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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 800
} | Medical Text: Admission Date: [**2121-6-26**] Discharge Date: [**2121-7-4**]
Date of Birth: [**2071-7-18**] Sex: M
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: This is a 49-year-old gentleman
who has a history of aortic stenosis with increased dyspnea
on exertion over the past year with associated dizziness and
lightheadedness. Cardiac catheter on [**2121-6-18**] showed left
ventricular end-diastolic pressure of 20, an aortic valve
area of 1.3, and a left ventricular ejection fraction of 72%.
Catheterization also revealed no significant coronary artery
disease. The patient was then scheduled for an elective
aortic valve replacement with Dr. [**Last Name (STitle) 1537**] at a later date,
however, on [**2121-6-25**], the patient noticed chest pain and
shortness of breath and presented to the Emergency
Department. He was found to be in rapid atrial fibrillation
and at that time he was treated with diltiazem and discharged
home. The patient was admitted on [**2121-6-26**] to the cardiac
surgery service in preparation for aortic valve replacement.
PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2.
Hypertension.
MEDICATIONS: Pravachol 10 mg p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: His physical examination upon
admission was unremarkable with the exception of a grade 3/6
systolic ejection murmur.
LABORATORY DATA: His EKG upon admission was sinus rhythm
with no acute ischemic changes. His chest x-ray upon
admission was also within normal limits.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2121-6-27**] where he underwent an aortic valve replacement
with a limited access incision by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. He had a
25-mm CarboMedics mechanical valve placed.
Postoperatively he was transported from the operating room to
the cardiac surgery recovery unit in good condition. He was
weaned from the mechanical ventilator and extubated later on
the day of surgery.
On postoperative day one the patient was noted to have some
atrial fibrillation which was treated with IV diltiazem
through the course of the day. He had been out of bed and
was beginning to ambulate.
On postoperative day two the patient had since converted back
to normal sinus rhythm on the diltiazem. This was
transitioned to Lopressor and the diltiazem was ultimately
discontinued. He was started on Coumadin on postoperative
day two, and transferred out of the intensive care unit to
the telemetry floor. The patient began to progress with
cardiac rehabilitation, increasing ambulation and pulmonary
toilet, and had tolerated that advancement in his activity
level well. The patient had a subsequent episode of atrial
fibrillation with a ventricular response in the 120s the
following day on [**2121-7-1**], which was treated with IV
Lopressor, and he has since converted back to normal sinus
rhythm. He had been started on a heparin drip at that point
due to his atrial fibrillation as well as having a mechanical
aortic valve placed. He had been maintained on the telemetry
floor over the next few days on an IV heparin drip, with a
PTT in the 50-70 range while increasing his daily Coumadin
dosing to get him to a therapeutic level for his mechanical
aortic valve. He has remained in sinus rhythm with good
hemodynamics, and he is now ambulating independently, has not
had any other difficulties during his postoperative course,
and is ready to be discharged today, [**2121-7-4**].
CONDITION ON DISCHARGE: Good; neurologically he is
completely intact. His lungs are clear to auscultation
bilaterally. His heart is regular rate and rhythm. His
abdomen is benign and he has no peripheral edema.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o. q.d. This is to be continued until
stopped by the patient's primary cardiologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 13175**] at his discretion.
2. Lasix 20 mg p.o. b.i.d. x 5 days.
3. Potassium chloride 20 mEq p.o. b.i.d. x 5 days.
4. Ibuprofen 400 mg p.o. q. 6 hours p.r.n. pain.
5. Percocet 5/325, 1-2 tablets p.o. q. 4-6 hours p.r.n. pain.
6. Coumadin 7.5 mg today, [**2121-7-4**], [**2121-7-5**], and [**2121-7-6**].
The patient is to then report to Dr.[**Name (NI) 51522**] office on
Monday, [**2121-7-7**] to have an INR checked and to have his
Coumadin dosed accordingly. His target INR is 2.5 to 3 and
this has already been discussed with the office staff from
Dr.[**Name (NI) 51523**] office.
7. Lopressor 75 mg p.o. b.i.d.
8. Protonix 40 mg p.o. q.d.
DISCHARGE DIAGNOSES:
1. Aortic stenosis status post aortic valve replacement.
2. Postoperative atrial fibrillation.
CONDITION ON DISCHARGE: Good.
FOLLOW-UP PLANS: The patient is to follow up with his
primary care doctor in [**11-28**] weeks, Dr. [**Last Name (STitle) 9969**]. The patient is
also to follow up with his primary cardiologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 13175**], in [**12-30**] weeks, and the patient is to follow up with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in approximately one month for postoperative
check.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2121-7-4**] 11:16
T: [**2121-7-4**] 11:33
JOB#: [**Job Number 51524**]
ICD9 Codes: 4241, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 801
} | Medical Text: Admission Date: [**2171-1-24**] Discharge Date: [**2171-1-26**]
Date of Birth: [**2103-9-18**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy with polypectomy site clipping [**2171-1-25**]
History of Present Illness:
67 y/o M CAD who presents with bright red blood per rectum.
Patient had a colonoscopy [**2171-1-17**] and underwent a cecum
polypectomy (final pathology adenoma). He restarted his
Aspirin/Plavix on [**1-19**] and had one episode of bloody stool on
the morning of admission ([**1-24**])with several clots. and
consequently presented to the ED.
Past Medical History:
- CAD. Last catheterization was [**5-/2170**], which showed one-vessel
disease of the main coronary artery of 30 to 50%. There was
diffuse narrowing. He also had two patent stents in his LAD.
His circumflex showed 70% stenosis which underwent pressure
wire, but no new stent was placed. Cath [**2169-11-15**] mid-LAD had a
80% lesion at the
D2 which was small and had an ostial 70% lesion. The Lcx had a
60-70%
ostial lesion. Two DES placed in the mid-LAD.
- Prostate cancer status post brachytherapy, followed by Dr.
[**Last Name (STitle) **] in radiation oncology. Last visit was in [**10-8**], at which
time PSA was normal.
- External hemorrhoids
- Erectile dysfunction
- Hypertension
- Low back pain for status post lumbar surgery at [**Location (un) **]
[**Location (un) 1459**]
approximately 12 years ago.
Social History:
He lives in [**Hospital1 392**], [**State 350**]. He is married and his wife
works as a clerk. He retired from his job as an airline
mechanic in [**2160**]. He has history of 60 pack years tobacco use -
he quit 30 years ago smoked two packs a day. Denies any illicit
substances. He has no drug use.
Family History:
His father had cirrhosis at age 47. His mother had a stroke in
her 90s. He has three brothers. Two brothers with carotid
stenosis and CAD. One brother is healthy. He has three healthy
children and numerous grandchildren who are also healthy. No
history of GI cancer.
Physical Exam:
on admission to the ICU:
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - pale conjunctiva, NC/AT, PERRLA, EOMI, sclerae
anicteric, dryMM
NECK - no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA b/l
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-3**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
[**2171-1-24**] 04:25PM Hct-37.2*
[**2171-1-24**] 09:58PM Hct-33.6*
[**2171-1-25**] 04:23AM Hct-35.7*
[**2171-1-25**] 07:44AM Hct-34.4*
[**2171-1-25**] 01:29PM Hct-34.1*
[**2171-1-25**] 09:14PM Hct-33.7*
[**2171-1-26**] 05:30AM Hct-34.0*
.
[**2171-1-24**] 04:25PM
WBC-6.8 Plt Ct-167
[**2171-1-25**] 04:23AM BLOOD
WBC-9.4 Plt Ct-127*
[**2171-1-25**] 01:29PM
WBC-6.3 Plt Ct-122*
[**2171-1-25**] 09:14PM
WBC-6.4 Plt Ct-115*
[**2171-1-26**] 05:30AM
WBC-5.8 Plt Ct-111*
.
[**2171-1-26**] 05:30AM
Glucose-95 UreaN-10 Creat-0.9 Na-143 K-3.8 Cl-113* HCO3-25
AnGap-9
[**2171-1-25**] 04:23AM
ALT-16 AST-25 LD(LDH)-297* AlkPhos-43 TotBili-2.5* DirBili-0.2
IndBili-2.3
[**2171-1-25**] 04:23AM
Hapto-94
Brief Hospital Course:
#Acute blood loss anemia from lower GI bleed: Patient's
presenting vitals were T 97.1, BP 114/77, HR 58, RR 20, Sa 99%.
Patient's HCT was found to be 37 from baseline 41. Patient was
initially admitted to the general medicine floor with plan to
prep overnight for colonoscopy in the morning. Aspirin and
plavix were stopped and his anti-hypertensives were held.
.
After starting prep he had a large bright red bloody bowel
movement and became hypotensive with a blood pressure of
80/palpable. His repeat hematocrit was 33 (from 37) Patient was
started on 1 L with mild improvement in BP (SBP 104). Given the
concern for inability to control the site of bleeding, he was
transferred to the MICU to complete the prep and have a
colonoscopy.
.
In the ICU, the patient received a total of 3 units of PRBCs.
His HCT did not increase appropriately but did increase to 35.7.
He had a colonoscopy the next morning by GI who found
ulceration with 2 visible vessels at prior polypectomy site. 2
clips were placed for hemostasis, they also saw small rectal
ulcers; grade 2 internal hemorrhoids.
.
His HCTs were checked q4 hours for 24 hours and remained stable
33-35. He tolerated clears and then on the morning of diacharge
ate a full breakfast. He had no more bowel movements, no
abdominal pain and he remained normotensive without any more
fluids or blood products. His atenolol and aspirin were
restarted on the day of discharge. He was instructed to restart
his lisinopril on the day after discharge (Sunday) and come to
the clinic for a CBC on Monday. After the results of his CBC,
if HCT is stable, he was instructed to restart his plavix after
discussion with his PCP and his cardiologist. His cardiologist
wand PCP were not [**Name9 (PRE) 12304**] during his admission but an email was
sent to let them know the patient was off his plavix (had DES in
[**2168**]).
.
# Indirect Hyperbilirubinemia: Patient with T. Bili of 2.5 and
I. Bili of 2.3, LDH was increased and platelets were decreased
so there was concern for hemolysis or DIC but it was then
realized that these were checked on a hemolyzed sample of blood
which would falsely elevate these tests. Haptoglobin was normal
and reticulocyte count was 1.8.
.
# Thrombocytopenia: Platelets trended down from 167 to 111. It
was felt most likely dilutional from IVF and packed RBCs. The
patient did not receive any heparin products. He will have an
outpatient CBC on Monday [**1-28**].
.
# h/o CAD s/p DES: No chest pain during admission. EKG was
unchanged. As above, Aspirin and plavix were held, aspirin
restarted. Patient was continued on his simvastatin.
.
# HTN: Patient's anti-hypertensives were held during admission
given hypotension and GI bleed.
.
Medications on Admission:
- ATENOLOL - 25 mg by mouth daily
- CLOPIDOGREL [PLAVIX] - 75 mg Tablet by mouth once a day do NOT
stop this medication without to speaking to your cardiologist
- LISINOPRIL - 10 mg by mouth once a day
- NITROGLYCERIN - 0.4 mg prn as needed for chest pain
- SIMVASTATIN - 40 mg Tablet by mouth once a day
- ASPIRIN - 81 mg by mouth daily
- OMEGA-3 FATTY ACIDS-VITAMIN E 1,000 mg Capsule - 2 Capsule(s)
by mouth once a day
** Currently on hold due to hypotension: HYDROCHLOROTHIAZIDE -
25 mg by mouth daily
** Currently on hold ISOSORBIDE MONONITRATE - 30 mg Sustained
Release 24 hr by mouth daily
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Omega-3 Fatty Acids-Vitamin E 1,000 mg Capsule Sig: Two (2)
Capsule PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please restart this medication today upon arriving home.
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet
Sublingual once a day as needed for chest pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastrointestinal bleeding after polypectomy
Discharge Condition:
Mental status intact, ambulating freely without difficulty.
Discharge Instructions:
You were admitted with bleeding from your rectum and blood in
your stool This was due to bleeding from your recent polyp
removal in your colon. You were transfused 3 units of blood
cells. The GI specialists put clips on your prior polyps sites
and there was no further evidence of bleeding.
You need to get a repeat blood test done on Monday, [**1-28**] to
check your blood levels. This can be done at your primary care
office.
You should not take your Clopidogrel (Plavix) until instructed
to do so.
Please continue your prior outpatient medications.
Please keep all your outpatient appointments.
Followup Instructions:
You should call and schedule a follow-up appointment for the
next 1-2 weeks post-discharge with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Her
office can be contact[**Name (NI) **] at [**Telephone/Fax (1) 250**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 2851, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 802
} | Medical Text: Admission Date: [**2126-10-3**] Discharge Date: [**2126-10-10**]
Date of Birth: [**2054-8-10**] Sex: F
Service: NEUROSURGERY
Allergies:
Morphine / Codeine
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Headache and Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72F with MS [**First Name (Titles) **] [**Last Name (Titles) **] for h/o DVT and PE has had progressive
headche today with associated nausea and vomiting. Presented to
OSH with CT showing left cerebellar hemorrhage. Pt received Vit
K for INR 5.5 and was transferred to [**Hospital1 18**] ED.
Past Medical History:
MS,HTN, incontinence,inc chol,neuropathy,non-healing L ankle
wound, fx R ankle
Social History:
Hx:lives with husband, [**Name (NI) 269**], nonsmoker, no EToH
Family History:
Noncontributory
Physical Exam:
O: T: 97.5 BP: 186/50 HR:83 R18 O2Sats92
Gen: WD/WN, comfortable, NAD, drowsy but easily arousable
HEENT: Pupils:L 5, R 4.5 both briskly reactive EOMs full
Neck: Supple.
Extrem: Warm and well-perfused. birthmark left arm
Neuro:
Mental status: Awake though slightly drowsy, trying to be
cooperative with exam, normal affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils round and reactive to light, 5mm on left and 4.5 on
right.
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. antigravity all 4 extremities, cast on right LE
Sensation: Intact to light touch bilaterally.
Coordination:unable to assess
** Upon Discharge **
AOx3, PERRL, EOM intact, face symm, tongue midline. MAE [**3-26**]
except RLE in cast- + antigravity
Pertinent Results:
[**2126-10-4**] 02:11AM BLOOD WBC-10.2 RBC-3.22* Hgb-9.9* Hct-30.1*
MCV-94 MCH-30.9 MCHC-32.9 RDW-14.8 Plt Ct-324
[**2126-10-4**] 02:11AM BLOOD Plt Ct-324
[**2126-10-2**] 11:00PM BLOOD Neuts-90.1* Lymphs-7.6* Monos-1.7*
Eos-0.5 Baso-0.1
[**2126-10-4**] 02:11AM BLOOD Glucose-84 UreaN-44* Creat-2.0* Na-144
K-4.9 Cl-113* HCO3-23 AnGap-13
[**2126-10-4**] 02:11AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
[**2126-10-3**] 02:27AM BLOOD Triglyc-78 HDL-46 CHOL/HD-3.6 LDLcalc-104
HEAD CT [**2126-10-2**]:
IMPRESSION: Interval mild enlargement of the left superior
cerebellar
hyperdense area with mildly increased mass effect. Clinical
correlation is
recommended. While this is most likely to represent hemorrhage,
DDX includes dense neoplasms like meningioma; underlying
vascular or neoplastic causes cannot be excluded.
HEAD CT [**2126-10-3**]:
IMPRESSION: Little change since the prior study of the left
cerebellar
hemorrhage with mass effect on 4th ventricle and cerebral
aqueduct. Stable 2- mm rightward shift of midline structures.
Underlying vascular or neoplastic lesions, if any, can be better
assessed by MR/CTA after resolution or as indicated clinically.
EKG [**2126-10-6**]
Normal sinus rhythm, rate 59. Non-specific anterolateral
repolarization
changes. Possible inferior myocardial infarction of
indeterminate age. Compared to the previous tracing of [**2126-10-2**]
no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 146 92 422/420 41 -4 75
NECK/Soft tissue Ultrasound [**2126-10-6**]:
No abnormal fluid collection or mass in the right neck.
Carotid US [**2126-10-7**]:
Less than 40% stenosis of the bilateral extracranial internal
carotid arteries.
Brief Hospital Course:
Ms [**Known lastname 4223**] was admitted to the NeuroICU after a CT showed
cerebellar hemorrhage. Her neurological status was monitored
very closely and remained unchanged throughout her hospital
course. Her INR was reversed to a goal of less than 1.5 A CTA
was desired for rule out vascular cause of bleed. Due to her
renal insufficiency a MRA was recommended. Given her exterme
claustrophobia, an open MRI was scheduled after discharge.
On [**10-6**] it was noted that there was some swelling to her right
neck- a soft tissue ultrasound was done which was negative. She
subsequenty had one 15 minute episode of Left chest discomfort.
Cardiac work up was unimpressive and cardiology consult felt
that there were no acute cardiac episodes. She was evaluated by
PT and ultimately discharged home.
Medications on Admission:
[**Month/Year (2) **] 6.5', lipitor
20',altase5',metoprolol 25',valium 2qhs,neurontin 400'',ramipril
5', lasix 80', aspirin
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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Ramipril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Care Tenders
Discharge Diagnosis:
Cerebellar Hemorrhage
Carotid stenosis
UTI
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????We are making your appointments for MRI, CT and Dr
[**Location (un) 84339**] will be sending you a letter with the exact
appointment times. The follow up appointment is in the next 4
weeks.
??????You will need a MRA +gad in open MRI prior to your appointment.
This can be scheduled when you call to make your office visit
appointment or you may have the scan done at an outside
facility. You must bring a CD with the images to your
appointment.
During your hospital stay you had an ultrasound of the neck.
This showed carotid stenosis. You should follow up with you PCP
[**Name Initial (PRE) 176**] 2 weeks to discuss this diagnosis.
Completed by:[**2126-10-10**]
ICD9 Codes: 431, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 803
} | Medical Text: Admission Date: [**2153-11-6**] Discharge Date: [**2153-11-13**]
Date of Birth: [**2100-1-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2153-11-6**] - CABGx3
[**Last Name (NamePattern4) 15255**] of Present Illness:
Splendid 53 year old gentleman with shortness of breath and
chest pressure with activity. A cardiac catheterization was
performed which revealed three vessel disease. Due to the
severity of his disease, he was referred for elective coronary
artery bypass grafting with Dr. [**Last Name (Prefixes) **].
Past Medical History:
Hypercholesterolemia
HTN
Anxiety
Postoperative Corneal Abrasion
Torn Bicep s/p Repair
Asthma
GERD
Separated Right Shoulder
Current Smoker
S/P (R) Bicep Repair
S/P (R) Peri-renal abscess
Social History:
Currently not working. Smokes around [**12-10**] pack per day. "Few"
drinks/beers daily. Lives with wife in [**Name (NI) 5176**], MA
Family History:
Mother with CABG in her 60's
Father with prostate cancer
Physical Exam:
GEN: WDWN in NAD
SKIN: Warm, no edema
HEENT: NCAT, PERRL, OP benign. Few remaining teeth in fair
repair.
NECK: Supple, no JVD
LUNGS: Clear
HEART: RRR, nl s1-s2
ABD: Soft, nontender, benign
EXT: Well perfused, no edema, no varicosities noted
NEURO: Nonfocal
Pertinent Results:
[**2153-11-8**] 06:35AM BLOOD WBC-7.9# RBC-3.34* Hgb-10.9* Hct-30.3*
MCV-91 MCH-32.8* MCHC-36.0* RDW-12.5 Plt Ct-208
[**2153-11-8**] 06:35AM BLOOD Plt Ct-208
[**2153-11-8**] 06:35AM BLOOD Glucose-152* UreaN-13 Creat-0.9 Na-135
K-4.1 Cl-99 HCO3-26 AnGap-14
[**2153-11-8**] CXR
Comparison made to prior study of one day earlier. The
cardiomediastinal silhouette is unchanged. There has been
interval removal of the left basilar chest tube. Minimal linear
atelectasis is present in the left mid lung zone. There is no
pneumothorax. There is mild subcutaneous emphysema in the left
chest. Minimal linear atelectasis is present in the right lung.
[**2153-11-6**] EKG
Sinus rhythm. Consider inferior myocardial infarction, of
indeterminate age. Diffuse ST-T wave abnormalities, cannot
exclude ischemia/injury. Clinical correlation is suggested.
Since the previous tracing of [**2153-10-30**] further ST-T wave changes
are present.
Brief Hospital Course:
Mr. [**Known lastname 5261**] was admitted to the [**Hospital1 18**] on [**2153-11-6**] for elective
surgical management of his coronary artery disease. He was taken
directly to the operating room where he underwent coronary
artery bypass grafting to three vessels. Postoperatively he was
taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mr. [**Known lastname 5261**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Beta blockade and
aspirin were resumed. He was then transferred to the cardiac
surgical step down unit for further recovery. He was gently
diuresed towards his preoperative weight. He complained of left
eye pain for which the ophthalmology service was consulted. A
corneal abrasion was found on exam and polymyxin eye ointment
was prescribed four times daily. An eye patch was worn and his
eye pain and irritation slowly improved. Mr. [**Known lastname 5261**] [**Last Name (Titles) 77102**] and
pacing wires were removed per protocol. stopped [**2153-11-8**]\
[**Last Name (STitle) 58527**]nued to make steady progress and was discharged home on
postoperative day seven. He will follow-up with Dr. [**Last Name (Prefixes) **],
his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Toprol XL 50mg daily
Aspirin 325mg daily
Nitrostat as needed
Lipitor 20mg daily
Advair as needed
Nexium 40mg daily
Xanax 0.5mg as needed
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1
weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD
Hypercholesterolemia
HTN
Corneal abrasion
GERD
S/P Right Bicep Repair
S/P Drainage of perirenal abcess
Current smoker
Asthma
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain greater then 2 pounds in 24 hours or 5
pounds in one week.
4) Take lasix as directed with potassium and stop ________.
5) No lifting more then 10 pounds for 10 weeks.
6) No creams, lotions or powders to wounds until they have
healed. Steristrips will fall off on there own. If have not
fallen off in 2 weeks from discharge, please remove.
7) Call with any questions or concerns.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. ([**Telephone/Fax (1) 104910**]
Follow-up with cardiologist Dr. [**Last Name (STitle) **] in [**12-10**] weeks.
Call all providers for appointments.
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 804
} | Medical Text: Admission Date: [**2157-5-29**] Discharge Date: [**2157-6-16**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
SSCP x 3 days
Major Surgical or Invasive Procedure:
Catheterization
cabg x3 on [**2157-6-3**] (LIMA to LAD, SVG to OM, SVG to RCA)
History of Present Illness:
Pt is as [**Age over 90 **] y/o male who was seen in the ER for non-radiating
SSCP of three days duration and now admitted to the floor for
Acute Coronary Syndrome. Pt explains CP as a "tooth ache", that
will last 10-20 minutes at most. He denies CP currently, SOB,
diaphoresis, dizziness, nausea or vomitting during his prior CP.
Pt explains that he had a dry non-productive cough without
fever and chills. He states that his son had pneumonia last
week. No previous cardiac hx.
Past Medical History:
HTN
Left shoulder hemiarthroplasty
Legally blind
CRI (baseline 2.1)
Social History:
lives at home with children, denies smoking/alcohol/drugs
Family History:
non-contrib
Physical Exam:
PEx:
Vitals: 97.2 143/67 59 18 95% on 2L
Gen: AAOx3, NAD, [**Last Name (un) 1425**]
HEENT: normocephalic, PERRLA, MMM, no LAD, no JVD
PULM: CTA b/l
CV: RRR, nl S1 S2, no m/r/g
Abd: soft, NT/ND, obese, no r/g
LE: + palpable pedal pulses, minimal non-pitting edema b/l
73" 275#
Pertinent Results:
[**2157-6-16**] 10:40AM BLOOD WBC-5.2 RBC-3.76* Hgb-10.8* Hct-32.6*
MCV-87 MCH-28.6 MCHC-33.0 RDW-15.2 Plt Ct-281
[**2157-6-12**] 05:10AM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.2*
[**2157-6-16**] 10:40AM BLOOD Glucose-125* UreaN-38* Creat-2.7* Na-143
K-3.9 Cl-110* HCO3-23 AnGap-14
RADIOLOGY Final Report
CHEST (PA & LAT) [**2157-6-14**] 10:46 AM
CHEST (PA & LAT)
Reason: eval effusions
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with HTN, and ACS s/p CABGx3
REASON FOR THIS EXAMINATION:
eval effusions
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: [**Age over 90 **]-year-old man with hypertension, ACS, S/P
CABG. Please follow up pleural effusions.
Comparison is made with prior study dated [**2157-6-10**].
FINDINGS: Allowing the difference of technique and positioning
of the patient, moderate bilateral pleural effusions are again
seen, likely the right decreased and increase in the left side.
There is no evidence of CHF. There are bibasilar atelectasis.
Patient is S/P median sternotomy and CABG. Stable cardiomegaly.
Widened superior mediastinum and deviation of the trachea to the
right, unchanged from prior studies.
IMPRESSION: Bilateral pleural effusions, likely increase in the
left and decrease in the right side. Bibasilar atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: WED [**2157-6-15**] 4:36 PM
Cardiology Report ECHO Study Date of [**2157-6-3**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function. Mitral valve disease. Valvular heart
disease.
Status: Inpatient
Date/Time: [**2157-6-3**] at 09:59
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW04-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: *0.23 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 2.1 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 0.86
Mitral Valve - E Wave Deceleration Time: 299 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus
in the LA/LAA or the RA/RAA. All four pulmonary veins identified
and enter the
left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No
spontaneous echo
contrast or thrombus in the body of the RA or RAA. No ASD by 2D
or color
Doppler. The IVC is normal in diameter with appropriate phasic
respirator
variation.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Mild symmetric LVH. Normal LV cavity size. Normal
regional LV systolic
function. Overall normal LVEF (>55%).
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
thickening of
mitral valve chordae. Mild to moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure.
Conclusions:
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial
appendage or the body of the right atrium/right atrial
appendage. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium
or the right atrial appendage. No atrial septal defect is seen
by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left
ventricular cavity size is normal. Regional left ventricular
wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple
atheroma in the descending thoracic aorta. There are three
aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. Mild to moderate ([**11-22**]+) mitral
regurgitation is
seen. There is no pericardial effusion.
POST CPB:
Preserved biventricular systolic function.
Mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
No other change.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2157-6-3**] 12:43.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 22048**])
Brief Hospital Course:
Pt received ASA, Lopressor and Heparin in the ED. Labs of note
were troponin at .11, and a chest x-ray that stated possible
pneumonia in his left lower lobe.
Pt underwent catheterization on [**5-30**] which revealed severe 3
vessel disease, and did not receive stenting. It was then
determined that his best next option would be CABG, CT surgery
was consulted. Pt was monitored on the floor, received SL nitro
for CP and repeat EKGs. Of concern was his renal function,
however his creatinine remained stable around 2.0 pre- and post-
catheterization. He had an echo, carotid US, UA and LFTs
completed before his CABG procedure on [**6-3**] with results above.
Underwent cabg x3 with Dr. [**Last Name (STitle) **] on [**6-3**] and transferred to the
CSRu in stable condition on neosynephrine and propofol drips.
Epinephrine and insulin drips added overnight, slightly acidotic
and transfused on POD #1 as vent wean started. Platelet count
decreased to 88K and HIT panel sent. Extubated on POD #2 and
Swan removed. Went into AFib on POD #3 and amiodarone started as
well as beta blockade and gentle diuresis. Pacing wires removed
without incident on POD #4.HIT negative on [**6-7**] and converted to
SR on amiodarone.Foley removed on POD #5 and transferred to the
floor to begin increasing his activity level. Lethargy improved
and alert and oriented on POD #6. Had some confusion overnight
and treated with haldol.
He eventually improved and had a creat of 3.0. Renal was
consulted and felt that he was pre renal, and he was encouraged
to increase PO intake. His creat decreased to 2.7 and he was
discharged to home on POD#13 in stable condition.
Medications on Admission:
ASA 325mg daily
lipitor 10 mg daily
plavix 75 mg daily (LD [**5-31**])
Protonix 40 mg daily
lopressor 25 mg [**Hospital1 **]
SL NTG ?
Multivitamin
mucomyst
bicarbonate
heparin drip
colace 100 mg daily
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 month supply* Refills:*2*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p cabg x3
HTN
CRI
renal calculi
legally blind
left shoulder surgery
Discharge Condition:
stable
Discharge Instructions:
may shower over incisions and pat dry
may not drive for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, or drainage
no lotions, creams or powders on any incision
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**11-22**] weeks
follow up with Dr. [**Last Name (STitle) 171**] in [**12-24**] weeks
follow up with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2157-6-16**]
ICD9 Codes: 5849, 2762, 5180, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 805
} | Medical Text: Admission Date: [**2158-7-14**] Discharge Date: [**2158-7-20**]
Date of Birth: [**2120-3-22**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 38-year-old white male has
a history of chest discomfort. He had a history of mitral
valve prolapse and mitral regurgitation. He is status post
cardiac catheterization in [**2154**], which was negative and in
[**2158-4-25**], he had an episode of severe substernal chest pain
associated with diaphoresis, shortness of breath, nausea, and
vomiting. He ruled out for a MI and had exercise tolerance
test, which was negative for reversible defects, but had a
possible small LAD infarct. An echocardiogram at that time
revealed worsening MR and he again had chest pain in [**Month (only) **] and
was admitted to [**Hospital1 69**] for rule
out MI and had a positive tox screen for cocaine, but ruled
out for MI.
An echocardiogram on [**5-23**] revealed a left to right shunt
across the intraatrial septum, a secundum ASD and EF of 75
percent, mitral valve leaflets were myxomatous and elongated.
He had moderate-to-severe mitral valve prolapse with partial
mitral leaflet flail and 4 plus MR. His stress test at that
time revealed no significant ST changes and he underwent
cardiac catheterization in [**2158-5-25**], which revealed an EF of
71 percent, 4 plus MR, and normal coronaries.
He was admitted for elective mitral valve repair, and on
[**7-14**], he underwent mitral valve repair with a quadrangular
resection of the posterior leaflet and an anuloplasty with a
30 mm [**Doctor Last Name 405**] band. He had some bleeding in the OR. His
chest was opened right after it was closed. They had not
left the OR yet, and he had platelet transfusion and his
bleeding subsided.
He was transferred to the CSRU in stable condition. He
remained intubated overnight. He was on Precedex overnight.
He was extubated on postoperative day number one.
Postoperative day two, his chest tubes were D/C'd, and he was
transferred to the floor in stable condition. He continued
to progress and had pacing wires D/C'd on postoperative day
number three.
DICTATION ENDED HERE.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2158-7-20**] 16:05:35
T: [**2158-7-20**] 16:32:03
Job#: [**Job Number 36691**]
ICD9 Codes: 4240, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 806
} | Medical Text: Admission Date: [**2141-7-23**] Discharge Date: [**2141-8-2**]
Date of Birth: [**2060-10-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
nausea, vomiting, unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 RHM chinese speaking only, with PMH significant for HTN, a.
fib (on Coumadin), presented to ED for evaluation of nausea and
vomiting. History provided by son in law, who speaks English.
Per him and patient, he went out at around 11 am today to have
breakfast and tea with the family. After having the
refreshments , he was returning from subway to home. he felt a
little lightheaded while travelling back but was able to walk
and come back home. After coming home, around 3 pm, as he tried
standing up, he felt sudden onset dizziness. He means
lightheadness by :"dizzy". He could not stand and was going
towards right when tried to stand and felt like a drunk man. He
felt "imbalance". Shortly, he had an episode of vomiting and 3
more after that in next hour. He started having dull bifrontal
diffuse headache with no radiation. It was [**5-29**], non throbbing,
no photophobia but nausea. Due to this , the family called 911
who brought him to [**Hospital1 18**] ED.
Per ED team, his blood pressure was 177 systolic when he
presented. ED team got CT head which revealed 3.2 cm right
cerebellar bleed, hence neurology and
neurosurg were consulted.
ROS
Neuro- No visual symptoms, diplopia, No sensory symptoms, no
weakness, no bladder/ bowel issues.
Gen-
Negative than mentioned
Past Medical History:
HTN
dyslipidemia
a. fib (on Coumadin)
Social History:
No smoking
No alcohol
retired restaurant worker
Family History:
Neg for stroke, DM
Physical Exam:
General: Awake, NAD
HEENT: NC/AT, , MMM, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: rapid, regular
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic: done with help of son in law as chinese interpreter
Mental Status: Awake and alert, cooperative with exam, normal
affect
Oriented to person, place, month
Language: Fluent with good comprehension and repetition.
There is no dysarthria, no paraphasic errors and naming is
intact
Fund of knowledge normal
No apraxia, No neglect
Cranial Nerves:
pupils [**3-21**] equally round and reactive to light
bilaterally.Visual
fields are full to confrontation
Extraocular movements intact. He has nystagmus on right as well
as upgaze. Facial sensation intact to pain and touch . facial
movement are normal and face is symmetric. Hearing intact to
finger rub bilaterally. Tongue midline, no fasciculations.
Sternocleidomastoid and trapezius normal bilaterally.
Motor:
Normal bulk and tone bilaterally.
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
No pronator drift
Sensation was intact to light touch, pin prick, temperature
(cold), vibration, and proprioception all over.
Reflexes: B T Br Pa A
Right 2 2 2 1 -
Left 2 2 2 1 -
Toes were upgoing bilaterally.
Coordination -
Has dysmetria on FNF on right side, RAMS clumpsy on right side,
has difficulty with alternate hand tapping on right, knee shin
test clumsy on right side, repetitive foot tapping was clumspy
and incoordiated on the right side.
Gait / Rhomberg - deferred.
Pertinent Results:
[**2141-7-23**] 06:45PM WBC-16.2* RBC-4.67 HGB-13.6* HCT-39.5* MCV-85
MCH-29.1 MCHC-34.3 RDW-13.9
[**2141-7-23**] 06:45PM NEUTS-87.8* LYMPHS-8.6* MONOS-2.8 EOS-0.6
BASOS-0.2
[**2141-7-23**] 06:45PM PLT COUNT-267
[**2141-7-23**] 06:45PM GLUCOSE-190* UREA N-23* CREAT-1.2 SODIUM-142
POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-28 ANION GAP-16
[**2141-7-23**] 06:45PM ALT(SGPT)-11 AST(SGOT)-28 ALK PHOS-75
AMYLASE-55 TOT BILI-0.4
[**2141-7-23**] 08:18PM LACTATE-2.5*
[**2141-7-23**] 06:45PM MAGNESIUM-1.8
[**2141-7-23**] 06:45PM cTropnT-<0.01
[**2141-7-23**] 09:59PM PT-29.5* PTT-27.3 INR(PT)-2.9*
[**2141-7-23**] 06:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2141-7-23**] 06:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
Imaging:
EKG: sinus rhythm
CXR: Low lung volumes which may accentuate the hila, but small
right hilar opacity cannot be excluded, which may reflect
developing pneumonia.
CT head: 3.2 cm right intraparenchymal cerebellar hemorrhage. no
herniation.
MRI head: Right cerebellar hemorrhage unchanged compared to
recent CTs. Little to no mass effect. Multiple additional foci
of prior parenchymal hemorrhage noted in the basal ganglia,
thalamus, pons, subcortical white matter and left cerebellum.
Overall, this pattern is most compatible with amyloid
angiopathy.
ECHO: There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**1-21**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Brief Hospital Course:
1) Neuro: Patient presented with symptoms of nausea, vomiting,
unsteadiness. CT scan of the head was performed, which showed a
3.2 cm right cerebellar hemorrhage. Neurology and Neurosurgery
were subsequently consulted and the patient was admitted to the
ICU for close monitoring. No neurosurgical intervention was
required. Antiseizure prophylaxis was not indicated given the
region of the hemorrhage. The patient was managed medically. A
repeat CT scan was performed the morning after admission, which
showed a stable hemorrhage. An MRI was subsequently performed to
evaluate for possible etiologies of the bleed and this showed
multiple additional foci of prior parenchymal hemorrhage in the
basal ganglia, thalamus, pons, subcortical white matter and left
cerebellum. These multiple microhemorrhages noted is most
consistent with a diagnosis of amyloid angiopathy. The
hemorrhage secondary to the amyloid angiopathy was then likely
exacerbated by the patient being coagulopathic secondary to the
Coumadin the patient was on for a. fib (initial INR was 2.9).
The INR was corrected with FFP and Vitamin K. INR should be less
than 1.6 to avoid extension of hemorrhage. The patient continued
to note vertiginous symptoms and was started on Meclizine for
symptomatic relief. The patient was started on baby aspirin (to
avoid further bleeding risks) for anti-platelet activity. A
lipid panel was performed as part of the stroke work-up and this
noted dyslipidemia, so the patient was started on Simvastatin.
Patient's condition gradually improved and he was stable for
transfer to floor. While on floor, patient eventually passed
speech and swallow and was started on regular diet. Patient was
seen by PT/OT who determined that patient would benefit from
rehab placement.
2. Cardiology: Patient initially hypertensive, with goal <160
given hemorrhage. Patient received prn doses IV Hydralazine to
help control blood pressure. For continued elevated BP, patient
was on Metoprolol 50 mg [**Hospital1 **] and Lisinopril 5 mg daily. The
patient continued to require IV doses Hydralazine despite the
standing anti-HTN meds; however, one night after receiving a
dose of IV Hydrlazine for a BP of 170s systolic, the patient
developed an episode of epigastric pain and chest pain without
radiation that was associated with lightheadedness. Patient
became hypotensive at this time with SBP into 80s. An EKG was
performed which showed ST changes concerning for ischemia. A
cardiology consult was obtained and the patient was transfered
back to the ICU for closer monitoring. The ST depression on EKG
were transient and have since resolved. Cariology noted this was
most likely demand-perfusion ischemia. An outpatient stress test
is reccomended to further work-up this event. In a separate
event, patient developed a. fib episode with RVR; heart rate
into 160s. The patient received IV Metoprolol and PO Metroprolol
was increased to 50 mg tid. Patient has remained rate controlled
on this higher dose. Will avoid anticoagulation with Coumadin
for the a. fib at this time given the hemorrhage.
3. Renal: After the hypotensive episode, patient had Creatinine
level rise to 1.4 from 1.2. Determined to be pre-renal and was
likely secondary to hypotension. The [**Last Name (un) **] imrpoved with IVF; it
is currently 1.1. Another possibility for the elevated
creatinine is the addition of Lisinopril for blood pressure
control. The Lisinopril has been stopped. Will need to monitor
BUN and creatinine as an outpatient.
4. Heme: Hematocrit trended down after hypotensive episode with
concurrent drop in Hemoglobin from 13.5 to 11.5. Iron panel was
ordered, there was no evidence of acute blood loss or iron
deficiency anemia.
5. HTN: Patient initially required IV Hydralazine prn for BP
control. Metoprolol now at 50 tid for rate as well as blood
pressure control. Patient initially started on lisinopril for BP
control but given elevated Creatinine, this was swtiched to
Amlodipine 5 mg daily, with possible need to increase to 10 mg
daily in future if BP remains elevated.
Medications on Admission:
Terazosin 10 mg po qhs
Metoprolol (dose unknown)
Discharge Medications:
1. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for vertigo.
2. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain fever. Tablet(s)
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for c.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
R cerebellar hemorrhage secondary to amyloid angiopathy
atrial fibrillation
Acute kidney injury
Demand Ischemia
HTN
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital with sudden onset nausea, vomiting, and
unsteadiness. A CT scan of your brain showed that there was a
bleed in a part of your brain called the cerebellum, resulting
in the above symptoms. This bleed was due to something called
amyloid angiopathy. The bleed was likely made worse because of
Coumadin, the medication you were on for your heart arrythmia,
atrial fibrillation. Because of the bleeding, your Coumadin was
stopped. You were started on a baby ASA for the stroke. You were
also started on a medication called Simvastatin for a high
cholesterol.
While you were in the hospital, you had an episode of low blood
pressure, which caused some EKG changes that have since returned
to normal. The cardiologists would like you to get a stress test
as an outpatient to be followed by your PCP. [**Name10 (NameIs) **] also had an
episode of a fast heart rate, so your Metoprolol was increased
to 50 mg three times a day.
Also, on Friday [**2141-8-4**], would like you to have your kindey
function checked with labwork (BUN, Creatinine) as the time you
were hypotensive seemed to affect your kidneys, though function
has improved with the IV fluids you received.
Followup Instructions:
Please follow with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2141-9-1**] 1:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-8-31**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2141-8-31**] 2:00 ([**Hospital **] Medical Building [**Hospital Unit Name 12193**])
Completed by:[**2141-8-2**]
ICD9 Codes: 431, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 807
} | Medical Text: Admission Date: [**2141-6-26**] Discharge Date: [**2141-6-30**]
Date of Birth: [**2068-12-15**] Sex: F
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Heart palpitations and fatigue times two
years with mild shortness of breath.
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: The patient is a 72-year-old
female with a history of heart murmurs since childhood with
increasing frequency and intensity of heart palpitations,
fatigue and shortness of breath. Over the last several years
the patient sought medical attention, at which time she had
an echocardiogram revealing a "leaky valve." The patient was
then referred to Dr. [**Last Name (Prefixes) **] for a mitral valve
replacement. The patient's echocardiogram which was done on
[**2140-5-20**] showed: (1) Left atrium mildly dilated.
(2) Thickened mitral valve, moderate-to-severe. (3) Mitral
valve prolapse of the posterior leaflet. (4) Torn mitral
chordae. (5) Moderate-to-severe mitral regurgitation.
PAST MEDICAL HISTORY:
1. Esophagitis/gastroesophageal reflux disease.
2. Hypercholesterolemia.
3. Mild arthritis.
4. No hypertension.
PAST SURGICAL HISTORY: (Past surgical history includes)
1. Appendectomy at the age of 10.
2. Status post cataract surgery of left eye in [**2137**].
3. Status post breast reduction in [**2125**].
4. Status post lip tumor removal.
5. Status post face lift six to seven years ago.
MEDICATIONS ON ADMISSION: (Preoperative medications include)
1. Prilosec 20 mg p.o. q.d.
2. Celexa 30 mg p.o. q.d.
3. Gentle eyedrops OU b.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Initial physical
examination included a heart rate of 64, blood pressure
of 138/87, an initial weight of 140 pounds. In general, in
no acute distress. Skin was well hydrated, no rashes. HEENT
revealed pupils were equal, round, and reactive to light and
accommodation. Extraocular muscles were intact. No
dentures. No abnormal buckle mucosa. Neck was supple, mild
jugular venous distention. Chest was clear to auscultation
bilaterally. No wheezes or rhonchi. Cardiovascular revealed
a regular rate and rhythm, positive S1 and S2, plus [**2-24**]
murmur heard best at point of maximal impulse. Abdomen was
soft, nontender, and nondistended. Positive well-healed
right lower quadrant scar. Extremities were warm, minimal
edema, varicosities, mild spider veins bilaterally,
nontender. Neurologically, cranial nerves II through XII
were grossly intact. Normal motor and sensory function.
Pulses were 2+ femoral, dorsalis pedis, posterior tibialis,
and radially bilaterally. Negative carotid bruits right or
left.
RADIOLOGY/IMAGING: Electrocardiogram showed normal sinus
rhythm at 62 beats per minute.
HOSPITAL COURSE: The patient was admitted on [**2141-6-26**], and taken to the operating room with the initial
diagnosis of mitral regurgitation. The procedure was a
mitral valve replacement (#33-CE-[**Location (un) **]). The patient
tolerated the procedure well and was transported to the
Postanesthesia Care Unit in stable condition. On
postoperative day one the patient did well in the
Cardiothoracic Intensive Care Unit and was transported to the
floor.
On postoperative day two, the patient's chest tube was put on
water seal and discontinued later that day. The patient also
increased ambulation and had her Foley discontinued.
On postoperative day three, the patient continued to do well
with a PT level of 4. On postoperative day four, during the
final physical therapy session, the patient ambulated well
with an oxygen saturation in the 90s, but desaturated to the
middle 80s several times at rest. The patient was
reassessed, and in her latest x-ray which was taken on
[**6-30**] was reviewed. The x-ray showed no changes from the
previous x-ray with no infiltrates suggesting pneumonia. It
was decided that the patient could be discharged to home with
[**Hospital6 407**] and home oxygen until followup.
On postoperative day five, the patient continued to ambulate
well and was reassessed with a PT level of 5. After weighing
the options between rehabilitation and discharge home, the
surgical team, care coordinator, and patient thought she was
well enough to go home.
PHYSICAL EXAMINATION ON DISCHARGE: Temperature 97.7,
pulse 76, blood pressure 98/50, respiratory rate 20, oxygen
saturation was 90% on room air. Cardiovascular revealed a
regular rate and rhythm. Respiratory was clear to
auscultation bilaterally. Abdomen was soft, nontender, and
nondistended. The incision was clean, dry and intact. PT
level was 5.
COMPLICATIONS: None.
MEDICATIONS ON DISCHARGE:
1. Lopressor 12.5 mg p.o. b.i.d.
2. Colace 100 mg p.o. b.i.d. times seven days with Percocet.
3. Percocet one to two tablets p.o. q.4-6h. p.r.n.
4. Captopril 6.25 mg p.o. t.i.d.
5. Lasix 20 mg p.o. b.i.d. times seven days.
6. Home oxygen with [**Hospital6 407**], titrate for
SaO2 greater than 93%.
CONDITION AT DISCHARGE: Good/stable.
DISCHARGE STATUS: To home with [**Hospital6 407**]
and home oxygen.
DI[**Last Name (STitle) 408**]E FOLLOWUP: Follow up with Dr. [**Last Name (Prefixes) **] in three
to four weeks.
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement.
2. Gastroesophageal reflux disease.
3. Hypercholesterolemia.
4. Mild arthritis.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 33068**]
MEDQUIST36
D: [**2141-6-30**] 21:42
T: [**2141-7-1**] 06:16
JOB#: [**Job Number 20434**]
ICD9 Codes: 4240, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 808
} | Medical Text: Admission Date: [**2166-4-11**] Discharge Date: [**2166-4-17**]
Date of Birth: [**2113-11-25**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male admitted to an outside hospital on [**4-7**] for a four-day
history of dyspnea. The patient was found to be in pulmonary
edema, and further review of systems indicated that the
patient had nausea and vomiting four days prior to the
outside hospital admission. The patient also had the
sensation of abdominal discomfort at that time.
Although no labs were available from the outside hospital,
the patient reportedly had a flat CK but positive troponin,
suggesting nausea, vomiting, and abdominal pain were symptoms
of acute myocardial infarction. At that time, the patient
was treated with intravenous Lasix, heparin drip, Aspirin,
ACE inhibitor, Metoprolol, Plavix, and Zocor.
His dyspnea improved, but a TTE at the outside hospital
showed an ejection fraction of 50 percent with severe
inferior-posterior lateral akinesis/hypokinesis. Earlier
this morning, the patient had epigastric discomfort, similar
to that which he experienced recently and was transferred to
[**Hospital6 256**] for cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Type 2 diabetes. 2. Hypercholesterolemia. 3.
Hypertension. 4. Bipolar disorder. 5. Recent dental
infection.
MEDICATIONS ON TRANSFER: Lopressor 12.5 b.i.d., Lisinopril
2.5 q.d., Plavix 75 q.d., Zocor 80 q.d., Lasix 40 p.o. q.d.,
Aspirin 325 q.d., Protonix 40 q.d., Depakote 2500 q.a.m.,
Lamotrigine 1000 mg p.o. b.i.d., Gabapentin 300 h.s., Augment
500 t.i.d., Duragesic 15 mg transdermal q.72 hours, regular
Insulin sliding scale.
SOCIAL HISTORY: He smokes [**11-28**] 1/2 packs per day. He quit
alcohol four years ago. He has a remote cocaine history.
His father passed at age 65 secondary to myocardial
infarction and cerebrovascular accident. His mother is alive
at 85.
The patient was brought to the Cardiac Catheterization
Laboratory. Cath showed a mildly diseased left main, mild
diffuse disease in the left anterior descending coronary
artery, and a totally occluded proximal left circumflex with
right-to-left and left-to-left collaterals to the first
obtuse marginal. The patient subsequently had a left
circumflex stent placed. He was also noted to have normal
cardiac input and cardiac index.
PHYSICAL EXAMINATION: Vital signs: Temperature 100, blood
pressure 137/80, heart rate 97, respirations 14. General:
He was a disheveled-appearing male in no acute distress. He
had poor dentition with no purulence drainage in his mouth.
HEENT: His JVP was 9 cm. Lungs: He had crackles one-half
of the way up bilaterally. Heart: Regular rate and rhythm.
No murmurs, rubs, or gallops. Extremities: He had 2+ pulses
throughout and had no peripheral edema.
Electrocardiogram at the catheterization laboratory showed
normal sinus at 95, right atrial abnormality, normal axis, T-
wave inversions in I, II and AVF, V4-V6, as well as 1-2 mm ST
segment depressions in V2-V4.
An echocardiogram on [**2166-4-8**], showed an ejection
fraction of 30 percent with severe hypokinesis and akinesis
of the inferior wall, severe hypokinesis of the
posterolateral wall, [**11-29**]+ mitral regurgitation, 2+ tricuspid
regurgitation, and mild pulmonary hypertension.
HOSPITAL COURSE:
1. Coronary artery disease: The patient was continued on
Aspirin, Plavix, and Integrelin for 18 hours. He was also
continued on Lipitor 80 mg p.o. q.d. His cardiac
medications were subsequently titrated. Eventually his
medications were titrated up, and he was switched to
Lisinopril 5 mg p.o. q.d., Lopressor 37 mg p.o. b.i.d.,
and was given Lasix p.r.n. for edema.
During the rest of his hospitalization, his coronary artery
disease issues remained stable.
2. Infectious disease: The patient spiked a fever on [**2166-4-14**] to over 102 degrees. As noted, the patient had a history
of a recent dental infection and had been started on Augmentin
500 mg t.i.d. by the outside hospital. Blood and urine
cultures were subsequently sent and were unrevealing.
The Cardiac Care Unit Team empirically added Clindamycin for
better anaerobic coverage. The Coronary Care Unit Team
requested an inpatient dental consult. The Dental
consult felt that he did not have a dental abscess, and
Panorex films that obtained were unrevealing.
An Oromaxofacial Surgery consult was also obtained, and they
felt that while the patient had chronic dental issues, they
did not believe that his teeth were the cause of fevers (and
they represented chronic infection).
Subsequent work-up of the fevers included placement of a PPD
which was negative. The patient also reported a mild cough
and a [**12-31**] week history of chronic night sweats. A chest x-
ray was obtained which showed a very large left-sided pleural
effusion. This was eventually tapped and was exudative in
nature.
The patient three induced sputums which did not
grow any acid-fast bacilli. Furthermore, as mentioned
previously, he had several series of blood and urine cultures
which were all pending to date. Studies from the pleural
fluid showed no organismss. There were no AFB on
direct smear from the fluid, and fluid cultures were also
negative.
The patient subsequently returned for an addition
thoracentesis, as a CAT scan of the chest (after the initial
thoracentesis) showed that the remaining fluid had become
loculated. An addition 900 cc of fluid was drained. A chest CT
was obtained to evaluate for possible malignancy or granulomatous
disease suggestive of tuberculosis.
CT of the chest showed a small right-sided pleural
effusion, a tiny patchy opacity within the right lower lobe,
and a loculated left-sided pleural effusion which was lying
the major fissure. There were also patchy ground glass
opacities in the left lung. There was a tiny nodule in the
left lower lobe. There were also noted to be mild
cardiomegaly. There was also a small pericardial effusion,
as well as nonpathologically enlarged mediastinal and
axillary nodes. There was no significant axillary
mediastinal hilar adenopathy.
To complete his Infectious Disease work-up, a sinus CT was
also obtained, as the patient had also been complaining of
some sinus pain. This showed minimal mucosal thickening in
the right maxillary sinus. The remainder of this study was
unremarkable.
3. Endocrine: The patient was continued on sliding scale
Insulin, as well as his outpatient dose of Glyburide.
4. Psychiatric: He was continued on all of his outpatient
psychiatric medications. Also Celexa was added 20 mg p.o.
q.d.
Because the patient's acute coronary issues had been
intervened upon, the patient was transferred to the Medicine
Team for resolution of the patient's infectious disease
issues, as well as the issues regarding his pleural effusion.
This dictation covers the [**Hospital 228**] hospital course from [**2166-4-11**], through [**2166-4-17**]. The remainder of the
[**Hospital 228**] hospital course will be dictated by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
[**First Name8 (NamePattern2) **] [**Doctor Last Name 1299**], INT
Dictated By:[**Doctor Last Name 10457**]
MEDQUIST36
D: [**2166-4-19**] 19:02:03
T: [**2166-4-21**] 10:23:14
Job#: [**Job Number 55754**]
ICD9 Codes: 5119, 486, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 809
} | Medical Text: Admission Date: [**2184-1-21**] Discharge Date: [**2184-1-25**]
Service: MEDICINE
Allergies:
Codeine / Penicillins / Aspirin / Fentanyl
Attending:[**First Name3 (LF) 3552**]
Chief Complaint:
Elective bronchoscopy
Major Surgical or Invasive Procedure:
Bronchoscopy x2 with biopsy of LUL mass
Intubation
Arterial Line
Central Venous Line
History of Present Illness:
80 year old woman with past medical history significant for
broncheoalveolar carcinoma who was undergoing an elective
bronchoscopy for biopsy of a LUL mass on [**2183-1-20**]. Approximately
~45 minutes into procedure, the patient became hypertensive ,
rigid and unresponsive, with oxygen saturations falling into the
50s. These symptoms resolved immediately once the bronchoscope
was removed and she was bagged. She was given hydralazine IV
with improvement in her SBP from 2227 to 125. She was
subsequently intubated for airway protection. The patient had
received 3.5mg versed and 100mg fentanyl over 45 minutes. Noted
by IP staff to be very difficult to ventillate when bagmask
initiated.
She was transferred to the MICU with what was thought to be a
dystonic reaction to fentanyl. She was noted to have a right
sided neck mass after CVL placement (during which the subclavian
artery was hit) and underwent an U/S which did not show a
hematoma. She was also noted to have very labile BPs with
systolics going into the 80s after propofol. An arterial line
was placed. She was briefly placed on neo with resultant SBPs
in the 220s and then controlled on a labetolol gtt; once BPs
were well controlled she was transitioned to po meds (norvasc,
isordil). She was extubated without incident on [**2184-1-22**]. She
was also noted to have a UTI (GNR) and was started on
ciprofloxacin.
Past Medical History:
1. Chronic obstructive pulmonary disease.
2. Bronchoalveolar carcinoma; status post right and left
upper lobectomies.
3. Hypothyroidism.
4. History of strokes and transient ischemic attacks.
5. Parkinson disease.
6. Claudication.
7. Cervical myelopathy; status post anterior disc excisions
and fusions at C3-C4, C4-C5, and C5-C6.
8. Hypertension.
9. Osteoarthritis.
10. Status post right total hip replacement in [**2171**].
11. History of drop attacks; previously on Dilantin but this
was stopped and she has had no further symptoms.
12. Obstructive sleep apnea; on continuous positive airway
pressure at home.
13. Restless leg syndrome.
Social History:
The patient lives in [**Hospital3 **] in Springhouse. She is
widowed. She has no children. She smoked three quarters of a
pack per day for 45 years; she
quit in [**2169**]. She drank wine, one to three glasses per day, for
30 years until several months ago. No history of illicit drug
use. She is a retired lawyer.
Family History:
Father died of gastric cancer in his 70s.
Mother died of a myocardial infarction in her 60s.
Physical Exam:
Tm 99.2
BP 133-193/51-83
HR 69-80
RR 15
O2Sat 96%RA
Gen: reclining in bed, NAD. Very gravelly voice.
HEENT: PERRL, EOMI, OP clear, MMM
Neck: non tender right sided neck bulge, +subclavian line.
CV: regular, S1S2 2/6 SEM at RUSB
Lungs: coarse breath sounds bilaterally
Abd: soft, NTND, +BS
Ext: w/wp, no edema
Neuro: alert and oriented x3.
Pertinent Results:
Chemistries
[**2184-1-21**] 03:55PM GLUCOSE-104 UREA N-28* CREAT-1.8* SODIUM-144
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-27 ANION GAP-14
[**2184-1-21**] 03:55PM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-1.8
CBC
[**2184-1-21**] 03:55PM WBC-7.6 RBC-3.80* HGB-11.9* HCT-33.8* MCV-89
MCH-31.3 MCHC-35.2* RDW-13.6
[**2184-1-21**] 03:55PM PLT COUNT-350
Coags
[**2184-1-21**] 03:55PM PT-12.2 PTT-25.3 INR(PT)-0.9
[**2184-1-22**] 03:50AM BLOOD CK(CPK)-43
[**2184-1-23**] 04:28AM BLOOD CK(CPK)-130
[**2184-1-22**] 03:50AM BLOOD CK-MB-2 cTropnT-<0.01
[**2184-1-23**] 04:28AM BLOOD CK-MB-3 cTropnT-<0.01
[**2184-1-22**] 10:40 am URINE CULTURE > 100,000 Klebsiella, I to
nitrofurantoin, S to all else.
Bronch [**1-21**]
COMPLICATIONS: Muscle rigidity secondary to Fentanyl resulting
in hypoxemia, airway obstruction and respiratory failure.
Bronch [**1-22**]
DESCRIPTION OF PROCEDURE: The bronchoscope was inserted via
the endotracheal tube which terminated 2 cm proximal to the
carina. The right-sided airways were within normal limits,
as was the trachea and left mainstem bronchus, except the
presence of severe tracheobronchomalacia. The left lower
lobe was patent, however, the left upper lobe lingular
bronchus was completely obstructed. Endobronchial biopsies
of the soft tissue mass were obtained and sent to pathology.
COMPLICATIONS: None.
Tissue Biopsies of LUL
pending on discharge
Brief Hospital Course:
80 year old woman with complicated PMH including
broncheoalveolar carcinoma for which she was undergoing an
elective bronchoscopy when she had an episode of rigidity,
hypertension and desaturation attributed to a dystonic reaction
to fentanyl and was subsequently intubated and in the MICU. s/p
extubation she was transferred to the floor for observation
prior to discharge back to [**Hospital3 **].
Dystonic Reaction
The patient's rigidity, desaturation and hypertension were
thought to be due to a dystonic reaction to fentanyl. She was
intubated for airway protection and extubated without
diffuculty. She subsequently maintained her oxygen saturations
on room air. Fentanly was added to the patient's allergies.
Broncheoalveolar Cancer
The patient successfully underwent bronchoscopy the day after
her dystonic reaction and biopsy specimens were obtained of her
LUL mass. These were pending on discharge.
Right neck mass
After right sided central line placement, complicated by
puncture of the subclavian artery, the patient was noted to have
a right sided neck mass. This mass was non tender and stable in
size, however, a neck U/S was done to rule out hematoma/aneurism
and was negative. This should be followed as an outpatient.
Labile BP
The patient has a history of hypertension and was on isordil and
norvasc as an outpatient. During her dystonic reaction her
systolic pressure went as high as 225, she was given 10mg IV
diltiazem with good effect and systolic pressure returning down
to 125. Subsequently her ICU course was complicated by lability
in blood pressures, with systolics falling to the 80s with
administration of propofol. For this the patient was briefly on
a neo gtt and pressures again went >200 for which she was on a
labetolol gtt. Prior to leaving the MICU her pressures were
stabilized on her home medications and remained well controlled
through the remainder of her stay.
UTI
In the MICU, the patient was noted to have a urinary tract
infection growing gram negative rods. She was started on a 7
day course of ciprofloxacin for a complicated UTI, which grew
out klebsiella that was pan sensitive (I to nitrofurantoin).
Elevated Cr
Peaked at 2.2 and trended down; likely UTI and prerenal.
OSA
The patient will resume her CPAP at night on discharge (she
declined it here).
?Dementia
Continued Aricept.
Hypothyroidism.
Continued levoxyl.
Claudication.
Continue pletal.
GERD
Continue prevacid.
Access
Radial line dc'd [**2184-1-23**]. Right subclavian central line dc'd on
[**2184-1-24**].
Communication
With patient and nephew, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 102585**].
Discharged back to [**Hospital3 **] with her 24 hour caregiver.
Medications on Admission:
Methylphenidate 10mg [**Hospital1 **]
Aricept 10mg qhs
MVT
Norvasc 10mg daily
Zocor 40mg daily
Lexapro 20mg daily
Pletal 100mg [**Hospital1 **]
levoxyl 50mg daily
prevacid 30mg daily
loratidine 10mg daily
isordil 10mg tid
Discharge Medications:
1. Donepezil Hydrochloride 5 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
2. Methylphenidate HCl 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Pletal 100 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
1. Respiratory failure requiring intubation [**1-21**] reaction to
Fentanyl
2. Labile Hypertension
3. Catheter associated UTI
4. Tracheobronchomalacia
5. COPD
Discharge Condition:
stable
Discharge Instructions:
1. Please f/u with your PCP (Dr. [**Last Name (STitle) 713**] or Dr. [**Last Name (STitle) **] in the
next week. Call to schedule an appointment
2. Please note that you are allergic to a medicine called
FENTANYL. Please list it as an allergy on all medical papers.
3. You have been diagnosed with a bladder infection. Please
take the antibiotic Cipro for next 5 days.
4. Take all other medications as previously prescribed.
5. Call Dr. [**Name (NI) **] should you develop worsening shortness
of breath, chest pain, blood sputum.
6. Call your PCP if you develop painful swallowing or swelling
of the mouth or worsened swelling of the right side of the face.
Followup Instructions:
Call Dr.[**Name (NI) 1602**] office at ([**Telephone/Fax (1) 6846**] to schedule a follow
up appointment in 1 week.
Keep the following appointment:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2184-5-26**] 2:30
[**Name6 (MD) 1592**] [**Name8 (MD) 1593**] MD, [**MD Number(3) 3555**]
ICD9 Codes: 5185, 5849, 5990, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 810
} | Medical Text: Admission Date: [**2102-3-21**] Discharge Date: [**2102-3-28**]
Date of Birth: [**2036-3-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Medicine Admission Note
CC: Abdominal pain
HPI: Ms. [**Known lastname **] is a 66 yo woman with history of
hypertension, possible CKD, prior CCY ([**2089**]), here from [**Hospital1 5979**] with pancreatits, after she presented there with
abdominal pain. She in fact developed abdominal pain 10 days
ago, on good [**Hospital1 2974**], and presented to LGH. She was discharged
from the ED. She was called back for possible pulmonary edema,
and to rule out MI, which was negative.
After discharge, she continued to have abdominal pain, with
nausea and anorexia. The pain has been constant, throughout her
entire abdomen, and radiating to her back. The pain was not
relieved by tylenol. She has had shortness of breath with the
pain. She had dark urine, but no changes in her stool. She has
not had fevers, but has had chills.
Prior to the onset of pain, she had been taking protein shakes,
substituting for one meal a day, for weight loss. She lost 7
lbs.
She has intermittent headaches. She denies any other urinary
symptoms, rashes, diarrhea, masses or lesions. ROS otherwise
reviewed in 13 systems and negative.
Past Medical History:
PMH
Hypertension, poorly controlled
?Hyperlipidemia
?CKD
Prior CCY, [**2089**]
Prior hysterectomy, for benign mass
Prior abnormal pap smears
Social History:
SH:
Originally from [**Male First Name (un) 1056**]. Works as secretary. No alcohol or
tobacco. Married, 2 children, grown, one grandchild.
Family History:
FH: Mother died in early 80s, "old age", father still alive,
age [**Age over 90 **], just diagnosed with cancer.
Physical Exam:
Physical exam
Vital signs: Tmax 98.0 BP 148/78 HR 60 16 91% RA O2 sat
General: in NAD, obese
HEENT: Faint scleral icterus, OP moist, no LAD, JVP difficult to
see.
Lungs: decreased at bases, no rales, no wheezes with forced
expiration.
CV: RRR without murmurs
Abdomen: soft, tender in epigastrium, and throughout upper
abdomen, no rebound or guarding. Nondistended, bowel sounds
present.
Ext: no edema
Neuro: alert/oriented X3, face symmetric, answers all questions
appropriately, full strength in upper and lower extremities.
Sensation normal.
Pertinent Results:
Relevant data:
Labs [**3-21**]
139 105 11 119 AGap=15
-------------
3.7 23 1.0
Trop-T: <0.01
Ca: 8.7 Mg: 1.9 P: 3.1
ALT: 803 AP: 329 Tbili: 4.1 Alb: 3.8
AST: 628
Lip: 8590
wbc 6.4 hgb 12.0 hct 38.1 plts 259
N:81.1 L:15.5 M:2.8 E:0.4 Bas:0.2
PT: 11.6 PTT: 27.8 INR: 1.1
UA with trace ketones, trace protein, 1 wbc, 1 rbc
urine culture pending
RUQUS [**Hospital1 18**] [**3-21**]:
IMPRESSION:
1. Status post cholecystectomy with common bile duct dilatation
to 13 mm, but no intrahepatic biliary duct dilatation. No stones
are seem in the visualized portions of the common bile duct,
though the distal duct is not well evaluated. MRCP is a more
sensitive exam for the detection of choledocholithiasis and can
be performed for further evaluation.
2. Echogenic liver consistent with fatty infiltration of the
liver. More severe hepatic disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on the basis of this study
EKG [**3-21**] SB nl axis, intervals, no ischemic changes.
Labs at LGH [**3-21**]:
Cr 1.04
Alk phos 372
Bili 5.4
AST 732
alt 911
Lipase 6741
CT from LGH, dissection protocol: No dissection, found to have
acute pancreatitis, without pseudocyst or abscess. Small 5 mm
increased density in the region of the pancreatic head/distal
CBD could be an obstructing stone/choledocholithiasis.
ERCP REPORT: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
A single stone was extracted successfully using a balloon. Two
more balloon sweeps were performed that did not reveal
additional stones or sludge.
Impression: The ampulla appeared bulging concerning for an
impacted stone
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique
A moderate diffuse dilation was seen at the biliary tree with
the CBD measuring 13 mm.
The cholangiogram did not definitively show a filling defect in
the distal CBD. However given the clinical picture suggestive
of gallstone pancreatitis and the finding of bulging ampulla
concerning for an impacted stone, a decision was made to perform
a sphincterotomy.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A single stone was extracted successfully using a balloon.
Two more balloon sweeps were performed that did not reveal
additional stones or sludge.
Otherwise normal ercp to second part of the duodenum
[**2102-3-26**] 06:10AM BLOOD ALT-132* AST-25 LD(LDH)-223 AlkPhos-159*
TotBili-0.7
Brief Hospital Course:
ICU Course:
66F with PMHx of hypertension, s/p CCY [**2089**], who was transferred
to [**Hospital1 18**] from LGH for acute gallstone pancreatitis s/p ERCP
w/sphincterotomy [**3-22**], hospital course complicated by new onset
atrial fibrillation with rapid ventricular response.
# Afib w/RVR: After the ERCP, the patient developed new-onset
afib w/RVR. Etiology unclear, possibly related to
hypersympathetic tone in the context of acute pancreatitis. TSH
was normal. Cardiac enzymes were negative. Did not anticoagulate
her given CHADS2 score of 1 and bleeding risk from
sphincterotomy [**3-22**] during ERCP. A TTE was performed which
showed normal global and regional biventricular systolic
function, However there was mild left atrial dilatation which
may have been a cause or effect of the atrial fibrillation. The
patient spontanously converted back to sinus rhythm. Given her
CHADS 2 score, use of both aspirin and plavix can be considered.
She was started on aspirin alone, and advised to discuss with
her PCP any additional use of plavix.
# Hypoxemia: Most likely secondary to flash pulmonary edema in
the context of fluid resuscitation and new atrial fibrillation.
Resolved.
# Pancreatitis: Patient is s/p ERCP with sphincterotomy and
stone extraction. LFTs are trending down and she reports
improvement in her abdominal pain. Will continue symptom
management. LFTs improved over course of hospitalization.
# Leukocytosis: Patient presented with normal WBC 6.4 on
admission, which rose to 16.8. Likely due to inflammation from
acute pancreatitis. S/p ERCP w/sphincterotomy; no evidence of
cholangitis on ERCP, but given low-grade fevers (99.5) and
increasing leukocytosis, started empiric cipro. No evidence of
pneumonia on CXR. She will complete one week of ciprofloxacin
at home.
# Hypertension: She was discharged on amlodipine and
metoprolol. She will f/u with her PCP for continued blood
pressure management.
# ? NASH/hepatic fibrosis on ultrasound. PCP should discuss
dietary measures, consider liver biopsy to further assess.
Medications on Admission:
Home medications:
Per [**Company 25282**] -
she does not know her medications
Metoprolol tartare 25 mg po bid
lisinopril 10 mg po bid
HCTZ 12.5 mg po daily (last refilled in [**Month (only) 958**])
amlodipine 5 mg po daily (last refilled in [**Month (only) 958**])
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*5 Tablet(s)* Refills:*0*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*10 Tablet(s)* Refills:*0*
5. Aspirin [**Hospital1 1926**] 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
gallstone pancreatitis
atrial fibrillation
pumonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and found to have
pancreatitis caused by gallstones. An ERCP was performed to
remove the stone. Your course was complicated by Atrial
Fibrillation (irregular heart rhythm) with rapid heart rate and
fluid in the lung requiring ICU stay. Your heart rate was
controlled and you were moved back to the medical floor. You
were able to start eating on [**2102-3-26**]. You will need to follow up
with your PCP to discuss treatment for Atrial Fibrillation with
at least daily aspirin, but this may also include an additonal
medication, Clopidogrel. You need to complete one week of
antibiotic treatment with ciprofloxacin and this will end on
[**3-30**].
In regards to your blood pressure, please take metoprolol 25 mg
by mouth twice a day, and restart the amlodipine at 5 mg daily.
Hold the hydrochlorothiazide and lisinopril until you see Dr
[**Last Name (STitle) 63252**] on [**Last Name (STitle) 2974**]. Please start taking a baby aspirin every
day starting on [**3-30**]. You may take dulcolax (bisacodyl)
to help you move your bowels.
Followup Instructions:
PCP [**Name Initial (PRE) **]: [**Last Name (LF) 2974**], [**3-31**] at 4:15pm
With: [**Name6 (MD) **] [**Name8 (MD) **],MD
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 46646**]
Phone: [**Telephone/Fax (1) 34574**]
ICD9 Codes: 9971, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 811
} | Medical Text: Admission Date: [**2186-1-25**] Discharge Date: [**2186-1-28**]
Date of Birth: [**2138-12-11**] Sex: F
Service: PLASTIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 16920**]
Chief Complaint:
acquired deformity, right breast
Major Surgical or Invasive Procedure:
right [**Last Name (un) **] breast flap on [**2186-1-25**]
History of Present Illness:
This 47-year-old female was seen in the Multidisciplinary Breast
Unit with a new diagnosis of carcinoma of the right breast
diagnosed by core needle biopsy
[**2185-11-14**]. This was ductal carcinoma in situ. She is here for
mastectomy and breast reconstruction.
Past Medical History:
The patient sustained a right hemiparesis from a subarachnoid
brain hemorrhage in [**2185-10-20**]. She has recovered almost
completely from the right hemiparesis. Other significant past
medical history includes hypertension and vertigo.
Social History:
n/c
Family History:
She has a sister who was diagnosed with breast cancer at age 36.
Physical Exam:
GENERAL: She is a very pleasant 47-year-old woman who looks her
stated age, pleasant, and appropriate affect.
VITAL SIGNS: Height five feet eight inches. Weight 190 pounds.
Blood pressure 150/90. Pulse is 66.
HEENT: Within normal limits.
NECK: Supple. There is no thyroid enlargement or nodules. There
is no cervical or supraclavicular adenopathy.
BREASTS: Symmetric. There is no nipple retraction nor skin
dimpling. She has an area suggestive of some fullness in the
lower outer quadrant of the right breast. There is no axillary
adenopathy.
CHEST: Clear to percussion and auscultation.
CARDIAC: Regular rate and rhythm.
BACK: Nontender without bony tenderness. There are no abnormal
pigmented lesions and she has a normal gait.
Pertinent Results:
[**2186-1-25**] 10:23PM BLOOD Calcium-8.0* Phos-5.2* Mg-1.3*
[**2186-1-25**] 10:23PM BLOOD Glucose-136* UreaN-10 Creat-0.7 Na-138
K-4.6 Cl-106
[**2186-1-25**] 10:23PM BLOOD Plt Ct-318
[**2186-1-25**] 10:23PM BLOOD WBC-15.3*# RBC-3.87* Hgb-10.7* Hct-33.5*
MCV-87 MCH-27.7 MCHC-32.0 RDW-15.2 Plt Ct-318
[**2186-1-26**] 02:54AM BLOOD Calcium-7.7* Phos-4.1 Mg-2.5
[**2186-1-26**] 02:54AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-139
K-4.4 Cl-107 HCO3-24 AnGap-12
[**2186-1-26**] 02:54AM BLOOD Plt Ct-287
[**2186-1-26**] 02:45PM BLOOD Plt Ct-224
[**2186-1-26**] 02:54AM BLOOD WBC-14.2* RBC-3.38* Hgb-9.5* Hct-29.1*
MCV-86 MCH-28.0 MCHC-32.5 RDW-15.5 Plt Ct-287
[**2186-1-26**] 02:45PM BLOOD WBC-9.2 RBC-2.86* Hgb-8.0* Hct-24.6*
MCV-86 MCH-28.1 MCHC-32.6 RDW-15.4 Plt Ct-224
[**2186-1-27**] 01:33AM BLOOD Calcium-7.7* Phos-2.0*# Mg-1.7
[**2186-1-27**] 01:33AM BLOOD Glucose-96 UreaN-8 Creat-0.5 Na-139 K-3.7
Cl-108 HCO3-27 AnGap-8
[**2186-1-27**] 01:33AM BLOOD Plt Ct-213
[**2186-1-27**] 01:33AM BLOOD WBC-9.6 RBC-3.13* Hgb-8.9* Hct-26.9*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.6* Plt Ct-213
Brief Hospital Course:
The patient was taken to the operating room where she underwent
a mastectomy and [**Last Name (un) **] flap of the right breast. She tolerated
the procedure well and was transferred to the ICU. She had good
dopplerable pulses throughout her ICU stay. She tolerated a
regular diet on POD 1. She voided appropriately and her foley
was removed on POD 2. She was transferred to the floor on POD 2
and continued to have good dopplerable pulses on the floor. She
was discharged in good condition on POD 3.
Medications on Admission:
Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
4. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p right [**Last Name (un) **] breast flap on [**2186-1-25**]
Discharge Condition:
good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed
from your wounds.
Be sure to record your drain output every day.
Followup Instructions:
Call to schedule a follow-up appointment next week with Dr.
[**First Name (STitle) 3228**]. His phone number is ([**Telephone/Fax (1) 23640**].
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 812
} | Medical Text: Admission Date: [**2132-8-6**] Discharge Date: [**2132-8-21**]
Date of Birth: [**2062-5-28**] Sex: M
Service:
CHIEF COMPLAINT: Difficulty swallowing x2 days
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old man
with a history of diabetes, hypertension and alcohol abuse,
as well as a recent embolic stroke diagnosed on [**2132-7-19**]. He presented with his initial stroke to [**Hospital3 **]
Hospital. He apparently had multiple small embolic strokes
that left him with a left sided residual hemiparesis. At
that time, he had a CT scan, MRI, cardiac echocardiogram and
Holter monitor. His head CT was significant for an area of
low attenuation at the left head caudate and another area
adjacent to the occipital lobe with no mass effect. His MRI
on [**7-20**] showed a wedge shaped infarct in the medial cortex of
the left occipital lobe and multiple smaller areas extending
from this area anterior into the left occipital lobe and
posterior temporal lobe, also significant for lesions in the
left cerebellar hemisphere, several small punctate lesions in
the brain stem and the right median lower pons and centrally
in the upper pons.
and there was a questionable lesion in the right cerebellar
hemisphere, as well as a possible region in the right
thalamus.
His MRA on [**7-20**] showed stenosis of the right vertebral artery
and abrupt termination of the distal left vertebral artery.
His basilar artery was patent without any significant
stenosis and he had an abnormal appearance of both posterior
cerebral arteries. He had a Holter monitor which showed no
evidence of any abnormal activity. His echocardiogram on
[**7-21**] was a transesophageal echocardiogram which showed his
left atrium was normal size, normal right ventricular and
left ventricular function with mild atheroma of the left
descending aorta and no evidence of a patent foramen ovale
and his tricuspid aortic
valve showed mild thickening. He was eventually discharged
from [**Hospital3 **] Hospital and sent to [**Hospital3 **] Manor for acute
rehabilitation from his multiple infarcts. According to his
primary care physician, [**Name10 (NameIs) **] was doing well in his
rehabilitation until Monday, [**2132-8-4**]. At that time,
he was noted to have significant left residual weakness in
both arms and legs, but he seemed motivated to participate in
rehabilitation and was able to feed himself, as well as
participate in group activities.
According to his primary care physician, [**Name10 (NameIs) **] was an acute
change in his behavior on the Monday prior to admission. He
appeared to be less interested in group activities and to
have a lot more difficulty with feeding himself. He was
observed to take food into his mouth, but then did not seem
to know what to do with it. He had pushed it around, but he
would not swallow it appropriately. He was also observed not
to have any choking with these events. He denied having any
swallowing problems himself when the patient is asked
directly.
REVIEW OF SYSTEMS: On admission, he denies chest pain,
shortness of breath, palpitations, abdominal pain, nausea,
dysuria and diarrhea.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type II
2. Stroke on [**2132-7-19**]
3. Hypertension
4. Coronary artery disease, status post myocardial
infarction at uncertain time in past.
5. Possible history of alcohol abuse
ADMISSION MEDICATIONS:
1. Plavix 75 mg po q day
2. Aspirin 325 mg po q day
3. Colace 100 mg po bid
4. Senokot 2 tablets po q hs
5. Zestril 10 mg po q day
6. Cardizem 90 mg po 4x a day
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: The patient reports a history of heavy
alcohol use in the past. When asked, the patient says he
used to drink about half a bottle of whiskey a day. History
of tobacco use in the past of a half pack per day, however he
has not smoked since his initial stroke on [**2132-7-19**]. He lives
in [**Location 3615**] and has four children in [**State 350**].
FAMILY HISTORY: The patient was unable to answer at that
time.
EXAMINATION ON ADMISSION:
GENERAL: The patient was sleepy, but easily arousable.
VITAL SIGNS: His blood pressure was 173/106. Pulse was 87,
respirations 18.
HEAD, EARS, EYES, NOSE AND THROAT: He was normocephalic,
atraumatic. Oropharynx was clear. Dry mucous membranes.
He had no carotid bruits. Audible breath sounds, but he
would not cooperate with holding his breath.
LUNGS: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm, S1, S2 normal, no murmurs,
rubs or gallops appreciated.
ABDOMEN: Soft, obese, nontender with normoactive bowel
sounds.
EXTREMITIES: He had no edema.
ADMISSION NEUROLOGIC EXAM: Mental status: He was oriented
to person and [**Location (un) 86**], but could not come up with the word
hospital. He said it was [**2093**] and that it was Spring. Asked
how he knew it was Spring and he said because the snow melts
in the Spring. He agreed that he was in the hospital when
asked and when asked if he was in school, he said no. The
patient was moderately attentive, able to name the days of
the weeks forwards and backwards, but unable to get past
[**Month (only) 1096**] on months of the year backwards. He recalled zero
objects at two minutes. He was able to repeat three objects,
however and was able to repeat sentences with mild
dysarthria. His naming was intact to ring, watch, eyeglasses
and pen. He had poor knowledge for current events. He said
that the current president is [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 780**] and when asked
if [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 780**] was still alive, he said probably not.
The patient had no spontaneous verbal output for responding
to questions, without any paresthesias or perseveration. His
sentence length was varied and up to at least five or six
words.
When asked if I was wearing a hat, he appropriately responded
no. He was able to demonstrate brushing his teeth. When
asked to pretend to drink a cup of coffee, he refused. His
writing was very poor. When asked to write today is a sunny
day, he started writing in the middle of the paper and then
quickly ran out of paper on the side of the page and tried to
write on the examiner's hand. When given a piece of paper
with two numbers written on it, he was only to name the
number on the right hand side and ignored the other number.
When asked to draw a clock, he drew a tiny circle on the
right hand side of the page and when asked to draw the
numbers on the face, he drew the 1 and 2 inside the circle
and then proceeded to draw the other numbers off the right
hand side of the paper.
Cranial nerves: His visual acuity was normal, but difficult
to test. He was able to name objects shown to him
appropriately, however when shown a visual acuity card, he
was only able to name the first number and then just appeared
to name numbers randomly. His pupils react normally to
light. His visual fields appeared possibly reduced over the
left hemifield, though again the patient would not cooperate
His optic fundi were normal in appearance. His eye
movements were normal and full. Sensation on his face was
decreased to light touch and pinprick over V1 through V3 on
the left base. He has a left facial droop. His hearing is
intact to bilaterally. He had a palate that
elevated in the midline with a good gag reflex. His
sternocleidomastoid muscles were 5/5 strength bilaterally.
His tongue was midline.
Motor system: The patient had decreased tone in the left
upper extremity and left lower extremity. No adventitious
movements. His drain on the left in his deltoid was one.
Biceps strength was [**4-1**], triceps strength was [**2-2**]. Wrist
flexors and wrist extensors only had 3/5 strength. His
finger flexors and finger extensors had minimal movement.
Iliopsoas on the left was 4/5 strength. His hamstrings were
[**3-4**]. Tibialis anterior was only [**2-2**] and his toe extensors
and toe flexors only had about 2/5 strength. His right upper
extremity and lower extremity had full strength throughout.
Sensory exam was difficult due to poor cooperation, however
the patient had sensation intact to light touch and position
sense in all four extremities. Decreased vibration sense
bilaterally in the lower extremities and pinprick decreased
over the left base and left leg, but not decreased in the
left arm. His reflexes were 2+ and symmetric throughout,
except for plantar responses upgoing in the left and
downgoing in the right. On coordination testing, the patient
was unable to cooperate on left upper extremity because of
weakness, however on his right finger nose finger test he
significantly overshot to the right on every motion. His
gait was not assessed on admission.
ADMISSION LABS AND STUDIES: White count 7.9, hematocrit
39.3, platelets 149. Sodium 135, potassium 3.5, BUN 10,
creatinine 0.8, glucose 204. His urine output was
unremarkable and he had a chest x-ray that showed no evidence
of any infiltrates or effusions. The patient had an MRI on
the night of admission which showed bilateral occipital
infarcts on FLAIR imaging. Diffusion weighted imaging was
unobtained due to problems with the scanner. Also, note was
made of a lesion in the right dome. His MRA was significant
for a hypoplastic left vertebral artery that possibly ended
in pica. His right vertebral artery was noted to be
significantly stenotic, although the basilar artery was
unremarkable.
The patient was admitted to the neurological service.
HISTORY OF HOSPITAL COURSE: The morning after admission, it
was decided to start him on a heparin drip due to the
stenosis in his right vertebral artery as well as the thought
that he may be continuing to throw emboli into his posterior
circulation. He had a angiogram on the [**8-7**] which
again was significant for right vertebral artery stenosis.
He remained stable over the weekend on heparin except for the
fact that he was unable to be propped up in bed at all
because his mental status significantly decreased any time
you sat him up. Due to the nature of his significant
inability to tolerate any position other than lying flat,
decision was made to try and place a stent in his right
vertebral artery.
On [**8-11**], he had a repeat angiogram in the interventional
radiology suite and two stents were placed in his right
vertebral artery. There were no complications of the
procedure and the patient did well.
The patient was briefly transferred out to the floor team on
[**2132-8-14**], but then was noted to have a fever to about 102?????? and
it was noted that in the area of his right wrist where he had
had his arterial line, he now had evidence of an infection
and right hand cellulitis. He had blood cultures, urine
cultures, a chest x-ray and an abdominal film done.
The chest x-ray and his abdominal film were both
unremarkable. His blood cultures ended up growing 4/4
bottles of coagulase positive Staphylococcus aureus bacteria
which were sensitive to oxacillin. The patient was started
on oxacillin for this infection as well as for his
cellulitis. He was also found to have an enterococcal
urinary tract infection which was treated with levofloxacin.
Surgery was also consulted regarding his right wrist
infection, however they recommended antibiotics only with no
debridement. After several days, his fever cleared and his
mental status improved significantly.
Overall, throughout his hospital course, he has had minimal
improvement in his right upper extremity and left lower
extremity weakness with progressive increase in tone and
hyperreflexia throughout his hospital course. He did improve
significantly after his right vertebral stent in the sense
that he is now able to tolerate multiple postural positions
without any worsening of his mental status.
The patient had a swallowing study which he successfully
passed and he will be started on a pureed and honey thickened
diet and advanced if he tolerates it. He is going to
continue on oxacillin, as well as continue Diltiazem for his
blood pressure control.
DISCHARGE DIAGNOSES:
1. Status post multiple embolic strokes in the past month
2. Hypertension
3. Diabetes
4. Coronary artery disease
5. History of prior heavy alcohol use
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Discharge to rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg po q day
2. Zantac 150 mg po bid
3. Oxacillin 2 gm intravenous q6h
4. Diltiazem 90 mg po qid
5. Multivitamin 1 tablet po q day
6. Aspirin 325 mg po q day
7. NPH insulin 5 units subcutaneous breakfast and dinner
time
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-190
Dictated By:[**Last Name (NamePattern1) 1203**]
MEDQUIST36
D: [**2132-8-20**] 08:22
T: [**2132-8-20**] 08:31
JOB#: [**Job Number 42864**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 813
} | Medical Text: Admission Date: [**2188-6-11**] Discharge Date: [**2188-6-30**]
Date of Birth: [**2124-3-3**] Sex: F
Service: SURGERY
Allergies:
aspirin / Erythromycin Base / Ether / Penicillins /
Sulfa(Sulfonamide Antibiotics) / Tetracycline
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Perineal erythema and pain.
Major Surgical or Invasive Procedure:
Incision and debridements of Fournier's gangrene X 5 ([**2188-6-11**],
[**2188-6-12**], [**2188-6-13**], [**2188-6-13**], [**2188-6-15**])
Wound vac change X 4 ([**2188-6-17**], [**2188-6-19**])
Abdominal and perineal wound washout, V.A.C. change, partial
wound closure ([**2188-6-21**], [**2188-6-24**], [**2188-6-27**]).
PICC line insertion: [**2188-6-23**]
History of Present Illness:
64F presents to the [**Hospital1 18**] ER as a transfer from an OSH with
increasing erythema and pain in her perineum. She stated she
first noticed some mild pain and swelling in the perineal region
2 days prior. She stated over the past 2 days the erythema has
been spreading and increasingly more painful. A CT performed at
the OSH demonstrated subcutaneous edema and air concerning for
Fournier's gangrene and the patient was immediately transferred
to [**Hospital1 18**] for further care. She was also given Vancomycin,
cefepime and clindamycin en route.
Past Medical History:
Past Medical History: COPD, OA, Meniere's, Anxiety, AVNRT s/p
ablation
Past Surgical History: cholecystectomy, appendectomy,
tonsillectomy, breast biopsy, knee surgery
Social History:
[**1-27**] ppd smoker, occasional alcohol, denies illicit drugs.
Family History:
Non-contributory.
Physical Exam:
On admission:
Vitals: T 100.0 P 116 BP 94/58 RR 20 O2 99% 2L
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, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, well healed
midline
scar
DRE: decreased tone, no gross or occult blood
Skin: Erythema and edema extending for the right perineum
through
the labia and mons pubis, area is very tender to mild palpation
Ext: No LE edema, LE warm and well perfused
On discharge:
Vitals: T 98, HR 98, BP 128/60, RR 18, Sat 92% room air.
Gen: AAO x 3, NAD.
Card: S1, S2, RRR. No m/r/g.
Pulm: Clear bilaterally (from anterior).
Abd: Soft, obese, non-tender. Active BS throughout.
GU: Foley catheter with clear yellow urine.
Skin and wounds: Four large surgical wounds closed with stures.
CDI.
1) Right lateral superior (just lateral to umbilicus)
2) Right lateral inferior (in close proximity to incision #1)
3) Right groin incision
4) Left groin incision
Extrem: Warm, dry, well-perfused. Patient with erythema and
pruritis of upper extremities.
Pertinent Results:
[**2188-6-11**] 03:30AM WBC-21.0* RBC-3.79* HGB-12.1 HCT-35.6* MCV-94
MCH-31.9 MCHC-33.9 RDW-13.4
[**2188-6-11**] 03:30AM NEUTS-91.1* LYMPHS-6.6* MONOS-2.0 EOS-0.2
BASOS-0.1
[**2188-6-11**] 03:30AM PLT COUNT-240
[**2188-6-11**] 03:30AM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.7
[**2188-6-11**] 03:30AM GLUCOSE-103* UREA N-16 CREAT-0.9 SODIUM-135
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18
[**2188-6-11**] 03:42AM LACTATE-2.9*
[**2188-6-12**] 07:05AM BLOOD WBC-17.2* RBC-3.43* Hgb-10.7* Hct-32.6*
MCV-95 MCH-31.1 MCHC-32.7 RDW-13.5 Plt Ct-240
[**2188-6-12**] 07:05AM BLOOD Plt Ct-240
[**2188-6-11**] 03:30AM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-135
K-3.8 Cl-99 HCO3-22 AnGap-18
[**2188-6-12**] 07:05AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 43313**] was admitted to the TSICU after her operation. She was
initially kept NPO and on IVFs. Her wound was closely monitored.
She did not complain of pain and felt better throughout the day.
She was given a regular diet. She was able to get out of bed to
chair. She was ready for transfer out of ICU on HD 1. However,
once on the floor, her cellulitis continued to spread. She was
taken to the OR urgently that night and had further debridement.
She was taken to the SICU after the OR, intubated and sedated.
Her cellulitis continued to spread and she was again taken to
the OR for further debridement and packed with saline gauze. On
HD 5, she was taken back to the OR. There appeared to be no
further evidence of infection and her fascia and soft tissues
appeared okay, a wound VAC x2 was placed over her abdomen &
perineal incisions. She was stable in the ICU. Her vent settings
were weaned until she was successfully extubated on [**2188-6-16**]. She
was intermittently agitated and haldol and ativan were given
prn. She went to the OR again on [**6-17**] for VAC change. She was
started on tylenol and dilaudid prn for pain control. Speech and
swallow evaluated her and she was given thin liquids, which she
tolerated. On [**6-18**] clindamycin was dc'd. Overnight, she had high
stool output, with diarrhea multiple times during the day, and
she was taken to the OR for VAC change. A rectal tube was placed
the next day and a cdiff sent, which was negative. Vancomycin
was also discontinued and a planned 3 week course of meropenem
was recommended by ID. She passed speech and swallow eval and
was continued on a regular diet, which she tolerated. She was
transferred to the floor on [**6-19**].
On the floor she remained alert and oriented. She continued on
meropenem. A PICC line was placed under fluoroscopy on [**6-23**]. Her
leukocytosis resolved and vac changes continued q3 days and as
needed in the operating room. Through each procedure, the
majority of her wounds have been surgically closed.
Her diarrhea slowed and her rectal tube was discontinued. Her
foley catheter was kept in place to avoid wound contamination.
She has been urinating without issue. She was encouraged to
mobilize out of bed as tolerated.
On the day of discharge, Mrs.[**Known lastname 112272**] right lateral (most
superior) wound was closed at the bedside. She is
hemodynamically stable and afebrile. She remains with a foley
catheter, which may be discontinued once assessed at the rehab
facility. She has been informed of her transfer to a
rehabilitation facility. I have also instructed her on the
importance of keeping her wounds (perineal, groin area) clean
and use of miconazole powder to prevent fungal infections.
Medications on Admission:
Calcium, vit b12 100 mcg, omeprazole 20'', prednisone 10',
effexor 225', vicodin prn, atrovent 17mcg 2 puffs '''', ativan
2''' prn, meclizine 25 q4h prn, compazine 5 q4h prn, ultram 50
q6h prn, hydrochlorathiazide 12.5'
Discharge Medications:
1. Sarna Lotion 1 Appl TP QID:PRN itching
2. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
apply to groin, clean area daily before re-application
3. Meropenem 1000 mg IV Q8H
4. Omeprazole 20 mg PO DAILY
5. PredniSONE 10 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Venlafaxine XR 225 mg PO DAILY
8. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
9. Albuterol Inhaler [**11-26**] PUFF IH Q4H:PRN wheeze
10. Ipratropium Bromide MDI 2 PUFF IH QID
11. Lorazepam 2 mg PO Q4H:PRN anxiety
12. Meclizine 25 mg PO Q6H:PRN dizziness
13. Prochlorperazine 5 mg PO Q4H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Fournier's Gangrene
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 with an infection of your
fascia in your perineal area called Fournier's Gangrene. This
infection required multiple debridements in the operating room
and a wound vac dressings. You were treated with IV antibiotics
along with surgical debridment and your infection stopped.
After your surgeries, you now have multiple surgical incisions
that are closed with sutures. It will be very important that
you keep those areas clean and dry. Wash with soap and water in
your perineal area daily, if not twice a day, and place
Miconazole (anti-fungal) powder to those areas after cleaning.
You are being discharged to a rehabilitation facility who will
coordinate and administer your medications. Follow up
appointments have been made for you to see your PCP and [**Name Initial (PRE) **]
surgeon from [**Hospital1 18**] (see below).
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
When: THURSDAY [**2188-7-17**] at 2:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 112273**], MD
Specialty: Primary Care
Address: [**Last Name (un) 59485**], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 9674**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2188-6-30**]
ICD9 Codes: 496, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 814
} | Medical Text: Admission Date: [**2155-8-16**] Discharge Date: [**2155-8-22**]
Date of Birth: [**2079-10-10**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with a past medical history notable for peptic ulcer
disease with a history of "bleeding ulcer," coronary artery
disease, diabetes mellitus type 2 and multiple sclerosis, who
presented to the [**Hospital1 69**]
emergency department early on the morning of admission
complaining of epigastric pain. The patient stated that,
approximately two weeks prior to presentation, she began
experiencing diarrhea alternating with constipation. Then,
approximately two days prior to admission, the patient began
having only constipation. When the patient did have bowel
movements, they were black and tarry. This was an
unprecedented occurrence for her. The patient denied having
any recent hematochezia, hemoptysis or hematemesis.
At approximately 2 AM on the morning of admission, the
patient was awakened by epigastric pain which was [**6-10**] in
severity and constant in duration. The patient could not
describe the quality of pain. She felt that it was well
localized to her epigastrium, although she admitted that she
also experienced interscapular pain with this episode of
epigastric pain. She was not surprised by this, as she
reported that she had interscapular pain "whenever I get
stomachaches--since I was a kid." The patient was brought by
EMS to the [**Hospital1 69**] emergency
department, where her pain abated completely shortly after
receiving Maalox at approximately 9:30 AM.
REVIEW OF SYSTEMS: Of note, the patient admitted that for
approximately five years her stool had been of smaller
caliber. She denied any other change in her bowel or bladder
patterns. She specifically denied fevers, chills, nausea,
vomiting, diarrhea or headache. She denied sore throat,
cough, recent change in weight and night sweats. In terms of
the patient's cardiovascular status, she specifically denied
having had any pain radiating to her left jaw (her anginal
equivalent) since her coronary artery bypass grafting in
[**2141**]. She denied chest pain, dyspnea, palpitations,
diaphoresis, lower extremity edema, paroxysmal nocturnal
dyspnea and orthopnea. (Although she used two pillows for
sleeping, she said that she did not become dyspneic without
them.) The patient denied any recent illnesses, including
changes in her multiple sclerosis. Similarly, she denied
recent changes in her appetite, diet and medication regimen.
Her fingerstick blood sugars had been consistently running
under 120.
PAST MEDICAL HISTORY:
1. Coronary artery disease: The patient had no history of
known myocardial infarction. She did have angina (left jaw
pain), which led to cardiac catheterization, which
subsequently led to coronary artery bypass grafting in [**2151**].
The patient had not had any angina since her coronary artery
bypass grafting.
2. Congestive heart failure: The patient had an ejection
fraction of 20-25% by echocardiogram in [**2155-10-2**] with
left ventricular hypokinesis, moderate mitral regurgitation
and mild pulmonary hypertension.
3. Peptic ulcer disease: The patient had a history of a
"bleeding ulcer" in [**2146**] with hematochezia. Per the patient,
this was an upper gastrointestinal bleed. No intervention
was required at that time. No pertinent records were
currently available for this history of bleeding ulcer. The
patient was on ranitidine.
4. Diabetes mellitus type 2: This was diagnosed
approximately one year prior to admission, per the patient.
This was well controlled on Glyburide with fingersticks
consistently under 120.
5. Hypertension: Per the patient, her blood pressure
typically ran in the 120s-130s/80s.
6. Hypercholesterolemia.
7. Multiple sclerosis: This was diagnosed when the patient
was approximately 35 years old. Per the patient, this had
not affected her vision but rather her lower extremities and
balance, such that she had difficulty walking well.
8. Spinal stenosis.
9. Mild dementia.
10. Urinary incontinence, likely functional, as the patient
had trouble getting to the bathroom in time.
11. History of right shoulder pain, status post a fall.
12. Chronic lower back pain, which continued status post
laminectomy in [**2148**].
13. Status post appendectomy in [**2120**].
14. Status post surgery to correct trigeminal neuralgia in
[**2118**].
MEDICATIONS ON ADMISSION:
1. Amantadine 100 mg p.o. b.i.d.
2. K-Dur p.o. q.d.
3. Lopressor 50 mg p.o. b.i.d.
4. Lipitor 20 mg p.o. q.d.
5. Lorazepam 2 mg p.o. h.s.
6. Vioxx p.o. q.d.
7. Glyburide 1.25 mg p.o. q.d.
8. NitroQuick p.r.n.
9. Ranitidine 150 mg p.o. b.i.d.
10. Folic acid 400 mg p.o. q.d.
11. Aspirin 325 mg p.o. q.d.
12. Moexipril 15 mg p.o. q.d.
13. Lasix 20 mg p.o. q.d.
14. Zoloft p.o. q.d.
15. Tylenol #3 p.r.n.
15. Ditropan p.r.n.
SOCIAL HISTORY: The patient lived alone at home in
[**Location (un) **], [**State 350**]. She had two boarders who lived
upstairs in her home. She would like to move to an [**Hospital3 12272**] facility soon. The patient denied a tobacco history.
She admitted rare alcohol use, but not abuse. The patient
denied any other drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 97.2??????F, a heart rate of 86, a blood pressure
of 171/86 in the left arm and 181/80 in the right arm,
respirations of 14 per minute and an oxygen saturation of 97%
on room air. In general, the patient was a pleasant
75-year-old woman, awake and in bed, in no acute distress.
On head, eyes, ears, nose and throat examination, the pupils
were equal, round and reactive to light and accommodation
bilaterally. The extraocular movements were intact
bilaterally. The nasal and oral mucosa were clear. The
mucous membranes were moist. The neck was supple without
thyromegaly, jugular venous distention, lymphadenopathy or
bruits.
The heart had a II/VI systolic ejection murmur heard
maximally at the apex with a sinus S1 and S2 and no rubs or
gallops. The chest had mildly decreased breath sounds with
occasional rhonchi at the bases bilaterally. Otherwise, the
chest was clear to auscultation bilaterally with a well
healed sternotomy scar.
The abdomen was soft, but mildly tender to palpation,
especially in the left lower quadrant. The abdomen was
nondistended with positive normal active bowel sounds. There
was a well healed midline scar, apparently due to exploratory
laparotomy, which eventually led to appendectomy. The
gastrointestinal evaluation revealed dark stool that was
guaiac positive. The patient was nasogastrically lavaged in
the emergency department with 250 cc of fluid, revealing no
blood and no bile.
In the extremities, the venous graft harvest site was well
healed at the right lower extremity with no clubbing,
cyanosis or edema. Pedal pulses were 2+ bilaterally. On
neurological examination, the patient was alert and oriented
times three. Speech was normal and appropriate. Cranial
nerves II through XII were intact bilaterally with the
possible exception of the tongue deviating slightly to the
right. Strength was [**4-5**] in the upper extremities and lower
extremities proximally and distally bilaterally. Sensation
was intact to light touch bilaterally at the distal lower and
upper extremities as well as the three divisions of cranial
nerve V. Rapid alternating movements were intact
bilaterally. Reflexes were 0 at the lower extremities
bilaterally and 2+ symmetrically at the upper extremities.
The right toe was downgoing and the left toe was equivocal.
LABORATORY DATA ON PRESENTATION: Note that the patient was
guaiac positive, but nasogastric lavage negative (as noted
above.) The CBC revealed a white blood cell count of 10,300,
hematocrit of 30.0 (which upon repeat was 31) and platelet
count of 289,000. Chem 7 revealed a sodium of 138, potassium
of 6.0 (which upon repeat was 4.0), chloride of 108,
bicarbonate of 19, BUN of 49, creatinine of 1.3 and glucose
of 121. Coagulation studies revealed a prothrombin time of
12.4, partial thromboplastin time of 25.6 and INR of 1.0.
Liver function tests and pancreatic function tests revealed
an ALT of 33, AST of 52, total bilirubin of 0.2, amylase of
41 and lipase of 21. Cardiac enzymes were cycled times
three: CK #1 was 287 with an MB of 6, CK #2 was 177 with an
MB of 4 and a troponin of less than 3 and CK #3 was likewise
negative.
RADIOLOGY DATA ON PRESENTATION: The chest x-ray showed
cardiomegaly with no increase in pulmonary vasculature and no
infiltrates or effusions. There was degenerative joint
disease of the spine. There was no air under the diaphragm.
ELECTROCARDIOGRAM: The electrocardiogram showed an old left
bundle branch block and sinus rhythm with no acute changes.
HOSPITAL COURSE: What follows is an outline of the [**Hospital 228**]
hospital course by problem list.
1. GASTROINTESTINAL BLEED: The patient was admitted
initially to the medicine service and the gastrointestinal
service was consulted. On [**2155-8-17**], the patient
underwent an esophagogastroduodenoscopy, which revealed grade
1 esophagitis at the gastroesophageal junction as well as a
large, cratered, 3 cm ulcer with adherent clot in the
proximal bulb of the duodenum. A visible vessel suggested
recent bleeding. BICAP electrocautery was applied
successfully for hemostasis. Otherwise, the
esophagogastroduodenoscopy was normal to the third part of
the duodenum.
The patient was continued on Protonix 40 mg p.o. b.i.d. Her
aspirin and Vioxx had been held since admission.
Helicobacter pylori was sent, which eventually came back as
positive. Late in the evening of [**2155-8-17**], the
patient began to experience hematemesis. Nasogastric lavage
could not successfully clear the patient and thus she was
transferred to the medical intensive care unit. The patient
was transfused two units of packed red blood cells and
subsequently underwent embolization by the interventional
radiology team. Following embolization, the patient
experienced a second mild hematocrit drop and was transfused
an additional two units. Thereafter, her hematocrit remained
stable.
In terms of the patient's Helicobacter pylori, she was
started on a Prevpac, which she is to continue for two weeks.
Following conclusion of the Prevpac, the patient should be
maintained on Protonix or some other gastrointestinal
prophylaxis and she should not be given non-steroidal
anti-inflammatory drugs or aspirin, as she has a risk of
re-bleeding.
Other gastrointestinal issues for the patient include the
fact that she has a history of decreased stool caliber for
approximately the past five years. Thus, she will need a
follow up colonoscopy as an outpatient to evaluate for
possible malignancy.
2. CARDIOVASCULAR:
a) In terms of the patient's coronary artery disease, she was
ruled out for myocardial infarction. Her aspirin was
discontinued upon admission because of the risk of
gastrointestinal bleed. She was continued on Lipitor,
Lopressor and a cardiac diet.
b) In terms of the patient's blood pressure, pump status and
history of congestive heart failure, she was continued on
Lopressor and Lasix.
3. DIABETES MELLITUS TYPE 2: The patient was maintained on
her outpatient regimen of Glyburide and maintained good
fingerstick blood sugars.
4. MULTIPLE SCLEROSIS: The patient was continued on her
amantadine without any exacerbations of her multiple
sclerosis.
5. FLUID, ELECTROLYTES AND NUTRITION: Following
embolization, the patient's diet was advanced successfully
and she tolerated it without nausea, vomiting or diarrhea.
Her electrolytes remained stable.
6. PROPHYLAXIS: The patient was maintained for a time on
Protonix drip, followed thereafter by her Prevpac which,
after outpatient discharge, is to be followed by other
gastrointestinal prophylaxis per her primary care physician.
CONDITION ON DISCHARGE: The patient remained stable and
afebrile.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed: duodenal ulcer.
2. History of coronary artery disease.
3. Congestive heart failure.
4. Diabetes mellitus type 2.
5. Hypertension.
6. Multiple sclerosis.
DISCHARGE MEDICATIONS: The patient was discharged on her
above noted outpatient medication regimen with the notable
exceptions of aspirin and non-steroidal anti-inflammatory
drugs, which were discontinued due to the risk of re-bleed.
Furthermore, the patient was discharged on Prevpac q.d., of
which she is to finish a two week course. Following
conclusion of her Prevpac, the patient should be placed on
gastrointestinal prophylaxis such as Protonix or an H2
blocker.
FOLLOW UP: The patient should follow up with her primary
care physician within the following week.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2155-8-22**] 11:00
T: [**2155-8-22**] 11:52
JOB#: [**Job Number 27714**]
ICD9 Codes: 2851, 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 815
} | Medical Text: Admission Date: [**2105-6-12**] Discharge Date: [**2105-6-19**]
Date of Birth: [**2018-1-15**] Sex: F
Service: NEUROLOGY
Allergies:
Novocain
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
IV tPA before arrival at this hospital
History of Present Illness:
87 yo RHF with past medical history of AFib off coumadin for
past
week for colonoscopy, HTN,HL,AR, CHF p/w acute onset left sided
weakness at 3:15 p.m. She was in USOH till 3:00 p.m. today and
was seen by her son at 3:15 p.m. while eating to have acute
onset
weakness on the left side, noticed due to her food dribbling
down
on the left side of her face. EMS was called and she was taken
to
[**Hospital1 **] [**Location (un) 620**] at 3:26 p.m. and was found to have dense left
hemiplegia, hemineglect and left visual field cut. Head CT
showed
a dense RMCA M1 thrombus extending up to M2. She received IV tPA
starting at 4:29 p.m. and received the full dose. She then
started complaining of mild right sided headcahe ([**12-2**]) which
persisted. She was then transferred to [**Hospital1 18**] for evaluation for
possible neurointerventional procedure.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies 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:
-AFib previously on coumadin, but held for colonoscopy on [**6-10**]
(for 1 week now)
-HTN
-HL
-moderate aortic regurgitation
-PDA
-CHF EF 55-60%
-h/o syncope
-hypothyroidism
-polymylagia rheumatica
Social History:
lives independently and is fully functional
at baseline. Retired secretary, drives a car. Has very involved
children. Denies tobacco, occasional
alcohol.
Family History:
Father died at age 75 of CAD, mother died at 95 of
CHF, brothers with [**Name2 (NI) 499**] cancer, daughter with lymphoma.
Physical Exam:
Vitals: T: AF P:86 (afib) R: 16 BP: 146/102 SaO2: 99%RA
General: Eyes closed, arouses to voice, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregularly irregular.
Abdomen: soft, NT/ND
Extremities: WWP
Skin: Bruises/ecchymoses noted in bilateral arms, with large
skin
tear on left elbow.
Neurologic:
(If applicable)
NIH Stroke Scale score was: 14
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 2
3. Visual fields: 2
4. Facial palsy: 1
5a. Motor arm, left: 3
5b. Motor arm, right: 0
6a. Motor leg, left: 2
6b. Motor leg, right: 1
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 2
-Mental Status: Alert, oriented to name, month, and [**Hospital1 **] [**Location (un) 620**].
Drowsy, and dozes off when not being questioned. Speech is
fluent
in conversation. There were no paraphasias. Only able to report
"chair" and read the word "room" on stroke card, which are the
farmost right items, demonstrating dense neglect vs hemianopia.
Speech was not dysarthric. Able to follow both midline and
appendicular one-step commands. Dense visual, sensory, and
auditory neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. Does not BTT in left visual field
in either eye. Funduscopic exam deferred.
III, IV, VI: Forced gaze deviation to R that does not cross
midline. No nystagmus noted.
V: Facial sensation intact to light touch.
VII: Left facial paresis w NLF and inability to close L eye.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, decreased tone on left. Moves LLE in plane
of bed but is unable to lift antigravity. Withdrawal response to
pain in LUE. Right sided extremities are antigravity.
-Sensory: Senses light touch reliably on right; sometimes when
left side is touched, she states she feels it on the right,
othertimes she does not feel it at all. Again sensory neglect is
profound.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was upgoing on the left.
-Coordination: No gross dysmetria when reaching out w right
hand.
-Gait: deferred.
**********
Laboratory Data:
Pertinent Results:
[**2105-6-13**] 02:58AM BLOOD WBC-8.1 RBC-4.12* Hgb-12.6 Hct-38.5
MCV-93 MCH-30.6 MCHC-32.7 RDW-15.4 Plt Ct-157
[**2105-6-13**] 02:58AM BLOOD PT-11.2 PTT-25.2 INR(PT)-1.0
[**2105-6-13**] 02:58AM BLOOD PT-11.2 PTT-25.2 INR(PT)-1.0
[**2105-6-13**] 02:58AM BLOOD Glucose-119* UreaN-15 Creat-0.7 Na-133
K-3.8 Cl-99 HCO3-26 AnGap-12
[**2105-6-13**] 02:58AM BLOOD CK-MB-1 cTropnT-<0.01
[**2105-6-13**] 02:58AM BLOOD Triglyc-99 HDL-57 CHOL/HD-2.5 LDLcalc-66
[**2105-6-13**] 02:58AM BLOOD %HbA1c-5.6 eAG-114
[**2105-6-15**] 06:20AM BLOOD Digoxin-0.4*
CT/CTA/CTP
No acute intracranial hemorrhage.
2. CT perfusion study suggests acute infarctions in the
superior right middle
cerebral artery territory and in the right posterior cerebral
artery
territory. These are not yet detectible on the conventional CT
images, with
only a small focus of mild cytotoxic edema noted in the right
anterior insula.
3. Large thrombus extending from the distal right common
carotid artery into
the proximal right internal carotid artery with 99% stenosis.
This thrombus
also extends into and completely occludes the proximal right
external carotid
artery, which demonstrates distal reconstitution, most likely
via retrograde
filling through its branches.
4. Occlusion of the superior division of the right middle
cerebral artery.
5. Bilateral fetal configuration of posterior cerebral
arteries. The
posterior communicating arteries appear patent bilaterally.
6. Enlarged and multinodular thyroid. This may be further
evaluated by
[**Name (NI) 13416**], if not previously performed elsewhere.
MRI/MRA head and NEck
1. Large acute infarctions involving the right frontal lobe,
insula, and
temporal lobe in the middle cerebral artery territory and the
right occipital lobe in the posterior cerebral artery territory.
2. Focal hemorrhagic transformation in the posterior right
temporal lobe.
3. Motion-limited MRAs of the head and neck demonstrate no
appreciable change
from the preceding CTAs of the head and neck. There is a large
thrombus
extending from the distal right common carotid into the proximal
right
internal carotid and external carotid arteries, with 99%
stenosis of the right
internal carotid artery, better demonstrated on the CTA, and
complete
occlusion of the proximal external carotid artery (with
reconstitution via
retrograde filling). Persistent occlusion of the superior
division of the
right middle cerebral artery. Bilateral fetal posterior
cerebral arteries
with bilateral patent posterior communicating arteries.
Echocardiogram:
Patent ductus arteriosus. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Moderate to severe tricuspid regurgitation.
Pulmonary artery hypertension. Mild aortic valve stenosis. Mild
aortic regurgitation. Dilated ascending aorta.
CTA neck [**6-18**]:Interval decrease in size of the thrombus in the
right common carotid artery extending into both the internal and
external branches. A small amount of thrombus is still present.
2. The previously seen occlusion of the superior division of the
right MCA is not completely included in the field of view of
today's study given that the study is a neck CTA. If there is
any clinical concern for continued occlusion, recommend a
dedicated CTA of the head for further evaluation. 3. Worsening
pulmonary edema with bilateral pleural effusions.
Brief Hospital Course:
The patient is an 87 y/o with past medical history of
AFib off coumadin for pastweek for colonoscopy, HTN,HL,AR, CHF
p/w acute onset left sided weakness and found to have
left hempiplegia and profound neglect consistent with R MCA
syndrome.
Neuro: At [**Hospital1 **] [**Location (un) 620**] a dense MCA sign was seen on imaging, and
the pt received
IV TPA at 90 min after onset of symptoms. NIHSS was slightly
improved here to 14 from 17 at [**Location (un) 620**]. The patient had a CTA
head and neck here which revealed recanalization of the R MCA
with cutoff seen at R M2 superior division and evidence of
thrombus at the R CCA occluding 99%, extending to R ECA and R
ICA with recanalization distally. Endovascular intervention was
discussed with the
neurointerventional attending as well as stroke attending, Dr.
[**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] and the decision was made that the risk of
attempting recanalization of the R CCA thrombus could
potentially outweigh the benefit given the risk of distal
embolization with manipulation, and relatively intact blood
supply currently to circle of [**Location (un) 431**]. The patient had a MRI head
which showed large acute infarctions involving the right frontal
lobe, insula, and temporal lobe in the middle cerebral artery
territory and the right occipital lobe in the posterior cerebral
artery territory as well asa focal hemorrhagic conversion. The
patient was briefly placed on a heparin drip despite this due to
concern for the right carotid occlusion. This was later
discontinued when the patient had a headache due to concern for
bleed. CT head was obtained 24hours after tPA and showed no
progression of hemorrhagic conversion noted on MRI the previous
day. The patient remained in the ICU overnight and then was
transferred to the floor the following day. She was started on
aspirin and then restarted on Coumadin. The patient regained
some left sided strength and her left sided neglect improved
slightly. While on the floor she began to open her eyes
spontaneously and answered questions appropriately. A repeat CTA
of the neck showed decreased thrombus of the right common
carotid.
Cardiac: The patient was monitored on telemetry and remained in
atrial fibrillation. Her cardiac enzymes were negative. She was
continued on metoprolol at lower doses initially and home
antihypertensives were held to allow for autoregulation. Her
heart rate trended up and her metoprolol was increased to her
home dose. As above, she was started on aspirin bridge to
coumadin. Echocardiogram revealed a PFO.
Endocrine: Her fingersticks were checked and she was placed on
sliding scale insulin. Glycohemoglobin was normal and LDL
cholesterol was <100.
FEN: The patient was not able to swallow safely so a NG tube was
placed and tube feeds begun on [**6-13**]. On [**6-17**] the patient was
cleared to start ground solids and nectar thickened liquids. Her
tube feeds were held during the day and the plan is to continue
nightly tube feed until she is able to take in an adequate
number of calories.
Infection: The patient was noted to be delerious on [**6-15**] and UA
came back positive. She was started on Ceftriaxone for UTI,
urine culture pending at this time. Once antibiotics were
started her delerium cleared.
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- (x) No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - () No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? x() Yes (Type: (x)
Antiplatelet - (x) Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Simvastatin 40 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Warfarin MD to order daily dose PO DAILY16
2.5-5mg as directed
4. Digoxin 0.125 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Metoprolol Tartrate 100 mg PO BID
7. PredniSONE 1 mg PO DAILY
7 tabs daily
8. Docusate Sodium 100 mg PO BID
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. PredniSONE 1 mg PO DAILY
7 tabs daily
5. Metoprolol Tartrate 100 mg PO BID
6. Simvastatin 40 mg PO DAILY
7. Aspirin 325 mg PO DAILY
stop when INR [**12-26**]
8. Nystatin Cream 1 Appl TP [**Hospital1 **]
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
10. Nitrofurantoin (Macrodantin) 50 mg PO Q6H
Please continue through [**6-22**]
11. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right frontal, temporal and occipital lobe stroke
Patent foramen ovale
Discharge Condition:
oriented to date, does not believe we are at [**Hospital1 18**], thinks she's
in hospital in [**Country 6607**]. opening eyes. Answers questions
appropriately. Naming intact. left facial droop, L hemineglect,
L hemiparesis (antigravity). Increased tone in left arm.
localizes to pain on the left arm, withdraws to pain in left
leg. Toes up on left and down on Right. Bibasilar crackles in
lungs, improved.
Discharge Instructions:
Dear Ms [**Known lastname **],
You were admitted for a stroke. This was thought to be
secondary to your atrial fibrillation. You were restarted on
coumadin for stroke protection. Your stroke risk factors were
checked. You should continue to not smoke. Your LDL
cholesterol was 66. You were continued on a statin. You had a
cardiac echocardiogram which demonstrated no cardioembolic
source, but did show a patent foremen ovale. You were checked
for blood glucose control with a HgB A1c. The level was 5.6
which is normal. You need to continue your blood pressure
control.
You should continue to eat a low fat healthy diet, and follow up
with your primary care physician and stroke Neurology as
detailed below.
It was a pleasure taking care of you.
Followup Instructions:
PLease follow up
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern1) 57824**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 17200**]
Date/Time:[**2105-6-30**] 11:00
Provider: (neurology) [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2105-8-18**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2762**], MD Phone:[**Telephone/Fax (1) 3965**]
Date/Time:[**2106-4-14**] 1:30
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 4280, 5990, 4019, 2724, 2449, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 816
} | Medical Text: Admission Date: [**2175-9-11**] Discharge Date: [**2175-9-14**]
Date of Birth: [**2113-6-17**] Sex: F
Service: MEDICINE
Allergies:
Adalat Cc
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
dizziness, vomiting, hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62yo F w/ a PMH of afib, CAD, and CHF (diastolic dysfunction)
now admitted with nausea and dizziness in the setting of afib w/
RVR. Pt states that she first had symptoms of dizziness [**1-21**]
weeks ago in the setting of what she thought was a cold. She
took Sudafed for several days and the symptoms seemed to
improve. Her cold then seemed to settle into her chest, with a
sore throat predominating. She had 24hrs of diarrhea but then
felt well up until last night. During dinner last night, she
began to feel dizzy again. She describes her dizziness as a
sensation of a "heaviness" in her head. She denies any spinning
sensation, of either herself or the room. She denies any vision
changes. She states that she came home from dinner and went to
bed, but then got up in the middle of the night and had
difficulty walking to the bathroom and had to hold on to the
walls as she walked. She then decided to come to the ER for
further evaluation.
.
The dizziness is associated with a mild headache and nausea.
She's had emesis or more specifically, dry heaves x2. She denies
any presyncope, LH, falls or LOC. She denies any URI sx,
including cough, rhinorrhea or sinus tenderness. She denies any
SOB, CP or palpitations. She has had minimal PO's since the
start of these sx, but previously denied any weight loss, night
sweats, diarrhea. No urinary sx. No leg swelling, numbness,
tingling or weakness in her arms or legs.
.
In the ER, VS were T 97.5, BP 236/106, HR 120-130s, RR 16, sats
of 99% on RA.
Past Medical History:
Afib
- On [**Month/Day (3) 197**]/Coreg
- S/P cardioversion [**6-24**]
CAD
- cath in [**2169**]: The LMCA was angiographically normal. The LAD
had a 40-50% stenosis in the mid portion. The D2 branch had an
ostial/proximal 70% stenosis. The LCX had proximal mild luminal
irregularities. The RCA had a 30% mid stenosis. The R-PDA had a
70-80% proximal stenosis involving its takeoff.
Papillary thyroid cancer - Diagnosed in the summer of [**2173**], s/p
total thyroidectomy and radiation, on synthroid
Obesity
- S/P gastric bypass in [**12-22**]
HTN
CHF
- Diastolic Dysfunction, EF of 55%, LVH
DM type II
Hypercholesterolemia
TTP
OA
Social History:
Patient has a remote history of tobacco use for approximately 5
years, up to 1 ppd. She reports being a social alcohol drinker
and denies any illicit drug use.
Family History:
M died of lung cancer at age 56; F died of pna at 72, but also
had stomach cancer. Brother is 58 and healthy, other than HTN.
Physical Exam:
VS: T - 97.6, BP - 140/57, HR - 77, RR - 16, O2 - 97% on RA
Gen: Fatigued, intermittently dry heaving, but awake, alert and
oriented x 3 in NAD
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous with mildy
dry mucous membranes
CV: S1, S2 nl, no m/r/g appreciated
Lungs: CTAB
Abd: Soft, obese, NT, ND, +BS
Ext: No c/c/e
Neuro: CN II - XII intact; sensation intact; strength 5/5 in UEs
and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], reflexes 2+ in biceps, triceps,
brachioradialis bilaterally; downgoing toes bilaterally;
finger-to-nose intact, no dysdiadokokinesia; gait not assessed,
[**Last Name (un) **]-Hallpike deferred given patient's nausea
Pertinent Results:
WBC-10.7 RBC-4.97 HGB-12.7 HCT-39.9 MCV-80 MCH-25.6 MCHC-31.9
RDW-17.7
TSH 0.053, T4 10.2
CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-2.2
GLUCOSE-193* UREA N-21* CREAT-0.7 SODIUM-139 POTASSIUM-3.5
CHLORIDE-101 TOTAL CO2-31 ANION GAP-11
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
CK-MB-3 cTropnT-<0.01 CK(CPK)-54
.
Studies:
CT Head with contrast:
There is no hemorrhage, mass effect, shift of normally midline
structures or hydrocephalus. Tiny hypodensity is seen in the
right centrum semiovale, unchanged from the prior study,
consistent with microangiopathic change. No air- fluid levels
are seen in the paranasal sinuses. The mastoid air cells are
clear. The soft tissues appear unremarkable.
.
EKG: Baseline artifact. Regular supraventricular rhythm. There
is a late
transition which is probably normal. Compared to the prior
tracing regular
supraventricular tachycardia is now present.
.
MRI/A Brain: Multiple T2 and FLAIR hyperintense signals seen in
the periventricular and subcortical white matter, consistent
with chronic
microangiopathic changes. No evidence of acute hemorrhage or
stroke.
Brief Hospital Course:
A/P: 62 y.o. female with PMHx of A fib, s/p cardioversion, HTN,
CHF who presents with complaints of N/V and dizziness in the
setting of a. fib with RVR and hypertensive urgency.
.
# Nausea/Dizziness: Initial differential included vertigo, acute
MI, posterior CVA, labrynthitis with recent URI. ACS ruled out
by CEs x 2, 12 hours apart and has no ischemic changes on EKG,
making MI less likely. Posterior CVA assessed by MRI/MRA without
evidence of thrombosis or new CVA. Patient was followed by
neurology during stay and gave input concerning symptom
management. On the third day of admission, symptoms had
completely resolved, which is consistent with vertigo associated
with labrynthitis following her recent URI. Upon discharge
denies any further symptoms of nausea, vomiting or vertigo.
.
# HTN: Poorly controlled upon arrival to the ED at 236/106. OMR
notes demonstrate BP range of 120s-150s, though given 3
antihypertensive agents, suspected that patient likely has
chronically elevated blood pressure. Cause of acute elevation
was unclear, but likely related to poorly tolerating po
medications. Patient does report compliance with her medications
prior to hospitalization. Acute cardiac event was ruled out as
detailed above. Initially on ICU admit BP was being controlled
on Labetalol gtt. She denied HA and UA shows no evidence of
end-organ damage. Labetalol gtt was discontinued and she was
briefly hypotensive to low 100s. She continued to have labile
BP, with averages to 170s but had much improvement with addition
of home lasix dosing. Electrophysiology was consulted
concerning her afib despite prior cardioconversion and suggested
adding verapamil 80mg [**Hospital1 **]. This medication was only given once
while inpatient as she persistently had heart rates in the
mid-60s. She was not discharged on this medication, but sent
home on her prior antihypertensive medications with a VNA to
visit and perform BP checks.
.
# Atrial Fibrillation: S/P cardioversion in [**Month (only) 205**] on admit found
to be in atrial fibrillation again. Patient denied chest pain or
palpitations on presentation which might suggest asymptomatic a.
fib, thus making it difficult to tell if she has been in sinus
since her conversion. Underlying etiologies include
hyperthyroidism or infection. TSH suppressed, not hyperthyroid
on labs. Patient is afebrile now with no signs of infection, but
had a recent URI. Again, MI has been ruled out as above. HR
labile the evening of admit with swings from HR 120s to 65s
indicative of possible Afib vs autonomic dysfuntion. EP
consulted and thought she likely had atrial tachycardia and
recommended verapamil, maximum dosing of carvediol/lisinopril
and lasix. Verapamil held as above. Discharged with
instruction to decrease [**Month (only) 197**] dosing for next three days,
given elevated INR of 3.6. Should follow-up with [**Hospital 197**]
Clinic next week for INR check and dose adjustment.
.
# CAD: History of two vessel CAD with no intervention. Admitted
on ASA, BB and statin at outpatient dosing. No evidence of MI on
admit. Continue all outpatient meds.
.
# CHF: Preserved EF with LVH and elevated left-sided filling
pressures on echo in [**2173**] with overall greater evidence of
diastolic dysfunction, compared to previous echo in [**2169**].
Patient is followed by Dr. [**First Name (STitle) 437**] as an outpatient and took Lasix
PRN. On admit was hypovolemic given recent nausea and vomiting.
Given IVF and tolerated po on discharge, sent home on outpatient
medications.
.
# S/P Thyroidectomy: On suppressive therapy with Synthroid,
recently decreased. TSH is very suppresed at 0.053 despite
recent decrease in Synthroid from 225 mcg to 200 mcg. Patient is
followed by Dr. [**Last Name (STitle) **] in endocrine and per a conversation with
her yesterday, patient could benefit from decrease in Synthroid
to 175 mcg. On discharge was instructed to continue Synthroid
at 175 mcg and follow-up with her endocrinologist as outpatient.
.
# DM: Patient has a history of DM2, reportedly controlled with
diet and improved since gastric bypass. Most recent HbA1C is 6.5
in 4/[**2174**]. Patient is not on standing diabetic medications as an
outpatient. Was monitored with QID fingersticks and did
require a low dose ISS while inpatient. Instructed to follow-up
with PCP on this issue and continue to monitor her fingersticks
as an outpatient.
.
# TTP: Stable. Platelets are normal though slightly lower than
baseline approximately one year ago. Currently no signs of
bleeding. Patient also has no fever and hematocrit and
creatinine are normal. No active issues during hospital stay.
Medications on Admission:
Aspirin 81mg PO QD
Coreg 50mg PO BID
[**Year (4 digits) 197**] 5mg PO QHS
Cyanocobalamin 1000mcg PO QD
Co Q-10 100mg PO BID
Diovan 40mg PO QD
Lasix 40mg PO QD
Ibuprofen 800mg PO TID
Levoxyl 200mcg PO QD
Lisinopril 40mg PO QD
MVI 1tab PO QD
Simvastatin 80mg PO QD
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary: Hypertension, vertigo
Secondary: DM, coronary artery disease, congestive heart
failure, history of papillary thyroid cancer, atrial
fibrillation.
Discharge Condition:
Hemodynamically stable, tolerating oral intake and afebrile.
Discharge Instructions:
You have been admitted for hypertensive urgency, nausea and
dizziness. You were treated symptomatically with medicine for
nausea and your blood pressure. You were additionally evaluated
with CT Scan and MRI of your head, which did not reveal new
abnormalities concerning of recent stroke or bleeding. Once
your symptoms had resolved, you were discharged home with
continued services to help you during your recovery period.
While in the hospital, your medications were continued. The
only medication change we advise on discharge is that you hold
your [**First Name3 (LF) 197**] dose tonight, and then take only 3mg daily for the
following two days. After that you should resume your regular
dosing and follow-up with your [**Hospital 197**] Clinic in the next [**6-27**]
days for monitoring of your INR.
Additionally, you have required insulin while inpatient to
control your blood sugar. You should continue checking your
blood sugar four times daily and follow-up with your PCP in the
next 1-2 weeks to discuss your diabetic management.
Please return to the ED or contact Dr. [**Last Name (STitle) **] should your
symptoms return or should you become nauseated and unable to
tolerate oral intake.
Followup Instructions:
Provider: [**Name10 (NameIs) **] CLINIC [**Telephone/Fax (1) 10413**] Call to schedule
appointment
Please call your Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule and
appointment in the next 1-2 weeks to discuss your hypertension
and diabetes management further.
ICD9 Codes: 4019, 4280, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 817
} | Medical Text: Admission Date: [**2168-6-16**] Discharge Date: [**2168-6-21**]
Date of Birth: [**2098-6-17**] Sex: F
Service: MEDICINE
Allergies:
Ceclor / Vasotec / Talwin / Elavil / Iodine; Iodine Containing /
Vioxx / Bactrim Ds / Colchicine
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
s/p septal ablation
Major Surgical or Invasive Procedure:
ETOH septal ablation
Cardiac cath
History of Present Illness:
69 yo lady with h/o CAD (one vessel dz), diastolic CHF,
longstanding HTN, obesity, PBC, DJD admitted s/p etoh septal
ablation of LVOT obstruction. Patient was first diagnosed with
LVOT obstruction in [**2-25**] when she was admitted for chest
pressure and shortness of breath. Patient notes longstanding
chest pressure symptoms that have been present for more than 10
years. She says that she has diffuse chest pressure over her mid
sternum, poorly localized, not associated with any other
symptoms such as sob, diaphoresis, radiation. Her first cardiac
cath in [**2156**] revealed clean coronaries. In terms of her sob, she
reports symptoms starting in [**2-25**] where she could only walk 20
yards before having to stop to cath her breath. Also sob with
walking [**12-25**] stairs. She reports sleeping in a recliner with her
feet elevated, "can't breath" if lying flat. She states that she
was diagnosed with HTN at 15 and has been "well controlled"
however does not check her BP at home. She was admitted [**2090-3-17**]
with chest pressure, sob, LE edema. It was felt that her SOB was
likely due to diastolic dysfuntion with CHF exacerbation due to
Prednisone, dietary indescretion, and poorly controlled HTN. She
was diuresed with Lasix and sent home with outpatient follow up
of her LVOT obstruction.
Most recently, she was referred for a diagnostic catheterization
at [**Hospital6 **] on [**2168-5-30**]. During the
procedure it was noted that her LAD had a 50% lesion and
confirmed the left ventricular outflow obstruction (50mmHg). She
is now admitted for elective septal ablation and LAD stenting.
.
Upon arrival to the floor, patient talkative and feeling well,
no sob or chest pain. Lying flat, having some back pain, groin
site minimally painful. ROS negative for F/C/S, no N/V/D, no
other recent illnesses.
Past Medical History:
# Primary biliary cirrhosis [**2158-11-8**] by liver biopsy, recent
biopsy [**1-25**] w/ minimal findings
# Lactose intolerance.
# Celiac sprue:has not followed a gluten-free diet. Her last
upper endoscopy was done in [**2158**] with findings consistent with
celiac sprue.
# neuropathy from ?celiac
# gout
# Hypertension.
# Obesity.
# osteoporosis- not on treatment
# Obstructive sleep apnea, moderate-to-severe on study [**2159-3-2**].
# Musculoskeletal problem, cervical spondylotic myopathy, C5,C6,
C7 discectomies, anterior C6 carpectomy, anterior cervical
fusion with iliac crest bone graft, knee osteoarthritis, lower
spine degenerative spondylosis, left knee torn meniscus, left
hip trochanteric bursitis, recent knee replacement. She also had
recent surgery on her back to
repair prior surgery.
# monoclonal gammopathy of uncertain significance in 09/00
# spine surgery(anterior spinal fixation) in [**Month (only) **] followed
by a postoperative wound infection
Social History:
She is divorced with one adult son. [**Name (NI) 3003**] to retiring she
worked as a bookkeeper for an insurance agency. Quit smoking
approximately 15 years ago. Prior to quitting she smoked 1.5ppd
for approximately 40 years. Rare etoh.
Family History:
Non-contributory
Physical Exam:
VS: 166/74 48 15 95% RA Ht: 5'2" Wt: 210lbs BMI 38.4
Gen: Obese, NAD, very pleasant
HEENT: OP clear, moist, EOM, anicteric, no pallor
Neck: obese, ?JVD to mid jaw at 30 deg, normal carotids
Chest: clear anteriorly, trace crackles at bases
CVS: nl S1 S2, harsh ESM at LSB, radiates throughout
Abd: obese, soft, NT x 4, NABS
Ext: groin site intact, non tender, no hematoma, distal pulses
2+ b/l
Neuro: grossly intact
Pertinent Results:
[**2168-6-16**] 10:17PM CK(CPK)-709*
[**2168-6-16**] 10:17PM CK-MB-94* MB INDX-13.3*
[**2168-6-16**] 03:58PM CK(CPK)-444*
[**2168-6-16**] 03:58PM CK-MB-55* MB INDX-12.4*
[**2168-6-16**] 09:23AM GLUCOSE-102 UREA N-43* CREAT-1.4* SODIUM-141
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15
[**2168-6-16**] 09:23AM CK(CPK)-61
[**2168-6-16**] 09:23AM cTropnT-<0.01
[**2168-6-16**] 09:23AM WBC-17.5* RBC-4.63 HGB-11.8* HCT-34.4*
MCV-74* MCH-25.5* MCHC-34.3 RDW-17.7*
[**2168-6-16**] 09:23AM NEUTS-77.0* LYMPHS-17.0* MONOS-4.8 EOS-0.6
BASOS-0.7
[**2168-6-16**] 09:23AM ANISOCYT-1+ POIKILOCY-1+ MICROCYT-3+
[**2168-6-16**] 09:23AM PLT COUNT-456*
[**2168-6-16**] 09:23AM PT-11.4 PTT-21.0* INR(PT)-1.0
[**2168-6-15**] 04:05PM GLUCOSE-123*
[**2168-6-15**] 04:05PM UREA N-42* CREAT-1.4* SODIUM-141
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-19
[**2168-6-15**] 04:05PM WBC-19.2*# RBC-4.58 HGB-11.5* HCT-35.2*
MCV-77* MCH-25.0* MCHC-32.6 RDW-17.8*
[**2168-6-15**] 04:05PM PLT COUNT-557*
[**2168-6-15**] 04:05PM PT-11.7 PTT-23.2 INR(PT)-1.0
.
ECHO ([**2168-6-16**])Pre-Ablation:There is symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
There is a severe resting left ventricular outflow
tract/midcavity obstruction (125 mmHg). Right ventricular
chamber size and free wall motion are normal. There is no
pericardial effusion.
.
ECHO ([**2168-6-16**])Post-Ablation:Post ethanol injection into the
third septal perforator (2 injections) and the second septal
perforator (1 injection), the resting intracavity pressure
gradient is 24 mmHg. Compared to the previous study prior to
ethanol injection, the intracavbity gradient is greatly reduced.
.
Cardiac Cath ([**2168-6-16**]):One vessel coronary artery disease.
Elevated left-sided filling pressures at rest. Dynamic left
ventricular outflow tract gradient of 20-30 mmHg at rest and >
90 mmHg with valsalva manuever, post-PVC, and dobutamine
infusion. Successful alcohol septal ablation with decrease in
the left ventricular outflow gradient to < 25mmHg with
dobutamine infusion.
.
Cardiac Cath [**2168-6-20**]: 1. One vessel coronary artery disease.
2. Mildly elevated left and right sided filling pressures.
3. Resting LVOT gradient present on day#4 post alcohol septal
ablation.
4. Successful stenting of the mid LAD.
Brief Hospital Course:
The patient is a 69yo F with CAD (70% mid LAD), HTN, CHF, MMP
underwent cardiac catheterization on [**6-16**] for septal ablation to
relieve left ventricular outflow tract obstruction. The LVOT
gradient was 80-90 mmHg on dobutamine infusion prior to ablation
and 25 mmHg post ablation, both measured during the procedure
(see results section). A 70% concentric hazy lesion of the LAD
was also noted during this procedure (and was known prior to
admission). On [**6-20**] she underwent a second cardiac
catheterization for elective stenting of the LAD lesion with a
drug eluting Cypher stent. Her creatinine was slightly above
baseline on admission and she received renal protection prior
catheterization with mucomyst and iv fluids with bicarb.
During her hospitalization, she had native sinus bradycardia and
was discharged on half her previous dose of her outpatient
atenolol. Her verapamil was discontinued because of it's nodal
blocking properties, and for blood pressure control, she was
switched to amlodipine 10 mg daily.
.
Medications on Admission:
Verapamil 180mg daily every morning
Atenolol 100mg daily every morning
Lasix 40mg daily every morning
Allopurinol 300mg daily every morning
Fexofenadine 180mg daily every morning
Lyrica 100mg three times a day
Ursodiol 900mg every morning and 600mg every evening
Aspirin 325mg daily every morning
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
2. Ursodiol 300 mg Capsule Sig: Three (3) Capsule PO QAM (once a
day (in the morning)).
3. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
5. Lyrica 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day).
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*3*
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
1. s/p Septal Ablation
2. Hypertension
3. Coronary Artery Disease
Discharge Condition:
Good
Discharge Instructions:
Please take your medications as directed. Please note that you
are no longer taking Lasix or Verapamil. Your Atenolol dose have
been decreased to 50 mg daily and you are now taking a new
medication called Amlodipine 10 mg (two tablets) daily. It is of
utmost importance that you take your Aspirin and Plavix every
single day until directed by your Cardiologist.
*
Call your primary care physician to schedule [**Name Initial (PRE) **] follow-up
appointment within the next 2 weeks. Please note that your white
blood cell count was slightly elevated during your
hospitalization and your primary care doctor should check this
in the future to make sure that it is now back down to normal.
*
Please call your doctor or come to the nearest emergency room if
you experience any chest pain, shortness of breath or any other
complaints.
Followup Instructions:
1. Primary Care Doctor in [**11-23**] weeks following discharge
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**] Appointment should
be in [**5-30**] days
2. Dr. [**Last Name (STitle) 9751**] within one month following discharge
You also have the following appointments scheduled:
Provider: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2168-9-21**] 1:00
Completed by:[**2168-12-5**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 818
} | Medical Text: Admission Date: [**2176-11-16**] Discharge Date: [**2176-12-4**]
Date of Birth: [**2111-1-21**] Sex: F
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:
IVC filter, tracheostomy and percutaneous gastrostomy tube
placement
History of Present Illness:
Ms. [**Known lastname 75891**] is a 65 F who was transferred [**Hospital 75892**] Hospital
with gallstone pancreatitis. The patient reports that the pain
began at 11am with nausea and small bouts of comitting. The
patient denies alcohol use. She reports that at the time of
admission, her abdominal pain has improved
Past Medical History:
HTN, DM, DVT [**2173**], hyperlipidemia, anxiety,
PSHx: D&C
Social History:
The patient denies alcohol use. She is married by separated from
her husband who is an alcoholic and banned from her housing
complex. She also denies tobacco, drug use. She lives
independently.
Family History:
noncontributory
Physical Exam:
On admission: 97.1 80-120 ST 140/60 16 97%
AAOx3
tachycardic, regular rhythm
CTA b/l
+ BC, spigastric tenderness, - [**Doctor Last Name 515**] sign
mild abdominal dilation
DRE: Guiac neg, NL tome
no c/c/e
Pertinent Results:
[**2176-11-16**] 09:37PM BLOOD WBC-26.7* RBC-5.11 Hgb-14.0 Hct-43.8
MCV-86 MCH-27.4 MCHC-32.0 RDW-13.7 Plt Ct-297
[**2176-12-4**] 03:12AM BLOOD WBC-11.2* RBC-3.43* Hgb-9.3* Hct-30.1*
MCV-88 MCH-27.1 MCHC-30.9* RDW-16.7* Plt Ct-981*
[**2176-11-16**] 09:37PM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1
[**2176-12-4**] 03:12AM BLOOD PT-13.3 PTT-29.5 INR(PT)-1.1
[**2176-12-4**] 03:12AM BLOOD Plt Ct-981*
[**2176-11-16**] 09:37PM BLOOD Plt Smr-NORMAL Plt Ct-297
[**2176-12-4**] 03:12AM BLOOD Glucose-219* UreaN-16 Creat-0.6 Na-145
K-4.5 Cl-108 HCO3-33* AnGap-9
[**2176-11-16**] 09:37PM BLOOD Glucose-323* UreaN-19 Creat-1.0 Na-144
K-2.9* Cl-105 HCO3-26 AnGap-16
[**2176-12-2**] 01:45AM BLOOD ALT-23 AST-34 AlkPhos-295* Amylase-52
TotBili-0.4
[**2176-12-3**] 02:44AM BLOOD AlkPhos-229*
[**2176-11-16**] 09:37PM BLOOD ALT-124* AST-102* LD(LDH)-236
AlkPhos-197* Amylase-1494* TotBili-2.0* DirBili-1.6* IndBili-0.4
[**2176-12-2**] 01:45AM BLOOD Lipase-32
[**2176-11-16**] 09:37PM BLOOD Lipase-2211*
[**2176-12-4**] 03:12AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.5
[**2176-11-16**] 09:37PM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.9 Mg-1.5*
[**2176-11-20**] 12:33AM BLOOD calTIBC-202* Ferritn-155* TRF-155*
[**2176-11-23**] 11:26AM BLOOD Lactate-0.8 K-4.7
[**2176-11-29**] 03:31AM BLOOD freeCa-1.13
[**11-16**]: RIGHT UPPER QUADRANT ULTRASOUND: Exam is somewhat limited
due to patient body habitus. The liver is unremarkable with no
focal lesions. The gallbladder has multiple gallstones, with a
large gallstone measuring up to 1.4 cm. There is no wall
thickening or pericholecystic fluid to suggest cholecystitis. No
son[**Name (NI) 493**] [**Name (NI) **] sign was present. The common bile duct is
markedly dilated measuring 1.5 cm, and there is central
intrahepatic biliary ductal dilatation, raising the possibility
of a distal CBD obstruction. The distal CBD and pancreas are not
able to be visualized due to overlying bowel gas. The portal
vein is patent with anterograde flow. There is no ascites
[**11-17**]: ERCP: Ten fluoroscopic spot images obtained during ERCP
procedure without radiologist present. Cholangiogram
demonstrates dilated intra- and extra- hepatic bile ducts. There
is suggestion of irregularity of the intrahepatic ducts which
may be projectional. No filling defect is identified within the
opacified biliary tree. The cystic duct is normally opacified.
IMPRESSION: Intra- and extra-hepatic biliary dilatation. No
filling defect is identified within the biliary tree.
[**11-18**]: Ampullary mucosal biopsy:
Ampullary mucosa with focal acute inflammation and
fibrinopurulent exudates consistent with ulceration.
[**11-26**]: U/S FINDINGS: The study is limited due to patient's body
habitus. The liver texture is within normal limits allowing for
technique. The gallbladder demonstrates multiple gallstones.
There is no gallbladder wall edema or pericholecystic fluid.
There is no intra- or extra- hepatic biliary ductal dilatation,
and the common duct measures 7 mm. Main portal vein is patent
with antegrade flow.
[**12-2**]:CT- 1. Extensive severe pancreatitis with diffuse
enlargement of the pancreas and fat stranding and ongoing
formation of peripancreatic fluid collection/pseudocyst with
attenuated SMV. Diffuse peritoneal fat stranding suggestive of
panperitonitis with bowel dilatation.
2. Cholelithiasis.
3. Small ascites, slightly decreased in the lower pelvis.
4. Diffuse anasarca.
5. Diverticulosis.
6. Post G-tube placement.
7. New pneumomediastinum within the pericardial fat along the
pericardium, of unknown etiology. Clinical correlation with
recent procedure and interventions is recommended.
Brief Hospital Course:
On transfer to [**Hospital1 18**], Ms. [**Known lastname 75891**] was admitted to the trauma
service and transferred to the SICU for further evaluation. She
was made NPO, with IVF and a FOley was placed; the patient
refused an NGT at the time. The patient's pain was to be
controlled, and the patient was consented for an ERCP. THe
patient received subcutaneous heparin for DVT prophylaxis, her
hematocrit was watched on a dialy basis, ad the patient was put
on an insulin sliding scale. The patient was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 3 at
admission. A RUQ ultrasound was performed revealing
cholelithiasis without cholecystitis, and CBD dilation as well.
On [**11-17**], the patient underwent an ERCP with sphincterotomy; the
report read "Intra- and extra-hepatic biliary dilatation. No
filling defect is identified within the biliary."
Her post procedure course was complicated by increased
secretions, and hypoxia to 78%; the patient was made aware of
the risk of aspiration pneumonia and respiratory distress, but
she refused both an NGT and intubation at the time. The patient
was made comfortable with anti-anxiety and pain medications, and
her vital signs were closely monitored. The patient required
fluid bolusing for volume depletion.
A geriatric consult was called for further treatment and
evaluation while the patient was in the ICU as the patient
became delirious and had been quite agitated despite lorazepam
and Haldol. Geriatrics recommended low dose dilaudid for pain
control PRN, altering the dose of Haldol, removing all
unneccessary tubes, lines and drains, and getting the patinet on
a better sleep cycle. On [**11-18**], the patient became tachypneic
to a respiratory rate in the 30s, oxygen saturation of 82% on
RA, and was put on a face tent as she was not tolerating other
oxygen supplementation. The patient's vital signs were
unstable, and the patient was combative and aggressive. Her
mental status began deteriorating, and the patient required
intubation for airway protection, and adequate sedation for
safety during hospital treatment. The patient was started on
Unasyn for pneumonia (aspiration). On [**11-19**], the patient was
intermittently tachycardic with decreased urine output; she was
bolused for presumed volume depletion; her urine output improved
and her renal function remained within normal limits. The
patient also had an OGT and subsequently a DObhoff tube placed
for tube feeds. The patient's respiratory status was frequently
monitored and changed according to evaluations. Her sedation
and ventilation were attempted to be weaned. Her hospital
course was complicated by post-procedure fevers; blood cultures
were sent when the patient spiked, and chest x-rays, urine
analysis/cultures were also taken. The patiemt was noted to
have a R base consolidation, and went for bronchoalveolar lavage
on [**11-23**]. The patient was put on vancomycin and later levo as
well as zosyn for empiric VAP treatment; these antibiotics were
stopped when appropriate, i.e, when cultures returned with
sensitivities, and/or fevers and leukocytosis decreased.
The patient was diuresed when appropriate as she was fluid
overloaded with pleural effusions during her hospital stay. A
right sided pleural effusion was worsening, and the patient
underwent a pleural tap and pigtail placement to expand the
lung and rule out empyema as the patient continued to be febrile
with some vital sign lability.
The patient had stable post procedure anemia until [**11-26**], at
which time, the patient had to be transfused 2units of prbcs.
As the pt continued to be vent dependednt, the patient underwent
a trach, IVC filter, and PEG on [**11-27**]; for details please see
operative note. Om [**11-30**], the patient's trach was inadvertently
dislodged, and an emergent trach had to be placed; placement was
confirmed by bronch.
The patient was discharged to rehab on [**12-4**] in stable
condition; she was hemodynmically stable, afebrile, tolerating
tube feeds, off antibiotics, with normalizing wbc and LFTs.
Medications on Admission:
GLipizide, Lipitor, Metformin, Lisinopril, Prilosec
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
4. Bisacodyl 10 mg Suppository Sig: Ten (10) mg Rectal DAILY
(Daily): Suppository(s).
5. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H
(every 6 hours) as needed for fever.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for wheeze.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q6H (every 6 hours).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Insulin Regular Human Injection
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q6H (every 6 hours) as needed for n/v.
17. Magnesium Sulfate 4 % Solution Sig: Sliding SCale Injection
PRN (as needed).
18. Calcium Gluconate 100 mg/mL (10%) Solution Sig: Sliding
Scale Intravenous ASDIR (AS DIRECTED).
19. Potassium Chloride Intravenous
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
21. Potassium Phosphate Dibasic 3 mMole/mL Parenteral Solution
Sig: Sliding Scale Intravenous ASDIR (AS DIRECTED).
22. Lorazepam 2 mg/mL Syringe Sig: 0.5-1.0 mg Injection Q4H
(every 4 hours) as needed for agitation.
23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
24. Roxicet 5-325 mg/5 mL Solution Sig: [**5-30**] ml PO every [**4-26**]
hours.
25. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Gallstone pancreatitis
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**1-23**] weeks; make an
appointment at [**Telephone/Fax (1) 6429**]
ICD9 Codes: 5070, 5119, 2930, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 819
} | Medical Text: Admission Date: [**2199-10-20**] Discharge Date: [**2199-10-23**]
Date of Birth: [**2135-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Mr. [**Known lastname **] is 64-year-old man with liver cirrhosis [**1-19**] NASH, DM,
HTN, CHF EF 40%, CAD, Sizure disorder who p/w cough. Per report
from his nursing home, he has had cough, low grade fever x 3
days. Today, he had an episode of likely aspiration while using
mouth wash, had a coughing fit and during this episode desat'ed
to 80's. His family reports that he has been on small amounts of
oxygen at the nursing home, which he has been on chronically
since [**Hospital 671**] Rehab for unclear reasons. They state that he has
had a ratteling cough for several days but has not appeared
unwell. They also note that he has normally waxing and [**Doctor Last Name 688**]
mental status, that he is not "chatty" normally and that his
mental status appears to be at baseline. Per the patient, he
feels relatively well and denies SOB. He was BIBA from his NH,
enroute EMS had a difficult time obtaining a good pleth/sats and
reported variable O2 sats in high 80's.
.
In the ED: The patient was thought to be ill appearing and
"dry". His vital signs were temp 100.0, HR 107, BP 120/80's, RR
22-26, Sa 96% 2LNC. EKG unchanged, trop 0.06.CXR was noted to
have hazy RLL and LLL. He received Vanc and CTX.
Past Medical History:
1. Seizure disorder with history of status epilepticus with
recent admission for recurrent seizures & 2 prior admission in
[**2197**] & [**2199-1-18**] for status requiring intubation. He has been on
multiple antiepileptic drugs
2. NASH, cirrhosis, hepatocellular carcinoma, recently removed
from [**Year (4 digits) **] list [**1-19**] chronic illness
3. Diabetes.
4. Hypothyroidism.
5. Hypertension.
6. CHF with ejection fraction of 40% on an echo in [**2198-7-18**].
7. Coronary artery disease status post cardiac catheterization
in [**2187**] w/o stenting.
8. History of upper GI bleed status post tips in [**2197**].
9. Stage IV sacral decubitus ulcer.
Social History:
Prior to his illness, he was living with wife; remote tobacco,
no EtOH or drug use. He now resides at [**Hospital 1820**] Nursing Home.
Family History:
Non-contributory.
Physical Exam:
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA 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
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: sacral ulcer, heel ulcers
Neurologic:
-mental status: waxing and [**Doctor Last Name 688**] between, persistently alert
but oriented to person only at times and occasionally a&ox3.
-contractures in hands and arms.
Pertinent Results:
Labwork on admission:
[**2199-10-20**] 09:45AM BLOOD WBC-5.2 RBC-3.63* Hgb-12.5* Hct-37.6*
MCV-104*# MCH-34.4* MCHC-33.2 RDW-15.1 Plt Ct-65*
[**2199-10-20**] 09:45AM BLOOD Neuts-81.1* Lymphs-12.2* Monos-5.2
Eos-1.4 Baso-0.2
[**2199-10-20**] 09:45AM BLOOD Glucose-178* UreaN-50* Creat-1.1 Na-150*
K-4.1 Cl-110* HCO3-34* AnGap-10
[**2199-10-20**] 09:45AM BLOOD ALT-27 AST-23 CK(CPK)-53 AlkPhos-124*
TotBili-0.3
[**2199-10-20**] 10:35AM BLOOD Ammonia-73*
[**2199-10-20**] 09:45AM BLOOD TSH-0.77
[**2199-10-20**] 09:45AM BLOOD Free T4-1.9*
.
Labwork on discharge:
[**2199-10-23**] 07:45AM BLOOD WBC-2.2* RBC-2.95* Hgb-9.9* Hct-30.7*
MCV-104* MCH-33.7* MCHC-32.4 RDW-14.6 Plt Ct-59*
[**2199-10-23**] 07:45AM BLOOD Glucose-72 UreaN-22* Creat-0.8 Na-146*
K-3.9 Cl-109* HCO3-34* AnGap-7*
.
CHEST (PORTABLE AP) Study Date of [**2199-10-20**]
Formal report pending, but right upper and lower lobe
consolidations present.
.
CHEST PORT. LINE PLACEMENT Study Date of [**2199-10-23**]
Preliminary Report !! PFI !!
Tip of PICC catheter 8 cm from SVC will need to be withdrawn.
Brief Hospital Course:
64 year-old man with cirrhosis, type 2 diabetes, coronary artery
disease, hypertension, congestive heart failure with EF 40%, and
seizure disorder presenting with cough, fevers, and
consolidations on chest x-ray consistent with pneumonia.
.
1. Pneumonia: Chest x-ray from admission showed right middle
and lower lobe consolidations. His oxygen saturations remained
above 92% on room air. He was monitored in the intensive care
unit overnight and transferred to a general medical floor the
morning after admission. He was started on vancomycin and
ampicillin-sulbactam to complete a two-week course for
hospital-acquired versus aspiration pneumonia. A PICC line was
placed [**2199-10-23**] for intravenous access to complete the course of
antibiotics, ending [**2199-11-4**].
.
2. Hypernatremia: Asymptomatic and due to free water depletion.
His free water flushes were increased to 400 cc q4h with
improvement in sodium. His sodium should be monitored
intermittently and his free water flushes should be adjusted
accordingly for hypernatremia.
.
3. Question urinary tract infection from nursing home: The
patient was on nitrofurantoin on admission, and it is unclear
whether this was for treatment or prophylaxis of urinary tract
infection. This was discontinued when the above antibiotics
were started for pneumonia. He can restart nitrofurantoin if
this was being given for prophylaxis when the course of
vancomycin and unasyn is complete.
.
4. Mental status: It was believed that the patient was delirious
on admission, however, after discussion with the patient's wife
and the nursing home his mental status was thought to be at
baseline. He was treated for pneumonia as above. He was
frequently redirected.
.
5. History of nonacloholic steatohepatitis/cirrhosis: The
patient is status post TIPS. He is not [**Month/Day/Year **] candidate
currently due to his multiple comorbiditis. His MELD score was 5
on admission. He was continued on rifamixin and lactulose.
.
6. Chronic systolic congestive heart failure: EF is 40%. His
metoprolol was continued during admission. The patient was
hypovolemic on admission and lasix was held. Lasix was
restarted prior to discharge.
.
7. Seizure disorder: No active issues. The patient was
continued on keppra, topomax and zonisamide. There was initial
confusion regarding his dose of keppra, and the patient was
initially given 2250 mg on admission, however, this was
subsequently changed to his home dose of 500 mg twice daily.
.
8. Type 2 diabetes: No active issues. The patient was continued
on glargine 100 units twice daily as per his outpatient regimen.
He received humalog sliding scale insulin as needed.
.
9. Coronary artery disease: No active issues. The patient was
continued on metoprolol. He is not on aspirin or statin at
baseline, likely due to his liver disease, and this can be
readdressed as an outpatient.
10. Hypothyroidism: The patient was continued on his outpatietn
dose of levothyroxine 400 mcg daily. During admission, his T4
was elevated to 1.9 with normal TSH. His laboratories should be
checked after resolution of this acute illness and his dose of
levothyroxine adjusted accordingly.
.
11. Sacral decubitus ulcer: The patient was followed by the
[**Month/Day/Year **] care nurse.
.
12. Pancytopenia: His blood counts were at baseline during
admission. His pancytopenia is believed secondary to liver
disease. This should be monitored intermittently.
Medications on Admission:
Topiramate 100 mg PO BID
Metoprolol 25 mg PO BID
Levetiracetam PO BID
Zonisamide 500 mg DAILY
Levothyroxine PO DAILY
Fluocinolone 0.025 % Cream
Lactulose 10 gram/15 mL Syrup
Rifaximin PO TID
Lorazepam 0.5 mg PO DAILY
Furosemide 40 mg PO DAILY
Heparin (Porcine) 5,000 unit/mL
Multivitamin PO DAILY
Folic Acid 1 mg PO DAILY
Lansoprazole 30 mg
Thiamine HCl 100 mg PO DAILY
Polyvinyl Alcohol 1.4 % Drops
Discharge Medications:
1. Topiramate 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times
a day).
2. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2
times a day).
3. Levetiracetam 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2
times a day).
4. Zonisamide 100 mg Capsule [**Month/Day/Year **]: Five (5) Capsule PO DAILY
(Daily).
5. Levothyroxine 100 mcg Tablet [**Month/Day/Year **]: Four (4) Tablet PO DAILY
(Daily).
6. Lactulose 10 gram/15 mL Syrup [**Month/Day/Year **]: Thirty (30) ML PO TID (3
times a day).
7. Rifaximin 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a
day).
8. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
9. Furosemide 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
10. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
Injection TID (3 times a day).
11. Multivitamin Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
12. Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
13. Omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Thiamine HCl 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day/Year **]: [**12-19**]
Drops Ophthalmic Q6H (every 6 hours).
16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Day (2) **]: One (1)
Tablet PO DAILY (Daily).
17. Insulin Glargine 300 unit/3 mL Insulin Pen [**Month/Day (2) **]: One Hundred
(100) units Subcutaneous twice a day: plus novolin sliding
scale.
18. Tramadol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO three times a
day: hold for oversedation and confusion.
19. Scopolamine Base 1.5 mg Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
20. Ascorbic Acid 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2
times a day).
21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) Inhalation Q4H (every 4 hours).
22. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q4H (every 4 hours).
23. Nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO TID
(3 times a day).
24. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day (2) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
25. Ampicillin-Sulbactam 3 gram Recon Soln [**Month/Day (2) **]: One (1) Recon
Soln Injection Q6H (every 6 hours): continue until [**2199-11-4**].
26. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1)
Intravenous Q 12H (Every 12 Hours): continue until [**2199-11-4**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) 731**]
Discharge Diagnosis:
Primary diagnoses:
Pneumonia (hospital acquired versus. aspiration)
Hypernatremia
Delirium
Secondary diagnoses:
1. Seizure disorder with history of status epilepticus with
recent admission for recurrent seizures & two prior admission in
[**2197**] & [**2199-1-18**] for status requiring intubation. He has been on
multiple antiepileptic drugs
2. Nonalcholic steatohepatitis, cirrhosis, hepatocellular
carcinoma, recently removed from [**Year (4 digits) **] list due chronic
illness
3. Diabetes - insulin dependent
4. Hypothyroidism
5. Hypertension
6. Congestive heart failure with ejection fraction of 40% on an
echo in [**2198-7-18**]
7. Coronary artery disease status post cardiac catheterization
in [**2187**] w/o stenting
8. History of upper GI bleed status post tips in [**2197**]
9. Stage IV sacral decubitus ulcer
Discharge Condition:
Afebrile, vital signs stable
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were transferred to the hospital with fevers and a cough.
You were found to have a pneumonia and PICC line was placed in
your arm so that you can complete a two week course of
antibiotics (12 more days).
You were also noted to have high levels of sodium in your blood,
and this is probably because you were not getting enough water
in your diet. You are being given more water with your tube
feeds.
We did not change any of your medications (except adding those
two antibiotics for two weeks). Your thyroid levels were high,
and they should be re-checked and the dose of your thyroid
medicine may need to be adjusted.
If you develop increased difficulty breathing or any other
symptoms which seriously concerns you, please return to the
hospital.
Followup Instructions:
Previously scheduled appointments:
Provider: [**Name10 (NameIs) 2841**] LABORATORY Phone:[**Telephone/Fax (1) 2846**] Date/Time:[**2199-11-5**]
10:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 19105**] Date/Time:[**2199-11-5**] 1:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2199-11-27**] 10:20
.
You should try to see your Primary care Provider [**Name Initial (PRE) 176**] 2 weeks.
PCP: [**Name10 (NameIs) **],[**Known firstname **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 70526**]
Completed by:[**2199-10-29**]
ICD9 Codes: 5070, 2760, 5990, 5715, 4280, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 820
} | Medical Text: Admission Date: [**2164-5-30**] [**Month/Day/Year **] Date: [**2164-6-1**]
Date of Birth: [**2121-8-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hallucinations, agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 78755**] is a 42yoM with a history of diabetes mellitus and
longstanding alcoholism s/p numerous hospitalizations for
detoxification who was brought to the emergency room after being
found running through the streets naked and trying to choke
himself. He was barking like a dog during his ambulance ride,
and continued to seemingly respond to internal stimuli
thereafter.
.
On arrival to the ED, his initial vital signs were T100 P120
BP160/112 RR18 99% ra. Collateral information was gathered by
the psychiatry team, who evaluated him for a possible primary
psychiatric disorder, and spoke at length to both the patient
and the patient's mother. [**Name (NI) **] apparently drank "a lot of vodka
and windex" yesterday morning and subsequently blacked out. He
has detoxed many times and was prescrived antabuse, which he has
not recently taken. He endorses actively experiencing visual and
auditory hallucinations, including "voices" and "shadows" but is
again not able to elaborate with further details about these
symptoms. He has experienced both alcoholic hallucinosis and
delirium tremens, however fails to specify when those symptoms
occurred.
.
His mother, with whom he lives, notes a 20 year alcohol
dependence and despite many detoxification hospitalizations,
found a half-gallon of vodka in is closet recently. He had been
sober for 6 months and had been acting normally through
yesterday, but made paranoid statements about his neighbors this
morning.
.
Per the psychiatrist note, a psych review of systems, he denies
symptoms consistent with depression including anhedonia,
hopelessness, guilt, fatigue, difficulty concentrating, changes
in appetite, and sleep disturbances. He denies symptoms
consistent with anxiety including panic attacks or agoraphobia.
He denies symptoms consistent with mania including elevated
mood, racing thoughts,
decreased need for sleep, or thoughtlessness.
.
His ED management involved a liter of NS with IV thiamine. A
head CT did not reveal any structural disease and a chest XR did
not show any acute cardiopulmonary abnormality. He received an
2mg IM lorazepam dose and 10mg IV diazepam. Serum tox was
negative but Cr elevated to 1.8 from unknown baseline.
Toxicology consulted re: windex ingestion and was told it is
relatively benign and that fluids would help.
.
On arrival to the [**Hospital Unit Name 153**], his VS were: T98.7 HR80 BP128/78 RR19
Sat 98RA. He is fully AAOx3. He had been sober for six months
but started drinking again when the Bruins won the championship,
at which point he has been drinking [**3-13**] pints of vodka daily
with about 6 beers daily for chasing. He drank an unknown
amount of windex two days ago, which also was around the same
time of his last alcoholic drink. He drank the windex to
experiment with harming himself but denies frank SI. With
regard to the events leading up to his hospitalization, he ran
naked down the street on a dare. He does not recall having been
brought in by ambulance or barking like a dog. He does not
recall audio/visual hallucinations. He hopes to get sober again
but cannot elaborate a specific plan. He does confirm that he
had a bad alcohol withdrawal about 5 months ago complicated by
hallucinations, though no DTs.
Past Medical History:
- alcohol abuse/dependence s/p previous withdrawal
hallucinosis/DT's
Social History:
Patient lives with his mother and brother in [**Name (NI) 2312**].
Unemployed.
Family History:
maternal grandmother with alcohol dependence
Physical Exam:
Admission:
Vitals: T98.7 HR80 BP128/78 RR19 Sat 98RA.
General: fatigued appearing in NAD, answering all questions
appropriately, very mildly tremulous
HEENT: Sclera anicteric, dry MM
Neck: tenderness upon palpation of submandibular neck. No LAD.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, positive bowel sounds, liver span to 7cm by
percussion, no splenomegaly, diffuse mild soreness
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
[**Name (NI) **]:
T 98.9, BP 143/93, HR 87, RR 22, 98% on RA
General: Awake in bed, comfortable, NAD. Denies active
hallucinations.
Pertinent Results:
[**2164-5-30**] 05:30PM WBC-11.8* RBC-5.46 HGB-15.3 HCT-45.0 MCV-82
MCH-28.1 MCHC-34.1 RDW-18.3*
[**2164-5-30**] 05:30PM NEUTS-79* BANDS-1 LYMPHS-15* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2164-5-30**] 05:30PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2164-5-30**] 05:30PM PLT COUNT-162
[**2164-5-30**] 05:30PM ALT(SGPT)-84* AST(SGOT)-81* LD(LDH)-325*
CK(CPK)-243 ALK PHOS-82 AMYLASE-194* TOT BILI-0.8
[**2164-5-30**] 05:30PM LIPASE-23
[**2164-5-30**] 05:30PM ALBUMIN-5.0
[**2164-5-30**] 05:30PM OSMOLAL-279
[**2164-5-30**] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-5-30**] 11:30PM URINE HOURS-RANDOM UREA N-445 CREAT-234
SODIUM-20 POTASSIUM-35 CHLORIDE-11
[**2164-5-30**] 11:30PM URINE HOURS-RANDOM
[**2164-5-30**] 11:30PM URINE GR HOLD-HOLD
[**2164-5-30**] 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2164-5-30**] 11:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2164-5-30**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2164-5-30**] 11:30PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2164-5-30**] 11:30PM URINE HYALINE-51*
[**2164-5-30**] 11:30PM URINE MUCOUS-FEW
[**2164-5-30**] 05:30PM GLUCOSE-137* UREA N-16 CREAT-1.8* SODIUM-134
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-19* ANION GAP-23*
Brief Hospital Course:
Mr. [**Known lastname 78755**] is a 42yoM with alcohol dependence presenting with
hallucinations and agitation. The patient presented with
bizarre behavior as per HPI and was noted to have elevated
creatinine to 1.8, transaminitis, and anion gap acidosis; he was
felt to be at high risk for withdrawal and was therefore
admitted to the ICU for close monitoring. During his brief
hospitalization, he remained alert and oriented and did not
exhibit evidence of alcohol withdrawal; labs trended toward
normal.
# HALLUCINATIONS, AGITATION: The patient provides a variable
drinking history over the past few days though a relapse appears
likely given his mother's finding of vodka in his closet, and
his history of multiple withdrawal syndromes. While he did show
autonomic hyperactivity, agitation, and hallucinosis, his
current generally preserved orientation is inconsistent with
delirium tremens, as is the brief time course since his last
drink (<48hr). That he improved so quickly with a very small
benzo load is highly unusual for withdrawal. He was monitored
on a CIWA scale though did not receive any further
benzodiazepine after arrival to the ICU. He also received folate
and thiamine given his history of alcoholism. He was seen by the
psychiatry service who recommended dual-diagnosis inpatient
treatment. He was also seen by social work. During the day, he
was oriented x 3 and did not exhibit evidence of withdrawal. He
did not offer direct answers in response to questions about the
events leading up to this admission (would not state exactly
what substances he used or describe why he was behaving so
oddly). He did state that the Windex ingestion was in part in
response to a desire to harm himself. He reports that he has had
visual hallucinations for some time, and has been disturbed by
these though he knows that they are not real. His overall
presentation raises concern for a possible primary psychiatric
diagnosis. PCP and ketamine levels were sent as these substances
could produce a similar picture, though he denied use of either
substance. These labs were pending at the time of [**Known lastname **].
# AMMONIA INGESTION: He ingested an unknown amount of ammonia.
Household cleaners typically do not have the concentration to
cause severe alkali burns. He has the typical sore throat and
irritation caused by such ingestions, and his elevated amylase
may be reflecting some of this inflammation. He received a dose
of PPI while inpatient. The hospital toxicologist was consulted
and recommended supportive care and IV fluids.
# ELEVATED CREATININE: Cr up to 1.8 from unclear baseline. His
relatively low BUN may reflect poor nutritional status at
baseline, but may also indicate chronic renal disease. His
creatinine improved to 1.3 following IVF. He should have repeat
electrolytes checked on follow up with PCP.
# ANION GAP METABOLIC ACIDOSIS: On arrival, the patient had an
anion gap of 20. His lactate was normal at the time that it was
checked several hours after arrival. His blood alcohol was
negative and there was no evidence of DKA, uremia, salicylates.
Anion gap closed with repeat electrolytes.
# ELEVATED TRANSAMINASES: This may be secondary to chronic
alcoholism though he does not display the characteristic AST:ALT
ratio of 2:1. His actual ingestion history is unclear as above,
and it is possible that he used substances which he does not
report that may have caused this finding. His LFTs trended down
on repeat labs in the AM though had not yet fully normalized at
the time of [**Known lastname **] (ALT 73, AST 61).
# POSSIBLE OSA: Patient was noted to snore loudly with periods
of apnea. He may benefit from sleep study as an outpatient.
TRANSITION OF CARE:
- PCP and ketamine levels pending [**2164-5-31**]
- Patient will require PCP follow up after [**Month/Day/Year **] from
dual-diagnosis facility with re-check of liver and kidney
function
Medications on Admission:
Antabuse
[**Month/Day/Year **] Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Day/Year **] Disposition:
Extended Care
[**Month/Day/Year **] Diagnosis:
Visual hallucinations
Transaminitis
Anion gap acidosis
[**Month/Day/Year **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Month/Day/Year **] Instructions:
Mr. [**Known lastname 78755**],
It was a pleasure to care for you during this hospital stay. You
were admitted to [**Hospital1 69**] after you
exhibited strange behavior and reported visual hallucinations
and ingestion of alcohol and Windex. You were admitted to the
ICU for close monitoring, and you remained medically stable
throughout your stay. You were seen by social work and
psychiatry, who have recommended transfer to a dual-diagnosis
facility to further [**Hospital1 4656**] your substance abuse problems and
the possibility of a psychiatric illness as the cause of your
hallucinations.
We have made the following changes to your medication regimen:
- BEGIN TAKING folate 1 mg PO daily
- BEGIN TAKING thiamine 100 mg PO daily
- BEGIN TAKING multivitamin 100 mg PO daily
Please follow up with your primary care doctor as recommended
below.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 11144**]
Please schedule a follow up appointment with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **] from the dual-diagnosis facility.
Please ask your doctor [**First Name (Titles) **] [**Last Name (Titles) 4656**] your liver and kidney
function with blood tests to make sure that the abnormalities
noted during this stay have resovled.
Completed by:[**2164-6-1**]
ICD9 Codes: 5849, 2875, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 821
} | Medical Text: Admission Date: [**2134-1-31**] Discharge Date: [**2134-2-16**]
Date of Birth: [**2084-2-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Cafergot / Prochlorperazine / Penicillins / Chlorpromazine Hcl /
Prozac
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2134-2-1**] Mitral valve replacement with a 25 mm Biocor tissue
valve.
Tricuspid valve replacement with a 27 mm Biocor apical
tissue valve.
[**2134-2-4**] PICC placement
History of Present Illness:
49 year old female with history of paroxysmal atrial
fibrillation, rheumatic heart disease, Hepatitis C, liver
fibrosis found to have moderate MS and
mild tomoderate MR [**First Name (Titles) **] [**Last Name (Titles) 113**]. She reports symptoms of shortness of
breath and chest pain which have gotten progressively worse. She
states that she is unable to climb a flight of stairs without
stopping 3 times to rest.
Past Medical History:
Rheumatic heart disease with 2-3+ MR, minimal MS (valve area 1.3
cm2), [**1-22**]+ tricuspid regurgitation and mild pulmonary
hypertension
RVE/[**Last Name (un) **] with IVC dilation by [**Last Name (un) 113**]
Global RV dysfunction
AI
Prior IVDA-currently methadone clinic, stopped drugs 1.5 yrs ago
ETOH abuse-stopped about 1.5 yrs ago
Atypical chest pain
PAF-on Coumadin last dose [**2134-1-24**]
Chronic anemia
Hepatitis C c/b liver fibrosis->followed by Dr. [**Last Name (STitle) 86971**]
False Positive Syphilis Test
Fibromyalgia
Migraines
IBS
GERD
Prior suicide attempt
PTSD
Pleural effusion s/p evacuation
Bipolar Disorder
Arthritis
Acid reflux
Breast Lumpectomy
Endometriosis s/p laparoscopy
Syncope/fall -approx [**2130**]
Hypoglycemia
Cholecystectomy
Hysterectomy
Tonsillectomy
Endometriosis s/p laparoscopy
s/p tubal ligation
s/p lumpectomy from breast
Social History:
Lives with:husband- [**Name (NI) **]
Occupation: unemployed
Tobacco:1.5ppd x 30 years
ETOH:none in 1.5 yrs
Rec drugs: none in 1.5 yrs. H/o IVDA and cocaine use in past
Family History:
father died of an MI
mother died of heart problems
Brother died in his 50s from heart problems
Physical Exam:
Pulse:76 Resp:18 O2 sat:99% RA pO2 76 on 2L NC
B/P Right: 113/89 Left:
Height:5'1" Weight: 67.3 kg
General: NAD, alert and cooperative
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 [**1-24**] HSM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ sl. hepatomegaly
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None 2+ pitting edema on bilat. LE
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2134-2-16**] 05:10AM BLOOD WBC-6.5 RBC-3.15* Hgb-9.4* Hct-27.8*
MCV-89 MCH-29.8 MCHC-33.6 RDW-17.4* Plt Ct-215
[**2134-1-31**] 09:00PM BLOOD WBC-5.4 RBC-4.35 Hgb-13.1 Hct-36.6
MCV-84# MCH-30.1 MCHC-35.8* RDW-15.8* Plt Ct-151
[**2134-2-1**] 12:32PM BLOOD Neuts-89.2* Lymphs-9.1* Monos-1.1*
Eos-0.5 Baso-0.1
[**2134-2-16**] 05:10AM BLOOD Plt Ct-215
[**2134-2-16**] 05:10AM BLOOD PT-18.1* PTT-28.7 INR(PT)-1.6*
[**2134-1-31**] 09:00PM BLOOD PT-13.3 PTT-34.7 INR(PT)-1.1
[**2134-1-31**] 09:00PM BLOOD Plt Ct-151
[**2134-2-16**] 05:10AM BLOOD Glucose-108* UreaN-42* Creat-0.8 Na-133
K-3.6 Cl-96 HCO3-28 AnGap-13
[**2134-2-15**] 05:40PM BLOOD Glucose-119* UreaN-50* Creat-1.0 Na-133
K-4.6 Cl-95* HCO3-28 AnGap-15
[**2134-2-1**] 02:05PM BLOOD UreaN-8 Creat-0.6 Na-136 K-4.2 Cl-104
HCO3-27 AnGap-9
[**2134-1-31**] 09:00PM BLOOD Glucose-92 UreaN-9 Creat-0.7 Na-135 K-4.5
Cl-99 HCO3-29 AnGap-12
[**2134-2-9**] 03:04AM BLOOD ALT-17 AST-37 LD(LDH)-525* AlkPhos-67
TotBili-1.4
[**2134-1-31**] 09:00PM BLOOD ALT-41* AST-49* LD(LDH)-224 AlkPhos-87
Amylase-66 TotBili-0.6
[**2134-2-3**] 03:29AM BLOOD Lipase-11
[**2134-2-16**] 05:10AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.4
[**2134-1-31**] 09:00PM BLOOD %HbA1c-5.9 eAG-123
[**2134-2-5**] 05:14AM BLOOD Osmolal-276
[**2134-2-5**] 09:23AM BLOOD TSH-1.7
[**2134-2-5**] 09:23AM BLOOD T4-9.0 T3-78*
[**2134-2-5**] 09:23AM BLOOD Cortsol-36.1*
CHEST TWO VIEWS, [**2134-2-14**]
FINDINGS:
Two views of the chest compared to prior study from [**2134-2-11**].
There is
multifocal interstitial and airspace opacification, not
appreciably changed from the prior study, could represent a
combination of congestive failure or even ARDS. Heart is
enlarged. Mediastinum is within normal limits.
IMPRESSION: Left PICC unchanged in superior vena cava.
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Lateral Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.03 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *40 < 15
Aorta - Sinus Level: 2.4 cm <= 3.6 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - Peak Velocity: 1.4 m/sec
Mitral Valve - Mean Gradient: 6 mm Hg
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: *400 ms 140-250 ms
TR Gradient (+ RA = PASP): 7 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV free wall thickness. Dilated RV
cavity. RV function depressed.
AORTA: Normal aortic diameter at the sinus level.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR
well seated, with normal leaflet/disc motion and transvalvular
gradients.
TRICUSID VALVE: Bioprosthetic tricuspid valve (TVR). TVR well
seated, with normal leaflet motion and transvalvular gradients.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - bandages,
defibrillator pads or electrodes.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with depressed
free wall contractility. A bioprosthetic mitral valve prosthesis
is present. The mitral prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. A
bioprosthetic tricuspid valve is present. The tricuspid
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2133-8-3**], the mitral and tricuspid valves have been
replaced. The right ventricle is somewhat hypocontractile.
Brief Hospital Course:
Admitted [**2134-1-31**] for bridge from coumadin with heparin drip.
Completed preoperative workup and [**2134-2-1**] was brought to the
operating room and underwent mitral valve and tricuspid valve
replacements, see operative report for further details. She
was transferred to the intensive care unit for postoperative
management. In the first few hours she had significant
ventricular ectopy that was treated with amiodarone boluses and
drip with improvement however underlying rhythm was complete
heart block and continued to be paced with epicardial wires.
She remained intubated overnight for hemodynamics and was
extubated the morning of postoperative day one. She was started
on lasix for diuresis due to pulmonary edema and continued
amiodarone. Electrophysiology was consulted for rhythm
management and she was placed on lidocaine drip with improvement
but continued runs on ventricular tachycardia that worsened with
activity. Pain medications were adjusted, she was weaned off
lidocaine and started on betablockers for rhythm management.
She continues with ventricular ectopy but no ventricular
tachycardia. She was restarted on coumadin for history of
pulmonary embolism and atrial fibrillation. She was continued
to be diuresed for pulmonary edema, however was noted to have
hyponatremia with sodium to 122 with no clear cause that was
treated with hypertonic saline and saline tabs and sodium
improved however pulmonary edema worsened. Her oxygen
requirements increased and she continued to require aggressive
diuresis and non invasive ventilation for few days. She
continued to improve and respiratory status improved. She was
transferred to the floor for the remainder of her care.
Physical therapy worked with her on strength and mobility. She
continues on intravenous lasix for diuresis via PICC line that
she is being discharged to rehab with, and plan for PICC removal
when no longer requires IV lasix. She was discharged to acute
rehab on post operative day 15 to [**Hospital3 **] in [**Hospital1 **] new
[**Location (un) **].
Medications on Admission:
DIGOXIN - 250 mcg Tablet - 1 Tablet(s) by mouth daily in the PM
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth daily
in
the PM
HYDROXYZINE HCL 25 mg Tablet by mouth twice a day
METHADONE - 40 mg Tablet Soluble - 1 Tablet(s) by mouth daily
plus 5mg tablet = 45mg daily dose
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth daily in the PM
POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Sustained
Release - 1 Tablet(s) by mouth daily
SERTRALINE - 100 mg Tablet in the PM
TRAZODONE - 100 mg Tablet - [**12-24**] Tablet(s) by mouth daily at hs
WARFARIN [COUMADIN] - 7.5 mg Tablet - 1 Tablet(s) by mouth daily
on Fridays only, 5mg all other days last dose [**2134-1-24**]
ZOLPIDEM [AMBIEN] 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY (Daily): total dose 45 mg .
9. methadone 5 mg Tablet Sig: One (1) Tablet PO once a day:
total dose 45 mg daily .
10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO bid () for 2 days.
14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. PICC line
Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
[**Month (only) 116**] remove PICC line when no longer on intravenous lasix
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO twice a day for 3 days:
then decrease to 40 meq daily with IV lasix .
17. furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
DAILY (Daily) for 3 days: then decrease to 40 mg IV daily .
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation every four (4) hours
as needed for shortness of breath or wheezing.
19. methadone clinic
Methadone clnic in [**Hospital1 487**], [**Street Address(2) 86972**]. Phone # [**Telephone/Fax (1) 86973**]. Open from 6am to 1015am daily
Has received 45 mg daily while in the hospital [**Date range (1) 86974**]
20. coumadin and INR
[**2-16**] coumadin 7.5 mg inr 1.6
[**2-15**] coumadin 4 mg inr 1.8
[**2-14**] coumadin 5 mg inr 1.9
[**2-13**] coumadin 2.5mg inr 2.2
[**2-12**] coumadin 4 mg inr 2.6
[**2-11**] coumadin 2.5mg inr 2.7
[**2-10**] coumadin 2.5mg inr 3.1
[**2-9**] coumadn 3mg inr 2.2
[**2-8**] coumadin 5 mg inr 1.9
[**2-7**] coumadin 5 mg inr 1.5
[**2-6**] coumadin 5 mg inr 1.4
nutriton had been poored and now improved with shakes (ensure)
which contain vitamin K
home doses prior to admission 5-7.5 mg daily
21. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation and
pulmonary embolism
Goal INR [**12-24**]
First draw wendesday [**2-17**]
Physician at rehab to monitor INR and dose coumadin based on
results - please check monday and wednesday and friday for 3
weeks to maintain close monitoring due to liver disease and then
twice a week
Please arrange for coumadin management with PCP prior to
discharge from rehab
22. Outpatient Lab Work
Chem 10 twice a week while on IV lasix
23. warfarin 5 mg Tablet Sig: Goal INR 2.0-3.0 Tablets PO once a
day: dose based on INR by rehab physician [**Name Initial (PRE) **] [**Name10 (NameIs) **] draw [**2-17**] for
further dosing .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Mitral regurgitation s/p MNR
Tricuspid regurgitation s/p TVR
Ventricular trachycardia
Respiratory failure
Rheumatic heart disease
Hypertension
Right ventricular failure
Prior IVDA-currently on methadone
ETOH abuse-stopped about 1.5 yrs ago
Atypical chest pain
paroxysmal atrial fibrillation
Chronic anemia
Hepatitis C
Liver fibrosis
Fibromyalgia
Migraines
Irritable bowel syndrome
Gastric esophageal reflux disease
Post traumatic stress disorder
Pleural effusion
Bipolar Disorder
Arthritis
Breast Lumpectomy
Endometriosis s/p laparoscopy
Syncope/fall -approx [**2130**]
Hypoglycemia
Cholecystectomy
Hysterectomy
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with 1 assist
Incisional pain managed with tylenol prn
Continues on methadone 45 mg as prior to admission
Incisions:
Sternal - healing well, no erythema or drainage
Edema +1 bilateral LE
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: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2134-2-25**] 1:00
Cardiologist: Dr [**Last Name (STitle) 4783**] - cardiac surgery office to contact
you with appointment
Liver: Dr [**Last Name (STitle) 497**] [**Telephone/Fax (1) 2422**] [**2134-4-2**] 11:00
Please call to schedule appointments with your
Primary [**First Name (STitle) 86975**] in [**2-23**] weeks [**Telephone/Fax (1) 77368**]
**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 and
pulmonary embolism
Goal INR [**12-24**]
First draw wendesday [**2-17**]
Physician at rehab to monitor INR and dose coumadin based on
results - please check monday and wednesday and friday for 3
weeks to maintain close monitoring due to liver disease and then
twice a week
Please arrange for coumadin management with PCP prior to
discharge from rehab
Completed by:[**2134-2-16**]
ICD9 Codes: 4271, 2761, 2851, 3051, 4168, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 822
} | Medical Text: Admission Date: [**2169-6-26**] Discharge Date: [**2169-6-30**]
Date of Birth: [**2143-4-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / morphine / Codeine
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Abdominal pain, hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 9625**] is a 26F with a history of type I diabetes
complicated by chronic gastroparesis and prior DKA (last episode
[**5-/2169**]) who presents with a ~4 day history of uncontrolled
sugars, abdominal pain, and malaise. She states that her
symptoms began on Thursday, when she noticed that her
fingerstick values were getting very high. Since that time, she
reports that her lowest FS were in the 300s, and many were > 400
(in the early part of the month, she estimates that average
readings were in the 160s). She takes 36 units Lantus QHS and
[**10-26**] untis of Novolog per day with her sliding scale. States
that she has been compliant with fingersticks and insulin
administration. Took 16 units of insulin (Novolog) prior to
coming to ED at 11:00 AM today.
.
She has chronic gastroparesis and is never fully pain-free, but
notes that her abdominal pain is worse than baseline and
different from her standard pain. She feels bloated. This pain
does not feel like her prior episodes of kidney stones. In the
ED, she reported vomiting 5-10 times daily, but on the floor
reports that N/V have not been severe and that she feels that
she has been keeping down fluids adequately. She has poor
appetite and did not eat solid food today but was able to keep
down food yesterday. However, she has had "no energy" and was in
bed most of the day yesterday, which she states is very unusual
for her. Denies diarrhea but does suffer from chronic problems
with constipation. She does report that she has had on-and-off
chills and drenching nightsweats two of the last four nights to
the point that her boyfriend has had to wake her because the
sheets were wet. She does not own a thermometer so did not take
her temperature. She has not had SOB or URI symptoms, and though
she does report some dysuria she states that this is usual for
her and unchanged from her baseline. She reports several prior
UTI which have caused "kidney infections" and states that she
has been hospitalized for treatment multiple times. She does not
currently have flank pain but does report that she had some mild
right flank pain on Saturday. Also reports feeling "out of it"
like she's drunk, though has not had any alcohol.
.
In the ED, initial vs were: T 98.1, HR 102, BP 125/82, RR 16, O2
sat 100%. Patient was given IV cipro x 400 mg for possible UTI,
at least one liter IVF, started on an insulin gtt, dilaudid 1 mg
IV, and IV Zofran.
.
On the floor, she reports abdominal pain is [**8-16**] severity. Also
states that she is hungry and would like to eat, feels that she
could tolerate food at this time.
.
Review of sytems:
(+) Per HPI. Also reports recent episode of leg swelling in feet
and ankles one week ago, now largely resolved.
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. No recent change in bowel or bladder
habits. Denied arthralgias or myalgias.
Past Medical History:
- Type I diabetes complicated by gastroparesis and prior DKA,
diagnosed age 2
- GERD
- Anxiety
- Cholecystectomy
Social History:
Lived in [**Location **] with her aunt and uncle until recently, when
she moved in with her boyfriend in [**Name (NI) 86**]. She does not work
(disabled). She denies cigarette use but occasionally smokes
marijuana (none in past few weeks). Does not drink alcohol. No
other recreational drug use.
Family History:
Paternal grandfather had [**Name2 (NI) 499**] cancer. Maternal grandmother had
breast cancer. Per notes, her mother is deceased from heroin
overdose and her father was murdered by her step mother. She has
one brother and one sister who are alive and healthy.
Physical Exam:
Physical on Arrival to [**Hospital Unit Name 153**]
Vitals: T:97.6 BP:104/73 P:98 R: 14 O2: 97% on RA
General: Alert, oriented, appears comfortable in bed from
doorway though reports [**8-16**] pain
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Back: No vertebral body, SI or CVA tenderness
Abdomen: Soft, diffusely tender to palpation but worse in RLQ,
non-distended, bowel sounds present, + rebound tenderness but no
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on Admission: [**2169-6-26**] 12:10PM
lucose-671* UreaN-14 Creat-0.7 Na-129* K-5.3* Cl-90* HCO3-24
AnGap-20
WBC-5.8 RBC-4.61 Hgb-12.6 Hct-39.0 MCV-85 Plt Ct-324
Neuts-65.9 Lymphs-29.1 Monos-2.5 Eos-1.7 Baso-0.8
ALT-19 AST-23 LD(LDH)-140 AlkPhos-177* Amylase-44 TotBili-0.2
Lipase-22
Calcium-9.1 Phos-4.1 Mg-1.7
Acetone-NEG Osmolal-285
HCG-<5
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-10
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
URINE RBC-1 WBC-9* Bacteri-NONE Yeast-NONE Epi-<1
Microbiology:
[**2169-6-26**]
- URINE CULTURE: E. coli sensitive to Cipro
Brief Hospital Course:
26 F with type I diabetes presenting with anion gap acidosis and
+ ketones in urine.
# DKA. Patient's 2nd DKA in 1 month. Last HgbA1C 8.4. Trigger
thought likely to be her underlying UTI given her symptoms, +
UA, and + UCx growing E. coli. Prior notes also suggested
possible problem with compliance with her insulin and her uncle
has raised concern that she may on occasion have intentionally
elevated her blood glucose in order to be treated in the
hospital with narcotic pain medication. Per her last D/C
summary, she was scheduled to see a new PCP, [**Name10 (NameIs) **] missed the
appointment and has yet to reschedule. Patient was transitioned
to D5 and subcutaneous glargine soon after arriving the ICU.
Her BS improved significantly with taking in po. Her anion gap
closed. [**Last Name (un) **] followed her throughout her hospitalization, and
she was discharged on an adjusted sliding scale and Lantus 23u
in the evening.
# ABDOMINAL PAIN: Initially thought to have rebound tenderness
and RLQ pain, concerning for appendicitis and other
intra-abdominal pathology (no ovarian cyst, but has prominent
right ovary). Her presentation is nearly identical to that at
her prior admission in [**Month (only) 116**], at which time she underwent CT
abdomen/pelvis which was unrevealing. Given her young age and
desire to minimize radiation exposure, patient had serial
abdominal exam. She did not have persistent nausea or vomiting
and she reported being able to pass gas and tolerate food
intake. She was given IV dilaudid, which was transitioned to
her home regimen of PO Oxycodone. She was given a prescription
for several days worth of Oxycodone and instructed to follow-up
with her new PCP.
# URINARY TRACT INFECTION: U/A is mildly positive with 9 WBC, +
LE, and also + UCx. Patient states that she has chronic
dysuria, frequent UTI's, and that she has had multiple prior
hospitalization for pyelonephritis and two prior episodes of
kidney stones. She was started on ciprofloxacin and discharged
to complete a total of 7 days.
# ANXIETY: Per patient, prescriptions had previously been given
by her PCP prior to moving to [**Location (un) 86**]. Per last discharge
summary, attempts were made to contact a pharmacy and her prior
PCP, [**Name10 (NameIs) **] no record of prescriptions could be obtained. She was
continued on her home medications and no prescriptions were
given at discharge.
Contact: HCP is uncle [**Name (NI) **] [**Name (NI) 9625**] [**Telephone/Fax (1) 88920**]. Boyfriend with
whom she lives is second emergency contact at [**Telephone/Fax (1) 88922**].
Medications on Admission:
- Zoloft 100 mg PO daily (this is dose per recent D/C summary;
patient reported 400 mg daily)
- Buspar 20 mg PO BID
- Clonazepam 2 mg PO TID
- Hydroxyzine 50 mg QID
- Trazadone 50 mg [**1-8**] tab qHS for insomnia
- Omeprazole 40 mg PO BID (this is dose per patient report; D/C
summary had 20 mg PO daily)
- Novolog insulin sliding scale
- Lantus 36 units SC QHS
- oxycodone 5 mg 1-2 tabs po q4h prn for pain
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with diabetic ketoacidosis and
a urinary tract infection. You were treated with antibiotics and
an insulin infusion. You tolerated a regular diet prior to
discharge. Your blood sugars will continue to be adjusted by
your [**Last Name (un) **] doctors. Please call them with any questions or
concerns regarding your blood sugars or your insulin dosage.
You will need to complete a course of Ciprofloxacin as an
outpatient; a prescription for this medicaiton is provided.
Followup Instructions:
Please follow-up with Dr.[**Last Name (STitle) 32886**] on [**7-4**] at 2pm at the
[**Last Name (un) **] Diabetes Center. You are also scheduled for the following
appointment with your new PCP, [**Last Name (NamePattern4) **].[**First Name (STitle) **]:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2169-7-5**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 815**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 823
} | Medical Text: Admission Date: [**2137-2-27**] Discharge Date: [**2137-3-19**]
Date of Birth: [**2058-10-27**] Sex: M
Service: MEDICINE
Allergies:
Hydromorphone / Morphine / Amoxicillin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
HD catheter placement
History of Present Illness:
Patient is a 78 year old male with past medical history of CAD
NSTEMI, s/p CABG (LIMA to the LAD, SVG to OM1 and OM2) and St.
[**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] ([**12-12**]) with course complivated by wound dehisence,
chronic systolic dysfunction EF 30%, ESRD on HD, afib on
coumadin, stroke, chronic anemia, recent lower GI bleed with
bleeding rectal ulcers and CMV colitis, and chronic left-sided
pleural effusion transferred from [**Hospital 100**] Rehab for increasing
SOB and lethargy after receiving 1 unit PRBCs earlier today for
Hct 21; he recieved HD yesterday. HD was stopped prematurely
yesterday due to hypotension to 60/40. His discharge weight on
[**2-15**] was 60 kg; he was 73 kg pre-dialysis on [**2-21**]. Of note,
patient was discharged on [**2-15**] from the [**Hospital1 **] service after a
similar presentation, with status improving after emergent
dialysis removing 10 liters and thoracentesis. Course
complicated during this admission by presumed c. diff colitis
due to profuse diarrhea, treated with 14 days flagyl.
.
On arrival to the ED, initial vitals were T 97.2 HR 120 (afib)
BP 123/110 RR 20 100% 4L NC in acute respiratory distress. Labs
significant for H/H 7.1 AND 21.0, BNP [**Numeric Identifier 89668**] INR 2.3. He was
placed on BiPAP with resolution of respiratory distress. Prior
to transfer, patient was started on levophed for SBPs in 80s.
.
On review of systems, he has a history of stroke, PE, bleeding
with surgery, deep venous thrombosis. He denies 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 chest pain, severe SOB,
DOE, ankle edema, PND, Orthopnea, absence of chest pain,
palpitations.
.
In the ED initial VS were noted to be T97.2, HR 120, BP 123/110,
RR 20, Sat 100% on 4L.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
In [**2135-9-3**], per the patient's wife report, the patient
had a stent placed to the LAD and two other vessels and did well
on plavix, aspirin and coreg with an EF of 45%. On [**2136-12-7**]
after episode of CP, the patient was admitted to OSH with non- Q
wave MI and underwent cardiac catheterization which revealed 70%
LAD instent stenosis, 70-80% instent stenosis at the RCA and the
LCx had 90% stenosis and an
aortic valve area of 0.9cm. He underwent a CABG LIMA to LAD
saphenous graft sequential to an OM1 and OM2 and [**Hospital3 **] [**Hospital3 1291**].
Post -operatively course complicated by severe hyptnesion
requiring high dose pressor support with vasopressin,
epinephrine and levophed. A balloon pump was placed for several
days. He required multiple blood products. His post-op EF was
noted to be 30% per [**Hospital 100**] Rehab records. he was transferred to
[**Hospital 100**] rehab from OSH for an NSTEMI, [**Hospital 1291**] and CABG complicated by
multiple issues described below.
-CABG: LIMA to LAD saphenous graft sequential to an OM1 and OM2
and [**Hospital3 **] [**Hospital3 1291**] [**12-12**]
-PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD in [**2136**], prior
stent to RCA and LAD
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Chronic systolic dysfunction (EF 30%)
ESRD on HD
Chronic left-sided pleural effusion
Prior GI bleed - ?rectal ulcer
Hyperlipidemia
IDDM
chronic atrial fibrillation on coumadin
Stoke with no residual neurologic deficits
Hypothyroid
AS s/p [**Year (4 digits) 1291**] [**Hospital3 **]
Hyperparathyroidism
Right AV fistula
Rectal Ulcers: CMV positive
Blood cultures during his prior hospitalization grew gram
negative rods speciated to Aeromonas hydrophilia for which he
was treated with
6 weeks of ciprofloxacin last day of therapy [**2137-2-5**]. During
this time he developed lower GI bleed, colonscopy revealed
rectal uclers which were cauterizated and biospy was CMV
positive. Patient s/p 2 wks IV ganciclovir. Coumadin for afib
held and was restarted the nigth prior to admission to [**Hospital1 18**].
More recently on [**2-5**] at [**Hospital 100**] Rehab, due to persistent
diarrhea, the patient was empirically started on Flagyl for
cdiff colitis
Social History:
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Married, former salesman, several children. His wife and
children are very involved in his care.
Family History:
non contributatory
Physical Exam:
VS: BP= 69/37 HR=120s-130s RR= 24 O2 sat= 99% BiPAP 10/5 40%
FiO2
GENERAL: Mild respiratory distress.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at mandible.
CARDIAC: Irreg irreg nl S1 mechanical S2 .
LUNGS: CTAB, diffuse crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm wel perfused
Pertinent Results:
ADMISSION LABS:
[**2137-2-27**] 07:45PM BLOOD WBC-15.9* RBC-2.35*# Hgb-7.1*# Hct-21.0*#
MCV-90 MCH-30.7 MCHC-34.3 RDW-16.9* Plt Ct-297
[**2137-2-27**] 07:45PM BLOOD PT-23.7* PTT-30.8 INR(PT)-2.3*
[**2137-2-27**] 07:45PM BLOOD Glucose-139* UreaN-33* Creat-2.0*# Na-138
K-3.8 Cl-96 HCO3-34* AnGap-12
[**2137-2-27**] 07:45PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 89668**]*
[**2137-2-28**] 05:10AM BLOOD Calcium-10.3 Phos-4.7* Mg-2.1
[**2137-2-27**] 10:26PM BLOOD Type-ART pO2-330* pCO2-51* pH-7.45
calTCO2-37* Base XS-10 Intubat-NOT INTUBA
.
CHEST XRAY [**2137-2-28**] IMPRESSION: Findings compatible with
pulmonary edema.
.
.
TTE [**2137-2-28**]
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
with regional variation (lateral wall relatively preserved). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with depressed free wall
contractility. There are focal calcifications in the aortic
arch. A bileaflet aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of 10 Janaury [**2137**], the tricuspid regurgitation appears reduced,
but the technically suboptimal nature of both studies precludes
definitive comparison.
.
CARDIAC CATHETERIZATION [**2137-2-28**]
1. Resting hemodynamics revealed elevated left-sided filling
pressure
with a mean PCWP of 20 mmHg. There was moderate pulmonary
hypertension
with a PA pressure of 60/28 mmHg. Cardiac output was mildly
depressed
at 4.76 L/min with an index of 2.61 L/min/m2.
2. The RVH sheath was coverted to a CVVH catheter following
right heart
cathterization.
.
FINAL DIAGNOSIS:
1. Elevated left sided filling pressure
2. Moderate-severe pulmonary hypertension.
3. CVVH catheter placed.
.
.
CT ABD/PELVIS: [**2137-3-2**]
1. No CT evidence of colitis.
2. Stable appearance of bilateral pleural effusions and
compressive
atelectasis.
3. Stable small pericardial effusion.
.
.
TTE [**2137-3-4**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is moderate global left
ventricular hypokinesis (LVEF = 30 %). Right ventricular chamber
size and free wall motion are normal. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. There is no pericardial
effusion.
.
Compared with the prior study (images reviewed) of [**2137-2-28**],
the findings are similar (estimated PASP may be slightly lower).
.
CHEST XRAY
IMPRESSION: AP chest compared to [**2-27**] through 30:
.
Progressive consolidation at the left lung base is most likely
atelectasis, worsened since [**3-3**], but pneumonia,
particularly due to aspiration could have the same appearance.
Previous pulmonary vascular congestion continues to improve.
Moderate cardiomegaly is longstanding. Small left pleural
effusion is stable. Stomach is distended with air and fluid,
gastrostomy tube in place. No pneumothorax
.
MICRO DATA
.
[**2137-2-28**] 12:27 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2137-3-2**]**
FECAL CULTURE (Final [**2137-3-2**]):
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final [**2137-3-2**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-2-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2137-2-28**] 2:52 pm Immunology (CMV) Source: Line-A Line.
**FINAL REPORT [**2137-3-5**]**
CMV Viral Load (Final [**2137-3-5**]):
CMV DNA not detected.
.
[**2137-3-4**] 7:36 am BLOOD CULTURE
Source: Line-femoral dialysis line.
**FINAL REPORT [**2137-3-7**]**
Blood Culture, Routine (Final [**2137-3-7**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED ON REQUEST..
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final [**2137-3-5**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 89669**] #[**Numeric Identifier 25630**] [**2137-3-5**] 1350.
Anaerobic Bottle Gram Stain (Final [**2137-3-5**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
**FINAL REPORT [**2137-3-12**]**
Blood Culture, Routine (Final [**2137-3-12**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
[**Year/Month/Day **]------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2137-3-7**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 25629**] ON [**2137-3-7**] AT 0030.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
.
Labs at discharge [**3-18**]:
HGB:9.3*
HCT:28.7*
PTT: 97
INR 1.4
WBC: 10.3
PLT: 246
Na: 123
K: 4.1
CL: 94
BUN: 20
Creat: 3.3
Gluc: 123
CA:10.3
Phos: 5.6*
Mag: 2.2
.
Brief Hospital Course:
HOSPITAL COURSE
78 year old male with past medical history of CAD, NSTEMI, s/p
CABG (LIMA to the LAD, SVG to OM1 and OM2) and St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**]
([**12-12**]) with course complivated by wound dehisence, chronic
systolic dysfunction EF 30%, ESRD on HD, afib on coumadin,
anemia, recent lower GI bleed with bleeding rectal ulcers and
CMV colitis with worsening SOB, acute decompensated heart
failure.
.
# GOALS OF CARE: Goals of care continuously discussed with
family members and the [**Name (NI) 89670**] consult team who had care for
the patient through two hospitalizations. After significant
discussion regarding sepsis, failure of dialysis without pressor
support, multiple wound infections and multiple co-morbities,
the patients was made comfort measures only on HD 9. Heparin gtt
was continued to prevent stroke per families wishes and dopamin
was slowly weaned off. CVVH, antibiotic therapy and all other
medications and lab draws were discontinued. On HD 13, the
patient was noted to be more alert with improved quality of
life. Goals of care was readdressed with the family and
hemodialysis was re-initiated. Antibiotic therapy ([**Name (NI) **])
was restarted to cover staph and enterococcus (VRE) positive
blood cultures. As Mr. [**Known lastname 89671**] [**Last Name (Titles) **] picture continued to
stabilize and he tolerated HD, there needs to be continuing
discussions regarding quality of life and goals of treatment.
Still holding all cardiac meds to allow BP for HD.
....
# CHF: Patient initially floridly volume overloaded in acute
decompensated heart failure. Patient 13 kg over discharge
weight several days prior to admission at dialysis, likely 15-20
Liters overloaded. Hyponatremia and extremely high BNP also
consistent with florid hypervolemia. Patient did not get full
HD session prior to admission due to hypotension. Acute
decompensation also likely triggered by unit of blood given
earlier today at rehab facility. Swan could not be floated but
had RHC during HD cath placement which showed wedge of 20. CKMB
stabilized at 6. Echo on [**2-28**] showed mild symmetric left
ventricular hypertrophy. The left ventricular cavity size was
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 25 %) with regional variation (lateral wall
relatively preserved). CVVH initiated for volume management and
NC for respiratory support. Dopamine gtt required to maintain
diuresis with CVVH. Ultimately, unable to wean dopamine gtt with
CVVH. Goals of care were discussed as above. Pt's fluid status
now being managed through HD and ACEi, Beta blocker being held
to allow for blood presure room during HD.
.
#. ESRD: Status post HD catheter placement on [**2-28**] after large
graft hematoma. CVVH via right groin line. Right upper arm
fistula repaired and now working normally. Tolerating HD
treatments as above and plan Mon/Wed/Fri schedule. Dr. [**Name (NI) 118**],
pt's nephrologist who has followed pt very closely here, will
continue to consult for HD issues after transfer.
.
#. ANEMIA: Patient with Hct 21 on admission, has a history of
transfusion-dependent anemia with GI sources, including rectal
ulcers. Transfused 3 units of PRBCs during admission. Initially
concerning for CMV colitis versus rectal ulcers. C diff sent
off as patient was being treated at rehab facility with PO vanco
and flagyl. Flexiseal placed. CMV VL negative and cdiff PCR
negative. Hct now 28. Has rec'd 2U PRBC during last HD
treatments and continued epogen injections during HD.
.
# GPC BACTEREMIA: GPC??????s in pairs & clusters grew from blood cx
from femoral line and art line on HD 6 which ultimately
speciated to staph aureus. Likely responsible for his
leukocytosis and worsening [**Name (NI) **] picture. He was continued
on Vancomycin. HD line was not removed, but changed over wire HD
7 after extensive discussion with Renal consult and family
regarding access. Dopamine was continued. After patient was
made CMO, vancomycin resistent enterococcus was positive in a
second set of blood cultures from HD 8. At this time the patient
was CMO and off antibiotic therapy. On HD 13, [**Name (NI) **] PO was
started to treat staph aureas and VRE after rediscussion of
goals of care. His last day will be [**2137-3-20**].
.
# HYPERCALCEMIA: Unclear etiology. Developed in the setting of
discontinuation of CVVH (in absence of citrate). Hypercalcemia
also possibly secondary to ischemia, in setting of hypotension
and elevated lactate. Lastly, patient likely has underlying
tertiary hyperparathyroidism from ESRD, known to have chronic
hypercalcemia in prior records. Likely acute on chronic
physiology. Ca has been stable at 10.
.
#. HYPOTENSION: Likely secondary decompensated heart failure,
septic physiology, and overdiuresis at times w/ CVVH. He was
continued on continuous dopamine for pressor support until goals
of care were discussed and dopamine was discontinued. Now BP is
rising off of cardiac meds.
.
#. GRAFT HEMATOMA: Large hematoma of RUE near graft site. Tender
to touch with small area of induration. Transplant surgery had
no plans to evacuate hematoma or fix graft while patient
unstable and bacteremic. Heparin gtt was continued for
anticoagulation. Now fixed and functioning well.
.
#. DIARRHEA: Flexiseal placed at rehab facility. Prior history
of CMV colitis. Per [**Hospital 100**] Rehab med list, was on PO Vanco. He
was started on oral vancomycin, metronidazole and gancyclovir. C
diff negative toxin two times, and PCR negative. No evidence of
colitis on CT scan. CMV VL negative. Gangcyclovir discontinued
on HD 6. Oral vancomycin and IV metronidazole were discontinued
on HD 7 after culture date negative. Has resolved but perineal
area still red and inflamed.
.
#. ANTICOAGULATION: Despite persistent anemia and GIB risk with
rectal ulcers, he was continued on heparin gtt given multiple
indications, including atrial fibrillation, mechanical valve and
presumed clot burden noted on previous hospitalizations.
Coumadin was restarted on [**3-18**] at 2mg daily and INR should be
checked on [**3-20**].
.
# AF: Patient presented in AFib with RVR. Has history of
chronic AFib, rate controlled with carvedilol, anticoagulated on
coumadin. He was started on amiodarone 400mg three times daily
but this medicine was held when pt made comfort care. Pt
currently in AF wtih rates 70's-80's. Coumadin restarted on [**3-18**]
at 2mg daily and currently on heparin drip as a bridge. Needs
INR on [**2137-3-20**] with goal 2.0-3.0.
.
#. CAD: Status post CABG [**12-12**]. Holding aspirin due to GIB. No
evidence of acute MI on ECG. Lateral ST changes on admission
likely secondary to demand ischemia from tachycardia. Enzymes
elevated likely due to renal failure.
.
# IDDM: Humalog SS, fingersticks QID. Will need to restart
lantus when tube feedings are started. Holding Lantus now in
setting of poor PO's.
.
#. Hypothyroid: On levothyroxine 75 mcg.
.
#. Depression: Zoloft should be restarted after [**Year (2 digits) **] is
finished on [**3-20**]. Pt is alert, talkative, aware of his situation
but wants to continue aggressive care for his family. He
currently has minimal SOB that is managed well with low dose
Morphine IV and no further CP. His goals of care may change if
his SOB and chest pain return and cannot be managed.
Medications on Admission:
Acetaminophen 650 mg QID PRN pain
ASA 81 mg daily
Ergocalciferol (vitamin D2) 50,000 unit qWednesday
Lantus 17units qPM
Lactobacillus acidoph-pectin
Levothyroxine 75 mcg daily
Metronidazole 500 mg TID (completed [**2-26**])
Omeprazole 40 mg daily
Sertraline 50 mg daily
Warfarin 1 mg daily
Carvedilol 3.125 mg [**Hospital1 **]
B complex-vitamin C-folic acid 1 mg daily
Cinacalcet 30 mg daily
PO Vanco
Megestrol
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) ml PO
Q6H (every 6 hours) as needed for fever, pain.
2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Mid-line, non-heparin dependent: Flush with 10 mL Normal
Saline daily and PRN per lumen.
4. zinc oxide-cod liver oil 40 % Ointment Sig: One (1)
application Topical [**Hospital1 **] (2 times a day) as needed for bottom
irritation.
5. [**Hospital1 11958**] 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): Last dose after dialysis on [**2137-3-20**].
6. morphine 2 mg/mL Syringe Sig: 0.5-1 ml Injection five times a
day as needed for pain or shortness of breath.
7. lorazepam 2 mg/mL Syringe Sig: 0.5-1 ml Injection Q4H (every
4 hours) as needed for anxiety.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for confusion or
agitation.
9. insulin lispro 100 unit/mL Solution Sig: 0-14 units
Subcutaneous four times a day: before meals and qhs.
10. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please start on [**2137-3-21**] when [**Date Range **] is finished.
12. heparin (porcine)-0.45% NaCl 25,000 unit/250 mL Parenteral
Solution Sig: as per weight based heparin protocol units
Intravenous continuous: D/C when INR > 2.0.
13. warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day:
Check INR on Thursday [**2137-3-21**] and adjust dose accordingly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure
Sepsis
End Stage Renal disease
Atrial Fibrillation
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had trouble breathing and was found to be in an acute
exacerbation of your congestive heart failure. It was difficult
to do dialysis because your blood pressure was very low and you
needed medicines to help keep your blood pressure up. At one
point, you and your family decided that you wanted to be made
comfortable. After we stopped all of your medicines, you
improved and was not short of breath or having chest pain. We
have resumed dialysis and restarted some of your medicines.
.
We made the following changes to your medicines:
1. Stop taking Omeprazole, Megatrol, vancomycin, carvedilol,
lactobacillus, aspirin, ergocalciferol, and nephrocaps.
2. Start taking Tylenol as needed for pain and fever
3. Start Heparin drip to prevent blood clots. We have started
coumadin pills to replace the heparin when the coumadin level is
therapeutic
4. Start Zinc ointment to use on your perineal area
5. Start [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic to treat the bacteria in your
blood. Your last day is [**3-20**].
6. Start Morphine as needed for pain
7. Start Lorazepam as needed for anxiety
8. Start olanzipine as needed to agitation
9. Use Humalog as per sliding scale to treat your high blood
sugars.
10. You will need to restart lantus if tube feedings are
started.
.
Daily weights. Call provider if weight goes up more than 3 lbs
in 1 day.
Followup Instructions:
Dr. [**Last Name (STitle) 118**] from Nephrology will follow patient in the MACU in a
consultative fashion.
.
Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 62**] on [**Hospital Ward Name 23**] 7 at [**Hospital1 18**].
He will be available to see patient on an emergent basis but
does not feel that routine f/u is needed at this time.
ICD9 Codes: 0389, 5856, 2761, 5119, 4280, 4168, 412, 2724, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 824
} | Medical Text: Admission Date: [**2156-6-1**] Discharge Date: [**2156-6-4**]
Date of Birth: [**2093-5-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Tape
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right lower lobe nodule
Major Surgical or Invasive Procedure:
[**2156-6-1**] Flexible bronchoscopy, Video assisted thoracoscopic
thoracoscopy. Right lower lobe superior segment and inferior
right
middle lobe wedge resections.
History of Present Illness:
Mr. [**Known lastname 55562**] is a 63-year-old man who, 4 years ago, was found to
have a 2 cm right upper lobe nodule for which he underwent a
right upper lobectomy. The
nodule at that time was found to be carcinoid tumor. He
developed a new right lower lobe nodule which was suspicious for
cancer and he is being admitted for excision of this nodule.
Past Medical History:
Right lower lobe superior segment nodule
RUL typical carcinoid
Asthma/COPD
Parkinson's
Coronary artery disease
Sick sinus syndrome w/pacemaker
Anxiety/Depression
Osteoarthritis
PSH: RULobectomy [**2151**], Partial Nephrectomy [**2151**],
Cholecystectomy [**2151**]
Social History:
Married lives with wife. Quit smoking [**2117**]
Family History:
non-contributory
Physical Exam:
VS:
General: 63 year-old male no apparent distress
HEENT: normocephalic
Neck: supple no lymphadenopathy
Card: RRR
Lungs: scattered crackles on right, left clear
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Incision: Right VATs site clean/dry/intact no erythema
Neuro: flat affect, mobility difficult to mobilize
Pertinent Results:
[**2156-6-2**] WBC-12.4*# RBC-4.14* Hgb-12.7* Hct-36.7 Plt Ct-205
Brief Hospital Course:
Mr. [**Known lastname 55562**] was admitted on [**2157-6-1**] and underwent Flexible
bronchoscopy, Video assisted thoracoscopic thoracoscopy, Right
lower lobe superior segment and inferior right middle lobe wedge
resections. He was monitored in the PACU prior to transfer to
the floor with a right chest-tube, foley and an epidural in
place managed by the acute pain service. On POD #1 the epidural
removed and he was converted to PO pain medication with good
control. The chest-tube was removed and a chest x-ray revealed
a collapsed right lower lobe and his oxygenation requirements
increased. He was later transferred to the TSICU and was
bronched for a mucus plug. A repeat film revealed a re-expanded
right lower lobe. He was restarted on his parkinsion's
medication. The foley was removed but was re-inserted for
urinary retention. Physical therapy was consulted to assist with
mobilization. On POD #2 he transferred back to the floor.
He continued to progress, was ambulating with assistance,
tolerating a regular diet, urinating without difficulty, he is
discharged home with PT services
Medications on Admission:
Carbidopa-Levodopa 25-100 mg qid, entacapone 200 mg qid,
amantadine 100 mg daily, tamsulosin 0.4 mg daily, clonazepam
0.5-1mg qhs prn anxiety.
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
2. Entacapone 200 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
3. Amantadine 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety/insomnia.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while taking oxycodone.
Disp:*60 Capsule(s)* Refills:*0*
9. Medications
Take Tylenol 1000mg every 6 hours for pain. You can alternate
with ibuprofen 400mg every 6 hours for pain. These do not
interact, so you can take them together.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
Right lower lobe superior segment nodule
RUL typical carcinoid
Parkinson's
Coronary artery disease
Sick sinus syndrome w/pacemaker,
Anxiety/Depression
Osteoarthritis
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, or cough
-Chest pain
-Incision develops drainage or increased redness
Chest-tube remove dressing Friday and cover site with a bandaid
Should site begin to drain cover with a clean dressing and
change as needed to keep site dry.
You may shower on Friday: No Swimming or tub bathing for 4 weeks
No driving while taking narcotics
Walk frequently throughout day
Followup Instructions:
Follow-up with Dr.[**Doctor Last Name 4738**] [**Telephone/Fax (1) 170**] NPs [**Female First Name (un) **] or [**First Name4 (NamePattern1) 1439**] [**6-15**] at 1:00pm in the [**Hospital Ward Name 121**] Building, [**Hospital1 **] I Chest Disease
Center.
Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiolgoy
Department for a Chest X-Ray 45 minutes before your appointment.
Completed by:[**2156-6-4**]
ICD9 Codes: 5185, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 825
} | Medical Text: Admission Date: [**2104-6-3**] Discharge Date: [**2104-6-19**]
Date of Birth: [**2043-10-7**] Sex: M
Service: SURGERY
Allergies:
Enalapril
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**6-10**]: ex lap, colon & SBR, abd left open
[**6-11**]: ex lap, hematoma evacuation,
[**6-12**]: ex lap, end jejunostomy
History of Present Illness:
60M with PMHx of COPD, HTN, ESRD s/o CRT, DM2 presented
overnight to ED with acute onset SOB. States he noted
progressively worsening dyspnea over past two days. Reports
subjective fevers 99-100 at home with chills. No recent increase
in sputum production.
Past Medical History:
-Coag negative staph right hip joint infection, s/p removal,
spacer placement 9/08and prolonged abx course.
-Chronic pain on narcotics
-COPD, not on home 02, last spirometry from [**2092**] with mild to
moderate obstructive defect.
-HTN
-End stage renal disease secondary to malignant hypertension
-s/p CRT [**2097**]
-baseline creat [**3-4**]
-Diverticulitis s/p right colectomy.
-Prostate cancer status post radiation therapy in [**3-5**]
-Diabetes, not on medication
-Perirectal abscess [**1-31**]
-bilateral avascular necrosis
-s/p fall with femoral neck fracture
Social History:
Lives alone at home, now retired, formerly worked as a security
guard. Tobacco x 30-40 yrs, [**2-1**] pk/day, [**Doctor First Name 1638**] EtOH or illicit
drugs, per OMR has h/o alcoholism and marijuana use.
Family History:
malignant hyperthermia - mother, siblings
Physical Exam:
On admission
Vitals: T:96.8 BP: 190/90 P:61 R:13 SaO2: 96%3L NC
General: Awake, alert, appears comfortable.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM slightly dry.
Muddy sclera.
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Limited air movement, quiet deep pitched wheezes
anteriorly and posteriorly, with prolonged expiratory phase. No
crackles, no rhonchi.
Cardiac: Unable to appreciate through breath sounds.
Abdomen: Minimally distended, hypoactive bowel sounds present.
Diffusely minimally tender to palpation. No rebound or guarding.
No tympany
Extremities: No edema. Has non-functional right UE fistula.
Skin: Multiple keloids
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout.
Pertinent Results:
[**2104-6-19**] 04:05AM BLOOD WBC-2.3*# RBC-2.34* Hgb-7.1* Hct-22.6*
MCV-97 MCH-30.2 MCHC-31.2 RDW-16.5* Plt Ct-35*
[**2104-6-19**] 04:05AM BLOOD PT-24.1* PTT-96.9* INR(PT)-2.3*
[**2104-6-19**] 04:05AM BLOOD Glucose-138* UreaN-54* Creat-2.0* Na-134
K-5.5* Cl-102 HCO3-18* AnGap-20
[**2104-6-19**] 04:05AM BLOOD ALT-91* AST-123* AlkPhos-67 TotBili-8.3*
DirBili-6.6* IndBili-1.7
[**2104-6-19**] 06:13AM BLOOD Type-ART Temp-35.6 pO2-62* pCO2-78*
pH-6.97* calTCO2-19* Base XS--16
[**2104-6-19**] 04:19AM BLOOD Type-ART pO2-148* pCO2-76* pH-7.00*
calTCO2-20* Base XS--14
[**2104-6-19**] 06:13AM BLOOD Glucose-88 Lactate-8.6*
Brief Hospital Course:
In ED, initial VS 96.8 193/113 78 24 100% NRB. He desatted to
91% on RA. He had a CXR which did not show any infiltrate or
effusion. His labs were notable for acute renal failure and
hypernatremia, BNP lower than last value from [**6-4**]. His
shortness of breath worsened acutely and he was tried on BiPap
which he did not tolerate. He was admitted to the [**Hospital Unit Name 153**] for
further monitoring in setting of elevated BP and transient need
for BiPap. He detereorated further and was intubated. Abdominal
exam became more distended and a tranplant Surgery consult was
requested . Initially, he was persistently hypertensive and was
treated with nitro and nicardipine drips. On HD #2, renal U/S
showed no abnormalities. On HD #3, he was intubated for
progressive pulmonary decompensation. On HD #4, renal biopsy
concerning for rejection with superimposed ATN. Progressive
acidosis at this time. On HD #7, acute hypotensive episode, SBP
70, minimally responsive to fluid resuscitation and
vasopressors, guiac positive stool, KUB showing bowel
dilatation. CT abdomen showed bowel pneumatosis. On HD #8,
approximately 6 hours after initial surgical consultation, the
patient was taken to the OR. At this point, he was on three
vasopressors, LFT markedly elevated, coagulopathic, and anemic.
Also of note, he demonstrated a methemoglobinemia as high as 13%
(nl 0-2%) on the day of his decompensation. There was frankly
necrotic and perforated bowel, encompassing the majority of his
small bowel and transverse/proximal left colon, as well patchy
necrosis of his liver. These portions of dead bowel were
resected and the patient was left in discontinuity, abdomen
open, and returned to the [**Hospital Unit Name 153**] and then later transferred to the
SICU. Massive resuscitation continued, with copious blood
product transfusions, CVVH initiated. On POD #1, he was taken
back to the OR and there was a large amount of hematoma
evacuated without obvious source of bleeding, omentectomy was
performed, bowel looked viable, abdomen left open. On POD #2,
he went into rapid afib with associated hypotension, treated
with electrical cardioversion and rate control. Later that day,
he was taken back to the OR and an end jejunostomy was performed
after failed attempts at re-establishing continuity secondary to
tissue friability. On POD #[**4-4**], vasopressors on and off,
continued CVVH, developed neutropenia (WBC 0.3) treated with
Neupogen, gradual increase in ventilator requirements (increased
FiO2 and PEEP). On POD #7, he was taken back to the OR for
abdominal wash-out, vicryl mesh closure of abdomen, and VAC
dressing placement. Bowel looked viable at this time. On POD
#8, the patient went back into rapid afib with hypotension,
treated with electrical cardioversion, but progressed to
refractory shock requiring three vasopressors. On POD #9,
precipitous decompensation ensued, family was consulted, CMO
status and expiration shortly thereafter.
Medications on Admission:
HOME MEDICATIONS (per OMR as pt did not know on admit, now
intubated:)
Albuterol inhaler 1-2 puffs Q4 hours
Atorvastatin 20mg daily
duloxetine 30mg daily
ezetimibe 10mg daily
Fosomax 70mg daily
Furosemide 40mg daily
Gabapentin 900mg TID
Hydromorphone 4mg up to 5x per day prn
Methadone 7.5mg PO TID
Metaclopromide 10mg TID (per transplant)
Metoprolol 50mg [**Hospital1 **]
Mycophenolate mofetil 500mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Oxycodone SR 30mg [**Hospital1 **]
Prednisone 5mg daily
Salmeterol 50mcg 2 puffs [**Hospital1 **]
Tacrolimus 4mg [**Hospital1 **]
Valsartan 160mg [**Hospital1 **]
Varenicline 0.5mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Discharge Medications:
Calcium Gluconate/ 500 mL D5W
Albuterol Inhaler
Artificial Tears
Calcium Chloride
Chlorhexidine Gluconate 0.12% Oral Rinse
Citrate Dextrose 3% (ACD-A) CRRT
Ciprofloxacin
Famotidine
Fentanyl Citrate
Filgrastim
Fluticasone Propionate 110mcg
Hydrocortisone Na Succ.
Insulin
Ipratropium Bromide MDI
Magnesium Sulfate
MetRONIDAZOLE (FLagyl)
Meropenem
Midazolam gtt
Phenylephrine
Potassium Chloride
Prismasate (B22 K4)*
Tacrolimus
Vancomycin
Vasopressin
Discharge Disposition:
Expired
Discharge Diagnosis:
COPD, Sepsis, Mesenteric ischemia, Afib, Death
Discharge Condition:
Deceased
Completed by:[**2104-6-20**]
ICD9 Codes: 9971, 5845, 0389, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 826
} | Medical Text: Admission Date: [**2164-2-18**] Discharge Date: [**2164-2-22**]
Date of Birth: [**2090-1-23**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 25383**] is a 74 year-old woman, patient of Dr. [**Last Name (STitle) **], with
history of treated MAC, obstructive lung disease (FEV1/FVC 56 in
[**10-18**]), and s/p recent right TKR on [**2164-1-24**] who presents with
cough, fevers, and dyspnea and is admitted to the MICU for
respiratory distress.
She was feeling well until three days ago when her symptoms
began. She noted cough productive of yellow sputum, worsening
dyspnea, and fevers with tmax 101.5. No sick contacts. She did
receive seasonal flu vaccine but not H1N1. She has also lost 10
lbs over the last 6 weeks because of lack of appetite.
In the ED, vital signs were initially: 97.4 155 115/57 24 90%ra.
She was noted to be speaking in short sentences with pursed lip
breathing. Exam was significant for wheezes and rales. CXR was
negative for acute process. She was given 2L NS and
ceftriaxone/azithro and admitted to the MICU.
Past Medical History:
- Mycobacterium avium intracellularae - treated for MAC from
[**2-/2157**] to [**7-/2158**]
- bronchiectasis
- Right total knee replacement [**2164-1-24**], on coumadin
- cholecystitis s/p cholecystectomy
- endometrial carcinoma s/p hysterectomy in [**10/2152**]
- Obstructive lung disease (FEV1/FVC 56 IN [**10-18**]), NOT on home 02
- Anxiety
Social History:
Retired, lives alone. Friend [**Name (NI) 1312**] has been staying with her
since her surgery. Her HCP is her sister. Smoked 1 pack/week x
20 years. Has not smoked for 25 years. She drinks 6-8 drinks per
week. Last drink 3 days ago. No history of withdrawl.
Family History:
colon cancer
Physical Exam:
Admission Vitals - T:97.8 BP:117/82 HR:95 RR:22 02 sat:98% 3L
GENERAL: Thin, frail appearing elderly woman sitting in chair.
HEENT: Normocephalic, temporal wasting. MM dry. Multiple
telangiectasias.
CARDIAC: Tachycardic, regular
LUNGS: Decreased air movement. Fine crackles and distant wheeze.
can only speak [**3-14**] words at a time, is easily winded.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. s/p recent TKR, incision well healed.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
.
Discharge Vitals: T:96.5 BP:136/65 HR:64 RR:20 02 sat:95%RA
Pertinent Results:
[**2164-2-18**] 01:18PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2164-2-18**] 01:18PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2164-2-18**] 01:18PM URINE RBC-89* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
[**2164-2-18**] 01:18PM URINE MUCOUS-RARE
[**2164-2-18**] 06:29AM TYPE-ART TEMP-38.1 O2 FLOW-4 PO2-98 PCO2-50*
PH-7.32* TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2164-2-18**] 04:01AM LACTATE-1.0
[**2164-2-18**] 02:19AM GLUCOSE-121* UREA N-15 CREAT-1.0 SODIUM-136
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
[**2164-2-18**] 02:19AM estGFR-Using this
[**2164-2-18**] 02:19AM CK(CPK)-41
[**2164-2-18**] 02:19AM CK-MB-NotDone cTropnT-0.01
[**2164-2-18**] 02:19AM TSH-1.4
[**2164-2-18**] 02:19AM WBC-9.2 RBC-4.35# HGB-12.9# HCT-40.4# MCV-93
MCH-29.5 MCHC-31.8 RDW-15.3
[**2164-2-18**] 02:19AM NEUTS-79.0* LYMPHS-15.0* MONOS-3.3 EOS-2.3
BASOS-0.4
[**2164-2-18**] 02:19AM PLT COUNT-515*
[**2164-2-18**] 02:19AM PT-51.9* PTT-47.4* INR(PT)-5.7*
.
[**2164-2-18**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2164-2-18**] URINE URINE CULTURE-FINAL INPATIENT
[**2164-2-18**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL {RESPIRATORY SYNCYTIAL VIRUS (RSV)};
Respiratory Viral Antigen Screen-FINAL INPATIENT
[**2164-2-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2164-2-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2164-2-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2164-2-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
.
BASIC COAGULATION (PT, PTT, PLT, INR)
[**2164-2-22**] 06:50AM 17.4* 29.8 1.6*
[**2164-2-21**] 04:55AM 18.8* 31.4 1.7*
[**2164-2-20**] 08:50AM 23.0* 32.8 2.2*
[**2164-2-19**] 03:51AM 51.0* 44.6* 5.6*1
[**2164-2-18**] 02:19AM 51.9* 47.4* 5.7*2
.
[**2-18**] CXR No focal consolidations. Hyperinflation suggestive of
possible
emphysema or COPD.
Brief Hospital Course:
Ms [**Known lastname 25383**] was initially admitted to the MICU given concern for
her tachypnea and tachycardia. She was treated for pneumonia
with levofloxacin and for COPD with steroids and nebulizers.
Her oxygen saturations remained in the high 90s with 3L
supplemental oxygen. Her chest-xray did not show consolidation.
She tested negative for legionella urinary antigen and was
negative for flu. She was transferred to a regular medical
floor on the second day of her hospitalization. Her warfarin
for her knee replacement was held when her INR became
supratherapeutic >5 in the setting of antibiotic use.
On the floor, the following issues were managed:
# Respiratory distress. Patient was treated for CAP/HAP with
levoquin and discharged to complete a 7 day course. CXR on
admission showed hyperinflation without focal findings and
repeat showed now interval change. No sputum culture to guide
therapy. She was also treated for COPD flare/bronchitis with
burst of prednisone 60mg daily and with aggressive nebulizer
treatment. Over the course her stay, her resp status
dramatically improved. She was discharged with a slow 10 day
taper. She was weaned off oxygen with some residual cough. Lung
exam improved with some residual crackles and wheezing at bases.
Had been ruled out for flu. PE also possible but less likely
given therapeutic on coumadin on admission. Viral culture showed
RSV and after discussion with ID the treatment is just
supportive care.
.
#.Anemia. Hct stable. Iron studies c/w mixed iron deficiency and
likely chronic disease. Recent baseline hct low 30s, however was
40 on admission likely hemoconcentrated in setting of illness.
No obvious bleeding. Hct remained stable. Her iron was increased
to [**Hospital1 **].
.
# Coagulopathy: Pt on warfarin at home for planned 4 week
post-op course since [**1-26**]. Elevated INR in setting of abx use
on admission but then became subtherapeutic after holding doses.
It was restarted but she was not yet therapeutic upon
discharge. No evidence of bleeding.
.
# Anxiety: stable, cont home PRN ativan
.
# HTN: reasonably controlled, cont home lisinopril
.
# TKR: Followed by Dr. [**Last Name (STitle) **]. Has outpatient appt with him on
Friday. Cont warfarin management as above, patient to go home
with PT, pain control with oxycodone. Given subQhep while
subtherapeutic on coumadin and TEDS.
.
# General Care: FEN: noIVFs / replete lytes prn / regular diet,
PPX: home PPI, subQ hep, bowel regimen, ACCESS: PIV, CODE: FULL,
confirmed with pt, CONTACT: [**Name (NI) **] and sister is HCP [**Name (NI) 2147**]
[**Name (NI) 5263**] [**Telephone/Fax (1) 25384**], DISPO: home with services
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q4h PRN as needed
for pain.
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 4
weeks: goal INR 2.0-2.5
adjust dose accordingly.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times 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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
10. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for SBP<110.
16. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. Desonide 0.05 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
18. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily).
19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day for
14 days.
Disp:*42 Tablet(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
12. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
13. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 10 days: Take 5 tab for 2 days([**Date range (1) 25385**]), take 4 tab
for 2 days ([**Date range (1) 25386**]), take 3 tab for 2([**2073-2-25**]), take 2 tab
for 2 days([**Date range (1) 25387**]), take 1 tab for 2 days([**Date range (1) 25388**]).
Disp:*30 Tablet(s)* Refills:*0*
14. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Please have INR drawn twice a week starting on Thursday [**2164-2-23**] and have results called in to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1228**]
who should call you with instructions on how to change the
coumadin dosing.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Community Acquired Pneumonia
COPD flare
Iron deficient anemia
Supratherapeutic INR
.
Secondary:
bronchiectasis
anxiety
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 because of difficulty breathing which required
you to be admitted to the intensive care unit overnight. We
believe this was secondary to a pneumonia and possible
exacerbation of your chronic lung disease. You were given
antibiotics for the infection and steroids to help with the
inflammation. You slowly improved and we were able to get you
off oxygen.
.
Medication changes:
1)We started you on an antibiotic called levaquin which you
should take for 2 more days.
2)You iron was increased to twice a day.
3)We started you on prednisone with decreasing doses over the
next 10 days.
4)We started compazine if you have any nausea.
.
You should have your INR drawn and Thursday by the visiting
nurses.
.
Please keep all your follow up appontments.
.
If you develop any of the warning signs below or any other
concerning symptoms, please do not hesitate to call or your PCP
or go to your local emergency room.
Followup Instructions:
You have an appointment with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Wednesday,
[**2-29**] at 10:40am. [**Telephone/Fax (1) 24396**]. Please have him follow up
your anemia.
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2164-2-24**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2164-3-2**] 11:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2164-4-19**] 11:10
Completed by:[**2164-2-22**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 827
} | Medical Text: Admission Date: [**2106-8-30**] Discharge Date: [**2106-9-2**]
Date of Birth: [**2067-4-16**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 39 year old right handed woman with a
history of hypertension, DM2, and oral contraceptive use who
presents with an 8 day history of bilateral frontal throbbing
headaches associated with blurry peripheral vision which changed
to left occipital throbbing headaches on the day prior to
admission, an episode of loss of power and balance in her right
arm and leg 5 days prior to admission, 2 episodes of vertigo and
projectile vomiting, and leaning to the left when walking, who
was found to have occlusion of her left vertebral artery with
embolic left PICA and PCA infarcts.
The patient reports that her symptoms started 8 days ago on
Sunday ([**8-22**]). She reports that she very rarely gets headaches,
but on Sunday woke up from her afternoon nap with a bilateral
frontal, throbbing, [**2107-3-10**] headache. She said this was
associated
with blurry vision out of the peripheral vision of her bilateral
eyes. She noticed this when watching TV and when [**Location (un) 1131**] her
book. She did not close each eye individually to test her
vision.
There was no sensation of movement in her periphery, and no
fortification spectra. She took Advil for this headache, which
improved after 2-3 hours. She slept well overnight, and then on
Monday ([**8-23**]) woke up again with a [**2107-6-13**] frontal throbbing
headache, this time was associated with photophobia,
phonophobia,
and nausea but no vomiting. The headache did not get worse when
she layed flat. Because of this, she went to her PCP where she
described the headache as the worse headache of her life, and
was
referred to the [**Hospital1 18**] ED where head CT was normal. She was given
Compazine and Ibuprofen with improvement in her headache. Her
headache ended up lasting 6-7 hours.
On Tuesday ([**8-24**]) she was able to go to work in the lab, and did
not have a headache. On Wednesday ([**8-25**]) she had a central
frontal headache, which improved with Advil. That day, she had
an
episode in which she was holding the door with her left hand and
then lost power and lost balance in her right leg. She could not
bear weight on the right leg, and this lasted 5 minutes. During
the episode for 1 minute she also felt as though she had lost
power and balance in her right arm. Her sensation on the right
side was normal during this episode, and she had no facial
weakness, dyarthria, or aphasia. She called her PCP, [**Name10 (NameIs) 1023**]
reassured her given the normal head CT in the ED. On Thursday
([**8-26**]), she did not have a headache but was evaluated by
ophthomology where her vision was 20/20 bilaterally.
On Friday ([**8-27**]), she had a left frontal headache despite taking
Motrin. She continued to have blurry vision with each frontal
headache (and even reported that if she had a headache on one
side, she would have the blurry vision on the opposite side).
She
again saw her PCP who recommended Claritin D for a possible
sinus
infection, and ordered the patient an MRI head. At 10:00 pm that
night, the patient had [**2107-6-14**] pain in her left frontal region
despite the Motrin. She took Claritin and went to bed. She woke
up from sleep on Saturday morning ([**8-28**]) at 2:00 am and felt the
room spinning around her. She even remembers feeling a spinning
sensation in her dream before waking up. She began to have
projectile vomiting which she said she could not control. The
dizziness lasted for 15-30 minutes, and she had no associated
diplopia, dysarthria, or dysphagia. She had a slight headache at
that time. She did not get up to walk during this event, and
ended up going back to bed. However, she woke up again at 5:00
am
with the room spinning around her and projectile vomiting. She
could not get up, so again was taken to the [**Hospital1 18**] ED. Per the ED
report she had a "negative [**Last Name (un) **]-Hallpike, and was thought to have
a sinus infection as the cause of her symptoms". No further
imaging was obtained. She was given Valium 5 mg prn and
discharged home. The dizziness lasted a total of [**4-11**] hours and
improved with Valium.
Yesterday ([**8-29**]), at 6:00-7:00 pm she developed a mild,
throbbing, left occipital headache, and she noticed when she
walked she was drifting to the left side. She called her PCP
about these symptoms on [**8-30**], and she changed her MRI head with
and without contrast to be done today. This showed an
acute/subacute embolic infarct in the left PICA territory and
small left PCA territory with long segment occlusion of the left
vertebral artery. The patient was referred to the [**Hospital1 18**] ED.
On ROS, she currently reports a [**2107-4-11**] left occipital headache.
She denies any numbness. She denies neck pain. She denies
bowel/bladder incontinence. She denies diplopia, dysarthria,
dysphagia, or aphasia. She denies fevers/chills, coughs/colds,
diarrhea, or pain/burning on urination. She has not had any
recent travel outside of the country, and the last trip was to
Montreal x1 day in [**11-14**]. She does not have a history of
miscarriages or blood clots. She has never had symptoms like
this
before.
Past Medical History:
Hypertension x7 years
Diabetes type 2 diagnosed in [**3-/2106**]
PCOS diagnosed in [**2101**]
Social History:
She lives at home with her husband and 7 year old
daughter. She works as an instructor in Dr.[**Name (NI) 80545**] laboratory
in
sleep and circadian rhythm. She denies working with any viruses
and denies any chemical exposure. She denies cigarette, EtOH, or
illicit drug use ever.
Family History:
There is no family history of blood clots or miscarriages. There
is no family history of stroke. Her father had hypertension and
died of an MI at age 60. There is a strong maternal family
history of type 2 diabetes.
Physical Exam:
VS: temp 98.2, HR 109, bp 136/100, RR 21, SaO2 99% on RA
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Tachycardic, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**]
backwards. Speech is fluent with normal repetition; naming
intact. No dysarthria. Registers [**3-9**], recalls [**2-9**] in 5 minutes
even with prompting. No right-left confusion. No evidence of
apraxia or neglect.
Cranial Nerves: Fundoscopic examination reveals sharp disc
margins bilaterally. Pupils equally round and reactive to light,
4 to 3 mm bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally without nystagmus.
Sensation intact V1-V3. Facial movement symmetric. Hearing
intact
to finger rub bilaterally. Palate elevation symmetric.
Sternocleidomastoid and trapezius full strength bilaterally.
Tongue midline, movements intact.
Motor: Normal tone bilaterally. No observed myoclonus,
asterixis,
or tremor. No pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE
R 5 5 5 5 5 5 4+ 5 5 5 5 5
L 5 5 5 5 5 5 4+ 5 5 5 5 5
Sensation: Intact to position sense throughout. She has
decreased
sensation to cold temperature and pinprick in her entire right
leg which she says is 80% of the left side. No extinction to
DSS.
Reflexes: 2+ and symmetric in biceps, brachioradialis, triceps,
and knees. 1+ and symmetric in ankles. Toe downgoing on the
left,
upgoing on the right.
Coordination: Finger-nose-finger, finger-to-nose, and [**Doctor First Name **]
normal.
Fine finger movements slightly slowed on the left, but not
clumsy
bilaterally.
Gait: Wide based, unsteady and tends to lean to the left. Unable
to tandem and leans to the left. Romberg positive and leans to
the left and forward.
Pertinent Results:
Admission Labs:
[**2106-8-30**] 11:25AM
RET AUT-1.5
PLT COUNT-443*
WBC-11.8* RBC-5.88* HGB-11.2* HCT-35.0* MCV-60*
MCH-19.0* MCHC-31.9 RDW-16.0*
NEUTS-64.0 LYMPHS-31.8 MONOS-2.5 EOS-1.0 BASOS-0.7
FERRITIN-78
IRON-37
PT-11.5 PTT-22.2 INR(PT)-1.0
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
GLUCOSE-102 UREA N-11 CREAT-0.5 SODIUM-135 POTASSIUM-4.4
CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
MR HEAD W & W/O CONTRAST Study Date of [**2106-8-30**] 12:53 PM
IMPRESSION:
1. Acute/subacute embolic infarct in the left PICA territory and
small left PCA territory.
2. Long segment occlusion of the left vertebral artery.
CTA NECK W&W/OC & RECONS Study Date of [**2106-8-30**] 9:03 PM
IMPRESSION:
1. Occlusion of the left vertebral artery from the distal V2
segment through
the distal V4 segment. While there are no specific signs to help
differentiate between thrombosis and dissection, the
distribution of the
occlusion is suggestive of dissection.
2. Left posterior inferior cerebellar artery origin is not
opacified. Vessels
along the inferior left cerebellar hemisphere appear to
represent branches of
the large left anterior inferior cerebellar artery and veins.
3. Infarctions in the left posterior inferior cerebellar artery
distribution,
shown to be acute on the preceding MRI. The small left occipital
lobe acute
infarction seen on the preceding MRI is poorly visualized on
this study.
4. Aberrant right subclavian artery. Common origin of the right
and left
common carotid arteries.
5. Enlarged left thyroid lobe and bilateral thyroid nodules.
Recommend
thyroid ultrasound if not done previously.
Discharge labs:
[**2106-9-2**] 04:40AM BLOOD WBC-11.5* RBC-5.33 Hgb-9.7* Hct-32.7*
MCV-61* MCH-18.2* MCHC-29.6* RDW-15.5 Plt Ct-438
[**2106-9-1**] 04:45AM BLOOD Neuts-40.9* Lymphs-51.8* Monos-3.5
Eos-3.0 Baso-0.8
[**2106-9-2**] 04:40AM BLOOD Plt Ct-438
[**2106-9-2**] 04:40AM BLOOD PT-15.1* PTT-26.5 INR(PT)-1.3*
[**2106-8-31**] 05:01AM BLOOD ESR-21*
[**2106-8-30**] 11:25AM BLOOD Ret Aut-1.5
[**2106-9-2**] 04:40AM BLOOD Glucose-129* UreaN-10 Creat-0.6 Na-137
K-4.7 Cl-102 HCO3-20* AnGap-20
[**2106-8-31**] 05:01AM BLOOD ALT-7 AST-15 LD(LDH)-176 CK(CPK)-24*
AlkPhos-63 TotBili-0.2
[**2106-9-2**] 04:40AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.1
[**2106-9-1**] 04:45AM BLOOD calTIBC-378 VitB12-151* TRF-291
[**2106-8-31**] 05:01AM BLOOD %HbA1c-6.8*
[**2106-8-31**] 05:01AM BLOOD Triglyc-881* HDL-55 CHOL/HD-3.9
[**2106-9-1**] 04:45AM BLOOD TSH-2.8
Brief Hospital Course:
Ms. [**Known firstname 80546**] is a 39 yo woman with a history of hypertension,
diabetes (type II) and PCOS who presented with 8 days of
headache with progression to vertigo and left neck/occipital
pain.
# PICA/PCA infarcts/Vertebral Dissections: The patient was
referred to the ED by her PCP following MRI identification of a
cerebellar infarct. An occipital infarct was also identified.
CTA of the head was notable for an apparent intracranial left
vertebral artery dissection. She was started on a heparin gtt,
and then switched to a Lovenox bridge to Coumadin. An
echocardiogram was performed and showed no abnormalities. She
is currently on Lovenox while bridging to a goal INR of 2.0-2.5.
She was found to have significantly elevated triglycerides, and
was also on oral contraceptives, both of which could make her
hypercoagulable. In addition, a hypercoagulable panel was sent,
the results of which are still pending. Her exam on discharge
is notable only for slight slowing of rapid alternating
movements with the left hand, and very mild gait instability,
most notable when turning.
# Hypertriglyceridemia. The patient was noted to have a
triglyceride of 880. She was started on gemfibrozil and
simvastatin. She is not aware of any family history of lipid
elevations, however this raises suspicion for Type IV
hyperlipidemia. It is also possible that her high triglycerides
increased the viscosity of her blood, contributing to her
current stroke.
# Diabetes: HgA1c on admission was 6.8. Metformin was held in
the setting of IV contrast. Blood sugars were controlled with
insulin. She is to resume her metformin on discharge, however
given her significant hyperlipidemia, she may benefit from
switching back to insulin in the future.
# Tachycardia: Throughout her admission the patient had
constant asymptomatic sinus tachycardia. Her heart rate did
increase to the 140s with activity, but even at rest, while
sleeping she remained in the 100-110s. The tachycardia was not
fluid responsive, and not related to pain. She remained
afebrile during the entire admission. She had a TSH checked,
which was normal at 2.8. While she was anemic, her Hct ranged
from 30-32, which is around her baseline. While pulmonary
embolism should be considered, given the possibility that she
may be hypercoagulable, her SaO2 remained 97-100% on room air,
and she was not tachypnic. She had both an EKG and TTE which
showed no signs of right heart strain. Given that constellation
of findings, there was a much lower suspicion for PE. She had
already had significant contrast exposure from her earlier
imaging, and she was already being anticoagulated, so the
decision was made not to get a PE CT, as it would not change
management and there was low suspicion that this was causing her
tachycardia. Given her known thrombus elsewhere, a D-dimer
would not have been useful. There is evidence that medullary
involvement in PICA strokes can result in tachycardia, and it is
suspected that this was the underlying cause. She was started
on a low dose beta-blocker for rate control, and this should
continue to be followed.
# PCOS: The patient was taking oral contraceptives for
treatment of her PCOS. Given her stroke, this medication was
discontinued. Reinitiation of this medication verus alternative
treatment should be discussed with her endocrinologist.
# Hypertension: Micardis was held on admission to allow for
autoregulation in the setting of stroke, but was restarted on
discharge, in addition to a low dose of metoprolol.
# Anemia: The patient was noted to have a significantly
microcytic anemia. On further questioning she noted that she
actually had been diagnosed with thalassemia trait in the past.
It also appears as though she has a component of iron
deficiency, and should continue on iron supplementation.
# Thyroid: Incidentally the patient was noted to have an
enlarged left thyroid lobe and bilateral nodules on MRI. TSH
was normal at 2.8. It is recommended that she have a thyroid
ultrasound as an outpatient.
Medications on Admission:
Metformin 500 mg daily
Micardis 80 mg-12.5 mg daily
Ocella (Drospirenone-Ethinyl Estradiol) 0.03 mg-3 mg daily x7
years
Tylenol prn
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
2. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) 60mg syringe
Subcutaneous Q12H (every 12 hours): Continue taking until
instructed by Dr. [**First Name (STitle) **] to stop.
Disp:*12 60mg syringe* Refills:*1*
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
Disp:*10 Tablet(s)* Refills:*0*
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Micardis HCT 80-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Only
take if instructed to do so by Dr. [**First Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Please check INR on [**2106-9-4**] and every other day after that.
Please FAX results to Dr. [**First Name (STitle) 9466**] [**Name (STitle) **] at [**Telephone/Fax (1) 4004**].
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebellar infarction
Vertebral artery dissection
Hypertriglyceridemia
Anemia - thalassemia trait
Discharge Condition:
Improved. Very mild dysmetria and impaired rapid alternating
movements on the left. Very mild gait instability.
Discharge Instructions:
You were seen for headache, nausea and vomiting. You were found
to have a cerebellar stroke. This is likely due to a vertebral
dissection. You were started on Coumadin, but will need to take
Lovenox until your Coumadin levels become therapeutic. You
should have your INR checked every other day, and have the
results sent to Dr. [**First Name (STitle) **]. You were also found to have an
elevated heart rate, and were started on a new medication called
Metoprolol.
If you developing worsening headache, nausea or dizziness, or
any other new neurological symptoms, please return to the ED for
further evaluation.
Followup Instructions:
You have the following follow-up appointments:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2106-9-6**]
9:40
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2106-10-19**] 2:00
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 828
} | Medical Text: Admission Date: [**2124-3-22**] Discharge Date: [**2124-3-30**]
Date of Birth: [**2059-4-10**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
lady with dementia, seen in the catheterization holding area
for two vessel disease. She is status post ventricular
fibrillation arrest on [**2123-10-6**], cardioverted to atrial
fibrillation by medics. She is status post silent myocardial
infarction x 2, status post stent and arterectomy to the
mid-left anterior descending on [**2123-10-13**], diabetes mellitus,
hypertension, high cholesterol. She presented to an outside
hospital with profuse diaphoresis. It was seen that she had
a large are of anteroseptal ischemia. She has an ejection
fraction of 45%. The patient is unable to give a history due
to her dementia. History obtained from the chart.
HOME MEDICATIONS: Insulin, Lopressor, Zestril, Synthroid,
Lipitor, iron, Colace, multivitamin, aspirin.
ALLERGIES: Sulfa, Biaxin.
PAST MEDICAL HISTORY: Myocardial infarction x 2, arterectomy
to mid-left anterior descending and stent.
SOCIAL HISTORY: The patient is a nonsmoker.
PHYSICAL EXAMINATION: In general, the patient is somnolent.
She doesn't know why she is in the hospital. Blood pressure
138/48, heart rate 58. Extremities: All pulses are felt.
Heart: Regular rate and rhythm.
PLAN: The patient was admitted to [**Hospital1 190**] for coronary artery bypass graft.
HOSPITAL COURSE: The patient was admitted on [**2124-3-22**]. On
[**2124-3-23**], the patient was taken to the operating room, where a
coronary artery bypass graft was performed, with left
internal mammary artery to the diagonal, and saphenous vein
graft to the obtuse marginal. The patient was thereafter
sent to the Intensive Care Unit for postoperative care.
Postoperative care appeared to be somewhat unremarkable. She
was seen by Physical Therapy. While in the Intensive Care
Unit, the patient experienced quite brittle blood sugar
control, and the [**Last Name (un) **] was consulted for assistance in
controlling her insulin.
The patient was transferred to the floor on [**2124-3-28**] in good
condition. Her pacing wires and sutures were removed on
[**2124-3-29**]. It is now [**2124-3-30**], and the patient is being
discharged in good condition. She is to follow up with her
cardiologist in two to three weeks, with her primary care
physician in one to two weeks, and with Dr. [**Last Name (STitle) 1537**] in four
weeks. She is being discharged with Lopressor 12.5 mg by
mouth twice a day, sliding scale and fixed doses of insulin,
atorvastatin 10 mg by mouth once daily, multivitamin one
capsule by mouth once daily, Benecol 50 mg by mouth four
times a day, Haloperidol 1 mg by mouth once daily, Protonix
40 mg by mouth once daily, Risperidone .5 mg by mouth once
daily, fluticasone 110 mcg two puffs inhaled twice a day,
levothyroxine 75 mcg by mouth once daily, citalopram 20 mg by
mouth once daily, levofloxacin 500 mg by mouth once daily for
three days, amiodarone 400 mg by mouth once daily, Colace 100
mg by mouth twice a day, ibuprofen 400 mg by mouth every six
hours as needed, Tylenol 650 mg by mouth every four hours as
needed, enteric-coated aspirin 325 mg by mouth once daily,
potassium chloride 20 mEq by mouth every 12 hours, and lasix
20 mg by mouth once daily. She may shower. She may observe
ad lib activity, although she should be closely monitored
when standing or walking. She has had a fall in the hospital
when standing. Diet: Diabetic, heart healthy.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1332**]
MEDQUIST36
D: [**2124-3-30**] 08:57
T: [**2124-3-30**] 09:02
JOB#: [**Job Number 20762**]
ICD9 Codes: 4019, 412, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 829
} | Medical Text: Admission Date: [**2186-7-16**] Discharge Date: [**2186-7-21**]
Date of Birth: [**2135-4-22**] Sex: M
Service: MEDICINE
Allergies:
Cocaine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Thoracic back pain and leg weakness
Major Surgical or Invasive Procedure:
T4 laminectomy
History of Present Illness:
51 yo man w/ PMH of esophageal CA s/p chemo and radiation w/
known progressive disease presented to OSH [**7-16**] for evaluation
of new onset LE paralysis. He had upper back pain for 2 days
prior to admission. On the day of presentation he woke up and
noted LLE weakness. Over the course of the day he developed RLE
weakness and came to the ED for further evaluation. His ROS is
significant for reporting no bowel movements or urination for
1-2 days.
.
Team was concerned for spinal cord compression, but could not
get MRI as pt has surgical clips after traumatic head injury. CT
myelogram showed occlusion of spinal canal at T4, so taken
emergently to OR. Found epidural abscess, which was washed out.
.
On POD#2, pt became acute dyspneic and hypoxic to 77% after
nasotracheal suctioning. ABG 7.40/40/43 on 100% FM. On arrival
to MICU, Sats ranged from 85-95% on NRB + 6L NC; briefly placed
on BiPAP, but oxygenation actually decreased with this. After
repositioning and chest PT, Sats stabilized between 90-96% on 6L
NC.
Past Medical History:
-Esophageal CA s/p chemo and radiation- Oncologist is Dr. [**First Name (STitle) **]
[**Name (STitle) 103290**] stenting after radiation induced esophageal stenosis
-Suicide attempt ([**2171**]) w/ a circular saw, surgically repaired
injury w/ L eye ptosis and brain clips, treated at [**Hospital1 2025**]
-GERD
-HTN
-Former EtOH
-MI's x 2 ([**2174**], [**2175**]?)
Social History:
Homeless; lived in shelter before diagnosis of cancer, but has
been living with his mother since being treated for cancer.
-tobacco: 1ppd (80 PYH)
-"off and on" EtOH use, occasional marijuana, history of cocaine
use
Family History:
noncontributory
Physical Exam:
T: 96.4 BP: 112/74 HR: 101 R 22 O2Sats 86-96% on 6L + NRB;
pulsus 8 mm Hg
Gen: able to speak [**12-20**] words between breaths, wearing NRB and
10L NC
Neck: Supple.
Lungs: bronchial breath sounds, Left lower and mid fields;
rhonchorous R field.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
Cranial Nerves:
II: Pupils round and reactive to light w/ mild anisocoria (R>L)
III, IV, VI: Extraocular movements intact bilaterally with few
beats of nystagmus, ptosis of L eye
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:
No pronator drift. Normal bulk and tone bilaterally in UE. LE
decreased muscle bulk. No adventitious movements, no tremor, no
asterixis.
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 - - - - - - - > 0 - - - - - - - - - >
Left 5 - - - - - - - > 0 - - - - - - - - - >
REFLEXES:
Toes: mute bilaterally
B T Br Pa Pl
Right 2+ 2+ 2+ 0 0
Left 2+ 2+ 2+ 0 0
SENSORY SYSTEM:
-light touch: symmetric and intact in UE; sensation in legs
intact to deep pressure only
-pinprick: absent until T3-T4 bilaterally (L side is slightly
higher than R), pt able to feel touch very faintly at T12
posteriorly
COORDINATION: nl [**Doctor First Name **] in UE
GAIT: unable to access
Pertinent Results:
[**2186-7-16**] 08:04AM WBC-10.1 RBC-4.12* HGB-13.4* HCT-40.1 MCV-97
MCH-32.7* MCHC-33.5 RDW-14.9
[**2186-7-16**] 08:04AM NEUTS-70.9* BANDS-0 LYMPHS-5.1* MONOS-23.9*
EOS-0.1 BASOS-0.1
[**2186-7-16**] 08:04AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2186-7-16**] 08:04AM PLT SMR-NORMAL PLT COUNT-235
[**2186-7-16**] 08:04AM GLUCOSE-142* UREA N-17 CREAT-0.9 SODIUM-136
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
[**2186-7-16**] 08:04AM ALT(SGPT)-6 AST(SGOT)-13 LD(LDH)-163 ALK
PHOS-75 AMYLASE-24 TOT BILI-0.6
[**2186-7-16**] 10:40AM CEREBROSPINAL FLUID (CSF) WBC-92 RBC-31*
POLYS-42 LYMPHS-4 MONOS-54
[**2186-7-16**] 10:40AM CEREBROSPINAL FLUID (CSF) PROTEIN-670*
GLUCOSE-59 LD(LDH)-52
CT Myelogram (pre-op): Contrast flowed readily from the injected
level (L3/4) through the lumbar spine and extending cephalad to
the thoracic spine. There is complete block of contrast material
at the thoracic [**3-23**] vertebral body level. The post- myelogram CT
of the thoracic and cervical spine reconfirmed that there is
complete block of contrast within the subarachnoid space at the
T4/5 level.
Bedside Echocardiogram: There is a moderate sized pericardial
effusion most prominent anterior to the right atrium with brief
right atrial diastolic collapse. A promient echogenic area is
seen overlying the right ventricular free wall which likely
represents epicardial fat (cannot exclude thrombus or tumor if
this is clinically suggested). There is but no right ventricular
diastolic collapse with relatively minimal fluid anterior to the
right ventricle. There is mild eccentuation of transmitral
Doppler E wave suggesting increased pericardial pressure. Serial
evaluation is suggested.
CXRs have shown intermittent, recurrent opacification
alternately of the left and right lungs.
Chest CT on [**7-18**] showed debris in the distal L mainstem bronchus
consistent with aspirated material. CTA was negative for PE.
Brief Hospital Course:
51 yo man with esophageal cancer s/p chemo and XRT presenting
with abrupt onset lower extremity flacid paralysis found to have
T4 epidural abscess, s/p operative debridement, now with acute
onset respiratory distress
.
# Respiratory distress: acute dyspnea with severe hypoxemia and
tachycardia on HD#3, now maintaining adequate saturation on high
flow nebulizer mask. Ruled out DVT and PE with lower extremity
dopplers and CTA. The combination of locally advanced esophageal
cancer and weakened chest muscles leading to poor cough
predispose to recurrent, significant aspiration. This was
discussed at length with the patient, and he wishes to continue
chest PT and other non-invasive measures to augment his cough
and support his breathing. If non-invasive measures cease to be
effective, he has stated clearly that he would want to be made
comfortable. He has continued to affirm that he should not be
intubated.
- aggressive chest PT & nebs since cough is very weak due to T4
spinal lesion.
- supplemental O2 as needed to keep SpO2>90%, currently
requiring Hi Flow venti mask; titrate up to non rebreather if
needed
- DNR/DNI; if noninvasive means to support oxygenation are
ineffective, pt would want to transition to hospice
.
# Pericardial effusion: given cardiomediastinal enlargement on
CXR, stat echo was obtained, which showed moderate pericardial
effusion with invagination of RA, equivocal respiratory
variation of RV movement, but no collapse of RV. Given
low/normal pulsus and no signs of tamponade by echo, this
effusion is likely not the cause of his respiratory
decompensation.
.
# T4 epidural abscess: s/p open debridement on [**7-16**], wound
cultures growing Strep milleri, but wound GM stain also showed a
GM Neg coccobacillus, suspect mouth flora. Ceftriaxone 2gm Q24H
for once-daily dosing regimen to cover Strep milleri, and
metronidazole 500mg tid for anaerobes. Will plan to continue
course for 6 weeks given serious CNS infection. After 6 week
course is complete, recommend suppressive therapy with
amoxicillin 500mg daily indefinitely, as the locally advanced
esophageal cancer will remain a risk for thoracic spine
infection.
- TLSO brace while out of bed, multipodis boots to prevent heel
breakdown
- Neurology consult indicated that patient will most likely not
recover meaningful motor function of his legs, ie, ambulation is
unlikely. Any recovery of motor function will be limited and
gradual.
.
# Esophageal CA: s/p chemo and xrt, with stenting for stenosis.
Pain control. Patient's goals for treatment have been to be able
to eat; oncologist Dr [**First Name (STitle) **] has indicated that further chemo or
xrt will likely not help in this regard but continue to follow.
Pain control.
.
# GERD: continue protonix
.
# Nutrition: pt cannot tolerate solid foods. Ensure supplements,
soft foods only.
.
# Tobacco Dependance: nicotine patch
.
# Prophylaxis:
-heparing subcutaneous, pneumoboots, and protonix
.
# Code Status: DNR/DNI, discussed with patient and family
including HCP (mother)
Medications on Admission:
-Percocet
-Prilosec
-Unknown BP med
-Stool softener
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Thiamine HCl 100 mg/mL Solution Sig: One (1) Injection DAILY
(Daily).
4. Folic Acid 5 mg/mL Solution Sig: One (1) Injection DAILY
(Daily).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection TID (3 times a day).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for COPD.
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
nebulizer Inhalation Q6H (every 6 hours) as needed for COPD.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 weeks.
12. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
14. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
15. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
16. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
17. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
18. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
esophageal cancer
T4 epidural abscess, polymicrobial, with spinal cord compression
and paraplegia
Discharge Condition:
fair, although with tenuous respiratory status.
Discharge Instructions:
You had surgical decompression of a T4 epidural abscess and will
need 6 weeks of antibiotics to treat this. You may or may not
regain much motor function in your legs because of the spinal
cord compression injury.
For your respiratory status, the combination of esophageal
cancer and weakness have predisposed you to aspirating and
prevent you from coughing effectively. Continue with aggressive
chest physical therapy and MIE as long as patient feels
subjective benefit. Supplemental O2.
Followup Instructions:
Dr [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 92277**], Friday [**7-28**], 2:00pm.
(Oncology)
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5185, 5070, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 830
} | Medical Text: Admission Date: [**2105-5-22**] Discharge Date: [**2105-5-25**]
Date of Birth: [**2044-9-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with placement of bare mental stents x 4
History of Present Illness:
60 yo male with history of gout, HLD, HTN, anemia of chronic
inflammation presents with substernal chest pain.
.
Patient notes that over the last several days he has had
intermittent chest discomfort when at work. He notes that the
pain would go away if he stopped relaxed and took a deep breath.
The day of presentation the patient developed substernal chest
pain without radiation which was associated with palpitations,
diaphoresis, shortness of breath. His brother gave him 4 baby
aspirins which he chewed and called 911. In the ambulance the
patient recieved nitroglycerin without improvement in his [**9-7**]
chest pain.
.
In the ED, initial vitals 80 160/80 16 98% 2L. EKG concerning
for inferior [**Month/Year (2) **] with A. Fib with [**Month/Year (2) 5509**]. Code [**Month/Year (2) **] called.
Patient started on heparin gtt, morphine 4 mg IV, Diltiazem 50mg
IV x one, Plavix 300mg.
.
In the Cath lab, catheterization revealed a 90% mid RCA lesions.
Other vessels without significant disease. Case complicated by
RCA dissection, at one point vessel was lost, entire vessel
ballooned with four bare metal stents. Patient transiently on
dopamine for borderline hypotension. Patient in A. Fib with [**Month/Year (2) 5509**]
and given Lopressor 17.5 mg IV total IV. One unit of blood given
for HCT of 24.9 . Bivalrudin given during case given history of
iron deficiency anemai. Angioseal placed.
.
In the CCU, patient remains in Afib with [**Month/Year (2) 5509**] with stable blood
pressure. He reports no chest pain.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
SHe denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, Hyperlipidemia
2. CARDIAC HISTORY: None
3. OTHER PAST MEDICAL HISTORY:
- Gout
- Anemia: Admission in [**3-/2105**] with HCT of 15 without clear
etiology 7 units of pRBCs transfused. Hemolysis labs negative.
Stool Guaiac negative. Bone marrow biopsy with Heme/Onc
negative. Last colonoscopy 10 years ago.
Social History:
He is unmarried and has no children. He lives with his brother
in [**Name (NI) 64936**]. He is currently unemployed, but works odd jobs when
he can, usually construction. He has a 42 pack year history. He
drinks 4-6 beers a week. He denies use of illicits.
Family History:
Hypertension - mother (died at 92)
Father - unknown medical history, died of unknown causes
Physical Exam:
On Admission:
VS: Afebrile BP=114/86 HR=150 RR=15 O2 sat= 100% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Poor dentition.
NECK: Supple with JVP at base of neck.
CARDIAC: Irregular, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: Unable to examine posterior lung field as patient post
cath. Anterior lung field with coarse breath sounds. Resp were
unlabored, no accessory muscle use. CTAB, no crackles, wheezes
or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
On Discharge:
Temp Max:101.9 Temp current: 99.1 HR:67-83 RR:18
BP:139-183/87-98 O2 Sat: 100% RA
Gen: NAD, sitting comfortably in chair
CV: RRR, systolic murmur RUSB
RESP: CTAB, no rales or wheezes, unlabored
ABD: S/NT/ND, +BS
EXTR: no peripheral edema, R knee edematous, blottable, no
erythema or warmth
NEURO: A/O, no focal deficits
Pertinent Results:
CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2105-5-25**] 06:50 9.4 4.15* 11.7* 35.5* 86 28.2 33.0 17.1* 242
[**2105-5-24**] 23:00 30.9*
[**2105-5-24**] 15:00 32.5*
[**2105-5-24**] 06:30 10.0 3.77* 10.8 32.3* 86 28.7 33.4 17.3* 223
[**2105-5-23**] 21:20 30.1*
[**2105-5-23**] 13:15 29.1*
[**2105-5-23**] 04:55 8.5 3.01* 8.6* 25.7* 86 28.7 33.5 17.3* 232
[**2105-5-22**] 21:45 9.8 2.87* 7.9* 24.9*1 87 27.6 31.8 18.0* 273
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2105-5-25**] 06:50 109*1 16 0.9 139 4.7 102 26 16
[**2105-5-24**] 06:30 961 15 0.9 138 4.7 105 24 14
[**2105-5-23**] 04:55 108*1 23* 0.8 141 4.7 111* 19* 16
[**2105-5-22**] 21:45 111*1 27* 0.9 142 3.4 106 18* 21*
CPK ISOENZYMES CK-MB cTropnT
[**2105-5-23**] 13:15 27*
[**2105-5-23**] 04:55 38*
[**2105-5-22**] 21:45 0.02*
HEMATOLOGIC Hapto
[**2105-5-23**] 04:55 253*
Studies/Procedures
- ECG: Afib with [**Year (4 digits) 5509**] approx 160, Normal Axis. ST elevation in
III with depresssions V3-V6. Right sided leads with 1mm ST
elevation V4-V6.
.
- CARDIAC CATH: Per Report. 90% occlusion of MID RCA. Case
complicated by dissection with near loss of vessel. Vessel
balloned and 4 BMS placed with resolution of flow. Final report
pending at time of discharge.
.
- TTE: The left atrium is elongated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. There is mild regional
left ventricular systolic dysfunction with inferior hypokinesis
to akinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal. with borderline normal free
wall function. The ascending aorta is mildly dilated. The aortic
valve leaflets are moderately thickened. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2105-4-13**], regional LV systolic dysfunction is new.
The aortic valve area is similar despite lower gradients due to
decreased stroke volume.
Brief Hospital Course:
60 yo male with HLD, HTN, Gout, Anemia who presents with CP
found to have inferior [**Year (4 digits) **] s/p cardiac catheterization
complicated by RCA dissection necessitating placement of BMS x
4.
ACTIVE ISSUES:
#[**Name (NI) **] - Pt presented with CP and was found to have inferior
[**Name (NI) **] on EKG. In the Cath lab, catheterization revealed a 90%
mid RCA lesions. Other vessels without significant disease. Case
complicated by RCA dissection, entire vessel ballooned with four
bare metal stents. Patient transiently on dopamine for
borderline hypotension. One unit of blood given for HCT of 24.9.
Bivalrudin given during case given history of iron deficiency
anemia. Pt started on clopidogrel 75 mg PO daily, simvastatin
40mg, metoprolol XL 150 po daily, and losartan 50 mg PO daily.
ECHO revealed mild regional left ventricular systolic
dysfunction with inferior hypokinesis to akinesis. He was
initially started on aspirin 325mg, however this was decreased
to 81mg po daily given concern for possible GI bleed. This
should be re-evaluated as an out-patient with PCP and GI.
Patient will follow up with cardiology on [**6-2**].
.
#Afib with [**Name (NI) 5509**] - Pt was in Afib with [**Name (NI) 5509**] in Cath lab and CCU so
given Lopressor 17.5 mg IV total during cardiac catheterization.
In the CCU, started on esmolol gtt. Blood pressures remained
stable. Pt returned to sinus rhythm, esmolol gtt d/c'ed [**5-23**],
remained in sinus for remainder of hospitalization.
.
#Normocytic Anemia - Hct at 24.9 following catheterization, down
from baseline in low 30s. Pt responded well to 3 units PRBC.
Ongoing outpt work up of anemia without clear etiology.
Hemolysis labs negative. GI was consulted given hct drop in
setting of dark stools while on plavix and aspirin. Given recent
[**Month/Year (2) **], stablization of hct, and normalization of stools, EGD was
deferred at this time. Pt needs to follow-up with GI in 6 weeks
for EGD and colonoscopy for continued work-up of anemia. He was
started on pantoprazole 40mg PO BID. He should continue Plavix
75mg po daily, however aspirin was decreased from 325mg to 81mg
pending further work-up because of increased risk of bleeding.
CHRONIC ISSUES:
#Gout - Pt complained of gouty R knee pain, so started on
colchicine in addition to his home allopurinol. He was not
started on prednisone given the risk of GI bleeding. His pain
was well managed with oxydocone 5mg po prn.
.
#HTN - Increased blood pressure managment with Metoprolol XL 150
po daily, losartan 50mg PO. His blood pressure improved to
130's/80s so will need close monitoring and medication
adjustment by PCP.
.
#HL - increased simvastatin to 40mg po daily in setting of
recent [**Month/Year (2) **].
TRANSITIONAL ISSUES:
Full Code. Blood cultures and urine cultures were sent given low
grade fever and are still pending at time of discharge. Pt is
being discharged home with many new medications and medication
changes. These changes were discussed with the patient in
detail. He has several follow-up appointments in the next few
weeks including PCP ([**5-29**]), Cardiology ([**6-2**]), Endocrine and
HEM/ONC([**6-3**]). He will need a referral from his PCP to see GI
for EGD and colonoscopy.
Medications on Admission:
--Metoprolol 50mg [**Hospital1 **]
--Simvastatin 20mg Daily
--Cyclobenzaprine 10mg TID
--Tramadol 50 [**11-29**] Q6hrs PRN Pain
--Prednisone 10mg PRN gout flair
--ASA 325mg Daily
--Allopurinol 200mg Daily
--Losartan 25mg Daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. 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*
6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for knee pain for 2 days: Do not take this medication and
drive or consume alcohol.
Disp:*4 Tablet(s)* Refills:*0*
8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
10. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
11. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three
times a day.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Inferior [**Month/Day (3) **]
Atrial Fibrillation with [**Month/Day (3) 5509**]
Hypertension
Gout
Anemia requiring blood transfusion
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 at [**Hospital1 827**]. You were admitted for chest pain. You were
found to be in atrial fibrillation and were diagnosed with a
heart attack. We treated your heart attack by placing 4 stents
in the arteries to keep the blood flowing. Your heart rate
returned to [**Location 213**] during your hospitalization.
Take all your home medications as directed EXCEPT for the
following medication changes or additions that were made during
your hospital stay:
1. Increase the dose of Losartan to 50 mg by mouth daily.
2. Increase simvastatin to 40mg by mouth daily.
3. Start taking Clopidogrel 75mg by mouth daily. Do not stop
taking this medication unless instructed by your cardiologist.
4. Stop taking Aspirin 325 mg and instead take Aspirin 81mg
until GI follow-up. You must take this medication daily unless
instructed otherwise by your cardiologist.
5. Change metoprolol to metoprolol XL 150mg by mouth daily.
6. Start taking Pantoprazole 40mg by mouth twice a day until GI
follow-up.
7. Start taking colchicine 0.6 mg by mouth twice a day until
gout flare resolves.
8. Stop prednisone until GI follow-up because of increased risk
of bleeding.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2105-6-2**] at 10:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV OF GI AND ENDOCRINE
When: WEDNESDAY [**2105-6-3**] at 1:40 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2105-6-3**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Apartment Address(1) 89324**], [**Location (un) **],[**Numeric Identifier 14512**]
Phone: [**Telephone/Fax (1) 31235**]
Appt: Friday, [**5-29**] at 1pm
NOTE: It is recommended that you have an EGD and Colonoscopy
within the next 6 weeks. Please work with Dr [**Last Name (STitle) **] for help
coordinating these procedures.
Completed by:[**2105-5-26**]
ICD9 Codes: 4019, 2724, 2749, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 831
} | Medical Text: Admission Date: [**2129-3-15**] Discharge Date: [**2129-3-24**]
Date of Birth: [**2068-1-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2129-3-15**] Aortic Valve Replacement(21mm On-X mechanical valve) and
Replacement of Ascending Aorta(26mm Gelweave Graft)
History of Present Illness:
Mrs. [**Known lastname 12143**] is a 61 year old female with hypertension. During
evaluation for lymphadenopathy, she underwent CT scan which
revealed dilated ascending aorta. Further workup included an
echocardiogram which showed a bicuspid aortic valve with 1-2+
aortic insufficiency. Ascending aorta measured 4.7cm, aortic
root measured 3.9 cm. The LVEF was 60-70%. Subsequent cardiac
catheterization was notable for normal coronary arteries and
normal left ventricular function. Given the above findings, she
was admitted for surgical intervention. Of note, she recently
underwent hematology evaluation for low white blood cell count.
Etiology is unclear at this time but there was no
contraindication to surgery.
Past Medical History:
Biscupid Aortic Valve; Aortic Insufficiency; Ascending Aortic
Aneurysm; Hypertension; Epilepsy; History of Rheumatic Fever;
Thyroid Nodules; Reactive Axillary Lymph Nodes; Pulmonary
Nodules
Social History:
Quit tobacco over 30 years ago. Denies excessive ETOH. Works as
a teacher. She is married.
Family History:
Denies premature CAD.
Physical Exam:
Vitals: BP 132/64, HR 70, RR 14
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, soft diastolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
Echo [**3-15**]: PRE-BYPASS: Overall left ventricular systolic
function is normal (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. The aortic valve is bicuspid. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The sinotubular junction of the ascending aorta is preserved.
The ascending aorta is moderately dilated. The mitral valve
appears structurally normal with trivial mitral regurgitation.
No atrial septal defect is seen by 2D or color Doppler. There
are simple atheroma in the aortic arch and n the descending
thoracic aorta. There is no pericardial effusion. POST-BYPASS:
Preserved [**Hospital1 **]-ventricular systolic function. A well seated
mechanical prosthetic valve is seen in the aortic position.
Trivial aortic regurgitation. No perivalvular leak. Mean trans
aortic valvular gradient is 8 mm Hg. A tubegraft is seen in the
ascending aorta position with a diameter of 2.6 cm. Thoracic
aortic contour is preserved. Trace TR and MR.
CXR [**3-23**]: Interval decrease in pulmonary edema and vascular
congestion, as well as cardiac size. Interval improvement in
bibasilar atelectasis as well. Stable bibasilar pleural
effusions. No major residual pneumothorax and stable appearance
of the lung apices as compared to two days ago.
[**2129-3-15**] 10:46AM BLOOD WBC-4.6 RBC-2.20*# Hgb-7.4*# Hct-20.4*#
MCV-92 MCH-33.6* MCHC-36.4* RDW-13.6 Plt Ct-139*#
[**2129-3-22**] 02:16AM BLOOD WBC-7.0 RBC-2.65* Hgb-9.0* Hct-26.0*
MCV-98 MCH-33.8* MCHC-34.5 RDW-14.0 Plt Ct-447*
[**2129-3-15**] 10:46AM BLOOD PT-16.1* PTT-75.8* INR(PT)-1.4*
[**2129-3-23**] 07:25AM BLOOD PT-18.6* PTT-68.5* INR(PT)-1.8*
[**2129-3-23**] 09:15PM BLOOD PT-22.0* PTT-150* INR(PT)-2.2*
[**2129-3-24**] 12:48AM BLOOD PT-22.0* PTT-132.0* INR(PT)-2.2*
[**2129-3-15**] 12:09PM BLOOD UreaN-13 Creat-0.5 Cl-109* HCO3-23
[**2129-3-22**] 02:16AM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-133
K-4.2 Cl-99 HCO3-26 AnGap-12
Brief Hospital Course:
Mrs. [**Known lastname 12143**] was admitted and underwent aortic valve
replacement with replacement of her ascending aorta. For
surgical details, please see separate dictated operative note.
Following the operation, she was brought to the CSRU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident. She maintained stable
hemodynamics and weaned from intravenous therapy without
difficulty. Her CSRU course was uneventful and she transferred
to the SDU on postoperative day one. On postoperative day two,
chest tubes and epicardial wires were removed without
complication. Warfarin anticoagulation was initiated.
Prothrombin times were monitored daily and Warfarin was dosed
for a goal INR between 2.0 - 3.0. Over several days, she
continued to make clinical improvements with diuresis. On
post-op day five she was treated for some atrial fibrillation
and converted back to sinus rhythm. Heparin was restarted until
INR was increased while receiving Coumadin. Over next couple of
days her INR trended upward over 2. She appeared to be doing
well and worked with physical therapy for strength and mobility.
On post-operative day nine she was discharged home with VNA
services and the appropriate follow-up appointments. Dr.[**Last Name (STitle) 2472**]
will be following her INR and adjusting her Coumadin as needed.
Medications on Admission:
Tegretol XL 800 qam, 400 qlunch, 800 qhs
Lisinopril 10 qd
Labetolol 100 [**Hospital1 **]
Evista 60 qd
Caltrate-D 1200 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: Ten
(10) Tablet Sustained Release 12 hr PO once a day: 4 tabs [**Hospital1 **]
(morning & night)and 2 tabs once daily (midday)as before your
surgery.
Disp:*300 Tablet Sustained Release 12 hr(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 6 days: then daily until D/C'd by .
Disp:*45 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three
times a day.
Disp:*135 Tablet(s)* Refills:*0*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Outpatient [**Name (NI) **] Work
PT/INR
PT/INR as needed
goal 2.5-3.5 for Aortic Valve (On-x)
first check [**2129-3-25**] with results to Dr [**Last Name (STitle) 2472**] office #
[**Telephone/Fax (1) 133**]
Fax: [**Telephone/Fax (1) 445**]
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Dose to be titrated per Dr.[**Name (NI) 5049**] instruction.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Biscupid Aortic Valve, Aortic Insufficiency, Ascending Aortic
Aneurysm s/p Aortic Valve Replacement and Replacement of
Ascending Aorta
PMH: Hypertension, Epilepsy, History of Rheumatic Fever, Thyroid
Nodules, Reactive Axillary Lymph Nodes, Pulmonary Nodules
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, 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
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**3-3**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**First Name (STitle) **] in [**1-1**] weeks, call for appt
Dr. [**Last Name (STitle) 2472**] in [**1-1**] weeks, call for appt [**Telephone/Fax (1) 133**]
PT/INR goal 2.5-3.5 for Aortic Valve (On-x)
first check [**2129-3-25**] with results to Dr [**Last Name (STitle) 2472**] office #
[**Telephone/Fax (1) 133**]
Fax: [**Telephone/Fax (1) 445**]
Completed by:[**2129-4-4**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 832
} | Medical Text: Admission Date: [**2163-4-15**] Discharge Date: [**2163-4-29**]
Date of Birth: [**2087-2-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old
female with a history of aortic stenosis, coronary artery
disease, congestive heart failure, diabetes, hypertension.
She was seen in the Emergency Room on [**4-11**] with bronchitis
and treated with Azithromycin. She saw her primary care
physician [**Last Name (NamePattern4) **] [**4-13**] who treated her with meter dose inhalers
and cough syrup for shortness of breath and wheezing. The
patient is now here with a two to three day history of chest
tightness, increased shortness of breath, wheezing, cough, no
history of GI bleeding and no fevers or chills. The patient
is otherwise in her usual state of health until one week ago.
PAST MEDICAL HISTORY:
1. Congestive heart failure.
2. Coronary artery disease.
3. Diabetes type 2.
4. Remote history of stroke.
5. Hypertension.
6. Gangrenous left first toe.
7. Left SFA.
HOME MEDICATIONS:
1. Lopressor 25 b.i.d.
2. Lipitor 10 mg q.p.m.
3. Lasix 40 mg q.a.m.
4. Relafen 750 mg b.i.d.
5. Ecotrin 325 mg po q.d.
6. K-Dur 20 milliequivalents q.a.m.
7. Colace 100 mg b.i.d.
8. NPH 22 units q.a.m., 15 units q 8 p.m.
SOCIAL HISTORY: No history of tobacco or alcohol.
PHYSICAL EXAMINATION: Pulse 85. Blood pressure 95/69.
Respiratory rate 24. 96% oxygen saturation on 4 liters.
General, the patient is an elderly female in no acute
distress. Neck JVP 10 cm. HEENT mucous membranes are moist.
Extraocular movements intact. Left eye lateral abduction.
Cardiac sounds obscured by increased rhonchi. Pulmonary
diffuse rhonchi and wheezing. Abdomen positive bowel sounds,
soft. Extremities bilateral lower extremity 1+ pitting
edema, 1+ bilateral dorsalis pedis pulses.
LABORATORY: The patient was hyponatremic with a sodium of
127 and acute elevation of her creatinine to 1.2 from .7.
Chest x-ray showed bibasilar opacities bilaterally.
Pulmonary edema infiltrate, versus atelectasis.
Electrocardiogram showed ST elevation in V1 through V3.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2163-4-15**] and initially treated
medically by the Medicine Service. She was started on
Levaquin for pneumonia. She was started on aspirin, heparin
drip, beta blocker for her myocardial infarction. The
patient also received Lasix for her acute congestive heart
failure exacerbation. Cardiology was involved in the
patient's care. An echocardiogram was performed, which
showed an ejection fraction of less then 20%. Cardiac
catheterization was also performed showing mitral
regurgitation, left ventricular ejection fraction of 25%,
global hypokinesis, 1+ mitral regurgitation, right dominant
coronary angiography LMCA calcified plaque 40% proximally,
left anterior descending coronary artery diffuse 70% long
proximal calcified, Dig okay, left circumflex moderate distal
right coronary artery 70%, osteal 95% mid lesion. The
patient was taken to the Operating Room on [**2163-4-21**] where a
coronary artery bypass graft times four and aortic valve
replacement was performed. The patient was left with a chest
tube and pacing wires in place. She required immediately
postoperatively epinephrine and Propofol drips.
The first postoperative day she was noted overnight to have
ventricular ectopy for which she received Amiodarone. The
patient received Vancomycin times four perioperatively for
prophylaxis. She was started on beta blockers and Lasix at
the appropriate time. At the appropriate time the patient's
pacing wires and chest tubes were removed. She was stopped
from her various drips when appropriate. The patient was
also shown to have a wide complex tachycardia at times per
cardiologist Dr. [**Last Name (STitle) **]. The patient was sent out of the
Intensive Care Unit when appropriate on Lasix, Captopril and
Lopressor as well as Amiodarone. Due to the patient's age
and stability it was determined by her cardiologist that
Coumadin probably would not be an appropriate course of
therapy due to significant risks. Once the patient was on
the floor when of her major issues was blood pressure control
for which her blood pressure medications were progressively
increased. Physical therapy saw the patient on repeated
occasions and believed the patient would do well at a rehab
facility. It is now [**2163-4-29**] and the patient is in stable
condition. It is likely that she will be discharged today or
tomorrow for rehab. The patient may shower, but should not
take baths. The patient is to avoid strenuous activity. The
patient should not drive while on pain medication. She is to
follow up with Dr. [**Last Name (STitle) 1537**] in four weeks. She is to follow up
with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 11139**] in one to two weeks and Dr. [**Last Name (STitle) **] in two
to three weeks. She will be discharged on Lopressor 50 mg po
b.i.d., Captopril 37.5 mg po t.i.d., Reglan 10 mg q 6,
Timolol .5% one drop OD b.i.d., _____________ 2%, Timolol .5%
one drop OS b.i.d., insulin sliding scale, Atorvastatin 10 mg
po q.d., Amiodarone 400 mg po q.d., Benadryl 25 to 50 mg po
q.h.s. prn, Milk of Magnesia 30 mg po q.h.s. prn, Percocet
one to two tabs q 4 prn, Ibuprofen 400 mg po q 6 prn, Tylenol
650 mg po q 4 prn, enteric coated aspirin 325 mg po q.d.,
Ranitidine 150 mg po b.i.d., Colace 100 mg po b.i.d.,
potassium 20 milliequivalents po q 12 and Lasix 20 mg
intravenous q 12.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 5919**]
MEDQUIST36
D: [**2163-4-29**] 10:11
T: [**2163-4-29**] 10:31
JOB#: [**Job Number 107516**]
ICD9 Codes: 4241, 486, 2761, 4280, 4254, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 833
} | Medical Text: Admission Date: [**2148-6-25**] Discharge Date: [**2148-6-29**]
Date of Birth: [**2088-11-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation for hypoxia
History of Present Illness:
59F with recent left foot surgery and osteomyelitis, s/p ant-inf
MI s/p stent to pLAD, hx EtOH abuse with CHF and EF 20-25% (?
mixed myopathy) admitted to [**Hospital Unit Name 153**] [**6-25**] with acute pulmonary
edema. She denied dietary indiscretion and did not have any
chest pain PTA. Intubated and diuresed, then extubated.
Initially required nitro gtt for HTN, then 1 day of dopamine for
hypoTN (weaned [**6-26**]). Patient had 1 run of irregular short-lived
(3 to 9 beats) WCT which resolved without treatment and was
called out from [**Hospital Unit Name 153**] to [**Hospital1 1516**] service for ?ICD placement. Per EP
consult note on [**6-26**], no emergent reason for ICD placement.
.
Prior to call out patient noted to have 6 point HCT drop (28->
21)and drop in WBC (9 -> 2) of unclear etiology. Guiac negative.
Got two units PRBC and transferred to floor.
Past Medical History:
s/p ant-inf MI with stent to pLAD ([**2142**])
CHF with EF 20-25%
s/p Left foot HAV repair & 2nd digit PIPJ arthroplasty
HTN
Hypercholesterolemia
Hx. of substance Abuse
Hx. of EtOH Abuse
Depression
Anxiety
Social History:
(+) EtOH
(+) Recreational Drug usage including Marijuana, but denies IVDU
Family History:
Father died of heart disease
Physical Exam:
Vitals: T: 98.9 P:76 BP:109/71 R: 18
General: Awake, alert, NAD.
HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: faint crackles BL
Cardiac: RRR, nl. S1S2. II/VI SEM. No S3, no S4.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Neurologic: alert, oriented, CN grossly intact, movess all
extremities, no abnormal movements noted.
Psych: Full affect, somewhat dramatic
Pertinent Results:
[**2148-6-24**] 10:47PM WBC-9.3# RBC-2.54* HGB-8.7* HCT-24.2* MCV-95
MCH-34.3* MCHC-36.0* RDW-14.7
[**2148-6-24**] 10:47PM MACROCYT-1+
[**2148-6-26**] 03:50AM BLOOD calTIBC-229* VitB12-811 Folate-16.3
Hapto-130 Ferritn-1177* TRF-176*
[**2148-6-24**] 10:47PM NEUTS-41.8* LYMPHS-50.6* MONOS-5.3 EOS-2.0
BASOS-0.3
[**2148-6-24**] 10:47PM PLT COUNT-474*#
.
[**2148-6-24**] 10:47PM PT-13.4* PTT-26.4 INR(PT)-1.2*
.
[**2148-6-24**] 10:47PM GLUCOSE-302* UREA N-26* CREAT-1.4*
SODIUM-125* POTASSIUM-4.3 CHLORIDE-89* TOTAL CO2-18* ANION
GAP-22*
.
[**2148-6-24**] 11:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
.
[**2148-6-25**] 03:06AM D-DIMER-2368*
.
[**2148-6-25**] 03:06AM CORTISOL-21.6*
[**2148-6-25**] 03:06AM TSH-3.9
.
[**2148-6-24**] 10:47PM BLOOD CK(CPK)-160*
[**2148-6-24**] 10:45PM BLOOD cTropnT-<0.01
[**2148-6-25**] 03:06AM BLOOD ALT-11 AST-55* LD(LDH)-511* CK(CPK)-253*
AlkPhos-97 Amylase-117* TotBili-0.6
[**2148-6-24**] 10:47PM BLOOD CK-MB-4
[**2148-6-25**] 02:59PM BLOOD CK(CPK)-208*
[**2148-6-25**] 03:06AM BLOOD CK-MB-6 cTropnT-0.05* proBNP-7406*
[**2148-6-25**] 02:59PM BLOOD CK-MB-7 cTropnT-0.02*
.
[**2148-6-29**] 05:30AM BLOOD WBC-4.8 RBC-3.47* Hgb-11.2* Hct-32.2*
MCV-93 MCH-32.4* MCHC-34.9 RDW-16.6* Plt Ct-405
[**2148-6-29**] 05:30AM BLOOD Plt Ct-405
[**2148-6-29**] 05:30AM BLOOD PT-13.8* PTT-40.8* INR(PT)-1.2*
[**2148-6-29**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-1.2* Na-133
K-4.7 Cl-99 HCO3-26 AnGap-13
[**2148-6-29**] 05:30AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7
.
Tox Screen on admission:
[**2148-6-24**] 10:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
AP ERECT PORTABLE RADIOGRAPH OF THE CHEST (on admission): A PICC
is seen with the tip in the superior vena cava. Interval
development of interstitial pulmonary edema. There is discoid
atelectasis at the right lung base. No pleural effusions are
apparent. The heart size is within normal limits. IMPRESSION:
Interval development of pulmonary edema. Discoid atelectasis at
the right lung base.
.
CHEST CT to R/O PE:
IMPRESSION:
1. Bilateral patchy opacities represent asymmetric pulmonary
edema versus
multifocal pneumonia. Clinical correlation recommended. No
evidence for PE.
2. Bibasilar atelectasis and very small bilateral pleural
effusions.
.
EKG on admission:
Sinus rhythm, Probable old anteroseptal infarct. Since previous
tracing, no significant change
Brief Hospital Course:
59F with osteomyelitis, s/p ant-inf MI s/p stent to pLAD, CHF
with EF 20-25%, was admitted intially to the [**Hospital Unit Name 153**] with CHF
exacerbation and then called out from [**Hospital Unit Name 153**] [**6-25**] to [**Hospital1 **] service
for further work-up and treatment.
.
# CHF exacerbation: Patient was hypoxic on admission with
pulmonary edema on CXR, so was intubated and diuresed in ICU;
given her known EF = 20-25%, CHF was the most likely cause of
her dyspnea. No apparent cause for the acute exacerbation could
be identified; patient denies any dietary indiscretion, cardiac
enzymes were negative and EKG was unchanged from prior. PE was
also considered as a cause of her dyspnea, and given an elevated
D dimer, CTA of the chest was performed which did not identify
any PE. After 24 hours of ventilatory support and aggressive
diuresis, she was able to be extubated and transferred to the
[**Hospital Ward Name 121**] 3 telemetry [**Hospital1 **].
.
At the time of transfer to the [**Hospital1 **], patient appeared clinically
normovolemic. She was gently diuresed to slightly below her home
dry weight of 95lbs. She was started on metoprolol and
lisinopril was added once her creatinine had stabilized.
.
# Hct drop: From 28-21 with no evidence of active bleeding -
guiac negative. Patient received 2 units of PRBC in [**Hospital Unit Name 153**] prior
to transfer with appropriate response, Hct stable thereafter.
Heme consult reviewed peripheral smear with no concerning
findings. Does not appear to be a consumptive process--no signs
of hemolysis on lab work. Iron studies c/w anemia of
inflammation. Acute change in Hct during acute pulmonary edema
appears to have resulted from fluid volume shifts.
.
# WBC drop: 9.1 to 2.3 on [**6-26**], gradually increased to 4.8 on
[**6-29**] without intervention. Unclear etiology; lymphocyte
predominant with a monocytosis suggestive of toxin-mediated bone
marrow suppression. Heme consult suspects drug reaction,
possibly levafloxacin, which was given in [**Hospital Unit Name 153**] and has been
reported to cause agranulocytosis. HIV infection can also cause
leukopenia, although patient denies high-risk behaviors such as
unprotected sex with anyone other than husband or IVDA, she
consented to be tested for HIV and test results pending.
.
# Short runs of WCT, asymptomatic: EP consulted and felt that
emergent ICD placement was not indicated given current
comorbidities. Had a negative V-Stim at [**Hospital1 112**] [**2145-12-17**] with Dr.
[**Last Name (STitle) **] (EF 20-25% at that time). Pt. wants to avoid ICD if
possible. Continued beta blocker therapy should decrease the
incidence of the NSVT/WCT.
.
# Anxiety/depression: Patient says she has had a psychiatrist
for many years and used to take valium with good effect. Her new
doctor, Dr [**First Name4 (NamePattern1) 47716**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 108658**], stopped benzos b/c she had
a history of abusing the valium and started prozac plus
neurontin. [**6-27**] patient expressed SI and was seen by in-house
psychiatry consult, who felt patient was not at risk to self and
did not need 1:1 sitter but recommended treating her significant
anxiety with resperidone and uptitrating neurontin. However,
patient had symptomatic hypotension after first dose risperidone
1mg, but patient said she slept well and felt much better the
morning after the risperidone, so restarted risperidone at
0.25mg hs prn. Continued home dose of fluoxetine 60 mg po and
gabapentin 300mg tid as recommended per psych. Patient will see
Dr [**Last Name (STitle) **] to adjust outpatient anti-anxiety and anti-depressant
regimen next week.
.
# Substance abuse: Pt admits to smoking marijuana daily and has
history of abusing diazepam. Social work consulted to discuss
coping mechanisms with patient. They recommended, as did
psychiatry consult, that patient go to day treatment center such
as [**Doctor First Name 1191**] Day Center for ongoing substance, which psychiatry
recommended is best arranged through her outpatient psychiatrist
for continuity.
.
# Osteomyelitis - Receiving cefazolin via home pump. Per
podiatry notes, still needs 3 more weeks, so D/C'd with
prescription to continue through [**7-19**] to completely treat
osteomyelitis of L great toe. Pt has home IV nursing who
maintains PICC line and helps her with Abx infusions; will
contact the agency before discharge to reinitiate their
services.
.
# Hyponatremia - serum osms low, so hypoosmolar, hypervolemic
hyponatremia upon presentation to ER, likely CHF as etiology.
Resolved steadily with diuresis and sodium normal at 133 on the
morning of discharge.
Medications on Admission:
Cefazolin 1gm IV Q8H for infection
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Gabapentin 300mg tid (patient has not been taking)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for heart disease.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime:
for cholesterol.
[**Month (only) **]:*30 Tablet(s)* Refills:*2*
3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily): for depression.
[**Month (only) **]:*90 Capsule(s)* Refills:*2*
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): for anxiety.
[**Month (only) **]:*90 Capsule(s)* Refills:*2*
5. Risperidone 0.5 mg Tablet Sig: one-half Tablet PO at bedtime
as needed for insomnia for 4 days.
[**Month (only) **]:*2 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): for
blood pressure and heart failure.
[**Month (only) **]:*15 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily): for
blood pressure and heart failure.
[**Month (only) **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for heart failure.
[**Month (only) **]:*30 Tablet(s)* Refills:*2*
9. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous
Q8H (every 8 hours) for 3 weeks: for osteomyelitis, to be
administered by IV nurse.
[**Last Name (Titles) **]:*3 weeks' supply* Refills:*0*
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed for 3 weeks: instill
in PICC line.
[**Last Name (Titles) **]:*qs for one month* Refills:*0*
11. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection
once a day for 3 weeks: to flush PICC line.
[**Last Name (Titles) **]:*qs one month* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Crititcal Care Services
Discharge Diagnosis:
Primary: excerbation of congestive heart failure
.
Secondary: osteomyelitis of left great toe, hypertension,
substance abuse, depression, hyperlipidemia
Discharge Condition:
At the time of discharge, patient is afebrile, tolerating po
diet and meds, and ambulatory. Additionally, she does not have
any suicidal or homicidal ideation.
Discharge Instructions:
Weigh yourself daily and call your cardiologist if you gain more
than 2 pounds in one day.
.
Follow a low-sodium diet to prevent heart failure exacerbations.
.
Continue taking all medicines as prescribed.
.
Call 911 if you have chest pain or shortness of breath. Call
your doctor if you have chills, fevers, nausea, vomiting, or
diarrhea.
Followup Instructions:
On Monday, call Dr. [**Last Name (STitle) 4628**] [**Name (STitle) **] ([**Telephone/Fax (1) 108658**]), your
psychiatrist, for first available appointment.
.
When you get home, call Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 32963**] ([**Telephone/Fax (1) 34119**]),
your cardiologist, for an appointment in [**1-12**] weeks.
.
Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2148-7-9**]
9:30
ICD9 Codes: 4280, 2761, 4271, 4254, 412, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 834
} | Medical Text: Admission Date: [**2177-2-25**] Discharge Date: [**2177-2-28**]
Date of Birth: [**2117-9-30**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 59-year-old gentleman
who has a history of multiple myocardial infarctions in the
past including an inferior myocardial infarction in [**2171**] and
a non-Q-wave myocardial infarction in [**2176-11-19**] who is
admitted from [**Hospital6 33**] with an unstable anginal
syndrome, a positive troponin, and negative creatine kinases.
The patient had been having several days of worsening
exertional chest pain associated with some shortness of
breath, diaphoresis; his typical anginal symptoms which led
him to present to the outside hospital, at which time his
studies became concerning for an acute coronary syndrome. He
was started on Lopressor, Plavix, aspirin, Integrilin, and
nitroglycerin and transferred to [**Hospital1 190**] for further care.
The patient's most recent cardiac catheterization prior to
this admission revealed the following: an ejection fraction
of 38%, a normal left main, a 60% tubular middle left
anterior descending artery with a totally occluded first
diagonal, faint left-to-left collaterals, a distal left
anterior descending artery of 90%, a small ramus with a
proximal 70%, circumflex system with a 90% first obtuse
marginal inferior lesion, and a 70% superior pole lesion, a
diffusely diseased third obtuse marginal. The right coronary
artery had mild diffuse disease with a moderate in-stent
restenosis on previously placed posterior descending artery
stent; unchanged from [**2175-8-20**] catheterization, and a
posterior left ventricle that was totally occluded and filled
by right-to-right collaterals. Left ventricular
end-diastolic pressure was 20 mm; and at that time the
patient had stent to the first obtuse marginal with
additional percutaneous transluminal coronary angioplasty of
the upper pole of the first obtuse marginal. The proximal to
middle left anterior descending artery lesion underwent
successful percutaneous transluminal coronary angioplasty and
stenting, and the distal left anterior descending artery was
treated with a stent also. The first diagonal which had an
in-stent restenosis could not be treated at that time.
The patient was directly admitted to the catheterization
laboratory at [**Hospital6 33**], at which time he
underwent a limited study notable for in-stent restenosis of
the proximal left anterior descending artery stent placed in
[**2175-8-20**] and a 90% distal left anterior descending
artery occlusion, and a distal left anterior descending
artery that was subtotally occluded immediately proximal to a
prior distal left anterior descending artery stent. The
proximal left anterior descending artery 80% in-stent
restenosis underwent successful brachy therapy, and a stent
was placed in the distal left anterior descending artery
proximal to a prior stent to treat a restenosis. The
procedure was complicated by hypotension in to the 70s with
bradycardia into the 40s, in a sinus rhythm.
An echocardiogram done on the catheterization table revealed
no evidence of tamponade. It was felt that the patient was
having an severe vagal reaction. He was started on dopamine
which was eventually increased to 10 mcg/kg per minute, and
the Coronary Care Unit team was then asked to evaluate and
observe the patient overnight while peripheral anatropes were
weaned.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post inferior myocardial
infarction in [**2171**], status post non-Q-wave myocardial
infarction in [**2176-11-19**]. Most recent intervention in
[**2176-11-19**].
2. Hypercholesterolemia.
3. Hypertension.
4. Cluster headaches.
MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d.,
Cardizem 240 mg p.o. q.d., Lipitor 10 mg p.o. q.d.,
Paxil 10 mg p.o. q.d., multivitamin.
ALLERGIES: BETA BLOCKER apparently causing bronchospasm.
FAMILY HISTORY: Family history notable for coronary artery
disease and diabetes in multiple family members.
SOCIAL HISTORY: The patient is a divorced high school
teacher with six children. He does not smoke. There is no
illicit drug use such as cocaine.
PHYSICAL EXAMINATION ON PRESENTATION: Admission physical
examination with vital signs revealing afebrile, blood
pressure of 100/60, pulse of 80s on 10 mcg/kg per minute of
dopamine, respiratory rate of 12, oxygen saturation of 98% on
room air. In general, alert and oriented times three.
Cranial nerves II through XII were intact. Head, eyes, ears,
nose, and throat revealed pupils were equal, round, and
reactive to light. Extraocular movements were intact.
Sclerae were anicteric. The oropharynx was clear. Neck was
supple, no lymphadenopathy, no jugular venous distention.
Chest was clear to auscultation bilaterally. Cardiovascular
revealed a regular rhythm with a normal rate. No murmurs,
rubs or gallops. Abdomen was soft, nontender, and
nondistended, normal active bowel sounds. Extremities
revealed soaked dressing, no femoral bruits. No firmness or
ecchymosis consistent with a hematoma, preserved distal
pulses.
PERTINENT LABORATORY DATA ON PRESENTATION: Admission
laboratories from the outside hospital revealed troponin
of 0.29, creatine kinases were flat. First creatine kinase
at [**Hospital1 69**] was 94.
RADIOLOGY/IMAGING: CT of the abdomen, pelvis, and leg
revealed a 1.5-cm X 1.5-cm hematoma with surrounding fat
stranding. No evidence of an acute hemorrhage or continued
extravasation of fluid.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit for management of hypotension, for which the short
differential included active blood loss which was effectively
ruled out by the CT study and a vagal response necessitating
inotropic support.
Over the course of the first evening in the Coronary Care
Unit the patient became progressively anxious and reported
difficulty urinating, and eventually was given 1 mg of
Ativan. After the dose of Ativan, the patient's dopamine
requirement decreased from 9 mcg/kg per minute to 2 mcg/kg
per minute over the course of an hour and a half.
The following morning, dopamine was discontinued. The
patient had excellent blood pressures, and the groin appeared
stable. The patient's hematocrit was also stable, and
subsequent creatine kinases remained flat. Electrocardiogram
showed no evolving changes.
The patient did suffer nonsustained ventricular tachycardia
while in house.
DISCHARGE DIAGNOSES:
1. Three vessel coronary artery disease; status post left
anterior descending artery intervention times two on current
admission.
2. Hypertension.
3. Exuberant vagal response.
4. Nonsustained ventricular tachycardia in the setting of
unstable angina.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Cardizem 240 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Paxil 10 mg p.o. q.d.
5. Multivitamin.
6. Plavix 75 mg p.o. q.d. (indefinitely).
7. Folate 1 mg p.o. q.d.
DISCHARGE FOLLOWUP: The patient was to follow up for an
electrophysiology study as an outpatient on [**2177-3-6**].
Otherwise, the patient was to follow up with his
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], for further followup.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2177-3-3**] 13:48
T: [**2177-3-4**] 12:27
JOB#: [**Job Number 99685**]
ICD9 Codes: 4111, 4271, 412, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 835
} | Medical Text: Admission Date: [**2135-5-18**] Discharge Date: [**2135-6-17**]
Date of Birth: [**2062-1-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Fall with facial abrasions and neck pain
Major Surgical or Invasive Procedure:
Halo placement [**2135-5-26**], with revision [**2135-6-9**]
GJ tube placement [**2135-5-26**], with revision [**2135-6-4**]
Tracheostomy [**2135-5-26**]
EGD x2 [**2135-5-28**], [**2135-6-3**]
Cystoscopy [**2135-6-10**]
History of Present Illness:
Patient was trasfer from an OSH, he presented s/p fall at home
with facial abrasions and neck pain after an unknown period of
LOC. Patient was drinking heavily prior to fall.
Past Medical History:
Type 2 DM
Rheumatic Heart Disease
Aortic Mechanical Valve
AI, MR, Afib
Prostate CA
Iron deficency Anemia
LV failure s/p pacer/defibrillator
Emphysema
Depression
Gout
Social History:
EtOH+
Denies Cocaine, Heroine
Family History:
denies
Physical Exam:
On admission:
VS: 97, 116, 140/77, 15 93%
Gen: Alert+O x3, NAD
HEENT: antreior face abrasions
Cardiac: irregularly irregular
Chest: CTAB
Abd: Soft, NT/ND +BS
Ext: no c/c/e, no deformity
Neuro: 5/5 strength UE/LE, sensation intact
Pertinent Results:
[**2135-6-17**] 05:38AM BLOOD WBC-8.3 RBC-3.06* Hgb-9.3* Hct-27.5*
MCV-90 MCH-30.2 MCHC-33.6 RDW-14.9 Plt Ct-237
[**2135-6-16**] 05:15AM BLOOD WBC-8.1 RBC-3.18* Hgb-9.7* Hct-28.8*
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.9 Plt Ct-223
[**2135-5-24**] 02:54PM BLOOD WBC-9.4 RBC-2.77* Hgb-9.2* Hct-26.3*
MCV-95 MCH-33.3* MCHC-35.1* RDW-13.1 Plt Ct-181
[**2135-5-18**] 07:38PM BLOOD WBC-7.9 RBC-3.83* Hgb-12.6* Hct-35.9*
MCV-94 MCH-32.8* MCHC-35.0 RDW-13.7 Plt Ct-198
[**2135-6-17**] 05:38AM BLOOD PT-12.7 PTT-49.2* INR(PT)-1.1
[**2135-6-16**] 07:00PM BLOOD PT-12.9 PTT-50.1* INR(PT)-1.1
[**2135-6-16**] 04:15PM BLOOD PT-13.0 PTT-54.6* INR(PT)-1.1
[**2135-5-18**] 07:38PM BLOOD PT-17.1* PTT-29.1 INR(PT)-1.9
[**2135-5-19**] 01:09AM BLOOD PT-17.7* PTT-52.0* INR(PT)-2.1
[**2135-5-19**] 08:26AM BLOOD PT-18.3* PTT-150* INR(PT)-2.2
[**2135-6-17**] 05:38AM BLOOD Glucose-182* UreaN-27* Creat-1.1 Na-135
K-3.8 Cl-98 HCO3-26 AnGap-15
[**2135-6-16**] 05:15AM BLOOD Glucose-137* UreaN-28* Creat-1.2 Na-136
K-4.2 Cl-99 HCO3-26 AnGap-15
[**2135-5-19**] 01:09AM BLOOD Glucose-167* UreaN-8 Creat-0.6 Na-130*
K-3.5 Cl-97 HCO3-21* AnGap-16
[**2135-5-18**] 07:38PM BLOOD Glucose-186* UreaN-10 Creat-0.7 Na-135
K-4.4 Cl-100 HCO3-20* AnGap-19
[**2135-5-29**] 03:11AM BLOOD ALT-24 AST-26 LD(LDH)-294* AlkPhos-67
Amylase-30 TotBili-4.3*
[**2135-5-28**] 01:00PM BLOOD ALT-21 AST-29 AlkPhos-60 Amylase-23
TotBili-4.1*
[**2135-5-18**] 07:38PM BLOOD CK(CPK)-97 Amylase-40
[**2135-5-29**] 03:11AM BLOOD Lipase-40
[**2135-5-19**] 03:59PM BLOOD Lipase-23
[**2135-5-31**] 12:20PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2135-5-18**] 07:38PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2135-6-17**] 05:38AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9
[**2135-6-16**] 05:15AM BLOOD Calcium-9.2 Phos-5.2* Mg-2.0
[**2135-5-19**] 01:09AM BLOOD Calcium-6.1* Phos-2.5* Mg-2.2
[**2135-5-18**] 07:38PM BLOOD Calcium-9.8 Phos-2.6* Mg-2.5
[**2135-5-19**] 03:59PM BLOOD TSH-0.29
[**2135-6-12**] 08:30AM BLOOD PSA-0.2
[**2135-5-19**] 01:19PM BLOOD Type-ART pO2-338* pCO2-39 pH-7.35
calHCO3-22 Base XS--3
Psych Consult ([**6-13**]):
ASSESSMENT:
73 y/o man presented s/p C2 traumatic neck fracture following
fall 6 weeks ago. He is s/p Halo, trach, and PEG placement
([**5-26**]) with readjustment during this admission. In the past
weeks, his mental status diminished to the point where he could
not make medical decisions, so his proxy (son) served as a
surrogate decision-maker. At this time, he is able to weigh
benefits of risks of treatment, and in general is very accepting
to continued medical treatment. He has capacity to medical
decisions regarding his care. His current CODE status is
DNR/DNI
PLAN:
reverse DNR/DNI status to FULL CODE
approach pt re: medical decisions during this hospitalization
make clear to son that his role as proxy is to represent
patient's wishes if pt. were able to convey them
Cytology on Cystoscopy ([**6-10**]):
ATYPICAL.
Atypical urothelial cells, present singly and in clusters.
Squamous cells, anucleate squames, histiocytes, neutrophils
and red blood cells.
EGD: [**2135-6-3**]:
Diffuse erosive esophagitis with active oozing of blood noted
throughout the entire esophagus
ECHO (TTE) [**5-30**]:
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity is mildly dilated. There is
severe global left
ventricular hypokinesis. Overall left ventricular systolic
function is
severely depressed.
3. The right ventricular cavity is dilated. Right ventricular
systolic
function appears depressed.
4. The aortic root is moderately dilated. The ascending aorta is
moderately
dilated.
5. A bileaflet aortic valve prosthesis is present. The aortic
prosthesis
leaflets appear to move normally. The transaortic gradient is
normal for this
prosthesis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
EGD ([**5-28**])
A single non-bleeding erosion was noted in the antrum, near
the gastrostomy site.
RUQ U/S ([**5-28**])
IMPRESSION: Normal right upper quadrant ultrasound without
evidence for intrahepatic or extrahepatic biliary ductal
dilatation or cholecystitis
CT of Cspine [**2135-5-19**]
IMPRESSION:
1) Fracture of C2, with posteriorly displaced odontoid fracture
fragments causing spinal canal narrowing and cord compression at
C1/2.
2) Anterior subluxation of C3 on C4, a finding that, in the
setting of trauma, could indicate disruption of the joint
capsule at the facet joints, and may be indicative of
ligamentous instability.
3) No other fractures identified within the cervical spine.
Brief Hospital Course:
Pt is a 72 yo man with a significant PMH of Afib, LVF with
pacer/defibrillator, Aortic Mechanical valve requiring
anticoagulation, Rheumatic Heart Disease, MR, AI, DM, Emphysema,
Gout, and Depression who presented to an OS s/p fall where he
was found to have an unstable dens fracture. The patient was
taken to the OR where a Halo was placed, tracheostomy was
performed and open GJ tube was placed. The patient, did well
post procedure but developed coffee ground emesis as
anticoagulation was restarted, an EGD was performed finding a
single non-bleeding 2cm, clean based ulcer in the
gastroesophageal junction, a RUQ US was also performed which was
normal, the patients Hcts remained stable. Subsequently, the
patient developed leakage of gastric contents around the GJ tube
and increased G tube output around the GJ site. The patient
also developed some hematuria and Heme positive gastric
secretions at this time. The Patients Hematocrits continued to
drop so much so that Transfusions were required. At this point
the decision was made to perform a follow up EGD which showed
diffuse erosive esophagitis with active oozing of blood noted
throughout the entire esophagus. This occurred despite
antiulcer regimens, Heparin was stopped and the patient was
brought back to the OR for repositioning of the GJ tube. After
this procedure, gastric secretions around the GJ Tube decreased
significantly, and the Pts Hct stabilized, the patient was
restarted on Heparin, but hematuria persisted, Urology consult
was obtained who did cystoscopy and found only an irritated
portion of the bladder that was most likely from foley trauma.
Bladder irrigation was performed and the patient's urine
cleared, anticoagulation was restarted, and the patient's
hematocrits remained stable. The patient did have continued
episodes of hematuria, but hematocrits remained stable and
events always subsided and were often after foley manipulation.
In addition, during the course of his stay, the patient had
episodes of Confusion and agitation which mostly occurred in the
ICU and step down units. Once moved to the floor, the patient
cleared considerably and Psych consult deemed the patient to
have decision making capacity. Through out the patients stay,
his Afib was rate controlled.
Medications on Admission:
Allopurinol
Lasix
Coumadin
Lexapro
Glyburide
HCTZ
Topral
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: [**12-5**] PO BID (2 times
a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
Q4H (every 4 hours) as needed for aggitation.
8. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
10. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
17. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
20. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
21. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) Intravenous ASDIR (AS DIRECTED): 1200 units/hr.
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): SSI:0-50 mg/dL [**12-5**] amp D50
51-120 mg/dL 0 Units
121-140 mg/dL 3 Units
141-160 mg/dL 7 Units
161-180 mg/dL 11 Units
181-200 mg/dL 15 Units
201-220 mg/dL 19 Units
221-240 mg/dL 23 Units
> 240 mg/dL Notify M.D.
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
C2 odontoid fracture, status post halo fixation and revision
GE junctional nonbleeding ulcer
Diffuse erosive esophagitis
Hematuria
Discharge Condition:
Stable
Discharge Instructions:
Return to the Emergency room if you develop high fevers,
abdominal Pain, weakness, sensory changes, or other concerns.
Take medications as prescribed, follow up as indicated below.
Halo must be on for 6-8 weeks, be sure to follow up with
Orthopaedic spine regarding removal.
Followup Instructions:
Follow up with:
Ortho Spine: Dr. [**Last Name (STitle) 363**], follow up lateral C-spine x-ray in 10
days, call ([**Telephone/Fax (1) 11061**] for appointment and eval of x-ray.
Urology: Call ([**Telephone/Fax (1) 5278**] for appointment
Gastroenterology: Dr. [**First Name (STitle) 2643**], follow up in 2 wks, call ([**Telephone/Fax (1) 26817**] for appointment
Your Primary Care Doctor, Dr. [**Last Name (STitle) 12982**] ([**Telephone/Fax (1) 30118**], as needed
Your Primary Cardiologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 22764**], as needed
ICD9 Codes: 5185, 2851, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 836
} | Medical Text: Admission Date: [**2154-12-16**] Discharge Date: [**2155-1-2**]
Date of Birth: [**2071-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2154-12-24**] 1.Coronary artery bypass grafting x3 with left internal
mammary artery, left anterior descending coronary;
reverse saphenous vein single graft from aorta to first
obtuse marginal coronary artery; reverse saphenous vein
single graft from aorta to the distal right coronary
artery.
2. Bilateral pulmonary vein isolation using the [**Company 1543**]
BP2 irrigated bipolar RF system with resection of left
atrial appendage.
3. Endoscopic left greater saphenous vein harvesting.
4. Epiaortic duplex scanning.
History of Present Illness:
83yo man admitted to [**Hospital6 10443**] 6 days prior to transfer with dyspnea on exertion. He
had history of COPD and was presumed to be having COPD
exacerbation. CT revealed effusion and the patient had
thoracentesis. He also had stress test that showed normal
perfusion w/o defects. Following the stress test he develped
chest pain and had ST depression in V2-6. During this episode
the
patient was noted to be in atrial fibrillation. He had cardiac
catheterization today that revealed 3VD with preserved EF.
Referred for surgery.
Past Medical History:
CAD
COPD
HTN
Atrial fibrillation
Past Surgical History: Laparoscopic Cholecystectomy
Social History:
Lives with: widowed-lives alone
Occupation:currently works as driver
Tobacco: Quit 35 yrs ago/105pack year hx
ETOH:none
Family History:
non-contrib.
Physical Exam:
Pulse: 85 Resp: 22 O2 sat: 96%-2LNP
B/P Right: 110/60 Left:
Height: 66 in Weight: 160lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs diminished w/o rales or wheezing
Heart: RRR [x] Irregular [] Murmur-no
Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x]
Edema: [**12-29**]+ bilat
Varicosities: None [x]
Neuro: Grossly intact, non focal exam
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit none Right: Left:
Pertinent Results:
Conclusions
PRE BYPASS The left atrium is moderately dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Left ventricular wall thickness,
cavity size, and global systolic function are 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 aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is a trivial/physiologic pericardial effusion. Dr.
[**Last Name (STitle) 914**] was notified in person of the results in the operating
room at the time of the study.
POST BYPASS The patient is being a paced. There is normal
biventricular systolic function. The left atrial appendage has
been resected. There is mild to moderate tricuspid
regurgitation. Other valvular function is unchanged from the
pre-bypass study. The thoracic aorta is intact s/p
decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2154-12-24**] 13:35
Brief Hospital Course:
Mr. [**Known lastname 30620**] was admitted on [**12-16**] from an outside hospital and
his pre-op work-up was done. Over the next several days he was
diuresed and had thoracentesis by Dr. [**Last Name (STitle) **] for a pleural
effusion. He also had a plavix washout. Antibiotics also were
started as well as BP med titration. He underwent coronary
artery bypass, MAZE, and left atrial appendage ligation with Dr.
[**Last Name (STitle) 914**] on [**12-24**] and was transferred to the CVICU in stable
condition on phenylephrine and propofol drips. He extubated
later that day and remained in the CVICU over the next few days
for aggressive pulmonary conditioning. His atrial fibrillation
returned and he was treated with amiodarone. A renal consult was
requested for acute renal failure with highest creat 3.8. He
also had an ileus but was ultimately transferred to the floor on
POD #6 to begin increasing his activity level. His beta blockade
was titrated. Coumadin was not started for atrial fibrillation
per Dr. [**Last Name (STitle) 914**] [**Name (STitle) 88067**] to fall risk. By post-operative day
nince he was ready for discharge to rehab per Dr. [**Last Name (STitle) 914**]. All
follow-up appointments were advised.
Medications on Admission:
Medications at home:
Prilosec 20 [**Hospital1 **]
ASA 81 QD
Combivent 2 puffs QID
Ativan 0.5 HS-prn
Symbicort 160/45 1 puff [**Hospital1 **]
Losartan 50 QD
Colace 100 [**Hospital1 **]
Meds on Transfer:
Tylenol 650 Q4-prn
Lactinex 2 abs TID
Maalox 30cc Q$-prn
Combivent 2 puffs QID
ASA 81 QD
Symbicort 160/4.5 1 puff [**Hospital1 **]
Plavix 75 QD
Colace 100 [**Hospital1 **]
Pepcid 20 QD
Lasix 40 QD
Levaquin 250 QD
Ativan 0.5 QHS-prn
Cozaar 50 [**Hospital1 **]
MOM-prn
Metoprolol 25 [**Hospital1 **]
NTG 0.4 sl-prn
MSO4 2 IV-PRN
Senna 1 tab [**Hospital1 **]
Ocean spray nasal spray QID-prn
Calan SR 180 QD
Plavix - last dose:[**12-16**]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units SQ Injection TID (3 times a day): until ambulating
regularly.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks: [**Date range (1) 33500**] (400 mg daily), then 200 mg daily starting
[**1-8**].
10. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): 75mg [**Hospital1 **].
Disp:*90 Tablet(s)* Refills:*2*
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*30 ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 12564**] hospital
Discharge Diagnosis:
Severe 3-vessel coronary diseases s/p Coronary artery bypass
grafting x3(left internal mammary artery, left anterior
descending coronary;
reverse saphenous vein single graft from aorta to first obtuse
marginal coronary artery; reverse saphenous vein single graft
from aorta to the distal right coronary artery).
2. History of atrial fibrillation.
3. Severe chronic obstructive pulmonary disease.
4. acute renal failure
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema ............
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) 914**] on [**2155-1-21**] at 1:30pm # [**Telephone/Fax (1) 170**]
Cardiologist:Dr.[**Last Name (STitle) **] on [**2155-1-30**] at 2:15pm
Please call to schedule appointments with your:
Primary Care Dr.[**Last Name (STitle) 5239**] in [**12-29**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2155-1-2**]
ICD9 Codes: 4280, 5845, 5180, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 837
} | Medical Text: Admission Date: [**2162-5-16**] Discharge Date: [**2162-5-28**]
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Codeine / Amiodarone
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
MV Repair ([**5-17**])
History of Present Illness:
86 y/o female w/increasing DOE for 4 months, increased fatigue,
Echo: severe MR.
Past Medical History:
1) Atrial fibrillation X 15 years
2) s/p pacemaker placement
3) s/p appendectomy
4) s/p TAH
5) s/p tonsillectomy
6) s/p adenoidectomy
Social History:
The patient has 10 pk-yr smoking history, quit 15 years ago. [**12-6**]
alcoholic beverages per week. No other drug use. Lives in North
[**Doctor First Name **]; currently visiting her daughter.
Family History:
Sister has a pacemaker. Brother had a CVA. Father died of an MI
at 72 years.
Physical Exam:
Unremarkable pre-op
Pertinent Results:
[**2162-5-27**] 07:05AM BLOOD Hct-33.8*
[**2162-5-26**] 05:50AM BLOOD PT-17.8* INR(PT)-2.1
[**2162-5-25**] 06:35AM BLOOD Glucose-100 UreaN-25* Creat-0.9 Na-141
K-4.3 Cl-108 HCO3-26 AnGap-11
Brief Hospital Course:
to OR [**2162-5-17**] for MV repair (26mm [**Doctor Last Name **] band) Weaned from vent
and extubated day of surgery. Weaned off phenylephrine by POD #
1, transferred to telemetry floor on POD # 1. Had low urine
output after transfer, with rising creatinine. Trasferred back
to CSRU on morning of POD # 2, PA catheter placed, found to be
hypovolemic, treated with volume. Also had PPM rate increased
to 80/minute to maximize cardiac output. Creatinine peaked at
1.9, but quickly reverted back down to normal (0.9-1.0 for past
4 days) after fluid resuscitation.
Anticoagulation resumed for atrial fibrillation, presently
V-paced at 70/minute (rate decreased to 70 on [**5-26**]).
She was not restarted on Altace due to elevatd creatinine (now
normalizeed), she was started on Norvasc. This should be
re-evaluated by Dr. [**First Name (STitle) 805**] or Dr. [**Last Name (STitle) 32548**] upon discharge from
rehab.
She has remained hemodynamically stable, with normalized
creatinine, and good urine output. She remains weak, and
requires assistance to ambulate. She is ready for discharge to
rehab today.
Medications on Admission:
Coumadin 7.5 mg QD
Lasix 40 mg QD
Altace 5 mg QD
Toprol XL 50mg QD
Calcium
Glocosamine
Magnesium
Selenium
Folic Acid
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
10. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: then recheck INR, and dose for target INR 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*0*
11. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
MR
AFib
s/p PPM (SSS)
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# or driving for 1 month
no creams lotions, or powders to incisions
may shower, no bathing or swimming for 1 month
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (Prefixes) **] in 4 weeks
with Dr. [**First Name (STitle) 805**] in [**1-7**] weeks, or upon discharge from rehab
with Dr. [**Last Name (STitle) 32548**] in [**1-7**] weeks or upon discharge from rehab
Completed by:[**2162-5-27**]
ICD9 Codes: 4240, 2765, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 838
} | Medical Text: Admission Date: [**2161-12-12**] Discharge Date: [**2162-1-5**]
Service: ONCOLOGY
CHIEF COMPLAINT:
Worsening dyspnea.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old
woman with metastatic breast cancer, diagnosed in [**2161-11-13**], presenting to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on
[**2161-12-12**] for shortness of breath times several
weeks, worsening over the last few days. She does have two
pillow orthopnea but negative paroxysmal nocturnal dyspnea,
no chest pain or palpitations. She has noted increasing
lower extremity edema over the last week. She has cough
which is productive of white sputum but no night sweats or
weight loss. She denies fever, chills, nausea or vomiting.
She has been using inhalers but does not feel that they have
been effective with regard to her dyspnea. She is not on any
oxygen at home.
The patient's previous workup for shortness of breath has
included a CT angiogram on [**2161-12-2**] which was
negative for pulmonary embolism but notable for bilateral
ground-glass opacities. A transthoracic echocardiogram
showed a left ventricular ejection fraction of greater than
70% with mild aortic and mitral regurgitation. She has
moderate pericardial effusion as noted by the transthoracic
echocardiogram.
PAST MEDICAL HISTORY:
1. Pernicious anemia.
2. Chronic obstructive pulmonary disease.
3. Depression.
4. Bilateral total knee replacements.
5. Pelvic mass found in the left adnexal region measuring
6 x 4 cm, which is likely metastatic versus primary ovarian
in origin.
6. Infiltrating ductal carcinoma, ER positive, HR2/neu
negative with omental metastases, retroperitoneal lymph
nodes. MRI of the head revealed no metastatic disease,
however, bone scan indicated thoracic metastases.
SOCIAL HISTORY: The patient lives alone on the third story
of an apartment building and is independent. Her daughter
and son-in-law live nearby and are very supportive.
FAMILY HISTORY: Family history is significant for coronary
artery disease in the patient's father, however, no family
history of cancer.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Zoloft 100 mg p.o.q.d., Lasix 40
mg p.o.b.i.d., Combivent one to two puffs q.i.d., AeroBid
four puffs b.i.d., vitamin B12 q. month, Femara 2.5 mg
p.o.q.d.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 97, blood pressure 162/82,
heart rate 88, respiratory rate 28, and oxygen saturation 98%
on three liters nasal cannula. General: Patient in no acute
distress, resting comfortably in bed, appears younger than
her stated age. Head, eyes, ears, nose and throat:
Oropharynx clear, moist mucous membranes, jugular venous
pulsation not elevated, neck supple, anicteric sclerae,
extraocular movements intact, no lymphadenopathy present in
the cervical region. Chest: Bilateral basilar crackles
without wheezing, left axillary lymphadenopathy.
Cardiovascular: Regular rate, normal S1 and S2, no S3 or S4,
II/VI murmur at left sternal border. Abdomen: Soft,
nontender, nondistended, positive bowel sounds, no
hepatosplenomegaly. Extremities: 2+ bilateral pitting
edema, no cyanosis or clubbing, 2+ dorsalis pedis pulses
bilaterally, skin warm and dry. Neurologic examination:
Alert and oriented times three, cranial nerves II through XII
intact, [**5-17**] motor strength in bilateral upper and lower
extremities.
LABORATORY DATA: Admission white blood cell count 6.1,
hematocrit 32.2, platelet count 263,000, sodium 137,
potassium 4.1, chloride 106, bicarbonate 18, BUN 34,
creatinine 1.3, glucose 109.
STUDIES DURING HOSPITALIZATION:
1. Chest x-ray, [**2161-12-12**] revealed bilateral
interstitial infiltrates, bilateral pleural effusions, mild
congestive heart failure.
2. Transthoracic echocardiogram, [**2161-12-16**] showed
mild left ventricular hypertrophy, hyperdynamic left
ventricular function with a moderate pericardial effusion, no
change from echocardiogram on [**2161-12-8**].
3. Transthoracic echocardiogram, [**2162-1-4**] showed
left ventricular ejection fraction greater than 55% with
loculated moderate sized 1.5 cm pericardial effusion with
fibrin deposits on the surface of the heart; no
echocardiographic signs of tamponade; compared with prior
echocardiogram, the pericardial effusion appears loculated at
this point.
4. Electrocardiogram on admission showed normal sinus
rhythm, Q waves in III and AVF which were old and T wave
abnormalities in V2 through V6 which were nonspecific.
HOSPITAL COURSE: The patient is a [**Age over 90 **] year old female with
chronic obstructive pulmonary disease, breast cancer and
anemia, who presents with acute worsening of chronic
shortness of breath.
1. Cardiovascular: The patient was initially thought to be
in congestive heart failure and was aggressive diuresed until
her creatinine bumped. She was ruled out for a myocardial
infarction by negative cardiac enzymes on numerous occasions
during her hospitalization. Serial echocardiograms were
performed times four, which showed moderate sized pericardial
effusion without signs of tamponade but evidence of diastolic
dysfunction.
As the patient's dyspnea did not improve, there was concern
that the effusion was compromising cardiac output and her
ability to mobilize fluid. Therefore, a pericardial window
was placed on [**2162-1-1**] with greater than 200 cc of
bloody fluid out, and the drain was left in until [**2162-1-5**]. There was no improvement in the patient's dyspnea
after the window was placed and the pericardial drainage tube
was pulled.
As the pericardial fluid was bloody, there was concern for a
malignant effusion, however, cytology revealed no malignant
cells. It was significant for reactive mesothelial cells,
red blood cells, lymphocytes and neutrophils.
The patient also had occasional episodes of ectopy, both
atrial fibrillation and supraventricular tachycardia, which
was thought to be related to the pericardial window and
drain, with resulting irritation. She was started on
metoprolol 25 mg twice a day for both rhythm abnormalities
and for improvement of congestive heart failure.
2. Pulmonary: The patient's main complaint on admission was
acute worsening of chronic dyspnea over the last month. Upon
medical record review, it appears that the patient has had
complaints of dyspnea since [**2161-7-13**] and, during her
previous admission at the beginning of [**Month (only) **], she was
noted to have oxygen saturation of 91% in room air.
The cardiologic etiologies of the dyspnea was extensively
investigated but, as she had no improvement with diuresis,
pericardial window and multiple rule outs for myocardial
infarction, it was felt that there was a pulmonary etiology
as the most likely explanation for her dyspnea.
Given the patient's history of chronic metastatic breast
cancer, lymphatic spread of the cancer was thought to be the
source of her dyspnea. A thoracentesis was performed on
[**2161-12-30**] and 600 cc of yellow straw colored fluid
was removed. The fluid was later found to be positive for
malignant cells, consistent with adenocarcinoma.
The patient was ruled for pulmonary embolism just prior to
admission. Although she was not on oxygen at home, she had a
consistent three to four liter nasal cannula oxygen
requirement throughout the hospitalization.
The patient was transferred to the Medical Intensive Care
Unit following pericardial window placement and consideration
for Swan-Ganz catheter was undertaken, however, the patient
and family opted to pursue a less aggressive treatment
course. The Swan-Ganz was not placed and her volume status,
instead, was estimated per clinical examination and
radiograph evidence that was available.
3. Renal: On admission, the patient's creatinine was 1.3
and bumped to as high as 2.1 with diuresis. With fluid
hydration after the pericardial window was placed, the
creatinine trended down and is currently at 1.6 at the time
of discharge.
4. Infectious disease: The patient was treated with a ten
day course of antibiotics for presumed pneumonia, which did
not improve her pulmonary status.
5. Hematology: The patient has a baseline pernicious anemia
and received B12 injection on admission. She is to continue
these injections monthly.
6. Gastrointestinal: The patient is chronically constipated
but had worsening of her constipation throughout her
hospitalization. Her abdomen became progressively more
distended and tender during the end of her hospital course
while she was in the MICU. Liver function tests were
performed and found to be normal on several occasions. An
abdominal x-ray showed a distended large bowel, however, she
was eventually able to move her bowels two to three days
prior to discharge. Her abdominal exam did not significantly
improve after the bowel movements and, given her elevated
lactate, there was concern for bowel wall ischemia, ileus or
obstruction from her previous known large pelvic mass. The
option of a CT abdomen was discussed with the patient and
family, who both agreed not to perform the study given the
risks of worsening renal function from contrast load and
their wish not to pursue surgical intervention. The etiology
of her abdominal pain was most likely functional constipation
and she was continued on an aggressive bowel regimen with per
rectum medication and enemas as needed.
7. Fluids, electrolytes and nutrition: Throughout her
hospitalization, the patient had a minimal appetite secondary
to cancer anorexia and had a few episodes of nausea and
emesis. Her emesis was thought secondary to functional
constipation. She was able to tolerate fluids and pureed
food on occasion and was able to take most of her oral
medications. During a family meeting, a nasogastric tube was
discussed with the possibility of starting tube feeds. The
family, however, did not think this was consistent with the
patient's wishes and, therefore, no nasogastric tube was
placed. Likewise, the option of a percutaneous endoscopic
gastrostomy tube was also felt by the family not to be
consistent with the patient's wishes.
8. Oncology: On admission, the patient had a known
diagnosis of metastatic breast cancer, which was recently
diagnosed in [**2161-11-13**]. Her outpatient oncologist, Dr.
[**First Name (STitle) **], did not feel chemotherapy was indicated at the time of
diagnosis. She was instead started on Femara given that the
tumor was estrogen receptor positive.
9. Code status: A family meeting was held on [**2162-1-4**] and, after a long discussion of the progression of the
patient's disease and lack of response to medical management,
it was decided by both the patient and her family that she
would be "Do Not Resuscitate", "Do Not Intubate" and not to
pursue aggressive medical treatment at this point. Her
medications were simplified and she was prepared for
transition to a skilled nursing facility with the possibility
of hospice care in the near future. At this time, she was
not "Comfort Measures Only", however, future medical decision
making would be contingent upon optimizing the quality of
life.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Metastatic breast cancer, bone, retroperitoneal lymph
nodes and omentum.
2. Pelvic mass thought secondary to breast cancer metastases
or primary ovarian tumor.
3. Diastolic congestive heart failure.
4. Chronic obstructive pulmonary disease.
5. Acute renal failure/chronic renal insufficiency.
6. Constipation.
7. Status post pericardial window, [**2162-1-1**].
8. Status post thoracentesis, [**2161-12-30**].
9. Chronic dyspnea, thought secondary to lymphangitic spread
of carcinoma.
10. Paroxysmal atrial fibrillation.
11. Pernicious anemia.
DISCHARGE MEDICATIONS:
Metoprolol 25 mg p.o.b.i.d.
Pepcid 20 mg p.o.b.i.d.
Reglan 10 mg p.o.q.i.d.
Dulcolax p.r.p.r.n.
Senna two tablets p.o.q.d.
Colace 100 mg p.o.b.i.d.
Lactulose 30 cc p.o. or 300 cc p.r.t.i.d.p.r.n.
Combivent q.6h.
Flovent 110 mcg two puffs b.i.d.
Zoloft 100 mg p.o.q.d.
Femara 2.5 mg p.o.q.d.
Roxanol p.r.n.
Supplemental oxygen, three to four liters.
Tylenol p.r.n.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to
[**Location (un) **] Skilled Nursing facility with the possibility of
transition to hospice. Her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **],
[**First Name3 (LF) **] continue to follow the patient after discharge.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**]
Dictated By:[**Last Name (NamePattern1) 18697**]
MEDQUIST36
D: [**2162-1-9**] 22:07
T: [**2162-1-14**] 17:24
JOB#: [**Job Number **]
ICD9 Codes: 4280, 5990, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 839
} | Medical Text: Admission Date: [**2162-5-14**] Discharge Date: [**2162-5-21**]
Date of Birth: [**2162-5-14**] Sex: M
Service:
NOTE: This is an interim summary covering the date of birth
([**2162-5-14**]) through [**2162-5-21**].
ADMISSION DIAGNOSES:
1. Premature male infant at 34-3/7 weeks gestation.
2. Hyperbilirubinemia.
3. Desaturations; some with apnea of prematurity and some
without.
HISTORY OF PRESENT ILLNESS: The infant is a former 2.24-kg
male infant born to a 24-year-old O positive hepatitis B
surface antigen female.
Past obstetrical/gynecologic history was notable for a double
uterus and cervix. The pregnancy was uncomplicated until
premature rupture of membranes, and the infant was noted to
be in the breech presentation, so a cesarean section was
performed three hours status post rupture. The infant was
born with Apgar scores were 8 at one minute and 8 at five
minutes and was transferred to the Newborn Intensive Care
Unit for further evaluation and management of prematurity.
On admission, the baby weighed 2.24 kilograms, length 144 cm,
head circumference was 30.5 cm; all appropriate for
gestational age.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
was essentially within normal limits.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The infant remained on room air
throughout his hospital course; however, he did have multiple
desaturations, some accompanied with apnea and bradycardia
and others not. On [**5-21**], he had 2 full 24-hour periods of
having no episodes.
2. CARDIOVASCULAR SYSTEM: There were no cardiovascular
issues.
3. INFECTIOUS DISEASE ISSUES: The infant had a benign
complete blood count, and no antibiotics were initiated.
Because of the mother's hepatitis B surface antigen positive
status, the infant received hepatitis B immune globulin and
hepatitis B immune vaccine on [**5-14**].
4. FEEDING AND NUTRITION ISSUES: On day of life seven, the
infant weighed 2.140 kilograms and was being fed Enfamil 20
calories per ounce at 150 cc/kg. He required more than half
of this by gavage feeding.
5. HEMATOLOGIC ISSUES: The infant had a bilirubin of 11.6
which peaked at 13.8, for which he underwent several days of
phototherapy.Phototherapy d'c d on [**5-21**] with rebound bili
pending on [**5-22**].
6. HEARING SCREEN: Hearing screen was performed on [**5-16**]
and was normal.
7. DISPOSITION ISSUES: Upon discharge from the Neonatal
Intensive Care Unit when he is feeding well and has had five
days free of any major desaturations or apnea or bradycardia,
he will be seen at [**Hospital1 **] Center by Dr. [**First Name (STitle) **].
Parents decline VNA service.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 47613**] 50-393
Dictated By:[**Last Name (NamePattern1) 38304**]
MEDQUIST36
D: [**2162-5-20**] 08:42
T: [**2162-5-20**] 08:51
JOB#: [**Job Number 47614**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 840
} | Medical Text: Admission Date: [**2141-10-16**] Discharge Date: [**2141-10-19**]
Date of Birth: [**2099-1-29**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
I feel terrible
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 42 year old man with a PMH of alcohol abuse,
seizures secondary to alcohol withdrawal and pericarditis who
was in his usual state of health until 9 days ago when he had
his last drink. He was admitted to [**Hospital1 **] for detox and had been
doing well until a week ago when he developed the onset of
subjective fevers and chills with HA and anorexia. He also had
nonradiating right sided chest pain which worsened with deep
inspiration. He became so weak that he could not get out of bed.
On ROS, Mr. [**Known lastname **] [**Last Name (Titles) **] N/V/constipation/sick contacts.
In the ED, he was found to have a blood pressure of 78/62 and
tachycardia to 120 for which he was given 4L NS. He responded by
increasing his BP to 94/63 with a HR of 89. He also got 500 mg
of azithromycin and 1 gm ceftriaxone in addition to multivitamin
and thiamine and folate.
Past Medical History:
EtOH with 3-4 detoxs including seizures
pericarditis 5 years ago
dislocated shoulder
Social History:
Lives with wife and 16 year old daughter. [**Last Name (Titles) 4273**] tobacco or
illicits. Admits to drinking 12-16 beers per day or a quart of
vodka.
Family History:
noncontributory
Physical Exam:
vitals: 97.1 HR 89 BP 94/63 RR 16 and 100% on NC
Gen: looks uncomfortable, curled in fetal position, having a
hard time participating in physical exam
HEENT: MM, 2 front teeth from mandible absent (secondary to
seizure trauma 1 month ago)
Neck: supple
Cor: tachy but regular
Pulm: crackles and dullness to percussion on right
Back: TTP at costovertebral angle on right
Abd: soft without guarding +BS but TTP on RUQ
Ext: WWP 2+ DP/PT, radial pulses bilaterally
Neuro: CN II-XII grossly intact but patient unable/unwilling to
open eyes simultaneously
Pertinent Results:
[**2141-10-15**] 11:52PM D-DIMER-5142*
[**2141-10-16**] 01:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-9.0*
LEUK-NEG
[**2141-10-15**] 10:51PM LACTATE-1.1
[**2141-10-15**] 10:40PM GLUCOSE-117* UREA N-9 CREAT-0.6 SODIUM-136
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-26 ANION GAP-16
[**2141-10-15**] 10:40PM ALT(SGPT)-13 AST(SGOT)-42* CK(CPK)-1144* ALK
PHOS-131* AMYLASE-87 TOT BILI-1.2
[**2141-10-15**] 10:40PM LIPASE-20
[**2141-10-15**] 10:40PM CK-MB-3 cTropnT-<0.01
[**2141-10-15**] 10:40PM WBC-11.8* RBC-3.87* HGB-12.3* HCT-35.2*
MCV-91 MCH-31.9 MCHC-35.1* RDW-13.4
[**2141-10-15**] 10:40PM NEUTS-79.8* LYMPHS-15.8* MONOS-3.1 EOS-1.1
BASOS-0.2
09/1/1/05 10:40PM PLT COUNT-254/
blood and urinary cultures were negative for growth
EKG: [**10-15**]: Sinus tachycardia at 120 with normal axis and
nonpathologic Qs in V3-V6. Poor R wave progression in leads
VI-V3. Prolonged
Q-T interval. Diphasic T waves in leads V4-V6 and low amplitude
T waves
in leads II, III and aVF which are non-specifically abnormal.
Tall R waves
fulfilling voltage criteria for left ventricular hypertrophy in
lead V5.
CXR [**2141-10-15**]: The heart is of normal size. The mediastinal and
hilar contours are within normal limits. There are no pleural
effusions seen. There is a nodular density seen in the lateral
view anteriorly. The other pulmonary opacity seen in the right
middle lobe in the CT in the same day cannot be identified in
the radiograph. The aorta is tortuous. There is no evidence of
pneumothorax.
IMPRESSION: Nodular density seen in the lateral view anteriorly.
Another density seen in the CT in the same day cannot be
identified in the radiograph. Please review report of the CT
performed in the same day for differential diagnosis.
CTA [**2141-10-16**]: There are 2 large nodules in the right middle lobe.
They are low attenuation and do not enhance. Considering the
patients symptoms and the hypothesis that the patient is
immunocompetent, this most likely represents bacterial
pneumonia. However, follow up until resolution is necessary to
exclude malignancy. small right pleural effusion.
CXR: [**2141-10-18**] Pulmonary edema is resolved. Persistent
consolidation at the base of the right lung is probably
pneumonia. Hyperinflation suggests COPD. Heart size is normal.
There is no pneumothorax or appreciable pleural effusion.
Brief Hospital Course:
A: 42 year old man with high Ddimer and PNA in addition to high
CK and hypotension.
P:
PNA - ceftriaxone and azithro. He was also started on flagyl for
question of aspiration. The flagyl was stopped on [**10-17**]. The
patient initailly went to the [**Hospital Unit Name 153**] for concern of his
hemodynamic status where overnight his hypotension improved
after 5L NS. He was transfered to the floor on [**10-17**]. On the
floor he was afebrile continued to improve and was discharged on
[**2141-10-19**] with antibiotics. The patinet also received pneumovax
prior to discharge
# EtOH: patient most likely out of window for withdrawal, but
was placed on a CIWA was used for which he required no meds. He
was given thiamine, folate. An addiction consult was requested
and it was recommended that he continue to attend AA meetings.
Medications on Admission:
NONE
Discharge Medications:
1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Capsule(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Augmentin XR 1,000-62.5 mg Tablet Sustained Release 12HR Sig:
Two (2) Tablet Sustained Release 12HR PO twice a day for 10
days.
Disp:*40 Tablet Sustained Release 12HR(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Community acquired pneumonia
Alcohol abuse
Discharge Condition:
Stable. Afebrile with improved chest pain on antibiotics.
.
Discharge Instructions:
You were admitted with a community acquired pneumonia. Please
continue to take your antibiotics for ten more days even if you
start to feel better. You should call your physician or come to
an emergency room if you develop fevers > 101, trouble
breathing, cough with green or yellow sputum or chest pain.
Please also call if you have diarrhea as the antibiotics can
cause infectious diarrhea which will need to be treated by your
physician.
You will need to follow up with a primary care physician and
have [**Name Initial (PRE) **] chest CT scan done in six to eight weeks to assess
resolution of the pneumonia.
Followup Instructions:
Please schedule an appointment with your primary care physician
for repeat chest CT to evaluate for pneumonia resolution in six
to eight weeks.
Completed by:[**2141-10-26**]
ICD9 Codes: 0389, 486, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 841
} | Medical Text: Admission Date: [**2119-3-31**] Discharge Date: [**2119-4-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**4-12**] Right-sided crani for evac of subdural hematoma
History of Present Illness:
81 year-old male with history of CHF, atrial fibrillation,
ascending aortic aneurysm and mitral regurgitation who is
admitted with dyspnea and failure to thrive.
.
The patient's daughter reports that the patient has been sick
for "a while", particularly since he was admitted in [**2119-2-22**].
Since his discharge, he was improving and doing better at home
until three days ago when he started declining rather rapidly.
She reports that he has had shortness of breath, slurred speech
and difficulty walking over the last three days. He has also
been confused and falling asleep in his chair and falling out of
the chair and from his bed. He has been refusing help, but
unable to get up. She also reports that her father has had
decreased grip strength and things have been falling out of his
hands. As a result of his confusion, he has been eating less,
though he has been very thirsty and is drinking a lot of fluids.
There have been no fevers, chills, night sweats, cough, emesis,
diarrhea. She also reports "difficulty with motor planning", as
if he had trouble "putting one foot in front of the other".
Interestingly, his mental status has been waxing and [**Doctor Last Name 688**].
Although he has been confused, he was able to have a completely
coherent conversation with his sister yesterday. [**Name2 (NI) **] was recently
on Coumadin but this was held secondary to fall risk.
.
In the ED, he was given 100mg of IV Lasix and ASA 325mg x 1.
.
Today, the patient states that his main concern is his shortness
of breath. He has been feeling dyspneic over the last several
days. Has a mild cough, non-productive. No chest pain or
palpitations. Denies edema. Reports orthopnea but no PND.
Past Medical History:
1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2. 3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia
Social History:
Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).
Family History:
no Alzhemer's or Parkinson's
Physical Exam:
Vitals: T 98.7 BP 116/69 (104-136/49-69) HR 91 (87-101) RR 25
(25-38) 100% 4L
General: restless in bed, no spontaneous eye opening, answers
questions, follows some commands (aside from eye opening)
HEENT: pupils small but reactive, dry mucous membranes
Neck: no evidence of JVD
Lung: rales at bilateral bases
Cor: irregularly irregular, 3/6 systolic murmur loudest at apex
Abd: NABS, soft, non-distended, reports some tenderness in RUQ
Ext: warm, no edema, pneumoboots in place
Neuro: oriented x 2 (hospital, name), follows some commands,
somewhat restless
Pertinent Results:
Head CT ([**4-1**]): Moderate right subdural hemorrhage with
associated subfalcine herniation.
.
CTA ([**4-1**]): New CHF with enlarging moderate/large bilateral
pleural effusions with concomitant atelectasis. No evidence for
pulmonary embolus
.
Head CT ([**4-2**]): No significant change from prior study with
right-sided pleural hematoma and subfalcine herniation again
seen.
.
EKG ([**4-2**]): very wavy baseline, largely uninterpretable secondary
to motion, afib with HR 100s, no ST changes (but diff to
interpret)
.
Renal US ([**4-2**]): No evidence of hydronephrosis or stones.
.
Echo ([**4-3**]): LVEF>55%. Significant aortic regurgitation is
present, but cannot be quantified. The mitral valve leaflets are
mildly thickened. At least, moderate (2+) mitral regurgitation
is seen.
.
Head CT ([**4-3**]): Stable appearance of the right-sided subdural
hematoma and stable to mildly improved subfalcine herniation
.
Abd US ([**4-4**]): No focal or textural hepatic abnormality is
identified. Patent portal vein with hepatopetal flow. Mild
splenomegaly. Small amount of ascites.
.
Head CT ([**4-4**]): Stable appearance of a large right subdural
hematoma
.
CXR ([**4-5**]): Cardiomegaly, bilateral effusions, and borderline
vascular congestion with little interval change
.
Head CT [**4-14**] evacuation of hematoma stable.
.
Head CT [**4-17**] hematoma stable.
Brief Hospital Course:
1. altered mental status -
He was admitted with subacute course of non-specific mental
status changes and was found to have a chronic appearing with
superimposed acute features subdural hemorrhage. He was followed
by neurosurgery, who deferred evacuation on account of the
stability of the SDH as well as his concomitant medical issues
(liver failure,
renal failure, UTI, CHF).
.
His mental status was poor with marked delirium, but remained
stable. Serial head CTs demonstrated stable subdural hemorrhage.
Pt was taken to the operating room on [**4-12**] for a right crani for
evacuation of Subdural hematoma. [**Name (NI) **] pt was extubated and
reintubated within 1 hr. Pt had aggressive pulm toilet and self
extubated overnoc on [**5-2**]. Drain removed [**4-13**]. Pt
currently doing well extubated. Staples to be dc'd [**4-21**]. .
Patient transferred to Neurosurgery service on [**2119-4-12**] for
subdural hematoma evacuation after become medically stable. His
INR has been stable under 1.3. His mental status improved over
the course of time, as his electrolytes, and coags improved. His
initial INR went up as high as 1.8 which stayed around the same
level until given factor VIIa on [**4-5**] then stayed around
1.2-1.3 range per recommendation of Hematology service. His
creatinine improved greatly, his creatinine jumped up to 2.5,
but now dropped down to 1.5 renal service has been following
along. He is cleared by medicine team to be operated on his
subdural hematoma. He had a left lower lobe pneumonia which is
treated with Levo. He had a hypernatremia Na up to 157 on [**4-11**],
eventually corrected with fluid.
.
He underwent right craniotomy on [**2119-4-12**] for evacuation of
subdural hematoma and placement of subdural JP drain placement
under general anesthesia without complications, he was able to
extubated in [**Hospital **] transferred to PACU, however 2 hour later he
required re-intubation secondary to hypoventilation. He is
neurologically moving all extremities, opens his eyes to voice
intermittently, squeezes to command. He placed on a beta-blocker
[**Hospital **] for heart rate control, [**Hospital **] ECG remained unchanged,
underlying rhythm being atrial fibrillation. His postoperative
head CT([**4-12**]) is revealed residual small amount of hemorrhage
mixed with fluid, pneumocephalus and postoperative changes. No
further shift of normally midline structures. Repeat head CT on
[**4-13**] remained stable, therefore his right subdural JP removed,
patient tolerated procedure well.
.
Patient will need drain stitch and staples removed on [**4-21**]. If
cant be done at nursing home will need to see Dr. [**Last Name (STitle) 739**].
Switched from dilantin to keppra.
.
2. congestive heart failure -
He was worked up for dyspnea and hypoxemia. Final etiology
was clearly congestive heart failure. He had a repeat Echo
which demonstrated preserved EF and some MR. [**Name13 (STitle) **] was
maintained on a regimen of hydral/nitro, beta blocker,
and cautious diuresis. He was maintained on oxygen by
nasal canula. Patient sent out on lasix.
.
3. Liver failure/coagulopathy -
He had a self limited course of liver failure with associated
coagulopathy. This was felt to be secondary to dilantin
toxicity.
Dilantin was stopped and his liver enzymes ultimately trended
down
toward normal. Alternative explanation could have been acute
hepatic congestion from heart failure.
.
Re: coagulopathy, he was treated with vitamin K, FFP, and
also proplex in acute setting. Thereafter, his INR trended
down and he was given po vitamin K. Heme/onc involved
in his care; agreed with hepatic synthetic dysfunction
as etiology of coagulopathy.
.
4. Acute on chronic renal failure -
Likely pre-renal exacerbation of chronic kidney disease.
Resolving toward baseline.
.
5. Atrial fibrillation
Continued rate control with bblocker. Held warfarin on account
of
coagulopathy and SDH.
.
6. DM
Held oral hypoglycemics; kept RISS. Patient has been having low
blood sugars so sliding scale reduced. Patient will need
frequent blood sugar.
Medications on Admission:
levothyroxine 25mcg daily
allopurinol 150mg qOD
Toprol XL 25mg daily
tylenol 325mg q4-6h prn
lasix 40mg daily
ferrous gluconate 300mg [**Hospital1 **]
combivent inh [**Hospital1 **]
celexa 10mg daily
glipizide 2.5mg daily
lipitor ? dose
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-26**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): see insulin sliding scale.
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day): hold for SBP < 100.
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary diagnoses:
1. Subdural hematoma s/p evacuation
2. Congestive heart failure
3. Pneumonia
4. Urinary Tract infection
.
Secondary diagnoses:
1. Mitral regurgitation
2. Atrial fibrillation
3. Diabetes Mellitus
Discharge Condition:
Stable
Discharge Instructions:
You are discharged to a Rehabilitation facility where you should
continue all medications as prescribed.
Please alert the physicians at the facility or contact your
physician if you experience headache, visual changes, shortness
of breath, chest pain, palpitations, or other concerns.
You should be weighed every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
You will need a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3649**] in [**1-27**] weeks. Please call [**Telephone/Fax (1) 3070**] to
make that appointment.
You will need an appointment with Dr. [**Last Name (STitle) 739**] 4 weeks
after your surgery with a head CT. Please call ([**Telephone/Fax (1) 11314**] to
make that appointment.
Right craniotmy drain stitch to be dc'd [**4-21**]; Craniotomy staples
to be dc'd [**4-21**]. If pt in house this will be done by
neurosurgery team; if in rehab they can be dc'd there, otherwise
pt to return to Dr.[**Name (NI) 4674**] office to be dc'd.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5845, 486, 5990, 2760, 4240, 2930, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 842
} | Medical Text: Admission Date: [**2190-6-30**] Discharge Date: [**2190-7-3**]
Date of Birth: [**2109-12-3**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2190-6-30**] cardiac catheterization with bare metal stent placement
to SVG-LAD/D1 graft
History of Present Illness:
80 year old male with history of CAD s/p CABG (SVG->LAD-D1,
SVG->OM RPLB), a-fib on coumadin, CVA presenting with new onset
chest pain. Pain had been occuring since yesterday morning.
Improved slightly with one SL NTG but was worse this am. He
reports that the pain started when he was having a bowel
movement, no associated SOB, N/V, or diaphoresis. This pain did
not feel like when he had his prior stents or CABG--at those
times he did not have chest pain at all.
In the ED, initial vitals were Temp: 98.6 HR: 90 BP: 144/82
Resp: 18 O(2)Sat: 98 Normal. Labs and imaging significant for
EKG with ST depressions in lateral leads. Cardiology was
consulted and they recommended a heparin gtt and nitro gtt for
ongoing chest pain. However, after about 1 hour, he was still
having chest pain and a posterior lead ECG with 1 mm STE in V5,
and 1/2 mm STE V4. Thus, he was taken to the cath lab.
In the cath lab, he had deployment of a BMS to the SVG-LAD near
the 1st diag. Also administered metoprolol 12.5 mg, aspirin 325
mg, and lisinopril 5 mg.
On arrival to the floor, patient is chest pain free. No
compliants.
REVIEW OF SYSTEMS
On review of systems, he denies any prior deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, 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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Hypertension
2. CARDIAC HISTORY:
-CABG: [**2158**]
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2177**], [**2181**]
3. OTHER PAST MEDICAL HISTORY:
- embolic stroke in [**2177**] after PCI c/b hemorrhagic conversion
after receiving TPA
- psoriasis
- hypothyroid
- afib
Social History:
Retired, lives with his wife. [**Name (NI) **] is a doctor [**First Name (Titles) **] [**Last Name (Titles) 2025**].
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. His son does
have CAD and is s/p MI with stent placement in his 50s.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=afebrile, BP 154/85, HR 45, RR 10, O2 sat 97% 2LNC
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: IRRR, 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.
EXTREMITIES: No c/c/e. No femoral bruits. Right groin with
dressing c/d/i, no ecchymoses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ radial 2+
Left: DP 2+ radial 2+
.
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.0 Tc 97.3 BP 114-129/63-76 HR 51-97 RR 18
GENERAL: WDWN M in NAD. Mood, affect appropriate.
HEENT: MMM, OP clear
NECK: Supple without appreciable JVD sitting up at 60 degrees.
CARDIAC: Irregularly irregular rhythm, normal S1, S2. No m/r/g
LUNGS:Nonlabored, CTAB.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Holds left arm in contracture. Left leg
in brace with decreased strength
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
[**2190-6-30**] 08:20AM BLOOD WBC-4.9 RBC-4.46* Hgb-13.5* Hct-42.2
MCV-95 MCH-30.4 MCHC-32.1 RDW-15.0 Plt Ct-191
[**2190-6-30**] 08:20AM BLOOD Neuts-56.9 Lymphs-30.9 Monos-3.7 Eos-7.7*
Baso-0.9
[**2190-6-30**] 08:20AM BLOOD PT-19.5* PTT-37.8* INR(PT)-1.8*
[**2190-6-30**] 08:20AM BLOOD Glucose-104* UreaN-9 Creat-0.9 Na-142
K-4.6 Cl-108 HCO3-25 AnGap-14
[**2190-6-30**] 08:20AM BLOOD CK(CPK)-76
[**2190-6-30**] 08:20AM BLOOD CK-MB-4
[**2190-6-30**] 08:20AM BLOOD cTropnT-0.03*
[**2190-6-30**] 08:20AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1
.
CXR [**2190-6-30**]:
AP AND LATERAL VIEWS OF THE CHEST: Patchy left mid lung lower
opacities are best seen on the frontal view. Heart size is top
normal, slightly enlarged from [**2182**]. There is no pleural
effusion or pneumothorax. Sternotomy wires and CABG clips are
again noted. Small bowel appears minimally distended.
Hypodensities overlying the area of the gallbladder may
represent cholelithiasis.
IMPRESSION:
1. Patchy mid left lung lower opacities could be pneumonia in
the correct
clinical setting, otherwise, may represent atelectasis.
2. Cholelithiasis.
3. Slight small bowel distension.
.
CATH [**2190-6-30**]:
PRELIMINARY REPORT
- diffuse instent restenosis < 50% to LCX
- LAD: proximally occluded
- Lcx: no significant disease
- RCA: known occluded
- SVG-ramus-OM: normal, provides collaterals to LAD
- SVGY to LAD and D1: proximally thrombotic occlusion, stent
placed
.
TTE [**2190-7-1**]:
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction. Doppler parameters are
indeterminate for LV diastolic function. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Focal calcifications in ascending aorta. Normal
aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild to moderate ([**2-1**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**2-1**]+] TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is dilated. The right atrium is moderately
dilated. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the distal anterior wall,
anteroseptum and of the apex. The distal inferior wall is
probably mildly hypokinetic also. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild to moderate ([**2-1**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction
consistent with CAD (distal LAD distribution). Mild aortic
regurgitation. Mild to moderate MITRAL REGURGITATION.
Brief Hospital Course:
PRINCIPLEREASON FOR ADMISSION
Mr. [**Known lastname **] is an 80 year old male with history of coronary artery
disease (CAD) status post CABG and PCI who presented with chest
pain x 24 hours with EKG showing ST depressions in V3-V4 and
posterior EKG with [**Street Address(2) 4793**] elevations. He underwent stenting
with bare metal stent (BMS) to SVG/LAD-D1 with resolution of his
chest pain.
.
# non-ST elevation Myocardial infarction: His posterior leads
showed ST elevations and he was taken to the cath lab with
successful deployment of bare metal stent (BMS) to SVG/LAD-D1
via access in his right groin. He was monitored in CCU
overnight and has been chest pain free since intervention. He
had a transthoracic echo post-MI which showed apical hypokinesis
in the LAD territory but preserve ejection fraction at 45-50%
and no diastolic dysfunction. He was started on plavix 75 mg
daily and his atorvastatin was increased from 20 mg daily to 80
mg daily. Lastly, his atenolol was converted to metoprolol in
house and the dose was decreased to metoprolol succinate 12.5 mg
daily due to pauses on higher doses. His discharge regimen was:
ASA 325 mg daily, Plavix 75 daily, Metoprolol succinate 12.5 mg
daily, Atorvastatin 80 mg daily, lisinopril 5 mg daily.
# Atrial fibrillation (afib): Patient has afib and is on
warfarin and atenolol at baseline. On admission he was
subtherapeutic at 1.8 so he was bridged with heparin drip while
his warfarin was restarted at home dosing 1 mg daily. On
discharge, his INR was 2.5. He will have INR draw qweekly and
followed by PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]. For rate control, his atenolol
was changed to metoprolol. He was having several second pauses
so the dose was down titrated to metoprolol succinate 12.5 mg
daily. Metoprolol was held day prior to discharge due to pauses
and transient hypotension, which was fluid responsive, but was
restarted when he was noted to increase his HR asymptomatically
to 140's with exertion.
# Hypertension: The patient's BP was stable during his admission
although slightly elevated at 150s early in his stay. He did
develop transient asymptomatic hypotension day prior to
admission which was fluid responsive. His goal BP is <140/80.
He was continued on lisinopril 5 mg daily. Metoprolol was dosed
as above. By discharge his blood pressures were well controlled.
CHRONIC ISSUES:
# History of embolic stroke with hemorrhagic conversion: His
afib was managed as above to prevent further strokes. He was
also continued on keppra 500 mg daily for seizure prophylaxis.
He was seen by physical therapy for his left hemiparesis and
contractures and they felt that he was well compensated to go
home.
# Hypothyroid: continued home levothyroxine 75 mcg daily.
# Psoriasis: continued clobetasol and desonide creams.
.
TRANSITIONAL ISSUES:
- Please monitor his INR weekly and adjust the dose of warfarin
as needed
- Please continue to monitor systolic blood pressures
Medications on Admission:
warfarin 1 mg daily
lisinopril 2.5 mg qam
ASA 81 mg qam
atorvastatin 20 mg qpm
keppra 500 mg qpm
atenolol 25 mg qpm
levothyroxine 75 mcg qam
clobetasol oint [**Hospital1 **]
dovonex
desonide cream [**Hospital1 **]
Discharge Medications:
1. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 tablets* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO Once Daily
at 4 PM.
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. aspirin 81 mg Tablet, Effervescent Sig: One (1) Tablet,
Effervescent PO once a day.
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 (one half) Tablet Extended Release 24 hr PO once a day.
Disp:*15 Tablet Extended Release 24 hr(s)* Refills:*2*
10. Dovonex Topical
11. desonide Topical
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY DIAGNOSIS
non-ST elevation myocardial infarction
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**].
You were admitted to the hospital because you had chest pain.
Your EKG showed some changes in the electrical pattern of your
heart, which indicated an impaired blood flow. Thus, you
underwent a procedure called cardiac catheterization to place a
stent in your heart and open up the blood flow. Your stent was
placed in the bypass graft leading to your LAD artery. After
the procedure you did well and your chest pain resolved.
The following changes were made to your medications:
Medications started:
1. Plavix (blood thinner since you have the stent in your
artery)
2. Metoprolol succinate (Toprol XL) [**2-1**] a 25mg tablet daily
(total 12.5mg)
Medications changed:
1. Atorvastatin- increased from 20mg a day to 80mg a day
Medications stopped:
1. Atenolol (blood pressure medicine similar to metoprolol)
**Continue taking your baby aspirin (81mg) by mouth once a day**
Follow-up needed for:
1. INR - Make sure to have your INR checked the morning of your
doctors [**Name5 (PTitle) 648**] with Dr [**Last Name (STitle) 3357**] next week.
It is also very important that you keep the follow-up
appointments listed below. You should bring your medications to
each [**Last Name (STitle) 648**] so your doctors [**Name5 (PTitle) **] update their records and
adjust the doses as needed.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
[**Telephone/Fax (1) **]: Friday [**2190-7-9**] 11:45am
ICD9 Codes: 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 843
} | Medical Text: Admission Date: [**2183-3-6**] Discharge Date: [**2183-3-21**]
Date of Birth: [**2120-12-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation and extubation
Hemodialysis catheter line placed
cardiac catheterization with two bare metal stents to the left
circumflex artery and the left [**Doctor Last Name **] artery.
History of Present Illness:
Please see nightfloat admission note for full details of
admission history. In brief, this is a 62yoM with CAD s/p CABG
[**11/2182**], dCHF, ESRD (on HD [**12/2182**] - [**2-6**]), history of DVT & PE
on Coumadin who presented [**3-6**] with AMS and acute on chronic
kidney injury.
.
Of note, the patient was recently admitted [**Date range (1) 91915**] for melena
from duodenal ulcer from migration of a metal biliary tract
stent that was exchanged for a new stent. His course was
complicated by septic pancreatic stent, micro bowel perforation,
citrobacter bacteremia, as well as hypoxia from volume overload.
He was ultimately discharged to rehab. Two weeks ago, the
patient developed abdominal pain for two weeks and began having
nausea/vomiting on Monday. He was to have the biliary stent
changed [**2183-3-3**] but missed his appointment due to excessive
vomiting.
.
On [**3-5**], the patient went to the bathroom and had an unwitnessed
fall for unclear reasons. The patient reports he slipped and
fell. Since the fall, the patient had altered mental status and
presented to an OSH with a negative CT head and neck. He was
given vancomycin and zosyn at transferred to the [**Hospital1 18**] ED, where
he was 99% NC. Repeat CT head and neck was negative, and
abdominal CT showed no migration of the biliary stent. CXR
showed pulmonary edema but not significantly different from
prior, and trop 0.19, previously 0.26. K was 5.9 without EKG
changes. Cr was 3.9 from 2.5. He remained afebrile. On transfer
to the medicine floor, the patient had HR 101 with 92%3L. He was
delirious and oriented x1 with myoclonic jerks but was
redirectable.
.
The morning of transfer to the MICU, the patient became
tachycardic and became hypoxic. He was transferred to the MICU
for further management.
.
On arrival to the MICU, the patient was breathing comfortably on
4L NC and denied shortness of breath, chest pain, nausea, or
other symptoms. However, he was delirious and oriented x1.
Past Medical History:
DMII complicated by neuropathy, nephropathy
CKD on HD briefly [**12/2182**]
CAD s/p CAB on [**11/2182**] at [**Hospital1 2177**] - 1 vessel
-- Diffuse multi-vessel disease. LIMA-LAD [**11/2182**] but other
vessels were not amenable to intervention
?COPD on 2L NC
Hypothyroidism
DVT in [**5-/2182**] has been on Coumadin
PE ?
Seizure
Renal mass
Right adrenal mass
Cholecystectomy
Left femur fracture
Left humeral fracture [**2-27**] fall
Depression
Chronic pancreatitis s/p biliary tract metal stenting
Pancrectomy in [**2176**] for necrosis
PVD with angioplasty
PVD s/p femoral popliteal artery PTA
Pericarditis
C. diff colitis [**12/2182**] on po Vanco
s/p rotator cuff repair in [**2169**]
s/p carotid endarterectomy
Laminectomy c-spine
Cholecystectomy
Tonsillectomy
Social History:
Currently living in rehab. He has two daughters who are involved
in his care - [**Female First Name (un) **] and [**Doctor First Name 3095**].
- Tobacco: quit 11 months prior
- Alcohol: denies
- Illicits: denies
Family History:
Unable to answer due to altered mental status
Physical Exam:
PHYSICAL EXAM:
T 97.8 HR 111 BP 145/94 RR 18 SaO2 100% on 100% NRB
GENERAL - Alert and interactive but oriented x1
HEENT - Dry mucous membranes, sclera anicteric
NECK - Supple
LUNGS - Coarse inspiratory crackes at bases b/l, no wheezes or
rhonchi
HEART - Tachycardic but normal rhythm, nl S1/S2, no m/g/r
ABDOMEN - Soft, non-tender, non-distended, +BS
EXTREMITIES - No pedal edema
NEURO - Oriented to self, able to follow commands, moving all
extremities.
Pertinent Results:
Admission Labs:
[**2183-3-5**] 10:50PM BLOOD WBC-11.0 RBC-3.29* Hgb-9.8* Hct-30.0*
MCV-91 MCH-29.7 MCHC-32.7 RDW-14.9 Plt Ct-173
[**2183-3-5**] 10:50PM BLOOD Neuts-79.2* Lymphs-10.8* Monos-3.0
Eos-6.7* Baso-0.4
[**2183-3-5**] 10:50PM BLOOD Plt Ct-173
[**2183-3-5**] 11:12PM BLOOD PT-32.3* PTT-48.2* INR(PT)-3.1*
[**2183-3-7**] 09:30PM BLOOD FDP-10-40*
[**2183-3-5**] 10:50PM BLOOD Glucose-119* UreaN-75* Creat-3.9*# Na-137
K-5.9* Cl-102 HCO3-22 AnGap-19
[**2183-3-5**] 10:50PM BLOOD ALT-12 AST-22 CK(CPK)-63 AlkPhos-126
TotBili-0.5
[**2183-3-5**] 10:50PM BLOOD cTropnT-0.19*
[**2183-3-6**] 07:31AM BLOOD CK-MB-6 cTropnT-0.17* proBNP->[**Numeric Identifier **]
[**2183-3-6**] 07:31AM BLOOD Calcium-8.7 Phos-5.5* Mg-1.3*
[**2183-3-7**] 09:30PM BLOOD Hapto-260*
[**2183-3-5**] 10:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2183-3-5**] 10:50PM BLOOD HoldBLu-HOLD
[**2183-3-6**] 07:22AM BLOOD Type-ART pO2-98 pCO2-37 pH-7.31*
calTCO2-20* Base XS--6
[**2183-3-5**] 11:05PM BLOOD Lactate-1.0
MICRO:
[**2183-3-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-NEGATIVE
[**2183-3-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL POSITIVE
[**2183-3-15**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2183-3-15**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2183-3-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-NEG
[**2183-3-12**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2183-3-12**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2183-3-12**] URINE URINE CULTURE-NEGATIVE
[**2183-3-6**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-NEGATIVE
[**2183-3-6**] URINE URINE CULTURE-NEGATIVE
[**2183-3-6**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2183-3-5**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
Imaging:
Echo: The left atrium is moderately dilated. Left ventricular
wall thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis and lateral hypokinesis. The
remaining segments contract normally (LVEF = 35-40%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The 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. Moderate to severe
(3+) mitral regurgitation is seen, stemming from a posterior
mitral leaflet being tethered to the akinetic inferolateral LV
wall. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Moderate to severe ischemic mitral
regurgitation. At least moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2183-2-12**],
left ventircular cavity has further dilated, LV function has
deteriorated and amount of mitral regurgitation has increased.
The regional distribution of wall motion abnormalities is quite
similar. Findings discussed with Dr. [**Last Name (STitle) **] at 1600 hours on
the day of the study.
[**2183-3-6**] Radiology CT ABD & PELVIS W/O CON [**Last Name (LF) 10902**],[**First Name3 (LF) **]
Approved
1. Unchanged location of biliary stent.
2. Right lower lung consolidation may represent aspiration,
pneumonia, or
worsening atelectasis.
3. Within the limits of a non-contrast study, no acute
intra-abdominal
process. Bilateral adrenal and left renal nodules as described
above.
Consider non-emergent followup.
[**2183-3-10**] Cardiovascular C.CATH [**2183-3-10**] [**Last Name (LF) **],[**First Name3 (LF) **] M.
Preliminary
1. Limited selective coronary angiography of this right dominant
system
revealed three vessel coronary artery disease. The LMCA had a
50% ostial
lesion and calcified distal 50% lesion. The LAD was heavily
calcified
and diffusely diseased with 80% ostial lesion; there was
competative
flow in the distal LAD indicating patent LIMA. The single
diagonal
arises from the proximal vessel and has 80% ostial lesion. The
Lcx was
severely and diffusely diseased; it had a retroflexed takeoff
with 80%
long segment from the ostium onward followed by ectatic segment,
then
another 60% lesion; the LCx supplies three OM's, the first is
very
proximal originating from the diseased segment and is
substantive
bifurcating with two branches supplying lateral wall.
Collaterals to rca
seen on prior cath are no longer as apparent. The RCA was not
engaged
and known to be chronically occluded from OSH films.
2. Limited resting hemodynamics showed severe systemic
hypertension with
central pressure of 184/91/131 mmHg on nitroglycerin IV gtt.
3. Successful PTCA and stenting of proximal LM into LCx with
2.5x26mm
Integrity bare metal stent, postdilated with 3.5mm Nc Balloon.
STent
placement complicated by spiral dissection in distal Lcx. Final
angiography showed dissection and TIMI 2 flow.
4. Successful PTCA and stenting of LMCA with 4.0x15mm INtegrity
bare
metal stent.
5. Unsuccessful attempt to stent distal spiral dissection as
unable to
deliver stents into LCx.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe systemic hypertension.
3. Successful PCI of proximal LCx with BMS, complicated by edge
spiral
dissection.
4. Successful PCI of LMCA with BMS.
5. Unsuccessful attempt to stent dissection.
6. Continue heparin and Reopro.
7. Continue aspirin and plavix.
[**2183-3-10**] Cardiovascular ECHO [**2183-3-10**] [**Last Name (LF) **],[**First Name3 (LF) **]
Finalized
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %) with global hypokinesis and akinesis of the infero-lateral
segments. No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. There is no aortic
valve stenosis. 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. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2183-3-10**],
LVEF has decreased.
[**2183-3-16**] Radiology SHOULDER 1 VIEW LEFT PO [**Last Name (LF) **],[**First Name3 (LF) **]
M. \
HISTORY: Old left fracture with persistent pain.
FINDINGS: In comparison with study of [**2-3**], there is progressive
healing of
the left proximal humeral fracture. Evidence of prior rotator
cuff repair
with mild widening of the AC joint.
[**2183-3-6**] Radiology CT HEAD W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **]
Approved
IMPRESSION: No intracranial hemorrhage or fracture.
[**2183-3-6**] Radiology CT C-SPINE W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **]
Approved
IMPRESSION: No fracture or malalignment with normal prevertebral
soft tissue thickness.
Brief Hospital Course:
62yoM with CAD s/p CABG [**11/2182**], dCHF, ESRD (on HD [**12/2182**] -
[**2-6**]), history of DVT & PE on Coumadin admitted s/p fall with
worsening respiratory distress in the setting of ARF and new
ischemic MR, who is now s/p stenting to LAD and LCx c/b spiral
dissection of LDx and recurrent MI, and who now has worsening
renal failure requiring initiation of HD.
.
# ISCHEMIC MR/CAD: patient became acutely tachycardic and
hypoxic on the floor, with flash pulmonary edema. He was
monitored in the MICU after this event. The patient's wife
reports she was in the room at the time of the event and the
patient was resting in bed without any triggers for his
tachycardia or dyspnea. He was given diuretics and improved.
Another episode occured several hours later. He had an
echocardiogram that showed ischemic MR affecting the posterior
mitral leaflet and worsening LV function. Cardiology was
consulted and requested transfer to the CCU for further
intervention. Patient was electively intubated in preparation
for possible cardiac cath. Prior CABG records from [**Hospital1 2177**] revealed
that pt has completely occluded RCA and significant disease of
collaterals perfusing the posterior wall. It was decided to
perform cardiac cath to determine whether pt having intermittent
occlusion of coronary artery (e.g. RCA) causing posterior
leaflet dysfunction and posterior wall dysfunction. Prior to
cath, MR [**First Name (Titles) **] [**Last Name (Titles) 91916**] managed with afterload reduction and goal
CVP~8. On [**3-10**] pt had viability study and then underwent cardiac
cath, with stents placed to LMCA and LCx. Procedure c/b spiral
dissection inside the LCx stent. Several balloon angioplasties
were performed at dissection site without success, but as
interim angiography showed reasonable flow in dissected LCx
attempts were aborted and it was decided not to repeat cath as
risks outweigh benefits. MB peaked to 49 and troponin to 0.77
after the dissection. After this, pt went into acute pulmonary
edema several more times (see below), in the setting of becoming
progressively more oliguric and volume overloaded. Repeat TTE
showed [**Month/Year (2) 28495**] EF to 20% and basilar hypokinesis. Pulmonary
edema improved greatly once pt started CVVH with significant
fluid ultrafiltration. Mitral valve replacement was considered,
but per patient and family preference this was ultimately not
pursued. Given EF 20% and basilar hypokinesis, patient was
anticoagulated with heparin gtt (goal PTT 60-80) to decrease
risk of apical thrombus. He also received Plavix 75mg PO daily,
ASA 81mg PO daily, atorvastatin 80mg PO daily and metoprolol
12.5mg PO BID. Hydralazine and isosorbide mononitrate were also
started for afterload reduction (pt was also intermittently on
nitro gtt and esmolol gtt for refractory HTN before starting
CVVH). Lisinopril was initiated on [**3-18**] after CVVH was
initiated.
.
#.ACUTE ON CHRONIC RENAL FAILURE: patient has h/o stage IV CKD
and required HD during prior hospitalization, at the end of
which Cr was 2.9. On admission Cr had risen to 3.9, and pt was
acutely hyperkalemic with anion gap acidosis. Etiology of
worsening renal failure most likely poor forward flow [**2-27**] new
severe ischemic MR [**First Name (Titles) 39849**] [**Last Name (Titles) 28495**] cardiac output. Patient also
had peripheral eosinophilia on admission, making AIN or
cholesterol embolus as possible etiology. Renal U/S showed good
flow to both kidneys with no e/o thrombolembolic events. Patient
was making urine up to the point of cardiac catheterization.
Despite pre- and post-hydration with HCO3, and Lasix during
cath, his creatinine rose significantly in the 48 hours
following cath and he became severely oliguric. He had several
episodes of flash pulmonary edema at this time with suboptimal
response to Lasix, morphine, nitrates and afterload reduction.
Due to these changes he required initiation of CVVH on [**3-12**],
with large ultrafiltrate removal daily and temporary line was
placed by Interventional Radiology. His volume status
subsequently improved greatly, with improved BPs and resolution
of pulmonary edema on CXR. As patient had now progressed to
stage V CKD, decision was made to initiate hemodialysis.
Tunnelled line was placed on [**2183-3-18**].
.
# Leukocytosis likely secondary to c diff colitis: - initial DDx
included infectious versus reactive versus allergic given
eosinophilia. No new medications, but initially considered
allergic interstitial nephritis in context ARF, eosinophilia and
urinary eosinophils. Initially, Mr. [**Known lastname 28221**] was treated for VAP
starting [**3-15**] with Vanc/Zosyn/levaquin. C diff stool assay was
positive, and PO vancomycin was started. After Mr. [**Known lastname 91917**]
cardiogenic pulmonary edema resolved, there were no further
pulmonary infiltrates and VAP therapy was stopped. Furthermore,
Mr. [**Initials (NamePattern4) 91917**] [**Last Name (NamePattern4) 91918**] and decrease in WBC coincided with PO
vanc therapy for c diff. Oral vancomycin was started on [**3-16**] and
will be continued until [**3-31**] for a planned 14 day course.
# AMS: The patient had been delirious with leukocytosis and was
worked up for potential infectious cause of AMS. CT head
following his fall showed no ICH. There were reportedly no new
medication changes. BUN 70s near baseline and not high enough to
cause uremia typically. Renal also felt the patient was not
likely to have uremic encephalitis. Neurology was curbsided
overnight and recommended r/o infection, seizure (given
history), toxic metabolic syndrome. Given the patient's recent
abdominal pain, n/v, initial consideration was given to a
gastrointestinal cause but GI felt this to be unlikely. After
discontinuation of benzodiazepines and initiation of HD, Mr.
[**Known lastname 91917**] mental status began to clear tremendously. He was Alert
and oriented x 3 upon discharge.
# Pain control: During this admission, Mr. [**Known lastname 28221**] complained of
worsening of his baseline back/abdominal and flank pain. Due to
exquisite pain, a left shoulder X ray was obtained on [**3-16**] which
demonstrated a healing proximal humerus fracture. Pain control
improved with starting long acting oxycodone. According to his
outpatient pain specialist he took a total of 240 of oxycodone
at home (including long and short acting medications) in
addition to 30mg morphine (long acting mscontin) at night. Given
his new onset renal failure, we decided to go slow on the
morphine, but at patient's insistence we started PRN IV morphine
for breakthrough pain.
.
# Biliary stent: Mr. [**Known lastname 28221**] is status post stenting of the
biliary duct. CT Abdomen this admission demonstrated stability
of the placement. He should follow up with ERCP for follow up
for this stent as an outpatient.
.
# Depression: Continued home duloxetine at 40mg initially. Due
to concerns for worsening mood, a psych consult was obtained.
They recommended 60mg daily, avoidance of benzodiazepines given
profound altered mental status in the peri-extubation setting,
use of trazodone for sleep (with caution for orthostatic
hypotension), and recommended referral for an outpatient
therapist.
.
# History of DVT/PE: Mr. [**Known lastname 28221**] suffered a provoked perioperative
DVT/PE 6 months prior to admission, and was on warfarin for this
indication. He was continued on anticoagulation for low-EF and
concern for apical hypokinesis and LV thrombus.
.
Transitional Issues:
- needs TSH/LFTs rechecked 6 weeks after discharge as
adjustments have been made to levoxyl while inpatient and his
statin was increased.
- Mr. [**Known lastname 28221**] will need to follow up in psych as an outpatient
following discharge from rehab for evaluation and management of
his chronic depression and anxiety.
- Mr. [**Known lastname 28221**] will need to follow up with ERCP at [**Hospital1 18**] for follow
up of stent placement and possible removal upon discharge from
rehab
- See other f/u appts
Medications on Admission:
Furosemide 120 mg [**Hospital1 **]
- Furosemide 160 mg daily prn shortness of breath or wheezing
- Diltiazem 30 mg tid
- Duloxetine 40 mg daily
- Labetalol 200 mg [**Hospital1 **]
- Levothyroxine 25 mcg daily
- Simvastatin 40 mg qhs
- Aspirin 81 mg daily
- Insulin Lispro sliding scale tid
FBS:
100-150=2U
151-200=4U
201-250=6U
251-300=8U
301-350=10U
- NPH 12 units SC bid
- Warfarin 3 mg daily
- Lidocaine 5% patch daily
- Ativan 1 mg po q6h prn anxiety
- Morphine 30 mg ER q12h
- Hydromorphine 8 mg q4h prn pain
- Niacin 500 mg [**Hospital1 **]
- Zofran 8 mg q8h prn nausea
- Pantoprazole 40 mg [**Hospital1 **]
- Sevelamer 800 mg tid
- B complex-vitamin C-folic acid 1 mg daily
- Camphor-menthol 0.5-0.5 % Lotion qid prn itching
- Trazodone 50 mg qhs prn
- Acetaminophen 325-650 mg po q6h prn
- Polyvinyl alcohol-povidone 1.4-0.6 % [**1-27**] Eye Drops PRN dry
eyes
- Prochlorperazine 10 mg q6h 30 minutes prior to meals
- Miconazole 2 % [**Hospital1 **] prn
- Epoetin alfa 10,000 unit/mL injection qweek
- Cholecalciferol (vitamin D3) 800 units daily
- Calcium carbonate 500 mg tid
- Sodium polystyrene sulfonate 15 g/60 mL Suspension: 30 g PO
bid prn K > 5.5
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day): with
meals.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): continue for at least one month.
9. heparin (porcine) 1,000 unit/mL Solution Sig: 4,000-11,000
units Injection PRN (as needed) as needed for line flush.
10. sodium citrate 4 % (3 mL) Syringe Sig: 1.2-1.4 ml
Miscellaneous ASDIR (AS DIRECTED): Dialysis catheter.
11. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days: last day [**2183-3-30**].
13. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
15. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-27**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
17. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Check INR on [**3-22**] and titrate warfarin to INR 2.0-3.0.
18. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
19. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: before breakfast.
20. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO at
bedtime as needed for back pain.
21. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Three (3)
Tablet Extended Release 12 hr PO Q12H (every 12 hours): pts dose
at home was 240 mg daily (oxycodone PO).
22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
23. heparin (porcine) in NS 2,500 unit/500 mL (5 unit/mL)
Parenteral Solution Sig: 0-[**2171**] units Intravenous continuous:
See weight based protocol attached.
24. Morphine Sulfate 2 mg IV Q4H:PRN pain
Hold for somnulance or RR< 12
25. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center NH/RMU
Discharge Diagnosis:
Acute kidney failure requiring dialysis
Non ST Elevation myocardial infarction
Diabetes
Hypertension
Dyslipidemia
C-difficile
Chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you during your hospitalization at
[**Hospital1 18**].
You had a heart attack and received 2 bare metal stents to
blocked arteries in your heart. You will need to take Plavix
every day for at least one month and possibly longer. Do not
stop taking plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] (at
[**Hospital1 18**]) tells you it is OK. Your heart is weaker after the heart
attack and you have been started on medicines to help the heart
pump better and to prevent blood clots from forming in your
heart. For your heart failure diagnosis: Weigh yourself every
morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 3 day
or 5 lbs in 2 days, follow a low salt diet and restrict your
fluidsto 1500 ml/ day or about 6 cups.
After the cardiac catheterization, your kidneys stopped working
and you were started on dialysis. You will likely need dialysis
for a long time and will need to have permanant access placed in
your arm to get the dialysis. You will have a kidney doctor at
your new dialysis center.
You have an infection in your bowel called c difficile again and
are on vancomycin to treat this.
.
We made the following changes to your medicines:
1. STOP taking lasix, diltiazem, labetolol, compazine, zofran,
miconazole, kayexelate
2.Increase Duloxetine to 60mg daily
3. Increase levothyroxine to 50 mcg as your TSH was low. You
will need to check another TSH in 6 weeks.
4. Change simvastatin to atorvastastin to lower your cholesterol
after your heart attack
5. Change NPH to glargine insulin to be taken before breakfast,
continue the humalog sliding scale according to blood sugars
before meals and at bedtime.
6. Increase warfarin to 5mg daily
7. STOP taking Ativan
8. Cont Epoetin per your nephrologists
9. STOP pantoprazole, take famotidine instead
10. Stop morphine pills, take oxycontin instead to treat your
pain. You are on [**1-27**] your normal dose and will increase slowly.
11. Take morphine intravenously as needed for severe pain
12. Increase trazadone to 100 mg at HS, decrease this medicine
once pain control is better.
.
*please continue to not smoke. quitting smoking is the best
thing you can do for your health.
Followup Instructions:
Dr. [**Last Name (STitle) **]
[**Name (STitle) 5279**] Cardiovascular Consultants
A Department Of [**Hospital 5279**] Hospital
1 [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **], [**Apartment Address(1) **], [**Location (un) 5450**], [**Numeric Identifier 85099**]
Phone: ([**Telephone/Fax (1) 84379**] Fax: ([**Telephone/Fax (1) 91919**]
Date/Time: [**4-1**] at 11:00am
.
Primary care:
Please make an appt with [**Last Name (un) 18908**] family medicine [**Telephone/Fax (1) 91920**]
when pt is leaving rehab. Please stress to pt and family the
importance of keeping all physician [**Name9 (PRE) 32723**] to prevent
rehospitalization.
.
Pain Clinic:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Address: 1 MOUND COURT, [**Location (un) **],[**Numeric Identifier 91921**]
Phone: [**Telephone/Fax (1) 91922**]
Fax: [**Telephone/Fax (1) 91923**]
Monday [**3-31**] at 11:15 AM
.
Gastroenterology:
[**Last Name (LF) **],[**First Name3 (LF) **] B.
[**Hospital Unit Name **], [**Location (un) **]
[**Doctor First Name **]
[**Location (un) 86**] [**Numeric Identifier 718**]
Phone:([**Telephone/Fax (1) 2306**]
Fax:([**Telephone/Fax (1) 23366**]
Completed by:[**2183-3-22**]
ICD9 Codes: 5845, 2762, 2875, 5856, 9971, 2761, 4240, 4280, 3572, 2767, 2724, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 844
} | Medical Text: Admission Date: [**2128-7-14**] Discharge Date: [**2128-7-19**]
Date of Birth: [**2046-11-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
basic trauma for MVC
Major Surgical or Invasive Procedure:
[**2128-7-16**]- ORIF left femur fracture
History of Present Illness:
This patient is a 81 year old male with a history of atrial
fibrillation (on coumadin) and hypertension who was transferred
from [**Hospital 11560**] [**Hospital3 **] with a distal left femur
fracture involving his previous total knee replacement. He was
an unrestrained driver going approximately 30 MPH when he had a
left headlight to left headlight MVC with moderate vehicle
damage. He was brought to [**Hospital 11560**] [**Hospital3 **] complaining
only of left knee pain. He had a head and C-spine CT which were
negative. He had a distal left femur fracture. His INR was 1.7.
His systolic blood pressure varied at the OSH, but remained in
the 80s prior to transfer. En route, his systolic blood pressure
dropped to the 70s. He received 50 of fentanyl and 4 of morphine
prior to transfer, and currently complains only of left knee
pain. He did not have an abdominal CT scan prior to transfer to
[**Hospital1 18**].
Past Medical History:
- Afib on Coumadin
- previous back injury
- HYPERthyroidism
- s/p L TKA
Social History:
lives alone in [**Location (un) 3844**] during the week and works as a
private carpenter and handyman; goes to stay w/dtr and her
family on weekends in [**Location (un) 1475**], MA
Family History:
non-contributory
Physical Exam:
Discharge Physcial Exam:
VS: 98.3 109 116/66 19 997%4L
Gen: alert, occasionally confused but easily orients. NAD
CV: RRR
Pulm: Easy WOB CTAB
Abd: Soft NT ND
Ext: LLE in ACE and knee immobilizer, DP palp bilat
Pertinent Results:
[**7-14**] CT abd/pelvis
IMPRESSION:
1. Multilevel bilateral rib fractures without pneumothorax.
These include at least right anterior second through fifth ribs
and left posterior third through fifth ribs. Probable small
right upper lung pulmonary contusion.
2. No solid organ injury.
3. Angulated mildly impacted left basicervical femoral
fracture.
4. 2.3-cm right thyroid nodule/cyst, to be further assessed by
ultrasound.
5. Chronic interstitial changes in the right lung and mild
bronchiectasis. Bilateral nodular opacities including a 12-mm
nodular opacity in the left upper lobe (2, 32), which could be
correlated with prior CT and if needed, follow up in six months
to one year is recommended.
6. Trace right pleural effusion.
7. Hypodensities in the liver, spleen, kidneys, most of which
too small to fully characterize.
8. Subcentimeter hyperdense lesion in the left hepatic lobe (2,
72), which could represent a small flash-filling hemangioma.
9. Ectatic ascending aorta to 4.5 cm without frank aneurysm.
Diffuse
atherosclerotic disease. No acute vascular injury.
Brief Hospital Course:
Mr. [**Known lastname 112367**] was initially admitted to the trauma ICU for
neurological checks given concern for delayed head bleed. He
remained in the ICU throughout his course, which is summarized
by systems below. In brief, he was taken to the OR for ORIF of
the left femur fracture; did well postoperatively, and is
discharged to rehab on HD 6.
Neuro: He did have some episodes of ICU delirium which were
managed with PRN haldol and seroqeul. Otherwise pain was well
controlled with IV medication that was transitioned to orals as
he began to tolerate PO. His confusion improved during the day
and with reorientation by family.
CV: He was initially hypotensive to the 60's in the ED;
hypotension responsed to IVF initially, and then 2u pRBC. He had
a bedside echo and was started on a phenylephrine drip. He is on
coumadin at baseline for afib; this was held for concern for
head bleed. His INR was reversed with 3u FFP on [**7-15**] in
anticipation of going to the OR for repair of his femur
fracture. He did require pressors immediately postop but these
were weaned off on POD1 and at time of discharge he is
cardiovascuarly stable.
Pulm: He was intubated to go to the operating room for his femur
fracture and remained intubated overnight. He also had a
bronchoscopy during the OR procedure. He was diuresed
postoperatively with albumin and lasix drip. The lasix drip was
transitioned to intermittent lasix and his respiratory status
improved; he was weaned to room air and remained stable.
GI: He was kept NPO until he went to the operating room.
Postoperatively diet was advanced and he tolerated well with no
issues.
GU: A foley catheter was placed in the ED and remained in place
until POD2; at this time it was discontinued and he voided
without difficulty.
Heme: Pt recieved 2u pRBC upon admission. INR was elevated due
to home coumadin; 3u FFP to reverse prior to OR. Postop his Hct
decreased to 21 and he recieved 2u pRBC; his Hct bumped
appropriately to 26 and remained stable throughout the remainder
of his course. Coumadin was restarted on [**2128-7-18**].
MSK: Injuries included bilateral rib fractures (L ribs [**12-25**] and R
ribs [**2-24**]) and fracture of the left femur. Ortho was consulted in
the ED and followed throughout the patient's course. He was
taken to the OR with ortho for ORIF of the femur fracture on
[**7-16**]; for full details please see the dictated operative report.
At discharge he is non-weight bearing on the left lower
extremity with an unlocked [**Doctor Last Name **] brace. Physical therapy did
see him inpt and recommended rehab.
Medications on Admission:
Methimazole 2.5mg PO q48
Coumadin 5mg PO daily
Sotalol 80mg PO AM
Sotalol 40mg PO QPM
Digoxin 0.25mg PO daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever/pain
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Digoxin 0.25 mg PO DAILY
Please draw digoxin level before 2nd dose
4. Docusate Sodium 100 mg PO BID
5. Methimazole 2.5 mg PO Q48H
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
7. Senna 1 TAB PO BID:PRN constipaiton
8. Sotalol 80 mg PO QAM
9. Sotalol 40 mg PO QPM
10. Warfarin 5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA)
home rx
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
bilateral rib fractures
L distal femur fracture
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 ACS service after your trauma.
You may continue to eat a regular diet. You should exercise as
much as possible and continue to ambulate. However, you should
not bear any weight on your L left. You may take tylenol for
pain and narcotic medication as directed. You should also resume
your coumadin.
Followup Instructions:
Follow-up with Orthopedic surgery by [**7-30**] w/ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Please call to make an appointment: [**Telephone/Fax (1) 1228**]
You should follow up with ACS in [**12-22**] weeks after discharge. Call
to make an appointment: [**Telephone/Fax (1) 600**]
Completed by:[**2128-7-19**]
ICD9 Codes: 5180, 2851, 2930, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 845
} | Medical Text: Admission Date: [**2129-4-12**] Discharge Date: [**2129-4-16**]
Date of Birth: [**2052-7-14**] Sex: M
Service: BLOOMGARD
HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old
gentleman with history of coronary artery disease, ischemic
cardiomyopathy, ejection 20 percent, atrial fibrillation,
diabetes mellitus with neuropathy, end stage renal disease on
hemodialysis. The patient was admitted on [**4-7**] to an
outside for failure to thrive and hypotensive. The patient
was found to have a large right pleural effusion at the
outside hospital. He was also hypoxic to the 70s on 6 liters
and thoracentesis revealed [**12-10**] liter of transudative fluid
removed. Patient's oxygenation reportedly improved after
that. At the outside hospital the patient's left upper
extremity antecubital AV fistula was noted to be
nonfunctional and a temporary femoral line was placed for
dialysis. The patient was transferred to the [**Hospital1 346**] for evaluation of fistula, repair
and further medical management. The patient was transferred
to the Intensive Care Unit on the [**Hospital Ward Name 516**] of [**Hospital1 346**] on [**2129-4-12**]. Upon transfer his
systolic blood pressures were marginal in the 70s. Otherwise
the patient was stable and afebrile. The patient was
aggressively dialyzed as well as ultrafiltration by
nephrology and was transferred to the regular internal
medicine floor on [**2129-4-13**].
PAST MEDICAL HISTORY: Coronary artery disease, status post
coronary artery bypass graft times three in [**2099**], [**2112**] and
[**2121**] at [**Hospital 4415**]. Patient underwent
catheterization with no intervention in [**2127-8-10**] at
the [**Hospital1 69**]. In [**2127-8-10**]
transesophageal echocardiogram showed ejection fraction of
about 20 percent, 1+ mitral regurgitation, 2+ tricuspid
regurgitation. Patient reportedly with a chronic right lung
pleural effusion, chronic atrial fibrillation, status post
multiple failed cardioversions. Intermittently
anticoagulated but this was limited by a GI bleed which the
patient has had in the past related to Barrett's esophagus.
Also history of stroke with short term memory loss. History
of falls and syncope. History of sick sinus syndrome with
pacemaker placed DDI. Also diabetes mellitus with neuropathy
and nephropathy. Patient with end stage renal disease on
hemodialysis in [**2126-11-9**] on Monday, Wednesday and
Friday. Also hypothyroidism. Also gout. Also depression.
Also prostatic hyperplasia. Also status post appendectomy.
Also reported restrictive and obstructive lung disease on
home oxygen. Also history of Legionnaire's disease.
SOCIAL HISTORY: Patient lives in [**Hospital3 **]. His wife
is alive but demented. [**Hospital **] health care proxy is one of
his daughters. Remote tobacco history with history of 100
pack years. Alcohol once to twice per week.
ALLERGIES: Cardizem "makes me turn into a puffer fish."
MEDICATIONS ON TRANSFER: Prevacid 30 once a day, Zoloft 20
once a day, Synthroid .75 once a day, Neurontin 300 once a
day, Renagel 800 t.i.d. on Monday, Wednesday and Friday,
Midodrine 10 pre-hemodialysis Monday, Wednesday and Friday.
Digoxin .125, Tums 1,000 mg t.i.d., amiodarone 200 t.i.d.,
Reglan 10 q.i.d., allopurinol 100 q.d., Zebeta 2.5 mg
Tuesday, Thursday, Saturday, Sunday, Coumadin 1 mg q.d. which
had been held at the outside hospital.
PHYSICAL EXAMINATION: On admission temperature 97.1, blood
pressure 89/50, heart rate 60, saturating 97 percent on 4
liters nasal cannula. Patient is an elderly gentleman in no
apparent distress. Lungs with coarse breath sounds
anteriorly. Heart with S1, 2, II/VI systolic murmur.
Patient's abdomen was benign. Skin with decubitus ulcer,
also skin breakdown on right and left upper extremities as
well as right lower extremity. Neuropsychiatric: Patient
responds appropriately and answers questions appropriately
but with poor recall. Alert and oriented times three.
Muscle strength 4 out 5 throughout, decreased sensation to
light touch in bilateral lower extremities.
LABORATORY DATA UPON TRANSFER: White count 6.6, hematocrit
39, platelets 171. Chemistries within normal limits except
for potassium of 5.2, BUN/creatinine 30/5.5, TSH 15, Digoxin
level 2.2.
SUMMARY OF HOSPITAL COURSE: This 76 year-old gentleman with
history of severe coronary artery disease, status post
coronary artery bypass graft, severe congestive heart failure
and cardiomyopathy, pacemaker, diabetes, end stage renal
disease on hemodialysis, transferred from an outside hospital
with a nonfunctioning AV fistula used for dialysis.
Transiently in the Intensive Care Unit for one day for close
monitoring and then transferred to Medicine on [**4-13**].
1. Congestive heart failure: Ejection fraction estimated at
20 percent per echocardiogram in [**2126**]. Patient's Digoxin was
held due to his low blood pressures as well as elevated serum
levels. Patient's serum levels should be monitored and
consider restarting as an outpatient. Renal followed the
patient closely and performed ultrafiltration daily as well
as dialysis three times per week for fluid removal for the
patient's congestive heart failure. The patient's oxygen
saturations remained stable throughout his hospital stay.
Clinically the patient initially with jugular venous
distention and lower extremity edema. However, this improved
with dialysis and ultrafiltration.
2. Blood pressure: Patient with marginal systolic blood
pressure in the 70s to 80s on admission. However, blood
pressure remained in the 90s to 100s throughout the remainder
of his hospital stay. Patient's cortisol was checked and was
within normal limits. Patient's blood pressure remained
stable and tolerated the hemodialysis and ultrafiltration
well. Given the patient's cardiac risk factors we discussed
starting low dose ACE inhibitors as well as beta blocker.
For this patient, however, given his marginal blood pressures
which were very hemodialysis dependent, the patient was not
started on one. Recommend outpatient consideration of
starting low dose ACE inhibitor on beta blocker.
3. Pulmonary: Patient with congestive heart failure as
mentioned above. Also with restrictive lung disease per
report. Patient also with stable transudative pleural fluid
per report. Patient on home oxygen as well. Patient's
oxygen saturation was stable in the mid 90s throughout his
hospital stay on low amounts of oxygen via nasal cannula.
4. End stage renal disease: Patient followed by renal
consult and team and underwent ultrafiltration q.d. as well
as dialysis three times per week which he tolerated well.
Patient's AV fistula was found to be clotted and
interventional radiology attempted to fix this, however, were
unable to. Therefore, patient had a tunneled right internal
jugular dialysis catheter placed for access. Patient was
evaluated by transplant surgery regarding possible fistula
repair or placing a new access site for hemodialysis.
Transplant surgery deferred doing this at this time given the
patient's skin breakdown over the sites that they would want
to do that. Recommend outpatient follow up for possible
access procedure in the future. Patient tolerated renal low
sodium diet well. Patient also with Nephrocaps and phosphate
binders.
5. Dermatology: Patient with skin breakdown on his back,
right shin and bilateral upper extremities. These were
changed with dressings and monitored closely.
6. Atrial fibrillation: Patient's Coumadin was held due to
interventional radiology procedure. Given the patient's
history of GI bleed, patient's Coumadin was continued to be
held at discharge. Defer to outpatient primary care
physician regarding pros and cons of restarting Coumadin with
patient likely to undergo re-access in the future. Patient's
Digoxin was held as mentioned above. Patient was continued
on amiodarone for his atrial fibrillation which he tolerated
well.
7. Coronary artery disease, status post coronary artery
bypass graft most recently in [**2121**]: Patient's cardiac
enzymes negative times three, however, with slightly elevated
troponins likely related to chronic end stage renal disease.
Patient continued on aspirin. Cardiology was consulted
regarding patient's heart issues and stated that the patient
could be a candidate for ICD placement due to his low
ejection fraction. Medical team discussion with patient and
patient decided against this given patient's likely prognosis
due to other comobidities.
8. Diabetes mellitus: Patient maintained on insulin sliding
scale throughout this hospital stay. This was stable.
Continue diabetic diet.
9. Infectious disease: Patient's skin swab from [**4-14**] grew
out methicillin resistant staph aureus and patient was placed
on precautions. No signs of active infection, however.
10. Fluid, electrolytes and nutrition: Patient maintained
on low sodium renal diet. Also proton pump inhibitor.
Patient's stools were guaiaced. Patient's hematocrit
remained stable.
CODE: Code status is full confirmed with the patient as well
as his health care proxy, his daughter. Communication daily
with the patient as well as his daughters.
ACCESS: Peripheral intravenous as well as femoral dialysis
catheter placed at the outside hospital on [**4-11**]. Plan to
discontinue the femoral dialysis catheter once the right
internal jugular tunnel catheter is confirmed to be working
properly.
CONDITION ON DISCHARGE: Fair, at baseline.
DISCHARGE STATUS: To skilled nursing facility.
DISCHARGE DIAGNOSES:
End stage renal disease on hemodialysis.
Coronary artery disease, status post coronary artery bypass
graft.
Congestive heart failure.
Diabetes mellitus.
Depression.
Hypotension.
Pleural effusions.
Hyperlipidemia.
Skin breakdown.
DISCHARGE MEDICATIONS: Pantoprazole 40 once a day,
gabapentin 300 mg once a day, allopurinol 100 q.o.d.,
cevalomir 800 t.i.d., vitamin B, vitamin C, folate,
ranitidine 10 mg 30 minutes prior to dialysis, amiodarone 200
t.i.d., Reglan 10 q.i.d. AC, h.s., aspirin 325 q.d., calcium
carbonate 1,000 t.i.d., senna b.i.d., colace b.i.d.,
bisacodyl p.r.n., insulin sliding scale, Synthroid 75 mcg
q.d., subcutaneous heparin 5,000 q 12 q.d., Lipitor 10 q.d.,
sertraline 50 q.d., polyvinylalcohol 1.4 percent ophthalmic
drops p.r.n., albuterol MDI p.r.n.
FOLLOW UP PLANS: Patient to follow with primary care
physician and hemodialysis as outpatient as scheduled.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 6906**]
MEDQUIST36
D: [**2129-4-15**] 19:05
T: [**2129-4-15**] 20:55
JOB#: [**Job Number 40565**]
ICD9 Codes: 4280, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 846
} | Medical Text: Admission Date: [**2109-3-28**] Discharge Date: [**2109-4-4**]
Date of Birth: [**2043-5-31**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with
a complicated medical history who was transferred from
[**Hospital **] Hospital with renal failure and metabolic acidosis.
He had also complained of odynophagia and difficulty with a
severe feeling of thirst. He was transferred to [**Hospital1 346**] for further management of his
metabolic acidosis.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft 17 years ago with a preserved ejection fraction
as of [**2109-1-7**].
2. Type 2 insulin-dependent diabetes mellitus.
3. Chronic renal insufficiency (with a baseline creatinine
of 2).
4. Cirrhosis of the liver secondary to alcohol (Child class
A)
5. Peripheral vascular disease; status post right-sided
below-knee amputation.
6. Head and neck squamous cell carcinoma; specifically in
the right mandibular region which was diagnosed in [**2105**];
status post radiation therapy.
7. Hypertension.
8. Paroxysmal atrial fibrillation.
ALLERGIES: The patient had no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed heart rate was 104, blood pressure was
94/60, oxygen saturation was 98% on room air, and temperature
was 98, and respiratory rate was 18. In general, the patient
was very agitated and was not cooperative with the
examination. He did not appear to be in acute respiratory
distress. Head, eyes, ears, nose, and throat examination
revealed his pupils were reactive to light. Extraocular
movements were full. Sclerae were muddy and injected. There
was no clear icterus or subungual jaundice. The neck
revealed no jugular venous distention. The lungs were clear
to auscultation anteriorly with decreased breath sounds at
the right posterior base. Heart was irregularly irregular
and tachycardic. Normal first heart sounds and second heart
sounds. There was no third heart sounds or fourth heart
sounds appreciated. A 2/6 systolic murmur at the apex was
appreciated. The abdomen revealed decreased bowel sounds.
Soft, nontender, and nondistended. Liver was palpable four
fingerbreadths below the costal margin. Extremity
examination revealed there was palmar erythema. The patient
was status post right below-knee amputation. There was no
pedal edema on the left. Neurologic examination revealed
awake, alert and oriented times three. There was no facial
droop. The tongue was midline. Extraocular movements were
full. Shoulder shrug was equal, [**4-14**] bilaterally. Grimace
was symmetric. He had left pronator drift. Otherwise, motor
strength was [**4-14**] throughout.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratory findings on admission revealed an arterial blood
gas of 7.10/18/126. White blood cell count was 12.,
hematocrit was 31.7, and platelets were 124. Chemistry-7 was
notable for a potassium of 6.2, bicarbonate was 7, with a
creatinine of 6.9, and glucose was 135. Anion gap was
calculated at 20. AST was 52, ALT was 25, alkaline
phosphatase was 120, and a total bilirubin of 0.3. Creatine
kinase was 1018 on admission. Lactate was 0.8. FENa was
calculated at 0.8%.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram at the time
of admission revealed a rate of 100 and was a normal sinus
rhythm at that time, with normal axis and intervals. There
were no peaked T waves or ST-T wave changes noted.
HOSPITAL COURSE BY ISSUE/SYSTEM: This was a 74-year-old
male with an extensive past medical history who was
transferred to the [**Hospital1 69**] with
severe metabolic acidosis, acute-on-chronic renal failure,
history of Child class A cirrhosis, coronary artery disease,
and type 2 insulin-dependent diabetes mellitus.
1. METABOLIC ACIDOSIS ISSUES: The metabolic acidosis was
felt to be an anion gap acidosis; secondary to either ongoing
alcohol abuse (which was an issue for this patient), or
possibly diabetic ketoacidosis or starvation ketoacidosis.
Diabetic ketoacidosis was not felt to be the leading cause,
as his glucose was never high. Nonetheless, he was insulin
dependent.
His acidosis improved somewhat with aggressive hydration and
nutrition; however, never completely normalized during his
hospital course.
2. CORONARY ARTERY DISEASE ISSUES: The patient ruled in for
a non-Q-wave myocardial infarction and had a transthoracic
echocardiogram showing new regional wall motion abnormalities
with a dyskinetic left ventricle.
He was started on a heparin drip to prevent thrombus.
Coumadin was never stated on the patient.
3. RENAL FAILURE ISSUES: The patient had an acute tubular
necrosis with a FENa that was less than 1%; however, his
creatinine clearance never improved during his hospital stay.
Despite aggressive hydration, and renally dosing medications,
as well as holding ACE inhibitors and angiotensin receptor
blockers, the patient's creatinine never improved. His urine
output continued to deteriorate during his hospital course
and in the Intensive Care Unit prior to his death.
4. RESPIRATORY FAILURE ISSUES: During his hospital course,
the patient had hypoxic respiratory failure requiring
intubated and was also quite difficult to ventilate;
requiring the use of paralytics.
The patient's respiratory course was complicated difficulty
clearing secretions by the patient as well as
hospital-acquired pneumonia. Sputum cultures did grow out
Staphylococcus aureus, and the patient was covered with
appropriate antibiotics.
5. ATRIAL FIBRILLATION ISSUES: The [**Hospital 228**] hospital
course was also complicated by atrial fibrillation with a
rapid ventricular response; requiring atrioventricular nodal
blockade with a calcium channel blocker or a beta blocker.
6. DISSEMINATED INTRAVASCULAR COAGULATION ISSUES: The
patient did have disseminated intravascular coagulation
toward the end of his hospitalization; presumably secondary
to profound infection.
On the day prior to his death, his urine output continued to
be very marginal after aggressive fluid hydration. His
maximum urine output was only 40 cc per hour. Sediment
continued to reveal a muddy brown cast consistent with acute
tubular necrosis; however, his FENa was always less than 1%.
His heart rate decreased to the 40s and 50s on the afternoon
prior to his death; showing a sinus arrhythmia and
ventricular escape beats. There were no ST elevations. His
electrolytes were repleted at that time.
His overall prognosis was extremely poor because of his renal
failure and sepsis which was complicated by disseminated
intravascular coagulation. This was communicated to Mrs.
[**Known lastname 41304**], the [**Hospital 228**] health care proxy, who stated that Mr.
[**Known lastname 41304**] would not have wanted extensive life support. His
wife agreed to withdrawing care on [**2109-4-3**], and she
stated that he would not have wanted an autopsy done. On
[**2109-4-4**], the patient expired.
DISCHARGE DIAGNOSES:
1. Renal failure.
2. Pneumonia.
3. Heart failure.
4. Head and neck squamous cell carcinoma.
5. Coronary artery disease.
6. Congestive heart failure.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 8167**]
MEDQUIST36
D: [**2110-3-13**] 14:05
T: [**2110-3-14**] 19:26
JOB#: [**Job Number 41305**]
ICD9 Codes: 5845, 2762, 2765, 486, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 847
} | Medical Text: Admission Date: [**2184-4-17**] Discharge Date: [**2184-4-21**]
Date of Birth: [**2100-2-6**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
R sided weakness with aphasia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Patient is a 84 yo right handed walker-dependent women for
frequent falls who lives in a nursing home with hx of prior ICH
(location unclear) in [**2182**] here from [**Hospital 1110**] Hospital after
presenting with aphasia and R sided weakness found to have L
IPH.
Hx obtained per daughter who was with the patient given that
patient unable to express herself. Per daughter, patient had
dinner at the daughter's house and was attending her grandson's
acapella concert around 7pm. While the daughter was getting the
tickets, she walked ahead with her walker and when the daughter
looked after buying the tickets, she noticed that a passerby was
assisting her mom who seemed to be leaning to the R. She did
not
fall but she was not able to speak. They grabbed a chair nearby
and sat her down and just dragged the chair to the daughter's
car
who transported the patient to a hospital in [**Location (un) 1110**].
While at [**Location (un) 1110**], she was reported to have R sided weakness with
aphasia. Her BP was in 160's/80's and head CT revealed 2X2cm L
IPH with some ventricular extension hence patient was
transferred
here for further care.
The daughter does not recall the patient complaining of any
headache or nausea. Patient seems to deny having any HA or
nausea currently but difficult to assess the extent of her
comprehension. Per nursing home, patient walks with a walker at
baseline and has mild dementia but is quite oriented at
baseline.
She is called the "secretary of her [**Doctor Last Name 7594**] [**Doctor Last Name **]/nursing home."
The nursing home and the HCP (another daughter) confirms that
patient is DNR/DNI. Also, she was recently diagnosed with UTI
and started on Amoxicillin yesterday. ROS negative otherwise.
Repeat head CT here (10:30pm) compared to [**Location (un) 1110**] (~8pm) appears
to be without significant change.
Past Medical History:
1. ICH in [**2182**] - ?base of the brain
2. Dementia
3. Hypercholesterolemia
4. GERD
5. hx of pulmonary edema (?)
Social History:
Lives in nursing home and ambulates with the walker.
Daughter [**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 6382**] is HCP ([**Telephone/Fax (1) 86736**]) and is DNR/DNI.
Remote smoking hx - quit before [**2129**]. No EtOH. Used to work
for
the phone company.
Family History:
Three daughters - all healthy.
Physical Exam:
T 98.3 BP 180/99 HR 68 RR 18 O2Sat 96% RA
Gen: Comfortable appearing, smiling 84 yo woman, NAD.
HEENT: No signs of trauma.
Neck: No carotid or vertebral bruit
CV: RRR and no murmurs/gallops/rubs
Lung: Clear anteriorly
Abd: +BS, soft, nontender
Ext: Venous stasis skin changes esp. RLE. No edema.
Neurologic examination:
Mental status: Awake and alert, oriented to self. Non-fluent
speech but repetition intact. Although follows simple commands
including open/closing eyes, sticking tongue out, showing thumb
and wiggling toes, difficult to assess extent of comprehension.
Appears to have R/L confusion. Unclear about apraxia whether
its
comprehension or apraxia.
Cranial Nerves:
II: Pupils small but reactive (1.5 -> 1mm). Blinks to visual
threat bilaterally.
III, IV & VI: Extraocular movements intact bilaterally, no
nystagmus.
V: Reports R/L difference to LT but unclear how.
VII: R facial droop - less evident with natural smile.
XII: Tongue midline, movements intact
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. Severe R pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF
R 5- 5 5 5 5 5 5- 5- 5 5 5
L 5- 5 5 5 5 5 5 5 5 5 5
Sensation: Appears to have R/L asymmetry to LT and cold but
extent is unclear.
Reflexes:
+2 and symmetric throughout except for dropped ankle jerks.
R toe mute but upgoing on L.
Coordination and Gait: Deferred.
Pertinent Results:
[**2184-4-17**] 09:20PM WBC-7.6 RBC-4.86 HGB-14.6 HCT-43.9 MCV-90
MCH-30.0 MCHC-33.2 RDW-13.3
[**2184-4-17**] 09:20PM NEUTS-55.3 LYMPHS-33.2 MONOS-6.8 EOS-3.2
BASOS-1.4
[**2184-4-17**] 09:20PM PLT COUNT-330
[**2184-4-17**] 09:20PM PT-11.8 PTT-24.8 INR(PT)-1.0
[**2184-4-18**] 12:25AM URINE RBC-0-2 WBC-[**7-15**]* Bacteri-RARE Yeast-NONE
Epi-0
[**2184-4-17**] EKG:
Sinus rhythm. Left ventricular hypertrophy with secondary
repolarization changes.
[**2184-4-17**] CT HEAD W/O CONTRAST:
1. Unchanged left parenchymal hemorrhage centered in the
thalamus, with
increased surrounding edema.
2. Unchanged intraventricular hemorrhage and ventricular
enlargement.
[**2184-4-18**] Chest X-Ray:
No pneumonia is seen.
[**2184-4-18**] CT Head W/O Contrast:
Motion degraded study which reveals no new intracranial
abnormalities at this time.
[**2184-4-20**]: Chest X-ray:
In comparison with study of [**4-18**], there are lower lung volumes
but
otherwise little change.
[**2184-4-20**]: CHEST (PA & LAT):
No significant change.
Brief Hospital Course:
Assessment and Plan at admission: In summary, patient is a 84 yo
RHW with mild dementia and hx of prior CNS hemorrhage here with
sudden onset of leaning to the
R and aphasia without any trauma found to have L intracerebral
hemorrhage with some ventricular extension. Patient has severe
aphasia but intact repetition. Appears to follow simple motor
commands but extent of comprehension difficult to assess. Mild
R
facial droop and appears to have R sided sensory deficit.
Weakness if difficult to detect but has marked R pronator which
appears to be from sensory deficit rather than [**Last Name **] problem.
Given the location of the bleed (L BG) and no evidence/report of
trauma, most likely hypertensive hemorrhage versus amyloid.
Although no significant change since OSH imaging, will need to
admit to ICU for close observation.
RECS:
1. Admit to ICU under Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] with telemetry.
2. Maintain SBP < 160 and HOB > 30 degrees.
3. Keep NPO overnight.
4. DVT PPX with pneumo boots.
5. STAT head CT if change in exam.
6. Follow-up on labs including UA - may need to start on
ceftriaxone if +UTI.
7. Further rec's to follow in the morning
Hospital Course:
#Neuro:
Patient admitted to ICU for close monitoring. Head CT on
admission showed unchanged left parenchymal hemorrhage centered
in the thalamus, with increased surrounding edema, and unchanged
intraventricular hemorrhage and ventricular enlargement. Repeat
head CT the following morning showed no new intracranial
abnormalities.
Neuro exam notable for being awake, alert, spontaneous language,
able to repeat with paraphasic errors, able to follow most
simple commands, occasional word finding difficulties, right
sided inattention/neglect, ? right sided field cut/inattention,
moves all extremeities well.
Transferred to floor on [**4-19**]. PT and OT evaluation recommended
rehab.
Speech eval recommended intensive speech therapy services for
her aphasia.
ASA was placed on hold during this hospital stay. Plan is to
restart ASA 325 mg daily on [**2184-4-24**].
Neuro exam at dishcarge was significant for:She remained
aphasic. Able to name some objects and to repeat with paraphasic
errors. Questionable decreased blink to threat on R that was
(inconsistent), Right-sided extremitities spastic, strength
ranging 4 -4+, toes upgoing
#Resp:Oxygen requirement throughout hospital stay: 2LNC.
Repeated chest x-rays showed no signs of pneumonia
#ID: Started on ciprofloxacin on admission for presumed UTI with
positive UA. Urine culture negative. Cipro continued as of day
of discharge
#CVS: Optimized BP managment. increased dose of metoprolol
#F/E/N: Started on NG Tube feeds in the ICU. Swallowing eval on
[**4-19**] suggest she should continue primary nutrition via feeding
tumbe, begin small amounts of honey thick liquids by tsp and
pureed solids, 1:1 supervision for all po intake, Q4 hr oral
care. Repeat swallow eval recommended upgrade to nectar thick
liquids and ground solids, alternate bites and sips, q6 oral
care.
#Prophylaxis:DVT prophylaxis with subQ heparin/GI prophylaxis
with pantoprazole
#Code status:DNR/DNI
Medications on Admission:
1. Aricept 10mg bedtime
2. Simvastatin 40mg daily
3. ASA 325mg daily
4. Prilosec 20mg daily
5. Ca2+/D 500 daily
6. Fe2+ 325 daily
7. Vitamin C 500 daily
8. Amoxicillin - started [**4-16**] for UTI
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): FOR DVT PROPHYLAXIS AS INPATIENT.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day:
***NOTE: HOLD ASA UNTIL [**2184-4-24**]. [**Month (only) **] RE-START ASA ON [**2184-4-24**]***.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Ciprofloxacin 100 mg Tablet Sig: Four (4) Tablet PO once a
day for 4 days: 400 mg PO/NG daily for 4 days.
7. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
left sided intracerebral hemorrhage
Discharge Condition:
Neuro exam at dishcarge was significant for: She remained
aphasic. Able to name some objects and to repeat with paraphasic
errors. Questionable decreased blink to threat on R that was
(inconsistent), Right-sided extremitities spastic, strength
ranging 4 -4+, toes upgoing
Discharge Instructions:
You were admitted with a left sided intracerbral hemorrhage.
You have had diffculty expressing yourself verbally. After
evaluation, you have required feeding through a nasogastric tube
as well as small amount of food by mouth. You have been
evaluated by physical and occupational therapy as well. You are
being transferred to a rehabilitation hospital for intensive
speech therapy, further swallowing evaluation, and intensive
physical and occupational therapies.
During your hospital stay, your aspirin was held. You should
restart you aspirin on [**2184-4-24**].
Please follow-up with neurology as listed below.
Should you develop any symptoms as listed below or concerning to
you, please call your doctor or go to the emergency room.
Followup Instructions:
Neurologist: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2184-6-9**] 2:00 LOCATION: [**Hospital1 18**]
***Note: Before this appointment, you need your PCP send [**Name Initial (PRE) **]
referral to Dr.[**Name (NI) 34043**] office. Also, you must have someone
call registration at [**Hospital1 18**] on your behalf at [**Telephone/Fax (1) 10676**] before
you can be seen for this follow-up visit.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2184-4-21**]
ICD9 Codes: 431, 5990, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 848
} | Medical Text: Admission Date: [**2156-9-19**] Discharge Date: [**2156-9-27**]
Date of Birth: [**2095-5-7**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides) / Percocet
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Fever, neutropenia, and swollen, painful left elbow
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
61-year-old right-handed woman with glioblastoma multiforme, s/p
subtotal resection on [**2156-7-2**], involved-field cranial XRT, and
chemotherapy (last taken on [**2156-9-10**]). She developed a fever to
102 F, hypotension to SBP 90s today, and came to our emergency
room. Husband first noted left elbow 3-4 weeks ago which
resolved in 2 days after application of neosporin (there was a
question of spider bite). Then 3 days ago she noted erythema
which increased and associated with increasing edema and
tenderness. Today, the patient was practically unable to move
elbow due to pain. She experienced fever and chills that began
yesterday, but she did not take her temperature. Her Review of
System is notable for a new dry cough x 6 days. She also
developed diarrhea but stopped 3 days ago when she stopped
taking Colace. She has fatigue but no SOB, congestion,
abdominal pain, dysuria, bright red blood per rectum, or melena.
There was no trauma to elbow. There was no recent sick
contacts or travel.
Regarding her oncologic history, her symptoms began in late [**Month (only) 205**]
[**2155**] with headache, word-finding difficulties, memory loss, and
confusion. She was found to have a left parietal brain lesion.
After subtotal resection on [**2156-7-2**], underwent involved-field
XRT with concurrent temozolomid. She also received 1 treatment
with CyberKnife radiosurgery to an enhancing lesion in the right
occipital lobe, together with temozolomide.
In the emergency room, her temperature was 102.6 F, HR 130s
(sinus tachycardia), and systolic BP 90s-100s (baseline SBP
120s-130s). Her WBC was 0.3 with no neutrophils or bands. Her
U/A showed no WBC but there was nitrates and bacteria. Her
serum lactate was 3.9. Blood and urine cultures were sent. Her
chest CTA was negative for pulmonary embolism, but there was
mild left lung apical patchy ground-glass opacity; there was a
question of atelectasis versus pneumonia. She received oxygen
at 7 liters via nasal cannula in the emergency room but her
systolic BP persisted in 90s-100s. Emergency Department did not
start on sepsis protocol because her serum lactate was not > 4
and she was responsive to fluid, despite the elevated
temperature, heart rate, and WBC.
Past Medical History:
Glioblastoma multiforme of left temporoparietal lobe
Anxiety
Social History:
Never smoked, drinks alcohol on rare occasions. Lives with
husband. Worked as secretary.
Family History:
Father had lung cancer. Mother had [**Name (NI) 2481**] disease. Her
siblings are all healthy. She has 1 son and 1 daughter, and
both of them are healthy.
Physical Exam:
Physical Examination:
Vital Signs: Temperature 102.6 F in Emergency Department;
Current Temperature 100.2 F; Heart Rate 108; Blood Pressure
106/56; Respiratory Rate 16; Oxygen Saturation 99% on 2 Liters.
Gen: Cushingnoid faced woman, fatigued appearing, otherwise in
no acute distress lying in bed
HEENT: PERRLA, EOMI, anicteric, pale conjunctival membranes, dry
mucous membranes, +scars on scalp from prior neurosurgery
Neck: No LAD
CV: RRR tachycardic, nl S1, S2 no m/r/g
Pulmonary: CTA bilaterally
Abdomen: NABS, soft, NT/ND, well-healed vertical [**Doctor First Name **] incision
Extremities: LUE elbow has 5-cm area of erythema, warmth, mild
fluctuance, and tenderness to palpation. She is unable to
abduct at elbow more than 5 degrees secondary to pain. Her
lower extremities are cool, without c/c/e. She has 2+ dorsalis
pedis pulses bilaterally
Neurologic Examination: Her mental status is intact. She is
awake, alert, and oriented x 3. Her language is fluent with
good comprehension. CN II-XII are intact. Her motor strength
is [**4-15**] motor in RUE; LUE examination limited due to pain at
elbow. In the lower extremities, she has 4-/5 strength
bilaterally at thigh flexors, 5/5 strength at quadriceps,
hamstrings, foot dorsiflexion, and plantar flexion. Her
reflexes are 2- but her ankle jerks are absent. She has
downgoing toes. Sensory examination reveals normal sensory
examination. Coordination examination does not reveal
dysmetria. Her gait is steady. She does not have a Romberg.
Pertinent Results:
[**2156-9-19**] 12:10PM WBC-0.3* RBC-4.61 HGB-14.8 HCT-41.3 MCV-90
MCH-32.1* MCHC-35.8* RDW-13.9
[**2156-9-19**] 12:10PM NEUTS-0* BANDS-0 LYMPHS-65* MONOS-35* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2156-9-19**] 12:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-OCCASIONAL
[**2156-9-19**] 12:10PM PLT SMR-LOW PLT COUNT-140*
[**2156-9-19**] 12:10PM PT-13.5* PTT-24.5 INR(PT)-1.2
[**2156-9-19**] 12:10PM SED RATE-70*
[**2156-9-19**] 12:10PM GLUCOSE-114* UREA N-14 CREAT-0.6 SODIUM-138
POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
[**2156-9-19**] 12:10PM ALT(SGPT)-35 AST(SGOT)-22 ALK PHOS-88 TOT
BILI-0.6
[**2156-9-19**] 01:05PM LACTATE-3.9*
[**2156-9-19**] 01:07PM CK-MB-NotDone cTropnT-<0.01
[**2156-9-19**] 01:07PM CRP-67.5*
[**2156-9-19**] 01:07PM CK(CPK)-11*
[**2156-9-19**] 02:08PM URINE RBC-0 WBC-0 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2156-9-19**] 02:08PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-9-19**] 02:08PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023
L elbow Xray [**2156-9-19**]: Four radiographs of the left elbow
demonstrate no joint effusion. No fracture. No cortical
fragmentation to suggest osteomyelitis. Regional soft tissues
are unremarkable.
IMPRESSION:
Unremarkable radiographs, left elbow.
MRI of L elbow: MR LEFT ELBOW WITHOUT CONTRAST: There is a
moderate elbow joint effusion. The bone marrow appears normal in
signal intensity characteristics. There is circumferential edema
within the subcutaneous tissues about the elbow. There is fluid
signal intensity in the region of the olecranon bursa,
suggestive of bursitis. There is more confluent high signal
intensity surrounding the musculature at the elbow joint. It is
not clear if this represents dense edema or frank fluid, as this
study is limited without intravenous contrast. Also noted is
diffuse increased signal intensity within the musculature about
the elbow, suggestive of myositis.
IMPRESSION:
1. Moderate elbow joint effusion.
2. Diffuse increased signal intensity within the musculature
about the elbow, consistent with nonmyositis.
3. Olecranon bursitis.
4. Edema within the subcutaneous tissues about the elbow,
suggestive of cellulitis.
CT OF THE CHEST: There are no significant axillary, mediastinal,
or hilar lymph nodes. There is a small hypodense area in the
left lobe of the thyroid measuring 1.2 x 0.8 cm. Ultrasound
could be performed for further evaluation.
There is no pericardial effusion. The heart is of normal size.
The great vessels are unremarkable. There is no evidence of
aortic dissection. There is fluid in the pericardial recess
anterior to the aorta, which is unchanged when compared to prior
study. The pulmonary artery is normal size. There are no filling
defects in the pulmonary artery branches. There is no evidence
of pulmonary embolism. The airway is patent to level of
subsegmental bronchi. There are subsegmental atelectasis in the
right middle lobe and lower lobes. There are emphysematous
changes in the lungs. There is a patchy ground-glass opacity in
the left upper lobe near the apex that is new when compared to
the prior study and of unclear significance. It most likely
represents an area of pneumonia. There are no pleural effusions.
Limited images of the upper abdomen do not reveal significant
abnormality.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Emphysema.
3. Subsegmental atelectasis.
4. Small patchy ground-glass opacity in the left apex of unknown
clinical significance. It could representa small focus of
pneumonia. It is new when compared to the prior study from [**6-30**], [**2155**]. Attention on follow to confirm resolution is
recommended.
EKG [**2156-9-25**]: Sinus tachycardia
Modest diffuse nonspecific ST-T wave abnormalities
Since previous tracing of [**2156-9-19**], sinus tachycardia rate
slower and ST-T wave abnormalities are less prominent
[**2156-9-26**] 1:20 pm SWAB Source: Left elbow bursa pus.
**FINAL REPORT [**2156-10-5**]**
GRAM STAIN (Final [**2156-9-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2156-9-30**]):
STAPH AUREUS COAG +. RARE GROWTH.
Please contact the Microbiology Laboratory ([**6-/2457**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
ANAEROBIC CULTURE (Final [**2156-10-5**]): NO ANAEROBES ISOLATED.
BCX [**2156-9-19**]: No growth (final)
BCX [**2156-9-20**]: No growth (final)
Brief Hospital Course:
This is a 61-year-old woman with glioblastoma multiforme, s/p
involved-field XRT, surgery, involved-field cranial irradiation,
and chemotherapy presented with neutropenic fever, left elbow
bursitis/cellulitis, UTI, and possible pneumonia on chest CT.
1. Neutropenic Fever/Hypotension: In the [**Hospital Unit Name 153**], the patient was
aggressively fluid resuscitated, and her blood pressure
responded without any pressor. Sources of infection included
left elbow bursitis/cellulitis, pneumonia, and UTI. In the
setting of neutropenic fever, the patient was started on broad
spectrum antibiotics with vancomycin, ceftazidime, and
azithromycin (for atypical pneumonia), as well as gentamicin x 1
dose in context of continued destabilization and need for double
gram negative coverage. Central venous pressure improved to
[**6-23**] over the course of 48 hours, and blood pressures
stabilized. Patient had no more fever. Patient received stress
dose steroids as well as Neupogen. Orthopedics was consulted
for her left elbow bursitis/cellulitis. X-ray and MRI did not
reveal osteomyelitis. Orthopedics felt that possible bursitis;
however, symptoms improved with antibiotics.
On transfer to the OMED service, the patient was afebrile and
hemodynamically stable. She was continued on Neupogen,
vancomycin, ceftazidime, and azythromycin. On [**2156-9-23**], given
her enterococcal UTI is pansensitive and the patient no longer
neutropenic, vancomycin and ceftazidime were discontinued and
cefazolin IV was started to cover both enteroccocus and left
elbow cellulitis. Neupogen was discontinued on [**2156-9-24**].
Azythromycin was discontinued after completion of 7 day course
on [**2156-9-26**]. Also, on [**2156-9-26**], the left elbow had increased
warmth and erythema as well as enlargement of fluid sac. Also,
patient's WBC increased despite the discontinuation of Neupogen
was disproportionately high with a presence of dohl bodies and
toxic granulations on smears suggestive of undertreated or
persistant infection. Thus, cefazolin was discontinued, and
vancomycin was restarted on [**2156-9-26**]. The left elbow responded
well to vancomycin and the fluid sac broke open spontaneously,
draining pus. The patient had a PICC line placed in her right
arm and was discharged with 10 more days of vancomycin to finish
a 2 week course.
2. Hypoxia: The paitnet required O2 supplement temporarily. CXR
showed small bilateral pleural effusions and atelectasis. With
incentive spirometry use, the patient's sat improved to 95% on
RA.
3. Glioblastoma Multiforme: Chemotherapy was held. Continued on
Keppra and Decadron. Given on steroids, FS blood glucose was
checked 4 times daily and they were mostly in the 100's, not
requiring a long acting insulin.
4. Transaminitis: She had elevated AST and ALT from [**2156-7-12**].
Rechecked and was normal.
5. Anxiety: Lorazepam prn helped.
6. Prophylaxis: Sliding scale insulin and finger stick blood
glucose given on steroids; PPI, subcutaneous heparin, and bowel
regimen were administered as well.
7. FEN: Regular diet
8. Full code: Patient does not want prolonged intubation if
M.D.s think poor recovery.
Medications on Admission:
Decadron 4 mg p.o. TID
Keppra 1000 mg p.o. [**Hospital1 **]
Protonix 40 mg p.o. [**Hospital1 **]
Colace 100 mg p.o. [**Hospital1 **]
Lorazepam 1 mg p.o. p.r.n.
Percocet 1-2 tablets p.o. p.r.n.
G-CSF 300 mcg x 10d, started 2d ago
Pentamidine, aerosolized
Temodar chemotherapy
Discharge Medications:
1. Saline Flush 0.9 % Syringe Sig: Five (5) ml Injection SASH as
needed for flushing for 10 days.
Disp:*qs for 10 days * Refills:*0*
2. Heparin Flush 100 unit/mL Kit Sig: Three (3) ml Intravenous
SASH as needed for iv abx therapy for 10 days.
Disp:*qs for 10 days * Refills:*0*
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous Q
12H (Every 12 Hours) as needed for for cellulitis/bursitis for
10 days.
Disp:*qs for 10 days gm* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Left elbow bursititis/cellulitis
Urinary tract infection
Dehydration
Glioblastoma multiforme
Discharge Condition:
Afebrile, no longer neutropenic, improved left elbow and feeling
good.
Discharge Instructions:
Return to the emergency department or call Dr. [**Last Name (STitle) 724**] if you
develop fever, chills, nausea, vomiting, worsening pain or
redness in your left elbow, chest pain, shortness of breath, or
any other concerning symtpoms.
Take your medications as instructed.
Keep your follow up appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-10-11**]
12:15
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2156-10-11**]
2:00
ICD9 Codes: 0389, 486, 5180, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 849
} | Medical Text: Admission Date: [**2101-6-27**] Discharge Date: [**2101-7-4**]
Date of Birth: [**2026-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Severe epigastric burning - Ruled in for NSTEMI
Major Surgical or Invasive Procedure:
[**2101-6-30**]
Coronary artery bypass grafting x3 with left internal mammary
artery to left anterior descending artery and reverse saphenous
vein graft to the first obtuse marginal artery and the distal
circumflex artery.
History of Present Illness:
74 year old male with presented to the OSH with severe
epigastric burning, improved with sublingual nitroglycerin. He
was ruled in for NSTEMI with + troponin (2nd set 1.24, 3rd set
2.0 on Sat PM). Reportedly chest pain free
since admission to the OSH. He is transferred to [**Hospital1 18**] for
cardiac catheterization and found to have coronary artery
disease. He was referred to cardiac surgery for
revascularization.
Cardiac Catheterization: Date:[**2101-6-27**] Place:[**Hospital1 18**]
LMCA: non obstructed
LAD: severe ostial stenosis then tapered proximal lesion
LCX: severe OM1 and OM2, dominant
RCA: occluded
Past Medical History:
Hypertension
Hyperlipidemia
Rhabdomylosis [**1-5**] statin
GERD
CAD s/p cath in [**2074**] with "2 blockages", denied angioplasty or
stent, ? MI in the past with stents, details unclear
Past Surgical History:
s/p appendectomy
s/p Hernia repair
Social History:
- widower, works as a chef, lives alone
- 2 daughters
- [**Name (NI) 1139**] history: 1 ppd x ~ 50 years, still currently smoking,
[**9-14**] cigarettes/day
- ETOH: rare
- Illicit drugs: denies
- daughter [**Name (NI) **] is health care proxy and coming up
- independent of ADLs
- exercise: walks for exercise
Family History:
Family History:Father deceased at 58 from MI and Daughter 29
with
SVT and AF
Physical Exam:
Pulse:62 Resp:18 O2 sat:99/RA
B/P Right:124/60 Left:119/59
Height:5'9" Weight:170 lbs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI []
Neck: Supple [X Full ROM [X
Chest: Lungs clear bilaterally [X
Heart: RRR [X Irregular [] Murmur [] grade ______
Abdomen: Soft [X non-distended [X non-tender [X bowel sounds +
[]
Extremities: Warm [X] well-perfused [X] Edema [X] _____
Varicosities: None [x]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: P Left:P
DP Right:P Left:P
PT [**Name (NI) 167**]:P Left:P
Radial Right:P Left:P
Carotid Bruit Right: Left:
Pertinent Results:
[**2101-6-27**] 04:15PM BLOOD Glucose-135* UreaN-17 Creat-0.9 Na-135
K-3.9 Cl-102 HCO3-23 AnGap-14
[**2101-6-27**] 04:15PM BLOOD CK-MB-3 cTropnT-0.11*
[**2101-6-28**] 08:30AM BLOOD CK-MB-3 cTropnT-0.13*
[**2101-6-29**] 08:10AM BLOOD CK-MB-14* MB Indx-8.0* cTropnT-0.13*
[**2101-6-28**] 08:30AM BLOOD Triglyc-183* HDL-41 CHOL/HD-5.7
LDLcalc-157*
[**2101-6-27**] 04:15PM BLOOD %HbA1c-5.8 eAG-120
[**2101-7-4**] 10:45AM BLOOD Hct-32.1*
[**2101-7-3**] 07:05AM BLOOD WBC-9.9 RBC-3.14* Hgb-9.6* Hct-27.7*
MCV-88 MCH-30.7 MCHC-34.8 RDW-14.1 Plt Ct-172
[**2101-7-4**] 10:45AM BLOOD UreaN-21* Creat-0.9 Na-137 K-4.4 Cl-100
[**2101-7-3**] 07:05AM BLOOD Glucose-132* UreaN-18 Creat-0.9 Na-136
K-3.8 Cl-100 HCO3-26 AnGap-14
[**2101-7-2**] 07:40AM BLOOD Glucose-136* UreaN-12 Creat-1.0 Na-139
K-3.8 Cl-101 HCO3-28 AnGap-14
[**2101-6-30**] Echo
LEFT ATRIUM: Marked LA enlargement. Good (>20 cm/s) LAA ejection
velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Mildly dilated
descending aorta. Simple atheroma in descending aorta. No
thoracic aortic dissection.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild to moderate ([**12-5**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Mild PR.
Conclusions
PRE-CPB:
The left atrium is markedly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. 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
simple atheroma in the descending thoracic aorta. No thoracic
aortic dissection is seen.
The aortic valve leaflets (3) are mildly thickened. Mild (1+)
central aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-5**]+) mitral regurgitation is seen.
POST-CPB:
LV systolic function remains normal, estimated EF>55%.
The MR [**First Name (Titles) **] [**Last Name (Titles) 7968**] to mild. There is no evidence of aortic
dissection.
Brief Hospital Course:
74 y/o M with history of HTN, Hyperlipidemia, and CAD s/p PCI in
[**2074**] who initially presented to OSH on Friday night with severe
epigastric burning. Ruled in for MI with troponins of 1.24 and
2.0. with no EKG changes and was found to have 3VD on cath and
was referred for CABG. The patient was brought to the operating
room on [**2101-6-30**] where he underwent Coronary artery bypass
grafting x3 with left internal mammary artery to left anterior
descending artery and reverse saphenous vein graft to the first
obtuse marginal artery and the distal circumflex artery. See
operative note for full details. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. He did have some
issues with nausea/ vomiting on POD2 and KUB revealed scattered
air within non-dilated loops of large and small bowel and no
evidence of bowel obstruction. He was given multiple bowel
medications with subsequent bowel movements and resolution of
symptoms. The patient was transferred to the telemetry floor for
further recovery. He was restarted on half his home dose
Zestril with SBP100-130 and he was not started on a statin due
to a history of rhabdomyolysis with Lipitor. PCP to determine
if/when he should start an alernative statin. Chest tubes were
removed POD#4 (left in longer due to serous drainage) and CXR
showed questionable loculated left pneumothorax. Follow up
lateral decub CXR showed no pneumothorax. Pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to [**Location (un) 582**] at
[**Location (un) **] in good condition with appropriate follow up
instructions.
Medications on Admission:
- metoprolol 25 mg [**Hospital1 **]
- omeprazole 25 mg daily
- Ambien 10 mg qHS prn
- ASA 81 mg
Discharge Medications:
1. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 HR<60. Tablet(s)
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
10. Zestril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP<100.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]
Discharge Diagnosis:
primary diagnosis:
non-ST elevation myocardial infarction
coronary artery disease
secondary diagnosis:
hypercholesterolemia
hypertension
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 Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
[**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Surgeon: Dr. [**Last Name (STitle) **] on [**7-28**] at 1 PM in the [**Hospital **] medical
office building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 8725**] on [**2101-8-12**] at 2:40 PM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 69074**] in [**3-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2101-7-4**]
ICD9 Codes: 4019, 2859, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 850
} | Medical Text: Admission Date: [**2191-8-23**] Discharge Date: [**2191-8-27**]
Date of Birth: [**2151-6-25**] Sex: M
Service: CA/TH [**Doctor First Name 147**]
CHIEF COMPLAINT: Occasional palpitations with no shortness
of breath or dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: The patient was diagnosed at the
age of 30 with a murmur. The patient had been followed by
echocardiogram and exercise tolerance test serially over the
past decade.
PAST MEDICAL HISTORY:
1. Mitral regurgitation.
2. Hemorrhoids.
3. Old fracture of left wrist.
PAST SURGICAL HISTORY:
1. Sinus surgery in 06/99.
2. Lumbar disk resection in [**2186**].
3. Vasectomy in [**2183**].
4. Revision of vasectomy in [**2187**].
ADMITTING MEDICATIONS: Ultram 50 mg tid.
ALLERGIES: Aspirin which causes airway problems requiring
epinephrine.
PHYSICAL EXAMINATION: Initially, pulse 57, blood pressure
142/94, blood pressure 133/84, initial weight 180 pounds.
Generally well nourished, muscular young man. Skin: clear.
Head, eyes, ears, nose and throat: negative lymphadenopathy,
negative jugular venous distention, negative carotid bruits,
negative thyromegaly. Chest is clear to auscultation
bilaterally. Heart was S1, S2 with a IV/VI systolic murmur.
Thrill was palpable at PMI, left anterior chest. Abdomen was
nontender, nondistended, positive bowel sounds. Extremities:
negative edema or cyanosis, no venous stasis. Varicosities:
positive left lower extremities. Neurologic: grossly intact,
no focal abnormalities. Cranial nerves II through XII
grossly normal. Excellent strength in all four extremities.
Pulses were +2 bilaterally, femorals, posterior tibial, and
radial. Dorsalis pedis was +1 bilaterally.
ADMISSION LABORATORY DATA: White blood cell count 5.4,
hemoglobin 14, hematocrit 42, platelets 255,000. PTT 35.6,
PT 12.7, INR 1.1. Sodium 140, potassium 4.4, chloride 103,
CO2 24, BUN 14, creatinine 1.0, glucose 124.
HOSPITAL COURSE: The patient was admitted on [**2191-8-23**] with a
diagnosis of mitral valve regurgitation and was transported
to the Operating Room for an mitral valve repair. The
patient tolerated the procedure well and was transported to
the Post Anesthesia Care Unit in stable condition. After the
postoperative course, the patient was then transferred to the
Cardiothoracic Intensive Care Unit where on postoperative day
one, the patient did well and was extubated. The patient was
transferred to the floor and continued to do well.
On postoperative day two, the patient spiked a temperature to
103 F at which time a chest x-ray was ordered and pan
cultures were performed. The chest x-ray showed a right
hemidiaphragm with atelectasis in the right lower lobe. On
postoperative day three the patient continued to do well, but
also continued to have a low grade fever with an average of
100.7 F. The patient's ambulation level increased to a level
of between a III and a IV.
On postoperative day four, the patient's ambulation level was
V and the patient was scheduled for discharge on [**8-27**].
The patient was instructed to continue on [**8-27**] after
discharge, to use the incentive spirometry, increase
ambulation, and to cough as much as possible to bring up
mucus.
DISCHARGE PHYSICAL EXAMINATION: Temperature 99.4 F, pulse
78, respiratory rate 20, oxygen saturation 93% on room air,
blood pressure 126/80, in 2,000 cc, out 2,600 cc.
Cardiovascular: regular rate and rhythm, patent murmur.
Respiratory: clear to auscultation bilaterally. Abdomen:
soft, nontender, nondistended. Incisions clean, dry, and
intact. Extremities: no peripheral edema. Physical Therapy
level V.
COMPLICATIONS / SIGNIFICANT EVENTS: None, other than low
grade temperature.
DISCHARGE MEDICATIONS: Percocet one to two tablets po q four
to six hours, acetaminophen 650 mg po q four to six hours
prn, Lopressor 25 mg po bid, and Ultram 50 mg po tid.
DISCHARGE CONDITION: Good and stable.
DISCHARGE STATUS: To home.
FO[**Last Name (STitle) **]P: Follow-up with Dr. [**Last Name (Prefixes) **] in three to four
weeks.
PRIMARY DIAGNOSIS:
Status post mitral valve repair.
SECONDARY DIAGNOSES:
1. History of mitral valve regurgitation.
2. Hemorrhoids.
3. Fracture of left wrist.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2191-8-27**] 12:22
T: [**2191-8-27**] 13:30
JOB#: [**Job Number 28545**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 851
} | Medical Text: Admission Date: [**2156-1-17**] Discharge Date: [**2156-1-20**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
gentleman who reported walking down [**Doctor Last Name **] on an icy driveway
this morning and slipped on the ice. His feet went out from
under him when he fell backwards striking the occiput on the
pavement. He recalls his feet slipping, but does not
consciousness for a few seconds. Denies shortness of breath,
chest pain, headache, or lightheadedness before the slip and
fall. The patient got up and returned to the house, and
wanted to rest, but his wife called EMS. He was transported
to the Emergency Room for evaluation and treatment.
PAST MEDICAL HISTORY:
2. Hypercholesterolemia.
PAST SURGICAL HISTORY: Radical prostatectomy seven or eight
years ago.
MEDICATIONS:
1. Synthroid 50 mcg po q day.
2. Lipitor.
ALLERGIES: IV dye.
The patient was admitted to the Neuro Intensive Care Unit,
where his vital signs were stable. His blood pressure was
133/56. He was in afib. Heart rate was 65. Respiratory
rate 19, and sats is 98%. He was in no acute distress awake,
alert, and oriented times three, following commands. Speech
was fluent, small, superficial mild area of abrasion,
contusion in the posterior occiput without laceration.
Pupils are equal, round, and reactive to light bilaterally.
EOMs full. Smile is symmetric. Face is symmetric. Tongue
midline. Neck is supple. Moving all extremities
spontaneously. Strength is [**4-19**] in all muscle groups.
Sensation is intact to light touch throughout. His reflexes
are 2+ throughout, 1+ at the ankles, and toes are downgoing
with no clonus.
CT scan showed multiple areas of small linear areas of
traumatic subarachnoid hemorrhage within the sulci of the
inferior frontal lobes bilaterally and an area of
intraparenchymal hemorrhage, measures 2 x 2 cm in
inferolateral left frontal lobe with a small dural based
component and small subdural hematoma with no shift. C spine
was cleared radiologically and clinically with no fractures
or malalignment.
The patient was monitored in the Intensive Care Unit. Had a
repeat head CT scan on the morning after admission, which was
found to be stable, and the patient was transferred to the
regular floor.
The patient was transferred to the regular floor, seen by
Physical Therapy and Occupational Therapy, and found to be
safe for discharge to home. He also underwent a brain MRI to
rule out tumor involvement and this was negative.He will follow
up with Dr. [**Last Name (STitle) 1132**] in one week with a repeat head CT scan.
DISCHARGE MEDICATIONS:
1. Synthroid 50 mcg po q day.
2. Zantac 150 mg po bid.
3. Oxycodone 5 mg po q4h prn for moderate-to-severe headache.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2156-1-20**] 13:19
T: [**2156-1-20**] 13:19
JOB#: [**Job Number 106929**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 852
} | Medical Text: Admission Date: [**2141-10-27**] Discharge Date: [**2141-12-18**]
Date of Birth: [**2141-10-27**] Sex: F
Service: NEONATOLOG
HISTORY OF PRESENT ILLNESS: The 1100 gram product of a 28
and [**1-11**] week gestation, Baby Girl [**Name2 (NI) 4027**] was born to a 37
year-old G unknown, P1 female with prenatal screens after
delivery that were A positive, antibody negative, Rubella
immune, RPR non-reactive, hepatitis surface antigen negative.
Other prenatal information was limited given that the mother
undertook no prenatal care. Mother developed acute abdominal
pain early on the morning of delivery and called 911, however
she deliver precipitously at 3:10 AM prior to the arrival of
EMS. The EMTs described the baby as active and breathing
well on arrival and a found an Apgar score of 8 minutes
without the time being noted. They wrapped the baby in baby
towels and transferred the baby by ambulance with mother to
the [**Hospital1 69**], where the baby was
brought directly to the newborn Intensive Care Unit.
On arrival the baby appeared [**Name2 (NI) **] with good spontaneous
activity, although she appeared mildly hypotonic. Vital
signs were temperature 92.0 F per rectum, heart rate 122,
respiratory rate 55, blood pressure 59/27 with a mean BP of
38. Weight was 1.1 kilos which was at the 50th percentile.
Length was 34 cm which was at the 15th percentile. Head
circumference was 24 cm which was between the 5th and 10th
percentile. Valid was consistent with a 29 week gestation
pregnancy. Head, eyes, ears, nose and throat: Prominent
molding, anterior fontanelle soft and flat. The sutures were
mobile. The palate was intact. Respiratory: Only fair air
entry was noted bilaterally with mild retractions also noted.
Cardiovascular: S1, S2 were of normal intensity, no murmur
appreciated. Capillary refill was slightly delayed at two
seconds, but overall profusion was good. Abdominal: Soft
with normal bowel sounds, no masses or organomegaly noted. A
3 vessel cord was noted. GU: Normal [**Doctor First Name **] female external
genitalia. The anus was normally placed. Neurologic: Tone
was overall mildly reduced, but was symmetric. Initial
dextrose stick was 58.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Initially intubated with a 3.0 endotracheal
tube. The baby was given one dose of Surfactant and was able
to be weaned off mechanical ventilation by the second day of
life. The baby continued on [**Name (NI) 39000**] through day of life #6.
Nasal cannula therapy was discontinued by [**12-9**]. The baby
was off of diuretics by [**12-12**]. There have been no
episodes of apnea or bradycardia since being off of the
diuretics.
2. CARDIOVASCULAR: The baby did not require pressor
therapy; however a murmur was noted by [**11-1**].
Echocardiogram revealed a moderate PDA for which Indomethacin
was given for one course. The infant was hemodynamically
stable thereafter.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Initially NPO, the
baby was on TPN by the second day of life. Enteral feedings
were started on [**11-2**] and were advanced to maximum
calories of PE 30 with ProMod by [**11-15**]. Given good growth,
the baby has been on [**Name (NI) 37112**] 24 for the past week and taking
it p.o. without difficulty over the last week. Minimum
feedings have been 130 cc per kilo per day and the weight on
discharge is 2510 grams.
4. GASTROINTESTINAL: Started on phototherapy for
hyperbilirubinemia. The baby had a maximum bilirubin total
of 11.6 on [**10-29**]. Phototherapy was discontinued by [**11-5**] and
the baby had a rebound max bilirubin of 4 on [**11-6**].
5. HEMATOLOGY: Initial hematocrit was 65.1%. The baby did
not receive any transfusions during this admission. The last
hematocrit was drawn on [**12-5**] and was 32.5%. The baby has
received iron therapy and vitamin E during this admission.
6. INFECTIOUS DISEASE: Initially on Ampicillin and
Gentamycin for the presenting history, the child was treated
with a seven day course. Blood cultures were no growth [**Name6 (MD) **]
the NNP notes.
7. NEUROLOGIC: The initial maternal tox screen was positive
for cocaine. There were no other positive screens in follow
up testing. Initial head ultrasound done on [**10-30**] was
without evidence of hemorrhage. Follow up head ultrasound
performed on [**11-28**] showed a left subependymal cyst was
considered consistent with an early general matrix
hemorrhage. There was no evidence of periventricular
leukomalacia.
8. SENSORY: Etiology hearing screen was performed with
automated auditory brainstem responses. The baby passed this
hearing screen.
9. OPHTHALMOLOGY: Seen on [**11-29**], the baby was felt to have
mature retinas bilaterally. Follow up was suggested at eight
months.
10. PSYCHOSOCIAL: The [**Hospital1 69**]
Social Work Service was involved with the mother. The
contact social worker was [**Name (NI) **] [**Name (NI) **] whose page number is
[**Numeric Identifier 45010**]. She can also be reached at [**Telephone/Fax (1) 8717**]. DSS was
also involved. Ms. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was the case worker and
her phone # [**Telephone/Fax (1) 45011**]. A 51-A has been filed.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: The baby is being discharged to home
under the mother's care.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and his clinic
phone # [**Telephone/Fax (1) 38541**]. The first appointment with the
pediatrician is to be in two days on [**12-20**] at 8:20 in the
morning.
CARE RECOMMENDATIONS:
1. Feeds at discharge [**Month/Year (2) 37112**] 24 with iron. Also the baby
is to receive some supplementary iron sulfate which would be
0.2 milliliters of 25 mg elemental Ferrous Sulfate per ml
solution.
2. Care seat testing was passed on [**12-15**].
3. Newborn screens were sent multiple times. Most recently
on [**11-15**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern4) 45012**]
MEDQUIST36
D: [**2141-12-18**] 10:50
T: [**2141-12-18**] 12:05
JOB#: [**Job Number 45013**]
ICD9 Codes: 769, 7742, 0389, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 853
} | Medical Text: Admission Date: [**2191-12-8**] Discharge Date: [**2191-12-23**]
Date of Birth: [**2191-12-8**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 58859**] is an 850 gram
product of a 26 and 6/7 weeks gestation born to a 35-year-old
gravida 2, para 1 (now 2) mother with prenatal screens blood
type O positive, antibody negative, RPR nonreactive, rubella
immune, hepatitis B negative, group B strep unknown.
The pregnancy was complicated by pregnancy induced
hypertension. The mother was admitted at 25 weeks for
betamethasone and bed rest. Her preeclampsia worsened and
she developed thrombocytopenia, so baby boy [**Name (NI) 58859**] was
delivered by cesarean section. In the delivery room he was
initially limp and apneic. He required positive pressure
ventilation and intubation in the delivery room. His Apgar
scores were 3 at 1 minute and 7 at 5 minutes of life. He was
transferred to the Neonatal Intensive Care Unit for
management of his issues or prematurity.
INITIAL PHYSICAL EXAMINATION: Birth weight was 850 grams
(50th percentile), the length was 33.5 cm (25th percentile),
and head circumference was 44.25 cm (25th percentile). In
general, baby boy [**Name (NI) 58859**] was an intubated preterm male.
Active and in no acute distress. HEENT examination revealed
a normocephalic infant with an anterior fontanel that was
open and flat with an intact palate. His neck was supple.
His lungs had equal breath sounds bilaterally but were
coarse. His heart examination revealed a regular rate and
rhythm with no murmurs and bilateral 2 plus femoral pulses.
His abdomen was soft without organomegaly and had no bowel
sounds. His GU examination revealed a normal preterm male.
His anus was patent. His clavicles were intact. His hips
were stable. His neurological examination revealed slight
hypertonia.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: Baby boy [**Known lastname 58859**] had an initial poor
respiratory effort and was thus intubated in the delivery
room. He was treated with two doses of Surfactant and did
very well; extubating from low settings to CPAP of 6 cm at
about 24 hours of life. As he was less than 1000 grams at
birth, he was treated with 12 doses of vitamin A. Since
extubation he has been quite stable on CPAP 6 cm and less
than 30 percent oxygen; primarily in 21 percent. He was
bolused with caffeine at the time of his extubation. At
the time of this interim summary, he has [**5-4**] apnea of
bradycardia spells per day. These seem to be related to
thick secretions for which he requires suctioning.
2. CARDIOVASCULAR: Baby boy [**Known lastname 58859**] was hemodynamically
stable on admission. He developed a murmur on day of life
two and received a single course of indomethacin.
Echocardiogram showed his patent ductus arteriosus to be
closed. He has had no further murmur or other
cardiovascular issues since that time. His blood
pressures and perfusion have been normal.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Baby boy [**Known lastname 58859**]
was initially held nothing by mouth and started on
parenteral nutrition and intravenous fluids at 100 cc/kg
per day. His total fluids were gradually advanced to 150
cc/kg per day. On day of life five, he had hyperglycemia
with Dextrostix's in the 200 to 300 range. He received a
second rule out sepsis for this, but appeared clinically
well. No cause of his hyperglycemia was found. He
received a single dose of intravenous insulin for a peak
blood sugar of 348 with good affect. Blood sugars fell
into the 100 range and have been stable between 100 and
150 since that time. Trophic feedings were begun on day
of life six and have been successfully advanced to full
feedings of breast milk or Special Care 24 calories per
ounce at 150 cc/kg per day at the time of this summary,
day of life 15. Electrolytes have been stable. Urine
output and stooling have been normal. BUN and creatinine
were slightly elevated on day of life six with BUN of 26
and a creatinine of 0.6. These had fallen by day of life
nine to a BUN of 17 with a creatinine of 0.6.
4. HEMATOLOGIC: Baby boy [**Known lastname 58860**] initial hematocrit
was 48.7 percent on admission. He has not required any
blood products thus far. Iron and vitamin E were begun on
[**12-23**] (day of life 15). His most recent hematocrit
was 39.3 percent on day of life six. Bilirubin at 24
hours of life was 4.4; for which he began phototherapy.
Bilirubin peaked at 4.5 on day of life six. Phototherapy
was discontinued on day of life seven, and a rebound was
2.8.
5. INFECTIOUS DISEASE: Baby boy [**Known lastname 58859**] was delivered
primarily for maternal reasons, and was clinically well at
delivery, he received a complete blood count and blood
culture but was not treated with antibiotics. His initial
complete blood count had a white count of 7000 with 31
percent polys and no bands. His platelet count was normal
at 218,000. On day of life six, with his sudden increase
in blood glucose - that was otherwise unexplained - a
complete blood count and blood culture were again sent.
Complete blood count at that time had a white count of 7.8
thousand with 30 percent polys and 1 percent bands. Blood
cultures remained negative and antibiotics were
discontinued after 48 hours. Baby boy [**Known lastname 58859**] has had
no further infectious issues at the time of this interim
summary.
6. NEUROLOGIC: Baby boy [**Known lastname 58859**] had his first head
ultrasound on day of life seven ([**12-15**]). This
revealed no intraventricular hemorrhage or other
abnormality. He will have a repeat head ultrasound
at day of life 30.
7. SENSORY: A hearing screening has not yet been performed
but is recommended prior to discharge. Baby boy
[**Known lastname 58859**] has not yet had his first ophthalmologic
examination, but this will be performed at four to six
weeks of life.
CONDITION AT TIME OF INTERIM SUMMARY: Stable.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 58861**] of [**Location 50977**].
CARE RECOMMENDATIONS AT TIME OF INTERIM SUMMARY:
1. Feedings are breast milk or Special Care 24 at 150 cc/kg
per day; all NG.
2. Medications include caffeine, vitamin A, iron, and vitamin
E.
3. Car seat position screen has not yet been performed but
should be done prior to discharge.
4. A State newborn screen has been sent.
5. No immunizations have yet been received, but hepatitis B
is recommended prior to discharge.
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 gestation; (2) born between 32 and 35 weeks gestation
with two 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 six months of age. Before
this age (and for the first 24 months of the child's life)
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES AT TIME OF INTERIM SUMMARY:
1. Prematurity at 26 and [**5-1**] week gestation.
2. Respiratory distress syndrome.
3. Patent ductus arteriosus - resolved.
4. Feeding immaturity.
5. Hyperbilirubinemia - resolved.
6. Hyperglycemia - resolved.
7. Rule out sepsis - resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Doctor Last Name 56593**]
MEDQUIST36
D: [**2191-12-23**] 17:25:47
T: [**2191-12-24**] 09:24:07
Job#: [**Job Number 58862**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 854
} | Medical Text: Admission Date: [**2117-9-14**] Discharge Date: [**2117-9-15**]
Date of Birth: [**2043-8-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Bactrim / Vancomycin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Reason for MICU admission: Drug reaction
Major Surgical or Invasive Procedure:
Placement of Central Line
History of Present Illness:
hpi: 74 yo female presents to ED from [**Hospital 100**] Rehab with
pruritic, painful rash over trunk, chest, back, arms, and
proximal legs. Patient had been recently admitted to [**Hospital1 18**] for
COPD flare requiring brief stay in the ICU, during that
admission she was found to have [**3-7**] blood cultures positive for
MRSA. She was started on Vancomycin and Gent at that time, Gent
later discontinued but Vancomycin continued to complete a two
week course after TTE was negative for vegetation. Per report
from [**Hospital 100**] Rehab, rash developed on [**2117-9-9**]. Vancomycin was
stopped on [**2117-9-10**], but rash continued getting worse with
exfoliation and bullae concerning for [**Doctor First Name **]-[**Location (un) **]. In
addition, per ED report she had positive blood cultures (GPC in
clusters) from [**2117-9-12**] at [**Hospital 100**] Rehab, although the
documentation from the HR stated the repeat blood cultures were
negative. She was transferred to [**Hospital1 18**] for further management
and dermatologic evaluation.
.
In the ED, she denied fevers, chills, CP, SOB, palpitations,
headache, swelling in tongue, throat or wheezing. Vital signs
were 96.2 111 125/74 18 100%3L. She was given Sarna lotion,
Benadryl, and changed to Linezolid.
.
Currently she complains of prurutis and pain.
Past Medical History:
pmhx:
1.COPD - GOLD Stage III with FEV1 32% predicted on PFTs in [**2115**],
on home O2
2.Moderate-to-severe aortic stenosis - valve area 0.9 cm, Mean
gradient 29mmHg, peak velocity 3.4 on echo in [**8-/2117**]
3.Diastolic CHF
4.Obstructive sleep apnea - No formal sleep study and not on
CPAP
5.Achalasia, s/p pneumatic dilatation and botulinum toxin
injection of LES
6.Morbid obesity
7.Chronic lower extremity edema
8.S/P cholecystectomy: [**2102**]
9.Chronic low-back pain
Social History:
4 children. One adult daughter is deceased at age 47, [**2-5**] to
cancer, the remaining daughers are alive. Currently at [**Hospital 100**]
Rehab, previously lived alone. remote history of tobacco use for
"few years" after she was married, no ETOH. No drug use.
Family History:
Mother deceased at age 72, [**2-5**] to trauma. Daughter died at age
47 of cancer.
Physical Exam:
PE:
vitals: 97.1 101-120 117/24 29 100%RA
GEN: In discomfort, speaking comfortably
HEENT: Sclera anicteric, erythematous rash not sparing the
nasolabial folds, no stridor or OP swelling, OP clear without
lesions
NECK: Supple
CV: RRR, [**3-9**] sys cres-descres murmur RUSB -> carotids
LUNGS: Decreased air movement anteriorally
ABDOMEN: Obese, soft, NTND, no HSM
EXT: 3+ BL edema
SKIN: Exfoliating erythematous rash with evidence of ruptured
bullae over chest with dry base, back, anterior thigh, no rash
on palms/soles
NEURO: AAOx3, CN II-XII intact
Pertinent Results:
[**2117-9-14**] 06:30AM WBC-26.1* RBC-3.69* HGB-10.5* HCT-32.4*
MCV-88 MCH-28.3 MCHC-32.2 RDW-16.1*
[**2117-9-14**] 06:30AM NEUTS-92.3* BANDS-0 LYMPHS-4.9* MONOS-2.0
EOS-0.7 BASOS-0.1
[**2117-9-14**] 06:30AM PLT SMR-NORMAL PLT COUNT-292
.
[**2117-9-13**] 06:55PM GLUCOSE-114* UREA N-24* CREAT-0.8 SODIUM-134
POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-36* ANION GAP-10
.
Pertinent results:
CXR: Bedside AP and lateral views labeled "upright, stretcher at
10:00 p.m." are compared with PA and lateral views dated
[**2117-8-29**]. Allowing for differences in radiographic technique,
motion-blurring and patient positioning, the overall appearance
is essentially unchanged. There is evidence of pulmonary
hyperinflation with diaphragm flattening, suggestive of
underlying obstructive lung disease, but no focal airspace
process is seen. The cardiomediastinal silhouette and pulmonary
vessels are unchanged with no evidence of CHF. DISH involving
the thoracic spine is redemonstrated.
.
ECHO [**8-/2117**]: Mild LAE, mild LVH, normal function (EF>55%). RV
size and free wall motion normal. Mod to severe AS, no AR.
trivial MR.
.
EKG:
.
UA: small leuks, neg nit, occ bacteria, 0-2 WBC
Brief Hospital Course:
A/P: 74F Vancomycin for MRSA bacteremia, transferred from [**Hospital 100**]
Rehab for worsening rash and persistent bacteremia.
.
# Rash: On presentation, dermatology was consulted. They
believe that it is most consistent with AGEP (acute generalized
exanthematous pustulosis), which is a drug hypersensitivity
recation. Fever and leukocytosis can acompany this reaction.
They recommened supportive care. A biopsy was taken and should
be follow up after the patient is discharged. Petrolatum can be
applied to entire body surface [**Hospital1 **]-TID to help with healing.
Also, ABD pads or other cushioning in intertriginous areas to
prevent trauma as well as viscous lidocaine prn oral comfort.
She will need suture removal in [**10-17**] days and should follow up
at dermatology clinic. ([**Telephone/Fax (1) 1971**] to schedule a follow-up
appointment.) The patient was also aggressively hydrated
because of the large volume of fluids that she is losing from
her skin.
.
# Bacteremia: Unclear etiology but likely pulmonary; from
previous admission. The patient remained afebrile despite
growing [**3-7**] blood cultures for gram positive cocci in clusters
during that admission. TTE was performed at that time revealing
knwon stable AS with a thickened valve but no evidence of
vegetation. The patient's vancomycin was stopped on admission
and she was started on Linezolid. Repeat blood cultures are
pending at the time of discharge. She will need a total of a 14
day course starting from [**9-7**] (ending on [**9-21**]).
Medications on Admission:
Meds(per last dc summary, needs to be confirmed)
Aspirin 325 mg PO DAILY
Furosemide 40 mg Tablet PO DAILY
Ipratropium Bromide neb Inhalation Q6H
Albuterol Sulfate neb Inhalation Q6H
Aluminum-Magnesium Hydroxide QID as needed.
Miconazole Nitrate Topical [**Hospital1 **]
Pantoprazole 40 mg PO Q24H
Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4-6H
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours) as needed for pruritis.
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheeze.
8. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed for SOB, wheeze.
9. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
[**1-5**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
12. Petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
13. Linezolid 600 mg IV Q12H
14. Morphine Sulfate 2-4 mg IV Q3-4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Rash secondary to vancomycin
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a rash secondary to an antibiotic that
you had taken. During your stay, your antibiotics were changed
and you were treated with fluids and aquaphor cream. You will
need to continue taking the Linezolid medication to complete a
14 day course (to be completed on [**9-21**])
Followup Instructions:
You will be discharged to the MACU at [**Hospital 100**] Rehab for ongoing
care.
--Please arrange for suture removal in [**10-17**] days.
--Please call the dermatology clinic at [**Telephone/Fax (1) 1971**] to schedule
a follow-up appointment.
ICD9 Codes: 496, 4241, 4280, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 855
} | Medical Text: Admission Date: [**2188-7-15**] Discharge Date: [**2188-7-18**]
Date of Birth: [**2159-7-30**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p Gunshot wounds to left chest/posterior neck
Major Surgical or Invasive Procedure:
[**2188-7-15**] FLEXIBLE BRONCHOSCOPY; ESOPHAGOGASTRODUODENOSCOPY
History of Present Illness:
28 y/o M s/p GSW with 2 wounds, left chest/axilla region and
other to posterior neck. Intubated at the scene and taken to an
OSH where a needle
decompression of left hemothorax was performed and had chest
tube placed. Received 2 units PRBC prior to transport. Once at
[**Hospital1 18**] it was noted that not much was draining from the left
chest tube and another was placed in
the ED. CT scan showed bony damage to clavicle, no great vessel
injury. EGD and Bronch in the OR showed no esophageal, tracheal
or bronchial injury. Patient arived intubated and sedated.
Past Medical History:
Unknown
Social History:
+ ETOH, no tob
Family History:
Noncontirbutory
Physical Exam:
Temp:97.7 HR: 82 BP: 128/67 RR: 18 O2 Sat:100% @ ACVC 100% 16
x
500, PEEP: 5
GENERAL: intubated and sedated
HEENT: C-collar in place
RESPIRATORY: chest tubes x 2 present in Left midaxillary line,
entry wound in midaxillary line a 3rd interspace
CARDIOVASCULAR: pulses equal b/l, RRR
GI: S NT/ND
NEURO: intubated and sedated, MAE
Pertinent Results:
[**2188-7-15**] 06:04AM GLUCOSE-97 UREA N-10 CREAT-0.8 SODIUM-141
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-19* ANION GAP-16
[**2188-7-15**] 06:04AM CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-1.6
[**2188-7-15**] 06:04AM WBC-17.6* RBC-5.00 HGB-14.8 HCT-44.3 MCV-89
MCH-29.6 MCHC-33.4 RDW-14.8
[**2188-7-15**] 06:04AM NEUTS-73* BANDS-1 LYMPHS-15* MONOS-8 EOS-1
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
[**2188-7-15**] 06:04AM PLT COUNT-237
[**2188-7-15**] 06:04AM PT-12.7 PTT-24.7 INR(PT)-1.1
[**2188-7-15**] 04:49AM TYPE-ART PO2-283* PCO2-44 PH-7.28* TOTAL
CO2-22 BASE XS--5
[**2188-7-15**] 03:00AM ASA-NEG ETHANOL-281* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
IMAGING:
- [**7-15**] (CXR): 1. ET tube and left chest tube in place.
2. Left hemithoracic opacity may represent pleural effusion.
3. Comminuted left clavicular fracture.
- [**7-15**] (CT Head): no ICH, L maxillary air-fluid level, no fx
- [**7-15**] (CT C-spine): 1. No fx/malalignment of cervical spine.
2. Left clavicle comminuted fx, 3. Nondisplaced fx C7 L lat
mass.
- [**7-15**] (CT C/A/P): LUL hemorrahage, concern for L subclavian
injury, ascending/transverse colon bwl wall thickening.
- [**7-15**] (CTA Head/Neck):- AICA/PICA intact, ?Lsc vessel inj
- [**7-15**] (MRA neck): - 1. No bone marrow edema is seen in
association with the known fracture of the left posterior
elements of C7, likely due to the low ratio of bone marrow to
cortex. No evidence of ligamentous injury, cord injury, or
epidural hematoma.
2. Posterior paravertebral soft tissue edema, R>L
3. No vertebral or ICA intramural hematoma or dissection.
[**2188-7-17**] CXR post CT removal :
1. Resolving left upper lobe pulmonary contusion.
2. Probable very small left apical pneumothorax.
Brief Hospital Course:
He was admitted to the Acute Care team and transferred to the
Trauma ICU. His ICU course was as follows:
On [**7-15**], the patient was intubated in the field and brought to
the ICU. He had 1 left CT placed at the OSH, the other was
placed upon arrival to [**Hospital1 18**]. He received 2 units of PRBCs at
the outside hospital. A bronch and EGD were down and both
negative. The patient was initially on propofol gtt and neo gtt
at 0.5. The Neo was discontinued upon arrival to the TICU as
his blood pressure was stable. He was given 3L of crystalloid
during his EGD and bronch and his uop was adequate. MRA of the
neck was performed that did not show any vertebral artery injury
and the basilar CT was pulled. His aline was also pulled. On
[**7-16**], the patient was extubated and transitioned to dilaudid pca
for pain control. He was doing well and was hemodynamically
stable. He was transferred to the floor on [**7-16**].
He was transferred to the regular nursing unit in the late
afternoon on [**7-16**] with 1 remaining chest tube to water seal. he
was noted with some pain control issues requiring continuation
of PCA Dilaudid. On the following morning his chest tube output
was minimal and the decision was made to pull the chest tube. A
post pull chest film was ordered showing a tiny left apical
space. He remained without shortness of breath and able to use
his incentive spirometer.
He was given a regular diet and changed to oral narcotics for
pain control which was effective.
Social work was consulted due to the nature of his trauma; he
was offered assistance from the Center for Violence Prevention
and Recovery.
He is being discharged to home and will follow up in Acute Care
clinic in about 1 week for repeat chest xray. He will also
follow up in the [**Hospital **] Clinic in 2 weeks.
Medications on Admission:
Denies
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Gunshot wound to left chest and posterior neck
Left clavicle fracture
Left hemopnuemothorax
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a gunshot wound to your
left chest and back of your neck. You required that 2 chest
tubes be placed into your lung to drain the blood and excess
air. You underwent a procedure to check your the inside of your
lungs and swallowing pipe which did not sho any abnormalities.
You are being discharged to home with the following
instructions:
*If you notice that you are short of breath, coughing up blood
and/or having any difficulty with breathing you should return to
the Emergency room immediatley.
*Keep the bandage on your left chest in place for at least the
next 5 days. It is OK to shower with this bandage just cover it
with Saran wrap and tape around the edges of the wrap.
*Avoid smoking tobacoo or other illicit drugs.
*You should not fly as high altitudes can interfere with the
pressure in your lungs.
*Because of your broken collar bone you should wear a sling when
you get out of bed. Avoid putting full weight on your left arm.
*You have been prescribed narcotics for pain - DO NOT drink
alcohol, take illicit drugs, drive and/or operate heavy
machinery while on the se medications. Take a stool softener and
laxative to prevent constipation.
Followup Instructions:
Follow up in Acute Care clinic next week for a chest xray to
evaluate your injuries. Upon discharge please call [**Telephone/Fax (1) 600**]
to make this appointment.
Follow up in 2 weeks in [**Hospital 5498**] clinic for your clavicle
fracture, call [**Telephone/Fax (1) 1228**] upon discharge to make this
appointment.
Completed by:[**2188-7-18**]
ICD9 Codes: 2851, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 856
} | Medical Text: Admission Date: [**2143-12-17**] Discharge Date: [**2143-12-20**]
Date of Birth: [**2083-5-22**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin Hcl / Diphenhydramine / baclofen
Attending:[**First Name3 (LF) 10435**]
Chief Complaint:
Shortness of Breath - Outside hospital transfer for pneumonia.
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation at outside hospital
PICC Line Placement
History of Present Illness:
Ms. [**Known lastname 31824**] is a 60 year old woman s/p OLT in [**2142**] due to HCV
cirrhosis with recurrent hep C (on peg-interferon) and ESRD on
dialysis who was admitted to OSH MICU for pneumonia and is now
transferred to [**Hospital1 18**] for further management. She was in her
usual state of health until the day of admission ([**2143-12-15**]) when
she woke up with SOB and cough productive of frothy pink sputum.
.
In the OSH ED she was febrile to 101.2. CXR showed bilateral
infiltrates, new from CXR taken [**12-13**] in ED for evaluation of
possible rib fractures s/p fall. The patient subsequently
developed respiratory failure requiring intubation. She was
started on IV Zosyn and Azithromycin. Her course was
complicated by hypotension requiring Levophed, and IV Vancomycin
was started. She also developed atrial fibrillation with RVR
requiring IV Cardizem. Her RVR resolved and she was weaned off
pressors. On HD#3 (day of transfer) she was extubated without
difficulty. Her liver [**Month/Day (4) **] coordinator was [**Name (NI) 653**], and
agreed to have the patient transferred to [**Hospital1 18**] for further
management.
.
On transfer, initial vitals were T 96.3, HR 98, BP 113/60, RR
16, O2 sat 99% on 2L NC. She denies current SOB, but continues
to have occasional cough productive of brown sputum. She also
complains of R rib pain, which she attributes to a mechanical
fall she sustained 2 days PTA.
Past Medical History:
-Hep C cirrhosis status post OLT on [**2142-6-13**] complicated by
recurrent hep C
-End Stage Renal disease on dialysis
-Esophageal varices
-AFib, status post ablation x2
-EtOH, EtOH abuse
-Status post left SFA stent for traumatic AV fistula.
-History of recurrent UTI with VRE and ESBL Klebsiella.
-Hypothyroidism.
-Biliary stricture - ERCP with 3 stents placed on [**10-28**]
-Fibromyalgia
Social History:
She lives alone. Daughter lives 20 minutes away from her; very
involved in her care. She denies current ETOH, smoking or drug
use. Has hx of ETOH abuse.
Family History:
Father with heart problems and diabetes
Physical Exam:
Admission Exam:
Vitals: HR 97 120/54 99% 2 liters n/c
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diminished breath sounds in lower right lung field, no
wheezes, rales, ronchi
Abdomen: soft, mildly tender, non-distended, bowel sounds
present, no organomegaly. Well-healed midline scar.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
.
Discharge Exam:
Vitals: 96.8 128/64 69 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular S1, S2, no murmurs, rubs, gallops
Lungs: CTAB; no wheezes, rales, ronchi; right lower chest tender
to palpation
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. Well-healed midline scar.
GU: no foley
Ext: warm, well perfused, 2+ pulses
Pertinent Results:
Admission Labs:
[**2143-12-17**] 09:28PM BLOOD WBC-5.5# RBC-3.10* Hgb-9.3* Hct-29.0*
MCV-94# MCH-30.1 MCHC-32.1 RDW-18.6* Plt Ct-136*
[**2143-12-17**] 09:28PM BLOOD Glucose-125* UreaN-38* Creat-3.5*# Na-136
K-3.4 Cl-93* HCO3-28 AnGap-18
[**2143-12-17**] 09:28PM BLOOD ALT-16 AST-29 AlkPhos-212* TotBili-0.5
[**2143-12-17**] 09:28PM BLOOD Calcium-8.3* Phos-4.3# Mg-2.4
.
Discharge Labs:
[**2143-12-20**] 04:50AM B1LOOD WBC-2.9* RBC-3.24* Hgb-9.5* Hct-30.3*
MCV-94 MCH-29.4 MCHC-31.5 RDW-18.3* Plt Ct-139*
[**2143-12-20**] 04:50AM BLOOD Glucose-90 UreaN-30* Creat-3.5*# Na-135
K-4.0 Cl-100 HCO3-25 AnGap-14
[**2143-12-20**] 04:50AM BLOOD ALT-22 AST-39 AlkPhos-194* TotBili-0.6
[**2143-12-20**] 04:50AM BLOOD Albumin-2.9* Calcium-8.2* Phos-1.8*
Mg-2.0
.
Sirolimus levels:
[**2143-12-19**] 04:45AM BLOOD rapmycn-7.4
[**2143-12-20**] 04:50AM BLOOD rapmycn-7.6
.
AP Portable CXR [**2143-12-17**]: Mild cardiac enlargement is new,
mediastinal venous engorgement is more pronounced and there is
persistent pulmonary [**Month/Day/Year 1106**] plethora. Edema in the left lung
is mild. On the right side, there are larger areas of perihilar
opacification which could be the residual of what was previously
more widespread edema, or could be pneumonia or hemorrhage in
the right lung. It would be very helpful to have recent prior
chest radiographs.
Left PIC line ends in the region of the superior cavoatrial
junction. No
pneumothorax. Pleural effusion, if any, is not appreciable in
size.
Brief Hospital Course:
60 year old female with a history of hepatitis C complicated by
cirrhosis s/p OLT in [**2142**], with recurrent hep C (on
peg-interferon), and ESRD on dialysis who was admitted to OSH
MICU for pneumonia and transferred to [**Hospital1 18**] for further
management.
.
#Pneumonia: Patient transferred from outside hospital with
RML/RLL pneumonia, status-post two-day intubation for
respiratory failure. Patient was treated for health care
associated pneumonia because of her ongoing dialysis treatments.
On arrival to the MICU she was afebrile with stable vital
signs, breathing comfortably on NC. She was continued on IV
vancomycin from OSH and her zosyn/azithromycin was changed to IV
cefepime/flagyl. She was transferred to the liver service. On
the floor, the patient breathed comfortably on room air with
vast improvement in her cough. She was continued on
ipratroprium nebs for dyspnea and incentive spirometry. She was
treated with a lidocaine patch to her right chest for rib pain
to prevent further splinting. The patient was discharged on
vancomycin with hemodialysis and levofloxacin to complete a
14-day antibiotic course.
.
# Hep C cirrhosis status-post OLT with recurrent hepatitis C:
Currently on peginterferon for hepatitis C. On sirolimus and
mycophenolate following OLT. Sirolimus levels and LFTs remained
stable throughout admission. The patient was continued on
single-strength bactrim for prophylaxis. She will follow up in
the [**Hospital1 **] clinic upon discharge.
.
# Atrial fibrillation with rapid ventricular response: The
patient has a history of atrial fibrillation, on propafenone,
diltiazem, and aspirin 325mg daily s/p ablation x 2. The
patient had self-discontinued use of coumadin in [**2141**], as she
did not want further blood draws. On admission to the outside
hospital, the patient was reported to have rapid ventricular
response controlled with IV diltiazem. On the liver service,
the patient had several episodes of symptomatic rapid
ventricular response with rates to the 120's to 150's. The
patient was seen by electrophysiology, who recommended an
increase in diltiazem and discontinuation of propafenone. Her
rates improved. The patient was discharged on diltiazem 240 ER
and ASA 325 daily. She will follow up with her outpatient
cardiologist on discharge.
.
# Hypothyroidism: Stable. The patient was continued on home
levothyroxine throughout admission.
Medications on Admission:
pregabalin 50 mg PO BID
propafenone 150 mg TID
sulfamethoxazole-trimethoprim 400-80 mg daily
mycophenolate mofetil 500 mg [**Hospital1 **]
zolpidem 5 mg qHS
calcium carbonate 200 mg TID
Nephrocaps 1 daily
duloxetine 30 mg daily
levothyroxine 112 mcg daily
omeprazole 40 mg daily
Vitamin D3 400 units daily
lidocaine-prilocaine 2.5 - 3.5% cream, 1 application PRN graft
pain
aspirin 325 mg daily
diltzac ER 180 mg daily
colace 100 mg [**Hospital1 **] PRN
peginterferon alfa-2a 135 mcg weekly
tylenol 325 mg TID PRN
polyethylene glycol 17 gram daily PRN
Sirolimus 0.5 mg PO daily
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. peginterferon alfa-2a 180 mcg/mL Solution Sig: One Hundred
Thirty Five (135) mcg Subcutaneous 1X/WEEK ([**Doctor First Name **]).
6. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
7. sirolimus 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
12. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
Disp:*30 Capsule, Extended Release(s)* Refills:*0*
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: to right thorax .
Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0*
14. vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous HD PROTOCOL for 10 days.
15. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a
day. Capsule(s)
16. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO once a
day.
17. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
18. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day. Tablet,
Chewable(s)
19. Tylenol 325 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
20. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Central & [**Hospital3 29991**] [**Hospital3 **]
Discharge Diagnosis:
Primary diagnosis: Pneumonia
Secondary diagnoses: Atrial fibrillation with rapid ventricular
response, Hep C cirrhosis s/p OLT with recurrent hepatitis C,
Chronic Kidney Disease V - dialysis dependent, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 31824**],
.
You were admitted from an outside hospital with a pneumonia. At
the outside hospital, your pneumonia required use of a tube to
help you breathe for two days. You were started on antibiotics
and your pneumonia improved. You were transferred to the ICU at
[**Hospital1 18**] for further treatment of pneumonia, and quickly graduated
to the regular medical floor. Prior to discharge, you were able
to breathe comfortably without the use of oxygen. You will
remain on antibiotics for 10 days following discharge. While
you were in the hospital, your atrial fibrillation (irregular
heart rate) caused your heart to beat rapidly. You were seen by
heart specialists, who recommended stopping your propafenone and
increasing diltiazem. You were discharged to home. You should
follow up with your primary care physician, [**Name10 (NameIs) 2085**], and
[**Name10 (NameIs) **] physician as previously scheduled.
.
The following changes were made to your medication regimen:
STOP propafenone
CHANGE diltiazem to 240 mg ER by mouth daily
Start levofloxacin by mouth for 10 days
You will receive vancomycin with dialysis over the next 10 days
Followup Instructions:
Name: NP[**First Name8 (NamePattern2) 31986**] [**Last Name (NamePattern1) **]
Location: [**Hospital3 **], INC
Address: 3130 STATE HWY,ROUTE 6, [**Location (un) 31977**],[**Numeric Identifier 31978**]
Phone: [**Telephone/Fax (1) 31979**]
Appointment: Tuesday [**2143-12-24**] 2:40pm
.
Department: CARDIAC SERVICES
When: FRIDAY [**2144-1-3**] at 10:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital Ward Name **]
When: WEDNESDAY [**2144-1-8**] at 11:00 AM
With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]
ICD9 Codes: 486, 5856, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 857
} | Medical Text: Admission Date: [**2117-3-30**] Discharge Date: [**2117-4-3**]
Date of Birth: [**2037-5-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5510**]
Chief Complaint:
Lower GIB
Major Surgical or Invasive Procedure:
4 units of packed red blood cells
History of Present Illness:
79 year old female with a past history of hypertension, type 2
diabetes, CAD s/p CABG x 4 and history of lower gastrointestinal
bleeding of unclear source who presents to the emergency room
with 4 days of "vaginal bleeding." Patient reports that she
first noted that she was bleeding on Saturday. It was primarily
bright red blood in the toilet bowel with stool with associated
fecal urgency. She denies abdominal pain. This is similar to her
episode of gastrointestal bleeding in [**2116-5-24**] but not as
profuse. The bleeding has continued over the past three days. It
is associated with mild left sided chest pressure which is not
worse with exertion, dyspnea on exertion, lightheadedness and
dizziness. She has not had any nausea, vomiting or hematemasis.
She denies melena. She has been eating well until the day of
presentation. Her urine output has been normal. Otherwise she
has been in her regular state of health.
.
In the emergency room her initial vitals were T: 98.1 BP: 169/67
HR: 87 RR: 16 O2: 98% on RA. She received one liter of normal
saline. She had a CXR which showed no acute process. She had a
normal EKG. She had two 20 g IVs placed and one liter of PRBCs
was hung. Vaginal exam was within normal limits. Rectal exam
showed no external hemorroids and gross blood at the anus. She
was hemodynamically stable throughout her time in the ER. She
was admitted to the MICU for further management.
.
Upon arrival to the MICU she denied any complaints. Her
lightheadedness, dizziness, chest pain and dyspnea have
resolved. Her last bowel movement was morning of admission. She
denies nausea, vomiting or abdominal pain. No dysuria or
hematuria or decreased urine output. No leg pain or swelling.
All other review of systems negative in detail.
Past Medical History:
Past Medical History:
- Coronary Artery s/p CABG [**2107**]
- Peripheral Vascular Disease
- Stage III chronic kidney disease (baseline creatine 1.3)
- Hypertension
- Type II Diabetes complicated by retinopathy, nephropathy
- Diverticulosis seen on colonoscopy [**5-31**]
- s/p toe amputation
Social History:
She is a retired administrator at [**Street Address(1) 5904**] Inn. She works
out at a senior gym three times a week. She does not smoke
cigarettes, drink alcohol, or use any recreational drugs. She
lives by herself but has family in the area.
Family History:
Diabetes mellitus-- mother, brother, and sister
[**Name (NI) 5905**] mother, father.
There is no history of kidney disease.
No family history of gastrointestinal bleeding.
Physical Exam:
On admissions -
Vitals: T: 98.4 BP: 136/72 HR: 73 RR: 14 O2: 99% on RA
Orthostatics: 122/59 (73); 119/67 (78); 112/55 (69)
General: Well appearing elderly female, no acute distress
[**Name (NI) 4459**]: Sclera anicteric, moist mucous mebranes, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Heart: RRR, s1 + s2, no murmurs, rubs, gallops
Abd: soft, non-tender, non-distended, +BS
Ext: Warm and well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact
Skin: no rashes or jaundice
Pertinent Results:
CHEST (PORTABLE AP) Study Date of [**2117-3-30**]:
IMPRESSION: No acute pulmonary process.
HEMATOLOGY:
[**2117-3-30**] 12:55PM BLOOD WBC-9.2 RBC-2.43*# Hgb-7.2*# Hct-21.3*#
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.1 Plt Ct-283
[**2117-3-30**] 07:34PM BLOOD Hct-26.6*
[**2117-3-31**] 04:10AM BLOOD WBC-8.9 RBC-3.77*# Hgb-11.1*# Hct-31.6*
MCV-84 MCH-29.5 MCHC-35.2* RDW-16.2* Plt Ct-207
[**2117-3-31**] 06:44PM BLOOD Hct-30.2*
COAGS:
[**2117-3-30**] 12:55PM BLOOD PT-13.6* PTT-29.0 INR(PT)-1.2*
[**2117-3-31**] 04:10AM BLOOD PT-13.2 PTT-29.3 INR(PT)-1.1
CHEMISTRY:
[**2117-3-30**] 12:55PM BLOOD Glucose-298* UreaN-43* Creat-1.4* Na-138
K-4.8 Cl-107 HCO3-23 AnGap-13
[**2117-3-31**] 04:10AM BLOOD Glucose-157* UreaN-33* Creat-1.1 Na-141
K-4.1 Cl-111* HCO3-22 AnGap-12
CARDIAC ENZYMES:
[**2117-3-30**] 12:55PM BLOOD CK(CPK)-224*
[**2117-3-30**] 12:55PM BLOOD CK-MB-7
[**2117-3-30**] 12:55PM BLOOD cTropnT-0.02*
[**2117-3-30**] 07:34PM BLOOD CK(CPK)-208*
[**2117-3-30**] 07:34PM BLOOD CK-MB-6 cTropnT-0.01
[**2117-3-31**] 04:10AM BLOOD CK(CPK)-172*
[**2117-3-31**] 04:10AM BLOOD CK-MB-5 cTropnT-0.02*
Brief Hospital Course:
MICU COURSE:
Patient presented with a hematocrit of 21 down from her baseline
of ~35. Gastroenterology was consulted and reported that this
was a likely diverticular bleed given her history of
diverticulosis on colonoscopies in the past. She was to be
treated conservatively with transfusions and monitoring. She
received a total of 4 units of packed red blood cells following
admission and had an appropriate HCT bump to 31.6. Serial HCTs
on [**2117-3-31**] revealed stabilized of her HCT at ~30 prior to
transfer to the floor. Her initial episode of chest pain in the
ED was not repeated following resuscitation with PRBCs. She had
a rule out for MI with three serial sets of cardiac enzymes with
downtrending CKs and normal troponins throughout. Concerning her
chronic kidney disease, at presentation she was at her baseline
Cr of approximately 1.3 and this fell to 1.1 on morning prior to
transfer out of MICU. Given her unknown volume status, her home
antihypertensives were initially held and after assurance of
stable hemodynamics, she was restarted on lisinopril. Concerning
her diabetes, she was managed with a lower dose of lantus given
that she was NPO when presenting to the unit. After
stabilization of her HCT, she began a diet of clears that was to
be advanced as tolerated. In the MICU the patient had no bowel
movements and was hemodynamically stable throughout her stay in
the MICU. She was feeling well when transferred out of the MICU.
.
MEDICINE FLOOR COURSE:
Patient had several red, guaiac positive BMs on the floor but
remained Hd stable and did not receive any further transfusions.
On the day of discharge, patient had guaiac postive stools that
was brown. Her lisinopril and metoprolol were continued but HCTZ
was held. Patient also had her ASA held given GIB with plan to
restart when she follows up with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] next week. She
was restarted on her home dose of Lantus on the floor and was
managed on an insulin sliding scale.
Medications on Admission:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
daily
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
daily
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
8. CALCIUM 500+D 500 (1,250)-200 mg-unit daily
9. Lantus 100 unit/mL Solution Sig: Forty Five (45) units SC at
HS.
10. Insulin Sliding Scale
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
Units Subcutaneous at bedtime.
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
9. Insulin Aspart Subcutaneous
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: GI bleed requiring blood transfusion
Secondary: Diabates, Chronic kidney disease, Coronary artery
disease
Discharge Condition:
stable, afebrile
Discharge Instructions:
You presented to the hospital with a gastroentestinal bleed.
This was felt to be secondary to diverticula (or outpouchings)
in your colon. You were initially admitted to the ICU for
monitoring and received 4 units of blood. Your blood counts
stablaized prior to discharge and you were tolerating a regular
diet.
.
All of your medications were continued except aspirin and
hydrochlorothiazide which you should continue to hold until you
see Dr. [**Last Name (STitle) 131**] next week. Please keep your appointment with Dr.
[**Last Name (STitle) 131**] this [**Last Name (STitle) 2974**].
.
Please seek immediate medical attention if you note blood in the
stool, dizziness, shortness of breath, chest pain, abdominal
pain, vomitting, fevers, chills or any change from your baseline
health status.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 131**] at your previously scheduled
appointment on [**2117-4-9**]. Call [**Telephone/Fax (1) 133**] if you need to
reschedule.
Completed by:[**2117-4-4**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 858
} | Medical Text: Admission Date: [**2130-7-16**] Discharge Date: [**2130-7-18**]
Date of Birth: [**2043-4-12**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**Last Name (un) 11220**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
R IJ central line placement and removal
History of Present Illness:
History of Present Illness: Mr. [**Known lastname 13639**] is 87M with history of
dementia, diastolic CHF (EF%60), HTN who presented s/p fall.
The patient was taking a shower at 3AM this morning when her son
her a pounding sound. The patient's son found the patient
laying on the floor of the shower; unsure if there was LOC. The
patient reports that he was in the shower this morning when he
slipped and fell; denies hitting his head. Denies any chest
pain, denies any shortness of breath. Denies having any light
headedness or dizziness.
In the ED, initial VS were 91/68 90 RR 34. While in the ED, the
patient's only complaint was back pain, which moved after he was
transferred off stretcher. The patient was noted to be
tachycardic to the 160s by EMS. Of note, as per report, the
patient was given Dilt by EMS during transit to [**Hospital1 18**].
The patient was intermittently tachycardic while in the ED with
heart rates to the 110s. His pressures dropped as low as the 60s
systolic; the patient responded to IVF with pressures recovering
to the 90-100s. However, his pressures soon dropped again into
the 70s and a R IJ was placed and the patient was started on
Levophed. The patient was also initially 86% on RA, and
maintained his sats on face mask. The patient also had multiple
imaging studies done, with no e/o acute source of infection, or
any acute intracranial pathology. Labs notable for white count
of 14, lactate of 5.8. EKG with e/o LBBB c/w priors, Scarbossa
criteria negative. In total the patient received 3L IVF, and
was given Vanc/Cefepime, in addition to being started on
Levophed.
On ROS, the patient denies having any fevers/chills. Denies any
shortness of breath, no trouble breathing. Denies any chest
pain. Denies any nausea/vomiting, no abdominal pain. Denies
any coughing. Denies any pain or burning with urination.
On arrival to the MICU, patient's VS 94.5 124/59 62 24 100% on
50% high flow mask. The patient reports feeling well, without
any current complaints.
Past Medical History:
Patient without regular medical follow up, and self prescribes
his own medications.
Hypothyroidism
Bilateral hypoacusis, s/p bilateral hearing aids
Right eye retinal detachment
Severe myopia s/p surgery with residual exotropia
Atrial flutter
Diastolic CHF
Dementia
HTN
Anemia
Ezcema
Social History:
Patient is a retired primary care physician. [**Name10 (NameIs) **] for
activities of daily living. He takes care of his wife, who has
developed dementia. Lives with his son, who is 57 years old and
has dyslexia. Has not smoked for many years. Denies any alcohol
consumption or other illicit drug use.
Family History:
Noncontributory. There is no family history of premature
coronary artery disease or sudden death.
Physical Exam:
ADMISSION EXAM:
91/68 90 RR 34
General: elderly gentleman, NAD, laying comfortably in bed,
alert and appropriately answering questions, alert and oriented
to person, place, time
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, + R sided
surgical pupil
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, soft SEM loudest at RUSB, S1 + S2
Lungs: crackles throughout lung fields, good air movement, no
audible wheezes appreciated
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: + foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry areas of skin with flaking prominently on head/scalp
and lower extremities; 2cm skin abrasion on coccyx, area clean
with no e/o drainage
Neuro: CNII-XII intact, muscle strength and sensation grossly
intact, noted to have resting tremor at baseline, worse with
movement
Pertinent Results:
ADMISSION LABS:
[**2130-7-16**] 04:45AM BLOOD WBC-14.5* RBC-4.46* Hgb-13.9* Hct-43.4
MCV-97 MCH-31.2 MCHC-32.1 RDW-14.5 Plt Ct-295
[**2130-7-16**] 04:45AM BLOOD Neuts-87.5* Lymphs-7.3* Monos-1.4*
Eos-3.5 Baso-0.3
[**2130-7-16**] 04:45AM BLOOD PT-11.9 PTT-24.8* INR(PT)-1.1
[**2130-7-16**] 04:45AM BLOOD Glucose-291* UreaN-33* Creat-1.7* Na-141
K-3.2* Cl-101 HCO3-19* AnGap-24*
[**2130-7-16**] 04:45AM BLOOD ALT-26 AST-35 CK(CPK)-164 AlkPhos-101
TotBili-0.6
[**2130-7-16**] 04:45AM BLOOD cTropnT-0.07*
[**2130-7-16**] 04:45AM BLOOD Albumin-4.0 Calcium-9.7 Phos-2.6* Mg-1.8
[**2130-7-16**] 04:49AM BLOOD Lactate-5.8*
INTERVAL LABS:
[**2130-7-16**] 04:45AM BLOOD CK-MB-3
[**2130-7-16**] 10:19AM BLOOD CK-MB-9 cTropnT-0.17*
[**2130-7-17**] 03:28AM BLOOD CK-MB-8 cTropnT-0.09*
[**2130-7-16**] 10:19AM BLOOD WBC-14.2* RBC-3.76* Hgb-11.7* Hct-35.6*
MCV-95 MCH-31.2 MCHC-32.9 RDW-14.3 Plt Ct-277
[**2130-7-17**] 03:28AM BLOOD WBC-9.5 RBC-3.52* Hgb-10.9* Hct-33.7*
MCV-96 MCH-31.0 MCHC-32.3 RDW-14.4 Plt Ct-230
[**2130-7-16**] 10:19AM BLOOD Glucose-176* UreaN-28* Creat-1.1 Na-143
K-3.0* Cl-108 HCO3-24 AnGap-14
[**2130-7-17**] 03:28AM BLOOD Glucose-98 UreaN-23* Creat-0.8 Na-140
K-3.7 Cl-109* HCO3-19* AnGap-16
[**2130-7-16**] 10:19AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.5*
[**2130-7-17**] 03:28AM BLOOD Calcium-8.3* Phos-1.9* Mg-2.2
[**2130-7-16**] 04:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-7-16**] 10:45AM BLOOD Lactate-1.6
[**2130-7-16**] 10:45AM BLOOD freeCa-1.13
[**2130-7-16**] 05:40AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-7-16**] 05:40AM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-1
[**2130-7-16**] 05:40AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2130-7-16**] 05:40AM URINE Hours-RANDOM UreaN-645 Creat-163 Na-24
K-94 Cl-33
IMAGING:
-----------
CT C SPINE:
1. No evidence of acute fracture.
2. Extensive degenerative changes in the cervical spine, worse
from C2 through C7 levels, with multilevel moderate spinal canal
stenosis and neural foraminal narrowing.
3. A 2.3 cm calcified right thyroid lobe nodule.
-----------
NCHCT:
No evidence of hemorrhage or recent infarction. Old right
parietal and frontal infarctions. Severe involutional changes.
-----------
CT TORSO:
1. No acute traumatic injury identified in the chest, abdomen
and pelvis.
2. Extensive atherosclerotic disease of the thoracoabdominal
aorta, with
ectasia of the infrarenal aorta measuring 2.7 cm. High-grade
stenosis at the right renal artery origin. Extensive coronary
arterial calcification.
3. A 4 mm right upper lobe pulmonary nodule. If the patient
does not have risk factors for lung cancer, no further followup
is required. In the presence of risk factors, followup chest
CT in a year is recommended.
4. Mild small airways wall thickening especially in the left
lower lobe,
suggestive of bronchitis.
5. Cholelithiasis.
----------
ECHO:
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is mildly depressed
(LVEF= XX %). The right ventricular cavity is mildly dilated
with borderline normal free wall 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. 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. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild biventricular dilation with mild biventricular
global hypokinesis. Moderate mitral regurgitation. Moderate
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of [**2128-4-27**], the
severity of tricuspid regurgitation has increased. Estimated
pulmonary artery systolic pressures are slightly higher. The
right ventricle was probably mildly dilated with borderline
systolic function on the prior echo also.
Brief Hospital Course:
Assessment and Plan: Mr. [**Known lastname 13639**] is 87M with history of dementia,
diastolic CHF (EF%60), HTN who presented s/p fall found to have
elevated white count and lactate in the ED, as well as some
hypotension who was started on Levophed.
# Hypotension: The patient was found to be hypotensive in the ED
in the settting of elevated lactate and white count. He had
been afebrile, as per report, with no clear evidence of source
of infection. CXR negative for any acute pulmonary process, UA
negative for nitrite/leuks; cultures NGTD at discharge. The
patient also had e/o skin abrasion on lower back -- not
infected. Lactate initially elevated to 5.8 with acute rise in
creatinine as below. Patient initially required levophed which
was quickly weaned once in the MICU. He was started on levoquin
out of concern for possible respiratory process seen on CT
chest, but this was stopped after further review. LENIs were
performed for evalaution of possible pulmonary embolism causing
his symptoms and were negative. All of the patient's lab
abnormalities corrected with IV fluid arguing for hypovolemia
rather than sepsis as no source of infection could be
identified.
.
# Acute renal failure: The patient had a baseline creat of 0.9;
1.7 on presentation. Urine lytes suggestive of prerenal,
corrected with volume resusitation.
.
# Troponin leak with atrial flutter and RVR: The patient was
noted to have troponin of 0.07; baseline 0.02. No chest pain,
peaked at 0.17, cardiology consulted felt related to demand,
ECHO unchanged from prior. The patient has previously refused
treatment of his tachy-brady syndrome, so no changes were made
to his medications. He had no further issues during this
hospitalization.
.
# Elevated CK: likely from small amount of rhabdo due to fall.
Was resolving at discharge.
.
# Hypoxia: The patient was initially noted to be hypoxic in the
ED satting 86% on RA. He was transferred to the unit on 50%
high flow mask. He was easily weaned to room air.
.
# S/p fall: The patient fell while in the shower; as per OMR
documentation, he apparently has fallen the shower before.
Based on history, it seems like this was a mechanical fall.
Trauma work up negative. Physical therapy cleared the patient
to go home with home PT, home nursing and home safety eval.
This plan was discussed extensively with the patient and his son
[**Name (NI) **] and both felt it was reasonable and safe.
.
# Dementia: The patient has history of dementia, independent
with his ADLs, but needs assistance with cooking, cleaning, etc.
There were no issues with this during the hospitalization.
# Diastolic CHF: no evidence of acute failure despite 4 L of
fluid resusitation. ECHO unchanged from prior.
.
# HTN: Stopped his HCTZ at discharge given that it likely
caused/exacerbated his dehydration that led to the fall.
# Other: A calcified thyroid nodule was seen on his CT spine,
and may require outpatient follow-up.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver Admission
note.
1. Aspirin 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Calcitriol 0.25 mcg PO 1X/WEEK (MO)
5. Thyroid 90 mg PO DAILY
6. potassium citrate *NF* 10 mEq Oral DAILY
Aka "Klyte"
7. famciclovir *NF* 500 mg Oral TID
8. Vitamin A Dose is Unknown PO DAILY
9. Thiamine 100 mg PO DAILY
10. Triamcinolone Acetonide 0.1% Cream Dose is Unknown TP
Frequency is Unknown
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thyroid 90 mg PO DAILY
4. Calcitriol 0.25 mcg PO 1X/WEEK (MO)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Dehydration leading to a fall
Dementia
Diastolic heart failure, ejection fraction 60%
Atrial flutter
Hypertension
Anemia not otherwise specified
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 after a serious fall at home, and were found
to have low blood pressure, fast heart rate and dehydration.
You were given intravenous fluids, and these problems resolved.
I suspect you fell due to dehydration -- you need to stay better
hydrated. You should be urinating several times a day, clear to
light yellow in color. If it's darker, you're dehydrated and
need to drink more. You are at risk for future falls and as a
result need home nursing, home physical therapy and a home
safety evaluation.
Followup Instructions:
2.3 cm calcified thyroid nodule seen on CT spine. [**Month (only) 116**] require
outpatient follow-up.
Department: GERONTOLOGY
When: WEDNESDAY [**2130-7-26**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
Completed by:[**2130-7-18**]
ICD9 Codes: 5849, 4019, 2449, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 859
} | Medical Text: Unit No: [**Numeric Identifier 69928**]
Admission Date: [**2165-1-2**]
Discharge Date: [**2165-1-19**]
Date of Birth: [**2165-1-2**]
Sex: M
Service: NB
IDENTIFICATION: Baby boy [**Known lastname **] #1 is a 16-day old former 34-
week twin infant who is being discharged from the [**Hospital1 18**]
Neonatal Intensive Care Unit.
HISTORY: Baby boy [**Known lastname **] was born on [**2165-1-2**] as
the 2245-gram product of a 34-week twin gestation to a 32-
year-old gravida 2, para 1 (to 3) mother with [**Name (NI) 37516**] of [**2165-2-13**]. Prenatal laboratory studies included blood type O+,
antibody negative, RPR nonreactive, rubella immune, hepatitis
B surface antigen negative and group B strep unknown. The
pregnancy was notable for spontaneous monochorionic-diamniotic
twin gestation and was complicated by an 18-week ultrasound
showing growth discrepancy with oligohydramnios of one twin
and polyhydramnios of the other twin, consistent with
twin/twin transfusion syndrome. Mother was followed closely
by the maternal fetal medicine service and underwent amniotic
reduction at 18 weeks and again at 26 weeks. Amniotic fluid
volumes appeared to equilibrate following the procedure,
suggesting the possibility of an inadvertent septostomy.
Donor twin, initially labeled as twin A in utero and
subsequently found to be nonpresenting, remained growth
restricted underneath the 10th percentile but did show
appropriate interval growth. Doppler flow studies were
reassuring, and fluid has been seen in both bladders and
stomachs. Due to the presence of the growth restriction of
the donor twin and the twin-twin transfusion syndrome,
delivery was scheduled for today at 34 weeks by C-section.
Mother had been given a course of betamethasone 2 weeks
earlier. She was not in labor at the time of delivery and did
not receive intrapartum antibiotics. At delivery, twin #1
emerged vigorous with good tone; requiring only brief blow-by
oxygen. Apgars were 8 and 9. The infant was brought to the
NICU.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2245 grams, 50th
to 75th percentile; head circumference 32 cm, 50th to 75th
percentile; length 43.5 cm, 25th to 50th percentile. The
infant was an active premature infant with moderate
respiratory distress and was started on CPAP. Skin was warm
and pink. The facies were nondysmorphic. Fontanelles are soft
and flat. Ears and nares were normal. Palate was intact. Neck
was supple without lesions. Chest was coarse with moderate
aeration and moderate retractions and flaring. Cardiac was
regular rate and rhythm without murmurs. Abdomen was soft
without hepatosplenomegaly and with no masses. Umbilical cord
had 3 vessels. Genitalia was that of a normal male with
testes descended bilaterally. Anus was patent. Hips and back
were normal. Tone and activity were appropriate.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The infant exhibited mild-to-moderate
respiratory distress syndrome and was treated with CPAP
support for 2 days. By day of life #2, the infant was
able to be weaned to room air and has remained in room
air since that time. The infant did not exhibit apnea of
prematurity, and no spells were noted.
2. CARDIOVASCULAR: The infant remained hemodynamically
stable throughout admission. A murmur was noted prior to
discharge, and this was evaluated with a chest x-ray, EKG
and 4-extremity blood pressures; all of which were within
normal limits. No further evaluation was performed.
3. FEN: The infant was initially maintained on IV fluids.
Enteral feedings were introduced on day of life #2. These
were advanced without difficulty to full enteral feedings
with a maximum caloric density of 24 calories per ounce.
By the time of discharge, the infant is feeding breast
milk supplemented to 24 calories per ounce or Similac 24
calories per ounce, all p.o. on an ad lib basis with
adequate intake and adequate weight gain. Urine and stool
output have been normal. Discharge weight was 2370 gm.
4. GI: The infant did exhibit hyperbilirubinemia of
prematurity, treated with phototherapy for 48 hours.
Maximum bilirubin level was 11.2 on day of life #5.
5. ID: The infant did undergo a sepsis evaluation following
delivery with an unremarkable CBC and a negative blood
culture. The infant received 48 hours of antibiotics,
which were then discontinued.
6. HEMATOLOGY: Hematocrit at birth was 45.2.
Repeat hematocrit on [**1-17**] was 36.2 with a
reticulocyte count of 1.3%. The infant has been treated
with iron supplementation.
7. NEUROLOGY: The infant has maintained a normal neurologic
exam throughout admission.
8. SENSORY: The infant passed the hearing screen prior to
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38832**] [**Hospital 50079**].
CARE AND RECOMMENDATIONS:
1. Diet: Breast milk or Similac supplemented to 24 calories
per ounce and then switch to breast feeding.
2. Medications: Fer-In-[**Male First Name (un) **] 2 mg/kg/day.
3. State newborn screening status: Initial State newborn
screen on [**1-5**] reported an elevated 17-OH
progesterone level. A repeat specimen was sent on
[**1-9**], results of which are pending at the time of
discharge. Electrolytes were checked at that time, and
they were within normal limits.
4. Car seat position screening was performed and passed.
5. Immunizations: The infant received synagis and hepatitis B
vaccine [**Date range (1) 69929**].
6. Immunizations recommended:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of
the following 3 criteria: (1) born at less than 32
weeks; (2) born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway
abnormalities, or school-age siblings; or (3) with
chronic lung disease.
2. Influenza immunization is recommended annually in the
Fall for all infants once they reach 6 months of age.
Before this age (and for the first 24 months of the
child's life) immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
7. Follow-up appointments: The infant will follow up with
primary pediatrician 3 days after discharge. A VNA
referral will be made.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks.
2. Twin gestation.
3. Presumed recipient twin of twin-twin transfusion
syndrome.
4. Respiratory distress syndrome.
5. Hyperbilirubinemia of prematurity.
6. Sepsis evaluation.
7. Physiologic murmur.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2165-1-18**] 12:04:01
T: [**2165-1-18**] 12:57:41
Job#: [**Job Number 69930**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 860
} | Medical Text: Admission Date: [**2132-4-22**] Discharge Date: [**2132-5-2**]
Date of Birth: [**2090-7-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Dyspnea and hypoxia following resection of left renal mass
Major Surgical or Invasive Procedure:
L nephrectomy
Bronchoscopy
History of Present Illness:
This is a 41 year old man with a PMH significant for Factor V
Leiden mutation, who is now POD2 s/p resection of a left renal
mass, who had episodes of oxygen desaturation on the floor and
for whom a CT showed likely mucus plugging. He was transferred
to the [**Hospital Unit Name 153**] for planned bronchoscopy by the interventional
pulmonology service.
.
He originally presented with back pain and in the process of
workup for this got an MRI which incidentally showed a 2 cm left
renal mass. A CT scan confirmed the presence of the mass. He
came to Dr. [**Last Name (STitle) **] for urological follow-up, who scheduled and,
on [**4-22**], performed an open partial nephrectomy to resect the
mass. This included chest tube placement in the left; the chest
tube was pulled [**4-23**]. At midnight [**Date range (1) 62333**], he had a trigger on
the floor for hypoxia and fever, with temp 102.2 and O2
saturation of 87% on 3.5L NC. This increased to 92% with 5L NC
and use of an incentive spirometer. At that time, the covering
MD noted that he was "asymptomatic" without SOB, CP, dyspnea,
N/V, chills, or calf pain. An ABG at that time was 7.38/52/74 on
5L NC.
.
A PE protocol CT chest was ordered stat, and a provisional read
showed "Small left pneumothorax... [and] obstructive atelecatsis
of the left lower lobe and right middle and lower lobe due to
fillings of the lower lobe bronchi, most likely mucous plug."
.
An EKG done around that time appears to show diffuse T-wave
flattening compared to his earlier pre-op EKG but otherwise
without diagnostic focal changes.
.
On the floor today, he continued to be febrile for much of the
day, with Tmax of 102.8 at 1415; he continued to require oxygen
support of 5L NC with 40% facemask for much of the day, with
oxygen saturations in the mid 90s to this. He was also
tachycardic to the 110s-120s for most of the day.
Past Medical History:
Lower extremity DVT in [**2127**], diagnosed with heterozygous Factor
V Leiden mutation; on coumadin, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2805**]
Right leg vein stripping for varicose veins, [**2128**]
Essential tremor
Social History:
Professor [**First Name (Titles) **] [**Last Name (Titles) 20367**] at [**University/College **]. Married. Quit smoking
in [**2120**], was light smoker before then. 3 glasses of
alcohol/month. Denies recreational or IV drug use.
Family History:
Mother and sister with factor V Leiden mutation; sister w past
DVT
Physical Exam:
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), ([**Year (4 digits) **] Sounds:
Bronchial: , Rhonchorous: diffusely)
Abdominal: Soft, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
x3, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2132-4-22**] 06:09PM GLUCOSE-131* UREA N-10 CREAT-1.3* SODIUM-142
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
[**2132-4-22**] 06:09PM estGFR-Using this
[**2132-4-22**] 06:09PM MAGNESIUM-1.8
[**2132-4-22**] 06:09PM WBC-14.3*# RBC-4.64 HGB-13.8* HCT-39.9*
MCV-86 MCH-29.6 MCHC-34.5 RDW-13.9
[**2132-4-22**] 06:09PM PLT COUNT-157
[**2132-4-22**] 06:09PM PT-16.6* PTT-22.0 INR(PT)-1.5*
[**2132-4-22**] 11:45AM PT-16.6* PTT-29.3 INR(PT)-1.5*
[**2132-4-28**] 06:05AM BLOOD WBC-8.9 RBC-3.39* Hgb-10.1* Hct-29.8*
MCV-88 MCH-29.9 MCHC-34.1 RDW-13.8 Plt Ct-191
[**2132-4-27**] 04:30AM BLOOD WBC-11.6*# RBC-3.61* Hgb-10.8* Hct-31.9*
MCV-88 MCH-29.7 MCHC-33.7 RDW-13.7 Plt Ct-157
[**2132-4-28**] 06:05AM BLOOD Neuts-82.0* Lymphs-10.2* Monos-5.3
Eos-2.3 Baso-0.1
[**2132-4-28**] 06:05AM BLOOD PT-27.8* PTT-38.2* INR(PT)-2.8*
[**2132-4-27**] 05:10PM BLOOD PT-41.8* PTT-51.5* INR(PT)-4.6*
[**2132-4-27**] 04:30AM BLOOD Plt Ct-157
[**2132-4-27**] 04:30AM BLOOD PT-35.1* PTT-41.8* INR(PT)-3.7*
[**2132-4-26**] 03:28AM BLOOD Plt Ct-154
[**2132-4-28**] 06:05AM BLOOD Glucose-103 UreaN-14 Creat-1.3* Na-141
K-3.1* Cl-104 HCO3-28 AnGap-12
[**2132-4-27**] 05:10PM BLOOD Na-139 K-4.1 Cl-103
[**2132-4-27**] 04:30AM BLOOD Glucose-103 UreaN-16 Creat-1.4* Na-134
K-3.9 Cl-101 HCO3-23 AnGap-14
[**2132-4-26**] 03:28AM BLOOD Glucose-95 UreaN-14 Creat-1.3* Na-141
K-3.9 Cl-102 HCO3-29 AnGap-14
[**2132-4-25**] 04:32AM BLOOD ALT-26 AST-40 AlkPhos-64 Amylase-84
TotBili-1.0
[**2132-4-28**] 06:05AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.3
[**2132-4-27**] 04:30AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0
[**2132-4-26**] 03:28AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.0
[**2132-4-25**] 12:34PM BLOOD Type-ART pO2-67* pCO2-53* pH-7.40
calTCO2-34* Base XS-5
[**2132-4-25**] 05:54AM BLOOD Type-ART FiO2-100 O2 Flow-15 pO2-52*
pCO2-50* pH-7.42 calTCO2-34* Base XS-6 AADO2-630 REQ O2-100
Intubat-NOT INTUBA
CTA:
IMPRESSION:
1. Given a borderline suboptimal study, there is no pulmonary
embolism to the
segmental level.
2. Obstruction of the bronchus intermedius and all segmental
bronchi of the
left lower lobe, likely due to mucus plugging, causing complete
collapse of
the middle lobe, right lower lobe, and almost all the left lower
lobe.
3. New dependent opacities in the left upper lobe, lingula and
less in the
right upper lobe, could be due to aspiration.
4. Left thyroid hypodensity, should be evaluated by ultrasound
if not already
known.
5. Extensive post-operative changes of left partial nephrectomy.
6. Small left pneumothorax.
Echo
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a small pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal global and regional
leftventricular systolic function. Mild left ventricular
hypertrophy. Right ventricle could not be adequately assessed.
Brief Hospital Course:
41 yo M w PMHx of Factor V leiden mutation and DVT, L renal mass
sp partial L nephrectomy w post-op complications of fever,
hypoxia
.
#. Hypoxia - [**12-31**] to multiple etiologies. Initially thought to be
due to mucus plugging but the due to aspiration vs
hospital-acquired pneumonia with ?component of fluid overload.
Pt needed to be on bipap w high oxygen requirement which was
been weaned down to RA. Pt continues to do well on RA. is sp 7
day course of IV Vanc/Zosyn for HAP.
.
#. Cdiff colitis - continue oral vancomycin. Will tx for 2 weeks
p last abx dose. Low grade temps likely to resolving cdiff
colitis. Pt reports that diarrhea is getting better.
.
#. Hx of L renal mass sp partial nephrectomy - Urology
following. Wound site looks good. Path report from nephrectomy
shows angiomyolipoma, no cancer. Outpt FU w Dr. [**Last Name (STitle) **] at dc
next thursday
.
#. Hx of Factor V Leiden mutation and DVT - seen by heme preop
and coumadin w goal INR of [**12-31**].5 4-6 weeks post op. His INR was
supratherapeutic in ICU, so coumadin was held and vitamin K
given, Coumadin restarted at low dose. INR on day of dc was 1.9.
Discussed w primary hematologist and dc on coumadin alone at 2mg
MWF and 1mg T,T, Sat, [**Doctor First Name **] dose and INR check on monday
.
#. Anemia - likely from post-op blood loss.remained stable
throughout hospital stay around 30-31.
.
#. R flank discomfort - At one point pt complained of R flank
pain, likely MSK but was resolved at dc. UA only showed 13 RBC,
not concerning for renal stone. pain resolved on its own
.
# ?CKD- Baseline Cr ~1.2, given young age, nl for pt his age. Cr
flucutated but remained around 1.3 at dc.
.
.
Medications on Admission:
Home medications:
Warfarin 5 mg daily
Advil 600 mg prn ("occasionally")
Propranolol 20mg, prn ("very occasional" per pre-op med list)
for palpitations before presentations
Fish oil
MVI
.
Transfer medications:
cefazolin 2 g IV q8h
acetaminophen 650 pr q4H: prn fever
maalox 15-30 po qid:prn heartburn
dilaudid PCA 0.25 mg lockout 6 mins, basal 0, 1 hr max 2.5 mg
ondansetron 4 mg IV q4H: prn nausea
docusate sodium 100 mg po BID
diphenhydramine 25-50 mg q6h: prn pruritus or insomnia
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. Warfarin 2 mg Tablet Sig: use as directed below Tablet PO
once a day: take 2mg (1tab) on M, W, F and 1mg on tues, thurs,
sat, sun ([**11-30**] tab).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
-SP L partial nephrectomy for renal mass - confirmed to be
angiomyolipoma
-Healthcare assoicated pneumonia
-C diff colitis
Discharge Condition:
Good
Discharge Instructions:
-You were admitted to the hospital for partial removal of Left
kidney due to a mass, which turned out not be cancer. After
surgery you developed complications of mucus plugging and
pneumonia. You also developed an infection of your bowel called
C diff colitis. You finished the course of IV antibiotics for
the pneumonia. You will need to take 2 additional weeks of oral
vancomycin for the Cdiff colitis. If at the end of the oral
antibiotic course you are still having diarrehea, abdominal pain
or fevers, you need to let your doctor know as you may need
additional antibiotics.
You have hx of factor V leiden mutation which makes you
vulnerable to form blood clots especially around surgery, so per
your hematologist, you have been placed on coumadin which will
be continued for about 4-6 weeks after your surgery. Please
follow up with them regarding INR checks and coumadin adjustment
Please call your doctor right away or return to ED for fevers,
chills, abdominal pain, chest pain, shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**]
concerning signs of infection at the incision site, worsening
diarrhea
Followup Instructions:
1. Urology, Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2132-5-8**] 3:30
2. PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14477**], ph: [**Telephone/Fax (1) 25302**], Appt is on Tuesday, [**5-6**], 9:00 AM
3. Hematology, RN [**Doctor Last Name 9449**], ph: [**0-0-**]. Come to [**Hospital Ward Name 23**] 9,
have blood drawn for INR check and [**Doctor Last Name 9449**] will call you with
results
ICD9 Codes: 486, 2851, 5185, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 861
} | Medical Text: Admission Date: [**2190-3-3**] Discharge Date: [**2190-3-6**]
Date of Birth: [**2120-12-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Bloody Emesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 69 year old male with a history of HTN, gastric
ulcers, HLD and old CVA who woke up this morning feeling weak,
dizzy and diaphoretic. He then went to the bathroom and had
some bloody emesis and bloody bowel movements. He does not
describe melena rather bloody appearing stools. He called [**Company 191**]
who advised a call to EMS, and he was tranferred to the ED. He
was in his usual state of health prior to this. No recent
infections or bowel movement changes.
.
Of note patient reports that he had an upper GI bleed similar to
this in the late 70s early 80s which was due to an ulcer
possibly related to EtOH. At that time he required 6 U of PRBC.
.
In the ED, initial vs were: 97.3 82 142/94 20 100. An NG tube
was placed that revealed about 200cc of coffee ground emesis
with some bright red blood. The BRB cleared after 200cc NS was
flushed. He was given 1L of normal saline and protinix IV x
40mg. Two 18G PIV were placed. His vitals at the time of
transfer were: 89 139/92, 16, 100% RA
.
On the floor, patient was mildly tachycardic ranging from
87-130. He was not complaining of anything.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
hypertension, not treated
possible diabetes
Social History:
Married, with two daughters and a son. Retired, used to work as
a manager of a manufacturing plant. Tobacco use was 1ppd x
approx 40yrs, now 1ppwk. Used to be a heavy drinker x 40yrs, now
EtOH only once a month. No drug use.
Family History:
DM, CAD in parents, brother. Children healthy. No strokes or
seizures.
Physical Exam:
Physical Exam on Admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress, NGT in place
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, one non tender freely mobile LN
in the L ant cervical chain
Lungs: Coarse breath sounds, rhales and rhonchi on right.
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, no bruits
ascultated.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on Admission:
[**2190-3-3**] 11:05AM BLOOD WBC-7.9# RBC-4.29* Hgb-11.8* Hct-37.9*
MCV-88 MCH-27.4 MCHC-31.1 RDW-15.4 Plt Ct-232
[**2190-3-3**] 11:05AM BLOOD PT-13.9* PTT-21.5* INR(PT)-1.2*
[**2190-3-4**] 04:05AM BLOOD Glucose-114* UreaN-21* Creat-0.9 Na-142
K-3.6 Cl-113* HCO3-22 AnGap-11
[**2190-3-3**] 11:05AM BLOOD ALT-40 AST-52* CK(CPK)-134 AlkPhos-68
TotBili-0.9
Labs on Discharge:
[**2190-3-6**] 08:05AM BLOOD WBC-5.9 RBC-4.11* Hgb-11.6* Hct-34.1*
MCV-83 MCH-28.2 MCHC-34.0 RDW-15.2 Plt Ct-206
[**2190-3-6**] 08:05AM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-142
K-3.3 Cl-108 HCO3-24 AnGap-13
Microbiology:
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2190-3-5**]): POSITIVE BY
EIA.
[**2190-3-4**]: Blood Cx x2: no growth to date
Studies:
EGD ([**2190-3-3**]): Erythema and petechiae in the stomach body
compatible with gastritis. Ulcer in the duodenal apex
(injection)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
This is a 69 year old male with a history of gastric ulcers,
HTN, HLD old CVA without deficits who had bloody emesis on
morning of admit.
Hematemesis: On admission, 2 large bore PIVs were placed and PPI
drip was initiated. NGT tube was placed and revealed about 200cc
of coffee ground emesis with some bright red blood. The BRB
cleared after 200cc NS was flushed. The patient's Hct fell from
a baseline of 41 to a nadir of 29. He was transfused a total of
3 units pRBCs. He underwent EGD which showed gastritis and a
non-bleeding ulcer in the duodenal apex which was injected with
epinephrine. The patient's antihypertensive medications were
held and he briefly needed NTG gtt for hypertension after volume
repletion. The patient had a single episode of temperatures to
101 during the time of transfusion. Blood culutres yielded no
growth prior to discharge. Following EGD, general surgery was
consulted who felt no surgical intervention was necessary.
Hematocrit stabilized and the patient required no further
transfusions. The patient'as diet was advanced and he tolerated
PO intake. He was switched to PO PPI [**Hospital1 **]. After positive H.
polyri antibody test, treatment for H. pylori was initiated with
Amoxicillin, Clarithromycin and PPI x 10 days. He will follow up
in [**Hospital **] clinic after discharge.
ECG changes: On the day of arrival, the patient had mild ST
depressions inferior/laterally which resolved with pRBC
transfusion and were not assoicated with CE leak. They were
likely related to demand in setting of bleed. Miocardial
infarction was ruled out by negative cardiac biomarkers.
HTN: Antihypertensives were transiently held in the setting of
GI bleed and re-started prior to discharge.
Hyperlipedemia: Atorvastatin was held in acute setting and
re-started after EGD.
Medications on Admission:
Atorvastatin 40mg daily
lisinopril 30mg daily
sildenafil 25mg prn sex
aspirin 325mg daily
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
5. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastritis, Upper GI bleed
Secondary: Hypertension, Hyperlipidemia
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 developed
lightheadedness, dizziness, vomited blood and had bleeding from
below. Tests performed at the hospital showed that you had a
bleed from your stomach or small intestine. An endoscopy was
performed to look for the source or bleeding and located an
ulcer, which was injected with epinephrine to help stop bleed.
After the procedure, you were observed closely to make sure you
did not have a repeat bleed. However, your red blood cells
remained stable and there was no evidence of further bleeding.
You tested positive for bacteria known as H. pylori, which
causes ulcers in the small intestine. We prescribed you
medicine to eracidate this bacterium. You are now ready to be
discharged home.
We made the following changes to your medicaitons:
1. We prescribed you Pantoprazole 40mg [**Hospital1 **]. Please make sure to
take this medicine as directed to prevent repeat bleeds. Do not
stop it unless told specifically to do so by your doctor.
2. We started you on Amoxicillin 1 gram twice a day. Please take
it for 8 more days, for a total of 10 days of antibiotics.
3. We started you on Clarithromycin 500mg twice a day. Please
take it for 8 more days, for a total of 10 days.
4. We stopped your Aspirin. Please do not take that medicine
until told otherwise by your doctor.
Please continue to take all your other medications as
prescribed.
You have follow-up appointments with your GI doctor and in
[**Hospital 1944**] clinic (see below).
If you develop any of the concerning symptoms, such as
dizziness, lightheadedness, changes in vision, bleeding from
below or vomiting blood, black stools, worsening abdominal pain,
please return to the Emergency Department right away.
Followup Instructions:
You have the following follow-up appointments:
Appoitment #1
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: [**Hospital3 **] Post [**Hospital **] Clinic
Date/ Time: [**Last Name (LF) 2974**], [**3-12**] at 10:30am
Location: [**Hospital3 **], [**Hospital Ward Name 23**] Clinical Center, [**Apartment Address(1) **] North, [**Location (un) 830**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 250**]
Special instructions for patient: This appointment is for follow
up to your hospitalization. You will then be connected to your
Primary Care provider after this visit.
Appointment #2
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: Gastroenterology
Date/ Time: Tuesday, [**3-16**] at 2:00pm
Location: [**Last Name (LF) **], [**First Name3 (LF) 452**] Bldg [**Location (un) **], [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 463**]
Completed by:[**2190-3-9**]
ICD9 Codes: 2851, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 862
} | Medical Text: Admission Date: [**2104-1-25**] Discharge Date: [**2104-2-1**]
Date of Birth: [**2045-12-2**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
CC: elevated blood sugar
Major Surgical or Invasive Procedure:
PICC
Renal Artery Stent
History of Present Illness:
56 yo M with history of renal cell cancer s/p nephrectomy and
renal transplant in [**2101**], hypertension who presents with 2 days
of general malaise, weakness, nausea, polyuria, polydipsia, and
chills. Pt notes 1 week h/o nonproductive cough. Denies fever,
CP, or SOB. Pt was seen in renal clinic today where he was noted
to have a glucose of >500. On arrival to [**Name (NI) **], pt found to have
glucose >900, T 99.1, BP 236/108. In ED given 10 units of SC
insulin x2 and then started on insulin gtt. Pt had a h/o DM
while on Prograf in [**2101**]. Not currently treated for DM. Pt was
transferred to the MICU and was placed on an insulin drip with
better sugar control was transferred to the floor.
Past Medical History:
Renal cell ca s/p L nephrectomy [**2093**]
s/p cadaveric renal transplant [**8-7**]
diabetes mellitus type 2
asthma- not treated, hospitalized as child
s/p left AV graft
h/o ciguatera poisening from barracuda ingestion
nasal polyps
hypertension
DM type 2
Barrett's esophagus
mild pulmonary hypertension
trivial MR
Social History:
married, works in nutrition at [**Hospital1 18**]
remote tob hs, no EtOH, no IVDA
Family History:
mother with renal disease
Physical Exam:
VS: Tm 98.4 Tc98.1 86 68-96 BP 170/39 150-204/39-82 RR 19
SaO2 96, 95-97 RA I/O 5300/750
Gen: well appearing male in NAD
HEENT: dry MM, PERRL, EOMI, No JVD
CV: rrr, SEM II/VI greatest RUSB
Chest: CTA b/l
Abd: soft, NT/ND, +BS
Ext: no edema, strong DP/PT pulses
Neuro: A&Ox3
Pertinent Results:
[**2104-1-25**] 09:15PM GLUCOSE-732* UREA N-18 CREAT-1.8* SODIUM-134
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-19* ANION GAP-21*
[**2104-1-25**] 06:49PM GLUCOSE-931* K+-6.1*
[**2104-1-25**] 06:30PM GLUCOSE-837* UREA N-20 CREAT-1.8* SODIUM-127*
POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-23 ANION GAP-20
[**2104-1-25**] 06:30PM CK(CPK)-294*
[**2104-1-25**] 06:30PM CK-MB-4 cTropnT-0.03*
[**2104-1-25**] 06:30PM CALCIUM-10.7* PHOSPHATE-2.3* MAGNESIUM-2.3
[**2104-1-25**] 06:30PM WBC-4.5 RBC-5.35 HGB-13.8* HCT-43.2 MCV-81*
MCH-25.8* MCHC-31.9 RDW-13.7
[**2104-1-25**] 06:30PM NEUTS-67.6 LYMPHS-26.6 MONOS-4.7 EOS-1.2
BASOS-0.1
[**2104-1-25**] 06:30PM HYPOCHROM-3+ MICROCYT-1+
[**2104-1-25**] 06:30PM PLT SMR-NORMAL PLT COUNT-168 LPLT-2+
[**2104-1-25**] 06:30PM PT-12.4 PTT-25.0 INR(PT)-1.0
[**2104-1-25**] 01:14AM GLUCOSE-692*
[**2104-1-25**] 01:14AM UREA N-19 CREAT-1.8* SODIUM-134 POTASSIUM-3.7
CHLORIDE-94* TOTAL CO2-30 ANION GAP-14
[**2104-1-25**] 01:14AM ALT(SGPT)-30 AST(SGOT)-19 TOT BILI-0.5
[**2104-1-25**] 01:14AM ALBUMIN-3.7 CALCIUM-10.4* PHOSPHATE-2.1*
[**2104-1-25**] 01:14AM rapamycin-14.6*
[**2104-1-25**] 01:14AM URINE HOURS-RANDOM CREAT-41 TOT PROT-207
PROT/CREA-5.0*
[**2104-1-25**] 01:14AM WBC-4.2 RBC-5.52 HGB-14.0 HCT-44.1 MCV-80*
MCH-25.3* MCHC-31.7 RDW-13.3
[**2104-1-25**] 01:14AM PLT SMR-NORMAL PLT COUNT-167
[**2104-1-25**] 01:14AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.036*
[**2104-1-25**] 01:14AM URINE BLOOD-TR NITRITE-NEG PROTEIN->300
GLUCOSE->1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2104-1-25**] 01:14AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
<BR>
CXR in ED: No active lung disease.
<BR>
ECHO: The left atrium is moderately dilated. There is probably
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size is
normal. Right ventricular systolic function is normal. The
aortic valve leaflets are mildly thickened. The study is
inadequate to exclude significant aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no
pericardial effusion.
<BR>
CXR [**1-26**] (after unsuccessful SC/IJ line attempts): Cardiac
silhouette and mediastinum is within normal limits. No
pneumothoraces are identified on either side. No parenchymal
opacities are seen. There is no evidence for gross pulmonary
edema.
<BR>
RUE US: No evidence of right upper extremity DVT.
<BR>
Renal Artery Cath:
1. Significant renal artery stenosis of the transplanted kidney.
2. Normal central blood pressure.
3. Successful stenting of transplant renal artery.
4. Successful Perclose Proglide closure of right femoral artery.
5. Successful Angioseal closure of left femoral artery.
<BR>
Renal US: Normal appearance of transplant kidney. No evidence
of
hydronephrosis.
<BR>
V/Q Scan: Low likelihood for pulmonary embolism.
<BR>
Abdominal/Pelvic CT:
1. No evidence of intra-abdominal hematoma.
2. Status post left nephrectomy, with a residual soft tissue
nodule of unclear etiology. If there is a neoplasm and any
concern for recurrence, comparison to prior studies could be
helpful if available.
3. Renal transplant in the right lower quadrant, with delayed
excretion of contrast from prior catheterization procedure.
4. Bibasilar atelectasis.
Brief Hospital Course:
Mr. [**Known lastname **] was initially treated for severe hyperglycemia in
the ICU, and once stable, transferred to the [**Location (un) **] Chief
Medicine Service for further evaluation of his symptoms and
underlying medical problems. During his admission, he was noted
to have severe HTN, and received surgical intervention for his
renal artery stenosis. He was also noted to be hypoxic on finger
pulse oximetry to 85% RA, leading to a workup for causes of this
hypoxia which was most likely [**2-7**] venous/arterial mixing of
blood in his extremities due to b/l shunts and grafts. SaO2 as
measured on his ear was much improved. His creatinine levels
rose slightly after the procedure, with concern for renal
toxicity from surgical contrast. CT scan was remarkable for a
small soft tissue mass in the area of his L nephrectomy, with
concern for malignancy. Renal team recommended f/u with repeat
CT scan in three months.
<BR>
1) Hyperosmolar Nonketotic Hyperglycemia: Upon initial
presentation to the [**Name (NI) **], pt. had glucose of 837. He had been
symptomatic for hyperglycemia for past several weeks
(polydipsia, polyuria, malaise). Pt was not on medications for
DM2 prior to admission. In [**2100**], he was noted to be
hyperglycemic, but this was thought to be [**2-7**] his Prograf and
this medication was changed. Random glucose in [**Month (only) 1096**] had been
measured at 214. His hyperglycemia was likely exacerbated by his
steroid medications. Other possibilities included viral syndrome
or bacterial bronchitis, although blood and urine Cxs were
negative. There was also a possibility that the renal artery
stenosis, combined with mild dehydration, could have lead to a
pre-renal azotemia that compounded the underlying hyperglycemia.
<BR>
The pt. was aggressively hydrated in the ICU and started on an
insulin drip until glucose levels returned to baseline. He was
then transferred to the floor with a RISS and followed by the
[**Last Name (un) **] endocrine service for modifications to his sliding scale.
Prior to d/c, pt. was educated about the use of insulin and
symptoms of hyper/hypoglycemia.
<BR>
2) HTN: Pt. stated that his BP has not been well controlled for
a long time, and that the loss of his R kidney had originally
been due to HTN. He was on an extensive list of medications for
bp at home, including amlodipine, clonidine, lisinopril,
valsartan, furosomide, and metoprolol. These medications were
optimized when possible, and hydralazine and nitro prn were also
added to his regimen. Metoprolol was switched to labetalol in
consult with the renal service out of concern for a paradoxical
interaction between his beta-blocker and the alpha-agonist. It
was thought that the beta-2 agonism and alpha-1 antagonism
effects of labetalol would avoid the risk of unopposed alpha-2
vasoconstriction. When his pressures remained elevated to the
190s on this aggressive regimen, interventional cardiology was
consulted to evaluate his known renal artery stenosis.
<BR>
A renal artery stent was placed on [**1-30**], at which time it was
determined that the stenosis had occluded 90% of the renal
artery, with a 30mmHg pressure gradient across the stenosis. His
bps were much improved the next day, and he was able to come off
of the nitro. Gradually, he was also taken off of his [**Last Name (un) **],
ACE-I, and hydralazine as SBPs remained 120s-140s out of concern
for preserved renal function.
<BR>
3) Hypoxia/SOB: The pt. complained of chest tightness upon
admission, and was ruled out for MI with three sets of cardiac
enzymes, EKGs, and telemetry. He had an ECHO which did not show
any acute processes. His symptoms resolved without intervention.
Once out of the ICU, the pt. was noted to have mild SOB on
occasion in the AM, stating he found it easier to breathe when
sitting upright. His O2 sats as measured on his fingers were
typically lowest overnight and in the AM, down to 85% on room
air, and ranging from 89-97% on 4LPM via nasal cannula. His O2
sat did not drop appreciably upon ambulation. Ddx for his SOB
was considered to be infectious/PNA/PCP [**Last Name (NamePattern4) **]. fluid overload vs.
cardiac vs. PE vs. OSA/obestity-hypoventilaion syndrome. He
stated that IV fluids made his SOB worse, but CXR showed no
acute process and physical exam showed clear lung sounds
throughout. The pt. was monitored with telemetry and EKGs to
monitor cardiac activity. The pt. was evaluated for PE w/ a V/Q
scan (CTA contraindicated given decreased renal function).
Blood/urine cultures were obtained and negative at 48 hours,
without evidence for an infectious process. An ABG showed
hypercapnea, hyperoxemia, and a normal pH and A-a gradient. The
level of hyperoxemia did not correlate with the SaO2 as measured
on the pulse oximeter on his fingers bilaterally. An oximeter
was applied to his ear, which indicated an SaO2 in the
middle-to-high 90s on RA, which better fit his clinical picture.
<BR>
A sleep study from the medical record had remarked about his
nocturnal hypoxia and symptoms concerning for OSA. Pt. was not
using CPAP/BiPAP at home as had been recommended. He was started
on BiPAP prior to discharge, with improvement in his oxygenation
and symptoms.
<BR>
4) Anemia: The pt. had a fall in hematocrit from 35.9 -> 29.6 on
the day following his cath. This was concerning for a femoral or
RP bleed, which was ruled out with a non-contrast CT. Crit
remained constant after the initial drop, and the retic count
was appropriately elevated.
<BR>
5) OSA: Pt previously had a sleep study at [**Hospital1 **] showing very bad
OSA. He has pHTN, daytime sleepiness, and apnea/[**Last Name (un) 6055**] [**Doctor Last Name 6056**]
breathing while sleeping. He was started on BiPAP while in
hospital and scheduled for follow-up in the sleep clinic.
<BR>
6) S/P Renal Transplant: Pt was continued on his home doses of
CellCept, Rapamune, and prednisone while in hospital. His
rapamycin trough was found to be within the therapeutic range.
His creatinine rose gradually on the days following his stent
placement, which was concerning for contrast toxicity. The rise
was gradual, however, and pt. was not thought to be in renal
failure or have the need for HD. He will need creatinine levels
monitored as an outpt.
<BR>
7) Soft Tissue Mass: A 14mm x 8mm soft tissue mass in the area
of the pt's L nephrectomy was seen on CT. This could be old
scarring, but given pt.'s Hx of RCC, could be malignancy. No CT
scan was available for comparison, so pt. was recommended to
repeat the CT in three months.
<BR>
8) FEN: Pt. was monitored with daily lytes, and repleted as
necessary. He was kept on a Cardiac/Diabetic diet. RISS was
initiated as described above.
<BR>
9) Access: Given difficultly of placing peripheral lines and
need for hydration/medications/procedure, pt. had a PICC placed.
It was removed prior to discharge.
<BR>
10) Code: Pt was FULL CODE on this admission.
Medications on Admission:
- Diovan 320 mg a day
- metoprolol 100 twice a day
- lisinopril 40 a day
- Norvasc 5 daily
- Lasix 40 mg a day
- clonidine 0.3 twice a day
- Rapamune 4 mg a day
- Bactrim single strength MWF
- CellCept [**Pager number **] twice a day
- baby aspirin
- prednisone 5 mg daily
Discharge Medications:
1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*12 Tablet(s)* Refills:*2*
3. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
9. 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*
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
Subcutaneous twice a day: Take 24 U in the morning.
Take 22 U in the evening.
Disp:*1 qs* Refills:*0*
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: Use per sliding scale.
Disp:*1 qs* Refills:*0*
12. Insulin Needles (Disposable) 29 X [**1-7**] Needle Sig: Four (4)
Miscell. four times a day.
Disp:*1 qs* Refills:*2*
13. Lab Work Sig: One (1) once a day: On [**2104-2-4**] please go to
the lab and have your CBC, Chem-10, drawn and faxed to Dr.
[**Last Name (STitle) **], and Dr. [**Last Name (STitle) 5717**]
[**Name (STitle) 21867**]10 = sodium, potassium, chloride, bicarbonate, bun,
creatine, magnesium, calcium, phosphate.
Disp:*1 time* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hyperosmolar Nonketotic Hyperglycemia, Diabetes
Mellitus Type 2, Renal Artery Stenois, Hypertension, Sleep
Apnea
<BR>
Secondary: s/p renal transplant
Discharge Condition:
stable
stable
Discharge Instructions:
-please continue with medications as prescribed
-please attend all of your appointments
-if symptoms of nausea, vomiting, headaches, shortness of
breath, chest pain/palpitations, leg swelling, or any other
concerning symptoms occur, please come back to the ED
immediately
-if you start to feel symptoms of increased thirst, increased
urination, dizziness, weakness, or fatigue, check your blood
sugar levels. If you are having trouble controlling your blood
sugar, please call the [**Hospital **] clinic or your primary doctor.
You will need to schedule the following appointment with your
primary doctor: CT scan of your abdomen and pelvis in 3 months.
Provider:
Followup Instructions:
You have the following appointments scheduled:
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2104-2-20**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-2-5**] 8:30
AM
[**Last Name (un) **] Diabetes with Dr. [**Last Name (STitle) 978**] on [**2104-2-5**] at 4:00pm
[**Last Name (LF) **],[**Name8 (MD) **] MD, SLEEP CLINIC Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2104-2-5**] 3:00 PM
You will need to schedule the following appointment with your
primary doctor: CT scan of your abdomen and pelvis in 3 months.
Provider:
ICD9 Codes: 2768, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 863
} | Medical Text: Admission Date: [**2189-11-14**] Discharge Date: [**2189-11-20**]
Service: MEDICINE
Allergies:
Sulfasalazine / Percocet
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is an 84 yo M with PMH of CVA w/residual weakness, CAD
s/p stent, h/o COPD, h/o aspiration PNA and chronic pleural
effusion/LLL collapse presenting with worsened dyspnea and cough
over two weeks. He reports that symptoms started two weeks ago
with increased dyspnea and a "head cold" and progressed to a
productive cough. He denies any fevers, does endorse 8 pound
weight gain and some increased leg edema. He has also been
using his nebulizer treatments more frequently as well increased
from QHS to TID.
.
Of note he was recently admitted from [**Date range (1) 94557**] and treated with
course of Vanc/Zosyn for HAP/aspiration pneumonia. In addition,
his wife was recently admitted with GPR bacteremia with growth
of Corynebacterium Diptheria on [**3-27**] blood culture bottles with
concern from ID consult of infection rather than contamination.
.
VS on arrival to the ED T99.4 BP 138/86 HR 84 RR 16 97% on 4L
NC. He had a CXR which showed stable LLL effusion with stable
LLL consolidation. He was given levofloxacin and flagyl to
treat aspiration pneumonia. While in the ED he had acute
episode of tachycardia, likely Afib with rate in the 140's-150's
with associated drop in blood pressure to 101/37. He was given
500ml NS and diltiazem 10mg IV x2, with improvement in HR to the
120's. He was admitted to the ICU [**1-24**] concern for persistent
tachycardia with borderline blood pressure.
Past Medical History:
1. Type 2 DM
2. Ulcerative colitis s/p ileostomy and colectomy
3. Hypertension
4. CAD s/p stent (90's)
5. s/p CVA X3 (94, 95, 96)
6. Prostate ca s/p XRT on Hormone therapy
7. Paget's disease
8. GERD
9. Esophageal ulcer and stricture
10. Venous stasis
11. Anxiety
12. Bladder Cancer secondary to prostate ca therapy
13. Macular Degeneration
14. Pulmonary Embolism [**2170**]
15. Anemia
16. Hyperlipidemia
17. Hearing Loss
18. Melanoma
Social History:
Patient lives at [**Hospital **] [**Hospital **] Nursing Home. Wife was in the
ICU. No smoking, EtoH or IVDU. Has local sons.
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL:
VS: T98.3 HR 132 BP 149/64 RR 24 95% 3L NC
Gen: alert, resting comfortably in NAD
HEENT: NC AT, dry mucous membranes
CV: irregularly irregular
Lungs: breath sounds diminished at bases L> R, scattered ronchi,
no wheezing
Abd: distended, nontender, ileostomy, no rebound or guarding,
normoactive bowel sounds
Ext: 1+ pitting edema in RLE, trace LE edeam LLE, DP's palpable
bilaterally
Pertinent Results:
Admission Labs:
WBC-10.9 RBC-3.58* Hgb-10.2* Hct-30.7* MCV-86 MCH-28.4 MCHC-33.2
RDW-15.3 Plt Ct-295
Neuts-88.7* Lymphs-5.5* Monos-4.1 Eos-1.4 Baso-0.3
PT-12.5 PTT-23.8 INR(PT)-1.0
Glucose-248* UreaN-34* Creat-2.1* Na-135 K-5.3* Cl-93* HCO3-30
AnGap-17
Calcium-8.9 Phos-3.2 Mg-1.3*
Lactate-2.6*
.
Labs on discharge:
WBC-10.6 RBC-3.17* Hgb-8.7* Hct-27.1* MCV-86 MCH-27.6 MCHC-32.2
RDW-14.4 Plt Ct-316
BLOOD Glucose-202* UreaN-36* Creat-1.9* Na-137 K-3.9 Cl-95*
HCO3-35* AnGap-11
BLOOD Calcium-9.2 Phos-3.1 Mg-1.9
.
Studies:
[**2189-11-14**] CXR - CONCLUSION:
1. Stable left basal effusion and left lower lobe consolidation.
2. Atelectasis at the right lung base.
3. Increased density and trabeculation in the right humerus is
unchanged and most likely related to Paget's disease.
Brief Hospital Course:
84 yo M with PMH of CVA w/residual weakness, CAD s/p stent, h/o
COPD, h/o aspiration PNA and chronic pleural effusion/LLL
collapse presenting with worsened dyspnea and cough over two
weeks, with new Afib w/RVR in the ED.
MICU Course:
Mr. [**Known lastname **] was admitted to the MICU with worsening and cough for
2 weeks in the setting of Afib with RVR. His SOB was in the
setting of new onset afib and an 8lb weight gain and it was
believed to due to afib. He was started on PO Diltiazem 15mg PO
QID but he had converted back to sinus rhythm by the time he
arrived in the ICU. He was continued on low dose Diltiazem for
control of his afib. His amlodipine was stopped due to
borderline hypotension in the setting of afib. He was continued
on his home COPD regimen of Spiriva and Atrovent and also
treated with Albuterol. He is being discharged on albuterol PRN.
Sputum and blood cultures were obtained and were negative.
Urine legionella was ordered and was negative. He was given an
insulin sliding scale for his diabetes. His blood pressure
stayed in the 120s-130s/50s and heart rate remained in the 70s
throughout his MICU stay.
.
# GI Bleed: The patient was transferred to the floor. He had
been started on a heparin drip and coumadin because of his A
fib. He began to pass blood and maroon stool through his
ostomy, and thus his heparin and coumadin was stopped. His HCT
nadired at 25.9 and gradually increased without blood
transfusion to 27.1. His HCT on admission was 30.7. The maroon
stool resolved and the patient was passing only brown stool and
no blood for the last 3 days prior to discharge. The goals of
care were discussed with patient and he did not want aggressive
care and he did not want a colonoscopy to investigate the source
of the bleeding.
.
#Dyspnea/cough: The patient's dyspnea and cough were likely due
to his COPD exacerbation in conjunction with his chronic lung
disease. He has known pleural effusion and long standing
emphysema. His atrial fibrillation likely exacerbated his
dyspnea by causing some mild pulmonary edema. The patient has
CHF and had an 8 lb weight gain before admission suggesting an
element of heart failure. He was treated for a COPD
exacerbation with prednisone 60mg x 3 days. He was given
spiriva, atrovent, and albuterol PRN and was discharged on these
medications. The patient is at high risk for aspiration and
understands the risk of aspiration but has decided to eat a
regular diet. His oxygen saturation was 99% on 2L at the time
of discharge. Please use humidified oxygen as pt requests this
for comfort given that pt has very dry throat.
.
# Afib w/RVR - He presented in A fib with RVR in the ED. He was
placed on diltiazem. He was in NSR in the unit and has been
since. He should be continued on the diltiazem. His amlodipine
was stopped.
.
# CKD - The patient renal function slightly worsened while in
the hospital with a creatinine of 2.1 from a baseline of 1.9.
He was given 1L of NS given that this was thought to be
prerenal. His creatinine returned to his baseline of 1.9 prior
to discharge. The patient was continued on metolazone.
.
# Type 2 DM - The patient had several days of high blood sugars,
at times greater than 500, in the setting of being on
prednisone. His NPH was increased during this time. He was
discharged on his home regimen of NPH. His glipizide was held
while in the hospital and restarted on discharge.
.
# Hypertension - The patient has been normotensive since
admission. He was on amlodipine as an out patient and is now on
diltiazem.
.
# Skin Ulcer - The patient has a stage II cocyx ulcer which
should be cared for as follows: clean with wound cleanser and
pat dry. Use no sting barrier to wipe peri wound tissue and let
dry. Then apply wound gel and cover with Allevyn foam dressing
which should be changed q 3 days. The patient should be turned
q2hrs and as needed. He should also be getting up out of bed to
his chair. Sitting time should be limited to 1 hr at a time
with a 4 inch foam cushion. He also has skin tears between his
thumb and first finger bilaterally which should be cared for as
follows: on hands bilaterally between thumbs and first finger
has skin tears. Apply aquaphor and 4 x 4 to cover. This should
be changed daily.
Medications on Admission:
Amlodipine 5 mg Tablet PO DAILY
Multivitamin One (1) Tablet PO DAILY (Daily)
Acetaminophen 1000mg QHS
Omeprazole 20 mg PO DAILY
Clopidogrel 75 mg Tablet PO DAILY
Simvastatin 20 mg PO DAILY
Bicalutamide 50 mg PO DAILY
Tiotropium Bromide 18 mcg One (1) Cap Inhalation DAILY
Ditropan 10mg daily
FerrouSul 325mg daily
Glipizide 5 mg [**Hospital1 **]
Ocuvite
zaroxyln 2.5mg daily
Wellbutrin 37.5mg [**Hospital1 **]
Atrovent nebs TID
NPH 8 unis SC QAM
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Ditropan XL 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Ocuvite Tablet Sig: One (1) Tablet PO once a day.
11. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Bupropion 75 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
13. Other
8 units sc qAM
14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
15. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) cap
Inhalation three times a day.
16. humalog sliding scale
pls resume prior scale
Finger sticks [**Hospital1 **]
<60 give [**Location (un) 2452**] juice or [**12-24**] amp of D50 and call physician
60-249 do nothing
251-300 4 units
301-350 6 units
351-400 8 units
>400 give 10 units and call physician
17. Diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day): hold for HR<60 or SBP<100.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation q4hrs as needed for
shortness of breath or wheezing.
19. Procrit 10,000 unit/mL Solution Sig: One (1) dose Injection
every 2 weeks.
20. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: One (1) dose PO every six (6) hours as
needed for cough.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
A fib
COPD exacerbation
GI bleed
.
Secondary diagnosis:
DM
Ulcerative colitis s/p ileostomy and colectomy
HTN
CAD s/p stent
CVA x3
Prostate cancer
Bladder cancer
Paget disease
GERD
Esophageal ulcer and stricture
Venous stasis
Anxiety
Macular degeneration
Pulmonary embolism
Anemia
Hyperlipidemia
Hearing loss
Melanoma
Discharge Condition:
Stable. Oxygen at 2 liters which is his baseline. Slightly
decreased BS at bases of his lungs with some crackles. Cough.
Afebrile.
Discharge Instructions:
You were admitted to the intensive care unit with Atrial
fibrillation. This lead to some difficulty breathing. You were
also found to have a COPD exacerbation which was treated with
prednisone. You now are only requiring your baseline amount of
oxygen of 2L. Being on the prednisone caused your blood sugars
to be high but they have greatly improved. Because of your A
fib you were started on a blood thinner which caused you to
bleed into your ostomy bag. You decided that you did not want
anything invasive done by gastroenterology. Your
anticoagulation was stopped and you understand the risks of not
being anticoagulated. Please return to the hospital if you
develop blood in your ostomy, worsening shortness of breath, or
any other new concerning symptom.
Followup Instructions:
Please follow up with a physician at your nursing facility.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2189-11-20**]
ICD9 Codes: 5119, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 864
} | Medical Text: Admission Date: [**2108-3-27**] Discharge Date: [**2108-4-7**]
Service: Vascular
CHIEF COMPLAINT: Right first toe gangrene.
HISTORY OF PRESENT ILLNESS: This is a 78-year-old black
female with right first toe gangrene refractory to
conservative treatment x1 month with a history of right calf
claudication x1 year. She denies rest pain. She claudicates
at least 8 feet. Underwent arteriogram on [**2108-3-8**] which
demonstrated a left common iliac with severe stenosis. Right
common iliac with diffuse disease. Right external iliac,
common femoral, and SFA were totally occluded. The right
popliteal reconstitutes below the knee level. The right
tibioperoneal trunk and PT are occluded. The right AT is
attenuated, but refuses a DP with distal stenosis. The right
peroneal reconstructs proximally, but is attenuated.
REVIEW OF SYSTEMS: Positive for angina at rest, relieved
with nitroglycerin. The last episode was two weeks prior to
initial assessment which was on [**2108-3-8**]. Frequency is
infrequent. She does complain of dyspnea with walking. She
denies recent congestive heart failure, PND, orthopnea, or
edema. She does have a history of CVA with no reoccurrence
of symptoms. The patient is now admitted for elective
revascularization.
ALLERGIES: None.
MEDICATIONS:
1. Enteric coated aspirin 325 mg q day.
2. Coumadin 3 mg q day.
3. Keflex 500 mg q8h.
4. Potassium chloride 200 mg [**Hospital1 **].
5. Digoxin 0.125 mg q day.
6. Pravachol 80 mg q day.
7. Trental 400 mg [**Hospital1 **].
8. Lasix 20 mg q day.
9. Lopressor 75 mg [**Hospital1 **].
10. Captopril 25 mg tid.
11. NPH 52 units plus 14 of R q am and NPH 16 units plus 7 of
R at dinnertime.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Chronic atrial fibrillation.
3. Acute myocardial infarction in [**2103**].
4. Congestive heart failure with an ejection fraction
calculated 25-30% distal by echocardiogram in 04/96.
5. Insulin dependent diabetes.
6. Hypertension.
7. Hypercholesterolemia.
8. Cerebrovascular accident in the [**2085**] that manifested as
right sided weakness which resolved over 24 hours.
9. History of cataracts.
10. History of fatty liver disease diagnosed by ultrasound
with no ductal obstruction secondary to elevated LFTs, ALT
245, AST 108, alkaline phosphatase 91, total bilirubin 0.7.
PAST SURGICAL HISTORY:
1. Cardiac catheterization in [**2100**], three vessel disease.
2. A repeat cardiac catheterization in [**2107-10-25**] showed severe
left ventricular systolic-diastolic dysfunction, pulmonary
wedge pressure 22, left end diastolic pressure 27. Cardiac
index 2.6, ejection fraction of 24%. Right coronary artery
was dominant. Left main trunk was patent. AD was totally
occluded in mid portion, left circumflex 70% at mid portion,
right coronary artery 70% at origin, and 50% mid stenosis.
No intervention.
3. Cholecystectomy secondary to stones.
4. Remote right ureteroscopy with stent placement in [**2102-12-2**].
5. Bilateral cataracts.
6. Appendectomy remote.
SOCIAL HISTORY: She lives with her family and ambulates with
a cane or walker. She denies alcohol or smoking.
PHYSICAL EXAMINATION: Vital signs: 97.9, 142/72, 73, and
18, and 96% O2 saturation on room air. Chest examination:
lungs are clear to auscultation. Heart is a regular rhythm.
There are no murmurs, rubs, or gallops. Abdominal
examination: Obese, nontender, and nondistended, bowel
sounds diminished x4, no bruits. Vascular examination:
Carotids without bruits. Left brachial artery site of angio
without hematoma, clean, dry, and intact. Pulse examination
shows brachioradial arteries on the left side 1+, 2+, ulnar
2+, femorals are absent on the left, popliteals absent on the
left. Dorsalis pedis and posterior tibial pulses are absent.
The patient has 1+ femorals on the right with no pulses
palpable distal to the femorals on the right. Neurologically
she is grossly intact.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2108-3-28**], and she underwent a
right axillofem bypass which was complicated by
intraoperative ischemic ST changes. Transesophageal
echocardiogram showed essentially only lateral minimal wall
motion and with lateral wall being akinetic to hypokinetic.
The patient was admitted to the SICU, intubated for continued
vasopressor and respiratory support. The patient required
dobutamine at 3 mcg/kg/min for pressor support, IV Heparin
was begun, serial enzymes were obtained.
Postoperative hematocrit was 35.7 which drifted to 31.3. BUN
and creatinine remained stable at 19 and 0.4. Initial CK was
105 with a MB of 1 and troponin less than 0.30
.................... troponins remaining flat. Cardiology
was requested to assist in patient management and management
of her paroxysmal atrial fibrillation. Recommendations were
continue hydration, hold diuresis. They could increase her
metoprolol to 75 tid. Echocardiogram was obtained which
showed an ejection fraction of 10%.
Patient was transferred after extubation to the VICU for
continued monitoring and care. By postoperative day three,
her diet was advanced to tolerated. She continued with
aggressive pulmonary toilet. Her Swan was discontinued, and
she remained in the VICU for continuing monitoring and
surveillance. Physical Therapy to see the patient and felt
that she would require rehabilitation once she is medically
stable.
As she continued to have episodes of atrial
fibrillation/flutter, which eventually was controlled with
increasing her beta blockade. The patient required
manipulation of her ACE inhibitors and beta blockers to
improve her rate control. She remained on perioperative
Levaquin while lines were in place. She was transferred to
the regular nursing floor on postoperative day number eight.
Often blood pressure systolically is 120-150, and they felt
from their standpoint that she was at a bed at
rehabilitation, they can be discharged from their standpoint.
Remaining hospital course is unremarkable.
At the time of discharge, lungs were clear, dry, and intact.
She had a functioning axobifem graft. The patient should
follow up with Dr. [**Last Name (STitle) 1391**] in two weeks time. She is then
to followup with her primary care physician once discharged
from rehabilitation.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg [**2-2**] q4-6h prn as indicated.
2. Protonix 40 mg q day.
3. Pravastatin 80 mg q day.
4. Digoxin 250 mcg q day.
5. Metoprolol 50 mg tid.
6. Aspirin 81 mg q day.
7. Lasix 40 mg [**Hospital1 **].
8. Coumadin 3 mg q day.
9. Captopril 50 mg tid.
10. Insulin-sliding scale in six insulin doses. Please see
enclosed flow sheet.
DISCHARGE INSTRUCTIONS: Patient's INR should be monitored on
a continual basis until she is in a steady therapeutic state
for her atrial fibrillation with a goal INR 2.0-2.5. Patient
should follow up with Dr. [**Last Name (STitle) 1391**] in two weeks.
DISCHARGE DIAGNOSES:
1. Aortoiliac disease status post axillobifemoral bypass.
2. Myocardial infarction by enzymes, stable.
3. Diabetes controlled.
4. Blood loss anemia corrected.
5. Paroxysmal atrial fibrillation rate controlled.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2108-4-5**] 20:17
T: [**2108-4-6**] 04:31
JOB#: [**Job Number 92911**]
ICD9 Codes: 9971, 2851, 4280, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 865
} | Medical Text: Admission Date: [**2145-1-28**] Discharge Date: [**2145-1-29**]
Date of Birth: [**2095-4-21**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Transfer from [**Hospital **] Medical Center with a spontaneous
SubArachnoid Hemmorhage
Major Surgical or Invasive Procedure:
External ventricular drain placed emergently [**2145-1-28**]
History of Present Illness:
Patient is a 49M in his usual state of health, when 3-4 days
prior to admission began to report headache. He was seen by his
physician who diagnosed him with migraine headaches. On [**1-27**],
he was found by his son to be unresponsive. When he arrived home
from work on date of admission his family found him to be "not
quite right".EMS activated and brought pt to [**Hospital 15096**] medical
center where CT imaging of the brain revealed the Subarachnoid
hemorrhage with marked hydrocephalus and mass effect. Clinical
deterioration progressed requiring endotracheal intubation for
airway protection.
Past Medical History:
Asthma
Social History:
Married, resides with his wife who is supportive.
Family History:
Non-contributory
Physical Exam:
visible or audible respirations. Eyes and mouth open. No
peripheral pulses detected, No Carotid upstrokes. No
spontaneous movements. EVD, foley catheter and IV sites secure.
Pertinent Results:
[**2145-1-28**] 05:00AM BLOOD WBC-15.1* RBC-4.89 Hgb-15.3 Hct-43.2
MCV-88 MCH-31.4 MCHC-35.5* RDW-13.1 Plt Ct-325
[**2145-1-27**] Neuts-85.9* Lymphs-10.0* Monos-3.6 Eos-0.3 Baso-0.2
[**2145-1-28**] Plt Ct-325
[**2145-1-28**] PT-13.2 PTT-24.3 INR(PT)-1.1
[**2145-1-28**] Glucose-178* UreaN-11 Creat-0.8 Na-145 K-4.2 Cl-110*
HCO3-29 AnGap-10
[**2145-1-28**] 05:00AM BLOOD Phenyto-9.5*
[**2145-1-27**] 11:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
At [**Hospital1 18**], Head CT showed obstructive hydrocephalus d/t colloid
cyst in foramen of [**Last Name (un) **]. Right ventricular drain was placed.
Initial clinical exam details unresponsiveness, absent
appendicular responses. MRI showed extensive bihemispheric
infarcts and persistent hydrocephalus of left lateral ventricle.
Bilateral ventricular drains were placed. Pt continued on
Dilantin and Nicardipine with no improvement in his neurologic
exam. CT showed On [**2145-1-28**] an increased hypodensity within the
parafalcine frontal lobes, and in the distribution of the
posterior
circulation, consistent with evolving infarction that is seen on
the MR performed hours earlier. Regions of hypodensity include
bilateral thalami. During the 3:00pm hours pts ICP was noted to
climb. There was a lengthy family meeting with Stroke Neurology,
Neurosurgery and family to discuss the patients grave illness
and poor prognosis. After this meeting, the family decided to
make pt [**Name (NI) 9036**] measures only.
A Morphine infusion was started for [**Name (NI) **]. The patient was
extubated and expired on [**2145-1-29**] @12:15am. Please refer to
Death certificate for final time designation.
Medications on Admission:
Albuterol
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sub Arachnoid Hemmorage
Colloid Cyst
Hydrocephalus
Discharge Condition:
poor
Discharge Instructions:
To morgue for transfer to Funeral Home of family's designation.
Followup Instructions:
None
Completed by:[**2145-1-29**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 866
} | Medical Text: Admission Date: [**2150-12-5**] Discharge Date: [**2150-12-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Dyspnea
Reason for MICU Admission: Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 59386**] is a [**Age over 90 **] yo F with history of HTN, SVT, hx
cholangitis/E.coli bacteremia ([**2-10**]), freq UTIs, who presents
from her nursing home with acute dyspnea, hypoxia to low 80's on
RA, and fever to 102. She was recently hospitalized for LLL PNA
and D/C'd on [**12-1**] on a course of levofloxacin and flagyl. She
was changed at the nursing home from levofloxacin to cefpodoxime
for better facility acquired coverage, but has no sputum cx data
to date. She also had a urine cx sent on [**12-3**] at the NH which
is no growth to date. Per nursing home staff, she had been doing
well for the last 2 days (no O2 requirement) until 9am this
morning when she was found to be confused and lethargic and an
O2 sat was in the low 80s and did not respond to nasal cannula.
She was also found at that time to have a fever to 102.
On interviewing the patient, she denies chest pain, shortness of
breath, abdominal pain or urinary sx. She reports R ear pain.
.
In the ED, her VS were T 99.8 BP 155/96 HR 160 (sinus) O2 84% on
4L. CXR showed a worsening LLL PNA compared to [**11-30**], U/A showed
> WBC. She received CTX, azithro, and vanco as well as 2L IVFs
which brought her HR to 115. On transfer she was satting 98% on
NRB. After discussions w/ family members - she remains DNR/DNI -
plan for abx, supplemental O2, no pressors, no line, and if
worsens or in increased distress plan to switch focus to
comfort.
.
ROS: Other than above, pt unable to provide further hx.
.
Past Medical History:
--History of SVT
--hyperthyroidism
--htn
--b12 deficiency
--h/o cholangitis s/p ERCP
--Macular degeneration
--s/p TAH BSO
--s/p nephrectomy
--s/p appendectomy
--s/p hip hemiarthroplasty
Social History:
Pt lives at [**Hospital1 **] at [**Location (un) 55**]. Denies tobacco, etoh.
Reportedly a retired math teacher (7th and 8th). Played the
organ in church for years. Originally from upstate
[**State 5887**], married in [**2070**] and moved to [**Location (un) 86**] at that time.
Widowed since [**2126**]. She is a non-smoker, no EtOH, no illicit
drugs.
Son = HCP = [**Name (NI) **] [**Name (NI) 59386**] [**Telephone/Fax (1) 59387**]. Daughter ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 59388**] -[**Telephone/Fax (1) 59389**]) lives in [**Location **] and is ill with COPD
and home oxygen. Patient has close friend who identifies
herself as her "daughter" though admits that she is not related,
her name is [**Name (NI) 32400**] [**Name (NI) 7756**] [**Telephone/Fax (1) 59390**]. Son [**Name (NI) **] gives
permission to speak with [**Location (un) 32400**] but says that he should be the
first contact. [**Name (NI) **] family and friend [**Name (NI) 32400**], patient normally
alert, fully oriented and coherent.
Family History:
Non-contributory.
Physical Exam:
Vitals: T: 98.0 BP: 141/71 HR: 115 RR: 35 O2Sat: 99% on NRB
GEN: Respiratory distress with use of accessory muscles
HEENT: surgical pupils b/l, MM dry, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Tachycardic, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs decreased BS at bases, L > R. No crackles, wheezes
or rhonchi.
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Awake, answers simple questions. moving all extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
Other labs/interpretation:
Resp cx: GRAM STAIN (Final [**2150-12-7**]): >25 PMNs and <10
epithelial cells/100X field ? OROPHARYNGEAL FLORA. YEAST, SPARSE
GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH. MRSA
.
.
UA [**12-5**] >50wbc, mod bact, UCx [**12-5**] >100K yeast
UA [**12-7**] 6wbc, no bacteria, UCx [**12-7**]: >100K yeast
.
.
Imaging/results:
[**2150-12-5**] CXR: Increasing left lower lobe infiltrate and pleural
effusion is concerning for progression of pneumonia. The
remainder of the study is relatively unchanged.
.
[**2150-12-7**]
Unchanged area of worsening right basilar area of consolidation
and
stable appearance of left basilar consolidation.
Unchanged slight volume overload and bronchial wall thickening.
.
[**12-10**]: Increased right pleural effusions, bilateral basilar
consolidations unchanged. Pulm vasc congeston.
Brief Hospital Course:
[**Age over 90 **] year old female with h/o SVT, HTN, recent admission with LLL
PNA (discharged [**12-1**] on levo/flagyl), admitted from [**Hospital1 1501**] with
acute onset hypoxia/dyspnea/fevers 102, CXR with worsening LLL
PNA, which has now progressed to b/l PNA, clinical evidence of
aspirartion. Afebrile and mostly stable, but episodes of
clinical deterioration.
.
.
Pneumonia, admitted with acute hypoxic resp failure, much
improved. CXR with progressive infiltrates, LLL->now bilateral
(infection vs fluid). Acuity suggests component of aspiration
pneumonitis. Has resp and oral secretions, aspirating oral
secretions, but has trouble bringing up tracheal secretions
(weak cough) and requires deep suctioning. No fevers. White
count finally coming down. She will be treated to complete a 14
day course of vanc/zosyn.
.
Given likely aspiration risk, she had multiple swallow
evaluations, with evidence of aspiration. Based on family
discussion, there is a goal of primarily comfort for patient,
with thin liquids, despite risk of aspiration. If there is
evidence of significant coughing, further evaluation or
discussions regarding goals of care should continue with her
family.
.
.
Pleural effusions: developing over 3days, likely due to
tachycardia and fluid. Diuresis for the most part was deferred
further, given minimal oral intake.
.
.
Leukocytosis: She had a leukocytosis that worsened, likely due
to pneumonia. This had resolved by [**2150-12-12**].
.
Atrial fibrillation, with intermittent tachycardia: While in the
ICU, she had evidence of tachycardia, possibly atrial
fibrillation, which broke with IV metoprolol. She continued to
have intermittent episodes of tachycardia throughout her stay,
likely sinus tachycardia in the setting of mucous plugging and
anxiety. She was maintained on IV lopressor, and transitioned
on d/c to oral lopressor.
.
Contaminated UA: UA/UCx on admission wtih >100K yeast, foley
removed, 1 dose diflucan in MICU, but repeat UCx again >100K
yeast, though UA less WBC 50->6.
No treatment pursued.
.
.
Encephalopathy: She had evidence of intermittent confusion,
consistent with delirium, due to ICU stay, pneumonia. She
gradually improved, though remains off her baseline.
.
.
HTN: Well controlled on metoprolol
.
.
PUD. cont PPI
.
.
OA/shoulder pain: lidocaine patch, no narcotics, esp given
aspiration risk
.
.
FEN/proph: HLIV, monitor lytes, soft diet with honey thick
liquids per speech only when awake, otw NPO, strict aspiration
precautions, TEDs/SCDs, heparin [**Hospital1 **], PPI
.
.
Dispo/Code status: DNR/DNI. Goals of care defined with goal
toward comfort, based on family meeting between geriatrics
service and her family (son, daughter, daughter in law). They
would like her to return to her nursing home. A
do-not-rehospitalize order will likely need to be discussed on
return to [**Hospital1 599**].
.
[**First Name8 (NamePattern2) **] [**Known lastname 59386**] is HCP(wife [**Doctor First Name **] [**Telephone/Fax (1) 59387**], c [**Telephone/Fax (1) 59391**].
Daughter ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 59388**] - [**Telephone/Fax (1) 59389**]) lives in [**Location **]
(but is ill).
Medications on Admission:
1. Metoprolol Tartrate 12.5 mg po bid
2. Docusate Sodium 200mg po bid
3. Acetaminophen 1g q8hr
4. Prilosec 20mg po q24hr
5. Cefpodoxime 100mg po bid
6. Metronidazole 500 mg po bid
7. MVI with iron
8. Remeron 15mg po qhs
9. [**Last Name (un) 7139**]-128 5% eye gtt 4x daily to each eye
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Pneumonia, bilateral
Aspiration, chronic
Pleural effusions
Atrial fibrillatoin
Encephalopathy
Discharge Condition:
Stable. Prognosis is poor.
Discharge Instructions:
You were admitted secondary to pneumonia that is likley
secondary to aspiration. You were treated for pneumonia with
antibiotics.
.
We had extensive discussion with you and your family regarding
the risk of aspiration depending on what type of food/liquids
you
consume but you will be allowed to eat food with aspiration
precautions.
.
Your doctor will discuss future plans for rehospitalization with
your family.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] on return to [**Hospital1 599**].
ICD9 Codes: 5070, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 867
} | Medical Text: Admission Date: [**2148-8-6**] Discharge Date: [**2148-8-9**]
Date of Birth: [**2079-12-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 4691**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy ([**2148-8-8**])
ERCP with sphincterotomy and balloon sweep ([**2148-8-6**])
History of Present Illness:
The patient is a 68-year-old male who is transferred to [**Hospital1 18**]
from [**Hospital **] Hospital with chief complaint of abdominal pain.
He was brought to [**Hospital **] Hospital by supervisors at his group
home. He reports dull pain in the midepigastrum At [**Hospital1 **] he
had a lipase of greater than 4000 and an US which demonstrated
gallstones and slude, with no evidence of cholecystitis.
Past Medical History:
Past Medical History:
1. h/o CHF, MR
2. DM2
3. GERD
4. h/o diverticulitis
5. [**Location (un) 805**] syndrome, Mental retardation
6. HTN
7. h/o SBO (last in [**10-22**])
8. Impulse control d/o
9. Depression
Past Surgical History:
s/p colectomy (reason unclear)
Social History:
Lives in a group home.
Family History:
Non-contributory.
Physical Exam:
99.3 F 86 113/63 16 97% RA Pain [**4-22**]
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: well healed midline incision, soft, mildly distended,
mildly
tender in midepigastrum, no RUQ pain, no [**Doctor Last Name **] sign, no rebound
or guarding, normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2148-8-6**] 12:20AM BLOOD WBC-15.7* RBC-3.71* Hgb-12.7* Hct-37.2*
MCV-100* MCH-34.4* MCHC-34.2 RDW-14.0 Plt Ct-168
[**2148-8-6**] 10:14AM BLOOD WBC-11.4* RBC-3.18* Hgb-11.6* Hct-32.5*
MCV-102* MCH-36.4* MCHC-35.6* RDW-14.0 Plt Ct-143*
[**2148-8-7**] 01:47AM BLOOD WBC-8.5 RBC-3.60* Hgb-11.8* Hct-36.8*
MCV-102* MCH-32.8* MCHC-32.0# RDW-13.7 Plt Ct-151
[**2148-8-8**] 05:30AM BLOOD WBC-5.7 RBC-3.60* Hgb-12.3* Hct-36.7*
MCV-102* MCH-34.1* MCHC-33.5 RDW-13.7 Plt Ct-160
[**2148-8-6**] 12:20AM BLOOD ALT-57* AST-77* AlkPhos-155* TotBili-0.9
[**2148-8-6**] 10:14AM BLOOD ALT-40 AST-45* AlkPhos-112 Amylase-724*
TotBili-0.7
[**2148-8-6**] 07:10PM BLOOD ALT-56* AST-91* AlkPhos-170* Amylase-562*
TotBili-2.1*
[**2148-8-7**] 01:47AM BLOOD ALT-93* AST-165* AlkPhos-247*
Amylase-356* TotBili-2.6* DirBili-2.4* IndBili-0.2
[**2148-8-7**] 01:47AM BLOOD ALT-93* AST-165* AlkPhos-247*
Amylase-356* TotBili-2.6* DirBili-2.4* IndBili-0.2
[**2148-8-8**] 05:30AM BLOOD ALT-68* AST-66* AlkPhos-272* Amylase-85
TotBili-1.1
[**2148-8-9**] 06:00AM BLOOD ALT-73* AST-57* AlkPhos-221* TotBili-0.9
[**2148-8-9**] 08:33AM BLOOD ALT-70* AST-54* AlkPhos-207* TotBili-0.8
[**2148-8-6**] 12:20AM BLOOD Lipase-1890*
[**2148-8-6**] 10:14AM BLOOD Lipase-793*
[**2148-8-6**] 07:10PM BLOOD Lipase-450*
[**2148-8-7**] 01:47AM BLOOD Lipase-244*
[**2148-8-8**] 05:30AM BLOOD Lipase-36
Brief Hospital Course:
The patient was initially admitted to the unit because of
concern for hypotenstion in the ED. His SBPs were never lower
than the 80's but a central line was placed prior to his leaving
the ED. His pressures responded to fluid resuscitation and he
never required pressors. The patient was taken to ERCP on the
day of admission, the results of which are listed below. He
tolerated the procedure well and was transferred to the floor.
His labs were checked the next day and his lipase was
decreasing. He was taken for laparoscopic cholecystectomy the
following day. His diet was then advanced as tolerated and his
pain was controlled with PO pain meds. He was ready for
discharge on HD4. His foley catheter was removed and the patient
voided.
RUQ/Liver US ([**2148-8-6**]) - Intra and extrahepatic biliary
dilation with intraductal sludge. Choledocholithiasis cannot be
excluded due to limitations of visualization.
ERCP or MRCP could be used for further evaluation. Gallbladder
distention with sludge and wall thickening. Imaging findings
suggest cholecystitis. Clinical correlation is recommended as
son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was negative; HIDA could be performed
to better evaluate for cholecystitis if clinically appropriate.
Trace ascites.
CXR ([**2148-8-6**]) - Multifocal opacities, worrisome for infection.
Right internal jugular central line with tip at cavoatrial
junction. Pulmonary vascular congestion. Cardiomegaly, which may
be in part due to pericardial fluid.
ERCP ([**2148-8-6**]) - A moderate diffuse dilation was seen at the
main duct with the CBD measuring 13 mm. The intrahepatic ducts
were also dilated. The cystic duct filled with contrast.
Successful sphincterotomy. Biliary sludge was seen exiting the
ampulla along with very dark, almost black, bile. Otherwise
normal ercp to third part of the duodenum.
Medications on Admission:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Align 4 mg Capsule Sig: One (1) Capsule PO once a day.
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
10. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Discharge Medications:
1. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*40 Capsule(s)* Refills:*0*
10. Align 4 mg Capsule Sig: One (1) Capsule PO once a day.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
13. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Sympomatic choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent (Baseline mental retardation)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-22**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call the Acute Care Surgery clinic at [**Telephone/Fax (1) 600**] to
arrange for a follow-up appointment in [**1-17**] weeks. The clinic is
located on the [**Location (un) 10043**] of the [**Hospital **] Medical Building at [**Last Name (NamePattern1) 12939**].
ICD9 Codes: 4240, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 868
} | Medical Text: Admission Date: [**2100-8-18**] Discharge Date: [**2100-8-23**]
Date of Birth: [**2057-1-23**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Multinodular goiter
Major Surgical or Invasive Procedure:
Total thyroidectomy
History of Present Illness:
The patient is a 43 year old woman who has had a history of
hypothyroidism,here for total thyroidectomy for MNG.She had an
increasing thyroid swelling since a couple of years,and showed
up at Dr[**Name (NI) 10946**] clinic. The goiter went basically from
her chin down to her sternum. She was diagnosed with MNG and was
planned for a total thyroidectomy.
Past Medical History:
hypothyroidism
Social History:
She works as a hotel manager. Prior smoker and quit in [**2098**].
Drinks alcohol rarely per hospital records. Denies illicit drug
use.
Family History:
No history of thyroid disease, diabetes, heart disease, or COPD.
Father's side of family has had uterine cancer and other cancers
of unknown etilogy.
Physical Exam:
General: Alert and oriented x3, Obese female with large neck
swelling, no distress, appears comfortable.
Eyes: Anicteric sclerae. Extraocular movements normal.
ENT: Normal external appearance.
Oropharynx is without lesions.
Neck: incision with steri strips clean dry intact,no erythema,
positive edema.
Cardiovascular: Regular, borderline tachycardic, [**1-16**] SM at LUSB.
Respiratory: Normal to inspection, percussion, and
auscultation.
GI: Normal bowel sounds. Abdomen not distended or tender. No
hepatomegaly.
Neurologic: Normal deep tendon reflexes. No tremor. No spasms.
Vulvar exam: erythematous vulva with redness extending out to
inner thigh. underlying skin - moist with concern for wheeping
from the wound. No vaginal discharge noted.
Extremities:[**12-12**]+ pitting edema present bilaterally, warm, no
clubbing.
Pertinent Results:
[**2100-8-18**] 08:50PM BLOOD WBC-12.7* RBC-2.75* Hgb-8.8* Hct-26.6*
MCV-97 MCH-31.9 MCHC-33.0 RDW-13.5 Plt Ct-213
[**2100-8-18**] 08:50PM BLOOD PT-13.7* PTT-30.2 INR(PT)-1.2*
[**2100-8-18**] 08:50PM BLOOD Plt Ct-213
[**2100-8-18**] 08:50PM BLOOD Glucose-154* UreaN-10 Creat-0.6 Na-140
K-4.0 Cl-108 HCO3-22 AnGap-14
[**2100-8-18**] 08:50PM BLOOD Calcium-8.2* Phos-4.6* Mg-1.6
[**2100-8-18**] 09:49PM BLOOD Lactate-0.9
[**2100-8-18**] 09:49PM BLOOD Type-ART Temp-35.9 Rates-14/ Tidal V-500
PEEP-5 FiO2-40 pO2-149* pCO2-44 pH-7.38 calTCO2-27 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2100-8-19**] 03:52AM BLOOD WBC-11.6* RBC-2.46* Hgb-7.9* Hct-25.4*
MCV-103* MCH-32.0 MCHC-31.0 RDW-14.1 Plt Ct-193
[**2100-8-19**] 05:54AM BLOOD WBC-13.4* RBC-2.88* Hgb-9.1* Hct-27.4*
MCV-95# MCH-31.6 MCHC-33.2 RDW-14.2 Plt Ct-228
[**2100-8-19**] 03:52AM BLOOD Plt Ct-193
[**2100-8-19**] 05:54AM BLOOD PT-13.0 INR(PT)-1.1
[**2100-8-19**] 05:54AM BLOOD Plt Ct-228
[**2100-8-19**] 03:52AM BLOOD Glucose-686* UreaN-8 Creat-0.4 Na-110*
K-3.4 Cl-88* HCO3-17* AnGap-8
[**2100-8-19**] 05:54AM BLOOD Glucose-139* UreaN-11 Creat-0.5 Na-139
K-4.0 Cl-107 HCO3-21* AnGap-15
[**2100-8-19**] 01:50PM BLOOD CK(CPK)-375*
[**2100-8-19**] 08:16PM BLOOD CK(CPK)-448*
[**2100-8-20**] 04:03AM BLOOD CK(CPK)-482*
[**2100-8-19**] 01:50PM BLOOD CK-MB-9 cTropnT-<0.01
[**2100-8-19**] 08:16PM BLOOD CK-MB-9 cTropnT-<0.01
[**2100-8-20**] 04:03AM BLOOD CK-MB-9 cTropnT-<0.01
[**2100-8-19**] 05:54AM BLOOD Calcium-7.4* Phos-5.1* Mg-2.3
[**2100-8-19**] 08:16PM BLOOD Calcium-7.7*
[**2100-8-19**] 03:52AM BLOOD PTH-12*
[**2100-8-19**] 05:54AM BLOOD PTH-14*
[**2100-8-19**] 05:53AM BLOOD Type-ART pO2-113* pCO2-45 pH-7.38
calTCO2-28 Base XS-1
[**2100-8-19**] 04:28AM BLOOD freeCa-1.11*
[**2100-8-19**] 05:53AM BLOOD freeCa-1.06*
[**2100-8-20**] 04:03AM BLOOD WBC-10.3 RBC-2.37* Hgb-7.5* Hct-22.7*
MCV-96 MCH-31.6 MCHC-33.1 RDW-14.2 Plt Ct-122*
[**2100-8-20**] 03:41PM BLOOD Hct-24.0*
[**2100-8-20**] 04:03AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-137 K-3.8
Cl-104 HCO3-20* AnGap-17
[**2100-8-20**] 03:41PM BLOOD Calcium-8.0*
Brief Hospital Course:
43 year old female with diagnosis of a massive goiter is status
post total thyroidectomy on [**2100-8-18**]. Intraoperatively patient
was intubated and transferred to the intensive care unit for
observation as there were concerns that the patient may not be
able to maintain her airway due to preoperatively concerns that
the thyroid was compressing the airway. Over the night of her
operation she became hypotensive with systolic blood pressure to
the 80s and she was started on Dopamine drip this was ultimately
thought to be related to hypocalcemia. She was infused with 250
ml of albumin to which her systolic blood pressure responded and
she was successfully weaned off dopamine drip and was extubated
on [**2100-8-19**] and on room air. On [**2100-8-20**] she was transferred out of
the intensive care unit to the surgical inpatient unit.Of note,
she was noted to have extensive vulvar irritation and erythema
while in the intensive care unit and Gynecology were consulted
and provided recommendations.
On [**2100-8-21**] she her oxygen saturation was in the mid 90s on Room
air during the morning,and then triggered at noon time for O2
Sat of 85% Room air. Patient had no dyspnea and was
asymptomatic. She was placed on 1 to 4 liters via nasal cannula
to maintain her O2 sats. However patient continued to have an O2
Sat 90% on 3 liters nasal cannula. Therefore a chest xray was
done which was negative for pneumonia and chest scan was done
and was negative for pulmonary embolism. She was diuresed with
Lasix intravenously. She continued to have low grade temperature
99 up to 100.2, an electrocardiogram and continued to be
tachycardic, although denied dyspnea or chest pain.
On [**9-28**] she continued to have decrease Oxygen
saturation, mid 90's on 40-50% shovel mask. She received Lasix
20 mg intravenous and diuresed well. Overnight she was ordered
for blood transfusion for a hematocrit of 22 which was stopped
due to a rise in temperature from 99.2 to 100.2. She was
expectorating green and brown sputum and a sputum culture was
obtained. She has some intermittent productive sputum but
otherwise is dry and per the patient this is usually worse
during the night. A sputum culture and repeat chest Xray PA/Lat
was done to rule out pneumonia. The patient continued to have no
dyspnea, no respiratory distress and the oxygen was subsequently
weaned to 40% and her O2 sats 92% to 94%room air. She was
started empirically on Levofloxacillin but has no evidence of
lower respiratory tract infection. The pulmonary team were
consulted for etiology of hypoxia and recommendations. The
patient will follow-up with Pulmonology Outpatient for a bubble
study.
The patient has no nausea or emesis and diet was advanced from
clears to regular which was tolerated well. Her pain was well
controlled with oral analgesia. She is ambulating independently
with a steady gait. The neck incision with steri strips is
clean, dry and intact without erythema, there is edema in the
neck. She will follow-up with Dr. [**Last Name (STitle) **] on [**2100-8-26**] for her postoperative visit. She will be discharged home on
Levothyroxine, Calcium carbonate and Calcitriol. She will
follow up with primary care provider and gynecology in [**12-12**] week.
Medications on Admission:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily)
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*20 Capsule(s)* Refills:*2*
5. Aluminum-Calcium Packet Sig: One (1) Packet Topical TID
(3 times a day) as needed for vulvar pruritis.
Disp:*20 Packet(s)* Refills:*0*
6. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical TID
(3 times a day) as needed for vulvar pruritis.
Disp:*2 tubes* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Multinodular goiter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the General Surgery Inpatient Unit and
underwent a total thyroidectomy.Your tissue was sent to
pathology and you should have your results in 1 week. Please
monitor your neck incision for any drainage, swelling or
redness. Please seek immediate attention if you develop
shortness of breath or increase neck swelling. Please notify
Dr. [**Last Name (STitle) **] office if you have any questions or concerns.
You have steri strips on your neck incision, please keep clean
and dry. These steri-strips will fall off on their own, please
do not remove them. You may shower but avoid swimming or
bathing. Please take Tylenol for pain as directed. Please do not
drink alcohol or drive while taking this medication as it may
cause drowsiness. Do not take more than 4000 mg of acetaminophen
(Tylenol) in a 24 hour period. Please monitor for signs and
symptoms of hypothyroidism: watch for numbness or tingling
around mouth or legs, confusion, muscle spasm,or changes in
level of conciousness, these could be signs of low calcium which
can happen after thyroid surgery. Please monitor for signs and
symptoms of Hyperthyroidism: Anxiety, irritability, trouble
sleeping
Weakness (in particular of the upper arms and thighs, making it
difficult to lift heavy items or climb stairs), Tremors (of the
hands, Perspiring more than normal, difficulty tolerating hot
weather
Rapid or irregular heartbeats, Fatigue,Weight loss in spite of a
normal or increased appetite, Frequent bowel movements. If you
experience any of these signs or symptoms please contact Dr.
[**Last Name (STitle) **] office [**Telephone/Fax (1) 9**]. Your follow-up appointment with
Dr. [**Last Name (STitle) **] is scheduled for Thursday [**2100-8-26**] at
11:00 A.M. You will be given a prescription for Ciprofloxacin to
treat your respiratory infection, please take 500mg twice a day
for 2 weeks, please take all antibiotics as prescribed. Please
follow-up with the Pulmonary Clinic ([**Telephone/Fax (1) 3554**] as an
Outpatient for a Bubble Study. Please resume your home
medication. Please schedule an appointment with your primary
care provider for monitoring of your thyroid level. You will be
given a prescription for Calcium Carbonate(Tums)and Calcitriol
please take as directed.
Followup Instructions:
Your follow-up appointment with Dr. [**Last Name (STitle) **] is scheduled for
Thursday [**2100-8-26**] at 11:00 A.M.([**Telephone/Fax (1) 84720**] [**Street Address(2) **]., [**Location (un) **] Division: General Surgery
Please schedule an appointment with Pulmonary Clinc for Bubble
study [**Telephone/Fax (1) 612**]
Please schedule follow-up appointment with primary care provider
[**Last Name (NamePattern4) **].[**Last Name (STitle) **] in 2 weeks.
Please schedule follow-up appointment with Gynecology in 1 week.
Completed by:[**2100-8-24**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 869
} | Medical Text: Admission Date: [**2177-11-13**] Discharge Date: [**2177-11-21**]
Date of Birth: [**2101-12-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Chest pain, SOB.
Major Surgical or Invasive Procedure:
Arterial line
Central venous line
History of Present Illness:
75 year-old man with history of stage IV non-small cell lung ca
with mets to spine diagnosed [**9-22**], HTN, AF, CRI, who presents
with pleuritic chest pain and dyspnea for one day. The patient
states that he received his first round of chemotherapy of
[**Doctor Last Name **]/taxol 4 days prior to admission. He felt well one day
prior to admission, but then began feeling unwell today. He
stated that he had a productive cough, chills, fatigue and well
as bilateral plerutic CP with taking a deep breath. He denied
dyspnea. He denied N/V/D or poor po intake - eating eggs and
bacon. Temp at home 100.4; referred to ED by heme/onc fellow.
The pt was BIBA. Enroute the patient c/o CP and was given nitro
with drop in BP to 70's.
.
In the ED, the patient vomited once. He had a chest CT, neg for
PE. CT abd/pelvis neg. Due to the ? of PNA with fever and WBC
16.8, the pt received levo, cefepime - did not yet receive vanc.
The patient remained hypotensive with SBP's 70-90's despite
repeat fluid boluses - total 2L. An IJ was placed and neo was
started. The patient was also found to be in afib with RVR HR
130-170. He received IV diltiazem x with improvement in HR to
100's. He was then switched to a diltiazem drip. The patient was
not cardioverted as he had been in afib for 10+ years. VS were
temp 99.0 HR 105 SBP 105/50 RR 20 SAo2 100% NC.
Past Medical History:
# stage IV adenocarcinoma of the lung dx [**2177-10-21**] by
bronchoscopy, MRI [**10-26**] with bony mets to T11, 50-75% narrowing
of spinal canal and mild to moderate spinal cord compression,
s/p radiation on [**10-28**]
- started clinical trial with Pacitaxel, Carboplatin, Anamorelin
vs. placebo at [**Company 2860**], day 1 was [**2177-11-11**]
# DM2
# Atrial fibrillation
# HTN
# chronic renal failure
# Anemia
# Hyperlipidemia
# COPD
Social History:
-Tob: quit in [**2166**], approx 150 pk yrs, + asbestos exposure
-EtOH: quit in [**2166**]
-Illicits: None
-Living situation: lives alone, no children but his extended
family is very close to him
-Occupation: used to be a [**Doctor Last Name 9808**] operator
Family History:
No family history of lung cancer
Physical Exam:
Physical Exam at Admission
VS: 98.9 HR 92 Bp 112/77 RR 12 SaO2 96%RA
Gen: NAD, flushed, Aox3 easily able to relate history
HEENT: right IJ in place, mild JVD, no LAD, benign OP
CV: RRR, no MRG
PULM: mild bilateral crackles, good air movement, no labored
breathing
ABD: soft, NT/ ND
EXT: warm well perfused
.
Physical Exam at Discharge
VS: 97.7, 112/68, 106, 16, 95%RA
In general patient is alerat and oriented, in NAD
Neck is supple and non-tender with no LAD
Heart exam shows irregular rate and rhythm. No m/r/g.
Chest exam is clear to auscultation bilaterally in posterior
fields
Abdomen is non-tender with normal bowel sounds
Extremities shows no lower pitting edema; they are warm and well
perfused
Pertinent Results:
[**2177-11-13**] 04:40PM BLOOD WBC-16.8* RBC-3.86* Hgb-11.4* Hct-33.6*
MCV-87 MCH-29.5 MCHC-34.0 RDW-14.0 Plt Ct-313
[**2177-11-13**] 04:40PM BLOOD Neuts-95.4* Lymphs-3.2* Monos-0.7*
Eos-0.7 Baso-0.1
[**2177-11-14**] 05:11AM BLOOD PT-15.5* PTT-31.7 INR(PT)-1.4*
[**2177-11-13**] 05:00PM BLOOD Glucose-163* UreaN-24* Creat-1.4* Na-130*
K-4.8 Cl-95* HCO3-22 AnGap-18
[**2177-11-13**] 05:00PM BLOOD CK(CPK)-31*
[**2177-11-14**] 05:11AM BLOOD LD(LDH)-344* CK(CPK)-34* TotBili-0.9
[**2177-11-13**] 05:00PM BLOOD cTropnT-<0.01
[**2177-11-14**] 05:11AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2177-11-13**] 05:00PM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
[**2177-11-14**] 05:11AM BLOOD Hapto-345*
.
CXR: Interval worsening of the left upper lobe opacity and left
subpulmonic effusion. There is a large left hilar mass, better
appreciated on prior CT study.
.
Head CT: No acute intracranial process. Lucency involving the
inner table of the left occipital bone may represent venous [**Doctor Last Name **]
or arachnoid granulation, although metastatic disease cannot be
excluded. Opacification of the left mastoid air cells and
middle ear opacification may represent mastoiditis in the
correct clinical context.
.
CTA Chest: Extensive left hilar tumor masses with lesions
narrowing the left upper segmental branches without evidence of
PE.
Brief Hospital Course:
MICU Course:
Mr. [**Known lastname 1007**] was admitted to the MICU with likely post-obstructive
PNA with elevated WBCs, productive cough and fever. A CTA
showed a lung mass but no clear infiltrate and was negative for
PE. ECGs initially were without ischemic changes and troponins
were negative. He was started on Vancomycin and Zosyn. He had
a thoracentesis which showed an exudate, cytology pending at
time of transfer. He initially required Levophed for blood
pressure but was able to be weaned off on [**2177-11-16**]. He was never
intubated. He was feeling well the day after admission and
asymptomatic with regards to the hypotension. Cultures were all
negative.
.
He also had Afib with RVR on presentation. He was initially
managed with Diltiazem gtt in the ED, then put on standing
Diltiazem in the MICU. He was transitioned to Metoprolol which
was titrated up to 75 mg PO TID. He had some occasional
episodes of rapid heart rate which were controlled with
additional doses of Metoprolol. He was loaded with Digoxin
0.25mg PO X 3 and then put on standing Digoxin of 0.125mg PO
qday. His rate was better controlled on transfer but
occasionally required additional Metoprolol for HR>120s. An ECG
showed some T wave inversions compared to admission his cardiac
enzymes were negative. He never complained of chest pain. He
had an echocardiogram which showed moderate pericardial effusion
without signs of tamponade.There was possible but not confirmed
pericarditis causing his symptoms and ECG findings.
.
He developed neutropenia with an ANC of 540 on the day of
transfer. He had been started on Neupogen on [**2177-11-18**]. He was
afebrile at this time and continued on broad-spectrum
antibiotics. He was transfused 2 units PRBCs over his course in
the ICU for a hematocrit of 23.9 on [**2177-11-14**]. He was continued
on standing Zofran and Ativan for post-chemotherapy nausea and
was continued on his clinical trial medication of anamorelin.
He was put on an insulin sliding scale for a diagnosis of
diabetes for which he was not taking medication.
.
He was transferred to the Oncology service on [**2177-11-19**] with a
controlled heart rate in the 100s-120s, hemodynamically stable
and asymptomatic.
.
FLOOR COURSE:
He was transferred to OMED service and maintained on metoprolol
for rate control. He was monitored on telemetry and although he
remained in atrial fibrillation, his ventricular rate was
well-controlled on metoprolol 75 mg Q6H. His antibiotics were
switched to levofloxacin, and he was discharged to complete a
seven day course for presumptive CAP. He was seen by physical
therapy who recommended discharge to home with home PT. He
remained on the floor for two nights. There were no concerning
episodes on telemetry and he was afebrile without chest pain or
cough. He was no longer neutropenic at time of discharge.
Neupogen was stopped.
Medications on Admission:
Fluticasone-Salmeterol 250/50 mcg disk, 1 disk [**Hospital1 **]
Tiotropium Bromide 18mcg 1 cap qday
Enalapril 10mg PO qday- not taking
Simvastatin 20mg PO qday
Albuterol 90mcg [**1-15**] puff q6hours PRN
Atenolol 75mg PO daily
Colace 100mg PO BID
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)
Zofran 8 mg [**Hospital1 **]
Ativan 1mg [**Hospital1 **]
Hydrocodone as needed
Tramadol as needed
Discharge Medications:
1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: nausea.
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
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. Anamorelin Sig: One (1) DAILY (Daily) for 3 weeks: study
drug, take as directed.
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
12. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pneumonia
Atrial fibrillation with rapid ventricular response
hypotension secondary to afib/dehydration
Neutropenia
.
Secondary:
# Stage IV adenocarcinoma of the lung
# DM2
# Atrial fibrillation
# HTN
# Chronic renal failure
# Anemia
# Hyperlipidemia
# COPD
Discharge Condition:
Vital signs stable, afebrile, tolerating POs, ambulatory
Discharge Instructions:
You presented to the hospital for low blood pressures and
trouble breathing likely due to a pneumonia. You were treated
with antibiotics and pressors in the ICU and your blood pressure
improved. During this time, occasionally you had a rapid heart
rate due to atrial fibrillation and you were started on
medications, digoxin and metoprolol, to control your heart rate.
.
Please take all medications as prescribed.
New medications: digoxin, toprol XL, levofloxacin
Discontinued medications: atenolol
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, abdominal pain, sweating, fevers, chills, bleeding, or
other concerning symptoms.
Followup Instructions:
You should schedule an appointment with Dr. [**Last Name (STitle) 3274**] for next
week on Tuesday or Thursday. You said you had already called his
office to set this up prior to discharge. Call his office at
([**Telephone/Fax (1) 3280**] with any questions.
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2177-12-2**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**]
Date/Time:[**2177-12-4**] 1:00
Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2177-12-24**] 10:10
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2177-11-22**]
ICD9 Codes: 486, 5119, 2761, 496, 5859, 2859, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 870
} | Medical Text: Admission Date: [**2117-4-5**] Discharge Date: [**2117-4-8**]
Date of Birth: [**2043-7-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
left-sided chest pain and new left-sided pleural effusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 y/o woman with PMH notable for malignant melanoma admitted
with left-sided chest pain and new left-sided pleural effusion
on [**2117-4-6**] s/p thoracentesis w/ 1000cc drainage of hemorrhagic
fluid c/w metastatic effusion. Overnight she developed recurrent
left chest/shoulder pain while ambulating to the bathroom and an
increase in her oxygen requirement. On the am of transfer to the
[**Hospital Unit Name 153**] she developed acute tachycardia to 170s while ambulating to
the bathroom and progressive hypoxia with sat in mid 90s on 5L
facemask. Repeat CXR obtained at that time demonstrated
increasing left pleural effusion. EKG showed SVT at a rate of
130. ABG was 7.29/64/77 on 5L facemask, RR of 22. She was
transferred to the [**Hospital Unit Name 153**] for closer monitoring and consideration
of non-invasive ventilation.
.
On arrival to the [**Hospital Unit Name 153**], she received 1L NS bolus. She noted her
SOB was improved but continued with left shoulder/chest pain.
.
Past Medical History:
HTN
malignant melanoma (see below)
.
Oncologic history (per OMR):
Ms. [**Known lastname 32058**] [**Last Name (Titles) 1834**] shave biopsy of a left eyebrow skin
lesion revealing a 1.3 mm thick, [**Doctor Last Name 10834**] level IV, non-ulcerated
melanoma with 15 mitoses per high-powered field in 12/[**2112**]. In
[**12/2113**], she [**Year (4 digits) 1834**] wide local excision and left parotid
sentinel lymph node biopsy. There was no sentinel lymph node
biopsy involvement with melanoma. Wide local excision revealed
residual melanoma extending to 4.5 mm thick, [**Doctor Last Name 10834**] level IV
with evidence of microsatellitosis. She did not receive adjuvant
therapy. She [**Doctor Last Name 1834**] punch biopsy of a right forearm lesion in
[**2115-5-24**] revealing microinvasive melanoma, [**Doctor Last Name 10834**] level II,
0.22 mm, extending to the peripheral specimen margins. She
[**Doctor Last Name 1834**] wide local excision in [**2115-6-23**] revealing focal
residual melanoma in situ, completely excised. On her three-year
followup scans in [**3-1**], her torso CT revealed multiple lung
nodules with a large left hemidiaphragm lesion measuring 7.9 x
6.3 x 3.7 cm. Biopsy was positive for melanoma. Considered for
IL2 therapy but not a candidate [**1-25**] PFTs. Plan for chemotherapy.
Social History:
Lives with husband. Daughter is [**Name8 (MD) **] RN at [**Hospital1 **], very
involved in care. Quit smoking. No alcohol.
Family History:
NC
Physical Exam:
GENERAL - ill-appearing female in NAD, in mild respiratory
distress, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - decreased BS bilat, L>R, fair air movement, resp
minimally labored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no calf tenderness
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-27**] throughout, sensation grossly intact throughout, cerebellar
exam and gait deferred
Pertinent Results:
[**2117-4-5**] 07:18PM LACTATE-1.6
[**2117-4-5**] 12:10PM GLUCOSE-145* UREA N-17 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14
[**2117-4-5**] 12:10PM estGFR-Using this
[**2117-4-5**] 12:10PM WBC-12.2* RBC-4.15* HGB-12.2 HCT-35.1* MCV-85
MCH-29.5 MCHC-34.8 RDW-14.5
[**2117-4-5**] 12:10PM NEUTS-88.4* LYMPHS-6.8* MONOS-3.9 EOS-0.6
BASOS-0.3
[**2117-4-5**] 12:10PM PLT COUNT-308
[**4-5**] CTA
IMPRESSION:
1. No pulmonary embolism.
2. Marked interval increase in size of metastatic lesions at the
left lung
base, now associated with a large, and likely malignant, left
pleural
effusion. The right paraesophageal mass has also increased in
size with other small bilateral pulmonary nodules again noted.
[**4-7**] CXR
: Large left and small right pleural effusion, unchanged.
Streaky right
perihilar opacities, could be atelectasis. Dense LLL opacity
likely a
combination of known mass atelectasis and effusion. Widened
right lower
paramediastinal region part of it is likely due to known
paraesophageal mass.
Brief Hospital Course:
73 yo F with metastatic melanoma with acute presentation of
malignant pleural effusion s/p thoracentesis with short-interval
reacummulation concerning for hemothorax from melanoma.
#. Respiratory Distress, hypercapnic/mild hypoxia - [**1-25**]
effusion, space occupying lesion, underlying COPD, respiratory
depression from narcotics. Possible PE but unable to
anticoagulate [**1-25**] hemorrhagic effusion. In setting of hemothorax
from melanoma there are few options for treatment. Any further
drainage would like result in another quick reexpansion. Given
there is no treatment to stop the bleeding, placing a permanent
drain or pleurex cath is not indicated. Patient's family chose
to transition Ms. [**Known lastname 32058**] to comfort measures with morphine.
Patient died on the AM of [**4-8**] from respiratory failure.
.
#. Metastatic Melanoma - Mets to pleural space, likely
hemorrhagic, prognosis poor. As a result, family chose to
transition patient to comfort measures.
Medications on Admission:
At home:
- atenolol 50 mg daily
- caltrate 600 mg daily
- multivitamin daily
- asa 81 mg daily
- hctz/lisinopril 12.5/10 mg daily
- compazine/zofran prn
.
On transfer:
Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Aspirin 81 mg PO DAILY
Docusate Sodium 100 mg PO BID
HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN
Heparin 5000 UNIT SC TID
Ipratropium Bromide Neb 1 NEB IH Q6H
Multivitamins 1 TAB PO DAILY
Ondansetron 4-8 mg IV Q8H:PRN nausea
Prochlorperazine 10 mg IV Q6H:PRN
Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient passed away [**4-8**]
Discharge Condition:
Patient passed away [**4-8**]
Discharge Instructions:
Patient passed away [**4-8**]
Followup Instructions:
Patient passed away [**4-8**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2117-4-8**]
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 871
} | Medical Text: Admission Date: [**2144-2-27**] Discharge Date: [**2144-3-5**]
Date of Birth: [**2079-5-27**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Found down by family, stuporous.
Major Surgical or Invasive Procedure:
Intubation (outside)
Placement of oraogastric tube (outside)
History of Present Illness:
Mr. [**Known lastname **], "[**Last Name (un) **]", is a 64-year-old man transferred from
[**Hospital3 **] after being found down and description of
intracerebral hemorrhage on NCHCT, on a background of chronic
hypertension.
He was last seen at baseline by his son, [**Name (NI) 5758**] [**Name (NI) **], [**Name (NI) **]., on
Monday evening. On Tuesday morning he was seen by his neighbor
who described him as lethargic and as having slurred speech. The
neighbor came back to Mr. [**Known lastname 94143**] door about ten minutes
later and Mr. [**Known lastname **] did not respond or open his door as he
normally would. On Wednesday his family tried to call and when
they could get no response, decided to visit. His daughter
arrived and knocked, then called to him when the door didn't
open. She asked how he was and he said "Okay" and clearly
recognized that it was his daughter. [**Name (NI) **] then started to mumble,
then did not respond. This was at about 6 p.m., and given their
concerns they forced their way in before 7 p.m. Mr. [**Known lastname **] was
on the floor of his living room. It looked as if he had fallen,
was lying on his back and likely hit the sofa with his head on
the upper left side, deflecting it to the right. He opened his
eyes to voice and was mumbling, sometimes saying things. He
could not move when asked, but lifted up his shirt and said he
had chest pain. There were no other apparent injuries, but he
had been incontinent of urine. EMS took him to [**Hospital3 **].
Upon arrival his family say that he was no longer coherent or
opening his eyes. He was intubated given his mental status and
concern for aspiration (his family tell us). Non-contrast head
CT scan revealed left sided intraparenchymal hemorrhage
dissecting into the left thalamus and ventricles (see Imaging
below). He was transferred on propofol to [**Hospital1 18**] for further
management.
At [**Hospital1 **] he was given 1.5 L NS, fentanyl/Versed, etomidate,
Ativan. CT head, C-spine and chest x-ray were performed (see
below). CK was 5374 (with normal CK-MB index). He had a
leukocytosis with predominant neutrophils, some bands (22.5, 85
%, 5%). [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] note: Patient denied pain, said "it was
light out", unable to get up. They noted that he was difficult
to understand. Patient reported high cholesterol.
In the ED he was continued on propofol and nicardipine was
started to control blood pressure.
Review of systems negative except as above.
Past Medical History:
- Hypertension, 20 years, on HCTZ monotherapy, per family
- Hiatus hernia
- Cardiomegaly per family, likely concentric hypertrophy in
context of hypertension
- Nasal polyps, s/p surgery
- Recent extraction of all teeth in last couple of months
- Anxiety (takes Klonopin)
- Dyslipidemia, per patient at [**Hospital1 **] (as stated in their note)
- Family deny diabetes
Social History:
Lives alone. Retired barber. 40-50 pack years, current smoker of
1 ppd. Some alcohol, but not for 8 years.
Family History:
Hypertension in many family members, both [**Name2 (NI) **]. Mother had
'small stroke'. Father with coronary disease.
Physical Exam:
Exam on Discharge:
Mr [**Known lastname **] is drowsy at times, but will wake to full alertness.
He is oriented to self, year and hospital. He mumbles (worse
after hemorrhage), but language itself is normal. He does not
easily follow midline commands (poke out tongue, smile), but
will follow appendicular commands. He has a mild right facial
droop with generally decreased facial expression. He has
significant ataxia, with a mild right upper motor neuron pattern
of weakness, worse in the arm than the leg. Weakness seems,
prima facie, much worse in the context of ataxia. Sensation is
intact. Coordinated appendicular movements are slow but
accurate.
Exam on Admission:
Appearance:
Appears stated age, well kept and likely BMI ~ 26. Intubated and
sedated. Son, daughter and wife present at bedside.
Vitals:
Afebrile, 174/82 mmHg, 48 BPM and regular, 16 breaths, 99%,
intubated, CMV: FiO2 0.5, 550 cc, rate 16, PEEP 5 cmH2O
Respiratory pattern/ventilator settings:
Will overbreathe vent. when sedation off. On CMV.
Primary Survey/Evidence of Trauma:
Contusion at junction of parietal and occipital bones on left,
no skin breakage, no other trauma noted.
Evidence of Chronic or Systemic Illness:
Darker pigmentation on face, ? acanthosis nigricans. Trophic
changes at feet. No surgical incisions.
Evidence of Drug Ingestion/Use:
None.
Nuchal Rigidity
Neck tone normal.
HEENT: Otherwise NC, intubated, with OG.
Neck: Supple. No bruits. Some secretions audible in upper
airway.
Lungs: CTA bilaterally/vent. sounds.
Cardiac: RRR. Enlarged PMI. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 1+.
Neurologic:
Eye Response:
When propofol off will open eyes to command, but not
spontaneously.
Motor Response:
Will move feet, but not lift from bed. Will squeeze both hands,
stronger on left, but can make thumbs up on right. Will nod when
touched on either side.
Verbal Response:
Mouthed hello on command and daughter thought he mouthed 'hey
baby' to his daughter during exam.
Optic Fundi:
Miotic pupils. Not examined.
Pupillary Responses:
Pupils miotic at 1.5 mm with small symmetric reaction.
Spontaneous Eye Movements:
Made eye contact briefly before closing eyes. Will look to right
and left. Gaze conjugate.
Corneal Responses:
Present bilaterally.
Remaining Cranial:
Face symmetric. Hearing grossly intact - follows verbal
commands.
Gag intact when sedation light.
Respiratory Pattern
Overbreathing vent. when sedation lowered.
Skeletal Muscle Tone:
Tone normal throughout.
Motor Responses:
As above. Can move both feet, squeeze left hand and seems weaker
on right. No whole limb antigravity movements noted.
Myotatic Reflexes:
B T Br Pa Ac
Left 2 1 2 2 0
Right 0 0 0 1 0
Cutaneous Reflexes:
Toes go down bilaterally.
Sensory Responses:
Can move hand or foot that is touched to command for both feet
and hands.
Pertinent Results:
On Admssion:
[**2144-2-27**] 12:47AM BLOOD WBC-17.2* RBC-5.07 Hgb-14.9 Hct-43.1
MCV-85 MCH-29.3 MCHC-34.5 RDW-15.9* Plt Ct-202
[**2144-2-27**] 04:15AM BLOOD Neuts-73.1* Lymphs-19.2 Monos-6.1 Eos-1.2
Baso-0.4
[**2144-2-27**] 12:47AM BLOOD PT-13.1 PTT-24.6 INR(PT)-1.1
[**2144-2-27**] 04:15AM BLOOD Glucose-75 UreaN-11 Creat-0.5 Na-143
K-2.4* Cl-117* HCO3-18* AnGap-10
[**2144-2-27**] 04:15AM BLOOD ALT-19 AST-75* LD(LDH)-243 CK(CPK)-3625*
AlkPhos-39* TotBili-0.4
[**2144-2-27**] 12:47AM BLOOD Lipase-22
[**2144-2-27**] 12:47AM BLOOD cTropnT-<0.01
[**2144-2-27**] 04:15AM BLOOD CK-MB-27* MB Indx-0.7
[**2144-2-27**] 08:52AM BLOOD CK-MB-37* MB Indx-0.6 cTropnT-<0.01
[**2144-2-28**] 03:53AM BLOOD CK-MB-6
[**2144-2-27**] 04:15AM BLOOD Albumin-2.5* Calcium-5.2* Phos-1.6*
Mg-1.4* Cholest-147
[**2144-2-27**] 04:15AM BLOOD %HbA1c-6.2* eAG-131*
[**2144-2-27**] 04:15AM BLOOD Triglyc-79 HDL-28 CHOL/HD-5.3 LDLcalc-103
[**2144-2-29**] 06:10AM BLOOD TSH-0.86
[**2144-2-27**] 12:47AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-2-27**] 04:24AM BLOOD Type-ART Rates-20/16 Tidal V-550 PEEP-5
FiO2-50 O2 Flow-9.3 pO2-99 pCO2-37 pH-7.43 calTCO2-25 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2144-2-27**] 12:50AM BLOOD Glucose-107* Lactate-2.1* Na-143 K-3.8
Cl-99* calHCO3-26
[**2144-2-27**] 12:50AM BLOOD Hgb-14.9 calcHCT-45 O2 Sat-55 COHgb-2
MetHgb-0
[**2144-2-27**] 04:24AM BLOOD freeCa-1.12
[**2144-2-27**] 12:47AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2144-2-27**] 12:47AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2144-2-27**] 12:47AM URINE RBC-35* WBC-4 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2144-2-27**] 12:47AM URINE CastHy-0-2
[**2144-2-27**] 12:47AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
On Discharge:
[**2144-3-5**] 06:05AM BLOOD WBC-17.9* RBC-5.24 Hgb-15.0 Hct-43.8
MCV-84 MCH-28.7 MCHC-34.3 RDW-15.4 Plt Ct-327
[**2144-3-5**] 06:05AM BLOOD Neuts-63.6 Lymphs-23.1 Monos-7.9 Eos-2.8
Baso-2.5*
[**2144-3-5**] 06:05AM BLOOD Glucose-108* UreaN-17 Creat-0.7 Na-132*
K-3.6 Cl-92* HCO3-28 AnGap-16
[**2144-3-2**] 07:20AM BLOOD CK(CPK)-569*
[**2144-3-5**] 06:05AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0
EKG [**2144-2-27**]
Sinus rhythm with increase in rate as compared with previous
tracing of [**2144-2-27**]. The ischemic appearing ST-T wave
abnormalities have improved but may represent
pseduonormalization in the context of increase in rate. The
initial forces in lead V2 are consistent with prior anteroseptal
infarction. Followup and clinical correlation are suggested.
Rate PR QRS QT/QTc P QRS T
84 162 90 386/428 59 -2 87
Non-Contrast Head CT [**2144-2-27**]
FINDINGS: There is a similar moderate-sized left thalamic
hemorrhage with surrounding edema which extends into the
occipital horns of the bilateral lateral ventricles and the
body of the left lateral ventricle. Possible small foci of
subarachnoid/cortical hemorrhage are noted in the right frontal
lobe and unchanged. No increase in the size or new focus of
hemorrhage is appreciated. There is a minimal amount of
rightward shift of midline structures, though the basal cisterns
are preserved. Periventricular white matter hypodensity is
likely related to chronic small vessel ischemia. The ventricles
and sulci are normal in size. Elsewhere in the brain, [**Doctor Last Name 352**]
matter/white matter differentiation is preserved. There is a
small air-fluid level within the right maxillary sinus. The
mastoid air cells are clear.
IMPRESSION: Similar appearance of left thalamic hemorrhage with
extension into the bilateral occipital horns and body of left
lateral ventricle and possible small foci of
subarachnoid/cortical hemorrhage in the right frontal lobe.
There is minimal rightward shift of midline structures also
unchanged. Though the hemorrhage may relate to hypertension or
fall, underlying vascular/neoplastic etiology cannot be
excluded and further workup as clinically indicated.
CT C-Spine
IMPRESSION:
1. No acute cervical fracture or malalignment.
2. Multilevel degenerative changes, with likely chronic uniform
vertebral height loss at C5 and C6.
3. Partially-imaged brain demonstrates bilateral
intraventricular hemorrhage, compatible with the known left
thalamic hemorrhage.
Duplex Renal Ultrasound
IMPRESSION:
1. Normal sized kidneys, without evidence of renal artery
stenosis.
2. Mildly elevated renal arterial resistive indices could relate
to underlying chronic kidney disease.
CT Head [**2144-3-4**]
IMPRESSION:
1. Similar appearance of left thalamic hematoma and surrounding
edema with extension to the body of the left lateral ventricle
and 3rd ventricle and bilateral occipital horns of the lateral
ventricles. F/u as clinically indicated.
2. No new interval hemorrhage.
3. Stable mild rightward shift of midline structures.
Chest X-ray [**2144-3-5**]
IMPRESSION: Marked improvement of previously identified
congestive pattern. No new parenchymal infiltrates and only a
plate atelectasis remaining on the left base.
Brief Hospital Course:
Mr. [**Known lastname **] was intubated prior to arrival given vomiting,
concern for aspiration and stupor. He was admitted to the
Neurology ICU service for monitoring and blood pressure control,
given intraparenchymal hemorrhage with intraventricular
extension. Intraventricular extension was limited to the
posterior horns of the lateral ventricles, the ventricular
system remaining patent, so ventricular drain placement was not
necessary. He was transferred to the floor service when
stabilized and extubated where the primary issues became blood
pressure control, monitoring for pneumonia given persisting
leukocytosis, physical therapy and his dysphagia.
Intraparenchymal Cerebral Hemorrhage
Typical location and historical features for hypertensive
etiology. Given location and appearance, underlying mass,
amyloid and traumatic seem much less likely. Blood pressure was
controlled and the hemorrhage remained stable. Treatment of
hypertension will be important for reducing the risk of
subsequent hemorrhage. A statin was started given his lipid
profile. Aspirin is safe to continue as prophylaxis.
Hypertension
Mr. [**Known lastname 94143**] antihypertensive regimen was broadened and
increased during the admission. Amlodipine was started. HCTZ was
increased to 50 mg daily, then decreased again to 25 mg owing to
hypokalemia, with carvedilol initiated to help control blood
pressure further. Valsartan is at maximum dose and hydralazine
was also added at 10 mg every six hours. The latter [**Doctor Last Name 360**] is
less ideal for home use given potential rebound and likely
non-compliance given four times daily dosing. We would recommend
caution in uptitrating carvedilol given heart rate and
concomitant use of amlodipine (concern for heart block).
Clonidine patch and long-acting nitrates might also be
considered. Mr. [**Known lastname 94143**] blood pressure was improved after
diuresis with Lasix 20 mg IV also, after receiving fluid in
excess of urine output (not hypotonic given cerebral edema)
earlier in the admission. Doppler ultrasound of the renal
arteries was performed. Aldosterone level was not checked given
that hypokalemia was explained by HCTZ use.
Hypokalemia
Increased and decreased with hydrochlorothiazide dosing, to
which this was attributed. Serum potassium has been around 3.5
on the present 25 mg of HCTZ. This should be monitored in
rehabilitation to determine whether supplement is necessary.
Leukocytosis
Initially attributed to stress-related demargination of
neutrophils, but then persisted. This, is conjunction with prior
aspiration, along with a hazy left base on portable film raised
concern for pneumonia. He remained afebrile, but was treated
with ceftriaxone for possible aspiration-related pneumonia. He
remained afebrile and further evidence of clinical or
radiographic pneumonia did not develop. WBC increased on the day
of discharge, but this was attributed to an increase in
eosinophils that were not present at admission, suggesting mild
allergic reaction to ceftriaxone. Nonetheless, given no other
evidence of allergy and this short course due to finish after
four more doses, we recommend continuing this medication to
complete the course, with the last dose of [**2144-3-9**].
Question of Pneumonia
See leukocytosis.
Relative Eosinophilia
There is no absolute eosinophilia, but has been a relative
increased in this cell line since admission. This may represent
a mild allergic response to ceftriaxone. Please check CBC with
differential to see that this does not climb further.
Drowsiness
Given peri-thalamic hemorrhage, some decreased level of arousal
is not uncommon and this will often improve over several days.
Klonopin was a home medication that was used at uncertain dose
in the home setting, so this was titrated during the admission.
He presently is taking 0.5 mg TID, which can likely be tapered
to 0.25 mg TID then off over the next few days.
Hyponatremia
Mild hyponatremia on discharge that is attributable to mild
SIADH in the context of intracerebral hemorrhage. This is just
under the normal range, 132 versus 133, and has been stable, so
no specific intervention seems warranted at this time.
Elevated CK
Attributed to rhabdomyolisis given immobility at home - it is
likely that he was in the same position for about 36 hours. This
trended down and we stopped checking this when in the normal
range for African-American males (< ~ 800).
Prediabetic State
A1c was mildly elevated. Continued monitoring for diabetes is
indicated. We did not initiate treatment during the admission.
Myocardial Ischemia
Suggested by EKG (see above), but may be prior. Enzymes were
negative.
Medications on Admission:
- HCTZ, dose unknown
- Klonopin
- Total of [**2-28**], maybe more medications per family. Pharmacy,
[**Company 25282**] in [**Location (un) 5110**] dispensed Klonopin, Zoloft, Trazodone.
Family will bring list in a.m.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary
Intracerebral Hemorrhage
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital after being found confused at home by
your family. You went to an outside hospital where you were
noted to have vomiting and were very drowsy and you were
therefore intubated. CT scan of your head revealed that there
was bleeding in your brain. You were transferred to [**Hospital1 771**] and initially monitored in the
intensive care unit until it was clear that bleeding had
stopped. We attribute this intracerebral hemorrhage to high
blood pressure. We got your blood pressure under better control.
This process of progressively controlling your blood pressure
will need to continue at rehabilitation. Please stay in regular
touch with your primary care physician so that this can be
watched closely. You will also need to see Dr. [**Last Name (STitle) **] in
[**Hospital 878**] Clinic, before which you will need an MRI (ordered at
[**Hospital1 18**]) and laboratory test (prescription attatched).
Followup Instructions:
Please follow up in [**Hospital 878**] Clinic with Dr. [**Last Name (STitle) **]:
[**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2144-4-28**]
7:30
Please see your primary care doctor immediately after dishcarge
from rehabilitation.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 5070, 4019, 3051, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 872
} | Medical Text: Admission Date: [**2132-12-31**] Discharge Date: [**2133-1-27**]
Date of Birth: [**2076-5-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Progressive signs of dizziness, visual difficulties, unsteady
gait
Major Surgical or Invasive Procedure:
Right-sided high frontal stereotactic biopsy, CT-guided target
point, definition and MRI-guided intraoperative imaging.
History of Present Illness:
The patient is a 56-year-old male with a history of colon
cancer, as well as testicular cancer, who presents with
progressive signs of dizziness, visual difficulties, unsteady
gait for approximately 12 months. He was worked up including an
MRI scan that showed a brainstem lesion. He was referred to the
brain tumor clinic for consideration of a biopsy.
The patient has been followed at the [**Hospital6 **] at [**Location 10050**]. He had been treated for a number of medical issues. He
was examined by Dr. [**Last Name (STitle) 66170**] whose physical exam reportedly
showed bilateral facial numbness and swaying, and a MRI of the
head was preformed. This demonstrated expansion of the
brainstem without significant contrast enhancement. The patient
was thus considered to have a brainstem glioma and started on
Decadron. The patient now presents for a surgical opinion. In
the office, the patient complains about dizziness, blurred
vision, double vision, occasional headaches, and unsteady gait.
He feels better with medications. He takes at baseline 2 Tylenol
a day. Has a history of arthritis in the lower back, otherwise,
he reports that the numbness in his hands has disappeared since
starting the Decadron. The patient has tapered his Decadron to a
dose of 2 mg p.o. b.i.d. The patient is otherwise feeling
himself stable. He was told that he had a left lazy eye at
baseline, but the patient is not quite sure about the symptoms.
He denies otherwise any extreme fatigue, weight loss or other
symptoms.
Past Medical History:
Hypertension
Hypercholesterolemia
Sigmoid colon cancer [**2125**]
Testicular cancer s/p Left orchiectomy and was found to be a
germ cell tumor T1, N0.was treated with adjuvant chemotherapy no
radiation.
Hemorrhoids
Recurrent bouts of thrush
Social History:
He is a high school graduate. He is an electrician. He is
divorced. He has no other people in the household. He has a
40-pack-year history of smoking. He drinks about three drinks a
week, and he denies any recreational drug use.
Family History:
His mother died at 63 of a heart attack. His father died at 44
after a MVA. He has two sisters 58 and 54, the 54-year-old has
gallbladder stones. Other than that, they both are healthy.
There are two brothers, one brother at 47 who has
hypertension and two daughters that are in good health.
Physical Exam:
GENERAL: He is alert, pleasant, middle-aged man in no acute
distress. Weight was 170 pounds, height was 74 inches, blood
pressure was 154/90, pulse of 96, respirations 20, temperature
of 97.4.
HEENT: The patient did have a head tilt to the left.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or
rubs.
LUNGS: Clear to auscultation.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: The patient is awake, alert and oriented. He has
bilateral reactive pupils. Eye movements are full and we cannot
detect a clear deficit of a particular muscle, at current, the
patient has no diplopia. Visual fields seem to be fully intact.
He has non-exhaustible end gaze nystagmus with rotatory
component. Face is symmetric. Tongue is midline. No
fasciculations. He has a hoarse voice. He has full strength
bilaterally. He has intact sensation and symmetric reflexes. The
patient does not have any memory problems, blackouts, nausea,
concentration, or speech problems, as well as hearing problems.
On motor examination, he was [**4-24**] bilaterally, normal tone, no
drift. I found no evidence of any weakness in his hands. Upper
sensory, he was intact to light touch throughout, and he was
intact to pinprick over in the hands
Reflexes were 2+ throughout.
Cerebellar: He had bilateral intention tremor in the hands as
well as finger tapping and rapid alternating movements were
fine. Foot tapping and heel-knee-shin was normal.
Gait: He had a wide based gait, he is unable to toe tandem or
heel walk.
Pertinent Results:
[**2132-12-31**] 09:40AM GLUCOSE-116* LACTATE-1.2 NA+-132* K+-4.0
CL--95*
[**2132-12-31**] 09:40AM TYPE-ART PO2-83* PCO2-35 PH-7.50* TOTAL
CO2-28 BASE XS-3 INTUBATED-INTUBATED VENT-SPONTANEOU COMMENTS-RM
AIR
[**2132-12-31**] 09:48AM PT-11.1* PTT-21.2* INR(PT)-0.8
[**2132-12-31**] 09:48AM PLT COUNT-241
[**2132-12-31**] 09:48AM WBC-17.9* RBC-4.30* HGB-12.2* HCT-34.0*
MCV-79* MCH-28.4 MCHC-35.9* RDW-17.9*
[**2132-12-31**] 09:48AM GLUCOSE-115* UREA N-16 CREAT-0.5 SODIUM-133
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
[**2132-12-31**] 11:21AM freeCa-1.12
[**2132-12-31**] 11:21AM HGB-11.1* calcHCT-33 O2 SAT-97 CARBOXYHB-1
[**2132-12-31**] 11:21AM GLUCOSE-129* LACTATE-1.7 NA+-133* K+-3.9
CL--98*
.
Pathology [**2132-12-31**]:
MIDDLE CEREBELLAR PEDUNCLE/PONS STEREOTACTIC BRAIN BIOPSY
(including intraoperative smear):
DIFFUSELY INFILTRATING FIBRILLARY ASTROCYTOMA. WHO ([**2126**]) grade
II out of IV.
.
Brief Hospital Course:
56 M with PMH sigmoid and testicular ca in [**2125**], HTN, COPD,
admitted for new diagnosis pontine glioma s/p posterior fossa
decompression and necrotizing pna.
.
# Pontine glioma:
56 year-old man initially seen and discussed in brain tumor
clinic. Patient taken to OR on [**12-31**] for brainstem lesion biopsy
under general anesthesia. Postoperatively stayed in the PACU 6
hours then transferred to floor. On postop day one patient
demonstrated difficulty of swallowing which he failed his speech
and swallow evaluation. Patient kept NPO, started IV fluids. On
[**2133-1-2**] patient taken back to OR for a suboccipital chiari
decompression. Patient tranferred to neuro ICU for hemodymanic
and neurologic monitoring. Due to postoperaive respiratory
secretion extubated on [**2133-1-4**] after bronchcospy.
.
Brain stem biopsy pathology result is significant for
infiltrative astrocytoma. Radiation oncology decided not to
perform radiation mapping and to hold off for another several
weeks before planning to start XRT, since patient has a slow
growing glioma, and XRT could exacerbate pna. Patient known by
Dr [**Last Name (STitle) 4253**] will follow up with him as scheduled. Patient was
transferred to Step-down unit on [**2132-1-7**]. His speech continued
to become more articulate and clear, and his mental status
continued to become more clear. The patient stated that his
dizziness has improved.
.
# Necrotizing pneumonia:
Patient has a known pulmonary process that been followed in
[**Hospital 669**] [**Hospital **] hospital in MA. In house repeat CT of the chest
significant for left lower lobe, consolidative opacity, with
central area of necrosis, an air-fluid level, and
low-attenuation material. Additionally, there are several areas
within the right and left lungs peripherally, with patchy
opacity and tree-in-[**Male First Name (un) 239**] opacities, concerning for multifocal
opacity. There is also a wedge-shaped opacity in the right lower
lung zone, some of which may represent atelectasis.There is a
3.3 x 2.6 cm nodule with multiple foci of calcification within
the left lower lobe. Attempt to obtain images from [**Hospital **] hospital
regarding pulmonary lesions for comparison, [**Name (NI) 653**] with
MEdical records to sent ua CD images. Medicine and
interventional pulmonary services recommended continue
antibiotics, and follow up with chest CT with and with out
contrast in 4 weeks in pulmonary clinic. In the mean time
[**Name (NI) 653**] with Dr [**First Name (STitle) **] at the [**Hospital **] hospital regarding
tranfering him over to VA regarding his known pulmonary process,
and colon carcinoma for further work up which he was agreed with
the transfer.
.
Pleural fluid culture grew out positive to MSSA, GNR, [**Female First Name (un) 564**]
albicans, staph coag neg. BAL culture grew out Stenotrophomonas
maltophila and Klebsiella sensitive to almost all abx tested.
ID was consulted and created antibiotic regimen of clindamycin,
bactrim, ceftriaxone, to be continued for 4-6 weeks. Levo was
completed for 2 weeks (last date [**2133-1-27**]). Patient should be
reassessed to refine abx regimen within 2-4 weeks. The patient
greatly improved on suctioning and chest PT, maintaining >95% RA
on the floor.
.
The following labs will need to be followed up after discharge:
LFTs, mycolytic/fungal cx, Cdiff x3, legionella urinary antigen
.
# Urinary retention:
Patient had no urine output after foley was d/ced. Straight
cath released 980 ml of urine. After 2 days of straight caths,
patient recovered normal urination, and does not have a foley
upon discharge.
.
# Skin lesions:
Dermatology consulted in reference to his left deltoid skin
lesion, non-bleeding which is present for 5 year according to
patient. Dermotalogy recommended excision of the lesion to rule
out melanoma once acute issues resolved with Derm Surgery
([**Telephone/Fax (1) 2977**]).
.
# Anemia:
Patient's Hct was around 25 during admission.
.
# HTN:
Controlled. Diltiazem and captopril were continued as per her
outpt regimen.
.
# Access: Picc placed [**2133-1-9**].
Medications on Admission:
The patient is a 56 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with a PMH significant for sigmoid
and testicular cancer in '[**25**], HTN, and COPD who was admitted to
the neurosurgery service on [**2132-12-31**] with a new diagnosis of a
pontine mass after 1yr of progressive dizziness and ataxia. He
underwent a stereotactic bx on [**12-31**] showing a low grade glioma
and received a palliative posterior fossa expansion on [**1-2**].
.
Routine pre-op CXR revealed multiple opacities and a 3x3 cm well
demarcated cavitary lesion with an air/fluid level in left
posterior lung. Following his surgery, he was extubated w/out
event but required reintubation later that evening [**1-22**]
desaturation. On [**1-3**], a chest CT was done which showed a
multifocal pneumonic process with LLL necrotizing PNA. He
underwent a bronch on [**1-4**] with BAL revealing MSSA and
stenotrophamonas and was started on Levofloxacin (now d10/14),
Vanco (since d/c), and Clinda (d10/42) at this time. Bactrim
(d5/14) was added on [**1-8**] when BAL grew stenotrophamonas.
.
During this time, he has been intermittantly hypoxic with thick
secretions requiring frequent suctioning. Over the past 2d, he
has been afebrile and his secretions have cleared appreciably.
He has maintained his O2 sats on 4L NC. Other than this, the
patient has been intermittantly hypertensive requiring the
addition of captopril to his outpatient regimen. He has also
failed numerous speech and swallow evaluations requring NG tube
feeds to maintain his nutritional status. From an oncologic
standpoint, his pontine lesion is not amenable to resection and
the plan is to initiate palliative radiation therapy. Per
neurosurgery, his prognosis is extremely poor. Finally, the
patient has requested transfer to the [**Location 1268**] VA system
over the past several days as he has received much of his care
at this hospital. Discussions are still ongoing to facilitate
this transfer.
.
PMH:
1. Colon cancer
2. testicular cancer
3. Hemorrhoids
4. Hypertension.
5. Thrush.
6. Hypercholesterolemia.
.
Transfer Meds:
Acetaminophen
Albuterol
Bisacodyl
Captopril
Clindamycin
Dexamethasone
Diltiazem
Docusate
HSQ
Sulfameth/Trimethoprim
Oxycodone
Nystatin
Nicotine Patch
Levofloxacin
Lansoprazole
Ipratropium
ISS
.
PE: 97.0 (98.5), 124/72, 81, 21, 95% 4L NC
Gen: Cachetic [**Male First Name (un) 4746**] sitting up in a chair in NAD
HEENT: MMM, PERRLA, EOMI, O/P clear w/ NGT in posterior
oropharynx
Neck: No LAD, No JVD
CV: RRR, S1/S2 wnl, -M/R/G appreciated
Lungs: Decreased breath sounds bilaterally L>R w/ coarse
inspiratory sounds bilaterally and anteriorly, -wheezes
appreciated, dullness to percussion at the L base
Abd: S/NT/ND, +BS
Ext: -C/C/E, 2+ peripheral pulses bilaterally
Neuro: CN 2-12 grossly intact, dysarthric, strength 5/5 in the
RLE, on the LLE he has decreased dorsal flexion in the
foot/flexion and extension at the knee/flexion at the hip,
mildly decreased L grip strength compared to R hand
================
Micro:
- Sputum [**1-3**]: E. coli (pan-sensitive), Coag + staph
(pansensitive)
- BAL [**1-4**]: Stenotrophamonas (sensitive bactrim), Coag + staph
(MSSA), sparse GNR
- MRSA/VRE swab: negative
================
CTA [**2133-1-9**]:
1. Some improvement in the consolidation in the left lower
lobe, although the large 4-cm cavitary lesion with an air-fluid
level persists, consistent with slight overall improvement in
necrotizing pneumonia.
2. New small cavitary lesion in the left upper lobe, possibly
related to aspiration. Of note, the patient has a small hiatal
hernia.
3. Improvement in some of the ground-glass opacities in the
right middle and upper lobes, with persistent 4-mm lung nodule.
4. Similar slightly prominent right hilar and mediastinal lymph
nodes.
6. No evidence of pulmonary embolism.
7. Similar calcified lung mass, possibly a hamartoma, although
metastatic colon cancer cannot be excluded.
.
CT Head ([**2133-1-9**]): No definite change in the mass effect
associated with the brainstem glioma. Interval development of a
small left frontal region subdural collection.
.
CXR [**2133-1-10**]: No interval change. Persistent opacity at the left
base. There is a 3.6-cm parenchymal opacity within the left
base as well which is also unchanged. There is no evidence for
overt pulmonary edema. The lines and tubes are stable in
position.
================
A/P: 56 yo M admitted for dizziness/weakness. Found to have a
pontine glioma now s/p posterior fossa decompression complicated
by necrotizing PNA and multiple episodes of hypoxia requiring
MICU level care. Called out to medicine service for further
management of his infection and pulmonary status.
.
# Hypoxia: He has been stable over the past few days w/ better
maintained SpO2. He has improved in the past w/with deep
suctioning. Chest CT c/w necrotizine PNA. He is on levo ([**1-9**]
-> 2 weeks), and clinda ([**1-9**] -> 6 weeks). Bactrim was started
on [**1-8**] (x 2 weeks): BAL + for stenotrophamonas.
- wean O2 as tolerated on the floor
- Per thoracic staff ([**2133-1-10**]) pt will need CT guided drain
placement this week; ? if best to schedule PEG at same time to
minimize procedures
- continue levaquin, clindamycin, and bactrim for full course
- will need repeat CT in 1 month
- continue nebs prn
- continue aggressive pulmonary toilet
- incentive spirometry on the floor
.
# Lung nodule. Chest CT from the VA on [**8-25**] demonstrated 2
lesions in LLL (anterior and posterior) both of which were felt
to be stable compared to prior CT [**2-/2127**].
- await old films being mailed from the VA
- f/u IP/thoracic recs
.
# Brainstem glioma. Prognosis estimated at a couple of months
per neurosurg. ? palliative radiation
- continue Decadron [**Hospital1 **] per neurosurgery
- continue prn pain meds
- Neurosurg following
- pt full code
- monitor CN exam, mental status, and strength exams
.
# Anemia. 4pt Hct drop on [**2133-1-9**], transfused on [**1-11**] w/
appropriate Hct elevation and has been stable overnight
- repeat Hct when called out to floor
- guaiac stools x3 then d/c if negative
- transfuse for Hct < 25
- continue PPI while on decadron
.
# HTN. BP well controlled on current regimen
- Continue diltiazem and captopril
- monitor BP and titrate prn
.
# Left deltoid lesion.
- f/u in Dermatologic surgery clinic on [**2133-1-15**] at 11am
.
# Communication: VA Chief - [**Telephone/Fax (3) 66171**].
Mrs. [**Name (NI) 66172**] (aunt) [**Telephone/Fax (1) 66173**] is HCP.
.
# FEN. TF's through NGT (failed video swallow again on [**2133-1-12**])
- continue aspiration precautions
- patient has decline PEG placement x2 per notes in chart
- will reevaluate patient's wishes once transferred to floor;
would be best to place PEG when placing drainage so as to
minimize procedures
- replete lytes prn
.
# Access: PICC line placed [**2133-1-9**]
.
# PPX. SC heparin, PPI, bowel regimen, ISS while on decadron,
replete lytes
.
# Code: Full
.
# Dispo: Patient would like to be transferred to [**Location 1268**]
VA. [**Name (NI) 1094**] aunt has a scheduled meeting today with Dr. [**Last Name (STitle) **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: Hold
for lose stool.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-22**]
Puffs Inhalation Q6H (every 6 hours).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4-6H
(every 4 to 6 hours) as needed.
11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day).
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-22**]
Drops Ophthalmic PRN (as needed).
14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
15. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours): Started on [**1-2**] Total of 14
days then d/c. .
Discharge Disposition:
Extended Care
Facility:
VA
Discharge Diagnosis:
Right brainstem lesion
Discharge Condition:
Neurologically stable
Discharge Instructions:
Monitor suboccipital staple sites for drainage, erthyma,
swelling, fever greater than 101.5, seizure activity, visual
changes, weakness, numbness or any other neurologic symptoms
that may be concerning.
Keep your all appointments as sheduled.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in 10 days from [**1-2**] for wound check
and staple removal or can be removed at the [**Hospital **] hospital.
Follow up with Dr [**Last Name (STitle) 4253**](neurooncology) and Dr
[**Last Name (STitle) 3929**](Radiation oncology) in brain tumor clinic on [**2133-1-26**]
at 1300 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) **].
Follow up with Pulmonary Clinic in 4 weeks with a Chest CT with
and without contrast.
Follow up with Dr [**First Name (STitle) **], Dermatologic surgery
clinic([**Telephone/Fax (1) 2977**]for left deltoid lesion on [**2133-1-15**] at
1100.
Follow up with VA infectious disease for possible repeat CT
chest in 4 weeks.
Completed by:[**2133-1-27**]
ICD9 Codes: 5185, 5070, 496, 4019, 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 873
} | Medical Text: Admission Date: [**2136-2-3**] Discharge Date: [**2136-2-19**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
1. Dyspnea
2. Hemoptysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname 46286**] is a [**Age over 90 **]yo man with history of sCHF (EF 20-25%
[**4-/2135**]), complete heart block s/p pacer, AS s/p AVR (St. [**Male First Name (un) 923**]
porcine valve, [**10-7**]), Afib s/p cardioversion on warfarin, HTN,
and GERD who presents with 1-2 week history of progressive
fatigue, weakness, and dyspnea on exertion, as well as new onset
hemoptysis in setting of supratherapeutic INR.
.
Patient was in his usual state of health until two weeks prior
to presentation when he developed slight DOE and increased lower
extremity edema, felt to be mild exacerbation of CHF by his PCP.
[**Name10 (NameIs) **] lasix dose was increased from 20mg daily to 40mg daily with
some effect. However, 1-2 weeks prior to presentation patient
reported increasing fatigue, weakness, and SOB. He developed
dyspnea with only several steps around his apartment. He denied
dyspnea at rest, orthopnea or PND. Denied any fever or chills,
but reported >1 week of rhinorrhea, nasal congestion, and a
terrible cough productive of white phlegm. The morning of
presentation ([**2136-2-3**]) he noted bright red blood mixed in with
his phlegm; he could not fully quantify the amount though likely
less than 1 tsp at a time. Patient reported several episodes of
recurrent hemoptysis, prompting presentation to the [**Hospital1 18**] ED for
further evaluation.
.
In the emergency department, initial VS were T: 96.4 HR: 80 BP:
120/73 RR: 16 O2%: 100% on an unknown amount of oxygen. Exam was
notable for blood in oropharynx, crackles and decreased breath
sounds on right. Stool was guiac negative. Labs were notable for
INR of 6.8, WBC 11.8 with 87.0% N, HCT 39.1. Difficult to obtain
blood draws per ED report, and several samples hemolyzed. CXR
demostrated whiteout of right lung fields, as well as left sided
effusion. EKG showed AFib with intermittent pacing, no ischemic
changes. Bedside echo to exclude severe MR [**First Name (Titles) 3**] [**Last Name (Titles) 46296**] of
right-sided effusion was limited study, but showed only mild MR.
[**Name13 (STitle) **] ordered for vitamin K 10 units IV, 2 units FFP and
profilnine. Also received vanco 1gm IV, zosyn 4.5mg IV,
oseltamivir. Admitted to MICU for ongoing evaluation and
management. On arrival to ICU, patient had an O2 sat > 94 on
NRB, though became dyspneic with desats to 80s when NRB removed.
He reports no recent changes in medications (other than increase
in lasix dose), no sick contacts, no recent change in diet. Most
recent INR reported in our system was 1.9 on [**2135-12-21**] (per OMR
notes), and patient's goal INR has been 2-2.5.
Past Medical History:
Complete heart block s/p pacer
Aortic stenosis s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-7**])
Atrial fibrillation s/p cardioversion
Systolic congestive heart failure, EF 25-30% on TTE [**4-10**]
HTN
GERD
s/p ORIF "right leg"
Cholecystectomy
Cataract removal
BPH s/p TURP
Carpal tunnel syndrome s/p release
Allergic rhinitis
L hip OA s/p THR [**9-8**]
Dementia dx [**2127**]
h/o rhabdomyalysis
Right lower extremity radiculopathy and sacroiliitis
Venous insufficiency
Social History:
Patient divorced. Lives alone. Has Meals-on-Wheels 5 days per
week, also has someone come into to clean. No home nursing other
than scheduled INR checks. Daughter has accompanied him to
recent health care visits. Former smoker, quit years ago. No
EtOH or illicit drug use.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: 95.7 72 122/58 25 97% on NRB
GEN: awake, alert, oriented, elderly male in NAD, able to speak
in full sentences, hard of hearing
HEENT: EOMI, sclera anicteric, MMM, OP with blood
NECK: supple, no cervical LAD, JVD to mandible
PULM: decreased breath sounds right lung with scattered
crackles, diffuse expiratory wheezes bilaterally, decreased
breath sounds at left base, also with scattered crackles
CARD: irregularly irregular, systolic murmur
ABD: bowel sounds present, soft, NT, ND, no guarding or rebound
tenderness, no hepatosplenomegaly
EXT: warm, well-perfused, radial/PT/DP pulses 2+ bilaterally, 1+
edema to knees bilaterally, compression stockings in place
SKIN: warm, dry
NEURO: AAOx3, CN 2-12 grossly intact, moving all four
extremities
PSYCH: calm, appropriate
.
DISCHARGE EXAM:
VS: T 97.8 BP 90/50 HR 76 O2 Sat 96 2L NC
GEN: Awake, alert, oriented, elderly, cachectic male in NAD,
able to speak in full sentences, hard of hearing
HEENT: EOMI, sclera anicteric, MMM, OP with blood
NECK: supple, no cervical LAD, no JVD
PULM: Good movement of air throughout, course expiratory ronchi
L>R, improved
CARD: irregularly irregular, 2/6 systolic murmur RUSB
ABD: Flat, bowel sounds present, soft, NT, ND, no guarding or
rebound tenderness, no hepatosplenomegaly
EXT: warm, well-perfused, radial/PT/DP pulses 2+ bilaterally, no
LE edema, pneumo-boots in place
SKIN: warm, dry
NEURO: AAOx3, CN 2-12 intact (sensorineural hearing loss bilat),
moving all four extremities, strength 5/5
PSYCH: Appropriate,
Pertinent Results:
ADMISSION LABS:
[**2136-2-3**] 06:35PM BLOOD WBC-11.8*# RBC-4.44* Hgb-13.1* Hct-39.1*
MCV-88 MCH-29.4 MCHC-33.4 RDW-15.2 Plt Ct-425#
[**2136-2-3**] 06:35PM BLOOD Neuts-87.0* Lymphs-7.6* Monos-3.2 Eos-1.8
Baso-0.4
[**2136-2-3**] 06:35PM BLOOD PT-59.8* PTT-43.0* INR(PT)-6.8*
[**2136-2-4**] 02:42AM BLOOD Glucose-105* UreaN-21* Creat-0.8 Na-134
K-4.1 Cl-98 HCO3-24 AnGap-16
[**2136-2-4**] 02:42AM BLOOD CK(CPK)-50
[**2136-2-4**] 02:42AM BLOOD CK-MB-4 cTropnT-0.03* proBNP-9700*
[**2136-2-4**] 02:42AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8
[**2136-2-3**] 06:42PM BLOOD Glucose-101 K-6.5*
[**2136-2-3**] 06:42PM BLOOD Hgb-13.3* calcHCT-40
.
DISCHARGE LABS:
.
MICRO:
[**2-8**] Sputum Cx: upper respiratory contamination
[**2-7**] Sputum Cx: upper respiratory contamination
[**2-6**] Sputum Cx:
GRAM STAIN (Final [**2136-2-6**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2136-2-8**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2-5**] Blood Cx: negative to date
[**2-4**] Rapid Viral Screen/Cx: negative
3/5 Blood Cx: negative
[**2-4**] Urine Legionella: negative
[**2-4**] Sputum Cx: commensal respiratory flora
.
IMAGING:
[**2136-2-3**] Echo: The left atrium is dilated. The right atrium is
dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. LV
systolic function appears depressed. The right ventricular
cavity is dilated with depressed free wall contractility. A
bioprosthetic aortic valve prosthesis is present. The mitral
valve leaflets are moderately thickened. There is severe mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Moderate symmetric LVH
with deoressed systolic function. Dilated and depressed right
ventricle. At least mild mitral regurgitation (not likely to be
severe however). Bioprosthetic AVR - limited study and gradients
not assessed. Compared with the prior study (images reviewed) of
[**2135-4-21**], this was an on-call, limited, study. Findings are
broadly similar.
.
[**2136-2-3**] CXR: New confluent patchy alveolar opacification of the
right hemithorax likely represents alveolar hemorrhage given
clinical context.
.
Chest CT [**2136-2-13**]:
1. Left hilar mass with associated atelectasis of the lingula
and anterior
segment of left lower lobe and bronchial stenosis of the
segmental bronchi is likely to be accessible bronchoscopically.
2. Bilateral bronchocentric pulmonary opacity with smooth septal
thickening in the right lung likely reflects aspiration.
3. Bilateral moderately large nonhemorrhagic pleural effusions.
4. Moderately severe aortic annular, valvular and mitral annular
calcification and mild-to-moderate coronary artery
atherosclerotic
calcification.
5. Right atrial and pulmonary arterial enlargement consistent
with pulmonary hypertension.
CXR: [**2136-2-18**]
One view. Comparison with the previous study done [**2136-2-17**].
Patchy bilateral pulmonary opacities are again demonstrated.
There are bilateral pleural effusions as well. These findings
are essentially unchanged, as are the mediastinal structures.
The left heart border is partially obscured. A bipolar
transvenous pacemaker remains in place.
IMPRESSION: No significant change.
Brief Hospital Course:
Mr. [**Known lastname 46286**] is a [**Age over 90 **]yo man with history of sCHF (EF 20-25%
[**4-/2135**]), complete heart block s/p pacer, AS s/p AVR (St. [**Male First Name (un) 923**]
porcine valve, [**10-7**]), Afib s/p cardioversion on warfarin, HTN,
and GERD who presented with 1-2 week history of progressive
fatigue, weakness, and dyspnea on exertion, as well as new onset
frank hemoptysis in setting of supratherapeutic INR with CXR
demonstrating almost complete alveolar opacification of the
right lung. His hospital admission is sumarized by problem
below.
# Hypoxemic Respiratory Distress: Initially admitted to the MICU
and was found to have almost complete opacification of the right
lung and a left pleural effusion. He was treated with Vancomycin
and Levofloxacin for presumed pneumonia for nearly 14 day
course. Also given a steroid pulse in case asthma/emphysema were
at play, as patient does have a smoking history, but no
documented COPD. Echo showed an EF of 25-35%, so given concern
for CHF exacerbation, he was diuresed aggressively and did
require bipap and a nitro gtt briefly. When his respiratory
status improved to saturations of >94 on 5 L NC he was
transfered to the medical floor. Given persistant pleural
effusion and hypoxemia, despite aggressive diuresis, IP was
consulted for both diagnostic and therapeutic thoracenteisis.
They felt these were not amenable to drain as minimal fluid on
ultrasound. He had a Chest CT which demonstrated a new large
mass in his left lung (5cm x 5cm) obstructing the bronchus to
the lingula concerning for malignancy. Pulmonary was consulted
to discuss further work up of this mass, and the patient and his
daughter decided not to pursue a biopsy at this time. Palliative
care was consulted as well. Ultimately, the patient would like
to be home and is willing to go to rehab with plans to
transition to home with hospice.
His respiratory status remained quite tenuous throughout his
hospitalization. He was diuresed aggressively with improvement
in oxygenation. However, he was then noted to be hypotensive
with SBPs in the low 70s. Of note, normal SBPs are in the 90s.
The patient was completely asymptomatic. His blood pressure
improved with a 250 cc bolus and holding further diuresis. The
following day, the patient triggered for respiratory distress
that was consistent with flash pulmonary edema which improved
with morphine. He was continued on his home lasix regimen of 40
daily as this appeared to balance his respiratory status with
his blood pressure with a goal fluid balance of even to -250 cc.
He remained normotensive for 48 hours prior to d/c and his
respiratory status remained stable for 24 hours prior to
discharge to the MACU. He will continue to need supplemental
oxygen as this was unable to be weaned completely off.
His volume status should be watched carefully as he has proven
to be quite tenuous -- too much volume and he goes into
respiratory distress, too little volume and he is hypotensive.
# Hemoptysis: In setting of elevated INR to 6.8 (on warfarin for
afib). He was reversed with vitamin K. Treated for presumed
pneumonia. Also [**Month/Year (2) 46296**] may be lung mass near bronchi, however
work up deferred per patient request. Resolved and restarted on
coumadin without incident. INR goal 2-2.5.
# Goals of Care: Numerous discussion with patient and daughter
were had regarding patient's goals of care. Given his likely
terminal illness from his lung mass, the patient and daughter
felt they did not want further workup of this. Both the
pulmonary team and paliative care aided in this discussion. Both
patient and daughter were in favor of intubation if the patient
needed, only for the short term. He was DNR, but not DNI. They
were both told that he will likely go into respiratory distress
again given his finely balanced fluid status. If this were to
occur, they were both in favor of coming back to the hospital if
needed.
# Elevated Troponin: During respiratory distress, patient's
troponin was elevated to 0.09 with flat CKs. EKG showed a paced
rhythm. Given this likely demand ischemia, patient was started
on aspirin and atorvastatin. Further care should be directed in
the outpatient.
# Aspiration: CT findings were suggestive of aspiration though
video swallow studied did not show aspiration. His diet was
therefore advanced.
#. Acute on Chronic Systolic CHF: EF 25-30% this admission in
setting of decompensated heart failure. Diuresed as above. Could
not wean patient off of oxygen completely. On day of discharge,
patient was ~95% on 2 liters.
#. Atrial fibrillation s/p cardioversion, AV node ablation:
Patient was in Afib, and ventricularly paced with rate in 70s.
Patient was supratherapeutic in terms of INR on admission and
was given Vit K in the ED due to hemopytsis. Goal INR was 2-2.5.
for atrial fibrillation. Patient with porcine valve. The patient
was rate controled on metoprolol throughout admission. Coumadin
restarted and INR 1.8 at time of discharge. Continued SQ heparin
while patient was < 2.0.
# Hyponatremia: As low as 129. Most likely hypovolemic from
aggressive diuresis. It resolved on the floor.
#. HTN: Patient's baseline sbp is in the high 80s-90s and at
times in the 100s. Given these low blood pressures, diuresis
could not be overly aggressive. He will be d/c'd on lasix 40 mg
daily (as above). Lisinopril 2.5 mg was held due to low bps.
Metoprolol was continued with intermittent holding in setting of
low blood pressures. Low BP felt secondary to diuresis along
with systolic heart failure.
#. GERD: Home omeprazole was continued throughout admission.
#. Osteoarthritis: Tramadol was continued throughout his
admission.
Medications on Admission:
Furosemide 40mg daily
Lisinpril 2.5mg daily
Metoprolol succinate 25mg daily
Omeprazole 20mg daily
Potassium chloride 20 mEq daily
Tramadol 50mg TID prn pain
Urea 40% cream applied to left shin daily
Warfarin 5mg daily, 7.5mg Friday
Calcium carbonate 500mg TID
Colace 100mg PO BID prn constipation
Vitamin D2 400 units daily
Ferrous sulfate 325mg daily
MVI daily
Senna 2 tabs daily prn constipation
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. multivitamin, stress formula Oral
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation Q6 hours PRN as needed for shortness of breath or
wheezing.
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation: Do not take if you're having
loose stools or diarrhea.
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO
QM/W/T/TH/SAT/SUN.
10. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Friday only.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-4**] ampulettes Inhalation Q2H (every 2 hours)
as needed for sob, wheeze.
12. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold
for BP < 100.
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for Constipation: Hold for loose
stool.
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): Hold for bleeding.
16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Continue until patient
ambulating.
17. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
18. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: PLEASE HOLD IF SBP < 100.
19. Urea 40 40 % Lotion Sig: One (1) application Topical twice a
day as needed for rash: Apply to left shin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Congestive heart failure exacerbation
2. New obstructive lung mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 46286**],
It was a pleasure taking care of you while you were an inpatient
at the [**Hospital1 69**]. You were admitted
to our medical intensive care unit on [**2136-2-3**] for severe
shortness of breath. While here, you were treated with
antibiotics, steroids, and diuretics for a possible pneumonia,
COPD exacerbation, and congestive heart failure exacerbation
respectively. You improved with this therapy in the ICU and
were transfered to the medical floor. You're antibiotics and
steroids were discontinued and we continued to diurese for a CHF
exacerbation. On [**2136-2-13**] a CT scan was taken that demonstrated a
new mass in your left lung. This was discussed with you and your
daughter [**Name (NI) **] by both the medicine and pulmonary teams and you
decided that a biopsy would not be prudent at this time. On
[**2136-2-19**] your respiratory status improved and were felt ready to
be dischargee to an inpatient rehabilitation facility.
Please note the following instructions:
more than 3 lbs.
2. Please use combivent and albuterol nebulizers as needed for
shorteness of breath
You should continue your home medications with the following
important changes:
1. STOP lisinopril 2.5 mg daily
2. Change metoprolol Succinate 25 mg daily to metoprolol
tartrate 12.5 mg [**Hospital1 **] due to several low blood pressures.
3. Stop potassium supplementation
4. Start Atorvastatin 80 mg daily
5. Start Aspirin 81 mg daily
Followup Instructions:
-Please call PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], for an appointment when patient
leaves rehab.
-Also, please go to the following upcoming appointents:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2762**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2136-3-26**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2136-4-18**] 2:00
ICD9 Codes: 486, 2761, 5119, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 874
} | Medical Text: Admission Date: [**2106-3-22**] Discharge Date: [**2106-3-27**]
Date of Birth: [**2038-3-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2106-3-22**] CABG x5 (LIMA to LAD, SVG to RAMUS, SVG to OM, SVG to
PDA, sequentially to PLB)
History of Present Illness:
68 yo male with angina and abnormal ETT referred to [**Hospital1 18**] for
cardiac cath.
Past Medical History:
NIDDM
HTN
elev. lipids
prior GI bleed on ASA ( w/u revealed vascular ectasias in small
bowel)
anemia
bacterial prostatitis [**8-26**]
Social History:
teaching consultant with PHD in organic chemistry
lives with wife in [**Name2 (NI) **],staying here with daughter(GI physician)
never used tobacco
occasional ETOH
Family History:
father died of MI at 75
Physical Exam:
5' 7" 160#
appears younger than stated age
lying flat for exam in cath lab
skin unremarkable, wears glasses
neck supple with full ROM, and no cartotid bruits appreciated
CTAB anterolaterally
RRR distant heart sounds, no murmur
abd soft, NT, ND
extrems warm, well-perfused, no edema or varicosities noted
neuro grossly intact, unable to assess gait
2+ bil. fem/DP/PT/radials
Pertinent Results:
[**2106-3-26**] 05:20AM BLOOD WBC-8.1 RBC-2.72* Hgb-8.2* Hct-24.2*
MCV-89 MCH-30.3 MCHC-34.1 RDW-13.5 Plt Ct-171
[**2106-3-26**] 05:20AM BLOOD Plt Ct-171
[**2106-3-26**] 05:20AM BLOOD Glucose-127* UreaN-34* Creat-1.1 Na-133
K-4.1 Cl-96 HCO3-30 AnGap-11
[**2106-3-26**] 05:20AM BLOOD ALT-18 AST-26 AlkPhos-48 TotBili-0.6
Co[**Last Name (STitle) 77854**]ons
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45-50 %).
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic root is mildly dilated at the sinus level. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. Dr.
[**Last Name (Prefixes) **] and [**Doctor Last Name **] were notified in person of the
results
POST-CPB: On infusion of norepi, nitroglycerine, propofol.
Preserved LV systolic function with LVEF= 55%. Trace MR. Aortic
contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2106-3-22**] 15:05
RADIOLOGY Final Report
CHEST (PA & LAT) [**2106-3-26**] 9:48 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
68 year old man s/p CaBG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
HISTORY: Status post CABG, to evaluate for pleural effusion.
FINDINGS: In comparison with study of [**3-24**], there is little
overall change in the appearance of the heart and lungs.
Opacification at the left base with blunting of the costophrenic
angle persists.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: FRI [**2106-3-26**] 12:05 PM
Brief Hospital Course:
Admitted on [**3-22**] and underwent cabg x5 with Dr. [**Last Name (STitle) 1290**]. He
noted poor graft targets and elected to have the pt. start
plavix and imdur postoperatively.Transferred to the CVICu in
stable condition on phenylephrine, nitroglycerin and propofol
drips. Extubated later that day and transferred to the floor on
POD #1 to begin increasing his activity level.Transfused for Hct
22.Chest tubes and pacing wires removed without incident. He was
gently diuresed toward his preop weight. Beta blockade was
titrated. One episode of vomiting on POD #3 as well as
generalized pruritis, without rash. sarna lotion applied. LFTs
normal and pt. tolerating food.Cleared for discharge to
daughter's home with VNA servies on POD #5. Pt. is to make all
followup appts. as per discharge instructions.
Medications on Admission:
ASA 81 mg ( started 2 weeks prior to cath)
toprol XL 25 mg daily
lotrel 5mg/20 mg daily
prandin 0.5 mg QID
metformin 500 mg TID
lipitor 10 mg dialy
omeprazole 40 mg daily
(plavix 300 mg [**3-14**], 75 mg [**3-15**])
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for poor grafts.
Disp:*30 Tablet(s)* Refills:*2*
2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*1*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*1*
4. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 5 days.
Disp:*5 Packet(s)* Refills:*1*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
8. Repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3
times a day (before meals)): take if eating.
Disp:*90 Tablet(s)* Refills:*1*
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. 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*
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*2 bottles* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Home
Discharge Diagnosis:
CAD s/p cabg x5
NIDDM
HTN
elev. lipids
prior GI bleed ( on ASA- w/u showed vascular ectasias in small
bowel)
anemia
bacterial prostatitis [**8-26**]
Discharge Condition:
good
Discharge Instructions:
SHOWER daily and pat incisions dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, drainage, or weight
gain of more than 5 pounds in [**5-26**] days
Followup Instructions:
see Dr. [**Last Name (STitle) **] in 2 weeks
see Dr. [**Last Name (STitle) 1290**] Thursday [**4-22**] at 12:45 PM [**Telephone/Fax (1) 170**]
see PCP as soon as you return to NY
Completed by:[**2106-3-27**]
ICD9 Codes: 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 875
} | Medical Text: Admission Date: [**2160-6-7**] Discharge Date: [**2160-6-23**]
Date of Birth: [**2098-11-23**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is a 61-year-old woman
transferred from [**Hospital 1474**] Hospital with known bilateral
subdural hematomas. The patient was in her usual state of
health until today on the 17th when she had a sudden onset of
headache after coughing. She was taken to [**Hospital 1474**] Hospital,
where she was intubated for airway protection, although
neurologically stable. She was transferred to [**Hospital3 **]
for further management. She is on Coumadin for a history of
valve surgery. Her INR at the outside hospital was 10.5.
She was given 1 unit of fresh-frozen plasma and 5 mg of
vitamin K.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Ventricular pacer.
3. Question of valve surgery.
PHYSICAL EXAMINATION: On physical exam, she is in AF, heart
rate 77, blood pressure was 208/49. She was intubated,
sedated, awakened to examiner, attentive. She has
antigravity strength in both upper and lower extremities.
She withdraws to pain bilaterally. Her pupils were symmetric
and reactive at 2.5. Her face was symmetric and her toes
were downgoing.
LABORATORIES AT OUTSIDE HOSPITAL: White count was 8.8,
hematocrit 36.2, platelets 286. Sodium 139, potassium of
4.2, chloride of 105, CO2 24, BUN 12, creatinine 0.7, glucose
147.
CT scan at the outside hospital showed right sided subdural
hematoma which was about 5 mm at the greatest thickness.
Also a chronic subdural hematoma with slight effacement of the
right lateral ventricle.
She was admitted to the Neurosurgical Intensive Care Unit.
On [**2160-6-8**], the patient had an episode of desaturation
with frothy sputum thought to be secondary to fluid overload
from blood products to correct INR. The patient remained
intubated. Pupils were symmetric. She localizes pain
bilaterally moving the legs to command. Spiked a temperature
to 102.6. Her sputum had gram-positive cocci in pairs and
clusters. She was started on Vancomycin for pneumonia.
She had positive blood cultures on [**2160-6-13**] with
gram-positive cocci pairs and clusters. On [**2160-6-11**], the
patient was seen by the EPS service for a question of problem
with her pacemaker. They recommended to getting an
echocardiogram and continuing her current medications, and
just continuing to monitor her condition. She continued to
spike to 102, and on [**6-15**], she had positive blood cultures
with gram-positive cocci. Was started back on Vancomycin.
On [**6-16**], the patient had a PICC line placed without any
problems. The patient continued to be awake to voice,
attentive, and following commands, moving arms and legs
spontaneously and purposefully. She remained in the
Intensive Care Unit, and patient was extubated on [**2160-6-18**].
She tolerated extubation well, and she was transferred to the
regular floor on [**2160-6-19**], where she has remained stable
from respiratory and neurologic standpoint. She is awake,
alert, and oriented times three, moving all extremities.
Still had some left upper extremity weakness which she has
had right along.
She has been followed by Physical Therapy and Occupational
Therapy, and found to be safe for discharge to
rehabilitation.
Pulmonary wise, she is on room air. Tolerating room air fine
without difficulty breathing. She has been restarted on her
anticoagulation after repeat head CT scan shows stable size
of the subdural hematoma with no change in that she is
currently on 850 units of IV Heparin and 5 mg of Coumadin.
Her INR today on [**2160-6-23**] is 1.9 with a PTT of 91.5
currently going at 850 an hour of Heparin.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gram IV q24h.
2. Ipratropium bromide inhaler one nebulizer q6h prn.
3. Albuterol one nebulizer q6h prn.
4. Lasix 40 mg IV bid.
5. Levofloxacin 500 mg po q24h.
6. Metoprolol 75 mg po bid.
7. Nystatin oral suspension 5 cc po qid.
8. Fluticasone propionate 110 mcg two puffs [**Hospital1 **].
9. Albuterol two puffs q6h prn.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP INSTRUCTIONS: She will follow up with Dr. [**Last Name (STitle) 1132**]
with a repeat head CT scan in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2160-6-23**] 09:37
T: [**2160-6-23**] 09:39
JOB#: [**Job Number 28697**]
ICD9 Codes: 7907, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 876
} | Medical Text: Admission Date: [**2179-7-16**] Discharge Date: [**2179-7-19**]
Date of Birth: [**2102-1-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
s/p Bronch and stent removal
History of Present Illness:
77M with tracheal malasia
Past Medical History:
COPD, home O2, TBM, OA, diverticulosis, nephrolithiasis, MRSA,
asbestosis, GERD
Social History:
sormer insulation (asbestos) worker
minimal smoking history
Family History:
none
Physical Exam:
AVSS
Course with wheezes
Pertinent Results:
[**2179-7-16**] 08:11PM TYPE-ART PO2-180* PCO2-57* PH-7.36 TOTAL
CO2-34* BASE XS-5
[**2179-7-16**] 08:11PM O2 SAT-97
[**2179-7-16**] 08:03PM GLUCOSE-110* UREA N-14 CREAT-0.9 SODIUM-140
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-32 ANION GAP-12
[**2179-7-16**] 08:03PM CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-2.0
[**2179-7-16**] 08:03PM WBC-13.0*# RBC-3.79* HGB-11.6* HCT-34.5*
MCV-91 MCH-30.5 MCHC-33.5 RDW-14.4
[**2179-7-16**] 08:03PM PLT COUNT-190
Brief Hospital Course:
Pt taken to OR for stent removal and clean out.
Post op admitted to CSRU on vent.
Kept on vent overnight and wean and extubated in AM.
Diet advanced.
CXR showed patent airways with minimal consolidation.
Medications on Admission:
Capsaicin
Dilt
Colace
Nexium
[**Doctor First Name **]
Advair
Xopenex
Levofloxacin
Lopressor
Prednisone
Spiriva
Tylenol
Codeine
Guaifenesin
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
As above
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
TBM
Discharge Condition:
stable
Discharge Instructions:
Continue IS, coughing, and deep breathing.
Followup Instructions:
F/U with Dr. [**Last Name (STitle) **] in [**12-13**] wks
F/U with Dr. [**Last Name (STitle) 952**] in 2 wks
Completed by:[**0-0-0**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 877
} | Medical Text: Admission Date: [**2158-12-13**] Discharge Date: [**2158-12-13**]
Date of Birth: [**2091-4-21**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 M with extensive PMH found unresponsive by family, found to
have SDH with midline shift and uncal herniation, transferred
here for further management
Past Medical History:
Esophageal varices, GIB, h/o MI x 2, h/o lung ca
Brief Hospital Course:
The patient was admitted to the trauma ICU. After discussion
with the family, given the patient's ICH, midline shift, and
uncal herniation, further aggressive treatment was felt to be
futile. He was made CMO and expired the night of [**2158-12-13**].
Discharge Disposition:
Expired
Discharge Diagnosis:
SDH, uncal herniation
Discharge Condition:
expired
ICD9 Codes: 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 878
} | Medical Text: Admission Date: [**2108-3-22**] Discharge Date: [**2108-4-3**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 17813**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a [**Age over 90 **] year old woman with a recent
cardiopulmonary arrest of unknown etiology and seizures who has
been transferred from [**Hospital1 **] [**Location (un) 620**] for further management of
suspected status epilepticus. This history was obtained from
discussion with her son [**Name (NI) 333**] and from review of the medical
record. On [**2108-2-18**] she was found down at her residence and was
noted to be bradycardic, hypotensive, hypothermic, and
lethargic.
She was transported to an ED at Upstate [**Location (un) **] Hospital in
NY
where she had a cardiopulmonary arrest and was intubated and
resuscitated. The intubation was difficult and she was found to
have a mediastinal mass (multinodular goiter with papillary
microcarcinoma, which was removed). She had a complicated
hospital course with hospital-associated pneumonia, lung
collapse
s/p bronchoscopy, sepsis, corneal abrasion/chemosis,
perioperative anemia from blood loss, and then confusion. She
was
started on quetiapine initially for suspected ICU-related
delirium. However, she started showing clinical signs of
seizures
(sudden behavioral arrest, blank stare, eye deviation to the
left
and down) which resolved with low dose of lorazepam. Despite
reportedly unremarkable head imaging, she was thought to
potentially has PRES (unclear what the blood pressure
measurements were at the time). She was started on Levetiracetam
750 mg [**Hospital1 **] for seizure prevention. An EEG done at that time
reportedly suggested potential epileptiform foci but no seizures
were seen. She was discharged to a rehab but per her family did
not return to her prior highly functional baseline mental
status.
On [**2108-3-21**], she was even more lethargic than usual and did not
respond promptly to sternal rub. She was observed as having
right
face and right shoulder twitches with associated bowel/bladder
incontinence which ceased with diazepam 2.5 mg given twice. She
had a normal blood sugar of 81 at that time and otherwise normal
vital signs after the episode. She was transferred to
[**Hospital1 **]
for further management where she was given two loading doses of
Fosphenytoin 500 mg with some improvement in the focal motor
activity. Neurology was consulted there and recommended
increasing Levetiracetam to 1000 mg [**Hospital1 **] and continuing
Phenytoin.
She had an unremarkable NCHCT. She was found to have a UTI and
was started on Ceftriaxone on [**3-21**]. She was thought to
potentially have pneumonia as well, but chest imaging did not
reveal an infiltrate so this was stopped. An EEG was obtained
which potentially showed frequent left parasagittal epileptiform
discharges, so she was transferred to [**Hospital1 18**] for further care.
Prior to transfer per her son, he [**Name2 (NI) 15598**]'t notice any more motor
activity but she was not very arousable (she would only briefly
open her eyes to voice).
Past Medical History:
[] Neurologic - Seizures (s/p cardiac arrest, ? hypoxic brain
injury), Recent ? Posterior Reversible Leukoencephalopathy
Syndrome (clinical diagnosis at onset of seizures)
[] MSK - Left hip fracture (s/p ORIF)
[] Cardiovascular - Recent cardiac arrest, HTN, HL, reportedly
CAD
[] Pulmonary - Recent hypoxic respiratory failure
[] Endocrine - Multinodular goiter with papillary carcinoma (s/p
resection, discovered during difficult intubation)
[] Ophthalmologic - Corneal abrasion/chemosis
Social History:
Until recently living independently, driving. Now
at [**Hospital3 4103**] on the [**Doctor Last Name **]. No tobacco, ETOH, or illicit drug
use.
Family History:
Ovarian cancer (mother)
Physical Exam:
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Alert, Oriented to self and year, but no year
or city. She follows commands.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to threat.
[III, IV, VI] Tracks to the left but has difficult crossing
midline to the right. [V] Corneals present bilaterally. [VII] No
facial asymmetry at rest. [XII] Tongue midline.
- Motor - No tremor or asterixis or myoclonus currently. She has
full strength on the left side of her body, with decreased
strengh on the right, but moving at least against gravity.
- Sensory - Response to noxious all four extremities.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 1
Plantar response extensor bilaterally.
- Gait - Unable to assess.
Brief Hospital Course:
Neuro:
Mrs. [**Known lastname 110651**] was very sleepy while in the ICU, and her EEG was
showing PLEDs. She was started on keppra and dilantin. Her PLEDs
improved, and her mental status continued to slowly improved.
Upon transfer to the floor, she had no further clinical
seizures. Her mental status was improving daily, and she was
back to having full conversations on the day of her discharge.
we stopped her dilantin and increased the keppra in order to
create a balance between her level of drowsiness and seizure
control. We decided not to treat the actual PLEDs, as she was
clinically improving.
CV/Resp:
She did not have any further acute issues during her stay. We
continued her anti-hypertensive medications.
FEN/GI:
She was initially too sleepy to eat on her own and therefore was
placed on tube feeds. She took her own tube out on [**4-1**], and as
she was awake enough, we decided not to replace it and allow her
to PO. We advanced her diet to soft + thin liquids based on the
recommendations of speech therapy, and she tolerated it well.
She needs to continue to work on her diet, and she needs
supplmentation with ensure.
ID:
She received 7 days of ceftriaxone for her UTI, she was
afebrile, and had no further complications.
We kept her foley in because she developed a bed sore, and we
did not want the area to become wet. The foley can come out once
the area has healed.
Medications on Admission:
Transfer Medications:
LEV 1000 [**Hospital1 **]
NovoLog sliding scale
Lovenox 40 SC
Mag PRN
PHT 100 q8h
CTX 1g daily,
ASA 325
Nexium 20 [**Hospital1 **]
APAP 650 q6h prn
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID
(2 times a day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Seizures
Discharge Condition:
Condition: good
Mental status: Alert, oriented to self and year, fluctuates in
terms of orientation to day/city.
Ambulatory: currently bed bound.
Discharge Instructions:
Dear Mrs. [**Known lastname 110651**],
It has been a great pleasure taking care of you.
You were admitted to our neurology/epilepsy service because you
were having seizures after you had your cardiac arrest.
Your EEG did show that you were having a lot of epileptic
discharges, you were placed on two medications, and we only kept
you on one of them, which was enough to control the seizures.
You also had a urinary tract infection which we treated.
Your mental status continued to improve dramatically.
You required a feeding tube through your nose initially, but you
were able to start eating by mouth soon after and therefore did
not need it anymore.
Followup Instructions:
Our neurology clinic will contact you for a follow up
appointment.
ICD9 Codes: 5990, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 879
} | Medical Text: Admission Date: [**2105-8-11**] Discharge Date: [**2105-8-12**]
Date of Birth: [**2034-12-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70yo man w/ h/o CAD s/p CABG, h/o afib, ETOH cirrhosis, DM, who
presented to an OSH on [**2105-8-4**] w/ a perforated small bowel,
underwent enterectomy & end-ileostomy on [**2105-9-5**], post-op course
complicated by renal failure, ileus, worsening hepatic failure
and mental status changes. He is being transferred to [**Hospital1 18**] for
evaluation of his multi-organ failure--there was question of him
having hepatorenal syndrome.
Summary of OSH Course:
- Pt p/w abd pain. Initially treated conservatively w/ IVF and
levo/ flagyl. However, his pain persisted and lactate up to 6.1.
- Pt went for ex lap, which reportedly revealed perforated small
bowel. He underwent enterectomy w/ end ileostomy.
- Post-op he was extubated. However, he had increasing
respiratory distress and required intermittent Bipap. On day of
transfer, he was requiring persistent Bipap due to hypoxemia:
ABG 7.48/30/68--on 50% Fi02 on Bipap. He was intubated prior to
transfer to [**Hospital1 18**].
- Pt described as having MS changes w/ possible hepatic
encephalopathy. He reportedly Opened eyes, responded
"intermittently" to voice.
- He developed acute renal failure of unclear cause. His bumped
from 0.48 to 1.58 post-op. OSH was unable to be measure crt on
last day or two of his OSH stay [**1-17**] elevated bili. Renal US w/
no hydro (per erport).
- Pt described as having post-op ileus for which an NGT placed.
He was started on TPN b/c ileus.
- LFTs notable for Tbili 20.8, up from 6.8 on admission. Direct
bili 14.9. AST 85, ALT 49. INR 2.1. Alb 2.4.
- Pt noted to have ascites w/ bacteroides uniformis (few) and
rare clostridium species (not perfringens) growing in it.
- Cdiff test positive from [**2105-8-4**]--day of pt's admission,
suggesting he had it prior to presenting.
- Pt treated with flagyl/levo from outset of hospital stay
([**8-4**]) and zosyn was added (? [**8-11**])
- Had afib w/ rates up to 140s. Was getting dig for this.
- Trop 0.11. EKG unchanged from prior.
- Pt developed hypotension. He was started on levophed. Serum
cortisol 22.1 (unclear if random level). Lactic acid 2.9 prior
to transfer.
- Plt 29K (chronically low--for years)
- Pt noted to have coagulopathy w/ INR 2.1
- Got re-intubated by EMS, AC 550x10/5/100%; on levophed,
Past Medical History:
- CAD s/p CABG
- DM
- ETOH cirrhosis
- Colon cancer s/p resection & radiation
- Chronic thrombocytopenia & ? leukonpenia
- Group B strep sepsis of unknown source in [**4-20**]
- AAA
- HTN
- Hypercholesterolemia
-GERD
-Esophagitis
- Echo [**6-22**] (OSH) nml LV function, LVH & biatrial enlargement.
Mild MR, Mild to mod TR, mild to mod PAH. (EF 64% on MIBI [**6-22**])
- EGD [**6-22**] showed "diffuse mild inflation at GE junction--not
biopsied--and gastritis.
- Colonscopy rectal polyp (rsected
Social History:
Married. Lives w/ wife on [**Name (NI) **]. Works 3day/wk in butcher shop.
Has grown kids. Drinks 4 gins /day. Former smoker
Family History:
nc
Physical Exam:
VS: T: 95.6 HR: 105 BP: 117/62 (on 0.25 levophed) Sat: 92% on AC
550x14, 5, 100%
Gen: NAD, when sedation wears off pt follows one step commands &
shakes his head "no" when asked if he is in pain.
HEENT: NCAT, PERRL, sclera icteric
Neck: Supple, no LAD, no JVD
CV: distant hrt sounds; nml S1/S2, no m/r/g
Resp: course breath sounds b/l anteriorly
Abdomen: Distended but Soft, absent BS, NT, vertical ~midline
surgical incision w/ areas open space where fluid is leaking out
(?[**Last Name (un) 12949**] fell out in those areas), fluid draining appears
serosanguinous. Ostomy draining serosainguinous fluid
Ext: No c/c/e. DP pulses are 2+ bilaterally
Neuro: A + O x 3, CN II-XII grossly intact, Motor [**4-20**] both upper
and lower extremities
Skin: Pink, warm, no rashes
Brief Hospital Course:
70 year-old man with CAD s/p CABG, PAF, reported cirrhosis from
ETOH abuse, and chronic thrombocytopenia, POD#7 s/p enterectomy
& end-ileostomy for small bowel perforation, who is transferred
with multiorgan failure.
.
# Shock: Pt presented from OSH already on one pressor with
evidence for multisystem organ failure including ARF. Had been
intubated prior to transport. On arrival pt rapidly
decompensated with hypotension refractory to IVF and eventually
maxed out on 4 pressors. He was treated broadly with
antibiotics, daptomycin, ceftazadime, PO vancomycin, IV flagyl.
His lactate continued to elevated and he stopped making urine. A
family meeting was held during the day when pt's pressures could
not be maintained on max presssors and fluids. The decision was
made not to withdraw care but it was agreed that CPR would not
be indicated. The patient passed away with his family present
at [**2026**].
Medications on Admission:
Dig 0.25mg
Toprol Xl 50mg
ASA 81
PRotonix 40mg
? Glyburide
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Multiorgan failure
Discharge Condition:
Expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 0389, 5849, 5185, 2875, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 880
} | Medical Text: Admission Date: [**2116-12-6**] Discharge Date: [**2116-12-10**]
Date of Birth: [**2063-1-24**] Sex: M
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
HPI: This is a 53 year-old gentleman with HCV cirrhosis and
refractory lymphoblastic lymphoma/ALL on rituximab and
prednisone who presents with altered mental status. His mother
found him this morning with increased lethargy and complaining
of diffuse back pain. The back pain was unchanged from his usual
back pain, secondary to his ALL, and was not relieved by
morphine or methadone. He was recently admitted to the BMT
service from [**11-27**] until [**12-1**] for fevers and progressive ALL.
Infectious work-up was unremarkable and his fevers were
atrributed to a reaction to platelet transfusion. Of note, he
had another admission earlier in [**Month (only) **] at which point he
developed a strep viridans line infection (from PICC line)-- the
PICC line was removed, he was treated with a course of PCN G
which was changed to augmentin at his last admission with the
last dose due either yesterday or today. After finding him this
morning, his mother brought him back to 7 [**Hospital Ward Name 1826**] today for
readmission and an ambulance was called from there to bring him
to the ED.
.
In the ED, initial vitals were T 98.3, BP 122/83, HR 100, RR 12,
100% on 4L. He was sleepy but A+O x3. Pt was noted to be very
uncomfortable, complaining of back pain. While in the ED, he
became
more delirious, writhing around in bed, refusing pain
medications, and perseverating on wanting to get out of bed to
urinate. Pt was intubated for CT head and abdomen. Spiked temp
to 101.8 rectally but remained hemodynamically stable. He was
given ceftriaxone, vanco, and acyclovir for empiric meningitis
coverage. LP was deferred given platelet count of 14. CT head
was negative and CT abdomen was notable for slightly worsened
ascites, new bibasilar opacities. Attempts to place OGT and
foley were unsuccessful and patient was noted to only have 40cc
of UOP while in the ED.
.
ROS: Unable to obtain.
Past Medical History:
<b>HEMATOLOGIC/ONCOLOGIC HISTORY:</b>
Mr. [**Known lastname 2479**] was diagnosed with lymphoblastic lymphoma in
[**2116-1-31**]. He presented to [**Hospital1 18**] on [**2115-12-30**] with
complaints of diffuse myalgias and arthralgias. A CT scan
demonstrated multiple enlarged portahepatis lymph nodes (largest
1.5 x 2.7 cm)and portacaval lymph nodes (largest 1.9 cm x 3.4 )
as well as multiple mildly enlarged paraaortic lymph nodes, the
largest measuring 1.2 x 1.9cm. On [**2116-1-6**], he underwent a
CT-guided fine-needle aspiration of a portahepatis lymph node
which was nondiagnostic.
A bone marrow biopsy was obtained on [**2116-2-26**], demonstrating
involvement by high-grade B-cell lymphoproliferative disorder.
Tumor cells were diffusely positive for pan B cell markers CD20
and PAX-5, with co-expression of CD10 and bcl-2. TdT staining
was equivocal, with predominantly cytoplasmic staining and a
rare cell with dim nuclear staining. MIB-1 staining showed an
overall proliferation index of 50-60%, with focal areas with a
higher fraction. The differential diagnosis was felt to include
lymphoblastic lymphoma/leukemia (precursor B-cell
lymphoma/leukemia) or a blastic transformation/progression of a
mature B cell lymphoma. It was noted that a definitive diagnosis
would require flow cytometry and molecular studies, which could
not be performed because there were no blasts in the peripheral
blood and a marrow aspirate could not be obtained (dry tap).
However, the peripheral blood sample was sent for
immunophenotyping, which demonstrated a new population of CD34
positive cells and a small population of CD19 positive cells in
the "blast" gait, without expression of TdT. It was felt that
these findings should be interpreted with caution since no
blasts were identified on a corresponding peripheral smear.
Given his significant liver dysfunction and other medical
co-morbidities, the initial treatment regimen chosen for the
patient consisted of R-CHOP, which was initiated on [**2116-3-4**].
He received a second cycle of chemotherapy on [**2116-3-24**],
consisting of R-CHOP without vincristine, which was held
secondary to neuropathy. Modified Hyper-CVAD Course A was given
on [**2116-4-10**], with a second course given on [**2116-5-15**] and a third
course on [**2116-6-22**]. Course B was not given due to his history of
hepatic cirrhosis. Of note, the patient has known retinal
involvement by his lymphoma, for which he is followed by Dr.
[**Last Name (STitle) **] of ophthalmology. A liver biopsy on [**5-8**] and repeat bone
marrow biopsies on [**6-12**] and [**7-19**] have shown no evidence of
recurrent lymphoma.
The patient presented on [**2116-10-15**] with myalgias, headache,
mental status changes, and fevers. A CBC showed a WBC of 7.2
with 14% blasts. A bone marrow biopsy demonstrated marked
fibrosis and relapsed acute lymphoblastic leukemia/lymphoma. He
was treated with rituximab 500mg, given in three doses of 100mg,
200 mg, and 200mg on [**10-9**] - [**10-11**]. In addition, he was treated
with rituximab 375mg/m2, cyclophosphamide 750mg/m2, doxorubicin
20mg/m2, and dexamethasone 20mg from [**10-19**]- [**10-21**].
The patient was noted to have recurrence of peripheral blasts on
[**2116-11-9**], with a bone marrow biopsy on [**2116-11-11**] showing residual
leukemia in the marrow. After extensive discussion, he opted to
continue palliative chemotherapy with rituximab and prednisone.
Rituximab was started on [**2116-11-16**] at 100mg, with plans to
continue threrapy with 200mg daily on [**11-17**] and [**11-18**].
<br>
<b>ADDITIONAL MEDICAL HISTORY:</b>
1. Hepatitis C, not treated.
2. Hepatic cirrhosis.
3. History of intravenous drug use.
4. History of depression.
5. Chronic lower back pain.
6. Status post tonsillectomy and adenoidectomy.
7. Lipomectomy.
8. Steroid-induced diabetes mellitus
Social History:
The patient is currently living with his mother and his brother,
[**Name (NI) 2259**]. [**Name2 (NI) **] has two children and four grandchildren. He is a
recovering heroin addict who used IV drugs for over 30 years
before becoming clean, but he admits that he intermittently uses
illegal drugs, most recently in early [**Month (only) 359**] (cocaine) and did
heroin ~5 years ago. He Currently smoke [**2-2**] cigarretes/day and
has history of ~20 pack-year. He denies alcohol use. He
formerly worked in housing construction as roof constructor.
Family History:
The patient's father died of lung cancer at 78. His maternal
grandmother died of colon cancer 78. His sister died of
leukemia. He has 2 brothers and 2 sisters who are healthy as
well as 2 children. He is separated
Physical Exam:
Vitals: T: 101.1 BP: 87/50 HR: 71 RR: 23 O2Sat: 100%
Vent settings: AC 600/14 PEEP 5 FiO2 100%
GEN: intubated
HEENT: PERRL (4-->2mm), sclera anicteric, no epistaxis or
rhinorrhea, MMM, ET tube in place
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, diminished breath sounds at the left
anteriorly, no W/R/R
ABD: Distended, +BS, difficult to assess HSM, +fluid wave
EXT: No C/C/E, no palpable cords
NEURO: opens eyes to voice, does not consistently follow
commands. Moves all 4 extremities spontaneously. Plantar reflex
downgoing.
SKIN: Scattered ecchymoses on LUE (by PICC line) and abdomen. No
jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2116-12-6**] 08:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL
TEARDROP-1+
[**2116-12-6**] 08:25AM NEUTS-25* BANDS-1 LYMPHS-21 MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-1* NUC RBCS-15* OTHER-48*
[**2116-12-6**] 08:25AM GLUCOSE-211* UREA N-26* CREAT-0.6 SODIUM-140
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15
[**2116-12-6**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2116-12-6**] 09:00PM GLUCOSE-133* LACTATE-2.3* NA+-137 K+-5.1
CL--115*
[**2116-12-6**] 09:00PM TYPE-ART PEEP-5 O2-60 PO2-92 PCO2-31* PH-7.43
TOTAL CO2-21 BASE XS--2 INTUBATED-INTUBATED
[**12-8**]
DIC labs +
Tbili: 5.1 Alb:
LDH: [**Numeric Identifier 35002**] Dbili: 0.8
Fibrinogen: 463
Plt: 24
CXR (s/p intubation): Although on the frontal view, the
electronic measurement of the distance from the ET tube tip to
the carina is less than 6 cm, the tip is above the upper margin
of the clavicles, and it is probably 3 cm above optimal
placement, with the discrepancy explained by marked patient
kyphosis. Aside from mild plate-like atelectasis at the base of
the left base, lungs are clear. There is no pleural effusion.
Heart size is normal.
.
CT abd/pelvis: Slightly worsened ascites. No change in
splenomegaly, cholelithiasis, portal lymphadenopathy. Bibasal
opacities new since [**Month (only) 359**], could be due to atelectasis,
pneumonia, aspiration.
.
CT head: No evidence of acute intracranial abnormalities. MR
with
gadolinium would be more sensitive for intracranial infections
or masses.
.
KUB: Non-specific bowel gas pattern without free intraperitoneal
air.
.
CXR PA and lat: Interpretation is limited by patient rotation
and
kyphotic angulation. However, there is no evidence of pleural
effusion or focal consolidation. Allowing for change in
positioning, the study is overall not significantly changed
since [**2116-11-27**]. There is a focus of linear atelectasis at the
left lung base. Wedge compression deformities of two low
thoracic vertebral bodies are unchanged.
Brief Hospital Course:
Patient was a 53 year-old male with a history of relapsing
refractory ALL on prednisone and rituximab and HCV cirrhosis who
presents with fever, altered mental status, and hypotension.
Patient was hypotensive, started on pressors, given IVF,
worsened in the setting of adrenal insuffiency, and synthetic
hepatic dysfunction. Patient was intubated. Once infectious
etiology was eliminated, patient's dim prognosis was discussed
with family and a determination was made to make the patient
CMO. Patient was extubated and started on morphine drip.
Patient, due to high drug tolerance, continued to have pain and
was responsive on morphine drip. Patient was transferred from
the [**Hospital Unit Name 153**] to BMT floor for CMO continuation. Patient continued to
show signs of discomfort and sedatation was switched to dilaudid
and ativan drip. Patient expired at 7:20 pm on [**2116-12-10**]
secondary to respiratory failure from relapsing refractory ALL
in the presence of the family. The proxy, [**Name (NI) **] [**Name (NI) 2479**], the
patient's son, consented to a full autopsy.
Medications on Admission:
Amoxicillin-Pot Clavulanate 500-125 mg PO Q8H
Lantus 50u daily
Humalog ISS
Gabapentin 300 mg PO HS
Lactulose 30 ML PO QID
Lorazepam 0.5 mg Tablet PO Q4H
Filgrastim 480 mcg/1.6 mL Q24H
Acyclovir 800 mg PO Q8H
Methadone 30mg PO QAM , 20mg PO NOON , 30mg PO QPM
Mirtazapine 30 mg PO HS
Morphine 15 mg PO Q4H prn
Nystatin Suspension 5 ML PO QID prn
Omeprazole 20 mg PO DAILY
Prednisone 20 mg PO daily
Spironolactone 100 mg PO DAILY
Allopurinol 300 mg PO DAILY
Furosemide 40 mg PO DAILY
Acetaminophen 650 mg PO Q4H prn
Discharge Medications:
expired --- none
Discharge Disposition:
Expired
Discharge Diagnosis:
lymphoblastic lymphoma / ALL
HCV cirrhosis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2116-12-10**]
ICD9 Codes: 0389, 2930, 5715, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 881
} | Medical Text: Admission Date: [**2199-2-10**] Discharge Date: [**2199-2-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
[**Age over 90 **] y/o F extensive PMH including CHF, A Fib on coumadin, chronic
thromboembolic PHTN who presents with hematemesis. Patient's
caretaker noticed her coughing up bright red blood (quarter size
clots) today and consequently brought her to the ED for
evaluation. Vitals on presentation were 97.5 88 99/62 18 85. On
evaluation patient produced large amounts of hematemesis and
required intubation for desaturation and airway protection. She
was given 40 mg protonix, 10 mg IV vitamin K and 2 L of NS. Her
labs were significant for HCT of 20 and creatinine 5.3. BP
ranged from 87-114/54-64. She was transferred to the MICU for
management of upper GI bleed.
.
Patient was recently discharged [**2199-2-8**] from the [**Hospital1 1516**] service
home with hospice following a complicated hospital course.
Patient presented with shortness of breath secondary to CHF
exacerbation, was aggressively diuresised but developed
hematemesis and worsening renal failure. Her renal failure did
not improve and her bleeding source was never found. During the
admission bloody material came from her mouth, but it was not
clear whether it was emesis or cough. There was concern for
malignancy based on prior CT showing thyroid mass and LAD, but a
follow-up non-contrast chest CT did not suggest new pathology.
ENT did not visualize any bleeding source down to the glottis
level. GI was consulted but GI and primary team agreed that
risks of EGD outweighed benefits unless Hct unstable. Prior to
discharge she did have grossly apparent dark red blood in her
bowel movements suggestive of GI etiology. Patient was also
treated for kleibsella UTI during the admission. Due to her
increasingly difficult-to-manage systolic and diastolic CHF,
combined with increasingly severe renal failure and unknown
source of bleed decision was made for comfort focus and she was
discharged home with hospice.
Past Medical History:
Risk factors: no HTN, DM, HL
no prior CABG or PCI
Probable CAD (focal wall motion abnormality & fixed
perfusion defect)
Congestive heart failure, systolic and diastolic, chronic
Atrial fibrillation on coumadin
Valvular disease: 2+ MR & 4+ TR
.
Chronic thromboembolic PHTN with RV failure, s/p IVC filter [**2185**]
CKD (cr 2-2.6)
pancytopenia
Peripheral vascular disease
h/o ischemic colitis
h/o LGIB
Gout/pseudogout: followed by rheum Dr. [**Last Name (STitle) **].
h/o h. pylori positive gastritis
s/p TAH/BSO
OA vs rheumatoid arthritis
Social History:
Lives in her own home with a 24hr home health aide, [**Last Name (STitle) 802**] [**Name (NI) **]
involved and lives nearby. She has a remote history of smoking.
Denies ETOH.
Family History:
Denies significant family history.
Physical Exam:
Initial PE:
General Appearance: Well nourished, No acute distress,
Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic
Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal
tube, No(t) NG tube, No(t) OG tube
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal,
No(t) Absent), (S2: No(t) Normal, Distant, No(t) Loud, No(t)
Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub,
(Murmur: No(t) Systolic, No(t) Diastolic), Distant heart sounds
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Breath Sounds: No(t) Clear : , Crackles : Few, No(t) Bronchial:
, No(t) Wheezes : , Diminished: , No(t) Absent : , No(t)
Rhonchorous: ), Periodic breaething
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , Obese
Extremities: Right lower extremity edema: 1+ edema, Left lower
extremity edema: 1+, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Tactile stimuli, No(t) Oriented (to): , Movement:
Non -purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Not
assessed
Pertinent Results:
[**2199-2-10**] 11:02AM HCT-24.2*
[**2199-2-10**] 03:30AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2199-2-10**] 03:30AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2199-2-10**] 03:30AM URINE RBC-[**10-26**]* WBC-21-50* BACTERIA-FEW
YEAST-RARE EPI-[**2-8**]
[**2199-2-10**] 03:22AM TYPE-ART RATES-18/ TIDAL VOL-400 PEEP-5
O2-100 PO2-37* PCO2-49* PH-7.32* TOTAL CO2-26 BASE XS--1
AADO2-644 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED
[**2199-2-10**] 02:09AM COMMENTS-GREEN TOP
[**2199-2-10**] 02:09AM LACTATE-3.4* K+-3.9
[**2199-2-10**] 02:09AM HGB-6.7* calcHCT-20 O2 SAT-62
[**2199-2-10**] 02:00AM PT-18.6* PTT-36.9* INR(PT)-1.7*
[**2199-2-10**] 01:50AM GLUCOSE-177* UREA N-138* CREAT-5.3*
SODIUM-134 POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-27 ANION GAP-18
[**2199-2-10**] 01:50AM estGFR-Using this
[**2199-2-10**] 01:50AM WBC-5.2 RBC-2.31* HGB-6.3* HCT-20.0* MCV-86
MCH-27.0 MCHC-31.3 RDW-19.2*
[**2199-2-10**] 01:50AM NEUTS-67.3 LYMPHS-25.1 MONOS-5.6 EOS-1.8
BASOS-0.2
[**2199-2-10**] 01:50AM PLT COUNT-151
CXR [**2199-2-10**]
Comparison is made to the prior study from [**2199-2-10**].
Endotracheal tube
terminates 21 mm above the carina which is acceptable.
Nasogastric tube
courses below the diaphragm but the tip is not seen, presumed in
the stomach.
The heart is markedly enlarged. There is patchy consolidation at
both lung
bases as well as in the perihilar region. There may be
superimposed
congestive failure. There are small bilateral pleural effusions.
Brief Hospital Course:
[**Age over 90 **] y/o F CHF, A Fib on coumadin, chronic thromboembolic PHTN who
presents with hematemesis. Patient recently discharged home with
hospice [**2199-2-8**] from [**Hospital1 1516**] service following complicated admission
with CHF exacerbation, renal failure and hematemesis.
.
# Hematemesis: Significant upper GI bleed with hematocrit drop
20 from most recent HCT of 25. Etiology most likely esophagitis,
gastritis versus peptic ulcer disease. Prior EGD [**2193**]
demonstrates gastritis (history of h. pylori). Patient given 10
mg IV vitamin K in ED. Patient home hospice/DNR/DNI prior to
admission, unfortunately unable to reach HCP at time of
presentation and thus she was intubated in the emergency
department. HCP was out of the country. Her [**Last Name (LF) 802**], [**Name (NI) **] was
the only family available by phone. Based on extensive
documention in OMR no central line, pressors or extreme
aggressive measures. We spoke with the hospice nurse involved
in the case as well as available family and decision was made
not to initiate any further invasive procedures.
.
# Positive Ua: Patient oliguric with multiple prior positive
cultures for KLEBSIELLA and is most likely colonized. Patient
treated last admission for Klebsiella with ceftriaxone. Abx
were held as most likely is colonized. Patient hypotensive
secondary to hypovolemia/blood loss and unlikely sepsis.
.
# CHF: Severe diastolic dysfunction and TR. Recent admission
with aggressive diuresis. This was monitored.
# Atrial fibrillation: Currently irregular rate. Patient is not
anticoagulated based on goals of care.
.
# CKD: Baseline renal insufficiency worsened last admission,
continues to climb. Lytes within normal limits. No further labs
were drawn after it was decided not to pursue further
monitoring.
.
# Goals of care: Patient recently discharged home with hospice
however was brought into ED for evaluation. Most likely
caretaker felt overwhelmed at home. Unfortunately, we are unable
to reach patient's HCP for further direction. Touched base with
primary providers, hospice nurse, and available family.
Confirmed that pt and HCP had decided on DNR/DNI, no furthe
treatment was initiated.
- DNR, no aggressive measures such as central access, pressors
.
# FEN: pRBC, replete electrolytes, NPO
# Prophylaxis: pneumoboots
# Access: peripherals X 2
# Communication: Patient
# Code: DNR
# Disposition: ICU pending goals of care discussion
.
Contact: [**Name (NI) **] (not HCP) ([**Telephone/Fax (1) 109254**])
[**Hospital 269**] Hospice [**Telephone/Fax (1) 32042**] [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) **]
*** On [**2199-2-13**], after BPs falling over prior 48 hours, pt. went
into intermittent asystole. Pupils were fixed, no heart or
breath sounds. Once asystolic, ventilator was turned off.
Physical exam repeated without change. Time of death was 04:45.
Her [**Last Name (LF) 802**], [**Name (NI) **] was notified and the family did not choose to
pursue autopsy.
Medications on Admission:
1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*2*
2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
Disp:*500 ML(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*2 inhalers* Refills:*3*
6. Home oxygen
Home oxygen, at 1-6L/min, pulse dose for portability
7. Morphine 10 mg/5 mL Solution Sig: One (1) mL PO every [**3-12**]
hours as needed for pain and/or respiratory distress.
Disp:*100 mL* Refills:*0*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Compazine 5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for nausea.
Disp:*60 Tablet(s)* Refills:*2*
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*500 mL* Refills:*2*
11. 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*
Discharge Medications:
Pt. expired
Discharge Disposition:
Expired
Discharge Diagnosis:
1. GI Bleed
2. Hypotension/Hypovolemia
Discharge Condition:
Pt. expired
Discharge Instructions:
Pt. expired
Followup Instructions:
Pt. expired
ICD9 Codes: 5789, 5849, 2851, 4280, 5859, 4168, 4439, 2749, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 882
} | Medical Text: Admission Date: [**2182-5-20**] Discharge Date: [**2182-5-30**]
Date of Birth: [**2119-6-30**] Sex: M
Service: MEDICINE
Allergies:
Lasix / Betalactams / Haldol / Ceftriaxone
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Tachypnea, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 yo Russian-speaking man w/anoxic brain injury and with hx of
DMI, s/p cadaveric kidney transplant([**2175**]), h/o CVA and chronic
aspiration (multiple admissions for aspiration PNA - last [**3-19**]),
CABG in [**2170**], widespread tracheomalacia with trach stent, and
recent admission to the ICU from [**Date range (2) 21579**] for PNA, stent
removal and tracheostomy. He was treated for aspiration PNA
with Vanc, Levo, Flagyl and then switched to Cefepime and
Azithro to complete a 10 day course. He was also given Cipro x
7 days for a UTI. He was discharged with a dobhoff feeding tube
and on tube feeds. He was found today at rehab to be hypoxic to
the mid-80s. Suction was attempted but did not show improvement
and he was sent to [**Hospital1 18**] ED.
.
In the ED, initial vs were: T100.4 HR102 BP163/93 RR24 O2sat96.
Patient was given Vanc, Cefepime, Azithro and Solumedrol 125mg
IV x 1. He was given Kayexalate PR for potassium of 5.7 and
aspirin for troponin of 0.62. He was seen by IP due to possible
air leak as he was pulling tidal volumes of 200. The plan was
to replace his trach once in the ICU.
.
On the floor, he appears comfortable, unable to answer
questions, not following commands.
Past Medical History:
- Cadaveric renal transplant in [**2175**]
- CVA-residual right hemiparesis
- DM Type I
- HTN
- Hx non-QMI and Vfib arrest [**2169**] with anoxic brain injury
- CAD/CABG [**2170**]
- Swallow study-showed silent aspiration
- hx of aspiration pneumonia
- tracheomalacia after long intubation requiring trach stent and
button complicated by site cellulitis and granulation tissue
requiring cryoptherapy.
Social History:
Lives with wife. Former endocrinologist in [**Country 532**]. Has homemaker
who comes in 5 times a week. Has 3 daughters who visit him.
Family History:
No history of lung disease
Physical Exam:
General: Awake, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Course breath sounds bilaterally, left sided rhonchi
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 with brown sediment
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
TRANSTHORACIC ECHO:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate regional left ventricular systolic
dysfunction with inferior/inferolateral akinesis/hypokinesis and
apical septal akinesis/dyskinesis. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2181-11-16**],
left ventricular sysotlic function is now more significantly
impaired. Focal apical septal hypokinesis was present
previously. Inferolateral /inferior akinesis is new (there may
have mild inferior hypokinesis previously).
.
.
CXR:
BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: Bilateral airspace
opacities which are more confluent in the left lung, worrisome
for pneumonia. Distended azygous contour, could represent volume
overload with part of the RUL opacity representing early edema.
There is no pleural effusion or pneumothorax. Heart size is
normal. Median sternotomy wire and mediastinal clips from prior
CABG are present. Tracheostomy tube is in standard location with
the tip terminating 3 cm above the carina.
.
IMPRESSION: Multifocal pneumonia with mild volume overload.
.
.
[**2182-5-20**] 05:35AM BLOOD cTropnT-0.62*
[**2182-5-20**] 02:40PM BLOOD CK-MB-23* MB Indx-6.7* cTropnT-1.47*
proBNP-[**Numeric Identifier 21580**]*
[**2182-5-20**] 11:01PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-1.70*
[**2182-5-21**] 04:36AM BLOOD CK-MB-12* MB Indx-4.7 cTropnT-1.79*
[**2182-5-21**] 01:59PM BLOOD CK-MB-7 cTropnT-1.36*
[**2182-5-20**] 05:35AM BLOOD Glucose-415* UreaN-65* Creat-2.4* Na-146*
K-5.7* Cl-106 HCO3-21* AnGap-25*
[**2182-5-20**] 02:40PM BLOOD Glucose-405* UreaN-75* Creat-2.7* Na-146*
K-4.9 Cl-111* HCO3-23 AnGap-17
[**2182-5-20**] 11:01PM BLOOD Glucose-170* UreaN-68* Creat-2.4* Na-149*
K-4.9 Cl-115* HCO3-23 AnGap-16
[**2182-5-21**] 04:36AM BLOOD Glucose-66* UreaN-67* Creat-2.2* Na-151*
K-4.7 Cl-117* HCO3-23 AnGap-16
[**2182-5-24**] 05:38AM BLOOD Glucose-98 UreaN-36* Creat-1.1 Na-144
K-3.8 Cl-107 HCO3-31 AnGap-10
[**2182-5-20**] 02:40PM BLOOD CK(CPK)-345*
[**2182-5-20**] 11:01PM BLOOD CK(CPK)-277
[**2182-5-21**] 04:36AM BLOOD CK(CPK)-254
[**2182-5-23**] 05:27AM BLOOD CK(CPK)-70
[**2182-5-20**] 05:35AM BLOOD tacroFK-14.6
[**2182-5-21**] 04:36AM BLOOD tacroFK-5.4
[**2182-5-23**] 05:27AM BLOOD tacroFK-7.2
[**2182-5-24**] 05:38AM BLOOD tacroFK-4.9*
[**2182-5-30**] 06:09AM BLOOD WBC-4.5 RBC-3.87* Hgb-9.9* Hct-30.9*
MCV-80* MCH-25.7* MCHC-32.2 RDW-17.2* Plt Ct-249
[**2182-5-30**] 06:09AM BLOOD Glucose-290* UreaN-30* Creat-1.1 Na-145
K-4.7 Cl-108 HCO3-30 AnGap-12
[**2182-5-27**] 07:38PM BLOOD ALT-23 AST-19 LD(LDH)-231 CK(CPK)-33*
AlkPhos-58 TotBili-0.4
[**2182-5-28**] 05:50AM BLOOD CK-MB-NotDone cTropnT-1.05*
[**2182-5-25**] 08:45AM BLOOD CK-MB-NotDone cTropnT-1.81*
[**2182-5-23**] 05:27AM BLOOD CK-MB-NotDone cTropnT-1.58*
[**2182-5-22**] 04:03AM BLOOD CK-MB-5 cTropnT-1.35*
[**2182-5-21**] 01:59PM BLOOD CK-MB-7 cTropnT-1.36*
[**2182-5-21**] 04:36AM BLOOD CK-MB-12* MB Indx-4.7 cTropnT-1.79*
[**2182-5-20**] 02:40PM BLOOD CK-MB-23* MB Indx-6.7* cTropnT-1.47*
proBNP-[**Numeric Identifier 21580**]*
[**2182-5-20**] 05:35AM BLOOD cTropnT-0.62*
[**2182-5-30**] 06:09AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
[**2182-5-23**] 05:27AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.8 LDLcalc-76
[**2182-5-28**] 02:36PM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.015
[**2182-5-28**] 02:36PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose->1000 Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-TR
[**2182-5-28**] 02:36PM URINE RBC->50 WBC-[**4-12**] Bacteri-FEW Yeast-FEW
Epi-0-2
MICRO:
[**2182-5-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2182-5-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2182-5-28**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2182-5-22**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-5-22**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2182-5-20**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2182-5-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT
[**2182-5-20**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2182-5-20**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY [**Hospital1 **]
[**2182-5-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL EMERGENCY [**Hospital1 **]
[**2182-5-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2182-5-27**]
FINDINGS: Despite repeated image acquisition, the study is
limited by patient motion. Hyperdensity projecting over the left
inferolateral frontal lobe (3:20) is likely a bone-related
artifact in the setting of motion. Otherwise, there is no
evidence of acute intracranial hemorrhage, mass effect, edema or
major vascular territorial infarct. The prominent ventricles and
sulci are unchanged in size or configuration. There is no shift
of normally midline structures. Moderate periventricular and
subcortical white matter hypodensities are compatible with known
chronic microvascular ischemic disease. Lacunar infarcts in the
basal ganglia are unchanged.
There is persistent moderate opacification of the left sphenoid
sinus.
IMPRESSION:
1. No evidence of an acute intracranial process on
motion-limited evaluation.
2. Moderate chronic microvascular ischemic disease with numerous
lacunar
infarcts.
3. Unchanged moderate opacification of the left sphenoid sinus
without
evidence of acute sinusitis.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2182-5-28**]
FINDINGS: In comparison with the study of [**5-24**], there has been
placement of a right PICC line that extends to the lower portion
of the SVC. There is increased aeration at the left base with
minimal residual atelectasis.
Nasogastric tube has been removed. Tracheostomy tube remains in
place.
Brief Hospital Course:
62 year old man with history of multiple strokes, type one
diabetes, and recurrent aspiration PNA s/p tracheostomy who
presents after witnessed aspiration event with hypoxia, diabetic
ketoacidosis, and NSTEMI.
.
#. Hypoxia: This was most likely due to an acute aspiration
event given his history and witnessed aspiration. He was
initially covered with broad spectrum antibiotics although
culture grew out sparse commensals and imaging was thought to be
more consistent with atelectasis and volume overload than
pneumonia so antibiotics were stopped after two days. He was
given bumex boluses to maintain fluid balance a negative fluid
balance until this volume overload resolved. His hypoxia
resolved after this.
.
#. NSTEMI: Patient with EKG changes, elevated cardiac biomarkers
with troponinT peaking at 1.8, and transthoracic echo with new
wall motion abnormalities. He was started on aspirin 325mg daily
and high dose statin initially. A heparin drip was continued for
48 hours. He was started on low dose beta blocker and
subsequently on clopidogrel. The cardiology service was
consulted and after discussion with the family the plan was for
in-patient cardiac catheterization. He was transfered to the
cardiology service for this. After discussion with the patient's
wife it was decided not to pursue cardiac catheterization due to
the patient being 5 days post medically treated NSTEMI and the
complications that could arise with this procedure. [**Hospital 21581**]
medical management was pursued.
.
#. CHF: Patient was found to be volume overloaded on admission.
This was thought to be the cause of his initial hypoxia and was
probably caused by his NSTEMI given the new wall motion
abnormalities and depressed EF of 35-40% (previously 55%) on
TTE. He was treated with bumex boluses and his volume overload
resolved. After resolution of the acute episode he remained
euvolemic and did not need further duiresis.
.
# Diabetic Ketoacidosis: In the emergency department, he had
hyperglycemia, an anion gap in the twenties, and ketones in the
urine on admission. The precipitant was thought to be cadiac
ischemia. Patient treated with insulin gtt with closure of
anion gap and return to normoglycemia. [**Last Name (un) **] was consulted
regarding glargine and insulin sliding scale dosing. He had
several episoded of hypoglycemia on his home dose of glargine
that were atributed to poor PO intake. Glargine was subsequently
decreased to 10 units at bedtime and his ISS was changed to
humalog and adjusted for meals. He then had episodes of
hyperglycemia and his HSS was adjusted further.
.
# Positive blood culture: He had one out of 2 sets of blood
cultures growing coag negative staph on [**5-20**] (with subsequent
negative blood cultures) and another [**2-9**] sets positive for coag
negative staph from [**5-29**] that came back after he was discharged.
This information was reported verbally to his nurse and by fax
to [**Hospital **] Hospital [**Hospital1 8**] where he is currently.
.
#. Acute renal failure: He was found to have an elevated
creatinine of 2.2, up from his baseline of 1.1-1.3. This was
thought to be pre-renal azotemia in the setting of dehydration
with osmotic diuresis due to DKA and poor forward flow due to
his NSTEMI and acute CHF exacerbation. His renal function
returned to baseline with gentle IVF initially and then with
diuresis. His medications were renally dosed and nephrotoxic
medications (enalpril) were held. The renal transplant team was
consulted given his history of cadevaric renal transplant in
[**2175**]. Once his renal function returned to his baseline enlapril
was re-started without complications.
.
#. Altered mental status: Patient was found to have acute mental
status change after he was transfered to the cardiology service
from the ICU. This was thought to be due delirium as the patient
was waxing and [**Doctor Last Name 688**] between agitation and somnolence. A CT
head was done to evaluate for an intracranial process causing
his AMS but this was negative. Infectious work up was also
negative. After reviewing patient's record it had been mentioned
in past discharge summaries that the patient had similar
episodes after long hospitalizations. He was treated with low
dose zyprexa prn which he received few doses of. His MS [**First Name (Titles) 21299**] [**Last Name (Titles) 21582**]r and he was back to his baseline on the day of
discharge.
.
#. Immunosuppression: s/p cadaveric renal transplant [**2175**]. His
tacrolimus level was monitored closely in the setting of acute
renal failure. He was continued on his home dosage for a goal of
[**4-13**]. The renal transplant service was consulted. He was
continued on cellcept and prednisone. He was continued on
bactrim.
.
#. Recurrent UTI: He recently completed a course of cipro for a
UTI. Urine culture grew out E.coli that was pan-resistant except
to nitrofurantoin (contraindicated in renal insufficiency)
ceftriaxone, ceftaz (allergy) and cefepime. He completed a 7
day course of cefepime.
Medications on Admission:
Medications from prior d/c summary:
1. Mycophenolate Mofetil 500mg PO BID
2. Pravastatin 20 mg Tablet PO qday
3. Fluvoxamine 100mg PO BID
4. Aspirin 81 mg Tablet qday
5. Docusate Sodium suspension 100mg PO BID
6. Senna 8.6 mg Tablet 1 tab [**Hospital1 **] PRN constipation
7. Prednisone 4mg PO qday
8. Sulfamethoxazole-Trimethoprim 800-160 mg qMWF
9. Metoprolol Tartrate 25 mg Tablet PO TID
10. Albuterol Sulfate neb q2H PRN wheezing
11. Insulin Glargine 100 unit/mL Solution 25 unit SC qHS
12. Bisacodyl 5 mg tab PO qday PRN constipation
13. Docusate Sodium 100 mg Capsule PO BID
14. Enalapril Maleate 20 mg Tablet PO qday
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, PO qday
16. Ipratropium Bromide 0.02 % Solution inhalation q6H
17. Tacrolimus 3mg PO qPM, 4mg PO qAM
19. Polyethylene Glycol 3350 17 gram/dose Powder PO qday PRN
constipation
20. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS
21. Morphine 2-4 mg Intravenous Q6H PRN as needed for pain.
23. Lorazepam 0.5-2 mg Injection Q4H (every 4 hours) PRN
agitation.
24. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: Last dose [**2182-5-20**].
.
Discharge Medications:
1. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
[**Month/Day/Year **]: 2.5 ML PO BID (2 times a day).
2. Pravastatin 80 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
3. Fluvoxamine 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times
a day).
4. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: Ten (10) ML PO BID (2
times a day) as needed for constipation.
6. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Prednisone 1 mg Tablet [**Month/Day/Year **]: Four (4) Tablet PO DAILY (Daily).
8. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Month/Day/Year **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
9. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID
(3 times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) neb Inhalation Q2H (every 2 hours) as
needed for wheezing.
11. Bisacodyl 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day as
needed for constipation.
12. Enalapril Maleate 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY
(Daily).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
15. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO QPM (once
a day (in the evening)).
16. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Four (4) Capsule PO QAM (once a
day (in the morning)).
17. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
19. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Ten (10) units
Subcutaneous at bedtime.
20. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1) units
Subcutaneous four times a day: per sliding scale.
21. Polyethylene Glycol 3350 17 gram Powder in Packet [**Last Name (STitle) **]: One
(1) packet PO once a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital-[**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Secondary Diagnosis:
Cadaveric renal transplant in [**2175**]
- CVA-residual right hemiparesis
- Hx NSTEMI and Vfib arrest [**2169**] with anoxic brain injury
- Swallow study-showed silent aspiration
- hx of aspiration pneumonia
- tracheomalacia after long intubation requiring trach stent and
button complicated by site cellulitis and granulation tissue
requiring cryoptherapy.
- recurrent aspiration PNA s/p tracheal stent removal and
tracheostomy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the [**Hospital1 18**] because you were breathing fast
and you oxygen was low. You were initially admitted to the
intensive care unit were they treated you for pneumonia. Upon
further testing you were found to have had a small heart attack.
We treated you with the appropriate medications for this. Your
heart attack caused acute systolic heart failure that we treated
with diuretics. This resolved with treatment and your heart
funtion remained stable. We spoke with your family about doing a
cardiac catheterization but this was not pursued as you had
already been treated medically. You also had a UTI and were
treated with antibiotics. You were found to be agitated and
disoriented at times but this improved. The diabetes doctors saw [**Name5 (PTitle) 17773**] and made changes to your insulin treatment. You should
follow the new sliding scale that was provided.
Medication Changes:
INCREASE: Pravastatin to 80 mg daily
INCREASE: Aspririn to 325 mg daily
START: Clopidogrel 75 mg daily
Followup Instructions:
Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2182-6-20**] 9:00
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2182-6-20**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2182-6-20**]
10:00
[**2182-6-21**] 02:20p [**Doctor Last Name **]-CC7 [**Hospital6 29**], [**Location (un) **]
CC7 CARDIOLOGY (SB)
ICD9 Codes: 5070, 5849, 5990, 2760, 7907, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 883
} | Medical Text: Admission Date: [**2116-12-5**] Discharge Date: [**2116-12-9**]
Date of Birth: [**2047-5-8**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
Episodic confusion, left-sided weakness, left-sided neglect, and
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 67988**] was diagnoses in [**8-13**] with GBM by stereotactic
brain bx and started on decadron and keppra. She received XRT
by 8 weeks and temazolamide for 3 weeks, discontinued due to
rash. Keppra was also discontinued at this time ([**2116-10-24**]). MRI
post XRT showed that the R. temperal parietal mass was stable
and a decadron taper was begun, reducing the dose from 6 to 4 to
2mg daily over 2 weeks. Her decadron was increased to 2mg [**Hospital1 **]
on [**11-30**]. On [**12-4**], Mrs. [**Known lastname 67988**] almost fell, was caught by her
husband who noted that her legs were intertwined. She was also
confused for 1-2 minutes, but had no post-ictal confusion or
incontinence. That night, she had another 5 minute episode of
sharp, sudden-onset headache over her right eyebrow, confusion,
and falling. Head CT outside on [**2116-12-4**] did show a 9 mm
midline shift and when compared to an MRI of the head done on
[**2116-11-30**] at [**Hospital1 **], there was only a 2-3 mm shift and review of
the head CT also showed signs of tight uncus with increased
swelling, although no frank herniation. On arrival, she
continued to be disoriented and had a [**10-18**] right-sided headache.
She vomited twice. She was admitted to the ICU.
Past Medical History:
1. hypertension
2. cervical spine surgery (at [**Hospital3 3765**] in [**Location (un) 1514**], MA)
3. hysterectomy for uterine fibroids
4. basal carcinoma, left side of nose (1st dx'd 20 yrs ago and
excised then 5 yrs ago required Mohs x3 as plastic surgeon
reports cancer and grown into deep structures of the face)
5. eczema well controlled with topical corticosteroids
6. carpel tunnel
7. seasonal allergies; allergy to dust, cats and feathers
8. normal colonscopy approx 3 yrs ago
Social History:
Lives with husband in in-law apartment in daughter's home. 40
pack year history smoking cigarettes, no ETOH, or illicit drug
use.
Family History:
Mother had DM2 and died of vulvar/rectal ca. Father died of
CAD.
Physical Exam:
PHYSICAL EXAMINATION:
VITALS: 97.4/99.1 p 68(53-71) 117/44(86/35-140/65) 17(19-21)
96% on 3L
GENERAL: She is alert, pleasant elderly lady in no acute
distress.
CARDIOVASCULAR: She had regular rate and rhythm. No murmurs,
gallops, or rubs.
LUNGS: Clear to auscultation bilaterally.
ABD: SNTND, +BS
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGICAL EXAMINATION:
MS:
Orientation: [**Hospital3 **], [**2116-11-8**] (no date)
Attn: Months of year backwards: "[**Month (only) 1096**], [**Month (only) **], [**Month (only) **],
stop"
Memory: Registration intact, Recall 0/3 at 5min
Language: Fluent, good comprehension and repetition. No
dysarthria, appropriate prosody, naming intact
Fronto-Parietal: Calculation intact, no apraxia, slight left
neglect, clock draw shows good planning, cannot copy cube or
intersecting pentagons
Coordination: She had normal appendicular coordination.
Gait: Deferred
CN: I: Not tested
II: R. anisocoria (stable since birth), both reactive to
light, sharp disc
margins
III,IV,VI: EOMI, no nystagmus, does not completely bury
V,VII: Facial strength, sensation intact/symmetrical
VIII: Hearing intact to finger rub b/l
IX,X: Palate elevation midline
[**Doctor First Name 81**]: SCM/Trap full strength
XII: Tongue midline, no fasciculations
Motor:
Normal bulk/tone b/l. No abnormal movements/tremors. Quite
mild l. hemiparesis, [**5-13**] deltoid and triceps, tibialis anterior.
No drift.
Reflexes: 2 right/left at
biceps,triceps,brachioradialis,patellar,achilles
Coordination: Slight delay on finger-nose, normal [**Doctor First Name **]
Gait: Deferred
Pertinent Results:
[**2116-12-9**] 06:25AM BLOOD WBC-8.6 RBC-3.52* Hgb-11.5* Hct-34.2*
MCV-97 MCH-32.8* MCHC-33.7 RDW-17.0* Plt Ct-203
[**2116-12-8**] 06:20AM BLOOD WBC-6.2 RBC-3.38* Hgb-11.1* Hct-32.8*
MCV-97 MCH-32.7* MCHC-33.7 RDW-17.3* Plt Ct-199
[**2116-12-7**] 04:58AM BLOOD WBC-8.4 RBC-3.10* Hgb-10.7* Hct-29.8*
MCV-96 MCH-34.5* MCHC-36.0* RDW-17.8* Plt Ct-181
[**2116-12-6**] 03:00AM BLOOD WBC-6.6 RBC-3.55* Hgb-12.0 Hct-33.9*
MCV-95 MCH-33.8* MCHC-35.5* RDW-17.8* Plt Ct-179
[**2116-12-4**] 11:00PM BLOOD WBC-6.1 RBC-3.59* Hgb-12.3 Hct-34.3*
MCV-95 MCH-34.3* MCHC-35.9* RDW-18.1* Plt Ct-186
[**2116-12-9**] 06:25AM BLOOD Plt Ct-203
[**2116-12-9**] 06:25AM BLOOD Glucose-76 UreaN-18 Creat-0.7 Na-141
K-4.0 Cl-103 HCO3-28 AnGap-14
[**2116-12-9**] 06:25AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2
[**2116-12-8**] 06:20AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.3
[**2116-12-9**] 06:25AM BLOOD Osmolal-297
[**2116-12-8**] 09:21PM BLOOD Osmolal-295
[**2116-12-6**] 03:00AM BLOOD Phenyto-10.2
[**2116-12-5**] 04:12PM BLOOD Phenyto-13.6
Brief Hospital Course:
Ms. [**Known lastname 67988**] was admitted to the ICU on [**12-4**]. The patient was
loaded with Decadron 10 mg and then put on Decadron 4mg q6hrs.
She was also loaded with Dilantin because of the history of the
seizures and the Keppra was increased to 750 twice a day,
frequent neuro checks were done and a repeat MRI of the brain
was considered and neurosurgery was consulted. Mannitol 20% was
begun 25g IV q6hrs, checking serum Na and osms prior to each
dose. Headache was managed with toradol q6 hrs. Neurosurgery
discussed potential surgical options with the family, and they
decided on no neurosurgical intervention at this time. While in
the ICU, her clinical condition improved, and she became more
oriented. Her left-sided neglect and left-sided weakness
persisted. On [**12-7**], Ms. [**Known lastname 67988**] was transferred to the floor.
Mannitol was weaned to 12.5mg [**Hospital1 **] with the last dose the morning
of [**12-9**]. PT/OT were consulted who cleared her for home with
services and a rolling walker. She will have follow-up with Dr.
[**Last Name (STitle) 724**] in the brain tumor clinic.
Medications on Admission:
Keppra 500po [**Hospital1 **]
Decadron 4mg po daily
Famotidine 20mg po daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Decadron 4 mg Tablet Sig: 1.5 Tablets PO every six (6) hours.
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Gliobastoma multiforme
Seizures
Discharge Condition:
Stable. Baseline left superior field cut, left nasolabial fold
flattening, left hemiparesis, left neglect.
Discharge Instructions:
Please take all of your medications as directed.
Please return to the Emergency Room if you experience headaches,
visual changes, lethargy, speech or language problems, new
weakness, nausea, or vomiting.
Followup Instructions:
Please call Dr.[**Name (NI) 6767**] office at [**Telephone/Fax (1) 1844**] to schedule follow
up.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 884
} | Medical Text: Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-7**]
Date of Birth: [**2056-10-13**] Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Hip fracture repair, intubation
History of Present Illness:
Mr. [**Known lastname 724**] is an 80 y/o man with T2DM, CRI with a baseline Cr 1.9,
and dementia who presented after a witnessed fall in his nursing
home with right hip pain. Reportedly this was a mechanical fall
per witnesses. Pt is poor historian and does not recall event,
but reportedly at time of fall denied CP, SOB, N/V, no LOC, no
head trauma. He was unable to bear weight after the fall. He was
sent to the [**Hospital1 18**] ER where a right hip XR showed an impacted
femoral neck fracture. CXR showed subacute L rib fractures but
no acute process. Knee XR pending final read.
.
ROS: currently denies CP, SOB, abd pain, n/v, no hip pain at
rest but states mild hip pain if moves hip.
Past Medical History:
T2DM
Diabetic nephropathy
Parkinsons Dementia
Anemia with unknown baseline hct 30, believed due to CKD
CRI with reported baseline Cr 1.9, but none on file here
Hyponatremia with reported baseline ~130
CHF
HTN
Depression
BPH s/p TURP
Irritable bowel syndrome
h/o pancreatitis
DJD
Hiatal hernia
Reflux esophagitis
Social History:
Lives in [**Location 35689**] House. Single.
Family History:
N/C
Physical Exam:
Vitals: 98.6, 168/88, 18, 100% RA, FS 129, wt 59kg
General: NAD, resting flat on back, pleasant, conversant,
oriented x 2 (believes he is at his NH)
HEENT: no OP injection, MMM, no sinus tenderness
Neck: supple, no LAD
Pulmonary: CTAB anteriorly
Cardiac: RRR, I/VI systolic murmur heard throughout precordium,
s1s2
Abdomen: soft, NT, ND, +BS
Extremities: no c/c/e, R leg shortened and externally rotated,
mild R hip tenderness to palpation, R hip tenderness on rotation
of hip. sensation grossly intact in BLE, DP 2+bilat
Pertinent Results:
[**2137-8-29**]: CXR: Subacute fractures involving the anterolateral left
sixth and
seventh ribs as detailed above. No radiographically evident
pneumothorax
seen.
.
[**2137-8-29**]: Right hip XR: Impacted femoral neck fracture. Marked
degenerative changes in lumbar spine.
.
[**2137-8-29**] Right Knee XR: There are no signs for acute fractures or
dislocations. There is joint space narrowing medially.
Extensive vascular calcifications are present. There is no
joint effusion. Limited cross-table lateral views of the right
hip are markedly limited and provides limited diagnostic detail.
Please refer to the AP view of the pelvis where there is a known
right femoral neck fracture.
.
EKG: NSR at 70. nl axis, nl intervals (borderline PR about
200ms), no peaked T waves. no Q waves. TWF in III. No prior for
comparison.
.
[**2137-9-1**] CT Abdomen and Pelvis W/O Contrast
No evidence of retroperitoneal hematoma. Post-surgical changes
are noted about the right hip as detailed above. Small pleural
effusions and small pericardial effusions as noted. Signs of
chronic pancreatitis. Sigmoid colonic wall thickening as noted
above, nonspecific finding.
.
[**2137-9-4**] U/S RLE
No DVT.
.
[**2137-9-5**] V/Q Scan
No evidence of pulmonary embolism.
.
[**2137-9-5**] TTE
The left atrium is mildly dilated. The estimated right atrial
pressure is
0-5mmHg. Left ventricular wall thicknesses are normal. 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 aortic valve
leaflets are mildly thickened. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
.
Micro Data:
Blood cultures: No growth
.
Urine cultures: No growth
.
C diff: Negative
.
[**2137-8-29**] 06:15PM BLOOD WBC-4.9 RBC-2.63* Hgb-8.9* Hct-27.7*
MCV-105* MCH-34.0* MCHC-32.3 RDW-15.3 Plt Ct-195
[**2137-9-7**] 04:18AM BLOOD WBC-7.5 RBC-3.07* Hgb-9.7* Hct-28.9*
MCV-94 MCH-31.7 MCHC-33.8 RDW-17.9* Plt Ct-190
[**2137-8-29**] 06:15PM BLOOD Glucose-131* UreaN-16 Creat-1.9* Na-127*
K-5.0 Cl-93* HCO3-24 AnGap-15
[**2137-9-7**] 04:18AM BLOOD Glucose-64* UreaN-20 Creat-1.6* Na-136
K-4.6 Cl-108 HCO3-21* AnGap-12
[**2137-9-1**] 03:29AM BLOOD ALT-10 AST-29 AlkPhos-55 Amylase-30
TotBili-1.8*
[**2137-9-7**] 04:18AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.9
[**2137-9-5**] 05:08AM BLOOD TSH-3.3
[**2137-9-1**] 11:20AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Negative
Brief Hospital Course:
80 y/o man with T2DM, anemia, dementia, and CRI who presented
s/p mechanical fall with subsequent right hip fracture. His
hospital course was complicated by bleeding and hypotension
along with atrial fibrillation. The following issues were
addressed during this admission.
.
1. Reason for MICU admission: The patient was initially
transferred to the MICU for hypotension that was thought to be
secondary to hypovolemia. The patient had pulled his foley
catheter and had profuse bleeding from the catheter site. For
this he was transfused and seen by urology. Initially the
patient had a 3-way catheter with aggressive irrigation.
Cystoscopy showed improved hemostatsis and bladder irrigation
was stopped. Bleeding was stable. CT of abdomen/pelvis did not
show retroperitoneal bleeding. No hemolysis. Hematocrit stable
since [**2137-9-1**].
.
2. Hypotension: The patient had persistent hypotension despite
cessation of bleeding from foley site as well as no signs of
hematoma in the OR. The patient was actively resusitated with
fluids and blood with improvement in his blood pressures.
Patient received 4 units of PRBC on [**9-1**]. Blood pressures
remained stable after that. Most likely he was hypotensive in
setting of blood loss.
.
3. Respiratory distress
The patient had period of a apnea after returning from the OR
and required reintubation. Given that the patient was clinically
unstable from a blood pressure standpoint, he remained
intubated. He did not have signs of respiratory compromise and
maintained his saturations. Patient was quickly extubated on
[**2137-9-2**] and remained stable.
.
4. Thrombocytopenia
The patient was noted to have a dramatic platelet drop, concern
for possible HIT, heparin was initially held and appropriate
studies were ordered. HIT returned negative. Platelet count
increased slowly and remained stable after Hct stabilized. This
was most likely in setting of blood loss.
.
5. Right Hip fracture
The patient was evaluated by orthopedics upon admission and
taken to the OR on [**8-31**]. The operation was without
complications but post-op had to be reintubated. Per ortho,
there was no hematoma at the surgical site while in the OR.
Pre-op betablocker was started for risk reduction but was
limited by hypotension as above. After patient's hematocrit was
stabilized, he was started on Lovenox for AC in the setting of
recent ORIF of right hip. He will continue on Lovenox for 4
weeks. He will follow up with orthopedics in 2 weeks after
discharge with Dr. [**Last Name (STitle) 7376**].
.
6. HTN
Initially pt's outpt lisinopril and catapres were held and a
perioperative BB was given, but discontinued with hypotension.
Given his new onset atrial fibrillation, he was started on
verapamil which was uptitrated to HR.
.
7. Atrial fibrillation
On [**2137-9-5**], the patient developed atrial fibrillation with a HR
to the 130s. EKG revealed evidence of atrial fibrillation
without any acute ST changes. Cardiac enzymes were drawn which
did not indicate an ischemic etiology for his atrial
fibrillation. A TSH was checked which was normal. The patient
had a TTE which revealed mild left atrial enlargement and an EF
greater than 60%. The patient also had a V/Q scan to r/o PE
given his recent hip fx and surgery which was negative. He was
started on verapamil as a nodal [**Doctor Last Name 360**] after IV diltiazem was
successful in controlling his heart rate.
.
8. Rib fractures
These appeared subaccute on XR. Likely these are not from his
admission fall, as appear subacute and also on L as opposed to R
side.
.
Communication: case manager [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15582**] (w) [**Telephone/Fax (1) 71590**];
(c) [**Telephone/Fax (1) 71591**]. Per note call CM first. Secondary contact
brother [**Name (NI) **] [**Telephone/Fax (1) 71592**].
.
Full code
Medications on Admission:
catapres 3 patch qweek
lisinopril 10mgpo qday
aricept 10mgpo qhs
asa 81mg po qday
sinemet 25/100: 0.5 tab [**Hospital1 **]
calcitriol 0.25mcg po qday
celexa 20mg po qday
cyanocobalamin 1000 mcg po qday
epo 4000 units qweek
lasix 20mg po qday
ferrous gluconate 25mgpo qday
glipizide 2.5mg po qday
omeprazole 20mg po qday
kayexelate 60mL (15g) po bid
Discharge Medications:
1. Donepezil 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
2. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: One (1) Tablet PO
BID (2 times a day).
3. Calcitriol 0.25 mcg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
4. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day) as needed.
6. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: per sliding
scale Injection ASDIR (AS DIRECTED).
7. Cyanocobalamin 500 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
8. Epoetin Alfa 2,000 unit/mL Solution [**Hospital1 **]: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours).
10. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY
(Daily).
13. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
14. Morphine Sulfate 2-4 mg IV Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right Hip fracture
Hemorrhage
Thrombocytopenia
Hypotension
Acute renal failure
Dementia
Discharge Condition:
stable
Discharge Instructions:
Please take your medication as prescribed and follow up with Dr
[**Last Name (STitle) 5351**]. Please call your doctor with any concerning symptoms.
Followup Instructions:
Dr [**Last Name (STitle) 5351**]
Completed by:[**2137-9-7**]
ICD9 Codes: 5849, 5859, 2875, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 885
} | Medical Text: Admission Date: [**2102-6-19**] Discharge Date: [**2102-6-27**]
Date of Birth: [**2040-6-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE, Fatigue, Palpitations, syncope
Major Surgical or Invasive Procedure:
Mitral valve replacement
History of Present Illness:
This is a 61 year old female who presents with DOE, Fatigue,
palpitaitons, and syncopal episodes. She had mitral valve
prolapse which was followed by servial echo, but her sx have
gotten to the point that surgical intervention is warrented
Past Medical History:
Cholesterol
MV prolapse
Multiple sclerosis
BrCA
CVA '[**87**] no residual
RA
MIgranes
Asthma
Social History:
Former heavy smoker and drinker
Lives alone
Family History:
CAD (brother died at age 61)
Physical Exam:
96.8 70 16 98% 94/47
NAD
RRR
CTA-B
Abd-benign
Ext-warm, well perfused
Pertinent Results:
[**2102-6-19**] 12:31PM freeCa-1.11*
[**2102-6-19**] 12:31PM HGB-12.5 calcHCT-38
[**2102-6-19**] 12:31PM GLUCOSE-92 NA+-140 K+-3.5
[**2102-6-19**] 12:31PM TYPE-ART PO2-468* PCO2-41 PH-7.38 TOTAL
CO2-25 BASE XS-0
[**2102-6-19**] 06:03PM GLUCOSE-51* NA+-142 K+-3.2* CL--110 TCO2-26
Brief Hospital Course:
Pt was admitted to the CSRU after uneventful MVR. She did well
post op, she did have some dehydration for which volume was
given. Pressors were needed in the unit, but these were weaned
succesfully. On POD 2 her PA catheter was d/c'ed and she was
sent to the floor. Her wires were d/c'ed on POD 3 and her
lopressor dose was increased. She was seen by PT but was
somewhat slow to fully ambulate. By POD 8 she was doing very
well on from the PT point of view, able to do stairs
appropriatly. She was Stable from a cardiac point of view the
entire post op period. She was sent home with lasix and
lopressor and follow up instructions
Medications on Admission:
Albuterol
Atenolol
Chloroquine
Flexeril
Lipitor
Lisinopril
Mucinex
ASA
Singulair
Flonase
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use while on percocet.
Disp:*60 Capsule(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mitral Valve stenosis
Discharge Condition:
Good
Discharge Instructions:
You should notify your primary care doctor if you have
increasing chest pain, shortness of breath, palpitation, or any
other sign or symptom that is concering to you. You should see
your doctors as directed below
[**Last Name (NamePattern4) 2138**]p Instructions:
You should see your cardiology within 1-2 weeks
You should see your primary care doctor within a week or two as
well: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**]
You need to see Dr. [**Last Name (Prefixes) **] in [**2-24**] weeks. Provider: [**Last Name (Prefixes) **],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**]
Completed by:[**2102-6-27**]
ICD9 Codes: 4240, 2765, 5180, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 886
} | Medical Text: Admission Date: [**2194-12-16**] Discharge Date: [**2194-12-20**]
Date of Birth: [**2150-10-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
diffuse exfoliating rash
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
44 year old female with h/o HTN initially admitted to [**Hospital 1562**]
Hospital on [**2194-12-11**] with 7 days of cough, fever, and 1 day of
change in mental sttatus. Her family/friends noted she had
slurred speech, few episodes of talking out of contexted causing
them to bring her to the ED. She was covered with
ceftriaxone/vancomycin for presumed meningitis (LP attempts
unsuccessful) and admitted to the ICU, where she was
subsequently intubated for hypoxia (O2 sat 80s RA) and change in
mental status. CXR should multifocal opacities, and antibiotics
were broadened to CTX/vanco/levo/doxy/ayclovir/metronidazole.
Over the course of the next few days, she developed
transaminitis (LFTs 600s), ARF (attributed to ATN, initiated
dialysis [**12-15**], [**12-16**]), thrombocytopenia (plt 23 from 90s on
admit), lactic acidosis (lactate 5). All bcx, spcx, ucx, BAL
NGTD. Antibiotics narrowed to levofloxacin/linezolid/doxycycline
(?when). On [**12-12**], pt was noted to be diffusely mottled. Over
the course of the next 4 days, she developed diffuse, dependent
purpura with areas of necrosis/skin sloughing. She was
transferred to [**Hospital1 18**] [**12-16**] given concern for TEN. Currently, the
patient is intubated and sedated.
Past Medical History:
1) HTN
2) obesity
3) s/p C-section
4) s/p cholecystectomy
5) Osteopenia
6) ?glucose intolerance
Social History:
1) HTN
2) obesity
3) s/p C-section
4) s/p cholecystectomy
5) Osteopenia
6) ?glucose intolerance
Family History:
Father with CAD and diabetes. Mother healthy
Physical Exam:
T
Gen: obese, middle-aged female, intubated, sedated
HEENT: anicteric, pinpoint pupils, symmetric bilaterally, pale
conjunctiva, oral mucosa moist, neck supple, JVP ~ 7 cm
Cardiac: tachycardic, no M/R/G appreciated
Pulm: Decreased lung sounds at bases bilaterally, coarse ronchi
throughout
Abd: Obese, soft, hypoactive bowel sounds, no apparent
tenderness
Extremities: anasarca, cool extremities and fingers bilaterally,
cyanosis/blackening of all 10 finger tips. 1+ DP bilaterally.
Poor cap refill in fingers and toes bilaterally.
Skin: Diffuse, patchy, non-palpable purpura, predominately over
dependent areas involving ~ 50% of skin, with bullae/sloughing
of ~ 10% of skin. No clear mucosal involvement.
Neuro: Pupils equal, minimally reactive, moves all 4 extremities
in responsive to painful stimuli, toes mute bilaterally, 1+ DTR
throughout.
Pertinent Results:
Micro:
[**Hospital1 18**]
[**12-16**] bcx pending, ucx pending
.
[**Hospital1 1562**]
bcx: [**12-12**] NGTD, [**12-13**] NGTD, [**12-14**] NGTD, [**12-15**] pending
vag cx [**12-13**] (-)
ucx [**12-12**] pending
spcx [**12-14**] (-)
BAL [**12-15**] negative
.
CXR ([**Hospital1 18**]) [**12-16**]: ETT, NGT, RSC in place. bilateral airspace
opacity, perihilar predominance, c/w pulmonary edema
.
Renal U/S (OSH) [**12-15**]: negative
.
Head CT (OSH) [**12-12**] (-)
.
EKG [**2194-12-13**]: ST @ 128 bpm w/ PVCs q II, III, avF, non-specific
TW changes
Brief Hospital Course:
A/P: 44 yoF w/ h/o HTN presents with rapidly progressive change
in mental status in the setting of fever. Course c/b multisystem
organ failure (renal, respiratory, liver) with coagulopathy and
diffuse purpura fulminans.
.
.
1) Purpura Fulminans: Seen by dermatology and biopsied upon
transfer with prelim path consistent with microthrombi. The
felt that findings are most consistent with purpura fulminans,
most commonly seen in setting of sepsis/DIC/meningococcemia. DDx
includes TEN (although minimal total-body exfoliation), toxic
shock, scalded skin syndrome. Initially duoderm dressings
appllied and as skin started exfoliated and denuding, was
cleaned with saline and silvadene with telfa applied to denuded
areas. She had significant weeping of the wounds and was
supported with IVF and albumins were monitored and last albumin
was 2.4. She was treated for her possible underlying infection
as below. Negative vaginal exam for tampon (vag cx, speculum
exam negative at OSH). As area of skin involved progressed, she
will be transferred to a specific burn unit to manage and
monitor her skin breakdown. she has been on heparin gtt to
prevent further microemboli and per rehumatology and hematology
should be started on IVIG and steroids to treat possible acute
antiphospholipid antibody syndrome which may also cause this
presentation of microemoli.
.
2) Sepsis: Improved hypotension off pressors X >24 hrs prior to
transfer and no need for pressors while here and no evidence of
lactic acidosis. Potential infectious sources include menignitis
(including meningococcus given rapid clinical deterioration),
pulmonary source (given report of cough, patchy infiltrates on
CXR). Given presentation meningococcus was leading infection
although Lp attempts at OSH and unable after repeated attempts
and here not attempted given antibioitcs and rash covering back
with thrombocyopenia. Initially broadly coverage again per ID
reccomendations with Ceftriaxone/vanco/acyclovir/ampicillin to
cover meningitis, levofloxacin to cover atypicals, doxycline to
cover for tick-[**Location (un) **] disease(RMSF). eventually levofloxacin,
ampicillin and acycovir were stopped as not clinically
consistent with those diagnoses. Ct of chest/abd/pelvis with
contrast did not reveal any abscesses, large PEs or other
infectious processes, although was consistent with ARDS. Crypto
Ag(-), histo Ag(p), erhlichiae Ab(neg) per ID. cultures here
including daily blood, urine and sputum have been negative.
tissue culture with 1+PMn, but no anaerobic gorwth and aerobic
cx still pending. Head MRI negative for septic emboli or
temporal enhancement suggestive of herpes encephalitis, but did
have scattered foci of FLAIR signal hyperintensity, nonspecific,
which may relate to post infectious/inflammatory process,
demyelination, or subacute or chronic infarction. TTe and TEE
without signs of vegetations. IVF boluses used to maintain CVP
>12, MAP >65. She was initially on droplet precautions, but no
longer needed as has been treated over 24hrs. She was continued
on sepsis dose steroids and then transitioned to steroids to
treat possible auto-immune source of rash even though [**Doctor First Name **] and
ANCA were negative. She is currently on ceftriaxone 2gm IV
q12hrs, vanc 1 gm pre levels<15, doxycycline 100mg IV q12.
.
3) Transaminitis: Most likely secondary to shock liver, trending
down while here Hepatitis A, B, C serologies (-) at OSH; EBV
serologies indicating prior infection, and again repeated here
although still pending. RUQ U/S did not shouw evidence of
portal thrombosis and unremarkeable liver and s/p ccy.
.
4) Thrombocytopenia: Plt 21 on admission and prior to d/c back
up to 40. thought to be secondary to DIC (although PT/PTT wnl,
D-dimer high, FDP and fibrinogen normal here) vs sepsis,
consumption in the setting of widespread purpura. HIT was
negative. Also initially concern for TTP, given ARF, MS change,
fever, but with no shistocytes on smear, no haptoglobin less
likely.
.
5) ARF: Sediment at OSH c/w ATN, likely secondary to
sepsis/renal hypoperfusion. Renal U/S at OSH (-). she continued
to require daily HD here for fluid management. As infection
resolves, she may recover renal function, although currently
seems unlikley.
.
6) CHF: Grossly total body fluid overloaded (in the setting of
aggresive fluid resuscitation) although CVP 7, however given
concern for sepsis/lactic acidosis, would not actively diurese
at this time, particularly as patient is ventilated. normal EF
on TTE, and as started weeping from wounds, slowed down diuresis
attempts. She was started on afterload reduction with
hydralazine, isordil and low dose metoprolol.
.
7) Rahbdo: she had persistently elevated CKs likely from
mircoemboli to muscles as well. Continued on IV hdration and
remained stable.
.
8) Anemia: HCT 28.8, microcytic. Likely secondary to volume
resuscitation in the setting of marrow-suppression (sepsis,
ARF). She was only transfused 1 uPRBC during her course here.
.
9) F/E/N: Tube feeds started to help support nutrition,
electrolytes morinotred twice a day and replete as needed.
Insulin drip for close glucose monitoring.
.
10) Ppx: IV H2 blocker, heparin drip
.
11) Code: Full Code
.
12) Communication: Father [**First Name4 (NamePattern1) **] [**Name (NI) **] cell [**Telephone/Fax (1) 64766**]),
Sister [**First Name8 (NamePattern2) 8513**] [**Name (NI) 64767**] cell [**Telephone/Fax (1) 64768**]). Family includes
husband (whom she is separated from), 2 sisters, son, mother,
and father. Next of [**Doctor First Name **] is adult son as separated from husband
who has deferred decision making to son and father.
.
13) Lines: Left radial a-line ([**12-13**]), RIJ cordis ([**12-13**]), Left
IJ dialysis catheter ([**12-16**])
Medications on Admission:
Meds (home):
1) metoprolol 50 mg PO TID
2) HCTZ 25 mg PO daily
3) Trazodone 50 mg PO daily
4) Wellbutrin 150 mg PO BID
5) Clarinex 5 mg PO daily
6) Motrin prn
.
Meds (on transfer):
1) Zyvox 600 mg IV BID
2) Protonix 40 mg IV daily
3) Procrit 1000 units after each hemodialysis
4) Doxycycline 100 mg IV q12h
5) Levofloxacin 250 mg IV daily
6) RISS
7) solumedrol 80 mg IV q8h
8) Albuterol/Atrovent MDIs prn
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: Three (3)
units Injection TITRATE TO (titrate to desired clinical effect
(please specify)).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q4H (every 4 hours).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical TID
(3 times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID
(2 times a day).
7. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
9. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Midazolam 5 mg/mL Solution Sig: Two (2) mg/hr Injection
TITRATE TO (titrate to desired clinical effect (please
specify)).
12. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One Hundred
(100) mcg/hr Injection INFUSION (continuous infusion).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Doxycycline Hyclate 100 mg IV Q12H
15. Pantoprazole 40 mg IV Q24H
16. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1100 (1100) units/hr Intravenous ASDIR (AS DIRECTED).
17. Vancomycin HCl 1000 mg IV ONCE Duration: 1 Doses
18. Ceftriaxone 2 gm IV Q12H
Dose antibiotic after dialysis
Discharge Disposition:
Extended Care
Discharge Diagnosis:
purpura fulminans
sepsis
multi-organ failure
thrombocytopenia
shock liver
acute renal failure
Discharge Condition:
fair, stable BP and HR, intubated on Pressure support 15/5 at
355 FIO2.
Discharge Instructions:
please continue aggressive skin care and managing sepsis as per
d/c summary.
Followup Instructions:
please follow up with PCP after discharged from hospital.
Completed by:[**2195-1-4**]
ICD9 Codes: 0389, 5185, 5845, 4280, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 887
} | Medical Text: Admission Date: [**2155-10-11**] Discharge Date: [**2155-10-14**]
Date of Birth: [**2155-10-11**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] is 3.675 kg
infant born at 38 weeks gestation. Mother is a 34-year-old
G2, P1, now 2. Prenatal screens O positive, antibody
negative, hepatitis surface antigen negative, RPR
nonreactive, rubella immune, GBS negative. Pregnancy
reportedly uncomplicated. No perinatal sepsis risk factors.
Infant delivered vaginally with Apgars of 9 and 9. At newborn
nursery, the infant was noted to be jittery. Glucose at that
time was 17. He was transferred to the newborn intensive care
unit with a repeat D-stick of 34.
PHYSICAL EXAMINATION: Non-dysmorphic, anterior fontanel soft
and flat. Eyes deferred. Palate intact. Neck supple with
clavicles intact. Lungs clear to apex. CARDIOVASCULAR:
Regular rate and rhythm. No murmurs. Abdomen soft. Positive
bowel sounds. GENITOURINARY: Normal male. Testes down
bilaterally. Patent anus with meconium and diaper hip stable.
Essentially pink with peripheral acrocyanosis.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Stable.
CARDIOVASCULAR: No issues.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight 3.675 kg.
Admitted to newborn intensive care unit with an initial
glucose of 17. Repeat of 19 at which time the infant was fed.
Follow up glucose at that time was 38. D10 bolus was given of
capture the infant and was started on 80 cc per kg of D10W in
addition to ad lib feeding of breast milk and Enfamil 20.
Over the next 48 hours, D10 was discontinued and the infant
has been ad lib feeding maintaining D-stick greater than 60.
GASTROINTESTINAL: Bilirubin on day of life 2 was 15.3/0.5
Bilirubin at discharge was 12.1
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign. Blood culture remained negative at
48 hours.
HEMATOLOGY: Hematocrit on admission was 57.6. Repeat
hematocrit on [**10-13**], was 65.4. On the day of discharge the
Hct was 58.9
NEUROLOGIC: The infant has been appropriate for gestational
age.
SENSORY; Hearing screen has been performed with automated
auditory brain stem responses and the infant ...
PSYCHOSOCIAL: Parents have been interested and involved with
this infant's care.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) 2433**]. Telephone No. [**Telephone/Fax (1) 62420**].
CAR SEAT POSITION SCREEN: Not applicable.
FEEDS AT DISCHARGE: Continue ad lib feeding breast milk and
Enfamil 20 calories.
MEDICATIONS: Not applicable.
STATE NEWBORN SCREEN: State Newborn Screens have been sent
for protocol and have been within normal limits.
IMMUNIZATIONS RECEIVED: The infant received Hepatitis B
vaccine on [**2155-10-13**].
DISCHARGE DIAGNOSE:
1. Term infant.
2. Hypoglycemia resolved.
3.
Hyperbilirubinemia.
4. Polycythemia resolved
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) 58682**]
MEDQUIST36
D: [**2155-10-13**] 21:34:15
T: [**2155-10-13**] 23:43:08
Job#: [**Job Number 62421**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 888
} | Medical Text: Admission Date: [**2152-2-2**] Discharge Date: [**2152-2-4**]
Date of Birth: [**2128-3-15**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
skull mass at vertex of head
Major Surgical or Invasive Procedure:
bilateral craniotomy
bilateral cranioplasty
History of Present Illness:
23 y/o M with skull mass at vertex of head presetns for elective
bilateral craniotomy and bilateral cranioplasty.
Past Medical History:
shoulder surgery, bipolar, insomnia
Social History:
+tobacco and ETOH
Family History:
NC
Physical Exam:
On Discharge:
nonfocal
Brief Hospital Course:
23 y/o M with no significant past medical history presents for
elective bilateral craniotomies for resection of skull lesion at
vertex. He was taken to the OR on [**2-2**]. He was extubated in the
OR however did not wake up enough to adequately protect his
airway so he was reintubated and trasnfered to the ICU for
further management and care. He was extubated shortly after
arrival to the ICU and post-operative Head CT showed expected
post-operative change. On [**2-3**] he was doing quite well and was
deemed fit for transfer to the floor. He also underwent an MRI
scan on [**2-3**] which showed expected post-surgical changes. On
[**2-4**] he was ambulatory in the halls, his pain was well
controlled, and he was deemed fit for discharge to home. He was
given instructions for follow-up and discharged.
Medications on Admission:
MVI, lamictal, melatonin
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*90 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain Fever > 101.4.
5. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Skull mass at vertex of head
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.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? If your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. You may shower before this time using a shower cap to
cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-1**] 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.
??????Follow up with Dr. [**Last Name (STitle) 724**] and Dr. [**Last Name (STitle) 12513**] in the BTC on [**Hospital Ward Name 5074**] on [**2152-2-28**] 09:30a.
Completed by:[**2152-2-4**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 889
} | Medical Text: Admission Date: [**2113-7-21**] [**Month/Day/Year **] Date: [**2113-7-23**]
Date of Birth: [**2049-3-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 9662**]
Chief Complaint:
Weakness
Reason for ICU Transfer: Hypotension
Major Surgical or Invasive Procedure:
Femoral CVL insertion - [**7-21**], removed [**7-23**]
History of Present Illness:
64yo M w/ PMHx of ESRD on HD (MWF), chronic aspiration, seizure
disorder, history of CVA with residual left-sided weakness and
dysarthria, upper extremity DVT, recently hospitalized at [**Hospital1 18**]
with melena found to have gastritis with no active bleeding
lesions, and h/o of Staph epidermidis treated with IV vancomycin
until [**7-20**], presented to the ED with generalized weakness and
hypotension.
He reported feeling well prior to HD, but upon returning from
HD, he reported generalized weakness. EMS was called. The
patient was found cool and diaphoretic with BP 70/50 and HR 100.
He only opened eyes when prompted, but was oriented x3. Repeat
BP was 90/palp and HR 100. ECG and 12 lead reveal NSR with no
ectopy and inverted T waves in the inferior leads as well as
V4-V6. Blood sugar 157 mg/dl.
In the ED, initial SBP in the 70s. The patient had a triple
lumen catheter placed in the right femoral [**2-23**] difficult access.
Pressure improved with fluids (1L) Patient with no focal
complaints in the ED, but minimally responsive to voice. Has a
cough, no fever, no chest pain. No abdominal tenderness. Patient
also received vancomycin and cefepime. CXR did not show focal
opacity. Pressures now in the 110s. Guiaic negative. EKG
consistent with priors- lateral TWIs. Has been mildly
tachycardic in 100-110. Pt received pressors and 1L IVF in the
ED, and was transferred to the ICU.
Past Medical History:
- ESRD on HD (M/W/F at [**Location (un) **])
- h/o multiple prior CVAs - per last dc summary ambulates at
home, has residual left-sided weakness
- UE DVT on coumadin
- Seizure disorder
- Chronic hepatitis B
- Chronic aspiration with failed speech and swallow eval -
family wants him to continue eating despite risks
- HTN
- CAD
- h/o MSSA bacteremia after manipulation of fistula
- hospitalization in [**12-31**] for incarcerated inguinal hernia
complicated by ESBL Klebsiella bacteremia and PNA
- Hyperlipidemia
- GERD
- S/p SBO [**2109**]
- Hernia repair
- Symptomatic Hypoglycemia
Social History:
Patient lives in [**Location **] with his daughter, [**Name2 (NI) **], who is
a former [**Hospital1 18**] employee. He denies any recent use of alcohol,
tobacco, illicit drugs, or herbal medications. He has a distant,
but considerable smoking history per his daughter. [**Name (NI) **] uses
the toilet himself, but needs help cleaning himself, and does
not cook or manage his finances. He is at HD on MWF and spends
TU and [**Doctor First Name **] in an adult day program. His daughter does not leave
him alone by himself.
Family History:
Mother died at 45 with hypertension. Father died at 60 of
unknown causes. He has eight living siblings, many of whom have
hypertension. He has six children who are all healthy.
Physical Exam:
Admission exam:
General: [**Doctor First Name **], oriented, no acute distress
[**Doctor First Name 4459**]: Sclera anicteric, MMM, oropharynx clear, [**Doctor First Name 3899**], PERRL
Skin: Skin in right groin clean and dry at site of femoral
catheter insertion.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
trace edema
Neuro: CNII-XII intact, dysarthria, 5/5 strength right
upper/lower extremities, 4+/5 strength left upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally
Pertinent Results:
ADMISSION LABS:
[**2113-7-21**] 02:00PM BLOOD WBC-7.2 RBC-3.34* Hgb-10.7*# Hct-34.6*
MCV-104* MCH-32.0 MCHC-30.8* RDW-17.4* Plt Ct-160
[**2113-7-21**] 02:00PM BLOOD Neuts-71.4* Lymphs-17.6* Monos-7.6
Eos-3.0 Baso-0.4
[**2113-7-21**] 02:00PM BLOOD PT-14.0* PTT-30.3 INR(PT)-1.3*
[**2113-7-21**] 02:00PM BLOOD Glucose-201* UreaN-13 Creat-4.7*# Na-139
K-3.8 Cl-104 HCO3-22 AnGap-17
[**2113-7-21**] 02:00PM BLOOD ALT-14 AST-17 AlkPhos-210* TotBili-0.1
[**2113-7-21**] 02:00PM BLOOD cTropnT-0.05*
[**2113-7-22**] 04:00AM BLOOD cTropnT-0.04*
[**2113-7-21**] 02:00PM BLOOD Albumin-4.1 Calcium-9.1 Phos-2.2*# Mg-1.6
[**2113-7-21**] 02:30PM BLOOD Lactate-1.9 K-3.7
[**Month/Day/Year 894**] LABS:
[**2113-7-23**] 07:30AM BLOOD WBC-5.9 RBC-3.27* Hgb-10.2* Hct-33.1*
MCV-101* MCH-31.2 MCHC-30.8* RDW-16.7* Plt Ct-184
[**2113-7-23**] 07:30AM BLOOD Glucose-72 UreaN-32* Creat-9.4*# Na-138
K-5.8* Cl-102 HCO3-21* AnGap-21*
[**2113-7-23**] 02:24PM BLOOD Glucose-155* UreaN-35* Creat-9.7* Na-139
K-4.6 Cl-100 HCO3-23 AnGap-21*
[**7-21**] PCXR:
Left-sided dual-lumen central venous catheter tip terminates
within the
proximal right atrium. The cardiac silhouette size is normal.
The
mediastinal and hilar contours, allowing for patient rotation,
are likely
unchanged. There is mild pulmonary vascular congestion.
Minimal atelectasis is likely present at the lung bases. No
focal consolidation, pleural effusion or pneumothorax is
identified. The bones are diffusely sclerotic suggestive of
underlying of renal osteodystrophy. Posttraumatic deformity of
the distal clavicle on the right is unchanged.
IMPRESSION:
Mild pulmonary vascular congestion. No definite radiographic
evidence for
pneumonia.
Brief Hospital Course:
64yo M w/ PMHx of ESRD on HD (MWF), chronic aspiration, seizure
disorder, history of CVA with residual left-sided weakness and
dysarthria, upper extremity DVT on coumadin, recently
hospitalized at [**Hospital1 18**] with melena found to have gastritis with
no active bleeding lesions and Staph epidermidis bacteremia s/p
IV vanc treatment [**7-20**], who was admitted to the ICU for
hypotension.
Upon arrival in the MICU, he was more responsive and stated he
was hungry. He denies chest pain, shortness of breath,
abdominal pain, n/v. He reports a cough that has been chronic.
He received an additional 750 cc, but no longer required
pressors. His SBP ranged 80-110s and he remained asymptomatic.
Vancomycin was discontinued, but he received cefipime overnight
on [**7-21**] before d/c. He was transferred to the floor [**7-22**]. On
the floor, he required no more IVF. SBP ranged 105-125.
# Hypotension: Patient underwent HD on day of admission; it is
likely that the patient's hypotension is related fluid shifts
during HD. Patient was initially with SBPs in the 70s upon
presentation to the ED and improved to 100s with 1L of fluid and
some pressors in the ED. Patient's SBPs were stable in the 120s
upon arrival to the ICU. He did have brief episodes of
hypotension to the 80s systolic while in the ICU but required a
total of only 750cc IVF while in the ICU. Troponins were cycled
and at baseline, EKG unremarkable. No clear evidence of
infection so antibiotics were NOT continued while in the ICU.
ACEI was held. Blood cultures were NGTD. On the floor SBPs were
stable 105-125.
# ESRD on HD: M/W/F. Patient went to HD prior to arrival in the
ED. Nephrology saw the patient in hospital. Home meds continued.
# Hyperkalemia: Pt is normally on HD and has baseline K around
5. K was 5.8 on the morning of [**7-23**]. EKG was checked and showed
now acute changes. Pt denied chest pain or palpitations,
dizziness, lightheadedness, nausea. Pt was given kayexelate per
nephrology, and K dropped to 4.5 at [**Date Range **] labs.
# UE DVT: Patient w/ clot in AVF previously on coumadin which
was held in light of anemia. Decision was made by daugther not
to continue coumadin in light of risk of bleeding per most
recent PCP [**Name Initial (PRE) 626**].
# Anemia: HCT 33 upon [**Name Initial (PRE) **], consistent with chronic anemia
secondary to ESRD, patient's baseline HCT is in the low 30s.
# GERD: H. pylori negative. Continued omeprazole.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Nephrocaps 3 CAP PO BID
2. Lanthanum 500 mg PO TID W/MEALS
3. LeVETiracetam 500 mg PO BID
4. Lisinopril 40 mg PO DAILY hypertension
5. Omeprazole 40 mg PO BID gastritis
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Pravastatin 40 mg PO DAILY
8. sevelamer HYDROCHLORIDE *NF* 800 mg Other TID:meals
9. Aspirin 81 mg PO DAILY
10. Ascorbic Acid 500 mg PO DAILY
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Senna 1 TAB PO BID:PRN constipation
[**Name Initial (PRE) **] Medications:
1. Aspirin 81 mg PO DAILY
2. LeVETiracetam 1500 mg PO BID
3. Nephrocaps 1 CAP PO DAILY
4. Pravastatin 40 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Lanthanum 500 mg PO TID W/MEALS
7. Lisinopril 40 mg PO DAILY high blood pressure
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 1 TAB PO BID:PRN constipation
11. Ascorbic Acid 500 mg PO DAILY
12. sevelamer HYDROCHLORIDE *NF* 800 mg Other TID:meals
[**Name Initial (PRE) **] Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
[**Location (un) **] Diagnosis:
Primary Diagnosis: Hypotension (Low blood pressure)
Secondary Diagnosis: end stage renal disease, seizure disorder,
hypertension, gastroesophageal reflux disease / gastritis,
chronic aspiration
[**Location (un) **] Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: [**Location (un) **] and interactive.
Activity Status: Ambulatory - Independent.
[**Location (un) **] Instructions:
Dear Mr. [**Known lastname **],
You were admitted for low blood pressure and weakness. It was a
pleasure being involved in your care.
You may continue your regular diet, activities, and dialysis
upon returning home. For now, because your blood pressure is
still on the low side of normal, PLEASE STOP TAKING LISINOPRIL
(your blood pressure medication). Please check your blood
pressure at home or at a CVS within the next 2 days, and if the
top number is higher than 150, call Dr. [**Last Name (STitle) **] to find out
whether you should start taking your blood pressure medicine
again.
Please contact your primary care physician, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD
[**Telephone/Fax (1) 2010**], to schedule an appointment to check your blood
pressure and decide whether you should start lisinopril again.
We will send him a copy of your [**Telephone/Fax (1) **] summary.
Followup Instructions:
1. Please call your primary care physician to schedule an
appointment within the next 1-2 weeks:
Department: [**Hospital3 249**]
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
2. Please call your outpatient nephrologist, Dr. [**First Name (STitle) **], for a
follow-up appointment in the next 1-2 weeks
3. Department: NEUROLOGY
When: THURSDAY [**2113-9-21**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD [**Telephone/Fax (1) 3294**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
3. Department: [**Hospital3 249**]
When: TUESDAY [**2113-10-3**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2113-7-24**]
ICD9 Codes: 5856, 2767, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 890
} | Medical Text: Admission Date: [**2146-5-15**] Discharge Date: [**2146-6-16**]
Date of Birth: [**2146-5-6**] Sex: F
Service: Neonatology
ID: [**Known lastname 40567**] Girl [**Known lastname 34030**] is a now 41 day old former 27 [**6-17**]
week premature infant who was hospitalized at [**Hospital6 1760**] Neonatal Intensive Care Unit.
The infant was born at the [**Hospital6 2018**] on [**2146-5-6**] and was transferred to [**Hospital3 18242**] secondary to lack of available bed space at the [**Hospital6 1760**] Nursery Intensive Care Unit.
The patient was transferred back to the [**Hospital6 649**] Nursery Intensive Care Unit on [**5-15**].
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 34030**] was born on
[**2146-5-6**] as the 1,025 gm product of a 27 6/7 weeks
gestation, delivered by cesarean section secondary to
concerns of chorioamnionitis as well as breech presentation.
Mother presented with spontaneous premature rupture of
membranes at 25 weeks gestation at which time she was treated
with a course of Betamethasone as well as intrapartum
antibiotics. Pregnancy was also notable for oligohydramnios
at 19 weeks gestation.
HOSPITAL COURSE: 1. Respiratory - The patient exhibited
moderate hyaline membrane disease and was intubated and
ventilated and treated with Surfactant times two doses. The
patient had a good response and was extubated to CPAP on day
of life #2. The patient did exhibit significant apnea of
prematurity and was begun on caffeine therapy. The patient
was taken off of CPAP on day 8 to 9 of life but was placed
back on one day later for increased spells.
The patient was last on CPAP from day 18 to day 22 of life
and was last on nasal cannula flow through day 26 of life. At
the time of this dictation the patient is on room air with
occasional apneic episodes, being continued on caffeine
therapy.
2. Cardiovascular - The patient did exhibit hypotension in
the first 24 hours of life treated with Dopamine to a maximum
of 20 mcg/kg/min. An echocardiogram revealed a large patent
ductus arteriosus and following a course of Indomethacin, the
clinical signs of the patent ductus arteriosus resolved and
the patient quickly weaned off of Dopamine. The patient has
been hemodynamically stable since that time. At
approximately two to three weeks of life, a consistent
systolic murmur was heard. An echocardiogram was performed
on [**5-28**] which revealed no patent ductus arteriosus but did
reveal left peripheral pulmonic stenosis.
3. Fluids, electrolytes and nutrition - The patient was
initially maintained on parenteral nutrition and begun on
enteral feeds on day of life #7. This was advanced easily to
a maximum of 28 cal/oz breast milk. At that time on day of
life #18, [**2146-5-24**], the patient had frankly bloody stool.
Physical examination was largely reassuring, although
complete blood count revealed a white count of 10 with 19
polys and 16 bands. Blood culture was sent, KUB was
basically normal with just mild dilation of intestinal loops,
and the patient was made NPO and begun on ampicillin,
gentamicin and Clindamycin. The patient remained clinically
well and follow up complete blood count revealed improvement
in the differential. KUBs remained normal. Due to the
initial left shift of the complete blood count it was decided
to continue the patient on bowel rest and antibiotics for one
week. After that time, antibiotics were discontinued and
enteral feedings were introduced gradually with Pregestimil.
These were advanced without difficulty and at the time of
this dictation the patient is tolerating 150 cc/kg/day of 30
cal/oz of Pregestimil formula. Stools remain occasionally
guaiac positive. Mother has decided to no longer breastfeed,
but it is anticipated that if the patient remains stable for
one to two additional weeks the formula can be transitioned
back to regular Enfamil with close monitoring for tolerance.
Weight at birth was 1,025 gm, weight on [**2146-6-16**] was 1,575
gms.
4. Gastrointestinal - The patient did exhibit mild
hyperbilirubinemia of prematurity early in life treated with
phototherapy through day #7 of life. As mentioned above, on
day 18 the patient experienced a grossly bloody stool that
was subsequently diagnosed as a nonspecific colitis, possibly
secondary to formula intolerance. The patient was treated
with bowel rest and antibiotics for one week and since then
has been able to be readvanced on Pregestimil formula without
difficulty.
5. Infectious disease - After birth the patient was treated
with Ampicillin and gentamicin for one week secondary to
presumed sepsis given maternal history of presumed chorio and
the severity of illness in the first one to two days of life.
A lumbar puncture at that time was negative for infection.
As mentioned above, the patient was also treated with
ampicillin, gentamicin and Clindamycin for one week from [**5-24**] through [**5-31**], day #18 through 25 of life, for a
nonspecific colitis.
6. Neurological - The patient has maintained a normal
neurologic examination throughout. Head ultrasounds were
normal on day #7 and 26. A head ultrasound prior to
discharge is anticipated.
7. Heme - The patient has received occasional transfusions
of packed red blood cells, the last being on [**5-23**] and then
again on [**5-31**]. The last hematocrit was on [**6-3**] and that
was 37.8 with a reticulocyte count of 2.8%. The patient is
on Fer-In-[**Male First Name (un) **].
8. HEALTH CARE MAINTENANCE - The patient has been maintained
on Vitamin E supplements for prematurity. Newborn screen on
[**5-26**] revealed elevated 17 OHP levels; repeat is pending.
The patient had an ophthalmologic examination on [**6-8**] that
revealed immature retinas in Zone 2 with follow up
recommended in two weeks. Finally, in terms of access, the
patient did have a PICC line placed during the episode of
colitis that was removed on [**6-7**] without difficulty.
CONDITION AT TIME OF SUMMARY: At the time of this summary
the patient is hemodynamically stable with a murmur thought
to be secondary to peripheral pulmonic stenosis. The patient
is in room air with occasional apnea and bradycardiac
episodes and is on caffeine therapy. The patient is
tolerating 150 cc/kg/day of Pregestimil 30 formula with
occasional guaiac positive stools.
FEEDINGS:
Pregestimil 30 (Pregestimil 24 + 4 cals/oz MCT Oil + 2 cals/oz
Polycose) pg with po attempts.
MEDICATIONS:
1. Fer-In-[**Male First Name (un) **] 0.15cc po qd
2. Vitamin E 5 IU po qd
3. Caffeine 12 mg po qd
PEDIATRICIAN:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37583**], [**Hospital **] Pediatrics
[**Telephone/Fax (1) 37584**]
DIAGNOSIS:
1. Prematurity at 27 6/7 weeks
2. Respiratory distress syndrome, resolving
3. Apnea of prematurity
4. Hypotension resolved
5. Patent ductus arteriosus, resolved
6. Peripheral pulmonic stenosis
7. Nonspecific colitis, resolved
8. Presumed sepsis, resolved
9. Retinal immaturity
DR [**First Name (STitle) 36400**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 50.595
Dictated By:[**Name8 (MD) 38043**]
MEDQUIST36
D: [**2146-6-12**] 14:31
T: [**2146-6-12**] 16:00
JOB#: [**Job Number 40568**]
ICD9 Codes: V290, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 891
} | Medical Text: Admission Date: [**2103-8-3**] Discharge Date: [**2103-8-13**]
Date of Birth: [**2041-1-21**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Benadryl Decongestant
Attending:[**Last Name (un) 2888**]
Chief Complaint:
Chest and Abdominal Pain
Major Surgical or Invasive Procedure:
Pericardiocentesis with drain placement
Pericardial drain removal
Hemodialysis
Attempted thrombectomy of HD graft in left arm by interventional
radiology
Placement of tunneled HD line through left IJ by interventional
radiology
History of Present Illness:
62 year old male with a pmh of ESRD s/p failed graft on HD, Hep
C genotype 1, DMII, HTN, HLD who presents from an OSH with
pericarditis complicated by pericardial effusion.
.
His OSH course is as follows:
He had an admission prior to this [**Date range (1) 27855**] with pleuritic CP
and rub, diagnosed with pericarditis. Also, new LBBB and tropI
of 0.125. Echo showed small effusion and normal wall motion,
mild AS, mild MR, unchanged from baseline. He was treated with
NSAIDs. Due to LBBB, prolonged PR and underlying dCHF (between
dialysis sessions) his dilt was stopped and coreg (3.125) was
added. He was discharged on 50mg TID of indocin.
.
Several days after discharge he developed general weakness,
vague diffuse low abd pain, and fatigue. Dialysis was
complicated by hypotension (new) and required fluid. [**8-2**]
admitted to OSH with hypotension of 75/50 and above symptoms. He
was fluid resuscitated, fluid responsive. CT A/P showed
diverticulosis (no inflammation) and a mod pericardial effusion
(incidental). RUQ U/S with GB wall thickening, otherwise
unremarkable.
.
He was admitted to the ICU, BPs maintained 100s-140s and HRs
50s-70s. Treated presumptively for adrenal insufficiency with
hydrocortisone. Echo showed circuferential pericardial effusion
(2.1-2.2 cm) reportedly without evidence of tamponade. His
vitals remained stable and his labs were unremarkable (stable
anemia HCT ~30) and WBC elevation of 19 after steroids.
Creatinine 8.9, sodium 131. He was transferred from OSH
([**Hospital1 1562**]) to [**Hospital1 18**] for further management.
.
At [**Hospital1 18**], he was admitted to inpatient medicine. He is
comfortable without any acute complaints. He does still have
mild chest discomfort that has persisted throughout his
admission at the OSH. He also has vague lower abdominal pain,
but is otherwise without any acute complaints. No SOB, no
orthopnea, no PND.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia,
+Hypertension
2. OTHER PAST MEDICAL HISTORY:
- ESRD secondary to FSGN, s/p failed graft placement and now
temporarily off of the [**Hospital1 **] list (due to current illness)
on hemodialysis from FSGS; AV graft is thrombosed (he is
dialyzed now through temp groin line)
- Hepatitis C genotype 1, biopsy showed fibrosis grade I
- Gout
- s/p Partial parathyroidectomy (adenoma)
- Neuropathy
Social History:
Lives in [**Hospital1 1562**] with his wife and daughter. [**Name (NI) **] is a former
smoker that quit many years ago. No alcohol or drugs. He is a
cab driver.
Family History:
No renal disease in family, father with CAD age 50s. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T:98.1 BP:120/72 P:64 R:18 18 O2: 99% - Pulsus 18
(doppler)
General: Alert, oriented, no acute distress, mildly fatigued
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~8, no LAD
Lungs: Clear to auscultation bilaterally, basilar crackles no
wheezes, rales, ronchi
CV: Normal rate, Regular rhythm, distant heart sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis, trace edema
Neuro: Oriented. No gross deficits.
.
DISCHARGE EXAM:
VS: Tm 98.1 BP 122/57 P 81-86, R18, 100%RA
Pulsus: 8
Gen: well-appearing male in NAD
HEENT: NCAT MMM EOMI anicteric
Neck: Supple without LAD, JVD not discernable
Pulm: CTA b/l without wheeze or rhonchi
Cor: RRR (+)S1/S2 without m/g, former drain site c/d/i
Abd: Soft, non-distended, non-tender to palpation, NABS
Extrem: 1+ LE edema b/l, good distal pulses, warm and well
perfused
LUE fistula with palpable cords. RLE with increased edema, pain
with passive movement.
Neuro: CNII-XII grossly intact, moving all extremities,
mentating well
Lines/Drains: RUE PICC, tunneled HD catheter
Pertinent Results:
#ADMISSION LABS:
[**2103-8-4**] 02:15AM BLOOD WBC-12.1*# RBC-2.82* Hgb-8.7*# Hct-27.6*#
MCV-98 MCH-30.9 MCHC-31.5 RDW-16.3* Plt Ct-302
[**2103-8-4**] 02:15AM BLOOD PT-16.5* PTT-67.6* INR(PT)-1.6*
[**2103-8-4**] 02:15AM BLOOD
[**2103-8-4**] 02:15AM BLOOD Glucose-202* UreaN-51* Creat-6.4*#
Na-132* K-4.6 Cl-97 HCO3-22 AnGap-18
[**2103-8-4**] 02:15AM BLOOD ALT-51* AST-49* CK(CPK)-46*
[**2103-8-4**] 02:15AM BLOOD Albumin-2.8* Calcium-7.7* Phos-5.5*
Mg-2.0
.
#DISCHARGE/PERTINENT LABS:
[**2103-8-13**] 03:24PM BLOOD Hct-28.2*
[**2103-8-13**] 04:00AM BLOOD WBC-7.6 RBC-2.45* Hgb-7.8* Hct-24.4*
MCV-100* MCH-31.6 MCHC-31.7 RDW-15.5 Plt Ct-294
[**2103-8-12**] 03:50AM BLOOD WBC-7.6 RBC-2.64* Hgb-8.2* Hct-26.0*
MCV-98 MCH-30.9 MCHC-31.4 RDW-15.6* Plt Ct-272
[**2103-8-11**] 02:50AM BLOOD WBC-7.1 RBC-2.68* Hgb-8.4* Hct-26.4*
MCV-98 MCH-31.4 MCHC-32.0 RDW-15.6* Plt Ct-253
[**2103-8-10**] 04:07AM BLOOD WBC-8.4 RBC-2.81* Hgb-8.5* Hct-28.1*
MCV-100* MCH-30.3 MCHC-30.3* RDW-15.8* Plt Ct-292
[**2103-8-9**] 05:47AM BLOOD WBC-7.0 RBC-2.70* Hgb-8.4* Hct-27.1*
MCV-100* MCH-31.1 MCHC-31.0 RDW-16.2* Plt Ct-285
[**2103-8-8**] 04:40AM BLOOD WBC-9.7 RBC-2.90* Hgb-9.0* Hct-28.3*
MCV-98 MCH-31.0 MCHC-31.7 RDW-16.5* Plt Ct-309
[**2103-8-7**] 04:23AM BLOOD WBC-9.7 RBC-2.97* Hgb-9.3* Hct-29.2*
MCV-98 MCH-31.1 MCHC-31.6 RDW-16.9* Plt Ct-327
[**2103-8-6**] 05:12AM BLOOD WBC-11.8* RBC-2.94* Hgb-9.2* Hct-28.8*
MCV-98 MCH-31.3 MCHC-32.0 RDW-17.2* Plt Ct-332
[**2103-8-5**] 06:30AM BLOOD WBC-12.2* RBC-3.07* Hgb-9.6* Hct-30.3*
MCV-99* MCH-31.3 MCHC-31.6 RDW-17.6* Plt Ct-372
[**2103-8-13**] 04:00AM BLOOD PT-25.1* PTT-55.0* INR(PT)-2.4*
[**2103-8-12**] 10:06AM BLOOD PT-24.9* PTT-138* INR(PT)-2.4*
[**2103-8-12**] 10:06AM BLOOD PT-24.9* PTT-138* INR(PT)-2.4*
[**2103-8-11**] 05:41PM BLOOD PTT-73.7*
[**2103-8-10**] 07:36AM BLOOD PTT-87.1*
[**2103-8-10**] 04:07AM BLOOD PT-17.7* PTT-64.0* INR(PT)-1.7*
[**2103-8-9**] 05:47AM BLOOD PT-14.9* PTT-98.4* INR(PT)-1.4*
[**2103-8-8**] 04:40AM BLOOD PT-15.0* PTT-40.6* INR(PT)-1.4*
[**2103-8-7**] 04:23AM BLOOD PT-15.8* PTT-106.6* INR(PT)-1.5*
[**2103-8-6**] 05:12AM BLOOD PT-13.8* PTT-30.6 INR(PT)-1.3*
[**2103-8-5**] 06:30AM BLOOD PT-14.7* PTT-29.9 INR(PT)-1.4*
[**2103-8-7**] 04:23AM BLOOD ESR-70*
[**2103-8-13**] 04:00AM BLOOD Glucose-147* UreaN-53* Creat-8.9*#
Na-130* K-4.4 Cl-91* HCO3-30 AnGap-13
[**2103-8-11**] 02:50AM BLOOD Glucose-83 UreaN-25* Creat-5.7*# Na-130*
K-4.0 Cl-90* HCO3-31 AnGap-13
[**2103-8-9**] 05:47AM BLOOD Glucose-94 UreaN-35* Creat-6.2*# Na-132*
K-3.9 Cl-93* HCO3-33* AnGap-10
[**2103-8-7**] 04:23AM BLOOD Glucose-126* UreaN-45* Creat-6.6*# Na-135
K-4.4 Cl-97 HCO3-29 AnGap-13
[**2103-8-6**] 05:12AM BLOOD Glucose-159* UreaN-105* Creat-10.6*#
Na-133 K-5.2* Cl-95* HCO3-21* AnGap-22*
[**2103-8-7**] 04:23AM BLOOD ALT-36 AST-35 AlkPhos-36* TotBili-0.5
[**2103-8-6**] 05:12AM BLOOD ALT-45* AST-37 LD(LDH)-176 AlkPhos-40
TotBili-0.3
[**2103-8-13**] 04:00AM BLOOD Albumin-2.3* Calcium-6.8* Phos-2.7 Mg-1.8
[**2103-8-11**] 02:50AM BLOOD Calcium-6.8* Phos-2.6*# Mg-1.7
[**2103-8-10**] 04:07AM BLOOD TotProt-5.4* Calcium-7.6* Phos-5.0*
Mg-1.8
[**2103-8-8**] 04:40AM BLOOD Calcium-7.5* Phos-6.3* Mg-1.9
[**2103-8-6**] 05:12AM BLOOD Albumin-2.8* Calcium-7.2* Phos-6.1*
Mg-2.1
[**2103-8-5**] 06:30AM BLOOD Calcium-7.6* Phos-6.0* Mg-2.1
[**2103-8-6**] 05:12AM BLOOD %HbA1c-5.2 eAG-103
[**2103-8-10**] 09:21AM BLOOD Cryoglb-NEGATIVE
[**2103-8-6**] 05:12AM BLOOD TSH-2.0
[**2103-8-6**] 12:55PM BLOOD dsDNA-NEGATIVE
[**2103-8-5**] 06:30AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:160
[**2103-8-10**] 04:07AM BLOOD PEP-NO SPECIFI
[**2103-8-9**] 05:47AM BLOOD C4-32
[**2103-8-6**] 05:12AM BLOOD C3-73*
[**2103-8-7**] 04:23AM BLOOD HIV Ab-NEGATIVE
[**2103-8-6**] 12:55PM BLOOD C2-Test
[**2103-8-6**] 09:30AM OTHER BODY FLUID WBC-2675* Hct,Fl-10.5*
Polys-67* Lymphs-23* Monos-5* Eos-2* Atyps-1* NRBC-1* Macro-2*
[**2103-8-6**] 09:30AM OTHER BODY FLUID TotProt-4.9 Glucose-129
LD(LDH)-1113 Amylase-32 Albumin-2.2
.
#STUDIES:
[]2D-ECHOCARDIOGRAM: [**2103-8-4**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a large pericardial
effusion. There is sustained right atrial collapse, consistent
with low filling pressures or early tamponade. There is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling.
IMPRESSION: Large circumferential effusion with
echocardiographic evidence of early tamponade physiology.
.
[]2D-ECHOCARDIOGRAM (POST-PERICARDIOCENTESIS): [**2103-8-6**]
Left ventricular wall thicknesses and cavity size are normal.
There is an anterior space which most likely represents a
prominent fat pad. No residual pericardial effusion identified.
Compared with the prior study (images reviewed) of [**2103-8-4**], the
pericardial effusion has resolved and tamponade physiology is no
longer suggested.
.
[]EKG [**2103-8-3**]:
Sinus rhythm with first degree atrio-ventricular conduction
delay. Borderline left axis deviation. Diffuse non-diagnostic
repolarization abnormalities. [**Last Name (un) **] QRS voltage in the precordial
leads. Compared to the previous tracing of [**2100-10-6**] there is no
diagnostic change.
Rate PR QRS QT/QTc P QRS T
72 [**Telephone/Fax (3) 27856**]/455 0 -25 129
Brief Hospital Course:
[]BRIEF CLINICAL COURSE:
62M w/ hx ESRD s/p failed graft on HD, Hep C genotype 1, DMII,
HTN, HLD who presents from an OSH with pericarditis complicated
by pericardial effusion. The patient was intially admitted to a
general medicine service. On [**8-4**], he developed atrial
fibrillation and was found to have significant tamponade
physiology, so was transferred to the cardiology service. A
pericardiocentesis was performed on [**8-6**], and he was transferred
to the CCU following the procedure. He was transferred back to
the inpatient cardiology team on [**8-9**], and he was discharged on
[**2103-8-13**].
.
[]ACTIVE ISSUES:
# Pericardial Effusion: On the floor, the patient was found to
have a pulsus paradoxus of 15mmHg. An echo demonstrated a large
effusion with significant tamponade physiology. He developed
atrial fibrillation at this time (see below) with rates in the
90s-100s, but beta blockers were not used given the patient's
hypotension, which was thoguht to be secondary to the tamponade
physiology. On [**8-6**], the patient underwent pericardiocentesis
with drain placement. Approximately 720cc of bloody fluid was
removed initially. An additional ~500cc of bloody fluid was
collected from the drain in the following two days. In the CCU,
the patient was nto hypotensive and did not demonstrate
tamponade physiology. Hi pulsus was measured to be 6-12mmHg in
the days following drainage. Echo following the
pericardiocentesis demonstrated resolution of the effusion. The
drain was removed on [**8-7**], and repeat echo demonstrated some
fluid surrounding the heart, which was thought to be
post-procedural inflammation as opposed to reaccumulation of an
effusion. Back on the cardiology floor, the patient had stable
pulsus checks daily and a repeat ECHO prior to discharge
demonstrated stable pericardial effusion. In terms of the
etiology of the pericarditis and pericardial effusion, uremia
was thought to be unlikely by the nephrology consult service,
given that the patient is regularly dialyzed. A viral etiology
was thought to be most likely and we continued the patient on
twice weekly colchicine dosing, though no specific pathogen was
identified. Malignancy was considered, but the pericardial
fluid showed no malignant cells on cytology. TB was considered,
but PPD was negative. Cryoglobulinemia was considered given the
patient's hepatitis C, and testing revealed negative
cryoglobulins. Autoimmune etiology was considered, and testing
revealed +[**Doctor First Name **] but negative dsDNA. The patient will follow up
with his outpatient cardiologist, his PCP, [**Name10 (NameIs) **] surgery,
and will return on [**8-22**] for a f/u ECHO to monitor.
.
# Atrial Fibrillation: On the medicine floor early in the
patient's hospitalization, the patient developed atrial
fibrillation. He converted to normal sinus rhythm, and remained
in sinus rhythm during his CCU stay. Due to the risk of
paroxysmal afib, he was started on heparin drip. This was
continued during his CCU stay. His CHADS2 score was [**12-29**]. The
cardiology floor team considered whether or not to anticoagulate
the patient with warfarin, and they decided to continue bridge
the patient to coumadin with a heparin drip; the patient was
therapuetic at discharge. The patient was continued on
carvedilol. He came into the hospital on diltiazem, but this
was held in favor of the carvedilol. The patient also
reportedly had LBBB on EKG at OSH. Here he had anterior
fascicular block, which was consistent with prior EKGs.
.
# Mild Diastolic Heart Failure: As per OSH report, the patient
has mild diastolic heart failure. Diastolic heart failure is
not clearly mentioned in [**Hospital1 18**] records or ECHOs and may need to
be reassessed after complete resolution of the current
pericardial disease.
.
# ESRD on HD with Thrombosed [**Last Name (un) **] graft: On admission to CCU,
BUN>100 and Cr>10 with associated anemia thought to be secondary
to the renal disease. The patient also has a graft in the left
upper extremity which has clotted multiple times. It was
stented in the past, but has re-thrombosed. A temporary HD line
was placed at the OSH, and he did not miss dialysis. The
temporary line was pulled after the patient was admitted to the
CCU, and he was sent to IR for an attempted thrombectomy. IR
removed a thormbus, but the graft reclotted within 10 minutes.
Therefore, a tunnel line was placed in the LIJ into the
brachiocephalic. However, there was stenosis at the confluence
of the left innominate/SVC junction, and the tunnelled line
obstructed the flow that had been previously able to get through
this stenosed vessel. This resulted in edema of the patient's
left arm. On [**8-9**], the patient returned to IR for balloon
expansion of the brachiocephalic through the tunneled line.
After the procedure, the edema subsided substantially within 24
hours. The patient was continued on his home Nephrocaps and
Phoslo. He received Epo with dialysis. he was follwed by
nephrology and received 3x weekly dialysis while here.
.
# HTN: Patient had relatively low pressures prior to admission
to the CCU compared to baseline, likely secondary to atrial
fibrillation and early tamponade. He was not at all hypotensive
after the pericardiocentesis procedure. His hypertension was
treated with lisinopril and carvedilol. His home diltiazem was
discontinued.
.
# DM: Patient treated with insulin sliding scale.
.
# HLD: Simvastatin was continued.
.
# Hep C: The patient's LFTs were not elevated boyond his
baseline.
.
# Gout: Inactive.
.
[]TRANSITIONAL ISSUES:
-patient will start back on his old HD regimen of TU, TH, SAT.
Patient discharged on a monday after received HD, will f/u on
Tuesday for HD session.
-patient will have his INR monitored by Dr. [**Last Name (STitle) 27857**].
-The patient will return on [**8-22**] for f/u TTE to
monitor for an evolving effusion.
Medications on Admission:
Preadmission medications listed are correct and complete
Information was obtained from Patient
1. Indomethacin 50 mg PO TID (recently added for pericarditis)
2. Carvedilol 3.125 mg PO BID (this was started recently when
dilt was being held, then it was held when dilt was restarted)
3. Omeprazole 20 mg PO DAILY
4. Diltiazem 60 mg PO QAM
5. Diltiazem 120 mg PO QPM
6. Calcium Acetate 667 mg PO TID W/MEALS
7. fenofibrate *NF* 160 mg Oral daily
8. Simvastatin 20 mg PO HS
9. Nephrocaps 1 CAP PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Lisinopril 10 mg PO DAILY
- also took Lactulose 15cc PRN constipation until recently
- was also on Hydrocortisone recently at OSH for pericarditis
Discharge Medications:
1. Outpatient Lab Work
Please check INR, CBC, on [**2103-8-16**] and fax results to
[**Last Name (LF) 27857**],[**First Name7 (NamePattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1105**] at [**Telephone/Fax (1) 27858**]
2. Carvedilol 3.125 mg PO BID
3. Calcium Acetate 1334 mg PO TID W/MEALS
RX *calcium acetate 667 mg 2 tablet(s) by mouth Three times a
day with meals Disp #*120 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Simvastatin 20 mg PO HS
7. Colchicine 0.3 mg PO TUESDAY AND FRIDAY
RX *colchicine [Colcrys] 0.6 mg 0.5 (One half) tablet(s) by
mouth TUESDAY AND FRIDAY Disp #*5 Tablet Refills:*0
8. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Omeprazole 20 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Pericardial effusion
DVT
Secondary diagnosis
End Stage Renal Disease
Hepatitis C
Hypertension
Diabetes
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 24049**],
It was a pleasure taking care of you.
You were admitted to [**Hospital1 69**] for
having fluid around your heart that caused an irregular heart
rhythm. You had the fluid removed and were monitored with
multiple ultrasounds of your heart that showed no further fluid
accumulation. You will follow up with your outpatient primary
care physician, [**Name10 (NameIs) **] cardiologists and you will get a routine
echocardiogram. Please contact your primary care physician if
you experience increased swelling or pain in your legs. We wish
you and your family the best.
Followup Instructions:
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 27859**]
Specialty: Primary Care
When: Monday [**2103-8-20**] at 9:40am
Address: [**Last Name (un) 27860**], UNIT [**Unit Number **], [**Hospital1 **],[**Numeric Identifier 27861**]
Phone: [**Telephone/Fax (1) 27862**]
*This is a follow up appointment for your hospitalization. You
will be reconnected with your primary care provider, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 27863**], after this visit.
You should also call your docotor's office tomorrow to discuss
monitoring of your blood tests while you are on the blood
thinner medication (coumadin)
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27864**], MD
Specialty: Cardiology
When: Wednesday [**2103-8-29**] at 1:45pm
Location: CARDIOVASCULAR SPECIALISTS
Address: 90 TER HEUN DR, STE#300, [**Hospital1 **],[**Numeric Identifier 19665**]
Phone: [**Telephone/Fax (1) 19666**]
Department: CARDIAC SERVICES
When: WEDNESDAY [**2103-9-5**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name **] CENTER
When: FRIDAY [**2103-10-12**] at 10:30 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ECHO LAB
When: WEDNESDAY [**2103-8-22**] at 1 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 5856, 4271, 2724, 4280, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 892
} | Medical Text: Admission Date: [**2127-11-14**] Discharge Date: [**2127-11-22**]
Date of Birth: [**2091-3-6**] Sex: M
Service: Medicine/MICU
HISTORY OF PRESENT ILLNESS: The patient is a critically ill
36 year old male who was transferred from the [**Hospital3 417**]
Hospital on [**2127-11-15**] for further management of
presumed intoxication complicated by acute renal failure
requiring dialysis, pancreatitis, hepatitis and meningitis.
The patient has had a history of alcohol abuse in the past.
He was sober for approximately seven years but, during the
summer, the patient had started to abuse alcohol again.
According to his wife, he had been in detoxification four to
five times since the summer.
On [**2127-11-2**], the patient drank alcohol, amount
unknown, and then, on [**2127-11-6**], ingested
approximately two pints of vodka according to [**Hospital3 417**]
Hospital. The patient's wife noted that, after the
ingestion, the patient had nausea, vomiting, diarrhea and
abdominal pain.
The patient then presented to [**Hospital3 417**] Hospital on
[**2127-11-8**] and was found to be severely acidemic with
arterial blood gases of 7.01/7/100 and a potassium of
approximately 6 with a creatinine of 3.7. According to [**Hospital3 418**] Hospital, a toxicology screen was negative and
alcohol was negative. The patient had low Tylenol levels.
The wife had noted that, in the past, the patient had
ingested Scope and cough syrup and had taken Tylenol P.M.,
regularly, approximately five pills at a time. She had also
noted that a bottle of Shout was nearly empty. The patient
was tested for ethylene glycol on [**2127-11-9**] after
hemodialysis, and was negative. A formaldehyde antibody test
was also sent to Quest Laboratories, which is currently
pending.
At the outside hospital, the patient was emergently dialyzed
and intubated for a severe metabolic acidosis and impending
respiratory failure. On presentation, the patient's liver
function tests were normal but began to rise to an ALT of
1,579 and AST 2,719 on [**2127-11-11**]. Sputum and stool
cultures were negative. An abdominal ultrasound and CT scan
showed hepatomegaly. A head CT showed sinusitis but no acute
intracranial pathology.
In total, the patient was dialyzed four times. He was also
noted to have hypercalcemia, with a total calcium of
approximately 13. He was given one dose of pamidronate on
[**2127-11-15**].
The patient was extubated on [**2127-11-3**]. He
apparently was speaking, recognized his wife and then became
somnolent. He was noted to have increased agitation and was
given significant amounts of Ativan and Haldol. He was then
transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
further management at the request of his wife.
On presentation, the patient was somnolent and unresponsive
to voice, but responded to pain. He moved all four
extremities. His pupils were 3 mm and unresponsive to light.
The patient also had a paradoxical breathing pattern and was
intubated for both airway protection and respiratory
distress.
PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Status post
appendectomy.
ALLERGIES: The patient has no known drug allergies.
OUTPATIENT MEDICATIONS: None.
MEDICATIONS ON TRANSFER: Vitamin K, nitroglycerin paste,
Haldol and Catapres 0.2 mg.
SOCIAL HISTORY: The patient smokes one pack per day. He is
married with an 11 year old daughter. [**Name (NI) **] works as a
mechanic. He has a history of alcohol abuse and used cocaine
occasionally.
FAMILY HISTORY: The patient has a brother with
hemochromatosis.
LABORATORY DATA: On admission to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **], white blood cell count was 14.7, hematocrit
28.8, platelet count 288,000, prothrombin time 13.7, partial
thromboplastin time 32, INR 1.3, albumin 3.1, sodium 144,
potassium 4.1, chloride 97, bicarbonate 31, BUN 65,
creatinine 7.6 and glucose 125. Arterial blood gases:
7.52/38/114.
HOSPITAL COURSE: The patient is a 36 year old critically ill
male, intubated, with presumed ethylene glycol ingestion
complicated by meningitis, unresponsive mental status, acute
renal failure, on dialysis, hepatitis, pancreatitis and
possible aspiration/ventilator associated pneumonia.
1. Cardiovascular/labile blood pressure: Since the patient
presented to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **], and at the
outside hospital, he has been largely hypertensive with a
systolic blood pressure at approximately 180 and diastolic
pressure at approximately 100. The patient has been
intermittently on a labetalol drip. At first, hypertension
was partly attributed to withdrawal, however, now it appears
that his hypertension may be neurologically driven.
2. Pulmonary/intubated with possible ventilator/aspiration
pneumonia: On [**2127-11-19**], the patient had episodes of
hypoxia and hypotension. After suctioning, multiple mucus
plugs were seen. The patient was planned for a bronchoscopy
but this was deferred because his hypoxia had resolved. A
chest x-ray showed bilateral lower lobe infiltrates
consistent with possible aspiration pneumonia. The patient
is currently on vancomycin, levofloxacin and ampicillin.
3. Renal/anuric, acute renal failure: This was thought
secondary to toxic ingestion. The patient is currently on
hemodialysis. During his hospitalization, the patient has
had significant hyperkalemia with a potassium of 7.4 and
peaked T waves on electrocardiogram. On admission, the
patient was noted to have red blood cell casts in his urine.
A glomerulonephritis workup is in progress but has been
largely negative thus far. The patient's BUN remains high
and it is unclear at this point whether uremia is
contributing to the patient's declining mental status.
4. Infectious disease/meningitis and increasing white blood
cell count: Due to the patient's poor mental status, a
lumbar puncture was done which showed 95 white blood cells, 3
red blood cells with a differential of 68% polycytes, 7%
lymphocytes and 27% monocytes. The second tube showed 49
white blood cells and [**Pager number **] red blood cells with 63% polycytes,
2% bands, 17% lymphocytes and 18% monocytes. Gram stain and
culture have been negative thus far. Protein was 428,
glucose 108.
The Infectious Disease Service has been consulted and is
following the patient closely. The patient is currently on
intravenous levofloxacin 250 mg every other day, ampicillin
and vancomycin to cover for Methicillin resistant
Staphylococcus aureus, drug resistant Streptococcus
pneumoniae, Listeria, atypical bacteria and Yersinia. There
is a question of whether the family history of
hemochromatosis may invoke Listeria, Yersinia, Vibrio and
fungal cryptococci. The suspicion of hemachromatosis in the
patient is low, with an iron of 26, low TIBC but ferritin of
greater than 1,000.
On [**2127-11-18**], a left subclavian catheter was positive
for Methicillin sensitive coagulase negative Staphylococcus.
The patient also had one peripheral blood culture with the
same sensitivities.
5. Gastrointestinal/hepatitis and pancreatitis: The
patient's hepatitis has been improving, however, his lipase
continues to rise. The patient was continued on supportive
care for pancreatitis.
6. Genitourinary: The patient has a Foley.
7. Hematology: The patient remains anemic but has no clear
source of bleeding. The patient has been transfused two
units of packed red blood cells on [**2127-11-18**].
8. Neurology/unresponsive and comatose: The patient's
mental status continues to decline. Upon presentation, he
had reflexes and was moving all extremities. Currently, the
patient does not have any spontaneous movement and pupils
remain unreactive. Neurology was consulted. The meningitis
is most likely a chemical meningitis but the patient is being
empirically treated with antibiotics.
The patient had an apnea test. Respiratory efforts were
thought to be seen but it was unclear. The patient had an
electroencephalogram and a repeat lumbar puncture planned for
the future.
9. Toxicology/presumed ethylene glycol ingestion: Dr. [**Last Name (STitle) **]
was consulted and believed that this presentation is
consistent with ethylene glycol ingestion, however, no
crystals were seen on cerebrospinal fluid or urine samples.
10. Fluids, electrolytes and nutrition: The patient is on
total parenteral nutrition.
11. Prophylaxis: The patient was on Protonix and Venodynes.
12. Code status: The patient was full code until [**2127-11-22**], when the family decided to make the patient comfort
measures only.
On [**2127-11-22**], the patient's wife, daughter and other
members of the patient's family approached the medical team,
including Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **], Dr. [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 37053**] and nurse,
[**First Name8 (NamePattern2) **] [**Doctor Last Name 37054**], and expressed their wish to withdraw ventilatory
support from Mr. [**Known lastname 37055**]. This decision was made after
considering the patient's wishes regarding a state of grave
clinical prognosis. A priest was called to administer Last
Rites. Many members of the family were present in the room.
The patient was extubated at 12:10 on [**2127-11-22**] and
the family gathered around him. The patient became asystolic
at 12:17 and was pronounced at 12:32. The patient did not
demonstrate any signs of discomfort. The medical examiner
was called because there was suspicion of acute ingestion of
a poison in this case. The medical examiner accepted the
case under her jurisdiction and stated plans to pick up the
body. [**Doctor First Name **] [**Known lastname 37055**], the patient's wife, was called
informing her of this situation.
DISCHARGE DIAGNOSIS:
Cardiopulmonary arrest secondary to possible ethylene glycol
ingestion.
DISCHARGE STATUS: Deceased.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2128-1-1**] 09:12
T: [**2128-1-3**] 18:08
JOB#: [**Job Number **]
ICD9 Codes: 2762, 5185, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 893
} | Medical Text: Admission Date: [**2169-6-22**] Discharge Date: [**2169-6-28**]
Date of Birth: [**2096-7-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
PICC line placed on [**6-22**]. S/p intubation and extubation.
History of Present Illness:
72 M with CAD s/p CABG, ESRD on HD, HTN, DM. Pt awoke on the
morning of admission with CP, SOB, called EMS who found pt to be
in VT. Pt subsequently lost pulse, was given lidocaine 100mg
bolus, and was transferred to [**Location (un) 620**] ED. There he persisted in
VT, received amiodarone 300mg bolus, was started on amio drip,
intubated for airway protection, had 2 cardioversions, had
subsequent PEA, received epi, atropine, also received CaCl,
bicarb, D50, insulin, kayexalate for empiric tx of hyperkalemia.
Started on levophed for hypotension, and was transferred to CCU
for further care.
Notably pt recently hospitalized at [**Location (un) 620**] from [**5-16**] to [**5-19**]
with CP/SOB, ruled out for MI and discharged home. Notably no
dialysis during that hospitalization, planned for outpt
dialysis.
EKG showed baseline LBBB, s/p arrest EKG showing deep ST
depressions in V2-3 post code.
.
Access: Hickman right chest. [**Location (un) 620**] ED attempted a subclavian
on left but couldn't threat wire, L femoral line placed instead
(has hx right fem-[**Doctor Last Name **] graft).
Past Medical History:
- CAD, MI [**11-28**], (S/P cath with PTCA to OM in [**4-30**], s/p CABG
[**2163-1-6**] [**Location 1268**], LIMA to LAD, SVG to PDA & OM) CATH
performed on [**2169-3-4**] : Severe native three vessel coronary
artery disease, Patent LIMA and vein grafts, widely patent OM
stent.
- CHF, EF 55%
- DM
- Hypertension
- Hyperlipidemia
- End stage renal disease, dialysis dependent, AV fistula in L
arm.
- Peripheral vascular disease s/p fem-[**Doctor Last Name **] on right
- s/p toe amputations
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension, PVD,
ESRD
.
Cardiac History: CABG LIMA-LAD, SVG-OM, SVG-PDA
Pacemaker/ICD: n/a
Old EKG from [**2169-3-29**] similar with same T wave inversions,
slightly less pronounced ST depressions V4-V5.
TELEMETRY demonstrated: VT on rhythm strips from outside
hospital, here in AFib with episodes of sinus tach.
.
2D-ECHOCARDIOGRAM [**4-30**]: EF 55%. mildly dilated LA, moderate
symmetric LVH, mod. dilated LV. mild LV systolic dysfunction
with basal infero-lateral thinning and akinesis. mildly
thickened AV. no AS. 1+AR. MV mildly thickened. 1+MR. [**First Name (Titles) **] [**Last Name (Titles) 33904**]l effusion. Compared with the prior study (images
reviewed) of [**2167-2-24**], no definite change (prior study was of
poor quality to exclude above findings).
.
CARDIAC CATH [**3-1**]:
1. patent LIMA to LAD with no significant disease distal to the
[**Female First Name (un) 899**]. The SVG to PDA and SVG to OM were also widely patent. The
stent in the OM was widely patent and the 80% lesion in the
lower pole was unchanged.
2. The native coronary arteries were not injected due to known
severe
disease.
3. Limited resting hemodynamics revealed an opening aortic
pressure of 114/61mmHg.
FINAL DIAGNOSIS:
1. Severe native three vessel coronary artery disease.
2. Patent LIMA and vein grafts, widely patent OM stent.
.
Social History:
>100 pack year smoking hx, worked as a security guard. No etoh
or drugs.
Lives at home in [**Location (un) 620**]. Daughter in law is the only family
member.
Family History:
father died of MI in 70's. Mother died in 80's of cerebral
aneurysm. Divorced & estranged from remainder of family.
Physical Exam:
VS: T 96.9 BP 97/58 HR 104 (AFib) RR 16 O2 100% on CMV
600x20/8/100%
Gen: elderly appearing male, intubated, sedated, nonresponsive.
HEENT: NCAT. Sclera anicteric. Pupils small, equal, minimally
responsive. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Neck: Supple, unable to visualize JVP.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Equal
breath sounds bilaterally with coarse crackles bilaterally.
Abd: Soft, NTND. + BS. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: L groin with triple lumen in place, R groin with old scar.
Extremities with chronic hemostatis, changes, multiple toe
amputations. Minimal pitting edema.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
LABORATORY DATA at OSH:
WBC 13.5, HCT 32.6, Plt 137
Na 142, K 5.3, Cl 104, Co2 27, Bun 44, Cr 7.0, Gluc 192
Ca 11.8, Mg 2.0, Alt 35, AST 33,
CK 98, MB 1.6, Trop T 0.240 (baseline)
LAB DATA [**Hospital1 18**]:
[**2169-6-22**] PT-14.1* PTT-53.3* INR(PT)-1.3*
[**2169-6-22**] WBC-12.3* RBC-3.63* HGB-11.7* HCT-35.7* MCV-99*
MCH-32.3* MCHC-32.8 RDW-17.8*NEUTS-88.9* LYMPHS-4.2* MONOS-6.6
EOS-0.1 BASOS-0.1
GLUCOSE-188* UREA N-49* CREAT-7.8* SODIUM-141 POTASSIUM-4.5
CHLORIDE-98 TOTAL CO2-29 ALBUMIN-3.6 CALCIUM-10.2 PHOSPHATE-6.7*
MAGNESIUM-2.2
ALT(SGPT)-105* AST(SGOT)-127* LD(LDH)-274* CK(CPK)-165 ALK
PHOS-82 AMYLASE-69 TOT BILI-0.6
[**2169-6-22**] 09:27AM CK-MB-13* MB INDX-7.9* cTropnT-0.49*
[**2169-6-22**] 06:21PM CK(CPK)-126 CK-MB-15* MB INDX-11.9*
cTropnT-0.91*
[**2169-6-22**] TYPE-ART PO2-147* PCO2-38 PH-7.49* TOTAL CO2-30 BASE
XS-6
IMAGING:
CXR [**2169-6-22**]: Increased right lower lobe opacity, probably due to
pulmonary edema or infection. (Initially read as wedge-shaped
opacity).
TTE [**6-22**]: Severe regional left ventricular systolic dysfunction
- EF = 20-25%. Mild AR. Moderate-to-severe MR. Compared with the
prior study (images reviewed) of [**2168-5-2**], LV systolic function
has markedly deteriorated and severity of MR has increased.
inferior and inferolateral hypokinesis was present on the prior
study.
CXR [**2169-6-23**]: More extensive left lower lobe opacity, probably
due to atelectasis, although pneumonia cannot be excluded.
Bilateral effusions and persistent right lower lobe process,
suggesting edema versus infection.
Brief Hospital Course:
Mr. [**Known lastname 33905**] is a 72 yo M with history of CAD s/p CABG, ESRD on
HD who presented with VT/ PEA/ cardiac arrest with prolonged
resuscitation (CPR > 45min), intubated for airway protection,
whose course was complicated by anoxic brain injury. Hospital
course by problem:
1)Arrhythmia: The original rhythm (VT/ PEA/ cardiac arrest) was
unclear as EMS found pt down and shocked him right away. The
patient was treated with cardioversion, initially started on
lidocaine, then started on amiodarone to prevent further
episodes of VT. The patient briefly went into atrial
fibrillation (although he had no documented history of this in
the past), but remained in NSR throughout the remainder of his
hospital course, with only occasional APBs and PVCs on
telemetry. The etiology of original arrhythmia was most likely
scar-induced. Electrolyte abnormality was unlikely given stable
electrolytes at OSH. Ischemic etiology was unlikely given
cardiac enzymes not commensurate with that of MI.
2)Hemodynamics: Upon admission the pt was initially hypotensive.
BP was maintained with a levophed drip, which was slowly weaned
as tolerated. Follow-up echo on [**2169-6-22**] showed EF of 20-25% with
severe regional left ventricular systolic dysfunction, which had
markedly deteriorated. Volume management was maintained via
hemodialysis.
3) CAD w/3 vessel disease:The patient was maintained on ASA and
statin given his history of CAD.
4)Poor oxygenation: CXR findings on [**6-22**] (above) were initally
read as concerning for PE. But because PE could not be ruled out
(as contrast could not be administered through the pt's IV site
and the patient??????s family did not want to place a central line
with a larger lumen for this purpose), patient was started on a
heparin drip. The patient remained intubated for airway
protection throughout his hospital stay. Ventilator settings
were weaned as tolerated to FiO2 of 50%. Subsequent CXR
findings (Above) showed evidence of a LLL infiltrate and +
sputum stain of GPC on [**6-22**], and the patient was empirically
treated for a PNA with vancomycin/levofloxacin/flagyl. On
hospital day 2 neurology recommended that levo/flagyl be
discontinued as these meds could decrease the seizure threshold
(see below), and ceftriaxone was started instead.
4) Anoxic brain injury: On hospital day 2, the patient was
observed to have twitching of his eyelids and chin. He was
placed on 24 hour EEG monitoring, and neurology determined him
to be in status epilepticus secondary to anoxic brain injury.
The patient was started on dilantin and phenobarbitol and was
placed on continuous EEG monitoring. After hospital day 3 there
were no observed recurrences of this seizure-like activity.
However, after performing serial neuro exams, the neurology team
felt that the patient??????s overall prognosis was grim for a
meaningful neurological recovery.
5) DM was controlled with an ISS.
6) FEN: On hospital day 2 tube feeds were started without
complication.
7) Prophylaxis: The patient received heparin gtt initially for
suspected PE, and was maintained on heparin drip for atrial
fibrillation. Pt also received a PPI, and bowel meds prn for
prophylaxis.
8)After much discussion with the primary team with input from
neurology, on [**2169-6-27**] the patient??????s daughter and health care
proxy decided to remove the ventilator and proceed with comfort
level of care. Patient was extubated on [**2169-6-27**]. He passed away
at 12:27 pm.
Medications on Admission:
Aspirin 81mg daily
Lipitor 40mg daily
Lisinopril 5mg daily
Toprol 50mg daily
Phoslo 1334 mg TID with meals
ISS (regular)
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Ventricular tacchycardia arrest
Atrial fibrillation
Status epilepticus
Anoxic brain injury
Pneumonia
End stage renal disease on hemodialysis
Coronary artery disease
Congestive heart failure
Diabetes
Hypertension
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2169-6-28**]
ICD9 Codes: 4271, 486, 5856, 7907, 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 894
} | Medical Text: Admission Date: [**2142-3-14**] Discharge Date: [**2142-3-20**]
Date of Birth: [**2073-6-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Vicodin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2142-3-14**] Ascending Aorta and Hemiarch Replacement with 28
millimeter Gelweave Graft
History of Present Illness:
This is a 67 year old female with a PMH significant for
hypertension. Over the several years, she has complained of
progressive dyspnea on exertion. She also admits to chest
pressure which is nonradiating. Her symptoms do not occur at
rest. A chest CT scan in [**2142-1-21**] revealed an ascending
aortic aneurysm, measuring 5.4 centimeters. Subsequent cardiac
catheterization confirmed dilated ascending aorta with normal
coronary arteries and preserved cardiac output. Based on the
above results, she was referred for cardiac surgical
intervention.
Past Medical History:
Chronic Obstructive Pulmonary Disease/Asthma
Hypertension
Osteoarthritis
Colon Polyps
Seasonal Allergies
s/p T&A
AAA
Social History:
Denies tobacco. Drinks alcohol socially. Denies recreational
drugs. Patient is single and lives alone on [**Location (un) **].
Family History:
Non-contributory. No family history of premature CAD.
Physical Exam:
Vitals: BP 157/75, HR 65, RR 20, SAT 100% on room air
General: well developed female in no acute distress
HEENT: oropharynx benign, EOMI
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
Echo [**3-14**]: Pre bypass: Left ventricular wall thickness, cavity
size, and systolic function are normal(LVEF>55%). The ascending
aorta is markedly dilated. The descending thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3)appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. Moderate
[2+]tricuspid regurgitation is seen. Post bypass: Perserved
biventricular function lvef >55% no wall motion abnormalities.
Trace AI. Proximal portion of ascending aortic graft visualized
in good position. Remaining exam unchanged from baseline.
CXR [**3-20**]: 1. Cardiomegaly, which is new in the interval. Upper
zone vascular redistribution without evidence of frank pulmonary
edema. These findings may be secondary to early congestive heart
failure and volume overload, however, a pericardial effusion is
also a possibility. 2. Interval worsening of bibasilar
atelectasis. Stable small bilateral pleural effusions.
[**2142-3-14**] 01:25PM BLOOD WBC-8.2 RBC-3.10*# Hgb-9.5*# Hct-26.5*#
MCV-85 MCH-30.7 MCHC-36.0* RDW-14.3 Plt Ct-125*#
[**2142-3-19**] 06:05AM BLOOD WBC-7.1 RBC-2.99* Hgb-8.9* Hct-25.9*
MCV-87 MCH-29.9 MCHC-34.4 RDW-15.1 Plt Ct-213
[**2142-3-14**] 01:25PM BLOOD PT-14.2* PTT-41.3* INR(PT)-1.3*
[**2142-3-20**] 06:50AM BLOOD PT-11.7 INR(PT)-1.0
[**2142-3-14**] 01:25PM BLOOD UreaN-21* Creat-0.8 Cl-112* HCO3-22
[**2142-3-19**] 06:05AM BLOOD Glucose-119* UreaN-16 Creat-1.0 Na-137
K-3.9 Cl-98 HCO3-29 AnGap-14
Brief Hospital Course:
On the day of admission, Ms. [**Known lastname 27853**] [**Last Name (Titles) 1834**] surgical
replacement of her ascending aorta and hemi-arch by Dr. [**Last Name (Prefixes) **]. The operation was uneventful and there were no
complications. For further details, please see separate dictated
operative note. Following the procedure, she was brought to the
CSRU for invasive monitoring. Within 24 hours, she awoke
neurologically intact and was extubated. She was weaned from
inotropic support without difficulty. She maintained stable
hemodynamics and was then transferred to the SDU on
postoperative day one. Low dose beta blockade was resumed and
advanced as tolerated. Diuretics were also started and she was
gently diuresed towards her pre-operative weight. She was
transfused with packed red blood cells for a postoperative
anemia. Her lowest hematocrit was around 23%. Her chest tubes
and epicardial pacing wires were removed on post-op day two.
Over several days, she continued to make clinical improvements
with diuresis and increased ambulation. Physical therapy
followed patient during post-op course for strength and
mobility. Intermittent episodes of paroxysmal atrial
fibrillation were noted on telemetry on post-op day five. Beta
blockade was further advanced while K and Mg levels were
optimized. She was eventually started on Amiodarone and
maintained sinus rhythm for >24 hrs prior to being discharge. On
post-op day six she was discharged home with VNA services and
the appropriate follow-up appointments.
Medications on Admission:
Lopressor 75mg twice a day, Advair 50-250 two puffs twice a day
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO twice
a day: 20mg [**Hospital1 **] x 7 days then 20mg QD x 10 days.
Disp:*25 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 * Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): 20mg [**Hospital1 **] x 7 days then 20mg QD x 10 days.
Disp:*25 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x1 wk then 400mg QD x1 wk then 200mg QD.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Ascending Aortic Aneurysm - s/p Ascending Aorta and Hemiarch
Replacement, Hypertension
Osteoarthritis
Asthma
Colon Polyps
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-25**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-23**] weeks - call for appt.
Local cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-23**] weeks - call for appt.
Completed by:[**2142-5-29**]
ICD9 Codes: 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 895
} | Medical Text: Admission Date: [**2177-3-18**] Discharge Date: [**2177-3-26**]
Date of Birth: [**2116-5-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zocor / Lipitor / Crestor / Pravachol / Rhubarb
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE/fatigue
Major Surgical or Invasive Procedure:
CABGx4(LIMA->LAD,SVG->[**Last Name (LF) **], [**First Name3 (LF) **], PDA)/MV repair (30mm band) [**3-18**]
History of Present Illness:
60 yo M with h/o CAD s/p MI and PCI in [**2169**], and ischemic
cardiomyopathy with EF 35%. In [**2176-7-28**] hospitalized with chest
pain, r/o for MI, but echo showed EF of 10%. Cath in [**10/2176**]
showed 3VD.
Past Medical History:
^chol., NSTEMI x 2, ischemic cardiomyopathy, CHF, HTN, s/p PTCA
and stenting x 2, s/p T+A
Social History:
works as computer programmer
no tobacco
3-4 beers 1-2 times per week
Physical Exam:
HR 84 RR 20 BP 124/80
WDWN M in NAD
Lungs CTAB
Heart RRR, no M/R/G apprec.
Abdomen benign
Extrem warm, no edema
No varicosities
Pertinent Results:
[**2177-3-26**] 09:00AM BLOOD WBC-9.1 RBC-3.35* Hgb-10.4* Hct-30.4*
MCV-91 MCH-31.1 MCHC-34.2 RDW-13.4 Plt Ct-381
[**2177-3-25**] 04:49PM BLOOD WBC-8.6 RBC-3.42* Hgb-10.8* Hct-30.1*
MCV-88 MCH-31.7 MCHC-35.9* RDW-13.7 Plt Ct-360#
[**2177-3-26**] 09:00AM BLOOD PT-24.9* PTT-31.4 INR(PT)-2.4*
[**2177-3-25**] 03:49PM BLOOD PT-29.1* PTT-37.9* INR(PT)-3.0*
[**2177-3-25**] 11:00AM BLOOD INR(PT)-3.6*
[**2177-3-24**] 07:10AM BLOOD PT-15.6* PTT-26.0 INR(PT)-1.4*
[**2177-3-23**] 08:00AM BLOOD PT-13.5* PTT-25.9 INR(PT)-1.2*
[**2177-3-26**] 09:00AM BLOOD Glucose-165* UreaN-15 Creat-0.8 Na-137
K-4.4 Cl-104 HCO3-25 AnGap-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 102304**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 102305**]Portable TEE
(Complete) Done [**2177-3-25**] at 2:50:26 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
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: [**2116-5-16**]
Age (years): 60 M Hgt (in): 72
BP (mm Hg): 114/75 Wgt (lb): 210
HR (bpm): 70 BSA (m2): 2.18 m2
Indication: Atrial flutter. Coronary artery disease. Left
ventricular function. Mitral valve disease.
ICD-9 Codes: 427.32
Test Information
Date/Time: [**2177-3-25**] at 14:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: Cardiology
Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W999-9:9 Machine: Other
Sedation: Versed: 0.5 mg
Fentanyl: 25 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Mitral Valve - Peak Velocity: 1.3 m/sec
Mitral Valve - Mean Gradient: 4 mm Hg
Findings
LEFT ATRIUM: Mild spontaneous echo contrast in the body of the
LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA
ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA
or RAA. Mild spontaneous echo contrast in the RAA. No ASD by 2D
or color Doppler.
LEFT VENTRICLE: Depressed LVEF.
RIGHT VENTRICLE: RV function depressed.
AORTA: No atheroma in ascending aorta. No atheroma in aortic
arch. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+)
AR.
MITRAL VALVE: Mitral valve annuloplasty ring. Well-seated mitral
annular ring with normal gradient. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. Local anesthesia was provided by
benzocaine topical spray. The posterior pharynx was anesthetized
with 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given
as an antisialogogue prior to TEE probe insertion. No TEE
related complications. The rhythm appears to be atrial flutter.
Cardiology fellow involved with the patient's care was notified
by telephone.
Conclusions
Mild spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. No mass or thrombus is seen in the right
atrium or right atrial appendage. Mild spontaneous echo contrast
is seen in the right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. LV systolic function appears
depressed. There is depressed right ventricular free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are mildly thickened.
Mild (1+) aortic regurgitation is seen. A mitral valve
annuloplasty ring is present. The mitral annular ring appears
well seated and is not obstructing flow. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: No intracardiac thrombus. Depressed biventricular
systolic function. Mild aortic regurgitation.
Normally-functioning mitral annuloplasty ring.
CHEST (PA & LAT) [**2177-3-25**] 5:18 PM
CHEST (PA & LAT)
Reason: evaluate for ? effusion
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate for ? effusion
HISTORY: Status post CABG.
FINDINGS: In comparison with study of [**3-21**], the right IJ central
venous catheter has been removed. Some residual enlargement of
the cardiac silhouette with some atelectatic streaks at the left
base. No evidence of pleural effusion.
Brief Hospital Course:
He was taken to the operating room on [**3-18**] where he underwent a
CABG x 4 and MV Repair. He was transferred to the ICU in
critical but stable condition on milrinone, levophed,
vasopressin and epinephrine. He was extubated on POD #1. He was
transfused. His vasoactive drips were weaned to off by POD #3.
He developed atrial flutter. He was pancultured for a fever. He
was transferred to the floor on POD #3. He was seen by
electrophysiology, and started on heparin and coumadin. He
underwent TEE and cardioversion on [**3-25**] with return to NSR. He
was ready for discharge home on POD #8.
Medications on Admission:
Dig 0.125', Coreg 6.25", ASA 325', Lisinopril 5', Lasix 20',
MVI'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 10
days: Sig: 40 mg (2 tabs) daily x 10 days then 20 mg (1 tab)
daily ongoing as prior to surgery.
Disp:*40 Tablet(s)* Refills:*0*
8. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime for
1 days: check INR [**3-27**].
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
CAD/MR now s/p CABG/MVR
Acute on Chronic systolic heart failure
^chol., NSTEMI x 2, ischemic cardiomyopathy, CHF, HTN, s/p PTCA
and stenting x 2, s/p T+A
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) 10740**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2177-3-26**]
ICD9 Codes: 4240, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 896
} | Medical Text: Admission Date: [**2112-3-30**] Discharge Date: [**2112-5-10**]
Date of Birth: [**2030-4-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
trach
fluid collection aspiration
fistula intubation
multiple wound debridements
History of Present Illness:
This is an 81 year old male who was transferred from an OSH on
[**2112-3-30**], POD 15 from a left colectomy for a lower GI bleed. (8
units of RBC transfused). On POD 8, the patient had an
anastamotic leak and underwent a Hartmann's procedure with
creation of an ascending colostomy. His post operative course
was subsequently complicated by acute renal failure, small
peripheral pulmonary emboli, HIT positivity on argatroban, and
atrial fibrillation a\on an amiodarone drip.
Past Medical History:
HTN, hyperlipidemia, EF 60%, DM2 diet controlled, history of
throat cancer s/p resection + xrt '[**89**], s/p empyema w/ CT
drainage, legally blind right eye secondary to injury
Social History:
widowed, lives alone independently
Family History:
noncontributory
Physical Exam:
ON ADMISSION
VS- T 98.6, P 61, BP 120/40, RR 18, O2 97% on ventillator
Gen- NAD, intubated, sedated
Heart- irregularly irregular
Lungs- coarse rhonchi throughout
Abdomen- soft, diffusley tender to palpationmidline incision
with necrotic edges, ostomy pink with green stool
Extremities- 2+ edema b/l
Pertinent Results:
[**2112-3-30**] 11:55PM TYPE-ART PO2-95 PCO2-50* PH-7.30* TOTAL
CO2-26 BASE XS--1
[**2112-3-30**] 11:17PM URINE HOURS-RANDOM CREAT-97 SODIUM-39
[**2112-3-30**] 11:17PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2112-3-30**] 11:17PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM
[**2112-3-30**] 11:17PM URINE RBC-[**6-7**]* WBC-[**3-2**] BACTERIA-MOD
YEAST-NONE EPI-0
[**2112-3-30**] 11:17PM URINE GRANULAR-<1 HYALINE-0-2
[**2112-3-30**] 11:12PM TYPE-ART PO2-86 PCO2-54* PH-7.26* TOTAL
CO2-25 BASE XS--3
[**2112-3-30**] 10:04PM TYPE-ART PO2-105 PCO2-56* PH-7.25* TOTAL
CO2-26 BASE XS--3
[**2112-3-30**] 10:04PM LACTATE-2.0
[**2112-3-30**] 10:04PM freeCa-1.05*
[**2112-3-30**] 09:54PM GLUCOSE-135* UREA N-63* CREAT-2.6* SODIUM-139
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18
[**2112-3-30**] 09:54PM CALCIUM-7.5* PHOSPHATE-2.8 MAGNESIUM-2.1
[**2112-3-30**] 09:54PM WBC-22.1* RBC-3.15* HGB-9.4* HCT-28.9* MCV-92
MCH-29.7 MCHC-32.4 RDW-16.0*
[**2112-3-30**] 09:54PM NEUTS-83* BANDS-3 LYMPHS-5* MONOS-2 EOS-3
BASOS-1 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-1*
[**2112-3-30**] 09:54PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2112-3-30**] 09:54PM PLT SMR-LOW PLT COUNT-104*
[**2112-3-30**] 09:54PM PT-38.5* PTT-100.0* INR(PT)-4.2*
Brief Hospital Course:
Briefly, Mr. [**Known lastname 77982**] was transferred to [**Hospital1 18**] from [**Hospital1 **] on [**2112-3-30**] after subtotal colectomy for LGIB requiring a
massive transfusion of 8u pRBC.
His [**Hospital 18**] hospital course is broken down by systems:
Neuro
He was intermittently sedated with fentanyl and propofol. His
sedation was weaned to prn dilaudid and oxycodone liquid. Pain
gradually became a nonissue. He should not require pain
medication even for VAC changes. He was seen by neurology for
dystonia, who recommended an MRI of the brain whcih showed an
acute left parietal subcortical infarct. The neurologist felt
that coumadinizing him with a goal INR 2.5- 3.5 would be best to
prevent another stroke. The etiology of his stoke is presumed
cardiac given his atrial fibrillation. His cognition gradually
improved throughout his hospital course, as did his dystonia,
for which he is on cogentin per neurology. At present, he is
alert and can communicate effectovely.
Cards
On admission, Mr. [**Known lastname 77982**] had afib with RVR for which he was on
an amiodarone gtt. He was evaluated by cardiology and weaned
off amiodarone. After amiodarone was weaned, his rhythm was
intermittently in and out of afib. He eventually stabilized on
PO lopressor and PO amiodarone. In addition, he was
intermittently on and off pressors, including levophed and
pitressin. Eventually he stabilized and has been off of all
pressors for over 2 weeks prior to discharge.
Pulm
The patient had a tracheostomy. He was gradually weaned on the
ventillator. Eventually he was weaned to trach collar, which he
has been tolerating for over 2 weeks. On [**5-4**], he did tolerate a
Passy-muir valve trial. He requires supervision with the PM
valve, because he desaturates. He does require suctioning
intermittently.
FEN/GI
Tube feeds via Dobhoff, TPN, ostomy, serial abdominal
debridements [**4-4**], [**4-8**], and abdominal VAC [**4-12**], 16, 17, 20, 24,
26 and Q 3 days thereafter. Last VAC change was [**2112-5-8**]. His
abdominal wound has been healing very well with a VAC dressing.
It is granulating nicely. There had been a fistulous connection
between the ostomy and the wound. This has since closed off
after a few vicryl sutures were placed at the bedside. He was
seen and evaluated by plastic surgery who recommended outpatient
skin grafting. He has been tolerating tube feeds at goal for
over 2 weeks prior to discharge and his ostomy is productive.
He gets his tube feeds via a Dobhoff. We did not feel that a
PEG was a good idea in him beacause of his anatomy. He was
hypernatremic to 153 at a maximum, but he did respond to free
water boluses and his sodium has since stabilized. We have
since decreased his free water boluses.
GU
He developed ARF and started hemodialysis at the referring
institution x3 days. Daily CVVH was started at [**Hospital1 18**] via R fem
HD catheter, and he was weaned off CVVH, intermittently on
lasix, and he now makes appropriate urine output without any
assistance. His azotemia gradually cleared. Withing the past
week, we have started gradual diuresis to make him about a liter
negative daily. His weights have been retruning to baseline of
98 kg.
H
Mr. [**Known lastname 77982**] was found to have small peripheral PEs and HIT at
the referring institution, and was continued on an argatroban
gtt. Eventually he was transitioned off the argatroban to
coumadin. He was found to be HIT negative by seratonin release
assay. He is currently on coumadin, goal INR 2.5- 3.5.
ID
The patient had a long and complicated infectious disease
course.
Meropenem ([**4-16**]) and vancomycin ([**4-17**]) for MRSA PNA, fluconazole
for [**Female First Name (un) **] torulopsis in the urine and sputum [**4-19**], flagyl
empircally for C. diff (although he never tested positive) [**4-20**]
Cultures include
Klebsiella in blood at OSH
[**3-31**] Wound cx: [**Female First Name (un) **], klebs
[**4-3**] Sputum: budding yeast, GNR, MRSA
[**4-10**] Sputum: sparse klebs [**Last Name (un) 36**] to cipro/bactrim
[**4-14**] Sputum: MRSA, Klebs
[**4-17**] sputum: MRSA, 2+budding yeast, sparse GNR
[**4-20**] sputum: MRSA and 1+budding yeast
Eventually, all antiobiotics were stopped on [**2112-5-4**].
Endo
Mr. [**Known lastname 77982**] was kept on a strict insulin sliding scale to keep
his sugars within a tight range.
Medications on Admission:
lisinipril 20', acebutolol 400', allopurinol 300', lipitor 10',
ASA 325', MVI
Discharge Medications:
1. Maalox 200-200-20 mg/5 mL Suspension [**Known lastname **]: One (1) ML PO TID
(3 times a day) as needed for constipation.
2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Known lastname **]: One (1)
Appl Ophthalmic PRN (as needed).
3. Polyvinyl Alcohol 1.4 % Drops [**Known lastname **]: One (1) Drop Ophthalmic
PRN (as needed).
4. Docusate Sodium 50 mg/5 mL Liquid [**Known lastname **]: One (1) PO BID (2
times a day).
5. Oxycodone 5 mg/5 mL Solution [**Known lastname **]: One (1) PO every eight (8)
hours as needed for pain.
6. Acetaminophen 325 mg Tablet [**Known lastname **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
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 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
9. Allopurinol 100 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY (Daily).
10. Benztropine 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
13. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once) for
1 doses: check daily INR.
14. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: One (1) Injection [**Hospital1 **] (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**]- [**Location (un) **]
Discharge Diagnosis:
LGIB s/p colectomy
anastomotic leak s/p exlap, Hartmann's
renal failure
pulmonary emboli
sepsis
rapid atrial fibrillation
large abdominal wound
dystonia
CVA
Discharge Condition:
good
Discharge Instructions:
Please call or come to the ED with any fevers > 101, nausea,
vomiting, abdominal pain, purulence from wounds, oliguria,
hypotension, rapid atrail fibrillation, or any other worrisome
issues. Please continue all medications as directed. Activity
as tolerated.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up
appointment ([**Telephone/Fax (1) 1483**]
Completed by:[**2112-5-9**]
ICD9 Codes: 5845, 2760, 2767, 4019, 2724, 2859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 897
} | Medical Text: Admission Date: [**2199-5-7**] Discharge Date: [**2199-5-10**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 yo female s/p unwitnessd fall down stairs; ? LOC, GCS 15 at
scene. She was taken to an area hospital and later transferred
to [**Hospital1 18**] for further care.
Past Medical History:
HTN
Osteoporosis
h/o Falls
Rib fractures
Pneumothorax
Family History:
Noncontributory
Pertinent Results:
[**2199-5-7**] 07:13PM GLUCOSE-186* LACTATE-3.3* NA+-138 K+-3.5
CL--96* TCO2-28
[**2199-5-7**] 07:10PM UREA N-8 CREAT-0.5
[**2199-5-7**] 07:10PM AMYLASE-51
[**2199-5-7**] 07:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2199-5-7**] 07:10PM WBC-23.2* RBC-4.77 HGB-17.3* HCT-49.8*
MCV-104* MCH-36.2* MCHC-34.7 RDW-15.2
[**2199-5-7**] 07:10PM PLT COUNT-304
[**2199-5-7**] 07:10PM PT-12.5 PTT-23.2 INR(PT)-1.1
[**2199-5-7**] 07:10PM FIBRINOGE-224
CHEST (PORTABLE AP)
Reason: ? shoulder fx
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall from bed, unwitnessed, hit head,
c/o neck pain but unreliable PE
REASON FOR THIS EXAMINATION:
? shoulder fx
REASON FOR EXAMINATION: Trauma.
Portable AP chest radiograph compared to [**2199-5-7**].
The heart size is normal. The mediastinal contours are
unremarkable. The aorta is calcified. The hila are slightly
enlarged bilaterally, most likely due to dilatation of the
pulmonary veins, which may be related to pulmonary hypertension.
The lungs are essentially clear but over inflated, which may
represent emphysema. There is no sizeable pleural effusion or
pneumothorax.
CT HEAD W/O CONTRAST
Reason: S/P FALL UNWITNESSED EVAL FOR BLEED
[**Hospital 93**] MEDICAL CONDITION:
83 yF s/p fall from bed, unwitnessed, hit head, forehead lac,
unreliable physical exam
REASON FOR THIS EXAMINATION:
? bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post fall from bed.
COMPARISON: Non-contrast head CT from yesterday.
FINDINGS: Again seen is stable focal hemorrhage in the splenium
of the corpus collosum. There is no mass effect or shift of
normally midline structures, or acute major vascular territorial
infarction. The density values of the brain parenchyma again
show periventricular white matter hypodensity consistent with
chronic microvascular infarction. Again seen is enlargement of
the lateral and third ventricles which may be related to
communicating hydrocephalus or age-related involutional change.
The surrounding soft tissue structures again show a large left
parietal scalp hematoma and new soft tissue swelling overlying
the left frontal bone. There is no skull fracture.
IMPRESSION:
1. Stable hemorrhage in the splenium of the corpus callosum
without evidence for new hemorrhage.
2. New soft tissue swelling overlying the left frontal bone.
Stable left parietal scalp hematoma.
3. Again seen is enlargement of the lateral and third ventricles
which may be related to communicating hydrocephalus or
age-related involutional change. Clinical correlation is
recommended.
CT C-SPINE W/O CONTRAST
Reason: S/P FALL EVAL FOR FX
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall from bed, unwitnessed, hit head,
c/o neck pain but unreliable PE
REASON FOR THIS EXAMINATION:
?fx
CONTRAINDICATIONS for IV CONTRAST: None.
C-SPINE
TECHNIQUE: Multidetector axial CT images were obtained through
the cervical spine. Coronal and sagittal reformatted images were
obtained.
COMPARISON: CT C-spine from [**2199-5-7**].
CT C-SPINE: There is no evidence of fracture, malalignment, or
prevertebral soft tissue swelling. The vertebral bodies and disc
space heights are normal. There are extensive degenerative
changes in the cervical spine which are stable. Again seen are
calcifications within the bilateral carotid arteries and within
the posterior longitudinal ligament. Again seen is scarring in
the bilateral lung apices. The visualized outline of the thecal
sac is unremarkable; however, CT is not able to provide any
intrathecal detail.
IMPRESSION: No evidence for cervical spine fracture or
malalignment.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: ? injury
Field of view: 32 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall down flight of stairs
REASON FOR THIS EXAMINATION:
? injury
CONTRAINDICATIONS for IV CONTRAST: None.
CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: 86-year-old woman with status post fall down flight
of stairs. Rule out injury.
COMPARISON: Not available.
TECHNIQUE: MDCT axial images of abdomen and pelvis were obtained
following the administration of 130 cc of Optiray intravenously.
Coronal and sagittal reformatted images were obtained.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, spleen, adrenal
glands, stomach, abdominal loops of large and small bowel are
unremarkable. Kidneys enhance equally and excrete contrast
normally. There is no free fluid in the abdomen, and no
pathologically enlarged mesenteric or retroperitoneal lymphatic
nodes.
CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, urinary bladder
are unremarkable. There is a high density material in the
iliacus muscle, adjacent to the left ilium, likely representing
hematoma.
There is no free pelvic fluid.
BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic
lesions. There are extensive degenerative changes, as well as
rotatory scoliosis. There is a compression deformity of
vertebral body of L1 of uncertain chronicity, but most likely
chronic, with extensive vertebral body sclerosis.
There is a lucent line, in the left ilium, extending from the
mid-aspect of the ilium, reaching the acetabular roof. There is
no significant displacement. There is another lucent line
extending to the superior-posterior aspect of the ilium, with
minimal displacement of the fracture fragments. No other
fractures are noted on this study.
IMPRESSION:
1. No evidence of traumatic injury of solid abdominal organs.
2. Two separate, and apparently discrete, essentially
non-displaced fractures of the left ilium, one of which involves
the left acetabular roof, with associated iliacus muscle
hematoma.
3. Chronic-appearing L1 compression fracture.
COMMENT: Findings were discussed with the Trauma Surgery team at
the time of the completion of the scan, at 20:15h, [**2199-5-7**].
Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery and
Orthopedic Surgery were consulted because of her injuries.
Repeat head CT imaging was performed which revealed a stable
intracranial hemorrhage; the injury was non operative. It was
recommended that she follow up in 4 weeks with Dr.[**Last Name (STitle) **],
Neurosurgery, at which time she will have an MRI of her brain.
She will also be evaluated for normal pressure hydrocephalus
based on a finding on head CT.
Orthopedic Surgery was consulted for her left ilium fracture;
this injury was deemed nonoperative; she is to remain touchdown
weight bearing and will require follow up with Dr. [**Last Name (STitle) 1005**] in
2 weeks. She was also started on bone prophylaxis with Calcium
and Vitamin D.
Physical and Occupational therapy were consulted and have
recommended rehab stay after discharge from the hospital.
Medications on Admission:
Dilt 60
Celexa 10
Aricept 10
Lisinopril 10
Protonix 40
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): hold fro SBP <110 & HR <60.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
9. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
s/p Fall
Large left parietal sub-galeal hematoma
Small intracranial hemorrhage left splenium/corpus collosum
Nondisplaced left ilium fracture involving the acetabular roof
Discharge Condition:
Stable
Discharge Instructions:
You may ONLY touchdown weight bear on your left lower extremity.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Neurosurgey in 4 weeks. Inform the
office that you will need an MRI of the brain w/ and w/out
contrast and that also you will need evaluation for possible
normal pressure hydrocephalus. Call [**Telephone/Fax (1) 1669**] for an
appointment.
Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedic Surgery, in 2 weeks.
Call [**Telephone/Fax (1) 1228**] for an appointment.
ICD9 Codes: 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 898
} | Medical Text: Admission Date: [**2157-12-26**] Discharge Date: [**2158-1-4**]
Date of Birth: [**2094-10-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / aspirin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mitral regurgitation
Major Surgical or Invasive Procedure:
Mitral valve repair(28-mm Physio II annuloplasty ring) [**2157-12-28**]
History of Present Illness:
This 63 year old hHispanic female has a history of asthma has
had shortness of breath which has increased recently. She had
new chest pain which radiated down the left arm and was admitted
to [**Hospital3 **] for further work up.
She underwent cardaic catheterization. She was found to have
mitral regurgitation with elevated pulmonary pressures and an
ejection fraction of 80%. Her coronaries without stenosis.
Past Medical History:
hypertension
insulin dependent diabetes mellitus
complete heart block
s/p c-section
s/p L cataract surgery with lens implant
s/[**Initials (NamePattern4) **] [**Last Name (un) 8509**] surgery
s/p R hand surgery
s/p dual chamber pacemaker implant(St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 10550**] 5820)
Social History:
Lives with: alone
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: none
Illicit drug use: denies
Race: Hispanic
Family History:
unremarkable
Physical Exam:
Pulse: 85 v paced Resp: 18 O2 sat: 100% RA
B/P Right: 127/74 Left:
Height: 67" Weight: 232 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] Dental: multiple bridges
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] well-healed pacer site
Heart: RRR [x] Irregular [] Murmur [x] grade __2/6 pan
systolic____
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [] Edema [x] __2+ bilat___
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
TEE [**2157-12-28**]:
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with hypokinetic apical
segments.
The aortic arch is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are moderately thickened. The mitral
valve leaflets do not fully coapt and bileaflet restriction is
appreciated. There is a central MR jet with Moderate to severe
(3+) mitral regurgitation.
There is no pericardial effusion.
POSTBYPASS:
The patient is AV paced on epinephrine & phenylephrine
infusions. There is a well seated annuloplasty ring in the
mitral position. The Mitral regurgitation is now trace to mild.
The RV function is maintained. The LV function is mildly
improved on inotropy, with EF 50%. The remaining valves are
unchanged. The aorta remains intact.
[**2158-1-1**] 06:10AM BLOOD WBC-8.6 RBC-3.30* Hgb-8.5* Hct-26.9*
MCV-82 MCH-25.9* MCHC-31.7 RDW-13.7 Plt Ct-165#
[**2157-12-30**] 02:14AM BLOOD PT-14.4* PTT-29.3 INR(PT)-1.3*
[**2158-1-1**] 06:10AM BLOOD UreaN-15 Creat-0.6 Na-135 K-4.8 Cl-100
[**2157-12-26**] 07:38PM BLOOD ALT-50* AST-32 LD(LDH)-239 AlkPhos-47
TotBili-0.2
[**2158-1-1**] 06:10AM BLOOD Mg-2.2
[**2157-12-26**] 07:38PM BLOOD %HbA1c-7.4* eAG-166*
Brief Hospital Course:
The patient was transferred from [**Hospital6 3105**] on
[**2156-12-26**]. She underwent preop testing including PFTs, Echo, and
dental consult. On [**2157-12-28**] she had a mitral valve repair with a
28mm annuloplasty ring. The cross clamp time was 38 minutes
and the total bypass time was 51 minutes. She tolerated the
procedure well and was transferred to the CVICU in stable
condition on Propofol. She was extubated on the post op night
and had her chest tubes discontinued on POD#1.
She was transferred to the floor but had to return to the CVICU
that night for hyperglycemia requiring an insulin drip. She was
restarted on her preop NPH and was stable by the morning of
POD#2. She was transferred back to the floor in stable
condition. Pacing wires and chest tubes wer removed per protocol
and sh3e was gently diuresed toward her preop weight.
Her glucoses remained somewhat problem[**Name (NI) 115**] and the 70/30 insulin
was downwardly adjusted to compensate. The evening dose was
discontinued. In conversation she says at home she snacks at
night and that is perhaps why her Morning glucoses in house have
been low. the glucoses the morning after stopping evening NPH
dosing her glucoses were in the mid 100s- the insulin can be
adjusted at rehab as her intake changes.
She continued to make good progress and was cleared for
discharge to [**Location (un) 16493**]rehab in N. [**Location (un) 7658**] on POD 8. All
follow up appointments were arranged.
Medications on Admission:
Xopenex 1.25 mg q 6 hours PRN
Lisinopril 20 mg PO daily
KCl QID
Loratadine 10 mg PO daily
Flonase 1 NU daily
Duonebs
Levoxyl 0.25 PO daily
FESO4 325 mg PO daily
Advair
Novolin 60 U SC BID
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units SC Injection TID (3 times a day): until ambulating
frequently.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily).
11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: Fifty (50) units Subcutaneous Q AM.
14. Humalog 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous ac & HS: 120-160:2unitsac/0units HS;161-200:4units
ac/2units HS;201-240:6units ac/4units HS,241-280:8units
ac/6units HS.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
hypertension
mitral regurgitation
s/p mitral valve repair [**2157-12-28**]
insulin dependent diabetes nellitus
complete heart block
s/p permanent dual chamber pacemaker
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on 2/1512 1PM
Cardiologist: Dr. [**Last Name (STitle) 66588**] on [**2158-1-26**] at 12:30
Please call to schedule appointments with your
Primary Care Dr. [**First Name11 (Name Pattern1) 1399**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**0-0-**]) in [**3-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2158-1-4**]
ICD9 Codes: 2449, 4240, 4280, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 899
} | Medical Text: Admission Date: [**2172-3-2**] Discharge Date: [**2172-4-3**]
Date of Birth: [**2118-6-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
S/p Fall
Major Surgical or Invasive Procedure:
Bronchoscopy
Transesophageal Echo
Thoracentesis
History of Present Illness:
53 yoM fell from standing and hit his head on a table. The
patient does not remember the event very clearly but he states
he remembers falling. When asked the symptoms that preceeded
his fall he states that he may have had lightheadedness prior to
the fall. In addition he is unable to answer what other
symptoms he may have had prior to the fall but answers "yes" to
all ROS questions. He has no other specific complaints,
although he is hungry.
At this current time he has no CP, SOB, HA, fever, chills,
urinary symptoms, diarrhea, constipation, abdominal pain or any
other symptoms.
The patient presented after his fall to [**Hospital6 302**]
where he was noted to be in atrial flutter with RVR, rate of
150. He rec'd ativan (no h/o recent ETOH use per patient,
however, per home health nurses patient does still drink), dilt
10mg IV x 2, lopressor 50mg po x 1 and he was started on a
diltiazem drip. He then underwent a CT of his head which was
concerning for a subarachnoid hemorrhage. He underwent an MRI
without contrast at [**Hospital 15405**] and was then transferred to the
[**Hospital1 18**] ER.
In the [**Hospital1 **] ER he underwent repeat CT and this read as negative,
his MRI was read as possible gyrohyperdensities in the L
parietal lobe which could be infectious versus malignant.
Repeat MRI with contrast was recommended. The patient was also
given 60mg PO dilt and continued on a dilt drip at 5mg / hr. He
was also given 2g calcium gluconate. He had a CXR with a L
pleural effusion and was given vanc/zosyn/azithro.
In the ED, initial VS: T 96.8 HR 80-110 BP 92/47 RR 16 O2 sat:
98%. VS prior to transfer to the floor: T 96.7 GBP 97/59 HR
103 96% on 4L. The patient has 2 PIV. Rec'd 3L of IVF and had
400cc UOP.
Past Medical History:
Seizure d/o (on valproic acid)
Hyperlipidemia
Schizoaffective disorder
Asthma / COPD
HTN
ETOH abuse (per pt sober x 1 year)
Social History:
Patient lives alone. Has visting nursing aid 5 days/wk and
visiting nurse 3 days/wk. He chain smokes. He has history of
alcohol abuse but has not drank in over a year. He is largely
independent of ADLs and can run simple errands by himself.
Family History:
Mother died almost 30 years ago. Patient has not had contact
with his father. [**Name (NI) **] has a single living sister [**Name (NI) 2048**] [**Name (NI) **].
He has one sister who is deceased.
Physical Exam:
Vitals - T: 97.1 BP: 92/57 HR: 89 RR: 22 02 sat: 100% on 2L
pulsus 8
GENERAL: NAD, Aox2, somewhat somnolent
HEENT: MM slightly dry, JVP 8cm, no lymphadenopathy or
thyromegaly, neck supple, no meningismus
CARDIAC: RRR, soft heart sounds, no m/r/g
LUNG: dullness at L base, diffuse transmitted upper airway
sounds
ABDOMEN: soft, NT, ND, no masses or organomegaly
EXT: WWP, no c/c/e
NEURO: AOx2 (place [**Hospital 86**] Hospital, unaware of date),
appropriate, EOMI no nystagmus, no asterixis, mild resting
tremor. normal sensation throughout, [**4-8**] stregnth in the upper
and lower extremities
Pertinent Results:
ADMISSION LABS:
[**2172-3-2**] 04:43PM LACTATE-1.3
[**2172-3-2**] 04:35PM GLUCOSE-99 UREA N-20 CREAT-0.6 SODIUM-140
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
[**2172-3-2**] 04:35PM CK(CPK)-26*
[**2172-3-2**] 04:35PM cTropnT-<0.01
[**2172-3-2**] 04:35PM TSH-2.8
[**2172-3-2**] 04:35PM VALPROATE-65
[**2172-3-2**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2172-3-2**] 04:35PM WBC-9.9 RBC-5.67 HGB-16.0 HCT-48.3 MCV-85
MCH-28.1 MCHC-33.0 RDW-16.8*
[**2172-3-2**] 04:35PM NEUTS-75.4* LYMPHS-15.7* MONOS-7.0 EOS-1.2
BASOS-0.7
[**2172-3-2**] 04:35PM PLT COUNT-144*
[**2172-3-2**] 04:35PM PT-13.3 PTT-25.9 INR(PT)-1.1
Path:
[**3-5**] FNA from bronch of mediastinal mass: Fine needle aspiration
of mainstem: Single fragment of atypical squamous cells,
insufficient for diagnosis; please see cytology report
(C10-[**Numeric Identifier 63202**]) for diagnosis
[**3-5**]: Bronch cytology consistent with squamous cell carcinoma.
[**3-4**] Bronch: Suspicious for malignant cells. Rare clusters of
highly atypical epithelioid cells with high N:C ratios and
prominent nucleoli.
[**3-4**] Pleural fluid: Rare cluster of atypical epithelioid cells
in a background of lymphocytes, neutrophils, macrophages and
mesothelial cells.
IMAGING:
[**2172-3-2**] EKG: Atrial flutter with rapid ventricular response.
Axis appears to be right axis deviation although is difficult to
assess. Borderline low limb lead QRS voltage. Right
bundle-branch block. Delayed R wave progression. Modest ST-T
wave changes. Findings raise the consideration of possible
chronic pulmonary disease, right ventricular overload and
possible prior anterior wall myocardial infarction.
[**2172-3-3**] EEG: This is an abnormal video EEG due to slowing and
disorganization of the background rhythm with bursts of
generalized
suppression. In sleep, note is made of intermittent generalized
sharp
waves with bifrontal predominance with a triphasic morphology of
unclear
significance. No electrographic seizures were seen during this
recording and this telemetry captured no pushbutton activations.
[**2172-3-3**] MRI Brain w/ contrast: Focal enhancement and edema
centered around the left postcentral gyrus is concerning for a
mestastasis given the location and large pulmonary mass on the
chest CT. Additional differential considerations would include
infection or a primary brain tumor. The appearance would be
unusual for a vascular malformation, despite the prominent
superficial vessel, and also unusual for an evolving infarct. A
repeat study with the leads removed and addition of perfusion
sequences would be useful in further evaluation.
[**2172-3-3**] CT Chest w/o contrast:
1. Locally invasive mass centered within the left hilum,
extending to and abutting the left side of mediastinum,
associated with secondary atelectasis of the left upper lobe and
an organized left pleural effusion. Pulmonary metastases in the
ipsilateral and contralateral lungs. These findings are
compatible with stage IV disease.
2. Borderline-sized mediastinal adenopathy.
3. Small airways disease.
CTA Chest w/ & w/o contrast:
1)Large infiltrating mass in the left hilum extending along the
occluded left pulmonary vein into the left atrium and
circumferentially encasing and infiltrating the left mainstem
bronchus with compression of the lingular bronchus and subtotal
compression of the left lower lobe bronchus causing atelectasis.
2)Mild mediastinal lymphadenopathy.
3)Multiple pulmonary nodules, presumed metastases, in both
lungs.
[**2172-3-2**] CXR: Left-sided pleural effusion with left basilar
atelectasis. No
overt CHF. Please note study is limited and if needed, a PA and
lateral view can be performed to better assess
[**2172-3-3**] TTE: The left atrium is mildly dilated. A highly mobile
small to medium sized mass (0.8 x 0.8 cm) is seen in the body of
the left atrium which appears to possibly be attached to the
base of the anterior mitral valve leaflet (differential
diagnosis included thrombus, myxoma, vegetation, papillary
fibroelastoma). This is best seen in clips 9, 11, 126. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened (?#). No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Small to medium sized mobile mass (0.8 x 0.8 cm) in
the body of the left atrium which appears to be attached to the
base of the anterior mitral valve leaflet (differential
diagnosis included thrombus, myxoma, vegetation, papillary
fibroelastoma). Low-normal left ventricular systolic function. A
TEE may serve to better define the size and attachment of this
mass.
[**2172-3-4**] TEE: A mass is seen in the poterior wall of the left
atrium near the site of the left upper pulmonary vein (not
seen). The left atrial mass has a broad base measuring 2.5 x 0.8
cm with a miobile, stalk-like aspect measuring 3 x 0.7 cm- ?
Thrombus versus extension of mass. The left atiral appendage is
seen and is free of mass or thrombus. No mass or thrombus is
seen in the right atrium or right atrial appendage. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is a small circumferential
pericardial effusion.
IMPRESSION: Heterogenous mass with broad base (2.5 x 1.8 cm) and
mobile stalk (3 x 0.7 cm) seen in the left posterior atrial wall
adjacent to entrance of the left lower pulmonary vein and
possibly occluding the entrance of the left upper pulmonary vein
(not seen). The mass may be entering the left atrium via the
left upper pulmonary vein. No valvular vegetations seen. Mild
mitral regurgitation. Normal biventricular systolic function.
Small pericardial effusion seen. Bilateral pelural effusions
seen.
[**2172-3-5**] CT Abdomen/Pelvis: IMPRESSION:
1. Bilateral enhancing low-density renal lesions which are
highly concerning for metastases. Focal renal abscesses could
also have this appearance, and clinical correlation is
recommended for signs of infection. Bilateral renal cell
carcinoma and lymphoma are considered less likely.
2. Moderate left pleural effusion and persistent left lower lobe
consolidation. No abnormal pleural enhancement.
3. Trace perihepatic ascites, and mild soft tissue edema and
retroperitoneal stranding, consistent with mild volume overload.
[**2172-3-20**] MRI w/o contrast: IMPRESSION:
Markedly limited study due to motion. The left parietal
abnormality appears to demonstrate slight further mass effect on
the adjacent sulci and slightly increased edema. This is not
typical for infarct. Gadolinium-enhanced images are recommended
for further evaluation. A repeat diffusion images will also help
for further assessment and differentiating mass lesion versus
infarct in this location.
Brief Hospital Course:
53 yoM w/ a h/o schizoaffective disorder presents s/p fall with
atrial flutter with a rapid ventricular response, intracranial
lesion, and lung mass who has new dx of squamous cell lung
cancer with extension into left atrium.
#. Squamous cell carcinoma of lung: New diagnosis found on
imaging and subsequent lung biopsy after bronchoscopy. Tissue
was consistent with advanced primary squamous cell lung cancer.
Given left upper lobe collapse, a left bronchial stent was
placed as well. His lung mass extended into his left atrium.
This left atrial mass likely had broken fragments that embolized
to the brain and bilateral kidneys. It is difficult to determine
if these sites were definitely emboli vs. metastasis. Mutliple
imaging over the course of his hospitalization could not
accurately ascertain the difference. It was decided that the
patient's functional status was too weak to tolerate
chemotherapy. He completed a course of palliative XRT while in
the hospital. He should follow up with thoracic oncology in the
outpatient for further evaluation. The patient stated he wanted
treatment despite his poor prognosis. He underwent 14
treatments of XRT prior to discharge.
#. Atrial & Ventricular Ectopy: He developed atrial flutter in
the MICU. He was amiodarone loaded in the MICU and started on
verapamil. He continued to have breakthrough runs of aflutter
so his Verapamil was uptitrated to to 360 daily. He had no
further episodes of tachycardia in the final week of his
hospitalization. This ectopy was largely secondary to his atrial
mass. He was continued on a maintenance dose of amiodarone as
well.
#. Hypoxic respiratory failure: S/p intubation for 5 days.
Extubated successfully on [**2172-3-9**] and had subsequent intermittent
need for supplemental oxygen. He had one episode of
desaturation to 80s on [**3-15**] and CXR showed new collapse of LUL
near recent stent placement. IP team was consulted and decided
to hold off on bronch for now as his hypoxia recovered with nebs
and mucomyst. He was monitored closely and given aggressive
chest PT, although his lung remained collapsed, he had no
further episodes of desaturation. He will follow up with IP in
the outpatient for a flex bronchoscopy. After several radiation
treatments, patient was saturating in low 90s on room air and
breathing comfortably for the week prior to his discharge. He
did intermittently require O2.
#. Pneumonia: He was placed on levofloxacin and Flagyl and
completed a 10 day course. He had no further fever or signs of
infection.
# Weakness over right UE/LE: Suspect this is due to L parietal
lesion. No mass effect from brain mass noted on repeat MRIs. He
remained unable to lift his right hand against gravity. His
muscle strengths are [**3-9**] in the right lower extremity, but [**4-8**]
in both left upper and left lower extremities. His exam remained
unchanged. He worked with physical therapy and patient will need
aggressive treatment in rehab. In the case this may have been a
ischemic CVA, the patient was placed on aspirin. He was seen by
neurooncology and radiation oncology during his admission and
will f/u as an outpatient for further care of brain lesion
#. MS Change: Patient with known schizoaffective disorder to
complicate what his baseline may be. Psychiatry was consulted
and helped manage his psychiatry medications. EEG was performed
twice ([**3-3**] and [**3-4**]) and both showed findings consistent with
mild to moderate encephalopathy that was improving. This was
likely a combination of medications, toxic/metabolic
disturbances, and infection. Through the course of his hospital
stay, his mental status improved where he became more alert and
interactive. He was oriented to person and place near the end of
his hospitalization. He appeared quite depressed as he began to
understand the gravity of his illness. He continued to complain
of poor sleep at night.
#. Testicular mass: Has nodularity in right scrotum noted in the
MICU which was not consistent with any metastatic mass by
ultrasound.
#. Schizoaffective disorder: Prolixin was altered (5 mg qAM and
10 mg qPM). His celexa was decreased to 20 mg daily (from 40 mg)
as patient developed SIADH of unclear etiology. This resolved
prior to full discontinuation of this drug.
#. Right upper extremity DVT: RUE ultrasound found R basilic
clot so PICC line pulled [**3-13**]. He was started on a heparin gtt.
This continued for nearly two weeks in trying to decide the
patient's disposition and whether the need for anticoagulation
was a clear benefit to the patient. It was ultimately decided by
the patient, health care proxy, and team that the patient would
continue anti-coagulation with lovenox.
#. SIADH: Patient's sodium hit a nadir at 119. His labs were
consistent with SIADH. He was placed on a tight fluid
restriction, given salt tablets, and given a one time dose of
lasix, which improved his sodium. Once the heparin gtt was
discontinued (which contained D5W) his sodium markedly improved
to normal range. His fluid restriction was lessened to 2 liters
per day and his salt tablets were discontinued. His mental
status remained stable.
#. Seizure Disorder: No seizure activity noted. Continued home
valproate dosage.
#. Code Status: [**Hospital **] health care proxy decided that patient
should be DNR/DNI with no escalation of care. The patient stated
he did not want to be left to die and wanted treatment.
However, at discharge he stated that he would not want to be
intubated if it was felt that he wouldn't have a meaningful
recovery and he agreed to be DNR/DNI.
Medications on Admission:
Depakote delayed release 500mg po qam, 1500mg po qpm
Cogentin [**Hospital1 **]
Duonebs prn
Celexa 40mg daily
Trazodone 300mg po qhs
Seroquel 200mg po qhs
Symbicort [**Hospital1 **]
Advair 250/50 [**Hospital1 **]
Tyelnol prn
Simvastatin 20mg daily
Prolixin 5mg po bid
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
4. Divalproex 125 mg Capsule, Sprinkle Sig: Five (5) Capsule,
Sprinkle PO BID (2 times a day).
5. Divalproex 125 mg Capsule, Sprinkle Sig: Three (3) Capsule,
Sprinkle PO QAM (once a day (in the morning)).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for cough.
10. Famotidine 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
11. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day) as needed for constipation.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
16. Fluphenazine HCl 2.5 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
17. Fluphenazine HCl 2.5 mg Tablet Sig: Four (4) Tablet PO HS
(at bedtime).
18. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
20. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
22. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs
puffs Inhalation every four (4) hours.
25. Verapamil 180 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO Q24H (every 24 hours).
26. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for sleep.
27. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Four
Hundred (400) mg PO BID (2 times a day).
28. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety/sleep.
29. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 3894**] Nursing & Rehabilitation Center - [**Location (un) 5503**]
Discharge Diagnosis:
Primary Diagnosis:
Squamous Cell Carcinoma of Lung
Right upper extremity DVT
Mass in Brain
Secondary Diagnosis:
Schizophrenia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted because you fell and were found to have a mass
in your head. You were monitored closely in the ICU. A CT scan
of your chest showed a large mass in your chest as well. This
was biopsied and found to be squamous cell carcinoma of the
lung. This mass was invading your heart. This caused you to
develop a fast heart rhythm. You were given medications to slow
your heart rate down. You also developed blood clots in your
right arm in the setting of a PICC line. You were started on a
blood thinner called heparin. You were transitioned to another
easier to use blood thinner called lovenox.
You were transferred to the oncology floor and began palliative
radiation to your chest.
You should continue your medications unless otherwise indicated.
It is important that you keep all of your doctor's appointments.
Followup Instructions:
You have the following appointments scheduled:
Department: Interventional Pulmonary
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
Phone: [**Telephone/Fax (1) 3020**]
Date/Time: [**2172-4-23**] 10:00am
You should also have follow-up in the thoracic oncology clinic.
You should hear from the clinic on Monday with an appointment.
If you do not hear from them, please call [**0-0-**] for an
appointment.
ICD9 Codes: 486, 5119, 2875, 2724, 4019 |
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