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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 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 18
} | Medical Text: Admission Date: [**2164-4-23**] Discharge Date: [**2164-4-27**]
Date of Birth: [**2096-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2164-4-23**] Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending artery and reverse
saphenous vein graft to the posterior descending artery and the
obtuse marginal artery.
History of Present Illness:
68 year old male has a history of an MI about 25 years ago. He
has been treated with medication since then. He has been doing
well over the years until about 3 weeks ago when he started to
notice some diaphoresis, shortness of breath and right sided
chest discomfort that has occurred with exertion such as yard
work or taking out the trash. His symptoms resolve with rest. He
also had one episode of chest pain, diaphoresis and back pain
that occurred at rest after a large meal. This episode lasted a
little longer than the other episodes and prompted the patient
to contact Dr. [**Last Name (STitle) 1270**]. He was sent for a stress echo which
was abnormal and referred for a cardiac catheterization. He is
was found to have three vessel disease and is now being referred
to cardiac surgery for revascularization.
Past Medical History:
diabetes type II -diagnosed [**2160**]; controlled on oral agents
hyperlipidemia
hypertension
MI [**2138**]
psoriasis
Social History:
Race:Caucasian
Last Dental Exam:[**1-/2164**]
Lives with:Wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 90854**]
Occupation:Retired from the FDA as a field investigator and
consultant
Cigarettes: Smoked no [] yes [x] Hx:smoked 2ppd for 28 years and
quit [**2138**]
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**12-27**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- unknown-adopted
Physical Exam:
Pulse:61 Resp:16 O2 sat:100/RA
B/P Right:138/86 Left:135/74
Height:6'2" Weight:230 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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] _____
Varicosities: (L)LE superficial varicosities
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit -none appreciated, pulses Right:2+ Left:2+
Pertinent Results:
[**2164-4-23**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
top normal/borderline dilated. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
to distal inferoseptal and anteroseptal walls. Overall left
ventricular systolic function is mildly depressed (LVEF= 50-55
%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results at time of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
no inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. The aorta is intact
post-decannulation.
[**2164-4-27**] 04:44AM BLOOD WBC-11.7* RBC-3.00* Hgb-9.8* Hct-28.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-14.0 Plt Ct-323
[**2164-4-27**] 04:44AM BLOOD Plt Ct-323
[**2164-4-27**] 04:44AM BLOOD Glucose-121* UreaN-22* Creat-1.0 Na-139
K-3.8 Cl-102 HCO3-28 AnGap-13
[**2164-4-27**] 04:44AM BLOOD Mg-2.3
COMPARISON: [**2164-4-25**] at 10:45 a.m.
FINDINGS: As noted previously, there is a similar-sized left
apical
pneumothorax. The left chest tube has been removed in the
interim. Left
basilar atelectasis remains. The cardiac silhouette and
mediastinal contours
are unchanged. Median sternotomy wires are unchanged.
IMPRESSION:
Unchanged small left apical pneumothorax, status post left chest
tube removal.
Brief Hospital Course:
Mr. [**Known lastname **] 68 yr old male with history of MI developed
worsening chest pain, underwent cath which revealed significnat
CAD. He was seen by the cardiac surgery service and accepted for
CABG. He was a same day admit and on [**4-23**] was brought directly to
the operating room where he underwent a coronary artery bypass
graft x 3. Please see operative note for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Later this day he was weaned
from sedation, awoke neurologically intact and extubated. He was
weaned from Neo overnight and was started on beta-blocker POD#1.
He was diuresed towards his preoperative weight. POD#1 he
transferred to the step down unit for further monitoring. He
continued to progress well on the floor. Physical Therapy was
consulted for evaluation of his strength and mobility. The
remainder of his postop course was essentially uneventful. He
was cleared for discharge to home with VNA services on POD#4.
Follow-up appts arranged.
Medications on Admission:
ATENOLOL 50 mg Daily
LIPITOR 20 mg Daily
PLAVIX 75 mg Daily (started on [**2164-4-14**]), LD [**4-17**]
DILTIAZEM HCL 240 mg Daily
ENALAPRIL MALEATE takes 10mg qam, 5mg qhs
HYDROCHLOROTHIAZIDE 25 mg Daily
METFORMIN 1,000 mg [**Hospital1 **]
NITROGLYCERIN 0.4 mg Tablet PRN
Aspirin 325mg Daily
Centrum Silver Multivitamin 1 tablet daily
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 2 weeks.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 * Refills:*2*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
diabetes type II -diagnosed [**2160**]; controlled on oral agents
hyperlipidemia
hypertension
MI [**2138**]
psoriasis
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
Wound Check: [**2164-5-8**] 10:00
Surgeon: Dr. [**Last Name (STitle) **] on [**2164-5-31**] @ 1pm
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**] [**Telephone/Fax (1) 1144**]
Date/Time:[**2164-5-15**] 10:30
**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:[**2164-4-27**]
ICD9 Codes: 2724, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 19
} | Medical Text: Admission Date: [**2115-2-22**] Discharge Date: [**2115-3-19**]
Date of Birth: [**2078-8-9**] Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Post-cardiac arrest, asthma exacerbation
Major Surgical or Invasive Procedure:
Intubation
Removal of chest tubes placed at an outside hospital
R CVL placement
History of Present Illness:
Mr. [**Known lastname 3234**] is a 36 year old gentleman with a PMH signifciant
with dilated cardiomyopathy s/p AICD, asthma, and HTN admitted
to an OSH with dyspnea now admitted to the MICU after PEA arrest
x2. The patient initially presented to LGH ED with hypoxemic
respiratory distress. While at the OSH, he received CTX,
azithromycin, SC epinephrine, and solumedrol. While at the OSH,
he became confused and subsequently had an episode of PEA arrest
and was intubated. He received epinephrine, atropine, magnesium,
and bicarb. In addition, he had bilateral needle thoracostomies
with report of air return on the left, and he subsequently had
bilateral chest tubes placed. After approximately 15-20 minutes
of rescucitation, he had ROSC. He received vecuronium and was
started on an epi gtt for asthma and a cooling protocol, and was
then transferred to [**Hospital1 18**] for further evaluation. Of note, the
patient was admitted to LGH in [**1-4**] for dyspnea, and was
subsequently diagnosed with a CAP and asthma treated with CTX
and azithromycin. Per his family, he has also had multiple
admissions this winter for asthma exacerbations.
.
In the [**Hospital1 18**] ED, 35.3 102 133/58 100%AC 500x20, 5, 1.0 with an
ABG 7.16/66/162. He had a CTH which was unremarkable. He then
had a CTA chest, afterwhich he went into PEA arrest.
Rescucitation last approximately 10-15 minutes with multiple
rounds of epi and bicarb, with ROSC. He was then admitted to the
MICU for further management.
.
Currently, the patient is intubated, sedated, and parlyzed.
Past Medical History:
Asthma
Dilated cardiomyopathy
Multiple admissions for dyspnea this winter ([**1-26**]).
Anxiety/depression
CKD
HLD
Obesity
HTN
Social History:
Unknown
Family History:
Unknown
Physical Exam:
ADMISSION:
VS: 35.9 124 129/67 99% AC 480x24, 5, 1.0
Gen: ETT in place, intubated, sedated.
HEENT: ETT in place.
CV: Tachy S1+S2
Pulm: Poor air movement bilaterally. Diffuse wheezes
bilaterally.
Abd: S/D hypoactive BS
Ext: 1+ edema bilaterally
Neuro: Unresponsive.
.
Discharge: 98.5 102/65 76 20 95-98% RA
In cage bed to prevent patient from falling out of bed.
Occasionally calling out. Lungs clear without wheezes.
Pertinent Results:
Labs on Admission:
[**2115-2-22**] 08:50AM BLOOD WBC-19.5* RBC-4.76 Hgb-14.9 Hct-44.3
MCV-93 MCH-31.4 MCHC-33.7 RDW-12.9 Plt Ct-201
[**2115-2-22**] 08:50AM BLOOD PT-14.1* PTT-25.9 INR(PT)-1.2*
[**2115-2-22**] 08:50AM BLOOD Glucose-306* UreaN-21* Creat-1.2 Na-144
K-4.1 Cl-111* HCO3-28 AnGap-9
[**2115-2-22**] 08:50AM BLOOD Albumin-3.4* Calcium-6.2* Phos-5.5*
Mg-2.2
[**2115-2-22**] 09:32AM BLOOD calTIBC-320 Ferritn-1129* TRF-246
[**2115-2-22**] 07:17AM BLOOD Type-ART pO2-162* pCO2-66* pH-7.16*
calTCO2-25 Base XS--6 Intubat-INTUBATED
.
Labs on Discharge
[**2115-3-18**] 11:34AM BLOOD Type-ART pO2-95 pCO2-33* pH-7.54*
calTCO2-29 Base XS-5 Intubat-NOT INTUBA
[**2115-3-5**] 05:35AM BLOOD ALT-49* AST-23 AlkPhos-53 TotBili-0.9
[**2115-3-19**] 04:45AM BLOOD Glucose-73 UreaN-25* Creat-1.4* Na-133
K-4.1 Cl-95* HCO3-21* AnGap-21*
[**2115-3-19**] 04:45AM BLOOD WBC-12.4* RBC-4.47* Hgb-14.3 Hct-41.3
MCV-93 MCH-32.0 MCHC-34.6 RDW-13.3 Plt Ct-352
[**2115-3-19**] 04:45AM BLOOD Neuts-56 Bands-0 Lymphs-38 Monos-3 Eos-3
Baso-0 Atyps-0 Metas-0 Myelos-0
.
CXR (in MICU): Mr read - cardiomegaly, RIJ in SVC, ETT 4.5 cm
above carina. Blunting of costophrenic angles bilaterally with
low lung volumes. Loss of retrocardiac diagphragm and bilateral
opacities (L>R)
.
CXR:
1. NG tube at 7.2 cm above the carina. [**Month (only) 116**] consider advancing
for optimal placement.
2. Severe cardiomegaly with globular shape. In the absence of
prior
comparison, the differential is broad, including moderate
pericardial
effusion, mediastinal hemorrhage, or acute cardiac failure.
Recommend
clinical correlation.
.
CTH: My read, no acute bleed
.
CTA Chest:
1. No evidence of pulmonary embolism, although evaluation of
subsegmental branches is limited.
2. Moderate cardiomegaly without pericardial effusion.
3. Bilateral dependent atelectasis.
4. Multiple nondisplaced rib fractures on the right, some of
which are subacute. Also possible subtle nondisplaced fractures
of the left ribs.
5. Nondisplaced acute sternal fracture in addition to a subacute
nondisplaced sternal fracture.
.
TTE: The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated. LV
systolic function appears depressed (ejection fraction ? 30
percent) with regional variation. There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
.
ECG (post-arrest): Sinus with 1:1 conduction. LAA. LAD, RBBB,
LAFB. STD in V4-V6.
.
ECG (pre-arrest): Sinus with 1:1 conduction. LAD, bifascicular
block. No lateral STD.
.
ECG (OSH, unclear pre/post arrest): Sinus with 1:1 conduction.
Bifascicular (RBBB, LAFB) block. STD in V5-6.
.
EEG [**2-27**]
IMPRESSION: This is an abnormal video EEG telemetry due to the
slow and
disorganized background of 6.5 Hz with bursts of generalized
slowing
that showed no clear reactivity. These findings indicate a
severe
encephalopathy. This may be consistent with the patient's
history of
anoxia; however, toxic/metabolic disturbances, infection, and
medication
effects are also among the most frequent causes of
encephalopathy. No
clear epileptiform discharges or seizures were seen.
LUMBAR SPINE [**2115-3-11**]
CLINICAL INFORMATION: Evidence of fracture, seizure, fall, low
back pain.
FINDINGS:
Three views of the lumbar spine demonstrate mild narrowing of
the left
femoroacetabular joint. There is mild scoliosis of the
thoracolumbar spine. The ventricular lead of a pacemaker is
identified. No fracture of L2 through L5 is identified. However,
there is a compression fracture of L1, with compression of the
superior endplate, and a sclerotic fracture line. Given the
mechanism of fall, if there is acute pain referable to L1, then
this would be considered an acute finding. There is no apparent
retropulsion of the posterior margin of L1 into the spinal
canal. No other fractures are identified at this time. Facet
joints are aligned. There is early calcification of the aorta.
IMPRESSION: Compression fracture of L1 with anterior wedge
deformity, likely an acute finding. No other fractures
identified.
EKG: Normal sinus rhythm. Complete right bundle-branch block
with left anterior fascicular block. Diffuse ST-T wave changes
laterally.
CT Head:
COMPARISON: [**2115-2-22**].
TECHNIQUE: Non-contrast axial images were obtained through the
brain.
FINDINGS: There is no intracranial hemorrhage, edema, or loss of
[**Doctor Last Name 352**]/white matter differentiation. Ventricles and sulci are
normal in size and configuration. The basilar cisterns are not
compressed. Paranasal sinuses demonstrate fluid in the sphenoid
air cells and right posterior ethmoid air cell, likely related
to prolonged hospitalization. Mastoid air cells are well
aerated.
IMPRESSION: No evidence of acute intracranial abnormalities.
Brief Hospital Course:
Mr. [**Known lastname 3234**] is a 36 year old gentleman with a PMH signifciant
with dilated cardiomyopathy s/p AICD, PE not on anticoagulation,
asthma, and HTN admitted to an OSH with dyspnea now the
transferred to [**Hospital1 18**] MICU after PEA arrest x2.
# PEA arrest and subsequent anoxic brain injury.: Suspect that
original OSH PEA arrest due to hypoxemia or acidosis, with [**Hospital1 18**]
ED PEA arrest due to acidosis with admission pH 7.16 on arrival.
TTE with evidence of RV failure to suggest PE. LVEF 30% with
known dilated cardiomyopathy. He was cooled per protocol.
Initially, his EEG was concerning without evident brain
activity. On hospital day 3, there was only comatose activity
and his prognosis was guarded. However, the patient was able to
be weaned off the vent and over the course of the next three
days his mental status improved. He was alert, oriented to
place and day of the week and moving all 4 extremities. He
became more interactive on transfer to the floor, was initially
speaking in spanish and English and not always making sense but
then started responding more appropiately and following
commands. On hospital day 11 he had a witnessed grand mal
seizure and was given ativan and started on Keppra with
neurology consult. His mental status was worse for 24 hours
after the seizure but then he slowly returned to his recent
baseline. He was somewhat aggitated so his Keppra was switched
to Topiramate. He had a subsequent seizure on [**3-18**] with LUE
tonic clonic activity and impaired consciousness but this
resolved spontaneously after 1-2 minutes. He was contineud on
topamax per neuro recommendations. OT and PT were consulted and
worked with the patient as he will likely require a long
rehabilitation course. At the time of discharge the patient was
alert, oriented (though not always to date), following commands
but impulsive with poor motor planning leading to several falls.
Neurology notes indicate the patient has the potential
toimprove from a neurologic standpoint. He also may have
recurrent seizures which should be treated with ativan IV or IM
and do not neccessarily indicate patient needs to return to
hospital unless they continue for greater than 5 minutes or he
has multiple recurrent seizures or complications such as
aspiration.
-patient will be on Topiramate 25mg PO BID until [**3-22**] PM then
increase to 50mg po BID for seven days then increase to 75mg [**Hospital1 **]
ongoing.
-patient will follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) **] in his s/p
arrest neurology clinic
-patient will require intensive PT and OT in an anoxic brain
injury unit.
.
# Respiratory failure: Believed to be due to status asthmaticus,
although inciting event unclear. [**Name2 (NI) 227**] multiple cardiac arrests,
also a concern for development of ARDS. The patient was
initially treated broadly with vancomycin, cefepime, flagyl,
cipro, and oseltamavir. He was treated with IV soludemedrol and
albuterol MDI. He was ventialted according to ARDS-Net protocol.
On admission, he had two chest tubes placed for pneumothoraces.
They were removed on hospital day 1. In his first several days,
his respiratory status was comprimised by lobar collapse, first
of the RUL and then of the RML. His extubation was initially
limited both by agitation requiring sedation and by requirements
for high PEEP to maintain oxygenation. His oxygenation was
improved with diuresis and agitation was better controlled with
seroquel. He was extubated on [**3-1**] and respiratory status was
stable. His Asthma was treated with standing and PRN albuterol
and ipratriopium and a slow prednisone taper which he l
completed on [**2115-3-18**] and he was restarted on Advair
-patient may require additional nebs on top of his standing
advair though his respiratory status has been very stable,
without wheezing for the last week.
- would like benefit from outpatient PFTs and is scheduled to
see a pulmonologist in follow up.
.
# Ventilator associated pneumonia: Patient developed a fever on
[**2-27**] with new infiltrates on chest xray while intubated. He was
initially covered with vanc/cefepime and cipro. Cipro was
eventually discontinued. He did not grow any organisms other
than yeast in his sputum. He completed an 8 day course of
Vanco/Cefepime.
.
# Myoclonus: when mental status improved, was noted to have
myoclonic jerks. per neurology, likely [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Syndrome
which is anoxic injury to the purkinje cells. These jerks
continued for about one week and then became rare.
.
# dilated [**Last Name (LF) 89982**], [**First Name3 (LF) **] 30%. s/p ICD. Patient was
diuresed with IV lasix in the ED and then transitioned to PO
lasix, home dose, on the floor. His respiratory status remained
stable. Also continued on home dose of carvedilol and Lisinopril
but ACE downtitrated from 40 to 20 when had elevated Cr 1.9 on
[**3-18**] and slightly low BPs high 90s/60s. BP improved to 100s/60s.
.
#Hypertension: Patient's home regimen was continued on the
floor, but his SBP dipped into the high 80s and low 90s so
lisinopril was decreased to 20mg po daily and his SBP remained
100-130.
.
# L1 compression fracture: After the patient fell, he was
complaining of low back pain so a L-spine Xray was performed and
showed L1 compressin fracture with No cord impingement on
imaging. The patient had no localizing deficits on serial neuro
exam. He was treated with pain medication including low dose
ultram, standing tylenol and a lidocaine patch. Calcitonin was
tried for pain with compression fracture but this did not seem
to help with symptoms so was discontinued.
.
# Leukocytosis: WBC >20 persistently in the MICU even after
being treated for infection. Since no new infection was found
this was presumed [**12-26**] steroids and the leukocytosis improved
with prednisone taper. WBC 12 on day of discharge
.
# Hyperglycemia: Patient is not known to be a diabetic and was
felt [**12-26**] steroids, his sugars were controlled on sliding scale
insulin in the hospital but he no longer had insulin
requirements as his prednisone was tapered.
.
#. [**Last Name (un) **]: Cr 1.9 on [**3-18**] from 1.2 which improved to 1.4 on [**3-19**]
with decreasing ACE and 500cc bolus. He should have repeat
creatinine and labs on [**3-22**] to ensure stability.
# Guardianship: Guardianship paperwork was started in the
hospital.
Medications on Admission:
Carvedilol 25 [**Hospital1 **]
Lasix 80 mg po bid
Xanax 0.25 mg 1-2 tabs prn
albuterol MDI
Ibuprofen prn
Benadryl prn
Advair diskus
Lsinopril 40 daily
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**11-25**] Tablet, Rapid
Dissolves PO QHS (once a day (at bedtime)) as needed for sleep.
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain/fever.
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on and 12 hours off every 24 hour period.
13. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
16. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 3 days: 1 [**Hospital1 **] until [**3-22**] PM then increase to 2
tablets [**Hospital1 **] for 7 days then 3 tablets [**Hospital1 **] ongoing.
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
18. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
19. lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection twice a day
as needed for seizure that last longer than 5 minutes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Anoxic Brain Injury s/p PEA arrest x2
Status Asthmaticus
Ventilator Associated Pneumonia
Chronic Systolic Heart Failure
L1 compression fracture
Seizures after hypoxic brain injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) because he has poor motor planning
Discharge Instructions:
You came to the hospital after having a cardiac arrest and an
asthma exacerbation. You had another cardiac arrest in our
hospital and were admitted to the MICU. You required intubation
but were able to wean off the machine and breathe on your own.
We treated you for pneumonia and asthma. Your mental status
slowly improved, though you did have 2 seizures, last on [**3-18**].
You were started ons eizure medications for this.
.
Please take your medications as prescribed and follow up with
your doctors [**Name5 (PTitle) 7928**].
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2115-4-3**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2115-4-3**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2115-4-11**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 4275, 4254, 5849, 2762, 2760, 5180, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 20
} | Medical Text: Admission Date: [**2187-7-13**] Discharge Date: [**2187-7-23**]
Date of Birth: [**2104-8-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillin V / Methyldopa
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
general malaise
Major Surgical or Invasive Procedure:
dental extractions [**2187-7-15**]
redo sternotomy/AVR (#19 CE Magna)-[**2187-7-17**]
History of Present Illness:
82 yo F s/p CABG [**2177**] now with severe AS and recent NSTEMI,
preop for [**Hospital 1291**] transferred from [**Hospital3 **] with SOB,
recurrent pulmonary edema.
Past Medical History:
Right carotid endarterectomy
CABG at [**Hospital6 **] in [**2181**] (LIMA to LAD, SVG to RCA,
SVG to first diagonal, SVG to OM2)
NSTEMI in [**2187-5-1**]
Renal insufficiency (baseline creatinine 1.5)
Hypertension
Severe Aortic stenosis
Dementia
Peripheral Vascular Disease
Anemia (baseline hematocrit 32-34)
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
Her mother died of a heart attack at age 61. Her dad died of a
CVA at age 47. Her sister has diabetes. She has a son who
passed away. She had six miscarriages.
Physical Exam:
HR 64 RR 20 BP 129/44
NAD
Lungs with scattered rales
Heart RRR 3/6 SEM radiating to neck
Extrem warm
62" 72 kg
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Resting bradycardia
for the patient. See Conclusions for post-bypass data The
post-bypass study was performed while the patient was receiving
vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is dilated. Mild spontaneous echo contrast is
seen in the body of the left atrium. A left atrial appendage
thrombus cannot be excluded. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area 0.5 cm2). No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. There is a small left pleural effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
OR.
POST-BYPASS:
For the post-bypass study, the patient was receiving vasoactive
infusions including phenylephrine and was AV paced.
1. A well-seated bioprosthetic valve is seen in the mitral
position with normal leaflet motion and gradients (mean gradient
= 11 mmHg and cardiac output of 2.6 L/min). Trivial central
aortic regurgitation is seen.
2. Regional and global left ventricular systolic function are
normal.
3. Right ventricular systolic function post-bypass is moderately
hypokinetic.
4. The intra-atrial septum is dynamic.
5. Aortic contours are intact post-decannulation.
[**Known lastname **],[**Known firstname 24357**] L [**Medical Record Number 41597**] F 82 [**2104-8-30**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-7-19**] 2:14
PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2187-7-19**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 41598**]
Reason: ? ptx s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
? ptx s/p ct removal
Final Report
STUDY: Single portable AP chest radiograph.
INDICATION: 82-year-old female status post CABG and chest tube
removal.
COMPARISON: [**2187-7-18**].
FINDINGS: Patient has been extubated with removal of right
basilar chest tube
and Swan-Ganz catheter/NG tube. Atelectasis at the left lower
lobe has
improved. Small left pleural effusion remains. The upper lungs
remain clear.
Bilateral subclavian artery calcifications are again noted.
Median sternotomy
wires remain in stable condition.
IMPRESSION:
1. Interval removal of multiple lines and tubes without
pneumothorax.
2. Improvement of left lower lobe atelectasis.
3. Residual small left pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**Doctor First Name **] [**2187-7-19**] 4:49 PM
Imaging Lab
Brief Hospital Course:
She was admitted to cardiac surgery. Dental consult was called
and tooth extractions were recommended. On [**7-15**] she had 5 teeth
extracted. On [**7-17**] she was taken to the operating room on [**7-17**]
where she underwent a redo sternotomy and AVR. She was
transferred to the ICU in stable condition. She as extubated on
POD #1. Chest tubes removed and she was transferred to the floor
on POD #2 to begin increasing her activity level. She was gently
diuresed toward her preop weight. Beta blockade was titrated.
Pacing wires removed on POD #3.She had several episodes of A fib
and coumadin was started. Target INR 2.0-2.5. She continued to
make good progress and was cleared for discharge to rehab on POD
#6. Pt. is to make all followup appts. as per discharge
instructions.
Medications on Admission:
ASA 325, lopressor 25", lipitor 10, lovenox 40, norvasc 5,
diovan 160,acidophilus [**Hospital1 **]
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
9. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) units SC
Subcutaneous once a day.
10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: 3 mg today only [**7-23**]; all further dosing per rehab
provider;target INR 2.0-2.5.
11. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO BID
(2 times a day): hold for K >4.8.[**Month (only) 116**] DC when lasix is stopped.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
AS s/p AVR
R CEA, CABG at [**Hospital6 **] in [**2181**] (LIMA to LAD, SVG
to RCA, SVG to first diagonal, SVG to OM2), NSTEMI in [**Month (only) 547**]
[**2187**], Renal insufficiency (baseline creatinine 1.5),
Hypertension, Severe AS, dementia, PVD, Anemia (baseline
hematocrit 32-34) ;postop A Fib
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds.
No driving until follow up with surgeon or at least one month.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2187-7-23**]
ICD9 Codes: 4241, 9971, 2762, 4280, 5859, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 21
} | Medical Text: Admission Date: [**2183-3-23**] Discharge Date: [**2183-5-9**]
Date of Birth: [**2124-10-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Bone marrow biopsy
History of Present Illness:
58 y/o M presented to [**Hospital1 **] [**Location (un) 620**] after a syncopal episode today
where he sustained a facial hematoma. Pt remembers going to the
bathroom in the early morning and then awoke on the floor approx
2hrs laterwith left sided facial bruising and incontinence. Pt
reports severe
nosebleeds that began 2 days prior to admission. On saturday,
he was feeling lightheaded and developped severe right thigh
pain. On Sunday, he noticed decreased appetite, left thigh pain
and fevers/chills. On further review of symptoms, pt has been
noticing increased bruising and general lethargy for the last
week. Per report, his wife has been trying to get him to see [**Name8 (MD) **]
MD for months as she has been concerned about his generalized
weakness.
.
Pt initially presented to [**Hospital1 **] [**Location (un) **] and was febrile to 101.2
and received Vanc and Ceftazidime for neutropenic fever. He
underwent head CT that revealed small foci of petechial
hemorrhage within the left frontal lobe and small subarachnoid
hemorrhage.
Initial VS on arrival to the [**Hospital1 18**] ED: T 100.4 P 76 BP 110/55 R
18 O2 sat 99% RA. Pt was given Acyclovir for possible Zoster.
He underwent CTA that was negative for PE and received 2L of NS
IVF. Pt was being transfused with a second bag of plts prior to
arrival to ICU.
.
On arrival, pt was complaining of right & left proximal thigh
pain approx [**8-22**]. Otherwise, denying CP, SOB, HA, abd pain,
nausea, visual changes. He was feeling exhausted and still
mildly lightheaded.
Past Medical History:
Osteoarthritis (knees)
Social History:
Pt works as a headmaster in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1573**] school. He lives with his
wife and has two healthy children, three grandchildren. He used
to be a marathon runner. Denies smoking and illicit drug use.
He reports consuming approx 1 drink per day.
Family History:
Father died of metastatic prostate cancer in his 80s, mother
alive with HTN and insulin resistance.
Physical Exam:
Vitals: T: 98.6 BP: 137/73 P: 83 R: 20 O2: 975 on RA
General: alert, oriented, large ecchymosis over left orbit, eye
swollen shut
HEENT: sclera anicteric, dry MM, oropharynx with dried blood
Neck: supple, JVP not elevated, precervical lymphadenopathy
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1/S2, no m/r/g
Abdomen: soft, NT, ND, NABS, no rebound tenderness or guarding,
no appreciable hepatosplenomegaly
Inguinal: no inguinal lymphadenopathy
Ext: Warm, well perfused, 2+ pulses
Neuro: CN 2-12 intact (except unable to assess left eye due to
swelling & eccyhmoses). Strength 5/5 all four extremities
distally. Unable to assess proximal muscle strength in lower
extremities [**3-17**] pain. Sensation intact distally. Gait not
assessed. No saddle anesthesia, no focal spinal tenderness.
Pertinent Results:
[**2183-3-23**] 08:46PM GLUCOSE-116* UREA N-14 CREAT-0.8 SODIUM-138
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13
[**2183-3-23**] 08:46PM ALT(SGPT)-21 AST(SGOT)-20 LD(LDH)-286*
CK(CPK)-126 ALK PHOS-65 TOT BILI-0.8
[**2183-3-23**] 08:46PM ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-3.1
MAGNESIUM-2.0 URIC ACID-5.1
[**2183-3-23**] 08:46PM WBC-0.7* RBC-2.21* HGB-7.6* HCT-20.3* MCV-92
MCH-34.5* MCHC-37.5* RDW-17.5*
[**2183-3-23**] 08:46PM I-HOS-AVAILABLE
[**2183-3-23**] 08:46PM PLT COUNT-43*
[**2183-3-23**] 08:46PM PT-17.0* PTT-29.8 INR(PT)-1.5*
[**2183-3-23**] 08:46PM FDP-160-320*
[**2183-3-23**] 08:46PM FIBRINOGE-303
[**2183-3-23**] 08:46PM GRAN CT-230*
[**2183-3-23**] 06:55PM PLT COUNT-53*#
[**2183-3-23**] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050
[**2183-3-23**] 03:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2183-3-23**] 03:40PM URINE RBC-[**4-17**]* WBC-[**4-17**] BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2183-3-23**] 03:40PM URINE MUCOUS-OCC
[**2183-3-23**] 03:16PM LACTATE-2.0
[**2183-3-23**] 03:10PM GLUCOSE-123* UREA N-16 CREAT-0.9 SODIUM-137
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2183-3-23**] 03:10PM estGFR-Using this
[**2183-3-23**] 03:10PM CK(CPK)-147
[**2183-3-23**] 03:10PM CK-MB-1 cTropnT-<0.01
[**2183-3-23**] 03:10PM WBC-0.7* RBC-2.63* HGB-8.9* HCT-24.2* MCV-92
MCH-34.0* MCHC-37.0* RDW-17.8*
[**2183-3-23**] 03:10PM NEUTS-8* BANDS-4 LYMPHS-76* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-2* NUC RBCS-2* OTHER-6*
[**2183-3-23**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2183-3-23**] 03:10PM PLT SMR-VERY LOW PLT COUNT-29*
[**2183-3-23**] 03:10PM PT-15.9* PTT-28.2 INR(PT)-1.4*
[**2183-3-23**] 03:10PM GRAN CT-290*
[**2183-3-24**] CT HEAD
IMPRESSION:
1. Increased size of left frontal and right posterior cingulate
gyrus
intraparenchymal hemorrhages.
2. Increased size of right frontal, right temporal, and
interhemispheric
subarachnoid hemorrhage.
3. No midline shift. No evidence of acute infarction.
[**2183-3-24**] MRI L/T-SPINE
No evidence of acute spine injury within the cervical, thoracic
or lumbar
spine. Note is made of a fluid level within the lower lumbar
spine, most
consistent with layering subarachnoid blood.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 40120**],[**Known firstname **] [**2124-10-29**] 58 Male [**Numeric Identifier 40121**] [**Numeric Identifier 40122**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. MARIAPPAN
SPECIMEN SUBMITTED: Immunophenotyping, Bone Marrow
Procedure date Tissue received Report Date Diagnosed
by
[**2183-3-24**] [**2183-3-24**] [**2183-3-25**] DR. [**Last Name (STitle) **]. MARIAPPAN/ttl
Previous biopsies: [**Numeric Identifier 40123**] BONE MARROW BIOPSY (1 JAR).
INTERPRETATION
Immunophenotypic findings consistent with involvement by: an
immature population of cells consistent with acute myelogenous
leukemia. Lack of CD34 and HLA-DR [**Last Name (STitle) 40124**] to be consistent with
a diagnosis of acute promyelocytic leukemia. Correlation with
morphologic and cytogenetic findings is recommended.
Brief Hospital Course:
58 y/o M presenting after syncopal episode found to have
multiple small ICH and new pancytopenia. Had complicated course
of AMPL treatment
# Leukemia: Patient found to have AMPL via bone marrow biopsy
the day of admission to the MICU. He was started on ATRA and
monitored closely for symptoms of DIC, TLS and ATRA syndrome.
He was transfused as needed with PRBC, platlets and FFP. He did
not develop overt signs of DIC. He was induced with Ara-c and
daunurubicin. His counts responded appropriatly. A repeat BM
biopsy showed remission and he will continue the ATRA for now
and follow up with Dr. [**Last Name (STitle) 410**] for plans of stage two of his
treatment.
.
# Fevers: He initially was on Vancomycin and cefepime when first
starting treatment due to a hx of fevers at home, but as his
culture data was negative and he remained afebrile his
antibiotics were discontinued. He remained afebrile until [**4-14**]
when he spiked a fever. He was cultured and his blood grew
strep viridans. He was started on vanco/cefepime at that time.
He also had a headache the day he spiked and a CT was done
showing what appeared to be brain abscesses. His antibiotics
were eventually broadened to vanco, meropenem, fluconzaole and
flagyl for the brain abscesses. He continued to spike, though
for approximately a week. He complained of some thigh pain and
we did an ultrasound showing bilateral fluid collections. They
were drained in IR and grew MSSA. He then developed a pneumonia
during his febrile period and was transferred to the ICU for
several days. He required O2 for a while after being discharged
from the ICU. While in the ICU, his neutrophil count started to
drop, and it was worried that he might be having a drug effect.
His vanco was discontinued and his counts began to recover.
Eventually he was on meropenem, voriconazole and acyclovir and
stopped having fevers. A repeat CT scan showed resolution of
his PNA. Serial repeat head CTs showed slow decrease in size of
his abscesses. And an MRI of his thigh showed retained small
fluid collections bilaterally. The plan is to complete 6 week
course of the above antibiotics for his brain abscesses. We
will reimage his thighs with an MRI as an outpatient and
depending on those results, he will either need surgical
drainage or still prolonged course of abx. He will follow up
with ID.
.
# ICH: Pt with multiple small ICH sustained from fall with acute
left sided head injury in the setting of profound
thrombocytopenia. CT head revealed small foci of
intraparenchymal hemorrhage and subarachnoid hemorrhage. (no
hydrocephalus or shift). On [**3-24**] follow-up Head CT revealed
interval increase in hemorrhage but without appreciable midline
shift or infarction. The pt's neurologic exam remained stable.
Neurosurgery followed closely. Platlet goal was > 75K. A
repeat head CT one month after a fall showed the brain abscesses
that were discussed above. Neuro onc was consulted and followed
along. It was decided not to do a biopsy. He also required
heparin and then lovenox for DVTs, and repeat head CTs while on
these anticoaulants remained stable and without new bleeds.
.
# Thigh pain/weakness: Etiology unclear and unable to get good
exam as limited by pain. This may be bone marrow pain. No
evidence of hematoma or cellulitis. No bowel or bladder
dysfunction, no saddle anesthesia, no focal spinal tenderness to
indicate acute cord compression. MRI or the T/L-spine revealed
no evidence of acute cord compression. There was evidence of
layering fluid likely from the SAH. Although unlikely to be
causing the pt's leg pain (nerve irritation secondary to blood)
Neurosurgery recommended starting Decadron on [**2182-3-24**]. He was
not kept on decadron because chemotherapy was initiated.
Eventually he was found to have abscesses in his thighs, as
discussed above.
.
# Afib - pt went into afib while in the ICU. His blood
pressures remained stable and he was started on metoprolol. His
high rates were 130s-140s; he contined to have afib on and off
for about a week and then remained in NSR the week prior to
discharge. His metoprolol was titrated to 25 mg tid for good
rate control.
.
# [**Name (NI) 6059**] - pt had one episode of 16 b [**Name (NI) 6059**] v. afib with aberrancy.
Cards was consulted and we did agressive electrolyte repletion
and continued the metoprolol. He did not have any more
occurrences.
.
# Vasovagal bradycardia - the day prior to admission, while the
patient was having a bowel movement, he was noted on telemetry
to brady to the 30s, he felt light headed and it resolved in 5
minutes. Appeared to be vaso-vagal and he did not have any more
occurrences. Again, cards was consulted and they recommended
leaving the metoprolol dose the same at 25 mg tid, as bb
actually helps prevent vagal episodes.
.
# DVTs - while patient was in the ICU, he developed bilaterally
pedal edema, thought initially to be due to large amount of
IVFs. Because of his new afib, though, we did ultrasounds and
found him to have DVTs in R leg, R arm (because he was edematous
and had pain around a new PICC line). Heparin was started
overnight, but because of his hx of ICHs, it was decided to stop
the heparin and place an IVC filter. It was put in place
without complications. Evenutally he was found to have
bilaterally leg DVTs and then bilateral upper extremity DVTs.
At that point, it was decided that he should be anticoagulated.
Heparin was initially. Repeat head CT showed no bleed. And
then he was converted to lovenox for outpatient treatment of the
DVTs. He also had a VQ scan during these findings of DVT that
showed low prob of PE.
.
# Access - pt initially had a subclavian line, then it was
pulled while the patient was febrile in early [**Month (only) 958**]. He had
PIVs until transfer to the ICU when a PICC line was placed. The
PICC line was removed after a DVT was found in the arm. He
again had PIVs for a while until a IR guided subclavian line was
placed. For outpatient continuation of his 6 week course of
antibiotics, a hickman was placed as PICCs could not be placed
due to bilateraly UE DVTs.
.
# Pt was discharged walking around, passing PT and going up
stairs. He respiratory status was much improved and he was not
on O2 and had no SOB. He was advised not to start work yet and
take it easy, although, he was ready to get back to work as soon
as possible.
Medications on Admission:
None
Discharge Medications:
1. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
6x/day.
Disp:*180 flushes* Refills:*2*
2. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection
10x/day.
Disp:*300 flushes* Refills:*2*
3. Meropenem 1 gram Recon Soln Sig: One (1) recon soln
Intravenous every eight (8) hours for 22 days: This will make
end date on [**5-30**]; will be total of 6 week course.
Disp:*66 recon soln* Refills:*0*
4. Vesanoid 10 mg Capsule Sig: Five (5) Capsule PO twice a day
for 14 days: No substitutions please.
Disp:*140 Capsule(s)* Refills:*0*
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*180 Capsule(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours).
Disp:*90 Tablet(s)* Refills:*2*
8. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*60 syringe* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
APML
Intracranial hemorrhage
Syncope
Discharge Condition:
vital signs stable, walking around, on lovenox, normal
neurological exam, afebrile
Discharge Instructions:
You were admitted to the hospital because you fell. You were
found to have low blood counts and a bone marrow biospy showed
that you have leukemia. You also had some small areas of
bleeding in your head that were stable based on repeat CT scans.
You received chemotherapy for your leukemia.
.
While you were here, you developed an infection both in your
brain around the areas where the inital bleeds were found, as
well as in your thighs. We treated you with antibiotics which
you will need to continue after going home.
.
You also developed blood clots in your arms and legs. We place
a filter in your inferior vena cave (a large vein in your
abdomen) so the clots would not go to your lungs. We also
anticoagulated you with heparin. You can go home on lovenox to
stay anticoagulated.
.
Lastly, you developed a heart arrhythmia called atrial
fibrillation. For that, you should continue taking the medicine
metoprolol.
.
You will have a home nurse help you and your wife do antibiotics
and the lovenox shots. You should make sure to start returning
to work very slowly. It is probably best to not work or work
from home the first week and see how you are feeling before
starting to think about going back to the school. You can
discuss your progress with Dr. [**Last Name (STitle) 410**] at your follow up
appointments.
.
You should return to the hospital for any fainting, headaches,
dizziness, chest pain, shortness of breath, swelling in your
extremities, palpitiations or any other concerns.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 410**] on [**Hospital Ward Name 23**] 7 on Tuesday [**2183-5-13**]
at 1:30 pm. Phone number [**Telephone/Fax (1) 3241**].
Please follow up with infectious disease and Dr. [**Last Name (STitle) **] on
[**2183-5-19**] at 3:00 pm. Phone number ([**Telephone/Fax (1) 4170**].
You will need a repeat MRI prior to seeing Dr. [**Last Name (STitle) **]. We
will give you the date and time at your next appointment.
Completed by:[**2183-5-15**]
ICD9 Codes: 5849, 486, 2875, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 22
} | Medical Text: Admission Date: [**2127-7-11**] Discharge Date: [**2127-7-13**]
Date of Birth: [**2070-1-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
dizziness,nausea,vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 57 y/o Spanish speaking female with h/o HTN, DM 2,
hyperlipidemia, CAD s/p 4V CABG [**4-12**], and asthma who presented
to her PCP for regularly scheduled visit, complained of
dizziness, nausea, vomiting for one week, and with chest pain,
and was found to be hypotensive. She was sent to the ED by her
PCP. [**Name10 (NameIs) **] the ED she got atropine x 3 for bradycardia, lasix, and
glucagon for blood sugar in the 30s, and was started on dopamine
drip for hypotension, which was weaned off once in the CCU
without futher hypotension. Ruled out for MI. AST/ALT and
amylase/lipase were normal. RUQ US done last month in [**State 108**]
was reportedly normal.
.
She decribes that she had been vomiting for one week before
going to her doctor's visit. She was vomiting almost daily for
one week. She was dizzy for most of that week, getting worse
when going from sitting to standing. Described as the room
spinning and lightheadedness. She did not have any syncope or
falls. Her chest pain lasted only one minute and occured after
vomiting. She had a mild cough for a week, no sputum and mild
fevers.
.
.
Past Medical History:
HTN
Hyperlipidemia
DM 2
CAD s/p 4V CABG ([**4-12**]) LIMA to LAD, SVGs to anterior
obtuse marginal, posterior obtuse marginal, and to RCA.
Obesity
Asthma
s/p CCY
s/p C-section
s/p Left foot surgery
Social History:
Married. Formerly from [**Male First Name (un) 1056**], Spanish-speaking only. No
history of tobacco use, EtOH, or IVDU.
Family History:
Mother had CAD, CVA, DM2. Father died of complications from
renal failure. Extensive DM in family.
Physical Exam:
Vitals: T 98.6 BP 120/70 HR 69 RR 18 SAT 96% RA
General: NAD
HEENT: NC, AT, amicteric, no injections, PERRLA, EOMI, OP clear.
Neck: no JVP elevation. wound over right neck tender to
palpation, no purulent drainage, no erythema.
CV: Normal S1, S2 with no m/r/g.
Pulm: Minimal bibasilar crackles. No wheezes.
Abd: Soft, NT, ND, + BS.
Ext: No c/c/e. DP 2+ B/L. Evidence of venous stasis changes.
Healing left thigh wound packed with dressing and covered with
gauze. No drainage or erythema.
Pertinent Results:
Labs on discharge: BUN 35 Cr 1.3 CK 69 trop <0.01 WBC 10.1 HCT
31.8
.
EKG: NSR at 60, normal axis, no acute ST changes
.
Last CXR lungs clear
.
[**2127-7-11**] 03:07PM BLOOD WBC-9.7 RBC-3.03* Hgb-8.8* Hct-25.7*
MCV-85 MCH-29.0 MCHC-34.1 RDW-15.3 Plt Ct-445*
[**2127-7-13**] 06:45AM BLOOD WBC-10.1 RBC-3.77* Hgb-10.9* Hct-31.8*
MCV-84 MCH-28.8 MCHC-34.2 RDW-15.4 Plt Ct-385
[**2127-7-11**] 03:07PM BLOOD Neuts-56.2 Lymphs-36.5 Monos-4.4 Eos-2.6
Baso-0.2
[**2127-7-11**] 06:19PM BLOOD Neuts-78.2* Lymphs-17.2* Monos-3.2
Eos-1.3 Baso-0.2
[**2127-7-11**] 03:07PM BLOOD Plt Ct-445*
[**2127-7-13**] 06:45AM BLOOD Glucose-119* UreaN-35* Creat-1.3* Na-140
K-5.1 Cl-104 HCO3-24 AnGap-17
[**2127-7-11**] 08:25PM BLOOD ALT-18 AST-16 CK(CPK)-49 AlkPhos-89
Amylase-79 TotBili-0.1
[**2127-7-11**] 08:25PM BLOOD Lipase-61*
[**2127-7-11**] 03:07PM BLOOD cTropnT-<0.01
[**2127-7-11**] 08:25PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2127-7-12**] 06:22AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2127-7-11**] 08:25PM BLOOD calTIBC-324 Ferritn-265* TRF-249
[**2127-7-11**] 06:29PM BLOOD Lactate-0.8
[**2127-7-11**] 03:07PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2127-7-11**] 03:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
bcx [**7-11**]: no growth
ucx [**7-11**]: genital contamination
Brief Hospital Course:
A/P: 57 y/o Spanish speaking female with h/o HTN, DM2, CAD s/p
4VCABG, hyperlipidemia, and asthma who presented to the ED with
hypotension, now resolved, a brief episode of chest pain, ruled
out, and abdominal pain, likely Gas/GERD.
.
1. Hypotension: the patient had nausea and vomiting prior to
admission and was found to be hypotensive at her PCP's office.
She was actually given lasix initially and started on dopamine
gtt. It is unclear from the note if she got fluid. The
hypotension was probably due to dehydration from vomiting the
week prior to admission. Dopamine gtt was weaned off and the
patient had no further issues with hypotension. She was
discharged on lisinopril and atenolol. Lasix dose was decreased
to 20 mg QD and her KCl was d/c'd because we halved her lasix
and her K on discharge was 5.1.
.
2. Renal Failure: Patient came in with a creatinine of 1.6 and
her baseline is unknown. Could be chronic renal failure from DM
that is giving her chronic renal insufficiency and perhaps she
was also prerenal from the vomiting prior to admission.
Creatinine steadily improved and is now 1.3 on discharge.
.
3. Anemia: Crit on admission was 25. Likely ACD from DM. s/p
transfusion of 2 units in the CCU. HCT improving. Crit now 31.8.
.
4. DM2:bedtime sugar was 152, fasting this am 73 and at noon
118. We continued actos and avandia as well as a RISS and
patient was advised to take her home doses of lantus and regular
insulin at home.
.
5. HTN: Blood pressure was stable after dopamine gtt was
titrated off in the CCU. No issues of hypertension or
hypotension. Discharged patient on atenolol and lisinopril.
.
6. CAD: Patient denies chest pain. Lipid profile showed LDL 84,
HDL 54. We continued ASA, atenolol, lisinopril. No acute issues.
.
7. Asthma: no wheezing, stable sats. We gave the patient
albuterol PRN.
.
Medications on Admission:
Lisinopril 20 mg PO daily
Lasix 40 mg PO daily
Trazodone
Avandia 2 mg PO daily
Lantus 100 QD
Regular insulin 20 in am, 30 in pm
Protonix 40 mg PO daily
Zoloft
Albuterol
KCl 10 meq PO daily
Atenolol 25 mg PO daily
ASA 81 mg PO daily
Lipitor 10 mg PO daily
Actos 45 mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Trazodone 50 mg Tablet Sig: .5 Tablet PO at bedtime as needed
for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Hypotension [**1-9**] volume depletion from vomiting
Discharge Condition:
Patient is afebrile, hemodynamically stable and tolerating her
BP meds.
Discharge Instructions:
Please take all of your medications as directed.
Please follow-up with all of your outpatient appointments.
Please return to the ED if you develop dizziness, loss of
consciousness, chest pain, trouble breathing, vomiting,
difficulty urinating or any other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 23903**]
this week. Her number is [**Telephone/Fax (1) 17826**]. At that time, they should
check right upper quadrant ultrasound. Patient also needs chem-7
checked as she is on lasix, lisinopril. We put patient on
reduced dose of lasix (20 mg QD) because of hypotension and took
her off KCl. Should see PCP this week to see if she really needs
to be on lasix 40 mg QD and KCl.
ICD9 Codes: 4589, 5849, 4019, 2859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 23
} | Medical Text: Admission Date: [**2174-4-18**] Discharge Date: [**2174-5-17**]
Date of Birth: [**2135-11-15**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Heparin Agents
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Upper GI series with small bowel follow through
Right heart catheterization
IR guided paracentesis
History of Present Illness:
38 yo F w/ h/o ALL in remission s/p cord transplant in [**1-13**],
anthracycline-induced cardiomyopathy (EF 15-20% [**1-14**]) and
recurrent nausea and vomiting who presents with abdominal pain,
N/V x1 week
Of note, the pt was admitted here from [**Date range (1) **] with nausea and
vomitting of unclear etiology. When discharged, she was
tolerating good PO and had planned f/u with neuro for ?
abdominal migraine and GI for possible other contributing
factors including food sensitivities and gastroparesis.
In the ED, VS: 98.8 94 138/100 16 100% and [**10-15**] pain. CT A/P
showed a small umbilical hernia; interval increase in size and
mild fat stranding and interval increase in ascites compared to
recent prior imaging. WBC 12.4 with no left shift, bili 2.1 up
from 1.1, Cr 2.7 up from 2.3. Surgery was consulted give CT
finding and did not feel there was an indication for surgery.
She received iv zofran and morphine 4mg iv and 1L IVF.
On arrival to the floor, patient reports [**11-14**] total body pain
and nausea. She has had ice chips today but threw them up in
the ED.
Review of Systems:
(+) Per HPI
(-) Review of Systems: Denies fevers, chest pain, SOB, diarrhea,
constipation, dysuria, HA, change in vision or dizziness.
Past Medical History:
ONCOLOGIC HISTORY:
ALL:
- initially presented in [**2172-8-5**] right chest and right upper
extremity pain and paresthesias and visual blurriness. WBC
149,000; received leukapheresis, started on hydroxyurea. Dx'ed
with precursor B-cell ALL.
- underwent phase I induction with daunorubicin, vincristine,
dexamethasone, L-asparaginase, MTX; phase II with
cyclophosphamide, cytarabine, mercaptopurine, MTX
- Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic
evidence of residual leukemia
- underwent allo double cord blood SCT [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD
OTHER MEDICAL HISTORY:
- Embolic stroke in [**3-/2174**] on coumadin
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity [**10/2172**]
- Chronic kidney disease stage III/IV, baseline creatinine
~2.0-2.2
- Asthma
- HTN
- Cervical Intraepithelial neoplasia
- C-section in [**2165**]
Social History:
Smoke: never
EtOH: Occasional in past, none currently
Drugs: Never
Lives/works: Single, has two children (ages 7 and 18). Lives in
[**Location 686**]. Was previously employed at [**Company 59330**], hasn't been
working since being diagnosed with ALL in [**2172-8-5**].
Family History:
Mother with gastric cancer, passed at the age of 40
Father with HTN.
Physical Exam:
VS: 98 145/76 87 15 100% RA
GEN: well appearing F in NAD
HEENT: slight dry MM, sclera anicteric, PERRL
Cards: RR S1/S2 normal. prominent S3
Pulm: CTAB
Abd: Hyperactive BS. Initially soft when palpating with
stethoscope over all 4 quadrants then suddenly exquisitely
tender on right. No guarding initially. Unable to assess for
HSM.
Extremities: wwp, no edema. PTs 2+.
Neuro: CNs II-XII grossly intact. normal gait
Psych: overly dramatic affect
Pertinent Results:
On admission:
[**2174-4-18**] 02:00PM BLOOD WBC-12.4* RBC-3.78* Hgb-11.4* Hct-36.3
MCV-96 MCH-30.2 MCHC-31.4 RDW-16.5* Plt Ct-212
[**2174-4-18**] 02:00PM BLOOD Neuts-67.3 Lymphs-23.8 Monos-7.7 Eos-0.5
Baso-0.7
[**2174-4-18**] 04:30PM BLOOD PT-30.1* PTT-29.4 INR(PT)-3.0*
[**2174-4-18**] 02:00PM BLOOD UreaN-30* Creat-2.7* Na-142 K-4.8 Cl-99
HCO3-31 AnGap-17
[**2174-4-18**] 02:00PM BLOOD ALT-15 AST-18 AlkPhos-127* TotBili-2.1*
[**2174-4-18**] 02:00PM BLOOD Lipase-63*
[**2174-4-18**] 02:00PM BLOOD cTropnT-<0.01
[**2174-4-18**] 02:00PM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.8* Mg-2.0
On discharge:
[**2174-5-17**] 12:00AM BLOOD WBC-19.1* RBC-3.86* Hgb-11.3* Hct-37.7
MCV-98 MCH-29.3 MCHC-30.0* RDW-17.8* Plt Ct-419
[**2174-5-17**] 12:00AM BLOOD Neuts-81.3* Lymphs-11.4* Monos-6.9
Eos-0.1 Baso-0.3
[**2174-5-17**] 12:00AM BLOOD PT-31.2* PTT-28.6 INR(PT)-3.1*
[**2174-5-17**] 12:00AM BLOOD Fibrino-162
[**2174-5-17**] 12:00AM BLOOD Glucose-152* UreaN-78* Creat-2.9* Na-137
K-4.7 Cl-95* HCO3-31 AnGap-16
[**2174-5-17**] 12:00AM BLOOD ALT-51* AST-41* LD(LDH)-327* AlkPhos-107*
TotBili-0.7
[**2174-5-13**] 12:11PM BLOOD cTropnT-<0.01
[**2174-5-17**] 12:00AM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.1* Mg-2.7*
UricAcd-8.7*
[**2174-4-27**] 02:51AM BLOOD calTIBC-246* Ferritn-107 TRF-189*
[**2174-5-2**] 05:55AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2174-4-28**] HHV-8 DNA, QL PCR Not Detected
[**2174-4-27**] QUANTIFERON(R)-TB GOLD NEGATIVE
NEGATIVE
[**2174-4-29**] ACE, SERUM 30 [**10/2130**]
U/L
Micro:
[**2174-4-25**] 1:07 pm PERITONEAL FLUID
GRAM STAIN (Final [**2174-4-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2174-4-28**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2174-5-1**]): NO GROWTH.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2174-4-30**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Final [**2174-5-13**]): NO FUNGUS ISOLATED.
[**2174-4-29**] 10:15 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
CMV Viral Load (Final [**2174-5-6**]): CMV DNA not detected.
ECG [**2174-4-18**]:
Sinus rhythm. Possible left atrial abnormality. Lateral ST-T
wave
abnormality. Cannot rule out myocardial ischemia. Poor R wave
progression. Cannot rule out anterior wall myocardial
infarction of indeterminate age. Compared to the previous
tracing of [**2174-4-2**] multiple described abnormalities persist.
CT abdomen/pelvis without contrast [**2174-4-18**]:
FINDINGS: There is a small-to-moderate right pleural effusion,
smaller in
size compared to last CT torso. There is a small pericardial
effusion. Study is suboptimal for evaluation of solid organs due
to lack of IV contrast. With this limitation in mind, there is
no extra- or intra-hepatic biliary duct dilatation. Previously
described presumably focal nodular hyperplasia in segment VI of
the liver is not clearly visualized on a non-contrast CT. There
is a presumably gallbladder wall edema from third spacing with
moderate amount of ascites. There is likely gallbladder sludge.
Pancreas and bilateral adrenal glands are within normal limits
considering the limitation of no contrast administration. There
is interval increase in size of a fat-containing umbilical
hernia measuring 2 cm in transverse dimension with mild fat
stranding(2:50), correlate with point tenderness/physical exam.
The appendix is not dilated (2:49), contains air and there is a
likely small appendicolith (2:53). There is no bowel
obstruction. There is no evidence of colonic wall thickening,
although evaluation is suboptimal given lack of IV or PO
contrast and adjacent ascites.. The kidneys are normal in size.
There is no evidence of hydronephrosis. Due to lack of oral
contrast, evaluation for mesenteric lymph nodes is suboptimal.
There are scattered lymph nodes in the retroperitoneum, however,
do not meet the CT criteria for pathologic enlargement.
CT PELVIS: There is free fluid in the pelvis - ascites. The
uterus and urinary bladder appear normal. The rectum and sigmoid
have scattered diverticula; however, no evidence of
diverticulitis.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion.
There is soft tissue stranding suggesting anasarca.
IMPRESSION:
1. Mild-to-moderate right pleural effusion; however, interval
decrease in size compared to prior.
2. Moderate ascites with interval increase.
3. No drainable fluid collection, however, evaluation is
suboptimal due to lack of IV and oral contrast.
4. Diverticulosis.
5. Interval increase in size of a small fat-containing umbilical
hernia with mild fat stranding, correlate with point tenderness.
6. No bowel obstruction. No definite bowel wall thickening,
although the examination is suboptimal for such.
7. Pericardial effusion, similar to prior.
RUQ ultrasound [**2174-4-18**]:
FINDINGS: The liver is of normal echogenicity. Previously
described presumably focal nodular hyperplasia in segment VI of
the liver is not clearly visualized. There is no intra- or
extra-hepatic biliary duct dilatation. The common bile duct
measures 2 mm. There is ascites. There is gallbladder wall
edema/thickening presumably from third spacing; the gallbadder
is not distended. No convincing evidence of sludge on
ultrasound. The main portal vein is patent. Pancreas is
suboptimally evaluated due to overlapping bowel gas. There is a
small-to-moderate right pleural effusion as seen on recent CT.
IMPRESSION:
1. Ascites.
2. Gallbladder wall edema presumably from third spacing.
3. Small-to-moderate right pleural effusion.
4. No biliary duct dilatation.
5. Previously described presummed focal nodular hyperplasia in
segment VI of the liver is not clearly visualized.
Small bowel follow through [**2174-4-20**]:
IMPRESSION:
1. Small, anterior cervical web that does not hinder the passage
of a 13mm
barium tablet.
2. Filling defect in the mid esophagus just below the carina
appears to be either extrinsic compression versus a submucosal
lesion. In correlation with the comparison CT torso, mediastinal
lesion is less likely. Submucosal esophageal lesion remains
within the differential, and direct visualization with EGD is
recommended. Other possibility includes an aberrant vessel in
this vicinity.
3. Mobile cecum which does not appear to be obstructive in any
manner on today's examination.
Renal ultrasound [**2174-4-20**]:
FINDINGS: The right kidney measures 10.5 cm. The left kidney
measures 9.7
cm. There is no evidence of hydronephrosis, stone or mass
bilaterally. The
bladder is unremarkable. Moderate amount of ascites is
incidentally noted.
IMPRESSION: No hydronephrosis, stone or mass within the kidneys.
Peritoneal Fluid [**2174-4-25**]:
ATYPICAL.
Scattered atypical lymphoid cells in a background of
reactive mesothelial cells
IR guided paracentesis [**2174-4-25**]:
IMPRESSION:
Ultrasound-guided diagnostic paracentesis, with a total of 200
mL of ascites removed.
TTE [**2174-5-2**]:
The left atrium is mildly elongated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = 20 %). Systolic function of
apical segments is relatively preserved. No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
is mildly increased with moderate global free wall hypokinesis.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
Severe [4+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a small
circumferential pericardial effusion without echocardiographic
signs of tamponade.
IMPRESSION: Severe biventricular global hypokinesis. Severe
tricuspid regurgitation. Pulmonary artery systolic hypertension.
Small circumferential pericardial effusion without evidence of
tamponade physiology.
Compared with the prior study (images reviewed) of [**2174-4-1**],
the findings are similar.
TTE [**2174-5-10**]:
The left atrium is dilated. A left-to-right shunt across the
interatrial septum is seen at rest consistent with a stretched
patent foramen ovale (or small atrial septal defect). There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal with mildly impaired global
left ventricular systolic function. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The tricuspid valve leaflets are mildly thickened. There is
moderate (2+) tricuspid regurgitation. There is mild pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
Compared with the prior study (images reviewed) of [**2174-5-6**],
ther pericardial effusion is now smaller. Biventricular
sysotolic function appears slightly less vigorous compared to
the prior study (on a lower dose of milrinone now than during
the prior study).
Cardiac cath [**2174-5-5**]:
COMMENTS:
1. Hemodynamics measurements in this patient demonstrate low
cardiac output. Following administration of milrinone, cardiac
index increased to the low-normal range with 2.5 L/min/m2.
2. Moderate pulmonary hypertension with right atrial v-waves
consistent with severe TR noted. Pulmonary vascular resistance
is elevated at 280 dyne-cm-sec5.
FINAL DIAGNOSIS:
1. Severe systolic ventricular dysfunction.
2. Moderate diastolic ventricular dysfunction.
3. Pulmonary hypertension
LE ultrasound [**2174-5-13**]:
IMPRESSION:
1. No evidence for deep venous thrombosis in either lower
extremity.
2. 3.6 cm [**Hospital Ward Name 4675**] cyst in the right popliteal fossa as previous.
Superficial soft tissue edema in the right mid thigh, may be
related to partial rupture of [**Hospital Ward Name 4675**] cyst.
TTE [**2174-5-16**]:
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion. The effusion appears circumferential. There are no
echocardiographic signs of tamponade. Echocardiographic signs of
tamponade may be absent in the presence of elevated right sided
pressures.
Compared with the prior study (images reviewed) of [**2174-5-10**],
biventricular systolic function is slightly worse. The size of
the pericardial effusion is slightly smaller.
Brief Hospital Course:
38 yo F w/ h/o ALL in remission s/p cord transplant in [**1-13**],
anthracycline-induced cardiomyopathy (EF 15-20% [**1-14**]) and
recurrent nausea and vomiting who presents with 1 week abd pain,
acute on chronic renal failure and new hyperbilirubinemia.
Unclear unifying diagnosis.
# Acute on Chronic Abdominal Pain: Pt noted to have significant
abdominal pain as well as increased [**Month/Year (2) 4394**] on admission. Of
note, she had an extensive work up of her chronic abdominal pain
in the past with no clear cause. Abdominal CT was unrevealing
for any obvious source of her pain. GI was consulted who
recommended a SBFT which did not reveal any significant
pathology. GI recommended bentyl for antispasmodic effect. She
was also continued on her home MS contin and IV morphine for
breakthrough. Her pain persisted as did her [**Last Name (LF) 4394**], [**First Name3 (LF) **] the
decision was made to perform a diagnositc paracentesis under
ultrasound guidance. 200ml peritoneal fluid was removed. This
revealed 775 WBCs, but a lymphocytic/monocytic predominance with
only 1% polys making SBP unlikely. Fluid was sent for culture
which showed no growth and flow cytometry which showed no
evidence of ALL recurrence. Despite lack of evidence for SBP,
she was started on zosyn empirically which was stopped on [**5-2**].
She continued to have mild-moderate abdominal pain but was able
to eat full meals and had BMs. She was continued on her home
mscontin and morphine IR.
.
# Anthracycline-induced/ GVHD cardiomyopathy: EF <20% on echo
from 2/[**2174**]. Pt was maintained on diuresis as above, which was
subsequently held in the setting of rising creatinine with
improvement in creatinine. Torsemide was slowly reintroduced and
uptitrated to 40mg [**Hospital1 **] which caused another bump in creatinine
to 3.0, so renal and cardiology were consulted. Renal ultrasound
was unrevealing. She was then taken to the Cath lab and placed
on a milrinone/lasix gtt and transfered to the CCU. Her volume
overload slowly improved and her peripheral edema/ascites slowly
improved as well. A repeat echo showed improved EF to 40-45% on
the milrinone gtt. She was then started on solumedrol 30mg IV
due to a concern for GVHD directed towards myocardium. After
further discussion between cardiology and her oncology team she
was also started on cellcept for further management of her GVHD.
She did well on milrinone and lasix drip, but the drip was
stopped when her creatinine bumped to 3.0 and it was felt her
volume status was near maximization. Her milrinone was then
discontiued and she was then transferred back to [**Hospital1 3242**] for further
management of her abdominal pain and GVHD. She was continued on
torsemide for diuresis with close follow-up with her outpatient
cardiologist. Of note, she had frequent alarms on telemetry for
tachycardia that cardiologist felt was mostly due to artifact;
her beta blocker was uptitrated. Repeat TTE prior to discharge
showed an EF of 35-40%. She was discharged home on cellcept and
prednisone for possible GVHD.
# Acute Renal Failure: On admission Cr was 2.7 (recent baseline
was 2), but at last discharge Cr was 2.3. Renal saw the patient
who thought this was likely from overdiuresis (home torsemide
regimen of 20mg [**Hospital1 **]) in conjunction with her [**Last Name (LF) **], [**First Name3 (LF) **] recommended
holding diuresis. Her Cr subsequently improved, but in the
setting of her worsening [**First Name3 (LF) 4394**] and her cardiomyopathy,
decision was made to slowly add back diuresis, and eventually
she was up titrated to toresemide 40mg [**Hospital1 **] and her [**Last Name (un) **] was
restarted. With this, however, her Cr began to climb again to
3.0. Given the delicate balance between her renal failure
cardiomyopathy, cardiology/renal were consulted. Given her
depressed EF, her rising Cr was thought to be [**3-9**] volume
overload. She was sent to the cath lab and started on a
milrinone/lasix gtt and transfered to the CCU with a goal
diuresis of 1L per day. She was actively diuresed on her
milrinone and lasix drip with a total net negative of close to
9L. Her Cr then returned to baseline by time of discharge and
she was discharged home on torsemide.
# Hyperbilirubinemia: Unclear cause, could have been related to
a viral infection but no transaminitis to support this. RUQ u/s
without cause for pain. This trended down to normal values and
remained stable by time of discharge
# Leukocytosis: patient had uptrending WBC in setting of
starting solumedrol, clutures were sent which revealed no
growth.
.
# H/O Embolic Stroke: Has new opening of PFO based on most
recent echo which likely contributed to her recent stroke. She
was maintained on coumadin 4mg daily, but anticoagulation was
held on day of paracentesis and remained subtherapeutic for
several days, so she was maintained on a heparin drip to bridge
her to a therapeutic INR [**3-10**]. She was maintained on a decreased
dose of coumadin throughout hospital admission with INR within
goal between 2 and 3. She was arranged with follow-up at
outpatient [**Hospital3 **].
Medications on Admission:
Carvedilol 25 mg [**Hospital1 **]
Fluticasone-salmeterol [**Hospital1 **]
Morphine 15 mg q6h prn pain
Valsartan 40 mg qd
Torsemide 20 mg [**Hospital1 **]
Multivitamin qd
Albuterol prn
Lorazepam 0.5 mg q6h prn nausea
Warfarin 4 mg qd
Ondansetron 8 mg tid prn
Pentamidine 300 mg inhalation qmonth
Colace 100 mg qd prn
Discharge Medications:
1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob or
wheeze.
5. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
8. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release(s)* Refills:*0*
9. dicyclomine 20 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*0*
10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
13. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
14. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal pain or
gas.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
15. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
16. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Disp:*500 ML(s)* Refills:*0*
18. morphine 15 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for pain.
19. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Abdominal Pain
-Acute on chronic renal failure
-Systolic Heart failure
Secondary:
-ALL
-History of embolic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital for abdominal pain. Your pain
was treated with pain medications, and a new medication called
Bentyl. You were also switched to a longer acting form of your
morphine. We did a test to look at your small bowel which was
negative. At this point we are not sure what is causing your
pain, but you had increased swelling of your abdomen which
likely contributed to your pain.
You underwent a right heart catheterization and [**Known lastname 461**]
to assess your heart function because worsening heart failure
can cause fluid in your belly and worsening kidney disease. You
were at the cardiac intensive care unit and placed on a
medication that improved your heart function. A repeat
[**Known lastname 461**] prior to your discharge showed that your heart
function has improved somewhat and is stable. You will follow
up closely with your cardiologist as several of your heart
medications have changed. You were started on steroids and
mycophenolate mofetil because it was felt that you heart
problems may be due to your leukemia.
You also had some worsening of your renal failure. You were
followed by our kidney consult team while you were in the
hospital. Your kidney function was stable prior to discharge.
We made the following changes to your medications:
-Mycophenolate Mofetil 1000mg twice a day was started
-Prednisone 60mg daily was started
-Coumadin was decreased to 2mg daily
-Torsemide was increased to 40mg daily
-Please hold your valsartan until you see your cardiologist
-Metoprolol succinate 100mg daily was started; please stop
carvedilol
-Bentyl (dicyclomine) was started for your abdominal pain
-Simethicone was started for abdominal discomfort/gas
-Your morphine was switched to long-acting Morphine 15mg twice a
day
-Bactrim single strength, 1 tablet daily, was started to help
prevent infection
-Acyclovir 400mg twice a day was started to help prevent
infection
-Allopurinol 100mg daily was started because your uric acid
levels were high
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You have the following appointments [**Name8 (MD) 1988**] for you. You will
need to follow up at [**Hospital3 **] on Thursday,
[**2174-5-19**], for an INR (coumadin level) check. Please come to
the [**Hospital Ward Name 23**] Center [**Location (un) 895**] for this lab test between 9am and
5pm.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2174-5-20**] at 3:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2174-5-20**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10565**], NP [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] MD, Cardiology
[**Last Name (LF) 766**], [**2174-5-30**] at 11:00AM
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2174-6-9**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2174-5-26**]
ICD9 Codes: 4254, 5849, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 24
} | Medical Text: Admission Date: [**2193-6-27**] Discharge Date: [**2193-6-30**]
Date of Birth: [**2162-12-8**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
chest, lower back and hip pain, s/p crush injury
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 88968**] is a 30 year old man with untreated hypertension who
suffered a crush injury to his chest (tractor loaded with weight
rolled onto his chest) requiring extraction with a fork lift.
He denied any LOC; VS were stable during [**Location (un) **]. Upon ED
presentation, he c/o hip and low back pain, yet denied chest
pain, dyspnea, abdominal pain, headache or neck pain.
Cardiology was consulted given concern for contusion, cardiac
injury. He was noted to have a new RBBB on ECG with TWI. The
patient has a CPK of 1464 and TnT<0.01. MB 5. Pt's chest pain
improved with narcotics. He also denied dyspnea, although it
hurts to take a deep breath.
He stopped taking anti-hypertensives because lack of insurance.
He had atypical chest pains in the past and was evaluated at
[**Hospital1 **] with an ECG. Denies any exertional chest symptoms. No
orthopnea or PND. Remaining ROS positive for back pain and pain
in the hips. All other ROS are negative.
Past Medical History:
HTN (not currently treated)
Social History:
Married (wife, [**Name (NI) **] [**Name (NI) 88969**], [**Telephone/Fax (1) 88970**] is emergency contact).
Non-smoker, no alcohol. No illicits.
Family History:
No premature CAD.
Physical Exam:
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Neuro: Speech fluent
Pertinent Results:
[**2193-6-27**] 02:03PM BLOOD WBC-5.0 RBC-5.25 Hgb-15.0 Hct-42.7
MCV-81* MCH-28.6 MCHC-35.2* RDW-14.0 Plt Ct-225
[**2193-6-27**] 02:10PM BLOOD PT-12.4 PTT-22.9 INR(PT)-1.0
[**2193-6-27**] 02:03PM BLOOD Plt Ct-225
[**2193-6-27**] 09:36PM BLOOD Glucose-111* UreaN-7 Creat-1.0 Na-140
K-3.2* Cl-108 HCO3-23 AnGap-12
[**2193-6-27**] 09:36PM BLOOD Glucose-674* UreaN-7 Creat-1.0 Na-136
K-2.6* Cl-102 HCO3-28 AnGap-9
[**2193-6-27**] 02:03PM BLOOD UreaN-10 Creat-1.3*
[**2193-6-27**] 09:36PM BLOOD CK(CPK)-909*
[**2193-6-27**] 02:03PM BLOOD ALT-40 AST-42* CK(CPK)-1464* AlkPhos-64
TotBili-0.6
[**2193-6-27**] 02:03PM BLOOD Lipase-48
[**2193-6-27**] 09:36PM BLOOD CK-MB-5 cTropnT-<0.01
[**2193-6-27**] 02:03PM BLOOD cTropnT-<0.01
[**2193-6-27**] 09:36PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9
[**2193-6-27**] 09:36PM BLOOD Calcium-6.8* Phos-1.8* Mg-1.6
[**2193-6-27**] 02:03PM BLOOD Calcium-9.1
[**2193-6-27**] 02:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-6-27**] 02:10PM BLOOD Glucose-105 Lactate-1.5 Na-145 K-3.5
Cl-107
[**2193-6-27**] 02:10PM BLOOD Hgb-14.8 calcHCT-44
.
[**2193-6-27**] 09:36PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2193-6-27**] 02:24PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2193-6-27**] 09:36PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2193-6-27**] 02:24PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
[**2193-6-27**] 09:36PM URINE RBC-12* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
[**2193-6-27**] 02:24PM URINE RBC-3* WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2193-6-27**] 02:24PM URINE Mucous-RARE
[**2193-6-27**] 02:24PM URINE Hours-RANDOM
.
[**2193-6-27**] 9:36 pm MRSA SCREEN; Source: Nasal swab.
(Final [**2193-6-30**]): No MRSA isolated.
.
[**2193-6-28**] 11:25AM BLOOD WBC-4.3 RBC-5.24 Hgb-15.1 Hct-44.0 MCV-84
MCH-28.8 MCHC-34.2 RDW-14.4 Plt Ct-228
[**2193-6-28**] 11:25AM BLOOD Plt Ct-228
[**2193-6-28**] 11:25AM BLOOD Glucose-133* UreaN-5* Creat-1.0 Na-142
K-3.6 Cl-109* HCO3-25 AnGap-12
[**2193-6-28**] 11:25AM BLOOD CK(CPK)-718*
[**2193-6-28**] 04:47AM BLOOD CK(CPK)-827*
[**2193-6-28**] 11:25AM BLOOD CK-MB-5 cTropnT-<0.01
[**2193-6-28**] 04:47AM BLOOD CK-MB-5 cTropnT-<0.01
[**2193-6-28**] 11:25AM BLOOD Calcium-8.3* Phos-2.0* Mg-2.2
[**2193-6-28**] 04:50AM BLOOD Type-[**Last Name (un) **] pH-7.32*
[**2193-6-28**] 04:50AM BLOOD freeCa-1.11*
.
[**2193-6-28**] 09:57AM URINE Hours-RANDOM
[**2193-6-28**] 09:57AM URINE Myoglob-PRESUMPTIVE
.
[**2193-6-29**] 05:55AM BLOOD WBC-5.9 RBC-5.40 Hgb-15.2 Hct-44.6 MCV-83
MCH-28.2 MCHC-34.2 RDW-14.2 Plt Ct-220
[**2193-6-29**] 05:55AM BLOOD Plt Ct-220
[**2193-6-29**] 05:55AM BLOOD
[**2193-6-29**] 05:55AM BLOOD Glucose-87 UreaN-15 Creat-1.2 Na-141
K-3.6 Cl-107 HCO3-25 AnGap-13
[**2193-6-29**] 05:55AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1
.
[**2193-6-27**] Cardiology ECG
Sinus rhythm. Right bundle-branch block with left anterior
fascicular block. Probable left ventricular hypertrophy. No
previous tracing available for comparison.
Rate 67, PR 192, QRS 170, QT/QTc 424/436, P 65, QRS -72, T -26
.
[**2193-6-27**] 1:45 PM, TRAUMA #2 (AP CXR & PELVIS PORT)
IMPRESSION: No acute intrathoracic or pelvic injury.
.
[**2193-6-27**] 1:59 PM, CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial injury or skull fracture.
.
[**2193-6-27**] 2:00 PM, CT ABD & PELVIS WITH CONTRAST, CT CHEST
W/CONTRAST
IMPRESSION: No acute injury in the chest, abdomen or pelvis. No
acute
fracture.
.
[**2193-6-27**] 2:00 PM, CT C-SPINE W/O CONTRAST
IMPRESSION: No acute fracture or malalignment.
.
[**2193-6-27**] 5:01 PM, MR CERVICAL SPINE W/O CONTRAST
[**2193-6-27**] 5:01 PM, MR L SPINE W/O CONTRAST
[**2193-6-27**] 5:01 PM, MR THORACIC SPINE W/O CONTRAST
IMPRESSION:
1. No evidence of fracture or ligamentus injury.
2. Mild degenerative changes of the spine.
.
[**2193-6-28**] at 10:02:43 AM, ECHO, Portable TTE (Complete)
IMPRESSION: No RV systolic dysfunction or pericardial effusion
to suggest significant cardiac contusion. Symmetric left
ventricular hypertrophy with mild global systolic dysfunction.
Dilated thoracic aorta with mild functional aortic
regurgitation. Mild mitral regurgitation.
These findings are most consistent with hypertensive heart
disease.
.
[**2193-6-28**] Cardiology ECG
Sinus rhythm. Right bundle-branch block with left anterior
fascicular block. Compared to the previous tracing no change.
Brief Hospital Course:
Mr. [**Known lastname 88968**] is a 30 year old man with untreated hypertension who
suffered a crush injury to his chest (tractor loaded with weight
rolled onto his chest) requiring extraction with a fork lift.
He denied any LOC; VS were stable during [**Location (un) **]. Upon ED
presentation, he c/o hip and low back pain, yet denied chest
pain, dyspnea, abdominal pain, headache or neck pain.
Cardiology was consulted, given concern for cardiac contusion,
injury. Assesment: chronic RBBB from HTN versus RV contusion
with conduction delay in the RV. LV function appeared
normal. Hx not c/w acute coronary syndrome. He was noted to
have a new RBBB on ECG with TWI. CPK of 1464 and TnT<0.01, MB 5,
AST 42, Ca 9.1, 3 RBC in the urine, Cr 1.3, Hct 42.7.
The patient was initially managed in the TICU for close fluid
status monitoring. The patient was hemodynamically stable. He
received agressive hydration with a goal Uop of >100cc/hr. The
patient's pain was controlled and on HD2, patient was doing
better. His CKs were cycled and trending down. His Creatinine
normalized, so IVF rate was cut back. The patient's diet was
advanced and he was transitioned to po pain meds and transferred
to the floor.
On the floor, he tolerated a regular diet, was ambulating with
physical therapy. He continued to have intermittent muscular
pain in his chest, lower back, and hips, unchanged from previous
days. His pain was controlled on oral narcotic pain medications.
CT imaging and MRI of spine showed no fracture or ligamentous
injury, CT did not show any acute injury or fracture in chest,
abdomen, or pelvis. He was ready for discharge on [**2193-6-30**] to
home.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for muscle spasm.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
rhabdomyolysis
muscular pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ACS service. You did not have any
fractures or organ injuries seen on imaging. You may feel a lot
of muscular aches in the next couple of weeks as your body
heals. Please resume all home medications. You can take the
prescribed narcotic for pain, but do not drive or operate heavy
machinery while taking the medication. You can also take tylenol
or ibuprofen for pain, but do not exceed 4g of tylenol per day.
Followup Instructions:
Follow-up at the acute care surgery clinic as needed:
[**Telephone/Fax (1) 600**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2193-6-30**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 25
} | Medical Text: Admission Date: [**2140-12-8**] Discharge Date: [**2140-12-12**]
Date of Birth: [**2076-5-24**] Sex: M
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 24524**] is a 64-year-old
male who had a history of progressive exertional dyspnea
after quitting smoking approximately six months ago. Workup
for this exertional dyspnea included an exercise treadmill
test that was ultimately positive for ischemic changes as
well as an echocardiogram and subsequently an elective
cardiac catheterization. Cardiac catheterization completed
on [**2140-12-5**] showed left main coronary artery disease with
modest calcification and distal 50% taper. The left anterior
descending also had moderate calcification with a proximal
70% lesion after D1 and R1. The D2 moderate vessel was 90%
proximal tubular lesions, D1 and R1 had ectatic proximal
vessel and a large distal vessel. The left circumflex artery
was nondominant vessel with a proximal 90% lesion with
moderate calcification as well. The right coronary artery
was the dominant vessel, with a total proximal occlusion and
bridging with left-right collaterals. The posterior
descending artery was known to be a good target. Additional
findings on the catheterization were abdominal aorta with a
large infrarenal aneurysm beginning 13 mm below the renals,
bilaterally single without disease. The largest extent of
the aneurysm was 4.8 cm with a length of over 11.7 cm.
Proximal runoffs reveals moderate ostial left iliac lesion.
The common femoral artery and the superficial femoral artery
are bilaterally normal.
Given the patient's significant three vessel coronary artery
disease and symptoms of occasional angina and dyspnea on
exertion, it was determined that he would be an appropriate
candidate for coronary artery bypass grafting. The
Cardiothoracic Surgery service was consulted after the
catheterization procedure, and the following history was
obtained.
PAST MEDICAL HISTORY: History of inferior myocardial
infarction by electrocardiogram, mild chronic obstructive
pulmonary disease, hypertension, hypercholesterolemia, 6 cm
infrarenal abdominal aortic aneurysm as noted previously that
was picked up incidentally on examination by his cardiologist
several months ago, benign prostatic hypertrophy, gout,
greater than 75 pack year smoking history but he recently
quit in the last six months. He is hypothyroid.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 325 mg by mouth once
daily, Lipitor 10 mg by mouth once daily, atenolol 50 mg by
mouth once daily, allopurinol 100 mg by mouth once daily,
Flomax .4 mg by mouth once daily, Tapazole 20 mg by mouth
once daily, and Mavik 1 mg by mouth once daily.
LABORATORY DATA: Preoperative hematocrit was 36. BUN and
creatinine were 17 and 1.1. Catheterization data as stated.
Chest x-ray showed no acute cardiopulmonary process. His
electrocardiogram was significant for sinus bradycardia at
54, with Q waves in II, III and AVF. He had no abnormal ST/T
wave changes. He had early J-point elevation. He did have
early R wave progression as well.
PHYSICAL EXAMINATION: Heart rate 54, blood pressure 134/70,
no acute distress, no chest pain, no carotid bruits
auscultated. The heart was regular, with a prominent S2, no
murmur. The lungs were clear to auscultation except
decreased breath sounds throughout. His abdominal
examination was soft, nontender, nondistended. There was a
pulsatile mass palpated between the xiphoid and umbilicus,
approximately 5 cm by examination. There was no
hepatosplenomegaly, there was no renal bruit. Flank
examination was negative. His lower extremities had palpable
dorsalis pedis and posterior tibial pulses distally
bilaterally.
HOSPITAL COURSE: Given this presentation, it was elected to
bring him to the operating room on [**2140-12-8**]. He was first
discharged after his elective catheterization on [**2140-12-5**] and
ultimately readmitted on [**2140-12-8**], where he underwent an
elective coronary artery bypass graft x 4 with Dr. [**Last Name (STitle) **],
including a left internal mammary artery to the left anterior
descending, a right saphenous vein graft to the diagonal, as
well as a saphenous vein graft to the obtuse marginal and
saphenous vein graft to the right posterior descending
artery. The patient tolerated the procedure well.
Intraoperative findings of transesophageal echocardiogram
were an ejection fraction of 45 to 50%, calcified aorta, good
distal targets. His pericardium was left open. He had a
right radial A-line. He had a right internal jugular cordis
in place, CVP, right atrial catheter. He had two ventricular
wires and two atrial wires, and two mediastinal tubes and one
pleural tube. His mean arterial pressure was 77, with a
right atrial pressure of 9. He was found to be in normal
sinus rhythm at a rate of 74. He was on a propofol drip of
20 mcg/kg/minute for sedation.
He was transferred to the Cardiac Surgical Recovery Unit,
where in the first 24 hours after surgery, all of his drips
were weaned off and he was rapidly extubated. He remained in
sinus rhythm at 88, with blood pressures in the 120s to 130s.
His hematocrit was 25 postoperatively, with a BUN and
creatinine of 18 and 1. Neurologically, he remained intact.
He was started on his lasix, Lopressor, aspirin. Chest tubes
were removed, as well as diet advanced.
He was subsequently transferred to the floor by postoperative
day number one. He was up and ambulating on postoperative
day number one, feeling well. He worked with Physical
Therapy aggressively, and continued pulmonary toilet with
incentive spirometry, coughing and deep breathing. His
electrolytes were repleted as needed.
By postoperative day number two, he continued to feel well.
He had a low-grade temperature of 100.9, but otherwise the
remainder of his vitals were normal, with a heart rate of 94
and sinus, blood pressure of 114/60. His Lopressor was
titrated accordingly. He had BUN and creatinine of 23 and
1.0, and a hematocrit of 24.
By postoperative day number four, the patient was ambulating.
His wires, chest tubes and Foley had been removed at this
point. He was in sinus tachycardia to sinus rhythm, between
90 and 103. His blood pressure was ranging 106 to 110 over
50s to 60s. Oxygen saturation was 95% on room air. He had a
stable sternum, with no evidence of drainage. His abdominal
examination was unchanged from admission. His extremities
were warm and well perfused, with palpable pulses at dorsalis
pedis and posterior tibial bilaterally.
Subsequently the patient was deemed stable and appropriate
for discharge.
DISCHARGE MEDICATIONS: Lopressor 75 mg by mouth twice a
day, Lipitor 10 mg by mouth once daily, lasix 20 mg by mouth
once daily for seven days, K-Dur 20 mEq by mouth once daily
for seven days, Protonix 40 mg by mouth once daily, aspirin
325 mg by mouth once daily, allopurinol 100 mg by mouth once
daily, Tapazole 20 mg by mouth once daily, Flomax .4 mg by
mouth once daily, percocet 5/325 one to two tablets by mouth
every four to six hours as needed, and Colace 100 mg by mouth
twice a day.
DISCHARGE STATUS: To home with VNA.
CONDITION ON DISCHARGE: Stable, afebrile, in normal sinus
rhythm, no evidence of sternal drainage.
DISPOSITION: To home with VNA with instructions not to
undergo any heavy lifting greater than ten pounds for 30
days, no driving for 30 days. Wound may get wet with shower.
He will have follow up with Dr. [**Last Name (STitle) **] in four weeks, follow
up with his cardiologist or primary care physician in three
weeks from the time of discharge. VNA will assist the
patient. If they happen to dismiss him after day seven
through ten, he can return to the Wound Care Clinic, where he
will receive a wound checkup.
DISCHARGE DIAGNOSIS:
1. Significant three vessel coronary artery disease status
post coronary artery bypass graft x 4, with left internal
mammary artery to left anterior descending, saphenous vein
graft to diagonal, obtuse marginal and also right posterior
descending artery.
2. Hypertension
3. Hyperlipidemia
4. 6 cm abdominal aortic aneurysm
5. Benign prostatic hypertrophy
6. Mild chronic obstructive pulmonary disease
7. 50 pack year smoker
8. History of inferior myocardial infarction and coronary
artery disease
9. Hypothyroidism
10. Questionable history of osteoarthritis
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2140-12-11**] 22:42
T: [**2140-12-12**] 00:35
JOB#: [**Job Number 24525**]
ICD9 Codes: 412, 496, 2449, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 26
} | Medical Text: Admission Date: [**2195-8-12**] Discharge Date: [**2195-9-14**]
Date of Birth: [**2195-8-12**] Sex: M
Service: Neonatology
HISTORY: Baby [**Known lastname 2470**] is a baby boy who was born at 35-3/7
weeks to a 24 year old G2, P1 mother with estimated date of
confinement of [**2195-9-13**]. Prenatal laboratories
included blood type to be O+, antibody negative, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune and
GBS status unknown.
MATERNAL HISTORY AND DELIVERY: The maternal history was
notable for previous primary C-section with postpartum
hemorrhage requiring uterine artery ligation. This pregnancy
was reportedly unremarkable until the day prior to delivery
when the mother developed contractions. She came to the
hospital in preterm labor, was noted with cervical dilation
and was taken for repeat C-section. No sepsis risk factors
were identified, and mother did not receive intrapartum
antibiotic prophylaxis. At delivery the infant emerged
vigorous with Apgars of 8 and 9, requiring only brief blow-by
O2. Increased work of breathing was noted that persisted.
Infant was brought to the NICU.
In the NICU moderate grunting, flaring and retractions were
apparent with room air saturations in the low 80s. Infant was
then placed on CPAP.
PHYSICAL EXAMINATION AT THE TIME OF ADMISSION: Weight: 2760
grams, 75th percentile. Head circumference: 33.5 cm, 75th
percentile. Length: 46 cm, 50th percentile. Vital signs:
Temperature 98.4, heart rate 150s, respiratory rate 40s-50s,
blood pressure 37/29 with a MAP of 34 and O2 saturations 95%-
98% on 40% FIO2. In general, this is a well developed, pre-
term infant, active and vigorous, with moderate grunting,
flaring and retractions at rest. Skin is warm, mildly pale.
Sluggish capillary refill. No rash. HEENT exam reveals
fontanels soft and flat. Positive for red reflex bilaterally.
Palate intact. Neck is supple. No lesions. Chest is coarse,
moderately aerated. Positive for grunting, flaring and
retractions. Cardiac is regular rate and rhythm. Soft
systolic murmur. Abdomen is soft. No hepatosplenomegaly. No
mass. Three-vessel cord. Quiet bowel sounds. GU: Normal male.
Testes palpable bilaterally. Anus patent. Extremities: Warm.
No lesions. Hips/Back: Stable. Neurologic: Appropriate tone
and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
patient was initially placed on CPAP and quickly, on day of
life 1 due to persist increased work of breathing and
increased O2 requirement, was intubated and placed on the
conventional ventilator. Patient also received Survanta x2,
and on day of life #4 was weaned to CPAP. On day of life #5
was weaned to nasal cannula and by day of life #6, [**2195-8-18**], patient was on room air and has remained on room air
until discharge. Two days prior to discharge, the infant
experienced a brief period of duskiness associated with crying.
He was not apneic at this time. The infant was monitored for an
additional two days without recurrence. This had not been
previously observed, and the infant remained well. This was
thought to be a breath holding event.
Fluids, electrolytes, nutrition: Patient was made NPO for the
1st 5 days of life and supplemented with parenteral nutrition
during this period. On day of life #6 started on p.o./p.g.
feeds of breast milk/Enfamil 20. Patient continued to advance
on p.o. feedings, and on day of life #30 achieved full p.o.
feeds of breast milk 24/Enfamil powder. Weight at the time of
discharge is 3535 g.
Cardiovascular: Patient was noted to have a soft murmur at
the time of birth. EKG was performed and revealed normal
sinus rhythm. Murmur has since resolved
GI: Patient was noted with hyperbilirubinemia on day of life
#4. Bilirubin was noted at 12.7/0.5. Phototherapy was
discontinued on day of life #6 with a rebound bilirubin of
7.7/0.3. Phototherapy was never restarted.
Hematology: This patient was not a known setup, and no
transfusion was ever given throughout his hospital course.
Infectious disease: CBC and blood culture were done at birth.
Patient was then started on ampicillin and gentamicin for 48-
hour rule out. The length of course of antibiotics was
increased to a 7-day course of antibiotics due to the
persistent O2 requirement and respiratory needs of the
patient despite no additional signs or symptoms of infection.
Blood cultures negative, final as of [**2195-8-18**]. An LP
was performed on [**2195-8-15**], with results unremarkable,
and then a CSF culture was negative, final on [**2195-8-18**]. Patient currently continues on Nystatin for treatment
of oral thrush.
Neurologic: Patient has a normal physical exam as noted with
normal suck, normal grasp, normal tone and is alert. Head
ultrasound was not indicated.
Sensory: Audiology: Hearing screen was performed with
automated auditory brainstem responses. Patient passed his
hearing screen on [**2195-8-23**].
Ophthalmology: Eye exam was not indicated for this ex-35-
weeker weighing more than 1500 g, who did not require
prolonged O2 throughout his hospital course.
Psychosocial: The [**Hospital1 18**] social work is involved with this
family. The contact social worker is [**Name (NI) 36130**] [**Name (NI) 6861**], who can
be reached at [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: Patient is currently in stable
condition.
DISCHARGE DISPOSITION: To home with mother.
PRIMARY CARE PEDIATRICIAN: [**Hospital 17566**] Pediatrics located in
[**Location (un) 5871**], MA; phone number is [**Telephone/Fax (1) 37911**]; fax [**Telephone/Fax (1) 37912**].
The primary care pediatrician will be Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) **].
CARE/RECOMMENDATIONS: At the time of discharge patient is to
be maintained on full p.o. feeds of breast milk 24 ad lib.
MEDICATIONS: Currently include Nystatin as needed for
treatment of oral thrush.
CAR SEAT POSITIONING SCREENING: Car seat positioning
screening was passed on [**2195-9-11**].
IMMUNIZATIONS RECEIVED: Patient did receive his hepatitis B
vaccine on [**2195-8-11**].
IMMUNIZATIONS RECOMMENDED: Synergist RSV prophylaxis should
be considered for [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1) Born at less than 32
weeks, 2) born between 32 and 35 weeks with 2 of the
following: 1) daycare during RSV season, 2) a smoker in the
household, 3) neuromuscular disease, airway abnormalities or
school-age siblings, or infants who have chronic lung
disease. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of age.
Before this age and for the 1st 24 months of the child's
life, immunization against influenza is recommended for
household contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS RECOMMENDED FOR THIS PATIENT: Patient
is recommended to follow up with PMD, Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) **], at
[**Hospital 17566**] Pediatrics on [**Last Name (LF) 766**], [**2195-9-14**]. Time of
appointment to be scheduled by mother.
DISCHARGE DIAGNOSES: Prematurity, Respiratory Distress Syndrome,
Presumed Pneumonia, Hyperbilirubinemia, Monilial Infection
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Last Name (NamePattern1) 62404**]
MEDQUIST36
D: [**2195-9-11**] 15:05:27
T: [**2195-9-11**] 16:00:25
Job#: [**Job Number 63522**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 27
} | Medical Text: Admission Date: [**2176-2-5**] Discharge Date: [**2176-2-15**]
Date of Birth: [**2106-8-2**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Heparin Agents
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
69 yo F with history of ESRD on HD, DM, recently admitted to
[**Hospital1 18**] for ORIF for left distal femur fracture (uncomplicated
hospital course) referred to ED today after she developed acute
change in mental status associated with decreased responsiveness
during a dialysis treatment today. History per daughter stated
that she last spoke to her mother night PTA and she was "fine"
(asking her daughter about her finances, etc.). She denies that
her mother has ever had a seizure, stroke in the past. Denies
any baseline weakness or numbness. States the patient was living
on her own prior to her recent hip fracture.
.
Per sparse history on dialysis notes, patient was given percocet
at approximately 9:55AM and at approximately 10:30AM developed
acute mental status changes, including confusion. Patient
continued through dialysis with stable vital signs (BP
130's-140's/60's, HR 40's-50's). After completion of dialysis,
EMS was called for transfer to the hospital.
.
EMS notes were significant for noting "rapid deterioration in
mental status", right gaze, dry blood on lips, no response to
pain, aphasia. EMS noted decreased HR to 30's x 2 on transfer,
FSBS = 185.
.
On presentation to ED at [**Hospital1 18**], exam was notable for minimal
responsiveness, GCS 13, withdrawl of all extremities to pain,
following occasional commands, non-verbal (groans). VSS with T
98.8, HR 58, BP 132/102, O2 sat 98%. Labs were notable for WBC
9.5 with 86 N and 2 B, Cr 5.1 (hx ESRD on HD), AST 59, LDH 450,
AP 218, T bili 3.9, lactate 2.8. Blood cxs x 2 were sent in ED.
Head CT demonstrated no evidence of intracranial bleed or edema.
CXR was wnl. MRI/A scan was performed (read pending). Evaluation
by neuro yielded diagnosis of possible seizure activity. Pt was
given narcan 0.4mg IV x 1, Ativan total of 2mg IV, dilantin load
(total of 2gm IV). She was intubated for airway protection
(given FFP prior to intubation as INR 1.9, on coumadin as outpt
as s/p hip surgery) and transferred to the ICU for further
managment.
Past Medical History:
1. Diabetes type 2
2. ESRD on HD Q M,W,F
3. s/p infection in left knee
4. h/o MRSA/C.diff
5. NASH [**3-7**] to tylenol
6. s/p ORIF for left distal femur fracture on [**2176-1-23**]
Social History:
SOH: lives at home with daughters. [**Name (NI) **] ETOH/TOB/illicts.
Family History:
FH: non-contributory
Physical Exam:
Gen- intubated and sedated
HEENT- Pinpoint pupils, reactive b/l. 2 cm healed scar of R
upper forehead. c/d/i
Neck- Supple, unable to assess JVP
Chest- CLA anteriorly, b/l
CV- Regular, bradycardic. no m/r/g
Abd- +bs. soft. nd. no hepatosplenomegaly. no masses
[**Name (NI) **]- 1+ le edema. 2+ dp pulses.
.
On transfer to the floor:
Physical Exam:
VS: BP 131-143/41-57, HR 74-85 RR 20 O2 92-96% RA
Gen - lying in bed, slurred speech, intermittently opens eyes,
intermittently answers questions
HEENT - PERRLA. 2 cm healed scar of R upper forehead. anicteric
sclerae
Neck - Supple, unable to assess JVP, patient with left
subclavian line
Chest - decreased breath sounds in left base
CV - RRR, S1S2 normal, systolic murmur [**4-8**] radiating into the
axillae
Abd - +bs. soft. nd. no hepatosplenomegaly. no masses, mild
tenderness in RUQ on deep palpation.
Ext - trace LE edema. 2+ dp pulses.
Pertinent Results:
[**2176-2-5**] 02:10PM PT-16.8* PTT-36.5* INR(PT)-1.9
[**2176-2-5**] 02:10PM PLT SMR-LOW PLT COUNT-149*#
[**2176-2-5**] 02:10PM NEUTS-86* BANDS-2 LYMPHS-5* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2176-2-5**] 02:10PM WBC-9.5# RBC-3.92* HGB-13.2# HCT-37.7# MCV-96
MCH-33.6* MCHC-35.0 RDW-20.1*
[**2176-2-5**] 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2176-2-5**] 02:10PM T4-19.8*
[**2176-2-5**] 02:10PM TSH-3.6
[**2176-2-5**] 02:10PM CALCIUM-9.4 PHOSPHATE-4.0# MAGNESIUM-1.8
[**2176-2-5**] 02:10PM LIPASE-524*
[**2176-2-5**] 02:10PM ALT(SGPT)-15 AST(SGOT)-59* LD(LDH)-450* ALK
PHOS-218* TOT BILI-3.9*
[**2176-2-5**] 02:10PM GLUCOSE-186* UREA N-29* CREAT-5.1*
SODIUM-131* POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-22 ANION GAP-20
.
Imaging:
[**2176-2-5**] CT head w/out contrast: No evidence of intracranial
hemorrhage or edema.
[**2176-2-5**] CXR: Unremarkable chest radiograph.
[**2176-2-5**] MRI brain w/out contrast [**2176-2-5**]: No evidence of acute
brain ischemia. Small arachnoid cyst in the right
cerebellopontine angle cistern. Limited MR angiography study-
the distal vasculature is poorly visualized, which could be
secondary to low cardiac output.
[**2176-2-6**] Liver U/S - Limited examination. Patent hepatic arteries
and veins and portal veins with flow in the appropriate
direction.
[**2176-2-7**] EEG - Markedly abnormal portable EEG due to the slow and
disorganized background and very frequent generalized sharp wave
discharges. These findings indicate a widespread encephalopathy
affecting both cortical and subcortical structures. Medications,
metabolic disturbances, and infection are among the most common
causes. The sharp waves were prominent and frequent and suggest
an increased risk of seizures. Nevertheless, they were not
particularly rhythmic or of higher frequency during this
recording so as to suggest ongoing seizures at the time of the
recording. There were no prominent focal findings although
encephalopathies can obscure such findings. If concern for
seizures persist clinically, a repeat tracing could be of
assistance.
[**2176-2-8**] MR [**Name13 (STitle) 430**] - Severely limited study. No large gross changes
identified compared to [**2176-2-5**], but more subtle acute
changes will not be discernable on today's study. If indeed
there is high clinical suspicion of an acute change from [**2-5**], repeat imaging may be necessary.
[**2175-2-9**] Abdominal U/S - There is no ascites. Marked splenomegaly
Brief Hospital Course:
# Mental status change: Initial exam was notable for minimal
responsiveness, withdrawal of all extremities to pain, following
occasional commands, non-verbal (groans). VSS with T 98.8, HR
58, BP 132/102, O2 sat 98%. Head CT demonstrated no evidence of
intracranial bleed or edema. CXR was wnl. MRI/A scan was
performed and did not show any evidence of ischemia. Evaluation
by neuro yielded diagnosis of possible seizure activity. Pt was
given narcan 0.4mg IV x 1, Ativan total of 2mg IV, dilantin load
(total of 2gm IV). She was intubated for airway protection and
transferred to the ICU for further managment. She was also
covered for possible encephalitis/ meningitis with Acyclovir,
CTX, Vanco and Ampicillin. A LP was done but did not show any
signs of meningitis or encephalitis. The pt continued to have
waxing and [**Doctor Last Name 688**] mental status. She was found to have elevated
LFTs and was thought to have a component of hepatic
encephalopathy. First EEG supporting seizure activity. Repeat
EEG showed slowed activity c/w encephalopathy. Possible hepatic
encephalopathy: Ammonia elevated at 65, therefore pt has been
started on lactulose to attempt to improve MS. Repeat was in
30's. Abx were discontinued. On the [**2-8**] the pt self extubated
and was reintubated to be extubated on the [**2-9**]. A NG tube was
placed for nutrition. Over the following two days the pt was
more lucid and stable. She was called out to the floor for
further management. The pt continued to improve and became more
lucid and oriented x3. Dilantin was continued orally at 300mg
QD. Free Dilantin levels were checked and below therapeutic
levels and therefore Dilantin was increased to 150 TID. Free
Dilantin level should be repeated in three days. Lactulose and
Rifaximin were continued. Lactulose should be titrated to three
bowel movements.
.
# Liver disease: Per pt's daughter the pt had tylenol induced
liver damage in past. Per daughter no ETOH/drug abuse in the
past. Hep A neg, B surface pos, core neg, Hep C neg. Serum IgG,
IgA, IgM were elevated without any specific pattern suggestive
of a disease process. [**Doctor First Name **] was negative, but Anti-SM and AMA were
mildly positive (Titer 1:20). HSV PCR was negative. Possible
primary biliary cirrhosis also consistent with obstructive
enzyme pattern. Also possible steatosis hepatis from obesity.
RUQ U/S showed splenomegaly, no ascites, no focal lesions in
liver, no sign of biliary dilatiation. Flow in appropriate
direction in portal vein. LFTs were followed up and were
trending down. Follow up of LFT, CBC and Chem 7 should be
obtained once in the following week. The pt has follow up
arranged for her with Dr. [**Last Name (STitle) 497**] on the [**2-13**] at
9.40am. A liver biopsy might be considered to investigate the
etiology of the problem further. The pt should be given
hepatitis A vaccine once she is more stable. She was adviced to
avoid hepatotoxic medications.
.
# Transient Leukocytosis and intermittent fever spike: Urine
with WBC, and one time positive urine culture for klebsiella. Pt
was initially treated for suspected meningitis with Ampicillin,
Vancomycin and Ceftraixone. Antiobiotics were discontinued five
days into her hospital course. The pt was afebrile after
discontinuation of the antibiotics and remained with a normal
WBC. The pt was found to have a new systolic murmur on exam,
radiating into her axilla, most consistent with a mild mitral
regurgitation. Follow up ECHO should be obtained. Given the fact
that all blood cultures were negative and the pt remained
afebrile and no other physical signs on examinations were found
consistent with endocarditis the suspicion for endocarditis was
considered low and no further workup was obtained.
.
# ESRD: Pt continued her outpatient dialysis schedule in house.
She tolerated dialysis well.
.
# Hypernatremia: transient. Due to lack of free water because of
to prolonged initial period without feeding as complicate NGT
placement. Free water deficit was calculated as about 4L. Pt was
repleted with free water boluses via NGT 250cc TID.
Hypernatremia resolved.
.
# Anemia - pt has baseline anemia - about three points decreased
from her baseline at around 29. Likely sequestration in spleen
and possible low grade hemolysis due to liver disease in
addition to renal anemia in ESRD. Hemolysis labs difficult to
interpret in the setting of liver disease. Iron studies
consistent with anemia of chronic disease, no iron deficiency.
Erythropoetin was administered during dialysis.
.
# Thrombocytopenia & elevated INR: HIT AB POSITIVE. Also with
splenomegaly and chronic liver disease, likely sequestering. All
heparin containing products were avoided. Thrombocytes were
consistently above 50,000.
.
# DM2: Endocrinology was consulted and sliding scale was
adjusted per recommendations. Lantus 20 and RISS to be continued
as outpatient. Pt had a one time episode of hypoglycemia to 49.
ISSC was decreased by unit two days prior to discharge. Further
fine adjustment should be achieved in the rehabilitation center.
.
# ORIF: pt was seen by orthopedics in house. Knee XR was
obtained. No dislocation of the hardware was seen. The pt should
remain not weight bearing on her L leg for 5 more weeks. F/u
appointment with ortho was obtained in 5 weeks.
Medications on Admission:
1. Colace 100 mg [**Hospital1 **]
2. Pantoprazole 40 mg QD
3. Acetaminophen 500 mg q6
4. Metoprolol Tartrate 25 mg [**Hospital1 **]
5. Warfarin 1 mg QD
6. Calcium Carbonate 500 mg TID
7. Hydromorphone 2 mg q6
8. Senna 8.6 mg [**Hospital1 **]
9. Bisacodyl 10 mg Tablet, QD
10. Sevelamer 800 mg TID
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
Disp:*qs * Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
Disp:*1350 ML(s)* Refills:*2*
6. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous As directed.
Disp:*qs * Refills:*2*
7. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day).
Disp:*270 Tablet, Chewable(s)* Refills:*2*
8. Insulin Glargine 100 unit/mL Solution Sig: as directed
Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Mental status changes
EEG with seizure like activity
Liver failure
Hepatic encephalopathy
...................
Diabetes type 2
ESRD on HD Q M,W,F
s/p ORIF for left distal femur fracture on [**2176-1-23**]
Discharge Condition:
Good, Pt [**Name (NI) 9830**]3, mental status changes resolved
Discharge Instructions:
Please come back to the hospital or see your primary care doctor
if you experience any worsening mental status, confusion,
headaches, jaundice or any other concerns.
.
Please take all medications as instructed.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 497**] on the [**2-13**] at
9.40am for your liver disease.
.
Please follow up with Neurology, Dr. [**Last Name (STitle) **] on the [**3-22**]
at 11.00am, [**Location (un) **] of [**Hospital Ward Name 23**] building.
.
Please also follow up with your primary care doctor.
.
And follow up with orthopedics for your fracture: Provider:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2176-3-19**]
9:00
ICD9 Codes: 5856, 2760, 5990, 2761, 2875, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 28
} | Medical Text: Admission Date: [**2183-10-23**] Discharge Date: [**2183-10-28**]
Date of Birth: [**2117-8-8**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman,
with a past medical history significant for chronic alcohol
abuse, and a history of alcoholic ketoacidosis, also
depression, COPD, and multiple ED visits and admissions for
intoxication, who was admitted to the ICU for severe
hypophosphatemia in the setting of a recurrence of her
alcoholic ketoacidosis. The patient's alcohol level was 370
on admission. She had an anion gap of 37 with a bicarbonate
of 11. Her phosphate level was 0.3.
PAST MEDICAL HISTORY:
1. Chronic alcohol abuse with a history of alcoholic
ketoacidosis.
2. Depression.
3. COPD.
4. Recently treated for herpes zoster.
5. Benign essential tremor.
6. History of adrenal mass.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Combivent 1-2 puffs [**Hospital1 **].
2. Naltrexone 50 mg po qd.
3. Neurontin 40 mg po tid.
4. Desipramine 10 mg po qd.
5. Zoloft 50 mg po qd.
SOCIAL HISTORY: A 60-pack year tobacco history. History of
alcohol abuse. No history of IV drug abuse. The patient is
a former nurse.
PHYSICAL EXAM: Vital signs - blood pressure 138/64, heart
rate 104, respiratory rate 24, oxygen saturation 96% on 4
liters face mask.
GENERAL: Chronically ill-appearing woman with a visible
tremor and the odor of alcohol upon her.
HEENT: Sclerae anicteric. Mucous membranes moist. PERRLA.
NECK: No JVD.
CHEST: Clear to auscultation. No rhonchi, rales or
wheezing.
CARDIOVASCULAR: Regular rate and rhythm. S1, S2 normal. No
murmurs, rubs or gallops.
ABDOMEN: Obese, soft, nontender with bowel sounds.
EXTREMITIES: Good distal pulses. No clubbing, cyanosis or
edema.
NEURO: Nonfocal with the exception of not responding to name
call.
PERTINENT LABS AND DIAGNOSTICS: CBC revealed a white count
of 5.5, with 11% bands, a hematocrit of 42.8, and a platelet
count of 239. Chem-7 was significant for a sodium of 140,
potassium 3.8, chloride 93, bicarbonate 11, BUN 24,
creatinine 1.2, glucose 186. Anion gap was 36. ETOH level
was 370. Acetone level was positive. ABG on room air was pH
7.40, PCO2 26, PO2 85.
ASSESSMENT: This is a 65-year-old woman, with a history of
alcohol abuse, who presents with hypophosphatemia and
alcoholic ketoacidosis. In the ED, she also had coffee
ground emesis, although her hematocrit remained stable.
HOSPITAL COURSE - The following is a summary of the [**Hospital 228**]
hospital course by systems:
1) HYPOPHOSPHATEMIA: The patient received ample phosphate
repletion while she was in-house, and on her day of discharge
was no longer hypophosphatemic.
2) ALCOHOLIC KETOACIDOSIS: The patient was aggressively
treated with Insulin and glucose, fluids, and electrolyte
repletion in the Medical Intensive Care Unit to the extent
that her anion gap and acidosis resolved.
3) COFFEE GROUND EMESIS: The patient was seen by the
gastrointestinal team while she was in-house. Her hematocrit
was followed in the hospital and did not drop significantly.
She was started on PPI. She was made NPO at first, but then
slowly advanced in her diet. She underwent an EGD prior to
discharge which revealed no [**Doctor First Name **]-[**Doctor Last Name **] tear, erythema, and
erosion in the antrum compatible with gastritis, no
esophageal varices, and an otherwise normal EGD. She was
continued on her PPI and will be continued for 4 weeks.
Biopsy results at the time of this dictation were pending.
The gastrointestinal team recommended follow-up appointment
as an outpatient, as well as a screening colonoscopy.
4) ALCOHOL INTOXICATION: The patient was maintained on a
CIWA scale to monitor her for withdrawal. She received
valium accordingly. The patient was visited by the substance
abuse team, and the patient requested transfer to an
inpatient psych facility for treatment of her alcohol
dependence.
5) ESSENTIAL TREMOR: The patient was treated with nadolol
with subsequent improvement of her essential tremor. She
continued to have one, however, at baseline.
6) DEPRESSION: The patient was continued on her Zoloft.
7) FEN: The patient underwent aggressive electrolyte
repletion, as mentioned above. She was made NPO at first,
but as her hematocrit remained stable and she had no
abdominal complaints, she was advanced as tolerated to a full
diet.
8) PROPHYLAXIS: The patient was treated with Protonix, as
mentioned above, as well as Pneumoboots and a bowel regimen.
DISCHARGE STATUS: To [**Hospital1 **] for inpatient substance abuse
treatment.
DISCHARGE CONDITION: Fair.
DISCHARGE DIAGNOSES:
1. Alcoholic ketoacidosis with hypophosphatemia.
2. Essential tremor.
3. Depression.
4. Chronic obstructive pulmonary disease.
5. Gastritis.
6. Alcohol abuse.
FOLLOW-UP PLANS: The patient will follow-up with GI for a
colonoscopy, as well as follow-up of her coffee ground
emesis. The patient will follow-up with her primary care
physician as needed. The patient will receive inpatient
psych care at [**Hospital1 **].
DISCHARGE MEDICATIONS:
1. Diazepam 10 mg po q 6 h prn CIWA scale greater than 10.
2. Calcium carbonate 500 mg po tid with meals.
3. Montelukast sodium 10 mg po qd.
4. Protonix 40 mg po q 12 h.
5. Nadolol 20 mg po qd.
6. Multivitamin 1 tablet po qd.
7. Folate 1 mg po qd.
8. Thiamine 100 mg po qd.
9. Albuterol and ipratropium nebs q 6 h prn.
10.Sertraline 50 mg po qd.
11.Tylenol 325-650 mg po q 6 h prn.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12*ADF
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2183-10-27**] 13:25
T: [**2183-10-27**] 13:33
JOB#: [**Job Number 47678**]
ICD9 Codes: 2762, 496, 5789, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 29
} | Medical Text: Admission Date: [**2179-9-19**] Discharge Date: [**2179-9-25**]
Date of Birth: [**2109-10-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2180-9-18**] Aortic Valve Replacement (23mm CE pericardial), Coronary
Artery Bypass Graft x 1 (LIMA to LAD)
History of Present Illness:
69 y/o male with h/o atrial fibrillation, aortic stenosis, and
coronary artery disease who is now having increased symptoms of
dyspnea on exertion. Along with fatigue and dizziness. He was
referred for surgical intervention.
Past Medical History:
Aortic Stenosis, Coronary Artery Disease, Gastroesophageal
Reflux Disease, Atrial Fibrillatoin s/p Ablation, s/p PPM [**2174**],
Erectile Dysfunction s/p Hernia repair, s/p Bilat knee
arthroscopy
Social History:
Denies tobacco or ETOH use.
Family History:
NC
Physical Exam:
VS: 72 18 154/98 6' 195#
Gen: WDWN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL NCAT
Neck: Supple, FROM, -JVD, -carotid bruit
Chest: CTAB
Cardiac: Irreg rhythm with 3/6 SEM radiating to carotids
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -edema, -varicosities
Neuro: grossly intact, A&O x 3
Pertinent Results:
[**2179-9-20**] Echo: PREBYPASS: 1. The left atrium is normal in size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. 2. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. 3. The ascending
and transverse thoracic aorta are normal in diameter and free of
atherosclerotic plaque. There are simple atheroma in the
descending thoracic aorta. 4. There are three aortic valve
leaflets, which are moderately thickened. There is severe aortic
valve stenosis (area <0.8cm2). 5. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened. 6.
There is no pericardial effusion. 7. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**2179-9-20**] at 1209. POSTBYPASS: 1. Pt is
currently on a phenylephrine infusion 2. The pt has thickened LV
walls with an underfilled ventricle. Wall motion is unchanged
from prebypass, with EF 50% 3. The aortic annular ring can be
seen well seated with no perivalvular leak. There is +1 Aortic
insufficiency 4. The contours of the aortic root are smooth
after aortic cannular was removed.
[**2179-9-21**] CXR: As compared to the previous radiograph, there is no
relevant change. The monitoring and support devices are in
unchanged position. There is no evidence of pneumothorax and no
evidence of major pleural effusion. Subtle retrocardiac
atelectasis. No focal parenchymal opacities suggestive of
pneumonia. Mild overinflation of the stomach.
[**2179-9-19**] 05:25PM BLOOD WBC-6.3 RBC-5.04 Hgb-15.7 Hct-44.2 MCV-88
MCH-31.2 MCHC-35.6* RDW-13.5 Plt Ct-210
[**2179-9-22**] 05:35AM BLOOD WBC-21.5*# RBC-4.63 Hgb-14.0 Hct-41.6
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.9 Plt Ct-142*
[**2179-9-19**] 05:25PM BLOOD PT-15.1* PTT-30.8 INR(PT)-1.3*
[**2179-9-20**] 09:11PM BLOOD PT-15.9* PTT-39.0* INR(PT)-1.4*
[**2179-9-19**] 05:25PM BLOOD Glucose-92 UreaN-19 Creat-1.2 Na-142
K-3.9 Cl-108 HCO3-26 AnGap-12
[**2179-9-22**] 05:35AM BLOOD Glucose-153* UreaN-20 Creat-1.2 Na-133
K-4.5 Cl-100 HCO3-19* AnGap-19
[**2179-9-19**] 05:25PM BLOOD ALT-23 AST-23 LD(LDH)-203 AlkPhos-56
TotBili-0.9
[**2179-9-25**] 08:16AM BLOOD WBC-7.6 RBC-4.02* Hgb-12.1* Hct-35.8*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.1 Plt Ct-174#
[**2179-9-22**] 12:27PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Brief Hospital Course:
Mr. [**Known lastname 1274**] was admitted a day before surgery d/t being on
Coumadin for h/o Atrial Fibrillation. He discontinued it 5 days
before surgery. Upon admission he was started on Heparin and
appropriately worked up for surgery. On [**9-20**] he was brought to
the operating room where he underwent a aortic valve replacement
and coronary artery bypass graft x 1. Please see operative
report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Later on op day he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one EP was
consulted to interrogate his pacemaker. Later on this day Mr.
[**Known lastname 1274**] appeared to be doing well and was transferred to the
telemetry floor for further care.
Mr [**Known lastname 1274**] was in chronic afib that was difficult to control and
his metoprolol was advanced. He was re-started on coumadin on
POD 2. A rub was noticed and he was started on Ibuprofen.The
remainder of his postoperative course was essentially
unremarkable. [**9-22**] due to an elevated WBC ct. blood and urine
cultures were sent and empiric antibiotics were started. Urine
Cx originally positive and sensitive to ABX but repeat finalized
negative. The WBC ct improved to normal and his temp.remained
afebrile, at time of discharge blood cultures were pending, it
was decided to continue a full week of antibiotic coverage. He
was restared on his preoperative dose of Digoxin, along with his
preoperative Coumadin regiment of 5 mg alt. with 2.5 mg daily,
with VNA. He was advised on all follow up appointments.
Medications on Admission:
Atenolol 100mg [**Hospital1 **], Prilosec 20mg qd, Tricor 146mg qd, Digoxin
0.25mg qd, Vit C, D and E, Zetia 10mg qd, Coumadin (stopped [**9-14**])
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:*1*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*1*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
7. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: resume
5mg alternating with 2.5 mg daily or [**Name8 (MD) **] MD .
Disp:*90 Tablet(s)* Refills:*0*
8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 7
days.
Disp:*28 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 4 days.
Disp:*32 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1
PMH: Gastroesophageal Reflux Disease, Atrial Fibrillatoin s/p
Ablation, s/p PPM [**2174**], Erectile Dysfunction s/p Hernia repair,
s/p Bilat knee arthroscopy
Discharge Condition:
good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain. In the event that you have drainage
from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**].
Report any fever greater then 100.5. Report any weight gain of 2
pounds in 24 hours or 5 pounds in 1 week.
No lotions, creams or powders to incision until it has healed.
Shower daily. No baths or swimming.Gently pat the wound dry.
o lifting greater then 10 pounds for 10 weeks.
No driving for 1 month
Take all medications as directed
Followup Instructions:
wound clinic in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] in [**2-14**] weeks
Completed by:[**2179-9-25**]
ICD9 Codes: 4280, 5990, 4241, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 30
} | Medical Text: Admission Date: [**2124-7-14**] Discharge Date: [**2124-7-19**]
Date of Birth: [**2067-12-2**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 year old with alcoholic cirrhosis and end-stage liver disease
who has been "in and out" of the [**Location 24355**] over
the past few months for repeated episodes of LE cellulitis
including ? nec fascitis on one occasion. He had been in a
rehab hospital today (was sent there from the VA) and was
feeling well per his report, wanting to be D/C'd when they got
labs that were concerning (hct, cr) and sent him to [**Hospital 6451**] Hospital. There he was found to have a Hct of 27, SBP
in the 60's, Melena. He was started on levophed and NS "wide
open" through one 20 Ga IV. He was transferred here. On
arrival in the ED here, he was afebrile, HR 91, BP 72/36 RR 20
Sat 96% on 2L. He was given 2 18 Ga PIV, a Rt. femoral TLC,
Vitamin K, a litre of NS, FFP (3 U), 1 U PRBC and IV protonix.
GI and renal were consulted. His Cr. was 3.6, his K was 5.8,
but he was not noted to have any ECG changes on 12-lead; he was
given kayexelate.
.
MICU admission requested.
Past Medical History:
Alcoholic cirrhosis with end-stage liver disease - not on
transplant list anywhere per pt. (was to be evaluated for this).
CRI (? baseline Cr.)
Mult. recent episodes cellulitis
DM2
Social History:
etoh, last drink per pt. over 10 yy ago; no IVDU, was in Army,
also worked as a delivery man
Family History:
DM - mother, denies hx. CHD in family
Physical Exam:
VS: BP 60's over 40's HR 115, AF, R 25, 96% NC
HEENT EOMI, sclerae are icteric
COR: Tachy, regular, [**12-27**] hsm
PULM: CTA ant
ABD: Distended and tense ascites
EXT: 4+ LE edema
NEURO: Alert, oriented to place, time, event
Brief Hospital Course:
Patient was admitted to the MICU. His condition continued to
deteriorate despite all measures and he was made DNR/DNI in
consensus with his family on [**2124-7-18**]. He continued to decline
and in the morning of [**2124-7-19**], after verbal discussion with
his three children, patient was made COMFORT MEASURES ONLY. He
was treated with morphine for respiratory distress and pressors
were withdrawn. Patient passed away shortly thereafter and was
pronounced deceased on [**7-19**] at 00:20 by [**First Name8 (NamePattern2) 11556**] [**Last Name (NamePattern1) 18721**] MD
and [**First Name8 (NamePattern2) 2894**] [**Last Name (NamePattern1) **] MD.
.
.
.
IMP:56 y/o with ETOH cirrosis and end-stage liver disease who
presented to OSH from rehab with hypotension, melena
.
#Hypotension: Likely cause is GIB/hypovolemia.
Place A line, cont. to bolus for Map less than 65. Add
vasopressin if not responding to levophed and IVF. Monitor UOP.
Serial Hct. Transfuse for hct less than 25. FFP to correct
coagulopathy. Discuss with GI.
.
#Melena - as above, call GI. [**Month (only) 116**] need NGL. Serial Hct. PPI IV
BID. Octreotide gtt.
.
#Cirrhosis/liver disease: obstructive picture. Patient had
pericentesis x 2 in order to relieve his abdominal ascites. The
first removed 4.5 liters of clear yellow ascites fluid and the
second removed about 2 liters.
Consult liver. Continue lactulose. Follow INR. Check albumin.
Hold diuretics while hypotense.
.
#Renal failure: ? baseline Cr. Possible HRS vs. pre-renal from
volume depletion [**12-23**] GIB. Consult liver and renal, continue
volume repletion, maintain SBP as above. Consider albumin post
tap, Consider adding midodrine. Patient was started on CVVH.
.
#Hyperkalemia: Resolved.
.
# FEN: IVF as above, lytes prn, NPO given GIB.
.
# PPX: PPI [**Hospital1 **], coagulopathic.
.
# Access: 2 PIV, TLC lt. groin.
.
# Code: COMFORT MEASURES ONLY
.
# Communication: Daughter - [**Name (NI) **], [**First Name3 (LF) **], and daughter [**Name (NI) **]
.
# Disposition: MICU
Medications on Admission:
Aldactone
Calcium
Lasix
Insulin
Lactulose
Nepro
Ocycodone
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
ICD9 Codes: 5845, 2875, 5859, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 31
} | Medical Text: Admission Date: [**2139-9-8**] Discharge Date: [**2139-9-26**]
Date of Birth: [**2082-11-16**] Sex: F
Service: Newurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
female with no past medical history who had sudden onset of
midback pain and severe headache. She said it felt like a
bomb while giving a speech in [**Country 2784**]. She finished her
speech and vomited once. This was on [**2139-9-4**]. The headache
persisted. She returned to the United States the following
day with increased fatigue, headache and backache. She went
to [**Hospital3 **] Emergency Department on [**2139-9-7**], where a
CTA revealed a large bilobed 1.2 to 2.0 centimeter ACA
aneurysm, was transferred to [**Hospital 4415**] on
[**2139-9-7**], for further workup. CTA was repeated confirming
the previously mentioned aneurysm. She was transferred to
[**Hospital1 69**] for embolization of the
aneurysm.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: None.
SOCIAL HISTORY: ETOH and was a thirty pack year smoker.
PHYSICAL EXAMINATION: Neurologically she was completely
intact. Speech was clear. The pupils were reactive to light
and accommodation, 3.0 millimeters and brisk. No facial
asymmetry. No drift. Speech was clear and fluent, awake,
alert and oriented times three. Vital signs revealed blood
pressure 92 to 106 over 60 to 70s, respiratory rate 14 to 18.
HOSPITAL COURSE: The patient was admitted and went directly
to the angiography suite where she had her bilobed ACA
aneurysm coiled. The coiling was only partially done at that
time. During the actual angiogram and coiling, the patient
did complain of chest pain. She was seen by cardiology in
the angiography suite and the chest pain resolved on its own.
It was felt to be anxiety produced. Postoperatively, vital
signs are temperature 96.0, blood pressure 103/60, pulse 69,
respiratory rate 18, oxygen saturation 99%. The patient was
awake, alert and oriented times three. She was unsure of
which hospital but was recently transferred. She did know
the month and not the day. Negative drift, symmetric smile.
The pupils were equal and reactive times light and
accommodation, 2.5 to 2.0. She did have some left
conjunctival hematoma. Positive pedal pulse. Groin was
intact with sheath. Her upper and lower extremities revealed
motor strength was [**3-23**]. She followed commands. She had no
headache. Her white blood cell count was 9.4, hematocrit
32.9. Her preoperative hematocrit was 37.7. Her prothrombin
time was 15.4, partial thromboplastin time 150. INR was 1.6.
On the first postoperative day, the patient's vital signs
were in the 99 to 100 range. She was awake and alert and
oriented times three. She complained of seven out of ten
headache, no diplopia. Extraocular movements were full.
Visual fields were intact. Negative drift. Grip was [**3-23**].
Positive femoral right pulse. She remained in the neurologic
Intensive Care Unit where she received Nimodipine 30 mg
q2hours, normal saline at 150 per hour. Central line was
placed. Her blood pressure was kept less than 140. Heparin
was continued at 600 per hour. On [**2139-9-9**], the patient was
brought back to complete her coiling. Postoperatively, she
was awake, alert and oriented times three. Her speech was
fluent. Naming was intact. She followed commands. Her
right groin sheath remained intact. Her blood pressure was
kept in the 100 to 130 range. She needed to remain on
Heparin as the apparent vessel was possibly thrombosed and we
did not want to wean her off. Heparin was kept at 600 per
hour. We did not want the area to thrombose quickly. Her
coiling went well and was successful. She remained on
Heparin postoperatively. The patient remained in the
Intensive Care Unit on Heparin and her partial thromboplastin
time was kept between 60 to 80. The sheaths remained in
place. On [**2139-9-14**], the patient was awake, alert and
oriented with no complaints and grips were [**3-23**], no drift.
The patient's Heparin drip was reduced on [**2139-9-14**], and she
was started on Aspirin 325 mg once daily. However, the
patient did start to complain of blurry vision with
peripheral type tunneling of the left eye lasting thirty to
forty-five minutes. A retinal fellow was consulted where she
was found not to have any evidence of vascular occlusion.
She did have some decreased vision in the left eye, however,
the patient claimed it was lasting greater than 1.5 years.
It was felt to be an ocular migraine in her left eye. The
patient did continue to stay on Heparin. On [**2139-9-15**], her
partial thromboplastin time was at 50. She was seen by the
retinal specialist who still felt that it was an ocular
migraine and they did sign off and wanted to follow-up as an
outpatient. Heparin was stopped on [**2139-9-16**]. Aspirin 81 mg
was continued. Her sodium was 136, and had dropped to 134.
Those were monitored twice a day. On [**2139-9-16**], the patient
underwent a cerebral angiogram to check the progressive
thrombus of the coiled left internal carotid artery. Stable
appearance of the coils were noted on that day. She was to
start on Plavix at 75 mg once daily and Aspirin 325 mg once
daily. She no longer needed Heparin. Postoperative check,
she was awake, alert. Extraocular movements were full, no
drift. On [**2139-9-18**], she remained awake and alert with no
headaches at this time. Extraocular movements were full.
Her face was symmetric. Her sodium was 134. Again, her
angiogram the previous day showed no spasm. Intravenous
fluids were kept at 150 per hour. She did continue on the
Nimodipine. On [**2139-9-18**], we did ask the retinal specialist
to reexamine the patient as she complained of decreased
vision in her left eye for the last one to two days. Her
ophthalmic examination was within normal limits. Her
decreased acuity to her left eye was unclear. Possibilities
included mass effect, compression of the aneurysm. They
recommended considering intravenous steroids, also
recommended getting an ESR, CRP and then a neurologic
ophthalmology consultation. Neurophthalmology did seen the
patient and felt that there was some compression of optic
neuropathy but they felt that it was related to her ACA
aneurysm and mass effect. They did request some steroids.
The patient was started on Decadron 4 mg p.o. q6hours. On
[**2139-9-19**], her vision was improved. On [**2139-9-21**], the patient
underwent status post neuroform stent mediated coiling of her
right internal carotid artery aneurysm. Postoperatively, she
did well with no intraoperative complications.
Postoperatively, she was to stay on Plavix and Aspirin. Her
sheaths remained in place overnight and she remained on
Heparin overnight. Postoperatively, she was alert without
complaints, denied headaches or double vision. Her left
groin was oozing around the sheath. Dressing was replaced.
The pupils are equal, round, and reactive to light and
accommodation. Extraocular movements were full. Visual
fields were full to confrontation. They recommended one unit
of packed red blood cells. Her blood pressure was kept in
the 120 range and continued on Aspirin and Plavix.
Postoperatively, her hematocrit was 28.5 and on [**2139-9-22**], she
did receive one unit of packed red blood cells. Sheath was
removed. On [**2139-9-23**], her vital signs were temperature 98.2,
blood pressure 97/49. White blood cell count was 10.0,
hematocrit was now 32.1, platelet count 364,000. The patient
was neurologically intact. There was no sign of hematomas.
On [**2139-9-24**], the patient was transferred out of the
Neurologic Intensive Care Unit. She was given a physical
therapy consultation. Her intravenous fluids were decreased
to 100 per hour. Her diet was increased as tolerated. She
was given intravenous boluses for her systolic blood pressure
less than 100. She remained on the surgical floor. The
patient was discharged on [**2139-9-26**].
DISCHARGE INSTRUCTIONS:
1. No strenuous exercise, no driving until cleared by Dr.
[**Last Name (STitle) 1132**].
2. She is to follow-up with Dr. [**Last Name (STitle) 1132**] in one week and
neurophthalmology, she was given the telephone number to
call.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. once daily.
2. Percocet 5/325 one to two tablets p.o. q3-4hours as
needed.
3. Plavix 75 mg p.o. once daily.
4. Aspirin 325 mg p.o. once daily.
5. Decadron wean over a week.
CONDITION ON DISCHARGE: The patient was discharged
neurologically stable on [**2139-9-26**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2139-10-28**] 13:00
T: [**2139-10-31**] 10:17
JOB#: [**Job Number 50244**]
ICD9 Codes: 2761, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 32
} | Medical Text: Admission Date: [**2198-2-1**] Discharge Date: [**2198-2-19**]
Date of Birth: [**2129-10-28**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 68 year old white male had
an abnormal stress test in 02/[**2194**]. He underwent cardiac
cath which revealed 100 percent RCA lesion. He had angina
again in [**2196**] and had an abnormal stress test and was re-
cathed, and that showed 100 percent RCA lesion, a 50 percent
left main stenosis, and a left circumflex stenosis. He had
no symptoms and surgery was deferred. He now has had a month
of angina again and had an abnormal treadmill with an EF down
to 27 percent. An angio on [**2198-1-31**] revealed a 95 percent
ostia left main, a 70 percent diagonal 2 lesion, 80 percent
OM and 100 percent RCA lesion with a normal LV. So he was
transferred to [**Hospital1 18**] for further treatment.
PAST MEDICAL HISTORY: His past medical history is
significant for a history of non-insulin dependent diabetes,
hypercholesterolemia, hypertension, prostate CA, and status
post removal of a basal cell carcinoma from his back two
weeks prior to admission. He is also status post cataract
surgery.
MEDICATIONS: His medications on admission were nitroglycerin
drip, Metformin, Lipitor, aspirin, multivitamin, Metamucil,
Atenolol.
ALLERGIES: He has no known allergies.
FAMILY HISTORY: Family history is significant for coronary
artery disease.
SOCIAL HISTORY: He does not smoke cigarettes and drinks
alcohol occasionally.
REVIEW OF SYSTEMS: His review of systems is as above.
PHYSICAL EXAMINATION: He is a well developed, well nourished
white male in no apparent distress. Vital signs stable.
Afebrile. HEENT exam normocephalic and atraumatic.
Extraocular movements are intact. Oropharynx benign. Neck
was supple. Full range of motion. No lymphadenopathy or
thyromegaly. Carotids 2 plus and equal bilaterally without
bruits. Lungs were clear to auscultation and percussion.
Cardiovascular exam regular rate and rhythm. Normal S1 and
S2 with no rubs, murmurs or gallops. Abdomen was soft and
nontender with positive bowel sounds. No masses or
hepatosplenomegaly. Extremities without cyanosis, clubbing
or edema. Pulses were 2 plus and equal bilaterally
throughout. Neuro exam was nonfocal.
HOSPITAL COURSE: Dr. [**Last Name (STitle) **] was consulted and on [**2198-2-2**]
the patient underwent a CABG times five with a free LIMA to
the LAD and reverse saphenous vein graft to the diagonal,
OM1, OM2 and PVA. Cross clamp time was 89 minutes. Total
bypass time was 125 minutes. He was transferred to the CSRU
on Neo in stable condition. He had a stable postop night.
He was extubated. On postoperative day one he was started on
a beta blocker and his nitro was weaned. Postop day two he
was transferred to the floor in stable condition and his
chest tubes were discontinued. Postop day three his
epicardial pacing wires were discontinued. Postop day number
four he began having sternal drainage. He was started on
Kefzol and had his wounds painted with Betadine tid. He did
have some more drainage and his lower two sternal wires
seemed to have pulled through on his x-ray, so on postop day
number five he underwent sternal re-wiring. He tolerated the
procedure well and was transferred back to the floor. He
continued to improve and had his chest tubes discontinued on
postop day number one from re-wiring. He was also changed to
Levofloxacin and Vanco. He continued to improve but
continued to have intermittent sternal drainage. He had
cultures which were negative. He had a PICC line placed and
was continued on Vanco. Eventually his drainage stopped
completely and he had two days of no drainage and his Vanco
was discontinued and he was discharged to home on a week of
Levofloxacin. So on postop day number 17 he was discharged
to home in stable condition.
LABORATORY DATA: His labs on discharge were white count
10,000, hematocrit 28.1, platelets 767,000, sodium 139,
potassium 5.2, chloride 104, CO2 28, BUN 17, creatinine 0.9,
blood sugar 116.
DISCHARGE MEDICATIONS:
1. Glucophage, 500 mg po bid.
2. Colace, 100 mg po bid.
3. Aspirin, 81 mg po q day.
4. Percocet, 1 to 2 po q4-6h prn pain.
5. Lipitor, 10 mg po q day.
6. Plavix, 75 mg po q day.
7. Lopressor, 100 mg po tid.
8. Lisinopril, 10 mg po q day.
9. Levofloxacin, 500 mg po q day for 7 days.
He will be seen by Dr. [**Last Name (STitle) **] in four weeks and by Dr. [**Last Name (STitle) 37063**]
in one to two weeks.
DISCHARGE DIAGNOSES: His discharge diagnoses include:
1. Coronary artery disease.
2. Hypertension.
3. Hyperlipidemia.
4. Non-insulin dependent diabetes.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2198-2-19**] 15:54:20
T: [**2198-2-19**] 16:33:56
Job#: [**Job Number 58744**]
ICD9 Codes: 4111, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 33
} | Medical Text: Admission Date: [**2111-5-25**] Discharge Date: [**2111-5-29**]
Date of Birth: [**2063-5-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 47 yo female with chronic pain in low back and
torticollis who has been hospitalized for 7 previous medication
overdoses(always denies SI)(most recently 2 days ago) who now
presents s/p OD on some combination of meds (baclofen, vicodin,
soma, fentanyl patches, methadone). Unclear if suicide attempt,
but she has denied this with each of her past ODs. Most recent
hospitalization indicates o/d on diazepam, methadone, baclofen.
Today found by halfway house staff "nodding off" and minimally
responsive (to sternal rub only). No other reports available.
Unable to contact halfway house o/n.
Past Medical History:
PMH:
1. Polysubstance overdose -- Pt had 5 suicide attempts within a
five month period in [**2109**]. Also recently admitted here [**Date range (1) 76337**]
for overdose of vicodin/soma/baclofen which she states was not
suicide attempt, but rather attempt to control pain.
2. Substance abuse-EtOH.
3. Depression- Seen at [**Hospital1 1680**] HRI and the Mind Body Institute
4. ? Bipolar disorder
5. Chronic buttock/back pain: trigger point injections to the
lower back region.
6. Cervical torticollis: receives botox injections, severe
left-sided head tilt together with what may be a compensatory
tilt in the opposite direction of her thoracic spine. Pain is
in region of right sternomastoid and right posterior cervical
muscles.
7. Gastroesophageal reflux disease.
8. h/o MRSA in sputum [**2108**], not treated
9. h/o assault requiring ICU admit last year.
10. h/o multiple miscarriages, 1 late in pregnancy, and h/o 2 yo
daughter drowning.
11. Recently started on methadone for pain control on [**2-17**]
.
Providers:
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5781**] at [**Company 191**], [**Telephone/Fax (1) 250**]
Neuro: Dr. [**Last Name (STitle) **] at [**Hospital1 18**], [**Telephone/Fax (1) 1942**]
Ortho: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], [**Telephone/Fax (1) 7807**]
Spinal surgeon: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28003**]
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Management Service: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 49911**]
.
PSYCHIATRIC HISTORY:
Diagnoses: depressed [**Telephone/Fax (1) **], question of bipolar disorder
h/o alcohol abuse, narcotic abuse; sexual assault
Hospitalizations: At HRI, [**Doctor Last Name 16471**], [**Hospital3 44097**].
Suicide Attempts: patient denies
Current [**Hospital3 2447**]: Dr. [**Last Name (STitle) 105809**] and
therapist: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 105810**] at [**Location (un) 86**] [**Hospital1 1680**] Trauma Center in
[**Location (un) 577**] [**Telephone/Fax (1) 7353**] (L/M with after hours line)
Counselor: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 105817**]
Social History:
Lives in [**Location 3952**] House. Smokes [**11-16**] ppd for 10 yrs. documented
h/o EtOH abuse in past, + abuse of prescription meds
Family History:
NC
Physical Exam:
VS 95.0 117/59 78 14 98% 2L NC
Gen: disheveled woman sleeping, responds to painful/noxious
stimuli
HEENT: anicteric, PERRL --> 4mm B, OP clear w/ MMM
CV: reg s1/s2, no s3/s4/m/r
Pulm: CTA B (poor effort), no wheezes or crackles
Abd: +BS, soft, NT, ND
Ext: warm, 2+ DP B, no edema
Neuro: responds to noxious stimuli, + gag reflex, moves all 4
extr.
Pertinent Results:
Pertinent Admission Labs:
wbc 7.7, hct 33.5, INR 1.0. Serum ASA 9, Ammonia 26, Utox +
benzo and methadone (neg for cocaine, opiates)
LFTs: ALT 14, AST 19, A/P 98, Tbili 0.1
.
EKG: NSR at 80, nl axis, nl intervals, no ST/T changes
CXR: R LL atelectasis
Brief Hospital Course:
47 y/o female with chronic pain in low back and torticollis who
has been hospitalized for 7 previous medication overdoses who
presents s/p likely OD with minimal responsiveness. A brief
[**Hospital 11822**] hospital course is outlined below.
1. mental status changes/respiratory depression: Likely
secondary to medication effects from substance abuse/overdose.
Of note initial tox screen positive for benzos and methadone.
Remainder of tox screen was negative. She was given narcan
initially at max dose of 1mg/hr without increased
responsiveness. Therefore this was discontinued. Her mental
status gradually improved over the next 24 hours. Of note, she
did not need intubation for respiratory support and she had no
evidence for withdrawl signs or symptoms. She was kept on
diazepam 5mg q4prn for CIWA scale > 12, however did not require
any valium. CIWA scale was subsequently discontinued. All
further benzos or opioid analgesics were stopped.
2. Psych: Initially held all meds on admission. Neurontin,
lamictal, seroquel restarted upon improvement of MS. Pt with
extensive psychiatric history including history of polysubstance
abuse and OD. Psych consulted day after admission - recommended
1:1 sitter, which was obtained. Also recommended holding off on
giving any benzos, other addictive substances - per psych,
unlikely for patient to withdraw because of long half life,
although kept on CIWA in case. Now off CIWA. Discontinued
lamictal per psych recs. Increased seroquel dose for symptoms of
anxiety. Plan for section 35 for patient to mandatorily receive
drug rehab.
3. Torticollis: Recieved botox injection by Dr. [**Last Name (STitle) **] on this
hospital stay.
Medications on Admission:
1. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Lamictal 25 mg Tablet Sig: One (1) Tablet PO once a day. 7
TABLETS ONLY
5. ASA prn
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day) as needed.
9. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
primary diagnosis:
1. respiratory depression
2. altered mental status
3. substance abuse/overdose
Secondary diagnosis:
1. torticollis
2. h/o suicide attempts
3. h/o substance abuse
4. depression
5. MRSA in sputum [**2108**]
Discharge Condition:
section 35 for involuntary detox
Discharge Instructions:
Report nausea, vomiting, fever, chills, shortness of breath or
pain not controlled by current regimen or other medical issues
to your primary physician.
Followup Instructions:
follow-up with your primary physician for any medical issues
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 34
} | Medical Text: Admission Date: [**2178-12-25**] Discharge Date: [**2178-12-27**]
Date of Birth: [**2116-2-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Transfer from [**Hospital3 **] where she was admitted for
atypical chest pain and SOB
Major Surgical or Invasive Procedure:
-Central venous line insertion into R IJ
-Multiple attempts at securing arterial access
History of Present Illness:
62F with hx of severe of pulm HTN, CAD s/p DES to Lcx/LAD in
[**10/2177**], prior CVA s/p b/l CEA's, PVD, and COPD who was admitted
to OSH [**12-23**] for atypical chest pain and SOB. She ruled out for
ACS with by enzymes (MB 8 -> 7 -> 5; Trop 0.06 -> 0.07 -> 0.06)
and EKG without acute ischemic changes but was found to have a
BNP of 11K on admission. She was assessed as having severe
decompensated R-sided CHF and was diuresed with 40mg IV lasix in
the ED but later that day experienced [**9-9**] back pain with desat
to the 50's and was transferred to the CCU for close monitoring
with HR in the 60's and BP's in the 90's. She had ECHO on [**12-24**]
which showed severe pulmonary hypertension, RV pressure
overload, modestly depressed RV function, and LVEF of 55-65%.
.
Here in the CCU she describes feeling gradually more short of
breath over the past 2 months which has become acutely worse in
the past 1-2 weeks. Interestingly, about 1 month ago she was
started on sildenafil for treatment of her pulm htn but felt she
became more short of breath when taking that medication and
stopped taking it about 2 weeks ago when she started feeling
acutely more short of breath. She states that she has only
gained about 2-3lbs in the past two weeks but noticed increased
ankle swelling, increasing need for oxygen (she is usually at
88-92 on 3LNC at home but prior to these past 2 weeks she has
only used oxygen at night). She has 2 pillow orthopnea, but
denies PND. She denies dietary indiscretion, recent illnesses,
fevers, chills, cough, sputum production, or other symptoms.
According to her family she has never had low back pain as a
problem before but the patient states her back pain gets better
with positional changes and rubbing. Also, her baseline daily
function has decreased as she is normally able to move around
the rooms of house but has not been able to walk more than 10
feet due to shortness of breath in addition to her basleine
vascular claudication.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY: CAD s/p LAD cypher stenting
- CABG: n/a
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
-Occult SBE with aortic valve vegetation
-Severe pHTN
-Severe PVD s/p multiple vascular surgeries
-Rt Fem-[**Doctor Last Name **] bypass
-Rt CEA following CVA prior to [**2173**]
-Lt CEA following TIA [**2173**]
-Stenting of LCx DPromus [**Name Prefix (Prefixes) **]
-[**Last Name (Prefixes) **] of Prox/Mid LAD with Promus Stent
Social History:
Pt livers with two daughters at home.
Tob: 0.5ppd x40years (since age 17)
EtOH: social - 2 beers every 2 weeks
Illicit drug use: denies
Family History:
Father had MI in his 50's and stroke in his 60's. Siblings with
DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=96.7 BP=103/66 HR=72 RR=10 O2 sat= 93% non-rebreather
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to the earlobes
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, loud S2. No m/r/g. S3 at apex. No thrills,
lifts.
LUNGS: Rales halfway up bases
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting to mid shin, several old scars from
prior vascular surgery procedures. No femoral bruits.
SKIN: Mild stasis dermatitis changes.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP dopplerable, PT
dopplerable
.
DISCHARGE PHYSICAL EXAM:
Patient expired.
Pertinent Results:
ADMISSION LABS:
.
[**2178-12-25**] 06:24PM BLOOD WBC-12.5* RBC-4.46 Hgb-11.4* Hct-35.8*
MCV-80* MCH-25.5* MCHC-31.7 RDW-17.5* Plt Ct-348
[**2178-12-25**] 06:24PM BLOOD Neuts-77* Bands-0 Lymphs-18 Monos-4 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1*
[**2178-12-25**] 06:24PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Burr-2+
[**2178-12-25**] 06:24PM BLOOD PT-17.0* PTT-34.3 INR(PT)-1.5*
[**2178-12-25**] 06:24PM BLOOD Glucose-40* UreaN-45* Creat-1.8* Na-131*
K-3.6 Cl-93* HCO3-22 AnGap-20
[**2178-12-25**] 06:24PM BLOOD CK(CPK)-180
[**2178-12-26**] 05:17AM BLOOD ALT-81* AST-65* LD(LDH)-365* CK(CPK)-149
AlkPhos-88 TotBili-1.2
[**2178-12-25**] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37*
[**2178-12-25**] 06:24PM BLOOD Calcium-8.7 Phos-5.6* Mg-1.4*
.
PERTINENT LABS:
.
[**2178-12-25**] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37*
[**2178-12-26**] 05:17AM BLOOD CK-MB-11* MB Indx-7.4* cTropnT-0.31*
[**2178-12-26**] 08:54PM BLOOD CK-MB-9 cTropnT-0.35*
[**2178-12-27**] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00*
[**2178-12-27**] 04:23AM BLOOD Cortsol-32.8*
[**2178-12-27**] 04:23AM BLOOD TSH-2.1
[**2178-12-26**] 05:41AM BLOOD Lactate-1.7
[**2178-12-26**] 03:52PM BLOOD Lactate-2.5*
[**2178-12-26**] 11:26PM BLOOD Lactate-7.5*
[**2178-12-27**] 01:50AM BLOOD Lactate-8.7*
[**2178-12-27**] 04:24AM BLOOD Lactate-11.1*
[**2178-12-27**] 05:05AM BLOOD Lactate-10.3*
[**2178-12-27**] 11:38AM BLOOD Lactate-5.1*
[**2178-12-26**] 03:52PM BLOOD Type-ART pO2-52* pCO2-35 pH-7.42
calTCO2-23 Base XS
[**2178-12-27**] 01:50AM BLOOD Type-[**Last Name (un) **] pO2-40* pCO2-69* pH-7.02*
calTCO2-19* Base XS--15
[**2178-12-27**] 04:24AM BLOOD Type-CENTRAL VE pO2-53* pCO2-60* pH-7.10*
calTCO2-20* Base XS--11
[**2178-12-27**] 05:05AM BLOOD Type-CENTRAL VE pO2-52* pCO2-58* pH-7.16*
calTCO2-22 Base XS--8
[**2178-12-27**] 11:38AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-73* pH-7.20*
calTCO2-30 Base XS--1
.
DISCHARGE LABS:
.
[**2178-12-27**] 11:16AM BLOOD WBC-26.6*# RBC-4.37 Hgb-11.3* Hct-36.8
MCV-84 MCH-25.8* MCHC-30.6* RDW-16.9* Plt Ct-335
[**2178-12-27**] 04:23AM BLOOD Glucose-506* UreaN-41* Creat-1.8* Na-131*
K-4.2 Cl-89* HCO3-19* AnGap-27*
[**2178-12-27**] 04:23AM BLOOD ALT-226* AST-262* LD(LDH)-905*
CK(CPK)-288* AlkPhos-89 TotBili-1.7*
[**2178-12-27**] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00*
[**2178-12-27**] 04:23AM BLOOD Albumin-3.4* Calcium-8.1* Phos-7.3*#
Mg-2.5
[**2178-12-27**] 11:38AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-73* pH-7.20*
calTCO2-30 Base XS--1
[**2178-12-27**] 11:38AM BLOOD Lactate-5.1*
.
MICRO/PATH:
.
Blood Cultures x 2: Pending
MRSA Screen: Pending
.
IMAGING/STUDIES:
.
CXR Portable [**12-25**]:
IMPRESSION: Mild interstitial pulmonary edema is present, along
with a very small right pleural effusion, decreased since [**9-5**]. Heart size is top normal, and the main pulmonary artery is
substantially dilated, as before indicating persistent pulmonary
arterial hypertension. Previous mediastinal adenopathy
documented on the chest CT in [**Month (only) 216**] is difficult to assess but
probably has not worsened. No pneumothorax.
.
Aorta/Branches U/S [**12-25**]:
IMPRESSION: No evidence of abdominal aortic aneurysm.
Atherosclerosis.
.
CXR Portable [**12-25**]:
Tip of the new right internal jugular line ends in the region of
the superior cavoatrial junction. No pneumothorax or increase in
small right pleural effusion. Interval increase in mediastinal
caliber due to vascular
engorgement, and due to elevated central venous pressure,
probably a function of biventricular heart failure, reflected
mild increase in the heart size, moderate increase in pulmonary
edema. Severe pulmonary atrial enlargement, an indication of
marked pulmonary arterial hypertension, aortic valvular
calcification, which could be hemodynamically significant
(particularly in setting of decreased LV filling), and severe,
global coronary calcification were shown on a Chest CT in [**Month (only) 216**]
[**2178**], discussed with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30814**] at the time of dictation.
.
R LENI [**12-26**]:
IMPRESSION: Limited assessment of the right lower extremity due
to early
termination of the examination. No DVT seen in the examined
veins.
.
CXR Portable [**12-27**]:
FINDINGS: In comparison with the study of [**12-25**], there has been
placement of an endotracheal tube with its tip at the upper
clavicular level, approximately 6.5 cm above the carina.
Nasogastric tube extends into the upper stomach, though the side
hole is within the lower portion of the esophagus. Continued
enlargement of the cardiac silhouette with substantial pulmonary
arterial enlargement consistent with pulmonary artery
hypertension. There is moderate pulmonary edema as well.
.
TTE [**12-27**]:The left atrium is mildly dilated. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis. The basal inferolateral wall
contracts best (LVEF = 25%). The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis.
[Intrinisic right ventricular systolic function is more
depressed given the severity of tricuspid regurgitation.] There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
are mildly thickened (?#). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate
to severe [3+] tricuspid regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with extensive systolic dysfunction c/w diffuse
process (multivessel CAD, toxin, metabolic, etc.). Marked right
ventricular cavity dilation with free wall hypokinesis and
abnormal septal motion c/w marked pulmonary artery hypertension
(not quantified). Moderate to severe tricuspid regurgitation.
Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2178-10-16**],
biventricular systolic function has deteriorated and the heart
rate is much higher. Biventricular cavity size is similar.
Brief Hospital Course:
62F with hx of severe of pulm HTN, CAD s/p DES to Lcx/LAD in
[**10/2177**], prior CVA s/p b/l CEA's, PVD, and [**Hospital 2182**] transferred from
OSH for evaluation and management of right-sided diastolic CHF
exacerbation with background of severe pulmonary hypertension
who rapidly decompensated and passed away despite maximal
medical therapy.
.
ACTIVE DIAGNOSES:
.
# Right-sided Diastolic CHF Exacerbation: Pt with clinical
evidence of rales halfway up lung fields, JVD, and peripheral
edema on admission with CXR evidence of pulmonary edema and BNP
11,000 at OSH, and ECHO demonstrating fluid overloaded RV with
S3 gallop on exam. She was ruled out for ACS at OSH with
negative enzymes and non-ischemic EKG's and was transferred on
dopamine drip for pressure support with max O2 on venturi mask
in moderate respiratory distress satting in the low 90's. On
arrival to the CCU, R IJ was placed without complications and
she was started on sildenafil 20mg QID with the hope that
pressor support and vasodilatation of the pulmonary vasculature
would increase cardiac output and allow for gentle diuresis.
Unfortunately she was found to be anuric despite these measures
with a Cr of 1.8 on transfer up from 0.8-0.9 the days prior at
OSH. In the late morning the day following transfer, dobutamine
was added in an attempt to improve ionotropy but after this
medication was started her BP began to drop and over the next
few hours norepinephrine had to be added to maintain MAPs >65.
These medications were up and down titrated to try to achieve a
stable blood pressure but this kept ranging from 70/40-140/50.
No stability could be reached. At the same time her HR was
between 100-130's. The CCU team (including the CCU attending)
attempted to place an arterial line for better BP monitoring
given very severe peripheral vascular disease but this was
unsuccesful via the radial aproach. Anesthesia was contact[**Name (NI) **] to
attempt an axial arterial line but this was not deemed feasible.
The anesthesia attending attempted to obtain a L femoral
arterial line without success. The right side was not attempted
given her previous Fem-[**Doctor Last Name **] bypass. Through all of this her
oxygenation was worsening and she had to be switched to 100%
non-rebreather. At around 1600 dobutamine was stopped as this
was felt to be contributing to her persistently low BP's. She
remained stable until around 2100 when her BP again began to
decrease. A 250 mL NS bolus was given without response and
phenylephrine was started at this point. Also at around this
time her oxygen saturation began to drop and BiPAP was started.
At this point the patient was on dopamine, norepinephrine and
phenylephrine for BP support and BiPAP for respiratory support
with BP in the 79/55-101/57 and O2 sat of 90%. At 2300 (after ~3
hrs on BiPAP) given her tenious state with persistently low BP,
persistnently low O2 sat and tachypnea a discussion was held
with the patient and the family regarding endotracheal
intubation. Given her worseining cardiopulmonary status the CCU
team recommended intubation to try to achieve better
oxygenation, prevent respiratory colapse and to allow us to
manage her worsening heart failure while maintaing a patent
airway with adequate oxygenation. Anesthesia was called at 0000
for non-emergent intubation. This was performed succesfully and
the patient tolerated it well. At ~0030, milrinone was added in
an attempt to improve ionotropy. At this point the anesthesia
attending was asked for assistance in placing an arterial line
given the need for better blood pressure and oxygenation
parameters. Right radial was attempted as well as left femoral
without success. At around 0100-0130 her BP began to drop,
milrinone was stopped and vasopressin added. Despite these 4
pressors her BP continued to drop. At this point she was given
4 amps of bicarb, 1 mg epinephrine and 1 amp of calcium
carbonate. Her family was updated of her condition. Despite
all of these additions her BP continued to drop and at this
point a bicarb drip and an epinephrine drip were started. After
this she stabilized at around 0200 and remained with HR
120-130's and SBP 80-100's for the next several hours. At
around 0500 the ventilator began alarming due to high
peak/plateau pressures. This was thought to be due to pulmonary
edema as repeated succitioning brought up frothy fluid. She was
continued on max doses of 5 pressors throughout the day with
maximal respiratory settings for the sake of oxygenation. Her
condition continued to deteriorate despite maximal medical
support. Her family was made aware of her grave circumstances
and started to carefully consider her code status. She coded in
the later morning 2 days following transfer for pulseless
electrical activity and was coded briefly until resuscitative
efforts were halted per family request. The cause of her rapid
decline was unclear but hypothesis of the team included possibly
a PE (with suboptimal LENI which was negative). She has an
abdominal ultrasound to look for possible ruptured AAA given
report of acute onset low back pain at OSH but this was
negative.
.
# Anuric Acute Kidney Injury: Cr 1.8 on admission with
oliguria/near anuria, 0.6-0.7 at baseline. Was 0.9 yesterday at
OSH and making urine. Thought to be due to her brief hypotensive
episode after receiving bolus of 40mg IV lasix at OSH.
# Severe Chronic Pulmonary Hypertension/Cor Pulmonale: Unclear
etiology. Perhaps related to her mild-moderate COPD on CT
(although re-assuring spirometry in records) or possibly
recurrent embolic phenomena. She was treated aggressively as
above but unfortunately had a poor outcome.
.
CHRONIC DIAGNOSES:
.
# COPD/Hypoxia: PT with mild-moderate COPD changes on most
recent CT chest but with essentially normal PFT's. She requires
3LNC at home often worn during sleep but more recently during
the day and even when at rest. Has a 20-40 pack-year smoking
history. Not on any home COPD medications. She ended up
ventilated for respiratory support as above.
.
# CAD: Pt with severe 3VD with prior [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LCx and LAD in
8/[**2177**]. Non-ischemic EKG here on admission and at OSH. Enzymes
unimpressive x 3. No chest pain or discomfort. She was continued
on aspirin, plavix, and a statin.
.
# HLD: Stable. Continued on her statin.
.
# Severe PVD: Stable. Continued on her statin.
.
# NIDDM Complicated by Neuropathy: Stable. Managed on HISS while
in-house as well as lyrica and gabapentin prior to her
hemodynamic compromise.
.
TRANSITIONAL ISSUES:
-To the deep regret of the CCU team, Mrs. [**Known lastname **] did very poorly
over her hospital course. Her team took solace in the fact that
she was surrounded by her large, loving family and hopefully
felt little pain or suffering in her final hours.
Medications on Admission:
- Plavix 75mg PO daily
- Gabapentin 200mg PO QHS
- Aspirin 81mg PO daily
- Metoprolol succinate 100mg PO daily
- Ativan 1mg PO TID PRN
- Metformin 100mg PO BID
- Glyburide 2.5mg PO daily
- Lisinopril 2.5mg PO daily
- Torsemide 40mg PO daily
- Lyrica 100mg PO BID
- Tylenol PM 1 tab QHS
- Simvastatin 40mg PO daily
- Prilosec 20mg PO daily
- Niacin 500mg PO BID
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
-Severe Pulmonary Hypertension/Cor Pulmonale
-Biventricular diastolic congestive heart failure
-Severe peripheral vascular disease
-Chronic obstructive pulmonary disease
Discharge Condition:
Deceased
Discharge Instructions:
Patient was transferred from OSH for acute decompensated
biventricular heart failure complicated by severe pulmonary
hypertension. She was managed aggressively with pressors (5 at
max doses) with the goal to optimize her cardiac function with
the hope of inducing diuresis. Unfortunately her hemodynamics
declined rapidly. Code was called for PEA with initiation of
chest compressions and epi x 1 at which time code was called off
per family preference.
Followup Instructions:
N/A
Completed by:[**2178-12-28**]
ICD9 Codes: 5849, 4280, 496, 3572, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 35
} | Medical Text: Admission Date: [**2169-8-3**] Discharge Date: [**2169-8-10**]
Date of Birth: [**2169-8-3**] Sex: F
Service: NB
IDENTIFICATION: [**Known lastname 63410**] [**Known lastname 63411**] is a 7 day old former 40 [**5-4**] wk
infant with meconium aspiration syndrome and neonatal depression
who is being discharged from the [**Hospital1 18**] NICU.
HISTORY OF PRESENT ILLNESS: [**Known lastname 63410**] [**Known lastname 63411**] was born on [**2169-8-3**] as
the 2.74 kg product of a 40 and [**5-4**] week gestation pregnancy
to a 37 year-old, G4, P1 now 2 woman. Prenatal screens:
Blood type B positive, antibody negative, Rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, HIV
negative, group Beta strep status negative. The pregnancy
was notable for normal fetal survey and amniocentesis with
karyotype 46XX. On the day of delivery, the mother presented
with decreased fetal movements. Fetal heart rate monitoring
showed a non-reassuring pattern with decreased variability and
late decelerations, and the mother was taken for urgent Cesarean
section delivery. At delivery, meconium stained amniotic
fluid and nuchal cord were noted. The infant emerged limp
with poor tone and absent respiratory effort. She was
intubated with meconium suctioned from below the cords.
Subsequent resuscitation included vigorous stimulation and
positive pressure ventilation for approximately 1 minute,
with gradual improvement in color, tone and onset of
respiratory effort. Apgars were 3 at 1 minute, 7 at 5
minutes and 8 at 10 minutes. Cord blood pH was 6.95.
Due to persistent work of breathing and oxygen requirement, the
infant was admitted to the Neonatal Intensive Care Unit.
PHYSICAL EXAMINATION AT ADMISSION: Wt 2740 gm (10-25%) HC 34.5
cm (50-75%). BP 59/38 (51). O2sats in 70s-80s on 100% blow-by
oxygen. Well developed infant in moderate respiratory distress,
stunned appearing with decreased responsiveness and open eyes.
Fontanelles soft and flat. Palate intact. Red reflex present
bilaterally. Neck supple. Chest coarse, poorly aerated, with
moderate grunting, flaring, and retractions. Cardiac regular
rate and rhythm without audible murmur. Abdomen soft, no
hepatomegaly, 3-vessel cord that is thin and meconium stained.
Normal female genitalia, anus patent. Tone grossly normal,
activity decreased, no clonus.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
System #1, Respiratory: Secondary to significant hypoxia, [**Known lastname 63410**]
was placed on continuous positive airway pressure shortly after
admission to the NICU with 100% oxygen. Initial oxygen
saturations revealed pre-ductal saturations in mid-80s with
post-ductal saturations in mid-70s, consistent with persistent
pulmonary hypertension. CXR revealed diffuse increased
interstitial markings consistent with aspiration, as well as a
small right pneumothorax. Initial blood gas had a pH of 7.06
witha PC02 of 52, and pO2 of 55. Oxygen saturations gradually
improved to mid- to high-90s, and subsequent blood gas revealed
pH 7.22, pCO2 41, and pO2 68. She initially received normal
saline boluses in presence of pulmonary hypertension and
metabolic acidosis, and subsequently received sodium bicarbonate.
Her respiratory status steadily improved. The pneumothorax
resolved over the first 24 hours of life. She was able to
transition to nasal cannula 02 on the second day of life and by
day of life 3, had weaned to room air. At the time of discharge,
she is breathing comfortably in room air with a respiratory rate
of 30 to 60 breaths per minute.
System #2, Cardiovascular: As described above, [**Known lastname 63410**]'s initial
course was consistent with pulmonary hypertension. She received
two normal saline boluses, and remained hemodynamically stable
throughout. No murmurs have been noted. Baseline heart rate is
120 to 160 beats per minute with a recent blood pressure of 65/54
with a mean of 57.
System #3, Fluids, electrolytes and nutrition: [**Known lastname 63410**] was
initially n.p.o. and treated with intravenous fluids. She
had umbilical, arterial and venous catheters placed. Initial
blood glucose was 13. She required multiple boluses of
dextrose and eventual continuous infusion of 15% dextrose with
normalization of her blood glucose level. Enteral feeds were
started on day of life 3 and gradually advanced. She was able to
wean off the glucose infusions by day of life number 5. Serum
electrolytes were within normal limits throughout. At the time
of discharge, she is breast feeding ad lib. Discharge weight is
2.895 kg with a corresponding head circumference of 34 cm and
a length of 47.5 cm.
System #4, Infectious disease: [**Known lastname 63410**] was evaluated for
sepsis upon admission to the Neonatal Intensive Care Unit.
White blood cell count was 33,800 with a differential of 39%
polymorphonuclear cells, 2% band neutrophils. A blood
culture was obtained prior to starting intravenous Ampicillin
and Gentamycin. Blood culture was no growth at 48 hours.
[**Known lastname 63410**] did receive a 7 day course of antibiotics for presumed
sepsis and possible meconium pneumonitis. Gentamycin levels
were within normal limits. A lumbar puncture was performed and
was reassuring without evidence of meningitis.
System #5, Hematologic: Hematocrit at birth was 57%. Initial
platelet count was 72,000. This was followed daily through
day of life 3 when her platelet count fell to 36,000. She
received a platelet transfusion with a post transfusion count
of 176,000. Subsequent platelet counts initially decreased but
then remained stable, with values of 111, 96, 105, and 96. Most
recent platelet count on the day of discharge is 96,000.
Coagulation studies revealed normal PT, PTT, and fibrinogen, with
mildly elevated D-dimers. Maternal blood was sent for platelet
antibody screen; HLA-antibodies were present, but no
platelet-specific antibodies were detected. The HLA-antibodies
are not thought to contribute to alloimmune thromobocytopenia.
Overall the thrombocytopenia is most likely secondary to mild
neonatal depression.
[**Known lastname 63410**] is blood type B+ and is Coombs negative.
System #6, Gastrointestinal: Liver function tests were sent
on day of life number 1 and were mildly elevated. The
repeated values on day of life 4 showed a gradual decline.
Peak serum bilirubin occurred on day of life 4, total of 12.4
over 0.6 mg/dl. She was not treated with phototherapy.
System #7, Neurology: Perinatal course was consistent with mild
neoantal depression. A head computed tomography scan was
performed on [**2169-8-6**] with results within normal limits, without
evidence of hemorrhage. She was evaluated by the
neurology service from [**Hospital3 1810**], and was thought to
have an improving exam with mild hypertonia. Follow-up with the
neonatal neurology program 1 month after discharge was arranged.
At the time of discharge, her neurological examination is
reassuring with normal tone and reflexes.
System #8, Sensory/Audiology: Hearing screening was
performed with automated auditory brain stem responses.
[**Known lastname 63410**] passed in both ears.
System #9, Psychosocial: This family is from [**Country 63412**] with
plans to return there at the end of [**Month (only) 216**]. Parents have been
very involved with [**Known lastname 63410**] and her care during admission. The
[**Hospital1 69**] social work department
was involved with this family. The contact social worker is
[**Name (NI) 36130**] [**Doctor Last Name 56162**] and she can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 2270**] [**Last Name (NamePattern1) 63413**], [**Hospital1 2921**], [**Country **]., [**Hospital1 3494**], MA, phone
number [**Telephone/Fax (1) 51263**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: ad lib breast feeding.
2. Medications: Tri-Vi-[**Male First Name (un) **] 1 ml p.o. once daily.
3. State newborn screens were sent on [**8-7**] and [**2169-8-10**] with
no notification of abnormal results to date. The initial
screen sent on [**2169-8-7**] was obtained prior to the
initiation of feeding.
4. Immunization administered: Hepatitis B vaccine was given
on [**2169-8-10**].
5. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 and 35 weeks with two of the following: Daycare during
RSV season , a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; or (3)
with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for house hold
contacts and out of home caregivers.
FOLLOW-UP:
Infant will be seen one day after discharge by pediatrician,
including a repeat platelet count.
Appointment has been scheduled with Dr. [**Last Name (STitle) **] of the Neonatal
Neurology Program at [**Hospital3 1810**] for [**2169-9-6**], at
1pm.
DISCHARGE DIAGNOSES:
1. Meconium aspiration syndrome.
2. Persistent pulmonary hypertension.
3. Right pneumothorax.
4. Presumed pneumonia.
5. Hypoglycemia.
6. Thrombocytopenia.
7. Neonatal depression.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2169-8-10**] 03:15:26
T: [**2169-8-10**] 06:13:18
Job#: [**Job Number 63414**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 36
} | Medical Text: Admission Date: [**2181-4-20**] Discharge Date: [**2181-4-22**]
Date of Birth: [**2135-4-5**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 23197**]
Chief Complaint:
intoxication / seizure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
46 y/o M with hx of etoh abuse (per ED signout) and possible
depression presented to the emergency room at around 6pm this
evening. He was obviously intoxicated. Was found by EMS in
front of a liquor store and brought in for eval. Initial vitals
were t 98.1, p 100, bp 112/94, r 20, 95% on RA. While in the
ED, he climbed over his side rails on his bed and fell. He was
transferred to the Red Zone after his fall and was found to be
mostly non-responsive despite noxious stimuli. He had a CT scan
of his head and C-spine at that time that were negative. He had
an EJ and femoral line place. He was almost intubated but then
became arousable.
.
Over the next few hours, he was alert and interactive. His
speech was slurred and he appeared drunk. On interview and
exam, the patient was complaining of abdominal pain, bloody
vomit and stool (was guiac negative), and suicidal ideation. He
had a fight with his brother-in-law and was feeling very
depressed because of that. He also claimed that he wanted to
hurt his brother-in-law, too. Psych was consulted for the SI/HI
but were waiting to interview him until he was sober.
.
While in the yellow zone waiting for evaluation, he had an
abrupt onset fall where he went to the ground and was
unresponsive for about a minute or two. He then had a witnessed
tonic-clonic seizure. He received 2 mg ativan at that time.
Several minutes later he had another tonic-clonic seizure, and
he was again given 2 mg ativan. He was intubated at that time
for airway protection. He was initially started on a midazolam
gtt but was aggitated. He was switched to a propofol gtt. He
had another CT head and C-spine that were preliminarily read as
normal.
.
On arrival to the floor, he was intubated and sedated. He was
moving all 4 extremities but would not follow commands
appropriately.
.
Past Medical History:
ETOH abuse
Hx of pancreatitis
Depression
Social History:
smokes occasionally, drinks heavily on a daily basis, also
history of ?heroin v. cocaine use in [**Male First Name (un) 1056**] (moved here 2
months ago), unmarried
Family History:
per brother-in-law, HTN
Physical Exam:
Vitals - afebrile, 141/96, 81, 18, 100% on cmv 18 x 550, 100% x5
Gen - thin man, intubated, sedated, intermittently aggitated and
trying to pull at his restraints
HEENT - PERRLA, ET tube in place
CV - RRR, no m,r,g
Lungs - CTA B, referred vent sounds
Abd - soft, NT, ND, no hsm or masses
Ext - warm, well perfused, palp pulses, track marks; LE scarring
Neuro - could not obtain secondary to infection
Pertinent Results:
[**2181-4-20**] 07:30PM ASA-NEG ETHANOL-295* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2181-4-20**] 07:30PM LIPASE-78*
[**2181-4-20**] 07:30PM cTropnT-<0.01
[**2181-4-20**] 07:30PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-182 ALK
PHOS-64 TOT BILI-0.1
[**2181-4-20**] 07:30PM WBC-6.3 RBC-5.35 HGB-15.1 HCT-46.1 MCV-86
MCH-28.1 MCHC-32.7 RDW-14.4
CT C-SPINE W/O CONTRAST Study Date of [**2181-4-21**] 1:05 AM
IMPRESSION: No evidence of acute injury to the cervical spine.
Head CT
NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass
effect, or
[**Doctor Last Name 352**]-white matter differentiation, abnormality. The ventricles
and
extra-axial spaces are within normal limits. There is no
evidence of
fracture. Mucosal thickening within bilateral maxillary sinuses
and ethmoid
sinus air cells and sphenoid sinuses are mild. There are
aerosolized
secretions in the nasopharynx.
IMPRESSION: No acute intracranial abnormality.
Brief Hospital Course:
46 y/o M with hx of etoh abuse (per ED reports), coming in
intoxicated and then complaining of abdominal pain,
n/v/diarrhea, and suicidal ideation. Had a seizure and was
intubated for airway protection.
.
# Seizure: No further seizure activity after initial one in ED.
[**Month (only) 116**] have been due to EtOH intoxication. CT head, labs were
unremarkable.
.
# Abdominal Pain: Resolved once pt was extubated.
.
# Respiratory Failure: The pt had to be intubated for altered
mental status and airway protection in the setting of a seizure.
Was successfully extubated the morning following admission, with
no further respiratory problems.
.
# EtOH/SI: The pt was seen by psychiatry and was found to have
capacity to make medical decisions. He declined rehab/detox and
reported that he had psychiatric follow up at [**Hospital1 **] CHC on
Tuesday. The pt was discharged in the care of his girlfriend who
planned to take him to her church to stay overnight.
Medications on Admission:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Medications:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Intoxication
Discharge Condition:
Mental Status: Clear and coherent, fluent Spanish
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with intoxication. You were intubated (a
breathing tube was placed) to protect your airway. You were
evaluated by psychiatry, and they felt that you were safe to
return home with your family, with close psychiatric follow up.
.
Please continue to take your seroquel and wellbutrin. We have
added folate and thiamine for your nutritional status.
Followup Instructions:
Please follow up with your psychiatrist at [**Hospital1 **] St.
Community Health Center as planned on Tuesday.
ICD9 Codes: 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 37
} | Medical Text: Admission Date: [**2147-6-8**] Discharge Date: [**2147-6-12**]
Date of Birth: [**2088-3-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
polyuria, polydipsia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 59M with HTN, glaucoma who presents with polyuria and
polydipia. He was at his regular health status until about 3
weeks prior to admission, when he started to note polyuria,
polydipsia, and altered taste while he was eating. The dryness
of mouth got worsen while he was chewing the food and eventually
he tasted the food like a "cardboard". He could not swallow the
food and "it stayed in the mouth". He stated that he could sense
and recognize the sweetness, salt taste, bitter taste and sour
taste of the food. He denies f/c/n/v, dysuria, cough, or
diarrhea.
.
In the ED, vitals showed T 96.0 HR 90, reg BP 177-193/96 RR 23
SO2 96% r/a. He was noted to have ARF with creatinine 1.8 and
hyperglycemia with a sugar 360, AG 22, with positive urine
ketones. He was started on insulin gtt, given 3L NS, and
admitted to MICU for further care.
Past Medical History:
1. Hypertension
2. Glaucoma
Social History:
Married, lives with wife, has a daughter.
[**Name (NI) 1403**] at Pharmaceutical company for drug development. Occasional
ETOH, Smoke [**12-20**] cigarette/day now, used to smoke 10-15years,
Denied drug.
Family History:
Mother had diabetes and stroke. Father died when the patient was
20 years, he is not sure of the cause.
Physical Exam:
vitals: T 97.9 78 174/70 17 97 RA
gen: awake, alert, NAD
heent: perrl, eomi, mmm
cv: RRR, no m/r/g
pulm: CTAB
abd: soft, NT/ND
ext: 1+ DP pulses, no edema
neuro: a+ox4. CN ii-xii intact, moves all extremities well.
Pertinent Results:
[**2147-6-8**] - Admission labs
WBC-5.5 RBC-5.39 Hgb-17.0 Hct-50.8 MCV-94 MCH-31.5 MCHC-33.4
RDW-13.5 Plt Ct-186
Glucose-360* UreaN-12 Creat-1.8* Na-129* K-6.6* Cl-95* HCO3-11*
AnGap-30*
Albumin-4.7 Calcium-9.4 Phos-2.9 Mg-2.6
%HbA1c-13.7*
tox screen: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG.
.
[**2147-6-9**]
Triglyc-176* HDL-34 CHOL/HD-7.3 LDLcalc-179* Homocys-7.1
.
[**2147-6-12**]
WBC-4.2 RBC-4.10* Hgb-13.3* Hct-37.2* MCV-91 MCH-32.4*
MCHC-35.7* RDW-14.0 Plt Ct-118*
Glucose-219* UreaN-4* Creat-1.2 Na-136 K-3.4 Cl-102 HCO3-21*
AnGap-16
Phos-2.4* Mg-2.3
.
[**2147-6-8**] CT OF THE HEAD WITHOUT CONTRAST: No intracranial mass
lesion, hydrocephalus, shift of normally midline structures,
minor or major vascular territorial infarct is apparent. Density
values of the brain parenchyma are within normal limits. The
surrounding osseous and soft tissue structures are unremarkable.
Falx calcifications are noted. The visualized paranasal sinuses
are unremarkable.
IMPRESSION: No acute intracranial pathology, including no sign
of intracranial hemorrhage.
.
[**2147-6-8**] PA AND LATERAL VIEWS OF THE CHEST: The cardiac
silhouette, mediastinal and hilar contours are normal. There is
an 8-mm nodule in the right lung base. Otherwise, the lungs are
clear. No evidence of pleural effusions. No evidence of
pneumothorax. The pulmonary vasculature is normal.
IMPRESSION: 8-mm lung nodule in the right lung base. Comparison
with prior outside studies, if feasible, or follow-up study is
recommended to assess stability.
.
[**2147-6-9**] CT CHEST W/O CONTRAST
FINDINGS: Linear scarring or atelectasis is present within the
right lower lobe, but there is no evidence of a suspicious lung
nodule or mass in this region. No suspicious endobronchial
lesions are identified. Small bulla is present in the right
upper lobe, and there are very minimal areas of emphysema at the
extreme lung apices.
No suspicious lytic or blastic skeletal lesions are identified.
Degenerative changes are present in the spine.
Left lobe of thyroid gland is enlarged measuring about 3.7 cm.
No enlarged mediastinal or hilar lymph nodes are present. Heart
size is normal. There is no pericardial or pleural effusion.
In the imaged portion of the upper abdomen, there is probable
mild fatty infiltration of the liver, with relative sparing
around the gallbladder. Imaged portions of the adrenal glands
and remaining portion of upper abdomen are unremarkable, but
please note the examination was not specifically tailored for
evaluating the abdominal structures.
IMPRESSION:
1. Linear scar versus atelectasis in the right lower lobe but no
evidence of discrete lung nodule or mass.
2. Probable fatty infiltration of the liver.
3. Enlarged left lobe of thyroid gland, probably representing
asymmetric goiter, but thyroid ultrasound may be considered for
more complete assessment if warranted clinically.
Brief Hospital Course:
59 AA M with HTN, glaucoma who presents in DKA and with ARF,
without prior diagnosis of diabetes. This presentation is
consistent with "flatbush" or type 1B diabetes.
.
1. Acute renal failure:
Cr 1.8 on admission. By discharge, had decreased to 1.2 with
IVF. Unclear baseline. Likely prerenal in setting of DKA.
.
2. DKA:
Newly diagnosed DM2; given age and race may represent Flatbush
Phenomenon given his mild DKA on presentation. There was no
evidence of any other cause of an anion gap acidosis, as patient
had a negative tox screen and lactate was not significantly
elevated. Was initially admitted to ICU on Insulin gtt;
transitioned to glargine 25 units daily with Humalog SS.
Received diabetes education from [**Last Name (un) **] consultants and nurse
educators, trained to administer home insulin until outpatient
follup with [**Last Name (un) **]. His BS were well controlled on this regimen
and his AG closed to normal. A HgA1c level sent was 13.9%. ASA
was started during this admission given that he now had multiple
cardiac risk factors and a CAD equivalent.
.
3. HTN:
Given his new onset DMII, started an ACE. BPs have been in
normal range. Can titrate up as needed as outpatient. Patient
has evidence of LVH on ekg, likely hypertensive in etiology.
Will need pcp f/u.
.
4. Lung nodule:
Incidental lung nodule was noted on CXR which on follow up Chest
CT revealed Linear scar versus atelectasis in the right lower
lobe but no evidence of discrete lung nodule or mass.
.
5. High Cholesterol
A cholesterol panel showed elevated levels (TC 248, LDL 179).
He was started on simvastatin 20mg daily.
.
6. Glaucoma
continued pilocarpine 0.5% 1 gtt to both eyes q6h
.
7. Incidental L Thyroid Lobe enlargement
probably represents asymmetric goiter, but thyroid ultrasound
may be considered for more complete outpatient assessment if
warranted clinically.
.
8. Altered Taste
Neurology consulted, felt that this is not necessary for
inpatient assessment at this time. Suggest Diamox as cause, as
it is known to have appetite loss and can alter the sensation of
taste. Can follow up as outpatient.
.
FEN: diabetic diet
.
Proph: heparin SC
.
Access: PIVs
.
full code
Medications on Admission:
1. Pilocarpine
2. Diamox
3. Kossup
Discharge Medications:
1. Pilocarpine HCl 0.5 % Drops Sig: One (1) Drop Ophthalmic Q6H
(every 6 hours).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Insulin Glargine 100 unit/mL Solution Sig: One (1) 25
Subcutaneous every morning before breakfast.
Disp:*1 vial* Refills:*2*
6. Humalog 100 unit/mL Solution Sig: One (1) see sliding scale
Subcutaneous qAC and HS.
Disp:*1 vial* Refills:*2*
7. Syringe with Needle, Safety 1 mL 28 X [**12-20**] Syringe Sig: Four
(4) Miscellaneous once a day.
Disp:*120 syringes* Refills:*2*
8. sharps box
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diabetes Mellitus II with ketoacidosis
.
Secondary:
Hypertension
Glaucoma
Discharge Condition:
Improved, stable
Discharge Instructions:
Please take all medications, including insulin, as prescribed.
Please check your blood sugar at home as instructed. If you
experience any symptoms that are concerning to you, including
dizziness/lightheadedness, fatigue/lethargy, or excessive
urination/thirst, please call your PCP or go to the nearest
Emergency Room.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**12-20**] weeks. Also, please call
the [**Last Name (un) **] Center to make an appointment for your diabetes care
and management.
ICD9 Codes: 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 38
} | Medical Text: Admission Date: [**2129-3-4**] Discharge Date: [**2129-3-6**]
Date of Birth: [**2053-6-30**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Ace Inhibitors
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
RCA dissection
Major Surgical or Invasive Procedure:
Cardiac Catheterization with placement of 4 bare metal stents
Intra-operative (catheterization) trans-esophageal
echocardiogram
History of Present Illness:
75 y/oF with hypertension, HL and exertional angina who
initially presented for elective cardiac catheterization c/b RCA
dissection, being transferred to the CCU for further management.
.
Briefly, patient complained of exertional angina for several
weeks. She described chest discomfort radiating to jaw while
walking on treadmill or riding exercise bike vigorously. Also
experianced dyspnea and chest discomfort while walking up 1
flight of stairs. Symptoms always resolved with rest. Exercise
stress test on [**2129-2-14**] was concerning for ischemia: after 8
minutes on [**Doctor First Name **] protocol, peak HR of 116 (80% predicted for
age), patient developed recurrent angina and EKG showing 0.5mm
ST depressions in infero-lateral leads. Given positive stress
test, patient was referred for elective coronary
catheterization.
.
This morning, he underwent coronary catheterization which showed
calcification in coronary arteries with diffuse disease in RCA
with proximal 90% stenosis and distal 60-80% stenosis. The
catheterization was complicated by an RCA dissection with
retrograde extention to the right sinus of valsalva. She
received four bare metal stent to the RCA: 2 overlapping distal,
1 non-overlapping proximal, and 1 ostial integrity stents.
Following ostial stent depolyment, contrast was no longer seen
flowing into the sinus. Post-catheterization TEE showed
unchanged AI, functioning leaflets and no pericadial effusion.
She was transfered to the CCU in stable condition.
.
On arrival to the CCU, she endorsed mild left sided chest and
jaw pain that had significantly improved compared to what she
had experienced in the cath lab. She endorsed comfortably
breathing and denied other complaints.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable chest pain as per HPI; she
denied paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- moderate AI, moderate MR
3. OTHER PAST MEDICAL HISTORY:
- Left Breast Cancer s/p Mastectomy in [**2103**]
- GERD
- Hemorrhoids
- Pneumonia x2 (in [**2097**]'s)
- Hiatial Hernia
- S/p Hysterectomy
- Osteopenia
- s/p Tonsillectomy
- s/p Adenoidectomy
- s/p Appendectomy
Social History:
Retired, lives with husband. [**Name (NI) **] very active lifestyle, going to
gym daily
- Tobacco history:
- ETOH: drinks approx 4oz red wine daily
- Illicit drugs: denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died at age 83 of CHF
- Father: died in 80s of CVA
Physical Exam:
Admission Exam:
VS: T=98.4 BP=127/80 HR=93 RR=14 O2 sat=100% on 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, systolic murmur loudest at apex. No thrills, lifts.
LUNGS: left mastectomy scar noted. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge Exam:
Tc 98.0, Tm 98.4, BP 128-146/49-68, HR 58-88, RR 16-18, Sats
95-99% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, systolic murmur loudest at apex. No thrills, lifts.
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. 2+ pulses in radial/DP
Pertinent Results:
Admission Labs ([**2129-3-4**]):
Hct-32.2*
Glucose-218* UreaN-17 Creat-0.6 Na-134 K-3.8 Cl-99 HCO3-23
AnGap-16
Calcium-9.5 Phos-3.7 Mg-2.1
[**2129-3-4**] 04:09PM BLOOD CK(CPK)-69
[**2129-3-5**] 06:00AM BLOOD CK(CPK)-98
[**2129-3-4**] 04:09PM BLOOD CK-MB-4 cTropnT-<0.01
[**2129-3-5**] 06:00AM BLOOD CK-MB-5 cTropnT-LESS THAN
.
Imaging:
Intra-operative TEE ([**2129-3-4**]):
Conclusions
No atrial septal defect is seen by 2D or color Doppler. The left
ventricle is not well seen but overall left ventricular systolic
function is normal (LVEF>55%). There are simple atheroma in the
aortic arch. A mobile density is seen in the aortic sinus at the
right coronary cusp consistent with an intimal flap/aortic
dissection.the flap extends minimally above the sinus of
Valsalva.The aortic valve leaflets (3) are mildly thickened.
Mild to moderate ([**12-12**]+) aortic regurgitation is seen. Moderate
(2+) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: Dissection flap at the right coronary sinus, largely
contained within the sinus of Valsalva. Preserved global LV
systolic function with mild to moderate aortic regurgitation and
moderate mitral regurgitation.
.
CTA of chest ([**2129-3-4**]):
FINDINGS: Trace pericardial sluid is noted. There is multivessel
coronary
arterial calcification and mitral annular calcifications.
Density in the right coronary artery is compatible with known
stent. The proximal RCA appears low attenuation centrally, but
assessment is limited by overlying stent and non-gated study.
Close to the origin of the RCA, a minimal linear mural
irregularity at the
proximal aorta is seen (4,58), which likely represents a small
focal
dissection as noted at time of coronary angiogram. No distal
propagation is seen.
Some calcification at the left anterolateral papillary muscles
is noted
(6,61). This is likely due to prior ischemia.
The pulmonary arterial tree is opacified without evidence of
pulmonary
embolism.
There is no mediastinal, hilar, or axillary lymphadenopathy by
CT size
criteria. With the exception of trace bibasilar dependent
atelectases , the lungs are clear. Central airways remain
patent.
Limited subdiaphragmatic evaluation demonstrates hyperdense
material within the gallbladder, compatible with vicarious
excretion of contrast status post recent cardiac
catheterization. A tiny hiatal hernia may be present. The left
adrenal gland is mildly prominent, without focal nodularity.
A small non-specific 7mm hypodensity is seen at the dome of the
right hepatic lobe (4,68), too small to characterize.
BONE WINDOW: No focal concerning lesion. Mild multilevel
thoracic
spondylosis is present. Mild levoconvex thoracic curvature is
noted.
IMPRESSION:
1. Tiny linear irregularity at the aortic root adjacent to the
RCA origin
compatible with known tiny dissection. No propagation seen.
2. Apparent opacification of the RCA proximally may be
artifactual related to stent and non-gated study, but clinical
correlation is advised.
3. Coronary calcification and small area of calcification at the
tip of
anterolateral papillary muscle.
.
Cardiac Cath ([**2129-3-4**]): Report not yet finalized
.
Discharge Labs:
[**2129-3-6**] 08:35AM BLOOD WBC-7.2 RBC-3.77* Hgb-11.8* Hct-32.7*
MCV-87 MCH-31.2 MCHC-36.0* RDW-12.6 Plt Ct-299
[**2129-3-6**] 08:35AM BLOOD Glucose-119* UreaN-17 Creat-0.6 Na-137
K-4.0 Cl-102 HCO3-24 AnGap-15
[**2129-3-6**] 08:35AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0
Brief Hospital Course:
ASSESSMENT AND PLAN
Mrs. [**Known lastname **] is a 75 year-old woman with HTN, HLD and exertional
angina s/p elective cardiac catheterization c/b RCA dissection
with placement of 4 BMS in the RCA.
# Coronaries: Patient has known CAD identified on cardiac cath
[**3-4**] now s/p RCA dissection during cardiac catheterization and
placement of 4 BMS to RCA. Patient received integrillin during
procedure. Chest pain has significantly improved. Discussed with
patient importance of avoiding valsalva or manuvers that
increase intra-thoracic pressure. CTA report not finalized but
per radiology wet read no significant dissection still noted
post-proceedure although contrast timing sub-optimal for
evaluation. Before CTA pt received premedication with benadryl,
prednisone, and mucomyst/IV hydration. Nitro gtt was weaned off
and cardiac enzymes were stable. Pt will be continued on ASA
indefinitely and will need to take plavix 75 mg daily for at
least 1 month. Plan will be for repeat CTA 2-3 weeks after
discharge to re-evaluate RCA dissection. Pt will follow-up with
Dr. [**Last Name (STitle) **] in outpatient setting.
# Pump: Patient has no know CHF symptoms. LVEF was not obtained
durring TEE performed in cath lab. Patient has remained
hemodynamically stable during hospitalization.
# RHYTHM: Patient was in sinus rhythm. She has no known
dysrhythmia. Was monitored on Tele in the CCU and then on the
floor but no signficiant arrhythmias noted.
# HTN: Patient with Hx of HTN on only metoprolol as home BP med.
Day after cath pt was started on 25mg daily of losartan for
better BP control and metoprolol increased from 50 mg po tid to
200 mg po daily.
# HLD: Patient takes rosuvastatin 20mg daily at home and was on
atorvastatin 80mg while admitted. She was discharged on her home
regimen of rosuvastatin 20 mg po daily.
#Code: Full (confirmed with patient)
Medications on Admission:
- ciprofloxacin 250 mg [**Hospital1 **] prn UTI
- hydrocortisone acetate - 25 mg Suppository - 1 rectally up to
tid
prn irritation and pressure
- metoprolol tartrate 50mg [**Hospital1 **]
- omeprazole 20 mg Capsule, Delayed Release(E.C.) daily
- rosuvostatin 20 mg daily
- vitamin C 500 mg daily
- ASA 81 mg daily
- calcium carbonate- vitamin D3 500 mg (1,250 mg)-400 U Tablet
daily
- geriatric MVI w/iron 1tab daily
- magnesium 250mg 4 tabs daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet
Sig: One (1) Tablet PO once a day.
9. geriatric multivit w/iron-min Tablet Sig: One (1) Tablet
PO once a day.
10. magnesium 250 mg Tablet Sig: Four (4) Tablet PO once a day.
11. hydrocortisone acetate 25 mg Suppository Sig: One (1)
Rectal once a day as needed for irritation and pressure .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Coronary artery disease
Coronary artery dissection
Secondary:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a small tear in one of
your coronary arteries occurred during your cardiac
catheterization. To help stabilize the artery and to open up
your coronaries which were found to have some narrowings, 4 bare
metal stents were placed in your coronary arteries. Your chest
pain improved significantly the next day and a CT scan of your
chest showed no worsening of the tear in your artery.
You were started on plavix 75 mg daily and Aspirin 325 mg daily.
You must take the plavix every day for at least the next month
and take the aspirin daily indefinitely in order to help keep
your stents from clotting. It is very important that you take
these medications every day otherwise you are at risk for clots
forming in your stents. We also increased your metoprolol dose
and started a new blood pressure medication called losartan to
help keep your blood pressure in a good range. You will
follow-up with Dr. [**Last Name (STitle) **] and will likely get a repeat CT scan or
your heart in [**1-13**] weeks.
The following changes were made to your medications:
- Metoprolol dose increased to metoprolol XL 200 mg by mouth
once daily
- Added Losartan 25 mg by mouth once daily for blood pressure
- Added clopidogrel (Plavix) 75mg by mouth daily for at least
the next month - it is very important that you do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s of this medication. Please talk with Dr. [**Last Name (STitle) **] about when
it is ok to stop taking this medication.
- Increased Aspirin dose from 81 mg daily to 325mg by mouth
daily
- Continue your other home medications
You should refrain from lifting weights greater than 20 pounds
for 1 month after your hospital discharge.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**12-12**] weeks. Please call her office to
make sure that you have an appointment. The number to call is
[**Telephone/Fax (1) 4105**]. You will likely have a repeat CT scan of your
heart in [**1-13**] weeks.
You should refrain from lifting weights greater than 20 pounds
for 1 month after your hospital discharge.
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 39
} | Medical Text: Admission Date: [**2192-1-5**] Discharge Date: [**2192-1-20**]
Date of Birth: [**2117-9-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Hydralazine / Opioid Analgesics / Compazine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain / epigastric pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 4 (LIMA-LAD,SV-DG,SV-OM,SV-PDA)
[**1-13**]
left heart catheterization, coronary angiography
History of Present Illness:
The patient is a 74 year-old female who has a significant PMH
for recent NSTEMI ([**2191-11-5**]), CAD, hyperlipidemia,
hypertension, DM-2, and ESRD on hemodialysis who presented after
several hours of epigastric pain which evolved into predominant
complaint of [**2193-8-13**] chest pressure. She had a similar
presentation on [**2191-11-22**] and was diagnosed with an NSTEMI after
positive cardiac enzymes noted with new LBBB on EKG. She
underwent cardiac catheterization at that time which showed LAD
lesion of 90% and totally occluded mid LAD lesion, RCA lesion of
90%, and circumflex showed minimal disease. Unfortunately, she
had unsuccessful PCI, and CT Surgery consulted to arrange for
future CABG plan.
Past Medical History:
-Hypothyroidism (thyroidectomy in [**2173**] for benign growth)
-Diabetes type II for >10yrs
-End-Stage Renal Disease: on hemodialysis left forearm AV graft
in [**2187**], now using Tunelled HD Line
-CVA [**2186**]: left caudate infarct; several mini-strokes before
that
-Gait disorder/shaky and unsteady when she walks
-Splenectomy in [**2145**] (trauma related)
-SVC stenosis
-Cataract surgery (bilateral)
-Hypertension
-Hyperlipidemia
-Coronary Artery Disease (recent cath [**11/2191**] showing 90%
proximal LAD totally occluded mid LAD and 90% RCA and minimal
disease of the circumflex)
Social History:
Patient lives alone at home but daughter [**Name (NI) **]([**Telephone/Fax (1) 108910**])
is extensively involved in her care. She has 7 other children.
She uses a walker at baseline, but has been wheelchair bound for
about 1 year per daughter because patient is afraid of
falling. She denies current or past tobacco, alcohol or illicit
drug use.
Family History:
Mother: died 5 year ago (cause unknown to pt)
Father: died when pt was 17 (cause unknown to pt)
Children have no major medical problems
Physical Exam:
Admission
VS -T 98.6F, BP 153/100, HR 80s, RR 20, 96% 3L oxygen
Gen: appears fatigued, middle aged female in NAD, Oriented x3.
Affect somewhat flattened.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7-8cm. Left EJ in place (clean/intact)
and left IJ HD catheter in place with non-erythematous
surrounding skin.
CV: S1/S2 appreciated, RRR, II-III/VI systolic murmur noted @
LUSB, No murmurs, rubs, gallops. No thrills, lifts. No S3/S4.
Chest: No chest wall deformities or scoliosis, but + Mild
kyphosis. Respirations unlabored, no accessory muscle use.
Decreased aeration at bases bilaterally (R>L). No wheezes or
rhonchi.
Abd: Soft, mild upper epigastric tenderness, moderate
distension. No HSM or tenderness at RUQ. Due to distension,
unable to ausculate well for abdominial bruits -but all 4
quadrants with +normoactive BS.
Ext: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] cool, 1+ DP and PT pulses on left and 2+ DP and 1+
PT pulse on right. No femoral bruits/femoral pulses 2+
bilaterally.
Skin: LE calves with scaling of skin, no sores/lesions/rashes.
Pulses:Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
.
Discharge
VS T 98.4 BP 144/71 HR 80 SR RR 20 O2sat 97%-2LNP
Gen NAD, sitting in chair
Neuro A&O x3, nonfocal exam
Pulm CTA bilat
CV RRR, sternum stable, incision CDI
Abdm soft, NT/+BS
Ext Warm, trace pedal edema bilat.
Skin staples L groin down thigh. Left subclav HD catheter
Pertinent Results:
ADMISSION LABS:
[**2192-1-5**] 03:57PM PT-41.6* PTT-37.8* INR(PT)-4.6*
[**2192-1-5**] 03:03PM GLUCOSE-381* NA+-138 K+-4.4 CL--91* TCO2-27
[**2192-1-5**] 03:03PM HGB-14.3 calcHCT-43
[**2192-1-5**] 02:45PM GLUCOSE-385* UREA N-33* CREAT-4.2* SODIUM-137
POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-27 ANION GAP-23*
[**2192-1-5**] 02:45PM ALT(SGPT)-150* AST(SGOT)-104* CK(CPK)-46 ALK
PHOS-205* TOT BILI-0.3
[**2192-1-5**] 02:45PM LIPASE-50
[**2192-1-5**] 02:45PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.2
[**2192-1-5**] 02:45PM WBC-14.1* RBC-4.46 HGB-13.8 HCT-44.2 MCV-99*
MCH-31.0 MCHC-31.3 RDW-17.4*
[**2192-1-5**] 02:45PM BLOOD cTropnT-0.21*
[**2192-1-6**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.29*
[**2192-1-6**] 12:19AM BLOOD CK(CPK)-77
[**2192-1-5**] 02:45PM BLOOD CK(CPK)-46
[**2192-1-19**] 09:30AM BLOOD WBC-17.8* RBC-3.11* Hgb-9.6* Hct-30.0*
MCV-97 MCH-30.8 MCHC-32.0 RDW-17.8* Plt Ct-280
[**2192-1-19**] 09:30AM BLOOD Plt Ct-280
[**2192-1-17**] 04:00AM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3*
[**2192-1-19**] 09:30AM BLOOD Glucose-233* UreaN-43* Creat-5.2*# Na-137
K-5.1 Cl-99 HCO3-28 AnGap-15
[**2192-1-12**] 09:00AM BLOOD %HbA1c-7.0*
[**2192-1-6**] 01:10PM BLOOD TSH-2.9
.
ADDITIONAL STUDIES:
[**2192-1-10**] Cardiac MD/Thallium Viability study: IMPRESSION: 1.
Moderate Anterior wall/apical defect that is completely
reversible by 24 h. 2. Moderate septal defect that is partially
reversible by 24 h.
.
[**2192-1-8**] CTA Chest/Pelvis/Abdomen : IMPRESSION: 1. There is
opacification of the SMA, without evidence of ischemic bowel. 2.
Extensive atherosclerotic disease, without aortic aneurysm or
dissection seen. 3. Extensive colonic diverticulosis, with
minimal stranding surrounding the descending colon, suggesting
mild uncomplicated diverticulitis. 4. Incompletely characterized
hypodense lesions in the kidneys again noted. 5. Soft tissue
nodule arising from the medial limb of the left adrenal gland
again incompletely characterized. 6. Increased number of
mediastinal and retroperitoneal lymph nodes, without size
enlargement.
===============================================================
[**Known lastname **],[**Known firstname 108974**] [**Medical Record Number 108975**] F 74 [**2117-9-11**]
Radiology Report CHEST (PA & LAT) Study Date of [**2192-1-19**] 4:15 PM
[**Hospital 93**] MEDICAL CONDITION:
74 year old woman s/p CABG x4
REASON FOR THIS EXAMINATION:
atelectasis
Final Report
HISTORY: Status post CABG with atelectasis.
FINDINGS: In comparison with study of [**1-17**], there is little
overall change.
Extensive opacification at the left base persists, possibly
increasing with
further pleural fluid. Central catheter remains in place. The
right axillary
catheter again remains outside of the hemithorax.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**First Name8 (NamePattern2) **] [**2192-1-19**] 6:21 PM
=
=
=
=
=
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=
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================================================================
[**Known lastname **],[**Known firstname 108974**] [**Medical Record Number 108975**] F 74 [**2117-9-11**]
Radiology Report [**Numeric Identifier **] PICC W/O PORT Study Date of [**2192-1-17**]
12:30 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2192-1-17**] SCHED
PICC LINE PLACMENT SCH Clip # [**Clip Number (Radiology) 108976**]
Reason: ESRD on HD. LT scv Permacath, s/p mult RIJ caths. Unable
to
[**Hospital 93**] MEDICAL CONDITION:
74 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
ESRD on HD. LT scv Permacath, s/p mult RIJ caths. Unable to
pass wire into IJs
at time of recent CABG. Has RT femoral Cordis. IV unable to
thread wire for
PICC at bedside. please place as midline only *****
Final Report
INDICATION: 74 year old woman requiring IV access. Request right
mid-line due
to presence of left HD catheter in SVC. The procedure was
explained to the
patient. A timeout was performed.
RADIOLOGIST: Dr. [**Last Name (STitle) 3012**] and Dr. [**First Name (STitle) **] performed the procedure.
Dr. [**Last Name (STitle) 2492**], the attending radiologist, was present and
supervised the
procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the
right brachial
vein was punctured under direct ultrasound guidance using a
micropuncture set.
Ultrasound images were obtained before and immediately after
establishing
intravenous access. A guidewire was advanced into the right
subclavian vein under fluoroscopic guidance. A peel- away sheath
was then placed over the guidewire and a double-lumen PICC
measuring 20 cm in length was placed through the peel- away
sheath with its tip positioned in the axillary vein under
fluoroscopic guidance. Position of the catheter was confirmed by
a
fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the
skin, flushed, and a sterile dressing applied. The patient
tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
double-lumen PICC placement via right brachial venous approach.
Final internal length is 20 cm, with the tip positioned in the
right axillary vein. The line is ready to use.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 2671**] [**Doctor Last Name **]
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: WED [**2192-1-18**] 9:17 AM
=
=
=
=
=
================================================================
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 108974**] [**Hospital1 18**] [**Numeric Identifier 108977**] (Complete)
Done [**2192-1-13**] at 6:17:28 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2117-9-11**]
Age (years): 74 F Hgt (in): 60
BP (mm Hg): / Wgt (lb): 140
HR (bpm): BSA (m2): 1.61 m2
Indication: Intraop CABG evaluate LV function, Valvular
function, Aortic contours
ICD-9 Codes: 410.92, 440.0, 424.0
Test Information
Date/Time: [**2192-1-13**] at 18:17 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: [**Doctor Last Name **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
LEFT ATRIUM: Marked LA enlargement. No mass/thrombus in the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline
dilated LV cavity size. Severe regional LV systolic dysfunction.
RIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal
RV systolic function.
AORTA: Mildly dilated ascending aorta. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the aortic arch. Mildly dilated descending aorta.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Moderate to severe (3+) MR. [**First Name (Titles) **] vena contracta is >=0.7cm
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR. Dilated main PA.
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. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre Bypass: The left atrium is markedly dilated. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is top normal/borderline
dilated. There is severe regional left ventricular systolic
dysfunction with septal hypokinesis at the base and akinesis at
mid and apical levels, and hypokinesis of anteroseptal and
anterior walls.. The right ventricular cavity is moderately
dilated with borderline normal free wall function. The ascending
aorta is mildly dilated. There are complex (>4mm) atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) central mitral regurgitation
is seen. The mitral regurgitation vena contracta is >=0.7cm.
There is a small pericardial effusion. TEE used for hemodynamic
monitoring throughout. Estimated PASP 43 pre bypass. Frequent
cardiac output measurements obtained. CO 2.0 to start case,
increased to 2.7, then later 3.9 just prior to bypass.
Post Bypass: Patient is on epinepherine infusion (.08) and
phenylepherine (2), AV paced.
Biventricular function is slightly improved on ionotropes. LVEF
30-35%. The anterior wall motion has improved. The septum is
paced with paradoxical movement and cannot be fully evaluated.
Mitral reguritation is now [**1-6**]+. Aortic contours intact. Remaing
exam is unchanged. Cardiac output post bypass initally [**2-7**],
improved by end of case to 4.1 with ionotropes and volume. All
finidings discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2192-1-16**] 14:34
Brief Hospital Course:
Ms. [**Known lastname 108904**] is a 74 year old female with a past medical history
of a recent NSTEMI ([**11/2191**]), extensive coronary artery disease,
hyperatension, diabetes mellitis type II, end stage renal
disease on hemodialysis, who presented to the emergency
department with several hours of epigastric pain and chest
pressure. She ruled out for acute coronary syndrome/myocardial
infarction. A workup for mesenteric ischemia was negative and
she was scheduled for a coronary artey bypass.
On [**2192-1-13**] she underwent a coronary artery bypass grafting times
four. This procedure was performed by Dr. [**Last Name (STitle) 914**]. She
tolerated the procedure well and was transferred in critical but
stable condition to the surgical intensive care unit. On
post-operative day one she was dialyzed, extubated, and weaned
from her pressors. Dialysis resumed on the following day. Her
chest tubes and epicardial wires were removed. She was seen in
consultation by the physical therapy service. Over the next
several days her hospital course was uneventful, she progressed
very slowly with physical activity and on POD7 it was decided
she was ready for discharge to rehabilitation at [**Hospital1 **].
Medications on Admission:
-Vitamin B Complex/Vitamin C
-Folic Acid 1 mg daily
-Renagel 800 mg tablet three times a day.
-Levothyroxine 100 mcg tablet daily
-Atorvastatin 80 mg Tablet PO daily
-Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 4,000-11,000
unit dwell Injection PRN (as needed) as needed for line flush:
**for use by dialysis ONLY.
-Prevacid 30 mg Capsule, (E.C.)daily.
-Lorazepam 0.5 mg tablet PO Q6H as needed for Anxiety.
-Acetaminophen 325 mg, 1-2 Tablets PO Q6H PRN
-Warfarin 7.5 mg tablet PO daily at 4 PM.
-Aspirin 81 mg tablet once a day.
-Lisinopril 40 mg tablet daily.
-Toprol XL 100mg daily.
.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-6**]
Drops Ophthalmic PRN (as needed).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000)
units Injection TID (3 times a day).
7. Sevelamer Carbonate 800 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
11. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
12. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
13. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day) as needed.
15. Ibuprofen 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
16. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [**Last Name (STitle) **]: One (1)
Appl Rectal QID (4 times a day) as needed.
17. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3
times a day).
18. Glipizide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
19. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: sliding scale
Subcutaneous Q AC&HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
unsatble angina
s/p coronary artery bypass grafts
end stage renal disease
hypertension
cerebrovascular disease
noninsulin dependent diabetes mellitus
hypothyroidism
s/p thyroidectomy
s/p hysterectomy
s/p splenectomy
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any fever greater than 100.5
report any redness of, or drainage from incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-6**] weeks ([**Telephone/Fax (1) 250**])
Completed by:[**2192-1-20**]
ICD9 Codes: 5856, 4111, 9971, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 40
} | Medical Text: Admission Date: [**2160-3-26**] Discharge Date: [**2160-3-30**]
Date of Birth: [**2103-6-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Egg / Fish Product
Derivatives / Milk
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
56 yo F with severe asthma presents with difficutly breathing
and a prominent wheeze. Patient had recently seen her
outpatient pulmonologist Dr. [**Last Name (STitle) **] [**3-3**] and was placed on a
steroid taper. She had been feeling much better until about a
week ago when her apartment was flooded. As a result she
reported than mold grew which is a trigger for her asthma. Also
her neighbors have been smoking which is also a trigger. 2 days
prior to admission the patients nebulizer broke and since then
her symptoms have been quite severe. She has been unable to eat
secondary to coughing.
.
In the ED the patient was given nebs, azithromycin, solumedrol,
magnesium with some effect. However still required continuous
nebs.
.
On arrival to the unit the patient was still extremely wheezy
and short of breath. Denied other symptoms. Denies HA, neck
stiffness, CP, abd pain, dysuria, hematuria, N/V, diarrhea.
.
Past Medical History:
- Asthma ([**3-3**] PFT FVC 1.7(56%); FEV1 1.1(50%) which is
decreased from prior. Mult admissions including ICU, however
never intubated. Peak flow generally 200-250 when feeling well.
- GERD
- chronic R hemiparesis
- Blind in R eye from cataracts
.
Social History:
Lives at home by herself, on disability. Divorced. Has many
family members dispersed throughout the country - 4 children, 5
grandchildren. Denies any tobacco, EtOH, or illicits. Not
sexually active for many years. No prior h/o STDs or HIV.
Family History:
h/o asthma, degenerative eye disease, CAD, CVA. No h/o any
cancers, HTN, NIDDM, or any bleeding/clotting disorders.
Physical Exam:
VS 98.6 134 148/60 25 95 on nebs
Gen - A+Ox3, dyspnic
HEENT - OP clear
Neck - supple, no LAD
Cor - RRR tachy
Chest - diffuse and severe wheeze, prolonged expiration
Abd - s/nt/nd +BS
Ext - no edema
.
Pertinent Results:
ADmit:
[**2160-3-26**] 11:25PM GLUCOSE-305* UREA N-13 CREAT-0.9 SODIUM-143
POTASSIUM-3.1* CHLORIDE-105 TOTAL CO2-21* ANION GAP-20
[**2160-3-26**] 11:25PM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.8*
[**2160-3-26**] 06:45PM GLUCOSE-116* UREA N-11 CREAT-0.8 SODIUM-145
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-18
.
[**2160-3-26**] 06:45PM WBC-12.8* RBC-4.34 HGB-13.6 HCT-38.8 MCV-89
MCH-31.3 MCHC-35.0 RDW-14.5
[**2160-3-26**] 06:45PM NEUTS-72.8* LYMPHS-13.4* MONOS-3.3 EOS-10.3*
BASOS-0.2
[**2160-3-26**] 06:45PM PLT COUNT-253
.
Transfer from MICU:
[**2160-3-28**] 03:49AM BLOOD WBC-30.8*# RBC-3.91* Hgb-11.9* Hct-34.9*
MCV-89 MCH-30.4 MCHC-34.2 RDW-14.5 Plt Ct-254
[**2160-3-28**] 03:49AM BLOOD Plt Ct-254
[**2160-3-28**] 03:49AM BLOOD Glucose-207* UreaN-19 Creat-0.8 Na-138
K-4.4 Cl-105 HCO3-21* AnGap-16
[**2160-3-28**] 03:49AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.3
.
Reports:
CXR:[**3-7**]: No acute pulmonary process
[**3-28**]: No acute pulmonary process
.
EKG - sinus tach, poor baseline, no sig change from prior
.
PFT [**3-3**]:
FVC 1.68; 56%
FEV1 1.11; 50%
Brief Hospital Course:
1) ASTHMA FLARE:
On HD#2, patient was taken off continuous nebs, and was
increased to q4 hour intervals and was switched to PO steroids.
She then developed anion gap acidosis/elevated lactate that was
thought to be attributable to respiratory muscle breakdown. On
HD#3, patient was transferred to the floor, after neb treatments
were decreased to q4 hours. On transfer to the floor she
reported feeling much improved. She was continued on PO
prednisone at 60mg. She was also continued on Z-pak which had
been started in ICU due to productive cough depsite clear CXR.
Her nebs were spaced out to 6hours. Her dyspnea resolved almost
completely though she still was wheezing on exam. She will
complete a 2 week steroid taper, Z-pak.
2) Eosinophilia:
[**Month (only) 116**] be related to asthma and allergy. There was also thought of
ABPA which can be worked up as an outpt.
Medications on Admission:
Meds:
Flonase
Advair 500/50
nebs
claritin 10
protonix 40
singulair 10
finished prednisone tape [**3-7**]
.
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
2. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Capsule(s)* Refills:*0*
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 10 mg Tablet Sig: taper as directed Tablet PO once
a day for 2 weeks: 4 tablets [**Date range (1) 9236**]
3 tablets [**Date range (1) 9237**]
2 tabs [**Date range (1) 9238**]
1 tabs [**Date range (1) 9239**]
half tab [**4-11**].
Disp:*15 Tablet(s)* Refills:*0*
5. Nebulizers Device Sig: One (1) device Miscellaneous AS
DIRECTED.
Disp:*1 device* Refills:*0*
6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
9. Claritin Oral
10. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-5**] puff Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 aersol* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Good.
Discharge Instructions:
Please take medications as prescribed.
Please call Dr. [**Last Name (STitle) **] if you have fevers, increasing shortness
of breath or wheezing, worsening cough, chest pain, or any other
symptoms that concern you.
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) 2185**]/[**Doctor Last Name **] or Dr.
[**Last Name (STitle) **] in the next 7-10 days to follow up.
You also have the following appointments already scheduled:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2160-6-11**] 3:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2160-6-11**] 3:40
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 41
} | Medical Text: Admission Date: [**2176-4-9**] Discharge Date: [**2176-4-12**]
Date of Birth: [**2121-4-8**] Sex: F
Service: SURGERY
Allergies:
Ovral-21 / Codeine / Sulfonamides
Attending:[**Doctor First Name 5188**]
Chief Complaint:
bruising and some mild abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, debridement of abdominal
wall, small and large bowel resection, and closure over a
[**Location (un) 5701**] bag.
Exploratory laparotomy.
History of Present Illness:
INDICATIONS FOR SURGERY: This is a 55-year-old woman who
noted some bruising and some mild abdominal pain over a large
incisional hernia site. She came to the emergency room where
she developed profound sepsis and a CT scan which showed
intraperitoneal air. She also was found to have crepitance
and expanding hematoma or bruising over her incisional
hernia.
The patient was taken emergently to the operating room.
Past Medical History:
s/p MVC ('[**61**]), s/p R AKA, ventral hernia repair w/ component
seperation ('[**66**]), anxiety
Social History:
Mother and son are the patient's support system
Family History:
noncontributory
Physical Exam:
gen: Intubated, secated
CV: +s1s2
Pulm: coarse BS diffusely
Abd: large [**Location (un) 5701**] bag in place
Ext: + edema
Pertinent Results:
[**4-9**] CT: 1. Large ventral abdominal wall hernia with two discrete
defects. The more inferior hernia defect (smaller defect)
contains several loops of necrotic- appearing bowel with
evidence of pneumatosis and possible perforation, suggesting
strangulated ventral hernia. Large amount of subcutaneous free
air within the ventral hernia sac inferiorly which tracks
retroperitoneally and into the mesentery, for which necrotizing
fascitis should be considered.
2. Likely aspiration at the lung bases, worse on the right side.
[**4-10**] Pathology: I) Ventral hernial sac (A-B):
Hernial sac with acute inflammation and serositis.
II) Abdominal wall (C-D):
Skin and subcutaneous tissue with extensive necrosis and abscess
formation.
III: Distal ileum and ascending colon, resection (E-L):
Extensive hemorrhagic necrosis and transmural infarction of the
small and large intestine:
a. Transmural necrosis is present at the proximal (ileal)
resection margin.
b. Viable distal (colonic) resection margin with serositis;
acute inflammation focally extends into the subserosa and
muscularis.
[**2176-4-9**] 06:00PM BLOOD WBC-19.2* RBC-3.46* Hgb-11.0*# Hct-33.3*
MCV-96 MCH-31.6 MCHC-32.9 RDW-13.5 Plt Ct-163
[**2176-4-11**] 02:39AM BLOOD WBC-63.3*# RBC-2.66* Hgb-8.0* Hct-25.5*
MCV-96 MCH-30.2 MCHC-31.4 RDW-17.1* Plt Ct-47*#
[**2176-4-11**] 08:09PM BLOOD WBC-50.3* RBC-3.14* Hgb-9.5* Hct-27.5*
MCV-88 MCH-30.1 MCHC-34.4 RDW-18.5* Plt Ct-25*
[**2176-4-9**] 06:00PM BLOOD Neuts-65 Bands-12* Lymphs-6* Monos-10
Eos-1 Baso-1 Atyps-0 Metas-2* Myelos-3*
[**2176-4-10**] 01:40AM BLOOD Neuts-79* Bands-3 Lymphs-11* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-1*
[**2176-4-9**] 06:00PM BLOOD ALT-62* AST-212* LD(LDH)-359*
AlkPhos-139* Amylase-17 TotBili-3.8*
[**2176-4-10**] 09:50AM BLOOD ALT-33 AST-98* LD(LDH)-245 AlkPhos-94
Amylase-42 TotBili-6.4*
[**2176-4-11**] 08:12AM BLOOD ALT-88* AST-406* AlkPhos-158* Amylase-27
TotBili-7.4*
[**2176-4-12**] 03:09AM BLOOD ALT-160* AST-576* AlkPhos-297*
TotBili-8.1*
[**2176-4-9**] 06:00PM BLOOD Lipase-22
[**2176-4-10**] 09:50AM BLOOD Lipase-63*
[**2176-4-11**] 08:12AM BLOOD Lipase-17
[**2176-4-11**] 03:54PM BLOOD Cortsol-30.6*
[**2176-4-11**] 03:54PM BLOOD Cortsol-34.2*
[**2176-4-9**] 06:06PM BLOOD Lactate-3.2* K-3.6
[**2176-4-10**] 10:03AM BLOOD Glucose-78 Lactate-4.3* Na-126* K-3.9
Cl-102
[**2176-4-11**] 02:51AM BLOOD Glucose-93 Lactate-5.9* Na-124* K-4.3
Cl-109
[**2176-4-11**] 11:46AM BLOOD Lactate-7.7*
[**2176-4-12**] 06:11AM BLOOD Glucose-146* Lactate-5.1* K-3.7
Brief Hospital Course:
The patient was admitted, and underwent the aforementioned
surgical procedures; for details, please see operative notes.
The patient returned to the SICU intubated and sedated for
further care. On [**4-12**], her family decided to make the patient CMO
after two exploratory laparotomies.
Neuro: The patient was sedated and received paralytics at times
to keep her comfortable while ventilated. She received pain
medications IV when appropriate.
CV: The patient's vital signs were routinely monitored, and was
put on vasopressin, norepinephrine and epinephrine during her
stay to maintain appropriate hemodynamics.
Pulmonary: Vital signs were routinely monitored. She was
intubated and sedated throughout her admission, and her
ventilation settings were adjusted based on ABG values. Serial
chest x-rays were performed.
A bronchoscopy was performed on [**4-10**], with aspiration of feculant
material from the right bronchus intermedius, blood clot
adherent to left main bronchus.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF. She was
unable to be extubated and did not receive any nutrition. On
[**4-12**], the patient was made CMO.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Her white blood count
continued to rise throughout her admission; for trends, please
see results section. The patient was in septic shock with
multiorgan failure. She was on vancomycin, fluconazole and
Zosyn during her stay, and culture data was routinely monitored.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly, and she was
put on a drip when necessary.
She received cosyntropin for a cortisol stimulation test.
Hematology: The patient's complete blood count was examined
routinely; multiple (over 6 units) transfusions were required
during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay.
The patient was made CMO on [**4-12**], after which she passed away.
Medications on Admission:
serax 15''', amitryptiline
Discharge Disposition:
Expired
Discharge Diagnosis:
Perforated viscus, dead bowel, and
deep tissue infection.
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
ICD9 Codes: 0389, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 42
} | Medical Text: Admission Date: [**2186-2-1**] Discharge Date: [**2186-2-10**]
Date of Birth: [**2163-2-7**] Sex: M
Service: NEUROLOGY
Allergies:
Codeine / Depakote
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Elective admission for depth electrode placement and invasive
EEG monitoring for possible temporal lobectomy
Major Surgical or Invasive Procedure:
Craniotomy for depth electrode placement
History of Present Illness:
The patient is a 22 year old right handed man with a history
of refractory complex partial epilepsy who has been admitted for
invasive electroencephalographic monitoring. He is being
transferred from the Neurosurgery service after placement of
depth electrodes and strips. His history of seizures began at
age
16. He had no history of febrile seizures, meningo-encephalitic
infection in early childhood, or head trauma. Preceding his
first
witnessed seizure by a few months, he was noted to have
intermittent stairing spells of unknown duration and
significance
that were noted in retrospect. He had an unwitnessed event while
driving a car, leading to a motor vehicle accident and possibly
a
head concussion. While hospitalized for this injury, he had
witnessed generalized convulsions at the hospital one day later.
He was initially started on Phenytoin after left temporal
slowing
was found on routine EEG. His medication compliance was poor,
resulting in generalized convulsions approximately every six
months.
His seizures have multiple semiologies. The generalized
convulsions (secondary generalized tonic-clonic) were usually
nocturnal, included loss of consciousness and tongue biting, and
were not preceded by auras. During some of these he sometimes
showed the appearance of experiencing ictal fear. He had a
different type of episode (complex partial) where he would have
pupillary dilation, staring, and behavioral arrest. These are
sometimes preceded by feelings of [**Last Name (un) 5083**] vu. These events
typically
last seconds to minutes (per OMR 5 seconds to 3.5 minutes). He
also has a third type of episode (simple partial) which only
includes the feeling of [**Last Name (un) 5083**] vu.
He reports having some feelings of jamais vu as well along with
the [**Last Name (un) 5083**] vu prior to the staring spells. With these auras, he
sometimes feels that things appear unreal or strange, almost as
though he were out of his own body. He denies any
micropsia/macropsia, tableau visual distortion, strange tastes
or
smells, or epigastric rising sensation.
He has had approximately three work-reated minor head injuries
after the initial onset of seizures. He has been tried on
Dilantin/phenytoin (ineffective vs noncompliance),
Depakote/valproic acid (weight gain, tremor), and
Trileptal/oxcarbazepine (headaches). He was subsequently
switched
to Keppra/levetiracetam and Lamictal/lamotrigine by our Epilepsy
service with some diminishment in seizure frequency per the
patient and his mother.
Past Medical History:
1. Epilepsy including generalized tonic-clonic and "absence
seizures" which are more likely complex partial seizures
2. Headache d/o related to (pre/post) seizures
3. h/o right hand fracture after punching a wall
4. h/o right UE trauma-related thrombosis after MVC [**11/2179**] for
which he was placed on Lovenox for two months (unrevealing
hypercoagulable workup).
Social History:
+Tobacco (occasional cigar, no cigarettes). +ETOH
(weekend, social). No illicit drug use. Born full-term without
perinatal complications. Reportedly achieved developmental
milestones early. Completed some college level education, but
did
not complete due to concentration difficulties. Currently
unemployed. Not currently driving.
Family History:
Seizures (maternal aunt, possibly from drug use).
No other seizure history.
Mother - hypothyroidism.
Father - died of PE (@bed rest for sciatic pain).
Physical Exam:
ADMISSION EXAM:
General: NAD, lying in bed comfortably. / Head: NC/AT, no
conjunctival icterus, no oropharyngeal lesions / Neck: Supple,
no
nuchal rigidity / Cardiovascular: RRR, no M/R/G / Pulmonary:
Equal air entry bilaterally, no crackles or wheezes / Abdomen:
Soft, NT, ND, +BS, no guarding / Extremities: Warm, no edema,
palpable radial/dorsalis pedis pulses / Skin: No rashes or
lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Recalls a coherent
history. Registration [**3-18**] and recall [**3-18**]. Concentration
maintained when recalling months backwards. Follows two step
commands, midline and appendicular. Language fluent with intact
repetition and verbal comprehension. Normal prosody. No
paraphasic errors. High and low frequency naming intact. No
dysarthria. No apraxia or neglect.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. Funduscopy shows crisp disc margins, no papilledema.
[III, IV, VI] EOMI, no nystagmus, slightly droopy eyelids with
left slightly lower than right but notably very tired/exhausted,
can hold up both eyelids volitionally. [V] V1-V3 without
deficits
to light touch bilaterally. [VII] No facial asymmetry. [VIII]
Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5
bilaterally.
[XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing.
Slight
change in cadence with right hand [**Doctor First Name **], less impaired on left
hand
[**Doctor First Name **].
- Gait - Unable to assess at the time of examination, in
restraints s/p electrode placement.
----
Pertinent Results:
WBC 14.7, Hgb 14.1, Plt 297, Na 145, Cr 1, Glu 158
NCHCT [**2-1**] - no hemorhage, depth electrodes in place,
pneumocephalus
MRI Head [**2-2**]
FINDINGS:
There is interval placement of electrodes, through the posterior
parietal and
approach, one on each side. The right-sided electrode, courses
through the
parietal and temporal lobes, and through the hippocampus, with
the tip
extending slightly beyond the margins of the hippocampus antral
medially and
inferiorly in the right temporal lobe. The left-sided lead has
the tip within
the left hippocampus.
There is no focus of slow diffusion to suggest acute infarction.
The
ventricles and extra-axial CSF spaces are normal. No focal areas
of altered
signal intensity are noted in the brain parenchyma on the
non-contrast images.
The major intracranial arterial flow voids are noted. The imaged
portions of
the paranasal sinuses and the mastoid air cells are clear.
Post-procedural
changes are noted in the soft tissues of the scalp and the bone
and adjacent
soft tissues in the posterior temporal regions.
NCHCT `[**2-9**]
FINDINGS: Previously visualized bitemporal depth electrodes as
well as
bilateral temporal grids have since been removed. Five burr
holes are again
noted in both temporal lobes, posterior aspect of both parietal
lobes, and
right lateral aspect of the frontal bone. Mild right frontal and
bitemporal
pneumocephalus is noted, as well as a focus of gas in the
subgaleal tissues
overlying the right temporal bone. There is, however, no
evidence of
hemorrhage, edema, large vessel territorial infarction, or shift
of normally
midline structures. The ventricles and sulci remain normal in
size and
configuration. The visualized paranasal sinuses and mastoid air
cells are
clear.
IMPRESSION: Interval removal of previously placed depth
electrodes and grids.
No evidence of post-procedural complications.
EEG [**2-2**]
IMPRESSION: This is an abnormal video intracranial EEG
monitoring
session because of a left temporal clinical focal seizure, as
described
above. This arose regionally from the antero-mesial temporal
region
(subdural strip anterior temporal strip hippocampus), but the
exact
ictal onset zone is not recorded. The only clinical
manifestation was
brief eye opening. This ictal activity briefly spread to the
right
subtemporal strip, with repetitive spikes and spike-wave
activity for
about 20 seconds, but did not spread to other right temporal
electrodes.
There were abundant bilateral hippocampal depth electrode
spikes, as
described above. Spikes are most frequent in the right anterior
hippocampus but are also seen frequently in the left anterior
hippocampus.
EEG [**2-3**]
IMPRESSION: This is an abnormal video intracranial EEG
monitoring
session because of two left temporal complex partial seizures as
described above. These appear to arise regionally from the
antero-mesial temporal region (subdural strip anterior temporal
strip
hippocampus), but the exact ictal onset zone is not recorded.
The
ictal activity spread briefly to right subdural strip
electrodes, with
repetitive spikes in RST2-3 and RST3-4, but did not involve
other right
temporal electrodes. There were abundant bilateral hippocampal
depth
electrode spikes, as described above. Spikes are most frequent
in the
right anterior hippocampus but are also seen frequently in the
left
anterior hippocampus. Compared to the prior day's recording,
there is
no significant change interictal activity, but two complex
partial
seizures are recorded.
EEG [**2-4**]
IMPRESSION: This is an abnormal video intracranial EEG
monitoring
session because of abundant bilateral hippocampal depth
electrode spikes
as described above. Spikes are most frequent in the right
anterior
hippocampus but are also seen frequently in the left anterior
hippocampus. No electrographic seizures are present. Compared
to the prior day's recording, there is no significant change
interictal
activity, but no seizures are recorded.
EEG [**2-5**]
IMPRESSION: This is an abnormal video intracranial EEG
monitoring
session because of abundant bilateral hippocampal depth
electrode spikes
as described above. Spikes are most frequent in the right
anterior
hippocampus but are also seen frequently in the left anterior
hippocampus. No electrographic seizures are present. Compared to
the
prior day's recording, there is no significant change in
interictal
activity, but no seizures are recorded.
Brief Hospital Course:
22yoW h/o epilepsy, depression electively admitted for depth
electrode placement, continuous EEG, and further localization of
temporal lobe seizure focus in anticipation of surgical
resection.
[] Depth Electrodes Placement for Invasive EEG Monitoring - The
depth electrodes were placed by Dr. [**Last Name (STitle) **]/Neurosurgery without
major perioperative complications, and they were removed
similarly without major complications. He had no persistent new
neurologic deficits after either procedure. He was covered with
antibiotics including 7 days of cephalexin after his discharge
(vancomycin and gentamicin while in-house).
[] Epilepsy - The patient was monitored with invasive EEG
monitoring with his medications downtitrated which revealed
bilateral temporal lobe seizures. His medications were restarted
with lamotrigine being uptitrated to 200 qAM and 300 qPM.
[] Depression - His Sertraline was increased to 100 mg daily. He
did not display any signs of worsening depression, but the new
findings of his bilateral temporal seizures and inability to get
temporal lobectomy could be a major trigger for worsening
depression.
PENDING STUDIES:
EEG final reports
TRANSITIONAL CARE ISSUES:
[ ] Please assess his seizure frequency on his new dose of
lamotrigine.
[ ] Please follow his emotional state/depression on the higher
dose of Sertraline.
Medications on Admission:
Keppra 1500mg [**Hospital1 **], Lamictal 200mg [**Hospital1 **], Sertraline
50mg Daily
Discharge Medications:
1. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO QAM.
Disp:*30 Tablet(s)* Refills:*2*
2. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO twice a
day.
3. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO PRN
as needed for headache.
4. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days: for prevention of infection after your
operation.
Disp:*28 Capsule(s)* Refills:*0*
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain for 3 days: Do not take more than prescribed
amount. Do not drive or operate heavy machinery as this can make
you drowsy.
Disp:*18 Tablet(s)* Refills:*0*
6. lamotrigine 200 mg Tablet Sig: 1.5 Tablets PO QPM.
Disp:*45 Tablet(s)* Refills:*2*
7. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Epilepsy/Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: No deficits.
Discharge Instructions:
[ NEUROLOGY DISCHARGE INSTRUCTIONS ]
Mr. [**Known lastname 88790**],
You were admitted to the hospital for invasive
electroencephalographic monitoring for your seizure disorder
(temporal lobe epilepsy). The depth electrodes and strips were
placed by our Neurosurgical team without any major
complications. We monitored you in the Epilepsy Monitoring Unit
and were able to record several seizures. The electrodes were
subsequently removed. Dr. [**First Name (STitle) **] will be using this data to
continue guiding you through the management of your epilepsy.
At this time, we are not making any changes to your medication
regimen. Please take your anticonvulsants as previously
prescribed.
We are changingthe following medications:
1. Please increased your evening dose of LAMICTAL/lamotrigine to
300 MG per night. You will take LAMICTAL 200 MG in the morning
and 300 MG in the evening.
2. Please take KEFLEX/cephalexin 500 MG four times per day
(every 6 hours) for 7 days for prevention of infection after
your surgery.
3. Your Sertraline has now been increased to 100 MG per day. I
am prescribing you a new tablet.
4. Please take Docusate Sodium and Senna as prescribed to
prevent constipation whiel taking Oxycodone for pain.
5. You can take Oxycodone 5 mg every 8 hours as needed for pain
over the next few days. Do not operate heavy machinery while
using this medication as it can make you drowsy. You can also
take Acetaminophen 650 MG three or four times daily as needed
for your headache for a few days (do not take as frequently in
the long term).
Please continue to take your own scheduled medications.
We would like you to followup with Dr. [**First Name (STitle) **] as listed below.
If you have any of the following symptoms, please seek medical
attention.
It was a pleasure providing you with medical care during this
hospitalization.
[ NEUROSURGERY DISCHARGE INSTRUCTIONS ]
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? If your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. You may shower before this time using a shower cap to
cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
NEUROLOGY Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone: [**Telephone/Fax (1) 3294**]
Date/Time: [**2186-3-3**] 1:00
NEUROSURGERY: Please call [**Telephone/Fax (1) 1669**] to set up a time to have
your staples removed. This should occur in about 1 week. (The
Neurosurgeons have provided you with this information and these
instructions.)
ICD9 Codes: 3051, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 43
} | Medical Text: Admission Date: [**2140-2-29**] Discharge Date: [**2140-3-4**]
Date of Birth: [**2069-7-18**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
C2 type II dens fracture s/p HALO placement
Major Surgical or Invasive Procedure:
[**2140-2-29**]:
Open reduction and internal fixation of type II C2 dens
fracture.
History of Present Illness:
Pt is a 79 year old woman with a known C2 fracture sustained
after a fall in [**2139-10-22**]. She was placed in a halo at that
time, then discharged to [**Hospital 100**] Rehab, and is here today for
follow up. She has not yet been discharged from rehabilitation.
She complains of pain related to the halo at times, and feels
that she has had a decrease in mobility especially when getting
out of bed or a chair. No additional complaints. No HA,
numbness/tingling.
Past Medical History:
CAD
Hiatal hernia
SVD
Vaginal hysterectomy
Post colporrhaphy and bladder neck suspension,
R breast lumpectomy
L mastectomy for Breast Ca
C2 type II dens fracture.
Social History:
widowed
Family History:
Father - CAD, [**Name (NI) **] Ca. Mother - PE
Physical Exam:
GENERAL: She is alert and oriented x 3, pleasant, and in no
acute distress.
NEUROLOGIC: She has a halo on and it is intact. She is able to
rise from her seat, but is tentative, uses her arms for
additional strength. Full strength throughout, [**3-25**]. Deep tendon
reflexes 2+ throughout. Sensation is intact. Halo pin sites, no
erythema, edema, or drainage.
C-spine CT from [**2-2**] - Again seen is an oblique fracture
involving the base of the odontoid process (type 2).
Fracture
fragments appear in unchanged alignment. Multiple small
osseous
fragments, also unchanged in appearance, are noted. There is
slight cortication of the still-evident fracture line margins.
However, the lack of change in alignment suggests development of
fibrous [**Hospital1 **].
Pertinent Results:
[**2140-3-3**] 06:45AM BLOOD WBC-8.9 RBC-4.32 Hgb-12.9 Hct-38.4 MCV-89
MCH-29.9 MCHC-33.6 RDW-14.0 Plt Ct-99*
[**2140-3-3**] 06:45AM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-145
K-4.3 Cl-105 HCO3-32 AnGap-12
[**2140-3-3**] 06:45AM BLOOD Calcium-8.5 Phos-2.8# Mg-1.8 RADIOLOGY
Final Report
CT C-SPINE W/O CONTRAST [**2140-3-1**] 12:03 PM
CT C-SPINE W/O CONTRAST
Reason: please evaluate post op at 0800 on [**2140-3-1**]. thank you.
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman s/p ORIF of C2 type II dens fx.
REASON FOR THIS EXAMINATION:
please evaluate post op at 0800 on [**2140-3-1**]. thank you.
CONTRAINDICATIONS for IV CONTRAST: None.
CT scan of the cervical spine with multiplanar reformatted
images.
Exam compared to previous examination of [**2140-2-2**].
FINDINGS: There has been intramedullary fixation of the fracture
of C2 and the odontoid with a metallic device extending from the
body of C2 into the odontoid process. There is no evidence of
abnormal calcification within the spinal canal. The
retropharyngeal mass is again demonstrated and is unchanged from
prior studies. There is no alteration in alignment.
IMPRESSION: Status post internal fixation of odontoid fracture.
Stable appearance of retropharyngeal mass.
DR. [**First Name (STitle) 23303**] [**Doctor Last Name **]
Approved: TUE [**2140-3-1**] 3:57 PM
Brief Hospital Course:
Pt admitted to the neurosurgery service s/p ORIF type II C2 dens
fracture.
Pt keep in the PACU overnight for q1 hr neurochecks. Post
operatively she was awake, alert and orientated X3 moving upper
extremeties with good strength.
She had a post op CT scan: FINDINGS: There has been
intramedullary fixation of the fracture of C2 and the odontoid
with a metallic device extending from the body of C2 into the
odontoid process. There is no evidence of abnormal calcification
within the spinal canal. The retropharyngeal mass is again
demonstrated and is unchanged from prior studies. There is no
alteration in alignment.
She was seen by PT and found to be hypotensive so she was
observed additional day. Social work was also involved with her
discharge planning and Ms [**Known lastname 98305**] agreed to return to rehab.
Medications on Admission:
protonix 40mg qd
triethanolamine/water (shampoo) Th@10 to scalp.
neosporin triple antibiotic ointment to pin sites
tylenol 650 q4h prn
tylenol 650 [**Hospital1 **]
fosamax 70mg qSat
lipitor 80mg qPM
dulcolax 10mg PR prn
calcium/vit D 500 tid
celexa 40 qhs
colace 250 qAM
[**Doctor First Name 130**] 30 qd prn
robitussin syrup 5ml q6prn
MOM 30ml qd prn
MVI
oxycodone hcl 5 q4 prn
senna 2 tabs qHS
trazodone 25 daily prn
lasix 40 qod
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Use
while on Percocet.
Disp:*30 Tablet(s)* Refills:*1*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain/fever.
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Use while on Percocet.
Disp:*60 Capsule(s)* Refills:*2*
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
12. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): to pin sites.
Disp:*1 500unit/g* Refills:*2*
13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
C2 type II dens fracture.
Discharge Condition:
neurologically stable.
Discharge Instructions:
Restart you home medications as usual. Please take newly
prescribed medications as instructed.
Must wear collar at all times except when bathing
No heavy lifting
Diet low in cholesterol and high in fiber.
Do not get steristrips wet until tomorrow, may shower starting
tomorrow.
Watch incision for redness, drainage, bleeding, swelling, or if
you develop a fever greater than 101.5 call Dr [**Last Name (STitle) 17511**] office
You may shower but please keep incision covered with tegaderms
during shower.
Please keep incision clean, dry, intact till you see Dr. [**Last Name (STitle) **]
clinic.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Reddness/swelling/discharge from wounds
* Anything that concerns you.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 8 weeks. Please call
[**Telephone/Fax (1) 1669**] to make an appointment.
Please keep the following appointments:
Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2140-3-4**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 98306**], [**Name12 (NameIs) 16569**] RNC Date/Time:[**2140-4-4**] 1:20
Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. Date/Time:[**2140-4-11**] 3:30
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 44
} | Medical Text: Admission Date: [**2126-2-27**] Discharge Date: [**2126-3-5**]
Date of Birth: [**2050-6-17**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 75 year-old woman with
a past medical history of hypertension, hypercholesterolemia
who was transferred from [**Hospital6 33**] for emergent
cardiac catheterization since she presented to that hospital
earlier this evening of admission with complaints of 6 out of
10 abdominal indigestion. The patient noted back pain, but
denies nausea or vomiting. Electrocardiogram showed ST
segment elevations about 6 mm in leads V2, V3 and 5 mm
changes in V5, 3 mm in V6 and 3 mm changes in leads 2 and
AVL. The patient with old right bundle branch block and with
reciprocal changes in the inferior leads. The patient was
given Lopressor, nitroglycerin and Integrilin at the outside
hospital with chest pain that decreased to 1.5 out of 10. Of
note patient with similar complaints on Sunday. At that time
those complaints were associated with nausea and vomiting as
well. In the catheterization laboratory the patient
underwent stenting of the mid left anterior descending
coronary artery lesion due to 50% proximal and 50% first
septal and 100% mid occlusion. The patient also underwent
percutaneous transluminal coronary angioplasty of the left
anterior descending coronary artery just beyond flow stent.
The patient had multiple infusions of intracoronary
nitroglycerin and Diltiazem to improve flow. Hemodynamically
the patient's right atrium was a pressure of 10, PA of 42/21,
wedge pressure of 26, cardiac output 3.24, cardiac index
1.95, FVR 2100. The patient was given 10 mg of intravenous
Lasix and transferred to the Coronary Care Unit.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Status post appendectomy.
ALLERGIES: Penicillin causes a rash.
MEDICATIONS:
1. Atenolol 50 once a day.
2. Lipitor 10 once a day.
FAMILY HISTORY: Negative for coronary artery disease.
Father with an aortic aneurysm. Mother with a stroke.
SOCIAL HISTORY: Former tobacco smoker about half a pack per
day for five yeas. Alcohol before dinner occasionally. No
drugs. She lives at home with her older sister.
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 150/80.
Pulse 78. O2 sat 96% on 2 liters. In general, she is a
pleasant elderly woman in no acute distress. HEENT
normocephalic, atraumatic. Pupils are equal, round and
reactive to light. Extraocular movements intact. Mucous
membranes are moist. Clear oropharynx. Cardiovascular
regular rate and rhythm. Normal S1 and S2. 1 out 6 systolic
ejection murmur. JVP at about 8 cm. Lungs clear to
auscultation anteriorly. Abdomen is soft, nontender,
nondistended. Positive bowel sounds. Extremities no
clubbing, cyanosis or edema. Good dorsalis pedis pulses and
posterior tibial pulses 2+ bilaterally. Right groin arterial
sheath and Swan in place. Skin no rashes or lesions.
LABORATORY DATA: White blood cell count 11.4, hematocrit
38.9, platelets 319, sodium 138, K 4.2, chloride 103, bicarb
26, BUN 23, creatinine 1.0, albumin 4.1, troponin 0.79.
Electrocardiogram as described previously.
HOSPITAL COURSE: This is a 75 year-old woman with a history
of hypertension, hypercholesterolemia status post large
anterior myocardial infarction with placement of stent in the
mid left anterior descending coronary artery. At
catheterization the patient was noted to have an elevated
wedge pressure and residual lesion of the left circumflex,
which was not intervened on.
1. Coronary artery disease: The patient has a large
anterior myocardial infarction and catheterization results as
noted above. The patient was continued on aspirin, Plavix,
Integrilin for 18 hours and then discontinued. Also
continued on heparin and beta-blocker was continued as
tolerated. The patient was continued on her Lipitor 80 mg
and weaned off her nitro drip. Otherwise the patient
remained mostly chest pain free throughout the course of her
stay. She was started on a beta-blocker and titrated up as
tolerated and the patient was evaluated by the EP team for
possible risk stratification in the future secondary to her
anterior myocardial infarction and decreased ejection
fraction. She did continue to have some episodes on
telemetry of tachycardia with exertion and plans were made to
have an outpatient Holter monitor and an outpatient stress in
six weeks time with T wave alternans at which time she will
follow up with Dr. [**Last Name (STitle) **] following those studies and to
reassess her obtuse marginal and right coronary artery
lesions for a possible reintervention. The patient was also
started on low level Coumadin for three to four months of
anticoagulation for her anterior myocardial infarction and
hypokinesis of her anterior wall and decreased ejection
fraction. For this she was also started on Lovenox as a
bridge waiting for Coumadin to become therapeutic and can
have this followed as an outpatient. Goal INR of 1.5 at
which time she can discontinued her Lovenox. The patient was
given teaching of her Lovenox during her stay and understood
injections. Otherwise the patient was also started on ace
inhibitor to improve cardiac function and for her decreased
ejection fraction.
2. Congestive heart failure: The patient with an ejection
fraction of 35% after her anterior myocardial infarction.
She had akinesis of her mid distal and anterior septum,
distal anterior wall and apical akinesis and the patient was
continued on her ace inhibitor for after load reduction and
we started her on low dose Coumadin. The patient's Is and Os
were monitored and she did receive some Lasix on a prn basis.
She was transfused one unit of blood for a hematocrit less
then 30 and was followed by a dose of Lasix as she had some
bibasilar crackles following the blood.
3. Hematuria: The patient had some hematuria, which was
likely secondary to a traumatic Foley placement during
admission, however, the patient was recommended to have
outpatient cystoscopy and urology follow up as she will get
this further evaluated once acute process is resolved.
4. Nutrition: The patient was continued on a cardiac diet
and her electrolytes were followed closely. The patient was
seen and evaluated by physical therapy with no acute needs
for rehab or physical therapy. The patient was ambulating
without difficulty or without desaturation or orthostasis.
DISCHARGE CONDITION: Good. Discharged with services for
Lovenox teaching. The patient ambulating without difficulty
and not requiring oxygen.
DISCHARGE DIAGNOSES:
1. Anterior wall myocardial infarction.
2. Congestive heart failure.
3. Hypertension.
4. Hypercholesterolemia.
5. Hematuria.
DISCHARGE MEDICATIONS:
1. Lovenox 100 mg subq q day until INR greater then 1.5.
2. Coumadin 5 mg po q day for three to four months with goal
INR of 1.5.
3. Toprol XL 100 mg one po q day.
4. Lisinopril 10 mg one po q day.
5. Sublingual nitroglycerin prn.
6. Atorvastatin 80 mg po q day.
7. Plavix 75 mg one po q day.
8. Aspirin 325 mg one po q day.
DISCHARGE FOLLOW UP: The patient is to follow up with her
primary care physician on [**Name9 (PRE) 2974**]. The patient is to have her
INR checked at that time and adjusted accordingly. The
patient is to follow up with an outpatient neurologist and
establish herself with a local cardiologist once she sees her
local primary care physician. [**Name10 (NameIs) **] she will follow up
with Dr. [**Last Name (STitle) **] on [**2126-4-17**]. The patient will have a
Holter monitor placed on [**4-8**] and then will return for a
stress test with T wave alternans on [**4-9**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2126-3-5**] 04:24
T: [**2126-3-6**] 08:50
JOB#: [**Job Number 54527**]
ICD9 Codes: 4280, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 45
} | Medical Text: Admission Date: [**2156-11-17**] Discharge Date: [**2156-11-19**]
Date of Birth: [**2156-11-17**] Sex: F
Service: NB
HISTORY: Baby Girl [**First Name4 (NamePattern1) 47506**] [**Known lastname **], twin #1, delivered at 35-
4/7 weeks gestation, was admitted to the newborn intensive
care nursery for management of prematurity. Birth weight 2215
gm (25th to 50th percentile), length 47 cm (50th percentile),
head circumference 32 cm (50th percentile).
Mother is a 38-year-old gravida 1 mother with estimated date
of delivery [**2156-12-18**]. Her prenatal screens included
blood type A positive, antibody screen negative, hepatitis B
surface antigen negative, rubella immune, RPR nonreactive,
and group B strep unknown. This pregnancy was conceived by in
[**Last Name (un) 5153**] fertilization resulting in dichorionic diamnionic twin
gestation. The pregnancy was complicated by advanced maternal
age, twin gestation, and gestational hypertension treated
with Aldomet. She presented on day of delivery with pre-term
premature rupture of membrane and pre-term labor. She was
delivered by cesarean section under spinal anesthesia
secondary to multiple gestation. The amniotic fluid was
clear. No maternal fever. No interpartem antibiotics. This
twin emerged with a cry, was dried, bulb suctioned. Apgar
scores were 9 at one minute and 9 at five minutes.
PHYSICAL EXAMINATION AT DISCHARGE: Weight 2205 gm. Awake and
alert infant. Anterior fontanelle open, soft, flat. No
clefts. Red reflex deferred. Breath sounds clear and equal
bilaterally with easy work of breathing. No murmur. Normal
pulses and perfusion. Abdomen soft, nondistended, positive
bowel sounds, cord dry. Spine intact. Hips stable. Normal pre-
term female genitalia. Active with normal tone and activity
for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory - has
been in room air since admission with comfortable work of
breathing, respiratory rate remains in the 30s to 40s, no
apnea.
Cardiovascular - no murmur, heart rates range 130s to 140s;
blood pressure 62/29 with a mean of 41.
Fluids, electrolytes, nutrition - the baby initially had an
IV on admission and was started on ad lib feeds. IV fluid was
discontinued on [**2156-11-18**]; is taking Enfamil 20 ad
lib, taking around 18-35 cc every 3-4 hours, is voiding and
stooling appropriately.
Gastrointestinal - very mild facial jaundice, bili has not
been drawn yet, plan to draw on day of life 3.
Hematology - hematocrit on admission 51%.
Infectious disease - a CBC and blood culture were drawn on
admission and was started on ampicillin and gentamicin for
rule out for infection on [**2156-11-19**]. CBC showed a
white count of 8.9 with 21 polys, no bands, platelets
331,000, hematocrit 51%. Blood culture has no growth to date.
Sensory - hearing screening has not been performed yet, will
need prior to discharge.
CONDITION AT DISCHARGE: Stable pre-term infant.
DISCHARGE DISPOSITION: Transferred to newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) 74887**], M.D., [**Location (un) 74888**], [**Apartment Address(1) 50442**], [**Location (un) **], [**Numeric Identifier 1415**], telephone
#[**Telephone/Fax (1) 43701**].
CARE RECOMMENDATIONS: Feeds - Enfamil 20 with iron ad lib,
monitor weight, may need 24 calories per ounce.
Medications - currently on no medications, iron and vitamin D
supplementation, iron is recommended for pre-term and low
birth weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive vitamin
D supplementation at 200 international units, may be provided
as a multivitamin preparation, daily until 12 months
corrected age.
Car seat position screening test has not been performed, will
need prior to discharge.
State newborn screen has not been drawn, plan to draw it on
[**2156-11-20**], when draw bilirubin.
IMMUNIZATIONS RECEIVED: Has not received hepatitis B
immunization yet.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 4 criteria - 1) born at less than 32
weeks, 2) born between 32 and 35 weeks with 2 of the
following - day care during RSV season, smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, 3) chronic lung disease, 4)
hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life
immunization against influenza is recommended for household
contacts and out of home caregivers.
This infant has not received rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of pre-
term infants at or following discharge from the hospital if
they are clinically stable and at least 6 weeks but fewer
than 12 weeks of age.
FOLLOW-UP APPOINTMENTS: Recommended followup per
pediatrician.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age, pre-term female at 35-
4/7 weeks.
2. Twin #1.
3. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2156-11-19**] 02:26:25
T: [**2156-11-19**] 03:52:12
Job#: [**Job Number 74889**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 46
} | Medical Text: Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
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 for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 47
} | Medical Text: Admission Date: [**2126-11-1**] Discharge Date: [**2126-11-6**]
Date of Birth: [**2069-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
s/p PEA arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 year old male with history of atrial fibrillation, DM2, prior
MI presents s/p PEA arrest at an OSH after VATS.
.
Patient is intubated and unresponsive on arrival, history is
obtained from outside records.
.
In early [**Month (only) 359**], he had a sore throat and felt poorly. He went
to his PCP and was treated with 10 days of ammoxicillin. he then
was treated with penicillin for a dental extraction. Shortly
after this, he became progressively short of breath. He saw his
PCP who referred him to Cardiology (Dr. [**Last Name (STitle) 77919**]. At that
time a CXR was performed that showed opacification of the right
lower [**12-9**] to [**12-8**] hemithorax, interpreted as infiltrate + pleural
effusion. He also had a stress echocardiogram and a cardiac
catheterization was planned. A chest X-ray was repeated on
[**2126-10-28**], which was unchanged. His cath was deferred and he was
scheduled to undergo VATS with possible pleural decortication.
.
He was admitted to [**Hospital3 26615**] on [**2126-10-30**] for VATS and
bronchoscopy. 2600 cc of straw colored pleural fluid was
removed, and pleural biopsy was taken. At the end of the
procedure, prior to extubation, patient had a drop in blood
pressure and suffered a PEA arrest. Patient received
defibrillation, epinephrine, and chest compresions for 17
minutes. He returned to [**Location 213**] sinus rhythm, and was transferred
to the ICU. He was put on a lasix drip. There an echo
demonstrated no pericardial effusion, and and CT PA demonstrated
no PE. His labs were significant for a WBC of 12. Cardiac
enzymes were flat. He was treated with levaquin and unasyn for
presumed PNA. He was weaned off of sedation and only responded
to noxious stimuli. He was evaluated by neurology who
recommended MRI and EEG. He is transferred to [**Hospital1 18**] for further
cardiology and neurology evaluation. On transfer, he was on a
heparin drip, midazolam/fentanyl for sedation and mechanical
ventilation (AC).
Past Medical History:
- Atrial Fibrillation
- Diabetes Type II
- H/O MI
Social History:
-Tobacco history: Quit smoking three years ago, 1 ppd x 20 years
previously
-ETOH: 12 pack on weekends
-Illicit drugs:
Family History:
NC
Physical Exam:
VS: T= 99.7 BP= 126/81 HR= 78 RR= 16 O2 sat= 100/ AC FiO2 100,
Tv 550, RR 16, PEEP 5
GENERAL: Intubated, sedated, not responsive to commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
NEURO: Unresponsive to commands. Pupils reactive to light,
corneal relfex intact. Babinski up going. no spontaneous
movement observed.
.
At time of death: extubated
Pertinent Results:
[**2126-11-1**] 06:22PM BLOOD WBC-9.1 RBC-4.64 Hgb-14.7 Hct-41.6 MCV-90
MCH-31.8 MCHC-35.4* RDW-13.5 Plt Ct-222
[**2126-11-1**] 06:22PM BLOOD Neuts-74.9* Lymphs-17.0* Monos-5.7
Eos-0.7 Baso-1.8
[**2126-11-1**] 06:22PM BLOOD PT-15.6* PTT-32.2 INR(PT)-1.4*
[**2126-11-2**] 04:11AM BLOOD ESR-30*
[**2126-11-1**] 06:22PM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-136
K-3.7 Cl-98 HCO3-29 AnGap-13
[**2126-11-1**] 06:22PM BLOOD ALT-24 AST-51* CK(CPK)-100 AlkPhos-75
TotBili-2.1*
[**2126-11-2**] 04:11AM BLOOD ALT-22 AST-50* AlkPhos-69 TotBili-2.0*
[**2126-11-3**] 04:26AM BLOOD ALT-22 AST-54* AlkPhos-69 TotBili-2.4*
[**2126-11-1**] 06:22PM BLOOD CK-MB-1 cTropnT-<0.01
[**2126-11-1**] 06:22PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
[**2126-11-2**] 04:11AM BLOOD CRP-41.7*
[**2126-11-2**] 04:11AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2126-11-1**] 06:27PM BLOOD Type-ART pO2-386* pCO2-39 pH-7.48*
calTCO2-30 Base XS-6
[**2126-11-3**] 05:12AM BLOOD Type-ART pO2-143* pCO2-39 pH-7.47*
calTCO2-29 Base XS-5
[**2126-11-1**] 06:27PM BLOOD Lactate-1.6
.
EEG: This is an abnormal routine EEG due to the presence of a
low-voltage background that was invariant and nonreactive to
external
stimulation. This finding suggests a diffuse and severe
encephalopathy,
such as that caused by hypoxic-ischemic injury, toxic-metabolic
changes,
or medication effect, among other things. There were no focal
abnormalities or epileptiform features noted.
.
PCXR: The ET tube tip is 5.2 cm above the carina. The NG tube
tip passes below the diaphragm with its tip being in the
stomach.
Diffuse pericardial calcification is noted, circumferential.
Mediastinum is minimally widened but it might be related to
portable technique of the study. There is minimal vascular
congestion but no overt edema. Left retrocardiac opacity might
represent area of atelectasis, aspiration or infectious process
and should be closely monitored.
.
TTE: The left atrium is elongated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. There is mild to moderate regional left ventricular
systolic dysfunction with basal to mid inferior, inferolateral,
and anterolateral hypokinesis. Due to suboptimal technical
quality, additional focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
mildly depressed (LVEF= 40%). Unable to assess left ventricular
diastolic function. Right ventricular chamber size and free wall
motion are normal. There is abnormal septal motion/position. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
.
MR HEAD W/ and W/O CON:
1. Extensive confluent areas of decreased diffusion in the
bilateral parietal and occipital [**Month/Day/Year 3630**] and parts of the frontal
lobes likely related to cortical infarction with some degree of
cortical swelling. Spreading of the temporal lobes, the basal
ganglia and the right cerebellar hemisphere and probably the
left cerebellar hemisphere. Correlate clinically and consider
followup/correlation with brain scan.
2. Area of increased signal intensity on the T2 and FLAIR
sequences in the
right frontal [**Last Name (LF) 3630**], [**First Name3 (LF) **] relate to changes in the parenchyma
surrounding small developmental venous anomaly. However, given
the lack of prior studies and the extent of FLAIR hyperintense
area, which measures 2.1 x 2.6 cm, consider followup to assess
stability/progression to exclude any associated low-grade
neoplasm.
3. Mucosal thickening in the mastoid air cells on both sides,
right more than left.
.
Brief Hospital Course:
#. s/p PEA arrest. Post-op/peri anesthesia hypotension most
likely precipitant of PEA. Possible contribution from hypoxia
given lung collapse seen on CT. CT PA negative for PE, echo
negative for tamponade. Labs essentially normal, cardiac enzymes
negative. Neurology consulted and EEG and MRI head done, all
consistent with very poor neurologic prognosis. Neurology team
explained prognosis to patient's family and they agreed that it
would not be within his wishes to exist without meaningful
interaction. NEOB was initially contact[**Name (NI) **] but pt. was no longer
a possible donor once extubated.
.
# Respiratory Failure/Pleural Effusion: Patient was never
extubated post-thoracentesis. Continued levaquin and unasyn
given concern for aspiration/oral flora given unilateral PNA,
recent tooth extraction and alcohol history. Pleural fluid
analysis not an empyema, but suggestive of exudate. Fluid
cytology negative. Patient was overbreathing vent with excellent
RSBI prior to extubation. He was made DNR/DNI prior to
extubation. He was successfully extubated on [**11-4**] and morphine
drip was given with scopolamine patch for comfort measures. He
expired on the morning of [**11-6**]. Autopsy was requested by the
family.
Medications on Admission:
HOME MEDICATIONS:
Metformin 1000mg PO bid
ASA 325mg PO daily
Glyburide 5mg PO bid
Imdur 30mg PO daily
.
MEDICATIONS ON TRANSFER:
Combivent
Heparin gtt 900 U/hr
Unasyn 3gm IV q6
Levaquin 750 mg q24
Lasix 40mg IV q daily
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p PEA arrest
Death
Discharge Condition:
Expired
ICD9 Codes: 9971, 486, 5180, 5119, 412, 4019, 4275, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 48
} | Medical Text: Admission Date: [**2176-5-31**] Discharge Date: [**2176-6-14**]
Date of Birth: [**2101-7-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Constipation, fatigue, weight loss
Major Surgical or Invasive Procedure:
Resection of transverse colon and splenic
flexure, colocolostomy, resection of small bowel (en bloc)
enteroenterostomy and feeding jejunostomy.
History of Present Illness:
Mrs [**Known lastname 1391**] is a 74F who presents with a several month history
of constipation, diarrhea, occasional nausea/vomiting, and a
weight loss of approx 25lbs over the past 6 months. She first
sought medical attention 3 weeks before admission, when her
workup, including colonoscopy and CT scan, showed a mass in the
transverse colon. Biopsy showed moderately differentiated
adenocarcinoma. She denies black or bloody stools, or dysuria.
Past Medical History:
CAD with CABG in [**9-/2172**]
Hypothyroidism
Recent onset of heartburn symptoms, no formal dx of GERD
Social History:
30-40py smoking history
Widowed for 6 years
3 Children
Family History:
Mother died of pancreatic cancer, father of prostate cancer
Physical Exam:
Physical exam on discharge:
VS:
RRR
CTAB
Abd soft, non-tender with jejunostomy tube in place. J-tube site
free of erythema or induration.
Brief Hospital Course:
Ms [**Known lastname 1391**] was admitted on [**2176-5-31**] to begin nutritional
optimization in preparation for surgery. A pre-operative
cardiology clearance was obtained with no cardiac intervention
required. A central line was placed on [**6-1**] and total parenteral
nutrition was initiated, although the pt continued to attempt
self-support through oral intake. A CT scan on [**6-5**] for
pre-operative planning was not encouraging, as it showed a
metastatic lesion invading the mesentery with likely involvement
of the celiac and mesenteric vessels. She underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
prep and Fleets #1 prep on [**6-5**], and was taken to the operating
room on [**6-6**]. Please refer to the operative report of Dr [**Last Name (STitle) 957**]
for further details on that procedure. Post-operatively she was
noted to be markedly bradycardic, with heart rates as low as 29
and blood pressures that proved very difficult to measure by
either machine or direct auscultation. She was thus placed in
the MICU overnight at the advice of the cardiology service, who
felt that in the unlikely event her HR dropped so low she was
unable to support her blood pressure, it would be essential to
have close monitoring. Fluid resuscitation continued, and the
patient's HR gradually normalized. Electrophysiology was
consulted, who recommended no pacemaker at this time, as the
rhythm was Wenckebach and did not constitute an indication for a
pacemaker. Although she was continued on TPN post-operatively,
as her functional level improved she was returned to oral
intake, with tubefeeds to supplement. On [**6-11**] she began to
complain of a suprapubic burning pain, but a urinalysis was
negative for UTI, and her pain was deemed post-surgical. As she
improved, her TPN was stopped, her tubefeeds and oral intake
were increased, and her central line was removed. She was
discharged to home with services on [**6-14**].
Follow up with Heme/Onc was arranged, and pt expressed a wish to
follow up with Dr [**Last Name (STitle) **] of [**Hospital3 **]. It has also been
recommended that she seek care with the [**Hospital3 35292**] service at
[**Hospital1 18**], as this modality may be well suited to her tumor.
Medications on Admission:
Atenolol 25
Fosamax 35 q week
Levoxyl 88mcg
81mg ASA
Ambien prn
Vicodin prn, MVI
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 7571**]Nursing Assc.
Discharge Diagnosis:
Colon cancer
Discharge Condition:
Good
Discharge Instructions:
Take all medications as prescribed. Do not drive while taking a
narcotic pain medication such as percocet or vicodin. Please
follow the VNA's instructions for your tubefeeds. If you develop
fevers, chills, nausea/vomiting, cessation of bowel movements or
flatus, difficulty flushing the J-tube, severe abdominal pain,
or other concerning symptoms, please contact our office or a
local emergency room. Please call Dr[**Name (NI) 6275**] office to
schedule your follow up appoitnment. They will also be able to
put you in contact with the [**Name (NI) 35292**] office, to help arrange
for your chemotherapy treatments. Dr[**Name (NI) 35293**] office will be
contacting you and Dr [**Last Name (STitle) **] for followup as well, if you don't
hear from them within one week please call their office.
Followup Instructions:
Please call Dr[**Name (NI) 6275**] office to schedule your follow up
appoitnment. They will also be able to put you in contact with
the [**Name (NI) 35292**] office, to help arrange for your chemotherapy
treatments. Dr[**Name (NI) 35293**] office will be contacting you and Dr
[**Last Name (STitle) **] for followup as well, if you don't hear from them within
one week please call their office.
ICD9 Codes: 9971, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 49
} | Medical Text: Admission Date: [**2162-6-3**] Discharge Date: [**2162-6-9**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
lethargy, bradycardia, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89M w/ COPD, Afib on coumadin, moderate dementia and urinary
retention with an indwelling foley, admitted with altered mental
status, admitted to MICU for fever, new complete heart block and
question of sepsis. The morning of admission, patient noted to
be fatigued and unable to walk. At baseline, he lives at [**Hospital1 100**]
and generally is oriented to self and can answer basic
questions, and walk with a walker. On exam at rehab, he had
bradycardia to 40s, BP 154/64, O2 sat 94% RA, temp 99.3. EKG
showed complete heart block. He was transferred to the ED for
further evaluation.
In the ED, initial VS were: 101.3 44 155/37 32 87% RA. Hypoxia
improved with 2L nasal cannula. UA sig for UTI (>182 WBC, lrg
leuks, pos nitrates, many bacteria). CXR concerning for ?
infiltrate. Pressures stable with SBPs 120s-130s. Got 2L IVF,
ceftriaxone and azithro. Confirmed 3rd degree heartblock on EKG.
Labs showed acute renal failure (Cr 1.6, baseline 1.0), lactate
2.7, and there was concern for mild sepsis. An 18G and 20G
placed. A&O&1. Patient confirmed DNR, but would consider a PPM.
His foley catheter was replaced.
On arrival to the MICU, patient resting comfortably. On
questioning by his daughter he denies pain. She felt that he
appeared better than this morning. On further discussion, they
would like temporary pacing if necessary. They would like their
father to be DNR/DNI, but would be okay with reversing that
status during a pacemaker placement.
Past Medical History:
- Bacteremia in [**11/2161**] with VRE and [**Female First Name (un) **]
- COPD (unclear history, always a nonsmoker)
- HTN not on meds
- AF on coumadin
- colon cancer [**2152**]
- dementia (recognizes children and oriented to place but not
able to converse normally and not oriented to place or time),
has significant behavioral component
- History of TB, found to have 10mm PPD in [**2153**], had a negative
CXR so treated in [**2153**] for 9 months for latent TB. CXR repeat in
[**2156**] looked increased density at the bases
- BPH with chronic indwelling foley, h/o [**Year (4 digits) 40097**] E.Coli urine
infection
- GERD
- anemia
- intermittent complete heart block. Asymptomatic, discussion
with family, no PPM as no clear benefit.
Social History:
Lives at [**Hospital 100**] Rehab. Never a smoker. Able to walk with a
walker with assist. Diet had been pureed/nectar thickened for
several months, recently switched back to thin liquids.
Family History:
Daughter does not know of any significant family history.
Physical Exam:
Admission Exam:
VS: 101.3 44 155/37 32 87% RA
General: Alert, oriented to self, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP mildly elevated to 8-10cm, no LAD
CV: Distant heart sounds, marked bradycardia, normal S1 + S2, no
audible murmurs, rubs, gallops
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all four extremities, unable to
cooperate.
Discharge Exam:
Vitals: afebrile x2.5days, Tc 98.5, 150/85, 51, 18, 99%RA
General: resting comfortably in bed, no acute distress,
interactive, smiling
HEENT: Sclera anicteric, dryMM
Neck: supple, JVP not elevated, no LAD
CV: bradycardiain the 50s, normal S1 + S2, no audible murmurs,
rubs, gallops
Lungs: + mild rales bilaterally at bases, no rhonchi/wheezes.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: indwelling foley in place
Ext: room temperature, improved cap refill, 2+ pulses, no
clubbing, cyanosis or edema
Dementia: Not speaking sensical Russian currently, oriented to
self. This is baseline.
Pertinent Results:
Admission Labs:
[**2162-6-3**] 02:20PM BLOOD WBC-14.0*# RBC-5.66# Hgb-13.2*# Hct-44.6#
MCV-79* MCH-23.3* MCHC-29.6* RDW-15.8* Plt Ct-221
[**2162-6-3**] 02:20PM BLOOD Neuts-89.0* Lymphs-6.7* Monos-3.7 Eos-0.6
Baso-0.2
[**2162-6-3**] 02:20PM BLOOD PT-32.5* PTT-39.6* INR(PT)-3.2*
[**2162-6-3**] 02:20PM BLOOD Glucose-145* UreaN-27* Creat-1.6* Na-138
K-7.4* Cl-106 HCO3-21* AnGap-18
[**2162-6-3**] 02:20PM BLOOD ALT-49* AST-76* AlkPhos-81 TotBili-0.5
[**2162-6-3**] 02:20PM BLOOD Lipase-40
[**2162-6-3**] 02:20PM BLOOD cTropnT-0.06*
[**2162-6-3**] 02:20PM BLOOD Albumin-3.8 Calcium-8.8 Phos-2.6* Mg-2.4
[**2162-6-3**] 02:28PM BLOOD Lactate-2.7* K-5.7*
Admission UA:
[**2162-6-3**] 02:30PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2162-6-3**] 02:30PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2162-6-3**] 02:30PM URINE RBC-9* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
Repeat UA:
[**2162-6-5**] 09:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2162-6-5**] 09:00PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2162-6-5**] 09:00PM URINE RBC-7* WBC-5 Bacteri-NONE Yeast-NONE
Epi-0
Lactate trend:
[**2162-6-3**] 02:28PM BLOOD Lactate-2.7* K-5.7*
[**2162-6-4**] 12:33AM BLOOD Lactate-1.4
[**2162-6-5**] 07:51PM BLOOD Lactate-3.4*
[**2162-6-5**] 08:14PM BLOOD Lactate-1.4
Troponin Trend:
[**2162-6-3**] 02:20PM BLOOD cTropnT-0.06*
[**2162-6-3**] 10:10PM BLOOD CK-MB-3 cTropnT-0.06*
[**2162-6-5**] 04:06AM BLOOD CK-MB-3 cTropnT-0.05*
WBC trend: 14.0->11.7->10.1->9.2->7.9->8.2->7.8->6.9
Discharge Labs:
[**2162-6-9**] 06:49AM BLOOD WBC-6.9 RBC-5.05 Hgb-11.9* Hct-39.7*
MCV-79* MCH-23.6* MCHC-30.0* RDW-16.1* Plt Ct-257
[**2162-6-9**] 06:49AM BLOOD PT-22.8* PTT-32.0 INR(PT)-2.2*
[**2162-6-9**] 06:49AM BLOOD Glucose-77 UreaN-22* Creat-0.9 Na-146*
K-4.4 Cl-114* HCO3-24 AnGap-12
[**2162-6-9**] 06:49AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.2
MICRO:
[**2162-6-3**] MRSA SCREEN MRSA SCREEN-negative
[**2162-6-3**] URINE URINE CULTURE- Mixed Flora
[**2162-6-3**] BLOOD CULTURE Blood Culture,
Routine-PENDING [**2162-6-3**] BLOOD CULTURE Blood
Culture, Routine-PENDING
[**2162-6-8**] STOOL C. difficile DNA amplification
assay-negative
[**2162-6-5**] BLOOD CULTURE Blood Culture,
Routine-PENDING [**2162-6-5**] BLOOD CULTURE Blood
Culture, Routine-PENDING [**2162-6-5**] URINE URINE
CULTURE-mixed flora
IMAGING:
[**2162-6-3**] EKG: Sinus rhythm with high grade A-V block. Baseline
artifact obscures interpretation but it appears that complete
heart block is present with a junctional escape of approximately
40 beats per minute. Compared to the previous tracing of [**2161-5-29**]
heart block is now new. High grade A-V block is new. TRACING #1
[**2162-6-4**] EKG: High grade A-V dissociation with junctional escape
at approximately 34 beats per minute. What appear to be
conducted P waves are likely isorhythmic dissociation. There is
variation in P-P interval which may be due to ventriculophasic
affect. Compared to the previous tracing of [**2161-5-29**] heart block
persists. TRACING #2
[**2162-6-3**] CXR: Low lung volumes. Probable bibasilar atelectasis
but aspiration is difficult to exclude. Possible trace
bilateral pleural effusions.
[**2162-6-4**] Echo: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2161-11-18**], no clear change.
[**2162-6-5**] CXR: The heart is moderately enlarged. There is a
moderate-sized left effusion that is increased compared to
prior. There is pulmonary vascular redistribution and alveolar
infiltrate suggesting an element of fluid overload; however, in
addition, there is more dense alveolar infiltrate involving the
left lower lobe. It is unclear if this is due to an infectious
process. Chronic right upper lobe and lower lobe lung changes
are again visualized.
IMPRESSION:
1. New infiltrate in the left lower lobe.
2. Increased fluid overload.
Brief Hospital Course:
89M w/ COPD, Afib on coumadin, moderate dementia and urinary
retention with an indwelling foley, admitted with altered mental
status, new complete heart block and infection of unclear
source.
Acute Issues:
# Complete heart block: Patient previously had PR interval of
218, suggesting progressive nodal disease. He has a narrow QRS,
but slow escape rhythm. Trial atropine suggestive of infranodal
disease, but telemetry also shows multiple foci of disease.
During course of hospital stay, his heart block resolved
intermittently and his heart rate at the time of discharge was
persistently in the 50-60s. The result of a family discussion
about the risks and benefits of a PPM in this elderly patient
with end stage dementia and intermittent asymptomatic complete
heart block on coumadin for afib, was that the potential (not
guaranteed) benefits of PPM placement would not outweight
potential risks.
# Fever/UTI/Infection of unclear source: Patient presented with
a fever to 101.3F and a grossly positive UA. Most likely source
is urinary, given very positive UA. Indwelling foley was
replaced in the ED. CXR very similar to prior. He has a history
of resistant bacteria (VRE and [**Month/Day/Year 40097**] e.coli), so he was
iniatially covered broadly with Meropenem and Linezolid and then
[**Last Name (un) **] and Daptomycin. Urine culture finalized as mixed flora with
no evidence of VRE or [**Last Name (LF) 40097**], [**First Name3 (LF) **] pt was narrowed to ceftriaxone.
10 hours after his last dose of meropenem, he became febrile to
102.9F, with a venous lactate of 2.4. As UTI does not cause high
fevers, ddx included prostatitis, pyelonephritis, PNA. Repeat UA
was without bacteria and repeat urine culture again with mixed
flora. CXR showed fluid overload with possible infiltrate/PNA,
but no sypmtoms. C. diff PCR negative. Blood cultures all NGTD.
He was rebroadened to Meropenem (Daptomycin not restarted, as no
suspicion for gram positive infection) and WBC continued to
trend down without subsequent fevers. Patient lost IV access
(pulling at all IVs and EKG leads) and no replacement IVs were
successfully placed. Given that the source of his infection was
unknown, and he failed a trial of narrowing antibiotics, he was
continued on [**First Name3 (LF) **] 1gm IM daily for the remainder of his
antibiotic course. He continued on the [**First Name3 (LF) 49799**] for 2 days
inhouse afebrile with normal WBC, and will continue his course
through [**2162-6-12**].
# Respiratory Alkalosis/Hypoxia/dCHF: On transfer from the MICU,
he was noted to be tachypneic with decreased O2 saturation. ABG
showed respiratory alkalosis, likely due to hyperventilation 2/2
hypoxia: pH 7.53, pCO2 23, pO2 62. Placed on O2 and repeat ABG
showed pH 7.40, pCO2 40, pO2 68. CXR showed acute congestive
heart failure with posible infiltrate in the LLL. Echo showed
mild pulmonary hypertension (increased TR gradient) with nml EF.
CHB has likely decreased CO and caused some mild CHF. Given 10mg
IV lasix for gentle diuresis with good urine output and
improvement in O2 sats. Patient was without symptoms of cough.
WBC continued to trend down on current meropenem/[**Last Name (LF) 49799**], [**First Name3 (LF) **]
pneumonia treatment was not initiated.
# Hypertension (Occult Hypoperfusion): Patient carries a
diagnosis of HTN, though is not noted to be on any
antihypertensives as an outpatient. Since being in CHB, patient
has been noted to have higher BPs (SBPs in the 150s-180s). With
low HRs (30-40s), patient is dry and cool, suggesting he is
vascularly constricted, likely in a effort to maintain perfusion
to tissues while in CHB. Venous lactate 3.4, arterial lactate
1.4, again supporting likely occult hypoperfusion [**2-4**] CHB.
Several days into his admission, his heart rates improved to the
50-60s, and he was rarely in complete heart block. His elevated
blood pressure never rose above a SBP of 200, and so were
tolerated in an effort to maintain perfusion to his tissues.
Chronic Issues:
# Dementia: Patient has end stage dementia, only oriented to
self and not able to communicate sensically. Initially he was
found to be fatigued and not able to walk around. Family was
concerned that he was below baseline in terms of mental status
at this time, however with treatment of infection he returned to
baseline MS. There may be an element of decreased MS with heart
rates in the 30s, however as infection improved, heart rate
improved, and so this was difficult to assess. Patient was
continued on home mirtazipine and zyprexa with rare doses of
zydis for agitation (which family reports it his baseline).
# [**Last Name (un) **]: Patient presented with [**Last Name (un) **] (Cr 1.6, baseline noted to be
1.0). Likely due to hypoperfusion from infection compounded by
complete heart block. Cr trended down since admission, and on
discharge was 0.9.
# Afib: CHADS score 2, on coumadin with goal [**2-5**]. Presented with
INR 3.2. Coumadin was initially held, but restarted and remained
therapeutic on home dose of 3mg daily except on Mondays when he
takes 3.5mg daily.
# COPD: Written for albuterol and ipratropium nebs as needed for
wheezing.
# BPH: Continued finasteride and the chronic foley, which was
exchanged in the ED [**2162-6-3**].
Transitional Issues:
DNR/DNI
Given that patient is only intermittently in complete heart
block, anticoagulated with end stage dementia, and given that he
appears to be at baseline mental status currently, it was
decided that the risks outweight the benefits of pacemaker
placement.
As long as blood pressure is <200, elevated blood pressures
should be tolerated when patient is bradycardic. These higher
blood pressures are a natural compensation to maintain blood
perfusion to the body when his cardiac output has decreased from
the slower heart rate.
Medications on Admission:
- mirtazapine 30mg QHS
- trazodone 50mg QHS PRN insomnia
- Senna 17.2mg QHS
- Miralax 17gm daily
- Bacitracin 1 application [**Hospital1 **]
- finasteride 5mg daily
- tylenol 650mg Q6hrs PRN
- olanzapine 2.5mg daily
- warfarin 3mg daily TuWeThFrSaSu
- warfarin 3.5mg daily Mo
Discharge Medications:
1. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
5. bacitracin Topical
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
8. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. warfarin 3 mg Tablet Sig: One (1) Tablet PO daily except
3.5mg on Mondays.
10. warfarin 1 mg Tablet Sig: 3.5 Tablets PO 1X/WEEK (MO): 3mg
daily, except 3.5mg on Mondays.
11. [**Hospital1 49799**] 1 gram Recon Soln Sig: One (1) gram Injection once
a day for 4 days: Give at 2pm daily for 4 doses, last dose on
[**2162-6-12**] at 2pm. Mix injection with lidocaine to lessen pain of
injection.
Disp:*4 gram* Refills:*0*
12. miconazole nitrate 2 % Aerosol Powder Sig: One (1)
application Topical four times a day: fungal rash on buttocks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis: Complete Heart Block, Urinary Tract Infection
Secondary Diagnosis:
Hypertension
Dementia
Acute Kidney Injury
Atrial Fibrillation
COPD
BPH
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 55195**],
It was a pleasure taking care fo you at [**Hospital1 827**]. You were admitted for extreme fatigue and an
irregular heart beat. During this admission you were found to
have a urinary tract infection, which you were treated for.
Additionally, you were noted to have an irregularly slow heart
rhythm called Complete Heart Block, however this improved on its
own during the admission. It was decided that the risks
outweight any possible benefit of placing a pacemaker for this
problem. [**Name (NI) **] improved with the treatment of your infection and
are now safe for discharge.
Please make the following changes to your outpatient medication
regimen:
START [**Name (NI) **] 1mg intramuscular injection daily for 4 more
days.
START miconazole powder to be applied 4 times daily to fungal
rash on buttocks. Keep area dry and clean.
No other changes have been made to your outpatient medications.
Continue all medications as previously prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You will be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab.
ICD9 Codes: 5990, 5849, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 50
} | Medical Text: Admission Date: [**2109-6-6**] Discharge Date: [**2109-6-7**]
Date of Birth: [**2051-9-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
afib w/ RVR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 85533**] is a 57 year old woman with hard to control HTN and
hypothyroidism, who is transferred from OSH to [**Hospital1 18**] after being
found to have atrial fibrillation for TEE/DCCV.
.
Ms. [**Known lastname 85533**] states that over the past week she has been having
mild chest pain, that last several minutes. She also has had
shortness of breath in the evenings that has kept her from
sleeping. On further questioning she states that her chest pain
in addition to palpitations and feeling of skipped beats have
been going on for two years. Throughout this time she thought it
was her "nerves." She went to her PCP, [**Name10 (NameIs) **] having not been
seen by a physician [**Last Name (NamePattern4) **] 2 years, and had an ECG done in office.
She was found to have atrial fibrillation and sent to the ED.
.
At the OSH, she was given metoprolol po and iv without
improvement in heart rate. Initially her labetalol was increased
and then stopped and switched to toprol XL. Her heart rates
ranged from 120s-130s. She was started on coumadin and lovenox.
She had an echo that showed mildly decrease in EF. Her labs:
d-dimer negative, hct 41.9, cr 0.8, trop <0.01.
.
Of note, she has poorly controlled hypertension sbp<200s and
dbp>100s. She reports being compliant with medications but
states that she infrequently goes to her PCP. [**Name10 (NameIs) **] last time she
was seen prior to this visit was two years ago.
.
Currently, she denies shortness of breath or chest pain.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, syncope or
presyncope.
.
ROS is positive for back/neck pain, chronic headaches, weight
gain over three weeks, chronic stable LE edema over the past 10
years.
.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- HTN poorly controlled
- Afib which is new, but ? if going on for 2 years given funny
feeling chest
- Hypothyroidism
- S/p ?thyroid or parathyroid surgery
Social History:
- Cigs: 3 PYs in 50s
- etOH: denies
- Illicits: denies
- Works as a CNA
- Kids in [**Country 19639**]
Family History:
- Father: MI age 63
- Mother: CVA age 64
Physical Exam:
Vital Signs: BP 150/90 HR 90 RR 16 98%RA
GEN: Sitting up in bed in NAD
Cardiac: nl JVP, irregular rhythm, no murmurs
Resp: Clear lungs
Abd: soft, NT ND
Ext: no edema noted
Pertinent Results:
[**2109-6-6**] 01:42PM %HbA1c-5.5 eAG-111
[**2109-6-6**] 12:20PM GLUCOSE-88 UREA N-16 CREAT-0.9 SODIUM-142
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-29 ANION GAP-13
[**2109-6-6**] 12:20PM estGFR-Using this
[**2109-6-6**] 12:20PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-2.3
[**2109-6-6**] 12:20PM TSH-2.5
[**2109-6-6**] 12:20PM TSH-2.5
[**2109-6-6**] 12:20PM NEUTS-78.2* LYMPHS-15.2* MONOS-3.6 EOS-2.4
BASOS-0.6
[**2109-6-6**] 12:20PM PLT COUNT-259
[**2109-6-6**] 12:20PM PT-16.9* PTT-27.5 INR(PT)-1.5*
Brief Hospital Course:
57 yo female with atrial fibrillation, severe hypertension and
diastolic heart failure. Initial plan was for TEE/cardioversion.
A TEE was performed which did not show any clot. She initially
had an attempted DC cardioversion X 3 however these attempts did
not bring her into sinus. She was initiated on sotalol with
good rate control established with HRs < 100 however she
remained in sinus rhythm. She was continued on coumadin for
anticoagulation. She was hypertensive and hypokalemic and a
work-up for hypertension was initiated; renal artery ultrasound
pending. Valsartan was increased from 80 to 160 daily for
improved BP control; spirinolactone was discontinued. Labetalol
was discontinued given initiation of sotalol. Plasma
renin/angiotensin were ordered but were pending. Given
symptomatic improvement and rate control, she was transferred to
the floor for further management. She was evaluated for [**Doctor Last Name **] of
hearts monitor on discharge; follow up with Dr [**Last Name (STitle) 171**] is
scheduled. She also has an appointment with her PCP scheduled on
Wednesday [**6-12**] for follow-up along with lab check [**Month (only) 766**]
[**6-10**] at [**Hospital3 **] for INR and for potassium.
Medications on Admission:
Benecar 40 + HCTZ 12.5 QD
Labetolol 100mg PO BID
Levothyroxine 100mcg PO daily
Tylenol PRN
Hx "water pills"
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
Disp:*45 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Diovan HCT 160-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
5. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
Please get INR, Potassium, Magnesium, calcium, and phosphate
checked on [**Last Name (LF) 766**], [**6-10**].
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
(1) Atrial fibrillation
(2) Hypertension
(3) Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 85533**],
You were admitted because your heart rate was too fast in the
rhythm that we can "atrial fibrillation" and also had high blood
pressure. We tried to convert you from this rhythm using
electrical shock, however this did not keep you in a normal
rhythm for long. For this reason, we started you on a new
medication while in the hospital to help control your heart
rates. We also made some other medication changes to help
control your blood pressure. These changes in medication are
scheduled below. You will need to follow up with your
cardiologist Dr [**Last Name (STitle) 171**] as an outpatient, who may try additional
therapies to try to convert you out of atrial fibrillation.
.
The medication changes we made during this hospitalization are:
(1) Started warfarin, a blood thinning medication, which you
should take every day. You need to take 3 mg daily. This is
important medicine because it prevents your heart from forming
blood clots while you are in atrial fibrillation. You will need
to see the [**Hospital3 **] on [**Hospital3 766**] morning to get labs
checked for this medicine. Instructions on attending this
clinic are listed below.
(2) Started Diovan HCT 160 - 12.5 mg which is a medicine to help
lower blood pressure.
(3) Started sotalol 120 mg twice a day. This medicine helps
prevent your heart rate from going too fast.
(4) Started amlodipine 10 mg daily - another medicine to help
control your blood pressure.
(5) Started spirinolactone 25 mg daily for your blood pressure.
(6) Stop your benicar-HCTZ combination pill.
(7) Stop labetolol.
(8) You should go to the [**Hospital3 **] at [**Hospital1 **] [**Location (un) 620**]
on [**Location (un) 766**] [**6-10**] to get your INR (coumadin level) checked.
The [**Hospital3 271**] will call you on [**Hospital3 766**] morning to
confirm this.
Followup Instructions:
Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **]
-You need to get your blood checked on [**First Name3 (LF) 766**] at the hospital:
you have a prescription to get this labwork done as an
outpatient.
-You have an appointment with Dr [**Last Name (STitle) 5419**] on: Wed 16th at 430 PM
Phone: [**Telephone/Fax (1) 31235**]
FAX [**Telephone/Fax (1) 85534**]
.
[**Hospital3 271**] at [**Hospital1 **] [**Location (un) 620**]: [**Telephone/Fax (1) 41860**]. Please go
to the hospital registration and ask for directions on [**Telephone/Fax (1) 766**] am
to have INR checked.
.
You have an appointment with Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2109-6-17**] 12:40
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 51
} | Medical Text: Admission Date: [**2108-9-26**] Discharge Date: [**2108-10-5**]
Service: MEDICINE
Allergies:
Aspirin / Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
transfer from MWH for cardiac catheterization for CP with trops
elevation to 0.79, likely NSTEMI (non ST elevation myocardial
infarction)
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
84yo male with CAD - CABG x5 in [**2094**] (LIM to LAD, SVG to DA, SVG
to [**Female First Name (un) **], SVG to PDA, SVG to lt ventr branches), MI in [**2070**], s/p
AAA repair, s/p fem-[**Doctor Last Name **] bypass, CRF on HD is transferred from
MWH for cath for ?dx of MI.
Patient initially presented to MWH ED on [**2108-9-24**] with c/o
continuous 7 out 10 shoulder to shoulder chest pain with no
radiation. He denied SOB or diaphoresis. Took nitro at home x2
with no relief. In ED, he had +Trop 0.79, EKG 100% paced,
received iv nitro and morphine,
plavix and heparin. No aspirin given (as per GI) because of the
h/o severe GI bleed on aspitrin. Pt had 2 subsequent episodes of
CP overnight relieved by Morphine. [**9-26**], pt was transferred to
[**Hospital1 18**] for cath.
Past Medical History:
CAD - MI [**2070**], CABG x5 in [**2094**] at [**Hospital1 336**]
s/p AAA repair [**2082**]
PPM [**2105**]
Bilateral Fem-[**Doctor Last Name **] Bypass
CRF-HD on T-Th-Sat (last dialysis [**9-25**], tolerated well)
severe duodenal ulcer bleed [**2105**] - received 11 PRBC
Chrone's Dx
diverticulosis
Social History:
past tobacco
Family History:
.
Physical Exam:
PE: pt in bed, looks comfortable, no acute distress
T 98.7 BP 130/72, HR 60, RR 18, 96% R/A
HEENT: symm neck, mouth clear, no LN, flat JBP
CHest: limited exam, clear, GAEB
CVS: rrr, N S1S2, syst gr II-III/VI murm over precordium
[**Last Name (un) **]: soft, N BS, NT
Extrem: no edema, varicose veins
Pulses: normal carotid, radial, doplerable pedal
Neuro: alert, oriented x3, grossly N
Lt Groin: no hematoma (4pm)
Pertinent Results:
[**2108-9-26**] 06:55PM CK-MB-30* MB INDX-13.8* cTropnT-0.89*
[**2108-9-27**] 03:00AM CK-MB-129* MB Indx-20.4*
[**2108-9-27**] 06:40AM CK-MB-155* MB Indx-20.9* cTropnT-2.54*
[**2108-9-26**] 06:55PM WBC-7.1 RBC-3.25* HGB-11.4* HCT-33.7*
MCV-104* MCH-35.0* MCHC-33.7 RDW-15.8*
[**2108-9-26**] 06:55PM PLT SMR-NORMAL PLT COUNT-178
[**2108-9-26**] 06:55PM GLUCOSE-74 UREA N-52* CREAT-6.4* SODIUM-135
POTASSIUM-5.3* CHLORIDE-92* TOTAL CO2-21* ANION GAP-27*
Cardiac cath:1. Coronary and grft angiography showed a previous
right
dominant system. The LMCA was diffusely disesed with no focal or
critical lesions. The LAD tapered off in the mid segment until a
large
S2 where it is totally occluded. The D1 and D2 are small vessels
and
are diffusely diseased. The D3 which recived a SVG is not seen
in the
LMCA injection. The Mid and the distal LAD receives the LIMA.
The Cx
vessel it self has no lesions. It gives a lengthy collateral.
The OM1
arises close to the LMCA and is small. The OM2 too arises close
to the
LMCA and is large. This has a proximal lesion of 80%. The OM3
recives the SVG and is not seen on LMCA injection. The
OM4/postero
latateral branch arises distally and is a small vessel. The RCA
is
occluded proximally. The distal RCA including the PDA and the
PLV are
collateralised by the left system. The PDA is poorly filled and
has a
mid 60% lesion. The LIMA , the LIMA-LAD anastomosis and the
distal LAD
are free of disease. The LIMA fills the LAD retrogradely to
supply the
proximal LAD and the D3. The D3 has an ostial 70% lesion with
TIMI III
flow. The SV grafts to the RCA and the PLB are occluded
completely and
are seen as stumps in the aorta. The graft to the Diagonal could
not be
located, but is likely to be occluded given the other
angiogaphic
findings. The SVG to the OM3 shows diffuse disease with a mid
lengthy
lesion of 99 % and the whole vessel showed TIMI II flow. There
were no
collaterals for this OM.
2. Left ventriculography was not performed.
3. Predilation using 1.5 X 15 Maverick balloon, stenting using
3.0 X 28
and 3.0 X 33 OTW Cypher stents and thrombus extraction using
export
catheter with gradual deterioration of flow of the SVG to the
OM3. The
flow deteriorated from TIMI I to TIMI 0.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease with functioning
LIMA to
the LAD.
2. Acute occlusion of the SVG to the OM and chronically occluded
SV
grafts to the PDA, PLB and Diagonal.
3. Unable to restore flow in the SVG to the OM despite stenting,
pharmacotherapy and thrombus aspiration. .
Echo: . The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed. Basal inferior
hypokinesis is present.
3. The aortic valve leaflets are severely thickened/deformed.
There is
moderate aortic valve stenosis.
4. The mitral valve leaflets are mildly thickened.
5. There is mild pulmonary artery systolic hypertension.
.
ct scan:
1. No evidence of intrahepatic gas as suggested on prior
ultrasound. Repeat ultrasound is suggested given this change in
appearance.
2. Bibasilar dependent atelectatic changes/consolidation with
associated effusions.
3. Gas distended loops of bowel with air-fluid levels but
without transition suggesting ileus. Stool distended rectum.
4. Small infrarenal abdominal aortic aneurysm.
Brief Hospital Course:
He was admitted with unstable angina, had total occlusion of all
svg grafts with a patent LIMA to LAD, and received 2 cypher
stents. His catheterization was compicted by failed thrombus
extractuib abd a TIMI 0. After catherization he had persistent
CP and evidence of a NSTEMI. Initially he was not treated with
ASA because of a past GI bleed, but with persistent ischemia, it
was added to the plavix. He required a significant of morphine
to controll his pain. Through discussions between the MICU team
and the family pain control was determined to be the only option
for him. His code status was changed to DNR/DNI/. Due to
ongoing ischemia, he had persistent hypotension that required
multiple pressors. His HD was changed to CVVH because of his
low blood presssure. He also had intermittent NSVT. He had
been transferred from the [**Hospital Unit Name 196**] team to the MICU team due to
hypotension at HD after his cardiac catheterization out of
concern for possible sepsis. There was a concern that he had an
acute abdomen but he appeared to be impacted with stool. He was
disimpacted and received an aggresive bowel regimen. His
distension and pain improved. He had low grade temperatures and
was initially treated for pneumonia because he was hypoxic. No
source of infection was identified. It is more likely that he
was in cardiogenic shock with fluid overload. A repeat bedside
echo did not reveal worsening ventricular function. He required
blood transfusions for persistently dropping HCT in the setting
of very frequent blood draws. He also had a coagulopathy which
did not appear to be from DIC. He required vitamin K
supplementation. He expired at 6:45am on [**2108-10-5**] after an
episode of severe chest pain.
Medications on Admission:
Plavix 300mg x2 [**2078-9-24**] mg [**Hospital1 **] starting [**2108-9-26**]
Lopressor 12.5mg [**Hospital1 **]
Foslo 667mg x4 TID
Quinine 324mg daily
Pentasa 250mg x4 QID
MVI
Mirtazapine 15mg qhs
Colace 100mg [**Hospital1 **]
Protonix 40mg daily
Morphine prn
Nitro prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
sinus tachycardia
nsvt
cardiogenic shock
coagulopathy
obstipation
nstemi
esrd
Discharge Condition:
expired
Discharge Instructions:
.
Followup Instructions:
.
Completed by:[**2108-12-21**]
ICD9 Codes: 4280, 486, 5856, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 52
} | Medical Text: Admission Date: [**2156-7-21**] Discharge Date: [**2156-9-3**]
Date of Birth: [**2156-7-21**] Sex: F
Service: NEONATOLOG
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 1071**]-[**Known lastname 29608**] is a former
961 gram product of a 31-5/7 week gestation pregnancy born to
a 28-year-old G1, P0, woman. Prenatal screens: Blood type O
positive, antibody negative, RPR nonreactive, Rubella immune,
hepatitis B surface antigen negative, Group beta Strep status
unknown. Estimated date of confinement was [**2156-9-17**],
based on last menstrual period and first trimester
ultrasound. The pregnancy was uncomplicated until [**2156-7-6**], when there was intrauterine growth restriction noted on
fetal ultrasound. There was extensive laboratory evaluation
and workup and no etiology for the growth restriction was
identified. She was followed closely with fetal biophysical
profiles [**9-3**] and normal amniotic fluid volume then. On the
day of delivery her amniotic fluid volume dropped and the
fetus was noted to have two heart rate decelerations. She
underwent elective induction but was taken to cesarean
section for concern for fetal distress. The infant emerged
with spontaneous cry, required blow-by oxygen, had Apgars of
8 at one minute and 8 at five minutes. She was transferred
to the Neonatal Intensive Care Unit for treatment of
prematurity.
PHYSICAL EXAMINATION ON ADMISSION TO NEONATAL INTENSIVE CARE
UNIT: Weight 961 grams, less than 10th percentile. Length
38 cm, 58th percentile. Head circumference 25.5 cm, less
than 10th percentile. General: Nondysmorphic,
well-appearing, pre-term infant. Head, eyes, ears, nose and
throat: Anterior fontanelle soft and level. Red reflex
present bilaterally. Palate intact. Symmetric facial
features. Chest: Breath sounds clear and equal. Minimal
retractions. Cardiovascular: Regular rate and rhythm
without murmur. Two plus peripheral pulses including
femoral. Abdomen benign without hepatosplenomegaly. Small
umbilical cord noted. Genitourinary: Normal female external
genitalia consistent with gestational age. Spine normal with
normal sacrum. Hips stable. Skin pink with brisk capillary
refill. Neuro: Normal tone and responsiveness. Alert and
in no acute distress.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: The retractions and tachypnea noted upon
admission resolved within the first eight hours of life.
[**Known lastname **] always remained in room air throughout her Neonatal
Intensive Care Unit admission. She had infrequent episodes
of apnea and bradycardia, the last occurring on [**2156-8-9**].
2. Cardiovascular: [**Known lastname **] has maintained normal heart
rates and blood pressures during admission. A soft murmur
has been noted intermittently and remains audible at the time
of discharge. It is felt to be consistent with peripheral
pulmonic stenosis and benign in nature.
3. Fluids, Electrolytes and Nutrition: Initial glucose was
45. [**Known lastname **] required several dextrose boluses for
hypoglycemia which resolved within 24 hours of birth. She
was initially NPO and maintained on intravenous fluids.
Parenteral feeds were started on day of life number two and
gradually advanced to full volume. Her maximum caloric
intake was 30 calories per ounce. She is currently taking
150/cc/kg/day of breast milk or Enfamil fortified to 26
calories per ounce. The formula is four calories by
concentration and two calories by corn oil and the breast
milk is four calories with Enfamil powder and two calories by
corn oil. Serum electrolytes were checked in the first week
of life and were within normal limits. Discharge weight is
1.875 kilograms which is 4 pounds, 2.1 ounces, a length of 47
cm and a head circumference of 30.5 cm.
4. Infectious Disease: Due to her prematurity, [**Known lastname **]
was evaluated for sepsis. A white blood cell count was 7,900
with 33% polys, 0% bands. A blood culture was obtained and
she was not treated with antibiotics. The blood culture was
no growth at 48 hours.
5. Hematological: Initial hematocrit at birth was 66.3% and
platelets were 43,000. [**Known lastname **] is blood type O positive
and is Coombs negative. Platelet count fell to 24,000 on day
of life one and [**Known lastname **] was transfused with platelets and
also received intravenous gamma globulin. On day of life
number four and again on day of life number seven she
required transfusion of platelets for counts less than
60,000. On the day after her third platelet transfusion her
platelet count was 104,000 and within 72 hours it was
255,000. A repeat count on day of life 17 was 694,000. The
etiology of the thrombocytopenia was consistent with the
intrauterine growth restriction. The platelet antibody was
sent on the mother and was negative. [**Known lastname **] low
hematocrit occurred on [**2156-8-25**], at 22.1%. Reticulocyte
count at that time was 7.9%. A repeat hematocrit on [**2156-8-1**], was 25.7%.
6. Gastrointestinal: [**Known lastname **] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Her peak
serum bilirubin occurred on day of life number one with a
total of 5.9 mg/dl. She was treated with phototherapy for
approximately five days. Her rebound bilirubin on day of
life nine was 2.6 total over 0.6 mg/dl direct.
7. Endocrine: A state screen sent on [**2156-8-5**], had a
thyroid stimulating hormone level of 45.7 with the reference
range being less than 15 microunits per mL. An Endocrine
consult from [**Hospital3 1810**] was obtained. Repeat
thyroid function tests showed a definite clinical
hypothyroidism and treatment with Synthroid was started on
[**2156-8-13**]. A significant part of the history was that the
mother was treating a wound dehiscence with Betadine packing
and it was theorized that the hypothyroidism may have been
induced by the infant's exposure to iodine through the
mother's milk. The breast milk was held for one week and
then breast feeding re-initiated. Thyroid function tests
have been followed weekly and have been slowly normalizing.
The most recent thyroid stimulating hormone was 9.1 down from
12 with a normal range of 0.27 to 4.2. T3 was 167 up from
140 and the free T4 was 1.8 up from 1.4 with a normal range
of 0.93 to 1.7. [**Known lastname **] is being discharged home on
Synthroid with Endocrine follow up in four weeks with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 51137**] at [**Hospital3 1810**], phone number
[**Telephone/Fax (1) 37116**]. Thyroid function tests will be checked again
at that time.
8. Neurology: Head ultrasounds were obtained on [**7-23**] and
[**2156-8-18**], and both studies were within normal limits.
There were no neurological concerns at the time of discharge.
9. Sensory: Audiology: Hearing screening was performed
with automated auditory brainstem responses. [**Known lastname **]
passed in both ears. Ophthalmology: The retinal examination
was performed on [**2156-8-12**], showing mature retinas
bilaterally. Recommended follow up at eight months of age.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 51138**] [**Name (STitle) 19419**], [**Location (un) 246**] Pediatric
Associates, [**Location (un) 51139**], [**Last Name (NamePattern1) 51140**], [**Location (un) 246**], [**Numeric Identifier 51141**], Phone number [**Telephone/Fax (1) 37501**], fax number [**Telephone/Fax (1) 51142**].
There is an appointment scheduled for [**Last Name (LF) 766**], [**9-6**] at
1:30 p.m.
RECOMMENDATIONS AT DISCHARGE:
1. Feeding: Enfamil 26 calorie per ounce at concentration
two by corn oil or expressed mother's milk fortified to 26
calories with four of Enfamil powder plus two of corn oil.
2. Medications: Ferrous sulfate 25 mg per mL dilution 0.3
cc p.o. q. day; levothyroxine 12.5 mcg p.o. q. day.
3. Car seat position screening was performed. The infant
was observed for 90 minutes without episodes of oxygen
desaturation or bradycardia.
4. State newborn screens were sent on [**7-25**], [**8-4**] and
[**2156-8-21**]. Except for the hypothyroidism as previously
mentioned, the results were within normal limits. The state
screen sent on [**2156-8-21**], showed a normal TSH and T4
level.
5. No immunizations have been administered to date. She did
not receive hepatitis B as she does not meet weight criteria
as yet.
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born at 32 to
35 weeks and plan for day care during RSV season, with smoker
in the household or with preschool sibs 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
care givers should be considered for immunization against
influenza to protect the infant.
FOLLOW-UP APPOINTMENTS:
1. Primary pediatrician, Dr. [**Last Name (STitle) 19419**], on [**2156-9-6**].
2. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 51137**] in four weeks after discharge with
thyroid function tests to be drawn at that time including T4
and thyroid binding globulin.
3. Pediatric ophthalmology at eight months of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 31-5/7 weeks gestation.
2. Symmetric small for gestational age.
3. Transitional respiratory distress.
4. Thrombocytopenia.
5. Anemia.
6. Suspicion for sepsis, ruled out.
7. Polycythemia.
8. Unconjugated hyperbilirubinemia.
9. Hypothyroidism.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2156-9-2**] 23:23
T: [**2156-9-3**] 03:10
JOB#: [**Job Number 51143**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 53
} | Medical Text: Admission Date: [**2108-4-4**] Discharge Date: [**2108-5-8**]
Date of Birth: [**2036-9-21**] Sex: F
Service: SURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics) / Heparin Agents
Attending:[**First Name3 (LF) 32612**]
Chief Complaint:
Painless jaundice.
Major Surgical or Invasive Procedure:
[**2108-4-4**]:
-Diagnostic laparoscopy.
-Peritoneal washings and cytology
-Exploratory laparotomy.
-Cholecystectomy.
-Harvest of pedicled omental flap for protection of anastomoses.
-Pancreaticoduodenectomy with standard gastrojejunostomy,
antecolic.
- Right hepatic artery reconstruction using right gonadal vein
interposition graft (performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]).
History of Present Illness:
71F presented with painless jaundice, dark urine, bloating, and
anorexia. She first noticed the onset of symptoms in [**Month (only) **] or
[**Month (only) 1096**] and then was alerted by a friend to her increasing
jaundice, which prompted medical evaluation. At [**Hospital3 3583**],
her labs were as follows: total bilirubin 28, Alk phos 338, ALT
128 prior to arrival. She underwent an ultrasound and a CT with
contrast and was found to have a 2.4 x 1.8 cm mass with a cystic
structre in the head of the pancreas, distended and thickened
gallbladder, intrahepatic (1.9 cm)and pancreatic duct (1.2 cm).
At the time of consultation she was clinically well and denies
nausea, vomiting, or changes in bowel habits. She underwent ERCP
which revealed a single irregular stricture of malignant
appearance that was 2 cm long at the lower third of the common
bile duct. There was severe post-obstructive dilation. A limited
pancreatogram revealed a stricture of the main duct at the head.
Cannulation of the biliary duct was successful. Contrast medium
was injected resulting in complete opacification. A
sphincterotomy was performed. A 7cm by 10FR biliary stent was
placed. Cytology samples were obtained for histology which
returned positive for adenocarcinoma. The patient was offered a
Whipple operation, with the following explained: a 1-2% risk of
death, a 30-40% risk of complication. From her OSH scan report,
she had no involvement of the mesenteric vessels and no evidence
of metastatic disease, although there is periportal
lymphadenopathy. She understood the risks/benefits of the
surgery, and decided to proceed with the operation.
Past Medical History:
PMH: None
PSH: Tonsillectomy/adenoidectomy, all teeth extracted
Social History:
Retired high school teacher, no children, lives with her female
HCP. [**Name (NI) 4084**] [**Name2 (NI) 1818**], drank [**2-17**] glasses of wine per night until
symptoms started in [**Month (only) **]/[**Month (only) **], no drug use.
Family History:
Sister died from leukemia at age 65, mother died of cervical
cancer. No history of benign or malignant pancreatic disease.
Physical Exam:
Physical Exam on Admission:
97.3 91 173/94 20 100%RA
Gen: Alert and oriented, pleasant
Skin: Pronounced scleral and dermal jaundice
CV: RRR
Resp: Clear to auscultation
Abd: Soft, non-tender, non-distended. Negative [**Doctor Last Name 515**] sign, no
palpable masses
Ext: 1+ edema, palp DP/PT pulses.
Pertinent Results:
[**2108-4-12**] 07:24AM BLOOD Vanco-31.4*
[**2108-5-8**] 06:05AM BLOOD Vanco-12.4
[**2108-4-4**] 07:54PM BLOOD Albumin-2.1* Calcium-8.9 Phos-5.7*#
Mg-1.9
[**2108-5-8**] 01:56AM BLOOD Calcium-10.9* Phos-2.1* Mg-2.7*
[**2108-4-4**] 07:54PM BLOOD CK-MB-2 cTropnT-<0.01
[**2108-4-15**] 12:58PM BLOOD CK-MB-2 cTropnT-0.03*
[**2108-4-5**] 03:30AM BLOOD Lipase-13
[**2108-5-7**] 01:23AM BLOOD Lipase-7
[**2108-4-4**] 07:54PM BLOOD ALT-303* AST-827* CK(CPK)-57 AlkPhos-56
TotBili-5.7*
[**2108-4-18**] 01:45AM BLOOD ALT-38 AST-80* AlkPhos-59 TotBili-32.4*
DirBili-23.7* IndBili-8.7
[**2108-5-2**] 01:18AM BLOOD ALT-49* AST-82* AlkPhos-65 TotBili-36.9*
[**2108-5-8**] 01:56AM BLOOD ALT-59* AST-94* LD(LDH)-202 AlkPhos-77
TotBili-33.6*
[**2108-4-4**] 07:54PM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-134
K-4.8 Cl-100 HCO3-15* AnGap-24*
[**2108-5-8**] 01:56AM BLOOD Glucose-143* UreaN-4* Creat-0.5 Na-142
K-4.7 Cl-101 HCO3-9* AnGap-37*
[**2108-4-4**] 08:12AM BLOOD Fibrino-515*
[**2108-4-5**] 07:50PM BLOOD Fibrino-156*#
[**2108-4-4**] 08:12AM BLOOD PT-12.3 PTT-27.8 INR(PT)-1.1
[**2108-4-6**] 03:48AM BLOOD Plt Ct-139*
[**2108-4-7**] 11:55PM BLOOD Plt Smr-VERY LOW Plt Ct-62*
[**2108-4-12**] 02:57AM BLOOD Plt Ct-56*#
[**2108-5-7**] 08:15PM BLOOD Plt Ct-<5
[**2108-5-8**] 01:56AM BLOOD PT-49.9* PTT-122.1* INR(PT)-4.9*
[**2108-4-7**] 11:55PM BLOOD Neuts-86* Bands-3 Lymphs-4* Monos-3 Eos-2
Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-1*
[**2108-5-6**] 02:16AM BLOOD Neuts-90* Bands-1 Lymphs-2* Monos-4 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0 Promyel-1*
[**2108-4-4**] 07:54PM BLOOD WBC-14.6*# RBC-2.58* Hgb-8.2* Hct-24.1*
MCV-93# MCH-31.7# MCHC-34.0 RDW-16.5* Plt Ct-88*
[**2108-4-5**] 07:50PM BLOOD WBC-26.4*# RBC-3.07* Hgb-9.7* Hct-28.4*
MCV-93 MCH-31.7 MCHC-34.2 RDW-16.3* Plt Ct-102*
[**2108-4-7**] 05:41AM BLOOD WBC-28.5* RBC-3.23* Hgb-9.7* Hct-29.7*
MCV-92 MCH-30.0 MCHC-32.6 RDW-16.0* Plt Ct-93*
[**2108-4-9**] 12:49PM BLOOD WBC-16.4* RBC-3.05* Hgb-9.5* Hct-28.8*
MCV-95 MCH-31.3 MCHC-33.0 RDW-18.0* Plt Ct-43*
[**2108-5-7**] 08:15PM BLOOD WBC-41.4* RBC-2.19* Hgb-7.5* Hct-23.7*
MCV-108* MCH-34.3* MCHC-31.7 RDW-22.5* Plt Ct-<5
[**2108-5-7**] 10:15PM BLOOD WBC-48.1* RBC-2.26* Hgb-7.7* Hct-24.9*
MCV-110* MCH-34.1* MCHC-31.0 RDW-22.8* Plt Ct-88*
[**2108-5-8**] 01:56AM BLOOD WBC-47.3* RBC-2.21* Hgb-7.7* Hct-24.5*
MCV-115* MCH-34.7* MCHC-30.2* RDW-23.0* Plt Ct-72*
.
[**2108-4-9**] 11:46 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2108-4-9**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2108-4-12**]):
Commensal Respiratory Flora Absent.
HAFNIA ALVEI. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
HAFNIA ALVEI
|
AMPICILLIN------------ 16 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2108-5-1**] 5:55 am PERITONEAL FLUID
DAS ACU VERIFIED BY [**First Name9 (NamePattern2) 92514**] [**Location (un) **] [**5-1**] @0950.
GRAM STAIN (Final [**2108-5-1**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2108-5-5**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2108-5-2**] 2:45PM
4-3130.
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final [**2108-5-5**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2108-5-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**2108-5-6**]:
[**2108-5-6**] 10:54 am URINE Source: Catheter.
**FINAL REPORT [**2108-5-7**]**
URINE CULTURE (Final [**2108-5-7**]):
YEAST. >100,000 ORGANISMS/ML..
.
[**2108-4-12**]: IMPRESSION: Non-occlusive deep vein thrombosis seen
within one of the two left brachial veins
.
[**2108-4-16**]: IMPRESSION:
1. Status post Whipple with serpiginous hypodensity seen in the
left lobe
most consistent with retraction injury. No drainable collection.
2. No radiologically evident cause of leukocytosis is observed.
3. Extensive anasarca, likely secondary to volume overload.
.
Final Pathology Report:
MACROSCOPIC
Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy.
Tumor Site: Pancreatic head, uncinate process.
Tumor Size: Greatest dimension: 2.9 cm. Additional dimensions:
2.5 cm x 2.5 cm.
Other organs/Tissues Received: Gallbladder, Stomach.
MICROSCOPIC
Histologic Type: Ductal adenocarcinoma.
Histologic Grade: G2: Moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric artery.
Regional Lymph Nodes: pN1: Regional lymph node metastasis.
Lymph Nodes
Number examined: 11.
Number involved: 1.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 1 mm from
peri-uncinate-process adipose tissue margin.
Venous/Lymphatic vessel invasion: Absent.
Perineural invasion: Present.
Additional Pathologic Findings: Pancreatic intraepithelial
neoplasia -- highest grade: PanIN: III; chronic pancreatitis.
.
Brief Hospital Course:
The patient was brought to the operating room on [**2108-4-4**] for
Whipple procedure, necessitating right hepatic artery
reconstruction with gonadal vein for which the vascular surgery
service was consulted intraoperatively. Reader referred to both
operative notes for full details. She received 6 u pRBC, 2 FFP,
and 500 of albumin in the OR, and was left intubated on
pressors, and taken to the surgical ICU post operatively. Her
course thereafter in the ICU was complicated. In brief: she
required frequent blood transfusions of pRBCs, FFP, and albumin,
with a persistent pressor requirement; she developed acute renal
failure requiring CVVH, had persistent elevations of LFTs, had a
persistent leukocytosis and in total the cardiology, infectious
disease, renal, and hepatology services were consulted.
Significant events by post-operative day included: On POD2 the
renal service was consulted given persistent renal failure
postoperatively, and she was begun on CVVH. Given down-trending
platelets, HIT panel was sent and returned positive on POD5, and
the patient was begun on a bivalirudin drip per hematology
recommendations. On POD6 TF were initiated via NGT, her foley
was removed, and sputum cultures revealed GNR for which she was
begun on vancomycin/ciprofloxacin/flagyl. Antibiotics were
thereafter tailored appropriately in consultation with the
infectious disease service. On POD8 a left brachial vein clot
was found on non-invasives and she was initiated on
fondaparinux, subsequently discontinued. On POD11 the patient
was noted to have QTC prolongation, for which the cardiology
service was consulted, and recommendations were followed
regarding medication adjustments. On [**2108-4-17**] the patient was
extubated, and briefly off pressors. She was found to have SBP,
and begun on meropenem in consultation with the hepatology and
ID services. Lactulose was initiated given poor mental status
(AOx1 initially), on which she seemed to initially improve. On
POD20 the patient failed a speech and swallow evaluation, and
continued on tube feedings. Her pressor requirement remained
persistent, and her WBC continued to trend upwards. On [**2108-5-4**],
in discussion with the patient's HCP, she was made DNR/DNI. On
the evening of [**2108-5-7**] she was noted to be hypothermic to 89,
was in DIC per labarotory values and she passed away on [**2108-5-8**],
post-operative day 34.
Discharge Disposition:
Expired
Discharge Diagnosis:
-Pancreatic cancer
-Spontaneous bacterial peritonitis
-Heparin Induced Thrombocytopenia
-Renal failure
Discharge Condition:
Expired.
Discharge Instructions:
N/A.
Followup Instructions:
N/A.
Completed by:[**2108-5-9**]
ICD9 Codes: 5845, 5856, 2762, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 54
} | Medical Text: Admission Date: [**2118-5-7**] Discharge Date: [**2118-5-19**]
Date of Birth: [**2047-9-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Chest pain and anemia
Major Surgical or Invasive Procedure:
Colonoscopy and Upper Endoscopy
History of Present Illness:
70 year old man with afib on coumadin, insulin dependent DM,
obseity, systolic and diastolic heart failure LVEF 40-45%, CAD
s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft
[**2118-4-8**], presents with fatigue and dyspnea on exertion over past
week. He was initially feeling well after discharge [**3-/2117**] and
began exercising and losing weight. However, this past week
dyspnea increased and exertional capacity decreased. He called
his cardiologist who thought he might be overdiuresed, therefore
his lasix and spironolactone were reduced to half prior doses.
Dyspnea worsened despite this change. Then on the day of
admission he had 2 bowel movements, the second of which was dark
black. The bowel movement was preceeded by crampy abdominal
pain. He attempted to walk from the bathroom to the kitchen but
because acutely dyspneic. He sat down and then developed chest
pain, took a nitro with relief. Tried to walk again but the
chest pain returned, thus called EMS and was brought to an OSH.
There his chest pain was relieved by repeated nitroglycerin and
he was eventually started on a nitroglycerin drip. Labs at OSH
were notable for HCT 25, INR 3.7, K 7. Enroute to [**Hospital1 18**], his
SBP dropped with increasing nitro drip doses.
Upon arrival to [**Hospital1 18**], he was chest pain free with VS 97.6
99/56, 74 16 97% 2L. ECG showed a new LBBB, trop negative.
Labs notable for K 7.2 (not hemolyzed) and thus he received
calcium, D50/insulin, and kayexalate. INR was 4.9. GI was
called given HCT drop from 31 to 25 and made plans to scope in
the morning. Rectal exam notable for brown stool guaiac
positive with specks of black stool. Nitroglycerin drip was
stopped and his pain was controlled with morphine PRN. He
received 1L NS. Vitals prior to transfer 98.1 69 109/41 16 99%
RA pain 0.
On arrival to the MICU, he was initially comfortable, but then
developed chest pain prompting morphine 2mg x3 without relief.
SL nitro was given with improvement in pain. ECG showed narrow
complex sinus rhythm with ST depressions in I, V4-V6. He later
had another episode of pain relieved by SL nitroglycerin.
Past Medical History:
CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever
Social History:
Lives with wife and four children. Worked as a carpenter. No
tob/ETOH/IVDA.
Family History:
Adopted, unknown
Physical Exam:
Admission exam:
Vitals: 98F 108/44 71 9 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Discharge exam:
VS - 98.0, 98.6, 96/49 (94-145/48-71), 71 (52-81), 20, 100RA
GENERAL - Obese late-middle aged man in NAD. Oriented x3.
HEENT - NCAT. Oropharynx clear
NECK - Supple, unable to assess JVD due to habitus
CARDIAC - RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS - CTAB, no crackles, wheezes or rhonchi.
ABDOMEN - Soft, obese NTND. No HSM or tenderness.
EXTREMITIES - WWP, no LE edema, no clubbing
SKIN - Multiple scars across lower extremities from vein
harvesting, some chronic stasis changes
Pertinent Results:
Admission Labs:
===============
[**2118-5-6**] 11:55PM BLOOD WBC-11.2* RBC-2.82* Hgb-8.0* Hct-24.7*
MCV-87 MCH-28.3 MCHC-32.3 RDW-19.2* Plt Ct-178
[**2118-5-6**] 11:55PM BLOOD Neuts-85.1* Lymphs-10.4* Monos-3.0
Eos-1.3 Baso-0.2
[**2118-5-6**] 11:55PM BLOOD PT-49.3* PTT-56.2* INR(PT)-4.9*
[**2118-5-6**] 11:55PM BLOOD Glucose-187* UreaN-78* Creat-1.9* Na-131*
K-7.2* Cl-99 HCO3-22 AnGap-17
[**2118-5-7**] 03:20AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.6
Pertinent Labs:
===============
[**2118-5-6**] 11:55PM BLOOD cTropnT-<0.01
[**2118-5-7**] 03:20AM BLOOD CK-MB-4 cTropnT-0.02*
[**2118-5-7**] 08:55AM BLOOD CK-MB-5 cTropnT-0.04*
[**2118-5-7**] 10:58PM BLOOD CK-MB-4 cTropnT-0.05*
[**2118-5-12**] 10:50AM BLOOD Hapto-164
[**2118-5-12**] 10:50AM BLOOD LD(LDH)-195 TotBili-2.0* DirBili-0.5*
IndBili-1.5
HELICOBACTER PYLORI ANTIBODY TEST: POSITIVE BY EIA.
Urine culture [**5-9**]- no growth
Discharge Labs:
===============
[**2118-5-19**] 06:35AM BLOOD Hct-29.5*
[**2118-5-17**] 11:00AM BLOOD PT-11.9 PTT-33.3 INR(PT)-1.1
[**2118-5-18**] 11:10AM BLOOD Glucose-108* UreaN-21* Creat-1.1 Na-136
K-4.6 Cl-100 HCO3-28 AnGap-13
[**2118-5-18**] 11:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-3.2*
Micro/Path:
===========
URINE CULTURE (Final [**2118-5-10**]): NO GROWTH.
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2118-5-9**]): POSITIVE BY
EIA.
MRSA SCREEN (Final [**2118-5-9**]): No MRSA isolated.
Imaging/Studies:
================
CXR [**5-9**]- Status post sternotomy, with mild prominence of the
cardiomediastinal silhouette. There is upper zone
re-distribution without overt CHF. There is minimal atelectasis
at both bases. No frank consolidation or effusion.
EKG [**5-9**]- LBBB -> sinus rhythm narrow complex, ST depressions
V4-V6 and I, avL
EGD [**5-9**]- Nodularity in the whole stomach compatible with
nodular gastritis. Normal EGD to third part of the duodenum.
CT abd/pelvis [**5-12**]-
1. No evidence of retroperitoneal bleed or acute
intra-abdominal process.
2. Fatty infiltration of the liver.
3. Cholelithiasis.
4. Right renal cyst.
Colonoscopy [**2118-5-18**]:
Impression:
Grade 1 internal hemorrhoids
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
70 year old man with afib on coumadin, insulin dependent DM,
obseity, systolic and diastolic heart failure LVEF 40-45%, CAD
s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft
[**2118-4-8**], presents with fatigue and dyspnea on exertion, found to
have hematocrit drop secondary to GI bleed.
ACTIVE DIAGNOSES:
=================
# Chest Pain: Demand ischemia in setting of GI bleed. He has
known coronary vascular disease with refractory angina that is
not amenable to intervention per cardiology team. No evidence of
consolidation or PTX on CXR to suggest pulmonary cause. Patient
was transfused a total of 8 units pRBCs; hematocrit initially
stabilized and when heparin gtt and coumadin were re-started,
hematocrit dropped again and chest pain returned without EKG
changes. He was continued on aspirin, plavix, and ranolazine.
Imdur was started at a lower dose than home dose given concern
for hypotension in setting of bleeding, but BP remained stable
so imdur was titrated up to his home dose. He then had return of
chest pain, with dynamic ST changes in V3-V5 and I/avL,
consistent with known non-intervenable areas of disease. His
imdur was increased to 240mg and metoprolol was increased to
tartrate 150mg PO BID without further episodes of chest pain.
# UGIB/H.Pylori + Nodular Gastritis: On EGD, patient had
evidence of nodular gastritis with superficial erosions.
H.pylori returned positive and patient began triple therapy with
amoxicillin (not candidate for clarithromycin given interaction
with ranolazine), metronidazole and pantoprazole. Coumadin was
held and INR was reversed with vitamin K. Patient had ongoing
hematocrit drop without obvious bleeding once heparin drip was
restarted, so both coumadin and heparin were stopped. Patient
will complete 2 weeks of triple therapy, then continue [**Hospital1 **]
pantoprazole. He does not require GI follow-up or test of cure.
He also underwent colonoscopy which did not reveal an additional
or alternative source of his bleeding. If he continues to bleed,
the next step would be a capsule endoscopy. He will have a [**Hospital1 **]
check prior to his PCP appointment to assess his hematocrit.
# Acute blood loss anemia: Source suspected to be gastritis as
above. Coumadin was held on admission to the ICU and reversed
with vitamin K and FFP. He was transfused a total of 8 units
during admission; initially 4 units in the ICU as he had an
inappropriate response to blood, then again on the floor as with
initiation of coumadin and bridge with heparin drip, patient's
hematocrit drifted down. Haptoglobin and LDH were normal, and
indirect bilirubin was only slightly elevated (and was post
transfusion) so low suspicion for hemolysis. With
discontinuation of heparin drip and coumadin, hematocrit
stabilized and patient did not require transfusion for >72 hours
prior to discharge.
# Constipation: Significantly constipated during admission.
Required 2 days of prep prior to his colonoscopy. Patient
discharged on senna/colace/miralax to prevent further
constipation.
# Acute on chronic systolic heart failure: On admission,
patient had mild pulmonary edema secondary to decreased lasix
and spironolactone dose over past week prior to admission.
Patient was diuresed in the ICU, and was euvolemic on transfer
to the floor. He was continued on home lasix 40mg daily, with
extra doses with transfusions. He had a few episodes of
orthostatic hypotension prompting decrease of his lasix dose to
20mg PO daily. Patient was euvolemic at the time of discharge,
and weight was stable at 120 kg.
# Hyperkalemia: 7.2 on admission likely secondary to ARF,
spironolactone, and lisinopril. ECG improved to narrow complex
once potassium normalized. Potassium remained stable for
remainder of admission. Spironolactone was not restarted, and
lisinopril was restarted at lower dose of 5mg PO daily.
# LBBB: Suspect metabolic etiology given improved with K
correction. Trop negative suggesting against acute coronary
syndrome. LBBB resolved after correction of K.
# Acute renal failure: Likely secondary to systolic CHF with
poor forward flow with second hit of poor perfusion due to acute
GIB. Patient's creatinine trended down and was 1.1 on day of
discharge.
# Leukocytosis: Unclear etiology, but may be due to stress of
GIB. No evidence of infectious colitis, UA without evidence of
infection and no consolidation seen on CXR. White count
resolved and remained normal for remainder of admission.
CHRONIC DIAGNOSES:
==================
# HLD: continued atorvastatin
# Depression: continued venlafaxine
# DMII: Blood sugar well controlled during admission.
Transitional issues:
# Spironolactone held on discharge given hyperkalemia to 7.2 on
admission.
# Coumadin held on discharge -> we anticipate holding this
medication for about a month while his gastritis heals with
protection against stroke with aspirin 325mg and plavix 75mg in
the interim.
# Lisinopril decreased to 5mg daily to prevent hyperkalemia and
increase pressure room to uptitrate Imdur to 240mg PO daily and
metoprolol to 150mg tartrate [**Hospital1 **]
# H.pylori triple therapy treatment to continue through [**2118-5-23**]
# Hematocrit and electrolytes should be rechecked by PCP at
[**Name9 (PRE) 702**] appointment, he has a script for this.
# Insulin decreased to 70/30 mix 80 units daily given in-house
hypoglycemia. We suggest setting him up with [**Last Name (un) **] for further
diabetes management but wanted him to discuss this with his PCP
[**Name Initial (PRE) **].
# Weight on discharge 120kg, discharged on furosemide 20mg
daily.
Medications on Admission:
1. aspirin 325 mg DAILY
2. nitroglycerin 0.4 mg q5min PRN
3. furosemide 40 mg PO daily
4. lisinopril 10 mg PO DAILY
5. atorvastatin 80 mg PO DAILY
6. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One Hundred (100) units Subcutaneous twice a day.
7. metformin 500 mg PO daily
8. venlafaxine 75 mg PO DAILY
9. warfarin 5 mg PO once a day.
10. pantoprazole 40 mg PO once a day.
12. ranolazine 1,000 mg PO twice a day.
13. clopidogrel 75 mg PO daily
14. isosorbide mononitrate 60 mg PO once a day.
15. metoprolol succinate 200 mg PO once a day.
16. spironolactone 25 mg PO once a day.
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ranolazine 500 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO BID (2 times a day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Name Initial (PRE) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
[**Name Initial (PRE) **]:*12 Tablet(s)* Refills:*0*
9. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 4 days.
[**Name Initial (PRE) **]:*16 Tablet(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Name Initial (PRE) **]:*30 Capsule(s)* Refills:*2*
12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO
twice a day.
[**Name Initial (PRE) **]:*180 Tablet(s)* Refills:*2*
14. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Eighty (80) units Subcutaneous twice a day.
15. Imdur 60 mg Tablet Extended Release 24 hr Sig: Four (4)
Tablet Extended Release 24 hr PO once a day.
16. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
[**Name Initial (PRE) **]:*30 packets* Refills:*2*
17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
18. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
19. Outpatient [**Name Initial (PRE) **] Work
Please obtain CBC, Chem 7 prior to your appointment.
Have the results communicated to your PCP:
[**Name Initial (NameIs) 7274**]: [**Name Initial (NameIs) **],[**Name Initial (NameIs) **]
Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**]
Phone: [**Telephone/Fax (1) 29149**]
Fax: [**Telephone/Fax (1) 29155**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
# Unstable Angina
# H. pylori + nodular gastritis with erosions
# Blood loss anemia
Secondary diagnosis:
# Coronary artery disease
# Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(rolling walker)
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you! You were admitted to [**Hospital1 18**]
for evaluation and treatment of chest pain, shortness of breath,
and GI bleeding. You were found to have a low blood count likely
due to a slow bleed in your GI tract related to all of your
blood thinners and gastritis with erosions from H. pylori (a
bacteria that pre-disposes to gastritis and ulcers). You were
started on a medication to protect your GI tract, treatment for
your infection, and you were given blood transfusions to improve
your blood counts. You underwent an upper endoscopy which showed
the inflammation of the stomach and erosions and a colonoscopy
which was without source of bleeding.
You also had an elevation in your potassium level, so your
spironolactone was discontinued.
We attempted re-starting anticoagulation but you began to bleed
again. As a result, your coumadin is being held until resolution
of your gastritis. We suggesting waiting a month or so until
resuming coumadin and would like to re-assure you that you are
recieving protection against stroke from your afib from your
aspirin and plavix.
The following changes were made to your medication regimen:
- START Metronidazole three times day through Monday [**2118-5-23**] to treat the infection in your stomach
- START Amoxicillin twice a day through Monday [**2118-5-23**] to
treat the infection in your stomach
- INCREASE pantoprazole to twice a day to protect your stomach
lining
- INCREASE Imdur to 240mg by mouth daily
- CHANGE to Metoprolol Tartrate 150mg by mouth twice daily
- DECREASE Lisinopril to 5mg daily
- DECREASE Lasix to 20mg daily
- DECREASE Insulin 70/30 to 80 units twice daily
- STOP Spironolactone
- STOP Coumadin -> you will have to discuss with your primary
care doctor restarting this medication about a month from now
once your gastritis has healed
- START Senna and Colace twice a day as needed for constipation
- START Miralax once daily as needed for constipation
Please follow up as suggested below.
Followup Instructions:
Name:[**Name6 (MD) **] [**Name8 (MD) **],MD
Specialty: Primary Care
Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**]
Phone: [**Telephone/Fax (1) 29149**]
When: Tuesday, [**5-24**] at 3:15pm
-Please have your labs checked prior to this appointment, on
discharge your hematocrit was 29.5
Department: CARDIAC SERVICES
When: THURSDAY [**2118-5-26**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2118-5-20**]
ICD9 Codes: 5849, 4280, 2851, 2767, 496, 412, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 55
} | Medical Text: Admission Date: [**2146-5-11**] Discharge Date: [**2146-5-14**]
Date of Birth: [**2068-2-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization with Drug eluting stent to Right
coronary Artery
History of Present Illness:
78 year-old male patient of Dr. [**First Name (STitle) 28622**] Attar and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 11493**] who has a history that includes CAD, s/p MI X 2, s/p CABG
in [**2139**], s/p prior stent to LAD and s/p prior PTCA of the
diagonal who was admitted to [**Hospital6 17032**] on
[**2146-5-7**] with shortness of breath. He was diagnosed with acute
on
chronic CHF with initial BNP 482. He was diuresed with IV Lasix
and ruled out for an MI with negative cardiac enzymes. A
nuclear
stress was performed on [**5-9**] showed several areas with
questionable reversible inferolateral and anteroapical ischemic
changes but no EKG changes or chest pain. It was believed that
his heart rate response was blunted [**2-14**] high dose BBlocker and
deconditioning. The overall duration of his treadmill time was
5 minutes with a heart rate max of 81 bpm. He was discharged to
home but returned to the [**Location (un) **]
ED with continued complaints of shortness of breath. Cardiac
enzymes were negative and he is now transferred for a cardiac
cathterization for further evaluation of his symptoms.
In cath lab, pt was unable to lie flat secondary to history of
PTSD, claustrophia, and anxiety and therefore required
intubation. A 90% distal lesion, just beyond the PDA was
stented with a [**Location (un) **]. At the end of the procedure, an NGT was
placed to dose plavix. Pt had already been started on
integrelin and heparin. Subsequently, the patient developed a
significant nose bleed. Heparin and integrelin were held, ENT
was called, pressure was held and the patient was given
intranasal afrin. Right heart cath also notable for elevated
RVEDP (16 mm Hg) and PCWP (28 mm Hg mean).
Past Medical History:
Coronary Artery Disease
s/p CABG in [**2139**] (LIMA->diag, SVG->OM1, SVG->LAD)
s/p Myocardial Infarction X 2
s/p prior LAD stent and PTCA of diag
Chronic systolic heart failure [**2-14**] ischemic cardiomyopathy, last
known EF 20%
Ischemic cardiomyopathy, s/p ICD implantation [**2141-7-14**]
Type 2 Diabetes Mellitus, insulin-dependent
Chronic Obstructive Pulmonary Disease, no home O2 requirement
Hypertension
Hyperlipidemia
Diabetic Nephropathy/Chronic Renal Insufficiency
Diabetic Neuropathy
s/p right renal artery stent
Severe Peripheral Vascular Disease, s/p left fem-[**Doctor Last Name **] bypass in
[**2137**]
GERD
Anxiety
Depression
Post Traumatic Stress Disorder
Paroxysmal Atrial Fibrillation
Nonsustained Ventricular Tachycardia
Social History:
Married and lives with his wife. Retired from
Army. Most recently worked as a cook at the [**Hospital **] [**Hospital6 28623**]. He used to drink alcohol heavily, but has had none in
40
years. 40+ pack year h/o smoking, quit 40 years ago.
Family History:
Father died of an MI at age 48. Brother died of
an MI at age 64.
Physical Exam:
Vitals: 129/48 - 67 - 17 - 100% on room air
Neuro: Alert, oriented to person, place, and time. Hard of
hearing.
Cardiac: Regular rate and rhythm. Normal S1,S2. No
murmurs/rubs/gallops.
Resp: Lungs have fine crackles at the bases bilaterally.
Breathing is regular and unlabored at rest.
Periph vasc: Bilateral femoral pulses are palpable. Bilateral
DP
and PT pulses are palpable. 1+ pedal edema bilaterally.
ECG: SR 73 with PVC's
Pertinent Results:
Admission labs:
[**2146-5-11**] 09:52PM BLOOD WBC-9.5# RBC-4.34* Hgb-13.3* Hct-39.0*
MCV-90 MCH-30.7 MCHC-34.2 RDW-14.6 Plt Ct-280
[**2146-5-11**] 09:52PM BLOOD Neuts-76.0* Lymphs-13.9* Monos-6.5
Eos-3.2 Baso-0.4
[**2146-5-11**] 09:52PM BLOOD PT-13.7* PTT-24.9 INR(PT)-1.2*
[**2146-5-11**] 09:52PM BLOOD Glucose-264* UreaN-29* Creat-1.6* Na-134
K-4.6 Cl-99 HCO3-27 AnGap-13
[**2146-5-11**] 09:52PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.4
.
Cardiac cath ([**5-13**]): 1. Coronary angiography of this right
dominant system revealed native three vessel coronary artery
disease. The LMCA had a distal 50% stenosis. The LAD was
occluded in the mid-vessel. The major diagonal branch had an
ostial 60% stenosis. The LCx had a long 60% lesion in OM1. The
RCA had a 90% stenosis just beyond the origin of the PDA.
2. Arterial conduit angiography demonstrated patent LIMA-D1 and
SVG-OM
grafts. The SVG-OM was occluded proximally. 3. Resting
hemodynamics revealed elevated right and left sided filling
pressures (RVEDP 16 mm Hg, PCWP mean 28 mm Hg). There was
moderate to severe pulmonary arterial hypertension (PASP 61 mm
Hg). The systemic arterial blood pressure was normal (SBP 122 mm
Hg). The cardiac index was normal at 2.7 l/min/m2. The systemic
vascular resistance was normal (911 dynes-sec/cm5). The
pulmonary vascular resistance was normal (PVR 135
dynes-sec/cm5). 4. Successful PTCA and stenting of the distal
RCA jailing the right PDA with a Xience (3x18mm) drug eluting
stent postdilated with a 3.25mm balloon. Final angiography
demonstrated no angiographically apparent dissection, no
residual stenosis and TIMI III flow throughout the vessel (See
PTCA comments). 5. Successful closure of the right femoral
arteriotomy site with a Mynx closure device.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease.
2. Patent LIMA-D1 and SVG-LAD grafts.
3. Occluded SVG-OM graft.
4. Moderate biventricular diastolic dysfunction.
5. Moderate pulmonary hypertension.
6. Successful PTCA and stenting of the distal RCA with a Xience
drug
eluting stent.
7. Successful closure of the right femoral arteriotomy site with
a Mynx
closure device.
.
Discharge labs:
[**2146-5-14**] 07:41AM BLOOD WBC-8.8 RBC-4.17* Hgb-12.7* Hct-36.9*
MCV-89 MCH-30.4 MCHC-34.3 RDW-14.6 Plt Ct-275
[**2146-5-14**] 07:41AM BLOOD Glucose-206* UreaN-31* Creat-1.6* Na-137
K-4.1 Cl-99 HCO3-25 AnGap-17
[**2146-5-14**] 07:41AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.4
Brief Hospital Course:
78 year-old man who was referred from OSH for a cardiac
catheterization secondary to persistent shortness of breath.
# Coronary Artery Disease - Patient with known hx of CAD, prior
CABG, prior stent/PTCA was referred for cardiac ctah for
persistent shortness of breath. Patient did not tolerate lying
flat for procedure due to significant history of claustrophobia,
PTSD and anxiety and was intubated for the procedure. He was
started on heparin, integrillin and plavix loaded pre-procedure
however developed severe epistaxis after intubation and
integrilin was stopped. Cardiac cath showed distal 90% RCA
lesion and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] was placed. He was continued on aspirin,
plavix and statin. After cath, he remained intubated for airway
protection from epistaxis nad was admitted to CCU for closer
management. He was extubated on hospital day #2 without
complication.
.
# Chronic systolic heart failure - Ischemic cardiomyopathy, EF
20%. RHC notable for elevated RVEDP (16 mm Hg) and PCWP (28 mm
Hg mean). After catheterization he was diuresed with bolus lasix
and his home dose of lasix was increased to 100mg [**Hospital1 **]. He was
continued on Inspra, Diovan and Toprol. At time of discharge
exam was notable for lower extremity edema, but patient had no
evidence of pulmonary edema with no oxygen requirement so he was
instructed to continue higher dose of lasix until he could
discuss lasix titration with his cardiologist as an outpatient.
.
# Epistaxis - Developed during cardiac catheterization and ENT
was consulted. This was managed with Afrin. Estimated blood loss
of 200cc which stabilized without tranfusion. This resolved
within 24 hours with no recurrent events.
.
# Hypertension: He was continued on home [**Hospital1 4319**] of Lasix, Diovan,
Norvasc, Inspra and Toprol with good control
.
# Hyperlipidemia: We do not have most recent lipid panel. On
admission he was on tricor and statin was added to his regimen.
.
# Type II Diabetes, Insulin-Dependent: He was continued on home
regimen of basal-bolus insulin with good control. No changed
were amde to insulin regimen during admission.
.
# Stage 3 chronic renal failure - Baseline Cr 1.8, received
pre-cath hydration and mucomyst and creatinine remained stable
after contrast load during procedure.
.
# Depression: Mood was stable on admission . Patient not
currently on pharmacological treatment for depression.
Medications on Admission:
Flonase 50 mcg one spray to each nostril daily
Proventil inhaler two puffs four times daily prn shortness of
breath or wheezing
Tricor 145 mg one tab daily
Lasix 80 mg twice a day (reduced at time of d/c from
NVMC from prior dose of 120 mg [**Hospital1 **])
Aspirin 325 mg one tab daily
Imdur 30 mg one tab daily
Insulin 70/30 60 units subcutaneous injection breakfast
Insulin 50/50 60 unit subcutaneous injection dinnertime
Levemir 37 units subcutaneous injection at bedtime
Diovan 40 mg one tab daily (recently added by Dr. [**Last Name (STitle) 11493**]
Inspra 25 mg one tab daily
Norvasc 2.5 mg one tab daily
Toprol XL 200 mg one tab daily
(added at NVMC)
Plavix 75 mg one tab daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension
Sig: Sixty (60) units Subcutaneous twice a day.
8. Levemir 100 unit/mL Solution Sig: Thirty Seven (37) units
Subcutaneous at bedtime.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
12. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Disp:*150 Tablet(s)* Refills:*2*
14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Epistaxis
Post Traumatic Stress Syndrome
Discharge Condition:
stable.
Discharge Instructions:
You had a cardiac catheterization with a drug eluting stent
placed in your right coronary artery. You will need to take
Plavix every day for one year. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop
taking Plavix unless Dr. [**Last Name (STitle) 11493**] tells you to. No lifting more
than 10 pounds in 1 week. No baths or pools for one week. You
may shower and take off the dressing on your groin. During the
procedure you were intubated and on a breathing machine. You had
a nose bleed that was caused by the blood thinners and needed to
have Afrin sprayed in your nose to stop the bleeding. You had a
fever and were on antibiotics for a short time. Your chest X-ray
did not show a pneumonia and the antibiotics were discontinued.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
.
Please call Dr. [**Last Name (STitle) 11493**] if you notice any increased trouble
breathing, chest pain, nausea, light headedness, increased
bruising or bleeding in your groin region, increasing coughs,
fevers or any other concerning symptoms.
Followup Instructions:
Primary Care:
ATTAR,[**Female First Name (un) **] Phone: [**Telephone/Fax (1) 24306**] Date/time: please call when you
get home for an appt in [**1-14**] weeks.
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:Friday [**6-10**] at 1:00pm
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2146-8-5**] 11:20
Completed by:[**2146-5-16**]
ICD9 Codes: 4280, 496, 412, 4168, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 56
} | Medical Text: Admission Date: [**2179-12-13**] Discharge Date: [**2179-12-23**]
Date of Birth: [**2107-1-5**] Sex: F
Service: CARDIOTHORACIC SURGERY
CHIEF COMPLAINT: Shortness of breath with exertion.
HISTORY OF PRESENT ILLNESS: The patient is a 72history of
woman with a history of hypertension, hyperlipidemia,
congestive heart failure, rheumatic heart disease and
paroxysmal atrial fibrillation, who was admitted to [**Hospital6 1760**] on [**2179-10-22**], for
cardioversion from rapid atrial fibrillation.
During that admission, she had transesophageal echocardiogram
which showed an ejection fraction of 60% with 1+ aortic
insufficiency, 2+ mitral regurgitation, 2+ tricuspid
regurgitation, and small pleural cardiac effusion. The
echocardiogram was unchanged from previous echocardiogram in
[**2179-7-11**].
She then underwent cardiac catheterization on [**11-19**] in
anticipation of future cardiac surgery. Her catheterization
showed a left main of 30%, left anterior descending 70%,
circumflex 30%, OM1 70%, right coronary artery 50%. Please
see catheterization report full details.
She was admitted on [**2179-12-13**], directly to the
Operating Room for coronary artery bypass grafting and mitral
valve replacement as postoperative admission.
PAST MEDICAL HISTORY: Rheumatic heart disease, congestive
heart failure, hypertension, hypercholesterolemia, paroxysmal
atrial fibrillation.
PAST SURGICAL HISTORY: Right upper lobectomy for nonsmall
cell cancer in [**2179-8-10**]. Bilateral cataract surgery.
SOCIAL HISTORY: She lives alone. The patient has a 30
pack-year tobacco history. She quit 15 years ago. Alcohol
use is occasional.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Toprol XL 25 mg q.d., Amiodarone
200 mg b.i.d., Aspirin 325 mg q.d., Lipitor 200 mg q.d.,
Levothyroxine 112 mcg q.d., Coumadin 4 mg q.d., Protonix 40
mg q.d., Lisinopril 10 mg q.d.
PHYSICAL EXAMINATION: General: The patient was a
frail-appearing woman in no acute distress. Skin: No breaks
or rashes. HEENT: Pupils equal, round and reactive to
light. Extraocular movements intact. Oropharynx clear.
Upper dentures intact. Neck: Supple. No jugular venous
distention. No bruits. Lungs: Clear to auscultation
bilaterally. She had a well-healed lobectomy scar on the
right. Heart: Regular, rate and rhythm. There was a 2/6
systolic ejection murmur. Abdomen: Obese, soft, nontender,
nondistended with no hepatosplenomegaly. Extremities: No
clubbing, cyanosis, or edema. The patient had bilateral
lower extremity spider veins. Neurological: The patient was
alert and oriented times three. Pulses: Grossly intact
pulses. Radial 2+ bilaterally, dorsalis pedis 2+
bilaterally, posterior tibial 1+ bilaterally, femoral 2+
bilaterally. Carotids not identified.
HOSPITAL COURSE: As stated previously, the patient was a
direct admission to the operating room.
On [**12-13**], she underwent mitral valve replacement and
coronary artery bypass grafting; please see operative report
for full details.
In summary, the patient had mitral valve replacement with a
#25 Mosaic and coronary artery bypass grafting times two,
with LIMA to the left anterior descending, saphenous vein
graft to the obtuse marginal. She tolerated the operation
well. Cardiopulmonary bypass time was 224 min, and her
cross-clamp time was 181 min. She was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, she had Milrinone at 0.5 mcg/kg/min,
Propofol at 20 mcg/kg/min, Neo-Synephrine at 3 mcg/kg/min.
Additionally the patient had epinephrine and Nitroglycerin
drips with no dose identified at this time.
The patient did well in the immediate postoperative period.
Her anesthesia was reversed. She was allowed to awaken
initially and was then resedated after a neurological check.
Her epinephrine drip was weaned to off shortly after arrival
into the Cardiothoracic Intensive Care Unit. The
cardioactive medications were titrated as tolerated by the
patient's hemodynamics throughout the night on her operative
date.
On postoperative day #1, the patient's sedation was
discontinued. She was weaned from the ventilator and
successfully extubated. Her Milrinone was weaned to off.
Her Neo-Synephrine was weaned to 0.25 mcg/kg/min.
Additionally, her Nitroglycerin drip was maintained at 0.25
mcg/kg/min.
The patient remained hemodynamically stable throughout
postoperative day #1 and 2. On postoperative day #3, all
cardioactive intravenous medications were weaned to off and
transitioned to oral medications. The patient's chest tubes
were discharge, and she was transferred from the
Cardiothoracic Intensive Care Unit to Far Two for continued
postoperative care and cardiac rehabilitation.
Over the next several days, the patient had an uneventful
hospital course with the exception of intermittent atrial
fibrillation which was treated with Amiodarone and
beta-blockade. Additionally the patient was restarted on her
anticoagulation, which she had been receiving preoperatively
for atrial fibrillation.
With the assistance of the nursing staff and Physical Therapy
staff, the patient's activity level was increased. On
postoperative day 8, it was decided that the patient was
stable and would be ready for discharge to home on the
following day.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature
98.2??????, heart rate 72, sinus rhythm, blood pressure 108/64,
respirations 18, oxygen saturation 98% on room air. Weight
preoperatively 58.5 kg, discharge 54.8 kg. General: The
patient was alert and oriented times three. She moved all
extremities. She followed commands. Nonfocal exam. Chest:
Clear to auscultation bilaterally. Sternum is stable.
Incision with Steri-Strips, open to air, clean and dry.
Heart: Regular, rate and rhythm. S1 and S2. Abdomen:
Soft, nontender, nondistended. Positive bowel sounds.
Extremities: Warm and well perfused. The patient had 1+
edema bilaterally. Right saphenous vein graft site with
Steri-Strips and large echymotic area of upper thigh.
DISCHARGE LABORATORY DATA: Sodium 138, potassium 4.2, BUN
21, creatinine 1.0; PT 13, INR 1.0.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times two with LIMA to the left anterior
descending, saphenous vein graft to obtuse marginal.
2. Mitral regurgitation status post mitral valve replacement
with a #25 mosaic valve.
3. Rheumatic heart disease.
4. Congestive heart failure.
5. Hypertension.
6. Hypercholesterolemia.
7. Paroxysmal atrial fibrillation.
8. Gastroesophageal reflux disease.
9. Status post right upper lobectomy.
10. Status post bilateral cardiac surgery.
DISCHARGE MEDICATIONS: Amiodarone 200 mg q.d., Lopressor 25
mg p.o. b.i.d., Coumadin 4 mg q.d., titrate to goal INR of
2.0-2.5, Aspirin 81 mg q.d., Lasix 20 mg q.d. x 10 days,
Potassium Chloride 20 mEq q.d. x 10 days, Levoxyl 112 mcg
q.d., Lipitor 20 mg q.d., Prilosec 40 mg q.d., Imdur 30 mg
q.d., Colace 100 mg b.i.d., Percocet 5/325 [**2-11**] tab q.4 hours
p.r.n.
DISCHARGE STATUS: The patient is to be discharged to home
with VNA.
FO[**Last Name (STitle) **]P: She is to have follow-up with Dr. [**Last Name (STitle) **] in [**4-13**]
weeks. Follow-up with Dr. [**First Name (STitle) 2031**] in [**4-13**] weeks. Follow-up
with Dr. [**Last Name (Prefixes) **] in four weeks. The patient is to have a
PT/INR drawn by visiting nurses on Friday, [**12-24**]. The
results of that are to be called to Dr.[**Name (NI) 48166**] office, and he
is to manage the patient's Coumadin dosing from that point
forward.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2179-12-22**] 18:27
T: [**2179-12-22**] 18:47
JOB#: [**Job Number 48167**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 57
} | Medical Text: Admission Date: [**2201-6-21**] Discharge Date: [**2201-7-3**]
Date of Birth: [**2171-2-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Perforated diverticulitis
Major Surgical or Invasive Procedure:
OSH procedure:
[**2201-6-20**]: Exploratory laparotomy, sigmoid colectomy and
formation of Hartmann's pouch colostomy
[**Hospital1 18**] operations:
[**2201-6-26**]: Exploratory laparotomy with revision of sigmoid
colostomy
[**2201-6-28**]: Abdominal washout, liver biopsy, abdominal closure
History of Present Illness:
HPI: 30 yo male with hx of significant etoh abuse presenting
from OSH with perforated sigmoid colon, s/p sigmoid colectomy,
currently septic on Neo. Intubated the evening prior to
transfer.
The pt initially presented to the OSH with one week of abdominal
pain, nausea and vomiting with associated diarrhea. CT scan in
the ED demonstrated free air. Labs at the time were pertinent
for ARF with Cr. of 2.3. Sodium 125, bicarb 22 with AG of 19 and
T.bili 3.8. Pt was taken to the OR for an ex-lap and found to
have perforated viscous in the sigmoid area. Fibrinous exudate
in the left side was present c/w longstanding process. A
Hartmann pouch and LLQ colostomy was performed. The pt was
started on levaquin, flagyl and zosyn.
Postop the pt had persistent acidosis with a bicarb of 15,
lactate 4.8. He was started on a bicarb gtt. During the course
of the OSH stay the pt has been 9 liters positive. He remains
hypotensive on neo. Of note the pt drinks up to half-a-gallon a
day of whiskey. His last drink was 8 days ago.
Past Medical History:
Alcohol abuse
PSH: Hartmann's procedure
Social History:
History of alcohol abuse
Lives with mother who works at [**Hospital6 5016**], which is
where the patient was admitted previosly
Family History:
Non-contributory
Physical Exam:
On transfer to [**Hospital1 18**]:
100 115 102/55 26 93% CMV 50% 450/13 5
Neuro: Awake responsive to questions/follows commands
Card: tachycardic, no m/r/g/c
Pulm: Intubated clear breath sounds bilaterally
GI:+Bowel sounds. Midline incision c/d/i. dusky sunken appearing
colostomy. Appropriately tender to palpation
Ext: peripheral edema palpable DP, radial pulses
Pertinent Results:
[**6-21**]: OSH CT abd/pelvis CT (OSH) free air and sigmoid
stranding/diverticulitis.
Labs on admission:
[**2201-6-21**] 07:40PM WBC-7.4 RBC-2.62* HGB-9.5* HCT-29.2* MCV-112*
MCH-36.1* MCHC-32.3 RDW-23.0*
[**2201-6-21**] 07:40PM PLT COUNT-171
[**2201-6-21**] 07:40PM PT-16.4* PTT-31.7 INR(PT)-1.5*
[**2201-6-21**] 07:40PM ALT(SGPT)-25 AST(SGOT)-58* ALK PHOS-52 TOT
BILI-3.3* DIR BILI-2.9* INDIR BIL-0.4
[**2201-6-21**] 07:40PM GLUCOSE-141* UREA N-45* CREAT-1.8* SODIUM-138
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-20* ANION GAP-21*
[**2201-6-21**] 07:40PM CALCIUM-6.5* PHOSPHATE-4.7* MAGNESIUM-2.2
[**2201-6-21**] 07:48PM freeCa-0.90*
[**2201-6-21**] 07:48PM GLUCOSE-127* LACTATE-3.7* K+-3.4
[**2201-6-21**] 07:48PM TYPE-ART PO2-70* PCO2-37 PH-7.38 TOTAL CO2-23
BASE XS--
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the trauma ICU on [**2201-6-21**] for further
management following his Hartmann's procedure for perforated
diverticulitis and septic shock. He remained on pressors which
were weaned slightly overnight. He received a blood transfusion
for a hematocrit of 24.1 which increased to 25.9 and was weaned
off pressors. Copious secretions were noted from his ET tube.
Intraoperative cultures from the OSH were obtained. They were
peritoneal cultures and were polymicrobial. He was extubated and
remained hemodynamically stable so was transferred to the floor
on [**2201-6-24**].
At the time of transfer to the floor the pt was NPO with IV
fluids and NG tube to suction. He was on IV zosyn for empiric
coverage and also had a foley catheter in place for urine output
monitoring. On [**6-25**] his NG tube output remained low so it was
removed along with the foley catheter as he was making good
amounts of urine. However, the appearance of his stoma continued
to be dusky and necrotic and his WBC count increased from 9.6 on
[**6-24**] to 15.2 on [**6-26**]. Therefore, he was taken back to the OR for
an ostomy revision on [**2201-6-26**].
Intraoperatively, he received over 3L in crystalloid for
hypotension. His abdomen was left open due to bowel edema and he
was brought to the trauma ICU intubated and sedated. He was
aggressively diuresed overnight and his abdomen was closed on
[**2201-6-28**]. Also of note, the liver was noted to be quite yellowed
in appearance suspicious of acute fatty liver and a biopsy was
sent during the abdominal closure procedure (please see
operative note for details). Postoperatively, his vent was
weaned with continued diuresis. He was extubated on [**2201-6-29**] and
transferred back to the floor hemodynamically stable.
On [**6-30**] he was noted to have gas and a small amout of stool from
his ostomy so his diet was advanced as tolerated. His foley
catheter which had been placed upon return to the operating room
was again removed and he voided without difficulty. His vital
signs were routinely monitored and he remained afebrile and
hemodynamically. His lung sounds were noted to have crackles and
his chest x-ray appreared wet and he was diuresed with lasix as
needed. His white blood cell count began trending downward to
18 from 27. His hematocrit has stabilized at 27. He was
encouraged to mobilize out of bed and ambulate as tolerated
throughout his postoperative course and he remained on SC
heparin for DVT prophylaxis.
Ostomy nursing was consulted and provided appropriate treatment
and supplies for the patient to care for his colostomy.
On HD #13, he was note to have mild erythema around the lower
aspect of his wound and he underwent further removal of staples
from the lower aspect of his wound. Remained of inferior staples
were removed on POD #5 and wound was lightly packed with wet to
dry dressing. The patient has been instructed in caring for his
wound and dressing changes. He partipated in dressing changes
and agreed to continue with them. VNA service will also provide
him with assistance.
His vital signs have been stable and he has been afebrile. He
is preparing for discharge home with follow-up in the acute care
clinic.
Medications on Admission:
None
Discharge Medications:
1. Ostomy supplies
1 piece Coloplast
Sensura ( Dist # [**Numeric Identifier 24338**] [**Doctor First Name **] # [**Numeric Identifier 20839**])
#3 boxes
Refills:6
2. Ostomy Supplies
[**Last Name (un) **] wafer Dist # [**Numeric Identifier 89560**], manf # [**Numeric Identifier 20840**]
#3 boxes
Refills: 6
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 16449**] Homecare and Hospice
Discharge Diagnosis:
Perforated diverticulitis
Sepsis
Acute Kidney Injury
Ischemic sigmoid colostomy
Open abdomen secondary to diverticulitis and sepsis
Acute fatty liver
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred from [**Hospital6 5016**] after undergoing
an emergent operation for perforated diverticulitis. You became
septic postoperatively and were transferred here to [**Hospital1 18**] for
further management. You were managed in the ICU and your
condition improved so you were transferred to the surgical
floor. You were then taken back to the operating for because
your stoma was necrotic and had your stoma revised. Because of
bowel swelling you abdomen was left open for a short period of
time. Two days later it was able to be closed in the operating
room. It was also noted that your liver appeared abnormal and a
biopsy of it was taken during your last operation. The results
of the biopsy are still pending at this time.
Your infection has improved and your colostomy is now
functioning well. You have resumed a regular diet and should
continue to do so. You are being discharged home with the
following instructions:
Please follow up in the Acute Care Surgery Clinic at the
appointment scheduled for you below.
Your colostomy: You have received teaching from the ostomy
nurses on how to care for your stoma. Empty the pouch when it
becomes [**2-10**] full as instructed.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Month/Day (4) 5059**] at your next visit.
Don't lift more than [**11-23**] lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal. Your staples will be removed at your follow up
appointment in clinic.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: TUESDAY [**2201-7-14**] at 2:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2201-7-8**]
ICD9 Codes: 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 58
} | Medical Text: Admission Date: [**2143-4-29**] Discharge Date: [**2143-5-12**]
Date of Birth: [**2083-3-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
abd pain, nausea/vomiting
Major Surgical or Invasive Procedure:
Intubation
Placement of central venous catheter
CVVHD
Hemodialysis
History of Present Illness:
60 y/o M w/alcohol abuse, HTN, who presented to [**Hospital3 **]
on Saturday [**4-27**] c/o severe abd pain, n/v. Had started 2 days
prior in setting of binge drinking with whiskey. Pain was
epigastric radiating to his back. He was found to have a lipase
of >3000. and was admitted to their medical service for acute
pancreatitis. He was kept NPO and given IVF. He also was given
Levaquin for "lethargy" and an infiltrate on CXR. The next day,
[**4-28**], his bilirubin increased (0.8-2.6) and he continued to have
severe abd pain, so he was changed from levaquin to primaxin,
and he was trnasferred to their ICU. He was put on a lasix [**Hospital1 **]
due to rales and cardiomegaly, and kept on NS at 100 cc/hr. He
had a CT scan with po and IV contrast that showed acute
pancreatitis with intrahepatic ductal dilatation; multiple
hypodense irregular lesions in the right lobe of the liver,
thickened GB wall with pericholecystic fluid, and a 5x4 cm
hypodense collection in the RLQ adjacent to the psoas muscle.
.
On [**4-29**], he was supposed to go to MRCP but was claustrophobic
and required ativan. After this, he felt better but required
more ativan while in Radiology. [**Name8 (MD) **] RN notes, his heart rate was
"sporadic" from the 40s to the 160s. He was given more ativan
and then his HR dropped to the 20s (bp 145/63 at this time). He
then became diaphoretic, c/o chest pain, and the MRCP was
stopped. He was transferred to the stretcher and then turned
[**Doctor Last Name 352**], "started to seize" and was noted to be pulseless. [**Name8 (MD) **] RN
note, he was asystolic but per d/c summary and cardiology
consult note, it was VT/VF. He received "several" shocks and CPR
as well as one bolus dose of amiodarone. He was intubated during
the code. He regained a pulse after an unknown amt of time. He
became hypotensive requiring dopamine. He was then seen by Renal
due to worsening renal failure (creatinine 0.8 on admission to
3.5 on d/c) who felt this was likely pre-renal failure from
volume depletion plus contrast from the CT. His MRCP was read as
showing small ascites, peripancreatic stranding, pericholecystic
fluid, and a large gallstone. CBD did not appear dilated but the
images were quite limited; no obvious intrahepatic biliary
ductal dilatation or pancreatic ductal dilatation. Complex T2
hyperintesnsity along right psoas muscle as seen by CT measuring
5.2 x3.7 cm, representing a complex fluid collection. He was
transferred here for further management.
Past Medical History:
Alcohol abuse (reportedly binge drinks regularly)
HTN
Hypothyroidism
? pancreatitis
Social History:
Per OSH notes, he "binge drinks all the time" with recurrent
bouts of pancreatitis. Smokes tobacco, amt not documented.
Denied illicit drug use.
Family History:
unknown
Physical Exam:
On admission:
T: 99.4 BP: 87/49 P: 56
AC 500x14 FiO2 0.7 PEEP 5 O2 sat 94%
CVP 13
Gen: intubated, sedated, paralyzed
HEENT: icteric, ETT/OGT in place, pupils constricted
Lungs: CTA anteriorly, no w/r/c
CV: RRR, no m/r/g
Abd: distended, hypoactive but present bowel sounds, not tense
but difficult to assess peritoneal signs as paralyzed
Ext: no edema, feet cold, 1+ dp bilaterally
Pertinent Results:
Pre-admission labs of note:
[**4-29**] at 9 pm: Na 136, K 6.0, Cl 108, Bicarb 18, BUN 56, Creat
3.7
Calcium 6.5, T bili 10.0, AST 359, ALT 168, alk phos 161, CK
282, MB 6.2, MBI 2.1, Troponin T 0.02
WBC 22 with 25% bands, Hct 42, Plt 157, INR 1.3
ABG at 2:30 pm 6.88/83/68
ABG at 6:30 pm 7.14/55/260
Urine cx <1000 colonies/ml
Hepatitis serologies negative
Lipase on [**4-29**] 1541
Triglycerides 52
AFP 2.0
.
EKG: [**2143-4-30**]
Sinus rhythm. Left anterior fascicular block. Non-specific ST-T
wave
abnormalities.
.
Labs:
[**2143-4-30**] 12:27AM BLOOD WBC-16.1* RBC-4.07* Hgb-12.9* Hct-38.7*
MCV-95 MCH-31.6 MCHC-33.3 RDW-14.6 Plt Ct-153
[**2143-4-30**] 12:27AM BLOOD Plt Smr-NORMAL Plt Ct-153
[**2143-4-30**] 12:27AM BLOOD Neuts-69 Bands-16* Lymphs-6* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2143-4-30**] 12:27AM BLOOD PT-13.8* PTT-30.8 INR(PT)-1.2*
[**2143-4-30**] 12:27AM BLOOD Glucose-339* UreaN-58* Creat-4.4* Na-139
K-5.8* Cl-108 HCO3-21* AnGap-16
[**2143-4-30**] 12:27AM BLOOD ALT-134* AST-313* LD(LDH)-1755*
CK(CPK)-559* AlkPhos-142* Amylase-[**2143**]* TotBili-7.6*
[**2143-4-30**] 12:27AM BLOOD Lipase-1032*
[**2143-4-30**] 12:27AM BLOOD CK-MB-9 cTropnT-0.15*, 0.14, 0.13
.
Micro:
See OMR
.
Imaging:
[**2143-4-30**]: Abd u/s -
1. Minimal ascites in right upper and right lower quadrants.
2. Gallstone in the neck of the gallbladder with edema of the
gallbladder wall. This could reflect acute cholecystitis but
also could be a manifestation of changes due to the patient's
known acute pancreatitis.
3. No intrahepatic or extrahepatic biliary dilatation.
4. Patent portal vein.
.
[**2143-5-3**]: Head CT -
Diffuse hypodensity and loss of [**Doctor Last Name 352**]-white differentiation
suggesting global hypoxia and infarction. However, a similar
appearance could be caused by severe acute hepatic or renal
failure.
Subacute left parietal infarction without hemorrhage.
Possible small right parietal subacute infarction.
Brief Hospital Course:
In brief, the patient is a 60 year old man with history of
alcohol abuse, admitted to an OSH with severe acute
pancreatitis/pseudocyst, complicated by cardiac arrest, and ARDS
transferred for further management. The patient was treated in
the [**Hospital1 18**] ICU for approximately two weeks without recovery of
neurologic function. During that time, he was treated for ARDS,
severe pancreatitis, acute renal failure (with CVVHD and then
HD), anemia, and altered mental status. The patient remained
unresponsive after weaning sedation, and the patient's family
agreed that he should be made comfort measures only given that
his severely depressed mental status was due to anoxic brain
injury. This conclusion was established with the aid of
Neurology consultants. At that time, the patient was transferred
out of ICJ to the general medicine floor. He passed away on [**5-12**], [**2142**].
Medications on Admission:
1. Amlodipine 10 mg daily
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Lisinopril 40 mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Anoxic brain injury secondary to cardiac arrest
Necrotizing pancreatitis
Alcohol abuse
Renal failure
Adult respiratory distress syndrome
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2143-5-13**]
ICD9 Codes: 5845, 5070, 2768, 2875, 4275, 4019, 2449, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 59
} | Medical Text: Admission Date: [**2166-4-9**] Discharge Date: [**2166-4-18**]
Date of Birth: [**2108-8-25**] Sex: M
Service: Fernard Intensive Care Unit
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 405**] is a 57-year-old
male who presented to [**Hospital 1474**] Hospital on [**2166-4-8**] with
hematemesis. The patient was treated with transfusions and
octreotide. Esophagogastroduodenoscopy was done with
unsuccessful therapeutic treatment of upper gastrointestinal
bleed.
The patient was transferred to [**Hospital1 188**] [**2166-4-9**], with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] for transjugular
intrahepatic portosystemic shunt procedure.
Indications included gastric variceal bleed that was
refractory to endoscopic treatment. The patient was
electively intubated prior to transfer.
On [**2166-4-10**], the patient had a transjugular intrahepatic
portosystemic shunt procedure complicated by innominate vein
perforation right internal mammary artery bleed with
hemothorax. The patient was taken to the operating room for
sternotomy with repair of vascular lesions. The patient was
stabilized, and a chest tube placed. The patient required 12
units of packed red blood cells, and 4 units of platelets,
and 4 units of fresh frozen plasma.
After initial period of stability, the patient became
increasingly hypotensive from [**2166-4-12**] to [**2166-4-14**]
requiring pressor support. A Swan-Ganz catheter was placed
and his systemic vascular resistance was decreased, and the
cardiac output and index were increased. The patient was
transferred to the Fernard Intensive Care Unit for further
care given picture of sepsis.
Of note, his packed red blood cell requirement has been
3 units per day over three days and has stopped bleeding
clinically. There was no nasogastric tube output. The
patient still had [**Last Name (un) **] tube in place. The patient is
paralyzed due to difficulty with ventilation postoperatively.
In the operating room on [**4-10**], the patient had an episode
of hypotension for about one to three minutes.
PAST MEDICAL HISTORY:
1. Cirrhosis.
2. Status post esophageal variceal bleed.
3. Status post transjugular intrahepatic portosystemic shunt
which was unsuccessful.
4. Status post innominate vein and right internal mammary
artery laceration with resultant hemothorax.
5. Status post sternotomy as described.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER: Medications on transfer from
Surgical Intensive Care Unit were octreotide 50 mcg q.d.,
insulin drip, Dilaudid drip, Ativan drip, oxacillin 2 g
q.6h., levofloxacin 500 mg intravenously q.d., Flagyl 500 mg
intravenously t.i.d., Protonix 40 mg intravenously b.i.d.,
Cisatracurium 80 mcg/kg per hour, Neo-Synephrine drip.
PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure
was 110/50, pulse was 80, temperature was 37. The patient
was on ventilatory support on AC 550 X 12 with an FIO2
of 60%, and positive end-expiratory pressure of 20.
Swan-Ganz catheter readings as follows: Central venous
pressure 22, pulmonary artery pressure 44/19, cardiac output
of 7.8, cardiac index was 3.95, systemic vascular resistance
was 522. Ins-and-outs 2700 in and 1800 out; 1300 of that
urine. In general, the patient was intubated and sedated.
Pupils were small and reactive. Neck revealed left internal
jugular in place; the site looks clean. The oropharynx was
clear. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was in place; some purulent green
discharge noted. Chest revealed fair breath sounds
bilaterally, positive rhonchi throughout. Cardiovascular had
a regular rate and rhythm. No murmurs, rubs or gallops.
Abdomen was soft, decreased bowel sounds. Extremities were
warm with fair pulses distally. Skin had no rash. Right
radial and femoral lines with no purulent discharge noted
from either line.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count was 13.4 (decreased from 19.6), hematocrit was 33.4,
platelets were 146. PT was 15.4, PTT was 42.2, INR was 1.7.
Chemistry-7 significant for a creatinine of 1.5 (increased
from baseline of 1). Albumin was 2.7, phosphate was 4.5,
magnesium was 2.1. ALT was 19, AST was 32, alkaline
phosphatase was 108, total bilirubin was 13.1 (increased from
admission of 6). Urine sodium was 19 on [**2166-4-11**].
Arterial blood gas revealed 7.4, PCO2 was 34, PO2 was 135,
unknown FIO2, lactate was 3. Blood cultures revealed no
growth to date so far. Sputum was positive for
methicillin-sensitive Staphylococcus aureus.
RADIOLOGY/IMAGING: A chest x-ray revealed bilateral
infiltrates suggestive of congestive heart failure.
HOSPITAL COURSE: In summary, this is a 57-year-old male with
recent gastric variceal bleed, status post unsuccessful
transjugular intrahepatic portosystemic shunt complicated by
hemothorax and innominate vein injury requiring
thoracotomy, now hypotensive on pressors requiring increased
FIO2 and positive end-expiratory pressure to maintain
oxygenation.
His Swan-Ganz catheter numbers and physical with complete
blood count and increased white blood cell count with left
shift were suggestive of sepsis. The patient was paralyzed
due to difficulty with ventilation postoperatively. The
patient seemed to no longer bleeding from his varices.
1. PULMONARY: Given decreased blood pressure we tried to
decrease the positive end-expiratory pressure as tolerated
and tried to wean off the paralytics. The patient was also
given fluid to maintain his blood pressure. Diuresis was not
an option given decreased blood pressure. A Swan-Ganz
catheter was placed perioperatively and was subsequently
discontinued.
2. CARDIOVASCULAR: The patient was requiring Neo-Synephrine
to increase his blood pressure. We tried to wean the
Neo-Synephrine and add vasopressin; however, this was
unsuccessful.
3. GASTROINTESTINAL: The patient had a stable hematocrit
and no longer had a transfusion requirement. The patient was
continued on Protonix, and the [**Last Name (un) **] tube continued to be
left in. The patient had hyperbilirubinemia; most likely
thought secondary to shocked liver given episode of
hypotension.
4. RENAL: Creatinine had increased to 1.5 and continued to
increase during the hospitalization. It was thought most
likely secondary to hepatorenal syndrome. The patient
continued to maintain a good urine output. On [**4-26**], the
patient was started on octreotide and midodrine given the
possibility of hepatorenal syndrome; however, his creatinine
continued to increase.
5. ENDOCRINE: The patient was maintained on an insulin drip
which was later changed to subcutaneous.
6. HEMATOLOGY: The patient's hematocrit remained stable.
His coagulopathy was most likely secondary to his liver
disease.
7. INFECTIOUS DISEASE: Oxacillin was changed to vancomycin
given that the patient continued to be febrile. It was also
thought that the patient may have a sinusitis secondary to
the [**Last Name (un) **] tube; however, Gastroenterology felt that the
[**Last Name (un) **] tube should be kept in given his recent episode of
upper gastrointestinal bleed.
The patient was continued on vancomycin, levofloxacin, and
Flagyl for general sepsis to cover for sinusitis, and
mediastinitis, and Staphylococcus aureus in the sputum.
8. FLUIDS/ELECTROLYTES/NUTRITION: The patient was initiated
on total parenteral nutrition.
The patient did not significantly improve, and given
worsening renal function, it was thought that the patient's
prognosis was very poor. After a family meeting, the patient
was made do not resuscitate.
On [**4-18**], given the poor prognosis, the family decided to
make the patient comfort measures only. At 11:58, the
patient expired.
CONDITION AT DISCHARGE: Expired.
DISCHARGE DIAGNOSES:
1. Gastric variceal bleed secondary to cirrhosis.
2. Cirrhosis; most likely secondary to ethanol use.
3. Hemothorax secondary to transjugular intrahepatic
portosystemic shunt procedure; status post sternotomy and
stabilization of perforations.
4. Sepsis.
5. Acute respiratory distress syndrome (ARDS).
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2166-8-29**] 11:36
T: [**2166-9-4**] 16:33
JOB#: [**Job Number 40542**]
ICD9 Codes: 5789, 5849, 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 60
} | Medical Text: Admission Date: [**2139-2-17**] Discharge Date: [**2139-2-24**]
Date of Birth: [**2072-4-24**] Sex: M
Service: CT Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old
male who presented with exertional angina. The patient noted
two months of exertional angina and band-like chest pain
radiating to the left arm, relieved with sublingual
nitroglycerin.
On the day of admission, the patient had a stress test and
developed 1.[**Street Address(2) 1755**] elevations inferiorly and [**Street Address(2) 2051**]
depressions from V4 to V6. Imaging showed severe reversible
perfusion defect over the inferior and lateral walls.
Cardiac catheterization was performed, demonstrating 60% to
70% stenosis of the left anterior descending artery, 90% left
circumflex, and 90% right coronary artery with a left
ventricular ejection fraction of approximately 50%.
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes
mellitus. 2. Hypertension. 3. Hypercholesterolemia.
MEDICATIONS ON ADMISSION: Lisinopril 40 mg p.o.q.d.,
lovastatin 20 mg p.o.q.d., hydrochlorothiazide 25 mg
p.o.q.d., amlodipine 10 mg p.o.q.d., metformin 500 mg
p.o.q.d., NPH insulin 36 units q.a.m. and 32 units q.p.m.,
terazosin 1 mg p.o.q.d., Zyrtec 10 mg p.o.q.d., and Ecotrin
p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: On physical examination, the patient
had a heart rate in the 70s, blood pressure 134/71 and oxygen
saturation 98% on two liters. General: Patient was in no
acute distress. Neck: No jugular venous distention.
Cardiovascular: Regular rate and rhythm, I/VI systolic
murmur. Lungs: Clear to auscultation bilaterally. Abdomen:
Soft, nontender, nondistended, positive bowel sounds.
Extremities: No edema.
HOSPITAL COURSE: The patient was admitted to the hospital
and it was decided that he would be taken to the Operating
Room on [**2139-2-19**]. Coronary artery bypass grafting
was performed with a left internal mammary artery to the left
anterior descending artery and saphenous vein grafts to the
obtuse marginal, posterior descending artery and diagonal
three artery. The pericardium was left open and an arterial
line was placed. Two atrial wires were placed. Two
mediastinal and one left pleural tube were placed.
Crossclamp time was 61 minutes.
Postoperatively, the patient was transferred to the Intensive
Care Unit, where he was rapidly extubated. On postoperative
day number one, the Neo-Synephrine drip was appropriately
weaned. The patient was A-V paced. On postoperative day
number one the chest tubes were also removed.
On postoperative day number two, the patient was transferred
to the floor. The Foley catheter was removed on
postoperative day number two. He was atrially paced for the
entire day on posterior day two. On postoperative day number
three, the wires were capped and the patient had a heart rate
of 70 and in sinus rhythm.
Wires were removed on postoperative day number five. The
patient was able to ambulate at level V, was tolerating an
oral diet, and his pain was controlled with oral medications.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
Lasix 20 mg p.o.b.i.d. times seven days.
Potassium chloride 20 mEq p.o.q.d. times seven days.
Lopressor 12.5 mg p.o.q.d.
Percocet one to two tablets p.o.q.4-6h.p.r.n.
Lovastatin 20 mg p.o.q.d.
Amlodipine 10 mg p.o.q.d.
Glucophage 500 mg p.o.q.d.
NPH insulin 36 units q.a.m. and 32 units q.p.m.
Terazosin 1 mg p.o.q.d.
Ecotrin 325 mg p.o.q.d.
Colace 100 mg p.o.b.i.d.
DI[**Last Name (STitle) 408**]E FOLLOW-UP: The patient will follow up with his
primary care physician or cardiologist in three weeks and
with Dr. [**Last Name (Prefixes) **] in four weeks.
DISCHARGE DIAGNOSIS:
Status post coronary artery bypass grafting times four.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2139-2-24**] 11:28
T: [**2139-2-24**] 11:33
JOB#: [**Job Number 29720**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 61
} | Medical Text: Admission Date: [**2153-1-5**] Discharge Date: [**2153-1-11**]
Date of Birth: [**2067-1-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Iodine
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
malaise
Major Surgical or Invasive Procedure:
Percutaneous Chol.
History of Present Illness:
85 yo male w/ h/o Afib, systolic CHF, and recent cholecystitis
treated medically p/w fatigue, poor po intake, and malaise. Upon
questioning he admits to mild ruq pain and chills but no fevers.
He lost ten lbs in the last week due to poor po intake. His son
brought him to the [**Name (NI) **] for evaluation after he had an appointment
at his cardiologist's office.
.
He had been hospitalized through [**2152-12-10**] at an OSH for rx of
cholecytitis afterwhich he developed lower extremity edema and
dyspnea on exertion. He was started on lasix one week ago and
has improved since then. He says that he gets extremely short of
breath after 20 steps. No chest pain.
.
He has had several mechanical falls lately and for this reason,
he is not anticoagulated.
In the ED, initial VS were: 97.8 48 95/76 18 90%. He was given
1.5L ivf. He was treated with azithromycin 500mg iv once,
ceftriaxone 1g iv once, unasyn 3g iv once. Lactate decreased
from 4.6 to 2.2 with fluids. Troponin stable at .03. Surgical
consultation recommends percutaneous cholecystostomy tubes. CT
head
.
Upon transfer to the micu, 98.0, Pulse: 94, RR: 16, BP: 129/72,
O2Sat: 97%, O2. On arrival to the MICU, he had no acute
complaints.
.
Review of systems:
(+) Per HPI
(-) Denie night sweats, recent wt gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
S/P BILATERAL TKR
*S/P ILIAL FRACTURE
ATRIAL FIBRILLATION
AWB DONATION- DEFFERRAL
B12 DEFICIENCY ANEMIA
BLADDER CANCER
CERVICAL SPONDYLOSIS
CHRONIC RENAL FAILURE
GASTROESOPHAGEAL REFLUX
HERNIATED DISC
HYPERCHOLESTEROLEMIA
HYPERTENSION
HYPOTHYROIDISM
MGUS
MITRAL VALVE PROLAPSE
PROCTITIS
PROSTATE CANCER
R SHOULDER DJD
TRANSIENT ISCHEMIC ATTACK
[**2141**] LVEF 25%
Social History:
lives alone but has daily help; no smoking or etoh
Family History:
Mother died of alzheimers dementia
Father died of prostate cancer
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs
[**2153-1-5**] 09:45PM GLUCOSE-136* UREA N-41* CREAT-1.8* SODIUM-141
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15
[**2153-1-5**] 09:45PM CALCIUM-8.1* PHOSPHATE-4.3 MAGNESIUM-2.0
[**2153-1-5**] 12:03PM URINE HOURS-RANDOM UREA N-932 CREAT-99
SODIUM-50 POTASSIUM-68 CHLORIDE-41
[**2153-1-5**] 12:03PM URINE OSMOLAL-595
[**2153-1-5**] 12:03PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2153-1-5**] 04:49AM GLUCOSE-136* UREA N-45* CREAT-2.1* SODIUM-139
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-17
[**2153-1-5**] 04:49AM ALT(SGPT)-55* AST(SGOT)-55* LD(LDH)-255* ALK
PHOS-128 TOT BILI-0.6
[**2153-1-5**] 04:49AM CALCIUM-8.2* PHOSPHATE-4.2 MAGNESIUM-2.0
IRON-38*
[**2153-1-5**] 04:49AM calTIBC-179* VIT B12-740 FOLATE-GREATER TH
FERRITIN-246 TRF-138*
[**2153-1-5**] 04:49AM WBC-8.6 RBC-3.08* HGB-9.9* HCT-30.7* MCV-100*
MCH-32.2* MCHC-32.4 RDW-17.9*
[**2153-1-5**] 04:49AM PLT COUNT-239
[**2153-1-5**] 04:49AM PT-13.4* PTT-20.7* INR(PT)-1.2*
[**2153-1-5**] 01:04AM LACTATE-2.2*
[**2153-1-5**] 12:55AM cTropnT-0.03*
[**2153-1-4**] 08:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2153-1-4**] 08:25PM URINE RBC-1 WBC-10* BACTERIA-MANY YEAST-NONE
EPI-0
[**2153-1-4**] 08:25PM URINE MUCOUS-RARE
[**2153-1-4**] 06:25PM LACTATE-4.6* K+-4.8
[**2153-1-4**] 06:25PM HGB-11.3* calcHCT-34
[**2153-1-4**] 06:12PM PT-14.7* PTT-24.4* INR(PT)-1.4*
[**2153-1-4**] 06:12PM PLT COUNT-267#
[**2153-1-4**] 06:12PM cTropnT-0.03*
[**2153-1-4**] 06:12PM LIPASE-33
Brief Hospital Course:
BRIEF HOSPITAL COURSE: This is an 85 year old gentleman with a
history of atrial fibrillation, systolic heart failure and
recent medically treated cholecystitis who presented with
recurrent cholecystitis that was treated with percutaneous
drainage and antibiotics. His hospital course was complicated
by delirium and mild pulmonary edema.
.
ACTIVE ISSUES:
ACUTE CHOLECYSTITIS: Mr. [**Known lastname 79**] presented with right upper
quadrant pain and nausea and fatigue. Labs significant for
normal LFTs. RUQ ultrasound demonstrate dacute cholecystitis.
Suurgery was consulted and recommended percutaneous drainage of
his gallbladder which was carried out by IR. Initial pus was
drained from the gallbladder which transioned to bilious
drainage on Day # 2 of admission. He was covered with Vancomycin
and Zosyn initially. Culture data from the biliary drain grew
ecoli sensitive to ciprofloxacin. Antibiotic therapy was changed
to ciprofloxacin and metronidazole to include anaerobic coverage
for a total of 14 days. His biliary drain was kept in place
with plan for discontinuation by general surgery in [**5-25**] weeks.
He was afebrile for the duration of his hospital course.
.
CONGESTIVE HEART FAILURE: On admission he was noted be dyspneic.
An initial chest xray was concerning for right lower lobe
pneumonia that could not be ruled out in the setting of
pulmonary edema. He was initially on vancomycin and zosyn on
admission to the intensive care unit. While diuresis was
initially held on secondary to concern for acute kidney injury
his pulmonary edema accumulated during his initial hospital
days. He was given IV lasix 20mg twice and restarted on his
home dose of lasix 20mg daily. This dose was uptitrated to 40mg
daily which appeared to better control his volume status and
improved his breathing. An echo demonstrated symmetric left
ventricular hypertrophy with cavity dilation and global systolic
dysfunction suggestive of a non-ischemic pattern with EF 25%. A
low dose ace-inhibitor (lisinopril 5mg) was started and he was
continued on an aspirin and beta blocker. He reported no cough
and was afebrile for the duration of hospitalization. A repeat
chest xray after diuresis revealed no evidence of pneumonia. His
nighttime oxygen saturations were noted to be stably in the low
90s.
.
URINARY TRACT INFECTION: A urine sample from admission was
concerning for infection and culture grew ecoli sensitive to
ciprofloxacin. A repeat UA prior to discharge was clear of
infection.
.
ATRIAL FIBRILLATION: Mr. [**Known lastname 79**] is rate controlled with metoprolol
and anticoagulated with aspirin given fall risk. He was noted
to have heart rates in the 110s with frequent episodes of non
sustained ventricular tachycardia, therfore his metoprolol was
incrased to 50mg three times a day with improvement in the
frequency of NSVT and heart rates in the 60-70s during the day.
Cardiology was consulted and agreed with management changes.
There was a question of whether he was on domperidone in the
past. It was taken off his medication list.
.
DELIRIUM: Mr. [**Known lastname 79**] was noted to have progressive delirium
throughout his hospitalization which was improving prior to
discharge. No pharmacologic agents were required for management.
He had an attentive family at his bedside at all his times.
Repeat infectious work-up including UA, chest xray and cdiff
toxin were negative for infection. His electrolytes were stable.
Etiology attributed to age, dementia and hospitalization
including ICU stay.
.
SPEECH AND SWALLOW: While delirius, Mr. [**Known lastname 79**] was noted to have
small aspiration events with eating and drinking. A speech and
swallow evaluation recommended nectar thickened liquids with
suggested re-evaluation when his delirium clears.
.
INACTIVE ISSUES
CHRONIC KIDNEY DISEASE: His renal function ranged between 1.8
and 2.0 throughout his hospitalization which was just above his
baseline.
.
HYPERTENSION: Well controlled. Furosemide increased to 40mg PO.
Amlodipine was discontined in favor of lisinopril 5mg.
Hydralazine was held on discharge given normotensive. He should
discuss restarting this medication with his primary care
physician after discharge.
.
HYPOTHYROID: He was continued on levothyroxine.
.
VITAMIN D: He was continued on vitamin D.
.
DYSLIPIDEMIA: He was continued on crestor 20mg daily.
.
DEPRESSION: He was continued on wellbutrin 300mg daily.
.
BENIGN PROSTATIC HYPERTROPHY: He was continued on flomax.
.
PAIN: Secondary to frequent falls. He was continued on tylenol
and gabapentin.
.
INSOMNIA: Lunesta was held on admission and should be
reconsidered on discharge.
.
GERD: He was continued on ranitidine and nexium.
.
TRANSITIONAL ISSUES:
- Continue ciprofloxacin and metronidazole for 8 additional days
- Primary care follow-up, Electrolytes should be checked within
1 week as she has started lasix and lisinopril.
- Full Code
Medications on Admission:
tylenol #3 daily prn
furosemide 20mg daily
amlodipine 5mg daily
bupropion 300mg daily
calcitriol .25mcg
domperidone 5mg daily
gabapentin 900mg daily
esmeprasole 40mg daily
eszopiclone (lunesta) 2mg hs
gabapentin 800mg daily
hydralazine 25mg [**Hospital1 **]
levothyroxine 112 mcg daily
metoprolol succinate 50mg [**Hospital1 **]
ranitidine 150mg daily
rosuvastatin 20mg daily
tamsulosin .4mg daily
asa 325
vitamin d
b12 1000mcg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
4. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
5. eszopiclone 2 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
11. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days: day 1 = [**1-5**] (total course 14
days).
13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 8 days: day 1 = [**1-5**] (total 14 days).
14. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
15. gabapentin 800 mg Tablet Sig: One (1) Tablet PO once a day.
16. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 1495**] [**Hospital 122**] Rehabilitation Center
Discharge Diagnosis:
Acute cholecystitis
Urinary tract infection
Atrial fibrillation
Decompensated systolic heart failure
Hypertension
Chronic kidney disease
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:
It was a pleasure taking care of you. You came with the feeling
of fatigue and fever. The reason was that you had inflammation
of your galbladder and urinary tact infection. The tube was
placed into your gallblader so that the bile can drain. We gave
you antibiotics and you recovered.
.
The tube should stay in your gallbladder. Wou will see the
surgeon on [**1-26**] and they will give you further
instructions.
.
We have done the following changes to your medications:
CONTINUE ciprofloxacin 500 mg tbl. twice a day for 8 more days
CONTINUE metronidazole 500 mg tbl. three times a day for 8 more
days
CHANGE furosemide 20 mg po daily to furosemide 40 mg daily
DISCONTINUE dronedorol
DISCONTINUE amlodipine 5 mg daily
START lisinopril 5 mg daily
DISCONTINUE hydralazine 25 mg twice a day
DISCONTINUE ranitidine 150 mg daily
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: FRIDAY [**2153-1-26**] at 10:15 AM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2153-2-7**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2153-3-28**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5990, 5849, 2930, 4280, 2449, 4589, 4240, 2724, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 62
} | Medical Text: Admission Date: [**2166-4-30**] Discharge Date: [**2166-5-9**]
Date of Birth: [**2100-7-6**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Bactrim / Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 y.o. female with PMHx of COPD, esophageal stricture s/p
dilatation in [**Month (only) 404**] who presents with a chief complaint of
falls. Patient reports a long history of falls, with 1 fall each
day for the past 3 consecutive days. She reports some dizziness
occasionally prior to these falls, but otherwise denies prodrome
of chest pain, SOB, palpitations. She reports hitting her head
with her falls, but denies LOC. She also recently fell on her
right chest and has had subsequent pain. She attributes her
falls to decreased vision (has a history of cataracts s/p two
surgeries on the right, many years ago) and is also supposed to
ambulate with a walker, but doesn't always comply. She also
wears 2 liters of oxygen at baseline and has noted that she
occasionally trips over her oyxgen tubing while trying to
ambulate. She thus primarily comes in with a complaint of falls,
but noted a cough productive of yellow/brown sputum for the past
2 months with subjective fevers (sweats) for which she was
further evaluated. She reports her grandchildren as well as a
gentleman in her building as potential sick contacts, but
otherwise denies any recent travel or exposures. She does report
getting her flu shot last year and receiving her pneumovax 2
years ago.
.
In the ED, patient was noted to be tachycardic to the 120s and
hypoxic to 89% on RA. This improved to 96% on NRB after a failed
attempt with nasal cannula. Patient was also noted to have a
lactate of 3.3 and a leukocytosis to 22.8 with a bandemia of 9%.
CXR showed right middle and lower lobe infiltrates, concerning
for PNA and given hypoxia, lactic acidosis and leukocytosis,
patient was started on Levofloxacin and Ceftriaxone. Otherwise,
patient was noted to have acute renal failure from 0.6 to 1.3
and she was given 1 L of NS. Additionally, potassium of 2.4 was
repleted. EKG was performed which was unremarkable, but troponin
x 1 was elevated to 0.05 in the setting of ARF and ASA was
given. Patient was asymptomatic otherwise. Lastly, given history
of recent falls, CT neck and head were performed without
evidence of fracture or bleed. Patient was subsequently admitted
to the ICU for further management of probable pneumonia with
significant hypoxia and bandemia.
.
Upon arrival in the ICU, patient was on NRB, speaking in full
sentences, not in acute distress. She complained of right sided
chest pain due to her fall and also endorsed dysuria and
hematuria. Otherwise, she had no complaints.
Past Medical History:
#Esophageal stricture s/p dilatation by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
#Peptic ulcer disease s/p subtotal gastrectomy and repair of
hiatal hernia with fundoplication in [**2163-8-19**] by Dr.
[**Last Name (STitle) **] for a
nonhealing ulcer
#COPD (no PFTs in OMR)
#GERD
#Depression
#PTSD
#Anemia
#Hyperlipidemia
#C-section x 2 ('[**27**], '[**28**])
Social History:
Lives alone in [**Hospital3 **] in [**Hospital1 3494**] on SSI and
disability. Still continues to smoke an unquantified amount. She
denies alcohol or illicit drugs. She has 3 children, but is
estranged from them. She was the victim of domestic disputes
with her ex-husband, but currently lives alone and feels safe.
Family History:
Asthma (children), brother with depression and PTSD
Physical Exam:
Vitals: T: 99.0, BP: 141/87, P: 110 R: 24 O2: 94% 4L NC.
General: Awake, alert, NAD, speaking in full sentences, no
accessory muscle use.
HEENT: NC/AT; pale conjunctiva, PERRLA, EOMI; OP clear,
nonerythematous
Neck: Supple, no JVD
Lungs: Decreased BS bilaterally, no wheezes, ronchi, crackles
CV: RR, normal S1 + S2, [**1-24**] SM at 2RICs not radiating, no
murmurs, rubs, gallops
Abdomen: Soft, tender to palpation RLQ, no rebound or guarding,
+ BS, old midline surgical incision
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Neuro: Alert, oriented x 2, attention impaired. Pt. unable to
cooperate with a full neurlogical exam. Proprioception appears
to be impaired in LLE, upgoing toes b/l. DTRs 3+ at patella b/l.
Impaired FTN and [**Doctor First Name **].
Pertinent Results:
Labs on admission and discharge:
.
[**2166-4-30**] 05:10PM BLOOD WBC-23.8*# RBC-3.35* Hgb-7.9* Hct-25.8*
MCV-77*# MCH-23.5*# MCHC-30.5* RDW-16.9* Plt Ct-548*
[**2166-4-30**] 07:35PM BLOOD Neuts-72* Bands-19* Lymphs-4* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2166-5-7**] 07:05AM BLOOD WBC-11.6* RBC-3.00* Hgb-7.7* Hct-23.3*
MCV-78* MCH-25.6* MCHC-32.9 RDW-18.3* Plt Ct-431
.
[**2166-4-30**] 05:10PM BLOOD PT-15.8* PTT-33.1 INR(PT)-1.4*
.
[**2166-5-5**] 07:50AM BLOOD Ret Aut-0.3*
.
[**2166-4-30**] 05:10PM BLOOD Glucose-181* UreaN-31* Creat-1.3* Na-136
K-2.4* Cl-95* HCO3-24 AnGap-19
[**2166-5-7**] 07:05AM BLOOD Glucose-122* UreaN-3* Creat-0.5 Na-141
K-3.1* Cl-100 HCO3-33* AnGap-11
.
[**2166-4-30**] 05:10PM BLOOD ALT-11 AST-25 CK(CPK)-794* AlkPhos-122*
TotBili-0.5
.
[**2166-4-30**] 05:10PM BLOOD cTropnT-0.05*
[**2166-5-1**] 12:00AM BLOOD CK-MB-5 cTropnT-0.05*
[**2166-5-1**] 06:15AM BLOOD CK-MB-6 cTropnT-0.03*
.
[**2166-4-30**] 05:10PM BLOOD Calcium-8.7 Phos-2.3*# Mg-2.1 Iron-7*
[**2166-4-30**] 05:10PM BLOOD calTIBC-256* Ferritn-160* TRF-197*
[**2166-5-1**] 06:15AM BLOOD Albumin-2.4* Calcium-7.4* Phos-2.6*
Mg-2.7*
.
[**2166-4-30**] 05:27PM BLOOD Lactate-3.3*
[**2166-5-1**] 01:12AM BLOOD Lactate-1.0
[**2166-5-3**] 04:48AM BLOOD TSH-0.33
.
[**2166-4-30**] 05:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2166-4-30**] 05:55PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2166-4-30**] 05:55PM URINE RBC-0-2 WBC-2 Bacteri-FEW Yeast-NONE
Epi-1
[**2166-4-30**] 10:49PM URINE Eos-NEGATIVE
[**2166-4-30**] 10:49PM URINE Hours-RANDOM Na-LESS THAN
.
[**2166-5-6**] 04:01AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2166-5-6**] 04:01AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2166-5-6**] 04:01AM URINE RBC-45* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
.
Microbiology:
.
[**2166-5-7**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING
INPATIENT
[**2166-5-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING
INPATIENT
[**2166-5-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2166-5-6**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2166-5-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2166-5-6**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2166-5-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2166-5-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2166-5-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
.
[**2166-5-2**] URINE Legionella Urinary Antigen - negative
.
[**2166-5-1**] BLOOD CULTURE Blood Culture, Routine-no growth
[**2166-5-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-mixed
flora
.
[**2166-4-30**] URINE URINE CULTURE-mixed flora
[**2166-4-30**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2166-4-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS PNEUMONIAE}; Anaerobic Bottle Gram Stain-FINAL
EMERGENCY [**Hospital1 **]
[**2166-4-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS PNEUMONIAE}; Aerobic Bottle Gram Stain-FINAL;
Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
.
Blood Culture, Routine (Final [**2166-5-6**]):
STREPTOCOCCUS PNEUMONIAE.
MEROPENEM = 0.016 MCG/ML = SENSITIVE BY E-TEST.
Penicillin SENSITIVE AT 0.032 MCG/ML Sensitivity
testing
performed by Etest.
CEFTRIAXONE SENSITIVE AT 0.023 MCG/ML Sensitivity
testing
performed by Etest.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
ERYTHROMYCIN---------- S
PENICILLIN G---------- S
TETRACYCLINE---------- S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ S
.
Imaging/studies:
.
CXR on admission:
.
FINDINGS: Portable upright AP chest radiograph is obtained.
There is patchy consolidation in the right mid and lower lung,
concerning for right middle and lower lobe pneumonia. The left
lung appears essentially clear.
Cardiomediastinal silhouette appears grossly unremarkable. There
is no
pneumothorax. Bony structures appear intact.
.
IMPRESSION: Findings concerning for right middle and lower lobe
pneumonia.
.
ECG on admission: Sinus tachycardia, rate 118. Low voltage in
the standard leads. Left atrial abnormality. Compared to the
previous tracing of [**2165-8-28**] sinus tachycardia is new as is
borderline first degree A-V block.
.
CT head on admission:
.
NON-CONTRAST HEAD CT: There is no hemorrhage, edema, mass
effect, or acute
large vascular territory infarction. There is extensive
periventricular white
matter hypodensity, consistent with sequelae of small vessel
ischemic disease.
There is mild prominence of sulci and ventricles, likely
secondary to global
parenchymal atrophy. There is no shift of normally midline
structures. The
basilar cisterns are preserved. Osseous structures and
surrounding soft
tissues, including the globes and orbits, are unremarkable. The
left lens
appears prosthetic. The visualized paranasal sinuses and mastoid
air cells
are normally pneumatized and clear.
IMPRESSION:
1. Global parenchymal atrophy and sequelae of small vessel
ischemic disease.
2. No hemorrhage, edema, mass effect, or acute large vascular
territory
infarction.
.
CT neck on admission:
.
IMPRESSION:
1. No fracture or malalignment.
2. Mild multifocal cervical spondylosis with no evidence for
canal stenosis.
3. Biapical pleural scarring.
.
CT chest [**5-1**]:
.
IMPRESSION:
1. Findings most consistent with multifocal pneumonia without
evidence of
cavitation. Partial right middle and left lower lobe atelectasis
and small
bilateral pleural effusions.
2. Boarderline enlarged mediastinal lymph nodes, likely reactive
in nature.
3. 2.6-cm benign-appearing left adrenal lesion.
.
CXR [**5-2**] -
.
Since yesterday, right mid and lower lung opacity increased.
Left upper and
mid lung opacity also increased, very worrisome for rapidly
progressing
multifocal pneumonia, could be Legionella. Small left pleural
effusion also
increased. Tiny right pleural effusion is unchanged. The
cardiomediastinal
silhouette and hilar contours are otherwise normal
.
ECHO [**2166-5-5**]:
.
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus and
arch levels are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No valvular pathology or
pathologic flow identified.
.
CXR [**5-5**]: IMPRESSION: Right upper and right middle lobe
pneumonia, not significantly
changed. Small right pleural effusion.
.
CT chest [**2166-5-6**]
.
IMPRESSION:
1. Consolidation in the left lung has almost completely
resolved.
2. Consolidations in the right middle lobe and right upper lobe
with new
areas of cavitation are present.
3. Unchanged left adrenal lesion.
4. Persistent slight decreased small effusions, greater on the
right side.
Brief Hospital Course:
65 y.o. female with PMHx significant for COPD and esophageal
stricture, s/p dilatation in [**Month (only) 404**] who presents with
multifocal Streptococcal PNA, sepsis.
.
Brief ICU course:
.
She was diagnosed w/ PNA via CT and w/ S. pneumococcal
bacteremia ([**2-19**] BCx [**4-30**]). She was started on IV CFTX and
Levaquine. Her BCx had been negative since starting CFTx and
Levofloxacin, but she had a persistent WBC count and low grade
fevers. She was treated w/ ABx as above, and her last fever was
noted on [**5-1**] of 101F prior to transfer to the floor, but she
has had low grade 100 fevers since admission. Her oxygen
requirement improved to 4L NC and her RR decreased to 18-22.
Pt. was also noted to have a microcytic anemia of unclear
etiology, with nadir HCT of 18, transfused 2 U prbcs and has
since been HD stable w/ HCT in mid 20s. Finally, patient has
been tachycardic in 100s - 110s, in sinus rhythm. This was felt
to be due to sepsis. She was transferred to the medical floor
on for further management.
.
Her course was complicated by worsening WBC and fever while on
the medical floor with RML consolidation developing cavitations,
and multiple loose stools. Please see below for detailed
discussion of each of the problems.
.
# PNA and S.Pneumo Sepsis. Infiltrates were felt to be due to
CAP with resultant bacteremia (strep pneumo). Pt. had persistent
leukocytosis. There was no aspiration noted with Video
swallow, however she was noted to have penetration of thin
liquids. She was continued on CFTX on the floor. However, on
[**5-6**], developed Fever, and increasing O2 requirement. She was
again pancultured and a CT was repeated showing improved L
consolidation, slight improvement on the right but new air
loculations. Due to concern for empyema (staph or strep), her
ABx regimen was broadened to Vancomycin and Zosyn for treatment
of HAP and Aspiration PNA. Patient remained HD stable. Due to
wheezing on exam, she was started on standing ipratropium and
albuterol nebulizers. With this treatment, her WBC continued to
improve, and her O2 requirement resolved. She had an an episode
of fever on [**5-6**] to 101.3F. CT chest was obtained and showed
improved infiltrate on L and R, but newe air loculation. She
was broadened to Vanco/Zosyn for one day but defervesced prior
to these ABx being administered. Pulmonary team was consulted
regardging bronchoscopy, and it was decided that in face of
clinical improvement and likelyhood of the cavitation being [**1-20**]
Strep Pneumo and/or anaerobes (too short of a course for Staph
to have developed cavitation in < 24hrs if VAP). She was
switched to Cefpodoxime PO and Flagyl PO for 2 weeks (day 1 =
[**5-8**], pt had already received 7 days of either CFTX/Levofloxacin
or Vanc/Zosyn) for a total course of 3 weeks. She will require
a follow up CXR by end for 2 weeks (last day [**2166-5-22**]). PCP
follow up is arranged for [**5-19**]. Please fax this summary and any
rehab course notes to PCPs office prior to discharge. She will
require weaning of nebulizers and restarting of home advair and
starting of tiotropium for her COPD.
.
# Leukocytosis: Likely reactive from pulmonary infection vs.
C.diff. as patient with loose stools and was on ABx > 5d prior
to onset of diarrhea. Given high grade bacteremia and new
murmur, TTE was obtained and did not show vegetations. Her
first C.Diff was negative but she was tx empiricaly with PO
Vanco given persistently loose stools and Age > 65. Her UA/UCx
were negative. C.Diff retunred negative x3 and PO vanco was
discontinued [**5-8**] after 2 days of tx. She was started on Flagyl
as above. She remained afebrile since [**5-5**] and her WBC was 11 on
day of discharge. She had persistent [**Last Name (un) 940**] stools, but of lower
frequency, 5 -> 3/day.
.
# Anemia, microcytic. Hct at baseline, 29-30. Currently HCT
23-25, same as on admission s/p 2U PRBCs. Pt. has hx of iron
deficiency anemia, confirmed on labs in [**2162**]. Previously was on
iron that was stopped for unclear reasons. No colonoscopy in our
system, but patient has had a history of UGI bleed, last EGD was
unremarkable. Guaiac negative in the ED. There were no signs of
hemolysis. Anemia was felt to be multifactorial (ACD, Fe
defficiency). Per discussio w/ PCP, [**Last Name (NamePattern4) **]. [**Doctor First Name 111639**], she
was reported to have had a colonoscopy that revealed 12 cm of
colitis, showing acute on chronic inflammation, with ? of
chronic ischemia. Her HCT upon discharge was 25 and stable.
She will require a repeat outpatient colonoscopy and endoscopy.
.
# Elevated Troponin: In the setting of renal failure with normal
EKG and asymptomatic. Troponins trended down, and there were no
CK elevations. Likely due to demand. No signs of HF, EF > 60%,
no WMA. She was continued on ASA 81mg.
.
# PTST/Depression: Contact[**Name (NI) **] patient's outpatient provider and
confirmed diagnoses of PTSD and Depression. Patient has been
actively obtaining treatment as OP prior to admission. She had
two episodes of emotional lability and crying spells. Her
attention was impaired (felt to be due to delerium in setting of
infection). Patient probably had underlying dementia (global
parenchymal atrophy and periventricular white matter disease on
CT head), however this could not be evaluated in setting of
delirium. She was continued on Celexa, Quetiapine and
Duloxetine at home doses. Her ativan was temporarily held due
to delerium but was restarted at 2mg [**Hospital1 **]. Her home dose is 2mg
[**Hospital1 **] and 4mg QHS, which can be restarted prn as pt is remains
stable.
.
# S/P Falls: Appears multifactorial - decreased vision,
non-compliance with walker, complicated by oxygen tubing
tripping and likely acutely worsened in the setting of impending
infection prior to admission. CT head and c-spine without
bleeding or fractures. Per PT will require acute level
rehabilitation.
.
# Poor nutritional status. Pt. denies poor PO intake, but
Albumin is 2.4. Noted to have poor PO intake by nursing staff in
CCU. Has hx of esophageal stricture. Was started on Ensure
supplementation TID.
.
# Code: FULL (confirmed with patient)
.
# Communication: Patient is currently at odds with her children
and would prefer that communication be done with her SW - [**First Name8 (NamePattern2) 51796**]
[**Last Name (NamePattern1) 111640**] at [**Street Address(2) 111641**] in [**Location 17065**]. She is in counseling
with this SW and reports a history of domestic violence in the
past. She currently feels safe now. She has only allowed staff
to speak with her son. Finally, Pt reports she is in the
process of being evicted, and states she does not want her
family to know. She said case manager at Elder Services has been
helping to deal with eviction problem, and consented to this SW
calling her (Anjale [**First Name9 (NamePattern2) 111642**] [**Hospital1 8**] [**Hospital1 3494**] Elder Services
[**Telephone/Fax (1) 16681**]).
Medications on Admission:
1. Combivent
2. Citalopram 40 mg PO QD
3. Advair 250-50 mcg [**Hospital1 **]
4. Lorazepam 2 mg PO QID and 4mg QHS
5. Pantoprazole 40 mg PO BID
6. Quetiapine 300 mg PO QHS and 200 mg QPM.
7. Duloxetine 30 mg PO QHS
8. Albuterol PRN
9. Mesalamine (in OMR, but patient can't recall if still taking)
10. Ondansetron 4 mg PO Q8 PRN
11. Aspirin 325 mg
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
3. Quetiapine 300 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO HS (at bedtime).
4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QPM as needed
for insomnia.
5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO HS (at bedtime).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
9. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Ativan 2 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for insomnia, anxiety: Hold for sedation.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Pain.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 weeks.
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 2 weeks.
16. Acetaminophen 500 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours) as needed for pain.
17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
18. Outpatient Lab Work
CBC, Chem 10 within 1 week of discharge from the hospital
19. Imaging
Patient will require a CXR after completion of ABx and results
faxed to PCP's office to confirm resolution of PNA.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2251**] Nursing and Rehab
Discharge Diagnosis:
Primary: Streptococcal sepsis, multifocal community acquired
pneumonia
Secondary: COPD, PUD, Esophageal stricture, Anemia, PTSD
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] with severe pneumonia and bacterial
in your blood. For this you were treated with intravenous
antibiotics. With this treatment your breathing improved. You
were transitioned to by mouth antibiotics.
Your course was complicated by worsening anemia (low blood cell
count) that require blood transfusions. After transfusions,
your blood levels remained stable. You will require an
outpatient colonoscopy and endoscopy.
Several changes were made to your medications, please refer to
the list below and take these medications as prescribed.
You should have an outpatient colonoscopy to evaluate your
anemia. Your PCP or your GI doctor can arrange this for you.
Please call your doctor or return to the nearest emergency room
for: recurrent nausea/vomiting, dehydration, blood in your
vomit, chest pain, bloody stools, shortness of breath, chest
pain, abdominal pain,
fainting, fevers, chills, cough, or any other concerning
symptoms.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2166-9-22**] 12:30
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2166-9-22**] 12:30
Please follow up with your psychiatrist, Dr. [**First Name (STitle) **] on [**First Name9 (NamePattern2) 111643**]
[**2168-5-27**].30 am, please call to confirm your appointment,
[**Telephone/Fax (1) 111644**].
Please follow up with your primary care doctor, [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) **]-[**Doctor First Name **], on [**2166-5-19**] at 11.30 am. Please call
[**Telephone/Fax (1) 14315**] to confirm your appointment. Should you be in
rehabilitation at time of your PCPs appointment, please change
this to acommodate with your discharge from rehabilitation.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2166-5-9**]
ICD9 Codes: 5849, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 63
} | Medical Text: Admission Date: [**2198-9-7**] Discharge Date: [**2198-9-11**]
Date of Birth: [**2117-12-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins / Erythromycin Base / Morphine
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
hypotension s/p syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 year old woman with a history of COPD, HTN, CRI who presents
with syncope and hypotension. She reports a recent over the past
5 days with whitish phlegm which turned green 1 day prior to
admission. She denies fevers, chills or night sweats. According
to the patient she awoke this morning to the sound of someone
knocking on the door and the phone ringing. She went to get up
and slid from her bed to the floor. She denies hitting her head
or losing consciousness. She states her legs gave out on her.
She report her legs given out 2 other times in the past. She
denies dizziness, lightheadedness, palpitations. According to
her daughter she was found by the concierge at her home on the
floor with vomit and urine and her fall was not witnessed. She
denies losing her urine and does not recall if she vomited. EMS
was called. Initial vitals by EMS were BP 120/70 O2 sats 95% on
NRB.
.
In the ED, initial vs were: T97.4 HR77 BP71/31 RR20 O2sats 93 on
4L NC. Patient was given 4L NS for resuscitation. A FAST scan
was done showing a 3.8cm AAA. Given her AAA and hypotension, a
vascular surgery consult was called. She underwent non-contrast
CT torso which showed a LLL infiltrate. Vascular surgery was not
concerned about the AAA. She was given 1gm CTX, 750mg
Levofloxacin and 500mg Flagyl. Blood pressures improved to the
mid-90s but then started to trend down. A R femoral CVL was
placed and she was started on Levophed. Lactate was 2.2. She was
found to be in acute renal failure with a creatinine of 2.6.
Potassium was 5.6. Her WBC was 19.1 with 13% bands. INR was
noted to be 4.3. Blood cultures were obtained.
.
On arrival to the ICU she complains of cough without significant
shortness of breath. She is otherwise comfortable without pain.
She denies nausea, headache, chest pain, dysuria. Pressors were
weaned, and the patient was transferred to the floor after being
afebrile.
.
Review of sytems:
(+) diarrhea in the past week. she reports diarrhea on and off
for her lifetime.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
- Pulmonary Embolism [**2-25**] on coumadin
- Hypertension
- Hypercholesterolemia
- Monoclonal gammopathy
- COPD
- Arthritis
- Gastrointestinal ulcers
- Gastric esophageal reflux disease
- Kidney stones 55 years ago in the setting of pregnancy
- Elevated PTH
- Chronic renal insufficiency with baseline 1.1 to 1.5
- Abdominal aortic aneurysm measuring 4.2 cm
- Possible pons lacune infart noted on [**1-24**] MR [**Name13 (STitle) 2853**]
- Peripheral Neuropathy of unclear etiology
Social History:
The patient lives alone. She is divorced and her former husband
is now deceased. She has five children. She previously worked as
a laboratory technician at [**Location (un) 86**] State Hospital and an office
manager. She has a 50 pack year smoking history but quit greater
than 25 years ago. She drinks [**2-17**] glasses of wine per day. She
denies use of illicit drugs.
Family History:
The patient's mother died from a myocardial infarction at age
60. Her mother had hyperthyroidism. The patient's father had a
myocardial infarction at age [**Age over 90 **] and a benign brain tumor. She
has a sister with breast cancer. Her daughter has juvenile
rheumatoid arthritis. There is no family history of gastric
disorders or kidney stones.
Physical Exam:
Vitals: T: 98.4 BP: 118/80 P: 81 R: 18 O2: 93% on RA
General: Alert, oriented, elderly female, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: decreased breath sounds on left side, otherwise clear
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
ejection murmur at the LUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
peripheral edema bilaterally, former site of femoral catheter
(now withdrawn) on the right is C/D/I
Neuro: A&O x 3, CNII-XII grossly intact.
Pertinent Results:
Labs
On admission:
[**2198-9-7**] 07:31PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2198-9-7**] 07:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2198-9-7**] 07:31PM URINE RBC-0-2 WBC-[**7-26**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2198-9-7**] 06:30PM URINE HOURS-RANDOM CREAT-96 SODIUM-27
POTASSIUM-98 CHLORIDE-62
[**2198-9-7**] 06:30PM URINE OSMOLAL-440
[**2198-9-7**] 03:51PM K+-5.6*
[**2198-9-7**] 12:42PM LACTATE-2.2*
[**2198-9-7**] 12:20PM GLUCOSE-144* UREA N-49* CREAT-2.6*#
SODIUM-137 POTASSIUM-7.0* CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2198-9-7**] 12:20PM estGFR-Using this
[**2198-9-7**] 12:20PM ALT(SGPT)-47* AST(SGOT)-69* ALK PHOS-65 TOT
BILI-0.3
[**2198-9-7**] 12:20PM LIPASE-18
[**2198-9-7**] 12:20PM cTropnT-<0.01
[**2198-9-7**] 12:20PM ALBUMIN-3.4*
[**2198-9-7**] 12:20PM WBC-19.1*# RBC-3.84* HGB-10.9* HCT-33.2*
MCV-87 MCH-28.5 MCHC-32.9 RDW-14.7
[**2198-9-7**] 12:20PM NEUTS-81* BANDS-13* LYMPHS-1* MONOS-4 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2198-9-7**] 12:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2198-9-7**] 12:20PM PLT SMR-NORMAL PLT COUNT-248
[**2198-9-7**] 12:20PM PT-40.5* PTT-41.4* INR(PT)-4.3*
On Discharge:
[**2198-9-11**] 05:15AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.0* Hct-29.9*
MCV-84 MCH-28.1 MCHC-33.5 RDW-14.3 Plt Ct-260
[**2198-9-11**] 05:15AM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
[**2198-9-11**] 05:15AM BLOOD ALT-31 AST-17
[**2198-9-11**] 05:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.4*
Radiology:
CHEST (PORTABLE AP) Study Date of [**2198-9-7**] 12:18 PM
IMPRESSION: Mild central vascular congestion without overt
failure.
Bibasilar atelectasis. Increased opacity of the retrocardiac
left lower lobe may reflect underlying pneumonia or aspiration.
Correlate clinically.
CT CHEST W/O CONTRAST Study Date of [**2198-9-7**] 12:34 PM
LUNG BASES: There is consolidation and ground-glass
opacification of the
superior segment of the left lower lobe, as well as portions of
the posterior basal segment of the right lower lobe.
CT HEAD W/O CONTRAST Study Date of [**2198-9-7**] 12:33 PM
IMPRESSION: No acute intracranial process.
CT ABDOMEN W/O CONTRAST Study Date of [**2198-9-7**] 12:34 PM
IMPRESSION:
1. No evidence of rupture of the patient's 3.8-cm abdominal
aortic aneurysm. Stability in size maintained.
2. Area of density within the left breast has a lucent center,
and may
represent an intramammary lymph node, fat necrosis, or oil cyst.
Recommend
correlation with mammogram.
3. Stable appearance of adrenal nodule over 5 years, described
above.
4. Status post cholecystectomy, with stable and expected
dilatation of the
common bile duct.
5. Diverticulosis with no evidence of diverticulitis.
US ABD LIMIT, SINGLE ORGAN PORT Study Date of [**2198-9-8**] 1:54 PM
IMPRESSION: Stable common bile duct at approximately 9 mm. The
liver
echotexture is normal and there is no underlying suggestion of
cirrhosis or
other parenchymal disease. No mass lesion identified. There is
no
intrahepatic biliary dilatation. There has been interval
development of a
small right pleural effusion. Known abdominal aortic aneurysm is
stable in
size since yesterday.
BILAT UP EXT VEINS US Study Date of [**2198-9-8**] 1:54 PM
IMPRESSION: No DVT in either upper extremity.
Brief Hospital Course:
80 year old woman with a hx of PE on coumadin, HTN who presents
with syncope, hypotension and likely PNA concerning for sepsis.
.
1. Hypotension: Likely from sepsis given her chest CT findings
of PNA, elevated WBC and cough. She had no fevers. She received
4L NS in the ED but continued to appear clinically dry. Volume
resuscitation was continued in the MICU along with levophed
which was weaned over 24 hours. PNA treatment was begun with
with ceftriaxone and levofloxacin, but was later switched to
cefpodoxime and levofloaxin, for a total 8 day course.
Patient's blood pressure on the floor was normotensive, although
we continued to hold her home medications of HCTZ, Amlodipine,
and Benzepril, and discharged her with instructions to follow-up
with her PCP if she should resume this medications.
.
2. Acute Renal Failure: Prior kidney function 1.2. Patient made
good urine throughout her hospitalization. Her creatinine peaked
at 2.6 and trended down to a nadir of 1 upon discharge with
volume resuscitation and holding nephrotoxic meds.
3. UTI: On [**2198-9-7**], the patient was noted to have a UTI on urine
culture from E. Coli, which was sensitive to ceftriaxone. As the
patient was being treated for PNA with ceftriaxone and
levofloxacin, we did not change her antibiotic regimen, which
should appropriately cover her for an uncomplicated UTI.
.
3. Hyperkalemia: Felt to be secondary to acute renal failure in
the setting of taking potassium and triamterene and benazepril.
ECG without peaked T waves. Offending meds were held during the
hospitalization, and were held until patient can follow-up with
her primary care physician. [**Name10 (NameIs) **] patient's hyperkalemia improved
with aggressive IV fluid resusitation, and her discharge K was
4.0.
.
4. Syncope: Likely from hypotension, hypovolemia. It is
concerning that the patient lost urine but not other signs of
seizure activity during her stay in the MICU or on the floor.
The patient was monitored on tele without event. An EEG was not
done.
.
5. Elevated INR: Likely due to infection and coumadin use. No
signs of active bleeding. Would expect INR to rise with recent
antibiotics. Coumadin was initially held and then restarted
prior to discharge, with an INR on discharge of 2.7.
.
Code: Full (discussed with patient)
Medications on Admission:
Hydrochlorothiazide 25 mg Tab PO daily
Bisoprolol Fumarate 2.5 mg Tab PO daily
Omeprazole 40 mg Cap, Delayed Release 1 tab PO Daily
Klor-Con 8 mEq Tab 1 tab PO BID
Amlodipine 5 mg Tab 1 tab PO daily
Benazepril 40 mg Tab PO daily
Multivitamin Tab 1 tab PO daily
Triamterene 50 mg PO daily
Simvastatin 80mg PO daily
Trazadone 100-150mg PO qHS PRN - has not taken this in the past
few day but perhaps monday, tuesday and wednesday
Coumadin alternating 1.5mg with 2mg this week
Gabapentin 100mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Sepsis secondary to Community Acquired Pneumonia
Urinary Tract Infection
.
Secondary Diagnoses:
Hx Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU for low blood pressure in the
setting of pneumonia. You were treated with IV fluids and
antibiotics and your symptoms improved. You should complete a
total of 8 days of antibiotics, and follow-up with your PCP.
.
We made the following changes to your home medications:
-Start Cefpodoxime - continue for 6 more days to end on [**2198-9-16**]
-Start Levofloxacin - continue for 6 more days to end on [**2198-9-16**]
(this is an every-other-day medication).
-STOP Hydrochlorothiazide, Amlodipine, Benazepril, Triamterene
and Klor-Con until you see your PCP on [**Name9 (PRE) 2974**]. He will decide
if you should resume this medications.
-CHANGE Coumadin to 1.5 Mg daily for this week - please have
your INR drawn tomorrow, Wednesday the 28th at your PCP's
office.
Followup Instructions:
Please have your INR drawn tomorrow at your PCP's office. You
have an appointment to see your PCP on [**Name9 (PRE) 2974**]:
Name: [**Last Name (LF) 7726**],[**First Name3 (LF) 177**] A.
When: FRIDAY, [**2198-9-14**]:30 AM
Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 7728**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 0389, 5849, 486, 5990, 5859, 2767, 496, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 64
} | Medical Text: Admission Date: [**2117-7-22**] Discharge Date: [**2117-7-31**]
Date of Birth: [**2036-6-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
EGD
Central venous line access
History of Present Illness:
This is a 81 year old female who presented to an outside
hospital 3 weeks prior to admission with nausea, vomiting,
diarrhea, and abdominal pain. She was diagnosed with cirrhosis
of unknown etiology; she was negative for hepatitis,
hemachromatosis, and history of alcoholism. Her symptoms
improved and she was discharged. She presented to [**Hospital1 18**] with
similar symptoms. CT scan of the abdomen demonstrated complete
thrombosis of the SMV with partial thrombosis of the main PV and
intrahepatic left and right portal veins and multiple abnormal
loops of small bowel in the pelvis with wall thickening.
Patient was started on heparin drip. Foley & NGT were placed.
She received vancomycin & Zosyn in the ED, which was switched to
Cipro and Flagyl on admission to the ICU.
Past Medical History:
hypertension
cirrhosis
osteoarthritis
dyslipidemia
h/o ureteral stone
seborrheic keratosis
thrombocytopenia
appendectomy
herpes zoster
GERD
osteopenia
depression
hip replacement
cellulitis
Social History:
She denies EtOH, tobacco, and illicit drug use. She denies
herbal and over-the-counter medications.
Family History:
aunt with ovarian ca
daughter with breast ca in 50s
no family history of liver disease
Physical Exam:
per Dr. [**Last Name (STitle) **] on initial presentation:
98.1 65 145/61 20 98% 4L
gen: minimally response
CV RRR
pulm: CTAB
abd: soft, nondistended, mildley tender on right
rectal: heme pos
Pertinent Results:
Admission labs:
137 105 15
-------------< 117
3.7 21 0.7
Ca: 9.4 Mg: 1.7 P: 2.6
ALT: 25 AP: 271 Tbili: 2.0 Alb: 3.2
AST: 32 LDH: Dbili: TProt:
[**Doctor First Name **]: 52 Lip: 54
.
12.9
9.9 >-----< 165 D
41
N:85.3 Band:0 L:9.7 M:3.7 E:0.9 Bas:0.4
.
Trends and discharge labs:
[**2117-7-31**] 06:45AM BLOOD WBC-5.7 RBC-3.16* Hgb-10.1* Hct-30.7*
MCV-97 MCH-32.0 MCHC-32.9 RDW-16.2* Plt Ct-PND
[**2117-7-26**] 05:06AM BLOOD PT-19.5* PTT-67.8* INR(PT)-1.9*
[**2117-7-27**] 06:00AM BLOOD PT-21.1* PTT-62.3* INR(PT)-2.0*
[**2117-7-28**] 05:21AM BLOOD PT-21.5* PTT-93.3* INR(PT)-2.1*
[**2117-7-29**] 05:03AM BLOOD PT-20.7* PTT-33.5 INR(PT)-2.0*
[**2117-7-30**] 06:15AM BLOOD PT-20.6* PTT-33.0 INR(PT)-2.0*
[**2117-7-31**] 06:45AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-134
K-3.4 Cl-98 HCO3-33* AnGap-6*
[**2117-7-22**] 06:05AM BLOOD ALT-25 AST-32 AlkPhos-271* Amylase-52
TotBili-2.0*
[**2117-7-23**] 02:15AM BLOOD ALT-17 AST-26 LD(LDH)-231 AlkPhos-193*
Amylase-36 TotBili-0.8
[**2117-7-24**] 01:57AM BLOOD ALT-17 AST-21 LD(LDH)-202 AlkPhos-171*
Amylase-28 TotBili-0.6
[**2117-7-25**] 05:30AM BLOOD ALT-15 AST-21 LD(LDH)-191 AlkPhos-164*
Amylase-27 TotBili-0.7
[**2117-7-26**] 05:06AM BLOOD ALT-15 AST-25 AlkPhos-159* Amylase-46
TotBili-0.8
[**2117-7-27**] 06:00AM BLOOD ALT-13 AST-26 LD(LDH)-213 AlkPhos-151*
Amylase-45 TotBili-0.8
[**2117-7-28**] 05:21AM BLOOD ALT-16 AST-31 AlkPhos-156* TotBili-1.0
[**2117-7-29**] 05:03AM BLOOD ALT-15 AST-34 AlkPhos-179* TotBili-0.8
[**2117-7-27**] 06:00AM BLOOD Albumin-2.1* Calcium-7.9* Phos-2.8 Mg-2.1
[**2117-7-24**] 06:21AM BLOOD Lactate-1.4
.
CT Abd/Pelvis ([**2117-7-22**])
IMPRESSION:
1. Complete thrombosis of the superior mesenteric vein with
partial thrombosis of the main portal vein and intrahepatic left
and right portal veins.
2. Multiple abnormal loops of small bowel within the pelvis with
wall thickening. This likely represents venous congestion from
thrombosis of the mesenteric veins. An enterocolitis
(inflammatory/infectious) with secondary thrombosis of the
mesenteric veins is also a possibility. The mesenteric arteries
are patent; however, mesenteric ischemia from venous congestion
cannot be excluded.
3. Shrunken, nodular liver, esophageal varices and ascites, all
compatible with cirrhosis.
.
CT Abd/Pelvis ([**2117-7-27**])
IMPRESSION:
1. Stable thrombosis of the portal vasculature including partial
thrombosis of the main portal vein, complete thrombosis of the
left portal vein, partial thrombosis of the right portal vein,
complete thrombosis of the superior mesenteric vein.
2. Improving multiple small bowel loops with decreased wall
thickening and dilatation.
3. Stable cirrhotic liver.
4. Markedly increased ascites.
.
EGD:
Impression: Grade 1 varices at the lower third of the esophagus
Portal Hypertensive Gastropathy - oozing with blood and causing
melena.
Otherwise normal EGD to second part of the duodenum
Recommendations: Requires:
1) Protonix- 40mg [**Hospital1 **]
2) Carafate - 1gram qid
.
Micro:
c diff neg
stool cx neg
blood cx ngtd
Brief Hospital Course:
81yo woman with cirrhosis here with SMV thrombosis. Hospital
course by problem:
.
#Complete SMV and partial portal vein thrombosis.
SMV and portal vein thromboses demonstrated on CT of [**7-22**] which
was repeated on [**7-27**] showing little change. Hepatobiliary
Surgery was consulted urgently in the ED for management of SMV
thrombosis with ischemic bowel. Serial abdominal exams were
benign. Lactate peaked at 1.5 on [**7-22**]. She had episodes of
melena on [**7-17**], but remained otherwise asymptomatic. She was
in the ICU for close monitoring then transferred to the floor on
[**7-25**]. NGT was removed and Coumadin was started. On [**7-26**], her
diet was advanced and she was transferred to Hepatology for
further management of newly diagnosed cirrhosis. We continued
heparin and coumadin until INR was 2.0 for two consecutive days.
She received coumadin as follows: 1mg, 1mg, 1mg, 2mg, 2mg, 2mg
and discharged on 2mg daily. Her HCT remained stable. She will
followup with Dr. [**Last Name (STitle) **] in the liver clinic. [**Last Name (STitle) 18303**] INR is [**2-20**].
.
#GI Bleeding
Patient had guaiac positive stools and underwent an EGD to
assess for varices which showed no active bleeding but had
portal gastropathy which was thought to explain the patient's
melena. Melena may also have come from venous congestion in
small bowel as a result of SMV thrombosis. Repeat CT scan
showed resolving venous congestion. HCT dropped 5.5 points from
41 to 34.5 from HD0 to HD1 and then to 30 by HD4, it remained
stable after this, without further melena. Ms. [**Known lastname 73649**] had
spotting of red blood on pads and toilet paper which was thought
to be causing persistant guaiac positive stools. Exam confirmed
presence of hemorrhoids but also raised the possibility of
vaginal bleeding, which should be investigated as an outpatient.
Colonoscopy was deferred given likely friable colon in setting
of thrombosis. If BRBPR, we recommend checking hematocrit with
[**Known lastname **] >28. If less than 28, discuss with patient's PCP re
stopping coumadin and need for eval. In terms of the possible
vaginal bleeding, we recommend outpt gynecology appt. We
continued nadolol and PPI and sucralfate.
.
#Cirrhosis/Edema/abdominal pain
Etiology of cirrhosis remains uncertain. Report of
investigations at OSH ruled out common viral and autoimmune
etiologies, and genetic causes would be unlikely to present at
81years of age. NASH remains a possibility, but this should be
investigated further with outpatient hepatology follow up which
has been arranged for Ms. [**Known lastname 73649**].
She has experienced significant fluid retention with ascites and
lower extremity edema, her weight increasing approximately 4kgs.
With Lasix and Aldactone, lower extremity edema has improved
significantly but ascites is persistant.
Ascites has caused intermittent band like upper abdominal pain
which was mostly controlled with oxycodone but occassionally
required 0.5mg dilaudid IV. By time of discharge, pain was
controlled with oral medications alone.
.
# HTN: we regulated with her nadolol, spirono, and lasix. We
did not continue HCTZ
.
# Depression: sertraline
.
# Activity: seen by PT. able to ambulate with assist.
.
# Code: Full
.
# Contact: daughter [**Name (NI) **]: [**Telephone/Fax (1) 100371**]
Medications on Admission:
lorazepam, Darvocet, Fosamax, HCTZ, MVI, Propoxyphene,
ranitidine, sertraline, Zocor
Discharge Medications:
1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Propoxyphene 65 mg Capsule Sig: One (1) Capsule PO every six
(6) hours as needed for pain.
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain for 1 weeks.
Disp:*20 Tablet(s)* Refills:*0*
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
please adjust per recommendations from your PCP. [**Name10 (NameIs) 18303**] INR [**2-20**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Primary:
- SMV thrombosis
- Cirrhosis
- Portal gastropathy
Secondary:
- GERD
- arthritis
- HTN
- Hyperchol
- thrombocytopenia
Discharge Condition:
well. Able to ambulate with assist
Discharge Instructions:
You were admitted with abdominal pain and noted to have an SMV
thrombosis. This is a clot in the vein near your liver. You
also have cirrhosis and some fluid overload. We treated you in
the ICU and you stabilized. We continued heparin and started
coumadin to keep your blood thin. We also performed an EGD to
look for any bleeding in your stomach. You remained stable.
.
Please take all of your medications as instructed. Please keep
your followup appts. It is very important for you to have your
coumadin level checked on Monday and followed closely by your
PCP.
.
Please contact your PCP or [**Name (NI) **] if you experience worsening
shortness of breath, chest pain, abdominal pain, fevers, or
blood loss.
.
You described some possible vaginal bleeding. You should
discuss this with your PCP and possibly see a gynecologist.
Followup Instructions:
Please followup with Dr. [**Last Name (STitle) **] on Thursday [**8-5**] at
11:30am. His office is [**Telephone/Fax (1) **]
.
Please followup with Dr. [**Last Name (STitle) **] on [**8-24**] @ 12:15pm. You
may reach him at ([**Telephone/Fax (1) 1582**].
ICD9 Codes: 5715, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 65
} | Medical Text: Admission Date: [**2165-8-2**] Discharge Date: [**2165-8-5**]
Date of Birth: [**2098-2-18**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dark blood from G-tube
Major Surgical or Invasive Procedure:
EGD-ulcer in the distal esophagus with active bleeding. s/p
clipping of the vessel with good homostasis.
History of Present Illness:
67 yo M with h/o CAD, recently admitted from [**6-21**] to [**7-25**] where
he presented with severe headache, CT notable for large
intracranial bleed. Found to have vertebrobasilar aneurysm, s/p
coiling and stenting, ventriculostomy. Course complicated by L
sided PE and was treated with heparin. Hospital course also
complicated by CHF, failure to wean from vent, s/p trach, PEG
placment. Patient was eventually weaned from vent at end of
hospitalization. On discharge, patient was able to open eyes to
stimulation, and had spontaneous movment of the R side. Patient
was discharged on [**Month/Day (4) **], plavix, heparin gtt. Pt. sent to
[**Hospital3 **]. Came to ED on [**7-26**] with hypotension , sbp in
80s, responded to IV boluses, cleared by N-[**Doctor First Name **] (no change).
On [**8-1**], patient noted to have 50 cc dark blood in G-tube at
rehab. In ED, patient was afebrile, hr-82, bp-121/64. Dark
blood failed to clear with lavage. GI was subsequently
consulted. In ED, hct-30, INR-2.9. Got vit K 5mg sq, IV
protonix, 4 units FFP, 2 large [**Last Name (un) **] IVs placed. CXR showing CHF
opacities or effusions. EKG showing NSR at 90 bpm, nl axis,
IVCD in L bundle pattern, 1-[**Street Address(2) 1766**] depr in V3-6 (old) and TWI
in V3-6, I L (old).
Past Medical History:
-CAD, s/p MI, CABG x 2 in '[**50**] and '[**62**], multiple stents
-htn
-s/p MV annuloplasty in '[**62**]
-s/p AICD
-s/p intracranial bleed [**5-28**], per HPI
-mult L sided PEs ([**6-28**])
-h/o hyponatremia
-VRE pos
-CHF - [**6-28**] echo with EF 30%, moderate regional LV systolic
dysfunction with near AK of inferior and inferolateral walls,
sever HK of anterolat. wall.
Physical Exam:
T 97.6 BP 121/64 P82 RR30 100% 4LNC
Gen: Minimally resonsive, unable to follow commands
HEENT: NC/AT, PERRL 2mm bilaterally
Lungs: +upper airway sounds, no crackles, no wheezing, good air
movement
CV: RRR, nl S1, S2, no murmurs
Abd: Soft, NTND, no withdraw with deep palpation. +G-tube
Ext: no edema, clubbing, cyanosis
Neuro: responds minimally to verbal stimuli, withdraws to pain.
Pertinent Results:
[**2165-8-5**] 04:49AM BLOOD WBC-9.2 RBC-3.52* Hgb-10.6* Hct-32.2*
MCV-92 MCH-30.1 MCHC-32.9 RDW-15.6* Plt Ct-400
[**2165-8-4**] 04:34PM BLOOD Hct-34.2*
[**2165-8-3**] 11:41PM BLOOD Hct-32.5*
[**2165-8-3**] 04:00AM BLOOD WBC-10.0 RBC-3.51* Hgb-10.6* Hct-31.5*
MCV-90 MCH-30.4 MCHC-33.8 RDW-15.6* Plt Ct-379
[**2165-8-2**] 10:42PM BLOOD Hct-28.3*
[**2165-8-2**] 08:13PM BLOOD Hct-29.2*
[**2165-8-2**] 10:03AM BLOOD Hct-23.7*#
[**2165-8-5**] 04:49AM BLOOD PT-14.7* PTT-56.5* INR(PT)-1.4
[**2165-8-4**] 08:16PM BLOOD PTT-39.1*
[**2165-8-4**] 04:32AM BLOOD PT-14.7* PTT-24.2 INR(PT)-1.4
[**2165-8-3**] 04:00AM BLOOD PT-15.2* PTT-26.1 INR(PT)-1.5
[**2165-8-2**] 10:40AM BLOOD PT-16.7* PTT-30.1 INR(PT)-1.8
[**2165-8-2**] 04:15AM BLOOD PT-20.8* PTT-37.0* INR(PT)-2.9
[**2165-8-5**] 04:49AM BLOOD Glucose-117* UreaN-22* Creat-0.4* Na-143
K-3.9 Cl-108 HCO3-27 AnGap-12
[**2165-8-2**] 04:15AM BLOOD Glucose-113* UreaN-26* Creat-0.6 Na-133
K-5.3* Cl-96 HCO3-29 AnGap-13
[**2165-8-4**] 04:32AM BLOOD ALT-28 AST-30 AlkPhos-124*
[**2165-8-3**] 06:45PM BLOOD CK-MB-3 cTropnT-0.07*
[**2165-8-2**] 10:43PM BLOOD CK-MB-4 cTropnT-0.05*
[**2165-8-2**] 04:00PM BLOOD CK-MB-3 cTropnT-<0.01
Brief Hospital Course:
1)Upper GI bleed: Patient was on coumadin for recent hx of PE
and received 4 units of FFP and vit K in the EW to correct his
INR. Coumadin was held intinitally for possible active bleed.
GI was consulted and EGD was done on [**2165-8-2**] which showed an
ulcer in the distal esophagus with active bleeding from that
site. Successful clipping of the vessel was achieved using a
Resolution Endoclip device and then injected with epinephrine
for hemostasis. Patient received total of 3 units of PRBC.
Patient was continued on PPI for prophylaxis and serial
hematocrit was done which remained stable (Hct>30).
2)Neuro: Patient has a hx of intracranial bleed s/p basilar
stent. Patient on Plavix and [**Date Range **] for post-stent prophylaxis.
Patient remained lethargic which is his baseline. He was able
to follow simple commands at times, moving his hands and feet
and occasionally giving verbal response. Per family member,
patient appears to be more alert than before. Neurosurgery
following this patient and strongly urged to hold Coumadin for
the risk of re-bleeding intracranially. After discussion with
Dr. [**Last Name (STitle) 1132**] from neurosurgery, it was decided to discharge patient
with Lovenox.
3)A-fib: During EGD proceduse, clipping of the bleeding vessel
was done and epinephrine was injected to that site. Right after
the epinephrine was injected, he went into rapid afib to 150's
with ST depressions. He was given a total of 10 mg of lopressor
with some decrease in his HR to the 120's-130's. After 10 mg of
IV diltiazem, his HR came down to the 90's-100's and his BP
dropped to the 80's briefly. MI was ruled out with serial
cardiac enzymes and he was given 25 mg of lopressor. Patient
remained on sinus tachycardia, and lopressor was titrated up to
50 mg tid. Patient did show good response to IV diltiazem 10
mg.
4)PE prophylaxis: Patient initially on Coumadin 12.5 mg qd and
Dalteparin 7500 units [**Hospital1 **], but were held due to GI bleed with
INR 2.9 and PTT 37. Neurosurgery seen the patient and strongly
discouraged discontinuing Coumadin due to recent history of
intracranial bleed. However, patient just had PE and is at risk
for another thrombotic event. After discussion with the
neurosrugery attending Dr. [**Last Name (STitle) 1132**], it was decided to discharge
the patient with Lovenox.
5)ID: On [**8-4**] sputum gram stain showed gram positive cooci and
rhonchi on exam. CXR intially appeared as LLL opacity so
Vancomycin 1 g q12 was started. However after reviewing the
film with the team on [**2165-8-5**], CXR was more consistent with
fluid overload with effusion than consolidation. Since patient
is afebrile with normal WBC and not showing symptom of
pneumonia, Vancomycin was discontinued.
Medications on Admission:
protonix 40 qd, senna 2 [**Hospital1 **], epo [**2161**] units q Tu/Sat, amantidine
100 [**Hospital1 **], coumadin 12.5 [**Last Name (LF) **], [**First Name3 (LF) **] 325 qd, lopresor 25 [**Hospital1 **],
dalteparin 7500 units [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Esophageal bleed
Atrial fib
Intracranial bleed s/p stent at vertebrobasilar aneurysm
Hx of pulmonary embolism
CAD
CHF
Discharge Condition:
Hemodynamically stable, no active bleeding.
Discharge Instructions:
Patient needs to seek medical attention (ED, PCP), if he has
bloody vomit, bloody stool, blood from G-tube, dyspnea, chest
pain, new neurological deficit, fever/chills.
Followup Instructions:
Patient needs to be seen by his PCP as soon as possible and he
has an appointment with neurosurgery on following date.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Where: LM [**Hospital Unit Name 12006**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2165-8-9**] 2:30
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2165-8-5**]
ICD9 Codes: 4280, 2851, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 66
} | Medical Text: Admission Date: [**2127-5-30**] Discharge Date: [**2127-6-11**]
Date of Birth: [**2127-5-30**] Sex: M
Service: NB
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestation.
2. Feeding immaturity, resolved.
HISTORY OF PRESENT ILLNESS: [**Known firstname 37958**] [**Name (NI) **] [**Known lastname **] is a 3125 gram
product of a 33 and [**5-3**] week gestation (EDC [**2127-7-10**]) [**Month/Day/Year **] to
a 33 year-old, Gravida I, Para 0, now I mom, with prenatal
screens 0 positive, antibody negative, RPR nonreactive.
Rubella immune. Hepatitis B surface antigen negative. GBS
negative. Pregnancy was complicated by hypertension. The
[**Known firstname **] was [**Name2 (NI) **] by an emergent Cesarean section because of non
reassuring fetal heart rate tracing after a trial of
induction of labor secondary to hypertension. He had Apgars
scores of 4 at 1 minute and 8 at 5 minutes. Mom had been
given general anesthesia. He required some positive pressure
ventilation in the delivery room for the first minute and a
half of life. He was brought to the Neonatal Intensive Care
Unit for further evaluation.
PHYSICAL EXAMINATION: The infant was large for gestational
age; weight 2125 grams, greater than 90th percentile. Head
circumference was 32.75 cm, 90th percentile. Length 48 cm,
90th percentile. Temperature 98. Heart rate 160.
Respiratory rate 44. Saturating 98% on room air. Blood
pressure 86/37, mean 53. HEENT: Normocephalic, atraumatic.
Anterior fontanel open and flat. Red reflex present
bilaterally. Neck supple. Lungs clear bilaterally. CV:
Regular rate and rhythm, no murmur. Femoral pulses 2+
bilaterally. Abdomen soft, with active bowel sounds, no
masses or distention. Extremities: Warm and well perfused.
Feet smooth. Consistent with premature infant. Anus
normally placed, patent. Spine midline. Hips stable.
Clavicles intact. Neurologic: Good tone, moves all
extremities equally.
HOSPITAL COURSE: Respiratory: He remained stable in room
air throughout hospitalization. He had no episodes of apnea
or desaturations.
Cardiovascular: He remained hemodynamically stable through
his hospitalization.
Fluids, electrolytes and nutrition: He was started on total
fluid volume of 80 cc per kg per day and was advanced to a
total fluid volume of 150 cc per kg per day by day of life
five. He was started on enteral feeds on day of life two and
was able to take all p.o. feeds by day of life six. He is
currently on breast milk or premature Enfamil 24 calories per
ounce and takes between 140 and 150 cc per kg per day volume
feeds. G-sticks have been stable. Electrolytes on day of
life four were sodium of 144; potassium of 4.7; chloride of
107 and bicarbonate of 21.
Gastrointestinal: Peak bilirubin on day of life 3 was 10.5
with a direct component of .3. He did not require
phototherapy.
Infectious disease: He received Ampicillin and Gentamycin
for 48 hours. These were discontinue when cultures remained
negative at 48 hours.
Routine health care management: Hepatitis B vaccine was
given. Hearing screen was passed. Initial car seat test
failed at the time of dictation and will be repeated before
discharge.
DISCHARGE MEDICATIONS: Fer-in-[**Male First Name (un) **].
WEIGHT AT TIME OF DISCHARGE: 3.070 kg.
DISCHARGE DATE: Discharged on day of life 12, corrected to
35 and 3/7 weeks.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2127-6-10**] 16:41:37
T: [**2127-6-10**] 17:03:11
Job#: [**Job Number 94151**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 67
} | Medical Text: Admission Date: [**2103-7-24**] Discharge Date: [**2103-7-26**]
Service:
CHIEF COMPLAINT: The patient is a 78 year old female with a
past medical history significant for obstructive sleep apnea,
pulmonary hypertension, chronic hypercapnic and hypoxemic
respiratory failure, who presented with worsening shortness
of breath and decreased oxygen saturation.
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
woman with a history of long-standing obstructive sleep apnea
and subsequent pulmonary hypertension. Two days prior to
admission, the patient reported experiencing gradual
worsening shortness of breath. On the morning of admission,
the patient's daughter found the patient severely short of
breath, cyanotic and called EMS. When EMS arrived, the
patient was noted to have a room air oxygen saturation in the
60% range and she was noted to be tachypneic with a
respiratory rate in the 40s.
Upon arrival in the [**Hospital1 69**]
Emergency Department, the patient was noted to be cyanotic
and her vital signs showed a heart rate of 85, blood pressure
175/77, respiratory rate 32, and she was saturating at 97% on
100% nonrebreather face mask. She denied any chest pain at
the time of Emergency Department presentation. She denied
any [**Last Name (LF) **], [**First Name3 (LF) 691**] fever or chills. She denied any nausea or
vomiting. There was no abdominal pain. She denied any
urinary symptoms, and she denied any symptoms of paroxysmal
nocturnal dyspnea.
The patient was placed on full face mask BIPAP and was
admitted to the Medical Intensive Care Unit for monitoring of
her respiratory status.
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea. This was diagnosed at least five
years prior to the time of admission when sleep studies
performed in [**2098-2-17**], showed 43 hypopneas and oxygen
saturation in the 70s. This data was from records provided
by the patient's primary pulmonologist, Dr. [**Last Name (STitle) 10132**], from [**Hospital3 **] Medical Center. At home, the patient wore CPAP
for four to six hours every night and received oxygen via
nasal cannula at a rate of 2 to 2.5 liters per minute during
the day.
2. Chronic hypercapnic hypoxemic respiratory failure. The
patient had room air oximetry studies performed in [**2102-7-21**], again at an outpatient hospital which showed that she
spent approximately 63% of her time with oxygen saturation in
the 90s, 24% of her time with oxygen saturation in the 80s
and 5% of her time with oxygen saturation in the 70s.
3. Restrictive lung disease.
4. Pulmonary hypertension.
5. Hypertension.
6. Coronary artery disease, status post coronary artery
catheterization in [**2097-10-18**], which showed clean coronary
arteries.
7. Status post inferior myocardial infarction approximately
fifteen years ago.
8. Inguinal hernia.
9. Chronic anemia thought to be due to Vitamin B12
deficiency.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg q.d.
2. Atenolol 25 mg once a day.
3. Nitroglycerin patch 0.4 mg transdermal patch applied once
a day.
4. Carvedilol 3.125 mg once a day.
5. Allopurinol.
ALLERGIES: Reported allergies were to Penicillin and
Streptomycin.
FAMILY HISTORY: Not assessed.
SOCIAL HISTORY: The patient was a Russian speaking woman who
had come to the United States from [**Country 532**] eight years ago.
She lives alone in the [**Location (un) 86**] area but had two daughters who
lived nearby. She had no history of tobacco use and no
history of exposure to asbestos or known industrial agents.
PHYSICAL EXAMINATION: When we examined the patient, her
vital signs revealed a heart rate of 48, blood pressure
89/48, respiratory rate 26, oxygen saturation 92% on BIPAP
face mask with a pressure support of 15, PEEP of 5 and FIO2
of 40%. She was noted to be awake, alert and able to respond
to questions with the help of translation. Her skin
examination was notable for pallor but no cyanosis.
Examination of the jugular venous distention revealed jugular
venous pulse of 9.0 centimeters. Her chest examination
showed diffusely decreased breath sounds, decreased more so
on the left side than on the right side, however, there were
no wheezes or crackles noted. Her cardiac examination
revealed a bradycardic heart rate but at a regular rhythm
with a harsh IV/VI systolic murmur heard across the
precordium, an occasional S3 but no rubs. Her abdominal
examination revealed normoactive bowel sounds, obese but soft
abdomen, which was nontender. There was no costovertebral
angle tenderness. Examination of her extremities showed
dorsalis pedis pulses 1+ bilaterally. Her extremities were
warm. There was 1+ bilateral lower extremity edema. She was
also noted to have bilateral calf tenderness.
LABORATORY DATA: On admission, sodium 142, initial potassium
of 7.0 in a hemolyzed specimen with a repeat potassium of
4.9, chloride 96, bicarbonate 37, blood urea nitrogen 23,
creatinine 0.8, and glucose of 151. Her complete blood count
revealed a white blood cell count of 6.9, hematocrit 37.5,
and platelet count of 357,000. The white blood cell count
differential included 72% polys, 20 lymphocytes and 7
monocytes. Her coagulation panel showed a prothrombin time
of 13.0, partial thromboplastin time of 29.1 and INR of 1.2.
Initial CK level was 65.
Electrocardiogram showed normal sinus rhythm at a rate of 78
beats per minute with some right axis deviation and right
bundle branch block which was unchanged from previous
electrocardiogram provided from outside hospital.
A chest x-ray showed opacification at the right mediastinal
border and prominent pulmonary vasculature but no focal
consolidation.
HOSPITAL COURSE: In the Emergency Department, an initial
arterial blood gas was performed with the patient on 100%
nonrebreather face mask. This blood gas revealed a pH 7.19,
pCO2 122, and pO2 of 150. After the patient was placed on a
face mask with 50% FIO2, a repeat blood gas showed a pH of
7.13, pCO2 of 137, and pO2 of 132. The patient was given a
single dose of Levofloxacin in the Emergency Department to
treat for community acquired pneumonia. She was also given
intravenous Solu-Medrol to treat for any underlying
bronchospastic component contributing to her pulmonary
decompensation. She was given 1 mg of Morphine Sulfate and
also Nitroglycerin paste in the Emergency Department.
At the time of her Emergency Department presentation, the
patient reported a DNR/DNI code status. Therefore,
intubation was not attempted in this patient. Instead, full
face mask was the preferred method of oxygen delivery and she
was admitted to the Medical Intensive Care Unit for
monitoring of her oxygenation and ventilatory status.
On the evening of admission, ultrasound studies of the lower
extremities were performed and revealed no evidence of deep
vein thrombosis. The patient was also diuresed with Lasix,
having received a total of 100 mg intravenous Lasix in the
Emergency Department and an additional 40 mg of Lasix after
admission to the Intensive Care Unit. This produced a net
diuresis of negative two liters on the evening of admission.
Further antibiotics were held at this time as the patient was
afebrile and did not have an elevated white blood cell count
and there was low clinical suspicion for pneumonia. Further
steroids were also held.
Overnight, the patient's oxygenation and ventilatory status
improved somewhat based on repeat arterial blood gas
analysis. She was placed on nasal CPAP overnight. She
subsequently ruled out for myocardial infarction via cardiac
enzymes.
On [**2103-7-25**], hospital day two, an echocardiogram was obtained
in order to assess the possible role of diastolic congestive
heart failure contributing to pulmonary edema and the
patient's shortness of breath. Following the echocardiogram
which was performed at the bedside, the patient experienced a
desaturation with oxygen saturation noted to be in the 30 to
40% range. The patient was noted to be profoundly cyanotic
and also began to report left sided chest pain. An
electrocardiogram was obtained and showed no changes
suggestive of acute ischemia. Stat portable chest x-ray also
showed no acute change from prior chest x-rays.
At the time of this desaturation event, the patient was on
nasal CPAP and ultimately after being placed on full face
mask BIPAP, the patient's oxygen saturation returned to the
80% range. The echocardiogram ultimately showed an ejection
fraction greater than 55%, mild symmetric left ventricular
hypertrophy. Both the left atrium and the right atrium were
noted to be dilated. There was an overall decrease in right
heart function and there was severe pulmonary artery systolic
hypertension.
Although previously obtained lower extremity ultrasounds had
revealed no deep vein thrombosis, we continued to entertain
the diagnosis of pulmonary embolism. From the time of her
Emergency Department presentation, the patient had been
unable to lie flat without becoming profoundly short of
breath. Therefore, we had been unable to send the patient
for a CT angiogram study to prove the presence of pulmonary
embolism. However, after this desaturation event, the
decision was made to empirically anticoagulate the patient
with Heparin. Her Levofloxacin was also restarted to treat
for a presumptive pneumonia.
This same day an initial blood culture taken in the Emergency
Department returned positive for gram positive cocci in pairs
and clusters in one out of two bottles and the patient was
begun on Vancomycin.
The patient subsequently remained stable from a respiratory
standpoint but was noted to have intermittent bradycardia
with heart rates in the 30 or 40s which were transient and
were not associated with any hypotension. Atropine was placed
at the patient's bedside.
On the morning of [**2103-7-26**], the patient was restarted on
Solu-Medrol to treat for any possible underlying component of
bronchospastic disease and the decision was made to obtain a
bedside abdominal ultrasound to evaluate the question of a
pleural effusion at the right lung base seen on serial chest
x-rays. However, before the ultrasound could be obtained,
the patient experienced another desaturation event early in
the afternoon on [**2103-7-26**]. This was accompanied by
bradycardia and eventually cardiopulmonary arrest and the
patient ultimately succumbed and was declared deceased on the
afternoon of [**2103-7-26**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] R. 12-207
Dictated By:[**Doctor Last Name 35468**]
MEDQUIST36
D: [**2103-7-27**] 14:50
T: [**2103-7-30**] 17:13
JOB#: [**Job Number 35469**]
ICD9 Codes: 486, 496, 4168, 0389, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 68
} | Medical Text: Admission Date: [**2196-6-10**] Discharge Date: [**2196-6-14**]
Date of Birth: [**2145-1-10**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51M restrained driver s/p T-bone motor vehicle crash with + LOC.
He was taken to an area hospital where found to have mulitple
injuries and was then transported to [**Hospital1 18**] for further care.
Past Medical History:
HTN, kidney stones, GERD
Family History:
Noncontributory
Physical Exam:
Upon exam:
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: In cervical collar.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3.5 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-10**] throughout. No pronator drift
Sensation: Intact to light touch throughout.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal rapid alternating movements
Pertinent Results:
[**2196-6-10**] 11:38PM GLUCOSE-158* UREA N-14 CREAT-0.8 SODIUM-141
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
[**2196-6-10**] 11:38PM WBC-17.6* RBC-4.61 HGB-14.1 HCT-40.0 MCV-87
MCH-30.6 MCHC-35.2* RDW-14.4
[**2196-6-10**] 11:38PM PLT COUNT-302
[**2196-6-10**] 11:38PM PT-13.1 PTT-21.5* INR(PT)-1.1
[**2196-6-10**] 08:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-6-10**] 08:54PM WBC-23.7* RBC-5.03 HGB-15.2 HCT-44.6 MCV-89
MCH-30.1 MCHC-34.0 RDW-14.0
CT Head [**2196-6-10**]
IMPRESSION:
1. Longitudinal left temporal bone skull base fracture appears
to spare the carotid canal. This fracture does traverse the
middle ear and ossicular disruption cannot be excluded.
2. Small left posterior frontal subarachnoid hemorrhage.
3. Asymmetric left occipital hypoattenuation is suggested and
acute infarct cannot be excluded. Recommend MRI/MRA versus CTA
for further evaluation
CT C-spine [**2196-6-10**]
IMPRESSION: Non-displaced fracture of right intra-articular
portion of C7, as described. No other fracture or listhesis.
CT Chest/Abdomen/Pelvis [**2196-6-10**]
IMPRESSION:
1. Moderately large mesenteric hematoma may represent a
significant vascular injury to small bowel.
2. Left inferior pole renal infarct. While the left renal artery
appears
intact, a dissection cannot be excluded and CTA is recommended
for further
evaluation.
3. Nondisplaced right first rib fracture.
4. Bilateral transverse process fractures at L3 with left
transverse process fracture at L4.
5. Bibasilar consolidations and lingular consolidation likely
represent
atelectasis, however a component of aspiration is not excluded.
5. Right adrenal nodule, too small to characterize.
CTA Head/Neck [**2196-6-11**]
IMPRESSION:
1. Left parietal subarachnoid hemorrhage is less apparent. No
new
hemorrhage.
2. Normal CT angiography of the neck.
3. Normal CT angiography of the head.
4. Fracture of right C7 is visualized extending to the
transverse foramen,
but the vertebral artery does not enter the foramen
transversarium at this
level but interrupts at C6 level. Right first rib fracture is
identified.
CT Right arm [**2196-6-11**]
FINDINGS: The distal humerus is normal in appearance. There is
no evidence
of acute fracture.
Brief Hospital Course:
He was admitted to the Trauma service. Neurosurgery and
Orthopedic spine consulted because of his injuries. His left
parietal subarachnoid hemorrhage was managed non operatively;
serial head CT scans were performed and remained stable. He will
follow up with Dr. [**First Name (STitle) **] in 4 weeks for repeat head imaging.
He was noted with a skull base fracture through the left
temporal bone; dedicated CT of the temporal bone was done and he
will require outpatient follow up with ENT for audiogram.
His spine injuries were also managed non operatively with a hard
cervical collar to be worn at all times and a lumbar corset to
be worn when out of bed. He will follow up in 2 weeks with Dr.
[**Last Name (STitle) 363**], Orthopedic Spine surgery.
Orthopedics was consulted for concern of a possible right
humerus fracture given that patient had increased complaints of
right arm pain with movement and upon palpation. A CT of his arm
was performed and no fracture was identified. It was felt that
the pain he had been experiencing was likely related to the
cervical spine fracture and the dermatome path that followed
along the arm. He was started on Neurontin, Ultram and prn
Percocet for the pain which he reported as helpful.
He was evaluated by Physical therapy and was discharged to home
on hospital day 5 with specific instructions for follow up.
Medications on Admission:
hctz, nexium, simvastatin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML
PO Q6H (every 6 hours) as needed for constipation.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: DO NOT exceed 2,000mg in a day.
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Small subarachnoid hemorrhage
Basilar skull fracture
Left temporal bone fracture
C7 facet fracture
Bilateral tranverse process fractures L3 & left L4
Mesenteric hemotoma
Neuropathic pain
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
You must continue to wear the cervical collar at all times for
the next 10 weeks.
You will need to wear the corsett brace when out of bed for your
lumbar fractures.
Wear the sling for comfort on your left arm.
Return to the Emergency room if you develop any fevers, chills,
headache, weakness/numbness in any of your extremities,
shortness of breath, chest pain, nausea, vomiting, diarrhea,
loss of bowel or bladder function and/or any other symptoms that
are concerning to you.
Followup Instructions:
Follow up next week in [**Hospital **] clinic, you will need an audiogram at
this appointment as well. Call [**Telephone/Fax (1) 41**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 363**], Orthopedics Spine Surgery
for your spine fracture. call [**Telephone/Fax (1) 3573**] for an appointment.
Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery for your
subarachnoid hemorrhage. Call [**Telephone/Fax (1) 1669**] for an appointment.
Inform the office that you will need a repeat head CT scan for
this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2196-6-22**]
ICD9 Codes: 4019, 2768, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 69
} | Medical Text: Admission Date: [**2109-7-21**] Discharge Date: [**2109-8-13**]
Date of Birth: [**2053-6-5**] Sex: F
Service: [**Doctor Last Name 1181**] MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 56-year-old white
female with a history of right frontal craniotomy on [**2109-7-1**], for a dysembryoplastic angioneural epithelial lesion
with features of an oligodendroglioma who was started on
Dilantin postoperatively for seizure prophylaxis and was
subsequently developed eye discharge and was seen by an
optometrist who treated it with sulfate ophthalmic drops.
The patient then developed oral sores and rash in the chest
the night before admission which rapidly spread to the face,
trunk, and upper extremities within the last 24 hours. The
patient was unable to eat secondary to mouth pain. She had
fevers, weakness, and diarrhea. There were no genital
the morning of [**7-20**].
PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Benign
right frontal cystic tumor status post right frontal
craniotomy on [**2109-7-1**].
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Lipitor, Tylenol with Codeine, Dilantin,
previously on Decadron q.i.d. tapered over one week and
discontinued a week ago.
SOCIAL HISTORY: The patient lives with her husband,
daughter, and son. [**Name (NI) **] smoking or ethanol use history.
PHYSICAL EXAMINATION: Vital signs: T-max 104.3??????, currently
100.8??????, heart rate 107-110, blood pressure 110/27,
respirations 15-20, oxygen saturation 98% on room air.
General: The patient was an alert, ill-appearing woman with
postsurgical occiput. Head and neck: Injected conjunctivae,
greenish ocular discharge, ulcerative oral lesions.
Cardiovascular: Regular rhythm. Rapid rate. No murmurs.
Pulmonary: Clear to auscultation bilaterally. Abdomen:
Normoactive bowel sounds. Soft, nontender, nondistended.
Extremities: No edema. Skin: Diffuse erythema and pustules
on the face. Patulous pustules on the chest, back, and
proximal upper extremities. GU: No genital lesions.
LABORATORY DATA: Hematocrit 34.1, WBC 10.3, platelet count
291,000, differential of 87 neutrophils, 0 bands; sodium 133,
potassium 3.8, chloride 93, CO2 21, BUN 17, creatinine 0.9,
glucose 121; ALT 39, AST 42, LDH 434, amylase 63, albumin
3.4, total bilirubin 0.3; urinalysis with positive ketones,
negative nitrites; urine culture pending; blood cultures
times two pending; conjunctival culture pending.
HOSPITAL COURSE: Given the patient's severe exfoliative skin
involvement with rapid progression and extensive involvement
of the body, she was admitted to the Medical Intensive Care
Unit for close monitoring. She was started on prophylactic
Oxacillin to cover skin flora, and Dermatology was consulted
along with Neurology and Ophthalmology for the ophthalmic
involvement.
The patient's course in the Intensive Care Unit was
uneventful, and she was discharged to the floor with very
close monitoring which included q.1 hour Pred Forte
application to the eye and close consultation with
Ophthalmology. With regard to her skin lesions, they
continued exfoliate over the next couple of days, and her
skin care included frequent Vaseline hydrated petroleum
application to decrease insensible losses. The patient's
intake and output were closely monitored and replaced
appropriately; however, the intensive nursing care
requirement made it difficult for the patient to receive
adequate on the floor, and therefore, she was transferred to
the Medical Intensive Care Unit again for frequent ophthalmic
applications and skin care.
While in the MICU, the patient continued to have meticulous
skin care and eye care. The skin lesions continued to
desquamate and exfoliate which is the natural
progression of this disease. She began to have involvement
of the genital area with continued desquamation of the
exfoliative lesions. Her course in the Intensive Care Unit
within the next 8-10 days was a slow but gradual improvement
from a dermatologic and ophthalmologic standpoint.
From a cardiovascular standpoint, she was in sinus
tachycardia which was felt to be secondary to her
[**Doctor Last Name **]-[**Location (un) **] syndrome leading to dehydration and
insensible fluid losses.
While in the Intensive Care Unit, she was also found to be
mildly hypoxic which is likely secondary to atelectasis
because of the patient's immobility. Lower extremity
Dopplers were also done, and no deep venous thromboses were
found.
From and Infectious Disease standpoint, the patient was
started on intravenous Oxacillin empirically. Blood cultures
on the 5th was with no growth times two; however, one bottle
from her PICC line grew out gram-positive cocci on [**7-27**].
She was started on a course of Vancomycin. Subsequently the
organism was found to be CNS with Corynebacterium, and
Vancomycin was discontinued prior to transfer to the floor on
[**8-5**].
The patient's course on the floor was uncomplicated with
continued improvement.
Dermatology: The patient, as indicated, improved
dramatically from her presentation to the time of discharge.
Her exfoliative lesions healed over the course of this
admission. Her skin care requirements decreased to Petroleum
jelly twice a day at the time of discharge. She was able to
take in oral foot without problems.
Ophthalmology: The patient's eye care requirement improved
markedly. She was able to open her eyes and use her vision
without significant problems at the time of discharge. Her
Pred Forte was discontinued on the day of discharge, and she
is to have follow-up with Ophthalmology a couple of days
after discharge.
Fluid, electrolytes, and nutrition: On admission the patient
was begun on TPN for nutritional support. As the patient
improved from a medical perspective, her TPN was weaned, and
at the time of discharge, the patient was taking adequate
p.o. with supplementation of Boost.
Infectious Disease: At the time of admission, she was
started on empiric antibiotics and placed on contact
precautions secondary to her extensive skin lesions; however,
as the patient improved throughout the course of this
admission, contact precautions were discontinued, and the
patient was discharged home with services.
Cardiology/Pulmonology: The patient was tachycardiac
throughout this admission which was attributed to her fluid
losses secondary to [**Doctor Last Name **]-[**Location (un) **] syndrome; however, given
the patient's immobility throughout the course of this
admission, a CT angiogram was performed to evaluate for
possible pulmonary embolism, and none were found.
Neurology: The patient has a history of cystic tumor status
post resection in [**Month (only) 205**] of this year and was started on
prophylactic Dilantin leading to presumed [**Doctor Last Name **]-[**Location (un) **]
syndrome. At the time of this admission, the patient's
Dilantin was discontinued, and no other anticonvulsants were
started, given the patient's risk of seizures several weeks
after her surgery was unlikely. This decision was made with
the support of her neurosurgeon, Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1338**].
Five days before discharge, the patient did have a syncopal
event while in the bathroom showering with the help of a
nursing aide. The likely etiology of this is orthostatic
hypotension from her fluid losses; however, given the
patient's neurologic history, Neurology was consulted to
evaluate for possible seizure. Neurology's recommendations
were to obtain a repeat CT scan which was unchanged from
previous showing a right frontal lobe extra-axial hypodensity
which was stable. They also recommended repeat MR imaging
which was again unremarkable except for a stable extra-axial
lesion noted on CT scan. Neurology therefore agrees with the
primary team that the syncopal event was likely secondary to
a vasovagal reaction. A follow-up MR scan would be
recommended with gadolinium to evaluate for the presence of
residual tumor. This can be done as an outpatient with Dr.
[**Last Name (STitle) 1338**].
Rehabilitation: The patient throughout this admission worked
with our physical therapy people and continued to improve
with regard to range of motion and strength in the upper and
lower extremities, and by the time of discharge, she was
ambulating throughout the [**Doctor Last Name **] and around the hospital
without problems. She was therefore discharged home without
need for Physical Therapy Services.
At the time of discharge, the patient has markedly improved
from her initial presentation and is to be discharged home
with nursing assistance.
DISCHARGE STATUS: Markedly improved.
DISCHARGE DIAGNOSIS:
1. [**Doctor Last Name **]-[**Location (un) **] syndrome secondary to Dilantin.
2. Status post craniotomy on [**2109-7-1**], for a cystic
cranial lesion, likely dysembryoplastic angioneural
epithelial lesion with features consistent with an
oligodendroglioma.
DISCHARGE MEDICATIONS: Polysporin ophthalmology O.U. q.i.d.,
hydrated Petroleum as needed, Lipitor 10 mg p.o. q.d.,
Nystatin, Boost t.i.d.
FOLLOW-UP: 1. Ophthalmology [**2109-8-20**], at 12:45
p.m. 2. Primary care physician in two weeks. 3.
Dermatology as needed.
DISCHARGE NOTE: PLEASE NOTE THAT THE PATIENT IS ALLERGIC TO
DILANTIN AND TEGRETOL GIVEN HER [**Doctor Last Name **]-[**Location (un) **] SECONDARY TO
DILANTIN. The patient is recommended to wear an alert
bracelet which indicates this reaction.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern4) 40425**]
MEDQUIST36
D: [**2109-9-3**] 12:59
T: [**2109-9-3**] 12:58
JOB#: [**Job Number 99931**]
[**Name6 (MD) **] [**Name8 (MD) **], M.D.(cclist)
ICD9 Codes: 2765, 311, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 70
} | Medical Text: Admission Date: [**2144-3-7**] Discharge Date: [**2144-3-16**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
transfer from OSH in [**State 108**] with R hip IT fx.
Major Surgical or Invasive Procedure:
R hip ORIF
History of Present Illness:
HPI: [**Age over 90 **]F with hx dementia, CAD, CHF EF 40%, chronic afib, lives
with 24 hour caretaker. Was brought into OSH for neck pain and
inability to hold her head up as well as confusion, found to
have transverse C2 dens fracture, which has been immobilized
with [**Location (un) 5622**] collar. Pt fell 3 weeks prior to admission,
but home aide stated that there were no injuries from fall.
Noted to have CHF exacerbation --> resolving with diuresis and
now is reportedly stable on [**3-20**] liters NC (uses no O2 at home).
In-house at OSH, had a fall and unfortunately suffered right
intertrochanteric fracture. Pt has family in [**Hospital1 1559**] and had
pt med flighted from [**State 108**] to [**Hospital1 18**]. Family connection to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Reportedly, her C2 fracture is stable and the surgeons there
only wanted to immobilize it until her hip could be addressed.
.
Pt had a cardiology consult in [**State 108**], she had a CHF
exacerbation with a BNP of 15,000. Her Toprol XL was increased
from 37.5 to 50 mg PO qd with a plan to increase to 100 mg po
QD. She was started on digoixin. Her lasix was increased.
.
Of note, transfer paperwork notes that the pt was seen by PCP in
[**Name9 (PRE) 108**] for exertional CP and SOB relieved by NTG in [**Month (only) 1096**]
[**2143**]. At that time her Imdur was increased from 30 to 60 mg PO
qd.
.
Before her hospitalization she had been increasingly agitated
and had been started on Risperdal, which was recently d/c'd
after she became increasingly confused.
.
Labs at OSH:
[**3-6**]: INR 1.1, Na 146, K 3.8, Cl 106, HCO3 33, BUN 29, Cr 1.0,
Ca 8.7
Dig 1.0, [**3-2**] Blood Cx: NGTD
.
Studies:
[**3-2**] EKG: afib at 98bpm RAD, LVH, QTc 526, bad baseline
[**3-4**] CT Head mod-severe atrophy, no bleed
[**3-5**] R hip/pelvis, comminuted IT fx R hip
[**3-5**] CT cervical spine: transverse fx through base of dens. No
displacement. Transverse lucency through the spinous process at
C3 (chronic) Transverse lucency through spinous process at C3
(chronic).
[**3-3**] CXR: Mild CHF, patchy infiltrate base of right lung, small
bilateral pleural effusions.
.
Past Medical History:
PMH:
CHF EF 40%, [**2-20**] echo: inf hypokinesis
CAD, hx MI, s/p PCI of LAD, LCx and RCA with stents [**2136**] at
[**Hospital1 **]
afib
hypercholesterolemia
COPD
HTN
severe AS ([**2-20**] echo 59 mmHg peak gradient, valve area 0.6 cmsq)
mod-severe MR
mild MS [**First Name (Titles) **] [**Last Name (Titles) **]
Dementia (Mild Alzheimer's vs vascular) per transfer paperwork,
however pt's family states that before this hospitalization pt
was living independently with live in help.
Hiatal hernia s/p repair
hx GIB from AVM associated with elevated INR [**4-18**]
s/p ccy
s/p TAH
macular degeneration
kyphoscoliosis
DJD/OA
Social History:
Social Hx: widowed, with 4 children. Lived independently with
24 hour aides. No EtOH or tob.
Transferring physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 24606**] [**Last Name (NamePattern1) 79**] cell [**Telephone/Fax (1) 65356**] (is
on-call this weekend) [**Hospital 32303**] Medical Center in [**Hospital 65357**],
[**State 108**] [**Telephone/Fax (1) 65358**]. [**Name (NI) **] son: [**Name (NI) **] [**Name (NI) 122**]
[**Telephone/Fax (1) 65359**] is her HCP, he lives in [**Name (NI) 108**] and is coming to MA
[**3-7**]. Pts daughter ([**Name (NI) 19948**] [**Last Name (NamePattern1) **]) lives in [**Name (NI) 1559**] and her
phone number is [**Telephone/Fax (1) 65360**].
.
[**Hospital1 1559**] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] ([**Hospital1 **])
[**Hospital1 1559**] Cardiologist: Dr. [**Last Name (STitle) 65361**] ([**Hospital1 **])
Physical Exam:
PE: VS: T 98.6 HR 64 R 20 BP 88/54 95%2L
Gen: NAD, laying in bed in Aspen collar
HEENT: slight droop L eyelid, PERRL, MMM, O/P clear
Neck: in Aspen collar
Chest: crackles at bases, clear at apices
CV: [**Last Name (un) 3526**] [**Last Name (un) 3526**] rate and rhythm, 3/6 SEM at RUSB rad to carotids,
3/6 systolic murmur at apex
Abd: soft, NT, ND +BS
Ext: pain with palpation R hip, lim ROM. no edema, 2+ DP pulses
bilaterally
Neuro: alert, oriented to person only, moves all 4.
Brief Hospital Course:
[**Age over 90 **] yo F with h/o dementia, CAD, diastolic CHF (EF 55%), severe
AS, chronic afib, transferred from OSH with R hip fracture and
possible C2 fracture for operative management of hip. She was
stable on the floor on her initial arrival. Given her CHF and
AS, she was a high risk surgical candidate, but the family
decided to go ahead with the operation. Postoperatively she was
in the MICU briefly for hypotension but was extubated without
difficulty, weaned off pressors after rehydration and
transferred back to the floor. Perioperatively, she developed a
UTI and a LIJ clot, which were both treated. Postoperatively,
she also developed delirium, and was less verbal than she was
previously. She failed a speech and swallow evaluation, but the
medical team was optomistic that she would improve. In the
meantime, multiple attempts at NGT placement were unsuccessful.
While on the floor, [**3-14**]-30, patient showed signs of
inability to clear her secretions. On [**3-15**], she had an episode
of hypoxia. CXR at that time revealed fluid overload, and she
seemed to improve with lasix. Overnight that night, 1/2 blood
culture bottles were positive for S.aureus and Vancomycin was
started. [**3-16**], she continued to do poorly, and again was
hypoxic. CXR this time revealed dry lungs, but likely
aspiriation PNA or LUL. Despite aggressive suctioning and
broadening of antibiotic coverage, Mrs. [**Known lastname 65362**] continued to
deteriorate and ultimately died approx 4:25 PM on [**3-16**].
.
# COde - DNR/DNI verified with son who is HCP.
.
# Communication: son [**Name (NI) **] [**Name (NI) 122**] [**Telephone/Fax (1) 65359**] (HCP; daughter
([**Name (NI) 19948**] [**Name (NI) **] [**Telephone/Fax (1) 65360**]). [**Hospital1 1559**] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**]
([**Hospital1 **]); [**Hospital1 1559**] Cardiologist: Dr. [**Last Name (STitle) 65361**] ([**Hospital1 **]).
Previously at [**Hospital 32303**] Medical Center in [**Last Name (LF) 65357**], [**First Name3 (LF) 108**]
[**Telephone/Fax (1) 65358**].
.
Medications on Admission:
Meds on transfer:
Lipitor 40 mg PO qd
Digoxin 0.125 mg qD
Lasix 80 mg IV BID
Atrovent neb QID
Imdur 30 mg PO qd
Levalbuterol neb QID
Losartan 12.5 mg PO BID
Toprol XL 50 mg PO qd
coumadin 2 mg PO alternating with 3 mg PO qd (held)
Tylenol prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Hip fracture s/p ORIF
LIJ clot
UTI
Aspiration PNA
Perioperative delirium
Discharge Condition:
Death
Discharge Instructions:
None.
Followup Instructions:
None.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
ICD9 Codes: 5990, 5070, 4241, 496, 2851, 2930, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 71
} | Medical Text: Admission Date: [**2179-3-5**] Discharge Date: [**2179-3-24**]
Date of Birth: [**2105-3-13**] Sex: F
Service: MEDICINE
Allergies:
Benzodiazepines
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
shortness of breath, red hands and feet
Major Surgical or Invasive Procedure:
endotracheal intubation, mechanical ventilation, right IJ
central line placed, tracheostomy tube placed in OR
History of Present Illness:
Ms. [**Known lastname 94714**] is a 73yo woman with h/o ALS who presents with 3
weeks of redness in her hands and feet as well as more recent
difficulty breathing. The patient had not complained of dyspnea
and her husband had noted tachypnea or respiratory distress but
per her husband she went to her doctor today, who noted that she
was "not breathing well" and sent her to the ER where she was
hypoxic in the 80s, responding well to O2 by NC. She was then
found to have an ABG of 7.19/126/525/51 and was started on
Bipap. She did not tolerate the non-invasive mask ventilation
despite sedateion (versed 2mg, and fentanyl 100mg). She
experienced a reduction of blood pressure to 66/30, and was
subsequently intubated.
Per husband, the patient has had ALS for three years. She
performs ADLs on her own but has had trouble with speech as well
as with keeping her mouth closed at baseline. She has not had
any respiratory complaints. She had previously lost 40 pounds
but last year was given a Gtube and since then has gained back
14 pounds. [**Name (NI) 1094**] husband states that prior to the last 3 weeks
she was in her USOH, and denies any new symptoms including
cough, sputum, no sick contacts. She is entirely NPO and has
been for about a year. CXR in the ER showed no acute CP process
and UA was negative for signs of infection.
Per the pt's husband they have never had any sort of
conversation regarding code status. The patinet did try bipap in
the past but was unable to tolerate it, but her outpatient
neurologist has never mentioned intubation or tracheostomy. Mr.
[**Known lastname 94714**] states that these are all new thoughts for him and
he's not entirely certain what his wife would want at this
point.
She was transferred to the [**Hospital Unit Name 153**], and she was started on AC
450x16, 100% FiO2, PEEP 5. ABG on this setting was
7.40/57/426/37 and her FiO2 was turned down to 50%.
Past Medical History:
- ALS diagnosed 3y ago - has Gtube with tube feeds, has
difficulty with speech
- hypercholesterolemia
-?depression
Social History:
lives at home with husband, has three children two of whom live
on the west coast and one of whom lives in [**Location **]. never used
tobacco, does not drink alcohol, no other drugs. Works as a
writer. At baseline performs ADLs, writes, uses internet to chat
with her grandchildren.
Family History:
father MI age 52, mother deceased at age [**Age over 90 **]
Physical Exam:
96.7, 78, 112/64, 16, 100% on AC settings as above
Gen: sedated, unresponsive, intubated
HEENT: PERRL, NCAT
Cor: s1s2, RRR, no r/g/m
Pulm: CTAB
Abd: soft, NT, ND, +BS, Gtube c/d/i
Ext; no c/c/e, bilateral toes with skin changes c/w venous
stasis, bilateral fingers with erythematous dry excoriated skin
Neuro: babinski upgoing bilaterally, myoclonus BLE,
hyperreflexic B patellar, biceps
Pertinent Results:
on arrival Na 126, CK 273-->115, MB 14-->10, trop <0.01-->
<0.01, bicarb 40, UA negative
[**2179-3-23**] 02:44AM BLOOD WBC-10.0 RBC-2.88* Hgb-9.4* Hct-27.6*
MCV-96 MCH-32.7* MCHC-34.1 RDW-13.5 Plt Ct-316
[**2179-3-23**] 02:44AM BLOOD Neuts-78.7* Bands-0 Lymphs-15.8*
Monos-3.6 Eos-1.6 Baso-0.3
[**2179-3-22**] 04:15AM BLOOD PT-11.7 PTT-22.6 INR(PT)-1.0
[**2179-3-23**] 02:44AM BLOOD Glucose-127* UreaN-24* Creat-1.3* Na-145
K-4.5 Cl-107 HCO3-31 AnGap-12
[**2179-3-19**] 05:54AM BLOOD ALT-49* AST-44* LD(LDH)-267* AlkPhos-142*
Amylase-41 TotBili-0.3
[**2179-3-19**] 05:54AM BLOOD Lipase-30
[**2179-3-5**] 02:50PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-<0.01
[**2179-3-5**] 10:15PM BLOOD CK-MB-10 MB Indx-8.7* cTropnT-0.01
[**2179-3-23**] 02:44AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4
[**2179-3-19**] 05:54AM BLOOD TSH-3.0
[**2179-3-18**] 11:55AM BLOOD Cortsol-23.9*
[**2179-3-18**] 12:51PM BLOOD Cortsol-43.3*
[**2179-3-18**] 01:48PM BLOOD Cortsol-51.1*
[**2179-3-22**] 04:11PM BLOOD Type-ART pO2-136* pCO2-50* pH-7.45
calHCO3-36* Base XS-9
[**2179-3-22**] 04:11PM BLOOD Lactate-1.2
.
[**2179-3-12**] 10:57 pm BLOOD CULTURE LT PIV.
**FINAL REPORT [**2179-3-18**]**
AEROBIC BOTTLE (Final [**2179-3-15**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2179-3-13**] @ 2:35 PM.
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2179-3-18**]): NO GROWTH.
.
[**2179-3-13**] 12:20 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2179-3-15**]**
GRAM STAIN (Final [**2179-3-13**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2179-3-15**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**3-15**] ECHO: 1.The left atrium is normal in size.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
6.There is no pericardial effusion.
.
[**2179-3-5**] EKG: Sinus rhythm. Slight ST segment elevation in leads
II, III and aVF which may represent active inferior ischemic
process. Followup and clinical correlation are suggested. No
previous tracing available for comparison
.
[**2179-3-12**] EKG: Atrial fibrillation with a rapid ventricular
response, rate 160. Non-specific repolarization changes.
Compared to the previous tracing of [**2179-3-5**] normal sinus rhythm
with abbreviated P-R interval has given way to atrial
fibrillation with a rapid ventricular response
.
[**3-21**] CXR: There continues to be dense opacification in the
retrocardiac region consistent with left lower lobe collapse and
a small left effusion. There are some patchy areas of increased
opacity in the right lower lung and left mid lung that may
represent early infiltrate or volume loss. There is no
significant change compared to the film from two days ago. The
right subclavian line is unchanged.
.
[**2179-3-22**] Renal US: Mildly echogenic but otherwise
normal-appearing kidneys may be secondary to medical renal
disease. 1.1 x 0.9 cm echogenic focus in the left kidney may
represent a cholesterol deposit versus a nonobstructing kidney
stone.
Brief Hospital Course:
# hypercarbic resp failure: This was felt to be likely ALS
induced muscular weakness combined with possible acute PNA given
LLL consolidation on CXR. She was intubated for repiratory
failure, and treated for a possible pneumonia. She was not able
to tolerate weaning off the ventilator, and therefore required
tracheostomy for longer term ventilator support. While awaiting
trach placement, Ms. [**Known lastname 94714**] also developed a ventilator
associated pneumonia. She grew MRSA in her sputum and blood, and
was treated with a course of vancomycin. Zosyn was added after 5
days of vancomycin as she had repeated L lung collapse with
thick mucous plugging, and we wanted to cover for pneumonia as
well. Subsequent surveillance cultures were clean. Zosyn was
later switched to Cefepime [**1-7**] worsening renal failure
attributed to Zosyn. She completed an 8 day course of
antibiotics. Her tracheostomy went well, and she was started on
an in/exsufflator as well to aid in clearing her
secretions/mucous to prevent recurrent lung colapse.
.
# A fib: Ms. [**Known lastname 94714**] had several episodes of atrial
fibrillation with RVR, all in the setting of L lung collapse.
She was initially started on a beta blocker with good response.
After having multiple episodes she was started on amiodarone and
anticoagulation with heparin. In all cases she converted to
sinus rhythm on her own. Shortly after starting heparin, she had
an episode of guaiac positive stool, and then a small amount of
melena. Her heparin was stopped, and was not restarted as she
remained in sinus rhythm, and the concern was that her risk of
GI bleeding is higher than her risk of stroke. Her PEG was
lavaged, and was OB negative. She will also need a colonoscopy
as an outpatient to further evaluate the cause of her melena.
She has subtle ST changes on inital EKG, but ruled out for an MI
by enzymes.
.
# hypotension: Ms [**Known lastname 94714**] was hypotensive on intial
presentation, responding well to fluid boluses. She had a
cortisol stimulation test with normal response. It became clear
that she responds to sedation with benzodiazepines with
prolonged hypotension (as well as increased delerium and
agitation), and therefore these were stopped, and put into her
allergy list. After cessation of benzodiazepines, her blood
pressure was much more stable, and she did not require bolusing.
She never required pressors.
.
# ALS: It was felt that she likely had progression of her ALS,
with diaphragmatic weakness and CO2 retention. Her respiratory
mechanics were repeatedly asessed, and showed that she would not
be able to come off the vent. Therefore a trach was placed in
the OR by thoracic surgery (IP unable to place due to her
anatomy).
.
# hyponatremia: Mrs [**Known lastname 94714**] was hyponatremic on admission. Tis
resolved with hydration, indicating that she was likely
hypovolemic and total body sodium depleted. She had no further
problems with this for the duration of her stay.
.
#Diarrhea: New on [**2179-3-24**]/ Slight increase in in WBC to 15.
Afebrile. No abdominal pain. Has been on course of antibiotics
for vent associated PNA. Those antibiotics stopped today. ALso
on tube feeds. C. Diff is a possibility given recent abx but it
may also be related to tube feeds. On C.Diff is pending. At this
point it is reasonable to follow fever curve and stool output.
C.Diff lab should be followed up. [**Month (only) 116**] consider empiric treatment
of c. diff with flagyl if febrile or diarrhea persists.
.
#Hypernatremia - Likely releated to low volume. WIll increase
free water with tube feeds from 100cc q4hr to 150cc q4h. A
chenistry panel should be checked on [**2179-3-26**] to make sure Na
remains stable.
.
# conjunctivitis: Ms. [**Known lastname 94714**] had bilateral conjunctivitis on
admission. This resolved with a 7 day course of erythromycin eye
cream.
.
# skin changes: Ms [**Known lastname 94715**] intitial presenting chief
complaint was erythema of her hands and feet. Dermatology was
consulted, and said that she likely has erythromyalgia. The
treatment for this is sarna lotion and aspirin, and improvement
does not occur in less than a month. She was treated with sarna
and ASA throughout her stay. Additionally she had burns on the
inside of both thighs from a hot tea spill at home prior to
admission. Per dermatology recs, these areas were treated with
antibiotic cream and xeroform dressings, and healed over cleanly
without infection.
.
# FEN: Ms. [**Known lastname 94714**] had a PEG on admission as she has not been
able to take PO intake for some time secondary to progression of
her ALS. She was continued NPO, with tubefeeds per nutrition. We
monitored & repleted her electrolytes lytes. She was kept
euvolemic.
#Renal Failure: Pt's Creatinine increased during this admission
from 0.7 to 1.3.
BUN remained around 20 .Urine lytes were consistent with
ATN>Reanla failure was attributed to ATN d/2 Zosyn.Although it
was chenged to Cefepime, there was no improvement. Renal US
showed no obstruction.
Pt's creatinitne remained near 1.3.Plan will be to keep pt
hydrated , avoid nephrotoxins and follow creatinine as
outpatient.
.
# PPX: Ms. [**Known lastname 94714**] was treated with SC heparin, protonix, and
a bowel regimen. She did have some constipation, and her bowel
regimen was increased with good results.
.
# access: She was maintained with PIVs throughout most of her
hospitalization. Shortly before discharge a PICC line was placed
as she was losing all her peripheral access.
.
# code status: Per discussion with Ms [**Known lastname 94714**] and her husband
she was full code throughout her stay.
Medications on Admission:
Elavil (stopped a few weeks ago)
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: [**12-7**] PO BID (2 times
a day).
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
6. Bisacodyl 10 mg Suppository Sig: [**12-7**] Suppositorys Rectal
DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Amiotrophic Lateral Sclerosis
Hypercarbic Respiratory Failure
Atrial Fibrillation
Recurrent Pneumonia-Ventilator Associated Pneumonia
Renal Failure
Discharge Condition:
good , afebrile , no cough , no fever, tracheostomy in good
condition.
Discharge Instructions:
Please continue using exsuflator as needed.PLease come back to
ED if you have a new episode of worsening cough, fever and
productive sputum.
.
Pleae take your medications as as prescribed.
.
You were noted to have diarrhea on the morning prior to
discharge, please call [**Hospital1 18**] to check on the results of her c.
diff stool culture on [**2179-3-25**], and consider a c. diff study if
diarrhea continues.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2936**]
.
Recent onset of diarrhea. Please call [**Hospital1 18**] microbiology lab at
([**Telephone/Fax (1) 94716**] to follow up results of c. diff toxin assay.
.
Please check cbc and chem 7 on [**2179-3-26**]. New onset of
hypernatremia on [**2179-3-24**]. Free water increased in tube feeds on
[**2179-3-24**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2179-3-24**]
ICD9 Codes: 486, 5845, 2760, 4589, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 72
} | Medical Text: Admission Date: [**2196-9-27**] Discharge Date: [**2196-10-17**]
Date of Birth: [**2151-3-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESLD
Major Surgical or Invasive Procedure:
[**2196-9-27**] liver transplant
History of Present Illness:
45M with history of EtOH cirrhosis, MELD 28 and Child class
C cirrhosis recently admitted to [**Hospital1 18**] last month for fevers,
anemia, ascites and ARF. In brief, during his recent hospital
course, he was treated for C.perfringens bacteremia and was
treated with Zosyn. Paracentesis was performed and did not
reveal
spontaneous peritonitis. EGD evaluation only showed Grade I
varices. His renal failure issues responded to octreotide and
midodrine. He was resumed on his diuretic and last Cr normalized
at baseline (1.0).
He is admitted in preparation for a liver transplant. Denies any
change in health since previous admission. Afebrile but still
rather lethargic at home. Tolerating regular diet. Normal bowel
habits, described as often loose. No abdominal tenderness but
tender to paracentesis site. Has not had any food since
midnight.
Past Medical History:
EtOH cirrhosis
EtOH Abuse
Gout
s/p appendectomy several yrs ago
h/o HTN now normotensive off all meds
[**2196-9-27**] liver transplant
Social History:
lives with wife and sons 10 and 14 yo. Works as an energy
broker. Denies drug or tobacco use. Quit drinking 6 weeks ago
Family History:
Adopted so family hx is unknown
Physical Exam:
98.9 91 128/77 18 98RA
Gen: AAOX3, NAD
HEENT: scleral icterus, MMM, EOMi, NCAT
Skin: Jaundice
Cardio: RRR
Pulm: CTAB
Abd: Soft, obese, umbilical hernia noted, tender to paracentesis
site, distended/ascites, spider angiomas
Ext: 3+ pitting edema b/l LE
Neuro: no focal deficits
CXR:
EKG: Sinus rhythm. Non-specific anterior ST-T wave changes.
Delayed precordial R wave transition
Labs:
135 97 11 estGFR: >75
---|----|----< 104
4.3 28 1.0
Ca: 9.7 Mg: 1.7 P: 3.4
ALT: 16 AST: 48 AP: 92 Tbili: 18.6 Alb: 4.0
7.7> 8.2 <149
25.1
PT: 27.2 PTT: 55.8 INR: 2.7
Fibrinogen: 59
Most recent workup:
Liver/RUQ US ([**2196-8-26**]): 1) Cirrhosis with ascites. 2) New,
partially occlusive main portal vein thrombosis extending into
the left portal vein. Please note, the study is limited because
the right portal vein, splenic vein, portal venous confluence
was
not well visualized. 3) Distended gallbladder without signs of
acute cholecystitis. Findings may be due to a fasting state
EGD ([**2196-8-26**]): Varices at the lower third of the esophagus and
gastroesophageal junction, Linear non bleeding erosion at 35 cm.
Erythema, abnormal vascularity and mosaic appearance in the
whole
stomach compatible with portal hypertensive gastropathy.
Otherwise normal EGD to second part of the duodenum
TTE [**8-30**]: EF> 60%
Pertinent Results:
[**2196-10-17**] 04:53AM BLOOD WBC-9.5 RBC-2.90* Hgb-8.7* Hct-27.0*
MCV-93 MCH-29.9 MCHC-32.1 RDW-16.4* Plt Ct-334
[**2196-10-13**] 09:32AM BLOOD PT-11.7 PTT-23.6 INR(PT)-1.0
[**2196-9-30**] 02:52AM BLOOD Fibrino-180
[**2196-9-27**] 05:00AM BLOOD Glucose-104 UreaN-11 Creat-1.0 Na-135
K-4.3 Cl-97 HCO3-28 AnGap-14
[**2196-9-28**] 04:16PM BLOOD Glucose-114* UreaN-30* Creat-2.3* Na-142
K-4.6 Cl-104 HCO3-28 AnGap-15
[**2196-9-30**] 10:50PM BLOOD Glucose-122* UreaN-70* Creat-4.6* Na-137
K-5.8* Cl-97 HCO3-26 AnGap-20
[**2196-10-2**] 06:10AM BLOOD Glucose-137* UreaN-87* Creat-5.2* Na-135
K-5.2* Cl-93* HCO3-26 AnGap-21*
[**2196-10-7**] 05:07AM BLOOD Glucose-147* UreaN-94* Creat-3.6* Na-130*
K-4.2 Cl-94* HCO3-24 AnGap-16
[**2196-10-17**] 04:53AM BLOOD Glucose-93 UreaN-69* Creat-2.0* Na-132*
K-5.2* Cl-100 HCO3-21* AnGap-16
[**2196-9-27**] 05:00AM BLOOD ALT-16 AST-48* AlkPhos-92 TotBili-18.6*
[**2196-10-17**] 04:53AM BLOOD ALT-33 AST-31 AlkPhos-276* TotBili-1.6*
[**2196-10-17**] 04:53AM BLOOD Calcium-8.7 Phos-4.7* Mg-1.5*
Brief Hospital Course:
On [**2196-9-27**], he underwent deceased donor liver transplant.
Surgeon was Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Two 19-French [**Doctor Last Name 406**] drains were
placed posterior to the liver and behind the portal structures.
Please refer to operative note for complete details. Aggressive
blood product resuscitation by anesthesiology staff as well as
administration of protamine was performed. Induction
immunosuppression was started intraop (solumedrol).
Postop, he was transferred to the SICU for management where he
received blood products to maintain hemodynamic stability per
protocol. LFTs initially increased as expected. Hepatic duplex
revealed inadequate flow demonstrated within the right posterior
portal vein which could have been technical in nature versus a
small amount of thrombus. Patency and appropriate direction of
flow within the hepatic arteries, hepatic veins, and the left
and main portal veins was seen. Splenomegaly was noted. A repeat
study on [**10-1**] revealed patency and appropriate direction of flow
within the hepatic and portal venous systems. High flow
velocities in the main portal vein, with aliasing in the
expected region of the anastomosis were noted. There was
notation of fatty infiltration of the liver. LFTs trended down
(ast 580, alt 530, alk phos 130, t.bili 6.6). JP outputs
remained high averaging 900-1100ml per day. LFTs started to
trend up on postop day 4 and 5. JP output appeared foamy.
On [**10-4**], an ERCP was performed noting common bile duct with mild
narrowing at the bile duct anastomosis, and minimal associated
proximal ductal
dilatation. There were no filling defects in the CBD or
intrahepatic ducts.
There was no evidence of bile leakage. A plastic biliary stent
was placed. Post procedure, amylase and lipase were wnl. JP
drain outputs continued to be high averaging as much as
2200ml/day. IV fluid replacements and albumin were administered
per output. The lateral JP was removed on [**10-5**]. The medial JP
continued to drain as much as 1800ml per day. IV lasix was given
for anasarca over several days. Teds stockings were applied with
improvement of edema. Weight decreased to 90.4 Kg on [**10-16**] from
117.4 on [**9-26**]. The medial JP was removed on [**9-14**]. The site
remained dry after suturing.
Of note, alk phos continued to rise to 518. Repeat ERCP was done
on [**10-13**]. There was no obstruction of the biliary stent. The
stent was exchanged. The alk phos continued to increase. On
[**10-14**], a liver biopsy was performed noting no rejection. Marked
bile ductular proliferation with associated neutrophilic
inflammation, focal ductal dilation, marked cholestasis, bile
plug formation and portal tract edema; Rare foci of mild portal
mononuclear inflammation with scattered eosinophils; no
endothelialitis or diagnostic involvement by acute cellular
rejection identified. No steatosis or viral inclusion was seen.
Rare peri-venular lipofuscin-laden macrophages, suggestive of
resolving reperfusion injury. After the ERCP, LFTS trended down
(ast 31, alt 33, alk phos 276, t.bili 1.6). The postop pyloric
feeding tube was replaced on [**10-6**] as this was removed during the
ERCP.
He experienced ATN likely from intraop hemodynamics. Creatine
was 1.0 on on [**9-27**]. This started to rise postop to as high as
5.2 on postop day 5. Very gradually, creatinine improved with.
Creatinine decreaed to 1.8 on [**10-13**], but started to trend up
again to 2.0 likely from Prograf as this trough was elevated.
Levels increased to 14.1 on [**10-16**]. Prograf dose was adjusted to
0.5mg [**Hospital1 **] on [**10-16**] for 1mg [**Hospital1 **]. Immunusuppression consisted of
cellcept 1gram [**Hospital1 **] which was well tolerated. Solumedrol which
was tapered per transplant protocol to prednisone. Prograf was
started on postop day 1 and adjusted per trough levels.
Diet was slowly advanced, but poorly tolerated as the patient
had no appetite. A postpyloric feeding tube was placed and tube
feedings were started (novasource renal). Oral intake slowly
increased, but was insufficient to support caloric needs.
On [**10-10**] Dermatology biopsied his L thumb for a chronic
non-healing, bleeding punctate lesion (started in [**4-21**]). Biopsy
report noted many features suggestive of lichen simplex
chronicus/prurigo nodularis, and the mild atypia which is
present is favored to be reactive in this context. The central
ulceration could be secondary to excoriation; alternatively, it
may represent a channel for transepidermal elimination of a
foreign body or in the setting of a perforating disorder
(although the clinical history is not suggestive of the latter).
An underlying pyogenic granuloma cannot be entirely excluded on
the basis of this sample; if clinical suspicion persists, deeper
sampling may be helpful for more definitive diagnostic
evaluation. The bleeding stopped and site remained clean and
dry.
PT worked with him extensively during this hospital course for
deconditioning. He did experience a fall onto right hip(slipped
while transferring to bed). He had pain with hip flexion and
pain on exam over greater trochanter. Xrays of the hip were
negative. He required contact guard and a rolling walker at time
of discharge, but was not ready for discharge to home. Rehab was
recommended and [**Hospital1 **] accepted him. He was transferred there
on [**10-17**].
Medications on Admission:
Folic Acid 1, Thiamine HCl 100, Ursodiol 300''', Ranitidine
HCl 150'', lactulose, Furosemide 20, Spironolactone 100, Zofran
4, Maalox, Rifaximin 200'''
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours): Please fax prograf trough levels to
[**Telephone/Fax (1) 697**].
Call [**Telephone/Fax (1) 673**] for dose adjustments, attn [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN
coordinator.
13. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
follow taper schedule per [**Hospital1 18**] Transplant .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
etoh cirrhosis s/p liver transplant [**2196-9-27**]
bile duct narrowing, s/p stent
malnutrition
Left thumb bleeding s/p biopsy: pyogenic granuloma
ATN, resolving
Discharge Condition:
good
Discharge Instructions:
Please call the [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**] if fever,
chills, nausea, vomiting, inability to take any of your
medications, jaundice, abdominal distension, increased abdominal
pain, edema, dizziness, incision redness/bleeding/drainage or
any concerns
Continue tube feedings as ordered (Novasource renal at 45cc/hr
continuously via the feeding tube)
Labs every Monday and Thursday by 9am for cbc, chem 10, LFTs,
albumin and trough prograf level with results fax'd to [**Hospital1 18**]
Transplant Office [**Telephone/Fax (1) 697**] attention [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN
coordinator [**Telephone/Fax (1) 10575**]
[**Month (only) 116**] shower, no heavy lifting/straining
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-10-20**] 3:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2196-10-27**]
11:30
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-10-27**] 1:20
Completed by:[**2196-10-17**]
ICD9 Codes: 5845, 2761, 4280, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 73
} | Medical Text: Admission Date: [**2151-6-14**] Discharge Date: [**2151-9-18**]
Date of Birth: [**2151-6-14**] Sex: F
Service: Neonatology
HISTORY: This is a 1320 g female, twin A, born via c-section
to a 37-year-old G4, P [**1-27**] mother at 32 1/7 weeks for IUGR of
twin B. She had a history of decreased Doppler flow to twin
B. Maternal labs include blood type O+, antibody negative,
RPR nonreactive, hepatitis B surface antigen negative,
rubella immune, and GBS unknown. The infant emerged vigorous
and had Apgars of 8 and 8. She received blow-by O2 and
routine stimulation and suctioning.
ADMISSION PHYSICAL EXAMINATION: Vital Signs: Weight 1320 g
(25th percentile); length 41.5 (25th to 50th percentile);
head circumference 29.25 (25th percentile); temperature 97;
heart rate 170; respiratory rate 36; blood pressure 43/34
(34); O2 saturation 89% with blow-by O2. General: Alert;
pink; crying. HEENT: Anterior fontanelle open and flat;
mucous membranes moist; palate intact. Lungs: Decreased air
movement throughout, with prolonged expiratory phase.
Cardiovascular: Regular rate and rhythm; no murmur; 2+
femoral pulses. GI: Soft; no masses. GU: Normal premature
female external genitalia. Musculoskeletal: Hips and
clavicles intact. Neurologic: Moved all extremities.
DISCHARGE PHYSICAL EXAMINATION: Weight 3835 g; head
circumference 36.0 cm; length 52 cm.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. Respiratory. Upon admission, the baby was started on
nasal CPAP. She needed to be intubated on day of life 1
and remained intubated until day of life 3 when she
transitioned back to nasal CPAP. On day of life 4, she
was transitioned to room air and has been on room air
since that time. She did have apnea of prematurity that
was treated with caffeine. That was discontinued on day
of life 14. She has had no issues since that time.
2. Cardiovascular. At birth, she had a normal blood
pressure and never required pressors or fluid boluses.
She does not have a murmur and has been stable.
3. Fluids, Electrolytes, and Nutrition. The baby started
n.p.o. and on IV fluids. She did have a UVC in for
several days and received several days of parenteral
nutrition. On day of life 3, she started feeds, which
were advanced as tolerated. She did have many problems
with p.o. feeds. Secondary to her difficulty with p.o.
feeds and not taking enough, she received a jejunostomy tube.
Currently, she is on p.o. ad. lib. feeds during the day
and at night, starting at 10 p.m. and going till 6 a.m.,
she receives J tube continuous feeds of 100 mL/kg over 8
hours.
4. GI. The baby was found to have hyperbilirubinemia on day
of life 2 with a peak of 6.8/0.2. She received several
days of phototherapy, and all phototherapy was stopped
on day of life 5 and she has had no further bilirubin
issues. On day of life 12, she was started on iron 2
mg/kg/day, which continued through today. The baby was
found to have severe reflux which was worked up through
GI at [**Hospital3 1810**], [**Location (un) 86**]. She was started on
multiple medications, which she continues today and are
Prilosec, Reglan, Zantac, and Maalox. Secondary to this,
they did an endoscopy on [**2151-9-10**]. This was
negative for esophagitis although pathology on the
biopsies is still pending. An NJ tube was placed to see
if that would improve the feeding and also improve the
irritability, arching, and other reflux-related
behaviors and it did. So, a jejunostomy tube was placed on
[**2151-9-14**]. She will need to follow up with Dr. [**Last Name (STitle) 79**] at the
[**Hospital **] clinic at [**Hospital3 1810**], [**Location (un) 86**].
5. Hematology. At birth, a CBC was done and the baby had a
hematocrit of 41.2 and 283 platelets. Her latest
hematocrit was 31.1 on day of life 91.
6. Infectious Diseases. At birth, a rule-out sepsis workup
was done. The baby had a white count of 7 with 51
neutrophils and 2 bands. She had 48 hours of ampicillin
and gentamicin, which were discontinued. On postop day
#1, [**2151-9-15**], she spiked a fever to 101.3 and a
sepsis workup was done again. This was reassuring and
negative. She had received 48 hours of ampicillin and
gentamicin with no further issues.
7. Neurology. The baby has always had a normal neurologic
exam and has had 2 normal head ultrasounds - the latest
being [**2151-7-20**].
8. Sensory.
a. Audiology. A hearing screen was performed with
automated auditory brain stem responses, which the baby
passed.
b. Ophthalmology. The baby had 2 ophthalmologic
exams. The eyes were most recently examined on [**2151-7-26**], revealing mature retinal vessels. A follow-up
exam in 6 months is recommended.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: [**Last Name (un) **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] of Pediatric
Associates of [**Location (un) 3786**] (phone number [**Telephone/Fax (1) 45614**]).
CARE RECOMMENDATIONS:
1. Feeds at discharge - Please continue Neocate 24 feeds
p.o. ad. lib. during the day and J tube feeds at 100
mL/kg over 8 hours at night.
2. Medications - Prilosec 1 mg/kg/dose b.i.d.; Reglan 0.1
mg/kg q.i.d.; Zantac 10 mg p.o. b.i.d.; Maalox 2.5 mL q
p.o. feed; iron sulfate 2 mg/kg/day.
3. Iron and vitamin D supplementation.
a. Iron supplementation is recommended for preterm
and low birth weight infants until 12 months corrected
age.
b. All infants fed predominantly breast milk should
receive vitamin D supplementation at 200 IU (may be
provided as a multivitamin preparation) daily until 12
months corrected age.
4. Car seat position screening test was passed prior to
discharge.
5. State newborn screening status - The baby had 3 state
newborn screens - [**2151-6-17**]; [**2151-6-28**]; [**2151-7-26**] - all of which were normal.
6. Immunizations received - The baby received no
immunizations prior to discharge.
7. Immunization recommendations:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: 1) born at less than 32 weeks; 2)
born between 32 and 35 weeks with 2 of the following:
daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, and school-
age siblings; 3) chronic lung disease; 4)
hemodynamically significant congenital heart disease.
b. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age (and for the first 24 months of
the child's life), immunization against influenza is
recommended for household contact and out-of-home
caregivers.
c. This infant has not received a rotavirus vaccine.
The American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks, but fewer than 12 weeks of
age.
FOLLOW-UP APPOINTMENT SCHEDULE RECOMMENDED:
1. The baby has a follow-up appointment with her primary
care pediatrician on [**Last Name (LF) 766**], [**2151-9-20**].
2. A follow-up appointment needs to be made with [**Hospital1 62374**] GI, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79**], for 2 weeks after discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 and 1/7 weeks' gestation.
2. Twin gestation.
3. Rule out sepsis.
4. Respiratory distress syndrome.
5. Severe gastroesophageal reflux.
6. Status post J tube placement.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**First Name3 (LF) 72788**]
MEDQUIST36
D: [**2151-9-20**] 14:06:19
T: [**2151-9-20**] 15:21:09
Job#: [**Job Number 72789**]
ICD9 Codes: 7742, 769, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 74
} | Medical Text: Admission Date: [**2150-12-24**] Discharge Date: [**2150-12-26**]
Date of Birth: [**2092-10-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58f with breast cancer, HTN, CHF, PAF s/p PVI presents with
shortness of breath, increasing over the past day. She notes
that the symptoms became gradually, with increasing dyspnea on
exertion and a productive cough but that she then developed
palpitations, with increased dyspnea related to this. Her pulse
was fast and irregular. She came into the emergency department
and was found to be in rapid atrial fibrillation; a chest x-ray
revealed a pneumonia. She recieved levofloxacin and IV
diltiazem in the ED and was admitted.
Past Medical History:
1. PAF s/p pulm vein isolation, w/ recurrence s/p radiation, now
on amiodarone.
2. CHF diastolic EF 62% by MRI [**3-6**]
3. Breast cancer Stage II status post right mastectomy and
status post six months of tamoxifen therapy, now s/p XRT
4. Hypertension.
5. Hyperlipidemia.
Social History:
Patient is married and lives with her husband. She denied
smoking or alcohol use.
Family History:
NC
Physical Exam:
t 99.4, bp 134/86, hr 122, rr 18, spo2 96% 2L nc
gen- pleasant f, looks age, mild distress, non-toxic
heent- anicteric, op clear with mmm
neck- no jvd/lad/thyromegaly
cv- tachy, irreg irreg, no m/r/g
pul- moves air well, slight bibasilar rales r>l
abd- soft, nt, nd, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/color changes/indentations
neuro- a&ox3, no focal cn/motor deficits
Pertinent Results:
[**2150-12-24**] 10:00PM BLOOD WBC-6.5 RBC-4.33 Hgb-13.0 Hct-36.7
MCV-85# MCH-29.9 MCHC-35.4*# RDW-14.7 Plt Ct-150
[**2150-12-26**] 06:00AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-25 AnGap-13
[**2150-12-24**] 10:00PM BLOOD CK(CPK)-54 TotBili-0.6
[**2150-12-24**] 10:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-12-26**] 06:00AM BLOOD CK(CPK)-81
[**2150-12-26**] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-12-25**] 06:40AM BLOOD ALT-31 AST-18 AlkPhos-76 TotBili-0.5
[**2150-12-25**] 06:40AM BLOOD TSH-4.6*
Brief Hospital Course:
58f with breast cancer, htn, chf, paf s/p pvi admitted with
pneumonia and afib with rapid ventricular response
.
Afib -- Mrs. [**Known lastname **] is maintained on amiodarone at home in sinus
rhythm. It was felt that her pneumonia was the likely culprit
in this exacerbation back into fibrillation. She was seen by
the EP staff who felt she would do well with a loading dose of
amiodarone of 400mg twice daily for three days; she would then
return to her usual dose of 200mg daily. This was begun with a
good response. Sinus rhythm was quickly re-instated. Her
symptoms of dyspnea and palpitations seems to improved with
reversion to sinus. She was discharged with one day of
loading-dose amidodarone left in sinus rhythm, with rates
generally in the 70's.
.
Pneumonia -- Although clinically mild, it was felt sufficient to
cause her loss of sinus rhythm. She had no O2 requirement and
was treated with a course of levofloxacin. By the time she was
discharged, she was afebrile with decreased cough and sputum
production. Micro data was unrevealing.
Medications on Admission:
Pantoprazole 40mg daily
Amiodarone 200mg daily
Metoprolol 25mf twice daily
Warfarin 2mg mon-fri and 1mg sat-sun
ASA 325mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO SAT-SUN ().
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO MON-FRI ().
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 days: Take 2 pills twice a day on Saturday and
Sunday, then return to 200mg once a day.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Pneumonia
Secondary:
1. PAF s/p pulm vv isolation, w/ recurrence s/p radiation, now
on amiodarone.
2. CHF, one episode post cardioversion, diastolic EF 55% 2/04
3. Breast cancer Stage II status post right mastectomy and
status post six months of tamoxifen therapy, now s/p XRT
4. Hypertension
5. Hyperlipidemia
Discharge Condition:
Good, in sinus rhythm, with improved symptoms
Discharge Instructions:
You were admitted for a pneumonia and a rapid heart rate; your
heart rate was controlled with a temporarily increased dose of
amiodarone, and you were given antibiotics for the pneumonia.
.
Call your PCP or return to the ED for fevers/chills, chest pain,
shortness of breath, lightheadedness, loss of conciousness, or
other concerning symptoms.
.
Take 400mg of amiodarone twice a day on Saturday and Sunday,
then return to your usual dose of 200mg once a day on Monday.
Followup Instructions:
Please see your primary care doctor in the next 1-2 weeks; call
[**Telephone/Fax (1) 2740**] to make an appointment.
.
Provider: [**Last Name (NamePattern4) 105871**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-3-4**] 8:00
.
Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2151-3-9**] 11:00
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2151-3-19**] 3:15
ICD9 Codes: 486, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 75
} | Medical Text: Admission Date: [**2115-1-11**] Discharge Date: [**2115-1-19**]
Date of Birth: [**2033-12-10**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
81 year old man with CAD s/p CABG in [**2103**] with a LIMA to the
LAD, SVG to the PDA, SVG to the OM, HTN, IDDM, PVD s/p bilateral
LE bypass, CRI, admitted to [**Hospital3 417**] Hospital [**1-7**] with
shortness of breath and chest pain x one week. Initially thought
to be rest angina. Ruled out for MI, no EKG changes. Transferred
here for cath.
In holding area pt had chest pain, no EKG changes. Underwent
difficult catheterization today(received large amount of
radiation)which demonstrated severe native three vessel disease.
The left main was heavily calcified with an 80% distal stenosis.
The left anterior descending received blood from the LIMA graft.
The left circumflex demonstrated a 90% ostial lesion. RCA was
diffusely diseased. The LIMA-LAD graft was patent. SVG-OM
patent; SVG-RPDA patent with an 85% mid RCA lesion. No attempt
at PCI today due to excessive radiation dose and dye dose. Pt
scheduled for for planned PCI to the SVG-rPDA and possible LMCA
intervention on Monday.
Past Medical History:
HTN
IDDM
CAD s/p CABG in [**2103**] with a LIMA to the LAD, SVG to the PDA, SVG
to the OM ([**2103**])
PVD s/p bilateral LE bypass
COPD
carotid disease
CRI
BPH s/p TURP
nephrolithiasis
history of thrombocytopenia
Social History:
Social history is significant for 50 pack year smoking history;
quit '[**03**], no ETOh or drug use. Lives at home with wife,
independent ADLs.
Family History:
NC
Physical Exam:
GEN: elderly male, NAD
HEENT: NC/AT, EOMI, PERRL, O/P clear, MMM
Neck: JVP+9, supple
CV: RRR, no m/r/g
Lungs: CTA bilaterally
Abd: Obese, soft, NT, ND
Ext: WWP, no edema
Neuro: A&O x3
Pertinent Results:
[**2115-1-11**] 09:15PM GLUCOSE-208* UREA N-45* CREAT-1.9* SODIUM-136
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13
[**2115-1-11**] 09:15PM CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-2.2
[**2115-1-11**] 09:15PM WBC-4.1 RBC-3.07* HGB-10.1* HCT-29.7* MCV-97
MCH-32.9*# MCHC-34.0 RDW-15.7*
[**2115-1-11**] 09:15PM PLT COUNT-96*
[**2115-1-11**] 06:16PM GLUCOSE-369* UREA N-45* CREAT-1.8* SODIUM-134
POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-20* ANION GAP-14
[**2115-1-11**] 06:16PM estGFR-Using this
C.CATH [**1-11**]
COMMENTS:
1. Selective cornary angiography in this right dominant system
revealed
diffuse three vessel coronary artery disease. The LMCA was
unable to be
engaged selectively despite using a 4 french JL4, JL4.5, JL5. A
five
french JL5, JL4.5, AL1, AL2, and AL3 were also unsucessful. The
LMCA
was heavily calcified and had an ostial plaque. There was an
80% distal
LMCA lesion that involved the origins of the LAD, ramus, and
[**Month/Day (4) **]. The
LAD had a functional ostial stenosis (extended from distal
LMCA);
signficiant proximal stenosis; and minimal flow into the mid
LAD.
Overall, the LAD was not able to be well visualized because of
difficulty engaging the LMCA. The [**Month/Day (4) **] had a 90% stenosis in the
origin
that extended from the distal LMCA. The AV groove [**Month/Day (4) **] supplied
a
diffusely disease OM1 (up to 70% stenosis) and LPL. The ramus
was not
well seen but had an ostial 80% stenosis. There was heavily
calcified
plaque in the aorta at the origin of the RCA. The RCA had heavy
calcification proximally with 70% and 90% stenoses. The mid
vessel had
a 50% stenosis. The distal RCA was a tortuous vessel that
supplied a
long lower acute marginal with lateral branches that supplied
the
inferior septum. The native AV groove RCA was heavily calcified
and
subtotally occluded after the take-off of the large lower AM.
2. Venous conduit angiography revealed an SVG to OM (engaged
with a 5
french AL2) that was patent thoughout and touched down onto the
lower
pole OM that does not communicate with the native AV groove [**Name (NI) **].
The
SVG-rPDA (engaged with 5 french MPA) had an ostial 30% and mid
85%
stenosis; this graft retrogradely filled a severely diffusely
diseased
distal AV groove RCA that gave septal collaterals to the LAD.
3. Nonselective arterial conduit angiography revealed a patent
LIMA
with a 30% ostial stenosis that touches down on a small calibur,
heavily
calcifed LAD (not well imaged).
4. Left subclavian angiography revealed a heavily calcifed
vessel with
a proximal 50% stenosis. The left subclavian stenosis prevented
advancement of a 4 french [**Female First Name (un) 899**] catheter despite use of an angled
glide
wire, slip catheter, and Amplatz stiff wire. A 4 french
Berenstein was
ultimately advance to the subclavian distal to the LIMA over the
angled
glide wire.
5. Left ventriculography was not perfomed secondary to renal
insufficency.
6. Limited hemodynamics demonstrated systemic systolic
hypertension
with a central aortic pressure of 167/68 (systolic/diastolic in
mmHg).
There was severe diastolic dysfunction with an LVEDP of 32 mmHg.
There
was no gradient across the aortic valve on pullback.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe diastolic ventricular dysfunction.
.
[**1-14**] Cardiac cath:
1. Planned intervention of a 90% body of SVG-PDA lesion
with direct stenting with a Vision 3.5x18mm stent.
2. Limited hemodynamics with BP 142/59 with HR 55 with
significant
ventricular ectopy.
3. Access via 6F long sheath in RFA.
FINAL DIAGNOSIS:
1. Succesful direct stenting of SVG-PDA graft with bare metal
stent.
Brief Hospital Course:
.
#. CAD: The patient presented to an OSH on [**1-7**] with shortness
of breath and chest pain. He was transferred to [**Hospital1 18**] for
cardiac cathterization. This diagnostic procedure on [**2115-1-11**] was
complicated requiring a signficant amount of dye and radiation,
therefore, the intervention was planned for another day. It
demonstrated severe native 3vd, patent LIMA-LAD, SVG-OM, 90% [**Date Range **]
ostial lesion, diffusely diseased RCA with 85% lesion and patent
SVG-RPDA. He received Reopro post cathterization and developed a
hematoma requiring a pressure dressing. The patient developed
refractory chest pain without ECG changes before the
intervention could be performed, and was transferred to the CCU
for monitoring and management.
In the CCU, he was given Argatroban for ACS (reported concern
re: HIT). He had cardiac cathterization on [**2115-1-14**] with
intervention and stenting of SVG-RCA. His sheath was pulled
while on Argatroban and the patient developed a significant
hematoma requiring 2 units pRBC transfusion. The next day, the
patient developed stuttering chest pain and plans were made to
take him back to the cath lab for possible intervention on left
main or RCA. He was transitioned from a nitro gtt to isosorbide
for the chest pain. He was started on argatroban prior to the
procedure. He underwent a third catheterization on [**1-17**] with
stenting to his L. Subclavian. He subsequently remained chest
pain free. He was continued on aspirin, Plavix, statin, and
Toprol. No further events occured, chest pain had resolved and
he was sent home on the above medications.
.
#. Systolic Heart Failure: An echo was performed which showed EF
60%. Patient was continued on his Lasix and his beta blocker
was increased.
.
#. Rhythm: Patient in normal sinus rhythm during most of his
hospital stay, however during the CCU he had a few episodes of
bradycardia and his beta blocker was held. This was subsequently
resumed prior to discharge.
.
#. Diabetes-Patient was placed on an insulin sliding scale and
placed back on his home glyburide prior to discharge.
.
#CRI-Baseline 2.2 at OSH. It initially increased after the first
catheterization but subsequently improved after post-cath
hydration and IVF. His creatinine was monitored and remained
stable throughout the rest of his hospitalization. All of the
medications were renally dosed and he received pre- and
post-cath hydration for each of his procedures.
.
#Hematuria-Pt has gross blood in foley which was thought to be
related to traumatic insertion. His foley was subsequently
flushed and there were no clots. There was no further evidence
of hematuria and no further intervention was taken.
.
#BPH-Patient was continued on his home hytrin
.
#Thrombocytopenia-Patient has known chronic thrombocytopenia. It
is unclear what his baseline is, but at the OSH his platelets
were in the low 100s. HIT Ab was sent which was negative.
Heparin was held throughout his stay and his platelets remained
stable in the 80s to low 100s. NO further intervention taken.
.
#Chronic Anemia-Pt on Procrit q week (tues). He received 2 units
of prbcs in the CCU for his hematoma and his HCt subsequently
remained stable. He did not receive any Procrit during his
hospitalization but this should be resumed per his regular
schedule upon discharge.
.
#Sciatica-Patient was continued on his home Neurontin.
Medications on Admission:
ASA 325mg daily
Nexium 40mg daily
Toprol XL 25mg daily
MVI
Neurontin 300nmg daily
Hytrin 2mg PO QHS
Lasix 40mg daily
Glyburide 5mg daily
Iron 325mg daily
Procrot q week (tues)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Procrit Injection
12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes up to three times as needed for pain:
Tkae every 5 minutes up to three doses; if not working call your
doctor or go to the ER.
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Primary
CAD s/p 3 PCIs
.
Secondary
HTN
IDDM
COPD
PVD
CRI
BPH
Thrombocytopenia
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital with chest pain. You
underwent 3 cardiac catheterizations and had stents placed to
the blocked vessels in your heart. You had a complication after
one of the procedures and had some bruising and swelling in your
groin which resolved.
.
There were some changes made to your medications. You were
started on Lipitor, and Plavix. The other medications were kept
the same.
.
If you have any chest pain, shortness of breath,
nausea,vomiting, palpitations, lightheadednes, bleeding from the
groin, or any other concerning symptoms, please call your doctor
or return to the ER.
.
Please follow up as below
Followup Instructions:
Please follow up with your cardiologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2
weeks.
Please call and make an appt with your PCP [**Last Name (NamePattern4) **] [**4-8**] weeks.
ICD9 Codes: 5849, 4111, 4019, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 76
} | Medical Text: Admission Date: [**2179-9-22**] Discharge Date: [**2179-10-14**]
Date of Birth: [**2125-3-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
[**2179-10-7**]: MV repair/MAZE/ left atrial appendage resection
[**2179-10-13**]: AICD placement
History of Present Illness:
This 54 year old male with no known pmh presented s/p
ventricular fibrillation arrest on [**2179-9-22**]. He was at the Red
Sox game with his sister and they were walking to their car when
he stopped to smoke a cigarette and then he collapsed. A passing
physician initiated CPR within 3-5 minutes per his sister's
report. He was found to be in ventricular fibrillation and was
shocked 5 times, given 3mg of epinephrine, 2mg of magnesium for
torsades rhythm. He eventually had spontaneous return of
circulation and breathing. He was intubated
in the field on route to [**Hospital1 18**]. He was transferred from the ED
to the CCU and put on the arctic sun protocol. He was
unresponsive and sedated and was eventually extubated on [**9-25**]
and has been very agitated and uncooperative.
He has a history of ETOH and is a heavy smoker. Cardiac cath
[**2179-9-29**] revealed no coronary disease but he has 3+ mitral
regurgitation. He is being evaluated for mitral valve repair.
Past Medical History:
unknown, has not gone to a doctor for at least 20 years.
Social History:
Lives with: sisters
Occupation: works in [**Last Name (un) **] chemical pipefitting
Tobacco:1.5 ppd for many years, current
ETOH: a few beers per night, several on weekends
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:108 Resp: 20 O2 sat:
B/P Right: 93/81 Left:
Height: 6'3" Weight: 60.7 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] NGT in place for tube feeds.
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur III/VI holo diastolic
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: A+Ox3 but unable to swallow and is still impulsive and
restrained.
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2179-10-12**] 04:40AM BLOOD WBC-12.4* RBC-3.24* Hgb-10.5* Hct-31.2*
MCV-96 MCH-32.5* MCHC-33.8 RDW-14.4 Plt Ct-242
[**2179-10-11**] 06:05AM BLOOD WBC-15.0* RBC-3.33* Hgb-10.6* Hct-32.4*
MCV-97 MCH-32.0 MCHC-32.9 RDW-14.4 Plt Ct-213
[**2179-10-12**] 04:40AM BLOOD PT-14.0* INR(PT)-1.2*
[**2179-10-11**] 06:05AM BLOOD PT-12.9 INR(PT)-1.1
[**2179-10-12**] 04:40AM BLOOD Glucose-104* UreaN-14 Creat-0.7 Na-137
K-3.6 Cl-99 HCO3-31 AnGap-11
[**2179-10-11**] 06:05AM BLOOD Glucose-91 UreaN-14 Creat-0.6 Na-134
K-3.7 Cl-96 HCO3-31 AnGap-11
[**2179-10-12**] 04:40AM BLOOD WBC-12.4* RBC-3.24* Hgb-10.5* Hct-31.2*
MCV-96 MCH-32.5* MCHC-33.8 RDW-14.4 Plt Ct-242
[**2179-10-13**] 04:40AM BLOOD PT-16.6* INR(PT)-1.5*
[**2179-10-13**] 04:40AM BLOOD UreaN-14 Creat-0.7 Na-133 K-4.2 Cl-100
[**2179-10-14**] 04:20AM BLOOD WBC-14.4* RBC-3.32* Hgb-10.4* Hct-31.5*
MCV-95 MCH-31.4 MCHC-33.1 RDW-14.5 Plt Ct-307
[**2179-10-14**] 04:20AM BLOOD UreaN-16 Creat-0.7 Na-132* K-4.2 Cl-94*
CT HEAD W/O CONTRAST Study Date of [**2179-9-22**]
FINDINGS: There is no hemorrhage, edema, mass effect, or
evidence for acute vascular territorial infarction. There is no
shift of normally midline structures and [**Doctor Last Name 352**]-white matter
differentiation is well preserved. The size and configuration of
the ventricles appears normal. Osseous structures are intact.
There is opacification of bilateral maxillary sinuses. Ethmoid
air cells demonstrate mucosal thickening. There is trace fluid
within the mastoid air cells bilaterally. There is a left
occipital posterior scalp hematoma.
IMPRESSION:
1. No acute intracranial process.
2. Left occipital scalp hematoma, without fracture.
Intra-op TEE [**2179-10-7**]
Pre-CPB:
Mild spontaneous echo contrast is seen in the body of the left
atrium.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 - 45 %). with mild global free wall hypokinesis.
1+ AI.
There are simple atheroma in the descending thoracic aorta.
The mitral valve shows characteristic myxomatous deformity.
There is moderate/severe posterior leaflet mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is on infusons of Epi and NTG, AV-Paced.
There is a mitral ring in good position with no leak and no MR.
Residual area is 2.8 cm2.
Biventricular systolic fxn is mildly improved.
TR remains 1+, AI remains 1+. Aorta intact.
Brief Hospital Course:
54 year old male with no known past medical history admitted
with VF arrest while at the Red Sox game. He underwent CPR in
the field along with defibrillation and transition to atrial
fibrillation. He was admitted to the [**Hospital1 18**] CCU and was
initiated on the Arctic Sun cooling protocol for cardiac arrest.
Initial echocardiogram showed severe mitral valve prolapse and
regurgitation with a flail mitral valve, which was most likely
the precipitant of his VF arrest. The patient was extubated
successfully approximately 48 hours after rewarming. Upon
admission, he was started on empiric antibiotic therapy for
possible aspiration pneumonia with cefepime, vancomycin and
metronidazole. He was taken to the operating [**2179-10-7**] and
underwent left sided maze procedure and Mitral Valve repair (see
operative note for full details). Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
Vancomycin was used for surgical antibiotic prophylaxis, given
the length of preoperative stay. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable,
weaned from inotropic and vasopressor support. Amiodarone was
started for atrial fibrillation. Beta blocker was initiated and
the patient was gently diuresed toward the preoperative weight.
Intra-operatively, the patient was found to have an osteoporotic
appearing sternum. [**Month/Day/Year 6091**] was consulted and has
recommended outpatient follow up following recovery from cardiac
surgery. The patient continued to exhibit dysphagia, and
dobhoff tube was placed for feeding purposes. Coumadin was
started for atrial fibrillation. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. A dual chamber ACID was
placed on [**2179-10-13**] without complication. This was interrogated
[**10-14**] and follow up appointment with the device clinic was
arranged. He had a repeat video swallow study and was cleared
for nectar thick ground diet and tube feeds were cycled. His
Dobhoff tube was removed on day of discharge and patient was
instructed by the speech and swallow team for aspiration
precautions. He is to follow up as an outpatient with a video
swallow study (scheduled) for diet advancement. He was started
on an ACE-I for EF 35% once blood pressure tolerated. His INR
was 2.3 on the day of discharge and he was given 1 mg of
Coumadin with plans to have INR drawn [**10-15**] with results to be
called in to [**Hospital3 271**] at [**Telephone/Fax (1) 2173**] for further
Coumadin dosing instructions. INR goal [**2-3**] for atrial
fibrillation. By the time of discharge on POD 7 the patient was
ambulating freely, the wound was healing well with staples in
place and pain was controlled with oral analgesics and he was
tolerating a ground diet. The patient was discharged home with
services in good condition with appropriate follow up
instructions and follow up appointments arranged.
Medications on Admission:
None
Discharge Medications:
1. furosemide 20 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal [**Month/Day (3) **]:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Month/Day (3) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. nicotine 14 mg/24 hr Patch 24 hr [**Month/Day (3) **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*1*
5. thiamine HCl 100 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. folic acid 1 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Month/Day (3) **]: One
(1) Tablet, Chewable PO BID (2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Day (3) **]: 2.5 Tablets
PO DAILY (Daily).
9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
10. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day) for 30 days: Take x 30 days then per cardilogist
instructions.
Disp:*60 Tablet(s)* Refills:*0*
12. warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once) for
1 doses: Take as instructed by cardiologist for INR goal of
2.0-3.0.
Disp:*60 Tablet(s)* Refills:*0*
13. clindamycin HCl 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice
a day for 2 days.
Disp:*4 Capsule(s)* Refills:*0*
14. lisinopril 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Mitral regurgitation/ Atrial fibrillation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg 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
Provider: [**Name10 (NameIs) 6091**] [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2179-11-29**] 2:30
Provider: [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2179-10-29**] 9:10
Surgeon: Dr [**Last Name (STitle) **] [**2179-10-27**] at 1:00 PM
Cardiologist: [**Last Name (LF) 171**], [**First Name3 (LF) **] [**2179-11-8**] at 1:20 PM
EP Device Clinic in 1 week [**Telephone/Fax (1) 62**] [**10-19**] at 11:30 AM
Primary Care Dr. [**Last Name (STitle) **] [**4-5**] weeks
Video swallow follow up in 2 weeks - to be scheduled
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2/0-3.0
First draw [**2179-10-15**]
Results to Dr[**Name (NI) 87655**] office phone [**Telephone/Fax (1) 1989**] or NP [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 87656**]
**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:[**2179-10-14**]
ICD9 Codes: 5070, 5119, 2762, 7907, 2761, 5849, 4240, 3051, 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 77
} | Medical Text: Admission Date: [**2111-9-29**] Discharge Date: [**2111-10-5**]
Date of Birth: [**2050-1-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ampicillin / Amoxicillin / Ativan
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
OP CABGx2(LIMA-LAD,SVG-OM)[**10-1**]
History of Present Illness:
61 yo M with 2 month decline in energy and malaise who was
walking at home, unable to sleep and tripped/lost balance and
fell against the bath tub and developed SOB. At OSH, Was found
to have R ptx and rib fx. Was also found to have pulmonary edema
with elevated trops.Had known CAD, uncerwent repeat cath which
showed significant CAD. Tansferred to [**Hospital1 18**] for further eval.
Past Medical History:
Acute on Chronic systolic heart failure
DM
HTN
[**Hospital1 18048**]
ESRD - on HD (MWF) - last dialysis [**11-8**]; [**11-11**]
Thrombectomy L arm fistula [**12-22**]
Hypercholesterolemia
GIB [**10-20**] in prepyloric area by EGD (? [**12-19**] NSAIDS)
Gastritis [**12-22**] (EGD)
Anemia
Hip surgery [**6-21**] - on coumadin
Prostate adenocarcinoma
Chronic low back pain
Social History:
Occasional EtOH, No tobacco, No drugs
Family History:
Mother: [**Name (NI) 18048**]
Physical Exam:
Obese M in NAD
Neuro A&O, forgetful train of though, wanders, grip strenth L
[**3-21**], R [**2-19**] PERRL
CV RRR 2/6 SEM
Resp crackles thoughout Right, Left clear
GI obese, soft/NT
Right groin macerated/fungal infection
Pertinent Results:
[**2111-10-4**] 08:20AM BLOOD WBC-8.0 RBC-2.74* Hgb-8.4* Hct-24.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.4* Plt Ct-130*
[**2111-10-3**] 08:35AM BLOOD WBC-7.9 RBC-3.03* Hgb-9.4* Hct-27.5*
MCV-91 MCH-31.1 MCHC-34.2 RDW-16.9* Plt Ct-127*
[**2111-10-4**] 08:20AM BLOOD Plt Ct-130*
[**2111-10-3**] 08:35AM BLOOD Plt Ct-127*
[**2111-10-1**] 01:33PM BLOOD PT-19.9* PTT-39.1* INR(PT)-1.9*
[**2111-10-4**] 08:20AM BLOOD Glucose-155* UreaN-38* Creat-6.8*#
Na-129* K-4.4 Cl-89* HCO3-30 AnGap-14
[**2111-10-3**] 08:35AM BLOOD Glucose-123* UreaN-22* Creat-5.2* Na-135
K-4.2 Cl-92* HCO3-31 AnGap-16
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 21518**] (Complete)
Done [**2111-10-1**] at 10:54:10 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2050-1-9**]
Age (years): 61 M Hgt (in): 70
BP (mm Hg): 137/74 Wgt (lb): 235
HR (bpm): 68 BSA (m2): 2.24 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 410.91, 440.0
Test Information
Date/Time: [**2111-10-1**] at 10:54 Interpret MD: [**Name6 (MD) 3892**]
[**Name8 (MD) 3893**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% >= 55%
Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm
Hg
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *2.0 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the LA/LAA or the RA/RAA. All four pulmonary
veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Moderate regional LV systolic dysfunction. Mildly depressed
LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Simple atheroma in aortic arch. Mildly dilated descending aorta.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-revascularization:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is mildly dilated. There is moderate to
severe regional left ventricular systolic dysfunction of the
inferior, septal and anterior walls. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened with focal calcification of
left coronary cusp causing aorto sclerosis. There is no aortic
valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
7. There is no pericardial effusion.
Post revascularization:
Pt on phenylephrine infusion in intrinsic sinus rhythm:
1. Normal Rv function. LVEF 40%
2. No new regional wall motion abnormalites, valves as listed
pre-revascularization.
3. Thoracic aortic contour is intact
CHEST (PORTABLE AP) [**2111-10-2**] 4:28 PM
CHEST (PORTABLE AP)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p cabg and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
HISTORY: Status post CABG with chest tube removal; to assess for
pneumothorax.
FINDINGS: In comparison with the study of [**9-21**], the endotracheal
tube, Swan-Ganz catheter, and nasogastric tube have all been
removed. Left chest tube has also been removed and there is no
evidence of pneumothorax. There is probably some residual
atelectatic change at the left base as well as in the right
upper zone, both of which are decreasing.
Brief Hospital Course:
He was admitted to cardiac surgery. He was seen by renal to
continue his HD. He was taken to the operating room on [**10-1**]
where he underwent an OPCABG x 2. He was transferred to the ICU
in critical but stable condition. He was given vancomycin
perioperative prophylaxis as he was in house preoperatively. He
was extubated the morning of POD #1. He continued on HD postop.
He was transferred to the floor on POD #1. He was started on
renagel per renal. He did well postoperatively and was ready for
discharge to rehab on POD #4.
Medications on Admission:
crestor 40', colace 150", zoloft 100', lisinopril 40', norvasc
10', asprin 81', thiamin 100', plavix 75', protonix 40', toprol
xl 200', ambien 10', folate 1", sensipar 180', lovaza 1""
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
5. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Cinacalcet 30 mg Tablet Sig: Six (6) Tablet PO DAILY
(Daily).
12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab [**Location (un) 1110**]
Discharge Diagnosis:
CAD now s/p CABG
Acute on Chronic systolic heart failure
ESRD on HD(L AV fist), CAD s/p MI, HTN, ^lipids, DM2 , s/p L
THR, prostate CA s/p cryo/lupron, h/o gastric ulcer
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions,creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 20764**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2111-10-5**]
ICD9 Codes: 5856, 5180, 4280, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 78
} | Medical Text: Admission Date: [**2173-10-1**] Discharge Date: [**2173-10-20**]
Date of Birth: [**2133-4-7**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
perineal infection
Major Surgical or Invasive Procedure:
[**2173-10-1**] Radical debridement of scrotum, perineum and
abdomen.
History of Present Illness:
HPI: The pt is a 40yM with a history of diabetes who was
transferred from [**Hospital 8641**] Hospital by Mediflight where he
presented with scrotal pain and swelling 2 days after an
incision and drainage of a small scrotal abscess and was found
to have an exam c/w Fournier's Gangrene and subcutaneous gas on
CT. The pt reports that he waited in the ED at [**Location (un) 8641**] for 3
hours in early afternoon where erythema of his scrotum and
swelling progressed to his lower abdominal region. After his
transfer to [**Hospital1 18**], he was noted to be afebrile but over the
course of an hour became diaphoretic and ill appearing. The pt
denies SOB< CP, neurological sx, urinary sx, or GI sx.
PMH: DM, HTN, chronic back pain
PSH: Vasectomy
Med: Atenolol 50", oxycontin 40", ASA 81', Metformin 1000'
All: NKDA
Soc: Live in [**Last Name (un) 53428**], NH. Wife [**Doctor First Name 803**] can be reached at
[**Telephone/Fax (1) 79837**]
Labs: CH 7
129 94 25 306 AGap=18
3.3 20 1.3
CBC- 11.5 / 34.1 / 142
PT: 15.1 PTT: 26.2 INR: 1.3
OSH CT Abd: Scrotal air tracking anteriorly and posteriorly with
additional gas in the buttock
PE:
VS: 100.4 96 100/56 21 94
Diaphoretic
RRR
CTAB
Abdomen soft, NT, NT, erythema tracking to the right inguinal
crease, within marker, crepitus palpable over left inguinal
crease
Phallus circumcised mild, ecchymosis at base
Scrotum the size of grapefruit, ecchymotic, crepitus present,
focal area of dark purple with break in skin in midline, testes
non-palpable
Perineum indurated without crepitus, bleeding from perineal
wound
Anus without crepitus,
Past Medical History:
DM, HTN, chronic back pain
Vasectomy
Social History:
Live in [**Last Name (un) 53428**], NH. Wife [**Doctor First Name 803**] can be reached at
[**Telephone/Fax (1) 79837**]
Physical Exam:
On Day of Discharge
Gen: No acute distress
Cards: RRR
Pulm: Lungs clear to Auscultation
Abdomen: soft non-tender
Wound: well-approximated, healing, drains maintaining suction
with clear serosanguinous drainage. Skin graft with 100% take.
Mild maceration/irritation of skin on medial bilateral thighs
secondary to moisture and friction.
Pertinent Results:
[**2173-9-30**] 10:30PM NEUTS-89.1* LYMPHS-7.5* MONOS-2.9 EOS-0.5
BASOS-0.1
[**2173-9-30**] 10:30PM WBC-11.5* RBC-5.24 HGB-11.8* HCT-34.1*
MCV-65* MCH-22.5* MCHC-34.6 RDW-13.9
[**2173-10-1**] 02:30AM HGB-10.4* calcHCT-31
[**2173-10-1**] 04:25AM WBC-12.5* RBC-4.21* HGB-9.6* HCT-29.5*
MCV-70* MCH-22.8* MCHC-32.5 RDW-13.5
[**2173-10-1**] 11:18AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2173-10-1**] 12:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
Pt life-flighted to [**Hospital1 18**]. Pt diagnosed with Fournier's
gangrene, taken emergently by Urology to OR from ER for radical
perineal debridement. Please see operative note dictated
separately. Pt transferred to SICU still intubated for IV
insulin, IV antibiotics (Vanc, Zosyn, Clinda), hourly wound
checks, and pressor/ventilator support. POD2 Pt taken back to OR
for re-debridement of wound margins by Gen [**Doctor First Name **] and Urology.
In the SICU, the pt had a relatively uneventful course. see
notes below.
[**9-30**]: transfer from [**Hospital 8641**] Hospital, s/p incision and drainage of
perineal abscess 2 days ago followed by increasing pain and
redness and fever, evaluated today and found to have clinical
and radiological findings c/w Fournier's gangrene. Transferred
to [**Hospital1 18**] for surgical evaluation and treatment. States fevers
and
chills.
[**10-1**]: added clindamycin for antibiotic coverage, minimally
marching erythema, added propofol for sedation. A wound swab
from this day was taken and was + enterococcus. All other
cultures neg.
[**10-2**]: back to OR for some more debridement of right thigh. weaned
off of levo using fluid
[**10-3**]: bronchoscopy was performed
[**10-4**]:NGT placement--TF started. low grade temp. flexiseal placed
[**10-5**]:started insulin gtt for refractory blood sugars in the
setting of chronic wound care, lasix gtt with albumin
[**10-6**]: weaned versed/fent, weaned vent, started diamox, started
precedex to wean to extubation
[**10-7**]: Extubated. Aggitated, responding to haldol prn
[**10-9**]: no acute events, changed to po meds, po lasix, increased
RISS, PCA and oral pain control, d/c'ed insulin gtt
Pt transferred to Urology floor service in stable condition.
Wound care, glycemic control, and continued antibiotics
provided. Pt taken to OR by Plastic Surgery for local flap
closure of debrided area and VAC placement to bolster skin graft
over testicles. The patient did well on the floor. He was kept
on bed rest POD1-5 with strict restrictions against abducting
his legs. In addition, he was continued on IV antibiotics per ID
recommendations. On POD 5 his VAC dressing was taken down and
his skin graft had 100% take. On day of discharge POD 7, the
patient was doing very well. He was Afebrile vital signs stable,
his pain was well controlled with an oral regimen, he had been
cleared for home by Physical therapy, and his drain outputs had
decreased appropriately. Per ID recs, the patient did not
require additional IV antibiotic therapy.
Medications on Admission:
Atenolol 50", oxycontin 40", ASA 81', Metformin 1000'
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*24 Tablet Sustained Release(s)* Refills:*0*
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen
(16) units Subcutaneous twice a day: take at breakfast and
Bedtime. Take [**2-28**] dose if not eating. .
Disp:*2 vials* Refills:*2*
14. Diabetic supplies
1/2 cc 30gauge insulin syringes prn
Glucometer testing strips PRN
Discharge Disposition:
Home With Service
Facility:
ROCKINHAM VNA
Discharge Diagnosis:
Fournier's Gangrene
Discharge Condition:
hemodynamically stable, tolerating oral intake, ambulating,
voiding without difficulty, pain controlled on oral regimen
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Meds
Take all medications as ordered.
Drains
You will have a VNA who will help you with dressing changes and
wound checks as well as drain care. It will be important for you
to keep good records of your drain output and bring the records
with you when you return to clinic.
Followup Instructions:
Please call Dr.[**Name (NI) 29526**] office at ([**Telephone/Fax (1) 26412**] for a
followup appointment in 1 week.
Please call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for a followup
appointment.
F/u with your PCP regarding your insulin regimen and blood
glucose control
Completed by:[**2173-10-20**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 79
} | Medical Text: Admission Date: [**2171-8-17**] Discharge Date: [**2171-8-21**]
Date of Birth: [**2134-4-7**] Sex: F
Service: Transplant Surgery Service
CHIEF COMPLAINT: Fever, chills, nausea, vomiting, and
dysuria.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old
female postop pancreas transplant [**2171-8-7**], and living
unrelated renal transplant [**2170-8-14**]. She presents with
36 hours of history of increasing fever and chills, nausea
and vomiting. The patient reported shakes at home.
Temperature was 101.7. The patient noted that she had foul
smelling urine. Upon admission the patient was very agitated
and tachycardic with a heart rate of 120. Her vital signs
were normal.
PAST MEDICAL HISTORY: IDDM, status post living unrelated
renal transplant [**2170-8-14**].
MEDICATIONS AT HOME:
1. Prograf 3 mg PO b.i.d.
2. CellCept 1 gram b.i.d.
3. Valcyte 900 mg once a day.
4. Prednisone 4 mg once daily.
5. Bactrim single strength 1 once daily.
6. Nystatin 5 ml PO QID.
7. Protonix 40 mg PO b.i.d.
8. Os-Cal b.i.d
9. Fosamax q week.
PHYSICAL EXAMINATION: Temperature 102.8, heart rate 108,
blood pressure 136/80, respiratory rate 18, 98% on room air.
The patient was alert and oriented, very agitated. Cranial
nerves II through XII are intact. Pupils are equal, round and
reactive to light. Lungs are clear bilaterally. Incision was
clean dry and intact. Abdomen was tender approximately around
the incision. Positive bowel sounds. Legs - no edema.
HISTORY OF BRIEF HOSPITAL COURSE: The patient is a 37-year-
old female presenting with severe nausea and vomiting, fever
and foul smelling urine. This lady's likely diagnosis was
pyelonephritis versus UTI with superimposed anxiety attacks.
The patient was admitted to the transplant unit and started
on IV fluid and empiric Zosyn. Chest x-ray was done and
demonstrated no pleural effusions. No infiltrates. Lung
fields were clear. A nasogastric tube was inserted. Correct
position was noted in the stomach. The patient underwent
supine film of the abdomen. Gas was noted in the loops of the
colon.
The patient underwent CT of the abdomen and pelvis without
contrast. This demonstrated evidence of an abscess with
benign appearing fluid collection along the course of the
right iliac vessels, likely representing lymphocele. The
patient was admitted to the SICU for monitoring. White blood
cell count on admission 21.1, hematocrit 31.5, creatinine
1.2, up from day 1 of 0.9, amylase 22, lipase 14, and glucose
91. EKG revealed sinus tachycardia. No ST-T wave changes.
Urine was positive for nitrates. WBC 30, large amount of
blood. As previously stated the patient was started on Zosyn.
Urine and blood cultures were sent. Blood cultures were
subsequently negative. Urine culture demonstrated E. coli
with 100,000 colonies, resistant to ampicillin and Bactrim,
sensitive to the cephalosporins, imipenem, Levo, and
meropenem.
On hospital 2, the patient had a temperature of 104.5. She
was given Tylenol and aggressive IV hydration. She continued
on Zosyn and Linezolid. White blood cell count increased to
30.3. She complained of some back pain as well. Temperature
defervesced. The patient was transferred to the medical-
surgical unit on hospital day 3. Temperature was 99. Abdomen
was soft. She was slowly advanced to house diet. IV therapy
was decreased. Urine output was approximately 500 cc per day
of clear yellow urine. The patient continued to feel anxious.
Glucoses were normal. Foley catheter was removed. The patient
was followed by nephrology throughout this hospital course.
Prograf level was 7.1. Prograf was adjusted accordingly.
Creatinine was 1.2, BUN 13, amylase 23, and lipase 17 with a
glucose of 112. Of note, the patient complained of right hip
pain on hospital day 3. She was medicated with IV Dilaudid
with fair relief. The patient felt there was muscle spasm in
right hip, erythematous with some swelling. Physical therapy
was consulted. Localized inflammation was noted. Concern was
for trochanteric bursitis. The patient was independent with
mobility. She was independent with transfer, stairs, and
hallway ambulation. Outpatient PCA was recommended.
The patient's antibiotic was switched to ceftriaxone IV. The
patient was discharged home on hospital day 5. She was given
a prescription for Keflex for 1 week and Macrobid. Urine
output was approximately 1.5 liters per day. Glucose has
remained within normal range. She was afebrile.
DISCHARGE MEDICATIONS:
1. Prednisone 4 mg PO once daily.
2. Valcyte 900 mg PO once daily.
3. Nystatin 5 mg PO QID.
4. Bactrim single strength 1 PO once daily.
5. CellCept 1 gram PO b.i.d.
6. Prograf 3 mg PO b.i.d.
7. Protonix 40 mg PO once daily.
8. Aspirin 81 mg, enteric coated, one PO once daily.
9. Hydrocodone/ acetaminophen 5/325 mg 1 tab PO p.r.n. q4
hours.
10. Keflex 500 mg PO QID x 10 days.
11. Macrodantin 100 mg cap 1 PO once daily.
DISCHARGE DIAGNOSES:
1. Status post pancreas transplant on [**2171-8-7**].
2. Status post living unrelated renal transplant [**2170-8-14**].
3. Urinary tract infection.
4. Urosepsis.
The patient was instructed to follow up with Dr. [**First Name (STitle) **]
[**Name (STitle) **] on [**2171-8-26**]. She was also to follow up with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] from social service as well as Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**2171-9-6**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PhD [**Numeric Identifier 8353**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2171-11-12**] 16:00:13
T: [**2171-11-13**] 02:12:59
Job#: [**Job Number 41013**]
cc:[**Name8 (MD) **]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 80
} | Medical Text: Admission Date: [**2136-7-14**] Discharge Date: [**2136-7-17**]
Date of Birth: [**2059-8-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
76F s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76F s/p fall; patient originally seen at outside hospital, and
transferred to [**Hospital1 18**].
Past Medical History:
hypertension
bilateral total hip replacements
Social History:
EtOH use
Family History:
unknown
Physical Exam:
AXO to person, place, event
CN 2-12 intact
RRR
CTA b/l
+bs, nt, nd, soft
no pelvic instability
no gross abn of extremities
rectal guaiac neg, no mass
LE palp distal pulses
Pertinent Results:
[**2136-7-14**] 02:00AM BLOOD ASA-NEG Ethanol-46* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2136-7-14**] 07:50AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.1*
[**2136-7-15**] 02:40AM BLOOD Calcium-7.3* Phos-2.1* Mg-3.3*
[**2136-7-14**] 02:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2136-7-14**] 07:50AM BLOOD CK-MB-3 cTropnT-<0.01
[**2136-7-14**] 02:00AM BLOOD CK(CPK)-104
[**2136-7-14**] 07:50AM BLOOD CK(CPK)-106
[**2136-7-14**] 02:00AM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-142
K-3.5 Cl-102 HCO3-21* AnGap-23*
[**2136-7-14**] 07:50AM BLOOD Glucose-188* UreaN-7 Creat-0.7 Na-142
K-3.2* Cl-102 HCO3-21* AnGap-22*
[**2136-7-15**] 02:40AM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-142
K-4.1 Cl-111* HCO3-21* AnGap-14
[**2136-7-14**] 02:00AM BLOOD PT-12.6 PTT-21.0* INR(PT)-1.1
[**2136-7-14**] 02:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
[**2136-7-14**] 02:00AM BLOOD Neuts-90.6* Bands-0 Lymphs-5.6* Monos-3.6
Eos-0.1 Baso-0
[**2136-7-14**] 02:00AM BLOOD WBC-13.7* RBC-3.81* Hgb-14.5 Hct-42.1
MCV-110* MCH-38.1* MCHC-34.5 RDW-15.9* Plt Ct-407
[**2136-7-15**] 02:40AM BLOOD WBC-5.4 RBC-2.92* Hgb-11.2* Hct-32.3*
MCV-111* MCH-38.5* MCHC-34.8 RDW-16.1* Plt Ct-284
[**2136-7-16**] 09:05AM BLOOD Hct-37.8
[**2136-7-14**] 01:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2136-7-14**] 01:20AM URINE Hours-RANDOM
[**2136-7-14**] 01:20AM URINE RBC-[**2-12**]* WBC-[**2-12**] Bacteri-MOD Yeast-NONE
Epi-1
[**2136-7-14**] 01:20AM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2136-7-14**] 01:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
AP CXR: 1. There are compression deformities of several lower
thoracic vertebral bodies, of uncertain chronicity.
2. There is widening of the ascending aortic contour, which may
represent aneurysmal dilatation.
AP Pelvis: bilat THR, no Fx
CT c-spine: Marked osteopenia and degenerative changes are seen,
without any definite fracture or subluxation identified
CT head: Bilateral areas of intraparenchymal (hemorrhagic
contusions) and subarachnoid hemorrhage
EKG: Sinus tachycardia. Left ventricular hypertrophy. Diffuse
ST-T wave changes may be secondary to left ventricular
hypertrophy. No previous tracing available for comparison
Brief Hospital Course:
Patient was admitted with intraparenchymal and subarachnoid
hemorrhages, and with poorl controlled hypertension. Her
hospital course (by system):
Neuro: Patient had 2 CT of head done, without interval change,
and her mental status improved during hospital course. Patient
also did not develop any focal neurologic deficits. She was
treated with dilantin for seizure prophylaxis for a 7-day
course, and she also received valium for DT prophylaxis.
CV: Patient was treated with metoprolol and lisinopril for her
hypertension, and her BP was maintained under 160 SBP throughout
hospital course. Patient also had an EKG which showed her to be
in sinus tachycardia on [**7-14**]; her HR decreased to within normal
limits on discharge.
Resp: Patient was treated with incentive spirometry during her
hospital course, and her respiratory status was good throughout
hospital stay.
GI: Patient received colace during hospital course, and she
tolerated a regular diet throughout; she also received protonix
for GI prophylaxis.
GU: patient had a foley in place through most of hospital
course; it was d/c'd without incident, and patient was able to
urinate on her own.
FEN: Patient received thiamine, folate and a mulivitamin on
admission because of EtOH use and risk of Wernicke-Korsakoff
syndrome.
Heme: no issues
ID: no issues
Medications on Admission:
norvasc
zestril
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day: hold for SBP <100 or HR <55.
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 4 days.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
1) subarachnoid hemorrhage
2) frontal intraparenchymal hemorrhage
*3) hypertension (poorly controlled at admission)
Discharge Condition:
stable
Discharge Instructions:
You have suffered an intraparenchymal hemorrhage and a
subarachnoid hemorrhage following a fall. You should return to
headache, nausea/vomiting, difficulty breathing, chest pain,
decreased sensation or motor function, or any other symptoms
that are concerning to you.
Followup Instructions:
follow-up at Trauma Clinic in 2 weeks ([**Telephone/Fax (1) 6439**])
follow-up with neurosurgery in 2 weeks ([**Telephone/Fax (1) 1669**])
follow-up with PCP regarding BP control
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2136-7-17**]
ICD9 Codes: 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 81
} | Medical Text: Admission Date: [**2115-1-20**] Discharge Date: [**2115-1-31**]
Service: NEUROLOGY
Allergies:
Percocet / Penicillins / Atropine / Keflex / Bactrim / Inderal /
Levaquin / Reglan / Ciprofloxacin Hcl / Doxycycline /
Azithromycin
Attending:[**Doctor Last Name 15044**]
Chief Complaint:
prolonged R sided shaking
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Briefly, pt is a [**Age over 90 **] year old woman with PMH notable for breast
CT
in [**2081**] (s/p R mastectomy), pancreatic CA [**2094**] (s/p whipple's),
colon CA d/c'ed [**1-2**], s/p total colectomy, who is transferred
from the ICU after presenting in partial status epilepticus.
According to the daughter, after her recent colectomy she has
had
complications of post-operative ileus, overall decreased po's
and
weight loss. She was in her nursing home and was relatively
stable until the day prior to admission when she was more tired
and not taking in any po's. That night her nursing aid noted
that
she had L face, arm, and leg twitching, unclear if true LOC
associated with it. The twitching began around midnight and
continued through the morning and she was brought to [**Hospital1 18**] for
further evaluation.
IN ED she was noted to be talking coherently through the
twitching, with O2 sats down to the low 90's on 2L NC. She was
given a total of 4 mg ativan and then 1 gm dilantin bolus that
stopped the shaking, however she became so sedated that she
required intubation.
She was admitted to the ICU for further management.
Past Medical History:
1. pancreatic cancer status post Whipple procedure [**2094**]
2. Multiple duodenal strictures and ulcers
3. Adhesions status post lysis from radiation to pancreas.
4. Status post transverse colectomy for radiation-induced injury
to colon.
5. Status post appendectomy [**2041**].
6. Status post cholecystectomy for gangrenous cholecystitis [**2105**]
7. Status post gastrojejunostomy.
8. Macular degeneration reportedly legally blind in left eye
9. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
10. Breast cancer status post modified radical mastectomy in
[**2081**]
11. Hypertension.
12. History of Methicillin resistant Staphylococcus aureus
infection.
13. Multiple falls.
14. status post ileocolectomy for colon cancer [**1-2**]
15. osteoarthritis
16. reported history of hepatitis A in [**2064**]
17. status post partial hysterectomy [**2061**]
18. status post ventral incision hernia repair [**2095**]
Social History:
nursing home resident, formerly a lawyer, per
daughter cognitively at baseline very intact, was writing her
life memoir until her recent surgery, which left her quite ill.
Family History:
Noncontributory
Physical Exam:
Exam on admission to the floor (from ICU)
very limited by pt's mental status.
Gen: sleeping, arousable but not following commands, breathing
comfortably, heart RRR with 2/6 SEM at LSB, lungs with crackles
on L mid and base anteriorly, abd soft, non distended, incision
site C/D/I. Peripheral pulses easily palpable
Neuro:
follows no commands, but does intermittently wiggle toes,
unclear
if to command
CN: R pupil 3--2, L pupil surgical, +OC's but no purposeful
EOM's, face symmetric, tongue midline, +gag
M: moves all 4 extremities vigorously to mild painful stimuli,
but moves LUE less than others.
S: localizes to pain in all 4
R: RUE and LUE 1+ throughout, patellae 1+ bilaterally, 5 beats
of ankle clonus non sustained bilaterally, toes up bilaterally,
+jaw jerk, -[**Doctor Last Name **]
Pertinent Results:
[**2115-1-20**] 11:54AM TYPE-ART TIDAL VOL-500 O2-100 PO2-437*
PCO2-33* PH-7.40 TOTAL CO2-21 BASE XS--2 AADO2-252 REQ O2-49
INTUBATED-INTUBATED
[**2115-1-20**] 11:54AM O2 SAT-100
[**2115-1-20**] 09:51AM CEREBROSPINAL FLUID (CSF) PROTEIN-49*
GLUCOSE-64 LD(LDH)-50
[**2115-1-20**] 09:51AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1550*
POLYS-73 LYMPHS-26 MONOS-1
[**2115-1-20**] 09:51AM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-2550*
POLYS-67 LYMPHS-30 MONOS-3
[**2115-1-20**] 08:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2115-1-20**] 08:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2115-1-20**] 08:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2115-1-20**] 07:38AM TYPE-ART PO2-301* PCO2-39 PH-7.42 TOTAL
CO2-26 BASE XS-1 INTUBATED-NOT INTUBA
[**2115-1-20**] 07:38AM GLUCOSE-112* LACTATE-3.3* NA+-131* K+-4.4
CL--99*
[**2115-1-20**] 07:38AM HGB-11.5* calcHCT-35 O2 SAT-99 CARBOXYHB-0.4
MET HGB-0.7
[**2115-1-20**] 07:38AM freeCa-1.10*
[**2115-1-20**] 07:20AM GLUCOSE-93 UREA N-15 CREAT-1.1 SODIUM-136
POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-26 ANION GAP-19
[**2115-1-20**] 07:20AM ALT(SGPT)-9 AST(SGOT)-31 AMYLASE-141* TOT
BILI-0.5
[**2115-1-20**] 07:20AM WBC-7.8 RBC-3.95*# HGB-11.8*# HCT-36.7 MCV-93
MCH-30.0 MCHC-32.3 RDW-14.1
[**2115-1-20**] 07:20AM NEUTS-82.0* LYMPHS-14.9* MONOS-2.7 EOS-0.3
BASOS-0.2
[**2115-1-20**] 07:20AM PLT COUNT-472*#
Brief Hospital Course:
ICU/Floor course by system:
Neuro:
1. First time seizures - This episode was thought to be focal
status, and once stopped she never had a recurrent of
seizure-like activity. It was thought that perhaps her seizure
was secondary to severe electrolyte abnormalities in the setting
of poor nutrition post operatively. She was continued on
dilantin, initially 100 mg IV TID, but her levels were
persistently supratherapeutic and upon transfer to the floor the
dilantin was held each day while levels were checked. On [**1-29**] the
level was finally within low-therapeutic range (4.4, when
corrected for albumin was approximately 9) and she was restarted
on 100 mg qday. It was thought that has intrinsic slow clearance
of dilantin, as none of her other medications are known to
decrease dilantin clearance. Upon discharge her level was 3.7.
Her levels should be followed 2x/week.
Further neurologic workup for seizure included LP that was
unremarkable and MRI that showed no enhancing lesions, one small
area of DWI right thalamus without FLAIR correleate of unclear
significance. Radiology reported diffuse meningeal uptake, but
this was likely s/p LP effects. No EEG was performed.
2. Encephalopathy - Pt was initially very encephalopathic,
thought to be due to infection as well as dilantin toxicity. As
her pneumonia was treated and her dilatnin level was reduced,
she became markedly awake and lucid, and by discharge was
conversant and easily following commands.
ID:
1. Aspiration pneumonia - She had a LLL infiltrate on CXR,
leukocytosis to
13K, low grade temp (98.8 ax), she was started on levofloxacin
and flagyl and completed a 10 day course. Her wbc was 6 upon
discharge and her lung exam was much improved. Her blood and
urine cultures were negative to date.
Pulm:
She was intubated on [**1-20**] for airway protection after the
multiple sedating medications she received for her seizure. She
was easily extubated at 6pm on [**1-21**]. On [**1-24**] she had an episode
of acute respiratory distress, her CXR and lung exam were
consistent with pulmonary edema and she was given IV lasix with
excellent response. She was started on a maintenance dose of
lasix for the remainder of her stay and this was discontinued
upon discharge.
Heme:
On admission, hct dropped from 36->29, repeat was 32 She does
not appear to be iron deficiency or anemia of chronic disease,
she does however have borderline low B12 and folate. Stool
guiaic's were negative. Her hct stayed around 28-29 for the
remainder of her stay.
Pain:
Continued fentanyl patch (for OA) to prevent withdraw, prn
tylenol.
FEN:
Pt was not PO'ing due to encephalopathy. Upon transfer,
nutrition consulted and plan for PICC placement for TPN made.
PICC was placed but it was only able to be placed peripherally,
therefore she was started on [**Month/Year (2) 32813**]. Electrolytes were followed
daily and her initial hyponatremia resolved. She also initially
had hypomagnesemia, hypocalcemia, and hypokalemia, all of which
were stabilized with her [**Month/Year (2) 32813**]. On [**1-28**] she passed her
speech/swallow evaluation and an oral diet was started. She
tolerated this well and upon discharge her [**Month/Day (4) 32813**] was discontinued
with plans to augment her oral nutrition as well as possible.
Her daughter met with the medial nutrition group prior to
discharge. Her electrolytes should be followed weekly. She also
should be restarted on pancrease once she is eating a more full
diet.
PPx:
for stroke ppx, was initially given ASA, but due to decreasing
hct and recent surgery, upon transfer the ASA was d/c'ed. As DVT
prophylaxis she was receive heparin in her [**Last Name (LF) 32813**], [**First Name3 (LF) **] was not given
SC heparin, but was started back on SC heparin upon discharge.
For GI prophylaxis she was receiving pepcid, and was switched
back to her home regimen of protonix upon discharge.
Code: She was intially DNR but not DNI, after much discussion
with her daughter and her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] the decision was made
to make her DNR/DNI.
Dispo: She was transferred back to her nursing home in much
improved condition on [**2115-1-31**].
Medications on Admission:
1. Zestril 10mg daily
2. Protonix 40mg daily
3. Pancrease 3 packets per meal
4. Fentanyl patch 25mcg/hr every 72 hours.
5. Ocuvite twice daily
Discharge Medications:
1. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Ocuvite Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: One (1)
Injection three times a day.
Disp:*qs * Refills:*2*
4. Dilantin 100 mg qday
5. Protonix 40 mg qday
6. Fentanyl patch
7. Zestril 10 mg qday
8. Multivitamin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Partial seizure
Pneumonia
Discharge Condition:
improved
Discharge Instructions:
Please return to ED if pt develops worsening respiratory
distress or seizure-like activity.
Once she is taking a more complete diet she should be restarted
on her pancrease
Her dilantin level and electrolytes should be followed weekly.
CHeck an albumin with the dilantin level.
Followup Instructions:
Dr. [**Name (NI) **], pt will schedule
ICD9 Codes: 5070, 2761, 4280, 2768, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 82
} | Medical Text: Admission Date: [**2114-11-18**] Discharge Date: [**2114-11-19**]
Date of Birth: Sex:
Service:
DIAGNOSIS: Right temporal intracranial mass.
HISTORY OF THE PRESENT ILLNESS: This is a 53-year-old
gentleman who presented with vertigo and ringing in his ears
and headache since [**Month (only) 359**]. He had had a C-scan and MRI with
and without gadolinium at an outside hospital, where he was
diagnosed to have a 3-cm x 3-cm intracranial right temporal
mass. He was referred to the [**Hospital1 188**] for further evaluation.
HISTORY OF THE PRESENT ILLNESS: The patient has history of
headache, ringing of ears, and vertigo since [**Month (only) **] to
early [**Month (only) 359**]. There was no history of nausea, vomiting,
visual disturbance, diplopia, or seizures. There was no
evidence of weakness or tingling or numbness anywhere.
On admission, the patient was found to have a mass with edema
around it and bleeding surrounding the tumor. He was
admitted to the Intensive Care Unit for blood-pressure
control
and anti-seizure medication therapy and for close monitoring.
Further workup revealed left lung mass and adrenal mass;
preliminary diagnosis of carcinoma of the lung with extensive
metastasis had been made. Further workup was required. The
patient expressed explicit desire to be home on [**Holiday **] Eve
until [**Holiday **] and had no intentions of staying in the
hospital on [**Holiday **] Day. Therefore, he was started on
high-dose Decadron for anti-edema measures. He was
discharged home on high-dose Decadron. He will be having
further followup. He us scheduled for CT guided lung biopsy
on the [**3-22**] in the [**Hospital Unit Name 1825**] at 9:30 am. He
is also to continue on Decadron 8 mg p.o. q.6h. for two days
and 6 mg Decadron q.6h. for two days followed by 4 mg
Decadron q.6h. until he meets with Dr. [**Last Name (STitle) 724**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in the Brain [**Hospital 341**] Clinic on [**2114-11-26**].
Based on the tissue diagnosis, the patient will be having
eyelid surgery and chemotherapy or chemotherapy or
radiotherapy, which is to be decided. The patient was also
given strict instruction to contact us at the earliest date
if there is any change in his mental status or in the
severity of his headache.
ALLERGIES: The patient is allergic to LIPITOR AND SULFA. A
new allergy to DILANTIN was documented.
DISCHARGE MEDICATIONS:
1. Zantac 150 mg p.o.b.i.d.
2. Depakote 350 mg p.o. three times a day.
3. Decadron starting at 8 mg, tapering down to 4 mg p.o.
q.6h. until further followup and further plans will be made.
The patient is also noted to have a past medical history of
coronary artery disease with three-vessel stenting and
angioplasty; hypertension; diabetes mellitus, for which he
takes Insulin.
DISCHARGE CONDITION: The patient is awake, alert, oriented,
but no localizing signs, no focal lesions. The patient is
fully aware of the risks of him being discharged. The
patient is willing to go home.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 14-120
Dictated By:[**Last Name (STitle) 22910**]
MEDQUIST36
D: [**2114-11-21**] 10:43
T: [**2114-11-21**] 12:44
JOB#: [**Job Number 24026**]
ICD9 Codes: 3051, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 83
} | Medical Text: Admission Date: [**2175-8-10**] Discharge Date: [**2175-8-22**]
Date of Birth: [**2148-2-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
Right flank pain, fever
Major Surgical or Invasive Procedure:
embolization of bleeding artery under IR
History of Present Illness:
27 F here for 2 days of right flank pain, sharp, worsened by
deep breaths. No similar pains on past. Associated fatigue and
fevers x 2 days. No dysuria, hematuria or any other urinary
symptoms. Chronic tingling in the right foot (since she was
diagnosed with cord compression many months back. No headache.
ER course - given Abx as below. Temp 103.9
ROS:
Constitutional: Fatigued, weight loss in past 5 weeks. Fever and
associated chills as above. Also anorexic.
Neuro: No confusion, numbness of extremities, dizziness or
light-headedness, vertigo, weakness of extremities, confusion,
tremor. Parasthesias-as above
Psychiatric: no depression, suicidal ideation
Eyes: No blurry vision, diplopia, loss of vision, photophobia.
Wears glasses.
ENT: No dry mouth, oral ulcers, bleeding nose, gums, tinnitus,
sinus pain, sore throat
Cardiac: no chest pain, DOE, syncope, PND, orthopnea,
palpitations, peripheral edema
Pulmonary: No shortness of breath, hemoptysis, pleuritic pain.
Has chronic coung for many weeks
GI: Had some nausea and vomiting. No diarrhea, constipation,
hematemesis, melena, hematochezia. Abd pain as above.
Heme: no easy bleeding, bruising, lymphadenopathy
GU: no dysuria, hematuria, increased frequency, urgency or
incontinence
Endocrine: Lost hair since starting chemo. No skin changes, heat
or cold intolerance
Skin: no rash or pruritis
Musculoskeletal: no myalgias, arthralgias, back pain
Allergy: no seasonal allergies- NKDA.
.
[x] All other systems negative on detailed review except as
noted.
Past Medical History:
- Hepatocellular carcinoma - metastasis to bone, lung, abdomen
-Had been receiving weekly 5-FU leucovorin after having
progressed on the weekly doxorubicin. She previously was
treated with gemcitabine, Cisplatin, and Avastin.
- Pulmonary embolism and SVC clot - on anticoagulation.
-R ovarian cyst-She affirms increasing abdominal girth [**2168**],
feeling increased bloating, presented to the ED found to have a
right ovarian cyst, was resected.
- [**2155**] (7yrs old) hospitalized for 6 months for fever/cough,
weakness, unclear source of infection, did require blood
transfusions.
- Gyn- no menstrual periods for the past year
Social History:
Social History: Lives with her sister and brother. Recently
relocated from [**Country 3587**] [**12-21**] - speaks Creole and Portugese.
Denies stds, denies etoh, ivdu, smoking.
Family History:
1 sister age 27, with question of R leg mass resected 4 yrs ago.
Brother had liver problems as a child.
Father - HTN
Denies other cancer history
Physical Exam:
VS T 99.6 P 123/min, BP 104/68 RR 16 100% RA
Gen - Thin female appears chronically sick. Not in acute
distress.
Eyes - pale, not jaundiced
ENT - moist mucosae, no thrush, ulcers or erythema
Neck - supple, no LAD, JVP normal
CV - S1, 2 - normal, No murmurs or rubs, or gallops. Tachycardia
RS - no crackles or wheezing
Abd - rt UQ abd pain, no RT or distenstion. Liver edge palpable.
Rt CVA tenderness
Extremeties - no edema
Skin - no rash
GU - no catheter
Neuro - Alert and oriented x3, Cr n [**3-27**] normal. Motor - [**5-20**] UE
and LE bilaterally equal, prox and distal. Sensory normal to
crude touch bilaterally. Plantars flexor bilaterally. No
pronator drift. Fluent speech.
Psychiatric - not anxious. Calm. Not depressed
Heme/lymph - no cerv LAD, thyroid normal.
Pertinent Results:
CXR - IMPRESSION: No acute cardiopulmonary process. Multiple
pulmonary masses present at the lung base is better evaluated on
the CT examination of [**2175-7-26**]
CT abdomen, pelvis - IMPRESSION:
1. Significant interval worsening of metastatic disease as
described above.
2. Interval increase in size of the left adnexal dermoid.
3. Unchanged appearance of osseous metastasis
.
.
Brief Hospital Course:
# acute blood loss anemia/hemoperitoneum: Likely bleeding from
hepatic tumors, however, angio did not identify obviously
bleeding lesions, so no embolization performed initially. Pt
then had increased abdominal distension and pain; repeat CT scan
did not show demonstrable change in hemoperitoneum, but could
not rule out continued oozing from liver lesions. R hepatic
artery was therefore embolized with Gel-foam to prevent
further/future bleeding. Following procedure, patient had a
stable hematocrit, and did not require additional transfusions.
.
# Fevers: No clinical signs that would indicate current
infection, as pt w/o cough, SOB, dysuria, or diahrea. Serial
blood cultures were without crowth. Fevers believed to be
secondary either to diffuse cancer or blood in peritoneum.
.
# Pain: Pt swtiched from PCA to MS contin w/ diluadid PRNs.
While patient was significantly uncomfortable on admission, pain
ins well controlled at time of discharge. Pain due to
carcinomatosis of abdomien.
.
# hepatocellular carcinoma: HepB +, widely metastatic. last
chemo over 2 weeks ago. As pt has failed multiple
chemotherapeutic regimens, felt that would not gain advantage
from additional treatment. Pt seen by palliative care, and their
assistance is most appreciated. Patient discharged with home
hospice.
Medications on Admission:
LOVENOX 60MG subcutaneously [**Hospital1 **]
Discharge Medications:
1. Roxanol Concentrate 20 mg/mL Solution Sig: [**1-17**] mL PO q 1 hour
as needed for discomfort/respiratory distress.
Disp:*4 syringes* Refills:*0*
2. Wheelchair Misc Sig: One (1) Miscellaneous once a day.
Disp:*1 * Refills:*0*
3. hospital bed
please provide pt w/ one hospital bed
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4
Hours) as needed for Pain.
Disp:*150 Tablet(s)* Refills:*2*
8. Morphine 30 mg Tablet Sustained Release Sig: Four (4) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*240 Tablet Sustained Release(s)* Refills:*2*
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*250 ML(s)* Refills:*1*
10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*50 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VistaCare
Discharge Diagnosis:
Metastatic liver cancer
hemoperitoneum
Discharge Condition:
Stable
Discharge Instructions:
You are discharged after an admission due to bleeding in your
belly. This bleeding was from one of your liver tumors. You
had the blood suppy to that tumor blocked so that it won't
bleed. Because of these bleeding tumors, you are no longer a
canidate for the serafinib treatment. Unfortuantly all the
chemotherapy we normally use to treat liver cancer has not
proven successful. You are now being discharged home, and
arangements are being made to give you the support to remain
comfortable.
Followup Instructions:
Call your Dr. [**Last Name (STitle) **] you develop severe abdominal pain, confusion,
difficulty breathing, vomiting.
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 84
} | Medical Text: Admission Date: [**2118-12-2**] Discharge Date: [**2118-12-16**]
Date of Birth: [**2039-1-27**] Sex: M
Service: SURGERY
Allergies:
Ativan / Morphine
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
weakness, abdominal pain
Major Surgical or Invasive Procedure:
None
Attempted IV Port placement
History of Present Illness:
The patient is a 79y man with end ileostomy, well-known to
the surgery service and recently discharged on [**11-30**], who returns
to the ED with 24h of peristomal abdominal pain and weakness.
The pain began the day following his discharge, and he describes
it a constant dull pain, non-radiating. He also complains of
weakness. His ostomy out-put has been within normal limits for
the patient. The out-put has been liquid with no visible blood.
He denies dizziness, fever, chills. He had one episode of emesis
the morning of presentation. His SBP on admission to the ED was
70s.
PMH:
1. Gout
2. Hypertension
3. atrial fibrillation
4. h/o spontaneous pneumothorax
5. ? pulmonary fibrosis
6. h/o rheumatic fever
7. h/o of multiple small bowel obstructions
8. carotid artery stenosis
9. brain infarct asymptomatic
10. h/o recent c.diff
11. GERD
12. Chronic renal insufficiency
13. h/o Port-a-cath
14. Colonic stricture with chronic small bowel obstruction,
partial.
PSH:
1. Colectomy, ileostomy for "gangrene"/diverticulitis/"toxic
megacolon"
2. Ileostomy reversal 2 years ago
3. Lysis of adhesions on [**2118-7-5**]
4. Appendectomy
5. Removal of cyst on his neck
6. Left hip replacement
7. Removal of 2 burs from his elbows
8. s/p talc pleurodesis ([**Hospital1 112**])
9. s/p port removal for staph sepsis
10. Resection of ileocolic anastomosis and creation of
end-ileostomy ([**11-2**])
Past Medical History:
PSH:
1. Colectomy, ileostomy for "gangrene"/diverticulitis/"toxic
megacolon"
2. Ileostomy reversal 2 years ago
3. Lysis of adhesions on [**2118-7-5**]
4. Appendectomy
5. Removal of cyst on his neck
6. Left hip replacement
7. Removal of 2 burs from his elbows
8. s/p talc pleurodesis ([**Hospital1 112**])
9. s/p port removal for staph sepsis
10. Resection of ileocolic anastomosis and creation of
end-ileostomy ([**11-2**])
Social History:
Social History:
Quit smoking 35 years ago. No ETOH.
Family History:
Family History:
Noncontributory
Physical Exam:
VS: 97.5 85 122/56 17 1003L
Gen: no acute distress
CV: RRR S1 S2
Lungs: coarse breath sounds bilaterally, no rales or wheeze
Abd: soft, non-distended, moderate tympany, tender to palpation
diffusely but primarily around ileostomy site. No rebound or
guarding. Ostomy is pink and healthy appearing. Brown liquid
out-put in the bag.
Ext: Warm, well perfused
Pertinent Results:
Admit Labs
CBC: 26/35.9\539
Chem: 128/98/42
---------<239
5.8\13\2.0
Lactate:7.4
Tbil:0.5 AST:26 ALT:57 AP:96
.
[**2118-12-2**] 01:10PM BLOOD WBC-26.3*# RBC-3.66* Hgb-11.8* Hct-35.9*
MCV-98 MCH-32.1* MCHC-32.8 RDW-15.1 Plt Ct-539*
[**2118-12-3**] 04:48AM BLOOD WBC-23.5* RBC-3.47* Hgb-11.1* Hct-32.4*
MCV-94 MCH-32.0 MCHC-34.2 RDW-15.5 Plt Ct-454*
[**2118-12-13**] 05:45AM BLOOD WBC-12.6* RBC-2.92* Hgb-9.4* Hct-27.7*
MCV-95 MCH-32.2* MCHC-34.0 RDW-16.4* Plt Ct-422
[**2118-12-11**] 04:25AM BLOOD PT-27.8* INR(PT)-2.8*
[**2118-12-2**] 01:10PM BLOOD Glucose-239* UreaN-42* Creat-2.0* Na-128*
K-5.8* Cl-98 HCO3-13* AnGap-23*
[**2118-12-3**] 04:48AM BLOOD Glucose-132* UreaN-37* Creat-1.5* Na-132*
K-5.5* Cl-102 HCO3-18* AnGap-18
[**2118-12-13**] 05:45AM BLOOD Glucose-106* UreaN-18 Creat-1.1 Na-131*
K-4.8 Cl-101 HCO3-22 AnGap-13
[**2118-12-5**] 03:54AM BLOOD ALT-27 AST-18 LD(LDH)-151 AlkPhos-54
Amylase-36 TotBili-0.5
[**2118-12-13**] 05:45AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.9
[**2118-12-7**] 04:30AM BLOOD TSH-13*
[**2118-12-7**] 04:30AM BLOOD Free T4-0.91*
[**2118-12-6**] 06:15AM BLOOD Digoxin-0.7*
[**2118-12-2**] 01:28PM BLOOD Lactate-7.4*
[**2118-12-3**] 05:04AM BLOOD Lactate-3.0*
[**2118-12-5**] 04:17AM BLOOD Lactate-0.6
.
[**2118-12-5**] 11:08 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2118-12-6**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
.
Radiology Report CT PELVIS W/CONTRAST Study Date of [**2118-12-2**]
2:10 PM
IMPRESSION:
1. Significant small bowel dilation and fecalization just
proximal to the
right mid abdominal anastomosis concerning for massive
impaction. Stricture at the stoma cannot be excluded. Small
amount of free intra- abdominal air and pneumatosis of several
loops of ileum deep within the pelvis are all concerning for an
ischemic process.
2. Unchanged aneurysm (x2) of the infrarenal abdominal aorta.
.
Brief Hospital Course:
The patient is a 79yM w/ end ileostomy presenting w/ abdominal
pain and weakness, found to have small foci of free air and
pneumatosis of the ileum proximal to the ostomy.
He was admitted to surgery and started on IVF for resuscitation
for dehydration, weakness and elevated Lactate. A CT scan was
done which showed some fecal impaction and he was disimpacted in
the emergency room. It also demonstrated a small foci of free
air and possible pneuomotosis in proximal illeum. Currently he
reports
significant improvement in his abdominal pain since the
disimpaction.
Vascular was consulted due to his history of superior mesenteric
artery
stent for mesenteric ishemia and resection of ileocolic
anastomosis and creation of end-ileostomy. He presented with
increased watery ostomy output and parastomal abdominal pain.
Review of the CT scan shows the stent is patent and this
unlikely is mesenteric ischemia.
Leukocytosis: He was started on Zosyn and a 1 week course in
which his WBC defervesced. C.diffs were negative.
Hyponatremia/Hyperkalemia: Improved with hydration
Hypotension/Hemodynamic Instability: Dehydrated and improved
with hydration.
His diet was advanced and he was eating well. His ostomy output
was about 1-liter/day. He was ordered for Opium Tincture and
Psyllium 1.7 g Wafer. His abdomen was soft and nontender and
nondistended.
An IV Port was attempted, but not successful. He needs continued
close monitoring of his I&O's.
Medications on Admission:
protonix 40', amiodarone 200'', digoxin 0.125', lopressor
12.5''', Tylenol prn, Imodium 2mg tab''', coumadin (for afib,
3mg/d), levothyroxine 50mcg PO daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Monitor INR.
5. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO QID (4 times a
day).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Opium Tincture 10 mg/mL Tincture Sig: Three (3) Drop PO TID
(3 times a day): 0.3mL. Titrate according to stool consistency.
Avoid constipation.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Abdominal pain
Weakness
Leukocytosis
Elevated Lactate to 7.4
Hyponatremia/Hyperkalemia
Hypotension
Hemodynamic Instability
Dilated loops of small bowel with fecalization of distal ileum
Acute Renal Failure
Discharge Condition:
Good
Discharge Instructions:
You were admitted with dehydration, weakness and hemodynamic
instability.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* Continue with Ostomy care
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in [**2-27**] weeks. Call [**Telephone/Fax (1) 2998**]
to schedule an appointment.
Completed by:[**2118-12-15**]
ICD9 Codes: 5849, 2760, 2762, 2767, 5859, 2449, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 85
} | Medical Text: Admission Date: [**2120-11-9**] Discharge Date: [**2121-1-9**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old
female with a history of rectal cancer who was admitted to
[**Hospital1 69**] on [**2120-11-9**] for a low
anterior resection of her rectal cancer with ileostomy and
omental flap placement over the stump. Her initially course
was complicated by necrosis of the omental pouch and a
prolonged postoperative ileus. Multiple CT scans of her
abdomen revealed no evidence of obstruction and the ileus was
thought to be secondary to inflammation and irritation from
the necrotic omentum. On [**12-18**], the patient was found to be
less responsive with increasing respiratory effort. An
arterial blood gas revealed a pH of 7.22, CO2 100 and a PA2
of 84 on 3 liters of oxygen. At this point the patient was
intubated for hypercarbic respiratory failure and was
transferred to the Medical Intensive Care Unit.
From a respiratory standpoint, the patient was extubated on
the following day, but required reintubation after three days
secondary to increasing secretions and need for constant
pulmonary toilet. The patient remained difficult to wean.
This was attributed to volume overload secondary to diastolic
dysfunction as well as a component of chronic obstructive
pulmonary disease. A sputum culture from [**12-18**] subsequently
grew MRSA and the patient was treated with a ten day course
of Vancomycin. The patient was finally extubated on [**1-5**]
after extensive diuresis. From a gastrointestinal standpoint
a CT of the abdomen on [**12-16**] revealed a communication between
Hartmann's pouch and the peritoneal cavity with an abdominal
fluid collection. Per the Surgery Service the collection was
noted to be draining into the rectal stump and
they recommended no further surgical management.
From an infectious disease standpoint four out of four blood
culture bottles from [**12-5**] and [**12-6**] grew coag negative
staphylococcus, which has been treated with Vancomycin.
Surveillance cultures from [**12-28**] revealed no growth to date.
As mentioned previously, the patient had a sputum on [**12-18**],
which grew MRSA. Blood cultures from [**12-18**] subsequently grew
[**Female First Name (un) **] [**Female First Name (un) 29361**], and the patient completed a fourteen day
course of Fluconazole on [**1-4**]. Lastly, sputum from [**1-4**]
grew Pseudomonas. The Infectious Disease Service was
consulted and they believed the patient is colonized,
particularly since she currently has no evidence of
pneumonia.
From a cardiac standpoint there has been concern about volume
overload secondary to diastolic dysfunction. The patient had
an echocardiogram on [**12-19**], which revealed a left ventricular
ejection fraction of 55% and unremarkable chamber sizes and
thicknesses. There was also concern about coronary artery
disease. The patient reportedly had a cardiac
catheterization at the outside hospital with a 30% left
anterior descending coronary artery and a 50% right coronary
artery. She had several episodes of atypical chest pain
during her stay and was ruled out for myocardial infarction
multiple times. During her MICU stay the patient had
frequent episodes of paroxysmal atrial fibrillation. She has
been treated with Amiodarone and Lopressor with good effects.
From a nutrition standpoint the patient was initially on
total parenteral nutrition, but this was discontinued after
the [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**] fungemia. The patient has since been
on tube feeds via nasogastric tube and is at her goal.
From a psychiatric standpoint the patient has been profoundly
depressed and is being followed by the Psychiatry Service.
There was on episode of a self extubation attempt. At this
point they do not feel that she is a suicide risk. She has
been tried on Celexa and Ritalin without benefit. She is
currently on Wellbutrin.
PAST MEDICAL HISTORY: 1. Rectal carcinoma status post
radiation therapy and chemosensitization and low anterior
resection on [**2120-11-15**]. 2. Hypertension with a question
diastolic dysfunction. 3. Coronary artery disease with a
30% left anterior descending coronary artery, 50% right
coronary artery. 4. Status post cholecystectomy.
ALLERGIES: Penicillin, Erythromycin and intravenous contrast
(but she can tolerate the contrast).
MEDICATIONS ON TRANSFER: Lopressor 50 mg po b.i.d.,
Wellbutrin 100 mg po t.i.d., Lasix 80 mg po b.i.d., Prevacid
30 mg po q.d., Amiodarone 400 mg po q.d., Atrovent, Colace
100 mg po b.i.d., Reglan 10 mg po q.i.d., heparin subQ,
Tylenol prn.
SOCIAL HISTORY: She lives with her husband. She has a
positive tobacco history.
PHYSICAL EXAMINATION: The patient had a temperature of 99.9.
Her blood pressure was 129/34. Heart rate 78. Respiratory
rate 30. She was sating 100% of 4 liters of oxygen by nasal
cannula. In general, the patient was a sad, but conversant
older female in no acute distress. Neck examination she had
a jugulovenous pressure of approximately 8 cm of water. Her
neck was supple without lymphadenopathy. Cardiovascular
examination regular rate and rhythm. No murmurs, rubs or
gallops. Respiratory examination, the patient had decreased
breath sounds bilaterally as well as soft bibasilar rales.
Abdomen examination the patient had positive bowel sounds.
Her abdomen was soft, nontender, nondistended. Her colostomy
site was clean and intact. Her extremities are warm without
clubbing, cyanosis or edema. She had 2+ dorsalis pedis
pulses bilaterally.
LABORATORY: The patient had a white blood cell count of
11.6, hematocrit 32.2, platelet count 376, sodium 137,
potassium 4.8, chloride 88, CO2 41, BUN 15, creatinine 0.4,
calcium 9.1, mag 1.8, phosphate 4.3. Studies, the patient
had a chest x-ray on [**1-6**], which revealed interval
improvement in upper zone redistribution with a small left
pleural effusion and residual left lower lobe collapse with a
questionable consolidation in the retrocardiac region thought
to be secondary to atelectasis. She had a CT of the abdomen
on [**12-25**], which revealed a collection of fluid and air within
the abdomen consistent with an abdominal abscess. She had a
CT of the adomen on [**12-16**], which revealed a collection of
fluid and air within the abdomen with no identifiable
Hartmann's pouch. She had a TTE on [**12-19**]. She was found to
have an ejection fraction of 60%. Her left atrium was mildly
dilated. Her left ventricular thickness and cavity size were
normal. Her right ventricular thickness and size were
normal. She was found to have a moderate mitral annular
calcification and 1+ mitral regurgitation.
Microbiologic data, sputum culture from [**1-4**] grew
Pseudomanas. On [**12-28**] MRSA, [**12-22**] MRSA and [**12-18**] MRSA. Blood
cultures on [**12-28**] no growth times two sets. [**12-18**] one out of
four [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**], [**12-6**] two out of two coag negative
staph. [**12-5**] two out of two coag negative staph. [**11-27**] no
growth times two.
HOSPITAL COURSE: The patient was transferred to the General
Medicine Service on [**1-6**] for further management.
1. Pulmonary: The patient had daily chest physical therapy
and an aggressive pulmonary toilet. She was encouraged to
use her incentive spirometer. We decided to treat the
patient with a course of Ciprofloxacin for the Pseudomonas in
her sputum. We discussed her treatment with the infectious
disease fellow who did not think that she needed to be double
covered for the pan sensitive Pseudomonas in her sputum. The
patient's respiratory status continued to improve on a daily
basis. Her oxygen saturations improved dramatically to the
point that she required 3 to 4 liters by nasal cannula to
maintain appropriate oxygen saturation.
2. Infectious disease: As was mentioned previously we
treated the patient empirically for a Pseudomonas pneumonia
with Ciprofloxacin. There was no clear evidence of
pneumonia, but given her history and tenuous status we opted
to treat her empirically with a single [**Doctor Last Name 360**]. From an
infectious disease standpoint the patient did very well. She
did not have any overt signs of infection. We followed her
blood cultures carefully and there was no additional growth
to date on her surveillance cultures. Her white blood cell
count and fever curve remained within normal limits.
3. Gastrointestinal: The patient has been noted to have an
abdominal collection that is draining into the rectal stump.
She was followed by the Surgery Service during her stay and
they did not believe that she needed any further surgical
management. Her abdominal examination remained benign.
4. Cardiovascular: From a cardiovascular standpoint we did
not have any evidence of acute ischemia, however, after her
stay in the Medical Intensive Care Unit the patient had
several episodes of paroxysmal atrial fibrillation. She was
continued on the Amiodarone and Lopressor. Despite this she
did have several episodes during her stay on the general
medicine floor. Each time she remained hemodynamically
stable with a ventricular response rate to the 150s. She
responded quite well with low dose intravenous Lopressor
converting to sinus rhythm almost instantaneous. We think
that the atrial fibrillation is secondary to all the
patient's general medical problems. Toward the end of her
hospital stay the patient remained in normal sinus rhythm.
Despite this we opted to continue the Amiodarone and
Lopresor. During her stay in the Medical Intensive Care
Unit, the patient was felt to have a diastolic dysfunction,
but was noted to be very fluid sensitive and responsive to
Lasix. By the time she arrived to the medical floor we felt
that she was euvolemic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2121-3-18**] 17:00
T: [**2121-3-19**] 05:41
JOB#: [**Job Number 36073**]
ICD9 Codes: 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 86
} | Medical Text: Admission Date: [**2117-7-18**] Discharge Date: [**2117-7-29**]
Date of Birth: [**2047-11-12**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old
male with a history of coronary artery disease status post
myocardial infarction who was transferred to [**Hospital1 346**] for percutaneous angioplasty after a
seven minute episode of ventricular tachycardia without
intervention. The patient was found in the bed by his wife,
choking and unresponsive in the mid afternoon on the day of
admission. The wife called her daughter who in turn
activated the Emergency Medical System. The patient was
found in V fibrillation and was treated with epinephrine,
atropine and Dopamine. He was then taken to [**Hospital 35774**] Hospital
where he was given Lidocaine and Amiodarone.
Electrocardiogram was notable for ST depressions in V4 and 5
and 6 leads with junctional rhythm. He was transferred to
[**Hospital1 69**] for emergent cardiac
catheterization. Cardiac catheterization was notable for
mild to moderate left anterior descending coronary artery
stenosis and stenting of first diagonal was performed. He
was then transferred to the floor sedated and intubated.
PAST MEDICAL HISTORY: Significant for hypertension, which is
life long, coronary artery disease, questionable myocardial
infarction in [**2108**], percutaneous transluminal coronary
angioplasty [**2116-6-14**], left anterior descending coronary
artery 95% stenosis, OMI 90% stenosis, obtuse marginal one
stent and diabetes apparently diet controlled.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Significant for coronary artery disease.
The patient's father died at age 57 of an acute myocardial
infarction.
SOCIAL HISTORY: The patient has an 80 pack year history of
smoking until [**2115**]. No ethanol. He is an engineer and
married with children.
MEDICATIONS ON ADMISSION: Zocor 40 once a day, Plendil 5
once a day, atenolol 25 once a day and Vaseretic dose
unknown.
PHYSICAL EXAMINATION: Temperature 99.8. Heart rate 66.
Blood pressure 124/61. The patient was intubated on AC at
600 tidal volume 14 respirations with an FIO2 of 40% PEEP 5.
On physical examination intubated, sedated, spontaneous
monoclonic jerks. HEENT pupils small, minimally reactive to
light. No gag reflex. Cardiovascular regular rate and
rhythm. No murmurs. Pulmonary clear to auscultation
anteriorly. Abdomen nondistended, soft. Extremities
positive pulses in all four extremities. The patient has
paroxysmal monoclinic jerks. Neurological examination eyes
open spontaneously. No tracking. No roving eye movements.
No response to verbal or painful stimuli. Cranial nerves
examination pupils 2 mm no light reaction appreciated except
for possible minimal change in left pupil. No corneal reflex
bilaterally. Does not blink to light bilaterally. Slide
both eye movements, but no response to ________ testing. No
gag obtainable. Motor increased tone throughout with normal
bulk and intermittent myoclonic movements of all four
extremities that increase in frequency when the patient is
stimulated. No drawer, no flexor or extensor response to
pain. The patient does not protect face when arm drop
towards it. Reflexes has 3+ brachial radialis biceps and
triceps reflexes, both left and right arms. 3+ triceps
reflexes bilaterally, 2+ patella reflexes bilaterally and 4+
ankle reflexes bilaterally. No plantar movements. The
patient has positive [**Doctor Last Name **] sign bilaterally in upper
extremities three to four beats of clonus at both ankles.
LABORATORY: White blood cell count 10.0, hematocrit 41.5,
platelets 165, sodium 145, K 3.3, chloride 105, bicarb 19,
BUN 20, creatinine 1.6, glucose 237. Arterial blood gas pH
7.3, PCO2 46, PO2 292, calcium 8.4, total bilirubin 0.4, CPK
44, alkaline phosphatase 83, troponin less then 0.4.
HOSPITAL COURSE: Immediately upon admission a neurological
consult was obtained and indicated wide spread severe anoxic
brain damage. CT scan of the head was done and showed a
small subcortical hemorrhage in the left frontal lobe
multiple lacunar infarcts, which were chronic and reduced
great white matter of visibility consistent with global
ischemic change. Given the patient's history he was started
on Amiodarone to prevent further arrhythmias. He was also
hypertensive and was started on Lopressor, aspirin, Plavix,
statin, Captopril. Since admission the patient started
spiking low grade fevers and was started on Flagyl and
Levofloxacin for empiric treatment of possible infection.
Since the beginning of the [**Hospital 228**] hospital stay there were
multiple meetings with the patient's family were undertaken
by the primary care team and neurology team in attempt to
explain the poor prognosis, which according to neurology
given the patient's status 93% no improvement and 7% slight
improvement with severe neurologic damage, 0% moderate to
complete improvement of the patient's neurological status.
The patient's family voiced their understanding of the
current situation and decided to proceed with tracheostomy
and PEG tube placement and maintain the patient full code.
On [**7-23**] a tracheostomy tube was performed at the bedside
by interventional pulmonology without complications. PEG
tube placement was performed by GI on [**7-27**]. The patient
was extubated on [**7-28**] in the early a.m. and remained
stable over the next 24 hours on flow by oxygen at 35%. His
cardiovascular status remained stable with high normal blood
pressures and cardiac rhythm significant for intermittent
atrial fibrillation with spontaneous conversion to sinus
bradycardia without requiring any intervention. Infectious
disease wise he remained afebrile since the initiation of
antibiotic treatment. His neurological status remained
unchanged. The patient was in a vegetative state at the time
of discharge.
The patient was discharged to [**Hospital3 **] Hospital
Naddick for long term care and management with a diagnosis of
acute myocardial infarction status post ventricular
fibrillation and anoxic brain injury. His discharge
medications were insulin sliding scale per flow sheet,
calcium gluconate 500 po t.i.d., Lansoprazole oral solution
30 mg nasogastric q.d., heparin 5000 units subQ q 12, aspirin
325 mg po q day, Metoprolol 75 mg nasogastric b.i.d. being
held for a systolic blood pressure less then 100 or a heart
rate less then 60, Captopril 75 mg po t.i.d. to be held for
systolic blood pressures less then 90. Saliva substitute 1
to 3 milliliters po q 1 to 2 hours prn, Metronidazole 500 mg
intravenous q 8 last dose [**8-1**]. Acetaminophen 325/650
po q 4 to 6 hours prn for fever or pain, Levofloxacin 500 mg
po q 24 hours last dose to be given on [**8-1**].
Simvastatin 40 mg po q day and Plavix 75 mg po q.d. last dose
[**2117-8-18**]. Aspirin 325 mg po q day and Atropine
sulfate 0.5 mg intravenous prn for symptomatic bradycardia
and hypertension. He was discharged on tube feeding diet.
The staff at [**Hospital3 **] Hospital at Naddick to
schedule primary care physician for follow up on this
patient.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-222
Dictated By:[**Doctor First Name 35775**]
MEDQUIST36
D: [**2117-7-29**] 12:01
T: [**2117-7-29**] 12:08
JOB#: [**Job Number 35776**]
ICD9 Codes: 5070, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 87
} | Medical Text: Admission Date: [**2153-2-3**] Discharge Date: [**2153-2-7**]
Date of Birth: [**2074-10-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hypotension, fever to 101
Major Surgical or Invasive Procedure:
femoral central line
History of Present Illness:
78 yo man c PMH of Chronic Liver disease, Hepatoma s/p
[**First Name3 (LF) 54267**] x 2, COPD, Afib on coumadin, was in his USOH until
[**2153-2-3**] AM when he began having chills, rigors and was febrile
at home to 101, per pt. He went to [**Location (un) **] ED were he was found
to be hypotensive BP in low 70 s. Pt denies having: cough, SOB,
dysuria, urinary frequency, diarrhea, abdominal pain, n/v, night
sweats, anorexia. Last BM was yesterday. At [**Location (un) **]: Levaquin, 3
L NS, dopamine 5 mcg/min. Pt arrived to [**Hospital1 18**] ED c BP in near
120/48 HR 80-90s. Dopamine drip was stopped. However pt was
noticed to have refractory hypotension and started on Levophed
again. In the [**Hospital1 **] ED, he received IV Vanco, Levoflox, FFP and
NS IVF at 100cc/hour.
.
His MICU course: The pt was on vanc, levo, flagyl in the unit.
Panculture negative to date. CXR without infiltrates. Abd u/s
negative for cholecystitis. Abdominal CT to r/o new liver
abscess considering pt's PMH was negative. Vancomycin was
tapered off [**2-6**] (received 4 days). IV levoflox and flagyl were
continued. Pt was also on steroids for bronchospasm, COPD in
MICU, and received prednisone 60mg po qd in the unit, with
bronchodilators. He is satting 99-100% on 2L NC (his baseline
oxygen requirement). Initially, his INR was supratherapeutic to
4.9, so coumadin was held initially. Coumadin was restarted for
goal INR [**1-12**]. His foley was d/c'd and he continues to urinate
well. He is tolerating a regular diet, taking all meds orally.
Past Medical History:
-Afib for many years on coumadin
-HTN
-COPD
-Hepatocellular carcinoma and cirrhosis s/p [**Month/Day (3) 54267**]
surgery
x 2, dx'd 2 years ago, folloed by Dr. [**First Name (STitle) **] at [**Hospital1 18**] .
Pt has hx of liver abscess s/p second [**First Name9 (NamePattern2) 54267**] [**5-13**].
-Prosthetic rigtht eye s/p HSV and subsequent enucleation
-Stent in pancreas for mass and h/o obstructive jaundice
-Sarcoidosis s/p lung biopsy on right
-h/o Right temporal infarct [**1-11**] subtherapeutic INR, Afib by MRI,
[**6-13**]
-h/o splenic infarct thought [**1-11**] subtherapeutic INR, Afib [**6-13**]
-last echo [**2152-6-13**]: EF 55%, mod-markedly dil atria b/l. dil RV
with free wall hypokinesis, RV pressure overload, 1+MR, 4+TR,
severe pulm artery HTN, Cardiologist at [**Location (un) **] is Dr. [**Last Name (STitle) 3503**],
dry weight 162 lbs.
Social History:
The patient lives at home with wife, independent in ADLs, has 2
daughters, originally from [**Name (NI) 4754**] but here since [**2103**], smoked
2ppd x 20 years quit 40 yrs ago, no etoh, no drugs. Former
construction worker for [**Location (un) **] gas co.
Family History:
The patient is one of 11 children. 2 brothers and 1 sister with
strokes, brothers at ages 38 and 50. One brother with [**Name2 (NI) 499**]
cancer. No seizures run in family.
Physical Exam:
Physical Exam on admission:
VITALS: 99.7 HR 90-110 afib, 88-96/58-70, 18, 95% 2 Lt
GEN: no acute distress, pleasant elderly man
SKIN: no rash , jaundiced
[**Name2 (NI) 4459**]: NC/AT, anicteric sclera, mmm
NECK: supple, no meningismus , + JVP
CHEST: normal respiratory pattern, CTA bilat anteriorly ,
decreased breath sounds in both bases
CV: irregular irregular rate, no murmurs
ABD: soft, nontender, nondistended, +BS, liver edge not
palpable , no ascites.
EXTREM: no edema, 1+ dorsalis pedis pulses, 2+ radial pulses
.
Phys Exam on call out from MICU:
Vitals: Tm: 96.8 Tc: 96.6 BP: 111/64 (99-120/49-69) P: 81 RR:
19-25 O2sat: 98-100% on 2L NC. 24 hour I/O 3090/1310 +1780. 8
hour I/O: 1250/2365 -1115.
General: Well appearing CM in NAD. Pleasant and cooperative.
Sitting upright in chair talking with daughter.
[**Name (NI) 4459**]: right eye is prosthetic, left eye PERRL, left eye EOMI.
No nasal discharge. MM slightly dry, OP clear. Poor dentition.
JVD mid neck. No cervical LAD.
Lungs: CTAB
CV: Irregularly irregular rhythm. S1 and S2 audible.
Abd: Soft, NT, ND, Positive BS, No ascites. No HSM.
Ext: No peripheral edema. No cyanosis/clubbing. Ext warm and
well perfused. 2+ DP pulses b/l.
Pertinent Results:
[**2153-2-3**] 08:00PM WBC-12.2*# RBC-2.92* HGB-10.3* HCT-29.8*
MCV-102* MCH-35.1* MCHC-34.5 RDW-16.8*
[**2153-2-3**] 08:00PM NEUTS-73* BANDS-11* LYMPHS-11* MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2153-2-3**] 08:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2153-2-3**] 08:00PM PLT COUNT-163
[**2153-2-3**] 07:45PM LACTATE-1.3
[**2153-2-3**] 08:00PM PT-43.3* PTT-39.9* INR(PT)-4.9*
.
[**2153-2-3**]: CXR IMPRESSION: Cardiomegaly with congestive heart
failure.Bibasilar atelectasis with small bilateral pleural
effusions.
.
[**2153-2-4**]: Abdominal Ultrasound
IMPRESSION: No evidence of acute cholecystitis or
cholelithiasis. Patchy areas of increased echogenicity in the
right lobe of the liver likely representing changes associated
with prior RF ablation.
.
[**2153-2-5**] CT TORSO
IMPRESSION:
1. Bilateral predominantly peripheral ground glass opacities,
which are new from the prior study. The etiology is uncertain,
but differential diagnosis includes includes infectious or
inflammatory process, cryptogenic organizing pneumonia,
eosinophilic or hypersensitivity pneumonia and pulmonary edema
superimposed on severe emphysema. Clinical correlation and
follow up if indicated is recommended.
2. Stable renal cysts.
3. Stable appearance of the radiofrequency ablations site. No
evidence of abdominal abscess or pseudocyst.
4. Peripheral high attenuation area transiently seen ?perfusion
anomaly, as described.
.
CULTURE DATA:
[**2153-2-3**] Blood cx X 4 neg
[**2153-2-4**] Blood cx X 4 neg
[**2153-2-3**] Urine cx no growth
[**2153-2-3**]: UA neg nitr, neg leuks, 0-2 WBC, [**2-11**] RBC, rare bact,
0-2 epi.
.
Brief Hospital Course:
78 yo man with Chronic Liver disease, Hepatoma s/p [**Month/Day (1) 54267**]
x 2, h/o liver abscess, COPD, Atrial fibrillation on coumadin
admitted for fever and hypotension, thought to be septic
secondary to unclear etiology-- CXR negative for infiltrate but
with bilateral pleural effusions (effusions too small for a
diagnostic thoracentesis), Urinalysis negative, urine cx
negative, blood cx X 4 negative. Pt covered empirically X 4
days on Vanco/Levo/Flagyl, d/c Vanco [**2153-2-6**], and continued
Levo/Flagyl to complete 7 day course given history of liver
abscess in past.
.
1. Hypotension, Fever on admission thought to be [**1-11**]
Septic-picture: with no clear source. However low BP,
documented fever at OSH, and hx of chills makes infection
likely. Pt started on Levofloxacin + Vanc in ED and on Levophed
trough peripheral IV. On vanc, levo, flagyl in the MICU.
Panculture negative to date. CXR without infiltrates. Abd u/s
negative for cholecystitis. CT torso showing ground glass
opacities in lungs inflamm vs. infectious, bilateral effusions
too small to tap. No intraabd abscess.
- Plan to continue Levo/Flagyl for 2 more days to complete 7
day course given h/o liver abscess in past.
.
2. Cardiovascular:
A. Coronaries: No signs of ischemia on EKG, enzymes negative.
Aspirin was held and his beta blocker was continued.
B. Pump: No signs of ischemia on EKG or enzymes. Getting 20mg
IV lasix for diuresis, transitioned to 40mg po lasix on transfer
to medical floor. Of note, he usually gets 80mg po qd of lasix
at home. Last echo was [**6-13**] showing EF 55%, severe pulm a HTN,
dil atria b/l, dilated right ventricle with pressure overload.
On discharge, he is monitor his daily weight and call his PCP if
his weight increases by 3 lbs or more, as this may indicate
heart failure.
C. Rhythm: Atrial fibrillation. He is to continue his beta
blocker, atenolol, for rate control, and coumadin for
anticoagulation. Goal INR [**1-12**]. The pt is at goal INR with 1mg
coumadin po qday.
.
3. COPD: Started prednisone 60mg qday for total of 5 days, which
was completed during this hospitalization. He is to continue
bronchodilators. Pt satting well on 2L NC, his baseline oxygen
requirement. He was satting well ambulating with physical
therapy.
.
4. GI: Pt with hx of liver disease, hepatocellular carcinoma
status post [**Month/Day (3) 54267**]. LFTs are elevated, AFP high, however
stable and trending downward. No abd pain, nausea, vomiting,
diarrhea, constipation. No intraabdominal abscess was seen on
CT abdomen. Stable appearance of radiofrequency ablations site
on CT Abdomen.
.
5. HTN: Pt's blood pressure has remained stable, he has not
required pressors in over 48 hours, no fluids needed for past 24
hours. Taking well po. Restarted Beta blocker and his [**Last Name (un) **] with
tight hold parameters.
.
6. Code: Pt is full code.
Medications on Admission:
1. Aspirin 81 mg Tablet
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
4. Atenolol 25 mg Tablet Sig
5. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a
day.
7. LT4 25 ug QD
8. Lasix 20 QD
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*3*
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
You will need to see Dr. [**Last Name (STitle) 8521**] for refills and to monitor your
INR lab values/adjust dose. .
Disp:*30 Tablet(s)* Refills:*0*
5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
You will need to follow up with Dr. [**Last Name (STitle) 8521**] for refills, and to
check your electrolytes.
Disp:*60 Tablet(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for wheezing.
Disp:*1 MDI* Refills:*2*
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 MDI* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
1. Hypotension
2. Atrial fibrillation
3. Hypertension
4. Chronic Obstructive Pulmonary Disease
5. Hepatocellular carcinoma
6. history of right temporal infarct
7. history of splenic infarct
8. history of sarcoidosis status post lung biopsy on the right
9. history of prosthetic right eye
Discharge Condition:
Stable, Good
Discharge Instructions:
If you experience fever, chills, chest pain, shortness of
breath, abdominal pain, nausea, vomiting, please report to the
emergency room immediately.
Please take all of your medications as prescribed.
Please follow up with your physician. [**Name10 (NameIs) **] information below.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 31446**] [**Name (STitle) 8521**], 11:00am, [**2-14**], [**2152**]. Please call her office at [**Telephone/Fax (1) 54268**] if you need to
reschedule your appointment.
Completed by:[**2153-2-7**]
ICD9 Codes: 0389, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 88
} | Medical Text: Admission Date: [**2146-3-28**] Discharge Date: [**2146-3-31**]
Date of Birth: [**2105-8-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7202**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2146-3-28**]:
2 Cypher stents to the right coronary artery
History of Present Illness:
The patient is a 40 year old male with a history of 2 ppd x 20
years tobacco history and a family history of heart disease who
presented to [**Hospital3 **] this afternoon after having [**10-24**]
substernal chest pressure around 2 pm after shoveling snow today
around 12:30-1 pm. The patient returned indoors and felt [**10-24**]
substernal chest pressure associated with diaphoresis, shortness
of breath and left arm radiation with tightness radiating to the
area between his clavicles in his back. He reports no prior
history of chest pain. He was taken to [**Hospital6 3105**]
where his EKG showed 1-[**Street Address(2) 1766**] elevations in II, III and avF,
normal axis and [**Street Address(2) 4793**] elevation in V3 with inverted T waves in
I, avL with no prior EKG for comparison. Right-sided EKG showed
persistent II, III and avF ST elevations with [**Street Address(2) 4793**] V2-V6, TWI
I and avL. His CK was 105.
At [**Hospital3 **], he was placed on a nitro drip, heparin gtt,
integrillin and given IV morphine and aspirin. His SBP was
123/90 with a pulse of 58. He was transferred to BIMC for
cardiac catheterization.
His cath on [**2146-3-28**] showed:
Right-dominant system
LMCA normal
LAD mild disease without lesions
LCX Non-dominant vessel with lesions
RCA dominant with mid-segment 99% lesion with evident thrombus
RA 19
PCW 31
PA 40
CO 7 CI 3
Cypher x 2 to RCA placed
Past Medical History:
2 ppd x 20 years tobacco history
h/o hernia repair
herniated disc in upper spine (on disability)
no [**Date Range 2320**]
Social History:
The patient is currently on disability. He formerly worked in a
warehouse doing heavy lifting when he herniated a disc in his
upper spine and is now on disability. He smokes 2 ppd x 20
years. He also drinks 6-7 beers/week. He denies any illicit drug
use.
Family History:
Father - Deceased from MI at age 44
Paternal father - MI at age 55
Mother - [**Name (NI) 2320**], MI x 2
11 brothers and 3 sisters - no major medical problems
Physical Exam:
Tc = 97.3 P=74 BP=159/100 RR=16 99% O2 on 2liters NC
Gen - NAD, AOX3, heavy-set male
HEENT - PERLA, EOMI, no JVD, no carotid bruits bilaterally
Heart - RRR, Soft holosystolic murmur Grade II/VI at RUSB
Lungs - CTAB (anteriorly)
Abdomen - Soft, NT, ND no hepatosplenomegaly, + BS
Ext - Right groin oozing from venous catheter site, +2 d. pedis
bilaterally, no C/C/E
Pertinent Results:
ECHO Study Date of [**2146-3-29**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness and cavity
size are normal. There is probably mild basal inferior wall
hypokinesis with
overall preserved LV ejection fraction (LVEF>55%). Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
There is no aortic valve stenosis. The mitral valve appears
structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional LV hypokinesis with preserved overall
LVEF c/w CAD.
C.CATH Study Date of [**2146-3-28**]
COMMENTS:
1. Coronary angiography of this right dominant system revealed
severe
single vessel coronary artery disease. The left main coronary
artery
had no angiographically apparent flow limiting stenoses. The
LAD had
mild luminal irregularities. The LCX was a non-dominant vessel
without
lesions. The RCA was a dominant vessel with a 99% stenosis in
the mid
vessel with evidence of thrombus.
2. Resting hemodynamics were performed. Right sided pressures
were
severely elevated (mean RA pressure was 18 mm Hg). Pulmonary
artery
pressures were moderately elevated (PA pressure was 50/29 mm
Hg). Left
sided filling pressures were markedly elevated (mean PCW
pressure was 29
mm Hg). Central arterial pressures were moderately elevated
(aortic
pressure was 161/104 mm Hg). Cardiac index was normal (at 3.2
L/min/m2).
3. Successful PCI of the RCA with two overlapping Cypher DES
(3.5 x 8
mm and 3.0 x 23 mm).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Severely elevated left and right sided filling pressures.
3. Successful Primary PCI of the RCA with two drug-eluting
stents for an
acute inferior myocardial infarction.
[**2146-3-28**] 07:52PM GLUCOSE-121* UREA N-9 CREAT-0.9 SODIUM-140
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-30* ANION GAP-13
[**2146-3-28**] 07:52PM ALT(SGPT)-142* AST(SGOT)-107* LD(LDH)-319*
ALK PHOS-82 AMYLASE-48 TOT BILI-0.7
[**2146-3-28**] 07:52PM LIPASE-29
[**2146-3-28**] 07:52PM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-2.4*
MAGNESIUM-2.1 CHOLEST-228*
[**2146-3-28**] 07:52PM %HbA1c-5.7
[**2146-3-28**] 07:52PM TRIGLYCER-114 HDL CHOL-42 CHOL/HDL-5.4
LDL(CALC)-163*
[**2146-3-28**] 07:52PM WBC-11.9* RBC-5.34 HGB-16.5 HCT-48.8 MCV-91
MCH-30.8 MCHC-33.7 RDW-13.3
[**2146-3-28**] 07:52PM PLT COUNT-254
[**2146-3-28**] 07:52PM PT-12.7 PTT-29.1 INR(PT)-1.0
[**2146-3-28**] 06:31PM TYPE-ART PO2-303* PCO2-56* PH-7.28* TOTAL
CO2-27 BASE XS--1 INTUBATED-NOT INTUBA
[**2146-3-28**] 06:31PM HGB-16.8 calcHCT-50 O2 SAT-96
Brief Hospital Course:
The patient is a 40 year old male with a history of heavy
tobacco use, family history of CAD who presented with inferior
MI s/p RCA stent x 2
1. CAD
- The patient had a Cypher stent placed to the right coronary
artery with no further events. He had a few isolated episodes of
NSVT post-cath attributed to reperfusion.
- The patient was continued on aspirin and must take Plavix for
the next 9 months. He was placed on a statin with close
monitoring of his LFTS which were slightly elevated on
presentation given his history of EtOH use. He was titrated up
to Toprol XL 50 mg and Lisinopril 5 mg.
2. HTN
- The patient originally felt a little dizzy and lightheaded
with Lopressor 25 mg TID with systolic blood pressures in the
90s. Therefore, he was changed to Toprol XL 50 mg without
difficulty. He was also titrated to Lisinopril 5 mg.
3. CHF
- The patient had a PAWP of 31 in the cath lab. His CXR showed
no evidence of CHF. He was given lasix 20 IV x 2 total and
auto-diuresed on his own, remaining euvolemic throughout the
rest of his stay.
- He had an echocardiogram which showed an EF of 55-60% with
hypokinesis of the inferior wall. An echocardiogram should be
repeated in 4 weeks post-MI to re-evaluate any residual wall
motion abnormality.
4. Smoking cessation
- The patient was encouraged to quit smoking. He has tried the
nicotine patch and gum in the past without success. We discussed
the possibility of wellbutrin, however, given his alcohol
consumption, we felt it may be a risk in lowering his seizure
threshold. The patient was encouraged to join group tobacco
cessation therapy but he appeared hesitant. He will try to quit
tobacco on his own but admits there is temptation given that
most of the people he lives with at home smoke.
Medications on Admission:
Aspirin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*9*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation inferior myocardial infarction
Premature coronary artery disease
Discharge Condition:
Stable.
Discharge Instructions:
You MUST take your plavix every day for the next 9 months.
Failure to do so may result in another heart attack or even
death.
Please call 911 or return to the ER if you experience any more
chest pain.
Followup Instructions:
Please call to schedule an appointment with your primary care
physician [**Last Name (NamePattern4) **] [**1-16**] weeks. You should have liver function tests
drawn at this time. You will need to follow up with a
cardiologist in 4 weeks. You may have a repeat echo at this time
to evaluate the function of your heart.
ICD9 Codes: 4271, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 89
} | Medical Text: Admission Date: [**2167-11-13**] Discharge Date: [**2167-11-27**]
Date of Birth: [**2167-11-13**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 75017**] [**Known lastname **] is the former 1.135
kilogram produce of a 31-2/7 week gestation pregnancy born to
a 33-year-old G1, P0 now 1 woman. Prenatal screen: Blood type
A-, antibody negative, rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group beta strep status
unknown. The mother's medical history was complicated by
pneumonia requiring initiation of steroids. She continued on
her steroid taper into her pregnancy. She developed
gestational diabetes most likely secondary to the steroid
taper. She was also a smoker and has an anxiety disorder. She
suffered a cerebral vascular accident at age 18. She was
monitored closely for the known intrauterine growth
restriction and was noted to have absent diastolic flow on
the day of delivery. She was taken to cesarean section for
nonreasurring fetal heart rate tracing. There was large
amount of blood noted at the time of delivery. The infant
emerged apneic and required positive pressure ventilation and
blow-by O2. Apgars were 5 at one minute and 7 at five minutes
and 8 at 10 minutes. He was admitted to the neonatal
intensive care unit for treatment of prematurity.
Anthropometric measurements at the time of admission to the
neonatal intensive care unit: Weight 1.135 kilograms, less
than the 10th percentile, length 37 cm 25th percentile, head
circumference 24.6 cm, less than 10th percentile.
PHYSICAL EXAMINATION UPON DISCHARGE: Weight 1.345 kilograms,
length 39 cm, head circumference 27 cm. General: Well
appearing preterm male in room air. Skin warm and dry. Color
pink. Well perfused. Head, ears, eyes, nose and throat,
anterior fontanel open, level, sutures opposed, eyes clear,
palate intact. Positive red reflex bilaterally. Chest: Breath
sounds clear, equal, easy respirations. Cardiovascular:
Regular rate and rhythm. No murmur. Normal S1, S2, femoral
pulses +2. Positive palmar pulses. Abdomen soft, nontender,
nondistended. No masses. Positive bowel sounds. Cord remnant
on and drying. Extremities: Moving all stable hips. Neuro:
Active with exam. Symmetric tone and movements. Positive
suck, positive grasp.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: This infant required treatment with
continuous airway pressure upon admission to the
neonatal intensive care unit. His respiratory distress
resolved and he weaned to room air by day of life #1. He
continued in room air through the rest of his neonatal
intensive care unit admission. He has had rare episodes
of spontaneous apnea and bradycardia that have been
monitored and with no further treatment provided. At the
time of discharge he is breathing comfortably in room
air 40-60 breaths per minute with oxygen saturations
greater than 96%.
2. Cardiovascular: This infant has maintained normal heart
rates and blood pressures. An intermittent murmur was
noted from day of life 5 through 6 and is not audible at
the time of discharge. Baseline heart rate is 130-170
beats per minute with a recent blood pressure of 56/28
mmHg, mean arterial pressure of 46 mmHg.
3. Fluids, electrolytes, nutrition: This infant had initial
hypoglycemia requiring treatment with 20% glucose and
water. He had an umbilical venous catheter placed for
central access. Enteral feeds were started on day of
life #2 and gradually advanced to full volume. He
successfully weaned from the high glucose intravenous
solution and has been off intravenous fluids for the 72
hours prior to delivery. He is currently being fed 150
mL per kilo per day of preemie Enfamil 28 calorie per
ounce formula. His serum glucoses have been 57-80 mg per
deciliter. At the time of discharge he weighs 1.345
kilograms. Serum electrolytes were checked several times
in the first week of life and were within normal limits.
4. Infectious disease: Due to his respiratory distress and
presentation at the time of birth and the unknown group
beta strep status of his mother, this infant was
evaluated for sepsis upon admission to the neonatal
intensive care unit. A white blood cell count and
differential were within normal limits. A blood culture
was obtained prior to starting intravenous ampicillin
and gentamycin. The blood culture was no growth at 48
hours and the antibiotics were discontinued. Urine CMV
was sent but was negative.
5. Hematological: This infant is blood type O+ and is
direct antibody test negative. His hematocrit at birth
was 38. He did not receive any transfusions or blood
products. He is being treated with supplemental iron.
6. Gastrointestinal: This infant required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life at 6.1 mg per
deciliter. He was treated with phototherapy for
approximately 96 hours. Most recent rebound bilirubin on
[**2167-11-20**] was 1.6/0.5 mg per deciliter.
7. Neurology: A head ultrasound was performed on day of
life #5 and showed a left germinal matrix hemorrhage.
Repeat head ultrasound on [**2167-11-25**] showed the
previously mentioned left germinal matrix hemorrhage but
stable and no increased ventricular size. This infant
has maintained a normal neurological exam during his
admission.
8. Sensory: Audiology hearing screening has not yet been
performed. It is recommended prior to discharge.
Ophthalmology: This infant will require screening eye
exams for retinopathy of prematurity starting at
corrected age 33-34 weeks.
9. Placenta: The placental pathology was normal.
10. Psychosocial: This mother was very ill postoperatively
from her cesarean section. She remained hospitalized
until [**2167-11-25**]. The infant is being retro
transferred to [**Hospital **] Hospital upon her request. [**Hospital1 35990**] social work was involved
with this mother. The contact social worker is [**Name (NI) 4457**]
[**Name (NI) 36244**] and she can be reached at [**Telephone/Fax (1) 70445**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to [**Hospital **] Hospital for
continuing level II care.
PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital 75018**]
Medical Center, [**Last Name (un) 75019**], [**Location 56504**]
[**Numeric Identifier 75020**]. Phone number [**Telephone/Fax (1) 56498**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding. Preemie Enfamil 28 calorie per ounce formula at
150 mL per kilo per day by gavage every 3 hours.
2. Medications. Ferrous sulfate 25 mg per mL dilution, 0.1
mL p.o. once daily; vitamin E 5 units pg once daily.
3. Iron and vitamin D supplementation: Iron supplementation
is recommended for preterm and low birth weight infants
until 12 months corrected age. All infants fed
predominantly breast milk should receive vitamin D
supplementation at 200 international units (may be
provided as a multivitamin preparation) daily until 12
months corrected age.
4. Car seat position screening is recommended prior to
discharge.
5. State newborn screens were sent on [**11-16**] and
[**2167-11-27**]. There has been no notification of
abnormal results to date.
6. Immunizations. No immunizations have been administered
thus far.
7. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following four criteria:
1) Born at less than 32 weeks;
2) Born between 32 and 35 weeks with two of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school
age siblings;
3) Chronic lung disease
4)Hemodynamically significant congenital heart disease
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
This infant has not received rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of preterm
infants at or following discharge from the hospital if they are
clinically stable at at least 6 weeks but fewer than 12 weeks
of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 31-2/7 weeks' gestation.
2. Intrauterine growth restriction.
3. Transitional respiratory distress.
4. Suspicion for sepsis ruled out.
5. Apnea of prematurity.
6. Unconjugated hyperbilirubinemia.
7. Profound hypoglycemia.
8. Last germinal matrix IVH.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 43348**]
MEDQUIST36
D: [**2167-11-27**] 01:20:30
T: [**2167-11-27**] 12:40:47
Job#: [**Job Number 75021**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 90
} | Medical Text: Admission Date: [**2151-10-1**] Discharge Date: [**2151-10-5**]
Date of Birth: [**2091-12-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
59 yo F w/ PMH of alcohol and hepatitis C cirrhosis with history
of varices and upper GI bleed presents with loss of consciousnes
and was Guiac positive with a HCT drop from 44-->33 in the
setting of being intoxicated on alcohol who developed
hematemesis in the ED.
Per ED report, the patietn was alert and oriented x3 on
admission, intoxicated, and hypotensive to systolic of 70s. She
was given multiple listers of fluid and then developed
hematemesis with vomiting bright red blood and clots. She had an
NG tube placed and continued to vomit blood. She was started on
an octerotid and PPI drip with boluses, given a dose of
ceftriaxone and vancomycin and transffused 2u of PRBC. Her
pressures continued to be low and she received a 4th L of fluid
prior to transfer to the MICU.
On arrival to the MICU, she was intubated and sedated.
Review of systems:
unable to obatin as patient is sedated
Past Medical History:
- Alcoholic cirrhosis- low grade varices- not banded, not
bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint
brandy per day for more than a year. She had tried detox once.
Denies withdrawal
seizures.
- Chronic Back pain
- Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown
how she got it, denies IVDU, transfusions. Never had liver bx.
- Hypertension
- Alcoholic cirrhosis- low grade varices- not banded, not
bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint
brandy per day for more than a year. She had tried detox once.
Denies withdrawal
seizures.
- Chronic Back pain
- Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown
how she got it, denies IVDU, transfusions. Never had liver bx.
- Hypertension
Social History:
Lives in [**Location 686**] with her 16yo son. [**Name (NI) **] history of alcohol
abuse, over 10 years. Current smoker. Denies other drug use. Has
been in alcohol detox once - relaped shortly thereafter. Drinks
[**2-8**] to 1 pint brandy per day though is actively trying to quit.
Family History:
Mother had MI
Sister with diabetes.
Many family members with alcohol abuse
Physical Exam:
Exam on Admission:
General: sedateed and intubated, in NAD
HEENT: Sclera anicteric. Intubated with blood in the ETT ,
unable to assess JVP
CV: RRR, no MRG appreciated
Lungs: Rhonchrousou breath sounds bilaterally
Abdomen: soft, protuberant but nondistended. Hypoactive bowel
sounds.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated and inutbated
AT DISCHARGE:
O: AF 120s/70s 83-97 18 97%RA
Gen: NAD, sitting in chair comfortable
HEENT: MMM, hallitosis.
CV: RRR, normal S1/S2, no m/r/g.
Pulm: CTAB, no wheezes, rhonchi or rales.
Abd: Soft, non-tender, obese.
Neuro: AAO to person, place, time, president
Pertinent Results:
Labs on Admission:
[**2151-10-1**] 02:15AM BLOOD WBC-7.2# RBC-3.03* Hgb-11.1*# Hct-33.1*
MCV-109* MCH-36.7* MCHC-33.5 RDW-16.4* Plt Ct-78*
[**2151-10-1**] 02:15AM BLOOD Neuts-37.2* Lymphs-54.5* Monos-5.9
Eos-1.8 Baso-0.7
[**2151-10-1**] 09:03AM BLOOD PT-22.6* PTT-34.9 INR(PT)-2.2*
[**2151-10-1**] 02:15AM BLOOD Glucose-129* UreaN-18 Creat-1.0 Na-138
K-5.1 Cl-104 HCO3-22 AnGap-17
[**2151-10-1**] 07:40PM BLOOD ALT-28 AST-61* LD(LDH)-161 AlkPhos-97
TotBili-2.5*
[**2151-10-1**] 02:15AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.5*
[**2151-10-1**] 02:15AM BLOOD ASA-NEG Ethanol-292* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2151-10-1**] 09:13AM BLOOD Type-[**Last Name (un) **] pH-7.20*
[**2151-10-1**] 02:36AM BLOOD Lactate-4.8* K-4.6
[**2151-10-1**] 09:13AM BLOOD freeCa-0.86*
Labs on Discharge:
[**2151-10-5**] 05:01AM BLOOD WBC-4.5 RBC-2.56* Hgb-8.7* Hct-26.2*
MCV-102* MCH-34.0* MCHC-33.2 RDW-21.8* Plt Ct-57*
[**2151-10-5**] 05:01AM BLOOD Glucose-122* UreaN-4* Creat-0.4 Na-136
K-3.5 Cl-107 HCO3-27 AnGap-6*
[**2151-10-5**] 05:01AM BLOOD ALT-27 AST-55* AlkPhos-117* TotBili-1.9*
[**2151-10-5**] 05:01AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.9
Imaging:
EGD ([**2151-10-1**]): "Source of bleeding is identified as [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] tear at the GE junction, not bleeding at the time of the
endoscopy. No interventions were done. Otherwise grade I
varices at the lower third of the esophagus with no stigmata of
bleeding. Moderate amount of old blood and clots in the stomach,
with no other sources of bleeding identified in the stomach;
Normal mucosa in the duodenum and otherwise normal EGD to third
part of the duodenum."
Portable Chest ([**2151-10-1**]): "Single frontal view of the chest was
obtained. Cardiac mediastinal and hilar contours are
unremarkable. Both lungs are clear with no focal consolidation,
pleural effusion or pneumothorax."
Portable Abdomen ([**2151-10-1**]): "Gaseous distention of a loop of
small bowel in lower abdomen, with paucity of gas remaining
throughout the abdomen. These findings are nonspecific, but
cannot exclude partial small-bowel obstruction. No evidence of
free intraperitoneal air, though image quality limits
assessment. Nasogastric tube in place. Right-sided pelvic
catheter consistent with a central venous access line."
Brief Hospital Course:
59 year old female with a history of of hepatitis C and
alcoholic cirrhosis and known Grade I varices who presented with
UGIB secondary to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear.
#UGIB- The patient has a history of esophageal varices and is
followed by Dr. [**Last Name (STitle) **] for her cirrhosis. She is on nadalal as
one of her home medications. She developed hematemesis in the
ED, where she received 3L crystalloid and 2 units of PRBC. She
was trasnferred to the MICU, and she had an EGD performed by GI
which revealed [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears of the esophagus. She was
monitored in the MICU and her HCT remained stable throughout her
MICU stay. She was started on sucralfate and received 48 hours
of a protonix drip. After transfer to the floor, she continued
to remain hemodynamically stable, although did continue to have
melanic stools. Her HCT continued to remain stable at discharge.
She was sent home with sucralfate and pantoprazole daily, along
with iron supplementation in the setting of acute blood loss.
#Hypovolemic shock- Patient presented with hypotension and
elevated lactate which resolved with fluid resusciation and
blood products. Since her EGD, she remained hemodynamically
stable, her lactate trended down, and she required no additional
blood products.
#Altered mental status- Patient was found altered at home while
intoxicated. She had a positive flapping tremor and was started
on lactulose at time of transfer from MICU. The patient was
continued on a CIWA scale on the floor, and required minimal
diazepam for symptoms.
#Cirrhosis- Patient has alcoholic/HepC cirrhosis. SHe is
followed in the liver clinic by Dr. [**Last Name (STitle) **]. She is still actively
drinking per her postiive blood alcohol today in the ED. Her
MELD score is 15. She has thormbocytopenia and known esophageal
varices. She has no history of ascites or hepatic
encephalopathy, however had a flapping tremor and was somnolent
at time of d/c from MICU, which was persistent on the floor. She
was treated with a 4d course of ceftriaxone in the setting of GI
Bleed.
#Alcohol abuse- Patient came to MICU intoxicated to >200 BAL.
Social work was consulted. The patient demonstrated interest in
attending AA after discharge.
#Hypertension- Patient was normotensive during MICU admission,
nadolol was restarted on transfer from MICU and continued on the
floor. Her home lasix and lisinopril were held in the setting of
GI bleeding, and she had no signs of fluid overload on the day
of discharge so these were not restarted.
#hypokalemia - K around 3.3-3.5. Unknown etiology. Was repleted
with PO K.
#Depression- Patient was restarted on citalopram once she was
able to tolerate PO
#Migraines- Fiorecet was held while in the hospital.
The patient was full code throughout admission.
TRANSITIONAL ISSUES:
Pt will need weekly labs to follow hypokalemia and hematocrit
for several weeks, has f/u appt with primary care [**10-14**]. Has
f/u appointment with GI and will need repeat EGD in roughly 3
weeks per GI recommendations.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Furosemide 20 mg PO DAILY
Hold for SBP<90
2. Spironolactone 50 mg PO DAILY
Hold for SBP<90
3. Nadolol 20 mg PO DAILY
Hold for SBP<90, HR<60
4. Acetaminophen-Caff-Butalbital [**2-8**] TAB PO Q8H:PRN headache
5. Citalopram 10 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Nadolol 20 mg PO DAILY
Hold for SBP<90, HR<60
2. Acetaminophen-Caff-Butalbital [**2-8**] TAB PO Q8H:PRN headache
3. Citalopram 10 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Thiamine 100 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*31
Tablet Refills:*3
8. Sucralfate 1 gm PO BID
RX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*31
Tablet Refills:*4
9. Lactulose 30 mL PO TID
RX *lactulose [Constulose] 10 gram/15 mL 15-30 mL by mouth use
up to 4 times a day Disp #*1000 Milliliter Refills:*3
10. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*62 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
[**Doctor First Name **]-[**Doctor Last Name **] Tears
Alcoholic intoxication
Secondary:
Hepatitis C Virus
Cirrhosis
Migraines
Hypertension
Chronic low back pain
Lower extremity edema
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were recently admitted to [**Hospital1 18**] after you were found to have
altered mental status. While you were here, you had an EGD after
some vomitting of blood which showed no change in your varices,
but there was evidence of tearing which most likely caused the
bleeding. There have been no changes to your home medications.
It is imperitive that you discontinue drinking, as this was the
most likely cause of your hospital admission. It was our
pleasure to take care of you while you were a patient here.
Please do not hesitate to contact us with any questions,
comments or concerns.
With Warm Regards,
Your Inpatient Medicine Team
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2151-10-14**] at 2:10 PM
With: Dr. [**Last Name (STitle) **] [**Name (STitle) **]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: LIVER CENTER
When: FRIDAY [**2151-10-22**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: FRIDAY [**2151-10-22**] at 9:00 AM
With: ULTRASOUND [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 2851, 4019, 311, 3051, 2768, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 91
} | Medical Text: Admission Date: [**2200-2-24**] Discharge Date: [**2200-3-4**]
Date of Birth: [**2123-2-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Nitroglycerin / Penicillins / Amoxicillin / Norvasc / Celecoxib
/ Adhesive Tape / Lovenox
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2200-2-25**] - Coronary artery bypass grafting to three vessels.
(Saphenous vein graft->Diagonal artery, first obtuse marginal
artery and second obtuse marginal artery.
[**2200-2-24**] - left heart Catheterization,coronary angiogram
History of Present Illness:
This 77 year old white female has known coronary artery disease,
having undergone stenting of the LAD and circumflex vessels in
the past. She presented with recurrent angina elsewhere and
ruled in for a non ST myocardial infaction with Troponin of
1.19. She was transferred here and underwent catheterization on
[**2-25**].
Catheterization revealed osteal circumflex and subtotal in stent
circumflex stenosis. LV function has been shown to be ~55%. She
was referred for surgical revascularization.
Past Medical History:
hypertension
hyperlipidemia
noninsulin dependent Diabetes mellitus
Moderate aortic stenosis
Chronic atrial fibrillation
Congestive heart failure in past
Coronary artery disease with percutaneous interventions in past
Anxiety
Cerbrovascular disease-60-70% bilateral carotid arteries
H/O breast cancer, s/p right lumpectomy and radiation
H/O cervical cancer, s/p hysterectomy and radiation
appendectomy
cholecystectomy
H/O multinodular goiter
S/P removal of a pylonidal cyst
S/P bilateral carpal tunnel surgery
S/P bone spur removal
Osteoarthritis
coccyx ulcer - stage IV
Social History:
The patient currently lives alone. Her husband has alzheimer's
disease and lives in a care facility. She has one son who is
handicapped and a grandson. She quit smoking 35 years ago;
previously 4 ppd. She does not drink alcohol or use ilicit
drugs.
Family History:
Family history negative for premature coronary artery disease or
sudden death. Mother died of complications from alcoholism.
Father died of pneumonia. Grandmother died of colon cancer.
Physical Exam:
Admission:
VS - 97.3, 100/74, 16, 95%RA
Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect
appropriate. Patient lying supine post-cath.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple without lymphadenopathy.
CV: Irregularly irregular, normal S1, S2. [**3-31**] holosystolic
murmur loudest at the LUSB that radiates to both carotids. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anteriorly.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: Brown skin changes around left lower leg. No stasis
dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
Pertinent Results:
[**2200-2-24**] 04:45PM GLUCOSE-113* UREA N-11 CREAT-0.5 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11
[**2200-2-24**] 04:45PM ALT(SGPT)-18 AST(SGOT)-36 CK(CPK)-166* ALK
PHOS-58 AMYLASE-16 TOT BILI-0.8
[**2200-2-24**] 04:45PM cTropnT-0.22*
[**2200-2-24**] 04:45PM WBC-6.2 RBC-2.99* HGB-9.9* HCT-28.6* MCV-96
MCH-33.1* MCHC-34.6 RDW-14.7
[**2200-2-24**] 04:45PM WBC-6.2 RBC-2.99* HGB-9.9* HCT-28.6* MCV-96
MCH-33.1* MCHC-34.6 RDW-14.7
[**2200-2-24**] 04:45PM PT-17.2* PTT-31.9 INR(PT)-1.6*
[**2200-2-24**] Cardiac Catheterization
1. Coronary angiography in this right dominant system
revealed three vessel coronary artery disease. The LMCA had no
angiographycally apparent coronary artery disease. The LAD was
non-obstructed. The D1 had an ostial 80% lesion. The LCx had a
subtotally occluded in-stent restenosis in the mid stent at the
ostium
of the vessel. The RCA was small caliber, with a 70% lesion
proximally.
2. Resting hemodynamics revealed elevated left sided filling
pressures
with LVEDP of 20 mmHg. There was normal systemic arterial
systolic and
diastolic pressure with SBP of 109 mmHg and DBP of 72 mmHg.
3. There was a peak to peak transaortic gradient of 5 mmHg
4. Left ventriculography was not performed.
[**2200-2-25**] ECHO
The left atrium is mildly dilated. The left atrium is elongated.
The right atrium is moderately dilated. The estimated right
atrial pressure is 0-10mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-27**]+) mitral regurgitation
is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2199-10-19**],
the severity of mitral and tricuspid regurgitation has
increased. Estimated pulmonary artery pressures are higher.
Aortic stenosis is mild in severity.
[**2200-3-2**] 06:13AM BLOOD WBC-9.7 RBC-3.01* Hgb-9.6* Hct-27.8*
MCV-93 MCH-32.0 MCHC-34.6 RDW-16.0* Plt Ct-121*
[**2200-3-3**] 05:04AM BLOOD PT-20.6* INR(PT)-1.9*
[**2200-3-2**] 06:13AM BLOOD PT-19.8* PTT-30.8 INR(PT)-1.9*
[**2200-3-1**] 05:30PM BLOOD PT-22.3* INR(PT)-2.1*
[**2200-3-1**] 03:45AM BLOOD PT-20.0* PTT-35.0 INR(PT)-1.9*
[**2200-2-28**] 02:10AM BLOOD PT-16.6* PTT-32.6 INR(PT)-1.5*
[**2200-2-27**] 12:58AM BLOOD PT-16.3* PTT-31.4 INR(PT)-1.5*
[**2200-2-26**] 03:09PM BLOOD PT-17.8* PTT-40.7* INR(PT)-1.6*
[**2200-2-26**] 01:55PM BLOOD PT-18.0* PTT-34.4 INR(PT)-1.6*
[**2200-2-26**] 02:20AM BLOOD PT-17.0* PTT-53.2* INR(PT)-1.5*
[**2200-2-25**] 05:19PM BLOOD PT-16.8* PTT-80.5* INR(PT)-1.5*
[**2200-2-25**] 05:10AM BLOOD PT-18.5* PTT-59.1* INR(PT)-1.7*
[**2200-3-3**] 05:04AM BLOOD UreaN-22* Creat-0.6 Na-129* K-4.0
Brief Hospital Course:
Ms. [**Known lastname 14330**] was admitted to the [**Hospital1 18**] on [**2200-2-24**] for a cardiac
catheterization and further management of her myocardial
infarction. A cardiac catheterization revealed two vessel
disease with severe instent restenosis of her circumflex artery.
Given the severity of her disease and the fact that she refused
to take plavix, surgical revascularization was decided upon.
Ms. [**Known lastname 14330**] was worked-up in the usual preoperative manner
including a carotid ultrasound which showed mild right and
moderate left internal carotid artery stenosis. Heparin was
continued and she remained without chest pain. The wound care
nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for assistance with her coccyx ulcer and
appropriate dressings and barrier creams were applied. On
[**2200-2-26**], Ms. [**Known lastname 14330**] was taken to the Operating Room where she
underwent coronary artery bypass grafting to three vessels.
Please see operative note for details. Postoperatively she was
taken to the intensive care unit for monitoring. Over the next
several hours, she awoke neurologically intact and was
extubated. Beta blockade, aspirin and a statin were resumed.
Diuresis towards her preoperative weight was begun.
The coccyx wound is being treated with Aquacel AG daily.
Surgical wounds are clean and dry. Pacing wires and CTs were
removed according to protocol. Bactroban was administered for
MRSA positive nasal swab. Lopressor and digoxin were given and
advanced for rate control of her chronic atrial fibrillation and
diuretics were continued, to be so until she achieves her
preoperative weight.
STOP [**3-3**]
Medications on Admission:
ativan 3 HS, atenolol 25, lipitor 80, ASA 325, digoxin 0.125,
lisinopril 40, colace, coumadin 2.5, januvia 100, magnesium
oxide 400, lasix 40 and KCl 10 every other day, MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Digoxin 250 mcg Tablet Sig: [**12-27**] alter w/ 1 tab Tablet PO
EVERY OTHER DAY (Every Other Day).
11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
12. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. Warfarin 1 mg Tablet Sig: to be dosed per INR Tablet PO
DAILY (Daily): Goal INR [**1-28**]
INR 2.6 on [**3-4**]- no coumadin given.
14. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
Q12H (every 12 hours).
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass
Hyperlipidemia
Hypertension
Atrial fibrillation
non insulin dependent Diabetes mellitus
Anxiety
s/p Myocardial infarction
Peripheral vascular disease
Cerebrovascular disease
Multinodular goiter
Osteoarthritis
h/o Cervical cancer
Discharge Condition:
deconditioned
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 8725**]
Please follow-up with Dr. [**Last Name (STitle) 1057**] in [**1-29**] weeks. [**Telephone/Fax (1) 14331**]
Please call for appointments
Completed by:[**2200-3-4**]
ICD9 Codes: 4280, 4019, 4241, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 92
} | Medical Text: Admission Date: [**2103-5-19**] Discharge Date: [**2103-5-27**]
Date of Birth: [**2080-7-19**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Dilaudid
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Back pain for one day
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 14164**] is a 22 year-old African-American woman with known
[**Known lastname 14165**] cell disease, who presents with a 1-day history of
right-sided posterior chest pain.
She notes that she was well until 4-days prior to admission when
she developed URI symptoms, including headache, rhinorrea, and
generalized fatigue. She subsequently developed a cough,
productive of small amounts of dark yellow sputum. Yesterday,
she developed right-sided posterior chest pain, pleuritic in
nature, worse with coughing, deep breathing and lying on the
culprit side. She reports only mild SOB. She felt warm over the
past few days, but did not measure her temperature. She denies
chills. She is unsure whether she has received Pneumovax and
Influenza vaccines.
ROS is otherwise negative for other joint pain. No GI or urinary
complaints. No lightheadedness, no dizziness.
In the ED, vitals initially T 99.4, HR 80, BP 119/58, RR 16,
oxygen saturation 95% on 3L, 88% on room air. A CXR revealed a
RLL infiltrate. She was given Ceftriaxone 1 gm IV X1 and
Azithromycin 500 mg PO QD. She was also given Morphine 1 mg IV
X1, Benadryl 25 mg X1, and Dilaudid for pain control.
Past Medical History:
1. [**Known lastname **] cell disease, with 1 admission per year since [**2100**] for
acute pain crisis.
2. History of gonorrhea
3. Prior pneumonia versus acute chest syndrome in [**2100**]
4. History of pre-eclampsia during her first pregnancy
5. Known multiple RBC allo-antibodies and difficult cross-match
Social History:
She lives with her 2 children aged 4 and 2 years-old. She is an
active smoker, and smokes about 5 cigarettes per day. She quit
for about 3 years, but restarted last year. No EtOH consumption.
She also denies illicit drug use.
Family History:
She lived in a [**Doctor Last Name **] home from the age of 5 onwards. Per OMR
records, both her mother and father have [**Name2 (NI) 14165**] cell trait. Both
her children have [**Name2 (NI) 14165**] cell trait.
Physical Exam:
Physical examination on admission:
VITALS: T 99.4, HR 100, BP 110/55, RR 20, Sat 99% on 3 liters
via NC.
GEN: Sleepy. Scratching all over. Uncomfortable with motion.
HEENT: Anicteric. EOMI. PERRL. Frontal bossing.
LN: No cervical lymphadenopathy.
RESP: Dullness to percussion at right base. Decreased air entry
at right base, with basilar crackles. No bronchial breathing. +
egophony, + whispered pectoriloquy.
CVS: PMI not displaced. Normal S1, physiologic splitting of S2.
No S3, S4. Soft, late systolic murmur at apex, non-radiating.
GI: BS NA. Abdomen soft and non-tender.
EXT: Strong pedal pulses. No pedal edema.
Pertinent Results:
Relevant laboratory data on admission:
CBC:
WBC 11.1, Hb 6.9, Hct 19.9, Platelet 552
NEUTS-54 BANDS-1 LYMPHS-35 MONOS-7 EOS-2 BASOS-1 ATYPS-0 METAS-0
MYELOS-0 NUC RBCS-1
HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-3+ MACROCYT-2+ MICROCYT-1+
POLYCHROM-NORMAL SPHEROCYT-1+ OVALOCYT-1+ TARGET-2+ [**Name2 (NI) **]-2+
Chemistry:
Na 138, K 4.7, Cl 106, HCO3 24, BUN 8, Creat 0.7, Glucose 0.7
Relevant imagind studies:
[**2103-5-19**] CXR: Stable cardiac contours. Interval development of
patchy opacity in right lower lobe, no pleural effusion.
[**2103-5-20**] CXR: Heart size is within normal limits and there is no
evidence for CHF. There is consolidation in the right middle and
right lower lobes with an associated small right pleural
effusion, increased when compared with the prior film of [**5-19**], 05. There is atelectasis at the left lung base as previously
demonstrated. There is probably some associated collapse of the
right lobe.
IMPRESSION: Increase in extent of right middle lobe and right
lower lobe consolidation with small right pleural effusion. Left
basilar atelectasis.
[**2103-5-21**] CXR: The cardiac silhouette is upper limits of normal
in size and there is slight increase in pulmonary vascularity,
consistent with the patient's known [**Year/Month/Day 14165**] cell status. There
are multifocal areas of consolidation involving the right middle
and both lower lobes, which have progressed in the interval.
There are also bilateral probable small pleural effusions.
IMPRESSION: Worsening multifocal consolidation suggesting
multifocal pneumonia. [**Year/Month/Day **] cell lung is in the differential
diagnosis if there are not infectious symptoms present.
[**2103-5-22**] CXR: No significant interval change.
[**2103-5-23**] CXR: Increased mild to moderate left pleural effusion.
Persistent right middle and lower lobe infiltrate with right
pleural effusion, stable.
[**2103-5-24**] CXR: Slight interval improvement in right middle lobe
aeration. Slight improvement in right pleural effusion. Stable
left pleural effusion with left lower lobe retrocardiac
atelectasis.
[**2103-5-26**] CXR: Improving right middle lobe and left lower lobe
opacities. There is a small left-sided pleural effusion
unchanged.
********
[**2103-5-22**] ECHO: The left atrium is mildly elongated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is trivial mitral regurgitatino. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
22 year-old African-American woman with [**Year/Month/Day 14165**] cell disease
admitted with respiratory symptoms and right-sided back pain,
found to have RLL infiltrate + hypoxemia.
1) Pneumonia +/- acute chest syndrome: CXR on admission revealed
a RLL infiltrate suspicious for pneumonia, although acute chest
syndrome can not be ruled out. Examination was also remarkable
for hypoxemia, with saturation in the low 80s. She was
empirically started on Ceftriaxone and Azithromycin for coverage
of Mycoplasma, Chlamydia, Hemophilus and pneumococcus, and
hydrated. She was afebrile on admission, but subsequently
developed a fever in hospital with rising WBC up to 34.6 on
[**5-21**]. She also developed worsening hypoxemia on [**5-21**] with
increasing SOB in the setting of decreasing hematocrit to 15.5,
then 14.3. An ABG revealed pH 7.41/38/70. A repeat CXR was
performed and remarkable for worsening RML/RLL pneumonia. Given
the above as well as inability to transfuse PRBCs [**3-21**] no
available cross-matched blood (multiple allo-antibodies), Ms.
[**Known lastname 14164**] was transferred to the ICU on [**5-20**].
In the ICU, supportive care was provided. She was continued on
Ceftriaxone and Azithromycin. Sputum cultures returned as OP
flora, without predominance of organisms (can not rule out
Chlamydia or Mycoplasma). Blood and urine cultures all returned
negative. Serial CXRs initially revealed worsening picture, with
interval development of a LLL infiltrate consistent with
multilobar process, and bilateral pleural effusions. An echo was
performed that showed normal EF>60%. The effusions were
ultimately felt most likely [**3-21**] fluid overload in the setting of
aggressive IVF administration, and she was diuresed with Lasix
on [**5-23**] and [**5-24**]. She eventually improved and defervesced,
with decreasing oxygen requirements and improved radiographic
picture. Antibiotics were changed to PO Levofloxacin on [**5-24**],
Ceftriaxone D/C'd on [**5-24**] (received 6 days), and Azithromycin
D/C'd on [**5-25**] (received 7 days). She will complete a 14-day
course (total) of Levofloxacin (last dose on [**2103-6-1**]).
Of note, the effusions persist at discharge, stable in size. She
also has persistent leukocytosis with WBC 16.2 at discharge.
Both should improve with time. She will need follow-up imaging
after completion of her antibiotic course to document complete
resolution of infiltrate/effusion, as well as repeat WBC. If the
effusions persist, then a thoracentesis would be indicated to
rule out a parapneumonic effusion. She was given Pneumococcal,
Meningococcal and Hib vaccines prior to discharge. She will
follow-up with her PCP [**Name Initial (PRE) 176**] 1 week of discharge.
2) [**Name Initial (PRE) **] cell disease: Hematocrit on admission was 19.9 (around
baseline), down to 15.3 on [**5-20**] with 2+ [**Month/Year (2) 14165**] cells on
peripheral smear, then a nadir of 14.3 on [**5-21**]. The hematology
service was consulted. Ms. [**Known lastname 14164**] has multiple allo-antibodies
and HRB absent which is rare except in some African-Americans.
The blood bank was unable to provide matched blood. She was
transfused 1 unmatched unit on [**5-22**] after pre-medication with
Prednisone 60 mg PO QD, without response. Further transfusion
was therefore held. Per hematology, folate was increased to 5 mg
PO QD. Her hematocrit slowly trended up to 22 at discharge. Of
note, ferritin was sent to rule out concomitant iron deficiency,
and returned elevated at 791. She had appropriate
reticulocytosis to 22% in the setting of her anemia.
She will follow-up with Dr. [**Last Name (STitle) **] in Hematology within 1 week of
discharge. Treatment with hydroxyurea should be addressed.
3) Pain control: Pain control was achieved with Dilaudid IV prn
and pre-medication with Benadryl. She was switched to PO
OxyContin 10 mg PO BID and oxycodone for breakthrough on [**5-26**],
with fair pain control. Tylenol around the clock and Naproxen
were also added. She was discharged on
OxyContin/Oxycodone/Naproxen/Tylenol + bowel regimen.
4) Bacterial vaginosis: Ms. [**Known lastname 14164**] was diagnosed with bacterial
vaginosis prior to admission, treated with Flagyl. She completed
a 5-day course of Flagyl in hospital, with resolution of her
symptoms ([**5-22**] --> [**5-26**]).
5) Oral lesions: While in hospital, she developed oral lesions
suspicious for oral HSV. She was started on Valtrex 1 gm PO TID
with plan to complete 3 days. She will complete her course as an
out-patient (last doses on [**2103-5-28**]).
Medications on Admission:
Folate 2 mg PO QD
Metronidazole (has been taking only intermittently for bacterial
vaginosis)
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
Disp:*150 Tablet(s)* Refills:*1*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Please take while on Oxycontin.
Disp:*60 Capsule(s)* Refills:*0*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days: Start on [**5-28**], last dose on [**6-1**].
Disp:*5 Tablet(s)* Refills:*0*
4. Valacyclovir HCl 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for HSV for 3 doses: Please take 1 pill
tonight, 1 pill tomorrow morning and 1 pill tomorrow night. .
Disp:*6 Tablet(s)* Refills:*0*
5. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*25 Tablet Sustained Release 12HR(s)* Refills:*0*
6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
[**Month/Year (2) **] cell disease
Anemia
Pneumonia
RBC antibodies
Secondary diagnoses:
Bacterial vaginosis
Probable oral herpes simplex
Discharge Condition:
Patient discharged home in stable condition. Saturation 94-96%
on room air. Hematocrit 22.5.
Discharge Instructions:
Please return to the hospital or call your PCP if you develop
worsening respiratory symptoms, including increasing shortness
of breath, or increasing cough. You should also return if you
develop a fever.
Please continue to take Levofloxacin daily, last dose on [**6-1**].
This is to treat your pneumonia. Start on [**5-28**].
Please note that we have also increased folate to 5 mg daily.
Please take Oxycontin 10 mg twice daily for pain control. You
can also take oxycodone 5 mg as needed every 4 to 6 hours for
breakthrough pain.
Note that we have given you 3 vaccines (Haemophilus influenza,
Pneumococcal, and Meningococcal vaccines)
Followup Instructions:
Please call your PCP (Dr. [**Last Name (STitle) 14166**] [**Telephone/Fax (1) 14167**] and schedule an
appointment to see him within 1 week of discharge. You will need
a repeat CXR in the next 2 weeks.
Please call Dr.[**Name (NI) 220**] office (Hematology) [**Telephone/Fax (1) 9645**], and
schedule an appointment to see him within 1-2 weeks of
discharge.
Completed by:[**2103-5-27**]
ICD9 Codes: 486, 5119, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 93
} | Medical Text: Admission Date: [**2151-1-31**] Discharge Date: [**2151-2-16**]
Date of Birth: [**2096-2-11**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old man
admitted to Intensive Care Unit on [**2151-1-31**], from [**Hospital3 6265**] for evaluation of hematemesis, melena and abdominal
mass. The patient had been doing well until the Tuesday
prior to admission when he developed a headache at which
point he took Vicodin and developed nausea and vomiting and
abdominal pain. On the Thursday evening prior to admission,
he states he passed out on the floor of the bathroom and had
a fall secondary to severe pain. He states that he had loss
of consciousness for about fifteen minutes. He denies head
trauma.
On the Saturday prior to admission, the patient states that
he had some retching with blood. He presented to the
Emergency Department at [**Hospital3 3583**] where he was admitted
and found to have a hematocrit of 26.3, potassium 6.2, and he
was also in acute renal failure. Abdominal CT indicated a
large peripancreatic mass. The patient was transferred to
[**Hospital1 69**] for further evaluation.
On transfer, his white blood cell count was 28, and his
creatinine was 3.4.
PAST MEDICAL HISTORY:
1. History of spontaneous pneumothorax.
2. History of immune complex mediated glomerulonephritis.
3. History of peptic ulcer disease, status post surgery.
4. Acute renal failure.
MEDICATIONS ON ADMISSION: Vicodin p.r.n.
ALLERGIES: The patient states he is allergic to Sulfa,
Aspirin and Naprosyn.
SOCIAL HISTORY: The patient works in sales. He has a twenty
pack year history of smoking. He denies alcohol or street
drug use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission, the patient's
temperature was 97.0, heart rate 107, respiratory rate 15,
blood pressure 135/42, oxygen saturation 98% on two liters.
In general, the patient was alert, in no acute distress. The
neck was supple. Pulmonary examination indicated scant
crackles bilaterally. Cardiovascular examination indicated
regular rhythm, normal S1 and S2, and a II/VI systolic
murmur. The abdomen was distended with decreased bowel
sounds and mild diffuse tenderness to percussion. On
extremity examination, the patient had 2+ peripheral pulses
with no edema. His stool was guaiac negative.
LABORATORY DATA: Initial laboratory studies indicated a
white count 28.6, hematocrit 25.6, platelet count 404,000.
Chem7 indicated a blood urea nitrogen 43 and a creatinine of
3.4. INR was elevated at 1.9. Liver function tests were
within normal limits.
Electrocardiogram indicated normal sinus rhythm, rate 99
beats per minute, normal axis, normal intervals and no
ischemic changes.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit. Nasogastric lavage was performed which indicated
the presence of coffee ground emesis. He was evaluated by
the gastroenterology service and emergent endoscopy was
performed which indicated the presence of a hiatal hernia as
well as compression of the second and third part of the
duodenum. A biopsy was taken at the compression site which
indicated chronic inactive duodenitis and focal Brunner gland
hyperplasia. There was also gastric mucocele metaplasia.
CT of the abdomen indicated a 10 by 6.0 centimeter soft
tissue mass within the mesentery just below the pelvic rim as
well as a 10 by 16 centimeter mesenteric and retroperitoneal
hematoma displaying the duodenum anteriorly and compressing
the inferior vena cava. Significant mesenteric
lymphadenopathy was also noted.
Renal and surgery services were consulted. On the
recommendation of the surgery service, a follow-up abdominal
CT with p.o. contrast was completed which indicated
persistent intra-abdominal hematoma but no intra-abdominal
mass. The patient was also now noted to have increased liver
function tests with an ALT of 622, AST of 649, and normal
total bilirubin and alkaline phosphatase.
As the patient's hematocrit continued to drop, a bleeding
scan was conducted which indicated active bleeding into the
abdomen with no clear source. The patient therefore received
an angiogram which indicated the presence of a superior
mesenteric artery aneurysm as well as active bleeding from
the gastroduodenal artery which was embolized.
The patient also developed shortness of breath following the
administration of a total of fourteen units of packed red
blood cells in the Intensive Care Unit. Chest x-ray
indicated the presence of congestive heart failure and a
possible left sided infiltrate. The patient was started on
Lasix as well as Levaquin and Flagyl. A hepatitis panel was
sent which was negative. ANCA was sent out of concern over
possible polyarteritis nodosa, however, this study was
negative. The patient was also started on total parenteral
nutrition secondary to an expected ileus following
embolization.
While in the Intensive Care Unit following embolization, his
transaminases trended downward, and his creatinine improved,
and his hematocrit remained stable. The patient did develop
transient episodic hypertension to a systolic pressure of 200
requiring Labetalol drip, however, this was successfully
weaned and the patient was transitioned to Labetalol tablets.
While in the unit, he also developed bipedal and scrotal
edema, which again was thought secondary to volume overload
in the setting of multiple transfusions.
Echocardiogram conducted on hospital day number four
indicated ejection fraction of greater than 55% with 1+
tricuspid regurgitation.
On hospital day number six, the patient was transferred to
the floor for additional workup of questionable abdominal
mass. On repeat [**Location (un) 1131**] of the patient's existing CAT scans,
it was determined that what was initially read as a mass on
the first CT was likely to be extension of the hematoma.
Follow-up imaging in four weeks was recommended.
On his first day on the floor, the patient spiked a
temperature to 101.3 degrees Fahrenheit. Repeat chest x-ray
indicated worsening pulmonary infiltrates bilaterally. At
this point, the patient was switched to Ceftazidime and
Clindamycin to treat possible nosocomial pneumonia. Sputum
and blood cultures were sent which were negative.
The patient's pulmonary status improved significantly on
intravenous antibiotics. As the patient was able to tolerate
p.o. intake, his total parenteral nutrition was discontinued.
However, the patient noted some pain with eating and was
found to have a small lesion at the site of his denture
insertion site. The patient was able to tolerate food after
pretreatment with Viscous Lidocaine solution.
Although the patient's initial abdominal pain subsided, he
was maintained on Oxycontin for control of residual abdominal
pain while on the floor. The patient's lower extremity edema
decreased with the administration of intravenous and then
subsequently p.o. Lasix.
On hospital day number ten, the patient was noted to have
increasing jaundice and altered mental status. Liver
function tests at that time indicated an alkaline phosphatase
of 1091 and total bilirubin of 11.4. His transaminases were
only slightly elevated. A right upper quadrant ultrasound
was performed which indicated a dilatation of the common bile
duct as well as the presence of biliary sludge. There was no
intrahepatic biliary duct dilatation and no gallstones.
Endoscopic retrograde cholangiopancreatography was performed
after consultation with the gastroenterology service. This
study indicated a fifteen millimeter common bile duct which
was stented as well as stenosis of the distal bulb. The
patient's liver function tests, jaundice and mental status
improved following endoscopic retrograde
cholangiopancreatography. The patient was to have a
follow-up endoscopic retrograde cholangiopancreatography in
three months for stent removal.
Although the patient's mental status did improve following
endoscopic retrograde cholangiopancreatography, some residual
symptoms of agitation and paranoia prompted a psychiatry
consultation who recommended low dose of Haldol p.r.n. for
worsening of these symptoms. However, the patient's mental
status slowly returned to his baseline.
The patient was evaluated by the physical therapy service who
found that he would benefit from acute rehabilitation. At
the time of this discharge summary, the patient was being
screened for placement in an acute rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Superior mesenteric artery aneurysm.
2. Status post embolization of the gastroduodenal artery.
3. Biliary sludge.
4. Pneumonia.
5. Glomerulonephritis.
6. History of peptic ulcer disease.
7. History of pneumothorax.
MEDICATIONS ON DISCHARGE:
1. Lasix 80 mg p.o. q.d.
2. Viscous Lidocaine 2% solution 15 ccs swish and spit with
meals p.r.n.
3. Senna two tablets p.o. q.h.s. p.r.n.
4. Colace 100 mg p.o. b.i.d.
5. Boost t.i.d. with meals.
6. Protonix 40 mg p.o. b.i.d.
7. Labetalol 200 mg p.o. q12hours.
8. Albuterol and Atrovent MDI two puffs q4hours p.r.n.
9. Lipitor 10 mg p.o. q.d.
10. Nephrocaps 1 mg p.o. q.d.
DISPOSITION: At the time of this dictation, the patient was
being screened for placement in an acute rehabilitation
facility.
He was to have a follow-up endoscopic retrograde
cholangiopancreatography with stent removal three months
following discharge as well as a follow-up abdominal CT scan
three weeks following discharge. He was to follow-up in
[**Hospital **] Clinic.
DISCHARGE DISPOSITION: Improved.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2151-2-15**] 19:22
T: [**2151-2-15**] 19:42
JOB#: [**Job Number 96120**]
ICD9 Codes: 5789, 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 94
} | Medical Text: Admission Date: [**2135-12-26**] Discharge Date: [**2136-1-3**]
Date of Birth: [**2080-2-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old man
with multiple medical problems including insulin dependent
diabetes secondary to severe pancreatitis in [**2123**], remote
history of Hodgkin's disease in [**2113**] treated with among other
things, radiation therapy which has left the patient with
severe osteoporosis and resulting compression fractures,
history of alcohol abuse, on chronic opioids for residual
pain secondary to pancreatitis, who presented on [**12-26**] with
delta MS.
Per the patient's lifetime partner, the patient self
increased his dose of opiate using approximately four patches
of Fentanyl and increasing his Seroquel dose from 150 to 300
mg. He presented to the ED on [**2135-12-26**] with increased
weakness, tremor, disorientation x2 months, worse over the
prior three days.
In the ED, the patient's temperature was 98.4, blood pressure
was 136-145/60-70. His heart rate was 71-130. He was
treated with Ativan 7 mg for what they thought was alcohol
withdrawal, which increased the patient's sedation and
subsequently his systolic blood pressure decreased to 88-97.
Patient had a negative head CT. A lumbar puncture was
attempted, but was not successful. Patient was started on
acyclovir, Vancomycin for empiric meningitis coverage. The
patient's Chem-7 at that time was significant for a glucose
of 354, an anion gap of 13, 15 ketones in his urine. With
these results, the ED started the patient on an insulin drip.
His blood gas initially was 7.23/55/46, but then decreased to
7.16/56/260. The patient was minimally alert at this time.
He had progressive somnolence. Patient was then started on
BiPAP 10 of 5, and was admitted to the MICU.
PAST MEDICAL HISTORY:
1. COPD.
2. Diabetes mellitus insulin dependent secondary to chronic
pancreatitis.
3. Chronic alcohol induced pancreatitis status post
debridement.
4. History of alcohol abuse.
5. Osteoporosis.
6. CHF with an ejection fraction of 40%.
7. Hodgkin's disease status post XRT, chemotherapy,
splenectomy.
8. Hypothyroidism.
9. GERD.
10. Vocal cord paralysis.
11. Chronic pain on multiple narcotics.
12. Anxiety and depression.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient has a 40 pack year history of
tobacco. No recent ethanol use.
PHYSICAL EXAM: Temperature 98.5, blood pressure 104/64,
heart rate 107. Cardiovascular: Patient has a 3/6 systolic
murmur heard best at the left lower sternal border and at the
apex. Abdomen is soft, nontender, nondistended, multiple
surgical scars. Extremities: No cyanosis, clubbing, or
edema. Pulses are [**12-30**]+ bilaterally. Neurologic: The
patient responds to commands, is moving all four extremities.
HOSPITAL COURSE: The patient was admitted to the MICU for
further management. On [**2135-12-27**], he was intubated due to
increased somnolence and hypoxia.
On [**2135-12-28**], an EEG was performed, which was read as
possibly consistent with encephalitis. Patient was then seen
by the Neuro team, who recommended a MRI and LP.
On [**2135-12-28**], the patient's temperature spiked to 101.6. He
was continued on ampicillin, ceftriaxone, and acyclovir for
possible meningitis. He was also started on a bicarb drip
for metabolic acidosis. The patient was initially treated
with Ativan for narcotic withdrawal, but then this was D/C'd
and he was later started on a lower dose of Fentanyl.
On [**2135-12-29**], the patient was transferred to the VICU.
Analysis of the CSF fluid revealed 2 monocytes, 15
lymphocytes, 1 band. Gram stain was negative for PMNs,
macrophages, or bacteria. Culture was negative. PCR for
Listeria and HSV were negative.
Results from the patient's MRI on [**2135-12-28**] revealed normal
brain parenchyma. No blood breakdown or edema present.
Overall impression was that the MRI was grossly normal,
however, the study was limited by patient motion.
In the MICU, the patient was extubated. His mental status
continued to improve. He was continued on antibiotics for
treatment of presumed community acquired pneumonia. He was
noted to have eosinophilia, which improved over the course of
his hospitalization. He was transfused with 1 unit of blood
and transiently went into pulmonary edema in the setting of
this transfusion. This resolved with Lasix and nebulizers.
Acyclovir was D/C'd as the patient's MRI and lumbar puncture
were negative.
The patient was then transferred to the medical floor, where
he was alert and oriented, able to ambulate with cane, and
was tolerating good p.o. intake. He was seen by Physical
Therapy, who felt that he would benefit from a rehabilitation
stay.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital3 2558**] [**Hospital **] Hospital.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Insulin dependent diabetes.
3. History of chronic alcoholic-induced pancreatitis.
4. Remote history of alcohol abuse.
5. Severe osteoporosis.
6. Congestive heart failure with an ejection fraction of 40%.
7. Hodgkin's disease.
8. Hypothyroidism.
9. Gastroesophageal reflux disease.
10. Vocal cord paralysis exacerbated by recent intubation.
11. Chronic pain on multiple narcotics.
12. Anxiety and depression.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. q.d.
2. Pantoprazole 40 mg p.o. q.d.
3. Lisinopril 5 mg p.o. q.d.
4. Morphine sulfate 15 mg p.o. q.6h. prn.
5. Clindamycin 600 mg IV q.8h.
6. Ceftriaxone 1 gram IV q.24h.
7. Docusate 100 mg b.i.d.
8. Fentanyl patch 150 mcg/hour transdermal patch q.72h.
9. Quetiapine fumarate 100 mg p.o. q.h.s.
10. Insulin-sliding scale with 7 units of glargine at
bedtime.
11. Lorazepam 1-2 mg IV q.3-4h. prn.
12. Levothyroxine 125 mcg p.o. q.d.
13. Folic acid 1 mg p.o. q.d.
14. Multivitamin.
15. Pancrease four capsules p.o. t.i.d. with meals.
16. Tylenol prn.
17. Vitamin D.
18. Citalopram 40 mg p.o. q.d.
19. Calcium 500 mg p.o. t.i.d.
20. Antibiotic therapy to be completed on [**2136-1-10**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8184**], M.D. [**MD Number(1) 8185**]
Dictated By:[**Last Name (NamePattern1) 9725**]
MEDQUIST36
D: [**2136-1-3**] 10:42
T: [**2136-1-3**] 11:00
JOB#: [**Job Number 108105**]
ICD9 Codes: 486, 496, 4280, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 95
} | Medical Text: Admission Date: [**2165-4-29**] Discharge Date: [**2165-5-15**]
Service: MEDICINE
Allergies:
Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Chest pain, total body pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o F with PMHx of CAD, CHF with EF of 40%, recent admission
with respiratory failure requiring intubation who presents with
total body pain and chest pain. The patient's current symptoms
began on Saturday with nausea. The following day (one day prior
to admission), the patient experienced aching throughout her
body, including her back, chest, and the back of her head. This
morning, the patient awoke from sleep at 6am due to right index
finger pain, erythema, swelling, and calor which then spread to
the rest of her body (back, chest, back of head). Finger pain
is described as stiff, sore, and achy with associated calor.
Total body pain is described as sharp body aches which is
generalized, which lasted until she received Morphine in the ED.
The patient describes chest pain along with her total body
pain, and received SL Nitro x3 without relief. The pain had
similar features to her prior anginal equivalent, during which
she experienced chest pain, shortness of breath, and upper back
pain, but her current pain consists of nausea without dyspnea or
lightheadedness.
.
In the ER, vitals were T99.9 BP 156/61 P76 R18 PO2 100% 2L.
Chest pain was [**7-18**] on arrival and she was started on a nitro
gtt without significant relief of symptoms. However, symptoms
resolved with morphine, currently 0/10. EKG revealed sinus
rhythm with baseline LBBB and no acute EKG changes. She
received Morphine and a 500cc bolus while en route with EMS, and
received additional Morphine in the ED.
.
On evaluation on the floor, pt was asymptomatic and complaining
of thirst. She denies PND, reports 2 pillow orthopnea which has
remained unchanged for years.
.
.
REVIEW OF SYSTEMS:
She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. Denies fevers/chills,
night-sweats, abdominal pain, diarrhea, dysuria, rash. She does
report (+) congestion/cough with white sputum since
hospitalization, helped by albuterol. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
# Diabetes
# Dyslipidemia
# Hypertension
# Coronary Disease - s/p NSTEMI [**9-16**] medically managed and Cath
s/p stent in [**3-20**].
# Chronic systolic/diastolic congestive heart failure, most
recent EF>60%
# Chronic renal failure, stage III CKD - Dr [**Last Name (STitle) **]
# Hypertension
# Hyperlipidemia, intolerant of statins
# Type 2 diabetes, diet-controlled
# GERD
# Breast Cancer - diagnosed in [**2145**], s/p lumpectomy in [**State 108**]
# s/p total abdominal hysterectomy [**2094**] for fibroids
# Cataracts
Social History:
She lives at home alone, but has family in the area. Social
history is significant for the absence of current tobacco use,
remote social tobacco use in college. There is no history of
alcohol abuse. Has home [**Year (4 digits) 269**] w tele reports daily and PT.
Presents from rehab following multiple admissions.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her father had hypertension. Her sister is
alive and healthy at 93.
Physical Exam:
On admission
VS: T=98.6 BP=146/70 HR=75 R=20 PO2 sat= 100% 2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of <9 cm.
CARDIAC: RRR, normal S1, S2. GII systolic murmer at LSB, no
gallops, rubs. S4 present at LSB and apex. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bases b/l;
no egophany. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. NABS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
On discharge
VS: 97.3, 120/47, 52, 18, 100%RA
I/O: 120/350 today, [**Telephone/Fax (1) 93520**] yesterday
GENERAL: AAOx3, pleasant elderly female in NAD. Fatigued, but
interactive.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of <9 cm while sitting at 90 degrees
CARDIAC: RRR, normal S1, S2. S4 present at LSB and apex.
LUNGS: mild kyphosis. Resp were unlabored, no accessory muscle
use. soft crackles bibasilarly, breath sounds at bases decreased
ABDOMEN: Soft, NTND. No HSM or tenderness. NABS.
EXTREMITIES: No c/c/e.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
CXR ([**4-29**]): Two views are compared with the bedside examination
obtained some 10 hours earlier, as well as previous examinations
of [**4-16**] and [**2165-4-19**]. There has been clearing of the findings of
CHF and bilateral pleural effusions, with residual rounded LV
enlargement and atherosclerotic change involving the thoracic
aorta. The lungs appear hyperinflated, suggestive of underlying
obstructive disease; however, there is no focal airspace
opacity. There is diffuse osteopenia with slight anterior
wedging of several thoracic vertebrae and resultant slight
kyphosis. There is no acute abnormality of the thoracic
skeleton.
.
CXR ([**5-5**]):
1. Worsening pulmonary edema and increasing small pleural
effusions.
2. Bilateral lower lobe airspace opacities, which may be due to
dependent
areas of pulmonary edema or superimposed secondary process such
as aspiration or infectious pneumonia. Followup radiographs
after diuresis may be helpful in this regard.
.
CXR ([**5-6**])
CHEST, AP: Mild interstitial edema has slightly worsened. Mild
cardiomegaly and small bilateral pleural effusions are
unchanged. Bibasilar consolidation is stable. The cardiac
silhouette is normal. The aorta is calcified and tortuous.
IMPRESSION: Slightly increased vascular congestion.
.
SUPINE ABDOMEN ([**5-6**])
Limited study with partially imaged left abdomen. Bowel gas
pattern present is nonobstructive with air seen in non-dilated
loops of small and large bowel. There is no free intraperitoneal
air or pneumatosis. The cardiac silhouette is moderately
enlarged. There is a questionable deep sulcus sign in the right
hemithorax, which in the right clinical setting, may represent a
pneumothorax. There is small opacification in the left lower
lung.
.
CBC
[**2165-5-13**] 05:15AM BLOOD WBC-8.3 RBC-3.41* Hgb-10.1* Hct-30.1*
MCV-88 MCH-29.7 MCHC-33.7 RDW-15.2 Plt Ct-402
[**2165-5-12**] 04:35AM BLOOD WBC-8.4 RBC-3.45* Hgb-10.5* Hct-30.3*
MCV-88 MCH-30.5 MCHC-34.7 RDW-14.9 Plt Ct-355
[**2165-5-11**] 06:10AM BLOOD WBC-7.8 RBC-3.28* Hgb-9.7* Hct-28.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-15.0 Plt Ct-369
[**2165-5-10**] 05:20AM BLOOD WBC-6.0 RBC-3.09* Hgb-9.1* Hct-27.1*
MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 Plt Ct-389
[**2165-5-9**] 05:30AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.1* Hct-27.2*
MCV-86 MCH-28.9 MCHC-33.5 RDW-14.7 Plt Ct-341
[**2165-5-8**] 05:15AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.1* Hct-26.5*
MCV-87 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-286
[**2165-5-7**] 06:02AM BLOOD WBC-6.6 RBC-3.02* Hgb-9.0* Hct-26.2*
MCV-87 MCH-29.9 MCHC-34.5 RDW-14.8 Plt Ct-305
[**2165-5-6**] 12:48AM BLOOD WBC-7.4# RBC-3.03* Hgb-8.9* Hct-25.7*
MCV-85 MCH-29.4 MCHC-34.7 RDW-14.8 Plt Ct-239
[**2165-5-5**] 04:10AM BLOOD WBC-4.5 RBC-2.71* Hgb-8.3* Hct-23.8*
MCV-88 MCH-30.6 MCHC-35.0 RDW-14.9 Plt Ct-248
[**2165-5-4**] 07:30AM BLOOD WBC-4.9 RBC-3.01* Hgb-9.1* Hct-26.6*
MCV-88 MCH-30.3 MCHC-34.3 RDW-15.0 Plt Ct-239
[**2165-5-3**] 05:05AM BLOOD WBC-5.7 RBC-3.06* Hgb-9.4* Hct-27.2*
MCV-89 MCH-30.6 MCHC-34.4 RDW-15.3 Plt Ct-242
[**2165-5-2**] 05:25AM BLOOD WBC-5.8 RBC-3.36* Hgb-10.1* Hct-29.2*
MCV-87 MCH-30.0 MCHC-34.6 RDW-15.0 Plt Ct-225
[**2165-5-1**] 07:30AM BLOOD WBC-8.6 RBC-3.31* Hgb-9.9* Hct-29.5*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-245
[**2165-4-30**] 10:50AM BLOOD WBC-7.8 RBC-3.29* Hgb-9.8* Hct-28.6*
MCV-87 MCH-29.7 MCHC-34.1 RDW-15.2 Plt Ct-215
[**2165-4-30**] 07:25AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.3* Hct-29.9*
MCV-89 MCH-30.7 MCHC-34.5 RDW-15.5 Plt Ct-245
[**2165-4-29**] 07:55AM BLOOD WBC-16.0*# RBC-3.75* Hgb-11.3* Hct-32.3*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.6* Plt Ct-269
Coags
[**2165-5-11**] 06:10AM BLOOD PT-12.7 PTT-30.2 INR(PT)-1.1
[**2165-5-10**] 05:20AM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0
[**2165-5-9**] 05:30AM BLOOD PT-12.0 PTT-28.0 INR(PT)-1.0
[**2165-5-8**] 05:15AM BLOOD PT-12.8 PTT-28.9 INR(PT)-1.1
[**2165-5-7**] 06:02AM BLOOD PT-12.6 PTT-31.4 INR(PT)-1.1
[**2165-5-6**] 01:01AM BLOOD PT-13.1 PTT-26.5 INR(PT)-1.1
[**2165-4-30**] 07:25AM BLOOD PT-13.2 PTT-28.4 INR(PT)-1.1
Chemistry
[**2165-5-13**] 05:15AM BLOOD Glucose-117* UreaN-116* Creat-3.7*
Na-131* K-3.5 Cl-78* HCO3-40* AnGap-17
[**2165-5-12**] 04:35AM BLOOD Glucose-121* UreaN-117* Creat-3.5*
Na-131* K-3.7 Cl-78* HCO3-39* AnGap-18
[**2165-5-11**] 06:10AM BLOOD Glucose-131* UreaN-117* Creat-3.7*
Na-130* K-3.8 Cl-79* HCO3-38* AnGap-17
[**2165-5-10**] 05:20AM BLOOD Glucose-118* UreaN-119* Creat-3.7*
Na-130* K-4.0 Cl-79* HCO3-37* AnGap-18
[**2165-5-9**] 05:30AM BLOOD Glucose-109* UreaN-119* Creat-3.7*
Na-129* K-3.2* Cl-79* HCO3-35* AnGap-18
[**2165-5-8**] 05:15AM BLOOD Glucose-111* UreaN-118* Creat-3.9*
Na-128* K-3.4 Cl-77* HCO3-34* AnGap-20
[**2165-5-7**] 06:02AM BLOOD Glucose-115* UreaN-116* Creat-4.1*
Na-125* K-3.3 Cl-76* HCO3-34* AnGap-18
[**2165-5-6**] 04:08PM BLOOD UreaN-112* Creat-4.2* Na-129* K-3.7
Cl-81* HCO3-32 AnGap-20
[**2165-5-6**] 12:48AM BLOOD Glucose-137* UreaN-108* Creat-4.4*
Na-123* K-3.8 Cl-75* HCO3-29 AnGap-23*
[**2165-5-5**] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3*
Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19
[**2165-5-4**] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126*
K-3.9 Cl-80* HCO3-29 AnGap-21*
[**2165-5-3**] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125*
K-4.2 Cl-81* HCO3-28 AnGap-20
[**2165-5-5**] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3*
Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19
[**2165-5-4**] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126*
K-3.9 Cl-80* HCO3-29 AnGap-21*
[**2165-5-3**] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125*
K-4.2 Cl-81* HCO3-28 AnGap-20
[**2165-5-3**] 05:05AM BLOOD Glucose-136* UreaN-91* Creat-3.6* Na-127*
K-4.1 Cl-85* HCO3-29 AnGap-17
[**2165-5-2**] 05:25AM BLOOD Glucose-135* UreaN-84* Creat-3.1* Na-135
K-4.0 Cl-92* HCO3-28 AnGap-19
[**2165-5-1**] 07:30AM BLOOD Glucose-110* UreaN-82* Creat-3.0* Na-136
K-4.3 Cl-94* HCO3-32 AnGap-14
[**2165-4-30**] 10:50AM BLOOD Glucose-186* UreaN-81* Creat-2.9* Na-135
K-3.4 Cl-92* HCO3-32 AnGap-14
[**2165-4-30**] 07:25AM BLOOD Glucose-109* UreaN-81* Creat-2.9* Na-136
K-3.4 Cl-92* HCO3-32 AnGap-15
[**2165-4-29**] 07:55AM BLOOD Glucose-163* UreaN-84* Creat-2.9* Na-138
K-3.5 Cl-94* HCO3-30 AnGap-18
[**2165-5-13**] 05:15AM BLOOD Calcium-9.0 Phos-5.1* Mg-3.8*
[**2165-5-12**] 04:35AM BLOOD Calcium-9.0 Phos-4.7* Mg-4.0*
[**2165-5-11**] 06:10AM BLOOD Calcium-8.7 Phos-4.2 Mg-4.0*
[**2165-5-10**] 05:20AM BLOOD Calcium-8.5 Phos-4.1 Mg-4.0*
[**2165-5-9**] 05:30AM BLOOD Calcium-8.8 Phos-5.3* Mg-3.8*
[**2165-5-8**] 05:15AM BLOOD Calcium-8.6 Phos-5.4* Mg-4.0*
[**2165-5-7**] 06:02AM BLOOD Calcium-9.2 Phos-6.5* Mg-4.1*
[**2165-5-6**] 12:48AM BLOOD Albumin-3.6 Calcium-9.2 Phos-5.8* Mg-3.6*
[**2165-5-5**] 04:10AM BLOOD Calcium-8.9 Phos-6.1* Mg-3.3*
[**2165-5-4**] 07:30AM BLOOD Calcium-9.1 Phos-5.1* Mg-3.0*
[**2165-5-3**] 05:05AM BLOOD Calcium-9.1 Phos-4.2 Mg-3.0*
[**2165-5-2**] 05:25AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.7*
[**2165-5-1**] 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.9*
[**2165-4-30**] 10:50AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.6
[**2165-4-30**] 07:25AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.5
[**2165-4-29**] 07:55AM BLOOD Calcium-9.9 Phos-4.2 Mg-2.5
Cardiac Enzymes
[**2165-5-6**] 12:48AM BLOOD CK(CPK)-17*
[**2165-5-5**] 04:10AM BLOOD CK(CPK)-11*
[**2165-5-2**] 05:25AM BLOOD CK(CPK)-16*
[**2165-5-1**] 09:14PM BLOOD CK(CPK)-20*
[**2165-4-30**] 07:25AM BLOOD CK(CPK)-17*
[**2165-4-30**] 03:40AM BLOOD CK(CPK)-15*
[**2165-4-29**] 03:05PM BLOOD CK(CPK)-19*
[**2165-4-29**] 07:55AM BLOOD CK(CPK)-20*
[**2165-5-6**] 12:48AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2165-5-5**] 04:10AM BLOOD CK-MB-1 cTropnT-0.19*
[**2165-5-2**] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2165-5-1**] 09:14PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2165-4-30**] 07:25AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2165-4-30**] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2165-4-29**] 03:05PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-[**Numeric Identifier 93521**]*
[**2165-4-29**] 07:55AM BLOOD cTropnT-0.03*
Brief Hospital Course:
[**Age over 90 **]yoF with CAD s/p stent to mid-[**Name (NI) **], PTCA of jailed OM1, IVUS of
LMCA with MLA presenting with body pain and chest pain.
.
# CORONARIES: Patient has h/o prior stent to [**Name (NI) **] and PTCA of
jailed OM1 presenting with atypical chest pain not concerning
for ACS. There were no significant EKG changes in light of LBBB
(by Sgarbossa criteria), and CE's were negative. The patient
was continued on Aspirin 162mg daily and Clopidogrel 75 mg daily
per outpatient regimen.
.
# PUMP/CHF: Patient has a history of chronic systolic and
diastolic heart failure with EF 40% [**3-/2165**], moderate (2+) MR,
small secundum ASD with left-to-right shunt across the
interatrial septum at rest. She appeared clinically fluid
overloaded without hypoxia, with BNP >45,000. Pt had complex
course on the medicine floor with multiple episodes of worsening
resp status thought due to flash pulm edema. Initially, her
symptoms responded to lasix and additional BP control. However,
the renal function slowly worsened and she had a decreasing
response to diuresis. Pt became progressively uremic and
confused on [**5-5**] with mild respiratory distress. She was
transferred to the CCU on [**5-6**] and received 240mg Lasix IV bolus
followed by gtt. She was aggressively diuresed, per renal recs,
started on Lasix 80mg PO BID. She has had good volume output
with the lasix. Patient has been in good volume status since,
has not had any further episodes of flash pulmonary edema. Has
had fluctuating O2 requirements, at times saturating well on
room air and other times requiring 2L of O2.
.
# Chronic renal failure: Stage III CKD, followed by Dr [**Last Name (STitle) **].
Patient has baseline Cr of 1.5 until [**Month (only) 956**] when baseline
increased to 2.4. On this admission patient had worsening renal
function with creatinine rising from 2.9 to 4.3. It was unclear
whether the patient's increasing creatinine was due to
dehydration vs volume overload - particularly given her
recurrent episodes of flash pulmonary edema and CXR showing
evidence of fluid overload. She was aggressively diuresed in
the CCU and her volume status has been stable on 80 mg of PO
lasix [**Hospital1 **]. Patient and family have decided to decline
hemodialysis and focus more on comfort measures.
# Renal Artery Stenosis: Patient with atrophic right kidney,
left renal artery stenosis. Very likely that this is the reason
that she is very difficult to diurese and the reason why she
flashes easily. She was originally planned for renal artery
stenting, but the procedure was held off because she was
unstable, requiring CCU transfer. Goals of care were discussed
with patient and renal stenting was tabled as patient decided
against aggressive management and to focus more on comfort.
.
# Body Pain: Patient describes body pain since waking up in
the morning of her admission. Unclear etiology, but likely
viral symptoms vs non-specific findings [**3-12**] CHF exacerbation.
Infectious workup was negative. Leukocytosis resolved on
discharge. Patient has had 2 transient episodes of chest pain
on this admission which was reproducible with palpation and
worse with movement, likely of musculoskeletal etiology,
relieved with 0.5 mg of PO morphine.
.
# Right Finger Pain: Pt initially presented with right index
finger with erythema, swelling, calor consistent with gout;
septic arthritis or osteomyelitis was less likely given no
fevers, no effusion, no nidus of infection. Resolved without
intervention.
.
# Hypertension: Patient's home antihypertensives were initially
continued, but following her CCU transfer for recurrent flash
pulmonary edema, she was changed to amlodipine, carvedilol,
furosemide, and imdur. Following her CCU admission she has been
stable with SBP ranging in 110s-130s.
.
# Hyperlipidemia: Pt is intolerant of statins, and was not
given statins after discussion with her PCP [**Last Name (NamePattern4) **]: goals of the
patient's care.
.
# Type 2 diabetes: diet-controlled. Covered with SSI in-house.
.
# GERD: Continued Famotidine 20 mg Tablet per outpatient
regimen
.
# Goals of care: patient was made DNR/DNI while in the CCU.
Patient and family decided against starting hemodialysis,
preference was for comfort directed care. Just prior to
discharge from the hospital, patient was asked to sign a DNR/DNI
form which would continue her DNR/DNI status during transport
and at the nursing facility, which she refused to sign. Patient
repeatedly stated that she DID NOT want to be resuscitated,
however refused to sign the form. She is amenable to her
daughter (HCP) signing the DNR/DNI forms for her, however the
daughter was not available prior to discharge to sign the
papers. The daughter understands that she would be able to sign
the DNR/DNI papers at the nursing facility. At the nursing
facility, patient's care should be focused on comfort care.
Medications on Admission:
1. Senna 8.6 mg [**Hospital1 **]
2. Famotidine 20 mg Tablet
3. Calcitriol 0.25 mcg Capsule PO QMOWEFR
4. Aspirin 162mg daily
5. Clopidogrel 75 mg daily
6. Cyanocobalamin 500 mcg daily
**7. Hydralazine 10 mg q6hr
**8. Isosorbide Mononitrate 20 mg [**Hospital1 **]
9. Docusate Sodium 100 mg [**Hospital1 **]
10. Felodipine 10 mg daily
11. Carvedilol 12.5 mg [**Hospital1 **]
**12. Furosemide 40 mg Tablet [**Hospital1 **]
13. Iron (Ferrous Sulfate) 325 mg daily
14. Nitrostat 0.4 mg Tablet, Sublingual prn
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
up to 3 tablets as needed for chest pain 5 minutes apart.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath, wheezing.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS
OFF ().
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
16. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams
PO once a day as needed for constipation.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every
six (6) hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Systolic and Diastolic Heart Failure
Pulmonary Edema
Left Renal Artery Stenosis
Secondary Diagnosis:
Hypertension
Diabetes
Coronary Artery Disease
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You presented to the hospital for body pain and chest pain.
Your EKG and blood tests did not show any evidence of a heart
attack, but you were found to be in heart failure. While in the
hospital, you had frequent episodes of shortness of breath was
improved with starting you on Lasix to help remove fluid.
During this admission, we had many discussions about whether or
not to start dialysis. Your final decision was for dialysis
not to be started, but instead to pursue hospice care instead.
You will be discharged to a nursing facility where they can help
with treating your symptoms and making you comfortable.
.
Your medications have changed, please only take the medications
as
listed below:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
up to 3 tablets as needed for chest pain 5 minutes apart.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath, wheezing.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS
OFF ().
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
16. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams
PO once a day as needed for constipation.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every
six (6) hours as needed for pain.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call and schedule an appointment to see your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] ([**Telephone/Fax (1) 250**]), as needed.
ICD9 Codes: 5849, 2761, 4280, 496, 412, 2749, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 96
} | Medical Text: Admission Date: [**2191-11-28**] Discharge Date: [**2191-12-21**]
Date of Birth: [**2114-4-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine / Heparin Agents
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mrs. [**Known lastname **] is s/p CABG [**2187**], and now has increasing
SOB/DOE. She underwent cardiac catheterization [**11-24**] which
showed patent LIMA-LAD, totally occluded SVG-OM and ectatic
SVG-PDA, and an aortic valve area of 0.59cm2. She was admitted
to [**Hospital 24356**] hospital for diuresis due to an elevated wedge
pressure and then was transferred to [**Hospital1 18**] for surgery
Major Surgical or Invasive Procedure:
s/p redo sternotomy/CABGx1 SVG-PDA/AVR 21mm pericardial [**12-7**]
History of Present Illness:
Mrs. [**Known lastname **] is s/p CABG [**2187**], and now has increasing
SOB/DOE. She underwent cardiac catheterization [**11-24**] which
showed patent LIMA-LAD, totally occluded SVG-OM and ectatic
SVG-PDA, and an aortic valve area of 0.59cm2. She was admitted
to [**Hospital 24356**] hospital for diuresis due to an elevated wedge
pressure and then was transferred to [**Hospital1 18**] for surgery.
Past Medical History:
CAD
s/p CABG [**2187**]
aortic stenosis
h/o breast CA s/p lumpectomy and radiation therapy to R breast
carotid stenosis-bilateral 50-70% lesions
DM-type 2
elevated cholesterol
venous stasis
Physical Exam:
discharge physical exam:
T:98.1 P63 atrial fibrillation BP:123/62 RR:18 RA:SpO2 95% on RA
weight:[**12-21**] 91.4kg
Neurological exam:She is awake, alert, oriented x3, non-focal.
Cardiovascular exam: regular rate and rhythm without rub or
murmur
Respiratory:breath sounds are clear without wheezes or rales
GI:positive bowel sounds, soft, obese, non-tender,
non-distended, no nausea
Extremities:warm and well perfused, bilateral lower extremeties
with mild erythema, chronic venous stasis changes with plaques.
No warmth or tenderness.
Sternal incision is clean and dry, there is an area at the at
the proximal portion of the incision with 2 areas of scabbed
skin tears. There is no erythema or drainage.
The veing harvest site at the knee is clean, dry and intact
Pertinent Results:
[**2191-12-21**] 05:58AM BLOOD WBC-8.4 RBC-4.27 Hgb-12.9 Hct-37.9 MCV-89
MCH-30.3 MCHC-34.1 RDW-15.7* Plt Ct-277
[**2191-12-21**] 05:58AM BLOOD Plt Ct-277
[**2191-12-21**] 05:58AM BLOOD PT-20.3* PTT-32.6 INR(PT)-2.6
[**2191-12-21**] 05:58AM BLOOD Glucose-66* UreaN-16 Creat-1.0 Na-138
K-4.2 Cl-95* HCO3-34* AnGap-13
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to [**Hospital1 18**] on [**11-28**] for
pre-operative evaluation. She was started on IV heparin for her
coronary disease. She was taken to the operating room on [**12-2**]
and was induced with general anesthesia. It was then noted that
she had purulent drainage from her lower extremeties in the area
of the venous stasis. The surgery was canceled and she was
transferred to the ICU to allow to awaken and she was started on
antibiotics. A vascular surgery and infectious disease consult
was obtained and patient underwent ultrasound studies of her LE
which did not show any significant reflux and no arterial
occlusion. With the antibiotics, the erythema and drainage
improved and with continued Lasix the edema improved and patient
was taken to the operating room on [**12-7**] for a redo sternotomy,
CABGx1-SVG-PDA, and AVR with a 21 mm pericardial valve. The
patient was transferred to the ICU in stable condition. She was
weaned and extubated from mechanical ventilation on [**12-7**]
without difficulty. She had episodes of nausea and was started
on Reglan and an antiemetic with some relief. Her chest tubes
and pacing wires were removed without incident. She was started
on lo dose Lopressor which she tolerated well, and had
escalating doses of Lasix to achieve adequate diuresis. She was
transferred from the ICU to the regular floor on POD#5. In the
early morning of POD 6, she developed atrial fibrillation which
was rate controlled. She had some thrombocytopenia
postoperatively and a heparin antibody test was found to be
positive. A hematology consult was obtained and it was
recommended that she be started on argatroban for
anticoagulation. This was started as well as Coumadin and the
argatroban was turned off when her INR became therapeutic. She
underwent an ultrasound of her R arm due to swelling which did
not show any venous clot or obstruction. During her
postoperative course, she continued to be nauseaus, a KUB showed
a lot of stool and she had an aggressive bowel regime. During
this time, her PO intake was poor. A GI consult was obtained
and it was recommended to continue the current therapy and by
POD#13 the nausea was improving. On POD#12 it was noted that
she was having some periods of bradycardia with the atrial
fibrillation and it was decided to discontinue the Lopressor,
after which there were no further pauses.
Medications on Admission:
aspirin 325mg qd
lisinopril 5mg qd
insulin 70/30 18 units qam, 15units qpm
lopressor 50mg qam 25mg qpm
nitropaste
lasix 80mg iv qd
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed for pain.
12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
16. Insulin 70/30 70-30 unit/mL Suspension Sig: Five (5) units
Subcutaneous twice a day.
17. Insulin Regular Human 300 unit/3 mL Syringe Sig: as directed
Subcutaneous four times a day: BS 121-140 2units SC
BS 141-160 3units SC
BS 161-180 4units SC
BS 181-200 5units SC
BS 201-220 6units SC
BS 221-240 7units SV
.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
AS/CAD
h/o CHF
DM
PVD
s/p breast lumpectomy d/t CA
s/p radiation to R breast
carotid stenosis 50-70% bilaterally
s/p CABG [**2187**]
s/p redo sternotomy/AVR/redo CABG
bilateral LE venous stasis
bilateral LE cellulitis
post op atrial fibrillation
post op urinary retention
post op gastroparesis/ileus/constipation
+heparin antibodies
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not drive for 1 month
do not lift anything heavier than 10 pounds for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in 2 weeks
follow up with [**Doctor Last Name **] in 2 weeks
follow up with Dr. [**Last Name (STitle) **] in [**3-31**] weeks
Completed by:[**2191-12-21**]
ICD9 Codes: 4241, 9971, 4280, 5180, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 97
} | Medical Text: Admission Date: [**2162-10-10**] Discharge Date: [**2162-10-14**]
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
Single lead [**First Name8 (NamePattern2) **] [**Hospital 923**] Medical Identity ADx SR 5180
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] yo female h/o dementia, hypertension,
osteoporosis who presented to [**Hospital1 43650**] s/p fall at [**Hospital3 **].
She was found down in bathroom with wet floor and did not recall
what happened. She initially complained of left knee pain and
was found to have left eye hematoma. She denied head injury/LOC
and had normal head imaging in the ED. Additionally with
unremarkable C/T/L spine, bilaterall knee xray, and CXR in ED.
The patient was initially placed in observation and plan was to
have PT and case managment see her and then send her back to
assissted living.
However, in the ED around 8 AM she became bradycarduc to 30s,
asystolic, and pulseless. A few compressions were delivered and
the patient had ROSC, no shock was delivered. After a 7 second
pause she went back in to sinus rhythm. The patient was unable
to describe how she felt, however was back to her baseline
mental status within 1-2 minutes. She had no complaints or
recollection of the event. She responded to questions and said
she felt "lousy", but could not provide more details.
Of note the patient visited [**Hospital1 18**] ED for mechanical fall on [**8-14**]
and was also admitted for mechanical fall in [**2161-8-20**].
Most recent previous admission [**2162-6-20**] for E. Coli Septicemia
likely secondary to Cholangitis c/b pancreatitis that resolved
with antibiotics and conservative management.
In the ED the patient received ASA 300mg PR and oxycodone. Prior
to transfer to CCU the patient was hemodynamically stable with
VS T 97.7, HR 68, BP 128/51, RR 20, 99% on RA.
On arrival to the floor, patient reports that her bladder hurts
since the foley was placed. She denies pain. She denies CP, SOB,
palpitations, dizziness/lightheadedness. She reports that she is
at the hosptial because she fell, but can not provide other
details.
REVIEW OF SYSTEMS:
Postive for achy joints and frequency of urination. Negative for
dysuria.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- Dementia
- Hypertension
- Arthritis
- Sjogrens
- Cataracts
- h/o Bleeding ulcer
- Narrow complex tachycardia: [**1-29**], reverted to sinus, on
toprol.
- L2-L3 compression fractures
- Anterior abdominal wall fat-containing hernia and right
inguinal hernia
- Osteoporosis
- Spinal Stenosis
Social History:
Lives in [**Hospital3 **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] facility and ambulates with
walker. All of her cooking and cleaning are done for her. She
has help in shower three times per week. Previously interior
decorator, has 3 children, widowed, family very involved.
Patient states had a daughter in [**Name (NI) **] and a daughter in
[**Name (NI) 6607**]. Reports that her grand-daughters visit her frequently.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
Mother/Father with CAD.
Physical Exam:
Admission Exam:
VS: T=98.1 BP=161/74 HR= 60 RR=18 O2 sat= 93-97% on RA
GENERAL: WDWN [**Age over 90 **] y/o female in NAD. Oriented to person, place,
and some time (knows month, but not year). Hard of hearing.
Mood, affect appropriate. Pleasantly confused.
HEENT: NC. Left eye with hematoma and bruising present. Sclera
anicteric. PERRL, EOMI. sl dry mucous membranes.
NECK: Supple with flat neck veins.
CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best at
Right upper sternal border and radiating to clavicles. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c/e.
SKIN: Scattered bruises of UE bilaterally. 5-8 mm slightly
raised round lesions scattered over upper LE bilaterally
(posterior>anterior and L>R).
PULSES: DP pulses 2+ bilaterally
Discharge Exam:
T 97.8, P 80, BP: 94-159/50-80, RR: 18, 94% on RA
GENERAL: WDWN [**Age over 90 **] y/o female in NAD. Hard of hearing. Mood,
affect appropriate. HEENT: NC. Left eye with hematoma and
bruising present. Sclera anicteric. PERRL, EOMI. sl dry mucous
membranes.
NECK: Supple with flat neck veins.
CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best at
Right upper sternal border and radiating to clavicles. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c/e.
SKIN: Scattered bruises of UE bilaterally. 5-8 mm slightly
raised round lesions scattered over upper LE bilaterally
(posterior>anterior and L>R). bruising over left knee.
PULSES: DP pulses 2+ bilaterally
Pertinent Results:
Admission Labs:
[**2162-10-10**] 02:30AM BLOOD WBC-9.7 RBC-5.00 Hgb-13.7 Hct-41.6 MCV-83
MCH-27.3 MCHC-32.8 RDW-16.6* Plt Ct-517*
[**2162-10-10**] 02:30AM BLOOD Neuts-66.0 Lymphs-21.4 Monos-10.5 Eos-1.3
Baso-0.7
[**2162-10-10**] 02:30AM BLOOD PT-9.4 PTT-20.4* INR(PT)-0.9
[**2162-10-10**] 02:30AM BLOOD Glucose-107* UreaN-12 Creat-0.5 Na-127*
K-7.8* Cl-94* HCO3-26 AnGap-15 (hemolyzed specimen)
[**2162-10-10**] 04:41PM BLOOD CK(CPK)-209*
[**2162-10-10**] 04:41PM BLOOD CK(CPK)-209*
[**2162-10-10**] 08:55AM BLOOD cTropnT-<0.01
[**2162-10-10**] 04:41PM BLOOD CK-MB-7 cTropnT-<0.01
[**2162-10-10**] 01:00PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2
[**2162-10-10**] 04:21AM BLOOD Na-132* K-4.2
Discharge labs
[**2162-10-14**] 05:47AM BLOOD WBC-9.6 RBC-4.45 Hgb-12.4 Hct-37.4 MCV-84
MCH-27.9 MCHC-33.2 RDW-17.0* Plt Ct-518*
[**2162-10-14**] 05:47AM BLOOD UreaN-14 Creat-0.7 Na-131* K-4.4 Cl-94*
HCO3-25 AnGap-16
[**2162-10-12**] 08:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.1
Images:
CT Head [**10-10**]: 1. No acute intracranial hemorrhage or
fractures.
2. New opacification of the left mastoid air cells and middle
ear cavity, please correlate with signs of infection.
CT C-Spine [**10-10**]: No acute cervical spine fracture. Multilevel
moderate-to-severe degenerative changes of the cervical spine,
worse at C4-C5 level.
CT L-Spine [**10-10**]: 1. No new lumbar spine fracture. Stable
compression of L2 and L3 vertebral bodies.
2. Multilevel severe degenerative changes of the lumbar spine,
worse at L3-L4 level with moderate spinal canal stenosis.
CT T-Spine [**10-10**]: No acute thoracic spine fracture. Mild
compression of the superior endplate of T3 vertebral body, is
likely chronic.
Bilateral Knee Xray [**10-10**]: 1. No acute fracture.
2. Bilateral tricompartmental osteoarthritis, severe on the
left and mild on the right.
CXR [**10-10**]: The cardiomediastinal and hilar contours are normal.
The lung volumes are low, with crowding of the bronchovascular
markings in the lung bases. Patchy right basilar opacity may
reflect
atelectasis, aspiration or focal/early pneumonia.
CXR [**10-10**] (post chest compressions): Cardiomediastinal contours
are normal in appearance. Lungs are clear except for a tiny
calcified granuloma in the periphery of the right lower lobe.
No rib fractures are identified, but portable chest radiographs
are relatively insensitive for detecting rib fractures,
especially those involving the anterior ribs. There is no
visible pneumothorax or pleural effusion.
Echo: [**2162-10-11**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Doppler parameters are most consistent with Grade I
(mild) left ventricular diastolic dysfunction. There is a mild
resting left ventricular outflow tract obstruction. with normal
free wall contractility. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Mild to moderate ([**12-21**]+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. Trivial mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
The tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric LVH with small LV cavity size with
hyperdynamic LV systolic function. Consequently there is a mild
left ventricular outflow tract gradient during systole. The
aortic valve is thickened but opens reasonably well - the high
velocity is due to the LVOT gradient. Mild to moderate aortic
regurgitation. Probable diastolic dysfunction.
CXR [**10-13**]
Single-lead pacemaker in standard position, terminating in the
right ventricle. No acute cardiopulmonary disease.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] y/o female with a history of dementia,
hypertension, and previous h/o narrow complex tachycardia with
no known other cardiac history that presented [**1-21**] to fall and
was found to have a symptomatic 7 second asystolic pause in ED
with ROSC after chest compressions, no shock delivered.
Active issues:
# RHYTHM: Patient with previous history of narrow complex
tachycardia on metoprolol. Now with 7 second asystolic pause in
ED. Patient with mulitple falls recently, unclear whether
mechanical or secondary to bradycardia and conduction
abnormality. Differential includes high vagal tone, sick sinus
syndrome, junctional abnormality. Tropnoin negative x 2. Normal
K+ and Mg2+. Metoprolol was held. Patient monitored on telemetry
and XX. EP consulted and followed patient. A pacemaker was
implanted on [**10-12**] out of concern for arrhythmia as a cause for
recurrent falls. The patient will follow up with EP for
pacemaker interrogation after discharge. She was started on
diltiazem 45 mg po QID for control of rate and rhythm given
family report of "fuzziness" and fatigue that they attributed to
the beta-blocker. She will have one more day of levofloxacin
after discharge for prophylaxis against infection.
# s/p Fall: patient presented to ED secondary to fall. Patient
with multiple falls recently. Cause unclear, likely
multifactorial given dementia, patient uses walker, and now
found to have symptomatic 7 second asystolic pause. Patient with
negative head CT, C/T/L spine CT, bilateral knee xrays in ED.
Falls sound mostly mechanical after talking with family. PT
consulted and recommended rehab.
# ? bladder pain and increased frequency of urination: UA with
neg nitrite, neg leuks. Patient with mild leukocytosis, however
after CPR preformed and likely stress reaction. Of not on last
admission patient with asymptomatic bacturia. Urine culture sent
in ED, grew proteus mirabilis sensitive to ciprofloxacin and
levofloxacin. She received a dose of ciprofloxacin and was
continued on levofloxacin for prophylaxis after pacemaker
insertion. She completed a three day course for UTI on [**10-14**].
# Hypertension: patient with reported hypertension, labile on
last admission. Home metoprolol held for bradycardia and
asystole. BP monitored throughout stay and was stable on 45mg of
diltiazem QID.
Chronic issues:
# Dementia: patient currently AAO x 3, however confused. Home
donezepil continued.
# Sjogren's: continued saline eye drops
# Osteoporosis, compression fractures: continued calcium,
vitamin D, and weekly alendronate. Home oxycodone continued prn
for pain.
Transitional:
-will need pacemaker interrogated in [**12-21**] weeks
-titrate diltiazem dose to target BP and HR, then change to
long-acting formulation when on a stable dose
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 10 mg PO HS
2. Omeprazole 20 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES HS:PRN dry
eyes
6. Alendronate Sodium 70 mg PO QMON
7. Calcium Carbonate 600 mg PO DAILY
8. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain
9. Polyethylene Glycol 17 g PO TID
10. cranberry *NF* unknown Oral daily
11. Glucosamine Sulf-Chondroitin *NF* (glucosamine [**Doctor First Name **]
2KCl-chondroit) 500-400 mg Oral daily
2 tabs daily
Discharge Medications:
1. Alendronate Sodium 70 mg PO QMON
2. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES HS:PRN dry
eyes
3. Calcium Carbonate 600 mg PO DAILY
4. Donepezil 10 mg PO HS
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain
7. Vitamin D 1000 UNIT PO DAILY
8. Glucosamine Sulf-Chondroitin *NF* (glucosamine [**Doctor First Name **]
2KCl-chondroit) 500-400 mg Oral daily
2 tabs daily
9. cranberry *NF* 0 unknown ORAL DAILY
10. Levofloxacin 500 mg PO Q24H Duration: 1 Days
Last day [**10-15**]
11. Diltiazem 45 mg PO QID
12. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Sinus arrest
Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You fell at home and was brought to the hospital. All of the
tests to look for serious injury were negative. You had a slow
heart rate and needed a pacemaker. The pacemaker was placed on
[**10-12**] and there were no complications. A urine sample showed
that you had a urinary tract infection and you will be on an
antibiotic for one week.
No lifting more than 5 pounds with your left hand or lift your
left arm over your head for 6 weeks.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2162-10-18**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: FRIDAY [**2163-4-22**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4275, 5990, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 98
} | Medical Text: Admission Date: [**2107-1-17**] Discharge Date: [**2107-2-12**]
Date of Birth: [**2042-4-4**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Penicillins / Erythromycin Base / Demerol / Ceclor
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
64 yo woman w/ h/o recurrent PEs s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter, GIB
while anticoagulated, COPD, who was discharged [**2107-1-12**] after
being treated for new PE presented to the ED with SOB and
productive cough. She was readmitted [**2107-1-17**] after she was
found to have a multifocal pneumonia and was treated with
Levo/Flagyl and Vanco. Cultures were positive for MRSA. Levo and
Flagyl were continued for suspected aspiration PNA. The pt
recovered quickly over since admission and she is now back on
her home O2 requirement. She was getting bridged for her
anticoagulation with Lovenox starting [**1-18**] in preparation for
discharge. However, she developed severe abdominal pain and a
palpable mass in her L abdomen. A CT was showed a new large
hematoma in the muscles of the left anterior and lateral lower
abdominal and pelvic wall, without any intraperitoneal or
retroperitoneal extent, but with associated mass effect on the
lower abdominal and pelvic bowel loops. Surgery was [**Month/Year (2) 4221**]
and suggested no intervention, but monitoring for now. HCT
dropped 6 points in this setting, but she remained
hemodynamically stable with tachycardia which has been present
throughout her hospital stay (95-115).
She required a total of 5 units PRBC and 4 units FFP
transfusions and was transferred to the MICU for further
monitoring. Her hematocrit has since been stable with serial
checks.
.
ROS: She has baseline left to mid chest pain with exertion that
is not currently bothering her. She denies current chest pain,
SOB, dysuria, increased urinary frequency. She has stable R knee
pain.
Past Medical History:
1. H/O Rheumatic Fever - age 8 -dx'ed last year with rheumatic
heart disease per pt (states ED diagnosed this) and has had
syndenham chorea
2. ?CHF per pt. although [**12-13**] Echo revealed low normal LVEF,
mildly thickened aortic and mitral valves with mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
3. Orthostatic hypotension
4. Chest pain - nearly monthly visits to ED with negative
ischemic w/u in the past
5. Duodenal/gastric ulcer
6. Seven miscarriages
7. Ulcerative colitis
8. Diverticulosis-s/p colostomy and reversal colostomy-had
Colonoscopy [**1-12**] showed only diverticuli without e/o active
bleed
8. Panic attacks x 15 yrs
9. Depression - several SA in past
10. Schizoaffective disorder
11. h/o polysubstance abuse
12. Iron deficiency anemia (baseline unclear-high 20's to 30's)
13. COPD
14. PE [**7-13**], c/b GIB while on anticoagulation, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]
filter. New PE on [**2107-1-2**], again on anticoagulation
Social History:
Lives in lodge house. She has a homemaker help with her
cleaning. She gets meals on wheels. She has very limited funds.
Smoked 2 PPD X 40 yrs, quit smoking 4 months ago. Former
drinker, reports drinking two 6 packs per day for 2 yrs; quit 27
yrs ago. Denies h/o illicits and IVDA. H/O domestic violence.
Family History:
Daughter -40 - colitis. Had 6 siblings. One sister died, 35,
ovarian CA. Brother, died at 48, stroke. Sister, died at 64 from
infection. Father died at 65 of MI. Mom was "psychotic", died of
stroke at 93
Physical Exam:
VS: 97.6 HR 114, Bp 118/74 RR 20-30 Sats 98% 2L.
Gen: NAD, pleasant
HEENT: PEERLA, MMM.
Neck: supple, no LAD
Lungs: moderate air movement, decreased breath sounds at bases
CV: RRR, S1S2 present, distant heart sounds, no murmurs
Abd: +BS, S/ND, + umbilical hernia, ulcer mid abdomen-reportedly
chronic, unchanged, mildy errythematous base. no secretions.
Tenderness in L abdomen, palpable mass over unclear extension,
no guarding, no rebound
Back: no CVA tenderness.
Ext: 2+ on RLE, 1+ edema LLE/ no c/c/ 1+ DP
Neuro: A&Ox3, CN II-XII intact. moving all extremities.
Pertinent Results:
ADMISSION LABS:
[**2107-1-16**] 08:40PM PT-87.9* PTT-41.3* INR(PT)-11.8*
[**2107-1-16**] 08:40PM WBC-16.2*# RBC-3.63* HGB-11.6* HCT-33.5*
MCV-93 MCH-32.1* MCHC-34.7 RDW-14.0
[**2107-1-16**] 08:40PM NEUTS-90.5* BANDS-0 LYMPHS-4.7* MONOS-2.4
EOS-2.0 BASOS-0.5
[**2107-1-16**] 08:40PM GLUCOSE-127* UREA N-16 CREAT-1.0 SODIUM-136
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
[**2107-1-16**] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2107-1-17**] 12:47AM LACTATE-1.3
[**2107-1-22**] 03:07AM BLOOD WBC-7.5 RBC-2.85*# Hgb-8.6*# Hct-25.6*
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.4 Plt Ct-243
[**2107-1-22**] 03:07AM BLOOD PT-22.4* PTT-31.1 INR(PT)-2.2*
[**2107-1-22**] 03:07AM BLOOD Glucose-105 UreaN-11 Creat-0.6 Na-141
K-4.0 Cl-102 HCO3-35* AnGap-8
[**2107-1-22**] 03:07AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1
[**2107-1-23**] 04:34PM BLOOD PEP-HYPOGAMMAG IgG-535* IgA-254 IgM-109
.
CTA chest:
1. Interval development of patchy areas of consolidation with
mucous plugging, particularly in the right lower lobe, right
upper and mid lobes suggest a new infectious process or
aspiration.
2. Resolution of the previously identified pulmonary embolism.
3. Extensive centrilobular and paraseptal emphysematous change.
4. Fluid-attenuating structure adjacent to the right T11-12
neural foramen is also unchanged and could be a perineural cyst.
.
CT abdomen/pelvis:
1. New large hematoma in the muscles of the left anterior and
lateral lower abdominal and pelvic wall, without any
intraperitoneal or retroperitoneal extent, but with associated
mass effect on the lower abdominal and pelvic bowel loops.
2. Unchanged infectious or inflammatory opacities in the right
middle and lower lobes.
.
[**2107-2-1**] IR Embolization: 1. Right inferior epigastric
arteriogram demonstrates no extravasation of contrast and
successful embolization with Gelfoam until stagnation of flow.
2. The right internal mammary artery demonstrated no areas of
active extravasation of contrast.
.
[**2107-2-3**] CXR: There is an irregular opacity in the right lower
lobe
concerning for pneumonia. There are no pleural effusions.
There is no
pneumothorax. The left subclavian catheter tip overlies the mid
SVC. Heart size normal. Mediastinal and hilar contours are
normal. IMPRESSION: Opacity in the right lower lobe concerning
for pneumonia.
.
[**2107-2-8**] LENIS: Extensive occlusive thrombus is demonstrated from
the common femoral vein at the takeoff of the greater saphenous
vein extending distally to the popliteal veins bilaterally. No
color flow, compressibility, or waveforms are demonstrated
within these areas of thrombus. IMPRESSION: Extensive,
completely occlusive, bilateral deep venous thrombi extending
from the common femoral veins to the popliteal veins.
.
[**2107-2-9**] ECG: Sinus tachycardia, Normal ECG except for rate
Brief Hospital Course:
64F w/ h/o recurrent PE s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter, GIB on
anticoagulation, COPD, recently admitted for new PE, readmitted
for multifocal PNA, who developed a large abdominal wall
hematoma in the context of enoxaparin injections.
# Multifocal Pneumonia: She was admitted with multifocal
pneumonia. She was started on levofloxacin and vancomycin. She
completed a 7 day course of levofloxacin. MRSA was found to
grow in her sputum so she was continued on a 14 day course of
vancomycin. She originally presented with elevated WBC count and
left shift which quickly resolved with the initiation of
antibiotics. Her productive cough improved as well and she
remained on her baseline home O2 of 2L. Approximately 4 days
after completion of her 14 day course of Vancomycin, the patient
developed worsening cough, SOB, and upper respiratory symptoms.
A repeat CXR showed evidence of a new consolidation in the RLL.
The patient was started back on Levofloxacin/Flagyl. Vancomycin
was added to her regimen when blood cultures showed 2/4 bottles
with GPC in clusters and chains. Additionally, her sputum
culture grew out GNRs. Levofloxacin was discontinued and
Meropenem was started for concern for Pseudomonas given the
patient's long hospital course. Her O2 sat remained stable
93-100% on 2L nasal cannula (which is her baseline). She was
given mucomyst inhaled nebulizers to assist in breaking up thick
sputum. Her GNRs in the sputum grew out E. coli. Because of
the sensitivity profile of the E. coli and the patient's allergy
to penicillin and cephalosporins, the patient was continued on
Meropenem. Her GPCs were found to grow out Coag negative Staph.
Surveillance cultures had no further growth and the coag
negative staph was thought to likely be a contaminant. Her
Vancomycin was discontinued. She will continue a 14 day course
of Meropenem and she was discharged with a PICC to complete this
course.
.
# Pulmonary embolism/DVTs: She has had multiple PEs and has had
one even since the placement of a TrapEase IVC filter. CT during
recent previous hospitalization revealed appropriate location of
filter and CTA on this admission showed improvement of clot.
Admission labwork revealed an INR of 7.9. Coumadin was thus
held and reversed with FFP and vitamin K given her history of
GIB on anticoagulation. In the interim, therapeutic lovenox
injections were initiated, but within days of starting, she
developed a large abdominal wall hematoma near to lovenox
injection site. Once her hematocrit stabilized, she was started
on a heparin gtt with coumadin overlap. While [**Last Name (NamePattern4) 9533**] her
Coumadin with an INR 1.2, she was found to have a large Hct drop
and a CT scan of the abdomen showed a new rectus hematoma. She
was subsequently transferred to the MICU for closer monitoring.
It was decided after her second hematoma while on
anticoagulation, the risks of anticoagulation outweigh the
benefits at this time and she was not anticoagulated. In terms
of her hypercoagulable workup, it has been negative thus far for
hyperhomocysteinemia, Factor V Leiden and antiphospholipid
antibody. Malignancy workup included a colonoscopy and EGD as
well as CEA, all of which were within normal limits. SPEP
revealed hypogammaglobulinemia, but was otherwise unremarkable.
During her hospital course, she also began to complain of
worsening lower extremity pain. LENIs were obtained which
showed evidence of extensive, completely occlusive, bilateral
deep venous thrombi extending from the common femoral veins to
the popliteal veins. Radiology felt that these clots were most
likely acute to subacute in nature. In this setting,
hematology/oncology saw the patient again to consider the risks
vs benefits of anticoagulation. Antithrombin III, prothrombin
mutation, Lupus anticoagulation and [**Location (un) 1169**] Venom Viper were
sent to reevaluate the reason for her hypercoagulability. The
hematology/oncology team still felt that the risks of
coagulation outweigh the potential benefits given that the
patient has had multiple bleeding episodes in the setting of
anticoagulation.
# Abdominal wall hematoma: As mentioned above, she developed a
large left-sided abdominal wall hematoma from a Lovenox
injection site that caused a significant hct drop (originally
28.1-->19.4). Despite the drop, she remained hemodynamically
stable (has sinus tachycardia at baseline prior to bleed). She
received 3 units prbcs, 4 units FFP. Her hematocrit then
stabilized and once stable, she was restarted on heparin gtt.
Coumadin was re-initiated and heparin gtt was continued while
awaiting her INR to become therapeutic. While [**Location (un) 9533**] her
Coumadin with an INR 1.2, she was found to have another Hct drop
(25.9-> 22.2) and a CT scan of the abdomen showed a new
right-sided rectus hematoma. She was subsequently transferred
to the MICU for closer monitoring. She was given 1 unit FFP and
9 units PRBCs between [**Date range (1) 39125**] until her hematocrit became
stable and she bumped appropriately to transfusion. It was
decided after her second hematoma while on anticoagulation, the
risks of anticoagulation outweigh the benefits at this time and
she was not anticoagulated. She has complained of [**6-16**]
abdominal pain with movement and has maintained stable
hematocrits. Her pain is most likely [**3-11**] to the large rectus
hematoma that will resolve over time. Her Hct remained stable
after her anticoagulation was discontinued.
# Thoracic mass: CT chest and abdomen revealed a stable
thoracic mass (stable x 3years) and thought potentially
consistent with neural cyst. It was not further evaluated by
MRI given its long term stability and also she has metal
hardware in place s/p elbow surgery and facial plates. It
should be followed up with imaging to ensure it remains
unchanged in the future.
# ? Zoster: Patient reports having a history of "herpes" on her
right buttock. During her stay, she developed a tingling,
itchiness and multiple small erythematous skin lesions on her
right buttock over the S2, S3 dermatomal distribution. There
were no vesicles appreciated. She was treated with acyclovir.
# Candidal vaginitis: Treated with fluconazole x 2 with
resolution of symptoms.
# H/o GI bleeding during recent admission: Recent colonoscopy
showed diverticulosis with no active signs of bleeding. She had
no blood in her stools during this admission even while
anticoagulated. Her stools were guiac-ed multiple times and
were found to be guiac negative.
# Constipation: She is constipated at baseline and requires
daily scheduled bowel regimen to maintian regularity.
# Hyperlipidemia: Continued on lipitor.
# Depression/SAD: Continued on Prozac, risperdone, wellbutrin,
and klonopin.
# Ulcerative Colitis: Remains in remission. She was continued
on mesalamine.
# Orthostatic hypotension: She remained asymptomatic even while
ambulating with physical therapy. She was continued on
midodrine.
Medications on Admission:
1. Fluoxetine 30 mg daily
2. Risperidone 3 mg PO HS
3. Bupropion SR 150 mg [**Hospital1 **]
5. Nicotine 7 mg/24 hr Patch
6. Hexavitamin daily
7. ascorbic acid 500 tab 1 [**Hospital1 **]
8. Calcium Carbonate 500 tab [**Hospital1 **]
9. Ferrous gluconate 325 PO daily
10. Atorvastatin 20 mg daily
11. Fluticasone Salmeterol 250/50 [**Hospital1 **]
12. Midodrine 5 mg tab 1 TID
13. Tiotropium bromide capsule one cap /day
14. Mesalamine 1200 TID
15. Pantoprazole 40/ day
16. Albuterol nebs prn (tid generally)
17. docusate sodium
18. Warfarin 5 mg/day
19. Ipratropium nebs prn (tid generally)
20. clonazepam 1mg po tid
Discharge Medications:
1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please do not take this with levofloxacin.
13. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
Q4H (every 4 hours) as needed.
Disp:*100 Lozenge(s)* Refills:*0*
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-8**] Sprays Nasal
QID (4 times a day).
Disp:*QS bottle* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
18. Saline Flush 0.9 % Syringe Sig: Three (3) ml Injection twice
a day for 20 doses: prior to each vanco dose.
Disp:*20 syringe* Refills:*0*
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
21. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for pain.
24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
25. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
26. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
27. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
28. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
29. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
30. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: for PICC line.
31. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1) Pulmonary Embolism with history of DVT and IVC filter
placement in [**2106-7-8**]
2) Community Acquired Pneumonia
3) History of GI Bleed (extensive) in [**2106-7-8**] when
anticoagulated
4) Abdominal wall hematoma, with acute blood loss anemia
requiring 10 units PRBCs when anticoagulated for current
pulmonary embolism
5) Noscomial Pneumonia with GNR in sputum,
6) Coagulopathy
7) Noscomial UTI with E. coli - quinolone resistant
8) Vagnitis, attributed to broad spectrum antibiotic usage
9) otitis externa
10) tachycardia
11) diarrhea
12) incidentally noted left renal cyst/mass NOS
13) Coagulase negative staphylococcal bacteremia
14) Rectus sheath hematoma in setting of anticoagulation
.
Secondary:
1) chronic orthostatic hypotension
2) recurrent otitis externa
3) ulcerative colitis in remission
4) chronic obstructive pulmonary disease
5) depression
6) h/o schizoaffective disorder
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed, please keep all
follow-up appointments. Please call your primary care doctor,
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **], or return to the Emergency Department if you
experience fevers, chills, worsening shortness of breath,
dizziness, lightheadedness, worsened chest pain, nausea,
vomiting, diarrhea, blood in your stools or any symptoms that
concern you.
.
Please take all of your medications as prescribed and follow up
with your primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
Followup Instructions:
You need to set up a followup appointment to see Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **]
in [**2-8**] weeks. Please call ([**Telephone/Fax (1) 39126**] to set up this
appointment.
.
You had the following appointment scheduled prior to your
hospitalization:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2107-1-28**] 1:00
***Follow up CT scan or ultrasound of left kidney is recommended
as well as Urologic follow up due to incidentally noted left
renal cyst/mass that may be malignant.*******
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2107-2-12**]
ICD9 Codes: 496, 2851, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 99
} | Medical Text: Admission Date: [**2193-4-11**] Discharge Date: [**2193-4-16**]
Date of Birth: [**2121-3-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Elective Admission for Mass resection
Major Surgical or Invasive Procedure:
[**4-11**]: Right craniotomy for mass resection
History of Present Illness:
Patient is a 72M known to the neurosurgery service for prior
hospitalization for AVM hemorrhage. At that time, incidental
mass was identified, and he now presents electively for
resection of said mass.
Past Medical History:
IVH/AVM bleed [**10-3**] h/o Lt temporal AVM, HTN, depression ,
BPH, UTI, seizure, bladder stone
s/p VP shunt, cyberknife (AVM [**11-3**]), cysts removal from skin,
lithotripsy, extra-ventricular drain [**10-3**]
Social History:
resides at home with wife
Family History:
Non-contributory
Physical Exam:
On Discharge:
The patient is oriented x 3. His pupils are 2mm bilaterally.
EOMs intact. Face symmetric. Tongue midline. Left pronator
drift. LUE is weak as well as his IP in the LLE. His right side
is full strength. The dressing was removed and the staples are
clean, dry, and intact.
Pertinent Results:
Labs on Admission:
[**2193-4-11**] 02:46PM BLOOD WBC-18.4*# RBC-3.81* Hgb-11.0* Hct-32.7*
MCV-86 MCH-28.8 MCHC-33.5 RDW-15.5 Plt Ct-517*
[**2193-4-12**] 03:11AM BLOOD PT-12.8 PTT-24.1 INR(PT)-1.1
[**2193-4-11**] 02:46PM BLOOD Glucose-179* UreaN-11 Creat-0.7 Na-139
K-4.2 Cl-107 HCO3-24 AnGap-12
[**2193-4-11**] 02:46PM BLOOD Calcium-8.3* Phos-4.2 Mg-1.7
Imaging:
MRI/A Head Neck [**4-13**]:
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion
axial images of the brain were acquired before gadolinium. T1
axial and MP-
RAGE sagittal images were obtained following gadolinium. 3D
time-of-flight
MRA of the circle of [**Location (un) 431**] obtained. Gadolinium-enhanced MRA of
the neck and fat-suppressed axial images of the neck were
acquired.
FINDINGS: BRAIN MRI:
Comparison was made with the previous MRI of [**2193-4-11**]. Since the
previous study, the patient has undergone resection of a large
meningioma in the right frontal region. Extensive right-sided
brain edema is again identified. There are blood products at the
surgical site. Although no
residual nodular enhancement is seen, there is enhancement seen
along the
sulci and meningeal enhancement identified in the region. These
findings
indicate both pachy and leptomeningeal enhancement. Mild slow
diffusion in
the surrounding area on diffusion images is indicative of
postoperative
change. There is blood in the left lateral ventricle. There is
persistent
mass effect on the right lateral ventricle. Changes of small
vessel disease
are seen. A left frontal drainage catheter is identified. Note
is made of new areas of slow diffusion in the right medial
thalamus. These findings are indicative of acute infarcts which
are new since the previous study.
Again noted is enhancing meningioma in the tuberculum sella
region.
Additionally, enhancement and flow void in the left medial
temporal lobe
region indicative of an aneurysm at the site of previously noted
arteriovenous malformation. Post-craniectomy changes are seen in
the right frontal region. Pneumocephalus identified.
IMPRESSION: Previous MRI examination, the patient has undergone
resection of a large frontal meningioma with blood products at
the surgical site without residual nodular enhancement.
Leptomeningeal and pachymeningeal enhancement is seen which
appears postoperative. Acute right-sided thalamic infarcts are
seen which are new since the previous study. Other findings are
stable as described above.
MRA OF THE NECK:
The neck MRA demonstrates normal flow in the carotid and
vertebral arteries. The fat-suppressed images demonstrate subtle
increased soft tissues adjacent to the proximal right common
carotid artery as seen on the CTA. This could be related to
small amount of blood in the surrounding soft tissues from
recent attempted central venous line placement. There is no
definite dissection seen.
IMPRESSION: Normal MRA of the neck.
MRA OF THE HEAD:
The head MRA demonstrates no evidence of vascular occlusion or
stenosis. The previously seen aneurysm in relation with the left
posterior cerebral artery is not apparent on the MRA. The left
medial temporal lobe arteriovenous malformation is also not
clearly visualized.
IMPRESSION: No vascular occlusion or stenosis seen on the MRA of
the head.
Postoperative changes are noted following removal of frontal
lobe tumor.
Acute right thalamic infarcts are identified. MRA of the neck is
normal
without dissection. MRA of the head demonstrates no stenosis or
occlusion.
Brief Hospital Course:
Patient was electively admitted on [**4-11**] to undergo resection of
his brain mass. Post-operatively, he was transferred to the ICU
for continuous monitoring. During his perioperative course,
central line placement was complicated by access to the carotid
artery. Post-op, vascular surgery was consulted, duplex studies
performed, and determined to be without injury to the carotid
artery. MRI/A was also done to further confirm this as well as
evaluate surgical resection. The vascular surgery team agreed
that there was no carotid artery dissection and no intervention
needed on their part.
The patient was extubated in the ICU and was then transferred to
the floor. He did well over the weekend. The patient was able to
eat without difficulty. PT and OT evaluated him and recommended
rehab placement. On [**4-16**] the patient was noted to have bloody
urine in the foley. A urinalysis revealed a UTI. He was started
on a 14-day course of cipro. The patient was sent to rehab on
[**4-16**].
Medications on Admission:
APAP, Celexa 20mg', Compazine 20mg prn, Flomax 0.4mg', Folic
Acid 1mg', Keppra 500mg", lactulose prn,Ativan 1mg prn,
Metoprolol 50mg"', [**Name (NI) 10687**], MOM, Ritalin 20mg', Seroquel 25mg"',
Trazadone 50mg hs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. [**Name (NI) 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right Frontal Meningioma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after staples have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office [**4-26**] at 10:00 am for removal of
your staples and a wound check [**Telephone/Fax (1) 1669**].
??????You need to have an appointment in the Brain [**Hospital 341**] Clinic. They
will call you with an appointment. The Brain [**Hospital 341**] Clinic is
located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building.
Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to
change your appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization.
Completed by:[**2193-4-16**]
ICD9 Codes: 5990, 4019 |