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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 0
} | Medical Text: Admission Date: [**2117-9-11**] Discharge Date: [**2117-9-17**]
Date of Birth: [**2082-3-21**] Sex: F
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy,
nephropathy, HTN, gastroparesis, CKD and retinopathy, recently
hospitalized for orthostatic hypotension [**2-3**] autonomic
neuropathy [**Date range (1) 25088**]; DKA hospitalizations in [**6-12**] and [**7-12**], now
returning w/ 5d history of worsening nausea, vomiting with
coffee-ground emesis, chills, and dyspnea on exertion. Last
week she had a fall and hit her right face. she also had 1 day
of diarrhea, which resolved early last week. Found to be in DKA
with AG 30 and bicarb 11.
.
In the ED inital vitals were 09:00 0 98.2 113 181/99 22 100% RA.
K 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) She is
on her 3rd L NS. Insulin srip at 5 units/hr. On home at 22
levemir in am and 12 at with difficult to control sugars. BPs
have been high. Given 30 mtroprolol tartrate in ED.
She was started on an insulin drip at 5 units/hr and 3L NS
boluses. Also aspirin 325mg PO and Morphine 4mg IVx1 for pain.
CXr was clear. EKG NAD.
.
Review of systems: otherwise negative.
Past Medical History:
Type 1 diabetes mellitis w/ neuropathy, nephropathy, and
retinopathy - 2 episodes of DKA in [**6-12**] and [**7-12**]
HTN - 5 years
gastroparesis - 1.5 years
CKD - stage III, baseline Cr 2.4-2.5, proteinuria
L1 vertebral fracture - [**2117-7-17**]
Systolic ejection murmur
Social History:
Patient lives at home in [**Location (un) **] with her 8 y/o daughter and
boyfriend. She has no history of EtOH, tobacco, or illicit drug
use. She is currently unemployed and seeking disability.
Family History:
Both parents have HTN and T2DM. Grandfather had an MI in his
40s.
Physical Exam:
GEN: Awake, alert, and oriented
HEENT: PERRLA. MMM. no JVD. neck supple. No cervical LAD
Cards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard
best at the L upper sternal border.
Pulm: CTABL with no crackles or wheezes.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. radials, DPs, PTs 2+.
Skin: no rashes or bruising. no skin tenting.
Neuro: CNs II-XII intact. Upper extremities: Power [**5-6**]
bilaterally. Le: left power: 4.5/5 right: power [**3-6**]. Bilateral
symmetric, reduced sensation distal LE to ankles.
Pertinent Results:
Admission Labs: [**2117-9-11**] 09:22AM
WBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466*
LIPASE-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5
GLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9
CL-101 CO2-11*
LACTATE-1.9
Discharge Labs: [**2117-9-16**] 07:10AM
WBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298
Glucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23
AnGap-14
Calcium-8.7 Phos-3.5 Mg-2.0
Radiology:
CXR: No evidence of pneumonia or other pathological
abnormalities. No
pleural effusions. No pulmonary edema. Normal size of the
cardiac
silhouette.
Microbiology: Urine culture negative, blood cultures no growth
to date, stool for C.difficile negative
Brief Hospital Course:
35 yo F with HTN & poorly controlled type I DM, c/b neuropathy,
gastroparesis, nephropathy ?????? CKD, retinopathy presents with DKA
and hypertension SBP to 200s.
.
# Diabetic ketoacidosis: Patient controls diabetes at home with
Humalog SS and long acting Levemir. Sugars at home recently
have been in 250s. In the ED, glucose was 466. UA was +ve for
ketones ?????? corrected to 200s, but rose again to 300s. She was
treated with an insulin drip which was transitioned to subq when
she tolerated POs. Her electrolytes were repleted and she
received aggressive volume resuscitation. [**Last Name (un) **] saw her and
gave sliding scale recommendations which were implemented. No
source for DKA found, beleived to be [**2-3**] gastroparesis. Nausea
managed with ativan, compazine, and promethazine. She was
discharged on her home Insulin and sliding scale with
instructions to follow-up with [**Last Name (un) **].
# HTN: Hypertensive with SBP in 190s initially, attributed to
DKA, as she has experienced in the past. As she improved her
blood pressures normalized and she was re-started on her home
Lopressor and Midodrine regimen.
# Coffee grounds emesis: Emesis started off as clear, then with
prolonged wretching, she started having coffee-grounds vomiting.
This had also occurred on prior admissions for DKA with
associated vomiting. Her hematocrit remained stable and her
hematemesis self-resolved, and so work-up was deferred to the
outpatient setting.
# Acute on chronic kidney disease, Stage III: Patient's Cr on
admission was 2.7, trending down to 2.1-2.3 following fluids,
consistent with her known CKD secondary to diabetic nephropathy.
Medications on Admission:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous every AM.
3. Levemir 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
4. Humalog 100 unit/mL Solution Sig: sliding scale as directed
Subcutaneous four times a day: Please use sliding scale as
directed by MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **].
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily): take in the evening.
6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for nausea.
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Please take
only 1 capsule daily (30 mg) for first 2 weeks of treatment.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain.
10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4)
hours: Can hold while sleeping.
Disp:*270 Tablet(s)* Refills:*2*
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
Once Daily at 6 PM.
5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Levemir 100 unit/mL Solution Sig: As directed by [**Last Name (un) **] units
Subcutaneous As directed.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic keotacidosis
Hematemesis (blood in your vomit)
Hypertension
Chronic renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with DKA, hypertension, and
blood in your vomit. You were initially treated in the ICU with
an insulin drip, and your blood sugars improved. Your blood
pressure medications were adjusted to better control your blood
pressure while you were in DKA, but you were re-started on your
home regimen at discharge. The blood in your vomit was likely
secondary to mechanical trauma from repeated wretching, but you
should follow-up with your primary care doctor to discuss
whether you should undergo further evaluation such as an upper
endoscopy. Given your complaints of chronic cough and heartburn,
you should also discuss beginning a trial of a proton pump
inhibitor such as Nexium or Prilosec to see if this helps your
symptoms.
Your insulin regimen was adjusted by the [**Last Name (un) **] team while you
were here. You should continue to follow-up with them with any
questions or concerns regarding your insulin management.
Followup Instructions:
Please call Dr.[**Last Name (STitle) 805**]' office to schedule a follow-up
appointment within 7-10 days of discharge. Her office number is
[**Telephone/Fax (1) 85219**].
You should also continue to follow-up with your [**Last Name (un) **] doctors
as needed.
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1
} | Medical Text: Admission Date: [**2150-4-17**] Discharge Date: [**2150-4-21**]
Date of Birth: [**2090-5-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
EGD
Right IJ CVL
History of Present Illness:
Mr. [**Known lastname 52368**] is a 59M w HepC cirrhosis c/b grade I/II esophageal
varices and portal gastropathy (last EGD [**3-/2150**]), who p/w
coffee-ground emesis and melena x2 days.
.
Pt was in his USOH until about 2-3 days PTA, when he began
experiencing intermittent nausea. He had 2-3 episodes of
coffee-ground emesis and 1 episode of tarry black stool in the
morning of admission. He reports some lightheadedness which is
not new, but denies frank hematemesis, BRBPR, abdominal pain,
fever, chills, significant increases in his abdominal girth. He
denies drinking or medication non-compliance. He also reports
taking naproxen for back pain 2-3 times a day in the recent
past.
.
In the ED, his vitals were 97.4, 93/41, 69, 18, 100% on RA. He
was given 4L NS IV, protonix 40mg IV, started on an octreotide
drip. He had guaiac positive brown stool on rectal exam. He was
seen by the liver fellow in the ED who felt this was unlikely a
variceal bleed and recommended work up for infection. An NG tube
was attempted, however, patient was unable to tolerate it in the
ED. Abdominal ultrasound was done which showed a patent portal
vein, scant ascites but not enough to tap. BP dropped to 80/34,
pt transferred to MICU for hemodynamic monitoring.
.
In the MICU, pt was given 3 pRBC, Hct bumped from 21.3 to 28.
Started on norepinephrine gtt for a few hours, but BP
stabilized. On transfer to the floor, remains hemodynamically
stable. Feels good, denies tarry or bloody BMs, emesis.
Past Medical History:
HCV Cirrhosis (tx with interferon x2 with no response)
Portal Gastropathy
Grade II Esophageal varices
HTN
Social History:
He lives alone. He is drinking alcohol, usually one session per
week. He has four to five drinks per session. He was told to
completely abstain from alcohol, effective as of today. He
smokes about 20 cigarettes per day.
Family History:
NC
Physical Exam:
ON ADMISSION:
VS: T95.9 HR 71 BP 83/36 RR 11 96% 2L NC
Gen: somnolent, oriented x 3, unable to assess for asterixis
given somnolence
HEENT: PERRLA, EOMI
Neck: supple, JVP at angle of jaw (fluid bolus running wide
open)
CV: RRR s1 s2 no appreciable murmur
Lungs: CTAB
Abd: distended, non tender, no rebound or guarding, bowel sounds
positive
Ext: 1+ pitting edema bilaterally
Skin: warm, diaphoretic, no rash or lesions noted
Pertinent Results:
LABS ON ADMISSION:
[**2150-4-17**] 01:30PM BLOOD WBC-17.9*# RBC-2.78* Hgb-8.5* Hct-26.0*
MCV-94 MCH-30.6 MCHC-32.7 RDW-20.6* Plt Ct-186
[**2150-4-17**] 01:30PM BLOOD Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2
Baso-0.9
[**2150-4-17**] 02:13PM BLOOD PT-17.7* PTT-34.5 INR(PT)-1.6*
[**2150-4-17**] 01:30PM BLOOD Glucose-92 UreaN-51* Creat-1.3* Na-131*
K-5.7* Cl-104 HCO3-21* AnGap-12
[**2150-4-17**] 01:30PM BLOOD ALT-126* AST-260* LD(LDH)-426*
AlkPhos-157* TotBili-3.3*
[**2150-4-17**] 06:41PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.9
.
LABS ON DISCHARGE:
[**2150-4-21**] 05:00AM BLOOD WBC-10.7 RBC-2.94* Hgb-9.6* Hct-27.0*
MCV-92 MCH-32.6* MCHC-35.6* RDW-21.2* Plt Ct-110*
[**2150-4-21**] 05:00AM BLOOD PT-17.4* PTT-35.6* INR(PT)-1.6*
[**2150-4-21**] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-132*
K-4.4 Cl-99 HCO3-25 AnGap-12
[**2150-4-21**] 05:00AM BLOOD ALT-113* AST-210* AlkPhos-111
TotBili-3.6*
[**2150-4-21**] 05:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7
.
OTHER LABS:
[**2150-4-18**] 06:25AM BLOOD CK-MB-9 cTropnT-<0.01
[**2150-4-17**] 06:41PM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-<0.01
[**2150-4-17**] 01:30PM BLOOD Lipase-85*
.
URINE:
[**2150-4-17**] 11:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2150-4-17**] 11:01PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2150-4-17**] 11:01PM URINE RBC-63* WBC-7* Bacteri-NONE Yeast-NONE
Epi-<1
.
MICROBIOLOGY:
Blood, urine cultures - negative
H.pylori serum antibody - negative
.
CARDIOLOGY:
.
TTE ([**4-18**]):
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular systolic function
is hyperdynamic (EF>75%). Right ventricular chamber size and
free wall motion are normal. 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
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Hyperdynamic LV systolic function. Mild mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
.
EKG ([**4-17**]):
Sinus rhythm
Prolonged QT interval is nonspecific but clinical correlation is
suggested
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 160 96 462/479 70 55 52
.
GI:
EGD ([**4-20**]):
1. Varices at the lower third of the esophagus and middle third
of the esophagus.
2. Erythema and erosion in the antrum and pylorus compatible
with non-steroidal induced gastritis.
3. Bleeding from a pyloric ulcer in the pylorus compatible with
non-steroidal induced ulcer (injection, thermal therapy).
4. Normal mucosa in the duodenum.
5. Otherwise normal EGD to third part of the duodenum
.
RADIOLOGY:
.
CXR ([**4-17**]):
The prominent bulge to the right heart border could be due to
pericardial
effusion, _____ cyst, and enlarged right atrium. There is no
mediastinal
vascular engorgement to suggest cardiac tamponade. Pulmonary
vasculature is normal. The lungs are clear and there is no
pleural effusion. Overall heart size is normal. Right jugular
line ends at the junction of the
brachiocephalic veins. No pneumothorax or pleural effusion.
.
ABD U/S ([**4-17**]):
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for portal venous thrombosis. Portal
vein flow is hepatopetal and wall-to-wall.
2. No significant ascites. A sliver of perihepatic ascites.
3. Persistent coarsened echotexture of the liver consistent with
known
history of cirrhosis.
4. Splenomegaly
Brief Hospital Course:
Mr [**Known lastname 52368**] is a 59M w HCV cirrhosis w grade II esophageal varices
admitted w coffee-ground emesis and melena concerning for UGIB,
s/p MICU stay for hypotension.
.
# UGIB: Pt did not have any more bleeds while in hospital. EGD
revealed erythema and erosion in the antrum and pylorus
compatible with non-steroidal induced gastritis. Pt did remember
taking increased doses of naproxen for backache. Started on
pantoprazole 40mg PO BID for one week with repeat endoscopy
scheduled in one week ([**4-30**]). Recommended to take tylenol (max
daily dose of 2gm) for pain instead of NSAIDs. Blood pressure
meds were held at first, given MICU admission for hypotension,
but were restarted on discharge.
.
# HCV Cirrhosis: appears to be progressing to liver failure,
with elevated INR at 1.6, decreased albumin at 2.6, tbili
slightly elevated at 3.6, and chronic LE edema. Pt was continued
on prophylactic medications.
.
# FULL CODE
Medications on Admission:
FUROSEMIDE 20mg daily
LISINOPRIL 10 mg daily
SPIRONOLACTONE 100 mg daily
Discharge Medications:
1. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane PRN (as needed).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-15**]
hours as needed: no more than 6 tablets of regular strength
tylenol per day.
8. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 1 weeks.
Disp:*qs * Refills:*0*
9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 1 weeks:
then take 1 tablet daily.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*qs * Refills:*0*
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Peptic ulcer
GI bleed
Discharge Condition:
asymptomatic
Discharge Instructions:
You were admitted for bleeding from an ulcer in your stomach.
This ulcer is at least partially caused by naproxen. You should
stop taking naproxen and take only tylenol for pain. You should
not take any NSAIDS for pain including ibuprofen, naproxen,
aleve, motrin, aspirin, toradol, or advil. It is okay to take
tylenol but do not take more than 4 extra strength tylenol a day
(2gram daily maximum).
.
The following medication changes were made:
Do not take naproxen
Take pantoprazole 40 mg twice daily for one week. Then take 40
mg daily.
.
You are scheduled to get a repeat endoscopy next week. Prior to
the procedure do not have anything to drink or eat after
midnight.
.
Please return to the ER if you have any chest pain,
lightheadeness, fever, chills, bloody or black stools or any
other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-4-30**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-4-30**]
1:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2150-5-7**] 11:00
Completed by:[**2150-4-24**]
ICD9 Codes: 2851, 5715, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2
} | Medical Text: Admission Date: [**2108-4-6**] Discharge Date: [**2081-4-7**]
Date of Birth: [**2059-5-7**] Sex: F
Service: O MED
CHIEF COMPLAINT: Dyspnea.
HISTORY OF PRESENT ILLNESS: This is a 48 year old African
American female with a history of multiple myelomas being
admitted for respiratory distress. The patient has been
recently discharged one week ago from outside hospital ([**Hospital3 7900**]) for respiratory distress. Back at [**Hospital3 7362**],
she was given nebulizer, antibiotics and steroids. She also
had elevated INR and was given medication to lower INR
although there was no evidence of bleeding.
Last night, she reports having increased difficulty with
breathing. She has also had a cough. She denies any fever
or chills. The patient admitted to decreased p.o. intake but
has been recently sedimentary. She denies any swelling of
the legs. The patient had noted some wheezing but then took
her Albuterol inhaler without any effect. She has been on a
Prednisone taper but reports that she has been coughing up
thick sputum.
She went to her primary care provider today but could not say
a sentence so was sent to the Emergency Department. In the
Emergency Department, she was tachypneic and wheezing with
heart of 120 and blood pressure of 127/82. She received
Solu-Medrol and continued with nebulizer treatment. She
improved, but seemed to be tiring. Her ABG was done and
showed pH of 7.41; PCO2, 40; PO2, 92. She can speak in full
sentences but still just making wheezing. She is requiring
continued nebulizer treatment but denies any chest pain,
nausea, vomiting, diarrhea or abdominal pain. She feels weak
in general.
PAST MEDICAL HISTORY:
1. Multiple myeloma diagnosed in [**2107-12-9**], with
increase protein in bone marrow biopsy. She is to receive
Decadron 40 mg q d every other week.
2. Pulmonary embolism, [**2108-1-2**].
3. Asthma. No PFTs .....................
4. History of steroid psychosis.
5. Pneumonia requiring intubation in [**2107-12-9**].
MEDICATIONS UPON ADMISSION:
1. Coumadin 2.5 mg p.o. q d.
2. Serevent two puffs q.i.d.
3. Albuterol inhaler one to two puffs q 6 hours prn.
4. Dexamethasone 10 mg p.o. q d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Socially, she lives with her children and
works at home as a home health aid. She has twenty years of
two pack a day smoking history but quit in [**2107-12-9**].
She drinks an occasional alcohol.
FAMILY HISTORY: Family history shows father died of an
myocardial infarction. Sister with ovarian cancer.
PHYSICAL EXAMINATION UPON ADMISSION: Temperature, 96.6;
heart rate, 122; blood pressure, 127/82; respiratory rate,
24; O2 saturation, 99%. Head, eyes, ears, nose and throat,
pupils are equal, round, and reactive to light and
accommodation and extraocular movements intact. No accessory
muscles are being used. Neck is supple without
lymphadenopathy. Pulmonary, diffuse wheezing with bibasilar
crackles with the left greater than right. Cardiac, regular
rate and rhythm with normal S1 or S2. No murmurs or thrills
noted. Abdomen is soft, nontender, nondistended with normal
active bowel sounds. Extremities, no edema, cyanosis or
clubbing noted. Neurologically, the patient is somnolent but
oriented x 3. No focal defects are noted.
LABORATORIES UPON ADMISSION: White count, 9.6; neutrophils,
66%; lymphocytes, 5%; bandemia, 21%; monocytes, 1%. Sodium,
131; potassium, 4.4; chloride, 92; bicarbonate, 24. BUN, 14;
creatinine, 0.8. Glucose, 131. INR, 1.3. PTT, 29.1. ABG,
7.41; PCO2, 40; PO2, 92.
HOSPITAL COURSE:
1. Pulmonary - Dyspnea secondary to chronic obstructive
pulmonary disease/emphysema under this hospital course.
Briefly, the patient received BIPAP, ....................,
intravenous Solu-Medrol, nebulizer treatment and inhaler
treatment while in the Intensive Care Unit. She was able to
be weaned off of the oxygen back to room air, sating to about
93 or 94 percent.
Though her chest x-rays show hyperinflation and no signs of
infection, she was given five days worth of Zithromax. An
echocardiogram was to rule out any cardiac wheezes which then
showed an ejection fraction of greater than 55%, mild right
ventricular dilation and mild pulmonary arterial pressure.
Pulmonary function tests were performed showing obstructive
pattern with FEC of 2.56 which is 93% of the predicted and
FEV1 of 0.9 which is 43% of the predicted in FEV1 to FEC
ratio of 46%.
When the patient was transferred to the Medical Floor, a CT
was performed showed no evidence of a pulmonary embolism but
did show signs of emphysema. Sputum cultures were sent and
showed no growth of any organism. Alpha antitrypsin was sent
out but is still pending.
2. Pulmonary Embolism - The patient was continued on
Coumadin for an INR between 2 and 3. Since she was
subtherapeutic, she was started on Lovenox until she became
therapeutic on the Coumadin.
3. Psychiatry - Anxiety. The patient was quite anxious
during the hospital course. Psychiatry was called to consult
and recommended that she be on Risperidone at 0.25 mg q hs.
The patient did well on this medication.
4. Oncology - Multiple myeloma. A protein electrophoresis
was done showing a monoclonal IGG capa gammaglobulinopathy
(60% of the total protein in [**2108-1-8**], but now is 66%
of total protein on [**2108-4-9**], despite q weekly
Dexamethasone treatment. Bone marrow biopsy was done
revealing 70 to 80 percent plasma cells. Given these
findings, the patient was then transferred to the [**Hospital Ward Name 516**]
for start of chemotherapy with Vincristine,
................... and Decadron in preparation for bone
marrow transplant to be done.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**First Name3 (LF) 30667**]
MEDQUIST36
D: [**2108-4-17**] 15:47
T: [**2108-4-17**] 15:46
JOB#: [**Job Number 30668**]
ICD9 Codes: 486, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3
} | Medical Text: Admission Date: [**2145-3-31**] Discharge Date: [**2145-4-7**]
Date of Birth: [**2071-6-4**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Dilantin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Severe abdominal and back pain
Unable to take oral intake.
No flatus or bowel movement.
Abdominal distention.
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Lysis of adhesions
Small Bowel Resection
Jejunosotomy
History of Present Illness:
Ms [**Known lastname **] is a 73 year old female with a history of multiple
abdominal surgeries, pancreatitis and previous SBO. She
presented to the Emergency Department on [**2145-3-30**] with complaints
of [**11-10**] abdominal pain, radiating to her back that began in the
morning. She complains of distention, inability to have a bowel
movement, inability to take oral intake, no fever, chills or
diarrhea.
Past Medical History:
Chronic Pancreatitis
Migraines
Surgical history:
Pancreatic diversion, cholecystectomy, appendectomy,
small bowel obstruction.
Social History:
Married, lives with husband who is a retired pediatric
infectious disease doctor.
Family History:
Father: deceased, leukemia
Brother: colon cancer
Physical Exam:
T: 97.9 HR: 79 BP: 153/60 RR: 22 Spo2 100% on RA
Constitutional: in pain
Head/Eyes: mucous membranes dry
ENT/Neck: neck supple
Chest/Respiratory: Clear to auscultation Bilaterally
GI/Abdominal: Tender to light palpation. Multiple well healed
scars + guarding, hypoactive bowel sounds
GU: no costovertebral angle tenderness
Musculoskeletal: WNL
Skin: Dry
Neuro: alert & oriented
Pertinent Results:
[**2145-3-30**] 09:15PM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2145-3-31**] 10:26AM BLOOD WBC-12.3*# RBC-4.01* Hgb-12.3 Hct-37.1
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259
[**2145-3-30**] 09:15PM BLOOD ALT-12 AST-22 AlkPhos-89 Amylase-169*
TotBili-0.3
[**2145-4-2**] 06:15AM BLOOD Amylase-107*
[**2145-3-31**] 10:26AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.6
[**2145-3-31**] 12:44AM BLOOD Lactate-3.1*
[**2145-4-2**] 02:10PM BLOOD Lactate-1.9
[**2145-3-30**] 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
.
ABDOMEN (SUPINE & ERECT)
IMPRESSION: Nonspecific bowel gas pattern without evidence of
obstruction.
.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
IMPRESSION:
1. High grade small-bowel obstruction. Unusual configuration of
a loop of small bowel in the mid abdomen is concerning for
closed loop obstruction. There is a moderate amount of free
fluid within the abdomen.
2. Ill-defined opacity in the right middle lobe representing
infection or BAC and should be further evaluated with PET CT.
3. Thickening of the first portion of the duodenum, of uncertain
clinical significance.
.
CHEST (PORTABLE AP) [**2145-4-2**] 1:51 PM
IMPRESSION: Right lower lobe airspace opacity, which could
represent pneumonia in the appropriate clinical setting. Small
bilateral pleural effusions. Followup to assure resolution is
recommended.
.
CT Chest [**2145-4-2**]
IMPRESSION:
1. New right lower lobe pneumonia. Small bilateral pleural
effusion and left basilar atelectasis.
2. Ill-defined opacity in the right middle lobe representing
either infection or BAC and should be further evaluated once
acute issues resolve.
3. No evidence of pulmonary embolus or aortic dissection.
4. Small mediastinal and axillary lymph nodes, which do not meet
CT criteria for pathologically enlargement.
CXR [**2145-4-6**]
IMPRESSION:
1. Improving airspace consolidation in the right lower lung
field consistent with resolving pneumonia.
2. Small bilateral pleural effusions.
Brief Hospital Course:
Ms [**Known lastname **] was admitted through the emergency room on [**2145-3-31**] and
taken to the operating room. She underwent an uncomplicated
exploratory laparatomy for small bowel resection, jejunosotomy
and lysis of adhesions, see op report for details. She was
stabilized in the PACU, and transferred to SICU on POD#1. She
was extubated, her pain was well controlled with morphine PCA,
she remained NPO with NGT and foley catheter. She was initiated
on Cefazolin/Flagyl x 24 hours.
POD#2 she developed confusion and decreased oxygen saturation,
requiring 3L nasal cannula. Narcotics were stopped, CXR and CT
of chest were obtained and revealed right lower lobe pneumonia,
see pertinent results for details. Vanc/Levo/Flagyl were
initiated as well as an ID and medicine consult. She was
transferred to SICU. POD#[**4-4**] she remained in SICU, her mental
status and respiratory status improved. POD#4 her NGT was
removed and she was transferred to [**Hospital Ward Name 121**] 9, she was weaned to
room air. Her pain was well controlled with tylenol and small
doses of oxycodone. POD#5 she reported flatus followed by
multiple loose stools. Stool for C diff was negative. She was
started on sips, and tolerated it easily. POD#6 she tolerated
clear liquids but no longer wanted to take antibiotics due to
frequent stools. CXR was repeated which showed resolving
pneumonia. She tolerated a regular diet in the evening without
difficulty. Infectious disease team recommended completion of 7
days of Levofloxacin. Clips were removed on POD#7, she was
discharged home in stable condition with antibiotics, pain
medication and all appropriate follow up appointments.
Medications on Admission:
Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime)
as needed.
Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6
hours).
6. Trileptal
Resume your home dose of trileptal
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*0*
Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6
hours).
6. Trileptal
Resume your home dose of trileptal
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Internal hernia with necrotic jejunum
Pneumonia
Discharge Condition:
good
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**11-15**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications. If you have a problem
with constipation, you should take a stool softener, Colace 100
mg twice daily as needed. You will be given pain medication
which may make you drowsy. No driving while taking pain
medicine.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2145-4-20**] 2:00
You have an appointment to see Dr. [**Last Name (STitle) **] on Friday, [**2145-4-23**] at
3:30. Phone #: [**Telephone/Fax (1) 2723**].
Please see your primary care physician regarding follow up from
your CT scan within 1 month. Your CT results and Discharge
summary will be faxed to her.
Completed by:[**2145-4-7**]
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4
} | Medical Text: Admission Date: [**2162-5-16**] Discharge Date: [**2162-5-21**]
Date of Birth: [**2101-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2162-5-17**]: CABGx4 LIMA-> LAD, RSVG-> Diagonal, Posterior
Descending Artery, Obtuse marginal
[**2162-5-19**]: Right Atrial lead placement
History of Present Illness:
60yo man with known coronary disease (AMI in [**2143**] and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LCx [**2155**]). Doing well until last week when he developed angina
initially with exertion then progressed to rest angina. Each
episode was releived with SL NTG, no episode lasting more than 5
minutes. He presented to cardiologist for treatment. He was
admitted to MWMC, a cardiac catheterization revealed 3 vessel
disease. He was transferred to [**Hospital1 18**] for coronary bypass
grafting.
Cardiac Catheterization: Date: [**2162-5-11**] Place: MWMC
-LAD- chronic total occlusion proximally(distal filling via
collaterals)
-RCA- chronic total occlusion of non-dominant RCA 90%
-LCx- new complex 90% stenosis of prox LCx involving the
bifurcation of the LCx proper and large OM2.
Old stent in LCx is widely patent
-mod LV systolic dysfx, with anterior, apical, and infero-apical
AK and reduced EF 30%
LVEDP 36mmHg
No valvular dz
Past Medical History:
CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**])
Cardiomyopathy- EF 35-45% depending on study
Ventricular tachycardia s/p AICD [**8-/2155**]
Atrial flutter s/p ablation [**8-/2155**]
Hypertension
Dyslipidemia
Insulin dependent diabetes Mellitus
Obesity
Conduction disease-LAFB
Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**]
Left leg claudication
Right thigh tumor s/p radiation and excision [**2141**]'s
Social History:
Race: caucasian
Last Dental Exam:
Lives with: wife
Occupation: [**Name2 (NI) 56028**] owns company
Tobacco: 2ppd x20 yrs quit [**2143**]
ETOH: occaisional
Family History:
Father died 50yo cirrhosis, mother died 42yo MI
Physical Exam:
Pulse: 58 Resp: 16 O2 sat: 97%-RA
B/P Right: 124/76 Left:
Height: 5'[**62**]" Weight: 259 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema -none
Varicosities: None [x]. Well healed right vein harvest site.
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit none Right: +2 Left:+2
Pertinent Results:
[**2162-5-17**]:
Prebypass
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the apex and septum. Overall left
ventricular systolic function is mildly depressed (LVEF=30-35%).
The estimated cardiac index is depressed (<2.0L/min/m2). Focal
abnormalities are seen in the mid and apical anteroseptal wall,
apical anterior wall, mid and apical inferoseptal wall, apical
inferior wall. NO thrombus was seen in LV apex.
Right ventricular chamber size and free wall motion are normal.
The descending thoracic aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened with focal
calcification of the non-coronary cusp which moves poorly. There
is a minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-3**]+) mitral regurgitation is seen. There is no mitral valve
prolapse or flail segments. There is no pericardial effusion.
Postbypass
The patient is A-paced and on a phenylephrine infusion.
Biventricular systolic function is unchanged. Mitral
regurgitation remains mild-to-moderate. The thoracic aorta is
intact post decannulation.
[**2162-5-20**] 05:00AM BLOOD WBC-10.9 RBC-3.73* Hgb-11.2* Hct-31.7*
MCV-85 MCH-30.1 MCHC-35.4* RDW-13.9 Plt Ct-114*
[**2162-5-20**] 05:00AM BLOOD Glucose-151* UreaN-19 Creat-0.7 Na-135
K-3.9 Cl-100 HCO3-28 AnGap-11
[**2162-5-16**] 05:00PM BLOOD ALT-66* AST-55* LD(LDH)-206 AlkPhos-73
TotBili-0.3
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2162-5-17**] where the patient underwent Coronary
artery bypass graft x 4. See operative note for details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The Electrophysiology team was consulted now due to non
capturing atrial lead after permanent pacemaker was initially
interrogated and epicardial wires were removed. Ventricular lead
and ICD were functioning appropriately. The right atrial lead
was revised on [**5-19**] without complication. He is to follow up the
device clinic at [**Hospital1 **] in 2 weeks - operative note was given
to patient to bring to follow up appointment. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight.
Lisinopril was restarted for better blood pressure. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes were discontinued without complication on post
operative day 3. 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 sternal and pacer pocket wound was healing and pain
was controlled with oral analgesics. He is to continue on 1 week
of antibiotics per EP s/p atrial lead placement. The patient
was discharged home with VNA services in good condition with
appropriate follow up instructions. All follow up appointments
were arranged.
Medications on Admission:
Lisinopril 20'
Atenolol 100'
Vytorin [**10/2131**] QHS
Fenofibrate 200'
ASA 325'
NTG-sl/PRN
Insulin-NPH 22u QAM/24u QPM- followed by [**Last Name (un) **]
Insulin- Humalog SS
MVI
Calcium 600'
Plavix - last dose:[**2162-5-12**]
Allergies: NKDA
Discharge Medications:
1. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*100 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. 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*
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
12. 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*
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: Take 22 units in AM and 24 units in
PM.
Disp:*QS 1 month * Refills:*0*
16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease
CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]),Cardiomyopathy- EF
35-45% Ventricular tachycardia s/p AICD [**8-/2155**], Atrial flutter
s/p ablation [**8-/2155**], Hypertension, Dyslipidemia,Insulin
dependent diabetes Mellitus, Obesity, Conduction disease-LAFB,
Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**], Left
leg claudication, Right thigh tumor s/p radiation and excision
[**2141**]'s
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**6-10**] at 1:45pm [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 1295**] on [**6-14**] at 3:30pm
EP [**Hospital 19721**] Clinic at [**Hospital1 **] in [**1-3**] weeks: Call for appointment
-
[**Telephone/Fax (1) 6256**]
Wound check appointment in [**Hospital **] Medical office building
[**Telephone/Fax (1) 170**]
Date/Time:[**2162-5-26**] 12:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 27187**] in [**4-6**] weeks [**Telephone/Fax (1) 3658**]
Follow up with [**Hospital **] [**Hospital 982**] Clinic to be arranged by patient
**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:[**2162-5-24**]
ICD9 Codes: 4111, 2859, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5
} | Medical Text: Admission Date: [**2177-8-29**] Discharge Date: [**2177-9-12**]
Date of Birth: [**2156-2-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Helmeted motocyclist who hit tree
Major Surgical or Invasive Procedure:
[**2177-8-29**]
1. Irrigation and debridement down to and inclusive of
bone, right open femur fracture.
2. Retrograde intramedullary nailing with Synthes 11 x 360
nail.
3. Open reduction and internal fixation of patella fracture
with K-wires and figure-of-8 tension band construct.
[**2177-9-4**]
Tracheostomy
IVC filter
[**2177-9-12**]
PICC right bascilic vein
History of Present Illness:
21 y.o. male helmeted moped rider who struck a tree with
reported GCS of 6 on the scene. Patient was transported to OSH
and noted to have a right sided open femur fracture. He received
antibiotics and was intubated prior to transfer.
Patient was transported and had radiographic studies performed
that showed right femur fracture, SAH, grade II liver lac,
pulmonary contusions, and small PTX. Patient reportedly received
1 unit of pRBCs in the ED and was placed into a traction splint
on RLE.
Past Medical History:
None
Social History:
tobacco none
ETOH none
Family History:
Non-contributory.
Physical Exam:
96.9 130 150/97 20 100%
intubated and sedated
HEENT - L eye abrasions, pupils nonreactive bilaterally
CTA b/l
rapid HR, regular rhythm
SNDNT
pelvic fracture
+ palpable distal pulses
Pertinent Results:
[**2177-8-29**] 04:35AM BLOOD WBC-17.7* RBC-4.76 Hgb-15.2 Hct-45.5
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.2 Plt Ct-314
[**2177-8-30**] 12:50AM BLOOD WBC-7.6 RBC-2.73* Hgb-9.0* Hct-25.0*
MCV-92 MCH-32.8* MCHC-35.9* RDW-13.5 Plt Ct-188
[**2177-8-31**] 01:49AM BLOOD WBC-9.4 RBC-2.42* Hgb-7.8* Hct-21.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-14.5 Plt Ct-148*
[**2177-9-1**] 03:13AM BLOOD WBC-9.2 RBC-2.87* Hgb-9.0* Hct-25.6*
MCV-90 MCH-31.6 MCHC-35.3* RDW-15.0 Plt Ct-128*
[**2177-9-2**] 01:40AM BLOOD WBC-7.7 RBC-2.78* Hgb-8.8* Hct-24.6*
MCV-88 MCH-31.5 MCHC-35.7* RDW-15.4 Plt Ct-164
[**2177-9-3**] 12:53AM BLOOD WBC-8.9 RBC-2.94* Hgb-9.3* Hct-26.2*
MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-220
[**2177-9-4**] 01:08AM BLOOD WBC-7.7 RBC-2.99* Hgb-9.5* Hct-27.3*
MCV-91 MCH-31.7 MCHC-34.7 RDW-15.5 Plt Ct-313
[**2177-9-5**] 02:32AM BLOOD WBC-8.4 RBC-2.91* Hgb-9.0* Hct-26.9*
MCV-92 MCH-30.9 MCHC-33.5 RDW-15.6* Plt Ct-412
[**2177-9-6**] 01:58AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.0* Hct-26.5*
MCV-93 MCH-31.6 MCHC-34.0 RDW-15.2 Plt Ct-418
[**2177-9-7**] 02:12AM BLOOD WBC-14.4* RBC-3.00* Hgb-9.3* Hct-27.6*
MCV-92 MCH-30.9 MCHC-33.7 RDW-14.7 Plt Ct-556*
[**2177-9-8**] 01:59AM BLOOD WBC-14.7* RBC-3.25* Hgb-10.0* Hct-29.7*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-748*
[**8-29**]
CT head - Multiple foci of parenchymal hemorrhage as well as
small amount
of likely subarachnoid hemorrhage. The location of some of these
foci at the [**Doctor Last Name 352**]-white matter interface is concerning for
diffuse axonal injury
CT Cspine - No fracture or traumatic malalignment in the
cervical spine
CT torso - Extensive pulmonary contusions, worse on the right
than the left. Hepatic lacerations with a small amount of
abdominal and pelvic free fluid of intermittent density.
Bilateral rib fractures.
Right femur/knee xrays - There is a mid shaft femoral fracture
with mild varus angulation of the distal fragment relative to
the proximal. There is also medial subluxation by ~ 1 cortical
width.
[**9-2**]
MRI cspine - Edema in the interspinous ligaments from C3-C4
through C7-T1, without evidence of distraction. lobal central
canal narrowing due to congenital short pedicles. This is
slightly exacerbated by a disc bulge at C3-4. No cord signal
abnormality. Moderate right C4-5 neural foramen narrowing due to
uncovertebral osteophytes.
[**9-3**]
Bilateral LE LENIs - No deep venous thrombosis involving the
right or left lower extremity.
LUE LENI - No deep venous thrombosis in the left upper
extremity.
[**9-7**]
CT Abdomen/Pelvis - Right pleural effusion with associated
compressive atelectasis. Considerable improvement in the
appearance of the right lobe of the liver laceration. Small
amount of free fluid in the pelvis. Fractures of the left first
and right fourth and fifth ribs. Fracture of
the right transverse process of T1.
Brief Hospital Course:
The patient was admitted to the trauma ICU.
[**8-29**] - Patient was admittd to the ICU. He was taken to the
operation room with ortho for ORIF of his right femur (see
operative report for full details). Neurosurgery was consulted
and an ICP was placed. He was started on dilantin and q1 hour
neurochecks.
[**Date range (1) 58392**] - The patient was transfused 4u PRBC for a decreasing
Hct. He had a right femur hematoma which was expanding but his
limb was soft and there was no fear of compartment symdrome.
His Hct stabilized. Head CT was stable.
[**9-1**] - His ICP was discontinued and neurosurgery signed off.
Head CT was stable.
[**9-2**] - MR of head and c-spine were performed.
[**9-3**] - Bilateral LE and LUE LENIs were performed which
demonstrated no DVT.
[**9-4**] - The patient went the OR with the acute care service for
tracheostomy and IVC filter placement.
[**9-6**] - Patient dc'ed his dophoff tube twice.
[**9-7**] - A CT A/P was done because of persistent fevers and rising
white count. No source for his fevers was identified. Patient
was put to trach collar.
[**9-8**]: Awake, off-versed, following commands. Passed S&S for
regular diet and Passy [**Last Name (un) 87596**] Valve. BAL cultures grew MRSA, kept
only on Vanc now. Patient ready to be transferred to floor,
waiting for a bed. `
Following transfer to the Surgical floor he continued to make
slow progress. His trach tube was plugged with a PMV and he
tolerated it well. After confirming no aspiration by video
swallow he was tolerating a regular diet with thin liquids.
The Physical Therapy and Occupational Therapy services followed
him on a daily basis to increase his mobility and increase
cognitive abilities. His memory is decreased and he
occasionally has some confusion but is improving each day.
He has a PICC line placed on [**2177-9-12**] for IV antibiotics and will
require Vancomycin thru [**2177-9-16**] for MRSA pneumonia. He has
minimal secretions but is undergoing nebulizer treatments.
Potentially his IVC filter can be removed but Dr. [**Last Name (STitle) **] will re
evaluate in a few weeks therefore he will need to return to the
[**Hospital 2536**] Clinic. He will also follow up in the Neuro cognitive clinic
with Dr. [**First Name (STitle) **] following his discharge from rehab.
After a lonfg hospitalization he was transferred to rehab on
[**2177-9-12**] for further therapy with the goal to return home soon.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for temp > 101.5.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed for abrasions.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg
Intravenous every eight (8) hours: thru [**2177-9-16**].
10. Morphine Concentrate 20 mg/mL Solution Sig: Fifteen (15) mg
PO Q2H (every 2 hours) as needed for pain.
11. HYDROmorphone (Dilaudid) 1-2 mg IV Q2H:PRN pain
Please use for breakthrough only after PO/NG MSIR.
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
S/P scooter v tree
1. Left eye abrasion
2. Rib fractures right [**5-5**], left 1
3. Bilat pulmonary contusions
4. Grade 2 liverlaceration
5. Open right femur fracture
6. Right thigh laceration
7. Right patellar fracture
8. Right metatarsal neck fracture [**3-7**]
9. Small SAH
10.Right TP fracture T1
11.[**Doctor First Name **]
12.Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital with multiple injuries
following your accident including head trauma, rib fractures,
knee fracture and liver laceration.
* You have made alot of progress but will need further
rehabilitation before you can return home.
* You are now breathing well on your own with your trach tube
plugged and hopefully it will be removed as you improve.
* Continue to work with physical therapy to increase your
mobility.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 1
month, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment
in [**3-5**] weeks
Call the Vascular Surgery Clinic at [**Telephone/Fax (1) 1237**] for an
appointment in 2 weeks with Dr. [**Last Name (STitle) **].
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 6 weeks with Dr. [**First Name (STitle) **]. You will need a Head CT
prior to your appointment. The secretary can book that for you.
Call Dr. [**First Name (STitle) **] in the Neuro cognitive Clinic at [**Telephone/Fax (1) 1690**]
for an appointment after your discharge from rehab
Completed by:[**2177-9-12**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6
} | Medical Text: Admission Date: [**2177-3-12**] Discharge Date: [**2177-3-22**]
Date of Birth: [**2109-6-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional angina
Major Surgical or Invasive Procedure:
[**2177-3-14**]
Coronary ARTERY BYPASS GRAFTING x3 with: Left Internal Mammary
Artery to Left Anterior Descending Artery, Saphenous Vein Graft
to Obtuse Marginal Artery, Saphenous Vein Graft to Posterior
Descending Artery
History of Present Illness:
67 year old man with known coronary artery disease-s/p stents x
6(2004x5 and [**11-21**]) who developed exertional angina while
walking [**3-9**]. Angina resolved w/
rest after few minutes. Angina recurred [**3-11**], patient was brought
to [**Hospital **] Med Ctr where enzymes were negative. He had cardiac
catheterization which showed: tapering distal LM,70% osteal
LAD,90% mid RCA. LVEF 60% by LVgram.
He was then transferred to [**Hospital1 18**] for surgical management of his
coronary artery disease. At the time of transfer he was pain
free.
Past Medical History:
Coronary artery disease(PCI/stents x6), Hypertension,
HYPERCHOLESTEROLEMIA, CA- Left vocal cord(RT/chemo)[**3-20**]
PSH:Left knee arthroscopy, Left chest Portacath
Social History:
Works as administrator at [**University/College 33918**].
Married, 2 children.
Tob: Former smoker, quit 30 yrs ago.
ETOH: Drinks a few beers or cocktails per night.
No drugs
Family History:
Brother: MI at 60, uncle: MI at 50
Mother: htn
Physical Exam:
Pulse: Resp: O2 sat:
B/P Right:130/72 Left: 128/72
Height: 70" Weight:175#
General:WDWN, NAD
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]glasses
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur n
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
Admission Labs:
[**2177-3-12**] 04:05PM PT-11.7 PTT-23.8 INR(PT)-1.0
[**2177-3-12**] 04:05PM PLT COUNT-199
[**2177-3-12**] 04:05PM NEUTS-78.7* LYMPHS-9.6* MONOS-5.6 EOS-5.6*
BASOS-0.5
[**2177-3-12**] 04:05PM WBC-6.9 RBC-3.93* HGB-14.0 HCT-38.2* MCV-97#
MCH-35.6* MCHC-36.6* RDW-13.5
[**2177-3-12**] 04:05PM %HbA1c-5.2 eAG-103
[**2177-3-12**] 04:05PM ALBUMIN-4.1 MAGNESIUM-1.7
[**2177-3-12**] 04:05PM ALT(SGPT)-36 AST(SGOT)-24 LD(LDH)-148 ALK
PHOS-100 TOT BILI-2.0*
[**2177-3-12**] 04:05PM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-137
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
[**2177-3-12**] 04:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2177-3-12**] 04:33PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
Discharge Labs:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2177-3-17**] 7:29
AM
Final Report: Comparison with study of [**3-15**], all of the
monitoring and support devices have been removed except for the
left subclavian catheter and the right IJ sheath. With the chest
tube removed, there is no evidence of pneumothorax. Residual
opacification at the left base is consistent with atelectasis
and effusion.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Color-flow imaging of the
interatrial septum raises the suspicion of an atrial septal
defect, but this could not be confirmed on the basis of this
study.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: No MS. Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Focused Intraoperative TEE during chest exploration for
post-operative bleeding.
Color-flow imaging of the interatrial septum raises the
suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
Borderline normal RV free wall function.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
Mild (1+) mitral regurgitation is seen.
There is a small pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
Brief Hospital Course:
Mr [**Known lastname 732**] was transferred fro [**Hospital **] Med Ctr for surgical
management of his coronary artery disease. After the usual
pre-operative workup he was brought to the operating room for
coronary artery bypass grafting on [**2177-3-14**]. Please see the
operative report for details. In summmary he had: Coronary
Artery Bypass Grafting x3 with Lwft Internal Mammary Artery to
Left Anterior Descending Artery, Saphenous Vein Graft to Obtuse
Marginal Artery, and Saphenous Vein Graft to Posterior
Descending Artery. His cardiopulmonary bypass time was 51
minutes with a crossclamp time of 39 minutes. He tolerated the
operation well and post-operatively was transferred to the
cardiac surgery ICU in stable conditio. He remained
hemodynamically stable in the immediate post-op period. He woke
from anesthesia neurologically intact and was extubated on the
operative day.
On POD1 he continued to have significant drainage from his chest
tubes and was brought back to the operating room for mediastinal
exploration-no source of bleeding was found. He tolerated this
procedure well and was again returned to the cardiac surgery ICU
in stable condition. He recovered from anesthesia and was
extubated shortly after the surgery was completed. He remained
hemodynamically stable throughout this period.
All tubes lines and drains were removed per cardiac surgery
protocol. On POD 3 he was transferred from the ICU to the
stepdown floor for continued post-op care and recovery. Physical
therapy worked with the patient to advance his activities of
daily living and to improve strength and endurance.
POD # 4, Pt develope some drainage from his sternal incision. He
was started on IV Vancomycin. Betadine was cleanse TID was
started. from POD # [**4-19**], pts wound improved. He is to be
discharged on PO keflex x 10 days. His wound on DC is without
drainage.
On POD 10 was discharged home with visiting nurses. He is to
follow up with Dr [**Last Name (STitle) **] in 3 weeks, He has a sternal check
[**3-26**] on [**Hospital Ward Name **] 6. He is to follow up with his cardiologist, appt
made, He was also instructed to follow up with his PCP.
Medications on Admission:
Lisinopril 20mg daily,
Lipitor 80mg daily,
Plavix 75 mg [**Last Name (LF) **],
[**First Name3 (LF) **] 325mg daily,
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. [**Last Name (un) 1724**]
Lisinopril 20mg daily,EcASA 325mg daily,Lopressor 25mg
[**Hospital1 **],Plavix 75mg daily,NTG prn,Lipitor 80mg daily
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. potassium chloride 8 mEq Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Bypass Grafting x3
PCI/stents(6)
PMH:
Hypertension,
HYPERCHOLESTEROLEMIA,
CA- left vocal cord(RT/chemo)[**3-20**]
PSH:lt knee arthroscopy, LT chest Portacath
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] on [**2177-4-10**] at 9AM at [**Hospital1 **]
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] on [**2177-4-16**] at 3PM
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) 488**] J. [**Telephone/Fax (1) 8036**] in [**4-15**] weeks
You have a wound check scheduled for [**5-26**] at 1000 hrs,
please come to [**Hospital Ward Name **] 6 at this scheduled time. Thw midlevelers
will look at your wound to see if this is stable.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR
First draw
Results to phone fax
Completed by:[**2177-3-22**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7
} | Medical Text: Admission Date: [**2188-5-24**] Discharge Date: [**2188-5-30**]
Date of Birth: [**2132-11-19**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin / Thorazine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Trach change
Mechanical ventilation
History of Present Illness:
Mr. [**Known lastname 89172**] is a 55 yo man with PMH significant for Downs
Syndrome, MRSA pneumonia and respiratory failure in [**10/2187**]
resulting in tracheostomy which was reversed [**2188-5-13**], who is
transferred from s/p intubation at [**Hospital1 **] in [**Location (un) 1110**] today.
Patient had been predominantly in rehab since developing MRSA
pneumonia in [**10/2187**] (first [**Last Name (un) **] and then [**Hospital 5279**] Rehab
Centers) and presented to [**Hospital1 **] from rehab for respiratory
distress. He had been started on Rocephin [**5-22**] for presumed
pneumonia at Rehab in setting of labored breathing. Patient was
intubated at [**Hospital1 **] for labored breathing, accessory muscle
use. Per report, there may have been some failed attempt in OSH
ED to re-open his tracheostomy prior to intubation.
.
At OSH, patient received, levoquin 750mg @ 03:25, Vancomycin 1g
@ 5:09 for pneumonia. He was ordered for 4L NS and received at
least 2.5L. CXR and CT Chest appeared to show some fluid
overload. Patient was difficult to maintain on sedation; blood
pressure dropped on propofol, so patient was briefly on dopamine
until sedation was switched to versed boluses prn, which he
tolerated well. Trach site had some serosanguinous fluid
leakage, so it was covered with guaze and tegaderm. Respiratory
therapist in ED confirmed no air leakage while on the
ventilator. Patient was transfered to [**Hospital1 18**] for further
management.
.
In ED, initial VS were as follows: 99.9 (Rectal temp) 101
174/100 22 98% on ventilator with 100%FiO2. He was given 1amp
D50 for a blood sugar of 69. He also received 250cc of IVF and
2.5mg bolus of IV versed for sedation while ventilated. EKG
showed sinus tach with rate 103. CXR showed fluid overload with
possible consolidation, so CTA of chest was done to further
characterize ?consolidation and rule out PE. CTA showed no
signs of PE and confirmed RUL and RML pneumonia, as well as
fluid filled esophagus, suggesting aspiration. CT also showed
moderate left and small right effusions, but no pulmonary edema.
Vitals in ED prior to transfer to ICU were as follows: 99.8F HR
91 BP 92/53 RR 16 O2sat100% cpap FIO2 60%, PS 10, PEEP 5.
.
On arrival to the unit, patient is mechanically ventilated and
appears comfortable. He is accompanied by his sister who was
able to corroborate the above story. Of note, the patient is
non-verbal at baseline but does make some signs, only eats
icecream and [**Last Name (un) **] tea by mouth (for pleasure) and is otherwise
fed through tube feeds.
.
Past Medical History:
- Downs Syndrome
- MRSA Pneumonia complicated by tracheostomy [**10/2187**]
- reversed [**2188-5-13**]
- C Diff Colitis - [**2188**]
- Pseudomonas Colitis - [**2188**] - dx by colonoscopy, tx w cipro
through G-tube
- Adrenal Insufficiency
- Seizure History, per sister this [**Name2 (NI) 89173**] with
hospitalization in [**11-3**] - on keppra
- Hx transaminitis - presumed to be secondary to antiepileptics
- Hx of HBV
- Membranoproliferative Glomerulonephritis
Social History:
Lives at Group Home, but has spent significant amount of time at
Rehab since [**10/2187**] and presented from [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **]. [**Last Name (NamePattern1) 6961**]
are his guardians, but his sister [**Name (NI) **] is also very involved in
his care and finances.
Family History:
NC
Physical Exam:
ADMISSION EXAM:
GEN: Comfortable appearing, opens eyes to command
HEENT: ETT in place.
NECK: Tegaderm placed over anterior neck; difficult to assess
opening in skin. No drainage or erythema.
CV: RRR, no murmur
LUNGS: Rhonchi anteriorly R>L, CTAB laterally on both sides
ABD: Soft, non-tender but distended. Central G-tube covered with
gauze with tube feeds draining around opening. Ostomy
erythematous, raw. No erythema on surrounding skin.
EXT: LE cachectic, No LE edema.
DISCHARGE EXAM:
GEN: Comfortable appearing, opens eyes to command, not in
distress
HEENT/Neck: EOMI, trach in place with sputum surrounding, mild
erythema around site
CV: RRR, no murmur
LUNGS: Rhonchi anteriorly, CTAB laterally on both sides
ABD: Soft, non-tender but distended. Central G-tube covered with
gauze. Mildly erythematous around opening.
EXT: LE cachectic, No LE edema.
Pertinent Results:
ADMISSION LABS:
.
[**2188-5-24**] 11:50AM PT-18.8* PTT-31.4 INR(PT)-1.7*
[**2188-5-24**] 11:50AM URINE RBC-28* WBC-7* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
[**2188-5-24**] 11:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2188-5-24**] 11:50AM WBC-11.7* RBC-2.84* HGB-10.5* HCT-31.6*
MCV-111* MCH-37.1* MCHC-33.4 RDW-18.9*
[**2188-5-24**] 11:50AM GLUCOSE-69* UREA N-54* CREAT-1.0 SODIUM-136
POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-10
[**2188-5-24**] 12:00PM LACTATE-2.0
.
DISCHARGE LABS:
.
[**2188-5-30**] 03:56AM BLOOD WBC-8.1 RBC-2.32* Hgb-8.9* Hct-26.7*
MCV-115* MCH-38.5* MCHC-33.5 RDW-17.4* Plt Ct-130*
[**2188-5-30**] 03:56AM BLOOD Glucose-83 UreaN-29* Creat-1.1 Na-135
K-3.7 Cl-108 HCO3-24 AnGap-7*
[**2188-5-30**] 03:56AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.5*
[**2188-5-30**] 03:56AM BLOOD Vanco-25.0*
.
MICRO:
C. diff negative
Urine culture - no growth
Blood culture x2 - no growth to date
IMAGING:
CXR [**2188-5-24**]:
1. Endotracheal tube terminating at the carina.
2. Mild pulmonary interstitial edema.
3. Right upper zone opacity may reflect aspiration pneumonitis
or developing
pneumonia.
CT-A [**2188-5-24**]:
IMPRESSION:
1. RUL and RML pneumonia, possible due to aspiration since the
esophagus is fluid filled and dilated.
2. No PE.
3. Moderate left and small right effusions, but no pulmonary
edema.
4. Mediastinal lymphadenopathy
5. Acute left 7th rib fracture.
G/GJ/GI TUBE CHECK
FINDINGS: Supine radiographs demonstrate jejunostomy tube with
tip at the
junction of the distal duodenum or proximal jejunum. Contrast is
seen passing distally in the jejunum without evidence of leak.
Bowel gas pattern is normal without evidence of leak. Imaged
portion of the lungs are clear. Surgical clips are noted
overlying the base of the heart.
IMPRESSION: Jejunostomy tube in appropriate position with normal
passage of contrast without evidence of leak.
Brief Hospital Course:
55M with hx of Downs Syndrome, MRSA pneumonia c/b respiratory
failure and tracheostomy, s/p tracheostomy reversal 10d prior to
admission, transferred to [**Hospital1 18**] for hypoxic respiratory failure
[**2-27**] RUL/RML aspiration PNA
.
# Aspiration PNA/respiratory distress: PE was ruled out as
potential cause of respiratory distress. Imaging demonstrated
RUL/RML pneumonia secondary to aspiration, as well as airway
narrowing at site of prior tracheostomy. Likely secondary to
aspiration, as patient was also noted to have fluid filled
esophagus on CT scan. Patient was treated with hospital
acquired and community acquired pneumonia with Vancomycin,
Levoquin and Cefepime (8-day course). Cultures of urine and
blood from OSH showed no growth. Aspiration may have been
related to overflow at g-tube site. Tube feeds were initially
held, and G tube study was ordered which showed jejunostomy tube
in appropriate position with normal passage of contrast without
evidence of leak. Patient on steroids at home for adrenal
insufficiency, was not on PCP prophylaxis at home so bactrim
daily was started. Patient was arranged to be transferred to
[**Hospital Ward Name 517**] ICU service for extubation and potential IP
intervention at site of airway narrowing. IP found an 0.8 cm
focal area of stenosis with dynamic collapse at 2nd tracheal
ring. The granulation tissue was debrided and IP replaced
percutaneous trach through existing stoma. Patient will need
evaluation for tracheal resection/reconstruction at IP o/p f/u
in 2 weeks. Post-procedure CXR showed multifocal PNA, unchanged
bilateral effusions, trach in appropriate position. Patient
remained stable with new trach in place and did well prior to
discharge. His last day of levaquin and cefepime will be on
[**2188-5-31**].
.
# Recent history of colitis: Reported recent history of both
C.diff and Pseudomembranous colitis. Patient with with several
episodes of lose stool. C. diff was checked and was negative.
.
# Down syndrome/Anxiety: At baseline, pt nonverbal. Pt was
restarted on home dose of ativan given evidence of anxiety and
aggitation w/groups of people while intubated.
.
# Adrenal Insufficiency: History unclear but patient currently
on prednisone 20 daily - patient has not had outpatient
endocrine evaluation. As per [**Hospital 228**] rehab facility steroids
were started to treat low sodium. Patient currently with normal
blood pressures. Steroid dose tapered to 10mg daily for 1 week
with outpatient follow up of electrolytes. Patient started on
PCP prophylaxis, which he should remain on if he is going to
continue steroids long term. Patient will follow-up with
endocrinology for further work-up of possible renal
insufficiency. OSH records were faxed to endocrinology
department when appointment was made.
.
# Hx of seizure disorder: Reportedly first seizure [**11-3**] at time
of hospitalization with MRSA pneumonia. Continued home dose of
Keppra.
.
#FEN: Concern for leaking at J tube site. Tube feeds were held
as concern for leaking at feeding tube. Surgery was consulted
and sutured the tube in place with clamp. Dressing in place over
tube site.
.
# Prophylaxis: SubQ heparin, Famotidine
.
# Contact: [**Name (NI) 6961**] = guardians, [**Name (NI) 449**] and [**Name (NI) **]
([**0-0-**]), Sister [**Name (NI) **] [**Telephone/Fax (1) 89174**].
.
# Code Status: FULL CODE (Confirmed with family)
Medications on Admission:
Prednisone 20mg daily
Omeprazole 20mg [**Hospital1 **]
Keppra 500mg [**Hospital1 **] (do not crush)
Ativan 0.25-0.5mg via PEG Q8h PRN (for moderate to severe
anxiety)
Duonebs prn wheezing
oxycodone
Zinc
Bacitracin ointment
Bowel Regimen prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) 1110**]
Discharge Diagnosis:
Primary diagnosis:
Subglottic stenosis
Hosptial acquired pneumonia
.
Secondary diagnoses:
? Adrenal insufficiency
Down's syndrome
Seizure disorder
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Mental Status: Confused - sometimes. (baseline)
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 89172**]. You
were admitted to [**Hospital1 18**] for evaluation of respiratory failure.
You were found to have narrowing of your trachea. You were
taken to the OR to have a procedure to replace tracheostomy.
You were also treated for a pneumonia.
.
There was concern for your G tube not working appropriately.
Surgery evaluated you and fixed your J tube.
.
You were started on steroids at your outpatient facility as you
had low sodium. We decreased your dose of steroid and started
you on Bactrim to prevent a type of lung infection called PCP.
[**Name10 (NameIs) **] will have you follow-up with endocrinology here to further
evaluate if you need to take steroids.
.
MEDICATION CHANGES:
START Cefepime 2gm Q24 for one more day
START Levofloxacin 750mg daily for one more day
START Bactrim SS daily for prophylaxis for PCP
DECREASE Prednisone to 10mg daily
Followup Instructions:
Department: Thoracic Multi [**Hospital 4094**] Clinic
When: TUESDAY [**2188-6-10**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Thoracic Multi [**Hospital 4094**] Clinic
When: TUESDAY [**2188-6-10**] at 3:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES - Endocrinology
When: WEDNESDAY [**2188-6-11**] at 3:15 PM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2188-6-10**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2188-6-10**] at 3:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2188-6-11**] at 3:15 PM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2188-5-30**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8
} | Medical Text: Admission Date: [**2176-8-29**] Discharge Date: [**2176-9-6**]
Date of Birth: [**2121-2-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Upper extremity weakness
Major Surgical or Invasive Procedure:
C5-C6 anterior cervical decompression and fusion, C1 tumor
removal
History of Present Illness:
55-year-old man with diabetes mellitus type 2, hypertension,
severe peripheral [**First Name3 (LF) 1106**] disease s/p R SFA stent angioplasty
and L SFA stent placement, congenital pulmonic valve stenosis,
CAD s/p BMS stents, diastolic CHF, atrial fibrillation s/p
ablation on warfarin, stage 3 diabetic nephropathy, intradural
tumor compressing his spinal cord at C1/C2, who was admitted on
[**2176-8-29**] to neurosurgery for anterior cervical decompression at
C5/6 fusion ([**8-29**]) and extradural tumor removal of C1 intradural
tumor ([**8-30**]).
The patient was post-operatively managed in the ICU with a
dexamethasone taper. He developed a small subdural hematoma
([**8-30**]) with no new neurologic symptom. Aspirin and heparin SC
were restarted. Clopidogrel, for L SFA stent, is scheduled to be
restarted on POD#5, [**2176-9-4**], and warfarin, for atrial
fibrillation, to be restarted on [**2176-9-9**].
Patient was extubated on [**9-1**], and is coming off a furosemide
drip for dCHF. [**Month/Day (4) **] is following the patient for a mottled
right foot and his recent [**Month/Day (4) 1106**] procedures.
Patient's other medical issues diabetes, HTN, CKD (Cr 1.1),
atrial fibrillation (HRs 70s-80s), CAD s/p stent and "chronic
hyponatremia" (Na 138) have been stable. Transfer is requested
for ongoing management of diastolic CHF.
On evaluation in the SICU before transfer, patient was sleeping
but arousable, complaining of old back pain and of constipation.
Vital signs were stable with O2 saturation 98% on 3L.
Past Medical History:
(1) Type 2 diabetes mellitus, requiring insulin, and the
complications from years of poor glycemic control:
-hypertension
-severe peripheral [**Month/Day (4) 1106**] disease
-peripheral neuropathy
-pressure, venous stasis, and neuropathic ulcers on his right
and left lower extremities
-stage 3 diabetic nephropathy
-renal insufficiency (baseline creatinine 1.5 to 1.7)
(2) Atrial fibrillation status post ablation [**2169**] and [**2174**], on
coumadin
(3) Congenital pulmonic valve stenosis status post two childhood
surgeries
-history of RV failure
-history of peripheral edema and anasarca
(4) Chronic hyponatremia
(5) Chronic low back pain status post car accident
(6) Spinal cord meningioma compressing his spinal cord at C1/C2
(7) COPD
(8) Coronary artery disease status post stenting [**2169**] (bare
metal stent by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] ([**Telephone/Fax (1) 8725**])) and repeat
stenting at [**Hospital1 18**] in [**2174**] (bare metal stent - see d/c summary
[**2175-2-7**])
(9) MI in [**2161**]
Social History:
The patient is married and has two adult sons who do not live at
home. He lives in [**Hospital1 1474**], MA. His wife works 60 hours a week,
and he is left at home for most of the day. He has been bedbound
for several years. A visiting nurse can only come once a week to
change the dressings on his lower extremity ulcers. His sons
struggle with alcoholism and heroin abuse. His younger son has
recently threatened suicide and homicide (against the patient's
wife), a source of much stress at home. He used to work as a
"bouncer" and in construction, and enjoyed riding his
motorcycle. The patient says he tries to keep a positive
attitude about his condition. He says he feels depressed, but
says he is not interested in therapy or medication for
depression. He has not seen his primary care physician [**Last Name (NamePattern4) **] 2
years because he will only travel in an ambulance but his PCP's
office is in touch with the patient and wife weekly.
-[**Name2 (NI) **] has a 2 pack per year smoking history for "several years"
-He drinks alcohol occasionally, and has never had a problem
with alcoholism
-He denies recreational or IV drug use
Family History:
Heart disease in unspecificed family members.
Physical Exam:
Physical exam on admission:
Gen: obese, deconditioned, pain with movement of extremities.
Extrem: B LE edema
Neuro:
Mental status: Awake and alert, cooperative with exam.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Motor: Patient with severe bilateral wasting of muscles of hand.
UE's: FI's:[**2-1**] WE 4+/5 Grip 4+/5 Bi4+/5 Tri 4+/5. RLE: [**1-4**] PF/DF
0/5 LLE: IP3/5 PF/DF 0/5
Pertinent Results:
[**2176-8-29**] 12:10PM GLUCOSE-94 UREA N-42* CREAT-1.2 SODIUM-133
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14
[**2176-8-29**] 12:10PM estGFR-Using this
[**2176-8-29**] 12:10PM WBC-7.6 RBC-3.91* HGB-9.7* HCT-30.5* MCV-78*
MCH-24.9* MCHC-31.9 RDW-13.6
[**2176-8-29**] 12:10PM PLT COUNT-206
IMAGING STUDIES:
# C-spine Xray [**8-29**]: Single lateral view of the cervical spine
obtained portably in the OR, labeled #1. C1 through the C4/5
disc space is visualized. The C5 vertebral body is faintly seen
-- bony structures lower than this are obscured by overlying
soft tissues. However, surgical markers are seen overlying the
anterior aspects of the C4-5 and C5-6 disc spaces, from an
anterior approach. Support tubing and temperature probles noted.
# C-spine CT [**2176-8-29**]:
1. New interval C5-C6 anterior fusion with intervertebral disc
spacer, no
immediate hardware complication. Post-surgical changes in the
soft tissue
with subcutaneous emphysema mostly in the right submandibular
region.
2. Mass at C1 level with associated cord compression consistent
with known
meningioma better described on recent MRI.
3. Soft tissue thickening at the right lung apex, not fully
characterized on the current CT. In comparison with CT neck from
[**2176-8-9**], it has increased in size. CT chest is
recommended to evaluate this further, if clinically warranted.
# Head CT [**2176-8-30**]:
1. New interval left frontal subdural hyperdense extra-axial
fluid collection with new interval subdural subfalcine
extra-axial hyperdense fluid collection, indicating subdural
hemorrhage, likely post-surgical but clinical correlation
recommended.
2. Pneumocephalus with distribution at the basilar cisterns,
mostly at the
left sylvian fissure, and bifrontally at the falx, likely
post-surgical, and additionally in the posterior fossa near the
site of the occipital craniotomy.
3. Post-surgical changes with left craniotomy at the occipital
bone and
laminectomy at C1 with subcutaneous emphysema and hyperdense
products, likely post-surgical.
4. Soft tissue hyperdensity at the posterior parietal, occipital
soft tissue region, could be small post-surgical hematoma.
.
# C-spine MRI [**2176-8-31**]: Status post resection of C1 extradural
tumor, likely meningioma with expectorated postoperative
changes. No large intraspinal hematoma seen. There remains some
persistent narrowing of the spinal canal at C1 level with
indentation on the posterior aspect of the spinal cord.
Continued followup recommended. Mild spinal cord atrophy could
be secondary to chronic myelomalacia.
.
# LE arterial Duplex [**2176-9-3**]: The peak systolic velocity
involving the native right common femoral artery is 104 cm/sec.
Velocities within the superficial femoral artery range from 85
to 234 cm/sec and that within the popliteal artery on the right,
is 25 cm/sec. On the left, peak systolic velocity within the
common femoral artery is 132 cm/sec, SFA, velocities range from
146-75 cm/sec and that within the popliteal artery is 85 cm/sec.
IMPRESSION: Findings as stated above which indicate widely
patent common
femoral, superficial femoral and popliteal arteries bilaterally.
.
PATHOLOGY:
# C1 tumor [**2176-8-30**]: Cervical medullary junction tumor:
Meningioma, psammomatous subtype (WHO Grade I). The tumor is
composed of meningothelial cells with numerous psammoma bodies
and collagen deposition with no typical features or mitotic
activity.
Brief Hospital Course:
55-year-old man with diabetes mellitus type 2, severe peripheral
[**Month/Day/Year 1106**] disease, CAD, diastolic CHF, atrial fibrillation,
presented for planned anterior cervical decompression at C5-6
and removal of C1 meningioma.
# Cervical myelopathy and meningioma: Patient underwent anterior
cervical decompression and C5/6 fusion on [**2176-8-29**] and removal of
C1 meningioma on [**2176-8-30**].
The patient was post-operatively managed in the ICU with a
dexamethasone taper. He developed a small subdural hematoma on
[**2176-8-30**] with no new neurologic symptom. Per neurosurgery
recommendations, aspirin and heparin SC were restarted.
Clopidogrel, for recent left SFA stent, was restarted on POD#5,
[**2176-9-4**], and warfarin, for atrial fibrillation, is to be
restarted on [**2176-9-9**]. Of note, there was some concern that he
had developed LE weakness after his procedure, but after
re-evaluation with the neurosurgery team they felt that his
strength in his legs were his baseline and this was not a
change. He continued to work with PT during his
hospitalization.
# Diastolic heart failure: The patient experienced an acute
exacerbation of his diastolic heart failure likely secondary to
significant fluid administration during surgery. He was placed
on a furosemide gtt in the SICU, which was transitioned to his
home dose of lasix on the floor. At discharge he was slightly
under his admission weight of 115kg with O2 sats in the mid 90's
on room air.
# Peripheral [**Date Range **] disease. The patient recently underwent
bilateral SFA angioplasties and Left SFA stenting. In
preparation for his neurosurgery, the plavix was held
pre-procedure and was subsequently re-started on [**2176-9-4**]. He
underwent bilateral arterial ultrasound on [**2176-9-3**] which
demonstrated patent SFA and femoral arteries.
# Atrial fibrillation: The patient was not in atrial
fibrillation during his hospitalization. Given his need for
neurosurgery his coumadin was held. It is scheduled to be
restarted 10 days post-procedure ([**2176-9-9**]). He was well
rate controlled at the time of discharge.
# DM II. The patient's insulin regimin was adjusted to 50 units
of insulin glargine nightly with humalog insulin sliding scale
and achieved good control of his blood sugars (FSBS 100-180).
# Pressure ulcers. The patient has a 2x2cm right heel full
thickness ulcer that was without odor or drainage. A right
dorsum small 1x1cm partial thickness ulcer. Wound care nursing
consult was obtained. Pressure ulcer care was performed by
repositioning, skin cleansing and conditioner application, and
cover with ABD and kerlex.
# Coping. The pt expressed to some staff members that his mood
was poor and he was not coping well after his surgery. He never
expressed suicidal ideations. He further expressed that he was
extremely frustrated with his hospitalization and his inability
to walk and function independently. Discussed the possibility
of talking to psychiatrists in the hospital, but he declined.
He felt that if these feeling persisted he would pursue further
psychiatric care. A number for psychiatric services was
provided to him on discharge.
# Chronic pain syndrome: The patient was continued on his home
regimen of dilaudid 4mg PO Q3H:prn
# Chronic hyponatremia. The patient had a history of chronic
hyponatremia although his sodium remained between 130-140 during
this admission.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID:
PRN as needed for constipation.
2. Furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection [**Hospital1 **]
(2 times a day): Hold for SBP<100.
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 or HR<60.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
8. Petrolatum Ointment Sig: One (1) Appl Topical DAILY
(Daily): Please apply to leg wounds per wound care orders. thank
you!
.
9. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation q6H: PRN as needed for shortness of
breath or wheezing.
11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain: Hold for RR<12 or sedation.
12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO q6H: PRN
as needed for itching.
15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO BID: PRN as needed for constipation.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: hold for diarrhea.
17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
18. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for dry mouth, sore
throat.
19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): Please apply to upper forehead and scalp for
seborrheic dermatitis (day 1 = [**2176-8-11**]). Also, please apply to
wound on left shin for overlying fungal infection(day 1 =
[**2176-8-15**]). Thank you!
.
20. Glycerin (Adult) Suppository Sig: One (1) Suppository
Rectal PRN (as needed) as needed for constipation.
21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for headache: Hold for
somnolence.
22. Heparin drip
Heparin IV Sliding Scale (please see included scale):
Diagnosis: DVT/A-fib,
Patient Weight: 114.76 kg,
Initial Bolus: 0 units IVP,
Initial Infusion Rate: 1450 units/hr,
Target PTT: 60 - 100 seconds,
.
PTT <40: 4600 units Bolus then Increase infusion rate by 450
units/hr,
PTT 40 - 59: 2300 units Bolus then Increase infusion rate by 250
units/hr,
PTT 60 - 100*:,
PTT 101 - 120: Reduce infusion rate by 250 units/hr,
PTT >120: Hold 60 mins then Reduce infusion rate by 450
units/hr,
23. Insulin sliding scale
Glargine 46 units at bedtime;
Humalog sliding scale per included sliding scale.
Discharge Medications:
1. Hydroxyzine HCl 25 mg/mL Solution Sig: One (1) Intramuscular
Q6H (every 6 hours) as needed for pruritis.
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4
hours).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-1**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO Q3hr:prn.
13. simvistatin 10mg Qday
14. Petrolatum Ointment Sig: One (1) Appl Topical DAILY
(Daily).
15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
16. Outpatient Lab Work
Chem 10 to monitor electrolytes and creatinine while taking
lasix
17. Turn and reposition off back prn and limit sit time to 1hour
at a time using pressure redistribution cushion. Cleanse skin
with wound cleanser or NS then pat dry nad apply aquafor to
gluteals and legs and feet daily
18. For heel and lateral foot ulcer apply thin layer of duoderm
wound gel, cover dorsum and lateral wound with adaptic and heel
with gauze followed by ABD pad, wrap iwth kerlix and change
daily
19. headrest to occiput with frequent repositioning
20. please remove sutures from posterior neck on tuesday [**9-10**] [**2175**]
21. Please start warfarin on [**2176-9-9**] (post op day 10)
and monitor INR prn
22. check weight Qday
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Cervical myelopathy
C1 tumor with cervical myelopathy
Acute on chronic diastolic heart failure
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2176-8-29**] for worsening upper
extremity weakness due to your spinal tumor. You underwent an
operation to remove the tumor. You also underwent an operation
to decrease the pressure on the spinal cord in your neck. You
will need to have the staples out from your surgical site on
[**2176-9-10**], which they will do at your rehab facility. An
appointment was made for you to follow up with Dr. [**Last Name (STitle) **] in 6
weeks.
Please return to the Emergency department for fever, chills,
difficulty breathing, worsening upper extremity weakness, or
worsening symptoms.
Followup Instructions:
1. [**Last Name (STitle) **] LAB
[**Hospital1 18**] [**Hospital Unit Name **], [**Location (un) **]
[**Location (un) **] surgery
Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2176-9-26**] 3:15
2 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD
LM [**Hospital Unit Name **], [**Location (un) **]
[**Location (un) **] surgery
Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2176-9-26**] 4:15
3. Dr. [**Last Name (STitle) 47032**] [**Name (STitle) **]
address: [**Doctor First Name **] [**Hospital Unit Name **] [**Location (un) 470**] [**Hospital Unit Name **]
phone: [**Telephone/Fax (1) **]
appointment: [**2176-10-8**] 1:15PM
4. Psychiatry Clinic
[**Hospital1 18**] Psychiatry Clinic
Please call the bottom number to schedule an appointment if your
mood is sad or you are not taking pleasure in life:
[**Telephone/Fax (1) **]
ICD9 Codes: 2761, 5119, 4280, 3572, 496, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 9
} | Medical Text: Admission Date: [**2138-6-9**] Discharge Date: [**2138-6-12**]
Date of Birth: [**2111-2-28**] Sex: M
Service: Cardiothoracic Surgery
PREOPERATIVE DIAGNOSIS:
1. Bicuspid aortic valve.
2. Dilated aorta.
3. Aortic insufficiency.
HISTORY OF PRESENT ILLNESS: The patient has had a heart
murmur since childhood and found to have a bicuspid aortic
valve on echocardiogram, and recently had an increase in the
size of the ascending aorta. Otherwise, the patient denies
any other medical problems. [**Name (NI) **] did have surgery in [**2124**] for
an undescended testicle.
SOCIAL HISTORY: Denies a smoking history. Occasional
alcohol, maybe once per week.
FAMILY HISTORY: Noncontributory.
MEDICATIONS ON ADMISSION: Prophylactic antibiotics.
ALLERGIES: No known drug allergies.
LABORATORY ON ADMISSION: Preoperative vital signs were a
heart rate of 78, blood pressure 102/68, respiratory rate
of 18. He was a healthy, 27-year-old male. Lungs were
clear. Heart had a 3/6 systolic ejection murmur. Otherwise,
the examination was within normal limits.
HOSPITAL COURSE: So, on [**2138-6-9**], the patient
underwent homograft aortic root replacement, resection, and
grafting proximal aortic arch. He underwent general
anesthesia. There were no intraoperative complications.
Postoperatively, the patient was transferred to the recovery
room on a nitroglycerin drip in normal sinus rhythm. He was
transferred from the recovery room to the Intensive Care
Unit, and on postoperative day one was transferred to the
floor, where he continued with an uncomplicated postoperative
course.
The patient did experience some tachycardia with a heart rate
of around 117. For this tachycardia the patient's beta
blockers were increased, and he did respond. His beta
blockers were increased to 75 mg p.o. b.i.d. Potassium was
repleted. The patient was diuresing about 4 liters per day.
The patient had very good pain control. He was ambulating
around the halls without difficulty on his own.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home with prescription. No
services needed.
MEDICATIONS ON DISCHARGE:
1. Lopressor 75 mg p.o. b.i.d.
2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 40 mEq p.o. q.d. times five days.
3. Iron sulfate 325 mg p.o. t.i.d.
4. Percocet 5 one to two tablets p.o. q.6h. p.r.n.
5. Aspirin 81 mg p.o. q.d.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2138-6-12**] 23:01
T: [**2138-6-13**] 18:17
JOB#: [**Job Number 13750**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 10
} | Medical Text: Admission Date: [**2142-11-30**] Discharge Date: [**2142-12-10**]
Date of Birth: [**2084-5-2**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Bactrim Ds / Lisinopril
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 25925**] is a 58 yo m w/ multiple sclerosis and seizure
disorder who presented to an OSH for delusions and AMS x 2 days.
At OSH, he was noted to have a Na of 124. He does have a history
of hyponatremia; he had a Na of 117 in [**2-27**] but had been in the
mid 130s since then. He has seen nephrology. At the OSH, he had
an approx 45sec generalized tonic clonic seizure, received 1mg
Ativan, and transferred to the ED at [**Hospital1 18**]. He also has a
history of seizures especially in the setting of infection and
hyponatremia. It is unclear if he has had seizures without an
inciting event. He is currently being weaned off of Keppra and
Gabapentin and is being started on Tegretol. In the ER, his VS
were: 97.5; 189/105; 78; 16; 95% 3L. He was given 2L of NS.
Given that he has had AMS in the setting of infection and is
known to have chronic UTIs [**12-24**] indwelling suprapubic catheter
and neurogenic bladder, blood and urine cultures were obtained
as well as a CXR. He had a urine culture from [**11-28**] that grew
pseudomonas and his CXR showed a possible infiltrate and he was
treated with vancomycin and cefepime. A head CT was negative.
Past Medical History:
MS - since [**2119**], progressive, quadriplegic, neurogenic bladder
with suprapubic catheter, restrictive PFT's
History of Aspiration PNAs
Esophageal Ulcer - [**12-24**] NSAIDs, [**2139**], small bowel bx negative
Recurrent UTIs
CHF (EF > 65% with moderate LVH in '[**39**])
HTN
Legally Blind
Social History:
He is married 32 years and lives with his wife at home. He has
three children and three grandchildren. He was a professor [**First Name (Titles) **] [**Last Name (Titles) 25949**] engineering at [**University/College 25932**], but
retired on disability after the [**2128**] spring semester due to his
MS. [**Name13 (STitle) **] is wheelchair-bound. He denies tobacco, alcohol, and
recreational drug use. Has personal care assistant.
Family History:
Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother
has diabetes.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2142-11-29**] 10:47PM BLOOD WBC-6.4 RBC-3.99*# Hgb-11.8*# Hct-33.1*
MCV-83# MCH-29.7 MCHC-35.7* RDW-15.0 Plt Ct-235#
[**2142-12-10**] 05:50AM BLOOD WBC-8.8 RBC-3.54* Hgb-10.8* Hct-31.0*
MCV-88 MCH-30.5 MCHC-34.7 RDW-15.3 Plt Ct-424
[**2142-12-7**] 05:50AM BLOOD PT-13.6* PTT-34.1 INR(PT)-1.2*
[**2142-11-29**] 10:47PM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-126*
K-4.5 Cl-88* HCO3-29 AnGap-14
[**2142-11-30**] 06:58AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-125*
K-4.6 Cl-90* HCO3-28 AnGap-12
[**2142-11-30**] 12:40PM BLOOD Na-128*
[**2142-11-30**] 09:45PM BLOOD Na-127*
[**2142-12-1**] 07:40AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-131*
K-4.0 Cl-93* HCO3-29 AnGap-13
[**2142-12-1**] 03:00PM BLOOD Glucose-101 UreaN-16 Creat-0.8 Na-131*
K-4.5 Cl-94* HCO3-30 AnGap-12
[**2142-12-2**] 05:45AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-133
K-4.6 Cl-95* HCO3-28 AnGap-15
[**2142-12-2**] 04:10PM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-131*
K-4.9 Cl-93* HCO3-27 AnGap-16
[**2142-12-3**] 06:20AM BLOOD Glucose-121* UreaN-21* Creat-1.2 Na-131*
K-4.3 Cl-93* HCO3-28 AnGap-14
[**2142-12-3**] 05:40PM BLOOD Glucose-115* UreaN-25* Creat-1.3* Na-134
K-4.4 Cl-96 HCO3-27 AnGap-15
[**2142-12-4**] 07:18AM BLOOD Glucose-101 UreaN-23* Creat-0.8 Na-135
K-4.0 Cl-98 HCO3-27 AnGap-14
[**2142-12-5**] 05:30AM BLOOD Glucose-83 UreaN-21* Creat-0.7 Na-135
K-3.9 Cl-96 HCO3-26 AnGap-17
[**2142-12-6**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-134
K-4.2 Cl-97 HCO3-28 AnGap-13
[**2142-12-7**] 05:50AM BLOOD Glucose-102 UreaN-21* Creat-0.8 Na-137
K-4.2 Cl-97 HCO3-26 AnGap-18
[**2142-12-8**] 07:00AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-136
K-3.9 Cl-99 HCO3-27 AnGap-14
[**2142-12-9**] 06:30AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-140
K-4.0 Cl-101 HCO3-28 AnGap-15
[**2142-12-10**] 05:50AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-140
K-4.5 Cl-102 HCO3-26 AnGap-17
[**2142-11-29**] 10:47PM BLOOD Osmolal-260*
[**2142-11-30**] 12:40PM BLOOD Osmolal-264*
[**2142-12-8**] 07:00AM BLOOD ALT-23 AST-16 LD(LDH)-213 AlkPhos-87
TotBili-0.2
[**2142-12-10**] 05:50AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.4
U/A [**11-28**]: nit +, LE +, WBC 55, RBC 6, Epi 1, bact few
U/A [**11-29**]: sm bld, 100 prot/gluc; WBC [**1-24**], RBC [**1-24**], Epi [**1-24**], bact
mod
U/A [**12-2**]: sm LE, WBC 10, RBC 2, Epi 1, bact none
U/A [**12-5**]: 30 prot, 10 ket, lg LE; WBC 99, RBC 11, Epi 1, bact
few
U/A [**12-6**]: 30 prot, mod LE; WBC 22, RBC 8, Epi 3, bact none
U/A [**12-8**]: neg leuk
CULTURES:
BCx [**11-29**] x2: neg
BCx [**12-2**] x2: neg
UCx [**11-28**]: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML
UCx [**11-29**] pseudomonas
UCx [**12-2**] yeast
Ucx [**12-5**] neg
Ucx [**12-6**] yeast
Ucx [**12-8**] neg
c.diff neg x 2
- CXR from [**12-2**]: Patchy opacity at left base again noted, but
the significance in the setting of low inspiratory volumes is
uncertain.
- CTA from [**12-2**]: No PE. Scattered patchy ground-glass opacities
may represent expiratory state with air trapping.
- Renal u/s from [**12-2**]: No evidence of abscess, hydronephrosis or
mass
- abd xray from [**12-3**]: non-specific bowel gas pattern, stool
throughout colon, no free air
- abd xray from [**12-4**]: Stool- and air-filled loops of large and
small bowel consistent with ileus.
- Liver u/s from [**12-5**]: Hypoechoic right hepatic mass, measuring
up to 4.2 cm in size
- CT abd: prelim read: Arterially enhancing liver lesion cannot
be fully characterized, may represent adenoma, FNH, or less
likely HCC.
Brief Hospital Course:
58 yo male w/ progressive multiple sclerosis was admitted for
AMS and seizure after having a 45s GTC at the OSH that responded
to 1mg Ativan. He had a negative head CT but was found to have
a Na level of 126. He has been hyponatremic in the past and
this has often caused changes in his mental status. In the ED,
he was treated with 2L NS for concern of hypovolemic
hyponatremia. At that time, his urine osm was 423 and serum osm
was 263. He also had a CXR and there was prelim concern for
pneumonia which can cause an ADH like effect (the final read was
neagtive). Neurology was consulted for his AMS and seizure and
they felt that his hyponatremia was likely related to recent
initiation of carbamezapine for sensory illusions.
Carbamezapine has a known ADH like effect and can cause
hyponatremia. Following discontinuation of carbamezapine along
with fluid restriction, his Na increased. After several days,
the pt appeared slightly dehydrated so his fluid restriction was
lifted. By time of discharge, his serum Na was 140.
.
In the past, his seizures have been instigated by an underlying
infection. However, upon admission he was afebrile and did not
have a leukocystosis. The most likely source was either
pneumonia or a UTI. He has a suprapubic catheter [**12-24**] neurogenic
bladder and on the day prior to admission, he had a urine sample
that grew pseudomonas, a bacteria he has had in the past. He
has also had several pneumonias in the past, most likely [**12-24**]
frequent aspirations and his first CXR was concerning for lung
infiltrate. He was treated with one dose of vancomycin and
cefepime for pneumonia. Ultimately, repeat CXR and a CTA were
both negative for pneumonia.
.
Because of his pseudomonal bacteriuria, he was started on
ciprofloxacin. A urine culture drawn prior to abx inititian also
grew pseudomonas. Because he was afebrile and did not have a
leukocytosis and there was thought that it may actually have
been colonization as opposed to infection. However, he was
treated with a full course of cipro for a complicated UTI. His
catheter was changed and all other cultures remained negative.
.
On admission, the pt was afebrile and hypertensive to 180-200.
However, shortly after arriving on the floor, he had an episode
of hypotension down to the 70's systolic. During this time he
was mentating well, he did not have any complaints, denied chest
pain, headache, and visual changes. IVFs were given, however
the hypotension did not initially respond, however came up
eventually prior to getting to the ICU. This labile blood
pressure was most likely secondary to the patient's autonomic
dysfunction secondary to his SPMS. Other considerations were
infection or possible sepsis, however the patient was continued
to be afebrile. Blood and urine cultures were negative. He was
monitored in the ICU for 24 hours with stable swings in BP which
were asymptomatic and consistent with autonomic dysfunction.
Changed clonidine dosing from 0.2mg [**Hospital1 **] to 0.1mg TID.
Maintained other blood pressure medications at home doses.
.
The next day, he was transferred out of the MICU and returned to
the floor. Shortly after arrival, he developed a fever. More
blood and urine cultures were sent and all were negative.
Pneumonia had been ruled out and his UTI was being treated with
a medication that was appropriate per sensitivities. He had a
CTA which was negative for PE. However, he was started on
meropenem and was treated for 2 days. He was still slightly
febrile but his meropenem was discontinued for concern of drug
fever. He defervesced without any further treatment.
.
However, his mental status continued to fluctuate despite being
afebrile, no obvious source of infection, and he was eunatremic.
He was occasionally aggressive and would say that he was being
murdered or kidnapped. Neurology was reconsulted but did not
feel that his symptoms were related to the keppra and they did
not think he was having subclinical seizures. He continued to
have repetitive shaking moves of his head but he was conscious
and able to speak during these episodes. Also, despite the
Keppra, he continued to have sensory illusions, mostly centered
around the feeling of having a bowel movement (when he actually
was not).
.
During the work up for a source of infection and source of AMS,
he had a CTA which revealed a liver lesion. He had an
ultrasound and a multiphase liver CT to further describe the
lesion because he cannot have an MRI [**12-24**] an implanted baclofen
pump. Mr [**Known lastname 25925**] and his family decided to not biopsy the lesion
at this time but it was not ruled out completely for malignancy,
although unlikely. During this work up he also had KUB that was
concerning for ileus but he continued to have BMs so he was kept
on a regular diet.
.
Prior to discharge, his mental status had not completely
returned to baseline but he was alert and oriented x 3 and was
no longer aggressive towards staff. No definite etiology was
elucidated and it was hypothesized that this could be a result
of the progression of his established disease.
Medications on Admission:
BACLOFEN 2,000 mcg/mL Kit -pump
BRIMONIDINE Dosage uncertain
CARVEDILOL - 25 mg Tablet [**Hospital1 **]
CARBAMEZAPINE - 100mg [**Hospital1 **]
CLONIDINE - 0.2 mg Tablet [**Hospital1 **]
CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream tid
FENTANYL - 12 mcg/hour Patch 72 hr
FUROSEMIDE - 40 mg Tablet qd
IPRATROPIUM-ALBUTEROL prn
LACTULOSE prn
MINOCYCLINE - 100 mg Tablet [**Hospital1 **]
MODAFINIL [PROVIGIL] 50 [**Hospital1 **]
OMEPRAZOLE 20 [**Hospital1 **]
OXYBUTYNIN CHLORIDE - 15 mg qhs
SIMVASTATIN - 40 mg qd
TRAVOPROST1 drop L eye once a day
ACETAMINOPHEN prn
ASCORBIC ACID 500 [**Hospital1 **]
BISACODYL hs
CALCIUM 500 mg Tid
CRANBERRY 475 mg Capsule [**Hospital1 **]
ERGOCALCIFEROL (VITAMIN D2)400 [**Hospital1 **]
MINERAL OIL prn
OMEGA-3 FATTY ACIDS [**Hospital1 **]
PSYLLIUM [METAMUCIL] prn
SENNA - 8.6 mg Tablet prn
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Oxybutynin Chloride 5 mg Tablet Sig: Three (3) Tablet PO QHS
(once a day (at bedtime)).
7. Ascorbic Acid 500 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) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. Simvastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: through [**2142-12-13**].
16. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
18. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
19. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) inh
Inhalation twice a day as needed.
20. TRAVATAN Z 0.004 % Drops Sig: One (1) Ophthalmic once a
day: To Left eye.
21. Cranberry 475 mg Capsule Sig: One (1) Capsule PO twice a
day.
22. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO
twice a day.
23. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.
The patient has an allergy listed to ACE Inhibitors, and was
therefore not discharged on an ACE Inhibitor. This will be
communicated to PCP.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
1. Multiple Sclerosis
2. Urinary Tract Infection, complicated
3. Hyponatremia
.
Secondary:
1. Chronic Diastolic CHF
Discharge Condition:
Stable vital signs.
Discharge Instructions:
You were admitted with altered mental status and found to have
low sodium and a urinary tract infection. You were started on
antibiotics for your urinary tract infection (cipro) to complete
a 2 week course. Your sodium corrected after adjusting your
medications and reducing your water intake.
.
You were found to have an abnormality in your liver. You had a
CT scan and the results are pending final interpretation. We
have provided a phone number below so that you can schedule an
appointment in [**Hospital **] clinic. It may be necessary to reimage the
liver or take a biopsy of the lesion seen on CT scan.
.
Your medications have changed. You were switched from tegratol
to keppra. Please review your most recent medication list and
take only these medications, and discard any old medications not
on this list.
.
Please return to the hospital if you develop fevers, chills, or
worsening symptoms.
Followup Instructions:
1. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2143-1-8**] 1:30
.
2. [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-1-15**]
4:00
.
3. [**Hospital **] CLINIC at [**Hospital1 18**]: ([**Telephone/Fax (1) 2233**]
Completed by:[**2142-12-13**]
ICD9 Codes: 5990, 2761, 5849, 4280, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 11
} | Medical Text: Admission Date: [**2109-8-17**] Discharge Date: [**2109-10-16**]
Date of Birth: [**2054-10-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
B/L ankle fractures, s/p fall
Major Surgical or Invasive Procedure:
[**8-18**]
.
1. Closed reduction of left pilon fracture.
2. Application of multi-planar external fixator left lower
extremity.
3. Closed treatment of calcaneus fracture with mild amount
of manipulation.
4. External fixation of Right Pilon fracture
.
[**8-30**] Adjustment of external fixator of R pilon fracture
.
[**9-17**] ORIF right intra-articular distal tib-fib fracture R
History of Present Illness:
54 year old Spanish speaking male, in the US on vacation, with a
questionable PMH of liver disease presents after
jumping?falling? out a window. Per his daughter he was drinking
alcohol with his son and reported feeling that someone was out
to kill him. He locked himself in a second-story bedroom and
was later found by his daughter crawling outside. He was
initially seen at [**Hospital3 **] and found to have opiates and
cocaine on UA in the emergency department there. He was
transported to [**Hospital1 18**] with b/l ankle fractures. Per family, the
pt has been confused at home. In [**Name (NI) **], pt was aggitated and
received haldol and ativan. He was later somnolent. EKG
demonstrated atrial flutter with HRs in 110-140's, rate
controlled in the ED with IV diltiazem.
Patient is a poor historian, most information obtained from his
daughter
ROS: + b/l ankle pain, -CP, -SOB, -Abdominal pain
Past Medical History:
"Gets yellow"
High ammonia
HTN
questionable anginal history
depression, family states he see a psychiatrist
Social History:
EtOH abuse, polysubstance abuse, one ppd for mayn years
Urine positive for cocaine and opiates in ED
Not married
Daughter is involved in care
Family History:
Noncontributory
Physical Exam:
Vitals: 96.7 140/90 76 16 99% on 2L NPO/1000
Physical Exam:
General: sleepy but arousable, oriented to place and person,
able to name the months of the year forwards, but not backwards,
not oriented to current month/year
HEENT: icteric sclerae, dry MM, + c-collar
CVS: irregular rate, tachy, no murmurs/rubs/gallops appreciated
Pulm: CTA b/l, no wheezes, rales or rhonchi
Abd: soft, NT, mild hepatosplenomegaly, +BS
Ext: b/l ankle splints, mild bruising over b/l knees, - for
asterixis
GU: + foley
Pertinent Results:
CT C-Spine: negative for fracture
Left tib/fib: Comminuted fracture of the calcaneus. Dense sliver
of bone along the medial aspect of the proximal fibula, seen
only on a single view. This could represent additional
calcification of the intraosseous ligament, a small cortical
fracture fragment, or a foreign body.
Right tib/fib: Comminuted, intraarticular, impacted, and
displaced fractures of the distal tibia as well as fracture of
the distal fibula as detailed above.
.
CT bilat LE
1. Comminuted intra-articular distal right tibial fracture.
2. Comminuted distal right fibular fracture with displacement.
3. Comminuted left calcaneal fracture.
.
RUQ U/S:
FINDINGS: The liver is coarse in echotexture without evidence of
focal lesion. The gallbladder is not distended due to nonfasting
stage. No evidence of gallstones. No evidence of intra- or
extra-hepatic biliary ductal dilatation and the common duct
measures 3 mm. The pancreas is not well visualized due to bowel
gas. There is no evidence of free fluid. The main portal vein is
patent with antegrade flow.
IMPRESSION: No evidence of cholecystitis.
.
Head CT ([**8-21**])
IMPRESSION: No evidence of acute intracranial pathology,
including no sign of intracranial hemorrhage.
.
CXR ([**8-21**])
No previous studies for comparison. Low lung volumes. Heart size
is difficult to evaluate in this semi-upright AP film. There
could be some LVH but no evidence for CHF and the lungs are
clear. Questionable slight impression on the right margin of the
tracheal air column which can be better evaluated by standard PA
and lateral chest films when condition permits.
.
Chest CT ([**8-23**]):
1. No juxtatracheal mass or left upper lobe lesion as questioned
on chest radiograph report.
2. Three foci of ground glass, right upper lobe, not detectable
on routine radiographs, a nonspecific finding. Six- month CT
follow up is recommended to look for change, because
bronchoalveolar cell carcinoma, though unlikely, cannot be
excluded.
3. Borderline size mediastinal and hilar lymph nodes should be
checked on followup CT.
4. Mild atherosclerotic coronary artery calcification.
Chest CTA ([**8-24**]):
1. No pulmonary embolism.
2. Relatively unchanged appearance of multiple ill-defined
opacities and tiny nodules in the right upper lobe. Follow-up
stated on the examination from 1 day prior is again recommended.
3. New foci of opacification present at the lung bases compared
to examination from one day prior likely related to aspiration.
Layering debris present within the right main stem bronchus most
suggestive of aspiration as well. Clinical correlation is
recommended.
4. Recommend advancing NG tube at least 4-5 cm. The current
position elevates the risk of further aspiration.
.
CT RLE with contrast ([**8-24**]):
IMPRESSION: Comminuted distal tibial and fibular fractures with
intra- articular involvement of the tibial plafond and lateral
displacement of the talus with respect to the tibia. Posterior
displacement of the distal fibular fragment.
.
CT LLE without contrast ([**8-24**])
Comminuted left calcaneal fracture.
Lentiform area of fluid attenuation at the skin on the
posterolateral aspect of the left foot. The significance of the
latter finding is uncertain, but may be due to a skin blister or
possibly dressing material within the cast. Clinical correlation
requested.
.
CXR ([**8-26**])
1. NG tube could be advanced several centimeters for standard
positioning, as described in prior exams.
2. New perihilar opacities, likely due to acute aspiration in
the superior segments.
.
Head CT ([**9-3**])
IMPRESSION: There is no evidence of hemorrhage or CT evidence of
acute infarct.
.
CT abd/pelvis ([**9-22**]):
IMPRESSION: No CT evidence of pyelonephritis or abscess within
the abdomen/pelvis.
.
CT LLE without contrast ([**9-26**])
1. Markedly comminuted fracture of the calcaneus with wide
distraction and dispersal of the fracture fragments as above.
2. Non-displaced fractures of the sustentaculum tali and of the
middle facet of the talus.
3. No fracture identified of the medial malleolus.
4. Non-displaced fractures of the anterior aspect and of the
inferior aspect of the lateral malleolus.
5. Non-displaced fracture of the cuboid.
6. No fracture identified of the navicular.
7. No other fractures identified within the remainder of the mid
foot or the forefoot.
8. Lateral subluxation of the peroneal tendons with respect to
the fibula.
9. Probable tear of the anterior talofibular ligament.
.
Echo ([**9-26**]):
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 estimated
pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
Brief Hospital Course:
During course of hospitalization, pt was put on CIWA scale for
EtOH withdrawal and given thiamine, folate and a multivitamin,
his AFib with RVR was initially treated with metoprolol, then
diltiazem, his high ammonia levels were treated with lactulose.
His b/l ankle fractures were followed by orthopedics.
The patient was severely agitated on more than one occassion
during this hospitalization, requiring three codes puples to be
called as well as requiring restraints for protection of both
the patient and the staff.
The patient was originally sent from the floor to the MICU with
delirium of unknown cause and severe agititation. He required
increased amounts of sedation and was returned to the floor
after a NG tube was placed. Once returned to the floor, the
patient required less sedation, was taken off of any
benzodiazipines and only intermittently needed restraints.
The patient remained somnolent and delerious. He pulled out his
NG tube. He was also febrile and rhoncorous on the floor. He
was initially treated with vancomycin and flagyl, which was
changed to azithro/ceftriaxone/flagyl. He was scheduled to
return to the OR for revision of his right external fixation.
In preop holding, he was found to be hypoxic and sent to the
MICU.
MICU COURSE: Morning of [**8-28**], patient scheduled to return to OR
for revision of externally fixated RLE. Upon transport to PACU,
patient became more somnolent and had reported "agonal
breathing". O2 sats 83% on 2LNC and NRB applied with O2 sats to
100%. BP in 90s/60s, HR in 80s, RR 17-19. ABG drawn: 7.38/58/90.
During stay in MICU, patient coughed up large amount of thick
sputum with improved respiratory status. Surgery postponed and
patient transferred to MICU for further monitoring. In the MICU,
respiratory status has remained stable with Sp02 in the high 90s
on room air. Pt is hemodynamically stable in chronic a-flutter.
Called out to floor on [**8-29**]- no further intensive care needs
identified.
In the MICU, patient was started on Zosyn and restarted on
Vancomycin wiht marked improvement in his respiratory status.
Within a few days of returning to the floor, Vancomycin and
zosyn were stopped as CXR showed resolution of questionable
aspiration pneumonia - this was felt to be more likely
pneuomonitis which resolved.
.
After the MICU, patient's delirium started to improve, but then
worsened when he returned to the OR for removal of external
fixation. He developed fevers to 102F post-operatively which
likely worsened delirium. Source of fevers unclear - of note
patient had recently developed VRE in his urine but infectious
disease did not feel this was an active infection. he received
three days of antibiotics (daptomycin and then linezolid). When
these were stopped he became afebrile and delirium began to
lift.
.
#Aggitation was mostly controlled with haldol. Zyprexa was
tried for two weeks but it did not seem to help acute
aggitation. QTc was monitored while patient was on
antipsychotics and was stable at approximately 420-440msec.
Overall etiology of delirium has remained unclear but was
thought to be multifactorial due in part to chronic alcohol use,
hepatic encephalopathy, benzodiazepine use, and post-operative
delririum. Although spanish-speaking 1:1 sitters and
interpreters were employed as much as possible, language also
likely contributed to persistance of delirium. Delirium has
completely resolved patient is now restraint and sitter free.
All haldol has been stopped. He has past the period of etoh
withdrawal. It is recommended that patient follow up with
alcohol abuse counseling.
.
#Afib/flutter
While febrile, his afib/flutter was complicated by more frequent
episodes of rapid ventricular rate. This was controlled with IV
metoprolol when needed but also by increasing PO metoprolol and
diltiazem. Treating fever with tylenol also seemed to help. He
was briefly put on therapeutic lovenox for atrial fibrillation,
but this was stopped as he was not felt to be eligible by CHADS
criteria and also because of high fall risk. Patient was
transitioned off of beta blockers and placed on Diltiazem 120mg
daily.
.
#Urinary retention
patient failed several voiding trials. He also pulled out his
foley on several occasions, causing hematuria. Intermittent
straight catheterization was tried to reduce infection risk of
long-term indwelling foley. However given delirium and
aggitation this was untenable. This resolved with reductions in
haldol. Patient now able to void freely on his own. History of
VRE on urine culture, but no signs of infection, dyruria,
increased urinary frequency. There is no evidence based
literature or other clinical indications to treat this
asymptomatic bacteuria at this time.
.
#Fractures
patient followed by orthopedics during admission. L ankle
fractures treated with casting, however repeat plain films and
CT scan 4-6 weeks post-op showed fractures which were not
initially visualized. Orthopedics felt casting was still
appropriate and that there was no indication for surgery. R
pilon fracture managed initially with external fixation system
because of skin breakdown making internal fixation difficult.
One month into hospitalization ex-fix removed and tibial and
fibular plates were placed. He is to remain Non-weight bearing
for a total of one month after his hospital discharge. Patient
has completed the necessary course of lovenox.He has a follow up
appointment scheduled with his orthopaedic surgeon Dr. [**Last Name (STitle) **]
for [**11-28**] at 1030am, at [**Hospital3 **] [**Hospital Ward Name **], [**Location (un) 1385**] of the [**Hospital Ward Name 23**] building.
.
Transfer to [**Hospital **] Rehab Hospital.
Medications on Admission:
Diltiazem 180 mg one daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*1*
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1) Bilateral Lower Extremity fractures
a. Closed left tibial plafond fracture/pilon fracture.
b. Dislocation left tibiotalar joint.
c. Right calcaneus fracture, intra-articular
2) Persistent agitated delirium ?????? resolved
3) Aspiration Pneumonitis - resolved
4) Alcoholism ?????? continuous
5) Delirium Tremens
6) Polysubstance Abuse (cocaine, opiates, alcohol)
7) Atrial Fibrillation/Atrial Flutter
8) Abnormal CT chest ?????? follow-up ([**2111-1-5**]) recommended
9) Liver Failure ?????? presumed secondary to alcoholism (No evidence
for HBV or HCV infection)
a. Thrombocytopenia presumed secondary to thrombopoitin
deficiency. No evidence for splenomegaly on imaging.
10) Elevated AFP level ?????? etiology as yet undetermined
Secondary:
1) Hypertension
2) Urinary retention ?????? resolved
3) Bactiuria ?????? asymptomatic, colonized with Vancomycin resistant
enterococcus
Contact information:
[**First Name8 (NamePattern2) **] [**Known lastname 1794**] (daughter): [**Telephone/Fax (1) 74301**]
[**Female First Name (un) 74302**] & [**First Name9 (NamePattern2) 74303**] [**Known lastname 1794**](son) cell [**Telephone/Fax (1) 74304**]
For Follow-up:
1) Repeat CT scan of chest in [**2111-1-5**] to f/u 3 foci of
ground glass in the RUL as well as borderline mediastinal and
hilar lymphadenopathy
2) Assess etiology of elevated alpha-fetoprotein
3) Further evaluate etiology of pancyctopenia ?????? consider bone
marrow aspirate as well as HIV testing
Discharge Condition:
Stable, Non-weight bearing in both legs for one month starting
[**10-15**]
Discharge Instructions:
You were transferred to [**Hospital1 18**] emergency room after a large fall.
You were found to have bilateral ankle fractures. You had a CT
scan of your head which did not show any acute bleed. When you
came into the emergency room your heart rate was fast, and you
were given medications to help slow it down.
.
On [**8-18**] you had an operation on your left leg for a heel
and ankle fracture, you had several pins placed in your left
leg. Your left leg was then casted.
.
On [**8-30**] you had an operation on your R tibula fibula fracture
that stabilized the leg externally.
.
On [**9-17**] you had an operation on your right tibula and
fibula and screws were placed to help your leg heal.
.
During your hospital stay. You were very confused and placed on
many psychiatric medications, you became very agitated at
times,and had to be restrained at times. This has resolved you
are no longer on any psychiatric medications.
.
While in the hospital you developed some breathing problems. [**Name (NI) **]
spent time in the intensive care unit, because there was some
worry that you might have a pneumonia, you were started on
antibiotics, but your breathing problems improves, and your
chest xray improved. It was thought that you did not have a
pneumonia and the antibiotics were normal.
.
You were also found to have some bacteria in your urine called
VRE, because you were not having, any burning with urination.
The infectious disease doctors thought that the bacteria should
not be treated.
.
You are being transferred to a rehab facility. It is important
that while at that rehab facility you, follow up and get
counseling for your problems with alcohol abuse.
.
You have follow up appointments schedule with both orthopaedics
and a new primary care physician. [**Name10 (NameIs) **] is important that you
follow up with both of these appointments.
.
It is also important that you do not put any weight on your legs
for next month. Please return to the hospital or the emergency
room if your condition worsens in any way.
You had an abnormal chest x-ray/CT scan and should have this
repeated in [**2111-1-5**] to make sure you don't have lung
cancer.
Your blood counts were low but stable during your
hospitalization. You should see a Hematologist (Blood Doctor)
about this and consider testing for HIV.
You had an elevation of a marker in your blood called AFP (alpha
fetoprotein). The significance of this is not know. It may be
related to your underlying liver disease but should be further
evaluated by a specialist.
You should absolutely refrain from further use of alcohol,
cocaine or any illicit drugs not explicitly prescribed to you by
a physician.
Ten??????as una exploraci??????n anormal [**Doctor First Name **] pecho x-ray/CT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 7214**]
esto
repetido en diciembre de [**2110**] para cerciorarse de t?????? no [**Last Name (un) 7214**]
pulm??????n
c??????ncer.
Tus cuentas de sangre [**Doctor First Name **] [**First Name9 (NamePattern2) 74305**] [**Last Name (un) **] [**First Name9 (NamePattern2) 74306**] [**Last Name (un) 33761**] tu
hospitalizaci??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7213**] [**Last Name (un) **] a un hemat??????logo (el doctor [**Last Name (Titles) **]
[**Last Name (Prefixes) 74307**])
sobre esto y considerar el probar para el VIH.
Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP
(alfa
fetoprotein). [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 74308**]??????n de esto no es saber. Puede ser
relacionado con tu enfermedad [**Doctor First Name **] higado [**First Name9 (NamePattern2) 74309**] [**Last Name (un) **] debe
ser m??????s futuro
evaluado por un especialista.
[**Last Name (un) 7213**] refrenarse absolutamente [**Doctor First Name **] uso adicional [**Doctor First Name **] alcohol, de
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????na o de cualquier droga il??????cita prescritos no
expl??????citamente a ti por un m??????dico.
Followup Instructions:
Ten??????as una exploraci??????n anormal [**Doctor First Name **] pecho x-ray/CT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 7214**]
esto
repetido en diciembre de [**2110**] para cerciorarse de t?????? no [**Last Name (un) 7214**]
pulm??????n
c??????ncer.
Tus cuentas de sangre [**Doctor First Name **] [**First Name9 (NamePattern2) 74305**] [**Last Name (un) **] [**First Name9 (NamePattern2) 74306**] [**Last Name (un) 33761**] tu
hospitalizaci??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7213**] [**Last Name (un) **] a un hemat??????logo (el doctor [**Last Name (Titles) **]
[**Last Name (Prefixes) 74307**])
sobre esto y considerar el probar para el VIH.
Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP
(alfa
fetoprotein). [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 74308**]??????n de esto no es saber. Puede ser
relacionado con tu enfermedad [**Doctor First Name **] higado [**First Name9 (NamePattern2) 74309**] [**Last Name (un) **] debe
ser m??????s futuro
evaluado por un especialista.
[**Last Name (un) 7213**] refrenarse absolutamente [**Doctor First Name **] uso adicional [**Doctor First Name **] alcohol, de
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????na o de cualquier droga il??????cita prescritos no
expl??????citamente a ti por un m??????dico.
Please follow up with Dr. [**Last Name (STitle) **] from orthopedic surgery you
have an appointment scheduled for [**2112-11-28**]:30 am, [**Location (un) 1385**] of the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name **] of [**Hospital1 771**]. Please call [**Telephone/Fax (1) 9769**] if would like
to change this appointment.
Please follow up with your new primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 15259**] on [**2109-11-19**] at 3pm in the [**Hospital Ward Name 23**] Center on
the [**Location (un) **] of the [**Hospital Ward Name 516**] [**Hospital1 1170**].
You had an abnormal chest x-ray/CT scan and should have this
repeated in [**2111-1-5**] to make sure you don't have lung
cancer.
Your blood counts were low but stable during your
hospitalization. You should see a Hematologist (Blood Doctor)
about this and consider testing for HIV.
You had an elevation of a marker in your blood called AFP (alpha
fetoprotein). The significance of this is not know. It may be
related to your underlying liver disease but should be further
evaluated by a specialist.
ICD9 Codes: 4019, 2875, 5990, 5070, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 12
} | Medical Text: Admission Date: [**2170-9-19**] Discharge Date: [**2170-9-25**]
Date of Birth: [**2099-5-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion and fatigue
Major Surgical or Invasive Procedure:
[**2170-9-19**] Coronary artery bypass graft x 4 (Left internal mammary
artery to diagonal, saphenous vein graft to left anterior
descending, saphenous vein graft to obtuse marginal, saphenous
vein graft to posterior descending artery)
History of Present Illness:
71 year old male who presented to his PCP for [**Name Initial (PRE) **] routine visit
with complaints of recent onset fatigue, dyspnea on exertion,
exertional throat discomfort and left arm. He denied any rest
pain but reports the discomfort and dyspnea occur with minimal
activities such as showering. He was found to be hypertensive
and was started on Atenolol 25mg daily. His EKG was normal and
he was sent for a nuclear stress test. He underwent a nuclear
stress test on [**2170-8-1**] which revealed inferolateral ischemia and
a moderate inferior, inferolateral, and posterolateral perfusion
abnormality. He is now refereed for cardiac catheterization. He
is now being referred to cardiac surgery for revascularization.
Past Medical History:
Hypertension
Right rotator cuff tear
Compound fracture of left arm/plated as a child
Benign colon polyps
Arthritis
s/p right rotator cuff repair
s/p repair if left arm fracture, plated
Social History:
Race:Caucasian
Last Dental Exam:"a very long time ago", does not recall when
Lives with:Wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (3) 74913**]
Occupation:self employed painter
Cigarettes: Smoked no [x]
Other Tobacco use:denies
ETOH: stopped drinking in [**12-20**]
Illicit drug use:denies
Family History:
No premature coronary artery disease
Physical Exam:
Pulse: 56 Resp:13 O2 sat:97/RA
B/P Right:173/82 Left:164/76
Height:5'9" Weight:200 lbs
General: NAD, WG, WN
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] none_
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2170-9-25**] 06:35AM BLOOD WBC-10.9 RBC-2.94* Hgb-9.3* Hct-26.3*
MCV-89 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-261
[**2170-9-24**] 06:20AM BLOOD WBC-13.4* RBC-3.27* Hgb-10.1* Hct-28.7*
MCV-88 MCH-31.0 MCHC-35.3* RDW-14.2 Plt Ct-197
[**2170-9-25**] 06:35AM BLOOD Na-139 K-4.0 Cl-99
[**2170-9-24**] 06:20AM BLOOD Glucose-118* UreaN-26* Creat-0.9 Na-139
K-4.0 Cl-98 HCO3-31 AnGap-14
[**2170-9-23**] 05:00AM BLOOD UreaN-25* Creat-0.9 Na-137 K-4.3 Cl-99
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit and on [**9-19**] was brought to the
operating room where he underwent a Coronary artery bypass graft
x4 (left internal mammary artery to the diagonal and saphenous
vein grafts to the left anterior descending, obtuse marginal,
and posterior descending arteries) with Dr.[**First Name (STitle) **].
CARDIOPULMONARY BYPASS TIME:104 minutes. CROSS-CLAMP TIME:93
minutes. Please see operative report for further surgical
details. Following surgery he was transferred to the CVICU
intubated and sedated in critical but stable condition. Later
this day he was weaned from sedation, awoke neurologically
intact and extubated without incident. He weaned from pressor
support and beta blocker/Statin/Aspirin and diuresis was
initiated. Chest tubes and epicardial pacing wires were removed
per protocol. POD#1 he was transferred to the step-down unit for
further monitoring. Physical Therapy was consulted for
evaluation of strength and mobility. During his postoperative
course he developed atrial fibrillation and was treated with
beta blockers and amiodarone. Anticoagulation was initiated with
Coumadin. He developed a phlebitis from IV Amio and was placed
on a course of Keflex x 7 days. This was slowly improving. His
pulmonary status waxed and waned with a strong productive cough
and wheezing, which improved by the time of discharge. He
continued nebulizer treatments. CXR showed small bilateral
pleural effusions with atelectasis, no infiltrate or density.
His pulmonary status slowly improved by his day of discharge. On
POD 4 he developed a tender erythematous right knee and was
treated with colchicine for presumed gout. This had improved by
the time of discharge and the colchicine was discontinued. On
POD 6 he was afebrile, ambulating with assistance, tolerating a
full po diet and his wounds were healing well. On POD 6 he was
discharged to Lifecare Center of [**Location 15289**] in stable
condition. All follow up appointments were advised.
Medications on Admission:
ATENOLOL 25 mg Daily
ASPIRIN 325 mg daily
FISH OIL-DHA-EPA 1,200 mg-144 mg-216 mg Daily
MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [A THRU Z HIGH POTENCY] 400
mcg-162 mg-18 mg-300 mcg-250 mcg Tablet Daily
NAPROXEN SODIUM [ALEVE]PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 1 week then 200 [**Hospital1 **] x 1 week then 200 mg daily
directed by caridologist.
8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughing .
14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: For right arm phlebitis.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14
days.
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 14 days.
17. warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once):
Give 4 mg on [**9-26**] then as directed for INR goal 2.0-2.5 for A
fib.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 4
Past medical history:
Hypertension
Right rotator cuff tear
Compound fracture of left arm/plated as a child
Benign colon polyps
Arthritis
s/p right rotator cuff repair
s/p repair if left arm fracture, plated
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**10-29**] at 1:15pm, #[**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] on [**9-25**] at 2:00pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **]. Nikolaos Michalacos in [**4-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Patient to be given 4 mg Coumadin on [**2170-9-25**]
Goal INR 2.0-2.5
First draw [**2170-9-26**]
Please arrange follow up with PCP or cardiologist prior to
discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2170-9-25**]
ICD9 Codes: 4111, 5119, 5180, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 13
} | Medical Text: Admission Date: [**2191-7-13**] Discharge Date: [**2191-7-15**]
Date of Birth: [**2191-7-13**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname 1661**] was born at 39 weeks gestation to
a 32-year-old gravida 1, para 0 now 1 woman. The mother's
prenatal screens were blood type O positive, antibody
negative, rubella immune, RPR nonreactive, hepatitis surface
antigen negative, and group B strep negative. The infant
not crying and was intubated and no meconium was suctioned
from below the cords. He was given a brief period of bag and
mask ventilation with good responses. Apgars were 8 at two
minutes and 9 at five minutes.
His birth weight was 3885 grams, his birth length was 20 [**1-19**]
inches, and his birth head circumference was 34 cm. The
transferred to the Newborn Intensive Care Unit at four hours
of age for hypoglycemia. His blood dextrose stick was 36.
PHYSICAL EXAMINATION: Reveals a vigorous, non-dysmorphic,
term-appearing infant. Anterior fontanel open and flat,
cranial molding present, small caput posteriorly, palate
intact. Respirations unlabored, lung sounds clear and equal.
Heart was normal heart sounds and no murmur. Femoral and
brachial pulses +2 and equal. Soft abdomen with no masses.
Normal external male genitalia with both testes descended.
Symmetric tone and reflexes.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant has remained in room air
throughout his Newborn Intensive Care Unit stay. He has had
no apnea, bradycardia or desaturations.
2. Cardiovascular: He has remained normotensive throughout
his Newborn Intensive Care Unit stay. There are no
cardiovascular issues.
3. Fluids, electrolytes and nutrition: The infant required
supplemental intravenous fluid, from which he weaned
successfully at 28 hours of age, maintaining euglycemia with
feedings of Enfamil 20 on an ad lib schedule, taking
approximately one ounce every three to four hours. His last
blood glucose at the four hour mark was 59.
4. Gastrointestinal: The infant has been passing meconium.
5. Sensory: Hearing screening was performed with automated
auditory brain stem responses, and the infant passed in both
ears on [**2191-7-15**].
6. Psychosocial: The parents have been involved in the
infant's care during his Newborn Intensive Care Unit stay.
DISCHARGE STATUS: The infant is being discharged to the
Newborn Nursery.
CONDITION ON DISCHARGE: His condition is good at the time of
discharge.
PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**Last Name (STitle) 43003**]
[**Name (STitle) 17494**] of [**Hospital3 **] Medical Center, telephone number
[**Telephone/Fax (1) 17663**].
CARE RECOMMENDATIONS:
1. Feedings: Enfamil 20 on an ad lib schedule.
2. Medications: The infant is discharged on no medications.
3. A state screening has not been drawn yet.
4. The infant has not yet received the hepatitis B vaccine.
DISCHARGE DIAGNOSIS:
1. Resolved hypoglycemia
2. Term male infant
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2191-7-15**] 01:36
T: [**2191-7-15**] 02:18
JOB#: [**Job Number 43004**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 14
} | Medical Text: Admission Date: [**2142-12-23**] Discharge Date: [**2142-12-30**]
Date of Birth: [**2070-6-15**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Right upper quadrant pain
Major Surgical or Invasive Procedure:
[**2142-12-23**]: ERCP with sphincterotomy and stent placement
[**2142-12-28**]: cholecystectomy
History of Present Illness:
This is a 72 year-old female with a history of mild mental
retardation, who presents with RUQ that started this AM. Pt with
some back pain. Pt went to [**Hospital1 **] and was found to have a fever
of 102.9 and elevated LFTs. RUQ u/s with concern for stone in
CBD. WBC was 9.4 and 56% bands, tbili 8.7, dbili 5.3 and she was
given levo/flagyl, tylenol, and IVF and transfered to [**Hospital1 18**] with
presumed cholangitis. She is orientated to person and
"hospital". Lives at home.
In the ED, VS on arrival were 97.3 82 132/74 20 96% 2L NC. Pt
was given IVF, unasyn, zofran, and morphine. Labs showed WBC of
31, lactate 3.2, and bili of 7.7 with elevated LFTs. ERCP and
surgery were consulted. ERCP wanted pt in [**Hospital Unit Name 153**] for ERCP tonight.
Surgery requested u/s and CT abd with contrast. CXR with concern
for LLL PNA, but no resp sx. RUQ u/s prelim showed: gallstones,
no evidence of acute cholecystitis. Angiomyolipoma in left upper
pole, 1.5cm. CT prelim showed: No intrahep bil dil. Slight
enhancement of the normal caliber cbd, cbd raises the
possibility of cholangitis. Pulmonary bronchiectasis. Pt was
admitted to surgery in [**Hospital Unit Name 153**]. VS on transfer were 98 66 104/39 16
99% 2LNC.
Pt went for an ERCP that showed pus in the bile duct with a
small stone causing obstruction. There was also a stricture
1/3rd of the way in the CBD. Malignacy can not be ruled out. A
stent was placed that will need removal in 3 weeks. Pt was given
3 liters LR by the time she arrived post procedure in the [**Hospital Unit Name 153**]
including her ER IVF.
Past Medical History:
-Mild mental retardation
-Arthoscopy of knee
-Hysterectomy
-Low plts at [**Hospital1 2025**] [**2129**], dx with ITP
-Cataract surgery
-Right 3rd nerve palsy
-Esophageal web, with food obstruction removed in past
Social History:
Lives with her sister, brother-in-law, and mother. [**Name (NI) **] tobacco or
etoh use. Ambulates independently. Enjoys watching the TV and
news and Today show.
Family History:
no bleeding or plt disorders
Physical Exam:
Vitals: 98.8 87 97/36 13 94%RA
GEN: Well-appearing, no acute distress
HEENT: mild sclera ictericus, MMM, OP Clear
NECK: JVP at 5-6cm, no bruits, no cervical lymphadenopathy,
trachea midline
COR: RRR, soft SEM at Rt 2nd ICS, radial pulses +2
PULM: Lungs with coarse crackles at right bsea with decreased BS
at left base and few crackles
ABD: Soft, NT, ND, +BS, no HSM, no masses, neg Murphys
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person and time, and "hospital".
Moving all ext, right third nerve palsy (in abduction at rest
and no elevation past midline and no adduction) and pupil is
asymetric offcenter but contract; CN otherwise grossly intact.
SKIN: Mild jaundice
Pertinent Results:
Admission labs-
[**2142-12-23**] 04:54PM BLOOD WBC-31.3* RBC-5.04 Hgb-13.2 Hct-38.0
MCV-75* MCH-26.1* MCHC-34.7 RDW-13.9 Plt Ct-162
[**2142-12-23**] 04:54PM BLOOD Neuts-57 Bands-30* Lymphs-6* Monos-2
Eos-0 Baso-0 Atyps-2* Metas-3* Myelos-0
[**2142-12-23**] 04:54PM BLOOD PT-16.0* PTT-27.9 INR(PT)-1.4*
[**2142-12-23**] 04:54PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-141
K-3.4 Cl-108 HCO3-20* AnGap-16
[**2142-12-23**] 04:54PM BLOOD ALT-263* AST-184* AlkPhos-172*
TotBili-7.7*
[**2142-12-23**] 04:54PM BLOOD Lipase-14
[**2142-12-24**] 12:08AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.7
[**2142-12-23**] 05:08PM BLOOD Lactate-3.2*
[**2142-12-23**] Liver US :
Gallstones, without gallbladder wall thickening or
pericholecystic fluid to suggest acute cholecystitis. No biliary
dilation.
[**2142-12-23**] CT Abd/pelvis :
1. No intrahepatic biliary ductal dilatation, no gallstones, the
gallbladder
is normal in appearance.
2. Slight mural hyperenhancement of the nondilated common
hepatic and common bile duct - can be seen with cholangitis.
2. Diverticula, no evidence of diverticulitis.
[**2142-12-23**] ERCP :
Esophageal web
Periampullary diverticulum
Successful biliary cannulation.
A single stricture that was 6 mm long was seen at the middle
third of the common bile duct.
There was an irregular appearance to the lining of bile duct,
likely secondary to cholangitis.
Sucessful sphincterotomy performed
Small 4mm stone was extracted. Pus was seen exiting the bile
duct.
Successful plastic biliary stent placement
Otherwise normal ercp to third part of the duodenum
Possible Mirizzi's versus tumor as a cause of stricture.
[**2142-12-26**] CXR ;
1. New small-to-moderate right-sided pleural effusion with
parenchymal
opacity which could probably be explained by compressive
atelectasis, although pneumonia is an additional differential
consideration.
2. Similar left lower lung opacity which is a more chronic
finding.
[**2142-12-28**]:
INDICATION: CBD stricture of unclear etiology. Evaluate for
pancreatic mass.
COMPARISON: CT of the abdomen [**2142-12-23**] and ERCP [**12-23**], [**2142**].
TECHNIQUE: Multidetector helical scanning of the abdomen was
performed prior
to and following the administration of 200 cc of IV Optiray
contrast.
Coronal, sagittal, volume-rendered and MIP reformats were
displayed.
CTA OF THE ABDOMEN: Left lower lobe bronchiectasis and small
bilateral
pleural effusions are unchanged from prior exam. There is
pneumobilia and a
common bile duct stent in place traversing the mid CBD stricture
seen on ERCP.
There is no soft tissue surrounding the CBD to definitively
suggest a biliary
malignancy. There is mild intrahepatic biliary ductal dilation.
There is an
8-mm low-density lesion within segment V/VI of the liver
(3A:43), which is too
small to characterize but likely a cyst.
No intrahepatic lesions. The portal vein is patent. The hepatic
arterial
anatomy is conventional. The pancreas enhances homogeneously and
there is no
evidence of a pancreatic mass. The superior mesenteric artery
and vein are
patent and normal in caliber and course. There is a prominent 12
mm portal
hilar lymph node (3B:110), likely reactive. There is also a
13-mm precaval
node (3B:119).
The spleen, gallbladder, and adrenal glands are normal. The
kidneys enhance
and excrete contrast symmetrically with multiple subcentimeter
hypoattenuating
lesions which are too small to characterize but likely cysts. A
16-mm
exophytic fat-containing left renal lesion is consistent with an
angiomyolipoma (3A:66). There is a left extrarenal pelvis. No
ascites. No
mesenteric adenopathy. The small bowel loops are normal. There
are
moderately extensive colonic diverticula.
The bones are mildly osteopenic and there are degenerative
changes, however,
no concerning lytic or sclerotic lesions.
IMPRESSION: Mild biliary dilation and stent within the CBD, with
no
pancreatic or biliary mass identified.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 18394**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18395**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: SAT [**2142-12-29**] 10:56 PM
Brief Hospital Course:
This is a 72 year-old female with a who presented with acute
cholangits and was transfered for a ERCP and surgery evalaution.
# Acute Cholangitis: Pt has elevated LFTs and bili with RUQ pain
and fever of 102.9 at OSH. She was transfered for ERCP and
surgery eval. Pt had appearance of sepsis due to WBC from 9.4
with 56% bands at OSH to WBC of 31.3 and 30% bands in [**Hospital1 18**] ER
and fevers. ERCP showed stone obstruction with drainage of pus,
and stent was placed. Pt was admitted to the [**Hospital Unit Name 153**] post procedure
and remained NPO. Her LFTs started to down trend post ERCP. 2
hours post ERCP she developed some hypotension with BP dropping
from mid 90s to 70s. She was mentating and making urine. She was
given IVF bolus with LR and her BP improved to 90-100. She was
given IVF as needed to maintain UO and SBP>90. She had no
further abd pain post procedre. She continued on tx with unasyn.
[**2142-12-23**] OSH blood cx are growing GNR 2/4 bottles as of [**2142-12-24**]
at 9AM. She was transferd to the SICU per request of the surgery
team.
# CBD Stricture: On ERCP pt was found to have a stricture of
unclear cause. She then had a pancreatic protocol CTA, which
showed Mild biliary dilation and stent within the CBD, with no
pancreatic or biliary mass identified.
# Cholelithiasis: Following ERCP and sphincterotomy with stone
extraction, pt clincally stabilized and her LFTs gradually
returned to [**Location 213**]. At this point, she was taken to the
operating room for definitive management of her cholelithiasis.
Pt was found to have acute suppurative cholecystitis and
laproscopic cholecystectomy was performed. She recovered
uneventfully from this procedure.
# Atrial fibrillation: She developed RAF to 150 on [**2142-12-25**] and
was given IV lopressor and subsequently Diltiazem with
conversion to NSR. No further episodes.
# Possibe PNA: no clear resp sx or hypoxia. CT Abd showed some
lower lung fields with pulm bronchiectasis, which may expalin
the ER findings on her CXR. She has a 3 liter oxygen requirment
which is likely from IVF given in setting of sepsis.
Following transfer to the Surgical floor she continued to make
good progress. She remained free of any arrhythmias and was
gradually weaned off of oxygen with adequate saturations. She
was up and ambulating independently and voiding without
difficulty. Her diet was gradually advanced to regular and well
tolerated.
Medications on Admission:
Multivitamin
Discharge Medications:
1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Take while using oxycodone to avoid constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis
choledocholithiasis
gram negative bacteremia
paroxsymal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with abdominal pain due to a
stone in your bile duct. You underwent ERCP with stent
placement.
* You had a surgery and your gallbladder was removed.
* You should continue to eat a regular diet and stay well
hydrated.
* Take the antibiotics as prescribed.
* You had an irregular heartbeat for a short time when you were
in the ICU. It normalized with a medication called lopressor.
You will continue that until Dr. [**Last Name (STitle) 39288**] evaluates you in thge
office.
* If you develop any more abdominal pain or any other symptoms
that concern you, please call your doctor or return to the
Emergency Room.
* You will need to have the stent removed later on. Please call
the number below to schedule an appointment.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**12-27**] weeks.
Call the GI unit at [**Telephone/Fax (1) 1983**] to schedule an appointment for
a repeat ERCP with stent removal in 3 weeks.
Call Dr. [**Last Name (STitle) 39288**] for a follow up appointment in 2 weeks.
ICD9 Codes: 0389, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 15
} | Medical Text: Admission Date: [**2185-4-17**] Discharge Date: [**2185-5-2**]
Date of Birth: [**2185-4-17**] Sex: F
Service: Neonatology
HISTORY: [**First Name4 (NamePattern1) 14552**] [**Known lastname **], twin #2, was born at 34-2/7 weeks
gestation to a 40-year-old gravida 3, para 2 now four woman
by spontaneous vaginal delivery. The mother's prenatal
screens were blood type O+, antibody negative, rubella
immune, RPR nonreactive, hepatitis surface antigen negative,
and group B Strep unknown. This pregnancy was achieved
in-[**Last Name (un) 5153**] fertilization resulting in dichorionic-diamniotic
twin. The mother received betamethasone at 23 weeks
gestation due to cervical shortening. The pregnancy was also
complicated with hypertension and urinary tract infection x2
with an unknown organism, and mother was also a chronic
smoker.
The labor ensued after spontaneous rupture of membranes 12
hours to delivery of twin #1. This twin emerged vigorous.
Apgars were eight at one minute and eight at five minutes.
The birth weight was 2,125 grams, the birth length 44.5 cm,
and the birth head circumference 31.5 cm. All parameters in
the 25-50th percentile for gestational age.
ADMISSION PHYSICAL EXAM: Reveals a vigorous preterm infant.
Anterior fontanel is soft and flat. Sutures are proximated.
Positive bilateral red reflex. Mild subcostal-intercostal
retractions, and some positive grunting. Breath sounds are
equal. Heart was regular, rate, and rhythm, no rhythm. Pink
and well perfused. Soft abdomen with positive bowel sounds,
three vessel umbilical cord. Normal preterm female
genitalia, femoral pulses +2, and a nonfocal neurological
examination.
HOSPITAL COURSE BY SYSTEMS:
Respiratory: The infant initially had some grunting flaring
and retracting which resolved by a few hours of life. She had
some occasional episodes of desaturation in the first two
days of life, and has had no further apnea, bradycardia, or
desaturation. On examination, her respirations are
comfortable. She has always remained on room air throughout
her NICU stay.
Cardiovascular: The infant has remained normotensive
throughout her NICU stay. There are no cardiovascular issues.
Fluids, electrolytes, and nutrition: At the time of
discharge, her weight is 2,180 grams, her length is 45 cm,
and her head circumference is 31.5 cm.
Enteral feeds were begun on day of life #1 and advanced
without difficulty to full volume feeding by day of life #2.
At the time of discharge, she is eating on an adlib schedule
of 24 calories/ounce of breast milk or Enfamil and breast
feeding when the mother is present.
Gastrointestinal: She had one bilirubin drawn on day of life
#3 that was total 6.4 and direct 0.3. She never required
phototherapy.
Hematology: At the time of admission, the hematocrit was
46.8. She has never received any blood product transfusion
during her NICU stay.
Infectious disease: [**Doctor First Name 14552**] was started on ampicillin and
gentamicin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours when the
blood cultures were negative, and the infant was clinically
well.
Neurology: There are no neurological issues.
Audiology: Hearing screening was performed with automated
auditory brain stem responses, and the infant passed in both
ears.
Psychosocial: Parents were very involved in the infant's
care throughout their NICU stay.
The infant is being discharged in good condition home with
her parents.
PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **]
in [**Hospital1 1562**], telephone #[**Telephone/Fax (1) 49156**].
CARE AND RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings: 24 calories/ounce of breast milk or Enfamil and
breast feeding to maintain consistent weight gain.
MEDICATIONS:
1. Iron sulfate (25 mg/ml of elemental iron) 0.2 cc po q day.
The infant has passed the car seat oxygenation test.
State newborn screens were sent on [**4-21**] and [**2185-5-1**]. The
infant has not yet received any immunizations in our attempt
to keep the twins on the same immunization schedule and her
twin has not yet reached the 2 kg weight recommendation for
the first hepatitis B vaccine.
RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: 1) Born at less than 32 weeks, 2) born between 32
and 35 weeks with plans for daycare during RSV season, with a
smoker in the household, or with preschool siblings, or 3)
with chronic lung disease.
2. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age, the family
and other caregivers should be considered for immunization
against influenza to protect the infant.
FOLLOW-UP APPOINTMENTS FOR THIS INFANT:
1. The [**Hospital6 407**] of [**Hospital3 **], telephone
#1-[**Telephone/Fax (1) 46331**].
2. Lactation consultant at the Learning Center at [**Hospital1 **], telephone #[**Telephone/Fax (1) 47507**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34-2/7 weeks.
2. Twin #2.
3. Status post transitional respiratory distress.
4. Sepsis ruled out.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2185-5-2**] 15:03
T: [**2185-5-2**] 06:58
JOB#: [**Job Number 49158**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 16
} | Medical Text: Admission Date: [**2199-12-3**] Discharge Date: [**2199-12-19**]
Date of Birth: Sex: M
Service:
CHIEF COMPLAINT: Hypoxia
HISTORY OF PRESENT ILLNESS: This is a 33 year old male with
no significant past medical history who initially presented
to the [**Company 191**] Outpatient Clinic on [**11-27**] with four days of
high fevers (103 degrees F), nonproductive cough, malaise,
diffuse myalgias, mild resting dyspnea, no exposure to ill
contacts. On [**2199-11-27**] his vital signs in the office
were temperature 99.5, blood pressure 120/85, heartrate 113
and respiratory rate 20, oxygen saturation 89% on room air.
Weight was 238 lbs. Nonspecific pulmonary examination was
appreciated at the time. He was prescribed Levaquin 500 mg
p.o. q.d. and discharged to home. He represented to his
outpatient [**Hospital 191**] Clinic on [**2199-12-3**] complaining of
persistent fever to 102 degrees F, weakness, bilious emesis,
worsening dyspnea, and nonproductive cough. Vital signs in
the office were temperature 97.3, blood pressure 108/70,
respiratory rate 20, heartrate 108, oxygen saturation 70% on
room air. No wheezes were noted on examination. He was
given 1 gm of Ceftriaxone and sent to the Emergency
Department where he received normal saline and 1 gm of
Vancomycin. He denied pleuritic chest pain. He has no risk
factors for human immunodeficiency virus. He denies a
history of seizure disorder, alcohol use, recent somnolence,
or symptoms of gastroesophageal reflux disease. He was
transferred to the Intensive Care Unit on arrival.
PAST MEDICAL HISTORY: No significant past medical history or
surgical history.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Levofloxacin 500 mg p.o. q.d.
SOCIAL HISTORY: Originally from [**Male First Name (un) 1056**]. A bus driver,
lives with his wife and daughter, no alcohol, no elicit drug
use. Rare alcohol use.
FAMILY HISTORY: Father had diabetes mellitus.
PHYSICAL EXAMINATION ON ADMISSION: General, moderately
obese, sitting up in bed, no accessory muscle use.
Vital signs, temperature 99.0, heartrate 92, blood pressure
137/74, respiratory rate 16, oxygen saturation 100% on 100%
nonrebreather.
Head, eyes, ears, nose and throat, pupils equal, round and
reactive to light, extraocular muscles intact, anicteric,
oropharynx clear, fair dentition.
Neck, no lymphadenopathy.
Chest, rhonchi, right greater than left, no crackles, no
wheezes. Normal I to E ratio, no egophony, no fremitus, no
dullness to percussion.
Cardiac, regular rate and rhythm, no murmurs, rubs or
gallops.
Abdomen, obese, normoactive bowel sounds, nontender,
nondistended, no masses.
Neurological, cranial nerves II through XII grossly intact.
Alert and oriented times three. Conversant appropriately.
Strength 5/5 in all extremities.
LABORATORY DATA: Laboratory findings on admission revealed
white blood cell count 8.4, 73% neutrophils, 0 bands, 19
lymphocytes, 6 monocytes, hematocrit 43.8, platelets 104, MCV
83, RDW 13.0, sodium 137, potassium 3.4, chloride 92,
bicarbonate 29, BUN 13, creatinine 0.8, glucose 129.
Arterial blood gases on 100% nonrebreather, PH 7.49, carbon
dioxide 39, oxygen 77.
Imaging: [**2199-11-27**], chest x-ray, normal, no acute
cardiopulmonary process. Chest x-ray [**2199-12-3**], (on
admission), patchy right upper lobe, right middle lobe
infiltrate and diffuse right greater than left interstitial
pattern, normal mediastinum, no effusion.
HOSPITAL COURSE: A 33 year old male with no past medical
history originally admitted to the Intensive Care Unit with
hypoxia, bilateral pneumonia, received Ceftriaxone and
Azithromycin, and then Doxycycline was added since he had a
parakeet at home (he also has rats at home). He underwent a
bronchoscopy and had a computed tomographic angiography of
the thorax which demonstrated right middle lobe and right
lower lobe pulmonary emboli with a question of infarction.
He was subsequently heparinized. His human immunodeficiency
virus test was negative. He received Bactrim and steroids
for a few days but were stopped when his human
immunodeficiency virus test came back negative. A
hypercoagulability workup was pending when he arrived on the
floor in stable condition. On arrival to the floor he was
clinically improving on the heparin drip, Ceftriaxone,
Azithromycin, and Doxycycline. The further studies that were
obtained while in the Intensive Care Unit included [**First Name8 (NamePattern2) **] [**Doctor First Name **]
which was negative, an ANCA which was negative, hepatitis
panel which was negative. LENIS demonstrated no deep vein
thrombosis, a thrombosis of the right lesser saphenous vein,
echocardiogram was obtained as well on [**12-6**], that
demonstrated an ejection fraction of 50%, a mildly dilated
right ventricle and mild tricuspid regurgitation. The chest
computerized tomography scan mentioned above was on [**12-4**] and that demonstrated multiple small pulmonary emboli
(right lower lobe and right middle lobe) and bilateral
atypical pneumonias. Workup for the organism of said
pneumonia was undertaken. He had negative viral culture,
negative Chlamydia, negative leptospirosis, negative C.
Psittaci and negative mycoplasmas. Blood cultures were
negative as well. He was maintained on Azithromycin and
completed a 14 day course for his pneumonia. The Doxycycline
was withdrawn. He completed a ten day course of Ceftriaxone.
Regarding the pulmonary emboli, he remained hemodynamically
stable on a heparin drip throughout his admission. A repeat
computerized tomography scan of the thorax demonstrated
bilateral expanded heterogenous soft tissue densities within
the rectus abdominis muscle ? hematomas, partial resolution
of bilateral perihilar ground-glass opacities, left SVC,
however, no pulmonary emboli. Given the discrepancy between
the [**12-4**] and [**12-11**], computerized tomography
scans, it would be very difficult to prove that there were no
pulmonary emboli on the [**12-4**] film. The decision to
anticoagulate him for three to six months and then to pursue
further evaluation was made. Regarding his anticoagulation
workup, the patient had a positive anticardiolipin IgM
(46.9). This is an intermediate range value. The IgG
anticardiolipin value was 1.6. The patient had a normal PTT
on admission. While we can not make the diagnosis of
anticardiolipin syndrome on a single value, the finding
stands as nonspecific, however, the anticardiolipin panel
will have to be repeated in six weeks. The patient was
subsequently continued on anticoagulation for pulmonary
emboli. His heparin drip was discontinued by discharge where
he was bridged to Coumadin with Lovenox. Regarding the
rectus hematomas noted on computerized axial tomography scan,
this finding is commonly seen in the setting of
anticoagulation. The patient concurrently had fevers
maximally to 101 degrees F. There was concern perhaps the
fevers may be attributable to the hematoma or a local
infection thereabouts. He was started on Clindamycin in
conjunction with the Infectious Disease Consult Service's
recommendations. He completed a ten day course of
Clindamycin.
Finally, the patient was noted to have a drop in his
hematocrit during his anticoagulation. He was guaiac
negative. There was no other source for bleed identified.
It is likely he bled into the abdominal hematoma attributing
for the drop in hematocrit. The patient was also
intermittently hyponatremic during his stay, likely secondary
to syndrome of inappropriate antidiuretic hormone secondary
to the thoracic processes (namely bilateral pneumonia,
pulmonary embolisms) on this admission.
DISCHARGE DIAGNOSIS:
1. Bilobar pneumonia with atypical fevers
2. Pulmonary embolus
3. Rectus hematoma
4. Anticardiolipin antibody IgM positive
5. Hyponatremia
6. Anemia
FOLLOW UP: The patient will follow up with his primary
provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] the week following discharge.
MEDICATIONS ON DISCHARGE: He will be discharged on Lovenox
bridge to Coumadin. He was also discharged on Clindamycin to
complete his ten day course.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 17844**]
MEDQUIST36
D: [**2200-5-7**] 17:14
T: [**2200-5-7**] 19:08
JOB#: [**Job Number **]
ICD9 Codes: 486, 2761, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 17
} | Medical Text: Admission Date: [**2140-11-11**] Discharge Date: [**2140-11-24**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a scheduled
admission by aortic aneurysm repair. This is an 81 year old
woman with a history of hypertension, who had recurrent
pericarditis and pleuritis requiring percutaneous drainage in
[**2137**]. An echocardiogram in [**2137-12-13**], showed normal left
ventricular function with a dilated aortic root of 48mm,
mildly thickened aortic valve with mild aortic regurgitation.
Follow-up in [**2140-9-12**], with echocardiogram showed an
ejection fraction of 60% with dilated aortic root at 55mm,
mild aortic sclerosis, mild aortic regurgitation, and
bilateral atrial enlargement. Cardiac catheterization done
on [**2140-10-26**], showed an ejection fraction of 80% with normal
wall motion, severe aneurysmal dilatation of the ascending
aorta into the arch, recurrent dilatation in the descending
aorta with no dissection, 1+ aortic regurgitation, normal
coronaries.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Raynaud's disease.
3. Phlebitis.
4. Osteoporosis.
5. Tonsillectomy.
6. Spinal fusion.
7. Umbilical hernia repair.
8. Appendectomy.
9. Cholecystectomy.
10. Total abdominal hysterectomy.
MEDICATIONS ON ADMISSION:
1. Metoprolol 100 mg twice a day.
2. Hydrochlorothiazide 25 mg once daily.
3. Lisinopril 10 mg once daily.
4. Enteric Coated Aspirin 81 mg once daily.
5. Centrum Silver one once daily.
6. Calcium 600 once daily.
7. Nexium 40 mg once daily.
ALLERGIES: Stated allergy to Codeine which caused bad
abdominal cramps and adhesive tape which causes a rash.
SOCIAL HISTORY: The patient lives at home with her husband.
[**Name (NI) 1139**] one half pack per day times eighteen years, quit
forty-five years ago. Alcohol one drink per day, none times
the past four weeks.
PHYSICAL EXAMINATION: At the time of preadmission testing,
the heart rate is 74 beats per minute, blood pressure 148/80,
respiratory rate 18, oxygen saturation 96% in room air,
height four feet eleven inches, weight 106 pounds. In
general, she appears younger than stated age in no acute
distress. Skin - no breaks or rashes. Head, eyes, ears,
nose and throat - The pupils are equal, round, and reactive
to light and accommodation. Extraocular movements are
intact. Pharynx is clear. The neck is supple with no jugular
venous distention, no bruits, carotid pulses are 2+
bilaterally. The chest is clear to auscultation bilaterally.
The heart is regular rate and rhythm, no murmurs, rubs or
gallops. The abdomen is soft, nontender, nondistended,
positive bowel sounds, no hepatosplenomegaly, well healed
surgical scars. Extremities without cyanosis, clubbing or
edema. Left upper extremity with nodularity at old
intravenous site near the left wrist. No varicosities in the
lower extremities. Neurologically, the patient is alert and
oriented times three, grossly intact. Pulses - femoral not
indicated. Dorsalis pedis 1+ bilaterally. Posterior tibial
not detected. Radial 2+ bilaterally. No carotid bruits
bilaterally.
HOSPITAL COURSE: As stated previously, the patient was a
direct admission to the operating room on [**2140-11-11**], at which
time she underwent a supracoronary ascending aortic graft
with a resuspension of the aortic valve. Please see the
operative report for full details. The patient tolerated
the operation well and was transferred from the operating
room to Cardiothoracic Intensive Care Unit. Circ arrest time
was eleven minutes. At the time of transfer, the patient had
Milrinone at 0.4 mcg/kg/minute, Amiodarone at 1 mg per
minute, Neo-Synephrine no dose indicated and Propofol, also
no dose indicated. The patient did well in the immediate
postoperative period. Her anesthesia was reversed. She was
weaned from the ventilator. In the morning of postoperative
day one, she was successfully extubated. On postoperative
day number one, her cardioactive medications were begun to be
weaning beginning with Amiodarone and Milrinone. By
postoperative day two, the patient was maintained with
minimal amounts of Amiodarone, Milrinone and Nipride. On
postoperative day two, the patient's Milrinone was
discontinued. Her Amiodarone was changed to p.o. Her
Nipride was discontinued with initiation of beta blockade.
Her chest tubes were removed. She was maintained in the
Cardiothoracic Intensive Care Unit for monitoring of her
hemodynamic and pulmonary status. On postoperative day
three, the patient continued to do well. She remained
hemodynamically stable. She was transferred from the
Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 121**] Two for continuing
postoperative care and cardiac rehabilitation. Once on the
floor, it was noted that the patient had gone into sustained
atrial fibrillation with a heart rate of 100 to 110,
hemodynamically tolerated well. She was seen by the
electrophysiology service and was maintained on her p.o.
Lopressor as well as her p.o. Amiodarone and continued to be
monitored on the floor. Over the next two days, the patient
was in and out of atrial fibrillation. She remained
hemodynamically stable throughout these periods. On
postoperative day five, it was noted that the patient had a
drop in her hematocrit with guaiac positive stools. She was
seen by the gastroenterology service. At that time, she was
also transferred back to the Cardiothoracic Intensive Care
Unit for close monitoring. The patient underwent a KUB which
was read as normal. She also had stools sent for Clostridium
difficile which were negative. She was empirically started
on Flagyl at that time. The patient remained in the
Intensive Care Unit for the next several days to monitor her
gastrointestinal status to make sure that she had no further
guaiac positive stools. On postoperative day seven, she was
again transferred to the floor for continuing postoperative
care. Prior to transfer from the Intensive Care Unit, it was
noted that the patient had some left upper extremity
swelling. She underwent ultrasonography of her upper
extremities at that time to rule out a thrombosis.
Ultrasound showed a right internal jugular and cephalic
thrombus. Following transfer, the vascular service was
consulted and they recommended oral anticoagulation with
Coumadin, which was begun at that time. Over the next
several days, with the exception of intermittent atrial
fibrillation, the patient had an uneventful hospital course.
She was again seen by the electrophysiology service given her
episodes of atrial fibrillation, the last episode lasting
greater than 24 hours. The patient was additionally begun on
Heparin given the duration of this episode of atrial
fibrillation. The patient was scheduled for a direct current
cardioversion, however, prior to cardioversion, the patient
spontaneously converted to normal sinus rhythm. On
postoperative day twelve, it was decided that if the patient
remained in a rate controlled rhythm for the next 24 hours,
she would be stable and ready to be transferred to
rehabilitation.
At the time of this dictation, the patient's physical
examination is as follows; vital signs revealed temperature
98.2, heart rate 71, sinus rhythm, blood pressure 147/68,
respiratory rate 20, oxygen saturation 98% in room air.
Weight preoperatively was 50 kilograms and at transfer to
rehabilitation is 53 kilograms. Laboratory data on [**2140-11-23**],
white blood cell count 11.7, hematocrit 34.5, platelet count
219,000. Prothrombin time 15.0, partial thromboplastin time
25.0 with Heparin off. INR is 1.5. Sodium is 129, potassium
4.8, chloride 95, CO2 29, blood urea nitrogen 16, creatinine
0.8, glucose 183. The patient is alert and oriented times
three, moves all extremities, follows commands. Respiratory
revealed scattered rhonchi. Cardiac is regular rate and
rhythm with no murmur. The sternum is stable and incision
with Steri-strips open to air, clean and dry. The abdomen is
soft, nontender, nondistended with positive bowel sounds.
Extremities are warm and well perfused with no edema. Right
upper arm with minimal edema which has been resolving over
the last several days.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Amiodarone 200 mg p.o. three times a day times one week
and then 200 mg p.o. once daily times one month.
3. Metoprolol 100 mg twice a day.
4. Lasix 20 mg once daily times ten days.
5. Potassium Chloride 20 meq once daily times ten days.
6. Prilosec 40 mg p.o. once daily.
7. Heparin 600 units per hour to keep partial thromboplastin
time 40 to 60 until INR is therapeutic.
8. Warfarin to maintain an INR between 2.0 and 2.5. The
patient received 2 mg of Coumadin two days prior to discharge
and no Coumadin on one day prior to discharge and 2 mg of
Coumadin on the night before discharge. We will check the
INR in the morning and dose Coumadin on the day of transfer
to rehabilitation center.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Status post supracoronary ascending aortic graft with a
resuspension of the aortic valve.
2. Hypertension.
3. Raynaud's disease.
4. Phlebitis.
5. Osteoporosis.
6. Status post tonsillectomy.
7. Status post spinal fusion.
8. Status post umbilical hernia repair.
9. Status post inguinal hernia repair.
10. Status post appendectomy.
11. Status post cholecystectomy.
12. Status post total abdominal hysterectomy.
DISCHARGE STATUS: The patient is to be discharged to [**Location 50742**].
FO[**Last Name (STitle) **]P: She is to have follow-up with Dr. [**First Name (STitle) **] in two to
three weeks and follow-up with Dr. [**Last Name (STitle) 1159**] in one month and
follow-up with Dr. [**Last Name (Prefixes) **] in one month.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2140-11-23**] 16:44
T: [**2140-11-23**] 18:31
JOB#: [**Job Number 50743**]
ICD9 Codes: 4241, 4019 |
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