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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 900
} | Medical Text: Admission Date: [**2161-11-29**] Discharge Date: [**2161-12-2**]
Date of Birth: [**2087-11-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SOB, HYPOXIA,
Major Surgical or Invasive Procedure:
Pt was intubated
History of Present Illness:
.
History of Present Illness: 74F with DM, chronic bronchiectasis
c/b recurrent pseudomonal PNA, COPD on home O2, lung abscess s/p
L lower lobectomy admitted to [**Hospital1 **]-[**Location (un) 620**] [**11-14**] with 2 days of
fever, dyspnea, and chest heaviness. Noted to be hypoxic to 55%
per transfer summary. CXR showed R-sided PNA. Initially managed
on the floor and treated with zosyn and steroids. Zosyn switched
to tobramycin & imipenem [**11-22**] when sputum Cx returned MDR
pseudomonas. Eventually transferred to ICU for Afib with RVR,
treated with diltiazem and digoxin. Bronch/BAL [**11-23**] also grew 2
strains of MDR pseudomonas and [**Female First Name (un) **]. Intubated [**11-24**] with 7.5
ETT for hypercapnic resp failure, at which time ABG
7.34/89/82/48. She remained hemodynamically stable. However,
WBC# rose from 14.3 on [**11-27**] to 28.1 today. ABG this AM
7.50/52/144/41 on 400/12/5/0.4. Transferred to [**Hospital1 18**] for further
evaluation and treatment.
.
On the floor, patient denies pain or difficulty breathing.
.
Past Medical History:
DM
Chronic bronchiectasis c/b recurrent pseudomonal PNA
COPD on home O2
Lung abscess s/p L lower lobectomy
+PPD with remote TB exposure
Diverticulitis
Osteoporosis
Social History:
Social History (per med records): Lives at home. Independent.
Drinks [**1-24**] glasses of wine per day. Former smoker, quit smoking
~50 years ago.
Family History:
Family History: Not assessed.
Physical Exam:
Vitals: T 98.4 BP 116/56 P 84 RR 17 O2sat 95% on 400/12/5/0.35
General: Awake, opens eyes, appears comfortable, no access
muscle use
Neck: No JVD
Lungs: diffuse rhonchi bilat no wheeze/rales
CV: reg rate nl S1S2 no m/r/g
Abdomen: soft NTND hypoactive BS
Ext: warm, dry +PP 1+ pitting edema of all distal ext
Pertinent Results:
[**2161-11-29**] 02:25PM BLOOD WBC-29.2*# RBC-3.56* Hgb-10.8* Hct-34.0*
MCV-95 MCH-30.4 MCHC-31.8 RDW-12.1 Plt Ct-262
[**2161-11-30**] 04:06AM BLOOD WBC-27.7* RBC-3.46* Hgb-11.0* Hct-33.6*
MCV-97 MCH-31.8 MCHC-32.8 RDW-12.5 Plt Ct-279
[**2161-12-1**] 05:35AM BLOOD WBC-30.0* RBC-2.56*# Hgb-8.1*# Hct-24.9*
MCV-97 MCH-31.4 MCHC-32.4 RDW-12.8 Plt Ct-279
[**2161-11-29**] 02:25PM BLOOD Neuts-94.6* Lymphs-1.8* Monos-3.4 Eos-0.1
Baso-0.1
[**2161-11-30**] 04:06AM BLOOD Neuts-95.4* Lymphs-1.5* Monos-2.5 Eos-0.5
Baso-0.1
[**2161-12-1**] 05:35AM BLOOD PT-13.9* PTT-150* INR(PT)-1.2*
[**2161-11-29**] 02:25PM BLOOD Glucose-263* UreaN-61* Creat-0.3* Na-150*
K-4.3 Cl-110* HCO3-36* AnGap-8
[**2161-12-1**] 05:35AM BLOOD Glucose-286* UreaN-76* Creat-0.4 Na-140
K-5.0 Cl-102 HCO3-35* AnGap-8
[**2161-11-29**] 02:25PM BLOOD ALT-20 AST-16 LD(LDH)-197 AlkPhos-52
TotBili-0.2
[**2161-11-29**] 02:25PM BLOOD Albumin-2.3* Calcium-7.4* Phos-3.0
Mg-2.7*
[**2161-11-30**] 04:06AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.5
[**2161-11-30**] 04:06AM BLOOD TSH-2.1
[**2161-11-29**] 02:25PM BLOOD Tobra-2.0*
[**2161-11-30**] 05:30PM BLOOD Tobra-1.0*
[**2161-11-29**] 02:44PM BLOOD Type-ART Temp-36.9 Rates-[**12-26**] Tidal V-420
PEEP-5 FiO2-35 pO2-113* pCO2-52* pH-7.48* calTCO2-40* Base XS-13
-ASSIST/CON Intubat-INTUBATED
[**2161-11-30**] 06:20AM BLOOD Type-ART pO2-128* pCO2-60* pH-7.42
calTCO2-40* Base XS-12
[**2161-12-1**] 05:48AM BLOOD Type-ART pO2-129* pCO2-63* pH-7.40
calTCO2-40* Base XS-11
[**2161-11-29**] 02:44PM BLOOD Lactate-1.6
[**2161-11-30**] 03:49PM BLOOD Lactate-1.2
[**2161-12-1**] 05:48AM BLOOD Lactate-1.3
[**2161-12-1**] 05:48AM BLOOD freeCa-1.09*
[**2161-11-29**] 03:30PM BLOOD B-GLUCAN-Test
[**2161-11-29**] 03:30PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
IMAGING :
[**2161-12-1**]
ABDOMINAL ULTRASOUND:
The liver is diffusely heterogeneous in echotexture, but without
focal
lesions. There is no intrahepatic biliary ductal dilation.
Common bile duct
appears mildly dilated in the suprapancreatic portion, measuring
9-10 mm. The
pancreatic duct tapers entering the pancreas but is not well
seen distally
There is normal antegrade flow in the main portal vein.
The gallbladder is not distended, though there is marked
gallbladder wall
edema, which may reflect underlying liver disease or other
causes of third
spacing. There is no cholelithiasis identified.
The spleen is normal in size, measuring 7 cm. Small amount of
free fluid is
identified in the left upper quadrant.
The kidneys are symmetric in size, measuring 10.4 cm on the
right and 10.9 cm
on the left. There is no renal mass lesion, and no
nephrolithiasis or
hydronephrosis.
The midline structures including the aorta, IVC, and pancreas,
are obscured by
overlying bowel gas.
IMPRESSION:
1. Heterogeneous, coarse liver echotexture suggesting liver
disease such as
hepatitis or fibrosis. No focal liver lesions are identified. If
further
evaluation is desired, MRI could be considered when clinically
feasible.
2. Mild dilation of suprapancreatic common bile duct, measuring
9-10 mm,
without intrahepatic biliary ductal dilation. This is of dubious
significance.
MRCP could be performed if there is further concern.
3. Gallbladder wall edema, without associated distention or
cholelithiasis to
suggest acute cholecystitis. This may reflect third spacing,
secondary to a
number of causes, or may be from underlying liver disease.
4. Small amount of free fluid in the left upper quadrant
adjacent to the
spleen.
5. Obscuration of midline structures including the pancreas,
aorta and IVC by
overlying bowel gas.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Assessment and Plan: 74F with DM, chronic bronchiectasis c/b
recurrent pseudomonal PNA, COPD on home O2, lung abscess s/p L
lower lobectomy transferred for further management of
hypercapnic respiratory failure due to MDR pseudomonal PNA.
.
#Hypercapnic respiratory failure/Pneumonia - pt respiratory
status detiorated after presentation to the ED and she was
intubated. Pt was diagnosed with MDR pseudomonal PNA and was
being treated with Abx. She had an acute episode on a-fib with
RVR and was medically managed. Ultimately it was planned for
her to have DC cardioversion and so she was placed on Heparin
drip in preparation for TEE and cardioversion. The morning
after starting the drip, it was noticed that the patient had a
large melenic stool and an acute drop in her hemoglobin and
hematocrit. GI was consulted and an EGD showed bleeding around
the ampulla. It was unclear whether the bleeding was coming
from around the ampulla or within the ampulla. A RUQ U/S was
done to rule out hemobilia or hemorrhagic mass. The family was
contact[**Name (NI) **] at this time as goals of care have been a constant
discussion. In addition, the patient was intubated, but clear
and alert and she was aslo actively involved in the discussion
of her care. The RUQ U/S was negative and IR and Surgery were
notified for possible angiogram and intervention. As these
events were developing, the family and pt were in active
discussion with the medical team. The patient and family
decided not to go ahead with the angiogram. The patient decided
she wanted to be made CMO and be extubated. The patient was
terminally extubated on [**2161-10-31**]. The patient died on [**2161-12-2**].
Medications on Admission:
Vitals: T 98.4 BP 116/56 P 84 RR 17 O2sat 95% on 400/12/5/0.35
General: Awake, opens eyes, appears comfortable, no access
muscle use
Neck: No JVD
Lungs: diffuse rhonchi bilat no wheeze/rales
CV: reg rate nl S1S2 no m/r/g
Abdomen: soft NTND hypoactive BS
Ext: warm, dry +PP 1+ pitting edema of all distal ext
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 901
} | Medical Text: Admission Date: [**2161-2-21**] Discharge Date: [**2161-2-21**]
Date of Birth: [**2095-7-1**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Septic Shock
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Pt is a 65 y/o female unknown to [**Hospital1 18**], who was referred for
cardiac cathetrization. She has a hx of CVA and bowel
perforation 5 months ago s/p colostomy, and has not recovered
well from this surgery and is cared for by her husband. She was
noted to have N/V 2 days ago, and was told to increase her PO
fluids. Temp at home was 99. She improved somwehat, but was
noted by her husband to have decreased ostomy output. The
evening prior to admission she begam clammy, vomited, and was
unresponsive.
EMS was called and she was difficult to intubate in the field.
She was taken to [**Hospital3 **], and there was suspicion for
STE MI by EKG. Also coffee ground emesis but stable Hct. She was
hypotensive and placed on pressors, and referred to [**Hospital1 18**] for
cardiac cath. Cardiac cath did not reveal significant coronary
lesions, but some mild global dysfunction. Given her clinical
picture this was likely c/w sepsis.
Past Medical History:
CVA in '[**53**] w/ L-sided hemiparesis
[**8-/2160**] had bowel perforation w/ colostomy
Osteoporosis
Social History:
Cared for at home by her husband
Family History:
Mother w/ hx of CVA, Father w/ CAD
Physical Exam:
T=91 BP=96/65 HR=110 O2=95%
GEN=Intubated
LUNGS=normal BS's bilaterally
CARDIAC=difficult secondary to BS's
ABD=tense, no bowel sounds
EXT=no edema, cold extremities, cyanotic toes/fingers
NEURO=pupils fixed and dilated, absent corneal reflexes, absent
gag reflex; positive doll's eye per surgery
Pertinent Results:
[**2161-2-21**] 09:53AM GLUCOSE-190* UREA N-32* CREAT-1.4* SODIUM-140
POTASSIUM-2.0* CHLORIDE-113* TOTAL CO2-12* ANION GAP-17
[**2161-2-21**] 07:40AM GLUCOSE-128* LACTATE-8.1* K+-1.8*
[**2161-2-21**] 09:53AM WBC-0.4* RBC-3.77* HGB-11.9* HCT-37.5
MCV-100* MCH-31.5 MCHC-31.6 RDW-14.4
[**2161-2-21**] 10:18AM TYPE-ART PO2-69* PCO2-36 PH-7.03* TOTAL
CO2-10* BASE XS--21
Brief Hospital Course:
She was transferred to the CCU, where she was found to be
hypothermic, has an elevated Lactate, and was hypotensive
requiring 4 pressors and fluids wide-open. Her neuro exam
revealed loss corneal and gag reflexes. Surgery was consulted
about possible abdominal process at the etiology of her septic
shock, but surgery felt that given her unstable picture and
neurological impairements that surgery was not indicated. Her
husband and son were notified, and it was felt that the
patient's wishes were not to have aggressive measures. After
discussion with the family and medical team, it was decided to
withdraw care. Pressors were stopped, her ventilation was weaned
down, and she was given Morphine for comfort. At 13:30 she was
noted to have absent heart sounds, pulse, and was without
spontaneous respirations or brainstem reflexes. She was
pronounced dead at 13:30 by the medical resident Dr. [**Last Name (STitle) **]. The
attending, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], was notified. The family requested
an autopsy.
Discharge Disposition:
Expired
Discharge Diagnosis:
Likely Septic Shock
Discharge Condition:
Deceased
Completed by:[**2161-2-21**]
ICD9 Codes: 0389, 2768, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 902
} | Medical Text: Admission Date: [**2174-4-6**] Discharge Date: [**2174-4-12**]
Date of Birth: [**2122-4-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
trauma: pedestrian struck:
R subgaleal hematoma
small left apical ptx
R inf rami fx
R acetabular fractures
1 cm left anteromedial temporal cont
right pararenal hematoma
head laceration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
52 year old male struck by a car on [**4-6**] and was brought to [**Hospital1 18**]
for further
management. Patient was admitted to the TSICU under ACS for the
following injuries: subgaleal hematoma, Right pubic ramus
fracture, Right
acetabular fracture, Left pneumothorax.
Past Medical History:
HCV per report; h/o Heroin use; chronic back pain; OSA (should
wear CPAP, but does not at home)
Social History:
History of heroin use in past, reportedly been clean for some
time.
Family History:
NC
Physical Exam:
Pt intubated upon admission [**2174-4-6**]:
Vital signs: hr=82m bp=100/62, rr=20, 100 % oxygen saturation
CV: normal
chest: normal
abdomen: normal
skin: abrasions left shoulder, right knuckle abrasions,
laceration scalp
neuro: 3mm to 2mm sluggish
Physical examination upon discharge: [**2174-4-12**]
vital signs: t=98.3, hr=76, bp=130/70, rr=18, oxygen saturation
98% RA
General: sitting in chair, conversant, NAD
CV: ns1, s2,-s3, s-4
LUNGS: clear, diminshed BS left lateral
ABDOMEN: soft, non-tender
EXT: feet warm, + dp bil. mild left ankle edema lateral aspect,
ecchymosis left calf., abrasions left knuckles, no spinal
tenderness, mild tenderness left SI, muscle st lower ext., left
+4/+5, right +5/+5, full dorsi/plantar flexion bil., hip flex.
right +5, left +[**5-5**].
NEURO: alert + oriented x 3, speech clear, no tremors, full
EOM's bil.
SKIN: staples head
Pertinent Results:
CT Head [**2174-4-6**]: No hemorrhage or fracture. Large right subgaleal
hematoma and laceration.
CT C-spine [**2174-4-6**]: No fracture or malalignment in the cervical
spine. Malpositioned NG tube with its tip at the vallecula
anterior to the epiglottis. Repositioning was discussed with the
trauma team at the time of initial review. Tiny left apical
pneumothorax better assessed on the subsequent CT torso.
CT abdomen and pelvis [**4-6**] 12:
. Acute fractures of the right inferior pubic ramus and the
anterior column of the right acetabulum with no significant
surrounding hematoma. Probable nondisplaced fracture of the
right sacral ala.
2. Locatized hematoma within the right anterior pararenal space
tracking
inferiorly into the space of Retzius, the source of this
hemorrhage is unclear though no solid organ injury is evident.
3. Left chest tube in place with only trace left pneumothorax.
Small areas
of contusion in the lung as detailed above. Bibasilar opacities
likely
represent a combination of atelectasis and aspiration.
CT Torso [**2174-4-6**]: Tiny left apical and basal pneumothoraces.
Bilateral lower lobe opacities could be secondary to mild
aspiration in the setting of intubation. Small quantity of
hemorrhage in the right anterior pararenal space. No definite
solid organ or hollow viscus injury. Right anterior acetabular
and inferior pubic ramus fractures. Mild widening of the left
sacroiliac joint.
[**2174-4-8**]: x-ray of the ankle:
. Mild soft tissue edema in [**Last Name (un) 22044**] fat pad. This can be seen in
Achilles
tendinopathy.
2. Mild lateral malleolar soft tissue swelling.
3. No fracture
[**2174-4-8**]: ct of the chest:
IMPRESSION:
1. Interval layering of hematoma with decreased component in the
right
anterior pararenal space and tracking inferiorly into the right
paracolic
gutter and pelvis.
2. No definite evidence of solid organ injury. No evidence of
duodenal wall hematoma. No extraluminal oral contrast.
3. Small left pneumothorax with mild interval increase in size
compared to
prior. Chest tube with tip terminating at the left lung base.
4. Similar bibasilar opacities likely atelectasis and
aspiration. Subtle
increase in size of focal opacity in the left lower lung could
be contusion.
5. Known fracture of the right inferior pubic ramus and anterior
of the right acetabulum.
[**2174-4-10**]: chest x-ray:
This particular study was acquired using a somewhat lordotic
technique
creating many superimposed bony structures over the apices.
Given this
limitation, no pneumothorax is appreciated on the current study,
although a small pneumothorax could be overlooked. There is
interval decrease in the amount of left chest wall subcutaneous
emphysema. A left subclavian central line continues to have its
tip in the proximal SVC. Lung volumes remain low with no focal
airspace consolidation, pulmonary edema, or pleural effusions.
Overall cardiac and mediastinal contours are stable. Interval
resolution of bibasilar patchy opacity is consistent with
resolved atelectasis.
[**2174-4-11**]: LS spine x-rays:
FINDINGS: There is a transitional vertebra at the lumbosacral
junction. At
this level, there is hypertrophic spurring with intervertebral
disc space
narrowing. Less prominent narrowing is seen at the interspace
just above
this. These findings are consistent with degenerative change.
No evidence of compression fracture or alignment abnormality.
[**2174-4-11**]: x-ray of the pelvis:
FINDINGS: In comparison with the study of [**4-6**], there is again a
substantially displaced fracture of the right inferior pubic
ramus. The right femoral neck fracture seen on CT is obscured
due to a somewhat rotated position.
[**2174-4-11**] 04:29AM BLOOD WBC-3.2* RBC-2.77* Hgb-8.8* Hct-24.1*
MCV-87 MCH-31.8 MCHC-36.5* RDW-13.7 Plt Ct-63*
[**2174-4-10**] 03:03PM BLOOD Hct-25.9*
[**2174-4-10**] 04:20AM BLOOD WBC-2.8* RBC-2.65* Hgb-8.6* Hct-23.0*
MCV-87 MCH-32.3* MCHC-37.3* RDW-13.4 Plt Ct-47*
[**2174-4-6**] 07:30PM BLOOD WBC-10.2 RBC-3.63* Hgb-11.3* Hct-32.7*
MCV-90 MCH-31.2 MCHC-34.6 RDW-13.5 Plt Ct-82*
[**2174-4-11**] 04:29AM BLOOD Plt Ct-63*
[**2174-4-10**] 04:20AM BLOOD Plt Ct-47*
[**2174-4-9**] 02:13AM BLOOD Plt Ct-33*
[**2174-4-11**] 04:29AM BLOOD Glucose-88 UreaN-9 Creat-0.5 Na-140 K-3.5
Cl-105 HCO3-29 AnGap-10
[**2174-4-10**] 04:20AM BLOOD Glucose-99 UreaN-11 Creat-0.5 Na-141
K-3.1* Cl-105 HCO3-33* AnGap-6*
[**2174-4-7**] 02:15AM BLOOD ALT-94* AST-93* LD(LDH)-315* AlkPhos-52
TotBili-0.2
[**2174-4-6**] 07:30PM BLOOD Lipase-83*
[**2174-4-11**] 04:29AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.0
[**2174-4-10**] 04:20AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.8
[**2174-4-6**] 07:38PM BLOOD Glucose-140* Na-139 K-4.1 Cl-104
calHCO3-28
[**2174-4-8**] 05:09AM BLOOD freeCa-1.08*
Brief Hospital Course:
52 year old gentleman, pedestrian struck, admitted to the the
hospital intubated and sedated. Upon admission, he was made NPO,
given intravenous fluids and underwent imaging. He was found
to have a right acetabular fracture,right pubic rami fracture
and a right subgaleal hematoma. He was also found to have a left
pneumothorax after having a needle thoracostomy tube placed in
the field. In the emergency department he had a chest tube
placed and was admitted to the trauma intensive care unit where
he was hemodynamically stable.
On HD #2, he was extubated and placed on face tent with good
oxygenation. His chest tube was placed to water seal and he was
transfused 2 u of blood after his hematocrit dropped to 24.8.
His Hct drop was thought to be from a pararenal hematoma that
was found vs his pelvic fracture. He was started on IV
equivalent of home methadone regimen, standing intravenous
Tylenol, and dilaudid PCA for pain control. The orthopedic
service was consulted and recommended non-operative management
for pelvic fracture. C-spine and TLS spine cleared clinically at
this time.
He again was transfused with 2 units blood on HD #3 for
down-trending of his hematocrit. He was re-scanned in this
setting and his pararenal hematoma was found to be stable. His
methadone was decreased in the setting of somnolence. He also
had a cat scan scan of his head which showed new hyperdensity in
the left temporal lobe. Neurosurgery was consulted and thought
this hyperdensity was too small to require seizure prophylaxis
or further imaging with MRI, and thought most likely to be
contusion. His left chest tube was removed on HD #4.
He was transferred to the surgical floor on HD#4 with stable
vital signs and adequate control of his pain with oral
analgesia. He is tolerating a regular diet. Serial hematocrits
continued with evidence of improvement of his thrombocytopenia
to 80,000 and stabilization of his hematocrit to 25. He was
evaluated by physcial therapy and occupational therapy and was
found to have impaired mobility related to his pelvic fracture.
Upon evaluation, it was determined that he had left leg weakness
and the inability to bear weight on his left leg. The left leg
weakness was noted on physical examination upon admission. He
underwent a lumbar spine x-ray which showed no compression
fracture or alignment abnormality. The pelvix x-ray continued
to show the displaced fracture of the right inferior pubic
ramus. He was provided instruction in the use of the walker and
has been ambulating with assistance.
He is preparing for discharge to a rehabilitation facility with
follow-up instructions with Orthopedics, and with the acute care
service.
Medications on Admission:
xanax 2mg AM 4mg HS, methadone 50mg TID
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
4. methadone 10 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8
hours).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: hold for incresed sedation, resp.
rate <12.
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for anxiety: hold for increased sedation ,resp.
rate <12.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
Trauma: pedestrian struck
Injuries:
R subgaleal hematoma
small left apical ptx
R inf rami fx
R acetabular fractures
1 cm left anteromedial temporal cont
right pararenal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital after being struck by a car and were
found to have mulitple injuries including a acetabular fracture,
pelvic fractur and a small bleed in your head. You were seen by
the orthopedic service for the fractures who recommended
non-operative management for both your pelvic and acetabular
bone fractures. You were seen by physical therapy and
recommendations made for discharge to an extended care facility.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2174-4-28**] at 2:00 PM
With: ACUTE CARE CLINIC with Dr [**Known firstname **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
Department: ORTHOPEDICS
When: TUESDAY [**2174-5-3**] at 10:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2174-5-3**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please follow-up with Dr. [**First Name (STitle) **], cognitive neurologist, upon
discharge from the rehabilitation center. You can schedule this
appointment by calling # [**Telephone/Fax (1) 6335**]
Completed by:[**2174-4-12**]
ICD9 Codes: 2851, 2875, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 903
} | Medical Text: Admission Date: [**2163-10-30**] Discharge Date: [**2163-11-3**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Chest pain and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Most of the interview was conducted with telephone interpretor
as patient is
Russian speaking only.
[**Age over 90 **]yo female Russian speaking only resident of [**Hospital1 5595**] with CAD,
CHF (EF 25%), HTN, and Afib, recently admitted with episode of
PNA vs. CHF exacerbation on [**2163-9-29**], now presents with chest
pain, abdominal pain and hypotension. The chest pain is located
in the right side of the chest and radiates to the back. The
pain is characterized as the same chest pain she has had for
most of her life and is rated [**2169-5-5**], no radiations and
nonpositional, no associated diaphoresis. She had one episode
of n/v, early today. The emesis was clear without signs of
blood or coffee grounds. She describes her abdominal pain as
generalized, diffuse, x 2d. She denies any current abdominal
pain. Her last bowel movement was three days prior to admission.
In the ED, her BP was 98/66 and dropped to 60/40 sitting and
80/60 lying after ASA, SL NTG and lasix (given for ?ACS, CHF)
->1400 cc u/o. She begun dopamine to avoid fluid boluses given
her CHF. The patient was subsequently given morphine for chest
pain refractory to nitro which lead to further decrease in BP to
46/24 (15 min. after morphine was given). She failed a weaning
trial of dopamine with BP of 79/50. She then received decadron
10mg IV along with levofloxacin 500mg IVx1 and Flagyl 500mg IV
x1 for ?PNA, and sent to [**Hospital Unit Name 153**] for w/u.
The patient also reports some baseline shortness of breath
with a chronic cough that has been present for 2 years. The
cough has periods of improvement and worsening. Recently, the
cough has worsened over the last two weeks with some clear
sputum production (since her recent discharge). The patient
also reports some subjective fevers, and chills, but denies
rigors. She is DNR/DNI.
Past Medical History:
1. Sick sinus syndrome s/p pacemaker placement.
2. Coronary artery disease.
3. CHF with EF of 25%
4. Atrial fibrillation.
5. Hypertension.
6. Osteoporosis.
7. Dementia
8. R hemicolectomy for mussinous colon CA
1. Sick sinus syndrome s/p pacemaker placement.
2. Coronary artery disease.
3. CHF with EF of 25%
4. Atrial fibrillation.
5. Hypertension.
6. Osteoporosis.
7. Dementia
8. R hemicolectomy for mussinous colon CA
Social History:
The patient has never smoked cigarettes.She lives in the [**Hospital1 10151**] Center secondary to an inability to take care of
herself. She is retired. She has a large family. She is
Russian speaking.
Physical Exam:
PE:
VS: Tc: 97.8 HR: 80 BP: 134/47 on left and 141/57 on right
RR: 19 SaO2: 93% on 2L
Gen: elderly women lying in bed at 30 degree angle with nasal
canula in place. The patient appears to be relatively
comfortable, in NAD. poor skin turgor
HEENT: temporal wasting. pupils are 2mm bilaterally, reactive?,
EOMI. mucous membranes very dry.
Neck: supple, full ROM, JVP 8-10cm
CV: RRR, S1, S2, no murmurs, rubs, gallops
Chest: [**Month (only) **] breath sounds on R>L. Egophony on R>L up 1/3 up
scapula. bibasilar crackles.
Abd: soft, NT, ND, BS+ bilaterally, no rebound, guarding,
peritoneal signs. negative [**Doctor Last Name **] signs.
Ext: warm to palpation, with trace pulses, [**Doctor First Name 15799**] stasis, no
c/c/e
Neuro: pt appeared appropriate throughout. A+O not assess due to
difficulty with language barrier.
Pertinent Results:
[**2163-10-30**] 11:20AM WBC-11.0# RBC-3.79* HGB-11.1* HCT-33.8*
MCV-89 MCH-29.4 MCHC-32.9 RDW-16.4*
[**2163-10-30**] 11:20AM NEUTS-82.2* LYMPHS-12.4* MONOS-4.9 EOS-0.2
BASOS-0.2
[**2163-10-30**] 11:20AM PT-13.1 PTT-24.2 INR(PT)-1.1
[**2163-10-30**] 11:20AM ALBUMIN-3.1* CALCIUM-8.8 PHOSPHATE-3.7
MAGNESIUM-1.4*
[**2163-10-30**] 11:20AM ALT(SGPT)-15 AST(SGOT)-28 CK(CPK)-82 ALK
PHOS-73 AMYLASE-51 TOT BILI-0.6
[**2163-10-30**] 11:20AM GLUCOSE-154* UREA N-56* CREAT-2.8*#
SODIUM-135 POTASSIUM-3.3 CHLORIDE-91* TOTAL CO2-30* ANION GAP-17
[**2163-10-30**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2163-10-30**] 12:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2163-10-30**] 12:45PM URINE RBC-0-2 WBC-0 BACTERIA-MOD YEAST-NONE
EPI-0
[**2163-10-30**] 01:20PM LACTATE-1.6
[**2163-10-30**] 11:20AM CK-MB-NotDone
[**2163-10-30**] 11:20AM cTropnT-0.02*
[**2163-10-30**] 05:36PM CK(CPK)-91
[**2163-10-30**] 05:36PM CK-MB-NotDone
[**2163-10-30**] 05:37PM cTropnT-0.02*
.
.
[**2163-10-30**] CXR:
"1. Cardiomegaly and calcified unfolded aorta. There is no
disproportionate
mediastional widening.
2. Probable CHF.
3. More confluent opacity right apex --- question atypical
distribution of
CHF vs. pneumonia.
4. Osteopenia with partial wedging of multiple vertebral bodies.
"
.
.
Brief Hospital Course:
A/P: [**Age over 90 **]yo female resident of [**Hospital1 5595**] with CAD, HTN and recent admit
for PNA and CHF exacerbation (admitted [**2163-9-27**]-discharged
[**2163-9-29**]) presents with CP, abd pain and hypotension.
1: Hypoxia: We thought that her hypoxia might have been
secondary to fluid overload/CHF or a pneumonia. We thus
broadened her coverage by adding zosyn. She also received small
doses of IV lasix with a small improvement. She eventually
weaned from a NRB to 6L nasal cannula on the day of discharge.
We advise continued weaning of her oxygen as tolerated by the
patient.
2. Hypotension: We thought that the patient's hypotension was
secondary to volume depletion as demonstrated by its rapid
response with IV fluids. We held her antihypertensive
medications initally and slowly added them as her pressure
stabilized.
3. Chest pain: We were concerned that her chest pain might have
been secondary to an acute coronary syndrome. She was ruled out
with negative serial cardiac enzymes and the absence or ECG
changes. We increased her
3. PNA: The patient was first started on levoquin but in light
of her increasing hypoxia she was switched to zosyn to broaden
her coverage. She remained afebrile and without a leukoctyosis
was thus discharged on a 7 day course of levofloxacin.
4. Abd pain: The occurance of abdominal pain is conincident
with her recent onset of constipation. The abd on exam is soft,
and completely benign, without a suggestion of a surgical
abdomen. The pain is most likely secondary to constipation.
Her abdominal pain and distension improved significantly with
the administration of an enema which resulted in a successful
bowel movement.
5. Afib/Sick Sinus: Pt is s/p pacemaker placement. While in
the ICU she was on telemetry and her heart rate did not
decreased to less than 80.
6. CHF: We held her cardiac meds in light of her hypotension.
On the day of discharge we had restarted metoprolol and we
advise that the other medications be slowly added as her blood
pressure tolerates.
7. Prophylaxis: The patient was continued on heparin SQ for
DVT prophylaxis along with a PPI as per her outpatient regimen.
Medications on Admission:
1. Metoprolol 100mg [**Hospital1 **]
2. Amiodarone HCl 200mg PO once daily
3. Lisinopril 5mg once daily
4. Furosemide 40mg once daily
5. Pantoprazole 40mg Q24 hours
6. Albuterol neb Q6hrs PRN
7. Ipratroprium Bromide 0.02% neb Q6 hours
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation every four (4) hours.
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 4 days.
10. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
14. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
15. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 7 days.
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) mL PO twice a
day.
17. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Aspiration Pneumonia
Hypertension
Congestive Heart Failure
Atrial Fibrillation
Discharge Condition:
Fair
Discharge Instructions:
Please take all of your medications as prescribed.
Followup Instructions:
Primary Care: Please follow up with a physician within one week
of discharge from the hospital. At the time, please have your
oxygen saturation checked and a CXR within two weeks to verify
improvement of your pneumonia.
Laboratory: Please have the levels of your potassium checked at
[**Hospital1 5595**] with the results sent to the house physician.
ICD9 Codes: 5070, 4280, 2765, 2767, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 904
} | Medical Text: Admission Date: [**2140-7-22**] Discharge Date: [**2140-8-29**]
Date of Birth: [**2082-7-22**] Sex: F
Service: SURGERY
Allergies:
Amoxicillin / Wellbutrin
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
SOB, hypoxia
Major Surgical or Invasive Procedure:
paracentesis, thoracentesis
History of Present Illness:
58F w/Alcoholic cirrhosis with consequent diuretic-refractory
ascites, edema, hyponatremia, and pleural effusions presents
from the IR outpatient clinic for admission because of fever to
101.7. Pt has known alcoholic liver disease with ascites
worsening over the past 6 months. She is being worked up for
liver [**First Name3 (LF) **] here. Over the past week she has been
increasingly fatigued walking across a room. Needs to sleep
nearly-upright with multiple pillows because of breathing
difficulty when lying down. Having daily fevers at nighttime. No
chills, no nausea/vomiting/abdominal pain. Some non-productive
cough. No sick contacts or contact with children. No dysuria or
hematuria. No bloody stools, but does always have black stools,
which she attributes to occasional lactulose use. When asked
about weight changes she states she hasn't been able to
recognize her body for 6 months.
.
This morning she presented to previously-scheduled outpatient
session with IR for therapeutic thoracentesis and paracentesis
to offload her ascites and pleural effusions, all thought to be
secondary to decompensated cirrhosis. First such session was
last week; at her last taps 1.75L of pleural fluid was removed
from her chest, she did not require post-procedure albumin, and
was able to go home the same day. Plan was not to be drained so
soon thereafter, but increase in dyspnea this week prompted a
return visit in just 1 week. At IR VS were 101.7 107/56 108
82%/3L. Because of the fever, she had just a diagnostic
paracentesis, but she did have 1L straw-colored drained by
thoracentesis due to O2 desaturation. O2 sat resolved to 90%/RA
by the end of the procedure, and post-procedure CXR show some
interval improvement of her R hydrothorax. Pleural and
peritoneal fluid sent for analysis and culture, blood cultures
also sent. Admitted for IV albumin, antibiotics for possible RUL
PNA seen on CXR, and fluid optimization.
Past Medical History:
Papillary Thyroid Carcinoma s/p resection
Alcohol Abuse
Alcoholic Cirrhosis c/b ascites and edema no hepatic
encephalopathy
Celiac Sprue
Psoriasis
HTN (prior to diuretic therapy; not an active issue off
diuretics now)
Rosacea
Hx Depression
Social History:
Hx alcohol abuse and daily smoking; stopped both recently.
Family History:
CVA, depression, alcohol abuse.
Physical Exam:
Admission Exam:
Vitals: 101.3 99/44 69 18 96/3LxNC
General: well-appearing pleasant woman sitting upright in bed
w/2 pillows, frequently coughing, jaundiced. Walking around
floor earlier tonight.
[**First Name3 (LF) 4459**]: NCAT EOMI PERRL icteric sclera
Neck: supple, no thyromegaly, JVD nondistended
Heart: RRR 3/6 holosystolic murmur throughout precordium loudest
LLSB
L Lung: slightly diminished lung field w diffuse rales,
base>apex
R Lung: absent breath sounds except above 4th rib posteriorly;
clear breath sounds above that level, with percussible air/fluid
level. Bandaged site c/d/i, nontender.
Abdomen: soft nontended +distended, tympanic superiorly but
w/also w/persussible air/fluid level, bulging flanks. Bandage
c/d/i, site nontender.
Extremities: pitting edema to groin, psoriatic plaques R elbow L
dorsal forearm, no spider angiomatas
Neurological: AOX3, no asterixis
.
MICU Admission Exam:
General: Alert, oriented, increased work of breathing,
moderately uncomfortable
[**First Name3 (LF) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~10cm, no LAD
Lungs: Clear to auscultation on left, right side with wheeze,
particularly in the lower lung zone, with some crackle
CV: Tachycardic Regular rhythm, 4/6 SEM, no rubs, gallops
Abdomen: soft, non-tender, mildly distended, + ascites, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley
Ext: warm, well perfused, 3+ edema to mid thigh, no clubbing,
cyanosis
Pertinent Results:
Admission labs:
[**2140-7-23**] 05:40AM BLOOD Glucose-84 UreaN-20 Creat-1.2* Na-122*
K-4.4 Cl-88* HCO3-27 AnGap-11
[**2140-7-23**] 05:40AM BLOOD WBC-8.1 RBC-2.20* Hgb-8.5* Hct-23.9*
MCV-109* MCH-38.5* MCHC-35.4* RDW-15.8* Plt Ct-112*
[**2140-7-23**] 05:40AM BLOOD PT-21.3* PTT-47.5* INR(PT)-2.0*
[**2140-7-23**] 05:40AM BLOOD ALT-26 AST-66* LD(LDH)-253* AlkPhos-90
TotBili-6.4*
[**2140-7-23**] 05:40AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.4 Mg-2.1
.
[**2140-7-25**] 04:40PM BLOOD Type-ART pO2-90 pCO2-38 pH-7.43
calTCO2-26 Base XS-0
[**2140-7-25**] 04:40PM BLOOD Lactate-2.2*
Brief Hospital Course:
57 F w/decompensated alcoholic cirrhosis and worsening ascites
and R-sided pleural effusions initially admitted to the Liver
service with fever for therapeutic [**Female First Name (un) 576**] and paracentesis. On
[**2140-7-25**], she developed hypoxia post thoracentesis requiring NRB
and was transferred to the MICU. Hypoxia was felt to be
re-expansion pulmonary edema, potentially complicated by
pneumonia given her fevers, worsening shortness of breath and
hypoxia. In the MICU, she initially required 100% face mask. IP
placed a pigtail catheter to drain re-accumulated right pleural
effusion [**2140-7-26**]. Initially, 600cc of serosanguinous fluid was
drained. The next day, 2L were drained. She was able to be
weaned to 3L NC and went back to the medical floor for
management of hyponatremia and worsening renal function.
Creatinine increased from baseline of 1.0. It was felt that she
was developing hepatorenal syndrome.
On [**8-9**], a liver donor became available and patient accepted
offer. She underwent ABO (A) incompatible liver (she was blood
type O) with splenectomy on [**2140-8-9**]. Three JPs were placed.
Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Pheresis was done just prior
to [**Last Name (NamePattern4) **] for Anti A titer of 512. CVVHD was done intraop.
Postop, she was transferred to the SICU intubated for
management. She required blood products in the immediate postop
period, but remained hemodynamically stable. LFTs increased
initially as expected then trended down daily. Liver duplex on
postop day 1 was normal. JP outputs were non-bilious. The JP in
the splenic bed had the highest output and appeared bloody.
Plasmapheresis continued daily based on Anti A antibody titers.
Titers decreased to 4. A total of 13 treatments were done. ATG
was given daily for a total of 7 doses (75mg each). Platelets
were administered prior to ATG in the immediate postop period.
Immunosuppression consisted of steroid taper per protocol,
CellCept [**Hospital1 **], ATG and Prograf which was started on postop day 1.
Doses were adjusted per trough levels. Goal prograf level was
10.
CVVHD was continued for hepatorenal syndrome. CVVHD was switched
to HD via temporary HD line. Nephrology followed her throughout
the hospital stay. Urine output increased around postop day 7
and dialysis was stopped ([**8-19**]). Urine output was approximately 2
liters, however, creatinine and BUN continued to increase up to
105. Dialysis was resumed on [**8-24**], and continued daily on [**8-25**] and
[**8-26**]. This was repeated on [**8-29**]. The plan was for her to continue
on hemodialysis at least twice weekly on Mondays and Fridays. On
[**8-25**], the temporary dialysis line was exchanged for a tunnelled
HD line in interventional radiology. A right-sided 23-cm
tip-to-cuff hemodialysis line with tip was seen in the right
atrium, ready for use.
She was transferred out of the SICU on [**8-20**] to the medical
surgical floor where diet was advanced and tolerated, but intake
was insufficient. Therefore, a feeding tube was placed and tube
feeds were started. Nutren 2.0 at 40cc/hour continuous was
recommended by the dietician. This was well tolerated. She
required intermittent sliding scale insulin for hyperglycemia
due to steroids.
Medial and lateral JPs were removed. The splenic bed JP drain
output appeared milky. Fluid was sent for amylase. On [**8-13**],
amylase was 537. This decreased to 76 on [**8-24**]. Drain output
volume decreased from 900ml/day to 300ml/day. JP was removed on
[**8-26**]. Incision was intact with staples.
Lower extremity non-invasives were done on [**8-25**] for asymmetrical
lower extremity swelling (Left>right). This was negative for
DVT. Teds were applied. Lower legs appeared erythematous with
puffiness of left dorsum.
Physical therapy worked with her noting improved strength and
balance. Medication teaching went well. A bed became available
at [**Hospital1 **] in [**Location (un) 86**] and she transferred there on
[**8-29**].
Medications on Admission:
(discharge meds [**2140-7-3**], confirmed with patient):
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. tolvaptan 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lactulose (takes occasionally)
Discharge Medications:
1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
follow printed taper schedule
17.5 start [**8-30**].
3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,TH): Monday and Thursday.
8. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
13. insulin regular human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
14. Outpatient Lab Work
every Monday and Thursday w results fax'd to [**Telephone/Fax (1) 697**] ([**Hospital 18**]
[**Hospital 1326**] Clinic)
cbc, chem 10, ast, alt, alk phos, t.bili, albumin and trough
prograf level
15. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
16. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
17. FreeStyle Lancets Misc Sig: One (1) Miscellaneous four
times a day.
Disp:*1 box* Refills:*2*
18. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous
four times a day.
Disp:*1 box* Refills:*2*
19. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous
once a day.
Disp:*1 kit* Refills:*2*
20. Insulin Syringes
U100 Low dose with 25-26 gauge needle
supply:1 box
refill: 2
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - at [**Hospital 1263**] Hospital - [**Location (un) 686**]
Discharge Diagnosis:
etoh cirrhosis
hepatorenal syndrome
malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You will be transferring to [**Hospital1 **] Rehab in [**Location (un) 86**]
Please call the [**Location (un) 1326**] Office [**Telephone/Fax (1) 673**] if you have any
of the following:
fever, shaking chills, nausea, vomiting, inability to take any
of your medications, jaundice, increased abdominal pain,
incision redness/drainage/bleeding, increased urine
output,constipation/diarrhea, malfunction of dialysis catheter
or any concerns
You will need to have blood drawn for lab monitoring every
Monday and Thursday
You will require hemodialysis at least twice weekly (Monday and
Friday)
You may shower, but must keep the tunnelled dialysis line dry
No straining/heavy lifting (nothing greater than 10 pounds)
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-8-31**] 2:00
Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-8-31**] 2:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-9-7**] 10:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2140-8-29**]
ICD9 Codes: 486, 5119, 5849, 2761, 2762, 4271, 4168, 5859, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 905
} | Medical Text: Admission Date: [**2127-12-16**] Discharge Date: [**2127-12-24**]
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male admitted with failure to thrive. The patient lives in
an independent living facility for long-term senior citizens.
The patient was feeling weak for the last few days with lower
social worker visited him and sent to the Emergency Room for
issues of neglect, and weakness, and poor hygiene. The
patient had no other complaints besides the weakness. The
patient had no fevers or chills, nausea, vomiting, shortness
of breath, cough, diarrhea, constipation, bright red blood
per rectum, or night sweats. The patient with some weight
loss, but he cannot define how much. Poor insight into state
a cleaning lady once a week who came in strictly to clean the
house but no other home care. The patient cleans and feeds
himself. His son visits his twice per month. His last
primary care visit was [**2126-11-1**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation.
3. Heart attack five years ago at [**Hospital6 15291**].
MEDICATIONS ON ADMISSION: The patient's medications on
admission included Vasotec, digoxin, atenolol, Coumadin 2 mg,
with other drugs (unknown doses).
ALLERGIES: Allergy to CODEINE.
SOCIAL HISTORY: The patient lives alone. He has three
children. His daughter is [**Name (NI) 5969**] (telephone number
[**Telephone/Fax (1) 15292**]). The patient is separated from his wife. [**Name (NI) **]
drinks no alcohol. He quit tobacco 20 years ago.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 95, heart
rate 37, blood pressure 90/50, weight 86.2 pounds, 95% oxygen
saturation on room air. In general, the patient was a
cachectic and disheveled elderly man. Head, ears, nose, eyes
and throat showed redness around eyes/erythema, pail sclerae.
Oropharynx was clear. Neck was supple. Full range of
motion. No lymphadenopathy. Chest revealed decreased breath
sounds at bases. Heart revealed bradycardia, irregularly
irregular. No murmurs, rubs or gallops. Positive first
heart sound and second heart sound. Spine with an area of
erythema at approximately T10, nontender. Abdomen was soft,
nontender, and nondistended, positive bowel sounds. Positive
inguinal hernia bilaterally. Extremities revealed dry flaky
skin. Feet were hyperkeratotic skin, toes stuck together due
to buildup of skin. Neurologic examination revealed alert
and oriented times three; did not know day. Upper
extremities with 5/5 strength. Lower extremities proximally
with 3/5 and distally with 5/5 strength. Rectal was
heme-negative.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count 6, hematocrit 41, platelets 167 (76% neutrophils,
0 bands, 17% lymphocytes). The patient's PT was 22.4,
PTT 40.3, INR 3.5. Sodium 144, potassium 4.6, chloride 103,
bicarbonate 31, blood urea nitrogen 28, creatinine 0.9,
glucose of 96. Anion gap 15. Digoxin level 2.5.
ASSESSMENT AND PLAN: A [**Age over 90 **]-year-old male with failure to
thrive.
1. FAILURE TO THRIVE: Due to inability to care for himself at
home the patient will need placement options, increased
nutrition, a
Physical Therapy consultation. The patient will need
Podiatry and Wound Care consultation. The patient with chest
x-ray, urinalysis, and urine culture for possible urinary
tract infection. The patient will need correction of
electrolyte abnormalities, supplements, and Protonix, and
subcutaneous heparin for prophylaxis.
2. CARDIOVASCULAR: The patient with atrial fibrillation and
bradycardia. The patient was hypothermic, may be
contributing to the bradycardia. The patient will be put on
telemetry. We will hold his antihypertensive medications,
hold Coumadin since INR was 3.5.
HOSPITAL COURSE: The patient had an episode of oxygen
desaturation to 70s and 80s even on 5 liters nasal cannula.
The patient was put on a nonrebreather, taken to the Medical
Intensive Care Unit for an overnight stay. The patient was
stable in the Medical Intensive Care Unit and was discharged
back to the floor and started on ceftriaxone and Flagyl
intravenously.
The patient with question of aspiration. A swallowing study
showed poor reflex, and the patient failed the swallowing
study. The patient had nasogastric tube placement for
feedings, and upon questionable placement via chest x-ray the
nasogastric tube was removed. Radiology report revealed
nasogastric tube/Dobbhoff tube was in the duodenum.
Gastrointestinal evaluation was done. The patient was not a
candidate for a percutaneous endoscopic gastrostomy tube or
surgical placement of G-tube or J-tube. The patient was
getting nutrition via intravenous via "Quick Mix" and now
getting oral thickened liquid diet and Boost in the full
upright position in light of failed nasogastric tube, and
since he cannot have a percutaneous endoscopic gastrostomy
tube placed. The patient will continue to get nutrition
orally at the nursing home.
The patient had a run of nonsustained ventricular tachycardia
and continued to have atrial fibrillation. The patient was
taken off telemetry monitor, as the patient was not a
candidate for pacemaker implant or arrhythmia surgery. The
patient has been asymptomatic with tachycardia. The patient
continued to have episodes of bradycardia and tachycardia.
The patient was started on captopril 6.25 mg b.i.d. for
congestive heart failure and hypertension. The patient has
been given Lasix multiple times for episodes of questionable
pulmonary edema and desaturations of oxygen saturation.
These were most likely due to mucous plugging and aspiration
of secretions. The patient's digoxin was discontinued for
high levels.
Podiatry consultation appreciated, the patient's feet were
properly clean and dressed via Podiatry. The patient was to
go to the nursing home on oral feeding with thickened liquids
in the upright position.
The patient will be followed by his attending, and do not
resuscitate/do not intubate status was addressed. The
patient would not like any intubation or invasive measures
taken if he should be in a code situation. The attending
will follow up with this. The patient's daughter also agreed
with this and agreed to have the patient go to a nursing
home. The patient asked to be kept comfortable and hoped he
will gain his strength back, but has been made fully aware of
his failing condition. He wished to "die peacefully" with
family or friends surrounding him if this should happen. We
hope he will regain some strength. If the patient's oxygen
saturation drops he made need suctioning of secretions, but
is not to be intubated and has been doing fine on oxygen via
nasal cannula and face mask with humidification. The patient
may need morphine for breathing comfort, but has not required
any to date.
On the day of discharge, the patient felt "fine" and was
looking forward to going to the nursing home where he has a
female friend/partner already staying there.
DISCHARGE DIAGNOSES:
1. Failure to thrive.
2. Atrial fibrillation.
3. Congestive heart failure.
4. Hypothyroidism.
5. Pulmonary issues.
CONDITION AT DISCHARGE: Condition on discharge was fair.
MEDICATIONS ON DISCHARGE:
1. Levoxyl 0.025 mg p.o. q.d.
2. Captopril 6.25 mg p.o. b.i.d.
3. Levaquin 500 mg p.o. q.d. times 10 days.
4. Flagyl 500 mg p.o. t.i.d. times 10 days.
5. Protonix 40 mg p.o. q.d.
6. Morphine 0.5 mg to 2 mg as needed for breathing issues;
not to be used if the patient is sedated or respiratory rate
decreases below 10.
DISCHARGE FOLLOWUP: The patient will be followed by
Dr. [**Last Name (STitle) **], his primary care physician. [**Name10 (NameIs) **] note, the
patient with high thyroid-stimulating hormone indicative of
hypothyroidism. The patient was started on Levoxyl.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15293**], M.D. [**MD Number(1) 15294**]
Dictated By:[**Last Name (NamePattern1) 4724**]
MEDQUIST36
D: [**2127-12-24**] 15:12
T: [**2127-12-24**] 15:11
JOB#: [**Job Number 15295**]
ICD9 Codes: 4280, 4019, 412, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 906
} | Medical Text: Admission Date: [**2179-9-29**] Discharge Date: [**2179-10-22**]
Date of Birth: [**2102-1-6**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
77M with history of CAD, AF, esophageal adenocarcinoma s/p XRT,
resection and chemotherapy who initially presented with
tachypnea [**12-30**] pericardial and pleural effusions and transferred
to MICU after thoracentesis, pericardiocentesis and pericardial
window with chest tube for pneumothorax. Stable respiratory
status since transfer to floor.
Major Surgical or Invasive Procedure:
Pericardiocentesis
Right Anterior Mini Thoracotomy and Pericardial Window
Bronchoscopy
Right heart catheterization
PICC placement
History of Present Illness:
Admitted to [**Location (un) **] from [**Hospital **] Rehab with tachypnea and
hypoxia.
Per OSH records, patient had been experiencing shortness of
breath, with O2 sats in the high 60's, RR in 40's. O2 sats
improved with Lasix up to 90% on 2L, BP 98-109/40-60s, HR
70-80s. Pt was given cefepime and levaquin for R-sided
infiltrate seen on CXR and underwent a US guided thoracentesis
for R-sided effusion. 1 liter of serous fluid removed,
post-procedure CXR showed 10% R apical pneumothorax. In
addition, patient went into a-fib w/ hr into 160's. Patient
given dig, amiodarone (loaded and drip x 6 hours) and diltiazem
drip. Patient underwent echo which showed large pericardial
effusion, sent to [**Hospital1 18**] for evaluation/pericardiocentesis.
.
Of note, patient recently discharged from [**Hospital3 **] after 2
week hospitalization for bilateral pleural effusions and
pneumonia.
.
On admission, patient states that he been feeling progressively
SOB for the past week, and has noticed increased swelling of his
lower extremities, making it difficult to walk. Denies any
current chest pain, reports currently breathing comfortably. No
F/C/N/V. H/o productive cough. + orthopnea.
Past Medical History:
HTN, lung disease, pleural tap 1L on right [**9-29**], COPD
exacerbation, esophageal cancer- Barrett's, stage II, T1, N1, MO
adenocarcinoma, s/p resection, chemo and radiation (completed
approx. 2 months ago), J-tube in place for supplemental
nutrition, PAF on coumadin (saw Mirbach for tachy thought to be
a-fib/flutter after adenosine x1), h/o cardioversion, anemia,
h/o kidney stones, "trigger finger", cataract surgery
Social History:
married w/ two sons, lives w/ wife [**Name (NI) 382**]. Former manager of
phone company. + 60 pack year tob history, quit 6 months ago.
+h/o ETOH, quit 6 months ago.
Family History:
Mom deceased at 78 from MI, Dad deceased from MS at 44. Brother
w/ quad bypass 78.
Physical Exam:
97.0/ 72/ 28/ 111/72 85kg/ 93% on 5L NC
GEN:pale, awake, alert, sitting up in bed, breathing comfortably
HEENT:atraumatic, anicteric sclerae, clear OP
NECK:no carotid bruits, JVP about 10cm
CV:muffled and distant HS, no murmurs appreciated, +pleural rub,
+femoral pulses, faint but +DP and PT pulses. Pulsus of 9.
LUNGS:diminished on R, crackles at bases, deeply productive
cough
ABDOMEN: soft, j-tube in place, site CDI, NABS, nt
EXT:[**1-29**]+ pitting edema bilaterally on LE, UE edema bilaterally,
+ clubbing of nails, resting tremor of R leg
NEURO:A/O X3, spontaneous movement x4. no focal deficits
Pertinent Results:
EKG: a-fib, low voltage in precordial and limb leads, no ST
changes or TWI
.
Cath ([**9-30**]): Right heart catheterization demonstrated elevated
right atrial and right ventricular end diastolic pressures which
were approximately equal to pericardial pressures (12 mmHg0
suggestive of early tamponade. After pericardiocentesis,
pericardial pressures returned to 0 mmHg. Cardiac output
calculated using the Fick method demonstrated moderate to
severely diminished cardiac index of 2.0L/min/m2 prior to
pericardiocentesis, with improvement to 2.6L/min/m2 after
pericardiocentesis. PA sat improved 48 to 58.
.
Echo ([**10-11**]): approximately 1 cm wide partially echo dense
region around the heart (most prominent anteriorly) consistent
with probable somewhat organized pericardial effusion and
pericardial thickening. No definite echocardiographic signs of
tamponade are identified but views are technically suboptimal.
Echo ([**10-6**]): moderate sized pericardial effusion. No right
ventricular diastolic collapse is seen. There is sustained right
atrial collapse, consistent with low filling pressures or early
tamponade
Echo ([**10-2**]): moderate pericardial effusion, anterior to RA and
RV, consistent with loculation
Echo ([**9-30**]): anterior space fat pad, but possible loculated
anterior pericardial effusion
Echo ([**9-29**]): large pericardial effusion with increased
intrapericardial pressure, EF 50-60%
.
CXR ([**10-11**], 14:26): Probable small right apical pneumothorax.
Status post placement of small bore chest tube. Moderate right
and small left pleural effusions.
CXR ([**10-11**], 10:30): Worsening atelectasis in the right lung.
Lucency at right lung apex, without definitive visceral pleural
line identification. Status post esophagectomy and pullup
procedure.
Improving left pleural effusion and enlarging right pleural
effusion
CXR ([**10-10**]): Bilateral pleural effusions and associated
atelectases in both lower zones. No pneumothorax.
CXR ([**10-2**]): mild pulmonary edema, moderate bilateral pleural
effusions (R>L)
CXR ([**9-29**]): bilateral pleural effusions (L>R), pulmonary edema
on right side, RLL collapse
.
Cytology [**10-11**] - bronchial brushings - reactive bronchial
epithelial cells.
.
Chest U/S [**10-12**] - bilateral pleural effusions
.
CT-Chest/abd/pelvis - [**10-13**] - Interval decrease in pericardial
effusion and right-sided pleural effusion with left-sided
pleural effusion, not significantly changed. Interval increase
in size of right-sided pneumothorax compared to prior chest CT.
Compressive atelectasis in both lungs with no specific evidence
for aspiration. No evidence of GI or bowel obstruction.
Cholelithiasis. Small nonobstructing stones in the right kidney.
Low attenuation lesion in the left kidney that likely represents
a cyst, that is not fully characterized on this noncontrast
study.
.
[**2179-9-29**] 07:26PM GLUCOSE-128* UREA N-25* CREAT-0.6 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12
[**2179-9-29**] 07:26PM CK(CPK)-13*
[**2179-9-29**] 07:26PM CK-MB-NotDone cTropnT-<0.01
[**2179-9-29**] 07:26PM ALBUMIN-2.3* CALCIUM-7.4* PHOSPHATE-3.2
MAGNESIUM-1.5* IRON-28*
[**2179-9-29**] 07:26PM calTIBC-212* VIT B12-933* FOLATE-14.0
FERRITIN-347 TRF-163*
[**2179-9-29**] 07:26PM WBC-12.6* RBC-2.83* HGB-9.2* HCT-27.3* MCV-96
MCH-32.5* MCHC-33.7 RDW-15.8*
[**2179-9-29**] 07:26PM RET AUT-2.8
[**2179-9-29**] 07:26PM PT-17.8* PTT-33.5 INR(PT)-2.2
[**2179-9-29**] 07:26PM BLOOD calTIBC-212* VitB12-933* Folate-14.0
Ferritn-347 TRF-163*
[**2179-10-1**] 01:35AM BLOOD Type-ART Temp-37.1 pO2-66* pCO2-54*
pH-7.40 calHCO3-35* Base XS-6
[**2179-9-30**] 10:45AM OTHER BODY FLUID WBC-444* Hct,Fl-2* Polys-22*
Lymphs-10* Monos-7* Eos-1* Mesothe-1* Macro-59*
[**2179-9-30**] 10:45AM OTHER BODY FLUID TotProt-3.6 Glucose-99
LD(LDH)-343 Amylase-16 Albumin-2.0
[**2179-10-13**] 02:26PM PLEURAL TotProt-2.1 LD(LDH)-88 Albumin-1.1
[**2179-10-13**] 02:26PM PLEURAL WBC-17* RBC-510* Polys-39* Lymphs-26*
Monos-25* Meso-8* Macro-2*
[**2179-10-7**] 06:06AM BLOOD WBC-8.8 RBC-3.16* Hgb-10.3* Hct-29.5*
MCV-93 MCH-32.5* MCHC-34.8 RDW-16.5* Plt Ct-245
[**2179-10-8**] 05:11AM BLOOD WBC-12.1* RBC-3.27* Hgb-10.7* Hct-30.5*
MCV-93 MCH-32.6* MCHC-35.0 RDW-16.4* Plt Ct-235
[**2179-10-9**] 05:00AM BLOOD WBC-13.8* RBC-3.12* Hgb-10.1* Hct-30.2*
MCV-97 MCH-32.4* MCHC-33.4 RDW-16.1* Plt Ct-266
[**2179-10-11**] 05:15AM BLOOD WBC-8.6 RBC-2.71* Hgb-8.8* Hct-27.0*
MCV-100* MCH-32.4* MCHC-32.5 RDW-15.9* Plt Ct-245
[**2179-10-12**] 04:15AM BLOOD WBC-10.3 RBC-2.80* Hgb-9.0* Hct-26.0*
MCV-93 MCH-32.3* MCHC-34.7 RDW-16.2* Plt Ct-318
[**2179-10-14**] 03:52AM BLOOD WBC-9.6 RBC-3.40*# Hgb-10.9*# Hct-30.3*#
MCV-89 MCH-32.1* MCHC-36.0* RDW-16.0* Plt Ct-225
[**2179-10-9**] 05:00AM BLOOD PT-15.0* PTT-32.3 INR(PT)-1.5
[**2179-10-10**] 06:51AM BLOOD PT-14.4* PTT-50.4* INR(PT)-1.4
[**2179-10-10**] 07:45AM BLOOD PT-14.3* PTT-32.8 INR(PT)-1.4
[**2179-10-12**] 04:15AM BLOOD PT-16.2* PTT-108.1* INR(PT)-1.8
[**2179-10-13**] 04:12AM BLOOD PT-15.1* PTT-74.0* INR(PT)-1.6
[**2179-10-14**] 03:52AM BLOOD PT-14.3* PTT-28.9 INR(PT)-1.4
[**2179-10-7**] 06:06AM BLOOD Glucose-83 UreaN-21* Creat-0.5 Na-140
K-4.8 Cl-100 HCO3-35* AnGap-10
[**2179-10-9**] 05:00AM BLOOD Glucose-128* UreaN-16 Creat-0.5 Na-139
K-4.3 Cl-99 HCO3-34* AnGap-10
[**2179-10-12**] 04:15AM BLOOD Glucose-100 UreaN-22* Creat-0.4* Na-140
K-4.0 Cl-98 HCO3-37* AnGap-9
[**2179-10-14**] 03:52AM BLOOD Glucose-71 UreaN-18 Creat-0.5 Na-143
K-4.2 Cl-98 HCO3-33* AnGap-16
[**2179-10-2**] 02:16PM BLOOD ALT-10 AST-8 LD(LDH)-126 AlkPhos-66
TotBili-0.3
[**2179-10-13**] 04:12AM BLOOD TotProt-4.7* Calcium-8.2* Phos-3.3
Mg-1.5*
[**2179-10-11**] 02:51PM BLOOD Type-ART Rates-/28 FiO2-100 pO2-194*
pCO2-91* pH-7.26* calHCO3-43* Base XS-10 AADO2-450 REQ O2-75
Intubat-NOT INTUBA
[**2179-10-11**] 09:48PM BLOOD Type-ART Temp-37.7 pO2-76* pCO2-54*
pH-7.47* calHCO3-40* Base XS-13 Intubat-INTUBATED
[**2179-10-12**] 12:18AM BLOOD Type-ART Temp-37.4 Rates-20/26 Tidal
V-450 PEEP-5 FiO2-50 pO2-102 pCO2-54* pH-7.46* calHCO3-40* Base
XS-12 -ASSIST/CON Intubat-INTUBATED
[**2179-10-13**] 04:12AM BLOOD Type-ART Temp-36.9 Rates-/24 PEEP-5
FiO2-50 pO2-73* pCO2-58* pH-7.43 calHCO3-40* Base XS-11
Intubat-INTUBATED Vent-SPONTANEOU
[**2179-10-13**] 01:43PM BLOOD Type-ART Temp-37.8 Rates-/72 FiO2-40
pO2-103 pCO2-75* pH-7.37 calHCO3-45* Base XS-13 Intubat-NOT
INTUBA Comment-NEBULIZER
[**2179-10-14**] 05:56AM BLOOD Type-ART Temp-36.7 FiO2-50 pO2-81*
pCO2-61* pH-7.39 calHCO3-38* Base XS-8
[**2179-10-14**] 03:45PM BLOOD Type-ART Temp-36.7 pO2-118* pCO2-62*
pH-7.37 calHCO3-37* Base XS-8
.
Discharge Labs:
[**2179-10-22**]
07:05a
Na 137 Cl 98 BUN 18 Glc 114
K 4.6 Bicarb 33 Cr 0.5
Ca: 7.9 Mg: 1.6 P: 3.6
PT: 13.9 PTT: 62.7 INR: 1.3
-----------
[**10-22**] 12AM
heparin dose: 1180
PTT: 60.8
----------
[**2179-10-21**]
5:05p
heparin dose: 1180
PTT: 65.2
-----------
[**2179-10-21**]
09:05a
heparin dose: 1120
PT: 13.9 PTT: 53.8 INR: 1.3
Brief Hospital Course:
77 y/o male w/ long history of smoking, a-fib, htn, COPD, and
esophageal cancer rx w/ chemo, surgery, and radiation; s/p
thoracentesis, who presents with hypoxia, tachypnea, concern for
tamponade on echo done at OSH.
1. Cardiac
In terms of his vessels, he was stable, with no acute concerns
to suggest ischemia. The patient had negative cardiac enzymes
on admission. He was restarted on his beta blocker once his
blood pressure was able to tolerate it, and was titrated up to a
dose of metoprolol 25mg TID. In terms of his pump, the patient
underwent a repeat echo immediately upon admission which showed
a large circumferential effusion, with an estimated EF >55%. He
underwent a pericardiocentesis on [**9-30**] with removal of over 300
cc of bloody exudative fluid. Cultures from the fluid were
negative, and the preliminary report on the cytology of the
fluid is negative for malignancy. The patient underwent
subsequent repeat echoes which showed a stable, persistent
anterior effusion. Thoracic surgery was consulted to evaluate
patient for a pericardial window, felt that procedure would
carry a higher risk given past surgery for esophageal cancer.
Patient would need risk stratification prior to surgery. The
patient had an echo on the day of discharge, which showed an
increase in the pericardial effusion (loculated) w/ RA collapse
and evidence of constrictive pericarditis as well. The decision
was made for patient to undergo a pericardial window, and was
taken to the OR on [**10-7**]. Will need to follow up on fluid
cytology, pathology, and culture results. Report was negative
for malignant cells.
In addition, the patient had a history of atrial fibrillation,
and underwent both electro cardioversion and chemical conversion
with ibutilide at the OSH. Although in NSR on admission, the
patient subsequently developed an atrial tachycardia/a-flutter
rhythm with a heart rate up to 140's. Rate control was
attempted with IV calcium channel blocker, IV metoprolol, and IV
amiodarone; but ultimately required conversion again with
ibutilide. The patient remained in NSR with effective rate
control on amiodarone and metoprolol. Patient currently on TID
Amiodarone but can be switched to once daily Amiodarone on [**11-1**].
The patient was restarted on heparin after an occluding thrombus
was seen in his left cephalic vein. He is being transferred to
rehab on heparin drip for bridge to coumadin. His goal PTT is
60-80 and his goal INR is [**12-31**]. Patient will need to have his INR
followed closely as an outpatient once discharged from extended
care facility.
.
2. Pulmonary- the patient was admitted with hypoxia/tachypnea,
likely secondary to bilateral effusions and ?
infiltrate/infection seen on chest x-ray. The patient was
placed on oxygen with a goal saturation in low-mid 90's given
his history of COPD, with continuation of his
Advair/Atrovent/spiriva/Xopenex. The OSHs were contact[**Name (NI) **] for
results from his thoracentesis-->which were c/w a transudative
fluid, all cultures negative, however it was unclear as to
whether any sample was sent for cytology. The patient underwent
a chest CT, which showed significant consolidation on the right,
a right hydropneumothorax from the prior tap at the OSH,
bilateral pleural effusions, and changes consistent with
pneumonitis form XRT. Given that the patient had recently been
treated with Levaquin at the OSH, the patient was started on
ceftriaxone to complete a ten day course, and azithromycin.
Pulmonary was consulted, and they recommended completing the
course of antibiotics and felt that further thoracentesis would
be low yield, but that the patient should have a repeat CT in a
few weeks to evaluate for resolution of his effusions. The
patient underwent a repeat CT prior to pericardial window
procedure, which showed an increase in his effusions
bilaterally, thus pleural fluid was also removed during the
procedure with samples sent for cytology/path/culture. The
patient's breathing and oxygen saturation remained stable
throughout his hospitalization, and his cough lessened in
severity. The patient became acutely hypoxic and tachypneic on
am of [**10-11**], requiring transfer back to CCU for intubation. CXR
showed R apical pneumothorax, dart chest tube placed by thoracic
service w/out much improvement on repeat CXR. Pulmonary
reconsulted, decided patient will need bronch and that primary
issues were no longer cardiac but rather pulmonary. Decision
made to transfer patient to MICU team.
While on the MICU service the pt's minichest tube was pulled on
[**10-14**]. F/U CXR revealed a stable PTX. The pt was extubated on
[**10-14**] and continued to do well from a respiratory standpoint
with chest PT and pulmonary toilet. However post extubation pt
continued to have recurrent atrial tach. Patient cardioverted on
[**10-2**] w/ ibutilide (1.6 mg) and is now on amiodarone, rhythm
mostly sinus with freq PACs. Beta blocker was re-added once his
hypotension resolved. He was back in afib/flutter [**10-15**],
unresponsive to IV metop and dilt drip, converted by EP with
ibutilide. The pt is now stable in NSR on amiodarone. His
respiratory status has been stable since transfer to the floor.
His O2 sats are 94-96 on 2L NC. Patient can be weaned off
supplemental O2 as tolerated. Patient started on standing Lasix
for prevention of volume overload.
.
3. ID- The patient was started on ceftriaxone and azithromycin
for pneumonia, showed some improvement in his productive cough
while on antibiotics and completed course. Cultures from his
pericardial fluid were negative, cultures from pleural fluid
negative from [**10-13**] following "very low numbers" of coagulase
negative staphylococcus on [**10-7**]. Patient remained afebrile
without a leukocytosis during remainder of his admission.
.
4. Anemia- likely iron deficiency anemia in addition to element
of anemia of chronic disease secondary to malignancy. The
patient was transfused 2 units of PRBCs with appropriate
increases in his HCT during admission. Iron studies were sent,
which were c/w iron deficiency anemia, vitamin B12 and folate
were normal. The patient had several episodes of guaiac
positive brown stool, and although he states that he has had a
colonoscopy within the past five years, he will likely need a GI
workup as an outpatient. Although kidney function appeared
normal with a creatinine of .5, the patient would likely benefit
from iron/Epogen supplementation as an outpatient. Would
recommend starting weekly Epoen injections.
.
5. FEN- The patient was restarted on TF through his j-tube per
nutrition recommendations. Evaluated with bedside speech and
swallow evaluation as well as video swallow. He can have thin
liquids and pureed consistency solids as per their recs. He MUST
take small, single sips of thin liquids by cup or straw. He was
noted to have a metabolic alkalosis, with an initial bicarb of
34 that rose to 37. This was thought to be secondary to
contraction alkalosis as patient received some Lasix, in
addition to a compensatory alkalosis for a respiratory acidosis
from his COPD, and resolved without specific intervention.
Bicarb 33 at time of discharge. Would monitor closely as patient
started to standing Lasix to prevent volume overload. Patient
required aggressive magnesium supplementation and should have
his electrolytes monitored closely.
.
6. Oncology- the patient was recently treated for Stage II
esophageal cancer, s/p resection, chemo and XRT with intended
cure. Heme/onc was consulted and recommended that patient
undergo restaging with a PET scan as an outpatient. The patient
did not show signs of metastasis on CT done here, and the
preliminary cytology report from his pericardial fluid was
negative for malignancy, however it was noted that this does not
rule out a malignant effusion given the low sensitivity of
cytology.
The patient stated that he wants to continue his oncology care
through [**Hospital3 2358**], and has a follow-up appointment scheduled
with his oncologist for [**2179-11-18**].
.
7. Dispo: The patient was seen by PT/OT prior to discharge, and
the patient should see his PCP after leaving extended care
facility so that a follow-up echo can be arranged, in addition
to Coumadin management and monitoring of his QT interval, as
many of his medications cause a prolonged QT.
Medications on Admission:
Admit meds from OSH:
Amiodarone gtt at 0.5mg/min
Diltiazem gtt
Furosemide 40mg daily
Advair
KCl
Metoprolol 100mg tid
Dulcolax
MOM
Albuterol
[**Name (NI) 10687**]
MVI
Reglan
Coumadin
Levofloxacin
Cefepime
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 3 weeks.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. [**Hospital1 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) sliding scale Intravenous ASDIR (AS DIRECTED):
Please continue heparin sliding scale w/ PTT goal 60-80 until
INR therapeutic at 2-3.
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times
a day: Please continue this dose for 10 days through [**2179-11-1**] and
then switch to 200mg once daily.
16. Epogen 20,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 19504**] of [**Hospital1 189**]
Discharge Diagnosis:
pericardial effusion
pleural effusion
COPD
a-flutter/a-fib s/p chemical conversion
hypertension
esophageal adenocarcinoma
Discharge Condition:
Stable
Discharge Instructions:
Please take all of your other medications as instructed. Please
maintain your follow-up appointments as listed below. Please
call your doctor or return to the hospital if you develop
shortness of breath, chest pain, fever or chills. Please have a
follow-up echo in about 4 weeks.
Followup Instructions:
1. You have an appointment scheduled with your oncologist for
[**2179-11-18**] at 9AM at the [**Hospital3 **] with Dr.[**Last Name (STitle) **] at
[**Telephone/Fax (1) 66282**].
2. Please follow up with your primary care doctor within [**11-29**]
weeks of discharge from rehab facility.
3. Please contact Dr.[**Last Name (STitle) **] with any questions by paging him at
[**Telephone/Fax (1) 8717**], pager #[**Numeric Identifier 9522**].
Completed by:[**2179-10-22**]
ICD9 Codes: 486, 496, 5180, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 907
} | Medical Text: Admission Date: [**2120-11-4**] Discharge Date: [**2120-11-12**]
Date of Birth: [**2061-5-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2120-11-4**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
OM, SVG to Ramus)
History of Present Illness:
59 y/o female with multiple cardiac risk factors who experienced
chest pain and admitted on [**10-17**] with a myocardial infarction.
Underwent Cardiac Cath at that time which revealed Left main and
three vessel disease. Stent was placed in RCA and now returns
for surgical revascularization.
Past Medical History:
1) Myocardial Infarction with PTCI/Stent to RCA [**10-14**]
2) Hypertension
3) Hyperlipidemia
4) s/p MVA ([**10/2112**]) with chronic neck pain
5) Carpal tunnel syndrome
6) Seborrheic psoriasis with postinflammatory hyperpigmentation
of face
Social History:
No ETOH, +smoking history ([**12-11**] ppd), no illicit drugs.
Family History:
No history of MI or diabetes.
Physical Exam:
Preop
General: Pleasant woman in NAD
HEENT: EOMI, PERRL, NC/AT]
Cardiac: RRR -c/r/m/g
Pulm: CTAB -w/r/r
Abd: Soft, NT/ND +BS
Ext: W/D -c/c/e
Neuro: A&O x 3, MAE, non-focal
Discharge
Gen NAD
Neuro A&Ox3, MAE-nonfocal exam
Pulm CTA bilat
Cor RRR, S1-S2, sternum stable- incision CDI
Abdm Soft/NT/ND/NABS
Ext Warm & well perfused. Trace edema bilat. Left EVH site with
steris CDI
Pertinent Results:
Echo [**11-4**]: PRE-BYPASS: Left ventricular wall thicknesses and
cavity size are normal. There is moderate to severe regional
left ventricular systolic dysfunction with severe hypokinesis of
the mid inferior wall. Overall left ventricular systolic
function is mildly depressed. The remaining left ventricular
segments contract normally. 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. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Torn mitral chordae are present. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
POST CPB: No change in biventricular systolic function with
persistent wall motion abnormalities. No change in valve
structure and function
CXR [**11-8**]:
[**2120-11-4**] 11:29AM BLOOD WBC-12.5* RBC-2.54*# Hgb-7.8*# Hct-21.8*#
MCV-86 MCH-30.6 MCHC-35.6* RDW-14.7 Plt Ct-215
[**2120-11-8**] 06:20AM BLOOD WBC-19.0* RBC-3.37*# Hgb-10.3*#
Hct-29.1*# MCV-86 MCH-30.7 MCHC-35.6* RDW-15.2 Plt Ct-302
[**2120-11-4**] 12:30PM BLOOD PT-14.2* PTT-39.0* INR(PT)-1.3*
[**2120-11-4**] 12:41PM BLOOD UreaN-12 Creat-0.5 Cl-112* HCO3-25
[**2120-11-8**] 06:20AM BLOOD Glucose-97 UreaN-14 Creat-0.7 Na-140
K-4.6 Cl-99 HCO3-31 AnGap-15
[**2120-11-12**] 06:00AM BLOOD WBC-15.4*
[**2120-11-11**] 06:05AM BLOOD WBC-23.0*# RBC-4.09* Hgb-12.1 Hct-36.1#
MCV-88 MCH-29.5 MCHC-33.4 RDW-15.3 Plt Ct-604*
[**2120-11-11**] 06:05AM BLOOD Glucose-99 UreaN-18 Creat-0.8 Na-138
K-5.2* Cl-95* HCO3-30 AnGap-18
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit and was brought directly to the
operating room where she underwent a Coronary Artery Bypass
Graft x 3(LIMA-LAD, SVG-OM, SVG-Ramus). Please see operative
report for surgical details. She tolerated the procedure well
and was transferred to the CSRU for invasive monitoring in
stable condition. Later on op day she was weaned from sedation,
awoke neurologically intact and was extubated. On post-op day
one chest tubes were removed and beta blockers and diuretics
were started. She was gently diuresed towards her pre-op weight.
Also on this day she was transferred to the SDU. On post-op day
three epicardial pacing wires were removed. She was started on
Folic Acid and Iron secondary to low HCT, but was not
transfused. Over the next several days she slowly improved while
working with physical therapy for strength and mobility. She
cleared level five physical therapy and on post-op day 8 it was
decidecd she was stable and ready for discharge home
Medications on Admission:
Lisinopril 5 qd, Plavix 75 qd, Nitro SL prn, Lipitor 80 qd,
Lopressor 50 [**Hospital1 **], Folic Acid, Methotrexate 2.5 (8 qtues),
Etanercept 50 qMon/[**Last Name (un) **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Last Name (un) **]:*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).
[**Last Name (un) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
[**Last Name (un) **]:*50 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (un) **]:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (un) **]:*30 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Last Name (un) **]:*30 Tablet(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Last Name (un) **]:*30 Tablet(s)* Refills:*2*
8. Methotrexate 2.5 mg Tablet Sig: Eight (8) Tablet PO Q
Tuesday.
9. Enbrel 50 mg/mL (0.98 mL) Syringe Sig: One (1) Subcutaneous
Q Monday/Thursday.
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
[**Last Name (un) **]:*180 Tablet(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
[**Last Name (un) **]:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO once a day for 2 weeks.
[**Last Name (un) **]:*56 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: Myocardial Infarction, Hypertension, Hyperlipidemia, Carpal
Tunnel Syndrome, Seborrheic psoriasis with postinflammatory
hyperpigmentation of face, s/p MVA with chronic neck pain
Discharge Condition:
Good
Discharge Instructions:
no lotions, creams or powders on any incision
no driving for one month
shower over incision and pat dry
call for fever greater than 100, redness or drainage
no lifting greater than 10 pounds for 8 weeeks
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**First Name (STitle) 3510**] in [**12-11**] weeks
Dr. [**Last Name (STitle) **] in [**1-12**] weeks
Completed by:[**2120-11-12**]
ICD9 Codes: 4271, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 908
} | Medical Text: Admission Date: [**2182-5-30**] Discharge Date: [**2182-6-5**]
Date of Birth: [**2099-9-16**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 33015**]
Chief Complaint:
Shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
.
82 year old male with complicated PMH including metastatic
adenocarcinoma to liver of unknown primary (possibly
cholangiocarcinoma), systolic HF with EF45%, CAD, CRI, MICU
transfer following 3 day admission in the MICU. Has experienced
functional decline in the setting of new dx of met. adenoca.
found incidentally in 09. Of note, he was recently discharged
from [**Hospital1 18**] on [**2182-5-24**] following 10 day admission for acute on
CRI(peak Cr 4.7) thought related to prerenal phsyiology in
setting of ESBL UTI. During admission, his home lasix and
lisinopril were discontinued and his metoprolol and imdur were
decreased. He was discharged to rehab to complete 2L NS
infusion. He was evaluated by speech and swallow for dysphagia
and palliative care was involved in goals of care discussion
where family was clear about wishes for continued aggressive
measures during that stay.
.
Pt returned to the ED on [**2182-5-30**] with following vitals: HR 116
BP 198/119 RR 28 POx 100 O2 sat. Found to have O2 sat of 94% on
NRB. Patient was given 80mg IV lasix with 600cc output, nitro
gtt, 4mg IV morphine, antibiotic coverage for suspected hospital
acquired pneumonia (ceftriaxone 1gm, levaquin 750mg IV, and
vancomycin 1gm IV). He was placed on CPAP with improvement. Labs
were significant for troponin 0.36, creatinine 1.7, WBC 11.6
with left shift.
EKG with ST changes laterally.
.
Pt was admitted to the ICU p/w s/s of flash pulmonary edema in
the setting of hypertensive urgency, likely secondary to CRI
where meds were decreased. He was diuresed with 80mg IV lasix.
Due to low clinical suspicion regarding hospital-acquired
pneumonia, pt was discontinued from ceftriaxone and vancomyin
and kept on levaquin. Palliative care was involved. Pt now
stable and ready for transfer to the floor.
.
Review of systems: denies CP, abdominal pain, nausea, vomiting,
diarrhea
Past Medical History:
H/o PNA with MRSA
GERD
CAD: NSTEMI in [**2180**] that was medically managed
CHF: Systolic dysfunction, EF 45-50%
HTN
Hyperlipidemia
Parkinson's disease: Diagnosed in [**2166**], on dopamine agonists,
disease course complicated by autonomic dysfunction
Adenocarcinoma in the liver: Incidentally discovered in [**2181**],
moderate to poorly differentiated adenocarcinoma metastasis from
unknown primary
Chronic renal insufficiency: Baseline Cr 1.3-1.6
BPH
H/o mulitple UTIs: has been complicated by sepsis in the past
Renal cysts on R
Melanoma s/p excision (R ear) in [**2177**]
Anterior subluxation of L4/L5
Incomplete paraplegia: [**1-7**] spinal stenosis, s/p surgery
Depression, anxiety
Social History:
The patient is a retired sociology and IR professor. He has been
residing in [**Hospital 100**] Rehab for several years now. He is a former
smoker but quit 45 years ago. Rare alcohol. His wife and
daughter live in the great [**Name (NI) 86**] area
Family History:
The patient has one daughter with breast cancer. No other h/o
malignancy. Both his son and daughter have renal cysts
Physical Exam:
Physical Exam:
.
Vitals: T: 98.2 BP: 145/59 P: 68 R: 15 O2: 98% on 3L O2. Water
balance: negative 2252 cc.
.
General: Alert, no acute distress, pleasant
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, JVP elevated to clavicle, no LAD
Lungs: no accessory respiratory muscle use; rales in bilateral
lobes with decreased [**Name (NI) 1440**] sounds; expiratory rhonchi
CV: Regular rate and rhythm, normal S1 + S2, HS distant, no
murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, mildly-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, chronic venous stasis changes in legs, well perfused,
2+ pulses, 3+ pitting edema to knees, slight resting tremor of
both arms, mild cogwheeling
Left brachial PICC line - appears to be pulled out, no erythema
skin: pale
Psych: alert and oriented to person, place, and time
Pertinent Results:
[**2182-6-4**] 07:48AM BLOOD WBC-7.0 RBC-3.37* Hgb-9.3* Hct-30.1*
MCV-89 MCH-27.7 MCHC-31.0 RDW-16.5* Plt Ct-184
[**2182-6-3**] 07:25AM BLOOD WBC-8.1 RBC-3.42* Hgb-9.5* Hct-30.5*
MCV-89 MCH-27.8 MCHC-31.2 RDW-16.6* Plt Ct-190
[**2182-6-2**] 06:25AM BLOOD WBC-8.5 RBC-3.36* Hgb-9.3* Hct-30.1*
MCV-90 MCH-27.6 MCHC-30.8* RDW-16.6* Plt Ct-188
[**2182-6-1**] 04:30AM BLOOD WBC-8.1 RBC-3.18* Hgb-8.9* Hct-28.6*
MCV-90 MCH-28.1 MCHC-31.2 RDW-16.7* Plt Ct-184
[**2182-5-31**] 03:35AM BLOOD WBC-12.5* RBC-3.40* Hgb-9.5* Hct-30.8*
MCV-91 MCH-27.9 MCHC-30.8* RDW-16.6* Plt Ct-224
[**2182-5-30**] 09:30PM BLOOD WBC-11.7*# RBC-4.02*# Hgb-11.1*#
Hct-36.4*# MCV-90 MCH-27.7 MCHC-30.6* RDW-16.6* Plt Ct-288#
[**2182-5-30**] 09:30PM BLOOD Neuts-81.6* Lymphs-11.1* Monos-4.1
Eos-2.5 Baso-0.7
[**2182-6-4**] 07:48AM BLOOD Plt Ct-184
[**2182-6-3**] 07:25AM BLOOD Plt Ct-190
[**2182-6-2**] 06:25AM BLOOD Plt Ct-188
[**2182-6-1**] 04:30AM BLOOD Plt Ct-184
[**2182-5-31**] 03:35AM BLOOD Plt Ct-224
[**2182-5-30**] 09:30PM BLOOD Plt Ct-288#
[**2182-5-30**] 09:30PM BLOOD Plt Ct-288#
[**2182-5-30**] 09:30PM BLOOD PT-13.3 PTT-24.0 INR(PT)-1.1
[**2182-6-4**] 02:35PM BLOOD Glucose-143* UreaN-34* Creat-1.7* Na-138
K-4.1 Cl-99 HCO3-31 AnGap-12
[**2182-6-3**] 07:25AM BLOOD Glucose-129* UreaN-35* Creat-1.7* Na-137
K-4.2 Cl-99 HCO3-30 AnGap-12
[**2182-6-2**] 06:25AM BLOOD Glucose-153* UreaN-37* Creat-1.7* Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
[**2182-6-1**] 04:30AM BLOOD Glucose-145* UreaN-40* Creat-1.7* Na-140
K-4.2 Cl-101 HCO3-31 AnGap-12
[**2182-5-31**] 03:35AM BLOOD Glucose-220* UreaN-39* Creat-1.6* Na-141
K-4.8 Cl-103 HCO3-31 AnGap-12
[**2182-5-30**] 09:30PM BLOOD Glucose-246* UreaN-39* Creat-1.7*# Na-139
K-5.3* Cl-103 HCO3-24 AnGap-17
[**2182-5-31**] 03:35AM BLOOD CK(CPK)-61
[**2182-5-30**] 09:30PM BLOOD CK(CPK)-74
[**2182-5-31**] 03:35AM BLOOD CK-MB-NotDone cTropnT-0.36*
[**2182-5-30**] 09:30PM BLOOD cTropnT-0.36*
[**2182-6-4**] 02:35PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
[**2182-6-3**] 07:25AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
[**2182-6-2**] 06:25AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
[**2182-5-31**] 03:35AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.2
[**2182-5-30**] 09:30PM BLOOD TotProt-6.9 Albumin-3.3* Globuln-3.6
Calcium-8.9 Phos-4.1 Mg-2.2
[**2182-5-31**] 04:34AM BLOOD Type-ART pO2-151* pCO2-41 pH-7.43
calTCO2-28 Base XS-3
[**2182-5-31**] 01:36AM BLOOD Type-ART pO2-113* pCO2-47* pH-7.39
calTCO2-30 Base XS-3 Intubat-NOT INTUBA
[**2182-5-30**] 09:39PM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2182-5-31**] 01:36AM BLOOD Lactate-1.2
[**2182-5-30**] 09:39PM BLOOD Glucose-235* Lactate-2.7* Na-140 K-5.3
Cl-103 calHCO3-24
[**2182-5-31**] 01:36AM BLOOD O2 Sat-99
[**2182-5-30**] 09:39PM BLOOD Hgb-12.0* calcHCT-36 O2 Sat-97
[**2182-6-5**] 05:33AM BLOOD WBC-5.7 RBC-3.21* Hgb-8.8* Hct-28.6*
MCV-89 MCH-27.3 MCHC-30.6* RDW-16.4* Plt Ct-174
[**2182-6-5**] 05:33AM BLOOD Plt Ct-174
[**2182-6-5**] 05:33AM BLOOD Glucose-130* UreaN-32* Creat-1.7* Na-139
K-3.8 Cl-100 HCO3-29 AnGap-14
Brief Hospital Course:
Pt is an 82 year old white male with complicated past medical
history of metastatic adenocarcinoma, systolic heart failure
with an ejection fraction of 45%, chronic renal insufficiency,
parkinson's disease, transfer from 3 day medical intensive care
unit admission who presents from rehab after recent admit for
acute on chronic renal insufficiency, flash pulmonary edema in
the setting of hypertensive urgency likely [**1-7**] to the holding of
antihypertensive medication.
.
Acute pulmonary edema with acute on chronic systolic heart
failure: likely due to flash pulmonary edema in setting of
hypertensive urgency and acute exacerbation of heart failure.
Prior to the MICU admission, lisinopril and lasix had been
discontinued, while the imdur and BB had decreased. - [**1-7**] flash
pulmonary edema in setting of HTN urgency. Prior to MICU, the
lisinopril/lasix had been d/c'd, and imdur and BB decreased. Pt
tolerated diuresis and responded well to IV lasix, which was
later switched to PO administration. Creatinine levels held
steady at around 1.6-1.7, with a baseline level at around
1.4-1.6. Strict input and output levels were maintained, and
showed that pt was tolerating aggressive diuresis. The goal of
diuresis for each day was approximately 500cc-1L per day.
.
There was also a suspected right lower lobe pneumonia that was
treated with levofloxacin for a 1 week duration (renal dosage).
Sputum and blood cultures were negative.
.
Aspiration Risk: Evidently a chronic issue, thought to be due to
worsening decline of Parkinson's Disease as well as fluctuating
mental status. Speech and swallow had evaluted patient and
deemed him unable to take anything by mouth, and pt was kept NPO
until family and patient could agree upon next step in
management, with guidance from medical team. Lengthy family
discussion occurred while hospitalized to discuss feeding
options, including a repeat video swallow vs. a temporary NG
tube. Pt and family ultimately decided for him to undergo repeat
video swallow study which he passed, and the following
recommendations were made: moist, ground solids, nektar
thickened liquids, pills crushed with applesauce, and sips of
thin liquids in between meals. If he is choking/coughing on the
thin liquids, this should be discontinued. Patient should
continue to be monitored by speech and swallow back at rehab. He
is still a known chronic aspirator despite the results of video
speech and swallow, and goals of care for nutrition should
continue to be addressed at rehab.
.
Metastatic adenocarcinoma of unknown primary: thought to be due
to cholangiocarcinoma. Pt is not a candidate for any
chemotherapy due to multiple comorbidities and acute medical
issues. Family still wants aggressive treatment. Palliative care
was involved.
.
Dysphagia: Was evaluated on last admission by speech and swallow
team as well. Due to chronic medical issues and worsening of
parkinson's disease, patient's ability to swallow worsened
during admission. He was unable to tolerate thickened liquids,
and was ultimately sent for repeat video swallow analysis as per
above.
.
Hypertension: Was controlled with hydralazine and isosorbide,
with a goal SBP of 130-140 range. Aggressive BP lowering was
avoided.
.
During this admission, pt also developed constipation, which was
treated with senna, colace, dulculax, and finally enema.
.
Coronary artery disease: history of NSTEMI. Troponin mildly
elevated on admission, likely [**1-7**] demand in setting of
hypertensive urgency. Patient was given aspiring, beta blockers,
imdur, statin, and diuresis.
.
Chronic renal insufficency: patient maintained a stable
creatinine level that was close to baseline despite aggressive
diuresis.
.
Prophylaxis: Subcutaneous heparin, aggressive bowel regimen,
home PPI
.
Access: PICC, PIV x2
.
Code: full
.
Communication: Patient, wife and daughter
Medications on Admission:
Docusate Sodium 250 mg PO daily
Senna 8.6 mg Tablet PO BID
Polyethylene Glycol One (1) packet PO DAILY
Aspirin 325 mg PO DAILY
Finasteride 5 mg PO DAILY
Tamsulosin 0.4 mg SR 24 hr PO HS
Pramipexole 0.125 mg PO tid
Gabapentin 300 mg PO Q24H
Omeprazole 40 mg PO once a day.
Simvastatin 40 mg PO DAILY (Daily).
Carbidopa-Levodopa 25-100 mg PO 5 TIMES DAILY
Carbidopa-Levodopa 25-100 mg half a pill Tablet PO TID at 6 am,
11 am and 4 pm.
Ferrous Sulfate 325 mg PO DAILY (Daily).
Sertraline 25 mg PO once a day.
Primidone 25mg PO once a day.
Vitamin D 1,000 unit PO once a day.
Acetaminophen 325 mg 1-2 Tablets PO Q6H prn pain
Metoprolol Succinate 25 mg Tablet SR PO DAILY
Isosorbide Mononitrate 30 mg SR 24 hr PO DAILY (Daily).
Oxycodone 10 mg Tablet SR 12 hr PO Q12H (every 12 hours).
oxycodone IR 10mg Q4H prn pain
Morphine oral [**Male First Name (un) **] 4mg Q6H
Medications upon transfer to [**Hospital Ward Name 121**] 2:
Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Levofloxacin 750 mg IV Q48H day #1 [**5-31**]
Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
Metoprolol Tartrate 25 mg PO BID
hold for HR <60 sBP<100 Order date: [**5-31**] @ 0054
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing
Morphine Sulfate (Oral Soln.) 4 mg PO Q6H pain
Aspirin 325 mg PO DAILY Start
Carbidopa-Levodopa (25-100) 1 TAB PO 5X/DAY
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Carbidopa-Levodopa (25-100) 0.5 TAB PO TID
please administer at 6, 11, 16
OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
Docusate Sodium 250 mg PO DAILY
Polyethylene Glycol 17 g PO DAILY
Finasteride 5 mg PO DAILY
Pramipexole *NF* 0.125 mg Oral TID
Furosemide 80 mg IV ONCE
PrimiDONE 25 mg PO HS
Gabapentin 300 mg PO HS
Senna 1 TAB PO BID
Heparin 5000 UNIT SC TID
Sertraline 25 mg PO DAILY
HydrALAzine 37.5 mg PO TID
Give with 20 mg of isosorbide dinitrate
Simvastatin 40 mg PO DAILY
Insulin SC
Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob, wheezing
Tamsulosin 0.4 mg PO HS
Isosorbide Dinitrate 20 mg PO TID
20 mg of hydralazine
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Year (2) **]: [**12-7**] Tablet PO TID (3
times a day): please administer at 6, 11, 16 .
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
3. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO
5X/DAY (5 Times a Day).
4. Finasteride 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
5. Lasix 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
6. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
Tablet(s)
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: 2.5 Tablets
PO DAILY (Daily).
8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: [**12-7**] PO DAILY (Daily).
9. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day).
10. Polyethylene Glycol 3350 100 % Powder [**Month/Day (2) **]: One (1) PO DAILY
(Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Month/Day (2) **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Pramipexole 0.125 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3
times a day).
13. Gabapentin 250 mg/5 mL Solution [**Month/Day (2) **]: One (1) PO HS (at
bedtime).
14. Simvastatin 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
16. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: One (1) PO Q6H
(every 6 hours) as needed for pain.
17. Isosorbide Dinitrate 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
(3 times a day).
18. Oxycodone 10 mg Tablet Sustained Release 12 hr [**Month/Day (2) **]: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
19. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: One (1) PO Q4H (every 4
hours) as needed for pain.
20. Primidone 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO HS (at bedtime).
21. Sertraline 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily).
22. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
23. Levofloxacin in D5W 750 mg/150 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q48H (every 48 hours).
24. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
acute pulmonary edema secondary to acute on chronic heart
failure
pneumonia
.
Secondary:
metastatic adenocarcinoma with unknown primary
systolic heart failure with EF of 45%
coronary artery disease
chronic renal insufficiency
GERD
high blood pressure
hyperlipidemia
parkinson's disease
benign prostatic hypertrophy
Discharge Condition:
afebrile, vitals signs stable
Discharge Instructions:
You were admitted for shortness of [**Hospital6 1440**] due to fluid in the
lungs. Following stabilization in the medicine intensive care
unit, you were given a diuretic to remove this fluid in your
lungs. You were found have a pneumonia and were treated with
antibiotics. Also, you developed difficulty in regards to
swallowing, making you at risk for aspiration pneumonia.
Following a video swallow study, we decided to recommend 1)
moist, ground solids 2) nektar thick liquids 3) sips of thin
liquids in between meals 4) pills crushed with applesauce.
.
If you develop worsening shortness of [**Hospital6 1440**], CP, fever, chills,
please contact your doctor or go to the emergency room.
.
Please continue to take 40mg lasix by mouth every day. Please
continue all other medications prior to your admission to the
hospital.
.
Followup Instructions: Please contact your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 27593**] to schedule a follow up appointment within 1
week of discharge.
Followup Instructions:
Please make the following appointments within 1 week of
discharge:
.
Primary Care Provider:
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 53953**]
ICD9 Codes: 486, 4280, 2724, 412, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 909
} | Medical Text: Admission Date: [**2115-5-22**] Discharge Date: [**2115-6-19**]
Date of Birth: [**2038-1-11**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Percocet
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bipap
Endotracheal Intubation
Cardiac Catheterization w/ stent placement
History of Present Illness:
This is a 77 female with h/o atrial fibrillation (on coumadin),
aortic stenosis (mod/severe), cardiomyopathy (LVEF 40-50%), DM2,
who presents from rehab hospital with several days of increasing
shortness of breath. She was recently discharged from [**Hospital1 18**]
after a prolonged stay for a right psoas phlegmon s/p CT guided
drainage. She was discharged 7 days PTA, and reports initially
feeling well upon discharge. Beginning two days after arriving
at rehab she began to get worsening lower back pain (same pain
from abscess drain), that would cause her "BP to rise and HR to
rise" and subsequently would get SOB. She then began PT and was
doing well.
.
On Sunday (3 days PTA) she became significantly more SOB, and
her family describes her as clamy. She had increasing orthopnea
at this point, with worsening peripheral edema and wt gain. She
[Of note, she had been maintained on lasix during her last
hospitalization, but lasix was not continued as a standing order
on discharge as she was felt to be euvolemic.] The following
day she was given 20 mg lasix twice, and had a CXR done. She
continued to gain weight and feel increasingly SOB, feeling as
if "there was no more breath left." On the day of admission,
be hospitalized.
.
She has not had any chest pain, cough, fever, chills HA,
diarrhea, consitpation, urinary symptoms. She things her urine
output was less at the rehab. She describes intermittent clamy
feelings when getting SOB. She has had no appetite and
decreased PO intake.
.
ROS: as above
.
ED COURSE: She was triaged with a requirement of 5L NC to
maintain sats in mid 90s; she was afebrile, normotensive. She
was found to be in AF with RVR (to 150s - 160s). She was given
40mg IV lasix, and then subsequently given 80mg IV lasix, to
which she put out ~1L. She was given dilt 5mg IV x 3, and
subsequently dilt 15mg IV x 1, with only modest effect on her
HR. A CXR showed worsening CHF with pulm edema and a left
pleural effusion. Her ECG showed AF at 115, no acute changes
from prior. She was also given one dose of IV levaquin for
presumed respiratory coverage.
Past Medical History:
AS
HTN
chronic AF on coumadin
DJD with multiple joint replacements (R hip [**2105**], R knee [**2108**], L
knee [**2109**], R shoulder [**2111**])
NIDDM
S/P cholecystectomy [**2106**]
Social History:
5 Children, very supportive. No tob/etoh/drugs.
Family History:
NC
Physical Exam:
VS- 97 122/74 130 22 97% 2.5L
GEN- Pale elderly female lying in bed with family at side
HEENT- Anicteric, dry MM, EOMI, PERRL, OP clear, upper dentures,
no lower teeth
NECK- supple, JVP to 9cm, no LAD
CV- Irreg irreg, tachy, III/VI SEM at USB, hyperdynamic PMI
CHEST- Decreased BS at bases (L>R) with rales [**1-28**] bilaterally,
dullto percussion on left
ABD- soft, obese, NT, ND, +BS
EXT- 1+ pitting edema bilaterally, 1+ DP pulses bilaterally,
scars over knees and right shoulder, well healed. PICC line in
right forearm
NEURO- AAO x 3, moving all extremities
SKIN- no lesions noted
MSK- palpable hardware right shoulder, nontender, no other joint
effusions noted.
Pertinent Results:
[**2115-5-22**] 02:50PM BLOOD WBC-6.3 RBC-3.24* Hgb-10.6* Hct-32.2*
MCV-99* MCH-32.8* MCHC-33.0 RDW-14.9 Plt Ct-274
[**2115-5-23**] 03:55AM BLOOD WBC-5.7 RBC-3.03* Hgb-9.7* Hct-29.9*
MCV-99* MCH-32.1* MCHC-32.5 RDW-15.0 Plt Ct-264
[**2115-5-26**] 09:14AM BLOOD WBC-6.6 RBC-3.48* Hgb-11.1* Hct-34.6*
MCV-99* MCH-31.7 MCHC-32.0 RDW-15.6* Plt Ct-234
[**2115-5-22**] 02:50PM BLOOD Hypochr-2+ Poiklo-1+ Macrocy-2+
[**2115-5-26**] 09:14AM BLOOD PT-24.4* PTT-32.3 INR(PT)-2.4*
[**2115-5-22**] 02:50PM BLOOD Glucose-128* UreaN-21* Creat-0.7 Na-132*
K-3.7 Cl-87* HCO3-39* AnGap-10
[**2115-5-23**] 03:55AM BLOOD Glucose-105 UreaN-22* Creat-0.8 Na-134
K-3.7 Cl-88* HCO3-40* AnGap-10
[**2115-5-25**] 06:25AM BLOOD Glucose-132* UreaN-20 Creat-0.7 Na-134
K-4.0 Cl-86* HCO3-45* AnGap-7*
[**2115-5-26**] 09:14AM BLOOD Glucose-176* UreaN-20 Creat-0.7 Na-134
K-3.4 Cl-84* HCO3-47* AnGap-6*
[**2115-5-22**] 02:50PM BLOOD CK(CPK)-69
[**2115-5-23**] 03:55AM BLOOD CK(CPK)-59
[**2115-5-22**] 02:50PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 66784**]*
[**2115-5-23**] 03:55AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2115-5-23**] 03:55AM BLOOD Calcium-9.2 Phos-4.7* Mg-1.5*
[**2115-5-24**] 06:09AM BLOOD Calcium-9.2 Phos-3.0# Mg-2.1
[**2115-5-26**] 09:14AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.8
[**2115-5-26**] 09:14AM BLOOD Digoxin-1.5
[**2115-5-26**] 11:42AM BLOOD Type-ART pO2-115* pCO2-90* pH-7.38
calHCO3-55* Base XS-22
[**2115-5-26**] 05:17PM BLOOD Type-ART pO2-92 pCO2-80* pH-7.43
calHCO3-55* Base XS-22--
STUDIES:
.
Chest CT:
This non-contrast-enhanced study demonstrates interval increase
in size of bilateral pleural effusions, left slightly greater
than right which are moderate in size. Mild basilar atelectasis.
They are no pathologically enlarged nodes within the
mediastinum, axillae, hila. Stable cardiomegaly. Coronary
calcifications. No pericardial effusion. Ground-glass opacities
again noted bilaterally, appear more prominent with associated
septal thickening, likely presenting pulmonary edema. Again
noted are few scattered nodules, less than 5 mm bilaterally.
Previously seen lesion in right psoas not clearly visualized on
this study. Probable dropped gallstone in hepatorenal recess. No
evidence of pneumothorax. Osseous structures are stable.
IMPRESSION:
1. Interval increase in size of bilateral moderate pleural
effusions with associated bibasilar atelectasis.
2. Interval worsening of bilateral diffuse ground-glass opacity,
likely representing pulmonary edema. No definite evidence of
emphysematous change.
3. Bilateral tiny pulmonary nodules, unchanged. Recommend follow
up to ensure stability.
.
MRI L-spine:
FINDINGS: Again scoliosis of lumbar spine is seen. At T12-L1,
increased signal is seen within the disc with some enhancement
indicative of discitis. There is abnormal signal seen in the
adjacent endplates indicative of marrow edema. Again paraspinal
soft tissue abnormalities with fluid collection are seen
indicative of abscess. Compared to the prior study, the
paraspinal fluid collections have slightly decreased. The
persistent signal changes and slight
enhancement within the disc could be secondary to evolution of
inflammatory change within the disc and [**Known firstname **] not necessarily
indicate worsening of discitis. Further followup is therefore
essential. There is no evidence of new inflammatory changes seen
within the spinal canal.
Increased signal is seen within the L1-2 and L2-3 discs on the
inversion recovery images which was not identified on the
previous study. There is no enhancement seen in this region.
This finding [**Known firstname **] be secondary to technical differences or due to
fluid within the disc from increased motion. Further followup is
recommended to exclude inflammation at this level. Mild
degenerative changes and bulging from L3-4 to L5-S1 level are
again noted.
The distal spinal cord shows normal signal intensities. No
evidence of compression of the distal cord is seen.
IMPRESSION: 1. Changes of discitis and osteomyelitis at T12-L1
level are noted with slightly increased endplate signal changes
and subtle enhancement within the disc. This could represent
evolution of inflammatory changes from discitis. No new soft
tissue abnormalities are seen to suggest worsening of the
inflammatory changes. 2. The paraspinal fluid collections are
still noted indicating abscesses which are decreased in size
from the previous study.
3. Increased signal is seen within the L1-2 and L2-3 discs which
is a new finding since the previous study and it could indicate
fluid within the discs or early inflammatory changes. Followup
is recommended.
.
[**6-11**] CXR:
FINDINGS: There has been no significant change in the mild
pulmonary edema from the comparison study. Left retrocardiac
opacity likely atelectasis and small left pleural effusion are
unchanged. A left IJ catheter is again identified unchanged in
position. ET tube is unchanged. NG tube projects below the
diaphragm.
IMPRESSION: No significant change from [**2115-6-8**].
.
[**2115-6-14**] - Worsening CHF.
Brief Hospital Course:
This is a 77 female with h/o atrial fibrillation (on coumadin),
aortic stenosis (mod/severe), cardiomyopathy (LVEF 40-50% on
[**5-2**] TTE), DM2, who presented from rehab hospital with several
days of increasing shortness of breath. She had recently been
discharged from [**Hospital1 18**] after a prolonged stay for a paraspinal
infection with multiple para-aortic retroperitoneal abscesses
and right MSSA psoas abscesses s/p CT guided drainage, with
T12-L1 discitis. No evidence of dissection, endocarditis,
intraspinal or epidural involvement. She also had SOB during
admission, with evidence of hypercapnia, and was found to have
bilateral pleural effusions and mild pulmonary edema. She was
treated with lasix with reasonable effect, but with residual
SOB, thought to be [**2-28**] COPD or pulmonary HTN. She was discharged
7 days PTA, and reportedly initially felt well upon discharge.
Beginning two days after arriving at rehab she began to get
worsening lower back pain (same pain from abscess drain). She
then began PT and was doing well.
.
On [**5-19**] she became significantly more SOB, and diaphoretic. She
had increasing orthopnea, peripheral edema and wt gain, and was
given 20mg lasix. Of note, she had been maintained on lasix
during her last hospitalization, but lasix was not continued as
a standing order on discharge as she was felt to be euvolemic.
The following day she was given 20 mg lasix twice, and had a CXR
done. She continued to gain weight and feel increasingly SOB,
and was sent to the ED.
.
In the ED she was diuresed with 40mg and then 80mg IV lasix; she
was found to be in rapid AF and was give a total of 30mg IV
dilt. This was not effective, and she was started on a dig load.
On the medical floor, her afib was controlled with digoxin and
metoprolol. She was cautiously diuresed, and was treated for her
abscess pain with tylenol #3. The next morning, she was noted to
be less responsive. ABG at that time was 7.38/90/115. She was
given Lasix 20 mg IV with 800 cc UOP over the next few hours,
and her mental status improved. However at 5 pm she became
unresponsive again and her ABG was 7.43/80/92. She was
tachypneic but not hypoxic. MICU eval was called at that time
for bipap, because per respiratory she needed bipap via mouth
and not through her nose, and therefore could not get bipap on
the floor.
.
In the MICU she was felt to have a mixed acid base status, with
metabolic alkalosis with superimposed respiratory acidosis. It
was felt that the metabolic alkalosis could have been due to
diuresis on the floor. Her resp acidosis was thought to be due
to obstructive disease of unclear etiology. She was given Bipap
overnight ([**5-26**]), and her ABG in AM was 7.39/87/196. She
subjectively felt better on 2L NC. She did not have any chest
pain or fever. Her diuresis was held, and her lytes were
repleted.
.
Over the next two days, intermittently on NC and BiPap with
mixed contraction alkalosis and hypercarbic respiratory
acidosis, thought to be chroinic, possibly [**2-28**] OSA. Cards
consulted, who recommended L and R heart cath to evaluated
filling pressures and to evaluate severity of AS for possible
AVR. This was not possible at the time [**2-28**] respiratory status
and inability to lie flat.
.
On [**5-30**], Neurology consulted to assess possible neuromuscular
etiology of respiratory failure, which was thought unlikely [**2-28**]
normal respiratory pattern, ability to take deep breaths,
overall normal neurological exam. EMG demonstrated mild-mod
generalized sensory polyneuropathy, but no findings suggestive
of MG or proximal myopathy. SNIF test done, but uninterpretable
in setting of pleural effusions. ENT evaluated, confirmed no
vocal cord paralysis. PFTs done, which were incomplete [**2-28**] pt
fatigue, with MIPs decreased with each inspiratory effort, with
FEV1/FVC 167%, c/w restrictive pattern.
.
Over the next couple of days, continued to have respiratory
distress, with intermittent need for BiPap, complicated by pt
refusal to wear. Pt was also gently diuresed. CT chest
demonstrated moderate bilateral pleural effusions, ground glass
opacities with associated septal thickening c/w CHF, bibasilar
atelectasis, old tiny pulmonary nodules. Head CT obtained [**2-28**]
lethargy, demonstrated no evidence of acute bleed or mass
effect. Brain MRI done, which demonstrated no significant
abnormalities. Consideration given to thoracentesis, but IP felt
not indicated at that time. Family discussion held [**6-3**], as pt
not tolerating BiPap, and would likely require either intubation
with possible progression to trach, or comfort measures. Family
confirmed full code status, with intubation if necessary.
Acetazolamide also given [**2-28**] decreased pH and hypercarbia.
.
Pt was electively intubated [**6-6**] [**2-28**] somnolence and difficulty
acheiving adequate oxygenation with intermittent BiPap. She also
experienced transient hypotension after intubation and
sedatives, with no response to IVF, and was started on pressors.
Found to have UTI, started on CTX [**6-7**].
.
Repeat L-spine MRI done [**6-7**], to evaluated previous psoas
abscesses. MRI demonstrated changes of discitis and
osteomyelitis at T12-L1 level with slightly increased endplate
signal changes and subtle disc enhancement, possibly
representing evolution of inflammatory changes from discitis. No
new soft tissue abnormalities seen to suggest worsening of the
inflammatory changes. Paraspinal fluid collections are still
noted, but decreased in size from the previous study. CRP
increased from 14 on [**5-29**] to 87 on [**6-9**]. ID consulted,
reviewed MRI with radiology. It was felt that new enhancement
probably represent natural progression in setting of therapy.
Recommend continuing nafcillin therapy for 8 weeks total post
abscess drainage, (end date [**6-28**]), at which point CRP could be
rechecked. Urine culture grew E. Coli, switched to Cipro on
[**6-7**].
.
As pt intubated, MICU team proceeded with preparation for
cardiac cath, as described above. Coumadin reversed, LIJ placed,
placed on heparin gtt. Was slowly weaned off pressors by [**6-8**].
[**Last Name (un) **] stim test inappropriate, started on stress dose
hydrocort/fludrocort on [**6-8**]. Pan-cultured to look for possible
septic etiology for hypotension. Blood cultures have been no
growth. Sputum cultures growing GNR at time of transfer. Pt also
had loose stools, C. diff x 3 sent, which were negative.
.
Ms. [**Known lastname 122**] [**Last Name (Titles) 1834**] cardiac cath on [**6-10**], while intubated. AV
area found to be 1.0cm2, with gradient of 20mmHg. Cath
demonstrated 80% mid-LAD lesion, and 2 overlapping BMS. Placed
on ASA, plavix x 1 month, integrillin x 6 hours, after which
heparin gtt was restarted to re-bridge to coumadin for AF. Pt
had residual small intermedius and ostial RCA disease that could
be amenable to PCI if pt had recurrent evidence of myocardial
ischemia. RA 18, PCWP 18, MAP 75, CI 2.7. No complications
post-cath.
.
Ms. [**Known lastname 122**] was successfully extubated on [**6-11**] post-cath, and
was called out to floor on [**6-12**]. Pt has appt with Dr. [**Last Name (STitle) 66785**]
in ID on [**6-26**] at 12pm. Per ID, should have qwk CBC, BUN/Cr
checked and FAXed to Dr. [**First Name (STitle) **].
.
On the floor, she continued to have episodes of Afib with RVR
with tachy-brady syndrome and has only been cautiously diuresed
because of marginal BPs on the floor. Today, pt was triggered at
9am for relative hypotension and was given back 500ccNS bolus.
Cardiology recommended increasing beta-blockade for HRs but
might need pacer for possible tachy-brady syndrome. Then, at
6:30 AM, she became tachypneic to the 40's with labored
breathing and complained of a "panic attack". O2 sat was noted
to be 48% on 3L NC. She was temporarily placed on a NRB with
increasing O2 sats to 94% and weaned off quickly on the floor to
O2 sats 93% on 5L NC. Her ABG showed 7.30/85/67 with bicarb 38.
She was triggered and MICU consulted for further managment. She
states that her breathing does feel shallow but denies any chest
pain, nausea, vomiting. She has no other complaints now. She was
transferred to ICU for initiation of BiPAP therapy.
.
.
MICU COURSE:
## Respiratory: Pt. was transferred to the MICU for mental
status changes in the setting of hypercarbia. The etiology of
her hypercarbia is unclear - no history of COPD. She most likely
presented with a CHF exacerbation. Pt. has AS, afib, and CHF
which [**Known firstname **] have contributed to her dyspnea. Her pleural
effusions (L >R) could be limiting the expansion of her lung,
causing a restrictive physiology. She also has evidence of
pulmonary hypertension on last TTE. However, given pt's
difficulty w/ ventilation and normal oxygenation - CHF is not
the [**Last Name **] problem. Concern for diaphragmatic dysfuction
bilaterally during stay, but pt. unable to do Sniff test to
assess diaphragms [**2-28**] pleural effusions. ENT saw pt. - no vocal
cord paralysis. Neuro saw pt. and no neuromuscular disease
appreciated. PFTs unable to be completed [**2-28**] to exhaustion, but
pt. w/ restrictive pattern and MIPS decreased w/ each subsequent
effort. Overall, probably has a poor LV fx, poor forward flow.
It was decided that pt. would be electively intubated to do a
cardiac catheterizatio nwhere she was found to have an LAD
lesion that was stented. During intubation, pt's hypercarbia
improved (PCO2 in 60s which is probably her baseline). After
cardiac cath, pt. was sucessfully extubated and did not have the
feeling of dyspnea anymore.
.
## Acid/Base: Pt. w/ hypercarbia and high bicarb in MICU. Pt.
w/ hypercarbia w/ CO2 of 90s-100s. Unclear what the cause was.
Twice during her MICU stay she was found lethargic w/ high CO2.
She was placed on bipap w/ some improvement. Pt. refused bipap
when alert and oriented for the first few days, but then began
using it with some regularity. Pt. was then intubated and
hypercarbia improved - 60s, which is likely her baseline. In
the beginning of MICU course, pt. give KCl aggressively to try
to get rid of some bicarb - this improved somewhat. Once, pt.
intubated, pt's bicarb began to trend down. Stable after
extubation.
.
## CHF - pt. w/ diastolic CHF w/ AS - Based on exam,labs,
history, she most likely presented with a CHF exacerbation, due
to long standing tight AS and diastolic failure. This is
probably exacerbated by decreased diastolic filling with atrial
fibrillation. Pt. continued to be fluid overloaded w/ b/l
effusions. At times hard to diurese pt. secondary to
hypotension. Goal was negative a liter a day.
.
## CAD - Pt. w/ LAD lesion s/p 2 bare metal stents. Since cath,
pt. has been breathing more comfortably so unclear if this is
what was causing pt. to be so dyspneic. Pt. will need to be on
ASA,plavix, and beta blocker.
.
## Hypotension - initially hypotension seemed to be in the
setting of intubation and then it was found that pt. had adrenal
insufficiency. Pt. failed [**Last Name (un) 104**] stim. test so is on of steroids
(started 7 dday course on [**6-8**]).
.
## Anemia - Pt. w/ progressively declining crits over MICU stay,
but no obvious source of bleeding. Pt. will need a c-scope/EGD
as an outpatient or more urgently if crit does not increase
.
#Afib: pt has a fib and has been going into afib w/ RVR a few
times in MICU. Pt. was controllled w/ IV medications PRN for
rate control. Will continue pt's beta blockade now that she is
no longer on pressors. Spoke to cards - no need for amio. Pt.
initially on coumadin and then switched to heparin for cath.
After cath, pt. switched back to coumadin. INRs will have to be
followed.
.
# UTI - pt. w/ positive UA on [**6-4**] w/ ctx that are growing 2
strains of E.coli
- Pt. on day [**7-3**] of abx on [**2115-6-12**].
.
## Abscess/Discitis: Had MSSA bacteremia with spinal discitis,
numerous psoas abscesses s/p drainage on a previous
hospitalization. Pt. had MRI to evaluate spinal abscesses while
in MICU- stable abscesses, new L1-L2/L2-L3 increased signal in
the disks [**Known firstname **] indicate re-accumulating fluid in discs/early
inflammatory changes. ID reviwed MRI w/ radiology and believe
that pt. should have an 8 week course of abx total (first day
[**5-4**]). Pt. will likely have to have a follow MRI per ID recs and
then f/u w/ ID and possibly neurosurgery depending on MRI. Pt.
will need to cont nafcillin day 21 (started on [**5-23**]). Overall,
pt. is on day 40/56 of abx (was previously on oxacillin) in
order to finish an 8 week course. (First day of 8 week course
was [**2115-5-4**]).
.
## DM2: At home, pt. on glipizide 5qd and pioglitazone 15 qd but
will hold oral meds. Pt. w/ good glycemic control on insulin
sliding scale
.
## Hypercholesterolemia: cont lipitor 10 qd
.
## FEN: TF while intubated and then switched to heart
healthy/diabetic diet. Replete lytes prn
.
## PPX: coumadin, PPI, bowel meds
.
## CODE: full, discussed with pt and family. Per discussion
today, family still wants BiPap and intubation as needed.
.
## Communication: with pt and daughters.
.
## Dispo: ICU for compromised ventilation
CC: MICU call out after hypercarbic respiratory failure
.
HPI: This is a 77 female with h/o atrial fibrillation (on
coumadin), aortic stenosis (mod/severe), cardiomyopathy (LVEF
40-50% on [**5-2**] TTE), DM2, who presented from rehab hospital with
several days of increasing shortness of breath. She had recently
been discharged from [**Hospital1 18**] after a prolonged stay for a
paraspinal infection with multiple para-aortic retroperitoneal
abscesses and right MSSA psoas abscesses s/p CT guided drainage,
with T12-L1 discitis. No evidence of dissection, endocarditis,
intraspinal or epidural involvement. She also had SOB during
admission, with evidence of hypercapnia, and was found to have
bilateral pleural effusions and mild pulmonary edema. She was
treated with lasix with reasonable effect, but with residual
SOB, thought to be [**2-28**] COPD or pulmonary HTN. She was discharged
7 days PTA, and reportedly initially felt well upon discharge.
Beginning two days after arriving at rehab she began to get
worsening lower back pain (same pain from abscess drain). She
then began PT and was doing well.
.
On [**5-19**] she became significantly more SOB, and diaphoretic. She
had increasing orthopnea, peripheral edema and wt gain, and was
given 20mg lasix. Of note, she had been maintained on lasix
during her last hospitalization, but lasix was not continued as
a standing order on discharge as she was felt to be euvolemic.
The following day she was given 20 mg lasix twice, and had a CXR
done. She continued to gain weight and feel increasingly SOB,
and was sent to the ED.
.
In the ED she was diuresed with 40mg and then 80mg IV lasix; she
was found to be in rapid AF and was give a total of 30mg IV
dilt. This was not effective, and she was started on a dig load.
On the medical floor, her afib was controlled with digoxin and
metoprolol. She was cautiously diuresed, and was treated for her
abscess pain with tylenol #3. The next morning, she was noted to
be less responsive. ABG at that time was 7.38/90/115. She was
given Lasix 20 mg IV with 800 cc UOP over the next few hours,
and her mental status improved. However at 5 pm she became
unresponsive again and her ABG was 7.43/80/92. She was
tachypneic but not hypoxic. MICU eval was called at that time
for bipap, because per respiratory she needed bipap via mouth
and not through her nose, and therefore could not get bipap on
the floor.
.
In the MICU she was felt to have a mixed acid base status, with
metabolic alkalosis with superimposed respiratory acidosis. It
was felt that the metabolic alkalosis could have been due to
diuresis on the floor. Her resp acidosis was thought to be due
to obstructive disease of unclear etiology. She was given Bipap
overnight ([**5-26**]), and her ABG in AM was 7.39/87/196. She
subjectively felt better on 2L NC. She did not have any chest
pain or fever. Her diuresis was held, and her lytes were
repleted.
.
Over the next two days, intermittently on NC and BiPap with
mixed contraction alkalosis and hypercarbic respiratory
acidosis, thought to be chroinic, possibly [**2-28**] OSA. Cards
consulted, who recommended L and R heart cath to evaluated
filling pressures and to evaluate severity of AS for possible
AVR. This was not possible at the time [**2-28**] respiratory status
and inability to lie flat.
.
On [**5-30**], Neurology consulted to assess possible neuromuscular
etiology of respiratory failure, which was thought unlikely [**2-28**]
normal respiratory pattern, ability to take deep breaths,
overall normal neurological exam. EMG demonstrated mild-mod
generalized sensory polyneuropathy, but no findings suggestive
of MG or proximal myopathy. SNIF test done, but uninterpretable
in setting of pleural effusions. ENT evaluated, confirmed no
vocal cord paralysis. PFTs done, which were incomplete [**2-28**] pt
fatigue, with MIPs decreased with each inspiratory effort, with
FEV1/FVC 167%, c/w restrictive pattern.
.
Over the next couple of days, continued to have respiratory
distress, with intermittent need for BiPap, complicated by pt
refusal to wear. Pt was also gently diuresed. CT chest
demonstrated moderate bilateral pleural effusions, ground glass
opacities with associated septal thickening c/w CHF, bibasilar
atelectasis, old tiny pulmonary nodules. Head CT obtained [**2-28**]
lethargy, demonstrated no evidence of acute bleed or mass
effect. Brain MRI done, which demonstrated no significant
abnormalities. Consideration given to thoracentesis, but IP felt
not indicated at that time. Family discussion held [**6-3**], as pt
not tolerating BiPap, and would likely require either intubation
with possible progression to trach, or comfort measures. Family
confirmed full code status, with intubation if necessary.
Acetazolamide also given [**2-28**] decreased pH and hypercarbia.
.
Pt was electively intubated [**6-6**] [**2-28**] somnolence and difficulty
acheiving adequate oxygenation with intermittent BiPap. She also
experienced transient hypotension after intubation and
sedatives, with no response to IVF, and was started on pressors.
Found to have UTI, started on CTX [**6-7**].
.
Repeat L-spine MRI done [**6-7**], to evaluated previous psoas
abscesses. MRI demonstrated changes of discitis and
osteomyelitis at T12-L1 level with slightly increased endplate
signal changes and subtle disc enhancement, possibly
representing evolution of inflammatory changes from discitis. No
new soft tissue abnormalities seen to suggest worsening of the
inflammatory changes. Paraspinal fluid collections are still
noted, but decreased in size from the previous study. CRP
increased from 14 on [**5-29**] to 87 on [**6-9**]. ID consulted,
reviewed MRI with radiology. It was felt that new enhancement
probably represent natural progression in setting of therapy.
Recommend continuing nafcillin therapy for 8 weeks total post
abscess drainage, (end date [**6-28**]), at which point CRP could be
rechecked. Urine culture grew E. Coli, switched to Cipro on
[**6-7**].
.
As pt intubated, MICU team proceeded with preparation for
cardiac cath, as described above. Coumadin reversed, LIJ placed,
placed on heparin gtt. Was slowly weaned off pressors by [**6-8**].
[**Last Name (un) **] stim test inappropriate, started on stress dose
hydrocort/fludrocort on [**6-8**]. Pan-cultured to look for possible
septic etiology for hypotension. Blood cultures have been no
growth. Sputum cultures growing GNR at time of transfer. Pt also
had loose stools, C. diff x 3 sent, which were negative.
.
Ms. [**Known lastname 122**] [**Last Name (Titles) 1834**] cardiac cath on [**6-10**], while intubated. AV
area found to be 1.0cm2, with gradient of 20mmHg. Cath
demonstrated 80% mid-LAD lesion, and 2 overlapping BMS. Placed
on ASA, plavix x 1 month, integrillin x 6 hours, after which
heparin gtt was restarted to re-bridge to coumadin for AF. Pt
had residual small intermedius and ostial RCA disease that could
be amenable to PCI if pt had recurrent evidence of myocardial
ischemia. RA 18, PCWP 18, MAP 75, CI 2.7. No complications
post-cath.
.
Ms. [**Known lastname 122**] was successfully extubated on [**6-11**] post-cath, and
was called out to floor on [**6-12**]. Pt has appt with Dr. [**Last Name (STitle) 66785**]
in ID on [**6-26**] at 12pm. Per ID, should have qwk CBC, BUN/Cr
checked and FAXed to Dr. [**First Name (STitle) **].
.
On the floor, she continued to have episodes of Afib with RVR
with tachy-brady syndrome and has only been cautiously diuresed
because of marginal BPs on the floor. Today, pt was triggered at
9am for relative hypotension and was given back 500ccNS bolus.
Cardiology recommended increasing beta-blockade for HRs but
might need pacer for possible tachy-brady syndrome. Then, at
6:30 AM, she became tachypneic to the 40's with labored
breathing and complained of a "panic attack". O2 sat was noted
to be 48% on 3L NC. She was temporarily placed on a NRB with
increasing O2 sats to 94% and weaned off quickly on the floor to
O2 sats 93% on 5L NC. Her ABG showed 7.30/85/67 with bicarb 38.
She was triggered and MICU consulted for further managment. She
states that her breathing does feel shallow but denies any chest
pain, nausea, vomiting. She has no other complaints now. She was
transferred to ICU for initiation of BiPAP therapy.
.
77 F c mild AS, diastolic CHF atrial fibrillation, recent psoas
abscess, admitted to the MICU for hypercarbia and altered mental
status s/p cardiac cath (LAD lesion) w/ 2 bare metal stents who
has been on the floor with worsening CHF and afib with RVR.
.
## Respiratory: The etiology of her hypercarbia is unclear, but
likely due to CHF and COPD (undx'd previously). There is likely
a component of obesity hypoventillation syndrome also involved
(will need sleep study w/u as outpt). She most likely presented
with a CHF exacerbation, in setting of AF with RVR, diastolic
failure. Her pleural effusions (L >R) could be limiting the
expansion of her lung, causing a restrictive physiology seen in
PFTs. She has evidence of mild pulmonary hypertension on cath.
There was concern for diaphragmatic dysfuction bilaterally. Pt.
unable to do SNIF test to assess diaphragmatic strength 2/2
pleural effusions. ENT saw no evidence of vocal cord paralysis.
No evidence of neuromuscular disease contributing to SOB. PFTs
unable to be completed [**2-28**] to exhaustion, but c/w restrictive
pattern. Recently, she had acute respiratory acidosis for
unclear reasons, xfered back to MICU. Overnight, gases on Bipap
and gases on nasal cannula seemed not to be different, but the
patient's breathing seemed to be much more confortable on Bipap.
Patient was diuresed as much as her blood pressure would allow,
on standing lasix as well as lasix gtt. As above, the patient
was made DNR/DNI, after discussion with family, but BiPAP was
allowed. Patient was given intermittent breaks from bipap on
nasal cannula, but her PCO2 became much worse after being taken
off bipap. On [**6-19**], the patient went to IR suite for PICC line
placement. She was required to be lying flat while getting the
line placed and returned with significant respiratory distress.
She was placed on Bipap and her respiratory status and gas
exchange improved significantly. However, later that night, the
patient developed "agonal type" respirations despite being on
bipap, with 2-8 second pauses between respirations. The
patient's family was informed that the patient was not doing
well and [**Known firstname **] pass soon--and DNR/DNI status was confirmed once
again. The patient was given maximal non-invasive ventillatory
support, but became progressively more somnolent and obtunted.
Within a short time, the patient's respiration suddely ceased,
and staff coudl not arouse the patient even with sternal rubs.
The patient then became bradycardic to 30s, then went into PEA
and passed shortly after with family by her side.
.
## CHF - pt. w/ likely diastolic CHF with AF with intermittent
RVR. Patient continued to be fluid overloaded during her stay
despite maximum efforts to diurese her.
.
#Afib: Afib with RVR. frequent bursts into 160s/170s
unresponsive to dilt and BB. Patient was placed on amiodarone,
since dc cardioversion was thought to be not indicated by
cardiology consultants. Sotalol was also suggested. After
amiodarone, HR decreased to 120s-140s. Please see above
regarding the rest of hospital course and conditions around
patient decompensating and eventually expiring.
.
## Abscess/Discitis: Had MSSA bacteremia with spinal discitis,
numerous psoas abscesses. Pt. had MRI to reevaluate spinal
abscesses - stable abscesses, new L1-L2/L2-L3 increased signal
in the discs. ID favoring continuing 8 week course nafcillin,
due to complete [**6-28**]. Patient was continued on IV abx, but
expired as described above
Medications on Admission:
Atorvastatin 10, colace, protonix 40, fluticasone 110/actuation
aerosol [**Hospital1 **], dulcolax prn, metoprolol 75 [**Hospital1 **],
acetaminophen-codeine q4 prn, oxacillin 2g q4, glipizide 5 qd,
coumadin 2.5 qhs, pioglitazone 15 qd
Discharge Disposition:
Expired
Discharge Diagnosis:
CHF
Atrial fibrillation
Discitis
Osteomyelitis
Obesity Hyperventillation syndrome
Hypercarbic Respiratory Failrue
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2115-6-29**]
ICD9 Codes: 4280, 4241, 5990, 2761, 496, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 910
} | Medical Text: Admission Date: [**2188-9-6**] Discharge Date: [**2188-9-12**]
Date of Birth: [**2126-11-6**] Sex: M
Service:
CHIEF COMPLAINT: Status post right coronary artery stent
secondary to myocardial infarction.
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old
male intubated and sedated upon arrival. History was taken
from medical records only. The patient without history of
coronary artery disease presented to outside hospital with
complaints of chest pain. The patient noted that he felt
lightheaded and called EMS to be transported to outside
hospital. Initial laboratories there showed a troponin I of
less then 0.04. Electrocardiogram with bradycardia, left
axis deviation and ST elevations in 2, 3 and AVF, V3-V5 and
ST depressions in AVL, V2, V1 also with a right bundle branch
block. He was given aspirin, morphine and fluids in the
field and then the Emergency Department gave him atropine,
started a Dopamine and heparin drip. At that point he went
into a wide complex tachycardia, which was read as V
fibrillation and was shocked with 200 jewels with conversion
to junctional rhythm of 100 beats per minute and the patient
at that point was hemodynamically stable. The patient was
given a half a dose of Retavase for lytic therapy and was
transferred to [**Hospital1 69**] for
further evaluation and catheterization.
The patient was intubated prior to arrival to [**Hospital1 346**]. In the [**Hospital1 190**] the patient was sinus tachy, normal axis,
normal intervals, 2 to [**Street Address(2) 2051**] elevation in inferior leads
and anterior leads. He was taken to the catheterization
laboratory. Catheterization wet read showed a three vessel
disease with left anterior descending coronary artery totally
occluded, left circumflex was 40% lesion and right coronary
artery with a 95% mid vessel lesion thought to be the culprit
lesion. He had an angiojet and his right coronary artery was
stented at that point at which point he was transferred to
the Coronary Care Unit for further observation and
management.
PAST MEDICAL HISTORY: No past medical history was recorded.
ALLERGIES: No known drug allergies.
MEDICATIONS: The only medication was recorded was Benadryl
prn.
SOCIAL HISTORY: Recorded as two packs per day.
FAMILY HISTORY: Father with myocardial infarction and mother
with myocardial infarction and brother with myocardial
infarction at the age of 59.
PHYSICAL EXAMINATION: Vital signs upon arrival to the
Emergency Department, pulse of 71 and blood pressure of
106/palp and afebrile. Generally he was a frail appearing
male intubated and sedated. HEENT pupils are equal, round,
and reactive to light and accommodation. No lymphadenopathy.
No JVD. Cardiovascular regular rate and rhythm. No murmurs,
rubs or gallops appreciated. Pulmonary was not examined.
Abdomen soft, nontender, nondistended. Positive bowel
sounds. Extremities no clubbing, cyanosis or edema.
LABORATORIES ON ADMISSION: Sodium 139, potassium 3.6,
chloride 105, bicarb 27, BUN 10, creatinine 1.1, glucose 108,
white blood cell 9.2, hematocrit 42.8, platelet 440, MCV 101.
INR .91 and PTT of 28.2. The troponin I of less then 0.04.
Chest x-ray showed EP tube in right main, opacity in
retrocardiac, possible atelectasis versus pneumonia and on
arrival his electrocardiogram was pending. His
catheterization showed an RA of 23/24/22, RV of 33/23, PA
33/22, wedge of 22/24, [**3-24**], LV of 90/22, SVR 1082 and PVR of
25. His EF was 39% with hypokinetic anterolateral apical and
inferior walls.
HOSPITAL COURSE: The patient was status post stent mid right
coronary artery. For his coronary artery disease three
vessel disease. He was continued on aspirin and Plavix and
did well. His beta blockers were initially held secondary to
bradycardia and negative inotropic effects. At that point
later on he was switched over two days later to beta
blockers. On discharge date his beta blockers were switched
over from Metoprolol 75 b.i.d. to Toprol XL 150 q.d. His
lipids were checked and liver function tests were checked.
He had an elevated AST, slightly elevated ALT at which point
Lipitor was not started, but the day of discharge Lipitor was
started given that his AST rise was most likely secondary to
his myocardial infarction insult. He may need future
percutaneous intervention on left anterior descending
coronary artery and D1. His CKs were followed post
intervention and the goal was to keep the CVP around 18 to
20. He did well after transfer to the Emergency Department
and was extubated the next day and weaned off of his O2 and
transferred to the floor.
For his pump status he was later on started on Captopril and
on the day of discharge his Captopril t.i.d. was switched to
Lisinopril q.d. for after load reduction.
Rhythm, his electrolytes were checked regularly. The goal
was to keep his K over 4 and his magnesium over 2. Initially
he was continued on the Lidocaine drip until the morning
after admission to the Coronary Care Unit at which point he
was discontinued off the Lidocaine. He had an atropine at
bedside for possible bradycardia and secondary hypotension
secondary to bradycardia, which was not used and his beta
blockers as we noted earlier was held on the first day and
later on started as he tolerated it. The day after admission
he was started on Levaquin for presumed right lower lobe
consolidation secondary to community acquired pneumonia. The
patient did well and has been afebrile and white blood cell
count decreasing daily since transfer to the floor. For him
to continue a ten day course of Levaquin. He is now on day
three of ten and will continue the next seven days when
discharged to home or to rehab.
Gastrointestinal, no issues. Tolerating his medications and
his diet well.
The patient was sent to rehab center for further evaluation
and further treatment.
FINAL DIAGNOSIS:
Inferior myocardial infarction status post right coronary
artery stent.
RECOMMENDED FOLLOW UP: The patient is to follow up with his
primary care physician and also with cardiologist in the next
week or two for post discharge care. Call for an
appointment.
MAJOR SURGICAL INVASIVE PROCEDURES DONE: Status post right
coronary artery stent and catheterization.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q.d.
2. Plavix 75 mg po q..d
3. Levofloxacin 500 mg po q.d. for the next seven days, that
will be a ten day regimen.
4. Protonix 40 mg po q.d.
5. Thiamine 100 mg po q.d.
6. Folic acid 1 mg po q.d.
7. Multivitamins one per day.
8. Lisinopril 10 mg po q day.
9. Atorvastatin 10 mg po q.d.
10. Toprol XL 150 mg po q.d.
DIET: Cardiac diet as tolerated.
The patient received physical therapy and medical teaching
about his medications.
ACTIVITIES: As tolerated, out of bed with assist initially.
FOLLOW UP: As discussed above.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2188-9-10**] 01:11
T: [**2188-9-10**] 13:32
JOB#: [**Job Number 50072**]
ICD9 Codes: 5180, 9971, 4275, 486, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 911
} | Medical Text: Admission Date: [**2139-1-17**] Discharge Date: [**2139-2-16**]
Date of Birth: [**2139-1-17**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname 16543**]-[**Known lastname 45978**] is a former 32-4/7 week
twin #1 male admitted to the Newborn Intensive Care Unit for
prematurity.
A 1760 gram male born to a 32-year-old G6 P0-2, SAB 5 white
female.
PRENATAL SCREENS: O+, antibody positive anti-E. RPR
nonreactive. Hepatitis B surface antigen negative. GBS
negative. Rubella immune mom with chronic hypertension
treated with Aldomet.
IVF pregnancy diamniotic-dichorionic twins. Pregnancy
complicated by 1) cervical shortening treated with cerclage
at 18 weeks. 2) Premature labor beginning two days prior to
delivery treated with magnesium sulfate, betamethasone
complete on [**1-3**]. Antepartum testing on the day of delivery
revealed discordant growth and concern for fetal well-being
of twin A, this twin, which was 1538 grams, less than 3rd
percentile. Biophysical profile [**4-14**]. Nonstress test absent
diastolic flow. Twin B was [**2155**] grams 38th percentile,
biophysical profile [**8-14**]. Reactive nonstress test, normal
diastolic flow.
Therefore, proceeded to cesarean section under spinal
anesthesia. This baby emerged vigorous who required blow-by
O2 and suctioning only. Apgars 8 at 1 minute and 9 at 5
minutes. Baby was transferred to the Newborn Intensive Care
Unit for additional care.
PHYSICAL EXAMINATION ON ADMISSION: Premature male with mild
retractions. Temperature 98.0, pulse 160, respiratory rate
60, blood pressure 46/27 with a mean of 35. O2 sat is 93% on
room air. Anterior fontanel is soft, flat, nondysmorphic.
Intact palate. Red reflex deferred. Clear breath sounds.
Mild retractions, no murmur, normal pulses. Soft abdomen.
Cord cut close to clamp, therefore unable to see vessels. No
hepatosplenomegaly. Normal male genitalia. Testes
descending. No hip click. No sacral dimple. Patent anus.
Active, normal tone for age.
REVIEW OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Baby
continued to exhibit grunting and mild respiratory distress.
Was initially placed on nasal cannula O2 and then
transitioned to CPAP of 6. Had an initial blood gas of 7.37,
46, cap gas. Baby required CPAP for approximately 24 hours
and then transitioned to room air and had no further
respiratory distress. He did exhibit some apnea and
bradycardia of prematurity. He did not require
methylxanthine treatment, and at the time of discharge, he
has been free of apnea, bradycardia, and desaturations for
greater than five days.
Cardiovascular: Baby did not have any cardiovascular
instability. Did not require pressor support. Had an
intermittent murmur that has resolved. Baseline heart rate
is 130s-140s with blood pressures systolics in the
60s-70s, diastolics in the 30s and means in the 40s.
Fluids and electrolytes: Baby had significant hypoglycemia
required IV fluid of D12.5 initially and boluses. Initial
D stick was 8, repeat was 6, and subsequent ones were
improving to greater than 50s. The hypoglycemia persisted.
He was slowly weaned off IV fluids by day of life seven.
He required additional enteral glucose with 4 calories of
Polycose to maintain glucoses greater than 50. Polycose was
discontinued on day of life 16, and D sticks have subsequently
been stable at greater than 60. Endocrine was consulted
secondary to prolonged hypoglycemia. They thought it was
related to immaturity and intrauterine stress. Baby is
currently eating a minimum of 150 cc/kg of Enfamil 24 with
iron ad lib doing well with feeding. Baby is voiding and
stooling.
Last electrolytes were on day of life three, slightly
hemolyzed: Sodium 143, potassium 6.0, 111, and 18.
Previous electrolytes on day of life two: 141, 4.8, 107, 24.
Discharge weight 2445, which is 25th percentile. Length 47
cm 25th-50th percentile. Head circumference 32.5 cm
25th-50th percentile. Baby is also receiving supplemental
iron 0.2 cc po q day which equals 2 mg/kg/day.
Gastrointestinal: Baby required single phototherapy for
physiologic jaundice. Showed no signs of hemolysis. Peak
bilirubin was 7.7/0.3 on day of life five. Rebound bilirubin
was 6.3/0.3. There have been no further issues.
Hematology: Baby did not require any blood products during
this admission.
Infectious Disease: Baby initially had a sepsis evaluation
because of his respiratory distress and hypoglycemia. He
had initial white count of 6.4 with 34 polys, 3 bands,
platelet count of 210, and hematocrit of 45.4. Nucleated red
blood cells is [**Pager number **]. Baby was started on ampicillin and
gentamicin. Baby was clinically well and cultures remained
negative therefore antibiotics were discontinued at 48 hours.
He has had no further issues with infection.
Neurology: Because of the concerns of intrauterine growth,
baby had a head ultrasound on day of life four that was
within normal limits. No evidence of intraventricular
hemorrhage.
Baby's clinical examination is appropriate for gestational
age.
Sensory: Audiology hearing screen passed. Ophthalmology
examination none indicated based on gestational age of
greater than 32 weeks.
Psychosocial: Parents have been visiting, have sibling at
home. Mom is still being followed for hypertension, and they
look forward to transitioning both children home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE/POSITION: Home with family.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 45979**] [**Last Name (NamePattern1) 21056**], [**Hospital 13820**]
[**Hospital3 1810**], telephone number no[**Serial Number 45980**].
CARE RECOMMENDATIONS: Continue feeding Enfamil 24 with
iron ad lib.
MEDICATIONS: Fer-In-[**Male First Name (un) **] 0.2 cc po q day.
CAR SEAT POSITION SCREENING: Passed.
STATE NEWBORN SCREEN: Sample of [**1-28**] showed borderline
elevated 17 OH progesterone of 82 with the range being less
than 80. Repeat was sent on [**2-5**] which is still pending at
the time of this dictation.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2139-2-3**],
Synagis given prior to discharge on [**2139-2-16**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the
following three criteria: 1) Born at less than 32 weeks, 2)
born between 32 and 35 weeks with plans for daycare during
RSV season, with a smoker in the household, or with preschool
siblings, or 3) with chronic lung disease.
2. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age, family and
other caregivers should be considered for immunization
against influenza to protect infant.
FOLLOW-UP APPOINTMENTS: Dr. [**First Name8 (NamePattern2) 45979**] [**Last Name (NamePattern1) 21056**] within 1 week
DISCHARGE DIAGNOSES:
1. Former premature 32-4/7 week
2. Twin #1.
3. Sepsis ruled out.
4. Respiratory distress secondary to transient tachypnea of
the newborn.
5. Hypoglycemia, treated, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Doctor First Name 45981**]
MEDQUIST36
D: [**2139-2-16**] 03:32
T: [**2139-2-16**] 04:12
JOB#: [**Job Number 45982**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 912
} | Medical Text: Admission Date: [**2168-4-16**] Discharge Date: [**2168-5-13**]
Date of Birth: [**2107-2-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Benadryl / zidovudine / Enalaprilat
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
endoscopic retrograde cholangiopancreatoscopy
fiducial placement
Cyberknife
History of Present Illness:
61M w/ HIV, HCV cirrhosis, HCC, CAD, cholelithiasis and small
gallbladder polyps p/w RUQ pain. He has had worsening RUQ pain
w/o radiation since Sunday. Oxycodone with ES tylenol helps
somewhat but will only bring the pain from 8 to [**5-15**]. He [**Month/Year (2) **]
any f/c/n/v/night sweats. He believes he has lost some weight.
He has not seen his bowel movements but does not know if they
are acholic, or with blood/melena. He [**Month/Year (2) **] any jaundice. The
pain is a "gripping" type of pain, occasionally sharp, and is
constant. It is not related to PO intake or bowel movements.
Sitting up and putting pressure on his abdomen exacerbates the
pain. He [**Month/Year (2) **] any chest pain or dizziness. His SOB is at
baseline. Of note, he recently completed a course of abx for
HCAP and is currently being treated for cdif.
ER: 98.3, 106, 125/76, 20, 94% 3L.
ROS:otherwise negative
Past Medical History:
- HCV cirrhosis c/b HCC, s/p TACE [**6-1**], RFA [**6-17**]
- HIV diagnosed 20 years ago, on HAART
- HLD
- HTN
- CAD, s/p cath at [**Hospital1 2025**] without intervention, mild CAD noted - 3
years ago, no caths since
- Inclusion body myositis, diagnosed in [**2154**], on chronic
prednisone
- cholelithiasis
- Small gallbladder polyps
- s/p cataract surgery [**2160**]
- recent Cdif [**3-17**]
- recent pins place in hip @ OSH
Social History:
lives with [**Last Name (un) 1063**] [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 40593**] [**Telephone/Fax (1) 40594**], who is his HCP
uses electric wheelchair
no tobacco
social etoh
no illicits
Family History:
mother died of colon cancer age 42
father died at age 86 from suicide
Physical Exam:
ADMISSION EXAM
VS: Tm 98.5, BP 120-132/87, HR 78-95, RR 18-20, O2 Sat: 98%
2L/BiPap overnight I/O: [**Telephone/Fax (1) 40598**]0/2300 + 3 BM
Gen: NAD, chronically ill appearing, emaciated male, hunched
over in bed.
HEENT: NCAT, sclera anicteric, OP clear
CV: RRR, no m/r/g appreciated
Lungs: anterior exam, mild crackles. no wheezes appreciated; air
movement throughout.
Ab:+BS, soft, no TTP in RUQ, no rebound/guarding, no mass/hsm
Ext:no c/c/e
Skin:atrophic LE
Neuro:A&O x 3, strength in UE is [**3-10**], CN II-XII intact. Strength
in LE: knee extension 0/5; hip abduction/adduction and hip
extension [**3-10**]. [**Last Name (un) **] and plantarflexion [**4-9**]. Equal bilaterally.
Sensation intact. Unable to ambulate. Finger to nose intact.
Speech normal.
DISCHARGE EXAM
Vitals - T:98.5 BP:110/78 HR:105 RR:20 02 sat:100% 2L
GENERAL: middle aged male appearing comfortable
CARDIAC: RRR, S1/S2, no mrg
LUNG: decreased air entry on the left base, right sided
scattered wheezes.
ABDOMEN: nondistended, +BS, non tender to palpation, no
rebound/guarding
Chest: Tenderness along left costal margion and left sternal
border improving.
Pertinent Results:
ADMISSION LABS
[**2168-4-16**] 03:30PM GLUCOSE-122* UREA N-8 CREAT-0.7 SODIUM-131*
POTASSIUM-5.1 CHLORIDE-95* TOTAL CO2-25 ANION GAP-16
[**2168-4-16**] 03:30PM estGFR-Using this
[**2168-4-16**] 03:30PM ALT(SGPT)-171* AST(SGOT)-149* ALK PHOS-643*
TOT BILI-1.2
[**2168-4-16**] 03:30PM ALBUMIN-3.5
[**2168-4-16**] 03:30PM ALBUMIN-3.5
[**2168-4-16**] 03:30PM LACTATE-2.1*
[**2168-4-16**] 03:30PM WBC-13.7*# RBC-4.43* HGB-11.3* HCT-38.8*
MCV-88 MCH-25.6*# MCHC-29.2* RDW-14.8
[**2168-4-16**] 03:30PM NEUTS-89* BANDS-0 LYMPHS-7* MONOS-1* EOS-1
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2168-4-16**] 03:30PM PLT SMR-HIGH PLT COUNT-434#
[**2168-4-16**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2168-4-16**] 03:30PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
DISCHARGE LABS:
[**2168-5-13**] 06:15AM BLOOD WBC-8.1 RBC-3.35* Hgb-8.1* Hct-27.6*
MCV-82 MCH-24.3* MCHC-29.5* RDW-18.5* Plt Ct-356
[**2168-5-13**] 06:15AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-134
K-3.3 Cl-99 HCO3-26 AnGap-12
[**2168-5-13**] 06:15AM BLOOD ALT-24 AST-30 AlkPhos-235* TotBili-1.0
[**2168-5-13**] 06:15AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.3
MICRO:
[**2168-5-8**] STOOL C. difficile DNA amplification assay- negative;
FECAL CULTURE-NO ENTERIC GRAM NEGATIVE RODS FOUND, NO SALMONELLA
OR SHIGELLA FOUND; CAMPYLOBACTER CULTURE- negative
[**2168-5-2**] BLOOD CULTURE - no growth
[**2168-5-2**] BLOOD CULTURE - no growth
[**2168-5-2**] STOOL C. difficile DNA amplification assay- negative;
FECAL CULTURE-NO ENTERIC GRAM NEGATIVE RODS FOUND, NO SALMONELLA
OR SHIGELLA FOUND; CAMPYLOBACTER CULTURE-negative;
Cryptosporidium/Giardia (DFA)-NO CRYPTOSPORIDIUM OR GIARDIA
SEEN.
[**2168-4-30**] BLOOD CULTURE - no growth
[**2168-4-29**] BLOOD CULTURE - no growth
[**2168-4-29**] BLOOD CULTURE - no growth
[**2168-4-28**] BLOOD CULTURE - ENTEROCOCCUS FAECIUM
[**2168-4-27**] BLOOD CULTURE - no growth
[**2168-4-27**] BLOOD CULTURE - ENTEROCOCCUS FAECIUM
[**2168-4-26**] BLOOD CULTURE - ENTEROCOCCUS FAECIUM, STAPHYLOCOCCUS
EPIDERMIDIS
[**2168-4-26**] BLOOD CULTURE ENTEROCOCCUS FAECIUM, STAPHYLOCOCCUS
EPIDERMIDIS
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
| STAPHYLOCOCCUS
EPIDERMIDIS
| |
AMPICILLIN------------ =>32 R
CLINDAMYCIN----------- =>8 R
DAPTOMYCIN------------ S S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>64 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R 2 S
[**2168-4-21**] IMMUNOLOGY HIV-1 Viral Load/Ultrasensitive--1 Viral
Load/Ultrasensitive (Final [**2168-4-21**]): HIV-1 RNA is not
detected.
[**2168-4-20**] BLOOD CULTURE - no growth
[**2168-4-20**] BLOOD CULTURE - no growth
[**2168-4-16**] BLOOD CULTURE - no growth
[**2168-4-16**] BLOOD CULTURE - no growth
[**2168-4-16**] URINE CULTURE- no growth
PATHOLOGY:
COMMON BILE DUCT STENT PATHOLOGY [**2168-4-25**] POSITIVE FOR MALIGNANT
CELLS,
consistent with poorly differentiated carcinoma
PERTINENT STUDIES
# CXR [**2168-4-16**]: No significant interval change from prior with
continued chronic elevation of left hemidiaphragm and associated
left basilar opacity likely reflective of atelectasis. Right
PICC tip terminates in the mid SVC.
# RUQ U/S [**2168-4-16**]:
1. Limited study. Gallbladder could not be visualized.
2. Cirrhosis with ill-defined 15-mm nodule in the left lobe,
without a clear correlate on the prior MR.
3. Stent in the CBD without intrahepatic biliary dilatation.
CT or MRI is recommended for further evaluation of the
gallbladder, as well as the left lobe hepatic nodule.
# MRI ABDOMEN WITH CONTRAST [**2168-4-17**]
1. Interval increase in the size of the hepatic mass in the
left lobe of the liver which causes more extensive obstruction
of the left lateral segment bile ducts and has increased
intraductal extent into the primary bifurcation of the biliary
system.
2. Stable right-sided renal cysts, hepatic cyst in the left
lateral segment, and gallstones.
3. Rounded, expanded lesion in the right 9th rib at the level of
the
costochondral junction that demonstrates heterogeneous signal on
T2 weighted images and post contrast enhancement. Dedicated CT
examination is recommended to rule out metastasis.
4. Slight increase in size of satellite lesion (9 x11mm) in the
border of
segment V/VIII that shows increased signal on T2 weighted
images, arterial hyperenhancement and washout pattern.
# FIDUCIAL PLACEMENT [**2168-4-19**]
1. Two gold fiducial markers placed within liver mass as
described above.
2. Bilateral atelectasis in the lung lower lobes.
3. Soft tissue density surrounding the right 8th rib, favor
nondisplaced
fracture with callus formation (please refer to the body of the
report).
# CXR [**2168-4-19**]
Mediastinal silhouette with left mediastinal shift, most likely
due to left lower lung atelectasis/volume loss, is unchanged.
Lung volumes remain very low. Small amount of pleural effusion
is most likely present bilaterally. Catheter projecting over
the right upper abdomen is redemonstrated. Elevation of left
hemidiaphragm is unchanged. There is no pneumothorax.
# ERCP [**2168-4-25**]
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: 2 previously placed plastic stents placed in the
biliary duct were found in the major papilla. The Cotton [**Doctor Last Name **]
stent was removed using a snare. A double pigtail stent was
removed using a rat tooth forceps. Evidence of a previous
sphincterotomy was noted in the major papilla.
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree Fluoroscopic Interpretation: A moderate diffuse
dilation was seen at the right main hepatic duct and left main
hepatic duct. The dilation was greater on the left than right
intra-hepatic ductal system.
There was a large filling defect in the common hepatic duct c/w
known HCC invading and causing bleeding within the biliary tree.
Impression: Previously placed plastic stents were removed
Evidence of a previous sphincterotomy was noted in the major
papilla.
There was a large filling defect in the common hepatic duct c/w
known HCC invading and causing bleeding within the biliary tree.
Multiple balloon sweeps were performed and large amount of blood
clots and blood was extracted.
Given tumor in the common hepatic duct and a double pig tail
biliary stent was placed
# CTA CHEST [**2168-4-27**]
1. Progressive left lung and right lower lobe collapse. This
is likely
related to chronic mucoid impaction, and possible underlying
tracheobronchomalacia.
2. No pulmonary embolism.
# TTE [**2168-4-28**]
There is mild symmetric left ventricular hypertrophy. There is
mild global left ventricular hypokinesis (LVEF = 45 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious vegetations
seen
# CHEST (PA & LAT) Study Date of [**2168-5-4**]
IMPRESSION: Complete left upper and lower lobe collapse.
Bronchoscopy is suggested.
# RIB BILAT, W/AP CHEST Study Date of [**2168-5-4**]
IMPRESSION:
1. Near-complete whiteout of the left lung with areas of cystic
changes in the left upper lobe which are better evaluated on
prior chest CT.
2. There are subacute fractures of several of the left lower
ribs, which
demonstrate some bridging callus.
# CHEST (PORTABLE AP) Study Date of [**2168-5-6**]
FINDINGS: Whereas the left hemithorax was previously completely
opacified, there is now marked improved aeration of the left
upper lobe, with residual atelectasis involving the left lower
lobe. Small-to-moderate pleural effusion on the left is
difficult to compare to the previous study for change due to the
presence of complete lung collapse on the prior exam. Partial
atelectasis of the right lower lobe is present, manifested by a
right retrocardiac opacity and inferior displacement of the
right hilum. Small right pleural effusion is
not appreciably changed.
Brief Hospital Course:
61M w/ HIV, Hep C cirrhosis, HCC with recent admission for CAP,
presented with RUQ pain and increasing bilirubin with
progression of HCC on imaging, s/p ERCP with stent placement on
[**4-25**] resulting improvement in tbili. Pt had placement of
fiducial and completed [**2-6**] rounds of cyberknife treatment. His
hospital course was complicated by VRE bacteremia and complete
left lung collapse, requiring brief ICU stay. Pt has opted to
transition to home hospice.
ACTIVE ISSUES:
# Complete Left Lung Collapse: Pt has poor baseline lung
capacity secondary to inclusion body myositis and diaphragmatic
weakness. During his hospitalization, he had increasing
difficulty clearing his secretions, due to his myositis,
immobility and pain from subacute rib fractures. On two
occasions, he developed increasing respiratory distress,
initially requiring ICU admission, where he was placed on BiPAP.
The etiology of his respiratory decompensation was thought to be
secondary to mucous plugging. His respiratory status improved
with chest PT, suctioning, standing nebs, acapella device and
incentive spirometry. Pt was also encouraged to get out of bed
and his rib pain was well controlled with medications. At time
of discharge, he was stable on 2 liters of supplemental oxygen
via nasal canula with oxygen saturation maintaining in the mid
90s. He continues to require BiPAP at night secondary to his
myositis.
# VRE and Staph epidermidis Bacteremia: Pt was found to be
bacteremic with multiple blood cultures positive for VRE and s.
epidermidis on [**4-19**]. The etiology was likely a biliary
source, possibly secondary to fiducial placement, or pneumonia
given chest CT findings of complete left lung collapse.
Surveillance cultures cleared on [**4-29**]. He was initially on
vancomycin and then transitioned to Daptomycin. He completed a
14 day course of treatment.
# Left Lower Chest pain: Pt developed left lower rib pain during
his hospitalization. His rib xray revealed multiple subacute
fractures, likely responsible for his pain. He was treated with
pain medications and his pain improved.
# RUQ pain: He was admitted with worsening RUQ pain. On MRCP,
the patient's HCC lesion was enlarged and causing mass effect on
his biliary system (the likely the etiology of his pain) so he
underwent ERCP and is s/p stenting with resulting improvement in
his LFTs and Tbili, despite lack of improvement in pain because
the lesion was still large. Thus, he underwent cyberknife [**5-4**], which provided dramatic improvement in his pain.
# Diarrhea: Pt continue to have diarrhea throughout his
hospitalization. His C diff assay was negative on multiple
occasions, as were stool studies. His diarrhea was thought to be
secondary to his antibiotics. He was ultimately started on
Imodium with improvement in his symptoms.
CHRONIC CARE
# HIV: Currently, HIV is undetectable in his blood. CD4 count is
1000. For his HAART, his dosing was confirmed with pharmacy
given liver failure, thus, he was continued on Leviva, Zetia and
Truvada
# Hep C cirrhosis c/b HCC: slight elevation in LFTs, which were
normal in [**2168-3-6**]. After discussion with the patient and
his HCP, he decided to transition to DNR/DNI and ultimately
would like to go home with hospice.
# Cdiff: Pt had recent C diff infection and was on PO vanc at
time of admission. His course was continued and repeat PCR
showed no evidence of C diff.
# Inclusion body myositis: Pt has limited mobility at baseline
and requires BiPAP nightly. He was continued on prednisone with
Bactrim prophylaxis.
TRANSITIONS IN CARE
# Code Status: DNR/DNI
# Contact: [**Name (NI) 5969**] [**Name (NI) 40593**], HCP and Partner, [**Telephone/Fax (1) 40594**]
# ISSUES TO DISCUSS AT FOLLOW UP:
During this hospitalization, pt expressed a desire to change
code status to DNR/DNI and transition to hospice. Ultimately, he
would like to receive home hospice but does not have the
necessary support at this time. His plan is to be discharged to
rehab for 2 weeks. At that time, a friend will be moving to
[**Name (NI) 86**] and will be able to provide home health care for the
patient. He should be discharged from rehab to home with
hospice. He would like to continue all medications at this time,
but is aware that he has the option of discontinuing any or all
of them. He would like to forgo any further treatment for his
HCC, but should he change his mind, he should have a repeat ERCP
in 6 to 8 weeks with Dr. [**Last Name (STitle) **].
Medications on Admission:
Fexofenadine 60 mg po bid
Prednisone 15 mg po daily
Heparin sq tid
Pseudoephedrine 30 mg po bid
Sertraline 50 mg po daily
Bactrim DS daily
Lansoprazole 30 mg daily
Fosamprenavir 1400 mg po bid
Truvada 200-300 daily
Vitamin D daily
Calcium daily
Multivitamin
Vancomycin 250 mg po qid (until [**2168-4-30**])
Oxycodone 5 mg po q6h prn pain
Tylenol ES 500 mg po q6h prn pain
Xanax 0.25 mg po tid prn anxiety
Ambien 5 mg po qhs prn insomnia
Alb/atrovent inh q6h prn
NTG 0.4 mg sl q5 mins x 3 prn pain
Anusol prn
Discharge Medications:
1. fexofenadine 60 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times
a day).
2. prednisone 5 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO DAILY
(Daily).
3. pseudoephedrine HCl 30 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID
(2 times a day).
4. heparin (porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: 5000 (5000)
units Injection TID (3 times a day).
5. sertraline 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Month/Day/Year **]: One (1)
Tablet PO DAILY (Daily).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. fosamprenavir 700 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q12H
(every 12 hours).
9. Truvada 200-300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
10. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Last Name (STitle) **]: One (1) Tablet, Chewable PO TID (3 times a day).
12. multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours).
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours).
15. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for moderate pain.
Disp:*1 Tablet(s)* Refills:*0*
16. sodium chloride 3 % Solution for Nebulization [**Last Name (STitle) **]: One (1)
neb Inhalation Q 8H (Every 8 Hours).
17. Tylenol 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every six (6)
hours as needed for fever or pain: Do not take more than 2
grams/24 hours.
18. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety/nausea.
19. Ambien 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
20. Anusol-HC 2.5 % Cream [**Last Name (STitle) **]: One (1) application Rectal three
times a day as needed for hemorrhoids.
21. Imodium A-D 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day
as needed for diarrhea.
22. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice
a day as needed for constipation.
23. senna 8.6 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY
hepatocellular carcinoma
hospital acquired pneumonia
bacteremia
SECONDARY:
inclusion body myositis
HIV
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for right sided abdominal
pain, which was likely from progression of your cancer. You did
receive cyberknife radiation treatment to your tumor, which
helped improve your pain.
During your hospitalization, you were also treated for a
pneumonia and an infection in your blood stream, for which you
received antibiotics.
You had several episodes of difficulty breathing, which we
treated with breathing treatments and chest physical therapy. It
is important that you continue these treatments at home
Please note the following changes to your medications:
# Use Sodium Chloride 3% nebulizers every 8 hours
# START ativan 0.5 mg every 6-8 hours as needed for anxiety;
STOP taking xanax
# START imodium 2-4 times daily as needed for diarrhea
# Use your incentive spirometer and acapella device every hour
while you are awake
Followup Instructions:
Department: RADIOLOGY
When: THURSDAY [**2168-6-9**] at 11:55 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2168-6-13**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2168-5-14**]
ICD9 Codes: 486, 7907, 5715, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 913
} | Medical Text: Admission Date: [**2127-9-15**] Discharge Date: [**2127-9-23**]
Date of Birth: [**2069-2-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Motor Vehicle Collision
Major Surgical or Invasive Procedure:
Chest tube- Right
History of Present Illness:
Mr. [**Known lastname **] is a 58 year-old man transferred from [**Hospital3 **] after a he was the restrained driver of a car that
struck a telephone pole with significant damage to the front of
the car, with airbag deployment. Per report , he was reportedly
ambulatory at the scene but disoriented and intoxicated.
Past Medical History:
Hypertension
s/p Appendectomy
Social History:
Pt lives in [**Location 7661**] with his wife. [**Name (NI) **] 2 children in the
[**Country 13622**] Republic and 3 in US. Pt works at [**Hospital3 **].
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
.
Vitals: HR 90, BP 180/80, RR 18 O2: 96%
HEENT: Pupils 1 mm b/l.
Airway: intact
Chest: Equal and bilateral breath sounds. Left and right chest
wall tenderness.
Abd: Epigastric tenderness. Reducible right ventral hernia.
Rectal: Normal tone, no gross blood.
MSK: No long bone deformities. Pelvis stable.
Spine: No tenderness, no step-offs.
Pertinent Results:
Labs on Admission: WBC 13.0, Hgb 12.7, Hct 36, Platelets 246,
Sodium 138, Potassium 3.6, Chloride 102, Bicarb 23
Ethanol 153
Hematocrit trend: [**2127-9-16**] 33.5 [**9-18**] 24.5 [**9-22**] 29.3
.
Chest X-Ray [**2127-9-19**]: IMPRESSION:
1. No evidence of pneumothorax.
2. Interstitial pulmonary edema.
3. Bilateral small pleural effusions, right greater than left.
.
CT abd/pelvis [**2127-9-15**]-IMPRESSION: 1. Hepatic
lacerations/contusions which given the number of segments
involved, and the depth of penetration would likely represent
grade III injury. There is associated hemoperitoneum. No active
extravasation is noted. 2. Grade I splenic laceration with a
small amount of perisplenic hematoma. 3. Fluid adjacent to the
pancreas without evidence of pancreatic injury possibly
representing blood tracking into this region from other injuries
as described above. Recommend attention to this area on followup
imaging. 4. Right anterior rib fractures in ribs four through
six, with subcutaneous emphysema, tiny right pneumothorax and
small right hemothorax. 5. Patchy airspace opacity in the right
lower lobe, likely a combination on atelectasis and aspiration.
Small foci of pulmonary contusions in the right middle lobe.
.
CT Head [**2127-9-15**]-IMPRESSION: No evidence of fracture, hemorrhage
or mass effect. Old right cerebellar infarct.
.
Echo, transthoracic [**2127-9-16**]-The left atrium is mildly dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
.
Gallbladder Scan [**2127-9-18**]-IMPRESSION: Nonvisualization of the
gallbladder 30 minutes following morphine administration.
.
MRCP [**2127-9-21**]-IMPRESSION:
1. Segment VIII liver laceration with some free fluid around the
liver in patient status post MVC.
2. Cholelithiasis with thickened edematous gallbladder wall and
pericholecystic fluid which may be secondary to the recent
trauma.
3. Pericholecystic hepatic enhancement which may represent a
perfusion abnormality.
4. Right pleural effusion.
.
KNEE (AP, LAT & OBLIQUE) LEFT [**2127-9-22**]- No acute fracture,
dislocation
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the Trauma intensive care unit with
the following injuries:
right-sided rib fractures, right hemothorax, grade III hepatic
laceration, and a grade I splenic laceration.
.
# Respiratory Distress- # [**Hospital 74469**] hospital day 2, Mr.
[**Known lastname **] was intubated for declining mental status and increased
work of breathing. A right-sided chest tube was placed for
right hemothorax and put out 600ml in the first 24 hours. He
was extubated on HD3. Chest tube was discontinued on HD4 and he
was saturating well on room air prior to discharge.
.
# Hepatic/Splenic Lacerations- Serial hematocrits and abdominal
exams were performed to monitor the evolution of hepatic and
splenic lacerations. Hematocrit dropped to 29 on HD1 from 36 on
admission and reached a nadir of 24.6 on HD4. Hematocrit was
stable at 29 prior to discharge and his abdomen was soft and
non-tender. Repeat CT revealed decreased size of hepatic and
splenic lacerations.
.
# Tachycardia- Mr. [**Known lastname **] had tachycardia on HD2. Cardiac enzymes
were negative for ischemia. Cardiology was consulted and
recommended benzodiazepines for alcohol withdrawal as well as a
beta-blockade. Transthoracic echo was obtained and was normal
with an EF > 55%. Tachycardia improved by hospital day 3.
.
# Acute cholecystitis- Mr. [**Known lastname **] developed a fever on HD3. He
was started on vancomycin and Zosyn. Blood cultures were sent
and revealed Klebsiella in [**12-24**] bottles. Urine culture was
negative. CT abdomen and pelvis revealed thickening of
gallbladder wall. A HIDA scan was positive. Pancreatic enzymes
were elevated. An MRCP revealed no dilation of intra or
extra-hepatic ducts. Vancomycin was discontinued and he was
started on levofloxacin. He was afebrile with soft, non-tender
abdomen prior to discharge. He was discharged with oral
levofloxacin to complete a 2 week course. He will follow-up
with Dr. [**Last Name (STitle) **] in 2 weeks in Trauma clinic.
.
Left Ankle Pain- Mr. [**Known lastname **] reported left ankle pain.
Orthopedics was consulted and recommended plain films which were
negative for fracture. He was given a CAM boot for walking. He
will follow-up with Dr. [**Last Name (STitle) 1005**] in 4 weeks in orthopedics
clinic.
.
# Alcohol Use- Social work was consulted and discussed alcohol
counseling and treatment programs which Mr. [**Known lastname **] [**Last Name (Titles) **].
Medications on Admission:
Hydrochlorothiazide 25mg PO daily
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day: Take this medication as prescribed by your primary care
doctor.
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): Do not take other medications containing tylenol
(acetaminophen) at the same time.
4. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor Vehicle Collision
Right anterior rib fractures in ribs four through six
Right hemothorax
Grade III hepatic lacerations
Grade I splenic laceration
Acute cholecystitis
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital after a motor vehicle
accident. You were found to have bleeding from your liver and
your spleen. You were admitted to the intensive care unit and
required a breathing tube. Because you had fluid surrounding
your right lung, a chest tube was placed and was later removed.
You had tests done which showed possible gallbladder infection.
For this reason you were started on antibiotics. You should
continue taking the antibiotic Levofloxacin until [**2127-10-4**]. You
should see Dr. [**Last Name (STitle) **] in 2 weeks. You were seen by the orthopedic
surgeon Dr. [**Last Name (STitle) 1005**] for your left ankle pain. X-rays were
ordered and did not show any fracture. You were given a boot
for walking. You should follow-up with Dr. [**Last Name (STitle) 74470**] in 4
weeks. You may take Tylenol for pain but do not exceed 2 grams
(2000mg) per day. You may take Dilaudid (hydromorphone) for
pain but it is important not to drive, drink alcohol or take
sedative medications while taking Dilaudid. Dilaudid causes
constipation- therefore it is important to take a stool softener
(Colace) while taking Dilaudid.
.
Please call your doctor or return to the hospital for:
* Fever (Temp > 101), chills
* Abdominal pain
* Nausea or vomiting
* Chest pain
* Shortness of breath
* Worsening ankle pain
* Any other symptoms that concern you
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in Trauma Clinic in 2 weeks.
Call ([**Telephone/Fax (1) 376**] to make an appointment.
.
Please see Dr. [**Last Name (STitle) 1005**] in orthopedics clinic in 4 weeks. Call
([**Telephone/Fax (1) 2007**] to make an appointment.
.
Please see your primary care provider at your earliest
convenience.
ICD9 Codes: 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 914
} | Medical Text: Admission Date: [**2169-10-11**] Discharge Date: [**2169-10-21**]
Date of Birth: [**2109-8-8**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Naprosyn / Keflex / Shellfish / Glucophage / Tetracycline /
Penicillins / Erythromycin Base / Ciprofloxacin / Biaxin /
Bactrim / Vancomycin / Latex / Duoderm Cgf / Morphine Sulfate /
Levofloxacin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Intubation and extubation
History of Present Illness:
This is a 60 year old female with past medical history of
asthma, CAD, AF, and embolic stroke who presented from [**Location (un) 620**]
with respiratory failure. Per report the patient called EMS
today reporting dyspnea. When they arrived she was very short
of breath and appeared cyanotic with diffuse crackles.
Therefore, she was put on NIPPV and transferred to [**Hospital1 **] [**Location (un) 620**]
where she was intubated with succinylcholine etomidate. Given
pink, frothy secretions from the tube and bilateral fluffy
infiltrates presumed etiology was heart failure exacerbation so
the patient received 80 mg of IV furosemide and was transferred
to [**Hospital1 18**]. En route the patient was hypotensive on propofol,
which was discontinued. On arrival she was agitated and
received fentanyl/midazolam for sedation before receiving
linezolid and pipercillin-tazobactam due to concern the
patient's infiltrates were due to pneumonia. Initial ABG here
was 7.23/ 71 / 406 on AC with Tv 450, RR 16, PEEP 5, and 02
100%. The patient was noted to have high peak pressures (>30)
with high plateaus raising concern for auto-PEEP. Therefore, he
received 10 mg IV vercuronium. He also received an unclear
amount of fluid for transient hypotension. With increasing her
minute ventilation pH rose to 7.9 and CO2 dropped to 60. He was
transferred to the MICU. Of note, the patient had a VERY
similar presentation on [**2169-8-5**] in which the patient was
admitted for multifocal pneumonia with concern for volume
overload. During that hospitalization she had very quick
resolution of her chest radiograph and was discharged on a
course of linezolid / piperacillin-tazobactam.
On arrival to the MICU the patient was intubated and sedated.
Paralysis was coming off but patient still not interacting/
reacting in a meaningful way. Some spontaneous movements.
Past Medical History:
Left MCA territory embolic infarct, likely of cardioembolic
etiology in [**2166-5-16**]
Atrial fibrillation on sotalol and coumadin
CAD - MI [**2155**] @ age 44, [**2156**], and NSTEMI in [**2164**] (Trop T 0.06)
Sick sinus syndrome status post dual-chamber pacemaker
MVR
Hyperlipidemia
Diabetes mellitus, type 2
Obesity
Hypertension
Asthma
Ostructive sleep apnea on BIPAP
Mild pulmonary HTN 36/18 on cath in [**8-21**]
Social History:
Significant for the absence of
current tobacco use (quit at age of 22) No heavy alcohol.
Family History:
Per OMR - Her father died of CAD in his 50's, he had his first
MI at age 41. She has multiple younger brothers with "heart
problems."
Physical Exam:
VS: 95.9 Temp: BP:102/62 HR:72 RR 18, and O2sat 93 % on vent
GEN: Intubated, sedated, markedly hirstute, NAD
HEENT: anisocoria (appears old), not following commands,
occasionally aoviding noxiious stimuli or maoning. NO LAD or
masses appreciated.
RESP: Crackles bilaterally with prolonged espiratory phase.
CV: Distant heart sounds, regular, not taychcardic
ABD: Soft, NT, ND, BS+
EXT: cool, large (3-2 cm) round, smooth edged ulcer on right
anterio thigh with erythema and granulation tissue but no acute
pus.
NEURO: intubated and sedating, moving all four extremities
equally.
Pertinent Results:
===================
LABORATORY RESULTS
===================
WBC-15.5*# RBC-4.56 Hgb-12.4 Hct-38.7 MCV-85RDW-16.9* Plt Ct-203
PT-23.8* PTT-29.8 INR(PT)-2.3*
Glucose-306* UreaN-25* Creat-1.3* Na-139 K-4.7 Cl-102 HCO3-27
ALT-27 AST-35 LD(LDH)-367* AlkPhos-143* TotBili-0.9
Calcium-8.6 Phos-2.6* Mg-1.8
URINE: Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Color-Straw
Appear-Clear Sp [**Last Name (un) **]-1.006
==============
OTHER RESULTS
==============
Admission EKG: A paced at 80. IVCD. No acute ST changes.
Chest Radiograph [**2169-10-11**]:
IMPRESSION:
1. Hilar prominence with bilateral lung opacities is concerning
for pulmonary congestion/edema with possible pneumonia.
2. Tubes positioned appropriately
Chest Radiograph [**2169-10-13**] 3:31 AM(post extubation):
IMPRESSION:
AP chest compared to [**10-12**]:
The patient has been extubated, lung volumes are normal, and the
lungs are
clear following resolution of heterogeneous opacification in
both lower lungs yesterday. Given the rapid clearance, these
findings were not due to
hemorrhage or pneumonia or noncardiogenic edema. Cardiac edema
and toxic
inhalation or massive aspiration, the likely causes.
Heart size is top normal and unchanged. No pleural abnormality.
Transvenous
right atrial and right ventricular pacer leads in standard
placements.
Chest Radiograph [**2169-10-13**] 6:59 PM (post reintubation)
IMPRESSION:
1. Interval intubation and placement of NG tube.
2. New diffuse bilateral alveolar opacities. Given the time
course, this
most likely represents pulmonary edema.
Transesophageal Echo [**2169-10-14**]:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
At least mild-moderate mitral regurgitation. Dilated ascending
aorta.
Compared with the report of the prior study (images unavailable
for review) of [**2169-8-7**], an [**Year (4 digits) 34486**] jet of at least
mild-moderate mitral regurgitation is now seen.
Due to the [**Year (4 digits) 34486**] nature of the mitral regurgitation jet, if
clinically indicated a cardiac MRI [**Telephone/Fax (1) 9559**] may be best able
to assess the severity of mitral regurgitation.
CT Chest W/O Contrast [**2169-10-14**]:
IMPRESSION:
1. Multifocal ground-glass opacities, compatible with multifocal
pneumonia.
2. Small bilateral pleural effusions.
3. Unchanged multilobulated right hepatic hypodense lesion,
compatible with
the previously described biliary cystadenoma.
4. 1.3 cm simple left renal cyst.
5. Status post cholecystectomy.
.
CXR [**10-16**]:
1. Significant interval clearing of the lungs. Despite previous
description as multifocal pneumonia, the apparent rapid
resolution of these infiltrates suggest that this more likely
may be due to pulmonary edema.
2. Interval extubation and removal of the NG tube.
.
[**10-19**] Renal CTA:
1. No evidence for renal artery stenosis. No significant
atherosclerotic
disease.
2. Complex hepatic cyst, unchanged in size compared to [**Month (only) 216**]
[**2168**], and also previously characterized by ultrasound. If
further characterization is required, this could be accomplished
by MRI.
3. Status post cholecystectomy.
4. Left parapelvic cysts, with additional exophytic cyst arising
posteriorly from the interpolar region of the left kidney.
.
Brief Hospital Course:
60 y.o. female with [**Hospital 7235**] medical problems and recent
admission for "pneumonia" now readmitted for pneumonia and CHF.
.
1. Acute on Chronic Diastolic CHF: Patient presented with
bilateral infiltrates consistent with multifocal pneumonia vs
CHF. She was empirically treated with antibiotics and
furosemide with improvement but difficulty assessing exactly
what process was predominant. Quick resolution and reappearance
of infiltrates was thought to be more consistent with diastolic
CHF. After her first extubation proceeded uneventfully the
patient rapidly decompensated on arrival to the medical floor
with severe hypoxia and needed to be reintubated urgently. It
is unclear what precipitated these episodes of decompensation
though hypotension was considered possible. Cardiac enzymes
remained negative. Echocardiogram showed MR [**First Name (Titles) 151**] [**Last Name (Titles) 34486**] jet.
Cardiology recommended gentle diuresis and gentle volume
resuscitation as needed to maintain SBP>100. They also
recommended starting an ACE inhibitor or CCB as an outpatient.
Given her predispositoin for flash pulmonary edema, we obtained
a renal CTA to rule out renal artery stenosis, and this was
negative. Pt's blood pressure remained around SBP 100 but we
were able to restart her home lasix dose 20mg (every other day)
prior to discharge with stable pressure. She will have follow up
with cardiology within 1 week.
.
2. Multifocal Pneumonia: Given diffuse infiltrates that waxed
and waned dramatically these were thought less likely to be
multifocal pneumonia so though the patient received linzeolid
and pip-tazo at presentation these were rapidly discontinued.
On [**10-14**] when CT showed clear infiltrate CAP coverage with
ceftriaxone/azithro was restarted. Levo was discontinued when
CXR on [**10-16**] did not show clear consolidation and pt's
oxygenation status improved significantly with diuresis in MICU.
Additionally, pt reported an "allergy" to levo, among multiple
other antibiotic allergies, though reaction seemed to only be
diarrhea.
.
3. Afib w/ RVR: Was well controlled on sotalol. She was
continued on coumadin, had supratherapeutic INR to 4.1 in
setting of levofloxacin use. Coumadin was held and restarted
when INR dropped to 1.6. She was bridged on heparin drip and
discharged on lovenox course with INR of 1.6, instructed to
check INR at home and to adjust coumadin as needed for goal >2.
Discharged on coumadin 5mg daily (home dose 3mg).
.
#. Chest pain - pt had one episode of CP after coming to the
floor, ECG unchanged from previous and no acute findings on
right sided ECG, cardiac markers slightly elevated but stable
over 2 draws. Cardiology was consulted and recommended interval
repeat cathetrization as outpt, last cath a few years ago was
clean and low likelihood of stenosis. Markers likely elevated
due to repeated cardiac stress, not concerning at this time for
ischemia. She was given full dose ASA and high dose statin while
being ruled out, and monitored on tele without any major events.
Pt was chest pain free for the rest of the hospital stay.
Returned to home dose ASA and statin on discharge, cardiology
outpt f/u.
.
5. HTN: Held home lasix and help captopril that was started
during this admission (per cardiology recs) given hypotension to
SBP 90s. Likely in setting of overdiuresis. Gave gentle 250cc
fluid boluses with caution given easy predisposition for flash
pulm edema. Prior to discharge, BP stabilized and we restarted
home lasix dose 20mg qod.
.
6. Hx embolic stroke: continue levetiracetam at home doses
.
7. DM: On large doses at home, on sliding scale in the hospital
with well controlled blood sugars
.
Medications on Admission:
-Albuterol Q4hrs PRN
-Fluticasone 110 mcg/spray 2 puffs [**Hospital1 **]
-Sotalol 80 mg [**Hospital1 **]
-Calcium Carbonate 500 mg PO QID PRN heartburn
-Levetiracetam 250 mg PO BID
-Warfarin 3 mg PO daily
-[**Hospital1 54306**] 2 mg PO BID
-ASA 162 mg PO daily
-Humalog 75-25 15-20 in AM and 15-20 PM
-Humulin N 35-42 QHS PRN
-Atorva 20
-Atroven 17 mcg/actuation Q6hrs PRN
Discharge Medications:
1. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain fever.
4. aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-17**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
7. calcium carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO four times a day as needed for
heartburn.
8. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: take
5mg today ([**10-21**]), measure INR and take 3mg daily after INR >1.8.
9. [**Month/Day (4) 54306**] 2 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Humalog 100 unit/mL Solution Sig: 75-25 Subcutaneous twice
a day: take 15-20 in AM, 15-20 in PM.
11. Humulin N 100 unit/mL Suspension Sig: Thirty Five (35) u
Subcutaneous at bedtime.
12. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-17**]
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
14. Lovenox 100 mg/mL Syringe Sig: 100mg injection Subcutaneous
twice a day for 4 days: please use 1 injection in AM, 1
injection in PM.
Disp:*8 * Refills:*0*
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Flash pulmonary edema
.
Secondary:
diastolic CHF
MVR
DM2
HTN
asthma
OSA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
with respiratory distress and found to have flash pulmonary
edema (acute accumulation of fluid in your lungs) and had to be
intubated twice for this. You were extubated and stabilized in
the ICU and then transferred to the medical floor. We did not
see a pneumonia on your last chest x-ray and did not continue
the antibiotics started in the ICU. We diuresed you gently and
started you back on lasix when your blood pressure stabilized.
Your INR was very high (>4) in the beginning of your admission
and we held your coumadin, we restarted it and prior to
discharge your INR was 1.6. We started a heparin drip the day
before you left to cover you while your INR came back to normal.
You will be discharged with Lovenox to bridge your
anticoagulation until your INR is at goal >2, you should take
coumadin 5mg today and remeasure your INR at home. You can
return to your home dose of 3mg daily when your INR is in the
acceptable range. Our cardiologists saw you while you were in
the hospital and recommended that you start a medication called
an ACE inhibitor after you leave the hospital, you should
discuss this with your cardiologist at your appointment. You did
not have a heart attack while you were at the hospital.
.
You should follow up closely your PCP and cardiologist within 1
week of leaving the hospital.
.
We have made the following changes to your medications:
- Take coumadin 5mg tonight ([**10-21**]) and remeasure your INR at
home, you can return to your home dose of 3mg daily after your
INR is >2
- Start lovenox, take 1 injection in the morning and 1 in the
evening (12 hours apart), you are given 4 days of doses, check
your INR daily and continue your coumadin, take lovenox until
your PCP appointment
[**Name Initial (PRE) **] Take lasix 20mg EVERY OTHER day
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
We recommended home services for you prior to discharge (PT and
nursing) but you declined these.
Followup Instructions:
Please follow up at your already [**Name8 (MD) 1988**] appointments with
your PCP and your cardiologist.
.
You summarized them as below:
PCP [**Name Initial (PRE) **] [**Name Initial (NameIs) 3816**] @12:15
Electrophysiology/Cardiology - Thursday @2:00
Dr. [**Last Name (STitle) 32878**] - [**10-31**] @2:00
Pleases call Dr. [**Last Name (STitle) **] to schedule an appointment within the
next 2 weeks
Completed by:[**2169-10-21**]
ICD9 Codes: 4280, 412, 2724, 4589, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 915
} | Medical Text: Admission Date: [**2189-4-15**] Discharge Date: [**2189-4-17**]
Date of Birth: [**2133-2-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Right arm swelling.
Major Surgical or Invasive Procedure:
Venography of right arm/chest. Angioplasty of right
subclavian/brachiocephalic thrombus. TPA infusion.
History of Present Illness:
Patient is well-known to the Transplant service. He has ESRD
secondary to anti-GBM disease, and recently was admitted for
thrombectomy of his left AV Vectra graft. Ultimately, that
failed and a right subclavian Permacath was placed for dialysis
access. He now returns having been seen at his dialysis center
after successful dialysis, but with noticeable pain-free right
arm swelling.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-7**]
2. DM2: dx [**2177**]
3. HTN
4. Chronic low back pain [**2-5**] herniated discs
5. CHF
6. Peripheral neuropathy
7. Anemia
8. h/o nephrolithiasis
9. s/p cervical laminectomy
10. h/o depression
11. h/o MSSA bacteremia
12. s/p L AV graft: [**7-7**]
Social History:
Lives w/ wife, son, daughter-in-law, and three grandchildren in
[**Name (NI) 86**] area, has been unemployed [**2-5**] disability, smokes tobacco
1 ppd x45 years, past alcohol, no recreational drug use.
Family History:
1. DM
2. Renal failure
Physical Exam:
AVSS.
Gen: NAD, A&O x3
Chest: CTA, RRR
Abd: S, NT, ND
Ext: trace RUE edema, otherwise warm and well-perfused
Pertinent Results:
[**2189-4-15**] 07:00AM BLOOD PT-27.6* INR(PT)-2.8*
[**2189-4-17**] 02:18AM BLOOD WBC-6.7 RBC-2.81* Hgb-8.4* Hct-26.8*
MCV-95 MCH-30.0 MCHC-31.5 RDW-17.5* Plt Ct-432
[**2189-4-17**] 02:18AM BLOOD PT-22.3* PTT-35.2* INR(PT)-2.2*
[**2189-4-17**] 02:18AM BLOOD Glucose-120* UreaN-40* Creat-9.3* Na-142
K-4.8 Cl-100 HCO3-29 AnGap-18
[**2189-4-17**] 02:18AM BLOOD Calcium-8.9 Phos-6.0* Mg-1.7
Brief Hospital Course:
Patient was seen in the ER and ultrasound revealed that he had a
right IJ thrombus, and that the tip of the Permacath was in the
right IJ. This is despite having an admission INR of 2.8. He
was admitted for work-up of the thrombus and possible resiting
of the dialysis line.
On HD #2, patient went to IR for venography to delineate the
extent of thrombus and catheter position, as well as to look for
central stenoses or other reasons for his failed left arm AV
graft and new clot in right system. IR found an occlusion of
the right subclavian/brachiocephalic, performed angioplasty of
the presumed thrombus and left a venous sheath in place for TPA
thrombolysis with the intention of follow-up venography on HD
#3. Incidentally, the Permacath was seen to be in good
position. Subsequent to this, discussion between Dr. [**First Name (STitle) **]
and the patient's nephrologist concluded that the risk of
bleeding outweighed the possible benefit of thrombolysis; TPA
administration was stopped.
On HD #3, the patient had his sheath removed, was dialyzed
successfully through the Permacath and he was discharged home.
Medications on Admission:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHD (each
hemodialysis).
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Sevelamer 400 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
13. Choline & Magnesium Salicylate 750 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day).
14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHD (each
hemodialysis).
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Sevelamer 400 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
13. Choline & Magnesium Salicylate 750 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day).
14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
DVT of right internal jugular/subclavian/brachiocephalic veins.
Discharge Condition:
Stable. Mild residual swelling of right arm.
Discharge Instructions:
DC to home. Continue with hemodialysis via right subclavian
Permacath. Continue with outpatient Coumadin and INR checks
with goal INR 2 - 3. Elevate right arm when possible to reduce
swelling.
Followup Instructions:
Follow-Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2189-4-23**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. Date/Time:[**2189-6-12**] 11:30
Completed by:[**0-0-0**]
ICD9 Codes: 4280, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 916
} | Medical Text: Admission Date: [**2130-1-16**] Discharge Date: [**2130-1-20**]
Date of Birth: [**2052-5-31**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Melanoma
Major Surgical or Invasive Procedure:
[**2130-1-16**]
1. Right modified radical neck dissection.
2. Right parotidectomy with facial nerve
monitoring/dissection.
History of Present Illness:
The patient is a 77-year-old male who in [**2125**]
was found to have a lesion overlying the right angle of the
mandible. Interestingly, he also had the same region biopsied
in [**2116**]. In both cases, the lesion was read as lentiginous
compound melanocytic nevus, dysplastic type, with apparent
complete excision. The pathology from [**2125**] was interpreted as
a darkly pigmented lentiginous junctional nevus with
architectural disorder and moderate cytologic atypia and
numerous pigment-laden macrophages extending to the tissue
edge. He underwent a re-excision of the lesion in [**2126-4-10**]
which showed residual atypical dysplastic nevus cells. This
was completely excised and there was a scar consistent with a
prior excision.
He did well until [**2129-10-11**] at which time he was noted
to have a swelling in the region of the tail of the right
parotid. A CT scan was obtained that demonstrated a 3-cm mass
involving the lower aspect of the right parotid. He was
presented at the Multidisciplinary Cutaneous [**Hospital **] Clinic
at which time surgery and probable postoperative radiation
was recommended.
Past Medical History:
Past medical history remarkable for coronary artery disease with
cardiac catheterization showing 2 completely blocked arteries
that were not stentable. He has angina with exertion, but this
is
largely controlled with topical worn Nitro patch. He rarely has
to take sublingual nitroglycerin. He underwent a transient
global attack in [**2127-10-11**] and has subsequently been on
Plavix. He has hypercholesterolemia, treated with Lipitor, and
is status post appendectomy in [**2117**] and cholecystectomy in [**2119**].
He is status post herniorrhaphy and has a history of chronic
thrombocytopenia of unclear etiology, with most recent platelet
count being 101,000.
Social History:
He is widowed from his
first wife and has a daughter, age 52. [**Name2 (NI) **] has been remarried
for
the past couple of decades, and he and his new wife have a
19-year-old son. [**Name (NI) **] does not smoke and drinks a glass of wine
per night.
Family History:
The family/social history: There is no family history of
melanoma. His father had [**Name2 (NI) 499**] cancer.
Physical Exam:
Elderly man in no acute distress.
NECK: There was a soft tissue mass approximately 3 cm in
diameter in the tail of the right parotid gland. There is a
surgical scar anterior to this
over his right jawline without surrounding pigmentation. There
is no cervical, supraclavicular, bilateral axillary or bilateral
inguinal adenopathy.
LUNGS:CTA-B
CV: reveals a 1/6 systolic ejection murmur.
ABD: Without masses, tenderness, or organomegaly.
NEURO: CN-II-XII intact grossly
Pertinent Results:
[**2130-1-16**] 04:45PM CK-MB-4 cTropnT-<0.01 proBNP-236
[**2130-1-16**] 04:52PM freeCa-1.09*
[**2130-1-16**] 04:52PM HGB-13.8* calcHCT-41
[**2130-1-16**] 04:52PM GLUCOSE-142* LACTATE-2.1* NA+-138 K+-3.7
CL--102
[**2130-1-16**] 04:52PM TYPE-ART PO2-207* PCO2-34* PH-7.46* TOTAL
CO2-25 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED
[**2130-1-16**] 07:48PM CK(CPK)-276*
[**2130-1-16**] 07:48PM CK-MB-4 cTropnT-<0.01
Brief Hospital Course:
77 yo M with history of CAD and recent diagnosis of melanoma who
is s/p parotidectomy w/ neck node dissection. Had ST depressions
intraoperatively and transferred to ICU for monitoring
overnight.
#. ST depressions: Anesthesia noted ST depressions
intraoperatively. Patient remained without chest pain or
dyspnea. His post-op EKG was significant for new RBBB and
associated diffuse T-wave inversions. The patient was
transferred to the ICU post-operatively for close hemodynamic
monitoring overnight. He had three negative sets of cardiac
enzymes over twelve hours and no further ECG changes. He
remained asymptomatic throughout and was transitioned to his
home cardiovascular medications except plavix and discharged
from the ICU on POD#1.
#. Melanoma s/p parotidectomy and node dissection: Patient felt
well post-op aside from hoarseness and some irritation from his
foley catheter. He received prophylactic antibiotics
peri-operatively and throughout his hospital stay. His JP
drains were removed on POD#3 and #4 when drainage was <30cc/day.
He recieved DVT prophylaxis throughout his hospitalization and
was restarted on his home dose of plavix on discharge. Patient
is being discharged: afebrile, tolerating regular diet without
nausea/vomiting, pain well controlled on oral medication,
voiding, incision clean, dry and intact, and ambulating well.
Medications on Admission:
1) Nitropatch 0.2 mg/hr DAILY (on in AM and off at bedtime)
2) Plavix 75 mg DAILY
3) Niaspan ER 1000 mg QHS
4) Atorvastatin 20 mg QHS
5) Lisinopril 5 mg DAILY
6) Metoprolol Succinate 100 mg DAILY
7) Nitroglycerin SL 0.4 mg PRN
8) Folic acid 1 mg DAILY
9) Aspirin 81 mg DAILY
10) ICaps MV 2 tabs [**Hospital1 **]
Discharge Medications:
1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic melanoma, right neck/parotid.
Discharge Condition:
Stable, A&O, ambulating
Discharge Instructions:
OK to shower but do not soak incision until follow up
appointment, at least. No strenuous exercise or heavy lifting
until follow up appointment, at least.
Do not drive or drink alcohol while taking narcotic pain
medications. Narcotic pain medications may cause constipation,
if this occurs take an over the counter stool softener.
Resume all home medications.
Your stitches/staples will be reomoved at your follow-up
appointment.
Followup Instructions:
[**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2130-1-24**]
10:00
ICD9 Codes: 9971, 2875, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 917
} | Medical Text: Admission Date: [**2140-7-16**] Discharge Date: [**2140-8-5**]
Date of Birth: [**2095-12-26**] Sex: F
Service: MEDICINE
Allergies:
Macrodantin / Heparin Agents
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Transfer from [**Hospital3 **] for variceal bleeding.
Major Surgical or Invasive Procedure:
EGD
Dobhoff Post-Pyloric Feeding Tube
History of Present Illness:
Ms. [**Known lastname **] is a 44yo F with ETOH abuse, HCV, h/o IVDA presented
to OSH with intermittent hematemasis and on [**2140-7-14**] is for TIPS.
Pt has been having black tarry stools and hematemasis since
[**2140-7-11**]. At OSH, initial hct 31, INR 1.9, TB 3.2, AST 99, ALT 41,
alk phos 99,plt 43,000, ETOH 173. Pt was given vitamin K 10mg SC
and was admitted and started on octreotide. Pt received 2 units
PRBC for hct 25.9 and 6 bags of platelets for platelets of 37K
on [**7-15**]. Pt underwent EGD [**7-15**] and showed 4 grade [**3-12**] distal
esophageal varices, which were banded and there was a concern
for a couple of gastric varices. On day of admission, she had
400cc of melanotic stools with clots, and her hct was noted to
have dropped from 33.5 to 18 with SBP in 70s. Pt was given 4
units PRBC, central line placed and was transferred to [**Hospital1 18**] for
TIPS.
.
Currently, denies any n/v, abdominal pain, chest pain, or sob.
Past Medical History:
1. Hepatitis C
2. DM II c/b neuropathy
3. EtOH abuse
4. Tobacco abuse
5. h/o IVDA quit more than 20 years ago
Social History:
h/o IVDA 20 years ago, drinks 2 glasses of wine daily, +
smoking.
Family History:
non-contributory
Physical Exam:
PE: 100.6, 82, 62/46, 14, 97% on RA, CVP 4
GEN: AOx 3, answering questions appropriately
HEENT: + scleral icterus, PERRL, EOMI, No JVD appreciated.
Skin: jaundiced
CV: RRR without m/r/g
LUNGS: CTA bilat, no wheezes, rhonchi, crackles.
ABD: obese, hypoactive BS, NT.
EXT: palpable pulses bilaterally. No edema
Neuro: AOx 3, CN II to XII grossly intact. moving extremities.
grossly normal sensation to touch. No asterixis.
Pertinent Results:
[**2140-7-16**] 10:03PM GLUCOSE-176* UREA N-20 CREAT-0.6 SODIUM-144
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-16
[**2140-7-16**] 10:03PM CALCIUM-8.0* PHOSPHATE-4.3 MAGNESIUM-2.7*
[**2140-7-16**] 10:09PM LACTATE-4.3*
[**2140-7-16**] 10:09PM TYPE-[**Last Name (un) **] PO2-47* PCO2-48* PH-7.32* TOTAL
CO2-26 BASE XS--1
[**2140-7-16**] 10:03PM HCT-30.8*#
[**2140-7-16**] 07:53PM HGB-8.8* calcHCT-26
[**2140-7-16**] 06:43PM HGB-9.1* calcHCT-27
[**2140-7-16**] 04:26PM LACTATE-3.4*
[**2140-7-16**] 03:39PM WBC-4.5 RBC-2.35*# HGB-8.2*# HCT-21.9* MCV-93
MCH 34.8* MCHC-37.3* RDW-19.0*
[**2140-7-16**] 03:39PM PLT COUNT-114*#
[**2140-7-16**] 02:49PM HCT-25.2*#
[**2140-7-16**] 11:11AM GLUCOSE-128* UREA N-23* CREAT-0.6 SODIUM-145
POTASSIUM-4.3 CHLORIDE-113* TOTAL CO2-20* ANION GAP-16
[**2140-7-16**] 11:11AM ALT(SGPT)-35 AST(SGOT)-109* LD(LDH)-263* ALK
PHOS-65 AMYLASE-30 TOT BILI-10.4*
[**2140-7-16**] 11:11AM LIPASE-20
[**2140-7-16**] 11:11AM WBC-7.6 RBC-3.70* HGB-12.1 HCT-34.0* MCV-92
MCH-32.6* MCHC-35.5* RDW-19.0*
[**2140-7-16**] 11:11AM NEUTS-75.5* LYMPHS-18.4 MONOS-5.8 EOS-0.1
BASOS-0.3
[**2140-7-16**] 11:11AM PLT SMR-VERY LOW PLT COUNT-57*
[**2140-7-16**] 11:11AM PT-23.9* PTT-43.2* INR(PT)-2.4*
.
Imaging at OSH: Liver u/s with doppler: Coarse echogenic liver,
suggestive of fatty liver but cannot exclude a micronodular
cirrhosis in the appropriate clinical setting. Mild
splenomegaly. patent portal vein. no vevidence of varices or
portal hypertension. A small amount of ascites. 14.cm
echotextures. Spleen 13.8cm.
.
CXR [**2140-7-16**]: RSC in SVC. No acute cardiopulm processes.
.
Abdominal ultrasound [**2140-7-18**]:
IMPRESSION: Very limited study. TIPS stent is patent but
velocities could not be obtained due to respiratory motion and
therefore satisfactory baseline data could not be obtained.
.
Feeding tube placement [**2140-7-20**]:
IMPRESSION: Successful placement of post-pyloric feeding tube
in the fourth portion of the duodenum.
.
Abdominal Ultrasound [**2140-7-29**]:
IMPRESSION:
1. Patent TIPS with slightly increased velocities.
2. New 4 cm echogenic wedge-shaped structure in the right lobe.
Given its development since examinations of 9 and 11 days ago,
it is unlikely to be a mass, however, MRI can be performed on a
nonemergent basis for further characterization.
3. Slight increase in ascites.
.
Portable CXR [**2140-7-31**]:
There has been interval extubation and removal of right-sided
vascular
catheter and sheath. Right PICC line has been placed,
terminating in the
proximal superior vena cava. Cardiac silhouette is upper limits
of normal in size allowing for low lung volumes. Previously
present mild pulmonary edema has resolved. There is improved
aeration in the left retrocardiac region with residual patchy
opacity containing several air bronchograms. Although possibly
due to resolving atelectasis and dependent edema, infectious
pneumonia is also possible in the appropriate setting. Minor
right basilar atelectasis is noted as well as a possible small
right pleural effusion.
.
Renal U/S [**2140-7-31**]:
FINDINGS: The right kidney measures 12.2 cm and the left 11.2
cm. The renal parenchymal thickness and echogenicity are
normal. There is no evidence of hydronephrosis or calculi.
Small amount of ascites is noted.
.
IMPRESSION: Unremarkable renal ultrasound.
.
EGD [**2140-8-3**]:
IMPRESSION:
1. A feeding tube passing into duodenum was noted. No
significant varices noted in esophagus. Granularity, friability,
erythema, congestion, abnormal vascularity and mosaic appearance
in the whole stomach
2. Duodenum was not entered due to the feeding tube. No bleeding
noted in stomach.
3. Otherwise normal EGD to second part of the duodenum.
Brief Hospital Course:
# Alcoholic Cirrhosis/Acute Alcoholic Hepatitis: Admitted to
[**Hospital3 **] from outside hospital after recent variceal bleed
s/p variceal banding. Here, repeat EGD was performed which
showed previously banded esophageal varices and gastric varices
with stigmata of recent bleeding. No new bands placed.
Subsequently underwent uncomplicated TIPS on [**2140-7-16**]. Completed 5
day course of octreotide and 7 day course of levofloxacin for
SBP prophylaxis. Unfortunately, patient continued to
decompensate, with rising bilirubin and INR. She was treated
with lactulose and rifaximin for encephalopathy. Ultrasound [**7-18**]
and [**7-20**] both showed patent TIPS.
.
Given rising bili/INR, she was given a trial of pentoxyfilline
and ursodiol for suspected acute alcoholic hepatitis.
Corticosteroids not given because of recent bleeding. However,
her synthetic function did not improve, and her creatinine
subsequently rose from 0.6 to 3.0. A diagnostic paracentesis was
performed (on [**7-29**]), which demonstrated no evidence of SBP. Her
pentoxyfilline and ursodiol were discontinued as there was no
clear improvement on treatment. She was started empirically on
octreotide/midodrine for possible hepatorenal syndrome.
Nephrotoxic medications were held and she was given volume
repletion both with normal saline and albumin. Creatinine
subsequently improved to 1.2-1.4 at the time of discharge.
.
For nutritional support a post-pyloric feeding tube was placed
and tube feeds were intiated per nutrition recommendations. She
will be discharged for continued nutritional support to meet
caloric goals.
.
She was seen by social work for substance abuse support. In
addition, she was provided with information on post-discharge
support services.
.
MELD at time of discharge was 33, driven by a bilirubin of 19.8,
creatinine of 1.4, and an INR of 2.9.
.
Diuretics held given renal failure and lack of ascites on
ultrasound, s/p TIPS.
.
# s/p Upper GI bleed: Initial hct was 34 which drifted down to
25 then 21.9 on day of admission. She underwent EGD a few hours
after arrival, and it showed 3 esophageal variceal bands and
gastric varices which had recent stigmata of bleeding but no
active bleeding. She was supported with blood products and
underwent TIPS as above. Her hematocrit subsequently remained
stablized with no further evidence of active GI bleeding. Repeat
EGD on [**2140-8-3**] prior to discharge showed no significant varices
in the esophagus. There was noted granularity, friability,
erythema, congestion, abnormal vascularity and mosaic appearance
in the whole stomach consistent with portal gastropathy, but no
active bleeding.
.
# Acute renal insufficiency: As outlined above, developed
rising creatinine, initially concerning for hepatorenal syndrome
(HRS), with UOP <30 cc/hour in setting of known ETOH cirrhosis.
Started empirically on midodrine/octreotide. However urine
sodium >10, so was not completely consistent with HRS.
Paracentesis [**7-29**] demonstrated no evidence of bacterial
peritonitis. Urinalysis demonstrated no eosinophils. Ultrasound
on [**7-30**] showed no hydronephrosis, but did show a new echogenic
wedge shaped structure in right lobe, of unclear clinical
significance. No other evidence of infarcts/ischemia were
noted, and lupus anti-coagulant was sent and was negative as
well. Renal service was consulted and nephrotoxic medications
were held. She was repleted with IV fluids and renal function
subsequently improved, with creatinine trending down from 3.0 to
1.4, with good urine output.
.
# Hypotension: Initially likely from GIB, hypovolemia.
Subsequently remained stable in low 90's-100's systolic, in
setting of chronic liver disease. Initially started on Zosyn
and Vancomycin as well as Levaquin for concern for infectious
etiology, however antibiotics subsequently discontinued as no
infectious source identified. Of note, blood cultures from [**7-17**]
grew 1/4 bottles STAPHYLOCOCCUS, COAGULASE NEGATIVE. This was
considered contaminant and repeat blood cultures were negative.
.
# HCV: Repeat HCV viral load on this admission ([**2140-7-21**]) showed
no HCV viral RNA.
.
# DM II: On Metformin prior to hospital admission. Covered as
inpatient on sliding scale insulin and glargine. Discharged on
glargine 24units/night, and the patient demonstrated how to use
SSI at home. Metformin and alternative oral hypoglycemics
contra-indicated in setting of her cirrhosis.
.
# HIT antibody positive: HIT antibody sent due to
thrombocytopenia, and was noted to be positive on this
admission; however, she could not be anti-coagulated given her
recent variceal bleed and coagulopathy from liver disease. All
heparin products were held. Platelet count remained low
secondary to liver disease, but stable, with no clear evidence
of clinical thrombosis.
.
# Nutritional Deficiency: Post-pyloric dobhoff placed for
nutritional support to meet caloric goals. Tube feeds will
continue upon discharge with outpatient services arranged.
.
# Communication: [**Name (NI) **] (boyfriend [**Telephone/Fax (1) 72890**]), [**Name (NI) **] (mother)
[**Telephone/Fax (1) 72891**].
Medications on Admission:
MEDS at home: metformin 500 [**Hospital1 **].
.
MEDS on Transfer:
Protonix 40mg IV BID
MVI po daily
Thiamine 100mg qday
Folate i mg po daily
nicotine patch 14gm qday
nadolol 20mg qday
oxazepam q2 prn for agitation per CIWA
[**6-18**] 10mg
13-20 20mg
Octreotide gtt
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*90 Capsule(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*1 container* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health Services
Discharge Diagnosis:
Primary Diagnoses:
1. Alcoholic Cirrhosis
2. Acute Alcoholic Hepatitis
3. Esophogeal Varices with Variceal Bleed
Secondary Diagnoses:
1. Nutritional Deficiency
2. Acute Renal Failure
3. HIT antibody Positive
Discharge Condition:
Liver cirrhosis requiring ongoing nutritional support.
Discharge Instructions:
You were admitted for alcoholic cirrhsosis and variceal bleed.
Your liver is extremely sick, and it is important that you
continue to abstain completely from alcohol. Alcohol cessation
is required for you to be a candidate for a liver transplant.
Information on substance abuse centers has been provided to you
to help with this. Nutrition is also very important, and a
feeding tube was placed for nutritional support. You were set up
for services at home to continue the tube feeds.
Please call your primary physician or return to the ER if you
develop fever >101, abdominal pain, bright red blood per rectum,
melanotic stools, or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] [**2140-8-23**] @ 2:15pm. You may call
to confirm your appointment at [**Telephone/Fax (1) 2422**].
Please follow-up with your primary physician [**Name Initial (PRE) 3390**]:
[**Name10 (NameIs) 72892**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 50168**] in [**2-9**] weeks after discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2140-8-6**]
ICD9 Codes: 5789, 2851, 5849, 5990, 3051, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 918
} | Medical Text: Admission Date: [**2199-4-23**] Discharge Date: [**2199-4-24**]
Service: SURGERY
Allergies:
Keflex / Bactrim
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Hemodynamic instability with right retroperitoneal bleed.
Major Surgical or Invasive Procedure:
Arteriogram of right kidney.
Coil embolization of right lower pole renal artery branch bleed.
History of Present Illness:
93-y.o. male h/o CAD, COPD, and worsening renal insufficiency,
recently admitted to [**Hospital1 18**] [**Date range (1) 19174**] for worsening renal
insufficiency leading to volume overload. He underwent a R
renal biopsy on [**2199-4-10**]. His renal failure was managed with
steroids, the volume overload with diuretics, and a UTI with
meropenem from [**Date range (1) 19175**]. His aspirin was held for 5days pre-
and post- renal biopsy. He has been doing well at rehab until
last evening when began to experience R flank and abdominal
pain. Brought to [**Location (un) 620**] ED where hemodynamically borderline,
Hct 26.5 (prior 28.5 on [**4-18**]), and CT non-contrast showed R
retroperitoneal hematoma. Bolused 2L [**Hospital 19176**] transferred to [**Hospital1 18**]
ED, received 2u PRBC en route. On arrival initial BP 70/40 and
emergent surgical consult requested. Pt currently reports
notable R-flank pain, denies abd pain, and has mild dyspnea.
Denies chest pain. Remaining interview truncated for placement
of CVL.
Past Medical History:
CAD s/p velocity stent x2 to RCA [**2190**]
Diastolic CHF (EF 55% [**2-/2199**])
Hypertension
Hypercholesterolemia
COPD on 2L home O2
Chronic renal insufficiency (recent exacerbation s/p R renal bx)
L parotid cancer
BPH
Obesity
PAST SURGICAL HISTORY:
EVAR [**4-/2193**]
Debridement and closure of R3 toe [**2-/2199**]
Bilateral cataracts [**5-/2189**] and [**4-/2190**]
Social History:
Retired. The patient is widowed, two children, 4 grandchildren,
7 great-grandchildren.
-Tobacco history: 40+ pack year history, quit in [**2148**], smoke a
pipe until [**2181**]
-ETOH: none currently, whiskey daily for many years, stopped two
months ago
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Sister and brother had strokes. Father had CAD. Mother had an
"enlarged heart."
Physical Exam:
On admission:
Dopamine gtt 15
T 96.5 P 124 BP 122/68 RR 22 O2sat 100 on NRB
A&Ox3, uncomfortable and moaning
Lungs CTAB
Heart RRR / tachy
Abdomen soft, NT, ND, ecchymoses across lower abdomen
bilaterally (c/w subcutaneous injections)
R flank diffusely tender
No L CVA tenderness
Pertinent Results:
[**2199-4-23**] 05:23AM WBC-20.0*# RBC-2.99* HGB-8.7* HCT-26.7*
MCV-90 MCH-29.1 MCHC-32.5 RDW-14.8
[**2199-4-23**] 05:23AM NEUTS-88.0* LYMPHS-8.9* MONOS-3.0 EOS-0
BASOS-0
[**2199-4-23**] 05:23AM PLT COUNT-78*#
[**2199-4-23**] 05:23AM PT-13.7* PTT-31.2 INR(PT)-1.2*
[**2199-4-23**] 05:23AM GLUCOSE-184* UREA N-132* CREAT-2.5*
SODIUM-140 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13
[**2199-4-23**] 05:23AM ALT(SGPT)-12 AST(SGOT)-14 ALK PHOS-38* TOT
BILI-0.4
[**2199-4-23**] 05:23AM LIPASE-51
[**2199-4-23**] 05:23AM ALBUMIN-2.1*
[**2199-4-23**] 05:23AM cTropnT-0.08*
[**2199-4-23**] 06:55AM HCT-33.7*#
[**2199-4-23**] 11:54AM TYPE-ART PO2-78* PCO2-43 PH-7.38 TOTAL CO2-26
BASE XS-0
[**2199-4-23**] 11:54AM LACTATE-5.1*
[**2199-4-23**] 12:10PM WBC-31.1*# RBC-3.25* HGB-9.5* HCT-27.6*
MCV-85 MCH-29.1 MCHC-34.4 RDW-15.6*
[**2199-4-23**] 12:10PM PLT COUNT-123*#
[**2199-4-23**] 01:44PM TYPE-ART PO2-78* PCO2-45 PH-7.35 TOTAL CO2-26
BASE XS-0
[**2199-4-23**] 01:44PM LACTATE-4.8*
[**2199-4-23**] 04:16PM WBC-27.9* RBC-3.30* HGB-9.5* HCT-27.4* MCV-83
MCH-28.8 MCHC-34.7 RDW-15.7*
[**2199-4-23**] 04:16PM PLT SMR-LOW PLT COUNT-83*
[**2199-4-23**] 04:52PM TYPE-ART PO2-185* PCO2-47* PH-7.39 TOTAL
CO2-30 BASE XS-3
[**2199-4-23**] 04:52PM LACTATE-4.7*
[**2199-4-23**] 08:40PM WBC-30.9* RBC-3.63* HGB-10.5* HCT-29.3*
MCV-81* MCH-28.9 MCHC-35.9* RDW-15.9*
[**2199-4-23**] 08:40PM PLT COUNT-85*
[**2199-4-23**] 08:54PM TYPE-ART PO2-111* PCO2-50* PH-7.38 TOTAL
CO2-31* BASE XS-3
[**2199-4-23**] 08:54PM LACTATE-4.3*
Brief Hospital Course:
On [**2199-4-23**] morning, the patient was admitted to the SICU for
retroperitoneal bleed and started on norepinephrine gtt for
hemodynamic instability. Family was [**Name (NI) 653**], and the surgical
team discussed and confirmed DNR/DNI status and treatment wishes
with patient and family. According to patient's wishes, he
underwent endovascular arteriographic coil embolization by
interventional radiology. Throughout the day, the patient
received a total of 11 units PRBC, 6 units FFP, and 2 units
platelets to maintain hemodynamic stability. He remained stable
on norepinephrine gtt after the procedure. On [**2199-4-24**] early
morning, he suffered respiratory distress with increased oxygen
requirement, and CXR showed near complete opacification of the
right lung, likely secondary to mucous plug. Bronchoscopy was
offered, which would have required intubation with low
likelihood of successful extubation, and patient and family
understood and declined in accordance to DNR/DNI wishes. Over
the subsequent few hours, the patient suffered respiratory
failure and expired at 0715. The family declined autopsy.
Medications on Admission:
prednisone 60 mg daily
ASA 81 mg daily
metoprolol 50 mg [**Hospital1 **]
lisinopril 2.5 mg daily,
isosorbide dinitrate 40 mg TID
doxazosin 2 mg daily
lasix 120 mg daily
simvastatin 20 mg dailiy
nitro SL PRN
spiriva 18 mcg daily
atrovent PRN
albuterol PRN
omeprazole 20 mg dailyi
lidocaine 5% patch
colace 100 mg [**Hospital1 **]
vit D2 50,000 units Qweek
cyanocobalamin 1000 mcg daily
calcium carbonate 500 mg TID
acetaminophen PRN
senna PRN
trazadone 50 mg QHS PRN
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Retroperitoneal bleed.
Respiratory failure.
Discharge Condition:
Expired.
Discharge Instructions:
He who has gone, so we but cherish his memory.
Followup Instructions:
None needed.
Completed by:[**2199-4-24**]
ICD9 Codes: 5845, 4280, 5859, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 919
} | Medical Text: Admission Date: [**2189-11-20**] Discharge Date: [**2189-11-30**]
Date of Birth: [**2114-4-27**] Sex: M
Service: MEDICINE
Allergies:
Levaquin / Shellfish Derived / Latex / Aranesp
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Lumbar Puncture
Paracentesis
History of Present Illness:
75 yo M hx CAD s/p NSTEMI, a. fib not on Coumadin with 1 day hx
generalized fatigue, weakness, poor PO, decreased UOP. Patient
was in his USOF on Weds when he saw his new PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. On
[**Holiday **] Eve, his daughter brought him to dinner at her house
and noticed that after walking down the stairs that he was
having difficulty walking. His daughter also notes that he just
seemed "off" that night. He did not sleep well that night, and
today he felt lethargic, but otherwise denied fevers, abdominal
pain, dysuria, headaches, neck pain and diarrhea. Decreased
urine output was noted today.
In the ED, patient's altered mental status improved and he did
not receive CT head. CXR revealed pleural effusions but no
obvious consolidation. FAST was positive for fluid in ruq and
luq. Troponin was elevated but consistent with prior falues. EKG
was paced without ischemic changes. UA was clean. Saturating was
80% according to EMS, but 100% on 4 l in the ED. He was
hypotensive to the 80s/50s in the ED and responded to 3 L NS.
Cardiology was consulted and advised Medicine bed. When bed was
assigned, patient became hypotensive with MAP of 58. He was
initially started on dobutamine which was later transitioned to
levphed. He received Vanco and Zosyn in the ED.
He has had 2 recent hospital stays this month. The first at
[**Hospital1 18**] was from [**10-29**] through [**11-4**] was for NSTEMI which was felt
to be related to demand ischemia in the setting of afib with
RVR. He was not started on anticoagulation given prior GI
bleeding. Failure to thrive workup was not pursued given that he
had a recent colonoscopy/egd, CT head and chest at [**Hospital 6451**] hospital within the past year.
The second hospital stay was from [**11-6**] to [**11-8**] for hypotension
in the setting poor po intake. He was thought to have food
poisoning. Po intake improved with zofran and fluids. The
patient's hypotension was not symptomatic, wht SBP ranging from
90 to 100. Right pleural effusion was noted in the setting of
smoking history, and thoracentesis was deferred until patient
could follow up as an outpatient.
In the ICU, Mr. [**Known lastname 64592**] is feeling well and has no specific
complaints. He says that his neck feels stiff but that this is
chronic. He has [**Last Name **] problem with neck ROM.
ROS was otherwise essentially negative. The pt denied recent
fevers, night sweats, chills, headaches, dizziness or vertigo,
changes in hearing or vision, including amaurosis fugax, neck
stiffness, lymphadenopathy, hematemesis, coffee-ground emesis,
dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea,
constipation, steatorrhea, melena, hematochezia, cough,
hemoptysis, wheezing, shortness of breath, chest pain,
palpitations, dyspnea on exertion, increasing lower extremity
swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while
walking, joint pain.
Past Medical History:
1) CAD (cath in [**2161**] showed 3-vessel disease, patient states he
had MI [**09**] years ago), presented with NSTEMI believed to be
secondary to demand
2) Atrial fibrillation (not on Coumadin given h/o GI bleeding)
3) [**Company 1543**] Kappa KDR701 dual-chamber placement
4) Cirrhosis (classified as cryptogenic although patient has
history of heavy EtOH use 35 years ago)
5) chronic kidney disease with baseline Cr 2.7
6) angiodysplasia of stomach and small intestine with serial
endoscopic cauterization ([**2186**])
7) GI bleeding chronic anemia (multifactorial, thought to be [**12-29**]
kidney disease + GI bleeding)
8) prior TIA ([**4-3**], ? [**8-5**])
9) melanoma, right forearm
10) multiple BCCs
11) Diverticulosis
12) Colon polyps
13) Left carotid stenosis with stent ([**2184**])
14) BPH ([**3-4**])
15) Gout
16) Pneumonia ([**12-3**])
17) portal gastropathy
18) low grade esophageal varices
19) remote appendectomy
Social History:
Lives independently, across the street from daughter. Smoked 1.5
packs/day x 15 years, quitting 35 years ago. Former heavy EtOH
use, sober x 35 years. No drugs. Pt previously worked as a
letter carrier for the United States Postal Service.
Family History:
Notable for MI. Both parents lived to be >[**Age over 90 **] years old.
Physical Exam:
Vitals: T: 92.1 BP: 132/98 P: 76 R: 20 SaO2: 100% RA
General: Awake, alert, NAD, Oriented x3
HEENT: NCAT, PERRL, EOMI, pale conjunctivae, no scleral icterus,
MMM, no lesions noted in OP
Neck: supple, JVP at clavicle
Pulmonary: decreased breath sounds at right base, otherwise CTA
Cardiac: distant HS, RR, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted, no shifting dullness
Extremities: 1+ RLE edema, no LLE edema
Skin: mild erythema at left foot
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. [**3-1**] quadriceps and
gastroc bilaterally. Grip [**3-31**]. Sensation intact to gross tough
throughout.
Pertinent Results:
[**2189-11-24**] 04:41AM BLOOD WBC-7.2 RBC-2.28* Hgb-8.1* Hct-24.8*
MCV-109* MCH-35.6* MCHC-32.6 RDW-19.0* Plt Ct-52*
[**2189-11-20**] 04:40PM BLOOD WBC-2.5* RBC-2.84* Hgb-9.6* Hct-31.1*
MCV-110* MCH-33.9* MCHC-30.9* RDW-18.4* Plt Ct-77*
[**2189-11-24**] 04:41AM BLOOD Neuts-94.4* Lymphs-3.9* Monos-1.6*
Eos-0.1 Baso-0
[**2189-11-20**] 04:40PM BLOOD Neuts-73.6* Lymphs-15.3* Monos-8.8
Eos-1.9 Baso-0.3
[**2189-11-24**] 04:41AM BLOOD Plt Ct-52*
[**2189-11-24**] 04:41AM BLOOD PT-15.3* PTT-44.7* INR(PT)-1.3*
[**2189-11-20**] 04:40PM BLOOD PT-13.4 PTT-45.2* INR(PT)-1.1
[**2189-11-24**] 04:49PM BLOOD Glucose-168* UreaN-86* Creat-3.2* Na-147*
K-3.2* Cl-119* HCO3-16* AnGap-15
[**2189-11-24**] 04:41AM BLOOD Glucose-110* UreaN-85* Creat-3.5* Na-148*
K-3.5 Cl-118* HCO3-16* AnGap-18
[**2189-11-20**] 04:40PM BLOOD Glucose-110* UreaN-82* Creat-3.1* Na-142
K-4.6 Cl-111* HCO3-20* AnGap-16
[**2189-11-23**] 04:09AM BLOOD ALT-54* AST-48* LD(LDH)-271* AlkPhos-170*
TotBili-0.9
[**2189-11-21**] 02:42AM BLOOD ALT-68* AST-74* LD(LDH)-282* CK(CPK)-72
AlkPhos-241* TotBili-1.0 DirBili-0.5* IndBili-0.5
[**2189-11-21**] 02:42AM BLOOD CK-MB-NotDone cTropnT-0.30*
[**2189-11-20**] 11:33PM BLOOD CK-MB-NotDone cTropnT-0.28*
[**2189-11-20**] 04:40PM BLOOD cTropnT-0.32*
[**2189-11-24**] 04:41AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.3 UricAcd-8.4*
[**2189-11-23**] 04:09AM BLOOD Albumin-3.1* Calcium-8.8 Phos-4.7* Mg-2.1
[**2189-11-21**] 09:11AM BLOOD Ammonia-75*
[**2189-11-20**] 11:33PM BLOOD TSH-15*
[**2189-11-21**] 02:42AM BLOOD T4-5.3
[**2189-11-20**] 04:40PM BLOOD CRP-33.4*
[**2189-11-21**] 03:36PM BLOOD Cortsol-19.3
[**2189-11-22**] 05:12PM BLOOD HIV Ab-NEGATIVE
[**2189-11-24**] 04:41AM BLOOD Vanco-24.8*
[**2189-11-22**] 03:27AM BLOOD Vanco-8.3*
[**2189-11-22**] 03:38AM BLOOD Type-ART Temp-36.1 pO2-168* pCO2-27*
pH-7.38 calTCO2-17* Base XS--7
[**2189-11-20**] 09:58PM BLOOD Type-ART Temp-32.7 FiO2-21 O2 Flow-15
pO2-511* pCO2-27* pH-7.40 calTCO2-17* Base XS--5 Intubat-NOT
INTUBA Comment-NON-REBREA
[**2189-11-20**] 09:58PM BLOOD Glucose-105 Lactate-0.9 Na-140 K-4.4
Cl-116* calHCO3-17*
[**2189-11-21**] 09:55AM BLOOD O2 Sat-68
[**2189-11-24**] RENAL ULTRASOUND:
Small echogenic right kidney, with normal-appearing left kidney.
No hydronephrosis.
ULTRASOUND (ABD) [**2189-11-22**]: Moderate ascites with appropriate
spot for paracentesis marked in the right lower quadrant.
[**2189-11-23**] LENI: No evidence of DVT in bilateral lower extremity.
[**2189-11-21**] CT HEAD W/O CONTRAST:
No acute intracranial hemorrhage or mass effect. Hypodense white
matter changes- current CT is significantly limtied due to
motion.
Pt. appears to have pacemaker on concurrent PXR Chest, whick
precludes MR
study. Hence, a close follow up with motion elimination when the
pt. is cooperative, can be onsidered for better assessment for
any intracranial
abnormality.
[**2189-11-25**]: ECHO - The left atrium is moderately dilated. 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 (3)
are mildly thickened. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2189-10-30**], there is no significant change. As noted in the prior
study, there is evidence of plaque in the descending thoracic
aorta.
[**2189-11-26**]: Duplex/Doppler Hepatic US - FINDINGS: The liver is
shrunken and has a coarse echotexture and an irregular outline
in keeping with liver cirrhosis. No focal liver lesions are
seen. There is extensive ascites, and a right-sided pleural
effusion. The common bile duct is not dilated, and there is no
intrahepatic bile duct dilatation.
The main portal vein, left, and right portal veins are patent
with hepatopetal flow. The main, right, and left hepatic veins
are patent. The IVC is patent and demonstrates normal flow. The
gallbladder contains gallstones, however, there is no evidence
of acute
cholecystitis. The spleen measures 9.8 cm longitudinally, and
there is no focal abnormalities.
Brief Hospital Course:
# Systemic Inflammatory Response Syndrome:
No obvious source for infection but leukopenic and hypothermic
on admission. (WBC 1.8, T 92.1). Both have improved w/ empiric
antibiotcs (vanc/zosyn). The patient underwent a paracentesis
which was negative for SBP, although had been on antibiotics for
3 days prior to paracentesis, so it is feasible that the
infection had already been partially treated. He further
underwent an LP which was negative for infection, blood cultures
that did not reveal a source, and urinalysis/urine culture that
was also not revealing. CXR was performed that revealed
bilateral pleural effusions but no pneumonia. Possible
partially treated SBP is the most likely source for infection in
this patient, especially given the non specific symptoms of
fatigue and the presentation including confusion. The patient
was treated with an empiric course of vanc/zosyn for 6 days
given no clear etiology. After antibiotics were discontinued,
the patient did not develop any further signs or symptoms of
SIRS.
The patient was initially admitted to the medical intensive care
unit because of hypotension and he transiently received
levophed(low doses), discontinued at 6 a.m. on [**11-24**]. Please
note that the patient's systolic blood pressure appears to range
between 95-110 mmHg.
The patient further received stress dose steroids after a
cortisol stim test that tapered to completion on [**2189-11-26**].
# End Stage Liver Disease:
Cirrhosis, labeled as cryptogenic but patient with previous
history of heavy alcohol use. Lactulose as needed for confusion
has been somewhat effective. Liver team was consulted and the
patient was followed by Dr. [**Last Name (STitle) 497**] and his time while an
inpatient. The patient had a duplex/doppler ultrasound that
showed patent hepatic veins and braches as well as moderate
ascites.
# Pancytopenia:
Leukopenia has resolved and likely related to infection.
Thrombocytopenia is possibly related to liver disease, however,
his platelets drifted to a nadir of 31. We monitored his
fibrinogen, FDP, and LDH for concern of developing disseminated
intravascular coagulopathy. The patient's anemia was likely due
to his chronic kidney injury.
The patient's platelets have risen for the past several days,
now at 89. During this time, the patient's fibrinogen also
continued to rise. His platelets began to recover after
antibiotics were discontinued. It is possible that the
antibiotic administration contributed to his worsening of
thrombocytopenia.
The patient appears to have a baseline hematocrit around 29-30.
On [**2189-11-25**] patient was found to have a hematocrit of 23.9 and
was transfused 2 units of pRBCs. His hematocrit bumped
appropriately to 28.5 and has remained stable around 28. HCT on
discharge was 29.2.
# Hypoxia
Patient was transiently hypoxic upon presentation, though this
promptly resolved. The patient has bilateral pleural effusions
but his oxygenation improved w/o intervention. Possibly as MS
improved he had some atelectasis that resolved.
# Altered Mental Status:
Patient presented with altered mental status. He was evaluated
by neurology and they believed his altered mental status to be
due to a toxic-metabolic abnormality. With the improvement in
mental status with lactulose treatment and the elevated ammonia
level, his altered mental status was likely due to hepatic
encephalopathy.
We would recommend continuing lactulose 30gm PO TID prn for
confusion.
# Acute on Chronic Renal Injury:
Baseline creatinine appears to be 2.7, though we have limited
data from [**2189-10-27**] only. The patient was admitted with a
creatinine of 3.1, reached a peak of 3.5. Initially thought to
be related to pre-renal vs. hepatorenal although creatinine did
not improve w/ fluid resuscitation. Renal ultrasound w/ small
right kidney but no hydroneprhosis. Uric acid slightly
elevated. Renal was consulted and followed the patient during
his hospitalization. As the patient's overall condition
improved, his creatinine also returned to baseline. Upon
discharge, his creatinine was 2.1.
Initially, the patient's lasix, nadolol, spironolactone, and
finasteride were held due to renal failure. His lasix was able
to be added back on but at half of his usual home dose.
The patient will start sodium bicarb tablets 650mg PO BID.
# Coronary Artery Disease:
NSTEMI earlier in [**2189-10-27**] with medical management. No
signs of ischemia on EKG upon presentation. The patient
underwent transthoracic echo with preserved systolic function
early in his hospitalization and had a second echo towards the
conclusion of his hospitalization - both showed preserved LV EF
of 55-60% and borderline diastolic heart failure. Patient
initially presented on aspirin and a statin. Due to his
decreasing platelet level, his aspirin was discontinued as was
all heparin products. Due to patient's blood pressure around
100 mm Hg, beta blocker was not restarted during
hospitalization. We would recommend that both aspirin and beta
blocker be restarted as tolerated.
#Atrial Fibrillation:
Not on coumadin given history of GI bleed and presence of
melena. Patient has remained rate controlled and intermittently
paced.
# Hypernatremia:
Patient initially was not taking much oral food or liquid given
his mental status, but is now tolerating a regular diet.
Hypernatremia is likely from the initial restriction of free
water. He had a free H2O deficit is 2.7 liters. Patient was
given D5W and had slow correction of his hypernatremia. Of
note, patient reports that he drinks 32 water bottles per week
(1 pint bottles) in addition to other fluids.
# Hypothermia:
Throughout the hospitalization the patient was hypothermic. He
initially had rectal temperatures around 32.7 degrees celcius
while in the intensive care unit. He initially was treated with
the use of a Bair hugger while in the intensive care unit as
well as on the medical floor. As the patient's condition
improved, his temperature moderately improved. He remained with
temperature between 95-96 degrees fairenheight, though rectal
temperatures were 97. The patient was always warm and well
perfused with temperatures of 94-95 PO farenheit. We would
recommend obtaining rectal temperatures for a true core
temperature.
# FEN/GI: Initially recommended soft (dysphagia); Nectar
prethickened liquids per speech and swallor recommendations,
however, as his condition improved he was transitioned to thin
liquids and regular solids.
Medications on Admission:
- ATORVASTATIN 40 mg po daily
- ESOMEPRAZOLE MAGNESIUM 40 mg po daily
- FINASTERIDE 5 mg po daily
- FUROSEMIDE 40 mg po BID
- LEVOTHYROXINE 25 mcg po daily
- NADOLOL 20 mg po daily
- SPIRONOLACTONE 50 mg [**Hospital1 **]
- ASPIRIN 81 mg po daily
- CHOLECALCIFEROL (VITAMIN D3) 800 units po daily
- FERROUS SULFATE 325 mg po daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
10. Lactulose 10 gram/15 mL Solution Sig: Forty Five (45) ML PO
Q8H (every 8 hours) as needed for confusion.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
13. Hydrocortisone 2.5 % Ointment Sig: One (1) Appl Topical PRN
(as needed) as needed for pruritis.
14. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Altered Mental Status
Systemic Inflammatory Response Syndrome
End Stage Liver Disease
Acute on Chronic Kidney Injury
Pancytopenia
Hypoxia
Hypernatremia
Discharge Condition:
Mental Status: Alert, sometimes confused
Ambulatory Status: out of bed to chair with assist
Discharge Instructions:
You presented to the hospital with low blood pressure, fatigue,
confusion, and weakness.
Because your blood pressure was so low, you were initially
admitted to the intensive care unit where you received
antibiotics. You began to improve, and there was suspicion that
you may have had an infection in your abdomen. Fluid was taken
from your abdomen, but did not show any infection. As you were
already on antibiotics, we cannot be sure if there was initially
an infection causing your symptoms.
Your liver function was noted to be worsening, and you were seen
by Dr. [**Last Name (STitle) 497**], the hepatologist (liver doctor), while you were in
the hospital.
Your kidney function also was more impaired than usual when you
arrived to the hospital. With the help of the kidney doctors,
your kidney function returned better than its baseline.
You were taken off of antibiotics and were stable without fever
or other signs of infection.
Your confusion may have been due to an infection in your
abdomen, or your confusion may have been due to a build up of
ammonia that your liver could not break down. You should
continue to take the medicine lactulose if you are found to be
confused.
We discontinued several of your medicines while you were in the
hospital:
(1) Aspirin 81mg by mouth daily
(2) Nadolol 20mg by mouth daily
(3) spironolactone 50mg by mouth twice daily
(4) finasteride 5mg by mouth daily
Some of these medicines will be slowly reintroduced into your
regimen by Dr. [**Last Name (STitle) 497**].
We also introduced new medications while you were in the
hospital:
(1) hydrocortisone 2.5% topical cream, apply to affected areas
[**Hospital1 **]
(2) clotrimazole cream, apply to affected area over buttocks and
back [**Hospital1 **]
(3) sarna lotion, apply to topical area QID prn itch.
(4) lactulose 30 gm PO TID prn confusion
The following medications were changed while you were in the
hospital:
(1) Lasix 20 mg PO BID
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-12-3**] 7:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2189-12-11**] 2:20
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2189-12-21**] 10:20
Completed by:[**2189-11-30**]
ICD9 Codes: 0389, 5849, 2760, 5119, 2859, 4168, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 920
} | Medical Text: Admission Date: [**2166-6-25**] Discharge Date: [**2166-9-3**]
Date of Birth: [**2121-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Worsening angina
Major Surgical or Invasive Procedure:
[**2166-6-27**] Urgent coronary bypass grafting x2 with a reverse
saphenous vein graft from the aorta to the first diagonal
coronary artery; reverse saphenous vein graft from the aorta to
the left anterior descending coronary artery
[**2166-7-2**] Placement of PICC Line
[**2166-7-7**] Tracheostomy
[**2166-7-14**] PEG placement
History of Present Illness:
Mr. [**Known lastname 85300**] is a 44 year old Jehovah Witness with known coronary
artery disease s/p DES of OM lesion [**2166-3-6**], grade 1 diastolic
dysfunction, and chronic pericarditis who presented to outside
hospital with increasing angina on exertion. Cardiac
catheterization at [**Hospital6 **] revealed significant LM
disease. Patient was deemed to be poor surgical candidate and
was subsequently transferred to the [**Hospital1 18**] for further evaluation
and treatment.
Past Medical History:
- Coronary Artery Disease, s/p inferior MI(STEMI), s/p Drug
eluting stent to obtuse marginal
- History of positive PPD, negative CXR [**10-11**]
- Chronic pericarditis
- Hypertension
- Hyperlipidemia
- Type II Diabetes Mellitus
Social History:
Originally from [**Country 2045**], lives with wife and 2 children. Denies
tobacco and ETOH.
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: 87 BP: 102/77 RR: 25 O2 sat: 100%
Height: 74 inches Weight: 86 kg
General:A&Ox3
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left:2+
Carotid Bruit none Right: 2+ Left:2+
Pertinent Results:
[**2166-6-26**] Echocardiogram: The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
akinesis of the basal to mid inferolateral wall, hypokinesis of
the anterolateral wall. Overall left ventricular systolic
function is mildly depressed (LVEF= 45 %). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
[**2166-6-26**] Chest CTA: 1. Acute pulmonary embolus in the left
descending pulmonary artery, extending in the lingula, and basal
truncus, involving more than half of the vessel lumen. No
evidence of right heart strain. 2. No pneumonia. No evidence of
active, or chronic granulomatous disease.
[**2166-6-26**] Lower Extremity Ultrasound: No evidence of deep vein
thrombosis in either leg.
[**2166-6-26**] Carotid Ultrasound: Right ICA with no stenosis. Left ICA
with no stenosis.
[**2166-6-27**] Intraop TEE: PRE-CPB: 1. The left atrium is mildly
dilated. No spontaneous echo contrast is seen in the left atrial
appendage. No thrombus is seen in the left atrial appendage. 2.
No atrial septal defect is seen by 2D or color Doppler. 3. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %). There is
moderate lateral hypokinesis. 4. Right ventricular chamber size
and free wall motion are normal. 5. The ascending, transverse
and descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. 6. There are three aortic valve leaflets. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. 7. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pericardium may be thickened. **Prior to
bypass, there was an episode of hypotension with EKG changes.
TEE showed severe hypokinesis of the anterior and anteroseptal
walls, with an LVEF of 10 %. CPR was initiated and the patient
emergently placed on cardiopulmonary bypass.** POST-CPB: On
infusions of vasopressin, Epi, Norepinephrine, Milrinone. In
sinus rhythm. Improved anterior wall on inotropic support, with
LVEF now 35%. MR [**First Name (Titles) **] [**Last Name (Titles) **] remain trace. There is no change in the
aortic contour post decannulation.
[**2166-7-1**] Head CT Scan: 1. Limited study due to patient motion. A
small hypodensity in the right parieto-occipital lobe is of
indeterminate age, likely chronic. No acute intracranial
hemorrhage or acute major vascular territorial infarction. 2.
Marked paranasal sinus disease as above.
[**2166-7-2**] EEG: This is an abnormal video EEG study because of
severe diffuse background slowing and disorganization. These
findings are indicative of severe diffuse cerebral dysfunction,
which is etiologically non-specific. There were no epileptiform
discharges or electrographic seizures.
[**2166-7-2**] MRI Head/Brain: 1. Innumerable punctate foci of signal
on the diffusion-weighted images, many of which are also bright
on FLAIR suggestive of multiple acute, likely embolic, infarcts.
A more confluent area of FLAIR signal abnormality in the right
posterior temporal lobe could be another area of older infarct.
2. Scattered punctate foci of susceptibility artifact could
represent areas of microhemorrhage or calcification.
[**2166-7-6**] Abd Ultrasound: Limited view of pancreas. No evidence of
cholelithiasis or intra-or extrahepatic biliary dilatation.
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study [**2166-9-1**] 1:25
PM
[**Hospital 93**] MEDICAL CONDITION: 45 year old man s/p decannulation
Final Report
INDICATION: Evaluate for aspiration in patient with history of
aspiration.
FINDINGS: Barium passes freely through the oropharynx without
evidence of
obstruction. The patient demonstrates a slow oral phase and weak
swallow with weak pharyngeal muscle contraction. There is
penetration and aspiration of thin barium without penetration or
aspiration of nectar or thick barium. The patient does sense the
aspiration and coughs appropriately. He has an increased residue
in both the valleculae and piriform sinuses, which spills over
in between swallows. For more details please see the speech and
swalllow division note in OMR.
There is again noted an opacity projecting over the tracheal air
column that likely represents an endoluminal lesion, possibly
tracheal polyp or other mass lesion. Recommend further
evaluation with direct visualization or Neck CT.
IMPRESSION:
1. Aspiration of thin barium without aspiration of thick or
nectar barium
which represents some improvement from the prior study.
2. Lesion projecting over the trachea that may represent
tracheal polyp or
other mass lesion. Recommend further evaluation with dedicated
CT of trachea or direct visualization for further evaluation.
Radiology Report CHEST (PA & LAT) Study Date of [**2166-8-12**] 10:26
AM
[**Hospital 93**] MEDICAL CONDITION: 45 year old man with s/p cabg
FINDINGS: In comparison with the study of [**7-31**], the lungs are
now essentially clear except for some mild atelectatic changes
at the left base. No vascular congestion. Tracheostomy tube
remains in good position, and the PICC line again extends to the
lower SVC or cavoatrial junction.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Admission
[**2166-6-25**] 07:02PM BLOOD WBC-6.9 RBC-4.41* Hgb-12.6* Hct-38.9*
MCV-88 MCH-28.5 MCHC-32.3 RDW-15.0 Plt Ct-274
[**2166-7-7**] 01:46AM BLOOD WBC-17.9* RBC-1.66* Hgb-4.8* Hct-15.9*
MCV-96 MCH-28.7 MCHC-30.0* RDW-21.0* Plt Ct-515*
[**2166-8-4**] 05:00AM BLOOD WBC-6.4 RBC-3.09* Hgb-8.1* Hct-27.0*
MCV-87 MCH-26.2* MCHC-29.9* RDW-17.6* Plt Ct-544*
[**2166-6-25**] 07:02PM BLOOD PT-11.1 PTT-26.1 INR(PT)-0.9
[**2166-7-7**] 01:46AM BLOOD PT-14.8* PTT-29.2 INR(PT)-1.3*
[**2166-7-13**] 05:02AM BLOOD PT-15.7* INR(PT)-1.4*
[**2166-6-25**] 07:02PM BLOOD Glucose-131* UreaN-17 Creat-1.1 Na-142
K-3.9 Cl-105 HCO3-28 AnGap-13
[**2166-7-5**] 05:02AM BLOOD Glucose-143* UreaN-24* Creat-0.7 Na-148*
K-3.7 Cl-114* HCO3-29 AnGap-9
[**2166-8-4**] 05:00AM BLOOD Glucose-110* UreaN-15 Creat-0.5 Na-137
K-4.4 Cl-100 HCO3-30 AnGap-11
[**2166-6-25**] 07:02PM BLOOD ALT-23 AST-27 LD(LDH)-143 AlkPhos-63
Amylase-86 TotBili-0.2
[**2166-7-7**] 01:46AM BLOOD ALT-426* AST-267* LD(LDH)-569*
AlkPhos-588* Amylase-478* TotBili-0.4
[**2166-7-24**] 09:45AM BLOOD ALT-36 AST-33 LD(LDH)-259* AlkPhos-158*
Amylase-106* TotBili-0.3
[**2166-6-26**] 05:25AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
[**2166-7-22**] 12:35PM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.7 Mg-2.5
Discharge
[**2166-8-31**] 07:35AM BLOOD WBC-5.0 RBC-3.93* Hgb-10.3* Hct-32.4*
MCV-83 MCH-26.1* MCHC-31.7 RDW-17.1* Plt Ct-374
[**2166-8-31**] 07:35AM BLOOD Plt Ct-374
[**2166-8-18**] 06:13AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2*
[**2166-8-31**] 07:35AM BLOOD Glucose-140* UreaN-25* Creat-0.8 Na-138
K-4.6 Cl-101 HCO3-30 AnGap-12
[**2166-7-24**] 09:45AM BLOOD ALT-36 AST-33 LD(LDH)-259* AlkPhos-158*
Amylase-106* TotBili-0.3
[**2166-8-31**] 07:35AM BLOOD Mg-2.0
[**2166-6-25**] 07:02PM BLOOD %HbA1c-8.3* eAG-192*
Brief Hospital Course:
Mr. [**Known lastname 85300**] was admitted to the cardiac surgical service. Given
severe left main disease and unstable angina, he remained on
Integrilin and Nitroglycerin. Preoperative evaluation was
notable for mildly depressed LV function and pulmonary embolus -
see result section for additional details. After extensive
discussion with the patient and his family about risks and
benefits especially refusal of blood products, he agreed to
proceed with surgical revascularization.
On [**6-27**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting surgery. Operative course was notable for hypotensive
cardiac arrest following induction of anesthesia. See operative
note for additional details.
Following surgery, he arrived to the CVICU in critical
condition, on multiple pressors. Given labile hemodynamics, he
required insertion of IABP. The IABP was eventually removed on
postoperative day two, and inotropic support was gradually
weaned over several days. Given severe anemia and refusal of
blood products, Epogen was administered.
Initially unresponsive, Neurology was consulted. Head CT scan
was unrevealing, and EEG showed no evidence of seizure activity.
Neurology initially attributed his severe obtundation to
possible hypoxic-ischemic injury related to hypotensive cardiac
arrest and persistently severe anemia. MRI of brain was notable
for multiple emboli and infarcts. Given that there was no
intervenable etiology of his unresponsiveness neuro initially
signed off.
Due to prolonged ventilation, Dobhoff feeding tube and PICC line
were placed. Tracheostomy was eventually performed on [**7-7**],
with subsequent PEG placment on [**7-14**]. Mr. [**Known lastname 85300**] transferred
from the ICU to the floor on [**7-16**] (POD #19).
He intermittently spiked fevers which subsided and he was
treated for staph PNA. Neuro was re-consulted to evaluated his
bilateral leg weakness on [**7-16**]. His leg weakness was believed to
be due to low flow state and profound anemia with a HCT of 9. No
clinical diagnostic evidence was found to support an etiology
for this persistant lower extremity immobility. Over the course
of his hopsital stay he slowly began moving his lower
extremities and is now able to move his lower extremities and
partial weight bear.
He was eventually weaned from the vent to a trach collar and
finally decanulated on [**2166-8-21**].He was evaluated and followed
throughout his hospital stay by speech and swallow pathologists
for Passy-Muir valve trails and he had mutiple video swallow
evaluations. He is presently taking po's and receiving cycled
tube feeds at night which can be weaned off when taking adeq
oral nutrition. His most recent video swallow [**9-1**] revealed a
tracheal lesion that Radiologist recommend follow up for
tracheal polyp vs mass. Per Dr.[**Last Name (STitle) 914**], Mr.[**Known lastname 85300**] should have
follow up done with his referring physician.
Physical therapy and Occupational therapy continued to work with
Mr.[**Known lastname 85300**]. He continues to make slow improvements toward
regaining his lower extremity strength and functioning.
[**Last Name (un) **] Diabetes service was consulted for glucose management.
He remains in stable condition.
Dr.[**Last Name (STitle) 914**] cleared Mr.[**Known lastname 85300**] on POD# 67 from his original
surgery, for discharge to [**Hospital **] rehabilitation.
All follow up appointments were advised.
Medications on Admission:
Aspirin
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
5. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily).
6. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
PO TID (3 times a day).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-4**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q8H (every 8 hours) as needed for pain.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
18. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
19. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
21. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
22. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Coronary Artery Disease s/p Urgent coronary bypass grafting x2
with a reverse saphenous vein graft from the aorta to the first
diagonal coronary artery; reverse saphenous vein graft from the
aorta to the left anterior descending coronary artery.
Endoscopic vein harvesting of the left leg.
s/p cardiac arrest
s/p Percutaneous endoscopic gastrostomy tube
placement/Percutaneous tracheostomy tube placement
Intra-op Cerebral Vascular Accident
Anemia
Pneumonia
Past medical history:
Diabetes Mellitus
s/p inferior Myocardial Infarction(STEMI)
s/p DES to LCX OM1(90% stenosis)
PPD+ negative CXR [**10-11**]
Chronic pericarditis
Hypertension
Hyperlipidemia
Discharge Condition:
Alert and oriented x3
Upper extremities [**5-7**] strengths, full range of motion
Lower extremities limited motion and generalized weakness. Able
to stand.
Incisional pain managed with Ibuprofen
Incisions: Sternal - healed, 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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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:
NEED UPDATED APPOINTMENT W/RH
Surgeon: Dr. [**Last Name (STitle) 914**] on Tuesday [**2166-9-16**] at 2:30 PM [**Hospital Ward Name **] 2A
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Wednesday [**10-1**] @ 8:00 AM
Please call to schedule appointments with:
Primary Care Dr. [**Last Name (STitle) 85301**] [**Doctor Last Name 85302**] in [**1-4**] weeks
******Please have tracheal lesion work up with referring/primary
care physician********
**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:[**2166-9-3**]
ICD9 Codes: 4275, 4111, 9971, 2851, 412, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 921
} | Medical Text: Admission Date: [**2111-6-9**] Discharge Date: [**2111-6-16**]
Date of Birth: [**2087-1-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
2 days of headache and neck pain
Major Surgical or Invasive Procedure:
Exploration of neck wound with posterior decompression and
evacuation of hematoma
IVC filter placement
History of Present Illness:
This is a 24 year old man admitted to the Neurosurgery Service
on
[**2111-5-14**] following flu like symptoms including neckache and
headache. Imaging of head and spine demonstrated Chiari
malformation/cervical and thoracic syringomyelia. Suboccipital
craniectomy was performed on [**2111-5-22**]. Post operative course was
complicated by R pulmonary artery PE. He was also treated for
possible pneumonia. There was some L arm weakness and L sided
arm
and leg numbness several days post operatively without clear
cause identified despite CT brain/repeat imaging of c-spine. He
was discharged to rehab on [**2111-6-2**].
He had been progressing well at rehab. INR had been low (1.45)
and increased coumadin given. Also covered over last several
days with therapeutic doses of lovenox. Rehab
notes indicate anticipation of discharge home today. Unable to
participate in OT today due to neck pain and referred for MRI.
The patient notes increasing neck discomfort and headache over
the last 2 days. He has persistent LUE weakness much the same as
previously. Denies fall at rehab.
MRI was performed at [**Hospital1 **] which showed postoperative
changes and small R paraspinal hematoma. He was transferred
here
for further care.
The patient admits to some low mood recently. Overwhelmed by
current illness. Appetite has been okay. He has no complaints of
fever, cough, rhinorrhoea, nausea, vomiting, diarrhoea, urinary
symptoms.
Past Medical History:
-Chiari I malformation with cervical/thoracic syringomyelia
s/p suboccipital craniectomy with posterior fossa decompression
([**2111-5-22**])
-PE
-pneumonia
Asthma
Social History:
[**Hospital **] rehab. Previously living alone in [**Location (un) 47**]. Working
at a school for children with autistic spectrum disorders. Has
girlfriend. Mother resident in [**Name (NI) 531**]. Lifetime non-smoker.
Denies EtOH and drugs.
Family History:
Noncontributory
Physical Exam:
T-98.6 BP-137-138/76-83 HR-62-106 RR-20 O2Sat 96-97% RA
Gen: Lying in bed on left side
HEENT: NC/AT, moist oral mucosa, thick coating around inside of
lips
Neck: Well healed midline posterior cervical wound without
warmth
or discharge. Generalised tenderness to palpation midline neck.
Decr ROM.
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Decr CE bilat; decr AE bilat; clear to auscultation, no
added sounds
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, flat
affect. Oriented to person, place, and date. Speech is fluent
with normal comprehension and repetition; naming intact. No
dysarthria. No right left confusion. No evidence of apraxia or
neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, nystagmus bilat extremes of
horizontal gaze. Sensation intact V1-V3. Facial movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 4 4+ 4- 5- 5- 5- 5- 5 5 5 5 5 5 5
Sensation: Intact to light touch sl decr on left foot, vibration
and proprioception intact bilat LE. No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Toes downgoing R, up on L.
Coordination: finger-nose-finger normal.
Gait/Romberg: Deferred
Pertinent Results:
135 98 12 111 AGap=16
4.3 25 0.9
estGFR: >75 (click for details
78
20.5 D 15.8 368 D
43.1
N:91.4 L:6.3 M:1.8 E:0.2 Bas:0.3
PT: 20.8 PTT: 34.3 INR: 2.0
OSH MRI of c-spine shows rounded fluid collection in paraspinal
muscles on R side of cervical spine with fluid level. Possible
hematoma ?acute versus subacute. Post-operative changes with
seroma.
CT neck:
Large complex fluid collection in the surgical bed with
characteristics consistent with new hemorrhage in this region.
The mild enhancement could be post-operative, though infection
cannot be excluded.
NCHCT:No intracranial hemorrhage. Postsurgical change in the
4th
ventricle, posterior fossa, and C1 related to recent surgery for
chiari malformation.
CXR: decr lung volumes, no consolidation
MRI c-spine [**6-10**]:
New hemorrhage into the fluid collection within the surgical
bed, causing increasing compression of the cervicomedullary
junction and an increase in the size of the syrinx. The new
enhancement of the dural graft could represent inflammation or
infection.
Brief Hospital Course:
24y man s/p posterior decompression for [**Doctor Last Name 1193**] Chiari
Malformation type 1 on [**2111-5-22**] with increasing
neck pain and headache. Examination showed progressive LUE
weakness and MRI of c-spine showed hematoma in operative site.
On the day of admission, he had decreased O2 saturation in ABG;
CTA done and acute PE was ruled out. Aspiration pneumonia was
indicated and is treated with ceftriaxone for 10 days. His ABG
improved to normal after the surgery.
Bilateral lower extremity ultrasound was also performed which no
evidence of DVT. The patient was taken to the OR for evacuation
of hematoma on [**2111-6-10**], following reversal of INR and IVC filter
placement.
The following day ([**6-11**]) patient was extubated, placed in a soft
collar and transferred to the step down unit. A hematology
consult was then obtained. Hematoloy recommended coumadin for
possible hypercoagulable state for 6 months while pulmonology
recommended no anticoagulation. After thorough discussion, it
was agreed that the patient should be anticoagulated and a
heparin drip was to be started POD 7 to reduce the risk of head
bleed. On [**6-12**] a speech and swallow consult was obtained and
after performing a bedside swallow they recommended that the pt
be advanced to a diet of thin liquid (by cup) and soft
consistency solids and pills were to be given whole or crushed.
Culture from the operating room showed no growth, blood culture
showed no growth; and sputum cultures were positive for GNR and
GPC, which was treated with ceftriaxone and placed on aspiration
precautions. On [**6-13**] patient's surgical drain was removed.
Patient is to continue on ceftriaxone until [**2111-6-20**] and to have
his soft collar in place for 2 weeks
Medications on Admission:
Coumadin 5mg po qhs
Flexeril 5mg po tid prn
Colace 100mg po bid
Bisacodyl 5mg po qd
Protonix 40mg po qd
Tylenol 650mg po q4h prn
Percocet-5 5/325 [**1-20**] q4h pr prn
Hydromorphone 1-2mg po q6h prn
Nystatin 5ml po qid prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for neck pain.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): SC injection.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
13. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gm Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
1) Posterior cervical hematoma
2) Aspiration Pneunomia
3) Chiari malformation type I s/p posterior fossa/Chiari
decompression
including C1 and partial C12 laminectomy.
Discharge Condition:
Stable
Discharge Instructions:
** PLEASE START IV HEPARIN DRIP / PO COUMADIN ON [**2111-6-17**].
1) HEPARIN DRIP: PLEASE START WITH 800 UNITS/HR; NO BOLUS;
ADJUST HEPARIN DOSE TO PTT GOAL 40-60; CHECK PTT Q6H UNTIL 2
CONSECUTIVE THERAPEUTIC THEN CAN BE CHECKED QD; D/C HEPARIN WHEN
COUMADIN THERAPEUTIC.
2) COUMADIN GOAL IS INR 2.0 - 3.0.
** PLEASE HAVE YOUR STAPLES REMOVED BETWEEN [**6-23**] - [**2111-6-26**]
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have your incision checked daily for signs of infection
?????? Please wear soft cervical collar for two weeks from your date
of surgery.
* You may shower briefly and pat dry your incision with
CLEAN towel.
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
You have been scheduled to see Dr [**First Name (STitle) **] [**Last Name (NamePattern4) 9151**], MD
(Phone:[**Telephone/Fax (1) 1669**]) on [**2111-9-1**] at 11:00. Please have a brain
MRI done in RADIOLOGY (Phone:[**Telephone/Fax (1) 327**]) on [**2111-9-1**] 10:00
prior to your appointment with Dr [**Last Name (STitle) **].
Completed by:[**2111-6-16**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 922
} | Medical Text: Admission Date: [**2144-3-18**] Discharge Date: [**2144-3-25**]
Date of Birth: [**2068-1-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 76 yo woman with known h/o HTN, hypercholesterolemia, PVD,
B12 deficiency and recent diagnosis of positive anti-[**Doctor Last Name **] antibody
with cranial neuropathy and respiratory failure secondary to
paraneoplastic disorder related to a neuroendocrine tumor.
Patient was recently admitted to [**Hospital1 18**] [**Hospital Unit Name 153**] for progressive
respiratory failure from progressive diaphragmatic weakness, and
returns from rehab 9 days after discharge with a new multifocal
pneumonia. Patient is sent here for further work-up of her PNA
and possible bronchoscopy.
Per daughter, patient was noted to have increased respiratory
effort over the last week and on CXR was found to have a
white-out of the left lung, thought to be secondary to pna. She
also was with low grade temps to 100 and O2 desaturations
requiring ventilator adjustments and increased FiO2. Patient is
scheduled for chemo early next week at [**Hospital3 **] (Dr. [**Last Name (STitle) 2036**].
She is hard of hearing, but otherwise oriented and at baseline,
denies any pain or other complaints. Per daughter patient is
more comfortable today than yesterday. She also notes that she
has had increased secretions over last few days. ED nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 58716**]a since admission as well, although was constipated last
week and started on bowel meds. She was started on Ceftaz on
[**3-14**] and then on amikacin on [**3-15**] for presumed double coverage
for pseudomonas. Of note on arrival from rehab she came on SIMV
450/18/7.5/80%
Past Medical History:
- Paraneoplastic disease as above with cranial neuropathy and
respiratory failure
- Respiratory failure, trach and vented
- HTN and bilateral renal artery stenosis
- High cholesterol
- PVD
- eye surgery?
- Hyponatremia/SIADH
- Depression
- Iron deficiency anemia
- B12 deficiency
- DVT left leg, [**11/2143**], on coumadin
- S/p PEG tube
- perivascular white matter changes on MRI consistent with small
vessel disease.
- adenexal cyct seen on CT at OSH, not further explored
surgically
Social History:
currently at [**Hospital6 58717**], had been living independently
previously. No tobacco, rare EtOH. Supportive family. Daughter
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16844**] is HCP, phone [**Telephone/Fax (1) 58711**]
Family History:
No stroke, seizure, neurological disease. No DM. +MI in sister
age 79. [**Name2 (NI) **] cancer in sister, age 16.
Physical Exam:
VS: T 98.8 BP146/63 P63 R18 Currently on AC 550/18/5/100% with
Sats of 93-95% and PIPS of 28 and plateau 25 and ABG
7.56/43/56/40/94%
Gen: Pleasant elderly woman in NAD, sleepy but arousable
HEENT: PERRL, 3mm bilaterally, anicteric, MMM
Neck: Supple, floppy, trach in place
Cardiac: RRR, S1, S2 no murmur
Lungs: coarse BS throughout, good air mvmt on vent
Abd: Soft,+BS, slightly distentded, G tube inplace, no
tenderness
Extr: no edema, R heel ulcer wrapped, dropped foot on right
Neuro: sleepy but arousable, decrease strength of all muscles,
but sensation intact and withdraws foot to touch
Pertinent Results:
[**2144-3-18**] 10:51PM TYPE-ART TEMP-37.6 RATES-16/0 TIDAL VOL-450
PEEP-10 O2-50 PO2-90 PCO2-49* PH-7.51* TOTAL CO2-40* BASE XS-13
-ASSIST/CON INTUBATED-INTUBATED
[**2144-3-18**] 09:58PM TYPE-ART TEMP-37.6 TIDAL VOL-550 PEEP-10
O2-100 PO2-317* PCO2-38 PH-7.60* TOTAL CO2-39* BASE XS-14
AADO2-375 REQ O2-65 -ASSIST/CON INTUBATED-INTUBATED
[**2144-3-18**] 09:54PM URINE HOURS-RANDOM CREAT-51 SODIUM-<10
[**2144-3-18**] 09:54PM URINE OSMOLAL-674
[**2144-3-18**] 04:20PM TYPE-ART O2-100 PO2-56* PCO2-43 PH-7.56*
TOTAL CO2-40* BASE XS-14 AADO2-631 REQ O2-100 -ASSIST/CON
INTUBATED-INTUBATED COMMENTS-TRACH/VENT
[**2144-3-18**] 04:20PM LACTATE-1.4
[**2144-3-18**] 04:20PM O2 SAT-94
[**2144-3-18**] 03:23PM TYPE-[**Last Name (un) **] PO2-43* PCO2-45 PH-7.54* TOTAL
CO2-40* BASE XS-13
[**2144-3-18**] 12:15PM LACTATE-1.6
[**2144-3-18**] 12:08PM GLUCOSE-113* UREA N-47* CREAT-0.4 SODIUM-131*
POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-40* ANION GAP-7*
[**2144-3-18**] 12:08PM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2144-3-18**] 12:08PM WBC-38.1*# RBC-3.31* HGB-10.0* HCT-29.6*
MCV-89 MCH-30.1 MCHC-33.6 RDW-16.6*
[**2144-3-18**] 12:08PM NEUTS-73* BANDS-19* LYMPHS-4* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2144-3-18**] 12:08PM PLT COUNT-273
[**2144-3-18**] 12:08PM PT-19.1* PTT-45.7* INR(PT)-2.3
[**2144-3-18**] 11:36AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2144-3-18**] 11:36AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2144-3-18**] 11:36AM URINE RBC-[**12-13**]* WBC-[**12-13**]* BACTERIA-MANY
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2144-3-18**] 11:36AM URINE WAXY-<1 WBCCAST-<1
.
.
CXR: new multifocal opacities RUL, LUL and peri-hilar area with
possible left sided effusion
*
EKG: NSR @81, nl axis, flat t in III, twi V1. no prior ekg.
Brief Hospital Course:
A/P: 76 yo woman transferred to [**Hospital1 18**] from [**Hospital **] rehab after
developing new multifocal pneumonia, leukocytosis and low grade
temps.
.
# Respiratory Failure: secondary to multifocal pneuomia, on top
of her underlying diaphragmatic weakness caused by the
paraneoplastic syndrome. While in the hospital she was
maintained on a ventillator via her tracheostomy. A
bronchoscopy was performed and showed normal airways. Her
sputum grew out serratia and pseudomonas and she was treated
with zosyn. The patient was initially also treated with
gentamycin for double pseudomonas coverage but her culture
showed gentamycin resistance.
.
# Leukocytosis: in addition to the pneumonia as a source of
infection, the patient had one blood culture positive for
klebsiella on [**2144-3-18**]. The klebsiella was also sensitive to
zosyn. Her blood cultures from [**2144-3-19**] were negative. The plan
for antibiotics was to continue zosyn for a total of 2 weeks. A
PICC line was placed by IR on [**2144-3-23**].
.
# Paraneoplastic syndrome secondary to neuroendocrine tumor:
Discussed plan with Dr [**First Name (STitle) **] who agreed that chemo therapy should
be held until after the patient completes her course of
treatment.
*
# HTN: The patient's ACEI was initially held given the
questionable history of bilateral renal artery stenosis, labile
BPs which were thought to be secondary to her autonomic
dysfunction from paraneoplastic source, and concern for
infection/sepsis. Her ACEI was restarted while in hospital and
she maintained normal blood pressures.
.
# DVT in [**2143-11-25**]: The patient was continued on her home dose of
coumadin. Her INR rose to 4.8 on [**2144-3-24**] and her coumadin was
held. On [**2144-3-25**] her INR was 4.2. The presumption was that the
increasing INR was secondary to antibiotics and decreased GI
flora. No external signs of blood loss and hct stable at 27.
Patient was discharged to an acute care rehab where her coumadin
can be held and her INR can be rechecked in 2 days. Plan to
hold coumadin for an INR > 3.5. Goal INR [**2-27**].
Medications on Admission:
Norvasc 5mg qd
Lisinopril 10mg qd
Ceftaz 1gm q8hrs
Amikacin 500mg qd x10days
Robitussin 10ml qid
lasix 40mg qd
mucomyst nebs q4hrs
vitamin c 500mg [**Hospital1 **]
Prozac 20mg qd
senakot 2tabs qd
neupogen 300mcg/ml q24
simethicone 80mgqid
lactulose 30ml tid
coumadin 5mg qd
FeSO4 325 daily
Colace 100mg [**Hospital1 **]
compazine 5mg q6hrs
morphine sulfate 2mg q4hrs
dulcolax/fleet prn
hepartin 500units
Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for INR > 3.5.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Albuterol 90 mcg/Actuation Aerosol Sig: 2-6 Puffs Inhalation
Q4H (every 4 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed. treatment
15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1)
treatment Miscell. Q4-6H (every 4 to 6 hours).
16. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day).
17. Zosyn 4.5 g Recon Soln Sig: 4.5 gram Intravenous every
eight (8) hours: last day of antibiotics will be [**2144-4-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
Pneumonia
-- paraneoplastic disease secondary to neuroendocrine tumor
-- HTN
-- DVT in left LE
-- hyperlipidemia
-- PVD
-- SIADH/hyponatremia
-- Small vessel disease on MRI
-- Stage II decubitus ulcer
-- right heel with ulcer and drop foot
-- Anemia
Discharge Condition:
Stable on trach ventillation
Discharge Instructions:
Take all your medications as prescribed
Call your primary care doctor or go to the ER if you are having
trouble breathing, fevers, lethargy, or any other worrisome
symptoms
Followup Instructions:
Call Dr. [**First Name8 (NamePattern2) 7810**] [**Last Name (NamePattern1) **] for a follow up appointment after you are
discharged from the rehab hospital. Please call for an
appointment: [**Telephone/Fax (1) 18067**].
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 5799**]
ICD9 Codes: 7907, 4019, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 923
} | Medical Text: Admission Date: [**2179-3-12**] Discharge Date: [**2179-4-12**]
Date of Birth: [**2106-7-8**] Sex: M
Service: MICU
CHIEF COMPLAINT: Transferred from outside hospital for
thrombocytopenia.
HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old
gentleman who was transferred from [**Hospital6 2561**] for
concern for TTP. Patient initially had presented on [**2179-2-28**] with a [**2-2**] day history of URI symptoms and was found
to be hypotensive and admitted with pneumonia and sepsis.
Patient required intubation and was treated with ceftriaxone,
azithromycin, and Flagyl with improvement over the next few
days. Patient was extubated. During that time, patient also
had a troponin leak and a catheterization was done that
showed one-vessel disease with a RCA occlusion of 70-80%.
Patient also had an abdominal CT at the outside hospital that
showed a questionable adrenal mass, however, patient was
discharged home on [**3-6**] on Augmentin and Flagyl. A
couple of days later the patient began to have copious
diarrhea stating about 15-20 bowel movements in a 24-hour
period, and also developed altered mental status and fever up
to 106 degrees. The patient returned back to [**Hospital6 **], where he was found to have mild elevation of his
creatinine to 2.7, and he was intubated for airway protection
during the performance of a lumbar puncture since patient was
oversedated.
The lumbar puncture at the outside hospital showed no
evidence of any infection, however, the patient was started
on ceftriaxone and p.o. vancomycin. Subsequently, the
patient developed thrombocytopenia with schistocytes and was
transferred to [**Hospital1 18**] for further evaluation, questionable
plasmapheresis.
PAST MEDICAL HISTORY:
1. TIA/CVD.
2. Hypertension.
3. Hyperlipidemia.
4. CAD - Catheterization on [**2179-2-28**] that showed
70-80% mid RCA stenosis and 40-50% LAD stenosis.
5. Obesity.
6. Chronic lower back pain with sciatica.
7. Mild CHF with an EF of 45%, apical hypokinesis.
8. Questionable seizure disorder.
MEDICATIONS ON ADMISSION:
1. Atenolol 50 mg p.o. q.d.
2. Aspirin 81 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
5. Diltiazem 30 mg p.o. q.i.d.
6. Phenobarbital 120 mg p.o. q.h.s.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home with his wife and
was a retired city worker in [**Hospital1 8**]. Patient has two
children. Denies any tobacco, alcohol, or IV drug use.
PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 101.4,
pulse 96, blood pressure 108/62, respiratory rate 20, and O2
saturation 100% on AC 14 x 650, FIO2 of 35%, PEEP of 5.
General: Intubated, sedated. Heart: S1, S2 regular rate
and rhythm, no murmurs, rubs, or gallops heard. Lungs:
Coarse bilateral sounds heard anteriorly. Abdomen is soft,
obese, positive bowel sounds, nondistended. Extremities:
[**1-1**]+ edema, 2+ femoral pulses bilateral. Neurologic: Was
following commands on admission, but was sedated for
intubation.
LABORATORIES ON ADMISSION: White count 15.6, hematocrit
26.0, platelets 35. Sodium 140, potassium 3.0, chloride 106,
bicarb 21, BUN 34, creatinine 1.5, glucose 160. AST 1203,
ALT 1783, alkaline phosphatase 99, total bilirubin 1.3, total
protein of 4.5, and albumin 2.1. PT 12.7, INR 1.1, PTT 23.
ABG: 7.51, 20, 164.
HOSPITAL COURSE:
1. Respiratory - The patient was initially intubated for
airway protection after being sedated during the procedure of
a LP. Patient had a LP done because he presented with an
acute mental status change. The LP showed no evidence of
infection, however, through the course of the hospital stay,
it became difficult to extubate the patient and an attempt
was made to wean him off his vent, but patient was not
successful, and so patient was eventually trached.
On his trach, patient has been on pressure support of 20 with
PEEP of 5, and is slowly being weaned. On the day of this
discharge summary, patient is on pressure support of 10 and
PEEP of 5 with a FIO2 of 40% and patient seems to be doing
well. We will continue to wean his vent settings as
tolerated.
2. Thrombocytopenia - Patient presented with acute
thrombocytopenia with the initial thinking of TTP. However,
since the patient was exposed to Heparin in the outside
hospital, a HIT antibody was sent, which returned positive.
Patient also had a right upper extremity ultrasound that was
done due to increased swelling of his right upper extremity
and he was found to have a right subclavian thrombus. The
patient was started on lepirudin drip as per the
Hematology/Oncology team for anticoagulation.
Patient's platelets slowly rose and at the time of this
discharge summary, the patient's platelets were 139. Patient
was also started on Coumadin as patient is going to require
about six months of anticoagulation with goal INR of [**2-2**].
Patient will be on both lepirudin drip and Coumadin until his
INR hits 4. At that time his lepirudin drip will be stopped
and patient will continue Coumadin.
3. Infectious disease - Patient presented febrile with an
elevated white count. Blood cultures were drawn at the time
of arrival to [**Hospital1 18**] and the patient was 6/6 bottles positive
for Enterococcal bacteremia. Patient was initially started
on gentamicin and ampicillin for broad coverage. The source
of the infection was unclear, but it was thought to be
secondary to nosocomial exposure in the outside hospital and
ID team was also consulted for concern that patient may have
seeded in his right subclavian thrombus and possible cardiac
valve.
During his hospital course when it was difficult to extubate
him, a chest x-ray was obtained that showed possible left
lower lobe pneumonia and patient was thought to develop
vent-associated pneumonia. Patient was started on vancomycin
and cefepime for vent-associated pneumonia, and the
ampicillin was stopped since the vancomycin would cover for
the Enterococcal bacteremia.
As per discussion with the ID team, it was decided that
patient will complete a six-week course of gentamicin 120 mg
IV b.i.d. and vancomycin 1 gram IV b.i.d. as tolerated. If
patient develops renal insufficiency, the gentamicin will be
stopped and patient will continue vancomycin. Patient also
had a transesophageal echocardiogram that was done to rule
out endocarditis. No vegetations were seen, however, there
was a highly mobile complex atheroma of 3 x 0.7 cm located in
the distal aortic arch and proximal descending aorta. After
discussing these findings with the ID team and the fact the
patient had endovascular infection, it was decided that we
will still continue the six-week course of antibiotic.
Patient will get a total of two weeks of cefepime 2 grams IV
q.8 for vent-associated pneumonia, which should be stopped on
[**2179-4-4**].
4. Cardiology - There was some concern that patient may have
developed endocarditis given his high degree of bacteremia.
Patient received a transesophageal echocardiogram that was
unremarkable except for this mobile complex atheroma found in
the aortic arch and the proximal descending aorta. It was
decided that he would anticoagulate for this finding.
Patient also has a history of hypertension and patient was on
Lopressor 75 mg p.o. b.i.d. at the time of this discharge
summary.
5. Neurologic: Patient was initially intubated due to
oversedation and decreased mental status during the procedure
of a LP. However, after intubation, patient's motor function
did not improve and patient continued to have decreased
mental status with occasional spontaneous movement of the
head. Patient did not respond to any commands. The Neuro
team was consulted, who recommended obtaining a MRI and an
EEG, both of which were unremarkable. The concern came for
Guillain-[**Location (un) **] syndrome versus ICU polyneuropathy.
At the time of this discharge summary, ongoing discussions
were held with the Neuro team regarding performing an EMG to
rule out Guillain-[**Location (un) **] syndrome. In addition, there was
some concern about patient having a seizure since the patient
was on Keppra 500 mg p.o. b.i.d., which the Neuro team
recommended to continue.
6. Renal - Patient initially presented with acute renal
failure of unclear etiology. However, through the course of
the hospital stay, the patient's creatinine improved. At the
time of this discharge summary, his creatinine was 0.9 with a
BUN of 29. Patient was making good urine and was self
diuresing over a liter per day.
7. Hyperglycemia - Patient was on an insulin drip initially,
but as we stopped the hydrocortisone, patient was switched
over to regular sliding scale insulin and patient's blood
sugars had been well controlled at this point.
8. Adrenal hemorrhage: Patient developed some adrenal
hemorrhage as per the abdominal CT done at the outside
hospital. This is most likely in the setting of HIT antibody
positive. Patient also had a Cortrosyn stim test that was
done, that did not respond as expected. Patient received a
seven-day course of hydrocortisone 100 mg IV q.8. Patient
appeared clinically stable and so no further imaging was
done, however, it may be considered as an outpatient to
obtain a repeat abdominal CT to assess any changes of the
adrenal hemorrhage.
9. GI: Patient had decreased mental status and was unable to
swallow. Patient had a PEG tube that was placed and was
receiving tube feeds.
Please note that this discharge summary describes the
hospital course events from [**2179-3-12**] to [**2179-4-2**].
Please see additional discharge summary for the rest of the
hospital course.
[**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2179-4-1**] 11:14
T: [**2179-4-1**] 11:18
JOB#: [**Job Number 55207**]
ICD9 Codes: 4280, 486, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 924
} | Medical Text: Admission Date: [**2164-6-5**] Discharge Date: [**2164-6-22**]
Date of Birth: [**2092-5-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Fatigue, fever, and lethargy
Major Surgical or Invasive Procedure:
ICD pacemaker lead extraction with attempt at vegetation removal
via femoral access
History of Present Illness:
The patient is a 72 yo woman with h/o CAD s/p CABG in [**2157**], sick
sinus syndrome s/p PM/ICD placement in [**2163**], and dilated
cardiomyopathy with EF of 35%, who presented to [**Hospital3 **]
Hospital on [**6-3**] with fever and lethargy. The patient was
reportedly feeling unwell for approximately one month prior to
admission. On the day of admission, she was at a family [**Holiday **]
dinner and was noted to be lethargic, weak, and pale. EMS was
thus called, and she was brought to [**Hospital3 **] Hospital for
further evaluation.
.
At the OSH, the patient was initially febrile to 102 and her K+
in the ED was 7.6. She was in respiratory distress and was
placed on BiPAP and was noted to have a LLL infiltrate on CXR.
Blood cultures subsequently grew GPCs in clusters in [**5-14**]
bottles, and a TTE demonstrated a vegetation on her AICD lead.
She was started on Vancomycin and Ampicillin. The decision was
made to transfer her to [**Hospital1 18**] for lead extraction.
.
Review of systems is positive for headache and mild shortness of
breath. Otherwise, she denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia
2. CARDIAC HISTORY:
-CABG: 3-vessel CABG in [**2157**] at the [**Hospital1 756**]
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2157**] and [**2163**]
-PACING/ICD: Placed in [**2163-5-12**] for NSVT and sick sinus
syndrome
3. OTHER PAST MEDICAL HISTORY:
Dilated cardiomyopathy with an EF of 35% (TTE in [**2163**])
CRI with ARF in [**2163**] requiring 2 sessions of HD (baseline Cr
1.2)
Retinopathy
Hypothyroidism
Cataract disease
Gout
Rubeosis iritis
Carotid stenosis
Insomnia
Cholelithiasis
Anemia
Syncope
Social History:
The patient lives with her husband. She previously smoked
tobacco and quit 10 years ago. She does not drink EtOH
regularly (1 drink/year on their anniversary)
Family History:
Her mother passed away in her 50s from a CVA and renal failure.
Her father died from cardiac disease at a relatively young age
(not specified). Sister passed away of cancer and one brother
had "kidney problems".
Physical Exam:
On admission:
VS: T=99.6, BP=104/55, HR=65, RR=20, O2 sat=96% on 2L
GENERAL: elderly female, hard of hearing, in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, tachycardic, normal S1, S2. II/VI holosystolic,
blowing murmur heard best in 5th LICS mid-clavicular line. No
thrills, lifts. No S3 or S4. No ICD pocket tenderness.
LUNGS: No chest wall deformities, mild kyphosis. Resp were
unlabored, no accessory muscle use. Crackles to mid lungs
bilaterally, R>L.
ABDOMEN: Soft, NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP pulses dopplerable bilaterally
On discharge:
Pertinent Results:
On admission:
[**2164-6-5**] 05:25PM BLOOD WBC-16.4* RBC-3.11* Hgb-8.7* Hct-28.5*
MCV-92 MCH-28.1 MCHC-30.6* RDW-20.0* Plt Ct-247
[**2164-6-5**] 05:25PM BLOOD Neuts-87.2* Lymphs-7.8* Monos-4.5 Eos-0.3
Baso-0.2
[**2164-6-5**] 05:25PM BLOOD PT-30.8* PTT-30.1 INR(PT)-3.0*
[**2164-6-5**] 05:25PM BLOOD Glucose-204* UreaN-40* Creat-1.5* Na-137
K-4.7 Cl-101 HCO3-26 AnGap-15
[**2164-6-5**] 05:25PM BLOOD ALT-15 AST-52* LD(LDH)-235 AlkPhos-33*
TotBili-0.4
[**2164-6-5**] 05:25PM BLOOD Albumin-2.9* Calcium-8.8 Phos-2.7 Mg-2.1
[**2164-6-5**] 05:25PM BLOOD %HbA1c-7.7* eAG-174*
Hct and WBCs
[**2164-6-6**] 04:15AM BLOOD WBC-13.9* Hct-27.4*
[**2164-6-7**] 05:34PM BLOOD WBC-12.6* Hct-25.0*
[**2164-6-8**] 03:06PM BLOOD WBC-16.5* Hct-28.0*
[**2164-6-9**] 03:32PM BLOOD WBC-11.6* Hct-26.3*
[**2164-6-10**] 06:11AM BLOOD WBC-9.8 Hct-26.2*
Creatinine
[**2164-6-6**] 04:15AM BLOOD Creat-1.3*
[**2164-6-7**] 05:34PM BLOOD Creat-1.2*
[**2164-6-8**] 03:06PM BLOOD Creat-0.8
[**2164-6-10**] 06:11AM BLOOD Creat-1.0
INR
[**2164-6-5**] 05:25PM BLOOD INR(PT)-3.0*
[**2164-6-6**] 04:15AM BLOOD INR(PT)-1.9*
[**2164-6-7**] 12:45AM BLOOD INR(PT)-1.4*
[**2164-6-8**] 04:24AM BLOOD INR(PT)-1.3*
[**2164-6-10**] 06:11AM BLOOD INR(PT)-1.2*
.
.
.
Discharge labs:
[**2164-6-21**] 04:36AM BLOOD WBC-9.0 RBC-3.06* Hgb-9.6* Hct-28.6*
MCV-94 MCH-31.5 MCHC-33.7 RDW-18.5* Plt Ct-349
[**2164-6-21**] 04:36AM BLOOD Plt Ct-349
[**2164-6-21**] 04:36AM BLOOD Glucose-97 UreaN-36* Creat-1.6* Na-135
K-4.0 Cl-94* HCO3-30 AnGap-15
[**2164-6-16**] 04:23PM BLOOD ALT-18 AST-41* AlkPhos-42 TotBili-0.4
[**2164-6-21**] 04:36AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.9
.
MICROBIOLOGY
Blood and urine cultures: no growth
IMAGING
TTE [**6-18**]:
.
.
The left atrium is normal in size. 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 akinesis. There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. A mitral valve annuloplasty ring is
present. The gradient across the mitral valve is increased (mean
= 17 mmHg). There is a moderate-sized vegetation on the mitral
valve ([**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] of the anterior leaflet, 0.8 cm). Mild to
moderate ([**2-12**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] 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 prior study (images reviewed) of [**6-11**]/201, the
tricupsid valve vegetation is not clearly seen (may be because
of poor image quality rather than resolution). The degree of
pulmonary hypertension and RV dilation has decreased. The mitral
vegetaiton appears similar.
.
.
EKG: The rhythm appears to be intermittent atrial paced and
sinus but low amplitude wave forms make assessment difficult.
Left bundle-branch block with left axis deviation. Since the
previous tracing of [**2164-6-6**] the rate is slower and ectopy is
absent.
Brief Hospital Course:
This is a 72 year old female with h/o CAD s/p CABG in [**2157**], DM2,
SSS s/p PM/ICD placement in [**2163-6-11**] and dilated cardiomyopathy
who presented to [**Hospital3 **] Hospital on [**6-3**] with fever and
lethargy, found to have vegetations on AICD leads, Mitral valve
and Tricuspid valvee and Enterococcal sepsis, was transfered to
[**Hospital1 18**] [**6-5**] where ICD leads were extracted and IV antibiotics
were initiated for endocarditis. Now discharged to rehab and
planned for completion of 6 week course of antibiotics.
.
#. enterococcal endocarditis with ICD lead + MV + TV
vegetations: Patient presented to OSH with fevers to 102 and
lethargy,Blood cultures revealed entercocci in [**9-17**] bottles as
well as in her urine culture. TTE showed vegetations involving
the AICD leads, likely [**3-14**] enterococci urosepsis. She was
started on vancomycin and ampicillin at the OSH. She was then
transferred to [**Hospital1 18**] on [**6-5**] for AICD lead extraction. Prior to
the procedure, her antibiotic regimen was switched to
ampicillin/gentamicin upon learning the sensitivities of the
organisms from the OSH culture. During the procedure, heavy
vegetations were seen involving the leads as well as the mitral
and tricuspid valves. Once the leads were extracted, great
efforts were made to snare these vegetations via femoral access,
but we were unable to remove them from their location in the
right ventricular cavity. With increased concern for
embolization, she was monitored in the CCU, with continued
airway protection with ET tube as well as central access with a
subclavian line. Due to post-procedure hypotension, her home
anti-hypertensives were discontinued and she was maintained
briefly on a dopamine gtt. Post-procedure TTE confirmed the
location of residual vegetations on tricuspid and mitral valves.
She was extubated without complication the next day, with
mental status intact. Daily surveillance blood cultures were all
negative and her repeat urine culture was negative as well. IV
antibiotic therapy with ampicillin/gentamicin was continued and
planned for a total of 6 weeks. Peak and trough levels of
gentamicin were checked and therapeutic. Her renal function was
monitored closely during this time and worsening renal function
prompted change from gentamycin to ceftriaxone. PICC line was
placed for continued Abx administration, her subclavian line was
pulled after confirmation of this line placement. Patient was
afebrile throughout her [**Hospital1 18**] course accept for a single spike
of fever on [**6-16**] to 100.7. Urine and Bcx remained negative. CXR
was without focal infiltrate. Most recent TTE on [**6-18**] showed
mild-mod MR [**First Name (Titles) 151**] [**Last Name (Titles) 1506**] mitral valve vegetation, vegetation
was no longer seen on the tricuspid valve but this may be
because of poor image quality rather than resolution. There was
moderate TR and moderate pulmonary artery systolic hypertension
and RV dilatation which were improved from [**6-11**] study. Patient
was seen by cardiac surgery who recommended repeating TTE after
completion of Abx course for assessment of need for valve repair
surgery. She will need to have this ECHO done per her outpatient
cardiologist and the report sent with pt to her appt with Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) **].
Patient is discharged on continue ampicillin and ceftriaxone for
total 6 week course, last day [**2164-7-17**].
.
Follow-up Plan:
-- Monitor fever curve and WBC
-- Close follow-up with Dr. [**Last Name (STitle) **] in the [**Hospital1 18**]
Infectious Disease outpatient clinic with weekly CBC w/ diff,
chem 7 (most important BUN,Cr) and LFT's.
-- Continue on ampicillin and ceftriaxone for total of 6 weeks,
last day [**2164-7-17**]
.
# Congestive Heart Failure. Admission TTE with LVEF= 25-30%, 2+
mitral regurgitation, 1+ tricuspid regurgitation. Due to initial
episodes of hypotension diuretic regimen held. On [**6-11**] patient
noted to be dyspneic and tachypneic. CXR consistent with
pulmonary edema with bilateral pleural effusions. Patient was at
that point 4 L positive since admission. Repeat TTE with
worsening valvular function, Moderate to severe [3+] TR. Severe
PA systolic hypertension. Patient aggressively diuresised with
Lasix ggt + daily Metalozone with good result. Patient diuresed
well and at time of transfer saturating 93-97% on 2L. Weight at
time of discharge is 65.7, she appears clinically euvolemic.
Patient was continued on home digoxin, carvedilol. ACEi and
diurises are currently held in the setting of renal failure.
Digoxin was decreased to three times a week because of renal
function. EF at time of discharge is 40%.
OUTPATIENT Follow-up plan:
-- Monitor weights daily, I/O and diurese as needed to maintain
clinical euvolemia.
-- Monitor renal function, restart ACEi when renal function
improves and stabilizes
-- Diuretic regimen at time of discharge: held
.
#. RHYTHM: The patient has a history of sick sinus syndrome,
prompting the original placement EP study in [**2163**] which showed
inducible polymorphic VT. AICD was placed for primary
prevention in the setting of depressed LV function (EF =
25-30%). Recent ICD interrogation did not show life threatening
arythmia in the prior year. Telemetry during her hospital course
showed multiple VPB's and runs of accelerated idioventricular
rythm but no life threatening arrythmias. Patient will require
continued telemetry monitoring while she is at rehab and at
discharge per her outpatient cardiologist. She will see Dr.
[**Last Name (STitle) 75381**] in [**Month (only) **] at which point it will be determined whether
re-implantation of ICD is indicated.
.
Out patient follow up plan
- continue telemetry monitoring
- follow-up with Dr. [**Last Name (STitle) **] on [**2164-8-1**] at 1:40 PM
#. Acute on Chronic renal insufficiency - baseline creatinin
1.2, trended up to peak of 2.4 in the setting of agressive
duresis for heart failure and pulmonary edema. Cr:BUN ratio
changes were consistent with pre-renal etiology evolving to ATN.
There was no periheral eosinophilia. Microscopy of the urine
showed rare muddy-brown cast.Patient was also on gentamycin at
the time, levels were theraputic but as contribution of
gentamycin to ATN could not be ruled out this was switched to
ceftriaxone. Diuresis was held upon achievment of euvolemia,
ACE-I was also held. Creatinin is trending down to 1.6 on day of
discharge.
OUTPATIENT FOLLOW_UP ISSUES:
-- Close monitoring of renal function.
-- please check Cme-7 on [**6-23**].
#. Elevated INR: Patient was not on anticoagulation on
admission, but her INR was 3.0. No evidence of liver injury or
failure at the OSH. Given her improving clinical condition,
this was unlikely to be DIC or acute liver failure. LFTs and
DIC labs were unremarkable. She was given vitamin K with good
result, reversing her INR appropriately for her lead extraction
procedure. INR remained stable throughout remainder of her stay.
#. Normocytic anemia: Hct was stable, without signs of active
bleeding. She was given 2 units of pRBCs prior to the
procedure, with an unimpressive Hct bump. However, her Hct
remained stably low and was followed closely. Fe studies wnl.
HCT did note to trend down on [**4-3**]. Patient transfused with
2u prbc with appopriate bump in HCT to 28. HCT stable prior to
transfer 28.6
#. DM2: Patient takes Amaryl and janumet at home with 20 units
of Glargine at hs, with last HbA1c > 7. Glucose at OSH trended
in 200s-300s in the setting of infection, with initiation of
Lantus to 40 (from 20) units nightly. Peri-procedurally, her
Lantus dosing was decreased to 15 units nightly, but then
increased again to her home dose once she was eating more
consistently. At time of transfer sugars were well controlled on
Lantus 30 units QHS with supplemental ISS. She should be
transitioned back to pills upon discharge.
#. CORONARIES: She is s/p 3-vessel CABG in [**2157**]. She was
otherwise asymptomatic, ruled out for MI at OSH, and was without
EKG changes compared to prior. She was continued on her ASA
325mg and statin.
#. Hyperlipidemia: She was continued on statin, niacin, but her
fenofibrate was held.
#. Hypothyroidism: She was continued on levothyroxine.
.
Medications on Admission:
-Lisinopril 10 mg daily
-Lasix 20 mg daily
-Coreg 6.25 mg [**Hospital1 **]
-Synthroid 150 mcg daily
-Fenofibrate 200 mg daily
-Calcium plus D one tablet [**Hospital1 **] (500/200)
-Niaspan ER 500 mg [**Hospital1 **]
-Digoxin 0.125 mg daily
-ASA 325 mg daily
-glimepiride 4 mg daily
-Lipitor 20 mg daily
-Janumet unknown dose
- Lantus 20 units at bedtime
Discharge Medications:
1. Ampicillin 2 g IV Q6H
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium+D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO twice a day.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. 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.
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO BID (2 times a day).
10. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
12. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
13. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
15. CeftriaXONE 1 gm IV Q12H
16. Outpatient Lab Work
Please check labs weekly starting on [**6-27**], Chem-7, CBC, LFT's
with results faxed to [**Doctor Last Name 2808**] from Infectious Disease at [**Hospital1 18**]
[**Telephone/Fax (1) 1419**]
17. Outpatient Lab Work
Please check chem-7 and CBC tomorrow [**2164-6-23**]
18. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
19. Humalog 100 unit/mL Solution Sig: 0-14 units Subcutaneous
four times a day: check FS before meals and at hs per sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary:
Endocarditis
Infected pacemaker and ICD
Acute Systolic Congestive Heart Failure: EF 40% ACE inhibitor
has been held because of acute kidney injury
Coronary Artery Disease
Acute on Chronic Kidney Injury
.
Diabetes Mellitus
Secondary diagnoses:
Hypothyroidism
Ventricular Tachycardia
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 69742**] it was a pleasure taking care of you.
.
You were admitted to the [**Hospital1 18**] for treatment of infection of
your ICD, pacemaker and heart valves. The pacemaker/ICD was
removed in the operating room and you had some trouble with low
blood pressures, fluid overload and kidney failure. Your blood
pressure is now stable and your kidney function is improving. We
have held some of your medicines and decreased others while your
kidneys are not working well. You were started on IV antibiotics
for a planned 6 week course to treat the infection on your heart
valves. You will need an echocardiogram again after the
antibiotics are finished on [**7-17**]. Please have Dr. [**Last Name (STitle) 89111**]
arrange this (he has been contact[**Name (NI) **]) and you will need
While hospitalized an ultrasound of your heart demonstrated that
your heart was not pumping forward as well as it could and as a
result fluid was pooling in your lungs and extremities. We
placed you on medications to faciliate diuresis. At time of
discharge your breathing was much improved.
.
CHANGES TO YOUR MEDICATIONS
To treat infection:
1. Start taking Ampicillin and Ceftriaxone; plan to complete 6
week course, last day [**7-17**] to treat the infection on your
heart valves
Start taking Gentamycin; plan to complete 6 week course
.
To prevent damage to your kidneys:
2. Stop Lisinopril and Furosemide until kidney function
stabilizes.
3. Decrease Digoxin to three days a week instead of daily until
your kidney function improves.
4. Stop taking fenofibrinate and glimepiride
5. Start taking tylenol as needed for minor pain
6. Start taking Lorazepam as needed for anxiety
7. Increase Vitamin D to 1000u daily
8. STart senna and colace as needed to prevent constipation
9. STop taking glimepiride and Janumet. Continue Glargine
insulin while you are in the rehabilitation at 30 units. You can
restart pills once you are home to control your blood sugar.
.
Again it was a pleasure taking care of you. Please contact with
any questions or concerns.
Followup Instructions:
Cardiologist: Dr. [**Last Name (STitle) 56071**] ([**Telephone/Fax (1) 34149**]): please make a
follow up appt for when you get out of rehabilitation.
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2164-7-12**] at 2:10 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2164-8-3**] at 9:30 AM
With: [**Name6 (MD) 2324**] [**Name8 (MD) 2323**] MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) Basement, [**Hospital1 18**]
Department: CARDIAC SURGERY
When: MONDAY [**2164-7-23**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: CARDIAC SERVICES
When: WEDNESDAY [**2164-8-1**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2164-6-23**]
ICD9 Codes: 5845, 4254, 5990, 2724, 2449, 2749, 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 925
} | Medical Text: Admission Date: [**2105-10-15**] Discharge Date: [**2105-10-22**]
Date of Birth: [**2047-11-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
intubation [**2105-10-17**]
History of Present Illness:
Mr. [**Known lastname **] is a 57 year old RHM with prior L MCA infarct
([**2102**])
and seizure disorder who now presents following a seizure. He
was
at home having coffee with his son this morning when he had
sudden onset right arm rhythmic contractions. He also seemed
disoriented according to his son who brought him to the [**Hospital1 **]
[**Name (NI) 620**] ED where opon pulling into the parking lot the movements
generalized to GTC movements with LOC. He was given 1mg Ativan
IV
which stopped the movements. Head CT performed at [**Location (un) 620**] was
without acute process. Neurology was contact[**Name (NI) **] by the [**Name (NI) 620**] [**Name (NI) **]
attending and he was given an additional 1g Keppra IV, and then
transferred to [**Hospital1 18**] for further care.
.
At present the patient has a productive speech deficit and is
able to appropriately answer yes or no to questions. His naming
is not intact. He reports he does not feel back to his usual
self
(unable to describe further). His speech is worse than usual. He
denies any headache. His right side is more weak than usual. He
denies any bowel or bladder incontinence. No oral trauma.
.
On general review of systems, He denies any recent fevers,
chills, he denies diarrhea or constipation. No cough or SOB. No
chest pain, rashes, arthralgias or myalgias.
Past Medical History:
-Left hemispheric stroke in [**Month (only) **]/[**2102**]
-Epilepsy sinc [**2100**], last seizure was [**8-9**]
-?HTN after the stroke patient has been taken med for high blood
pressure
-Dyslipidemia
-Two cataract surgery.
-Left hemispheric stroke in [**Month (only) **]/[**2102**]
-Epilepsy sinc [**2100**], last seizure was [**8-9**]
-?HTN after the stroke patient has been taken med for high blood
pressure
-Dyslipidemia
-Two cataract surgery.
Social History:
Widower. Has a son. Since stroke can not do ADLs. Heavy alcohol
use until stroke. +tobacco use.
Family History:
non-contributory
Physical Exam:
Exam on Admission:
Vitals: T 97, BP 156/78, HR 90, R 14, 98% RA
Gen- well appearing on gurney in the ED, NAD
HEENT: NCAT, MMM, anicteric, OP clear
Neck- no carotid bruits, no nuchal rigidity.
CV- RRR, no MRG
Pulm- soft crackles at bases bilat.
Abd- soft, nt, nd, BS+
Extrem- no CCE
.
Neurologic Exam:
MS- eyes open, attends examiner, appropriately answers yes or no
questions. He follows all axial and appendicular commands. Dense
anomia- attempting to say the words, but visibly frustrated with
inability to do so. No evidence of apraxia. No neglect.
.
CN- PERRL 3-->2mm, could not visualize fundi, EOMI no nystagmus,
face appears symmetric with symm strength, palate elevates symm,
hearing intact to FR bilat, SCM and trap full strength, tongue
protrudes at the midline.
.
Motor- right arm > leg hemiparesis. R hand flexor contracture.
No
adventitious movements noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 5- 5 5 5 5 5
R 3 4 3 3 4 3 3 3 - - 4 4 4
.
Sensory- + sensory neglect of right side to DSS. detailed
sensory
exam was limited d/t productive speech deficit.
.
Coordination- unable to perform FNF or HKS on right.
.
Reflexes: 3+ on right [**Hospital1 **], tri, brachiorad, patellar. 2+ right
achilles. 2+ left [**Hospital1 **], tri, brachiorad, patellar.
.
right great toe upgoing, left downgoing.
.
Gait testing deferred given marked R hemiparesis.
Pertinent Results:
[**2105-10-16**] 05:50AM BLOOD WBC-17.6* RBC-4.72 Hgb-14.6 Hct-40.3
MCV-85 MCH-31.0 MCHC-36.3* RDW-14.0 Plt Ct-272
[**2105-10-16**] 05:50AM BLOOD Neuts-84.2* Lymphs-8.6* Monos-6.6 Eos-0.2
Baso-0.5
[**2105-10-16**] 05:50AM BLOOD Glucose-90 UreaN-10 Creat-0.6 Na-138
K-3.3 Cl-96 HCO3-29 AnGap-16
[**2105-10-17**] 06:45AM BLOOD ALT-24 AST-22 AlkPhos-88 TotBili-0.8
DirBili-0.3 IndBili-0.5
[**2105-10-17**] 09:31AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2105-10-17**] 06:45AM BLOOD TotProt-6.6 Albumin-4.3 Globuln-2.3
Calcium-9.3 Phos-4.0 Mg-2.1
[**2105-10-20**] 02:32AM BLOOD Triglyc-144
.
[**2105-10-17**] Sputum Culture: E. Coli
.
EEG [**2105-10-15**]: IMPRESSION: Markedly abnormal EEG due to the
prominent slowing broadly over the left hemisphere with very
frequent epileptiform sharp wave discharges in the
parieto-temporal region, recurring every one to two seconds for
much of the record though less as time went on. In the
early portions of the record this appeared most suggestive of
PLEDs
(periodic lateralized epileptiform discharges), usually a sign
of an
acute lesion with epileptogenic potential. No faster rhythms
suggestive
of ongoing seizures were evident. The background appeared better
on the
right though it was frequently disrupted or disorganized
.
CTA [**2105-10-17**]: IMPRESSION:
1. No Pulmonry Embolus.
2. Left lower lobe complete atelectasis with mucous plugging of
the airways.
3. Right upper lobe and basilar atelectasis.
.
Transthoracic Echo [**2105-10-22**]: The left atrium is dilated. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2105-8-31**], the left ventricle is now small and
hyperdynamic.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted with status epilepticus. His Keppra
dose was initially increased and he was given Ativan for his
seizures. The Keppra was then changed to Trilptal and he was
loaded with Depakote. He was then started on a Propofol drip.
On the morning of [**2105-10-17**] he experienced and episode of
hypoxia. He was intubated after a likely aspiration event. He
transferred to the medicine service for further management of
his seizures and aspiration. His respiratory distress was
likely secondary to aspiration from sedation as he had received
large amounts of ativan. He had a CTA which was negative for PE
and cardiac enzymes were negative suggesting this was not an MI.
He was started initially on Vancomycin, Ceftriaxone and Flagyl
for his aspiration pneumonia. This was changed to Vancomycin
and Unasyn on [**2105-10-18**].
On [**2105-10-19**], Acyclovir was added for possible HSV encephalitis.
.
For his seizures, his propofol was increased in order to
suppress seizure activity as recommended by the neurology team.
He was started on Levophed for hypotension. He continued to
have frequent seizure activity as monitored by his continuous
EEGs. He was loaded with Dilantin on [**2105-10-20**]. An LP was
attempted on [**2105-10-18**] by the medicine team and was unsuccessful.
An LP was attempted on [**2105-10-20**] by the Neurology team and was
unsuccessful. His antibiotics were changed to include bacterial
meningitis coverage with Vancomycin, Ceftriaxone and Ampicillin.
.
In the early morning of [**2105-10-22**], his telemetry [**Location (un) 1131**] changed.
A 12-lead ECG showed an abnormal appearing QRS. The rhythm was
regular without clear p waves and there were diffuse ST
depressions in V2-V6 with ST elevations in leads II and AVL. 2
gm of magnesium were given. An ABG with calcium was checked and
the ionized calcium was normal. Cardiology was consulted for
aid in evaluation and management of changes in the ECG. Over
the course of that morning, his propofol was decreased as was
recommended by neurology. His levophed requirements continued
to increase and he was persistently hypotensive. An echo was
checked and showed a small, hyperdynamic LV. At 1pm, the
patient was noted to be markedly hypotensive. He was started on
a second and then third pressor. He then lost a pulse. A code
blue was initiated. After 30 minutes of resuscitative efforts
the patient was still in asystolic and was pronounced dead at
1:42pm.
Medications on Admission:
asa 81mg
keppra 2000mg IV q12hr
Lorazepam 1 mg IV Q4H:PRN seizure > 5min Seizure > 5min or more
than 2 seizures in 30min.
Lorazepam 1 mg IV Q6H
Oxcarbazepine 600 mg PO BID - not getting b/c no NGT in place
Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation
Simvastatin 80 mg PO DAILY Order
Fludrocortisone Acetate 0.1 mg PO DAILY
Heparin 5000 UNIT SC TID
Valproate Sodium 500 mg IV 12hr
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
1. Status Epilepticus
.
Secondary Diagnoses:
2. Aspiration Pneumonia
3. prior L MCA stroke
Discharge Condition:
pt expired
Discharge Instructions:
pt expired
Followup Instructions:
pt expired
ICD9 Codes: 5070, 5180, 4019, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 926
} | Medical Text: Admission Date: [**2146-5-24**] Discharge Date: [**2146-6-1**]
Date of Birth: [**2081-3-30**] Sex: M
Service: Cardiology
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 7053**] is a 65-year-old
diabetic male who was referred for cardiac catheterization
following a positive stress test.
He had an episode of chest tightness while at work sitting at
his desk approximately one month ago. It lasted for about 10
minutes and resolved after he took aspirin and Tums. He has
not had any further chest pain but has had some left hand
tingling each night while lying in bed. He also has had some
shortness of breath after climbing two flights of stairs.
He went to go see his local cardiologist and was referred for
a stress test. This test had to be stopped prematurely due
to fatigue and marked dyspnea in addition to chest pain. He
did become hypertensive during his stress test and had
electrocardiogram changes that were suggestive, but not
diagnostic, in the lateral leads and was hence referred for
cardiac catheterization.
He denies any claudication, orthopnea, edema, paroxysmal
nocturnal dyspnea, or lightheadedness.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Insulin-requiring adult-onset diabetes mellitus.
3. Arthritis.
PAST SURGICAL HISTORY: Past surgical history was negative.
ALLERGIES: He is allergic to CELEBREX.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Glucophage 850 mg p.o. b.i.d.
3. Glyburide 2.5 mg p.o. q.d.
4. NPH 20 to 25 units subcutaneous q.h.s.
5. Zestril 10 mg p.o. q.d.
PERTINENT LABORATORY DATA ON PRESENTATION: Admission
laboratories revealed his white blood cell count was 8.4,
hematocrit was 31.6, platelets were 236. Blood urea nitrogen
and creatinine were 19 and 1. Potassium was 4.7.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination his heart rate was 60, his blood pressure
was 160/70. His neck was without bruits. His heart had a
regular rate and rhythm without murmurs. The lungs were
clear to auscultation bilaterally. The abdomen was obese
with no palpable masses. His extremities demonstrated no
varicosities and had normal pulses.
HOSPITAL COURSE: The patient was admitted for an inpatient
cardiac catheterization on [**2146-5-24**]. This was
significant for multiple vessel disease including a long
proximal severe narrowing of the left anterior descending
artery and a long severe stenosis of the diagonal. In
addition, he had a 60% lesion in his right coronary artery
and another 60% lesion in his posterior descending artery.
Due to the distribution of the patient's disease, it was felt
that he was a candidate for cardiac surgery. Six hours
following his catheterization, a heparin drip was started.
In addition, Cardiac Surgery was consulted.
The following day, he was taken to the operating room.
There, he had coronary artery bypass graft times three. His
grafts were left internal mammary artery to left anterior
descending artery, saphenous vein graft to left anterior
descending artery first diagonal (?), and saphenous vein
graft to distal right coronary artery.
The patient's procedure itself was unremarkable.
Postoperatively, he was taken intubated to the Cardiac
Surgery Intensive Care Unit. He was atrially paced with
Neo-Synephrine and propofol drips. That evening, he was kept
on a ventilator with his Neo-Synephrine running at a lower
rate. Later that day, he was extubated without incident and
was subsequently weaned off his Neo-Synephrine.
By the second postoperative day, his chest tube was
discontinued, and he was transferred to the floor.
On the floor, the patient had an unremarkable
hospitalization. All of his diabetes medications were
restarted. His Foley catheter was discontinued, and his
pacing wires were removed. The patient was a bit slow to
progress with his ambulation and required more diuresis than
is typical.
By the fifth postoperative day, he was finally weaned off of
his oxygen and was ambulating adequately in the hallway.
However, he had a rise in his white blood cell count from
9000 to 14,000. For this reason, he had a urinalysis that
was sent that was negative for signs of infection. By the
following day, his white blood cell count had normalized
to 10,000. For this reason, we believed that he was safe to
be discharged home.
Finally, he had some very mild hyperkalemia with a potassium
of approximately of 5 to 5.2 despite his Lasix therapy. His
potassium repletion was held for two days, and the decision
was made to continue to replete him as an outpatient but at a
lower dose. He will have visiting nurse assistance to draw
potassium in two days and telephone the results to his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. His telephone number is
[**Telephone/Fax (1) 13687**].
DISCHARGE STATUS: The patient was discharged to home.
MEDICATIONS ON DISCHARGE:
1. Glyburide 2.5 mg p.o. q.d.
2. Enteric-coated aspirin 325 mg p.o. q.d.
3. Glucophage 850 mg p.o. b.i.d.
4. NPH 20 units subcutaneous q.h.s.
5. Lopressor 25 mg p.o. b.i.d.
6. Lasix 20 mg p.o. b.i.d. (times seven days).
7. Potassium chloride 20 mEq p.o. q.d. (times seven days).
8. Colace 100 mg p.o. b.i.d.
9. Percocet 5/325 one to two tablets p.o. q.4-6h. p.r.n.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**First Name (STitle) **] in approximately two weeks. In addition, he was to
follow up with Dr. [**Last Name (STitle) 70**] in six weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; now status post coronary artery
bypass graft times three.
2. Adult-onset diabetes mellitus, insulin-requiring and
controlled.
3. Hypertension.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2146-6-1**] 12:06
T: [**2146-6-4**] 06:32
JOB#: [**Job Number 42570**]
ICD9 Codes: 4111, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 927
} | Medical Text: Admission Date: [**2161-2-13**] Discharge Date: [**2161-3-5**]
Date of Birth: [**2104-8-2**] Sex: M
Service: NEUROLOGY
Allergies:
Alcohol
Attending:[**Doctor Last Name 15044**]
Chief Complaint:
referred to ED for DVT, admitted for fever
Major Surgical or Invasive Procedure:
intubation, extubation, lumbar puncure
History of Present Illness:
56-year-old male with metastatic rectal cancer with ongoing
chemo--C6D15 of FOLFOX on [**2161-2-2**]--s/p brain radiation, s/p
resection in [**9-/2158**], presented with an alleged thrombus in right
common iliac vein seen on routine staging CT. He was referred to
the ED by his outpatient oncologist.
Patient reports no symptoms at home--no respiratory difficulty,
no leg swelling or warmth or swelling--besides his mild fatigue
that has been going on for months. A few days ago he had a fever
that then spontaneously resolved. No coughs, no dysuria. No sick
contact. [**Name (NI) **] chills, headache, visual changes, chest pain,
shortness of breath, abdominal pain, diarrhea, constipation,
weakness, numbness, tingling.
In the ED, initial vitals were T 99.8, HR 87, BP 121/76, RR 16,
100%RA. Exam was unremarkable. LENIS were negative. He was about
to be discharged when he spiked a fever to 102F. WBC was 10.5
with 16% bands--patient received Neulasta on [**2161-2-5**] and had 24%
bands last week. CXR, urinalysis was unremarkable. Received
vanco and cefepime in the ED. Admitted for further management.
Past Medical History:
Rectal adenocarcinoma:
- diagnosed in [**2158**]
- neoadjuvant capacitabine and radiation from mid-[**5-15**] to
[**2158-7-6**] by [**First Name8 (NamePattern2) 324**] [**Last Name (NamePattern1) **], M.D., followed by surgical
resection and a colostomy; completed 4 cycles of adjuvant
capacitabine on [**2159-1-28**]
- chest CT on [**2160-5-26**] showed pulmonary metastases, and a right
lung biopsy showed adenocarcinoma, treated with bevacizumab
and FOLFOX since [**2160-9-8**]
- headache in summer [**2160**], head CT and MRI on [**2160-9-16**] disclosed
a 2-3 cm mass in the right cerebellum, resected by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
on [**2160-9-17**], followed by Cyberknife radiosurgery to the
resection cavity on [**2160-10-10**]
Social History:
Cantonese-speaking. He is married. Lives with wife and son in
[**Name (NI) **].
He does understand some english, speaks little english.
Family History:
non-contributory
Physical Exam:
Gen: middle-aged Chinese man in no acute distress
HEENT: EOMI, PERRL, sclerae anicteric, OP moist without lesion
Neck: supple, no LAD
Lungs: CTAB
CV: normal rate, regular rhythm, normal S1/S2, no m/r/g
Abd: soft, nontender, nondistended, BS present
Ext: no swelling, no warmth, no tenderness, 2+ bilateral pedal
pulses
Neurological exam on first evaluation by neurology team [**2161-2-15**]:
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty (via interpreter on telephone). Language is
fluent with intact repetition and comprehension. Normal
prosody.
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Full strength of neck flexors and extensors.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Decreased proprioception at toes bilaterally and
decreased vibration (5-6 seconds). Patient reported pinprick
intact throughout.
-DTRs: 1+ at biceps, triceps, brachioradialis, 0 at patellars
and
achilles bilaterally. However, patient was unable to relax legs
appropriately for testing despite repeated attempts.
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. No truncal ataxia.
-Gait: Good intiation. Wide-based, unsteady. Short stride.
Falls in all directions. Romberg positive.
[**2-18**] Neurological exam:
awake, alert, appears ill. His RR is 22-24, and
his SaO2 is 100%. Speech is fluent. PERRL 3->2 mm bilaterally,
EOMI bilaterally without nystagmus, bifacial weakness, palate
elevates symmetrically, tongue midline movements intact.
He reports feeling diffusely weak, with some giveway weakness
and
other real weakness. He can keep his bilateral arms lifted above
gravity, but both drift down to the bed. No myoclonus or tremor.
Decreased pinprick sensation in his bilateral legs to [**1-10**] way up
the lower leg, normal in the bilateral hands. Trace reflexes in
the bilateral brachioradialis, otherwise 0 and symmetric in the
biceps, triceps, knees, and ankles.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE IP H Q DF
R 4- 4 5- 4- 3+ 3- 3+ 5 3-
L 4- 4 5- 4- 3+ 3- 3+ 5 3-
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - -
Neurological exam at time of discharge:
Cognitively intact, no limitations
Mild bifacial weakness, L>R, otherwise cranial nerves normal
Reflexes diffusely absent
Strength: at least [**3-13**] in all muscle groups. Deltoids, Biceps,
Triceps, gastrocs are 4+ to 5-, some effort dependence
Pertinent Results:
[**2161-2-13**] 04:55PM WBC-10.5# RBC-3.84* HGB-11.9* HCT-35.7*
MCV-93 MCH-31.0 MCHC-33.4 RDW-16.4*
[**2161-2-13**] 04:55PM NEUTS-51 BANDS-16* LYMPHS-14* MONOS-9 EOS-0
BASOS-0 ATYPS-2* METAS-2* MYELOS-5* PROMYELO-1*
[**2161-2-13**] 04:55PM PLT SMR-LOW PLT COUNT-142*
[**2161-2-13**] 04:55PM PT-12.1 PTT-27.4 INR(PT)-1.0
[**2161-2-13**] 04:55PM GLUCOSE-151* UREA N-7 CREAT-1.2 SODIUM-140
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
IMAGING STUDIES:
# LENIS [**2161-2-13**]: no DVT
# Head CT [**2161-2-13**]: There has been previous right occipital
craniectomy
with slight interval increase in hypodensity within the
cerebellar resection bed. There is no hemorrhage, mass effect,
shift of midline structures, or evidence of major vascular
territorial infarction. Unchanged bilateral basal ganglia
calcifications. There is mild right maxillary sinus mucosal
thickening
(3:2).
IMPRESSION:
1. No hemorrhage or mass effect.
2. Apparent increase in hypodensity at right occipital
craniectomy site. MRI
w/ gadolinium recommended to evaluate for tumor recurrence.
# CXR [**2161-2-13**]: (prelim) no acute cardiopulmonary process
# MRI spine [**2161-2-15**]: Evaluation of the cervical spine
demonstrates no evidence for osseous metastatic disease.
Multilevel spondylosis is seen including a disc osteophyte
complex at C5/C6
and C6/C7. There is also a left paracentral disc protrusion
which is
broad-based at C6/C7 extending into the foramen. There is
moderate stenosis
at these two levels.
There is a small nonspecific lesion in the right thyroid lobe
measuring
approximately 7 mm.
There is no epidural disease seen.
Evaluation of the thoracic and lumbar spine demonstrates mild
marrow
hypointensity. There is high signal within the sacrum which may
be related to prior radiation to the rectum. No convincing
evidence for epidural or
intradural metastatic disease is seen. There is a central to
left paracentral disc protrusion at L4-L5 causing left lateral
recess narrowing and then abutting the left L5 nerve root.
There is heterogeneous appearance to the iliac wings bilaterally
which again may be related to prior radiation.
The pre- and para-vertebral soft tissues are unremarkable.
IMPRESSION:
No evidence for metastatic disease.
Degenerative changes in the cervical and lumbar spine as
detailed. Probable
post-radiation sequela in the sacrum.
EMG: Clinical Interpretation: Abnormal study. The
electrophysiologic abnormalities are most consistent with a
moderate generalized neuropathy with demyelinating and axonal
features. The sural nerve is spared. Given the time course of
progression, the findings are consistent with an acquired
neuropathy such as [**First Name9 (NamePattern2) 7816**] [**Location (un) **] syndrome. The low amplitude
motor responses may or may not be due to axonal involvement; a
follow-up study would clarify the extent of axonal involvement
if indicated.
PRIOR STUDIES:
# Torso CT [**2161-2-12**]:
1. New DVT in the R common iliac v, appears to emanating from
the R internal iliac v. The thrombosis extends to near the
confluence of the common iliac. Recommend urgent DVT ultrasound
in the lower extremities.
2. Interval decrease of lung disease burden. Decrease of
mediastinal and hilar LAD.
3. Post-radiation changes in the perirectal region. No bowel
obstruction.
Brief Hospital Course:
56M with rectal carcinoma s/p resection, chemoradiation who was
referred to ED for R common iliac DVT and was found to be
febrile. He was treated with Lovenox, empiric antibiotics,
however developed progressive weakness initially concerning for
spinal cord compression (MRI pan spine showed no cord
compression, while MRI of head showed a stable cerebellar
herniation through craniotomy site without evidence of
infection). His exam progressed to bilateral leg weakness,
worsened bilateral hand and lower leg numbness, tongue numbness,
and dysphagia to liquids and solids and patient developed
progressive loss of reflexes. He underwent LP and was diagnosed
with GBS. He was transferred from Medicine Service to Neurology
Service on [**2161-2-22**].
# GBS
Patient with ascending weakness, loss of reflexes and CSF with
albuninocytologic dissociation. His NIF and vital capacity
apparently declined while in medical ICU and he was intubated on
[**2161-2-20**] based on above and in setting of tachypnea. Completed 4
days of IVIG on [**2161-2-21**]. His strength slowly improved, however
there remained mild assymetry of L > R weakness (including face)
as well as more proximal vs. distal weakness. He has made
steady improvement throughout his recovery phase, and is at
least antigravity strength in all muscle groups at the time of
discharge.
# Weakness and parathesias: Overnight [**2-14**] patient developed
neurologic sxs concerning for cord compression of the low
cervical or high thoracic vertabrae, however normal spinal MRI
without compression. [**Month (only) 116**] also be complicated by cerebellar mets
and chemo induced neuropathy. Neurology and neurosurgery
followed the patient and he was maintained on standing
dexamethasone which was subsequently discontinued given negative
imaging. He failed a speech and swallow and was determined to be
likely aspirating on [**2-17**] so was changed to Levo/Flagyll. He
subsequently proved to have steadily improving oropharyngeal
control, and was taking all calories PO at the time of
discharge.
Of note, at admission the patient did have diarrhea, though he
was camplobacter negative. Also on [**2-18**] the patient developed
dyspnea with a RR to the low 20s and maintance of oxygen
saturation in the 90s on RA. He developed urinary retention
(bladder scan with 500cc) though also may have been holding in
his urine due to physical difficulty using urinal. He developed
difficulty managing his secretions with NIFs -20 to -30 and was
then transferred to the ICU.
A bedside LP was attempted on [**2-17**] and was unsuccessful. On [**2-18**]
the patient had an IR guided LP revealing elevated protein with
1 WBCs. A diagnosis of GBS was made based on progressive
weakness and loss of reflexes (see above for GBS management).
# DVT: R common iliac thrombus seen on outpatient CT. LENIS
showed no lower clot. Enoxaprin was initially started and then
held starting [**2-16**] for an LP. He was switched to Heparin SC TID
during that interval and changed back to Lovenox on [**2-18**]. He
continues on treatment doses of Lovenox.
# Fever: Given recent chemotherapy, was initially concerning for
infection. However, patient was not neutropenic. Bandemia
reflects recent Neulasta administration. No evidence of sepsis.
CXR, u/a, UCx were unremarkable. Fever might also be related to
DVT or chemo itself. At admission patient was maintained on
Cefepime/Vanc. After switch to Levofloxacin he spiked and was
thus changed back to Cefepime/Vanc before being changed to
Levo/Flagyll as above with plan to continue for 7 days.
Following completion of this course he remained fever-free.
All of infectious evaluations proved to be unrevealing including
BCx, UCx, Stool Cx, C.diff Assay, Legionella antigen, sputum and
BAL washings. Antibiotics were thus discontinued on [**2-22**]. He
continued to have intermittent low grade fevers (101F) which
were attributed to DVT.
# Rectal cancer: No intervention done this admission. Patient
should follow up with Dr.[**Name (NI) **] office one month
following discharge from the hospital. This appointment has
already been made.
# elevated blood glucose: Hemoglobin A1C of 6.5 suggests glucose
intolerance. He was maintained on an insulin sliding scale. It
is suggested that Metformin be started discharge.
# FULL CODE (confirmed with interpreter at admission) and
confirmed with Dr. [**First Name (STitle) **] (outpatient oncologist)
Medications on Admission:
ranitidine 150 mg [**Hospital1 **]
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe [**Hospital1 **]: 0.7 ml Subcutaneous Q12H
(every 12 hours).
2. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**1-10**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
3. Senna 8.6 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Acetaminophen 650 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every four
(4) hours as needed for fever or pain.
6. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
7. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
8. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: [**First Name9 (NamePattern2) 30065**] [**Location (un) **] syndome
Secondary: Pelvic DVT
Additional: Rectal adenocarcinoma, metastases to the cerebellum
s/p resection.
Discharge Condition:
Mental status - intact
Strength - diffusely weak, distal > proximal. At least [**3-13**] in
all muscle groups, with scattered 4/5s in bilateral
[**Hospital1 **]/tri/gastrocs. Near-daily improvement in exam throughout his
recovery period. Reflexes diffusely absent
Sensory - intact to fine touch, position, temperature.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a clot in your left leg and
fevers. You were evaluated for multiple causes of the fever,
but they were negative. You were temporarily treated with
antibiotics, but in the end were treated for the blood clot with
a blood thinner.
You also developed progressive weakness in your arms and legs,
and difficulty swallowing, and were diagnosed with [**Last Name (un) 30836**]
[**Location (un) **] syndrome (also known by the acronym AIDP). For this you
were treated with IVIG (immunoglobulin) and required temporary
intubation (breathing tube to make sure you do not suffocate).
Your weakness improved somewhat, but will likely require several
weeks (perhaps as long as 12 weeks) to return to normal.
In addition, while at the hospital, you were found to have
signficantly elevated blood sugars. This may be related to
stress or an underlying early diabetes. You should follow up
with your primary care doctor regarding this.
Please follow up with all of your appointments.
Should you develop any symptoms concerning to you or some of the
listed below, please call your doctor or go to the emergency
room.
Followup Instructions:
NEUROLOGY: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**3-25**] at 2pm. [**Location (un) 8661**] Building,
[**Location (un) **], [**Hospital1 18**] [**Hospital Ward Name 516**]. Call ([**Telephone/Fax (1) 1703**] with any
questions.
ONCOLOGY: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] on
[**4-1**], 3:30pm. Call ([**Telephone/Fax (1) 694**] with any questions.
PCP: [**Name10 (NameIs) **] your PCP within [**Name Initial (PRE) **] week of discharge from rehab to
review the many changes to your medical care over the last few
weeks.
Completed by:[**2161-3-5**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 928
} | Medical Text: Admission Date: [**2112-7-6**] Discharge Date: [**2112-7-15**]
Date of Birth: [**2112-7-6**] Sex: M
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 10208**] was delivered at
37-6/7 weeks weighing 3010 g and was admitted to Neonatal
Intensive Care Unit from Labor and Delivery for respiratory
blood group, antibody negative, received RhoGAM at 20 and 28
weeks, hepatitis B surface antigen negative, rapid plasma reagin
nonreactive, Rubella immune, afebrile, with rupture of membranes
seven hours prior to delivery. She had chronic abruption
observed in house early in her pregnancy.
Spontaneous vaginal delivery . Apgar scores were 8 and 9. He
received blow-by oxygen only. He was transferred to the Newborn
episode in the newborn nursery at about 3 hours of life.
Measurements revealed birthweight 3010 g (which was the 50th
percentile), length of 50 cm (which was the 75th percentile), and
a head circumference of 33.5 (which was also the 50th
percentile).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed a pale, pink, nondysmorphic male with palate intact.
Bilaterally equal breath sounds. No murmur. In respiratory
distress. The abdomen was soft and nontender with a 3-vessel
cord. No hepatosplenomegaly. Back and spine were normal.
Hips were stable. Red reflex was present. Anterior fontanel
was open and flat and molding of the head was also noted.
The child was placed on CPAP for respiratory support. He also
received a bolus of IV normal saline for poor perfusion.
HOSPITAL COURSE:
1. RESPIRATORY: Intubated after around 12 hours of
life and received one dose of surfactant for persistent
respiratory distress and oxygen requirement, self- extubated
within the next 12 hours and remained on CPAP since then. He was
taken off CPAP to nasal cannula on [**7-11**]. He remained
intermittently tachypneic and on nasal cannula oxygen until [**7-13**]. By [**7-14**] he was oxygenating well in room air except with
bottle feeding. Spent 24 hours nursing exclusively with no
desaturations prior to discharge.
2. CARDIOVASCULAR: No murmurs. No issues. Blood pressure
was stable.
3. FLUIDS/ELECTROLYTES/NUTRITION: He was initially started
on D-10-W at 60 cc/kilo per day, and the first set of
electrolytes were sodium of 143, potassium of 3.6, chloride
of 107, and bicarbonate of 22. Feedings advanced once
respiratory status stabilized. Difficulty oxygenating with
bottle feeds prior to discharge as noted above. Currently, he is
breast feeding ad lib; parents counseled re: feeding cues,
expected frequency/duration of feeds, signs of milk transfer.
Discharge weight 2835 g (4.5% below birthweight).
4. INFECTIOUS DISEASE: He received ampicillin and
gentamicin for seven days based on respiratory distress and
prolonged distress, presumed pneumonia. The complete blood count
showed a white blood cell count of 17.9 (73 neutrophils and 2
bands). Blood cultures remained negative.
5. GASTROINTESTINAL: He is on full feeds and tolerating
them. No abdominal distention. Blood sugar has been stable.
The initial bilirubin was 6/0.3 on day two, peaked at
15.8/0.9 on day five and responded well to phototherapy, down to
9.7/0.7 day six at which time lights were discontinued with a
rebound of 7.6/0.4 on day seven. His blood group was A negative,
and Coombs was negative.
6. NEUROLOGICAL: No issues.
7. HEMATOLOGY: His initial hematocrit was 51, and a
platelet count of 299. WBC diff as noted above. Pink and well
perfused at discharge.
8. GENITOURINARY: Underwent circumcision [**7-14**] with subsequent
suture placement by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] for persistent bleeding a
few hours later. Wound/suture site is clear without sign of
infection or bleeding at discharge.
Passed hearing screen in both ears. Passed car seat test.
Received hepatitis B vaccine [**2112-7-14**]. State screen sent per
routine.
Discharged home in stable condition with parents, to follow up
with primary pediatrician Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3450**] in [**Location (un) **] on [**2112-7-16**] at
10am.
Discharge diagnoses:
1. Respiratory distress syndrome, resolved.
2. Presumed pneumonia, resolved.
3. Status post sepsis evaluation with negative blood cultures.
4. Exaggerated physiologic hyperbilirubinemia, resolved.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] 50-563
Dictated By:[**Name8 (MD) 42804**]
MEDQUIST36
D: [**2112-7-12**] 16:35
T: [**2112-7-12**] 16:39
JOB#: [**Job Number 42805**]
ICD9 Codes: 769, 486, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 929
} | Medical Text: Admission Date: [**2115-2-1**] Discharge Date: [**2115-2-6**]
Date of Birth: [**2056-4-16**] Sex: M
Service: Medicine
The patient is a 58-year-old male with a history of COPD on
home oxygen, diastolic dysfunction, obesity, type 2 diabetes,
who presented on [**2115-2-1**], to the emergency department
complaining of one days duration of shortness of breath. His
ABG on 6 liters was pH 7.24, pCO2 114, pO2 123. The patient
states that his shortness of breath is above his baseline,
reports exercise intolerance, chest tightness, denies fevers
and chills, denies upper respiratory symptoms. He complains
of chronic cough with scant sputum production.
PAST MEDICAL HISTORY:
1. COPD on 3 liters home oxygen. Pulmonary function test in
[**Month (only) 359**] showed FVC of 1.7 liters (39%), FEV1 0.5%, which is
18% of predicted, ratio of FEV1 to FVC is 45% of predicted.
2. Diastolic dysfunction, ejection fraction 55%.
3. Obesity.
4. Diabetes.
5. Diverticulosis.
6. C6-C7 disc herniation.
7. History of thrombocytopenia on heparin with negative
heparin dependent antibodies.
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS: Atrovent 2 puffs inhaler q.i.d.,
Prilosec 20 b.i.d., albuterol 4 puffs inhaler q.i.d.,
Serevent 2 puffs inhaler b.i.d., Flovent 4 puffs inhaler
b.i.d., Combivent p.r.n., Norvasc 5 mg p.o. q.d., Metformin.
SOCIAL HISTORY: Lives with wife and two children. Positive
smoking 160 pack year, currently smokes one pack a day.
Heavy alcohol use in the past, none in 5 years. No history
of DTs.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.8, pulse
116, blood pressure 136/86, respirations 20, 86% on 6 liters.
General - elderly appearing man in mild respiratory distress.
HEENT - clear oropharynx, moist mucous membranes. Neck - no
lymphadenopathy. Lungs - decreased breath sounds and
decreased respiratory effort bilaterally. Heart -
tachycardiac, regular rate and no murmurs, rubs or gallops.
Abdomen is soft, distended, positive bowel sounds, no
tenderness. Extremities - 1+ pitting edema.
LABS ON ADMISSION: White count 10, hematocrit 34.8,
platelets 196, sodium 142, potassium 4.7, chloride 95, bicarb
44, BUN 18, creatinine 0.6, glucose 201. ABG on 6 liters pH
7.23, pCO2 114, pO2 123. Chest x-ray shows mild CHF. EKG
normal sinus rhythm at 120 beats per minute, no apparent
ischemia.
HOSPITAL COURSE:
1. Respiratory distress: The patient was initially admitted
to the medical intensive care unit for Bi-PAP. The patient
initially refused Bi-PAP on the following morning, house
officer was notified that the patient was somnolent and
nonresponsive. The patient was subsequently intubated for
hypercarbic respiratory failure. The patient was started on
azithromycin and prednisone 60 mg p.o. b.i.d. The patient
was diuresed with Lasix and had one liter of fluid out on day
one. The next day the patient extubated himself and his
repeat ABG was pH 7.45, pCO2 58, pO2 62 on three liters nasal
cannula. The patient showed no signs of respiratory distress
and was subsequently transferred to one of the general
medical teams. The patient continued having respiratory
status at baseline. His prednisone was continued at 60 mg
p.o. b.i.d. The patient received nebulized treatments as
well as his regular inhalers and finished a three day course
of azithromycin. His respiratory function appeared to be at
baseline. The patient reported shortness of breath only with
exertion. The patient was subsequently discharged with a
prednisone taper and close outpatient follow up.
2. Diastolic dysfunction, likely secondary to a combination
of COPD and obstructive sleep apnea. A trial of CPAP was
offered to the patient, however, the patient refused and it
is recommended that the patient have an outpatient sleep
study due to likely diagnosis of obstructive sleep apnea.
3. Diabetes. The patient's finger stick blood sugars were
somewhat elevated in the range of 200 to 300 secondary to
prednisone. The patient was continued on his regular dose of
Metformin and was covered with regular insulin sliding scale.
4. Neurologically the patient was put on CIWA protocol, but
has not required any Valium and did not show any signs of
alcohol withdraw.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. COPD with acute exacerbation, status post intubation for
hypercarbic respiratory failure.
2. Type 2 diabetes.
3. Hypertension.
4. Obesity.
5. Smoking.
DISCHARGE MEDICATIONS: Prednisone taper, the patient is to
take 60 mg of prednisone q.d. for one more day followed by 40
mg of prednisone q.d. x3 days, 30 mg q.d. x3 days, 20 mg q.d.
x3 days, 1 mg q.d. x3 days and then stop. No other changes
in his medications were made.
FOLLOW UP PLANS: The patient is to follow up with his
primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1391**] within 1 to 2 weeks after
the hospitalization while still on prednisone taper.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], MD
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2115-2-6**] 11:42
T: [**2115-2-11**] 13:57
JOB#: [**Job Number 109511**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 930
} | Medical Text: Admission Date: [**2127-11-20**] Discharge Date: [**2127-12-2**]
Date of Birth: [**2057-9-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
70 year old white male with chest pain.
Major Surgical or Invasive Procedure:
Cardiac catheterization
CABGx4(LIMA->LAD, SVG->OM, PDA, PLV)[**2127-11-24**]
LUE partial fasciotomy [**2127-11-24**]
History of Present Illness:
Thiw 70 year old male with DM type 2 on insulin, HTN,
hyperlipidemia, prior tobacco use and stable exertional angina
for many years developed pain similar to his typical angina
while undergoing a knee MRI. He took a nitroglycerin and the
pain didnt resolve, it was sub sternal, radiating up to his
neck, accompanied by diaphoresis. He was taken to he ED where
he was found to have inferior ST depressions and mild 1mm
anterior ST changes in v1-2. He received heparin, IIb/IIIa
inhibitor, ASA, and beta blocker and his chest pain resolved for
one hour. He was transferred to [**Hospital1 18**] for urgent cardiac
catheterization and management of NSTEMI. CXR at OSH also
showed pulmonary edema. He required treatment with IV Lasix for
low o2 sats.
Past Medical History:
1. Diabetes Melitis type 2
2. HTN
3. Hyperlipidemia
4. CAD, stable exertional angina on NTG sl at home
Social History:
Married, 50 pack/yr history of pipe smoking, 3 drinks/ week
Family History:
Father with angina in 60s, MI at 82
Physical Exam:
BP 155/88
Pulse 80
Resp 97% on 100% FM, 90% on 4L
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally, no crackles or
wheezes
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**1-30**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2127-12-1**] 10:05AM 9.6 3.39* 10.8* 31.4* 92 31.7 34.3 15.4
334
BASIC COAGULATION (PT, PTT, PLT, INR) PT Plt Ct INR(PT)
[**2127-12-2**] 05:50AM 20.7* 2.7
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2127-12-2**] 05:50AM 73 26* 1.6* 142 4.2 105 25 16
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2127-12-2**] 05:50AM 2.3
Brief Hospital Course:
70 year old with HTN, hyperlipidemia, longstanding angina
presents with SSCP found to have NSTEMI. In catheterization he
had 60% LMCA, total occlusion of LAD, 95% ulcerated circ, 90%
PLV. Also presenting with acute pulmonary edema felt to be due
to ischemic MR, resolved with Lasix. He had new onset atrial
fibrillation. Dr. [**Last Name (STitle) **] was consulted and on [**2127-11-24**] he
underwent CABGx4 with LIMA->LAD, SVG->PDA, PLV, OM. Cross clamp
time was 90 mins and total bypass time was 73 mins. He was
transferred to the CSRU on Milrinone, Epidural, Propofol,
Insulin, and Neo. While in the OR, the IV in his left arm
infiltrated and he needed a partial fasciotomy which was
performend by Dr. [**Last Name (STitle) 5385**].
He was extubated on his post op night and went into afib on POD
#1. He weaned off all of his drips and was slowly improving.
He was transferred to the floor on POD#2 and had his fasciotomy
closed on POD#3. He continued to progress and was
anticoagulated as he still had occasional runs of AF at a
controlled rate. He was discharged to home in stable condition
on POD# 8.
Medications on Admission:
ASA
Cartia VT 240 Daily
Lisinopril 5 daily
Insulin (in AM: 28 units Humalin N and 6 units Humalin R, in PM:
14 units Humalin N)
Lipitor 40mg 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. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime for 1
days: Then take as directed by PCP for INR goal of [**1-20**].5.
Disp:*90 Tablet(s)* Refills:*0*
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Eight (28) units Subcutaneous q AM: Then take 14 units sc q PM.
Disp:*15 15* Refills:*0*
12. Insulin Regular Human 100 unit/mL Cartridge Sig: Six (6)
units Injection q AM.
Disp:*3 3* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 1295**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 5385**] for next Tues. [**12-9**].
[**2127**]
Completed by:[**2127-12-2**]
ICD9 Codes: 4280, 4240, 4019, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 931
} | Medical Text: Admission Date: [**2114-3-9**] Discharge Date: [**2114-4-9**]
Date of Birth: [**2114-3-9**] Sex: F
Service: NEONATOLOGY
ADMISSION DIAGNOSES:
1. Prematurity (34 weeks).
2. Small for gestational age (birth weight 1560 grams).
MATERNAL HISTORY: [**Known firstname 65784**] [**Known lastname **] is a 25-year-old G1 P0
mother with BNS, B positive, antibody negative, HBS antigen
negative, RPR NR, GBS unknown, rubella immune. She had
amniocentesis in the first trimester, which showed fetal
karyotype of 46 XX. She had an uneventful pregnancy. However,
when she was seen on [**2114-3-8**] at [**Hospital1 18**] for a 3D
ultrasound scan, she was noted to have fetal IUGR (9%), low
AFI (8) and was therefore monitored at the antepartum testing
unit before being sent to labor and delivery for evaluation.
She was also noted to have borderline hypertension of 130 to
140/80 to 85 along with proteinuria attributed to pre-eclampsi
a.
In view of unclear etiology for IUGR, TORCH screen was sent on
the mother. CMV IgM was negative, but IgG positive. Toxo IGG a
nd
IGM were negative, HSV 1 and 2 pending. She proceeded for
elective cesarean section at 34 weeks in view of poor fetal
growth.
BIRTH HISTORY: Baby was [**Name2 (NI) **] by elective cesarean section
(mother not in labor). She was [**Name2 (NI) **] in good condition,
requiring no resuscitation at birth. Apgar scores were 9 and
10 at 1 and 5 minutes respectively.
PHYSICAL EXAMINATION ON ADMISSION: On arrival to NICU she
continued to be active, had mild oxygen requirement with no
obvious respiratory distress. Growth birth weight 1560 gram
(10th percentile), length 39.5 cm (11 to 10th percentile),
head circumference 29.5 cm (10 to 25th percentile).
Examination, general, small for gestational age, active,
alert, vigorous. HEENT no dysmorphic features, sutures and
fontanelle normal. No cleft, neck supple. Respiratory,
breathing comfortably. No retractions. Bilateral equal breath
sounds. Cardiovascular, pink, well perfuse. Normal pulses.
Femoral pulses were normal, no murmur. Abdomen, soft,
nondistended, no hepatosplenomegaly. Neuro, tone and reflexes
normal. Extremities and spine normal. Hip not examined, stable
on
subsequent examination.
HOSPITAL COURSE:
1. Respiratory. After a brief period of oxygen
requirement soon after birth, baby [**Name (NI) **] showed no evidence
of respiratory distress and continued to breath comfortably
in room air throughout her hospital stay. She did not have
evidence of apnea of prematurity.
2. Cardiovascular. She remained hemodynamically stable wiht a
normal cardiac examination throughout this admission
3. Fluid, electrolyte, nutrition. She was initially started on
IV fluids at 60 ml per kilo per day. Feeds were introduced on
the third day of life and gradually advanced so that she was
on full feeds by day of life 4. This was further advanced to
a maximum of 150 ml per kilo per day of breast milk PE/30
with ProMod for better weight gain. She has been on exclusive
oral feeds since [**3-30**] and is currently on ad lib breast mi
lk
of Enfacare 26 kcal/oz. Weight at discharge is 2130 grams, wit
h
good growth in the week prior to discharge.
4. GI. She did not have any gastrointestinal problems during h
er
hospital stay. Liver function testing was within normal limits
([**4-3**]: Alt 12; AST 23; Alkaline phosphatase 208; total bilirub
in
0.3; conjugated bilirubin 0.1))
5. Heme. She did not receive any blood products during her
hospital stay. There was no thrombocytopenia or neutropenia wi
th
the commencement of valganciclovir therapy. [**2114-4-7**] CBC showed:
WBC 6,700 (PMN=13%, ANC 871), Plt 209K; Hct 29%. _____________.
6. Neurological: An initial ultrasound scan showed echodensity
in
the caudothalamic notch, thought to be consistent with a germi
nal
matrix hemorrhage, as well as mineralizing vasculopathy in bas
[**Doctor Last Name **]
ganglia. CT ([**3-21**]) and MRI ([**3-22**]) were normal (the latter show
ed
a right poserior parietal developmental venous anomaly, a norm
[**Doctor Last Name **]
variant). A repeat ultrasound on [**4-3**] showed complex cystic
changes in the caudothalamic notch, thought to be suggestive o
f
CMV infection. Neurological examination showed hypertonicity i
n
symmetric distribution.
7. Infectious diseases. The infant had no episodes of suspecte
d
or proven bacterial sepsis. She was, however, investigated for
CMV in view of maternal positive IgG serology and her small fo
r
gestational age status. Initial urine was CMV antigen positive
,
but CSF CMV pcr was negative, as was ophthalmology examination
and initial ultrasound. Following the abnormalities on the sec
ond
ultrasound, as described above, CMV investigations were repeat
ed.
At that time, serum CMV viral load was 2580 copies, confirming
congenital CMV infection. CSF CMV pcr is pending at the time o
f
this dictation. In light of the evidence of CMV infection with
growth restriction and cranial ultrasound abnormalities, she w
as
started on valgancyclovir therapy orally for an anticipated
course of 6 weeks. Valganciclovir levels have been sent and ar
e
pending at the time of discharge.
8. Sensory: Ophthalmology examination on [**3-21**] showed no eviden
ce
of chorioretinitis. Two auditory evoked response screens were
performed, on [**3-16**] and [**4-3**], and were normal.
9. Psychosocial: No concerns.
CONDITION ON DISCHARGE: Asymptomatic.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**First Name (STitle) 65785**] [**Name (STitle) 65786**] (dim
[**Hospital **]
Health Center [**Telephone/Fax (1) 3581**])
CARE AND RECOMMENDATIONS FEEDS AT DISCHARGE: Breast milk 26,
EnfaCare 26 ad lib po feeds.
MEDICATIONS:
1. Valganciclovir 30 mg PO BID (equivalent to 15 mg/kg/dose PO
BID)
2. Ferrous sulfate 0.15 ml PO once daily
CAR SEAT POSITION SCREENING: Passed.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2114-4-2**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria; 1) [**Month (only) **] at less than 32
weeks, 2) [**Month (only) **] between 32 and 35 weeks with 2 of the
following; daycare during RSV season, smoker in the
household, neuromuscular disease, airway abnormalities, or
school age siblings or 3) with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants more than 6 months of age. Before this age
(and for the first 24 months of the child's life),
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW UP APPOINTMENT SCHEDULE RECOMMENDED:
1. With primary care pediatrician 1 to 2 days following
discharge.
2. VNA.
3. Early intervention (Bay Cove Early Intervention [**Telephone/Fax (2) 65787**])
4. [**Hospital3 1810**] Infectious Disease Clinic - Appointmen
t
made for [**4-24**](Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 50148**] [**Telephone/Fax (1) 50149**])
5. [**Hospital3 1810**] Neonatal neurology clinc (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
ul,
appointment made for [**7-11**])
6. [**Hospital3 1810**] ophthalmology clinic (Dr. [**Last Name (STitle) 65788**] [**Telephone/Fax (1) 65789**])
7. [**Hospital3 1810**] Infant Follow-Up Program (will contact
)
8. She should receive weekly CBC, liver function tests and
BUN/Cr while on valganciclovir
DISCHARGE DIAGNOSES:
1. Prematurity (34 weeks gestation).
2. Small for gestational age.
3. Congenital cytomegalovirus infection
REVIEWED BY: [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **] , MD [**MD Number(2) 56576**]
Dictated By:[**Doctor Last Name 65790**]
MEDQUIST36
D: [**2114-4-3**] 07:34:20
T: [**2114-4-3**] 08:37:44
Job#: [**Job Number 65791**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 932
} | Medical Text: Admission Date: [**2132-11-29**] Discharge Date: [**2132-12-1**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fever and hypotension at HD.
Major Surgical or Invasive Procedure:
Femoral tunneled catheter replacement
History of Present Illness:
48 yo M w/ h/o ESRD s/p failed transplant, h/o hep B/C/?D, h/o
paf on coumadin, h/o sarcoid, h/o pulmonary aspergillosis, and
h/o MRSA line sepsis [**5-6**] and presumed recurrence [**10-6**] though cx
negative a/w F and hypotn at HD. Patient states he has been
having fevers w/ rigors at the last 3 HD sessions. Today blood
cx were obtained, vanc was given, and patient was transferred to
[**Hospital1 18**] following dialysis. VS on arrival: T 98.6 hr 140 bp 113/42
rr 12 O2 95% RA. While in the ED bp dipped as low as sbp 81.
Patient received a total of 3.3 L NS. On ROS, patient reports
c/o N and V x couple times over the past couple days (w/o
blood). + chills at HD. He was c/o back pain at HD. + cough w/o
sputum. No c/o SOB or CP and no sick contacts. [**Name (NI) **] D. No urinary
sx (makes about 4 oz urine qd). No rash, HA, neck stiffness. No
skin ulcers.
.
Past Medical History:
1. ESRD s/p failed transplant [**7-4**] now collapsing
glomerulonephritis, HD qMWF at [**Location (un) 4265**]
2. Amyloidosis
3. Sarcoidosis
4. Hx of pulmonary aspergillosis - on itraconazole, followed by
pulm
5. Hx of hyperkalemia
6. Hep B, C, ? D
7. HTN
8. Hx of IV drug use
9. h/o sinusitis requiring drainage
10. recent epistaxis requiring intubation
11. SPEP/UPEP positive
12. paroxysmal atrial fibrillation - off BB, on coumadin
13. h/o C diff [**3-8**]
14. MRSA line sepsis ([**5-6**]), new tunneled fem line [**5-6**], TTE neg
for veg
15. h/o purulent ascites [**3-8**] while on PD
16. gynecomastia
17. iron deficiency anemia
18. renal osteodystrophy
19. adrenal insufficiency - on prednisone 5 mg po qd
20. h/o UE DVT [**3-8**]
21. h/o pancreatitis [**3-8**]
** ECHO [**5-6**]: EF > 55%, 1+ MR
Social History:
Lives with girlfriend, on disability; 1 packper day x30 years of
tobacco use, still currently smoking.No alcohol, but previous
history of abuse.
Family History:
Diabetes
Physical Exam:
Tm 100.8 in ED Tc 98.8 hr 102 bp 109/57 rr 13 O2 98% on 2 L NC
genrl: sleepy but easily arousable, shaking chills
heent: perrla (3->2mm), periorbital edema (patient reports
common w/ volume overload, op clear - mmm, no sublingual icterus
cv: rrr, no m/r/g
pulm: bibasilar crackles, no wheeze/ronchi
back: no focal spinal tenderness, no CVA tenderness
abd: nabs, soft, tender to palpation of RLQ w/o
rebound/guarding, scar overlying RLQ from "jumping out a window
when he was young and cutting his skin in the process," o/w NT /
ND, no masses/hsm
extr: no [**Location (un) **], dry skin, unable to palpate DP or PT pulses
neuro: a, o x3, strength grossly [**6-5**] bilaterally UE/LE, sensory
grossly intact in UE/LE
Pertinent Results:
[**2132-11-29**] 04:40PM WBC-10.3 RBC-4.83# HGB-15.8# HCT-45.1# MCV-93
MCH-32.7* MCHC-35.0 RDW-14.4
[**2132-11-29**] 04:40PM NEUTS-88.5* BANDS-0 LYMPHS-7.4* MONOS-2.3
EOS-1.5 BASOS-0.4
[**2132-11-29**] 04:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2132-11-29**] 04:40PM PLT SMR-NORMAL PLT COUNT-291#
[**2132-11-29**] 04:40PM GLUCOSE-130* UREA N-20 CREAT-6.8* SODIUM-139
POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
[**2132-11-29**] 04:40PM CALCIUM-10.4* PHOSPHATE-3.8 MAGNESIUM-1.3*
[**2132-11-29**] 05:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2132-11-29**] 05:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-7.0 LEUK-NEG
[**2132-11-29**] 05:20PM URINE RBC-0-2 WBC-[**4-5**] BACTERIA-MOD YEAST-NONE
EPI-[**4-5**]
[**2132-11-29**] 04:53PM LACTATE-1.6 K+-3.7
[**2132-11-29**] 11:10PM PT-26.5* PTT-150* INR(PT)-5.2
[**2132-11-29**] 04:40PM CK(CPK)-22*
[**2132-11-29**] 04:40PM cTropnT-0.12*
[**2132-11-30**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2132-11-30**] 11:11AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2132-11-30**] 11:11AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2132-11-30**] 05:00AM BLOOD ALT-23 AST-30 CK(CPK)-19* AlkPhos-139*
Amylase-144* TotBili-0.4
[**2132-11-30**] 11:11AM BLOOD ALT-19 AST-26 LD(LDH)-177 CK(CPK)-29*
AlkPhos-122* TotBili-0.4
[**2132-11-30**] 11:11AM BLOOD CK(CPK)-28*
[**2132-12-1**] 06:20AM BLOOD AST-32 LD(LDH)-132 AlkPhos-118*
TotBili-0.3
.
CHEST (PORTABLE AP) [**2132-11-29**] 4:49 PM
Reason: please eval lung fields for infiltrates
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with ESRD now with hypotension and lactatemia .
REASON FOR THIS EXAMINATION:
please eval lung fields for infiltrates
HISTORY: End-stage renal disease, now hypotension and lactic
acidemia. Question infiltrate. The patient has a history of
sarcoid and aspergillomas as well as renal transplant based on
the chest CT report from [**2131-12-11**].
CHEST, SINGLE AP VIEW.
There is [**Hospital1 **]-apical scarring with upper zone infiltrates. There
are calcifications superimposed over the mediastinum and hila
and some pleural plaquing in the right mid and lower zones.
There is blunting of the left costophrenic angle. Appearances
are unchanged compared with [**2132-10-21**]. No superimposed CHF,
infiltrate, or gross effusion is identified. Apparent oral
contrast in the bowel.
IMPRESSION: Appearances are suggestive of scarring related to
previous infection and the presence of calcified nodes is
suggestive of prior granulomatous infection.
ECG [**2132-11-29**]: This Ecg received late and out of sequence
Baseline artifact
Sinus tachycardia
ST-T configuration consistent with early repolarization pattern/
normal variant although baseline artifact makes assessment
difficult
Since previous tracing of same date, sinus tachycardia rate
slower, not
suggestive of right atrial abnormality and ST-T wave changes
decreased
[**2132-11-30**]:
HISTORY: Right lower and left lower quadrant pain.
COMPARISON: CT from [**2132-5-12**].
TECHNIQUE: MDCT acquired contiguous axial images from the lung
bases to pubic symphysis were acquired following the
administration of oral and 150 cc of IV Optiray. Nonionic
contrast was administered secondary to patient's debility.
Coronal and sagittal reconstructions were performed.
CT OF THE ABDOMEN WITH IV CONTRAST: Again demonstrated at the
lung bases is diffuse pleural thickening with calcifications
consistent with prior asbestos exposure. Calcified left
paraaortic lymph node is also seen, and additionally, there
appears to be calcification along the pericardium. The liver,
pancreas, spleen, adrenal glands, stomach, and loops of large
and small bowel are all unremarkable. Within the gallbladder,
there are at least 2 calcified 2-mm structures, likely
representing gallstones. Gallbladder otherwise is collapsed
without evidence of pericholecystic fluid. The kidneys again
demonstrate multiple subcentimeter low-attenuation lesions,
stable in the interval, and too small to fully characterize. No
hydronephrosis is noted. Extensive atherosclerotic
calcifications are seen within the abdominal aorta, but the
aorta is normal in caliber. There is no free air or free fluid.
There is no evidence of bowel obstruction.
Again demonstrated within the retroperitoneum are several
prominent lymph nodes within the aortocaval and left paraaortic
region. The largest lymph node measures approximately 14 mm, and
is relatively stable since the prior examination. There is no
free air or free fluid.
CT OF THE PELVIS WITH IV CONTRAST: Transplanted kidney is seen
within the right lower quadrant, without evidence of
hydronephrosis, renal masses, or perinephric fluid collections.
A focal area of hypoenhancement/cortical scarring is again noted
within the lateral aspect of the kidney, unchanged. Rectum,
sigmoid colon, and pelvic loops of bowel all appear
unremarkable, and the appendix is normal in caliber, filled with
contrast. Prostate and bladder are within normal limits. There
is no free fluid. No pelvic or inguinal lymphadenopathy is
demonstrated. A left common femoral central venous catheter is
demonstrated with tip in the inferior aspect of the inferior
vena cava.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
present.
CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were
essential in confirming the above findings.
IMPRESSION:
1. No abnormality noted within either lower quadrant to account
for the patient's pain. Stable appearance of the transplanted
kidney.
2. Calcified pleural thickening in both lower lobes consistent
with prior asbestos exposure.
3. Stable prominent lymph nodes within the retroperitoneum.
4. Stable appearance of the native kidneys with multiple
subcentimeter cysts seen, which may represent acquired cystic
renal disease vs. polycystic kidney disease.
5. Cholelithiasis.
[**Hospital 102855**] MEDICAL CONDITION:
48 year old man with ESRD on HD, s/p multiple episodes of MRSA
line sepsis, now w/ fever, GPC on blood cx.
REASON FOR THIS EXAMINATION:
Please change left shoulder hemodialysis catheter over a wire
HEMODIALYSIS CATHETER CHANGE
INDICATION: Endstage renal disease on hemodialysis, now with
left femoral tunneled dialysis catheter and MRSA line sepsis.
Details of the procedure and possible complications were
explained to the patient and informed consent was obtained.
RADIOLOGISTS: Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 380**]. Dr. [**Last Name (STitle) 380**], staff
radiologist, was present for the entire procedure.
TECHNIQUE: Using sterile technique and local anesthesia, two
Amplatz super stiff wires were advanced into the indwelling left
femoral tunneled dialysis catheter. The cuff of the catheter was
released by blunt dissection and the catheter was removed over
the wire. A new 14-French tunneled dialysis catheter was then
placed over the wires with the tip positioned in the IVC just
above the confluence of the common iliac veins. This was
confirmed by injection of small amount of contrast material. No
extravasation of the contrast material was seen. The catheter
was secured to the skin.
The patient tolerated the procedure reasonably well. There were
no immediate complications.
CONTRAST MATERIAL: 20 cc of nonionic contrast material were
used.
IMPRESSION: Exchange of a left femoral tunneled dialysis
catheter for a new tunneled dialysis catheter over the wire.
Brief Hospital Course:
48 yo M w/ h/o ESRD s/p failed transplant, h/o hep B/C/?D, h/o
paf on coumadin, h/o sarcoid, h/o pulmonary aspergillosis, and
h/o MRSA line sepsis in [**5-6**] and presumed recurrence in [**10-6**]
admitted with fever and hypotension at HD.
.
# Sepsis: Bcx was drawn at HD on [**11-29**], and vanc was given, and
patient was transferred to [**Hospital1 18**] following dialysis. Pt's BP
drifted down to 81, tachy at 140 but afebrile in the ED. Patient
received a total of 3.3 L NS. Because of hypotension, the
patient was observed in the MICU overnight. The patient was
continued on IV vanc and gent x i was given. The patient did
not require any pressors but received stress dose steroids. Pt
had abd tenderness and was covered with flagyl and cipro
transiently as there was a concern for GI abscess, but was
discontinued on the day of transfer to the floor on [**11-30**] as the
CT of abdomen was negative for any intra-abdominal inflammatory
processes or abscess. Bcx 1/4 bottles from [**11-29**] grew Staph
coag negative species and sensitivities pending. Surveillance
blood cultures were drawn and were negative to date. On [**11-30**],
the patient had the femoral dialysis catheter exchanged over the
wire and tolerated it well. The cath tip culture is negative to
date. The patient was continued on iv vancomycin and random
vanc levels were checked and if the level<15, additional 1gm of
vancomycin was given. The patient was discharged with 14 days
of vancomycin to be administered at dialysis or when vanc level
<15.
.
# Troponin leak: No c/o chest pain and unremarkable EKG.
Nevertheless, in the MICU enzymes were cycled to confirm CK/CKMB
did not increase.
.
# ESRD: s/p failed transplanted kidney. Continued HD Tues,
Thurs,Fri. Renally dosed meds. Continued tacrolimus and Bactrim
for prophylaxis.
- Hyperphosphatemia- Continued sevelamer and calcium acetate.
Renal felt that given elevated calcium simultaneously, the
patient may have vit D toxicity. Renal will decrease vit D
administration during dialysis.
- Hypercalcemia- See above. Per Renal, no acute need for
treatment. No IVF given already received 3 L in the MICU.
.
# PAF: Coumadin was held due to elevated INR 5.2. Once
hypotension was resolved, the patient was started on metoprolol
for rate control. The patient's INR at time of discharge was
3.1. The patient was instructed to start coumadin 1mg every
other day when the level <3.0. INR is to be checked during
dialysis and requested to fax the results to Dr. [**Name (NI) 2427**], pt's
PCP. [**Name10 (NameIs) **] patient has an appointment with Dr. [**Last Name (STitle) 2427**] on
[**2132-12-5**].
.
# HTN: Once hypotension resolved with fluids in the MICU, the
patient was noted to be hypertensive on the floor. The patient
was not taking any antihypertensives as an outpatient recently
given hypotension (he has been on Lopressor and diltiazem in the
past). We restarted Lopressor, and the patient will f/u with Dr.
[**Last Name (STitle) 2427**] for further HTN management.
.
# H/o pulm aspergillosis: Continued itraconazole.
.
# Hep B/C: No acute issues.
.
# Adrenal insufficiency- The patient received stress dose
steroids in the MICU. On the floor, the patient was continued
on prednisone 5mg qday.
.
# Depression: Continue sertraline
.
# PPX: home PPI, bowel reg, and no sc heparin given elevated
INR.
.
# FEN: IVF given in the MICU for hypotension. Continued renal
diet. Repleted 'lytes/prn. Continued thiamine, Nephrocaps, and
folic acid.
.
# Full code
.
# Communication: GF [**Doctor Last Name 2808**] [**Telephone/Fax (1) 102392**]
Medications on Admission:
1. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
2. Thiamine HCl 100 mg PO DAILY
3. Folic Acid 1 mg PO DAILY
4. Itraconazole 200 mg PO BID
5. Calcium Acetate 1200 mg PO TID W/MEALS
6. Pantoprazole Sodium 40 mg PO Q24H
7. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO DAILY
8. Prednisone 5 mg PO DAILY
9. Tacrolimus 0.5 mg daily
10. Docusate Sodium 100 mg PO BID
13. Sevelamer HCl 1600 mg PO TID
14. Lactulose 30 ML PO TID
15. Warfarin Sodium 1 mg PO every other day.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 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. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QD ().
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMON,WED,FRI ().
11. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
14. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous during dialysis on Tues, Thurs, Sat for 14 days:
please administer vancomycin 1000mg iv during dialysis and prn
if vancomycin level <15. .
Disp:*9000 mg* Refills:*0*
16. Outpatient Lab Work
Vancomycin random level at dialysis. Also, please check INR and
fax results to Dr. [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**] to adjust coumadin dose. Fax
number is [**Telephone/Fax (1) 3382**].
17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO every other day:
Take this when your INR is <3.0. Check your INR at dialysis on
[**2132-12-2**]. .
Disp:*3 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Line sepsis/bacteremia
End-stage Renal Disease
Adrenal insufficiency
Paroxysmal atrial fibrillation
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
Return to the emergency department if you develop fever, chills,
severe abdominal pain, nausea, vomiting, or any other worrisome
symptoms.
.
Keep your follow-up appointments. Discuss with your primary care
physician regarding your hypertension management and coumadin.
.
Take your medications as instructed. Have dialysis unit check
your vancomycin level at dialysis and administer vancomycin.
Also, have your INR checked at dialysis tomorrow and start
coumadin if your INR<3.0.
Followup Instructions:
Dialysis at Gambor on Tues, Thurs, and Sat as previously
scheduled.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2132-12-5**] 3:30
.
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2133-2-17**]
3:00
ICD9 Codes: 5856, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 933
} | Medical Text: Admission Date: [**2162-6-20**] Discharge Date: [**2162-6-23**]
Date of Birth: [**2091-1-24**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
R sided weakness, intracranial hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo L handed M with history of kidney stones, BPH, and pelvis
fracture from a fall presents wtih acute R face, arm and leg
weakness today found at OSH to have a L basal ganglia
hemorrhage.
He was transferred from [**Hospital **] hospital to [**Hospital1 18**] for further
evaluation and managment.
He was well until today, no recent illnesses. He was out
gardening today, ~11:30-noon as he was walking back in the house
he suddenly felt like something was wrong but not sure what.
Then he made brunch for he and his wife. [**Name (NI) **] cooking he felt
somewhat clumsy with his R hand, though he is L handed so it
wasn't a big deal. While eating his wife noticed his speech was
slurred, his R face was drooped, and he was weak in his R arm.
He had trouble getting his R arm even up to the table. Then
when
he stood he was dragging his R foot. At that point, his wife
convinced him that he needed to go to the hospital, as she
suspected he was having a stroke. He went to [**Hospital **] hospital
by
ambulance. There he was noted to have R face/arm/leg weakness.
CT head showed a 3cm.1.3cm.2.6cm hemorrhage in the L basal
ganglia, primarily putaminal. He was transferred for further
neurological management. There blood pressure was close to SBP
200s. He did not receive any antihypertensive or other
medications at the OSH.
He was never sleepy or confused. He never had trouble coming up
with words, just slurred speech. R face, arm, and leg weakness
has gradually improved overall with slight fluctuation such as
transiently more weak in ambulance on the way here.
He takes allopurinol and ibuprofen daily, no antiplatelet or
anticoagulant medications. No trauma. no known history of
hypertension, and he says he has been seeing his doctor over the
last few years with normal BP checks.
ROS: Denies fevers, neck stiffeness, vision changes (blurry,
double or other), swallowing difficulties, numbness/tingling,
difficulty sensing temperature. He has been able to walk though
dragging R leg. No recent travel.
Past Medical History:
BPH
Recent prostate biopsy normal.
Kidney stones
Fall off ladder 3 years ago with no LOC, but had a pelvis
fracture.
osteoarthritis
After calling PCP it appears patient has had BPs in the 140s/90s
for the last few years, and last [**Month (only) **] a measurement of 170/100
Social History:
Lives with wife [**Name (NI) 4457**], who is his health care proxy if he
could not make decisions for himself. Her contact information
is
[**Name (NI) 4457**] [**Name (NI) **], home phone [**Telephone/Fax (1) 85360**] or patient's cell which she
will take [**Telephone/Fax (1) 85361**]. He is a retired carpenter. He smoked
for 15yrs, average [**2-6**] PPD, and quick 30 years ago. One
alcoholic drink per day (i.e. one shot). Denies drug use. Have
5
grown children and 8 grandchildren
Family History:
No family history of bleeding or clotting disorders, vascular
malformations or aneurysms, or brain tumors. Children and
grandchildren all healthy.
Physical Exam:
Physical Exam:
T98.5 Hr 96 BP 172/120 -->155/90s RR 16 O2 98% RA
Gen: Awake, alert, not in distress, sitting up in bed.
Non-toxic
appearance.
Skin: No rashes
Heent: NCAT, mucous membranes moist, oropharynx clear.
Neck: Supple, no meningismus. Full ROM without pain. No
cervical
bruit.
Back: no spinal tenderness
Resp: Clear to auscultation bilaterally
CV: Regular rate, normal S1/S2, no murmurs, rubs, or gallops
Abd: Abdomen soft.
Extrem: Warm and well-perfused. Arthritic changes in joints
especially PIP and DIP joints (appears to be osteoarthritis).
RLE slightly externally rotated on the bed.
Neuro:
MS - Awake, alert, interactive. Oriented to person, place
(hospital, city, state, and room number in ED), and date
(day/month/year). Speech is fluent. Intact registration,
recall
0/3 and [**2-7**] with clues. Repetition, naming, comprehension
intact. Attentions is considered to be appropriate. No
left-right
confusion.
Cranial Nerves - Pupils R 3.5--->3 and L 3-->2 both briskly
reactive (likely physiologic anisocoria); EOMs smooth and full,
no diplopia; no nystagmus; optic disc margins sharp on
funduscopic exam, Visual field full with confrontation test,
intact facial sensation V1-V3, R UMN facial droop less apparent
with spontaneous than forced smile, slight dysarthria, hearing
intact to finger rub bilaterally, palate elevation is symmetric,
and tongue protrusion is symmetric and full movement.
Sternocleidomastoid and trapezius are strong and normal volume.
Tone - Normal
Strength -
Pronator drift on R
Delt [**Hospital1 **] Tri WrEx FEx FFlx IO [**Location (un) **]/IP Quad Ham Gastr TA [**First Name9 (NamePattern2) **] [**Last Name (un) 938**]
R 4+ 5 5 5* 5- 5 4+ 4+ 4+ 5 5- 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
*Note wrist extensor shakey on R but unable to break it
Reflexes -
Biceps Triceps Brachioradialis Patellar Ankle
R 2+ tr 2+ 2+ 2+
L 2+ 2+ 2+ 2+ 2+
Plantar responses extensor bilaterally
Sensation - Intact to light touch, temperature. Mildly
decreased
vibration and JPS bilaterally at the big toes. Vibration
symmetric and intact at knees. Romberg negative.
Coordination - Finger to nose intact with no dysmetria out of
proportion to weakness. RAMs slightly slumsier on the R, again
in
proportion to weakness.
Gait - Narrow based and stable with slight circumduction and
foot
drop of RLE. Unable to walk on toes.
Pertinent Results:
[**2162-6-20**] 09:48PM CK-MB-3 cTropnT-<0.01
[**2162-6-20**] 02:40PM cTropnT-<0.01
[**2162-6-20**] 02:40PM TSH-1.6
[**2162-6-20**] 04:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2162-6-20**] 04:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2162-6-20**] 02:40PM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-99
[**2162-6-20**] 02:40PM WBC-9.2 RBC-5.21 HGB-15.0 HCT-45.4 MCV-87
MCH-28.7 MCHC-33.0 RDW-13.3
Imaging:
CT head [**6-20**]:
IMPRESSION: No short interval change of 1.3 x 3 cm left external
capsule
hemorrhage with minimal mass effect. No new foci of hemorrhage.
No evidence
of herniation or midline shift.
MRI/A brain [**6-21**]:
MRI OF THE BRAIN: A 33 x 13 mm left basal ganglia hemorrhage
with minimal
surrounding vasogenic edema, is stable in size and location
compared to CT
scan of [**2162-6-20**], previously 13 X 34mm. There is minimal
local mass
effect without shift of normally midline structures. Ventricles
are normal in
size and configuration. Suprasellar and basal cisterns are
patent. No area of
abnormal enhancement or abnormal vascular structures are seen
within the area
of the hemorrhage. No area of abnormal enhancement or abnormal
vascular
structures are seen within the remainder of the brain
parenchyma. A small
hypointense focus in the right posterior temporal region on
axial FLAIR likely
represents encephalomalacia.
BRAIN MRA: Arteries of the anterior and posterior circulation
appear normal
without evidence of stenosis, occlusion or aneurysm greater than
3 mm.
IMPRESSION: Left basal ganglia hemorrhage with surrounding edema
is stable in
size and appearance since CT scan of [**2162-6-20**]. No underlying
mass or
vascular malformation identified. MRA is normal.
Brief Hospital Course:
71 yo M with h/o kidney stones, BPH, prior pelvic fracture,
oseoarthritis admitted with acute onset R face, arm and leg
weakness secondary to L basal ganglia hemorrhage. Overall
strength has gradually improved since onset. The patient had a
head CT at the OSH which showed the hemorrhage and he was
transferred to [**Hospital1 18**]. He was admitted to the Neuro ICU
The CT head repeated here shows stable size of hemorrhage
3cm.1.3cm.2.6cm. He is not
on antiplatelet or anticoagulant medications, but does take
NSAIDs for arthritis. Platelet number is normal here. Blood
pressures have been ~SBP160s/100s. His bleed was in a typical
location for a hypertensive bleed. He did not report that he
had a history of HTN, however on taking to his PCP his pressures
over the last few years have ranged in the 140s/90, and his last
measurement was in [**12-14**] with a measurement of 170/100.
To rule out other possible etiologies the patient had an MRI/A
of the brain which showed Left basal ganglia hemorrhage with
surrounding edema as stable in size and appearance since CT
scan on [**2162-6-20**]. There was no underlying mass or vascular
malformation identified. MRA was normal
The patient spent the evening in the ICU. His right sided
weakness improved, and he was primarily left with some
difficulty with rapid alternating movements and coordination in
his right hand and foot. He was restarted on his home
medication and started on HCTZ for blood pressure. The patient
was awake and alert the entire time and did not suffer a
headache.
He was transferred to the floor on [**2162-5-22**].
While on the floor, SBP remained elevated. HCTZ was discontinued
and pt. was started on lisinopril 10mg daily. BP improved on
day of discharge and K and Cr were wnl. Given ICH, ibuprofen
was discontinued. ASA 81 mg was not started for primary cardiac
prevention, however if felt it would be appropriate, could be
started at 1 month after discharge.
The above findings were communicated to patient's PCP.
Medications on Admission:
Flomax 1 tab po qday
Alloporinol 300mg po qday (not sure of dose)
ibuprofen 600mg po qday for arthritis pain
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Left basal ganglia hemorrhage, likely hypertensive in
origin.
Discharge Condition:
Neurological exam at time of discharge notable for:
MS: Impaired FAS and Luria sequence. Impaired recall at 5
minutes ([**3-10**]) items.
CNs: intact
Motor: bilateral FE 4+/5 weakness.
Sensory: intact.
Gait: Mild extension of RLE and abduction but overall normal
stride and armswing.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with right sided weakness. You were
found to have a bleed on the left side of your brain. This was
felt to be due to your persistently elevated blood pressure.
You underwent an MRI of your brain that did not reveal an
underlying mass or another reaason for your bleed.
Your weakness and incoordination improved thoughout the hospital
stay.
The following changes were made to your medications:
- Started on Lisinopril 10mg daily (you will need to follow up
with your PCP regarding blood pressures and checking your kidney
function and your potassium).
- Your Ibuprofen was stopped.
- ASA 81 mg can be started in 1 month if it is deemed of benefit
for primary CAD prevention in this patient.
You were discharged home.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] within 10 days of discharge. Please
call [**Telephone/Fax (1) 51033**] to set up your appointment that is most
convenient for you.
NEUROLOGY:
[**Hospital1 18**], [**Hospital Ward Name 23**] building.
Provider: [**Known firstname **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2162-7-23**] 1:30
Completed by:[**2162-6-29**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 934
} | Medical Text: Admission Date: [**2141-7-14**] Discharge Date: [**2141-7-20**]
Date of Birth: [**2066-10-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
74 years old female admitted, underwent right lobe liver
resection for metastic breast cancer.
Major Surgical or Invasive Procedure:
74 years old female admitted, underwent right lobe liver
resection for metastic breast cancer.
History of Present Illness:
Ms. [**Known lastname 27935**] is a 74-year-old female with a history of breast
cancer approximately 20 years ago who presents with a large
right-sided hepatic tumor. The preoperative biopsy and
immunostaining have characterized this as consistent with a
breast primary. She underwent a CT abdomen/chest, bone scan,
and CT pet, which did not demonstrate any extrahepatic disease.
The
plan is to proceed with right hepatic lobectomy this coming
Friday.
Past Medical History:
Her past medical history is significant for coronary artery
disease. She had a CABG performed in [**2134**]. She had a breast
cancer in the past, hypertension, and osteoporosis. She has
noted previously a CABG, a right breast excision, right mass
excision in the breast, and left lumpectomy with radiation
therapy and chemotherapy in [**2119**] for a stage III breast cancer.
Social History:
Pt lives alone in [**Hospital3 **].
Family History:
non-contributory
Physical Exam:
AVSS
NAD, comfortable
alert, follows commands
neck supple
PERRLA EOMI
CTA bilaterlly
RRR no MRG nl s1 s2
soft, incision c/d/i, JP intact
no c/c/e pulses 2+
Pertinent Results:
CBC:
[**2141-7-14**] 03:19PM BLOOD WBC-11.1* RBC-3.79* Hgb-11.6* Hct-34.5*
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.3 Plt Ct-188
[**2141-7-19**] 06:20AM BLOOD WBC-14.2* RBC-3.07* Hgb-9.0* Hct-28.0*
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.6 Plt Ct-264
P7:
[**2141-7-14**] 03:19PM BLOOD Glucose-129* UreaN-15 Creat-0.6 Na-141
K-4.0 Cl-112* HCO3-21* AnGap-12
[**2141-7-19**] 06:00PM BLOOD K-3.5
COAGS:
[**2141-7-14**] 03:19PM BLOOD PT-13.0 PTT-25.1 INR(PT)-1.1
LFT's:
[**2141-7-14**] 03:19PM BLOOD ALT-317* AST-333* AlkPhos-48 TotBili-0.5
[**2141-7-19**] 06:20AM BLOOD ALT-234* AST-100* AlkPhos-96 TotBili-0.8
SPECIMEN SUBMITTED: FNA LIVER CORE BX.
Procedure date Tissue received Report Date Diagnosed
by
[**2141-5-23**] [**2141-5-23**] [**2141-5-26**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/cwg
Liver, core needle biopsy:
Adenocarcinoma; see note.
Note: Immunohistochemistry stains are positive for estrogen
receptor and cytokeratin CK-7, and negative for cytokeratin
CK20. GCDFP shows no definite specific staining. This
immunophenotype is most consistent with metastatic breast
carcinoma in the appropriate clinical setting. Clinical
correlation is suggested. Trichrome stain confirms the presence
of fibrosis surrounding foci of cancer. Iron stain is
non-contributory.
Path [**2141-7-14**]: pending @ discharge - preliminary read -
metastatic CA, negative margins.
Brief Hospital Course:
This is a 74 yo Female admitted to [**Hospital1 18**] s/p R hepatic lobectomy
for metastatic lobectomy on [**2141-7-14**]. Operation was uncomplicated
with EBL=600. She received 1unit PRBC and 4 L crystalloid. Pt
was extubated in stable condition to the PACU awake and alert on
POD#0. Pain was well controlled on morphine PCA. Epidural was
d/c'd [**12-28**] hypotension and Pt was transfered to the SICU.
On POD#1 pt was comfortable with pain well controlled, lungs
were clear, and pt tolerated sips of clears. Her NGT was d/c'd
and she was transferred to the floor. On POD#2 her JP continued
to have serosanguinous drainage. On POD#3 pt was ambulatory with
PT and continued to do well. She had poor strength and mobility
anticipated rehab placement versus home with PT services. By
POD#5, Pt passed flatus but had still not moved her bowel. Her
PCA and Foley were d/c'd and her diet was advanced to a regular
diet. On POD#6 pt was ambulatory, comfortable, tolerated a
regular diet, and discharged to rehab.
Medications on Admission:
Evista *NF* 60 mg Oral daily
Atorvastatin 20 mg PO DAILY
Atenolol
Discharge Medications:
Oxycodone-Acetaminophen [**11-27**] TAB PO Q4-6H:PRN
Evista *NF* 60 mg Oral daily
Atorvastatin 20 mg PO DAILY
Atenolol 25 PO Daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital 24806**] Care Center - [**Hospital1 1562**]
Discharge Diagnosis:
Metastatic Breast CA
Discharge Condition:
Stable
Discharge Instructions:
Please [**Name8 (MD) 138**] M.D. for Temp>101.5, breakdown of abdominal wound,
redness or increased pain at incision site, or change in
symptoms.
No heavy lifting, no driving while on narcotics.
Followup Instructions:
Follow-up w/ Dr. [**First Name (STitle) **] in [**11-27**] weeks in [**Hospital Ward Name **] 7. Please call
[**Hospital 18**] [**Hospital 1326**] clinic to schedule.
Completed by:[**2141-7-19**]
ICD9 Codes: 4240, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 935
} | Medical Text: Admission Date: [**2196-5-4**] Discharge Date: [**2196-5-13**]
Date of Birth: [**2143-5-24**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Methotrexate / Ceftazidime
Attending:[**First Name3 (LF) 21731**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Transesophageal [**First Name3 (LF) **]
History of Present Illness:
Mr. [**Known lastname **] is a 52yo M with Crohn's disease s/p multiple
surgeries with resultant short gut syndrome and TPN dependency
who was recently admitted to [**Hospital1 18**] for evaluation of low grade
fevers. The pt has a history of multiple line infections, MV
endocarditis and osteomyelitis for which the pt is on chronic
vancomycin. The pt initially presented to the ED on [**2196-4-21**] at
which time he was started empirically on levofloxacin and sent
home. Fevers continued at home and the pt was subsequently
admitted to [**Hospital1 18**] on [**2196-4-26**] with Tmax of 102 in the ED. Of
note, the pt also had elevated LFT but with normal US and normal
ERCP. The pt was placed on unasyn with gradual reduction in
fever curve. At the time, an extensive workup was performed,
however the pt was discharged with continuing low grade fevers.
The pt was discharged on [**2196-4-29**] with continuing low grade
temperatures.
Since his discharge from [**Hospital1 18**], the pt reports continual low
grade fevers. The pt has a 24hour RN service who had recorded a
Tmax of 102 this AM as well as sx of disorientation. The pt
admits to fevers as above but denies any chills, rigors, night
sweats, chest pain, palpitations, abd pain, n/v, head ache,
photophobia, neck stiffness. The pt admits to chronic diarrhea
secondary to his short gut syndrome but there has not been any
change in his stool frequency or characteristic. The pt does
report orthopnea and some LE edema which has been ongoing for
over one year. The pt does report some mild weight gain over
the course of the last couple of months but no change in his
appetite. The pt denies any heat or cold intolerance, or
flushing.
In the ED, the blood cultures were drawn, UA and urine
cultures were sent and a CXR was performed. LFT and ESR was
added on. A TTE and CT scan of the chest, abd and pelvis was
also performed.
Past Medical History:
1. Crohn's disease s/p multiple surgeries with resultant
ileostomy and shortgut syndrome dependent on TPN with chronic
hypocalcemia, vitamin D deficiency.
2. [**Hospital1 **]: Staph epidermidis C4-C5 Osteomyelitis (On
Chronic Vancomycin), Endocarditis with Mitral Valve [**Hospital1 **],
[**Hospital1 **] Polymicrobial Line Sepsis, Previous RLL PNA, LE
Cellulits
3. Respiratory - COPD (Baseline PaCO2 of 48), H/O ARDS with
Intubations/Tracheostomy ([**2192**] and [**2193**]).
4. Severe MR
5. CKD (Baseline Cr 1.3 to 1.4)
6. Anemia of Chronic Inflammation (on EPO)
7. Mild Dementia
8. Chronic Pain (Fentanyl 50 mcg Patch)
9. Restless Leg Syndrome
10. Steroid-Induced Osteoporosis
11. Multiple Spinal Compression Fx
12. Peripheral Neuropathy
13. UGIB/Duodenal Ulcer ([**2193**])
14. Depression
15. Bilateral SVC Thrombi.
Social History:
Lives alone; 24[**Hospital 8018**] nursing care with multiple nurses; fully
intact ADLs; ambulates without assistance; never married; has no
children; has worked many odd jobs; he has five brothers and one
sister that are very supportive. His three brothers, [**Name (NI) **],
[**Name (NI) **], and [**First Name8 (NamePattern2) **] [**Name (NI) **], are all his health care proxies. He
smokes one to one and a half packs per day; has a 60-pack-year
history of smoking. He reports minimal alcohol use and previous
use of marijuana but denies any IVDU. Pt does admit to previous
blood transfusions, he has never exchanged sex for money and he
does not remember if he has ever had an HIV test. Full code.
Family History:
F: Crohn's disease
M: TIA in her 70s
GF: DM
Physical Exam:
GEN: middle aged caucasian male wearing baseball cap and lying
on stretcher. Pt appears comfortable in NAD. Pt conversing
fluently in full sentences. No accessory muscle use.
Skin: warm to touch, slight jaundice, no obvious rashes or
lesions.
HEENT: EOMI, slightly icterics, mmm, op clear
Neck: full rom, difficult to assess suppleness due to some
guarding by pt.
CV: [**1-24**] holosystolic murmur heard best over the LLSB without
radiation.
Chest: clear to auscultation bilaterally, line site on left
chest appears to be clean and intact without signs of erythema,
induration, tenderness, or discharge.
Abd: soft, NT, ND, ostomy bag full of greenish-brown stool and
air in the bag. stoma is pink and moist. BS+
Ext: wwp, trace to +1 pitting edema bilaterally, PT +1
bilaterally
Brief Hospital Course:
A/P: 52yo M with Crohn's disease s'p multiple surgeries
complicated by shortgut syndrome and dependency on TPN with hx
of multiple line infections, endocarditis and osteomyelitis.
.
1. Fever: Initially felt to be septic with SBP in 90's.
Cultures were initially negative, clear CXR, fungal cx negative.
TEE was performed which showed reappearance of MV [**Month/Day (4) **] and
worsening MR. [**Name13 (STitle) **] was started on daptomycin, ambisome. Then found
to have fungal elements on blood smear, and then had a fungal
culture consistent with malassezia furfur. In addition gram +
cocci seen on the same blood smear and Staph epi grew out of 1
culture. Further identification is pending to determine if it is
a contaminant of the same organism that was present in his
osteomyelitis.Initially had wanted to have his Hickman pulled,
but per IR this would be a very difficult and involved procedure
and they prefer to treat through the line if possible. After ID
conference discussion plan is to treat with ambisome 3mg/kg IV
daily for 6 weeks, daptomycin 400 mg IV daily for 10 more days,
then transisiton to vancomycin 1g IV qod ongoing. He will need
to have f/u fungal cx with lipid supplemented media after 6
weeks to document clearance.
A). Cards: The pt has a history of endocarditis for which he
has previously undergone medical treatment. Given the
dependency on TPN, the pt is at significant risk for possible
endocarditis, especially with fungal organisms. TEE showed
slightly worsened MR [**First Name (Titles) **] [**Last Name (Titles) 16169**] MV [**Last Name (Titles) **]. Will plan 6
weeks ambisome with f/u cx. Daptomycin 400 mg IV daily for 10
more days, then vancomycin 1g IV qod. Had initially been
diuresed for CHF, now euvolemic.
.
B). Pulm: The fever is unlikely to be due to a pulmonary source
given his lack of focal signs or symptoms including lack of
cough, sputum. Initialy appeared in CHF after transfer out of
[**Hospital Unit Name 153**]. Diuresed well, now euvolemic.
.
C). GI/Liver: Patient's Crohn's disease appears to be stable,
without evidence of a hepatobiliary source by LFTs. No abdominal
pain, and able to take some pos.
.
D). Musculoskeletal: The pt has a known history of
osteomyelitis for which he is on chronic treatment with
vancomycin QOD (which is an unusual dose given his creatine
clearance would suggest a once daily to [**Hospital1 **] dosing). No neck or
back pain.
.
E). Lines: As stated above, the pt has an existing Hickman
catheter for his TPN and history of multiple line infections.
Will hold off on pulling Hickman at this time and will need to
be pulled if fungal BCx comes back positive after 6 weeks.
.
4. Renal: The pt has a history of CKD with creatinine baseline
in 1.2 range, now elevated at 1.8, looks dry on exam, giving IVF
now, will recheck chem 10 tomorrow, K elevated at 5.9 [**5-13**],
giving IVF and recheck today. Will need to have potassium free
TPN on discharge and repeat chem 10 [**5-14**].
.
5. FEN: low salt diet, replete electrolyts with cautions.
.
6. PPx: heparin sub Q TID for DVT prophylaxis, protonix for GI
ppx. Pt does not need bowel regimen given his chronic diarrhea.
.
7. Code status: full code
Medications on Admission:
MEDICATIONS:
1. Niferex 150mg [**Hospital1 **]
2. Protonix 40mg once daily
3. Imodium 4mg Q6hours
4. Vitamin C 500mg once daily
5. Tums 1250mg 5x/day
6. Rocaltrol 0.25mg once daily
7. Vitamin D 50,000u Qweek
8. Zestril 20mg once daily
9. Vancomycin 1gm IV Q48hours
10. Unasyn 3g IV Q8hours
11. Tylenol
12. Risperdal 0.25mg [**Hospital1 **]
13. Norvasc 2.5mg once daily
14. Zofran 4mg IV Q8hours PRN N/V
15. Erythropoietin 10,000SQ weekly
16. Glutamine 10 g powder 3x/day
17. Sandostain LAR depot30mg IM Qmonthly
18. Ativan 1mg QHS PRN
19. Ambien 5-10mg QHS PRN
.
ALLERGIES: NKDA
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO 5X/D
(5 times a day).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Glutamine 10 g Packet Sig: One (1) Packet PO TID (3 times a
day).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5,000
units Injection TID (3 times a day).
9. Opium 10 % Tincture Sig: 0.6 ML PO QID (4 times a day).
10. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
11. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed for insomnia.
12. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea.
13. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale sliding scale Injection ASDIR (AS DIRECTED).
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
15. Daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg
Intravenous Q24H (every 24 hours) for 10 days.
Disp:*qs 10 days* Refills:*0*
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
17. Amphotericin B Liposome 50 mg Suspension for Reconstitution
Sig: Two Hundred (200) mg Intravenous Q24H (every 24 hours) for
6 weeks: Will need mycolytic blood cultures with oil
supplemented media after completion.
Disp:*qs 6 weeks* Refills:*0*
18. Vancomycin 1,000 mg Recon Soln Sig: 1,000 mg Intravenous
every other day: Please start on [**2196-5-23**] (day after finishes
daptomycin course).
Disp:*qs 1 month* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Fungemia with Malassezia furfur
Bacterial/fungal endocarditis
Mitral valve regurgitation
Crohn's disease
Short gut syndrome
osteoporosis
Dependence on TPN
Discharge Condition:
stable
Discharge Instructions:
Please continue your regular medications. In addition please
continue ambisome 200 mg IV daily for next 6 weeks. Please
continue taking daptomycin for next 10 days then will change to
vancomycin 1g IV every other day ongoing. You will need to have
your creatinine checked every week and faxed to Dr. [**Last Name (STitle) 22874**] at
[**Telephone/Fax (1) 1419**]. After 6 weeks of therapy with ambisome you will
need mycolytic blood cultures with oil supplemented media to
make sure you have cleared your fungal infection. Please
continue to perform an amphotericin lock of your Hickman
catheter daily when not recieving medications or TPN (3cc of
1mg/ml amphotericin B to lock your Hickman catheter).
Followup Instructions:
1. Please have your Chem 7 checked [**2196-5-14**], as your K had been
elevated [**5-13**]. Please also have weekly Chem 10 drawn and faxed
to Dr. [**Last Name (STitle) 22874**].
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2196-6-2**] 11:00
2. Please follow up with Dr. [**Last Name (STitle) 5717**] in [**11-22**] weeks.
3. Please also follow up with Dr. [**Last Name (STitle) 79**] in [**12-25**] weeks.
ICD9 Codes: 4280, 5849, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 936
} | Medical Text: Admission Date: [**2160-11-13**] Discharge Date: [**2160-11-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 22656**] is an 85 year-old man with a history of hypertension
and coronary artery disease who presented with angina, now being
transferred to the CCU after bieng found to have left main
coronary artery disease.
Six months prior to admission, began experiencing
"palpatations", described as chest pressure over the left
nipple. It would occur in the morning and occasionally
throughout the day and would be worsened by his morning weight
lifting. Each episode would last ~5-10 minutes. They were not
associated with SOB, diapheresis or nausea. He contact[**Name (NI) **] his PCP
he referred him to a cardiologist (Dr. [**Last Name (STitle) **]. A stress MIBI was
performed and reportedly positive per the patient though we do
not have the report. He was then prescribed SL nitro which he
took twice daily, with or without symptoms though he does
believe that taking it with symptoms did help.
Four months ago he underwent cataract surgery, at which time he
stopped aspirin. The surgery was uneventful.
Three months prio to admission, the angina resolved and he ran
out of nitro. Two weeks prior to admission he stopped aspirin in
preparation for spinal stenosis surgery. Five days prior to
admission, he again began to experience palpatations. He was in
[**State 108**] for his surgery and, upon describing his symptoms to the
anesthiologist, was cancelled. He flew back to [**Location (un) 86**] on [**11-13**]
and called his PCP who referred him to the ED for further
evaluation.
In the ED VSS, EKG showed old LBBB per his PCP. [**Name10 (NameIs) **] CP resolved
with SL NTG x1. He was given ASA 325mg and started on a heparin
gtt.
Overnight, he was continued on nitro and heparin gtts and had
stuttering chest pain. On the morning of transfer he was loaded
with Plavix 600mg and sent for cardiac cath where he was found
to have a 80% ulcerated left main lesion.
ROS
(-) PND/orthopnea
(+) Edema, chronic
(-) Fevers/chills/weight change
(+) Sinus congestion with Flomax
(-) Cough
(+) Occasional heart burn
(+) Constipation (BM every 2-3 days)
(-) Nausea/vomiting/diarrhea
(-) Bloody stools
(+) "Black stools"
(+) Chronic leg pain, anteriorly, though secondary to spinal
stenosis
Negative colonoscopy in [**2155**], per patient
PSA normal, per patient
Past Medical History:
1. CARDIAC RISK FACTORS:
(-) Diabetes
(-) Dyslipidemia
(+) Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PCI: None.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
- Old LBBB (old per PCP)
- History of paroxysmal atrial fibrillation (patient denies)
- BPH
- Spinal Stenosis
- Cataracts, s/p surgery
- History of nephrolithiasis
- History of bilateral hip fracture, s/p repair (right in [**10-3**];
left in [**12-4**])
Social History:
Orginially from [**Country 2784**]. Retured from teaching mechanical
engineering at [**University/College **]. Quit smoking 45 years ago, rare EtOH, no
drugs. Married.
Family History:
(+) HTN, (+) CAD.
Physical Exam:
VS: Afebrile, 127/55, 56, 12, 95% on room air
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: MMM. NCAT. Sclera anicteric. Right pupil 3mm --> 2mm and
left faintly reactive, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: Regular rate, normal S1, S2. II/VI systolic murmur at
LUSB
LUNGS: Anteriorly clear.
ABDOMEN: Soft, NTND.
EXTREMITIES: 2+ edema bilaterally; 2+ DP pulses
BUTTOCK: 4x3cm tan discolorated area on right buttock; blanches;
skin intact.
SKIN: No rashes.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
Laboratory values:
[**2160-11-13**] 06:05PM BLOOD WBC-6.2 RBC-4.64 Hgb-13.8* Hct-39.2*
MCV-85 MCH-29.9 MCHC-35.3* RDW-14.2 Plt Ct-142*
[**2160-11-16**] 04:09AM BLOOD WBC-6.3 RBC-4.13* Hgb-12.5* Hct-35.4*
MCV-86 MCH-30.4 MCHC-35.4* RDW-14.2 Plt Ct-144*
[**2160-11-13**] 06:05PM BLOOD PT-13.0 PTT-30.5 INR(PT)-1.1
[**2160-11-16**] 07:59AM BLOOD PT-12.8 PTT-50.3* INR(PT)-1.1
[**2160-11-16**] 07:59AM BLOOD FDP-0-10
[**2160-11-16**] 07:59AM BLOOD Fibrino-344 D-Dimer-As of [**10-28**]
[**2160-11-15**] 11:12AM BLOOD ESR-10
[**2160-11-13**] 06:05PM BLOOD Glucose-121* UreaN-15 Creat-0.9 Na-140
K-4.0 Cl-107 HCO3-26 AnGap-11
[**2160-11-16**] 04:09AM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
[**2160-11-14**] 04:00PM BLOOD ALT-11 AST-15 CK(CPK)-51 AlkPhos-60
Amylase-38 TotBili-0.9
[**2160-11-13**] 06:05PM BLOOD CK(CPK)-71
[**2160-11-14**] 02:39AM BLOOD CK(CPK)-57
[**2160-11-14**] 10:33AM BLOOD CK(CPK)-50
[**2160-11-13**] 06:05PM BLOOD cTropnT-0.02*
[**2160-11-14**] 02:39AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2160-11-14**] 10:33AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2160-11-14**] 04:00PM BLOOD cTropnT-0.03*
[**2160-11-15**] 02:28AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9
[**2160-11-16**] 07:59AM BLOOD D-Dimer-476
[**2160-11-14**] 04:00PM BLOOD VitB12-277
[**2160-11-15**] 11:12AM BLOOD Triglyc-44 HDL-60 CHOL/HD-3.0 LDLcalc-109
[**2160-11-15**] 11:12AM BLOOD CRP-15.3*
[**2160-11-14**] 10:11PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.050*
[**2160-11-14**] 10:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Imaging/Studies:
CXR - 1.2 cm nodular opacity in the left upper lung zone,
concerning
for lung mass. Followup imaging is recommended.
ECG - Sinus rhythm with a first degree A-V block. Old left
bundle-branch block.
ECHO - The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%), mostly secondary
to left bundle branch block-related septal motion. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are three aortic valve
leaflets. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Symmetric LVH with borderline global systolic
function. Mild mitral regurgitation. Mild pulmonary
hypertension.
CT head w/o - IMPRESSION: Loss of [**Doctor Last Name 352**]-white matter
differentiation in the medial right frontal lobe, MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted imaging is recommended to rule out acute
infarction.
MRI/A head:
IMPRESSION:
1. Acute right anterior cerebral artery territorial infarct.
2. Tiny small areas of slow diffusion in the right parietal,
right medial
occipital, left parietal and the left frontal regions indicate
multiple small infarcts, which could be embolic in nature.
MRA OF THE HEAD:
Head MRA demonstrates normal flow signal within the arteries of
anterior and posterior circulation.
IMPRESSION: Normal MRA of the head.
Brief Hospital Course:
85M presenting with chest pain admitted initially to cardiology
service. Patient continued to have chest pain and underwent
emergent catheterization and found to have left main disease. He
was transferred to the CCU to await CABG, but had a R ACA stroke
and CBAG was deferred. He was discharged to rehab in stable
condition.
# Coronary Artery Disease: Initially presented with concern for
unstable angina; ruled out by cardiac enzymes; ECG was difficult
to interpret in setting of LBBB. Medically managed overnight
with heparin gtt, nitro gtt, ASA, BB, statin. Caridac cath on
[**11-14**] showed LMCA ulcerated lesion of 70% and tortuous aorta.
Given LMCA lesion and its nature, patient was transferred to CCU
for further observation prior to possible CABG. He was continued
on ASA, heparin gtt and metoprolol and high dose statin. Nitro
gtt was started to maintain patient symptom free and maintain BP
<120. ASA was decreased to 81 mg QD. Patient was also started on
Integrillin drip on [**11-15**] which was discontinued on [**11-16**], given
no further catheterization. Metoprolol was started low dose, and
he is charged on 25mg toprol daily. ACEI held for now. Can start
amlodipine 5mg if neeeded at rehab.
# CVA: On [**11-15**] patient was noted to have LLE paresis and LUE
weakness, urinary incontinence on routine vitals check. VS were
stable. Given that these findings were new, neurology
consultation was immediately obtained. Last normal exam was 3
hrs prior to observation of symptoms. Heparin was temporarily
stopped given concern for intracranial hemorrhage (ICH). CT head
confirmed no ICH and heparin gtt was restarted. Given unclear
timing of the event, tPA was not administered. MRI of head
showed acute infarct in the Right ACA territory consistent w/
exam. Given relatively small size of infarction and being
outside of 5hr window, pt did not undergo MERCI retrieval. By
[**11-16**], patient's exam markedly improved w/ [**3-1**] distal and 4+/5
proximal LLE. At time of discharge pt's exam was [**3-1**] upper and
lower extremity strength. Per Neurology recommendations patient
was started on coumadin for total duration of at least 3mo.
Patient discharged on Lovenox as bridge to therapeutic INR on
coumadin. Patient discharged to rehab and has neurology follow
up in 3 months.
.
# Acute on Chronic Diastolic Heart Failure: On admission,
patient had 2+ lower extremity edema dn elevated JVP to 10cm, no
prior history of heart failure. Echo showed symmetric LVH with
borderline global systolic function, EF 50-55%, likely secondary
to LBBB. Mild mitral regurgitation and mild pulmonary
hypertension were also noted. Given CVA, no lasix was
admininistered to maintain pressures > 120 systolic. ACE-I was
also held due to concern for hypotension, and betablocker dose
dose was decreased temporarily while hypotetnsive, but was
titrated back up to 12.5 mg [**Hospital1 **]. Patient was provided with [**Male First Name (un) **]
stockings.
.
# Sinus bradycardia: Bradycarid to the 50's throughout
admission. Patient has reported history of PAF but patient
denies this. Patient remained in sinus rhythm throughout
hospitalization. Given history of Atrial fibrillation, patient
will require 2wk monitoring of HR to assess for duration of
anticoagulation. If goes into atrial fibrillation, will likely
need life-long anticoagulation, to be determined by out patient
cardiologist.
.
# Acute Anemia: Patient was found to have Hct decreased from 39
to 34 post cath. No active sources of bleeding were identified,
however pt had one guiac positive stool on [**11-17**]. HCT improved
to 35 by [**11-16**] and remained stable for the remainder of
hospitalization.
.
# Spinal Stenosis: Surgery was delayed until cardiac disease
issues were resolved. Patient was treated w/
oxycodone/acetaminphen and IV morphine prn for pain control.
.
# Hypertension: Patient was hypertensive on admission. He was
continued on home regimen of norvasc, quinopril and motoprolol
prior to catheterization w/ SBPs in 140-150 range. ACE-I and CBB
were held in setting of relative hypotension. amlodipine can be
restarted as needed.
.
# Lung Nodule: Noted on CXR as incidental finding, no priors for
comparison.
Patient will require CT as outpatient for further evaluation.
.
# Right Buttock Prior Decub Ulcer Site: Patient reports this is
site of prior decub which occured during hip fracture surgery.
Per his report, was difficult to heal. On exam, a well healed,
erythematous area was noted. Skin care w/ frequent
repositioning and dry dressings was performed.
.
# Propylaxis: DVT - lovenox 90mg sq [**Hospital1 **] transitioned to
warfarin. Continue lovenox until therapeurtic INR ([**12-30**]) for 2
days. Protonix 40mg PO daily while in ICU, discontinued on
discharge.
.
# Code: FULL CODE
Medications on Admission:
Norvasc 10mg daily
flomax
quinapril 20mg daily
Aspirin 81mg daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: dose adjust for goal INR [**12-30**]. x 3 months (until [**2160-2-9**]).
8. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q12H (every 12 hours): 90 mg sq [**Hospital1 **]. Continue until therapeutic
on coumadin (INR [**12-30**]) for 2 days.
9. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
Unstable Angina
Left Main Coronary Artery Disease
Right Anterior Cerebral Artery Stroke
Secondary Diagnoses:
Left Bundle Branch Block
Hypertension
Spinal Stenosis
Possible history of Atrial Fibrillation
BPH
Discharge Condition:
Good, vitals stable.
Discharge Instructions:
You were admitted with chest pain and you had a cardiac
catheterization which showed a blockage the main left artery of
the heart which cannot be fixed with a stent. The cardiac
surgeons saw you and determined that you would be a candidate
for bypass surgery. Unfortunately, you had a small stroke as a
complication of the catheterization. Because of this, you will
need to go to rehab to regain your strength before considering
heart surgery.
Several medications were adjusted:
- Atorvastatin 80mg daily should be taken every day
- Toprol 25mg daily
- You were started on Coumadin for your stroke, this is a blood
thinner that prevents clots from forming. Lovenox will be
administered until the coumadin levels are therapeutic
- Quinipril has been held.
If you have chest pain, shortness of breath, high fever, pain at
your groin, severe abdominal pain, dizziness or lightheadedness
or any other concerning symptom, please seek medical care
immediately.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
CARDIOLOGY:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2160-12-5**] at 10:30AM
NEUROLOGY:
Dr. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2574**] [**2161-2-17**] at 2:00pm
CARDIAC SURGERY:
Dr. [**Last Name (STitle) 81943**] [**Name (STitle) **] ([**Telephone/Fax (1) 6876**] on [**12-18**] (thursday) at
1:30 [**Initials (NamePattern4) **] [**Hospital Unit Name **], [**Location (un) **], suite A at [**Hospital1 18**] on the
[**Hospital Ward Name **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4111, 4019, 2875, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 937
} | Medical Text: Admission Date: [**2124-8-18**] Discharge Date: [**2124-8-29**]
Date of Birth: [**2045-2-15**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
transferred for preoperative evaluation and management of MSSA
endocarditis complicated by aortic root abscess.
Major Surgical or Invasive Procedure:
1) cardiac catheterization [**2124-8-18**]
2) temporary pacemaker implantation [**2124-8-18**]
3) electrophysiology study [**2124-8-24**]
4) PICC placement
History of Present Illness:
79 yo male with bioprosthetic AVR in [**2116**], CAD s/p CABG x2 in
the past(cath [**2124-8-18**] all three grafts are patent),
bifascicular block, recent redo total L hip who was transferred
to [**Hospital1 18**] on [**2124-8-18**] from OSH where he was admitted [**8-7**] with
acute MSSA endocarditis.
The patient was intially admitted to [**Hospital 4068**] hospital on [**8-7**] s/p
fall at home with sepsis, MS changes and hypotension SBP in
70's, CVP 5. He was diagnosed with LLL PNA which was initially
thought to be the source of his infection and was given
Ceftriaxone/Vanc and IV hydration with response (no pressors).
Blood cx then grew MSSA and Abx were changed to Oxacillin on HD
#2. Pt continued to be febrile and on HD #4 Gentamycin/Rifampin
were added. (Initial TEE [**8-9**] showed no vegetations, repeat TEE
[**8-17**] was positive for AVR vegetations with valve ring abscess).
His outside hospital course was complicated by 1) enzyme leak
without ECG changes for which he was started on [**Last Name (LF) **], [**First Name3 (LF) **],
heparin 2) anemia (guaiac +) for which patient received
trnasfusions 3) plt drop 145 -->95-->72 over two days - heparin
products were held, HIT Ab later came back negative, and he was
restarted on SQ heparin without problems 4) PR prolongation HD
#8
The patient was seen by orthopedic consultants and his L hip was
aspirated but culture was negative for infection.
Past Medical History:
1. CAD s/p CABG [**2096**], [**2109**]
2. bioprosthetic AVR [**2116**]
3. Bilateral carotid EA; left in [**2106**]
4. CRI baseline Cr 1.3
5. prostate cancer diagnosed [**3-31**] [**Doctor Last Name **] 3 and 3
6. MDS (dx [**11/2118**])
7. DJD
8. bilat THR; left THR revision [**2124-6-30**]
9. chronic LE ulcers
10. s/p appy
11. s/p chole
12. s/p enzyme leak likely demand ischemia on [**2124-8-8**]-peak trop
of 5.2.
Family History:
Non contributory
Physical Exam:
At the time of presentation to the CCU
General: lethargic, tired-looking, oriented to self and year
only, does not always answer questions appropriately
HEENT: NC, AT, sclera white, conjunctiva pink, EOM intact,
PERRLA, MM moist without lesions
Neck: JVD at about 10 cm
Pulm: CTA bilaterally
CV: regular, 2/6 SEM best heard at the apex and along LSB
Abd: +BS, soft, NT, ND
Extr: no c/c/e, bilateral calcaneal eschars R>L
R groin; no bruit, no ecchymosis, no hematoma
Hands: no splinter hemorrhages, no [**Last Name (un) 1003**] lesions, no Osler
nodes.
Pertinent Results:
[**2124-8-18**] 08:21PM WBC-9.8 RBC-3.21* HGB-10.0* HCT-30.9* MCV-96
MCH-31.1 MCHC-32.2 RDW-15.3
[**2124-8-18**] 08:21PM PLT COUNT-261
[**2124-8-18**] 08:21PM PT-15.4* PTT-28.1 INR(PT)-1.5
[**2124-8-18**] 08:21PM FIBRINOGE-684*
[**2124-8-18**] 08:21PM TSH-1.8
[**2124-8-18**] 08:21PM HAPTOGLOB-132
[**2124-8-18**] 08:21PM ALT(SGPT)-7 AST(SGOT)-14 LD(LDH)-247 ALK
PHOS-79 TOT BILI-0.3
[**2124-8-18**] 08:21PM ALBUMIN-2.3* CALCIUM-6.7* PHOSPHATE-11.5*
MAGNESIUM-1.6
[**2124-8-22**] 04:01PM BLOOD CRP-15.52*
[**2124-8-22**] 04:01PM BLOOD ESR-82*
[**2124-8-21**] 08:06PM BLOOD VitB12-332
[**2124-8-20**] 04:59AM BLOOD LD(LDH)-615* TotBili-0.6 DirBili-0.1
IndBili-0.5
[**2124-8-23**] 03:22AM BLOOD ALT-7 AST-15 LD(LDH)-253* AlkPhos-82
TotBili-0.3
[**2124-8-25**] 04:33AM BLOOD ALT-12 AST-25 AlkPhos-88 TotBili-0.3
[**2124-8-26**] 05:54AM BLOOD Glucose-99 UreaN-26* Creat-2.2* Na-139
K-3.6 Cl-107 HCO3-21*
[**2124-8-26**] 05:54AM BLOOD PT-16.2* PTT-38.0* INR(PT)-1.7
[**2124-8-20**] 04:59AM BLOOD Ret Man-1.1
[**2124-8-18**] 08:21PM BLOOD HEPARIN DEPENDENT ANTIBODIES-negative
R knee joint fluid [**8-22**]: no crystals, moderately bloody, WBC
211, RBC [**Numeric Identifier 47330**], Poly 63%, Lymphs 19%, Mono 18%.
Microbiology:
Blood cultures 8/20 x1, and [**8-20**] x 2 - no growth (final)
Blood cultures 8/23 x2, [**8-23**] x2 - no growth to date
Stool for c diff x 2 - negative
R knee joint fluid [**8-22**] - no growth (final)
L heel eschar swab [**8-22**] - no growth
L heel eschar swab [**8-23**] - rare growth coagulase negative Staph
L heel foot culture [**8-23**] - rare growth coagulase negative Staph
[**8-18**] CARDIAC CATHETERIZATION - right dominant, three vessel
native coronary artery disease. (LMCA distal 50% lesion amid
diffuse disease throughout
the vessel. LAD 80% origin stenosis, totally occluded mid
vessel; D2 branch 70% lesion. LCX was totally occluded
proximally. RCA had a total occlusion mid vessel.)
Resting hemodynamics revealed a mean PCW pressure of 7mmHg
suggesting low normal filling pressures. CO was 3.9 l/min.
Graft angiography revealed patent LIMA to LAD, SVG to OM, and
SVG to RPDA. The three vein grafts from the patients prior CABG
in [**2091**] were stump occluded.
[**8-19**] CT head - negative for intracranial process
8/22 L hip and R knee films - moderate effusion of R knee.
Bilateral heel films - no osteomyelitis.
[**8-21**] TEE - Mild global depression of the left ventricular
systolic function (LVEF 45%). Moderate sized mobile echogenic
structure most consistent with a vegetation
(1.6 x 1.3 cm) attatched to the base of the anterior mitral
valve leaftet/junction of the mitral and aortic annulus.
Thickened mitral valve leaflets with moderate mitral
regurgitation. There is an aortic root abscess. The aortic
bioprosthesis appears well seated with mild to moderate aortic
insufficiency.
[**8-22**] CT bilateral LE - Soft tissue abnormality in each heel
extending down to the calcaneal cortical surface; osteomyelitis
cannot be excluded.
[**8-22**] CT abdomen/pelvis - Negative for emboli; bilateral pleural
effusions (L>R), intra-abdominal soft tissue stranding; calculus
in lower pole of right kidney; 4 cm simple renal cyst in right
kidney.
[**8-24**] Bone scan - Osteomyelitis of the posterior aspect of the
left calcaneus. Activity in L hip c/w post-surgical changes,
but an infectious process cannot be ruled out. Tracer activity
in the shoulders, knees, feet, lumbar spine c/w
degenerative changes.
[**8-25**] Renal US - No eidence of renal mass or hydronephrosis. 2 mm
non-obstructing stone in the lower pole of the right kidney.
Brief Hospital Course:
1. MSSA endocarditis s/p bioprosthetic AV - The patient was
admitted to the CCU service. Infectious disease was consulted
and has followed the patient throughout his stay. The patient
was continued on Oxacillin, Rifampin and renally dosed
Gentamycin. Gentamycin was stopped one day early 08/25 per ID
recommendations (expected end of therapy [**8-24**]) because of
worsening renal function. Oxacillin/Rifampin were continued with
the plan to complete a 6wk course (expected end [**9-20**]) until
the patient and family decided to change his code status to CMO.
The antibiotics were stopped the day of transfer to hospice.
The patient initially continued to spike fevers but has been
afebrile since [**2124-8-21**]. His WBC also has remained within normal
limits. Blood cultures from the OSH collected [**8-11**] and [**8-16**] had
no growth. Blood cultures 8/20 and [**8-20**] final results were also
negative. Blood cultures 8/23 and [**8-23**] show no growth to date.
LFTs were monitored in this paitent on Oxacillin and were WNL.
CT surgery was consulted regarding valve replacement because it
was felt that given aortic root abscess and conduction
abmormalities the patient may benefit from early surgical
intervention. CT surgery was reluctant to operate because of
concern that the patient may have another site of active
infection separate from his cardiac abscess. This prompted
extensive work up to r/o another site of infection. Dental
service was consulted to evaluate the patient prior to surgery
and they recommended extracting 2 molars prior to surgery. On
[**8-27**] per family's request, the patient's status was changed to
"comfort measures only".
2. CAD - 3VD s/p CABGx2 s/p enzyme leak on [**8-7**] CK peak 582, MB
peak 5.2, index only 1.0, TropI peak 5.3 likely due to demand
ischemia. The patient had cardiac catheterization performed on
[**2124-8-18**] which revealed that all 3 venous grafts were patent.
The patient was continued on [**Date Range **], low dose beta-blocker, and
lipitor. ACEI was not continued because of worsening Cr. The
patent has been tachycardic with HR in 90-100 most of the time.
This was attributed to infection and his tachycardia was not
controlled for that reason. TSH was checked and was normal.
3. RBBB with bifascicular block, AV conduction delay secondary
to aortic abscess. Temporary pacing wire was placed [**2124-8-18**].
The patient has been monitored on telemetry and has had no
events during his stay. His EKGs were carefully monitored for PR
or QT prolongation but have been stable. PR about 240-260 msec
and QTc 450-480 msec. Mr. [**Known lastname **] [**Last Name (Titles) 1834**] electrophysiology
study on [**8-24**] which showed AVN and HIS disease, but given the
dynamic nature of his problem in the context of abscess, the
decision was made to re-evaluate the patient in 2 weeks and to
leave temporary pacer wire in place for now. On [**8-27**] he and his
family decided to change his code status to CMO and further w/u
was discontinued. HIs pacer was turned off on [**8-29**] before he
went to hospice.
4. HTN - The patient's blood pressures have been controlled with
low dose beta-blocker. Procardia 10 mg po qd was added on [**8-21**]
to help with afterload reduction/improve forward flow.
5. CHF - EF40%; The patient has been euvolemic through most of
his hospital stay. The goal has been to keep i/o's even. He was
given small amounts maintenance fluids at a slow rate on the
days he was NPO for procedures.
6. MS changes/confusion - were thought to be likely due to
infection. The patient has had waxing/[**Doctor Last Name 688**] mental status and
was oriented only to self, year (occasionally to month and
place). Psychiatry was consulted to r/o other causes of MS
changes and to assist with medical management. They did not feel
that the patient is depressed and recommended adding Haldol 2.5
mg IV bid to his regimen while monitoring QT prolongation. CT of
head was negative on [**8-19**] and was also negative at the outside
hospital. The patient was not given any sedating medications.
His mental status continued to wax/wane but overall has improved
throughout the hospital stay. On discharge he was given
prescriptions for morphine, haldol, ativan and scopalamine.
7. Renal - The patient's creatinine slowly increased from Cr 1.3
to 2.5 on [**8-27**]. Renal consult was obtained on [**2124-8-24**]. It was
felt that deteriorating renal function is secondary to
Gentamycin toxicity and contrast that he received. The patient's
antibiotics were renally redosed. They were dc'd on the day of
dc to hospice.
8. Anemia - The patient received blood transfusions on [**9-22**], [**8-25**], [**8-26**] to keep Hct at goal >30 . Anemia was thought to
be multifactorial due to CRI, blood loss during EP study, and
possibly due to MDS. CT abd/pelvis done because of concern for
thromboemboli did not show any retroperitoneal hemorrhage.
9. Thrombocytopenia at the outside hospital with Plt count
145->95->72 over 2 days (HIT Ab negative x 1 at OSH). Heparin
products were initially held but heparin sc was restarted on
[**8-22**] after HIT serology came back negative. The patient was not
fully anticoagulated because he was >2 months after his hip
surgery.
10. S/p left THR revision [**2124-6-30**] - Orthopedic surgery was
consulted. Plain hip films were done and did not show obvious
pathology. Of note, left hip was aspirated at the outside
hospital and was negative.
11. R knee pain/effusion - R knee was tapped [**2124-8-23**] by
Orthopedic surgery and fluid culture was negative results
suggestive of non-inflammatory effusion. Rheumatology was
consulted [**2124-8-25**] and they recommended Tylenol but this was not
scheduled b/o concern that it would mask fevers.
12. Left calcaneal pressure ulcers was suspected to be a source
of bacteremia.
Podiatry consulted was consulted and ordered bilateral heel
films. CT [**8-22**] showed no evidence of OM. The decision was made
to proceed with bone scan which was done on [**8-24**] and showed
finding c/w OM of left heel. The patient was discharged to
hospice with instructions on dressing changes for his ulcers.
13. Nutrition - the patient has had poor po intake while in the
hospital. ALB 2.3 He passed video swallowing evaluation [**8-23**].
His oral meds were dc'd per patient and family request on [**8-28**].
14. Prophylaxis - Has been receiving prophylaxis with PPI, bowel
regimen, pneumoboots.
15. On [**8-27**] after discussion with Dr. [**Last Name (STitle) **], the family decided
to change the patient's status to comfort measures only. Hospice
consult was requested. A hospice was found and the patient was
transferred on [**8-29**].
Medications on Admission:
Outpatient medications: Zestril 40 qd, Lopressor 50 [**Hospital1 **], Zocor
20 qd, Lopid 600 [**Hospital1 **], [**Hospital1 **] 325 qd, Coumadin 2 mg po qd, Valium
prn
Transfer medications: Folate, MVi, Zocor, [**Hospital1 **], Heparin gtt,
Lopressor 25 [**Hospital1 **], Rifampin 300 q8 (started [**8-10**]), Gent 40 IV q 8
(started [**8-10**]), Oxacillin 2 q4
Discharge Medications:
1. Morphine Sulfate 20 mg/mL Solution Sig: One (1) PO Q2hours
as needed for pain, SOB.
Disp:*30 cc* Refills:*2*
2. Ativan 2 mg Tablet Sig: 0.5-1 Tablet PO q2hours as needed for
agitation: if haldol ineffective or if actively dying.
Disp:*30 Tablet(s)* Refills:*2*
3. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours as needed for secretions.
Disp:*30 patches* Refills:*0*
4. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] Home
Discharge Diagnosis:
1. Endocarditis, Staphylococcus aureus, methicillin sensitive
2. Aortic root abscess
3. Bifascicular block with new PR segment prolongation
4. Acute renal failure
5. Status post left total hip revision
6. Left calcaneal ulcer
7. Aortic insufficiency
8. Right knee effusion
9. Hypertension
Discharge Condition:
Comfort measures only, pacer turned off, antibiotics
discontinued.
Discharge Instructions:
Please keep Mr. [**Known lastname **] [**Last Name (Titles) **].
Followup Instructions:
None
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
ICD9 Codes: 2875, 5845, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 938
} | Medical Text: Admission Date: [**2168-8-10**] Discharge Date: [**2168-8-17**]
Date of Birth: [**2100-11-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Tunnelled Catheter Placement
History of Present Illness:
67m with htn, cad, afib, cva, esrd on hd presents with fevers
and sepsis. He apparently was found to be febrile at HD so was
transferred to the the ED.
In ED, attempts at subclavian and IJ's failed and a femoral line
was placed. A CT abdomen/pelvis was attempted, but contrast
extravasated out into the abdominal wall, for which surgery was
consulted.
At the time of admission, the patient was able to anwer basic
questions and follow commands, but seemed confused and was not
cooperative with the interpreter. His daughter was [**Name (NI) 653**] who
said that although normally fairly oriented, he generally
becomes confused in the setting of fever. She also noted that
she'd seen him the day prior to admission and that he had no
complaints and was acting his normal self. She said he'd had no
f/c, ha, neck pain, chest pain, sob, increased cough (has been
coughing since recent admit for aspiration pneumonia), abd pain,
n/v/d. He makes no urine. He was initially admitted to the MICU
and transferred out to the floor after 24 hours.
.
Currently, he has had no positive blood cultures for 48 hours
and is being maintained on vancomycin 1g QHD for MRSA sepsis. He
has no complaints, denies weakness, pain, shortness of breath,
chest pain, fevers, chills, nausea or vomiting. History taken
through bedside phone translator for Haitian Creole.
Past Medical History:
1) Left occipital lobe CVA [**2-22**] p/w change in MS [**First Name (Titles) **] [**Last Name (Titles) **],
chronic CVAs now on coumadin for likely embolic nature
2) Paroxysmal Afib, rate controlled with tachy/brady, occas 2
sec pauses, best managed with metoprolol 75 tid per cards
3) Chronic eosinophilia unknown etiology, strongyloides sent in
[**2-22**] for w/u as well as SPEP/UPEP
4) h/o GI Bleed in [**2167-7-20**] while on asa, plavix, IIb/IIIa
post-cath--no EGD or C-scope performed in f/u yet
5) ESRD secondary to HTN, dialysis MWF- followed by Dr. [**First Name (STitle) 805**]
6) h/o bacteremia w/ MSSA (last bacteremia [**11-22**] with coag neg
staph sensitive to oxacillin but resistent to PCN- treated
w/vanco)
7) h/o pulling out groin lines
8) HTN, controlled
9) CAD s/p NSTEMIS, 2 LAD stents, CABG [**2164**]: last ECHO [**2167-8-27**],
EF >55%
10) Hyperlipidemia
11) Diverticulosis
12) Severe Hyperparathyroidism, presumed adenoma, not on vitamin
D for this concern
13) chronic anemia
14) chronic transudative pleural effusions
15) h/o neurocysticercosis calcified
Social History:
Lives in nursing home. No tobacco, etoh, illicit drug use.
Transfer paper work from nursing home lists [**First Name4 (NamePattern1) **] [**Known lastname **] as the
relative or guardian ([**Telephone/Fax (1) 32722**].
Family History:
Mother with hypertension. No history of no strokes, seizures, or
heart disease
Physical Exam:
t 96.7, bp 130/86, hr 88, rr 12, spo2 99% 2lNC
gen- chronically-ill appearing male, pleasant, non-tox, NAD
heent- anicteric but muddy, op clear with mmm
neck- no jvd/lad
cv- irreg irreg, II/VI midsystolic murmur at the RLSB. no r/g.
PMI wnl.
Lungs- no resp distress or acc muscle use, poor air movement,
mild rales in bases l>r
abd- soft, nt, nd, +BS.
Ext- 1+ pitting edema LLE, none right, warm/dry
nails- no clubbing, [**Doctor First Name 15569**] nails
neuro- Knows name, knows at hospital, CN V, VII-XII in tact,
although the patient squints his right eye (he is capable of
opening both eyelids wide). EOM difficult to assess s/s
compliance. No asterixis. DTR's in tact and equal bilaterally.
Seems to be weaker on the left side.
Pertinent Results:
[**2168-8-10**] 11:00AM BLOOD WBC-14.3*#
[**2168-8-10**] 05:00PM BLOOD WBC-27.4*#
[**2168-8-10**] 07:00PM BLOOD WBC-21.5*
[**2168-8-11**] 03:38AM BLOOD WBC-18.0*
[**2168-8-12**] 02:00AM BLOOD WBC-11.6*
[**2168-8-12**] 03:41PM BLOOD WBC-9.7
[**2168-8-14**] 05:00AM BLOOD WBC-7.0
.
[**2168-8-14**] 05:00AM BLOOD PT-21.2* PTT-36.1* INR(PT)-2.1*
[**2168-8-10**] 11:00AM BLOOD Glucose-68* UreaN-19 Creat-3.8* Na-139
K-3.6 Cl-96 HCO3-33* AnGap-14
.
[**2168-8-10**] 11:00AM BLOOD cTropnT-0.14*
[**2168-8-10**] 05:40PM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2168-8-11**] 03:38AM BLOOD cTropnT-0.16*
[**2168-8-13**] 03:40PM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2168-8-14**] 12:15AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2168-8-14**] 05:00AM BLOOD CK-MB-2 cTropnT-0.12*
.
[**2168-8-14**] 05:00AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.4
[**2168-8-11**] 03:48AM BLOOD Type-[**Last Name (un) **] Temp-36.2 Rates-2/ pO2-31*
pCO2-52* pH-7.40 calTCO2-33* Base XS-5 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
.
CXR: IMPRESSION: AP chest compared to most recent prior chest
film [**2168-7-11**]: Consolidation in the lung bases has improved
and small left pleural effusion has decreased. Small region of
prior right apical consolidation has cleared. Moderate
enlargement of the cardiac silhouette has decreased. There is
no pneumothorax. No change in alignment of sternal wires
including fracture of the most superior and the off-line
configuration to the most inferior two.
.
CT Abd/Pelvis: IMPRESSION: 1. Complete extravasation of
administered contrast into the patient's right lower quadrant in
an extraperitoneal location. The likely explanation for this
finding is that the right femoral CVL tip was positioned in the
right inferior epigastric vein, which ruptured upon contrast
administration. 2. Slightly limited exam due to the lack of
intravenous contrast, but no definite acute intraabdominal
abnormalities identified.
.
ECG Study Date of [**2168-8-10**] 10:25:58 AM Shaky baseline. Probable
atrial fibrillation with rapid heart action and tachycardia.
Inideterminate axis. Non-specific ST segment depression in leads
V4-V6, either rate-related or ischemic. Compared to the previous
tracing of [**2168-7-10**] atrial fibrillation was previously present
with likely continuation to the present. Low voltage in the limb
leads as before. ST segment depressions were previously present.
.
TTE: Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is low
normal (LVEF 50-55%).
3. The right ventricular cavity is dilated. Right ventricular
systolic
function appears depressed.
4. The ascending aorta is mildly dilated.
5. The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
7. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension.
8. No evidence of endocarditis seen.
9. Compared with the prior study (images reviewed) of [**2168-5-31**],
tricuspid
regurgitation and pulmonary hypertension are worse.
.
Tunnelled Cath Report: IMPRESSION: Successful placement of a
tunneled left groin hemodialysis catheter for a left temporary
triple-lumen hemodialysis catheter.
Brief Hospital Course:
67m with cad, afib, esrd here with fevers and elevated WBC found
to have MRSA sepsis now on Vancomycin IV.
.
#MRSA Baceteremia -- Pt met SIRS criteria with fever, wbc, and
occasional tachycardia. There was no evidence of severe sepsis
or septic shock, with pt actually hypertensive and no other
end-organ disease noted during MICU stay. Possible primary
sources for MRSA sepsis would be his HD line which was removed
and site replaced. WBC is now wnl.
-D/w renal, do not feel it's necessary to pull L femoral
catheter at this time (placed on [**8-11**]) even though 1 pos Blood
cx on [**8-12**].
-Vanco for MRSA bacteremia administered during dialysis, s/p
Gentamicin 80mg QHD X 2 doses with HD for synergy.
- Decision made to defer TEE due to risk/benefit ratio in his
case - he has a h/o a GI bleed that has not been worked-up and
is at high risk for aspiration so would need to be intubated for
the procedure. Will plan to treat empirically for endocarditis
with 6 wks of Vanc (through [**2168-9-23**].)
- Last positive blood cx [**8-12**], afebrile, hemodynamically stable
.
# Chest Pain - Has had intermittant episodes of CP. Unlikely to
be cardiac in origin as without ECG changes, prior cycled
enzymes neg (elevated trop but his trop is elevated at
baseline). GI causes are also in the differential and after
giving maalox, symptoms resolved. Possible that the patient is
having gastritis. Ordered PPI and maalox/benadryl/lidocaine mix.
Patient is no longer symptomatic.
.
#Contrast extravasation -- Felt to be due to superficial
placement of CVL. Currently asymptomatic. NTD per surgery.
.
#CAD -- No active ischemia, con't asa, atorvastatin, metoprolol,
lisinopril. patient ruled out for mi.
.
#Afib -- Con't metoprolol - decreased dose to 12.5mg [**Hospital1 **] due to
episode of bradycardia to 30s (asymptomatic). Warfarin held for
several days for the possibility of procedures but he was
restarted on 3 mg po qd on [**8-16**].
.
#ESRD -- Con't HD on MWF. Con't sevelamer, nephrocaps
.
#HTN -- Con't lisinopril, metoprolol, clonidine, amlodipine
.
# Anemia -- Microcytic, likely a mixed picture of
iron-deficiency and ACD
- added iron supplement
.
#FEN -- Renal diet; vol even
.
#PPx -- boots, aspiration precautions
.
#Code -- full, confirmed with family
.
# Dispo -- d/c to nursing home with 6 wks antibiotics
- needs to have ongoing safety labs (CBC, Chem 10, LFTS, INR,
Vanc trough) followed by Dr. [**Last Name (STitle) **]
- PCP and ID [**Name9 (PRE) 32723**] scheduled
.
#Contact -- [**Doctor Last Name **], daughter, [**Telephone/Fax (1) 32724**]. [**Name (NI) **], wife,
([**Telephone/Fax (1) 32722**].
Medications on Admission:
-Lisinopril 10mg daily
-Folic Acid 1mg daily
-Docusate 100mg [**Hospital1 **]
-Nephrocaps
-Sevelamer 800mg TID
-Warfarin 3mg daily
-Lactulose 30cc daily
-Trazodone 50mg qHS
-Cinacalcet 30mg daily
-Aspirin 325mg daily
-Clonidine 0.2mg TID
-Amlodipine 5mg daily
-Atorvastatin 80mg qHS
-Metoprolol Tartrate 25mg [**Hospital1 **]
-Calcium Carbonate 500mg [**Hospital1 **]
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
6. Lactulose 10 g/15 mL Solution Sig: Thirty (30) cc PO once a
day as needed for constipation.
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 2 months.
16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous QHD (each hemodialysis) for 6 weeks: through
[**2168-9-23**].
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
MRSA bacteremia
Chest pain
Atrial fibrilation
ESRD on HD
HTN
Anemia
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
Please return to the hospital for fevers, chest pain, shortness
of breath.
.
Please take all medications as prescribed.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2168-9-1**] 10:40
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2168-9-20**]
9:00
Please have the following labs drawn weekly at dialysis and have
them faxed to Dr.[**Name (NI) 32725**] office: ([**Telephone/Fax (1) 9190**]
CBC with diff
CHEM 10
AST, ALT, Alk phos, TBili, INR, Vancomycin level prior to
dialysis
.
Continue to have dialysis Monday, Wednesday and Friday
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
ICD9 Codes: 4240, 5856, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 939
} | Medical Text: Admission Date: [**2138-1-1**] Discharge Date: [**2138-1-7**]
Date of Birth: [**2078-12-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet / Prozac
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2138-1-1**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
OM, SVG to RCA)
History of Present Illness:
59 y/o female with exertional chest pain that started in [**6-16**].
Underwent stress test and had no chest pain or SOB. But nuclear
images revealed perfusion defect involving distal inferior wall
and apex. She continued to be medically managed and initially
refused cardiac cath, but finally underwent one in [**12-17**]. Cath
revealed three vessel coronary artery disease.
Past Medical History:
Coronary Artery Disease, Hypertension, Hyperlipidemia, Diabetes
[**Last Name (LF) **], [**First Name3 (LF) **], Gastroesophageal Reflux Disease, Depression,
Anxiety, Chronic back pain s/p laminectomy, chronic headache,
s/p tubal ligation
Social History:
Denies tobacco or ETOH use.
Family History:
Non-contributory
Physical Exam:
VS: 67 20 218/102 5'4" 177#
Gen: WD/WN female in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, ?Bruit
Chest: CTAB
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused 1+rt leg edema
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**1-4**] CXR: Increasing pleural effusions (left greater than
right). Superimposed atelectasis or consolidation cannot be
excluded at the left base.
[**1-2**] Head CT: There is no evidence of acute hemorrhagic changes,
unchanged extensive chronic small microvascular ischemic disease
as described above. Bilateral dense arteriosclerotic
calcifications noted in both carotid siphons as well as in the
vertebral arteries. Please make note of MRI with diffusion-
weighted sequences is more sensitive in order to demonstrate
acute or subacute ischemic events.
[**2138-1-1**] Echo: Pre Bypass: The left atrium is moderately dilated.
A left atrial appendage thrombus cannot be excluded. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild to moderate
regional left ventricular systolic dysfunction with Severe
Apical Hypokinesis/akinesis, moderate septal and inferior
hypokinesis throughout. LVEF 40%. Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch and the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. Post
Bypass: The patient is initally AV-paced on phenylepherine,
later A paced on epinepherine (0.01 mcg/kg/min) and
nitroglycerin (0.5 mcg/kg/min) infusions. Overall LV function is
unchanged to slightly improved LVEF 45%. There is improvement in
inferior hypokinesis, which is now mild to moderate. Apical cap
is still severely hypokinetic to akinetic, but other apical
segments are now moderately to severely hypokinetic (previously
severely hypokinetic). There is trace mitral regurgitaton.
Aortic contours are intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
[**2138-1-1**] 02:18PM BLOOD WBC-10.6# RBC-2.94*# Hgb-8.6*# Hct-24.3*#
MCV-83 MCH-29.1 MCHC-35.3* RDW-13.3 Plt Ct-109*
[**2138-1-3**] 03:07AM BLOOD WBC-19.3*# RBC-3.36* Hgb-9.8* Hct-27.8*
MCV-83 MCH-29.1 MCHC-35.2* RDW-14.2 Plt Ct-132*
[**2138-1-6**] 05:00AM BLOOD WBC-9.6 RBC-3.09* Hgb-8.9* Hct-26.4*
MCV-85 MCH-28.7 MCHC-33.6 RDW-15.0 Plt Ct-216
[**2138-1-1**] 02:18PM BLOOD PT-15.2* PTT-35.8* INR(PT)-1.3*
[**2138-1-5**] 03:12AM BLOOD PT-13.1 PTT-24.4 INR(PT)-1.1
[**2138-1-1**] 03:44PM BLOOD UreaN-15 Creat-1.0 Cl-116* HCO3-21*
[**2138-1-6**] 05:00AM BLOOD Glucose-156* UreaN-24* Creat-1.2* Na-141
K-3.8 Cl-105 HCO3-27 AnGap-13
[**2138-1-6**] 05:00AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 8738**] was a same day admit and on [**1-1**] she was brought to
the operating room where she underwent a coronary artery bypass
graft x 3. Please see operative report for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. She remained intubated
overnight. On post-op day one she was weaned from sedation, but
was slow to wake up and had decreased response on left side.
Neurology was consulted and a head CT was performed. CT revealed
no CVA. The following day patient was more alert and had
improved movement on left side. Chest tubes and epicardial
pacing wires were removed per protocol. Patient required bedside
swallow d/t difficulty swallowing. She required tube feeds and
over a couple of days her swallowing improved and was able to
tolerate regular diet. On post-op day three she was transferred
to the telemetry floor for further care. Medications were
adjusted and electrolytes replete. She worked with physical
therapy for strength and mobility. Repaeat head CT was negative.
On post-op day six she appeared to be doing well without
deficits on left side, and was discharged home with VNA services
and the appropriate follow-up appointments.
Medications on Admission:
Lisinopril 40mg qd, Lopressor 100mg [**Hospital1 **], Nifedipine 60mg qd, NTG
SL prn, KCL 40mg qd, Spironolactone 25mg qd, Aspirin 500mg qd,
Lipitor 80mg qd, Imdur 60mg qd, Glyburide 10mg [**Hospital1 **], Tricor 48mg
qd, Conidine 0.1mg qd, Fioricet
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
7. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Disp:*4 Patch Weekly(s)* Refills:*0*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Hyperlipidemia, Diabetes [**Last Name (LF) **], [**First Name3 (LF) **],
Gastroesophageal Reflux Disease, Depression, Anxiety, Chronic
back pain s/p laminectomy, chronic headache, s/p tubal ligation
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 or while taking narcotic
pain medicine.
Followup Instructions:
Wound check on [**Hospital Ward Name 121**] 6 in 2 weeks
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**1-12**] weeks
Dr. [**First Name (STitle) **] in [**12-11**] weeks
Completed by:[**2138-1-7**]
ICD9 Codes: 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 940
} | Medical Text: Admission Date: [**2156-4-23**] Discharge Date: [**2156-4-27**]
Date of Birth: [**2071-1-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Transfer from OSH for hypoxia, hypotension, bilateral PE, s/p
MICU
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 year-old female, Russian-speaking, with hypertension
presented to [**Hospital **] Hospital with nausea, vomiting,
"trembling", found to have bilateral PE, and transferred to
[**Hospital1 18**] for further management. She felt well yesterday. This
morning upon wakening she developed shaking, nausea/vomiting,
headache, and overall felling unwell. She was noted by her
family to be pale and cool. She was taken to OSH by EMS. At OSH,
fluctuating oxygen saturation as low as 83% RA. During ED course
developed syncope vs. presyncope, sBP to 80s with standing,
fluid responsive. CTA chest reveal bilateral PE, small. Received
fondaparinux 7.5mg SC at 11:45am [**2156-4-23**], 1.5L NS, Zofran,
morphine. CT head per records within normal limits. Transferred
to [**Hospital1 18**] for further management.
.
In the ED, 99.1 92 124/73 96% 2L NC. Physical examination
notable for comfortable appearing female. Laboratory data
significant for chemistry panel within normal limits, hematocrit
35.5, WBC 11.0 with bandemia (10%), INR 1.7, lactate 2.0,
unremarkable UA. OSH CTA chest uploaded, again showing small
bilateral PE. EKG with sinus rhythm at 89, without evidence of
right heart strain or ischemia. Received Tylenol, IVF (total not
known). On transfer to MICU, 100.8, 95/58, 85, 26, 100 2L NC.
.
In the MICU, patient was accompanied by her son and husband. [**Name (NI) **]
translated for patient. She felt well. She denied chest pain,
palpitations, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, lower extremity edema or swelling. Denied
recent sick contacts. Pt was monitored in the MICU overnight.
Given pt was stable, she was called out of the MICU and
transferred to the medicine floor on [**2156-4-24**]. On arrival to the
floor, pt felt well. Reported small headache and min. shortness
of breath, but no other acute complaints.
.
Review of systems:
(+) Per HPI. Recent 2lb weight loss, unintentional. Dry cough
for several weeks. Intermittent discomfort left ankle - s/p
fracture several months ago.
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea, sore throat. Denies dysuria, urinary frequency.
Denies rashes or skin changes.
Past Medical History:
Hypertension
Hypercholesterolemia
s/p fracture to left ankle several months ago after slipping on
ice; managed non-operatively, able to ambulate
Denies prior malignancy.
?recent unexplained hypercalcemia - was supposed to see
endocrinologist on day of admission.
Social History:
Denies tobacco, alcohol use. Emigrated from [**Country 532**] in [**2142**].
Former engineer. Lives with her husband. [**Name (NI) **] lives in close
proximity.
Family History:
Son with multiple lower extremity blood clots following period
of immobilization. Mother with multiple blood clots. Niece
passed due to pulmonary embolism. No family history of
malignancy.
Physical Exam:
PHYSICAL EXAM on admission:
VS - Temp 98.9F, BP 118/43 , HR 78, R 22, O2-sat 95% NC 1L
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric,
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, + peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-17**] throughout, sensation grossly intact throughout.
.
PHYSICAL EXAM on discharge:
VS - VS: Tc 96.3 Tm:98.6 BP:108/62 HR:69 RR:18 O2 sat 97% RA
Exam: General: Sitting on bed, coughing
Cardiac: RRR
Pulm: CTA
Abdomen: soft, NT
Ext: Mild pedal edema, symmetric bilaterally, [**Location (un) 28048**] sign
absent
Pertinent Results:
[**2156-4-26**] 06:55AM BLOOD WBC-9.5 RBC-3.84* Hgb-11.5* Hct-34.1*
MCV-89 MCH-29.9 MCHC-33.6 RDW-14.2 Plt Ct-156
[**2156-4-27**] 07:05AM BLOOD WBC-5.5 RBC-3.87* Hgb-11.4* Hct-34.3*
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.4 Plt Ct-179
[**2156-4-26**] 06:55AM BLOOD PT-13.4 INR(PT)-1.1
[**2156-4-25**] 07:40AM BLOOD Glucose-94 UreaN-16 Creat-0.8 Na-144
K-3.6 Cl-112* HCO3-28 AnGap-8
[**2156-4-26**] 06:55AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-143
K-4.1 Cl-113* HCO3-23 AnGap-11
[**2156-4-26**] 07:15PM BLOOD CK-MB-2 cTropnT-<0.01
[**2156-4-27**] 02:25AM BLOOD cTropnT-<0.01
[**2156-4-25**] 07:40AM BLOOD WBC-15.6* RBC-3.99* Hgb-11.8* Hct-35.6*
MCV-89 MCH-29.6 MCHC-33.2 RDW-14.1 Plt Ct-135*
[**2156-4-24**] 03:59AM BLOOD WBC-19.8*# RBC-3.97* Hgb-12.0 Hct-35.0*
MCV-88 MCH-30.1 MCHC-34.2 RDW-14.0 Plt Ct-150
[**2156-4-23**] 03:15PM BLOOD WBC-11.0 RBC-3.98* Hgb-12.2 Hct-35.5*
MCV-89 MCH-30.6 MCHC-34.4 RDW-14.0 Plt Ct-175
[**2156-4-24**] 03:59AM BLOOD Neuts-79* Bands-9* Lymphs-7* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-4-23**] 03:15PM BLOOD Neuts-89* Bands-10* Lymphs-0 Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-4-24**] 03:59AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2156-4-25**] 08:45AM BLOOD PT-14.1* PTT-58.1* INR(PT)-1.2*
[**2156-4-25**] 07:40AM BLOOD PT-14.3* PTT-70.7* INR(PT)-1.2*
[**2156-4-24**] 03:59AM BLOOD PT-16.8* PTT-39.4* INR(PT)-1.5*
[**2156-4-23**] 03:15PM BLOOD PT-18.6* PTT-43.1* INR(PT)-1.7*
[**2156-4-25**] 07:40AM BLOOD Glucose-94 UreaN-16 Creat-0.8 Na-144
K-3.6 Cl-112* HCO3-28 AnGap-8
[**2156-4-24**] 03:59AM BLOOD Glucose-107* UreaN-21* Creat-1.1 Na-142
K-3.8 Cl-109* HCO3-24 AnGap-13
[**2156-4-23**] 03:15PM BLOOD ALT-132* AST-180* AlkPhos-90 TotBili-0.9
[**2156-4-23**] 03:15PM BLOOD cTropnT-<0.01
[**2156-4-23**] 03:15PM BLOOD proBNP-590
[**2156-4-25**] 07:40AM BLOOD Albumin-3.1* Calcium-8.7 Phos-1.9*#
Mg-2.0
[**2156-4-24**] 03:59AM BLOOD Calcium-8.3* Phos-4.0# Mg-1.5*
[**2156-4-23**] 03:15PM BLOOD Albumin-3.4* Calcium-8.7 Phos-1.8*
Mg-1.5*
[**2156-4-23**] 03:21PM BLOOD Lactate-2.0
.
Studies:
-[**2156-4-23**]: CTA at OSH
-[**2156-4-24**]: There is normal compressibility, flow and augmentation
of bilateral common femoral, superficial femoral and popliteal
veins. There is normal color flow of the calf veins. IMPRESSION:
No evidence of lower extremity DVT.
-[**2156-4-24**]: There is unchanged mild cardiomegaly. Mediastinal
contours are unremarkable. There is no evidence of appreciable
pulmonary edema. Small bilateral pleural effusions are present
as well as minimal bibasilar atelectasis. Overall, no
significant changes compared to prior CT was noted.
Brief Hospital Course:
85F with hypertension with bilateral pulmonary emboli, relative
hypotension, bandemia, low-grade fever in context of recent
malaise, nausea/vomiting x1 day. She was initially admitted to
the MICU for close monitoring and transferred to the medicine
floor the next day.
.
-Active issues:
#. PE: appeared to be small, bilateral on CTA from OSH. There
was no evidence of right heart strain on EKG. Pt was
hemodynamically stable throughout her hospitalization. Pt was
initially started on the heparin drip, then was changed to
Lovenox while pt was started on Coumadin and INR was still <2.
Pt had bilateral lower extremity US and there was no evidence of
DVT. Of note, per pt and family, pt had received routine cancer
screening. Her last mammogram was in [**2155**] and the result was
WNL, and her last colonoscopy was in [**2154**], significant for
polyps. Pt also reported ongoing outpatient malignancy workup
for hypercalcemia, however while pt was in the hospital, her Ca
level was only from 8.3-8.7. Pt has significant family history
of blood clots, can consider w/u as outpt for hypercoagulation
and to best determine the duration of Coumadin treatment.
- Recommend continue lovenox until INR > 2 for 48 hours, then
d/c lovenox
- goal INR [**3-18**]
.
#. Bandemia( WBC 11 10% bandemia) in the context of low-grade
fever. Her Lactate was 2.0. There was no clear evidence of
infection. Given nausea, vomiting on arrival to OSH ED, there
was a possibility for gastroenteritis. There was no clear
infiltrate on chest CTA. Pt was initially started on Tamiflu,
Vancomycin/Cefepime which was then changed to Levofloxacin for
empiric treatment and droplet precaution. Urine culture with
mixed bacteria, likely d/t contamination. Her Flu screening and
Legionella screening were negative. Her CXR did not show any
evidence of acute process. The above antibiotics were stopped
with these negative result. However, the levofloxacin was
continued to complete a 5 day course for empriric treatment of
community aquired pneumonia. At the time of discharge, she was
afebrile and her blood cultures were still pending.
.
#. Hypotension/hypoxia: pt demonstrated relative hypotension
with baseline hypertension. Unlikely to be due to PE given small
size on CTA chest. [**Month (only) 116**] be related to poor PO intake,
nausea/vomiting. Given fever, elevated lactate septic shock was
on the differential, thus pt was admitted into the MICU for
close monitoring. Her EKG did not show any evidence of ischemic
changes.Pt was placed on oxygen supplement via NC, and gradually
weaned off as tolerated. We also held home anti-hypertensives
(hold HCTZ, Propanolol, Lisinopril), added back Lisinopril as BP
improved. At the time of discharge, we were still holding HCTZ
and Propanolol. The patient was instructed to see her primary
care doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**] blood pressure medications. On the
day before discharge, she had an episode of weakness and
dizziness that spontaneously resolved. Her blood glucose and
orthostatic blood pressure were normal. An EKG was obtained that
showed some minor changes from a previous and so cardiac enzymes
were obtained which were negative. A cardiology fellow was
requested to review the EKG and felt that the changes were not
worrisome in nature and that if she continued to be symptomatic
to consider an outpatient echo. The symptom did not recur during
her hospital stay.
.
#. Anemia: HCT was stable at 35 and normocytic. Baseline
unknown. Pt was instructed to follow up as outpatient with PCP.
.
# Disposition: D/C home with PCP follow up as outpatient for the
above issues.
Medications on Admission:
Simvastatin 40mg PO daily
HCTZ 25mg PO daily
Detrol 2mg PO daily
Aspirin 325mg PO daily
Propranolol 20mg PO daily
Lisinopril 2.5mg PO daily
Calcium/vitamin D
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. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
Disp:*6 injection* Refills:*1*
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO once a day.
7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Please take 1 pill on Tuesday and 1 on Wednesday.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
hypoxia, hypotension, bilateral PE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: independent
Discharge Instructions:
Dear Ms.[**Last Name (Titles) 32737**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for shortness of breath, low
blood pressure, and was found to have small blood clots in your
lung. We started you on blood thinning medications and it is
very important for you to follow up with your primary care
physician to check the level (your INR) to ensure the medication
(Coumadin) is at the appropriate dosage. You also had a fever,
you were started on antibiotics. We would like for you to
continue levaquin until Wednesday [**2156-4-28**]. As for your blood
pressure, it was on the lower side, so we held your blood
pressure medications except Lisinopril. Please talk to your
primary care physician to discuss this matter and determine when
to restart some of your home blood pressure medications. Also
you should follow up with your primary care physician for
anemia.
In summary, the following medication changes were made:
-Started Lovenox twice a day
-Started Coumadin
-Started levofloxacin for 2 more days (for pneumonia)
-Held HCTZ due to low blood pressure
-Held Propanolol due to low blood pressure
-Held Detrol
-Decreased aspirin to 81 mg (since started coumadin)
Followup Instructions:
- Please go to Dr.[**Name (NI) 32738**] office anytime on Thursday to have
your INR checked at [**Location (un) 270**] Family Practice in [**Location (un) 47**].
phone ([**Telephone/Fax (1) 32739**]. It is very important that you keep this
appointment to measure your INR, a measure of anticoagulation.
Please make a follow-up appointment at that time.
ICD9 Codes: 486, 4019, 2720, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 941
} | Medical Text: Admission Date: [**2159-9-29**] Discharge Date: [**2159-10-6**]
Date of Birth: [**2082-12-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
nausea/vomiting: transferred from an outside hospital for ERCP
Major Surgical or Invasive Procedure:
endoscopic retrograde cholangiopancreatography
History of Present Illness:
The patient is a 76 year old woman with history of CAD s/p CABG
in [**2155**], bioprosthetic AVR, afib (on anticoagulation), DM who
initially presented to [**Hospital **] hospital on [**2159-9-27**] with nausea
and vomiting. The patient reports that she was in her USOH until
[**2159-9-23**] when she developed acute onset of nasuea, non-bilious,
non-bloody vomiting and abdominal pain. She initially attributed
these symptoms to food poisoning and did not seek medical
attention. She endorsed subjective fevers, chills, and sweats.
She denies any diarrhea. She was noted to have some jaundice. On
presentation to the OSH ED, her T was 102, SBP was in 70's. The
patient was admitted to the ICU with sepsis, hypotensive.
Admission labs: WBC 10.9 (up to 20 the next day with 20% bands),
Hct 38 (down to 28 the next day), Cr 1.8, ALT 277, AST, 248, T
bili 5.6 (direct 3.0). ABG 7.28/32/151 (on 4L NC). No lactate
documented. She was resuscitated with fluids (5L IV NS in the
ED) and started on Unasyn, Flagyl, pressors. Blood culture from
[**9-27**] grew GNR in [**1-18**] bottles. The patient also received Vitamin
K and 4 units FFP for elevated INR of ? 10 per report on
admission. Most recent INR 2.5. Femoral line was placed at the
OSH. She was ruled out for MI with 3 set of cardiac enzymes.
Because of elevated liver enzymes, CT of the abd was done. CT
abd was of limited quality, but showed pancreatic swelling. US
of RUQ showed CBD of 7 mm. GI was consulted and felt that the
patient had ascending cholangitis. Transfer to [**Hospital1 18**] for
possible ERCP was then arranged.
.
Of note, on admission, the patinet was also noted to have right
arm weakness for for approximately one week prior to admission.
Neurology was consulted and by their exam felt that she had a
subacute left basal ganglia infarct vs. subacute left cortical
infarct involving temporal lobe, less likely right
polyneuropathy.
MRI/MRA brain, carotid US and metabolic work up were
recommended. Head CT and carotid US were done (see results
below).
Past Medical History:
1. CAD s/p 3 vessel CABG in [**2157**]
2. s/p chole [**2155**]
3. Aortic Valve Replacement (bioprosthetic) [**2157**]
4. Diabetes mellitus
5. Atrial fibrillation, on coumadin
6. Hiatal hernia
7. Hypercholesterolemia
8. White coat hypertension
9. S/p C-section x 2
10. GxP8
Social History:
Lives with husband. She has 2 daughters and 6 sons. [**Name (NI) **] husband
is currently admitted to [**Hospital3 **] with MI and CHF. Never
smoked. No EtOH.
Family History:
non-contributory
Physical Exam:
Upon arrive to ICU:
Vitals: 97.1 98/37 66 26 98% (5L NC)
Gen: overweight woman, lying in bed, NAD, visibly short of
breath with sitting up in bed or talking
HEENT: NC, AT, MMM, OP clear w/o lesions, pupils equal and
round, no scleral icterus.
Neck: supple, no LAD, JVD difficult to asses
CV: regular, loud S2, no m/r/g
Chest: midline scar c/w open heart surgery
Lungs: bibasilar crackles, no wheezes
Abd: modline lower abd vertical scar from prior c-sections, RUQ
scar from cholecystectomy, + BS, obese, soft, ND, mildly tender
in LUQ
Ext: cold, DP pulses dopplerable, no edema
Neuro: alert and oriented x3, speech fluent, extinguishes to
double simultaneous stim on right
CNII-XII intact
Motor: normal tone and bulk, left arm [**4-20**] arm flex/extend, hand
grip, finger abduction; right arm [**3-21**] flex, [**4-20**] extend, [**4-20**] hand
grip, [**3-21**] finger abduction, could not grip pen with dominant
hand; lower ext [**4-20**] symmetric hip flex, ankle
plantar/dorsiflexion
Sensation: light touch intach to hands and legs
Reflex: 2+ bicep bilat, 0 bilat patellar and ankles, toes
equivocal
Coord: FTN normal on left, limited on right
Skin: No exanthems
Lines: Right femoral w/o signs/symtpoms of infection.
.
Pertinent Results:
Outside Hospital reports:
Carotid US: bilateral moderate ICA stenosis (20-49%).
.
CT abd/pelvis: limited study, edema around pancreas
Head CT: "old right sided infarct"
.
EKG [**2159-9-27**]: afib with RBBB pattern; ST depressions in V3-V6
not seen on prior EKG but cannot be interpreted with RBBB
.
[**2159-9-27**]: Blood cultures 2/2 bottles of E. coli: resistant to
gentamicin, sensitive to quinolones
.
On admission:
[**2159-9-29**] 05:51PM GLUCOSE-116* UREA N-39* CREAT-2.0* SODIUM-136
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-15* ANION GAP-19
[**2159-9-29**] 05:51PM ALT(SGPT)-173* AST(SGOT)-111* LD(LDH)-316*
ALK PHOS-197* AMYLASE-48 TOT BILI-4.4*
[**2159-9-29**] 06:19PM LACTATE-2.5*
[**2159-9-29**] 05:51PM ALBUMIN-2.9* CALCIUM-6.7* PHOSPHATE-3.7
MAGNESIUM-1.9
[**2159-9-29**] 05:51PM WBC-30.2* RBC-3.33* HGB-9.5* HCT-27.5* MCV-83
MCH-28.4 MCHC-34.4 RDW-15.3
[**2159-9-29**] 05:51PM PT-26.2* PTT-33.0 INR(PT)-2.7*
.
[**2159-9-29**]: Chest Xray: Mild CHF. Bibasilar atelectasis and
bilateral pleural effusions.
.
[**2159-10-1**]: ERCP report: mild inflammation of the major papilla,
mild biliary duct dilation, biliary stent placed successfully.
Brief Hospital Course:
1)SEPSIS:
On admission, patient presented hypotensive, with rapidly rising
WBC, bandemia. Blood cultures from OSH with found to be E. coli.
Presentation, exam, and elevated LFTs were consistent with
cholangitis. Had received 6 liters of normal saline prior to
transfer. The patient was fluid bolused for volume resusitation
and levophed was continued to keep the MAP >60. Initial broad
spectrum antibiotics were used until sensitivity data was
available. ERCP team was notified and recommended close
monitoring prior to proceeding with ERCP. The patient continued
the empiric steroid regimen while on pressors. She maintained
adequate urine output. Her vital signs improved. She underwent
ERCP on [**2159-10-1**] with peri-procedural intubation. No biliary
stone was found. A stent was placed in the bile duct. She was
weaned off pressors and the empiric steroids were stopped after
5 days of therapy as the patient was no longer hypotensive and
she had not failed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim test. After her pressors were
stopped, the femoral central venous catheter that had been
placed prior to transfer was removed. Patient was transferred
to the floor where she continued to do well. She was
transitioned to PO levaquin for a 2-week course.
Hemodynamically remained stable.
.
2) CV:
S/p CABG in [**2157**]. The patient r/o for MI with three sets of
enzymes at the OSH. She remained chest pain free. EKG with old
RBBB. The patient was monitored on telemetry during her ICU
stay. Her aspirin was held for the ERCP then restarted
post-procedure. Her home statin and zetia was held while her
transaminases were elevated. After her blood pressure
stabilized, an ACE inhibitor was introduced. She was
intermittently hypertensive and her ACEI was uptitrated and
imdure was restarted. Lasix was restarted at 20mg [**Hospital1 **], lower
than her home dose as she is not taking full POs yet.
.
Rhythm. The patient has a history of paroxysmal a fib with RBBB
(old) per EKG. Intially, anticoagulation was held pre-ERCP and
her INR was allowed to drift down. Following the procedure, she
was briefly heparin loaded while her coumadin was restarted with
goal INR of [**1-18**].5. Inr on d/c was 2.2. Amiodarone was held as
transaminases were up and can be restarted as outpt.
.
3) CVA:
Patient with new subacute neurological deficits which developed
approximately 10 days prior to transfer. The neurology consult
at the prior hospital recommeded cartid ultrasound, MRI/MRA.
She was not hemodynamically stable for MRI during at the OSH.
Carotid ultrasound did not reveal significant (i.e. >50%)ICA
stenosis. As she will be anticoagulated with regard to the
atrial fibrillation, the MRI was deferred to an outpatient
evaluation.
.
4) Acute Renal failure:
Creatinine upon transfer was 2. Her baseline was unknown.
Urine lytes were consistent with pre-renal azotemia. Her
medications were dose adjusted. Her creatinine trended down.
Upon discharge, her creatinine was 0.9.
.
5) DM, Non-insulin dependent:
Once eating, restarted metfromin .
.
Communication: Patient. Daughter [**Name (NI) **](HCP) ([**Telephone/Fax (1) 68847**].
Medications on Admission:
Glucophage 500 daily
ASA every other day
Coumadin 3 mg po qd
Imdur 30mg daily
Lasix 40 qam and 20 qpm
Amiodarone
Lipitor 80 daily
Zetia 10 daily
Citracal + D
Colace 100mg daily
Fish Oil caps
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
8. Iron Oral
9. Citracal + D Oral
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
11. Fish Oil Oral
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Sepsis
Stroke
Diabetes Type 2
Acute Renal Failure
Hypertension
Discharge Condition:
Good--afebrile, tolerating food.
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] or return to the hospital if you experience
abdominal pain, nausea, vomitting, fevers, chills, inability to
eat, or any other symptoms that concern you.
Please note, you should not take lipitor, zetia or amiodarone
until you see Dr. [**Last Name (STitle) **] given recent abnormalities in liver
function tests.
Also note that you should take lisinopril in place of cozaar for
now. Discuss with Dr. [**Last Name (STitle) **] about switching back.
Followup Instructions:
You will follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 68848**] on
[**2159-10-12**]@2:15pm.
Please call Dr. [**Last Name (STitle) **] of GI at ([**Telephone/Fax (1) 10532**] to set up an
appointment to have the biliary stent removed in [**3-22**] weeks.
You should have an outpatient MRI done to evaluate for stroke.
ICD9 Codes: 0389, 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 942
} | Medical Text: Admission Date: [**2137-11-11**] Discharge Date: [**2137-11-21**]
Date of Birth: [**2073-2-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Transfer from OSH for post cardiac arrest evaluation.
Major Surgical or Invasive Procedure:
Inplantable cardioverter defibrillator (ICD) placement
Intubation and extubation
Central venous line
PICC line placed and removed
History of Present Illness:
Ms. [**Known lastname **] is a 64 year-old woman with a history of idiopathic
cardiomopathy who presents on transfer after cardiac arrest.
Per OSH discharge summary, patient presented after found by her
boyfriend at home with unresponsiveness after hearing a thump.
911 was called immediately and when EMS arrived (~5 minutes
after arrest) they patient was noted to be in vfib, apneic and
pulseless. CPR, ALCS (shock x4) and intubation were perfomed.
At the OSH ED, patient was noted to be in sinus. Based on EMS
records, time between initial rhythm and 4th (successful) shock
was ~9 minutes.
OSH course: Evaluated by cardiology. Noted to have troponin
peak of 0.30. A TTE was performed and showed an LVEF of 30%
(unchanged from prior). To work-up an elevated WBC (13.4), a
chest CT was done and showed extensive multifocal pulmonary
opacities involving most of the LLL aand portions of the upper
lobes. She was treated with vancomycin, unasyn and azithromycin.
Regarding her neurologic status, patient was noted to be
unresponsive after admission (no purposeful movementswith
sluggish pupils) with a head CT being grossly normal.
The patient's hematocrit was noted to drop from 30.8 on
admission to 25.5 so a unit of pRBC was transfused.
Past Medical History:
1. CARDIAC RISK FACTORS:
(+) Diabetes
(-) Dyslipidemia
(+) Hypertension
.
2. CARDIAC HISTORY:
-CABG: None.
-CARDIAC CATH without flow limiting lesions ([**7-17**]).
-PACING/ICD: None.
-CHF: Idiopathic dilated CM with EF of 30% (echo [**7-17**]).
-History of LBBB
3. OTHER PAST MEDICAL HISTORY:
- Anemia, iron deficiency
- Sarcoidosis
- Glaucoma
Social History:
-Tobacco history: None currently
-ETOH: Occasional
-Illicit drugs: Unclear
-Widower
Family History:
Father died of MI in 60s
Physical Exam:
VS: T=98.8 BP=145/75 HR=83 RR=16 O2 sat=100% on vent
GENERAL: Intubated and on mild sedation. Responds to painful
stimuli but does not have purposeful movements.
HEENT: NCAT. Sclera anicteric. Pupils 4mm --> 2mm and brisk
bilaterally.
NECK: Supple.
CARDIAC: Palpable RV lift and prominent LV PMI. Regular rate. No
obvious murmur. +S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored on the ventilatro. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Midline line
rectangular patch with skin changes.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Amission labs:
[**2137-11-11**] 05:51PM GLUCOSE-78 UREA N-18 CREAT-0.9 SODIUM-146*
POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-25 ANION GAP-12
[**2137-11-11**] 05:51PM ALT(SGPT)-55* AST(SGOT)-44* LD(LDH)-263*
CK(CPK)-400* ALK PHOS-58 TOT BILI-0.9
[**2137-11-11**] 05:51PM CK-MB-2 cTropnT-0.03*
[**2137-11-11**] 05:51PM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-3.6
MAGNESIUM-2.2
[**2137-11-11**] 05:51PM WBC-13.0*# RBC-3.52* HGB-8.9*# HCT-26.8*#
MCV-76*# MCH-25.2*# MCHC-33.1 RDW-22.5*
[**2137-11-11**] 05:51PM PT-13.2 PTT-33.7 INR(PT)-1.1
[**2137-11-11**] 05:51PM RET MAN-1.3
OSH Labs:
K: 3.2 --> 4.1 --> 3.3
Mg: 1.6 --> 2.1
Cr: 1.2 --> 1.0
ALT: 79 --> 55
WBC: 8.6 --> 14.5 (25% bands)
HCT: 29.3 --> 25.5 (MCV 73)
PLT: 366 --> 386
INR: 1.1
Trop: 0.01 --> 0.30 --> 0.11
BNP: 358
D-Dimer: 2467
UA: 30-40 WBC
Discharge labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt Ct
[**2137-11-21**] 08:50AM 10.3 3.79* 9.3* 28.2* 74* 24.6* 33.0
21.2* 430
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2137-11-21**] 08:50AM 255* 10 0.8 136 3.6 101 28
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos TotBili
[**2137-11-13**] 05:49AM 39 32 256* 265* 69 1.0
CHEMISTRY Calcium Phos Mg
[**2137-11-21**] 08:50AM 8.7 3.4 1.8
PITUITARY TSH
[**2137-11-18**] 04:10AM 1.6
[**2137-11-12**] 5:21 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2137-11-15**]**
GRAM STAIN (Final [**2137-11-12**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2137-11-15**]):
OROPHARYNGEAL FLORA ABSENT.
ENTEROBACTER CLOACAE. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
YEAST. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S 2 I
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
EMS tracings: Ventricular fibrillation with NSR initiated after
fourth shock.
ECG ([**2137-11-11**]): NSR at 89. LBBB.
2D-ECHOCARDIOGRAM ([**7-17**]): 1. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate to severe global left ventricular hypokinesis. Overall
left ventricular systolic function is moderately depressed with
some preservation of basal inferior and basal lateral wall
motion.
2. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
CARDIAC CATH ([**7-17**]):
1. No angiographically apparent flow limiting coronary artery
disease.
2. Normal left and right sided filling pressures.
3. Depressed LV function of 30% with global hypokinesis.
TTE ([**11-12**]): The left atrium is elongated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe global left ventricular hypokinesis (LVEF = 30 %) with
somre preserved contraction of the basal inferolateral and
anterolateral walls. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade II (moderate) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-12**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Global left ventricular cardiomyopathy. Moderate
diastolic dysfunction with elevated filling pressures. Mild to
moderate mitral regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2135-8-11**],
the severity of mitral regurgitation has increased. Estimated
pulmonary artery pressures are elevated (previously
undetermined).
EEG ([**11-14**]): Abnormal portable EEG due to the slow and
disorganized
background. This indicates a widespread encephalopathy.
Medications,
metabolic disturbances, and infection are among the most common
causes.
There were no prominent focal abnormalities, but
encephalopathies may
obscure focal findings. There were no epileptiform features. The
background was not at all flat or markedly suppressed, findings
that
might be associated with continued Propofol use or with a severe
anoxic
encephalopathy. Those are still possible causes of the
encephalopathy,
but they are less likely, and the EEG is not strongly suggestive
of
them.
MRI head ([**11-15**]): The FLAIR and T2 as well as diffusion images
demonstrate increased signal in both thalami. There is no
evidence of restricted diffusion seen without evidence of
abnormalities on the ADC map. These findings could be indicative
of subacute changes of hypoxia. Bilateral chronic lacunes
identified. Changes of small vessel disease are seen in the pons
and in the periventricular region. There is moderate
ventriculomegaly without significant sulcal prominence. There
are no chronic blood products seen.
IMPRESSION: Signal changes bilaterally in the thalami without
evidence of
restricted diffusion are likely due to subacute changes from
hypoxic event. Moderate ventriculomegaly is seen. No mass effect
or signs of herniation seen. Mild mucosal thickening in the
sinuses.
Shoulder X-ray ([**11-17**]): Single view of the right shoulder shows
no fracture, dislocation, or subluxation of the shoulder and the
adjacent ribs are intact.
Brief Hospital Course:
64F with female with DM, htn, and history of idiopathic
cardiomyopathy presenting on transfer after vfib arrest.
# Ventricular fibrillation cardiac arrest: The patient received
4 shocks in the field and was in sinus rhythm at the OSH. Here
she remaiend in sinus rhythm without further arrhythmia. Her
carvedilol was increased to 25 mg po bid. After her other
medical issues improved (as below) she had a dual chamber ICD
placed on [**10-21**]. She received 1 mg IV vanc and 1 gm cefazolin
prior to placement and will need to complete three days of
cefalexin for to prevent infection post placement. She has a
follow up appointment scheduled with the device clinic.
# Neurologic function: The patient suffered a cardiac arrest
and was initally intubated on transfer. She was extubated after
9 days on the ventilator and one failed extubation attempt
earlier in the hospital stay. While on the ventilator and after
extubation she initally has some agitation, but this decreased
as her mental status cleared and she continued to gain
neurologic function. She has been working with PT, OT, and
speech therapy. She has been getting 1 mg po haldol at night to
decrease nighttime agitation, and 0.5 mg po ativan for insomnia
if she cannot sleep after the haldol. As she improves, this can
likely be stopped. She will follow up with Dr. [**First Name (STitle) **] as an
outpatient.
# Chronic systolic and diastolic heart failure: The patient has
a history of idiopathic cardiomyopathy with an EF of 30%. Per
her PCP she has class II heart failure. She underwent a TTE
which showed an EF of 30% and global left ventricular
cardiomyopathy with moderate diastolic dysfunction with elevated
filling pressures, mild to moderate mitral regurgitation, and
mild pulmonary hypertension. Her losartan was increased to 100
mg daily. Her carvediolol was increased to 25 mg po bid. She
was continued on her home dose of lasix at 20 mg daily as she
did not appear to volume overloaded.
# Hypertension: The patient's SBPs were found to be elvated so
her carvedilol was increased to 25 mg po bid and her losartan
was increased to 100 mg daily. She was continued on lasix 20 mg
daily. Prior to discharge her SBP ranged from 130's to 150's.
# Anemia: The patient has known iron deficiency anemia; she had
recieved one unit of pRBC at OSH. Her Hct ranged from 24.3 to
28.8 and she did not receive further tansfusion here as she was
not having active ischemia. Her Hct on discharge was 28.2.
# Pneumonia/Pulmonary: The patient had a leukocytosis on
admission of 13.0. She had blood cultures and urine cultures
which were negative. Her CXR showed a possible LLL infiltrate.
A sputum culture from [**11-12**] showed enterobacter cloacae and
klebsiella oxytoca which was sensitive to ceftriaxone. While
the culture and sensitivities were pending she was treated with
zosyn (she had been started on this at the OSH on [**11-9**]) until
[**11-16**] when she was switched to ceftriaxone to complete a 10 day
course of antibiotic therapy for a pneumonia.
The patient suffered a cardiac arrest and was initally intubated
on transfer. She was extubated after 9 days on the ventilator
and one failed extubation attempt earlier in the hospital stay.
It was thought that her inital failure to tolerate extubation
was due to a combination of the pneumonia, her mental status,
and her copious secretions. She was given a scopolamine patch
to decrease her secretions and as her pneumonia was treated and
her mental status improved she was able to tolerate extubation.
# Diabetes: The patient is on januvia and metformin as an
outpatient. During her hospitalization these medications were
held. She had qid finger sticks for monitoring of her blood
glucose and was covered with sliding scale insulin. By the end
of her stay she was eating more and her sugars were higher so
she was restarted on her januvia and metformin at discharge.
Medications on Admission:
MEDICATIONS (home):
1. Coreg 3.125 [**Hospital1 **]
2. Cozaar 50mg daily
3. Lasix 20mg daily
4. Potassium 10mEq daily
5. Januvia 50mg daily
6. Metformin 500mg [**Hospital1 **]
7. Ibuprofen 800mg PRN
8. Cosopt 2% both eyes daily
MEDICATIONS (on transfer):
Lopressor 2.5mg IV q4H
Insulin gtt
Nitropaste
Protonix 40mg IV daily
Versed gtt
Unasyn 1.5g Q6H
Vancomycin 1G [**Hospital1 **]
Azithromycin 500mg IV daily
SC heparin
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia: Give at least one hour after
haldol if needed.
7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
8. Cosopt 2-0.5 % Drops Sig: One (1) drop Ophthalmic once a
day: Place in both eyes.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Haloperidol 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for agitation.
12. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for skin tear.
13. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for ICD implant for 10 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary -
Ventricular fibrillation resulting in cardiac arrest
Secondary -
Dialated idiopathic Chronic systolic heart failure
Diabetes
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were tranferred to this hospital after you had a cardiac
arrythmia which caused you to pass out and have low oxygen
delivery to your brain. You were intubated on arrival
Medication changes:
1. Your losartan was increased to 100 mg daily.
2. Your coreg was increased to 25 mg twice daily.
3. While in rehab you will be given subcutaneous heparin
injections three times daily for deep vein thrombosis
prophylaxis, but you will not need to take this upon discharge
from rehab.
4. You will be given haldol 1 mg po every night to decrease
agitation (however this can be stopped as you improve and your
night time agitation abates). You can also be given 0.5 to 1 mg
po haldol as needed for agitation at other times.
5. You can be given 0.5 mg ativan po for insomnia as needed.
6. You can take 1-2 puffs of albuterol as needed for shortness
of breath or wheezing.
7. You will need to take 10 more doses of cephalexin 500 mg
every 6 hours for prevention of infection given your recent ICD
placement.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 L per day
Call your primary doctor or go to the emergency room if you
experience fevers, chills, chest pain, shortness of breath,
dizziness, or activity from your ICD.
Followup Instructions:
An appointment has been made for you to follow up with
cardiology:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2137-11-29**]
10:00
An appointment has been made for you to follow up with Dr.
[**First Name (STitle) **] from neurology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2137-12-23**] 3:30
You will need a referral for this appointment; please see you
primary care doctor prior to this for the referral. His office
his located on [**Location (un) **] in [**Location (un) 86**] on the [**Location (un) **] [**Apartment Address(1) 14414**].
It is important that you keep these appointments. Please call
to reschedule if you cannot make them.
Completed by:[**2137-11-21**]
ICD9 Codes: 2760, 4280, 4254, 4275, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 943
} | Medical Text: Admission Date: [**2148-7-1**] Discharge Date: [**2148-7-9**]
Date of Birth: [**2067-2-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
[**2148-7-5**] Aortic valve replacement ([**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] tissue),
coronary artery bypass graft surgery x2 (Left internal mammary
artery > left anterior descending, saphenous vein graft > obtuse
marginal), left carotid endarterectomy
History of Present Illness:
81M developed weakness and nausea lasting minutes. EMS was
called and the patient was found to be in A-fib with rapid
ventricular response. He was admitted to an OSH for workup.
Stress test was abnormal and cardiac cath revealed 2vessel CAD
and aortic stenosis. He is transferred for surgical evaluation.
Past Medical History:
hypertension
hyperlipidemia
hypothyroidism
colon cancer, s/p resection
partial colectomy ~20yo
Social History:
Lives with:wife
Cigarettes: Smoked no [] yes [x] last cigarette 40yo Hx:13-14yr
ETOH: < 1 drink/week [x]
Family History:
noncontributory
Physical Exam:
Pulse:68 Resp:18 O2 sat: 97%RA
B/P 136/87
Height: 5'9" Weight:168 LBS
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]decreased
Heart: RRR [x] Irregular [] Murmur [x] grade III/VI______
Abdomen: Soft [x] non-distended [x] non-tender []x bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: (L)LE superficial varicosities
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit (B)-soft bruits, pulses- Right: 1+ Left:1+
Brief Hospital Course:
Transferred in from outside hospital for surgical evaluation due
to coronary artery disease, aortic stenosis, and carotid
stenosis. His preoperative workup include CT scan,
echocardiogram, and dental clearance. Vascular surgery was
consulted for carotid stenosis on left 80-99% and was started on
heparin for anticoagulation. On [**7-5**] he was brought to the
operating room for aortic valve replacement, coronary artery
bypass graft and L carotid endartectomy. See operative report
for further details. He received vancomycin and cefazolin for
perioperative antibiotics and was transferred to the intensive
care unit for post operative management on propofol and
phenylephrine. He was weaned off phenylephrine and was started
on nitroglycerin and then nicardipine for hypertension
management. He remained intubated overnight and was weaned from
propofol but due to anxiety was placed on precedex for weaning
from ventilator, he awoke neurologically intact, was extubated
without complications, and then precedex was stopped. He was
weaned off all drips and started on betablockers and diuretic.
He continued to progress and was transferred to the floor in the
afternoon. On post operative day two, physical therapy worked
with him on strength and mobility.Chest tubes and pacing wires
removed per protocol. He had intermittent A Fib and was started
on amiodarone.Continued to make good progress and was cleared
for discharge to [**Hospital3 7665**] in [**Hospital1 3597**], NH on POD #4. All f/u
appts were advised
Medications on Admission:
methyldopa 250 [**Hospital1 **]
asa 81mg daily
zocor 10mg hs
cozaar 50mg daily
HCTZ 12.5
levothyroxine 50mcg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-17**]
Puffs Inhalation Q6H (every 6 hours).
6. methyldopa 250 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: 400 mg [**Hospital1 **] through [**7-15**], then 400 mg daily
[**Date range (1) 88761**]; then 200 mg daily ongoing.
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
please monitor weight and creatinine.
14. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO twice a day: hold for K+ > 4.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Aortic stenosis s/p AVR
Carotid stenosis s/p Left CEA
Paroxysmal atrial fibrillation
Non ST elevation myocardial infarction (troponin 0.23 OSH)
Hypertension
Hypothyroidism
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.
Left neck
Edema 1+ BLE
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**
Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm
ridge along the incision
?????? Your incision may be slightly red and raised, it may
feel irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes
or lasts longer than 2 hours- call vascular surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually
increase your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do
too much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose
some weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high
fiber, lean meats, vegetables/fruits, low fat, low cholesterol)
to maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use
stool softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer
taking pain medications
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the
soapy water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have
small amounts of drainage from the wound, then place a dry
dressing over the area that is draining, as needed
?????? Take all the medications you were taking before
surgery, unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin
daily, unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks
for staple/suture removal
What to report to office:
?????? Changes in vision (loss of vision, blurring, double
vision, half vision)
?????? Slurring of speech or difficulty finding correct words
to use
?????? Severe headache or worsening headache not controlled by
pain medication
?????? A sudden change in the ability to move or use your arm
or leg or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or
white, yellow or green drainage from incisions
Completed by:[**2148-7-9**]
ICD9 Codes: 4241, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 944
} | Medical Text: Admission Date: [**2106-5-6**] Discharge Date: [**2106-5-20**]
Date of Birth: [**2045-9-16**] Sex: M
Service:
DISCHARGE DIAGNOSES:
Dyspnea.
Renal cell carcinoma.
HISTORY OF PRESENT ILLNESS: Sixty-year-old male with history
of renal cell carcinoma with recent CT scan showing right
subcranial/hilar mass 6.9 x 3.5 cm with right lower lobe
bronchus obstruction and right lower lobe collapse presented
on the admission date to Interventional Pulmonary for
bronc. The IP team felt that the patient appeared too ill for
a procedure at that point. The exact details were unknown,
directly admitted for further work up, initially to the
service at which point, he denied any nausea, vomiting, fever
or chills, no increased shortness of breath except his
increased cough, complained of rib cage diffuse pain and dry
cough times two days which increased with rib pain and he
also has noticed a loss of seventeen pounds in the past few
months.
PAST MEDICAL HISTORY: His past medical history is significant
for renal cell carcinoma, diagnosed in [**5-/2104**], radical right
sided nephrectomy, RAF, left renal mass, two cycles vial II.
He was on UPenn's experimental protocol, XRT plus steroids
for T5 lytic lesions, resection lung mass in 02/[**2105**]. Other
past medical history, hypertension, rosacea, status post
vasectomy.
HOME MEDICATIONS: His home medications were Oxycodone 5 mg
every six hours PRN, Norvasc PO 10 mg every day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with his wife, CEO of his own company,
occasional alcohol, no tobacco.
PHYSICAL EXAMINATION: Vital signs on admission, temperature
99.3 F, heart rate 60, blood pressure 164/88, respiratory
rate 22, O2 saturation 93% on five liters nasal cannula. On
examination, he was a pleasant gentleman in no acute
distress, well developed male. HEENT, dry oral mucosa. The
neck was supple. Heart, decreased heart sounds, regular rate
and rhythm, no murmurs, gallops or rubs. Lungs, very small
breath sounds felt on the right side, especially basilar up
to one-half up to the right side, left side with mild rales,
mostly rales. Abdomen, bowel sounds were present, mild
hepatomegaly but nontender, nondistended abdomen.
Extremities, no clubbing, cyanosis or edema. Neurologic, he
was alert and oriented times three and grossly intact
neurologically.
LABORATORY DATA: Laboratory studies on admission, white blood
cell count 5.8, hematocrit 34.4 with previous one 34.7,
platelet count 159,000, INR 1.2, PTT 23.7, sodium 132,
potassium 5.0, chloride 97, bicarbonate 21, BUN 34,
creatinine 1.6, which was 1.3, the last check, glucose 238,
ALT 38, AST 45, alkaline phosphatase 99, total bilirubin 0.7,
albumin 2.5 and the blood cultures were drawn and were
pending at the time of admission. Chest x-ray showed right
lower lobe collapse/consolidation and large right pleural
effusion questionably on preliminary.
HOSPITAL COURSE: His course was respiratory alkalosis,
post-obstructive right lower lobe infiltrate with strep
pneumo in two out of two blood cultures from admit. He
defervesced on Levofloxacin and Flagyl, persistent O2
requirement so sent to bronc on [**2106-5-10**], by IP and he is
now since he has been sent to IP, he was status post removal
of endobronchial lesion, right bronchus intermedius and
post-procedure had respiratory distress requiring intubation,
which he was sent to the MICU and since did okay
post-extubation. He was sent back on the floor but now on
[**Hospital Ward Name 517**], admitted to the [**Hospital Ward Name 517**] [**Hospital1 139**] team. Since
being admitted to [**Hospital Ward Name 517**] [**Hospital1 139**] team, he underwent
another interventional pulmonary procedure, initially, it was
planned on him questionably getting a stent done in place but
the procedure was basically a similar procedure to the
previous one, no stent was placed. The patient tolerated the
bronchoscopy well without any problems. His O2 requirements
actually have improved prior to his discharge. The other
thing is that he has remained on Levo and Flagyl. The plan is
continuing him for a three week course. He is going to
continue another two weeks post-discharge and continuation to
be decided by primary physician. [**Name10 (NameIs) **] plan is to wean him off
his O2 nasal cannula, once he gets admitted to the
rehabilitation to keep O2 saturations greater then 92%. On
the day of discharge, he has been weaned down from six liters
to five liters now to four liters nasal cannula. Prior to his
discharge, he had an ultrasound done, which was with a
questionable right sided effusions, which were found not to
be effusions and mostly tissue and no need for tap at the
time by IP service. The patient was planned on following up
with Oncology later on and to continue his Levo-Flagyl since
his cultures have been negative so far. His acute renal
failure that he presented on admission has resolved and he is
now down to 0.7, it was thought to be probably most likely
secondary to pre-renal state, given BUN and creatinine ratio
close to 20 and also the patient being dry on examination.
The patient's hypertension is controlled with outpatient
medications. The patient's pain medications controlling the
patient's rib pain. No acute new problems on discharge. ID
wise, his pneumococcal/pneumonia/CAP plus post-obstructive
pneumonia was as noted, to continue his Levofloxacin and
Flagyl since when he was taken off Flagyl and was taken to
the unit from the, he required Clindamycin for a day and then
he was taken off the Clindamycin but then when he was brought
to the [**Hospital1 139**] service, he actually spiked a temperature. With
the elevated temperature and leukocytosis, it was felt that
the patient could benefit from some anaerobic coverage. At
that point, Flagyl was added, which was last week, prior to
discharge. The patient's elevated blood pressures resolved
since and he was continued on the Levo-Flagyl for resumed
post-obstructive pneumonia. In terms of heme, his hematocrit
has remained relatively stable. He received two units of
packed red blood cells last week and since then, his
hematocrit has remained relatively stable. It is thought that
his low hematocrit is probably secondary to decreased PO
intake, nutritional problem and also could be related to his
eighteen pound weight loss over the past few months. He has
normal LFT's normal platelets and he refused digital rectal
examination but we are guaiacing all of his stools. In terms
of his neurologic, per MRI on [**5-7**], there was no sign of
cord compression from his metastases and there was plan of
following up for XRT per Rad/Onc but Rad/Onc have decided for
now that he is not a candidate for the time being and to be
followed up by Oncology for further follow-up and possibly
maybe later on become a candidate at Oncology and Rad/Onc's
discretion. He also has a tachycardia with ectopy, which has
been pretty stable. We repleted his electrolytes PRN and his
tachycardia has remained sinus tachycardia since admission
and on discharge date, he still continues with the mild
tachycardia. The patient is being discharged to
rehabilitation facility for further rehabilitation care,
stable condition.
FINAL DIAGNOSES: Renal cell carcinoma, status post IP
intervention times two with debridement.
Follow-up with PCP
and primary oncologist as prescribed and the patient was sent
to rehabilitation on the following medications, Neutra-Phos
PRN and following his magnesium and phosphorous close,
Trazodone 12.5 mg PO at bedtime, PRN, Codeine 15 mg IV every
four to six hours PRN, Heparin subcutaneous every eight
hours, 5,000 units, Metronidazole 500 mg PO every eight hours
for fourteen more days and Pantoprazole 40 mg PO every
twenty-four hours, Amlodipine 10 mg PO every day, Metoprolol
50 mg PO twice a day, Levofloxacin 500 mg PO every
twenty-four hours for another twelve days, Docusate 200 mg PO
twice a day, Senna one tablet PO twice a day, Oxycodone 5 mg
PO every four to six hours PRN for pain and also continue on
insulin sliding scale per protocol. Follow-up is as discussed
above. The patient is going to the rehabilitation center
today.
[**Doctor Last Name 2511**],[**Name8 (MD) **] MD. [**MD Number(2) 12441**]
Dictated By:[**Name8 (MD) 6112**]
MEDQUIST36
D: [**2106-5-19**] 08:11
T: [**2106-5-19**] 08:15
JOB#: [**Job Number 12442**]
ICD9 Codes: 7907, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 945
} | Medical Text: Admission Date: [**2135-6-25**] Discharge Date: [**2135-7-7**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
CC:[**CC Contact Info 35172**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 51 yo male with a h/o ESRD on HD due to
amyloidosis (last HD Thursday) who is transferred from [**Hospital **]
Hospital for persistent hypotension. Per Dr.[**Name (NI) 4857**] note in
OMR, [**Hospital1 1501**] called to [**Hospital1 18**] HD unit on [**6-24**] to report that [**Known firstname **] had
disconnected his recently placed PD catheter. He was transported
into [**Hospital 2793**] Clinic and had 'transfer set' changed. Due to break
in sterility, 1 gram IP Vancomycin was infused empirically.
Catheter was taped down such that it would be more difficult for
patient to tamper with.
Upon returning to his [**Hospital1 1501**], Mr. [**Known lastname **] [**Last Name (Titles) **] was noted to
have increasing lethargy and hypotension and was transported to
[**Hospital **] Hospital, arriving at 3:45 p.m. At time of arrival, he
was reported as seeing bright blurred colors in front of eyes
and complaining of pain in fingers. His initial BP was recorded
as 54/40. With fluid resuscitation, BP's gradually increased
from 60's to 80 systolic, but then dropped to 68/42, prompting
initiation of dopamine gtt. HR remained in 70's until initiation
of dopamine gtt, then increased to 90's. Prior to transfer, he
received ASA 162 mg, hydrocortisone 100 mg IV, and gentamycin
150 mg IV, and dopamine gtt titrated up to 8 mcg/kg/hour for
target SBP >100. Blood cultures were drawn.
On arrival in the [**Hospital1 18**] ED, T 97.8, HR 83, BP 75/38, RR 18, SpO2
100% on 3L NC O2. He received cefepime 2 grams IV and morphine 4
mg IV for 6 out of 10 pain in his fingers.
Past Medical History:
ESRD secondary to amyloidosis -failed LRRT in [**7-5**] now on
hemodialysis (right groin line)
inferior vena cava stent
Sarcoidosis
Pulmonary aspergillosis - on chronic voriconazole
Type 2 Diabetes, on insulin
Chronic Hepatitis C
Hypertension
Sinusitis
Paroxysmal atrial fibrillation,
Clostridium difficile [**3-8**]
MRSA line sepsis
Renal osteodystrophy
Adrenal insufficiency
Upper extremity deep vein thrombosis ([**2132**])
Pancreatitis
Bilateral below the knee amputation
Right index and fifth finger amputations
Social History:
Smoked 1 pack per day X 30 years but quit. History of alcohol
abuse, but stopped 4 years ago. Previous drug use with cocaine
(+IV drug use), has been clean since about [**2127**]. Girlfriend
[**Last Name (un) 102399**] is involved in his care. Lives in a care home in
[**Location (un) 669**]. Mother lives nearby.
Family History:
Mother, brother with diabetes. No h/o kidney disease
Physical Exam:
VS: T 96.8, BP 110/67, HR 95, SpO2 100% on 3L
HEENT: clear OP, MMM, sclerae anicteric
CV: S1, S2, RRR, 2/6 systolic murmur best auscultated at LLSB,
Resp: Lungs clear b/l but with poor air movement throughout.
Abd: PD catheter intact, distended and diffusely tender,
diminished bowel sounds
Extrem: Right femoral catheter clean, dry, no erythema or
induration.
B/l BKA well healed, skin somewhat dry. No edema. Missing digits
of his hands with necrotizing segments distally.
Neuro: alert, oriented to self, place, year but not date; unable
to provided details of prior day or of his medical history
Pertinent Results:
[**2135-6-25**] 04:54AM GLUCOSE-88 UREA N-37* CREAT-6.0* SODIUM-140
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-18* ANION GAP-22*
[**2135-6-25**] 04:54AM CALCIUM-10.2 PHOSPHATE-8.3* MAGNESIUM-2.0
[**2135-6-25**] 04:54AM CORTISOL-128.7*
[**2135-6-25**] 04:54AM WBC-9.3 RBC-3.95* HGB-11.3* HCT-39.6*
MCV-100* MCH-28.6 MCHC-28.6* RDW-19.8*
[**2135-6-25**] 04:54AM NEUTS-81.4* BANDS-0 LYMPHS-17.2* MONOS-1.0*
EOS-0.4 BASOS-0
[**2135-6-25**] 04:54AM PLT COUNT-359
[**2135-6-25**] 04:54AM PT-14.5* PTT-34.7 INR(PT)-1.3*
[**2135-6-25**] 01:37AM COMMENTS-GREEN TOP
[**2135-6-25**] 01:37AM LACTATE-0.6
[**2135-6-25**] 01:25AM GLUCOSE-75 UREA N-35* CREAT-5.9* SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-20* ANION GAP-19
[**2135-6-25**] 01:25AM CK(CPK)-74
[**2135-6-25**] 01:25AM CK-MB-NotDone cTropnT-0.35*
[**2135-6-25**] 01:25AM CALCIUM-10.1 PHOSPHATE-7.7* MAGNESIUM-2.0
[**2135-6-25**] 01:25AM WBC-11.3* RBC-4.11* HGB-11.8* HCT-41.1
MCV-100* MCH-28.8 MCHC-28.8* RDW-20.0*
[**2135-6-25**] 01:25AM NEUTS-79.2* BANDS-0 LYMPHS-18.2 MONOS-1.8*
EOS-0.7 BASOS-0.1
[**2135-6-25**] 01:25AM PLT COUNT-356
[**2135-6-25**] 01:25AM PT-12.9 PTT-33.2 INR(PT)-1.1
[**2135-6-25**] 01:00AM GLUCOSE-70 UREA N-35* CREAT-5.7*# SODIUM-139
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-16* ANION GAP-22*
[**2135-6-25**] 01:00AM estGFR-Using this
[**2135-6-25**] 01:00AM CK(CPK)-170
[**2135-6-25**] 01:00AM cTropnT-0.29*
[**2135-6-25**] 01:00AM CK-MB-8
.
CXR [**6-25**]: IMPRESSION: Persistant right upper lobe ground glass
opacity, possibly infectious.
Brief Hospital Course:
Mr. [**Known lastname **] is a 50 year old man with history of end stage renal
disease secondary to amyloidosis, paroxysmal atrial
fibrillation, Type 2 diabetes on insulin admitted to the MICU
for hypotension and lethargy in the context of having the
transformer set changed of his peritoneal dialysis catheter.
# Change in mental status: Patient has progressive obtundation
with no obvious source on previous head CT. Repeat head CT
showing no evidence of acute intracranial process ([**6-27**]). Exam
was reportedly non focal, pt [**Name (NI) 9830**]0, and did not follow commands.
Pt currently non-responsive. Family contact and decision made
not to progressive with aggressive intervention for diagnosis
(i.e. no MRI, no intubation for imaging, no LP). Etiology
thought to be secondary to sepsis, ?meningitis for which he was
covered empirically with cefepime/vancomycin and also with
acyclovir. Additional etiology ?recent hypoglycemia, pt on IVF
with dextrose. Despite this therapy he continued not to respond.
After, several family meetings and involvment with social work
and palliative care a decision was made to make pt DNR/DNI with
no escalation of care. Over the last few days, pt's breathing
became more labored and his oxygen saturation declined. As pt
was DNR/DNI/no ICU transfer his respiratory status was made
comfortable. Despite continued broad spectrum antimicrobials and
continued dialysis sessions and treatment of transient
hypoglycemia, pt's mental status never improved and he was not
reactive even to sternal rub. On [**2135-7-6**], after meeting with
pt's girlfriend, HCP, and after discussion with patient's
family, decision was made to change the patient's status to CMO.
Pt was then placed on a morphine gtt and he passed away on
[**2135-7-7**] at 6am.
# Hypotension: The initial differential included distributive
shock due to infection vs. endocrine vs. cardiogenic. Given his
history of line infections and bacteremia and recent violation
of sterile PD catheter field, infectious etiology was considered
most likely. Exam on admission was significant for diffuse
abdominal tenderness, concerning for peritonitis. Also
considered was the HD line in right groin as possible source of
bacteremia. He had no other localizing symptoms.
He was started on vanc/cefepime as patient has h/o colonization
with both MRSA, pseudomonas. Blood cx were drawn at [**Hospital **]
Hospital, as well as at [**Hospital1 18**] - no growth to date at time of
discharge. An attempt was made to obtain peritoneal fluid for
cell count, cultures. He was on a dopamine gtt titrated to MAP
> 65, also received fluids at the OSH ([**Location (un) **]) and in the ED.
His dopamine was titrated off and he was transferred to the
medical floor where his blood pressures were stable, however his
mental status rapidly deteriorated.
# ESRD: The patient has been on dialysis secondary to amyloid,
currently on HD with plan for transition to PD. He is status
post peritoneal dialysis catheter placement [**6-10**], needs 2-3 weeks
to heal prior to use. Renal consult was following while he was
in the ICU. He was continued on his sevelamer at an increased
dose secondary to hyperphospetemia, cinecalcet. His vanc was
dosed at HD. HD sessions were continued until [**2135-7-6**] and the
renal team was very involved with the patient's care.
# Finger ischemia: The ischemia is consistent with history of
extensive
microvascular disease. He is not currently anticoagulated given
bleeding risk. He has previously been seen by Plastic Surgery
who felt his finger segment will auto-amputate. He generally
receives oxycodone PRN pain
# Thrombosis: The patient has known extensive inferior vena cava
clot burden to level of right atrium and likely involvement of
superior vena cava. There is a high degree of risk associated
with anticoagulation in this patient related to history of
hemodynamically signficant epistaxis, recurrent epistaxis, and
hemoptysis related to fungal lesion in left upper lobed of the
lung. The risks/benefits of anticoagulation have been discussed
at length during previous hospitalization, with decision not to
anticoagulate.
# DM2 uncontrolled with complications: The patient had several
episodes of hypoglycemia while on the floor which required amps
of D50 to correct. Pt was placed on a D5 gtt.
# PAF: The patient is currently in NSR. His beta blocker was
originally held in the setting of his hypotension.
# Sarcoidosis: The patient was on chronic prednisone.
# Pulmonary aspergillosis: The patient was continued on his
chronic suppressive voriconazole.
Medications on Admission:
1. Albuterol neb q4 hours
2. Metoprolol 12.5 mg [**Hospital1 **]
3. Omeprazole 20 mg daily
4. Prednisone 5 mg qAM
5. Prednisone 2.5 mg qHS
6. Bactrim 160/800 mg QHD
7. Colace 100 mg [**Hospital1 **]
8. Senna 8.6 mg [**Hospital1 **]
9. Nephrocaps
10. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]
11. Sodium Chloride nasal spray [**Hospital1 **]
12. Voriconazole 200 mg Tablet [**Hospital1 **]
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
14. Lantus 100 unit/mL Cartridge Sig: Eight (8) units qHS and
sliding scale
15. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
16. Lactulose 15 mL [**Hospital1 **]
17. Bisacodyl 5 mg PO daily
18. Oxycodone 5 mg q4 hours PRN
19. Cinacalcet 30 mg daily
Discharge Medications:
N/A pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Hypotension
Secondary:
ESRD [**3-5**] to amyloidosis
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 0389, 5856, 4589, 2767, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 946
} | Medical Text: Admission Date: [**2116-7-12**] Discharge Date: [**2116-7-24**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old
female with a history of coronary artery disease status post
percutaneous transluminal coronary angioplasty nine years ago
at [**Hospital6 33**] who presented to [**Hospital6 33**]
on [**7-6**] with acute onset of chest pain, back pain and
bilateral arm pain. She was admitted with unstable angina
symptoms and placed on an oxygen, nitroglycerin beta blocker.
Her cardiac catheterization revealed severe three vessel
coronary artery disease with a 50% left main stenosis and is
referred to the Coronary [**Hospital1 69**]
for revascularization. The patient is a resident of the
[**Hospital 2670**] Nursing Home where she was admitted with
fibromyalgia rheumatica. Prior to this diagnosis she lived
independently at [**Last Name (un) 42670**]. She also had a urinary tract
infection and she had been treated with Ceftriaxone
preoperatively. The patient is DNR/DNI.
PAST MEDICAL HISTORY: Significant for coronary artery
disease status post percutaneous transluminal coronary
angioplasty with 95% left circumflex lesion in [**2106**], type 2
diabetes, fibromyalgia rheumatica, gastritis, osteoarthritis,
Alzheimer's disease, rheumatoid arthritis, hypothyroidism.
MEDICATIONS AT HOME: Darvocet N 100 q 4 h prn pain,
nitroglycerin patch, Glucophage 500 mg po q.d., Pepcid 20 mg
b.i.d., Synthroid either 25 micrograms or 50 micrograms
b.i.d., Prednisone 5 mg po b.i.d.
MEDICATIONS AT OUTSIDE HOSPITAL: Synthroid 50 micrograms
once a day, Celexa 20 mg once a day, Neurontin 300 mg twice a
day, Glucophage 500 mg q.d., Aricept 5 mg q.o.d., Prednisone
5 mg b.i.d., Lovenox 80 mg b.i.d., Ceftriaxone two doses,
Nitropaste, Accupril 5 mg q.d., Lipitor 20 mg q.d., Trazodone
25 mg q.h.s., aspirin 81 mg q.d., Atenolol 12.5 mg q.d.,
sliding scale of regular insulin.
PHYSICAL EXAMINATION: On admission she was afebrile 97.2
with a heart rate of 58, blood pressure of 118/52,
respiratory rate 18, 92% on room air. She was an elderly
white female in no acute distress. Her lungs were clear
bilaterally. Her neck was within normal limits without any
evidence of JVD. Her heart was a regular rate and rhythm.
She had good breath sounds bilaterally. Her extremities
showed 1+ pitting pedal edema and she had multiple ecchymosis
over frail skin. Neurologically she was grossly intact,
alert and oriented, conversant and appropriate.
HO[**Last Name (STitle) **] COURSE: In summary the patient is an 84 year-old
former DNR who was taken to the Operating Room for a coronary
artery bypass graft with Dr. [**Last Name (Prefixes) **] where an saphenous
vein graft to left anterior descending coronary artery,
saphenous vein graft to posterior descending coronary artery
and saphenous vein graft to DM bypass was done. Cross clamp
time was 39 minutes, bypass time was 72 minutes.
Neurological: The patient was in the Intensive Care Unit
postoperatively where she remained until [**2116-7-21**]. She
was slow to wake up. She showed left sided weakness and
symptoms of possible stroke. A neurology consult was
immediately obtained after a suspicion grew to point toward a
stroke and a CT scan done showed that she might have had a
right or middle cerebral artery watershed event. The
patient's treatment was maintain her perfusion pressure,
which was done in the unit and to keep her symptomatically in
good support. Neurology will follow up with her upon
discharge.
Cardiovascular: The patient had several premature
ventricular contractions immediately postoperatively and was
put on a Lidocaine drip, which was switched over to
Amiodarone. The patient then in the Intensive Care Unit had
atrial fibrillation during the latter half of her Intensive
Care Unit stay. Her beta blocker was started of Lopressor
and this resolved on its own with Amiodarone and Lopressor.
She was weaned off drips and was maintaining her own blood
pressure upon discharge in sinus rhythm.
Respiratory: The patient was slowly extubated due to her
sedate state and questionable neurological status immediately
postoperatively. The patient woke up and demonstrated
adequate awareness she was immediately extubated and did
well.
Gastrointestinal: Consideration was given toward tube feeds
by postoperatively four to five while the patient was still
sedate, however, she was then extubated and she was allowed
to take a diet as tolerated. Otherwise she was given
gastrointestinal prophylaxis in the form of Prevacid 30 mg po
q.d.
Infectious disease: The patient had no acute infectious
disease issues and received Vancomycin perioperatively.
Hematology: The patient's hematocrit was stable. She
received several blood transfusion during her hospital stay.
She will be discharged to home with deep venous thrombosis
prophylaxis.
Extremities: The patient is fluid overloaded and will
require ambulation, physical therapy and help with diuresis.
Fluid, electrolytes and nutrition: The patient's
electrolytes and balanced fluids showed that she has
interstitial edema of her skin. She will be given a
diuretic. Her preop weight and postop weight are relatively
similar, however.
The patient is to follow up with her primary care physician
for all medical issues.
On [**7-21**] the patient was transferred out of the Intensive Care
Unit and on to the floor and all rehab services were
contact[**Name (NI) **] as well as the social worker. She was doing well
on the floor in no acute distress. On [**7-23**] no complications
occurred. On [**7-24**] she was given a chance for rehab screen and
is discharged to home in excellent condition.
DISCHARGE MEDICATIONS: Regular insulin sliding scale
starting at 150 going up by 3 for every 50 mg increase per
deciliter of blood sugar. Amiodarone 400 mg po b.i.d. for
thirty days and then q.d., Lopressor 12.5 mg po b.i.d. to be
titrated to a heart rate of 70 so long as the blood pressure
tolerates it. Lasix 20 mg po b.i.d. times five days and then
q.d. times one week. K-Ciel 20 milliequivalents po b.i.d.
times five days and then q.d. times one week. Aricept 5 mg
po q.h.s., heparin subQ 5000 units b.i.d., Gabapentin 300 mg
po t.i.d., Captopril 6.25 po q.d., Prevacid 30 mg po q.d.,
Glucophage 500 mg po q.d., Colace 100 mg po b.i.d.,
Prednisone 10 mg po q day, Synthroid 50 micrograms q.d.,
Prevacid 30 mg po q day.
Upon discharge the patient is in good and excellent condition
and will follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] for surgical
issues and four weeks Dr. [**First Name (STitle) **] [**Name (STitle) **] her primary care
physician and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42671**] at [**Telephone/Fax (1) 42672**] for all
neurological issues. The patient understands the discharge
plan and is in good condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2116-7-24**] 08:01
T: [**2116-7-24**] 08:14
JOB#: [**Job Number 42673**]
ICD9 Codes: 4111, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 947
} | Medical Text: Admission Date: [**2160-4-27**] Discharge Date: [**2160-5-7**]
Date of Birth: [**2094-2-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
AMS, fever
Major Surgical or Invasive Procedure:
Lumbar puncture
Intubation and extubation
Picc line placement and removal
History of Present Illness:
Mr [**Known lastname **] is a 66M with parkinson's s/p brain implant transferred
from nursing home with malaise, AMS, fevers. The pt was at
baseline and not complaining of any problems yesterday from [**6-24**].
Around 8 PM on [**4-26**], the pt was noted by nsg home staff to be in
bed, lethargic and not responsive to voice, which is different
from his alert/verbal baseline. There was some question of
seizure activity because he was found with both arms clenched
and rigid in upward position. Vitals at the time were 97.8, 74
24 120/60 96% on 2 L. When EMS arrived he was noted to be
unresponsive, with eyes open but pupils glossy but reactive. RR
was 22, 99% on RA. He was transferred to [**Hospital3 2783**]
where vitals were 100.7 160/80 79 20 95% and he was noted to be
weak and not responding to verbal stimuli initially, later was
responding to son who reported he was at baseline. He was given
zosyn 3.375 mg, 2 mg ceftriaxone. Pt was placed on BiPAP as
family was considering de-escalating goals of care from full
code.
On arrival to the [**Hospital1 18**] ED, initial VS were 118/49 71 16 100%.
ABG showed 7.25 pCO2 94 pO2 198 HCO3 43. UA showed sm
leukocytes, mod blood. Pt arrived here with somewhat improved
abg, but worsening resp rate and didn't seem to be protecting
airway. Discussions with family did not lead to reversal of full
code and so patient was intubated. Pt was started on
vanc/zosyn/ceftriaxone/cefepime at meningitis dosing, started on
a propofol drip. Blood and urine cultures were sent, LP was
attempted but was unsucessful.
On arrival to the MICU, patient's VS were T100 66 140/62. He is
intubated and sedated.
Review of systems: unable to complete due intubation/sedation
Past Medical History:
-parkinsons
-stroke, residual L-sided deficit
-brain stimulator
-GERD
-spinal fusion
-HTN
-CAD
-depression
-recent hospitalization x4 wks at [**Hospital1 2025**] for "assault" at nsg home
Social History:
Lives in [**Doctor Last Name **] View Care and Rehabilitation Center. Uses
wheelchair. tob/etoh/illicits hx unknown
Family History:
unknown
Physical Exam:
Admission Physical Exam:
Vitals: T100 66 140/62
General: intubated, sedated
HEENT: Sclera anicteric, MMM, pupils minimally reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse breath sounds anteriorly, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: sedated
Discharge physical exam:
Vitals: T 98.4 70s 164-171/80s 20 97% on RA
General: Interactive, following all commands and answering all
questions appropriately.
HEENT: PERRL, anicteric sclera, OP clear. Able to turn neck
left and right 45 degrees without pain. Very stiff muscles at
times
CV: S1S2, RRR, 2/6 systolic murmur over RUSB, non harsh not
radiating
Lungs: Poor air movement and rhoncorous with basilar crackles.
Ab: Positive BS??????s, NT, mildy distended. No HSM.
Ext: No c/c. Edema improved. [**12-24**]+ pulses. Tight quadricceps.
Hands flexed and contracted
Neuro: Alert, oriented to day / date / month / year and ??????[**Hospital 61**]??????. 5/5 strength in upper extremities. [**3-27**] in lower
extremities
Pertinent Results:
Admission Labs:
[**2160-4-27**] 03:30AM BLOOD WBC-6.7 RBC-4.73 Hgb-14.8 Hct-47.1
MCV-100* MCH-31.2 MCHC-31.3 RDW-13.5 Plt Ct-202
[**2160-4-27**] 03:30AM BLOOD Neuts-75.3* Lymphs-20.0 Monos-4.4 Eos-0.2
Baso-0.2
[**2160-4-27**] 03:30AM BLOOD PT-10.3 PTT-30.7 INR(PT)-0.9
[**2160-4-27**] 03:30AM BLOOD Glucose-100 UreaN-20 Creat-0.8 Na-141
K-4.5 Cl-97 HCO3-35* AnGap-14
[**2160-4-27**] 04:11AM BLOOD Type-ART pO2-198* pCO2-94* pH-7.25*
calTCO2-43* Base XS-10
[**2160-4-27**] 03:29AM BLOOD Lactate-1.9
[**Hospital3 **]:
[**2160-4-27**] 04:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2160-4-27**] 04:40AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2160-4-27**] 04:40AM URINE RBC-83* WBC-13* Bacteri-NONE Yeast-NONE
Epi-<1
[**2160-4-27**] 06:29AM BLOOD Type-ART Temp-37.8 Tidal V-448 PEEP-6
FiO2-100 pO2-368* pCO2-61* pH-7.35 calTCO2-35* Base XS-6
AADO2-290 REQ O2-54 -ASSIST/CON Intubat-INTUBATED
ABGs:
[**2160-4-27**] 10:26AM BLOOD Type-ART pO2-117* pCO2-40 pH-7.51*
calTCO2-33* Base XS-8 Comment-ADD ON
[**2160-4-27**] 10:26AM BLOOD Lactate-2.1*
CSF:
[**2160-4-27**] 01:15PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-0 Polys-0
Lymphs-96 Monos-4
[**2160-4-27**] 01:15PM CEREBROSPINAL FLUID (CSF) WBC-12 RBC-1* Polys-2
Lymphs-92 Monos-6
[**2160-4-27**] 01:15PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-80
[**2160-4-27**] 01:15PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Negative
Discharge Labs:
Specimen hemolyzed:
[**2160-5-6**] 06:55PM BLOOD WBC-6.3 RBC-4.43* Hgb-13.8* Hct-43.4
MCV-98 MCH-31.0 MCHC-31.7 RDW-13.9 Plt Ct-248
[**2160-5-7**] 10:12AM BLOOD Na-140 K-5.2* Cl-95*
[**2160-5-6**] 06:55PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.2
Microbiology:
[**2160-4-27**] 1:15 pm CSF;SPINAL FLUID
GRAM STAIN (Final [**2160-4-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2160-4-30**]): NO GROWTH.
VIRAL CULTURE: NO VIRUS ISOLATED.
[**2160-4-27**] MRSA SCREEN - Negative (final)
[**2160-4-27**] BLOOD CULTURE x2 - No growth
[**2160-4-27**] URINE CULTURE - Negative (final)
[**2160-4-30**] BLOOD CULTURE x2 - No growth
Imaging:
CXR [**4-27**]:
FINDINGS: A frontal supine view of the chest was obtained
portably. Low lung volumes result in bronchovascular crowding.
Part of the lung fields are obscured by bilateral pacemakers.
The endotracheal tube ends 4.3 cm above the carina. Opacity at
the left lung base may represent a small effusion and
atelectasis or infection. The cardiac silhouette is difficult to
evaluate due to the left lung opacity. The upper lung zones are
clear. No large pneumothorax. A nasogastric tube follows the
expected course, although the tip is not visualized, possibly in
the proximal duodenum.
IMPRESSION: Left lower lung opacity may represent small left
pleural effusion and atelectasis or infection.
CT Head [**4-27**]:
CT HEAD: Study is limited by intracranial leads and patient
motion. There is no large acute hemorrhage, mass effect, or
large territorial infarct obvious in the parts of brain where
well seen. Prominent ventricles and sulci are compatible with
global age-related volume loss. Basal cisterns are patent. There
is no shift of midline structures. No acute osseous abnormality
is identified. Fluid in the ethmoid air cells and and nasal
cavities may be related to intubation.
IMPRESSION: Limited study due to patient motion and streak
artifact from
intracranial leads. No acute intracranial large hemorrhage or
mass effect
identified. Consider repeat study when the pt. is co-operative.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2160-4-28**] 3:57
AM
FINDINGS: As compared to the previous radiograph, the
endotracheal tube is in correct position and unchanged. The
bilateral pectoral pacemakers are also unchanged. Unchanged
elevation of the left hemidiaphragm with cranially displaced
stomach. No pneumothorax. No other acute changes in the lung
parenchyma. The aspect of the cardiac silhouette is constant.
Neurophysiology Report EEG Study Date of [**2160-4-27**]
IMPRESSION: Abnormal EEG due to the presence of a slow,
disorganized
background mostly in the theta and delta frequency ranges. This
finding
suggests the presence of a moderate diffuse encephalopathy which
indicates widespread cerebral dysfunction but is non-specific as
to
etiology. No focal or epileptiform features were seen.
[**2160-4-30**], Right upper extremity US
Somewhat limited study due to difficulty in patient positioning.
Right forearm cephalic vein thrombophlebitis. No DVT in the
right upper
extremity.
CXR [**5-1**] - IMPRESSION: Left PICC line in the left internal
jugular vein. Recommend re-positioning. Persistant left
perihilar opacity, likely aspiration.
[**2160-5-1**], CT C spine w/o contrast:
Multilevel, multifactorial degenerative changes are noted, with
narrowing of the disc space, anterior and posterior osteophytes,
and facet and uncovertebral degenerative changes. The patient
is status post surgery at C3, C4, C5, and C6 levels. No obvious
canal stenosis is noted.
Multilevel foraminal narrowing is noted. No obvious acute
fracture is noted in the cervical vertebral bodies. Lucencies
noted in the osteophytes
anteriorly, may relate to orientation of the osteophytes. There
is no large amount of prevertebral soft tissue swelling.
Evaluation is somewhat limited due to the scoliosis and
motion-related artifacts. There are areas of increased
attenuation in the lungs on both sides, part of which may relate
to motion. This can be better assessed with dedicated chest
imaging.
IMPRESSION:
1. Scoliosis, diffuse osteopenia and motion-related artifacts
limit accurate assessment. Within this limitation, no obvious
large fracture. Lucencies noted in the osteophytes likely
relate to the oblique orientation of the osteophytes. Correlate
clinically to decide on the need for further workup with MRI if
not contraindicated for better assessment.
2. Status post surgery with anterior and posterior fusion
hardware. No
obvious loosening noted. Other details as above.
[**2160-5-2**] CXR:
As compared to prior study, left perihilar consolidation has
decreased and
small likely consistent with aspiration as opposite to
pneumonia. Left lower lobe consolidation is unchanged,
associated with pleural effusion. The right lung is unchanged
in appearance as well as the bilateral deep brain stimulators.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 66yo male with
PMH of Parkinson's Disease, stroke, and s/p bilateral deep brain
stimulator placement, who was admitted for altered mental
status.
# Altered mental status/encephalopathy: The patient had multiple
possible etiologies for his altered mental status. Most likely
given questionable pneumonia on CXRay and in the setting of
intubation and hypercarbic respiratory failure, it was felt that
pt had aspiration event vs pna vs both. There was some question
of seizure activity given his rigid state, however no overt
seizure activity was observed and it was felt that this rigidity
was at baseline due to to parkinson's and dystonia. EEG revealed
diffuse slowing but no epileptiform activity. Infectious causes
were likely given fever at OSH. Patient was started on
ceftazidime and vancomycin which was broadened to include
meningitis coverage plus acyclovir for possible HSV
encephalitis. LP showed lymphocytosis initially concerning for
viral infection. However, this slight leukocytosis with
lymphocytic predominence could be due to hardware. HSV PCR was
negative and preliminary viral cultures were negative. Thus,
antibiotics were downtitrated and acyclovir discontinued. Low
concern for stroke given patient was observed to be close to
baseline motor skills. Head CT from OSH showed no evidence of
intracranial bleed. The patient ultimately was placed on a
regimen of ceftazidime and levofloxacin to cover for health care
associated pneumonia. He remained afebrile and his mental
status improved dramatically. It is unclear whether this was
due to the treatment of an acutal pneumonia or the resolution of
an acute aspiration chemical pneumonitis event. Given how sick
he was, requiring intubation and the improvement while on
antibiotics, it was felt to be most reasonable and safest to
complete an 8-day course for HCAP with ceftazidime and
levofloxacin. Blood and urine cultures were negative. No
evidence of metabolic abnormalities to cause AMS based on
electrolyte panel. PICC line was placed to finish course of
abx: ceftazidime and levofloxacin, last day [**5-5**].
.
# Hypercarbic respiratory failure: Patient was unable to protect
his airway in the setting of altered mental status. This may
have been from pneumonia or aspiration event as above as no
other sources were identified. Per the patient's son, the
patient had respiratory problems since discharge from [**Name (NI) 2025**] in
[**Month (only) 956**], which the son was concerned could be due to cervical
spine injury. Patient was successfully extubated and weaned
from supplemental oxygen. By the time of discharge, he had O2
saturation levels around 97% on room air.
.
# Parkinson's disease: Advanced, requiring deep brain stimulator
placement. The patient was initially unable to take home
Sinemet, baclofen, and pyridostigmine due to NPO status. These
were provided later via NG tube. His DBS stimulators were
evaluated by the Neurology team who recommended continuing his
baclofen and pyridostygmine at home dosages. Pt was evaluated
by speech and swallow team and his diet was changed to thin
liquids and ground solids. His pills were crushed and the
patient tolerated this diet without difficulty.
.
# Hx CAD, native vessel: No evidence of active ischemia.
Continued atenolol, aspirin. Defer statin to outpatient
setting.
# Ileus: At the time of admission, the patient had bilious
drainage from his NG tube with a benign abdominal exam. LFTs
were wnl but for an elevated LDH. NGT stopped draining bilious
fluid and tube feeds were initiated as tolerated. Patient was
subsequently cleared by speech and swallow evaluation and
advanced diet per their recommendations to ground solids and
thin liquids.
.
# Neck stiffness: Son [**Name (NI) 112335**] concerned about leftward
positioning of neck. Patient with intermittent stiffness and
pain which resolved with muscle relaxants. CT scan of neck
showed no evidence of acute fracture with a limited study based
on motion artifact but with chronic degenerative changes,
osteophytes, osteopenia, and scoliosis present. The patient was
able to turn his head and complained of no pain over cervical
area on palpation. He did have intermittent episodes when his
neck became stiff, appeared more dystonic, and this was
accompanied by diaphroesis. He also complained of some leg pain
and on examination there were intermittent episodes where his
legs were stiff as well. These episodes resolved with time and
also with muscle relaxant medications. Thus, his baclofen was
increased, he was started on flexeril, and he was continued on
clonezapam. These medications resolved his symptoms. During
these episodes, the patient felt uncomfortable, but was still
very much responsive and at his mental baseline; his vital signs
were stable, with good O2 saturations >93% on room air.
Speaking with Dr. [**First Name (STitle) 7951**] and reviewing the [**Hospital1 2025**] discharge summary,
these are chronic issues. Reviewing the [**Hospital1 2025**] discharge summary,
imaging was not remarkable for fracture and ortho-spine was
consulted which found no acute injury and no need for surgical
intervention. Here, neurology and ortho-spine were consulted
and reviewed the imaging and reached similar conclusions,
feeling that outpatient management was the best option for these
chronic issues, and agreed with muscle relaxants as well as
outpatient Botox injection versus trial of cervical traction for
this patient. Despite these recommendations, the son remained
very upset about his dad's neck, and feels that these occurred
acutely after alleged assault at nursing home. There are a lack
of records regarding this alleged assault and discussion with
outpatient neurologist confirmed that rigidity and parkinson's
are chronic issues. The son became verbally aggressive toward
staff and providers and was demanding in terms of his requests
for surgical intervention at times insinuating litigation if we
did not act in accordance with his wishes, and stated that he
felt that these issues were new and occurred after a nursing
home "assault" and did not feel that dystonia, muscular
stiffness, torticollis, or severe Parkinson's was contributing
to the patient's clinical picture. The patient and his son are
aware that ortho-spine and neurology here evaluated the patient
during this hospitalization and offered to see the patient again
as an outpatient. Dr. [**First Name (STitle) 7951**] (the patient's outpatient
neurologist) was alerted to the plan of care and the patient
will follow up with him after discharge.
.
# Hypertension, benign: Pt was started on lisinopril. Continued
on atenolol and lasix.
.
# Edema: Pt with mild swelling throughout, despite being net
negative while here. Most likely, this is related to his being
bed bound. Pt continued on lasix.
.
Transitional:
-Follow up with neurology for parkinson's disease, neck
stiffness. Consider Botox injection to neck.
-Increased dose of baclofen and started Flexeril, per Neurology
recommendation.
-Outpatient neurologist: Dr. [**First Name (STitle) 7951**] (neurology) [**Telephone/Fax (1) 112336**]
-Continue 1:1 supervision during meals with ground solids and
thin liquids. Aspiration precautions.
-Last potassium level here was slightly elevated at 5.2, but
this specimen was moderately hemolyzed. All K levels here were
normal, except for those which were hemolyzed specimens.
-Consider follow-up chest x-ray. The last chest x-ray here, on
[**2160-5-3**], showed 1) PICC line tip over proximal/mid SVC. No ptx
detected. 2) Increased markings left lung -- ? inflammatory or
infectious pneumonitis. The appearance is improved compared with
[**2160-5-1**] and similar or slightly improved compared with [**2160-5-2**].
-CT of the C-spine on [**2160-5-2**] showed: 1. Scoliosis, diffuse
osteopenia and motion-related artifacts limit accurate
assessment. Within this limitation, no obvious large fracture.
Lucencies noted in the osteophytes likely relate to the oblique
orientation of the osteophytes. Correlate clinically to decide
on the need for further workup with MRI if not contraindicated
for better assessment. 2. Status post surgery with anterior and
posterior fusion hardware. No obvious loosening noted. Other
details as above.
Medications on Admission:
-albuterol PRN
-atenolol 100 mg
-baclofen 15 mg q hs
-baclofen 20 mg q daily
-carbidopa-levodopa 25-100 1 tab 9x/day between the hours of 6AM
and 10 PM
-Clonazepam 0.5 mg q 8 hrs PRN
-clonazepam 0.5 mg q HS
-Ferrous sulfate 220 mg [**Hospital1 **]
-lasix 20 mg q day until [**5-3**]
-lidocaine 5% topical to lower back
-MV daily
-omeprazole 20 mg PO daily
-polyvinyl alcohol 1.4 solution opthalmic 2 drops to each eye
TID
-pyridostigmine bromide 30 mg [**Hospital1 **]
-sinemet 25-100 [**12-24**] tab one hour after scheduled dose PRN, may
not exceed 4 times in 25 hrs
-vitamin D 1000 mg daily
-lorazepam 0.25 mg daily for anxiety or rigidity
-nystatin to groin daily
-fragmin [**Numeric Identifier 16351**] unit/0.2 mg solution sq daily
-cymbalta 60 mg delayed release particles by mouth 60 mg daily
-docusate 200 mg daily
-ducolax 5 mg daily prn constipation
-mgOH 400 mg daily prn constipation
-miralax 17 mg daily
-senna 8.6 mg daily
-acetaminophen 650 mg TID
-aspirin 81 mg daily
-oxycodone 15 mg q 4 hrs prn pain
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4
hours) as needed for SOB, wheeze.
2. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
Q2HRS (): Please give between 0600 and 2200 for total 9 tablets
daily. .
4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed.
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution Sig: Two
[**Age over 90 **]y (220) mg PO twice a day.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lidocaine 5 % Ointment Sig: apply over lower back Topical
every six (6) hours as needed for pain.
9. multivitamin Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. polyvinyl alcohol 1.4 % Drops Sig: Two (2) drops Ophthalmic
three times a day: to both eyes.
12. pyridostigmine bromide 60 mg Tablet Sig: 0.5 Tablet PO BID
(2 times a day).
13. Sinemet 25-100 mg Tablet Sig: 0.5 Tablet PO prn: 1 hr after
scheduled dose prn, may not exceed 4 times in 25 hrs .
14. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
15. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO once a day as
needed for anxiety or rigidity.
16. nystatin 100,000 unit/g Powder Sig: One (1) application
Topical once a day: groin.
17. Fragmin 25,000 unit/mL Solution Sig: continue dosing per LTC
facility Subcutaneous once a day.
18. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
19. docusate sodium 100 mg Tablet Sig: Two (2) Tablet PO once a
day.
20. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
21. magnesium hydroxide 400 mg/5 mL Suspension Sig: Four Hundred
(400) mg PO once a day as needed for constipation.
22. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
23. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
24. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
25. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day.
26. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
27. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
28. baclofen 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
29. oxycodone 5 mg/5 mL Solution Sig: Fifteen (15) mL PO Q4H
(every 4 hours) as needed for pain.
30. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] View Care and Rehabilitation Center
Discharge Diagnosis:
Primary: Pneumonia, aspiration, hypertension, Musculoskeletal
stiffness and rigidity
Secondary: Parkinson's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 112337**],
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted for altered mental status and respiratory
failure requiring intubation. It is unclear what caused this,
but it was thought to most likely be an aspiration, a pneumonia,
or a combination of the two. Tests were run to check for
infection in your blood, urine, and cerebrospinal fluid, and
these tests have all come back negative. You improved on
antibiotics, and it was decided to have you finish a course of
antibiotics for presumed pneumonia. Your blood pressure was
also found to be high and you were started on a new blood
pressure medication. You experienced some neck and body
stiffness that seems related to a dystonia and your parkinson's
disease. We obtained imaging of your neck, which did not reveal
any acute fracture as best as we could tell, and neurology and
orthopedic spine services were consulted which felt that there
was no acute surgical intervention that needed to be performed.
They felt that this neck stiffness could be better managed with
medications.
Medication changes:
START Lisinopril for high blood pressure
INCREASE Baclofen to three times a day for neck stiffness
START Flexeril for neck stiffness
Followup Instructions:
Please follow up with your extended care facility physician who
can continue to coordinate your care.
The following appointment was made for you:
Name: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 112338**],MD
Specialty: Neurology
When: Friday [**5-9**] at 3pm
Address: [**Apartment Address(1) 112339**], [**Location (un) **],[**Numeric Identifier 13108**]
Phone: [**Telephone/Fax (1) 25666**]
Completed by:[**2160-5-7**]
ICD9 Codes: 5070, 5990, 2760, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 948
} | Medical Text: Admission Date: [**2102-11-20**] Discharge Date: [**2102-11-27**]
Date of Birth: [**2043-2-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Cipro Cystitis / Benadryl
Decongestant / Motrin / Zofran / Prochlorperazine Maleate
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
AMS and tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59F with PMH of stage 4 colon CA s/p R hemicolectomy in [**2098**],
s/p chemo with recurrence and currently consented for phase I
trial who was referred by PCP for increasing confusion,
abdominal pain, and poor po intake.
In the ED, initial vital signs were 97.8 151 124/79 16 98% on
RA. She was found to be oriented x2, jaundiced, and endorsed RUQ
pain. Her exam was notable for jaundice, sinus tachycardia,
palpable mass in RUQ, abd nt, guaiac neg stools, and +asterixis.
Labs were notable for WBC 24.3 with left shift, positive UA,
ammonia level 61, VBG 7.50/40/51/32, Lactate 3.0, Na 129, K 3.0,
Cr 0.6, ALT: 39 AP: 756 Tbili: 9.4 Alb: 3.1 AST: 164, negative
Utox. Head CT showed no acute process. CTA chest was performed
to rule out PE, which was a suboptimal study, that showed Small
R pleural effusion with RLL atelectasis, multiple b/l pulmonary
nodules up to 6mm slightly increased in size from prior, but no
no central PE. It also showed innumerable hepatic metastases
infiltrating and enlarging entire liver, increased in number and
size since previous CT with marked compression of intrahepatic
IVC, hepatic veins, and portal veins, no biliary ductal
dilation. There was moderate increased perihepatic ascites. RUQ
US was notable extensive intrahepatic mets, patent main portal
vein. She was given 3.5L fluids and started on vancomycin and
aztreonam for empiric abx coverage.
Of note, her HR was noted to be 144 at her most recent onc visit
on [**11-8**]. She had complained of pain in her knees and back,
reportedly taking [**5-28**] vicodin per day. Her pain med regimen was
changed at that time to 10mg oxycontin [**Hospital1 **] with oxycodone for
breakthrough. She had also complained of nausea relieved by
lorazepam 1mg approx [**Hospital1 **]. She did not complain of abdominal pain
at that time, and no confusion was noted.
Her vital signs on transfer were 129 112/77 20 100%. On arrival
to the [**Hospital Unit Name 153**], her vitals were 97.7, 130/74, 127, 18, 94% on RA.
She complained of feeling tired and weak over the last few days
with nausea, no vomiting or diarrhea. She also endorsed
increased urinary frequency over the last few days, dizziness,
and confusion. She denies fever or chills. Her history is
unreliable however, as she is only oriented to self and
hospital.
Past Medical History:
1. Ovarian Cysts
2. Cervical Dysplasia
3. Osteoarthritis
4. Spinal Stenosis on chronic Darvocet
5. Torn Meniscus
6. Peripheral Edema
7. GERD
8. S/p CCK
9. Stage IV Colorectal cancer as above
10. MRSA R.buttock abscess, s/p I&D on [**2101-9-1**], tx with clinda
11. Klembsiella UTI ([**6-27**]--[**2102-7-2**] admit)
Past Oncologic History:
ertinent Oncologic history (include past therapies, surgeries,
etc):
[**2098-7-7**] when she was diagnosed with adenocarcinoma of the
colon at the splenic flexure
From [**6-/2098**]--[**1-/2099**] she received adjuvant chemotherapy with
FOLFOX which was complicated by severe neuropathy, minor PORT
problems and nausea.
-- [**2099-3-12**] She had a takedown ileostomy resection of distal and
proximal ileum w/ enterostomy.
-- [**2099-7-28**] her CT torso showed no evidence of disease. At this
time her CEA was 1.6 ([**2099-8-6**]).
-- She was followed serially and on [**2100-3-9**] her CEA had risen to
9.3.
-- [**2100-3-16**] CT abdomen that showed 4 solid appearing lesions w/in
the liver consistent w/metastatic disease
---- [**2100-8-11**] she was seen in consultation with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
and tentatively planned for colon resection, Right lobectomy,
segmental liver resection, IOUS, and resection of prior
ileosigmoid anastomosis on [**2100-8-27**]. A pre-operative CT torso was
done [**2100-8-11**] and again showed unchanged liver lesions (when
compared to [**7-28**] study), unchanged pelvic adenopathy and no new
interval lesions.
--[**2100-8-29**] MRI showed an 8-mm lesion in the left proximal
humerus, concerning for metastasis. Surgery was indefinitely
postponed.
-- [**2100-9-13**] PORT placed and C1D1 FOLFIRI, no avastin with cycle 1
due to recent PORT, Avastin started on C2
--[**2101-11-1**]; disease progression seen on CT scan. Started on
Erbitux/CPT-11. Rec'd a total of 7 cycles. treatment was
complicated by hypomagnesemia and severe diarrhea with several
doses of chemotherapy being held.
--[**2102-6-14**] CT with interval progression and >20% increase in
hepatic disease burden, no new disease sites, CEA rising
-- [**2102-6-20**] C1D1 Capecitabine 1500mg PO BID
-- [**6-27**]--[**7-2**] admitted for confusion and Klebsiella UTI
-- [**2102-7-17**]-started on CapeOx. C1 c/b n/v during infusion,
resolved with antiemetics. C2 ([**8-8**]) developed intractable n/v,
hives during infusion. admitted for observation. C3 ([**8-29**]) was
given per desensitization protocol in the ICU. developed n/v,
tachycardia, fever.
--[**2102-9-20**]-consented for phase 1 protocol
Social History:
Living/Support: Lives alone, no children. She has many local
friends.
[**Name (NI) **]/Income: Works as an educational consultant and standard
poodle breeder.
EtOH: 2 glasses of wine per day
Tobacco: 1ppdx10yrs, quit 20yrs ago
Illicits: denies, no h/o IVDU
Family History:
- Mother: Died at 91 of natural causes, had thyroid cancer
- Father: Died at 68 of CVA
- Other: No known malignancies. She has a first cousin with
hemachromatosis and an aunt with several gastric surgeries (not
for malignancy)
Physical Exam:
ADMISSION EXAM:
Vitals: 97.7, 130/74, 127, 18, 94% RA
General: jaundiced appearing caucasian female, in NAD,
comfortable
HEENT: Sclera mildly icteric, MMM and pink, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
Chest: port at the left subclavian appears nonerythematous,
nontender
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: decreased breath sounds at the right base, clear to
auscultation bilaterally, no wheezes, rales, rhonchi
Abdomen: portruding RUQ irregular mass, diffusely tender, no
guarding or rebound, BS present, no fluid wave or distention,
nontympanic, small umbilical hernia.
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, gait deferred
Pertinent Results:
ADMISSION LABS:
[**2102-11-20**] 01:37PM BLOOD Lactate-3.0*
[**2102-11-20**] 01:37PM BLOOD Type-[**Last Name (un) **] pO2-51* pCO2-40 pH-7.50*
calTCO2-32* Base XS-6 Comment-GREEN TOP
[**2102-11-20**] 01:26PM BLOOD LtGrnHD-HOLD
[**2102-11-20**] 01:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-11-20**] 01:26PM BLOOD Albumin-3.1* Calcium-10.3 Phos-2.0*
Mg-1.9
[**2102-11-20**] 01:26PM BLOOD Lipase-13
[**2102-11-20**] 01:26PM BLOOD ALT-39 AST-164* AlkPhos-756* TotBili-9.4*
[**2102-11-20**] 01:26PM BLOOD Glucose-112* UreaN-16 Creat-0.6 Na-129*
K-3.0* Cl-83* HCO3-29 AnGap-20
[**2102-11-20**] 01:26PM BLOOD PT-17.6* PTT-44.2* INR(PT)-1.6*
[**2102-11-20**] 01:26PM BLOOD Neuts-85.7* Lymphs-8.0* Monos-6.1 Eos-0.1
Baso-0.2
[**2102-11-20**] 01:26PM BLOOD WBC-24.3*# RBC-4.10*# Hgb-11.5*#
Hct-35.3*# MCV-86 MCH-28.0 MCHC-32.5 RDW-19.4* Plt Ct-481*#
MICRO:
[**2102-11-20**] URINE URINE CULTURE-PENDING INPATIENT
[**2102-11-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2102-11-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
IMAGING:
[**11-20**] CT Head
IMPRESSION: No hemorrhage or edema. No change from prior.
[**11-20**] CXR
IMPRESSION:
1. Interval increase in right basilar atelectasis.
2. Unchanged appearance of port overlying the left chest with
tip in the mid SVC.
[**11-20**] CT Chest/Abd/Pelvis
IMPRESSION:
1. Increased number and size of innumerable hepatic metastases,
with apparent compression of the intrahepatic IVC and
hepatic/portal vein branches on this non-venographic
examination, consistent with progression of metastatic disease
2. Slightly increased pulmonary nodules up to 6 mm, attention at
follow-up. No pulmonary embolism.
3. New pelvic peritoneal implant and periumbilical nodules,
consistent with metastatic disease.
4. Volume overload.
[**11-20**] RUQ u/s
IMPRESSION:
1. Extensive, innumerable intrahepatic metastases throughout
both lobes of the liver consistent with known metastatic
disease.
2. Patent main portal vein with hepatopetal flow. Reversal of
flow in the
right portal veins. Difficult to assess whether appropriate
direction of flow or reversal in the left portal vein.
Brief Hospital Course:
59F with Stage IV Colon CA refractory to treatments with
advanced hepatic metastasis who presented with altered mental
status in the setting of rapidly declining liver function.
Attempts were made to treat her encephalopathy, but her liver
function continued to worsen and she remained confused despite
treatment. She is unable to care for herself and lacks capacity
to make informed decisions. Family meeting was held with her
healthcare proxies and it was determined that patient should
receive Comfort Focused Care with transition to inpatient
hospice.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. bimatoprost *NF* 0.03 % OU QHS
1 drop topical at bedtime. apply to eyelashes
2. Dexamethasone 8 mg PO DAILY
take on day 2 and day 3 after chemotherapy
3. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
4. Omeprazole 20 mg PO DAILY
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN
breakthrough pain
hold for oversedation or RR <12
6. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
hold for oversedation or RR<12
Discharge Medications:
1. OxycoDONE (Immediate Release) 5-10 mg PO Q4H Pain
2. HydrOXYzine 25 mg PO Q6H:PRN itching
3. Ibuprofen 800 mg PO Q8H
4. Lactulose 30 mL PO BID:PRN constipation
5. Ondansetron 4-8 mg IV Q8H:PRN nausea
6. Sarna Lotion 1 Appl TP QID:PRN itching
7. Senna 1 TAB PO BID:PRN Constipation
8. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **]
Discharge Diagnosis:
Primary: Encephalopathy, Liver Failure
Secondary: Colon Cancer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 805**],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted because of confusion and
decline in your liver function. We transitioned our care to
focus on your comfort and safety. You should continue pain
medications, anti-nausea medications, and any other medications
needed to keep you comfortable.
Please contact your hospice providers with any questions or
concerns about your symptoms.
Followup Instructions:
Please contact your hospice providers with any questions or
concerns about your symptoms.
Completed by:[**2102-11-27**]
ICD9 Codes: 2762, 2761, 2768, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 949
} | Medical Text: Admission Date: [**2172-3-24**] Discharge Date: [**2172-3-30**]
Date of Birth: [**2152-10-20**] Sex: M
Service: [**Doctor Last Name 1181**]
ADMISSION DIAGNOSIS: Liver failure due to acetaminophen
overdose.
HISTORY OF PRESENT ILLNESS: The patient is a 19-year-old
male with history of polysubstance abuse/dependence, who
presented to outside hospital with nausea and vomiting
secondary to intentional Tylenol and Motrin overdose.
Patient is being transferred back to General Medicine floor
after a second short MICU stay.
On [**2172-3-19**], the patient was in a motor vehicle accident,
which totalled uncle's girlfriend's car. Uncle is quite
upset and chastised him. In addition to this, the patient
had been feeling more depressed over the past few weeks due
to legal problems. On [**2172-3-20**], the patient impulsively took
50-100 tablets of Tylenol as well as Motrin.
From [**3-20**] until [**3-23**], the patient felt sick and went to
outside hospital Emergency Department 2-3x before admitting
to his acetaminophen overdose when a tox screen returned
positive for Tylenol. Tylenol level on admission to outside
hospital Emergency Department was 44.75 with ALT of 14,064,
AST of 7,042. The patient was also found to have acute renal
failure, possibly due to Motrin overdose. That same day, the
patient was transferred to [**Hospital1 **] MICU, and given Mucomyst x15
doses.
While in the MICU, the patient was evaluated by Transplant,
Liver Service, Toxicology, and Psychiatry. According
psychiatric consult, the patient now regrets the OD and does
not want to die. Seemed relieved when told there was a
chance of survival. In the MICU, his LFTs trended down, no
acidosis or encephalopathy, lactate 3.2, creatinine 2.3, INR
of 5.7. Thus, the patient is determined not to be a
candidate for an urgent transplant, and on [**2172-3-25**], he was
transferred to General Medicine floor.
The patient's liver enzymes continued to trend downward and
ARF improved with hydration. The patient was then
transferred back to the MICU overnight for closer
observation. Overnight, his condition continued to improve.
Today he developed cellulitis in the left hand from IV and
was started on Keflex 500 mg IV q8h. The patient was seen by
Liver Service, which recommended switching to oral Mucomyst.
This evening he was transferred back to the General Medicine
floor.
PAST MEDICAL HISTORY: Mild asthma. The patient is on no
medications for this.
MEDICATIONS UPON TRANSFER:
1. Acetylcysteine 20%, 6,000 mg po q4h.
2. Cephalexin 500 mg po q6.
3. Pantoprazole 40 mg po q24.
4. Docusate sodium 100 mg po bid.
5. Senna one tablet po hs.
6. Ondansetron 2-4 mg IV q6 prn.
7. Insulin-sliding scale per insulin flow sheet.
ALLERGIES/ADVERSE REACTIONS: No known drug allergies.
SOCIAL HISTORY: The patient left high school [**Male First Name (un) 1573**] and is
studying to get a GED. He is single, never married, no
children, no current girlfriend. The patient has two
sisters, and is currently living with mother. [**Name (NI) **] grew
up in a home with alcoholism and violence. Drug use began as
a teen and has involved heavy use of cocaine, LSD, ecstasy,
marijuana, and heroin. The patient denies alcohol abuse,
recent detox for heroin. Has used needles, and has a history
of multiple arrests for various charges, but never
incarcerated.
FAMILY HISTORY: No family history of liver disease.
PHYSICAL EXAMINATION: Patient's vital signs: Temperature
99.0, pulse 58, blood pressure ranging from 120-140 systolic
and 50-80 diastolic, respiratory rate 14, and O2 saturations
is 98% on room air. General appearance: Patient appeared
stated age, alert, cooperative, and within no apparent
distress. Skin: Jaundice, normal hair distribution,
multiple ecchymoses on arms. HEENT: Normocephalic,
atraumatic, scleral icterus, no nystagmus. Extraocular eye
movements full. Pupils are equal, round, and reactive to
light. Lips and membranes unremarkable. Pharynx benign. No
tonsillar exudates. Neck is supple, full range of motion, no
thyromegaly. Lungs are clear to auscultation and percussion,
no crackles/rhonchi/rubs/wheezing. Cardiovascular: S1, S2
normal intensity, no jugular venous distention, no
clicks/murmurs/rubs. Abdomen: Soft, nontender, diminished
bowel sounds. Liver span within normal limits. Extremities:
Left hand: 2+ edema, tender to palpation, erythema on dorsum
of hand, radial/popliteal/dorsalis pedis/posterior tibial
pulse 2+ bilaterally, no cyanosis, no clubbing, and no edema.
Neurologic: Cranial nerves II through XII are grossly
intact. Motor: Muscle bulk and tone within normal limits.
Strength 3/5 bilaterally and throughout. Coordination: Fine
and repetitive finger movements intact.
MENTAL STATUS EXAMINATION: Patient is alert and oriented to
person, place, and time. Mental status examination within
normal limits.
LABORATORIES AND DIAGNOSTICS: Complete blood count: White
count 5.2, hemoglobin 13.1, hematocrit 37.5, platelets 112.
PT 19.3, PTT 38.2, INR 2.5. Blood chemistries: Sodium 137,
potassium 3.3, chloride -105, bicarb 23, BUN 22, creatinine
1.6, glucose 91. Calcium 8.7, phosphate 2.5, magnesium 1.9,
ALT 2593, AST 297, LD 299, alkaline phosphatase 130, T
bilirubin 14.0.
HOSPITAL COURSE: A 19-year-old man with a history of
polysubstance abuse/dependence, who presented to outside
hospital with nausea and vomiting secondary to intentional
acetaminophen and Motrin overdose. The patient is
transferred to [**Hospital1 69**] with
liver failure and acute renal failure.
1. Gastrointestinal: On admission to outside hospital,
acetaminophen level of 44.75 with ALT of 14,064 and AST of
7,042. Patient transferred to [**Hospital3 **] MICU on [**2172-3-24**]
with liver failure and INR of 5.7. The patient was placed on
IV Mucomyst and IVF. The patient responded well to IV
Mucomyst with LFTs trending down and was subsequently
transferred to the medicine floor on [**2172-3-25**].
Liver consult felt that patient was not an urgent candidate
for transplant and Toxicology recommended use of Mucomyst
until the patient's INR was less than 2. On the floor, the
patient's LFTs continued to trend down but the patient
determined to need closer monitoring, and was transferred
back to the MICU that same day. The patient was transferred
back to the Medicine floor on [**2172-3-26**], and placed on po
Mucomyst, bowel regimen, and continued IVF.
From [**Date range (1) **], the patient's LFTs continued trending down,
and on [**3-29**], the patient's INR was less than 2.0. The
patient's T bilirubin fluctuated from 12 to 14 during this
time, and he experienced occasional bouts of nausea mostly
related to Mucomyst ingestion. In addition to this, the
patient had no abdominal pains and all stools were guaiac
negative. Mucomyst was discontinued on [**3-29**]. On [**3-30**], the
patient was discharged to home with followup with PCP.
2. Renal: Patient transferred to [**Hospital3 **] MICU on
[**2172-3-24**] with acute renal failure and creatinine of 2.3.
Acute renal failure likely secondary to nonsteroidal
anti-inflammatories overdose. The patient was treated
supportive with IVF from [**3-24**] to [**3-28**]. IVF was
discontinued on [**3-28**]. During this time, the patient's renal
function gradually improved from a creatinine of 2.3 to 1.6,
and continued to remain around 1.6 on discharge. Patient
will have follow up with primary care physician regarding
renal function.
3. (ID): During second MICU stay, the patient developed left
hand cellulitis, possibly from his IV. The patient was
placed on renally dosed cephalexin 500 mg po q6h on [**2172-3-26**]
x7 days. From [**Date range (1) 47979**] resolved without complications.
On [**3-30**], only slight swelling visible in left hand. The
patient will continue with antibiotics for three more days
outpatient.
4. (Psych): Patient is seen by Psychiatry on admission and
setup with one-to-one sitter. Psychiatry determined that the
patient regretted the overdose and did not want to die. The
patient was relieved when told of chance of survival. Sitter
was discontinued on [**3-28**] per second recommendation. The
patient will have intensive followup in outpatient
psychiatric facility.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home with outpatient psychiatric followup.
DISCHARGE DIAGNOSES:
1. Acetaminophen overdose.
2. Hepatitis from acetaminophen suicide attempt.
DISCHARGE MEDICATIONS:
1. Diphenhydramine HCL 25 mg po q6h prn.
2. Pantoprazole SOD sesquihydrate 40 mg po q day x10 days.
3. Cephalexin monohydrate 500 mg po q6h x3 days.
4. Docusate sodium 100 mg po bid x7 days.
5. Ursodiol 300 mg po tid x7 days.
FOLLOW-UP PLANS:
1. The patient will follow up with new primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] located in [**Street Address(2) 47980**], Unit B210,
[**Location (un) 47981**], [**Numeric Identifier 47982**].
2. Psychiatric outpatient facility, Metalsedge Recovery
Center, [**Street Address(2) 47983**], [**Location (un) 47981**], [**Numeric Identifier 47984**].
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) 9336**]
MEDQUIST36
D: [**2172-3-30**] 15:25
T: [**2172-4-1**] 13:52
JOB#: [**Job Number 47985**]
cc:[**Telephone/Fax (1) 47986**]
ICD9 Codes: 5845, 2765, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 950
} | Medical Text: Admission Date: [**2170-10-22**] Discharge Date: [**2170-10-25**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Nausea and headache with walking trouble.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 88-year-old right handed female with a past
medical history significant for atrial fibrillation on Coumadin,
hypertension, hyperlipidemia, diabetes type 2, pulmonary
hypertension, was recently seen at [**Hospital1 18**] with an episode of
vertigo on Wednesday, [**2170-10-17**], who now returns six days later
with persistent nausea, left-sided occipital headache and
difficulty with walking. The patient had her first episode last
Wednesday on [**2170-10-17**]. She describes the episodes as follows:
She woke up after breakfast and went to go brush her teeth.
While standing in the bathroom, she had the sudden onset of
vertigo and the clock was spinning in the clockwise direction.
This sensation lasted for about 3 minutes, but she could not
stand during it and had to sit on the edge of the toilet seat
and
felt that she would fall off if she did not hold on to the seat.
The episodes started to slow down and then ceased at
approximately 3 minutes. Following this, she then noted a
headache in the left occipital/parietal area and she felt very
nauseous. At this point, she was able to stand without falling
and noted no dysarthria, dysphagia, diplopia, or any other
concerning brain stem findings or visual symptoms and because of
her history of a-fib, she called her son who advised her to call
EMS and then she came into [**Hospital1 18**], where she was seen by
neurology.
After being seen by neurology, she was complaining of mild
headache and mild nausea; however, her symptoms of vertigo had
resolved. On exam at the time, she did have a relatively normal
exam that was notable only for left cervical and trapezius
tenderness and evidence of cervical spondylosis with weakness in
the C5, C6, and C7 distribution bilaterally with some evidence
of myelopathy. A CTA and CT was performed. It did not show any
evidence of stroke or vessel blockage. It was felt that this is
possibly a peripheral process and the patient was discharged
home with followup.
Over the past five days, the patient has not had significant
improvement in her two primary symptoms, which are nausea and
her headache. She has not had any further episodes of vertigo;
however, she remains extremely nauseous and is unable to keep
most food or liquids down. She stated that she has not eaten
much in the past three to four days because of this. She notes
the nausea is significantly worse when she stands up and it is
somewhat improved when she lies flat with her eyes closed. She
still complains of her headache, which again she describes as
partially a pressure like sensation, non-throbbing, and
non-positional. She localizes it primarily to the posterior
side of her head on the left side. The patient had continuous
nausea for the last couple of days. Today and yesterday, she
felt that the nausea increased. She had one episode of emesis,
which was this morning. In addition, she did not get out of bed
all day. She gave two reasons for not getting out of bed, one
when she
rose up, she would become extremely nauseous and want to lie
flat again. The second reason was that she felt very unsteady
if she tended to stand up, she felt that if she leaned in one
direction or the other, she would be pulled down to the floor.
She was able to walk yesterday with a walker, which is unusual
for her, as she has never needed a walker prior to this.
The patient describes the headache as a numb, throbbing,
aching/pressure. She does not believe there is a positional
component. The patient does have a history of migraine
headaches, which she had from puberty to menopause. She
described the headaches as predominantly a throbbing unilateral
headache. She would get some nausea and vomiting with the
headache. There was photophobia and phonophobia. She described
this headache as different from her prior migraines, as she did
not have photophobia or phonophobia. Based on her continuing
symptoms, she called her PCP, [**Name10 (NameIs) 1023**] then spoke with one of our
outpatient neurologists, who recommended that she come into the
emergency room and be evaluated again by neurology.
The patient notes that she feels somewhat improved after getting
a dose of Zofran, although this medication has made her somewhat
sleepy.
On neuro ROS, the pt reports the mild pressure headache in the
left occiput as above, no loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, tinnitus or new hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, paraesthesia. Has long
standing increased urinary frequency with occasional
incontinence. No bowel incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. Some occasional night sweats, and a 9lb weight loss
over the last 6-8 months. Denies cough, shortness of breath.
Denies chest pain or tightness, occasional palpitations. Denies
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
1. Pulmonary hypertension noted first in [**2166**]
2. Diabetes mellitus has been taking oral hypoglycemics until
[**2170-5-8**] when she started insulin
3. Atrial fibrillation. Has been on warfarin for five years as
well as atenolol and digoxin.
4. Hypertension.
5. Hypercholesterolemia.
6. Hypothyroidism.
7. Recurrent urinary tract infections.
8. Dyspnea on exertion.
9. Hearing loss.
10. Basal cell carcinomas.
11. Osteopenia.
12. Nosebleeds. These are fairly new and have just started
recently.
Social History:
Ms. [**Known lastname **] was born in [**Location 8398**]at age four, she moved to
[**State 760**] where she graduated from high school. She then
finished nursing school and has [**Name8 (MD) **] RN from [**Location 85679**]. She then entered a master's program in
public health at [**University/College 85680**]. However, because of the
war, she went back to surgical nursing until the war was over.
She then married and had three children with whom she is quite
close. She has lived in [**State 2748**] for many years and has a
home on [**Hospital3 **]. She recently moved to [**Location (un) 86**] to live close to
her family. The husband of many years died in [**2168-1-8**].
SMOKING HISTORY: She used to smoke in the past for about 4
years in her 40s. She drinks only socially. No drugs.
Family History:
Her mother died at age 85 of dementia. Her father died at age
75 of complications of diabetes. She had two younger brothers,
both of whom have died. One had a myocardial infarction and one
had small bowel cancer.
Physical Exam:
Vitals: T:98.5 P:80 R: 16 BP:187/87 SaO2: 98% RA
General: Awake, cooperative, NAD. Lying in bed
HEENT: NC/AT, no scleral icterus noted, dry mucous membranes, no
lesions noted in oropharynx, no temporal tenderness
Neck: Supple, no carotid bruits appreciated. limited range of
motion in horizonal direction, left cervical tenderness and over
trapezius
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: [**Last Name (un) 3526**] [**Last Name (un) 3526**]
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**2-7**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. The patient has surgical pupils
bilaterally. VFF to confrontation. Funduscopic exam revealed no
papilledema.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, some decrease wasting in intrinsic muscles
of hand, EDB wasting, slightly increased tone in the legs No
pronator drift bilaterally. No adventitious movements, such as
tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ 5- 5- 5 5 5- 5- 4+ 5 5- 5 5
R 4+ 5- 5- 5 5 5- 5- 4+ 5 5- 5 5
Sensation: Intact to light touch. Decreased cold/pin at feet to
mid thigh in stocking pattern. Vibration reduced to knees.
Slight decrease in proprioception is reduced in the big toes
bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was upgoing bilaterally
-Coordination: Slightly intention tremor worse on the left than
the right. Overshoot on the left with mirror movements. HKS
worse on left.
-Gait: Unable to stand without immediate retropulsion, cannot
test Romberg. Able to lean on me and take broad base steps but
if let go immediate retropulsion.
Pertinent Results:
[**2170-10-22**] 03:55PM BLOOD WBC-6.4 RBC-3.90* Hgb-11.4* Hct-35.2*
MCV-90 MCH-29.2 MCHC-32.4 RDW-14.8 Plt Ct-142*
[**2170-10-25**] 05:55AM BLOOD PT-21.7* PTT-29.9 INR(PT)-2.0*
[**2170-10-22**] 03:55PM BLOOD ESR-21*
[**2170-10-25**] 05:55AM BLOOD Glucose-122* UreaN-27* Creat-1.0 Na-141
K-4.1 Cl-108 HCO3-24 AnGap-13
[**2170-10-22**] 03:55PM BLOOD ALT-28 AST-41* AlkPhos-113* Amylase-59
TotBili-0.6
[**2170-10-22**] 03:55PM BLOOD cTropnT-<0.01
[**2170-10-23**] 05:00AM BLOOD %HbA1c-7.3* eAG-163*
[**2170-10-23**] 05:00AM BLOOD Triglyc-86 HDL-61 CHOL/HD-2.7 LDLcalc-84
MRI of head: Acute left cerebellar infarct in a left AICA/PICA
distribution with hemorrhagic components on a background of
moderate microangiopathic small vessel disease involving the
supratentorial white matter and brainstem.
Echo: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF 65%). The right ventricular
free wall is hypertrophied. The right ventricular cavity is
moderately dilated with depressed free wall contractility.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] There
are focal calcifications in the aortic arch. 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. There is a minimally increased gradient consistent
with trivial mitral stenosis. Mild (1+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
The pt is a 88 year-old right-handed female with a history of
a.fib on Coumadin, HTN, HLD, diabetes type 2, pulmonary HTN, who
was recently seen at [**Hospital1 18**] with an episode of vertigo on Wed,
[**2170-10-17**], now returns 6 days later with persistent nausea,
left sided occipital headache and difficulty with gait. The
patient first episode was last Wednesday, while she was brushing
her teeth she had the sudden onset of clockwise vertigo, which
lasted for about 3-5 minutes. This was then
followed by a sensation of nausea and a left sided occipital
headache. Based on her history of a.fib she was concerned that
this may represent a stroke and she came to the [**Hospital1 18**] ED.
Her vertigo had resolved, and she had a normal exam with the
exception of left cervical/trapezius tenderness and evidence of
cervical spondylosis with weakness in c5/6/7 distribution
bilaterally and some evidence of myelopathy. A CT and CTA was
performed which did not show evidence of a stroke or vessel
blockage. Over the last 5 days the patient has remained
persistently nauseous. In addition she became more nauseous
yesterday, this morning, and also was having more difficulty
getting out of bed. She stated that if she stood up an leaned
in either direction she would be pulled down. Based on this she
was advised by her PCP and outpatient neurology to come back to
the ED.
NEUROLOGY:
On admission she felt somewhat improved after receiving Zofran.
She still had a non-positional, aching headache in the left
occiput. She has root signs at c5/7 bilaterally and evidence of
mild myelopathy. She does have worse end-intention tremor on
the left side, and mild dysmetria on HKS. She cannot stand up
without retropulsion and has a broad based gait when assisted.
Her repeat head CT shows evidence of a large left sided
cerebellar infarct, with swelling and effacement of the left
side of the 4th ventricle. This is likely the swelling of a
PICA infarct from last Wednesday, now evidenced by her left
sided cerebellar signs. If this occurred 5-6 days ago she was
likely she was at her maximal swelling and therefore was
admitted to the ICU care for frequent neuro checks and
monitoring. Her initial INR was 2.9 and therefore with the
development of hemorrhagic transfermation on CT her coumadin was
held. The plan was to hold this until dropping to 2.0 and then
to restart. The following day the patient had an MRI and was
transferred to the step down unit. MRI confirmed some
hemorrhagic transformation.
Patient had complete resolution of nausea and headache after
tranfer to the floor. Coumadin was restarted on the day of her
discharge and her INR was 2.0. Her BP meds were restarted and
after PT/OT evaluted her and found her safe to be discharged
home with home PT.
Cardiovascular:
Patient has a history of CHF, pulm HTN, an Echo done on [**7-17**]
demonstrated 1+AR, 2+MR, severe pulm artery HTN, and sig pulm
regurg. Patient was initially allowed to autoreg and given a
half dose of her home atenolol. On day 2 of admission she was
re introduced to her full dose of atenolol for control of her
afib. Patient's LDL was 84 and she was increased on her
lipitor.
Follow-up: In addition to home PT/OT, patient will be following
up with PCP and an appt was scheduled to follow-up with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **], neurologist who oversaw her care during this
admission.
Medications on Admission:
torsemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth once a day
as needed for edema
Lipitor 10 mg Tab 1 (One) Tablet(s) by mouth once a day
Nateglinide 120 mg Tab 1 (One) Tablet(s) by mouth twice a day
Lantus Solostar 100 unit/mL (3 mL) Sub-Q Insulin Pen 10 units at
bedtime
Januvia 100 mg Tab 1 (One) Tablet(s) by mouth once a day in
morning
Vitamin D-3 1,000 unit Chewable Tab
Allopurinol 100 mg Tab 2 (Two) Tablet(s) by mouth once a day
Atenolol 50 mg Tab 1 (One) Tablet(s) by mouth twice a day
lisinopril 10 mg Tab 1 Tablet(s) by mouth twice a day
Levothyroxine 50 mcg Tab 1 (One) Tablet(s) by mouth once a day
Warfarin 2.5 mg Tab
1 (One) Tablet(s) by mouth once a day 5 mg Q Mon and Friday, 2.5
mg the other 5 days. Has been checked monthly unless abnormal
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. atenolol 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. lisinopril 10 mg 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).
Disp:*60 Capsule(s)* Refills:*2*
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR).
9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
([**Doctor First Name **],TU,WE,TH,SA).
10. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Edema.
11. Lantus 100 unit/mL Cartridge Sig: Five (5) unit Subcutaneous
at bedtime.
12. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. nateglinide 120 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. Outpatient Lab Work
INR every Friday and Monday - frequency can be altered per PCP
and if the INR stable.
15. Outpatient Physical Therapy
16. Outpatient Occupational Therapy
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left cerebellar stroke
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 on [**10-22**] with persistent headache and nausea
plus trouble with walking. You were initially admitted to ICU
because of your cerebellar stroke and need for close monitoring
but you were able to be transferred to the neurology floor the
next day.
Given the stroke, Coumadin was initially held during this
admission but it was restarted on the day of discharge and your
INR was 2.0 on the day of your discharge. There is no change to
your meds including your Coumadin dosing.
Your headache and nausea abated during this admission and you
were evaluated per physical and occupational therapists who
recommended discharge home with home services.
Followup Instructions:
Please call your physician to schedule [**Name9 (PRE) 702**] and you will
need at least twice weekly INR checks initially to ensure
therapeutic/tight dosing of your Coumadin.
You are also scheduled to follow-up with Dr. [**Last Name (STitle) **], neurologist
who oversaw your care during this admission:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2170-12-19**] 2:00
[**Hospital Ward Name 23**] Building, [**Location (un) 858**].
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2170-10-25**]
ICD9 Codes: 431, 4019, 2724, 2449, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 951
} | Medical Text: Admission Date: [**2132-1-14**] Discharge Date: [**2132-1-28**]
Date of Birth: [**2074-6-22**] Sex: F
Service: SURGERY
Allergies:
Cyclobenzaprine / Codeine / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Acute pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per OSh report (as patient is intubated and sedated on
arrival to [**Hospital1 18**]) 57F with recurrent episodes of abdominal pain,
nausea, and vomitting ove the at least the past several months.
Would only last < 12 hours at each time with epigastric pain,
radiating to the back. No prior evidence of gallstones on
abdominal ultrasounds. She presented witha similar episode to
[**Hospital6 **] on [**2132-1-5**] but with very severe pain
and an episode of diarrhea. She had been afebrile, tender in
epigastric area, with admission labs of lipase > 3500, amylase
>1100, AST 428 AP 153 ALT 327 TB 1.5 Lactate 4.0 Cr 1.0 WBC
22.6,
BE 9.1. CT at the time just showed acute pancreatitis, and was
given a presumptive diagnosis of gallstone pancreatitis based on
history and labs. Transferred to the ICu that day and
subsequently intubated for worsening respiratory distress. The
patient then spiked a fever, had positive blood cultures, and
started on antibiotics. At some pont she was on pressors which
have since been dicontinued. For nutrition got TPN for a few
days, then enteral feeding, which is now stopped to due to
vomitting yesterday. Had ERCP with sphinctertomy done before
transfer; all biliary ducts filled normally as well as duodenum.
WBC decreased and then began to [**First Name8 (NamePattern2) **] [**Last Name (un) 7162**], 35.6 on transfer. Pab
[**Last Name (un) **] Klebsiella from FNA pancrease [**1-10**]. Urine Cx [**Female First Name (un) 564**],
Blood
culture [**1-4**] & 16 Klebsiella. OSH CT scans demonstrate no signs
of gas aroudn the pancreas, just extensive edema and
nonenhancement with some necrosis.
Past Medical History:
DM2, htn, hypothyroid, obesity
Social History:
married, banker, no smoking or etoh
Physical Exam:
intubated, sedated
sclera nonicteric, no jaundice
decreased bs, coarse, mild rhonchi b/l
RRR
obese, soft, nondistended
+1 pedal edema
Pertinent Results:
7.44 pCO2
37 pO2
69 HCO3
26 BaseXS 0
138 104 16 174
4.3 26 0.7
Ca: 7.7 Mg: 2.2 P: 3.5
ALT: 21 AP: 120 Tbili: 0.5 Alb: 2.0
AST: 29 LDH: 355 Dbili: TProt:
[**Doctor First Name **]: 26 Lip: 63
wbc 28.7 8.1 494 hct24.7
N:82
.
[**2132-1-23**] 06:45AM BLOOD WBC-19.7* RBC-2.85* Hgb-8.8* Hct-26.0*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.6 Plt Ct-557*
[**2132-1-23**] 06:45AM BLOOD Glucose-59* UreaN-18 Creat-0.6 Na-136
K-3.9 Cl-101 HCO3-27 AnGap-12
[**2132-1-14**] 10:45PM BLOOD ALT-21 AST-29 LD(LDH)-355* AlkPhos-120*
Amylase-26 TotBili-0.5
[**2132-1-21**] 01:46AM BLOOD ALT-65* AST-73* LD(LDH)-254* AlkPhos-105
Amylase-48 TotBili-0.3
[**2132-1-14**] 10:45PM BLOOD Lipase-63*
[**2132-1-23**] 06:45AM BLOOD Lipase-113*
[**2132-1-23**] 06:45AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.5
[**2132-1-15**] 05:17PM BLOOD Lactate-0.9
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
GENERAL COMMENTS: The patient appears to be in sinus rhythm.
Left pleural effusion.
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
IMPRESSION: Preserved [**Hospital1 **]-ventricular systolic function. No
evidence of vegitation on the aortic or mitral valves.
.
Radiology Report CT CHEST W/CONTRAST Study Date of [**2132-1-15**]
12:33 AM
IMPRESSION:
1. Necrotizing pancreatitis involving greater than two-thirds of
the
pancreas. CT severity index is [**9-1**] .
2. Large acute fluid collection extending superiorly around the
gastric
fundus.
3. Splenic vein thrombosis, with development of collateral flow
through a
prominent left gastroepiploic vein.
4. No pseudoaneurysm identified.
6. Multifocal ground glass and airspace consolidations
consistent with
multifocal pneumonia.
7. Prominent right mammary lymph node. Correlation with
mammography or
history of breast cancer is recommended. This finding was
entered into the
radiology critical results reporting system on [**2132-1-16**].
8. Fatty infiltration of the liver.
.
Radiology Report CT PELVIS W/CONTRAST Study Date of [**2132-1-25**]
12:48 PM
IMPRESSION:
1. Progressively enlarging pancreatic collections and
peripancreatic fluid in
the setting of extensive pancreatic necrosis.
2. Gas within the gallbladder lumen, wich would be expected
following
instrumentation (ie. ERCP) though no documentation is on the OMR
at time of
dication. Differential would also include cholecystitis due to
gas-forming
organism. 3. Improved right pleural effusion and resolved
abdominal ascites.
Brief Hospital Course:
57 obese female with severe necrotizing pancreatitis, developing
pseudocyst, intubated for almost 10 days with respiratory
failure. No signs of gas on
CT scan, pseudoaneursym or erosion into blood vessels. We will
keep the patient intubated and sedated, likely bronch/BAL,
introduce nutrition via enteral feeds after
reassessment, continue antibiotics for positive blood cultures,
urine culture, and presumptive pneumonias.
Culture data:
-OSH Urine Cx: [**Female First Name (un) 564**]
-[**1-4**] & [**1-7**] OSH BCx: Klebsiella
-[**1-10**] OSH FNA pancreas: Klebsiella
-[**1-13**] BCx [**2-27**] GPCs in clusters--coag neg staph
-[**1-14**] Sputum no orgs, no growth
-[**1-15**] BCx pending
.
ID:
Continue meropenem at 500mg q6h iv for likely polymicrobial
process (at least 2 weeks given bacteremia at OSH, day 1 here
[**1-14**], day 1 OSH [**1-6**])
-Continue fluconazole at 200mg q24h iv (prophylactic dose)
[**1-22**]: afebrile, on floor doing well.
-2 weeks total [**Last Name (un) 2830**] & fluco: END DATE [**2132-1-28**]
.
IMAGING:
[**1-13**] CXR: Bilateral lower lobe atelectasis and small bilateral
pleural effusions
[**1-14**] CT torso: necrotizing pancreatitis with fluid collection
and possible erosion into stomach. b/l pleural effusions and
basilar atelectasis
[**1-14**] TEE: wnl
[**1-15**] CXR: improved b/l atelctasis
[**1-16**] CXR: b/l pleural effusions, B atelectasis
[**1-18**] CXR: mildly improved pleural effusions
[**1-25**] CT PELVIS: Progressively enlarging pancreatic collections
and peripancreatic fluid in the setting of extensive pancreatic
necrosis.
.
[**1-13**]: admitted to TSICU. CT torso done
[**1-14**]: Pt went to IR for placement of post-pyloric feeding tube.
TF's were started and advanced toward goal. Attempt at
esophageal balloon placement was made and failed. ID consult was
obtained. Surgery was deferred.
[**1-15**]: A-line switched [**2-25**] (+) culture
[**1-16**]: attempted to wean PEEP and PS but did not tolerate well.
[**1-17**]: attempt at aggressive diuresis lasix drip + diamox, goal
negative 2-3L (-1866 on [**1-17**]), aggressive pulmonary toilet,
goal=extubate sun/mon. A-line pulled [**2-25**] not working. vent
pressure settings weaned but ABG with hypoxia to PO2 71: inc
FiO2, inc pressure settings
[**1-18**]: attempted to wean PS but again unsuccessful (increased
WOB and tachypnea), placed new Aline, cont Lasix Gtt
[**1-20**] extubated
diuresis, goal 2-3L neg: overshot -4.4 L [**1-20**], -700 [**1-21**]
.
GI / ABD: pancreatitis, medical management. stable, no abd pain.
Her pain improved and she was nontender on palpation.
NUTRITION: replete with fiber via post-pyloric feeding tube,
restarted 4hrs s/p extubation. consider speech/swallow c/s prior
to advancing diet today given long intubation. The NJ feeding
tube was D/C'd on [**1-21**] and her PO diet was advanced. She was
tolerating a low fat diet on [**1-22**].
RENAL: UOP and Cr stable. lasix gtt -4.4 L neg [**1-20**], met
alkalosis: s/p 2 doses diamox [**1-20**], Hco3 31. She was transited
from lasix drip to lasix bolus on [**1-21**].
HEMATOLOGY: stable anemia
ENDOCRINE: Insulin gtt, NPH 20/20: transition to RISS [**1-21**];
synthroid changed to PO dose
ID: meropenem, fluconazole; ID following; WBC trending down
She was discharged in good condition, tolerating a PO diet,
reporting no abdominal pain and blood sugars well controlled on
[**Hospital1 **] NPH. She will need a follow-up CT scan and pseudocyst
drainage and cholecystectomy at the end of the month.
Medications on Admission:
levoxyl 100, prozac 20, lisinopril 20, metformin 1000", asa
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) Units Subcutaneous twice a day.
Disp:*1800 Units* Refills:*2*
7. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale
Injection four times a day: See Sliding Scale.
Disp:*qs * Refills:*2*
8. One Touch Ultra System Kit Kit Sig: One (1)
Miscellaneous four times a day.
Disp:*qs * Refills:*2*
9. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*150 * Refills:*2*
10. One Touch Test Strip Sig: One (1) In [**Last Name (un) 5153**] four times a
day.
Disp:*150 * Refills:*2*
11. Insulin Syringe [**1-25**] mL 29 x [**1-25**] Syringe Sig: One (1)
Miscellaneous four times a day.
Disp:*150 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Acute severe pancreatitis
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**11-6**] lbs) until your follow up appointment.
Followup Instructions:
Dr. [**Last Name (STitle) **] on [**2-15**]. Pt needs to have a repeat abdominal CT with
PO and IV contrast with Pancreas protocol for evaluation of
pseudocyst. His office will call you with a time for the
appointment. Call [**Telephone/Fax (1) 1231**] with questions or concerns.
Completed by:[**2132-1-28**]
ICD9 Codes: 486, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 952
} | Medical Text: Admission Date: [**2199-3-3**] Discharge Date: [**2199-3-12**]
Date of Birth: [**2117-5-3**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Atrial fibrillation with RVR, fever.
Major Surgical or Invasive Procedure:
Endotracheal extubation.
History of Present Illness:
This is an 81-year-old woman with history of atrial fibrillation
on coumadin, coronary artery disease s/p PCI w/ DES on plavix
and left carotid endarterctomy who was admitted to the neurology
service on [**2199-3-3**] as a transfer from [**Hospital **] Hospital. She
presented to [**Hospital **] Hospital with unsteadiness, vomiting, and
hypertension to 230/90 and was found to have a 19mm/x12mm
midline cerebellar hemorrhagic stroke. She was intubated and
transfered to [**Hospital1 18**].
Past Medical History:
Atrial fibrillation for many years, on coumadin
TIA one year ago
MI in [**9-21**] s/p DES x2
Left carotid endarterectomy in [**2198-6-14**]
Uterine cancer in [**2188**]
Right breast cancer in [**2196**] s/p surgery and radiotherapy
Hypertension
Retinal hemorrhage of the right eye
?Congestive heart failure
Social History:
Retired, lives with daughter and her husband. [**Name (NI) **] tobacco or
alcohol use.
Family History:
Mother and father had strokes at ages 66 years old and 84 years
old respectively.
Physical Exam:
Vitals: T: 101 (101.3) BP: 136/85 P: 126 (81-160) R: 25 O2: 92%
on 4L NC
General: Alert, seems paranoid, oriented to person
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: expiratory wheezes anteriorly, crackles at L base
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, + pedal edema
Pertinent Results:
Labs at Admission:
[**2199-3-3**] 12:14AM BLOOD WBC-10.8 RBC-4.25 Hgb-12.4 Hct-34.2*
MCV-80* MCH-29.2 MCHC-36.4* RDW-15.3 Plt Ct-269
[**2199-3-3**] 12:14AM BLOOD Neuts-91.3* Lymphs-4.7* Monos-2.7 Eos-0.6
Baso-0.6
[**2199-3-3**] 12:14AM BLOOD PT-20.4* PTT-33.3 INR(PT)-1.9*
[**2199-3-3**] 12:14AM BLOOD Glucose-159* UreaN-11 Creat-0.8 Na-129*
K-3.7 Cl-93* HCO3-28 AnGap-12
[**2199-3-3**] 07:37AM BLOOD ALT-16 AST-22 LD(LDH)-223 AlkPhos-100
Amylase-36 TotBili-0.6
[**2199-3-3**] 07:37AM BLOOD Albumin-3.5 Calcium-8.2* Phos-2.8 Mg-1.9
[**2199-3-7**] 09:41AM BLOOD Triglyc-281* HDL-47 CHOL/HD-6.0
LDLcalc-180*
.
Micro Data:
[**2199-3-10**] BLOOD CULTURE negative
[**2199-3-10**] URINE CULTURE negative
[**2199-3-9**] BLOOD CULTURE negative
[**2199-3-8**] BLOOD CULTURE negative
[**2199-3-8**] BLOOD CULTURE negative
[**2199-3-7**] STOOL C DIF negative
[**2199-3-7**] URINE CULTURE negative
[**2199-3-6**] BLOOD CULTURE negative
[**2199-3-6**] BLOOD CULTURE negative
[**2199-3-3**] MRSA SCREEN negative
[**2199-3-3**] BLOOD CULTURE negative
[**2199-3-3**] BLOOD CULTURE negative
.
Studies:
.
CT Head ([**3-3**]): 1. Right cerebellar parenchymal hemorrhage with
mild surrounding edema and mass effect upon the fourth
ventricle. 2. Extensive chronic small vessel ischemic change.
.
CTA Head ([**3-3**]): Unchanged right medial cerebellar hemispheric
hematoma. No
evidence of aneurysm or arteriovenous malformation.
.
MRA Head and Neck ([**3-3**]): Right cerebellar hemispheric hematoma
again seen. There is minimal enhancement around the periphery
and slight vascular prominence. These findings may be related to
the hematoma itself, rather than revealing its etiology. If
there is clinical concern of a possible arteriovenous
malformation, a catheter arteriogram would be the most sensitive
study.
.
CT Head ([**3-6**]): No significant change of the right cerebellar
parenchymal
hemorrhage with mild surrounding edema and mass effect upon the
fourth
ventricle.
.
TTE ([**3-7**]): The left atrium is moderately dilated. The right
atrial pressure is indeterminate. 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 aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion. IMPRESSION:
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function.
.
CXR ([**3-9**]): Severe cardiomegaly and mild pulmonary vascular
congestion are improved since early on [**3-8**], unchanged
since 9:40 p.m. that day. No pneumothorax. Pleural effusion, if
any, is minimal.
Brief Hospital Course:
An 81 year-old woman with past history of atrial fibrillation,
CAD s/p recent stents presenting from OSH with cerebellar
hemorrhage in the setting of coumadin.
.
She was admitted initially to the neuro ICU. She was extubated
on [**3-4**] and her coumadin-induced coagulapathy was reversed with
FFP. She was transfered out of the ICU on [**2199-3-5**]. She was
started on vancomycin and Zosyn on [**3-4**] for question of LLL PNA.
She was also noted to be in atrial fibrillation with RVR and
diltiazem ggt was started for better rate control in the setting
of HR to the 150s. The drip was able to be stopped and changed
to po metoprolol and diltizem once stabilized and patient was
transferred to the floor on the morning of [**3-9**]. Floor course is
outlined by problem below.
.
1. Atrial fibrillation with rapid ventricular response.
As above, patient has a history of atrial fibrillation; she
developed RVR in the setting of fever and possible infection. A
TSH was checked that was normal. At time of transfer to the
medical floor, her rate was controlled with BB and CCB. However,
she intermittently had runs of RVR to the 140s, during which her
oxygen requirements increased and she became dyspneic. She was
given IV dilt prn and the oral diltiazem increased to achieve
better rate control. Metoprolol was stopped due to side effects
(patient said this caused "hallucinations"). At a dilt dose of
90 mg qid, adequate rate control was achieved during both rest
and exertion. With improved rate control, her oxygenation also
improved and she was able to be weaned off of O2. Her coumadin
has been held per neurology recs for at least two weeks. She
will follow-up in neurology clinic at [**Hospital1 18**] in one to two weeks
at which time coumadin may be restarted.
.
2. Cerebellar hemorrhage.
She underwent repeat head CT prior to transfer to floors; there
was no interval change. Neurology service continued to follow
and recommended for goal SBPs in the 120-160 range. They said it
was okay to continue clopidogrel and recommended holding
warfarin for at least two weeks after the cerebellar bleed. She
has follow-up scheduled in neurology clinic with Dr. [**Last Name (STitle) **].
.
3. Fever.
There was question of LLL pneumonia and left pleural effusion at
time of transfer. She had no cough and there was no
leukocytosis. Given her hypoxia (likely related to RVR) at time
of transfer, we were not comfortable stopping the antibiotics.
She was continued on vancomycin and Zosyn for one day and this
switched to oral levofloxacin when her symptoms improved. She
will complete a 7-day course for presumptive HAP.
.
4. Left pleural effusion.
This was concerning for parapneumonic effusion in the setting of
fever. Given her history of malignancy there was concern of
malignant effusion. Procedure service was consulted and
ultrasound imaging showed that there was not sufficient fluid
collection to drain. Furthermore, fluid appeared non-loculated,
layering out on decubitus films, and its appearance was felt to
be less likely consistent with empyema or malignant effusion.
Drainage was not attempted. The effusion resolved with
conservative measures and on repeat CXR was significantly
reduced in size.
.
5. Coronary artery disease s/p drug eluting stent.
We continued her outpatient clopidogrel and statin.
.
6. ?Congestive heart failure.
She had cardiomegaly on CXR but was found to have normal
systolic function on TTE; TTE did show mild symmetric left
ventricular hypertrophy. She is on [**Hospital1 **] lasix at home; once her
heart rate and blood pressure were stable, we restarted her
outpatient lasix at 40 mg twice daily.
.
7. Hypertension.
Goal SBP was 120-160. We held her irbesartan to avoid
hypotension.
.
8. Urinary retention.
This was noted when her foley was removed; she was found to have
PVRs of 500-600 ccs initially. Overnight however, she started to
void on her own. Bladder scan showed a post-void residual of
250cc. She continued to void without difficulty on day of
discharge. If needed, she can follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] urology
clinic. She has been provided with contact information for
scheduling an appointment if necessary.
Medications on Admission:
Coumadin 5 mg T/F; 2.5mg on other days
Plavix 75 mg qday
Metoprolol 50 mg [**Hospital1 **]
Lasix 40 mg [**Hospital1 **]
Irbesartan 75 mg [**Hospital1 **]
Simvastatin 20 qday
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Please complete 7-day antibiotic course on [**3-14**].
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnoses
Hemorrhagic cerebellar infarct
Atrial fibrillation with rapid ventricular response
.
Secondary Diagnoses
History of transient ischemic attack
Myocardial infarction in [**2198-9-14**] s/p DES x2 on clopidogrel
Left carotid endarterectomy [**2198-6-14**]
History of uterine cancer in [**2188**]
History of breast cancer in [**2196**] s/p surgery and radiotherapy
Hypertension
History of retinal hemorrhage in right eye
Discharge Condition:
Vital signs stable. Afebrile. Satting well on room air.
Discharge Instructions:
You were hospitalized for treatment of hemmorrhagic stroke.
There was bleeding into the cerebellum. We stopped the
anticoagulation and your symptoms improved. We noticed that your
heart rate was difficult to control during this admission. The
rapid heart rate responded to diltiazem, so we started you on
diltiazem and stopped the metoprolol. With this treatment, the
atrial fibrillation was better controlled. We were concerned on
chest x-ray that there was pneumonia. We have started you on
antibiotics for treatment of healthcare-associated pneumonia.
Please complete a seven-day course of antibiotics.
.
We have made the following changes to your medicines:
1. We started diltiazem at a dose of 360 mg once daily.
2. We started levofloxacin at a dose of 250 mg once daily.
Please complete a seven-day course on [**3-14**].
3. We stopped metoprolol.
4. We stopped coumadin. Please restart this medicine when
instructed to do so by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].
5. We started vitamin D and calcium for bone health.
6. We stopped irbesartan. Please restart this medicine when
instructed to do so by Dr. [**Last Name (STitle) **].
.
Please note your follow-up appointments below.
.
Please call your doctor or come to the emergency room if you
experience change in mental status, lightheadedness or
dizziness, chest pain, or other symptoms that are concerning to
you.
Followup Instructions:
1. Please follow-up with Dr. [**First Name (STitle) **] in [**2-15**] weeks: [**Telephone/Fax (1) 10508**].
2. Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
3. Please follow-up in neurology clinic with Dr. [**Last Name (STitle) **] in 2
weeks. Call the office to schedule an appointment: ([**Telephone/Fax (1) 8951**].
4. Please follow-up in urology clinic if you notice any
concerning urinary symptoms, such as difficulty urinating. The
number is [**Telephone/Fax (1) 921**] and the physician's name is Dr. [**Last Name (STitle) **].
Completed by:[**2199-3-12**]
ICD9 Codes: 431, 486, 5119, 2930, 4019, 412, 2859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 953
} | Medical Text: Admission Date: [**2156-9-23**] Discharge Date: [**2156-10-6**]
Date of Birth: [**2092-12-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
CC: dyspnea, hypoxia
Major Surgical or Invasive Procedure:
thoracentesis
History of Present Illness:
Ms. [**Known lastname 47417**] is a 63 y/o woman with PMH of stage IV breast
cancer with cutaneous & liver mets who presents to the ED with
worsening dyspnea. The patient states that she began therapy
with Megace on [**2156-7-21**]. Following initiation of therapy she
noticed lower extremity edema which progressed over several
weeks; she discontinued therapy on [**2156-8-13**] but the edema
persisted. Over the past several weeks, she has noticed
increasing dyspnea on exertion. She has 14 stairs in her home
and has noted increased difficulty in climbing them. At times,
she must stop to rest halfway up the flight. She denies
orthopnea, PND, chest pain, palpitations, and
dizziness/lightheadedness. She was given HCTZ to "help with
fluid" per her report; she has been taking 25 mg daily without
much improvement in her edema.
.
In addition, the patient had two separate bleeds from her
external tumor which were substantial per her report. On [**9-13**] and
[**9-20**], the patient bled from her tumor, requiring multiple
washcloths and prolonged application of pressure to stop the
bleeding. She denies any hematuria or blood in her stools.
.
In the ED, the patient was afebrile and 91% on RA; sats
increased to 97-98% on 3L NC. She had borderline low blood
pressures in the 80s/40s but maintained her mentation and urine
output; baseline BPs in the 100s per her report. She has
continued HCTZ as above at home. CTA of the chest demonstrated
no pulmonary embolism but a large R sided pleural effusion.
Blood cultures were sent, and she received levofloxacin 500 mg
IV X 1 for treatment of pneumonia. She also received 1 L NS and
was transferred to the [**Hospital Unit Name 153**] for further management. On arrival
to the [**Hospital Unit Name 153**], the patient states that her breathing is "much
better." She appears comfortable and is only complaining of
chest wall pain and back pain due to "all the moving around."
.
ROS: Feels thirsty. Appetite and PO intake good per her report.
No headache, sore throat, trouble swallowing, nausea/vomiting,
abdominal pain, diarrhea, constipation, bloody stools, dysuria,
or hematuria per her report.
.
Past Medical History:
* Stage IV breast cancer with mets to skin, bone, and liver
diagnosed in [**2151**]. Prior chemotherapy regimens included:
Lipodox, Navelbine (mitotic inhibitor), gemcitabine, Taxotere,
oral CMF (cyclophosphamide/MTX/5FU), Adriamycin given weekly
until [**9-16**], and oral etoposide ([**2155-9-23**]). She has also
previously been on hormonal therapy with Femara, Faslodex,
exemestane (start [**Date range (1) 47418**]), and Xeloda without success.
* Anemia: Previously aranesp dependent.
Social History:
Lives with sister. [**Name (NI) 1403**] in the trust industry with multiple
nonprofit organizations; she worked up until Saturday when she
felt too poorly to work. Never smoker. No alcohol use.
.
Family History:
Father passed away with pancreatic cancer. Mother lived into her
90s with Alzheimer's. Grandmother had breast cancer but also
lived into her 90s.
Physical Exam:
Afebrile, blood pressure ranging between 80-95 systolic, tach to
110 intermittently sats above 90% on 2 lpm.
Gen: Pleasant, cachetic, pale female in NAD.
HEENT: op clear
NECK: Supple.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: decreased to auscultation but comfortable respiration
ABD: benign, +sister [**First Name8 (NamePattern2) **] [**Name2 (NI) **] nodule
EXT: 2+ pitting edema to the thigh bilaterally, feet warm & well
perfused. 2+ dp pulses bilaterally. R arm lymphedema.
SKIN: extensive chest wall erythema, ulceration and tumor.
NEURO: grossly intact.
Pertinent Results:
[**2156-10-4**] 12:21 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2156-10-4**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Pending):
[**2156-10-1**] 1:53 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2156-10-3**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2156-10-3**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2156-9-24**] 4:35 pm PLEURAL FLUID PLEURAL FLUID FORPH.
**FINAL REPORT [**2156-9-30**]**
GRAM STAIN (Final [**2156-9-24**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2156-9-27**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2156-9-30**]): NO GROWTH.
Pleural fluid cytology: Positve for malignant cells consistent
with metastatic breast cancer
Pleural fluid found to be exudative ([**1-14**] lights criteria were
positive)>
CT chest [**2156-9-23**]:
CONCLUSION:
1. No pulmonary embolism or aortic dissection.
2. Large bibasal effusions with passive atelectasis at the lung
bases, more on the right. Small lung nodules in right middle
lobe worrisome for metastases.
3. Extensive metastatic disease involving the breasts and the
subcutaneous tissues of the chest and abdomen.
4. Metastatic disease in the liver and evidence of prior
chemoembolization. Abdominal lymph nodes are incompletely
covered/ assessed on this chest CTA and may be further evaluated
with a dedicated CT abdomen.
CXR [**2156-9-27**] (two days following Thoracentesis).
IMPRESSION: Bilateral pleural effusions, slightly increasing.
[**2156-9-30**] 07:15AM BLOOD WBC-14.6* RBC-3.61* Hgb-10.6* Hct-31.9*
MCV-88 MCH-29.5 MCHC-33.4 RDW-17.0* Plt Ct-440
[**2156-9-29**] 05:01AM BLOOD WBC-17.8* RBC-3.48* Hgb-10.5* Hct-30.6*
MCV-88 MCH-30.1 MCHC-34.2 RDW-16.9* Plt Ct-370
[**2156-9-24**] 12:09PM BLOOD WBC-35.5*# RBC-3.26*# Hgb-9.5*#
Hct-28.4*# MCV-87 MCH-29.0 MCHC-33.2 RDW-15.9* Plt Ct-418
[**2156-9-23**] 09:30PM BLOOD WBC-28.8*# RBC-2.49*# Hgb-6.6*#
Hct-21.9*# MCV-88 MCH-26.7*# MCHC-30.3* RDW-16.5* Plt Ct-663*
[**2156-9-24**] 03:11AM BLOOD Neuts-93* Bands-0 Lymphs-3* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-9-24**] 03:11AM BLOOD PT-13.0 PTT-20.3* INR(PT)-1.1
[**2156-9-24**] 03:11AM BLOOD Ret Man-2.8*
[**2156-9-30**] 07:15AM BLOOD Glucose-91 UreaN-49* Creat-1.1 Na-133
K-4.8 Cl-98 HCO3-23 AnGap-17
[**2156-9-23**] 09:30PM BLOOD Glucose-113* UreaN-63* Creat-1.3* Na-133
K-5.0 Cl-93* HCO3-20* AnGap-25*
[**2156-9-24**] 03:11AM BLOOD ALT-36 AST-47* LD(LDH)-281* CK(CPK)-32
AlkPhos-402* Amylase-42 TotBili-0.1
[**2156-9-23**] 09:30PM BLOOD CK(CPK)-35
[**2156-9-23**] 09:30PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 35250**]*
[**2156-9-30**] 07:15AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.7*
[**2156-9-24**] 03:11AM BLOOD Albumin-2.7* Calcium-8.2* Phos-5.3*
Mg-3.1* Iron-12*
[**2156-9-24**] 03:11AM BLOOD calTIBC-289 Ferritn-144 TRF-222
[**2156-9-25**] 06:02AM BLOOD Lactate-5.9*
[**2156-9-24**] 01:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2156-9-24**] 01:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2156-10-4**] 12:21PM PLEURAL WBC-165* RBC-215* Polys-24* Lymphs-55*
Monos-15* Macro-2* Other-4*
[**2156-9-24**] 04:35PM PLEURAL WBC-181* RBC-49* Polys-48* Lymphs-35*
Monos-6* Atyps-2* Other-9*
[**2156-10-4**] 12:21PM PLEURAL TotProt-2.0 LD(LDH)-106
[**2156-9-24**] 04:35PM PLEURAL TotProt-2.6 Glucose-137 LD(LDH)-137
CXR [**2156-10-4**] - IMPRESSION: No evidence of pneumothorax. Interval
increase in size in the moderate-to-large left pleural effusion
with decrease on the right side.
SINGLE AP PORTABLE VIEW OF THE CHEST: Comparison is made with
prior studies from [**9-25**] and 17.
Left subclavian vein catheter remains in place.
Moderate-to-large bilateral pleural effusions and bibasilar
atelectasis are grossly unchanged, accurate comparison is
difficult to be made due to difference in position of the
patient. Cardio-mediastinal contours are unchanged.
Brief Hospital Course:
Ms. [**Known lastname 47417**] is a 63 yo female with unresectable invasive
breast cancer s/p multiple chemotherapeutic agents, who was
admitted with dyspnea due to pleural effusions and anemia.
Breast cancer/palliative care. Ms. [**Known lastname 47419**] desire is to
concentrate on comfort and palliative care. She has reached a
stage where she in non-treatable with regards to her breast
cancer. Her chest wall lesions were infected on arrival, and
have a great liklihood of recurrent infection and bleeding. She
should continue on oral and topical antibiotics indefinitely.
She will require pain management and antianxiety medications for
supportive care. Hospice will be involved in her ECF care. She
initially desired to return home with hospice, but she is full
assist, and her elderly sister is not capable of 24 hour care
(hospice can only be present approx 2 hours daily). Hence she
was transferred to rehab with hospice.
Shortness of breath. This is secondary to malignant pleural
effusions. She is arranged for follow up with interventional
pulmonary for pleurodesis, and to call prior to appointment if
symptoms worsen. This is if the patient desires a thoracentesis.
Initial workup included the following: PE was ruled out by CTA
chest. Cardiac enzymes were negative. The pleural effusion was
tapped by IP and was found to be exudative. Cytology from
thoracentesis was positive for malignant cells. Repeat
thoracentesis was done on [**2156-10-4**] for relief of symptoms.
Patient was maintained on [**2-15**] Lit NC while in hospital with O2
sats greater than 92%.
Hypotension. Multifactorial, but stable. Patient was
hypotensive to SBP of 80s on admission. She was bolused IVFs
and given blood transfusions with improvement of her blood
pressure. Her BP is usually between 75-85 systolic, asymptomatic
and mentating well. She was treated initally with vanco/zosyn
and then started on levofloxacin.
Anemia: Patient had a Hct of 21.9 on admission with MCV of 88
with a baseline crit of 30 - 35. Anemia studes revealed an
anemia of chronic disease. Patient also reported several
episodes of bleeding from cutanous breast metastases requiring
pressure to be applied to stop the bleeding. Was guiaic
negative in ED. Patient was transfused 2 units to keep Hct
greater than 25. Hct remained stable.
LE Edema. Patient has had increasing LE edema and DOE over past
month, likely related to a combination of chronic disease with
decreased oncotic pressure as well as possible IVC compression
from liver metastases. Pt requests ACE wraps bilaterally for
comfort.
ARF. Patient has creatinine of 1.3 on admission with baseline
of 0.8. Cr did not improve with IVF. Etiology of ARF remained
unclear.
Chest wall infection at breast cancer site. Patient had
elevated WBC that improved with initiation of zosyn/ vanco and
topical flagyl. This was switched to levofloxacin. She
remained afebrile during hospitalization.
Atrial fibrillation. Patient went into afib on [**9-25**]. She was
rate controlled with Digoxin and started on PO digoxin. A
digoxin level was 1.4 on [**2156-9-28**]. However, digoxin was stopped
on [**9-29**] because of the difficulty with monitoring digoxin levels
due to difficulty drawing blood, absence of symptoms while in
atrial fibrillation, and patients' desire for hospice care.
Code Status: Patient decided to be DNR/DNI and will discharge to
local ECF with hospice care.
Palliative care followed her in the hospital and hospice will
care for her further needs.
### The patient does not have a primary care doctor, she used to
follow up with Dr [**Last Name (STitle) **] in clinic.
Medications on Admission:
HCTZ 25 mg daily
vicodin prn pain (mainly used at night)
Discharge Medications:
1. Roxanol Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q 2
hour PRN as needed for Shortness of breath or anxiety.
Disp:*30 mg* Refills:*0*
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Metronidazole 1 % Gel Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day): to chest .
9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours)
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. oxygen
continuous at 2-4 L by nasal canula to keep sats > 94%
13. Adaptic Bandage Sig: [**1-13**] Topical twice a day.
14. Xeroform Petrolatum Dressing 5 X 9 Bandage Sig: [**1-13**]
Topical twice a day.
15. Sof-[**Last Name (un) **] Sponge Sig: Four (4) Topical twice a day.
16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed.
17. Morphine 10 mg/5 mL Solution Sig: 10-20 mg PO Q2H (every 2
hours) as needed for for pain.
18. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for cough.
19. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea or
vomiting.
20. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
four times a day as needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Landing
Discharge Diagnosis:
1. metastatic (Stage IV) breast cancer, involving chest wall,
skin, liver, lungs, pleura.
2. Pleural effusion
3. Chest wall cellulitis
4. atrial fibrillation
5. Anemia
Discharge Condition:
comfortable, with chronically low blood pressures in the 80-95
systolic range
Discharge Instructions:
You were hospitalized with shortness of breath, related to fluid
in your lung space conpressing your lungs. This has improved
since thoracentesis. As you know, you have metastatic breast
cancer. You will be going to an inpatient extended care
facility, for supportive and comfort care during the remainder
of your illness. Your hospice company will work with you and
the extended care facility to assure you remain comfortable and
have good pain control.
Followup Instructions:
Please followup with interventional pulmonology on [**10-12**]
at 9am to discuss management of the fluid in your lungs, if you
wish to. Please have a chest xray done before that appointment
in the [**Hospital Ward Name 23**] building at [**Location (un) 830**] (you can walk in
at any time). The number for interventional pulmonology is
[**Telephone/Fax (1) **]. If you feel short of breath before the [**10-12**] and
desire fluid removed from the lungs, please call this number and
press option 1 to schedule a sooner appointment.
Provider: [**Name10 (NameIs) **],ROOM TWO IP ROOMS Date/Time:[**2156-10-12**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2156-10-12**]
9:00
Call Dr. [**Last Name (STitle) **] at [**0-0-**] to arrange a follow up
appointment with him if you desire.
ICD9 Codes: 5849, 486, 5180, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 954
} | Medical Text: Admission Date: [**2116-8-12**] Discharge Date: [**2116-8-22**]
Date of Birth: [**2040-7-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
Alcohol septal ablation
DDI pacer placement
History of Present Illness:
76yoF with h/o HOCM, HTN, and severe MR but otherwise healthy
who was having DOE for 1 wk, no chest pain. She was diagnosed
with HOCM by a doctor [**First Name (Titles) **] [**Last Name (Titles) **] and as taking Atenolol daily for
this, no previous interventions. She was very active until about
a week ago at which point she notes worsening fatigue and DOE
with walking, generalized weakness, chest pressure immediately
upon lying down (relieved with sitting up) but denies any
exertional CP or other anginal symptoms.
.
About 2 wks ago she saw her PCP who referred her to a
Cardiologist 2d ago, who sent her to the ED. There, she had a
CXR showing pleural effusions and pulmonary edema with a BNP of
8141, negative Troponins, and EKG with NSR and unchanged
non-specific TW changes. She was admitted to [**Hospital1 1516**] service where
they diuresed her and gave her beta blockers. Echo showed severe
sLVH with small LV cavity, EF >75%, severe resting LVOT gradient
in the 130's, [**Male First Name (un) **] of mitral leaflets and 3+ MR, all consistent
with HOCM of the elderly (and not due to abnormal myofibrils).
On [**2116-8-14**] she went to cath which showed clean coronaries and
elevated R heart pressures and had an alcohol septal branch
today which was tolerated well. She did however had some
widening of her QRS during the procedure and new appearance of
RBBB for which a temporary pacer wire was placed. She is
admitted to CCU for further monitoring.
.
Cardiac ROS as above: she was very active working 5d a week and
getting on the treadmill until the past week. She has been
generally weak, fatiguable on exertion and DOE even at minimal
walking distances. She reports chest pressure substernally
immediately when lying down but not with exertion and nothing
reminiscent of an MI. She's had minimal pitting edema around her
ankles. She felt palpitations with minimal exertion.
.
ROS otherwise states she was nauseous with food, but otherwise
her ROS is negative all other systems.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, denies HTN/HL, smoking,
FHx
2. CARDIAC HISTORY:
- HOCM: diagnosed 2.5 yrs ago in [**State 760**], for which she was
taking Atenolol only, until [**7-/2116**] at which point she had EtOH
ablation
- severe MR
- Denies AMI's, CABG, caths
3. OTHER PAST MEDICAL HISTORY:
- osteoperosis
Social History:
SOCIAL HISTORY Moved here from NJ a yr ago and wants to move
back. Very active without cane and walker at baseline, has a son
- Tobacco history: Smoked [**1-2**]/day for a few years but back in
the [**2084**]'s, not smoking
- ETOH: Recovering alcoholic, drank for 10 yrs but not now
- Illicit drugs: None
Family History:
FAMILY HISTORY:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: Was healthy
- Father: Deceased at 84, asthma, died of aneurysm in stomach
Physical Exam:
ON ADMISSION:
95.8 p72 102/41 96% 2L NC
Large but not obese F in no distress, laying flat with son at
bedside. Pleasant, alert, conversant, appears well. EOMI, no
scleral icterus, lips are dry appearing.
External jugulars are grossly distended and jugular pulsations
are noted mid earlobe while laying flat (cannot raise up as pt
post cath)
RRR with frequent PVC's and subsequent pauses. S1/S2 are clear
at BUSB's with a mid systolic crescendo murmur, moving towards
the apex the murmur is louder, loudest at midclavicular line,
and at apex is a whooshing, almost mechanical sound. Do not hear
S3/S4
Lungs grossly clear anterolaterally without w/c/r
Abd overweight, soft NT ND, benign
Minimal pitting edema around the ankles not extending upwards.
Extremities are warm, no mottling. RUE with temporary pacer wire
wrapped. Bilateral radials and DP's are palpable. L groin cath
site is nontender, no ecchymosis, palpable femoral, but does
have an audible bruit.
CN 2-12 grossly intact, no focal neuro deficits noted, but have
deferred full neuro exam given bedrest, she is
alert/attentive/conversant
.
On Discharge:
VS: T 98.5 BP 122/50 (104-129/50-91) HR 63 (63-72) RR 18 O2 95
RA
GENERAL: WDWN F in NAD.
HEENT: NCAT. Sclera anicteric. EOMI.
NECK: Supple with JVP of 7 cm.
CARDIAC: rrr, no m/r/g appreciated
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased breath sounds
in bases
ABDOMEN: Soft, NTND.
EXTREMITIES: t1+ pitting edema in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l
SKIN: no rashes
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Labs on admission:
.
[**2116-8-12**] 04:15PM BLOOD WBC-8.4 RBC-3.85* Hgb-11.5* Hct-30.2*
MCV-79* MCH-29.8 MCHC-38.0* RDW-13.3 Plt Ct-232
[**2116-8-12**] 04:15PM BLOOD Neuts-68.6 Lymphs-19.3 Monos-5.0 Eos-6.2*
Baso-0.8
[**2116-8-13**] 05:35AM BLOOD PT-12.1 PTT-27.9 INR(PT)-1.0
[**2116-8-12**] 04:15PM BLOOD Glucose-98 UreaN-26* Creat-1.1 Na-137
K-4.1 Cl-100 HCO3-26 AnGap-15
[**2116-8-12**] 04:15PM BLOOD ALT-18 AST-27 LD(LDH)-340* AlkPhos-62
TotBili-1.9*
[**2116-8-13**] 05:35AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.2 Iron-28*
[**2116-8-14**] 03:24PM BLOOD Type-ART pO2-94 pCO2-39 pH-7.41
calTCO2-26 Base XS-0
.
Labs on discharge:
.
[**2116-8-21**] 08:40AM BLOOD WBC-9.5 RBC-3.64* Hgb-10.5* Hct-29.3*
MCV-80*# MCH-28.7 MCHC-35.7* RDW-13.1 Plt Ct-408#
[**2116-8-21**] 08:40AM BLOOD Glucose-123* UreaN-11 Creat-0.8 Na-137
K-3.7 Cl-100 HCO3-27 AnGap-14
[**2116-8-21**] 08:40AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8
[**2116-8-21**] 08:40AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8
.
Other labs:
.
[**2116-8-13**] 05:35AM BLOOD cTropnT-<0.01
[**2116-8-12**] 04:15PM BLOOD cTropnT-<0.01
[**2116-8-12**] 04:15PM BLOOD proBNP-8141*
.
[**2116-8-16**] 09:11AM URINE RBC-85* WBC-14* Bacteri-FEW Yeast-NONE
Epi-<1
.
URINE CULTURE (Final [**2116-8-18**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
.
BLOOD CULTURE: NGTD, 2 cultures pending.
.
[**8-12**] CXR: Interval development of mild interstitial pulmonary
edema and
small bilateral pleural effusions. Unchanged opacity projecting
over the
right posterior hemidiaphragm, which again may represent a
Bochdalek hernia.
.
[**8-13**] ECHO: Severe symmetric LVH with small LV cavity size and
hyperdynamic LV systolic function. Consequently the mitral
leaflets and chordae are pulled towards the hypertrophied upper
septum during systole and a severe resting LVOT gradient
develops. Findings are more consistent with hypertrophic
cardiomyopathy of the elderly than hypertrophic cardiomyopathy
due to abnormal myofibrils. Moderate to severe mitral
regurgitation. Unable to determine pulmonary artery systolic
pressures.
.
[**8-15**] CXR:
The tip of the temporary pacemaker lies in the first part of the
right
ventricle.
The heart is not enlarged. A left pleural effusion is present.
Small right
effusion is also seen. The lung fields appear clear. There is no
evidence of failure, atelectasis at the left base is noted.
.
[**8-19**] CXR: Cardiomegaly is stable. Left transvenous pacemaker
leads are in standard position in the right atrium and right
ventricle. There has been improvement of now mild vascular
congestion. Mild left greater than right pleural effusions
associated with atelectasis are grossly stable allowing the
difference in positioning of the patient.
.
Labs on Discharge:
[**2116-8-22**] 07:27AM BLOOD WBC-9.5 RBC-3.11* Hgb-8.8* Hct-26.0*
MCV-84 MCH-28.3 MCHC-33.9 RDW-12.5 Plt Ct-425
[**2116-8-22**] 07:27AM BLOOD Glucose-97 UreaN-11 Creat-0.7 Na-136
K-4.1 Cl-99 HCO3-28 AnGap-13
Brief Hospital Course:
ASSESSMENT AND PLAN
76yoF basically healthy but with 2.5 yr h/o HOCM now with
worsening DOE, postural chest pressure, now s/p alcohol septal
ablation and DDI pacemaker placement.
.
# Hypertrophic Obstructive Cardiomyopathy: Patient had knon
history of HOCM treated with atenolol and presented with 1 week
hx of SOB and DOE raising concern for acute LVOT obstruction.
Unclear what her precipitant as patient had been taking beta
blockers, was not dehydrated, was in normal sinus rhythm and was
not on any significant afterload reducing medicaitons. Patient
was taken to the Cath lab for an alcohol septal ablation which
she tolerated well. She received a temporary pacing wire during
the procedure which was discontinued after 48 hours without
pacing requirment. Patient's symptoms improved post
operatively. Her LE edema improved with diuresis with 20mg daily
IV lasix. Ms. [**Known lastname 88536**] was discharged on her home dose of
torsemide 10mg daily and atenolol was increased to 100 mg.
.
# Bradycardia: Post alcohol ablation patient had a temporary
pacing wire placed per protocol. AFter 48 hours without pacing
requirement the temp wire was discontinued. Twenty minutes
later patient had an asystolic arrest. CODE BLUE was called
with atropine x3, chest compressions, Dopamine gtt and
transcutaneous pacing resulting in ROSC. A second transvenous
pacer was placed and patient paced at 70 bpm. Telemetry from
the event showed complete heart block. The following day the
patient had a second event with asystolic pause on telemetry,
unresponsiveness and PEA arrest. As CPR was about to be
administered transcutaneous pacer began firing and patient had
ROSC. Following these events the patient was very disoriented
and anticholonergic symptoms likely secondary to atropine
administration. A permanent DDI pacer was placed and Ms. [**Known lastname 88536**]
remained without bradycardic events without events on tele for
the next 4 days of her hospital course. Follow up with device
clinic and electrophysiology were obtained.
# Fevers: post-ablation patient developed fevers to 101 and
elevated WBC initially felt to be secondary to stress response.
Patient subsequently had an asystolic arrest with persistant
hypotension as described above and was covered with
vanc/cefepime for ? sepsis. In the following days pressor
support was weaned and antibiotics d/c'd as cultures were no
growth and concern for infection had decreased.
Upon arrival on the floor, Ms. [**Known lastname 88537**] fever recrudesed and
Vanc/Cefepime were restarted for 1 day. On [**8-19**], Ms. [**Known lastname 88537**] UA
came back positive for Enterococcus sensitive to vanco,
ampicillin, and macrobid. As Ms. [**Known lastname 88536**] also had symptoms of
urgency, was previously catheterized, and all other micro data
was unrevealing-Ms. [**Known lastname 88536**] was transitioned to macrobid for a
symptomatic UTI. Pyelonephritis was not seen as likely as she
lacked CVA tenderness and presently despite the fever, she was
without systemic symptoms. She remained afebrile until
discharge
# Anemia: Labs initially consistent with chronic disease with an
overlying acute drop from septal ablation. Patient recieved 1
unit pRBC with appropriate rise in HCT and was stable.
# CP: Mrs [**Last Name (STitle) **] experienced pain in her chest following CPR
which was treated NSAIDS. She was discharged to rehab for
physical therapy.
# Outstanding issues on discharge:
-2 Blood cultures pending and require f/u
-Pt will complete a 7 day course of antibiotics on discharge for
UTI
Medications on Admission:
Alendronate 70mg qweek
Atenelol 50mg daily
Torsemide 10mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
3. torsemide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays in both nostrils Nasal once a day.
5. nitrofurantoin macrocrystal 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 3 doses.
Disp:*3 Capsule(s)* Refills:*0*
6. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] and Rehab
Discharge Diagnosis:
Hypertrophic Obstructive Cardiomyopathy
Diastolic Congestive Heart Failure
Hypertension (High Blood Pressure)
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 88536**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted with a condition known as hypertrophic obstructive
cardiomyopathy. We were able to take care of the lesion
responsible for this with a technique known as ethanol ablation.
This therapy, however was complicated by another condition known
as heart block--a condition that required you to go to the
intensive care unit. Because of the heart block, you had a very
serious slow rhythm which required CPR. We were able to fix this
seriously slow rhythm with a pacemaker.
During this admission, you also were diagnosed with a urinary
tract infection and started on antibiotics for this infection.
The following changes have been made to your medications:
START Aspirin 81mg daily
INCREASE Atenolol from 50mg daily to 100mg daily
Continue Macrobid (Nitrofurantoin) 100mg twice daily
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2116-8-26**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 **] FAMILY MEDICINE
When: THURSDAY [**2116-8-27**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 88538**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: CARDIAC SERVICES
When: THURSDAY [**2116-9-17**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2116-10-2**] at 12:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4275, 5990, 4280, 4240, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 955
} | Medical Text: Admission Date: [**2188-4-29**] Discharge Date: [**2188-5-23**]
Date of Birth: [**2155-12-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2188-4-30**] renal transplant
[**2188-5-7**]: Kidney Biopsy
[**2188-5-19**]: Kidney Biopsy
History of Present Illness:
32 y.o. male with esrd secondary to chronic focal sclerosing
glomerulonephritis s/[**Name Initial (MD) **] failed CRT [**2182-2-3**]
Past Medical History:
ESRD on HD (M,W,F) ([**1-18**] glomerulonephritis)
HTN
Hypercholesterolemia
*
PSH:
AVF - R radial-cephalic
AVF - L aneurysm resection
Tunneled L subclavian catheter
Social History:
denies tobacco, ETOH, drugs
Family History:
sister who is 26 also has ESRD on HD (?etiology)
Physical Exam:
VS: 98.7, 89 NSR, 164/109, 20, 97%RA
Gen: NAD, A+Ox3,
HEENT: slera anicteric
Card: RRR, no M/R/G
Lungs: CTA bilaterally
Abd: Soft, NT, ND, +BS, well healed RLQ incision
Extr: No C/C/E, R forearm AV fistula, well healed LUE AV fistula
Neuro: CNII-XII intact
Pertinent Results:
On Admission: [**2188-4-29**]
WBC-5.8 RBC-3.88* Hgb-10.5* Hct-32.3* MCV-83 MCH-27.1 MCHC-32.5
RDW-18.2* Plt Ct-157
PT-12.6 PTT-30.8 INR(PT)-1.1
Glucose-144* UreaN-74* Creat-14.6*# Na-140 K-5.5* Cl-99 HCO3-23
AnGap-24*
ALT-7 AST-7 AlkPhos-353* Amylase-204* TotBili-0.3
Albumin-4.2 Calcium-9.3 Phos-9.3* Mg-2.8*
On Discharge: [**2188-5-23**]
WBC-4.7 RBC-3.03* Hgb-8.3* Hct-25.3* MCV-84 MCH-27.3 MCHC-32.7
RDW-17.5* Plt Ct-134*
Glucose-91 UreaN-49* Creat-4.7* Na-139 K-3.9 Cl-107 HCO3-21*
AnGap-15
Calcium-8.9 Phos-4.3 Mg-2.1
FK506-10.1
Brief Hospital Course:
He underwent cadaveric renal transplant into left iliac fossac
on [**2188-4-30**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see operative report for
details. He received standard induction immunosuppression
consisting of solumedrol taper, ATG, and cellcept. His
solumedrol was tapered. ATG was given for a total of 3 doses.
Cellcept was well tolerated. Urine output was excellent with
200-300cc per hour. Creatinine trended down to 11.2 from 15.9 by
pod 2. Diet was advanced without problems. [**Name (NI) **] was ambulatory.
The incision was clean, dry and intact.
He experienced hypertension postop and labetolol was restarted
and increased with improvement of BP.
Creatinine trended down to nadir of 2.9 on POD 6 and then it
began to rise again. Blood pressure was difficult to control and
Nifedipine and Minoxidil were added back. The patient underwent
a kidney biopsy on POD 7 which showed: Acute humoral rejection,
Banff Type II, (capillaritis/thrombotic microangiopathy pattern)
He was started on Plasmapheresis and IVIG, and also received an
additional 4 doses of ATG 100 mg each. IVIG for the initial
dosing was 90gms at completion of course.He also underwent a few
treatments of hemodialysis, in general for volume as his urine
output decreased to 300cc/day at the lowest point.
Biopsy was repeated on [**5-19**] as well as repeat of antibody screen.
This was reported as improved but not resolved. Pheresis was
restarted, he received a dose of Rituximab on [**2188-5-18**] following
the pheresis. In addition the IVIG was started with an
additional 40 gms.
Patient will complete pheresis/IVIG course as an outpatient with
an additional 2 treatments scheduled.
Creatinine fluctuates from 4.2-5.0 Urine output increased again
to 1.5-2L daily. He has not received additional hemodialysis,
last HD [**5-13**].
Medications on Admission:
lisinopril 60', minoxidil 10', labetalol 800', nifedipine 60',
sensipar 30', phoslo TT c meals
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO BID (2 times
a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
9. PredniSONE 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
10. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
11. Tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO twice a day.
12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
esrd s/p kidney transplant
htn
Humoral Rejection
Discharge Condition:
good
Discharge Instructions:
Please call Transplant office [**Telephone/Fax (1) 673**] if fevers, chills,
nausea, vomiting, inability to take medications, incision
redness/bleeding/drainage, decreased urine output, weight gain
of 3 pounds in a day. Call if you do not have any of your
medication right away.
Labs every Monday and Thursday for cbc, chem 7, calcium phos,
ast, t.bili, albumin, urinalysis and trough prograf level. fax
results to [**Telephone/Fax (1) 697**]
Come for outpatient pheresis on Monday [**5-26**] and Weds [**5-28**]
Followup Instructions:
[**Name6 (MD) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-5-27**] 10:10
PHERESIS,BED EIGHT PHERESIS ROOMS Date/Time:[**2188-5-26**] 8:00
PHERESIS,BED THREE PHERESIS ROOMS Date/Time:[**2188-5-28**] 8:15
Completed by:[**2188-5-23**]
ICD9 Codes: 5856, 2720, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 956
} | Medical Text: Admission Date: [**2173-9-24**] Discharge Date: [**2173-10-2**]
Date of Birth: [**2151-6-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
headache, neck pain, chills
Major Surgical or Invasive Procedure:
Lumbar puncture x 2
History of Present Illness:
Mr. [**Known lastname **] is a 22y/o M from [**Country 11150**] who presented to an OSH today
with a 10 day history of persistent headache, neck pain, fevers,
chills, nausea, vomiting, phonophobia, and generalized fatigue
and malaise. The patient first noticed these symptoms ten days
PTA with the insidious onset of headache and lethargy. The
symptoms were initially accompanied by nausea and vomiting. The
patient states that the symptoms went largely unchanged for most
of the remainder of the time PTA, until roughly one day ago the
nausea and vomiting went away and the headache began to get
worse, accompanied by severe neck stiffness and pain with hip
flexion. The patient began to notice that loud noises made his
head hurt worse, and that moving his eyes exacerbated his pain.
Throughout this period he continued to have fevers with shaking
chills and sweats. He endorses decreased PO intake. He denies
CP/SOB, dysuria, flank pain, cough, rash, itching, focal
weakness, difficulty swallowing, numbness, tingling, abdominal
pain, diarrhea, constipation, change in stool color or
consistency. He denies sick contacts. [**Name (NI) **] is unaware of PPD
status or of having received BCG vaccine. He is currently a
medical student in [**Country 9362**] and was scheduled to return there on
[**10-2**].
On arrival to the ED in the OSH, the patient was given a LP and
was started on Ceftriaxone 2g IV Q12h. The LP showed 357 WBC in
tube #4 with 3 RBC, protein of 356, glucose of 39, and diff of
49 PMN, 50 lymphs, initial gram stain negative. Pt was noted to
be in urinary retention, foley was inserted with 1.5L drainage,
foley left in. Because the OSH had no available negative
pressure rooms, the patient was transferred to [**Hospital1 18**] with direct
admission to 12R.
Past Medical History:
Asthma
Social History:
The patient lives in [**Country 11150**], where he is a medical student. He
has been visiting the USA over the past 2 months, and had spent
most of the trip in [**State 531**] City. The patient denies sick
contacts, environmental exposures, or unusual PO intake. The
patient has not travelled outside the NY area while in the US.
The patient has had no sexual contacts. [**Name (NI) **] with friends
while in NY. The patient does not use EtOH, tobacco, or
illicits. His family lives in [**Country 11150**].
Family History:
Noncontributory
Physical Exam:
VS: Tmax 102 | Tcurrent 101.1 | 116 | 28 | 98% RA
.
GEN: WDWN male in moderate distress, lying quietly in bed with
covers pulled up, shivering. Answers questions appropriately,
but frequently with delay.
NEURO: Oriented to person, place, time, and situation. CN
II-XII intact. Tenderness with evaluation of extraocular
muscles. Moves all extremities spontaneously. Motor exam with
[**6-3**] symmetric strength to flexion and extension in all major
muscle groups. Sensory exam intact to light touch throughout.
Gait not evaluated [**3-3**] pain.
HEENT: PERRLA, EOMI, OP clear, MM dry. No palatal petichiae or
tonsillar exudate. Anicteric sclerae.
NECK: supple, no supraclavicular or cervical LAD. Exquisite
tenderness to palpation in dorsal cervical midline. +Kernig
sign. +Brudzinski sign. +pain with neck flexion.
CHEST: CTA B
COR: tachy, regular rhythm. Normal S1, S2. No M/R/G
appreciated.
ABD: soft, NT, ND, bowel sounds present. No masses or HSM.
EXT: no edema. W/WP. Peripheral pulses intact and symmetric.
SKIN: no rashes, no petichiae, palms and soles specifically
evaluated.
Pertinent Results:
[**2173-9-24**] 08:59PM BLOOD WBC-15.4* RBC-5.38 Hgb-14.6 Hct-40.5
MCV-75* MCH-27.1 MCHC-36.0* RDW-11.9 Plt Ct-385
[**2173-9-24**] 08:59PM BLOOD Neuts-87.5* Lymphs-8.0* Monos-3.6 Eos-0
Baso-0.8
[**2173-9-24**] 08:59PM BLOOD PT-12.6 PTT-24.8 INR(PT)-1.1
[**2173-9-24**] 08:59PM BLOOD Fibrino-563*
[**2173-9-24**] 08:59PM BLOOD ALT-17 AST-15 LD(LDH)-177 AlkPhos-74
TotBili-0.8
[**2173-9-24**] 08:59PM BLOOD Calcium-9.1 Phos-2.5* Mg-2.1
[**2173-9-24**] 08:59PM BLOOD Hapto-367*
.
CSF Results:
LP #1: From OSH - CSF culture - no growth, Fungal cultures -
preliminary no growth, AFB cultures pending
Serologies - Lyme negative, Enterovirus negative
.
LP #2 [**9-25**]:
Tube 1: WBC 273, RBC, polys 14, lymphs 84 mono 2
Tube 4: WBC 304, RBC 10, polys 18, lymphs 78, mono 4
protein 442
Glucose 13
.
LP #3 [**9-28**]:
Tube 1: WBC 408, RBC 1, polys 10, lymphs 90, mono 0
Tube 4: WBC 394, RBC 9, polys 10, lymphs 89, mono 1
protein 208
Glucose 32
.
TB PCR pending x2
VDRL pending
HSV [**1-31**] - negative
.
Blood Serology:
Erlichia Antibody - pending
Strongyloides Antibody - pending
RPR - non reactive
Lyme - negative
.
Microbiology:
Urine culture [**9-24**] - no growth (final)
Urine culture [**9-27**] - no growth (final)
Blood cultures 8/26 - no growth (final)
Blood cultures 8/27 - no growth to date
Blood cultures 8/29 - no growth to date
Blood cultures 8/30 - no growth to date
.
CSF [**9-25**]: gram stain negative, fluid culture negative, fungal
cultures prelim negative, AFB culture pending, AFB smear
negative, viral cultures pending, cryptococcal Ag negative
.
CSF [**9-28**]: gram stain negative; cultures negative todate, fungal
culture pending, AFB pending
Stool cultures - C. Diff negative, O&P pending, marcoscopic - no
worms
.
Imaging:
CXR [**9-24**]: No acute cardiopulmonary disease.
_______________________________
CT HEAD [**9-25**]: IMPRESSION: No evidence of acute intra- or
extra-axial hemorrhage, mass effect. No evidence of enhancing
lesions, or meningeal enhancement.
______________________________
KUB [**9-25**]: The bowel gas pattern is nonspecific and
nonobstructive with no evidence for free air, pneumatosis or
ascites.
____________________________
MRI Head [**9-26**]: There is normal signal intensity throughout the
brain
parenchyma. The ventricles, sulci, and cisterns are
unremarkable. There is
no slow diffusion, susceptibility artifact, or areas of abnormal
enhancement. Surrounding soft tissues are unremarkable. There is
an isolated punctate focus of elevated T2/FLAIR signal in the
periventricular white matter of the left parietal lobe, likely
of little clinical significance. IMPRESSION: No evidence of
acute infarction, an infectious process, or an enhancing mass
lesion.
____________________________
MRI Lumbar Spine [**9-27**]: Vertebral body height, alignment, and
signal intensity are normal. There is no paraspinal or epidural
soft tissue enhancing masses. There is no spinal canal stenosis
or neural foraminal stenosis. There is diffuse, marked
leptomeningeal enhancement of the conus medullaris and the cauda
equina nerve rootlets. No definite enhancing leptomeningeal
nodules are appreciated. IMPRESSION: Leptomeningeal enhancement
of the conus medullaris and cauda equina. This finding can be
seen in diffuse meningeal infection as provided by history.
Other differential diagnostic consideration would include
metastatic disease.
_________________________
MRI Thoracic Spine [**9-27**]: The study is technically limited due to
extreme patient motion and is suboptimal for adequate evaluation
of the thoracic spine. There is some suggestion of abnormal
spinal cord enhancement along its surface, but this is difficult
to fully characterize given the poor resolution due to motion
degradation and the lack of axial images. Also, there is some
suggestion of increased abnormal STIR signal intensity from the
T6-T9 levels in the left paraspinal musculature with mild
corresponding enhancement, but this evaluation too is limited
due to lack
of axial images or adequate resolution. Of note, vertebral body
height and alignment appears normal. No definite paraspinal
fluid collection is seen.
IMPRESSION: Technically limited and suboptimal study for
adequate evaluation of the thoracic spine. Possible
abnormalities as described above need repeat imaging for
adequate interpretation.
________________________
EKG [**9-28**]: Regular narrow complex tachycardia - may be sinus
tachycardia but consider also atrial flutter with 2:1 response
Modest nonspecific ST-T wave changes No previous tracing for
comparison
_______________________
ECHO [**9-29**]: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
_______________________
CT OF THE ABDOMEN [**9-29**]: The imaged portions of the lung bases
are clear with no opacities, effusions, or nodules identified.
The liver appears normal with no focal lesions identified. The
gallbladder, pancreas, and spleen all appear normal. The
adrenals are normal. The kidneys enhance and excrete normally.
There is no mesenteric lymphadenopathy. There is no
retroperitoneal lymphadenopathy. There is no free fluid in the
abdomen. The small bowel appears unremarkable.
_____________________
CT OF THE PELVIS WITH CONTRAST [**9-29**]: The appendix is abnormally
thick with a diameter up to 7.6 mm. In addition, the wall of the
appendix abnormally
enhances. However, there is no sign of any periappendiceal fat
stranding or fluid. This may be consistent with a very early
appendicitis. Though this may not correlate with the clinical
history, careful clinical observation is recommended. The
terminal ileum and cecum are unremarkable, which suggests no
tuberculosis involvement. The large bowel is otherwise
unremarkable. The distal ureters and bladder appear normal. A
Foley tube and rectal tube are noted. There is no free fluid in
the pelvis or lymphadenopathy. BONE WINDOWS: The osseous
structures are unremarkable.
IMPRESSION: Possible early appendicitis, careful clinical
observation is
recommended. No radiographic evidence of tuberculosis
involvement in the abdomen.
_____________________
Repeat CT Abdomen and Pelvis [**9-30**]: normal contrast filling the
apendix, no acute change.
______________________
LENIs: no DVTs in lower extremities, bilaterally
Brief Hospital Course:
Mr. [**Known lastname **] is a 22 man, native of [**Country 11150**], with no significant PMHx
admitted with meningitis/encephalitis presumed to be Tuberculous
meningitis.
.
The patient was initially admitted to the regular medical floor,
vital sings were Tmax 102; Tc 98.8; P 62; RR 18; BP 94/56.
Patient was continued on Ceftriaxone for bacterial meningitis.
Patient then developed photophobia overnight and became
increasingly lethargic, with waxing/[**Doctor Last Name 688**] mental status. Also,
patient was noted to have new abdominal tenderness not noted on
previous exams. Infectious Disease was consulted who recommended
repeating the LP to obtain further specimen for TB PCR and other
exams; they also recommended starting patient on Acyclovir
pending HSV results and antibiotic coverage for suspected TB
meningitis in conjunction with steroids. The patient was started
on INH, pyrazinamide, pyridoxine, Rifampin, Ethambutol and
Dexamethasone.
.
Given the patient's worsening mental status including increasing
lethargy and new-onset photophobia without focal CNIII deficits,
patient was transferred to the [**Hospital Ward Name 332**] ICU for further
management. He was kept on respiratory precautions and with
negative pressure isolation.
.
1. Meningitis/Fever - Patient's history, physical exam, and LP
results from the OSH and repeated at [**Hospital1 18**] were concerning for
bacterial meningitis with very high opening pressures, although
the time course was somewhat more prolonged than would be
expected for a bacterial process. Gram staining was negative,
but showed a relative preponderance of lymphocytes with high
protein levels making a viral process or TB higher on the
differential diagnosis. Initially, the patient was maintained on
bacterial coverage with Ceftriaxone and Vancomycin which was
added to cover resistant pneumococcus. Mr. [**Known lastname **] continued to
have photophobia with waxing/[**Doctor Last Name 688**] mental status although his
WBC steadily trended downwards. He continued to show signs of
increased intracranial pressure with CN VI palsy bilaterally,
?CN IV palsy and sluggish pupils. The patient continued to have
headache, back pain and positive Kernig's sign. He was continued
on treatment for TB meningitis with steroids. Ceftriaxone and
Vancomycin were discontinued once CSF cultures from the OSH came
back negative. Acyclovir was later discontinued as CSF HSV 1 and
2 came back negative. Repeat LP was performed as per ID
recommendations which again showed a lymphocytic predominance
with decreasing levels of protein and increasing glucose. With
continued treatment the patient's mental status began to
steadily improve. He became more alert and oriented and was able
to respond quickly and appropriately to questioning. He
continued to have a left sided CN VI palsy on lateral gave but
his pupils were more reactive.
Pt continued to have periods of severe headache, back pain and
leg pain throughout his admission, treated with acetaminophen,
oxycodone and IV morphine as needed. Droplet precautions and
negative pressure isolation was discontinued as the patient has
no signs or symptoms or active TB. MRI of the head was also
performed which did not reveal any evidence of TB or other
abnormalities. Patient had 1 value of temp of 101.1 during the
last day of hospitalization. No source of infection was
immediately apparent, so, since patient is at an increased risk
for DVT (due to LE paraplegia), bilateral LENIs were ordered and
were negative for DVT bilaterally. DDx for the fevers included
atelectasis and incentive spirometer was placed at patient's
bedside.
2. Lower Extremity Weakness - On admission to the ICU, the
patient was acutely ill and remained in bed with altered mental
status. With improving mental status the patient was found to
have b/l lower extremity weakness. On admission, however, the
patient had full strength bilaterally. Lower extremity strength
was 2-3/5, upper extremity strength 5/5 b/l. In addition he had
b/l up going toes, b/l clonus. Sensations remained intact
throughout. There was at no time any saddle anesthesia or
incontinence although the patient did have one episode of severe
diarrhea as a result of aggressive bowel regimen for
constipation. MRI of the thoracic and lumbar spine revealed
leptomeningeal enhancement of the conus medullaris and cauda
equina in the setting of diffuse meningeal irritation. There was
question of a paraspinal soft tissue enhancement poorly seen on
MR of the thoracic spine. These findings supported meningeal
irritation of the cord as a cause for this patient's lower
extremities weakness, with a combination of upper and lower
motor neuron findings due to involvement of the conus
medullaris. Neurology was consulted who suggested continued
treatment of the underlying infection and continued steroids. CT
of the abdomen/pelvis did not reveal any involvement of the
paraspinal musculature or soft tissues. Patient received 6 days
of steroids, patient should be given his last day of 6mg IV Dex
q 6 today. ([**2173-10-2**]). Please refer to the enclosed taper of
steroid doses to treat the patient appropriately.
3. Abdominal Pain - Initially the patient had one episode of
abdominal pain with nausea/vomiting and decreased appetite. His
abdomen remained soft, mildly tender, with no rebound or
guarding. Abdominal x-ray did not reveal any free air or
obstruction. LFTs were within normal limits. This resolved and
the patient continued to have good PO intake without abdominal
pain. On [**9-28**] the patient again began to complain of abdominal
pain, diffuse in nature, constant and sharp in nature, rated
[**9-8**]. He did not have an acute abdomen on physical examination.
This was thought to be due to constipation as the patient had
not had a bowel movement for several days. The patient was
treated with an aggressive bowel regimen including PR lactulose
which caused the patient to have a large quantity of loose
stool. After this the patient continued to have an appetite with
good PO intake but continued to complain of diffuse abdominal
pain. A CT of the abdomen and pelvis was performed with oral and
IV contrast which showed a filling defect in the appendix with a
thickened wall suggestive of appendicitis. Surgery consult was
placed who recommended repeat imaging of the abdomen due to the
suboptimal quality of the first study which did not show filling
of the cecum. The patient remained without an acute abdomen
throughout, WBC count was steadily decreasing, fever curve
decreasing. The suspicion for TB enteritis or lymphadenopathy
causing appendiceal obstruction remained. Repeat CT
abdomen/pelvis however showed a normal filling appendix,
appendicitis was ruled out and surgery team signed off.
4. Urinary retention- At OSH, pt was found to have urinary
retention, requiring a foley. Pt was tried on voiding trial here
and failed, thus necessitating putting foley back in. Likely
related to conus syndrome as above. Voiding trial was attempted
once more, but the patient began to experience severe abdominal
pain several hours after the foley was removed. Patient
complained of inability to pass urine, the foley was placed back
in and 750cc of urine came out while abdominal pain resolved.
5. Tachycardia - The patient was in sinus tachycardia beginning
[**9-27**] which persisted and reached a maximum HR of 160s. This was
thought to be due to his underlying infection with persistent
low grade fevers. The patient was anxious and having at times
severe headaches, back ache and leg pain. The patient responded
appropriately to several fluid boluses of NS which caused his HR
to come down to the 60s. Baseline fluids were maintained with
intermitted NS boluses as needed. The patient continued to match
his urine input and output and was able to tolerate aggressive
fluids without any problems. In addition, he was treated with
Ativan for anxiety, Percocet and Morphine for pain which also
seemed to slow his heart rate. Notably, the patient's heart rate
decreased during sleep and increased during the daytime, likely
as a result of anxiety. On the last day, foley was clamped,
patient had urge to void, so foley was d/c'ed. However, patient
has a h/o of urinary retention while being in in the hospital,
so he should be evaluated for urine output frequently.
6. Cerebral salt wasting: Initially the patient was thought to
have SIADH with low serum sodium levels likely due to his
underlying CNS infection. A trial of fluid restriction however
failed to normalize the patient's sodium level. 24h urinary
sodium secretion was above normal suggesting cerebral salt
wasting as the cause for his low sodium. The patient was treated
with NS at 150 cc/hr with one day of salt tablets with
normalization of his sodium. Patient sodium normalized (135)
being the last [**Location (un) 1131**], while taking in POs.
7. F/E/N: Maintained on a regular diet, NPO during the time he
was suspected of having appendicitis. Serum electrolytes were
monitored carefully. As mentioned above, serum sodium levels
decreased to a low of 129 but increased to normal limits with
normal saline and salt tabs.
8.Prophylaxis: Heparin SC, pneumo boots due to high risk of DVT
with LE weakness. PPI, RISS due to steroids, PO intake.
9. Contact: [**Name (NI) **] and [**Name2 (NI) 62780**] [**Name (NI) **] (H)[**Telephone/Fax (1) 62781**],
(C)[**0-0-**]. [**Hospital3 13313**]: [**Telephone/Fax (1) 62782**], Micro lab
[**Telephone/Fax (1) 62783**].
Medications on Admission:
None
Discharge Medications:
1. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
2. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
Disp:*qs Capsule(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Ethambutol 400 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
6. Pyrazinamide 500 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. Morphine 2 mg/mL Syringe Sig: [**1-31**] Injection Q4H (every 4
hours) as needed.
15. Dexamethasone Taper
6 mg IV q6 hours - [**Date range (1) 62784**]
4.5 mg IV q6 hours- [**Date range (3) 62785**]
3 mg IV q6 hours- [**Date range (1) 62786**]
1.5 mg IV q6 hours- [**Date range (3) 62787**]
4 mg po (can divide doses) qday-[**Date range (3) 62788**]
3 mg po (can divide doses) qday-[**Date range (1) 62789**]
2 mg po (can divide doses) qday-[**Date range (1) 62790**]
1 mg po (can divide doses) qday-[**Date range (3) 62791**]
OFF
16. Regular Insulin Sliding Scale
Breakfast Dinner
0-150 0 0
151-200 2 units 2 units
201-250 4 units 4 units
251-300 6 units 6 units
301-350 8 units 8 units
351-400 10 units 10 units
>401- [**Name8 (MD) **] MD
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13313**]
Discharge Diagnosis:
Primary diagnosis:
Meningitis most likely tuberculous
Lower extremity weakness
Abdominal pain NOS
Discharge Condition:
stable, afebrile, improved, regaining strength
Discharge Instructions:
-please continue all treatments as directed
-please have PT work with the patient, especially strengthening
exercises
-please follow up all the CSF culture data. please call [**Hospital1 18**] at
[**Telephone/Fax (1) 4645**] to finfd out any additional results from
microbiology lab. Main number for [**Hospital1 **] is [**Telephone/Fax (1) 2756**]
-please continue all treatments as directed
-please have PT work with the patient, especially strengthening
exercises
-please follow up all the CSF culture data. please call [**Hospital1 18**] at
[**Telephone/Fax (1) 4645**] to finfd out any additional results from
microbiology lab. Main number for [**Hospital1 **] is [**Telephone/Fax (1) 2756**]
-please involve Neurology and Infectious Disease specialists at
your facility to care for the patient
-Medication (including dexamethasone taper) per instructions
Followup Instructions:
-Will need to call [**Hospital1 **] to follow up on CSF and culture data.
-other as per discharge summary
Completed by:[**2173-10-2**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 957
} | Medical Text: Admission Date: [**2184-8-7**] Discharge Date: [**2184-8-12**]
Date of Birth: [**2129-9-14**] Sex: F
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing / Thimerosal / Carboplatin / Taxol /
Erythromycin
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
Dyspnea, cough, nausea, emesis
Major Surgical or Invasive Procedure:
central catheter placement
nasogastric tube placement
History of Present Illness:
54 year old female with recurrent ovarian cancer, recently d/c'd
on [**8-3**] with gastritis/esophagitis, who presented on [**8-7**] with
increasing SOB, cough, nausea and vomiting x 3 days and acute
onset bilateral edema. Per the patient, she had experienced no
diarrhea with the nausea and emesis and instead noted decreased
ostomy output. No BRB in ostomy output. Cough was
nonproductive. She has baseline SOB due to asthma but she felt
that this had worsened over the 1-2 weeks prior to admission,
particularly with exertion. No orthopnea or PND, but worse when
lying on her sides (either side). + sinus congestion in week
preceding admission. No fevers, chills. Of note, she had
received desensitization for carboplatin on [**8-5**] with a
significant amount of IVF and her primary oncologist felt that
she was fluid overloaded and she was sent in for diuresis and
electrolyte monitoring.
.
In the ED course she had a leukocytosis, elevated lactate to
3.6, hypokalemia, and an elevated pro BNP. UA showed a UTI.
CTA for PE was negative but demonstrated bilateral ground glass
changes and nodular opacities consistnent with acute infection,
with atypical vascular congestion being more unlikely. A
central line was placed for concern of sepsis and she was given
3L given, cx sent, and vanc/cefepime/fluconzole/flagyl were
started.
.
She was transferred to the MICU for concern of sepsis where
broad spectrum antibiotics were continued. CT abd/pelvis showed
SBO and NGT placed, bowel rest. Cefepime was changed to
levofloxacin on [**8-8**] and vancomycin and flagyl were discontinued
today ([**8-9**]) due to clinical improvement. Bilateral LE U/S
performed for LE edema which showed no evidence of DVT. Due to
nausea/emesis/abd pain/elevated bilirubin RUQ US obtained which
showed contracted gallbladder completely filled with sludge and
tiny [**Known lastname **] and no evidence of cholecystitis. ECHO was
performed to evaluate etiology of LE edema and showed
hyperdynamic EF, small pericardial effusion, no significant
change from prior.
.
Currently on the floor she has mild SOB with positional changes
that responds to albuterol treatments. Continued cough,
nonproductive, somewhat worse than admission. No hemoptysis.
Nausea and vomiting has remarkably improved and she is
tolerating clears without difficulty. Fatigued and worn out.
.
ROS negative for fevers, chills. +18lb weight loss in last 2
months d/t decreased appetite. No current sinus or nasal
congestion. No sore throat. Mild dysphagia initially after
removal of NGT this afternoon, now improved. No abdominal pain,
dysuria.
.
Past Medical History:
Asthma
.
Oncologic History:
She was originally diagnosed in [**2180-4-20**] with stage III C
adenocarcinoma of the ovary. Post operatively she received six
cycles of carboplatin and Taxol chemotherapy, completing
treatment [**2180-8-23**]. She then enrolled on the OvaRex study at
the [**Hospital 4415**]. Right adnexal recurrence was
noted by CT scan in [**2182-9-21**]. She received two cycles of
Taxol and carboplatin, but had a severe platinum allergic
reaction requiring a switch to Doxil and Taxol for several
additional cycles of second line therapy. She then developed
mucositis on this regimen and received 5 additional cycles of
single [**Doctor Last Name 360**] Taxol. She developed a large bowel obstruction
during her fifth cycle which required a diverting ileostomy
performed on [**2183-11-21**]. She subsequently received four cycles
of Halichondrin B as part of the 06-125 protocol, but had
progressive disease and was taken off the protocol on [**2184-4-1**].
She then commenced gemcitabine at 600 mg/m2 and received three
weekly doses followed by a week off. She received two cycles of
gemcitabine but has progressed. She is now cycle 3 of
carboplatin desensitization.
Social History:
She has one son who is 30 years old. She has worked as a
freelance writer until recently. She lives in [**Hospital1 **], MA with
her son. She drinks alcohol occasionally and has quit smoking 20
yrs ago (15yr h/o of 1ppd).
Family History:
She had a maternal grandmother with heart disease who at the age
of 83 developed colon cancer. There is no other cancer in her
family. Her mother died of COPD. Her father had a gastric ulcer
and died of renal artery stenosis.
Physical Exam:
VS: 95% on RA, 96.8, 18, 95, 112/55
GEN: comfortable, NAD, conversive, eating broth
HEENT: PRRLA, EOMI, anicteric, MMM, OP clear
Neck : supple, unable to assess JVD on right d/t line but flat
on left, no [**Doctor First Name **]
CV: tachy, RR, no M/R/G
PULM: Decreased BS bilaterally at bases, R>L, no wheezes, no
crackles
GI: soft, minor tenderness around umbilicus, no reboung or
guarding, no tap tenderness, ileostomy in place and draining
actively while in room
EXT: 4+ edema b/l to thighs, pulses palpable, no cyanosis,
clubbing
NEURO: AAOx3. Cn II-XII grossly intact
Pertinent Results:
[**2184-8-7**] 01:30PM BLOOD WBC-16.3*# RBC-3.69* Hgb-11.4* Hct-35.2*
MCV-95 MCH-31.1 MCHC-32.6 RDW-21.6* Plt Ct-243#
[**2184-8-9**] 04:00AM BLOOD WBC-7.0 RBC-2.85* Hgb-8.6* Hct-26.3*
MCV-92 MCH-30.0 MCHC-32.5 RDW-22.0* Plt Ct-180
[**2184-8-9**] 04:00AM BLOOD PT-15.7* PTT-31.1 INR(PT)-1.4*
[**2184-8-9**] 03:39PM BLOOD Glucose-95 UreaN-24* Creat-0.8 Na-138
K-2.9* Cl-107 HCO3-26 AnGap-8
[**2184-8-9**] 04:00AM BLOOD ALT-34 AST-36 LD(LDH)-307* AlkPhos-170*
TotBili-1.1
[**2184-8-7**] 01:30PM BLOOD Lipase-16
[**2184-8-7**] 01:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-2181*
[**2184-8-9**] 03:39PM BLOOD Calcium-7.4* Phos-1.5* Mg-2.1
[**2184-8-8**] 03:28AM BLOOD Cortsol-24.3*
[**2184-8-8**] 04:09AM BLOOD Cortsol-34.3*
[**2184-8-8**] 05:11AM BLOOD Cortsol-39.7*
[**2184-8-7**] 03:31PM BLOOD Lactate-3.6*
[**2184-8-7**] 05:59PM BLOOD Lactate-2.3*
[**2184-8-8**] 12:12AM BLOOD Lactate-1.6
.
CT Abd/Pelvis [**8-7**]:
1. Limited study without contrast was designed primarily to
evaluate for obstruction. This demonstrates small- bowel
obstruction with transition point just proximal to the stoma
site.
.
CTA chest:
1. No evidence of pulmonary embolism.
2. Bilateral ground glass change and nodular opacities likely
represent acute infection. Consider opportunistic infection
based on immune status. Aspiration considered given #3 below,
however anterior upper lobe involvement difficult to reconcile.
Atypical edema is a less likely cause for these findings.
Mediastinal lymph nodes have progressed in size, though a
component of this may be reactive.
3. Dilated fluid filled esophagus may represent more distal
obstruction in the abdomen.
4. Stable right greater than left pleural effusions.
5. Evidence of metastatic disease within the abdomen
incompletely evaluated.
.
LE U/S Bilat 8/20: No evidence of DVT
.
ECHO [**8-9**]:
Hyperdynamic left ventricular function. Small circumferential
pericardial effusion without echocardiographic signs of
tamponade. Compared with the prior study (images reviewed) of
[**2183-11-24**], the findings are similar.
Brief Hospital Course:
A/P: 54 year old female with recurrent ovarian ca who presented
with SOB, cough, nausea, emesis, and edema who was found to have
SBO and pneumonia.
.
#)SBO - Upon admission the patient was found on CT Abdomen to
likely have a small bowel obstruction with transition point at
the site of her ostomy. A nasogastric tube was placed and she
was made placed on bowel rest. Her diet was slowly advanced
until she was tolerating solids and liquids without difficulty.
Complicating her course in the last several months has been
chronic appetite loss as well as chronic nausea.
.
#) PNA - The inital concern was for aspiration pneumonia in the
setting of nausea and vomiting. Sputum gram stain showed 1+GNR
and GPC. She improved on levofloxacin (vanc and flagyl stopped)
and this was continued for a full course.
.
#) Esophagitis - She was recently hospitalized for esophagitis,
and fluconazole was continued throughout her stay for concern
for [**Female First Name (un) **] esophagitis.
.
#) LE edema - She had no evidence of systolic or diastolic
dysfunction on ECHO. Also, she had no obvious pelvic or
abdominal mass causing lymphatic obstruction/venous obstruction
secondary to ovarian CA and mets. Most likely cause of edema
is hypoalbuminemia in the setting of very poor nutritional
status, which was exacerbated by fluid load from chemotherapy/
Medications on Admission:
MEDS AT HOME:
1. Venlafaxine 125 QD
2. Zolpidem 10 HS prn
3. Metoclopramide 10 mg PO QIDACHS PRN (only takes occasionally
4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
5. Dronabinol 2.5 mg PO BID - just started one week ago
6. Oxycodone 10 mg Tablet Sustained Release [**Hospital1 **]
7. Oxycodone 10 mg Tablet Q6H prn
8. Lorazepam 0.5 mg Tablet PO Q8H prn
9. Simethicone 80 mg Tablet PO QID prn
10. Loperamide 2 mg Capsule PO QID prn
11. Calcium Carbonate 500 mg Tablet PO QID prn heartburn
.
MEDS ON TRANSFER:
Venlafaxine XR 150 PO DAILY (to start in a.m.)
Levofloxacin 500 mg IV DAILY
Albuterol [**12-23**] PUFF IH Q6H:PRN
Lorazepam 0.5 mg IV Q4H:PRN
Pantoprazole 40 mg IV Q12H
Fluconazole 200 mg IV Q24H
Ondansetron 8 mg IV Q8H:PRN [**8-9**]
Acetaminophen 500 mg NG Q6H:PRN
Magnesium Sulfate IV Sliding Scale
Calcium Carbonate 500 mg PO QID:PRN
Simethicone 80 mg PO QID:PRN
OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN
Zolpidem Tartrate 10 mg PO HS
Docusate Sodium 100 mg PO BID
Bisacodyl
Loperamide
Dronabinol
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day
for 2 weeks.
2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO twice a
day.
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea.
12. Loperamide 2 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for diarrhea.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a
day: Take before meals.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
16. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**5-28**]
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
1.) Small bowel obstruction
2.) Aspiration pneumonia
3.) Stage II ovarian cancer
4.) esophagitis
Discharge Condition:
afebrile, displaying normal vital signs, tolerating regular
diet.
Discharge Instructions:
You were admitted to the hospital with cough, difficulty
breathing, and worsening nausea and vomiting. You were treated
with antibiotics, and a nasogastric tube was placed. This was
removed and your diet was slowly advanced.
.
Upon discharge be sure to continue the full course of
antibiotics and continue to keep all health care appointments as
scheduled.
.
If you develop worsening cough, shortness of breath, fever,
nausea + vomiting, abdominal pain or chest pain, or if your
condition worsens in any way, seek immediate medical attention.
Followup Instructions:
You have the following follow-up appointments with Drs. [**Last Name (STitle) 2244**]
and [**Name5 (PTitle) **]. Continue to follow up with your physicians at
[**Hospital3 328**] as previously scheduled.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-8-19**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-8-19**] 11:00
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
ICD9 Codes: 0389, 5070, 5990, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 958
} | Medical Text: Admission Date: [**2180-5-22**] Discharge Date: [**2180-5-26**]
Date of Birth: [**2129-4-20**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with a history of a myocardial infarction in [**2166**] and an
angioplasty in [**2167**]. He did well for almost 10 years with
medical treatment.
Over the past year, he has had increasing shortness of breath
with angina and left arm pain. To months ago he had a
positive exercise tolerance test which led him to cardiac
catheterization on [**2180-4-13**]. This revealed a left
ventricular end-diastolic pressure of 22 as well as coronary
artery disease consisting of left main 70 percent, left
anterior descending 80 percent, obtuse marginal 90 percent,
and posterior descending artery 90 percent, and proximal left
ventricle 80 percent. No mitral regurgitation. No left
ventriculography was done at that time. Prior to his
surgery, he had ongoing symptoms of chest pressure and left
arm pain with fatigue even with rest, occurring multiple
times per day.
PAST MEDICAL HISTORY:
1. Osteoarthritis.
2. Myocardial infarction in [**2166**].
3. Percutaneous transluminal coronary angioplasty in [**2167**].
4. Elevated cholesterol.
5. Psoriasis.
PAST SURGICAL HISTORY: Laparoscopic cholecystectomy in [**2171**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
PHYSICAL EXAMINATION ON PRESENTATION: Right arm blood
pressure was 108/57 and right arm blood pressure was 134/73,
his heart rate was 70, height was 5 feet 6 inches tall, and
weight of approximately 200 pounds. Cardiovascular
examination revealed a rate and rhythm. Normal first heart
sounds and second heart sounds. There was a 2/6 systolic
murmur. The lungs were clear to auscultation. The abdomen
was soft, round, nontender, and nondistended. There was no
costovertebral angle tenderness. Neck revealed negative
jugular venous distention and negative bruits. Extremities
with some psoriasis on the bilateral elbows and knees. Warm
and well perfused. Good CSM. Pulses were 2 plus right and
left radial, 2 plus right and left femoral, 2 plus right and
left dorsalis pedis, 1 plus right posterior tibialis, 2 plus
at left dorsalis pedis. Neurologic examination revealed
cranial nerves II through XII were grossly intact. Excellent
strength in all four extremities.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed
Poor R wave progression, sinus rhythm at 66.
A chest x-ray on [**5-24**] showed bibasilar patchy atelectasis;
unchanged from a previous study with some mild thickening of
the minor fissure, and no other changes.
PERTINENT LABORATORY VALUES ON PRESENTATION: On [**5-26**],
complete blood count revealed his white blood cell count was
9.2, his hematocrit was 28.2, and his platelets were 244.
Sodium was 143, potassium was 4.4, chloride was 105,
bicarbonate was 28, blood urea nitrogen was 19, creatinine
was 0.8, and his blood glucose was 113. Magnesium was 2.1.
SU[**Last Name (STitle) 42242**]OF HOSPITAL COURSE: The patient was admitted on [**5-22**] and underwent coronary artery bypass graft times four by
Dr. [**Last Name (Prefixes) **]. That evening, he had a brief episode of
atrial fibrillation lasting less than one hour that resolved
independently. His chest tubes were discontinued on [**5-24**],
and his cardiac pacing wires on [**5-26**].
The patient was transferred to the Inpatient Floor on [**5-25**].
He was followed by the Physical Therapy Service and was found
to safe for discharge to home on [**5-24**]. The remainder of
his hospital course was uneventful.
DISCHARGE DISPOSITION: To home on [**5-26**].
CONDITION ON DISCHARGE: Vital signs revealed a temperature
maximum was 100.9, temperature current was 98.4, his heart
rate was 88 to 96 (normal sinus rhythm), his blood pressure
was 98 to 108/50s to 60s, his respiratory rate was 18, and
his oxygen saturation was 94 percent on room air.
Fingerstick blood sugars were within normal limits. Weight
on discharge was 90.5 kilograms with a preoperative weight of
90.9 kilograms. He was alert, awake, and oriented times
three. The sternal incision was open to air with Steri-
Strips. Clean, dry, and intact with a stable sternum. He
had an incision at the right knee and ankle which were both
clean, dry, and intact with Steri-Strips. Respiratory
examination revealed the lungs were clear to auscultation.
Cardiovascular examination revealed a rate and rhythm. There
were no murmurs, rubs, or gallops. No edema was noted.
Gastrointestinal examination revealed there were positive
bowel sounds in all four quadrants. The abdomen was rounds,
soft, nontender, and nondistended.
DISCHARGE STATUS: The patient was to be discharged home with
Visiting Nurses Association.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post coronary artery
bypass graft times four.
2. Elevated cholesterol.
3. Status post laparoscopic cholecystectomy.
MEDICATIONS ON DISCHARGE:
1. Toprol-XL 25 mg by mouth once per day.
2. Lasix 20 mg by mouth once per day (for seven days).
3. Potassium chloride 20 mEq by mouth once per day (times
seven days).
4. Colace 100 mg by mouth twice per day.
5. Zantac 150 mg by mouth twice per day.
6. Aspirin 325 mg by mouth once per day.
7. Percocet 5/325-mg tablets one to two tablets by mouth q.4-
6h. as needed.
8. Crestor 10 mg by mouth once per day.
DISCHARGE INSTRUCTIONS-FOLLOWUP:
1. The patient was instructed to follow up with Dr.
[**Last Name (STitle) 54731**] in one to two weeks.
2. The patient was instructed to follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1159**] in one to two weeks.
3. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in three to four weeks.
4. The patient was also to be seen in the [**Hospital 409**] Clinic for
evaluation of his incisions in two weeks.
5. The patient will be followed by a visiting nurse briefly
at home.
[**Doctor Last Name **] [**Last Name (Prefixes) **], MD 2351
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2180-5-26**] 13:26:56
T: [**2180-5-26**] 15:00:00
Job#: [**Job Number 54732**]
ICD9 Codes: 5180, 4111, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 959
} | Medical Text: Admission Date: [**2113-12-31**] Discharge Date: [**2114-1-24**]
Date of Birth: [**2050-9-6**] Sex: F
Service: Medicine, [**Doctor Last Name **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
female with multiple medical problems including chronic
obstructive pulmonary disease, idiopathic pulmonary fibrosis
(on home oxygen), Takayasu's arteritis, diabetes, anxiety
disorder, and chronic motor seizures. The patient had a
recent admission from [**12-12**] to [**2113-12-25**] for
chest pain and tachycardia.
The patient is now admitted status post a fall with a hip
fracture; scheduled for surgical repair on [**2114-1-1**].
The patient has had a history of falls. This morning, she
fell after her right leg felt weak. She was also mildly
short of breath, but she ran out of home oxygen.
She denies any chest pain, loss of consciousness, or
dizziness preceding the fall. She states that her right knee
gave out on her. She denies any head trauma but may have had
loss of consciousness after the fall. She denies any urinary
or fecal incontinence.
In the Emergency Department, the patient was found to have a
T12 compression fracture on lumbosacral spine film and a
right femoral neck fracture. A chest x-ray showed chronic
changes with a question of a new pneumonia. A head computed
tomography was negative but with prominent ventricles. The
patient was given a total of 5 mg of intravenous morphine and
2 mg of Ativan, and two tablets of Percocet.
Review of systems was negative for fevers, chills, dysuria,
or any other constitutional symptoms.
Due to her tachycardia and shortness of breath, the patient
had a computed tomography angiogram which was negative for a
pulmonary embolism even though the patient had just had a
computed tomography angiogram performed only a few days prior
to this admission.
The Emergency Department staff felt that the patient's oxygen
saturations were on the lower side, even though they were 94%
on 4 liters. Given a negative computed tomography angiogram,
it was thought the patient was mildly fluid overloaded and
was given Lasix.
Please refer to the excellent Discharge Summary done by Dr.
[**Last Name (STitle) **] from the previous hospitalization for further
information. Of note, the patient frequently complains of
shortness of breath and continued low back pain (which was
alleviated with Percocet). She also has chronically low
blood pressures in her arms secondary to subclavian stenosis
from presumed Takayasu's arteritis. Consequently, blood
pressures should only be checked in the patient's thighs as
she is constantly admitted for similar workups for
sepsis/adrenal insufficiency when blood pressures are checked
in her arms.
PAST MEDICAL HISTORY:
1. Takayasu's arteritis.
2. Idiopathic pulmonary fibrosis.
3. Chronic obstructive pulmonary disease.
4. Chronic motor focal seizures; recently diagnosed in
[**Month (only) **] to [**2113-11-8**].
5. Hypothyroidism.
6. Type 2 diabetes mellitus.
7. Depression/anxiety.
8. Chronic low back pain.
9. History of pulmonary embolus in [**2112-8-8**].
MEDICATIONS ON ADMISSION:
1. Keppra 500 mg by mouth in the morning and 1000 mg by
mouth at hour of sleep.
2. CellCept [**Pager number **] mg by mouth twice per day.
3. Prednisone 5 mg by mouth once per day.
4. Synthroid 50 mcg by mouth once per day.
5. Flonase 100-mcg inhaler 2 puffs inhaled twice per day.
6. Salmeterol 50-mcg inhaler 2 puffs inhaled twice per day.
7. Ranitidine 150 mg by mouth twice per day.
8. Percocet one to two tablets by mouth q.4-6h. as needed
(for pain).
9. Olanzapine 2.5 mg by mouth at hour of sleep.
10. Aspirin 325 mg by mouth once per day.
11. Colace.
12. Fluoxetine 50 mg by mouth once per day.
13. Albuterol nebulizers.
14. Calcium carbonate 500 mg by mouth three times per day.
15. Vitamin D 400 International Units by mouth every day..
16. Metformin 500 mg by mouth twice per day.
17. Klonopin 1 mg to 2 mg by mouth twice per day.
18. Sarna lotion.
19. Benadryl 25 mg to 50 mg by mouth q.4-6h. as needed (for
pruritus).
ALLERGIES: SULFA and DILANTIN (which cause a rash).
SOCIAL HISTORY: The patient lives alone. She has a past
tobacco history times 10 years, but she no longer smokes.
She denied any alcohol or intravenous drug use. Family
members are minimally involved but are aware of her many
issues.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 98 degrees Fahrenheit,
her blood pressure was 194/55, her heart rate was 135, her
respiratory rate was 22, and her oxygen saturation was 94% on
4 liters of oxygen. In general, the patient was an alert and
oriented elderly female who appeared older than her stated
age. The patient was mildly tachypneic, but she was in no
apparent distress. Head, eyes, ears, nose, and throat
examination revealed pupils were equal, round, and reactive
to light. The extraocular movements were intact. The mucous
membranes were slightly dry. No jugular venous distention.
The neck was supple and nontender. No lymphadenopathy.
Cardiovascular examination revealed a regular rhythm with
tachycardia. Normal first heart sounds and second heart
sounds. A 3/6 systolic ejection murmur at the left sternal
border. Pulmonary examination revealed bilateral fine
crackles about half the way up. There were positive
expiratory wheezes diffusely bilaterally. The abdomen was
soft and nondistended. There were normal active bowel
sounds. There was right lower quadrant tenderness over the
iliac crest. There was positive ecchymosis in the right
lower quadrant to the midline. No masses. Extremity
examination revealed the right lower extremity was shorter
and externally rotated. There was no thigh ecchymoses.
Dorsalis pedis pulses were 2+ bilaterally. There were 2+
radial pulses present bilaterally. There was normal
sensation to light touch. Neurologic examination revealed
cranial nerves II through XII were intact bilaterally. The
patient was unable to move the right leg secondary to pain.
No obvious focal deficits, but the examination was limited.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed the patient's white blood cell count was 35.4 (with
a differential of 89% neutrophils, 0% bands, 7% lymphocytes,
2% monocytes, and 1% eosinophils), her hematocrit was 29.8,
and her platelets were 424. The patient's sodium was 137,
potassium was 4, chloride was 98, bicarbonate was 25, blood
urea nitrogen was 14, and her creatinine was 0.5. Her
creatine kinase was 91. Troponin was less than 0.01. Her
prothrombin time was 12.3, her partial thromboplastin time
was 21, and her INR was 1. Urinalysis was negative for
infection. Last thyroid-stimulating hormone was on [**12-29**] which was 0.58.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed
sinus tachycardia, but no ST changes.
The patient's last echocardiogram was in [**2113-3-11**]
which showed a mildly dilated left atrium and left
ventricular wall thickening. Cavity size and systolic
function were normal with a left ventricular ejection
fraction of 55%. Basilar and septal hypokinesis. Mild MS.
There was 1+ mitral regurgitation. Mild pulmonary artery
systolic hypertension.
ASSESSMENT: The patient is a 53-year-old female with
multiple medical problems here status post a fall with a
right femoral neck fracture.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RIGHT FEMORAL NECK FRACTURE: The patient was evaluated
by the Orthopaedic Service, and surgical repair of her right
hip was performed on [**2114-1-1**].
Prior to her right hip repair, the patient was medically
cleared with a stress MIBI which showed no perfusion defects
and an ejection fraction of 70%.
The patient had a right hip hemiarthroplasty performed
without complications. She has since been working with
Physical Therapy and is able to bear weight as tolerated.
She occasionally had some complaints of right leg numbness
which extended from her hip to her foot, but these would
resolve after movement of her leg and were very nonspecific
and infrequent. The patient is able to fully move her
extremities and will need followup with the Orthopaedic
Service in one week following her discharge.
2. TACHYCARDIA ISSUES: The patient's baseline heart rate
from previous hospital admissions seemed to be in the 90s to
low 100s. On admission, she was more tachycardic, but this
was thought to be secondary to pain and dehydration.
A computed tomography angiogram was initially negative for a
pulmonary embolus. Prior to her surgery, the patient was
placed on a beta blocker initially at a dose of 25 mg and
titrated up rapidly, and the patient is currently on 50 mg by
mouth twice per day of Lopressor. Her heart rate is
currently in the low 90s and is stable. We did not chose to
increase the beta blocker any further secondary to the
patient's bronchospasm.
3. HYPERTENSION ISSUES: The patient has chronic subclavian
stenosis from Takayasu's arteritis. Thus, blood pressures
can only be adequately measured in the thigh which should be
noted in future admissions. Her systolic blood pressures
usually range in the 120s to 140s in her thigh.
On admission, her blood pressure was quite elevated but this
was again thought to be secondary to the patient's pain.
Subsequently, after her pain was more adequately controlled
and following postoperative, the patient's blood pressures
remained in the normal range (in the 120s to 140s) when
measured in her thigh.
4. PULMONARY/IDIOPATHIC PULMONARY FIBROSIS ISSUES: The
patient was admitted on her chronic prednisone dose of 5 mg
by mouth once per day for Takayasu's arteritis. The patient
was maintained on this when she was admitted.
It was thought that prior to surgery the patient should be
given stress-dose steroids considering her poor pulmonary
function and probable prophylaxis against adrenal
insufficiency postoperatively. The patient was given two
days of 100 mg intravenously of hydrocortisone q.8h., and
then she was rapidly tapered off to 60 mg by mouth once per
day times two days; then 40 mg by mouth every day times two
days; etcetera.
The patient's pulmonary status began to deteriorate several
days postoperatively and continued for approximately one
week. No clear etiology could be found for why the patient
was more short of breath. She had been intubated during the
operative procedure and took many hours to extubate, but the
extubation proceeded without difficulties, and the patient
was weaned off the ventilator without event.
NOTE: A Discharge Summary Addendum will be added at this
point to continue the hospital course.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2114-1-24**] 12:28
T: [**2114-1-24**] 12:35
JOB#: [**Job Number 97092**]
ICD9 Codes: 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 960
} | Medical Text: Admission Date: [**2199-10-21**] Discharge Date: [**2199-10-25**]
Date of Birth: [**2141-3-24**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
right renal mass
Major Surgical or Invasive Procedure:
Right laparoscopic partial nephrectomy, laparoscopic
cholecystectomy
History of Present Illness:
58yF with 1.5 cm right posterior renal lesion and gallbladder
polyp now s/p CCY (Dr [**Last Name (STitle) **]/right partial Nx.
Additionally, she does have a history of Factor [**Doctor First Name 81**] def (Dr
[**Last Name (STitle) 3060**], [**Hospital1 18**]) and has rec'd 4FFP/Benadryl/Tylenol pre-op which
has been used in the past for this.
IVF: 2.0L + 8U FFP(!!) (plus 40IV lasix) EBL: 200cc
Plan:
Lap Partial Pathway
No Toradol
PACU labs
Run light, may HLIV in AM given large fluid load
q24 ptt and factor [**Doctor First Name 81**] levels
Hematology (Fellow, Dr. [**Last Name (STitle) **], [**Numeric Identifier 101405**]) following
If bleed tonight, the on call hematologist aware, will give more
FFP.
Past Medical History:
PMH: factor [**Doctor First Name 81**] deficiency, depression, recurrent genital herpes,
Hx of iron deficiency anemia, hypertension,
hypercholesterolemia, status post appendectomy , status post
tonsillectomy, C-section, ex-smoker and she quit smoking in
[**2176**].
Brief Hospital Course:
Patient was admitted to Urology after undergoing laparoscopic
right partial nephrectomy and cholecystectomy. No concerning
intraoperative events occurred; please see dictated operative
note for details. The patient received perioperative antibiotic
prophylaxis. The patient was transferred to the ICU given her
history of factor [**Doctor First Name 81**] defiency and drowsiness. She was
transferred to the floor on POD 1 in stable condition. On POD
0, pain was well controlled on PCA, hydrated for urine output
>30cc/hour, and provided with pneumoboots and incentive
spirometry for prophylaxis. She recieved 8 units of FFP on POD
0. On POD1, the patient ambulated, restarted on home
medications, basic metabolic panel and complete blood count were
checked, pain control was transitioned from PCA to oral
analgesics, diet was advanced to a clears/toast and crackers
diet. Hematology recommended 2 units of FFP that were given on
POD 1. On POD2, JP and urethral catheter (foley) were removed
without difficulty and diet was advanced as tolerated.
Hematology recommended another 2 units of FFP that were given on
POD 2. Her central line was removed on POD 2. The remainder of
the hospital course was relatively unremarkable. The patient was
discharged in stable condition, eating well, ambulating
independently, voiding without difficulty, and with pain control
on oral analgesics. On exam, incision was clean, dry, and
intact, with no evidence of hematoma collection or infection.
The patient was given explicit instructions to follow-up in
clinic with Dr. [**Last Name (STitle) 3748**] in 3 weeks.
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for break through pain only
(score >4) .
Disp:*30 Tablet(s)* Refills:*0*
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 heartburn: over
the counter.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking narcotics, over the counter.
Disp:*60 Capsule(s)* Refills:*0*
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
7. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Discharge Disposition:
Home
Discharge Diagnosis:
right renal mass
Discharge Condition:
stable
Discharge Instructions:
-You may shower but do not bathe, swim or immerse your incision.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up.
-Do not drive or drink alcohol while taking narcotics.
-Resume all of your home medications, except hold NSAID
(aspirin, advil, motrin, ibuprofin) until you see your urologist
in follow-up.
-Call your Urologist's office today to schedule a follow-up
appointment in 3 weeks AND if you have any questions.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest ER.
Followup Instructions:
1-2 weeks
Completed by:[**2199-10-23**]
ICD9 Codes: 4019, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 961
} | Medical Text: Admission Date: [**2127-7-8**] Discharge Date: [**2127-7-17**]
Date of Birth: [**2056-7-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Bee Pollens
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 4 on [**2127-7-9**]
History of Present Illness:
70 y/o female without significant cardiac disease who was stung
by a bee on saturday [**2127-7-5**]. Hand became swollen and pt went to
the ED on Monday, [**7-7**]. She was given Keflex and Prednisone. At
her second dose of Keflex she developed an anaphylactic reaction
with throat tightness, SOB. She came back to the ED, now with
chest pain. EKG showed ST depressions and was ruled in for
NSTEMI. Transferred from OSH to [**Hospital1 18**] for cath with revealed 3vd
and left main disease.
Past Medical History:
Hypertension
Right Carotid Disease
Social History:
Lives alone with family close by.
-ETOH/Tob
Family History:
Father MI at 65
Physical Exam:
VS: VSS [**5-13**]" 91kg BSA 2.09
General: WDWN female in NAD
HEENT: NC/AT, PERRLA, EOMI, oropharynx benign
Neck: Supple, FROM, -lymphadenopathy
Heart: RRR, +S1S2, -c/r/m/g
Lungs: CTAB -w/r/r
Abd: Soft, NT/ND, +BS -r/r/g
Ext: -c/c/e, pulses: BRA 2+, BPT/BDP trace, LFA 1+ RFA IABP
Neuro: Nonfocal, CN 2-12 intact
Pertinent Results:
[**2127-7-8**] 04:31PM BLOOD WBC-12.2* RBC-3.78* Hgb-11.8* Hct-35.8*
MCV-95 MCH-31.3 MCHC-33.0 RDW-13.0 Plt Ct-310
[**2127-7-15**] 05:58AM BLOOD WBC-10.3 RBC-2.91* Hgb-9.2* Hct-28.0*
MCV-96 MCH-31.8 MCHC-33.0 RDW-13.6 Plt Ct-332
[**2127-7-8**] 04:31PM BLOOD PT-12.3 PTT-35.3* INR(PT)-1.0
[**2127-7-10**] 02:59AM BLOOD PT-12.2 PTT-34.1 INR(PT)-1.0
[**2127-7-8**] 04:31PM BLOOD Glucose-169* UreaN-27* Creat-0.9 Na-138
K-3.3 Cl-103 HCO3-26 AnGap-12
[**2127-7-11**] 02:47AM BLOOD Glucose-146* UreaN-23* Creat-0.9 Na-134
K-4.5 Cl-99 HCO3-26 AnGap-14
[**2127-7-15**] 05:58AM BLOOD Glucose-104 UreaN-21* Creat-1.0 Na-135
K-4.7 Cl-102 HCO3-25 AnGap-13
[**2127-7-8**] 04:31PM BLOOD ALT-24 AST-59* AlkPhos-74 TotBili-0.7
[**2127-7-8**] 04:31PM BLOOD Albumin-3.6 Cholest-205*
[**2127-7-8**] 04:31PM BLOOD %HbA1c-7.7* [Hgb]-DONE [A1c]-DONE
[**2127-7-8**] 09:44PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.036*
[**2127-7-8**] 09:44PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
Brief Hospital Course:
AS mentioned in the HPI, pt had cardiac cath which revealed 3vd
and left main disease. An IABP was placed and heparin continued.
Pt was consented for bypass surgery and on [**7-9**] (HD#2) pt went to
the OR and underwent a coronary artery bypass graft x 4. Pt
tolerated the procedure well with CPB time of 92 minutes and XCT
of 79 minutes. Please see op note for full surgical details. Pt.
was A-paced at 88 and being titrated on Neo and propofol and was
transferred to CSRU in stable condition. Early POD #1, pt was
weaned fro sedation and extubated. She was awake, alert, MAE and
following commands. Later on the same day IABP was removed. By
POD #2 Neo was weaned off and both diuretics and b-blockade were
intitiated. Pt.'s chest tubes were removed on POD #2 and he was
transferred to step-down/telemetry floor. POD #3 pt's epicardial
pacing wired were removed. Post-operatively [**Last Name (un) **] was consulted
for elevated sugar and A1C (newly diagnosed DM). Over the
remaining hospital course pt slowly recovered. She was stable
thoughout without post-op complications. All lab work remained
stable. She slowly made it to level 5 and was discharged on POD
#8.
Medications on Admission:
1. Accupril 40mg qd
2. HCTZ 25mg qd
3. ASA 81mg 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. 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:*1*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Hypertension
Diabete Mellitus (newly diagnosed)
Right Carotid Disease
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with water and mild soap.
Do not bath or swim.
Do not apply lotions, creams, ointments, or powders.
Do not lift more than 10 pounds for 2 months
Do not drive for 1 month.
Take medications as prescribed.
If you notice drainage from incisions, redness, or fever please
contact office.
Followup Instructions:
Follow-up in [**Hospital 409**] Clinic ([**Hospital Ward Name 121**] 2) in 2 weeks
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks
Follow-up with Dr. [**Last Name (STitle) 3321**] in [**1-5**] weeks
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks
Completed by:[**2127-7-17**]
ICD9 Codes: 4240, 5180, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 962
} | Medical Text: Admission Date: [**2174-7-22**] Discharge Date: [**2174-7-29**]
Date of Birth: [**2132-3-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 yo with DM II and HTN who presents with 2 days of abdominal
pain. THe patient reports that on Wednesday after eating a
[**Last Name (un) **] he developed abdominal pain, nausea, vomiting and
diarrhea. He states that the abdominal pain is located
predominantly in the LLQ, was mostly crampy and intermittently
sharp in character, non-radiating. Over the next two days the
pain got progressivley worsening abdominal pain. He was only
able to take minimal po intake. Nothing appeared to make the
pain worse or better. He does not recall any aspiration however
he noted his breathing started to became more laboured on
Thursday. He reports mild pleuritic chest pain associated with
deep breaths, non positional. He also noted a fever for the
first time on Friday as well as worsening respiratory
secretions. Because of the worsening respiratory status and his
abdominal pain he decided to go to the [**Location (un) 620**] [**Hospital1 **] on Friday.
There he was found to have an elevated WBC, Lipase and Amylase
and a CT abdomen was consisted with pancreatitis. The patient
was transfered to [**Hospital1 18**] for further care after receiving 2L NS,
levofloxacin and Flagyl.
.
ED course: On arrival to the [**Hospital1 18**] ED the patient was
tachycardic to 136, febrile to 101, normotensive to 129/79 with
a RR of 19 and O2sat of 80RA. THe patient was started on O2 by
nasal canula which was uptitrated over the next hours ultimately
requiring a NRB. The patient was given a total of 5L of NS as
fluid resuscitation. A CTA was done as well as a CT abdomen and
pelvis which was negative for PE, but comfirmed a b/l lower lobe
pneumonia and acute pancreatitis without necrosis. He was given
Levofloxacin and Dilaudid 4mg for pain and Lorazepam 2mg iv for
anxiety.
.
On admission to the ICU the patient complaint of LLQ pain, [**4-7**],
non-radiating. He confirmed respiratory distress but rated that
stable over the last several hours. He denied any nausea
currently and did not have any further diarrhea. Pt denies any
recent travel, excessive ETOH or yellow discoloration of skin.
pt reports recent food excess during attendance of a symposium.
.
ROS: negative for rash, dysuria, changes in the color of the
urine or stool.
Past Medical History:
Polycythemia
Impaired fasting glucose-on metformin
Obesity
Depression
Pre-hypertension
Social History:
ETOH: occ social, no recent binge drinking
Tobacco: none
Occupation: chemistry researcher working with Iridium
Living situation: lives with wife and 2 children, age 16 and 4
[**11-30**]
Family History:
Father with valve replacement at age 72
Physical Exam:
VS T 100.4 BP 125/71 HR 130 RR 28 O2Sat 95 NRB
Gen: NAD, AAOx3, talking in full sentences
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breath sounds in b/l bases, positive egophony,
no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, obese, tender in LLQ and L flank,
no rebound or guarding
Skin: warm extremities, no rash
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: moving all extremities, 5/5 strength, following commands,
PERRLA, reflexes 2+ b/l
Pertinent Results:
EKG: SR, tachycardia, rate 120, NA, NI, no ST or TW changes
.
CTA/ CT abdomen: [**2174-7-22**]
1. No evidence of pulmonary embolism.
2. Bilateral lower lobe airspace consolidation, likely
pneumonia, with small bilateral pleural effusions.
3. Acute pancreatitis, without evidence of acute complication.
4. Fatty liver.
5. Bilateral renal hypodensities, likely small cysts
US liver - FINDINGS: The bedside ultrasound examination is
markedly limited by patient body habitus, and inability to
cooperate due to pain and respiratory distress. Limited images
of the liver demonstrate increased echogenicity, likely
representing fatty liver. Gallbladder was unable to be
identified.
IMPRESSION:
Markedly limited portable study. Nonvisualization of the
gallbladder. Echogenic liver.
[**2174-7-26**]
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST
Reason: Evaluate for pseudocyst formation, abscess, or interval
[**Doctor Last Name **]
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with pancreatitis and rising WBC, and SOB with
tachycardia.
REASON FOR THIS EXAMINATION:
Evaluate for pseudocyst formation, abscess, or interval change
in pancreatitis. R/o PE for persistent tachycardia and SOB.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 30-year-old man with pancreatitis and shortness of
breath.
Comparison is made to the CTA of the chest performed on [**7-22**], [**2173**].
TECHNIQUE: Axial MDCT images were obtained from thoracic inlet
to pubic symphysis. The CTA of the chest was performed based on
pulmonary embolism protocol; nontheless, there is suboptimal
contrast timing for assessing pulmonary embolism. The CT of the
abdomen and pelvis portion is performed with CTE protocol. Two
separate injections of contrast were administered, with the
chest covered with both injections.
CT OF CHEST WITH AND WITHOUT IV CONTRAST: The heart and great
vessels appear unremarkable. No pathologically enlarged hilar,
mediastinal or axillary nodes are noted. Severe degree of
atelectatic changes is noted within the anterior [**Doctor First Name **] segment
of right lower lobe and base of the right middle lobe. Moderate
degree of atelectasis is also noted at the left lung base. Given
the presence of air bronchograms particularly at the left lower
lobe, there is likely superimposed consolidation. Trace
bilateral pleural effusion is seen, which is more prominent on
the left side.
Although the pulmonary artery contrast bolus appears suboptimal
(probably due to patient habitus and slower injection rate due
to IV size) on both scans of the chest, there is no evidence of
pulmonary embolus within the limits of the study.
CT OF THE ABDOMEN WITH IV CONTRAST: The pre-pancreatic
fluid/phlegmon in the anterior pararenal space appears slightly
larger, especially inferiorly-- there is increased fluid along
the left lateroconal fascia. A small amount of fluid now tracks
down the left anterior pararenal space to the pelvis. A trace of
fluid is also seen within the right anterior pararenal space.
The pancreas enhances homogeneously and there is no site of
necrosis. No definite fluid collection is shown in the pancreas.
No loculated pseudoaneurysm is visualized. No evidence of SMV or
portal vein thrombosis.
There is hepatic steatosis. A 1.8 cm hypodense structure is
again noted within the dome of the liver, with fluid density
likely representing a cyst. Small amount of ascitic fluid has
developed adjacent to the liver and spleen. The gallbladder and
intra- and extra- hepatic bile ducts are unremarkable. This
spleen, adrenal glands and kidneys have normal appearance. No
pathologically enlarged retroperitoneal or mesenteric node is
noted. No free air is noted within the abdomen.
CT OF THE PELVIS WITH IV CONTRAST: The rectum has a normal
appearance. The sigmoid colon contains multiple diverticula,
with no evidence of diverticulitis. The urinary bladder and
distal ureters appear unremarkable. No pathologically enlarged
pelvic or inguinal nodes are visualized. No free air is noted
within the pelvis. As noted above, a small amount of fluid
tracks into the pelvis.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Overall similar appearance of peripancreatic inflammation;
however, anterior pararenal fluid and phlegmon is minimally
increased. No pancreatic necrosis, pseudocyst, or abscess is
visualized.
2. No evidence of pulmonary embolism.
3. Atelectatic with superimposed consolidation at both lung
bases.
4. Small amount of ascites is noted within the abdomen and
pelvis.
5. Small hypodense lesion of the dome of the liver, which are
too small to characterize, likely a cyst.
CHEST (PORTABLE AP) [**2174-7-26**] 6:16 AM
CHEST (PORTABLE AP)
Reason: ? interval change
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with DM2 presents with acute pancreatitis and ?
aspiration pneumonia, please assess for interval change
REASON FOR THIS EXAMINATION:
? interval change
CHEST
HISTORY: Aspiration pneumonia.
COMPARISON: [**2174-7-24**].
The patient has taken a poor inspiratory effort. Compared to the
prior study there is increased pulmonary vascular
re-distribution. There is blunting of both costophrenic angles
left greater than right consistent with pleural effusions. There
is persistent retrocardiac opacity.
IMPRESSION: Bilateral pleural effusions and persistent left
retrocardiac opacity.
Increased pulmonary vascular re-distribution consistent with
mild CHF.
[**2174-7-28**] - CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The
visualized portion of the lung bases demonstrates small left
pleural effusion which is unchanged. Linear atelectatic
changes/pulmonic infiltrate of the left lower lobe and right
lower lobe appear unchanged. The heart and great vessels appear
unremarkable. A small axial hiatal hernia is unchanged.
The pancreas and peripancreatic inflammation are unchanged. No
definite fluid collection is noted. No area of pancreatic
necrosis is identified. No definite gas is noted within the
peripancreatic tissue.
The liver has faaty infiltration. The gallbladder, intra- and
extrahepatic bile ducts, spleen, and adrenal glands appear
unremarkable. The small hypodense lesion of the dome of the
liver appears unchanged. The right kidney contains a small
hypodense lesion which is too small to characterize and appears
relatively unchanged compared to the prior study. The stomach,
duodenum, and small bowel loops are unremarkable. There is ileus
of the transverse colon adjacent to the site of inflammation.
The remainder of the colon appear unremarkable. Small amount of
ascites is noted within the abdomen. No free air is identified.
No pathologically enlarged retroperitoneal or mesenteric nodes
are noted.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon,
urinary bladder, and distal ureters are unremarkable. Small
amount of ascites noted within the pelvis. No pathologically
enlarged pelvic or inguinal nodes are noted. No free air is
noted within the pelvis.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Similar appearance of peripancreatic inflammation with no
necrosis, pseudocyst or abscess formation. The anterior
pararenal fluid and the phlegmon are stable.
2. Transverse colon ileus is unchanged compared to the prior
study.
3. Unchanged appearance of small bilateral pleural effusion with
atelectatic changes. Small ascites unchanged.
4. Stable appearance of a small hypodense lesion of the dome of
the liver.
5. Fatty liver.
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) Transmitral
and tissue Doppler imaging suggests normal diastolic function,
and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal (for BSA) biventricular cavity sizes with
preserved global
and regional biventricular systolic function.
[**2174-7-29**] 05:45AM BLOOD WBC-16.3* RBC-4.27* Hgb-13.2* Hct-37.9*
MCV-89 MCH-31.0 MCHC-35.0 RDW-14.1 Plt Ct-206
[**2174-7-28**] 06:00AM BLOOD WBC-17.1* RBC-4.48* Hgb-14.0 Hct-39.8*
MCV-89 MCH-31.4 MCHC-35.3* RDW-14.5 Plt Ct-237
[**2174-7-27**] 05:55AM BLOOD WBC-19.4* RBC-4.70 Hgb-14.3 Hct-42.3
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.6 Plt Ct-212
[**2174-7-22**] 03:00PM BLOOD WBC-19.6*# RBC-5.21 Hgb-16.3 Hct-45.5
MCV-87 MCH-31.3 MCHC-35.9* RDW-14.6 Plt Ct-188
[**2174-7-26**] 05:28AM BLOOD WBC-24.5* RBC-5.07 Hgb-15.7 Hct-45.2
MCV-89 MCH-31.0 MCHC-34.7 RDW-13.8 Plt Ct-235
[**2174-7-29**] 05:45AM BLOOD Neuts-74* Bands-0 Lymphs-9* Monos-10
Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-3* Promyel-1*
[**2174-7-22**] 03:00PM BLOOD Neuts-87.8* Lymphs-8.0* Monos-3.7 Eos-0.4
Baso-0.2
[**2174-7-26**] 05:28AM BLOOD Neuts-84* Bands-2 Lymphs-3* Monos-6 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-1* Promyel-2*
[**2174-7-29**] 05:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2174-7-26**] 05:28AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Burr-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2174-7-23**] 04:42AM BLOOD PT-13.8* PTT-23.5 INR(PT)-1.2*
[**2174-7-29**] 05:45AM BLOOD UreaN-5* Creat-0.7 Na-134 K-3.9 Cl-95*
HCO3-32 AnGap-11
[**2174-7-22**] 03:00PM BLOOD Glucose-284* UreaN-12 Creat-0.8 Na-137
K-4.0 Cl-105 HCO3-27 AnGap-9
[**2174-7-28**] 06:00AM BLOOD ALT-15 AST-19 AlkPhos-59 TotBili-0.5
[**2174-7-22**] 03:00PM BLOOD ALT-42* AST-24 CK(CPK)-54 AlkPhos-59
Amylase-141* TotBili-1.0
[**2174-7-27**] 05:55AM BLOOD Lipase-47
[**2174-7-24**] 04:16AM BLOOD Lipase-78*
[**2174-7-23**] 04:42AM BLOOD Lipase-140*
[**2174-7-22**] 03:00PM BLOOD Lipase-220*
[**2174-7-22**] 03:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-7-23**] 04:42AM BLOOD Albumin-2.7* Calcium-7.3* Phos-1.2*
Mg-1.8
[**2174-7-29**] 05:45AM BLOOD Mg-2.0
[**2174-7-28**] 06:00AM BLOOD Triglyc-318*
[**2174-7-22**] 03:00PM BLOOD Triglyc-832*
[**2174-7-27**] 05:55AM BLOOD Osmolal-287
[**2174-7-26**] 05:28AM BLOOD TSH-2.4
[**2174-7-24**] 01:51AM BLOOD Type-ART PEEP-8 FiO2-60 pO2-86 pCO2-43
pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2174-7-22**] 03:14PM BLOOD Comment-GREEN TOP
[**2174-7-22**] 03:14PM BLOOD Lactate-1.4
[**2174-7-26**] 08:02PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2174-7-26**] 08:02PM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-100 Ketone-150 Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2174-7-26**] 03:34AM URINE RBC->1000* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2174-7-26**] 03:34AM URINE AmorphX-MOD
[**2174-7-22**] 11:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]->1.035
[**2174-7-26**] 03:34AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-250 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2174-7-26**] 03:34AM URINE RBC->1000* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2174-7-26**] 3:34 am URINE Site: CATHETER
**FINAL REPORT [**2174-7-27**]**
URINE CULTURE (Final [**2174-7-27**]): NO GROWTH.
[**2174-7-28**] 6:27 am STOOL CONSISTENCY: LOOSE Source: Stool.
**FINAL REPORT [**2174-7-28**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2174-7-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2174-7-25**] 4:03 am BLOOD CULTURE Site: ARM
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2174-7-22**] 7:20 pm BLOOD CULTURE Site: ARM
**FINAL REPORT [**2174-7-28**]**
AEROBIC BOTTLE (Final [**2174-7-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2174-7-28**]): NO GROWTH.
Brief Hospital Course:
Acute pancreatitis - likely from hyperlipidemia/
hypertriglyceridemia. Started on niacin (pre Rx with EcASA).
Pancreatitis treated with NPO, IVF, analgesics and bowel rest.
Improved remarkably and tolerating low fat diet well at
discharge.
For a few days prior to discharge reported 'bloating' CT abdomen
showed transverse colon ileus, likely from the pancreatitis in
the neighbouring area. No colitis noted. GI consulted and hey
did not recommend any neostigmine, decompression etc. Avoiding
narcotics. The patient did not have much discomfort or pain and
was eating well on the day of discharge. Advised to follow up
with PCP.
Hyperlipidemia - Niacin as above with EcASA. Dietary consulted
to educate on a low fat diet. Patient advised weight loss as
well as low fat diet. To get LFT, lipids checked next week with
PCP.
Bilateral pneumonia - treated initially with IV zosyn and
improved with decreasing WBC. Was weaned off oxygen.
Transitioned to levofloxacin and flagyl. To complete a 14 days
course (total). CT chest neg for PE. Patient has symptoms of
OSA. Again advised to follow up with PCP for arranging [**Name Initial (PRE) **]
pulmonary sleep study.
Transverse colon ileus - as above
Abnormal CBC differential - heme consulted and they saw toxic
granulations of smear. Advised to get another CBC with diff with
PCP after active infection issues resolve.
Liver lesion on CT (incidental finding) - Advised to get a
follow up US/CT in 6 months. I shall defer to PCP for arranging
this.
Abnormal UA - repeat testing should be done with PCP [**Last Name (NamePattern4) **] [**11-30**]
weeks and if blood persists, patient will need more testing and
work-up. Will defer to PCP.
Depression - meds continued.
DM type 2 - metformin stopped and to be restarted at home (day
after discharge)
Medications on Admission:
Metformin 500mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
9. Niacin 250 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: take 30-60
mins before niacin.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
Bilateral pneumonia
Transverse colon ileus
Abnormal CBC differential
Liver lesion on CT (incidental finding)
Abnormal urinanalysis
Hyperlipidemia / hypertriglyceridemia
Hypertension
Depression
Discharge Condition:
stable
Discharge Instructions:
Return to the hospital if you notice worsening abdominal pain,
nausea, vomiting, fevers, chills or any other symptoms of
concern to you.
Keep your appointments.
Take medicines as indicated.
Complete the course of antibiotics.
Avoid alcohol use; avoid use around niacin dose. Take the
aspirin 30 - 60 mins prior to the niacin dose.
See your doctor next week to check a blood tests.
Strictly adhere to a low fat diet.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 4775**] on Friday [**2174-8-5**] at 1330 hours.
Please go there 15 mins prior to the appointment.
(Fax: 1-[**Telephone/Fax (1) 4776**])
Please follow up with your doctor for a repeat blood count (CBC,
renal function, liver tests as well as a lipid panel, UA)
ICD9 Codes: 486, 5119, 4280, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 963
} | Medical Text: Admission Date: [**2130-8-13**] Discharge Date: [**2130-8-22**]
Date of Birth: [**2064-4-19**] Sex: M
Service: MED
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
Alcohol withdrawal, urinary tract infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66M with a history of longstanding alcohol abuse and withdrawal
(three episodes in last month), relapsing remitting MS for 30
years, wheelchair-bound with a neurogenic bladder
(self-catheterizes at home) and history of multi-drug resistance
UTIs, anxiety; presents with tremulousness, hallucinations, and
tachycardia likely secondary to ETOH withdrawal. Patient also
complained of some bladder spasms consistent with his past
episodes of urinary tract infections. Upon admission, patient
was seen to have an episode of jerking, which was thought to be
possible seizure activity (although patient states that he was
awake the entire time and did not lose bowel or bladder
continence).
Past Medical History:
1. Progressive, relapsing, multiple sclerosis for the last 30
years. The patient is treated with monthly steroids, Solu-Medrol
and Avonex.
2. Prostate cancer status post brachytherapy.
3. Depression with multiple admissions in the past and history
of overdose of isopropyl alcohol. The patient's last admission
was in [**2130-1-5**]. Please see discharge summary for more
details.
4. Neurogenic bladder with recurrent urinary tract infections.
The patient self-catheterizes.
5. History of multiple UTIs. MRSA urine infection in [**Month (only) 404**]
[**2130**], also history of pansensitive Klebsiella recently in early
[**Month (only) 116**] that was untreated. History of Pseudomonas UTI sensitive to
Zosyn and enterococcal UTI sensitive to vancomycin in [**2129**]. Both
of the [**2129**] urine cultures were resistant to levofloxacin.
6. History of recent right elbow bursitis with MRSA.
7. Hypertension.
8. Chronic lower back pain with cervical and lumbar spinal
stenosis.
9. Osteoarthritis.
10. Impotence with penile prosthesis.
11. Chronic polyps.
12. History of peptic ulcer disease with upper GI bleed in the
setting of chronic NSAIDs use.
13. History of alcohol abuse with history of generalized tonic
clonic seizures in the setting of alcohol (see neuro note
written in [**2130-3-6**]).
14. Coagulase negative staphylococcal bacteremia in [**5-9**].
Social History:
Patient lives alone. Niece acts as attendant. EtOH abuse and
withdrawal (per HPI).
Family History:
Non-contributory.
Physical Exam:
VS. T98.6F P74 BP 120/68 RR18 O2Sat98% RA
HEENT: Normocephalic atraumatic. PERRL, EOMI, 4mm symmetric.
No evidence of tongue or oral mucosa trauma.
Neck: Supple, no JVD, no lymphadenopathy
Cardiovascular: normal S1, S2. Regular, rate, and rhythm. No
murmurs, rubs, or gallops.
Lungs: Clear to auscultation bilaterally. No wheezes, rales, or
rhonchi.
Abdomen: Bowel sounds present. Soft, nontender, nondistended,
no rebound or guarding.
GU: Light yellow purulent discharge, with caking under foreskin.
No foreskin edema, no erythema or duskiness of glans.
Extremities: Warm, no clubbing, cyanosis, or edema.
Pertinent Results:
[**2130-8-13**] 02:00PM GLUCOSE-144* UREA N-21* CREAT-1.1 SODIUM-141
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-18* ANION GAP-29*
[**2130-8-13**] 02:00PM ALT(SGPT)-17 AST(SGOT)-27 ALK PHOS-94 TOT
BILI-0.4
[**2130-8-13**] 02:00PM ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-1.0*#
MAGNESIUM-1.6
[**2130-8-13**] 02:00PM TSH-0.78
[**2130-8-13**] 02:00PM URINE GR HOLD-HOLD
[**2130-8-13**] 02:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2130-8-13**] 02:00PM WBC-11.4* RBC-4.77 HGB-11.6* HCT-36.8*
MCV-77* MCH-24.4* MCHC-31.6 RDW-18.6*
[**2130-8-13**] 02:00PM NEUTS-80* BANDS-0 LYMPHS-5* MONOS-15* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2130-8-13**] 02:00PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL TARGET-OCCASIONAL
[**2130-8-13**] 02:00PM PLT COUNT-386#
[**2130-8-13**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2130-8-13**] 02:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2130-8-13**] 02:00PM URINE RBC-0-2 WBC-[**11-25**]* BACTERIA-FEW
YEAST-NONE EPI-0-2 RENAL EPI-<1
[**2130-8-13**] 02:00PM URINE MUCOUS-FEW
[**2130-8-19**] 10:43AM BLOOD WBC-7.2 RBC-4.03* Hgb-9.8* Hct-31.5*
MCV-78* MCH-24.4* MCHC-31.2 RDW-18.8* Plt Ct-159
[**2130-8-18**] 06:44AM BLOOD WBC-6.8 RBC-4.12* Hgb-10.2* Hct-31.7*
MCV-77* MCH-24.7* MCHC-32.0 RDW-20.0* Plt Ct-144*
[**2130-8-17**] 10:25PM BLOOD WBC-7.5 RBC-4.19* Hgb-10.5* Hct-31.9*
MCV-76* MCH-25.1* MCHC-33.0 RDW-19.8* Plt Ct-154
[**2130-8-16**] 06:35AM BLOOD WBC-8.6 RBC-4.63 Hgb-11.2* Hct-35.9*
MCV-78* MCH-24.2* MCHC-31.2 RDW-18.5* Plt Ct-173#
[**2130-8-13**] 02:00PM BLOOD WBC-11.4* RBC-4.77 Hgb-11.6* Hct-36.8*
MCV-77* MCH-24.4* MCHC-31.6 RDW-18.6* Plt Ct-386#
[**2130-8-13**] 02:00PM BLOOD Neuts-80* Bands-0 Lymphs-5* Monos-15*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2130-8-13**] 02:00PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Target-OCCASIONAL
[**2130-8-19**] 10:43AM BLOOD Plt Ct-159
[**2130-8-18**] 06:44AM BLOOD Plt Ct-144*
[**2130-8-17**] 10:25PM BLOOD Plt Ct-154
[**2130-8-16**] 06:35AM BLOOD Plt Ct-173#
[**2130-8-13**] 02:00PM BLOOD Plt Ct-386#
[**2130-8-20**] 04:57AM BLOOD Glucose-87 UreaN-12 Creat-1.2 Na-142
K-3.9 Cl-107 HCO3-28 AnGap-11
[**2130-8-19**] 10:43AM BLOOD Glucose-95 UreaN-10 Creat-1.2 Na-143
K-4.3 Cl-108 HCO3-27 AnGap-12
[**2130-8-18**] 06:44AM BLOOD Glucose-92 UreaN-9 Creat-1.0 Na-142 K-4.5
Cl-108 HCO3-27 AnGap-12
[**2130-8-17**] 10:50AM BLOOD Glucose-87 UreaN-8 Creat-0.9 Na-140 K-3.6
Cl-104 HCO3-26 AnGap-14
[**2130-8-16**] 09:10AM BLOOD Glucose-97 UreaN-6 Creat-0.9 Na-141 K-3.5
Cl-103 HCO3-26 AnGap-16
[**2130-8-16**] 06:35AM BLOOD K-3.4
[**2130-8-15**] 05:15PM BLOOD K-3.6
[**2130-8-15**] 06:40AM BLOOD Glucose-88 UreaN-6 Creat-0.7 Na-138
K-5.7* Cl-101 HCO3-26 AnGap-17
[**2130-8-14**] 06:45PM BLOOD Glucose-84 UreaN-10 Creat-1.0 Na-142
K-3.8 Cl-104 HCO3-25 AnGap-17
[**2130-8-14**] 06:15AM BLOOD Glucose-123* UreaN-16 Creat-1.0 Na-140
K-3.2* Cl-100 HCO3-26 AnGap-17
[**2130-8-13**] 02:00PM BLOOD Glucose-144* UreaN-21* Creat-1.1 Na-141
K-4.7 Cl-99 HCO3-18* AnGap-29*
[**2130-8-14**] 06:15AM BLOOD ALT-15 AST-22 AlkPhos-84 TotBili-0.7
[**2130-8-13**] 02:00PM BLOOD ALT-17 AST-27 AlkPhos-94 TotBili-0.4
[**2130-8-20**] 04:57AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7
[**2130-8-19**] 10:43AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.7
[**2130-8-18**] 06:44AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.2
[**2130-8-17**] 10:25PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.5*
[**2130-8-17**] 06:50AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.3*
[**2130-8-16**] 09:10AM BLOOD Calcium-8.6 Phos-3.0# Mg-1.6
[**2130-8-16**] 06:35AM BLOOD Phos-3.0# Mg-1.5*
[**2130-8-15**] 06:40AM BLOOD Calcium-7.6* Phos-8.7*# Mg-1.4*
[**2130-8-14**] 06:45PM BLOOD Calcium-8.6 Phos-2.3* Mg-1.9
[**2130-8-14**] 06:15AM BLOOD Albumin-3.5 Calcium-9.1 Phos-1.2* Mg-1.5*
[**2130-8-13**] 02:00PM BLOOD Albumin-3.9 Calcium-9.0 Phos-1.0*# Mg-1.6
[**2130-8-13**] 02:00PM BLOOD TSH-0.78
[**2130-8-18**] 06:44AM BLOOD Ethanol-NEG Bnzodzp-POS Barbitr-NEG
Tricycl-NEG
[**2130-8-13**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2130-8-20**] 04:57AM BLOOD EDTA Ho-HOLD
[**2130-8-17**] 09:30PM BLOOD Type-ART pO2-71* pCO2-40 pH-7.46*
calHCO3-29 Base XS-4
[**2130-8-17**] 09:30PM BLOOD Lactate-0.9
Brief Hospital Course:
ALCOHOL WITHDRAWAL:
Mr. [**Known lastname 98193**] is a 66 y.o. man with a history significant for
longstanding etoh abuse with past episodes of DTs; relapsing MS
x30 years, wheelchair-bound with a neurogenic bladder and
history of multi-drug resistant urinary tract infections. More
recently, Mr. [**Known lastname 98193**] has presented to the [**Hospital1 **] ED three times in
the past month, twice admitted for treatment of withdrawal via
CIWA scale benzodiazepene administration. The most recent
admission was on [**7-24**], and at that time he was evaluated by
psychiatry who felt that his symptoms were also consistent with
considerable anxiety. He was discharged home on [**2130-7-31**] with
antibiotics for E. coli urinary tract infection.
On [**8-13**] he presented again to the ED complaining of
tremulousness, racing heartbeat, flushing, and diaphoresis. By
report in the ED he also had some auditory hallucinations. He
was given klonopin 1mg and valium 1mg. Subsequent tox screen was
negative for etoh, positive for benzos only. CIWA scale was 30+.
On admission to the floor he had two episodes of ??????shaking??????
described by the sitter. He remained conscious and oriented
during these episodes, which the sitter described as general
shaking of his arms and legs. These episodes were presumed to be
seizures and treated with a total of 40mg of IV valium, 10 mg of
po valium with a CIWA scale persistently >25. His exam has been
otherwise benign on the floor, VSS without fevers, tachycardia
~100s. Patient transferred to [**Hospital Unit Name 153**] for continued monitoring.
Patient did well and was returned to the floor and required no
further benzodiazepines per CIWA score <10 by [**2130-8-14**]. He
remained sleepy for several days due to the long half-life and
large quantity of benzodiazepines administered to treat alcohol
withdrawal.
As patient's mental status improved, he strongly endorsed a
desire for rehabilitation and interest in quitting drinking. He
was very interested in seeking institutional rehabilitation.
URINARY TRACT INFECTION:
On [**2130-8-13**], patient complained of "bladder spasms" which he
stated was consistent with previous episodes of urinary tract
infections. Urinalysis at the time revealed
bacteria and white cells in urine. Patient was treated with
ceftriaxone and then switched to cephalexin PO in anticipation
of discharge to continue treatment as outpatient.
EPISODE OF UNRESPONSIVENESS:
On hospital day 5, patient was found by nursing staff to be
unresponsive, with "pinpoint pupils". Patient was given Narcan
with good effect, and patient was roused for several minutes,
but urine toxicology revealed no evidence of narcotics (only
positive for benzodiazepines). Patient was transferred to the
ICU for frequent neuro checks overnight, although patient had no
loss of bowel continence and no evidence of mucous membrane or
tongue trauma. Patient was deemed stable on hospital day 6 and
returned to the floor. EEG revealed changes consistent with
mild toxic-metabolic encephalopathy. Neuro consult did not feel
that the episode was consistent with a seizure, as again,
patient stated that he remembered the episode and was conscious
for the entire duration of the event (but could not respond).
Neuro will follow patient in ten days following discharge.
PARAPHIMOSIS:
On hospital day 7, patient was noted to have significant edema
of the foreskin, consistent with paraphimosis without ischemia.
The foreskin was easily reduced and edema was treated with
compression and ice with good effect. However, on hospital day
9, patient was found to have purulent urethral discharge
(negative urinalysis) and caking on the glans underneath the
foreskin. Discharge was sent for gram stain and culture
(including yeast and fungus), and will be followed up after
discharge. Patient was restarted on Keflex for 7 days along
with a miconazole topical powder for empiric treatment of the
discharge.
DISPOSITION:
Patient was very interested in institutional alcoholic
rehabilitation throughout his hospital stay and felt very
strongly that he could not continue in this pattern of recurrent
abuse and withdrawal. Patient was deemed to be stable for
discharge on hospital day 9.
Medications on Admission:
Baclofen 5mg TID
Protonix 40mg QD
Nifedipine SR 60mg
Thiamine 100mg QD
Folic Acid 1mg QD
MVI
Colace 100mg [**Hospital1 **]
Olanzapine 5mg QD
Naltrexone 50mg QD
Keflex X 14 days
Lexapro 10mg QD
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QD (once a day).
4. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
8. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QD (once a day).
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
Hollywell - [**Location (un) 5110**]
Discharge Diagnosis:
Alcohol Withdrawal
Alcohol Detoxification
Urinary Tract Infection
Multiple Sclerosis
Discharge Condition:
Good
Discharge Instructions:
Please continue taking your medications as directed.
Please follow the recommendations of your rehabilitation
institution for staying sober.
Call your doctor or go to the emergency room if you have any
problems with fever, chills, urethral discharge, urinary tract
infection, loss of consciousness, or seizures.
Followup Instructions:
Please make an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 98194**]) ten days after discharge.
Please make an appointment to see Dr [**Last Name (STitle) 665**] within two weeks of
discharge ([**Telephone/Fax (1) 1247**]).
Urethral swab gram stain and culture for possible bacterial,
yeast, or fungal infection.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
ICD9 Codes: 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 964
} | Medical Text: Admission Date: [**2173-3-9**] Discharge Date: [**2173-3-18**]
Date of Birth: [**2114-6-13**] Sex: M
Service: MEDICINE
Allergies:
Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
ICD placement
cardiac catheterization
History of Present Illness:
58yo M s/p AVR ([**2165**]) on Coumadin, DM2, hyperlipidemia,
presented to OSH s/p cardiac arrest at home. At OSH, found to be
in CHB and is s/p temporary pacing wire placement. According to
wife, patient has had progressive DOE over the past few weeks.
He has also had increased LE edema recently. No known complaints
of chest pain. He returned home after coaching a baseball game
today and collapsed. He was found to be pulseless. A neighbor
who is an [**Name (NI) 9168**] was called, and began administering CPR. EMS
arrived ~15min later and found pt to be in VF. One shock was
administered and he returned to sinus rhythm. He was nasally
intubated in the field. En route, he was found to be
progressively bradycardic, and his rhythm was c/w CHB. He was
taken to [**Hospital 487**] Hospital and a temporary pacing wire was
placed through the R IJ (apparently done under unsterile
conditions). He was changed to oral intubation. He received IV
metoprolol, NTG gtt, atropine, and Versed. Bedside TTE showed EF
30-35% with anterio AK, 2+ TR, 2+ MR. CK was 337 with negative
troponin T. He was transferred to [**Hospital1 18**] for further management.
.
On presentation to the [**Hospital1 18**] ED, he was intubated and sedated,
with the temporary pacer appropriately capturing. He was
minimally responsive, on sedation, on admission. he was given
gentamicin, metronidazole, and cefazolin for his unsterile pacer
wire. Head CT was done to r/o bleed [**1-14**] fall and
anticoagulation. He was admitted to the CCU for further
monitoring.
Past Medical History:
1. AVR: [**2165**], mechanical valve, on Coumadin, done at [**Hospital1 18**]
2. DM2: last HgA1C 7.5, on metformin
3. Hyperlipidemia
4. Hypertension: on atenolol
Social History:
teacher and coach, remote tobacco use, social EtOH use, no drug
use
Family History:
1 sister with HTN and DM2, other sister died at 49 of
"infection", no sudden cardiac death in the family
Physical Exam:
vitals- T 99.1, HR 60 (paced), BP 154/89, RR 14, 99% on AC
700x14, PEEP of 5 and FiO2 of 100%
General- sedated, intubated, minimally responsive to sternal rub
HEENT- + dried blood in left nostril
Neck- R IJ cordis, difficult to assess JVP, carotid pulses 2+
b/l, no carotid bruit
Lungs- diffusely rhonchorous
Heart- RRR, mechanical S2, 2/6 SEM at LUSB
Abd- obese, hypoactive bowel sounds, slightly distended but
soft, no palpable organomegaly
Ext- 2+ pitting edema to knees b/l, DP/PT pulses 2+ b/l
Pertinent Results:
[**2173-3-9**] 11:00PM WBC-17.4*# RBC-4.48* HGB-13.3* HCT-39.0*
MCV-87 MCH-29.7 MCHC-34.2 RDW-13.9
[**2173-3-9**] 11:00PM NEUTS-90.1* BANDS-0 LYMPHS-4.5* MONOS-4.4
EOS-0.2 BASOS-0.9
[**2173-3-9**] 11:00PM PLT SMR-NORMAL PLT COUNT-360
[**2173-3-9**] 11:00PM PT-27.5* PTT-27.8 INR(PT)-2.8*
[**2173-3-9**] 11:00PM CK-MB-6
[**2173-3-9**] 11:00PM cTropnT-0.17*
[**2173-3-9**] 11:00PM CK(CPK)-293*
[**2173-3-9**] 11:00PM GLUCOSE-226* UREA N-17 CREAT-0.9 SODIUM-143
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-18* ANION GAP-19
.
OSH ECG: AV dissociation, RBBB, left axis deviation
ECG s/p temp pacer: paced at 60bpm, native p waves not
conducting, LBBB appearance to QRS
.
CXR: The tip of the right jugular temporary pacer is not clearly
identified. There is mild congestive heart failure with
cardiomegaly. Note is made of opacity in the left lower lobe
indicating aspiration. There is no evidence of pneumothorax.
.
CT head: no ICH, ethmoid sinusitis, no fracture
.
TTE ([**1-17**]): The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated. The ascending aorta is moderately dilated. A
bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is normal for this prosthesis. The aortic
prosthesis leaflets are not well seen. Mild to moderate valvular
([**12-14**]+) aortic regurgitation is seen. No paravalvular leak is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a physiologic pericardial
effusion.
.
Cath ([**2165**]): 1. Normal coronary arteries.
2. Normal ventricular function.
3. Severe aortic stenosis.
Brief Hospital Course:
.
# Cardiac arrest: On admission, it was reported that he had a VF
arrest by EMS, and converted with 1 shock in the field. EP,
however, felt his cardiac arrest was more likely secondary to
polymorphic VT as a result of his prolonged QT and complete
heart block. He had no CAD on cath so it was likely not
ischemic in etiology. Despite the suspicion for polymorphic VT,
EP felt primary VF could not be ruled out, so an ICD was placed
on [**3-12**].
.
# Complete heart block: He had a temporary pacing wire placed
at the outside hospital, and was V-paced at 60bpm. His native
heart rate was less than 30. The etiology of his complete heart
block was thought to be secondary to degenerative conduction
disease, as he seems to have had progressive conduction
abnormalities per past EKGs. Viral myocarditis was also
considered a possibility as his family gave a history of
flu-like symptoms a few days before his cardiac arrest. His TSH
was normal and his cath was clean. A dual chamber ICD was
placed on [**3-12**]. He was maintained on a beta blocker for rate
control as his rate was in the 90s after his dual chamber ICD
was placed. He developed a hematoma from his ICD site,
involving his left shoulder and inner arm. His heparin drip was
discontinued, and his hematoma resolved into an ecchymosis that
has been stable. He has an appointment in device clinic for
interrogation of his ICD the day after discharge. He will
follow up this and his other cardiac issues with his
cardiologist, Dr. [**Last Name (STitle) 120**].
.
# AVR: He is on Coumadin as an inpatient for his mechanical
aortic valve. He received vitamin K 5mg po on [**3-9**] to reverse
his INR in preparation for his ICD placement. IV heparin was
restarted s/p ICD placement. His mechanical aortic valve was
found to be functioning well on TTE. He was restarted on
Coumadin, and his INR was therapeutic for a few days before
admission. He was discharged on Coumadin 5mg po daily with the
plan to get her INR checked 4 days after discharge. He will
resume management of his anticoagulation with his PCP.
.
# Anoxic encephalopathy: According to the family, there was an
approximate 5-minute lapse between his collapse at home and
initiation of CPR. He was initially minimally responsive when
intubated, even with lightening of sedation. His CT head showed
no intracranial hemorrhage. Fortunately, he began to recover
some cortical function within 48 hours of his cardiac arrest,
and began to follow commands. Upon extubation and
discontinuation of his sedation, he was disoriented and became
agitated, responding well to olanzapine. He was maintained on
olanzapine for a couple of days, and his agitation resolved. He
also seemed to have some motor difficulty with impaired hand-eye
coordination, as well as some short-term memory deficit. His
cognitive and motor deficits are likely due to anoxic
encephalopathy. He has experienced rapid improvement while in
the hospital. He was evaluated by Occupational Therapy and
Physical Therapy, and felt to be safe to be discharged home. He
will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Behavioral
Neurology in 6 weeks for reassessment.
.
# Respiratory status: He was initially intubated for airway
protection during cardiac arrest. He had mild pulmonary edema
on chest x-ray, for which he received IV Lasix for diuresis. He
was weaned from the ventilator over the next couple of days, and
was extubated on [**3-13**]. He had a possible infiltrate on chest
x-ray and a leukocytosis, so he received a 7-day course of
levofloxacin and vancomycin for empiric treatment of VAP. He
was weaned off oxygen and had good sats with ambulation upon
discharge.
.
# CAD: No CAD on cath. He was continued on aspirin and his
outpatient dose of statin.
.
# CHF: He likely has diastolic dysfunction with his aortic
stenosis and hypertension. His TTE showed an EF of 60%. His
CHF symptoms were possibly due to progressive bradycardia and
complete heart block. He was volume overloaded on admission.
He diuresed well on IV Lasix, and was euvolemic for several days
before discharge. He was maintained on a BB and ACE-inhibitor.
.
# DM2: His blood sugars were initially well-controlled on
sliding scale insulin, but he had poor po intake. He was
restarted on his metformin after he resumed his diet.
.
# Leukocytosis: His initial leukocytosis was felt to be
secondary to a possible ventilator-associated pneumonia. He was
initially treated with ceftriaxone and vancomycin. Ceftriaxone
was discontinued for a possible drug rash. He was switched to
levofloxacin and maintained on vancomycin, and completed a 7-day
course of antibiotics. His leukocytosis resolved initially, but
then recurred, while still on antibiotics. He had no localizing
symptoms, a clear chest x-ray, and negative UA and culture. As
the origin for the elevated WBC count could not be identified,
his antibiotics were discontinued at the end of his 7-day course
for VAP. He was discharged to PCP follow up, with a check of
his WBC count in 4 days after discharge.
.
# FEN: After extubation, he had a video swallow evaluation that
showed aspiration of a regular diet. He was found to tolerate
ground solids and thin liquids with careful swallowing and
strict aspiration precautions. He was discharged home on this
diet. Speech and Swallow recommended repeat video swallow
evaluation in 2 weeks to reassess his aspiration risk, and
hopefully clear him for regular diet.
.
# Code status: FULL CODE.
.
Medications on Admission:
Atenolol 100mg qd
Coumadin
Lipitor 20mg qd
Metformin 1000mg [**Hospital1 **]
Tricor 48mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Outpatient Lab Work
Please check PT/INR, WBC count, and creatinine on Monday,
[**2173-3-22**] and speak to Dr. [**Last Name (STitle) **] regarding the results.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cardiac arrest
2. Complete heart block
3. Ventilator-associated pneumonia
Discharge Condition:
good
Discharge Instructions:
Please take all of your medications as prescribed.
Please have your INR, WBC count, and creatinine checked on
Monday.
Please follow instructions regarding aspiration precautions when
eating.
If you experience chest pain, palpitations, firing of your
defibrillator, fever >101, or other concerning symptoms, please
call your PCP or go directly to the ED.
Followup Instructions:
1) Cardiology: Please call ([**Telephone/Fax (1) 9169**] to schedule a
follow-up appointment with Dr. [**Last Name (STitle) 120**] within one month of
discharge. Although you already have an appointment for [**2173-12-28**]
at 2:30pm, you should see Dr. [**Last Name (STitle) 120**] sooner regarding this
hospitalization.
2) ICD: Please follow up at Device clinic as scheduled on
Friday [**2173-3-19**] on [**Hospital Ward Name 23**] 7, ([**Telephone/Fax (1) 9170**], [**2173-3-19**] 1:30pm.
3) PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2173-3-31**] 10:30, ([**Telephone/Fax (1) 9171**]. Please
call Dr. [**Last Name (STitle) **] on Monday regarding your lab results.
4) Neurology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 9172**], [**2173-5-3**]
10:00, [**Hospital Ward Name 860**] Building Rm 253.
Completed by:[**2173-3-18**]
ICD9 Codes: 4275, 486, 5990, 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 965
} | Medical Text: Admission Date: [**2129-10-21**] Discharge Date: [**2129-11-4**]
Service: CSU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 18719**] is an 89-year-old,
Russian-speaking woman with known CAD (coronary artery
disease) who presented to an outside hospital emergency room
on [**10-19**] with congestive heart failure and
hypertension. She had elevated cardiac enzymes and troponins
at that, along with ST elevations by EKG ruled in for non-
STEMI and was transferred to [**Hospital1 188**] for cardiac catheterization. Catheterization done at
[**Hospital1 **] MC showed three-vessel coronary artery disease and
cardiothoracic surgery was consulted for possible CABG
(coronary artery bypass graft). As stated, the
catheterization showed three-vessel disease, including 95
percent left main, 95 percent RCA (right coronary artery), 80
percent circumflex and 99 percent distal LAD (left anterior
descending) with an EF (ejection fraction) of 40 percent.
The patient's past medical history is significant for CAD,
CHF (congestive heart failure), hypertension, osteoarthritis,
BPV (benign positional vertigo) breast CA (carcinoma) status
post lumpectomy.
The patient has no known drug allergies.
Her meds at home include nifedipine XL 90 q.day, Lipitor 40
q.day, Paxil 20 q.day, atenolol 25 q.day, Celebrex 200 q.day,
meclizine 12.5 q.day, Imdur 120 in the a.m., 60 in the p.m.,
and Buspirone 10 b.i.d.
SOCIAL HISTORY: She lives alone in [**Location (un) 583**], is very active
doing volunteer work, uses a cane, does not drive, no tobacco
or alcohol use.
REVIEW OF SYMPTOMS: GENERAL: Sleeps poorly. SKIN: No
lesions. HEENT: Positive headaches, with glasses, history
of cataracts, status post removal. RESPIRATORY: No asthma,
COPD (chronic obstructive pulmonary disease), positive CHF.
CARDIOVASCULAR: Positive claudication, edema, palpitations,
angina and CHF. GI: Nausea with angina. No GERD
(gastroesophageal reflux disease) or melena. GU: No dysuria
or hematuria. MUSCULOSKELETAL: Positive arthritis.
ENDOCRINE: No diabetes or thyroid disease. HEME: No anemia
NEUROLOGICALLY: No seizures, CVA's (cerebrovascular), TIAs
(transient ischemic attacks), syncope.
PHYSICAL EXAM: Height 5 feet, weight of 154 pounds.
VITAL SIGNS: Heart rate 57 sinus rhythm, blood pressure
147/100, respiratory rate 22, O2 sat 99 percent on room air.
GENERAL: Lying flat in bed, in no acute distress.
Neurologically alert and oriented x3. Moves all extremities.
Strength equal bilaterally.
RESPIRATORY: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm, S1, S2, no murmurs,
rubs or gallops. GI: Soft, nontender, nondistended, normal
active bowel sounds. No hepatosplenomegaly.
EXTREMITIES: Warm, well-perfused with no to edema, no
varicosities. Right groin cath site with dry sterile
dressing. PULSES: Radial 2+ bilaterally. Dorsalis pedis 1+
bilaterally. Posterior tibial 1+ bilaterally.
LABORATORY DATA: White count 5.8, hematocrit 31, platelets
317, PT 13.3, PTT 41.9, INR 1.1, sodium 139, potassium 3.5,
chloride 105, CO2 27, BUN 13, creatinine 0.4, glucose 161,
ALT 18, AST 26, alkaline phosphatase 95, amylase 17, total
bilirubin 0.3.
The patient was seen by cardiac surgery and accepted for
coronary artery bypass grafting. She was followed by the
medicine service and on [**9-24**] was brought to the
operating room. Please see the OR report for full details
and summary. She had a CABG x4 with the LIMA (left internal
mammary artery) to the diagonal, saphenous vein graft to the
LAD (left anterior descending), saphenous vein graft to OM
(obtuse marginal) and saphenous vein graft to the PDA
(posterior descending artery). Her bypass time was 71 minutes
with a crossclamp time of 59 minutes. She tolerated the
operation well was transferred from the operating to the
cardiothoracic intensive care unit. At the time of transfer,
the patient was A paced at 88 beats per minute with a mean
arterial pressure of 71 and a CVP of 11. She had Neo-
Synephrine 0.5 mics/ kilogram/minute and propofol at 25
mics/kilogram/minute. The patient did well in the immediate
postoperative period. Her anesthesia was reversed. She was
weaned from the ventilator and successfully extubated on
postoperative day 1. The patient continued to do well and it
was felt that she was ready to transfer to the floor, but,
given her age, it was decided that she would be transferred
instead to a medical intensive care unit for close monitoring
of her hemodynamic status.
On postoperative day 2, the patient was transferred back to
the cardiac surgery recovery unit, due to rapid atrial
fibrillation with a ventricular response rate of 120 to 140.
At that point, she was begun on an amiodarone drip and
received IV beta blockade, following which the patient
converted back to normal sinus rhythm.
On postoperative day 3, the patient developed a fever of 102.
Blood, as well as urine cultures, were sent and the patient
was started on oral levofloxacin. Chest x-ray was also done
at that time that showed no infiltrates and the patient
stayed in the ICU at that point for close pulmonary
monitoring. The following day, all cultures returned negative
and patient's antibiotics were discontinued. She remained in
the ICU for vigorous pulmonary toilet, given her relative
hypoxia. By postoperative day 5, the patient's chest x-ray
had shown improving lung fields and diaphragmatic excursion,
and, at that time, she was transferred to the floor for
continuing postoperative care and cardiac rehabilitation.
Over the next several days, the patient showed slow progress
in her activity level. She had no further of bouts of atrial
fibrillation and, on postoperative day 9, it was decided that
the following day the patient would be stable and ready to be
discharged to rehabilitation.
At the time of this dictation, the patient's physical exam is
as follows. Temperature 97.9, heart rate 59 sinus rhythm,
blood pressure 139/64, respiratory rate 18, O2 sat 96 percent
on 3 liters. Weight preoperatively 69 kg, at discharge 66.6
kg.
LABORATORY DATA: Sodium 144, potassium 3.9, chloride 105,
CO2 31, BUN 32, creatinine 0.9, glucose 109, PT 14, PTT 31,
INR 1.3, white count 10, hematocrit 36.4, platelets 366.
PHYSICAL EXAM: NEURO: Alert and oriented x3. Moves all
extremities. Follows commands. Nonfocal exam. PULMONARY:
Breath sounds somewhat diminished in the bases bilaterally.
CARDIOVASCULAR: Regular rate and rhythm, S1,S2. No murmur.
Sternum is stable. Incision with staples and dry sterile
dressing, no erythema or drainage. ABDOMEN: Is soft,
nontender, nondistended with normal active bowel sounds.
EXTREMITIES: Warm and well-perfused with no edema, bilateral
leg incision from the saphenous vein harvest sites are clean
and dry with Steri-Strips.
MEDICATIONS AT THE TIME OF DISCHARGE: Include amiodarone 400
mg b.i.d., x7 days, then 400 mg q.day x7 days, then 200 mg
q.day, aspirin 81 mg q.day, Colace 100 mg b.i.d., Lasix 40 mg
b.i.d. x10 days then 40 mg q.day, metoprolol 50 mg b.i.d.,
potassium chloride 40 mEq b.i.d., x10 days and then q.day,
Zantac 150 mg b.i.d., Paxil 20 mg q.day, Buspirone 10 mg
b.i.d.
The patient's condition at time of discharge is good. She is
to be discharged to rehabilitation at the [**Hospital3 1761**] Center. She is to follow-up with Dr. [**Last Name (STitle) 28413**]
in 2 to 3 weeks, follow-up with Dr. [**Last Name (STitle) **] in 4 weeks and
follow-up with Dr.[**Last Name (STitle) 3357**] after being discharged from
rehabilitation.
DISCHARGED DIAGNOSES:
1. CAD (coronary artery disease) status post coronary artery
bypass grafting times 4, with LIMA (left internal mammary
artery) to the diagonal, saphenous vein graft to the LAD
(left anterior descending), saphenous vein graft to OM
(obtuse marginal) and saphenous vein graft to PDA
(posterior descending artery).
2. Hypertension.
3. Osteoarthritis.
4.
Benign positional vertigo.
5. Breast cancer status post lumpectomy.
6. Congestive heart failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2129-11-3**] 17:16:13
T: [**2129-11-4**] 03:41:42
Job#: [**Job Number 93087**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 966
} | Medical Text: Admission Date: [**2121-4-4**] Discharge Date: [**2121-4-21**]
Date of Birth: [**2067-9-28**] Sex: M
Service: NEUROLOGY
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
R putaminal hemorrhage
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Tracheostomy
History of Present Illness:
Mr. [**Known lastname 59501**] is a 53 year old male with history of
nephrolithiasis
and ? pyelonephritis who presents with large R putaminal
hemorrhage. The patient complained of feeling warm earlier
today,
and mild low back pain consistent with his history of kidney
for percocet for the pain. The patient had entertained guests in
his home this evening and was feeling well. He developed low
back
pain in the evening, took a percocet for the pain, went to his
prayer room, and he was then found by his wife on the floor,
vomiting and unable to get up. He was able to speak to her and
asked that he be put in bed. He never complained of having any
headache. His wife called EMS. The patient was intubated for
airway protection en route to the OSH by EMS.
At the [**Hospital3 20284**] Center the pt's head CT revealed a large
right putaminal hemorrhage extending posteriorly and inferiorly
in the right posterior midbrain with blood in the third
ventricle. The patient was given phosphenytoin 1500mg, Ativan
2mg, Pancuronium, zofran and transferred to [**Hospital1 18**] for further
care.
At present the pt is unable to provide a ROS. His wife reports
recent low back pain and perhaps fevers, but he did not take his
temperature at home. Otherwise he has been feeling well recently
without N/V/D. No recent wt loss. He does not have a history of
headaches.
Past Medical History:
Nephrolithiasis- as above
No known h/o hypertension
Social History:
Married, has two children, he works as a laotian translator
at [**Hospital3 1810**] and also formerly at [**Hospital1 18**], he has also
worked as a court transcriptionist. He smoked for many years,
quit 2 years ago. He does not drink any alcohol. Wife reports
that he has never used any illicit or IV drugs.
Family History:
pt's wife is unfamiliar with his FH, does not recall any h/o
stroke, ICH or bleeding diasthesis.
Physical Exam:
PHYSICAL EXAM:
Vitals: T 99, HR 60 (regular), BP 110/62, R 16, 97% on CMV
Gen- critically ill, male on gurney, spontaneous extensor
posturing of left hemibody, biting on ET tube.
HEENT- NCAT, anicteric, OP clear, no oral trauma
Neck- no carotid bruits bilat
CV- RRR, 2/6 SEM heard best at apex
PULM- CTA B
Extrem- no CCE
SKIN- multiple tattoos, R thigh, chest, patchy blanching
erythematous reticular rash on anterior chest.
NEUROLOGIC EXAM:
MS- no response to voice, not following commands. He does not
localize sternal rub.
CN- right pupil dilated to 9mm unreactive to light, left pupil
3mm-->2mm, absent doll's eye reflex, intact corneal reflex
bilaterally, brisk gag reflex.
Motor- occasional fasciculation of left anterior quads. appears
to withdraw with the RUE purposefully to noxious stimulation.
Extensor posturing of LUE and LLE with noxious stimulation.
Withdraws right leg to noxious.
Sensation- intact to noxious throughout. Pt flexes R arm to
noxious on left leg, but is unable to localize to sternal rub.
Reflexes- 2+ on R [**Hospital1 **], tri, brachioradialis and patellar, ankle.
On the left there are 3+ reflexes in the [**Hospital1 **], tri,
brachioradialis. The left patellar reflex spreads to the left
leg
inducing clonus- 4+.
left toe is upgoing. right toe is downgoing.
Pertinent Results:
Labs:
Trop-T: <0.01
BUN 11, Cr 0.6
CK: 132 MB: 3
[**Doctor First Name **]: 131
MCV 98
WBC 12.4, hgb 14.7, hct 45, Platelets 134
PT: 14.1 PTT: 31.3 INR: 1.2
At OSH: UA postive for RBC's, 3+ protein. PTT 28, INR 1.2
EKG (from OSH)- NSR with left atrial enlargement, RBBB.
<br>
Imaging:
Head CT [**2121-4-4**]:
FINDINGS: There is acute intraparenchymal hemorrhage in the
right basal
ganglia measuring roughly 4 x 3 cm, which extends inferiorly
into the right pons and mid brain. There is a moderate amount of
associated intraventricular blood seen within the lateral
ventricles, greater on the right than on the left. Small amount
of blood is seen within the third ventricle. There is slight
effacement of the suprasellar cistern, suggesting early uncal
herniation. There is minimal, 2 mm leftward subfalcine
herniation. Edema surrounding the area of hemorrhage causes mild
mass effect on adjacent sulci.
There is no extra-axial hemorrhage. There is no evidence of
infarction. There is no fracture.
IMPRESSION: Acute intraparenchymal hemorrhage in the right basal
ganglia,
with extension into the right pons and mid brain. Moderate
intraventricular extension into the lateral ventricles and third
ventricle. Early uncal herniation.
NOTE ADDED AT ATTENDING REVIEW: Although I agree with most of
the above
report, there is no evidence of uncal herniation associated with
this globus pallidus hematoma.
<br>
Head CT [**2121-4-5**]:
NON-CONTRAST HEAD CT: Since prior examination, there has been no
significant change in the hemorrhage within the right globus
pallidus extending into the midbrain. Although there is less
blood in the frontal [**Doctor Last Name 534**] of the lateral ventricles, the extent
of hemorrhage within the posterior [**Doctor Last Name 534**] of the lateral
ventricles, third ventricle, and fourth ventricle is not
appreciably changed. No new hemorrhage is identified. This is
associated with mildly increased hydrocephalus. A 5 mm vague
hyperdensity is seen within the inferior brainstem (series 2,
image 4), which was retrospectively present on prior exam and
may represent tiny focus of blood. Copious secretions are seen
within the nasopharynx. The visualized paranasal sinuses and
mastoid air cells remain normally aerated.
IMPRESSION:
1. Stable hemorrhage within the right globus pallidus extending
into the mid brain.
2. Minimally increased hydrocephalus.
<br>
CXR [**2121-4-4**]:
FINDINGS: Single portable supine chest radiograph is reviewed
without
comparison. Endotracheal tube is in place, just below the
thoracic inlet, 5.4 cm above the carina. Tube could be advanced
for more optimal positioning. Cardiomediastinal contours are
within normal limits allowing for portable supine technique. The
lungs are clear. There is no pleural effusion or pneumothorax.
IMPRESSION: Endotracheal tube tip seen just below the thoracic
inlet, 5.4 cm above the carina.
<br>
CXR [**2121-4-6**]:
SINGLE FRONTAL VIEW OF THE CHEST: The nasogastric tube has been
removed and Dobbhoff tube placed with tip terminating in similar
location within the proximal stomach. An endotracheal tube tip
terminates 3 cm from the carina. The cardiomediastinal
silhouette is stable and unremarkable. The lungs are clear.
There is no effusion.
IMPRESSION: Standard Dobbhoff tube tip placement terminating
over proximal
stomach.
<br>
KUB [**2121-4-9**]:
IMPRESSION: No evidence of ileus or obstruction
<br>
CT TORSO [**2121-4-14**]:
FINDINGS: The lung volumes are low. The patient is status post
tracheostomy. The airways are patent to the subsubsegmental
level. The heart and great vessels are unremarkable. There are
no pulmonary nodules. There is no mediastinal or axillary
adenopathy. There are bilateral moderate, pleural effusions with
adjacent atelectasis.
CT ABDOMEN WITH IV CONTRAST: There is massive ascites. The right
lobe of the liver is borderline small. The caudate lobe is
somewhat prominent, as is the left lobe, consistent with
cirrhosis. There is a hypoattenuating liver mass measuring 4.7 x
3.1 cm, in segment IV A of the liver, which encroaches on the
IVC and the portal vein. There are other smaller liver lesions,
which are too small to characterize. The gallbladder, pancreas,
spleen, adrenals are normal. There is a cyst in the upper pole
of the left kidney. The bowel shows generalized edema likely due
to the patient's cirrhosis. The SMA, SMV, celiac artery, and [**Female First Name (un) 899**]
are all opacified. There is no evidence of bowel obstruction or
ischemia. There is no mesenteric or retroperitoneal adenopathy.
CT PELVIS WITH IV CONTRAST: The free fluid tracks down into the
pelvis. There is again bowel wall edema. The bladder is
collapsed with a Foley in it. There is no pelvic or inguinal
adenopathy.
MUSCULOSKELETAL: No suspicious osseous lytic bony lesions.
IMPRESSION:
1. No evidence of bowel obstruction. Patent SMA, SMV, celiac,
and [**Female First Name (un) 899**],
without evidence of bowel ischemia, although there is bowel wall
edema, likely due to underlying cirrhosis.
2. New liver mass in segment IV A, which in the setting of the
prominent
left lobe, caudate lobe, and borderline small right lobe with
massive ascites is concerning for a primary liver lesion, such
as hepatocellular carcinoma, or less likely a
cholangiocarcinoma.
3. Low lung volumes with bilateral pleural effusions and
adjacent atelectasis.
<br>
PERITONEAL FLUID [**2121-4-15**]:
NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, neutrophils,
histiocytes and lymphocytes.
<br>
ABDOMINAL ULTRASOUND [**2121-4-16**]:
This study was done portably in the intensive care unit. Only
portions of the liver could be imaged,and the left lobe and
known left lobe mass could not be visualized due to the high
position deep to the sternum. The right lobe was well imaged and
showed no masses. The gallbladder was not overly distended, but
the wall was thickened and edematous undoubtedly related to the
underlying liver disease. There was marked ascites surrounding
the liver, which had a somewhat coarse nodular texture.
Color flow and pulse Doppler assessment was performed. The
hepatic veins were well identified and fully patent with normal
waveforms. Hepatic artery was also easily identified and patent
as well as the inferior vena cava. However, no detectable flow
could be identified within the right portal vein either by color
flow or pulse Doppler. The imaged portion of the portal vein
included only the right portal vein, but not the left or main
portal, which were obscured or impossible to access.
CONCLUSION: Cirrhotic liver with marked ascites. Limited views
do not allow for visualization of the known left lobe mass.
Doppler assessment shows patency of the hepatic artery and
hepatic veins, but no flow could be detected in the right portal
vein, even at low flow settings. This either indicates occlusion
or extremely low velocity flow, less than 10 cm/sec. It is not
possible to make distinction between these two possibilities on
this portable study.
Brief Hospital Course:
Mr. [**Known lastname 59501**] was admitted to the Neuro ICU for close monitoring
and blood pressure management after diagnosis of his putamenal
hemorrhage in the ED. His blood pressure was controlled with a
nicardipine gtt initially. He was kept euglycemic with insulin
sliding scale, and Tylenol was administered for any temperature
greater than 100.4F. It was presumed that the etiology was
long-standing hypertension, with an acute hypertensive episode
that likely led to the bleed perhaps precipitated by the pain
due to his renal stones.
To improve his intracranial pressure, he was hyperventilated and
treated with mannitol; his head elevation was maintained greater
than 30 degrees. Neurosurgery was consulted for possible EVD
placement, but as there was no significant hydrocephalus and his
4th ventricle appeared patent, no drain was placed. Mr. [**Known lastname 59501**]
was monitored with a repeat CT scan after 6 hours, which showed
no change in the hemorrhage and only minimal increase in the
hydrocephalus.
Throughout his hospitalization, his neurologic status showed no
improvement. He continued to have no pupillary reaction, minimal
oculocephalic response, and decerebrate posturing. Despite his
poor prognosis, his family wished to continue aggressive care.
This was addressed with them in multiple family meetings, nearly
daily for the first week of his hospitalization.
Because no significant neurologic recovery was expected, a
tracheostomy was performed at the end of his first week. A
percutaneous enterogastrostomy (PEG) was planned as well, but
before this could be performed, he developed significant
ascites. To investigate the cause of this ascites, a CT torso
was performed (lungs were evaluated for possible pneumonia,
which was not seen). The CT of the abdomen and pelvis revealed
massive ascites with one large liver mass and several smaller
liver nodules, consistent with a primary hepatocellular
carcinoma. At this point, the even poorer prognosis was
discussed with the family, who still wanted to proceed with
life-prolonging measures.
The day after this CT, he underwent paracentesis for diagnostic
and therapeutic measures. No malignant cells were seen in the
ascitic fluid and there was no evidence of peritonitis.
Following the paracentesis, he became hypotensive with systolic
pressures in the 70s; he was given albumin to restore
intravascular volume. Albumin needed to be given repeatedly over
the next four days until his death to maintain blood pressure.
At the same time, he began to develop a coagulopathy due to his
failing liver. He received several units of fresh frozen plasma
(FFP) and several doses of Vitamin K over the final 4 days of
his life.
Similarly, he began to develop renal failure due to hepatorenal
syndrome. His creatinine climbed as high as 2.3. He was
supported with the albumin in an effort to maintain
intravascular volume.
After several days of these heroic life-prolonging measures, a
meeting was held with his providers (the Neurology and the ICU
teams, including nursing), his family, social workers, and the
Legal/Ethics Consult team. It was explained to his family that
despite all the best medical care, there was no chance of his
surviving. The Legal/Ethics consult determined that the hospital
and the providers were under no obligation to provide treatment
that could not produce the goal of survival, which his family
identified as the goal of therapy (see separate note from
Legal/Ethics consult on OMR). Therefore, it was agreed that care
would be withdrawn. Mr. [**Known lastname 59501**] died within 48 hours, on
[**2121-4-21**].
Medications on Admission:
Meds:
Percocet PRN- filled Rx a few days ago
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Hypertensive intracerebral hemorrhage, right putamen, with
intraventricular and midbrain extension.
2. Hepatocellular carcinoma
3. Coagulopathy due to failed production of clotting factors
4. Hepatorenal syndrome
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2121-5-2**]
ICD9 Codes: 431, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 967
} | Medical Text: Admission Date: [**2186-9-21**] Discharge Date: [**2186-9-22**]
Date of Birth: [**2122-12-11**] Sex: M
Service: MEDICINE
Allergies:
Nitroglycerin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pain on exertion
Major Surgical or Invasive Procedure:
Cardiac catheterization, access through left brachial artery
History of Present Illness:
63yo male with early onset CAD s/p CABG [**2171**] (LIMA-->LAD, SVG
--> OM2 and LPLB), HTN, Hyperlipidemia who presented for
elective heart catheterization with a history of stable angina.
Pt reports chest pain with exertion for last several months,
worse recently while mowing his lawn. Baseline two flights of
stairs and develops CP. He denies any rest pain, PND or
orthopnea.
.
Pt underwent heart catheterization complicated by multiple
bilateral femoral sticks and required L brachial artery for
access. Catheter was unable to advance to LIMA or SVG grafts to
deliver stents due to severe vessel tortuosity. No stents were
deployed. Pt became hypotensive after nitroglycerin gtt was
started in the cath lab, required brief period on dopamine.
.
Pt arrived to CCU c/o [**2-10**] substernal chest pain consistent with
prior anginal pain. SBP 190's on arrival. Low dose nitroglycerin
gtt was started and patient became hypotensive to SBP 40's and
tachycardic to 150's. IVF's, dopamine, atropine was given with
return of SBP's 120's. Pt had HR 150's, SVT, adenosine given
without effect. HR gradually returned to 100's. Metoprolol 5mg
IV given and brought HR to 80's, 90's. The patient was monitored
in the CCU overnight.
Past Medical History:
CABG- [**2171**] (LIMA-->LAD, SVG --> OM2 and LPLB)
HTN
Hyperlipidemia
Social History:
worked as manager of computer company, widowed, wife died of
ovarian CA two years ago, now in a long term committed
relationship with female sig other. Drinks 1-2 drinks once per
week. 15py smoking history, quit 15 years ago. No Illicits.
Remains independent of all ADL's prior to admission.
Family History:
Mother d.57 DM, CAD
Maternal Aunts and uncles with multiple heart dx related
premature deaths
Brother CABG @ 51
Physical Exam:
Vitals: BP 190/100, HR 70, R 16, Sat 94% 4LNC
Ht: 6'5", Wt. 275lbs
Gen: Pleasant, lying flat in bed, c/o [**2-10**] SS CP.
HEENT: NCAT, PERRL, MMM
CV: Nl S1 and S2, no MRG, JVP 7cm
PULM: CTA B
ABD: obese, soft, NT, no masses
Extrem: no CCE, 2+ DP, PT pulses
Groin- No hematoma, No Bruits Bilaterally, Good pedal pulses as
above.
Pertinent Results:
[**2186-9-21**] 08:30PM WBC-11.7* RBC-4.69 HGB-15.8 HCT-44.2 MCV-94
MCH-33.8* MCHC-35.8* RDW-13.6
[**2186-9-21**] 08:30PM PLT COUNT-184
[**2186-9-21**] 08:30PM MAGNESIUM-2.2
[**2186-9-21**] 08:30PM CK-MB-NotDone cTropnT-0.06*
[**2186-9-21**] 08:30PM CK(CPK)-73
[**2186-9-21**] 08:30PM CK(CPK)-73
[**2186-9-22**] 04:04AM BLOOD WBC-10.8 RBC-3.87* Hgb-13.0* Hct-37.4*
MCV-97 MCH-33.6* MCHC-34.8 RDW-13.4 Plt Ct-154
[**2186-9-22**] 04:04AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-139
K-3.7 Cl-107 HCO3-25 AnGap-11
.
Cardiac Catheterization [**2186-9-21**]
**Preliminary Report**
1) Coronary angiography revealed a right dominant system status
post
coronary artery bypass grafting with three vessel disease. The
LMCA had
no stenosis. The LAD gave off a single, large patent D1 branch
prior to
a 100% proximal segment stenosis. The LCx showed a 100%
proximal
segment stenosis. The RCA showed a 100% midsegment stenosis
with right
to left collaterals to the distal LCx system. Graft angiography
revealed a stump occlusion of a graft which is likely the
SVG-LPL
branch. No other graft could be engaged or seen, suggesting
likely
occlusion of the SVG-OM2 graft. The LIMA-LAD graft revealed a
patent
LIMA graft with an 80% stenosis of the LAD immediately distal to
the
anastomosis site.
2) Hemodynamic studies demonstrated normal right atrial filling
pressures of
3) Unsuccessful attempts at PCI of the LAD distal to the [**Female First Name (un) 899**]
insertion
was performed. The attempts were unsuccesful due to the poor
guide
support from the brachial access and the excessive tortuousity
of the
[**Female First Name (un) 899**]. Further attempts were aborted due to the concern over
radiation
and dye exposure.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Unsuccessful attempts at PCI of the LAD after the insertion
of the
[**Female First Name (un) 899**].
.
ECHOCARDIOGRAM [**2186-9-22**]- **PRELIMINARY [**Location (un) **] ONLY**
The left atrium is dilated. The right atrium is moderately
dilated. The left ventricular cavity is mildly dilated. Overall
left ventricular systolic function is severely depressed.
Resting regional wall motion abnormalities include mid
anteroseptal and inferior akinesis with hypokinesis elsewhere.
Right ventricular chamber size is normal. Right ventricular
systolic function is borderline normal. The aortic root is
moderately dilated. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. 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. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
63yo M with early onset CAD s/p CABG [**2171**] (LIMA-->LAD, SVG -->
OM2 and LPLB), HTN, Hyperlipidemia. s/p heart cath complicated
by difficult vascular access, tortuous coronary vascular supply
impeding stent delivery, hypotension following administration of
nitrates.
.
1) Cardiac:
Ischemia- The patient presented with stable angina. No stents
were able to be delivered due to severely tortuous coronary
vessels. Cardiac enzymes were cycled and negative post
intervention. The patient was started on Metoprolol 12.5mg [**Hospital1 **]
for rate control given rate related LBBB. He was started on
Aspirin 325mg daily, Clopidogrel 75mg daily, Lisinopril 5mg
daily. Nitrates in any form were avoided due to episodes of
hypotension. A strict contraindication to nitrates should be
noted in all future patient records.
.
Rhythm- The patient remained in normal sinuse rhythm, he was
noted to have a rate related LBBB as noted on prior exercise
tolerance tests. Low dose Metoprolol 12.5mg was started while
inpatient.
.
Pump- Preliminary read revealed moderate dilation,
multi-regional hypokinesis/akinesis, severely depressed LVEF
~20%. The patient is well-compensated at present, no pulmonary
edema, peripheral edema, orthonea/PND. However is at high risk
of congestive failure. Given failure of percutaneous
revascularization, strict compliance and optimization of medical
therapy should continue as an outpatient. He was started on
Lisinopril and Metoprolol while inpatient.
.
2) Pulmonary- The patient had multiple apneic episodes overnight
with bradycardia to 50's. Pt had sleep study 1yr ago but could
not tolerate mask. Pt was informed of risks to his cardiac fx
and is amenable for re-evaluation for trial of [**Hospital1 **]/BiPAP.
He should be scheduled for repeat Sleep/Pulmonary evaluation as
an outpatient at the discretion of his primary care provider.
[**Name10 (NameIs) **] will likely improve his severely impaired cardiac
parameters and he should be strongly encouraged to re-trial the
device.
.
3) Seizure disorder-
No seizure activity was observed while during this
hospitalization. We continued his home dosage of phenytoin
during his inpatient stay.
.
4) Renal- Creatinine clearance was stable following dye-load
associated with catheterization and peri-procedure hypotension.
He had excellent urine output without the aide of urinary
catheter prior to discharge.
.
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Code: Full
Contact: (fiance) [**Name (NI) **] [**Name (NI) 68776**] [**Telephone/Fax (1) 68777**]
Medications on Admission:
Atorvastatin 80mg PO daily
Phenytoin 300mg PO qam
Phenytoin 200mg PO qpm
Multivitamin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QAM (once a day (in the morning)).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO QPM (once a day (in the evening)).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Elective cardiac catheterization
Coronary artery disease
Secondary:
Hypertension
Hyperlipidemia
Discharge Condition:
Stable. The patient is currently chest pain free.
Discharge Instructions:
You came to the hospital for an elective cardiac catheterization
which was complicated by difficulty accessing your arteries. In
addition, your blood pressure dropped while on a nitroglycerin
drip. No stents were placed.
You are taking some new medications: Plavix, aspirin,
lisinopril, and carvedilol.
You will continue to take a multivitamin, atorvastatin, and
dilantin as you were before.
Please keep all outpatient appointments.
If you begin to experience shortness of breath, chest pain,
dizziness or lightheadedness or any other concerning symptom
please call 911 or your physician right away.
Followup Instructions:
Please schedule the following appointments:
1. [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 2394**] Appointment should be in [**6-12**]
days
2. [**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 48826**] Call to schedule appointment
ICD9 Codes: 4111, 4019, 2724, 412, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 968
} | Medical Text: Admission Date: [**2183-11-6**] Discharge Date: [**2183-11-11**]
Date of Birth: [**2109-7-26**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old man
who presented with chest pressure and an irregular heart rate
for 14 days prior to admission that awoke him from a sound
sleep. He was noted to have elevated cardiac enzymes and
underwent an exercise tolerance test which was positive as
well as a positive nuclear imaging study. The imaging study
noted reversible inferior defect. The patient underwent a
cardiac catheterization on [**2183-10-23**] that revealed three
vessel coronary artery disease with significant left main
stenosis, left main had a 90% stenosis at its origin. There
was a 40% stenosis in the diagonal branch. There was a
dominant RCA that had a 90% stenosis in its proximal segment
and a 70% stenosis in its middle segment. Initial surgery
was delayed secondary to a diffuse rash the patient had noted
for approximately three weeks over his entire body. The
patient was seen by dermatology and was placed on Clobetasol
cream. Biopsies were consistent with psoriasis. The rash
improved with treatment. The patient was taken to the
operating room for CABG on [**2183-11-6**].
PAST MEDICAL HISTORY: Significant for bilateral carotid
disease. He had a carotid ultrasound on [**2183-10-24**] which
showed 40-60% right carotid stenosis and no left carotid
stenosis. He also has history of claudication and the right
lower extremity had a monophasic doppler tracing at all
levels with an ABI of .79. On the left the patient had an
ABI of .73. Arterial duplex consistent with significant
bilateral superficial femoral artery and tibial disease.
PAST SURGICAL HISTORY: Significant for fusion of his left
foot in [**2121**] secondary to polio and revision in [**2149**]. The
patient had a bilateral carotid endarterectomy and subclavian
bypass in [**2179**], status post laparoscopic cholecystectomy in
[**2181**].
MEDICATIONS: Prior to surgery include Isosorbide,
Atorvastatin, Lisinopril, Lasix, Atenolol, Nitroglycerin,
Co-enzyme Q, Diflucan, several herbal medications.
ALLERGIES: Penicillin. There was noted to be an anaphylactic
reaction.
FAMILY HISTORY: Significant for his father deceased at age
53 secondary to an MI.
HOSPITAL COURSE: The patient underwent cardiac surgery on
[**2183-11-6**]. The patient underwent CABG times three with a LIMA
to LAD, saphenous vein graft to OM, saphenous vein graft to
PDA. The patient tolerated the procedure well and was
transferred to the CSRU, not on any drips. The patient had
an endovein harvest on the left thigh. Postoperatively the
patient did well and was extubated successfully the evening
of his surgery. On postoperative day #1 he was started on
Lasix, Lopressor and Aspirin and was transferred to the
floor. The patient received Vancomycin as perioperative
antibiotic. The patient was noted on interoperative TEE to
have an EF of 55-60%. The patient was seen by physical
therapy and was noted to benefit from short term stay at
rehab. The patient continued to do well but on the evening
of postoperative day #1 was noted to be in atrial
fibrillation with rapid ventricular response. This was
controlled by IV Lopressor and patient was started on
Amiodarone. The patient did convert to normal sinus rhythm,
however, on the evening of postoperative day #2 he did have
another second episode of atrial fibrillation that was
converted to normal sinus rhythm after 10 mg of IV Lopressor.
The patient, on postoperative day #3, had third episode of
atrial fibrillation that converted spontaneously to normal
sinus rhythm, however, at this point after three episodes of
atrial fibrillation, it was decided to start the patient on
Coumadin with a goal INR of 2.0. On discharge patient is
doing well, he is afebrile, all vital signs stable, he is in
normal sinus rhythm with heart rate in the high 50's to low
60's, his blood pressure is 140/80 and his O2 sats are 96% on
room air. On exam patient is in no apparent distress, his
heart is regular, his sternal wound is clean, dry and intact,
his sternum is stable, his lungs are clear to auscultation
bilaterally, his abdomen is soft, nontender, non distended,
his extremities are warm and his incisions are clean, dry and
intact.
DISCHARGE MEDICATIONS: Include Amiodarone 400 mg po tid
through [**11-14**], then Amiodarone 400 mg po bid from [**11-14**] through
[**11-21**], then Amiodarone 400 mg po q d for one month, then
Amiodarone 200 mg po q d. He is started on Coumadin 2 mg po
q h.s. He will need to have his INR checked and his Coumadin
dose adjusted for a goal INR of 2.0. He is on Lopressor 25
mg po bid, Lasix 20 mg po q d, Aspirin 81 mg po q d,
Atorvastatin; he will be restarted on his preoperative dosage
which is unavailable at this time.
CONDITION ON DISCHARGE: The patient is being transferred to
rehab in good condition.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 25727**]
MEDQUIST36
D: [**2183-11-11**] 09:30
T: [**2183-11-11**] 09:14
JOB#: [**Job Number **]
ICD9 Codes: 4111, 9971, 4241, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 969
} | Medical Text: Admission Date: [**2126-3-1**] Discharge Date: [**2126-3-3**]
Date of Birth: [**2079-4-2**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Shellfish Derived
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Mr. [**Known lastname **] is a 46 year old man w/hx of CAD s/p inferolateral MI
[**3-25**] and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to proximal LCx into OM1 who presented to the
ED with chest pain. The patient reports [**4-24**] chest tightness
which started while he was walking to work this morning. He
works at [**Hospital1 **] and continued to walk from [**Location (un) 19903**]to the ED.
By the time he reached the ED, the chest tightness was [**7-25**], a
band sensation across his chest. No radiation to arm, jaw, or
back. He denies diaphoresis or nausea but does report
associated SOB. He did not take NTG. He reports rare instances
of chest pain since his MI [**3-25**] but did have an episode [**4-23**] for
which he was evaluated in the ED and it was determined to be
non-cardiac. He had an exercise tolerance test at that time
which was normal. He does not take NTG at home and does not
have any. Total time of chest pain prior to arrival to ED was
20 minutes.
.
In the ED, initial vitals were T99.2, BP175/86, HR99 RR18 O2 sat
99%. ECG showed ST elevations in II, III, AVF. He received
aspirin 325mg x 1, Plavix 600mg x 1, Morphine 4mg IV x 1. NTG
gtt, heparin gtt and integrillin gtt were started. A code STEMI
was called and he was taken to the cath lab with door-to-balloon
time of 40 minutes.
.
In the cath lab, his prior [**Month/Year (2) **] in OM1 was occluded with an acute
thrombus. An export wire extracted the clot and the patient
became chest pain free. A balloon angioplasty was performed and
IVUS showed the stent to be intact. He was given Prasugrel 60mg
X 1 in the cath lab.
.
On arrival to the CCU, the patient feels well and denies chest
pain, pressure or tightness, shortness of breath, nausea,
vomiting, headache, abdominal pain, calf pain. Of note, he
admits to missing several [**Month/Year (2) 4319**] of Plavix in the last few
months. His aspirin dose was recently decreased from 325mg to
81mg daily.
.
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.
He denies exertional buttock or calf pain. He states that he
has had a rash in his groin area recently. All of the other
review of systems were negative.
.
Cardiac review of systems on admission is notable for absence of
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
CAD s/p inferolateral MI [**3-25**] with 2 overlapping Cypher stents
to occluded LCx into OM1
prior RCA stenting [**6-19**]
Angioedema after starting Lisinopril [**3-25**], resolved
Pneumonectomy s/p MVA
Social History:
Social history is significant for the absence of current tobacco
use, quit in [**2121**], 1ppd prior. There is no history of alcohol
abuse. Lives with his wife and 2 children. Works in purchasing
at [**Hospital1 18**].
Family History:
There is family history of premature coronary artery disease in
his father at age 41.
Physical Exam:
VS: T=97.8 BP=142/59 HR=84 RR=16 O2 sat= 99% 2L NC
GENERAL: Alert and oriented x 3, NAD. Mood, affect appropriate.
HEENT: NCAT. Slight reddened appearance to face and neck area.
Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with flat JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. No
appreciable rash.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Right femoral cath site is clean, dry and intact with a small
soft hematoma palpable. No femoral bruits.
Pertinent Results:
ADMISSION LABS:
[**2126-3-1**] 07:59AM BLOOD WBC-8.5 RBC-4.72 Hgb-13.5* Hct-40.6
MCV-86 MCH-28.5 MCHC-33.2 RDW-14.4 Plt Ct-310
[**2126-3-1**] 07:59AM BLOOD PT-11.6 PTT-22.0 INR(PT)-1.0
[**2126-3-1**] 07:59AM BLOOD Glucose-143* UreaN-12 Creat-1.1 Na-141
K-4.0 Cl-106 HCO3-21* AnGap-18
[**2126-3-1**] 07:59AM BLOOD CK(CPK)-212
[**2126-3-1**] 07:59AM BLOOD cTropnT-<0.01
----------------
DISCHARGE LABS:
----------------
STUDIES:
.
EKGs:
pre-cath: NSR at 7bpm. nl axis, nl intervals. 3mm ST elevations
in II, III, AVF, V4-V6 with ST depression sin AVL, V1, V2, V3.
Hyperdynamic T waves in V3, V4, V5.
post-cath: resolving ST elevations which are not quite as
pronounced.
.
Cardiac Cath [**3-1**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated two vessel disease. The LMCA had no
angiographically apparent disease. The LAD had an origin 30%
stenosis. The LCx had a 30-40% origin stenosis and moderate
thrombus within the mid stented segment. The RCA had widely
patent stents and a 30-40% mid stenosis.
2. Limited resting hemodynamics revealed normaly systemic
arterial blood pressure with SBP 103mmHg and DBP 69mmHg.
3. Successful thrombectomy and PTCA of the OM stent thrombus
with a 3.5mm balloon.
4. Successful closure of the right femoral arteriotomy site with
a 6F Perclose device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Thrombus within mid LCx stent successfully treated with
thrombectomy and PTCA.
.
TTE [**3-1**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with infero-lateral
hypokinesis. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. There is no valvular aortic
stenosis. The increased transaortic velocity is likely related
to high cardiac output. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2124-4-14**], no change.
Brief Hospital Course:
Mr. [**Known lastname **] is a 46yo M with CAD s/p prior inferolateral MI and [**Known lastname **]
to OM1 [**3-25**] who presented to the ED with chest pain, was found
to have a STEMI and taken to the cath lab were OM1 stent showed
acute thrombus.
.
# STEMI: Patient presented with inferior STEMI, and
door-to-balloon time was 40min. In the cath lab, patient was
found to have thrombosis in the OM1 stent. An export wire
extracted the clot and the patient became chest pain free. A
balloon angioplasty was performed and IVUS showed the stent to
be intact. This acute thrombosis in the stent may be due to
missed Plavix dosing; however it is also possible that he has
failured plavix. As a result, plavix was switched to Prasugrel.
Pt was given 60mg loading dose in cath lab, and was kept on 10mg
PO qday. Patient was also continued on aspirin 325mg daily,
Metoprolol 25mg PO BID, Toprol XL 25mg daily and lipitor 80mg
daily. Patient came back from the cath lab on nitro gtt which
was promptly turned off, and he was chest pain free during the
rest of his hospital stay.
.
# PUMP: No evidence of heart failure; prior echo [**3-25**] showed
posterolateral hypokinesis with EF 50%. Repeat TTE was done on
[**3-2**], which showed EF 50-55% and mild regional left ventricular
systolic dysfunction with infero-lateral hypokinesis, not
significantly different compared to the one from approximately 2
years ago.
.
# RHYTHM: Patient was in sinus rhythm. Toprol 25mg daily was
continued.
.
# FEN: Patient received cardiac, heart-healthy diet, and he
tolerated POs well.
# PPX: Patient was on SC Heparin for DVT prophylaxis.
.
# CODE: FULL, confirmed on admission.
.
# COMM: wife [**Name (NI) 19904**]: [**0-0-**] (cell); [**Telephone/Fax (1) 19905**] (home)
Medications on Admission:
Lipitor 80mg PO qday
Plavix 75mg PO qday
Toprol XL 25mg PO qday
ASA 325mg PO qday
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Myocardial infarction
- Coronary artery disease
Discharge Condition:
Afebrile, hemodynamically stable, chest pain free
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname **]. You
were admitted to [**Hospital1 69**] after
having chest pain. You underwent a cardiac catheterization and
a blood clot was removed from the stents supplying blood to your
heart. Your Plavix was changed to Prasugrel 10mg by mouth once
a day to help prevent a clot from reforming. It is very
important that you take this medication, along with your
aspirin, every day. Please do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
As Prasugrel was not available at your home pharmacy in [**Location (un) 10059**]
today, a prescription was sent to CVS at [**Location (un) 19906**] in
[**Location (un) 86**] that you can pick up when you are discharged.
Your other medications have not been changed. Please continue
to take lipitor, toprol XL, and full dose aspirin (325mg daily).
Followup Instructions:
You need to see Dr. [**Last Name (STitle) **], your cardiologist, within the next
two weeks. We will try to make an appointment for you this
weekend, and please call the cardiology office at ([**Telephone/Fax (1) 2037**]
on Monday to confirm your appointment. If for any reason there
is no appointment made for you over the weekend, please make one
with the receptionist at that time.
Please see you primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] V., within
1-2 weeks after discharge. Please call [**Telephone/Fax (1) 4775**] to make an
appointment.
ICD9 Codes: 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 970
} | Medical Text: Admission Date: [**2182-2-13**] Discharge Date: [**2182-3-1**]
Service: CARDIOTHORACIC
Allergies:
Percocet / Percodan
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
80 year old white male with abdominal pain, nausea, vomitting,
and diaphoresis over past few days.
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, , SVG->PDA, SVG->OM) [**2182-2-14**]
History of Present Illness:
This 80 year old white male without significant past medical
history, complained of abdominal pain which was relieved with
antacids 5 days prior to admission. The morning before
admission, he had nausea, vomitting, and diaphoresis, and
presented to [**Hospital3 1443**] Hospital. He was transferred to
[**Hospital1 18**] because he had Q waves on his EKG, and had + troponin.
Past Medical History:
Smokes 1 pack per day
HTN
Social History:
Lives alone.
cigs: 1 ppd
ETOH: none
Family History:
unremarkable
Physical Exam:
Elderly [**Male First Name (un) 4746**] in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender, without masses or hepatosplenomegaly
Ext: without C/C/E, pulses 2+=bilat.
Neuro: nonfocal
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2182-2-26**] 06:35AM 10.2 4.35* 13.1* 37.7* 87 30.1 34.7 14.4
493*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2182-2-26**] 06:35AM 493*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2182-2-26**] 06:35AM 96 21* 1.4* 138 4.5 104 26 13
THYROID T4
[**2182-2-25**] 08:05PM 7.0
INR 2.2
Brief Hospital Course:
The pt. was admitted on [**2181-2-12**] and had a cardiac cath which
revealed: 90% LMCA stenosis, 90% mid LAD stenosis, 90% LCX
lesion with 90% OM2 stenosis, and dominant RCA with 99% serial
lesions. An IABP was placed, and Dr. [**Last Name (STitle) 70**] was consulted.
On [**2182-2-14**] the pt. underwent CABGx3 with LIMA->LAD, SVG->PDA and
OM. Cross-clamp time was 43 minutes with a total bypass time of
74 minutes. He tolderated the procedure well, and was
transferred to the CSRU in stable condition on Neo and Propofol.
He was extubated on POD#1 and his IABP was d/c'd. He went into
Afib on POD#2 and was started on Amio and anticoagulated with
coumadin. He continued having multiple episodes of Afib. He
developed disorientation which waxed and waned and complained of
dizziness. He continued to progress and was transferred to the
floor on POD#5. HIs epicardial pacing wires were d/c'd on
POD#3. He was seen by neurology and they felt his dizziness was
due to benign posteral vertigo, but they were concerned about
his disorientation. He had a low B12 and was started on
replacement, and had an MRI which revealed bilateral embolic
CVAs in the parietal occipital region, with sl. hemorrhagic
conversion. They wanted to continue coumadin, but keep his INR
between 2-2.5 and monitor very carefully. He will be followed
by Dr. [**Last Name (STitle) **] from Neurology following discharge from rehab. He
was discharged to rehab in stable condition on POD# 12.
Medications on Admission:
Aspirin PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 7 days.
5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: To start after 7 day [**Hospital1 **] cycle complete.
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-3**]
Puffs Inhalation Q6H (every 6 hours).
7. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
DAILY (Daily) for 7 doses: Then give 1000mg IM once per week for
1 month, then 1000mg IM once a month.
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO tonight: Dose for
an INR goal of [**3-6**].5. Check INR qd for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Coronary artery disease. S/P coronary artery bypass graft x 3.
Hypertension.
Benign postural vertigo.
CVA
Discharge Condition:
Good
Discharge Instructions:
Shower daily and wash your incisions with soap and water. Rinse
well. Do not apply any creams, lotions, ointments, or powders.
No swimming or tub bathing.
Do not lift anything heavier than 10 pounds.
You may not drive for 4 weeks.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 70**] in 6 weeks.
Make an appointment with Dr. [**Last Name (STitle) 5686**] in [**2-3**] weeks.
Make an appointment with Dr. [**Last Name (STitle) **] from neurology following
discharge from rehab. [**Telephone/Fax (1) **]
Completed by:[**2182-2-26**]
ICD9 Codes: 9971, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 971
} | Medical Text: Admission Date: [**2187-11-18**] Discharge Date: [**2187-11-28**]
Date of Birth: [**2117-7-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Nifedipine Er
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Palpitations/Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2187-11-19**]
s/p Coronary artery bypass graft x4 (Left internal mammary
artery>left anterior descending, Saphenous vein graft > obtuse
marginal, saphenous vein graft > RAMUS, saphenous vein graft >
diagonal) MAZE, Left atrial appendage ligation [**2187-11-23**]
History of Present Illness:
70yo Spanish speaking only F with h/o HTN, med-noncompliance, R
carotid stent p/w chest pain/palpitations x 3 days. States has
been having episode of chest pain lasting about 15 mins which
are not related to exertion and resolve with drinking garlic
water. Presented to emergency department for further evaluation.
Past Medical History:
HTN
GERD
carotid stenosis s/p R carotid stent
Hyperlipidemia
Osteoarthritis
venous insufficiency
Social History:
Lives in [**Location **] with daughter denies smoking, etoh
Family History:
mother and sisters with HTN. Uncle with MI
Physical Exam:
Vitals 97.5 BP 132/76 HR 70 RR 16 O2 94%RA
.
Gen: elderly female in nad
HEENT: MMM, PERRL, EOMI, OP clear
Neck: supple, JVP ~8CM
Chest: CTAB, no crackles. Decreased BS at bases
CVR: RRR, nl s1, s2, no r/m/g
ABD: soft, nt, nd
EXT: no edema
Pertinent Results:
[**2187-11-28**] 06:33AM BLOOD WBC-8.4 RBC-3.76* Hgb-11.2* Hct-32.5*
MCV-86 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-264#
[**2187-11-28**] 06:33AM BLOOD Plt Ct-264#
[**2187-11-23**] 12:41PM BLOOD PT-17.3* PTT-45.2* INR(PT)-1.6*
[**2187-11-28**] 06:33AM BLOOD Glucose-111* UreaN-12 Creat-0.7 Na-137
K-3.8 Cl-99 HCO3-30 AnGap-12
[**Known lastname 30941**], [**Known firstname 30942**] [**Hospital1 18**] [**Numeric Identifier 30943**]
(Complete) Done [**2187-11-23**] at 9:20:12 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2117-7-13**]
Age (years): 70 F Hgt (in): 60
BP (mm Hg): 135/78 Wgt (lb): 180
HR (bpm): 56 BSA (m2): 1.79 m2
Indication: Intraoperative TEE for CABG and MAZE procedure
ICD-9 Codes: 786.05, 786.51, 440.0, 424.0
Test Information
Date/Time: [**2187-11-23**] at 09:20 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2008AW1-: Machine: [**Pager number 14694**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 1.7 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 2.00
Findings
LEFT ATRIUM: Mild spontaneous echo contrast in the body of the
LA. 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 regional LV systolic function. Overall
normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**11-21**]+) MR.
TRICUSPID VALVE: Mild to moderate [[**11-21**]+] TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient.
Conclusions
Prebypass
1. Mild spontaneous echo contrast is seen in the body of the
left atrium. No thrombus is seen in the left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are complex (>4mm) atheroma in the descending thoracic
aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild to
moderate ([**11-21**]+) mitral regurgitation is seen.
Post Bypass
1. Patient is being A paced and receiving an infusion of
phenylephrine.
2. Biventricular systolic function is unchanged.
3. Aorta intact post decannulation.
Brief Hospital Course:
Admitted from ED ruling in for NSTEMI in atrial fibrillation.
Underwent cardiac catherization that revealed coronary artery
disease. She was treated with medications to control atrial
fibrillation. Cardiac surgery was consulted for surgical
evaluation. She underwent preoperative workup and [**11-23**] went to
the operating room for coronary artery bypass graft, MAZE, and
LAA ligation surgery. She received perioperative vancomycin as
she was inpatient preoperatively. See operative report for
further details. She was transferred to the ICU for hemodynamic
monitoring. In the first 24 hours she was weaned from sedation,
awoke neurologically intact, and was extubated. She was started
on betablockers and diuretics. On post op day 2 she was
transferred to the floor. Physical therapy worked with her for
strength and mobility. She continued to make progress and was
ready for discharge home with services on post operative day 5.
Medications on Admission:
Plavix 75 mg once daily
Fenlodapine 10 mg daily
Triamterene/HCTZ 50/25
Simvastatin 40 mg daily
Prilosec 20 mg daily
Discharge Medications:
1. 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*
2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 1 weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Atrial Fibrillation s/p MAZE and LAA excision
NSTEMI
Hypertension
Gastric esophageal reflux disease
Carotid stenosis s/p right carotid stent
Hyperlipidemia
Osteoarthritis
Venous insufficiency
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) **] in 2 weeks - please call for appointment
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2187-12-17**] 4:00
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 9045**] Date/Time:[**2188-1-15**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1241**]
Date/Time:[**2188-1-30**] 1:00
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2187-11-28**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 972
} | Medical Text: Admission Date: [**2130-8-7**] Discharge Date: [**2130-8-17**]
Date of Birth: [**2051-7-10**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male who
developed a productive cough 3-4 weeks ago. The cough then
became more dry and persistent. He saw his doctor a week
before admission. Was given Robitussin and Flonase.
Over the three days prior to admission, he noticed increasing
dyspnea on exertion. Patient also reported some back pain
along with pain around his right scapula. He denies fevers,
chills, nausea, vomiting, abdominal pain, diarrhea, or
constipation.
On admission to the ED, he was 89 percent on room air and was
noted to be tachypneic. Respirations were in the 30s. Using
his accessory muscles of breathing. He received ceftriaxone
and azithromycin. A chest x-ray revealed a large partially
loculated right pleural effusion. There is also a slight
left pleural effusion. There is no pneumothorax.
PAST MEDICAL HISTORY: Atrial fibrillation status post
pacemaker placement and on Coumadin.
Hypertension.
Prostate cancer status post XRT.
Osteoarthritis.
History of rectal bleeding in [**2128**].
Mild dementia.
Benign prostatic hypertrophy.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aricept 5 mg p.o. q.d.
2. Cozaar.
3. Coumadin 1 mg p.o. q.d.
4. Amiodarone 200 mg p.o. q.d.
5. Atenolol 25 mg p.o. q.d.
6. Oxybutynin.
7. Flomax 0.4 mg p.o. q.d.
8. Robitussin.
PHYSICAL EXAMINATION: General: He is an older gentleman in
mild distress. Vital signs: Temperature is 98.4, heart rate
75, blood pressure 117/52, respirations 36 and labored.
Oxygen saturation is 91-94 percent on 3 liters. Skin was
diaphoretic. HEENT: He had a normocephalic, atraumatic
head. Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Sclerae
were anicteric. Mucous membranes were dry. Neck was supple
with no JVD. Trachea was midline. Cardiovascular: Regular,
rate, and rhythm with S1, S2. Lungs had decreased breath
sounds at the right base compared to the left. Abdomen is
soft, nontender, nondistended, positive bowel sounds, no
hepatosplenomegaly, no rebound tenderness or guarding.
Extremities: No cyanosis, no edema, warm with palpable
pulses. Neurologic: He was alert and oriented times three.
LABORATORIES ON ADMISSION: Chemistry: Sodium is 134,
potassium 4.8, chloride is 100, bicarbonate is 21, BUN is 61,
creatinine is 2.5. CBC: White blood cells 25.3, hemoglobin
is 11.5, hematocrit is 34.5, platelets of 248.
Chest x-ray: As above.
Urinalysis was normal.
Renal ultrasound showed no hydronephrosis and simple cysts in
both kidneys.
HOSPITAL COURSE: Patient was admitted on [**2130-8-7**] and taken
to the operating room two days later for a right VATS
thoracotomy with decortication. The patient tolerated the
procedure well with 250 mL of blood loss. After the surgery,
he was admitted to the CSRU, where he was extubated and sent
to the floor on [**2130-8-13**]. Patient continued to do well on
the floor, where he had adequate pain control and ambulated
and voided appropriately.
On [**2130-8-14**], his chest tube was removed without incident, and
the following day, the second chest tube was converted to a
drain. He was also changed from IV Unasyn to p.o. Augmentin.
Patient was discharged on [**2130-8-17**] to an extended care
facility in good condition.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg p.o. q.d.
2. Tamsulosin 0.4 mg sustained release p.o. h.s.
3. Donepezil hydrochloride 5 mg p.o. q.h.s.
4. Levothyroxine sodium 5 mcg p.o. q.d.
5. Docusate sodium 100 mg p.o. b.i.d.
6. Senna 8.6 mg p.o. b.i.d. as needed.
7. Acetaminophen 325 mg 1-2 tablets p.o. q.[**4-25**]. prn pain.
8. Olanzapine 2.5 mg p.o. t.i.d. prn agitation.
9. Benzonatate 100 mg p.o. t.i.d. prn cough.
10. Pantoprazole sodium 40 mg sustained release p.o.
q.24.
11. Oxycodone/acetaminophen 5/325 1-2 tablets p.o. q.4h.
prn pain.
12. Polysaccharide iron complex 150 mg p.o. q.d.
13. Vitamin C 500 mg p.o. b.i.d.
14. Ibuprofen 600 mg p.o. q.6h.
15. Warfarin sodium 1 mg p.o. q.d.
16. Trazodone 25 mg p.o. q.h.s. prn sleep.
17. Metoprolol tartrate 50 mg p.o. b.i.d.
18. Amoxicillin/clavulanic acid 500/125 mg p.o. t.i.d.
for 10 days.
DISCHARGE PLANS: Patient was instructed to call for follow-
up appointment in [**1-20**] weeks with Dr. [**Last Name (STitle) **].
[**Name6 (MD) 106489**] [**Name8 (MD) **], M.D. [**MD Number(2) 39921**]
Dictated By:[**Last Name (NamePattern1) 32536**]
MEDQUIST36
D: [**2130-8-17**] 11:48:42
T: [**2130-8-17**] 13:42:00
Job#: [**Job Number **]
ICD9 Codes: 5119, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 973
} | Medical Text: Admission Date: [**2113-11-3**] Discharge Date: [**2113-11-13**]
Date of Birth: [**2113-11-3**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 10 day old
female, ex-34 [**5-12**] week gestational age female admitted to the
Neonatal Intensive Care Unit at [**Hospital1 188**] with primary complaints of respiratory distress and
prenatally diagnosed neonatal alloimmune thrombocytopenia.
The patient's mother is a 31 year old gravida IV, para III
woman with past medical history notable for bipolar disorder
being treated with Zoloft, Depakote and Risperidone.
Prenatal screens as follows: O positive, antibody negative,
hepatitis B antigen negative, RPR nonreactive, Rubella
alloimmune, GBS status unknown. Estimated date of delivery
was [**2113-12-10**]. The mother had been receiving IVIG since [**27**]
weeks of pregnancy for prenatal diagnosis of neonatal
alloimmune thrombocytopenia. There was no ultrasonographic
evidence of fetal hemorrhage prenatally.
Patient was born via repeat cesarean section under spinal
anesthesia. Rupture of membranes at delivery yielding clear
amniotic fluid. No intrapartum fever or clinical evidence of
chorioamnionitis. Infant was born with good tone and
spontaneous cry. Apgars were 8 and 9 at one and five minutes
respectively. There was no evidence of cyanosis at birth.
PHYSICAL EXAMINATION: On admission included birth weight of
2730 grams, OFC of 31.5 cm, length of 47.5 cm. Vitals as
follows: Heart rate 170 beats per minute, respiratory 78
breaths were minute, temperature 98.9 degrees Fahrenheit,
SAO2 92 percent on .3 FIO2 with C-PAP plus 6 cm of water.
Blood pressure was 65/35 with a MAP of 47.
General: Preterm female on radiant warmer in no apparent
distress.
Head, eyes, ears, nose and throat: AFOF, nondysmorphic,
palate intact, OP clear, mild facial bruising, mild caput,
nasal C-PAP in place.
Respiratory: Clear to auscultation bilaterally, mild coarse
breath sounds bilaterally, good air expansion bilaterally, no
crackles, no retractions.
Cardiac: Regular rate and rhythm, S1, S2 normal, no murmur,
well perfused, femoral pulses 2 plus and brisk bilaterally.
Abdomen: Soft, not distended, no hepatosplenomegaly, no
masses, hypoactive bowel sounds, anus patent.
Genitourinary: Normal female genitalia.
Neurologic: Appropriate tone on examination, moving all
extremities spontaneously. Moro/suck/palmar/plantar
reflexes intact.
Spine intact. No dimple. No hip click on examination.
SUMMARY HOSPITAL COURSE BY SYSTEMS: Respiratory: Patient
was placed on C-PAP plus six on FIO2 of room air for the
first 48 hours of life. On day of life 3, [**2113-11-6**] patient
was transitioned to room air without problems and remained on
room air throughout her hospital course. Patient had no
episodes of apnea or bradycardia throughout her hospital
course.
Cardiovascular: Patient cardiovascularly remained stable
throughout hospital course with blood pressures all within
normal range. She maintained good perfusion and strong
pulses throughout her hospitalization.
Fluid, electrolytes and nutrition: Patient was placed on
intravenous fluids of 80 cc per kilo per day of D10W for the
first 48 hours of life while she was not fed. On day of life
3, [**2113-11-6**], patient was started on Special Care Formula at 20
kilocals per ounce and tolerated initiation of feeds without
problems. By day of life 4 patient was P.O. ad lib feeding
up 150 cc per kilo per day with no signs of intolerance at
full feeds. At time of discharge the patient was on the same
formula of Special Care 20 kilocals per ounce at full feeds
of 150 cc per kilo per day. At time of discharge patient's
weight is 2620 grams.
Gastrointestinal: Patient had hyperbilirubinemia at birth
with initial bilirubin levels of 14.5 mg per dl at which time
double photo therapy was initiated and continued until day of
life 5, [**2113-11-8**] at which time her bilirubin had dropped to
8.0 mg per dl. Photo therapy was stopped with a rebound
bilirubin level of 6.0 mg per dl on day of life 6, [**2113-11-9**].
Hematology: Patient has a prenatally diagnosis of neonatal
alloimmune thrombocytopenia for which the mother had received
intravenous infusions weekly since [**27**] weeks of pregnancy.
The patient's platelet counts have been normal and stable
throughout her hospital course here with her initial platelet
count being 266 on [**2113-11-6**]. On day of life number five,
[**2112-11-7**] her platelet count was 316. On [**2113-11-10**] her platelet
count was 470. No further platelet counts have been checked.
She is recommended to receive a follow up CBC one week after
discharge.
Neurology: The patient has been neurologically normal
throughout her hospital course and did not receive a
screening head ultrasound.
Health Care Maintenance: Prior to discharge the patient did
receive a hepatitis B vaccination. She also passed her
hearing screening and her car seat test. State screening was
sent on day of life number two.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: [**Doctor First Name 56762**] [**Last Name (NamePattern5) 56763**], MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1411**]
Medical Office.
CARE RECOMMENDATIONS: Feeds at discharge include Special
Care 20 kilocals per ounce P.O. ad lib. No medications. Car
seat positioning screening passed. State Newborn Screening
sent. Immunizations received include hepatitis B
vaccination. This patient does not quality for Synagis
prophylaxis. Follow up appointments include follow up with
pediatrician two days after discharge.
DISCHARGE DIAGNOSES:
1. Respiratory distress.
2. Neonatal alloimmune thrombocytopenia.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 56760**]
MEDQUIST36
D: [**2113-11-13**] 14:22:51
T: [**2113-11-13**] 15:04:02
Job#: [**Job Number 56764**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 974
} | Medical Text: Admission Date: [**2119-1-17**] Discharge Date: [**2119-3-31**]
Date of Birth: [**2073-3-6**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Zofran / Toradol / Phenobarbital / Trazodone /
Compazine / Oxycodone
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
encephalopathy
Major Surgical or Invasive Procedure:
Blood transfusion
Paracentesis x2 ([**1-17**], [**1-23**])
[**2119-3-14**] liver transplant
History of Present Illness:
45 y/o male with ESLD from HCV, HBC, and EtOH who had a TIPS
done on [**2119-1-5**] who presented to the OSH yesterday with altered
mental status. The patient was treated with lactulose at the OSH
with some improvement in his encelpalopathy. There was concern
that there was a problem with the TIPS and he was transferred to
[**Hospital1 18**] for further workup.
Denied chest pain, shortness of breath, fevers, chills. He
reports abdominal pain slightly worse than his baseline. No
melena or BRBPR.
.
Labs at the OSH significant for AST/ALT 186/124, TB 12, DB 5,
Ammonia 330, Na 132.
Past Medical History:
# L4,L5,S1 fusion
# Decompensated liver cirrhosis [**1-28**] to HCV, HBC, and alcohol c/b
encephalopathy and ascites
# Chronic pancreatitis
# Non bleeding grade 2 esophageal varices in [**4-3**]
# GERD-Barrett's esophagus
# COPD
# s/p incarcerated umbilical hernia repair [**11-3**], recent
admission on [**2118-12-26**] to [**2118-12-30**] for concern for cellulitis
around his surgical incision, started on clindamycin then vanc
then bactrim for a total course of 7 days
#OLT [**2119-3-14**]
Social History:
Married, but separated, has 3 children. Lives with roommates -
limited support. Smokes a pack every 3 days. Quit cocaine and
heroine in [**2114**]. Quit EtOH in [**2101**].
Family History:
Family Hx: No known family history of hepatitis or liver
disease
Physical Exam:
VS: 97.5 95/69 90 12 93%RA
Gen: awake, oriented x 2 (able to state month and year, stated
he was at B+W's)
HEENT: NC/AT. PERRL, EOMI, MMM. OP clear.
Neck: Supple, no LAD.
CV: RRR, S1, S2 no m/r/g.
Chest: CTAB no wheezes or crackles.
ABD: Distended, + tense ascites, TTP diffusely
Ext: WWP, no edema. + asterixis
Pertinent Results:
Upon admission, a CT of the abd/pelvis was done [**2-1**]
demonstrating:
1. Large amount of ascites. Tiny amount of high-density fluid
layers in the deep pelvis consistent with blood not changed from
prior study at 2:13 a.m. today, [**2119-2-1**]. No subcapsular hepatic
hematoma.
2. Small subcentimeter focus of arterial enhancement of hepatic
segment VIII becomes isodense to liver parenchyma on the delayed
phase. This is more conspicuous compared to [**2118-12-27**] and [**2118-11-9**].
Finding is non- specific but given cirrhosis a small focus of
hepatocellular carcinoma cannot be excluded. Continued imaging
surveillance is recommended.
3. Cirrhosis with splenomegaly indicating portal hypertension.
4. Patent TIPS.
On [**2-25**] a ruq u/s was performed showing a patent TIPS with
increased velocities, little changed.
Head CT was negative and EEG was abnormal with findings
consistent with moderate encephalopathy . There were no
epileptiform features and no seizure activity.
.
[**2-27**] ct chest:
1. Abnormality in the right upper lobe demonstrates marked
panlobular
emphysematous changes. No evidence of pneumothorax.
2. Atelectasis within the right upper and bilateral lower lobes.
No evidence
of airspace consolidation.
3. Limited images through the upper abdomen show a large volume
ascites,
TIPS, and splenomegaly.
Brief Hospital Course:
Patient initially transfered from OSH with encephalopathy and
concern for clotted TIPS. TIPS initially placed [**2119-1-5**].
Ultrasound showed patent TIPS and his mental status improved
with lactulose and regular bowel movements. The patient was
tapped for a large amount of ascites and it was negative for
SBP.
He continued to have waxing and [**Doctor Last Name 688**] encephalopathy, He
required admission to the MICU twice for unresponsiveness, both
times which he was intubated for airway protection, and given
additional lactulose. His head CT on first MICU admission was
negative for any acute process such as intracranial bleed. EEG
findings were consistent with encephalopathy without seizure
activity.
An attempted Re-Do TIPS to divert blood through portal veins and
not the TIPS was attempted, but technically unsuccessful and
complicated by small hemoperitoneum that required transfusion
but otherwise self-limited. He finally had successful TIPS
revision on [**2119-2-6**].
He continued to receive therapeutic paracentesis. Ultrasound
initially showed patent TIPS but subsequent ones showed
increased velocities concerning for stenosis. He was restarted
on diuretics because his sodium was improved from prior
admissions, but these were held for worsening renal function.
He was continued on 1500ml fluid restriction and Cipro for SBP
prophylaxis. CVVHD was started.
A CXR showed new right sided infiltrate and the patient had
moderate growth of MRSA from his sputum with sparse growth of 2
colonies of GNR. He was treated with vancomycin and zosyn.
On [**3-14**] he underwent Orthotopic deceased donor liver transplant
(piggyback), portal vein-portal vein anastomosis, common bile
duct-common bile duct anastomosis with no T-tube, branch patch
(recipient) to celiac patch (donor)hepatic artery anastomosis.
Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see operative report
for further details. EBL was 2 liters replaced with PRBC, plt,
FFP, cryo and cellsaver. Two JPs were placed. He was maintained
on CVVHD during the case. He received HBIG intraop and on pod
[**12-31**]. HBsAb titers were greater than 450. HBIG IM was given on
pod 7 and 14. Entecavir was started immediately postop. This
dose was renally dosed.
Postop, he was transferred to the SICU per protocol. He was
extubated on POD 2. CVVHD continue for ~ 2 days then lasix was
started. He received prbc/plt/ffp on pod 0. Labs were monitored
q 6 hours. US of the liver demonstrated difficulty detecting
the expected hepatic arterial supply to the left lobe. Otherwise
U/S was normal. LFTs trended down. The medial JP was removed on
pod 5. The lateral JP continued to drain large amounts of
ascites. Outputs were as high as 4.5liters per day. He received
IV fluid replacements and albumin for JP outputs. Of note,
creatinine started trending up off CVVHD as high as 4.3 from
2.7. Urine output averaged 1000-1200cc/day. Nephrology was
consulted. It was felt that he had ATN on resolving hepatorenal
syndrome. Fluconazole dose was renally dosed to 200mg qd as this
was felt to increase the prograf level. Creatinine slowly
trended down to 2.9. Hyperkalemia was a persistent problem that
required treatment with insulin, dextrose, lasix and kayexalate.
Hyperkalemia improved with improved renal function. A low
potassium diet was ordered.
The lateral JP was removed on [**3-29**] for outputs of 600cc. The
transplant incision remained clean, dry and intact. His abdomen
appeared a little distended
PT evaluated him and initially recommended rehab, but he
improved significant and it was felt that he would be safe for
discharge to home. He was also started on insulin for
hyperglycemia. Glargine and humalog sliding scale were given.
Immunosuppression consisted of cellcept 1 gram [**Hospital1 **], steroids
were tapered to prednisone 20mg qd per protocol, and prograf was
started on pod 1. Prograf was decreased to 2.5mg [**Hospital1 **] per trough
levels of [**8-8**].2.
VNA services were arranged for home.
Medications on Admission:
1. Morphine 30 mg SR [**Hospital1 **]
2. Lactulose 30ML PO TID
3. Pantoprazole 40 mg Q24H
4. Folic Acid 1 mg DAILY
5. Oxycodone 5 mg Q6H as needed for Pain.
6. Colace 100 mg twice a day
7. Ciprofloxacin 250 mg Q24H
8. Entecavir 0.5 mg DAILY
9. Hexavitamin Daily
--Of note, has been off diuretics since last admission [**1-28**]
hyponatremia
.
Allergies: PCN, zofran, toradol, phenobarbital, trazadone
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
10. Entecavir 0.05 mg/mL Solution Sig: Three (3) ml PO DAILY
(Daily).
Disp:*50 ml* Refills:*2*
11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 MDI* Refills:*0*
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day.
15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
16. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day.
17. Insulin Syringes
Low dose syringes for qid injections
25 guage needle
supply: 1 box
Refill: 1
Discharge Disposition:
Home with Service
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ESLD from HCV/HBV/ETOH cirrhosis
Hepatic encephalopathy
Hepatorenal syndrome
ARF, improving
malnutrition
Chronic back pain
Barrett's esophagus
GERD
COPD
s/p incarcerated umbilical hernia repair
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
weight loss, jaundice, abdominal incision appears red, bleeds or
has drainage.
Labs every Monday and Thursday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-4-5**] 9:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-4-12**] 9:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2119-4-12**]
10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2119-3-31**]
ICD9 Codes: 5845, 5070, 2761, 4271, 2767, 496, 5859, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 975
} | Medical Text: Admission Date: [**2198-3-8**] Discharge Date: [**2198-3-23**]
Date of Birth: [**2137-2-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2198-3-8**]: OSH PCI: Prox LAD 95% occlusion, diffuse disease in
Circumflex, 100% ProxRCA lesion, s/p POBA, complicated by
dissection of the RCA, covered with BMS.
[**2198-3-19**]
1. Urgent coronary artery bypass graft x5: Left internal
mammary artery to left anterior descending artery;
saphenous vein graft to diagonal obtuse marginal and a
sequential saphenous vein grafting to posterior left
ventricular branch and the posterior descending artery.
2. Endoscopic harvesting of the long saphenous vein.
3. Mitral valve repair with size #30 [**Company 1543**] CG Future
Band.
History of Present Illness:
Mr. [**Known lastname 59124**] is a 61 y.o. male without a known past medical
history who presented to [**Hospital6 **] with
intermittent persistent substernal chest pressure assocaited
with epigastric pain, nausea/vomiting x 1 day. Patient was in
his usual state of health when he began to notice these symptoms
the evening prior to presentation. Initial ECG showed ST
elevations in the inferior leads with ST depressions in V1-V4.
He was started on a heparin gtt, brought emergently to the cath
lab, loaded with prasugrel on the table. Intraprocedurally, was
given infusion of bivalirudin. Noted to have prox LAD 95%
occlusion, diffuse disease in Circumflex, 100% ProxRCA lesion,
s/p POBA, complicated by dissection of the RCA, covered with
BMS. IABP was placed. Right heart cath was performed, showing
CI 2.4, SVR 1243, PCWP 17. Patient was transferred to [**Hospital1 18**] for
evaluation for urgent CABG.
.
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.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Coronary Artery Disease, s/p CABG and stent
Diabetes
Dyslipidemia
Hypertension
Social History:
- Arrived in the U.S. one week ago. no ETOH or tobacco
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ON ADMISSION
.
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2198-3-23**] 05:00AM BLOOD WBC-10.9 RBC-3.79* Hgb-11.2* Hct-31.6*
MCV-83 MCH-29.4 MCHC-35.3* RDW-14.1 Plt Ct-201
[**2198-3-22**] 04:50AM BLOOD WBC-11.6* RBC-3.58* Hgb-10.6* Hct-29.7*
MCV-83 MCH-29.7 MCHC-35.8* RDW-14.1 Plt Ct-143*
[**2198-3-23**] 05:00AM BLOOD Glucose-99 UreaN-24* Creat-0.8 Na-138
K-4.3 Cl-99 HCO3-30 AnGap-13
[**2198-3-22**] 04:50AM BLOOD Glucose-98 UreaN-18 Creat-0.7 Na-136
K-4.1 Cl-99 HCO3-29 AnGap-12
ADMISSION EKG: Sinus rhythm. A-V conduction delay. Left axis
deviation. Left atrial abnormality. Possible right atrial
abnormality. Left ventricular hypertrophy. Inferior wall
myocardial infarction with 1-2 millimeters of ST segment
elevation in the inferior leads. One millimeter of sloping ST
segment depression in high lateral leads. T wave inversions
inferolateral leads. No previous tracing available for
comparison.
.
OSH CATH [**3-8**]: prox LAD 95% occlusion, diffuse disease in
Circumflex, 100% ProxRCA lesion, s/p POBA, complicated by
dissection of the RCA, covered with BMS. IABP was placed.
Right heart cath was performed, showing CI 2.4, SVR 1243, PCWP
17.
.
ECHO [**3-8**]:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D
or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderately depressed LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV
chamber size. RV function depressed.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Focal calcifications in aortic arch.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS. Mild
to moderate ([**2-11**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. No TS. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
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 moderately depressed (LVEF= 30 %) secondary to
severe inferior posterior hypokinesis/akinesis; apex is
hypokinetic as well. The right ventricular free wall thickness
is normal. Right ventricular chamber size is normal. with
depressed free wall contractility. The ascending aorta is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**2-11**]+) mitral regurgitation is seen.
There is no pericardial effusion.
.
CXR [**2198-3-8**]: Lungs clear without significant effusion or
pneumothorax. Heart size and pulmonary vascularity is normal.
Apparent RUL opacity is likely superposition of venous and
osseous structures. A balloon pump marker is faintly seen
superimposed over the T6 spinous process, pulled back roughly
4cm compared wtih prior, now at the level of the carina.
Intra-op TEE
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30 - 35 %) with marked inferior and apical HK
and moderate global free wall hypokinesis.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Moderate to severe (3+)
central mitral regurgitation is seen. Mitral annulus is 4.1 cm.
There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on low-dose Epinephrine.
Biventricular systolic fxn is mildly improved, with EF now 35 -
40%.
There is a mitral ring repair with trace MR and no leak.
Residual mean gradient is 4.5 mmHg and area is 2.8 sq cm.
No AI. Aorta intact.
Brief Hospital Course:
Medical Course:
61 y/o Male with no known past medical history presenting with
inferior STEMI s/p POBA to 100% prox RCA lesion, small
dissection with BMS placed, prox LAD lesion, on IABP.
.
# STEMI: pt initially presenting to OSH with chest pain, found
to have inferior STEMI. s/p POBA to 100% prox RCA lesion, small
dissection with BMS placed, prox LAD lesion. He was placed on a
balloon pump and tranferred to [**Hospital1 18**] for CABG eval and for
repair of dissection. He was evaluated by CT surgery who
planned for surgery on [**3-16**].
He remained stable on the balloon pump which was subsequently
d/c'd on HD#2 given stable pressures. He was continued on ASA,
plavix, atorva 80mg, and heparin ggt with metoprolol added in
once after BPs remained stable. Of note, he had TTE which
showed EF 30% with hypokinesis in the inferior posterior region,
with 2+ MR. [**Name14 (STitle) 67294**] was followed and downtrended.
.
# Pump: Pt noted to have EF 30% on echo with severe inferior
hypokinesis. Clinically patient euvolemic, normal cardiac
index, slightly elevated wedge, and no evidence of cardiogenic
shock. Urine output was appropriate both on and off the pump.
.
# RHYTHM: NSR OSH cath lab noted 2nd degree AV block, however
no recording of this and pt remained stable on tele
.
# Social situations: Social work consult called. Multi-family
members giving conflicting report of their relationship to
patient. HPC now determined to be nephew.
Cardiac Surgery Course:
The patient was brought to the operating room on [**2198-3-16**] where
the patient underwent CABG with Dr. [**First Name (STitle) **]. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. 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 home in good condition with
appropriate follow up instructions.
Medications on Admission:
None
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for BMS.
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG and stent
Diabetes
Dyslipidemia
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema 1+ lower
extremity edema bilaterally
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:
Please come to [**Hospital Ward Name 121**] 6 for a wound check appointment on Thursday
[**2198-3-29**] at 11am [**Telephone/Fax (1) 3071**]
The following appointments have been made for you:
Cardiac Surgeon: DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**2198-4-23**] 1:45
Phone:[**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 4922**], [**Telephone/Fax (1) 2205**] [**2198-4-12**], 12:30pm
**call [**Telephone/Fax (1) 10676**] to register prior to your appt. w Dr.
[**Last Name (STitle) 4922**]**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2198-3-23**]
ICD9 Codes: 4240, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 976
} | Medical Text: Admission Date: [**2177-9-14**] Discharge Date: [**2177-9-18**]
Date of Birth: [**2100-1-30**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Pollen Extracts / Carvedilol
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Left Sided Substernal Chest Pain radiating to arm and jaw.
Major Surgical or Invasive Procedure:
Per-cutaneous Cardiac Catheterization with Drug-Eluting Stent of
Mid Left Anterior Descending Artery.
History of Present Illness:
Pt is a 77 yo M with a h/o dilated cardiomyopathy (EF 20%), Afib
on coumadin, s/p BiV PCM secondary to complete heart block, DM,
CRI (baseline 1.4-1.7), PVD s/p superficial femoral artery stent
transferred from OSH for ST elevation MI. Pt awoke this am with
Left sided substernal chest pain raditating to his arm and neck
lasting 4 hours. Sub-lingual NTG was given by EMS and reduced
his pain from [**11-23**] to [**5-24**]. His ECG at [**Hospital1 **] demonstrated
ST elevation in leads V2-V4, on a background of biventricular
pacing. He was hemodynamically-stable, but had exam findings of
heart failure. He was transferred to [**Hospital1 18**] for emergency
catheterization for acute anterior [**Hospital1 **].
Past Medical History:
Dilated Cardiomyopathy (EF 20%), Afib (coumadin), s/p
BiVentricular PCM secondary to Complete Heart Block, DM, CRI
(1.4-1.7), PVD s/p Superficial Femoral Artery stent, HTN, h/o
TIA, COPD, Right Internal Carotid Artery w/ 60-69% stenosis,
hypercholesterolemia
Social History:
The patient lives alone. He is a retired Biochem teacher. He is
a former cigarette smoker. He does not drink alcohol.
Family History:
Father died secondary to a cerebrovascular accident.
Physical Exam:
158/68 HR 76 Wt 88 kg
Gen: NAD
HEENT: MMM. Anicteric. PERRL.
Neck: JVD to mid ear at 0 degrees
Lungs: CTAB ant/lat
CV: RRR. Nl S1S2. No M/R/G. No S3S4
Abd: obese. soft. NT/ND. +BS
Ext: no palpable DP pulses b/l. L LE w/ 3+ pitting edema, R LE
w/ 1+ pitting edema
Pertinent Results:
[**2177-9-14**] 08:18PM CK(CPK)-4051* CK-MB-346* MB INDX-8.5*
GLUCOSE-314* UREA N-25* CREAT-1.5* SODIUM-137 POTASSIUM-5.3*
CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
[**2177-9-14**] 01:46PM CK(CPK)-4132*CK-MB-348* MB INDX-8.4*
cTropnT-14.11*
CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-1.9 CHOLEST-88
TRIGLYCER-83 HDL CHOL-36 CHOL/HDL-2.4 LDL(CALC)-35
WBC-12.2* RBC-4.60 HGB-13.4* HCT-38.6* MCV-84 MCH-29.0 MCHC-34.7
RDW-14.3
PLT COUNT-292
*
[**2177-9-15**] Echo:
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The
left ventricular cavity is moderately dilated. Overall left
ventricular
systolic function is severely depressed (ejection fraction 20
percent)
secondary to severe global hypokinesis with some relative
preservation of the
basal and midventricular segments of the inferior and posterior
walls. There
is no ventricular septal defect. The right ventricular cavity is
dilated.
There is focal hypokinesis of the apical free wall of the right
ventricle. The
aortic valve leaflets (3) are mildly thickened but not stenotic.
Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic
hypertension. There is a small pericardial effusion. The
effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
*
CT HEAD W/O CONTRAST [**2177-9-15**] 12:28 PM
1. No evidence of acute intracranial hemorrhage.
2. Evidence of previous infarcts in the posterior right temporal
and left occipital lobes, as well as chronic small vessel
ischemic changes.
3. There is no evidence of acute territorial infarct.
*
Cath [**2177-9-14**]
1. Two vessel CAD.
2. Acute anterior myocardial infarction, terminated by primary
PCI.
3. Markedly elevated filling pressures and pulmonary artery
hypertension.
4. Congestive heart failure.
*
CXR Portable [**2177-9-14**]
Congestive heart failure with interstitial pulmonary edema.
Brief Hospital Course:
Pt is a 77 yo M with a h/o dilated cardiomyopathy (EF 20%), Afib
on coumadin, s/p BiV PCM secondary to complete heart block, DM,
CRI (baseline 1.4-1.7), PVD s/p superficial femoral artery stent
transferred from OSH for [**Month/Day/Year **].
1. [**Name (NI) **] - Pt underwent a cardiac cathederization on [**2177-9-14**]
revealing a totally occluded LAD after a small first diagonal
branch. Two drug-eluting stents were placed in the proximal LAD
with residual distal occlusion.
Pt was started on Integrelin gtt, Plavix, [**Date Range **] 325, and Lipitor
40.
Ace-Inh was restarted and titrated to lisinopril 10 [**Hospital1 **]. His
B-Blocker was restarted on the day of discharge. BP meds were
weaned back given his recent likely CVA (described below) and
goal was for SBP>130.
2. CHF - DCM w/ PCWP 40 at cardiac catherization. History of
bivent pacer with EF of 15%. TTE 2 days post revascularization
showed EF 20% w/ severe global hypokinesis. He was diuresed
with Natrecor x24 hours and remained euvolemic off of the drip
for >72 hours prior to discharge. He will continue lasix at
rehab/home on a prn basis.
3. Probable CVA - on HD#2 patient developed acute onset of
mental status changes, primarily involving word finding
difficulties and slow/slurred speech. He was evaluated by the
stroke team who also noted mild weaknees in right UE. Lysis was
considered, however, given his recent cath and elevated PT from
anticoaggulation for Afib, this was felt not to be an option.
He had two negative CT of the Head. An MRI was contraindicated
given his pacemaker. He will need to have a CTA of the brain
sometime in the futuer as an outpatient. He mental status
gradually improved during the hospitalization, but never
returned to baseline. He was seen by speech and swallow and
felt to have no acute needs. Cartoid U/S was not repeated given
examination in [**1-16**]. Although not definitive, it was felt that
he had a minor ischemic CVA as a complication of his MI.
4. Afib- Heparin started HD#2, turned off after MS changes but
restarted once CT Head w/o evidence of bleed. Overlapped with
Coumadin with Goal INR 2.0-3.0. His INR was 3.3 on date of
discharge and he was instructed to hold coumadin until INR <3.0.
5. ARF on CRF - creat bumped from 1.5 -> 2.1 with diuresis.
Once stopped, creat normalized at 1.6 (baseline).
6. COPD - stable on MDIs. Likely partially responsible for
elevated pulmonary pressures at catherization.
7. Dispo - PT worked with patient on at least one occasion and
felt he was not safe for home. He was stubborn and initially
refused rehab, but eventually was agreeable. He will be d/c'd
to [**Hospital1 **] TICU where his Cardiologist will be able to
participate in his care.
Medications on Admission:
Coumadin, Dig 0.25 qd, lisinopril 10 mg po [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg po qd,
lipitor 10 mg po qd, glipizide 10 mg po qd, zyrtec, coreg 3.125
mg pi [**Hospital1 **], albuterol IH prn
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 300 days.
Disp:*300 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Glipizide 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
9. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO Please take if
your weight increases by 2 lbs in one day.
Disp:*30 Tablet(s)* Refills:*2*
11. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Please hold on evening of [**9-18**] and recheck in am. Goal
INR [**3-18**]. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location (un) 47**]
Discharge Diagnosis:
Myocardial Infarction with Stent of Left Anterior Descending
Artery.
Discharge Condition:
Fair.
Discharge Instructions:
Please call your primary care physician or return to the
hospital if your chest pain recurs or any other problems arise.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] Where: [**Name12 (NameIs) **]
[**Name12 (NameIs) 3628**] Date/Time:[**2177-10-2**] 9:00
2. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2177-10-2**] 10:
3. Follow up appointment with Dr. [**Last Name (STitle) 5051**]. [**2177-10-10**] at 4:30 PM.
4. Thurs [**2177-10-2**] at 1:30 PM for Nuclear Stress Test at [**Hospital **]
Hospital. Please do not eat or drink 4 hours prior to the test.
Please do not have caffeine 24 hrs prior to the test. Please
call [**Telephone/Fax (1) 6256**] with questions.
ICD9 Codes: 4254, 496, 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 977
} | Medical Text: Admission Date: [**2129-6-5**] Discharge Date: [**2129-6-6**]
Date of Birth: [**2059-2-5**] Sex: M
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
IPH.
Major Surgical or Invasive Procedure:
extubated
History of Present Illness:
Mr. [**Known lastname 69580**] is intubated and sedated; history obtained from
family.
Mr. [**Known lastname 69580**] is a 70 y/o man with PMH significant for "small
strokes" per the family (for which is is on Aggrenox) and HTN,
who was transferred from OSH for IPH. He awoke this morning and
noted his left hand was swollen, but was otherwise in his usual
state of health. Around 3PM this afternoon, he was eating dinner
with his family, when he coughed and suddenly developed left
sided weakness with slurred speech. He was brought to OSH
([**Hospital3 **]), and found to have 8.6 x 5.8 cm right basal
ganglia hemorrhage with intraventricular extenstion. He was
intubated and tranported to [**Hospital1 18**] for further care. In the ED,
he
was started on Nicardipine gtt for HTN as well as Propfol gtt.
He
was assessed by Neurosurgery, who thought that the hemorrhage
was
already too devastating that any intervention would be futile.
Past Medical History:
-"small strokes" per family
-HTN
Social History:
Unable to obtain from patient as he is intubated
Family History:
Unable to obtain from patient as he is intubated
Physical Exam:
At admission:
Vitals: P: 75 BP: 178/84
vent CMV mode
General: intubated, sedated
HEENT: ET tube in place
Pulmonary: anterior lung fields cta b/l
Cardiac: RRR, S1S2
Abdomen: nondistended
Extremities: warm, well perfused
Examined off sedation x 3 min.
Neurologic Exam: No eye opening. No commands. No response to
nasal tickle. Right pupil 4 mm and nonreactive. Left pupil 2 mm
and nonreactive. No Doll's eyes. Right corneal is present. Left
corneal is absent. Does not blink to threat. + cough/gag. No
spontaneous movement. Extensor posturing in UE b/l to nailbed
pressure. He withdraws LLE to nailbed pressure. Triple flexion
of
RLE to nailbed pressure. Left patellar reflex is 2+; unable to
elicit remainder of reflexes. Extensor plantar response L>R.
At discharge:
deceased
Pertinent Results:
[**2129-6-5**] 06:04PM BLOOD WBC-13.2* RBC-4.07* Hgb-12.8* Hct-37.5*
MCV-92 MCH-31.5 MCHC-34.2 RDW-14.0 Plt Ct-261
[**2129-6-5**] 06:04PM BLOOD PT-11.6 PTT-25.7 INR(PT)-1.1
[**2129-6-5**] 06:04PM BLOOD Fibrino-303
[**2129-6-5**] 06:04PM BLOOD UreaN-20 Creat-0.9
[**2129-6-5**] 06:04PM BLOOD Lipase-40
[**2129-6-5**] 06:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2129-6-5**] 06:54PM BLOOD Type-ART Temp-35.9 Rates-14/ Tidal V-550
FiO2-50 pO2-137* pCO2-46* pH-7.36 calTCO2-27 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2129-6-5**] 06:04PM BLOOD Glucose-180* Na-132* K-5.2* Cl-100
calHCO3-23
[**2129-6-5**] 06:04PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2129-6-5**] 06:04PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2129-6-5**] 06:04PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
[**2129-6-5**] 06:04PM URINE CastHy-11*
[**2129-6-5**] 06:04PM URINE Mucous-OCC
[**2129-6-5**] 06:04PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CXR:
IMPRESSION: ET and NG tubes positioned appropriately. Opacity
at the left lung base likely reflects atelectasis, aspiration,
and effusion.
NCHCT:
IMPRESSION:
1. Massive right cerebral hematoma with 17 mm of leftward shift
with
subfalcine and early downward transtentorial herniation.
Obstructive
hydrocephalus and occipital [**Doctor Last Name 534**] entrapment. Further
correlation should be made once prior study is uploaded for
comparison.
2. Paranasal sinus disease and oropharyngeal and nasopharyngeal
aerosolized material, likely related to recent intubation.
Brief Hospital Course:
The patient was transferred here from [**Hospital6 3105**]
for evaluation of IPH with intraventricular spread. He had been
intubated prior to transfer. A family meeting was held with his
wife and children. Given that this was a devastating hemorrhage,
the family came to the decision to extubate and focus care on
comfort measure. He was extubated at approximately 11pm [**2129-6-5**].
He passed away at 12:10 pm on [**2129-6-6**] with his wife and children
at bedside. His wife declined an autopsy. The medical examiner
waived an autopsy as well.
Medications on Admission:
-Vicodin 5mg-500mg prn
-Lisinopril 2.5 mg daily
-Celexa 10 mg daily
-Aggrenox 200mg-25 mg [**Hospital1 **]
-Valium 5 mg prn
-Vytorin 10mg-40mg daily
-Celebrex 200 mg daily
-Tramadol 50 mg prn
-Lovaza 2 grams [**Hospital1 **]
-Percocet 5mg-325 mg prn
-Avodart 0.5 mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 978
} | Medical Text: Admission Date: [**2164-8-20**] Discharge Date: [**2164-8-23**]
Date of Birth: [**2119-8-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
atypical chest pain and palpitations with exertion
Major Surgical or Invasive Procedure:
[**2164-8-20**] Minimally Invasive Mitral Valve Repair
History of Present Illness:
46 yo female with know history of MR since [**2147**], followed by
serial echos. She has atypical chest pain and palpitations with
exertion and is referred for surgical evaluation by Dr.
[**Last Name (STitle) 1290**]. Echo in [**4-12**] showed mild LVH, 4+MR, trace TR and LVEF
76%. ETT done in [**4-12**] showed no evidence of ischemia at stress
level and EF 65-75%.
Past Medical History:
migraines
[**Month/Day (1) **]
s/p breast lumpectomy for benign mass
mitral regurgitation
Social History:
lives with husband and 2 kids, homemaker, rare use of ETOH, and
has never smoked
Family History:
non-contrib.
Physical Exam:
133/78 R, 134/80 L, 72 SR, 5'6", 133 # pre-op exam:
NAD, benign nevi
HEENT in remarkable, and teeth in good repair
neck supple with no bruits
RRR grade [**2-10**]/ 6 SEM with diastolic rumble
lungs CTAB
abd soft, NT, ND with + BS
extrems warm, no c/c/e with 2+ bilat fem, DP/PT pulses, and no
varicosities
neuro grossly intact without focal deficits
Pertinent Results:
[**2164-8-22**] 07:00AM BLOOD WBC-8.6 RBC-2.76* Hgb-8.6* Hct-24.7*
MCV-90 MCH-31.0 MCHC-34.7 RDW-13.4 Plt Ct-128*
[**2164-8-22**] 12:55PM BLOOD Hct-25.4*
[**2164-8-22**] 07:00AM BLOOD Plt Ct-128*
[**2164-8-21**] 03:44AM BLOOD Fibrino-210#
[**2164-8-22**] 07:00AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-140 K-4.0
Cl-110* HCO3-26 AnGap-8
[**2164-8-21**] 03:44AM BLOOD Calcium-7.6* Mg-1.4*
[**2164-8-21**] 04:15AM BLOOD freeCa-1.21
cath [**7-13**]: MVP with 4+ MR, dil LA, normal cors
Brief Hospital Course:
Admitted [**8-20**] and underwent a minimally invasive mitral valve
repair with a 26 mm annulplasty band by Dr. [**Last Name (STitle) 1290**].
Transferred to the CSRU in stable condition on neo, epinephrine
and propofol drips. Extubated later that evening in SR, alert
and oriented, off all drips the following morning. Chest tubes
removed, and transferred to floor. Started aspirin therapy. Some
ecchymosis present in area of right thoracot. incision, but
continued to do well on the floor, immediately increasing her
level of activity and ambulation. Restarted topamax and using
toradol for pain management. On day of discharge, POD #3,
107/59, SR 74, RR20, sat 96% RA, incisions clean, dry and
intact, wt. 64.4 kg. Discharged home with VNA services in stable
condition.
Medications on Admission:
topamax 25 mg [**Hospital1 **]
maxalt 10 prn
clindamycin prn dental procedures
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
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:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*30 Tablet(s)* Refills:*2*
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
MR
[**First Name (Titles) **]
[**Last Name (Titles) 61640**] headaches
R Breast Lumpectomy
s/p min. inv. mitral valve repair
Discharge Condition:
Good.
Discharge Instructions:
Shower, wash incision with soap and water and pat dry. No baths,
lotions, creams or powders. No lifting more than 10 pounds or
driving until follow up with surgeon.
Call for fever, redness or drainage from incision or weight gain
more than 2 pounds in one day or five in one week.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 61641**] 2 weeks
Completed by:[**2164-9-5**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 979
} | Medical Text: Admission Date: [**2183-1-15**] Discharge Date: [**2183-2-10**]
Date of Birth: [**2137-5-17**] Sex: M
Service: MEDICINE
Allergies:
Zoloft
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Hypotension in the setting of decompensated liver disease
Major Surgical or Invasive Procedure:
Arterial line placement [**2183-1-15**]
Right internal jugalar line [**2183-1-16**]
History of Present Illness:
45M h/o EtOH cirrhosis c/b massive ascites, EtOH cardiomyopathy
s/p AICD placement, and PUD c/b GIB s/p EGD is transferred from
an OSH with hypotension in the setting of decompensated liver
disease. Briefly, after undergoing scheduled large volume
paracentesis (6L), he was admitted to [**Hospital3 **] on [**2183-1-10**]
with confusion accompanied by ammonia of 64, with some
improvement in mental status following lactulose administration.
In light of elevated Cr to 2-2.4 on admission, up from 1-1.2 at
baseline, diuretics were held. Hospital course was also
complicated by persistent hyponatremia.
When he developed SBP to 70s accompanied by low-grade fever,
shortness of breath, progressive abdominal pain/distention,
lethargy, and bandemia earlier today, he was transferred to the
OSH MICU, where he received 500 cc IVNS and albumin 12.5 g x2,
with improvement in SBP to 80s without pressor requirement.
Empiric ceftriaxone 1g x1 and vancomycin 1g x1 were administered
prior to diagnostic paracentesis, which revealed 43 wbc.
On arrival to the MICU, he was minimally conversant, but
somnolent and unable to provide detailed history. He endorses
minimal shortness of breath coupled with nonproductive cough, as
well as non-bloody emesis just prior to arrival. He denies pain
in his abdomen or elsewhere or bloody/tarry stools.
Past Medical History:
EtOH cirrhosis c/b diuretic-resistant ascites requiring weekly
large volume paracentesis
EtOH cardiomyopathy (EF 30% on TTE in [**11-28**]) s/p AICD placement
PUD c/b GIB, now s/p EGD
Gastic Bypass
Social History:
- Tobacco: Endorses previous tobacco use; now quit.
- Alcohol: Per OSH notes, last drink on [**2183-8-28**].
Family History:
Unknown.
Physical Exam:
Physical Exam on admission:
Vitals: 95 80 78/47 16 100% on 5LNC
General: Alert, oriented x3, somnolent in no acute distress
HEENT: Sclera anicteric, MM dry, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, distant heart sounds
Lungs: Rhonchi/wheeze in anterior fields bilaterally
Abdomen: Non-tender, tensely distended, +fluid wave
Ext: Thready pulses throughout, no clubbing, cyanosis or edema,
positive asterixis
Neuro: AOx3, somnolent, but minimally conversant and following
commands, weak UE grip bilaterally
MSK: UE proximal muscle wasting bilaterally
Skin: Few scattered spider angiomata, multiple scattered
excoriations overlying U/LE bilaterally, minimal palmar
erythema, no abdominal caput
Physical Exam on discharge:
98.5 103/74 88 18 98%RA
BS: 199, 169, 201
GENERAL: cachectic appearing man, AOx3, no asterixis
HEENT: Sclera anicteric. PERRL, EOMI.
CARDIAC: RRR no m/r/g
PULM: CTAB.
ABDOMEN: Distended and tense, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees.
NEURO: difficulty with concentration, CNII-XII grossly intact no
apparent focal lesions, no asterixis, intermittently combative
Pertinent Results:
Labs on admission:
[**2183-1-15**] 08:31PM BLOOD WBC-3.8* RBC-3.93* Hgb-11.0* Hct-32.5*
MCV-83 MCH-28.0 MCHC-33.9 RDW-15.5 Plt Ct-114*
[**2183-1-15**] 08:31PM BLOOD Neuts-72.2* Bands-0 Lymphs-21.6 Monos-5.1
Eos-0.7 Baso-0.3
[**2183-1-16**] 02:10AM BLOOD PT-21.0* PTT-60.2* INR(PT)-2.0*
[**2183-1-15**] 08:31PM BLOOD Glucose-163* UreaN-40* Creat-3.0* Na-125*
K-5.0 Cl-97 HCO3-17* AnGap-16
[**2183-1-15**] 08:31PM BLOOD ALT-33 AST-35 LD(LDH)-251* CK(CPK)-39*
AlkPhos-109 TotBili-0.3
[**2183-1-15**] 08:31PM BLOOD CK-MB-6 cTropnT-0.06*
[**2183-1-16**] 02:10AM BLOOD CK-MB-5 cTropnT-0.04*
[**2183-1-15**] 08:31PM BLOOD Albumin-2.6* Calcium-8.0* Phos-5.4*
Mg-1.7
[**2183-1-18**] 05:50AM BLOOD Vanco-25.9*
[**2183-1-15**] 09:32PM BLOOD Type-ART pO2-32* pCO2-42 pH-7.24*
calTCO2-19* Base XS--9 Intubat-NOT INTUBA
[**2183-1-15**] 08:43PM BLOOD Lactate-3.0*
[**2183-1-15**] 11:44PM BLOOD freeCa-1.08*
[**2183-1-16**] 02:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2183-1-16**] 02:10AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2183-1-16**] 02:10AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
TransE-<1
[**2183-1-16**] 02:10AM URINE CastHy-25*
[**2183-1-16**] 02:10AM URINE Mucous-OCC
[**2183-1-16**] 02:10AM URINE Hours-RANDOM UreaN-395 Creat-225 Na-<10
K-22 Cl-<10
Microbiology:
C diff [**1-17**]: negative
Blood cx [**1-16**]: No growth
Urine cx [**1-16**]: negative
Imaging:
Chest x-ray [**12/2099**]:
Cardiomediastinal contours are normal. Left transvenous
pacemaker leads are in a standard position with tips in the
right atrium and right ventricle.
There are low lung volumes. There are faint ill-defined
opacities in the left perihilar region. This could be due to
atelectasis, but developing infection cannot be excluded. There
is no pneumothorax or pleural effusion.
There is dilatation of small bowel loops in the upper abdomen
Chest x-ray [**1-18**]:
CHEST, SINGLE AP VIEW: Low lung volumes. Compared with [**2183-1-17**],
there is
increased opacity in the left upper and mid zones, which could
represent
worsening asymmetric CHF. The possibility of a left-sided
pneumonic
infiltrate cannot be entirely excluded, but is considered less
likely. No
effusions.
A left-sided dual-lead pacemaker is present with lead tips over
right atrium and right ventricle. An NG tube is present -- the
tip is obscured in the lower mediastinum due to overlying soft
tissues and cannot be definitively identified. A right IJ
central line is present, tip over distal SVC.
IMPRESSION: Worsening asymmetric opacity, likely worsening CHF.
Echo [**1-16**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The mitral valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined.
IMPRESSION: Limited study as patient could not cooperate. Left
ventricular systolic function is probably normal, a focal wall
motion abnormality cannot be excluded. The right ventricle is
not probably normal. No significant valvular abnormality
CT abdomen and pelvis without contrast [**1-16**]:
IMPRESSION:
1. Large amount of non-hemorrhagic ascites throughout the
abdomen. No
evidence of intra-abdominal hemorrhage.
2. Intact Roux-en-Y anastomosis.
3. Cirrhotic liver. Gas-distended loops of bowel with decrease
of caliber
just distal to the J-J anastomosis. While this could represent
post-operative changes from gastric bypass, early partially
small bowel obstruction cannot be excluded.
4. Minimal-to-mild colonic wall edema, likely secondary to
patient's
end-stage liver disease. Fecal loading in the rectum.
RUQ US with dopplers [**1-17**]:
IMPRESSION:
1. Large amount of intra-abdominal ascites.
2. No concerning focal liver lesion identified.
3. Somewhat limited Doppler evaluation of the left hepatic lobe,
however, no evidence of portal venous thrombosis.
Brief Hospital Course:
Mr. [**Known lastname **] is a 45 year old man with EtOH cirrhosis c/b massive
ascites and cardiomyopathy s/p AICD placement who was
transferred from an OSH with hypotension in the setting of
decompensated liver disease. His course was complicated by
hepatorenal syndrome necessitating dialysis as well as
encephalopathy.
.
#[**Last Name (un) **] (Hepatorenal Syndrome): Elevated Cr at 3.0 on admisison,
reportedly up from 1-1.2 at baseline. Urine sodium of less than
10 narrowed differential to pre-renal dehydration vs. HRS. Pt
was given albumin challenge for the first two days as well as
boluses of NS. Creatinine did not respond to resuscitation over
the first few days, ruling in favor of HRS. Pt was also started
on midodrine/octeotide for presumed HRS. Renal US was negative
for post-renal obstruction. Pt was started on dialysis once he
was transferred back to the MICU with the hope of bridging him
until he is a candidate for liver transplant.
.
#Liver Tranpslantation Eligibility: To become a liver transplant
candidiate, Mr. [**Known lastname **] will need to have been sober out of the
hospital for approximately 3 months. Per the liver transplant
committee, he must demonstrate that he is comitted to sobriety
by engaging in an intesive outpatient alcohol treatment program.
Sobriety within the hospital or an inpatient rehabilition center
does not count towards transplant eligibility.
.
#Alcoholic Cirrhosis: MELD is 22 upon discharge. Last drink was
[**2182-8-28**] but in context of hospitalization/physical
rehab. Not a transplant candidate as abstinence occurred in
healthcare setting as explained above. Lactulose/rifaximin were
continued for encephalopathy. Folate and thiamine were
continued.
.
#Altered mental status: On admission he was somnolent, but
conversant. Likely secondary to hepatic encephalopathy and
sepsis from HCAP. Altered mental status initially improved after
copious lactulose infusion, but worsened as Mr. [**Known lastname **] became
progressively uremic. Following initiation of dialysis and
aggressive lactulose infusion, Mr. [**Known lastname **] was back at his
baseline mental status. Patient is discharged on 1mg PO Haldol
[**Hospital1 **].
.
#Aspiration: Mr. [**Known lastname **] was noted to aspirate on beside
swallowing study, and had several episodes of desaturation which
were thought to be potentially secondary to aspiration (as noted
above). Per last Video Swallow evaluation, Mr. [**Known lastname **] had
experienced a bit of relief from his dysphagia with biofeedback
swallowing training, and progressed from strict NPO to ground
solids and nectar thick liquids.
.
# Hypoxemia: Upon admission, Mr. [**Known lastname **] was treated for a HCAP
with 8 days of vanc/zosyn/levofloxacin. Initially Mr. [**Known lastname **]
had an oxygen requirement which improved with treatment of his
pneumonia. He experienced hypoxemia on [**1-20**] following completion
of antibiotics which improved spontaneously several hours later
and was likely secondary to a mucous plugging episode. A similar
event occurred on [**2-3**] and improved with aggressive pulmonary
toilet. A component of aspiration is also likely as Mr. [**Known lastname **]
has known microaspiration/penetration on videoswallow
evaluation. He had no further desaturations after being made
NPO.
.
#Hypotension: On admission SBP was persistently in the 70s-80s
with improvement following IVF administration. This likely
represented sepsis [**12-19**] HCAP given fever, chills and bandemia
seen at the OSH. Although no e/o SBP on the basis of OSH
diagnostic paracentesis, systemic infection with possible
intrabdominal source could not be excluded. He was therefore
started on Vanc/Cefepime from empiric coverage of HCAP. Pt's
goal map of 65 was maintained prior to transfer to the floor.
On the floor BP's remained stable and he was disconrtinued from
antibiotics on [**1-23**]. Midodrine was continued thereafter with SBP
ranging from 80-90.
Medications on Admission:
Vancomycin 1000 mg IV x1
Ceftriaxone 1g IV x1
Folate 1 mg PO qd
Lactobacillus 1 tab PO qd
Omeprazole 20 mg PO qd
Sertraline 50 mg PO qd
VitD 800 IU PO qd
Zinc sulfate 220 mg PO qd
Gabapentin 100 mg PO tid
Lactulose 30 ml PO tid
Ascorbic acid 500 mg PO bid
Ondansetron 4 mg IV q6-8h prn
Discharge Medications:
1. folic acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO QID (4
times a day).
4. rifaximin 550 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
5. B complex-vitamin C-folic acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
6. midodrine 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a
day).
7. trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
8. thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
10. zinc sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q2H (every 2 hours) as
needed for shortness of breath.
12. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
13. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
14. haloperidol 0.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
15. fluoxetine 10 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Alcoholic cirrhosis
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 **],
It was a pleasure caring for you at [**Hospital1 18**]. You were initially
transferred from another hospital to our intensive care unit.
You were quite sick and developed kidney failure due to your
worsening liver disease. Dialysis was initiated due to this
kidney failure. You continued to be very confused after
dialysis was started and required medications to help this.
Upon discussions with you and your family, we have decided not
to pursue aggressive measures like resuscitation (chest
compressions and shocks) and intubation (breathing tube) should
your heart stop pumping or you stop breathing. Your "code
status" has been changed to DNR/DNI to reflect this wish.
You will continue on dialysis outside of the hospital at your
rehabilitation facility. Remember that any further alcohol
intake could kill you and you should avoid this at all costs.
Further information about possible liver transplant will be
provided to you once you have maintained sobriety for at least 3
months once you return home from the rehabilitation facility.
You will be discharged with a feeding tube in place because your
swallowing muscles are weak and you are at risk of aspirating
foods and liquids which can cause a dangerous pneumonia. Once
the medical staff determines that you are safe to swallow, the
tube can come out. You will receive your medications through
the tube as well.
We have made the following changes to your medications:
STOP spironolactone, sucralfate, metoprolol, omeprazole, and
gabapentin, furosemide
START lansoprazole instead of omeprazole while you have your
feeding tube
START midodrine 15mg three times a day to keep your blood
pressure up for dialysis
START lactulose and rifaximin to prevent your episodes of
confusion from returning
START folic acid and thiamine for your nutrition
START trazadone as needed for sleep
START nephrocaps for nutrition while on dialysis
START Vitamin D
START Zinc
START Albuterol and ipratropium as needed for shortness of
breath
Followup Instructions:
Once you are discharged from the rehabilitation facility, you
should call [**Hospital3 **] to schedule an appointment
with Dr. [**First Name8 (NamePattern2) 7568**] [**Last Name (NamePattern1) 12130**] at ([**Telephone/Fax (1) 30825**].
.
With: Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 7033**]
When: Wednesday, [**3-12**]
Department: LIVER CENTER
Location: [**Hospital1 **]
Phone: [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 0389, 5070, 486, 5849, 2761, 2762, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 980
} | Medical Text: Admission Date: [**2178-12-25**] Discharge Date: [**2178-12-30**]
Date of Birth: [**2139-10-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
Cardiac cath: no CAD
History of Present Illness:
39 yo f w/ h/o hypothyroid, type II DM who started to complain
of flu-like sx with generalized malaise, headache, neck and
[**First Name3 (LF) 93073**] pain approx 6d ago after going to a chinese restaurant
where all of her family members got nausea/diarrhea. According
to husband, [**Name (NI) 93073**] pain radiating around to abdomen in
"bandlike" pattern. Remained in bed most of next two days. Had
decreased p.o. intake, on Wed went to PCP, [**Name10 (NameIs) **] on NSAIDS,
flexaril, vicodin. Pt still complained of increased lethargy
that evening and brought to OSH ED where her glucose was 744, ag
28, bicarb 5, ph 6.9. Amylase 99, lipase 656 and ARF w/ cr 1.4.
Also WBC 18.7 w/ 17% bandemia. She was started on insulin gtt,
sodium bicarb, and IVF. CXR was clear, RUQ u/s w/o evidence of
cholelithiasis, of dilated CBD. Head CT neg. Started on
cefotax and levoflox on [**12-25**]. TTE reported to show anterior
and lateral and apical HK w/ EF 40%. Lipase peaked at 1649.
Glucose difficult to control and pt transferred to [**Hospital1 18**].
Past Medical History:
hypothyrodism
DM II- not taking meds for last 3 months.
Social History:
Marries w/ 2 children
Works at Catholic charity
Denies Etoh
Denies Tobacco
Denies IVDU.
Family History:
Father DM
Paternal GM DM
Mother died of MI at 69.
No h/o pancreatitis.
Physical Exam:
t 97.2, bp 106/68, p 124, r 17, 100% ra
Middle aged woman, resting in bed, w/ fluctuating ability to
hold a conversation.
PERRL.
OP clear. No JVD
Dry mucous membranes
LCA b/l
Bony protrusion of R cervical area of c6-7 area. Minimally
tender, no surrounding erythema, no flocculence.
+bs. soft. nt. nd. Horizontal stretch marks on both sides of
her abdomen.
No le edema.
Pertinent Results:
[**2178-12-26**] 04:24AM BLOOD WBC-13.8* RBC-3.55* Hgb-11.8* Hct-31.4*
MCV-89 MCH-33.2* MCHC-37.5* RDW-13.6 Plt Ct-127*
[**2178-12-26**] 04:24AM BLOOD Neuts-75.6* Lymphs-20.8 Monos-3.0 Eos-0.3
Baso-0.3
CXR: no acute cardiopulm dz
CT ABD/PELVIS: Small amount of nonspecific free fluid within the
pelvis and minimal right sided pleural effusion. Otherwise,
normal CT of the abdomen and pelvis.
CATH: a right dominant system with no angiographically apparent
flow limiting stenoses. The LMCA, LAD, and RCA had minimal
luminal irregularities. The patent LCX supplied 2 OMs. The
cardiac index was normal (3.5 l/min/m2). Left ventriculography
showed global hypokinesis (EF 40 to 45%) with no mitral
regurgitation.
Brief Hospital Course:
1) [**Name (NI) 75996**] Pt has a hx of Type II DM with no requirement of insulin
and was only on oral hypoglycemic [**Doctor Last Name 360**] previously. Pt
presesnted to the OSH with DKA and was managed in the ICU with
insulin drip, fluid resuccitation, and electrolyte replacement.
[**Last Name (un) **] was following her and started the patient on insulin (15
units glargine qhs, and humalog ISS). She may have a late onset
of Type I DM, or this could be secondary to pancreatitis with
beta cell dysfunction. She will be discharged with insulin and
a follow up with [**Last Name (un) **].
2) GPC bacteremia- Pt presented with 1/1 bottle GPC +blood cx at
OSH. It was most likely contaminant since it grew out staph.
epi at OSH. Vancomycin was initially started but discontinued
once repeat blood cultures were negative.
3) Pancreatitis-unclear diagnosis given relatively benign
presentation. Enzymes elevated out of proportion to clinical
symptoms but trended down on it's own. At OSH, triglycerides
and calcium were normal. Pt has no history of alcohol abuse and
denies any recent binge. CT of the abdomen/pelvis were normal.
It only showed small amount of nonspecific free fluid within the
pelvis and minimal right sided pleural effusion. Since pt had a
flu-like sx several days prior to these events, pancreatitis
could be from viral infection as well.
4) Systolic dysfunction- At OSH, TTE was ordered which showed EF
of 40%. The repeat TTE showed EF of 35%, moderate regional left
ventricular systolic dysfunction with focal hypokinesis of the
distal half of the septum and anterior walls and apex. The
remaining segments contract well. Right ventricular chamber size
is normal with mild global free wall hypokinesis consistent with
possible mid-LAD disease. Pt was taken to cath which showed
clean coronaries. Work up for cardiomyapathy including
SPEP/UPEP, iron studies, [**Doctor First Name **], rheumatoid factor, Lyme titer.
HIV study was not sent since she is does not have any risk
factor. Given the hx of flu-like sx, it could be from viral
etiology such as coxsacke virus which could also cause
pancreatitis which may have led to DKA. Pt should be seen by
Dr.[**Name (NI) 23312**] [**Hospital 1902**] clinic and should have a follow up echo in few
months. Pt was discharged with Toprol 25 mg qd, lisinopril 2.5
mg qd, and ASA 81 mg qd. Lisinopril was not titrated since sBP
runs in 80's-90's at baseline.
5)Hypothyroid: Pt's TSH and free T4 level were consistent with
hypothyroid. She was continued on Synthroid 150 mcg po qd.
6)Spine mass: Pt reports having painful spine bony protusion
for the last 2 years. She says that the pain is intermittent
and is paraspinal. On exam, she has a mass that is firm
consistent with bone, nontender to palpation that is at C5-C6
level. She has never gotten a work up for this. Pt should get
an outpatient MRI of the spine for further evaluation.
Medications on Admission:
On transfer:
Cefotaxime
Levoflox
Insulin gtt 7 units/h
Diflucan 100mg iv q24h
Synthroid 150mcg qday
Discharge Medications:
1. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. insulin
Take Glargine insulin 15 units at bedtime, and take Humalog
sliding scale as printed
4. insulin syringes and needles
Please give 120 syringes and needles, with 2 refills
5. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. ketone strips Sig: One (1) as needed.
Disp:*30 * Refills:*2*
7. Outpatient Lab Work
Serum Potassium within 2 weeks of discharge
8. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO at bedtime.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: Per sliding scale.
Disp:*1 vial* Refills:*2*
10. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
Disp:*10 ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Primary:
1. diabetic ketoacidosis
2. depressed ejection fraction/systolic dysfunction
Secondary:
1. hypothyroidism
2. tachycardia
Discharge Condition:
stable, tolerating po, ambulating
Discharge Instructions:
Please keep all of your appointments and take all of your
medicine. You should have your potassium checked within 2 weeks.
You will need to check your sugars 4 times a day and give
yourself insulin as prescribed on the insulin sliding scale. You
should call the [**Hospital **] clinic with any questions.
You should call your doctor or come to the hospital if you
experience chest pain, shortnes of breath, fevers or other
concerning symtpoms.
Followup Instructions:
1)[**Last Name (un) **]
-Thursday [**1-7**] MB [**Name8 (MD) 46218**] RN
-[**1-15**] 9:30am Dr. [**Last Name (STitle) **]
2) Cardiology: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Where: [**Hospital 273**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2179-1-14**]
2:00
Please call to make an appointment with a primary care doctor.
The number for the clinic is ([**Telephone/Fax (1) 1300**].Provider: [**First Name8 (NamePattern2) **]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital3 249**]
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2179-1-13**] 2:00
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16701**] [**Hospital 1902**] clinic to make an appointment in
[**2-6**] weeks. [**Telephone/Fax (1) 3512**]
Completed by:[**2178-12-30**]
ICD9 Codes: 2875, 2765, 4254, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 981
} | Medical Text: Admission Date: [**2199-6-13**] Discharge Date: [**2199-7-3**]
Date of Birth: [**2142-6-14**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
male with history of type 1 diabetes, status post cadaveric
renal transplant 1?????? years prior to admission, who presented
to his primary care physician with fevers for the past week.
He had a low grade fever approximately one week prior to
admission and felt some chills. These symptoms subsequently
improved but returned on the day of admission and his
temperature was 101.5 at home. He was admitted directly to
medical service.
PAST MEDICAL HISTORY: Type 1 diabetes diagnosed at 14 years
of age, neuropathy. He uses leg braces and walker,
retinopathy. He is status post laser surgery three years
ago. Chronic end stage renal disease on dialysis from [**2194**]
to [**2192**]. History of peritonitis while on dialysis. He is
status post cadaveric renal transplant [**2197-10-25**]. He has
a history of acute rejection in [**2197-12-26**] treated with
OKT3, history of hip fracture in [**2198-2-24**] status post hip
arthroplasty at that time, history of hypertension, history
of hypercholesterolemia, chronic hiccups, coronary artery
disease, GERD.
MEDICATIONS: On admission, insulin NPH 25 units q a.m., 6
units q p.m., Regular insulin sliding scale, Rapamycin 2 mg
po q d, Prednisone 10 mg po q d, Lipitor 10 mg po q d, Lasix
20 mg po q d, Prograf 4 mg po bid, Reglan 10 mg po bid,
Prilosec 20 mg po bid, calcium 1500 mg po q d.
ALLERGIES: Penicillin causes nausea.
HOSPITAL COURSE: The patient was admitted to medical
service. His temperature on admission was 101.3, blood
pressure 140/70, heart rate 80 saturating 100% on room air.
His white count was 34, hematocrit 36.2, platelet count
291,000, sodium 137, potassium 5.1, chloride 101, CO2 20, BUN
43, creatinine 2 and blood sugar 346. His ALT was 75, AST
96, alkaline phosphatase 180, bilirubin 0.5. He underwent
chest x-ray which showed no signs of infiltrate. His abdomen
was nontender and non distended with no signs of peritoneal
irritation. The patient was placed on Zosyn empirically and
his white count started to come down. He underwent
ultrasound which showed stones and sludge in the gallbladder
and common bile duct and signs of cholecystitis. ERCP
consult was called and he underwent ERCP for diagnosis of
cholecystitis and cholangitis. Sphincterotomy was done during
ERCP and multiple stones and sludge were extracted
successfully. There were no remaining stones in the common
bile duct at the end of procedure. The patient was
maintained on Zosyn and he underwent interval cholecystectomy
on [**2199-6-19**]. An attempt to remove gallbladder
laparoscopically was made but the gallbladder was very
inflamed and the procedure had to be converted to open
cholecystectomy. He tolerated the procedure well without
complications. He did well initially postoperatively but
then he noticed to have an increased scleral icterus. His
LFTs were checked and his alkaline phosphatase was 671 with
bilirubin going up to 6.4. His amylase and lipase were
normal. His creatinine was also rising up to 2.2. He
underwent another ERCP which showed dilatation of CVD and
multiple blood clots in common bile duct along with one
yellow stone. The sphincterotomy site was bicapped for
possibility of bleeding from the sphincterotomy site and
double pigtail stent was placed into common bile duct for
drainage. After this ERCP bilirubin peaked at 7.4 with
alkaline phosphatase at 1100 and then started to slowly
decrease. White count at the time was ranging between 12 and
17. He was afebrile. His blood sugars were under good
control. He was tolerating regular diet. On post ERCP day
#4, the patient was noticed to be passing several stools with
blood clots. He became lightheaded and his hematocrit
dropped from 29 to 24 and urgent ERCP was done which showed
oozing from the sphincterotomy site with pulsating vessel on
the bottom and stent eroding injury in sphincterotomy. Due
to close proximity of the sphincterotomy site to pancreatic
duct, BICAP could not be applied anymore but the vessel was
injected with Epinephrine several times and seemed to stop.
The patient was admitted to surgical ICU for close
observation and serial hematocrits. He was transfused
several units of packed red blood cells around the ERCP but
then his hematocrits were stable. He was eventually
transferred back from the surgical ICU to regular floor and
his diet was slowly advanced. He tolerated this well. He
was discharged home on postoperative day #14. At the time of
discharge he was afebrile, stable, with heart rate of 73,
blood pressure 140/60, blood sugars were well controlled. On
the day of discharge his white count was 16.7, hematocrit
26.3 which was stable, platelet count 308,000, sodium 141,
potassium 4.1, chloride 104, CO2 26, BUN 20 and creatinine
1.3, glucose in the morning was 94. His FK levels were 16.3
on discharge.
DISCHARGE MEDICATIONS: Included Prednisone 5 mg po q d,
Prograf 4 mg po bid, Rapamycin 5 mg po q d, Norvasc 5 mg po q
d, Lopressor 50 mg po bid, Flomax 0.4 mg po q d, Calcium 1500
mg po q d, Prilosec, Lipitor, NPH insulin 25 units subcu q
a.m. and 6 units subcu q p.m. and iron supplements. He is
also taking Reglan and Colace.
FOLLOW-UP: He will follow-up with Dr. [**Last Name (STitle) **] on Monday
following discharge and with Dr. [**Last Name (STitle) **] from ERCP in two
months for removal of his stent.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Name8 (MD) 20287**]
MEDQUIST36
D: [**2199-7-4**] 10:25
T: [**2199-7-9**] 08:07
JOB#: [**Job Number 20288**]
ICD9 Codes: 2851, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 982
} | Medical Text: Admission Date: [**2118-8-5**] Discharge Date: [**2118-8-25**]
Date of Birth: [**2094-5-3**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 24-year-old male with
past medical history significant for bilateral PE with
bilateral pleural effusions and pericardial effusions in [**2118-6-3**] requiring extensive MICU stay and prolonged
hospitalization. Since discharge, the patient had been
reasonably well, however, over the week prior to admission he
developed onset of pleuritic right sided anterior chest pain
associated with exertional dyspnea. Emergency Room
evaluation done at that time revealed no new clot by CTA but
revealed a right atrial abnormality. Follow-up echo showed
echo dense space intimately associated with either the
pericardium or the pleural space. The patient was
hemodynamically stable without pulses paradoxus or tamponade.
Repeat echo 7 days later was done with stability in the
patient's symptoms. Echo at this time showed increased size
of the right sided loculated pericardial effusion with
diastolic compression of the RV. Chest x-ray showed increase
in heart size. In clinic on the day of admission the patient
was hemodynamically stable. EKG showed ST elevations in 2,
3, and AVF with PR depressions in 3 and a pulsus paradoxus of
10. The patient was sent to the Emergency Room for
admission.
PAST MEDICAL HISTORY: Pericardial effusion status post
drainage with pigtail catheter in [**2118-6-3**] with negative
rheumatologic malignant and infectious work-up. Bilateral
pleural effusion status post pigtail drainage of the right
with negative work-up as well for rheumatologic infectious
disease and malignancy, bilateral pulmonary emboli diagnosed
in [**2118-6-3**], treated with Heparin initially and currently
anticoagulated on Coumadin, history of heterozygosity for
factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**] mutation.
MEDICATIONS: Coumadin 8 mg q day, Tylenol 650 mg prn.
ALLERGIES: None known.
SOCIAL HISTORY: He is a heterosexual male in a monogamous
relationship. He denies tobacco, denies drug use, used
alcohol in the past prior to his [**Month (only) **] hospitalization of
greater than 30 beers per week. He is from Great [**Last Name (un) 35668**]
and is a sailor.
FAMILY HISTORY: Grandfather had [**Name2 (NI) 499**] cancer and also a
grandparent with lung cancer.
PHYSICAL EXAMINATION: Temperature 99.0, heart rate 90-106,
blood pressure 128/76, respirations 12, satting 99% on room
air. In general, in no apparent distress sitting in bed.
HEENT: Pupils equally round and reactive to light, moist
mucus membranes, JVD approximately 4-5 cm above the right
atrium. Cardiovascular, regular rate and rhythm, no murmurs,
rubs, gallops. Respirations clear to auscultation
bilaterally. Abdomen soft, nontender, normoactive bowel
sounds. Extremities, no clubbing, cyanosis or edema.
Neurologically alert and oriented times three, grossly non
focal.
LABORATORY DATA: On admission, white count 6.3, neutrophils
58, 0 bands, 33 lymphs, 7 monos, 2 eos, hematocrit of 34.1,
platelet count 270,000, sodium 141, potassium 4.6, chloride
105, CO2 21, BUN 12, creatinine 0.9, glucose 93. Chest x-ray
as dictated in the HPI. EKG showed normal sinus rhythm, left
and right atrial abnormalities, 1-2 mm ST segment elevations
in leads 2, 3, and F, PR depression in 2. ST elevations were
new compared to EKG from [**6-3**].
HOSPITAL COURSE: The patient was admitted initially to the
medicine service where cardiothoracic consultation was
obtained for his pericardial effusion. Initially this was
thought secondary to recurrent pericarditis. Plans were made
for going to the OR for pericardial window. On [**2118-8-9**] the
patient was taken to the operating room by cardiothoracic
surgery for pericardial window. At the time of surgery,
transesophageal echocardiogram was performed and showed
abnormality in the right atrium consistent with perforation
with overlying clots and fluid loculated on pericardial
effusion. At this time plans were suspended for pericardial
window with plans for medial sternotomy in [**1-4**] days for
repair of right atrial abnormality. The patient was
transferred to the Coronary Care Unit overnight where he
remained hemodynamically stable. He was taken to the
operating room again on [**2118-8-11**] where the patient underwent
median sternotomy with exploration of his cardiac anatomy.
At the time of surgery multiple tumor nodules were noted
within the pericardium and eroding into the right atrium.
Major debulking occurred at the time. The right atrium was
closed and pericardial partial stripping was performed.
Hemostasis was achieved. The patient was transferred in
stable condition from the OR to the cardiac surgery Intensive
Care Unit where he remained intubated for 24 hours. He was
extubated on [**2118-8-12**] without complication. His postoperative
course was complicated by significant blood loss requiring a
number of blood transfusions to maintain a hematocrit between
25 and 30. His chest tubes and mediastinal tubes were
removed without complication on postoperative day #3. On
postoperative day #4 anticoagulation for history of bilateral
pulmonary emboli was reinitiated with IV unfractionated
Heparin without a bolus. Within 8-10 hours of reinstitution
of anticoagulation the patient became tachypneic, tachycardic
and hypoxic. At that time it was noted to have a large
re-accumulation of fluid in his right hemithorax on chest
x-ray as well as a small pneumothorax. Cardiothoracic
surgery inserted 32 French chest tube at the bedside without
complication. Drainage of 2 liters of bloody fluid was
yielded. Patient's anticoagulation was stopped and reversed
with Protamine at that time. The patient obtained
hemodynamic stability and his chest tubes were discontinued
without complications on postoperative day #7. Follow-up
chest x-ray throughout the remainder of the hospital course
showed resolution of the patient's pneumothorax and stability
in a small right sided pleural effusion. Follow-up CAT scan
revealed abnormality consistent with tumor and postoperative
changes along the right cardiac border with bilateral
atelectasis. No pulmonary metastases. Follow-up staging
abdominal CT was performed during this hospitalization which
revealed no evidence of metastases, showed a small right
inguinal seroma.
Infectious Disease: The patient began spiking fevers on
postoperative day #1, up to 104 degrees. Multiple cultures
were obtained which remained negative. Infectious disease
was consulted initially. The patient was placed briefly on
Vancomycin and Ceftaz but after pan CT revealed no evidence
of fluid collection or infectious etiology, these antibiotics
were discontinued. The patient's fever curve trended down
throughout his admission without any evidence of bacterial
etiology to his fevers. The thought was the fevers were
secondary to tumor fever. Upon discharge the patient's fever
curve had been trending down with occasional low grade
temperatures.
Heme: The patient's anticoagulation was initially restarted
but after re-complication with hemopneumothorax, was
discontinued and not restarted. The risks and benefits of
anticoagulation were weighed. Given the remainder of tumor
still involved in the cardiac tissue and the risk of bleed,
it was decided not to re-anticoagulate the patient for
several weeks, if ever. The patient required several blood
transfusions, platelet transfusions, FFP and cryoprecipitates
during his surgery and occasionally after to maintain
hematocrit between 25-30. Upon discharge the patient's
hematocrit was stable for 4-5 days at 26??????. He had no signs
of bleeding. He will avoid non steroidals as they may
increase his risk of bleeding.
Cardiovascular: As above. The patient developed a new
pericardial friction rub during this admission after his
operative course. Echocardiogram was performed on [**8-21**] to
evaluate this pericardial friction rub which revealed no
pericardial effusion, stable LV and RV function. The patient
had some tachycardia that resolved by discharge.
Pain: The patient had significant chest discomfort during
this hospitalization which initially required PCA. He was
transitioned to OxyContin with Percocet for breakthrough and
was discharged on 30 mg q a.m., 20 mg of OxyContin q p.m. and
Percocet for breakthrough.
Renal: The patient's kidney function remained stable
throughout this hospitalization.
Pulmonary: The patient had to rule out the possibility of
DVT leading to PE secondary to concerns over his chest pain.
This was negative on [**2118-8-24**]. The patient will not be
re-anticoagulated secondary to concerns of his bleed. The
patient's oxygen saturation was maintained between 94 and 95%
on room air at the time of discharge.
Fluids, Electrolytes & Nutrition: The patient was tolerating
full diet on discharge. He required intermittent
electrolytes repletion during his hospitalization.
Heme/Onc: Patient's tumor at resection was sent to
pathology. Pathologic diagnosis revealed angiosarcoma of low
grade type. Heme/Onc was consulted immediately
postoperatively. Plans were made for chemotherapy as an
outpatient vs transfer back to the United Kingdom for
treatment there. The patient will follow-up with Dr. [**First Name8 (NamePattern2) 189**]
[**Last Name (NamePattern1) **] on [**2118-9-2**] for arrangement of his chemotherapy at a
time when he is fully healed from his cardiothoracic surgery.
Social Work: The patient was seen extensively by social work
and case management during this hospitalization. Plans were
made for living situation upon discharge as the patient is
from Great [**Last Name (un) 35668**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 35669**] was instrumental in
arranging this. Patient was discharged on [**2118-8-25**] to home.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSIS:
1. Angiosarcoma of cardiac origin.
2. Right atrial perforation secondary to tumor.
3. Pericardial effusion causing tamponade physiology.
4. Anemia secondary to blood loss as a complication of
cardiothoracic surgery.
5. History of bilateral pulmonary embolus.
6. Status post hemopneumothorax.
7. Postoperative chest pain.
DISCHARGE MEDICATIONS: OxyContin 30 mg q a.m., 20 mg q p.m.,
Percocet 5/325 1-2 tablets po q 4-6 hours prn for
breakthrough pain, Colace 100 mg [**Hospital1 **], Zantac 150 mg [**Hospital1 **] and
Bacitracin topically to affected areas tid.
FOLLOW-UP: He will follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3640**] on [**2118-9-9**] at 3:30 p.m. in the
clinical center, [**Hospital Ward Name 23**] Bldg., [**Location (un) **]. He will also
follow-up with Dr. [**First Name8 (NamePattern2) 189**] [**Last Name (NamePattern1) **] on [**2118-9-2**] in the
clinical center, [**Location (un) **].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 35670**]
MEDQUIST36
D: [**2118-8-26**] 10:00
T: [**2118-8-30**] 16:07
JOB#: [**Job Number **]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 983
} | Medical Text: Admission Date: [**2157-7-15**] Discharge Date: [**2157-7-18**]
Date of Birth: [**2111-12-11**] Sex: M
Service: CORONARY CRITICAL CARE
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old man
who reports that he had had progressive shortness of breath
and occasional chest pain for the past several years,
especially with exertion. The patient was admitted in
[**Month (only) 404**] of last year, ruled out for myocardial infarction but
was diagnosed with hypertrophic obstructive cardiomyopathy
after transesophageal echocardiogram showed dynamic outflow
obstruction with a peak gradient of 32. A subsequent
catheter showed a systolic gradient of 130 after PVC and 96
after Valsalva. Trial of medical management failed to
relieve the patient's symptoms, as did a prior alcohol septal
ablation in [**2156-12-11**]. Therefore, the patient was
brought to catheter lab on the day of admission for a second
more aggressive alcohol ablation. In the catheter lab here,
the patient's systolic gradient was noted to be absent,
however it was seen to rise to 100 mmHg with dobutamine
stress. The initial septal artery was noted to be absent and
the second septal artery which had two branches, both of
which were injected with ethanol and that resulted in the
complete resolution of the gradient even with dobutamine
stress in the lab. The patient was brought to the Coronary
Critical Care Unit with 6/10 chest pain, however he had no
shortness of breath, diaphoresis, nausea or vomiting when he
arrived on the unit.
PAST MEDICAL HISTORY:
1. Hypertrophic cardiomyopathy
2. Hypercholesterolemia
MEDICATIONS PRIOR TO ARRIVING HERE:
1. Aspirin 325 mg q day
2. Verapamil 180 mg q day
3. Metoprolol 50 mg q day
PHYSICAL EXAM:
VITAL SIGNS: Temperature 96.3??????, pulse 72, blood pressure
125/78, respiratory rate 16. Patient was saturating 98% on
room air.
GENERAL: He is alert and oriented x3 in no acute distress,
obese middle aged man.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils were equal, round
and reactive to light. Mucous membranes were moist. His
oropharynx was clear.
NECK: He had no jugular venous distention, elevation while
lying flat. The patient had no thyromegaly. The patient had
no lymphadenopathy.
CARDIOVASCULAR: He had a regular rate, normal S1, normal S2
and no murmurs when he presented to the unit.
LUNGS: Clear to auscultation bilaterally. No wheezes.
EXTREMITIES: He had 2+ dorsalis pedis and posterior tibialis
pulses bilaterally. No thrill, hematoma or bruit over either
catheter site.
LABS UPON ADMISSION: Chem-7: Sodium 141, potassium 4.1,
chloride 104, bicarbonate 25, BUN 18, creatinine 0.8, glucose
101. His CK was 1237. CK/MB was 175. His index was 14.1.
His white blood cell count was 12.1, hemoglobin 14.4,
hematocrit 39.9, platelets 289. His second CK was 1874 with
a CK/MB of 281 and index of 15. His third CK on [**7-16**],
the second day of admission, was 1,119 with a CK/MB of 59 and
an index of 5.3. Fasting lipid profile was drawn on [**7-16**]
which showed a triglyceride level of 178, HDL 41 and an LDL
of 137 with a cholesterol to HDL index of 5.2.
HOSPITAL COURSE:
1. CARDIOVASCULAR: A. Coronary artery disease: The
patient had no known coronary artery disease, however he
demonstrated increased LDL on the fasting lipid profile and
has a history of hyperlipidemia. The patient should be
keeping his LDL under 100 in light of his compromised
cardiovascular situation. The patient was started on 20 mg q
day of Lipitor for his hyperlipidemia. The patient was
continued on his once a day aspirin regimen. B. Pump: The
patient's outflow gradient seemed to be decreased based on an
echocardiogram done in the catheter lab, but it was not clear
if the patient will have clinical improvement. The patient
had a quick CK washout as expected and peaked adequately
indicating good septal ablation. Serial electrocardiograms
showed evidence of a right bundle branch block that was
consistent with his prior electrocardiogram, but no other
evidence of AV conduction block. The patient was sent home
with 100 q day of atenolol and 240 mg q day of Verapamil. C.
Rhythm: The patient was placed on a prophylactic transvenous
pacer due to the high risk of complete heart block with
septal ablation. He was conducting on his own throughout his
hospitalization and his pacer was not needed to capture
beats. The transvenous pacer was removed on the day prior to
discharge. The patient had no evidence of heart block
throughout the hospitalization.
2. PULMONARY: The patient saturated well on room air
throughout his hospitalization.
3. RENAL: Serial chem-7 showed no adverse effect from the
large dye load the patient received in the catheter lab.
4. FLUIDS, ELECTROLYTES AND NUTRITION/GASTROINTESTINAL: No
issues.
5. INFECTIOUS DISEASE: The patient spiked a temperature to
104?????? on hospital day #2. Pan cultures were negative at the
time of discharge with no growth to date. Chest x-ray was
normal. The patient was thought to have spiked a fever as
the result of possibly atelectasis or potentially as a
symptom of alcohol withdrawal for which he was given Ativan
x1, however the patient had no other symptoms of alcohol
withdrawal, as he is a binge drinker reporting 12 drinks per
week all on the same occasion. The patient was monitored per
the CIWA protocol and the only evidence of withdrawal was the
fever. Low index is suspicion for alcohol withdrawal for his
hospitalization.
6. PROPHYLAXIS: The patient was given Protonix throughout
his hospitalization and docusate throughout his
hospitalization.
DISPOSITION: The patient was discharged to home.
DISCHARGE CONDITION: Good
DISCHARGE DIAGNOSES:
1. Hypertrophic obstructive cardiomyopathy, status post
septal ablation
2. Hyperlipidemia
3. Right bundle branch block
4. Alcohol withdrawal
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 11117**]
MEDQUIST36
D: [**2157-7-18**] 11:54
T: [**2157-7-18**] 12:15
JOB#: [**Job Number 36367**]
cc: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36368**] AT [**PO Box 36369**] BUCKSPORT, [**Numeric Identifier 36370**]
[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] AT ONE EVERGREEN [**Doctor Last Name **], [**Street Address(2) 36371**], [**Location (un) 36372**], [**Numeric Identifier 36373**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D., [**Location (un) **], [**Location (un) **], [**Numeric Identifier 36374**]
ICD9 Codes: 4254, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 984
} | Medical Text: Admission Date: [**2162-3-11**] Discharge Date: [**2162-3-31**]
Service: SURGERY
Allergies:
Univasc
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Abdominal pain, GI bleed
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube placement [**3-15**]
RUQ biloma drainage [**3-21**]
PICC line placement [**3-23**]
History of Present Illness:
Ms. [**Known lastname 18915**] is a 89 yo [**Location 7972**] female with HTN, HL, h/o
treated H. pylori infection, iron deficiency anemia, on coumadin
for pulmonary emboli diagnosed on [**2162-1-18**], poor historian who
presented to her PCP's office today for a scheduled visit. She
complained of intermittent epigastric pain and nausea and was
found to have epigastric tenderness on exam with guaiac positive
stool. Her Hct from [**2162-3-5**] was 29, decreased from her baseline
Hct 31-33, so her PCP referred her to ED for further evaluation.
Pt is not routinely on NSAIDs. She recalls taking some pain
medications for neck pain a few days ago but does not know which
one. She denies any alcohol use. She only drinks decaf coffee
and denies any acidic or fatty foods. She denies any fevers,
chills, night sweats, weight loss, appetite changes, early
satiety, or abdominal bloating. She denies any recent changes in
her stools, although they are dark at times and often hard; she
is on iron supplements. Of note, on her last admission, there
was concern for occult GI malignancy given her iron deficiency
anemia and monocytosis, but her last colonoscopy on [**2161-12-28**]
showed only internal hemorrhoids. No family history of GI
malignancy.
.
In the ED, initial VS were: T 98.6, P 80, BP 119/57, RR 18,
O2sat 100. Exam was notable for epigastric tenderness but guaiac
negative stools. EKG showed TWI in V3-5 TWI c/w prior. Hct was
28.5, stable from [**3-5**]. INR was 4; the decision was made not to
reverse given her recent large burden PE. GI was consulted and
initially recommended NG lavage, but this deferred given her
elevated INR. Patient was given pantoprazole 40 mg IV. Vitals on
transfer were BP 120/51, HR 66, RR 19, O2sat 99% on O2.
Past Medical History:
Hypertension
Hyperlipidemia
Iron deficiency anemia
Monocytosis
S/p H. pylori treatment in [**10-25**]
Social History:
She is a nonsmoker, does not drink alcohol or use illicit drugs.
Lives with family.
Family History:
No FH of CAD/MI, no history of malignancy
Physical Exam:
Vitals: T 98, BP 143/75, P 66, RR 18, O2sat 95% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: BS+, soft, mild tenderness over epigastrium without
guarding or rebound, non-distended, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAO x 3, CN II-XII intact, strength 5/5, toes downgoing
on Babinski, gait not assessed.
Pertinent Results:
[**2162-3-10**] 08:30PM GLUCOSE-110* UREA N-16 CREAT-0.7 SODIUM-139
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
[**2162-3-10**] 08:30PM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-78 TOT
BILI-0.3
[**2162-3-10**] 08:30PM LIPASE-33
[**2162-3-10**] 08:30PM ALBUMIN-3.4*
[**2162-3-10**] 08:30PM WBC-7.7 RBC-3.43* HGB-8.6* HCT-28.5* MCV-83
MCH-25.1* MCHC-30.2* RDW-17.4*
[**2162-3-10**] 08:30PM NEUTS-57.6 LYMPHS-26.0 MONOS-14.7* EOS-1.2
BASOS-0.4
[**2162-3-10**] 08:30PM PLT COUNT-238
[**2162-3-10**] 08:30PM PT-38.2* PTT-33.9 INR(PT)-4.0*
.
CT torso [**3-12**]:
IMPRESSION:
1. Large mass involving the gastric body and antrum with
associated
perigastric lymphadenopathy.
2. Dilation of the CBD appears somewhat increased from the prior
study.
Although this may represent papillary stenosis, if there is
concern based on laboratory data for obstruction of the lower
CBD, ERCP could be considered.
3. Emphysema. Abrupt caliber change of right pulmonary artery,
which may
relate to prior PE.
4. AAA with ulcerated plaque, with the AAA measuring 3.2 cm.
.
KUB [**3-14**]:
IMPRESSION:
1. Nonobstructed bowel gas pattern.
2. Large gastric mass, more fully characterized on recent CT.
3. Bibasilar atelectasis.
Brief Hospital Course:
This is an 89 year old female with hx of PE, iron deficiency
anemia, and monocytosis on peripheral smear admitted for
abdominal pain and guaiac positive stools and newly diagnosed
with a 10cm gastric adenocarcinoma with hospital course
complicated by acute cholecystitis requiring percutaneous
cholecystostomy tube placement, now with RUQ abscesses vs.
biloma from a likely gallbladder perforation and C Diff colitis.
.
#. RUQ biloma: The patient developed increasing RUQ abdominal
pain throughout the day on [**3-20**]. A CT abdomen was performed and
revealed interval formation and enlargement of two likely
abscesses vs biloma seen immediately posterior and medial to the
gallbladder. IR drained one of these fluid collections on [**3-21**],
but could not reach the second. The fluid removed was not
frankly purulent and it is likely that the patient's gallbladder
has perforated and is leaking bile into her peritoneum and RUQ
causing peritoneal irritation and pain.
.
#. C Diff colitis: The patient developed diarrhea with 10 bowel
movements and increased abdominal pain on [**3-22**] and a stool sample
at that time was positive for C Diff toxin. This is the likely
explanation for her increased WBC count to a peak of 19.2 on
[**3-22**]. The patient was started on [**Doctor Last Name **] co PO 125 mg q6 starting
[**3-22**] and Flagyl was added on [**2162-3-27**].
.
#. Gastric Adenocarcinoma: The patient has a new diagnosis of
gastric adenocarcinoma with a large 10cm mass in her gastric
antrum found on EGD. A staging CT showed only perigastric
lymphadenopathy. The family would not like the patient to be
told she has cancer, but using the word "tumor" is OK. Surgery
feels like she could be a surgical candidate for a partial
gastrectomy. Hem/onc says that gastric adenocarcinoma is
surgically staged and gastrectomy followed by chemotherapy would
be potentially curative if the tumor is localized. However, the
family has opted not to do chemotherapy. GI would not proceed
with an EGD for debulking purposes due to concern for bleeding
and is no longer following. A family meeting on [**3-19**] was held
and the decision was to proceed with surgical management with no
post-op chemotherapy. The family is aware that this surgery
would likely be palliative only. Ethics was consulted on [**3-22**] to
address the ethics surrounding not telling a competent patient
their true diagnosis secondary to cultural beliefs. It was
determined that the patient has deferred all decision making to
her family and it is ethically sound to proceed with the
family's wishes to pursue surgery without the patient knowing
her diagnosis.
.
#. GI Bleeding: Likely upper GI bleed given history of normal
colonoscopy and EGD with 10cm gastric adenocarcinoma. Hct down
to 22.8 overnight on [**3-16**] after being stable in the mid 20s for
several days. The patient was transfused 2 units pRBCs on [**3-17**]
and her hematocrit has remained stable. An active T&S was
maintained and her Hct was monitored closely. She was
maintained on a PPI twice daily.
.
#. Acute cholecystitis: The patient developed leukocytosis,
abdominal pain, and radiological evidence of cholecystitis on
[**3-15**]. IR placed a percutaneous cholecystostomy drain and she
was started on Unasyn. Her leukocytosis peaked at 34.6 on [**3-15**]
and then resolved but then climbed back up to a peak of 19.2
when she was diagnosed with C Diff. Urine and blood cultures
were negative. Bile was growing group B strep, Corynebacterium
diphtheroids species, and clostridium perfringens.
#. PE: The patient had a PE in [**Month (only) 404**] and had been
anticoagulated on Coumadin at home. Her Coumadin was initially
held in the setting of a GI bleed and she was placed on a
heparin gtt. Following a family discussion with the palliative
Care service anticoagulation was stopped.
In light of Mrs.[**Last Name (un) 37185**] multiple medical problems, poor
prognosis given all of these co morbidities and her age the
palliative Care service was contact[**Name (NI) **] to assist the patient and
her family in dealing with these difficult end of life issues.
Comfort measures is the number one priority. Her
anticoagulation and TPN was discontinued and her pain was
controlled with Morphine and a Fentanyl patch. She has had some
nausea which is relieved with Zofran but potentially it could be
from the Fentanyl and or Morphine so that will need to be
watched and assessed.
She was discharged on [**2162-3-31**] to rehab for further care.
.
Medications on Admission:
ATENOLOL 25mg daily
ATORVASTATIN 20mg daily
FUROSEMIDE 20mg daily (? if still taking)
IRON 90 mg-1 mg-12 mcg-120 mg-50 mg Tablet 1 tab daily
OMEPRAZOLE 20 mg [**Hospital1 **]
WARFARIN 5 mg Tablet q 4pm
ZOLPIDEM 5mg qhs prn insomnia
DOCUSATE SODIUM 100mg [**Hospital1 **] prn constipatino
FERROUS SULFATE 325mg daily
SENNA 8.5mg [**Hospital1 **] prn constipation
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily): Hold for SBP < 100
HR < 60.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Please send liquid Vanco
Thru [**2162-4-2**].
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Thru [**2162-4-6**].
6. Ampicillin-Sulbactam 3 gram Recon Soln Sig: One (1) Recon
Soln Injection Q6H (every 6 hours): Thru [**2162-4-2**].
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q2H (every 2
hours) as needed for pain.
9. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Gastric adenocarcinoma, acute cholecystitis s/p percutaneous
cholecystostomy tube, C diff colitis
.
Secondary diagnoses:
-Hypertension
-Hyperlipidemia
-Iron deficiency anemia
-Monocytosis
-Pulmonary embolism
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 [**Hospital1 69**] for
evaluation of abdominal pain and blood in your stool.
Unfortunately, an endoscopy diagnosed a stomach tumor that was
causing your symptoms. You developed a gallbladder infection
called cholecystitis that required a tube to be placed in your
gallbladder to drain the infected fluid. You also developed a
diarrheal infection called C diff that requires antibiotic
treatment.
* You need to eat and stay hydrated so take whatever food is
pleasing to you.
* Take your pain medication as needed to be comfortable.
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below:
.
1. Department: [**Hospital3 1935**] CENTER
When: FRIDAY [**2162-4-23**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
2. Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2162-4-28**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
3. Department: [**Hospital1 7975**] ST. HLTH CTR-KCSS
When: WEDNESDAY [**2162-5-5**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7980**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2162-3-31**]
ICD9 Codes: 5849, 5789, 2851, 5859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 985
} | Medical Text: Admission Date: [**2203-9-6**] Discharge Date: [**2203-10-4**]
Date of Birth: [**2122-4-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
CHF and NSTEMI
Major Surgical or Invasive Procedure:
Intubation x2
Hemodialysis
Esophagogastroduodenoscopy
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS: Mr [**Known lastname **] is a 81 yo man
with h/o transitional cell CA of the bladder s/p nephrectomy in
[**2198**], type I diabetes, hypertension, CRI (baseline Cr 3.5),
hypertension, hyperlipidemia who began having URI symptoms with
cough productive of thick sputum last friday. He underwent
radiation to a skin cancer on his cheek and has thereafter had
very dry mouth and thick sputum he has been unable to cough up.
He denies any fevers, chills, night sweats, weight-loss, or sick
contacts but does report paroxysms of shortness of breath and
one episode of dark red hemoptysis this morning. Sunday evening
he found himself breathing very uncomfortably with significant
orthopnea. He denies nausea, diaphoresis, or chest pain. He
presented to [**Hospital **] hospital at 3am on Monday where his initial
vitals were T 98.7, HR 88, RR 18, SaO2 85% RA and 95% on 2L N/C,
BP 151/72 with HR 85. CXR showed Rt-sided infiltrate so he was
started on CTX and azithromycin to treat community-acquired
pneumonia. EKG initially showed NSR with rate 85 and no
ischaemic changes. His hypoxia quickly worsened to requiring
100% NRB and was noted on CXR to possible pulmonary edema with
BNP of 1259. He was treated with lasix without good result. He
subsuquently ruled in for MI with CK peak of 211 and CK-MB of
8.5. He later went into rapid atrial fibrillation with heart
rates in the 130's-140's and was subsequently placed on a
diltialzem and heparin drip. He was also noted to have acute
renal failure with Cr of 3.5 up from his baseline of 2.8.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, joint pains, 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 mild chest pressure
earlier this morning chest pain. At baseline he has no dyspnea
on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope.
.
Past Medical History:
PAST MEDICAL HISTORY:
type I diabetes
Transitional cell carcinoma s/p right nephroureterectomy and BCG
therapy
CRI, baseline Cr 2.8 (Dr. [**First Name (STitle) 10083**] primary nephrologist)
HTN
Hypercholesterolemia
h/o A.Fib/flutter
s/p Cholecystecomy
s/p Achilles tendon rupture
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension. No
history of cardiac catheterization
Social History:
SOCIAL and FAMILY HISTORY:
Former smoker, quit 35 years ago. Owns his own company that
makes teflon that coats coronary stents.
Family History:
Has no FH early coronary disease.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 98.6, BP 140/83, HR 95, RR 22, 93 O2 % on 100% NRB
Gen: WDWN elderly male in moderate respiratory distress.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, JVP difficult to assess due to habitus.
CV: PMI located in 5th intercostal space, midclavicular line.
irregular rhythm, tachycardic, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis.
moderate respiratory distress, coughing. loud ronchi heard
throughout with [**Hospital1 **]-basilar crackles and scattered crackles
throughout rt lung.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; DP
pulses not palpable but feet warm
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; DP
pulses non-palpable, but feet warm
Pertinent Results:
OSH admission EKG: NSR with rate 86, normal axis, borderline
LAE, possible Q in V1-2. No ST of T wave changes.
.
EKG on transfer demonstrated coarse atrial fibrillation with
ventricular rate of 120, normal axis, no hypertrophy, normal
intervals. Non-spesific diffuse ST depression and TWI.
possible q wave in V1 and aVR.
.
.
[**2203-9-6**]. Echo.
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The aortic valve leaflets (3) are mildly
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2198-10-1**], there has been interval development of
mild aortic stenosis and left ventricular hypertrophy (aortic
valve velocity not evaluated on prior study). Elevated left
ventricular filling pressures are now present. Estimated
pulmonary artery pressures could not be assessed on the current
study. The rhythm is now atrial fibrillation with a rapid
ventricular response.
.
ETT performed at [**Hospital **] hospital (records not available) on
[**2-/2199**] demonstrated: He exercised for 3 min and 39 sec on a
[**Doctor First Name **] protocol achieved a maximal heart rate of 94% with no
angina or ischemic EKG changes there may have been a subtle
inferior wall defect thought to be artifact. EF 65%.
.
CXR. [**2203-9-6**]. IMPRESSION: New right upper lobe and right lower
lung pneumonia possibly aspiration pneumonia with likely
involvement of the left lower lung also.
.
EGD [**2203-9-23**].IMPRESION:The previously noted mucosal abnormality
on the incisura was not noted on this exam. Otherwise normal EGD
to duodenal bulb
.
CXR [**2203-10-3**]
Comparison is made to the prior examinations dated [**2203-9-26**] and
[**2203-9-27**]. The right-sided double lumen central venous catheter
is stable in position. The cardiac silhouette is within normal
limits. There is improvement of the vascular engorgement and
asymmetric pulmonary edema noted on the prior examinations. The
left retrocardiac opacity persists, likely reflects a
small-to-moderate effusion and atelectasis, difficult to exclude
pneumonia
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2203-10-4**] 06:38AM 12.4* 2.86* 9.2* 26.8* 94 32.0 34.1 15.9*
389
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2203-10-2**] 06:30AM 61.8 29.6 7.5 0.8 0.3
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2203-10-4**] 06:38AM 389
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2203-10-4**] 06:38AM 127* 32* 3.0* 138 4.1 100 30 12
Brief Hospital Course:
Briefly, this is a 81yM with medical history including
transitional cell CA s/p nephrectomy, HTN, Type I Diabetes
Mellitus, CRI (baseline Cr approximately 2.8), who was initially
admitted to [**Hospital1 18**] for NSTEMI in the setting of afib with RVR.
He had presented to an OSH with URI-like symptoms one month ago
and been treated for CAP with a course of Azithromycin. He
subsequently decompensated into afib with RVR and when he
presented to the [**Hospital1 18**] Tn was elevated over 2 and he had
prominent airspace opacities on CXR. The patient was admitted
to the CCU for hypoxia assumed to be secondary to pulmonary
edema and MRSA pneumonia requiring intubation. The patient was
transferred to MICU care given hemodynamics consistent with
sepsis, and eventually initiated on HD for worsening volume
status and renal function. The patient was eventually
successfully extubated although noted to develop hypoxia
previously while awaiting HD over the weekend, and has now
completed 14 day course of Vanc for MRSA PNA. His course has
been further complicated by GIB of an uncertain source while on
ASA, with EGD showing abnormal gastric mucosa and
esophagogastric erosions. ASA was initially d/c'd.
Additionally, he also had very labile and poorly controlled
blood glucose.
.
On [**2203-9-26**], while on medical floor, the patient developed
hyperglycemia into the 600s, uncontrolled with NPH, and SOB for
2-3 hours, with oxygen sats dropping to 88% even on supplemental
oxygen. Due to this hypoxia and hyperglycemia he was
transferred to the MICU for insulin gtt, HD, and closer
monitoring. Hypoxemia has responded to one session of HD [**9-28**]
with 2kg of ultrafiltration. He was taken off insulin gtt on
[**2203-9-28**] and placed on Lantus 40 and RISS. At this Lantus dose
his BS dropped to 61 and 1 amp glucose was given; that evening
Lantus was lowered to 35U [**First Name8 (NamePattern2) **] [**Last Name (un) 9718**] recs and morning labs
showed BS = 41. The Insulin was then sequentially lowered to 30,
then 24, the following nights [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs.
.
.
.
Cardiac--
# Rhythm. Patient was initially admitted for atrial fibrillation
with RVR to 140s, which required esmolol gtt and diltiazem gtt.
He converted back to NSR with few recurrent episodes of afib,
and is now back in afib. He has not reached target HR but well
tolerates high HRs (90-110) and drops SBP when rate control is
very aggressive. Although he was initially anticoagulated with
Heparin gtt this was discontinued for GI bleed on [**2203-9-6**].
- We held ASA for risk of bleed, and started ASA after his
repeat EGD which showed normal gastric mucosa.
- Current rhythm afib on high-dose Metoprolol and verapamil,
with SBP maintained in the 110s-130s and HR ranges from 80s-90s.
We changed his metoprol and verapamil to long-acting
forumulations the morning of discharge. He is currently Toprol
XL 200 mg po and Verapamil long acting 120 mg po. Metoprolol
can be titrated up as he was previously on metoprolol 100 mg
tid.
-He did not come into the hospital on coumadin, but recommended
that he follow up with his PCP regarding initiation of
anticoagulation. He had a regular rate and rhythm on morning of
discharge.
.
# Pump. Recent Echo with preserved EF. Volume overload was
present in setting of ARF, he has had 12# taken off during the
course of hospitalization.
- HD on Mon/Wed/Fri schedule
.
# Hypoxia. Hypoxia during hospitalization was secondary to
volume overload and later MRSA PNA (see below). Volume has
responded well to HD. Currently not hypoxic and off of O2.
Required intubation during first CCU stay and was extubated,
then reintubated during following MICU stay, stabalized, and
sent to the floor, extubated.
- Continued HD on Mon/Wed/Fri schedule per above
.
# Hyperglycemia. Labile and high blood sugars required insulin
gtt and MICU transfer. The [**Last Name (un) **] team was following. At
discharge on Lantus 18 U with sliding scale. His blood sugars
ranged 142-291 on day of discharge. .
.
# Pneumonia. Resolved. Patient had MRSA Pneumonia, initially
treated with Levo/Flagyl, now s/p 14 days Vancomycin/Zosyn
without evidence of infection.
- We continued chest PT, incentive Spirometry
-He had a low grade temp and a slightly elevated WBC, a repeat
CXR showed showed a L retrocardiac opacity that most likely was
a small effusion with atelectasis, but could not exclude
pneumonia. It was unchanged from pervious week's CXR. Blood
cultures are pending.
.
# Recent GI Bleed. Hct stable at last check. Endoscopy (EGD)
during admission to CCU revealed no active bleeding, but the
presence of abnormal mucosa, possible hematoma. repeat EGD
showed normal esophagus to duodenum. Previously noted mucosal
abnormality was not there. We stopped ASA initially but
restarted after the repeat EGD. We continued his PPI.
.
# ARF. Patient with chronic renal failure secondary to
hypertensive and diabetic nephropathy as well as s/p nephrectomy
for TCC. On admission, patient was in acute on chronic renal
failure and was oliguric. Impression was patient had pre-renal
ARF from poor forward flow in setting of Afib
- HD was inititated on Mon/Wed/Fri
.
# Low grade temperature [**10-3**]--?Aspitation
pneumonia/pneumonitis. Increase in WBCs. He denied fever, cough,
SOB, diarrhea, dysuria. Repeat CXR showed no change from
previous weeks study. Slight retrocardiac opacity that could not
exclude pneumonia. Urinalysis negative. Urine cultures and blood
culture pending. Recommend follow up speech and swallow
assessment.
Medications on Admission:
HOME MEDICATIONS: ***
Humalog 4 Units q AM, 6 Units q PM
Humalin N 26 Units q am
Lopressor 100 mg [**Hospital1 **]
Norvasc 5 mg [**Hospital1 **]
Lasix 40 mg qAM, 20 mg qPM
Allopurinol 100 mg [**Hospital1 **]
Colchicine 0.6 mg q day
Aspirin 81 mg q day
Colace 100 mg q day
Catapress 11 patch q week
Primrose Oil 1000 mg [**Hospital1 **]
1 Preservision [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
2. Allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Artificial Saliva 0.15-0.15 % Solution [**Hospital1 **]: 1-2 MLs Mucous
membrane Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 ML(s)* Refills:*0*
6. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Hospital1 **]: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*30 ML(s)* Refills:*0*
7. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Disp:*120 ML(s)* Refills:*0*
8. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q4H (every 4 hours) as needed.
Disp:*1 * Refills:*0*
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
11. Insulin Glargine Subcutaneous
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
13. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
14. Epoetin Alfa 4,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection
MWF (Monday-Wednesday-Friday).
15. Verapamil 120 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
16. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Atrial fibrillation
Hypertension
Diabetes Mellitus Type I
Upper gastrointestinal bleed
Acute Renal Failure - initiation of hemodialysis.
Secondary:
Chronic renal insufficiency
History of Methicillin Resistant Staph Aureus pneumonia
History of transitional cell carcinoma status post nephrectomy
peripheral arterial disease of rt leg, B carotids
Hypercholesterolemia
status post Cholecystecomy
status post Achilles tendon rupture
paget's disease of the bone s/p rt hip surgery
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. You
have had an extended hospital stay with multiple problems
including a high heart rate, an upper gastrointestinal bleed,
pneumonia, and high blood sugars.
.
We have made many changes to your medications, so it is
important that you dispose the old medications and continue
current meds as prescribe done on discharge.
.
If you have shortness of breath, chest pain, fevers, nausea,
vomiting, fluctuations in your blood sugars please contact your
PCP or return to the emergency room.
Followup Instructions:
You should also have a follow-up appointment with your PCP [**2-15**]
weeks after discharge. Please call Dr. [**Last Name (STitle) 1438**] at [**Telephone/Fax (1) 39397**].
Completed by:[**2203-10-6**]
ICD9 Codes: 4280, 0389, 5859, 5789, 5849, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 986
} | Medical Text: Admission Date: [**2188-4-11**] Discharge Date: [**2188-4-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
endotracheal intubation and mechanical ventilation
History of Present Illness:
This is an 88 y/o male with multiple medical problems who was
recently hospitalized for a fall from [**2188-2-23**] to [**2188-4-2**]. The
patient was discharged to [**Hospital 100**] Rehab. During this time the
patient's family feels that his course has been deteriorating.
Leading up to this presentation he was noted to be delirious
this week. He became hypoxic today desatting down to 77% RA
and tachypneic to the 40s. ABG 7.42/65/64/42. He was
transferred to [**Hospital1 18**] for further mgt.
.
Upon arrival to the ED, the patient's vitals were as follows T
98, P76, BP 111/54, RR 17, 02 sat 100% on NRB. There was later
concern that the patient had a weak gag reflex. He was
intubated to protect his airway. Patient became transiently
hypotensive with sedation which later improved with fluid
boluses.
.
CXR showed parenchymal and reticular opacities c/w aspiration
(seen on previous). Head CT was negative. The patient was
transferred to the unit for further management.
.
In terms of his recent hospitalization, the patient's course was
complicated. He originally presented with a fall during which
time he was noted to have minimally displaced anterior column
acetabular fractures with nondisplaced inferior pubic rami
fractures. These fractures were deemed stable by orthopedics.
Due to his poor nutritional status, PEG tube was placed. During
the EGD the patient was noted to have duodenal crater ulcers
which were cauterized. He was later bacteremic with Klebsiella
ESBL, treated with Meropenem. The patient was also treated for
aspiration pneumonia. He was initially started on levaquin and
flagyll but later transitioned to zosyn. The patient was also
kept on strict aspiration precautions.
The patient had a prolong complicated course which later
stabilized. He was discharged to [**Hospital 100**] Rehab.
.
ROS:
Unable to obtain, patient is intubated and sedated
Past Medical History:
1. Coronary artery disease. s/p MI and CABG [**93**] years ago, no
events since
2. Mitral regurgitation. Mod - severe
3. Hypertension
4. Pagets disease
5. Pelvic fractures
6. Bacteremia
7. FTT
8. Duodenal ulcers.
Social History:
Pt lives with wife [**Name (NI) 8797**]. [**Name2 (NI) **] walks with a cane. Past tobacco
use >40 years ago ([**2-13**] ppd). Rare EtOH.
Family History:
n/c
Physical Exam:
MICU Admission PE:
T 97.9, BP 109/56, HR 67, RR 13-18, O2 100%
AC 550 X 15/Fi02 .4/PEEP 5
Gen: Frail Elderly gentleman intubated and sedated
HEENT: MM extremely dry
Neck: Supple, no LVD, no bruits
Heart: RRR, nl S1, S2 no S3/S4, II/VI SEM > LUSB
Lungs: CTA b/l
Spine: stage I decub along upper thoracic spine
Sacrum: stage I-II along decub
Extrem: thin, severe muscle wasting, no cyanosis, clubbing or
edema
Rectum: liquid greenish stool noted at rectum
Pertinent Results:
[**2188-4-11**] 08:00PM WBC-9.4 RBC-2.96* HGB-9.8* HCT-28.8* MCV-97
MCH-33.2* MCHC-34.2 RDW-16.5*
[**2188-4-11**] 08:00PM PLT SMR-NORMAL PLT COUNT-379
[**2188-4-11**] 08:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL
[**2188-4-11**] 08:00PM NEUTS-80.7* BANDS-0 LYMPHS-9.2* MONOS-6.8
EOS-2.7 BASOS-0.5
[**2188-4-11**] 08:00PM PT-13.1 PTT-36.9* INR(PT)-1.1
[**2188-4-11**] 08:00PM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-2.4
[**2188-4-11**] 08:00PM proBNP-869*
[**2188-4-11**] 08:00PM GLUCOSE-120* UREA N-54* CREAT-1.1 SODIUM-137
POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-36* ANION GAP-12
[**2188-4-11**] 08:32PM LACTATE-1.4
.
Micro
[**4-13**] sputum cx negative
[**4-12**] sputum MRSA, GNRS (speciation *** PENDING *** as of
discharge)
[**4-12**] C. difficile toxin assay POSITIVE
[**4-12**] blood cx NGTD
[**3-/2109**] blood cx ** PENDING ** as of discharge
.
Imaging
[**3-/2109**] CXR
COMPARISON: Multiple priors, the most recent dated [**2188-3-27**].
FINDINGS: Extensive reticular nodular interstitial opacities
along with more nodular opacities are noted again predominantly
in the left upper lobe and to a lesser degree in the right upper
lobe and left perihilar regions. Lung volumes are markedly
diminished reducing the evaluation of the lung bases. The right
upper extremity PICC line has been replaced with a left upper
extremity- approach PICC line with the distal tip at the
superior cavoatrial junction. Again noted are clips and median
sternotomy wires consistent with prior CABG. No definite
effusion or pneumothorax is evident. Consistent with the given
history, an endotracheal tube is evident with the distal tip
approximately 6.2 cm from the carina.
IMPRESSION: Endotracheal tube as above. New left upper extremity
PICC line. Extensive parenchymal reticular and nodular opacities
previously ascribed to aspiration pneumonia. Given their
persistence, a non-emergent chest CT is recommended to assess
for interval change.
.
[**3-/2109**] CT head
FINDINGS: There is no intracranial hemorrhage, mass effect, or
shift of normally midline structures. The ventricles, cisterns,
and sulci are enlarged, unchanged in appearance. Extensive
periventricular and subcortical white matter hypodensities as
well as multiple lacunar infarcts are redemonstrated. The
visualized paranasal sinus is clear aside from mild ethmoid
sinus mucus thickening, and the mastoid air cells are clear.
Note of bilateral lens replacements.
IMPRESSION: No intracranial hemorrhage or mass effect.
.
[**3-/2109**] EKG
Sinus arrhythmia. Left atrial abnormality. Right bundle-branch
block. Left
anterior fascicular block. Compared to the previous tracing of
[**2188-3-26**] no
diagnostic interim change.
.
[**4-12**] CTA chest
1. Negative examination for pulmonary embolism.
2. Slight decrease in the scattered consolidations/ground-glass
opacities predominantly seen in the dependent most portion of
both lungs associated with mild bronchiectasis and impacted
bronchioles. The appearances although slightly decreased on
today's examination suggest a chronic process like aspiration
3.Retained secretion are seen in the carinal
bifurcation.Bronchoscopy is recommended.
3. The previously noted pleural effusions have resolved.
Brief Hospital Course:
1. Pneumonia
The patient's respiratory failure was thought to be due to an
aspiration pneumonia. CTA chest showed no evidence of PE, and
cardiac enzymes showed no evidence of myocardial ischemia.
Sputum grew MRSA and GNRs, the speciation of which was pending
at discharge and should be followed up by his physicians at his
rehabilitation facility. He was started empirically on
vancomycin and zosyn, which he will continue pending return of
the final culture data. He should complete a 14day course of
therapy to end on [**2188-4-25**].
.
2. C. difficile colitis
Patient's stool came back positive for C. diff toxin, was
started on flagyl. He should continue flagyl and continue for an
additional 2 weeks following completion of meropenem and
vancomycin to reduce risk of recurrence. Patient was afebrile
with minimal abdominal tenderness and no leukocytosis at
discharge.
.
3. History of delirium: Per patient's family leading up to his
admission he appeared confused. During his last admission, he
was found to have a PCA infarct. An EEG during the last
admission also showed encephalopathy.
A family meeting was held and the patient's code status was
changed to DNR/DNI.
Health care proxy is [**Name (NI) **] [**Name (NI) 25989**], patient's daughter-in-law.
Documentation has been provided and is in chart.
Medications on Admission:
lopressor 12.5mg [**Hospital1 **]
senna
thiamine 100mg via g tube
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): hold sbp<100, hr<60
per G tube.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): per G tube.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
per G tube.
5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: no more than 4 grams of acetaminophen in all
forms daily. per G tube.
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold sbp<100
per G tube.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: per G tube.
10. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily): one spray in one nostril
alternating daily .
11. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension Sig: 1000
(1000) mg PO BID (2 times a day): via peg.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day): per G tube.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed: hold for excess sedation. give via G tube.
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: see
below ML Intravenous DAILY (Daily) as needed: 10 ml NS followed
by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift. .
15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: 1000
(1000) mg Intravenous Q 12H (Every 12 Hours) for 8 days.
16. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q8H (every 8 hours) for 8 days.
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Continue for two weeks following completion of
vancomycin and meropenem. Give via G tube.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
1. Pneumonia
2. C. difficile colitis
Secondary
1. Hypertension
2. Paget's disease
3. CAD
Discharge Condition:
Fair, with improved respiratory status and hemodynamically
stable
Discharge Instructions:
You came into the hospital because of trouble breathing. You
were found to have a pneumonia. You were treated with
antibiotics, and initially placed on a breathing machine
(ventilator) in the intensive care unit. Your breathing and
pneumonia were improved by the time you left the hospital for
your rehab facility. You also developed diarrhea in the
hospital, for which you will need to take antibiotics.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 2204**] [**Telephone/Fax (1) 2205**] as needed.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5070, 2930, 4019, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 987
} | Medical Text: Admission Date: [**2124-1-17**] Discharge Date: [**2124-1-24**]
Date of Birth: [**2076-4-4**] Sex: M
Service: OTOLARYNGOLOGY
HISTORY OF THE PRESENT ILLNESS: The patient is a 47-year-old
male presenting with problems of chronic aspiration secondary
to hypoxic encephalopathy as an infant.
PAST MEDICAL HISTORY:
1. Mental retardation.
2. Neurologic deterioration with Parkinsonian features.
3. New onset seizure disorder which was first noted on
[**2123-7-2**].
4. Behavioral disorder including impulsive behavior with
psychotic features.
5. Gastroesophageal reflux disease.
6. Legal blindness.
7. History of chronic sinusitis.
8. History of MRSA.
9. History of Clostridium difficile.
10. Status post partial amputation of tongue secondary to
seizure disorder.
11. History of suboccipital craniectomy, C1 laminectomy, L3
fusion with rods in 11/00.
HOSPITAL COURSE: The patient was admitted on [**2124-1-17**] for
planned total laryngectomy for the above described reasons
which include chronic aspiration with multiple aspiration
pneumoniae requiring hospital admissions. In addition, it
was also desired to provide a permanent stoma for the patient
because of deteriorating mental status, numerous occasions
where he has self-decannulated.
Please see the operative note per Dr. [**Last Name (STitle) 1837**] for
details of the patient's operation.
The patient's postoperative course was complicated on
postoperative day number one with an episode of marked
hypotension reportedly with systolic pressures down into the
50s. Ultimately, this was felt to be secondary to
benzodiazepines and narcotics which he was receiving per the
ICU team. These were subsequently discontinued and the
patient did not have any further episodes of hypotension.
Of note, the ICU team did start the patient on a
pseudoephedrine drip in order to maintain pressures.
The patient was subsequently transferred to the floor on
postoperative day number four where he remained stable for
the remainder of his hospital course. Trach care was
minimally required predominantly for suctioning as well as
care of any drying secretions on the edge of his trach.
The first of two JPs was discontinued on postoperative day
number three. The patient was started on tube feeds on
postoperative day number one. The patient's antiepileptic
levels were monitored throughout his hospital course and they
remained stable.
At the time of discharge, the condition of the patient was
stable. He was tolerating tube feeds without any difficulty.
A swallow study was being obtained on the day of discharge to
evaluate the patient's swallowing function. Please see
addendum to this dictation for details of the swallow study.
DISCHARGE MEDICATIONS:
1. Reglan 10 mg p.o. q.i.d.
2. Flagyl 500 mg per NG tube t.i.d.
3. Keflex 500 mg per NG tube q. six hours.
4. Phenobarbital 100 mg per G tube b.i.d.
5. Prednisone 60 mg per G tube q.d.
6. Roxicet elixir 5 cc p.o. q. 4-6 hours p.r.n. per G tube.
7. Lansoprazole 30 mg per NG tube q.d.
8. Subcutaneous heparin 5,000 units subcutaneously q. 12
hours.
9. Vitamin D 400 units per NG tube q.d.
10. Trazodone 200 mg p.o. h.s. per G tube.
11. Risperidone 2 mg p.o. b.i.d.
12. Multivitamins 5 cc per NG tube q.d.
13. Milk of magnesia 30 cc per NG tube b.i.d.
14. Ativan 2 mg per NG tube q.d. given at 10:00 p.m.
15. Gabapentin 900 mg p.o. q. 8:00 a.m. and 4:00 p.m. per G
tube, 1,200 mg per NG tube h.s.
16. Carbamazepine 200 mg per NG tube b.i.d.
17. Dulcolax 5 mg p.o. q.d.
DISCHARGE DISPOSITION: To a rehabilitation facility.
FOLLOW-UP: Follow-up was scheduled with Dr. [**Last Name (STitle) 1837**] in
approximately one week.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 6152**], M.D.
[**MD Number(1) 6153**]
Dictated By:[**Last Name (NamePattern1) 1752**]
MEDQUIST36
D: [**2124-1-24**] 08:40
T: [**2124-1-24**] 09:30
JOB#: [**Job Number **]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 988
} | Medical Text: Admission Date: [**2177-3-29**] Discharge Date: [**2177-4-14**]
Date of Birth: [**2106-9-3**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: [**Known firstname **] [**Known lastname 620**] is a
70-year-old right-handed male with history of hypertension
(diagnosed five years ago), diabetes mellitus (since two
years ago) and atrial fibrillation on Coumadin for one month
now, who underwent elective cardioversion at [**Location (un) 511**]
observed overnight and discharged around 4 p.m. the next day.
Transesophageal echocardiogram, prior to cardioversion, was
within normal limits. He went from the hospital to his
orthopedist's office for routine follow-up appointment (he
had undergone total knee replacement one month prior to
admission). While sitting in the waiting room, he suddenly
slumped over to his right side, and he was not moving his
yes or no. CT scan was negative for hemorrhage. INR was
1.4. He was given 90 mg of IV TPA approximately 70 minutes
after the onset of symptoms. He was also given Labetalol for
elevated blood pressures to 192/109 mmHg.
On transferred to [**Hospital1 69**] early
on the morning of admission, he was briefly arousable,
consistently answering with yes or no and not following any
commands. He had a left gaze preference and a flaccid right
arm. Since arrival at [**Hospital1 69**]
the blood pressure has been stable around 120s to 170s.
PAST MEDICAL HISTORY: History is as described above. He had
a total knee replacement on [**2177-2-19**] and it was
during his preoperative evaluation for this that the atrial
fibrillation was noted. Medications, prior to admission,
were the following:
MEDICATIONS:
1. Glucophage.
2. Accupril.
3. Coumadin.
4. Betapace.
ALLERGIES: The patient does not have any drug allergies.
SOCIAL HISTORY: The patient is a former smoker and drinks
occasional alcohol. He lives with his wife in [**Name (NI) 41366**]
and owns his own limousine business.
PHYSICAL EXAMINATION: On physical examination, during
admission, he was afebrile. Blood pressure was 131/70 mmHg.
Heart rate was 94 per minute and respiratory rate was 17 per
minute. He had no carotid bruits. CARDIAC: Cardiac
examination revealed regular rate and rhythm without any
clicks or murmurs. LUNGS: Lungs were clear bilaterally with
good air entry. EXTREMITIES: Warm and well perfused with
positive pulses and brisk capillary refill without edema.
NEUROLOGICAL: The patient was sleepy and briefly opened his
eyes to loud voice. His right eye lid was ptotic. He could
hardly open it. He could lift his left eye lid. He
occasionally said no to questions, but had no other speech
output. He was not able to follow axial commands. Pupils
were equal bilaterally, 3 -mm and sluggishly reactive to
2-mm. Eyes were mid position with occasional roving
movements. He was able to move to the left with ocular
cephalics, but not to the right. He did not have any blink
to threat from the right side. He had right facial droop.
He was able to purposefully move his left arm. There was
minimal internal rotation of the right shoulder to noxious
stimulus. The left leg moved spontaneously. The right leg
was externally rotated, but he did withdraw to pain. Deep
tendon reflexes were 2+ in the left upper extremity and knee
and absent on the right. Ankle jerks were absent. Plantar
response was weakly extensor on the left and obvious extensor
on the right side.
MR imaging of the brain revealed a large area of restrictive
diffusion in the left frontal temporal parietal lobes
consistent with a left MCA territory infarct on DWI series.
MRA of the brain revealed complete occlusion of the left M1
segment of the middle cerebral artery.
HOSPITAL COURSE: Mr. [**Known lastname 620**] is a 70-year-old gentleman with
a large left MCA infarct after 30 hours after elective
cardioversion for atrial fibrillation, was admitted to [**Hospital Ward Name 121**] 6
Neurology Service for further assessment and management of
left MCA territory infarct. Since he had a relatively large
MCA territory infarct, his blood pressures were maintained
between 140 to 160 mmHg and for blood pressures greater than
200/100 treatment is initiated with Lopressor 5 mg IV every
six hours as needed. He received isotonic fluids only
(normal saline with 20 of [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] as maintenance). He was
followed up with frequent neurological checks.
Transesophageal echocardiogram revealed dilated left atrium;
mild spontaneous echocontrast seen in the body of the left
atrium; mild spontaneous echocontrast was seen in the left
atrial appendage. No thrombus was seen in the left atrial
appendage. No spontaneous echocontrast or thrombus was seen
in the body of the right atrium or the right atrial
appendage. There was significant regional left ventricular
systolic dysfunction. Resting regional wall motion
abnormalities included akinesis of the mid and distal
anterior and septal walls and apex. The apex was not
adequately visualized in order to exclude a mural thrombus.
The mid and distal inferior walls were hypokinetic. The
remaining left ventricular segments contracted normally. The
ascending, transverse, and descending thoracic aorta were
normal in diameter and free of atherosclerotic plaques.
There were three aortic valve leaflets. The aortic valve
leaflets were mildly thickened. Trace aortic regurgitation
was seen. Mitral valve leaflets were structurally normal.
There was mild 1+ mitral regurgitation. There was no clear
effusion. Echocardiogram repeated on [**2177-4-11**] did
not show any significant changes from the previous study.
The patient, on admission, also had elevated creatinine
kinase and troponin levels. On admission, the initial
troponin level was 13.3, and the creatinine phosphokinase
level was 174 on [**2177-3-30**]. The second troponin level
on [**2177-3-31**] at midnight was 10.7 and creatinine
phosphokinase level was 144. The third study of troponin on
[**2177-3-31**] at 6 a.m. was 8.1 and creatinine
phosphokinase MB was 1.0. Creatinine phosphokinase level was
117.
The patient was started on aspirin 325 mg daily and heparin
5000 units subcutaneously twice daily for deep venous
thrombosis prophylaxis, as well as pneumoboots. The patient
also had gastrointestinal prophylaxis with Ranitidine. The
patient did not show much improvement neurologically,
however, general status was within normal limits. Because he
failed swallow test, it was decided to have a
gastrojejunostomy tube placed.
On Apri 4th, [**2176**], the patient was still having atrial
fibrillation with rapid ventricular response and premature
ventricular contractions or aberrant ventricular conduction
with long QTC intervals and left axis deviation. The white
blood cell count was 11.8, hemoglobin last labs are the
following: CBC.9, hematocrit 34.4, platelet count 240,000,
PT 18.5, PTT 32.1, INR 2.4. The CPK was 44 and troponin was
6.4.
Under these circumstances, the patient underwent G-J tube
placement and tolerated the procedure well. However, that
night he developed some gastric hemorrhage and later on
started having low blood pressures. Since the blood
pressures could not be controlled with medical measures on
the floor, he was transferred to the Intensive Care Unit for
vasopressor [**Doctor Last Name 360**] administration and control of his
homostasis. The patient was started on IV Protonix twice
daily for better GI prophylaxis. He also received vitamin K
and fresh-frozen plasma. Also, aspirin and Coumadin were held.
During his stay at the ICU, the patient also had an elevated
sodium of 155 for which he received free water boluses.
However, consequently the mental status started declining and
he became somnolent. The CT scan revealed increasing edema
and midline shift most probably secondary to hypotonic
fluids, diffusing into the large stroke area. He was started
on monitor and over the course of three days, edema and
midline shift corrected and his neurological condition
improved dramatically. The patient, from then on, started
improving daily, and on [**2177-4-11**], he was transferred
to [**Hospital Ward Name 121**] 5. Care was continued by the Medicine Team. He was
also closely followed up by the Neurology Team. The patient
improved dramatically with the help of physical therapy and
he has been following commands involving the left arm and
slowly regaining tonus on the right upper and lower
extremities. Currently, the patient is stable from a
neurological standpoint and he is ready for transfer to an
acute care rehabilitation facility, as soon as a bed is
available.
Pt's aspirin was restarted prior to discahrge. Coumadin will need
to be restarted in the future to decrease embolic risk. We wre
awaiting input from neurology re: when this would be safe to do
as there was concern re: risk of hemorrhage into the CVA at this
time.
pt was on vanco for MRSA in sputum and flagyl and levaquin for
aspiration pneumonia during his stay.
Due to proably MI pt was started on betablockers and ace
inhibitors need to be added as tolerated to his regimen. he will
also need a statin if his cholesterol levels are elevated at
all.
The patient will be followed up by the Stroke Service
(Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **]) in one month.
Pt to f/u with his PCp [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 41367**] in [**Location (un) 9101**] after
discharge from rehab.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-162
Dictated By:[**Last Name (NamePattern4) 41368**]
MEDQUIST36
D: [**2177-4-14**] 14:12
T: [**2177-4-14**] 14:20
JOB#: [**Job Number 41369**]
ICD9 Codes: 5070, 5789, 4271, 2851, 412, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 989
} | Medical Text: Admission Date: [**2116-4-19**] Discharge Date: [**2116-4-21**]
Date of Birth: [**2058-5-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
thrombosed AVG
Major Surgical or Invasive Procedure:
Thrombectomy of AV graft with jump graft
revision, [**2116-4-19**]
History of Present Illness:
The patient is a 57y.o. man with ESRD seconddary to hypertensive
nephropathy on hemodialysis who presented on [**4-19**] after his LUE
AVG was not funtioning during HD on [**4-17**] secondary to thrombosis
of the graft. He was admitted for thrombectomy.
Past Medical History:
- Seizure disorder, onset of seizures in mid [**2097**] after
starting dialysis. He seems to have seizures quite frequently at
dialysis, per neurology this seems to be attributed to both
non-compliance with the medications, as well as taking his
medications later on those days.
- End stage renal disease on hemodialysis due to hypertensive
nephropathy
- Non-ischemic cardiomyopathy, EF 25-30% per echo in [**10/2114**]
- AV fistula, status post thrombectomy [**7-/2114**]
- Hungry bone syndrome status post parathyroidectomy
- Hepatitis B
- Pituitary mass
-LUE AVG thrombectomy [**2115-12-11**]
Social History:
Pt reports he lives alone in an apartment in the [**Location (un) 4398**].
Notes say he is living with a friend in [**Name (NI) 3494**] currently. He
denies any alcohol. No tobacco use. Occasion alcohol use as per
patient. No IV drug use that he admits. Reports director of
music at local church and states sole source of income.
Concerned illness will lead to loss of livelihood.
Family History:
Mother died at age of 41 of renal failure. Father is 85 and has
diabetes. He does have a son who is healthy.
Physical Exam:
On Admission:
VS: 98.7 74 144/77 18 98%RA
General: A&Ox3, NAD
Heart:RRR
Lungs:CTA B
Abd:soft, N-T, N-D
Extr:LUE graft: no thrill, no audible bruit
Pertinent Results:
[**2116-4-19**] 02:41PM K+-6.3*
[**2116-4-19**] 07:50PM CK-MB-7 cTropnT-0.08*
[**2116-4-19**] 07:50PM CK(CPK)-323*
[**2116-4-19**] 07:50PM POTASSIUM-7.4*
[**2116-4-19**] 11:23PM K+-6.6*
[**2116-4-20**] 06:44AM BLOOD WBC-5.8 RBC-3.41*# Hgb-9.5*# Hct-29.3*#
MCV-86 MCH-27.9 MCHC-32.5 RDW-17.2* Plt Ct-277
[**2116-4-20**] 09:00AM BLOOD PT-13.1 PTT-30.1 INR(PT)-1.1
[**2116-4-20**] 06:44AM BLOOD Glucose-58* UreaN-77* Creat-12.1*# Na-144
K-3.7 Cl-102 HCO3-21* AnGap-25*
[**2116-4-20**] 06:44AM BLOOD CK(CPK)-227*
[**2116-4-19**] 07:50PM BLOOD CK(CPK)-323*
[**2116-4-20**] 06:44AM BLOOD CK-MB-6 cTropnT-0.09*
[**2116-4-19**] 07:50PM BLOOD CK-MB-7 cTropnT-0.08*
Brief Hospital Course:
The patient was admitted to the transplant service on [**4-19**] and
was taken to the OR for thrombectomy of AV graft with jump graft
revision. He tolerated the procedure well. Following the
procedure he had an elevated K+ of 7.4 for which he was treated
with insulin, glucose, calcium and kayexalate. He received HD
in the AM of POD#1. His K+ following HD was 3.7. He was noted
to have a junctional rhythm on EKG but no sing of ischemia. He
was transferred to the floor and transitioned to regular low
sodium diet and pain was controlled with PO medication. He was
discharged home in good condition on POD#1.
Medications on Admission:
1.Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2.Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4.Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5.Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
6.Docusate Sodium 50 mg Capsule Sig: One (1) Capsule PO once a
day.
7.Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8.Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
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. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO post
hemodialysis.
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO after
dialysis.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Discharge Disposition:
Home
Discharge Diagnosis:
Thrombosed AVG
ESRD secondary to hytpertensive nephropathy
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Continue your regular home medications and take new medications
as directed.
Call your physician [**Name Initial (PRE) **]:
-fever, abdominal pain, nausea or vomiting
-increasing redness, swelling, pain or drainage at the incision
Followup Instructions:
[**Hospital **] Care Center [**4-21**] at 9am for catheter placement
Continue dialysis as scheduled.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **]
Date/Time:[**2116-5-12**] 8:30
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2116-6-3**] 4:30
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-5-7**]
9:00
ICD9 Codes: 5856, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 990
} | Medical Text: Admission Date: [**2104-1-13**] Discharge Date: [**2104-1-16**]
Date of Birth: [**2051-8-17**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Clindamycin
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
asthma exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 52 year old female with a history of moderately
severe asthma requiring intubation who presents with shortness
of breath worsening over the past week. She reports that her
exercise tolerance has gone down and attributes this
exacerbation to exposure to her daughter's dog and her son's
cats at home. She denies fever, chills, runny nose. Reports
dry cough, loss of appetite, and a little bit of bone aches in
her legs recently but "nothing like" before when she had a viral
illness. Over the past week, her SOB has progressed and over
the past 24 hours she has been using her nebs continuously at
home.
.
In the ED, initial VS were: 98.2, 97, 133/85, 24, 88% RA.
Appeared in distress, with wheezing, was having [**4-6**] word dyspnea
and was treated with nebulizers x3, methylprednisolone 125 mg
IV, and magnesium 2gm IV x1. Peak flows 180, satting 96% on
3LNC.
.
On arrival to the MICU, she is resting comfortably in bed and
able to complete a full H&P without conversational dyspnea. She
does not appear tired out and is not exhibiting increased work
of breathing.
At baseline, she is able to do her ADLs without resting, uses
oxygen 2L NC at night prn, does not use her albuterol at all
during the week. She had been on prednisone for about 3 months
prior to [**Month (only) **] but none since. Her baseline peak flow is
250.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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 rashes or skin changes.
Past Medical History:
1. severe COPD/asthma: [**9-13**] = FEV1 1.08 and FEV1/FVC 61%.
Baseline peak flow 250. Pulm suspicious of ABPA, followed with
Dr [**Last Name (STitle) 4507**]
2. bronchiectasis: negative alpha-1 antitrypsin
3. hypothyroidism
4. depression
5. hepatitis C VL > 1.6 million [**2103-2-3**]
Social History:
She lives with her son, daughter-in-law and granddaughter.
There is
a cat in her son's home and a dog at her daughter's place. She
is spending time between the 2 homes. She has not had any
recent
travel.
- Tobacco: [**3-10**] cigs per day with 20 pack yr history
- Alcohol: denies
- Illicits: IVDU, last use summer [**2102**]
Family History:
significant family history of asthma in many family members
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.0, BP 121/82, P 88, R 22 O2 87% 1LNC
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: bilateral wheezes and prolonged expiratory phase, no
rales or ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, + clubbing, no cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
DISCHARGE EXAM:
mild crackles at left base; few inspiratory and expiratory
wheezes at right base (improved)
otherwise stable exam
Pertinent Results:
ADMISSION LABS;
[**2104-1-13**] 02:53PM BLOOD WBC-5.7# RBC-5.31 Hgb-17.0* Hct-49.2*
MCV-93 MCH-32.1* MCHC-34.7 RDW-13.2 Plt Ct-198
[**2104-1-13**] 02:53PM BLOOD Neuts-44.7* Lymphs-31.0 Monos-6.1
Eos-17.3* Baso-0.9
[**2104-1-13**] 02:53PM BLOOD Glucose-153* UreaN-13 Creat-1.1 Na-139
K-5.5* Cl-100 HCO3-29 AnGap-16
[**2104-1-14**] 04:20AM BLOOD ALT-35 AST-47* LD(LDH)-265* AlkPhos-79
TotBili-0.4
[**2104-1-13**] 02:53PM BLOOD cTropnT-<0.01
[**2104-1-13**] 10:30PM BLOOD CK-MB-5 cTropnT-<0.01
[**2104-1-14**] 04:20AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.2
[**2104-1-13**] 03:20PM BLOOD Lactate-2.2* K-4.4
.
IMAGING:
[**1-13**] CXR COMPARISON: Chest radiograph from [**2103-11-17**] and
chest CT from [**2103-6-4**].
PORTABLE SEMI-ERECT AP CHEST RADIOGRAPH: Interstitial opacities
predominantly within the lung bases appear similar compared to
prior examination and correspond with known bronchiectasis. Mild
prominence of the upper lung vasculature suggests new
superimposed vascular congestion; however, there is no overt
edema or large effusions. No confluent consolidation is
identified. Cardiomediastinal and hilar contours are within
normal limits. No pneumothorax is evident. Healed right-sided
rib fractures are unchanged from prior.
IMPRESSION:
1. Stable basilar interstitial markings consistent with known
bronchiectasis. No superimposed confluent consolidation.
2. Mild pulmonary vascular congestion though no overt edema or
large
effusions.
Brief Hospital Course:
Ms. [**Known lastname **] is a 52 year old female with a history of severe
asthma requiring intubation in the past who was admitted to the
intensive care unit with hyoxemic asthma exacerbation.
ACTIVE PROBLEMS BY ISSUE:
# Asthma exacerbation: In the ED, she had already been started
on nebulizers, methylprednisolone, and magnesium. Her asthma
triggers are allergic, including allergic bronchopulmonary
aspergillosis (ABPA) although it doesn't look like she has been
treated with omeluzamab as an outpatient. She has been on a
long steroid taper for ABPA this calendar year but not in the
past 1.5 months. There was no evidence on her CXR to suggest a
focal pneumonia and she did not have a leukocytosis, thus
antibiotics were not started. Additionally, she did not have a
viral prodrome to support nasal swab. She was treated with
albuterol nebs q2h, ipratroprium nebs q6h, methylprednisolone 60
mg q8h x 1 day, then transitioned to prednisone 60 mg po. Her
home montelukast, loratidine, fluticasone nasal spray and
fluticasone/salmeterol inhalers were continued. She has had
pneumovax. She got the flu vaccine during this admission. She
was transferred to the floor where she continued to improve. On
the day of discharge she reported feeling back to baseline, was
breathing room air with good O2 saturation, minimal wheezing on
exam, and peak flows trending toward normal (was 200 at time of
discharge). IgE was sent but was pending at the time of
discharge and should be followed up by pulmonary as they noted
that this would inform the rapidity of the prednisone taper.
CHRONIC PROBLEMS BY ISSUE:
# Hypothyroid: Continued home levothyroxine.
# Depression: Continued home buproprion.
# Hepatitis C viral infection (HCV): Last viral load 1,690,000
in [**2103-2-3**]. Not on treatment because she has been travelling
back and forth to [**Male First Name (un) 1056**]. Her PCP should discuss whether
or not pt requires hepatology follow up at next visit.
.
# Code: Full code confirmed
# Communication: son and HCP [**Name (NI) 915**] [**Name (NI) **] [**Telephone/Fax (1) 101095**]
TRANSITIONAL ISSUES:
- Please ensure follow-up with a pulmonologist outpatient since
her previous one (Dr. [**Last Name (STitle) 4507**] is no longer at [**Hospital1 18**]
- Please set her up with hepatology as an outpatient for HCV
treatment
- please follow up IgE level
Medications on Admission:
Advair 500/50 2 puffs [**Hospital1 **]
albuterol MDI (uses this twice daily)
Singulair 10 mg daily
ipratroprium 2 puffs [**Hospital1 **]
BUPROPION 150 mg [**Hospital1 **]
FLUTICASONE 50 mcg nasal spary
LEVOTHYROXINE 150 mcg daily
POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - daily
CALCIUM-VITAMIN D3 600 mg-400 daily
LORATADINE 10 mg day
(finished prednisone 10-20 mg daily in [**2103-12-4**])
(uses nicotine patches prn)
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
Two (2) puffs Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 disk* Refills:*0*
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation twice a day.
4. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
6. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
8. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO once a day.
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation twice a day.
11. prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
You were admitted to the hospital because you were having
difficulty breathing. We believe that this was because of an
asthma exacerbation due to allergies. You should avoid allergic
triggers including animals, mold, and cigarettes.
.
The following changes were made to your medications:
- START prednisone 50mg by mouth daily on [**2104-1-17**]. Your PCP
will decide how to taper your steroids at your appointment.
.
It is very important that you keep all of the follow-up
appointments listed below. You should discuss with your PCP
whether or not you should be evaluated by a liver specialist.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2104-1-22**] at 11:20 AM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular
primary care doctor in follow up.
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2104-2-14**] at 12:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2104-2-14**] at 1 PM
With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 991
} | Medical Text: Admission Date: [**2125-6-11**] Discharge Date: [**2125-6-19**]
Date of Birth: [**2050-6-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p mvc
Major Surgical or Invasive Procedure:
intubation
bilateral chest tubes
History of Present Illness:
74 year old male s/p MVC vs tree with a 20 minute extrication,
presented to [**Hospital **] Hospital with GCS 15 & complaints of
SOB/CP. A chest Xray showed bilateral pneumothoraces and
bilateral chest tubes were placed. His SBP dropped to 90s and
he was intubated and transferred to [**Hospital1 18**].
Past Medical History:
HTN
MI
Physical Exam:
on arrival in the trauma bay:
vitals: 99.0, 87, 127/85, 100%
intubated, sedated
PERRL bilaterally 2->1mm
TMs with wax
no facial trauma
CTAB with bilateral crepitus
RRR, s1 s2, abrasions L costal margin
Abd soft ND
rectal guaiac neg, poor tone
abrasions L forearm and L patella
on discharge:
Gen: elderly gentleman, pleasant, alert and oriented x 4
HEENT: cervical collar in place, PERRL, EOMI, OP clear
PULM: poor air movement at bilateral bases, no wheeze, equal BS
bilaterally
CV: regular with normal S1,S2
ABD: soft, Nontender, nondistended, tolerating PO
EXT: moving all four extremities, full weight bearing, able to
ambulate and perform ADL
NEURO: CN II-XII intact, no focal motor or sensory deficits
Pertinent Results:
[**2125-6-11**] CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST
Reason: TRAUMA
Field of view: 40 Contrast: OPTIRAY
INDICATION: 74-year-old man with trauma.
TECHNIQUE: After administration of IV contrast, a multidetector
scanner was used to obtain contiguous axial images from the
thoracic inlet to the pubic symphysis. These were then
reconfigured and reformatted into coronal and sagittal planes.
CT OF THE CHEST WITH IV CONTRAST: The patient is intubated.
There is a moderate right pneumothorax and a small left apical
pneumothorax. Additionally, some mediastinal air is identified.
Bilateral chest tubes are seen; the one on the right traverses
through the lung parenchyma and enters the posterior pleural
space. The left chest tube also traverses through the lung, and
ending adjacent to the pericardium; as previously stated, there
is only a small left posterior apical pneumothorax. Small
bilateral pleural effusions and bibasilar atelectasis are seen.
A minor amount of air extends below the crus of the diaphragm,
in association with the mediastinal air. Extensive subcutaneous
emphysema is seen on the right; only a small amount is seen on
the left. The heart and great vessels are unremarkable; no
dissection or pulmonary embolism is identified. There is no
pericardial effusion.
CT OF THE ABDOMEN WITH IV CONTRAST: A small low density lesion
is seen at the dome of the liver, which is too small to
characterize, but probably represents a cyst. Two small low
density lesions are seen on the right kidney, also too small to
characterize, but probably representing cysts. Both kidneys have
extrarenal pelves. The spleen, adrenals, and pancreas are
unremarkable. An NG tube is seen coiling in the stomach, ending
in the pylorus. The imaged bowel is unremarkable, and there is
no evidence of vascular compromise. Of note, the infrarenal
abdominal aorta is dilated to a maximum diameter of 5.0 x 5.4
cm; there is no evidence of dissection, and the abdominal aorta
returns to normal caliber at the bifurcation; however, both
iliac arteries are ectatic and mildly dilated. Vascular
calcification is seen. Also of note is a moderately stenotic but
patent superior mesenteric artery. There is a small amount of
fatty infiltration around the gallbladder.
CT OF THE PELVIS WITH IV CONTRAST: No fluid is seen within the
pelvis. Diverticulosis is present, without evidence of
diverticulitis. The collapsed bladder has a thickened wall. A
Foley is present. There is an enlarged prostate and
fat-containing small inguinal hernias.
Several rib fractures are identified on the right, including the
anterolateral aspects of #2, #3, #4, #5, #6, #7, #8, #9, and the
anterior aspect of the left second rib, in two places. With the
left rib fractures, there is a small amount of associated
hematoma in the chest wall, and subcutaneous emphysema.
There is a small amount of stranding in the right inguinal
region, consistent with the patient's recent arterial phlebotomy
in that region.
Coronal and sagittal reconfigurations were essential in
establishing the diagnoses above (MPR value 4).
IMPRESSION:
1. No findings to explain patient's hypotension.
2. Bilateral pneumothoraces and mediastinal air, with multiple
bilateral rib fractures and subcutaneous air, right greater than
left. Chest tubes are also malpositioned. Small bilateral
pleural effusions and dependent atelectasis.
3. Infrarenal abdominal aortic aneurysm dilated to a maximum
diameter of 5.4 cm, without evidence of dissection. Vascular
calcification in the aorta and iliac arteries.
[**2125-6-11**] CT C-SPINE: No fracture is seen. There is separation of
the left C3-4 facet joint, possibly representing ligamentous
disruption. Degenerative changes are seen at multiple levels.
There is no prevertebral soft tissue swelling. The patient is
intubated, and a small amount of fluid is noted around the ET
tube. Bilateral apical pneumothoraces are noted in the
visualized portion of the lung apices.
MRI [**2125-6-13**] of Cervical and thoracic spine. FINDINGS: The
widened left C3-4 facet joint space is again demonstrated, with
irregularity of the joint space surfaces that correlate with the
recent CT scan. The STIR images do not appear to show contiguous
edema of the surrounding soft tissues. There is mild infolding
of the ligamentum flavum at the C5-6 and C6-7 interspace levels.
The bony central spinal canal is quite capacious. Uncovertebral
spurring produces moderate right-sided neural foraminal
narrowing at C5-6. There is a longitudinally extensive but
relatively thin (2 mm to 3 mm) prevertebral soft tissue swelling
anterior to the odontoid process and extending down to the C3-4
level. This finding is suspicious for ligamentous injury
involving the anterior longitudinal ligament. Adjacent to this
region is a 2 cm mass with low T1 and high T2 signal within the
midline posterior nasopharyngeal soft tissues. The finding is
suspicious for a large Tornwaldt cyst.
CONCLUSION: Continued demonstration of distraction of the left
C3-4 facet joint complex. The finding could represent a local
injury, although the irregularity of the bone surfaces seems
more in keeping with a degenerative arthritic process. However,
there is prevertebral soft tissue swelling in the upper cervical
spine, suspicious for ligamentous injury. The findings, as well
as the additional observations noted above were discussed in
detail with the trauma resident.
MR scan of the thoracic spine was performed using sagittal T1
and T2-weighted images.
FINDINGS: There are somewhat linear regions of elevated T2
signal within the upper three thoracic vertebral bodies.
However, there is no definite sign of deformation of these
bodies to indicate an overt compression fracture. Clearly, when
the patient becomes conscious, a detailed physical examination
of this area as well as the cervical spine will help to
determine whether these findings of abnormal signal could
indicate rather subtle trauma. The thoracic spinal canal is
capacious. There is no definite sign of spinal cord abnormality
appreciated. Within the limits of sagittal imaging, no gross
paraspinal pathology is apparent.
labs:
Brief Hospital Course:
Admission to [**2125-6-18**]:
After arrival to [**Hospital1 18**], the patient was stabilized and
transferred to the trauma SICU for further care. The results of
his imaging revealed his chest tubes were in good position with
no pneumothoracices. His head CT revealed an old infarct but no
acute hemorrhage. The CT of his C-spine revealed a C3-C4 facet
distraction which was further investigated with an MRI study.
Neurosurgery was consulted and this injury was non-operatively
managed with a hard cervical collar that should be worn at all
times for a total of 6 weeks. After this the patient will have
repeat x-rays and follow up with Dr. [**Last Name (STitle) 1327**] to determine further
care. The patient's CT of his torso revealed right and left rib
fractures as well as an infrarenal AAA. The patient was referred
to Dr. [**Last Name (STitle) 3407**] of vascular surgery and will follow up as an
outpatient for further monitoring of his AAA.
During this admission the patient initially was noted to have
elevated CK but never had an elevated troponin. An epidural was
placed for pain control of the patient's rib fractures.
Extubation was attempted on [**6-14**], but the patient was
reintubated secondary to respiratory distress. The patient
developed a fever and his chest x-ray indicated he may have
developed a ventilator associated pneumonia; therefore he was
started on antibiotic coverage with levaquin and vancomycin for
a five day course. Blood, urine, and sputum cultures remained
negative. The chest tubes remained in place until [**2125-6-16**].
The patient was successfully extubated on [**6-16**] and his
respiratory function continued to improve. The patient remained
afebrile and did well with physical therapy and was able to be
transferred to the hospital floor.
[**6-18**] to [**2125-6-19**]: The patient was tolerating PO, urinating
without difficulty, ambulating without assistance. He was
discharge to home with outpatient physical therapy services.
Medications on Admission:
ASA
Beta blocker
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lipitor 10 mg Tablet Sig: [**2-4**] Tablet PO once a day. Tablet(s)
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
While taking percocet.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Multiple rib fractures
C3-4 facet distraction
Bilateral pneumothoraces
Hypertension
Discharge Condition:
Good
Discharge Instructions:
You need to wear your hard cervical neck collar AT ALL TIMES
until you follow up with Dr. [**Last Name (STitle) 1327**] from neurosurgery. You may
take all of your regular medications prescribed by your regular
primary care doctor.
[**Name8 (MD) **] MD for temp >101, persistent pain, nausea or vomiting,
headache, numbness, tingling, or weakness in your arms or legs,
or any other questions.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1327**] in neurosurgery in 6 weeks. Call
tomorrow morning to schedule an appointment. The phone number is
[**Telephone/Fax (1) 1669**].
You should also follow up with Dr. [**Last Name (STitle) **], vascular surgeon, for
your aortic anuerysm. Please call [**Telephone/Fax (1) 1241**] for an
appointment.
Follow up with your regular primary care physician by the end of
this week. Call today to schedule an appointment.
ICD9 Codes: 486, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 992
} | Medical Text: Admission Date: [**2191-3-5**] Discharge Date: [**2191-3-24**]
Date of Birth: [**2128-12-9**] Sex: M
Service: BMT
This is a discharge summary detailing the events of hospital
stay between [**2191-3-21**], and [**2191-3-24**].
The only note of significance that occurred during this time
period was that the patient underwent a video swallowing
study with the following findings: Mild residual in the
vallecula sinuses with thin liquids, and no evidence of
laryngeal penetration or aspiration. Based on this study,
speech pathologist felt that the patient could be advanced to
thin liquids orally as tolerated, as well as continued on his
tube feeds.
Prior to the above-mentioned study, the patient had been
given a trial of sips of clears and was not noted to have any
difficulty nor any discrete episodes of aspiration. It was
emphasized that the patient should be strictly in a 90 degree
sitting position at the time of oral ingestion.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], M.D. [**MD Number(1) 7782**]
Dictated By:[**Name8 (MD) 2054**]
MEDQUIST36
D: [**2191-3-24**] 21:42
T: [**2191-3-25**] 01:22
JOB#: [**Job Number 35864**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 993
} | Medical Text: Admission Date: [**2173-12-23**] Discharge Date: [**2173-12-31**]
Date of Birth: [**2108-4-13**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman with
hypertension, hypercholesterolemia, obesity, question CAD,
diabetes mellitus, OSA with increased dyspnea and hypoxia x2
weeks, especially increasing over the past two days prior to
admission, has required constant CPAP for the past two-and-a-
half weeks. Of note, the patient's Lasix dose was decreased
from 100 mg b.i.d. to 60 mg b.i.d. three weeks ago for
unknown reasons.
REVIEW OF SYSTEMS: The patient has orthopnea, PND, and lower
extremity edema. No chest pain or diaphoresis. No cough or
fever. On arrival to the ER on [**2173-12-22**], the patient's blood
pressure was 128/78, heart rate was 85, and oxygen saturation
83 percent on room air and 97 percent on 1.5 liters nasal
cannula. The patient was diuresed with a total of 300 mg
intravenous Lasix with no change in oxygenation. She was
also started on intravenous nitro drip. Urine output has
been about 1200 cubic centimeters over the past six hours.
Chest x-ray this a.m. is consistent with CHF. EKG consistent
with atrial fibrillation, which was new. The patient was
started on intravenous heparin drip. CT was done, which was
negative for PE, though it was one minute secondary to the
patient's obesity. Lower extremity duplexes were negative
for DVT. The patient was switched to BiPAP after an ABG
showed a PCO2 of 77 and a PAO2 of 71 on 4 liters nasal
cannula. A repeat echo was performed and revealed an EF of
55 percent, concentric LVH, new 1 to 2 plus MR, moderate
pulmonary artery hypertension.
PAST MEDICAL HISTORY: Hypertension.
High cholesterol.
Obesity.
Coronary artery disease.
Prior knee surgery.
Osteoarthritis.
Gout.
Diabetes mellitus diagnosed in [**2169**], A1c 7.4.
Obstructive sleep apnea on 2 liters CPAP for pulmonary
hypertension, noncompliant previously (no sleep study).
Hypothyroid.
Diastolic heart function.
Chronic hypoxemia.
Restrictive lung disease, ground glass, on CT.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Insulin 70/30, 42 units in the morning and 16 units in the
night.
2. Aspirin 325 mg p.o. q.d.
3. Norvasc 10 mg p.o. q.d.
4. Lisinopril 40 mg p.o. q.d.
5. Atenolol 100 mg p.o. q.d.
6. Atorvastatin 20 mg p.o. q.d.
7. Colace.
8. Indocin p.r.n.
9. Lasix 60 mg b.i.d. as of [**2173-11-8**].
10. Protonix.
11. Insulin sliding scale.
12. Hydrochlorothiazide 50 mg q.d.
13. Levoxyl.
14. Nitro drip on admission.
SOCIAL HISTORY: No tobacco, no alcohol.
FAMILY HISTORY: Positive for CAD.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.2 degrees
F., pulse 95, blood pressure 112/59, respiratory rate 21,
pulse oximetry 95 percent on BiPAP. Examination: In
general, the patient is obese, comfortable appearing, in no
acute distress. HEENT: Obese. Neck veins difficult to
appreciate. Cardiovascular: Irregularly irregular, no
appreciated murmur, and no S3 or S4. Lungs: Clear
posteriorly without wheezes or crackles. Abdomen: Soft,
distended, nontender, bowel sounds positive. Extremities: 2
plus edema one-half way to the knees bilaterally. Rectal:
Guaiac positive per ED.
LABORATORY DATA: Laboratories are significant for an ABG on
[**2173-12-23**] at 10:00 a.m., which showed a pH of 7.35, a PCO2 of
61, and a PAO2 of 41 on room air. On [**2173-12-23**] at 3:45 p.m.,
pH of 7.34, PCO2 of 71, and PAO2 of 77 on 4 liters of nasal
cannula. An EKG showed atrial fibrillation at 90 with a
normal axis, normal QRS, QT, poor R-wave progression. An
echo showed elongated LA, elongated RA, moderate symmetric
LVH, and EF of 55 percent. Laboratories showed a white count
of 10.6, hematocrit of 37.7, platelets of 236,000, and
creatinine of 1.1. CK x3 were 5 and troponin x2 less than
0.01. Chest x-ray showed cardiomegaly and interstitial
edema. Chest CTA showed no PE and proximal pulmonary artery
bronchus and ground-glass opacity with question of some CHF.
HOSPITAL COURSE: Hypoxia. The patient was admitted to the
CCU for continued hypoxia requiring BiPAP in the ER. The
hypoxia was thought to be secondary to the patient's
obstructive sleep apnea and pulmonary hypertension in
addition to her diastolic heart failure, which was worsened
by the patient's new atrial fibrillation. Pulmonary
consultation was obtained. They recommended controlling the
patient's heart rate, diuresing the patient, continuing her
BiPAPs, following with a sleep study in the future, and
avoiding hypoxemia. The patient was diuresed while overnight
and was discharged to the floor. She continued with CPAPs at
night and was continued to be diuresed with Lasix with some
improvement, though continued dyspnea on exertion. On
discharge, she was able to ambulate with a cane, but was
requiring oxygen still. It was thought that the patient
would do better once she could be cardioverted, but this
would have to be done later. The patient was also continued
on ACE inhibitor for after-load reduction for her CHF, as
well as fluid restriction.
New atrial fibrillation. The patient was rate controlled
with Lopressor. She was started on a heparin drip in the ER
and also was initiated on Coumadin. The patient was planned
for outpatient cardioversion after therapeutic INRs.
Appointments were scheduled for cardioversion after
discharge.
Hematuria. The patient had episodes of hematuria after her
Foley was discontinued while on heparin. Her heparin drip
was turned down somewhat. The scale was tightened, and this
resolved. The UA and urine culture were negative. The
patient needs this hematuria to be worked up as an
outpatient.
Hypothyroidism. The patient is still hypothyroid by TSH;
however, she is already on Levoxyl. We thought that in this
initial setting, especially with atrial fibrillation, her
Levoxyl should not be increased. TFTs will be followed after
discharge and stabilization.
Diabetes mellitus. The patient was continued on a rising
insulin sliding scale and her 70/30 while in-house.
CONDITION ON DISCHARGE: Fair.
DISCHARGE FOLLOWUP: Pulmonary examination on [**2174-1-26**] and
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at that time and PFTs as
well that day. Also with Dr. [**Last Name (STitle) **] on [**2174-1-13**] at [**Company 191**],
as well as appointment for atrial fibrillation cardioversion
to be set up by Cardiology.
DISCHARGE DIAGNOSES: Hypoxia and hypoxemia.
Type 2 diabetes.
Obstructive sleep apnea.
Atrial fibrillation.
Congestive heart failure with left heart failure.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg one p.o. q.d.
2. Lisinopril 40 mg p.o. q.d.
3. Levoxyl 25 mcg p.o. once daily.
4. Atorvastatin 10 mg once at night.
5. Metoprolol 100 mg once three times a day.
6. Coumadin 7.5 mg once at night.
7. Lasix 80 mg once a day.
8. Weekly INR checks.
9. 20 units of insulin 70/30 in the a.m. and 8 units of 70/30
in the p.m.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 27875**]
Dictated By:[**Last Name (NamePattern1) 2864**]
MEDQUIST36
D: [**2174-10-31**] 15:00:14
T: [**2174-11-1**] 08:49:00
Job#: [**Job Number 101587**]
ICD9 Codes: 5849, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 994
} | Medical Text: Unit No: [**Numeric Identifier 63999**]
Admission Date: [**2138-10-5**]
Discharge Date: [**2138-10-11**]
Date of Birth: [**2059-9-19**]
Sex: M
Service: CSU
CHIEF COMPLAINT: A scheduled admission for mitral valve
replacement and coronary artery bypass grafting.
PAST MEDICAL HISTORY: Significant for congestive heart
failure, CAD, status post MI in [**2123**] treated with lytic
therapy, atrial fibrillation, GI bleed, TIA, AAA repair in
[**2130**], right inguinal hernia repair, AICD placement in [**2135**]
and ablation in [**2135**].
SOCIAL HISTORY: Remote tobacco; quit many years ago. No
EtOH. Married and lives with his wife.
FAMILY HISTORY: Noncontributory.
ALLERGIES: SOTALOL which causes a VFib arrest.
MEDICATIONS ON ADMISSION: Include lisinopril 2.5 mg daily,
aspirin 81 mg daily; Coumadin 5 mg on Monday and Friday and
2.5 mg every other day; digoxin 0.25 mg daily; ferrous
sulfate 325 mg daily; folate 1 daily; Lasix 40 on Monday,
Wednesday and Friday and 20 on Tuesday, Thursday, Saturday
and Sunday; Neurontin 300 mg daily; Lopressor 12.5 mg b.i.d.
and Ativan p.r.n.
PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate of 84, blood
pressure of 110/60, respiratory rate of 20, O2 saturation of
99% on room air. GENERAL: In no acute distress. NEURO: Alert
and oriented x 3. Moves all extremities. A nonfocal exam.
HEENT: Mucous membranes are moist. NECK: Supple. Carotids are
2+ without bruits. CHEST: Clear to auscultation bilaterally.
CARDIAC: Irregular rate, S1/S2. ABDOMEN: Soft, nontender and
nondistended. EXTREMITIES: Warm and 1+ bilateral edema.
PULSES: Femoral 2+ bilaterally, radial 2+ bilaterally and
dorsalis pedis 1+ bilaterally.
LABORATORY DATA: White count of 5.8, hematocrit of 36, PT of
14, PTT of 59, INR of 1.3, sodium of 138, potassium of 4.9,
chloride of 100, CO2 of 28, BUN of 27, creatinine of 1.1,
glucose of 121. LFTs were all within normal limits.
RADIOLOGIC AND OTHER STUDIES: Chest CT done on [**8-4**]
showed bilateral ground-glass opacities.
Carotid exam showed less than 40% lesions bilaterally.
Cardiac cath showed proximal LAD 90%, circumflex with 30% to
70% lesions and a diffuse RCA stenosis with an ejection
fraction of 43%. Additionally, he had 4+ mitral
regurgitation.
TEE showed an ejection fraction of 30% to 35% with severe MR
and global LV hypokinesis.
HOSPITAL COURSE: After admission, the patient was brought to
the operating room where he underwent mitral valve
replacement and coronary artery bypass grafting. Please see
the OR report for full details. In summary, the patient had a
MVR with a #33 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve and a
CABG x 1 with a LIMA to the LAD. His bypass time was 94
minutes with a cross-clamp time of 74 minutes. He tolerated
the operation well and was transferred from the operating
room to the cardiothoracic intensive care unit. At the time
of transfer the patient's mean arterial pressure was 71 with
a CVP of 10. He was A-paced at a rate of 60 beats per minute.
He had epinephrine at 0.03 mcg/kg/min, milrinone at 0.5
mcg/kg/min, Neo-Synephrine at 1.4 mcg/kg/min and propofol at
30 mcg/min.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. He was weaned from the
ventilator and successfully extubated. Throughout the
operative day, the patient was weaned from his cardioactive
IV medications; and by postoperative day 2, the patient's
milrinone was weaned to off. At that time it was decided that
he was stable and ready for transfer to [**Hospital Ward Name 121**] Two for
continuing postoperative care and cardiac rehabilitation over
the next several days. With the assistance of the nursing
staff and physical therapy, the patient's activity level was
advanced.
On postoperative day 3, his temporary pacing wires were
removed; and on postoperative day 4, it was decided that the
patient would be stable and ready for discharge on the
following day.
PHYSICAL EXAMINATION ON DISCHARGE: At the time of this
dictation, the patient's physical exam is as follows. VITAL
SIGNS: Temperature of 98, heart rate of 72 (V-paced), blood
pressure of 108/68, respiratory rate of 20, O2 saturation of
98% on room air. Weight preoperatively of 69 kilos; at the
time of discharge was 72 kilos. NEURO: Alert and oriented x
3. Moves all extremities. Follows commands. A nonfocal exam.
PULMONARY: Clear to auscultation bilaterally. CARDIAC:
Irregular rhythm, paced. The sternum is stable. Incision
without drainage or erythema. ABDOMEN: Soft, nontender and
nondistended with normal active bowel sounds. EXTREMITIES:
Warm and well perfused with trace edema bilaterally.
LABORATORY DATA ON DISCHARGE: White count of 11, hematocrit
of 29.2, platelets of 92. Sodium of 133, potassium of 4.1,
chloride of 97, CO2 of 28, BUN of 28, creatinine of 1.2,
glucose of 102. PT is 13.7, INR is 1.3.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement with a #33
[**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve as well as coronary
artery bypass grafting x 1 with a left internal mammary
artery to the left anterior descending.
2. Congestive heart failure.
3. Atrial fibrillation.
4. Coronary artery disease.
5. Gastrointestinal bleed.
6. Transient ischemic attack.
7. Abdominal aortic aneurysm repair.
8. Automatic internal cardioverter-defibrillator placement.
9. Hernia repair.
DI[**Last Name (STitle) 408**]E FOLLOWUP: The patient is to have followup in [**Hospital 409**]
Clinic in 2 weeks; with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3659**] in 3 to 4 weeks;
with Dr. [**Last Name (Prefixes) **] in 4 weeks; and with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8049**] in
1 month. Additionally, the patient is to be seen by the
visiting nurses and to have an INR drawn on Monday, [**10-14**] with the results called to Dr.[**Name (NI) 64000**] office.
DISCHARGE MEDICATIONS: Include aspirin 81 mg daily; Colace
100 mg b.i.d.; Bimatoprost 1 drop o.h. both eyes at bedtime;
Lasix 40 mg daily x 2 weeks/then to resume his preoperative
schedule; Neurontin 300 mg daily; metoprolol 12.5 mg b.i.d.
and warfarin 5 mg on Monday and Friday and 2.5 mg all other
days of the week.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2138-10-10**] 16:03:07
T: [**2138-10-10**] 16:42:43
Job#: [**Job Number 64001**]
ICD9 Codes: 4240, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 995
} | Medical Text: Admission Date: [**2163-7-20**] Discharge Date: [**2163-8-8**]
Date of Birth: [**2113-11-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p motorcycle accident
Major Surgical or Invasive Procedure:
1. external fixation open L distal radius/ulna fx
2. operative washout L open distal radius/unla fx
3. ORIF L metatarsal fx
History of Present Illness:
49 yo man status post motorcycle collision vs car. + helmet, ?
LOC. Patient was combative and agitated at the scene with a
GCS=10. Patient was brought by ambulance to [**Hospital1 1474**] ED, found
to have a GCS=14 on arrival. By report from [**Hospital1 1474**], patient
was found to have a closed book pelvic fracture, open L radial
fracture. He was electively intubated prior to [**Hospital 7622**]
transfer to [**Hospital1 **]. By report, a crack pipe was found with the
patient at the scene.
Past Medical History:
Hx Colon Ca (~[**2159**]), s/p [**Month (only) **], chemo, radiation
Hx multiple traumatic bony injuries
Hx substance abuse
Social History:
Homeless since [**2145**], rides motorcycle around country. +tobacco,
occ. EtoH, + substance abuse.
Family History:
Noncontributory
Physical Exam:
VITALS: 167/94 88 22 97% (intubated)
Exam on arrival:
GEN: sedated, intubated
HEENT: pupils equal + sluggish bilaterally. Face with large
amounts of dried blood, no obvious bony deformity or facial
laxity. Blood in L external auditory canal.
CHEST - equal BS bilaterally
CV - RRR
ABD - soft, nontender, nondistended, s/p colostomy
RECTAL - no anus, ostomy heme negative
GU - foley in place
EXTR - open L forearm deformity, L 5th metacarpal deformity
BACK - no abrasions, 1-2cm puncture wound R flank
NEURO - MAE x 4
Exam on discharge:
GEN: awake and alert
HEENT: PERRL, EOEMI
CHEST - equal BS bilaterally
CV - RRR
ABD - soft, nontender, nondistended, s/p colostomy
EXTR - extremity splints C/D/I
BACK - well-healed wound, sutures removed, no erythema/pus
NEURO - MAE x 4
Pertinent Results:
[**2163-7-20**] 05:20PM URINE RBC-[**2-12**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2163-7-20**] 05:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2163-7-20**] 05:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2163-7-20**] 05:20PM FIBRINOGE-222
[**2163-7-20**] 05:20PM PT-14.0* PTT-27.5 INR(PT)-1.3
[**2163-7-20**] 05:20PM PLT COUNT-201
[**2163-7-20**] 05:20PM WBC-18.5* RBC-4.06* HGB-12.8* HCT-36.3*
MCV-90 MCH-31.5 MCHC-35.2* RDW-13.0
[**2163-7-20**] 05:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2163-7-20**] 05:20PM URINE GR HOLD-HOLD
[**2163-7-20**] 05:20PM URINE HOURS-RANDOM
[**2163-7-20**] 05:20PM URINE HOURS-RANDOM
[**2163-7-20**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2163-7-20**] 05:20PM AMYLASE-75
[**2163-7-20**] 05:20PM UREA N-12 CREAT-0.9
[**2163-7-20**] 05:34PM freeCa-1.02*
[**2163-7-20**] 05:34PM HGB-13.6* calcHCT-41 O2 SAT-95 CARBOXYHB-4
MET HGB-1
[**2163-7-20**] 05:34PM GLUCOSE-115* LACTATE-1.9 NA+-145 K+-3.8
CL--112 TCO2-23
[**2163-7-20**] 05:34PM TYPE-ART PH-7.35 COMMENTS-GREEN TOP
RADIOLOGIC STUDIES (SUMMARY):
CXR: R mainstem intubation, bilateral clavicular fxs
Pelvis plain film: R superior/inferior pubic rami fxs (new?),
old sacral pinning
CT head: negative
C spine: negative
CT Chest/Abdomen/Pelvis: no fx's, no solid organ injury, s/p
ostomy
L arm: open, displaced distal radial/ulnar fxs
L ankle: no fx
Brief Hospital Course:
The patient was admitted to the TSICU from the ED. He was
evaluated via physical exam and review of the images that were
taken in the ED and found to have the following injuries:
open L ulnar fracture/dislocation, and distal radial fracture
L elbow dislocation
old R pubic fractures
new nondisplaced L inferior pubic ramus fracture
bilateral old clavicle fractures
R 8th rib fracture
R pulmonary contusions and small effusion
small R pneumothorax
face and R flank lacerations
He was taken to the OR on [**2163-7-21**] for irrigation and
debridement of the both fracture in the left arm, placement of
an external fixator across the wrist and examination of the left
elbow under anesthesia with confirmation of reduction. For
additional details regarding this procedure please see Dr. [**Name (NI) 64103**] operative note. He returned to the OR on [**7-23**] for
irrigation and debridement of his left open distal ulnar and
radius fractures. For additional details regarding this
procedure please see Dr.[**Name (NI) 21863**] operative note.
He was released from the unit to the floor. Here he was seen by
PT and social work. He was encouraged to stop smoking to
promote wound healing and was given a nicotine patch to aid in
this process. However he insisted on smoking and would take
himself downstairs in his wheelchair to do so.
On [**7-28**] L foot 2,3,4 metatarsal fractures with angulation of 4
were found on XRay. He was scheduled for surgery to fix his
metatarsal fractures on [**8-1**] but refused to adhere to his NPO
status so his surgery had to be postponed. On the evening of
[**8-2**] he ate a tray of homemade ziti and developed severe belly
pain. He stopped putting out stool into his ostomy and by the
morning of [**8-3**] CT revealed dilated loops of bowel, a tranistion
point in the mid abdomen, no passage of contrast beyond this
point, and compressed bowel in his pelvis with a transition.
These images along with his physical exam were consistent with
SBO and he was taken to the OR on [**8-3**] for lysis of adhesions,
closure of an internal space adjacent to the colostomy and
repair of a lateral internal hernia. For additional details
regarding this procedure please see Dr.[**Name (NI) 1863**] operative
note.
On [**8-6**] he returned to the OR for open reduction and internal
fixation 4th L metatarsal by podiatry concurrent with open
reduction and internal fixation of
his right distal radius fracture, volar by ortho. For
additional details regarding these procedures please see Dr. [**Name (NI) 64104**] and Dr.[**Name (NI) 4213**] operative notes.
He returned to the floor to await PT work and diet advancement
but again refused to adhere to his NPO status and requested to
be sent home with his girlfriend. After restarting his diet
against medical advice, he remained without abdominal pain or
vomiting for over 24 hours and began to pass gas into his
ostomy. He was discharged with a wheelchair and follow-up plans
in place with all participating services.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p motorcycle crash
open left ulnar fracture and dislocation
left distal radius fracture
nondisplaced left inferior pubic ramus fracture
right 8th rib fracture
right pulmonary contusion with small effusion
small right pneumothorax
lacerations on right flank and faceleft
left 2nd-4th metatarsal fractures
small bowel obstruction
internal hernia
Discharge Condition:
Fair to good
Discharge Instructions:
You should call a physician or come to ER if you have worsening
pains, fevers, chills, abdominal pain, nausea, vomiting,
shortness of breath, chest pain, redness or drainage about the
wounds, or if you have any questions or concerns.
It is important you take medications as directed. You may
continue to take your pre-admission medicaitons unless otherwise
directed, but you should not take motrin or for at least a week
after surgery. You should not drive or operate heavy machinery
while on any narcotic pain medication such as percocet as it can
be sedating. You may take colace to soften the stool as needed
for constipation, which can be cause by narcotic pain
medication.
You should keep your splints intact and dry until seen at
follow-up visit.
You may remove the bandage on your neck tomorrow.
Followup Instructions:
Call for a follow-up appointment at the Trauma Clinic
([**Telephone/Fax (1) 2359**]) in 1 week.
Left arm: Call for a follow-up appointment with Dr. [**Last Name (STitle) 1005**]
(Orthopedic Surgery; [**Telephone/Fax (1) 4845**]) in 2 weeks.
Right arm: Call for an appointment with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 4845**])
in 1 week.
Foot: Call for an appointment with Dr. [**First Name (STitle) 3209**] ([**Telephone/Fax (1) 543**]).
Call for an appointment at the [**Hospital **] Clinic ([**Telephone/Fax (1) 2384**]);
your blood glucose levels in the hospital were suggestive of
mild diabetes.
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 996
} | Medical Text: Admission Date: [**2200-4-15**] Discharge Date: [**2200-4-18**]
Date of Birth: [**2122-4-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Banding of esophageal varices
History of Present Illness:
77 year old male with history of portal HTN, cirrhosis,
presented with diffuse abdominal pain and one episode of large
volume hematemesis.
Past Medical History:
cirrhosis, portal HTN, diverticulitis, [**Doctor Last Name **] disease,
ventral hernia, CCY, appy, R. rotator cuff repair
Pertinent Results:
[**2200-4-14**] 04:40PM PT-15.3* PTT-24.1 INR(PT)-1.4*
[**2200-4-14**] 04:40PM WBC-9.0 RBC-2.32*# HGB-6.8*# HCT-21.4*#
MCV-92# MCH-29.3 MCHC-31.9 RDW-15.6*
[**2200-4-14**] 04:40PM CK-MB-NotDone
[**2200-4-14**] 04:40PM cTropnT-<0.01
[**2200-4-14**] 04:40PM ALT(SGPT)-114* AST(SGOT)-90* CK(CPK)-34* ALK
PHOS-84 AMYLASE-13 TOT BILI-2.6*
[**2200-4-14**] 04:40PM LIPASE-19
[**2200-4-18**] 05:40AM BLOOD Hct-30.2*
[**2200-4-17**] 05:45AM BLOOD Glucose-178* UreaN-18 Creat-1.0 Na-139
K-3.9 Cl-105 HCO3-27 AnGap-11
Brief Hospital Course:
The patient was admitted to the ICU on [**4-14**] after noting
hematemesis and bloody stool in the emergency department. Upon
admission his HCT was 21.4 and was transfused 4 units of PRBC's.
Given the patients history of cirrhosis and liver disease the
hepatology service was consulted who performed an EGD and found
grade 3 bleeding esophageal varices. The varices were banded and
the patient was transferred back to the ICU. The hepatology team
also recommended an octreotide drip, sucralfate and ceftriaxone
which were all started. Following the procedure the patient's
hematocrit stabilized and upon discharge was 30. The patient was
transferred to the floor once his hematocrit stabilized and was
restarted on his home medications and a soft mechanical diet. He
was continued on the octreotide drip until discharge and
recieved a 5 days course of ciprofloxacin on discharge per the
hepatology team. Patient also underwent an ultrasound of the
liver to assess for portal vein flow which was found to be
normal. Once the patients hematocrit was stabilized and was
tolerating a regular diet the patient was discharged home. He
will follow up with hepatology regarding his liver disease and
varices. Of note the patient had a difficult time with urination
and was started on flomax prior to discharge. He will make an
appointment with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6457**] regarding this issue. On
discharge the patient was afebrile with stable vital signs and
tolerating a regular diet.
Medications on Admission:
aspirin, glipizide, lipitor, lisinopril, metformin, metoprolol
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
2. 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*
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 * Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
10. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal varices
Discharge Condition:
Good
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or visit ER if you experience any of the
following: Temperature > 101.5, chest pain, shortness of breath,
severe abdominal pain, nausea/vomiting, bloody vomitus or
diarrhea, or inability to tolerate oral intake.
Please apply a warm compress to your arm three times a day and
keep your arm elevated.
Followup Instructions:
Please follow up with [**Last Name (LF) **], [**Name8 (MD) **], MD (hepatology) in [**2-12**]
weeks. You can schedule an appointment with him by calling
[**Telephone/Fax (1) 2422**].
Also please arrange a follow up appointment with Dr. [**First Name (STitle) 1313**]
within the next week. His number is [**Telephone/Fax (1) 7318**]
ICD9 Codes: 5715, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 997
} | Medical Text: Admission Date: [**2102-6-16**] Discharge Date: [**2102-6-24**]
Date of Birth: [**2055-9-8**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESLD in need of liver transplant
Major Surgical or Invasive Procedure:
[**2102-6-16**]: Orthotopic liver transplant
History of Present Illness:
46y man with liver failure secondary to HCV and alcoholic
cirrhosis, portal hypertension, and HCC who presents for liver
transplant. He has been feeling well and denies fever, chills,
abdominal pain, shortness of breath, or chest pain.
Past Medical History:
Cirrhosis [**3-20**] HCV/EtOH dx [**2095**]
s/p failed pef-interferon tx for HCV
h/o variceal hemorrhage [**5-21**]
Social History:
former EtOH - dry x 4 years, h/o IVDU but currently clean
Family History:
NC
Physical Exam:
VS: 99.2 78 122/69 20 98%RA Wt 87.8KG
Gen: NAD
Heart: regular, S1 S2
Lungs: CTA B/L, no wheeze or rales
Abd: soft, mild tenderness at umbilical hernia, non-distended,
bowel sounds present
Extr: warm, well perfused, no edema
Pertinent Results:
On Admission: [**2102-6-16**]
WBC-4.4# RBC-4.45* Hgb-14.6 Hct-42.3 MCV-95 MCH-32.8* MCHC-34.6
RDW-14.8 Plt Ct-46*
Glucose-94 UreaN-13 Creat-0.9 Na-135 K-3.7 Cl-101 HCO3-26
AnGap-12
PT-25.5* PTT-39.4* INR(PT)-2.5*
Albumin-3.3* Calcium-8.3* Phos-2.8 Mg-1.7
Brief Hospital Course:
46 y/o male admitted for liver transplant. The donor liver was
from a 33-year-old 110 pound woman who died from a combination
of an asthma attack and snorting heroin. The patient was made
aware of the nature of the donor death. Hepatitis C and HIV
testing were negative.
The patient was taken to the OR on [**2102-6-17**] by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for liver transplant. He received induction
immunosuppression consisting of Cellcept and Solumedrol.
Significant portal hypertension was noted, and the liver was
found to be quite adherent. Prior to surgery the patient was on
coumadin for portal vein thrombus. At time of surgery there
seemed to be a small clot in the portal vein, however, the vein
itself was open. Once opened it appeared to be a cavernous
transformation of the vein and there was an excellent flow. The
liver pinked up immediately and made bile on the table. The
patient tolerated the procedure well and was transferred to the
SICU, intubated.
He was extubated on postop day 1, and transferred out of the
SICU on postop day 2. Prograf was initiated on POD 1, steroid
taper continued and cellcept [**Hospital1 **] without notable side effect.
Urine output was appropriate and foley was removed without
incident.
JP drains outputs averaged 1-2 Liters total daily requiring IV
fluid replacements. JP drain bilirubins were 1.5 and 1.8. JP
drainge decreased allowing for removal of the lateral drain was
d/c'd on POD 6.
He was seen and cleared by PT, ambulating without difficulty. He
had return of bowel function and was tolerating diet without any
issues.
[**Last Name (un) **] was consulted for hyperglycemia. NPH (10 units)was
addded in addition to sliding scale humalog insulin with
improved glucose control. He received instructioin on glucose
management and self administration.
He was discharged to home in stable condition.
Medications on Admission:
Lasix 40 mg once a day, lactulose titrated to
[**4-19**] bowel movements per day, nadolol 20 mg once a day, Protonix
40 mg 1 twice a day, Aldactone 100 mg once a day, Carafate 10 cc
by mouth 4 times a day, Coumadin as directed (2.5 daily
Discharge Medications:
1. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous once a day: AM Dose.
Disp:*2 bottles* Refills:*2*
2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
follow taper.
3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
8. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours) as needed for s/p liver transplant.
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous once a day: at breakfast.
Disp:*1 vial* Refills:*2*
12. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale units Subcutaneous four times a day.
Disp:*1 vial* Refills:*2*
13. One Touch Ultra System Kit Kit Sig: One (1)
Miscellaneous four times a day.
Disp:*1 kit* Refills:*2*
14. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
15. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
liver failure secondary to HCV and alcoholic cirrhosis, portal
hypertension now s/p orthotopic liver transplant
Discharge Condition:
Stable/good
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] if you fever
greater than 101, chills, nausea, vomiting, diarrhea,
constipation.
Monitor the incision for redness, drainage or bleeding
Drain and record JP drain output as often as needed. Do not
allow the bulb to become more than half full. Bring a copy of
the drain outputs to your clinic visit.
Labs to be drawn every Monday and Thursday. Fax results to
transplant clinic at [**Telephone/Fax (1) 673**].
No heavy living
You may shower, allow water to run over incision, pat incision
dry. PLace new drain sponge following your shower or daily.
No driving if taking narcotic pain medication
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2102-6-29**] 8:30
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2102-7-6**] 9:30
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2102-7-6**] 10:30
Completed by:[**2102-6-27**]
ICD9 Codes: 3051, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 998
} | Medical Text: Admission Date: [**2134-6-13**] Discharge Date: [**2134-7-3**]
Date of Birth: [**2063-9-23**] Sex: F
Service: MEDICINE
Allergies:
epinephrine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
pneumonia, renal failure
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line placement
PICC line placement
History of Present Illness:
70yo woman with long smoking history, 1ppd for many years,
decreased to [**1-11**] ppd in the last month, none in the last 4 days;
comes in with four days of cough and progressive shortness of
breath. Rigors, chills, sweats 2 days ago.
She presented to the [**Hospital3 **] ED, where initial vitals
were 97.4 90/55 91 26 78% on RA. Cr 7.1, K+ 5.1 (without EKG
changes), lactate 5.3. Creatinine up to 7.1, BUN 120. ABG there
w/ pH 7.33. Sent here.
In the ED, initial VS were: 97.6 85 109/56 26 90% 15L venti. WBC
down to 1.2. Lungs decreased at right base, but no wheezing.
Added levofloxacin for coverage of severe CAP. Long-time smoker.
Vitals prior to transfer 81 16 93% on venti mask at 50% 107/51.
Has two 18G for access.
> 10# decrease in weight in the past month; not trying to lose
weight, has not been hungry. Denies history of previous kidney
problems. [**Name (NI) **] hx of requiring oxygen or nebulizers in the past.
On arrival to the MICU, the patient was on a non-rebreather mask
in no distress or discomfort, but having 1 sentence dyspnea.
She was alert and oriented.
Review of systems:
(+) Per HPI
(-) Denies weight gain. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies 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.
Social History:
- Tobacco: 1ppd for many years, 1 month ago down to 1/2ppd, none
for last 4 days
- Alcohol:
- Illicits: none
- worked as a nurse for many years in various venues
Family History:
NC
Physical Exam:
ADMISSION
Vitals: T: 97.7 BP: 115/58 P: 86 R: 18 O2: 97% on NR
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, slightly dry mucosa, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, bilateral 18GA IVs in forearms
Lungs: tachypneic, slight suprasternal retractions, no distress,
crackles b/l, R >L, diminished R side with bronchial lung sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
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, gait deferred
.
DISCHARGE
Pertinent Results:
ADMISSION
[**2134-6-13**] 07:08PM BLOOD WBC-1.2* RBC-4.36 Hgb-13.7 Hct-41.7
MCV-96 MCH-31.3 MCHC-32.8 RDW-14.8 Plt Ct-172
[**2134-6-13**] 07:08PM BLOOD Neuts-46* Bands-14* Lymphs-28 Monos-8
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0
[**2134-6-13**] 07:08PM BLOOD Glucose-83 UreaN-115* Creat-6.8* Na-138
K-4.4 Cl-98 HCO3-13* AnGap-31*
[**2134-6-14**] 01:37AM BLOOD ALT-42* AST-131* LD(LDH)-459* CK(CPK)-87
AlkPhos-60 TotBili-0.3
[**2134-6-14**] 01:37AM BLOOD Albumin-2.7* Calcium-7.5* Phos-7.9*
Mg-1.9
.
PERTINENT
[**6-13**] [**Hospital1 **] BLOOD CULTURE: 1. STREPTOCOCCUS PNEUMONIAE
INTERP M.I.C.
------ ------
LEVOFLOXACIN S
CEFTRIAXONE-(non-meningitis) S 0.012
CEFTRIAXONE(meningitis) S 0.012
PENICILLIN-MIC S 0.016
[**2134-6-14**] 5:57 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2134-6-17**]**
GRAM STAIN (Final [**2134-6-14**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2134-6-17**]):
Commensal Respiratory Flora Absent.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
PENICILLIN G---------- S
[**2134-7-1**] 5:42 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2134-7-1**]**
C. difficile DNA amplification assay (Final [**2134-7-1**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
CXR [**6-13**]
Moderate right pleural effusion with right lung base
consolidation. Smaller opacification likely pneumonia at the
left upper lobe. Repeat imaging to document resolution after
treatment.
.
U/S [**6-14**]
Satisfactory morphologic appearance of both kidneys with no
evidence of
hydronephrosis, renal mass or shadowing calculi.
The bladder is empty containing an indwelling Foley catheter.
.
ECHO [**2134-6-16**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a very small,
predominantly anterior pericardial effusion. There are no
echocardiographic signs of tamponade. No
IMPRESSION: Preserved regional and global biventricular systolic
function. No significant valvular disease. No valvular
vegetations identified.
.
KUB [**2134-6-16**]
IMPRESSION: Paucity of abdominal gas without evidence of toxic
megacolon.
.
U/S [**6-19**]
1. Distended gallbladder containing layering sludge without
definite stones. No gallbladder wall edema. Though no specific
signs of cholecystitis are present, acute acalculous
cholecystitis cannot be excluded.
2. Uniform dilation of the extrahepatic common duct, up to 1.0
cm, to the
level of the pancreatic head, below which the duct is not seen
well. MRCP may be helpful for further evaluation if there is
clinical concern. If not
obtained LFTs should be followed.
3. Small amount of ascites.
.
DOPPLER U/S
IMPRESSION: No evidence of deep vein thrombosis. Cephalic vein
(superficial) thrombosis at the level of the antercubital fossa.
.
CXR [**7-1**]
There is a new tracheostomy tube in standard position. Right IJ
catheter tip is in the mid SVC. NG tube tip is in the stomach.
Cardiomediastinal contours are unchanged. Mild vascular
congestion is increased. Bibasilar opacities are unchanged.
Small bilateral pleural effusions are also stable. There is no
evident pneumothorax. The opacities in the lower lobes may
reflect atelectasis, but superimposed infection cannot be
totally excluded.
.
MRI [**2134-6-30**]
FINDINGS: Diffusion images demonstrate multiple small areas of
restricted
diffusion in both cerebral hemispheres, predominantly in the
subcortical white matter in the periventricular region including
involvement of the left side of the corpus callosum suggestive
of acute infarcts. There are no acute infarcts seen in the
brainstem or cerebellum. Mild brain atrophy is seen. Mild
changes of small vessel disease identified. Small amount of
fluid is seen in the left sphenoid sinus and bilateral mastoid
air cells. There is no evidence of chronic microhemorrhages.
IMPRESSION: Multiple acute subcortical infarction in both
cerebral
hemispheres as described above. No mass effect or
hydrocephalus.
EEG [**6-29**]
This is an abnormal awake and sleep EEG because of
intermittent runs of bifrontocentral rhythmic slowing. In
addition,
there is excess slow activity admixed with background. These
findings
are indicative of a diffuse mild to moderate encephalopathy of
non-
specific etiology. If clinical suspicion for seizure is high, a
24
hour bedside EEG monitoring is recommended. No epileptiform
discharges
or electrographic seizures are present.
EEG [**6-30**]
IMPRESSION: This telemetry captured no pushbutton activations.
The
background was often disorganized and included a fair amount of
drowsiness. There were also brief bursts of slowing seen
multifocally,
especially in the right frontal region, but there were no areas
of
persistent and prominent focal slowing. There were no definitely
epileptiform features. There were no electrographic seizures.
[**7-1**] EEG
IMPRESSION: This telemetry captured no pushbutton activations.
The
recording showed a disorganized background, but one that reached
normal
frequencies. Much of the recording reflected drowsiness or early
sleep.
There was some slowing in several areas, but none was permanent.
There
were no epileptiform features, and there were no seizures.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
70 y/o female without significant past medical history who
presented initially with 4 days of cough, malaise, fever at home
dx with pneumonia via xray, admitted to MICU for increased O2
demand and acute kidney injury. Ultimately intubated for
respiratory distress and found to have Pneumococcal sepsis w/
course c/b MODS.
.
# Hypoxic respiratory failure:
Likely secondary to pneumonia in the setting of underlying COPD,
thus minimal reserve. Patient had progressive increasing work of
breathing ultimately requiring intubation. This was further
complicated by the development of ARDS in the setting of septic
shock, and pulmonary edema from fluid resuscitation. Her
pneumonia was treated with antibiotics (see below) and she
diuresis was started once she was HD stable. Her respiratory
status slowly improved. However, there was concern that due to
critical illness myopathy and resulting poor inspiratory effort,
she would be at high risk of re-intubation. A tracheostomy was
performed on [**6-30**]. Prior to discharge the patient was off the
ventilator with normal saturation on trach mask at FIO2 of 40%.
.
# Pneumosepsis:
Patient presented with leukopenia, bandemia, tachycardia and
tachypnea. Her CXR initially showed RLL infiltrate but evolved
quickly to involve both lungs. She shortly thereafter became
hypotensive and was aggressively fluid repleted and temporarily
required vasopressors. Her blood cultures from OSH prior to
transfer grew Peniccilin sensitive Streptococcus pneumoniae, as
did her sputum cultures here. She completed a 14 day course of
antitiobics on [**2134-6-27**]. She was afebrile and hemodynamically
stable prior to discharge.
.
# Acute renal failure:
Patient presented with BUN/Cr 115/6.8 in the setting of sepsis,
likely secondary to ATN, with evidence of muddy brown casts on
urine analysis. Renal ultrasound revealed no alternative cause
such as hydronephrosis. Her renal function gradually improved as
she became HD stable. Creatinine on discharge was 1.2.
.
# Thrombocytopenia
Patient had significant fall in platelet count during course of
hospitalization. Patter was concerning for [**Last Name (LF) **], [**First Name3 (LF) **] heparin was
discontinued, argatroban was started. [**First Name3 (LF) **] antibody was
eventually negative so argatroaban discontinued and resumed
heparin for DVT prophylaxis. Thrombocytopenia ultimately felt to
be medication related. Famotidine was discontinued. Patient's
platelet count gradually normalized.
.
# Altered/Persistent Depressed mental status:
Patient had significant delay in recovery of mental status,
initially attributed to build up of benzodiazepines used for
sedation (on ventilator) in the setting of [**Last Name (un) **], evidenced by
prolonged presence of benzodiazepines in urine. Slowly improved
but some concern for waxing/[**Doctor Last Name 688**] consciousness. MRI revealed
multiple acute subcortical infarctions in both cerebral
hemispheres. EEG was concerning for brief bursts of slowing seen
multifocally, but especially in the right frontal region
suggestive of possible seizure activity. Her EEG prior to
discharge demonstrated no seizure activity. Her clinical status
continued to improve. Outpatient neurology follow-up was
arranged.
.
# Critical Illness Myopathy/Polyneuropathy:
Patient with significant weakness and difficulty gaining motor
function in setting of sepsis and mechanical ventilation with
use of paralytics. Slowly improved throughout her course. Her
clinical status continued to improve. Outpatient neurology
follow-up was arranged.
.
# Fevers:
Patient intially febrile after completion of ATBx course,
however, repeat blood, urine cultures negative and CDiff toxin
negative and no leukocytosis. Gradually resolved and afebrile
for the 72 hours prior to discharge.
.
# Anemia:
HCT steadily trending down, could be from serial phlebotomies
vs. anemia of chronic disease. Stool guaiac negative.
B12/folate/iron studies unremarkable, hemolysis labs negative;
low ferritin and low retic index indicate hypoproliferative
anemia. Likely anemia of acute disease. Remained stable at 24.3
prior to discharge. She should have her hematocrit trended daily
initially. Our transfusion criteria had been hct < 21.
# Dental issues:
Patient noted to have poor dentition. Evaluation by general
dentistry revealed multiple broken molars which need extraction.
-> Panorex as outpatient given that patient is too weak to
stand/sit on stool independently. Will need outpatient f/u with
oral surgery as well.
# s/p Tachycardia
Patient's course was c/b developement of atrial flutter. She was
initially treated with nodal blocking [**Doctor Last Name 360**] with resulting
hypotension. She eventually responded well to amiodarone.
-> Will likely need taper off this medication given unclear need
and potential for more lung toxicity. Will need to discuss this
with her primaryoutpatient providers upon leaving rehab.
# Transaminitis
LFTs elevated on presentation. Ultimately felt secondary to
hypotension, however in setting of persisten fevers there was
some concern for acalculous cholecystitis. RUQ ultrasound was
initially concerning for tense/enlarged gallbladder, but upon
further review by interventional radiology felt to be within
normal limits and not consistent with alcalculous cholecystitis.
LFTs were downtrending throughout the remainder of her hospital
course.
.
.
TRANSITION OF CARE
- Follow-Up Required--Patient will need repeat CT chest to
evaluate potentitial underlying pulmonary mass
--She will need follow up with Primary Care Physician, [**Name10 (NameIs) **] does
not have an established physician.
[**Name10 (NameIs) 112069**] will need to follow-up with a dental/oral surgery
--She will need neurology follow up
--Tracheostomy: will need removal of sutures around [**2134-7-10**];
keep tracheostomy neck ties in place at all times per
interventional pulmonary recommendations.
--Will be continued on amiodarone and Lasix upon discharge. Will
need outpatient labwork to evaluate renal function,
electrolytes, normalization of LFTs
--Full code
Medications on Admission:
- Quinidine 300mg daily
- ibuprofen 400mg PRN
Discharge Medications:
1. Heparin 5000 UNIT SC TID
2. Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN mouth
pain
3. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
4. Albuterol-Ipratropium [**4-16**] PUFF IH Q4H:PRN SOB, Wheezing
5. Amiodarone 200 mg PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
7. Miconazole Powder 2% 1 Appl TP TID:PRN rash
apply to rash
8. Furosemide 40 mg PO BID:PRN volume overload
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
ACUTE ISSUES:
1. Septic shock with multiple organ dysfunction, secondary to
pneumococcal pneumonia
2. Hypoxic respiratory failure
3. Acute tubular necrosis (ATN) causing renal failure
4. Paroxysmal atrial fibrillation
5. Myopathy/polyneuropathy of critical illness
6. Lesions on brain MRI (acute stroke vs. infectious vs.
inflammatory)
7. Thrombocytopenia
8. Normocytic hypoproliferative anemia
CHRONIC ISSUES:
1. Smoking history
2. Chronic obstructive pulmonary disease (COPD)
3. Hypertension
4. Possible history of [**Name (NI) **] (unclear)
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:
Dear Ms. [**Known lastname **],
It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the medical ICU
on [**2134-6-13**] with pneumonia causing severe systemic infection and
respiratory failure. You were intubated and treated with
antibiotics. Your course was complicated by kidney failure which
caused your body to become severely fluid overloaded, and by
severe muscle weakness caused by long ICU stay. You were too
weak to be directly extubated so instead you had a tracheostomy
(breathing tube placed in your neck). Your symptoms slowly and
steadily improved with treatment and you are now ready for
discharge to a rehab facility where you will have frequent
physical therapy to help you regain your strength.
.
Please attend the follow-up appointment listed below with
dentistry (for dental x-rays and to possibly have some broken
teeth pulled). Also please attend the neurology appointment
listed below, to follow up on your weakness and the changes on
your brain MRI.
.
We made the following changes to your medications:
1. STOPPED quinidine.
2. STARTED amiodarone 200mg by mouth daily for paroxysmal atrial
fibrillation
3. STARTED heparin 5000 units subcutaneous three times daily
(continue until your mobility improves, rehab doctors [**Name5 (PTitle) **]
decide when you can stop)
4. STARTED colace and senna for constipation
5. STARTED maalox-diphenhydramine-lidocaine 15-30mL by mouth
every 4 hours as needed for mouth/throat pain
6. STARTED miconazole powder three applications per day for rash
Followup Instructions:
[**University/College 46453**] of Dental Medicine View Map
[**Last Name (NamePattern1) 112070**], R407
[**Location (un) 86**], [**Numeric Identifier 13108**]
Phone: [**Telephone/Fax (1) 108313**]
***It is recommended you see an Oral Surgeon as part of your
follow up care from the hospital. The above location may be a
possible resource for follow up.
Department: NEUROLOGY
When: WEDNESDAY [**2134-7-28**] at 4:30 PM
With: DRS. [**Name5 (PTitle) 540**]/[**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**You have also been placed on a wait list and will be called at
rehab with an appt if one becomes available.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5845, 2760, 2762, 4019, 3051, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 999
} | Medical Text: Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD,
malignant HTN, history of SVC syndrome, and history of Posterior
Reversible Encephalopathy Syndrome (PRES) and intracerebral
hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**],
[**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for
hypertension, but most recently for diarrhea in addition to
hypertension.
.
In the ED, vitals were 98 90 102/65 20 98% RA. She was
complaining of abdominal pain X 3 hours, more severe than usual
[**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg
IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt
stable for floor; however, BP rose during ED course to SBP 270.
She then received hydral 50 PO X 1, home aliskeren, labetalol
1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine
2.5 mg IV X 1 and started on nicardipine gtt.
.
Upon arrival to the floor, she complains of severe abd pain
which started earlier today, it is sharp all over her abd and
constant. It feels different from her usual abd pain, although
she is not able to characterize it more. She has been having
some nausea and bilious emesis X 1 earlier today. She has been
having some mild diarrhea 2-3 episodes of loose, greenish stools
for the past few weeks. She denies any chest pain, headache,
vision changes. She was not able to take all of the medications
due to her GI distress.
.
While in the MICU she was weaned off a nicardipine drip and her
diarrhea resolved. Her BP remained WNL while on her home regimen
and she was transferred to the floor in stable condition. Last
HD was [**2142-5-21**].
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and
now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension and history of hypertensive crisis
with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to
frequent hospitalizations and inability to see in outpatient
setting - has appt scheduled with gyn on [**5-25**]
17. History of two intraparenchymal hemorrhages that were
thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] which has resolved
Social History:
Denies any substance abuse (EtOH, tobacco, illicits). She lives
with her mother and brother. On disability for multiple medical
problems.
Family History:
No known autoimmune disease but there is a history of
cardiovascular disease and cerebrovascular accident in her
grandfather.
Physical Exam:
100/63 81 18 100RA
GENERAL: Pleasant, thin young female sitting in the bed in NAD
watching TV.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP
clear. Neck Supple, No LAD.
CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB.
LUNGS: Breathing comfortably, CTAB, good air movement
biaterally.
ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No
rebound or guarding.
EXTREMITIES: No edema. Right femoral HD line nontender,
nonerythematous.
SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm
scattered along her lower extremities.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation to light touch throughout. 5/5 strength in her upper
and lower extremities
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2142-5-20**] 09:14PM LACTATE-0.9
[**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93
MCH-29.2 MCHC-31.6 RDW-18.8*
[**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2142-5-20**] 09:13PM PLT COUNT-145*
[**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137
POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21*
[**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1
[**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93
MCH-30.2 MCHC-32.5 RDW-19.2*
[**2142-5-20**] 08:55PM PLT COUNT-126*
[**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2*
[**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT
BILI-0.4
[**2142-5-20**] 07:40AM LIPASE-58
Brief Hospital Course:
KUB: SBO
Head CT: (prelim read from radiology). unchanged from prior head
CT, no intracranial hemorrhage
EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3
(old), TW inversion V6 (new) compared to prior EKG [**5-15**].
CT CHEST/ABD: Preliminary Read
Normal aorta without dissection or acute abnormality. No PE.
Stable trace
ascites and small right pleural effusion. Unchanged small
pulmonary nodules
and lymphadenopathy in the chest. No acute abnormalities in the
abdomen to
explain epigastric pain.
EGD: Ulcer at GE junction.
# Hypertensive urgency: This is a chronic issue related to ESRD.
Head CT was negative for intracranial bleed. Weaned off
Nicardipine gtt and BP well controlled on home regimen.
Continued her home regimen of: Aliskiren 150 mg po bid,
Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID,
Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet
Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were
lower (see below) patient's BP meds were held occasionally, but
as she was transfused and the BPs started to trend back up the
meds were re-initiated. She then developed hypotension in the
setting of poor PO intake during her SBO. BP meds were held and
then re-initiated as the pressure came back up once she was able
to eat.
# Abdominal pain/UGIB: The patient has chronic abdominal pain
with previous negative workups. At first the pain resolved and
she was continued on her outpatient regimen of: 2-4 mg po
dilaudid q4 h as needed. GI was c/s re: abd pain and rec
CTA-abdomen to eval for mesenteric ischemia vs. partial SBO,
however with ESRD did not initially want to get CTA so KUB was
ordered. This showed no SBO. They recommended checking urine
porphyrobilinogen and serum lead levels which were negative and
LFTs were at baseline. The patient then developed a different
type of pain associated with her incision site. Pain service was
consulted and did a bupivicaine injection at the site which did
help. They will continue to follow her. She then developed a
third type of pain associated with a burning sensation in her
chest. EKG was unchanged from prior. A few hours later she had 3
episodes of coffee-ground emesis. She was placed on IV PPI and
transfused two units of blood. Afterward the pain resolved and
her hct remained stable. GI felt that the patient would need
general anesthesia in order to undergo an EGD which showed an
ulcer at the GE junction. She was started on empiric treatment
for H. Pylori and serologies were sent which came back negative
so the antibiotics were stopped. Her pain was controlled with
her outpatient regimen of PO dilaudid. She will follow up with
Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if
there has been resolution of the ulcer.
# SBO: Continued to be nauseous and vomited intermittently. she
was started on reglan and continued on zofran and compazine PRN
howeve she continued to have n/v. A KUB was done which showed an
SBO. Surgery was consulted, NGT was placed, she was made NPO and
serial abdominal exams were done. Eventually she was able to
transition to clear diet and then tolerated a regular diet
without pain or vomiting.
#. Fever: On hospital day #6 she spiked a fever to 101. Blood
and urine cultures were sent and a cxr were negative, however
she then had a seizure and in the post-ictal state aspirated
after vomiting. She had an episode of hypoxia with this and was
transferred to the ICU. In the ICU LP was attempted to rule out
meningitis as a possible cause of a seizure but this was
unsuccessful. Broad spectrum antibiotics were initiated (vanc
ctx) at meningeal dosing. She improved over the next few days
and antibiotics were discontinued because the suspicion for a
bacterial meningitis was low.
#. Seizure: This occured in the setting of fever, hypotension,
and initiation of reglan for vomiting. Neurology was consulted
and felt she should be continued on keppra indefinitely. EEG was
non-revealing. She should be continued on keppra 1gm with
dialysis three times weekly.
# ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent
dialysis on normal schedule.
# SLE: She was continued on prednisone 4mg daily. With multiple
abdominal symptoms it was thought she may have lupus flare in
the abdomen. C3, c4 were equivocal for active lupus flare, and
[**Doctor First Name **] was positive, as would be expected in lupus.
# Anemia: Has anemia of chronic renal disease and her Hct was
high on admission and epo was held per renal. However, her Hct
trended all the way down to 20 and she was borderline
hypotensive for her (ie SBP 120) and she developed coffee ground
emesis so she was transfused 2 units. Afterward her Hct was
stable at 25. She was also re-started on EPO per renal for her
chronic anemia. Hemolysis labs were negative.
# History of thrombotic events/SVC syndrome: She is
anticoagulated with warfarin as an outpatient. Previous
documentation in OMR states she does not need to be bridged
while subtherapeutic. Continued coumadin 4 mg po daily however
INR became supratherapeutic and the coumadin was then held. She
was started on heparin gtt while awaiting EGD. After EGD the
coumadin was re-started at 3mg daily however, in setting of poor
po intake her INR was supratherapeutic - likely [**2-12**] nutritional
deficiency of vitamin k. coumadin will be restarted when INR [**2-13**]
at dialysis.
# OSA: She is on CPAP at a setting of 7 as an outpatient.
Continued CPAP
#. CIN1: On last pap had CIN1. OB/GYN service was called re:
doing colposcopy in hospital as patient rarely makes o/p
appointments, hwoever they do not do this procedure in hospital
especially because it does not have to be done emergently - just
within one year. Will need outpatient colposcopy at some point
in next few months as they do not do this procedure in the
hospital.
# RLL nodule: A new 10 x 5 mm nodularity was found incidentally
within the right lower lobe of the lung on an abdominal CT.
This should be reassessed in 3 months.
# ACCESS: PIV, right groin HD line
# CODE: Full code
Medications on Admission:
1. Aliskiren 150 mg PO bid
2. Citalopram 20 mg PO DAILY
3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT
4. Hydromorphone 2 mg 1-2 Tablets PO Q4H
5. Fentanyl 25 mcg/hr Patch 72 hr
6. Gabapentin 300 mg PO TID
7. Hydralazine 100 mg PO Q8H
8. Hydralazine 100 mg PO BID PRn fro SBP> 180.
9. Prednisone 4 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Labetalol 1000 mg PO TID
12. Nifedipine 90 mg PO QAM
13. Nifedipine 60 mg PO QHS
14. Warfarin 3 mg PO Once Daily
15. Lidocaine 5 %(700 mg/patch) Topical once a day.
16. Nifedipine 90 mg PO once a day as needed for for SBP
persistently above 200.
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QHS (once a day (at bedtime)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
30 days.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
UGIB- Ulcer at GE junction
Hypertensive Emergency
Anemia
ESRD on HD
SBO
Discharge Condition:
The patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You had
an injection of lidocaine to help the pain around your surgery
sites. You then had some blood in your vomit. You were treated
for a bleed in your stomach with a blood transfusion and
medications. You stopped bleeding and felt better. You had a
scope of your abdomen that showed an ulcer. You were treated
with medications for this and need to have another scope of your
abdomen in 6 weeks. You also had high blood pressures while you
were here because you could not take your medicines with your
nausea and vomiting. Once you were on your home medicines your
blood pressure was better.
Medication Changes:
CHANGE: Pantoprazole to 40mg TWICE daily
Please call your PCP or come to the emergency room if you have
fevers, chills, worsening abdominal pain, nausea, vomiting,
blood in your vomit, blood in your stools, black/tarry stools or
any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**]
weeks for an EGD to re-look at your ulcer.
Please follow up with the OB/[**Hospital **] clinic for a colposcopy on
Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**].
Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in
the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm.
Completed by:[**2142-6-6**]
ICD9 Codes: 5856, 2851, 4254, 4589, 2767, 2875 |
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