine and the mediastinum, partly obliterating
the visualization of the endotracheal tube. Therefore, the tip
of the tube cannot be directly visualized. The lower parts of
the nasogastric tube project over the stomach. The left PICC
line is in unchanged position.
Unchanged is a moderate retrocardiac atelectasis, combined to
minimal blunting of the left costophrenic sinus, potentially
caused by a small left pleural effusion. There is no convincing
evidence of pneumothorax. Minimal atelectasis at the bases of
the right lung. Known right clavicular fracture. No pulmonary
edema. No evidence of pneumonia.
[**8-21**] EEG:
[**8-21**] CXR: As compared to the previous radiograph, there is no
relevant change with the exception of slightly increasing left
pleural effusion and a subsequent left basal atelectasis. No
evidence of pneumothorax. The
monitoring and support devices as well as the surgical
stabilization devices are in constant position.
[**8-22**] EEG:
[**8-22**] CXR:
Brief Hospital Course:
Pt was taken to the OR emergently from the ED and underwent a
craniectomy & evacuation of her SDH with drain placement. She
received 2 units PRBC in OR and 2 liters of IV fluid. Her
postoperative CT revealed good evacuation/decompression.
Overnight she was given a dilantin bolus for a corrected level
of 4. She had a fever to 102 so blood cx were sent. Optho was
consulted for her orbital fracture. Ortho was consulted for her
spinal fractures. She was kept in a hard collar and on logroll
precautions.
On [**8-18**] she was neurologically stable but having respiratory
difficulties. The ICU team performed a bronchoscopy. Her drain
was removed and she was cleared for Neuro checks q3 hours. An
MRI of her spine was ordered to further evaluate for spinal cord
damage.
On [**8-19**] she was brought to the operating room with the
orthopedics team and underwent a T1-10 fusion and decompression.
Surgery was without complication but she continued to have a
poor exam postoperatively. A Head CT was performed which
revealed an evolving right frontal infarct vs edema. Cervical
and Thoracic braces as well as a helmet were ordered.
On [**8-20**] Neurology was consulted for the R frontal edema vs CVA.
Her lipitor was discontinued and an EEG ordered was ordered per
their recs. Neuro exam remained poor. Her Hct dropped from 28 to
22, but her exam was not concerning for intrabdominal or
intracranial hemorrhage. Stool Guaiac was positive so 1U PRBCs
was transfused.
On [**8-21**] her neurological exam continued to be poor but improved
compared to [**8-20**]. Her EEG was negative for seizures.
On [**8-22**] social work worked on identifying the patient and
guardianship. A family meeting was held with the patient's
sister who decided to make patient comfort measures only. She
was extubated and expired.
Medications on Admission:
Trazadone
Citalopram
Ultram
Naltrexone
Ativan
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right SDH
Right displaced occipital fx
traumatic SAH
R orbital wall, roof fxs
C2 displaced fx of the transforamen
R clavical fx
T7 burst fx
R retro-orbital hematoma
R hydroureter
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 2851, 5180, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5717
}
|
Medical Text: Admission Date: [**2187-1-1**] Discharge Date: [**2187-1-8**]
Date of Birth: [**2106-8-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Chief Complaint: s/p fall, subdural hematoma at OSH
Reason for MICU admission: management of hyperglycemia, rhabdo,
ARF
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80M with DM on insulin, presenting after found down by EMS,
admitted to the medical ICU with hyperglycemia, rhabdomyolysis,
and acute renal failure. He was found in his driveway the
morning of admission, unknown down time. Had bags of diabetic
supplies with him and may have been trying to give himself
insulin per EMS report. Patient had been incontinent and found
to be hyperglycemic in the field. He was taken to an OSH where
he was found to have a FSG of >1200, elevated CKs with ARF. He
had a non contrast Head CT which showed small bilateral subdural
hematomas. He was then transferred to [**Hospital1 18**] for further
management.
.
In the [**Hospital1 18**] ED, initial vs were: T96.5, P79, BP 141/84, R16,
100% O2 sat. Labs notable for glucose 1010 with AG 20,
creatinine 5.4, CK [**Numeric Identifier 17451**], elevated transaminases, lactate 4.4.
No UA yet. He was oriented to self, but otherwise quite altered
and unable to provide further history. He got a RUQ ultrasound
given LFT abnormalities. Renal team was consulted. Patient
received >3L IVFs in the ED, including 1.5 amps bicarb.
.
On the floor, patient was lethargic but arousable. Able to
follow most commands, oriented to [**Hospital3 7569**]. Denied pain
anywhere.
.
Review of systems: patient unable to cooperate
Past Medical History:
- Diabetes mellitus
- BPH
- HTN
- Hyperlipidemia
Social History:
Lives at home alone (has brother and sister in [**Name (NI) 108**], no
friends), denies tobacco, denies EtOH (distant past), denies
drugs.
Family History:
Noncontributory
Physical Exam:
ON PRESENTATION TO Medical ICU:
General: Lethargic though arousable, C collar in place, no
distress.
HEENT: Sclera anicteric, PERRL, healing laceration/bruising over
R eye, MMM, oropharynx clear
Neck: supple, C collar in place, prominent thyroid cartilage
without gross abnormality.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, reports non-tender (though seems diffusely
uncomfortable with deep palpation), non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, no clubbing, cyanosis or edema
ON TRANSFER TO FLOOR:
Vitals: T:99 BP: 128/54-163/81 P: 61-72 R: 18 O2: 97-99% on RA
General: Lethargic but arousable
HEENT: Sclera anicteric, PERRL, EOMI, healing
laceration/bruising over R eye, MMM, oropharynx clear
Lungs: CTAB, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, no clubbing or cyanosis, bilat hands
edematous, onychomycosis in bilat feet
Pertinent Results:
Admission labs ([**2187-1-1**]):
WBC-14.9* RBC-4.44* Hgb-11.6* Hct-35.9* MCV-81* MCH-26.1*
MCHC-32.3 RDW-14.8 Plt Ct-139*
Neuts-93.3* Lymphs-4.1* Monos-2.3 Eos-0.1 Baso-0.2
PT-11.3 PTT-27.7 INR(PT)-0.9
Glucose-1010* UreaN-79* Creat-5.4* Na-129* K-5.1 Cl-90* HCO3-19*
AnGap-25
ALT-136* AST-649* CK(CPK)-[**Numeric Identifier 83893**]* AlkPhos-154* TotBili-0.6
Albumin-4.7 Calcium-8.9 Phos-7.9* Mg-3.5*
.
[**1-1**] RUQ ultrasound:
Limited study. No acute GB process.
.
[**1-2**] CXR:
No evidence of pleural effusion. Moderate cardiomegaly but no
pulmonary signs of edema. No focal parenchymal opacities
suggesting
pneumonia. No pneumothorax or pleural effusions.
.
[**1-2**] CT head:
1. Stable bilateral frontoparietal subdural collections.
2. New intraventricular hemorrhage layering the left occipital
[**Doctor Last Name 534**] and new tentorium hemorrhage.
3. Questionable high attenuation at interpeduncular cistern,
which could be consistent with a new hemorrhage or artifact.
4. Unchanged calcifications seen, more prominent at the basal
ganglia and
cerebellum bilaterally. Differential diagnosis should include
Fahr's disease.
Followup is recommended to assess progression of subdural
hematoma and new
hemorrhage foci.
.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2187-1-3**]
8:59 AM
IMPRESSION:
1. Frontoparietal subdural collections, unchanged over the
short-interval,
with no new foci of hemorrhage or acute vascular territorial
infarction.
2. Small intraventricular hemorrhage at the left lateral
ventricular
occipital [**Doctor Last Name 534**] and atrium, unchanged with the ventricles stable
in size.
3. Extensive dystrophic calcifications, as detailed above, with
pattern most suggestive of underlying Fahr disease.
.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-1-7**] 4:40
AM
Comparison with the previous study of [**2187-1-5**]. The lungs remain
clear except for minimal streaky density at the left base
consistent with
subsegmental atelectasis or scarring. The heart and mediastinal
structures
are unchanged. Nasogastric tube is in place, as before. It
terminates
approximately 7 cm beneath the level of the diaphragm. Its side
hole is not clearly identified.
.
.
Cardiology Report ECG Study Date of [**2187-1-4**] 7:48:54 AM
Sinus rhythm. Biphasic T wave in lead V2 is non-specific.
Otherwise, tracing is
within normal limits but clinical correlation is suggested.
Since the previous
tracing of [**2187-1-2**] atrial tachycardia is now absent.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 128 84 426/426 50 55 66
[**2187-1-1**] 12:40PM BLOOD WBC-14.9* RBC-4.44* Hgb-11.6* Hct-35.9*
MCV-81* MCH-26.1* MCHC-32.3 RDW-14.8 Plt Ct-139*
[**2187-1-2**] 03:36AM BLOOD WBC-19.6* RBC-4.38* Hgb-11.1* Hct-34.1*
MCV-78* MCH-25.5* MCHC-32.6 RDW-15.0 Plt Ct-148*
[**2187-1-3**] 03:44AM BLOOD WBC-9.5# RBC-3.89* Hgb-10.2* Hct-30.0*
MCV-77* MCH-26.1* MCHC-33.9 RDW-15.1 Plt Ct-113*
[**2187-1-3**] 03:32PM BLOOD WBC-7.6 RBC-3.67* Hgb-9.5* Hct-29.5*
MCV-80* MCH-25.8* MCHC-32.1 RDW-14.8 Plt Ct-91*
[**2187-1-6**] 05:55AM BLOOD WBC-7.3 RBC-3.80* Hgb-10.0* Hct-29.8*
MCV-78* MCH-26.4* MCHC-33.7 RDW-14.8 Plt Ct-94*
[**2187-1-7**] 05:50AM BLOOD WBC-9.0 RBC-4.15* Hgb-11.1* Hct-32.0*
MCV-77* MCH-26.7* MCHC-34.6 RDW-14.9 Plt Ct-134*
[**2187-1-8**] 06:35AM BLOOD WBC-8.0 RBC-3.71* Hgb-9.8* Hct-29.7*
MCV-80* MCH-26.4* MCHC-32.9 RDW-14.7 Plt Ct-118*
[**2187-1-1**] 12:40PM BLOOD Neuts-93.3* Lymphs-4.1* Monos-2.3 Eos-0.1
Baso-0.2
[**2187-1-3**] 03:44AM BLOOD Neuts-77.7* Lymphs-15.3* Monos-6.5
Eos-0.3 Baso-0.2
[**2187-1-1**] 12:40PM BLOOD PT-11.3 PTT-27.7 INR(PT)-0.9
[**2187-1-7**] 05:50AM BLOOD PT-12.2 PTT-29.0 INR(PT)-1.0
[**2187-1-1**] 12:40PM BLOOD Glucose-1010* UreaN-79* Creat-5.4*
Na-129* K-5.1 Cl-90* HCO3-19* AnGap-25
[**2187-1-1**] 06:06PM BLOOD Glucose-363* UreaN-73* Creat-4.8* Na-140
K-4.6 Cl-99 HCO3-23 AnGap-23
[**2187-1-1**] 10:13PM BLOOD Glucose-91 UreaN-60* Creat-3.6*# Na-143
K-3.2* Cl-97 HCO3-35* AnGap-14
[**2187-1-2**] 03:36AM BLOOD Glucose-306* UreaN-73* Creat-4.2* Na-140
K-4.5 Cl-100 HCO3-25 AnGap-20
[**2187-1-2**] 09:00PM BLOOD Glucose-175* UreaN-58* Creat-3.2* Na-143
K-4.4 Cl-105 HCO3-25 AnGap-17
[**2187-1-4**] 12:25PM BLOOD Glucose-119* UreaN-39* Creat-2.2* Na-142
K-4.8 Cl-110* HCO3-22 AnGap-15
[**2187-1-5**] 05:40AM BLOOD Glucose-125* UreaN-35* Creat-1.8* Na-142
K-4.4 Cl-110* HCO3-21* AnGap-15
[**2187-1-6**] 05:55AM BLOOD Glucose-207* UreaN-33* Creat-1.6* Na-142
K-4.4 Cl-109* HCO3-20* AnGap-17
[**2187-1-7**] 05:50AM BLOOD Glucose-216* UreaN-24* Creat-1.5* Na-141
K-4.0 Cl-108 HCO3-23 AnGap-14
[**2187-1-8**] 06:35AM BLOOD Glucose-318* UreaN-20 Creat-1.6* Na-142
K-3.8 Cl-109* HCO3-26 AnGap-11
[**2187-1-1**] 10:13PM BLOOD CK(CPK)-[**Numeric Identifier 83894**]*
[**2187-1-2**] 03:36AM BLOOD ALT-179* AST-921* LD(LDH)-1386*
CK(CPK)-[**Numeric Identifier 83895**]* AlkPhos-131* TotBili-0.7
[**2187-1-2**] 01:41PM BLOOD ALT-174* AST-820* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-105 TotBili-0.6
[**2187-1-2**] 01:41PM BLOOD ALT-174* AST-820* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-105 TotBili-0.6
[**2187-1-6**] 05:55AM BLOOD ALT-97* AST-181* LD(LDH)-419*
CK(CPK)-1046* AlkPhos-72 TotBili-0.6
[**2187-1-7**] 05:50AM BLOOD ALT-87* AST-114* LD(LDH)-422*
CK(CPK)-601* AlkPhos-82 TotBili-0.5
[**2187-1-1**] 12:40PM BLOOD cTropnT-0.15*
[**2187-1-1**] 06:06PM BLOOD CK-MB-151* MB Indx-0.3 cTropnT-0.13*
[**2187-1-2**] 03:36AM BLOOD CK-MB-116* MB Indx-0.2 cTropnT-0.11*
[**2187-1-3**] 03:44AM BLOOD cTropnT-0.05*
[**2187-1-7**] 05:50AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.5 Mg-1.7
[**2187-1-1**] 10:13PM BLOOD VitB12-656 Folate-8.5
[**2187-1-4**] 06:25AM BLOOD Ferritn-126
[**2187-1-2**] 03:36AM BLOOD %HbA1c-12.0*
[**2187-1-1**] 10:13PM BLOOD TSH-0.68
[**2187-1-1**] 10:13PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2187-1-1**] 06:40PM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-47* pCO2-40
pH-7.42 calTCO2-27 Base XS-0 Intubat-NOT INTUBA
[**2187-1-2**] 04:36AM BLOOD Type-[**Last Name (un) **] pH-7.40 Comment-GREEN TOP
[**2187-1-1**] 12:52PM BLOOD Glucose-GREATER TH Lactate-4.4* Na-132*
K-5.1 Cl-93* calHCO3-40*
[**2187-1-2**] 04:36AM BLOOD Lactate-2.9*
[**2187-1-4**] 07:16AM BLOOD Lactate-1.3
Brief Hospital Course:
Patient is an 80M with history of DM on insulin, presenting
after found down with hyperglycemia, rhabdomyolysis, acute renal
failure, and acute on chronic subdural hematoma.
.
# Hyperglycemia/Diabetes:
Patient may have experienced Hyperosmolar Hyperglycaemic
Non-Ketotic Coma on presentation. His serum glucose level was
>12,000 on presentation to the outside hospital. He did present
with an anion gap, though it was also in the setting of lactic
acidosis and renal failure. The patient did not show evidence
of ketosis at the outside hospital or on presentation to [**Hospital1 18**].
In the MICU, the patient was given a total of 8.5L of fluids
including 1/2 NS plus 1.5 amps bicarb which was then
transitioned to LR. Patient was initially on an insulin drip,
then transitioned to 7 units glargine on [**1-2**] PM with a Humalog
sliding scale. Patient initially had an anion gap metabolic
acidosis, which was closed by the time of transfer to the floor.
The glargine dose was later increased to 15 units at bedtime,
then further increased to 20 units at bedtime on [**2187-1-7**] in
addition to the Humalog sliding scale.
The patient has an HbA1c of 12%. His pioglitazone was held
during hospitalization. He should be continued on the fixed
glargine dose and Humalog sliding scale at the rehabilitation
center for now; the glargine may need to be further uptitrated.
The patient's home insulin regimen consisted of levemir 18units
each morning, lispro/lispro protamine (humalog 50/50)
18U/18U/10U with meals, which he may be able to transition back
to once he is able to tolerate meals.
#. Rhabdomyolysis
Patient had been found down after an unknown period of time and
had rhabdomyolysis with CK peak at 54,000 and corresponding
elevation of LFTs and troponin, all of which trended down by the
time of discharge after significant amount of IV fluids
including bicarbonate drip. CK was 601 the day prior to
discharge. Patient's atorvastatin was held on presentation, but
it was restarted upon discharge.
#. Acute on Chronic Renal Failure
The patient presented with creatinine elevated to 5.4 from
baseline of 1.7, per PCP records from [**2186-12-15**]. Patient had
severe volume depletion and rhabdomyolysis, as above. He was
followed by the Renal team initially as well. On transfer to
floor from the medical ICU, patient was on 300ml/hr of LR, and
urine output was >150cc/hr. His creatinine had returned to 1.6
by the time of discharge after significant fluid resuscitation.
.
# Altered mental status
The patient had presented with altered mental status, likely
multifactorial with subdural hematomas status post fall in
addition to metabolic disturbances and electroylte imbalances in
the setting of hyperosmolar hyperglycemia. Patient had a normal
TSH, B12 and folate. A repeat CT scan of his head showed that
the subdural hematomas and small intraventricular hemorrhage
were stable in size. Extensive dystrophic calcifications were
also noted on CT.
# Subdural hematoma
Subdural hematomas were thought to be acute on chronic; the
acute component was small and may have resulted from the fall.
Neurosurgery was consulted. Repeat Head CT showed that the
frontoparietal subdural hematomas were stable with no new foci
of hemorrhage or acute vascular territorial infarction. There
was also a small intraventricular hemorrhage at the left lateral
ventricular occipital [**Doctor Last Name 534**] and atrium, unchanged from previous
imaging with the ventricles stable in size.
Patient has no focal signs on neuro exam, but his neuro exam
should continue to be monitored. The aspirin was stopped on
admission in the setting of subdural bleed and low platelets and
may be restarted on [**2187-1-11**]. His platelet count on [**2186-12-15**] at
his PCP's office was 100k, which is stable. The patient should
follow up in [**Hospital 4695**] clinic, either locally near the
rehabilitation center or return to [**Hospital1 18**] neurosurgery clinic.
# Anemia
Patient has anemia with Hct stable around 30 during this
hospitalization and no signs of active bleeding. Hct at PCP's
office on [**2186-12-15**] was 31.6. His hematrocrit should be rechecked
at his next PCP [**Name Initial (PRE) **].
# BPH.
Patient was continued on an alpha-blocker for his prostatic
hypertrophy.
.
# Nutrition:
Patient was given tube feeds through NG tube: Fibersource HN
Full strength, advanced to goal rate of 70 ml/hr. He
accidentally pulled his NG tube out [**2187-1-8**]. He failed a
speech and swallow study initially but was somewhat improved on
[**2187-1-8**]. He will need a video swallow study. Until he gets
his video swallow study, he may eat small volume pureed foods
with 1:1 supervision.
Prophylaxis: Subcutaneous heparin
Code: FULL
Communication: Patient, no known contacts/relatives in the area
Medications on Admission:
- Alfuzosin 10mg daily
- ASA 81mg daily
- Atorvastatin 10mg daily
- Levemir 18U Qam
- Lispro/lispro protamine (humalog 50/50) 18U/18U/10U with meals
- Metoprolol 25mg daily
- Pioglitazone 30mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
2. Alfuzosin 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous at bedtime.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Insulin Lispro Subcutaneous -- sliding scale QACHS
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. Aspirin 81mg - to restart on [**2187-1-11**]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Hyperosmolar Hyperglycemic Non-Ketotic Coma
Rhabdomyolysis
Secondary Diagnoses:
Dehydration
Diabetes Mellitus
Discharge Condition:
Stable
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because you were found after
having fallen down in the driveway. You were found to be very
dehydrated with a very high blood glucose level. After your
fall, you also had some increased muscle breakdown which led to
some worsening of your kidney function temporarily. By the time
of your discharge, your kidney function had returned to the
level it was at your last doctor's visit. You were also found
to have some bleeding inside your head which was stable; the
neurosurgeons were following the head bleed and would like you
to follow up with them as an outpatient.
The following changes have been made to your medications:
- We have STOPPED the pioglitazone for now
- We STOPPED your levemir and lispro insulin regimen for now
- We have STARTED 20 units subcutaneous glargine insulin at
bedtime
- We have STARTED a Humalog insulin sliding scale
- We have INCREASED your metoprolol to 37.5mg and CHANGED it to
a short-acting dose to be taken TWICE DAILY
- We have STOPPED your aspirin for 10 days total, and it can be
restarted on [**2187-1-11**]
Please be sure to keep all of your followup appointments.
Please seek medical attention if you experience any symptoms
that are concerning to you.
Followup Instructions:
Please keep the following appointment with your Primary Care
Physician:
Thursday [**1-25**] 3:15pm
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) 77760**], [**Location (un) **],[**Numeric Identifier 29816**]
Phone: [**Telephone/Fax (1) 62842**]
Fax: [**Telephone/Fax (1) 15181**]
Please schedule a Neurosurgery followup appointment in the next
2 weeks either at a clinic close to your Rehab facility or at
[**Hospital1 18**].
- [**Hospital 18**] [**Hospital 4695**] Clinic ([**Telephone/Fax (1) 88**]
ICD9 Codes: 5849, 2762, 5859, 2724, 2859, 2875
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5718
}
|
Medical Text: Admission Date: [**2121-4-29**] Discharge Date: [**2121-5-3**]
Date of Birth: [**2054-2-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x3 (left internal mammary artery >
left anterior descending artery, saphenous vein graft > RAMUS,
saphenous vein graft > posterior descending artery) mitral valve
repair (30 mm CG future annuloplasty ring [**2121-4-29**]
History of Present Illness:
67 year old male with decreased exercise tolerance for several
months. Then with shortness of breath, underwent cardiac
catherization that revealed coronary artery disease and was
referred for cardiac surgery
Past Medical History:
Diabetes mellitus
MRSA in back [**11-11**]
Arthritis
severed fingers at age 12 - reattached
broken leg at age 20
Social History:
Works as a plumbing and electrical contractor
Tobacco - smoked for 10 years but quit 38 years ago
ETOH denies
Lives with spouse
Family History:
Mother with coronary artery disease at age 55
Physical Exam:
Well appearing male in no acute distress
HR 80, RR 20, b/p 140/89 weight 82.2 kg
Skin excision nasal basal cell cancer with scar
HEENT unremarkable
Neck supple Full range of motion
Chest clear to auscultation bilaterally
Heart RRR
Abdomen soft, nontender, nondistended, + bowel sounds
Extremities warm well perfused no edema pulses palpable
Neuro: grossly intact
Pertinent Results:
[**2121-5-2**] 05:35AM BLOOD WBC-8.1 RBC-2.93* Hgb-8.9* Hct-24.6*
MCV-84 MCH-30.5 MCHC-36.4* RDW-13.9 Plt Ct-138*
[**2121-5-2**] 05:35AM BLOOD Plt Ct-138*
[**2121-5-1**] 05:30AM BLOOD Glucose-157* UreaN-25* Creat-1.0 Na-134
K-4.7 Cl-100 HCO3-24 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 98064**] was admitted for same day surgery and went to the
operating room for a coronary artery bypass graft and mitral
valve surgery. Please see the operative report for further
details. He received vancomycin for perioperative antibiotics.
He was transfer to the intensive care unit on propofol,
epinephrine, neosynephrine, and amiodarone. Amiodarone was
started due to ventricular arrythmia in the operating room and
was stopped post operative day one due to no further rhythm
issues. In the first twenty four hours he was weaned from
sedation, awoke neurological intact, and was extubated without
complications. He was weaned from all vasoactive medications
and remained hemodynamically stable. He was transfered to the
post operative floor on day one for the remainder of his care.
He remained in a first degree atrioventricular block throughout
his stay, but was placed on beta blockade regardless due to his
intra-operative ventricular arrythmias. Physical therapy worked
with him on strength and mobility. He was gently diuresed and
betablockers titrated for heart rate control. His metformin was
increased as he regained his appetite. By post-operative day
four he was ready for discharge to home.
Medications on Admission:
Aspirin 325 mg daily
Motrin 400 mg twice a day
Metformin 1500 mg qam, 500mg qpm
Glipizide 5 mg twice a day
Lopressor 50 mg twice a day
Lipitor 80 mg at bedtime
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
6. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM.
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
14 days.
Disp:*14 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
10. Motrin 400 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
11. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Mitral Regurgitation s/p mitral valve repair
Diabetes Mellitus type 2
MRSA
Arthritis
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 5456**] in 1 week ([**Telephone/Fax (1) 25798**]) please call for appointment
Dr [**Last Name (STitle) **] [**Name (STitle) 98065**] in [**1-7**] weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2121-5-3**]
ICD9 Codes: 4240
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5719
}
|
Medical Text: Admission Date: [**2100-12-1**] Discharge Date: [**2100-12-9**]
Date of Birth: [**2027-1-21**] Sex: M
Service: MEDICINE
Allergies:
Lidocaine / Morphine / Ambien
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
transfered from OSH for medical management of AMI and other
multiple medical problems.
Major Surgical or Invasive Procedure:
right knee incision and drainage (bursa washout)
History of Present Illness:
Patient is a poor historian. The following history is taken from
the notes and from the patient.
.
Mr. [**Known lastname **] is a 73 yo M who is transferred from an OSH s/p fall
at home. He was brought by EMS to the OSH. He was found awake
and alert but on the ground complaining of weakness and fatigue.
Per patient, he just couldn't get up. No LOC or hitting his
head. No loss of bowel or bladder function. He was brought to
the OSH and was found to have an elevated WBC, Cr 4.8, and
slightly elevated troponin I on admission. Subsequent troponins
continued to rise with a max of 4.7 and he was started on a
heparin gtt. He was also found to be fluid overloaded and with
ascities. He received a paracentesis with removal of 5L and
dialysis (per his home schedule on T, TH, Sa). During the course
of his hospitalization, he developed what was thought to be a
gout flare in his right knee. He has received most of his
medical care at [**Hospital1 18**] in the past and was transferred here for
further medical management.
.
On ROS he denies current SOB, CP, n/v, f/c, diarrhea. He makes
very little urine on his own. He describes pain in his right
knee which has improved slightly from yesterday. He denies any
current lightheadedness, HA, changes in vision, cough,
palpitations, or abdominal pain.
Past Medical History:
1. Coronary artery disease status post coronary artery bypass
graft in [**2077**]
2. Right ventricular dysplasia with atrial and ventricular
tachycardia, status post ablation
3. Multiple arrhythmias status post ablation
4. DDD pacemaker secondary to sick sinus syndrome with
paroxysmal atrial fibrillation (h/o 4 pacemakers)
5. Congestive heart failure requiring multiple hospital
admissions
6. ESRD, now hemodialysis dependent, recent placement of
AV-Fistula ([**2099-6-16**]). Removal of 3L three times a week.
7. Passive liver congestion syndrome requiring 2x week
paracentesis for volumes of [**3-24**] L.
7. Type II diabetes mellitus
8. Gout s/p left great toe amputation
9. Degenerative joint disease of knees and back
10. Obstructive sleep apnea
11. Allergic rhinitis
12. History of peripheral vascular disease, right greater than
left. Status post right lower extremity angiography with three
stents with maximum diameter of 8 mm and now status post
angiography and atherectomy to the left lower extremity in [**Month (only) 958**]
of [**2097**]
13. Cardiomyopathy EF>55% with TR and hypokinesis of the R V per
echo in [**2097**]
14. Obstructive sleep apnea
15. Appendectomy
16. h/o GI Bleed from AVMs with chronic need for iron
replacement.
17. hypothyroidsm
18. hyperparathyroidism of renal disease
Social History:
Patient lives in [**Location **], MA, with wife. [**Name (NI) **] 2 children.
Patient is a retired printer.
-No alcohol history
-Quit smoking in [**2077**] after 2 ppd x 20 year smoking history
(40pack-year)
- Denies illicit drug use
Family History:
Cardiac disease, DM, Prostate ca, cirrhosis. Son also has RV
dysplasia .
Physical Exam:
T 96.0, BP 104/60, HR 60, RR 22, O2sat 95% on 3L, FS 216
General: Pleasant obese male lying in bed in NAD
Skin: several open sores on arms with dirty fingernails. PVD
skin changes with bilateral lower extremities
HEENT: NCAT, anicteral sclera, injected conjunctiva bilaterally,
left pupil reactive to light. Right pupil less reactive- pt says
he had recent cataract surgery in that eye. Could not assess JVD
given body habitus, no cervical LAD appreciated.
CV: distant heart sounds, but RRR with 2/6 systolic murmur heard
best at LUSB without radiation.
Lungs: bibasilar crackles; distant breath sounds at the right
base. No wheezes, rales, or rhonchi
Abdomen: distended but still soft. +BS, non-tender to palpation.
+ascities.
Extremities: very trace edema on left lower extremity.
peripheral vascular disease skin changes with erythema
bilaterally. Right knee with suprapatellar 3+ edema and beefy
red erythema extending past patella. Warm and mildly tender to
touch. ROM not fully tested secondary to discomfort.
Pertinent Results:
Labs on transfer from OSH: WBC 6.9 with 93.5%PMNs, 22% bands,
6%metamyelocytes, 1 nucleated RBC, Hgb 12.7, Plts 101, PTT 67 on
heparin gtt of 600 units, sodium 134, potassium 4, chloride 99,
CO2 18. BUN 38, Cr. 4.7, BS 117. Ammonia level elevated at 61,
BNP 1242, vanco level [**2100-12-1**] was 5
.
Trends: CK CK MB Trop I
94 6.4 0.71
133 14.2 2.96
144 13.5 3.61
-- --- 4.7
.
Studies from OSH:
[**2100-11-29**]: CXR 2 views: no pneumonia. Cardiomegaly. Pacemaker
inplace. no evidence of CHF. Small pleural effusion on lateral
view.
.
[**2100-11-30**]: U/S guided paracentesis: removal of 5100 mL fluid with
270 WBC, with 14%PMNs, 24% L, 60% monocytes, 10,000 RBC
.
[**2100-11-30**] VQ scan: low probability of PE
.
ECHO (per d/c summary from OSH- no actually report with transfer
papers) showed poor LV function with an EF of 30-35%.
Labs from [**Hospital1 18**]:
Micro: staph aurea from prepatellar bursa x3
Brief Hospital Course:
70 yo M with multiple medical problems including RV dysplasia
leading to right heart failure and chronic hepatic congestion,
ESRD requiring dialysis, DM2 and an AMI.
.
#AMI: patient was asymptomatic but was found to have largely
elevated troponins at the OSH. He does have ESRD which
obviously affects the troponin clearence in the blood. He was
continued on a heparin gtt originially on admission. This is
was stopped secondary to bleeding. Unsure about appropriate
medical regimen given his extensive history and RV dysplasia.
Has tried BB in past but had symptomatic hypotension from it.
Likely no statin given his liver function. Not on an ACEI
currently. Has h/o GI bleed- so careful with anticoagulation.
Probably reason he is not on ASA. While in the hospital an ASA
was started.
.
#h/o multiple arrhythmias: s/p multiple ablations. pacer in
place. EP consult in AM to evaluate pacer and found it to be
functioning well.
.
#PAF: Continued his home amiodarone and was monitored on
telemetry. The issue of anticoagulation is discussed above.
.
#DM2: patient not on medications on transfer. Will start with
humalog sliding scale and add standing insulin based on 24 hour
usage. His fingersticks were monitored and found to always be
within the 100-150 range qAC. He was placed on an insulin SS
with humalog but did not require any use of insulin.
.
#ESRD: requires dialysis T, TH, SA. The renal fellow was
notified and made recommendations regarding his nephrocaps and
phoslo and calcitriol. He underwent dialysis as schedule.
.
#Chronic hepatic congestion: requires paracentesis twice a week.
He was monitored closely and a therapeutic paracentesis was
performed on [**2100-12-6**].
.
#Right-sided and left-sided heart failure: from RV dysplasia.
He was placed on a 1L fluid restriction and a CXR on admission
showed no evidence of fluid overload. As above, he was
monitored for ascites build up.
.
#erythematous right knee: considered gout flare at OSH given
this is a recurrent site for him. Given WBC and diff with bands
and metamyl, concern for cellulitis. Patient received vancomycin
at OSH. Continued allopurinol and stopped colchicine secondary
renal insufficiency. Rheumatology was consulted and tapped his
pre-patellar bursa three times to remove fluid. It grew out
Staph aureas which was MSSA. Vancomycin was changed to
nafcillin. Ortho was consulted for concern over a septic joint.
Despite pain in his knee, the patient was able to ambulate on
the joint and it was believed the infection was not in the joint
itself. Ortho did decided to take him to surgery for a wash out
procedure. During the procedure he developed hypotension which
continued in the PACU. He was transferred to the CCU. He never
recovered from the procedure and expired in the CCU. His family
wanted an autopsy performed.
.
#hypothyroidism: continue levothyroxine. TFTs were WNL.
.
#Code status: Full code
Medications on Admission:
Meds on transfer:
heparin gtt
aminodarone 200mg daily
allopurinol 100mg [**Hospital1 **]
lovxyl 0.175mg daily
calcitrol 0.25mg daily
atarax 10mg TID
zoloft 100mg daily
nephrocaps PO TID
phoslo 2tabs QAC
lovenox SC 40mg qAM
protonix 40mg daily---had not received
procrit 1300mg ----had not received
digoxin 0.25mg [**Hospital1 **] given on [**11-29**]
colchicine 0.5mg IV q6 x2 on [**11-30**]
vancomycin 1g IV given [**11-30**] and [**12-1**]
NTG 0.4mg SL prn
acetaminophen 650mg PO/PR q4 prn
dulcolax PR qAM prn
reglan 10mg PO/IV q6 prn
vicodin 1 tab q3-4hrs prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
primary diagonsis:
cardiopulmonary arrest leading to death
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2101-1-12**]
ICD9 Codes: 0389, 4275, 4280, 4254, 5856, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5720
}
|
Medical Text: Admission Date: [**2101-1-10**] Discharge Date: [**2101-1-13**]
Date of Birth: [**2026-8-8**] Sex: M
Service: ICU Fennard
HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman
with a history of ruptured aneurysm in his brain in [**2098**] who
has been on Hospice care for the previous two years comes in
from home with respiratory distress. He was in his usual
state of poor health until two days prior to admission when
he noted nausea, vomiting, shortness of breath, and cough
with sputum.
On arrival to the Emergency Room, upon request of his family,
his code status was reversed from "Do Not Resuscitate"/"Do
Not Intubate" to full code. In the Emergency Department he
was tachycardiac and hypoxic but not hypotensive. He was
intubated given his hypoxia refractory to six liters nasal
cannula or nonrebreather. He was fluid resuscitated with
five liters normal saline and given ceftriaxone,
levofloxacin, and metronidazole. He was started on
phenylephrine for hypotension then transferred to the Fennard
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. "Brain aneurysm" rupture in [**2098**] at [**Hospital1 2025**].
2. Sacral decubitus.
3. Cataracts.
4. Hypertension.
MEDICATIONS:
1. Baclofen.
2. Trazodone.
3. Amantadine.
4. Multivitamin.
SOCIAL HISTORY: Disabled former Korean War veteran. He has
a history of smoking one pack per day but quit two years ago.
Alcohol in the past but quit. No drugs.
FAMILY HISTORY: His sister has had diabetes mellitus and
cervical cancer.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.5 F, pulse
is 157 in atrial fibrillation, blood pressure is 117/74, and
he is [**Age over 90 **]% on assist control 500 x 20 with a positive
end-expiratory pressure of 5. His CVP is noted to be 6. He
was sedated and intubated. Oropharynx is without thrush.
His neck is noted as flat jugulovenous pressure; no
lymphadenopathy or bruit. His chest shows diffuse rhonchi.
Heart is regularly irregular. Abdomen is soft. Bowel sounds
are present. Skin shows the sacral decubitus is clean, dry,
and intact. He has vesicles in his right thorax.
Extremities are unremarkable.
LABORATORY DATA: His white count was 4 with 28% neutrophils,
20 bands, 38 lymphs, 6 metamyelocytes, and 2 myelocytes. His
hematocrit was 47, platelets were 78. His INR was 1.4, his
PTT was 36.6. His DIC panel revealed a fibrinogen of 342.
His sodium was 141, potassium 5.1, BUN 101, bicarbonate 23,
BUN 58, and creatinine 2.4. His baseline was below 1.
Urinalysis showed greater than 50 white cells. Initial ABG
was 7.37 with a PCO2 of 35 and bicarbonate of 21 and a PO2 of
45.
He subsequently developed a metabolic acidosis during the
admission.
Chest x-ray showed right lung with patchy opacities, left
midline with nodular opacities suggestive of a right
multifocal pneumonia.
EKG revealed atrial fibrillation.
HOSPITAL COURSE IN TOTAL: The patient was admitted to the
Fennard ICU with the diagnosis of sepsis secondary to
pulmonary or urine source. He was aggressively treated with
pressors, broad spectrum antibiotics, and Acyclovir for
shingles. He was maintained on mechanical ventilation. His
blood cultures began growing gram negative rods for which
Gentamicin was added.
On the third hospital day at the results of a family meeting,
the decision was made to withdraw care and make the patient
"comfort measures only," at which point he was maintained on
Fentanyl drip only. The patient expired the following day.
Postmortem examination was declined.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 2396**]
MEDQUIST36
D: [**2101-1-13**] 11:53
T: [**2101-1-13**] 14:53
JOB#: [**Job Number 26791**]
ICD9 Codes: 5849, 4275, 5990
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5721
}
|
Medical Text: Admission Date: [**2159-7-9**] Discharge Date: [**2159-7-16**]
Date of Birth: [**2111-4-4**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4223**] is a 48-year-old
male resident at Rentham Developmental Center, who has a
problem with chronic severe aspiration. This problem was
first noticed around eight years ago. He had a gastrostomy
tube placed in [**2150**]. He continued to have reflux, however,
with aspiration and recurrent pneumonia. In [**2159-6-12**], he developed right pleural effusion. He had a
thoracoscopy and chest tube placement. The fluid was an
exudate with no infection or malignancy.
Due to the recurrent nature of the problem, he was scheduled
for a tracheoesophageal separation by total laryngectomy with
Dr. [**Last Name (STitle) 1837**] on [**2159-7-9**].
PAST MEDICAL HISTORY:
1. Chronic aspiration.
2. Pulmonary fibrosis secondary to Macrodantin.
3. Chronic constipation.
4. Acne.
5. Pre-procedural anxiety.
6. Contractures.
7. Hypothyroidism.
8. Hypothermia.
9. Atypical psychosis/frontal lobe syndrome.
10. Seizure disorder.
11. Dysphagia.
12. History of urinary tract infections.
13. Mental retardation.
HOSPITALIZATIONS:
1. [**Date range (3) 12357**] at [**Hospital3 934**] Hospital for
respiratory distress, pleural effusions, Pseudomonas urinary
tract infection.
2. On [**2159-4-8**] returned to [**Hospital **] Hospital for vomiting
with respiratory distress.
ALLERGIES: Ampicillin that causes swelling and rash.
MEDICATIONS:
1. Calcium carbonate 1250 mg q day.
2. Dilantin 300 mg q day.
3. Keflex 500 mg q6h.
4. Metronidazole 250 mg q8h.
5. Olanzapine 2.5 mg q day.
6. Senna four tablets daily.
7. Levothyroxine 25 mcg q day.
8. Milk of magnesia 60 cc daily.
9. Topamax 250 mg [**Hospital1 **].
10. Fludrocortisone 0.1 mg q day.
11. Albuterol/ipratropium nebulizers qid.
12. Dulcolax suppository qod.
13. Fleet's enemas q2-3 days prn.
DIET: His diet includes 3/4 strength 2-cal HN 70 cc/G tube q
hour with 1/4 strength Jevity Plus x12 hours q day along with
two tablespoons of ProMod [**Hospital1 **].
FAMILY HISTORY: Maternal parents colon cancer. Paternal
parents significant cardiac disease. Father died of
transient ischemic attack and stroke. Mother developed
diabetes in her 60s. Brother and maternal aunt diagnosed
with multiple sclerosis.
On examination, [**2159-5-16**] preoperative: In general, this
is a 48-year-old male with multiple physical handicaps, who
is alert, nonverbal, and cooperative. Skin: Good turgor,
scattered scars including permanent scar in right hip. Eyes:
Left exotropia. Pupils are equal, round, and reactive to
light. Visual acuity appears intact. Fundoscopic
examination limited, but grossly normal. Ears normal,
hearing acuity with bilateral cerumen. Nose: Nares patent.
Dental hygiene fair. No abnormal tongue movements. Neck is
supple, no thyromegaly or lymphadenopathy. Cyst noted at
base of the skull. Lungs: Occasional rhonchi, decreased
breath sounds at bases. Heart: Normal sinus rhythm, no
audible murmurs. Abdomen is soft, protuberant, bowel sounds
active in all quadrants, no hepatosplenomegaly, no tenderness
or masses. G tube in place mid abdomen. G site clean.
Rectal examination deferred. Extremities: Light
contractures of right upper extremity. Significant
contractures of the left upper extremity with left hand
flexed. No skin breakdown. All four limbs can be extended
left greater than right. Neurologic: Mental status: Alert,
minimally verbal, follows simple requests. Cranial nerves II
through XII intact except for exotropia. Deep tendon
reflexes hyperreflexive lower extremities, normal reflexes
upper extremities.
PREOPERATIVE CHEST X-RAY: Showed pleural thickening with no
acute consolidation or change.
PREOPERATIVE ELECTROCARDIOGRAM: Within normal limits, rate
80, normal sinus rhythm, no change since previous
electrocardiogram in [**2154**].
Patient underwent a total laryngectomy on [**2159-7-9**] with Dr.
[**Last Name (STitle) 1837**]. There were no complications. He received
4800 cc of crystalloid. Urine output 425 cc, 200 cc
estimated blood loss. He was transferred to the Intensive
Care Unit postoperatively.
HOSPITAL COURSE AND TREATMENT:
1. Otolaryngology: The patient had bacitracin applied to his
wounds [**Hospital1 **] throughout his stay. They continued to heal well.
Staples were removed prior to discharge. He received
humidified O2 by trache collar which was gradually weaned to
35% FIO2. He was on aspiration precautions throughout his
stay to prevent reflux.
Postoperative laboratories included a white count of 6.9,
hematocrit of 29.7, which subsequently rose to 31.9. He
continued to improve throughout his stay. His ionized
calcium postoperatively was 1.15, which dropped to 0.97 and
returned to 1.15 prior to discharge. He was transferred to
the floor on postoperative day three, [**2159-7-12**]. His drains
were originally to wall suction with high output around 100
cc a day until [**7-13**] and 2nd when they are switched to
bulb suction, and the output came down to between 50-70 cc a
day.
JP #2 was removed on [**2159-7-15**] after putting out 30 cc over 24
hours. JP #1 was removed on [**7-16**] prior to discharge.
2. Neurologic: The patient's Dilantin level postoperatively
was 4.3. He was loaded with 500 mg IV x1 and then placed on
a maintenance dose of 100 mg tid. He did have seizure
activity during his stay. His Dilantin level rose to 12.9,
which was in the therapeutic range, and he was continued on
the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **]
[**Last Name (Titles) 1506**] throughout his stay.
3. GI: Immediately, postoperatively the G tube was placed to
gravity. His tube feeds were resumed on [**7-10**], postoperative
day one with a Nutrition team following him. He had very low
residuals and no problems with aspiration into the
oropharynx.
4. Infectious Disease: The patient was afebrile throughout
his stay. He was on Ancef and Flagyl after the surgery. He
had a urinalysis that was positive and was placed on Cipro
throughout the length of his stay.
5. Respiratory: He continued to have thick secretions
requiring frequent suctioning and chest PT. He received
respiratory care multiple times a day. Wheezing was
controlled with albuterol and Atrovent nebulizers.
6. Endocrine: He had a TSH of 0.78 postoperatively. He
received his normal dose of Synthroid. No changes were made.
He was on an insulin-sliding scale throughout his stay.
On [**7-16**], staples and drains were discontinued. The
patient was in good condition with continuing needs for
frequent suctioning. He was discharged to Rentham with
antibiotics, pain medication, and instructed to followup with
Dr. [**Last Name (STitle) 1837**] in [**12-14**] weeks.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 6152**], M.D.
[**MD Number(1) 6153**]
Dictated By:[**Last Name (NamePattern1) 12358**]
MEDQUIST36
D: [**2159-7-16**] 08:23
T: [**2159-7-16**] 08:25
JOB#: [**Job Number 12359**]
ICD9 Codes: 5990, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5722
}
|
Medical Text: Admission Date: [**2127-12-24**] Discharge Date: [**2128-3-12**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea on exertion and weight gain
Major Surgical or Invasive Procedure:
[**1-7**] redo sternotomy, AVR(23 CE pericardial)/MVrepair(28mm CE
physio ring), aortic endarterectomy
[**1-28**] Trach & PEG
[**2128-2-6**] Sternal debridement
[**2-23**] Sternal debridement
[**2-25**] Sternal closure with plating
[**3-5**] RIJ Tunnelled dialysis catheter
History of Present Illness:
83 yoM w/ a h/o CAD initially admitted on [**12-17**] to OSH with a 15
lb weight gain over past 3 months. Dyspnea @ rest and pedal
edema upon presentation. Upon his hospitalization he developed
atrial flutter and has atrial flutter w/ tachycardia requiring
lopressor however while asleep at night his heart rate has been
slow to low 30s at times with 3 second pauses. Stress rates of
110-120s. Transferred to [**Hospital1 18**] for evaluation.
Past Medical History:
Coronary Artery Disease
Systolic heart failure
HTN
Atrial Flutter
Claudication
S/p nephrectomy for Left Renal Cell Carcinoma
Hypercholesterolemia
Gout
Social History:
Tobacco denies - quit many years ago
Rare ETOH
Lives alone
Family History:
Unknown
Physical Exam:
VS: BP 134/82 HR 109 RR 18 O2 95% 2L
GEN: NAD, AOx3
HEENT: JVP 10cm (but difficult to see)
CARD: tachycardia, regular rhythm, [**3-10**] early peaking systolic
cres decres murmur @ USB w/o radiation to the carotids
PULM: rales [**2-4**] way up on R, bronchial breath sounds [**2-4**] way up
on L side
ABD: Soft, NT, ND, no masses, BS+
EXT: WWP, 2+ pitting edema to thigh bilaterally symmetrical
Pertinent Results:
[**2128-3-12**] 12:22AM BLOOD WBC-15.1* RBC-2.81* Hgb-8.7* Hct-28.3*
MCV-101* MCH-31.0 MCHC-30.9* RDW-20.5* Plt Ct-222
[**2128-3-11**] 03:01AM BLOOD WBC-10.6 RBC-2.67* Hgb-8.6* Hct-27.0*
MCV-101* MCH-32.3* MCHC-31.9 RDW-20.5* Plt Ct-192
[**2128-3-12**] 12:22AM BLOOD PT-18.6* PTT-57.9* INR(PT)-1.7*
[**2128-3-11**] 11:04AM BLOOD PT-17.6* PTT-54.3* INR(PT)-1.6*
[**2128-3-12**] 12:22AM BLOOD Glucose-112* UreaN-28* Creat-2.2* Na-136
K-4.3 Cl-99 HCO3-26 AnGap-15
[**2128-3-11**] 03:01AM BLOOD Glucose-140* UreaN-37* Creat-2.7* Na-135
K-3.9 Cl-100 HCO3-22 AnGap-17
Brief Hospital Course:
He was admitted to the floor and diuresed. TEE on [**12-26**] showed
no thrombus and on [**12-26**] he underwent a flutter ablation. He
became hypotensive from diuresis and was started on dopamine and
tranferred to the CCU. Cardiac surgery was consulted for his
severe AS and MR. [**Name13 (STitle) **] was started on tube feeds for dysphagia. He
remained on a heparin drip. He had a VT arrest requiring CPR,
and recovered to rapid afib. He was started on amiodarone. He
was intubated electively, and cardiac cath was done and [**12-29**]
and graft to OM was stented. He was treated for a klebsiella
UTI. Repeat echo showed no improvement in EF after stent. He was
seen by renal for increasing creatinine however continued to
have good urine output with lasix and diuril. He was extubated
on [**1-1**]. He agreed to surgery, and on [**1-7**] was taken to the
operating room wher he underwent a redo sternotomy/AVR/MV Repair
and aortic endarterectomy. He became asystolic immediately post
op and was reopened with resolution and no findings. He was
transferred to the ICU in critical but stable condition on epi,
neo and propofol. He was given vancomycin periop as he was in
the hospital preoperatively. He was hypotensive overnight,
milrinone and pitressin were added, and he was transfused. His
pressors and vent were slowly weaned and he was diuresed. His
vasoactive drips were weaned to off and He was extubated on POD
#7. He had several runs of VT. He remained on heparin IV for
atrial fibrillation and Coumadin was held with plans for AICD.
He was started on a lasix drip, and required free water for
hypernatremia. On [**1-17**] he was reintubated for PCO2 of 90. AICD
placement was cancelled until patient is stabilized. After
multiple extubation attempts, on [**1-28**] a trach and were placed.
Diamox was added for diuresis. Coumadin was restarted. He
continued to progress and was able to tolerate trach collar
trials. Diuresis was stopped. EP was reconsulted in relation
to AICD and Mr. [**Known lastname 40177**] should follow up in one month with EP.
His distal incision began to drain serous fluid and it was
opened and packed. His trach was changed to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**] on [**2-5**]. His
sternum continued to open and He was taken to the operating room
on [**2-5**] for a sternal debridement and a VAC was placed. He
suffered a cardiac arrest in the operating room and was
resuscitated. He was started on 3 pressors and vanco zosyn and
flagyl. He was seen by nephrology for decreased urine output. He
was started on fluconazole for yeast in his sternal wound. He
was started on CVVH. He remained on multiple pressors. He
remained on full ventilator support, an dpressors for a number
of days. He stabilized hemodynamically, and weaned off
pressors. On [**2128-2-23**], he was again taken to the OR with Dr.
[**First Name (STitle) **] (plastic surgery) for a sternal debridement. He was
again returned to the OR for delayed sternal closure with
plating by Dr. [**First Name (STitle) **] on [**2128-2-25**]. He was able to tolerate
hemodialysis, no longer requiring CVVH, so he had a RIJ
tunnelled hemodialysis catheter placed on [**2128-3-5**] by Dr. [**Last Name (STitle) 816**].
He has remained hemodynamically stable, and is now ready to be
transferred to rehab for continued physical therapy, and
ventilator weaning. His Zosyn will be completed on [**2128-3-22**].
Fluconazole is to be lifelong. Daptomycin should continue for 4
week from start date of [**2128-3-11**].
Medications on Admission:
Metoprolol 100mg po daily
Lipitor 10mg po daily
Lasix 80mg po daily (patient is unsure if he takes lasix at
home)
Aspirin 81mg po daily
Cozaar 50mg po daily
Cilostozal 100mg po bid
Doxasosin 4mg po daily
Allopurinol 100mg daily
Discharge Medications:
1. Allopurinol 100 mg Tablet [**Date Range **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily): for stent .
3. Senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: Ten (10) PO BID (2
times a day).
5. Carvedilol 3.125 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: [**3-8**]
Puffs Inhalation Q6H (every 6 hours) as needed.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Lipitor 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Tablet(s)
10. Nephrocaps 1 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day.
11. Sertraline 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO once a day:
75 mg daily.
12. Zosyn 2.25 gram Recon Soln [**Last Name (STitle) **]: 2.25 Gms Intravenous every
eight (8) hours for 10 days: end date [**2128-3-22**].
13. Daptomycin 500 mg Recon Soln [**Month/Day/Year **]: 350 mg Intravenous every
other day for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Aortic Stenosis s/p avr
Mitral Regurgitation s/p MV repair
Acute on chronic systolic heart failure
PMH: HTN, Aflutter (s/p ablation [**12-26**]), Claudication, Chol,
Gout, CAD (s/p MI x 3)[**2112**], CHF (EF 20%)
PSH: CABG '[**12**], Lt Nephrectomy '[**99**], Rt knee [**Doctor First Name **] 70's
Discharge Condition:
Fair
Discharge Instructions:
Call with fever, or redness or drainage from incision.
[**Telephone/Fax (1) 170**]
Please monitor weight - systolic heart failure - monitor for
weight gain more than 2 pounds in one day or five in one week.
No baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon
Followup Instructions:
Dr. [**Last Name (STitle) 1637**] after discharge from rehab - please call to schedule
appointment [**Telephone/Fax (1) 14655**]
Dr. [**First Name (STitle) **] - [**Telephone/Fax (1) 170**] please call for appointment when
discharged from rehab
Dr. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 285**]
Dr. [**First Name (STitle) 1075**] in [**Hospital **] clinic on [**2128-3-19**] at 10 am ([**Last Name (NamePattern1) **],
basement) Please call if need to reschedule [**Telephone/Fax (1) 457**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2128-3-12**]
ICD9 Codes: 4240, 9971, 4275, 5990, 4271, 0389, 5845, 4280, 2720, 5859, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5723
}
|
Medical Text: Admission Date: [**2106-11-19**] Discharge Date: [**2106-12-3**]
Date of Birth: [**2045-10-13**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
gentleman with a past medical history significant for heavy
tobacco use and hypertension who was admitted from an outside
hospital with crescendo angina.
The patient reported having substernal chest pain with
radiation to his neck. The patient was initially admitted to
[**Hospital3 15174**] where he had positive enzymes.
In Cardiac Catheterization Laboratory it was found that the
patient had an ejection fraction of 30%, a 50% left main
lesion, a 90% left anterior descending artery lesion, a 99%
left circumflex lesion, and a 30% right coronary artery
lesion.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Hypertension.
3. Status post right hip replacement.
4. Carpal tunnel surgery.
5. Status post right carotid endarterectomy.
6. Status post left cataract surgery.
7. Degenerative joint disease.
8. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg by mouth once per day.
2. Atenolol 50 mg by mouth once per day.
3. Aspirin.
4. Lipitor 20 mg by mouth once per day.
ALLERGIES:
SOCIAL HISTORY: The patient reports an ethanol history
significant for six beers per day. The patient also reports
a significant tobacco history times 30 years with as many as
four packs per day; now down to one pack per day.
PHYSICAL EXAMINATION ON PRESENTATION:
PERTINENT LABORATORY VALUES ON PRESENTATION:
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Cardiology Service after his cardiac catheterization.
A Cardiac Surgery consultation was obtained. The patient was
started on thiamine, and folate, and Ativan per the CIWA
scale for his history of daily ethanol use.
The patient had a carotid ultrasound that showed no
significant stenosis bilaterally. The patient was noted to
have poor dentition and had a Dental consultation which
determined that the patient was stable for having a coronary
artery bypass graft but recommended postoperative extraction
of teeth 22 through 26, 29 and 30, and repair of the caries
in 27. It was determined that this would be postponed until
the patient had been discharged from the hospital.
The patient was also noted to have mild thrombocytopenia with
an admission platelet count of 109 which had decreased to 79
on [**11-23**]. A Hematology Service consultation was
obtained. Hematology felt that the patient's admission
thrombocytopenia was likely due to alcohol use. The
Hematology team recommended perioperative transfusion of
platelets. Upon review of the patient's peripheral smear, it
was thought that the patient had macrocytosis and mild anemia
consistent with myelodysplasia. It was overall felt that the
patient was fine to proceed with surgery.
It was also noted on [**11-23**] that the patient had a
significant area of ecchymosis and hematoma in his groin. An
ultrasound of his femoral artery revealed a pseudoaneurysm.
The Vascular Surgery Service was consulted. Vascular Surgery
recommended discontinuing heparin if at all possible and
possible compression and re-imaging of the pseudoaneurysm.
The heparin drip was held, and pressure was applied to the
site of the pseudoaneurysm. Re-imaging by ultrasound showed
resolution of the pseudoaneurysm without evidence of
arteriovenous fistula. Vascular Surgery felt that there was
no further intervention needed.
On [**11-27**], the patient was taken to the operating room
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] for a coronary artery bypass graft
times three with left internal mammary artery to left
anterior descending artery, saphenous vein graft to second
diagonal, and saphenous vein graft to obtuse marginal.
The patient was transferred to the Intensive Care Unit in
stable condition. The patient was extubated from mechanical
ventilation on the first postoperative evening. He remained
hemodynamically stable.
The patient was transferred from the Intensive Care Unit to
the regular part of the hospital on postoperative day one.
The patient began working with Physical Therapy. The patient
continued to require oxygen via nasal cannula with aggressive
chest physical therapy, and cough, and deep breathing. This
was weaned to off by postoperative day four. The patient's
pacing wires were removed on postoperative day one. The
patient was continued on around the clock Ativan with
subsequently decreasing doses with no evidence of alcohol
withdrawal.
The patient was expressing multiple times his anxiety and
being discharged to home. On postoperative day four, the
patient became anxious to go home and began displaying
impulsive behavior. It was felt by the nursing staff that
the patient was not safe to be left alone, and the patient
was placed with a one-to-one sitter because the patient was
slightly unsteady on his feet. The patient's sitter was
discontinued on postoperative day five. The patient worked
again with Physical Therapy, and they felt that he was safe
for ambulation on his own.
By postoperative day seven, the patient was cleared for
discharge to home with physical therapy followup at home.
CONDITION AT DISCHARGE: The patient's temperature maximum
was 98.5 degrees Fahrenheit, his heart rate was 82 (in a
sinus rhythm), his blood pressure was 116/72, his respiratory
rate was 14, and his oxygen saturation was 95% on room air.
Neurologically, the patient was alert, awake, and oriented
times three. Nonfocal examination. Cardiovascular
examination revealed a regular rate and rhythm. No murmurs
or rubs. Extremity examination revealed the extremities were
warm and well perfused. Respiratory examination revealed
breath sounds were rhonchorous bilaterally without wheezes.
There were decreased breath sounds at the left lung base.
Gastrointestinal examination revealed there were positive
bowel sounds. The abdomen was soft, nontender, and
nondistended. The patient was tolerating a regular diet.
The sternal incision was clean, dry, and intact. There was
no erythema or drainage. The left lower extremity vein
harvest site had some mild erythema at the distal medial
thigh incision. There was no tenderness. There was no
drainage. The Steri-Strips were intact. The right groin was
ecchymotic without bruits. The extremities were without
edema.
PERTINENT LABORATORY VALUES ON DISCHARGE: Laboratory data
revealed the patient's white blood cell count was 10.2, his
hematocrit was 38.3, and his platelet count was 413. The
patient's sodium was 137, potassium was 4.6, chloride was 99,
bicarbonate was 27, blood urea nitrogen was 19, creatinine
was 1.3, and blood glucose was 111.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray on [**12-2**]
revealed no effusion or infiltrate.
MEDICATIONS ON DISCHARGE:
1. Atenolol 50 mg by mouth once per day
2. Enteric-coated aspirin 325 mg by mouth every day.
3. Percocet 3/525-mg tablets one to two tablets by mouth
q.4-6h. as needed.
4. Thiamine 100 mg by mouth once per day.
5. Folate 1 mg by mouth once per day.
6. Protonix 40 mg by mouth once per day.
7. Ativan 0.5 mg by mouth twice per day as needed.
8. Lipitor 20 mg by mouth once per day.
9. Colace 100 mg by mouth twice per day.
10. Nicotine patch 21 mg transdermally once per day.
DISCHARGE STATUS: The patient's discharge status was to
home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his
cardiologist (Dr. [**Last Name (STitle) 11493**] in one week.
2. The patient was instructed to follow up with his primary
care physician (Dr. [**Last Name (STitle) 15131**] in one week.
3. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in five to six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2106-12-3**] 10:09
T: [**2106-12-3**] 10:28
JOB#: [**Job Number 29667**]
ICD9 Codes: 4111, 2875, 2720, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5724
}
|
Medical Text: Admission Date: [**2183-12-23**] Discharge Date: [**2183-12-25**]
Date of Birth: [**2113-7-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
ACOMM Aneurysm
Major Surgical or Invasive Procedure:
Cerebral Angiogram for ACOMM aneurysm stenting
History of Present Illness:
Pt presents for elective coiling of Acomm artery aneurysm
Past Medical History:
CAD 15 heart catheterizations and 3 stents in the past.
knee repair, back surgery, and a cluster of veins in his right
eye. He has diminished vision in the right eye.
Social History:
He is retired and works part-time as a security officer. His
wife works in a medical facility. He is married. He does not
smoke and quit in [**2157**]. He takes alcohol rarely.
Family History:
Family history is significant for cancer in the mother who died
at age 42, heart attack in father who died at age 49. He has a
sister who has a history of cancer and brother with liver
problems.
Physical Exam:
This pt is awake alert and oriented with a non focal
neurological exam. Full motor and sensory throughout. His
right groin angio site is flat and distal pulses are palpable.
Pertinent Results:
Head CT [**2183-12-23**]:
Stent spanning the A1 segment of the left anterior cerebral
artery, the
anterior communicating artery, and the proximal A2 segment of
the right
anterior cerebral artery. No evidence of acute hemorrhage.
his angio report from [**2183-12-23**] is not finalized at this time of
discharge
Brief Hospital Course:
70M with an unruptured ACOMM aneurysm who came for an elective
cerebral angiogram for stenting of the ACOMM aneurysm. No
coiling was done. Post-angio, the patient was placed on a
Heparin drip for a PTT goal of 60-80. His drip was discontinued
late [**12-24**] morning and he was transferred to the floor. He
remained neurologically intact without issue. He was d/c'd to
home with plans to follow up in 6weeks for completion of
coiling. His aneurysm at this time is not secured.
Medications on Admission:
metformin/ glipizide/ tylenol/ omeprazole/ atenolol/ ativan/ asa
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 6 weeks.
Disp:*42 Tablet(s)* Refills:*0*
10. prednisone 20 mg Tablet Sig: Two (2) Tablet PO as directed
for procedure: take 40mg 16 hours prior to test, 40 mg 8 hours
prior and 2 hours prior .
Disp:*6 Tablet(s)* Refills:*0*
11. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO take 50mg one
hour prior to your procedure.
Disp:*2 Capsule(s)* Refills:*0*
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO one hour
prior to your procedure .
Disp:*1 Tablet(s)* Refills:*0*
13. lancets
lancets for fingerstick glucose monitoring.
disp 1 box
Discharge Disposition:
Home
Discharge Diagnosis:
ACOMM Aneurysm (Unruptured)
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 6 weeks at
[**Telephone/Fax (1) 1669**] for your angiogram with coiling.
[**First Name9 (NamePattern2) 90411**] [**Doctor First Name **] from the office of Dr. [**First Name (STitle) **] will contact you
at home with your time for your procedure .... you will also
receive a packet in the mail regarding the same.
Completed by:[**2183-12-25**]
ICD9 Codes: 496, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5725
}
|
Medical Text: Admission Date: Discharge Date:
Date of Birth: [**2071-5-6**] Sex: M
Service: Medicine/[**Doctor Last Name **]
CHIEF COMPLAINT: Patient is a 67-year-old male with a
history of systolic dysfunction and PUD, presenting to the
Emergency Room with left lower extremity bilateral edema
times 8-10 days. The patient is a very poor historian and
noted that he had something like this years ago for which he
was hospitalized. The patient also states that he has
increased dyspnea on exertion and he gets short of breath
after ?????? block. The patient states he wakes paroxysmally in
the middle of the night with shortness of breath. Stable two
pillow orthopnea. Denies chest pain, palpitations,
lightheadedness, nausea, vomiting or diaphoresis.
HISTORY OF PRESENT ILLNESS: The patient presented to the
Emergency Room and was noted to be tachypneic in the 30's,
tachycardic in the 100's. O2 saturation was 85% on room air,
few crackles on lung exam were noted. Chest x-ray was
negative for edema. EKG showed extreme right axis deviation.
The patient was admitted to medicine for treatment and for
evaluation of predominantly right sided heart failure.
PAST MEDICAL HISTORY: Significant for CHF. Echocardiogram
done in [**2132**] showed moderate global left ventricular
hypertrophy and thinning of septum. EF 30-35%, mild MR, mild
AR, moderate TR, mild pulmonary hypertension. PASV of 35
mmHg. History of alcohol abuse, quit 4-5 years ago, history
of PUD, etiology Aspirin and ethanol use. H. Pylori negative
and Killian-[**Last Name (un) 10712**] cervical ring; patient is asymptomatic.
SOCIAL HISTORY: The patient is a retired maintenance worker,
lives alone, positive for tobacco one pack per week, formerly
two packs per day. Positive for alcohol, states none for the
last 4-5 years. No history of withdrawal. Patient has a
remote history of marijuana and Cocaine use, no IV drug
abuse.
FAMILY HISTORY: Mother alive and well at 84, father passed
away at 72 of unknown causes. Siblings all reportedly
healthy with one brother who died of pneumonia in his 60's
and a sister who died at childbirth.
PHYSICAL EXAMINATION: Initial exam, patient is a 67-year-old
black male, tachypneic, in no apparent distress, alert and
oriented times three, temperature 97.3, pulse 99, blood
pressure 102/87, respirations 34, 97% on 2 liters nasal
cannula oxygen. Skin is warm, dry, anicteric. HEENT:
Normocephalic, atraumatic, pupils are equal, round, and
reactive to light and accommodation, extraocular movements
intact, OP clear. Neck supple, positive for JVD. Lungs, few
crackles, right greater than left, no wheezes.
Cardiovascular exam, S1 and S2, tachycardic, 2/4 systolic
ejection murmur at right upper sternal border.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Last Name (NamePattern4) 8102**]
MEDQUIST36
D: [**2139-4-3**] 16:47
T: [**2139-4-3**] 19:43
JOB#: [**Job Number 10713**]
ICD9 Codes: 4280, 496, 2762
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5726
}
|
Medical Text: Admission Date: [**2149-4-16**] Discharge Date: [**2149-4-21**]
Date of Birth: [**2084-5-23**] Sex: M
Service:
Briefly, the patient is a 64-year-old male who is an
unrestrained driver of a car that was T-boned on the
passenger side and then rolled over to the driver side. The
patient was found unresponsive and caught under the
dashboard. He had a long extrication time. He is intubated
by EMS at the scene, later becoming agitated and localizing.
He was also hypertensive. His only obvious injury at the
time was a head laceration. He as Life Flighted to [**Hospital1 1444**].
PAST MEDICAL HISTORY:
1. Hypertension.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature was 97 rectal, heart rate
72, pressure of 170/133, respiratory rate 18, pulse oximetry
100% The patient was intubated and sedated. Pupils were 2
mm, fixed and equal. Mid-face was stable. TMs were clear.
Trachea was midline. The patient was in a hard collar.
There was an abrasion over the left forehead and scalp.
Chest and lungs are clear to auscultation bilaterally.
Cardiac is regular rate and rhythm. Neck is supple in hard
collar. Genitourinary is normal tone. Heme negative. The
abdomen was soft, nontender, nondistended. Back: He had no
stepoff or obvious deformities. Extremities are warm without
edema. His peripheral pulses were intact. Neurological
exam: He was sedated.
LABORATORY: On admission included a hematocrit of 37.7,
white count 8.7, BUN and creatinine 18.8, and amylase of 68,
lipase 2.1. Blood gas was 7.51, 29, 434, 24 and 1. Serum
tox was negative. Urinalysis showed 11 to 20 red blood
cells. His urine tox is negative.
Initial trauma workup and imaging included a chest x-ray
demonstrated adequate position of the endotracheal tube and
orogastric tube with tip in the esophagus. No hemothorax.
Pelvic x-ray which was without fracture. A Head CT which was
negative. A C-spine CT with reconstructions that was
negative. An abdominal pelvis CT which is also read as
negative initially.
HOSPITAL COURSE: Following his initial resuscitation imaging
workup the patient was transferred to the Trauma Intensive
Care Unit under the care of Dr. [**Last Name (STitle) **]. Overnight from
hospital day 0 to hospital day one the patient remained
intubated and sedated. On hospital day two the patient was
extubated in the Intensive Care Unit without any difficulty.
Following extubation the patient remained somewhat somnolent
but with a nonfocal neurologic exam otherwise the sedation
was held.
Hospital day two the patient remained in the Intensive Care
Unit, was transferred to the floor on hospital day three. On
the floor the patient again had somewhat decreased verbal
output per the patient's wife. Also appeared somnolent, at
times confused but otherwise a nonfocal neurologic exam.
Given that the patient was somewhat somnolent he had a repeat
head CT performed, this head CT demonstrated one small area
of intraparenchymal bleed consistent with diffuse axonal
injury verses artifact. Given the nonspecific findings on CT
it was decided to obtain an Magnetic resonance scan,
performed on Friday evening [**2149-4-18**] and this magnetic
resonance scan was significant for diffuse spinal injury.
For this the neurology service was consulted, felt that the
patient's exam was significant for decreased processing
speed. Attention, concentration and poor short-term verbal
recall. The patient was felt to have relatively preserved
procedural and remote memory but impaired frontal executive
function including fluency, some word finding difficulty and
impaired abstract reasoning and comprehension of complex
commands.
I felt this exam once again consistent with [**Doctor First Name **] verses an
acute concussional syndrome. They recommended an EEG,
neuropsych testing and assessment for neurology
rehabilitation. The [**Hospital **] Rehabilitation service was
consulted and they recommended an acute rehabilitation for
vertigo associated ataxia, cognitive therapy. Additionally
they recommended he remain out of work for at least three
weeks and restart part time. They felt there was no
neurologic event that caused a seizure or stroke and wanted
the patient to return to [**Hospital **] [**Hospital **] clinic
on [**2149-5-19**] at approximately 12 noon.
On [**2149-4-22**] the patient tolerating a regular diet, pain well
controlled and adequate neurologic rehabilitation, plan in
place and decided to discharge the patient to rehabilitation.
DISCHARGE DIAGNOSIS:
1. Motor vehicle crash.
2. Post concussional syndrome.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. twice a day.
2. Delapram 20 mg p.o. q day.
FOLLOW-UP for Mr. [**Known lastname **] should be with Behavioral Neurology,
Dr. [**First Name (STitle) **] or Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 1690**]. On the [**5-19**] at 12 o'clock.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**]
Dictated By:[**Doctor Last Name 43973**]
MEDQUIST36
D: [**2149-4-21**] 15:25
T: [**2149-4-21**] 17:31
JOB#: [**Job Number 46049**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5727
}
|
Medical Text: Admission Date: [**2194-8-30**] Discharge Date: [**2194-9-1**]
Date of Birth: [**2134-6-13**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Valium overdose
Major Surgical or Invasive Procedure:
Intubation on [**8-30**] s/p extubation on [**8-31**]
History of Present Illness:
This 60 year old white male was found wandering near ferry area
with pills and fishing knives and brought to [**Hospital3 **]. According to notes at [**Hospital3 **] his family in
[**Location (un) 7349**] dropped him at a car rental agency, from there he made his
way to Port Authority to [**Hospital3 4298**]. He has an extensive
psychiatric history and is followed by a psychiatrist. The
family filed a missing person's report when his daughter found
his favorite pieces of art in her room. His wife found a last
will and testament stating that he wanted to go to MV and be
found dead in the ocean. He was weaned off Zyprexa by his
psychiatrist two weeks ago. Further review of his personal items
and prior medication records revealed ingestion of 400-600mg
Valium (based upon empty bottle recently refilled).
.
At the [**Hospital6 **] he was observed in the ICU,
treated with Lorazepam/Zyprexa. He was intubated prior to
transfer and flown by [**Location (un) **] to [**Hospital1 18**] where he was admitted
to the MICU. He was successfully extubated the next morning and
felt to be stable to be transferred to medicine floor for
further management.
ROS: Denies fever, nausea, vomiting, abdominal pain, chest pain,
shortness of breath, leg pain. Denies visual problems or
hallucinations.
Past Medical History:
1. OCD/possible bipolar disease/severe depression
2. PTSD
3. History of abuse as a child
4. Asthma (as a child)
5. IBS
.
PSHx:
1. s/p multiple eye surgeries
Social History:
Smoker, denies recent EtOH (history of abuse but none in [**12-31**]
years), was pres/CEO of real estate until company was
restructured and he lost his job 3 years prior. States he
lives in the basement of a house with his wife, but they don't
stay on the same floor. Has a daughter and a son
Family History:
Mother died in fire after drinking and lighting herself on fire
with a cigarette, Father had heart attack
Physical Exam:
Vitals, Temp 97.2 Tmax 97.5 HR 93 (63-93) BP 130/72
(96-130/52-72), RR 16 95%RA
Gen: Alert and oriented to self and time, oriented to hospital
(did not know the name), appears sad, ocassionally tearing-up
while talking about events in the last day
HEENT: PERRL, MMM
Lungs: crackles at right base
CV: RRR, nl S1S2
Abd: positive BS, soft, nondistended, nontender, no rebound or
guarding
Ext: warm, no cyanosis or edema b/l
Skin: no rashes
Neuro: AOx2 +knows he's in the hospital, knows who the president
is and gives clear statements as to signficant recent national
events. Poor short term recall as cannot remember the name of
the hospital several minutes after repeating the name of the
hospital.
Pertinent Results:
[**2194-8-30**] 10:30PM BLOOD WBC-9.6 RBC-3.98* Hgb-13.1* Hct-37.7*
MCV-95
MCH-32.8* MCHC-34.7 RDW-12.6 Plt Ct-152 Neuts-79.2*
Lymphs-17.1*
Monos-3.4 Eos-0.2 Baso-0.2
PT-13.1 PTT-27.4 INR(PT)-1.1
Glucose-103 UreaN-6 Creat-0.8 Na-135 K-3.2* Cl-103 HCO3-23
AnGap-12
ALT-38 LD(LDH)-326* AlkPhos-58 Amylase-44 TotBili-1.0
Albumin-3.8 Calcium-7.9* Phos-3.0 Mg-1.6
[**2194-8-30**] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
[**2194-8-31**] 05:20AM BLOOD Glucose-86 UreaN-5* Creat-0.8 Na-137
K-3.7 Cl-104 HCO3-24 AnGap-13
Brief Hospital Course:
60 year old male with suicide attempt, most likely with Valium
based upon hospital records and empty bottle found on him. Tox
screen at OSH also positive for amphetamines, methamphetamines,
and PCP.
.
Plan:
1. Agitation - Most likely due to overdose which was suicide
attempt according to records. Repeat tox screen of urine and
blood only positive for benzos. Toxicology contact[**Name (NI) **]. [**Name2 (NI) **] was
Sedated o/n with Propofol while intubated. He was extubated
without complications the following day. Appreciate psychiatry
input. Will put on CIWA scale with Ativan prn Valium
withdrawal. 1:1 security sitter.
.
2. Psychiatric issues/suicidal ideation
- Psychiatry following patient who will need psychiatry
hospitalization.
.
3. FEN
- Cardiac Heart healthy diet, monitor electrolytes
.
4. ID - Spiked temp on [**8-31**], found to have urinary tract
infection likely from foley catheter. Foley was d/c'ed. Chest
x-ray negative, blood cultures negative. Patient started on
Cipro for 10 day course.
.
5. PPx
- SC Heparin
.
6. FULL code
.
7. Dispo - Patient was medically cleared for discharge to
psychiatry on [**9-1**]. He did have a temperature on [**8-31**], was
found to have a urinary tract infection as above and started on
antibiotics. He was hemodynamically stable since his transfer
to the medical floor and was afebrile on [**9-1**] after antibiotics
started.
Medications on Admission:
1. Wellbutrin unknown dose
2. Valium unknown dose
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: Please continue to take until
[**9-10**] for total 10 day course.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Valium overdose
Discharge Condition:
Stable
Discharge Instructions:
Please have your primary care physician called or return to the
hospital if you experience chest pain, shortness of breath or
fevers.
Followup Instructions:
Please follow-up with your psychiatrist as instructed
Completed by:[**2194-9-3**]
ICD9 Codes: 5990
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5728
}
|
Medical Text: Admission Date: [**2168-5-6**] Discharge Date: [**2168-5-11**]
Date of Birth: [**2126-8-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Kefzol / Ibuprofen / Ketoconazole / adhesive tape
/ Shellfish Derived
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
EtOH withdrawal sxs
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
41 y.o. Male with current EtoH abuse, h.o. DTs, seizures
presents EtoH withdrawal symptoms.
.
Pt states he usually drinks at least a 12 pack a day,
unfortunately he could not afford any more alcohol so he started
to withdraw. His last drink was yesterday at 5pm. He noted some
sweats, diarrhea chills and a headache along with tremors which
he usually experiences when he withdraws. He also noted some
epigastric pain with radiation to the back after he stopped
drinking, he started to eat something this morning and threw it
up. He threw it up because of his abdominal pain and nausea. He
said the 3 rd time he threw up he noted some blood which
increased in concentration the more he threw up. He decided to
come into the ED for his withdrawal and pain issues.
.
In the ED initial VS were noted to be T98.8, HR 116, BP 199/108,
RR 18, Sat 100% on RA. Her initial labwork was notable for a
negative serum tox screen including EtoH. He was noted to have
tongue fasiculations, tremors and was given initially Diazepam
10mg IV x 1, 10mg PO x 1. He was also noted to have nausea,
vomiting, epigastric pain. He was started on D5W gtt. Chem panel
showed an AG of 19 but HCO3 of only 23. Lactate 0.7. She was
given Thiamine 100mg PO x 1, Folic Acid 1mg PO x 1, Zofran for
nausea. Per ED signout pt had ketones in urine though it is
unclear as to where the urine findings were noted. He received
1L NS and was started on D5NS maintenance fluid and received
approx 100cc. Pt was also guaiac negative in the ED.
.
On the floor pt stated he still had some abdominal pain and
still felt as if he was withdrawing. He does not have any emesis
currently, his last episode was several hours ago in the ED. He
is usually seen at [**Hospital 882**] hospital and was recently there 2
months ago and hospitalized for a month for ?bad withdrawal. He
is contemplating detox at this time. The only time recently he
has been off EtoH is when he is hospitalized or in Jail. He has
a history of withdrawal seizures and DTs in the past.
Past Medical History:
-EtoH abuse x at least 10 years, h/o of DTs and withdrawal
seizure
-Gastritis - seen on [**1-17**] EGD, previously on PPI
-Pancreatitis - with normal lipase
-Bipolar Disorder vs Depression- h/o suicide attempt
-HTN - on meds in the past, but later thought to have HTN
only in setting of EtOH w/d
-Asthma
-Abdominal Surgery at [**Doctor Last Name 1263**] (doesnt know why)
- RLE pin - takes Tramadol for the pain
Allergies:
PCN: Rash, throat swelling
Social History:
Not currently working, lives with his mother. Endorses drink at
least a 12 pack a day. Endorses a 1 time cocaine use many years
ago. Occasional tobacco use. Has prison tattoos.
Family History:
Mother has type II diabetes.
Physical Exam:
VS: Temp: BP: / HR: RR: O2sat
GEN: Hispanic Male with tattoos laying down in bed with tremors
in NARD
HEENT: PERRL, EOMI, anicteric, MMM
CV: S1,S2, no m/g/r, RRR
RESP: CTA b/l with good air movement throughout
ABD: tender to palpation over epigastrum, umbilicus, + rebound
tenderness, guarding with abdominal exam, no gross orgranomegaly
EXT: 1+ edema in the RLE
SKIN: no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. Tremors
in both hands
RECTAL: Guaiac negative in the ED, Brown stool
Pertinent Results:
[**2168-5-5**] 10:35PM GLUCOSE-132* UREA N-16 CREAT-0.6 SODIUM-140
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-23 ANION GAP-24*
[**2168-5-5**] 10:35PM estGFR-Using this
[**2168-5-5**] 10:35PM ALT(SGPT)-35 AST(SGOT)-69* ALK PHOS-99 TOT
BILI-0.7
[**2168-5-5**] 10:35PM LIPASE-21
[**2168-5-5**] 10:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-5-5**] 10:35PM WBC-7.3 RBC-3.90* HGB-12.2* HCT-36.4* MCV-93
MCH-31.3 MCHC-33.5 RDW-13.9
[**2168-5-5**] 10:35PM NEUTS-86.1* LYMPHS-8.6* MONOS-3.8 EOS-0.7
BASOS-0.8
[**2168-5-5**] 10:35PM PLT COUNT-242#
CT Abd/Pelvis:
1. No evidence on CT to explain patient's symptoms.
2. Appendix not seen; however, no secondary signs of acute
appendicitis.
KUB:
1. No free air.
2. No evidence of free air within limitations of portable supine
abdominal
radiograph.
EKG ([**5-6**]): Normal sinus rhythm. Within normal limits. Compared
to the previous tracing of [**2166-3-24**] no diagnostic interval
change.
EKG ([**5-8**]): Sinus bradycardia. Compared to the previous tracing
of [**2168-5-6**] the rate is slower.
Brief Hospital Course:
41y.o.Male with current EtoH abuse, h.o. DTs, seizures presents
EtoH withdrawal symptoms.
#. EtoH Withdrawal: Pt has a reported history of seizures from
withdrawals and DTs. In the ED he required Valium 20mg IV. He
is currently not interested in terminating his EtoH abuse in
MICU. The patient was on a CIWA scale requiring q1h assessment
with IV Valium in the MICU, and was called out when he was
tolerating a q4h po Valium scale. Pt was spaced to Q8H CIWA/
Valium 5-10mg PRN withdrawal sxs on day 6 after improvement of
symptoms. He had no Valium requirement for the last 24 hrs, CIWA
0, prior to discharge.
---- His last drink Wed at 5pm, so Wednesday (day of discharge)
is day 7.
---- SW and addiction consult in MICU and on the floor; pt
currently not interested in stopping substance use
#. Abdominal pain: Pt has epigastric and umbilical pain which
he states occured after he noted withdrawal symptoms. Lactate
was normal, KUB was unremarkable, and CT abdomen/pelvis showed
no source of abdominal pain. The abdominal pain significantly
improved on PPI, and is likely [**12-16**] alcoholic gastritis. He does
reportedly have a history of pancreatitis with normal lipase,
and his epigastric pain radiated to back initially but the
patient's pain improved with a PPI as mentioned above. He was
transitioned to a po PPI [**Hospital1 **] and started on Sucralfate and
viscous Lidocaine with improvement of symptoms and was
tolerating a regular full diet without difficulty. His abdominal
pain resolved on this regimen. H pylori was negative. He was
discharged on a 14-day course of omeprazole for gastritis.
.
#. Hematemesis: Pt reports episode of hematemesis which
clinically appears to be MW-tear given the bleeding occurred
with continued vomiting. He was given zofran for nausea. He did
not have any episodes of hematemesis in-house, and he denied any
history of variceal blding or cirrhosis history. His hct
remained similar to prior baseline data and he was
hemodynamically stable. He was started on a PPI as above for 14
days. He will discuss potential GI follow up with his PCP.
.
#. EKG changes: Patient had tachycardia, likely in the setting
of nauesa and abdominal pain, and had an EKG which showed
inferior TWI with increase in rate that resolved with lower HR.
This non-specific finding may indicate possible coronary
insufficiency, and he may benefit from an outpatient elective
cardiac stress test. The patient denied any chest pain, cardiac
enzymes were negative.
.
#. Depression: Pt has a history of depression and reports taking
Zoloft at home. He was continued on his reported home Sertraline
50mg PO daily.
.
# R Ankle pain: He has chronic R ankle pain and spasms s/p pin
in ankle and trauma from prison. We continued him on his home
tramadol 50mg TID PRN pain.
Medications on Admission:
Pt reported taking the following:
Tramadol 50mg [**Hospital1 **] prn
Risperidal 2 mg hs
Albuterol 2 puff qid prn
Flovent 2 puff twice daily
Zoloft 50mg PO daily
Other medications reported by outpatient facility that the
reported not taking:
Omeprazole 20 mg daily prn
Multivitamin daily
Thiamine 100 mg daily
Fluoxetine 20mg daily
Seroquel 200mg PO hs
Loratadine 10 mg daily prn
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for ankle pain: do not take if drinking alchol,
driving, or sleepy.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-15**] Inhalation every 4-6 hours as needed for SOB.
7. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
8. risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary-
Alcohol withdrawal
Secondary-
Gastritis
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 because you were going through
alcohol withdrawal. We admitted you to the hospital to watch
your symptoms and give you Valium. You improved on this
medication. We recommend that you stop drinking alcohol. We had
our social workers talk to you and they gave you some
information about detox.
We also treated you for your gastritis. We gave you a medication
for that and your nausea and you got better and were able to eat
solid food again.
You were admitted to the hospital because you were going through
alcohol withdrawal. We admitted you to the hospital to watch
your symptoms and give you Valium. You improved on this
medication. We recommend that you stop drinking alcohol since it
is dangerous for your health and safety. We had our social
workers talk to you and they gave you some information about
rehab programs.
We also treated you for your gastritis, likely from stomach
irritation from drinking alcohol. We treated this with
medications and it is improving.
Please keep your follow up appointments.
The following changes were made to your medications:
-Start a multivitamin, folate, and thiamine
-Start omeprazole twice a day for your stomach
You were admitted to the hospital because you were going through
alcohol withdrawal. We admitted you to the hospital to watch
your symptoms and give you Valium. You improved on this
medication. We recommend that you stop drinking alcohol since it
is dangerous for your health and safety. We had our social
workers talk to you and they gave you some information about
rehab programs.
We also treated you for your gastritis, likely from stomach
irritation from drinking alcohol. We treated this with
medications and it is improving.
Please keep your follow up appointments.
The following changes were made to your medications:
-Start a multivitamin, folate, and thiamine
-Start omeprazole once a day for 14 days your stomach
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] E
Address: [**Location (un) 1264**], [**Location (un) **],[**Numeric Identifier 1265**]
Phone: [**Telephone/Fax (1) 1260**]
When: Monday, [**5-23**], 4PM
Please discuss with your physician the following issues:
- Your H. pylori antibodies test is pending.
- You are not currently written for Zoloft but you claim that
you're taking it at home. Please clarify this with your PCP.
Completed by:[**2168-5-11**]
ICD9 Codes: 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5729
}
|
Medical Text: Admission Date: [**2114-8-22**] Discharge Date: [**2114-9-5**]
Date of Birth: [**2030-7-13**] Sex: F
Service: MEDICINE
Allergies:
Sulfur / Norvasc
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Abd pain, crohns flare
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 F with PMHx of Renovascular HTN c/b NSTEMI now s/p renal
stents, Gout and h/o Crohn's disease who presented to the ED on
[**8-21**] with RLQ pain for approx 2 days. She denies any
nausea/vomiting/diarrhea or constipation but has not been taking
po well and felt dehydrated.
.
Initial VS on arrival to the ED: T 97.6 BP 116/63 HR 84 RR 20
Sats 97% on RA. Pt was noted to have a leukocytosis with
bandemia and underwent a CT abd which showed inflammation in the
terminal ileum likely consistent with Crohns flare. She was
noted to be guaic negative with normal lactate and was given 2L
of IVF prior to admission to the floor.
.
On arrival to the floor, pt was reporting [**5-5**] RLQ pain,
decreased appetite and general lethargy. She denied any fevers,
chills, N/V/D/C and had her last BM approx 24hrs ago which was
soft but non-bloody.
.
ROS: Denies CP/SOB/cough/congestion/fevers/rash/dysuria/sick
contacts/unusual food exposures but does report 2-3 days of
general malaise and poor po intake.
Past Medical History:
-Crohn's Disease
-Accelerated Hypertension
-Renal artery stenosis, s/p stents to renal arteries in [**5-31**]
-Gout
-B12 deficiency
.
Past surgical history
-fibrous tumor requiring abd rescection in [**2075**]
-s/p appendectomy at age 9 and tonsillectomy at age 21
Social History:
Divorced and lives alone. Pt has many supportive friends and
does not smoke cigarettes, denies any EtOH. Daughter is likely
her health care proxy, but not officially appointed.
Family History:
(+) [**Name (NI) 41900**] CAD father died at age 53 of CAD after having Rheumatic
fever as a child.
Physical Exam:
VS: T 96.2 BP 110/58 HR 85 RR 18 Sats 98% RA
GEN: NAD, tired appearing but responds appropriately to
questions
HEENT: NCAT, EOMI, dry MM, no apprec LAD
CV: RRR no apprec mr/r/g
RESP: CTAB no w/r apprec, no resp distress
ABD: soft, NABS, mild distended with TTP over RLQ, no
rebound/guarding
EXTR: warm, thin, no rash
Guaic- negative in ED
Pertinent Results:
[**2114-8-21**] 05:20PM BLOOD WBC-13.5*# RBC-4.07* Hgb-12.0 Hct-37.1
MCV-91 MCH-29.6 MCHC-32.4 RDW-13.8 Plt Ct-512*#
[**2114-8-21**] 05:20PM BLOOD Neuts-58 Bands-22* Lymphs-7* Monos-9
Eos-1 Baso-0 Atyps-1* Metas-2* Myelos-0
[**2114-8-21**] 05:20PM BLOOD PT-18.1* PTT-29.0 INR(PT)-1.6*
[**2114-8-21**] 06:13PM BLOOD Glucose-76 UreaN-113* Creat-1.5* Na-142
K-4.5 Cl-110* HCO3-15* AnGap-22*
[**2114-8-21**] 06:13PM BLOOD ALT-8 AST-11 LD(LDH)-185 CK(CPK)-19*
AlkPhos-45 TotBili-0.3
[**2114-8-21**] 06:13PM BLOOD Lipase-84*
[**2114-8-21**] 05:20PM BLOOD cTropnT-0.01
[**2114-8-22**] 12:50AM BLOOD Lactate-0.7
[**2114-8-22**] 12:50AM BLOOD Lactate-0.7
.
CT Abd [**2114-8-22**]- prelim read inflammation of the ileum consistent
with likely Crohn flare
.
EKG from [**8-22**]: NSR with LVH but otherwise unchanged from prior
tracings with some TW flattening in III.
Brief Hospital Course:
84 y/o F with PMHx of Renovascular HTN s/p stenting, Gout and
Crohns Dz who presents with RLQ pain and CT findings consistent
with crohns flare.
Hospital course:
Pt slowly improved with bowel rest, IVF, antibiotics (initially
ciprofloxacin and flagyl, and ultimately ciprofloxacin, flagyl,
and vancomycin). She was evaluated by general surgery who
assessed her as a risky surgical candidate. She was
intermittantly delerious, however this ultimately resolved.
Cultures were negative.
During the hospitalization, she experienced atrial fibrillation
and flutter with rapid ventricular response. This was rate
controlled with metoprolol. Anticoagulation was considered and
was not started.
She was also noted to have a coagulopathy attributed to
malnutrition. This was treated with oral vitamin K
supplementation with some improvement.
Medications on Admission:
Carvedilol 12.5mg [**Hospital1 **]
Calcium 500+D
Protonix 40mg daily
Aspirin 325mg daily
Lisinopril 40mg daily
Isosorbide Mononitrate 30mg daily
Colchicine 0.6mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Mesalamine 250 mg Capsule, Sustained Release Sig: Three (3)
Capsule, Sustained Release PO BID (2 times a day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 789**] Care Center of [**Location (un) 57605**]
Discharge Diagnosis:
Primary:
Crohns Flare
Delirium
Paroxysmal atrial fibrillation and flutter
.
Secondary:
CRI
Renovascular Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
...
Discharge Instructions:
You were admitted with a Crohns flare and you were evaluated by
our gastroenterologists. You have been treated with antibiotics
and ____.
You also experienced an abnormal heart rhythm known as atrial
fibrillation. This was largely controlled with medication. It
does place you at risk for strokes, however, and in order to
minimize this risk, anticoagulation with blood thinners was
______________.
Dr. [**Last Name (STitle) 19205**] will dictate an addendum with updated discharge
instructions.
Followup Instructions:
Department: Primary Care
When: WEDNESDAY, [**8-29**], 9:30AM
Name: [**Location (un) 6624**], [**Last Name (un) 16151**] K. MD
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 3329**]
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2114-9-5**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2115-1-2**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5789, 2851, 2762, 2760, 412, 2768, 2875
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5730
}
|
Medical Text: Admission Date: [**2172-11-14**] Discharge Date: [**2172-11-23**]
Date of Birth: [**2088-7-18**] Sex: M
Service: MEDICINE
Allergies:
Amitiza / Oxybutynin / Bactrim
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
Chest pain, diarrhea, "feeling lousy"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year old male with CAD s/p CABG and bovine AVR, T2DM,
hypotonic bladder with chronic foley and chronic cystitis who
presents with chest pain, diarrhea, and feeling lousy.
.
His last admission for chest pain was [**7-25**] and it was felt to
be due to GERD or gas/constipation and was recommended an
exercise stress test as an outpatient. He was last admitted to
the hospital [**8-25**] with weakness and falls of unclear etiology.
He has had 8 ED visits since that admission, typically for
dysuria and abdominal pain. He was seen in the ED yesterday for
UTI, worsening of a fungal groin infection and balanitis and
discharged to rehab. There are plans for suprapubic catheter
placement with urology next week due to his frequent UTIs and
fungal infections. He has been treated with Macrobid and
fluconazole intermittently since [**9-25**] and has a h/o ESBL E
Coli.
.
Today he reports that he started to "feel lousy" at rehab. He
developed diarrhea (2 episodes) that was nonbloody. Also had 2
episodes of vomiting, also nonbloody. After that, he developed
substernal chest pressure that moves across his chest. Denies
SOB, but endorses diaphoresis associated with the diarrhea and
vomiting. Also continues to complain of lower abdominal pain,
which is suprapubic and unchanged in character from his prior
presentations. Denies fevers, but states he has had chills. He
denies change in weight, PND, orthopnea.
.
Per rehab notes, he also complained of SOB and O2 sat decreased
to 88% on room air and improved with O2. Now denies SOB.
.
In the ED, initial VS were 98.0 60 111/64 16 99% 2L. Labs were
notable for troponin of 0.05 (baseline) and ECG showed NSR with
resolved RBBB. He was also given 1L IV fluids. Was guaiac
negative. UA was positive and he was given Macrobid. Given ASA
81mg x 4. Most recent vitals 95.6 64 106/62 18 93-97%2L
.
Review of systems:
(+) Per HPI. Also c/o chronic cough at night.
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied shortness of breath. Denied palpitations. Denied
arthralgias or myalgias.
Past Medical History:
1. Hypotonic hyposensitive bladder with incomplete emptying, s/p
indwelling foley since [**1-24**] c/b frequent Multidrug resistent
UTIs, incl MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in [**2158**]
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting [**2164**] of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in [**4-22**] with Dr. [**Last Name (STitle) 2230**].
4. Bovine AVR in [**4-22**]
5. Type 2 Diabetes Mellitus
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of [**Doctor First Name 3098**], [**Country **] with 40%
stenosis
Social History:
lives with daughter, her long term boyfriend, grandson. Wife
died several years ago. Retired from [**Country **] and from construction.
Distant tobacco use, denies EtOH or IVDU. Does to adult daycare
few days a week.
Family History:
Daughter died at 48 of breast cancer. Father died from MI in his
70s.
Physical Exam:
Vitals: 95.9 104/66 58 22 94%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to lower jawline, no LAD
Lungs: Rhonchi at right base with thin rales bilaterally at the
bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation over suprapubic area,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pitting edema bilaterally up to
calfs with mild erythema that appears chronic
GU: Erythematous patches in bilateral folds of groin and
erythema and mild swelling of the head of the penis, foley in
place
.
Pertinent Results:
Admission Labs:
[**2172-11-13**] 09:57AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-FEW
EPI-0
[**2172-11-13**] 09:57AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2172-11-13**] 09:57AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2172-11-13**] 09:57AM PLT COUNT-166
[**2172-11-13**] 09:57AM NEUTS-70.3* LYMPHS-21.3 MONOS-4.6 EOS-2.9
BASOS-1.0
[**2172-11-13**] 09:57AM WBC-5.2 RBC-5.19 HGB-15.0 HCT-44.7 MCV-86
MCH-28.8 MCHC-33.5 RDW-17.4*
[**2172-11-13**] 09:57AM GLUCOSE-124* UREA N-17 CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
.
Imaging:
CT abd/pelvis [**11-13**]: Stable appearence of enhancing right renal
mass concerning for renal cell Ca. Stable small left hydrocele.
Bilateral fat containing inguinal hernias. No acute pathology.
.
CXR (my read)): mild to moderate pulmonary edema, left elevated
hemidiaphragm, obscured right heart border
Inpatient Labs:
[**2172-11-20**] 08:00AM BLOOD WBC-5.7 RBC-5.10 Hgb-14.7 Hct-44.2 MCV-87
MCH-28.8 MCHC-33.2 RDW-17.5* Plt Ct-198
[**2172-11-20**] 08:00AM BLOOD Neuts-67.8 Lymphs-21.0 Monos-6.2 Eos-4.4*
Baso-0.7
[**2172-11-20**] 08:00AM BLOOD Plt Ct-198
[**2172-11-20**] 08:00AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.7
[**2172-11-19**] 08:00AM BLOOD PT-14.5* PTT-29.7 INR(PT)-1.3*
[**2172-11-20**] 08:00AM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-140
K-3.8 Cl-100 HCO3-32 AnGap-12
[**2172-11-15**] 04:58PM BLOOD ALT-20 AST-29 CK(CPK)-56 AlkPhos-74
TotBili-0.6
[**2172-11-15**] 04:58PM BLOOD CK-MB-4 cTropnT-0.04*
[**2172-11-15**] 12:37PM BLOOD Type-ART pO2-78* pCO2-49* pH-7.37
calTCO2-29 Base XS-1
[**2172-11-15**] 12:37PM BLOOD Lactate-1.3
Brief Hospital Course:
84 year old male with CAD s/p CABG and bovine AVR, T2DM,
hypotonic bladder with chronic foley and chronic cystitis who
presents with chest pain, diarrhea, and overall malaise.
.
# Complicated UTI: History of Vanc Sensitive Enterococci & ESBL
E.Coli.
The patient arrived with the following prior labwork: urine cx
from [**10-30**] was known to have ESBL E coli and VSE, urine cx from
[**11-13**] that ultimately grew ESBL E coli and yeast. Admitted to
the floor normotensive. Treated with [**Last Name (un) 2830**] given mico history,
and broadened to Vanc in the acute setting of hypotension. Vanc
was subsequently discontinued once the patient stabilized and
urine culture was negative. Completed inpatient [**Last Name (un) 2830**] course for
6 days.
.
# Labile blood pressure: Several hours after being admitted to
the floor, triggered for BP in the low 80s, subjective malaise /
lethargy, and decreased attention. ABG was reassuring. Was
transiently responsive to fluid boluses but because of
refractory hypotension and concern for urosepsis, transferred to
the MICU for observation; flagyl was empirically started because
of concern for C.Dif. While in the MICU remained hemodynamically
stable with SBP in the low 100s and satting 93% on 2L, never
requiring pressors; returned to the floor in < 24h. As discussed
above, vanc was discontinued; flagyl was also stopped once
clinically stable.
.
#. Diarrhea, lower abdominal pain, bladder spasm:
His pain was localized to his upper midline groin, and was
ultimately attributed to bladder spasm. Given patient's history
of antibiotic use, C.dif was considered when hypotensive;
started on empiric flagyl therapy in the acute setting of labile
pressures as discussed above. The patient did not produce any
stools for culture/guaiac after transfer from MICU even with
bowel regimen. C.Dif was never confirmed; Flagyl was
discontinued.
.
# Recurrent UTI s/p suprapubic catheter: Underwent placement of
a suprapubic catheter [**2172-11-20**] with urology for recurrent UTIs
and bladder spasm. Will follow-up with Dr. [**Last Name (STitle) **] 8 weeks after
discharge per urology.
.
# Hypoxia / Possible infiltrate on CXR:
Possible infiltrate on CXR: Patchy R Base infiltrate on CXR on
admission was concerning for PNA and in the setting of labile
pressures, was empirically covered with meropenem. Resolution of
hypotension and symptomatic improvement with improvement of UTI
was reassuring for the patient not having a pulmonary process.
Saturations were in the low 90s on RA on discharge.
.
#. Atypical, non-specific chest pain:
Presentation per the patient's usual non-specific CP. CK & Trop
flat x 3. Echo EF > 50%. No ECG changes. Pain was reproducible
with palpation pointing to it likely being MSK in etiology.
.
# Post-procedure hypoxia and CAD: Became hypoxic after placement
of the suprapubic catheter, thought to be due to volume overload
from IVF administered during the procedure. CXR was suggested of
pulmonary edema. Hypoxia improved with diuresis. The day of
discharge a nuclear stress test was performed that showed a
partially reversible inferior wall defect with associated
hypokinesis and reversible low inferolateral ischemia associated
with hypokinesis; EF was 43% from 63% in [**2164**] and EDV was
elevated at 104cc. Results were discussed with Dr. [**Last Name (STitle) **] who
deferred invasive intervention this admission; the patient was
sent home on medical management, including statin, ASA,
atenolol, ACEi. He has a long history of medication non
compliance and would not be a candidate for more aggressive
interventions at this time.
.
#. tinea cruris:
The patient was given topical Miconazole Powder 2% as needed.
The groin infection was likely fungal in etiology.
.
# Conjunctivitis:
The patient was observed to have injected conjunctiva on [**11-19**]
with thick white discharge bilaterally. Although he was
asymptomatic, he was given Bacitracin/Polymyxin B Sulfate
Ophthalmic Ointment for a 7 day course to cover for bacterial
conjunctivitis.
.
#. Hypertension:
The patient was restarted on his lisinopril following transfer
from the MICU back to the medicine floor and discharged on his
previously prescribed regimen.
.
# Diabetes mellitus:
The patient was kept on humalog insulin sliding scale with good
glycemic control. He was discharged on no oral hypoglycemics or
insulin per Dr. [**Last Name (STitle) **].
.
# CAD:
Med management of CAD with home dose atenolol and ASA 81mg po
daily.
Medications on Admission:
-Atenolol 25mg po daily
-Atorvastatin 80mg po daily
-Citalopram 40mg po daily
-Econazole 1% Cream to groin twice daily
-Lisinopril 20mg po daily
-Trazodone 50-75mg po daily
-ASA 81mg po daily
-Bisacodyl 10mg po daily prn
-Docusate 100mg po bid
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. econazole 1 % Cream Sig: One (1) application Topical twice a
day: to groin [**Hospital1 **].
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
solution Injection TID (3 times a day): If not ambulating daily.
10. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours) for 6 days.
11. trazodone 50 mg Tablet Sig: 1-1.5 Tablets PO once a day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary Diagnoses:
Antibiotic resistant urinary tract infection associated with
urinary catheter
Bladder spasm
Secondary Diagnoses:
Diabetes Mellitus type 2
Coronary Artery Disease
High blood pressure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It has been a privilege to take care of you in the hospital.
You were hospitalized because of a recurrent urinary tract
infection, which you were susceptible to developing because you
had an indwelling foley catheter in your penis. Your infection
was treated with IV antibiotics and your condition improved.
You had lower abdominal pain this admission as well, which we
believe was caused partially by your urinary tract infection.
This pain improved with IV antibiotics but did not resolve
completely because of your chronic bladder spasm. You underwent
a procedure this hospitalization to place a urinary catheter
into your bladder through your lower abdomen. This catheter
should improve your abdominal pain and also make you less
susceptible to infection.
During this hospitalization you had low blood pressures, which
may have been caused by your infection, although this is not
certain because no cultures have grown any bacteria. You were
briefly transferred to the ICU for close observation and fluids
until your blood pressure returned to [**Location 213**].
You had chest discomfort prior to this admission and difficulty
breathing as well. We performed numerous tests which showed that
you were not having a heart attack.
No changes were made to your medications other than as detailed
below. Please take your medications as previously prescribed.
# START Polymixin eye ointment for conjunctivitis - for 6 days
Please attend your follow-up appointments as detailed below.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2173-1-13**] at 2:00 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990, 4280, 2724, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5731
}
|
Medical Text: Admission Date: [**2187-8-20**] Discharge Date: [**2187-8-27**]
Date of Birth: [**2106-2-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zocor / Lipitor
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABGx4(LIMA->LAD, SVG->OM1, OM2, RCA) [**2187-8-20**]
History of Present Illness:
81 yoM with known CAD, had a syncpal episodewhile awaiting a TKR
for which he was admitted to MWMC and subsequently transferred
to [**Hospital1 51816**] for cath.
Past Medical History:
HTN
hyperlipidemia
PAF
DJD
GERD
Skin Ca
essential tremors
slight pulm fibrosis
S/p Left TKR
s/p inguinal hernia repair
appy
trigger finger release
Social History:
Quit tob 30 years ago, no etoh for several months
lives with wife
Family History:
both parents with CAD in 70's
Physical Exam:
NAD 74 20 120/70
Lungs CTAB
RRR no M/R/G
Abd benign
Extrem warm, left ankle with 1+edema s/p TKR
Pertinent Results:
[**2187-8-25**] 05:27AM BLOOD Hct-29.5*
[**2187-8-25**] 05:27AM BLOOD Hct-29.5*
[**2187-8-23**] 07:15AM BLOOD WBC-7.9 RBC-3.46*# Hgb-10.8* Hct-30.6*
MCV-88 MCH-31.4 MCHC-35.5* RDW-14.9 Plt Ct-155
[**2187-8-27**] 09:20AM BLOOD PT-24.7* PTT-29.7 INR(PT)-2.5*
[**2187-8-26**] 05:15AM BLOOD PT-22.3* PTT-85.2* INR(PT)-2.2*
[**2187-8-25**] 05:27AM BLOOD Glucose-96 UreaN-12 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-26 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 51817**] was taken to the operating room on [**2187-8-20**] where he
underwent a CABG x 4, please see operative note for details. He
was transferred to the SICU in critical but stable condition. He
was extubated that evening. He was started on amiodarone for
post operative atrial fibrillation. He was weaned from his
vasoactive drips and transferred to the floor on POD #2. He
continued to have intermittent atrial fibrillation for which he
was started on heparin and coumadin, His blood pressure did not
tolerate lopressor and it was dc'd. He then remained in a normal
sinus rhythm for several days, and he was ready for discharge on
POD # 7. His INR at d/c was 2.5. His coumadin is to be followed
by Dr. [**Last Name (STitle) 51818**] office, to be drawn buy the VNA on [**8-29**].
Medications on Admission:
protonix, primadone, inderal, norvasc, [**Last Name (LF) **], [**First Name3 (LF) **], niacin,
imdur, colace
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. 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. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Primidone 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 days: Then decrease dose to 400 mg PO daily for 1
week, then decrease dose to 200 mg PO daily.
Disp:*50 Tablet(s)* Refills:*0*
7. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO daily ().
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily) for 5 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
10. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: Take as directed by Dr. [**Last Name (STitle) 1655**] for an INR goal of [**3-15**].5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] Home Health
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powder on wounds.
Call our office for sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1655**] for 2-3 weeks, and for
coumadin follow up/dosing.
Completed by:[**2187-8-28**]
ICD9 Codes: 9971, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5732
}
|
Medical Text: Admission Date: [**2146-8-11**] Discharge Date: [**2146-8-18**]
Date of Birth: [**2067-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] Porcine Aortic Stenosis
History of Present Illness:
78 year old gentleman with a long history of cardiac murmur. He
has been followed by echo recently. He resides in [**State 108**], and
AVR was recommended. He has come to [**Location (un) 86**] for another opinion.
Echo done today reveals [**Location (un) 109**] 0.8-1cm2. He does have SOB but
denies chest pain, dizziness or syncope. Other medical history
includes relapsing polychondritis, for which he is on chronic
steroid therapy. Additionally, he has an abscess on his right
elbow that is being treated with azithromycin and I&D
periodically with dressing/wick changes.
Past Medical History:
- Aortic Stenosis s/p Aortic Valve Replacement
- Coronary artery disease, ?MI [**2137**]
- Hyperlipidemia
- Congestive heart failure
- Relapsing polychondritis
- Compression fracture of thoracic spine following traumatic
fall
- Diabetes Mellitus
- Hypothyroid
- Episcleritis/iritis
- saddle nose deformity
- Resection of left mainstem hamartoma
Social History:
Race: Caucasian
Last Dental Exam: 3mos ago
Lives with: Wife in [**State 86434**]
Occupation: Retired physician
[**Name Initial (PRE) 1139**]: Quit smoking >10 years ago. 120 pack years
ETOH: Occassional use
Family History:
mother died 91 h/o CVA
father died 91 h/o CAD, MI, CHF
brother with CAD, s/p CABG
Physical Exam:
Pulse: 78 Resp: 16 O2 sat: 98%
B/P Right: 151/60 Left: 130/60
Height: Weight:
General:
Skin: Dry [x] intact [x] well healed left thoracotomy incision
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema- pedal
Varicosities: None [] early venous stasis changes
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: radiation of cardiac murmur
Pertinent Results:
[**2146-8-12**] Pre CPB: The left atrium is mildly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The descending thoracic aorta is mildly dilated.
There are complex (>4mm) atheroma in the descending thoracic
aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen.
Due to co-existing aortic regurgitation, the pressure half-time
estimate of mitral valve area may be an OVERestimation of true
mitral valve area. Mild (1+) mitral regurgitation is seen.
[**2146-8-11**] Cath: 1. No significant CAD. 2. Moderate systemic
arterial hypertension.
[**2146-8-11**] 08:30AM BLOOD WBC-11.5* RBC-4.05* Hgb-12.4* Hct-38.8*
MCV-96 MCH-30.7 MCHC-32.0 RDW-16.8* Plt Ct-112*
[**2146-8-18**] 04:40AM BLOOD WBC-8.4 RBC-2.81* Hgb-8.6* Hct-25.6*
MCV-91 MCH-30.5 MCHC-33.4 RDW-16.4* Plt Ct-82*
[**2146-8-11**] 08:30AM BLOOD PT-12.2 PTT-25.2 INR(PT)-1.0
[**2146-8-16**] 01:24AM BLOOD PT-12.7 PTT-28.2 INR(PT)-1.1
[**2146-8-11**] 08:30AM BLOOD Glucose-112* UreaN-41* Creat-1.2 Na-145
K-4.3 Cl-110* HCO3-25 AnGap-14
[**2146-8-18**] 04:40AM BLOOD Glucose-79 UreaN-50* Creat-1.5* Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2146-8-14**] 01:45AM BLOOD Calcium-7.7* Phos-3.9 Mg-2.2
[**2146-8-17**] 04:40AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
[**2146-8-11**] 08:30AM BLOOD ALT-34 AST-30 AlkPhos-65 Amylase-65
TotBili-0.3
Brief Hospital Course:
Dr. [**Known lastname 86435**] was admitted to the [**Hospital1 18**] on [**2146-8-11**] for
surgical management of his aortic valve stenosis. He underwent a
diagnostic cardiac catheterization in preparation for his
surgery which revealed less then 50% stenosis of the left
anterior descending artery and right coronary artery. A
rheumatology consult was obtained due to his history of
polychondritis and steroid dependence. It was recommended that
he continue prednisone with the possibility of adding CellCept
in the future in the event that his symptoms worsen despite his
daily prednisone. Dr. [**Name (NI) 86435**] was worked-up in the usual
preoperative manner. On [**2146-8-12**], he was taken to the operating
room where he underwent an aortic valve replacement using a [**Street Address(2) 68430**]. [**Hospital 923**] Medical Epic Biocor tissue valve. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. He required continuous
pacing for underlying asystole. On postoperative day one, he
awoke neurologically intact and was extubated. He required
intravenous medication to control his hypertension. He was
transfused for postoperative anemia. On postoperative day three,
his underlying rhythm was complete heart block alternating with
a junctional rhythm. The electrophysiology service was consulted
for assistance in his care. As his underlying rhythm did not
i\improve, a pacemaker was placed on [**2146-8-16**]. He was then
transferred to the stepdown unit for further recovery. He was
gently diuresed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Interrogation of his
pacemaker showed it to be functioning properly. He continued to
make steady progress and was discharged to [**Hospital1 86436**] on [**2146-8-18**]. He will follow-up with Dr. [**Last Name (STitle) **],
his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
azithromycin 500mg daily
glimepiride 2mg daily
Aspirin 81 daily
Toprol XL 100 daily
Prednisone 15 daily
famotidine 20 daily
vytorin 10/40 QOD
Januvia 50 daily
Synthroid 50 daily
Centrum Silver
Vitamin D
Vytorin,
Flomax 0.4
Tylenol
Sudafed
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Sitagliptin 100 mg Tablet Sig: 0.5 Tablet PO daily ().
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal once a day.
11. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Potassium Chloride 10 % Liquid Sig: Ten (10) meq PO once a
day for 1 weeks.
16. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day.
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 1
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation Center of [**Location (un) 1121**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Past medical history
- Coronary artery disease, ?MI [**2137**]
- Hyperlipidemia
- Congestive heart failure
- Relapsing polychondritis
- Compression fracture of thoracic spine following traumatic
fall
- Diabetes Mellitus
- Hypothyroid
- Episcleritis/iritis
- saddle nose deformity
- Resection of left mainstem hamartoma
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2146-9-8**] 1:00
Cardiologist:
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 34384**] in [**3-7**] weeks [**Telephone/Fax (1) 86437**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2146-8-18**]
ICD9 Codes: 4241, 2851, 2720, 4019, 2449, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5733
}
|
Medical Text: Admission Date: [**2188-2-22**] Discharge Date: [**2188-2-28**]
Date of Birth: [**2133-5-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Blurry vision
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr [**Known lastname **] is a 54 year old man who presented with a 1 week history
of polyuria, polydipsia, blurred vision, nausea, emesis,
abdominal pain and was admitted to the MICU for treatment of
presumed DKA. He had no prior history of [**Known lastname **] and had never
been told he had a high blood sugar. He reports that since
[**2188-2-15**] he had had polyuria, polydipsia and severe "gastritis"
which prevented him from eating. He reports that the day prior
to that he had an episode of vomiting. He acknowledges that he
has a history of gastritis that he takes ranitidine for, but
since [**2188-2-15**] he has been unable to tolerate oral intake. On
[**2188-2-19**] he had an endoscopy at [**Hospital1 18**] that showed mild gastritis.
On admission on [**2188-2-21**] the pt denied any fever, chills, dysuria,
diarrhea, chest pain, dyspnea, diaphoresis or any localizing
signs of infection.
.
Review of systems is otherwise negative other than HPI.
.
In the emergency department the pt was noted to have a BG of
865. At that time he was started on an insulin gtt at 7
units/hr, 7 unit regular insulin bolus, morphine 4mg, and zofran
4mg. ECG showed TWI III, SR, nml axis and intervals. CXR was
normal.
.
Past Medical History:
Gastritis- EGD [**2-19**]
Hypothyroidism
Dyslipidemia
Social History:
Originally from El [**Country 19118**], emigrated 4 yr ago. Lives with 30
yr old daughter. [**Name (NI) **] worked as a car mechanic since he was
young. 10 pack year tobacco history but quit 25 years ago. Also
was a heavy drinker but quit 25 years ago.
Family History:
Mother is alive. His father died of alcohol related disease.
Sisters have [**Name (NI) **]. No h/o cardiac disease, htn or
hypercholesterolemia that he is aware of.
Physical Exam:
GENERAL: Pleasant, well appearing in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-23**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately
Pertinent Results:
[**2188-2-22**] 06:40PM WBC-10.1 RBC-5.04 HGB-14.9 HCT-45.0 MCV-89
MCH-29.5 MCHC-33.1 RDW-13.0
[**2188-2-22**] 06:40PM PLT COUNT-259
[**2188-2-22**] 06:40PM GLUCOSE-865* UREA N-32* CREAT-1.6* SODIUM-141
POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-22 ANION GAP-31*
[**2188-2-22**] 06:40PM ALT(SGPT)-58* AST(SGOT)-30 CK(CPK)-1224* ALK
PHOS-165* TOT BILI-0.4
[**2188-2-22**] 06:40PM LIPASE-54
[**2188-2-22**] 06:40PM cTropnT-<0.01
[**2188-2-22**] 06:40PM CK-MB-13* MB INDX-1.1
[**2188-2-22**] CXR: No acute cardiopulmonary process. Limited study due
to patient
positioning. Possible granuloma at right lung base.
Brief Hospital Course:
Mr. [**Known lastname **] is a 54 year old man with new onset [**Known lastname **] who
presented with abdominal pain, polyuria, polydipsia and blurred
vision for 7 days prior to admission and was found to have
diabetic ketoacidosis (DKA).
.
Hospital course by problem:
.
# [**Name (NI) 75996**] The pt had no prior diagnosis of [**Name (NI) **] mellitus to his
knowledge, and did not have a history of elevated blood glucose
that he knew of. The trigger of the DKA remains unknown, as the
pt never had any evidence of infection, chest pain or other
possible trigger. The pt was initially maintained on an insulin
gtt given anion gap of 31 and ketonuria. His gap closed by the
morning following admission and he was transitioned to NPH 10
units [**Hospital1 **] and HISS. He was volume resuscitated with 4L NS in
the ED and another 2-3L in the ICU. On the floor the pt's
insulin regimen was titrated with the help of [**Last Name (un) **]
consultation service, and the pt was discharged on insulin
glargine and humalog sliding scale, with plans to follow up in
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] Clinic with diabetic teaching and plans to be seen by
[**Last Name (un) **] when they travel to the clinic in [**Month (only) 116**]. Of note, the pt's
GAD antibody was negative during this admission, and his
hemoglobin A1C was noted to be 13. He likely has type II
[**Month (only) **].
.
# Hypernatremia- This resolved with managment of serum glucose
and half-normal saline. On discharge the pt's sodium was in a
normal range.
.
# Hypothyroidism- During this hospitalization the pt was
continued on his home levothyroxine.
.
# [**Name (NI) 75997**] The pt was noted to have an elevated CK on
admission, which trended down during the hospitalization. The
pt's home atorvastatin was held, and on discharge the pt was
instructed to continue to hold his statin until he saw his
primary care physician.
.
# Gastritis- During this admission the pt complained of burning
epigastric pain, which was likely due to a combination of the
pt's chronic mild gastritis (visualized just prior to admission
on EGD) and DKA. The pt's ranitidine was switched to
pantoprazole, with which the pt had symptomatic improvement. H.
pylori from recent EGD returned negative, and the pt was
discharged on pantoprazole.
.
Medications on Admission:
Levothyroxine 25 mcg daily
Lipitor 40mg daily
MVI
Ranitidine 150mg daily
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Five (35)
u Subcutaneous at bedtime.
Disp:*10 cartridges* Refills:*2*
4. Humalog 100 unit/mL Cartridge Sig: Per sliding scale
Subcutaneous four times a day: See attached sliding scale.
Disp:*20 cartridges* Refills:*2*
5. Insulin Syringe 1 mL 30 x 1 Syringe Sig: One (1) syringe
Miscellaneous four times a day.
Disp:*120 syringes* Refills:*2*
6. One Touch UltraSoft Lancets Misc Sig: One (1) syringe
Miscellaneous four times a day.
Disp:*120 lancets* Refills:*2*
7. One Touch Ultra Test Strip Sig: One (1) strip In [**Last Name (un) 5153**]
four times a day.
Disp:*120 strips* Refills:*2*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
diabetic ketoacidosis
[**Last Name (un) 982**] mellitus, likely type II
Secondary:
gastritis
Gastroesophageal Reflux Disease
hyperlipidemia
Discharge Condition:
Good, breathing comfortably on room air.
Discharge Instructions:
Mr [**Known lastname **]: You were admitted with a new diagnosis of [**Known lastname **]. You
presented with a condition called Diabetic Ketoacidosis, which
is sometimes provoked by an infection. We did not find any
evidence of infection. You had a CT scan of your abdomen that
showed fatty liver, a condition that had been noted on prior
abdominal radiology images.
.
You also had some pain after the nurse removed your IV on your
final day of the hospital stay. You were found to have a
superficial blood clot on ultrasound, and you should continue to
place hot pads and use tylenol for the pain.
.
You have been started on insulin for [**Known lastname **]. Your ranitidine
has been changed to pantoprazole. Please ONLY take pantoprazole.
Your lipitor has been STOPPED. Please do not start taking this
medication until you see your primary care doctor.
.
If you develop chest pain, shortness of breath or worsening
stomach burning, please call your doctor or return to the
emergency room.
Followup Instructions:
Appointment #1
MD: Dr [**Last Name (STitle) **]
Specialty: Primary Care
Date and time: [**Last Name (LF) 2974**], [**2-29**] @2:15pm
Location: [**Hospital3 33953**] Community Center,[**Street Address(2) 34193**],
[**Hospital1 **], Ma
Phone number: [**Telephone/Fax (1) 17826**]
Special instructions if applicable: this appt has been moved up.
disregard old form
.
Appointment #2
MD: Nurse [**First Name (Titles) 982**] [**Last Name (Titles) **]
Specialty: [**Last Name (Titles) 982**]
Date and time: [**3-6**] at 8pm
Location: [**Hospital3 33953**] Community Health Center, [**Street Address(2) 34193**],
[**Hospital1 **] Ma
Phone number: [**Telephone/Fax (1) 17826**]
Special instructions if applicable: Appt with [**Doctor First Name 440**] the nurse
[**Doctor First Name 30484**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2188-3-4**] 8:00
.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5849, 2760, 2449, 2724, 2768
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5734
}
|
Medical Text: Admission Date: [**2105-4-15**] Discharge Date: [**2105-4-19**]
Date of Birth: [**2051-4-3**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
male with a known history of mitral regurgitation and history
of chest pain twenty years ago who has had increasing
shortness of breath over the last two decades, most recently
becoming very severe, not being able to walk a flight of
stairs without severe dyspnea. The patient had a workup of
his dyspnea including exercise tolerance test which was
negative and a cardiac echocardiogram in [**2104-12-4**],
showing mild left ventricular hypertrophy, mild left atrial
enlargement, mildly dilated aortic root and three to four
plus mitral regurgitation, one plus aortic insufficiency, one
plus tricuspid regurgitation, with an ejection fraction of 60
percent. The patient underwent a cardiac catheterization in
[**2105-1-4**], which showed a codominant system with severe
mitral regurgitation, normal coronary vessels and dilated
left atrium, ejection fraction 60 percent.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Old fracture of the left first toe.
PAST SURGICAL HISTORY: Appendectomy at age 12.
MEDICATIONS ON ADMISSION: Amoxicillin p.r.n. during dental
procedures.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Significant for lupus in mother and father
is deceased at age 75 with cerebrovascular accident.
SOCIAL HISTORY: The patient reports a six year history of
smoking three packs per day, quit eighteen years ago. He
denies smoking any marijuana or Cocaine. The patient rarely
drinks alcohol.
REVIEW OF SYMPTOMS: The patient reports a fair appetite and
active life style. The patient reports psoriasis. Head,
eyes, ears, nose and throat - The patient denies any glaucoma
or cataracts or sinusitis. Respiratory - The patient denies
any asthma, pneumonia, emphysema or chronic bronchitis.
Cardiac - The patient reports lightheadedness without
syncope, occasional palpitations, no history of hypertension.
Gastrointestinal - The patient reports rare nausea without
vomiting or diarrhea, no liver or gallbladder disease. The
patient reports hemorrhoids, negative colonoscopy in [**2105-2-2**]. Genitourinary - The patient denies having any renal
disease or renal calculi and denies having benign prostatic
hypertrophy. Musculoskeletal - Negative peripheral vascular,
no varicosities or claudication. Neurologic - No
cerebrovascular accident or transient ischemic attack
symptoms. The patient denies have diabetes mellitus, thyroid
pathology or psychiatric illness. No bleeding diathesis.
PHYSICAL EXAMINATION: On admission, the patient was afebrile
with a heart rate of 68 and regular, blood pressure 140/80 in
the right arm and 130/72 in the left arm, height six feet
zero inches and a weight of 184 pounds, active muscular
appearing man with no obvious lesions of the skin. The
pupils are equal, round and reactive to light and
accommodation. Extraocular movements are intact. Normal
buccal mucosa. Nonicteric sclera. The neck was supple with
no jugular venous distension, no carotid bruits appreciated.
The lungs were clear to auscultation bilaterally . The heart
examination revealed regular rate and rhythm, S1 and S2,
III/VI holosystolic ejection murmur throughout the precordium
that radiates to the left axilla. Abdominal examination is
soft, nontender, nondistended, no hepatosplenomegaly or
costovertebral angle tenderness. Extremities are warm and
well perfused and no evidence of edema, claudication or
ecchymoses. No varicosities noted, mild spider veins noted.
Neurologic examination is grossly intact. Cranial nerves II
through XII are intact. No focal deficit in sensory or
strength. Pulses were two plus throughout.
Cardiac echocardiogram in [**2104-12-4**], showed mild left
ventricular hypertrophy, mild left atrial enlargement, mildly
dilated aortic root, three to four plus mitral regurgitation,
one plus aortic insufficiency and one plus tricuspid
regurgitation and ejection fraction of 60 percent. Cardiac
catheterization in [**2105-1-4**], showed a codominant system,
severe mitral regurgitation, normal coronaries, dilated left
atrium and ejection fraction of 60 percent.
HOSPITAL COURSE: After undergoing a full workup which found
severe mitral regurgitation as a cause of severe dyspnea, the
patient inquired about having surgical intervention and after
understanding full risks and benefits, the patient elected to
undergo mitral valve replacement and presented to the
operating room on [**2105-4-15**], for elective surgery. Please see
the operative report for further details. The patient
successfully underwent minimally invasive mitral valve
replacement with #30 kwashiorkor annuloplasty band via the
right anterior axillary thoracotomy. There were no
complications during the operative period. In the immediate
postoperative period, the patient did well and was extubate
on postoperative day zero and did well through postoperative
day one. During postoperative day two, the patient was found
to have new onset atrial fibrillation with a ventricular
response in the 120 to 130 beats per minute range. The
patient did not have any chest pain or shortness of breath at
the time. The patient was treated with Lopressor without
effect and eventually the patient received intravenous
loading doses of Amiodarone. Early in postoperative day
number three, the patient reverted to sinus rhythm. The
patient continued his postoperative course without any
significant problems. Chest tubes were discontinued on
postoperative day number three. The patient was started on
p.o. Amiodarone and by postoperative day number four, the
patient was well enough to be discharged. The patient's
cardiologist was contact[**Name (NI) **] regarding the new onset of atrial
fibrillation which was well controlled with Amiodarone. The
decision was made to discharge the patient on p.o. Amiodarone
and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to be followed by his
cardiologist within two weeks. On discharge, the patient was
in sinus rhythm. Incisions were clean, dry and intact.
DISCHARGE STATUS: The patient was discharged to home with
VNA services.
CONDITION ON DISCHARGE: Stable in sinus rhythm.
DISCHARGE DIAGNOSES:
1. Mitral regurgitation, status post minimally invasive
mitral valve replacement with #30 kwashiorkor annuloplasty
band.
2. New onset of atrial fibrillation.
3. Gastroesophageal reflux disease.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once daily.
2. Lopressor 25 mg p.o. twice a day.
3. Amiodarone 400 mg p.o. three times a day for five days and
then 200 mg p.o. three times a day for seven days and then
200 mg p.o. twice a day until follow-up with Dr. [**Last Name (STitle) **],
the patient's cardiologist.
4. Dilaudid 2 to 4 mg p.o. q6hours p.r.n. pain.
5. Colace 100 mg p.o. twice a day while taking Dilaudid.
6. Vitamin C 500 mg p.o. twice a day.
7. IM Polysaccharide Complex 150 mg p.o. once daily.
8. Ibuprofen and Tylenol p.r.n. pain.
FO[**Last Name (STitle) 996**]P: The patient is to follow-up with his
cardiologist, Dr. [**Last Name (STitle) **], in [**Hospital1 1474**] within two weeks with
the results of the [**Doctor Last Name **] of Hearts monitoring. The patient is
to follow-up with Dr. [**Last Name (Prefixes) **] within four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], MD 2351
Dictated By:[**Last Name (NamePattern1) 12164**]
MEDQUIST36
D: [**2105-4-19**] 12:04:20
T: [**2105-4-19**] 14:28:59
Job#: [**Job Number 54561**]
ICD9 Codes: 4240, 9971
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5735
}
|
Medical Text: Admission Date: [**2195-10-15**] Discharge Date: [**2195-10-22**]
Date of Birth: [**2138-12-16**] Sex: F
Service: SURGERY
Allergies:
seasonal
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal aortic aneurysm, status
post stent graft repair with enlargement and continued
endoleak
Major Surgical or Invasive Procedure:
[**2195-10-15**]: Explant of aortobi-iliac endovascular stent
graft, conversion open with aortobi-iliac 16-8 mm Dacron.
History of Present Illness:
56F with h/o AAA, who first presented with acute symptomatic
aneurysm approximately a year ago. We placed a stent graft
which stopped her pain and stopped the aneurysm from increasing
in size. However, she developed very large, persistent type 2
endoleak. We attempted to treat this with
a number of factors including realigning the graft but
thought there might be a type 3 leak, a proximal cuff,
extension iliac limbs, lumbar embolization and actually
translumbar sac embolization. The aneurysm continued to grow
and there were no other treatment options other than open
explant and repair. A long discussion was had with the patient
and her family, who understood the risks including death,
bleeding, intestinal damage, kidney damage.
Past Medical History:
symptomatic AAA (s/p endovascular repair on [**2194-8-2**])
- c/b type Ib endoleak right CIA (s/p endograft repair [**2194-9-2**])
- c/b type Ib endoleak left CIA (s/p endograft repair [**2195-5-12**])
- c/b type II endoleak (s/p coil embolization [**2195-8-11**])
- HTN, anemia, h/o hematuria, obesity, vertigo, ventral hernia,
h/o positive PPD, Diverticulosis c/b diverticular bleed x4 -
first one in [**2185**] requiring sigmoidectomy with colostomy
(now s/p Hartmann's takedown), diverticulitis, pancreatitis,
anemia, +H Pylori - [**4-27**], Colonoscopy [**2195-4-21**] - Previous
ileo-colonic anastomosis of the colon Diverticulosis of the
sigmoid colon Polyp in the rectum (polypectomy)
.
Social History:
lives with family, independent in ADLs
Tobacco - denies
ETOH - denies
Ilicit substances - denies
Family History:
Non-contributory
Physical Exam:
Gen: WDWN female in NAD
Card: RRR
Lungs: Cta bilat
Abd: Soft, non tender, non distended. Incision c/d/i
Extremities: warm, edematous
Pulses:
fem/ [**Doctor Last Name **]/ dp/ pt
R: p d d p radial - dopplerable
L: p d p p
Pertinent Results:
[**2195-10-15**] 6:40 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2195-10-18**]**
MRSA SCREEN (Final [**2195-10-18**]): No MRSA isolated.
Weight
Admission: 81.65kg
[**10-20**] 97.7kg
[**10-21**] 91.9kg
[**10-22**] 86.6kg
[**2195-10-22**] 03:28AM BLOOD WBC-8.4 RBC-3.61* Hgb-10.4* Hct-30.1*
MCV-83 MCH-28.7 MCHC-34.5 RDW-17.2* Plt Ct-281
[**2195-10-22**] 03:28AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-141
K-3.8 Cl-96 HCO3-37* AnGap-12
[**2195-10-22**] 03:28AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname 111557**] was admitted on [**10-15**] and underwent explant of
aortobi-iliac endovascular stent graft, conversion open with
aortobi-iliac 16-8 mm Dacron. She tolerated the procedure well
and was transfered to the CVICU post-operatively. She was
transfused several units of packed red blood cells for acute
blood loss anemia. She was started on metopolol 25mg twice daily
for cardioprotection and blood pressure control. Her weight was
up approximately 20kg post operatively, and she was diuresed
accordingly. Pain was controlled with an epidural and later oral
medications. She was monitored closely with good blood pressure
and pain control. On [**10-18**] she was transfered to the VICU where
she continued to be monitored. She tolerated a regular diet and
was placed on nutritional supplements. She continued to be
diuresed aggressively, with a weight of 86.6kg on the day of
discharge, which is 5kg up from admission weight. She worked
with PT and OT and continued to make steady progress. She is
discharged home on [**10-22**] in stable condition. She will continue on
furosemide and potassium at home for a few days for further
diuresis. She will have a VNA checking weights several times per
week. She will see her PCP in [**Name Initial (PRE) **] week to follow up. She will
follow up with Dr. [**Last Name (STitle) **] in a two weeks for staple removal.
Medications on Admission:
1. Ferrous Sulfate 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Vitamin B Complex 1 CAP PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Amlodipine 5 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
10. Oxycodone-Acetaminophen (5mg-325mg) [**2-16**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg [**2-16**] tablet(s)
by mouth q4-6h Disp #*50 Tablet Refills:*0
11. Furosemide 20 mg PO DAILY Duration: 3 Days
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
12. Potassium Chloride 10 mEq PO DAILY Duration: 3 Days
with furosemide
RX *potassium chloride [Klor-Con 10] 10 mEq 1 po by mouth once a
day Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Abdominal aortic aneurysm, status
post stent graft repair with enlargement and continued
endoleak.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
You were admitted for explantation of your aortic stent grafts,
and open repair. Post operatively you were significantly fluid
overloaded and your weight was up significantly. We started you
on furosemide (lasix) to help diurese this fluid. You will
continue to take furosemide at home for a short period of time.
We would like you to see your PCP in the next week to follow up.
Because this medication takes fluid off, it can make your
potassium low. We have started you on potassium supplement as
well. You should take 1 potassium pill with each dose of
furosemide. You will have a visiting nurse to check your
weight, and help you with your meds.
We have also started you on an additional blood pressure
medication, metoprolol 25mg twice daily. You should continue
to take this and monitor your bps closely. Again, you should
see your PCP to follow up with this.
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for [**7-24**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart with 2-3
pillows 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
??????
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one enteric coated aspirin daily, unless otherwise
directed
ACTIVITIES:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR : [**Telephone/Fax (1) 63033**]
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2195-11-3**] 9:30 Staples will be removed at this visit
Dr. [**Last Name (STitle) **] Thursday [**10-29**] 2:10pm
Completed by:[**2195-10-22**]
ICD9 Codes: 2851, 2768, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5736
}
|
Medical Text: Admission Date: [**2146-9-28**] Discharge Date: [**2146-10-1**]
Date of Birth: [**2083-8-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
<B>DIVISION OF CARDIOLOGY COMPREHENSIVE NOTE</B>
Initial Visit, Cardiology Service
Date: [**2146-9-28**]
.
OUTPATIENT CARDIOLOGIST: n/a
PCP: [**Name Initial (NameIs) **] ([**Hospital3 4262**] Group)
.
Ms. [**Known lastname 26172**] is a 63 yo female with no significant past medical
history who presents following acute onset of chest pain and
shortness of breath at 1 a.m. following a fight with her sister.
She states that she initially developed chest pressure that did
not radiate, followed by shortness of breath. She became
lightheaded and states that she felt as though she was going to
pass out. She vomited multiple times. EMS was called and she
took ASA 324 mg as instructed. Per EMS report, she was hypoxic
and tachycardic.
.
On arrival to ED, BP 140/90, HR 110, spO2 89% on 100% NRB, RR
89. She was placed on NIPPV 10/5/100% and immediately had one
episode of vomiting, requiring suctioning, but reportedly no
aspiration. She received Zofran 4 mg IV and CPAP mask was
replaced. A nitro gtt initiated with symptomatic improvement,
then weaned to off. A foley was placed and 20 mg IV lasix was
given with ~1.2 liters UOP in response. With finding of
pulmonary edema on CXR and positive troponin (1.10), she
received Plavix 600 mg PO and was started on integrillin and
heparin drips given concern for cardiac ischemia. She
subsequently became transiently bradycardic with HR 40, BP 50/p
and a dopamine drip was started. BP improved to 88/57. Patient
was transferred directly to cath lab.
.
In the cath lab, patient was found to have clean coronaries and
high biventricular filling pressures; no intervention was
performed. ABG was performed 7.31/42/54, and NIPPV was resumed
prior to transfer to CCU.
.
On review of symptoms, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative. Patient denies any
recent tick bites or rashes.
.
Patient reports two episodes of transient left sided chest
pressure this past weekend, which lasted 5 minutes and occurred
while lying in bed. She has had some mild shortness of breath
with exertion for the past two weeks. Cardiac review of systems
is notable for absence of paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, or syncope.
Past Medical History:
Multinodular goiter
s/p recent concussion
Social History:
Social history is significant for the absence of current tobacco
use. Patient smoked 1.5 PPD until [**2122**]. There is no history of
alcohol abuse. She states that she drinks only one glass of wine
when she goes out to dinner with friends. Travel history for
recent visit to [**Hospital3 **]. She currently resides with her
sister. She states that she feels safe at home, but states that
she has asked her sister to move out.
Family History:
She states that her paternal grandfather had an MI in his 70's.
Her brother died of a sudden MI at the age of 67. Sister has
bipolar disorder.
Physical Exam:
VS: T 96, BP 111/82, HR 90, RR 28, O2 94% on NIPPV 8/8/50%
Gen: WDWN middle aged female in NAD, in supine position,
tolerating NIPPV mask. Oriented x3. Mood, affect appropriate.
Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP to level of mandible.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral rales [**3-13**] of
the way up.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. Right groin with clean, dry
dressing intact.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG demonstrated NSR, HR 100. Normal axis and normal intervals.
TW flattening in AvL. [**Street Address(2) 4793**] elevation in, II, III, ? AvF.
V5-V6. Q wave present in leads I, II. No prior EKG available for
comparison.
.
TELEMETRY demonstrated: sinus rhythm with 5-beat run of NSVT, HR
94
.
CARDIAC CATH performed on [**2146-9-28**] demonstrated:
Right-dominant system with no angiographically apparent CAD in
LMCA, LAD, LCx, RCA.
Profound elevation of right and left sided filling pressures.
No Mitral regurgitation.
LVEF 20%
Apical balloning.
.
HEMODYNAMICS:
CO 4.73
CI 2.22
PCWP 38
PA 38
RA 21
RV 59/18
.
CXR (my read): diffuse infiltrates bilaterally, consistent with
pulmonary edema
Brief Hospital Course:
ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
Ms. [**Known lastname 26172**] is a 63 yo female with no significant past medical
history who presents with pulmonary edema in the setting of
new-onset cardiomyopathy
.
# Pump: Patient presents with pulmonary edema, found to have a
cardiomyopathy with EF 20%, with no evidence of active ischemia.
Development of cardiomyopathy follows acute stressful event in
this middle-aged female, supporting possible diagnosis of
Takotsubo's cardiomyopathy. This diagnosis is also supported by
characteristic left ventricular apical ballooning. Other
possible etiologies of cardiomyopathy include thyroid
dysfunction in this patient with h/o goiter vs. lyme myocarditis
given recent travel to [**Hospital3 **]. History does not support
alcoholic cardiomyopathy vs. other drug-induced cardiomyopathy.
- wean dopamine as able, maintaining MAP>65
- initiate AceI and beta-blocker once BP able to tolerate
- aggressive diuresis as tolerated by BP and renal function
- check lyme serology
- check TSH
- Social work consult
Pt was closely observed during her hospitalization, ambulation
was gradually increased, and she was ultimately discharged in
stable condition.
.
# CAD/Ischemia: Patient with no evidence of CAD on cardiac
catheterization.
- continue ASA daily
- d/c Plavix
.
# FEN:
- Goal I/O: 2 liters negative.
- Replete K>4, Mg>2
- Low sodium diabetic diet
.
# Prophylaxis:
- SQ heparin as DVT prophylaxis
- GI prophylaxis not indicated
.
# Code status: Full code, confirmed with patient at time of
admission to CCU.
.
# Communication: with patient.
Medications on Admission:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Takotsubo cardiomyopathy
Myocardial Infarction
Heart Failure, Acute Systolic
Thyroid Nodule
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for shortness of breath with associated chest
pain. After being admitted to the hospital, you had a procedure
done on your heart to determine the anatomy and pressures in
your heart called a cardiac catheterization. During the
procedure, it was found that the apex of your heart was bigger
than it should be. As a result, a diagnosis of takotsubo
cardiomyopathy was made, which is a condition in which you can
go into congestive heart failure and have acute changes in the
anatomy of your heart based on acute changes in emotion or
anxiety. You were given medications to remove fluid from your
lungs (which you will be started on at home) and medications to
control your heart. You have an appointment with a cardiologist
(Dr. [**Last Name (STitle) **] and one that you must make with your primary care
provider. [**Name10 (NameIs) **] you experience any acute shortness of breath,
cough up pink tinged sputum, chest pain, loss of consciousness,
or extreme lightheadedness/dizziness, please call your primary
care physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 608**].
In addition: weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs and adhere to 2 gm sodium diet every day.
Followup Instructions:
1) DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2146-10-14**]
9:20.
2) Follow-up with patient's PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) 8207**] [**Name Initial (NameIs) **]. [**Telephone/Fax (2) 608**]to be arranged by patient.
ICD9 Codes: 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5737
}
|
Medical Text: Admission Date: [**2194-6-19**] Discharge Date: [**2194-6-25**]
Date of Birth: [**2131-4-19**] Sex: F
Service: MEDICINE
Allergies:
Cyclophosphamide
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
transient CP found to be hypotensive with evidence of UTI -->
code sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63f with cholangiocarcinoma and metastatic RCC with known liver
involvement who presented to ED with c/o CP found to be
hypotensive and jaundice. Pt reports 4 days of worsening
jaundice and abdominal pain. Pain is poorly described without
clear localization. Pt with worsening N/V and ability to
tolerate PO. Most recent BM several days ago was normal in color
without evidence of bleeding. No hematemesis. No
dysuria/frequency/urgency. Pt describes a 30 minute episode of
CP in the setting of nausea that resolved on its own. No
associated SOB. No DOE. No LE Edema. Mild dry/unproductive
cough. No fever/chills/sweats. Upon arrival in the ICU, Pt feels
a better after getting IVF.
.
ED Course: Triaged as urosepsis for which a central line was
placed and aggressive hydration initiated. Initial lactate 4.4
improved to 2.0 after 4 liters of NS. ABx -> Levo/Flagyl. Given
BB and ASA for CP protocol and became transiently hypotensive.
Pt admitted to [**Hospital Unit Name 153**] from ED with concerns of sepsis.
Past Medical History:
-? Cholangiocarcinoma
-Metastatic RCC: Dx [**2193**]. Pt not tx candidate, being seen by
hospice.
-HTN
-DM2
-CAD: Small fixed and reversible defects in [**2193**]
-CHF: [**2193**] echo with impaired relaxation, lvh, normal lvef
-COPD
-Pul fibrosis
-HCV
-Gout
-RA
Social History:
Lives at home with husband. [**Name (NI) 669**]. Former nursing aid. Smoked
for 40 yrs, quit 12 yrs ago. Has home health aide and VNA;
refused hospice.
Family History:
Mother with DM, father with CAD
Physical Exam:
gen- fatigued, jaundiced but comfortable
heent- PERRL, EOMI, icteric, op wnl, dry MM
neck- no jvd/lad; L-IJ in place
cv- rrr, s1s2, no m/r/g
pul- fair air movement
abd- soft, ND, diffuse tenderness worse RUQ. with + HM, no
rebound, no [**Doctor Last Name **] present, hypoactive BS
extrm- R>L 1+ nonpitting LE edema (chronic), WWP, ra changes in
hands/feet
neuro- a&ox3, no focal cn deficits, appropriate,
strength/sensation grossly intact
Pertinent Results:
ADMISSION LABS:
[**2194-6-19**] 03:45PM BLOOD WBC-1.3* RBC-4.52 Hgb-12.2 Hct-36.7
MCV-81* MCH-27.0 MCHC-33.3 RDW-22.4* Plt Ct-399
[**2194-6-19**] 03:45PM BLOOD Plt Smr-NORMAL Plt Ct-399
[**2194-6-19**] 05:10PM BLOOD PT-13.7* PTT-20.8* INR(PT)-1.2*
[**2194-6-19**] 05:10PM BLOOD Glucose-151* UreaN-61* Creat-2.2*# Na-138
K-3.9 Cl-93* HCO3-28 AnGap-21*
[**2194-6-19**] 05:10PM BLOOD ALT-9 AST-64* CK(CPK)-31 AlkPhos-288*
Amylase-18 TotBili-16.3*
[**2194-6-19**] 05:10PM BLOOD Lipase-11
[**2194-6-19**] 05:10PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2194-6-21**] 04:00AM BLOOD Albumin-2.3* Calcium-8.6 Phos-3.9 Mg-1.8
[**2194-6-19**] 05:10PM BLOOD Calcium-9.1 Phos-4.4 Mg-1.5*
[**2194-6-19**] 05:10PM BLOOD Cortsol-41.9*
[**2194-6-20**] 04:15AM BLOOD Cortsol-20.1*
[**2194-6-19**] 05:10PM BLOOD CRP-51.3*
[**2194-6-19**] 03:49PM BLOOD Lactate-4.4*
[**2194-6-19**] 07:45PM BLOOD Lactate-2.2*
[**2194-6-19**] 08:58PM BLOOD Lactate-2.0
[**2194-6-20**] 04:58AM BLOOD Lactate-1.4
[**2194-6-19**] 4:30 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2194-6-21**]**
URINE CULTURE (Final [**2194-6-21**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
IMAGING:
[**6-19**]: Liver US: 1. Multiple heterogeneous masses in the liver,
representing known cholangiocarcinoma. Bilateral mild
intrahepatic ductal dilation. 2. Sludge in gallbladder, and
possibly in CBD.
.
MRCP:
1. Widespread liver metastases, with findings more suggestive of
cholangiocarcinoma than metastatic renal cell cancer.
2. Findings consistent with extrinsic compression of the
extrahepatic common hepatic duct by a large metastasis in the
caudate lobe, including associated intrahepatic biliary ductal
dilatation.
3. Smooth appearance of the intra- and extra-hepatic ducts
without strictures or areas of focal abnormality.
4. Layering sludge within the gallbladder, but no evidence of
sludge or stones in the bile ducts.
5. Low signal lesion in the left kidney, previously
characterized as most likely representing a renal cell
carcinoma.
.
Renal US: No hydronephrosis. This cystic structure projected
within the renal sinus on some of the sagittal images is
consistent with the previously known large renal cyst. No
definite hydronephrosis. The urinary bladder was empty on
account of Foley catheter.
.
CXR on admission: Consolidation in bilateral lower lobes, which
may represent pneumonia or aspiration superimposed upon
underlying chronic lung disease. A component of pulmonary edema
is also possible. (FINAL READ CHANGED FROM THE PREVIOUSLY
WRITTEN PRELIM READ: The cardiac and mediastinal contours are
unchanged compared to the prior study. Note is made of increased
faint opacities in left lower lobe, with interstitial opacities,
which may represent pulmonary edema, however, superimposed
pneumonia especially in left lower lobe is also a possibility if
the patient has infectious symptoms. Note is made of opacity in
right lower lobe as well, which may represent atelectasis versus
pneumonia. Possible small pleural effusion is seen. Lung volumes
are small due to low inspiratory level. Note is made of somewhat
prominent colon gas with elevated left diaphragm.)
.
DISCHARGE LABS:
Brief Hospital Course:
# ? Sepsis: On admission the pt was noted to have a lactate of
>4, tachycardia, hypotension and a UA that was suggestive of
infection. Later, the urine culture grew GNR. The preliminary
read of the patient's CXR was atelectasis, however, subsequent
read suggested bibasilar infiltrates that could be consistent
with pneumonia. Initially the Biliary tree was suspected to be
another possible source of infection. Following MRCP, it was
felt that this was less likely. On arrival to the ICU, the pt
was afebrile without tachycardia or tachypnea. The lactate
improved with IVF. The pt was treated with Zosyn and was
initially on the sepsis protocol with a central line. The
sepsis protocol was discontinued on HD#2 as the pt was afebrile
with stable vital signs. Zosyn was continued to cover uti,
possible cholangitis (though unlikely), and possible aspiration
pneumonia.
.
# Jaundice: The pt had a bilirubin that was elevated markedly
from baseline, though alkaline phosphatase remained only
somewhat elevated from baseline. This raised concer for
extrinsic compression of the biliary tree from tumor. MRCP was
obtained and showed extrinsic compression from a mass in the
caudate lobe of the liver. It was felt that it would be
possible to stent this open via ERCP if the patient so desired.
.
# ARF: FENA was low, renal US was negative for hydronephrosis.
Creat decreased in the ICU from 2.2 to 1.7 with hydration.
(Baseline 1.0)
.
# ONC: Peripheral Cholangio-CA and Met RCC. Not a therapeutic
candidate. There were
.
# CAD: CP was not felt to be cardiac in nature. The pt had a
fixed defect on MIBI but initial enzymes were negative by CK.
ASA and BB were held in the ICU. Atorvastatin was continued.
.
# CHF: reported EF 50-65% ([**2192**]). Diuretic and Aldactone were
held given volume status and ARF.
.
# HTN: as above held anti-HTN
.
# Pain control: One of the patient's main complaints was pain.
She described diffuse pain that was bothersome constantly. She
was continued on her home dose of fentanyl patch. She became
nauseated and did not tolerate her oxycontin. Morphine worsened
her nausea. Dilaudid was used in conjunction with anzemet with
good result.
.
# COPD/pulm fibrosis: Felt to be stable. Nebs were used as
needed and azathioprine was held until creatinine decreased to
normal range.
.
Pt was transferred to the [**Hospital Unit Name 153**] on [**6-24**], required pressors and
IVFs to maintain pressure. Pt became progressively more
dyspneic and after extensive discussion with the family, the
patient was made comfort care only. Pt expired on [**6-25**] at 1700.
Family was present and requested an autopsy
Medications on Admission:
Bumetanide 3mg [**Hospital1 **]
ASA 325
Aldactone 25 qd
Lipitor 20
Protonix 40
Toprol XL 25
KCL 180 MEq [**Hospital1 **]
Colace
Ambien 10mg qhs
Azathioprine 10mg qd
Oxycodone 5mg q4hr prn
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Discharge Diagnosis:
urosepsis
pneumonia
cholangiocarcinoma
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2194-6-25**]
ICD9 Codes: 0389, 5990, 4280, 496, 5849, 5070, 4019, 2749
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5738
}
|
Medical Text: Admission Date: [**2195-9-2**] Discharge Date: [**2195-9-29**]
Date of Birth: [**2195-9-2**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] is the 2415-
gram product of a 34 and [**1-5**]-week gestation (EDC of [**2195-10-12**] based on uncertain dates and a late ultrasound)
female admitted secondary to prematurity.
PRENATAL COURSE: This pregnancy was complicated by rupture
of membranes 3 weeks prior to delivery and unstoppable
preterm delivery. Mom is a 23-year-old gravida 3 para 2 female
with prenatal screens of blood type A positive, antibody
negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative and group B strep status negative.
There was no maternal fever. Mom was treated with a dose of
betamethasone 24 hours prior to delivery.
This baby was [**Name2 (NI) **] via cesarean section with Apgar scores of 8
at one minute and 8 at five minutes of age. She was given
blow-by O2 in the delivery room and transported to the newborn
intensive care unit for monitoring for prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Infant appearing slightly
older than stated age. Weight 2415 grams (90th percentile),
length 46 cm (75th percentile), head circumference 32 cm
(75th percentile). VITAL SIGNS: Temperature of 98 rectally,
heart rate of 156, respiratory rate of 50, oxygen saturation
of 99% in room air, blood pressure of 62/28 with a mean
arterial pressure of 41, and blood glucose of 31. HEAD, EYES,
EARS, NOSE, AND THROAT: Normocephalic/atraumatic, anterior
fontanel open and flat, palate intact, red reflex present
bilaterally, neck supple. LUNGS: Very shallow respirations
with intermittent nasal flaring, but clear breath sounds
bilaterally. CARDIOVASCULAR: Heart regular in rate and rhythm
without murmur, +2 femoral pulses bilaterally. ABDOMEN: Soft
with active bowel sounds. No masses or distention. Spine
midline. No sacral dimple. Anus patent. Hips stable.
Clavicles intact. NEURO: Slightly decreased tone, but moving
all extremities.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: [**Known lastname **] has been in room air throughout her
hospitalization, has not required any additional
respiratory support. She has not had any issues with
apnea of prematurity and has not required methylxanthines.
2. CARDIOVASCULAR: [**Known lastname **] has had normal blood pressures
throughout her hospitalization. She did not require any
fluid boluses or pressors for blood pressure support. A
heart murmur was first auscultated on day of life 6. An
echocardiogram on [**9-16**] showed small posterior
muscular VSD and a patent foramen ovale. She will be
followed by Dr. [**Last Name (STitle) **] from cardiology at [**Hospital1 62374**] after discharge.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: Upon admission to
the newborn intensive care unit [**Known lastname **] was placed on D-10-
W at 60 ml/kg/day. Her initial Dextrostix was 31, was
treated with one D-10-W bolus with resolving hypoglycemia
with blood glucoses climbing into the 40s and then into
the 70s. Enteral feeds of breast milk or PE-20 were
initiated on day of life 2. She advanced without
difficulty to full volume feeds and to a caloric density
of 24 calories per ounce without difficulty. On day of
life 11, she was noted to have grossly bloody stools, and
a KUB revealed featureless loops of bowel and probable
pneumatosis in the left lower quadrant. She was made
n.p.o. at that time and remained n.p.o. for 10 days.
During that time she received PN/lipids via a central
PICC line. At the end of 10 days, or day of life 20,
enteral feeds were reinitiated; and [**Known lastname **] worked back to
full volume feeds without difficulty. Her weight at time
of discharge is 2830 grams. She is being discharged home
on ad lib feeds of breast milk. She is gaining weight
well and taking in 160 to 170 ml/kg/day. Her last set of
electrolytes on [**9-24**] showed a sodium of 137, a
potassium of 5.1, a chloride of 105 and a bicarbonate of
17. She is voiding and stooling without difficulty.
Stools have been consistently heme-negative after being
re-fed.
4. GASTROINTESTINAL: [**Known lastname 62859**] peak bilirubin was on day of
life 4 with a total bilirubin of 10.5 and a direct
bilirubin of 0.3. Phototherapy was initiated at that
time. A follow-up bilirubin on day of life 5 was 9/0.3,
at which time phototherapy was discontinued with a
rebound bilirubin of 8.6 on day of life 6. As mentioned
before, [**Known lastname **] was treated for medical NEC with n.p.o.
and antibiotics for 10 days.
5. HEMATOLOGY: [**Known lastname 62859**] blood type is unknown at this time.
She has not received any transfusions during her
hospitalization. Her most recent hematocrit on day of
life 11 was 45.
6. INFECTIOUS DISEASE: Upon admission to the newborn
intensive care unit a CBC with differential and blood
cultures were drawn. The CBC at that time showed a white
count of 11,100; a hematocrit of 49.9; a platelet count
of 339,000; with 39% polys and 1% bands. At that time she
received a 48-hour course of ampicillin and gentamicin.
Blood cultures drawn at that time were
negative. As mentioned above, [**Known lastname **] presented with
bloody stools on day of life 11. At that time a CBC with
differential and blood cultures were drawn. The CBC at
that time showed a white blood cell count of 8300, a
hematocrit of 45, a platelet count of 362,000, with 21%
polys and 1% bands. At that time ampicillin and
gentamicin were started. Blood cultures that were drawn
at that time were negative. She remained on the
ampicillin and gentamicin for 10 days for medical NEC.
She is currently receiving some Nystatin powder to her
neck for a monilial rash in that area, and with the
powder the area is starting to heal nicely.
7. NEUROLOGY: A head ultrasound was not indicated for this
34 and [**1-5**] weeker.
8. SENSORY: A hearing screen was performed with automated
auditory brain stem responses, and the infant passed in
both ears.
9. OPHTHALMOLOGY: An eye exam was not indicated for this 34
and [**1-5**] weeker.
10. PSYCHOSOCIAL: Both parents are loving and involved. They
are primarily a Portuguese-speaking couple. [**Hospital1 29402**] Social Work has been involved
with the family, and the contact social worker can be
reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: [**Known lastname **] is stable in room air,
tolerating full volume feedings and gaining weight
appropriately. Her temperature is stable in an open crib.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62860**] at [**Hospital6 11241**] (telephone number [**Telephone/Fax (1) 7538**]).
CARE RECOMMENDATIONS:
1. Feeds at discharge: Ad lib demand feeds of breast milk.
2. Medications: None.
3. Car seat position screening: A car seat test was
performed, and [**Known lastname **] passed her car seat test.
4. Newborn screening status: State newborn screens were sent
on [**9-5**] and [**9-16**]; and no abnormal results have
been reported.
IMMUNIZATIONS RECEIVED: [**Known lastname **] received her first hepatitis
B vaccine on [**9-8**]. She has not received any further
immunizations.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) [**Month (only) **] at less than 32
weeks; (2) [**Month (only) **] 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.
DISCHARGE FOLLOWUP: A follow-up appointment has been made
with the primary pediatrician for [**2195-10-1**]; and
parents are to arrange a follow-up appointment with
cardiology 1 month after discharge. The cardiologist is Dr.
[**Last Name (STitle) **] at [**Hospital3 1810**] (telephone number [**Telephone/Fax (1) 62861**]).
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 2/7 weeks.
2. Sepsis ruled out.
3. Medical necrotizing enterocolitis, treated.
4. Hyperbilirubinemia, treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2195-9-29**] 16:54:08
T: [**2195-9-29**] 17:46:09
Job#: [**Job Number 62862**]
ICD9 Codes: 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5739
}
|
Medical Text: Admission Date: [**2175-3-15**] Discharge Date: [**2175-3-21**]
Date of Birth: [**2109-5-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue. Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2175-3-17**]
Mitral valve repair with a quadrangular resection of the middle
scallop of the posterior leaflet (P2), and the mitral valve
annuloplasty with a 32-mm Physio II annuloplasty ring.
History of Present Illness:
This is a 65yo male with known mitral valve prolapse/mitral
regurgitation. Over the last year, he has complained of
worsening fatigue and shortness of breath with exertion. He
denies chest pain, orthopnea, PND, syncope, pre syncope and
pedal edema.
Past Medical History:
Chronic Atrial Fibrillation, last 10 years (coumadin)
Hypertension
Dyslipidemia
Carpal Tunnel Syndrome
Benign Prostatic Hypertrophy s/p Laser therapy
Hemorrhoids, s/p Banding
Insomnia
History of Basal Cell Carcinoma
Hematuria in [**2174-7-14**](normal CTA of abdomen and pelvis)
PSH: Vasectomy, Appendectomy
Social History:
Race: white
Last Dental Exam: [**2174-12-14**]
Lives with: Wife
Occupation: Photographer
Tobacco: non-smoker
ETOH: Occasional. No history of abuse
Family History:
Non-contributory
Physical Exam:
Pulse: 63 Resp: 18 O2 sat: 100%
B/P Right: 121/75 Left: 111/78
General: WDWN male in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur 3/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: groin site Left: groin site
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
Admission labs:
[**2175-3-15**] 10:36AM PT-15.2* PTT-30.5 INR(PT)-1.3*
[**2175-3-15**] 10:36AM PLT COUNT-263
[**2175-3-15**] 10:36AM WBC-8.0 RBC-5.16 HGB-14.9 HCT-44.7 MCV-87
MCH-29.0 MCHC-33.4 RDW-14.7
[**2175-3-15**] 10:36AM ALBUMIN-4.6
[**2175-3-15**] 10:36AM GLUCOSE-90 UREA N-28* CREAT-1.1 SODIUM-139
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
[**2175-3-15**] 03:25PM %HbA1c-5.9 eAG-123
[**2175-3-15**] 03:25PM ALBUMIN-4.2 CHOLEST-142
[**2175-3-15**] 03:25PM ALT(SGPT)-30 AST(SGOT)-24 CK(CPK)-86 ALK
PHOS-60 AMYLASE-24 TOT BILI-0.9
Discharge labs:
[**2175-3-21**] 05:00AM BLOOD WBC-7.4 RBC-2.81* Hgb-8.5* Hct-24.1*
MCV-86 MCH-30.0 MCHC-35.1* RDW-14.8 Plt Ct-223
[**2175-3-21**] 05:00AM BLOOD Plt Ct-223
[**2175-3-21**] 05:00AM BLOOD PT-18.6* PTT-34.4 INR(PT)-1.7*
[**2175-3-21**] 05:00AM BLOOD Glucose-91 UreaN-24* Creat-0.9 Na-135
K-3.6 Cl-97 HCO3-31 AnGap-11
Radiology Report CHEST (PORTABLE AP) Study Date of [**2175-3-19**] 8:33
AM
Final Report:
Following removal of endotracheal tube and pleural drains and a
Swan-Ganz
catheter, moderate right pleural effusion is larger, severe left
lower lobe atelectasis and small left pleural effusion are
stable, large cardiac
silhouette is unchanged and there is no appreciable mediastinal
vascular
engorgement. There is no pulmonary edema or pneumothorax. Right
jugular line ends above the origin of the right brachiocephalic
vein.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.9 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.1 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Dilated LA. Dilated coronary sinus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Mildly depressed LVEF. [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Myxomatous mitral valve leaflets. Partial mitral leaflet flail.
Mitral leaflets fail to fully coapt. Eccentric MR jet. Severe
(4+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be
underestimated (Coanda effect).
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Resting tachycardia
(HR>100bpm). The rhythm appears to be atrial fibrillation.
patient.
Conclusions
Prebypass
The left atrium is dilated. The coronary sinus is dilated. The
right atrium is dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is severely dilated. Overall
left ventricular systolic function is mildly depressed (LVEF= 50
%). [Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size is normal with mild global free wall
hypokinesis. The mitral valve leaflets are moderately thickened
and myxomatous. There is posterior mitral leaflet flail
involving primarily the P2 scallop. The mitral valve leaflets do
not fully coapt. An eccentric, anteriorly directed jet of severe
(4+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened with mild tricuspid regurgitation. The degree
of tricuspid regurgitation did not increase in severity despite
administration of 1.5 Liters of crystalloid, giving a pressor to
increase afterload, and placing the patient in a Trendelenburg
position. There is no pericardial effusion.
Postbypass
The patient is in atrial fibrillation on an epinephrine
infusion. There is a new annuloplasty ring in the mitral
position. It appears well-seated. There is now only trace mitral
regurgitation. Gradients across the valve at a cardiac output of
6.5 L/min are peak/mean of [**10-17**] mmHg. Biventricular systolic
function appears unchanged. Tricuspid regurgitation is now
trace. The thoracic aorta is intact post decannulation.
Brief Hospital Course:
Mr [**Known lastname 3315**] was admitted to [**Hospital1 18**] for surgical repair of mitral
regurgitation on [**3-17**] by Dr [**Last Name (STitle) **]. Please see the operative
report for details, in summary he had:
Mitral valve repair with a quadrangular resection of the middle
scallop of the posterior leaflet (P2), and the mitral valve
annuloplasty with a 32-mm Physio
II annuloplasty ring. He tolerated the operation well and was
transferred from the operating room to the cardiac surgery ICU
in stable condition. He was hemodynamically stable in the
immediate post-operative period anesthesia was reversed he awoke
neurologically intact and he was extubated. He remained stable
and was transferred to the stepdown floor on POD1.
All tubes, lines, and drains were removed per cardiac surgery
protocol. Once on the stepdown floor he worked with physical
therapy to increase his strength and endurance. He remained in
atrial fibrillation and his coumadin was resumed.
The remainder of his post-operative course was uneventful. On
POD4 he was discharged home with visiting nurses. INR level and
Coumadin dosing will be followed by [**University/College **]
Vangaurd/ST-[**Last Name (LF) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 105742**].
Medications on Admission:
HYDROCHLOROTHIAZIDE - 25 mg daily
SIMVASTATIN - 20mg daily
TRAZODONE - - 50 mg Tablet prn sleep
WARFARIN - 5 mg Tablet
DOCUSATE SODIUM -100 mg daily
MULTIVITAMIN 1 daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 2 weeks.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
10. warfarin 5 mg Tablet Sig: as directed Tablet PO once a day:
resume pre op coumadin schedule.
Target INR 2-2.5.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Mitral regurgitation s/p mitral valve repair(32 mm ring)
PMHx:Chronic Atrial fibrillation(coumadin), Hypertension,
Dyslipidemia, Carpal Tunnel Syndrome, Benign Prostatic
Hypertrophy s/p Laser therapy, Hemorrhoids, s/p Banding,
Insomnia, History of Basal Cell Carcinoma, Hematuria/[**Month (only) 205**]
[**2174**](normal CTA abdomen/pelvis), Vasectomy, Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Edema- none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**4-13**] at 1:15PM
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] :date and time to be determined
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (LF) 105743**],[**First Name3 (LF) **] F. [**Telephone/Fax (2) 105742**]in 4-5 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? for atrial fibrillation
Goal INR 2-2.5
First draw [**3-22**]
Results to phone fax: [**University/College **] Vangaurd/ST-[**Last Name (LF) **],[**First Name3 (LF) **] F.
[**Telephone/Fax (1) 105742**]
Completed by:[**2175-3-21**]
ICD9 Codes: 4240, 4019, 2724, 4168
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5740
}
|
Medical Text: Admission Date: [**2122-1-21**] Discharge Date: [**2122-2-2**]
Date of Birth: [**2061-12-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
60 yr old female transferred from [**Hospital 18**] [**Hospital 620**] campus for eval
and management of acute resp failure requiring emergent
intubation following sepsis from pneumonia.
At [**Name (NI) 620**] pt was in the ICU intubated, swaned requiring volume
and pressure resusitation. Her hemodynamic status stabilized but
her oxygenation status deteriorated suggestive of ARDS prompting
a transfer to [**Hospital 86**] [**Hospital 18**] campus for lung biopsy.
Major Surgical or Invasive Procedure:
[**2122-1-23**]- left thoracotomy for open lung biopsy for diagnosis
done in the SICU.
History of Present Illness:
60 yo female who presented to [**Hospital1 18**] [**Location (un) 620**] after fall followed
ny N/V x2. Pt has Hx of falls d/t gait instability. This fall
was preceeded by several days of low energy, cough and urinary
symptoms. She denied fever chills and remainder of ROS
negative.
upon arrival to ER pt was febrile to 103 and hypotensive, sats
93% on 4LNC.
WBC 23, Hct 39, BUN 39, CREAT 2.3, troponin 1.3, CK 521, MB
6.99. urinalysis -mod bacteria, casts.
CXR: right apex opacity. Pelvic X-ray : non-displaced pubic
ramus fracture.
Past Medical History:
depression, paranoid schizophrenia, bipolar disorder, seizure
disorder following MVA in [**2087**]- last seizure [**2112**],
hypothyroidism,HTN, pneumonia.
SURGICAL HX: TAH
Social History:
Lives w/ sister who assists w/ medication management otherwise
independent w/ self care.
no tabacco or alcohol history.
Family History:
unknown.
Physical Exam:
Intubated and sedated.
heart: tacycardic, regular rhythm
lungs: decreased bilaterally- left>right. no wheezes, rhonchi or
rales.
abd: obese, soft, NT, ND, hypoactive bowel sounds.extrem:
edematous, DP +2.
neuro: sedated moves head spontaneously.
Lines and tubes: ETT, A-line, Swan, foley.
Pertinent Results:
[**2122-1-21**] 11:01PM TYPE-ART RATES-20/ TIDAL VOL-500 O2-100
PO2-50* PCO2-74* PH-7.25* TOTAL CO2-34* BASE XS-1 AADO2-602 REQ
O2-97 -ASSIST/CON INTUBATED-INTUBATED
[**2122-1-21**] 11:01PM O2 SAT-77
[**2122-1-21**] 05:41PM TYPE-ART PO2-55* PCO2-61* PH-7.30* TOTAL
CO2-31* BASE XS-1
[**2122-1-21**] 05:33PM GLUCOSE-112* UREA N-32* CREAT-0.7 SODIUM-144
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-33* ANION GAP-11
[**2122-1-21**] 05:33PM ALT(SGPT)-17 AST(SGOT)-27 LD(LDH)-383*
CK(CPK)-51 ALK PHOS-172* AMYLASE-287* TOT BILI-0.2
[**2122-1-21**] 05:33PM LIPASE-117*
[**2122-1-21**] 05:33PM CK-MB-NotDone cTropnT-0.28*
[**2122-1-21**] 05:33PM WBC-21.3* RBC-3.34* HGB-9.9* HCT-30.4* MCV-91
MCH-29.7 MCHC-32.6 RDW-13.5
[**2122-1-21**] 05:33PM PLT SMR-VERY HIGH PLT COUNT-733*
[**2122-1-21**] 05:33PM FIBRINOGE-785*
CHEST (PORTABLE AP) [**2122-1-21**] 5:34 PM
An endotracheal tube is in placed, with a tip located
approximately 5 cm from the carina. There is a left subclavian
Swan-Ganz catheter, with the tip overlying the right hilum and
is likely within the distal right main pulmonary artery. An NG
tube is in place, with the tip overlying the stomach. There is
relatively [**Name2 (NI) 15410**] opacification of the lung fields bilaterally,
with the majority of the cardiac contour silhouetted by the
opacities. The diffuse alveolar opacity, with some peribronchial
cuffing suggesting massive pulmonary edema. No pneumothorax is
detected on the supine radiograph. There is a rectangular
density overlying the majority of the right chest and
mediastinum, which is assumed to be external to the patient,
which limits the exam.
IMPRESSION:
Multiple tubes and lines as described. This limited evaluation
suggests severe pulmonary edema.
SPECIMEN SUBMITTED: LINGULA.
Procedure date Tissue received Report Date Diagnosed
by
[**2122-1-23**] [**2122-1-23**] [**2122-1-24**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/tk??????
The histology of the organizing process is consistent with the
organizing stage of diffuse alveolar damage (ARDS). Clinical
correlation is needed.
Cardiology Report ECHO Study Date of [**2122-1-22**]
Conclusions:
The left atrium is normal in size. A pacing wire is seen in the
RA.There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is top normal/borderline dilated.
There is moderate regional left ventricular systolic
dysfunction (LVEF 30-35%) with severe hypokinesis of the
inferior wall and the entire septum to the apex. The lateral
wall moves best. No masses or thrombi are seen in the left
ventricle. Abnormal interventricular septal motion consistent
with conduction defect/pacing. Right ventricular chamber size
is normal. The RV free wall is hypokinetic. The ascending aorta
is mildly dilated. The aortic valve leaflets are not well seen.
No significant aortic
regurgitation is seen. There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**12-7**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
IMPRESSION: Moderate, regional LV systolic dysfunction c/w CAD.
Mild to
moderate mitral regurgitation. Moderate pulmonary hypertension.
Brief Hospital Course:
Pt was admitted from [**Hospital **] [**Hospital 620**] campus on [**2122-1-21**] for lung
biopsy to confirm resp failure from presumed ARDS or identify
alternative process respnsible for current clinical presenation.
Pt arrived intubated and was admitted to the SICU.
Initially sedated w/ propofol and paralyzed w/ cisatracurium to
maximize ventilatory status requiring assist control
ventialtion, 20 peep, esophageal ballon, 100% FIO2 to mainatin
sats mid 80's ( see lab section for ABG's).
Systems review:
Neuro: initiaaly paralyzed and sedated to max vent status.
Presently awake, alert, MAE but does not folow commands.
Remains on fentanyl @125mcg/hr and propofol @ 100mcg/kg/min
Resp: oxygenation and ventilation significantly improved w/
decreased peep requirement. Sats now high 90's on current vent
settings of Assist control, 50%, 600x30, peep 12.
Trached on [**2122-1-29**].
CV: off all pressors. RRR S1,S2.
GI: Initially tube feed by NGT. G-tube placed on [**2122-1-29**] c/b
free air extravasation. Taken to the OR emeregently for
exploration, repair and open G-Tube. G-Tube cuurently to gavity
drainage.
Endocrine: on insulin drip w/ good gycemic control.
Renal: function has returned to [**Location 4222**] after initial volume
resusitation. BUN 15/ CREAT 0.4
Heme/ID: was transfused w/ now stable HCT 30.5. WBC 14.9 and
presently on Imipenim, vanco, diflucan for septic pneumonia.
Medications on Admission:
Neurontin 600mg qam, 300mg qhs; lexoxyl 50mcg [**Last Name (un) 98509**] thru friday
and 100mcg sat and sun; seroquel 400mg daily; calcium tid; ASA
325mg daily; fluoxetine 60mg daily; phentoin 400mg daily.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
ARDS seconary septic pneumonia.
[**2122-1-23**] left thoracotomy for lung biopsy- path positive for ARDS
pneumonia.
[**2122-1-29**] status post trach and peg c/b extrvasation of air
requiring open peg and repair of gastroscopy.
Discharge Condition:
stable
Discharge Instructions:
return to [**Hospital 98510**] [**Hospital 620**] campus for continued care.
Completed by:[**2122-1-30**]
ICD9 Codes: 486, 2859, 4019, 4280, 4240, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5741
}
|
Medical Text: Admission Date: [**2178-11-18**] Discharge Date: [**2178-12-2**]
Date of Birth: [**2109-5-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Paracentesis
Dynamic l.hip screw placement
History of Present Illness:
This is a 69 year old F h/o HCV cirrhosis, esophageal varices,
h/o falls, initially p/w encephalopathy and hip pain, now s/p
dynamic hip screw to L hip with difficulty extubating post op
requiring transfer to the MICU. Of note pt admitted [**Date range (1) 7136**]
s/p mechanical fall with L 5th digit fx. Pain noted in left hip
at the time but plain films negative. Pt d/c'd to [**Hospital 7137**].
.
She was readmitted on [**11-18**] after being noted to have fever to
100 at CH in association with abd pain. Pt noted to be
encephalopathic, which cleared with lactulose. Pt's fever
attibuted to pna (? right-sided consolidation) and treated with
levo (increased from home sbp dose)/flagyl. Once pt's mental
status more lucid, she was complaining of L hip pain. MRI
showing left intertrochanteric fracture.
.
On [**11-25**], [**Month/Year (2) **] took pt to OR for DHS. Pre-op CXR [**11-24**] showed
increased effusion on R and increased infiltrate on L. Intra-op,
spiked to 100.9, transiently on neosynephrine. [**Name (NI) **], pt
developed thick, copious secretions felt to preclude extubation.
Pt bronch'd in PACU: sputum cxs ultimately grew out MRSA.
.
Pt transferred to MICU with orthopedics following. Pt treated
initially with vanc/zosyn, narrowed to vanc with above cx
results. PT extubated [**11-26**] at 3 pm. She has been doing well
post-extubation. By report, evaluated by PT and is full weight
bearing, though no note in chart since [**11-25**]. She is transferred
to the medical floor for further evaluation and management.
.
Patient is comfortable on the floor on 3L NC. Without complaints
at this time.
Past Medical History:
-Hepatitis C: genotype 1b; acquired from blood transfusion;
complicated by cirrhosis, splenomegaly, ascites, variceal bleed,
partial portal vein thrombosis. s/p therapeutic tap [**2178-7-12**]
admission
-Diabetes Mellitus 2
-Esophageal varices secondary to portal hypertension s/p banding
after bleed in [**2171**]. Most recent EGD 5/06-2 cords of grade I
varices were seen in the middle third of the esophagus and lower
third of the esophagus non-bleeding and non-amenable to banding.
Also portal gastropathy seen.
-GERD
-HTN
-Asthma
-Depression/anxiety
-history of UTI urosepsis [**12-14**]
-s/p open CCY in [**Country 532**], [**2147**]
-s/p removal of ovary, [**2147**]
Social History:
Patient was admitted from [**Hospital3 2558**]. No EtOH, no tobacco,
no IVDU. Pt is a Holocaust survivor, she was living
independently prior to her last admission and her son was
spending nights with her.
Family History:
Patient was three when her parents were killed in the Holocaust.
Her son denies any health problems.
Physical Exam:
Vitals: T 97.8 BP 126/50, P 78, Resp 20 98% on 3L
General: Alert, no acute distress, no complaints
HEENT: PERRL, extraocular motions intact, sclera mildly icteric,
dry mucous membranes with some mucosal crusting
Neck: No JVD, no cervical lymphadenopathy
Chest: Decreased breath sounds R base, rhonchorous on L,
difficult to auscultate lower lobes due to positioning
CV: Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd: Soft, nontender, significant distention, hyperactive bowel
sounds
Extr: [**1-13**]+ pitting edema to knees b/l. 2+ DP pulses bilaterally.
L hand in splint, left leg with bruising of medial thigh,
patient propped on pillow for positioning of leg
Pertinent Results:
CXR ([**2178-11-18**]): There is elevation of the right hemidiaphragm
with blunting of the right costophrenic angle. There are
increased interstitial markings bilaterally with areas of
confluent opacities in the right middle lobe and right lower
lobe concerning for asymmetrical pulmonary edema and/or
aspiration. The cardiomediastinal and hilar contours are stable.
The osseous structures and soft tissues are normal.
.
CXR [**12-1**]: FINDINGS: In comparison with the study of [**2178-11-29**],
there is again prominence of interstitial markings consistent
with increased pulmonary venous pressure. Opacification at the
right base with preservation of pulmonary markings is consistent
with a large pleural effusion. Some underlying atelectatic
change may well be present.
.
The right IJ catheter has been removed. The left PICC line again
extends to the level of the carina.
.
Abdominal US: IMPRESSION: Findings compatible with cirrhosis and
portal hypertension. No evidence of portal vein thrombosis.
.
BLE US: IMPRESSION: No DVT, bilateral lower extremities
.
MRI: IMPRESSION:
1. Left intertrochanteric fracture with varus angulation and
marked surrounding muscular and soft tissue hematoma/edema
including a 2.7 x 4.3 x 4.0 cm fluid collection containing
hemorrhage posterior to the proximal left femur and contained
within the gluteus minimus muscle. Marked soft tissue swelling
of the left hip and subcutaneous edema extending
circumferentially around the proximal left thigh.
2. Not mentioned above, there is a focal area of increased
signal on STIR sequence with a ring and arc configuration most
consistent with enchondroma. This is seen distal to the fracture
line.
3. Marked pelvic ascites. Please correlate with patient's
previous medical history.
.
EXAMINATION: Left hip and pelvis.
One view of both hips and the pelvis and four views of the
proximal femur and two views of the distal left femur are
submitted showing a nonhealed nonacute intertrochanteric
fracture of the left femur with only mild superior overriding of
the distal fracture fragment, and no dislocation of the mildly
to moderately degenerated left hip joint. Pelvis is intact.
Distal left femur and knee are normal. There is no knee joint
effusion, and the pelvic ring is intact.
.
IMPRESSION: Study limited by overlying casting material. Mid
shaft fifth proximal phalanx fracture again seen.
.
ECHO: Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
Trace aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Moderate pulmonary hypertension.
.
Labs:
[**2178-11-18**] 08:00AM BLOOD WBC-12.6*# RBC-3.32*# Hgb-11.6*#
Hct-35.4*# MCV-107* MCH-34.9* MCHC-32.7 RDW-15.7* Plt Ct-208#
[**2178-12-1**] 01:53AM BLOOD WBC-7.0 RBC-2.60* Hgb-9.3* Hct-27.4*
MCV-106* MCH-35.6* MCHC-33.8 RDW-20.4* Plt Ct-137*
[**2178-11-18**] 08:00AM BLOOD Neuts-81.1* Lymphs-10.4* Monos-7.3
Eos-0.6 Baso-0.6
[**2178-11-28**] 12:46PM BLOOD Neuts-79.2* Lymphs-12.7* Monos-4.5
Eos-3.4 Baso-0.1
[**2178-11-18**] 08:00AM BLOOD PT-20.9* PTT-35.9* INR(PT)-2.0*
[**2178-12-1**] 01:53AM BLOOD PT-19.0* PTT-41.3* INR(PT)-1.8*
[**2178-11-18**] 08:00AM BLOOD Glucose-197* UreaN-20 Creat-0.9 Na-137
K-4.1 Cl-103 HCO3-27 AnGap-11
[**2178-11-29**] 07:00AM BLOOD Glucose-148* UreaN-18 Creat-0.9 Na-135
K-3.8 Cl-97 HCO3-34* AnGap-8
[**2178-11-30**] 03:29AM BLOOD Glucose-153* UreaN-23* Creat-1.2* Na-133
K-3.9 Cl-96 HCO3-33* AnGap-8
[**2178-12-1**] 01:53AM BLOOD Glucose-111* UreaN-25* Creat-1.3* Na-131*
K-4.0 Cl-95* HCO3-31 AnGap-9
[**2178-11-18**] 08:00AM BLOOD ALT-23 AST-31 LD(LDH)-319* AlkPhos-153*
Amylase-42 TotBili-7.6*
[**2178-11-28**] 08:24AM BLOOD ALT-11 AST-29 LD(LDH)-233 AlkPhos-140*
TotBili-6.3*
[**2178-11-18**] 08:00AM BLOOD TotProt-6.6
[**2178-12-1**] 01:53AM BLOOD Calcium-8.4 Phos-1.0* Mg-1.9
[**2178-11-18**] 09:20AM BLOOD Ammonia-60*
[**2178-11-20**] 06:20AM BLOOD Ammonia-69*
[**2178-12-1**] 01:53AM BLOOD Vanco-22.2*
Brief Hospital Course:
# PNA: Cx growing MRSA. Pt now afebrile, satting well on 1L NC.
Titrating off oxygen as tolerated. Patient's vanc trough was
supratherapeutic. We have been holding her vancomycin until it
returns to a normal range. She will need 14 days of vancomycin
total dose. PICC line in place. Vancomycin trough today 16.8.
Vanco dose held. Pt initally started on [**2178-11-25**]. She will need
treatment for a total of 14 days. Dose vanco if trough <15.
Check trough [**12-3**] am.
.
# Diarrhea: Patient was C. Diff positive in [**Month (only) **]. C. Diff
negative x3 here. On lactulose titrating to [**3-15**] loose stools
daily given her liver disease. Diarrhea has improved
considerably over the last few days.
.
# L hip fx: Patient was taken to the OR by [**Month/Day (3) **] for a dynamic
hip screw placement on [**11-25**]. She has been doing well
post-operatively. She is weight bearing and requires rehab for
physical therapy. On tylenol and prn morphine for pain control
Has some post-op edema in her L>R legs. She is on Lovenox and
will require 4 weeks as per [**Month/Year (2) **]. She should follow up with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP 2 weeks after dc ([**Telephone/Fax (1) 1228**]). Staples
are to be removed on post-operative day #14. She should follow
up with Dr. [**Last Name (STitle) **] one month after discharge.
.
# Hep C/Cirrhosis with known esophageal varices and ascites:
Patient had a diagnostic tap in the Emergency room prior to
admission that was negative for SBP. She has been continued on
her levofloxacin for SBP prophylaxis as well as her home
spironolactone and nadolol (was changed to Metoprolol pre-op but
then restarted nadolol afterwards). She has had evidence of
volume overload and has been diuresis with IV lasix, however,
has had a bump in her creatinine over the last few days. She
normally takes 40mg PO Lasix at home and 100mg aldactone.
.
# DM: On Lantus and insulin sliding scale. She should continue
this as an outpatient.
Sliding scale attached.
.
# Macrocytic Anemia: She has been anemic since surgery, but
stable. Her baseline Hct is 30. She has had multiple checks of
B12 and folate in the past, all have been normal. Thought to be
secondary to liver disease. Would continue to monitor.
.
# Hand Fracture: Left sided 5th digit fracture s/p fall. Patient
should continue to wear her ulnar gutter splint. She should
follow up in hand clinic 2 weeks after discharge. She was
evaluated by plastic surgery while in house.
.
# Pt discovered to have a UTI on [**2178-12-1**]. Culture thus far
shows no growth. Pt started on IV ceftriaxone for which she will
take for a total of 5 days. Last dose on [**2178-12-5**].
.
# GERD: Continued on outpatient PPI
.
# Depression/Anxiety: Continued on outpatient Citalopram
.
# PPX: Continued outpatient PPI, should have 4 weeks of Lovenox
as per orthopedic surgery.
.
# Access: PICC in place on Left.
.
# Contact: son [**Name (NI) **] 617*849*4375
.
# Full code
Medications on Admission:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for SEVERE pain for 10 days.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
10. Insulin Sliding Scale
Please continue Insulin sliding scale as directed, and perform
QID Fingersticks (QAC/HS). If NPO use the bedtime sliding
scale.
11. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO
every six (6) hours as needed for titrate to 3 bowel movements
daily: Please titrate administration to 3 bowel movements daily.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 loose stools daily.
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 4 total weeks:
Discontinue on [**2178-12-26**] (4 weeks total therapy).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): SBP prophylaxis.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. MS Contin 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day: hold for respiratory
depression, mental status changes.
14. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 3 days: total of
5 days. Day #1 [**12-1**] for UTI.
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 6 days: Day #1 [**11-25**]. Check trough [**12-3**] and give
dose if <15.
16. Insulin sliding scale
Insulin SC sliding scale-humalog as per attached scale.
finger sticks QACHS
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Left intertrochanteric fracture
Left 5th digit fracture
Hepatitis C cirrhosis
DM2
HTN
asthma
depression/anxiety
MRSA pneumonia
UTI
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for fever, abdominal pain, confusion and L.hip
pain. You were found to have a fracture of your L.hip that was
repaired by orthopedic surgery. After surgery, you were in the
MICU for respiratory difficulties. You were also found to have a
MRSA pneumonia for which you are receiving antibiotics. You are
currently
being treated for a urinary tract infection with another
antibiotic.
.
If you develop shortness of breath, chest pain, severe abdominal
pain, severe leg pain,weakness, or numbness/tingling in your
leg, blood or burning on urination or other symptoms that
concern you, please call your doctor or go to the nearest
Emergency Room as soon as possible.
.
Please take your medications as prescribed and keep all follow
up appointments.
Followup Instructions:
You should follow up with your primary care doctor as soon as
possible. You can call [**Telephone/Fax (1) 589**] to set up this appointment.
.
In addition, you should follow up in the hand clinic for your L
finger fracture in 2 weeks. You should call ([**Telephone/Fax (1) 7138**] to
set up this appointment.
.
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1228**] to schedule an
orthopedic follow up for your hip fracture in one month.
Your staples may be removed on POD 14. [**2178-12-7**] at rehab.
ICD9 Codes: 5990, 2762, 5849, 5185, 5715
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5742
}
|
Medical Text: Admission Date: [**2185-9-4**] Discharge Date: [**2185-9-9**]
Date of Birth: [**2124-8-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Subdural hematoma(acute on chronic)
Major Surgical or Invasive Procedure:
[**9-5**]: Left sided craniotomy for subdural collection
History of Present Illness:
61 yo Ethiopian F s/p resection of a R Frontal meningioma on
[**2185-7-29**] by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] who presents directly to the ED
with 3 day history of progressively worsening R sided weakness
and decrease sensation. On [**2185-8-20**] she was diagnosed with a
subsegmental posterior PE and was started on Lovenox 50mg [**Hospital1 **].
Per daughter's translation, pt. noticed sl numbness to RU/L
extremity with weakness and R foot drop. Denies confusion,
[**Hospital1 **] changes, N/V or L sided deficits.
Past Medical History:
1. resection of a planum sphenoidale chordoid meningioma on
[**2185-7-29**]
2. Hypercholesterolemia
3. Pulmonary Emboli
Social History:
from [**Country 4812**] and now lives in the U.S. with her daughter. She
has 7 children.
Family History:
non-contributory
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: 98 BP: 110/76 HR:66 R: 16 O2Sats:99%
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, Atraumatic. Pupils: 3, minimally reactive
R, 3-2 L EOMs: Intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date with the
English
translation of her daughter.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round, R trace reactive (3) L 3 to 2mm.
Decreased [**Country 12588**] Field R, since tumor resection [**7-28**]
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 to all extremities No abnormal
movements,tremors. Strength full power [**5-24**] to L-Side, but [**4-24**]
RUE/RLE. Slight R pronator drift.
Sensation: Subjective decrease sensation to RUE/RLE.
Toes downgoing bilaterally
On Discharge:
Alert, Oriented to person place and date. Persistent right
[**Month/Day (1) **] field deficit. PERRL(L more brisk than R). Full strength
and sensation in upper extremities(improved from admission).
Full strength and sensation in the lower extremites. Wound is
clean, dry and intact without erythema or exudate.
Pertinent Results:
Labs on Admission:
[**2185-9-4**] 07:00PM BLOOD WBC-4.1 RBC-3.88* Hgb-10.9* Hct-33.2*
MCV-86 MCH-28.1 MCHC-32.8 RDW-13.8 Plt Ct-375#
[**2185-9-4**] 07:00PM BLOOD Neuts-60.7 Lymphs-32.2 Monos-5.9 Eos-0.7
Baso-0.5
[**2185-9-4**] 07:00PM BLOOD PT-12.2 PTT-27.0 INR(PT)-1.0
[**2185-9-4**] 07:00PM BLOOD Glucose-106* UreaN-8 Creat-0.8 Na-142
K-4.6 Cl-107 HCO3-27 AnGap-13
[**2185-9-5**] 04:54AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.3
Labs on Discharge:
[**2185-9-8**] 05:05AM BLOOD WBC-5.5 RBC-3.84* Hgb-10.7* Hct-32.7*
MCV-85 MCH-27.8 MCHC-32.6 RDW-13.5 Plt Ct-297
[**2185-9-8**] 05:05AM BLOOD Plt Ct-297
[**2185-9-6**] 03:02AM BLOOD PT-12.5 PTT-22.2 INR(PT)-1.1
[**2185-9-8**] 05:05AM BLOOD Glucose-104 UreaN-7 Creat-0.7 Na-143
K-4.0 Cl-108 HCO3-27 AnGap-12
[**2185-9-8**] 05:05AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1
Imaging:
Head CT [**9-4**]:
FINDINGS: There are postoperative changes following a right
frontal
craniotomy. There is a predominantly hypodense right frontal and
right
temporal extra- axial collection, which is similar in size from
[**2185-8-20**], and may reflect evolving post-surgical blood products.
External to the dura, there is an additional hypodense
collection, measuring approximately 6mm in maximal dimensions,
which also likely reflects residual post-operative changes and
is not significantly changed. A tiny focus of hyperdensity in
the right frontal lobe likely reflects residual intraparenchymal
hemorrhage as seen on prior studies, decreased from [**2185-7-30**].
However, there is a new left acute-subacute subdural hematoma
overlying the left frontal and parietal convexity with a fluid
level, measuring up to 20 mm in width maximally. The subdural
hematoma extends to overlie the left inferior frontal lobe,
where there is hyperdense hemorrhage, compatible wtih acute
blood products. A new right subdural hemorrhage is also evident
overlying the right convexity near the vertex.
There is associated local mass effect, with sulcal effacement,
effacement of the left frontal [**Doctor Last Name 534**] and a rightward shift of
normally midline structures of approximately 5 mm. No uncal
herniation is appreciated. No major vascular territorial
infarction is identified. A hypodensity in the right basal
ganglia may be chronic. Visualized paranasal sinuses and mastoid
air cells are normally aerated. Osseous structures reveal
craniotomy defect in the right frontal bone.
IMPRESSION:
1. Enlarged left subdural hematoma, with acute-subacute
components,
compatible with interval bleeding from the prior study, with
subsequent
effacement of the frontal [**Doctor Last Name 534**] of the left lateral ventricle and
5 mm
rightward midline shift.
2. New right subdural hematoma overlying the convexity near the
vertex.
3. Evolving hemorrhagic products in the right frontal subdural
space, from
prior surgery.
4. Evolving small focus of intraparenchymal hemorrhage in the
right frontal lobe, decreased from [**2185-7-30**].
Head CT [**9-6**]:
FINDINGS: There has been interval evolution of the left frontal
subdural
hematoma. There is a decreased amount of pneumocephalus. The
collection now measures 12 mm in maximal radial dimension
(2A:13). The previously noted linear hemorrhage at the
evacuation site is less prominent on this
examination. The previously noted left frontoparietal
subarachnoid hemorrhage appears grossly unchanged. The
appearance of the previous right frontal craniotomy is
unchanged. There is a hypodense collection in the right epidural
as well as right subdural spaces consistent with prior surgery.
A previously noted right parietal hematoma is currently
measuring 29 mm in longest diameter versus 11 mm previously
(2A:26). This could represent either a subdural or epidural
hematoma. The ventricles are not enlarged. A hyperdense focus
(2A:15) within the left sylvian fissure is likely due to
layering of blood products in addition to different slice
position on this examination; however, a small new bleed cannot
be completely excluded. The paranasal sinuses and mastoid air
cells are unremarkable. The patient is status post remote right
craniotomy and status post left craniotomy. Otherwise, the
osseous structures are unremarkable.
IMPRESSION:
1. Interval increase in size of right parietal hemorrhage.
2. Interval evolution of left subdural fluid collection.
3. New focus of hyperdensity in the left parietal region may
represent
interval layering of blood, however, new hemorrhage cannot be
fully excluded
Cardiac Echo [**9-7**]:
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. 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). 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. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function
Brief Hospital Course:
Patient was admitted to the ICU/neurosurgery service following
vague complaints of right sided weaknes and gait abnormality.
She had been on lovenox for the treatment of a subsegmental
pulmonary embolus that was diagnosed on [**8-20**]. Hematology was
consulted for suggestion as to the reversal of lovenox.
Unfortunatley, there was no reversal [**Doctor Last Name 360**] that could be
recommened, and we were advised to continue to hold the lovenox
as we are doing. It was further suggested to pursue an IVC
filter to further prevent further embolus of clot. She was
taken to the operating room on [**9-5**] for a craniotomy to
decompress the subdural collection. Post-operatively, she was
returned to the ICU for overnight monitoring. The following day
on [**9-6**], an IVC filter was placed, as she would be unable to
continue on her lovenox therapy in the setting of intracranial
hemorrhage. She again tolerated this procedure well and was
transferred out of the ICU to the neurosurgical floor. Since the
decompression of the SDH, her weakness in the right upper
extremity has significantly improved. Her diet was advanced as
tolerated. She was seen and evaluated by PT/OT who determined
that she would be appropriate for disposition to home with 24h
supervision(which her children will provide). She was given
instructions to refrain from ANY anticoagulation until she is
seen in follow up in 4 weeks with Dr. [**Last Name (STitle) **]. She was
discharged to home on [**2185-9-9**]. By the time of discharge. the
patient had regained full strength of her right upper extremity.
Medications on Admission:
1. Lovenox SQ 60mg [**Hospital1 **]
2. Calcium with D Daily
3. Docusate 100 mg Daily
4. Percocet 5/325 mg PO, PRN
5. Zocor 20 mg Daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain. Tablet(s)
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QAM (once a day (in the morning)).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left sided acute on chronic subdural hematoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-29**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
??????You will not need an MRI of the brain.
The following appointment have been included for your
convenience:
Provider: [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2185-9-9**] 3:45
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2185-9-14**]
2:00
Provider: [**Name10 (NameIs) **] FIELD SCREENING Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2185-9-14**] 2:30
Completed by:[**2185-9-9**]
ICD9 Codes: 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5743
}
|
Medical Text: Admission Date: [**2133-11-26**] Discharge Date: [**2133-12-8**]
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Hydrochlorothiazide / Chlorthalidone
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
lethargy, hypoxia, hematuria
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
83 yo M well known to cardiac surgery, who is s/p MVR [**2133-8-24**]
with post op course c/b afib, respiratory failure, hematuria,
multiple infectious issues, tachy/brady syndrome requiring PPM
and renal insufficiency. Discharged to rehab again on [**11-24**] now
transferred back to CVICU with lethargy, hypoxia, and gross
hematuria.
Past Medical History:
Mitral Regurgitation, s/p MVR on [**2133-8-24**], AFib, Hypertension,
Hypothyroidism, Gastroesophageal Reflux Disease, Degenerative
Joint Disease, h/o Prostate Cancer s/p lupron and XRT, h/o
hyponatremia, GI bleed, radiation cystitis
Social History:
Married, lives with wife. Former [**Name2 (NI) 1818**], quit 15 yrs ago after
3ppd x 49yrs. [**2-10**] alcoholic drinks per day.
Family History:
Non-contributory
Physical Exam:
97.7 72 Afib 99/34 rr 18 sat 98%
Neuro arousable f/c MAE answers y/n appropriately
CV irreg irreg no murmur
Resp BS coarse no wheezes/rales
GI soft/NT/ND
GU foley with bloody urine
Extrem 4+edema warm, slight mottling at knees 2+ distal pulses
Pertinent Results:
[**2133-11-26**] 09:25PM PT-14.0* PTT-32.7 INR(PT)-1.2*
[**2133-12-1**] 04:19AM BLOOD WBC-7.0 RBC-3.07* Hgb-9.7* Hct-29.7*
MCV-97 MCH-31.5 MCHC-32.5 RDW-18.3* Plt Ct-303
[**2133-12-1**] 04:19AM BLOOD Plt Ct-303
[**2133-12-2**] 01:47PM BLOOD Glucose-102 Na-140 K-5.3*
Brief Hospital Course:
He was admitted to cardiac surgery. He was seen by urology and
his bladder was irrigated. He was started on alum CBI. He was
transfused several times. He remained sleepy but arousable.
After multiple discussions with his wife, he was made DNR on
[**12-1**]. It is the family's request to discontinue all invasive
procedures (including blood draws, IV access, blood
transfusions...etc.) We are continuing full ventilator support,
tube feeding, and oral (G Tube)medications. IV access and sub q
heparin were discontinued and he was switched from IV vancomycin
to PO linezolid. His aspirin was discontinued indefinitely per
urology. He has remained hemodynamically stable, in AFib with
controlled ventricular rate, on full ventilator support. On
[**12-5**], it was noted that he had abdominal distention an dbloody
stools. As we are no longer drawing labs or performing invasive
procedures, no treatment was changed as a result of this with
the exception of holding his tube feedings for 24 hours.
Feeding was resumed this am, and he appears to be tolerating it.
He is ready to be transferred to a palliative care facility.
Medications on Admission:
Ultram, Synthroid 50 mcg', Protonix 40', Doxazosin, Haldol prn,
Amiodarone 400", Toprol XL 25'
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Year (2) **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Five (5) ml PO BID (2
times a day).
4. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
6. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: Five Hundred (500) mg PO
DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Zinc Sulfate 220 (50) mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6)
Puff Inhalation QID (4 times a day).
10. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
11. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Last Name (STitle) **]:
Two (2) puff Inhalation [**Hospital1 **] ().
12. Levothyroxine 25 mcg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
13. Haloperidol 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime).
14. Linezolid 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours).
15. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
16. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
17. Haloperidol Lactate 5 mg/mL Solution [**Hospital1 **]: One (1) Injection
Q4H (every 4 hours) as needed.
18. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
19. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: Five (5)
ML PO Q3H (every 3 hours) as needed.
20. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
respiratory failure
MR, s/p MVR
radiation cyctitis
AFib
s/p sternal debridement
s/p pacemaker
Discharge Condition:
guarded
Discharge Instructions:
Palliative care
Full ventilator support (current settings are: A/C, 70%, Vt 550,
PEEP +15, rate 20)
Tube feedings via PEG (Nutren renal at 60ml/hour with 25 Gms
Beneprotein per day)
Followup Instructions:
with PCP if indicated
Completed by:[**2133-12-7**]
ICD9 Codes: 4019, 2449, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5744
}
|
Medical Text: Admission Date: [**2191-2-22**] Discharge Date: [**2191-4-12**]
Date of Birth: [**2148-10-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2191-2-23**] Splenectomy
[**2191-3-9**] PICC placement
History of Present Illness:
42 yo male inmate who presents with LUQ/LLQ abdominal pain on
transfer from
[**Hospital **] Hospital with scan showing ungraded splenic laceration.
He is s/p unspecified abdominal trauma to Left side during
"running game" in the prison yard two days ago ([**2-20**]). HCT at
[**Hospital1 **] 29.
Past Medical History:
Type II DM (diet controlled)
Cirrhosis, Hepatitis C
Family History:
Noncontributory
Physical Exam:
Exam on Admission:
Tc 100.7 HR 84 BP 143/64 RR 22 Sats 100% RA
GEN: WDWN M in NAD
HEENT: PERRLA
CV: RRR, no murmurs, rubs or gallops
RESP: CTAB
GI/ABD: soft, slightly distended
Ext: no cyanosis, clubbing or edema
Exam on discharge:
GEN: WD, thin M w/ no movement
HEENT: icteric sclera, pupils fixed at 6mm, nonreactive, blood
dripping from nose, excoriated lips with dried blood present
CV: no rhythm, no radial pulses, no brachial pulse, no carotid
pulse
RESP: no respirations, no breath sounds, no respiratory effort
Skin: grossly jaundiced
Pertinent Results:
[**2191-2-22**] 07:50PM GLUCOSE-96 UREA N-8 CREAT-0.8 SODIUM-136
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-13
[**2191-2-22**] 07:50PM AST(SGOT)-129*
[**2191-2-22**] 07:50PM WBC-5.9 RBC-3.00* HGB-9.3* HCT-29.2* MCV-97
MCH-30.8 MCHC-31.7 RDW-13.4
[**2191-2-22**] 07:50PM PLT SMR-VERY LOW PLT COUNT-81*
[**2-22**] CTA ABD: There is mild dependent atelectasis, (left greater
than right). A left pleural effusion is minute. A hiatal hernia
is small.
There is a complex splenic laceration, which traverses the
spleen at multiple sites. There are also multiple sites of
devascularized parenchyma, which comprise less than 25% of the
total splenic volume. In the arterial phase of enhancement,
there is an 8-mm contrast collection in the parenchyma, which is
contiguous with a splenic artery branch in the hilum (3A, 39).
There is a second 3- mm focus in the anterior superior spleen
(3A, 25), which is surrounded by more ill defined high
attenuation in the arterial phase. These focal collections are
suggestive of pseudoaneurysms, as they do not increase in size
and in fact become less conspicuous on delayed phases. The
hyperattenuation surrounding the smaller focus is suggestive of
active contrast extravasation. The spleen is enlarged at 16.2
cm. There is a heterogeneously hyperattenuating capsular
hematoma, which measures 33 mm in thickness. There is moderate
hemoperitoneum, particularly in the pelvis.
The liver, pancreas, adrenal glands, and kidneys are within
normal limits. There are multiple mildly enlarged periportal,
portacaval, celiac and retroperitoneal nodes, which measure up
to 13 mm in short axis and may be reactive. Gallstones are
present. There is no bowel dilatation or free intraperitoneal
air.
The osseous structures are intact.
IMPRESSION:
1. Complex splenic laceration (grade III/IV) with two
pseudoaneurysms, the smaller of which appears to be associated
with active extravasation. There is a moderate splenic capsular
hematoma and associated hemoperitoneum.
[**2-23**] Liver biopsy: 1. Advanced fibrosis with bridging, sinusoidal
fibrosis and multifocal early nodule formation, suspicious for
evolving cirrhosis (stage 3-4, confirmed by trichrome stain).
2. Mild-to-moderate portal septal, mild periportal and lobular
predominantly mononuclear cell inflammation (grade 2).
3. Mild cholestasis.
4. No significant steatosis or intracellular hyalin seen.
5. Iron stain shows mild focal iron deposition in hepatocytes
and Kupffer cells.
Note: The findings are consistent with chronic viral hepatitis,
clinically HCV. The sinusoidal fibrosis is suggestive of a
component of prior toxic/metabolic injury.
[**3-2**] CT head: Normal head CT without evidence of brain edema
[**3-2**] Abd US: The liver shows no focal or textural abnormalities.
The gallbladder contains sludge and shows wall edema. No intra
or extrahepatic biliary dilatation is appreciated. The common
duct measures 4 mm. The portal vein is patent with hepatopetal
flow. Small amount of ascites is present. The pancreas is poorly
visualized. The patient is status post splenectomy.
[**3-3**] CT Abd/pelvis: Status post splenectomy with small amount
of fluid remaining in the abdomen, but no evidence of abscess or
recurrence of hematoma. New bibasilar pulmonary parenchymal
opacities could reflect pulmonary edema/ARDS, aspiration or
pneumonia. Correlation is recommended.
Diffuse mild dilation of small bowel, most likely representing
ileus.
Decreased size of a small rim-enhancing collection in the right
lower quadrant, which could reflect appendiceal pathology
including improving tip appendicitis. However, there is a
question of coloenteric fistula and therefore repeat CT with
contrast is recommended when symptoms have resolved.
[**3-10**] Abd US: No significant interval change in the appearance of
gallbladder. Although these findings may be related to
hypoalbuminemia and prolonged NPO status, acute cholecystitis
cannot be excluded. Right pleural effusion.
Brief Hospital Course:
He was admitted to the Trauma service on [**2-22**]. He was taken to
the Trauma ICU for close monitoring. His hematocrit was followed
closely; he continued to have left shoulder pain and
tachycardia; concerning for hemorrhage. He was taken to the
operating room for splenectomy on [**2-23**]. There were no
intraoperative complications. Postoperatively his tachycardia
persisted; he also had a low urinary output. He was given
intravenous fluid bolus with increased urine output. He required
supplemental oxygen because of low oxygen saturations; incentive
spirometer use was strongly encouraged. On post operative day 1
([**2-24**]) he was transfused 1 unit pRBC and transferred to the
floor. On [**2-25**] he was again transfused for a low hematocrit. On
post op day 3, he developed increasing somnolence and he was
started on lactulose, his narcotics were discontinued and
hepatology was consulted. An ammonia level was 71 and he
continued to have low urine output. He was started on rifaximin
and albumin. On [**2-27**] his mental status worsened, he had
vomiting and his abdominal wound dehisced with an ascitic leak.
He was transferred back to the trauma ICU for further care. He
was started on tube feeds for nutrition. A VAC dressing was
placed in the abdominal wound. He was intubated for worsening
mental status and airway protection on [**2-28**]. 1 of 2 blood
cultures drawn on [**3-1**] returned as positive for vancomycin
sensitive enterococcus and he was started on Vancomycin and
Zosyn on [**3-2**], which was continued for 10 days. He had a normal
head CT and a RUQ ultrasound which showed a sludge filled
gallbladder and no stones. He continued to have an ascitic
leak, and his bloodwork results were followed closely for
increasing bilirubin, creatinine peak of 2.4, moderately
increased LFTs and pancreatic enzymes, elevated INR (peak of
1.9) and increased ammonia levels. He was extubated on [**3-8**] and
his mental status improved. His bilirubin remained elevated,
his ammonia level decreased and his creatinine returned to
baseline. He was awake and alert and was able to be transferred
to the floor on [**3-11**] and was started on a regular diet on [**3-12**].
He continued to have an ascitic leak and his vac was changed
every 3 days on the floor. His INR and bilirubin continued to
increase. In discussions with MDs regarding his overall poor
prognosis, he clarified that he still preferred aggressive
treatment unless he was dying of irreversible liver failure.
Psychiatry evaluated him and determined that he was currently
competent to make this decision despite any underlying
encephalopathic process. He was evaluated and treated by
physical therapy. A repeat CT abdomen on [**3-19**] showed slight
increase in the free fluid in the pelvis, decreased left
subphrenic collection and improvement in the bibasilar
aspiration and pneumonia of the lung fields. A chest xray on
[**4-1**] showed marked improvement in widespread pulmonary opacities
with no definite new abnormalities to suggest acute pneumonia.
Mr. [**Known lastname **] was made DNR/DNI per Dr. [**Last Name (STitle) **] on [**3-29**]. On the
evening of [**4-11**] the patient had blood pressures that dropped
into the 80s/50s while resting in a chair. He was found to have
electrolytes that were very irregular on the evening of [**4-11**].
Mr. [**Known lastname **] started to have agonal breathing later that evening,
and started bleeding persistently from his nose and mouth. On
the morning of [**4-12**] the patient appeared in distress with
agonal, noisy wet sounding breaths. The patient was made CMO by
Dr. [**Last Name (STitle) **] on [**4-12**]. Mr. [**Known lastname **] died secondary to respiratory
failure on [**4-12**] at 1:09PM.
Neuro: The patient was started on a narcotic pain regimen upon
admission to the trauma service. He was weaned off of the
narcotics on [**2-25**]. His mental status was noted to be worsened on
[**2-27**]. Between the dates of [**2-27**] and [**4-10**], his mental status has
waxed and waned persistently. On [**4-11**] his mental status
deteriorated profoundly to the point where the patient was
nonverbal and only moved his head in response to other people's
voices. On [**4-12**] the patient became unresponsive to others in the
room. He was put on a morphine drip which was titrated for
comfort.
HEENT: The patient had intermittent nose bleeds during his
hospitalization. An ENT consult was placed on [**3-29**] for
persistent nose bleeds. Absorbable packing was placed
intranasally which controlled the bleeding for some time. On
[**3-31**] ENT was reconsulted because the patient started bleeding
from the nose again and the bleeding vessel was identified and
cauterized. Nonabsorbable packing was placed intranasally and
antibiotics were started at that time. His packing was removed 5
days later and he did not have another nose bleed at that time.
CV: The patient had no problems with his cardiovascular status
during his hospitalization.
RESP: The patient had low oxygen saturations postoperatively. He
was extubated on [**3-8**]. He was weaned off of supplemental oxygen
when he was transferred to the floor on [**3-11**]. He developed
agonal breathing on [**4-11**] due to his worsening encephalopathy and
persistent, uncontrolled bleeding.
GI: The patient was started on lansoprazole on [**3-11**] for GI
prophylaxis. He was also started on lactulose for his chronic
hepatic failure. On admission his liver function panel had some
slightly elevated values. His ALT was 89 , AST [**Last Name (un) **] 175, T bili
3.1 D bili 1.8 Alb 2.4. His liver function panel on [**4-9**] had an
AST 342, ALT 140, T bili 28 D bili 15.4. A hepatology consult
was called on [**2-26**] and it was suggested that he be started on
rifamixin. On [**3-11**] hepatology agreed with continuing his
rifamixin and albumin replacement for wound vac losses.
GU: The patient had no problems with this system during his
hospitalization.
FEN: The patient was started on a regular diet on [**3-12**]. He was
tolerating a regular diet until [**4-10**] when he started having less
of an appetite. Mr. [**Known lastname 17391**] electrolytes were monitored every
third day showing a persistent hyponatremia starting on [**3-13**].
His BUN had a bimodal distribution of elevation first peaking at
45 on [**3-6**] and then peaking again at 97 on [**4-11**]. His potassium
peaked at 5.5 on [**2-24**] but then returned to [**Location 213**] only to peak
again on [**4-11**] to 7.0. His creatinine initially peaked at 2.4 on
[**3-5**] and then returned to [**Location 213**] levels until he peaked on [**4-11**]
to 6.9.
HEME: Mr. [**Known lastname 17391**] admitting coagulation profile was PT 14.7 INR
1.3 PTT 31.3. His admitting hematocrit was 29.2 and platelets
were 81. Postoperatively, the patient received 2units of packed
red blood cells for a hematocrit of 23.9. On [**3-29**], he received a
unit of FFP and a unit of packed red blood cells. His last
hematocrit on [**4-9**] was 27.1.
ID: The patient had [**1-19**] positive blood cultures on [**3-1**] for
vancomycin sensitive enterococcus. He also had a positive sputum
culture on [**3-1**] which grew haemophilus influenza. He was started
on vancomycin and zosyn on [**3-2**] for the positive cultures. The
antibiotics were stopped on [**3-9**]. Mr. [**Known lastname **] was started on
Augmentin on [**4-1**] for prophylaxis against gram positive microbes
while he had nasal packing in place. It was discontinued on
[**4-5**]. The patient had a history of viral hepatitis.
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p Assault
Grade III/IV splenic laceartion
s/p splenectomy
hepatic encephalopathy
respiratory failure
multi organ system failure
chronic hepatitis C
Discharge Condition:
deceased
Followup Instructions:
N/A
ICD9 Codes: 5070, 5715, 2761, 9971
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5745
}
|
Medical Text: Admission Date: [**2144-3-21**] Discharge Date: [**2144-4-3**]
Date of Birth: [**2082-1-25**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Fall onto face
Major Surgical or Invasive Procedure:
Cervical laminectomy [**2144-3-22**]
Tracheostomy & PEG placment [**2144-3-24**]
Tulip Retrievable IVC filter [**2144-3-31**]
History of Present Illness:
62 yo male s/p fall onto face, +LOC. Found on floor ~2 hours
later; + incontinence, c/o neck pain, numbness from chest down.
Transferred to [**Hospital1 18**] for continued trauma care.
Past Medical History:
None
Social History:
Formerly employed as a delivey peson, moved in with parents to
care for his ailing father. Denies tobacco, ETOH, IVDA.
Family History:
Noncontributory
Physical Exam:
VS upon admission:
HR 70 BP 124/68 RR 20 O2 Sats 97%
PERRL, EOMI, awake and answers questions
CTAB
RRR
Soft, NT/ND
Normal tone
No stepoffs
+bulbocalv reflex
Pelvis stable
No extr deformity; +DP pulse palp
No pinprick sensation shoulders, nipples and below
Pertinent Results:
[**2144-3-21**] 11:49PM GLUCOSE-120* UREA N-22* CREAT-1.0 SODIUM-137
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
[**2144-3-21**] 11:49PM PHOSPHATE-2.4* MAGNESIUM-1.8
[**2144-3-21**] 11:49PM HCT-37.1*
[**2144-3-21**] 07:50PM UREA N-22* CREAT-1.1
[**2144-3-21**] 11:49PM PT-13.0 PTT-21.7* INR(PT)-1.1
[**2144-3-21**] 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2144-3-21**] 07:50PM WBC-6.4 RBC-4.57* HGB-14.9 HCT-42.0 MCV-92
MCH-32.7* MCHC-35.6* RDW-12.9
[**2144-3-21**] 07:50PM PT-12.3 PTT-20.1* INR(PT)-1.1
[**2144-3-21**] 07:50PM PLT COUNT-171
[**2144-3-31**] 4:14 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2144-4-1**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2144-4-1**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2144-3-27**] 10:23 am SPUTUM
GRAM STAIN (Final [**2144-3-27**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Preliminary):
HEAVY GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CHEST (PORTABLE AP) [**2144-3-30**] 11:10 AM
CHEST (PORTABLE AP)
Reason: comparison to previous cxr [**3-27**]
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p trach placement; fever overnight.
REASON FOR THIS EXAMINATION:
comparison to previous cxr [**3-27**]
PORTABLE CHEST, [**2144-3-30**].
COMPARISON: [**2144-3-27**].
INDICATION: Fever.
A tracheostomy tube remains in satisfactory position. Cardiac
and mediastinal contours are stable. There has been interval
improvement in opacification in the left retrocardiac region,
likely due to resolving atelectasis. There is an area of
increased opacity in the right lung base partially obscuring the
right hemidiaphragm medially, new in the interval, and there is
also a probable small right pleural effusion.
IMPRESSION:
1. New right basilar retrocardiac opacity, which may relate to
atelectasis or developing pneumonia.
2. Resolving left lower lobe atelectasis.
CHEST (PORTABLE AP) [**2144-3-27**] 9:52 AM
CHEST (PORTABLE AP)
Reason: consolidation? infiltrate?
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p trach placement; fever overnight.
REASON FOR THIS EXAMINATION:
consolidation? infiltrate?
REASON FOR EXAMINATION: Fever and suspected infiltrate .
Portable AP chest x-ray was compared to the previous study from
[**2144-3-26**].
The heart size is normal. The mediastinum has normal shape and
position.
Lungs are grossly clear. Bilateral pleural effusion is again
noted.
The patient is after insertion tracheostome with its tip in good
position.
A grossly distended stomach with no NG tube demonstrated.
IMPRESSION: 1) Normal position of tracheostome
2) Grossly distended stomach with no NG tube inserted.
Sinus bradycardia with atrial premature beats. Incomplete right
bundle-branch
block. Non-specific T wave changes. Compared to the previous
tracing
of [**2144-3-21**] sinus bradycardia with atrial premature beats are new
and T wave
changes are more pronounced.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
53 132 104 482/463.15 73 63 -52
CT HEAD W/O CONTRAST [**2144-3-21**] 7:51 PM
CT HEAD W/O CONTRAST
Reason: FALL.?HIT HEAD.?BLEED
[**Hospital 93**] MEDICAL CONDITION:
51 year old man s/p fall
REASON FOR THIS EXAMINATION:
?injury
CONTRAINDICATIONS for IV CONTRAST: None.
CT HEAD
INDICATION: 51-year-old status post fall, question injury.
TECHNIQUE: Non-contrast axial head CT.
FINDINGS: There is no evidence for intracranial hemorrhage.
There is no mass effect or shift of normally midline structures.
No intracranial hemorrhage is identified. The cisterns, sulci
demonstrate no effacement. The [**Doctor Last Name 352**]-white matter junction is
distinct.
The osseous structures are unremarkable. The paranasal sinuses
and mastoid air cells are clear.
IMPRESSION: No evidence for intracranial hemorrhage.
CT C-SPINE W/O CONTRAST [**2144-3-21**] 7:52 PM
CT C-SPINE W/O CONTRAST
Reason: FALL.?CSPINE INJURY
[**Hospital 93**] MEDICAL CONDITION:
51 year old man s/p fall
REASON FOR THIS EXAMINATION:
?injury
CONTRAINDICATIONS for IV CONTRAST: None.
CT C-SPINE WITH CORONAL AND SAGITTAL RECONSTRUCTIONS
INDICATION: 51-year-old man status post fall, question injury.
COMPARISON: None.
TECHNIQUE: Non-contrast axial imaging of the cervical spine with
coronal and sagittal reformats was reviewed.
FINDINGS: There is significant degenerative disease within the
cervical spine with fusion of C4-C5, anterior and posterior
osteophytes, and calcification of the anterior longitudinal
ligaments. Spurring of the axo-atlanto articulation is also
present. No fractures are present. Vertebral body alignment is
anatomic. Facet joint alignment is anatomic.
There is increased prevertebral soft tissues. There is a very
small calcification anterior to the C3/C4 vertebral body that is
likely secondary to degenerative disease. However, this may also
represent a small fracture fragment from flexion/extension
injury.
There is increased soft tissue density seen within the cord most
significantly at C3 through C6, of uncertain etiology and
clinical significance. Evaluation of the components of the
spinal canal is limited on this CT, and thus urgent MR will be
necessary for further evaluation.
IMPRESSION: Increased soft tissue density seen within the cord,
concerning for cord injury. No acute fracture identified. Urgent
MR spine will be necessary to evaluate this abnormality.
Increased prevertebral soft tissue that may belie further
injury.
MR CERVICAL SPINE [**2144-3-21**] 8:50 PM
MR CERVICAL SPINE; MR THORACIC SPINE
Reason: Acute paralysis without spinal fracture
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with
REASON FOR THIS EXAMINATION:
Acute paralysis without spinal fracture
INDICATION: Trauma.
TECHNIQUE: Sagittal T1, T2 and STIR weighted images of the
cervical spine were obtained. Axial T2 and gradient and echo
images of the cervical spine were obtained from the level of
C3/C4 to the level of C7/T1.
FINDINGS: There is severe paravertebral soft tissue swelling.
There is concern for rupture of the anterior longitudinal
ligament. The vertebral bodies are of normal height. No evidence
of subluxation of the vertebral bodies. There is multilevel disc
desiccation. There is fusion of the vertebral bodies of C5/C6,
likely from prior surgery. There is skin edema in the region of
the posterior aspect of the occiput. There is also some edema in
the upper thoracic subcutaneous tissues.
There is increased signal in the spinal cord at the levels of C3
and C4 which could represent acute spinal cord edema secondary
to spinal cord injury. Differential diagnosis would include
gliosis from chronic spinal canal stenosis. Correlation with
physical exam is recommended.
At the level of C3/C4, there is moderate to severe spinal canal
stenosis caused by disc osteophyte complex at this level. There
is no foraminal narrowing at this level.
At the level of C4/C5, again noted is moderate to severe
narrowing of the spinal canal by disc osteophyte complexes.
There is also bilateral moderate neural foramen narrowing right
greater than the left.
At the level of C5/C6, there is mild spinal canal stenosis
caused by disc osteophyte complex, but no significant neural
foramen narrowing.
At the level of C6/C7, there is disc osteophyte complex causing
mild spinal canal stenosis and bilateral moderate- to-severe
neural foramen narrowing right greater than the left.
At the level of C7/T1, no significant abnormality is noted.
MRI OF THE THORACIC SPINE WITHOUT GADOLINIUM:
TECHNIQUE: Sagittal inversion recovery, T1- and T2-weighted
imaging of the thoracic spine was performed.
FINDINGS: There is no evidence of cord compression in the
thoracic spine. There is no evidence of thoracic spine fractures
or spinal stenosis in the thoracic spine.
IMPRESSION:
1. Increased signal in the cord at the level of C3/C4 could
represent edema from acute spinal cord injury versus gliosis
from chronic spinal canal stenosis.
2. Severe paravertebral soft tissue swelling and suggestion of
rupture of the anterior longitudinal ligament.
3. Multilevel spinal canal stenosis.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedic spine surgery
and Neurology were immediately consulted because of his
injuries; steroids were initiated and he was taken to the
operating room on [**3-22**] for decompression of his spine injuries.
On [**3-24**] he was taken to the operating room for a Trach and PEG
placement.
Patient febrile intermittently during his hospitalization; fever
workup done; sputum culture positive for Klebsiella pneumoniae.
He was started on Levo which will needto continue for a 21 day
course per ID recommendation. He continues to have a low grade
fevers. His final blood culture results are still pending at
time of this dictation.
Vascular surgery was consulted for IVC filter placement; a Tulip
retrievable IVC filter was placed on [**2144-3-30**] without incident.
Patient did receive IV narcotic analgesia for this procedure and
was slightly disoriented that same evening. On the next morning
his mental status cleared, he was able to state date and his
location. Chemistry 10, CBC with Diff, U/A and urine culture and
stool for C-Diff were all obtained to rule out any organic
causes. These results were unremarkable.
On HD #12 patient developed bloody stool; his hematocrits
however remained stable (currenetly 33 as of [**4-3**])GI was
consulted as well. Patient with a reported history of internal
hemorrhoids; GI deferred scope at time given that patient
remained hemodynamically stable with no drop in his hematocrits.
He will need a scope as an outpatient. He has a C-diff specimen
that is pending at time of this dictation; there is a low
probabiltiy that he has C-diff. The results from one C-diff
specimen noted on pertinent lab section was negative.
Speech and Swallow were consulted for Passy-Muir valve. Patient
is able to cough and clear his secretions effectively. A bedside
swallow evaluation was performed as well; patient still
aspirating thin liquids. He should have a repeat swallow study
once in rehab.
Physical and Occupational therapy were consulted early during
his hospitalization. Social work has also been closely involved
in patient's care for coping issues.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever > 100.4.
2. Docusate Sodium 150 mg/15 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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
7. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: [**12-30**] Tablet PO BID (2
times a day): hold for HR <60; SBP <100.
9. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours).
10. Regular insulin sliding scale Sig: One (1) four times a
day as needed for per fingersticks: See attached sliding scale
and fixed dose scale.
11. Sodium Chloride 0.9 % Syringe Sig: One (1) ML Injection
DAILY (Daily) as needed: NS flush per protocol.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day): per G-tube.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Cervical Spine Stenosis
Quadriplegia
Discharge Condition:
Stable
Discharge Instructions:
Follow up with Orthopedic Spine Surgery in [**4-2**] weeks.
Follow up in Trauma Clinic in 4 weeks.
Followup Instructions:
Call [**Telephone/Fax (1) 3573**] for an appointment with Dr. [**Last Name (STitle) 363**], Orthopedic
Spine
in [**4-2**] weeks.
Call [**Telephone/Fax (1) 6439**] for an appointment with Dr. [**Last Name (STitle) **], Trauma
Clinic in 4 weeks.
Completed by:[**2144-4-3**]
ICD9 Codes: 5180
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5746
}
|
Medical Text: Admission Date: [**2137-9-7**] Discharge Date: [**2137-9-9**]
Date of Birth: [**2095-6-15**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
STEMI from OSH
Major Surgical or Invasive Procedure:
Impella placement
History of Present Illness:
Pt is a 42 yo female with no significant past medical history
s/p cardiac arrest with [**Location (un) **] from [**Hospital3 4298**]. Pt
was found slumped on couch earlier this evening by husband with
report of possible seizure-like activity. She was taken to OSH
where she went into v fib arrest. She was shocked x 1, epi x 1
with return of spontenous circulation. She may have had
pulseless electrical activity during resuscitation efforts but
records were not readily available on transfer. She was
intubated at OSH and was given at least 1 dose of narcan. She
had 200 cc bright red blood return from ET at OSH so received 1
unit PRBC prior to transfer. Her head CT was negative.
On arrival to [**Hospital1 18**], pt had bedside TTE which showed very
depressed LV function. She received 2 units PRBC, 2 unit FFP.
ABG was notable for pH 6.91, pCO2 67, pO2 76, lactate 6.3, hbg
11.5. EKG notable for ST elevations in V2-V6. Pt was evaluated
by post-arrest team who felt that given ongoing bleeding/pulm
hemorrhage causing oxygenation/ventilation difficulties,
therapeutic hypothermia would cause significant HD instability.
In light of this, they recommended keeping pt normothermic.
.
Pt was initially admitted to MICU for management of pulmonary
hemorrhage. She had a bronchoscopy that showed mild diffuse
blood but no active bleeding. She was started on levophed which
was quickly titrated to maximum dose, then dopamine, and
epinephrine. She was difficult to ventilate wtih CMV 380 PP
18-20 PEEP 10 RR 28 and FiO2 100%. Pt remained unresponsive
despite not receiving any sedation. Decision was made to take
pt to cath lab for possible intra-aortic balloon pump for
mechanical hemodynamic support. Rectal temperature was 91.4.
.
In the cath lab, pt had Impella device inserted via right
femoral access. LHC showed 100% occluded LAD lesion with ?
spontaneous dissection. She received 1 BMS. Post-procedurally,
she was able to be weaned off pressors, oxygenation improved
slightly, pH improved to 7.0 and pt made some urine. She
received double dose of integrilin in the lab in place of
aspirin and plavix, given that pt did not have NG tube.
Past Medical History:
None. Initially thought to have anorexia nervosa with weight of
82 lb, per husband pt had been normal weight until 1 month ago
and had acute weight loss, unknown etiology, not worked up as
family recently lost health insurance?
Social History:
Lives with husband who reportedly witnessed unresponsive episode
Smoked 3 packs/day for 20 - 30 years. Has three daughters
Family History:
unknown
Physical Exam:
ADMISSION
GENERAL: intubated, sedated, paralyzed, thin. After Impella
ventricular assist device placed via right femoral artery.
HEENT: Sclera anicteric
CARDIAC: Difficult to appreciate. RR.
LUNGS: No chest wall deformities, Resp labored prior to
paralysis with dyssynchrony. Pt had hemoptysis
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Cold right leg below knee with mottling. Catheter
entering R femoral artery and venous access vein femoral vein.
DISCHARGE:
expired
Pertinent Results:
ADMISSION:
[**2137-9-7**] 11:06PM BLOOD WBC-31.9* RBC-4.05* Hgb-11.4* Hct-35.9*
MCV-89 MCH-28.1 MCHC-31.8 RDW-14.5 Plt Ct-289
[**2137-9-7**] 11:06PM BLOOD PT-13.8* PTT-40.5* INR(PT)-1.3*
[**2137-9-7**] 11:06PM BLOOD UreaN-22* Creat-0.6
[**2137-9-7**] 11:06PM BLOOD Lipase-82*
[**2137-9-7**] 11:06PM BLOOD cTropnT-0.96*
[**2137-9-7**] 11:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2137-9-7**] 11:22PM BLOOD pO2-62* pCO2-73* pH-6.91* calTCO2-16*
Base XS--21 Intubat-INTUBATED Comment-GREEN TOP
[**2137-9-7**] 11:22PM BLOOD Glucose-83 Lactate-6.7* Na-141 K-4.4
Cl-119*
[**2137-9-7**] 11:22PM BLOOD Hgb-11.5* calcHCT-35 O2 Sat-73 COHgb-2
MetHgb-0
[**2137-9-7**] 11:22PM BLOOD freeCa-1.02*
DISCHARGE:
expired
Brief Hospital Course:
42 yo female from OSH with STEMI (V2-V6) and vfib arrest at OSH,
shocked + epi x 1 with possible PEA then ROSC, helicoptered to
[**Hospital1 18**] in cardiogenic shock.
.
# On arrival pt was in cardiogenic shock- echo in the ED showed
severe global hypokinesis with EF 10%, patient was also markedly
acidemic with pH 6.88, lactate 8.2 . She was taken emergently to
cath lab where pt had Impella device inserted via right femoral
artery. LHC showed 100% occluded LAD lesion with ? spontaneous
dissection. She received 1 BMS. Post-procedurally, she had good
flow and was able to be wean off all pressors, oxygenation
improved slightly, pH improved to 7.0 and pt made some urine.
She received double dose of integrilin in the lab in place of
aspirin and plavix, given that pt did not have NG tube. Pt
transferred to CCU after Cath lab. At that time multiple
discussions with family took place about prognosis and decision
was made to keep patient DNR (pt was intubated at this time and
decision was made not to withdraw care). In the next 24 hours
the the patient continued to require maximal doses of three
pressors, and remained sedated and on maximal ventilatory
support and mechanical circulatory support (Impella). On [**2137-9-8**]
at 2200 telemetry showed asystole, confirmed by physical exam,
no ROSC, no CPR performed as pt DNR. Cardiology fellow, resident
and intern with Family at bedside through out this time. Support
given. Husband and family declined autopsy. Impella removed at
[**2137-9-8**] 2330.
Medications on Admission:
unknown
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2137-9-10**]
ICD9 Codes: 2762, 3051, 4275
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5747
}
|
Medical Text: Admission Date: [**2137-2-16**] Discharge Date: [**2137-3-3**]
Date of Birth: [**2068-5-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Rt thigh swelling and pain
Major Surgical or Invasive Procedure:
Cystoscopy
Thoracocentesis
IVC filter fixation
History of Present Illness:
68 yo male, who presented with right swollen painful thigh for 3
days. He could hardly walk due to the pain and pain is more when
he walks around otherwise while sitting there is minimal pain.
He never had similar compaint before. He was in his usual normal
state of health until [**Month (only) **] when he started to have right
lower abdominal pain and right flank pain for which he seeked
his doctor, percocet was prescribed however it worsened. He also
took Motrin for the last 3 months in addition to percocet for
the pain. In addition to this pain, he had intermittent
hematuria. For this, he had an abdominal US and CT abd/pelvis at
[**Hospital1 2177**], and according to the patient, there was a mass in the
urinary baldder and a cyst in his right kidney. He was reffered
for urology appointment, however his appoitnement was cancelled.
He also mentioned that it seems like he lost weight, however on
the scale it still shows 182, but the wife mentioned that his
arm size was bigger than what it is today. Also, the patient
mentioned that he has a new onset hypertension that started
about 3-4months ago for which he is on anti-hypertensive. In the
last 2-3 weeks, he also noted bilateral scrotal painless
swelling but no lower limb swelling bilaterally until wed. when
he started to have swelling and pain in his right thigh. No
fever or chill or sick contact. 2 years ago he had a left sided
abd pain, for which he also had a CXR that showed 3.5cm mass in
his left lung. For that mass he had an MRI, and he was told that
he doesn't need further MRI, it can be followed up by CXR. He
also mentioned shortness of breath on exertion and dry cough for
the last 3 months. 3-4 months ago he could go upstairs before he
gets SOB, however recently by minimal effort he is SOB. No
associated chest pain or dizziness or sweating or palpitations.
He uses valid-date puffer occasionally within the last few
months with minimal relief. He also described some lower chest
tightness, a few times post-meal, and not with his SOB.
In the ED, initial vs were: 98.3 118 163/72 18 95%. On exam
tender right leg, guiaic negative. Labs notable for WBC 13.3,
creatinine of 2.7 (unclear baseline). UA positive, urine culture
sent. Blood culture sent. LENI showed nonocclusive DVT of the
right distal SFV. He was started on a heparin gtt. He developed
new oxygen requirement in the ED. CXR showed RML opacity
obscuring right heart border. He was given levofloxacin 750mg
for presumed pneumonia. He was given tylenol, and morphine. He
was given 1L IVF. Vitals on transfer: 98.2 117 101/84 18 92%2L
.
On the floor, reports shortness of breath with minimal exertion.
Past Medical History:
bladder mass
Hypertension
COPD
Social History:
-married
-former construction worker
-former smoker = quit 10yrs ago, smoked 0.5ppd x40yrs
-denies IVDA
-denies ETOH
Family History:
non-significant
Physical Exam:
On admission:
-------------
Vitals: 97.4 159/96 68 20 98%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased BS right base, no wheezes, rales, ronchi
CV: S1, S2 regular rhythm, normal rate
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: oriented x3, CNII-XII intact, no gross sensory or motor
deficits, negative pronator drift, gait not assessed
The day before he decides for CMO
Vitals: 98.1, 104/64, 95 bpm, 20, sat97% on 3L O2
GEN: alert, oriented x3, sitting in bed, lethargic, Not in acute
distress. urine color is light brownish.
HEENT: Mucous membranes moist, no lesions noted. Sclerae
anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
LN: no axillary LN could be appreciated. A small LN is noted in
the right inguinal.
CV: normal rate and regular rhythm, no murmurs, rubs or gallops
PULM: relatively fair A/E on the Rt side. Still some crackles
are heard at mid & lower zone of Rt lung. No wheezes could be
appreciated.
ABD: Soft, slight tenderness on touching the peri-umbilical,
slightly distended, no rebound tenderness or guarding, no
organomegaly. bowel sounds positive. No CVA tenderness noted.
Spine & EXTR: right thigh looks well, no erythema at inner right
thigh, no tenderness to touch. Dorsalis pedis was felt on Lt
side, couldn't be felt on Rt side. Lt forearm's hematoma on the
medial side looks smaller. still has bilateral lower limb
pitting edema.
NEURO: Alert and oriented x3. CNII-XII grossly intact, no gross
sensory or motor deficits, gait not assessed.
Pertinent Results:
[**2137-2-16**] 09:19PM CK(CPK)-102
[**2137-2-16**] 09:19PM CK-MB-2
[**2137-2-16**] 07:35PM PT-16.8* PTT-38.5* INR(PT)-1.5*
[**2137-2-16**] 02:53PM URINE HOURS-RANDOM UREA N-618 CREAT-356
SODIUM-53 POTASSIUM-63 CHLORIDE-13
[**2137-2-16**] 10:00AM TSH-0.47
[**2137-2-16**] 10:00AM ALT(SGPT)-30 AST(SGOT)-29 LD(LDH)-283*
CK(CPK)-96 ALK PHOS-88 TOT BILI-0.6
[**2137-2-20**] 08:55AM BLOOD WBC-16.3* RBC-2.69* Hgb-7.7* Hct-23.2*
MCV-86 MCH-28.6 MCHC-33.2 RDW-13.2 Plt Ct-217
[**2137-2-28**] 06:35AM BLOOD WBC-21.0* RBC-2.86* Hgb-8.4* Hct-24.7*
MCV-87 MCH-29.3 MCHC-33.9 RDW-13.9 Plt Ct-173
[**2137-2-28**] 05:45PM BLOOD Glucose-111* UreaN-79* Creat-5.3* Na-134
K-5.2* Cl-101 HCO3-17* AnGap-21*
[**2137-2-28**] 05:45PM BLOOD Calcium-9.3 Phos-7.1* Mg-2.5
Cytology/histopathology:
[**2137-2-16**]: URINE CYTOLOGY: Very atypical urothelial cells, present
singly and in clusters, suspicious for urothelial
dysplasia/neoplasia.
[**2137-2-19**]: Pleural fluid: POSITIVE FOR MALIGNANT CELLS, Consistent
with poorly differentiated carcinoma. The neoplastic cells are
immunoreactive for keratin AE1/AE3; CAM 5.2, CK7, CK20, focally
positive for B72.3, [**Last Name (un) **]-31. They show no immunoreactivity for
calretinin, WT-1, TTF-1, P63, CK5/6, CEA, or CD15. Based on
this immunophenotypic profile, it is difficult to determine the
origin of the tumor.
[**2137-2-19**]: Bladder mass biopsy:
A. Bladder, left lateral dome, deep biopsy:
- Invasive high grade papillary urothelial carcinoma,
extensively invading lamina propria. No definitive muscularis
propria seen. Note: The invasive component is poorly
differentiated, in some areas growing in spindle cells and in
other areas in single pleomorphic cells.
B. Bladder tumor, dome, biopsy:
- High grade papillary urothelial carcinoma, suspicious for
lamina propria invasion. No muscularis propria seen.
Imaging:
--------
[**2137-2-16**]: Lower Ext. Doppler: Non-occlusive thrombosis of the
right distal superficial femoral vein.
[**2137-2-16**]: CT head without contrast: No overt intarcranial
pathology
[**2137-2-17**]: CT Chest w/o contrast:
1. Numerous multifocal pulmonary nodules several of which have a
central
solid component and peripheral ground glass component.
Additional nodules
have a more spiculated contour. Overall, the appearances are
highly
concerning for multifocal metastatic disease.
2. Abnormal soft tissue seen in the mediastinum posterior to the
esophagus
and in the superior paraaortic retroperitoneum consistent with
lymphadenopathy. In addition, there is a large soft tissue mass
in the left
supraclavicular region, likely a metastasis.
3. Bilateral pleural effusions, larger on the right. Possible
solid
components seen bilaterally as described.
4. 3.2-cm likely fat-containing mass at the left base consistent
with a
hamartoma. Stable since [**2132**].
[**2137-2-18**]: ECHO: 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 regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
[**2137-2-20**]: ECHO: BED-SIDE:
Mildly dilated right ventricle with free wall hypokinesis,
severe pulmonary hypertension, and abnormal septal movement
consistent with acute right ventricular pressure overload.
Compared with the prior study (images reviewed) of [**2-18**]/201, the
severity of pulmonary hypertension has increased. Right
ventricle is now mildly dilated and mildly hypokinetic.
[**2137-2-20**]: Upper ext. Doppler: No evidence of left upper extremity
DVT
[**2137-2-25**]: CT Abd/Pelvis:
1. No CT evidence for bladder leak in this somewhat limited
examination
secondary to lack of ability to distend the bladder with
contrast.
2. Extensive retroperitoneal lymphadenopathy concerning for
metastatic
disease.
3. Multiple pulmonary irregular opacities at the lung bases,
incompletely
imaged, concerning for metastatic disease.
4. Evidence for volume overload, including anasarca and
bilateral moderate
pleural effusions.
[**2137-2-26**]: CYSTOGRAM: No evidence of vesicoureteral reflux
[**2137-2-28**]: Duplex/Doppler US Abd?pelvis:
1. Inferior vena cava thrombosis extending at least from the
infrahepatic
inferior vena cava to the level of the IVC filter.
2. Pleural effusion on the right.
Brief Hospital Course:
68 yo M, with recent bladder mass & renal cyst, hypertension,
scrotal bilateral swelling, SOB on exertion and new hemoptysis
presented with swollen painful Rt thigh and was admitted to
[**Hospital1 18**] for further evaluation.
.
# DVT/PE: LENI on admission showed SFV non-occlusive DVT. Given
the patient has bladder cancer, most likely with metastatic
pleural effusion, he was at high risk for hypercoagulation and
DVT. He was started on heparin infusion since his Cr on
admission was 2.8 with baseline of 1.2-1.5 per OSH records from
[**Hospital1 2177**]. Heparin infusion was discontinued prior to thoracocentesis
[**2137-2-18**] by 6 hours and restarted after the procedure by 1 hr.
Also, Heparin was discontinued prior to cystoscopy [**2137-2-19**] by 6
hours and restarted after the procedure by about 12 hr. (total
time held peri-cystoscopy ~ 24 hr). The day following cystoscopy
his renal function deteriorated (Cr up to 5.3) and he
decompensated with hypotension and hypoexemia despite being on
O2. Bedside Echo showed severe pulmonary hypertension, which was
new compared to the Echo he had 2 days prior to this event. He
was transferred to the Medical ICU, where he received total of 3
units of PRBC (had a few episodes of coffee ground vomitus) and
Heparin drip was held. He was transferred back to the medical
floor after he was stabilized during his 2 day stay in the ICU
for 2 days. His renal function gradually improved (Cr down to
~3). IVC filter was fixed without using contrast on [**2137-2-27**] with
the aim to discontinue his heparin infusion, since his urine
wasn't clearing of blood following cystoscopy despite continuous
bladder irrigation. After IVC filter was placed, his kidney
function deteriorated again. Doppler US abd/pelvis on [**2137-2-28**]
showed Inferior vena cava thrombosis extending at least from the
infrahepatic inferior vena cava to the level of the IVC filter.
.
# HYPOXIA: Most likely was due to PE given his DVT and possible
hypercoag state due to bladder cancer.Another conern was that
the Rt pleural effusion that could be causing compression
atelectasis. Thoracocentesis was done on [**2137-2-18**] and 1.2L bloody
effusion was aspirated. Repeat CXR showed increasing small
right-sided pleural effusion. Pt transferred to the MICU on
[**2137-2-20**] for episode of hypotension, hypoxia, and with signs of
RV strain on TTE. Had been off heparin drip for nearly 24 hours
the day before for cystoscopy, which could have allowed PE to
progress or for second PE to occur. He was a poor candidate for
lysis as he had hematuria from bladder mass as well as bloody
pleural effusion. Diagnosis of PE not formally made on CTA
(poor renal function) or V/Q scan (pulmonary nodules). Heparin
drip was empirically restarted but was held due to coffee ground
emesis in the ICU, then restarted and transferred back to
medical floor after he became stable.
.
#TACHYCARDIA: Most likely it was due to PE due to DVT in distal
SFV. Echo done [**2137-2-18**] was WNL. Bedside echo (after the pt's BP
dropped to 70's/50's and sat down to 89-90% on [**2137-2-20**]) showed
new onset severe pulm HTN and new Right ventr. regional
hypokinesia and mild dilatation, suggesting RV strain and
concern of PE. Pt was transferred to the MICU. After returning
to the medical floor, he was still tachycardic.
.
# BLADDER/RENAL lesion: Found to have bladder exophytic polypid
lesion on CT abd/pelvis at [**Hospital6 **] [**2136-12-10**]. CT
urography at [**Hospital1 2177**] [**2136-12-10**] showed retroperitoneal conglumerate LN
(per report: nonspecific - lymphoma,granulomatous, mets). CT
chest w/o contrast showed 1.numerous multifocal pulmonary
nodules 2.Abnormal soft tissue seen in the mediastinum posterior
to the esophagus and in the superior paraaortic retroperitoneum
consistent with lymphadenopathy. 2.large soft tissue mass in the
left supraclavicular region, likely a metastasis. Had cystoscopy
for it [**2137-2-19**]. Bladder mass pathology showed high grade
papillary urothelial carcinoma, invasive and poorly
differentiated. He continued to have bloody urine post
cystoscopy despite continuous bladder irrigation. Cystogram
showed no reflux or bladder leak. IVC filter was fixed in an
attempt to stop heparin infusion, with the aim to remove the
foley. Palliative chemotherapy was limited due to his poor
kidney function. Palliative radiotherapy was not favored by the
patient due to possible irritative bladder and rectal side
effects.
.
# RENAL INSUFFICIENCY: a likely reason could be the motrin he
took for 3 months for his abd. pain. no hydronephrosis or
obstruction was seen on the US. Intra-operatively (cystoscopy
[**2137-2-19**]) retrograde pyelogram was done which didn't reveal [**Last Name (un) **].
He might have had an intra-op hypotension, giving acute renal
injury, possibly ATN. Baseline Cr 1.2-1.5 per OSH records from
[**Hospital1 2177**]. After gradual improvement, his kidney function deteriorated
further after IVC filter was placed though contrast was not
used.
.
# Leukocytosis: Possibly secondary to stress induced
(operation). Pt remained afebrile with no signs of localized
infection.
.
# hypertension: possibly secondary to renal failure. No
antihypertensive meds given while hospitalized due to concern
that tachycardia could be due to compensatory mechanism for a
possible PE.
.
# scrotal bilateral painless swelling: Concern for compression
on IVC from possible malignancy. Scrotal US at [**Hospital1 2177**] (done mid [**Month (only) **]
[**2136**]) showed bilateral hydroceles.
.
# NORMOCYTIC ANEMIA: Hematuria due to bladder cancer, cystoscopy
and biopsy, and was on heparin drip. Also, bloody pleural
aspirate. In addition, he had coffee-ground vomitus in the ICU.
# comfort measures: on [**2137-2-28**], pt and HCP decided for comfort
measures only after having extensive family meeting.
# Mr [**Known lastname 89666**] sadly passed away on [**2137-3-3**].
Medications on Admission:
percocet
antihypertensives
Discharge Disposition:
Expired
Discharge Diagnosis:
Bladder Cancer
Malignant pleural effusion
DVT
PE
Discharge Condition:
Passed away
ICD9 Codes: 486, 5845, 2762, 2851, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5748
}
|
Medical Text: Admission Date: [**2104-11-8**] Discharge Date: [**2104-11-12**]
Date of Birth: [**2053-10-2**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Tracheal foreign body
Major Surgical or Invasive Procedure:
Bronchoscopic removal of airway foreign body, removal of trach
tube: Dr. [**Last Name (STitle) 3373**] [**2104-11-8**]
History of Present Illness:
51F transfer from outside hospital hospital, was cleaning her
trach with a metal rod in brush when it broke off and is lodged
into her trachea. Outside hospital bronchoscopy was performed
showing piece of the metal with a brush attached in her left
mainstem bronchus. Patient doesn't have any shortness of breath
but does have some discomfort when she coughs patient was
transferred to b.i.d. for interventional pulmonology.
In the ED, initial VS were: 98.2 100 104/70 16 100% 6L. IP saw
the patient and rec'd admission. On arrival to the MICU, she is
stable and in NAD.
Past Medical History:
Throat cancer in [**2102**] S/p Tracheostomy
Social History:
- Tobacco: Occasional cigarettes
- Alcohol: None
- Illicits: None
Family History:
NC
Physical Exam:
Physical Exam on Admission:
Vitals: T98.2 HR100 BP104/70 RR16 O2Sat100% 6L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, Tracheostomy is CDI without edema or induration
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally diminished breathsounds
bilaterally
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Grossly intact
Physical Exam on Discharge:
Neck: tracheostomy tube is now removed
Lungs: slight diminished breath sounds in the left lower lung
field, otherwise good air movement bilaterally
Exam otherwise unchanged from admission
Pertinent Results:
Admission Labs:
[**2104-11-8**] 12:00AM WBC-7.1 RBC-3.99* HGB-12.6 HCT-38.0 MCV-95
MCH-31.7 MCHC-33.3 RDW-12.8
[**2104-11-8**] 12:00AM PLT COUNT-245
[**2104-11-8**] 12:00AM GLUCOSE-89 UREA N-7 CREAT-0.6 SODIUM-137
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16
[**2104-11-8**] 12:00AM PT-13.0 PTT-25.5 INR(PT)-1.1
IMAGING:
CT CHEST W/O CONTRAST [**2104-11-7**]
INDICATION: 51-year-old female with foreign body in trachea.
TECHNIQUE: Multidetector helical CT scan targeted to the region
of interest in the trachea was obtained without the
administration of contrast. Coronal and sagittal reformations
were prepared.
COMPARISON: None available.
FINDINGS: There is a linear dense foreign body measuring up to
6.6 cm in
length beginning in the mid trachea and extending inferiorly to
the left
mainstem bronchus. The proximal portion of the foreign body
abuts the right tracheal wall and appears lodged by
approximately 3 mm. Beginning at the left main bronchus, there
is fluid/mucoid material seen with several distended impacted
bronchi throughout the left lower lobe. Additionally, there are
ground-glass opacities of the lung parenchyma which are
nonspecific. A ground-glass opacity of the medial basal segment
of the right lower lobe is also nonspecific. There is a
tracheostomy.
The visualized portions of the heart and great vessels are
unremarkable. No concerning osseous lesion is seen. No
lymphadenopathy identified in the
visualized portions of the mediastinum and axilla. Incidental
note is made of scattered blebs.
IMPRESSION:
6.6-cm linear foreign body from the mid trachea and extending to
the left
mainstem bronchus. The left mainstem bronchus and distal bronchi
appear
distended with fluid/mucoid impaction. Distal ground-glass
opacities within the lung are nonspecific and consistent with
inflammation or possible infection likely postobstructive in
nature.
POST-PROCEDURE CXR [**2104-11-9**]:
The previously seen left-sided radiopaque foreign body is no
longer
visualized. There is volume loss with shift of the mediastinum
to the left
and elevation of the left hemidiaphragm. There is opacification
of the lower lung with obscuration of the cardiac borders,
slightly worse than on [**2104-11-8**]. There is some patchy opacity in
the remaining aerated left upper lung, which is also slightly
worse. The right diaphragm is slightly hyperinflated, with
findings raising question of background COPD, but no acute
right-sided pulmonary process is identified and there is no
right-sided effusion.
IMPRESSION: Interval removal of radio-opaque foreign bodies.
Volume loss on the left, with increased opacity in the left lung
and with slight increase in opacity of the left lung compared
with [**2104-11-8**] at 4:43 a.m. No pneumothorax is detected.
[**11-10**] CXR:FINDINGS: In comparison with the study of [**11-9**], there
is a slight increasein opacification in the left hemithorax,
consistent with increasing effusion.Shift of the mediastinum to
the left is consistent with substantial volume loss in the lower
lobe and lingula. Right lung remains clear.
[**11-11**] CXR: MPRESSION: Improved aeration of left lung with
continued significant volume loss of left lower lobe.
[**11-12**] CXR: IMPRESSION: Worsening left upper lobe opacity
concerning for pneumonia. Left lower lobe collapse and
atelectasis appears stable.
Lab Results on Discharge:
[**2104-11-12**] 06:00AM BLOOD WBC-5.5 RBC-3.45* Hgb-10.6* Hct-31.7*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.6 Plt Ct-301
Brief Hospital Course:
Primary Reason for Hospitalization:
51 [**Last Name (un) 9232**] with tracheostomy [**2-20**] throat cancer who presented to
[**Hospital1 18**] for removal of part
of a brush that broke off during cleaning of her tracheostomy
tube. The foreign body was removed, and the collapsed lung
beyond the lodged object re-expanded.
Acute Care:
1. Tracheal Foreign body: Patient was evaluated by
interventional pulmonology service, and bronchoscopy was
performed on [**2104-11-8**] to remove the foreign body. She tolerated
the procedure well without complications. During bronchoscopy
the tracheostomy site appeared narrowed indicating good upper
airway ventilation, and when the tube was covered she maintained
O2 saturation. Since she did not appear to require the trach
tube to maintain adequate ventilation, the tube was removed.
Following the procedure she was maintained on oxygen via nasal
canula which was slowly weaned as the lung distal to the site of
the foreign body impaction re-expanded. She had no fever and no
leukocytosis and showed no sign of post-obstructive pneumonia,
and was discharged home to f/u with PCP. [**Name10 (NameIs) 3754**] was an area of
haziness on CXR on final day of hospitalization but patient
showed no leukocytosis or fever, so she was left to follow-up
with PCP.
Chronic Care:
1. S/p chemo/radiation for tongue/laryngeal cancer: Speech and
swallow evaluated patient and found no swallowing deficits. She
was maintained on a puree diet per her request for comfort given
that she is edentulous and does not chew food. PT deemed her
appropriate for home discharge.
Transitions in Care:
Patient was scheduled for a follow-up appointment with her PCP,
[**Name10 (NameIs) **] with her outpatient radiation oncologist.
Medications on Admission:
Multivitamin
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary: foreign body in airway
.
Secondary: History of laryngeal cancer with tracheostomy tube
placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 71673**],
.
It was a pleasure taking part in your care. You were admitted to
the hospital because part of the brush you were using to clean
your tracheostomy tube broke off and became lodged in your
airway. In the hospital we removed the brush and saw
inflammation and that your lung had collapsed beyond where the
brush was lodged. Once the brush was removed your lung opened up
again and you no longer needed oxygen. We discharged you home
with no tracheostomy tube and plans to allow the stoma to heal.
.
Please do not make any changes to your medications and please
keep your follow-up appointment with your primary care
physician.
Followup Instructions:
Name: [**Last Name (LF) **],[**Name6 (MD) 3049**] CHALICE MD
Location: DEPT OF RADIATION ONCOLOGY
Address: [**Hospital3 **], [**Hospital1 **],[**Numeric Identifier 53049**]
Phone: [**Telephone/Fax (1) 87329**]
Appointment: Wednesday [**2104-11-19**] 1:00pm
*Appointment is downstairs.
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: FAMILY MEDICAL ASSOC
Address: [**Location (un) 24577**] [**Apartment Address(1) 91469**], [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 40489**]
**We were unable to schedule your follow up appointment with
your PCP. [**Name10 (NameIs) 357**] contact the office at the number above to
schedule and appointment. It is recommended you see your PCP
[**Name Initial (PRE) 176**] 1 week from your discharge**
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5180, 2859, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5749
}
|
Medical Text: Admission Date: [**2119-1-3**] Discharge Date: [**2119-1-7**]
Date of Birth: [**2043-2-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Heparin Agents
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75yo woman with history of DM2, HTN, CAD s/p CABG, diastolic
CHF with EF of 60-65%, and past GI bleeding with AVMs
on EGD and colonoscopy now presents with melena. On day of
admission, she had presented to the [**Hospital1 18**] day care unit where
she was to have teh patency of her AV fistula evaluated. There,
it was noted that her Hct was down to 21. She was referred to
the ED. In the ED,
she had a dark bowel movement that was guaiac positive. Initial
vitals in the ED were 99.4, 81, 133/44, 28, and 95% on 2L NC; FS
166.
There, she felt well with no complaints of chest pain, shortness
of breath, abdominal pain, lightheadedness or any other
complaints.
In Emergency department, a right IJ triple lumen catheter was
placed given difficult peripheral access, she was given
albuterol/atrovent nebs x 1, protonix 40mg IV x 1, and one unit
PRBC. She refused an NG lavage. She remained hemodynamically
stable throughout. On review, she does report that she has had
dark stools and mild diffuse abdominal pain for the past two
days. She had no hematemesis or BRBPR.
.
In ED, she was seen by Nephrology, who recommended starting
Epogen at 10,000 units MWF, continuing lasix at 80mg daily,
transfusing only 2units PRBC given risk for volume overload, and
to perform a fistulogram when she is stable. They noted that
there is no need for urgent hemodialysis. She was also seen by
Gastroenterology, who recommended (in light of her refusal of NG
lavage and Endoscopy) serial q4h hematocrits, holding ASA,
protonix [**Hospital1 **]. Will follow.
Past Medical History:
1. CRI [**3-2**] HTN and DM nephropathy, with baseline creatinine ~4.3
2. h/o GI bleeding:
.
- [**11-2**] EGD:
Angioectasias in the stomach body
Erythema and friability in the stomach compatible with gastritis
Angioectasia in the distal duodenum and/or proximal jejunum
Otherwise normal egd to jejunum
.
- [**11-2**] colonoscopy:
Erythema in the whole colon
There was no evidence of blood in colon. There were no AVMs but
visualization was somewhat limited by stool.
( does have h/o cecal AVM's).
3. Throbocytopenia (HIT)- in [**2116**], plts dropped from 130-160 to
80-90
4. MRSA endocardiitis ([**12-31**])
5. Coronary artery disease; status post coronary artery
bypass graft times two and status post myocardial infarction
in [**2103**] and [**2113**].
6. CHF EF 60-65% (diastolic)
7. DM2 on insulin
8. HTN, hyperlipidemia
9. Paroxysmal atrial fibrillation (no anticoagulation)
10. PUD, Barrett's esoph
11. Asthma
12. Hypothyroidism
13. Osteoarthritis
14. s/p CCY
15. Anemia with baseline ~27, thought related to GIB and CRI
Social History:
Primarily Spanish speaking, wheelchair bound and lives alone but
cared for entirely by her daughter. She denies EtOH, tobacco,
and drugs. Patient has 8 children, 40 grandchildren and one
great-grandaughter.
Family History:
CAD and DM
Physical Exam:
vitals: 97.5, 74, 130/43, 20, 99% on 2L nc
.
gen: alert, oriented, no acute distress
heent: sclera anicteric, oropharynx clear
neck: supple, full range of motion; left IJ in place
cv: RRR, no m/r/g
resp: good air movement; diffuse end-expiratory wheezing
bilaterally
abd: soft, obese, normoactive bowel sounds. Non-tender. No HSM.
extr: 1+ symmetric lower extremity edema; 1+ pedal pulses
bilaterally
neuro: non-focal
Pertinent Results:
Chest film (ap): cardiomegaly with vascular redistribution. Left
IJ with tip in likely brachiocephalic vein.
[**2119-1-3**] 09:00AM WBC-6.6 RBC-2.24*# HGB-7.2*# HCT-21.7*#
MCV-97 MCH-32.0 MCHC-33.1 RDW-18.3*
[**2119-1-3**] 09:00AM NEUTS-73.2* LYMPHS-18.0 MONOS-7.1 EOS-1.6
BASOS-0.2
[**2119-1-3**] 03:45PM GLUCOSE-169* UREA N-57* CREAT-3.9* SODIUM-137
POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16
[**2119-1-3**] 03:45PM ALBUMIN-2.7* CALCIUM-8.1* PHOSPHATE-3.1
MAGNESIUM-1.8
Brief Hospital Course:
75yo woman with recurrent GI bleeding secondary to AVM who
presented with melena and Hct drop from baseline of 30's to 21.
She was hemodynamically stable on arrival. GI was consulted,
but the patient refused NG lavage, as well as endoscopy. She
was admitted to the MICU where she was monitored with Q4 hour
Hct. She was transfused a total of 2units PRBC's. Her Hct
trended from 21.7 --> 28.2 after transfusion, and stabilized in
the mid-high 20's. Her coagulopathy was corrected and she
received DDAVP. She was also started on Procrit. Hematology
was consulted and recommended continued following of Hct, and
also suggested possible thalidomide or estrogen for treatment of
chronic AVM bleeding. The medicine team was reluctant to start
estrogen given her high risk of clot formation (HIT, obesity,
etc.). Eventually, she was given another 2 units PRBC's to
bring her Hct above 30. Dialysis was not intitiated on this
admission. The patient will follow up with renal as an
outpatient for initiation of dialysis. She will also follow up
with GI as an outpatient for monitoring of her chronic GI
bleeding, and for the possibilty of thalidomide therapy vs.
estrogen.
.
Medications on Admission:
1. Levothyroxine 175 mcg
2. Atorvastatin 40 mg
3. toprol xl 25mg
4. Fluticasone 110 mcg 2 puffs [**Hospital1 **]
5. Ipratropium Bromide 18 mcg 2 puffs QID
6. Pantoprazole 40 mg
7. Furosemide 80 mg daily
8. Insulin Regular
9. Aspirin 81 mg
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 14 days.
Discharge Medications:
1. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday): To be set up by
your nephrologist.
Disp:*3 inj* Refills:*2*
6. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
Disp:*1 unit* Refills:*2*
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. 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*
9. Hectorol 0.5 mcg Capsule Sig: Two (2) Capsule PO once a day.
Disp:*60 Capsule(s)* Refills:*2*
10. Thalidomide 100 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
11. Outpatient Lab Work
Please check CBC and Chem 7 on Monday [**2119-1-9**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1) Gastrointestinal bleeding
2) Coagulopathy
3) End Stage Renal Disease
4) Thrombocytopenia
5) Diabetes
Discharge Condition:
Stable, improved from the time of admission
Discharge Instructions:
Please return to the ER or call your doctor if you experience
further bleeding per rectum, black stool, chest pain, difficulty
breathing, or dizziness. You should take all medications as
prescribed.
Please come back if you present any new skin abnormality or
anything you notethat is different from usual.
Followup Instructions:
1) Please call your primary care doctor (Dr. [**Last Name (STitle) 20670**] for a
follow up appointment within one week following discharge.
.
2) Please call Dr. [**Last Name (STitle) 1860**] (Nephrology) for a follow up appointment
at ([**Telephone/Fax (1) 773**].
.
3) Please call [**Hospital **] clinic to make a follow up appointment with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 2427**] after discharge at ([**Telephone/Fax (1) 33689**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 4280, 5856, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5750
}
|
Medical Text: Admission Date: [**2123-4-4**] Discharge Date: [**2123-4-22**]
Date of Birth: [**2054-12-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hurricaine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Severe tricuspid regurgitation.
Major Surgical or Invasive Procedure:
[**2123-4-6**]: Removal of right ventricular dual coil
pace-sense-defibrillator lead, right atrial pacing lead, right
ventricular pacing lead, right atrial pacing lead.
[**2123-4-16**]: Redo Redo sternotomy 29 mm [**Company 1543**] Mosaic Porcine
Tricuspid Valve Replacement, Epicardial Lead Placement + PPM +
AICD placement
History of Present Illness:
Mr. [**Known lastname 80287**] is a 68 year-old male with complex cardiac history
yearly exam with his PCP who ordered an echocardiogram which
showed increased tricuspid regurgitation with possible
constrictive physiology. He's had a 5 pound weight gain over
the past 5 days but denies DOE, orthopnea, Occasional PND,
increased
abdominal girth with mild nausea and decreased appetite.
Cardiac surgery was consulted for evaluation and recommendations
for possible constricture pericarditis physiology and increased
TR.
Past Medical History:
Past Cardiac History
Atrial tachycardia [**2117**]
Tricuspid vegetation 0,03,05
CHB s/p DDD [**Company **] [**2114**]
Past Medical History
Diabetes Mellitus Type 2
Hypertension/Hyperlipidemia
COPD
Asthma exercise induced
GERD
Mild Carotid stenosis [**2120**]
Peripheral Vascular disease
Past Surgical History
Cardiac Surgery:
[**2121**]: atrial flutter ablation
[**2121-1-20**]: placement of 2 LV Epicardial pacing wires via Left
anterior thoracotomy. Evacuation of hematoma.
[**2121**]: ICD [**Name8 (MD) 1543**] CRT ICD left pectoral region with removal of
right sided DDM
[**2118**]: Left atrial papillary elastofibroma resection
[**2114**]: s/p device explanted and re-implant, infection [**2-3**] trauma
[**2106**]: s/p mechanical AVR ([**Company **] [**Doctor Last Name **])/Ao root prosthesis c/b
CHB
PFO, moderate atrial septal aneurysm s/p closure
Left Rotator cuff surgery
Tonsillectomy
Back surgery (disc herniation)
Social History:
Race: Caucasian
Last Dental Exam: several teeth removed 2 mos ago h/o gingivitis
Lives with:wife
Occupation: retired construction
Tobacco:35 pack year, quit [**2102**]
ETOH: none for over 1 year.
Family History:
Brother died age 29 DM & heart failure. Mother CA
Physical Exam:
Pulse: 72-73 SR Resp: 16 O2 sat: 97% RA
B/P Right: 128/82 Left:
Height:5;11 Weight: 99.6 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur Good Click
Abdomen: Soft [x] distended [] non-tender [x] bowel sounds + []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
[x]
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit radiating AVR Right: 2+ Left: 2+
Pertinent Results:
[**2123-4-21**] 04:40AM BLOOD WBC-9.8 RBC-3.00* Hgb-9.3* Hct-27.0*
MCV-90 MCH-30.9 MCHC-34.3 RDW-16.1* Plt Ct-180
[**2123-4-20**] 04:35AM BLOOD WBC-8.6 RBC-2.92* Hgb-8.8* Hct-25.9*
MCV-89 MCH-30.1 MCHC-34.0 RDW-16.7* Plt Ct-157
[**2123-4-21**] 04:40AM BLOOD PT-15.0* INR(PT)-1.3*
[**2123-4-18**] 01:35AM BLOOD PT-15.6* PTT-27.9 INR(PT)-1.4*
[**2123-4-21**] 04:40AM BLOOD Glucose-49* UreaN-42* Creat-1.4* Na-135
K-4.1 Cl-96 HCO3-28 AnGap-15
[**2123-4-20**] 04:35AM BLOOD Glucose-110* UreaN-40* Creat-1.5* Na-136
K-3.7 Cl-97 HCO3-29 AnGap-14
[**2123-4-21**]
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is dilated with mild global free wall hypokinesis. There
is abnormal septal motion/position. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. 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
bioprosthetic tricuspid valve is present. The tricuspid
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients. There is no pericardial effusion.
IMPRESSION: Normally functioning tricuspid valve replacement.
Dilated and hypokinetic right ventricle. There is abnormal
septal motion present, likely due to a combination of conduction
abnormality and pressure/volume overload. Normally functioning
aortic prosthesis, normal regional and global left ventricular
systolic function.
Compared with the prior study (images reviewed) of [**2123-4-9**], a
tricuspid valve prosthesis is now present. No tricuspid
regurgitation is seen. Pulmonary artery pressures cannot be
measured. The right ventricle is probably slightly smaller and
is hypokinetic on the current study. Dysfunction of the right
ventricle may have been masked by the degree of tricuspid
regurgitation on prior.
Brief Hospital Course:
Mr. [**Known lastname 80287**] was admitted on [**2123-4-4**] for a heparin bridge before
extraction of his RV lead and tricuspid valve replacement. His
lead was extracted and a new generator was implanted on [**2123-4-6**].
A perctoral hematoma formed which resolved with evaculation and
a pressure dressing. On [**2123-4-16**] he underwent a redo, redo
sternotomy, TV replacement (29mm porcine), epicardial lead
placement and PPM/AICD placement with Dr. [**Last Name (STitle) **]. Please see
the operative note for details. He tolerated this procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. He was extubated by the following
day. His pacer was interrogated and his epicardial wires were
removed. He was transferred to the surgical step down floor and
started on coumadin. By post-operative day six he was ready for
discharge to home with coumadin follow-up. All appointments
were advised.
Medications on Admission:
Dofetilide 250 mcg every 12 hours
Losartan 25 mg daily
Metoprolol 50 mg [**Hospital1 **]
ASA 81 mg daily
Spironolactone 25 mg daily
Furosemide 20 mg daily
Simvastatin 40 mg daily
Coumadin 5 mg M/W/F/7.5 mg Tu/[**Last Name (un) **]/Sat/Sun
Glyburide 10 mg [**Hospital1 **]
Metformin 1000 mg [**Hospital1 **]
Januvia 100 mg daily
Omeprazole 40 mg [**Hospital1 **]
Ranitidine 150 mg daily
Docusate 100 mg [**Hospital1 **]
Acetminophen prn
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-3**] inhalations Inhalation Q4H (every 4 hours)
as needed for sob, wheezing.
6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
10. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. potassium chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily) for 14 days: take 20meq for 14 days, then
discontinue.
Disp:*14 Packet(s)* Refills:*2*
13. glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
16. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
17. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 14
days: take 40mg daily for 14 days, then decrease to 20mg daily
ongoing.
Disp:*28 Tablet(s)* Refills:*2*
18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal [**2-4**] for afib. First INR to be drawn on [**4-23**] with results to
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**] Phone: [**Telephone/Fax (1) 11254**]
.
Disp:*30 Tablet(s)* Refills:*2*
19. Outpatient Lab Work
INR goal [**2-4**] for afib. First INR to be drawn on [**4-23**] with
results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**] Phone: [**Telephone/Fax (1) 11254**]
20. Outpatient Lab Work
BUN/Creatinine/Potassium check one week from discharge
Discharge Disposition:
Home With Service
Facility:
community health and hospice
Discharge Diagnosis:
1. Severe tricuspid regurgitation.
2. Status post biventricular implantable cardioverter
defibrillator [**2121**].
3. Status post unused previously implanted right atrial and
right
ventricular pacing leads [**2114**].
4. Status post aortic valve replacement
5. Congestive heart failure.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
1+ LE Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check [**4-28**] at 10:30
Surgeon: Dr [**Last Name (STitle) **] on [**5-13**] at 1:15 PM
ICD check 1 week with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 11250**], please call to
arrange
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] ([**Telephone/Fax (1) 59543**] at [**5-27**] at 11:45 AM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2123-4-23**]
Results to phone Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 11250**] [**Telephone/Fax (1) 11254**]
Completed by:[**2123-4-22**]
ICD9 Codes: 4254, 4280, 4439, 4168
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5751
}
|
Medical Text: Admission Date: [**2119-2-3**] Discharge Date: [**2119-2-8**]
Date of Birth: [**2085-10-21**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
dysphagia, vague chest discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
33 yo female with h/o DM2 diagnosed 2 yrs ago who presented to
the ED [**2118-2-3**] with chest discomfort for 1 week. She was
initially worked up for PE or intrathoracic problem, but was
found to have abnormal labs suspicious for DKA. She is followed
at [**Last Name (un) **] but has not been seen for a long time. Notes that
lateley her blood glucose has been poorly controlled with sugars
in the 200-400s over the past 2 months. She also has had 65 lb
weight loss since this summer with polydipsia and polyuria. For
the past two days she has felt more fatigued and short of
breath. Three days ago she ran out of her Metformin and did not
get it filled. She otherwise denies fevers, chills, nausea,
diarrhea, upper URI symptoms, cough, dysuria, flank pain, recent
steroid use or other new medications, night sweats. She has had
slightly decreased PO intake from her recent dysphagia and feels
dehydrated.
.
As for the chest discomfort, the pt describes a vague discomfort
that becomes painful with swallowing both liquids and solids.
She endorses palpitations, weakness, nausea x 2 days, and left
sided abdominal discomfort. No radiation of the pain. No similar
sx in the past and no hx of GERD. Denies regurgitation of the
food, but feels like it gets "stuck." She admitted to increased
stress and feeling overwhelmed and has seen someone in psych
recently for this in the ED, but denied this during my
interview.
.
In th ED, the patient was noted to be tachycardic to 104, other
vital signs were: BP 155/100 RR 20, 100% RA, temp 97.9. The
patient initially was complaining of dysphagia (although she was
still able to tolerate PO water) and had a d-dimer and CXR to
r/o PE, which were both negative. Trop was also negative. EKG
showed NSR. Chem 7 revealed glucose 513, sodium 131, and bicarb
7 (anion gap = 30), K 5.2, but hemolyzed. Hct was elevated at
48.6. UA pos for ketones. The patient was given 500 cc bolus of
NS and ordered for 2 more L. She was started on insulin gtt at
5U/hr after being boluesed 10 units. She was changed to D5 [**1-22**]
NS prior to arrival. VS at time of transfer were: HR 109 SBP 144
RR 20 100% RA.
Past Medical History:
Diabetes - c/b nephropathy. Followed at [**Last Name (un) **]
Pylonephritis [**1-/2116**] (Admission to [**Hospital1 18**])
B12 defficiency
abnormal pap -has been missing appointments for colposcopy
hypothyroid
Social History:
Ms. [**Known lastname 103512**] is divorced, mother of 2, works in administration
at [**Hospital **] clinic, recently started school to be a medical
assistant. Smokes [**1-22**] cig a day, drinks 2-3 glasses etoh a week,
denies other drug use
Family History:
glaucoma - grandmother
Physical Exam:
VS: Temp: BP: 132/79 HR: 100 RR:20 100% O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, Thyroid
feels slightly full
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses
EXT: no c/c/e, thin legs
SKIN: xeroderma, hyperpigmented macules on dorsum of hands. no
jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
Admssion labs:
[**2119-2-3**] 08:40PM BLOOD WBC-11.5*# RBC-4.76 Hgb-15.5 Hct-48.6*
MCV-102* MCH-32.6* MCHC-31.9 RDW-14.6 Plt Ct-311
[**2119-2-3**] 08:40PM BLOOD Neuts-77* Bands-2 Lymphs-15* Monos-4
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2119-2-3**] 08:40PM BLOOD Glucose-513* UreaN-4* Creat-1.1 Na-131*
K-5.2* Cl-94* HCO3-7* AnGap-35*
[**2119-2-4**] 12:40AM BLOOD Calcium-8.4 Phos-1.4*# Mg-1.7
.
Other labs:
[**2119-2-4**] 04:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2119-2-4**] 07:32AM BLOOD Cortsol-12.9
[**2119-2-4**] 07:32AM BLOOD TSH-4.4*
[**2119-2-3**] 08:40PM BLOOD Osmolal-317*
[**2119-2-4**] 12:40AM BLOOD Acetone-LARGE
[**2119-2-4**] 06:31AM BLOOD Triglyc-156* HDL-21 CHOL/HD-9.9
LDLcalc-156*
[**2119-2-3**] 08:40PM BLOOD D-Dimer-394
[**2119-2-4**] 07:32AM BLOOD VitB12-492 Folate-7.7
[**2119-2-3**] 08:40PM BLOOD cTropnT-<0.01
[**2119-2-4**] 06:31AM BLOOD cTropnT-<0.01
[**2119-2-4**] 06:31AM BLOOD ALT-7 AST-10 LD(LDH)-137 AlkPhos-57
TotBili-0.3
[**2119-2-4**] 03:59AM BLOOD Ret Man-.8
.
.
Urine:
[**2119-2-3**] 06:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.031
[**2119-2-3**] 06:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2119-2-3**] 06:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2119-2-3**] 06:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2119-2-4**] 03:02AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.018
[**2119-2-4**] 03:02AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose->1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-NEG
[**2119-2-4**] 03:02AM URINE RBC-3* WBC-9* Bacteri-NONE Yeast-NONE
Epi-2
[**2119-2-4**] 03:02AM URINE CastHy-2*
[**2119-2-4**] 03:02AM URINE Mucous-RARE
.
.
Microbiology:
[**2119-2-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2119-2-4**] URINE URINE CULTURE-FINAL
[**2119-2-4**] MRSA SCREEN MRSA SCREEN-PENDING
.
.
Radiology:
XR CHEST (PA & LAT) Study Date of [**2119-2-3**] 7:37 PM
FINDINGS: The cardiomediastinal and hilar contours appear
normal. The lungs
are clear. There is no pleural effusion or pneumothorax. The
osseous
structures are intact. The retrotracheal is not well demarcated
on the
lateral view, most likely due to patient position and overlying
scapulae and
soft tissues. No mass effect seen on the trachea.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
33 YOF with type II diabetes who presented to the ED with
dysphagia and was found to be in diabetic ketoacidosis. She was
transferred to the ICU for further management of the DKA and
transferred to the [**Hospital1 **] on [**2-5**].
.
.
# DKA: She is followed at [**Last Name (un) **] for what was thought to be
T2DM but had not been seen for a long time. The diagnosis of DKA
was made on routine labs during work-up for her chest pain. She
noted recent poor glycemic control with sugars in the 200-400s
over the past 2 months. She also noted 65 lb weight loss since
this summer with polydipsia and polyuria. She noted a 2 day hx
of fatigue and SOB and ran out of metformin 3 days prior to
admissioan dn did not get this refilled. Three days ago she ran
out of her Metformin and did not get it filled. She denied any
localising sx for infection by had slightly decreased PO intake
from her recent dysphagia and felt dehydrated. There was
evidence of rare bacteria on UA and no dysuria, CXR was clear.
The precipitant was felt to be likely medication noncompliance.
Labs on admission revealed Glc 513 Cl 94 HCO3 7 An Gap 35 and UA
pos for ketones. The patient was given 2.5L in the ED and
started on insulin IV infusion and transferred to the ICU on
[**2-3**]. She was managed on the ICU and received aggressive fluid
hydration receiving 6L whilst in the ICU. Potassiuma nd
Magnesium were repleted. We held antibiotics and pan-cultured,
urine and blood cultures were negtative at the time of writing.
She was initialy continued on an IV insulin sliding scale and
eventually by the evwning of [**2-4**] she was transitioned to a s/c
insulin scale and PO Lantus 25mg. She was reviewed by [**Last Name (un) **] who
recommended stopping metformin until stabilized, and hey felt
that given her presentation that her case was more in keeping
with T1DM. They further advised tranitioning to lantus when
taking. Her diet was slowly advanced and by [**2-5**] she was able to
take po and had eaten breakfast without issue. he wsa
transferred from the ICU to teh floor on [**2-5**] by which point her
anion gap had normalised to 15, her HCO3 was 15 and her Glc were
better controlled in the 200s. Ultimately pt will need better
outpatient management of her diabtes with better monitoring and
medication compliance.
- she was discharged on glargine 35units qHS in addition to HISS
.
# Pseudohyponatremia: Admission Na at 131 corrected to Na 140
when blood glucose in the 500s was take into account.
.
# Metabolic acidosis: Likely from ketoacids. + ketones in urine.
There was no clinical suspicion for sepsis, althouh WBC elevated
with 2% bands so was monitored closely for evolving infection
and bandemia spontaneously resolved. Cultures are negative at
time of writing.
.
# Dysphagia: Etiology could include eophagitis, esophageal
spasm, GERD, or mechanical stricture. Diabetic gastroparesis
unlikely to cause pain, more likely to cause discomfort. EKG no
ischemic changes with two negative troponins. Ddimer also
effectively r/o PE. No abnormalities were seen on CXR. We
started omeprazole and this was continued. Pt will need
outpatient work up for this, possibly including upper GI
endoscopy.
.
# Macrocytic anemia: B12 and folate were wnl and TSH was mildly
elevated at 4.4 but in the setting of acute illness. TSH should
be repeated as an o/p and this should be followed in the
community.
.
# HL: Pt volunteered that she was noncompliant with statin. Last
lipid panel in [**2113**] and repeat showed Chol 208 TGCs 156 HLD 21
LDL 156. Her statin was restarted and she was educated about
cardiovascular risk factors.
.
# ? hyperparathyroid: Seen in old record but pt was unaware of
diagnosis. Serum calcium was not elevated during this admission.
Repeat PTH was normal.
Medications on Admission:
metformin 500 mg [**Hospital1 **] (previously on humalog but not now)
.
prescribed but not taking: simvastatin 10 mg QHS
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Hospital1 **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Glucagon Emergency 1 mg Kit Sig: One (1) MG Injection as
needed: inject into muscle/fat if blood sugar critically low
with symptoms and unable to eat. [**Name6 (MD) 138**] your MD.
[**Last Name (Titles) **]:*1 syringes* Refills:*2*
4. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous at bedtime.
[**Last Name (Titles) **]:*1 vial* Refills:*2*
5. Humalog 100 unit/mL Solution Sig: 1-30 units Subcutaneous
qAC: according to sliding scale with meals.
[**Last Name (Titles) **]:*7 vials* Refills:*2*
6. insulin syringe-needle,dispos. 0.5 mL 29 x [**1-22**] Syringe Sig:
One (1) use Miscellaneous four times a day: with insulin.
[**Month/Day (2) **]:*1 month supply* Refills:*2*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day.
[**Month/Day (2) **]:*1 box* Refills:*2*
8. Lancets,Thin Misc Sig: One (1) lancet Miscellaneous four
times a day.
[**Month/Day (2) **]:*1 box* Refills:*2*
9. Ketostix Strip Sig: One (1) strip Miscellaneous as
needed: for blood sugar >250. call [**Last Name (un) 387**] if positive.
[**Last Name (un) **]:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Type 1 diabetes mellitus, uncontrolled
Dysphagia
Weight loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with chest pain and found to have high blood
sugars and diabetic ketoacidosis. With IV fluids and insulin
your symptoms resolved. You likely have "Type 1 diabetes"
meaning you MUST take insulin at all times to prevent this from
happening. Please check your blood sugar and use the insulin
doses recommended every day as directed. Please follow the
instructions provided by the [**Last Name (un) **] doctors regarding the use of
glucagon and high blood sugars.
Please follow up with your PCP and [**Name9 (PRE) **] doctor as soon as
scheduled
Followup Instructions:
Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**] (works with [**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **])
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appt: [**2-15**] at 3pm
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: WEDNESDAY [**2119-2-15**] at 6:00 PM
With: [**First Name11 (Name Pattern1) 2801**] [**Last Name (NamePattern4) 14773**], NP [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
ICD9 Codes: 2761, 2449, 2724, 2768
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5752
}
|
Medical Text: Admission Date: [**2123-8-27**] Discharge Date: [**2123-8-28**]
Date of Birth: [**2038-2-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Ativan
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 85y F NH resident who got OOB and fell this AM at her NH.
Apparently no LOC. Transferred to [**Hospital3 2783**], where
C-spine was cleared, but NCHCT reveaaled a non-displaced
parasaggital occipital fracture -- extending from roughly the
level of the torcula down through the foramen magnum -- as well
as a small SDH by report. She also had a UTI on UA
(asymptomatic)
and a Foley cath was placed. She was transferred here, and
arrived AOx3, HDS, and at her baseline mental status per the
family. After a dilantin load in our ED she became somewhat
delerious for my exam. Repeat HCT here showed stable findings
from OSH and exam was non-focal in the ED.
Past Medical History:
-RA -- on MTX
-Hypothyroidism -- on Levoxyl
-afib (NOT on A/C x 2y due to high fall risk; previously on
warfarin; INR at OSH was 1.0)
-HTN -- on BB, thiazide
-h/o MI (unknown details) on ASA
-h/o TIAs / old strokes on imaging (Sx unknown) on ASA
-dementia, thought to be vascular dementia per family
-h/o UTIs (last 2y ago)
Social History:
Social Hx:
Resides at Woodbriar NH ([**Location 9583**] nursing unit) in
[**Location (un) 4444**], MA -- phone [**Telephone/Fax (1) 87586**] (I attempted to call them
yesterday w.r.t. dispo planning, during the four o'clock hour
Friday [**8-27**], but could not get ahold of anyone on her unit.
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
T: 98.8F BP: 103/60 HR: 76 RR: 16 96%RA
Gen: WD/WN, comfortable, NAD. confused/delerious, but somewhat
redirectable.
HEENT: Periorbital ecchymosis R>>L.
Pupils: Left 2mm, post-surgical appearance, NR. Right 2mm
minimally reactive. Tracks.
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, oriented to person. Attention
severely impaired. Uncooperative with exam, normal affect.
Speech: dysarthric, tangential, limited.
Cranial Nerves:
I: Not tested
II: Pupils: Left 2mm, post-surgical appearance, NR.
III, IV, VI: Conjugate eye movements, tracks.
V, VII: Symmetric.
VIII: Hearing intact to loud voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Pt. not cooperating.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Pt poorly cooperative with exam (poor effort / rapidly
distracted), but no overt pattern of weakness is apparent.
Cannot
test drift.
Sensation: Grossly intact and subjectively equal to light touch
distally UE/LE.
Toes mutebilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Upon discharge:
awake alert, oriented to self, "hospital
"[**2109**]"
moves all 4, no deficit, follows simple commands
Pertinent Results:
UA [**6-24**] WBC, 0-2 RBC. +LE, +nitr, many bacteria
UCx pending
INR 1.0
WBC 12.8 / 93%Neutrophils
[**2123-8-27**]
head CT:
1. Stable appearance of multifocal subarachnoid hematomas over
the right and
left frontal cortices, and the right cerebellum, with a subdural
component
over the left frontal cortex. No new intracranial hemorrhage. No
herniation.
2. Stable occipital bone fracture extending to the foramen
magnum.
3. Stable right sphenoid air cell fluid, with otherwise clear
paranasal
sinuses.
Brief Hospital Course:
Pt was admitted to the hospital and monitored closely in ICU.
She remained at her neurologic baseline. Repeat Head CT and
neurologic examination revealed no interval progression of SDH
and stable examination. She was cleared for discharge back to
her nursing home, planned agreed to by family.
Medications on Admission:
ASA 325mg daily
metoprolol 25mg [**Hospital1 **]
HCTZ 12.5mg daily
Levoxyl 50mcg q9pm
Celexa 10mg daily
Senekot 2tb q9pm
Colace 200mg daily
Calcium 500mg [**Hospital1 **]
Folic acid 1gm daily
acetaminophen 1300mg qhs for RA pain
Methotrexate 2.5mg Sun q10am, q9pm; Mon q10am
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for anxiety.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)) as needed for hypothyroidism.
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for chronic constipation.
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed for chronic constipation.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for HTN, afib.
10. Acetaminophen 325 mg Tablet Sig: Four (4) Tablet PO QHS
(once a day (at bedtime)) as needed for rheumatic pain.
11. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig:
One (1) Tablets, Dose Pack PO SUN-10AM, SUN-9PM, MON-10AM ().
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 87587**] of [**Location (un) **]
Discharge Diagnosis:
traumatic head injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Take your 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.
?????? You were on Aspirin prior to your injury, you may safely
resume taking this in one week.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 4weeks, you will need Head CT
prior to appt. Please call [**Telephone/Fax (1) 1669**] to schedule.
Completed by:[**2123-8-28**]
ICD9 Codes: 5990, 2449, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5753
}
|
Medical Text: Admission Date: [**2167-11-5**] Discharge Date: [**2167-11-9**]
Date of Birth: [**2087-3-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
urosepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 Russian female with h/o CAD, AF s/p PPM, HTN, CHF (EF
45-50%), CRI (Cr 1.5), lung CA s/p resection in [**2153**], chronic
pain who presents to the ED with complaints of progressive LE
pain and weakness over the past several days to weeks. She also
c/o incresing DOE at home, now limited to [**1-30**] steps. She has
been sleeping in a recliner recently with her husband helping
her with most ADLs.
.
She also complained difficulty urinating recently, as well as
some constipation. The constipation is not new, and it can be 4
days between bowel movements. The urinary difficulties include
both getting to the bathroom in time (due to pain and DOE), as
well as the sensation that she does not completely void. She has
no dysuria. The swelling in her legs is associated with mild
increase in pain and redness, as well as itching. Her back pain
has been worse.
.
She was recently admitted to [**Hospital1 18**] cardiology service and d/c on
[**2167-10-12**]. She was dx with CHF and her medication regimen was
adjusted.
.
Cardiac ROS: She describes intermittent chest pain with
activity, marked DOE with minimal activity, positive orthopnea
and PND, and has a h/o claudication, though pain is different
now. She would intermittently hold her BP meds (ie metoprolol)
b/c "my blood pressure was too low" - she was getting systolic
BPs in the 70's over the past few weeks.
.
ED COURSE: In ER, she was found to be hypotensive to 70s/40s,
have a positive UA, lactate 2.1, acute renal failure. She was
started on levophed, gentle IVF given CHF, and levo/flagyl.
.
ROS: No HA, visual changes, hearing changes, trouble speaking,
swallowing, numbness/weakness elsewhere, vertigo. No head, neck
or back trauma recently. No F/C/NS, no cough, no sick contacts.
[**Name (NI) **] diarrhea or dysuria.
Past Medical History:
# Atrial fibrillation s/p pacemaker placement [**2167-6-25**], nodal
ablation [**2167-7-1**].
# Hypertension
# Coronary artery disease: status post bypass grafting [**2153**] (Dr.
[**Doctor Last Name **]). Cath [**2154-6-14**] prior to CABG. EF ">40" on [**2157**]
echocardiogram. Sees Dr. [**Last Name (STitle) 3302**] q 6
months.
# Hyperlipidemia
# Peripheral Vascular Disease status post stenting of the SFA
[**11/2165**] and [**12/2165**]- stents in bilateral SFA. (Dr. [**First Name (STitle) **]
# Lung cancer status post left lower lobe lobectomy and right
upper lobectomy. Adenocarinoma (Dr. [**Last Name (STitle) 175**]
# Rheumatoid arthritis- On plaquenil (Dr. [**Last Name (STitle) 3303**])
# Chronic renal insufficiency (baseline Cr 1.4-1.6)
# Lumbar spinal stenosis status post laminectomy, osteoporosis
# Intermittent Ashtmatic bronchitis
# Zoster ophthalmicus-resolved without sequela.
# s/p bilateral cataract surgery,
# left breast biopsy-negative pathology
# pneumococcal vaccine-[**2156-12-8**]
# Thalasemmia Trait
# History of severe epistaxis requiring hospitalization
# Gout
Social History:
Lives with her devoted husband, son lives nearby. No
tobacco-distant smoking past, no alcohol, minimal walking given
right hip and knee pain and spinal stenosis.
Family History:
NC
Physical Exam:
VS- 96.3 122/76 (on levophed) 75 (paced) 18 94% 2Lnc
GEN- Elderly, ill-appearing female lying in bed in NAD
HEENT- MMdry, anicteric, full dentures, NCAT
NECK- supple, though limited ROM due to CVL in R jugular vein;
no LAD, JVP flat
CV- RRR, II/VI SEM at LLSB, nl S1S2
CHEST- Relatively clear to auscultation anteriorlly
ABD- obese, soft, NT, ND, pos BS, no HSM
EXT- 3+ pitting edema with weeping of skin, mild erythema L>R
without warmth, no clubbing or cyanosis
NEURO- AAOx3, speaking fluently without difficulty, CN intact,
strength in UE [**5-1**] and equal; strength in LE [**4-1**] bilaterally (?
due to pain or massive swelling). Unable to get reflexes in LE.
Normal sensory exam to light touch throughout. Gait not
assessed.
SKIN- Weeping venous stasis changes of LEs.
MSK- Limited ROM at neck
Pertinent Results:
.
ECG: Paced at 75 without obvious change from prior.
.
STUDIES:
.
*CXR [**2167-11-5**]: The central venous line on the right crosses the
midline and presumably terminates within the left
brachiocephalic vein. The cardiac and mediastinal contours are
stable. Marked elevation of the left hemidiaphragm with
underlying bowel-containing air is again seen. There is adjacent
compressive atelectasis at the left lung base. The right lung
appears grossly clear. No evidence of pneumothorax. IMPRESSION:
Suboptimal position of the central venous line crossing the
midline and terminating presumably in the left brachiocephalic
vein.
.
*PMIBI [**2167-10-12**]: Moderate, predominantly fixed basilar inferior
wall perfusion defect. In comparison to the report from the
prior study, there has been no interval change. LVEF=49%.
.
*TTE [**2167-10-8**]: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function cannot be reliably assessed, but appears to be at least
mildly reduced, with inferior-posterior hypokinesis. 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 to moderate
([**12-29**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2167-7-1**], no major change is evident, but the technically
suboptimal nature of the present study precludes definitive
comparison.
.
*Renal US [**2167-3-16**]: No hydronephrosis, could not tolerate study
to eval renal arteries.
.
*Arterial study [**2167-1-30**]: 1. Heterogeneous bilateral ICA calcific
plaque, however, no associated ICA or CCA stenosis (graded as
less than 40% ICA stenosis bilaterally). 2. Lower extremity
arterial hemodynamics unchanged compared to the [**2-1**], i.e.,
minimal right-sided tibial disease, left-sided aortoiliac
disease.
.
[**2167-11-8**] 03:47AM BLOOD Glucose-56* UreaN-135* Creat-4.2* Na-137
K-5.4* Cl-93* HCO3-27 AnGap-22*
[**2167-11-8**] 03:47AM BLOOD WBC-14.2* RBC-4.12* Hgb-8.9* Hct-28.7*
MCV-70* MCH-21.5* MCHC-30.9* RDW-19.5* Plt Ct-301
[**2167-11-8**] 03:47AM BLOOD PT-72.7* PTT-51.6* INR(PT)-9.4*
[**2167-11-8**] 03:47AM BLOOD ALT-40 AST-77* LD(LDH)-460* AlkPhos-156*
TotBili-1.0
Brief Hospital Course:
Patient presented after a progressive decline in health over the
past few months. She presented with complaints of weakness and
hypotension and most likely cause was infection (UTI/urosepsis
and cellulitis given leg findings.) Initially, CVL placed in ED
and CVP >20 in ED. Fluids and levophed used to improve BP with
minimal effect. Her infections were initially covered by vanco,
levo, flagyl to broaden GP as well as possible MRSA from recent
hospitalizations. Then, this was changed to vancomycin and
cefepime. Urine cultures grew enterococus and e.coli. However,
during the course of treatment, patient developed acute renal
failure/oliguria, worsening CHF, and persistent hypotension.
Likely multifactorial on top of chronic renal insuffiency. She
has had poor PO intake, as well as episodes of hypotension over
the past few weeks. She was given fluid boluses with minimal
effect and decreased urine output ultimately to 5cc/hr.
Furthermore, her INR rose steadily and was felt also to be
multifactorial from poor PO intake, worsening liver synthetic
capabilities.
.
Her Primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3306**], saw the patient and
her husband. Ultimately, it was decided to make her comfort
measures only as she was rapidly developing multi-organ failure
resistant to treatment. Her husband and family were at bedside
when she passed away at 3:15 AM [**2167-11-9**].
Medications on Admission:
Atorvastatin 10 mg
Metoprolol Tartrate 25 mg [**Hospital1 **]
Isosorbide Mononitrate 30 mg
Furosemide 80 mg qpm
Furosemide 1000 mg qqm
Docusate Sodium 100 mg [**Hospital1 **]
Warfarin 2 mg qhs
Pantoprazole 40 mg
Aspirin 81 mg
Camphor-Menthol 0.5-0.5 % Lotion prn itching
Oxygen-Air Delivery Systems
Plaquenil 200 mg [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient passed away on [**2167-11-9**] at 3:15 AM from urosepsis,
cardiac arrest, acute renal failure and CHF
Discharge Condition:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5990, 5845, 4280, 4019, 4439, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5754
}
|
Medical Text: Admission Date: [**2189-8-22**] Discharge Date: [**2189-9-7**]
Date of Birth: [**2137-12-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2189-8-26**] Drainage of peri sigmoid abcess
[**2189-8-28**] PICC line placement
History of Present Illness:
50 year-old gentleman with history of HTN, hyperlipidema,
ETOH abuse,pancreatitis, and recent legionella PNA presents as
transfer from OSH for diverticular abscess. The patient has had
an MVR/AVR and had been on coumadin until hep gtt was started
for
potential intervention off the abscess. The patient had been
NPO
on IV abx at [**Hospital 5871**] hospital for the past week, however he was
transferred to [**Hospital1 18**] in case surgical intervention needed to be
performed on the abscess. At the current time, he reports
persistent pain and bloating of his abdomen. No N/V. He has
been
passing minimal amounts of flatus.
Past Medical History:
PMHx: colonoscopy >10 yrs ago, HTN, hyperlipidemia, ETOH abuse,
pancreatitis, legionella PNA, diverticulosis
[**Doctor First Name **] Hx: AVR/MVR
Social History:
Tobacco: Current 1PPD
ETOH: daily though able to stop at any point without
consequences
Family History:
non contributory
Physical Exam:
VS: 98.8, 98, 108/68, 16, 98%2L
GEN: NAD, A&O x 3
LUNGS: Clear B/L
CV: RRR, nl S1 and S2
ABD: Soft, distended, slight diffuse tenderness to palpation, no
guarding, no rebound, no hernias
EXT: 1+ edema of LE B/L
Pertinent Results:
[**2189-8-22**] 05:50PM WBC-13.7*# RBC-3.53* HGB-10.6* HCT-32.0*
MCV-91 MCH-29.9 MCHC-33.0 RDW-13.9
[**2189-8-22**] 05:50PM PLT COUNT-380
[**2189-8-22**] 05:50PM PT-29.0* PTT-38.1* INR(PT)-2.9*
[**2189-8-22**] 05:50PM GLUCOSE-107* UREA N-16 CREAT-1.1 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2189-8-26**] Abd. CT: IMPRESSION:
1. Large fluid collections within the abdomen and pelvis
containing gas and
amenable to percutaneous drainage. This fluid collection appears
grossly
larger than previous study.
2. Left renal calculus within the proximal ureter, mild
hydronephrosis.
[**2189-8-26**] CT guided drainage of colonic fluid collection:
IMPRESSION: Successful drainage of the prior colon abscess and
50 ml of the
Small amount of fluid was sent to laboratory as requested. The
catheter was
left in place.
[**2189-8-29**] Abd CT : 1. Interval decrease in size of abscess in the
superior aspect of the pelvic
cavity. A percutaneous drain remains in situ, with tip at the
left lateral
aspect of the collection. The collection appears partly
loculated.
[**2189-9-1**] Cardiac Echo : The left atrium is moderately dilated.
The right atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is top normal/borderline dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %). The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
ascending aorta is mildly dilated. A bileaflet aortic valve
prosthesis is present. The transaortic gradient is normal for
this prosthesis. Trace aortic regurgitation is seen. [Due to
acoustic shadowing, the severity of aortic regurgitation may be
significantly UNDERestimated.] A bileaflet mitral valve
prosthesis is present. The gradients are higher than expected
for this type of prosthesis. No mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is moderate
pulmonary artery systolic hypertension.
IMPRESSION: Bileaflet mitral and aortic valve prostheses.
Trivial aortic regurgitation. Elevated transmitral valve
gradients. Mild left ventricular systolic dysfunction. Mildly
dilated and hypokinetic right ventricle. Moderate pulmonary
hypertension.
Compared with the prior report (images not available for review)
of [**2187-7-23**], the gradient across the prosthetic valve is
higher. Left ventricular systolic function is less vigorous. The
right ventricle is now mildly dilated and hypokinetic. The
estimated pulmonary artery pressures are slightly higher. If
there is a clinical suspicion of valve dysfunction, a TEE may be
indicated.
[**2189-8-31**] Abd CT for drain reposition :
IMPRESSION: Successful CT-guided repositioning of the drainage
catheter
2. Focal fluid collection adjacent to the distal portion of
sigmoid colon has
also decreased in size.
3. Persistent distention of the ascending and transverse colon
with gas and
fluid, which is slightly more prominent than on previous CT.
[**2189-9-5**] Abd CT :
. Decrease in size of pelvic collection with drain in situ and
in good
position.
2. Improving acute diverticulitis of the sigmoid colon.
3. New diffuse mild thickening of the wall of the entire colon,
indicating a
superimposed colitis. Differential considerations include C.
difficile, given
that the patient is on antibiotics, however, and other
differentials such as
inflammatory bowel disease and ischemia are much less likely.
Brief Hospital Course:
Mr. [**Known lastname 1968**] was admitted to the hospital, continued NPO , hydrated
with IV fluids and placed on Flagyl and Ciprofloxacin. His
abdomen was very distended and tympanic and remained that way
for many days despite the fact that he was passing flatus. He
was placed on IV heparin for his prosthetic heart valves and
after 6 days of bowel rest and no significant improvement he was
placed on TPN via a PICC line.
A repeat Abd CT was done on [**2189-8-26**] which showed the same large
fluid collection from a diverticular abscess which was
subsequently drained. His partial large bowel obstruction
remained the same. The drainage grew out 2 strains of Ecoli and
coag negative staph. His antibiotics were eventually changed to
Bactrim DS and Ciprofloxacin orally. Over time the drainage was
very minimal, prompting a repeat scan on [**2189-8-29**]. On [**2189-8-31**] he
returned to Radiology to have his drain manipulated as there was
an un drained fluid collection. There was some decreased
distention of the large bowel and on exam his abdomen started to
appear less distended and he gradually had much less pain.
From a cardiac standpoint he had problems with severe DOE and 3+
leg edema requiring concentration of his fluids and vigorous
diuresis. Due to his cardiac history he had a cardiac echo
which revealed an EF of 45-50% and a slight increase in the
gradient across the mitral valve. The Cardiology service was
then consulted to address the need for a TEE. Mr. [**Known lastname 10881**]
symptoms improved after vigorous diuresis and the Cardiology
service felt that a TEE could be done on an out patient basis if
it was needed and he should have a TTE in 3 months anyway. His
cardiologist Dr. [**Last Name (STitle) **] will follow him after discharge.
His diet was very slowly increased from clear to regular as he
was having bowel movements and passing alot of flatus. His TPN
was weaned on [**9-3**] and his PICC line was eventually removed.
Coumadin was finally started after complete resolution of his
partial large bowel obstruction and his tolerance of a regular
diet.
After a protracted hospital course he was discharged home on
[**2189-9-7**] with VNA services as he was sent home with his drain in
place and will be on Lovenox 90 mg sc BID until his INR is
greater than 2.0. I spoke with Dr. [**Last Name (STitle) **] who will follow his INR
and regulate his Coumadin dose.
Mr. [**Known lastname 1968**] will follow up with Dr. [**Last Name (STitle) **] in 3 weeks and he will
have a colonoscopy in 6 weeks which will be arranged by Dr.
[**Last Name (STitle) **] office.
Medications on Admission:
Meds on transfer:zosyn, metoprolol, pantoprazole, odansetron,
albuterol, morphine
[**Last Name (un) 1724**] Coumadin 4.5', simvastatin 40', vit D 1.25q oweek,
benazepril 20'
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q12H (every
12 hours): thru [**2189-9-17**].
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*1*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*28 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
[**Hospital1 **] (2 times a day).
Disp:*10 syringes* Refills:*1*
8. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*20 Tablet(s)* Refills:*1*
9. Coumadin 5 mg Tablet Sig: 1 [**1-9**] Tablet PO once a day.
10. Outpatient Lab Work
11. Outpatient Lab Work
draw INR every MON-Wed-Fri
Results to Mr. [**Known lastname 1968**] who will in turn contact Dr. [**Last Name (STitle) **]
12. Outpatient Lab Work
INR every M-W-F
Results to Mr. [**Known lastname 1968**] who will in turn call Dr. [**Last Name (STitle) **]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis: Diverticulitis, partial LBO, and abscess
formation
Secondary Diagnosis: HTN, Asthma, pancreatitis, Etoh abuse,
mitral valve replacement.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-17**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2189-9-25**] 1:15
You need a colonoscopy in 6 weeks...dr.[**Doctor Last Name **] office will
call you with a day and time tomorrow
Call Dr. [**Last Name (STitle) **] tomorrow to follow up INR ([**Telephone/Fax (1) 7728**])
INR Mon-Wed-Fri at [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **] lab. call results to Dr. [**Last Name (STitle) **]
Completed by:[**2189-9-7**]
ICD9 Codes: 2859, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5755
}
|
Medical Text: Admission Date: [**2193-8-10**] Discharge Date: [**2193-8-21**]
Date of Birth: [**2114-12-22**] Sex: M
Service: NMED
Allergies:
Azithromycin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
tx from outside hospital with right frontal lobe hemmorhage
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 78 year old man with a history of CAD s/p MI in
[**2168**], ?seizure in [**2181**], and depression now presenting from an
outside hospital with a large right frontal hemorrhage. As per
the patient's daughter, the patient had a sudden drooping of the
left side of his face and difficulty speaking (she was on the
phone with her mother, who was telling her of these symptoms).
He
was taken to an outside hospital, where a large right frontal
hemorrhage was uncovered on CT scan and was transferred to [**Hospital1 18**]
for further management. In the ED, the patient was evaluated
and
admitted to the NICU service. While on this service the patient
had his blood pressure kept below 140 systolic with largely po
metoprolol. He was started on seizure prophylaxis with
phenytoin.
He currently denies any headache, chest pain, shortness of
breath, or dizziness.
Past Medical History:
-CAD s/p MI in [**2168**]
-emphysema
-major depression
-? of seizure in [**2181**]
-s/p left leg dermatofibrosarcoma resection plus radiation in
[**2176**]
-cholecystectomy in [**2180**]
-s/p pacer
-s/p cystourethotomy
Social History:
-Lives with wife
-Former [**Name2 (NI) 1818**]
-No recent ETOH use
Family History:
Non-contributory
Physical Exam:
Vitals: 98.4 130/45 60 25 98% room air
General: elderly man in no acute distress
Neck: supple, no carotid bruits
Lungs: wheezing heard anteriorly
CV: Regular rate and rhythm, faint s1, s2
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema, faint dp pulses
Neurologic Examination:
Mental Status: lethargic but arousable with loud voice, will
answer questions when pressed, will not open eyes
Oriented to person, but not place, month or president (thought
it
was [**2173**] and he was at home)
Attention: Can spell "world" forward but only 2 letters backward
Language: not fluent Fund of knowledge normal
[**Location (un) **] and writing deferred due to inattention
Cranial Nerves: unable to test visual fields. Pupils equally
round and reactive to light, 5 to 2 mm bilaterally. Extraocular
movements not assessable; prominent left sided facial droop
Hearing intact to finger rub bilaterally. Tongue midline, no
fasciculations
Motor:
decreased bulk noted in calves; tone increased on right
No tremor; unable to asses power, secondary to inattentiveness
Sensory exam not reliable; withdraws all extremities to pain
Reflexes: B T Br Pa Pl
Right 1 1 0 1 0
Left 1 1 0 1 0
Grasp reflex absent
Toe upgoing on left; down on right
Coordination not tested due to inattentiveness
Gait not tested
Pertinent Results:
Cbc: 15.4/34.9/147
Chem: 143/3.6 108/27 27/1.1 102
LFTs: AST:24 ALT:29 AP:127 TB: 0.8
CK: 185
C/M/P: 8.9/2.0/1.5
Cxr: no evidence of pna
Head Ct: large right frontal parenchymal hemmorhage
Brief Hospital Course:
Mr. [**Known lastname 30476**] is a 78 year-old man with a history significant for
CAD, s/p pacer, depression, baseline dementia, and skin cancer
of nose who presented on [**2193-8-10**] with a left facial droop,
drooling, and left sided weakness. Subsequent CT scan at
[**Hospital3 **] showed right frontal lobe hemorrhage. He
was transferred to [**Hospital1 18**] ED, then admitted to the NICU service.
On presentation, he denied headache, nausea, vomiting, visual
changes, numbness, dizziness, shortness of breath, chest pain,
abdominal pain. Wife noted no changes in balance, gait, tremor,
shaking, or seizure. He has had a 50lb. weight loss over a year
and has is on pureed diet at baseline. On [**8-10**], patient ruled
out for MI. Repeat CT confirmed presence of 4.5 x 3.5 x 8.0 cm
right frontal intraparenchymal hemorrhage. CTA showed no
evidence of abnormal vascular structures to indicate AVM. EKG
demonstrated A- and V- paced 60bpm, TWI avL, LAD. Repeat CT on
[**8-12**] no change in hemorrhage or edema and no mass effect.
Management has included BP control with metoprolol, seizure
prophylaxis with phenytoin, and treatment for suspected UTI with
SMX-TMP. UA/urine culture was negative for bacteria and yeast.
Blood cultures drawn on [**8-11**] are still pending. Sputum from
[**8-11**] was positive for coag+ staph. aureus. Pulmonary status
was initially managed with albulterol, fluticasone, and
ipratropium. Psych status was managed with olanzapine,
citalopram, and mirtazapine. During hospital course, patient
developed lethargy, fluctuant delirium, and mild dysarthria,
concurrent with pulmonary congestion suspicious for pneumonia.
CXR on [**8-13**] confirmed the presence of left lower lobe
infiltrate, and patient was treated with levofloxacin and
metronidazole with clinical improvement -- decreased lethargy,
improved mental status, and improved pulmonary exam with, at
present, mild rhonchi bilaterally. Repeat CXR on [**8-14**] showed
apparent interval improvement in LLL consolidation. Due to
nutritional concerns, patient was fed via NG tube plus
supplemental phosphate,
with multiple swallow studies before switching to PO diet.
While on NG tube, patient was on level II restraints to maintain
tube placement. Presently, neurologic exam has improved
slightly, with decreased lethargy and improved mental status
when awake. Mild left facial droop and left-sided weakness
persist. With improved mental status, stable neuro exam,
resolving pneumonia with antibiotics. He failed a swallow exam
on [**8-19**] for the 3rd time so the decision was made to place a GJ
tube for continued nutrition. He is now calm, not on
restraints, alert and ready for rehab.
Medications on Admission:
-mvi
-baby asa
-zocor 40 qd
-metoprolol 75/25
-vit. e and d
-albuterol
-atrovent
-celexa
-azmacort inh
-remeron 7.5 qhs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO QD
(once a day).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
7. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
QD (once a day).
8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Phenytoin 100 mg/4 mL Suspension Sig: Three Hundred (300) mg
PO Q24H (every 24 hours).
13. Oxacillin Sodium 10 g Recon Soln Sig: Two (2) grams
Injection Q6H (every 6 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1. hemorrhagic stroke
2. pna
Discharge Condition:
Stable, alert, following simple commands
Discharge Instructions:
Please cont. oxacillin for 10 more days.
Patient will need physical and occupational rehab
Patient will need tube feedings
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 4 weeks or
as needed.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2193-8-21**]
ICD9 Codes: 431, 496, 5990, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5756
}
|
Medical Text: Admission Date: [**2179-4-23**] Discharge Date: [**2179-4-27**]
Date of Birth: [**2149-2-15**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 30-year-old female
with a history of suicidal ideation and attempts,
schizoaffective disorder, type 2 diabetes, and a history of
an eating disorder (refusing to eat and drink for days at a
time) who was an inpatient at [**Hospital 1680**] Hospital and was
transferred over; reported to not be eating or drinking times
three days prior to admission. She continued to receive her
glyburide 5 mg p.o. and was found to have a blood glucose of
40 and was transferred to the [**Hospital1 188**] Emergency Department for further workup.
The patient was admitted from the Group Home to [**Hospital 1680**]
Hospital for purging behavior times two weeks, and she had
reportedly been purging all of her medications.
On presentation to the Emergency Department, the patient
became agitated and tried to leave the hospital. She
received 2 of Ativan and 5 of Haldol while in the Emergency
Department.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Type 2 diabetes.
2. Schizoaffective disorder.
3. Hypertension.
4. Asthma.
5. Bulimia.
6. History of previous suicide attempts.
7. History of a seizure disorder versus pseudoseizures.
ALLERGIES: The patient is allergic to PENICILLIN, MOTRIN,
and TYLENOL (reactions are unknown).
MEDICATIONS ON ADMISSION: (Medications included)
1. Flovent.
2. Glyburide 5 mg p.o. once per day.
3. Enalapril 5 mg p.o. once per day.
4. Serevent 21 mcg.
5. Neurontin 600 mg p.o. twice per day.
6. Trileptal 600 mg p.o. twice per day.
7. Topamax 200 mg p.o. once per day.
8. Paxil 20 mg p.o. once per day.
9. Cogentin 1 mg p.o. once per day.
10. BuSpar 15 mg p.o. twice per day.
11. Seroquel 25 mg p.o. three times per day.
12. Albuterol as needed.
13. Benadryl as needed.
14. Mylanta as needed.
15. Milk of Magnesia as needed.
SOCIAL HISTORY: The patient comes from a Group Home.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs in the Emergency Department with a
temperature of 99.4, blood pressure was 150/53, heart rate
was 80, respiratory rate was 18, and oxygen saturation was
98% on room air. Fasting fingerstick blood sugar was 90 at
this time. In general, she was sleeping comfortably, obese.
Pupils were equal, round, and reactive to light. The mucous
membranes were moist. The neck was supple. Heart was
regular in rate and rhythm. The chest was clear to
auscultation bilaterally. The abdomen was obese, soft,
nontender, and nondistended. Extremity examination revealed
there was no clubbing, cyanosis, or edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed sodium was 141, potassium was 3.5,
chloride was 112, bicarbonate was 19, blood urea nitrogen was
11, creatinine was 0.6, and blood glucose was 91. White
blood cell count was 9.8 (with a normal differential),
hematocrit was 37.7, and platelets were 326. Urinalysis was
negative. Urine human chorionic gonadotropin was negative.
Urine and serum toxicology screens were negative.
HOSPITAL COURSE: The patient was admitted to the Medicine
Service for agitation, history of hypoglycemia, and not
taking her oral medications.
On the floor, she was maintained on a one-to-one sitter and
Psychiatry continued to follow. She became agitated and had
numerous attempts to leave the floor; requiring both physical
and chemical restraint. The patient received Haldol and
later that day was found to have an episode of total body
shaking and urinary incontinence.
A computed tomography of her head was performed which was
negative. Neurology was consulted and felt that while Haldol
did decrease the seizure threshold, the patient had an
outside history of a seizure disorder and had not been taking
her anti-seizure medications for some period of time.
Once again, the patient had numerous attempts at attempting
to leave the hospital floor. The decision was made to
transfer her to the Unit for closer monitoring while loading
her with intravenous Dilantin.
The patient was transferred to the Medical Intensive Care
Unit on [**2179-4-25**] where she was maintained with a
one-to-one sitter. The patient was loaded on Dilantin and
monitored for any seizure activity. She also received Haldol
5 mg three times per day, and Ativan 1 mg q.4h. around the
clock, in addition to as needed Haldol and Ativan.
No seizure activity was noted. Psychiatry continued to
follow, and her Seroquel was increased.
NOTE: Dictation ended after 5.44 minutes.
[**Last Name (LF) **],[**Name8 (MD) **] M.D.12.AEW
Dictated By:[**Last Name (NamePattern1) 13577**]
MEDQUIST36
D: [**2179-4-27**] 13:41
T: [**2179-4-27**] 15:21
JOB#: [**Job Number 21471**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5757
}
|
Medical Text: Admission Date: [**2206-3-15**] Discharge Date: [**2206-3-17**]
Date of Birth: [**2143-6-19**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 F COPD, prior intubations, increased dypnea, productive cough
and increased phlegm over last 7 days, spoke with PCP 3 days ago
and was placed on azithromycin and prednisone which she has
taken the past 3 days. Her daughter was worried that her
breathing was worse so told her to go to the ED. She denied any
chest pain, dysuria, abdominal pain, diarrhea or any other
symtpoms.
.
In the ER she was placed on BIPAP in ER for brief period of
time. Vitals were 99.2, 120, 139/79, she was 96% on undocumented
level of oxygen and then placed on nasal bipap for unclear
reasons. Given solumedrol 125mg IV, azithromycin then levaquin,
duonebs, IVF. 2 liters of oxygen at home. Wheezing on exam. And
admiited to MICU, no ABG was checked. She was comfortable on
arrival to the MICU, breathing 93% on 3L. She was monitored for
a few hours, and called out to the floor.
Past Medical History:
- COPD, last PFTs [**8-4**] with FVC 1.72, FEV1 0.82, FEV1/FVC 66%
(61% and 40% predicted respectively); intubated several times in
the past. on 2L home O2.
- IgA deficiency, was on IV gamma globulin with Dr. [**Last Name (STitle) 2148**].
- CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in
[**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with
PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA
and LCx.
- Hypertension
- Hyperlipidemia
- Gastritis, on PPI
- Osteoporosis, with history of multiple compression and rib
fractures from coughing
- History of thrush/[**Female First Name (un) **] esophagitis [**12-30**] steroid therapy
- Depression
- Tremor
Social History:
She lives with her daughter, [**Name (NI) 6177**], son-in-law and 3
grand-children. She is a widow. She is an ex-smoker, with
about a 30-pack-year smoking history, quit in [**2200**]. No EtOH.
Uses a cane and walker to ambulate.
Family History:
Mother with DM, father with pancreatic cancer.
Physical Exam:
VS - BP 128/84, HR 114, R 22, O2-sat 93% 3L
GENERAL - Cachectic female, mildly SOB w/ speaking but able to
speak in full sentences. Mildly tachypneic. + productive cough.
HEENT - MMM, OP clear
LUNGS - Barrel chest, scattered wheezes bilaterally with good
air movement
HEART - very distant heart sounds, tachycardic
ABDOMEN - scaphoid, soft, nt/nd/nabs
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
Pertinent Results:
[**2206-3-15**] 03:30PM PLT COUNT-497*
[**2206-3-15**] 03:30PM NEUTS-92.9* LYMPHS-5.1* MONOS-0.9* EOS-0.8
BASOS-0.4
[**2206-3-15**] 03:30PM WBC-16.8* RBC-5.09# HGB-13.9# HCT-44.7#
MCV-88 MCH-27.4 MCHC-31.2 RDW-14.8
[**2206-3-15**] 03:30PM estGFR-Using this
[**2206-3-15**] 03:30PM GLUCOSE-125* UREA N-22* CREAT-0.7 SODIUM-139
POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-31 ANION GAP-17
[**2206-3-15**] 03:59PM LACTATE-2.7*
.
CXR:
Relatively stable chest x-ray examination with no acute
pulmonary
process.
Brief Hospital Course:
# COPD exacerbation: The patients symptoms and exam consistent
with a COPD exacerbation. She was initially admitted to the
MICU, but as she was breathing comfortably on 3L (baseline 2L
requirment,) she called out to the floor within a few hours.
She had been initially started on solumedrol, and switched to
prednisone 60mg, with a slower taper. She was continued on her
home nebulizer treatments, and started on a course of
levofloxacin. She breathing comfortably and felt closer to her
baseline on time of discharge.
.
#. Gastritis- She has a history of prior ulcer, egd [**2206-2-5**]
showed gastritis. She was srarted on a PPI while on steroids.
.
#. CAD- Continued statin and plavix.
Medications on Admission:
ALBUTERL SOLUTION - 0.83 MG/ML - USE EVERY 4-6 HOURS AS NEEDED
WITH NEBULIZER MACHINE
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs(s) by mouth every four (4) hours as needed for
cough/wheezing
ALENDRONATE SODIUM - (Not Taking as Prescribed) - 70MG Tablet -
ONE BY MOUTH Q WEEK, FIRST THING IN THE MORNING WITH A FULL
GLASS
OF WATER; AVOID LYING DOWN OR TAKING OTHER MEDICINES OR FOOD FOR
THE NEXT 30 MINUTES
CLOPIDOGREL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
EQUIPMENT - - oxygen by nasal canula at 2 liters/min at nite
and with exertion
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
Capsule(s) by mouth twice a week --take on Wed and Sunday
FENTANYL - 25 mcg/hour Patch 72 hr - apply one patch q72 hours
FLUTICASONE - 220 mcg Aerosol - 2 puffs twice a day - use with
spacer; rinse mouth after use
FLUTTER - Device - Use tid and as needed
IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) Solution - 1 (One) vial
inhaled via nebulizaiton up to every four (4) hours along with
albuterol solution as needed for shortness of breath or wheezing
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -
2
inhalations four times a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
NORTRIPTYLINE - 25 mg Capsule - 1 Capsule(s) by mouth at bedtime
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 10 mg-325 mg Tablet - 1
Tablet(s) by mouth up to qid as needed for pain
PAROXETINE HCL - 10 mg Tablet - 1 Tablet(s) by mouth qam
regularly, to treat anxiety
SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1
inhalation ih twice a day
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day in
the morning
Medications - OTC
DOCUSATE SODIUM - 100 mg Capsule - 2 Capsule(s) by mouth two
times a day with a big glass of water each time
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a
day
NEBULIZER & COMPRESSOR FOR NEB - Device - Use EVERY 3 HOURS PRN
as needed for wheezing not controlled by inhalers - please
replace old machine which is no longer delivering adequate
pressure
Discharge Medications:
1. Prednisone 20 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO DAILY
(Daily): take 60mg for 2 days, then take 40mg for for 3 days,
then 20mg for 2 days, then 10mg for 2 days.
Disp:*13 Tablet(s)* Refills:*0*
2. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) Inhalation
Q6H (every 6 hours).
3. Clopidogrel 75 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Salmeterol 50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
7. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
9. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet
PO Q6H (every 6 hours) as needed.
11. Levofloxacin 750 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
12. Docusate Sodium 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID
(2 times a day).
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
One (1) Inhalation every four (4) hours.
14. Vitamin D 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO qwed
and sat.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation every four (4) hours.
16. Omeprazole 20 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Dx: COPD exacerbation
Secondary Dx: HTN, Gastritis, CAD
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for shortness of breath, which is seconary to
a flare of your COPD. You are being started on steroids called
prednisone, which you should taper per the instructions.
Additionally, we are starting you on antibiotics. You should
continue all other medications as previous. If you develop
significant worsening of your shortness of breath, worsened
oxygen requirement, diahrea, or any other concerning symptoms,
please call your PCP or go to the emergency room.
Followup Instructions:
You have an appointment already scheduled with your PCP [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**Name Initial (PRE) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2206-4-15**] 12:00. I
would recommend calling tomorrow to see if you can get an
earlier appointment for next week.
ICD9 Codes: 412, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5758
}
|
Medical Text: Admission Date: [**2166-6-9**] Discharge Date: [**2166-6-15**]
Date of Birth: [**2166-6-9**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby boy [**First Name8 (NamePattern2) 40533**] [**Known lastname 10010**] delivered at 39 weeks
gestation weighing 1795 gm and was admitted to the Intensive
Care Nursery from Labor and Delivery for management of
transitional issues secondary to precipitous delivery and
severe IGUR/SGA.
Mother is a 20-year-old gravida 1, para 0 now 1 woman with
obstetrical dating by eight week ultrasound that was
consistent with last menstrual period; 18 week fetal survey
was within normal limits. Pregnancy was uncomplicated,
although some suspicion of size versus dates in last two
obstetric visits was raised.
antibody screen negative, RPR nonreactive, hepatitis B
surface antigen negative, Rubella immune, human
immunodeficiency virus negative and group B strep positive.
The mother presented to labor and delivery in active advanced
labor. Spontaneous rupture of membranes nine minutes prior
to delivery. Delivery without anesthesia and without
intrapartum antibiotic prophylaxis for group B strep
colonization. No maternal fever.
The delivery team arrived around two to three minutes of age.
The obstetrical nurse had provided suction, stimulation and free
flow O2. Apgar scores were 3 and 7 at 1 and 5 minutes of age
respectively. Baby was shown to the parents and brought to
the Intensive Care Nursery for transition.
ADMISSION PHYSICAL EXAM:
GENERAL: Alert, pink, scrawny infant with mild tachypnea.
HEAD, EARS, EYES, NOSE AND THROAT: Noteworthy for head
sparing proportions with wide fontanel open, back to
posterior fontanel with metopic open forward to mid forehead.
Skull otherwise did not seem abnormal. No splitting of
temporal or occipital sutures. Ears normally set, not curved
at edge of pinna and not fully cartilaginized. Eyes wide
open, hyper, alert. Red reflex present bilaterally. Trace
pupillary membrane on left upper cornea, otherwise normal.
Palate intact. Lower gums thickened.
NECK: Normal.
CHEST: Initial substernal retracting subsiding to near
normal within 20 minutes. No rales or rhonchi. Clear breath
sounds bilateral. No murmur, normal S1, S2. Exaggerated
sinus bradycardia.
PULSE EXAM: Femoral pulses present.
ABDOMEN: Belly soft, easy to palpate, normal size kidneys,
no hepatosplenomegaly. Skin at base of umbilical cord
extends 3 cm onto cord with redundant skin. Nothing palpable
inside skin extension, scar-like tissue. On skin on sides
around the cord with [**Last Name (un) 43554**] like scar attachment at 10 o'clock
on umbilical vein.
GENITALIA: Normal male phallus with right testicle and canal
and left and scrotum.
EXTREMITIES: Normal hips, clavicles and spine. Hands and
feet structurally normal with normal hand creases.
SKIN: Thin with no subcutaneous tissue. Tone slightly
decreased.
MEASUREMENTS: Weight 1795 gm less than 3rd percentile,
length 43 cm less than 3rd percentile, head circumference
30.5 cm in the 5th percentile.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Infant had grunting, retracting and then
tachypnea during transition that resolved on admission. He has
remained in room air since without any respiratory distress,
breathing comfortably in the 30s to 50s.
2. CARDIOVASCULAR: Initial blood pressure mean was 38 that
was treated with 10 cc per kg of normal saline with blood
pressure mean increasing to the 40s and 50s thereafter, has
been hemodynamically stable without murmur.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Initial glucose 66,
bottle fed 30 cc of Enfamil 20, but blood glucose three hours
after feed fell to 26. This was treated with 2 cc per kg bolus
of D10W and a peripheral intravenous was started with a D10W
infusion at 80 cc per kg per day. He continued to feed and
gradually weaned off the intravenous fluid by day of life 2.
At discharge, he is breast feeding well every three to four
hours and receiving two bottles a day of Neo-Sure 22 calories
per ounce. This twice a day supplemental formula was intended to
support his rapid mineral accretion as he does catch-up growth.
He has maintained blood glucoses in the 50s to 60s
before feeds. He is voiding and stooling appropriately.
Discharge weight 1890 gm, length 43 cm, head circumference
30.5 cm.
4. GASTROINTESTINAL: He received one and a half days of
phototherapy for hyperbilirubinemia. Total bilirubin 12.9,
direct 0.4. Phototherapy was initiall discontinued on [**2166-6-13**] and
a rebound bilirubin went to 12.5. He had 12 more hours of photo
therapy, then off overnight, and the follow-up was 8.8/1.0 on
the day of discharge.
5. HEMATOLOGY: Hematocrit on admission 50.7%.
6. INFECTIOUS DISEASE: Received a CBC and blood culture on
admission for maternal group B strep colonization without
antepartum prophylaxis. CBC showed a white count of 10.6
with 39 polys, 2 bands. Platelet count was 171,000. He did not
receive antibiotics.
Urine for CMV culture was sent and is pending at the time of
discharge. There was nothing in his exam or CBC to raise
suspicions of CMV.
7. NEUROLOGY: Head ultrasound not indicated. Exam has been
age appropriate.
8. SENSORY: Hearing screening was performed with automated
auditory brain stem response. Infant passed in both ears.
DISCHARGE CONDITION: Stable 6 day year old SGA infant.
DISCHARGE DISPOSITION: Discharge home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (NamePattern1) 43555**]at [**Hospital 8985**]
Pediatrics. Telephone number ([**Telephone/Fax (1) 43556**].
CARE RECOMMENDATIONS:
1. Feeds: Ad lib breast feeding every three to four hours
with two bottles a day of Neo-Sure 24, follow weight gain and
increase calories if needed for growth.
2. Medication: Fer-In-[**Male First Name (un) **] 0.5 cc po daily
3. Car seat position screening test done and passed.
4. State newborn screen was sent at 72 hours of life and is
pending.
5. Immunizations: Did not receive hepatitis B
immunizations, as does not weigh 2 kg.
FOLLOW UP APPOINTMENTS RECOMMENDED:
1. Follow up appointment with pediatrician [**6-16**] or 23rd
recommended.
2. VNA referral made to [**Company 1519**], telephone number
1-[**Telephone/Fax (1) 12065**], fax number 1-[**Telephone/Fax (1) 24704**].
DISCHARGE DIAGNOSES:
1. SGA term male
2. Transitional respiratory distress resolved
3. Transitional hypotension resolved
4. Hypoglycemia resolved
5. Sepsis ruled out
6. Rule out CMV
7. Indirect hyperbilirubinemia, resolving
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33795**], M.D. [**MD Number(1) 35944**]
Dictated By:[**Last Name (NamePattern1) 36138**]
MEDQUIST36
D: [**2166-6-13**] 15:05
T: [**2166-6-13**] 15:11
JOB#: [**Job Number 9937**]
Edited [**2166-6-16**] 18:23 DKR
ICD9 Codes: 7742, V290, 4589
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5759
}
|
Medical Text: Admission Date: [**2103-3-9**] Discharge Date: [**2103-3-11**]
Date of Birth: [**2052-4-2**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Heparin Agents / Dapsone / Atovaquone /
Levaquin
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Altered Mental status
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
Mr [**Known lastname **] is a 50 year old man with history of HIV (last CD4
393 last month), Type 2 diabetes, and CRI who presents from OSH
with confusion and agitation. The patient was brought in by his
partner after he was noted to be confused and combative
overnight. Patient is unable to provide history at this time and
history was obtained from chart and patient's family. per the
patient's mother he was in his USOH last evening. He came home
from work and watched tv and then went to bed. As far as she
knows he was without complaints. He awkoe in the night and went
to the bathroom with ? diarrhea. He was then noted to go
immediately back in the bathroom and vomited. After this he
became combative with his partner and insisted that he was ok.
He was then brought to an OSH. At the OSH the patient was noted
to be alert, but confused and unable to follow commands. FS in
ED was 126. He was intubated for "behavior". He received ativan
2mg IV, 2gm ceftriaxone IV, Flagyl 500mg IV, Acyclovir 800mg IV.
He was then transferred to [**Hospital1 **].
.
In the emergency department Temp 98, HR 76, BP 150/76,
intubated. An LP was performed that was notable for 2 WBC (80%
Lymphs), 0 RBC, prot 32 and glu 92. Serum tox was negative and
urine tox was pos. only for benzos. CT head showed no acute
process. He received 3L IV NS, and was placed on propofol for
sedation. He was given vancomycin 1gm IV, Azithromycin 500mg IV
and 2mg versed. He was then admitted to the [**Hospital Unit Name 153**] for further
management. On arrival to the ICU the patient is intubated and
sedated.
Past Medical History:
# HIV: Diagnosed in [**2097-5-26**], (CD4 393, VL undetectable [**Month (only) **]
[**2102**]) On Atripla
# Type 1 diabetes, hemoglobin A1C 8.0 in [**1-4**]
# Peripheral neuropathy
# h/o orthostatic hypotension, previously tx w/ midodrine and
Florinef
# Chronic renal insufficiency, baseline Cr 1.2-1.5
# History of PCP pneumonia treated with pentamidine,
Solu-Medrol, and prednisone in [**2097-5-26**].
# History of perforated peptic ulcer in [**2096**] s/p oversewing
# History of coag-negative Staph catheter related infection.
# Clostridium difficile colitis
# CMV viremia
# Magnesium wasting possibly secondary to pentamidine
# Anal condylomata
# h/o HIT
Social History:
Lives in [**Location 8072**] with his partner. [**Name (NI) 1403**] as IT manager. No h/o
tobacco use. Drinks alcohol rarely.
Family History:
maternal GF had MI in 60s
Physical Exam:
T 96.5 BP 115/73 HR 59 RR 11 O2 100% on AC
GENERAL: Intubated, sedated
HEENT: Normocephalic, atraumatic. No scleral icterus. Pupils
pinpoint, slightly reactive. ETT/OG tube in place. Neck Supple,
No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTA anteriorly
ABDOMEN: hypoactive BS, soft, ND. No HSM
EXTREMITIES: No edema, warm, well-perfused, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Sedated, does not respond to voice.
Discharge:
Afebrile, VSS
Gen -- middle aged male, NAD
HEENT -- anicteric op clear
Heart -- regular
Lungs -- clear
Abd -- soft, benign
Ext -- no edema
Neuro/psych -- alert, oriented x 3, stable gait, normal
coordination and strength
Pertinent Results:
[**2103-3-9**] 03:00AM PT-12.1 PTT-21.9* INR(PT)-1.0
[**2103-3-9**] 03:00AM PLT COUNT-195
[**2103-3-9**] 03:00AM NEUTS-83.9* LYMPHS-13.8* MONOS-2.0 EOS-0.3
BASOS-0.1
[**2103-3-9**] 03:00AM WBC-9.1 RBC-4.52* HGB-14.7 HCT-42.8 MCV-95
MCH-32.5* MCHC-34.4 RDW-15.1
[**2103-3-9**] 03:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2103-3-9**] 03:00AM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-2.5*
MAGNESIUM-2.7*
[**2103-3-9**] 03:00AM CK-MB-4
[**2103-3-9**] 03:00AM cTropnT-<0.01
[**2103-3-9**] 03:00AM LIPASE-191*
[**2103-3-9**] 03:00AM ALT(SGPT)-25 AST(SGOT)-21 LD(LDH)-226
CK(CPK)-139 ALK PHOS-131* AMYLASE-148* TOT BILI-0.2
[**2103-3-9**] 03:00AM estGFR-Using this
[**2103-3-9**] 03:00AM GLUCOSE-167* UREA N-36* CREAT-1.9* SODIUM-136
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2103-3-9**] 04:45AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 POLYS-0
LYMPHS-80 MONOS-20
[**2103-3-9**] 04:45AM CEREBROSPINAL FLUID (CSF) PROTEIN-32
GLUCOSE-92
[**2103-3-9**] 07:00AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2103-3-9**] 07:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2103-3-9**] 07:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2103-3-9**] 07:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2103-3-9**] 07:00AM URINE GR HOLD-HOLD
[**2103-3-9**] 07:00AM URINE HOURS-RANDOM
[**2103-3-9**] 07:00AM URINE HOURS-RANDOM
[**2103-3-9**] 09:53AM URINE HOURS-RANDOM CREAT-55 SODIUM-87
POTASSIUM-61 CHLORIDE-119
[**2103-3-9**] 10:49AM CK-MB-4 cTropnT-<0.01
[**2103-3-11**] 09:25AM BLOOD WBC-7.2 RBC-3.99* Hgb-13.0* Hct-36.8*
MCV-92 MCH-32.7* MCHC-35.4* RDW-14.4 Plt Ct-159
[**2103-3-11**] 09:25AM BLOOD Glucose-92 UreaN-18 Creat-1.3* Na-142
K-3.9 Cl-109* HCO3-24 AnGap-13
[**2103-3-9**] 03:00AM BLOOD WBC-9.1 Lymph-14* Abs [**Last Name (un) **]-1274 CD3%-69
Abs CD3-879 CD4%-13 Abs CD4-166* CD8%-55 Abs CD8-706*
CD4/CD8-0.2*
[**2103-3-9**] 03:00AM BLOOD ALT-25 AST-21 LD(LDH)-226 CK(CPK)-139
AlkPhos-131* Amylase-148* TotBili-0.2
[**2103-3-9**] 10:49AM BLOOD CK-MB-4 cTropnT-<0.01
[**2103-3-9**] 03:00AM BLOOD cTropnT-<0.01
[**2103-3-11**] 09:25AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.3
[**2103-3-9**] 04:45AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
Lymphs-80 Monos-20
[**2103-3-9**] 04:45AM CEREBROSPINAL FLUID (CSF) TotProt-32 Glucose-92
HERPES SIMPLEX VIRUS PCR
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Simplex Virus, Type 1 & 2 DNA, Real-Time PCR
HSV 1 DNA DETECTED Not
Detected
HSV 2 DNA Not Detected Not
Detected
----------
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with acute onset confusion, rule
out mass or
encephalitis.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion
axial images obtained before gadolinium. T1 axial and MP-RAGE
sagittal images
acquired following gadolinium. Comparison was made with the
previous study of
[**2097-7-28**].
FINDINGS: There has been no significant interval change seen.
Subtle
hyperintensities in the white matter are again noted indicating
minimal
changes of small vessel disease. No midline shift, mass effect
or
hydrocephalus seen. Following gadolinium no evidence of abnormal
parenchymal,
vascular or meningeal enhancement seen. No evidence of acute
infarct seen or
slow diffusion identified to indicate encephalitis.
IMPRESSION: Minimal changes of small vessel disease. No abnormal
enhancement
or mass effect. Overall no significant change since [**2097-7-28**].
Brief Hospital Course:
50 year old man with history of HIV, diabetes, presenting with
acute altered mental status, combative, without clear source of
infection.
#. Altered mental status: Differential is broad including
infection, toxic-metabolic, CNS, cardiac ischemia, hypoglycemia.
No clear etiology at this point. FS at OSH was 126. Given
immunosupression from HIV, most concerning for acute CNS
infection including bacterial, viral and fungal etiologies,
however LP is unremarkable. LP not c/w bacterial picture. CT
head negative for acute process. MRI more sensitive to look for
encephalitis, and given MS changes this is possible. MRI was
normal. EKG unchanged and CE negative x1 so less likely primary
cardiac event. Tox screen negative. BZ on tox likely from OSH.
Given h/o vomiting an acute GI process is in differential as
well. Currently afebrile, normal WBC which is reassuring. LFTs,
lipase, with the exception that alk phos was 131, and amylase
was 148. Acyclovir was started and continued overnight for risk
of HSV encephalitis. And
given low suspicion for bacterial meningitis will held vanc/ctx,
and not covered for Listeria meningitis. In the morning pt was
more alert and and extubated in the morning. By the afternoon pt
was A&Ox3 and in his USOH. ID consulted earlier does not beleive
that the etiolgy was infectious since his recovery was so quick,
and LP, MRI were negative. Acyclovir was d/c. They suggested
that the cause may be neurological- migraine variant vs. sz.
After Mr. [**Known lastname **] transferred to the floor from the [**Hospital Unit Name 153**], his
affect and mood were entirely normal. After discussion with the
ID team, he was discharged home on his previous medications.
Given the normal brain MRI and normal CSF cell count, there was
low suspicion for a positive HSV PCR on discharge, although the
result remained pending. His HSV PCR returned the day following
discharge as "detected." The ID fellow and his primary
outpatient ID physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2148**] were contact[**Name (NI) **] and
readmission was in coordination at the time of this discharge
summary.
.
#. HIV: On Atripla as an outpatient. Last CD4 count 394 and VL
<48 in [**2-5**]. Patient received pnemovax and hepatitis A and B
vaccines. Per discussion with ID will cont. his outpatient
HAART. Repeating CD4. Cont. HAART, given Atripla is NF will give
efavirenz 600mg daily and emtricitabine-tenofovir (truvada).
Renally dosed truvada during acute renal failure, but discharged
on his previous dose after renal function recovered.
.
#. DIABETES: insulin dependent. Previous A1c 8.0 one year ago.
He resumed his home lantus and ISS set up for follow up at
[**Last Name (un) **] on discharge.
.
#. ACUTE ON CHRONIC RENAL INSUFFICIENCY: Unclear etiology of
nephropathy, likely diabetic given h/o microabluminuria.
Baseline Cr 1.2, now 1.9 however was 1.8 last month. Unclear if
this represents a new baseline, however appears to have worsened
over last year. [**Month (only) 116**] have had progression of his underlying renal
disease. Acute bump may be pre-renal in setting of vomiting,
also on ACEi at home which appears to have been uptitrated. UA
normal. Most recently Cr 1.4. Likely resolving [**1-29**] prerenal.
Medications on Admission:
Atripla 600-200-300mg daily
Epipen prn bee stings
Lantus 47 units qhs
Humalog SS
Lisinopril 20mg daily (recently increased per OMR)
Aspirin 81mg
ALLERGIES: Sulfa (Sulfonamides) / Heparin Agents / Dapsone /
Atovaquone / Levaquin
Discharge Medications:
1. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO once a
day.
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Insulin Glargine 100 unit/mL Solution Sig: Forty Seven (47)
units Subcutaneous at bedtime.
5. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
qAC and qHS: by sliding scale as previously prescribed by Dr.
[**Last Name (STitle) 2148**].
Discharge Disposition:
Home
Discharge Diagnosis:
1. altered mental status
2. DMI
3. acute/chronic kidney disease
4. hypertension
5. HIV
Discharge Condition:
stable, baseline mental status
Discharge Instructions:
You were hospitalized with altered mental status. The tests
performed did not show any infection that could have caused your
problems.
Please follow up with your physicians as scheduled and take all
medications as prescribed. Call your primary doctor or return
to the emergency department if you have recurrence of confusion
or altered behavior, fever greater than 101, headache, chest
pain, dark urine or any other alarming symptoms.
Followup Instructions:
Call PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 457**] for a follow up
appointment in the next two weeks.
Neurology: Dr. [**Last Name (STitle) 2442**]. Phone: [**Telephone/Fax (1) 3506**]
ICD9 Codes: 2930, 5849, 5859, 3572
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5760
}
|
Medical Text: Admission Date: [**2187-9-17**] Discharge Date: [**2187-9-29**]
Date of Birth: [**2112-9-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2187-9-21**] Five vessel coronary artery bypass grafting - left
internal mammary to left anterior descending, vein graft to
first obtuse marginal, vein graft to second obtuse marginal,
vein graft to diagonal, vein graft to PDA.
History of Present Illness:
This is a 75 year old male with ESRD, on dialysis for the last
18 months. In [**2187-8-20**], he was admitted with CHF and found to
have severe three vessel coronary disease. ECHO at that time
showed severely depressed LV function with an EF 20-25% and only
1+MR. [**Name13 (STitle) **] was concomitantly treated with antibiotics for a
pneumonia. He was not an ideal surgical candidate at that time
and was eventually discharged on medical therapy.
On day prior to admission, he presented to OSH in pulmonary
edema. He ruled in for an acute MI with elevated troponins. He
was treated with Nitro and Lasix with improvement in symptoms.
He was subsequently transferred to the [**Hospital1 18**] for further
evaluation and treatment. On admission, his shortness of breath
improved. He denied chest pain, nausea, vomiting, orthopnea, PND
and palpitations.
Past Medical History:
Coronary artery disease, ESRD on dialysis for past 18 months,
Hypercholesterolemia, Hypertension, Heart Block - s/p PPM
placement, Neuropathy, Retinopathy, Anemia
Social History:
Lives with wife. [**Name (NI) **] 3 children. Never smoked. Occasional ETOH.
Family History:
Non-contributory, no premature coronary disease
Physical Exam:
Vitals: T 98 BP 150/75 P 81 RR 22 O2sat 100%4L
General: Elderly male lying in bed in no acute distress
HEENT: PERRL, EOMI,
NECK: Supple, JVP ~12cm
CV: Regular rate with ectopy, normal s1s2, no murmur or rub
Chest: Decreased breath sounds bilaterally up to mid lungs,
minimal crackles.
Abd: Soft, NT, ND. Normoactive bowel sounds
Ext: 1+ dp/pt pulses bilaterally
Neuro: Non-focal
Brief Hospital Course:
On admission, cardiac enzymes remained flat. Cardiac surgery was
consulted for surgical revascularization as multivessel PCI was
not an option. Antiplatelet therapy was therefore discontinued
and Warfarin was reversed with Vitamin K and FFP. He was
subsequently started on IV Heparin. Once his prothrombin time
improved, it was decided to proceed with surgical
revascularization. He otherwise remained pain free on medical
therapy and continued on his routine dialysis schedule.
On [**2187-9-21**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting. Following the operation, he was brought to the CSRU
for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
initially required inotropes for blood pressure support. By POD
#2, he weaned from intravenous therapy. He maintained stable
hemodynamics and transferred to the SDU on POD #3. He
experienced bouts of paroxsymal atrial fibrillation. Warfarin
therapy was eventually resumed
Medications on Admission:
1. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. Insulin Glargine 100 unit/mL Solution Sig: Twenty One (21)
units Subcutaneous at bedtime.
9. Insulin Aspart 100 unit/mL Solution Sig: Five (5) units
Subcutaneous every 6-8 hours: afternoon dose.
10. Insulin Aspart 100 unit/mL Solution Sig: Thirteen (13) units
Subcutaneous Sun, mon, wed, fri: Take as you do usually.
11. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
14. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) for 3 days: To complete a 10 day course.
Disp:*8 Tablet(s)* Refills:*0*
15. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*1*
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hosptial
Discharge Diagnosis:
CAD - s/p CABG, CHF, HTN, ESRD, PAF, Hyperlipidemia, Diabetes
mellitus, Anemia, History of 2nd and 3rd heart block - s/p PPM
placement, Neuropathy, Retinopathy
Discharge Condition:
Good
Discharge Instructions:
Patient may shower. No baths. No lotions or creams to incisions.
No driving for one month. No lifting more than 10 lbs for 10
weeks.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] in [**2-22**] weeks
Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**2-22**] weeks
Completed by:[**2187-9-29**]
ICD9 Codes: 4280, 2720, 2930
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5761
}
|
Medical Text: Admission Date: [**2190-2-12**] Discharge Date: [**2190-2-19**]
Date of Birth: [**2190-2-12**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname **] is the former 38 week 3015 gram
female infant delivered to a 32 year old Gravida 2, Para [**1-31**]
mother.
PRENATAL SCREENS: A positive, antibody negative, rubella
immune, RPR nonreactive, Hepatitis B surface antigen
negative. GBS negative.
No sepsis risk factors. Benign antepartum with no prolonged
rupture of membranes. Maternal intrapartum temperature less
than 100.3 F. The infant was delivered vaginally under
epidural anesthesia. Apgars 9 at one minute and 9 at five
minutes.
At about 40 hours of age, she was noted to be dusky in the
Newborn Nursery requiring blow-by O2 and stimulation. She
recovered with stimulation and supplemental oxygen. She again
had another dusky spell in the Newborn Nursery about one hour
later. The nurse practitioner was called to evaluate the
infant and the decision was made to monitor in the Neonatal
Intensive Care Unit overnight.
Shortly after admission to the Neonatal Intensive Care Unit
it was noted that the infant had a desaturation to 51 and
dusky, requiring blow-by O2 and stimulation. She also had a
desaturation to 70 with some uncoordinated feeding effort.
PHYSICAL EXAMINATION: On admission, this is a well appearing
full term infant. Skin smooth and pink. Anterior fontanel
soft and flat. Lips, gums, palate intact. She is pink and
well perfused. No murmur auscultated. Pulses normal in
quality and character. Chest symmetrical. Breath sounds
clear and equal. Abdomen soft, active bowel sounds, voiding
and stooling. Cord drying, spine straight, patent anus.
Normal female genitalia. Clavicles intact; no hip click,
good tone, active and alert.
REVIEW OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: At rest the infant has had oxygen
saturations greater than 94% in room air. Since admission and
over a five day observation period [**Known lastname **] did not have any
further desaturations while at rest or apnea and bradycardic
events suggesting mature cardiorespiratory control. Baseline
respiratory rate is in the 30s to 40s and bilateral breath
sounds are clear and equal.
Rarely or intermittently [**Known lastname **] did demonstrate desaturations
with bottle feeding. Initially she needed oxygen
administration with these events; however, later in her
hospital course she was able to self recover on her own with
routine maneuvers such as bottle removal. Currently these
events occur 1 a day to every other day and are variable
depending on who is feeding her. [**Known lastname **] does very well with
pacing and frequent breaks. These events are not clinically
significant and her parents feel quite comfortable feeding
her. We anticipate that her po feeding abilities will
naturally improve with time.
2. CARDIOVASCULAR: The baby has had no cardiovascular
issues and no murmur. Baseline heart rate 130s to 140s.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The baby is ad lib
feeding [**Name (NI) 37112**] 20 with iron, taking in greater than 150 cc
per kilo per day. She is voiding and stooling. Stools are
guaiac negative.
Admission weight 3015, greater than 50th percentile; length
48.5 cm, greater than 50th percentile. Head circumference 32
cm, 25th percentile. Discharge weight is 3000 gms.
4. GASTROINTESTINAL: The baby had physiologic jaundice and
did not require phototherapy. Bilirubin on day of life three
was 12/0.2 and on [**2-18**], day of life six, was 9.3/0.3/9.0.
5. HEMATOLOGY: The baby did not require any blood products
during this admission. The admission hematocrit was 51.
6. INFECTIOUS DISEASE: The baby did have a blood culture
and a CBC sent on admission to rule out infection. White
blood cell count was 19.8; 73 polys, one band; platelet count
of 314,000 and hematocrit of 51. Blood cultures remained
negative. The baby did not require any antibiotics.
7. NEUROLOGY: The baby has appropriate neurological
examination for gestational age.
A sensory hearing screen was performed with automated
auditory brain stem response and the baby passed.
Ophthalmology examination is not indicated based on
gestational age.
8. PSYCHOSOCIAL: The parents look forward to transitioning
[**Known lastname 53239**] home with her family.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
CARE AND RECOMMENDATIONS:
1. Continue ad lib feeding [**Known lastname 37112**] 20 with iron.
2. Primary pediatrician, Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], [**University/College **],
[**State 350**]. Telephone number [**Telephone/Fax (1) 53240**].
3. Car seat position screening passed.
4. State newborn screen last sent on [**2-15**]; the results are
pending.
5. Immunizations received: Hepatitis B vaccine on [**2-13**].
6. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
who meet any of the following three criteria: 1) Born at
less than 32 weeks; 2) born between 32 and 35 weeks with two
of three of the following: Day care during RSV season, with
a smoker in the household, neuromuscular disease, airway
abnormalities or with school age 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.
DISCHARGE INSTRUCTIONS:
1. Follow-up appointment schedule recommended with primary
care pediatrician. Parents report an appointment for Tuesday,
[**2-23**]. 2. [**Location (un) 1110**] [**Hospital6 407**] to do home visit,
telephone number [**Telephone/Fax (1) 46941**]; fax [**Telephone/Fax (1) 51178**].
DISCHARGE DIAGNOSES:
1. Former 38 week female
2. status post rule out sepsis
3. Status post spontaneous desaturations, probable
transitional respiratory changes
4. Resolving physiologic jaundice
5. Mild feeding dyscoordination
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 36251**]
MEDQUIST36
D: [**2190-2-18**] 23:36
T: [**2190-2-19**] 10:00
JOB#: [**Job Number 53241**]
ICD9 Codes: V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5762
}
|
Medical Text: Admission Date: [**2130-12-17**] Discharge Date: [**2131-1-4**]
Date of Birth: [**2060-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
[**Hospital Unit Name 153**] callout for further mgmt of encephalopathy and
osteomyelitis
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
70 yo m w/ h/o etoh cirrhosis who presented to [**Last Name (un) 60160**] Hop in [**Month (only) **]
w/ acute back pain. W/u revealed s. [**Month (only) 60161**] endocarditis w/
abscess to c4-c6 vertebral bodies, l pleural abscess, and lumbar
epidural abscess. S [**Month (only) 60161**] intermediately sensitive to PCN so pt
txt with PCN/gent and d/c to rehab. After rehab, abx changed to
ceftriaxone 2g. [**11-30**] pt developed massive epistaxis w/
reported swallowing of "4 units" of blood and trasnferred back
to [**Hospital 46**] Hosp. Briefly hypotensive and tachycardia but
responded to fluid resuscitation. Labs at OSH showed Hct 29.2,
plt 240, INR 1.6. Hospital course c/b onset of eeg verified
[**Hospital 19562**] encephalopathy that intialyl responded to lactulose but
[**Month (only) **]. in BM made it worse. A head CT showed no actue process. His
ammonia on admission was 181 and fell to 8 ([**12-9**]) but then rose
to 63 ([**12-13**]). UCx [**12-11**] grew out yeast so pt was started in
fluconazole. On [**12-15**], fever to 102 with eelvated WBC ct,zosyn
added. Bld cx NGTD and CXR no PNA. Transferred to [**Hospital1 18**] [**Hospital Unit Name 153**].
Pt a poor historian. Much of history from chart, unit
residents and notes. Pt not oriented, occasionally answers
questions and follows commands. He states he is in pain in his
belly and his back. Little insight into why he is here. Seen in
[**Hospital Unit Name **] prior to transfer.
Past Medical History:
S. [**Hospital Unit Name 60161**] endocarditis: TEE [**11-20**] sm veg attached to mitral
leaflet.
osteomyelitis of cervical vertebrae via spinal MRI
L pleural abscess
Etoh cirrhosis: one bought of encephalopahty in past, EGD in
[**9-13**] showed no varicies
Anemia of chronic dz
coagulopathy
hypoproteinemia
Social History:
Retired professor, lived with wife. +etoh prior to admission at
OSH
Family History:
NC
Physical Exam:
98 2 126/65 15 97% NC 2L O2 88 +751 cc LOS
Elderly non-communicative man, occ responsive to commands in
NAD; writign in bed at times trying to get out of bed, in
restraints
PERRL. Anicteric. EOMI.
Dry oral mucosa w/ crusting and lesions of his hard
pallate/tongue. Poor dentition. Hard to exam pts OP [**3-13**] to
collar and poor cooperation.
Hard collar.
Regular, S1, S1. no m/r/g.
Ant auscultation revealed bronchial BS no crackles on lat exam
no wheezes
+bs. soft. nt. nd. Liver tip palapble 3 cm below costal margin.
Spleen tip felt 4 cm below rib cage.
no edema. +splinter hemorrhages of R thumb and 2nd toe b/l,
+palmar erythema.
+responds to painful stimuli. upgoing Babinski on R, down on L.
Squeezes fingers.
Pertinent Results:
Labs on admission:
CBC:
[**2130-12-17**] 09:42PM WBC-8.4 RBC-3.68* HGB-11.2* HCT-35.6* MCV-97
MCH-30.5 MCHC-31.5 RDW-16.8*
[**2130-12-17**] 09:42PM NEUTS-66.3 LYMPHS-23.1 MONOS-5.3 EOS-4.6*
BASOS-0.7
[**2130-12-17**] 09:42PM PT-16.9* PTT-36.8* INR(PT)-1.8
Chemistries:
[**2130-12-17**] 09:42PM GLUCOSE-103 UREA N-41* CREAT-1.5* SODIUM-146*
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-34* ANION GAP-10
[**2130-12-17**] 09:42PM ALT(SGPT)-35 AST(SGOT)-80* LD(LDH)-357* ALK
PHOS-126* AMYLASE-35 TOT BILI-1.1
[**2130-12-17**] 09:42PM LIPASE-28
[**2130-12-17**] 09:42PM ALBUMIN-2.1* CALCIUM-8.4 PHOSPHATE-3.8
MAGNESIUM-1.9
Labs on transfer:
[**2130-12-25**] 10:32AM BLOOD WBC-4.7 RBC-2.81* Hgb-8.7* Hct-26.9*
MCV-96 MCH-31.0 MCHC-32.3 RDW-18.5* Plt Ct-185
[**2130-12-25**] 10:32AM BLOOD Plt Ct-185
[**2130-12-25**] 07:15AM BLOOD PT-16.6* PTT-33.6 INR(PT)-1.7
[**2130-12-25**] 07:15AM BLOOD Glucose-69* UreaN-10 Creat-1.0 Na-136
K-3.5 Cl-106 HCO3-24 AnGap-10
[**2130-12-29**] 04:28AM BLOOD ESR-25*
[**2130-12-29**] 04:28AM BLOOD Glucose-81 UreaN-9 Creat-0.8 Na-138 K-3.7
Cl-109* HCO3-26 AnGap-7*
[**2130-12-29**] 04:28AM BLOOD Mg-1.8
OSH:
cervical spine [**12-13**]: listhesis, cervical spondylosis with
foraminal encroachment
CT sinus ([**12-5**]): tiny mucous retension cyst in the floor of
right maxillary sinus otherwise clear
MRI spine ([**12-2**]): multifocal osteo and discitis of C4-6, T1-2,
T5, new disease in L1-2 vs [**11-12**] study; progression of disease at
L5/s1; mod. cent. stenosis mainly degnerative at C4-6 levels, no
epidural abscess; epidural abscess in the lumbar spine are
improving altho epidural abscess at L5-S1 and in the sacral
canal to cause compression of thecal sac
Head CT ([**12-2**]): no actue abn
[**Hospital1 **] radiology:
CXR [**12-18**]: no focal opacities
Abd U/s:
1) Small amount of perihepatic free fluid.
2) Mild gallbladder wall edema, presumably related to underlying
liver disease.
3) Splenomegaly.
4) Patent portal vein.
Micro: several blood and urine cx NGTD
Angio report: PROCEDURE: The procedure was performed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 60162**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Dr. [**First Name (STitle) **], the staff radiologist,
was present and supervising throughout. The patient was placed
supine on the angiography table. His right upper extremity was
prepped and draped in the standard sterile fashion. Since no
suitable superficial vein was visible, ultrasound was used for
localization of an appropriate vein. The right basilic vein was
patent and compressible. The skin and subcutaneous tissues were
anesthetized with 5 cc of 1% Lidocaine. Using ultrasound
guidance, the right basilic vein was accessed with a 21 gauge
micropuncture needle. A .018 Nitinol wire was advanced through
the access needle into the superior vena cava under fluoroscopic
visualization. The skin entry site was incised with a #11 blade
scalpel. The access needle was exchanged for a 4 French
micropuncture sheath with inner dilator. The inner dilator was
removed. Using the Nitinol wire for measurement, it was
determined that a length of 39 cm would be appropriate. The PICC
line was then trimmed to length and advanced over the guidewire
through the peel away sheath into the superior vena cava. The
guidewire and peel away sheath were removed. The catheter was
flushed, capped, and HEP-locked. It was secured to the skin
using a STAT-lock device.
Fluoroscopy was used to investigate the possibility of a PICC
fragment in the left upper extremity. Again, consisitent with
the examination performed [**2130-12-22**], there was no fragment
identified.
Hip xray [**12-24**]:
IMPRESSION: Marked degenerative changes in the lower lumbar
spine. No fracture seen.
Lumbar spine [**12-24**]:
Marked degenerative changes in the lower lumbar spine. No
fracture seen.
Echo [**12-22**]:
1. The left atrium is moderately dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Regional left ventricular wall motion is
normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is moderately dilated. The ascending aorta is
mildly
dilated. The aortic arch is mildly dilated. 5.The aortic valve
leaflets (3)
are mildly thickened. No aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is
seen.
7.There is moderate pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
CT Chest [**12-24**]:
1. No abscess identified.
2. Pulmonary edema with patchy atelectasis and small bilateral
pleural effusions.
3. In the visualized portion of the abdomen, there is ascites
seen. The liver has a nodular appearance.
MRI [**12-22**]:
Limited lumbosacral spine imaging suggests that there is
discitis osteomyelitis at L1/2 and L5/S1 levels. Previous
imaging examinations reported to have been delivered to the
radiology department are not available at the time of this
report. This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who is
covering for Dr. [**First Name (STitle) **] at 4:15p on [**2130-12-22**].
Limited examination demonstrates cervical mal-alignment and
spinal stenosis, most likely due to degenerative change. There
are signal abnormalities within the vertebrae which could
represent areas of edema from infection. There is a suggestion
of slightly increased T2w signal in the prevertebral soft
tissues, though there is only limited visualization of this
space. Findings were reported to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. A more
complete study with Gadolinium enhanced imaging should be
obtained when the patient is able to lie still for this study.
Head CT [**12-21**]:
1. No acute intracranial hemorrhage, mass effect, or abnormal
enhancing lesions. The contrast enhanced images are technically
suboptimal.
2. Polynasal sinus disease.
Brief Hospital Course:
Impression: 70 yo m w/ alcoholic cirrhosis, h/o epistaxis,
s.[**Month/Year (2) 60161**] endocarditis, transferred, on arrival w/ poor ms now
clearing with lactulose transferred from [**Hospital Unit Name 153**] for further mgmt
of encephalopathy and osteo.
In [**Name (NI) 153**], pt had low grade fever, tachycardia to 120's, now
resolved, and SBP's 119-150s, O2 sats 97% on 4 L FM --> 2L O2
NC. He arrived somnolent with little response to questions, and
over course, he awoke with lactulose. In the unit, he was given
a free water bolus and then D51/2 NS for MIVF with improvmeent
in his Na to the mid 140's from 150s. NGT showed bilious
material with some blood which then D/c'd. He recived an abd u/s
which showed . Transfused one unit FFP and vit K for
coagulopathy. MRI/repeat head CT deferred [**3-13**] MS. LP considered
but given possibility of other sites of osteo this was deferred.
ID following to determination of length of treatment. Zosyn
d/c'd as unclear what was being treated and pts MS clearing.
Medical floor course as follows:
1) Change in MS- Multifactorial including infectious,
toxic/metabolic (likely [**Month/Day (2) 19562**]), medication (opiate), alcohol
related. Also septic emboli to brain possible w/ known
endocarditis. Pt on rigerous lactulose regimen for [**4-13**] BM/day.
MS status began to clear in 48 hrs on transfer to floor with
decreased agitation. Agitation managed with haldol PO. Over the
next few days, MS markedly improved with longer intervals of
lucidity. CT of head showed no hemmorhage and no evidence of
septic emboli. On d/c, pts MS clear and agitation resolved. Pt
easily redirectable and needs to be reassured of his own saftey.
F/u with liver, ID, neurology to cont. monitoring this problem.
TSH, vitB12/folate all normal.
2) ESLD- [**3-13**] alcohol. Now hospitalized x approx 1 mo. No
current evidence of portal htn, although unclear if recent CT or
EGD. Most likely cause of delta ms [**First Name (Titles) **] [**Last Name (Titles) 19562**] encephalopathy.
Pt presented w/ epistaxis (h/o 4L blood loss) possible that
protein load is cause of decompensation. Cannot r/o bacterial
overgrowth, portal vv thrombosis. Additionally, S. [**Last Name (Titles) 60161**]
concerning for GI pathology, particularly malignancy. RUQ showed
no potral vein thrombus and good flow. Protonix 40 mg po qd, vit
k 10 mg sq x 3 days given during stay for elevated coags; with
stable INR after this. Will need EGD as outpt to look for
espohageal varicies for liver disease.
3) S. [**Last Name (Titles) **] bacteremia/endocarditis- s.[**Last Name (Titles) 60161**], s/p 4 wks therapy
w/ abx. Afebrile and no WBC ct. Splinter hemorrhages on exam.
See above for septic emboli [**3-13**] endocarditis. Started on [**Month/Day (2) 60163**] and
then changed to PCN G 2 MU IV q4 per ID on [**12-22**] and will need 3
more weeks total. Repeat TTE showed no change in valvular
disease. Chest CT showed small bilateral plueral effusions,
thought be a mild CHF. LAsix 10 mg IV given with good effect.
EKGs followed to look for conduciton abnormalities for extension
of disease; EKGs unchanged from prior. Given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] need
outpt colonsocpy. F/u arranged with GI, liver, and ID (tried
calling Dr [**Last Name (STitle) **] several times but busy) for this problem.
4)Osteomyelitis: Per MRI at OSH, unable to reimage to date [**3-13**]
MS. [**First Name (Titles) **] [**Last Name (Titles) 60163**] for endocarditis-->PCN (see above), which is
presumable source for this osteo. Given age and S [**Last Name (Titles) 60161**]
presence, need to consider bone mets. in differntial for
vertebral lesions. Repeat MRI of C spine attempted but pt
agitated an unable to complete satisfactory exam. Will need MRI
of spine with gad in [**3-14**] weeks prior to ortho f/u (please order
this study with gad and call Dr.[**Name (NI) 60164**] office to f/u on
results). Seen my ortho in house who suggested f/u in [**3-14**] weeks.
ESR still elevated on d/c, and will need weekly ESR check. Pain
controlled with fentanyl patch with no need for breakthrough
oxycodone; currently no pain or pain meds.
5) Aspiration PNA- h/o febrile at OSH. Started on pip/tazo for
coverage of asp pna however CXR clear so d/c'd after ID consult.
Aspiration precautions should be maintained until pts MS clears
fully.
6) Anemia: Anemia of chronic disease at baseline. However,
epistaxis is another source of blood loss. Possible GI with
small blood of prior NGT and OB + by [**Hospital Unit Name 153**] report. Hct stable in
house. GI follow up for colon/endo.
7) Fall: Pt had unwittnessed fall as he was getting up to use
the phone. Per report he lowered him self to ground and remained
there until nursing helped him. MD called who found no neuro
signs, no LOC per pt. MS unchanged. Hip and bakc xrays done. Pt
reports no pain. Fall precautions on discharge.
8) UTI- caniduria on transfer from OSH on fluconazole while in
[**Hospital Unit Name 153**]. Repeat UA negative. Pt incontinent so so diapers used.
9) FEN- hypovolemic on exam, labs c/w volume contraction. Slowly
improving hyperNa with D5W. Has 4 L deficit and was corrected
slowly, 2 L/24 hrs. also K wasting, perhaphs related to poor PO
intake. Sodium stable. Mg repleted daily, loss related to
diarrhea from lactulose. Eating regular diet.
10) Access: Pt arrived with PICC in right arm. During episode of
agitation, self d/c'd PICC. A CXR showed a retianed PICC
fragment. IR studies performed which showed no PICC fragment.
PICC placed on left arm for abx.
11) Prophylaxis: pneumoboots (altho not connected [**3-13**] writing in
bed), protonix, heparin sq
12) Code status: by report Full Code.
13) Oral sores: Poor oral care with hard dried plaques on
tongue. Improved now with oral care.
Pt d/c to rehab in stable condition.
Medications on Admission:
(on transfer)
fentanyl 75mcg q72h
fluconazole 100mg po qd
Lasix 20mg po qd (also via ngt at OSH)
Lactulose
Ativan 1mg iv q24h
Reglan 10mg iv q6h
morphine 4-8mg q4h prn
zosyn 3.375 mg iv q6h
flagyl 250mg tid
protonix 40mg qd
ceftriaxone 2g iv qd
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Primary:
1. Epistaxis.
2. [**Location (un) **] Encephalopathy.
3. Acute Renal Failure.
4. Coagulopathy.
5. S. [**Location (un) **] Mitral Valve Endocarditis.
6. S. [**Location (un) **] Cervical Epidural Abscess/Osteomyelitis.
Secondary:
1. Left Pleural Abscess.
2. ETOH Cirrhosis.
Discharge Condition:
Good.
Discharge Instructions:
If you have fevers/chills, worsening mental status, chest pain,
shortness of breath, or sharp back pain, please call your PCP or
come to the ED.
*f/u MRI with gad as outpt. Results to be followed up with Dr.
[**Last Name (STitle) **] (see below)
ICD9 Codes: 2760, 4280, 5849
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5763
}
|
Medical Text: Admission Date: [**2123-5-23**] Discharge Date: [**2123-6-3**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Ischemic right lower extremity
Major Surgical or Invasive Procedure:
[**5-23**]:
1. Aortogram with right lower extremity runoff, third order
catheterization.
2. Brachial artery access with third order catheterization.
3. Right superficial femoral artery antegrade access with
second order catheterization.
4. Mechanical thrombectomy (AngioJet).
5. Infusion for thrombolysis (TPA).
6. Right femoral-popliteal PTA.
7. Right popliteal stent 5 x 40 times two for residual
stenosis.
8. Right peroneal 4 x 40 and 3 x 120 PTA.
[**5-24**] Right lower extremity lytic check/catheter change
[**5-25**] removal of arterial sheath and percutaneous closure,
diagnostic right lower extremity arteriogram, follow-up tibial
thrombolysis, percutaneous balloon angioplasty of the mid
peroneal artery.
History of Present Illness:
The patient is an elderly gentleman who has an entire
aortobiiliac bypass graft with occlusion of the right limb and
femoral-femoral crossover graft. He presented to [**Hospital3 13347**] with knee pain and they thought that he had a septic
knee. He represented with worsening foot pain and discoloration.
He was sent here urgently. When we evaluated him, he had a very
ischemic foot. He had limited sensation, but did have motor,
although it was not completely normal. He had some calf
tenderness.
Physical Exam:
ON ADMISSION:
98.1 76 113/52 16 97% ROOM AIR
NAD
RRR
CTA Bilaterally
soft, ND, NT, NABS
Right extremity: knee tender to palpation with any motion, PT
dopplerable, DP not-dopplerable, cold foot.
Left extremity: DP palpable, PT dopplerable, warm throughout.
.
ON DISCHARGE:
97.8 67 142/60 18 96% ROOM AIR
NAD
RRR
CTA Bilaterally
soft, ND, NT, NABS
Right extremity: warm throughout, knee non-tender, DP/PT
dopplerable.
Left extremity: DP palpable, PT dopplerable, warm throughout.
Pertinent Results:
ON ADMISSION:
[**2123-5-23**] 06:21PM BLOOD WBC-22.6*# RBC-3.81*# Hgb-10.7*#
Hct-31.3*# MCV-82 MCH-28.0 MCHC-34.0 RDW-15.7* Plt Ct-317#
[**2123-5-23**] 06:21PM BLOOD Neuts-93.2* Bands-0 Lymphs-4.8*
Monos-1.6* Eos-0.3 Baso-0.1
[**2123-5-23**] 06:21PM BLOOD PT-14.3* PTT-60.9* INR(PT)-1.3*
[**2123-5-23**] 06:21PM BLOOD Glucose-118* UreaN-57* Creat-2.1* Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
[**2123-5-23**] 06:21PM BLOOD CK(CPK)-188*
[**2123-5-23**] 06:42PM BLOOD Lactate-1.4
.
ON DISCHARGE:
[**2123-6-3**] 04:50AM BLOOD WBC-8.0 RBC-4.26* Hgb-12.0* Hct-36.4*
MCV-85 MCH-28.1 MCHC-32.9 RDW-16.4* Plt Ct-387
[**2123-6-3**] 04:50AM BLOOD PT-22.5* PTT-62.2* INR(PT)-2.2*
[**2123-5-27**] 07:44AM BLOOD Fibrino-624*
[**2123-6-3**] 04:50AM BLOOD Glucose-111* UreaN-28* Creat-1.3* Na-137
K-4.3 Cl-107 HCO3-24 AnGap-10
[**2123-6-1**] 06:05AM BLOOD CK(CPK)-29*
[**2123-5-29**] 05:15AM BLOOD Lipase-89*
[**2123-6-2**] 12:32PM BLOOD CK-MB-4 cTropnT-0.13*
[**2123-6-3**] 04:50AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.3
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-23**] 6:11 PM
CHEST (PORTABLE AP)
Reason: eval [**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE thrombosis
REASON FOR THIS EXAMINATION:
eval pre-op
EXAMINATION: AP chest.
INDICATION: Right leg thrombosis.
A single AP view of the chest was obtained [**2123-5-23**] at 18:13 and
is compared with the prior study performed [**2118-9-19**].
Cardiomediastinal silhouette is unremarkable. The lungs show no
evidence of acute infiltrate, pleural effusion or pneumothorax.
There is some minimal linear atelectasis in the left base.
IMPRESSION:
Minimal linear basal atelectasis. No other acute process
demonstrated.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-23**] 11:53 PM
CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN
[**Name Initial (PRE) **]: check ETT position
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE ischemia
REASON FOR THIS EXAMINATION:
check ETT position
AP CHEST 1:27 A.M. ON [**5-24**]
HISTORY: Ischemia. Check ET tube placement.
IMPRESSION: AP chest compared to [**5-23**] at 6:13 a.m.:
Moderate-to-severe pulmonary edema is new, accompanied by
increased dilatation of pulmonary arteries though heart size is
normal and unchanged. Pleural effusions may be collecting
posteriorly, but are not substantial in size. ET tube in
standard placement. No pneumothorax.
.
RADIOLOGY Final Report
KNEE (AP, LAT & OBLIQUE) RIGHT PORT [**2123-5-24**] 7:42 PM
KNEE (AP, LAT & OBLIQUE) RIGHT
Reason: assess for [**Hospital 13348**]
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with
REASON FOR THIS EXAMINATION:
assess for sffusion
EXAMINATION: Right knee, 8:20 p.m., on [**5-24**].
HISTORY: Possible effusion.
IMPRESSION: Frontal and a lateral view of the right knee
suggests a small joint effusion in the suprapatellar recess. The
knee is other unremarkable. A vascular catheter lies posterior
to the lower femur and an arterial stent is posterior to the
upper aspect of the tibia.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-25**] 10:40 AM
CHEST (PORTABLE AP)
Reason: assess pulm edema
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE ischemia, MI s/p angio
REASON FOR THIS EXAMINATION:
assess pulm edema
INDICATION: Right lower extremity ischemia, myocardial
infarction.
CHEST, ONE VIEW: Comparison with multiple previous examinations,
the most recent being [**2123-5-24**]. Endotracheal tube is
unchanged in position. Pulmonary edema has resolved. Cardiac,
mediastinal, and hilar contours are now within normal limits.
Bilateral small pleural effusions may be present. No
pneumothorax. Osseous structures are unchanged. A 5-mm round
opacity overlying the right lung field has not been seen on
previous studies and probably represents a confluence of
shadows.
IMPRESSION: Bilateral pleural effusions. Improvement in
pulmonary edema
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-26**] 7:34 AM
CHEST (PORTABLE AP)
Reason: r/o infiltrates
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE ischemia, MI s/p angio
REASON FOR THIS EXAMINATION:
r/o infiltrates
HISTORY: 84-year-old man with right lower extremity ischemia,
myocardial infarction, status post angiogram.
COMPARISON: [**2123-5-25**].
CHEST, AP: Cardiac, mediastinal, and hilar contours are stable.
There is mild pulmonary edema, not significantly changed from
prior exam. The small bilateral pleural effusions appeared to
have slightly increased in size accounting for differences in
technique. Endotracheal tube is in unchanged position.
IMPRESSION: Mild pulmonary edema. Slight increase in size of
small bilateral pleural effusions.
.
Cardiology Report ECHO Study Date of [**2123-5-26**]
Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%)
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
16-20 mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is mild regional dysfunction with
focal mild hypokinesis of the distal septum and mid-anterior
walls. The remaining segments contract normally and overall LVEF
is preserved. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (?#) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction c/w CAD or focal myocarditis.
Moderate pulmonary artery systolic hypertension. Mild mitral
regurgitation.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-27**] 9:50 AM
CHEST (PORTABLE AP)
Reason: assess for infiltrates/effusions
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE ischemia, MI s/p angio
REASON FOR THIS EXAMINATION:
assess for infiltrates/effusions
REASON FOR EXAMINATION: Followup of a patient after _____.
Portable AP chest radiograph compared to [**2123-5-26**].
The patient was extubated in the meantime interval. The heart
size is normal. The bibasilar atelectasis and bilateral small
pleural effusion is unchanged, and there is no evidence of
congestive heart failure.
.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2123-5-27**] 8:42 AM
CT HEAD W/O CONTRAST
Reason: r/o cva/[**Hospital 13349**]
[**Hospital 93**] MEDICAL CONDITION:
84 year old man s/p rt popleteal stent and thrombectomy w/MS
changes. Had TPA w/thrombectomy
REASON FOR THIS EXAMINATION:
r/o cva/hemorrage
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post right popliteal stent and thrombectomy
with mental status changes. Head TPA with thrombectomy. Evaluate
for an intracranial hemorrhage or infarct.
TECHNIQUE: Non-contrast head CT.
COMPARISON EXAMINATION: [**2120-5-3**].
FINDINGS: Since the prior examination, there has been
development of an old appearing small right frontal lobe
infarct. The previously noted left frontal lobe infarct is
unchanged. Since the prior exam; however, there are new
periventricular white matter hypodensities, any one of which
could represent a small acute infarct. A MRI would be
recommended if exclusion of an acute infarct is needed.
As before, there are small lacunes in the caudate heads
bilaterally. There is no midline shift, mass effect or
hydrocephalus. There is no intracranial hemorrhage. The mastoid
sinus air cells are hypoplastic.
These findings were discussed with [**First Name8 (NamePattern2) **] [**Doctor Last Name **], the nurse
practitioner [**First Name (Titles) 767**] [**Last Name (Titles) 9686**] Surgery at the time of
dictation.
IMPRESSION:
Since the [**2119**] head CT, there has been interval development of a
small right frontal lobe infarct which appears chronic on this
examination. Numerous additional periventricular white matter
hypodensities are present, any one of which could represent a
small acute infarct. MRI would be needed to exclude that
diagnosis.
There is no intracranial hemorrhage.
.
RADIOLOGY Final Report
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2123-5-31**] 9:58 AM
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT)
Reason: pre-op for bypass
[**Hospital 93**] MEDICAL CONDITION:
84 y/o man presents with MI, cold R foot and hot R knee5/27: R
knee tap by ortho, R peroneal thrombectomy, stent, angioplasty
and placement of lysis catheter5/28 repeat angio, TPA5/29
peroneal cutting balloon, TPA5/30 angio, TPA cath removed
REASON FOR THIS EXAMINATION:
pre-op for bypass
VENOUS STUDY DATED 6
HISTORY: Extensive intervention for a cold right foot, now
requires vein mapping for possible bypass.
FINDINGS: The greater saphenous veins are patent bilaterally.
Please see digitized images on PACS for formal sequential vein
dimensions.
.
RADIOLOGY Final Report
PERSANTINE MIBI [**2123-5-31**]
PERSANTINE MIBI
Reason: 84 YO W/ MI; RT PERONEAL THROMBECTOMY, STENT,
ANGIOPLASTY, TPA [**5-26**] ANGIO, TPA CATH REMOVED
RADIOPHARMECEUTICAL DATA:
10.2 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2123-5-31**]);
29.6 mCi Tc-99m Sestamibi Stress ([**2123-5-31**]);
HISTORY: CAD, pre-operative evaluation.
SUMMARY OF DATA FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
mg/kg/min.
METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was
injected approximately one hour prior to obtaining the resting
images.
Two minutes after the cessation of infusion of dipyridamole,
approximately three times the resting dose of Tc99m sestamibi
was administered IV. Stress images were obtained approximately
one hour following tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is good.
Left ventricular cavity size is dilated at stress and rest.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium without signs of
reversible or irreversible
ischemia.
Gated images reveal hypokinesis.
The calculated left ventricular ejection fraction is low at 40%.
IMPRESSION: 1. Dilated left ventricle at rest and stress without
ischemic
changes. 2. Hypokinesis with depressed ejection fraction of 40%.
.
Cardiology Report STRESS Study Date of [**2123-5-31**]
IMPRESSION: No anginal symptoms or significant ST segment
changes from
baseline. Nuclear report sent separately.
Brief Hospital Course:
The patient was admitted to Dr.[**Name (NI) 1720**] Vascular Surgery
Service on [**2123-5-23**]. He was acutely taken to the operating room
where he underwent a aortogram with right lower extremity
runoff, third order catheterization, brachial artery access with
third order catheterization, right superficial femoral artery
antegrade access with second order catheterization, mechanical
thrombectomy (AngioJet), infusion for thrombolysis (TPA), right
femoral-popliteal PTA, right popliteal stent 5 x 40 times two
for residual stenosis, and right peroneal 4 x 40 and 3 x 120 PTA
on [**2123-5-23**]. During the procedure the patient became acutely
agitated with an elevated heart rate, and he was electively
intubated. Immediately post-op he was transferred to the CSRU
intubated. TPA infusion was continued into his right lower
extremity and his heart rate contorlled with b-blocker. On POD
1, his cardiac enzymes were elevated (Trop 2.13) and cardiology
was consulted, recommending aspirin, anticoagulation with
heparin drip, HR control with lopressor, and starting lipitor.
His knee was tapped by ortho after an knee xray showed a
possible effusion and cultures were later negative. He
continued to remain intubated and sedated and the TPA infusion
was continued. He was taken back for a right lower extremity
lytic check/catheter change. Please refer to the operative
report for further details. On POD 2, he was again taken back
for a diagnostic right lower extremity arteriogram, follow-up
tibial thrombolysis, percutaneous balloon angioplasty of the mid
peroneal artery. His cardiac enzymes continued rise peaking at
2.41 and then continued to trend downward until discharge. On
POD 4, he was extubated without complications. He was continued
on vancomycin for a possible knee infection and cipro floxacin
was started for a pneumonia (enterococcus). Post-extubation he
had a somnolent mental status with waxing and [**Doctor Last Name 688**] agitation.
Neurology was consulted believed it was post-operative delirium.
His mental status continued to improve daily after
extubation. He continued to remain afebrile and on POD 7 from
the first operation, he was stable for transfer from the CSRU to
the floor. While on the floor, the haperin drip was continued
and his post-operative course on the floor was uncomplicated.
He underwent a PMIBI per cardiology recommendations which showed
a dilated left ventricle at rest and stress without ischemic
changes and hypokinesis with depressed ejection fraction of 40%.
Cardiology felt this was unchanged from his previous studies
and recommeded no further intervention except follow-up on an
outpatient basis. He was started on coumadin in transition from
his heparin drip and was therapeutic by the day of discharge
with an INR of 2.2. He was deemed stable for discharge to a
rehab facility in POD 11 form the first operation. He was
afebrile and tolerating a regular diet. All his lines have been
discontinued without complications and he will be discharged no
14 days of ciprofloxacin for his pneumonia. His Trop level was
0.13. He will follow-up with Dr. [**Last Name (STitle) **] in 1 month with a
duplex of his lower extremities.
Medications on Admission:
plavix 75', lipitor 20', nifedipine 90', lisinopril 10',
metoprolol 25'' asa 81'
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-4**]
hours as needed for pain. Tablet(s)
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every
8 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Ischemic right leg, acute thrombosis
MI
Discharge Condition:
Stable
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-30**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**2-28**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Appointments to be made:
Call your primary care MD- Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 13350**] for a
follow-up appointment and INR (Coumadin test). He will manage
your anticoagulation but you MUST CALL FOR APPOINTMENT FOR
INR/blood draw. Goal INR is 2.5-3.0.
Expect to receive a call from Dr.[**Name (NI) 5695**] office to
schedule your appointment and lower extremity duplex. Please
call Dr. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD at [**Telephone/Fax (1) 1237**] to schedule a
follow-up appointment for 1 month from today if you do not hear
from the office within one week. You will need to get a lower
extremity duplex prior to your visit.
.
Scheduled Appointments :
You have a visit scheduled with Cardiology DR. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 10516**] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2123-6-18**] 4:00. he is
located in [**Hospital 23**] [**Hospital Ward Name 13351**]. He is the Cardiologist
that followed you during this hospital stay. You will need close
follow up with Cardiologist as outpatient given your Cardiac
history and inpatient events.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2123-7-13**] 10:15
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2123-11-1**] 2:00
ICD9 Codes: 5859, 2930, 4019, 412, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5764
}
|
Medical Text: Admission Date: [**2103-4-15**] Discharge Date: [**2103-4-24**]
Date of Birth: [**2040-11-1**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
syncope/ataxia
Major Surgical or Invasive Procedure:
[**2103-4-20**] Left craniotomy resection of tumor
History of Present Illness:
This is a 62 year old woman with PMH of recurrent Breast CA &
c/o sinusitis/
h/a's since mid [**Month (only) 1096**] despite mult antibiotics as well as
"tooth troubles" requiring extraction (which has continued to
leak since), presents to [**Hospital 1110**] hospital this afternoon. She
stated that she has noted confusion vs difficulty with words for
several months. While at the mall she had an episode where she
passed out. She was also noted (by her husband) to have gait
instability, and she says it was like she didn't know where her
foot was. She presented to OSH ([**Location (un) 1110**]) today where a CT i+ was
performed and revealed a Left occipital mass. She was
transferred to [**Hospital1 18**] and Neurosurgery consultation was
requested.
Past Medical History:
Breast Ca [**2089**] s/p R Mastectomy
recurrence in [**2101**], L Lumpectomy
partial hysterectomy
Social History:
Married, lives with husband. 1 son. +tobacco [**2-4**] ppd
at most. occasional etoh. no drugs. Current Oncologist is Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90056**] at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Assoc (assoc with [**Hospital3 1280**]).
Family History:
NC
Physical Exam:
On Admission:
O: T: 99.3 BP: 136/69 HR: 80 R 17 O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-7**] throughout. ? slight R pronator
drift
Sensation: Intact to light touch, propioception
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin, unsteady gait
Post op Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: incision c/d/i, PERRL, no lesion EOMs intact
Neck: Supple, no thyromegaly
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:
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Improved right homonymous hemianopsia
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-7**] throughout. slight R pronator
drift
Sensation: Intact to light touch, propioception
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin, unsteady gait
Pertinent Results:
[**2103-4-15**] 05:54PM URINE HOURS-RANDOM
[**2103-4-15**] 05:54PM URINE GR HOLD-HOLD
[**2103-4-15**] 05:54PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2103-4-15**] 05:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2103-4-15**] 04:29PM GLUCOSE-102* UREA N-9 CREAT-0.6 SODIUM-141
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13
[**2103-4-15**] 04:29PM estGFR-Using this
[**2103-4-15**] 04:29PM WBC-6.3 RBC-4.15* HGB-13.2 HCT-37.8 MCV-91
MCH-31.7 MCHC-34.9 RDW-13.0
[**2103-4-15**] 04:29PM NEUTS-75.0* LYMPHS-19.0 MONOS-5.3 EOS-0.4
BASOS-0.2
[**2103-4-15**] 04:29PM PLT COUNT-219
CT Torso [**2103-4-16**]
1. Cholelithiasis without evidence of cholecystitis.
2. Multiple hypodensities in the liver too small to be
definitively
characterized on CT possibly representing simple cysts or
hemangiomata.
3. No definitive evidence for tumor or infection
MRI head [**2103-4-16**]
1. Large left occipital lobe enhancing mass with areas of
central necrosis
and extensive surrounding edema is most likely a metastasis,
although the
differential diagnosis also includes a primary glial neoplasm.
The lack of
restricted diffusion within this mass excludes the diagnosis of
an abscess.
2. Approximately 15 mm of rightward shift of normally midline
structures,
without evidence of central herniation.
CTA Head [**2103-4-17**]
1. Left occipital mass with central necrosis and extensive
surrounding
vasogenic edema and contralateral midline shift.
2. The mass is highly vascular and partly supplied by the
branches of left
PCA. There is no evidence of an intracranial arterial
flow-limiting stenosis,
aneurysm or avascular malformation
Ct head [**2103-4-20**] Post op
1. Status post left occipitoparietal craniotomy with apparent
resection of
the left occipital mass. Expected postoperative changes in the
resection bed
include pneumocephalus and a small degree of hemorrhage. Minimal
subdural
hematoma is seen tracking along the left parafalcine region and
superior
portion of the left leaflet of the tentorium cerebelli. MR is
more sensitive
than CT for detection of residual tumor in the resection bed.
2. Unchanged left temporo-parieto-occipital region vasogenic
edema associated
with the previous left occipital lobe mass.
MR head [**2103-4-21**]
Status post resection of left occipital mass. Expected
post-surgical changes and blood products are seen. No definite
residual
enhancement is seen. No hydrocephalus. Marginal restricted
diffusion appears
to be due to postoperative change.
Brief Hospital Course:
Ms. [**Known lastname 58825**] was admitted to [**Hospital1 18**] for further work up of her
brain lesion. CT Torso did not show any obvious sources of
metastases. She was on steroids. Infectious work up was
initiated to rule out abscess.
On [**4-16**] She underwent a CT torso and MRI brain. CT Torso
revealed a liver cyst and cholelithiasis but no evidence of
tumor or mets.
On [**4-17**] infectious tests were resulted and did not indicate a
high suspicion of abscess. Neuro and Radiation Oncology were
consulted for assistance with plan of care. Ophthalmology was
also consulted.
On [**4-18**] the patient's exam continued to improve and she was
ambulating independently in the hallway. She went to the [**Hospital Ward Name **] for a formal ophthalmology evaluation. On [**4-20**], patient
underwent the above stated procedure. She tolerated the
procedure well and was extubated without incident. She was
trasferred to ICU for her acute post-operative course. Post op
CT revealed only postoperative changes. She remained in the ICU
on [**4-21**] and a post op MRI showed gross total resection with
postoperatvie changes. She was transferred to the floor in
stable condition. She was evaluated by PT/OT and was deemed
ready for discharge. She is tolerating an oral diet, her pain
is well controlled, she is neurologically stable, she is set for
d/c home and will f/u with Dr. [**Last Name (STitle) **] accordingly.
Medications on Admission:
advil, aromicin
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
Disp:*80 Tablet(s)* Refills:*0*
5. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*1*
6. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Left Occipital lesion
Sinusitis
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.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you been discharged on Keppra (Levetiracetam)for seizures,
you will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-12**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
??????You will / will not need an MRI of the brain with/ or without
gadolinium contrast.
Completed by:[**2103-4-24**]
ICD9 Codes: 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5765
}
|
Medical Text: Admission Date: [**2158-12-16**] Discharge Date: [**2158-12-27**]
Date of Birth: [**2081-2-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
transfer from OSH for brain lesion on CT
Major Surgical or Invasive Procedure:
Left cerebellar craniotomy with excision of lesion
History of Present Illness:
HPI: 77 yo R-handed female who presented to an OSH with
nausea/vomiting and diarrhea since midnight, diagnosed as
gastroenteritis but given her complaint of headache she had a
non-contrast head CT which showed a L cerebellar lesion. No
family member
present at this time for further history but the patient denies
chest pain/SOB, gait unsteadiness, vertigo/lightheadedness. No
fever or other constitutional symptoms. There was comment on the
OSH report about 5 mm midline shift but this was not appreciated
on her repeat NCHCT. Tx'd w/ Zofran and Decadron 10 mg iv. She
was noted to have BP up to 213/101 treated w/ Labetalol. At
baseline, pt oriented x 1.
Past Medical History:
PMHx:
-dementia
-COPD, O2-dependent at home
-HLD
-HTN
-THR
Social History:
SOCIAL Hx: lives with sons, past hx of tobacco, no EtOH.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM
T 96.5 BP 197 / 74 HR 58 R 15 O2Sats 94%
Gen: WD/WN, comfortable, NAD, prominent features of
hyperandrogenemia (hirsutism, male-pattern alopecia, coarse
facial features).
HEENT: Neck Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
NEURO on Admission:
MSE: drowsy, requires continual stimulation with loud voice and
touch to stay awake, oriented to month/year and person.
Inattentive and exhibits perseveration, possible L-sided
neglect.
CN: PERRL 2 to 1 bilat, blinks to threat bilat, EOMI without
nystagmus, facies symmetric, facial sensation intact and
symmetric, hearing intact to voice, tongue protrudes midline
without fasciculations.
MOTOR: nml bulk and tone bilaterally. No adventitious movements.
Does not participate in formal strength testing but moves all
limbs symmetrically antigravity and able to provide moderate
resistance. L-sided pronator drift.
SENSATION: intact to light touch bilaterally.
REFLEXES: DTRs 2 + and symmetric except absent ankle jerks;
plantars upgoing bilat.
COORDINATION: no obvious dysmetria on finger-nose-finger, slow
RAMS but symmetric.
GAIT: not tested as patient obtunded and could not specify
whether she walked with walker versus unassisted at baseline.
On discharge
oriented to herself - ambulatory - follows commands
Pertinent Results:
[**2158-12-19**] 02:11AM BLOOD CK(CPK)-329*
[**2158-12-18**] 02:19PM BLOOD CK(CPK)-332*
[**2158-12-19**] 02:11AM BLOOD CK-MB-8
[**2158-12-24**] 02:03AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0
[**2158-12-24**] 02:03AM BLOOD WBC-10.2 RBC-3.49* Hgb-10.9* Hct-32.3*
MCV-93 MCH-31.3 MCHC-33.8 RDW-13.9 Plt Ct-192
[**2158-12-24**] 02:03AM BLOOD Plt Ct-192
[**2158-12-24**] 02:03AM BLOOD Glucose-126* UreaN-24* Creat-0.8 Na-142
K-4.2 Cl-106 HCO3-31 AnGap-9
[**2158-12-24**] 02:26AM BLOOD freeCa-1.22
[**2158-12-26**] 7:15 am URINE Source: CVS.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
MR HEAD W & W/O CONTRAST [**2158-12-16**] 2:54 PM
Reason: eval masses, bleed
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with F w/new cerebellar lesions on CT with
Bleed. Exam for further evaluation per Neurosurgery
REASON FOR THIS EXAMINATION:
eval masses, bleed
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with left cerebellar lesion, for
further evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images were obtained before gadolinium. T1 axial
and coronal images were obtained following gadolinium. The
post-gadolinium images are somewhat limited by motion.
FINDINGS: As seen on the previous CT, there is an area of
hemorrhage seen in the left cerebellar hemisphere with
surrounding edema and mild mass effect on the fourth ventricle
with some effacement of the left side of the fourth ventricle.
Following gadolinium, subtle adjacent enhancement is suspected
on the medial aspect of the lesion, but the evaluation is
limited secondary to motion artifacts.
There are moderate changes of small vessel disease and brain
atrophy. No midline shift or hydrocephalus is seen.
There is no evidence of acute infarct on diffusion images.
IMPRESSION: Left cerebellar area of blood products with
surrounding edema and mild effacement of the left side of the
fourth ventricle. Subtle enhancement is suspected surrounding
the lesion suspicious for underlying abnormality. However, the
evaluation is limited by motion. A repeat post- gadolinium study
is recommended for further assessment.
MR HEAD W & W/O CONTRAST [**2158-12-23**] 12:20 PM
Reason: f/u
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman post-op excision L cerebellar tumor
REASON FOR THIS EXAMINATION:
f/u
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient is status post resection of left
cerebellar mass.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were acquired before
gadolinium. T1 sagittal, axial and coronal images were obtained
following the administration of gadolinium. Correlation was made
with the patient's preoperative MRI of [**2158-12-22**].
FINDINGS: Since the previous study, the patient has undergone
postoperative changes with the left-sided occipital craniotomy.
Blood products are seen in the left cerebellar hemisphere with
small amount of air from recent surgery. There is edema seen in
the left cerebellar hemisphere with minimal mass effect on the
left side of the fourth ventricle which has remained unchanged
from previous study. Following gadolinium administration, no
definite area of residual enhancement identified in the surgical
bed. There is no other abnormal area of enhancement seen. There
is mild-to-moderate prominence of ventricles identified with
prominence of temporal horns. The ventricular system appears to
be slightly more prominent than before. There is periventricular
hyperintensities visualized as before. There is no midline shift
seen.
Bilateral extensive soft tissue changes are identified in the
mastoid air cells.
IMPRESSION:
1. Status post resection of left cerebellar mass with blood
products at the surgical site with small amount of air from
recent surgery. No residual enhancement seen. No change in the
appearance of edema or mass effect identified.
2. Slightly more prominent ventricular system compared to the
preoperative MRI of [**2158-12-22**]. This is more apparent in the region
of temporal horns. Clinical correlation and a followup CT
recommended.
CT HEAD W/O CONTRAST [**2158-12-24**] 8:04 AM
Reason: LEFT CEREBELLAR MASS RESECTION, EVALUATE FOR POST OP
CHANGES
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman s/p Left cerebellar mass resection
REASON FOR THIS EXAMINATION:
post op changes
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post cerebellar tumor excision. Evaluate for
interval change.
COMPARISON: CT of the head [**2158-12-22**] and MRI of the brain [**2158-12-23**].
NON-CONTRAST HEAD CT: Left occipital craniotomy is consistent
with the history of left cerebellar resection. Pneumocephalus in
the resection site is slightly decreased compared to the prior
exam and there is a similar degree of mass effect on the fourth
ventricle. No evidence of tonsillar herniation is seen. The
overall ventricular size is unchanged. High-density foci at the
biopsy site are consistent with hemorrhage. There is no shift of
normally midline structures. Cerebral periventricular
hypoattenuation is consistent with chronic microvascular
infarction. Moderate-sized left parietal subgaleal fluid
collection has appeared, compared with the prior examination,
measuring 9 mm in greatest diameter; however, there is no
high-density material within it to suggest acute hemorrhage.
There is minimal opacification of the right mastoid air cells,
likely inflammatory in origin. The left mastoid air cells and
paranasal sinuses are clear.
IMPRESSION: Stable post-biopsy changes in the posterior fossa,
without evidence of new hemorrhage, herniation or mass effect.
Subgaleal post- operative seroma, which has evolved since the
prior study.
[**Known lastname **], [**Known firstname 95**] [**Hospital1 18**] [**Numeric Identifier 76852**]Portable TTE
(Complete) Done [**2158-12-20**] at 10:15:00 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] M.
[**Hospital1 **] C
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2081-2-26**]
Age (years): 77 F Hgt (in): 66
BP (mm Hg): 138/87 Wgt (lb): 170
HR (bpm): 68 BSA (m2): 1.87 m2
Indication: Left ventricular function. Preoperative assessment.
ICD-9 Codes: 410.92, 424.0, 424.2
Test Information
Date/Time: [**2158-12-20**] at 10:15 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2008W001-0:24 Machine: Vivid [**6-5**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.8 cm
Left Ventricle - Fractional Shortening: *0.25 >= 0.29
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Left Ventricle - Lateral Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *16 < 15
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 19 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Aortic Valve - Valve Area: *1.5 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.90
Mitral Valve - E Wave deceleration time: *253 ms 140-250 ms
Pulmonic Valve - Peak Velocity: 1.0 m/sec <= 1.5 m/sec
Findings
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. TDI E/e' >15, suggesting
PCWP>18mmHg. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
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 severe
hypokinesis/akinesis of the inferior wall. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Inferior hypokinesis/akinesis. Mild aortic stenosis.
Diastolic dysfunction.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2158-12-20**] 14:21
Cardiology Report ECG Study Date of [**2158-12-16**] 5:44:04 AM
Sinus rhythm. Possible left ventricular hypertrophy. Multifocal
ventricular
premature beats. T wave inversions are present in leads aVL and
V5-V6.
Myocardial ischemia cannot be ruled out. No previous tracing
available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 144 104 442/463 77 17 93
CHEST (PORTABLE AP) [**2158-12-23**] 5:48 AM
Reason: check placement of [**Last Name (un) **] gastric tube
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with
REASON FOR THIS EXAMINATION:
check placement of [**Last Name (un) **] gastric tube
INDICATION: Check nasogastric tube position.
COMPARISONS: [**2158-12-17**].
AP PORTABLE
CHEST: The ET tube terminates 5.8 cm above the carina. A
nasogastric tube is present coursing below the diaphragm,
although its tip is not seen. The lungs appear clear. There is
no pneumothorax. The heart size is normal.
IMPRESSION:
1. A nasogastric tube, the tip of which is not visualized.
2. No acute cardiopulmonary process.
CT CHEST W/CONTRAST; CT ABD W&W/O C
Reason: r/o occult primary malignancy, patient has clinical
hyperand
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with L cerebellar lesion, possibly metastasis
REASON FOR THIS EXAMINATION:
r/o occult primary malignancy, patient has clinical
hyperandrogenemia, please evaluate adrenals & ovaries.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 77-year-old with left cerebellar lesion and possible
metastasis. Evaluate for occult malignancy. Evaluate adrenals
and ovaries as the patient has clinical hyperandrogenemia.
COMPARISON: Chest radiograph, [**2158-12-16**] and CT of the head,
[**2158-12-16**].
TECHNIQUE: Multidetector helical scanning of the chest, abdomen,
and pelvis was performed following the administration of oral
and 130 cc IV Optiray contrast. Non-contrast images and delayed
images were obtained through the upper abdomen. Coronal and
sagittal reformats were displayed.
CT OF THE CHEST: A 13-mm hypoattenuating lesion within the right
lobe of the thyroid is seen. The thyroid gland is mildly
enlarged. There is no supraclavicular, mediastinal, hilar, or
axillary lymphadenopathy. Heart size is within normal limits;
however, there is extensive coronary artery calcification in the
LAD, left circumflex, and RCA. The great vessels and aorta are
unremarkable. The bronchi are patent to the subsegmental level.
There are no focal consolidations or evidence of pulmonary
edema. Scattered nodularities are seen throughout the lungs,
including 4- to 6-mm nodules within the right lower lobe (3:42),
and a 6-mm nodule within the left lower lobe. There is also
dependent atelectasis at the lung bases with some areas of
nodularity within this. Small axial hiatal hernia is noted.
CT OF THE ABDOMEN: There are two 1-cm hypodensities within the
right lobe of the liver which do not meet CT criteria for cysts
and may represent cysts or hemangiomas. The spleen, gallbladder,
right adrenal gland, and pancreas are normal. Prominence of the
left adrenal gland, without a discrete nodule, likely reflects
left adrenal hyperplasia. There is a 1- cm simple cyst within
the upper pole of the right kidney. The kidneys enhance and
excrete contrast symmetrically. The small and large bowel loops
are normal, and there is no free air or free fluid. The aorta is
tortuous and aneurysmal measuring up to 3.9 x 3.1 cm below the
level of the renal arteries (3:72). There is extensive
atherosclerotic plaque throughout the aorta and the iliac
vessels. The left ovarian vein is prominent.
CT OF THE PELVIS: Sigmoid diverticulosis without diverticulitis
is noted. There is no lymphadenopathy in the pelvis. Trace free
fluid is noted. The uterus, adnexa, and rectum are normal. Foley
catheter and air are seen within the bladder.
BONE WINDOWS: Right hip arthroplasty is noted. There are no bone
findings of malignancy. Extensive degenerative changes are noted
in the lower lumbar spine. Facet hypertrophy and ligamentum
flavum hypertrophy create moderate canal stenosis at L4-5 and
L5-S1.
IMPRESSION:
1. No evidence of intrathoracic or intraabdominal malignancy in
this patient with a cerebellar mass. Small bilateral
ground-glass nodules within the lungs are likely inflammatory or
infectious, and attention should be paid to these on followup
exams.
2. Extensive coronary artery and aortic calcifications.
3. Infrarenal AAA measuring up to 3.9 cm.
4. Hepatic hypodensities which cannot be further characterized
and may represent cysts or hemangiomas.
5. Small axial hiatal hernia.
6. Sigmoid diverticulosis.
7. Thickening of the left adrenal gland, without discrete
nodule, likely adrenal hyperplasia.
Brief Hospital Course:
Pt was admitted to the neurosurgical service for Left Cerebellar
mass and monitored in ICU. She remained neurologically stable.
MRI required intubation secondary to agitation. She was
pre-oped in preparation for the OR. CT torso showed no
malignancy, however, findings as reported previously in note.
She had an episode of atrial tachycardia [**12-19**], was seen in
consulatation by cardiology and cleared for surgery. On [**12-21**] she
underwent Left-sided suboccipital craniotomy for resection. She
tolerated procedure well and was closely monitored post op. Post
op CT showed Post-operative changes in the posterior fossa
without evidence of hemorrhage, herniation or new mass effect.
Her diet and actviity were advanced. She was seen by PT/OT.
Pathology report is not complete at this time however the prelim
diagnosis is melenoma.
She will follow up with oncology, radiation, dermatology and
opthomology for ?ocular melanoma as well as brain tumor clinic.
Medications on Admission:
MEDs:
-Aricept 10 Qhs
-ASA 81 mg Qday
-Advair 250/50 1 inh [**Hospital1 **]
-MVI Qday
-Citalopram 20 mg poQday
-Lisinopril 10 mg poQday
-Simvastatin 20 mg poQday
-Namenda 10 mg poQday
Discharge Medications:
1. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid ().
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO Qday ().
8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 34004**] Nursing And Rehab Center
Discharge Diagnosis:
Cerebellar tumor
Urinary tract infection
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? Continue taking steroids as prescribed.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
PLEASE RETURN TO THE OFFICE [**2159-1-8**] FOR A FOLLOW UP
APPOINTMENT AS WELL AS FOR REMOVAL OF YOUR STAPLES/SUTURES
PLEASE CALL [**Telephone/Fax (1) **] if you need to cancel
YOU WILL NOT NEED A CAT SCAN OF THE BRAIN PRIOR TO THE
APPOINTMENT
All other follow up appointments, please see below
Followup Instructions:
You have a Brain [**Hospital 341**] Clinic appointment on [**2159-1-8**]
at 2pm. You will have your sutures removed at that time as well.
It is located on the [**Hospital Ward Name 516**] on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building [**Telephone/Fax (1) 1844**].
You have an apptointment in the dermatology clinc on [**1-19**], [**2158**] at 2:15pm with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **]. Please call
[**Telephone/Fax (1) 1971**] if you need to cancel.
You have an appointment in the [**Hospital 7650**] clinic on [**1-16**],[**2158**] Tuesday at at 10:30am. Please call [**Telephone/Fax (1) 253**] if you
need to cancel.
Call Dr.[**Name (NI) 9034**] office with any questions at [**Telephone/Fax (1) 1669**].
Completed by:[**2158-12-27**]
ICD9 Codes: 5990, 496, 2724, 4019, 4241
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5766
}
|
Medical Text: Admission Date: [**2183-3-7**] Discharge Date: [**2183-3-21**]
Date of Birth: [**2112-1-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
71M with h/o ESRD on HD (M/W/F), chronic systolic HF (EF 15-20%)
s/p MI presenting with nonproductive cough x3d. His longstanding
DOE is not acutely changed with the onset of cough, but he is
able to ambulate significantly less than baseline due to
fatigue. He reports leg weakness and back pain limiting his
ability to get out of a chair. He can only walk a few feet
before feeling SOB, lightheadedness and needing to rest. He
denies chest pain on exertion. He has had orthopnea for several
months which is unchanged. He reports leg swelling that has been
stable for 2 months since starting HD in [**12/2182**] and fluctuates
with dialysis. Per OMR, he has been coming to dialysis above his
expected dry weights and has had 3-4L removed at dialysis
sessions recently.
.
Of note, pt was just admitted [**2-28**] to [**3-2**] for diarrhea and
abdominal pain. CT abdomen pelvis showed no colitis or acute
process. Nothing to suggest infection or systemic illness. Stool
Cx's negative and pt was treated and discharged on Imodium. He
c/o cough on that admission but CXR reportedly negative.
.
Initial ED vitals: 98.4 83 139/80 18 95% RA. On ED exam, had
extremely faint bibasilar crackles, faint wheezing, difficulty
taking a maximal inspiration due to cough, protuberant abdomen
but soft NT.
EKG showed sinus at 74 bpm, 1st degree AV block, no change from
prior. Bedside u/s showed minimal effusion visible, no evidence
of tamponade. Pt received albuterol and ipratropium nebs and
benzonatate. CXR showed fluid overload, so pt is admitted for HD
to remove fluid.
.
On the floor, pt has been started on HD - 3L removed with plan
for repeat HD tomorrow. He continues to have dry cough, but is
otherwise comfortable in bed and stable. Reports having eaten
take-out Chinese food several times since leaving the hospital a
few days before. Denies any more episodes of diarrhea or blood
in his stool.
Past Medical History:
- Chronic Systolic Heart Failure (EF 15% [**11/2182**] at [**Hospital1 112**])
- Chronic kidney disease of unknown recent level
- Hypertension
- Hx left basal ganglia lacunar infart, [**2176**]
- Hypercholesterolemia
- Elevated PSA with enlarged prostate; more recently the patient
chronically straight caths himself
- Recurrent UTIs w/ report of sterile pyuria
- Hemorrhoids
- s/p Right inguinal hernia repair, [**1-/2181**]
Social History:
He lives at home with his wife and daughter. [**Name (NI) **] is originally
from [**First Name8 (NamePattern2) 466**] [**Country 467**]. He is a former smoker having quit many years
ago. He drinks no alcohol. He denies history of drug use.
Family History:
Daughter who died of soft tissue sarcoma
Physical Exam:
ADMISSION
VS T 97.3 BP 147/76 HR 76 RR 16 O2 98/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, slightly dry MM, oropharynx clear
Neck: supple, JVP to ear, no LAD
Lungs: Decreased bilateral breath sounds at bases with faint
bibasilar crackles, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley, enlarged scrotal hernia
Ext: 2+ pitting edema to upper thigh, WWP, 2+ pulses, no
clubbing, cyanosis
Neuro: CNs2-12 intact, motor function grossly normal
.
MEDICINE - >ICU transfer exam
VS Tm 98.0 Tc 97.7 115/78 63 18 98/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, slightly dry MM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Faint bibasilar crackles; no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley, enlarged scrotal hernia
Ext: 2no edema (wrinkled skin), WWP, 2+ pulses, no clubbing,
cyanosis
Neuro: CNs2-12 intact, motor function grossly normal
.
DISCHARGE EXAM
VS 97.8 139/71 68 18 100/RA
24H UOP 600yellow
GEN alert, oriented, no acute distress, sitting up in HD
HEENT: Sclera anicteric, MM dry, oropharynx clear, no cough
Neck: supple, JVP nondistended, no LAD
Lungs: Good aeration, diffuse bilateral rales; no wheezes,
ronchi
CV: RRR, normal S1 + S2, II/VI systolic murmur
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds, no rebound tenderness or guarding, no organomegaly
GU: foley draining concentrated yellow urine
Ext: no pedal/ankle edema. skin dry/wrinkled, 2+ pulses, no
cyanosis
Neuro: CN2-12 intact, strength 5/5 throughout, sensation intact;
gait slow but narrow and stable
Pertinent Results:
ADMISSION LABS
[**2183-3-7**] 03:20PM BLOOD WBC-8.1 RBC-3.23* Hgb-9.5* Hct-31.3*
MCV-97 MCH-29.5 MCHC-30.4* RDW-18.0* Plt Ct-348
[**2183-3-7**] 03:20PM BLOOD Neuts-74.8* Lymphs-18.6 Monos-4.5 Eos-1.4
Baso-0.8
[**2183-3-7**] 03:20PM BLOOD Glucose-108* UreaN-39* Creat-5.1* Na-139
K-5.1 Cl-99 HCO3-25 AnGap-20
[**2183-3-8**] 06:05AM BLOOD ALT-26 AST-36 CK(CPK)-48 AlkPhos-244*
TotBili-0.6
.
CARDIAC ENZYMES/LIPIDS
[**2183-3-7**] 03:20PM BLOOD CK-MB-2 cTropnT-0.63* proBNP-GREATER TH
[**2183-3-8**] 06:05AM BLOOD CK-MB-2 cTropnT-0.58*
[**2183-3-9**] 06:30AM BLOOD CK-MB-2 cTropnT-0.46*
[**2183-3-9**] 06:30AM BLOOD Triglyc-41 HDL-58 CHOL/HD-2.3 LDLcalc-67
.
DISCHARGE LABS
[**2183-3-21**] 07:23AM BLOOD WBC-7.5 RBC-2.91* Hgb-8.6* Hct-26.8*
MCV-92 MCH-29.5 MCHC-31.9 RDW-16.7* Plt Ct-264
[**2183-3-21**] 07:23AM BLOOD Glucose-132* UreaN-44* Creat-4.5* Na-135
K-4.2 Cl-96 HCO3-28 AnGap-15
[**2183-3-21**] 07:23AM BLOOD Calcium-8.3* Phos-1.8* Mg-1.9
.
IMAGING
.
[**3-7**] CXR
FINDINGS: AP and lateral radiographs of the chest were acquired.
The heart
is massively enlarged, as before. Small bilateral pleural
effusions are not
significantly changed. Diffuse interstitial opacities with
perihilar
predominance are likely secondary to mild interstitial pulmonary
edema,
increased compared to radiographs from [**2183-3-1**]. No
focal
consolidations concerning for pneumonia. There is no
pneumothorax. The
mediastinal contours are stable.
IMPRESSION:
1. Mild interstitial pulmonary edema.
2. Massive cardiomegaly, not significantly changed.
3. Small bilateral pleural effusions, not significantly changed.
.
[**3-8**] CXR
MPRESSION: AP chest compared to [**3-7**]:
Mild pulmonary edema has improved, severe cardiomegaly has not.
Mediastinal
veins are not particularly dilated. There is no large pleural
effusion.
Dialysis catheter ends in the right atrium. No pneumothorax.
.
[**3-10**] TTE
Conclusions
The left atrium is moderately dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is 5-10 mmHg. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated with severe global
hypokinesis and relative preservation of basal inferior and
inferolateral function (LVEF = 25 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The estimated cardiac index
is depressed (<2.0L/min/m2). No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. Severe (4+)
mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. [In the setting of at least moderate to severe
tricuspid regurgitation, the estimated pulmonary artery systolic
pressure may be underestimated due to a very high right atrial
pressure.] There is a very small pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with cavity
dilation and extensive systolic dysfunction c/w diffuse process
(toxin, metabolic, valve, multivessel CAD). Severe mitral
regurgitation. Severe tricuspid regurgitation. Mild aortic
regurgitation.
.
[**3-19**] TTE
Conclusions
The left atrium is moderately dilated. The right atrium is
markedly dilated. A patent foramen ovale is present. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF=
20-25%). [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
The right ventricular cavity is moderately dilated with global
free wall hypokinesis. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Severe (4+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Severe [4+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension. [In the
setting of at least moderate to severe tricuspid regurgitation,
the estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is a very small pericardial effusion.
Compared with the prior study (images reviewed) of [**2183-3-10**],
the left and right ventricular cavities are probably slightly
smaller. RV function is marginally better. The severity of
mitral and tricuspid regurgitation is probably still severe but
the regurgitant volumes may be lower. Estimated pulmonary artery
pressures are substantially higher (were likely UNDERestimated
on the prior echo). Agitated saline was given on the current
study and demonstrated shunting, likely through a stretched PFO.
.
[**2183-3-12**] CT ABD/PELVIS
FINDINGS: Bilateral moderate pleural effusions, right great than
left. These are unchanged in size from previous. There is
overlying atelectasis. No pulmonary nodules. The heart is
enlarged. There is no pericardial effusion.
No coronary artery calcification.
Evaluation of the intra-abdominal viscera is limited by lack of
IV contrast.
Allowing for this, there are multiple coarse calcifications
within the liver and spleen consistent with a calcified
granulomata. There is no intra- or extra-hepatic duct dilation.
The spleen is normal in size. The pancreas and both adrenal
glands appear normal. Both kidneys are atrophied. There is
persistent hydroureter bilaterally. Mild hydronephrosis
bilaterally. No
renal stones.
There is calcification of the intra-abdominal aorta. The
intra-abdominal aorta demonstrates focal dilation measuring 2.9
cm which is unchanged from previous CT. Allowing for the lack of
oral contrast, the visualized stomach, small and large bowel are
normal.
Persistent perihepatic fluid which is decreased in amount from
previous.
There is persistent mesenteric edema. Multiple enlarged left
paraaortic lymph nodes are again identified, the largest
measuring 12 mm in diameter. These are unchanged from previous
CT (2:27).
CT PELVIS: The rectum, sigmoid are normal in appearance. There
are bilateral small bowel-containing inguinal hernias. No
evidence of obstruction. Foley catheter within the urinary
bladder. There is no significant pelvic or inguinal adenopathy.
Moderate prostatic enlargment.
OSSEOUS STRUCTURES: Bilateral degenerative disease of both hip
joints. No
suspicious osseous or sclerotic osseous lucent or sclerotic bone
lesion
identified. Schmorl's nodes present at L3 and L4. Osseous
changes of renal
osteodystrophy present with osteopenia and cortical thinning.
IMPRESSION:
1. No evidence of retroperitoneal bleed.
2. Volume overload with anasarca, moderate bilateral pleural
effusions, and mesenteric edema.
3. Bilateral inguinal hernias with a large right inguinal
hernia. Both
inguinal hernias contain nonobstructed small bowel loops.
4. Moderate prostatic enlargement.
5. Stable focal aortic dilation to 2.9 cm.
6. Renal atrophy and persistent mild-to-moderate bilateral
hydroureteronephrosis.
7. Osseous changes of renal osteodystrophy.
Brief Hospital Course:
71M with h/o ESRD on HD (M/W/F), chronic systolic HF (EF 15-20%)
s/p MI presenting with nonproductive cough x3d.
.
# COUGH
On admission, patient complained of 3 days of dry cough and
progressive leg swelling since last discharge 3d ago. Grossly
volume overloaded on exam & by CXR, likely the result of dietary
indiscretion coupled with dialysis-dependent ESRD and chronic
systolic HF (EF 15-20%) as below. Dialyzed for at least 3L
during each dialysis session (many) during this admission.
.
# CHRONIC SYSTOLIC HEART FAILURE (LVEF 25%)
Grossly volume overloaded on initial exam. Underwent urgent HD
session on admission during which 3L were removed, and another
5L were removed at a repeat session 24h later. Reasons for
exacerbation considered in this pt initially included dietary
indiscretion, worsening myocardial function (although enzymes
and EKG unimpresive), insufficient volume removal at HD
(unlikely given large-volumes recorded) and/or medication
noncompliance (esp diuretic). Dietary indiscretion was thought
most likely. However, when he became acutely edematous and SOB
while on a 1-day HD holiday, there was increasing concern for
worsening cardiac output as the primary problem. Chart review
(see PCP notes from [**12/2182**]) reveal that at the [**Hospital1 112**] in [**Month (only) **]
[**2182**], cardiomyopathy was attributed to irreversible ischemia in
the mid-to-distal LAD distribution as demonstrated on Stress
Echo. At this time we also suspect interval worsening because of
hypertension, worsening valvular disease, and/or cardiorenal
syndrome with some additional, but not primary, contribution
from dietary indiscretion/excessive fluid intake as above,
because repeat TTE on [**3-10**] showed improved LVEF at 25% but
worsening LV global hypokinesis & MR, TR. Cardiology consult
service recommend adjusting medications as follows:
- transition from lasix to torsemide 40 mg QD
- transition from metoprolol to carvedilol 25 [**Hospital1 **]
- start spironolactone 25 QD
- start metolazone 5 QD
- increase lisinopril 20 QD
He continued to require regular dialysis for 3L fluid removal
per session, but weights, volume status, HR and BP were stable
on this new medication regimen for several days prior to
discharge, even through 2-day weekend HD "holiday."
.
# ESRD on HD
On HD qMWF via RIJ HD line since [**83**]/[**2182**]. Oliguric. Initial
reason for ESRD appears to be bilateral hydronephrosis [**2-27**]
idiopathic obstruction, per [**Hospital1 112**] records. Patient has been
self-cath'ing for several years. Cr was [**5-1**] at [**Hospital1 112**] in [**Month (only) **]
[**2183**], then 10 here at [**Hospital1 18**] in [**Month (only) 1096**] - he was convinced to
start regular HD here at that time, but continues to believe his
renal failure is reversible and refuses fistula placement.
During this admission, he underwent numerous extra dialysis
sessions for total >15L volume removal via HD, including 8L
within the first 2 days. Patient counseled on low-salt diet, but
may need more frequent and/or higher-volume dialysis sessions in
the future if volume overload continues to be problem[**Name (NI) 115**]. There
was concern that worsening heart failure (as above) was a major
contributor to his increased dialysis needs. HD frequency will
require intermittent reassessment.
.
# BPH
Pt has chronic urinary obstruction, has been self-catheterizing
at home. Has been seen by urology, and is being followed for
BPH. Foley placed during admission since he refused to
self-catheterize or be catheterized by nurse. UA showed pyuria
as before; this was not treated.
.
# TRAUMATIC FOLEY REMOVAL
Patient had foley catheter placed, as above. At time of
anticipated discharge on HD 10, he suffered large-volume
urethral bleed after foley catheter removal (9 pt Hct drop over
the subsequent 6 hours). HD stable. Seen by urology consult who
recommended replacing foley for tamponade. Ongoing hematuria for
3-4 days, until the day of discharge, when urine was yellow,
clear of frank blood and clots. Despite strong urging of medical
staff to keep foley in place until scheduled urology follow-up
in a few days, patient insisted upon catheter removal. Warning
signs of recurrent bleeding/outflow obstruction by new clot
(bleeding, inability to urinate, pain/swelling in penis) were
review with the patient before discharge - he agreed to seek
urgent medical attention PRN. Catheter removal was atraumatic,
no further urethral bleeding.
.
# HTN
SBPs initially ranged 130s-150s. On lisinopril at home; this was
increased to 20 mg QD. Also started on carvedilol and lasix
switched to torsemide for CHF management (as above). BP baseline
improved fto 110s after these medication adjustments.
.
# UNEXPLAINED HCT DROP
On HD5, labs checked at HD reflected 9-pt Hct drop since last
check 24h prior. While dilution from fluid retention pre-HD
likely contributed, these was significant concern for recurrent
GIB (given recent admission for GIB). Pt did report some "black
stools" the night before (which he had previously denied).
Transfused with 2U PRBC and transferred to the ICU given
difficult access, unstable hct, relative hypotension (150->115),
and possible need for endoscopy. Curiously, stool guaiac was
negative x2 and he was HD stable. Underwent colonoscopy/EGD by
GI consult, with no evidence of bleeding source. GI recommended
capsule endoscopy but patient refused. CT abd/pelvis showed no
evidence of RP or other intra-abdominal bleeding. Hct stabilized
within 24h and remained stable for several days, until it fell 9
pts a second time in the setting of traumatic foley removal (as
above).
.
# LEG PAIN
Pt complained of intermittent bilateral leg pain which resolved
w/tylenol. Suspected to be [**2-27**] volume contraction in the setting
of frequent large-volume ultrafiltration at HD. If weights stay
stable on new CHF med regimen, would expect leg pain to
gradually subside.
.
TRANSITIONAL ISSUES
1. WILL NEED ONGOING MONITORING/COUNSELING FOR DIETARY
INDISCRETION/EDUCATION ABOUT PROGNOSIS AND SELF-CARE WITH CHF,
ESRD
2. MONITOR HR, BP (NEW MED REGIMEN)
3. MONITOR WEIGHTS, POSSIBLE NEED FOR OCCASIONAL EXTRA HD
SESSIONS AS AN OUTPATIENT
4. UROLOGY FOLLOW-UP FOR CHRONIC ISSUES, RECENT TRAUMATIC FOLEY
REMOVAL
5. ENCOURAGE PT TO UNDERGO CAPSULE ENDOSCOPY GIVEN UNEXPLAINED
HCT DROP, "BLACK STOOLS" AND REFUSAL OF CAPSULE ENDOSCOPY
IN-HOUSE
Medications on Admission:
1. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation: do not take if you
have diarrhea.
6. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation: do not take if you have diarrhea.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation: do not take if you have diarrhea.
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. loperamide 2 mg Capsule Sig: One (1) Capsule PO four times a
day as needed for diarrhea.
Discharge Medications:
1. cinacalcet 30 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).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
8. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
9. metolazone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for dry skin.
Disp:*1 bottle (100 cc or closest equivalent)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
- Chronic Systolic Heart Failure
- End-stage renal disease, on hemodialysis
- Hypertension
- Hypercholesterolemia
- Recurrent Urinary Tract infections
- Hemorrhoids
- Chronic constipation
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 weight gain and cough.
You were coughing because you had fluid in your lungs. You had
put on more than 10 liters-worth of water weight since leaving
the hospital. It was removed at dialysis.
We think you were retaining water because you were eating
take-out Chinese food and other salty foods at home, and because
your heart's pump function is getting progressively worse. We
are trying to manage this problem with frequent dialysis and
medications, but keeping a very low-salt diet is another
essential component. Take-out food and restaurant food is often
high-salt and contains hidden salts like MSG and soy sauce. Even
if you eat carefully, you may need extra dialysis sessions
occasionally to your weight stable.
You also had a traumatic foley catheter removal which resulted
in ongoing bleeding from your urethra for a few days. We placed
another foley catheter to tamponade the bleeding. It should stay
in place until it can be removed at a follow-up appointment by
urology. If the urine becomes more blood, please call your
doctor.
We made the following changes to your medications:
1. STOP LASIX
2. STOP METOPROLOL
3. STOP ASPIRIN
(Note: PCP will restart after foley removed/urinary bleeding
stops)
4. STOP LOPERAMIDE
5. STOP SEVELAMER
6. START TORSEMIDE, TAKE 40 MG ONCE DAILY (MORNING)
7. START METOLAZONE, TAKE 5 MG ONCE DAILY
8. START SPIRONOLACTONE, TAKE 25 MG ONCE DAILY (morning)
9. START CARVEDILOL, TAKE 25 MG TWICE DAILY (MORNING AND NIGHT)
10. START TESSALON PERLES, TAKE 100 mg PO TID AS-NEEDED FOR
COUGH
11. INCREASE LISINOPRIL to 20 mg DAILY
12. STOP COLACE and SENNA. If you become constipated you can
restart these medications.
.
Please review the attached medication list with Dr. [**Last Name (STitle) 4427**] at
your next primary care appointment and with Dr. [**First Name (STitle) 437**] at your
upcoming cardiology appointment.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2183-3-24**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital3 249**]
When: TUESDAY [**2183-3-25**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15398**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES/Urology
When: WEDNESDAY [**2183-3-26**] at 1:30 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will continue to have dialysis at [**Location (un) **] [**Location (un) **] Monday,
Wednesday, and Friday mornings as before.
.
You will be contact[**Name (NI) **] by Gastroenterology to schedule a
follow-up appointment for small-bowel capsule endoscopy. Dr.
[**Last Name (STitle) 4427**] may be able to help you arrange this appointment if you
do not hear from them.
ICD9 Codes: 5856, 2851, 4280, 2720
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5767
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|
Medical Text: Admission Date: [**2107-3-3**] Discharge Date: [**2107-3-5**]
Date of Birth: [**2048-2-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
near syncope, hypotension
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**3-3**]
History of Present Illness:
Ms. [**Known lastname **] is a 59 year old female with a PMH of near syncopal
episodes, ventricular ectopy, and hypothyroidism who presents
with hypotension in the setting of right groin pressure
following cardiac catheterization.
Briefly, patient complained of 3 episodes of near syncope in the
past several months (one episode possibly inciting a motor
vehicle collision). She describes a sensation of fluttering in
her chest accompanied by lightheadness and near- fainting.
Denies any associated chest pain, nausea/ vomiting, diaphoresis
or other symptoms. Extensive evaluation by her cardiologist
showed sinus bradycardia with ventricular ectopy for which she
was started on metoprolol. Echo in [**2104**] showed EF of 45% with
mild global hypokinesis and repeat in [**2105**] showed EF improved to
50% with grade II diastolic dysfunction.
Following her last episode of near syncope, she presented to her
cardiologist. EKG showed new inferolateral repolarization
changes compared to her prior EKG from [**2106-12-29**]. She
was admitted to an OSH on [**2107-3-2**], where she was r/o for MI
and had a stress test which reported showed a small fixed
deficit (offical read pending). Of note, she did have an
episode of bradycardia and low BP overnight which improved with
IVF. Transferred to [**Hospital1 18**] for catheterization.
Cardiac catheterization showed clear coronaries, patient
tolerated well with no immediate complications. Following
angioseal placement and during application of right groin
pressure to acheive hemostasis, patient complained of intense
pain and had a likely vagal episode: acutely diaphoretic,
dropped BP to 60s and HR to 40s. Episode resolved spontaneously
but given concern for possible RP bleed left arteriogram was
performed which showed no evidence of dissection or bleed.
Transferred to the CCU for overnight hemodynamic monitoring.
Upon arrival to CCU, patient comfortable, only complaining of
mild right groin pain. Review of systems was negative, denying
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. S/he
denies recent fevers, chills or rigors. S/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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (-)
Hypertension
2. OTHER PAST MEDICAL HISTORY:
- hypothyroidism
- sinus bradycardia
PAST Surgery:
- Partial Hysterectomy
- Total knee on the right
- Sinus surgery
Social History:
Lives with husband, works as x-ray technician
- Tobacco history: former, quit > 25 yrs ago
- ETOH: drinks 1 glass wine daily
- Illicit drugs: denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Father: MI at the age of 58
Physical Exam:
On Admission:
VS: T=Afebrile BP=88/50 HR=63 RR=20 O2 sat= 95 %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.
NECK: Supple with JVP of 7 cm.
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.
FLANK: no tenderness noted either on right or left
EXTREMITIES: No c/c/e. Pain on palpation of right groin but no
hematoma or 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:
[**2107-3-3**] 09:38PM Hct-39.9
[**2107-3-3**] 09:38PM PT-13.0 PTT-20.5* INR(PT)-1.1
Discharge Labs:
[**2107-3-5**] 08:20AM WBC-4.8 RBC-4.24 Hgb-14.0 Hct-41.2 MCV-97
MCH-32.9* MCHC-33.9 RDW-12.2 Plt Ct-192
[**2107-3-5**] 08:20AM Glucose-94 UreaN-14 Creat-0.9 Na-138 K-4.1
Cl-101 HCO3-31 AnGap-10
[**2107-3-5**] 08:20AM Calcium-9.0 Phos-3.6# Mg-2.1
[**2107-3-4**] 03:16AM Ferritn-67
[**2107-3-5**] 08:20AM Metanephrines (Plasma)-PENDING
Studies:
Cardiac Cath [**2107-3-3**] - COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically apparent, flow limiting,
coronary artery disease. The LMCA, LAD, LCx, and RCA were all
normal in appearence.
2. Limited resting hemodynamics revealed noral systemic blood
pressure, with a central aortic pressure of 115/73 mmHg.
3. Right femoral angiography revealed a high stick above the
pelvic rim.
4. 6F angioseal deployed successfully, without evidence of RP
bleed on angiography.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. High common femoral artery stick without evidence of RP
bleed.
TTE [**2107-3-4**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears depressed (ejection
fraction 30 percent) with a continuous gradient of worsening
hypokinesis from base (mild) to apex (severe). There is no
ventricular septal defect. The right ventricular free wall
thickness is normal. Right ventricular chamber size is normal.
with borderline normal free wall function. 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
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 59-year-old female with HTN, HL, chronic
palpitations and recurrent episodes of syncope and near syncope
transferred for cardiac cath in setting of EKG changes and
abnormal stress test without significant lesions found on
cardiac cath.
# Near-syncope and AVNRT: The patient has had multiple past
episodes of near syncope with lightheadedness and palpitations.
These episodes have increased in frequency in the past few
months with associated palpitations. Outpatient Holter monitor
reportedly showed PVCs. Cardiac catheterization showed no
coronary artery disease. She should avoid any heavy lifting for
the next week. While in the CCU she had an episode of SVT to the
170s with associated nausea that resolved spontaneously after a
few minutes. Review of telemetry was consistent with AVNRT.
Electrophysiology was consulted. They recommended a TTE that
showed decreased EF and hypokinesis. EF may have been slightly
more depressed than previously noted due to recent SVT. EP
recommended ablation of the AVNRT and cardiac MRI to further
evaluate for structural heart disease. They also recommended
blood tests for cardiomyopathy. The patient had a normal TSH at
the OSH prior to transfer and reported a recently negative HIV
test. Serum ferritin was within normal limits at 67 and plasma
metanephrines were also ordered and pending at discharge.
Patient was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to further
characterize her heart rhythm when she has presyncopal episodes.
Her history is not consistent with neurogenic etiologies such as
seizures. If this additional cardiac evaluation is unrevealing,
she may have some degree of autonomic dysfunction and may
benefit from referral to autonomic clinic. In light of her
recent car accident, she was advised to stop driving until the
etiology of her symptoms is better understood and resolved.
# Hypotension: The patient became hypotensive and bradycardic in
the setting of pressure being applied to her groin post-cath.
The episode was most likely vasovagal in nature. Her blood
pressure returned to [**Location 213**] and hematocrit remained close to
baseline over the following 24 hours. There was no evidence of
retroperitoneal bleed by angiography performed in cath lab. She
remained hemodynamically stable thereafter.
# Chronic systolic CHF: TTE showed EF of 30% with a continuous
gradient of worsening hypokinesis from base (mild) to apex
(severe), which may have been overestimated given the episode of
SVT earlier in the day. There were no signs of volume overload.
Metoprolol and lisinopril were initially held in the setting of
hypotension and restarted on discharge. She will return for
cardiac MRI as an outpatient.
# Hyperlipidemia: Stable. Patient continued on home
simvastatin.
# Hypothyroidism: Stable with normal TSH at OSH. She was
continued on her home levothyroxine.
Medications on Admission:
- metoprolol 25mg
- lisinopril 2.5 mg
- zantac 150mg
- levoxyl 100mcg
- simvastatin 20mg QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Chest Pain
Vasovagal hypotension
Atrioventricular nodal reentrant tachycardia (AVNRT)
Secondary Diagnosis:
Dyslipidemia
Hypothyroidism
Sinus bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were
admitted because of concern that you were having a heart attack.
Your cardiac catheterization showed normal heart vessels. You
did not have a heart attack.
You had a fast heart rhythm known as AVNRT (atrioventricular
nodal reentrant tachycardia). You were seen by the
electrophysiologists who recommended an ablation procedure to
prevent this rhythm from coming back. They also recommended a
cardiac MRI to further evaluate the heart. They will try to
arrange both of these studies on the same day and will contact
you with further details. You will be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor, which you should bring to your appointment with
Dr. [**Last Name (STitle) **].
Because of your history of lightheadedness and the symptoms you
had with the fast heart rate in the hospital, we recommend that
you DO NOT drive until your doctors have a [**Name5 (PTitle) **] sense of what
is causing these episodes as you could have another car
accident.
Also DO NOT LIFT MORE THAN [**4-12**] POUNDS FOR THE NEXT WEEK.
Please take your medications as described.
Followup Instructions:
Dr.[**Name (NI) 1565**] office will call regarding the scheduling of
your ablation procedure and cardiac MRI.
We have made the following appointments for you. Please be sure
to bring your [**Doctor Last Name **] of Hearts monitor when you come for your
appointment with Dr. [**Last Name (STitle) **].
Name: [**Last Name (un) **],[**Last Name (un) 75760**] A.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 86648**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 75761**]
Appointment: Friday [**3-11**] at 12PM
Name: [**Last Name (LF) **],[**First Name3 (LF) **] MD
Location: CLIPPER CARDIOVASCULAR ASSOCIATES
Address: [**Location (un) 90135**], [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 65733**]
Appointment: Monday [**3-14**] at 1:45PM
Completed by:[**2107-3-5**]
ICD9 Codes: 4280, 2724, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5768
}
|
Medical Text: Admission Date: [**2153-4-25**] Discharge Date: [**2153-5-2**]
Date of Birth: [**2093-10-2**] Sex: F
Service: MEDICINE
Allergies:
Lidocaine / Lipitor / Lovastatin / Haldol / Ativan
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
low blood pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Admission note and OMR were reviewed. Pt was examined. Briefly,
per admission note, "this is a 59 yo F with NSCLC dx in [**3-22**],
COPD, CAD s/p MI, has 2 recent admissions one with PNA and the
other with hemoptysis in [**3-22**], who presented with tremors and
HR 150. Pt had just completed her last radiation tx day PTA
(total of 14 tx) for both spine met and lung mass." The pt was
asymptomatic and admitted to stopping her metoprolol the day PTA
for low BP. In ED, found to have BP 80's/50's responded to IVF.
CTA was neg for PE, but showed a possible adrenal met and a
lytic/sclerotic density in a compression fracture of T7 with
probable posterior epidural extension of mass into spinal canal
(seen on MRI [**3-22**]). Got 2L IVF, 2.5 mg metop x3 with HR dropped
to 115's. The pt was monitored overnight in the [**Hospital Unit Name 153**]. She was
started on low dose metoprolol and a heparin gtt for the
pulmonary vein filling defect.
Past Medical History:
Onc History:
Pt presented to [**Hospital1 18**] on [**2153-3-22**] with hemoptysis. At that time
she was found to have a 8x8x9cm mass in the RUL displacing
segmental bronchi of the RML but no clear invasion. CT guided
biopsy showed non small cell lung CA. She had a PET and an MRI
and found to have a T7 likely metastatic lesion. She underwent
radiation treatment of both her spine mets and lung mass in
[**4-21**]. She is to receive palliative chemo.
.
PMH
-Diverticular bleeds, most recently in [**2152-9-16**].
-Strep pneumoniae pneumonia and sepsis and a prolonged intensive
care unit stay complicated by difficulty extubating, delirium,
and right internal carotid artery cannulization.
-HTN
-hyperlipidemia
-COPD
-panic disorder
-CAD with a MI infarction in [**2144**]. - EF 55% based on echo [**3-20**]
- hypothyroidism
Social History:
She is retired from working in [**Company 2486**]. She smoked two
packs per day for 40 years and quit four years ago. She does not
use alcohol.
Family History:
She has no siblings. Her mother passed away at age 76 of
osteoporosis and severe emphysema. Her father died at age 56 of
lung cancer, though he was a nonsmoker. She has no children. She
is widowed.
Physical Exam:
Vitals: Tm 98.5 Tc 98.5 BP 95-127/53-78 HR 99-123 R 25 Sat 99%RA
I: 1027 O: 1850
Gen: well appearing female lying in bed in NAD
HEENT: NC/AT, anicteric, OP clear, MMM
NECK: supple, no LAD
CV: tachy, s1 s2 distant heart sound, no murmur appreciated.
LUNG: +diffuse end expiratory wheezes, poor air mvt.
ABD: soft, NT/ND, +bs
EXT: no C/C/E
NEURO: alert+ox 3, CNII-XII intact.
Pertinent Results:
CXR [**4-25**]:
There is a large lobulated mass in the right upper lobe
measuring about 9 cm in greatest dimension and without change
from the prior radiograph. Heart size and mediastinal contours
are within normal limits. There is emphysema. No acute new
pulmonary abnormalities are identified. IMPRESSION: Persistent
large neoplastic right upper lobe mass, in keeping with lung
cancer. No new pulmonary abnormalities.
.
CTA:
1. No evidence for pulmonary arterial embolus. There is a
filling defect within a right upper lobe pulmonary vein at the
inferior margin of the large RUL mass which may represent venous
tumor invasion or thrombus. 2. Lytic/sclerotic density in a
compression fracture of T7 with probable posterior epidural
extension of mass into spinal canal at this level. An MRI exam
would provide better evaluation for cord compression. 3.
Unchanged large right upper lung lobe mass consistent with the
patient's history of lung cancer.
4. New left adrenal lesion measuring 9 mm concerning for
further metastatic disease. 5. Cholelithiasis without evidence
for cholecystitis.
.
EKG: SVT at 150, V3-V6 ST depression, II, III, F ST depression.
Brief Hospital Course:
Briefly, this is a 59 yo F with newly diagnosed NSCLC who
presented with hypotension and tachycardia. The pt was monitored
overnight in the ICU and then transferred to the floor.
.
# Tachycardia: The pt was started on metoprolol in the ICU at a
low dose given her hypotension. EKG was most c/w sinus
tachycardia. She was hydrated with 2L normal saline on
admission with mild decrease in pulse. On transfer to the floor
her HR was Still 110s-130s. Initially, titration of pts
metoprolol was been limited by pts blood pressure. Her EKG was
faxed to cardiology who confirmed this was sinus tachycardia.
The cause of her sinus tachycardia is unclear, but from prior
[**Name (NI) 21831**] over the past several years, the pts HR has varied from
60s-105. At baseline the pt may already be a little
tachycardic. The pt was hydrated with 2 more L of NS on the
floor with no decrease in her pulse. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was
performed given her recent dexamethasone course, but this was
WNL. The pts possible pulmonary vein thrombus was not felt to
be contributing to her tachycardia. TTE was negative for a
pericardial effusion. The pt seemed anxious, but she refused
ativan or any medication changes to her psychiatric drugs. Her
metoprolol was ultimately changed to atenolol and will need
follow up with her PCP.
.
# Hypotension: The pts initial hypotension on admission improved
after IVF. The pts metoprolol could not be increased back up to
her prior dose of 100 [**Hospital1 **] given that her blood pressure remained
low (SBP 90-100). She was titrated up to atenolol 50 mg po qd.
Pt becomes hypotensive in the setting of increase heart rate and
receiving
.
# Filling defect on right upper lobe pulmonary vein: CT chest
shows a RUL pulm vein filling defect at the inferior margin of
the large RUL mass which may represent venous tumor invasion or
thrombus. It is possible pt has an in situ thrombus from a
malignancy-related hypercoaguable state. On discussion with
radiology, there is no definitive way to tell if this is
thrombus vs tumor invasion, but there appears to be some
continuity with the tumor. The pt will likely need to be on
lifelong anticoagulation. She was started on a heparin gtt in
the ICU. Once transferred to the floor she was started on
coumadin 5 mg po qd with a Lovenox bridge. Her INR was
therapeutic at the time of discharge.
.
# Fever: The pt had a low grade fever on [**4-27**]. She had no clear
sign of infection or elevated WBC. She only had a mild cough.
The pt was started on levoflox on [**4-27**] for a 10 day course for
empiric treatment of pneumonia.
.
# NSCLC: Pt has likely T7 mets. There is also a new ?adrenal met
on CT. She is s/p XRT. She received palliative chemo with
[**Doctor Last Name **]/taxol on [**5-1**].
.
# CAD s/p MI s/p RCA stent in '[**44**]; preserved EF. Pt had some ST
depressions on admission EKG, likely in the setting of demand
ischemia. Cardiac enzymes were negative.She was continued on
ASA, BB, statin. Her lisinopril was held due to low BP. This
can be restarted as an outpatient as her BP tolerates.
.
# COPD (FEV1 0.56, 25% predicted; FEV1/FVC 34 (46% predicted);
Continued albuterol/atrovent/flovent
Medications on Admission:
Metoprolol 100 mg po bid
Imipramine 50 mg p.o. q.h.s.
Citalopram 20 mg p.o. qd
Levothyroxine 75 mcg p.o. daily,
Ipratropium nebulizer,
albuterol nebulizer
Simvastatin 40 mg p.o. qd
prilosec
fluticasone
Lisinopril 10 mg po qd
Discharge Medications:
1. Imipramine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea.
Disp:*10 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please have your PTT/INR checked on [**5-4**] prior to your
appointment with Dr. [**Last Name (STitle) **] at 2:30 pm at [**Hospital **] ([**Telephone/Fax (1) 21832**]/ FAX ([**Telephone/Fax (1) 16587**]
12. Anzemet 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea for 5 days: may susbtitute equivalent
12.5 mg tablets.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Possible pulmonary vein thrombus vs tumor extension
Sinus tachycardia
Non small cell lung cancer
Discharge Condition:
stable, HR 110 with BP of 120/80
Discharge Instructions:
Take all medications as prescribed. You will need to be on
coumadin permanently (this is to thin your blood given a
possible clot in your pulmonary vein). You will need to have
your labs drawn later this week and you will need to have
frequent lab draws to assess your PTT/INR levels (these assess
your coumadin levels). Please call your doctor or return to the
ER for worsening shortness of breath, heart racing, dizziness,
feeling like you are going to faint, fever, or any other
concerning symptoms. Please follow up with all of your
scheduled doctors [**Name5 (PTitle) 4314**].
Followup Instructions:
--Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21833**], MD Phone:[**0-0-**]
Date/Time:[**2153-5-31**] 2:00
--Please follow up with Dr. [**Last Name (STitle) **], your PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 2974**] [**5-4**].
You need to arrive at the lab with your lab request at least an
hour prior to your appointment with Dr. [**Last Name (STitle) **] at 2:30 pm, to
have your INR/PTT levels checked, so he can adjust the
medication if needed.
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
ICD9 Codes: 496, 486, 4019, 412, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5769
}
|
Medical Text: Admission Date: [**2192-2-3**] Discharge Date: [**2192-2-20**]
Date of Birth: [**2120-8-26**] Sex: M
Service: [**Location (un) 259**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old
man with a history of stage IV bladder cancer status post
neobladder reconstruction in [**2191-2-19**] and four cycles
of Gemcitabine and cisplatin in [**2191-7-19**], chronic
progressive bilateral hydronephrosis, and moderate alcohol
use, approximately three to four beers daily. Otherwise, the
patient was relatively well until about two weeks prior to
admission when he developed a fever of approximately 101.4 at
home. Additionally, the patient described decreased p.o.
intake and decreased urine output. He developed persistent
nausea, vomiting, and inability to take p.o. one day prior to
admission. He had coffee ground emesis at home on the day of
admission.
He was sent to the Emergency Department for evaluation of
bilateral hydronephrosis. In the Emergency Department, the
patient was noted to be tachycardiac and complaining of
diffuse abdominal pain. His laboratory data was significant
for acute renal failure with a BUN of 226, creatinine 15, and
a bicarbonate of 7. His amylase and lipase were also
elevated between 400 and 600. The ABGs were notable for a pH
of 7.22 on 2 liters nasal cannula.
After insertion of a Foley, 200 cc of cloudy urine were
obtained. NG suction was notable for coffee grounds with
dark blood. In the Emergency Department, he received Zosyn
for broad coverage and aggressive fluid hydration to
approximately 5 liters of normal saline as well as
bicarbonate. His urine output increased to 600 cc and he was
sent to the MICU for further evaluation of acute renal
failure and acidemia.
In the MICU, the patient's BUN and creatinine improved
steadily with IV fluid hydration. A CT study was performed
to evaluate possible fluid collections around the neobladder
which was drained percutaneously, revealing a creatinine of 8
which suggested that the fluid collection was not from urine
leakage. A right percutaneous nephrostomy tube was also
placed while the patient was in the MICU for persistent
right-sided hydronephrosis and elevated BUN and creatinine.
The patient had an EGD performed on [**2192-2-6**] after an
acute episode of upper GI bleed and a hematocrit drop of 9
points, revealing a duodenal ulcer.
The patient is status post cauterization. He was
hemodynamically stable and transferred to the floor for
further evaluation, status post 5 units PRBCs.
PAST MEDICAL HISTORY:
1. Stage IV bladder cancer.
2. Chronic hydronephrosis.
3. Hypercholesterolemia
ALLERGIES: The patient has no known drug allergies. The
patient does report an intolerance to Cipro.
ADMISSION MEDICATIONS:
1. Lipitor.
2. Ditropan.
3. Vitamin C.
4. Multivitamins.
5. Folic acid.
SOCIAL HISTORY: The patient lives with his wife at home. He
drinks approximately four beers daily and denied any tobacco
use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
95.3, heart rate 106, blood pressure 144/68, respiratory rate
29, 98% on 2 liters nasal cannula. General: The patient is
an elderly pleasant man in no apparent distress. HEENT:
Normal. Cardiac: Regular, tachycardia, no murmurs. Lungs:
Clear. Abdomen: Notable for moderate distention, diffuse
abdominal tenderness, mostly involving the left upper
quadrant, decreased bowel sounds, voluntary guarding in the
lower quadrants bilaterally. Extremities: No edema, Guaiac
positive. Neurologic: Grossly intact.
LABORATORY/RADIOLOGIC DATA: On admission, sodium 128,
potassium 6.7, BUN 226, creatinine 15.1, anion gap 35.
Amylase 418, lipase 635, lactate 2.3, albumin 3.6. White
blood cell count 23.2, hematocrit 37.2. The urinalysis
showed moderate leukocyte esterase, 100 protein.
Studies performed during the admission revealed a CT of the
abdomen without contrast showed mild wall thickening within
the cecum and ascending colon, fluid tracking along the left
pericolic gutter into the pelvis was noted. Right-sided
hydronephrosis and hydronephrosis within the left renal
collecting system were noted. Unchanged tiny noncalcified
pulmonary nodule within the right anterior middle lobe was
also noted.
EKG showed sinus tachycardia with a rate of 102, normal axis,
normal intervals.
HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient
presented with fevers, acidemia, and acute renal failure.
Blood cultures as well as fluid aspirated from the pericolic
gutter collection and a collection anterio to the neobladder
within the abdomen all grew E. coli ( no other organisms) which
was pan sensitive. The patient was treated with multiple
antibiotic regimens during his hospital course including
ceftriaxone, Flagyl, vancomycin, ampicillin, clarithromycin, and
Zosyn. These were directed at sepsis until a diagnosis
was established and then at E coli and H pylori noted in
the context of the duodenal ulcer. Eventually, his antibiotic
regimen was tapered to include Levo, Flagyl, and Clarithromycin
which coveredc E coli and H pylori. Additionally, the patient
was noted to be H. pylori positive, status post cauterization
of his duodenal ulcer and, therefore, he was also treated with
a PPI plus antibiotics as noted above..
2. ABDOMINAL PAIN: The patient presented with abdominal
pain, urinary retention, and acute renal failure upon
presentation. Interventional Radiology as well as the CT
body team evaluated the patient and were able to use
CT-guidance to drain the intra-abdominal collection as well
as place a right percutaneous nephrostomy tube. Eventually,
the left pericolic gutter and the anterior perineobladder
collection were also drained with CT-guidance. Fluid from all of
these culture samples grew E. coli. The patient's abdominal
examination improved throughout his hospital course. He was able
to take p.o.
An MR urogram was performed on [**2192-2-11**] which did not
reveal any extravasation of contrast. The patient had repeat
CT drainage of three of the five pockets involving the left
pericolic gutter collection. Follow-up CT on [**2192-2-16**] revealed re-accumulation of the other abscesses,
however, the left lower quadrant drain was able to be pulled.
The suprapubic drain was kept intact as there was fluid and
air still around it as evident by CT. Overall, the repeat CT
appeared to show some improvement in the fluid collection
intra-abdominally and the patient's examination reflected
this.
3. ACUTE RENAL FAILURE: The patient presented with elevated
BUN and creatinine as well as urinary retention and
urosepsis. The patient was started on multiple antibiotic
regimens and remained afebrile throughout the majority of his
hospital course. His BUN and creatinine slowly began to
trend down after placement of the right percutaneous
nephrostomy tube and with aggressive IV fluid hydration.
Renal consult services were following the patient throughout
his hospital course; however, the patient did not require
hemodialysis during this hospital stay.
4. METABOLIC ACIDOSIS: The patient's metabolic acidosis
resolved in the MICU after bicarbonate repletion and IV fluid
hydration.
5. HYDRONEPHROSIS: The patient is status post right kidney
drainage through percutaneous nephrostomy tube and he is
status post dilatation procedure on the 22nd on the right
with increased urine output. Left nephrostomy tube was not
placed during this hospitalization.
6. GASTROINTESTINAL BLEED: The patient presented with
coffee ground emesis and Guaiac positive stool. The GI
service was consulted early in his hospital course. EGD was
performed with cauterization of his duodenal ulcer. H.
pylori was treated with Clarithromycin and PPI and Levo. The
patient persistently had melenic stools throughout his
hospital course and his hematocrit hovered between 28 and 32.
Repeat endoscopy is scheduled to be performed as an inpatient
on [**2192-2-20**] to ensure no further bleeding of the
duodenal ulcer.
7. CODE STATUS: Code status was addressed during this
hospital course. The patient confirmed that he would like to
be full code.
8. ACTIVITY: The patient was able to ambulate with physical
therapy and was able to take p.o. intake of a renal diet.
Discharge planning, medications, and diagnoses will follow in
an addendum.
[**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**MD Number(1) 28963**]
Dictated By:[**Last Name (NamePattern1) 1600**]
MEDQUIST36
D: [**2192-2-17**] 05:07
T: [**2192-2-17**] 18:56
JOB#: [**Job Number 28964**]
ICD9 Codes: 5845
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5770
}
|
Medical Text: Admission Date: [**2123-6-22**] Discharge Date: [**2123-6-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo M with HTN, s/p L [**Hospital 6024**] hospital course [**Date range (1) 6025**] for
non-healing infected foot ([**1-13**] limb ischemia per non-invasives,
not on record in OMR) complicated by VRE infection requiring
intraoperative debridement and AKA. Patient was discharged to
[**Hospital3 2732**] and Retirement Home in [**Location (un) 55**], where
was in USOH until [**2123-6-21**], when noted chills, lethargy,
low-grade fever; no SOB, cough or sputum production, n/v,
diaphoresis, dysuria. Vitals at initial eval were P110, RR 28,
BP 166/80, T 99.5. Labs remarkable for WBC 16.8 K with left
shift 92P 2B, otherwise chemistries, LFTs, EKG wnl. Upon arrival
to [**Hospital1 18**] ED, hypotensive to 70/50, HR 100, RR 24, 93RA => 96-3L
NC. Placed R femoral line. CXR showed RLL and LML multifocal
infiltrate, c/w multifocal aspiration or PNA. Dosed vanco 1 gm
and ceftaz 1 gm and IVF 1500 ml, sent to [**Hospital Unit Name 153**]. Of note, chronic
sacral decubitus ulcers noted, and has R femoral line for
daptomycin for hx MRSA (not in our records); also with history
of VRE (from AKA). No other micro available. Of note, on
arrival, patient denies any localizing symptoms, including CP,
SOB, congestion, neck stiffness or light sensitivity, cough or
sputum production/secretions, abdominal pain, dysuria, diarrhea.
He does note that he notices that he coughs frequently while
drinking liquids; no associated dysphagia or odynophagia. Review
of systems otherwise negative.
Past Medical History:
HTN
PVD
Hyperlipidemia
R carotid stenosis, 80-99% (non-intervened)
OA
L BKA => AKA as noted above [**5-16**]
Left hip arthroplasty x2, bilateral inguinal herniorrhaphy
status post SFA angioplasty with stenting [**12-16**]
Social History:
SHx: no smoking, IVDU, alcohol, recent illnesses
Family History:
FHx: patient non-cooperative
Physical Exam:
T: 96.9 BP 117/48 HR 80 Sat 100-4L NC
Gen: chronic ill appearing, somnolent but easily arousable, in
NAD.
HEENT: Pupils [**3-14**] bilaterally, OP clear with dry membranes. JVP
at 8 cm +HJR. No sinus tenderness. False teeth, but clean OP.
Lungs: Crackles at RML and LUL lung fields, poor entry to bases.
OTW clear.
Heart: RRR with frequent PVC's. III/VI SEM at RUSB to clavicle,
III/VI HSM at apex to axilla. No lift, PMI displaced laterally.
No gallop.
Abd: Soft, +BS. No tenderness or rebound. No [**Doctor Last Name **]??????s.
Back: No CVAT. Sacral decubitus 1.5 cmx 1.5 cm on tip of coccyx,
no drainage or TTP.
Extr: L AKA, well healed. R femoral without tenderness,
drainage, or erythema, with slight amount of blood surrounding
catheter. Peripherals x2 in place without s/s infection. No
edema. 1+ DP on R. Lateral ulcer on dorsal-plantar margin of R
foot; no probe to bone, no drainage, +TTP +erythema.
Neuro: AAOx3, lethargic (hard of hearing).
Pertinent Results:
[**2123-6-21**] 06:50PM WBC-16.8*# RBC-3.77* HGB-10.4* HCT-32.0*
MCV-85 MCH-27.6 MCHC-32.5 RDW-16.3*
[**2123-6-21**] 06:50PM NEUTS-88* BANDS-8* LYMPHS-3* MONOS-0 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2123-6-21**] 7:05 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2123-6-25**]):
REPORTED BY PHONE TO 4I [**Numeric Identifier 6026**] [**First Name8 (NamePattern2) **] [**Doctor Last Name 6027**] [**2123-6-22**] @
11:10PM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
[**2123-6-21**] 06:50PM CORTISOL-25.4*
[**2123-6-21**] 06:50PM ALBUMIN-3.1* CALCIUM-8.5 PHOSPHATE-4.5#
MAGNESIUM-1.9
[**2123-6-21**] 06:50PM cTropnT-0.07*
[**2123-6-21**] 06:50PM ALT(SGPT)-11 AST(SGOT)-20 ALK PHOS-107 TOT
BILI-0.3
[**2123-6-21**] 06:50PM GLUCOSE-116* UREA N-23* CREAT-1.5* SODIUM-134
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
[**2123-6-21**] 07:04PM LACTATE-2.0
[**2123-6-21**] 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2123-6-21**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2123-6-22**] 04:10AM RET AUT-1.7
[**2123-6-22**] 04:10AM PT-12.6 PTT-39.0* INR(PT)-1.1
[**2123-6-22**] 04:10AM PLT COUNT-430
[**2123-6-22**] 04:10AM HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+
[**2123-6-22**] 04:10AM NEUTS-83.0* LYMPHS-12.9* MONOS-3.0 EOS-0.9
BASOS-0.3
[**2123-6-22**] 04:10AM WBC-9.0 RBC-3.19* HGB-8.7* HCT-27.7* MCV-87
MCH-27.3 MCHC-31.5 RDW-16.8*
[**2123-6-22**] 04:10AM URINE HOURS-RANDOM CREAT-83 SODIUM-99
[**2123-6-22**] 04:10AM CORTISOL-32.4*
[**2123-6-22**] 04:10AM TSH-4.4*
[**2123-6-22**] 04:10AM VIT B12-349
[**2123-6-22**] 04:10AM CALCIUM-7.4* PHOSPHATE-3.5 MAGNESIUM-2.1
[**2123-6-22**] 04:10AM proBNP-[**2084**]*
[**2123-6-22**] 04:10AM GLUCOSE-102 SODIUM-140 POTASSIUM-3.8
CHLORIDE-110* TOTAL CO2-23 ANION GAP-11
[**2123-6-22**] 04:41AM VANCO-9.5*
[**2123-6-22**] 04:41AM CORTISOL-39.4*
[**2123-6-22**] 04:41AM calTIBC-135* VIT B12-350 FOLATE-5.5
HAPTOGLOB-290* FERRITIN-551* TRF-104*
[**2123-6-22**] 04:41AM IRON-19*
[**2123-6-22**] 04:41AM LD(LDH)-135 TOT BILI-0.2
[**2123-6-22**] 04:41AM UREA N-18 CREAT-1.2
[**2123-6-22**] 07:12PM PLT COUNT-394
[**2123-6-22**] 07:12PM WBC-7.0 RBC-3.08* HGB-8.6* HCT-26.8* MCV-87
MCH-28.1 MCHC-32.2 RDW-16.3*
[**2123-6-22**] 07:12PM CALCIUM-7.2* PHOSPHATE-2.6* MAGNESIUM-1.9
[**2123-6-22**] 07:12PM GLUCOSE-97 UREA N-15 CREAT-1.0 SODIUM-139
POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-22 ANION GAP-10
Brief Hospital Course:
Sepsis: Patient afebrile with resolving WBC count through [**Hospital Unit Name 153**]
stay. Sources of infection included sacral decubitus ulcer (not
extending to bone, draining, or tender/erythematous), L AKA
stump (well-healed, though had history of VRE), R foot ulcer
(tender to palpation, not draining), or pulmonary (given CXR and
exam evidence for multifocal PNA and history of choking/cough
while eating). Patient was empirically covered with vancomycin
(history of MRSA), ceftazidime, and levofloxacin (for nosocomial
sources). Initial blood cultures on [**2123-6-21**] were 1/2 bottles
positive for gram-positive cocci in clusters and pairs
(speciation revealed staph epi), felt to likely be contaminant.
Required several fluid boluses initially to maintain urine
output, but was hemodynamically stable with good urine output
throughout the remainder of his [**Hospital Unit Name 153**] course. Cultures from tip
of PICC line removed on [**6-21**] at nursing home revealed
gram-negative rods, but NO blood cx were positive. Vancomycin
and ceftazidime were discontinued, and patient was discharged on
a 14-day course of levofloxacin for presumed community acquired
PNA (through [**7-6**]). In addition, UA prior to d/c appeared c/w
with UTI, cultures were pending upon d/c. PCP should [**Name9 (PRE) 702**]
on final cx results and sensitivities.
Mental status changes: Likely infection related. RPR and B12
were negative. TSH was mildly elevated at 4.4.
Respiratory: Patient denied respiratory symptoms throughout,
including cough, SOB, or pleuritic chest discomfort. Oxygen
requirment remained stable [**Hospital 6028**] hospital course, with
saturation 96-98% on 3.5 liters. CXR on [**6-24**] had improving
consolidations and decrease in bilateral pleural effusions as
seen on CXR at admission. Infiltrates were thought to be
consistent with pneumonia overlain on pulmonary congestion from
CHF. Pt discharged with good oxygenation with plans to complete
antibiotics course for his presumed pneumonia (Levofloxacin
500mg PO QD x 14 days through [**7-6**]). Speech and swallow
recommended nectar thick liquids and thick/ground consistency
diet given concern for aspiration.
Cardiovascular: Patient was ruled out for MI by 3 sets cardiac
enzymes and placed on ASA, statin. BB was held [**1-13**] initial
hypotension and question of septic physiology. Rhythm was normal
sinus throughout, with unifocal PVCs > 10/hr on telemetry, with
no other concerning EKG changes. BNP was 1800; echocardiogram
demonstrated EF 50% with evidence of increased LVEDP, pulmonary
hypertension and 3+ MR. [**Name13 (STitle) **] was titrated up on captopril for
afterload reduction, and switched to lisinopril on discharge.
Patient was autodiuresing throughout hospital course, and may
require outpatient lasix and initiation of beta-blocker for CHF.
Renal/FEN: Acute renal failure with creatinine 1.2 up from
baseline 0.5. Initial FeNa was 0.8% consistent with pre-renal
etiology from dehydration [**1-13**] poor PO intake and infection
versus CHF. Cre improved with fluid resuscitation, back to
baseline 0.9 at discharge. Speech and swallow consultation
performed for concern for aspiration, given history and
multifocality of CXR, with evidence of no gag reflex; placed on
mechanical soft diet.
UTI: On discharge, complained of some urinary urgency, thought
to mechanical (from foley) or infectious. Urinalysis seemed +
for UTI, culture pending at discharge. Discharged on
levofloxacin for CAP, likely covering UTI. Patient will also
need restarting terasozin as outpatient for BPH, which may aid
with BP/afterload management.
Heme: Initial studies consistent with anemia of chronic disease
(Fe low, TIBC low, Ferritin elevated), but difficult to
interpret in setting of acute illness. Would repeat as
outpatient and consider iron therapy.
Depression: Patient with decreased appetite, [**1-13**] depression. On
prozac and wellbutrin SR. Patient requested outpatient
psychopharmacology consultation after acute issues have
resolved.
Medications on Admission:
Lipitor 10 mg qd
ASA 81 mg qd
Prevacid 30 mg qd
Terazosin
Metoprolol 25 mg [**Hospital1 **]
Pletal 100 mg qd
Proscar 5 mg qd
Prozac 40 mg qd
Wellbutrin SR 100 mg [**Hospital1 **]
Klonopin 0.5 mg tid
Heparin SC 5000 U [**Hospital1 **]
Vicodin prn pain
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO qd ().
4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days: Complete day 14 course through [**7-6**].
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
11. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
13. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
dose subcutaneously Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnosis:
Community acquired pneumonia
Mild CHF
Acute on chronic renal failure
Secondary diagnoses:
HTN
PVD
Hyperlipidemia
Depression
BPH
R carotid stenosis, 80-99% (non-intervened)
OA
L BKA => AKA as noted above [**5-16**]
Left hip arthroplasty x2
Bilateral inguinal herniorrhaphy s/p SFA angioplasty with stent
[**12-16**]
Discharge Condition:
Stable, afebrile, with HR in 80s-90s, BP 107/43, RR of 24 and O2
sats of 94% on RA.
Discharge Instructions:
Please come to the hospital if you develop any of the following
symptoms: worsening cough, fever >100.4, shortness of breath,
chest pain or pressure, weakness or any other complaints.
Followup Instructions:
Please call your PCP for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment in [**12-13**] weeks.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2123-6-25**]
ICD9 Codes: 0389, 5849, 5070, 4280, 4240, 5990, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5771
}
|
Medical Text: Admission Date: [**2114-11-24**] Discharge Date: [**2114-11-30**]
Date of Birth: [**2049-6-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1. Cardiac Catheterization s/p Left circumflex thrombectomy and
placement of 3 bare metal stents
History of Present Illness:
65M h/o CAD s/p CABG [**2104**] (LIMA->LAD,SVG->D1,SVG->OM1,SVG->PDA;
cath [**2114-11-12**] revealed patent LIMA->LAD but all 3 SVG grafts
down) and DES [**2114-11-12**] to dLMCA and pLCx, DM2, HTN,
hyperlipidemia, former smoker presented to OSH with SSCP x 1
hour. First had CP 1 day PTA while walking to the bus. Lasted
2-3 hours and resolved. At 12pm the day of admission the chest
pain returned. Associated with SOB, nausea, dry heaves, and 2
episodes diarrhea. Felt well prior to these episodes. Presented
to OSH at approximately 5pm for evaluation.
.
At OSH, vitals T 101.1, HR 137, BP 118/69, and RR 20. ECG
revealed AF with RVR, 6mm ST depressions in V1-V4 and 2mm ST
elevations aVR. CK 111, troponin 0.6. Patient had already taken
aspirin and plavix in AM; was given NTG, IV lopressor,
integrillin, heparin, and levofloxacin. Became hypotensive to
81/45 and received 1500 cc NS IVF bolus with increase to 113/90.
Transferred to [**Hospital1 18**] for cath.
.
Cath revealed 100% proximal LCx in-stent thrombosis.
Thrombectomy performed f/b 3 overlapping BMS (2.5x14, 3.0x15,
3.0x12). RCA and grafts not imaged as anatomy known from prior
study. Procedure c/b transient bradycardia and unresponsiveness
during balloon inflation that spontaneously resolved (no
meds/shocks given). Hemodynamics: CO 3.3, CI 1.8, RA 11, RV
40/5, PA 39/20, PCWP 22. PA sat 47%, AO sat 94%. Received 270cc
contrast. In-cath echo revealed EF 30% with global hypokinesis.
Brought to CCU for further management.
Past Medical History:
CAD s/p
* CABG [**2104**] (LIMA->LAD,SVG->D1,SVG->OM1,SVG->PDA)
* PCI [**2114-11-12**] (DES to LMCA and LCx)
HTN
DM2
Hyperlipidemia
Prior tobacco abuse
h/o Barrett's esophagus c high-grade dysplasia s/p total
esophagectomy
Chronic anemia (baseline Hct 30-34)
h/o UGIB [**2-8**] hemorrhagic gastritis [**2114-11-13**]
h/o abnormal LFTs (elevated bilirubin x 30-40 years)
Social History:
Sales manager at [**Company **]'s Basement. Married, 4 children (3 own,
1 stepchild). Quit smoking 23 years ago. Occ EtOH. Denies
illicits.
Family History:
Father with MI (26); Mother with COPD (43); Brother killed after
hit by train
Physical Exam:
T 99.4 HR 106 BP 98/63 RR 32 SaO2 94% 4L
General: somnolent, WDWN, NAD, pale and ill-appearing
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink, OP with
blood
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: RRR, s1s2 normal, no m/r/g, no JVD appreciated, no
bruits
Pulmonary: CTAB anteriorally
Abdomen: +BS, soft, epigastrum tender to deep palpation,
nondistended, no rebound/guarding, no HSM, epigastric scar
Extremities: warm, dopplerable DP/PT pulses, no edema
Neuro: somnolent, follows commands, speech slurred, moves all
extremities
Pertinent Results:
[**2114-11-24**] 11:36PM TYPE-ART PO2-66* PCO2-31* PH-7.46* TOTAL
CO2-23 BASE XS-0
[**2114-11-24**] 09:15PM GLUCOSE-272* UREA N-12 CREAT-0.8 SODIUM-137
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-19* ANION GAP-18
[**2114-11-24**] 09:15PM CK(CPK)-2562*
[**2114-11-24**] 09:15PM CK-MB-93* MB INDX-3.6 cTropnT-7.90*
[**2114-11-24**] 09:15PM WBC-6.4 RBC-3.08* HGB-10.2* HCT-28.2* MCV-92
MCH-33.1* MCHC-36.2* RDW-15.5
[**2114-11-24**] 09:15PM PLT COUNT-185
Cardiac Catheterization - [**2114-11-24**] - FINAL DIAGNOSIS:
1. 100 proximal stent thrombosis of LCX.
2. ELevated left and right side filling pressures.
3. Depressed cardiac index.
Brief Hospital Course:
A/P: 65M h/o CAD s/p CABG recent LMCA/LCx DES presented with
post STEMI and in-stent thrombosis of LCx s/p PCI x 3 with bare
metal stents.
.
# Ischemia:
Patient with a history of CAD s/p CABG and recent LMCA admitted
with chest pain and was found on cardiac cath to have 100%
proximal LCx in-stent thrombosis. Thrombectomy performed
followed by placement of 3 overlapping BMS (2.5x14, 3.0x15,
3.0x12). RCA and grafts not imaged as anatomy known from prior
study. Procedure was complicated by transient bradycardia and
unresponsiveness during balloon inflation that spontaneously
resolved (no meds/shocks given). Patient was continued on
aspirin, plavix, statin, and was started on carvedilol 25mg PO
bid. Patient was recommended to start an ACE-inhibitor as an
outpatient.
.
# Pump:
Echo during the cath demonstrated an EF of 30% with a low
cardiac index and PA sat, and echo 2 days later on 11.20
demonstrated an EF 45-50% with inferolateral HK.
.
# Rhythm: paroxysmal AF, converted to sinus at arrival to CCU.
Sinus at discharge [**2114-11-14**]. No prior diagnosis. Prolonged PR
interval. Patient was not anti-coagulated given history of GI
bleed. Patient recommended to have an outpatient event monitor.
.
# Fever and nausea: Febrile at admission to OSH with normal WBC
and bandemia. + nausea and dry heaves. GI symptoms PTA. [**Month (only) 116**] all
be related to acute MI. Patient continues to have occasional dry
heaves and nausea but without other symptoms. WBC stable.
Amylase, lipase wnl. h/o chronic transaminitis, elevated Tbili
(chronic per patient). DDx nausea includes gastritis, ischemia,
gastroenteritis, cholecystitis (unlikely given nl AP) but no
localizing signs. Patient remained stable without fevers
throughout the admission.
.
# Anemia/GIB/gastritis: Chronic anemia likely [**2-8**] hemorrhagic
gastritis. EGD at last admission. Hematocrit has remained stable
and patient maintained on [**Hospital1 **] PPI. Patient reports having
outpatient GI follow-up in [**Month (only) 404**].
Medications on Admission:
ASA
Plavix
Metoprolol
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 BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. 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*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as
needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
STEMI
CAD
Fever
Anemia
.
Secondary Diagnoses
HTN
DM-II
Hyperlipidemia
History of tobacco use
History of UGIB
Discharge Condition:
Good. Patient hemodynamically stable, afebrile, with O2
saturation > 95% on room air.
Discharge Instructions:
1. Please take all medications as prescribed
.
2. Please keep all outpatient appointments
.
3. Please return to the hospital or seek medical care
immediately for symptoms of chest pain, shortness of breath,
fevers/chills, loss of consciousness or any other concerning
symptoms
.
4. You received a small amount of radiation exposure secondary
to necessary fluoroscopy time during your cardiac
catheterization. If you develop any skin burns or pain, you
should contact your Cardiologist.
Followup Instructions:
1. Please follow up with your primary care physician within one
week. Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8338**] at [**Telephone/Fax (3) **]
to make an appointment.
.
2. It is extremely important you follow up with your
Cardiologist within one to two weeks. Please call your
Cardiologist, Dr.[**Name (NI) 23187**] office today to arrange an
appointment for follow up.
.
3. Please have your blood pressure checked as an outpatient so
that you can have an ACE inhibitor (Lisinopril) added to your
drug regimen.
.
4. Please also discuss with your cardiologist for how long you
should continue to take Plavix twice a day.
ICD9 Codes: 4019, 2859, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5772
}
|
Medical Text: Admission Date: [**2111-1-10**] Discharge Date: [**2111-1-14**]
Date of Birth: [**2061-4-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
hypotension and left hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 92355**] is a 49yo man who presented to the ED after
transfer from OSH with atraumatic left hip pain and hypotension.
Pt reports taking viagra, alcohol, oxycodone, and new
prescription meds of Maloxicam, Lisinopril, and Gabapentin on
the night of [**2111-1-9**]. He went to sleep at 1am [**1-10**] and woke up
at 10am with a severe pain in his left gluteal region. He
reports that the pain was so bad that he immediatedly told his
fiance, who was asleep beside him, to call 911. He was taken
away in an ambulance to [**Hospital3 4107**]. At the OSH they found
him to be profoundly hypotensive 70s sbps and gave him dopamine
but no record of IVFs given. A non contrast CT showed no acute
process in the left hip. Labs were notable for troponin 1.39,
INR 2.1, hct 35.5, wbc 13.9, creatinine 2.4 and K of 6.0. He
received vancomycin and ASA and was transferred to [**Hospital1 18**] for
further management.
.
(adopted from MICU admit note)
In the ED, initial vs were: 124/82, 116, 18, and 98% on 3L on
peripheral dopamine. Patient was taken off dopamine and initial
blood pressures were notable for systolics in the 80s. He
received 3 L of fluid with improvement in pressures to the 110s
systolically. Labs were notable for EtOH level of 33 and lactate
of 3.6. WBC 12.8 with bands and Hct 36.6. INR was 1.8,
creatinine 2.4, ALT 341, AST 1428, AlkP 133. Troponin was 0.41
without any ischemic changes on EKG. Urine tox was positive for
methadone. Also had serum positive alcohol tox. He was given one
dose of cefepime for broad spectrum coverage and was admitted to
the MICU for further management.
In the MICU VS on transfer were: HR 101 BP 112/63 RR 12 and O2
sat 95% on 3L. He was found to have a CK [**Numeric Identifier 41242**] -> [**Numeric Identifier 14123**] ->
[**Numeric Identifier 81081**]. He was given IVFs. Lactic acid decreased to 1.4, Cr
decreased to 2.2. Troponins have remained elevated, CKMBI
corrected normal. He was taken off vancomycin and cefepime and
started on ceftriaxone for presumed UTI.
Of note, Mr. [**Known lastname 92355**] mentioned that he had been getting
surveillance colonoscopies "every three months or so" for
malignant polyps that he is prone to getting. He also mentioned
that he has had radiation for this "cancer" in the past, but has
never had any surgery. He denies chemotherapy. He also mentioned
that his urine started to change color "about a week ago." He
denies being on the ground for a long period of time prior to
his hip pain. His histories have been contradictory in regard to
the medicines that he was taking on the night he developed his
hip pain per his nurse.
Review of systems:
(+) Per HPI, otherwise negative.
Past Medical History:
-Obstructive Sleep Apnea
-Hypertension
-Chronic back pain, on opiates
-possible substance abuse (opiates)
-alcoholism ([**3-31**] drinks/day)
-equivocal result exercise stress test [**11/2110**]
Social History:
Divorced 2 years ago, has three children who live in [**Doctor Last Name **]
Island. Recently engaged. Lives with fiancee and her mother.
[**Name (NI) 1403**] as a flood restoration tech adn in recruiting. Denies h/o
tobacco abuse. Reports drinks 5-8 drinks nightly- vodka. No
history of blackouts or alcohol withdrawal. Reports has only
been drinking for one year. Reports remote use of cocaine 15
years ago, remote use of marijuana. Denies h/o IVDU.
Family History:
Father died of rheumatic heart disease. Mother died of
pancreatic cancer.
Physical Exam:
Physical Exam on Admission
Vitals: T: 97.9 BP: 136/83 P: 97 RR: 15 O2: 98% on RA
General: obese man sitting up in chair, alert, oriented, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, no JVP
CV: Distant heart sounds, but regular rate and rhythm, normal S1
+ S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally. Air movement ends high
up back, no wheezes, rales, ronchi
Abdomen: obese, soft, mildly tender to palpation in RUQ,
non-distended, bowel sounds present, no organomegaly
GU: Foley in place draining yellow urine with some trace brown
sediment
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
L Hip: full motion in tact but 4/5 strength with hip flexion and
hip extension. Area of swelling/edema firm over lateral left
hip. No visible signs of trauma at this time
Neuro: CNII-XII grossly intact
Physical Exam at Discharge
Vitals: T: 98.7,98.5 BP: 140-176/68-86 P: 93 RR:20 O2: 95% on RA
I/O: since 12a 920cc in 1.85L out ; past 24hrs 2.2L in, 3.2L out
General: obese man standing up in room, alert, oriented, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, no JVP
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally. Air movement ends high
up back, no wheezes, rales, ronchi
Abdomen: obese, soft, non tender, non-distended, bowel sounds
present, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
L Hip: full motion in tact. Area of swelling/edema still firm
over lateral left hip.
Pertinent Results:
Admission Labs
[**2111-1-10**] 09:42PM BLOOD WBC-10.3 RBC-3.99* Hgb-11.4* Hct-35.3*
MCV-89 MCH-28.6 MCHC-32.3 RDW-15.0 Plt Ct-153
[**2111-1-10**] 04:30PM BLOOD Neuts-80* Bands-4 Lymphs-3* Monos-13*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2111-1-10**] 04:30PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
[**2111-1-10**] 04:30PM BLOOD PT-18.9* PTT-36.7* INR(PT)-1.8*
[**2111-1-10**] 04:30PM BLOOD ESR-28*
[**2111-1-10**] 04:30PM BLOOD CRP-22.5*
[**2111-1-10**] 04:30PM BLOOD Glucose-146* UreaN-15 Creat-2.4* Na-136
K-6.5* Cl-105 HCO3-18* AnGap-20
[**2111-1-10**] 09:42PM BLOOD Calcium-7.2* Phos-4.6* Mg-1.9
[**2111-1-10**] 04:30PM BLOOD Albumin-3.3*
[**2111-1-10**] 04:30PM BLOOD ALT-341* AST-1428* CK(CPK)-[**Numeric Identifier 41242**]*
AlkPhos-133* TotBili-1.0
[**2111-1-11**] 04:50AM BLOOD Lipase-25
[**2111-1-10**] 09:42PM BLOOD CK-MB-226* MB Indx-0.6 cTropnT-0.31*
[**2111-1-10**] 09:42PM BLOOD CK(CPK)-[**Numeric Identifier 92356**]*
[**2111-1-11**] 11:18AM BLOOD %HbA1c-5.8 eAG-120
[**2111-1-11**] 04:50AM BLOOD Triglyc-125 HDL-22 CHOL/HD-6.1 LDLcalc-87
[**2111-1-10**] 09:42PM BLOOD TSH-3.0
[**2111-1-11**] 04:50AM BLOOD Cortsol-33.8*
[**2111-1-10**] 09:42PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE
[**2111-1-10**] 09:42PM BLOOD HCV Ab-NEGATIVE
[**2111-1-10**] 04:30PM BLOOD ASA-NEG Ethanol-33* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2111-1-10**] 04:30PM BLOOD Lactate-3.6*
[**2111-1-10**] 05:30PM BLOOD K-4.8
Discharge Labs
[**2111-1-14**] 05:00AM BLOOD WBC-6.7 RBC-4.10* Hgb-11.8* Hct-35.4*
MCV-87 MCH-28.8 MCHC-33.3 RDW-15.7* Plt Ct-135*
[**2111-1-14**] 05:00AM BLOOD Neuts-72.8* Lymphs-15.8* Monos-7.4
Eos-3.0 Baso-0.9
[**2111-1-14**] 05:00AM BLOOD PT-17.5* PTT-39.3* INR(PT)-1.6*
[**2111-1-14**] 05:00AM BLOOD Glucose-108* UreaN-20 Creat-1.3* Na-141
K-3.7 Cl-101 HCO3-32 AnGap-12
[**2111-1-13**] 08:40AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7
[**2111-1-14**] 05:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.5*
[**2111-1-13**] 08:40AM BLOOD ALT-282* AST-782* LD(LDH)-564*
CK(CPK)-6411* AlkPhos-141* TotBili-1.9* DirBili-1.1* IndBili-0.8
[**2111-1-14**] 05:00AM BLOOD ALT-227* AST-609* CK(CPK)-4076*
AlkPhos-158* TotBili-2.0*
[**2111-1-13**] 08:40AM BLOOD CK-MB-16* MB Indx-0.2 cTropnT-0.36*
[**2111-1-14**] 05:00AM BLOOD CK-MB-8 cTropnT-0.27*
LIVER US Study Date of [**2111-1-11**] 10:55 AM
IMPRESSION:
Significant increased echogenicity of the liver consistent with
fatty deposition. More advanced liver disease including hepatic
fibrosis/cirrhosis cannot be excluded. No ascites and no acute
hepatobiliary pathology. Splenomegaly.
CHEST (PORTABLE AP)Study Date of [**2111-1-10**] 9:45 PM
Some enlargement of the cardiac silhouette without vascular
congestion or pleural effusion. This raises the possibility of
cardiomyopathy or pericardial effusion. No evidence of acute
focal pneumonia.
HIP UNILAT MIN 2 VIEWS LEFT Study Date of [**2111-1-10**] 5:01 PM
No lytic or sclerotic lesions are present. No definite osseous
destruction is seen.
US EXTREMITY NONVASCULAR LEFT Study Date of [**2111-1-12**] 9:52 AM
(wet read)
Dedicated limited examination over the gluteus maximus on the
left
demonstrates edema with no distinct focal collections
Portable TTE (Complete) Done [**2111-1-13**] at 4:27:16 PM
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. 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 stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No definite valvular pathology identified
Brief Hospital Course:
49 yo M with a questionable history of substance abuse who
presented with R hip pain and hypotension now with resolving
[**Last Name (un) **], acidosis, and clinical picture suggestive of resolving
rhabdomyolysis.
#) Hypotension: Patient was briefly on peripheral pressors at
OSH, but responded to fluid boluses in the ICU, and was able to
wean off peripheral dopamine. There was a thought he might be in
distriubtive shock, as he did have some bandemia on his WBC
count; the source was felt most likely his urine, given that he
had no infiltrates on OSH CT torso, no ascites to suggest SBP,
no h/o diarrhea, no signs of meningitis). L hip as possible
focal source of infection, but no obvious evidence of septic
joint on exam or imaging. Urine cultures were negative.
Hypotension was also thought possibly secondary to poor PO
intake while possibly being down, although the patient denied
having been down for any period of time. The patient did report
taking Viagra and in the setting of alcohol and percocet
ingestion. This combination could have caused his hypotension
especially because of the potential vasodilatory effect of
viagra with an unclear dose. He responded well to fluids in the
MICU and hydration was continued on the floor with resolution of
hypotension.
#) Rhabdomyolisis: Differential for patient's rhabdo picture
included nontraumatic muscle compression or Nontraumatic
nonexertional causes(drugs or toxins, infections, or electrolyte
disorders) Although patient's history is inconsistent with
muscle compression, prolonged immobilization is likely given
that patient awoke with his left hip pain. He also had urine tox
studies positive for methadone and serum tox studies positive
for alcohol. Per his fiance, he had "six drinks and three
percocets". Prolonged immobilization/crush from drug consumption
+/- fall injury is likely given the quantity of mind altering
substances the patient consumed and the unilateral nature of his
pain. However, nontramatic nonexertional causes are possible
given the patient's multiple prescription drugs. Methadone is a
known cause of rhabdomyolisis. TSH was normal. The patient's
rhabdomyolisis picture resolved with hydration (Ck [**Numeric Identifier 14123**] -> 4000
at discharge)
#Acute renal failure: Caused by rhabdomyolysis and perhaps some
ATN in the setting of hypotension. His medication cocktail of
meloxicam, lisinopril undoubtedly contributed. We held his home
hold lisinopril, gabapentin, raloxicam. Cr resolved from 2.4 to
1.3 at discharge with hydration and avoidance of nephrotoxins.
.
#) Transaminitis/elevated CK: Likely [**12-25**] muscle breakdown given
rising CK over 20,000, which occurred in setting of dehydration
and possible occult trauma. Other etiologies for transaminitis
include hypoperfusion during hypotensive episode +/- alcohol
related liver disease given history and serum tox. Has signs of
synthetic dysfunction given high INR and low albumin, slight
increase in bili. No jaundice or significant RUQ pain or
anorexia to suggest dx of alcoholic hepatitis. RUQ U/S also
suggests fatty infiltration versus cirrhosis. He will need
further liver f/u as an outpatient for possible cirrhosis. Hep
serologies negative. Chol levels were WNL, and A1c is 5.8%.
.
#) Alcohol abuse: EtOH level 33 in our ED. Patient endorses h/o
heavy alcohol abuse. Drinks anywhere from [**3-31**] drinks per night.
Last drink was [**1-10**] at 00:00 and denies h/o withdrawal. Not
currently in window for withdrawal given alcohol level, but will
get there in the day or so. We started him on a CIWA scale in
house, and have given him 5 mg Valium prior to his floor
transfer. He was given oral thiamine, folate, and multivitamin
while in the hospital. He had a SW consult to discuss his
alcohol abuse.
#)Demand NSTEMI: positive troponin in the setting of
rhabdo/hypotension, less likely ACS. Trop peak of 0.41 at
[**Hospital1 18**]. He had ST depressions at [**Hospital1 **] on initial EKG which was
done in setting of tachycardia and hypotension. EKG in house
with less dramatic ST depressions 2hrs later. Given patient's
h/o palpitations, report of recent positive exercise stress, and
this "stress" test likely has underlying CAD though no evidence
of ACS. We started him on an aspirin, but tropinins were also
likely elevated in the setting of renal failure; in addition,
the MBI was WNL, makinga caridac etiology less likely. Echo was
performed and showed normal biventricular cavity sizes with
preserved global biventricular systolic function. No definite
valvular pathology identified.
#) Left hip pain: Unclear etiology- no history of trauma and
films w/o any evidence of inflammation or injury. On exam, hard
and swollen but with good range of motion and pain primarily in
lateral aspect of hip, not in joint- more muscular in area. U/S
of area showed no fluid collections. We also used a lidocaine
patch with PRN oxycodone in house and he was discharged on brief
regimen of oxycodone to supplement his chronic pain regimen.
#) Hypertension: we held lisinopril during his ongoing renal
recovery, and started 5mg amlodipine on discharge.
#) Colonic Polyposis: he described on admission a history of
colon cancer- this was actually a history of multiple colonic
polyps for which he gets q6monthly f/u. He is unaware of family
polyposis, and appears to have frequent followup.
#) ?Substance Abuse: he "borrowed" a methadone tab prior to
admission which he admitted to only after his tox revealed its
presence. He also had a high opiate tolerance in house.
Further steps in patient care management:
-Please check LFTs including Tbili to ensure downtrending after
plateau at discharge
-Please check Cr, CK to ensure that they are normalized.
Medications on Admission:
Viagra 100 mg PRN
Maloxicam 15 mg
Lisinopril 5 mg
Gabapentin 300 mg
Oxycodone 10 mg q6hr PRN pain
Adderal 30 mg qAM, 20 mg qPM
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Viagra 25 mg Tablet Sig: One (1) Tablet PO once a day as
needed for sexual intimacy: Do not take if taking nitrates for
chest pain, are light headed, or having low blood pressure.
3. Adderall 10 mg Tablet Sig: 2-3 Tablets PO 30 mg qAM, 20 mg
qPM .
4. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO every six (6) hours
for 3 days: Do not take if driving, do not take if operating
machinery, do not take if respiratory rate < 12 breaths per
minute.
Disp:*30 Tablet(s)* Refills:*0*
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
please check chem7, AST, ALT, Tbili, Dbili, LDH, AlkPhos on
Tuesday [**1-20**] and fax to Dr. [**Last Name (STitle) 13972**] [**Telephone/Fax (1) 92357**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Rhabdomyolsis, R hip
Acute Kidney Injury
Liver Injury with Transaminitis and cholestasis
Hypotension requiring pressor support
NSTEMI, demand related
Fatty Liver
Substance Abuse
Secondary Diagnosis
Hypertension
Obstructive Sleep Apnea
Chronic Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital because you had very low blood pressure
and injury to your kidneys and liver. You were given fluids to
raise your blood pressure and your kidney and liver function
were monitored closely. You began to recovered and are now able
to leave the hospital with close follow up with your primary
doctor.
We made the following changes to your medications:
- We STOPPED your Lisinopril, Meloxicam, and Gabapentin because
they may be harmful to your kidneys at this time.
- We INCREASED your Oxycodone to help you with your hip pain.
- We STARTED Amlodipine to treat your blood pressure
- We STARTED Aspirin to help prevent heart injury
Followup Instructions:
We recommend that you follow up with your primary doctor, Dr.
[**Last Name (STitle) 13972**], on Tuesday, [**1-20**] at 9:45 am.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Address: [**Street Address(2) 92358**], WEST, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 21975**]
Appt: [**1-20**] at 9:45am
You should also see a liver specialist due to your liver injury
from this hospitalization:
When: WEDNESDAY [**2111-1-28**] at 8:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 92359**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5849, 5990, 2762, 4019
|
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|
Medical Text: Admission Date: [**2153-3-19**] Discharge Date: [**2153-3-29**]
Date of Birth: [**2089-5-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
GU bleed
Major Surgical or Invasive Procedure:
Hemodialysis with temporary line
Paracentesis
Kidney Biopsy
History of Present Illness:
63-year-old male with hep C cirrhosis and HCC who was admitted
for new ARF (creatinine 11.9 up from 1.1 on [**3-8**], K max on day
of admission was 6.2) after recently moving to [**Location (un) 86**]. He
started HD yesterday which he tolerated well and then underwent
left renal biopsy today at 11:30. He got DDAVP for plts of 65
in setting of liver failure. He then began having hematuria.
From discussion with nursing over the course of the afternoon he
may have had up to 660cc of frank looking blood out his foley.
He never became tachycardic. He was seen by urology who began
CBI. He was having bladder pain. He also received 200cc IVF
with the plan to have it taken off by HD at a later time.
During HD he dropped his SBP to 70s and HD was discontinued for
labile pressures. Yesterday during dialysis his SBP were only
as low as 80s. He lives at a SBP of 90s per the patient. He
never was tachycardic today. HCT this AM 39.8 this am and was
25.5 this afternoon. HCT was 39.6 on arrival to the hospital but
likely baseline is 30. He received the beginning of a blood
transfusion on the floor but became hypothermic and developed
rigors. Blood transfusion was stopped. Pt states blood always
needs to be specially prepared for him. HCT on arrival to the
unit was 20.4. INR today was 1.4.
.
He has HCC [**2-14**] hepatitis C complicated by esophageal varices s/p
banding, anemia requiring transfusion, portal gastropathy, and
ascites requiring intermittent paracenteses. His most recent
chemotherapy was from was sorafenib between the dates of [**2153-1-22**]
and [**2153-3-6**]. He had stopped his chemo at that time due to an
admission for a GI bleed. He had banding of a non actively
bleeding variceal bleed at that time.
.
On arrival to the ICU vitals were T95.8 SBP98/50 HR66 RR14 100%
RA. The pt reported he was feeling much better. All bladder
discomfort and rigors has resolved.
Past Medical History:
Onc Hx:
-[**2150-11-19**]: resection of 4x4x3.8cm liver lesion in segment 5.
Pathology consistent with HCC. No lymphovascular invasion
-[**2151-5-20**]: resection of 1.8cm lesion in segment 5
-[**2152-2-14**]: chemoembolization of a branch of right hepatic artery
with taxotere and embospheres for two right lobe lesions
measuring 1.5 and 0.5 cm along with microwave ablation of the
1.5cm lesion
-had been on transplant list when MRI [**2152-8-11**] showed 2.4 x 4.3cm
lesion in segment 8 and thrombosis of a portal vein branch.
Underwent biopsy of the lesion which revealed a moderately
differentiated hepatocellular carcinoma with tumor embolus in
the portal vein branch. AFP started rising, 232ng/mL. Delisted
from transplant list.
-attempt to enroll in SEARCH trial. However, pt had anemia
(despite d/c-ing internferon and ribavarin), making him
ineligible from study
-began radiation in [**11/2152**] and finished 01/[**2153**]. Since [**2153-1-22**]
he has been on sorafenib 400mg [**Hospital1 **]. AFP steadily increasing over
last 5 months to 3000s.
-required large volume paracentesis twice [**2-/2153**] (7.6L and
7.8L). Episodes of anemia secondary to GI bleeding. EGD and
colonoscopy performed, revealing esophageal varices, hemorrhoids
and mild portal gastropathy.
-hospital admission [**2153-3-5**] for drop in Hct for which he
received PRBCs. No site of bleeding identified.
.
Other Past Medical History:
HTN
? CHF
Social History:
Recently moved from [**State 531**] to [**Location (un) 86**] to be near his son. Lives
alone but son lives ten minutes away. Worked in the past as
sheet metal worker but now retired. Denies hx of smoking, EtOH
or illicit drug use, including IV drugs.
Family History:
Father: cirrhosis, EtOH
Physical Exam:
EXAM ON ADMISSION:
VS: 95.5 88/50 60 20 100%RA
GEN: AOx3, NAD
HEENT: PERRL. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, distended, moderate ascites, NT, no rebound/guarding,
liver enlarged to 2cm below costal margin, no [**Doctor Last Name 515**] sign
Extremities: wwp. 3+ b/l edema, L > R, left calf pain, DPs, PTs
2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. no
asterixis
EXAM ON DISCHARGE:
VS: 98.2 120/64 66 16 97%RA
GEN: AOx3, NAD
HEENT: PERRL. MMM. no LAD. no JVD. no [**Doctor First Name **].
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, distended, moderate ascites, NT, no rebound/guarding,
liver enlarged 2cm below costal margin
Extremities: wwp. 2+ b/l edema, L > R
Skin: no rashes or bruising, anicteric
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. no
asterixis.
Pertinent Results:
ADMISSION LABS:
[**2153-3-19**] 11:00AM BLOOD WBC-11.6* RBC-3.94* Hgb-12.4* Hct-39.6*
MCV-100* MCH-31.5 MCHC-31.4 RDW-19.0* Plt Ct-113*
[**2153-3-19**] 11:00AM BLOOD PT-17.6* INR(PT)-1.6*
[**2153-3-19**] 11:00AM BLOOD Gran Ct-8810*
[**2153-3-19**] 11:00AM BLOOD UreaN-141* Creat-11.9* Na-134 K-5.2*
Cl-101 HCO3-16* AnGap-22*
[**2153-3-19**] 11:00AM BLOOD ALT-30 AST-65* LD(LDH)-170 AlkPhos-244*
TotBili-1.3 DirBili-0.8* IndBili-0.5
[**2153-3-19**] 11:00AM BLOOD TotProt-7.7 Albumin-2.6* Globuln-5.1*
Calcium-8.2* Phos-11.8* Mg-2.0
[**2153-3-19**] 11:00AM BLOOD AFP-2802*
[**2153-3-19**] 06:15PM BLOOD C3-83* C4-15
[**2153-3-20**] 07:10AM BLOOD HCV Ab-POSITIVE*
DISCHARGE LABS:
[**2153-3-29**] 07:02AM BLOOD WBC-6.4 RBC-2.98* Hgb-9.4* Hct-29.0*
MCV-97 MCH-31.5 MCHC-32.4 RDW-19.4* Plt Ct-95*
[**2153-3-29**] 07:02AM BLOOD PT-13.5* PTT-30.8 INR(PT)-1.2*
[**2153-3-25**] 05:50AM BLOOD Lupus-NEG
[**2153-3-25**] 05:50AM BLOOD ACA IgG-PND ACA IgM-PND
[**2153-3-29**] 07:02AM BLOOD Glucose-92 UreaN-74* Creat-2.9* Na-135
K-4.2 Cl-99 HCO3-29 AnGap-11
[**2153-3-24**] 06:00AM BLOOD ALT-24 AST-64* LD(LDH)-155 AlkPhos-183*
TotBili-1.5
[**2153-3-29**] 07:02AM BLOOD Albumin-2.5* Calcium-8.9 Phos-4.6* Mg-1.8
[**2153-3-21**] 06:00AM BLOOD Hapto-120
[**2153-3-19**] 06:38PM BLOOD Cryoglb-POSITIVE *
[**2153-3-20**] 07:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2153-3-19**] 06:15PM BLOOD ANCA-NEGATIVE B
[**2153-3-19**] 06:15PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:640
[**2153-3-19**] 06:15PM BLOOD RheuFac-<3
[**2153-3-19**] 11:00AM BLOOD AFP-2802*
[**2153-3-19**] 06:15PM BLOOD PEP-POLYCLONAL
[**2153-3-28**] 10:36AM BLOOD C3-97 C4-17
[**2153-3-27**] 06:44PM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO-PND
[**2153-3-19**] 02:19PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
Osmolal-378
[**2153-3-19**] 02:19PM URINE Hours-RANDOM Creat-198 Na-40 K-31 Cl-14
TotProt-44 Prot/Cr-0.2
[**2153-3-26**] 03:53PM ASCITES WBC-50* RBC-52* Polys-11* Lymphs-13*
Monos-68* Mesothe-8*
[**2153-3-26**] 03:53PM ASCITES TotPro-0.9 Glucose-125 LD(LDH)-27
Albumin-LESS THAN
MICROBIOLOGY:
URINE CULTURE (Final [**2153-3-20**]): NO GROWTH.
Blood Culture, Routine (Final [**2153-3-25**]): NO GROWTH.
Blood Culture, Routine (Final [**2153-3-27**]): NO GROWTH.
MRSA SCREEN (Final [**2153-3-24**]): No MRSA isolated.
[**2153-3-26**] 3:53 pm PERITONEAL FLUID
GRAM STAIN (Final [**2153-3-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2153-3-29**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
STUDIES:
[**2153-3-19**] GU U/S:
IMPRESSION:
1. Normal kidneys.
2. Enlarged prostate gland with calculated volume of 37.4cc.
3. Large volume intra-abdominal ascites.
[**2153-3-20**] Bilateral LENIs:
IMPRESSION:
Bilateral normal lower extremity US. Negative for above-knee DVT
bilaterally.
[**2153-3-22**] CT abdomen/pelvis:
IMPRESSION:
1. Mild perinephric stranding adjacent to the left kidney, most
likely from recent percutaneous biopsy. A small hyperdense focus
in the posterior aspect of the left kidney likely represents a
tiny hematoma.
2. Hyperdense blood within the left collecting system, including
the proximal ureter, with no evidence of obstruction. There is a
large amount of blood and clot within the bladder. There is no
large hematoma outside of the collecting system.
3. Massive abdominal ascites.
4. Multiple irregular hypodensities within the liver,
incompletely
characterized on this non-contrast enhanced study, compatible
with multifocal HCC, better seen on prior reference imaging
studies.
5. Mediastinal and porta hepatis lymphadenopathy.
6. Colonic diverticulosis.
[**2153-3-21**] Kidney biopsy:
ULTRASOUND GUIDANCE FOR RENAL BIOPSY BY NEPHROLOGIST: Ultrasound
examination of the kidneys was performed. The lower pole of the
left kidney was identified and the position was marked on the
patient's back for renal biopsy to be performed by the
nephrologist.
[**2153-3-21**] CXR:
Opacification in infrahilar right lung is probably atelectasis,
unchanged. There are no findings to suggest current pneumonia.
Heart size is normal. No pleural abnormality. Right jugular line
ends in the region of the superior cavoatrial junction.
[**2153-3-26**] Peritoneal Fluid:
NEGATIVE FOR MALIGNANT CELLS.
[**2153-3-26**] Paracentesis:
IMPRESSION: Successful ultrasound-guided diagnostic and
therapeutic
paracentesis of 3 liters of serous fluid.
[**2153-3-27**] CT abdomen/pelvis:
IMPRESSION:
1. Unchanged hyperdense focus in the posterior left kidney,
consistent with a small subcapsular hematoma.
2. Decreased amount of hyperdense blood and clot both within the
proximal
left collecting system and the bladder. No hematoma is seen
outside of the
collecting system.
3. Large amount of abdominal ascites.
4. Incompletely characterized irregular hypodensities within the
liver
consistent with the patient's known multifocal HCC.
Brief Hospital Course:
63-year-old male with hep C cirrhosis and HCC with new onset
acute renal failure and transferred to the unit for GU bleed
after left renal biopsy.
# Acute renal failure: Cr was elevated on admission to 11.9 from
baseline 0.9. Renal was consulted and advised dialysis as well
as a kidney biopsy. He received several sessions of bedside
hemodialysis; two sessions were prematurely stopped as his blood
pressure did not tolerate it. Cr came down to 4.2 following
dialysis and further trended down to 2.9 prior to discharge.
His lasix was held given his acute renal failure and
hypotension. His other antihypertensives, amlodipine and
aldactone, were also held. Renal ultrasound showed enlarged
prostate and large amount of ascites but normal kidneys.
Initially, it was felt that his acute renal failure was
secondary to sorafenib induced nephrotoxicity. However, the
kidney biopsy light microscopy showed mesangial proliferative
GN. Immunofluorescence showed 2+ IgG and 2+ lambda mesangial
deposition. There were no thrombi in the microvasculature to
make deifinite diagnosis of a TMA to implicate the sorafenib.
SPEP showed polyclonal hypergammaglobulinemia and UPEP showed no
monoclonal IG and was negative for bence [**Doctor Last Name 49**] proteins. The
serum free light chain assay was pending on discharge. [**Country 7018**]
Red was negative for amyloid. His [**Doctor First Name **] was also positive at
1:640, lupus anticoagulant was negative, and anti-cardiolipin
IgG/M were pending at discharge. Preliminary biopsy results
were suspicious for fibrillary glomerulonephritis. He was
discharged with follow-up at nephrology clinic for further
evaluation as outpatient. He was discharged on sevelamer for
hyerphosphatemia. He was also restarted on his lasix as Cr
stabilized.
# GU bleed s/p kidney biopsy: Pt underwent kidney biopsy on
[**2153-3-21**] that was complicated by gross hematuria. He was seen by
urology and put on CBI. His hematuria led to drop in Hct from
high 20s to low 20s and a drop in blood pressure to systolic
70s. He was transferred to the ICU for the hypotension. CT
abdomen showed perinephric stranding adjacent to the left
kidney, most likely from
recent percutaneous biopsy, a small hematoma in left kidney, and
blood in the collecting system and bladder. He required a total
of 5 units PRBCs and 1 bag platelets throughout hospital
admission. Hct was stable at baseline in high 20s by time of
discharge. Repeat CT abdomen showed that small hematoma in
kidney was stable. He no longer had hematuria at discharge and
was able to urinate without a foley.
# ?Transfusion reaction: Of note, pt exhibited rigors during his
first transfusion. He was not febrile. Per transfusion
medicine, this was likely not a febrile non-hemoltyic
transfusion reaction given the short duration of his symptoms,
no subsequent fever and that leukoreduction significantly
decreases the risk of these reactions. He experienced no
adverse reactions from his subsequent transfusions.
# Hypotension: BP at admission was systolic 80s. He was given
IV fluids and his antihypertensives and diuretics were held
(with the exception of nadolol). He later became hypotensive to
systolic 70s following hematuria after a kidney biopsy and
hemodialysis. Pt also with mild hyperthermia to 95 concerning
also for infection on admission. He was pan-cultured, with
negative urine and blood cultures. Patient started on CTX 2gm
Q24hrs x2 days for possible SBP, but was dicscontinued [**3-23**] as
likelihood of SBP felt to be very small with no abdominal pain,
normal WBC and no fevers. Peritoneal fluid showed no signs of
infection. Following transfusion of PRBCs and IV fluids, BP
stabilized in systolic 100s-120s throughout remainder of
admission.
# LE edema: Pt presented with LE edema, left worse than right.
On admission he endorsed some calf pain as well. B/l LENIs were
obtained, which were negative for DVT. Pain resolved and pt was
able to ambulate without difficulty. He was discharged back on
his lasix.
# Hepatocellular carcinoma: Pt was s/p sorafenib [**2153-1-22**] to
[**2153-3-6**]. He has recently transferred his onc care here. He was
continued on nadolol at admission but this was briefly held in
the ICU when GI bleed was being ruled out for drop in Hct. He
underwent a therapeutic paracentesis on [**2153-3-26**]; peritoneal
fluid was benign and 3L were removed from abdomen. He will
discuss with his outpatient oncologist whether sorafenib can be
restarted once kidney function stabilizes.
Medications on Admission:
1. oxycodone 5mg po q4h prn
2. aldactone 100mg po daily
3. lasix 40mg po daily
4. nadolol 20mg daily
5. protonix 40mg daily
6. amlodipine/benzapril 10/40
7. Nexavar (on hold)
8. levaquin 500mg po x 1 week
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute renal failure
Secondary:
Hepatocellular carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with acute kidney failure. The severity of your kidney
failure required several sessions of hemodialysis. Your kidney
function improved with the hemodialysis. You were evaluated by
our renal consult team who performed a kidney biopsy. This was
complicated by bleeding that caused your blood counts to drop
and your blood pressure to drop. You were transferred to the
intensive care unit briefly because of this and were transfused
with blood products. Your blood pressure recovered and the
bleeding in the urine stopped.
Your kidney biopsy showed a rare condition called fibrillary
glomerulonephritis. It is very important that you have regular
follow-ups at the [**Hospital 10701**] Clinic for frequent monitoring of
your kidney function and possibly further testing.
The following medications were changed:
1) STOP amlodipine/benzapril unless one of your outpatient
doctors wants to restart. Your blood pressure was extremely good
in the hospital so you didn't need it on discharge.
2) STOP aldactone. Ask your outpatient doctors when [**Name5 (PTitle) **] [**Name5 (PTitle) **]
restart this medication.
3) STOP levaquin
4) STOP nexavar
5) START sevelemar 800mg three times a day with meals to lower
your phosphorous levels
Followup Instructions:
You have the following appointments scheduled for you. You will
need to come to the [**Hospital 2793**] Clinic on the [**Location (un) 448**] of the [**Hospital Ward Name 121**]
building ([**Hospital Ward Name **]) on Monday [**2153-4-2**] to get your labs drawn.
Please come between the hours of 9am and 2pm and bring with you
the lab order slip.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2153-4-6**] at 3:30 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2153-4-4**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2153-3-29**]
ICD9 Codes: 5849, 2762, 4019, 4589
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5774
}
|
Medical Text: Admission Date: [**2168-9-28**] Discharge Date: [**2168-10-3**]
Service: NEUROLOGY
Allergies:
Trileptal
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
Decreased Responsiveness
Major Surgical or Invasive Procedure:
Video EEG monitoring
History of Present Illness:
[**Age over 90 **]y right handed F with a h/o progressive dementia, generalized
seizure disorder, hypothyroidism and colon cancer admitted to
Neuro-ICU for seizure, non-convulsive status epilepticus (NCSE).
She was p/w an episode of unresponsiveness, sleepiness and less
talkative, found by the staff at her [**Hospital3 **] facility.
Patient was brought in to [**Hospital1 18**] ED accompanied with her
daughter, who was called from facility suspected for seizure.
Patient showed above symptoms and also presistent shiverring
like movements, which was recognized 4mo ago when she was
brought into ED for seizure. At ED, patient was hypertensive
(SBP226) and had UTI. She had continued on shivering like
movement throughout.
She received Nitropaste, labetalol iv, Cipro 250mg, home dose of
Keppra (500mg), Ativan 2mg. Patient was admitted to medical
service in the beginning to control confusion, UTI, seizure.
After the admission, patient stayed still unclear, less
talkative and occasionally starring. Bedside EEG reveiled NCSE,
and patient was transferred to Neurology ICU service.
At ICU, she was loaded with Dilantin and has been doing better,
less confusive, no seizure episodes. The shiverring movements
were also disappeared. Follow up EEG study showed resolution of
electrical status. After the stabilization, patient was
transferred to Neurology service.
She has a history of "[**Doctor Last Name 11332**] mal" seizures, which she suddenly
stared and got uncouscious when she was younger, treated with
Dilantin -> Tegretol ->Keppra. Recently in [**2168-5-23**] she had an
episode, but since then no witnessed seizures.
She denies recent illnesses, fever, cough, cold sx, HA, chest
pain, abdominal pain, diarrhea, change in appetite, sleep.
At transfer, she was more awake, alert, attentive compare to the
time of admission. Has had stable VS.
Past Medical History:
1. Hypothyroidism
2. Generalized Seizure D/O - Followed by Dr. [**Last Name (STitle) **]. Her
seizures are "blackouts", no described tonic-clonic activity.
3. Colon Cancer - s/p right hemicolectomy [**2166-8-12**] - pt does not
know about diagnosis
4. Dementia
5. Hypertension
6. h/o chronic Anemia - on B12
7. h/o falls
Allergies: Trileptal (rash?)
Social History:
The patient lives at [**Hospital3 **]. She has been having
intermittent falls [**2-25**] vertigo. She is able to dress/bath/toilet
herself.
Family History:
Noncontributory
Physical Exam:
(At admission):
Vitals: T: 98F P: 70 R: 16 BP: 130/70 SaO2: 98% RA
General: Lying in bed with eyes closed.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no JVD or carotid bruits appreciated. No nuchal
rigidity
Pulmonary: Lungs with transmitted upper airway sounds
bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Opens eyes transiently to voice. Intermittently
and inconsistently follows commands. Can count fingers, but
cannot state her name.
-cranial nerves: PERRL 2.5 to 2mm and brisk. Visual fields full
to threat. EOMI. No facial asymmetry.
-motor: Normal bulk throughout. Tone mildly increased in lower
extremities. Withdraws briskly to noxious stimuli in all four
extremities. No adventitious movements noted. No asterixis
noted.
No myoclonus noted.
-sensory: Grimaces to noxious stimuli in all four extremities.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
(At Transfer to Neurology Floor - after seizure was controlled):
Gen: Awake, alert, no distress
HEENT: clear ears, conjunctivas, oral membrane, no neck bruit,
no goiter
Chest: vesicular sound, symmetrical, symmetrical chest
Heart: S1, S2 nl, no murmur
Abd: soft nt/nd no hepatosplenomegaly
Skin: no lesions, skin stigmata, moist, turgor nl
Exts: edematous legs with swollen, with increased tone
NEURO
MS Awake and alert, cooperative with exam, normal affect.
Oriented to person, place, and date. Inattentive, says 4 digits
backwards, foreward of 7. Speech is fluent with slightly
moderately comprehension and repetition. Difficult to understand
instruction and following commands. No dysarthria. [**Location (un) **]
intact. Registers 0/3, recalls 0/3 in 5 minutes. No right left
confusion. No evidence of apraxia or neglect.
CN Fundus bil clear/sharp margin. VF full (both at biocular
test), Pupils round, equal, Pupils reactive to light, right 5mm
to 2mm and left 5mm to 2mm. EOMI with 2-3beats of nystagmus at
bil extreme lateral gaze. Symmetrical facial sense, appearance,
NLF, WFH, uvla midline, tongue full, SCM normal
Motor Full throughout, normal tone
Reflex DTR brisk throughout, symmetrical at UEs. LEs, absent
patellar and ankle reflexes. planters going down
Sensory normal and symmetrical touch/temp/vibration throughout.
Coordination nl FNF. HS could not be peformed due to limitation
of knees. No DDK.
Gait: Unable to exam.
Pertinent Results:
([**2168-9-27**]) At admission
CBC: 5.9>12.8/35.7<157 diff. N:75.7 L:20.0 M:3.4 E:0.5 Bas:0.3
138 101 15 118 AGap=14
4.4 27 0.6 9.0 Mg: 2.2 P: 3.4
CK: 49 MB: Notdone Trop-*T*: <0.01
TSH:0.033
U/A: straw color/1.012/7.0/Nitrite small/LE
neg/WBC6-10/RBC0-2/Bac many/yeast none/Epi3-5
Urine Cx: mixed flora, most likely fecal contamination
CT w/o contrast: No intracranial hemorrhage. See above report.
EEG ([**2168-9-29**]): Markedly abnormal EEG due to the generalized
rhythmic [**2-26**] Hz high amplitude polyspike and wave or spike and
wave
discharges, which had a decreased frequency after ativan. This
EEG is
consistent with nonconvulsive status epilepticus, as the patient
clinically was responsive without any abnormal motor activity,
but was
confused during the recording.
LTM-EEG ([**2168-9-30**]):This 24 hour video EEG telemetry captured
sustained rhythmic [**2-26**] Hz polyspike and wave, spike and wave
discharges consistent with status epilepticus. The activity
resolved with apparent treatment. Automated and routine sampling
demonstrated isolated transient discharges more prominantly seen
over the right hemispheric leads.
Brief Hospital Course:
The pt is a [**Age over 90 **] year-old woman with a history of seizure disorder
and dimentia (considered as Alzheimer disease) who presented
with encephalopathy and was found to be in non-convulsive status
epilepticus (less responsiveness, shiverring movement).
On examination at transfer, patient was much clearer, showed
significant improvement in mental status except persistent
working [**Last Name **] problem (remote memory was preserved well). Head
CT did not show any intracranial lesions. After dilantin
loading, no seizure episodes were observed and EEG was improved
(less frequent spikes). After improvement in seizure with
Dilantin and once Keppra reached at target dose (750/500/750mg;
2g/day), Dilantin was tapered from 100mg tid to 100mg [**Hospital1 **] (for
5days) without any recurrence of seizure. It will be tapered
further to 100mg daily x5days and off. The epilepsy will be
managed with Keppra 750/500/750mg and be followed by Dr.
[**Last Name (STitle) **] (Neurologist).
Regarding to her dementia, with history and examination,
Alzheimer Disease will be most likely diagnosis. By reviewing
history, Memantine was not tried so far for her dementia, which
might be benefitial for the symptom especially for memory
impairment.
For UTI, patient was treated with Cipro initially, then changed
to Levofloxacin and also again switched to Ceftriaxone (given
total of 3 days) after tranferred to Neurology service,
considering epileptogenic effect of both Cipro and Levofloxacin.
The UTI could be the exacerbation factor of seizure and mental
status. Culture grew mixed pathogen (fecal contamination?). The
[**Last Name 22147**] problem has been followed by Dr. [**Last Name (STitle) **] as well
and will be followed at f/u visit.
Medications on Admission:
Cipro 250mg po qd
Aricept 10mg qd
Keppra 500mg TID (last adjustment; increased on [**2168-5-26**])
Zoloft 25mg [**Hospital1 **]
Levothyroxine 125mcg qd
folate 1mg qd
metoprolol 25mg [**Hospital1 **]
cyanocobalamin injection q month
senna, colace, heparin sc
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
3. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
10. Keppra 750 mg Tablet Sig: One (1) Tablet PO once a day: in
the morning.
Disp:*30 Tablet(s)* Refills:*2*
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY AT
2PM ().
Disp:*30 Tablet(s)* Refills:*2*
12. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 4 days: After 4days then
switched to 100mg once daily for 5days and stop.
Disp:*13 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Status epilepticus (non convulsive status epilepticus)
Dimentia
Discharge Condition:
Stable/Improved
Discharge Instructions:
Please continue on her regular medication and seizure medication
(see below).
Dilantin 100mg po bid will be decreased in 4days to 100mg daily
for 5days and then completed.
Keppra 750mg in am, 500mg in noon, 750mg bedtime will be
continued as regular medicine.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2168-11-17**] 4:00 (Also on cancelling list for earlier
visit).
**Dear Administrative office at facility**
Please call above number to provide the contact number to
[**Hospital 878**] clinic and for possible earlier appointment.
Completed by:[**2168-10-3**]
ICD9 Codes: 5990, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5775
}
|
Medical Text: Admission Date: [**2185-3-15**] Discharge Date: [**2185-3-21**]
Date of Birth: [**2120-1-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2185-3-16**] - Urgent coronary artery bypass graft times 3: Left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal 1 and 2.
[**2185-3-15**] - Cardiac Catheterization
History of Present Illness:
65M with h/o htn and hyperlipidemia who has developed dyspnea on
exertion over the preceeding months. Stress test was abnormal
and cardiac cath reveals left main disease. He is referred for
cardiac surgery.
Past Medical History:
hypertension
hypercholesterolemia
chronic renal insufficiency
gout
melanoma
obstructive sleep apnea (does not use CPAP)
Social History:
Last Dental Exam: 2 weeks ago, in the process of periodontal
work
Lives with: daughter
Occupation: retired, volunteers at soup kitchen, babysits
grandchildren 1-2 days/week
Tobacco: none
ETOH: 1/week
Family History:
dad died at 78 CHF
mom died 83 lung cancer
Physical Exam:
Pulse: 62 Resp: 18 O2 sat: 96%RA
B/P Right: 181/77 Left:
Height: 5'[**84**]" Weight: 90kg
General: NAD, pleasant
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] no edema or varicosities
Neuro: Grossly intact x
Pulses:
Femoral Right: cath Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left: no carotid bruits
appreciated
Pertinent Results:
[**2185-3-16**] ECHO
PRE-BYPASS
- The left atrium and right atrium are normal in cavity size. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
- Left ventricular wall thicknesses and cavity size are normal.
- Overall left ventricular systolic function is normal
(LVEF>55%).
- Right ventricular chamber size and free wall motion are
normal.
- There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
- The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Trace aortic regurgitation is seen.
- Mild (1+) mitral regurgitation is seen.
- There is no pericardial effusion.
- Dr. [**Last Name (STitle) **] was notified of the TEE findings in person
on [**2185-3-16**] at 11 am.
POST-BYPASS
- Post-bypass on Phenylephrine infusion. A-V pacing.
- LV function hyperdynamic with perserved EF. No regional wall
motion abnormalities.
- Mild mitral regurgitation
- Trace aortic insufficiency.
- Aorta intact.
[**2185-3-15**] Carotid Ultrasound
There is less than 40% stenosis within the internal carotid
arteries bilaterally.
[**2185-3-15**] Cardiac Catheterization
1. Coronary angiography in this right dominant system revealed
significant 3-vessel coronary artery disease involving the LMCA.
The
LMCA was mildly calcified, with an 80% stenosis in the mid
portion, as
well as an 80% distal stenosis extending into an ostial LCX
stenosis.
The LAD was moderately calcified, with an ostial 50% stenosis
with
post-stenotic dilatation, a proximal 40% stenosis, and a
mid-portion
that was likley deeply intramyocardial after a large branching
D2
branch. The LAD had TIMI 2 fast flow consistent with
microvascular
dysfunction. The LCX was mildly calcified, with an ostial 80%
stenosis,
and supplied OM1, OM2, OM3, OM4 (which was actually a vertical
L-PL),
and AV-groove LCX, and had TIMI 2 flow as well. The OM1 had a
mild
stenosis at the origin. The RCA had mild diffuse plaquing to
30%
proximally and distally, with a diffuse disease up to 30%
stenotic in
the proximal R-PDA, a large long R-PL2 with plaquing to 30% in
the
distal AV-groove RCA and mid R-PL2, and TIMI 2 flow consistent
with
microvascular dysfunction.
2. Left ventriculography revealed normal estimated stroke volume
of 60
mL/beat, with a normal ejection fraction of 65% and mild mitral
regurgitation. There was very mild inferior wall hypokinesis.
3. Resting hemodynamics revealed mild systemic hypertension with
SBP of
147 mmHg, and mildly increased left-ventricular filling
pressures with
LVEDP of 17 mmHg. There was no evidence of aortic stenosis as
measured
by LV pull-back technique.
[**2185-3-21**] 04:39AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.3* Hct-29.4*
MCV-85 MCH-29.7 MCHC-34.9 RDW-14.8 Plt Ct-211
[**2185-3-18**] 04:35AM BLOOD PT-12.4 PTT-30.1 INR(PT)-1.0
[**2185-3-21**] 04:39AM BLOOD Glucose-95 UreaN-29* Creat-1.6* Na-141
K-3.7 Cl-103 HCO3-29 AnGap-13
[**2185-3-20**] 03:58AM BLOOD UreaN-33* Creat-1.5* K-4.1
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2185-3-15**] for a cardiac
catheterization. This revealed severe left main and two vessel
disease. The cardiac surgical service was consulted and he was
worked-up in the usual preoperative manner. A carotid duplex
ultrasound was obtained which showed less then 40% stenosis of
the bilateral internal carotid arteries. On [**2185-3-16**] he was taken
to the operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative noted for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Over the next 24 hours, Mr. [**Known lastname **] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Beta blockade, aspirin
and a statin were resumed. There was some suggestion of
pericarditis and a nonsteroidal anti-inflammatory was used with
good results. Later on postoperative day one, he was transferred
to the step down unit for further recovery. Mr. [**Known lastname **] was
gently diuresed towards his preoperative weight. The patient
developed rapid atrial fibrillation. He was loaded with
amiodarone and beta blocker was titrated accordingly. He did
convert to sinus rhythm. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 5 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
atenolol 25', plavix 300mg x1, 75mg', lisinopril 15', sl NTG
prn, ambien 10 prn, asa 325', MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 7 days, then 400mg daily x 7 days, then
200mg daily until further instructed.
Disp:*120 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease s/p CABGx3
hypertension
hypercholesterolemia
chronic renal insufficiency
gout
melanoma
obstructive sleep apnea (does not use CPAP)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
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 from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**2185-4-18**] 2:00PM
Please follow-up with Dr. [**Last Name (STitle) 1968**] in [**1-26**] weeks. [**Telephone/Fax (1) 250**]
Please follow-up with Dr.[**Name (NI) 3733**] in [**1-26**] weeks. [**Telephone/Fax (1) 62**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2185-3-21**]
ICD9 Codes: 4111, 9971, 4240, 2724, 5859, 2749
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5776
}
|
Medical Text: Admission Date: [**2131-8-23**] Discharge Date: [**2131-9-3**]
Service: Cardiothoracic Surgery
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2131-9-3**] 10:53
T: [**2131-9-3**] 11:24
JOB#: [**Job Number 7488**]
ICD9 Codes: 4111, 4280, 5789
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5777
}
|
Medical Text: Admission Date: [**2128-1-13**] Discharge Date: [**2128-1-21**]
Date of Birth: [**2087-7-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
EGD with banding
paracentesis X2
History of Present Illness:
40yo woman with history of ETOH Abuse presented to the ED with
hematemesis. She has a history of ETOH abuse, and reportedly
went on a binge recently. In that setting, she had about 400cc
in hematemesis. She presented to an OSH where her Hct was 12.
She received 2 units PRBC and 2U FFP there. She was then
transferred here to [**Hospital1 18**]. No further episodes of hematemesis
here.
.
In the ED, she was hemodynamically stable. Initial vitals were:
101.1, 106, 132/66, 19, 99% RA. She was found to have a Hct of
17.6. Her labs were otherwise notable for platelets of 45 and
INR of 1.4. Her chemistry was otherwise normal with normal renal
function and an anion gap of 11. She had a mild transaminitis
with AST/ALT ratio of > 2:1. While in the ED, she had two Lg
bore peripheral IV's placed and was transfused in total 2 units
of PRBC as well as platelets. She was started on Protonix and
Octreotide drips. Got 1L banana bag, followed by > 1L NS.
.
Of note, she has a history of ETOH abuse. No documented history
of cirrhosis or esophageal varices. On interview, she confirms
the above history of ETOH binge with resultant episode of
hematemesis. Otherwise, she reports mild subjective fever,
abdominal fullness, and tenderness. Otherwise, ROS negative. No
CP, SOB, cough, dysuria, meningeal symptoms, or any other focal
complaints. She does report that she has been feeling
increasingly depressed resulting in her most recent ETOH binge.
.
Past Medical History:
1. ETOH abuse
2. cocaine abuse
3. depression
Social History:
Pt married, in long-standing abusive marriage and had recently
gotten
a restraining order on husband (3 months ago), but rescinded it
this past w/e to join him on [**Hospital3 4298**] where they were
drinking/using drugs. Pt lives in [**Location (un) 72459**] with 15yo
daughter. Pt has not worked inmany years. Pt is one of 5
siblings who live in the [**Location (un) 86**] area. both parents still living
although father has not been involved in many years and has hx
of etoh abuse. Currently, pt. adamant about stopping ETOH. She
states she has long history of drinking, mostly weekend binge
drinking of 2 pints/day on weekends. Interested in rehab from
home but cannot pay [**1-2**] insurance
Family History:
ETOH abuse in father
Physical Exam:
vs: 100.4, 92, 114/71, 20, 100% on 2L nc
.
gen a/o, nad
heent anicteric, mmm
neck supple, no meningeal signs, no JVD
cv rrr, no m/r/g
resp CTA bilaterally
abd mildly distended, soft, mild diffuse tenderness; no
peritoneal signs
extr warm, well perfused; no c/c/e
neuro + mild asterixis
Pertinent Results:
[**2128-1-12**] 10:55PM PT-15.8* PTT-30.2 INR(PT)-1.4*
[**2128-1-12**] 10:55PM PLT SMR-VERY LOW PLT COUNT-45*
[**2128-1-12**] 10:55PM NEUTS-80.7* BANDS-0 LYMPHS-13.5* MONOS-5.3
EOS-0.1 BASOS-0.4
[**2128-1-12**] 10:55PM WBC-9.9 RBC-1.98* HGB-6.0* HCT-17.6* MCV-89
MCH-30.4 MCHC-34.3 RDW-18.3*
[**2128-1-12**] 10:55PM ALBUMIN-3.2*
[**2128-1-12**] 10:55PM LIPASE-31
[**2128-1-12**] 10:55PM ALT(SGPT)-19 AST(SGOT)-73* LD(LDH)-169 ALK
PHOS-262* AMYLASE-37 TOT BILI-1.6*
[**2128-1-12**] 10:55PM GLUCOSE-99 UREA N-17 CREAT-0.5 SODIUM-141
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
CHEST (PA & LAT) [**2128-1-17**] 3:42 PM
There is patchy opacity in the right cardiophrenic region,
similar to that seen on the portable film from earlier the same
day. This most likely lies in the anterior segment of the right
lower lobe. There is a small-to-moderate right and small left
pleural effusion. Both the patchy opacity and the right effusion
are new compared with [**2128-1-13**].
IMPRESSION:
1. Bilateral right greater than left effusions.
2. Patchy opacity, right base, suggestive of a pneumonic
infiltrate.
ABDOMEN U.S. (COMPLETE STUDY) [**2128-1-13**] 8:06 AM
There are no prior studies for comparison. The liver is
intensely echogenic and heterogeneous compatible with fatty
infiltration. No discrete masses are identified. There is
massive ascites, and an appropriate spot was marked in the right
lower quadrant for paracentesis by the clinical team.
Liver Doppler shows fully patent portal veins with forward flow
and normal respiratory variations. There is evidence of portal
hypertension as manifested by a patent umbilical vein. The
hepatic veins, inferior vena cava, and hepatic arteries are all
fully patent. The pancreas and retroperitoneum are not well seen
and the splenic and superior mesenteric veins are also not well
visualized.
There is a small gallstone in the neck of the gallbladder, but
no signs of acute cholecystitis. There is no bile duct
dilatation. The right kidney measures 9.3 cm in length and the
left kidney 11.5 cm. Both kidneys are normal in appearance. The
spleen is upper normal in size at 12.3 cm.
CONCLUSION: Fatty heterogeneous liver with signs of portal
hypertension including a patent umbilical vein. The degree of
heterogeneity in the liver makes exclusion of small lesions
difficult and consideration of further imaging with MRI is
recommended.
Massive ascites with the spot marked in the right lower quadrant
for paracentesis by the clinical team.
Gallstone.
Brief Hospital Course:
In ICU, had elective intubation for EGD which showed grade III
varices which were banded. She also had nl. portal flow and RUQ
U/S with fatty liver and e/o portal hypertension including
patent umbilical vein and massive ascites. Extubated without
event. Had 4L paracentesis, no e/o SBP. On cipro ppx for 5 days
given recent bleed. Was also on CIWA scale with little diazepam
requirements.
Further management on the floor:
# GI bleed- s/p banding of variceal ulcer twice, 4U pRBCs; EGD
[**2128-1-13**] showed stage III varices. HCT stable since admit.
Hepatology following. [**2128-1-20**] had EGD with banding and no repeat
bleeding. Did have some post procedure pain, but improved with
pain meds and sucralfate. Will need follow up with GI [**2-12**]
for repeat EGD and then with Dr. [**Last Name (STitle) **] [**2-9**].
Discharged on PPI [**Hospital1 **], sucralfate qid. Propranolol [**Hospital1 **]
.
# Cirrhosis- [**1-2**] ETOH abuse w/LFT's elevated and AST/ALT>[**1-1**].
alk phos, tbili, transaminases trending down. Likely had
alcoholic hepatitis that is improving. Patient as tested for
hep C negative, hep B S-Ab positive, other hepB serologies
negative. Was also started on diuretics of lasix 40 mg,
sprinolactone 100mg per hepatology recommendations. [**Month (only) 116**] need
staging bx. as outpt. Should be maintained on low salt diet as
an outpatient.
.
# h/o ETOH abuse Currently with no signs and symptoms of
withdrawal. Was on CIWA but had minimal diazepam requirment.
Patient has been accepted at AD care treatment center.
.
# fever- positive UA with >100,000 e coli, treated with
ceftriaxone for 3 days, asymptomatic now and afebrile for
several days prior to discharge.
.
# thrombocytopenia: stable. likely [**1-2**] chronic liver dz.
Medications on Admission:
none
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*14 caps* Refills:*0*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*14 Tablet(s)* Refills:*0*
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*14 Tablet(s)* Refills:*0*
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*56 Tablet(s)* Refills:*2*
7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
8. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours:
no more than 2 grams/day (6 tablets).
9. Propranolol 10 mg Tablet Sig: One (1) Tablet PO twice a day:
hold for dizziness or light headedness.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12671**] Hospital - [**Hospital1 1559**]
Discharge Diagnosis:
Grade III esophageal varices
Blood loss anemia
ETOH abuse
ETOH cirrhosis
depression
Discharge Condition:
good, tolerating pos, ambulating without assistance, satting
>95% on room air
Discharge Instructions:
As you know you were admitted with a bleed from large veins in
the esophagus, called varices. These veins are large and prone
to bleeding because of your liver disease, called cirrhosis,
which is from alcohol use. We strongly advise you to remain
abstinent from all alcohol.
You should limit your salt and fluid intake as you have been
instructed by nutritional services here.
You need to take all medications exactly as prescribed,
especially spironolactone (for fluid, a diuretic), lasix (for
fluid, a diuretic), pantoprazole (to prevent acide in the
stomach), and propranolol (to keep BP low and prevent bleeding
in your esophagus). These medicines are very important to
prevent reaccumulation of your ascites, infection, and
rebleeding.
Follow up as below.
..........
DIET: you should only have clear liquids for 6 hours after EGD
today and then soft foods for the next 24 hours (as you had
bands placed today and you have to eat soft foods to allow them
to heal).
Followup Instructions:
Make an appointment to follow up with your primary care
provider's office within 1 week.
You will also need a follow up EGD as below. It is essential
that you attend this appointment
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Date/Time:[**2128-2-12**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 33499**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2128-2-12**] 9:30
ICD9 Codes: 5990, 2875
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5778
}
|
Medical Text: Admission Date: [**2103-5-30**] Discharge Date: [**2103-6-8**]
Date of Birth: [**2022-3-6**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin Hcl
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Mechanical Fall
Chronic Subdural Hematoma
Bilobar pneumonia
Repaired right eyebrow laceration
Right meacarpal fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is an 81 yo female with atrial fibrillation, schizophrenia,
mild dementia, who was initially transferred from [**Hospital **]
Hospital to [**Hospital1 **] for possible new SDH. On day of admission at her
nursing home, the patient had an unwitnessed fall. Per NH, she
got entangled in her sheets and fell to the ground. She was
found on the ground with laceration over her right eye and there
was noted to be a large amount of blood. She was sent to
[**Hospital1 **] ED via ambulance.
.
Head CT there showed a right subdural hematoma. She was given 1
gram of dilantin for ? seizure prophylaxis and 10 mg IV vitamin
K. She was then transferred via [**Location (un) **] to [**Hospital1 18**]. In route,
she received a total of 6 mg of ativan. Upon arrival to [**Hospital1 **], she
was intubated for airway protection as she was so sedated.
Repeat head CT done here showed a chronic subdural hematoma.
Neurosurgery and neurology were consulted and aside from an
upgoing toe on the left (thought to be due to chronic subdural)
they did not note any acute neurological issues.
.
CT scan of abd/pelvis/thorax also revealed a probable right
aspiration pneumonia and she was given 500 mg IV levaquin and
500 mg IV flagyl.
.
In speaking with the nursing home, pt is confused most of the
time. At baseline she is able to respond to name , speaks
"jibberish most of time," and doesn't make sense. She is able to
ambulate and feed herself but is totally dependent on ADLs. Upon
further questioning it was found that on [**2103-5-17**] at 10 pm, pt
fell and may have hit her head right side. She was on
anticoagulation with coumadin at that point and it was d/c'd.
She was not sent to the hospital at that time as vitals were OK
and neurological exam was reportedly intact. Also per NH, no
cough/fevers recently.
Past Medical History:
1. Atrial fibrillation- not on anticoagulation since fall as
above
2. Schizophrenia- s/p ECT. Hospitalized many times since age 28.
3. GERD
4. Dementia
Social History:
Lives in Resident Care NH ([**Telephone/Fax (1) 67707**]). Worked until 28 as a
clerk until first schizophrenia "attack." Never been married. No
children. Quit smoking last year ([**Location (un) 47**] [**Hospital1 **] for PNA); had
been "heavy smoker" ~ 2 ppd x many years; no EtOH; no drugs.
Family History:
NC
Physical Exam:
VS: T 97.7, BP 102/66, HR 96, RR 20, 94% 3.5 L (from 6L), Wt 158
lb
Gen: sleepy but arousable, speech incomprehensible
HEENT: pupils round and reactive b/l. op clear
CV: RRR. S1S2. No M/R/G
Lungs: coarse bs b/l. no focal ronchi
Abd: NABS. soft, NT, ND
Ext: no c/c/e. 2+ pulses
Neuro: demented, poorly follows commands, moving all extremities
Pertinent Results:
[**2103-5-30**] 04:25PM TYPE-ART RATES-[**11-1**] TIDAL VOL-560 PEEP-5
PO2-419* PCO2-42 PH-7.41 TOTAL CO2-28 BASE XS-2
INTUBATED-INTUBATED
[**2103-5-30**] 04:25PM LACTATE-1.5
[**2103-5-30**] 03:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2103-5-30**] 03:27PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2103-5-30**] 03:10PM LACTATE-2.8*
[**2103-5-30**] 11:15AM GLUCOSE-99 UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-13
[**2103-5-30**] 11:15AM CK(CPK)-41
[**2103-5-30**] 11:15AM CK-MB-NotDone cTropnT-<0.01
[**2103-5-30**] 11:15AM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-3.4
MAGNESIUM-2.2
[**2103-5-30**] 11:15AM WBC-10.0 RBC-4.79 HGB-12.7 HCT-36.7 MCV-77*
MCH-26.5* MCHC-34.5 RDW-15.1
[**2103-5-30**] 11:15AM NEUTS-82.5* LYMPHS-12.1* MONOS-5.0 EOS-0.2
BASOS-0.3
[**2103-5-30**] 11:15AM MICROCYT-2+
[**2103-5-30**] 11:15AM PLT COUNT-311
[**2103-5-30**] 11:15AM PT-12.5 PTT-22.7 INR(PT)-1.1
[**2103-5-30**] 11:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2103-5-30**] 11:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
..
Head CT without contrast [**2103-5-30**] prelim:
Rt chronic SDH extending across the entire convexity.
- Left frontal prominent extraaxial space
- No acute bleed
- Small vessel ischemic changes.
- Osseous findings consistent with Pagets
.
CT c-spine [**2103-5-30**]-C1 through T2 are visualized. There is no
evidence of acute fracture or malalignment of the cervical
spine. There are extensive degenerative changes ranging from
C4-C7 characterized by disc space narrowing, end plate sclerosis
and subchondral cyst formation and vacuum disc phenomena and
marginal osteophyte formation. Disc space narrowing is most
severe at
C5/6 and C6/7. Disc osteophyte complexes at C3/4 C5/6 and C6/7
moderately indent the spinal canal. The prevertebral soft
tissues are unremarkable. The patient is intubated. Limited
evaluation of the lung apices demonstrates apical scarring.
.
Chest AP ([**2103-5-30**])
1. Endotracheal tube and nasogastric tube in satisfactory
position, however, the endotracheal tube cuff is over-inflated.
2. Cardiomegaly and pulmonary edema.
.
CT orbit/sella ([**2103-5-30**])
1. Questionable mildly depressed nasal bone fracture with two
tiny 1-2 mm high- density foreign bodies in the adjacent soft
tissues in the nose.
2. Mottled appearance of the skull with mixed sclerotic and
lucent areas is suggestive of Paget disease. Further evaluation
with bone scan is suggested.
.
CT abdomen/pelvis ([**2103-5-30**])
1. No evidence for acute intrathoracic, intra-abdominal, or
intrapelvic injury including fracture, visceral laceration,
hematoma, free air, or free fluid.
2. Right lower lung lobe air space consolidation with soft
tissue density filling the bronchi to the right lower lung lobe.
This could represent tumor within the bronchi or mucoid
impaction. These findings could represent aspiration pneumonia
or a post-obstructive pneumonia. Right hilar lymphadenopathy
cannot be definitively excluded on this non-contrast scan. In
the non-acute setting, a contrast-enhanced scan could further
characterize this abnormality.
3. Enlarged pulmonary artery measuring 4.7 cm, which may be
secondary to pulmonary artery hypertension.
4. Large stool filled rectum measuring 28 x 10 cm. No evidence
for bowel dilatation proximal to this stool ball.
5. Multiple sclerotic lesions are of uncertain etiology and
should be further characterized with a bone scan in the
non-acute setting.
6. Multiple tiny hyperdense lesions of the right kidney which
are incompletely characterized. An ultrasound could further
evaluate these lesions.
7. Probable simple cyst in the mid pole of the left kidney.
8. Multiple prior rib fractures. No evidence for acute fracture.
.
Left shoulder AP/neutral ([**2103-5-30**]): No fracture.
.
Humerus films ([**2103-5-30**]): No fracture
Brief Hospital Course:
1. Respiratory- Initially intubated for airway protection in
setting of over sedation from both ativan (6 mg) and dilantin (1
g). Extubated, now saturating >94% on 3.5 L via NC.
Antipscyhotics held because of concern to for sedative effect.
Pt now titrated NC to 1.5 L and maintaining oxygen sat in low
90s range. [**Month (only) 116**] have element of atelectasis now that will
hopefully improve with increased activity. Titrate down oxygen
as tol with goal sat of 92-95%.
.
2. Pneumonia- On CT and CXR appears to have a RM/RL lobe PNA.
?aspiration vs [**Name (NI) 16630**]
Pt was on ceftriaxone and then once cleared to take po
medications changed to cefpodoxime. Today is day [**7-2**] of
antibiotics.
.
3. SDH- Appears chronic in nature. Reviewed by neurology/
neurosurgery. She did fall 2 weeks prior. She was given 1 g
dilantin at OSH. Now discontinued.
.
4. S/p fall- Seems completely mechanical in nature. Will need to
get more information regarding fall risk. PT eval.
.
5. ST depression- 1 mm STD in V2-V4; no old to compare with. [**Month (only) 116**]
be related to strain from RVR. CE's negative.
.
6. Afib- Heart rate has been elevated as patient has not been
able to consistently take rate related medications. [**Month (only) 116**] also be
secondary to hypovolemia. Now back on diet have restarted dig
and diltiazem. Should follow. Will not restart anticoagulation
with SDH and history of significant falls. This can be
addressed at [**Hospital1 1501**] as well as starting aspirin instead.
.
7. [**Name (NI) 3687**] Pt with schizophrenia requiring multiple
hospitalizations in the past. Has been sedate and comfortable
during this stay. No agitation. In the prior few days has not
taken good po. Unclear if behavioral or if she dislikes diet.
[**Month (only) 116**] consider restarting antipsychotics at [**Hospital1 1501**]. Unclear after
this fall what her new baseline level of function will be.
.
8. GERD- continue PPI per outpt dose.
.
9. F/E/[**Name (NI) **] Pt received swallow evaluation because of concern for
aspiration. Recommendations were for her to be on a pureed
solids and thin liquids diet. Aspiration precautions. Need to
encourage eating. If she continues to refuse, may need to
address with family other avenues to get her nutrition. Pt also
had episode of hypernatremia when not eating for a few days.
Responded to IVF of 1/2NS. Pt improved now.
.
10. Code Status: DNR/DNI. Discussed with pt's sister [**Name (NI) 4489**]
[**Name (NI) 2520**], her HCP.
Medications on Admission:
Digoxin 0.25 mg qday
MVI
Protonix 40 mg qday
Zyprexa 5 mg qam, 15 mg qhs
Trifluoperazine 5 mg QHS
Colace 100 mg [**Hospital1 **]
Bisacodyl 10 mg PR prn
Diltiazem 30 mg tid
Tylenol prn
Fleets prn
Guaifenesin prn
MOM prn
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 6 days.
6. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
resident care
Discharge Diagnosis:
Fall. Chronic Subdural Hematoma. Bilobar pneumonia.
Repaired right eyebrow laceration.
Right metacarpal fracture.
Discharge Condition:
Fair
Discharge Instructions:
Patient will need physical therapy to regain strength. Needs
full assist for ADLs at this point and encouragement in eating.
Should be seen by a doctor if develops fever.
Followup Instructions:
Patient should be followed up by physicians at her [**Hospital1 1501**].
ICD9 Codes: 5070, 2760
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5779
}
|
Medical Text: Admission Date: [**2119-11-13**] Discharge Date: [**2119-11-15**]
Date of Birth: [**2070-8-25**] Sex: F
Service:
ADMITTING DIAGNOSIS: Cardiac arrest.
DISCHARGE DIAGNOSIS: Cardiac arrest.
HISTORY OF PRESENT ILLNESS: 49-year-old woman with no past
cardiac history, nonsmoker, nondrinker with no known family
history of coronary artery disease, nondiabetic found down in
her home, found to be in VF arrest by EMTs. Transferred to
an outside hospital. Intubated. Respiratory failure.
Transferred unit to unit to [**Hospital6 2018**] under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the attending physician,
[**Name10 (NameIs) **] the Coronary Care Unit. Patient had cardiac
catheterization but remained neurologically unresponsive.
Neurology was consulted. Patient also required multiple
pressors to maintain her blood pressure. When no
neurological responses were was found during patient's
hospitalization, including absence of coronary blink
reflexes, minimum pupillary reflexes and decorticate
posturing. She was kept for observation for a 72-hour
period.
As per the recommendation of Neurology consult, an EEG was
performed. Evaluation of Neurology team felt that hope of
meaningful improvement was negligible, and therefore
discussion with the family present as well as Social Work,
the attending physician, [**Name10 (NameIs) **] the house staff team, decision
was made to withdraw care. Patient expired within five
minutes after withdrawal of ventilatory support. Time of
death was 5:55 p.m. on [**2119-11-15**]. The family was present.
The family declined autopsy.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2119-11-17**] 16:01
T: [**2119-11-17**] 23:18
JOB#: [**Job Number 105155**]
ICD9 Codes: 4280, 5070, 5845
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5780
}
|
Medical Text: Admission Date: [**2183-9-28**] Discharge Date: [**2183-10-8**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on Exertion, Fatigue
Major Surgical or Invasive Procedure:
Resection of the ascending aortic aneurysm and the ascending
aortic replacement with 32 mm Gelweave tube graft under deep
hypothermic circulatory arrest on [**2183-9-29**].
History of Present Illness:
89yo woman with 6.4 cm ascending aortic aneurysm. Cardiac
surgery
consulted back in [**2183-5-2**]. Cath at that time showed clean
coronaries. On Warfarin for atrial fibrillation and probable
thrombus in the left atrial appendage. Given this finding,
cardioversion was declined. Since that time, she has been
medically managed with beta blockade. She was seen again in [**Month (only) 205**]
and plan was made to proceed with Ascending Aortic replacement.
Past Medical History:
Asc. Ao aneurysm 6.4cm x 6.9cm-prox desc Ao 4.1cm, s/p Ascending
Aortic replacement on [**2183-9-29**]
Hypertension
Diverticulosis
cataracts
Osteoporosis-Osteoarthritis
Compression Fx
Rt rotator cuff injury
Wandering Atrial Pacemeaker
Social History:
Race:caucasian
Last Dental Exam: [**2183-9-24**]
Lives with: alone in senior housing
Occupation: retired banker
Tobacco: none
ETOH: social
Family History:
non contributory
Physical Exam:
Admission Physical Exam
Pulse:94 AF Resp: 16 O2 sat: 97%-RA
B/P Right: 134/78 Left:
Height: 5'3" Weight: 130 lbs
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [cataracts] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] NoMurmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema 1+ pedal edema
Varicosities: None [] prominent veins without varicosities
Neuro: Grossly intact X
Pulses:
Femoral Right: +2 Left:+2
DP Right: +1 Left:+1
PT [**Name (NI) 167**]:+1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 70% to 75% >= 55%
Aortic Valve - Peak Velocity: 0.7 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 13
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - E Wave deceleration time: *112 ms 140-250 ms
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Normal regional LV systolic function. Hyperdynamic LVEF >75%. No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Dilated RV cavity. Cannot assess regional RV
systolic function.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.
Mild (1+) AR.
MITRAL VALVE: No MS. Mild (1+) MR.
TRICUSPID VALVE: Moderate to severe [3+] TR. Indeterminate PA
systolic pressure.
PERICARDIUM: No pericardial effusion. No echocardiographic signs
of tamponade.
Conclusions
Left ventricular wall thicknesses are normal. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
The right ventricular cavity is dilated The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion. There
are no echocardiographic signs of tamponade.
[**2183-10-7**] 04:42AM BLOOD WBC-8.7 RBC-4.45 Hgb-14.0 Hct-42.1 MCV-95
MCH-31.5 MCHC-33.3 RDW-15.9* Plt Ct-140*
[**2183-10-6**] 02:09AM BLOOD WBC-8.2 RBC-4.11* Hgb-13.1 Hct-38.2
MCV-93 MCH-31.9 MCHC-34.3 RDW-15.7* Plt Ct-137*
[**2183-10-7**] 04:42AM BLOOD PT-16.9* PTT-28.9 INR(PT)-1.5*
[**2183-10-6**] 02:33PM BLOOD PT-16.6* INR(PT)-1.4*
[**2183-10-6**] 02:09AM BLOOD PT-16.8* PTT-30.2 INR(PT)-1.5*
[**2183-10-7**] 04:42AM BLOOD Glucose-104* UreaN-44* Creat-1.1 Na-147*
K-4.1 Cl-109* HCO3-25 AnGap-17
[**2183-10-6**] 01:46PM BLOOD Na-146* K-4.3 Cl-109*
[**2183-10-6**] 02:09AM BLOOD Glucose-113* UreaN-40* Creat-1.0 Na-143
K-4.4 Cl-108 HCO3-23 AnGap-16
[**2183-10-8**] 05:45AM BLOOD WBC-8.6 RBC-3.96* Hgb-12.7 Hct-37.0
MCV-94 MCH-32.0 MCHC-34.2 RDW-15.9* Plt Ct-170
[**2183-10-8**] 05:45AM BLOOD PT-17.7* INR(PT)-1.6*
Brief Hospital Course:
Mrs.[**Known lastname 12130**] was admitted to [**Hospital1 18**] for preoperative surgical
workup and Heparin
bridge while off Coumadin for her atrial fibrillation. Prior to
her admission Dental Clearance was obtained. On [**2183-9-29**] she was
taken to the operating room and underwent replacement of her
ascending aorta with Dr. [**Last Name (STitle) **]. Circulatory Arrest time=15
minutes. Please refer to operative report for further surgical
details. She tolerated the procedure well and was transferred to
the CVICU intubated and sedated, requiring inotropy and pressor
support. She was kept intubated overnight. POD#1 she awoke
neurologically intact and was extubated. She was confused and
had worsening respiratory status and a low mixed venous despite
inotropes which required reintubation. Initially she weaned off
Milrinone. Poor cardiac output/mixed venous results warranted an
echocardiogram which showed the heart to be underfilled and
volume was administered. Milrinone was resumed. [**10-1**] EP was
consulted in the setting of afib with rapid ventricular rate.
Per EP, Mrs. [**Known lastname 12130**] likely has significant diastolic
dysfunction given her LVH and would benefit from rate control
and restoration of sinus rhythm. She is high risk for embolus
given history of
LAA thrombus and was not yet back on anticoagulation. Per EP
recommendations, an Esmolol drip was initiated to allow more
diastolic filling time, she was placed on Digoxin and
anticoagulation was resumed with Coumadin. She again weaned off
inotropic support. On [**10-2**] HIT panel was sent secondary to
postoperative thrombocytopenia, which resulted negative. She was
placed on a lasix gtt for worsening pulmonary edema and
diuresed. Her pulmonary status improved and on [**10-3**] she was
weaned to extubation. All lines and drains were discontinued per
protocol. She remains in a rate controlled atrial fibrillation
on beta-blocker, Digoxin, and anticoagulated with Coumadin. Her
thrombocytopenia has been consistently improving. POD# 6 she was
placed on antibiotics for a urinary tract infection.
She remained in the CVICU until POD 8 when she was transferred
to the step down unit for further monitoring and increased
physical activity. Physical Therapy was consulted for evaluation
of strength and mobility. The patient was discharged to
*****[**Doctor First Name 391**] Bay****** on POD 9.
Medications on Admission:
ALENDRONATE - (Prescribed by Other Provider) - 70 mg Tablet - 1
Tablet(s) by mouth q weekly/wednesday
METOPROLOL SUCCINATE - 100 mg PO a AM, 50 mg PO q PM
MUPIROCIN CALCIUM [BACTROBAN NASAL] - 2 % Ointment - 0.5 (One
half) tube(s) nares twice a day please insert [**2-2**] tube into each
nares and then gently massage for 1 minute
WARFARIN - 2 mg Tablet - [**2-2**] Tablet(s) by mouth once a day take
2
and 1/2 tabs today and tomorrow then 1 tab daily, last dose
[**2183-9-24**]
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 4 Tablet(s) by mouth
once a day
CHLORHEXIDINE GLUCONATE - 4 % Liquid - 1 bottle Daily please
shower daily for the five days prior to surgery and the morning
of surgery
LOPERAMIDE [IMODIUM A-D] - (Prescribed by Other Provider) - 2
mg
Tablet - 1 (One) Tablet(s) by mouth as meeded PRN
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2183-10-9**]
Please set up Coumadin follow up with Dr [**Last Name (STitle) **] prior to discharge
from rehab
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Two (2) Tablet Extended Release 24 hr PO once a day: 100mg qam,
50mg qpm.
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO QHS: 100mg qam, 50mg
qpm.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every
Wednesday).
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dose
to change daily for goal INR 2-2.5.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
17. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Hypertension, Diverticulosis, cataracts,
Osteoporosis-Osteoarthritis, Compression Fx, Rt rotator cuff
injury, Wandering Atrial Pacemaker
PSH: cataract removal, tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
1+ LE Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointment
Surgeon: Dr. [**Last Name (STitle) **] on [**2183-11-5**] at 2:00, phone#[**Telephone/Fax (1) 170**] in
the [**Hospital **] medical office building [**Hospital Unit Name **]
Please call to schedule appointments with your
Cardiologist: Dr. [**Last Name (STitle) **] in [**4-4**] weeks
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 4475**] in [**5-6**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2183-10-9**]
Please set up Coumadin follow up with Dr [**Last Name (STitle) **] prior to discharge
from rehab
Completed by:[**2183-10-8**]
ICD9 Codes: 2875, 496, 2851, 5990, 4280, 4019, 4241
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5781
}
|
Medical Text: Admission Date: [**2138-11-10**] Discharge Date: [**2138-11-16**]
Date of Birth: [**2070-4-24**] Sex: F
Service: SURGERY
Allergies:
Succinylcholine
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
abd pain, abd wall abscess
Major Surgical or Invasive Procedure:
exlap, washout,R colectomy, CCY [**2138-11-11**]
History of Present Illness:
68F with morbid obesity, COPD and a recent admission for
cholecystitis most recently seen in [**Hospital 2536**] clinic on [**2138-10-14**] now
with five days of anorexia, RLQ pain and diarrhea. She notes
that pain is gradually worsening and does not radiate, though
she does feel a "heaviness" in her abdominal wall when walking.
She
denies recent fevers or sick contacts and has never had a
colonoscopy. She denies the presence of blood in her stool.
Past Medical History:
PMH: DM2, symptomatic cholelithiasis, spinal
stenosis,hypothyroidism, COPD, Depression, Anxiety,
Hyperlipidemia, hypertension, OSA
PSH: denies prior operations
Social History:
significant smoking history stopped 30 years ago. Denies alcohol
use.
Family History:
NC
Pertinent Results:
[**2138-11-10**] 05:00PM BLOOD WBC-14.3* RBC-3.68* Hgb-9.7* Hct-31.4*
MCV-85 MCH-26.4* MCHC-30.9* RDW-15.9* Plt Ct-325
[**2138-11-11**] 04:36AM BLOOD WBC-12.4* RBC-2.95* Hgb-7.8* Hct-24.8*
MCV-84 MCH-26.6* MCHC-31.5 RDW-15.6* Plt Ct-358
[**2138-11-12**] 02:05AM BLOOD WBC-9.1 RBC-3.15* Hgb-8.1* Hct-26.8*
MCV-85 MCH-25.7* MCHC-30.3* RDW-15.8* Plt Ct-337
[**2138-11-13**] 05:07AM BLOOD WBC-13.1* RBC-3.29* Hgb-8.9* Hct-28.8*
MCV-88 MCH-26.9* MCHC-30.8* RDW-16.3* Plt Ct-395
[**11-10**] CT abd pelvis (wet read): Area of circumferential
wall thickening of the proximal ascending colon, concerning for
malignancy. Abutting the abnormal colon is a large abscess
extending through the right lower anterior abdominal wall
measuring 11.8 (trv) x 11.3 (CC) x 9.2 cm (AP), presumably
caused
by perforation of the colon.
Brief Hospital Course:
The patient was admitted to the ACS surgery service on [**2138-11-11**]
and had a exlap, washout, R colectomy, CCY. The patient
tolerated the procedure well.
Neuro: Post-operatively, the patient received fentanyl IV. Once
extubated she was switched to a dilaudid PCA, with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient remained intubated on the night of POD 0,
she was successfully extubated on POD 1. The patient was stable
from a pulmonary standpoint; vital signs were routinely
monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced once bowel
function had returned. Foley was removed on POD#1. Intake and
output were closely monitored.
ID: Post-operatively, the patient was started on IV vancomycin
and zosyn. She may continue on vancomycin and zosyn until she
is seen in [**Hospital 2536**] clinic. The patient's temperature was closely
watched for signs of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD 6, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. Her pathology report returned a diagnosis of
colonic adenocarcinoma, pT3N2Mx, hence her discharge diagnosis
is perforated colonic adenocarcinoma.
Medications on Admission:
Gabapentin 300 mg Q AM, Hydrocodone-Acetaminophen 5-500 mg Oral
Tablet PRN, Doxepin 25 mg QHS, Levothyroxine 75 mcg Qday,
Lorazepam (ATIVAN) 0.5 mg [**Hospital1 **] PRN Sertraline (ZOLOFT) 100 mg
Qday, Glipizide 2.5 mg [**Hospital1 **], Metformin 1,000 mg [**Hospital1 **], Simvastatin
40 mg Qday, Albuterol Sulfate 90 mcg/Actuation Inhalation.
Q4-6hrs PRN, Tiotropium Bromide (SPIRIVA WITH HANDIHALER) 18 mcg
Inhalation Qday, Lisinopril 20 mg Qday, Hydrochlorothiazide 25
mg Qday
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per sliding scale.
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
COPD/SOB.
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for pain.
13. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
14. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
15. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
17. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Perforated colon adenocarcinoma pT3N2Mx
Abdominal wound debridement and washout with VAC placement
Discharge Condition:
At the time of discharge the patient was able to ambulate. She
was able to void and was tolerating a regular diet. Her pain
was well controlled and she had normal mental status.
Discharge Instructions:
You will go to an acute inpatient rehabilitation facility where
you will have VAC dressing changes to your abdominal wound every
three days. Additionally you will have ongoing care for your
incision site and your abdominal drain, which will remain in
place until you are seen in clinic.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Location (un) 5059**] at your next visit.
Don't lift more than 20-25 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medication. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
Followup Instructions:
Please follow up in the Acute Care Surgery clinic 5-10 days
after discharge. Call [**Telephone/Fax (1) 600**] upon discharge to schedule an
appointment. At this time she will have her staples removed and
her drain discontinued. Additionally, she should follow up with
Dr. [**Last Name (STitle) 28049**]. from oncology, who has indicated will be in touch to
schedule appropriate follow up appointments.
Completed by:[**2138-11-16**]
ICD9 Codes: 496, 2449, 2724, 4019, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5782
}
|
Medical Text: Admission Date: [**2164-7-10**] Discharge Date: [**2164-9-14**]
Service: BLUE SURGERY
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is an 80 [**Hospital **]
transferred from [**Hospital6 6640**] for management of
enterocutaneous fistula. The patient was initially admitted
at the [**Hospital3 8544**] on [**2164-6-17**] with complaint of severe
abdominal pain for two days. The patient describes as 15 out
of 10, very bad unrelenting pain. The patient could not
describe the quality of pain. The patient was found to have
left incarcerated inguinal hernia and underwent exploratory
laparotomy hernia repair. The patient was discharged to
rehab on postoperative day three, but continued to have
difficulty tolerating clear liquids, nausea most of the time
with dry heaves and bilious vomiting and diarrhea. The
patient was readmitted to [**Hospital3 8544**] for a small bowel
obstruction and underwent on [**2164-7-3**] exploratory
laparotomy, lysis of adhesions and multiple enterotomies,
repair of enterostomies and loop ileostomy approximately 165
cm from ligament of Treitz, nasogastric tube insertion.
Postoperatively, the patient was being treated with Levaquin
and Flagyl and Fluconazole for positive wound culture that
grew out yeast _______, S viridans and [**Female First Name (un) **] albicans and
positive blood cultures for bacteroides fragilis and
developed enterocutaneous fistula by postoperative day number
five with increasing output and transferred to [**Hospital1 346**] for this management.
PAST SURGICAL HISTORY: In addition to mentioned above,
hysterectomy approximately 20 years ago.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Glaucoma.
3. Asthma.
ALLERGIES: Penicillin cause rash. Ceclor and Fortaz causes
rash. Morphine causes confusion.
MEDICATIONS AT HOME:
1. Albuterol prn.
2. Aspirin.
3. Evista 60 mg.
4. Lipitor.
5. Ativan 1 mg a day.
6. Somantadine 400 mg.
7. Xalatan 0.05%.
MEDICATIONS FROM [**Hospital3 **]:
1. Lopressor 5 mg intravenously q 6.
2. Protonix 40 mg intravenously q day.
3. Compazine 25 mg pr q 12.
4. Levaquin 500 mg intravenously q day.
5. Diflucan 200 mg intravenously q day.
6. Flagyl 500 mg intravenously q 8.
7. ISS.
8. _____________.
9. Total parenteral nutrition.
FAMILY HISTORY: Hypertension. No history of diabetes. No
history of myocardial infarction. No history of
cardiovascular disease.
SOCIAL HISTORY: No smoking, alcohol or drugs.
PHYSICAL EXAMINATION: The patient's temperature was 98.6,
100, 108/64, 20, 94% on room air. The patient was alert and
oriented times three and the patient had a right IJCVL in
place. No signs of skin infection. Cardiac examination
regular rate and rhythm with a S1 and S2 and [**3-18**] holosystolic
murmur to the axilla. Lungs were clear to auscultation
bilaterally. Abdominal examination the patient had positive
bowel sounds with soft, mildly distended and uncomfortable in
the left lower quadrant, but not tender. Left lower quadrant
ileus ostomy bag in place as well as low midline incision
with major drainage at the inferior edge of the incision with
minor drainage at the middle of the incision tracking from
below. No edema on extremities. The patient had a stage one
sacral decubitus.
LABORATORIES FROM STURDY: White blood cell count 17.7,
hematocrit 32.8, platelets 386, PT 15.2, INR 1.3, PTT 29.7,
sodium 132, potassium 4.7, chloride 100, bicarb 29, BUN 16,
creatinine 0.4, glucose 128, calcium 7.5, magnesium 1.48,
phos 4.2, prealbumin 24. Urinalysis fro the 20th was
negative. Wound gram stain had moderate polys. The wound
culture from [**7-7**] showed Vanc sensitive E ________, strep
viridans and C albicans. On [**7-7**] blood culture showed
bacteroides fragilis, one out of four positive and three out
of four negative. [**7-1**] CT of the abdomen showed small bowel
loops slightly dilated with air in the colon and no free air.
CT of the chest showed minimal bilateral pleural effusion.
No cardiomegaly.
ASSESSMENT: The patient was assessed to have enterocutaneous
fistula likely caused by intraostomy and postop adhesion and
obstruction and the patient is currently stable being
afebrile with an increase in the white count. The patient
had a Whistle tip catheter that was placed and long angiocath
and ostomy ______ with continuous wall suction to control the
fistula stump and the stump was flushed with normal saline
and the patient was placed NPO with intravenous placed and
TPN. The patient was covered with Flagyl for the increasing
white blood cell count and the culture data as above. The
patient was admitted to the surgery service.
HOSPITAL COURSE: On [**2164-7-11**] the patient remained stable,
but hyponatremic and hyperkalemic that was corrected slowly.
The patient was otherwise sharp and alert. The G tube was
changed that day and the stump was changed as well. The
patient had yeast in wound, which was treated with
appropriate medication. The patient on [**2164-7-12**] ileostomy had
not put out anything and the patient continued to do well,
but continued to have a fistula. The patient was continued
on total parenteral nutrition. On [**2164-7-13**] the patient had a
urinalysis that was positive, which showed a urinary tract
infection. The patient was started on Ampicillin. The
patient's white blood cell count went down to 16 on that day.
On [**7-11**] the patient had nothing coming out of the ileostomy
that day. The patient had a left subclavian central line
placed on that day with a chest x-ray confirming the
placement. On [**7-14**] the patient had a fistulogram to evaluate
the presence of enterocutaneous fistula. The results showed
no communication between the bowel and the skin. On [**7-16**] the
patient had a revision of the ileostomy. The patient did
well from the procedure. The patient continued on total
parenteral nutrition and continued on Vancomycin to treat the
urinary tract infection. The patient was out of bed. The
patient's T tube was planned for po meals on [**7-18**]. However,
the patient did not do well with po diet, therefore the
patient was placed NPO and wait for the bowel function to
return. The patient will continue on total parenteral
nutrition and had a tube feed placement getting half Impact
plus fiber by the tube at nights and wait for the bowel
function to return.
However, on [**7-21**] the patient felt nauseated again, therefore
tube feeds were stopped and continued with total parenteral
nutrition. The patient continued to feel nauseated therefore
the patient was continued on total parenteral nutrition and
kept NPO with Reglan to treat nausea. On [**7-22**] the patient
had repair of the ostomy and continued the management and
waiting for the bowel function to return. On [**7-23**] the
patient had an episode of ventricular tachycardia six beats
that evening. The patient was ruled out for myocardial
infarction, which results were negative. The patient was
continued on total parenteral nutrition. The patient was
feeling better on [**7-24**], however, the patient was kept NPO.
On [**7-24**] there was a retrograde ___________ that showed
fistula in tube feed. On [**7-26**] total parenteral nutrition was
continued, still waiting for the bowel function to return.
On [**7-29**] the stump was replaced and continued the current
management. On the 18th the patient was continued on her
current management. The patient was still nauseated. The
patient's abdominal examination was improving. The patient
had an increase in stump output, which was replaced one to
one and continued with total parenteral nutrition. The
patient continued to have stump drainage on [**2164-8-1**]. The
patient was continued on the current management, increasing
nutrition and total parenteral nutrition at goal. By [**8-5**]
the patient's fistula on the lower aspect healed almost over
and total parenteral nutrition was continued. Continue the
stump management, total parenteral nutrition and NPO
throughout the course.
On [**8-10**] the patient was complaining of cough and the patient
had a chest x-ray, which showed improving lung aeration
without any presence of consolidation. On [**8-19**] the patient's
G tube was replaced. The patient still continued to have
drainage from the stump. The patient was managed with total
parenteral nutrition and kept NPO. On [**8-22**] the patient had a
barium enema and the patient was seen to have a barium
routine in sacrum and appendix and the presence of an
enterocutaneous fistula. The patient continued to do well
with preparing for Operating Room to have the enterocutaneous
fistula repaired after resolution of small bowel obstruction
and maintaining her nutritional status. The patient had
surgery on [**2164-8-28**] to have the fistula repaired. Please see
dictated note for the surgery. Immediately postop the
patient's pain was well controlled, extubated and
hemodynamically stable, kept NPO with the G tube placed to
gravity and the patient continued to have good urine output.
The patient continued on total parenteral nutrition and LR
for fluid management and continued on Vanco and Flagyl during
the postop period. The patient was started on tube feeds and
total parenteral nutrition was continued on [**8-31**]. On [**8-31**]
the patient had good bowel sounds with increasing tube feeds
to 30 cc an hour and continued total parenteral nutrition.
The patient's pain was well managed postoperatively. On [**9-1**]
continued on total parenteral nutrition and diuresed. The
patient's tube feeds were advanced on [**9-3**] and the patient's
tube feeds were cycled on [**9-4**] and the patient continued to
improve.
The patient was encouraged to ambulate on [**9-5**]. The
patient's G tube was clamped 2 out of 4 on [**9-6**]. Patient
continued to improve on tube feeds running at 50 cc overnight
on [**9-7**] and ambulating. On [**9-9**] the patient continued to do
well on total parenteral nutrition and tube feeds. The
patient's G tube was clamped. On [**9-8**] the patient complained
of back pain. LS of spine was obtained, which showed
degenerative changes, but no acute factors. The patient's
pain improved on pain medication. Abdominal x-ray showed G
tube placement. The patient's Reglan and total parenteral
nutrition was stopped on [**9-10**] and the patient was continued
on tube feeds. On [**9-11**] the patient was started on zinc. On
[**9-12**] the patient obtained one unit of packed red blood cells
for a hematocrit of 28 and continued tube feeds and the
patient's diet was advanced. The patient was tolerating po
diet without any difficulties. On [**9-13**] the patient received
another unit of packed red blood cells. The patient's G tube
was removed and JP tube was removed and the patient had tube
feeds cycled at night. The patient's wound looked good
without any drainage. On [**9-14**] the patient was stable and was
able to tolerate po diet with T tube placement, able to
ambulate and urinate without any difficulties. Pain was well
controlled on pain medication and the patient was doing well
and the patient was discharged to a rehab center for further
management of the tube feeds, wound care, wound changes and
physical therapy.
DISCHARGE INSTRUCTIONS: Please follow up with Dr. [**Last Name (STitle) 957**].
Please call his office to make an appointment. Please
continue the tube feeds and maintain po. Wean off of tube
feeds when the patient is taking adequate po and continue
physical therapy.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehab facility.
DISCHARGE DIAGNOSES:
1. Enterocutaneous fistula status post enterocutaneous
fistula repair.
2. Status post incarcerated inguinal hernia repair.
3. Status post exploratory laparotomy with lysis of
adhesions.
4. Hypertension.
5. Asthma.
6. Glaucoma.
7. Urinary tract infection.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (STitle) 51214**]
MEDQUIST36
D: [**2164-9-14**] 09:50
T: [**2164-9-14**] 13:51
JOB#: [**Job Number 51215**]
ICD9 Codes: 5990, 2761, 4271, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5783
}
|
Medical Text: Admission Date: [**2126-2-23**] Discharge Date: [**2126-3-7**]
Date of Birth: [**2081-5-14**] Sex:
Service:
HISTORY OF PRESENT ILLNESS: A 44-year-old female with
history of hepatitis C diagnosed 2 months ago, treated with
interferon and ribavirin for 2 months, who presented from
outside hospital with acute pancreatitis. The patient
reports 2-month history of abdominal pain with weekly
interferon and ribavirin injections, followed by abdominal
and back pain, nausea, vomiting, decreased appetite, and
increased abdominal distention. On [**2126-2-21**], the patient was
admitted in an outside hospital with 10/10 abdominal pain,
fever, and severe nausea and vomiting. Labs at the outside
hospital were significant for hematocrit of 39, white blood
cell count of 8.6, glucose of 129, calcium 9.1, lipase of
740, AST of 198, oxygen saturation 98 percent on room air.
CAT scan from the 18 showed peripancreatic fluid surrounding
the pancreas at the head with stranding. Abdominal
ultrasound was negative in terms of gallbladder disease. The
patient was treated with IV fluids, pain control, imipenem
500 IV q.6 h. with progressive decline in function and,
therefore, was transferred to [**Hospital1 18**] ICU for further
management. In the ICU, the patient's course was notable for
persistent hypoxia, worsening abdominal distention, post
initiation of tube feeds via postpyloric feeding tube.
Additionally, the patient had been persistently febrile,
despite treatment with imipenem. There is no clear-cut
source of her infection thus far. Repeat CT of the abdomen
did not reveal necrotic pancreas from [**2126-2-24**]. Upon
transfer, the patient was reporting abdominal pain to be
controlled with a PCA. She was denying sensation of
shortness of breath, chest pain, nausea, or vomiting. Her
last bowel movement was on transfer. Noted that her abdomen
was more distended this a.m.
PAST MEDICAL HISTORY: Hepatitis C x2 months on ribavirin and
interferon.
Fibromyalgia.
TAH.
Lumpectomy.
SOCIAL HISTORY: Negative for tobacco or alcohol use. The
patient is currently in the process of getting a divorce.
FAMILY HISTORY: Noncontributory.
ALLERGIES: TO SULFA, WHICH CAUSES A RASH.
PHYSICAL EXAMINATION: From transfer, T max 102.2, heart rate
107 to 111, blood pressure 128/62, respiratory rate 18 to 24,
93 to 96 percent on 6 liters nasal cannula, 24 hour I&Os 4
liters and 2.8 liters for the length of stay; however, the
patient was positive at 6 liters. General: In no apparent
distress. HEENT: Negative. Cardiac exam: Regular
tachycardia, no murmurs. Pulmonary exam: Upper expiratory
wheezes, bibasilar crackles, and egophony E to A, abdominal
distention, decreased bowel sounds, mild epigastric
tenderness to palpation, no ecchymosis in the flank or back
region. Extremities: Trace edema, no calf tenderness, 1+
dorsalis pedis. The patient has a NG tube in place, Foley in
place, and a PICC line in place.
LABORATORY DATA: From admission, white blood cell count 6.3,
hematocrit of 30.8, MCV 95, platelets 156. Chemistry profile
within normal limits with a calcium of 7.2, magnesium 2.1,
phosphorus 0.8.
HOSPITAL COURSE: Acute pancreatitis. There was no obvious
risk factors, however, the thought was entertained and
perhaps this was secondary to interferon and ribavirin
injections. The patient ransom criteria on presentation was
0, at 48 hours it was 3 to 4. On [**2126-2-24**], CT showed no
necrosis and appeared to be to be stabilized clinically. The
patient's lipase from the 22nd was 70 at the outside hospital
was as high as 700. Her abdominal distention was concerning
for possible ileus; however, the patient was passing stool
and felt that overall her abdominal exam was improving.
There was no evidence of Clostridium difficile colitis.
However, given her persistent fevers and elevated white blood
cell count, this was monitored closely as well as for
potentially worsening hepatobiliary disease. The patient was
maintained on IV fluids, Dilaudid PCA, Zofran, and Phenergan
for antiemetic support. The patient was maintained on
imipenem. KUB did not reveal any evidence of obstruction.
GI service continued to follow the patient and recommended
continuing tube feeds to maintain integrity of the gut flora.
Hypoxia. The patient was hypoxic in the ICU.
DIFFERENTIAL DIAGNOSES: Pneumonia.
Congestive heart failure.
Atelectasis versus pulmonary embolus.
A chest x-ray did show effusions and left lower lobe
atelectasis and vascular prominence mainly in the left
perihilar region. Question was what could this be, early
ARDS versus cardiogenic pulmonary edema mostly likely from
3rd spacing, however, given the patient's overall 6 liter
positive IV fluid intake, the patient maintained adequate
urine output. Repeat echocardiogram was obtained. The
patient reportedly had had a normal one in the outside
hospital, but given her new findings on chest x-ray and
clinically a repeat study was performed, which showed
preserved systolic function, normal valves, and no wall
motion abnormalities.
Fever. This is likely from pancreatitis, but the patient was
persistently pan cultured, her urine did grow enterococcus
for which she was adequately covered with antibiotics. She
also had E. coli in her urine with repeat urine cultures, no
growth to date. The patient's fever curve began to decrease
as her symptoms began to improve with loss of abdominal
distention and less diarrhea. All of her blood cultures
remain negative to date. Given the patient's positive urine
culture, the Foley catheter was removed.
Nutrition. The patient was on NG tube feeds; however, the NG
tube fell out on the evening of the 20th and the patient
refused to have a second one placed. Therefore, the patient
was maintained on TPN and was slowly advanced to a BRAT diet,
which she tolerated.
Depression and anxiety. The patient was instructed to follow
up with her outpatient therapist.
Abdominal pain. Thought was that this is likely related to
the patient's known condition of hepatitis C and surrounding
inflammation in the area. Persistently followed her LFTs
without any major abnormalities detected. Repeat imaging was
not warranted.
DISCHARGE DIAGNOSES: Acute pancreatitis.
Urinary tract infection.
Hepatitis C.
Fibromyalgia.
Depression and anxiety disorder.
DISCHARGE STATUS: The patient will be discharged to home.
DISCHARGE CONDITION: The patient is stable without an oxygen
requirement, tolerating a p.o. diet.
RECOMMENDED FOLLOWUP: The patient is instructed to follow up
with her PCP as well as Gastroenterology in 1 to 2 weeks
since discharge.
SURGICAL OR INVASIVE PROCEDURES PERFORMED DURING THIS
HOSPITALIZATION: PICC line placement for TPN.
Postpyloric feeding tube.
DISCHARGE MEDICATIONS:
1. Lorazepam 0.5 mg q.6 h. p.r.n. for anxiety.
2. Senna p.r.n. for constipation.
3. Percocet 1-2 tablets q.[**3-12**] h. p.r.n. for pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Last Name (NamePattern1) 12866**]
MEDQUIST36
D: [**2126-5-29**] 12:58:47
T: [**2126-5-29**] 16:25:39
Job#: [**Job Number **]
ICD9 Codes: 5990, 4280
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5784
}
|
Medical Text: Admission Date: [**2152-9-23**] Discharge Date: [**2152-10-5**]
Date of Birth: [**2075-7-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Respiratory distress/hypoxia
Major Surgical or Invasive Procedure:
elective intubation [**2152-9-26**]
History of Present Illness:
77 YO old male with PMH significant for DM, HTN, high chol, CAD
s/p stents [**2150**], CHF, Afib s/p PPM [**2150**], CKD who presents to ED
because of weakness and collapse at home. Patient was found on
admission to be febrile, tachypneic with RUL pneumonia on chest
film. Patient complained of chronic cough with increasing sputum
production. He denies fevers, chills, shortness of breath,
chest pain. He denies any loss of consciousness or head trauma
with falls. Denies bowel or bladder incontinence or changes in
function. Denies any weight loss or changes in eating habits.
No abd pain/n/v/d. No choking on food reported.
Patient was admitted and started on ceftriaxone and azithromycin
for CAP which was then changed to Levoflox and Flagyl as CXR
showed ? evidence for aspiration PNA. The patient since
admission has remained tachypneic and hypoxic requiring O2
today. He needed a non-rebreather for some time but has since
been titrated down. As the patient additionally has a history of
CHF, a repeat chest film was performed to evaluate for any
component of congestion. Although the film did not appear to be
all that congested, the patient's pneumonia appeared to worsen,
now a multilobar pneumonia involving the right upper and
middle/lower lung fields. ABG 7.43/37/54 at time of transfer to
ICU, he received 80 mg of Lasix with minimal urinary output
after 20 mg caused 250 cc of urine output earlier in the day.
Albuterol nebs with minimal improvement in O2 sat. Pt was
x-ferred to ICU and started on BiPAP. See additional course
below.
Past Medical History:
PAST MEDICAL HISTORY:
1. Congestive heart failure; ejection fraction of 55% in
02/[**2148**].
2. Diabetes mellitus, insulin dependent, complicated by
nephropathy and retinopathy.
3. Hypertension.
4. History of bradycardia.
5. Hypercholesterolemia.
6. Chronic renal insufficiency with baseline creatinine 1.9 to
2.1.
7. Anemia thought secondary to chronic disease.
8. CAD s/p stent of LCx and RCA in [**2150**]
9. A fib s/p [**Year (4 digits) 4448**] in [**2150**]
Social History:
Lives with wife and 1 daughter. [**Name (NI) **] 5 daughters. Quit smoking
25 years ago, but 10 year smoking history. No Etoh or IVDA.
Family History:
NC
Physical Exam:
Physical Exam: 101.7 Tm, 65 BP118/93 RR21 O2sat 91% on RA -->
100% 3L
NAD, +Diaphoretic.
MMM, JVD elevated around angle of jaw at 45 deg
neck FROM, no LAD
RRR with 3/6 SEM at RUSB
bronchial breath sounds at RUL, RLL
obese, paradoxical abdominal movements with abdominal grunting,
umbilical hernia- no erythema, easy to reduce, +BS
Trace LE edema, no cyanosis.
Moves all 4 extremeities, 2+ DTRs
Pertinent Results:
EKG: paced at 60bpm, no changes from prior
.
CXR: Cardiac, mediastinal, and hilar contours are not
significantly changed. There is a right upper lobe opacity.
There are mildly increased pulmonary vascular markings
indicating mild failure.
.
CT head: No evidence of acute intracranial hemorrhage. Findings
consistent with old lacunes.
[**2152-9-23**] 09:09PM LACTATE-2.1*
[**2152-9-23**] 09:05PM GLUCOSE-130* UREA N-30* CREAT-2.8* SODIUM-144
POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-28 ANION GAP-17
[**2152-9-23**] 09:05PM WBC-13.2*# RBC-4.12* HGB-12.4* HCT-36.9*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.3
[**2152-9-23**] 09:05PM NEUTS-86.0* LYMPHS-8.4* MONOS-5.1 EOS-0.3
BASOS-0.2
[**2152-9-23**] 09:05PM PT-14.5* PTT-27.4 INR(PT)-1.4
[**2152-9-23**] 09:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2152-9-29**] 4:10 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2152-10-1**]**
GRAM STAIN (Final [**2152-9-29**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2152-10-1**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
[**2152-9-28**] 12:30 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE
TEST.
GRAM STAIN (Final [**2152-9-28**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2152-9-30**]): ~1000/ML
OROPHARYNGEAL FLORA.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2152-9-29**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2152-9-29**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
VIRAL CULTURE (Final [**2152-9-29**]):
SPECIMEN NOT PROCESSED DUE TO:.
DUPLICATE ORDER.
REFER TO [**Numeric Identifier 4449**] FOR RESULTS [**2152-9-28**].
PATIENT CREDITED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2152-9-29**]):
SPECIMEN NOT PROCESSED DUE TO:.
DUPLICATE ORDER.
REFER TO [**Numeric Identifier 4449**] FOR RESULTS [**2152-9-28**].
PATIENT CREDITED.
Brief Hospital Course:
A/P: 77 year old male with hx of HTN, high chol, CAD, afib s/p
pacer here with lobar PNA.
.
1. Respiratory Distress: Initially, the patient was started on
ceftriaxone and azithro for CAP but Abx were adjusted to
levoflox/flagyl based on patient's continued hypoxia and CXR
[**Location (un) 1131**] concerning for aspiration event. The patient became more
distressed with his respiratory state over the first 3 days of
his hospitalization. It was felt that the most likely source of
his resp distress was thought to be his RUL pneumonia, perhaps
with contribution from his diastolic CHF. PE was considered but
felt to be very low suspicion given XRAY findings, febrile
state. Although the film did not appear to be all that
congested, the patient's pneumonia appeared to worsen to a
multilobar pneumonia involving the right upper and middle/lower
lung fields. The patient was found to be dangerously hypoxic on
[**2152-9-25**] with increasing work of breathing. ABG 7.43/37/54 at
that time, patient received 80 mg of IV Lasix with minimal
urinary output. Albuterol nebs resulted in minimal improvement
in O2 sat. Pt was x-ferred to ICU and started on BiPAP. He was
intubated [**2152-9-26**] due to continued respiratory distress (it was
a difficult intubation). His Abx was adjusted again to include
Vancomycin and levofloxacin to cover MRSA and CAP. Despite no
cx data, it was felt the patient most likely had strep pneum.
pneumonia due to clinical course. The pateint was liberated
from ventilator slowly due to difficult airway issues and he was
extubated on [**10-2**]. His sputum culture from BAL on [**9-28**] showed
1000 oropharyngeal flora; all other cultures were negative.
Serial CXRs showed clearing of pneumonia. He was transferred to
the floor on 4L NC on [**2152-10-3**]. He maintained excellent O2 sats
and he was weaned to 2L upon discharge. He has been
intermittently diuresed with Lasix (20mg IV), but his CXRs have
not shown congestion and the course of his respiratory status
has closely followed that of his pneumonia. He has also received
albuterol and atrovent nebs with improvement in his wheeze and
dyspena. He has completed 12 days of Vancomycin and
levofloxacin, and they were continued upon discharge to finish a
14 day course for ? pneumococcal vs staph aureus pneumonia. The
patient was given pneumococcal vaccine prior to discharge. No
blood cx were positive.
.
2. CAD: His EKG showed a paced rhythm and old LBBB. He was
without chest pain and had no signs of ischemia throughout his
stay. Cardiac enzymes were cycled to rule out the possibility
of silent ischemia, and were negative. He was maintained on his
ASA, BB, and statin. An outpatient echocardiogram may be
considered for future management.
.
3. HTN: Mr. [**Known lastname **] was maintained on metoprolol, [**Last Name (un) **] and
amlodopine and imdur. He will titrate up his HTN management
with his PCP. [**Name10 (NameIs) **] BP upon discharge was slightly above goal
(SBPs 140s).
.
4. Afib/AVNRT: Mr. [**Known lastname **] has a [**Known lastname 4448**] for tachy-brady
syndrome in the past. He has also had ablation for SVT with
aberrancy in [**2150**]. At that time he was started on amiodarone.
He has a ? history of atrial fibrillation/flutter, but is not on
anticoagulation as the history is unclear. [**Name2 (NI) **] was in NSR
throughout his stay. He has an appointment in EP Device Clinic
later this month and is also set up for a Cardiology appointment
in [**Month (only) **].
.
5. DMII: Mr. [**Known lastname **] was put on half of his outpatient dose of
NPH 75/25 and sliding scale insulin during his hospitalization.
He maintained good glucose control (FSBG < 150). He was
discharged on the half-dose NPH 75/25, and should follow up with
his PCP/[**Last Name (un) **] to adjust as needed.
.
6. FEN: He was maintained on a cardiac/diabetic diet and 2L
fluid restriction. The patient needed prn Lasix dosing for
volume overload (he responded well to 20-40mg IV lasix).
.
7. CKD: Baseline Creatinine 1.9-2.2. He had some variations in
creat throughout stay (likely due to varying volume status and
diuresis) but was back to baseline prior to discharge (1.9).
His medications were all renally dosed (Vancomycin by levels <
15). His kidney disease is related to lond standing diabetes and
he is followed at the [**Hospital **] clinic by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] for
this issue.
8. Anemia: patient's baseline Hct 27-31 with Fe studies
consistent with anemia of chronic disease. His hct remained in
the range (27-32) throughout his stay and the patient did not
receive any pRBCs. He would likely benefit from erythropoetin
as an outpt as his epo-deficient state from CKD is the likely
etiology of his anemia.
Medications on Admission:
MEDICATIONS:
1. Atenolol 50 mg p.o. q.d.
2. Amiodarone 400mg q.d.
3. Norvasc 10 mg p.o. q.d.
4. Doxazosin 2 mg p.o. q.d.
5. Cozaar 50 mg p.o. b.i.d
6. Niferex 150 mg p.o. b.i.d.
7. Plavix 75mg qd
8. Aspirin 325 mg p.o. q.d.
9. Humalog 75/25, 12U qam, 10U qpm
10. Furosemide 40mg qam, 20mg qpm
11. Atorvastatin 10 mg p.o. q.d.
12. Imdur 90mg q.d
13. Laxatives
14. Meclizine 25mg qhs
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebs
Inhalation Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
9. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
13. Meclizine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
once a day for 2 days: finish [**2152-10-7**].
16. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Six (6)
units Subcutaneous qAM: adjust as needed for glycemic control
(FSBG 80-120).
17. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Five (5)
units Subcutaneous qPM: adjust as needed for goal FSBG 80-120.
18. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Primary:
1. multilobar PNA (community-acquired)
2. diastolic CHF
Secondary:
3. HTN
4. ? AVNRT/aflutter s/p ablation/pacer
5. anemia of chronic disease
6. CKD
Discharge Condition:
stable, on 2L NC and improving daily.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500mL
If you experience any fevers > 101.5, chills, chest pain,
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2152-10-24**] 10:15
.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2152-11-29**] 9:00 (please consider outpt echocardiogram).
.
3. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2153-1-22**] 10:30
Completed by:[**2152-10-5**]
ICD9 Codes: 4019, 5070
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5785
}
|
Medical Text: Admission Date: [**2187-5-27**] Discharge Date: [**2187-5-31**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
man with a history of coronary artery disease and a long
history of duodenal arteriovenous malformations followed
closely with the primary care physician with periodic
hematocrit to monitor her blood loss. The patient's
hematocrit recently dropped from 42 to 35. The patient
presented to the Emergency Department with several days of
melena. Hematocrit on admission was 30. The patient denies
pain, non-steroidal anti-inflammatory drugs use or Aspirin
use.
PAST MEDICAL HISTORY: Coronary artery disease, multiple
duodenal intestinal arteriovenous malformations, status post
esophagogastroduodenoscopy on [**2184-6-29**] with cautery of
duodenal arteriovenous malformations, status post jejunal
arteriovenous malformations, diverticulosis, history of colon
cancer Duke's A, status post partial resection, aortic
stenosis, myocardial infarction in the past times two, status
post hernia repair, status post prostatectomy,
gastroesophageal reflux disease.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Atenolol 100 mg q.d.; Isordil 10
mg b.i.d.; Prevacid 30 mg q.d.; Celexa 20 mg q.d.;
Hydrochlorothiazide 12.5 mg q.d.; Lipitor 10 mg q.d.
SOCIAL HISTORY: Married, retired. Tobacco 5 pack years,
quit 35 years ago. Denies alcohol.
FAMILY HISTORY: Mother died of a stroke at 67, Father died
of lung cancer at age 87.
PHYSICAL EXAMINATION: Temperature 98.9, pulse 60, blood
pressure 96/36, respiratory rate 14, sating 99% on 4 liters
nasal cannula. Elderly man in no acute distress. Pupils
equal, round and reactive to light. Extraocular movements
intact. Sclera nonicteric. Oropharynx clear. Moist mucous
membranes, no jugulovenous distension. Lungs clear to
auscultation bilaterally. Regular rate and rhythm, S1 and
S2, III/VI systolic murmur at the left upper sternal border.
Abdomen soft, nontender, nondistended, positive bowel sounds.
No edema. Alert and oriented times three. Moves all
extremities.
LABORATORY DATA: In the Emergency Department
esophagogastroduodenoscopy was performed with Glucagon.
Excellent view of duodenum down past second portion was
achieved. No ulcers, arteriovenous malformations or active
bleeding was noted. Fresh bile was found in the duodenum.
Stomach had patchy gastritis in the prepyloric area and one
small patch in the fundus but no active bleeding and not
significant enough to account for his bleeding.
Laboratory data on admission revealed white count 13.9,
hematocrit 30, down from 34.7 on [**5-25**]. Platelets were 221.
Sodium 136, potassium 3.6, chloride 97, bicarbonate 25, BUN
28, creatinine 1.2, glucose 112. PT 12.5, PTT 22.6, INR 1.0.
Electrocardiogram was normal sinus rhythm at 68
beats/minute, left ventricular hypertrophy, normal axis, QRS
152, right bundle branch block, poor R wave progression, .[**Street Address(2) 34274**] depressions in V5 through V6. Iron 25, TIBC 393.
HOSPITAL COURSE: The patient was admitted to the Medicine
Intensive Care Unit where the patient was transfused a total
of 4 units of packed red blood cells. Two large bore
intravenous lines were placed. The patient was started on
b.i.d. Protonix. The patient had a tag red blood cell scan
performed which was negative. The patient was ruled out for
an myocardial infarction with serial creatinine kinase.
Aspirin was held. The patient was continued on beta blocker
and Lipitor. The patient also had his Atenolol and
Hydrochlorothiazide held secondary to his bleeding. The
patient's hematocrit remained relatively stable. He had
b.i.d. hematocrits checked. He was felt stable enough to
transfer back to the Medicine Floor. The patient was
transferred. He had esophagogastroduodenoscopy and
colonoscopy performed on [**5-30**]. The colonoscopy revealed
diverticulosis of the sigmoid colon and distal descending
colon, intact ileocolonic anastomotic site, otherwise normal
colonoscopy to the ileum. Endoscopy revealed normal
esophagus, patchy discontinuous erythema and granularity of
the mucosa with no bleeding noted in the antrum and stomach
body. These findings were compatible with gastritis. In the
duodenum a single sessile 2 mm nonbleeding polyp of benign
appearance was found in the jejunum. A single nonbleeding
arteriovenous malformation was found in the jejunum also.
The patient was switched from intravenous b.i.d. Protonix
back to once a day p.o. proton pump inhibitors. His diet was
advanced. His hematocrit remained stable. The patient was
felt stable for discharge the next day. The patient was
restarted on all cardiac medications.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Gastrointestinal bleed, status post multiple
esophagogastroduodenoscopies and colonoscopy which revealed
gastritis, nonbleeding arteriovenous malformation in the
jejunum and nonbleeding jejunal polyp.
2. Coronary artery disease
3. Aortic stenosis
4. Gastroesophageal reflux disease
DISCHARGE MEDICATIONS
1. Celexa 20 mg q.d.
2. Lipitor 10 mg q.d.
3. Prevacid 30 mg q.d.
4. Isordil 10 mg b.i.d.
5. Hydrochlorothiazide 12.5 mg q.d.
6. Atenolol 100 mg q.d.
The patient has been scheduled for a capsule endoscopy for
[**6-5**]. He was instructed to be NPO the night of [**6-4**],
after midnight and to report to the [**Hospital Ward Name 516**] Lobby at 8 AM
on [**2187-6-5**]. The patient will also follow up with Dr.
[**First Name (STitle) 2405**] and Dr. [**Last Name (STitle) 120**]. The patient is instructed to
follow up with his primary care physician in one to two
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 23326**]
MEDQUIST36
D: [**2187-5-31**] 16:20
T: [**2187-5-31**] 17:04
JOB#: [**Job Number 96687**]
ICD9 Codes: 2851, 4241, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5786
}
|
Medical Text: Admission Date: [**2160-12-4**] Discharge Date: [**2160-12-6**]
Date of Birth: [**2102-4-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
admit to CCU s/p pericardial drain
Major Surgical or Invasive Procedure:
Pericardial Drainage and drain placement [**12-5**], with drain
removal
History of Present Illness:
Ms. [**Known lastname 1104**] is a 58 y/o F with a a remote history of breast
carcinoma in situ (18 yrs ago, treated with
radiation/lumpectomy) who presented to her PCP with shortness of
breath, found to have a pericardial effusion. She endorses a one
month prodrome of weight gain that started after a diarrhea
illness. In the past couple of weeks she has notice increasing
dyspnea on exertion and chest discomfort. She says that the
chest discomfort is associated with palpitations. She thought
she was coming down with pneumonia which she has had in the past
because she has had a dry cough, chills at night, and post-nasal
drip. She states that she typically exercises 45 minutes daily
on a treadmill and suddenly found her self only able to last
5-10 minutes. She states that she also now struggles to climb
one flight of stairs. She reported feeling presyncopal on
treadmill after 15 minutes prior to admission.
.
Patient went to see her PCP and was noted to have enlarged
cardiac shadow on CXR, with concern of large pericardial
effusion accounting for her symptoms. In the ER, patient's
initial VS were 99.4 100 112/91 24 98%RA. Bedside ultrasound
revealed pericardial effusion, however patient did not have
pulsus on examination.
.
On transfer to floor, patient's VS were stable.
.
She had an echo this am that showed a moderate pericardial
effusion but no tamponade. She had a pericardial drain placed in
cath lab and 260cc of serosanguinous fluid was removed and sent
for analysis.
.
On review of systems, she 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. She admits to fevers, chills one month
ago. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is positive for chest discomfort and
dyspnea on exertion. Denies paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, or syncope.
Past Medical History:
breast cancer(CIS) 18 years ago treated with lumpectomy and
radiation
Social History:
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
Father had a MI in 50s and is alive in 80s with CAD. Mother with
CAD in 80s. Many uncles with [**Name2 (NI) **]. Otherwise, no family history
of arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
VS: T=99.3 BP=112/65 HR=95 RR=15 O2 sat=95%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: Supple with JVP of 10 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4. Pulsus 8.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, ND. Mild RUQ TTP. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2160-12-4**] 11:53PM D-DIMER-1580*
[**2160-12-4**] 08:13PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2160-12-4**] 08:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2160-12-4**] 08:13PM URINE RBC-0-2 WBC-[**7-2**]* BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2160-12-4**] 08:13PM URINE MUCOUS-MOD
[**2160-12-4**] 08:12PM GLUCOSE-93 UREA N-19 CREAT-0.6 SODIUM-140
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
[**2160-12-4**] 08:12PM LD(LDH)-327* CK(CPK)-86
[**2160-12-4**] 08:12PM cTropnT-<0.01
[**2160-12-4**] 08:12PM CK-MB-NotDone
[**2160-12-4**] 08:12PM TSH-1.4
[**2160-12-4**] 08:12PM RHEU FACT-11
[**2160-12-4**] 08:12PM WBC-6.4 RBC-3.76* HGB-11.1* HCT-33.5* MCV-89
MCH-29.5 MCHC-33.1 RDW-13.2
[**2160-12-4**] 08:12PM NEUTS-57.1 LYMPHS-35.2 MONOS-6.2 EOS-0.8
BASOS-0.7
[**2160-12-4**] 08:12PM PLT COUNT-296
[**2160-12-4**] 02:40PM GLUCOSE-88
[**2160-12-4**] 02:40PM UREA N-20 CREAT-0.6 SODIUM-141 POTASSIUM-4.0
CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
[**2160-12-4**] 02:40PM estGFR-Using this
[**2160-12-4**] 02:40PM ALT(SGPT)-271* AST(SGOT)-209* ALK PHOS-189*
TOT BILI-0.7
[**2160-12-4**] 02:40PM TOT PROT-5.8* ALBUMIN-3.8 GLOBULIN-2.0
CALCIUM-8.5 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2160-12-4**] 02:40PM WBC-6.2 RBC-3.62* HGB-10.8* HCT-32.7* MCV-90
MCH-29.8 MCHC-33.1 RDW-12.8
[**2160-12-4**] 02:40PM NEUTS-57.4 LYMPHS-32.4 MONOS-8.9 EOS-0.9
BASOS-0.4
[**2160-12-4**] 02:40PM PLT COUNT-313#
[**2160-12-4**] 02:40PM SED RATE-20
.
EKG: NSR at 100bpm, NA, NI, no STTW changes
.
2D-ECHOCARDIOGRAM: [**12-5**] pre-pericardiocentesis
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The aortic valve leaflets
(3) are mildly thickened. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a moderate
sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
[**12-5**] post pericardiocentesis: Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is a very small residual pericardial
effusion. The effusion appears circumferential. There are no
echocardiographic signs of tamponade. No right atrial or right
ventricular diastolic collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2160-12-5**], the pericardial effusion is much smaller;
no tamponade.
Brief Hospital Course:
58 y/o F with a a remote history of breast carcinoma in siut who
presented to her PCP with shortness of breath, found to have a
pericardial effusion now s/p pericardial drain.
.
# Pericardial Effusion: Patient found to have moderate effusion
on CT and Echo but no evidence of tamponade. Fluid analysis
consistent with exudate. Given history of cancer there is
concern that this could represent metastasis, ovarian cancer, vs
new lymphoma given history of radiation. Also possible is a
viral process which she is currently endorsing. Otherwise, she
is uptodate on age appropriate cancer screening. . No evidence
of uremia by labs. She was monitored in CCU, pulsus in am was
4mmHg, Ancef was given for prophylaxis with drain in place.
Repeat echo in am, with no reaccumulation of fluid drain to be
pulled. Fluid pathology pending. TSH, RF WNL. [**Doctor First Name **] pending at
time of discharge. Her drain did not drain significantly,
follow-up echo revealed no reaccumulation, her drain was pulled
and shw as discharged home.
.
# PUMP: Despite a mildly elevated JVP Ms [**Known lastname 1104**] never displayed
evidence of venous congestion or tamponade physioloyg. She has
no history of heart failure. Aside from pericardial effusion,
TTE without evidence of heart failure. Repeat TTE showed
decrease in fluid amount.
.
# Transaminitis: If viral syndrome is cause for effusion, it may
also explain transient transaminitis. LFTs were trending down
on the day of discharge. She has no risk factors of hepatitis.
It is doubtful that this is hepatic congestion but of concern an
underlying metastatic process should be ruled out. No elevated
bili to suggest cholecystitis.
.
# Small Pleural Effusions: Deferred for PCP follow up. Pt
stable on room air at discharge and notified of warning signs.
As with above discussion, oncologic and rheumatologic origins
would be unfortunate unifying diagnoses and should be followed
up.
Medications on Admission:
Calcium with Vitamin D
Discharge Medications:
Calcium with Vitamin D
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Effusion of unknown etiology
Pleural effusion of unknown etiology
Transaminitis of unknown etiology
?viral syndrome
Discharge Condition:
stable
Discharge Instructions:
Ms [**Known lastname 1104**]:
You were admitted to the hospital with shortness of breath and a
CT scan was performed which found a small amount of fluid in
your lungs and around the heart. While this fluid around your
heart was not dangerous at the time, we were concerned it might
worsen and you were taken to the catheterization lab for
drainage. The fluid around your heart was drained and the fluid
sent for analysis.
.
No changes were made to your home medications and you can feel
free to continue your calcium with vitamin D.
.
Please schedule an appointment with Dr. [**Last Name (STitle) 3707**] ([**Telephone/Fax (1) 8427**]
to be seen this week to follow-up on your elevated liver
enzymes, fluid in your lungs, and the fluid around her heart.
.
If you develop chest pain, shortness of breath, palpitations,
cough, fever, chills, nausea/vomiting, diarrhea, abdominal pain,
lightheadness or dizziness, please call your primary care doctor
or go to your local emergency room.
Followup Instructions:
Please schedule an appointment with Dr. [**Last Name (STitle) 3707**] ([**Telephone/Fax (1) 8427**]
to be seen this week to follow-up on your elevated liver
enzymes, fluid in your lungs, and the fluid around her heart.
Completed by:[**2160-12-6**]
ICD9 Codes: 5119
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5787
}
|
Medical Text: Admission Date: [**2119-1-15**] Discharge Date: [**2119-1-18**]
Date of Birth: [**2098-10-28**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Alcohol Intoxication and Depression
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
This a 20 year old woman with PMH ADHD, mood disorder, and
questions of conduct disorder w h/o previous suicide attempt in
[**11-15**] via Tylenol PM which required ICU admission, who was found
in the park, slurring speech, clinically intoxicated by police
report, but initially was alert and oriented at the time,
answering questions, admitting to drinking alcohol, admitting
some vague comments to wanting to kill herself. En route to ED
became more somnolent, and was felt not to be protecting airway,
and consented to have an oral airway placed. By the time of
arrival to the ED, was somnolent, and unarousable. She was
intubated, with sats in upper 80s prior off of oxygen. Prior to
intubation, narcan was given, improving respiratory rate, wich
was reported to be low initially, but mental status did not
change. Also at this time, NG tube was placed with bilious
return, given mixed bilious return, given charcoal - Could be
an acute ingestion, likely. While in ED was found to be positive
for TCAs and EtOH. Tox was consulted, who were on board with
charcoal and given no changes in EKG (normal QRS, normal QT), no
other interventions at the moment. They were considering bicarb
if QRS widens, but this did not occure. She was given a total of
3L of NS in ED.
Prior to transfer HR 106, BP 130/88, on Vent FiO250, PEEP 5, on
CPAP, pulling in about 450 volumes.
On the floor, patient was intubated, unable to answer questions.
BP was 103/49 HR 97, RR 14 sP02 was 100%
Past Medical History:
Depression
Multiple Past Suicide attempts (including tylenol and excedrin)
Self Cutting
Social History:
One of three children. Brother with schizophrenia.
Patient denied any h/o violence or sexual abuse.
Alledegly expelled from school in the 10th grade because, by her
report, she did not take the MCAS.
Patient does not have many friends.
- [**Name2 (NI) 1139**]: cigarettes on occasion
- Alcohol: drinks frequently often to the point of blacking out
with history of withdrawl tremors w/o seizures
- Illicits: unable to obtain
Family History:
Per [**Name (NI) **], brother has schizophrenia, mother has depression
Physical Exam:
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, ET tube in place. pinpoint,
minimally reactive pupils.
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: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, multiple linear healed scars on left wrist.
Pertinent Results:
[**2119-1-15**] 08:05PM BLOOD WBC-8.0 RBC-4.78 Hgb-14.3 Hct-42.4 MCV-89
MCH-29.9 MCHC-33.7 RDW-13.8 Plt Ct-367
[**2119-1-15**] 08:05PM BLOOD Neuts-42.8* Lymphs-52.3* Monos-2.4
Eos-1.8 Baso-0.9
[**2119-1-16**] 04:17AM BLOOD Glucose-116* UreaN-8 Creat-0.9 Na-146*
K-4.4 Cl-114* HCO3-21* AnGap-15
[**2119-1-15**] 08:05PM BLOOD ALT-74* AST-59* LD(LDH)-216 AlkPhos-118*
TotBili-0.3
[**2119-1-16**] 04:17AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.2
[**2119-1-15**] 08:05PM BLOOD ASA-NEG Ethanol-440* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
ECG: No QTc prolongation
Brief Hospital Course:
20yo female h/o several suicide attepmts, including excederin
overdose, tylenol overdose, now in MICU intubated.
1. Intoxication/Overdose - Patient found intoxicated in the park
with toxicology screen positive for alcohol, tricyclic
antidepressants and benzodiazepine. Although patient initially
admitted to a suicide attempt, she later claimed that she was
"only trying to get high." She initially required intubation by
EMS for airway protection and received activated charcoal in the
ED. Patient was initially admitted to the ICU with toxicology
following. She had no evidence of toxidrome from her ingestion
and was able to be extubated soon after arrival. Monitored on
telemetry and with serial EKGs showing normal QRS and QTc
interval.
2. ETOH intoxication - Patient presented with acute alcohol
intoxication soon after discharge from facility for alcohol
detox. Although serum osmolality was slightly elevated, there
was no evidence for ethylene glycol or methanol ingestion. She
was started on thiamine, folate and multivitamin and followed
closely for any signs of withdrawal. She did not require any
benzos per CIWA scale and was felt to be at low risk of
withdrawal given recent detox.
3. depression with suicidality - As above, patient initially
admited that ingestion was a suicide attempt which she later
denied. However, given multiple similar presentations, most
recently superficial wrist laceration and acetaminophen
overdose, she was felt to be high risk. Psychiatry followed her
throughout hospitalization, she was maintained on 1:1 sitter and
restarted on home medications of trazodone/ seroquel.
Discharged to psychiatric facility for further treatment.
4. transaminitis: initially admitted with mildly elevated AST/
ALT with elevated CK. These were likely secondary to mild
alcohol hepatitis as well as some minimal rhabdomyolysis in the
setting of ETOH ingestion/ intubation. Transaminitis trended
back to normal through hospital course. Of note, she should have
hepatitis panel as an outpatient given high risk behaviors.
Medications on Admission:
Unknown
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Primary Diagnoses:
Alcohol Intoxication
Tricyclic antidepressant overdose
Secondary Diagnosis:
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 3535**],
You were admitted to the hospital after being found intoxicated
with alcohol and tricyclic antidepressants. You initially
required intubation for stabilization and you were monitored
closely in the intensive care unit. When you had recovered from
your ingestions, you were restarted on your home medications.
You were seen by psychiatry who recommended that you go to a
psychiatric facility to further treatment of your depression.
Please make the following changes to your medications:
START folic acid daily
START thiamine daily
START multivitamins
START nicotine patch daily to stop smoking
You can take senna and colace twice daily as needed for
constipation
Followup Instructions:
Please follow up with your primary care physician after
discharge from the psychiatric hospital.
ICD9 Codes: 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5788
}
|
Medical Text: Admission Date: [**2133-11-28**] Discharge Date: [**2133-12-4**]
Date of Birth: [**2071-5-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
62 y/o M who was in his USOH until 8pm [**11-27**] when he felt
uncoordinated and weak on his R side. At 630sm [**11-28**] he woke to
find a tingling sensation on his R side with some right sided
weakness. Pt then came to ED to be evaluated at an OSH, and was
found to have an intraparenchymal hemorrhage.
Major Surgical or Invasive Procedure:
Left sided high parietal craniotomy, with intra-operative
imaging
Evacuation of hematoma, resection of underlying mass,
microscopic disection
Duraplasty with allograft, cranioplasty with dural graft.
History of Present Illness:
The patient is a 63 year-old male
who was in his usual state of health until [**11-27**] when he felt
"weak on the right side." He woke up on [**11-28**] with
significant right sided weakness. He was, therefore, seen at
an outside hospital in the emergency room and was worked up
including a CAT scan showing a left sided high parietal
intraparenchymal hemorrhage. He was transferred to the [**Hospital1 1444**] for further management.
Repeat MRI scan showed an intraparenchymal hemorrhage with a
questionable underlying mass and a second lesion anterior to
it.
Past Medical History:
HTN, hypercholesterolemia, hyper uric acid (no gout attack), R
nephrectomy'[**89**] for renal cell cancer of unknown type
Social History:
Retired nuclear power plant worker. Quit tobacco in [**2100**], drinks
2-3 beers a day, lives with significant other. Does not have any
children.
Family History:
Mother alive and well at [**Age over 90 **] years old. Father passed away at age
[**Age over 90 **]. Brother alive and well.
Physical Exam:
VS: Tm Tc HR BP RR O2 RA
Gen: Well appearing, comfortable, lying in bed in NAD.
HEENT: Well healing scalp incision with wound intact, no
swelling or erythema. PERRL, EOMI, sclera anicteric, MMM.
Neck: No LAD, JVD or thyromegly.
CV: RRR with no m/r/g
Lungs: CTA bilaterally
Abd: soft, NT, ND active BS, no hepatosplenomegly.
ext: No clubbing, cyanosis or edema.
Neuro: Alert and oriented x 3. CN II-XII intact and symmetric
bilaterally. Strength 5/5 in lower extremities bilaterally.
Deltoids are [**4-9**], bicepts [**4-9**], tricepts 5-/5, wrist extension
??????. FNF decreased on the right compared to left. Reflexes 2+
bilaterally.
Pertinent Results:
[**2133-11-28**] 09:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2133-11-28**] 09:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2133-11-28**] 09:55PM URINE RBC-0 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2133-11-28**] 09:55PM URINE MUCOUS-RARE
[**2133-12-2**] 05:10AM BLOOD Plt Ct-227
[**2133-12-2**] 05:10AM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-140
K-3.9 Cl-104 HCO3-27 AnGap-13
[**2133-12-2**] 05:10AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.2
[**2133-12-2**] 05:10AM BLOOD Phenyto-11.9
[**2133-12-1**] 03:31AM BLOOD Phenyto-11.4
[**2133-11-30**] 01:23AM BLOOD Phenyto-10.6
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2133-12-1**] 9:16 AM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: please evaluate for residual tumor with and wittout gad.
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with s/p left parietal resection of a tumor
REASON FOR THIS EXAMINATION:
please evaluate for residual tumor with and wittout gad.
INDICATION: Resection of left parietal tumor, evaluate for
residual.
TECHNIQUE: Multiplanar T1 and T2-weighted images of the brain
were obtained. Post-Gadolinium scans are provided in 3 planes.
Comparison is made to the previous examinations of [**11-28**]
through [**11-30**].
FINDINGS:
There has been evacuation of a large left parietal lobe
hemorrhagic mass. There was enhancement along the margins of the
hemorrhage on the preoperative studies and there continues to be
an ill-defined area of enhancement in the location of the most
inferior component of the hemorrhagic mass - involving the white
matter along the superior margin of the posterior left lateral
ventricle.
Overall, there is marked decrease in mass effect related to the
previous hemorrhage and edema. There is residual edema, as
expected in the immediate postoperative period.
There is no change in a smaller enhancing T2 intense mass which
is in the left frontal lobe.
IMPRESSION: There has been evacuation of the hemorrhagic mass
from the left parietal lobe. There may be residual enhancing
abnormal tissue in the deepest part of the surgical bed, within
the white matter immediately adjacent to the roof of the
posterior [**Doctor Last Name 534**] of the left lateral ventricle. The left frontal
lobe mass is unchanged.
RADIOLOGY Final Report
MR CONTRAST GADOLIN [**2133-11-28**] 6:34 PM
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: eval for AVM, aneurysm, mass
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with new left sided head bleed
REASON FOR THIS EXAMINATION:
eval for AVM, aneurysm, mass
EXAM: MRI brain.
CLINICAL INFORMATION: Patient with new left-sided hemorrhage,
for further evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were obtained before
gadolinium. T1 axial, sagittal and coronal images of the brain
were obtained following the administration of gadolinium. 3D
time-of-flight MRA of the circle of [**Location (un) 431**] was acquired.
FINDINGS BRAIN MRI:
There is an area of intraparenchymal hemorrhage in the left
parietal lobe with surrounding edema. The signal characteristics
of the blood products indicate acute hemorrhage. Following
gadolinium, enhancement is seen at the margin of hematoma. The
mass measures approximately 4.7 x 4 cm in size. In addition, an
approximately 1 cm rim-enhancing lesion with mild surrounding
edema is seen in the left frontal lobe. There are no other
distinct areas of abnormal enhancement identified. There is no
midline shift seen. There is mass effect on the left lateral
ventricle. The basal cisterns are patent. There is no evidence
of acute infarct seen on diffusion images.
IMPRESSION: Left parietal hematoma with surrounding enhancement
and additional 1 cm enhancing lesion in the left frontal lobe
are suggestive of metastatic disease. No midline shift is seen.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation.
IMPRESSION: Normal MRA of the head.
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2133-12-2**] 11:12 AM
CT CHEST W/CONTRAST; CT ABD W&W/O C
Reason: BRAIN METS, H/O RENAL CA, R/O PRIMARY TUMOR
Field of view: 40 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with brain lesion
REASON FOR THIS EXAMINATION:
r/o primary tumor
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Brain lesion, with history of renal cell carcinoma.
Evaluate for primary tumor.
TECHNIQUE: CT of the torso was performed using oncology
protocol. CT without contrast of the abdomen was performed,
followed by images of the torso after contrast. A total of 150
cc of Optiray nonionic contrast was given for this examination.
Nonionic contrast was used given single kidney status.
COMPARISONS: None.
FINDINGS:
CT OF THE CHEST WITH CONTRAST: There is no axillary
lymphadenopathy. There are bulky mediastinal lymph nodes, the
largest of which is conglomerate in the precarinal region. The
precarinal conglomerate measures approximately 3.1 x 6.0 cm in
size, and is both bowing the azygos vein, and slightly impinging
upon the superior vena cava. Bulky left hilar lymph nodes are
seen, adjacent to the region of tumor involvement/atelectasis of
the left upper lobe. This may be associated with some degree of
lymphangitic spread as well. Multiple scattered pulmonary
nodules are also seen, primarily scattered across the right
lung. These measure less than 8 mm in diameter. A couple of tiny
3 mm nodules may also be evident on the left.
Of note, there is an irregular tumor measuring approximately 1
cm in size, which is growing within the left mainstem bronchus,
presumably representing invasion from a mediastinal lymph node
through the left mainstem bronchus. There are bulky left hilar
lymph nodes, which measure up to 1.5 cm in diameter. Large right
hilar lymph nodes also measure up to approximately 1.6 cm in
diameter. No significant effusion is present.
CT OF THE ABDOMEN WITHOUT AND WITH CONTRAST: The patient is
status post right nephrectomy. No evidence of local recurrence
at the nephrectomy site. A punctate calcification adjacent to
the gallbladder probably represents external calcification.
There is a 1 cm low-density focus at the liver dome, probably
representing a small cyst. At the apex of the adrenal gland,
there is a 1.3 cm low-density nodule. This does not quite meet
attenuation criteria for adrenal adenoma. Especially given the
low density appearance of the thoracic nodes, this may represent
a small metastasis. There is no significant abdominal adenopathy
or free fluid present. No evidence of obstruction.
CT OF THE PELVIS WITH CONTRAST: The large bowel, bladder, and
distal ureters are unremarkable aside from diffuse
diverticulosis. A small amount of air within the bladder likely
represents recent instrumentation with Foley or straight
catheter.
Examination of osseous structures show degenerative changes of
the hips. There is a somewhat patchy and nonspecific pattern of
osteopenia within both iliac bones, as well as in the L5
vertebral body. There is also a 6 mm lytic focus in the seventh
vertebral body. This is also somewhat suspicious for malignancy.
IMPRESSION:
1. Bulky mediastinal and hilar adenopathy, with multiple tiny
nodules within the right lung, and a combination of tumor and
atelectasis, possibly associated with lymphangitic spread in the
left upper lobe. There is also invasion of the left mainstem
bronchus by tumor, with intraluminal mass size of approximately
1 cm. Together and given the history, appearances are most
suspicious for metastatic renal cell carcinoma. However,
metastases from primary lung neoplasm may have similar
appearances.
2. Small lytic focus within the seventh thoracic vertebral body,
as well as the L5 vertebral body. Also nonspecific patchy
osteopenia within the iliac bones. These may represent small
bony metastases.
3. Enlarged nodes adjacent to the SVC may lead to SVC syndrome
in the future. Currently, there is not significant compression
of the SVC.
Brief Hospital Course:
Patient was transferred to [**Hospital1 18**] from outside hospital with a
left sided high parietal intraparenchymal hemorrhage. Repeat MRI
on [**2133-11-28**] showed intraparenchymal hemorrhage with a
questionable underlying mass and a second lesion anterior to it.
He was admitted to the ICU for further observation and work-up
and was taken to the operating room on [**2133-11-30**] for
decompression, evacuation of hematoma, resection of underlying
mass and biopsy (for further details please see dictated
operative note). Patient tolerated the procedure well and was
transferred back to the ICU for recovery and further
observation. Patient was continued on dilantin and Decadron
perioperatively. He continued to do well. Diet was advanced
without complication. Decadron was subsequently stopped.
Patient was transferred to the floor on post-operative day 1. A
chest/abdomen/pelvis CT scan was obtained to assess for
metastatic disease (see results section) showing significant
lung lesions as well as possible spine lesions. Case discussed
with Hematology/Oncology fellow [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who wanted to
await final pathology result prior to directing further oncology
follow-up.
Patient remained neurologically intact with only minimal left
sided strength deficit. Visual field testing was done on post
operative day 3 and patient was discharged to rehab on
post-operative day 4 with instructions for follow-up with Dr.
[**Last Name (STitle) **] and the neuro-oncology.
Medications on Admission:
lipitor, allopurinol, ziac (bisoprolol/HCTZ), niacin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Niacin 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
9. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) for 2 days: Then change to Decadron 2mg [**Hospital1 **] on [**12-5**]
until seen in clinic.
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a
day: To start on [**12-5**] after 3mg dosing complete.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab - [**Location (un) **], NH
Discharge Diagnosis:
Left sided high parietal intraparenchymal hemorrhage with
suspicion of underlying tumor.
Discharge Condition:
good
neurologically stable
Discharge Instructions:
please seek medical attention if you experience fever > 101.5,
nausea, vomitting, severe pain, numbness, weakness, tingling,
double/blurry vision, mental status changes.
please watch you wound for erythema or drainage.
please take new meds as directed and resume old meds
no driving till follow-up - please ask physician
Please follow up with the brain tumor clinic. Have
Neuro-oncologist set up follow up with hematology/oncology once
pathology of tumor is back.
please go to your follo-up appointments
Followup Instructions:
1. Have staples removed at Dr[**Name (NI) 9034**] office [**Hospital **] Medical
Building [**Hospital Unit Name **] [**12-8**] between [**8-17**] with [**Doctor First Name **] [**Doctor Last Name **]
2. Follow up with brain tumor clinic on [**12-11**] 9:30am w/ Dr.
[**Last Name (STitle) 4253**] on [**Location (un) **] [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**] [**Hospital1 18**]
Completed by:[**2133-12-4**]
ICD9 Codes: 431, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5789
}
|
Medical Text: Admission Date: [**2104-8-19**] Discharge Date: [**2104-9-20**]
Service: Medicine
CHIEF COMPLAINT:
Cough and fever.
HISTORY OF PRESENT ILLNESS: The patient is an 84 year old
female who presented initially in [**2104-2-29**] with
acute/chronic cough and fever. The patient was treated over
several months with antibiotics, for three separate courses,
without relief. Eventually, a repeat chest x-ray showed a
right lower lobe infiltrate and the patient was sent to the
Emergency Room to be treated for pneumonia.
In the Emergency Room, a CT scan of the chest was obtained
and showed dense consolidation in the right lower lobe and
right middle lobe with a large loculated right pleural
effusion. The patient was admitted and started on broad
spectrum antibiotics, and her pleural effusion was tapped.
The pleural fluid obtained was consistent with an empyema,
however, the patient underwent bronchoscopy prior to VATS to
rule out malignancy. During the bronchoscopy, a blood vessel
was nicked. During the biopsy, the patient bled acutely,
decompensated and had to be intubated.
After intubation, the patient had a tonic-clonic seizure.
Subsequently, she underwent a neurological workup. The
seizure was thought to be hypoxic versus toxic metabolic.
The patient was loaded on Dilantin and, over the next several
days, her neurological status was noticed to be slowly
improving. She required multiple packed red blood cell
transfusions.
The patient eventually underwent a VATS with decortication in
the Operating Room. Over the next several days, the patient
was difficult to wean from the ventilator. She subsequently
developed a left pleural effusion which was tapped for 800
cc. She was eventually extubated successfully on hospital
day number 18, but had an acute episode of mucus plugging,
which led to desaturation and tachycardia.
The patient was ruled out for a pulmonary embolism by CT
angiogram and her acute desaturation was resolved with
suctioning. The patient, from that point on, was saturating
well on two liters of oxygen by nasal cannula and was felt
stable enough to be transferred to the floor. At the point
of transfer, the patient was still on antibiotics that were
started in the Unit.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Aortic
sclerosis. 3. Hyperthyroidism. 4. Anxiety. 5.
Depression. 6. Syndrome of inappropriate diuretic hormone,
on fluid restriction.
MEDICATIONS ON ADMISSION: Home medications include Diovan,
Norvasc, E-Vista, Levoxyl and hydralazine along with
multivitamins; at the time of transfer, the patient was on
levofloxacin 500 mg p.o.q.d., day 15 at time of transfer,
Synthroid 88 mcg p.o.q.d., Colace 100 mg p.o.b.i.d.,
lansoprazole 30 mg p.o.q.d., fentanyl patch 25 mcg, Norvasc
2.5 mg p.o.q.d., albuterol nebulizer, cefepime, and
vancomycin.
SOCIAL HISTORY: The patient does not use tobacco or alcohol.
REVIEW OF SYSTEMS: Unable to be obtained at this time.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 98.2, heart rate 70, respiratory rate
25, blood pressure 133/38 and oxygen saturation 96% on two
liters nasal cannula. General: Somnolent, arousable to pain,
apparently in no acute distress. Head, eyes, ears, nose and
throat: Anicteric sclerae, no pallor, mucous membranes dry,
no lymphadenopathy, no thyromegaly. Cardiovascular: Regular
rate and rhythm, no murmur, rub or gallop, no jugular venous
distention, no edema. Pulmonary: Lungs: Clear to
auscultation with bibasilar crackles. Abdomen: Soft,
nontender, nondistended, positive bowel sounds, no
organomegaly, no palpable masses. Neurologic: Only
arousable to pain, appears to be moving all four extremities
symmetrically.
LABORATORY DATA: White blood cell count 13, hematocrit 31.3,
platelet count 547,000, differential with 88% neutrophils and
4% bands, sodium 133, potassium 3.7, chloride 92, bicarbonate
32, creatinine 0.8, glucose 147, phenytoin level 2.1. Total
fluid culture from original thoracentesis on the right side
grew Streptococcus pneumoniae. Sputum, blood and urine
cultures drawn on [**2104-9-4**] were negative. Pleural
fluid obtained from the second thoracentesis on the left side
was negative. Blood, urine and sputum cultures drawn on
[**2104-9-8**] are pending at the time of transfer.
STUDIES: Chest x-ray obtained on the day prior to transfer
showed a moderate right sided pleural effusion with a small
left sided effusion. CT angiogram obtained the day prior to
transfer showed no pulmonary embolism, increasing left sided
pleural effusion and a decreasing right sided pleural
effusion. A right upper quadrant ultrasound obtained ten
days prior to transfer was negative. Magnetic resonance
imaging scan of the head obtained four days after initial
presentation to the hospital demonstrated hyperintense T2
signals in the brain stem thalamus and posterior parietal
lobes.
HOSPITAL COURSE: (continued from time of transfer) A repeat
magnetic resonance imaging scan of the head showed reversal
of the above noted hyperintense T2 signal changes, however,
the second magnetic resonance imaging scan did reveal an area
in the posterior parietal lobe possibly consistent with a new
small infarction.
The patient's entire course on the medicine service was
characterized by waxing and [**Doctor Last Name 688**] mental status. One moment
the patient would appear to be completely alert and engaging
conversation and, within an hour, she would be almost unable
to be aroused to pain. Overall, her inability to be aroused
abated and her mental status generally improved.
The patient was hydrated cautiously with intravenous fluids.
Nutrition was given via tube feeds via a nasogastric tube. A
TSH level was drawn and came back elevated at 22, with a free
T4 of 0.5. The patient's thyroid medication was increased.
Serial chest x-rays revealed persistent bilateral lower lobe
atelectasis with a newly evolving left lower lobe infiltrate,
which subsequently began to resolve. The patient's
antibiotics at the time of discharge were gradually
discontinued.
The patient was consistently subtherapeutic with her Dilantin
levels. After about one week on the floor, the patient began
to express discomfort to palpation of the abdomen. Liver
function tests were sent and were mildly elevated. A right
upper quadrant ultrasound was obtained and was normal.
Dilantin was considered a possible culprit for causing
hepatotoxicity as well as decreased mental status, and was
discontinued.
The patient continued to improve mentally. Several swallow
studies were obtained after the patient discontinued her own
nasogastric tube. She failed these and, prior to discharge,
a gastrostomy tube was placed. Her alkaline phosphatase
remained persistently elevated at a level of about 185 and
AST remained elevated at around 50. GGT was elevated at 210.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 2582**]
MEDQUIST36
D: [**2104-9-20**] 17:07
T: [**2104-9-20**] 18:25
JOB#: [**Job Number 105792**]
ICD9 Codes: 5119, 5185
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5790
}
|
Medical Text: Admission Date: [**2184-12-30**] Discharge Date: [**2185-1-10**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 yo M transferred from [**Hospital3 **] after presenting to ED
there with pain between shoulder blades. Found on CT chest to
have anterior mediastinal hematoma.
Past Medical History:
CVA
prostate cancer
s/p Colectomy with colostomy
Depression
Diabetes
Hyperlipidemia
Social History:
Lives with children and cares for himself.
Family History:
NC
Physical Exam:
138/70 SR 66
HEENT: Unremarkable
NECK: Supple, FROM, No carotid bruits
LUNGS: Clear to auscultation
HEART: RRR, Nl S1-S2, No M/R/G
ABD: S/NT/ND/NABS. Colostomy present
EXT: Warm. Non palpable DP/PT pulses. 2+ Femoral pulses.
Pertinent Results:
RADIOLOGY Preliminary Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2185-1-6**] 3:38 PM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
Reason: eval for growth of intramural hematoma
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with aortic intramural hematoma
REASON FOR THIS EXAMINATION:
eval for growth of intramural hematoma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Aortic intramural hematoma, evaluate for growth of
intramural hematoma.
COMPARISON: [**2185-1-4**]. CTA of [**2184-12-30**].
TECHNIQUE: Axial MDCT images were obtained from the lung apices
to the upper abdomen prior to the administration of intravenous
contrast. Axial MDCT images were then obtained from the lung
apices through the aortic bifurcation after the administration
of 80 cc of intravenous Optiray in the arterial phase. Coronal
and sagittal reformatted images, and oblique reformats, are
provided.
CONTRAST: Intravenous nonionic contrast was administered due to
the rapid rate of bolus injection required for this examination.
CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: An
anterior mediastinal hematoma measures 5.2 x 7.6 cm, slightly
increased since the most recent non-contrast chest CT of [**1-4**], [**2184**], at which time it measured 5.1 x 7.3 cm, and also
increased from the initial examination of [**2184-12-30**], at
which time it measured 4.2 x 7.4 cm. Hemopericardium is
unchanged. An ascending aortic aneurysm measures up to 5.0 cm,
unchanged over multiple examinations. Aortic mural thickening
involving the arch and proximal descending aorta is unchanged.
There are numerous calcifications consistent with atheromatous
disease. Post-contrast images show extensive irregularity in the
aortic arch consistent with atherosclerotic ulcers, but there is
no evidence of active extravasation of contrast into the
mediastinal hematoma. The great vessels are patent. Separate
origin of the left vertebral artery directly from the arch is
again noted. The pulmonary arteries appear unchanged. The
central airways are patent. The heart and coronary arteries
appear unchanged, including extensive coronary artery
calcification.
Bilateral pleural effusions have decreased since [**1-4**], and
the density of the left pleural effusion ranges between 5 and 12
Hounsfield units without evidence of new hemothorax on the left.
Bilateral emphysematous changes are again noted. The degree of
atelectasis in the lower lobes is improved along with the
decrease in pleural effusions. No definite pulmonary nodules or
masses are identified. Pleural thickening along the right
lateral chest wall is unchanged from multiple studies.
CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: The
liver, spleen, and adrenal glands appear unremarkable. The
gallbladder is non-distended. Borderline pancreatic ductal
dilation (3.5 mm) is unchanged. No masses are identified in the
pancreas. Bilateral renal cysts up to 9.2 cm in diameter are
unchanged. Marked atheromatous calcification of the abdominal
aorta is consistent with atherosclerotic disease. Three areas of
focal dilation of the infrarenal aorta proximal to the aortic
bifurcation, measure up to 3.1 cm and are unchanged from the
earliest study. Again noted is high-grade narrowing at the
origins of the celiac and superior mesenteric arteries. Single
renal arteries bilaterally are patent although there is
narrowing at the ostium of the left renal artery.
Bone windows show degenerative changes of the thoracolumbar
spine, bilateral L5 pars defects and grade 1 anterolisthesis of
L5 on S1. A compression deformity of the L2 vertebra is
unchanged
IMPRESSION:
1. Continued slight increase in size of an anterior mediastinal
hematoma with no evidence of active extravasation. The
progressive increase in size of the hematoma is again concerning
for continued leak.
2. Unchanged thoracic aortic aneurysm and marked mural
irregularity consistent with penetrating ulcers and intramural
hematoma.
3. Decreased bilateral pleural effusions and atelectasis.
4. Unchanged bilateral renal cysts and borderline pancreatic
ductal dilation.
5. Emphysema.
A page was sent to Dr. [**Last Name (STitle) **] at 6:16 p.m. on [**2185-1-6**]
and these findings were discussed.
DR. [**First Name (STitle) 8913**] R.M. SUN
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76803**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 76804**]Portable TTE
(Complete) Done [**2184-12-30**] at 11:19:35 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-9-6**]
Age (years): 84 M Hgt (in): 66
BP (mm Hg): 130/90 Wgt (lb): 140
HR (bpm): 54 BSA (m2): 1.72 m2
Indication: Intramural hematoma.
ICD-9 Codes: 424.1, 424.2
Test Information
Date/Time: [**2184-12-30**] at 11:19 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2008W001-0:33 Machine: Vivid [**6-19**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.2 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 70% >= 55%
Aorta - Sinus Level: *4.2 cm <= 3.6 cm
Aorta - Ascending: *5.1 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 0.63
Mitral Valve - E Wave deceleration time: 240 ms 140-250 ms
TR Gradient (+ RA = PASP): 17 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC
diameter (<2.1cm) with >55% decrease during respiration
(estimated RAP (0-5mmHg).
LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. No LV mass/thrombus.
Overall normal LVEF (>55%). Transmitral Doppler and TVI c/w
Grade II (moderate) LV diastolic dysfunction. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Complex (>4mm) atheroma
in aortic root. Focal calcifications in aortic root. Markedly
dilated ascending aorta. Mildly dilated descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Significant PR.
PERICARDIUM: Small pericardial effusion.
Conclusions
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. There is severe symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. No masses or
thrombi are seen in the left ventricle. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade II (moderate)
LV diastolic dysfunction. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level. There are complex (>4mm) atheroma in
the aortic root. The ascending aorta is markedly dilated The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. Significant pulmonic regurgitation is
seen. There is a small pericardial effusion.
IMPRESSION: Severe symmetric left ventricular hypertrophy with
normal systolic function and moderate diastolic dysfunciton.
Markedly dilated ascending aorta. Moderate aortic regurgitation.
Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2184-12-30**] 15:40
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2184-12-29**] via transfer
from [**Hospital6 5016**] for further management of a
mediastinal hematoma. As he was stable, he was admitted to the
cardiac surgical intensive care unit with aggressive blood
pressure control. He was oliguric which responded to fluids. His
CT scan showed a dilated ascending aorta showed no dissection of
his aorta however showed a large mediastinal hematoma consistent
with a penetrating ulcer which had stopped leaking. His
ascending aorta measured 5cm. He was transfused with packed red
blood cells for anemia. He underwent a left thoracentesis which
drained 700cc of bloody fluid. The ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] to
care for his colostomy. Serial CT scans showed a mild increase
in the size of an anterior mediastinal hematoma with no evidence
of active extravasation and an unchanged thoracic aortic
aneurysm with marked mural irregularity consistent with
penetrating ulcers and intramural hematoma. On [**2185-1-5**], he was
transferred to the step down unit for further monitoring. His
hematocrit stabilized. The physical therapy worked with him
daily for assistance with strength and mobility. As Mr. [**Known lastname **]
remained stable, the plan was to discharge him home with a CTA
in 1 week. Following his CTA, he will follow-up with Dr. [**First Name (STitle) **]
in clinic.
Medications on Admission:
Avodart 0.5 mg PO daily
Celexa 20 mg PO daily
Glipizide-ER 2.5 mg PO daily
Lasix 20 mg PO QOD
Zocor 20 mg PO daily
Flomax 0.8 mg qhs
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Zocor 20 mg Tablet Sig: One (1) Tablet PO QHS.
Disp:*30 Tablet(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Sust. Release 24 hr(s)* Refills:*2*
5. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
Disp:*60 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 MDI* Refills:*1*
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] home health
Discharge Diagnosis:
Anterior thoracic hematoma, aortic ulcerations
Discharge Condition:
Stable
Discharge Instructions:
1) Follow medications on discharge instructions.
2) Call our office or 911 for chest or back pain.
3) Follow-up with Dr. [**First Name (STitle) **] [**2185-1-19**] at 1:45PM as instructed.
4) Monitor at home blood pressure. Call with a systolic blood
pressure of greater then 130mmHg.
5) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for 1 week ([**2185-1-19**] at 1:45 in
[**Hospital Ward Name **] 2A). [**Telephone/Fax (1) **]. You will be contact[**Name (NI) **] by the office
about your CT scan which will be on the same day as your
appointment.
Make an appointment with Dr. [**First Name (STitle) 17859**] for 1-2 weeks. [**Telephone/Fax (1) 40171**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2185-1-10**]
ICD9 Codes: 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5791
}
|
Medical Text: Admission Date: [**2118-6-18**] Discharge Date: [**2118-6-23**]
Date of Birth: [**2118-6-18**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This is a 2-kilogram, 35 and
[**6-17**] week, female born to a 27-year-old gravida 3, para 0 now
2 mother with prenatal screens O positive, antibody negative,
rapid plasma reagin nonreactive, Rubella immune, and hepatitis
B surface antigen negative.
The pregnancy was complicated by in [**Last Name (un) 5153**] fertilization
twins. The infant was born via vaginal vacuum-assisted
delivery. Apgar scores were 8 and 9.
PHYSICAL EXAMINATION ON PRESENTATION: Weight was 2 kilograms,
length was 17 inches, temperature was 99.3, heart rate was
152, respiratory rate was 60, and oxygen saturation
was 83 percent on room air. Mean blood pressure was 40.
The infant was in respiratory distress with grunting,
flaring, and retracting. She had an anterior fontanel that
was open and flat. The palate was intact. She had nasal
flaring and grunting. Cardiovascular examination revealed a
normal rate and rhythm. No murmurs. Femoral pulses were 2
plus. The abdomen was soft with active bowel sounds. There
were no masses or distention. The hips were stable. The
spine was midline. The anus was patent with no sacral dimple.
She was warm and well perfused with brisk capillary refill.
Normal female genitalia.
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS:
1. RESPIRATORY ISSUES: The infant was initially placed on
continuous positive airway pressure of 6, and by day of
life one had weaned to room air. She has been stable on
room air since.
2. CARDIOVASCULAR ISSUES: The infant has been
cardiovascularly stable without any murmurs or
cardiovascular issues.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant was
initially nothing by mouth on D-10-W. Feedings were
initiated on day of life two. She initially had issues
with feeding coordination which have improved. She is
now taking by mouth ad lib breast milk or Enfamil 20 and
doing well with feedings. Her weight on discharge was 1.91
kilograms.
She has been voiding and stooling appropriately.
4. GASTROENTEROLOGY ISSUES: Bilirubin levels were followed.
Her peak bilirubin was 10.6/0.4 on day of life four.
Phototherapy was initiated. Phototherapy was discontinued
on day of life five after a bilirubin of 8.9/0.4.
Approximately six hours off of phototherapy, her bilirubin
was 7.3/0.3.
5. SENSORY ISSUES: An audiology hearing screen was performed
with automated auditory brain stem responses, and the
infant passed bilaterally.
6. PSYCHOSOCIAL ISSUES: [**Hospital1 69**]
Social Work was involved with the family during this
admission per routine.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) 40493**] (telephone number
[**Telephone/Fax (1) 55431**]).
CARE RECOMMENDATIONS:
1. Feedings at discharge: Breast milk by mouth ad lib to
supplement with Enfamil 20 as necessary.
2. Medications: None.
3. Car seat position screening to be performed.
4. State newborn screen was sent on day of life three, and
the results are pending.
5. Immunizations received: The infant received a hepatitis B
vaccination on [**2118-6-21**].
IMMUNIZATIONS RECOMMENDED: 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 gestation; (2) born
between 32 and 35 weeks gestation with 2/3 of the following:
Plans for day care during respiratory syncytial virus season,
airway abnormalities, or with school-age siblings; and/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, and for the first
24 months of the child's life, immunization against influenza
is recommended for household contacts and out of home
caregivers to protect the infant.
DISCHARGE INSTRUCTIONS-FOLLOWUP: Dr. [**First Name (STitle) **] [**Name (STitle) 40493**] - the
parents were to call on the day following discharge for a
follow-up appointment that day.
DISCHARGE DIAGNOSES:
1. Preterm at 35 and 5/7 weeks.
2. Transitional respiratory distress, resolved.
3. Hyperbilirubinemia.
4. Feeding discoordination, improved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 36463**]
Dictated By:[**Last Name (NamePattern1) 55432**]
MEDQUIST36
D: [**2118-6-23**] 18:06:06
T: [**2118-6-23**] 19:00:55
Job#: [**Job Number **]
ICD9 Codes: 7742, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5792
}
|
Medical Text: Admission Date: [**2168-9-30**] Discharge Date: [**2168-10-11**]
Date of Birth: [**2104-6-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
PEG
central venous catheterization, removed [**2168-10-11**]
History of Present Illness:
The pt is a 64 year-old man with PMHx of IDDM, Multiple
Sclerosis
and longterm tobacco abuse who presents with slurred speech and
worsened R-sided weakness, and was found at an OSH to have a
2.5cm pontine hemorrhage.
The hx was obtained mostly from pt's wife. She reports that at
baseline the patient has weakness from his MS of his R leg, most
notable for a R foot drop as well as weakness of his R hand, of
which he can only use his 1st digit and thumb, and the other are
"always closed in a fist". He uses a walker to get around.
However, this morning he woke up and was slurring his speech,
which is unusual for him unless his blood sugar is too low. She
checked his blood sugar and it was 30. She gave him glucose and
[**Location (un) 2452**] juice and unlike other times it has been too low, his
slurred speech didn't improve. In addition, she noticed that
his
R face was drooping and his R eye was at first "too open" and
then the eyelid was droopy. She called 911 and he was taken to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], where a CT scan showed a 2.5cm pontine hemorrhage.
He was then sent to us for further evaluation. Of note, he was
note noted to be hypertensive at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], with BP max
recorded in the 150's. He does not have hypertension at
baseline.
When he arrived in our ED, his BP was in the 130's and he was
taken to a repeat CT scan, which showed an essentially unchanged
hemorrhage in the pons. He was seen by neurosurgery who felt
that the bleed was too deep to intervene surgically at this
point. His initial neurological exam showed essentially full
eye
movements and then a repeat exam 1 hour later showed inability
to
look horizontally and difficulty with downward gaze L > R.
Therefore, given the changing exam and the location of his bleed
he was admitted to the ICU for closer monitoring.
On neuro ROS, the pt reports a mild R sided HA, [**3-26**], as well as
worsened right sided weakness, but denies loss of vision,
blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies new difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- IDDM
- Multiple Sclerosis follow by a [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98108**] (sp?)
Social History:
lives at home with his wife. Denies EtOH or illicits,
has smoked for "many years", is a retired respiratory therapist
Family History:
no hx of strokes or seizures
Physical Exam:
Vitals: T: 96.8 P: 62 R: 18 BP: 138/64 SaO2: 100% on 2L NC
General: Awake, cooperative, NAD.
HEENT: dry MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: multiple small areas of skin breakdown on legs bilaterally
Neurologic:
-Mental Status: Alert, oriented x 2 (said it was Wednseday and
didn't know the date), but could get the year, location and
current president. Able to relate history without difficulty
except for significant dysarthria. Attentive, able to name DOW
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Unable to read without glasses. Speech was
significantly dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm and brisk. VFF to confrontation.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages. R eye with ptosis.
III, IV, VI: EOMI without nystagmus on initial exam with
inability to bury the sclera bilaterally, but on repeated exam
pt
unable to look laterally to the left or right and when looking
down the L eye had upward beating nystagmus and both eyes had
difficulty with down gaze with skew deviation.
V: Facial sensation intact to light touch.
VII: R facial droop as well as R ptosis
VIII: Hearing intact to finger-rub in L, but decreased in R
(chronic hearing loss).
IX, X: Palate sluggish to elevate, no gag obtained on tongue
depressor testing.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protruded intially to the L, then on repeat testing
was midline.
-Motor: Decreased bulk in LE's bilaterally. No pronator drift on
L, but is unable to life R arm high enough to adequately test.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5- 5 5- 5- 5 4+ 5-
R 3 4 4 4 5 2 1 3 4+ 3 1 1 0 1
-Sensory: intact to light touch and pinprick throughout. No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 1
Plantar response was extensor R > L bilaterally.
-Coordination: Only able to test LUE as RUE is too weak, but no
dysmetria on the R FNF test.
-Gait: Deferred as pt requires walker at baseline and currently
weaker than baseline in RLE.
DISCHARGE EXAM
Unchanged from above.
Pertinent Results:
[**2168-9-30**] 11:20AM BLOOD PT-11.6 PTT-33.6 INR(PT)-1.1
[**2168-9-30**] 11:20AM BLOOD Glucose-166* UreaN-28* Creat-0.9 Na-136
K-4.4 Cl-99 HCO3-27 AnGap-14
[**2168-10-11**] 04:53AM BLOOD Glucose-186* UreaN-18 Creat-0.6 Na-140
K-4.3 Cl-103 HCO3-35* AnGap-6*
[**2168-10-1**] 02:36AM BLOOD ALT-15 AST-27 LD(LDH)-205 CK(CPK)-342*
AlkPhos-89 TotBili-0.5
[**2168-10-6**] 09:07AM BLOOD CK(CPK)-222
[**2168-10-1**] 02:36AM BLOOD CK-MB-5 cTropnT-<0.01
[**2168-10-11**] 04:53AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.5*
Mg-1.7
[**2168-10-1**] 02:36AM BLOOD %HbA1c-8.4* eAG-194*
[**2168-10-1**] 02:36AM BLOOD Triglyc-75 HDL-69 CHOL/HD-2.3 LDLcalc-74
[**2168-10-1**] 02:36AM BLOOD TSH-0.62
[**2168-10-1**] 02:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
The pt is a 64 year-old man with PMHx of IDDM, Multiple
Sclerosis
with baseline right side weakness and long term tobacco abuse
who
presents with slurred speech and worsened R-sided weakness, and
was found to have a 2.5cm pontine hemorrhage in CT , confirmed
with MRI. At the time of admission his exam was notable for
dysarthric speech, R ptosis and facial droop and R-sided
weakness
worse than his reported baseline. His pontine hemorrhage is in a
concerning location, but the etiology is not yet clear. His
hemorrhage is a typically hypertensive location, yet the patient
doesn't have HTN nor was he reported as hypertensive at the OSH.
He was admitted to the ICU for further monitoring.
1. Hemorrhagic lesion in L pontine: in serial CT hemorrhage size
remained stable, he recieved hypertonic saline for 24 hours. A
follow-up MRI was scheduled for outpatient.
2. ID: His urine analysis was positive for WBC and Bacteria, he
recieved 1 week of IV ceftriaxone. He developed fever and
leukocytosis again and as CXR was positive for infiltration, he
was started on cefepime, flagyl and vancomycin x 9 days
3. Feeding: he had swallowing evaluation, which showed impaired
swallowing, PEG tube placed for feeding
4. MS: Alert, oriented x3
5. Cardiovascular: TTE showed elongated left atrium but no focal
wall motion abnormalities, LVEV> 55%. He developed 2 episodes of
atrial fibrillation and recieved esmolol drip on the first
episode and diltiazem drip at the second episode. He was
subsequently started on labetalol. He was hypertensive prior to
discharge and his lisinopril was increased to 5mg.
Medications on Admission:
humalog ISS
- lantus 27 units QAM
- oxybutynin chloride ER 10mg QD
- zoloft 50mg QAM
- gabapentin 600mg [**Hospital1 **]
- tizanidine 4mg QAM and 8mg QHS
- ampyra 10mg [**Hospital1 **]
- copaxone 20mg SC QD
- ASA 81mg QD
- lisinopril 2.5mg QD
- MVI QD
- B12 QD
- vitamin D QD
Discharge Medications:
1. Copaxone *NF* (glatiramer) 20 mg Subcutaneous daily
2. Oxybutynin 10 mg PO TID
XR form
3. Ampyra *NF* (dalfampridine) 10 mg Oral [**Hospital1 **]
4. Cyanocobalamin 100 mcg PO DAILY
5. Gabapentin 600 mg PO BID
6. lantus 27 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
7. Labetalol 200 mg PO BID
HOLD FOR SBP LESS THAN 130 AND HR LESS THAN 50
8. Lisinopril 5 mg PO DAILY
Hold for sbp < 100
9. Multivitamins 1 TAB PO DAILY
10. Nicotine Patch 14 mg TD DAILY
11. Sertraline 50 mg PO DAILY
12. Tizanidine 4 mg PO QAM
13. Tizanidine 8 mg PO QPM
14. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
primary: left pontine hemorrhage, pneumonia (resolved)
secondary: multiple sclerosis, hypertension, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 48612**],
You were admitted to the hospital with speech difficulties and
worsening of your right sided weakness. These were found to be
due to a stroke, a bleed in the brain, in an area called the
pons. The reason for this stroke is not yet clear.
We have made the following changes to your medications:
1. We increased your lisinopril to 5mg daily.
2. We started a medication called labetalol for atrial
fibrillation.
3. We have stopped your aspirin.
Please continue your tizanidine, gabapentin, and labetalol at
your regular doses.
You have an MRI that is tentatively scheduled for [**2168-12-2**] prior
to your appointment with Dr. [**First Name (STitle) **] to evaluate the area of the
bleed. Radiology will contact you with the specific time and
date.
It was a pleasure caring for you.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2168-12-13**] 11:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2168-10-11**]
ICD9 Codes: 431, 5070, 5990, 4019, 3051
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5793
}
|
Medical Text: Admission Date: [**2166-11-6**] Discharge Date: [**2166-11-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to Left anterior
descending artery.
History of Present Illness:
88 yo M with PMH significant for HTN, h/o stroke [**2156**] and DVT on
coumadin, dementia presents with chest pain. The patient is a
poor historian due to his dementia and thus history of taken
with the help of his wife. The patient was in his normal state
of health until last night when he complainted of chest
discomfort to his wife. The episode resolved until the AM when
he woke up and complainted of severe chest tightness to his
wife. [**Name (NI) **] also was slightly diaphoretic, but denied SOB, nausea
or vomiting. The wife called 911 and he was taken to [**Hospital1 18**].
.
In the ED VS: 96.4 76 154/87 16 98% RA. The patient had ECG
changes consistent with anterior STEMI and Code STEMI was
called. He got ASA, plavix 600mg, heparin gtt and integralin
bolus (no gtt). He was also given IV metoprolol 5mg x2 for BP
and 1 SL nitro followed by a nitro gtt. CXR showed early
interstitial pulmonary edema. Labs were remarkable for a trop
0..09, CK 65 and MB: not done, Cr:1.3 and potassium 5.6
(not-hemolyzed). He was taken to the cath lab.
.
The cath revealed 80% thrombotic mid-LAD lesion that was stented
with a 3.0x15mm BMS, post with 3.0mm NC balloon. He also had 80%
lesions in ramus and mid RCA and a 90% stenosis in a small
distal LCx. Those lesions were not intervened upon. He
remained hemodynamically stable throughout and without
complications.
.
The patient denied any chest pain, SOB, nausea, vomiting.
.
On review of systems, he denies any prior history of 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:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
None
3. OTHER PAST MEDICAL HISTORY:
--h/o stroke [**2156**] with r sided weakness.
--Multiple DVT in the leg and upper ext. Last DVT was [**2161**]. On
life-long coumadin
--Dementia
--h/o melanoma on his back s/p removal
Social History:
Retired sales engineer. Lives with his wife. [**Name (NI) **] [**Name2 (NI) 269**] services
-Tobacco history: none
-ETOH: rare
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T=97.8...BP=125/63...HR=67...RR=19...O2 sat=94% 2L
GENERAL: NAD. Oriented x2. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
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. mild crackles at the
bases no 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 venoous stasis changes ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
EKG: sinus at 65 bpm, NI, [**Last Name (LF) **], [**First Name3 (LF) **]-elevations in v1-v4. No prior
for comparison
.
Cath Report [**11-6**]:
LAD: 80% hazy mid
LCx: 80% large ramus, 90% mid small distal circumflex
RCA: 80% mid
Bare metal stent to LAD, perclose right groin.
CXR [**11-6**]
IMPRESSION: Minimal increased interstitial linear markings in
the right lung base suggestive of early interstitial pulmonary
edema.
ECHO [**11-7**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
akinesis of the mid- and distal anterior wall and septum, apex
and distal inferior segment (mid-LAD territory). The remaining
segments contract normally (LVEF = 35%). The LV apex is not
visualized sufficiently for a thrombus to be definitely
excluded, although one is not seen. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Mild mitral regurgitation. Mild pulmonary
hypertension. Mildly dilated ascending aorta.
[**2166-11-6**] 01:30PM BLOOD CK(CPK)-65
[**2166-11-6**] 01:30PM BLOOD CK-MB-NotDone
[**2166-11-6**] 08:26PM BLOOD CK(CPK)-175*
[**2166-11-6**] 08:26PM BLOOD CK-MB-16* MB Indx-9.1* cTropnT-0.09*
[**2166-11-7**] 03:24AM BLOOD CK(CPK)-247*
[**2166-11-7**] 03:24AM BLOOD CK-MB-17* MB Indx-6.9* cTropnT-1.00*
[**2166-11-7**] 01:30PM BLOOD CK(CPK)-1147*
[**2166-11-7**] 01:30PM BLOOD CK-MB-113* MB Indx-9.9*
[**2166-11-7**] 10:05PM BLOOD CK(CPK)-951*
[**2166-11-7**] 10:05PM BLOOD CK-MB-71* MB Indx-7.5*
[**2166-11-8**] 05:20AM BLOOD CK(CPK)-731*
[**2166-11-8**] 05:20AM BLOOD CK-MB-44* MB Indx-6.0 cTropnT-2.81*
[**2166-11-9**] 06:20AM BLOOD CK(CPK)-410*
[**2166-11-9**] 06:20AM BLOOD CK-MB-11* MB Indx-2.7
[**2166-11-7**] 03:24AM BLOOD Triglyc-112 HDL-41 CHOL/HD-4.1
LDLcalc-105
On discharge:
[**2166-11-9**]
Glucose-101 UreaN-19 Creat-1.2 Na-140 K-4.8 Cl-104 HCO3-26
AnGap-15
WBC-10.8 RBC-4.24* Hgb-12.5* Hct-36.3* Plt Ct-630*
Brief Hospital Course:
88 yo M with PMH significant for HTN, h/o stroke [**2156**] and DVT on
coumadin, dementia presents with STEMI s/p BMS to 80% thrombotic
mid-LAD lesion.
.
# CORONARIES: Pt with anterior STEMI. He was taken to cath and
s/p BMS to 80% mid LAD lesion without further complication.
Patient with 80% lesions in ramus and mid RCA and a 90% stenosis
in a small distal LCx that were not intervened as they were not
likely the cause of his CP. TIMI risk score of 5 (12.4%
mortality). Pt developed another episode of chest pain, back
discomfort and shoulder pain the following morning with no
significant ECG changes. CE peaked only once to CK 1147, CKMB
113, Trop 9.9. Delay in elevation was considered to be due to
delayed washout. Pt was started on Plavix in addition to ASA
325, which should be continued for one year. Also maintained on
lipitor 80mg, metoprolol 37.5mg tid, lisinopril 10mg. Imdur was
uptitrated to prevent recurrance of anginal sx.
Pt developed no complications of his MI. He had no evidence of
heart failure. Follow up ECHO showed EF 35% with LV systolic
dysfunction with akinesis of mid and distal anterior wall and
septum, apex and distal inferior segment consistent with mid LAD
infarct. No intervention given pt already therapeutic on
coumadin for h/o DVT. Further intervention of mid RCA and
ramus lesions should be considered as outpt.
Medications on Admission:
Atenolol 25 mg daily
Lisinopril 10 mg daily
Nemenda 10 mg daily
Exelon 1.5 mg daily
Coumadin 3 mg daily
Supplement: Fibercon, Coenzyme Q10
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:*11*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Rivastigmine 1.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-29**]
Drops Ophthalmic PRN (as needed) as needed for eye pain.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Anterior ST Elevation Myocardial Infarction
Hypertension
Previous Stroke on coumadin
Dementia
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You had a heart attack which caused your heart muscle to be
weak. A cardiac catheterization showed 3 blockages in your
coronary arteries. One of the blockages was fixed and a bare
metal stent was inserted. this should keep the artery open. You
will need to take aspirin and Plavix every day for at least one
month and ideally one year to prevent the stent from clotting
off and causing another heart attack.
Medication changes:
1. Stop taking Atenolol
2. Start taking Metoprolol instead to slow the heart rate
3. Start taking Imdur, a long acting nitroglycerin to prevent
chest pain and lower the blood pressure
4. Start taking aspirin and Plavix every day to prevent the
stents from clotting off. Do not stop taking unless your
cardiologist says it is OK to do so.
5. Start taking ranitidine to prevent stomach upset from the
Plavix
6. Start taking Atorvastatin to lower your cholesterol and
prevent another heart attack.
7. continue your warfarin and medicines for dementia
8. Continue the eye drops if your eyes are dry at home.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Primary Care:
[**Last Name (LF) 8505**],[**First Name3 (LF) **] phone: [**Telephone/Fax (1) 8506**] Date/Time: Tuesday [**11-18**]
at 11:00 am.
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
[**Hospital1 **] Hospital
[**Location (un) 83706**], [**Numeric Identifier 46003**]
Phone: ([**Telephone/Fax (1) 11814**]
Date/time: Wednesday [**12-3**] at 1:00pm. Please come to the
hospital at 12:30pm to register and do new patient paperwork.
Completed by:[**2166-11-10**]
ICD9 Codes: 5859
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5794
}
|
Medical Text: Admission Date: [**2175-10-9**] Discharge Date: [**2175-10-17**]
Date of Birth: [**2175-10-9**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is the second born of
twins, born at 34 weeks gestation to a 33 year-old, G1, P0
woman. Prenatal screens: Blood type B negative, antibody
negative, Rubella immune, RPR nonreactive, hepatitis B
surface antigen negative, group Beta strep status unknown.
The pregnancy was complicated by pregnancy induced
hypertension and pre-eclampsia. The mother was treated with a
course of betamethasone and was complete on [**2175-10-2**]. This
infant was born breech by elective Cesarean section due to
concern for pregnancy induced hypertension. She required blow-by
oxygen in the delivery room. Her Apgars were 7 at 1 minute
and 8 at 5 minutes. She was admitted to the NICU for
treatment of prematurity.
Anthropometric measurements upon admission to the Neonatal
Intensive Care Unit: Weight was 1.935 kg. Length was 43 cm.
Head circumference 31 cm. All 50th percentile for
gestational age 34 weeks.
PHYSICAL EXAM AT DISCHARGE: Weight 1.810 kg, length 43 cm,
head circumference 31 cm. GENERAL: Well-appearing, active
infant, in no acute distress, breathing comfortably in room
air. Skin warm and dry, color pink. Mild underlying
jaundice. HEENT: Anterior fontanel open and flat. Sutures
apposed. Positive red reflex bilaterally. Palate intact.
Neck supple without masses. Chest clear. Lungs clear and
equal bilaterally. Easy respirations. Cardiovascular:
Regular rate and rhythm. No murmur. Femoral pulses +2.
Abdomen soft, nontender, nondistended, no masses. Cord on
and drying. Genitourinary: Normal preterm female. External
genitalia. Anus patent. Musculoskeletal: Hips w/moderate laxity,
however stable at this time. Clavicles intact. Spine midline.
No sacral dimple. Neuro:
Normal tone and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: This infant has been in room air for her
entire Neonatal Intensive Care Unit admission. She has
not had any episodes of apnea and bradycardia. Her
baseline respiratory rate is 30 to 60 breaths per minute
and she maintains oxygen saturations greater than 95%.
2. Cardiovascular: This infant has maintained normal heart
rates and blood pressures. No murmurs have been noted.
At the time of discharge, baseline heart rate is 140 to
160 beats per minute with a blood pressure of 83/38
mmHg, mean arterial pressure of 52 mmHg.
3. Fluids, electrolytes and nutrition: This infant was
initially n.p.o.. Glucoses were normal. Enteral feeds
were started on day of life one and gradually advanced
to full volume. This infant has been all p.o. feeding
and has not required any gavage feeding. She has been
taking 120 to 140 ml/kg per day of breast milk fortified
to 24 calories per ounce with human milk fortifier or
preemie Enfamil 24 calorie per ounce formula. She has
also been breast feeding. Weight on the day of
discharge is 1.810 kg. Serum electrolytes were checked
on day of life one and were within normal limits.
4. Infectious disease: Due to her prematurity and the
unknown group B strep status of the mother, this infant
was evaluated for sepsis upon admission to the Neonatal
Intensive Care Unit. A complete blood count and
differential were within normal limits. A blood culture
was obtained and was no growth at 48 hours. The infant
was not treated with antibiotics.
5. Hematologic: This infant is blood type B positive,
direct antibody test negative. Hematocrit at birth was
60%. She did not receive any transfusions of blood
products.
6. Gastrointestinal: This infant required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life 3, a total of
13.6 mg/day of life. She was treated with phototherapy
for approximately 96 hours. The phototherapy was
discontinued and rebound bilirubin on [**2175-10-16**] was
10.3. Her phototherapy was again initiated and serum
bilirubin on the day of discharge is .
7. Neurology: This infant has maintained a normal
neurologic examination during admission. There were no
neurologic concerns at the time of discharge.
8. Sensory: Hearing screening has not been performed and
is recommended prior to discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital 5279**] Hospital in
[**Location (un) 5450**], NH for continuing level II care.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62815**], MD, [**Hospital **]
Pediatrics, 360 Route 101, Unit 7B, [**Location (un) **], [**Numeric Identifier 75938**].
Telephone number [**Telephone/Fax (1) 75935**]. Fax number [**Telephone/Fax (1) 75936**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Ad lib breast feeding or p.o. feeding, breast milk
fortified to 24 calories per ounce with human milk
fortifier or preemie Enfamil 24 calorie per ounce
formula.
2. No medications.
3. Iron and vitamin D supplementation: Iron
supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
Vitamin D supplementation at 200 i.u. (may be provided
as a multi-vitamin preparation) daily until 12 months
corrected age.
4. Car seat position screening is recommended prior to
discharge.
5. State newborn screen was sent on [**2175-10-12**] with no
notification of abnormal results to date. A second
screening is recommended at 2 weeks of age.
6. Immunizations: No immunizations administered thus far.
7. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) 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 or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: Hip ultrasound
at 4 to 6 weeks after discharge as screening for developmental
hip dysplasia due to breech presentation.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestation.
2. Suspicion for sepsis ruled out.
3. Unconjugated hyperbilirubinemia.
[**First Name8 (NamePattern2) 73452**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 73453**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2175-10-17**] 01:23:46
T: [**2175-10-17**] 05:51:49
Job#: [**Job Number 75939**]
ICD9 Codes: 7742, V290
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5795
}
|
Medical Text: Admission Date: [**2184-11-9**] Discharge Date: [**2184-11-12**]
Date of Birth: [**2143-5-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Shortness of breath, back pain, and tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 76281**] is a pleasant 41 yo gentleman with history of
severe crush injury to the left lower extremity in [**2165**],
followed by a saddle embolus in [**2169**], and subsequent below the
knee amputation, now presenting with shortness of breath and
back pain. Pt states that following his initial deep vein
thrombosis (DVT), he had another DVT in [**2178**] and was started on
coumadin, however this was discontinued after seeing hematology
in [**2181**] because the clots were thought to be provoked. He is
now presenting with pleuritic back pain, tachycardia, shortness
of breath for 2 days, drenching night sweats for several days,
consistent with prior pulmonary emboli. Of note,
hypercoagulation workup performed in the past was negative. He
has recently been driving to [**Location (un) 3844**] for fitting of his
prosthesis and states that he noted that the night sweats began
with his first trip to [**Location (un) 3844**], however the pain and
dyspnea began just yesterday.
In the ED, initial vs were: 98.6 115 132/79 20 98%. EKG showed
sinus tach, V2 with RBBB morphology, CT showed massive PE.
Patient was started on heparin gtt, given morphine and dilaudid
for pain, as well as a dose of ceftriaxone for unclear reasons.
Currently 100% on 4L. Vitals on 97 24 97% on 4L 121/85.
On the floor, pt is complaining of ongoing R-sided back pain and
shortness of breath.
Past Medical History:
-crush injury to his leg in a workplace injury in [**2165**], followed
by amputation due to severe pain and swelling in [**2169**], also
complicated by multiple stump infections
-Reflex sympathetic dystrophy, s/p sympathemectomy prior to leg
amputation
-PE [**2169**], [**2178**]
-Depression
-recent tx for h. pylori
Social History:
He is single, and currently living with two daughters. Smokes 1
ppd, no alcohol or drugs. Has 5 children, is divorced. On
longterm disability, formerly steel worker.
Family History:
Mother with history of DVT/PE. No family history of CAD or
diabetes, to his knowledge.
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.2 BP:147/62 P:101 R:20 O2:97%
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,
rhonchi, poor inspiratory effort
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
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
.
DISCHARGE PHYSICAL EXAM
Vitals: Tm 100.5, Tc 98.9, BP 110/70, P 80, R 18, 93-95% 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 (improved from
yesterday), no wheezes, rales, rhonchi. Right mid-axillary line
TTP (less so than yesterday) just under the axilla
CV: Regular rate and rhythm, split S2, no murmurs, rubs, gallops
Physical exam otherwise unchanged from admission.
Ext: L above the knee amputation
Pertinent Results:
ADMISSION LABS:
[**2184-11-9**] 11:45AM BLOOD WBC-12.0* RBC-5.27 Hgb-16.1 Hct-46.4
MCV-88 MCH-30.6 MCHC-34.8 RDW-12.2 Plt Ct-287
[**2184-11-9**] 11:45AM BLOOD Neuts-79.5* Lymphs-14.7* Monos-4.0
Eos-1.4 Baso-0.4
[**2184-11-9**] 11:45AM BLOOD PT-13.8* PTT-24.1 INR(PT)-1.2*
[**2184-11-9**] 11:45AM BLOOD Glucose-124* UreaN-9 Creat-1.2 Na-136
K-3.9 Cl-100 HCO3-24 AnGap-16
[**2184-11-9**] 11:45AM BLOOD cTropnT-<0.01 proBNP-1306*
[**2184-11-9**] 08:52PM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
URINE:
[**2184-11-10**] 04:46AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2184-11-10**] 04:46AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
DISCHARGE LABS
[**2184-11-11**] 05:20AM BLOOD WBC-11.0 RBC-4.57* Hgb-14.0 Hct-41.3
MCV-90 MCH-30.6 MCHC-33.9 RDW-12.5 Plt Ct-257
[**2184-11-12**] 09:00AM BLOOD PT-15.1* INR(PT)-1.3*
[**2184-11-12**] 09:00AM BLOOD Glucose-101* UreaN-9 Creat-1.0 Na-137
K-4.3 Cl-100 HCO3-28 AnGap-13
MICRO:
[**2184-11-10**] MRSA SCREEN (Final [**2184-11-12**]): No MRSA isolated.
[**2184-11-10**] BCx x2: PENDING
[**2184-11-10**] URINE CULTURE (Final [**2184-11-11**]): <10,000
organisms/ml.
STUDIES:
[**2184-11-9**] CXR:
Single AP portable view of the chest was obtained. There has
been interval removal of the previously seen left-sided PICC.
Mildly increased perihilar opacities suggest mild pulmonary
vascular engorgement. Subtle opacity at the medial right lung
base may be due to atelectasis or focal consolidation. Dedicate
PA and lateral views would be helpful for further evaluation.
The cardiac and mediastinal silhouettes are stable, with the
main pulmonary appearing enlarged, which may be due to pulmonary
hypertension. No large pleural effusion or pneumothorax.
[**2184-11-9**] CTA chest:
1. Extensive pulmonary emboli affecting the distal right and
left main pulmonary arteries and all lobes with evidence of
right heart strain. Main pulmonary artery is also enlarged.
Recommend echocardiogram for further evaluation.
2. Right lower lobe pulmonary infarct. Small right pleural
effusion with overlying atelectasis; however, additional infarct
in this region cannot be excluded.
3. 7-mm pulmonary nodule in the right lower lobe. Recommend
three-month
followup with chest CT if no history of malignancy, otherwise
PET-CT.
[**2184-11-9**] LENIs: No evidence of DVT.
[**2184-11-10**] TTE: The left atrium is dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is markedly dilated with mild global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Markedly dilated right ventricle with mild global
hypokinesis and evidence of right ventricular pressure/volume
overload. Pulmonary artery pressure is moderately elevated.
Normal regional and global left ventricular systolic function.
Brief Hospital Course:
Mr. [**Known lastname 76281**] is a pleasant 41 yo gentleman, with history of
DVTs/PE, who was admitted for SOB, back pain, found to have
massive pulmonary embolus.
# Pulmonary embolus: Patient with history of PEs in the past,
now off coumadin since [**2181**]. Prior hypercoaguability work-up
negative. Admitted to MICU with massive pulmonary embolus on
admission CT. He was initially started on heparin gtt given clot
burden, but decision was made not to perform lysis with TPA. He
was transitioned to Lovenox while being bridged to Coumadin, as
there was no indication for thrombolysis or other procedures. He
began therapy with Coumadin on [**2184-11-10**] with 5mg daily and INR
upon discharge on [**11-12**] was 1.3. Since his last three
measurements of INR was 1.3 on 5mg of Coumadin daily, his dosage
was increased to 7.5mg daily upon discharge, along with lovenox
injections. LENIs showed no DVT. ECHO showed severe right heart
strain. He will have follow-up in [**Month (only) 956**] for repeat ECHO,
unless a sooner appointment becomes available.
# Chest Pain: Location is in the right mid-axillary line just
under the axilla that is pleuritic and musculoskeletal in
nature. Likely related to infarction of lung secondary to
massive PE. Pain controlled with Tylenol, Ibuprofen, and
Oxycodone, with Morphine IV for breakthrough pain. Pain was
improved upon discharge, and he was encouraged to take tylenol
at home for his pain.
# Tobacco use: Pt was offered nicotine patch in house, which he
wore initially. He was counseled on smoking cessation, as it can
increase his changes greatly of developing more clots.
# Lung nodule: 7-mm pulmonary nodule in the right lower lobe was
found on chest CT. Follow up is recommended in three-months with
chest CT if no history of malignancy, otherwise PET-CT.
TRANSITIONAL ISSUES
#Pt needs his INR followed-up on Monday, [**11-15**], and his
coumadin dose adjusted accordingly.
#Pt needs follow-up for repeat ECHO to assess improvement in his
right heart strain.
#Pt needs follow-up with repeat imaging based on 7mm pulmonary
nodule found on chest CT.
#Please follow-up pending blood cultures.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
3. warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day: For a
total of 7.5mg daily. Adjust dose per your doctor's
recommendations.
Disp:*45 Tablet(s)* Refills:*0*
4. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q12H (every 12 hours).
Disp:*28 syringes* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pulmonary Emboli
Pulmonary Infarct
Secondary Diagnosis:
Lung nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 76281**],
It was a pleasure taking care of you during your hospital stay
at [**Hospital1 69**]. You were admitted
because of shortness of breath, right-sided back pain, a fast
heart rate, and sweating. You were found to have a large
pulmonary embolus (blood clot in the arteries that supply blood
to your lungs) by imaging. You were started on Lovenox
(enoxaparin) injections while we gave you coumadin so that you
would still be anticoagulated until your INR reached the
therapeutic goal of [**1-29**]. You will have to be on life-long
anticoagulation therapy from now on, given your recurrent blood
clots and pulmonary emboli.
An ultrasound of your heart (echocardiogram) was performed,
which showed that the right side of your heart was straining to
pump against pressure in your your heart caused by the clot in
your pulmonary arteries. You need to follow up with your
pulomonologist in [**12-28**] months for a repeat echocardiogram.
You were also having right-sided chest pain that is likely due
to lack of blood flow to the corresponding area of your right
lung (pulmonary infarct). Your pain was treated with oxycodone.
In addition, your chest CT showed a 7-mm nodule in the lower
lobe of your right lung. This will also need to be followed-up
with further imaging and work up if necessary. Please discuss
this at your follow-up appointment with your pulmonologist (lung
doctor).
Regarding your medications, please make the following changes:
Please START taking:
1. Lovenox injections - please take these injections for 2 days
after your INR is at goal of [**1-29**]
2. Coumadin - your goal INR is [**1-29**]. Please have your PCP adjust
the dosage of this medication to keep the INR between [**1-29**]. You
will be discharged on 7.5 mg daily.
Followup Instructions:
You will need to get your INR checked by Dr.[**Name (NI) 7753**] office on
Monday, [**2184-11-15**]. You can just walk in to the clinic
to have your INR checked, you do not need to make an
appointment. The office just asks that you call prior to going
(tel: [**Telephone/Fax (1) 7751**]).
Name: [**Doctor Last Name **],ZINAIDA
Address: [**Doctor Last Name 51830**], UNIT [**Unit Number **], [**Location (un) **],[**Numeric Identifier 45899**]
Phone: [**Telephone/Fax (1) 7751**]
Appointment: Monday [**2184-11-22**] 2:00pm
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2185-2-3**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2185-2-3**] at 1:30 PM
With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*The office will call you at home with a sooner appointment if
one becomes available.
Completed by:[**2184-11-14**]
ICD9 Codes: 311, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5796
}
|
Medical Text: Admission Date: [**2201-7-18**] Discharge Date: [**2201-8-5**]
Date of Birth: [**2127-12-13**] Sex: F
Service: CCU
NOTE: This is a Death Summary.
HISTORY OF PRESENT ILLNESS: This is a 73-year-old Asian
female with a complicated past medical history significant
for diabetes, hyperlipidemia, hypertension, and coronary
artery disease (status post 4-vessel coronary artery bypass
graft on [**2201-5-4**] which was complicated by postoperative
atrial fibrillation). She was started on amiodarone and
converted back to sinus rhythm in one day. She was continued
on amiodarone and beta blocker and was sent to cardiac
rehabilitation.
She returned on [**2201-5-23**] with chest pain thought to be
associated with pericardiotomy syndrome. She was found to
have a moderate-sized left pleural effusion which was tapped
for about 500 cc, but this was not sent for any laboratory
studies.
She returned on [**2201-7-18**] with rapid worsening of dyspnea
over the last two days. She was brought by Emergency Medical
Service who had intubated her in the field.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post 4-vessel coronary
artery bypass graft on [**2201-5-4**] (left anterior
descending artery to left internal mammary artery, saphenous
vein graft to first diagonal, saphenous vein graft to
posterior descending artery).
2. Diabetes (hemoglobin A1c of 8.2 in [**2201-4-27**]).
3. Hyperlipidemia.
4. Hypertension.
SOCIAL HISTORY: No tobacco and no alcohol use.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Outpatient medications included
amiodarone 200 mg p.o. q.d., Zestril 20 mg p.o. q.d.,
oxycodone 5 mg p.o. q.4-6h. as needed, Lopressor 25 mg p.o.
b.i.d., Lasix 20 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.,
enteric-coated aspirin 325 mg p.o. q.d., Protonix 40 mg p.o.
q.d., Lipitor 20 mg p.o. q.d., Plavix 75 mg p.o. q.d.,
insulin 70/30 30 units q.a.m. and 16 units q.p.m.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to the Coronary Care Unit revealed a temperature
of 105, blood pressure was 117/61, heart rate was 91,
respiratory rate was 20, oxygen saturation was 97% on FIO2 of
100%. In general, physical examination revealed the patient
was intubated and sedated. Head, eyes, ears, nose, and
throat examination showed normocephalic and atraumatic, Asian
female. Pupils were equal, round, and reactive to light.
They were not icteric. Cardiovascular examination revealed
she had a regular rate. She had a normal first heart sound
and second heart sound. No murmurs, rubs or gallops were
heard. Pulmonary examination revealed she was clear to
auscultation bilaterally anteriorly. Abdominal examination
showed a soft, nontender, and nondistended abdomen with
normal active bowel sounds. Her extremities were cool to
touch. She had no noticeable edema, but her dorsalis pedis
pulses could not be appreciated. On neurologic examination,
she was sedated. She had an indeterminate Babinski, but she
was moving all four extremities. Her ventilator settings on
admission were synchronized intermittent mandatory
ventilation 500, respiratory rate was 20, positive
end-expiratory pressure was 8, FIO2 of 200%.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
values revealed a white blood cell count of 11.7, hematocrit
was 46.4, platelets were 231. PT was 16.5, PTT was 30, INR
was 1.2. Sodium was 143, potassium was 3.6, chloride
was 107, bicarbonate was 20, blood urea nitrogen was 27,
creatinine was 1.4, blood glucose was 88. Cardiac enzymes
showed a peak creatine kinase of 1787 on [**8-18**], with a
CK/MB of 11, and an index of 0.6. Troponin was 1.5.
RADIOLOGY/IMAGING: Initial electrocardiogram showed sinus
rhythm with a rate of 77, a normal axis, and a left
bundle-branch morphology.
A follow-up electrocardiogram on the same day showed a new
arteriovenous junctional rhythm with antegrade P wave
conduction.
Initial chest x-ray showed bilateral patchy basilar opacities
which could be consistent with aspiration pneumonia, as well
as a fine interstitial pattern, and engorgement of the
pulmonary vasculature; consistent with pulmonary edema.
HOSPITAL COURSE:
1. CORONARY ARTERY DISEASE: Upon admission, the patient had
signs of cardiogenic shock and status post coronary artery
bypass graft two months earlier. Therefore, she was taken
straight to the catheterization laboratory. Her hemodynamics
indicated elevated filling pressures with a cardiac index
of 1.09.
On coronary angiography, coronary angiography showed an 80%
left main stenosis, an occluded left anterior descending
artery, a left circumflex with a 70% proximal stenosis and
80% distal disease, and an occluded right coronary artery.
The saphenous vein graft to posterior descending artery had
50% middle and 80% stenosis at the touchdown site. The
saphenous vein graft to first diagonal had a 90% middle
stenosis which was stented with 0% residual stenosis with
normal flow afterwards. The saphenous vein graft to second
diagonal showed a 90% stenosis which was also stented and had
0% residual stenosis. The left internal mammary artery to
left anterior descending artery had an 80% distal stenosis.
Her hemodynamics initially improved with angioplasty, and she
was started on aspirin, Plavix, and Integrilin which was
continued for 24 hours.
Cardiac enzymes were cycled, and although creatine kinases
were elevated, the CK/MB fraction never bumped, and the
troponin remained flat at 1.5. Therefore, given the evidence
of restenosis on catheterization, it was unknown whether an
ischemic event precipitated the patient's presentation.
2. CONGESTIVE HEART FAILURE: The patient was started on
dopamine and dobutamine while in the catheterization
laboratory due to a cardiac index of 1.1. An echocardiogram
done after her initial coronary artery bypass graft on
[**2201-5-21**] showed an ejection fraction of 55%. A repeat
echocardiogram which was done on [**5-22**] (on hospital day
two) showed an ejection fraction of 35% with inferior wall
akinesis and biventricular hypokinesis.
The patient's initial presentation was consistent with
pulmonary edema secondary to congestive heart failure, and
likewise she was continued on pressors for the majority of
her hospital course. Pressors were weaned on a number of
occasions, at which time captopril and metoprolol were used
for blood pressure control. The patient was initially
diuresed approximately 9 liters of fluid; at which time she
was judged to be at her dry weight and the Swan-Ganz catheter
was removed.
Due to a fluctuating systemic vascular resistances and
cardiac output/cardiac index, it was unsure whether an
entirely cardiogenic versus septic (or both) etiology was
responsible for the patient's hypotension. Therefore, a
Swan-Ganz catheter was refloated on [**2201-7-29**] for better
hemodynamic monitoring. The patient was diuresed an
additional 2 liters to 3 liters at that time. Although
pressors had been weaned radically throughout the hospital
course; staring on [**8-2**], the patient's blood pressure
became dopamine dependent, and dopamine was unable to be
weaned until the patient expired on [**2201-8-5**].
3. ARRHYTHMIA: Upon admission to the hospital, the patient
had a junctional rhythm with arteriovenous dissociation and
significant sinus bradycardia.
While in the catheterization laboratory, a temporary
pacemaker was placed. It was assumed that the junctional
rhythm was associated with the beta blocker and amiodarone
used, which were both stopped. The patient had an occasional
episode of ectopy which was thought to be associated with
reperfusion, and the temporary pacemaker was pulled on
hospital day four without any additional arrhythmias noted.
4. PULMONARY: The patient was admitted with a 2-day history
of increasing dyspnea on exertion which eventually led to
dyspnea while at rest. The patient was intubated in the
field by Emergency Medical Service and was initially diuresed
9 liters for an episode of acute pulmonary edema.
An initial chest x-ray showed signs of left lower lobe
consolidation, and given the field intubation the patient was
started on empiric therapy for presumed aspiration pneumonia.
Her pulmonary mechanics improved throughout the first three
hospital days, and she was weaned from the ventilator and
extubated on [**2201-7-21**].
The following day, the patient developed a hypertensive
episode with systolic blood pressures in the 240s, and she
dropped her oxygen saturation. Her PO2 pressure was in the
low 50s. It was assumed that an episode of acute pulmonary
edema had occurred and the patient was temporarily managed on
intravenous nitroglycerin as well as a nonrebreather face
mask.
Her pulmonary status continued to deteriorate, and she was
electively reintubated on [**2201-7-23**]. By chest x-ray, the
known pleural effusion from the previous admission appeared
to have increased in size, and the effusion was tapped on
[**7-24**]; which indicated a purely transudative fluid.
By [**7-27**], chest x-rays indicated a collapse of the left
lower lung lobe. By [**2201-7-28**], the patient's bilateral
pulmonary infiltrates had increased in size, and a diagnosis
of acute respiratory distress syndrome was made.
The Pulmonary team was consulted, and a bronchoscopy with
bronchoalveolar lavage was performed. The bronchoscopy
showed very collapsible airways with thick mucous plugging in
the left lower lobe and thick secretions diffusely. There
were no endobronchial lesions. After the bronchoscopy, the
patient was maintained on an increased positive
end-expiratory pressure to prevent airways from collapsing.
However, the positive end-expiratory pressure was unable to
be weaned much lower than 12.5, and the patient had a
pressure support requirement of at least 10 without the PO2
falling below 60.
Staring on [**2201-8-2**], the patient's pulmonary mechanics
began to deteriorate, and her peak inspiratory pressures
began to rise into the 50s and plateau pressures rose into
the 60s. It was determined that the acute respiratory
distress syndrome was not improving, and the patient was
started on high-dose steroids.
By [**2201-8-4**], it appeared that pulmonary function was not
improving, and she was switched to pressure control
ventilation; however, she was unable to pull consistent large
tidal volumes. Her oxygen requirement increased, and she was
unable to be weaned from an FIO2 of 70%.
5. INFECTIOUS DISEASE: On presentation to the Coronary Care
Unit, the patient had a temperature of 105. Given recent
surgery, there was a concern for mediastinitis, and
Cardiothoracic Surgery was consulted who recommended a CT
scan of the chest once the patient was stable.
Given the high likelihood of aspiration pneumonia, the
patient was empirically started on ceftazidime, vancomycin,
and Levaquin. Her antibiotic regimen was changed after a
sputum culture on [**7-22**] and [**7-23**] grew out Pseudomonas
plus Enterobacter. She was continued on a 21-day course
which included ciprofloxacin, ceftazidime/imipenem.
The bronchoalveolar lavage showed stenotrophomonas
maltophilia which was started on Bactrim for a 21-day course.
Given her diminished systemic vascular resistance and high
cardiac output and index, there was concern for sepsis, and
the blood cultures were taken from the patient on
approximately 10 separate occasions which all were negative
for growth.
Despite the antibiotic regimen for aspiration pneumonia, the
patient continued to have fevers ranging from 101 to 103
consistently from the date of admission until [**2201-8-1**].
Infectious Disease was consulted, and appropriate changes
were made to her antibiotic regimen. The fevers defervesced
after initiation of Bactrim for stenotrophomonas as well as
vancomycin for a stage II decubitus ulcer on the patient's
back.
6. NEUROLOGY: During the patient's period of extubation
(between [**7-21**] and [**7-23**]), sedation was completely
weaned, and the patient was very agitated and fairly
nonresponsive. She would follow only occlusion commands but
was never completely coherent in speech or purposeful
movements. She was resedated during the time of reintubation
on [**7-23**]. Sedation was weaned again on [**2201-7-29**], and
for the following 48 hours the patient was completely
nonresponsive; would not respond to sternal rub, was unable
to follow commands, had a positive Babinski bilaterally, and
a weak gag reflex. Therefore, Neurology was consulted.
During Neurology's assessment (on [**2201-7-31**]), the patient
became hemodynamically unstable. Due to agitation leading to
hypertension, it was determined that sedation would have to
be restarted. The patient was continued on sedation for the
remainder of her hospital stay and for comfort measures.
7. HEMATOLOGY: The patient's hematocrit fell from 46 on
admission to a low of 26. She received 3 units of packed red
blood cells throughout her hospital course. Her platelets
fell to a low of 100, and she was found to be heparin-induced
thrombocytopenia antibody positive. On [**2201-7-24**], all
heparin was stopped and platelets rebounded. A DIC panel was
negative.
8. FLUIDS/ELECTROLYTES/NUTRITION/GASTROINTESTINAL: The
patient with mild transaminitis. A right upper quadrant
ultrasound was performed which was unchanged from [**2201-6-27**]. Hyponatremia developed in the last week which was
thought to be related to congestive heart failure.
Hyponatremia was treated with a concentration of intravenous
fluids. The patient was intermittently on tube feeds
throughout her hospital course; however, high residuals were
noted near the end of her hospital course. Red wine was used
to improve gastroparesis; however, tube feeds were unable to
be continued at goal at the end of her hospital course.
9. SOCIAL WORK: An initial family discussion occurred on
[**2201-8-2**]; at which time the patient's four children
agreed on pursuing aggressive diagnostic and therapeutic
interventions. As the patient's condition did not improve, a
second discussion was held on [**2201-8-1**]; at which time the
family changed the patient's code status from full code to do
not resuscitate.
On [**2201-8-5**], after the patient's pulmonary mechanics
continued to deteriorate and there was little sign that
pulmonary or neurologic condition would improve, the
patient's family decided to withdraw support, as this was
consistent with her wishes.
At 1820 on [**2201-8-5**], the patient was extubated and all
medication drips were stopped except for morphine sulfate.
The patient's four children were present after extubation.
At 1845 the patient oxygen saturation had fallen into the low
70s, and she became bradycardic to the 30s with continuation
of no electrical activity noted on the monitor.
The patient was examined by medical doctor and found to have
no pulses, respirations, with fixed dilated pupils. The
patient was pronounced dead at 1845.
DIAGNOSES AT THE TIME OF DEATH:
1. Acute respiratory distress syndrome.
2. Aspiration pneumonia.
3. Coronary artery disease; status post 4-vessel coronary
artery bypass graft and two bypass vessel stenting.
4. Cardiac arrest.
5. Respiratory arrest.
6. Cardiogenic shock.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2201-8-13**] 19:20
T: [**2201-8-18**] 11:30
JOB#: [**Job Number 100478**]
ICD9 Codes: 4280, 5070, 0389
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5797
}
|
Medical Text: Admission Date: [**2133-4-28**] Discharge Date: [**2133-5-7**]
Date of Birth: [**2051-10-23**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
confusion, fall
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
81 year old man with CAD s/p CABG, AF s/p pacemaker, CVA,
dementia presented to the Emergency Department from nursing home
with 1 day of increasing confusion and a fall. Per daughter
patient had fallen in bathroom. Found wearing only a towel--had
apparently been using toilet; further details unknown. Pt had
been off home medications Initial evaluation was unremarkable
with normal vital signs; laboratories only notable for mild
leucocytosis. Anticipated that he would be returned to the
nursing home.
Soon thereafter, the patient was found to be unresponsive and
cyanotic. Code called. Pt initially in PEA and then in VF
arrest. Shocked once and given one round of epinephrine and of
atropine. Pt intubated. BP and P reportedly returned. Shortly
thereafer the patient went again into VF arrest. Shocked once
and received one round of epinephrine and atropine. Pulse and
pressure returned. Central line (R IJ) placed. Cooling protocol
initiated. Pt did not require pressors.
VBG on vent 7.32/46/83/25, lactate 2.3. Chest X-ray
unremarkable. CTA without evidence of PE or dissection. Bedside
echo performed by cardiology fellow revealed akinesis of
anterior wall.
Past Medical History:
- ECHO [**2131**]: EF 55-60%, abnormal septal motion, mild enlargement
of atria bilaterally, moderate TR and MR. LV wall thickness
normal. LV slightly dialated. No other focal wall motion
abnormalities.
- cath [**2126**]: 80% lesion OM, 85% LAD mid, large intermedius with
80% proximal, 90% proximal LCx, dominant RCA with 50% ostial and
proximal.
- CABG (LIMA to LAD, SVG to D1, SVG to ramus), post operative
course c/b thyroid storm and bilateral pleural effusions.
Reportedly taken for CABG after new "block" noted on EKG. Pt
without chest pain
- Dementia, on aricept
- Atrial fibrillation s/p pacemaker placement in [**2123**], then in
[**2129**], [**Company 1543**]
- Status post L carotid endarectomy for severe stenosis;
however, no history of CVA per daughters.
- amio-induced thyroiditis
- afib s/p cardioversion [**2126**]
- rapid ventricular rhythms
- hx of PEG tube
- left foot drop
- perineal nerve damage [**2126**]
- mild hypercholesterolemia
- exercise mibi [**2126**] - moderate ischemia in LCx or RCA. EF was
50% then
- 50+ year smoking history
- hemorrhagic effusion
- sick sinus requiring DDD pacing in [**2123**]
Social History:
Recently moved by daughters from [**Name (NI) 108**] to Social history is
significant for tobacco use for several years. There is, per
daughter, a history of alcohol abuse--less use in recent year.
His health care proxy is his daughter [**Name (NI) **] [**Name (NI) 28221**].
Family History:
Family history is non-contributory
Physical Exam:
Admission:
VS: T 92.3 ( cooling protocol), BP 113/72 on 0.48 levophed , HR
70-80 , RR 14, O2 100% on
Ventilator settings: AC TV 500 RR 16 FiO2 100 PEEP 5
Gen: Intubated, sedated, paralyzed
HEENT: NCAT. Sclera anicteric. Pupils pinpoint reactive.
Mouth: Dry oral mucosa, poor dentition.
Neck: Supple with JVP of 10 cm on L. R IJ in place, L
endarectomy scar
CV: Irregularly irregular. Heart sounds somewhat distant. Could
not appreciate murmur.
Chest: Decreased breath sounds. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Rectal: Tone absent, guaiac negative.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Radial 1+; Femoral 2+ without bruit; DP dopplerable
(monophasic)
Left: Radial thready; Femoral 2+ without bruit; DP dopplerable
Pertinent Results:
CT C-SPINE W/O CONTRAST [**2133-4-28**] 9:00 AM
FINDINGS: The alignment is normal. There is no evidence of
fracture. There is cerumen in both external auditory canals,
suggest clinical correlation for hemotympanum. The vertebral
body heights are preserved. There is ossification of the
posterior longitudinal ligament. There are subchondral cysts and
osteophytes throughout the cervical spine both anteriorly and
posteriorly. There is some foramenal narrowing due to
uncovertebral and facet joint hypertrophy at C2-3 (right >
left), C3-4 (left > right), C4-5 (left > right) and bilaterally
at C5-6. There are dystrophic changes anterior to the spinous
processes, causing very mild canal stenosis at C4-C5. There is
no prevertebral soft tissue swelling. There are blebs at the
left lung apex and paraseptal emphysema.
IMPRESSION: No fracture. Multilevel degenerative change as
detailed above. Blebs at the left lung apex.
.
CT HEAD W/O CONTRAST [**2133-4-28**] 8:49 AM
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect or edema. There is marked cerebral atrophy. There is
thickened mucosa in bilateral maxillary sinuses. There is small
vessel ischemic disease. There is no evidence of fracture.
IMPRESSION: No acute intracranial hemorrhage.
.
CT Head w/ Contrast [**2133-5-5**]
FINDINGS: There is no evidence of intracranial hemorrhage,
hydrocephalus, shift of normally midline structures, edema, or
large vascular territory infarction. Prominence of the sulci and
ventricles is again noted, consistent with age-related
involutional changes. Regions of periventricular white matter
hypoattenuation are consistent with small vessel ischemic
disease. Hypodensity in the right basal ganglia is consistent
with old lacunar infarct. Calcifications are again noted in the
cavernous carotid arteries. No fractures are seen. Mild mucosal
thickening is again noted in bilateral maxillary sinuses.
IMPRESSION: No evidence of acute intracranial process. Mild
bilateral maxillary sinus mucosal thickening again noted.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2133-4-28**] 3:34 PM
CT OF THE CHEST WITH IV CONTRAST: An endotracheal tube is noted.
The heart is enlarged. Coronary artery calcifications are seen.
The pulmonary artery is normal in size without filling defects
to suggest pulmonary embolism. The ascending aorta demonstrates
calcifications within the wall without evidence of dissection.
There is a left apical paraseptal bullae. Bilateral dependent
atelectasis is identified. There are small pleural effusions,
left greater than right. There is no pneumothorax or
consolidation. There is no mediastinal, hilar, or axillary
lymphadenopathy.
This study is not designed for evaluation of the abdomen,
however, the visualized portions of the upper abdomen are
unremarkable. The patient is status post CABG.
No suspicious lytic or sclerotic lesions are identified.
Extensive degenerative changes of the spine are identified.
IMPRESSION: No evidence of pulmonary embolism or thoracic aortic
dissection.
.
Echo:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. There is
severe global left ventricular hypokinesis (LVEF = <20 %) with
contraction best at the base of the heart. No LV apical thrombus
is seen. The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe left ventricular
systolic dysfunction with contraction best at the base of the
heart (?stress-induced cardiomyopathy vs. large LAD territory
infarct). Mild right ventricular dilation with mild global
hypokinesis. Moderate to severe mitral regurgitation.
.
Cardiac Cath:
COMMENTS:
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had an 80% ostial stenosis.
--the LAD had a 50% mid-vessel stenosis. D1 was occluded and
filled via
SVG graft.
--the LCx had a 70% proximal lesion, and a subtotally occluded
high OM1
which fills via SVG with no significant disease.
--the RCA had <50% proximal disease.
2. Arterial conduit angiography revealed the LIMA-LAD graft to
be
atretic. The SVG-Diag-OM1 Y-graft was normal.
3. Limited resting hemodynamics revealed normal systemic
arterial
systolic pressures, with SBP 108 mmHg.
4. Successful ptca and stenting of the ostial Left main
coronary artery
with a 4.0x15mm vision stent which was postdilated to 4.5mm.
Final
angiography revealed 0% residual stenosis, no angiographically
apparent
dissection and timi 3 flow. The patient left the lab in
unchanged
condition and pain free.
FINAL DIAGNOSIS:
1. Native three-vessel coronary artery disease including
significant
left main disease.
2. Patent SVG-Diag-OM1 Y-graft
3. Atretic LIMA-LAD
4. Successful bare metal stenting of the left main coronary
artery.
.
EEG [**5-5**]
IMPRESSION: This is an abnormal portable EEG due to the low
voltage,
disorganized, and slowed background which was interrupted by
bursts of
generalized mixed frequency slowing. This constellation of
findings is
consistent with a mild encephalopathy suggesting dysfunction of
bilateral subcortical or deep midline structures. Medications,
metabolic disturbances, infection, and anoxia are among the
common
causes of encephalopathy. There were no areas of prominent focal
slowing although encephalopathic patterns can sometimes obscure
focal
findings. There were no epileptiform features. The superimposed
beta
frequency rhythm likely reflects concomitant medication effects
from
benzodiazepine or barbiturate administration. No electrographic
seizure
activity was noted.
.
CXR [**5-6**]:
FINDINGS: In the interim, there is increase in the size of the
heart, which is mild-to-moderate. Lesser pulmonary edema in both
lungs is noted. Right upper lobe opacity likely aspiration has
not changed. In the lung bases, there are bilateral
small-to-moderate pleural effusions with adjacent bibasilar
atelectasis. A feeding tube distal tip is out of view on this
image. No change in the lead position of the left-sided
pacemaker.
IMPRESSION:
1. Persistent right upper lobe opacity likely aspiration.
2. Lesser pulmonary edema bilaterally.
3. Persistent small bilateral pleural effusion and atelectasis.
4. Worsening cardiomegaly.
.
ABG
[**2133-5-6**] 09:10AM ART 7.34/ 54 / 176
[**2133-5-6**] 05:12AM ART 7.31/ 59 / 242
Brief Hospital Course:
81 year old gentleman admitted to CCU status post VF arrest, on
a ventilator, completed cooling protocol, continuing with
hemodynamic instability.
.
#) Hypotension: Patient was intubated, and on cooling protocol
at presentation. he was on levophed and maintained blood
pressures 80-85/40's. Given recent echo findings of LVEF being
only 20%, it was thought that the patient may have been in
cardiogenic shock. He was therefore started on dobutamine.
However, he had no pulmonary edema, which is inconsitent with
cardiac shock. He also had a large fluid requirement, receiving
over 11 liters of fluid over the first two days. Given his
tenuous hemodynamic status, a PA catheter was placed on [**4-30**]. He
was found to have a wedge of 20 and CI 3.6 and so was deemed to
not be in cardiogenic shock. His dobutamine was weaned off, and
his blood pressures were maintained with further IVF. As the
patient's cultures were negative, no fever and no leukocytosis,
it was not thought that he was in septic shock. As his blood
pressures remained stable, he was switched to maintenace fluids
and required no futher fluid resuscitation.
.
#) VF arrest. Patient was immediately placed on cooling
protocol. He had positive cardiac enzymes, and so was there
thought to have suffered an ischemic event. Given his new wall
motion abnormalities, with anterior and apical hypokinesis, he
was begun on IV heparin to prevent LV thrombus formation.
Heparin was subsequently discontinued when he had persistent
bloody secretions. He underwent cardiac catheterization on
[**2133-5-1**] with stenting of the left main.
.
#) CAD/Ischemia: Pt s/p CABG 9yrs ago. Presented with elevated
cardiac biomarkers. he was continued on IV heparin, aspirin, and
a statin. He underwent cardiac catheterization on [**2133-5-1**] with
stenting of the left main. He was started on Plavix and required
a dobhoff NG tube for Plavix administration due to aspiration
concerns. Heparin was subsequently discontinued when he had
persistent bloody secretions. Metoprolol was added once he was
found not be be in cardiogenic shock and as his blood pressure
stabilized.
.
#)Mental Status: The patient's mental status was carefully
monitored after extubation. He had persistant depressed mental
status w/o any purposeful movements. Three days after
extubation, he briefly appeared to be clearing, possibly saying
a few unitelligable words. However, his mental status then
declined - he was responsive only to pain, w/o purposeful
movements but with brainstem reflexes. A repeat head CT showed
no acute pathology. An EEG was performed showing encephalopathy.
.
#)Pneumonia: On [**5-4**], a new RUL infiltrate was noted on CXR. He
was started on Vanc and Zosyn for Aspiration vs ventilator
acquired PNA. Follow up CXR showed evolution of the PNA. The
patient then developed a fever and leukocytosis with left shift.
He was maintained on Vanc and Zosyn until the family determined
that he should be [**Month/Year (2) 3225**].
.
# Respiratory failure: On [**4-30**], the patient was noted to be
doing well with ventilator weaning, tolerating pressure support
with RISBI 99. Sedation was weaned, and the patient was
sucessfully extubated. Initially the patient was ventilating
well but requiring high flow O2 on shovel mask. He continued to
require O2, frequent suctioning for copious secretions and was
persistantly tachypnic. On [**5-6**], his respiratory status
worsened; he appeared to be tiring, taking shorter, shallower
breaths. An ABG revealed respiratory acidosis with acute CO2
retention. The family was contact[**Name (NI) **]. Based on a conversation
with the [**Hospital 228**] health care proxy, the patient was made [**Name (NI) 3225**].
He was started on a morphine drip to decrease dyspnea, and all
other medications were stopped.
.
#) S/p fall. Head CT unremarkable. C-spine without fracture,
cleared in ED.
.
#) Code status: On arrival, the patient had been rescusitated.
The family subsequently decided that he should be DNR/DNI. As
his condition worsened, he family further decided to proceed
with comfort measures only. The patient died on [**2133-5-7**].
Medications on Admission:
Risperdal .5mg PO qHS
Depakote 250mg PO daily
Digitek .125mg Po Daily
Folic Acid 1mg PO daily
Prilosec 20mg Po daily
Metoprolol 25mg PO twice daily
simvastatin 40mg PO qhs
thiamine 100mg Po daily
aricept 10mg qHS
Celexa 10 mg daily
Tylenol 325mg PO three times daily
.
ALLERGIES: Amiodarone
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
PEA arrest.
Ventricular Fibrillation
Myocardial Infarction
Discharge Condition:
expired
Discharge Instructions:
You were admitted to the hospital after being found in
Ventricular Fibrillation and cardiac arrest. You were
resuscitated.
.
Please continue to take your medications as prescribed.
.
Please call your doctor or return to the hospital if you
experience chest pain, or shortness of breath.
Followup Instructions:
N/A
ICD9 Codes: 486, 4280, 4275, 4240, 2720, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5798
}
|
Medical Text: Admission Date: [**2195-10-1**] Discharge Date: [**2195-10-12**]
Date of Birth: [**2117-3-1**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 78-year-old white male was
admitted to [**Hospital3 43992**] on [**2195-9-28**], with chest
tightness. He had increased wheezing, elevated CK enzymes,
and an electrocardiogram with ST depressions in V4-V5, and
T-wave inversions in AVL. The patient was transferred to
[**Hospital6 256**] for cardiac
catheterization.
His hematocrit at the outside hospital on presentation was
27, and he was transfused 2 U of blood.
PAST MEDICAL HISTORY: History of steroid dependent chronic
obstructive pulmonary disease. Peripheral vascular disease
with claudication. ................. sarcoma lesion on the
left foot status post radiation therapy in [**2188**]. Question of
history of prostate surgery. Status post hernia repair.
ALLERGIES: PENICILLIN.
MEDICATIONS ON ADMISSION: Diltiazem 240 mg p.o. q.d., Iron
325 mg p.o. b.i.d., Paxil 20 mg p.o. q.h.s., Ambien 10 mg
p.o. q.h.s. p.r.n., Prednisone 5 mg p.o. q.d., Combivent 2
puffs b.i.d., Advair 250/50 b.i.d.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] smoked two packs
a day for more than 40 years and quit 15 years ago. He
drinks beer occasionally.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: General: He was an elderly white male
in no apparent distress. Vital signs: Stable, afebrile.
HEENT: Normocephalic, atraumatic. Extraocular movements
intact. Oropharynx benign. Neck: Supple. Full range of
motion. No lymphadenopathy or thyromegaly. Carotids had a
bilateral thrill and were 2+. Lungs: Bilateral poor air
exchange with inspiratory and expiratory wheezing.
Cardiovascular: Regular, rate and rhythm. Normal S1 and S2.
There was a 3/6 systolic ejection murmur heard best at the
lower sternal border with radiation to bilateral carotids.
Abdomen: Soft and nontender. Positive bowel sounds. No
masses or hepatosplenomegaly. Extremities: Without
clubbing, cyanosis, or edema. Neurological: Nonfocal.
Pulses: 2+ and equal bilaterally throughout except for the
posterior tibial pulses being 1+ and equal bilaterally.
HOSPITAL COURSE: He underwent cardiac catheterization on
[**10-1**] which revealed the left ventricle at 1+ mitral
regurgitation, with an ejection fraction of 55%, normal
systolic function. The left main was satisfactory. The left
anterior descending had a 60% mid lesion, 60% major diagonal
lesion. The left circumflex had no significant disease. The
right coronary artery was small with no significant disease.
He also had some signs of severe aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**]
of 0.86 cm2, and Dr. [**Last Name (STitle) 70**] was consulted.
On [**10-5**], the patient underwent coronary artery bypass
grafting times two with LIMA to the LAD, reversed saphenous
vein graft to the diagonal, and AVR with a #21 Mosaic porcine
valve. His cross-clamp time was 91 min, total pump time 119
min.
He was transferred to the CSRU on Neo-Synephrine and
Propofol. He was extubated at night and had a stable night,
but he was started on Dopamine and was on an Insulin and
Neo-Synephrine. He was also followed by Pulmonary, and he
was treated with his steroids.
His chest tubes were discontinued on postoperative day #2,
and his drips were weaned. On postoperative day #3, he was
transferred to the floor, and his epicardial pacing wires
were discontinued. He continued to have a stable
postoperative course.
On postoperative day #7, he was discharged to rehabilitation
in stable condition.
DISCHARGE LABORATORY DATA: Hematocrit 32.5, white count
10,900, platelet count 429; sodium 137, potassium 4.1,
chloride 97, CO2 33, BUN 27, creatinine 0.8, blood sugar 97.
DISCHARGE MEDICATIONS: Lasix 20 mg p.o. b.i.d. x 7 days,
Colace 100 mg p.o. b.i.d., Potassium 20 mEq p.o. b.i.d. x 7
days, Aspirin 325 mg p.o. q.d., Combivent 1-2 puffs q.6
hours, Paxil 20 mg p.o. q.d., Advair b.i.d., Percocet [**1-22**]
p.o. q.4-6 hours p.r.n. pain, Captopril 6.25 mg p.o. t.i.d.,
Prednisone 5 mg p.o. q.d.
FOLLOW-UP: He will be seen by Dr. ................ in [**1-22**]
weeks, Dr. [**Last Name (STitle) 1270**] in [**2-23**] weeks, and Dr. [**Last Name (STitle) 70**] in six
weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2195-10-12**] 13:07
T: [**2195-10-12**] 13:23
JOB#: [**Job Number 96846**]
ICD9 Codes: 496, 4168
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5799
}
|
Medical Text: Admission Date: [**2140-4-28**] Discharge Date: [**2140-5-7**]
Date of Birth: [**2080-7-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
angiogram
History of Present Illness:
HPI: This is a 57 y/o male transferred from an OSH where CT scan
demonstrated subarachnoid hemorrhage. At approximately 10AM on
[**2140-4-26**], the patient experienced an electric shock sensation
travelling up his spine to his head while at work. The sensation
was not debilitating, but over the next several hours the
patient
developed a progressively severe headache to the point where he
had to leave work. He also began to have nausea and vomiting
that
continued throughout the day. Pt describes the headache as [**6-21**]
out of 10. He presented to his PCP [**Last Name (NamePattern4) **] [**2140-4-27**] who ordered a head
CT at the [**Hospital1 882**] ER. CT demonstrated a SAH, thus the patient
was transferred to [**Hospital1 18**] for neurosurgical evaluation. Currently
the patient notes a bifrontal headache.
Past Medical History:
PMHx: s/p cardiac stenting [**6-/2132**], s/p CABG x 2 [**10/2132**]
Social History:
Social Hx: works as an attorney, lives with wife, [**Name (NI) **] EtOH, no
tobacco
Family History:
Family Hx: multiple CVAs (sister at age 39, father in 70s,
mother
in 70s), denies family history of polycystic kidney disease,
Marfan's syndrome, or Ehlers Danlos syndrome
Physical Exam:
PHYSICAL EXAM:
O: T: 99.4 BP: 161/67 HR: 56 R: 17 98% on RA O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 mm B/L intact EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-15**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-18**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 3+ throughout
Left 3+ throughout
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger and heel to shin
Pertinent Results:
head CT from OSH at 6PM: subarachnoid hemorrhage
head CT and CTA: hyperdensity anterior to brainstem, small
degree
of hydrocephalus, no obvious aneurysm or AVM, no midline shift
[**2140-4-27**] 08:30PM GLUCOSE-98 UREA N-14 CREAT-1.1 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2140-4-27**] 08:30PM WBC-8.9 RBC-3.73* HGB-12.4* HCT-34.8* MCV-93
MCH-33.2* MCHC-35.6* RDW-13.2
[**2140-4-27**] 08:30PM NEUTS-75.2* LYMPHS-17.8* MONOS-6.2 EOS-0.4
BASOS-0.3
[**2140-4-27**] 08:30PM PLT COUNT-190
[**2140-4-27**] 08:30PM PT-13.0 PTT-24.5 INR(PT)-1.1
[**2140-4-28**]:
FINDINGS:
RIGHT COMMON CAROTID ARTERY: There is prompt flow of contrast
into the right internal and external carotid arteries. There is
normal appearance of the distal cervical, petrous, cavernous,
and supraclinoid segments of the right internal carotid artery.
The anterior and middle cerebral arteries are within normal
limits. There is no evidence of aneurysms or vascular
malformations. Evaluation of the origin of the right internal
carotid artery and distal common carotid artery is not included
on this film.
RIGHT EXTERNAL CAROTID ARTERY: There is prompt flow of contrast
through the external carotid artery and its major branches.
There is no evidence of an arteriovenous malformation.
LEFT VERTEBRAL ARTERY: The distal left vertebral artery appears
normal. There is reflux of contrast into the right vertebral
artery. The visualized basilar artery and posterior cerebral
arteries are normal. The posterior-inferior cerebellar arteries
and anterior-inferior cerebellar arteries as well as the
superior cerebellar arteries are also normal.
RIGHT VERTEBRAL ARTERY: The visualized right vertebral artery is
within normal limits. There is no evidence of stenosis. There is
prompt flow of contrast into the basilar artery and posterior
cerebral arteries which also appear normal.
LEFT EXTERNAL CAROTID ARTERY: The visualized left external
carotid artery appears within normal limits. The major branches
are also unremarkable. There is no evidence of arteriovenous
malformation or dural venous fistula
_____The distal cervical, petrous, cavernous and supraclinoid
segments of the left internal carotid arteries are normal. There
is prompt flow of contrast into the anterior and middle cerebral
arteries which demonstrate no aneurysm or vascular
malformations.
LEFT COMMON CAROTID ARTERY: The distal common carotid artery as
well as the origin of the left internal and external carotid
arteries are within normal limits.
RIGHT COMMON FEMORAL ARTERY: The visualized right common femoral
artery demonstrates no stenosis or dissection.
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] was present during the entire procedure.
Moderate sedation achieved utilizing 1.5 mg of Versed and 75 mcg
of Fentanyl.
IMPRESSION: Mr. [**Known firstname **] [**Known lastname 1637**] underwent a cerebral
angiogram which demonstrate no aneurysm or vascular
malformation.
[**2140-5-5**]:
CT HEAD: Compared to the CT of [**2140-4-27**], there has been interval
resolution of hyperdense blood in the prepontine cistern. There
is no new focus of hemorrhage seen. Mild prominence of the
ventricles is unchanged. There is no shift of normally midline
structures, or evidence of acute major vascular territorial
infarction. No fracture or bony destruction is seen within the
visualized calvarium. The paranasal sinuses and mastoid air
cells are well aerated.
CTA: Compared to the CTA of [**2140-4-27**], there is apparent diffuse
decrease caliber throughout the anterior and posterior
circulation. In the absence of subarachnoid hemorrhage, this
appearance is felt to be likely due to technical issues rather
than due to diffuse vasospasm. No focal narrowing is noted.
IMPRESSION:
1. Interval resolution of prepontine subarachnoid hemorrhage,
without interval development of new intracranial hemorrhage.
2. CTA demonstrates diffuse decreased caliber throughout the
intracranial arteries. In the absence of a subarachnoid
hemorrhage, this is felt to be due to technical factors rather
than representing diffuse vasospasm. If there is concern for
vasospasm, angiography would be recommended for further
evaluation.
Brief Hospital Course:
The patient was admitted after having a spontaneous SAH. He had
been on aspirin prior to admission so he had a platelet
transfusion on the day of admission. He had an angio by [**Doctor Last Name **]
which was neg for aneurysm. The patient continued to have
headaches while he was in the ICU but remained neurologically
stable the entire time. On [**2140-5-1**] he had a low grade temp of
100.8 and developed a fever of 101.5 on [**2140-5-4**]. He had blood
cultures sent which were still pending at the time of discharge.
The urine culture from the same day was negative. On [**2140-5-3**] the
patient had an MRI of the C/T spine which was negative for AVM
but there was spinal stenosis - discussed finding with the
patient.
Mr. [**Known lastname 1637**] was transferred to the floor after being in the ICU
for several days. He continued to be neurologically stable. On
[**2140-5-6**] he had a CTA which showed "technical vasospasm" but the
SAH was resolving and clinically he had no signs of spasm. He
was afebrile, ambulating without difficulty, and his pain was
well controlled prior to discharge. Dr. [**Last Name (STitle) **] felt that he did
not need to be sent home with dilantin since he had no seizures
and since his head CT showed resolving SAH prior to discharge.
His pharmacy was notified that he needed 10 more days of
nimodipine. Mr. [**Known lastname 1637**] was neurologically intact on the day of
discharge.
Medications on Admission:
Medications prior to admission: lopressor 12.5 mg [**Hospital1 **], lipitor
10', ASA 325', lisinopril 20, fish oil 1000 mg, MVI
Discharge Medications:
1. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4-6H () as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed: No driving while on narcotics.
Disp:*40 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
8. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 10 days: You need to continue for 10 more days.
Disp:*120 Capsule(s)* Refills:*0*
9. Outpatient Physical Therapy
Please allow this patient to have therapy for bilateral
tightening of his hamstrings.
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SUBARACHNOID HEMORRHAGE
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
Followup Instructions:
Please call ([**Telephone/Fax (1) 88**] on Tuesday to schedule an appointment
with Dr. [**First Name (STitle) **] for an angiogram in about 4 weeks.
If you have any concerns please call Dr.[**Name (NI) 9034**] office
[**Telephone/Fax (1) 1669**].
Completed by:[**2140-5-7**]
ICD9 Codes: 4019
|
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