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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2200 }	Medical Text: Admission Date: [2155-8-19] Discharge Date: [2155-8-24] Date of Birth: [2084-4-19] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: A 71-year-old man who suffered an acute myocardial infarction. He has had some vague chest pain since. He has had an angioplasty attempt of the left anterior descending artery which was unsuccessful. On physical examination, he is a well-nourished man in no acute distress. Cardiac examination is normal. Lungs are clear bilaterally. He has no jugular venous distention or carotid bruits. Abdomen is soft with no masses palpable. Lower extremity examination reveals normal pulses and no venous varicosities. Renal function was normal. Mr. [Known lastname 29876] [Last Name (Titles) 1834] coronary artery bypass grafting x1 on [2155-8-19]. The internal mammary artery was placed to the left anterior descending artery. Postoperatively he did well. He was discharged on [2155-8-24]. DISCHARGE MEDICATIONS: Toprol XL 50 mg q day, lisinopril 10 mg q day, Coumadin 5 mg q day. DISCHARGE DIAGNOSES: Status post myocardial infarction, status post coronary artery bypass grafting with mammary artery to left anterior descending artery. The patient is scheduled to see Dr. [Last Name (STitle) ] in three weeks in followup. See his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in one month. DR.[Last Name (STitle) ],[First Name3 (LF) 1112] 02-229 Dictated By:[Last Name (NamePattern1) 22050] MEDQUIST36 D: [2155-9-18] 14:08 T: [2155-9-23] 08:33 JOB#: [Job Number 29877] ICD9 Codes: 9971, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2201 }	Medical Text: Admission Date: [2151-1-13] Discharge Date: [2151-1-18] Date of Birth: [2128-10-8] Sex: M Service: MEDICINE Allergies: Penicillins / Hydralazine / Acetylcysteine Sodium Attending:[First Name3 (LF) 1377] Chief Complaint: transfer from OSH for tylenol OD Major Surgical or Invasive Procedure: None History of Present Illness: 22 yo M with no significant PMH who presented to OSH with abdominal pain, nausea on [1-13]. Pt states that he normally drinks 60-70 beers per week on average and about 1 week ago started taking tylenol for a severe headache. Took about 60-70 500 mg tylenol tabs over 3-5 days (last one [1-9]). Reports last drink being on Saturday. He started having abdominal cramps the following day and went to his grandmother's house and was given 1 tab tylenol and 0.5 mg ativan for pain. Pt started experiencing nausea and vomiting and went to [Hospital3 ] ED. He was noted to ahve ALT [Numeric Identifier 44157], AST [Numeric Identifier 69935], TBili 4.6, tylenol level < 2.0, Cr 3.1, INR 3.1. He was given [Numeric Identifier ] mg po mucomyst (140mg/kg), 1 L NS, zofran and transferred to [Hospital1 18]. Enroute to [Hospital1 18], pt vomited mucomyst. . In [Hospital1 18] ED, T 99.1, BP 157/61, HR 105, RR 18, O2 sat 97%. He was given NAC 140 mg/kg IV load X 1, anzemet, compazine, and reglan, 2 L NS, and transferred to MICU. Past Medical History: EtOH abuse Social History: Patient smokes [2-2] ppd for 3 years. Drinsk 60-70 beers per week on average for the past six months. Longest time without drinking in the past 2 months was for 2 weeks and he did not experience any withdrawl shakes, seizures or DTs Denies any illicit drug use. He is currently unemployed and lives in [Location ] with plans to move back with grandparents. he was incarcerated for 1 year (released six months ago) after MVA. Family History: Both grandfathers with HTN Physical Exam: Tc 98.3 Tm 98.3 BP 163/110 (153-182/85-110) HR 99 (99-122) RR 19 (19-28) O2sat 97% on RA . General: NAD, AAO X 3, pleasant HEENT: NC/AT, PERRL, no scleral icterus noted, sub-conjunctival hemorrhages noted in R eye, MMM, no lesions noted in OP, no tongue fasiculations Neck: supple Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT, ND, no hsm appreciated Extremities: No C/C/E bilaterally, No asterexis. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. Pertinent Results: [2151-1-13] 05:45PM WBC-3.4* RBC-4.91 HGB-16.4 HCT-44.2 MCV-90 MCH-33.3* MCHC-37.0* RDW-12.8 [2151-1-13] 05:45PM NEUTS-75.5* LYMPHS-12.9* MONOS-11.1* EOS-0.1 BASOS-0.4 [2151-1-13] 05:45PM PLT COUNT-160 [2151-1-13] 05:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.5 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2151-1-13] 05:45PM ALBUMIN-4.3 CALCIUM-8.9 PHOSPHATE-5.5* MAGNESIUM-1.6 [2151-1-13] 05:45PM LIPASE-57 [2151-1-13] 05:45PM ALT(SGPT)-[Numeric Identifier ]* AST(SGOT)-9780* CK(CPK)-193* ALK PHOS-140* AMYLASE-68 TOT BILI-3.5* [2151-1-13] 05:45PM GLUCOSE-101 UREA N-34* CREAT-4.2* SODIUM-137 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-21* ANION GAP-22* [2151-1-13] 06:15PM PT-30.3* PTT-37.3* INR(PT)-3.2* [2151-1-13] 09:24PM TYPE-ART PO2-98 PCO2-31* PH-7.35 TOTAL CO2-18* BASE XS--7 [2151-1-13] 10:00PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.018 [2151-1-13] 10:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR [2151-1-13] 10:00PM URINE RBC-[12-21]* WBC-[12-21]* BACTERIA-NONE YEAST-NONE EPI-[7-11] TRANS EPI-[7-11] [2151-1-13] 10:00PM URINE GRANULAR-[7-11]* [2151-1-13] 11:23PM PT-28.6* PTT-34.8 INR(PT)-3.0* [2151-1-13] 11:23PM HCV Ab-NEGATIVE [2151-1-13] 11:23PM HIV Ab-NEGATIVE [2151-1-13] 11:23PM AFP-3.8 [2151-1-13] 11:23PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM HAV-NEGATIVE [2151-1-13] 11:23PM ALT(SGPT)-9670* AST(SGOT)-6283* LD(LDH)-2940* ALK PHOS-120* TOT BILI-2.6* [2151-1-13] 11:23PM GLUCOSE-112* UREA N-38* CREAT-4.8* SODIUM-139 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-18* ANION GAP-25* . Abdominal US c doppler [1-14] - Slightly limited study demonstrates normal vascular flow to both kidneys. Normal portal venous waveforms to the liver. . CXR [1-14] - The heart size is normal. Mediastinal contours are unremarkable. The lungs are clear except for the lateral right chest which was not included in the field of view. No sizeable pleural effusion is identified. . CT head - [1-13] - No acute intracranial hemorrhage. No mass effect. . RUQ ultrasound [1-13] - 1. Diffusely echogenic liver, probably representing fatty liver, however, other forms of diffuse liver disease cannot be totally excluded. 2. Periportal nodes. Brief Hospital Course: In the MICU, IV NAC was continued at 17.5 mg/kg/hr with LFTS trending down (ALT [Numeric Identifier ] -> 4095, AST 9780 ->1144, Tbili 3.5 ->2.0, INR 3.0-> 2.0). The pt's Cr was noted to increase from 4.2 to 7.6 over a period of 48 hrs. Renal was consulted and it was felt that the pt's ARF was likely [3-5] tylenol toxicity vs. pre-renal causes [3-5] pt's emesis, poor po intake at home. FeNa 3.2%. During MICU course, the pt was also maintained on CIWA scale for withdrawal and became intermittently agitated along with elevated BPs, for which he was given IV hydralazine. Upon transfer to the floor, the pt was continued on IV NAC, ativan po per CIWA, and frequent labs were checked to monitor LFTs, INR, lytes, BUN/Cr. Cr was noted to peak at 9.7 on [1-16]. In spite of rising Cr, it was thought that the pt did not need meet criteria for urgent HD. Furthermore, the pt continued to put out good amounts of urine during the hospital course. During this time, the pt was also started on metoprolol for BP control as was thought that his elevated BPs were no longer [3-5] EtOH withdrawal as he was more than 1 week out from his last drink. It was also thought that volume overload was contributing to his elevated BPs. . On [1-16], the pt began to complain of throat pain and it was noted that his uvula looked swollen. Was given dose of 125 mg IV methylprednisilone, benadryl, and famotidine with improvement in sxs. However, within 2-3 hrs, the sxs returned and uvula appeared swollen again. Was transferred back to MICU for overnight observation and was continued on IV methylpred, famotidine, and benadryl. It was thought that the pt had an allergic rxn to either IV NAC or IV hydralazine, which were d/c'd. At this point, the pt's liver function had recovered with AST in the 500s, ALT in the [2144], TBili 2.5, INR 1.3. The following day, the pt was deemed stable to be transferred back to the floor as he had no difficulty managing his airway, was no longer exhibiting uvular swelling, and was sating well on room air. During this time, the pt's kidney function began to improve with Cr peaking at 9.7 and dropped down to 7.3 by time of discharge. Was placed briefly on bicarb drip per renal's recommendations for large anion gap metabolic acidosis thought to be [3-5] renal failure. . On the morning of discharge, the pt expressed a desire to leave the hospital to attend the funeral of his great-aunt. In spite of multiple members of the medical team (primary team, liver team, renal team) who stressed the importance of staying in the hospital given his ARF and resolving liver failure, the pt signed out of the hospital against medical advice with the knowledge that the consequences included liver failure, renal failure, or even death. He will f/u with Dr. [Last Name (STitle) 3271] for his renal failure, Dr. [Last Name (STitle) 497] for his resolving liver failure, and with Dr. [Last Name (STitle) ] at [Company 191] to establish primary care. The pt was also given specific instructions to have his labs drawn in [3-6] days to f/u his LFTs, lytes, BUN/Cr. Medications on Admission: none Discharge Medications: 1. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 2. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:90 Tablet(s) Refills:2 3. Laboratory Check Sig: One (1) test once: Please check - CBC, electrolytes, BUN, Creatinine, AST, ALT, Tbil, Alk Phos. Have results forwarded to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Company 191] [Telephone/Fax (1) 250]. Disp:1 test Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute Liver Failure from Tylenol toxicity Acute Kidney Failure from Tylenol toxicity Hypertension Anaphylaxis Discharge Condition: stable, eating well, on room air, walking Discharge Instructions: Please take all medications and make all follow up appointments as listed in the discharge paperwork. You have resolving liver and kidney failure. Please rest and do not engage in sny strenuous activities until your blood tests have stabalized. [Name6 (MD) ] your MD or come to the emergency room if you have fevers, chills chest pain, confusion, fainting, swelling or pain in the abdomen, swelling or pain in the legs, yellowing of the skin, pain with urination, color change of your urine, nausea, vomitting, diarrhea, chest pain, shortness of breath, throat swelling, head ache or other concerning symptoms. DO NOT TAKE TYLENOL. Do not drink ANY alchohol at all. This could hurt your liver and kidneys. You are leaving against medical advice. We feel that it is detrimental to your health to leave at this time. This may lead to liver or kidney failure, even death. Followup Instructions: Have your labs checked at [Hospital Ward Name ] 6. [Telephone/Fax (1) 250] 2-3 days post leaving the hospital and call Dr. [Last Name (STitle) ] to review results. [Telephone/Fax (1) 250] Renal (Kidney doctor) Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7198], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2151-2-3] 1:00 [Hospital Ward Name 23] Building, [Location (un) ] [Location (un) 830], [Location (un) 86], MA Primary Care Doctor Provider: [First Name8 (NamePattern2) 2671] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2151-2-17] 2:30 [Hospital Ward Name 23] Building [Location (un) ] [Location (un) 830], [Location (un) 86], MA Liver Doctor Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2151-1-22] 2:00 [Last Name (un) 2577] Building, [Location (un) 858] [Last Name (NamePattern1) 439], [Location (un) 69936], MA [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] Completed by:[2151-1-18] ICD9 Codes: 5849, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2202 }	Medical Text: Admission Date: [2182-7-16] Discharge Date: [2182-7-25] Date of Birth: [2125-9-30] Sex: M Service: MEDICINE Allergies: Codeine / Gentamicin Attending:[First Name3 (LF) 689] Chief Complaint: atrial fibrillation Major Surgical or Invasive Procedure: Cardiac catheterization Colonoscopy History of Present Illness: 56M w/ multiple medical problems including CAD s/p multiple PCI, CHF with EF 45%, PAF, DM Type I, ESRD on HD s/p [First Name3 (LF) ] transplant x2 who presented to [Hospital1 18] on [2182-7-16] after several episodes of atrial fibrillation and hypotension during HD and is now transferred to medicine for GI bleed. . He was originally admitted to [Hospital3 3765] on [2182-7-13] with complaints of R knee pain after a fall to his right side. He was seen by Rheumatology and there was a concern for possible gout or pseudogout. During that admission, he underwent HD per his normal schedule and during HD on [7-15] he went into a fib with a ventricular rate of 130-140. He had severe chest pain across his entire chest w/ radiation to his shoulders, jaw, and back. He also noted SOB and a need to move his bowels during this episode. He was given IV amiodarone during this episode but remained in a fib for several hours before spontaneously converting to sinus rhythm. He was hypotensive to the 80's with elevated JVP and was given IVF and stress-dose steroids for possible adrenal insufficiency. An echocardiogram revealed EF 55% with possible inferior HK. His cardiac enzymes were checked and were normal. . On the day of transfer on [7-16], during HD he again had an episode of a fib associated with the same chest discomfort and hypotension. He received 200mg of amiodarone, 2.5mg iv lopressor x2, dilaudid, and ativan for this episode but remained in a fib up until the time of transfer to [Hospital1 18]. He was also briefly hypotensive to the 80s and started on neosynephrine in the ICU there. On transfer, the pt reported dull chest pain that was pleuritic. He denied other symptoms. . On admission to [Hospital1 18] CCU, the patient stated that he had been on 200mg of amiodarone since last [Month (only) 205] when his colostomy was reversed. He had mild chest pain during HD for the past few weeks but the episodes during his previous hospitalization had been much more severe. There were no recent changes in his dialysis treatment. He had a mild non-productive cough over the week prior to admission but denied fever, diarrhea, constipation, nausea, decreased PO intake, or HA. He has had chronic abdominal pain for the past year. His knee pain began about 2 weeks ago and had responded well to NSAIDs. He stopped his NSAIDs because he was told that they can cause GI bleeds if taken for too long. Past Medical History: 1. ESRD: status pancreas-kidney transplant [2164], status post cadaveric [Year (4 digits) ] transplantation in [2172], now requiring dialysis 3x/wk 2. CAD: s/p myocardial infarction in [2164], s/p LCX stenting in [2174], s/p LCX and OM3 stenting in [2175], s/p mid-LCX stenting on '[78], s/p OM3 restenting in '[78] 3. DM 4. Hypothyroidism 5. Hypercholesterolemia 6. Hep C (dx in '[75]), viral load 7. CVA in [2174] with residual left-sided weakness 8. PVD 9. Diverticulitis, status post colostomy and Hartmann's pouch in [2175], status post reversal in [6-3], last Colonscopy ([12-4]): Erythema, friability and granularity in the very distal portion of the colon, just inside the afferent limb of the stoma, with overlying clot. Brown stool with no bleeding proximal to this. 10. PVD s/p multiple digit amputations 11. GERD 12. Wheelchair bound after gentamicin related vertigo 13. PAF: diagnosed in [2175], continued on CCB and started on Amio at that time 14. Benign prostatic hypertrophy, status post transurethral resection of the prostate. 15. SBP [1-31] Social History: Patient lives with his wife. They have two children who live nearby. He previously worked as a plummer but is now retired. He has a 30pk year smoking hx but quit 10 years ago. He denies IVDU and alcohol use. Family History: [Name (NI) 1094] father died at age 56 of MI, with DM and a "big heart". Mother died age 84 of "old age" s/p CVA, with DM and HTN. Sister has Grave's dz and brother died of 56 with DM. Physical Exam: Vitals: T 97.5 BP 106/39 (92-135/27-65) HR 58 (58-73) 18 98% RA Gen: well-appearing man, laying flat in bed, NAD HEENT: PERRL, EOMI, mmm, OP clear Neck: supple, no JVD or LAD Lung: crackles at left base, otherwise CTA bilaterally Cor: RRR, nml S1S2, 2/6 systolic ejection murmur heard best at the LSB w/out radiation Abd: large midline scar, well-healed, hyperactive bowel sounds, mildly distended with mild TTP in bilateral flanks, + splenomegaly Ext: changes of chronic venous insufficiency, no edema, could feel distal pulses, right knee without effusion, mild medial joint line tenderness, no pain on passive movement, pain on active movement Pertinent Results: IMAGING: Cath ([2182-7-17]): The left anterior descending coronary artery has mild diffuse disease in the proximal, mid, and distal portions. The ramus is a branching vessel that has a 70-80% stenosis at the upper pole. The left circumflex artery is the dominant vessel and is patent in the proximal portion. There is 60% in-stent restenosis in the mid-circumflex artery and the distal circumflex has diffuse disease. OM1 and OM2 are small vessels. OM3 has a 100% occlusion that is likely chronic. The right coronary artery is non-dominant and has a 70% proximal occlusion, the mid and distal vessel is without significant flow limiting disease. Left heart catheterization revealed normal diastolic filling pressures. . Echo ([2182-7-17]): Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Elevated LVEDP. Pulmonary artery systolic hypertension. Mild mitral regurgitation. . Femoral Vascular US ([2182-7-18]): No evidence of arteriovenous fistula or pseudoaneurysm. . KUB ([2182-7-19]): Limited study. Mild ascites.No acute pathology is demonstrated. . Abd CT ([2182-7-20]): Liver heterogenous attenuation throughout with two discrete foci of increased attenuation. One anteriorly in segment 8, the other more posteriorly in segment 6 and laterally. Splenomegaly and the spleen measures nearly 16 cm in craniocaudad direction. In addition, peripherally there is a wedge-shaped area of hypoattenuation. This likely reflects the vascular phase of enhancement, but would also be consistent with a splenic infarct. Both native kidneys are markedly shrunken and atrophic. There is evidence of marked osteopenia. In addition, multilevel fractures are identified, including the pelvic bones, left iliac bone and left femur. Brief Hospital Course: 1. Atrial fibrillation: The patient was transferred to the CCU from the OSH with a recent history of atrial fibrillation and hypotension complicating his hemodialysis treatments. This was considered potentially related to his coronary artery disease and ischemia. On hospital day 2, he underwent cardiac catheterization, which revealed disease in LCx and OM3. The plan was for medical management, without intervention. The pt was then evaluated by EP for possible ablation. EP recommended increasing amiodarone and not doing ablation at this time. His amiodarone and beta blocker doses were titrated and he remained in normal sinus rhythm throughout the remainder of his hospitalization, with the exception of one episode of atrial fibrillation during dialysis. . 2. CAD: As noted previously, the patient underwent cardiac catheterization on transfer from the OSH. The left main was calcified and widely patent. The left anterior descending coronary artery had mild diffuse disease in the proximal, mid, and distal portions. The ramus had 70-80% stenosis at the upper pole and the left circumflex artery was patent in the proximal portion with a 60% in-stent restenosis in the mid-circumflex and diffuse disease in the distal circumflex. OM3 had a 100% occlusion that is likely chronic. The right coronary artery is non-dominant and had a 70% proximal occlusion. The decision was made for medical management and the patient was continued on aspirin, statin and beta blocker with nitro prn for chest pain. He remained chest pain free throughout his admission. . 3. GIB: During his CCU stay, he had several episodes of maroon-colored stools with BRBPR, which were guaiac positive. His Hct was stable and he remained hemodynamically stable. His heparin and coumadin were discontinued and GI was consulted. Given his multiple comorbidities and need for long-term anticoagulation as an outpatient, it was decided to perform a colonscopy while the patient was in-house and his anticoagulation held. The patient was transferred to the medicine [Hospital1 ] service for this procedure. Colonoscopy was performed on [2182-7-25] and revealed esophageal varices and portal hypertensive gastropathy. For this reason, Coumadin will not be restarted as an outpatient. . 4. Abdominal pain: During his stay in the CCU, the patient also developed severe diffuse abdominal pain and distension on [2182-7-20]. A KUB showed a possible small bowel obstruction. The patient was evaluated with an Abdominal CT which showed possible hypoattenuation in the liver and a possible splenic infarct, without evidence of obstruction, though it was an inadequate study because the pt refused to finish the contrast. The patient's abdominal pain subsequently improved. An MRI was performed to further evaluate the areas of hypoattenuation and revealed peripheral wedge shaped areas of arterial hyperenhancement within the liver consistent with perfusion abnormalities without a focal hepatic mass identified. Continued follow up is recommended because of the patient's known history of liver disease. It also revealed a cirrhotic liver with evidence of portal hypertension and splenomegaly, with an area of T1 hypointensity in the spleen which most likely represents an area of splenic hypoperfusion in combination with focal iron deposition . 5. ESRD: The patient was followed by [Date Range 2793] throughout his stay and had scheduled hemodialysis. . 6. Knee pain: During his hospitalization at the OSH and here, the patient has had persistent right knee pain which improved with NSAIDs and steroids at the OSH. His physical exam was significant for pain on active movement and not passive movement, with medial joint tenderness. This suggests a possible MCL injury vs. tendonitis vs. anserine bursitis. RICE was recommended and the patient received Percocet for pain. NSAIDs were held in the setting of his GI bleed. . 7. Hypothyroidism: His TSH was within normal limits on admission and his synthroid was continued. . 8. Hepatitis C: Patient has a known history of hepatitis C. Colonoscopy revealed portal hypertensive gastropathy and varices. Coumadin will not be continued due to varices. His Toprol XL was continued rather than switching to nadolol. He will be seen by a gastroenteritis as an outpatient. Medications on Admission: Meds: (At OSH) 1. Amitriptyline 10mg qhs 2. Liptitor 10mg qd 3. Phosphorus 167mg tid 4. Lantus 14u qhs 5. Imdur 30mg qd 6. Synthroid 0.2mg qd 7. Protonix 40mg qd 8. Prednisone 30mg qd 9. Renagel 800mg tid 10. Bactrim DS 1tab q Mon/Wed/Fri 11. Amiodarone 200mg qd 12. ASA 160mg qd 13. Toprol 25mg qd Discharge Medications: 1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MON/WED/FRI (). Disp:12 Tablet(s) Refills:2 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily). Disp:15 Tablet Sustained Release 24HR(s) Refills:2 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 9. Pantoprazole Sodium 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 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:2700 ML(s) Refills:2 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for CHEST PAIN. Disp:20 Tablet, Sublingual(s) Refills:0 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed: Do not exceed more than six tablets in one day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home with Service Discharge Diagnosis: Primary diagnoses: 1. Atrial fibrillation 2. Coronary artery disease 3. GI bleed, likely secondary to esophageal varices Secondary Diagnoses: 1. End-stage [Date Range 2793] disease on Hemodialysis 2. Knee pain 3. Diabetes Mellitus 4. Portal Hypertensive gastropathy 5. Esophageal ulcer 6. Peripheral vascular disease 7. Hypothyroidism 8. Hypercholesterolemia Discharge Condition: Good, stable hematocrit Discharge Instructions: You are discharged to home and should continue all medications as prescribed. Please contact your physician or present to the ER if you experience chest pain, palpitations, lightheadedness, fevers, chills, maroon-colored stools, blood from your rectum or other concerns. Please keep all follow-up appointments. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500cc Followup Instructions: You have a follow-up appointment with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 2204] on [2182-8-28] at 3:20pm. You should call his office to see if you can schedule something sooner. Office number [Telephone/Fax (1) 2936] Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2182-8-13] 10:30 Please call Gastroenterologist Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679] [Telephone/Fax (1) 682] to schedule an outpatient appointment in one month after discharge. ICD9 Codes: 4280, 5715, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2203 }	Medical Text: Admission Date: [2144-5-12] Discharge Date: [2144-5-17] Date of Birth: [2093-11-21] Sex: F Service: MEDICINE Allergies: Codeine / onions Attending:[First Name3 (LF) 2297] Chief Complaint: hypotension, fever Major Surgical or Invasive Procedure: Nephrostomy tube exchange History of Present Illness: Ms. [Known lastname 70847] is a 50 year old woman with h/o rectal ca s/p radiation, chemotherapy, and surgery, radiation-induced damage s/p ileostomy, HIV on HAART (last CD4 263 in [1-26]), obstructive renal failure from radiation fibrosis with b/l nephrostomy tubes and h/o recurrent obstructions, DVTs on Coumadin, sacral decubitus ulcer with coccygeal osteomyelitis, who was sent to the ED with Na 115, K 6.3, Cr 4.8 on recent outpatient labs, now admitted to the ICU with hypotension. The patient endorses feeling some fatigue, malaise, abdominal cramping. She has had increased vaginal discharge for the past couple week. Occasional nausea and vomiting, nonbloody/nonbilious. She notes increased watery ostomy output for 1-2 weeks and decreased urine output from her b/l nephrostomy tubes for 1-2 days. She had decreased PO intake over the past day. She does receive IV Mg and 1LNS every other night at home. One fever to 100.8 several days prior to admission, but no recurrence. Of note, she was started on Ciprofloxacin 5 days prior for a UTI by her PCP. [Name10 (NameIs) ] has also been closely monitored for hyperK and ARF for the past 2 weeks as an outpatient, which was being treated with Lasix and IVF at home. In the ED, initial VS were: T 96.9 BP 85/51 HR 98 RR 16 O2sat 100%. She was triggered on arrival for hypotension and was given 2.5L NS, then started on Levophed for persistent hypotension. Exam notable for b/l nephrostomy tubes and sacral decub ulcer to the bone. Labs notable for WBC 25.5, Na 118, K 5.6, HCO3 16, anion gap 19, BUN 61, Cr 5.2, INR 4.2. EKG without peaked T waves per [Last Name (LF) ], [First Name3 (LF) ] they gave Kayexalate, but no Calcium or Insulin. Cultures sent for [First Name3 (LF) ], urine, and stool/Cdiff. CXR unremarkable. CT abd/pelvis with gas/fluid level in the bladder concerning for pyocystitis, ?SBO, and persistent coccygeal osteomyelitis. The patient was given Vanc/Zosyn per signout, but there is no documentation in the chart, and RN-RN signout confirms that no Abx were given in the ED. On arrival to the MICU, patient's VS 98.2 106/72 91 20 99%RA. She is currently feeling ok with no focal complaints. [First Name3 (LF) 159] has been by to place a 14FR Foley catheter without complication. Review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, dark or bloody stools. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: ONCOLOGIC HISTORY: 1) Rectal cancer: - late [2139]: 6 months of intermittent rectal bleeding, rectal pressure and a sensation of incomplete emptying. - [2141-1-26]: colonoscopy revealed a polyp in her sigmoid colon and a 2.5 cm distal rectal mass arising from the anal verge in the posterior rectum with a large area of induration. - [2141-1-31]: CT torso revealed an exophytic rectal mass measuring 4.8 x 3.8 cm, bulging posteriorly into the presacral space and anteriorly towards the uterus. There were enlarged lymph nodes in the perirectal fat adjacent to the mass, a 9-mm enhancing lymph node in the left pelvic sidewall, and enhancing lymph nodes in the right external iliac region. There was also a 7-mm hypodensity in the caudate lobe of the liver. Rectal ultrasound on [2141-1-31] and rectal MRI on [2141-2-7] were compatible with T3 disease. There were at least four abnormal perirectal lymph nodes seen on MRI, in addition to multiple bilateral enlarged pelvic sidewall lymph nodes, concerning for extensive disease. - [2141-2-20]: began chemoradiation - [2141-3-10]: 5-FU was discontinued due to mucositis, neutropenia, and abdominal cramping - [2141-3-13]: 5-FU was restarted at a reduced dose - [2141-3-22]: 5-FU was again stopped due to mucositis, perirectal skin changes, diarrhea, and electrolyte abnormalities. - [Date range (3) 70844]: Radiation was also held - [2141-3-27]: 5-FU was restarted at a further reduced dose - [2141-3-31]: completed radiation - [2141-4-3]: completed chemotherapy - [Date range (3) 70845]: hospitalized for bowel rest and the initiation of TPN due to presumed radiation enteritis. - [2141-5-31]: found to be HIV positive and began on HAART - [Date range (1) 70846]: required hospitalization for an SBO, underwent laparotomy, ileocecectomy, end-ileostomy, and placement of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] tube on [2141-6-16]. Pathology from this surgery revealed severe radiation-induced acute ischemic enteritis. She recovered from this surgery, but continued to require TPN. - [7-/2141]: Once her CD4 count had recovered, she underwent laparotomy, lysis of adhesions, ileal resection, proctosigmoidectomy, colonic jejunal pouch to near-anal anastomosis with EEA, takedown splenic flexure, resection of ileostomy and creation of new end-ileostomy. Pathology from the surgical specimen revealed no residual carcinoma and all 14 lymph nodes sampled were free of disease. - [9-/2141], [10/2141]: Subsequent imaging of the abdomen & pelvis showed no evidence of recurrence. - [2142-2-14]: CT abdomen showed "hyperdense thickening in the lumen near the anastomatic site, new since the earlier study. Local recurrence cannot be excluded, although possibly the appearance is associated with endoluminal debris." . OTHER MEDICAL HISTORY: 2) HIV CD4 count 124 on [12/2143] 3) Short gut syndrome secondary to bowel surgery for CA. 4) Obstructive renal failure from radiation fibrosis, in the past necessitating b/l nephrostomy tubes which have required multiple revisions. 5) Lower extremity neuropathy, likely secondary to radiation fibrosis, uses a wheelchair since 4/[2141]. 6) Pancreatic insufficiency. 7) Anemia. 8) Chronic pain. 9) DVT in LE X2: requires lifelong coumadin, most recent [4-24]. Social History: Lives in [Location 17566] with her husband and several children. No tobacco or EtOH use. Used to be account manager, now on long-term disability. Has [First Name9 (NamePattern2) 269] [Location (un) 5871], with skilled nursing 1h X 3/week + aid 1h X2/week. She is wheelchair bound. Family History: Father died at age 72 from MI. Mother is alive and well. Remote family history of breast cancer. Daughter with ulcerative colitis. Physical Exam: ADMISSION EXAM Vitals: 98.2 106/72 91 20 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic, S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-distended, bowel sounds present, ileostomy draining pale brown liquid stool in the RLQ GU: foley in place; prior to placement, dark green/brown discharge seen on vaginal pad Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper extremities, unable to move LE. . DISCHARGE EXAM 97.5 HR 70s-90s BP 112/68 RR 14 97% on room air General: Alert, oriented, no acute distress Neck: supple, JVP not elevated CV: RRR, S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally anteriortally Abdomen: soft, non-distended, bowel sounds present, ileostomy draining pale brown liquid stool in the RLQ GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS [2144-5-12] 06:20PM [Month/Day/Year 3143] WBC-25.5# RBC-3.89 Hgb-10.8# Hct-33.2 MCV-85 MCH-27.7 MCHC-32.4# RDW-17.6* Plt Ct-562# [2144-5-12] 06:20PM [Month/Day/Year 3143] Neuts-89.5 Lymphs-7.7* Monos-2.3 Eos-0.2 Baso-0.3 [2144-5-12] 06:20PM [Month/Day/Year 3143] PT-43.1* PTT-53.9* INR(PT)-4.2* [2144-5-12] 06:20PM [Month/Day/Year 3143] Glucose-136* UreaN-61* Creat-5.2# Na-118 K-5.6* Cl-83* HCO3-16* AnGap-25* [2144-5-12] 06:20PM [Month/Day/Year 3143] ALT-15 AST-13 AlkPhos-159* TotBili-0.1 [2144-5-12] 06:20PM [Month/Day/Year 3143] Albumin-3.8 Calcium-8.6 Phos-8.1# Mg-2.5 . RELEVANT LABS: [2144-5-16] 02:55PM [Month/Day/Year 3143] Cortsol-26.2 [2144-5-16] 03:38PM [Month/Day/Year 3143] Cortsol-31.5* [2144-5-16] 07:05PM [Month/Day/Year 3143] Vanco-33.0* . DISCHARGE LABS [2144-5-17] 05:18AM [Month/Day/Year 3143] WBC-7.8 RBC-2.58* Hgb-7.5* Hct-23.1* MCV-90 MCH-29.0 MCHC-32.4 RDW-17.1* Plt Ct-322 [2144-5-17] 05:18AM [Month/Day/Year 3143] Glucose-80 UreaN-17 Creat-1.0 Na-135 K-5.0 Cl-108 HCO3-19* AnGap-13 [2144-5-17] 05:18AM [Month/Day/Year 3143] Calcium-7.4* Phos-3.2 Mg-1.6 . URINE [2144-5-12] 10:10PM URINE [Month/Day/Year ]-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [2144-5-12] 10:10PM URINE RBC-85* WBC->182* Bacteri-MANY Yeast-MANY Epi-0 TransE-<1 [2144-5-12] 10:10PM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.013 [2144-5-13] 10:22AM URINE Color-Straw Appear-Cloudy Sp [Last Name (un) ]-1.010 [2144-5-13] 10:22AM URINE [Month/Day/Year ]-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [2144-5-13] 10:22AM URINE RBC-16* WBC-77* Bacteri-FEW Yeast-NONE Epi-0 [2144-5-13] 03:21AM URINE Hours-RANDOM UreaN-213 Creat-68 Na-37 K-41 Cl-47 [2144-5-13] 03:21AM URINE Osmolal-265 . MICROBIOLOGY [2144-5-13] URINE CULTURE-FINAL {YEAST} [2144-5-13] URINE CULTURE-FINAL {YEAST} [2144-5-13] 4:05 am SWAB PUS FROM FOLEY CATHETER. GRAM STAIN (Final [2144-5-13]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Preliminary): 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. GRAM POSITIVE BACTERIA. MODERATE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. [2144-5-13] STOOL C. difficile -Negative [2144-5-12] SWAB NEISSERIA GONORRHOEAE (GC) Negative; Chlamydia trachomatis- Negative [2144-5-12] GRAM STAIN-FINAL; WOUND CULTURE-PRELIMINARY {STAPH AUREUS COAG +} [2144-5-12] URINE CULTURE-PRELIMINARY {YEAST, STAPHYLOCOCCUS, COAGULASE NEGATIVE} [2144-5-12] [Numeric Identifier ] Culture, Routine-PENDING [2144-5-12] [Numeric Identifier ] Culture, Routine-PENDING . STUDIES EKG- [2144-5-12] Sinus rhythm. Low precordial voltage. Since the previous tracing of [2144-2-16] the rate is now slower. Otherwise, unchanged. . CXR [2144-5-12] IMPRESSION: Bibasilar subsegmental atelectasis. . CT abdomen pelvis [2144-5-12] 1. Interval development of air-fluid level within the bladder which is concerning for infection in the absence of recent instrumentation, particularly gas-forming organisms. 2. Gas identified within the renal collecting systems bilaterally, possibly introduced from the patient's nephrostomy tubes, though an infectious process/emphysematous pyelitis is not excluded. 3. Extensive radiation changes within the pelvis including findings compatible with radiation cystitis and enteritis. 4. Diffuse dilation of the small bowel, without a definite transition point, which is chronic, and essentially unchanged from [2144-2-16]. 5. 4 mm mid left ureteral stone, unchanged. Bilateral nephrostomy tubes in place without hydronephroureter. 6. Collapsed gallbladder, containing a small punctate gallstone. 7. Similar appearance of sacral decubitus ulcer, with erosive changes at the coccyx concerning for osteomyelitis. 8. Hepatic steatosis. . [5-14] Nephrostomy Exchange: CONCLUSION: Uncomplicated bilateral 12 French nephrostomy catheter exchange over a guidewire. Brief Hospital Course: Ms. [Known lastname 70847] is a 50 year old woman with h/o rectal ca s/p radiation, chemotherapy, and surgery, radiation-induced damage s/p ileostomy, HIV on HAART (last CD4 263 in [1-26]), obstructive renal failure from radiation fibrosis with b/l nephrostomy tubes and h/o recurrent obstructions, DVTs on Coumadin, sacral decubitus ulcer with coccygeal osteomyelitis, who was admitted to the ICU with hypotension. #. Septic shock: Patient was hypotensive on admission with e/o end-organ damage (renal failure), likely from infectious etiology given leukocytosis and several possible sources. Urinary tract was felt to be the most likely at this time -- dirty UAs from b/l nephrostomy tubes, as well as gas/fluid level in the bladder concerning for pyocystitis. CXR was without evidence of pneumonia. Foley placed by [Date Range ] drained scant purulent material culture from which grew S.aureus. Cultures of bilateral nephrostomy tube output grew only yeast. There was initial concern for C diff given increased ostomy output however PCR was negative. [Date Range ] cultures were pending at the time of discharge. She was started on broad spectrum antibiotics with linezolid (given history of [Date Range ]) and zosyn. She initially required pressor support with norepinephrine to maintain MAP > 65. Given concern for urinary tract infection she underwent exchange of bilateral nephrostomy tubes under general anesthetic. She tolerated the procedure well. [Date Range ] pressures improved with volume rescucitation and she was weaned from pressors. ID was consulted regarding antibiotic course and recommended two weeks of cetriaxone and vancomycin. [Date Range 159] recommended 5 day treatment with fluconazole. #. [Last Name (un) ]: Patients creatine on admission was elevated at 5.2 from a baseline of 1.0-1.5. This was felt to likely be prerenal etiology, as patient is infected and has had increased watery stool output from ileostomy. Fe Urea was consistent with a pre-renal etiology. Even on day before discharge, pt's urine sodium was <10, indicating a dry state. Less likely obstructive, as b/l nephrostomy tubes in place and draining, and no e/o hydronephrosis on CT abd/pelvis. The patient was given NS boluses with improvement in her Cr to 1.5 at discharge. As above her nephrostomy were also replaced by IR. Pt's creatinine was 1.0 at time of discharge after treatment of urosepsis and aggressive volume rescucitation #. N/V: Patient with N/V in the ED, which was felt to likely be [1-16] to infection vs renal failure, in addition to dehydration. CT was without evidence of SBO. She was managed symptomatically with zofran. Nausea resolved with hydration and the patient was able to tolerate a regular diet prior to discharge. # Acute on chronic anemia- On admission the patient's HCT was at baseline of 23. This fell to 20.7 in the setting of some [Month/Day (2) ] loss in her foley.She was transfused 1 unit of PRBCs. Bleeding resolved and HCT remained stable. #. Hyperkalemia: Patient was noted to have a potassium of 5.6 on admission which was attributed her her renal failure. Initial EKG was notable for slight prominence of Twaves on EKG. She was given insulin and D50 with improvement in her hyperkalemia as her renal function recovered. #. Hyponatremia: Patient was noted to have a sodium of 118 on admission. Her mental status was intact. The etiology of her hyponatremia was felt to be hypovolemic hyponatremia due to both nausea, vomiting and diarrhea. She was given normal saline boluses with improvement in her sodium to the 130s. On HD 4 pt continued to be hyponatremic with hypokalemia so a cosyntropin stimulation test was done which was negative. Urine Na was still low at that time with FeNa of 0.17%, so she was bolused with an additional three liters of NaCl. #. Metabolic acidosis: Patient was noted to have an anion gap acidosis on admission (AG of 19). This was felt to most likely be due to renal failure. Acidosis normalized with administration of IVF. . #. b/l DVTs: Patient's INR was supratherapeutic on admission. Therefore her home coumadin was held. Her INR trended downward to 1.1 as she was given 5 mg vitamin K and FFP for her nephrostomy tube exchange and coumadin was restarted at 4 mg prior to discharge. In the interim between last documented DVT in [2142-3-15], pt had subsequent LE dopplers which were negative for DVT as well as an MRI pelvis, which showed no DVT. Due to patient's hct drop requiring 1 unit PRBC, recent nephrostomy exchange, and no current clinical evidence of DVT, it was thought most prudent to not bridge the patient. INR monitoring and coumadin dose adjustment will be transitioned to the patient's PCP. STABLE ISSUES #. HIV: Patient was continued on her home HAART regimen. #. Peripheral neuropathy/Chronic pain: The patient was continued on her home lyrica. Pain was controlled initially with IV dilaudid. Once nausea was improved she was transitioned to her home PO dilaudid. Nortriptyline was initially held given concern for interaction with linezolid. This medication was restarted at discharge. Her home methadone and fentanyl were also held on admission and restarted at the time of discharge. #. Rectal ca: No e/o disease per heme/onc progress note in [1-25], but has not been seen in follow-up since that time. . TRANSITIONAL ISSUES -Patient was DNR/DNI throughout this hospitalization - INR monitoring and coumadin dose adjustment was transitioned to the patient's PCP. [Name Initial (NameIs) ] [Name11 (NameIs) ] cultures pending, urine cx pending - Patient will follow up with PCP, [Name10 (NameIs) ] and IR Medications on Admission: Abacavir-Lamivudine 600-300mg 1tab PO daily Darunavir 800mg PO daily Norvir 100mg PO daily Albuterol 1neb q4-6h prn Ciprofloxacin 250mg PO BID (start [2144-5-5]) Vitamin D 50,000units PO daily Fentanyl lozenges 200mcg PO q6h prn Folic acid 1mg PO daily Furosemide 20mg IV prn Dilaudid 32mg PO q2h prn IVF - NS prn Lansoprazole 30mg PO daily Lidocaine-Diphenhydramine-Maalox 10-15mL q4-6h prn Magnesium sulfate 2g IV 3x/week Methadone 15mg PO q6h Mirtazapine 15mg PO qhs Nortriptyline 50mg PO daily Zofran 4-8mg PO q6h / 4mg IV q6h prn Phenytoin 100mg applied to open wound daily Lyrica 50mg PO TID Ranitidine 300mg PO qhs Triamcinolone 0.1% paste TD TID prn Warfarin as directed Ascorbic acid 500mg PO daily Vitamin B12 1000mcg PO daily Ferrous sulfate 325mg PO daily Loperamide 4mg PO prn Miconazole 2% ointment [Hospital1 ] prn Discharge Medications: 1. ceftriaxone 2 gram Recon Soln [Hospital1 ]: Two (2) grams Injection Q24H (every 24 hours) for 12 days. [Hospital1 ]:24 grams Refills:0 2. vancomycin 1,000 mg Recon Soln [Hospital1 ]: One (1) gram Intravenous every twenty-four(24) hours for 12 days. [Hospital1 ]:12 gram Refills:0 3. IV fluids 1 liter normal saline IV every other day run at 125cc/hr [Hospital1 ]: 1 month supply 4. magnesium sulfate magnesium sulfate 16mEq (2g)/500cc NS Infuse over 4hrs 3 times per week 5. darunavir 400 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 6. ritonavir 100 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) nebulizer Inhalation every 4-6 hours as needed for SOB/wheezing. 8. folic acid 1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. hydromorphone 4 mg Tablet [Hospital1 ]: Eight (8) Tablet PO Q2HR () as needed for pain. 11. fentanyl citrate 200 mcg Lozenge on a Handle [Hospital1 ]: One (1) lozenge Buccal every six (6) hours as needed for pain. 12. Vitamin D2 50,000 unit Capsule [Hospital1 ]: One (1) Capsule PO once a day. 13. heparin lock flush (porcine) 100 unit/mL Syringe [Hospital1 ]: Ten (10) ML Intravenous PRN (as needed) as needed for DE-ACCESSING port. 14. heparin, porcine (PF) 10 unit/mL Syringe [Hospital1 ]: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 15. abacavir-lamivudine 600-300 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 16. methadone 10 mg Tablet [Hospital1 ]: Two (2) Tablet PO every eight (8) hours. 17. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution [Hospital1 ]: Forty (40) mg Intravenous prn as needed for as directed by PCP. 18. pregabalin 25 mg Capsule [Hospital1 ]: Two (2) Capsule PO TID (3 times a day). 19. ferrous sulfate 300 mg (60 mg iron) Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 20. cyanocobalamin (vitamin B-12) 500 mcg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 21. ascorbic acid 500 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 22. loperamide 2 mg Capsule [Hospital1 ]: Two (2) Capsule PO QID (4 times a day) as needed for diarrrhea. [Hospital1 ]:240 Capsule(s) Refills:0 23. nortriptyline 25 mg Capsule [Hospital1 ]: Two (2) Capsule PO DAILY (Daily). 24. warfarin 2 mg Tablet [Hospital1 ]: Two (2) Tablet PO Once Daily at 4 PM. 25. fluconazole 200 mg Tablet [Hospital1 ]: One (1) Tablet PO Q24H (every 24 hours) for 3 days. [Hospital1 ]:3 Tablet(s) Refills:0 26. phenytoin sodium Powder [Hospital1 ]: One Hundred (100) mg Miscellaneous once a day: apply to open wound daily. 27. Zofran 4 mg Tablet [Hospital1 ]: 1-2 Tablets PO 4-8mg as needed for nausea. Discharge Disposition: Home With Service Facility: [First Name5 (NamePattern1) 5871] [Last Name (NamePattern1) 269] Discharge Diagnosis: septic shock from pyocystitis hyponatremia hyperkalemia acute kidney injury 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 were admitted to [Hospital1 18] for a severe bladder infection resulting in low [Hospital1 ] pressures. We treated your infection with IV antibiotics and gave you intravenous fluids and IV medications to treat your low [Hospital1 ] pressure. During your hospital stay, we also changed out your nephrostomy tubes without complication. We now think that you are safe to go home. At home you will need to continue taking IV antibiotics for at total of 2 weeks. - start fluconazole for 3 days - start vancomycin 1g daily and ceftriaxone 2mg daily for 12 days - change you IV fluids to normal saline Followup Instructions: Please call your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 48223] at [Telephone/Fax (1) 3070] to schedule a follow up appointment within the next week Your percutaneous nephrostomy tubes will be replaced at your regularly scheduled appointment in 8 weeks time. At this time, Dr. [First Name (STitle) ], your urologist, plans on seeing you for a follow up. ICD9 Codes: 0389, 5849, 2762, 2761, 2767, 2768, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2204 }	Medical Text: Admission Date: [2200-9-16] Discharge Date: [2200-9-23] Date of Birth: [2127-7-19] Sex: F Service: ORTHOPAEDICS Allergies: Iodine Attending:[First Name3 (LF) 7303] Chief Complaint: left knee osteoarthritis Major Surgical or Invasive Procedure: left total knee replacement History of Present Illness: 73y/o with Dementia, parkinsons, Schizophrenia vs schizo-affective disorder, HTN CKD III, h/o DVT admitted [9-16] for elective left total knee replacement. Past Medical History: - Schizophrenia vs schizo-affective disorder - Hypertension - CKD III, baselien 1.5-1.7 - DVT - left leg (pre-[2194]) unclear associated factors - Right knee periprosthetic undisplaced medial condyle fracture of the femur ([11/2199]) - Dementia - major depressive disorder - osteroarthritis both knees - PVD - Parkinsons?--resting tremor - ?p Afib-daughter thinks - Diabetes Insipidus [12-23] lithium - LGIB, believed diverticular [5-29] in the setting of high INR - iliac aneurysm noted [5-29] Social History: Long-term resident of [Hospital1 ] Senior Care of [Location (un) 55]. Ambulates with walker and assistance, history of falls. Denies EtOH, tobacco, IV, illicit, or herbal drug use. Family History: unknown Physical Exam: PHYSICAL EXAM AT THE TIME OF DISCHARGE: At the time of discharge: AVSS NAD wound c/d/i without erythema [Last Name (un) 938]/FHL/TA/GS intact SILT distally LLE with 3+ edema Pertinent Results: Labs on admnission: [2200-9-16] 07:01PM BLOOD WBC-8.2 RBC-3.74* Hgb-11.0* Hct-34.0* MCV-91 MCH-29.4 MCHC-32.3 RDW-14.9 Plt Ct-156 [2200-9-17] 11:26AM BLOOD Neuts-83.3* Lymphs-6.4* Monos-9.6 Eos-0.5 Baso-0.2 [2200-9-16] 07:01PM BLOOD PT-12.1 PTT-25.0 INR(PT)-1.0 [2200-9-16] 07:01PM BLOOD Glucose-127* UreaN-32* Creat-2.1* Na-150* K-4.2 Cl-116* HCO3-27 AnGap-11 [2200-9-16] 07:01PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1 Imaging: CT head: No acute intracranial process. Note that if concern persists for acute infarct, MR [First Name (Titles) 151] [Last Name (Titles) 3631] imaging would be more sensitive. Brief Hospital Course: The patient was admitted on [2200-9-16] and, later that day, was taken to the operating room by Dr. [Last Name (STitle) 5322] for left total knee arthroplasty without complication. Please see operative report for details. Postoperatively patient underwent a delayed extubation in the PACU for a delayed wake up. The patient received IV antibiotics for 24 hours postoperatively. POD1 patient became somnelent and found to have hypercarbia on ABGs. She was immediately transferred to ICU. The rest of the hospital course is summarized below by systems. The drain was removed without incident on POD#1. TheThe surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. . 1. Acute hypercarbic respiratory failure: On POD#1, the patient was found at 4:30am, unresponsive to sternal rub. The patient was given Narcan at 5:05am and at 5:30 a.m. with dramatic improvement in mental status. Subsequently, ABG was 7.24/71/66. However, the patient's mental status again worsened, and she was again found to be unresponsive during ortho rounds, arousable to sternal rubs. ABG was 7.20/76/52. In the setting of hypercarbic respiratory failure, BiPAP was initiated and the patient was transfered to [Hospital Unit Name 153] for further care. The patient briefly required BiPAP but then her alertness and respiratory status improved. Prior to transfer out of the ICU, her ABG was 7.40/42/97. On the floor she continued to maintain her sats. . 2. Altered mental status: As the patient became more alert, she became increasingly agitated and paranoid. Psychiatry was consulted. Psychiatry obtained collateral information from the patient's daughter, who stated that the patient had been suffering from psychotic symptoms for decades. The patient takes Risperdal, Effexor, and Abilify at home, but was refusing all PO medications. Per psychiatry recommendations, her agitation and psychosis were treated with olanzepine IM. As the patient's psychosis improved, she stopped refusing PO, and she was restarted on her home medications. . 3. S/p left total knee replacement: The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. Her drain was removed POD2. Foley catheter was removed without incident. While in the hospital, the patient was seen daily by physical therapy. CPM was advanced daily. The patient's weight-bearing status was WBAT. The patient is to continue using the CPM machine advancing as tolerated to 0-100 degrees. . 4. Atrial fibrillation: The patient reportedly has a history of paroxysmal atrial fibrillation. The hematology service was consulted for recommendations with regard to anticoagulation and recommended a discussion of the risks and benefits in the outpatient setting. Pain was well controlled with a PO regimen. The patient's weight-bearing status was WBAT. The patient is to continue using the CPM machine advancing as tolerated to 0-100 degrees. The operative extremity was neurovascularly intact and the wound was benign. . 5. Acute on chronic renal failure: Post-operatively, the patient's creatinine rose from baseline 1.9, reaching 2.9 on [2200-9-19]. This was thought to be pre-renal. In the [Hospital Unit Name 153], the patient pulled out all of her IV's and remained too agitated to establish access, making it impossible to give the patient fluids. Creatinine returned to baseline in mid 2s prior to discharge. . 6. Hypertension: The patient's hypertension was poorly controlled in the setting of agitation and refusing PO meds. Her hypertension was managed IV hydralazine and metoprolol. As the patient's mental status improved, she restarted her home medications. 7. Heme: Patient received 1 unit pRBC for a hct of 26 POD2. Hct was thereafter stable in low 30s. 8. AC: The patient was initially anticoagulated with Lovenox and warfarin. This was changed to heparin gtt in the setting of renal dysfunction. The hematology service was consulted given the patient's history of DVT and GI bleed. Hematology recommended anticoagulation with Heparin IV gtt with bridge to Warfarin (goal INR 2-2.5) for 3 weeks postoperatively. If an only if her renal function returns to a GFR >15, Lovenox can be reinstituted for the 3 week duration with Anti-Factor Xa levels to be checked after the second dose for a goal of 0.6-1. Medications on Admission: metoprolol 25mg PO TID, lisinopril 15mg PO daily, Carbidopa-Levodopa 25-100 2 TAB PO hs, venlafaxine 75mg PO BID, pantoprazole 40mg PO q24h, oxybutynin 5mg daily, bisacodyl 10mg PO/PR daily prn, calcium carbonate 500mg PO TID, Vitamin D 400 U PO daily, multivitamin daily, senna 1 tab PO BID prn, docusate 100mg PO BID Warfarin, Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Risperidone 1 mg/mL Solution Sig: One (1) PO QAM (once a day (in the morning)). 7. Risperidone 1 mg/mL Solution Sig: 1.25 PO HS (at bedtime). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Aripiprazole 15 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for Constipation. 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 6 weeks: INR 2-2.5. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: left knee osteoarthritis Discharge Condition: stable Discharge Instructions: experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by Dr. [Last Name (STitle) 5322] 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 2 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your coumadin for 6 weeks to prevent deep vein thrombosis (blood clots). Your INR should be [12-24], and you will likley need 1mg coumadin daily depending on your INR level. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks. 12. ACTIVITY: Weight bearing as tolerated on the operative leg. No strenuous exercise or heavy lifting until follow up appointment. Continue to use your CPM machine as directed. Physical Therapy: LLE WBAT. CPM 0-100 as tolerated. Treatments Frequency: Wound checks, coumadin dialy (INR2-2.5), staples out by Dr. [Last Name (STitle) 5322]. Coumadin dosing when discharged to acute rehab to be completed by Dr. [First Name8 (NamePattern2) 622] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 719] Fax: [Telephone/Fax (1) 716] Followup Instructions: Provider: [First Name4 (NamePattern1) 6100] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2200-10-1] 12:45 [First Name4 (NamePattern1) 6100] [Last Name (NamePattern1) ] MD [MD Number(2) 7305] Completed by:[2200-9-22] ICD9 Codes: 5849, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2205 }	Medical Text: Admission Date: [2146-5-23] Discharge Date: [2146-6-1] Date of Birth: [2093-9-6] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4748] Chief Complaint: ischemic gangrenous right 3rd toe Major Surgical or Invasive Procedure: Right fem-PT [Name (NI) ] [Name (NI) 94000] and right 3rd toe amputation [2146-5-24] History of Present Illness: patient was refered to Dr. [Last Name (STitle) 1391] for nonhealing rt. toe ulceration evaluation and underwent a diagnostic angiogram on [2146-5-19]. Returns [2146-5-23] for perioperative antibiotics and rt. leg vascular revascularzation. No interval changes since d/c [2146-5-20]. Past Medical History: history of DM2, uncontrolled, insulin-dependant with hyperglycemia requiring IV insulin gtt. on admission [Date range (2) 94001]. history of ischemic heart disease, MI [2135], s/p PCI/stenting RCA [2139], s/p 4V CABG's w mitral annulus ring [2138], occluded graftx3 w/patient LIMA/LAD graft by cath [2-22] (Lima-LAD,SVG-dg,OM,RCA) history of chronic systolic and diastolic CHF, compensated history of progressive aortic valve stenosis by TEE [5-24] history of hyperlipdemia-statins history of chronic obstructive pulmonary disease-inhalers history of Bell's Palsey history of tobacco use 30pk-yrs d/c'd [2144] history of hypertension history of tonsillectomy Social History: habits smoking d/c since [2144] Denies ETOH Family History: positive for CAD father @ age 40 positive for MI mother @ age 64 w/b CHF Physical Exam: VSS NAD RRR, systolic murmur CTAB, no crackles Abd soft, NT/ND, +BS R leg with staples in place, c/d/i R 3rd toe amputation site with sutures in place, c/d/i DP/PT [Name (NI) ] bilaterally Pertinent Results: [2146-5-28] 03:55AM BLOOD WBC-6.2 RBC-3.51* Hgb-10.1* Hct-29.2* MCV-83 MCH-28.9 MCHC-34.8 RDW-13.9 Plt Ct-226 [2146-5-27] 08:22PM BLOOD Hct-30.3* [2146-5-27] 04:50AM BLOOD WBC-8.3 RBC-3.20* Hgb-9.4* Hct-26.7* MCV-83 MCH-29.2 MCHC-35.1* RDW-13.9 Plt Ct-225 [2146-5-26] 02:08PM BLOOD Hct-26.7* [2146-5-26] 04:36AM BLOOD WBC-9.4 RBC-3.15* Hgb-9.1* Hct-26.4* MCV-84 MCH-28.9 MCHC-34.4 RDW-14.0 Plt Ct-209 [2146-5-25] 02:49PM BLOOD Hct-25.6* [2146-5-25] 04:07AM BLOOD WBC-7.2 RBC-2.99* Hgb-8.5* Hct-25.4* MCV-85 MCH-28.5 MCHC-33.6 RDW-13.8 Plt Ct-248 [2146-5-24] 08:27PM BLOOD WBC-7.2 RBC-3.14* Hgb-9.1* Hct-27.0* MCV-86 MCH-28.8 MCHC-33.6 RDW-13.8 Plt Ct-273 [2146-5-24] 10:20AM BLOOD WBC-6.8 RBC-2.79* Hgb-8.0* Hct-23.6* MCV-85 MCH-28.5 MCHC-33.8 RDW-13.4 Plt Ct-291 [2146-5-24] 08:27PM BLOOD PT-14.6* PTT-29.7 INR(PT)-1.3* [2146-5-24] 10:20AM BLOOD PT-13.7* PTT-29.3 INR(PT)-1.2* [2146-5-28] 03:55AM BLOOD Glucose-156* UreaN-31* Creat-1.5* Na-138 K-4.2 Cl-102 HCO3-27 AnGap-13 [2146-5-27] 04:50AM BLOOD Glucose-170* UreaN-32* Creat-1.5* Na-136 K-4.4 Cl-102 HCO3-26 AnGap-12 [2146-5-26] 04:36AM BLOOD Glucose-120* UreaN-31* Creat-1.6* Na-137 K-4.2 Cl-103 HCO3-28 AnGap-10 [2146-5-25] 04:07AM BLOOD Glucose-183* UreaN-38* Creat-1.8* Na-139 K-5.0 Cl-106 HCO3-26 AnGap-12 [2146-5-24] 08:27PM BLOOD Glucose-158* UreaN-40* Creat-1.8* Na-139 K-4.9 Cl-105 HCO3-26 AnGap-13 [2146-5-24] 10:20AM BLOOD Glucose-104 UreaN-40* Creat-1.7* Na-140 K-4.7 Cl-105 HCO3-28 AnGap-12 [2146-5-26] 04:36AM BLOOD CK(CPK)-301* [2146-5-25] 09:45PM BLOOD CK(CPK)-206* [2146-5-25] 07:42AM BLOOD CK(CPK)-144 [2146-5-25] 04:07AM BLOOD CK(CPK)-126 [2146-5-24] 08:27PM BLOOD ALT-41* AST-56* CK(CPK)-66 [2146-5-26] 04:36AM BLOOD CK-MB-2 cTropnT-0.05* [2146-5-25] 09:45PM BLOOD CK-MB-2 cTropnT-0.06* [2146-5-25] 02:49PM BLOOD CK-MB-2 cTropnT-0.06* [2146-5-25] 07:42AM BLOOD CK-MB-3 cTropnT-0.08* [2146-5-28] 03:55AM BLOOD Calcium-8.8 Phos-4.5 [2146-5-27] 04:50AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0 [2146-5-26] 04:36AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.2 [2146-5-25] 04:07AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9 [2146-5-24] 08:27PM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1 [2146-5-24] 10:20AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2 Brief Hospital Course: [2146-5-23] Admitted. antibiotics began. Preop'd for surgery [2146-5-24] right fem-PT [Name (NI) 45029]. transferd to PACU IV NTG gtt for systolic HTN and elevated pulmonary aryery pressures. Stable and tansfered to VICU. [2146-5-25] POD #1 Temperature max 100.6 Vanco/Zosyn continued. diet advanced. Remain on bedrest. cardiac enzymes cycled. transfused 1 unit PRBCs Hct. 25.6. Swan remains in place. Remains in VICU [2146-5-26] POD#2 Temperature 102, blood cultures and urine cultures obtained. post transfusion HCT (2 units PRBC) 26.5. IV Ngtt continued. Insulin adjusted. Diuresed. [2146-5-27] POD#3 Transfused for Hct 26. NTG patch started and IV ntg weaned. Swan converted to CVL. lasix, spirolactone and ACE-I restarted. OOB to chair. PT to evaluate. [2146-5-28] POD#4 Stable. Afebrile. [2146-5-29] POD#5 Worked with PT with crutches and weight-bearing on right. Removed arterial line. [2146-5-30] POD#6 Removed central line. Worked with PT with walking and stairs. [Hospital ] rehab today. Medications on Admission: humalog 50-50 (35U), plavix 75', toprol XL 100 (1.5 tab daily), lisinopril 20', amlodipine 2.5', digoxin 50mcg ([11-17] cap daily), tramadol 50''', ibuprofen 800 (1 tab q6-8h prn), nitroquick 0.4 SL ([11-18] tab prn), Niaspan 500'' qhs, crestor 20', spiriva w/handihaler 18mcg and inhalation cap', combivent 18mcg-103mcg (3 aerosols prn), spironolactone', loperamide 2mg', protonix 40', tricor 48'', gabapentin 100''', lantus (25 cartridge), amoxicillin 500' Discharge Medications: 1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 9. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [11-17] Puffs Inhalation Q4H (every 4 hours) as needed. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). 16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO daily (). 19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 22. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 23. insulin please see attached insulin sliding scale 24. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: s/p right fem-PT bypass graft and right 3rd toe amputation DM2 insulin dependant, uncontrolled history of ischemic heart diseases/p MI s/p PTCI/stents [2135], s/p 4V-CABG's, [2138] with occluded grafts x3 with patent LiMA-lad graft by cardiac cath [1-22] history of hyperlipdemia history of chronic obstructive pulmonary disease history of depression and anxiety history of Bell's palsey history of tobacco use,d/c x 1 yr prior 30pkyrs history of acute diastolic and systolic congestive heart failure-compensated history of tonsillectomy postoperative blood loss anemia, transfused postoperative CHF excerbation, diuresed postop TEE-progressive AS history of mitral valve disease(MR) s/p mitral annulus ring placement w/CABG's Discharge Condition: stable Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. -Your staples will be removed during at your follow up appointment. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5(F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([8-31] lbs) until your follow up appointment. * Adhere to 2 gm sodium diet Followup Instructions: Follow-up with your cardiologist after discharge. Follow-up with your [Last Name (un) ] physician after discharge for any changes to your insulin regimen. Follow-up with Dr. [Last Name (STitle) 1391] in 2 weeks to have staples removed, call for an appointment [Telephone/Fax (1) 1393]. Completed by:[2146-5-30] ICD9 Codes: 5845, 3572, 5859, 2724, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2206 }	Medical Text: Admission Date: [2179-3-9] Discharge Date: [2179-3-12] Date of Birth: [2158-5-11] Sex: F Service: [Year (4 digits) 662] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3705] Chief Complaint: Hypertensive Emergency Major Surgical or Invasive Procedure: renal vein sampling in interventional radiology History of Present Illness: In brief, the pt is a 20y/o F with MPGN s/p renal xplant in [7-13] c/b multiple admissions for hypertensive emergency who presented on this admission with SOB/cough, N/V, and systolic BP in the 230s. She was admitted to the ICU where she was managed with a labetolol drip until her BP and N/V improved and she was able to tolerate PO medications. She responded rapidly in the ICU and her BP was well controlled by d2 of her hospitalization and remained so on oral medications. She received dialysis today and was called out to the floor team for further management. Of note, because of her frequent episodes of hypertension there is concern that the patient may have a kidney secreting higher than normal levels of renin and IR was contact[Name (NI) ] to obtain a renal vein sample tomorrow for further analysis. . On the floor, the patient notes resolution of all the symptoms that brought her to the emergency room and denies current chest pain, shortness of breath, headache, blurry vision, abdominal pain, nausea, dysuria, fever, weakness, or paresthesias. Past Medical History: #)MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[2175]. Post transplant pt was doing well, but had rising Cr for two year. On [6-/2178], pt presented with uncontrolled BP requiring ICU admission for Isradipine drip. Repeat biopsy showed a type 1 MPGN. Negative HepC,HepB,[Doctor First Name ], and renal U/S from NMEC showed stable AVF. Her creatinine peaked to 4's and she was started on steroids, prograf and cellcept. In [1-/2179], she required 3 sessions of HD through a right upper chest catheter. Creatinine slowly recovered to 3.2. Plasmapheresis was then initiated with plan to then treat with Rituximab. She only underwent 3 sessions of [Year (4 digits) ]. She is now transferred her care to Dr. [Last Name (STitle) ] at [Hospital1 18] to an adult clinic. #)Peripheral edema and abdominal striae [1-9] steroids #)HTN [1-9] steroids and renal disease, multiple admissions for Hypertensive Emergency. Most recently one month ago, [Date range (1) 76875] #)Hemolytic Anemia - was seen by heme/onc who felt it was [1-9] to malignant hypertension #)Migranes Social History: Lives at home with [Month/Day (2) ], brother and sister, college student at [Name (NI) 498] [Name (NI) 86] in the health sciences. Denies ETOH, illicit drugs, tobacco. Family History: No history of kidney disease, malignancy, heart disease, or diabetes. Physical Exam: VS: T 99.7, BP 141/84, HR 93, RR 22, 94% on 3 liters GEN: Eyes closed. Comfortable with flat affect. HEENT: EOMI, PERRL, MMM, OP clear NECK: Supple, no LAD RESP: Crackles ~1/2 up bilterally. CV: RRR 3/6 SEM heard best at LUSB and throughout precordium CHEST: Catheter intact, no tenderness noted ABD: Soft NT/ND + BS no rebound or guarding. No renal bruits noted. EXT: Warm well perfused, no peripheral edema SKIN: No rashes, mildly icteric NEURO: CN II-XII intact, strength 5/5 in all ext, no gross sensory deficits. Did not assess gait Pertinent Results: VENOUS SAMPLING [2179-3-11] 10:25 AM VENOUS SAMPLING Reason: PLEASE SAMPLE ALL 3 RENAL VEINS FOR RENIN LEVELS Contrast: VISAPAQUE [Hospital 93] MEDICAL CONDITION: 20 year old woman with MPGN with renal transplant with severe HTN REASON FOR THIS EXAMINATION: PLEASE SAMPLE ALL 3 RENAL VEINS FOR RENIN LEVELS RADIOLOGISTS: The procedure was performed by Dr. [Last Name (STitle) 15785], Dr. [Last Name (STitle) ], and Dr. [First Name (STitle) 3175], the atending radiologist who was present and supervisiong throughtout the procedure. INDICATION FOR EXAM: This is a 20-year-old woman s/p renal transplant and hypertension. PROCEDURE: VENOUS RENAL SAMPLING. PROCEDURE AND FINDINGS: After informed consent was obtained from the patient explaining the risks and benefits of the procedure, the patient was placed supine on the angiographic table and the left groin was prepped and draped in standard sterile fashion. Using palpatory technique and after injection of 5 cc of 1% lidocaine, the left common femoral vein was accessed with a 19-gauge needle and a 0.035 guidewire was advanced through the needle up to the level of the inferior vena cava under fluoroscopic guidance. Using a 5 French SOS catheter, access was gained into the contralateral common iliac vein and then into the vein draining the transplanted kidney. 5 cc of blood were collected from the renal vein of the transplanted kidney and from the left iliac vein. Subsequently, using a Cobra catheter, access was gained into the left and right native renal veins and 5 cc of blood draws were obtained. Blood draws were also obtained from the inferior vena cava above the level of the renal veins and inferior to the level of the renal veins. All the samples were sent for chemical analysis. The catheter was removed and manual compression was held for 5 minutes until hemostasis was achieved. Moderate sedation was provided by administering divided dose of 150 mcg of fentanyl and 3 mg of Versed throughout the total intraservice time of 1 hour and 30 minutes during which the patient's hemodynamic parameters were continuously monitored. IMPRESSION: Successful renal venous sampling from the native bilateral renal veins, transplanted kidney renal vein, left common iliac and inferior vena cava above and below the level of the renal veins Brief Hospital Course: A/P: 20y/o F w/ MPGN s/p renal xplant c/b failure and now back on HD presenting with hypertensive emergency . # Hypertensive Emergency Unclear etiology though thought to be partially due to her renal failure along with question of transplanted kidney excreting massive amounts of renin with the thought being it is not being perfused well. Patient underwent renal vein sampling of transplanted kidneys along with native kidneys. Results will be available in a few weeks to be followed up by renal. The results of the renin levels will have to be adjusted to the velocities in the renal vein. In the meantime the patient's blood presssure was well controlled on her current discharge regimen along with aggressive dialysis. Patient was symptom free at discharge with follow up scheduled with Dr. [Last Name (STitle) ] on [3-18]. Patient had ample medications at home, no prescriptions were needed. Medications on Admission: 1. Prednisone 5 mg every other day 2. Clonidine 0.2 mg/24 hr Patch Weekly (every Tuesday) 3. Hydralazine 50 mg Q8H 4. Furosemide 80 mg [Hospital1 ] 5. Losartan 75 mg [Hospital1 ] 6. Mycophenolate Mofetil 500 mg [Hospital1 ] 7. Labetalol 800 mg TID 8. Captopril 75 mg TID 9. Calcium Acetate 667 mg TID 10. B Complex-Vitamin C-Folic Acid 1 mg daily 11. Isradipine 15 mg TID Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 5. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Losartan 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). Discharge Disposition: Home Discharge Diagnosis: Hypertensive emergency Renal failure MPGN Anemia Discharge Condition: Stable, blood pressure controlled on oral medications Discharge Instructions: You were admitted with hypertensive emergency to 220/180, you were briefly in the ICU to control your blood pressure with IV medications. Your blood pressure was controlled and you underwent a study to sample blood from each of your kidneys to see if they are releasing an enzyme which could be causing your blood pressure to elevate. You received dialysis on the day of discharge which will help with your blood pressure. You have an appointment to follow up with Dr. [Last Name (STitle) ] on [3-18] to check on how you are doing. If your blood pressure is systolic>180 or diastolic>110 call the renal clinic or present to the ER for treatment. If you develop any chest pain, shortness of breath, headache, visual blurring when your blood pressure is elevated you must go to the ER for urgent evaluation as this may be life threatening. Followup Instructions: Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2179-3-18] 9:00 ICD9 Codes: 5856
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2207 }	Medical Text: Admission Date: [2173-4-9] Discharge Date: [2173-4-13] Date of Birth: [2089-12-18] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Nembutal Sodium / Zocor / Lescol / Midazolam Attending:[First Name3 (LF) 1505] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: [2173-4-9] Coronary artery bypass grafting x4: 1. Left internal mammary artery grafted to the left anterior descending artery. 2. Reverse saphenous vein graft to the posterior descending artery of the right. 3. Reverse saphenous vein graft to the first obtuse marginal branch of the circumflex. 4. Reverse saphenous vein graft to the first diagonal branch of the left anterior descending. History of Present Illness: 83 year old male with prior negative exercise stress test in [2163], now presents with one month history of increasing exertional angina, relieved by rest. Had positive exercise stress test in [Month (only) ] and underwent cardiac catherization that revealed coronary artery disease. Past Medical History: hypertension dyslipidemia anxiety gastroesophageal reflux disease benign prostatic hypertrophy osteoarthritis history of renal calculi history of concussion secondary to motor vehicle accident in [2162] s/p tonsillectomy Social History: Retired ETOH no in last 10years Tobacco denies Widow, lives with son Family History: Father deceased at 82 myocardial infarction Physical Exam: HR 64, 144/82, 63.5kg General no acute distress, thin Skin multiple nevi/moles throughout chest and back HEENT PERRLA, EOMI, anicteric sclera, oral pharynx unremarkable Neck supple full range of motion Chest clear to ausculation bilaterally Heart regular no murmur Abdomen soft, non tender, nondistended, + bowel sounds, no heptamegaly extremities warm well perfused no edema Bilateral lower extremity spider veins Neurological grossly intact moves all extremities, 5/5 strength non focal exam Pulses femoral +2, DP +2, PT +2, radial +2 no carotid bruits Pertinent Results: [2173-4-12] 06:35AM BLOOD WBC-13.6* RBC-3.35* Hgb-10.5* Hct-30.5* MCV-91 MCH-31.4 MCHC-34.5 RDW-13.4 Plt Ct-133* [2173-4-9] 01:21PM BLOOD WBC-9.4 RBC-3.05# Hgb-9.2# Hct-27.8# MCV-91 MCH-30.3 MCHC-33.3 RDW-13.1 Plt Ct-131 [2173-4-12] 06:35AM BLOOD Plt Ct-133* [2173-4-9] 02:39PM BLOOD PT-15.4* PTT-33.3 INR(PT)-1.4* [2173-4-12] 06:35AM BLOOD UreaN-20 Creat-1.2 K-3.8 [2173-4-9] 02:39PM BLOOD UreaN-14 Creat-0.8 Cl-109* HCO3-25 PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: SP CABG. Comparison is made to prior study performed on [4-10]. Small left hydropneumothorax is still present. There is mild right pleural effusion. Mild basilar atelectasis has minimally improved and greater on the right side. Moderate degenerative changes are in the thoracic spine. Sternal wires are aligned. There is no pulmonary edema. EKG Sinus bradycardia. Indeterminate QRS axis. Low voltage in the limb leads. Probable inferior wall myocardial infarction of indeterminate age. Right bundle-branch block. There is slight QTc interval prolongation. Compared to the previous tracing of [2173-4-1] a right bundle-branch block morphology is now present with associated QRS widening and QRS voltage is also slightly lower. Intervals Axes Rate PR QRS QT/QTc P QRS T 58 154 116 446/442 20 0 3 [Known lastname 27115], [Known firstname ] [Hospital1 18] [Numeric Identifier 27116] (Complete) Done [2173-4-9] at 11:44:40 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2089-12-18] Age (years): 83 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG ICD-9 Codes: 745.5, 440.0, 424.0, 424.3, 424.2 Test Information Date/Time: [2173-4-9] at 11:44 Interpret MD: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Name Initial (MD) ] [Name8 (MD) 4901], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW4-: Machine: AW1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.9 cm <= 4.0 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 70% >= 55% Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - Mean Gradient: 1 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body of the RA. No spontaneous echo contrast or thrombus in the body of the RA or RAA. A catheter or pacing wire is seen in the RA and extending into the RV. Aneurysmal interatrial septum. PFO is present. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[11-20]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Significant PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Mild spontaneous echo contrast is seen in the body of the right atrium. No thrombus is seen in the body of the right atrium or the right atrial appendage. The interatrial septum is aneurysmal. A patent foramen ovale is likely present. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is dilated with normal free wall contractility. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 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. Mild to moderate pulmonic regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal biventricular systolic function. Mitral regurgitation may be slightly worse. Likely PFO remains. Thoracic aorta appears intact. No other changes from pre-bypass study. I certify that I was present for this procedure in compliance with HCFA regulations. Brief Hospital Course: Admitted same day and went to operating room for coronary artery bypass graft surgery. Please see operative report for further details. He received cefazolin for perioperative antibiotics. He was transferred to the intensive care unit for hemodynamic management. In the first 24 hours he required vasoactive medications and fluids for hemodynamic management. He was also weaned from sedation, awoke neurologically intact and was extubated without complications. On post operative day one he was started on lasix and betablockers. He was transfered to the post op floor the remainder of his stay. Physical therapy worked with him on strength and mobility. On post operative day two he had short episode of atrial fibrillation which he converted back to sinus rhythm without intervention, but betablockers were increased for heart rate control. He was ready for discharge home on post operative day four with services. Started on crestor and to follow up with Dr [Last Name (STitle) 27117]. Medications on Admission: Aspirin 81 mg daily Atenolol 25 mg daily NTG sl prn Norvasc 5 mg daily Xanax 0.125 mg prn Protonix prn Tylenol ES prn 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:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:30 Tablet(s) Refills:0 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:3 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 3 days. Disp:3 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Crestor 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 9. Xanax 0.25 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for anxiety . Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: coronary artery disease s/p CABG post operative atrial fibrillation hypertension dyslipidemia anxiety gastroesophageal reflux disease benign prostatic hypertrophy osteoarthritis history of renal calculi history of concussion secondary to motor vehicle accident in [2162] s/p tonsillectomy Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) ] in [12-22] weeks at [Hospital1 ] heart center [Telephone/Fax (2) 6256] please call to schedule appointment Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] please call for appointment Dr [Last Name (STitle) 3659] in [12-22] weeks ([Telephone/Fax (1) 6256]) please call for appointment Completed by:[2173-4-13] ICD9 Codes: 9971, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2208 }	Medical Text: Admission Date: [2195-2-12] Discharge Date: [2195-2-18] Date of Birth: [2142-3-24] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2569] Chief Complaint: seizure Major Surgical or Invasive Procedure: Intubation History of Present Illness: 52yo M h/o etoh abuse, paraplegia s/p MVA in [2192] which left him wheelchair bound and with chronic SDH who was found out of his wheelchair today with a generalized seizure for 20min. He was given valium 7.5mg IV x 1 and ativan 2mg IV x 1 and brought to OSH with GCS 3 by report and intubated for airway protection. He was transferred here after CT showed "acute SDH" for neurosurgical intervention. He was also given vitamin K 10mg IV x 1 at OSH to reverse his INR. By report, he was loaded with dilantin. He has had no further seizure activity. Per dgtr, over the past 6 month, patient has been having seizures about once a month. He usually has nausea/vomitting the day before then typically on following morning gets confused and then "shakes" for about 15 minutes. Dgtr has had to pull over to the side of the road. Patient had the flu a couple of days ago. Dgtr reports patient still drinks ETOH last week drank a lot but since he was sick this week he has been drinking less. Doesn't know exactly how much he is drinking because he hides it from her. Smoking 1PPD cigarettes. Past Medical History: - CAD - Mechanical aortic valve - AFib on coumadin - MVA in [2192] caused L SDH s/p drainage, SAH, R frontal contussion, L occipital stroke, R eye hematoma, T11/12 burst fracture s/p arthrodesis and lateral screws T8-L2 - Alcohol abuse - Tobacco dependence Social History: - 20 pack year smoking history - History of intermittent heavy alcohol use and normally drinks [1-11] drinks per day. Currently lives at the [Location (un) ] in [Location (un) ] - wheelchair bound Family History: unknown Physical Exam: VS 101.4 90 130/88 100% Gen intubated in NAD Neck in collar CV irreg Pulm ctab Abd benign Ext no edema NEURO MS Opens eyes to noxious stimuli. Follows simple commands to squeeze fingers b/l hands CN Pupils 2mm and minimally reactive, then dilated to 3mm s/p noxious stimuli. Midline and conjugate. EOMI no nystagmus. +grimace symmetric to nasal tickle and + corneals b/l. Motor moves both arms spontaneously and anti-gravity. Triple flexion in both legs. Legs externally rotated but with contractures at knees and ankles with increased tone. Reflexes 2+ arms b/l. 3+ in legs. Toes up b/l Pertinent Results: wbc 14.8 (OSH) -> 6.8 here, hct 42, plt 137 Na 139, k 3.3, cl 109, co2 19, bun 13, cr 1.3, glu 176 Ca 9.3, mg 2.0 LFTs unremarkable INR 6.2 (OSH) -> 5.1 here Tox screen + only for benzos CE's neg x 1 UA +mod bacteria, 0 wbc's Imaging CT C-spine: On the sagittal view, the skull base to the T3 superior end plate are well visualized. The patient is intubated. There is no evidence of fracture or malalignment of the component vertebrae. Again noted is marked lordosis of the cervical spine, which appears similar to the prior study. There is no prevertebral soft tissue swelling. There are old fractures of the C7, T1 and T2 transverse processes. The outline of the thecal sac appears unremarkable. There is no significant osseous encroachment upon the spinal canal. The visualized lung apices are grossly clear. Regional soft tissues are unremarkable. Calcifications are seen within the bilateral carotid bifurcations. The visualized mastoid air cells are clear. IMPRESSION: 1. No evidence of fracture. 2. Persistent marked lordosis of the cervical spine likely secondary to positioning. NCHCT: High density extraaxial material layering over the convexity of the left cerebral hemisphere is without interval change. The collection remains bounded by the margins of the adjacent left craniotomy bone flap. Given the persistent high attenuation, findings may represent dural mineralization or chronic hemorrhage without acute component. There is no significant mass effect or shift of normally midline structures. No new foci of intracranial hemorrhage are identified. A focal area of encephalomalacia inferior to the right orbit is without change. Chronic porencephalomalacic change in the left occipital lobe with ex vacuo dilatation of the adjacent temporal [Doctor Last Name 534] is stable. The basal cisterns are widely patent. No major vascular territorial infarction. There is opacification of several ethmoid air cells. The visualized mastoid air cells are well aerated. IMPRESSION: 1. Stable CT appearance of a high-density extra-axial collection along the convexity of the left cerebellum. No significant mass effect or evidence of new hemorrhagic foci. 2. Unchanged appearance of areas of encephalomalacic change within the right frontal and left occipital lobes. FAST negative PCXR: 1. No evidence of traumatic injury. 2. Mild CHF with interstitial edema. Brief Hospital Course: The patient was brought to [Hospital1 18] after being intubated after a seizure. He was admitted to the ICU and extubated shortly therafter, with no further seizure activity after his keppra was increased from 500mg [Hospital1 ] to 1000mg [Hospital1 ]. His NCHCT on admission showed "1. Stable CT appearance of a high-density extra-axial collection along the convexity of the left cerebral cortex. No significant mass effect or evidence of new hemorrhagic foci. 2. Unchanged appearance of areas of encephalomalacic change within the right frontal and left occipital lobes." C-spine MRI was negative for new fracture, showing "marked lordosis of the cervical spine, which appears similar to the prior study. There is no prevertebral soft tissue swelling. There are old fractures of the C7, T1 and T2 transverse processes. The outline of the thecal sac appears unremarkable. There is no significant osseous encroachment upon the spinal canal" The patient was transferred to the neurology floor. He had been given vitamin K at an outside hospital and he was thus restarted on heparin gtt for his mechanical heart valve, given his subtherapeutic INR, which has not risen despite resuming his home dose of coumadin, which is 10mg daily. Workup was negative for infection, as his admission UA was contaminated and the culture negative. EEG showed "Markedly abnormal portable EEG due to the prominent focal higher voltage slowing over the left hemisphere with additional sharp features as well and due to the low voltage background and occasional slowing on the right side. The irregular sharp rhythm on the left suggests a skull defect on that side, but the prominent focal slowing indicates subcortical dysfunction on the left as well. The slowing on the right suggests additional subcortical dysfunction on the right. The lower voltage on that side may be a generalized or medication effect, but there is also the possibility that this represents more widespread cortical dysfunction or material interposed between the brain and recording electrodes such as subdural fluid. There was also prominent beta activity in all areas, likely related to medication. There were no clearly epileptiform features." Hospital course was uncomplicated. The patient is discharged to rehab for further treatment with heparin until his coumadin is therapeutic, as well as PT/OT. He prefers to follow-up with his scheduled neurology appointment at [Location (un) 511] Neurologic Associates. We will fax a copy of his discharge summary there, with his permission. Medications on Admission: Aricept 5 qpm keppra 500mg [Hospital1 ] coumadin 10mg qhs metoprolol 25mg [Hospital1 ] seroquel 25mg qhs bactrim DS [Hospital1 ] x 10 days (unknown source, ? urine) lisinopril 5mg daily prevacid 30 folate 1mg daily oxycodone 5mg 1-2 tabs q4-6 prn pain Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 11. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1800 units/hr for PTT goal 60-80 Intravenous ASDIR (AS DIRECTED): Until INR is 2.5-3.5. 14. Aricept 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) ] Discharge Diagnosis: Seizure Chronic subdural hematoma Paraplegia Mechanical heart valve Discharge Condition: Improved Discharge Instructions: Please continue to take all of your medications as prescribed. Return to the ED with any recurrent or new neurologic symptoms Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD at [Location (un) 511] Neurological Associates Phone: [Telephone/Fax (1) 9591] on [2195-3-13] at 10am Provider: [Name10 (NameIs) 13978] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2195-4-13] 10:05 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2195-2-18] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2209 }	Medical Text: Admission Date: [2167-12-11] Discharge Date: [2167-12-27] Date of Birth: [2087-5-5] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1234] Chief Complaint: Left Internal Iliac artery aneursym Major Surgical or Invasive Procedure: -Selective angiography of left internal iliac artery, coil embolization of 2 outflow vessels from the internal iliac artery aneurysm. This corresponds to CPT code [Numeric Identifier 7534], [Numeric Identifier 7535], [Numeric Identifier 7536], and [Numeric Identifier 7536]. -Endovascular repair of left hypogastric artery aneurysm with coverage stent graft. History of Present Illness: 80 M presents to ED c/o constant LLQ pain for 3 days. Pt has had anorexia over this period of time. Denies fever, chills, nausea, vomiting, chest pain, SOB, or similar pain in the past. Last BM was day of admission and was normal. Past Medical History: COPD, requiring home O2 (1 liter/min) CAP in [2160], [2165] hypertension TB in [2154], treated for active DZ thrombocytopenia, mild noted on prior admission BPH PCP is [Last Name (NamePattern4) ]. [Last Name (STitle) 7537] [Telephone/Fax (1) 7538] CRI, unknown etiology Social History: denies tobacco and EtOH Family History: non-contributory Physical Exam: On discharge 99.5 74 114/72 16 94% 3Liters NC NAD, A&Ox3 RRR CTAB soft, NT/ND Bilateral groin incisions- c/d/i w/o hematoma No LE CCE 2+ pulses throughout Pertinent Results: [2167-12-27] 05:30AM BLOOD WBC-6.3 RBC-2.95* Hgb-9.6* Hct-27.8* MCV-94 MCH-32.4* MCHC-34.4 RDW-14.2 Plt Ct-217 [2167-12-26] 03:10AM BLOOD WBC-5.3 RBC-2.97* Hgb-9.4* Hct-27.1* MCV-92 MCH-31.5 MCHC-34.5 RDW-14.1 Plt Ct-203 [2167-12-25] 02:31AM BLOOD WBC-7.3 RBC-3.00* Hgb-9.8* Hct-28.1* MCV-94 MCH-32.6* MCHC-34.7 RDW-14.4 Plt Ct-218 [2167-12-27] 05:30AM BLOOD Plt Ct-217 [2167-12-27] 05:30AM BLOOD PT-13.2 PTT-27.6 INR(PT)-1.2 [2167-12-26] 03:10AM BLOOD Plt Ct-203 [2167-12-26] 03:10AM BLOOD PT-13.5* PTT-30.1 INR(PT)-1.2 [2167-12-25] 02:31AM BLOOD Plt Ct-218 [2167-12-14] 05:39AM BLOOD D-Dimer-3164* [2167-12-27] 05:30AM BLOOD Glucose-104 UreaN-17 Creat-1.5* Na-140 K-4.5 Cl-104 HCO3-30 AnGap-11 [2167-12-26] 03:10AM BLOOD Glucose-99 UreaN-18 Creat-1.4* Na-139 K-4.4 Cl-105 HCO3-29 AnGap-9 [2167-12-25] 02:31AM BLOOD Glucose-93 UreaN-21* Creat-1.6* Na-140 K-4.5 Cl-107 HCO3-28 AnGap-10 [2167-12-24] 06:35AM BLOOD Glucose-119* UreaN-20 Creat-1.7* Na-143 K-4.5 Cl-109* HCO3-27 AnGap-12 [2167-12-25] 10:30AM BLOOD CK(CPK)-132 [2167-12-25] 02:31AM BLOOD CK(CPK)-110 [2167-12-24] 07:10PM BLOOD CK(CPK)-119 [2167-12-25] 10:30AM BLOOD CK-MB-2 [2167-12-25] 02:31AM BLOOD CK-MB-2 [2167-12-24] 07:10PM BLOOD CK-MB-2 cTropnT-0.02* [2167-12-14] 05:39AM BLOOD CK-MB-7 cTropnT-0.14* proBNP-8388* [2167-12-27] 05:30AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.2 [2167-12-26] 03:10AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.9 [2167-12-25] 02:31AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.2 [2167-12-13] 06:19PM BLOOD TSH-1.4 [2167-12-15] 01:50AM BLOOD Type-ART pO2-61* pCO2-44 pH-7.36 calHCO3-26 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2167-12-14] 04:03PM BLOOD Type-ART pO2-110* pCO2-43 pH-7.35 calHCO3-25 Base XS--1 [2167-12-14] 02:25PM BLOOD Type-ART pO2-116* pCO2-42 pH-7.35 calHCO3-24 Base XS--2 Brief Hospital Course: Pt admitted to Vascular surgery after CT shows: 1. 8-cm left pelvic mass arising from the left internal iliac artery. Appearances are consistent within an iliac artery aneurysm. This has a well-demarcated border, and there is no imaging evidence of continuing extravasation. However, although varying densities within this mass suggest at least some components to be chronic, the fact acuity cannot be assessed, and in this single examination we cannot determine whether this is an expanding lesion. 2. Mild left hydroureter and hydronephrosis. This is presumably due to compressive effect from the left pelvic mass. 3. Pulmonary artery hypertension. 4. Emphysema. Urology was c/s to assess Acute on Chronic renal insufficiency. It was felt a ureteral stent was not needed, and hydration would be helpful. . HD3 pt had difficulty breathing, like "asmtha attack". Pt became tachypnic/tachycardic. @ 1755 Code Blue was called for respiratory distress, w/ BP to 60/30. Pt was intubated, transferred to SICU on pressors, CVL was placed. EKG shows RBBB which resolved over a short interval. Cardiology was consulted; ASA, statin, Beta blocker and heparin drip were started. Work up was initiated to elucidate the cause of respiratory failure. Ultimately no definitive cause was found, though thought to be hypercarbic respiratory arrest. Echo ([12-14]): Limited views. Overall left ventricular systolic function appears normal (~60%) without apparent focal wall motion abnormality. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. . HD5 pt was extubated, all pressors were off. HD6 pt was transferred to the floor and CTA to eval anuersym: 1. Large left internal iliac artery aneurysm as described above which appears to have increased slightly in size compared to exam of seven days earlier. HD8 CVL was removed, pt was diuresed. HD10 pt was started on mucomyst for renal protection prior to angio study. IV bicarbonate was also given on call to angio. Pt was consented for procedure. On HD11 pt taken to angio for coiling of outflow vessels. Procedure: Selective angiography of left internal iliac artery, coil embolization of 2 outflow vessels from the internal iliac artery aneurysm. Pt tolerated well and was transferred to the floor in stable condition following the porcedure. HD15 pt taken to OR for second stage of aneurysm repair. Again mucomyst/bicarb was given prior. Pt and family wish to proceed. Procedure: Endovascular repair of left hypogastric artery aneurysm with coverage stent graft. Pt tolerated procedure well and was taken to the floor in good condition following the procedure. . On HD 17 pt was seen by PT and was cleared for home. The pt. required 3 Liters O2 by nasal canula to maintain O2 sats above 91%. Pt was sent home on 3 liters O2 and instructed to follow up with PCP to manage oxygen. Pt was discharged in good condition. Prior to d/c pt had both groins ultrasounded and was found to have no evidence of pseudoaneurysm or AV fistula. Pt remained afebrile throughout stay. Medications on Admission: Protonix Albuterol Lisinopril Atenolol Lasix Colchicine Indocin Discharge Medications: 1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet 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) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H (every 6 hours) as needed for dbp>90. 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Left hypogastric artery aneurysm COPD, requiring home O2 (1 liter/min) Respitory failure chronic renal insufficiency Discharge Condition: Good Discharge Instructions: Please resume taking your regular medications. Take all new medications as directed. Do not drive while taking narcotic pain medications. You may resume your regular activities. No heavy lifting (>20 lbs) for 3-4 weeks. You may shower, keep the wound covered, and pat dry. Do not soak the wound for 2 weeks. Please call your physician or return to the hospital if you experience: - Increasing pain or swelling at the wound - Fever (>101.5 F) - Inability to eat or persistent vomiting - Foul discharge from the wound. - Other symptoms concerning to you Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in [12-14] weeks. Please call, ([Telephone/Fax (1) 2867], to arrange an appointment. ICD9 Codes: 5849, 5859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2210 }	Medical Text: Unit No: [Numeric Identifier 73043] Admission Date: [2169-6-7] Discharge Date: [2169-6-25] Date of Birth: [2169-5-28] Sex: F Service: NB HISTORY: This is a 29-day-old former 31 [4-5] week infant who was initially transferred to [Hospital1 18] from [Hospital3 1810] for continued management of prematurity, and is now being discharged to home. The infant is the former 31 and [4-5] week, 1640 gm, female born to a 25-year-old G2, P1-3 woman. The pregnancy was notable for the detection of large neck mass in the twin of this patient. The mother was admitted to [Name (NI) 7635] [Name (NI) ] Medical Center in [State 3914] in mid [Month (only) 547] for preterm labor. The mother received several courses of betamethasone. Prenatal screens were O negative, hepatitis B surface antigen negative, RPR nonreactive, and rubella-immune. Both twins were delivered in [State 3914] and this twin was transferred with the sibling because of the large lymphatic neck malformation noted in the other twin. The sibling remains hospitalized at [Hospital3 1810]. At the time of transfer at 10 days of age, this patient's course is remarkable for a mild hyaline membrane disease requiring a single dose of artificial surfactant, intubation for 1 day, and CPAP for 5 days prior to transitioning to room air. The infant also required an umbilical venous line before eventual advancement on feedings. The initial hematocrit was 51. The infant received a 48-hour course of ampicillin and gentamicin while ruling out. The infant was treated with phototherapy briefly for hyperbilirubinemia and a peak bilirubin of 10.6. The infant also had 2 head ultrasounds on day of life 5 and 7, and both were within a normal range. Examination at the time of discharge is remarkable for a pink, well-appearing infant in no distress. The head circumference is 30 cm, the length is 43 cm and the weight is 2055 gm. The skin is pink, there is no exanthem, the anterior fontanelle is flat and soft. The palate is intact. There is no grunting, flaring or retraction, breath sounds are clear. There is no murmur. The abdomen is flat, soft, nontender. The hips are stable. The external genitalia are normal female. The tone and activity are normal. HOSPITAL COURSE: Respiratory. The infant did not have apnea of prematurity during continued monitoring in the [Hospital1 ] MC Neonatal ICU. There were no other respiratory issues. Cardiovascular. There are no cardiovascular issues. No murmur was heard and blood pressure remained in the normal range. Fluids, electrolytes and nutrition. The infant was transferred from [Hospital1 ] on feedings of 24 calorie breast milk. This was increased to 26 and then reduced again to 24 calories, on which the [Known firstname ] is now managed. Expressed breast milk has been supplemented with formula to make 24 calories per ounce per feed. The infant initially required p.o. and PG feeds. At the time of dictation, this infant has not required PG feeding for 4 days. GI. The infant had another bilirubin on day of life 12 and this was 6.1. Currently the [Known firstname ] is anicteric. Hematologic. There have been no hematologic issues. Hct on [6-26] was 31.2 with retic 1.2%. Infectious disease. There have been no further infectious disease issues with this infant. Neurology. The infant did have any neurological issues. Sensory. Hearing screening was performed with automated auditory brain stem responses. The infant referred in both ears; follow-up with audiology will be arranged. Ophthalmology: Eyes were examined most recently on [6-14] revealing immaturity of the retina vessels, but no ROP. A followup examination should be scheduled 3 weeks from the date of this examination, approximately [7-5]. Psychosocial. The [Hospital1 18] social worker has been involved with this family. The NICU social worker can be reached at [Telephone/Fax (1) 55529]. CONDITION ON DISCHARGE: Good. DIAGNOSES: 1. Prematurity. 2. Hyaline membrane disease. 3. Rule out sepsis. DISCHARGE DISPOSITION: To the family who is currently staying in a residential home for families of [Hospital3 18242] patients. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) ] [Name (STitle) 73044], [Street Address(2) 73045], [Doctor Last Name 1495] Albans, [State 3914]. The phone number is [Telephone/Fax (1) 73046]. While family remains in the local [Location (un) 86] area, infant will be followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 27837] of [Hospital 1426] Pediatrics. CARE AND RECOMMENDATIONS: The infant is discharged on expressed breast milk and breast feeding. Expressed breast milk has been fortified with 4 calories per ounce of supplemented term formula. MEDICATIONS: Ferrous sulfate (25 mg per mL) 0.3 mL p.o. daily. Goldline mutivitamins 1 mL p.o. daily. IRON AND VITAMIN D SUPPLEMENTATION: Iron is recommended for preterm and low birth weight infants to 12 months corrected age. All infants feed 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: Passed. STATE NEWBORN SCREENING: Performed on [6-6] at [Hospital1 ] and [6-12] at [Hospital1 ] MC, results reported normal. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was given [6-24]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [Month (only) ]-[Month (only) 958] for infants who meet any of the following 4 criteria: 1. Born at less than 32 weeks. 2. Born between 32-35 weeks with 2 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. 2. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home care givers. 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 clinical stable and at least 6 weeks, but fewer than 12 weeks of age. FOLLOW-UP: Follow-up has been scheduled with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 27837] of [Hospital 1426] Pediatrics for 1 day after discharge. VNA referral has been made for 2 days after discharge. Family will call opthalmologist to arrange eye appointment around [7-5]. [Hospital1 18] audiologist will call family to arrange audiology evaluation. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (NamePattern4) 58323] MEDQUIST36 D: [2169-6-23] 15:33:01 T: [2169-6-23] 17:01:54 Job#: [Job Number 73047] ICD9 Codes: 769, 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2211 }	Medical Text: Admission Date: [2118-8-7] Discharge Date: [2118-8-17] Service: Patient was originally admitted to the Urology service. HISTORY OF PRESENT ILLNESS: Patient is an 81-year-old male with multiple medical problems including end-stage renal disease on hemodialysis, who was admitted on [2118-8-7] preoperatively for left nephrectomy for a left renal mass found incidentally on arterial study for vascular disease. No specifics available regarding studies at this time. No associated symptoms were noted. No flank or abdominal pain. No hematuria. No dysuria. No fever or chills. Patient also has necrotic right fourth finger. PAST MEDICAL HISTORY: 1. AFib. 2. End-stage renal disease on hemodialysis. 3. Insulin dependent-diabetes mellitus. 4. Nephrolithiasis. 5. Prostate cancer. 6. Peripheral vascular disease. 7. Hypertension. 8. Anemia. 9. History of CVA. 10. History of diaphragmatic hernia. PAST SURGICAL HISTORY: 1. Significant for bilateral peripheral revascularizations, question of a femoral distal bypass. 2. Bilateral peripheral angioplasties approximately 5-6 years ago. 3. Left third toe amputation. 4. Right flap over DP wound. 5. Right upper extremity A-V fistula. 6. Question of bypass of that right A-V fistula. 7. Prostatectomy in [2112-8-31]. 8. Bilateral nephrolithotomy about 15 years ago. 9. Bilateral cataract surgery three years ago. MEDICATIONS ON ADMISSION: 1. Actos 15 mg q.d. 2. Colace 100 mg b.i.d. 3. Epogen 7200 units q week. 4. Hytrin 10 mg q.d. 5. Lasix 80 mg q.d. 6. Lipitor 20 mg q.d. 7. Lopressor 50 mg b.i.d. 8. Nepro vitamins one q.d. 9. Novolin NPH 5 units b.i.d. 10. Phenergan 12.5 mg q.6h. prn. 11. Protonix 40 mg p.o. q.d. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: Patient was afebrile and vital signs stable. Clear to auscultation bilaterally. Regular, rate, and rhythm, no murmurs. Abdomen is soft, nontender, nondistended. Pulses were palpable distally bilaterally. Patient had positive thrill over right arm fistula. Well-healed incision over the left lower extremity surgically absent to the left third toe. Flap over the right medial malleolus, which was well healed. Right second toe somewhat edematous and ecchymotic, and a little bit macerated at the tip. EKG showed AFib at a rate of 94. Patient was made NPO after midnight with IV fluids and preoped for a left nephrectomy by the Urology service. Was taken on [2118-8-8] for left nephrectomy. Please see operative report for detailed account of happenings. Subsequent to patient's left nephrectomy, patient was assessed for right arteriovenous steel syndrome, which had resulted in ischemic right hand and a necrotic gangrenous right fourth digit. Patient was discharged postoperatively to the ICU on [Hospital1 1444] [Hospital Ward Name 516] On postoperative day #2 from patient's left nephrectomy, the patient was taken by the Transplant Surgery Service to the OR for repair of a right arm fistula which seemed to be responsible for his right ischemic hand as well as a right fourth digit amputation. Patient received right A-V fistula patch angioplasty as well as a fourth digit amputation with simple closure. For detailed account, please see operative report. The patient was then transferred to the Transplant Service on the [Hospital Ward Name 517] to facilitate patient's frequent need for hemodialysis. Patient did well postoperatively with no complications. PT/OT saw patient and recommended a rehab facility. Patient was resistant to this idea, and instead opted to go home with VNA and with home PT. Patient was stable on discharge. DISCHARGE STATUS: Discharged to home with VNA and home PT. DISCHARGE DIAGNOSES: 1. Renal cell carcinoma. 2. Status post left nephrectomy. 3. Arteriovenous steel syndrome. 4. Ischemic right hand. 5. Gangrenous fourth digit on the right hand. 6. End-stage renal disease. 7. Diabetes mellitus. 8. Status post cerebrovascular accident. DISCHARGE MEDICATIONS: 1. Lipitor 20 mg p.o. q.d. 2. Terazosin 10 mg p.o. q.h.s. 3. Folic acid and vitamin B complex 1 mg p.o. q.d. 4. Colace 100 mg p.o. b.i.d. 5. Collagenase one application topical q.d. 6. Calcium carbonate 500 mg p.o. t.i.d. 7. Metoprolol 50 mg p.o. t.i.d. 8. Famotidine 20 mg p.o. b.i.d. 9. Lasix 80 mg p.o. b.i.d. 10. Pioglitazone 15 mg q.d. FOLLOW-UP PLANS: Follow up with Dr. [Last Name (STitle) 365] in the [Hospital 159] Clinic, call [Telephone/Fax (1) 2756] for appointment in one week and with Dr. [First Name (STitle) ] in the Transplant Center. Clinic will call patient to inform of appointment. Dr. [Last Name (STitle) 365] will arrange any Oncology followup that will be necessary. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1331] Dictated By:[Name8 (MD) 7190] MEDQUIST36 D: [2118-8-21] 00:01 T: [2118-8-24] 08:05 JOB#: [Job Number 41438] ICD9 Codes: 2859, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2212 }	Medical Text: Admission Date: [2158-7-17] Discharge Date: [2158-7-26] Date of Birth: [2128-5-18] Sex: F Service: [Last Name (un) ] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: Motor vehicle crash Major Surgical or Invasive Procedure: Bilateral chest tube placement History of Present Illness: The patient is a 30 year old Female status post motor vehicle crash in which sehe was the restreained driver. The patient lost control of the vehicle, struck a boulder with the drivers front end. The patient crawled out of the passenger side and then to the road where she was atttended to by EMS. She had loss of conciousness, and was sent to [Doctor Last Name 15594] [Hospital 107] medical center in [Hospital1 189] [State 350] and then was transferred via [Location (un) ] to [Hospital1 18]. She was hemodynamically stable on transfer, and a c collar and back board was placed in trauma bay. The initial injury reports includ liver laceration, pnuemothorax and pulmonary contusions Past Medical History: None Social History: Married, occ alcohol Family History: Non contributory Physical Exam: Temperature 97.8, Pulse 79, blood pressure 120/72, Respirations 25, 100% on 100% non rebreather General: alert, GCS 15, anxious HEENT: head atraumatic, normocephalpic. pupils equal round and reactive to light and accomodation. No obvious nasal or oropharyngeal injuries Neck: C collar in place, trachea midline, neck supple Chest: positive for abrasions in Left upper chest and above sternum. Left anterior deltoid ecchymosis Back: No obvious injuries, Postiive for distal throacic upper lumbar spine tenderness. NO stepoffs or deformities. Cardiac: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft obese, nondistended. slightly tender in epigastrum. No obvious injuries, small abrasions in right upper quadrant Pelvis: stable Extremities: No obvious long bone injuries. 2+ pulses bilaterally Rectal: normal tone, heme negative Pertinent Results: Chest Xray [2158-7-17]: Comparison is made to a prior study from the previous day. There has been interval placement of a right sided subclavian central venous line. Distal tip of this catheter is positioned crossing the midline with its tip in the region of the proximal left subclavian vein. An endotracheal tube is in satisfactory position 4 cm above the carina. Bilateral chest tubes are in place with their tips near the lung apices. There is widening of the mediastinum consistent with the patient's known history of mediastinal hematoma. Pulmonary parenchymal opacity within both lungs is unchanged consistent with the patient's known bilateral pulmonary contusions. Multiple right sided lower rib fractures are present and appear unchanged when compared to the prior study. There is no evidence of large pneumothorax. An NG tube is in position with its distal tip within the mid stomach. Excreted contrast is present within both renal collecting systems. IMPRESSION: 1) Right sided subclavian line with its distal tip crossing the midline into the proximal left subclavian vein. This finding was called to the surgical team caring for this patient shortly after interpretation. 2) Widening of the mediastinum consistent with the patient's known mediastinal hematoma, multiple right sided rib fractures with associated opacites in both lungs consistent with pulmonary contusion. [2158-7-17]: LEFT SHOULDER, THREE VIEWS. No fracture is detected involving the left proximal humerus or scapula. Visualized portion of distal clavicle and the AC joint are within normal limits. On the Y view obtained, it is difficult to exclude some posterior subluxation of the humeral head, though I suspect this is positional rather than real. If clinically indicated, a repeat Y view could be obtained at no additional charge to the patient. [2158-7-17]: AORTOGRAM, mesenteric angiogram: The thoracic aorta appears normal, without evidence of acute injuries. The arch vessels are also normal. Selective abdominal arteriogram reveals a replaced right hepatic artery from the superior mesenteric artery. No lacerated liver vessels are present. There are several areas within the liver that demonstrate an unusual blush on late arterial phase imaging. This may be due to liver contusion. CT abdomen [2158-7-17]: IMPRESSION: 1) New small amount of perisplenic fluid, without evidence of identifiable splenic lacerations, contusions or active bleeding. This finding may represent splenic laceration that was not apparent on the initial exam. 2) Small right-sided pneumothorax which appears to have slightly increased in size since the previous exam. 3) Evolving hepatic contusions, not significantly changed from previous exam. CT Head [2158-7-17]: There is no intraparenchymal or extra-axial hemorrhage. There is no shift of normally midline structures, mass effect or hyrocephalus. The ventricles, sulci and cisterns are within normal limits. The density values of the brain parenchyma are unremarkable. The visualized paranasal sinuses and osseous structures are unremarkable. Brief Hospital Course: The patient was intubated electively for airway protection, and bilateral chest tubes were placed for bilateral pneumothoraces. She was sent to teh IR angiography suite to rule out aortic injury per the cardiothoracic surgery consult service. She had serial hematocrits, and was weaned to extubate after being admitted to the trauma surgical intensive care unit. A thoracic epidural was placed on Juy 27th for pain management. Her left chest tube was removed on [7-19] after resolving of the pneumothorax. She was also started on niferex for blood loss anemia, however her hematocrit remained stable (22.7) and she remained hemodynamically stable. Her central ine was removed on hospital day 5. On hospital day 6 the patient began having fevers. Eventual blood cultures grew out methicillin sensitive staph aureus, and the patient had some infiltrate on chest xray, and she was started on levofloxacin for a 2 week course. The epidural was removed on [7-22]. Her right chest tube was removed on [7-24] (hospital day 8) and a post procedure xray demonstrated resolved pneumothroraces. She was tolerating regular food, her pain was well controlled on an oral regimen, she had a bowel movement, and was in stable condition be discharged to home. The patient still had some rib pain, but was ambulating well without shortness of breath on discharge Medications on Admission: None Discharge Medications: 1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(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. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). Disp:180 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:1 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. Disp:14 Tablet(s) Refills:0 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. bilateral pneumothoraces 2. bilateral pulmonary contusions 3. multiple liver contustions 4. Multiple rib fractures 5. Bacteremia 6. pneumonia 7. status post motor vehicle crash 8. Blood loss anemia 9. Respiratory failure requiring intubation 10. mediastinal hematoma Discharge Condition: Good Discharge Instructions: Please [Name8 (MD) ] MD [First Name (Titles) 151] [Last Name (Titles) 152] fevers, inability to tolerate food, increase in abdominal pain, severe weakness or dizziness, increasing shortness of breath. You can resume your regular diet. Please resume taking any medications you were taking prior to your admission Followup Instructions: Follow-up in the trauma clinic with Dr. [Last Name (STitle) ] on [2158-8-8] @ 1pm. The clinic is located on the [Location (un) 470] of the [Hospital Unit Name ] in dept 3A on [Last Name (NamePattern1) 439] in the [Hospital1 1426] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] ICD9 Codes: 486, 7907, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2213 }	Medical Text: Admission Date: [2186-4-14] Discharge Date: [2186-7-14] Date of Birth: [2186-4-14] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: [Known lastname 1059] [Known lastname 55699] is the former 705 gm product, of a 27-5/7 week's gestation pregnancy, born to a 28-year-old, G3, P1 to 2 woman. Prenatal screens: Blood type 0 positive, anti-[Doctor First Name ] antibody positive, RPR nonreactive, hepatitis B surface antigen negative, rubella immune, GBS status unknown. Pregnancy was complicated by diabetes mellitus diagnosed in [2184] which was previously diet controlled. She became insulin dependent during pregnancy. She also had pregnancy-induced hypertension and was treated with hydralazine and labetalol. The infant was noted to be growth restricted in utero with an estimated fetal weight of the 10th percentile. The mother also had trichomonas infection treated x 2 during pregnancy. She was taken to elective cesarean section under general anesthesia for worsening pregnancy-induced hypertension. The infant emerged limp, apneic with initial gasping. She received positive pressure ventilation, then facial CPAP. Her heart rate was always over 100, and color was pink after positive pressure ventilation. Apgar scores were 5 at 1 minute and 7 at 5 minutes. She was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAM UPON ADMISSION TO NEONATAL INTENSIVE CARE UNIT: Weight 705 gm--10th percentile, head circumference 23 cm-- less than the 10th percentile, length 32.5 cm. GENERAL: Nondysmorphic, preterm infant with decreased activity. HEAD, EARS, EYES, NOSE AND THROAT: Anterior fontanel open and flat. Positive red reflex bilaterally. CHEST: Coarse breath sounds, equal bilaterally, good chest excursion. CARDIOVASCULAR: Regular rate and rhythm without murmur. Normal S1, S2. Femoral pulses plus 2. ABDOMEN: Soft, nontender, nondistended, three-vessel cord. EXTREMITIES: Warm, well-perfused. NEUROLOGICAL: Tone and reflexes consistent with gestational age. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. RESPIRATORY: [Known lastname 1059] was intubated shortly after admission to the Neonatal Intensive Care Unit and placed on assisted ventilation. She received 2 doses of surfactant. Her maximum peak inspiratory pressure was 25/positive end- expiratory pressure of 5, intermittent mandatory ventilatory rate of 25, maximum oxygen requirement 40 percent oxygen. She was changed to the high-frequency ventilator on day of life 3 when her course was complicated by a pulmonary hemorrhage. She was changed back to the conventional ventilator on day of life 4, and was extubated to continuous positive airway pressure on number 5. On day of life 10, she had a respiratory decompensation requiring reintubation. She remained on ventilatory support through day of life 29, when she was again extubated to continuous positive airway pressure. She remained on continuous positive airway pressure through day of life 47, when she weaned to nasal cannula O2. She was in nasal cannula O2 until day of life 75, which was [2186-6-27], when she weaned to room air. At the time of discharge, she is breathing comfortably with respiratory rates 30-60 x per minute. Her baseline oxygen saturations are greater than 95 percent. [Known lastname 1059] was also treated for apnea of prematurity with caffeine. The caffeine was discontinued on [2186-6-3]. Her last episode of spontaneous bradycardia had occurred on [2186-5-18]. In the last few weeks prior to discharge, she would have drifting oxygenation saturations with feedings. She has not had any in the 5 days prior to discharge. 1. CARDIOVASCULAR: [Known lastname 1059] was presumptively treated for a patent ductus arteriosus from day of life 2 through 3. With her respiratory decompensation on [2186-5-12], and a chest x-ray showing pulmonary edema, she had a cardiac echo which showed a structurally normal heart and a small patent foramen ovale, and no patent ductus arteriosus. At the time of discharge, her heart rates are 140-160 beats per minute with a blood pressure 81/43 with a mean of 50. A soft murmur remains intermittently audible at the time of discharge which is felt to be consistent with the previously identified patent foramen ovale. 1. FLUIDS, ELECTROLYTES AND NUTRITION: [Known lastname 1059] was initially NPO and maintained on intravenous fluids. Enteral feeds were started on day of life 5 and gradually advanced to full volume. She also received total parenteral nutrition through a peripherally inserted central catheter. All intravenous fluids were discontinued on day of life 15. Her maximum caloric intake was 30 cal/oz with additional ProMod protein supplement. At the time of discharge, she is receiving mother's milk with 4 cal/oz of Similac powder added or breastfeeding. Her recent weight is 2.945 kg which is 6 pounds 8 ounces, with a head circumference of 33 cm, and a length of 51 cm. Serum electrolytes were checked frequently in the first month of life and were relatively normal. 1. INFECTIOUS DISEASE: At the time of admission, [Known lastname 1059] was evaluated for sepsis. A white blood cell count and differential were within normal limits. A blood culture obtained prior to starting intravenous antibiotics was no growth at 48 hours, and the antibiotics were discontinued. With her clinical decompensation on day of life 10, she was again evaluated for sepsis. Her white blood cell count and differential were normal. A blood culture was obtained prior to starting intravenous vancomycin and gentamycin. She received an empiric 7-day course for presumed sepsis. Blood culture and CSF cultures were no growth. 1. HEMATOLOGICAL: [Known lastname 1059] is blood type O positive, Coombs' negative. She received 3 transfusions of packed red cells during admission. Her most recent hematocrit was on [2186-6-30] at 29 percent with a reticulocyte count of 4 percent. She has been treated and will be discharged home on iron supplementation. 1. GASTROINTESTINAL: [Known lastname 1059] required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life 1, with a total of 5/0.4 mg/dl direct. She received phototherapy for approximately 5 days. Rebound bilirubin on day of life 7 was a total of 2.6/0.5 direct. 1. NEUROLOGY: [Known lastname 1059] has had 4 normal head ultrasounds during admission. She has maintained a normal neurological exam, and there are no neurological concerns at the time of discharge. She will be referred to the Infant [Hospital ] Clinic at [Hospital3 1810] after discharge. 1. SENSORY: Audiology: Hearing screening was performed with automated auditory brain stem responses. [Known lastname 1059] passed in both ears. Ophthalmology: [Known lastname 1059] has retinopathy of prematurity. Her eyes were most recently examined on [2186-7-7] showing a stage 1, zone II - 2 clock hours on the right, and stage 2, zone II - 1 clock hour on the left. Recommended follow-up is in 2 weeks which would be due the week of [2186-7-17]. The ophthalmologist is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 36137], phone number [Telephone/Fax (1) 43283]. Psychosocial: [Hospital1 ] social work has been involved with this family. They can be reached at [Telephone/Fax (1) 55700]. This is a single mother with supportive brother. She also has a 14-year-old son at home. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the mother. PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 55701], [Hospital3 55702], [Street Address(2) 55703], [Hospital1 1474], [Numeric Identifier 55704], phone number [Telephone/Fax (1) 55705], fax number [Telephone/Fax (1) 55706]. CARE RECOMMENDATIONS AT DISCHARGE: 1. Feeding: Breastfeeding or expressed mother's milk fortified to 24 cal/oz with Similac powder. 2. Medications: Vi-Daylin 1 ml po qd; Ferrous Sulfate 25 mg/ml dilution 0.5 ml po qd. 3. Car seat position screening was performed. [Known lastname 1059] was monitored for 90 minutes in her car seat without any episodes of bradycardia or oxygen desaturation. 4. Immunizations administered: Hepatitis B vaccine on [5-24] and [2186-6-23]. Diphtheria acellular pertussis, HIB, injectable polio vaccine, and pneumococcal 7-valent conjugate vaccine were all administered on [6-13]- [2186-6-14]. Next immunizations due approximately [2186-8-15]. 5. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following 3 criteria: First, born at less than 32 weeks; Second, born between 32 and 35 week's with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-aged siblings, or thirdly with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 month's of age. Before this age and for the first 24 month's of the child's life, immunization against influenza is recommended for household contacts and out-of- home caregivers. 6. Follow-up appointments: 1) Appointment with Dr. [Last Name (STitle) 55701] within 5 days of discharge. 2) Dr. [Last Name (STitle) 36137], [Hospital1 55707] [Hospital 8183] Clinic, in [Last Name (un) 9795] Bldg, 4th Fl, the week of [2186-7-17], phone number [Telephone/Fax (1) 43283]. DISCHARGE DIAGNOSES: Prematurity at 27-5/7 week's gestation. Respiratory distress syndrome. Suspicion for sepsis ruled out. Presumed sepsis. Presumed patent ductus arteriosus treated with indomethacin. Patent foramen ovale. Apnea of prematurity. Anemia of prematurity. Unconjugated hyperbilirubinemia. Retinopathy of prematurity. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2186-7-13] 14:53:06 T: [2186-7-13] 16:13:31 Job#: [Job Number 55709] ICD9 Codes: 769, 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2214 }	Medical Text: Admission Date: [2143-12-27] Discharge Date: [2144-1-3] Date of Birth: [2069-9-2] Sex: M Service: MEDICINE Allergies: Aspirin / lisinopril / Nifedipine / Cephalexin / Nafcillin Attending:[First Name3 (LF) 2782] Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: None History of Present Illness: This is a 74-year-old gentleman with a pmhx. significant for dCHF, afib on coumadin, CKD, MSSA/GBS bacteremia, and was recently discharged on [2143-12-19] for compression fracture of T11 vertebrea and afib with RVR who presents to the ED at the request of his nurse practioner for elevated potassium. Mr. [Known lastname 19829] had been evaluated in the infectious disease clinic on [12-25] and had routine labs drawn, at which time his potassium was found to be 5.7. He was told to go to the ED that night for evaluation, but decided to come in the next day. Patient denies any particular complaints but does complain of fatigue. No headache, fevers, chills, nausea, vomiting, diarrhea, or other concerning signs or symptoms. . In the ED, initial vitals were: 97.3 120 105/72 22 100% RA. Labs were significant for a creatinine of 3.3 up from a baseline of 1.5 and a potassium of 6.1. Patient complained of wheezing and chest congestion and received a dose of levaquin for presumed HCAP. He also received nebs, 15grams of kayexalate and 250cc of fluid. Mr. [Known lastname 19829] was transferred to the MICU for further evaluation and work-up. Past Medical History: --S. aureus/G-strep bacteremia: Unknown source although left maxillary dental abscess suspected. Was on IV nafcillin until [2143-12-16], followed in [Hospital ] [Hospital 4898] clinic. --Retroperitoneal Hemmorhage [2143-6-7] in the setting of INR of 8 --Diastolic CHF --HTN --Asthma --Atrial fibrillation, on warfarin. s/p multiple cardioversions, last TEE-guided cardioversion on [2143-11-5] --Atopic dermatitis --Hypercholesterolemia --CKD (creatine from 1.4-2.3 in the last 2 months) --s/p UGI bleed in [2130] from two gastric ulcers, H. pylori neg --hx of colonic adenomas on colonoscopy in [2133] --s/p appendectomy --Normocytic anemia- recent BM bx on [5-24] which showed mild erythroid dyspoiesis suggesting the possibility of an early evolving MDS. Cytogenetics and FISH for MDS were negative. --Herpes Zoster on upper back in [2143-5-8] --Gout Social History: Originally from [Country 19828]; came to US in the [2091]. Married, lives with his wife. Three adult daughters. [Name (NI) 1403] as a physicist for radiation oncology at [Hospital1 112]/[Company 2860]. Previously employed by [Hospital1 18]. Denies tobacco or illicit drug use. Occasional EtOH - 1 drink several times per week. Family History: Mother died of complications of childbirth. Father died in his 90s from complications of an aortic aneurysm. Brother died of cancer of unknown primary. Son died 10 years ago by drowning during a caving expedition. Three daughters are alive and well. Multiple family members have eczema. Physical Exam: VS: 96.6, 83, 109/70, 16 GENERAL: No acute distress, wheezy HEENT: EOMI, very dry mucous membranes NECK: Supple, no cervical LAD LUNGS: Moderate air movement bilaterally, expiratory upper airway wheezes HEART: Irregularly irregular, no MRG ABDOMEN: Obese, soft, NT, ND, no organomegaly, no rebounding or guarding EXTREMITIES: 2+ edema bilaterally, peripheral pulses intact SKIN: Diffuse blanching erythema over entire body NEURO: Alert and oriented x3 PSYCH: Calm, appropriate affect Pertinent Results: [2143-12-27] 10:18PM GLUCOSE-108* UREA N-90* CREAT-3.3* SODIUM-144 POTASSIUM-5.8* CHLORIDE-110* TOTAL CO2-22 ANION GAP-18 [2143-12-27] 10:18PM CALCIUM-8.4 PHOSPHATE-8.2# MAGNESIUM-2.4 [2143-12-27] 10:18PM WBC-7.4 RBC-2.48 HGB-8.2* HCT-25.6* MCV-103* MCH-33.3* MCHC-32.2 RDW-16.7* [2143-12-27] 10:18PM NEUTS-78.6* LYMPHS-10.9* MONOS-8.5 EOS-1.5 BASOS-0.5 [2143-12-27] 10:18PM PLT COUNT-409 [2143-12-27] 10:18PM PT-30.4* PTT-42.4* INR(PT)-2.9* [2143-12-27] 06:17PM PO2-47* PCO2-52* PH-7.22* TOTAL CO2-22 BASE XS--6 COMMENTS-GREEN [2143-12-27] 06:17PM LACTATE-1.7 K+-6.1* [2143-12-27] 04:30PM GLUCOSE-131* UREA N-88* CREAT-3.3# SODIUM-141 POTASSIUM-7.6 CHLORIDE-108 TOTAL CO2-20* ANION GAP-21* [2143-12-27] 04:30PM CK(CPK)-81 [2143-12-27] 04:30PM cTropnT-0.08* [2143-12-27] 04:30PM CK-MB-5 proBNP-4982* [2143-12-27] 04:30PM WBC-10.4 RBC-2.81* HGB-9.3* HCT-29.0* MCV-103* MCH-33.3* MCHC-32.2 RDW-16.7* [2143-12-27] 04:30PM NEUTS-80.3* LYMPHS-9.0* MONOS-8.4 EOS-1.5 BASOS-0.8 [2143-12-27] 04:30PM PLT COUNT-532* . TEE Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate bileaflet mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([12-9]+) mitral regurgitation is seen. There is no pericardial effusion. . IMPRESSION: Mitral and aortic leaflets are thickened but no discrete vegetation is identified. No abscess seen. . TTE: MPRESSION: Aortic leaflet thickened with mild aortic regurgitation but no discrete vegetation. Moderate mitral regurgitation with thickened leaflets but without discrete vegetation. Pulmonary artery hypertension. Minimal aortic valve stenosis. Dilated thoracic aorta. . MRI TSpine/LSpine: IMPRESSION: 1. No osteomyelitis, discitis or epidural abscess. 2. Interval subacute T11 compression fracture without retropulsion. 3. Interval progression of the known L1 compression fracture, but without retropulsion. 4. Low lumbar degenerative changes, without spinal stenosis. . [2143-12-27] Chest PA and lateral radiograph demonstrates unremarkable mediastinal and hilar contours. Stable mild cardiomegaly evident. Increased opacity overlying the right diaphragm on background of right lower lung atelectasis, may indicate pneumonia. No pleural effusion or pneumothorax evident. Stable L1 and T12 compression fractures. Stable degenerative changes of the right shoulder. IMPRESSION: Increased opacity of right lower lung may reflect worsening atelectasis, though in proper clinical setting, pneumonia is a possibility. No pleural effusion evident. . Culture data (organism and susceptibilities): STAPHYLOCOCCUS EPIDERMIDIS \| STAPHYLOCOCCUSEPIDERMIDIS \| \| CLINDAMYCIN----------- =>8 R =>8 R DAPTOMYCIN------------ S S ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ 4 S 4 S LEVOFLOXACIN---------- =>8 R =>8 R LINEZOLID------------- 1 S 2 S OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- =>32 R =>32 R TETRACYCLINE---------- =>16 R =>16 R VANCOMYCIN------------ 2 S 2 S Brief Hospital Course: BRIEF HOSPITAL COURSE: This is a 74-year-old gentleman with a pmhx significant for recent MSSA and group G strep bactremia, dCHF, asthma, and afib on coumadin who was admitted after routine lab tests showed an elevated potassium. He was found to be bacteremic on admission. A work-up for the source was inconclusive. He was discharged with a PICC line for likely 6 weeks of vancomycin therapy. . ACTIVE ISSUES: # POSITIVE BLOOD CULTURES: Blood cultures from [12-27] to [12-29] grew methicillin resistant staph. epidermis. Source search included evaluation for valvular vegetations included TTE and TEE which were unrevealing. Given history of compression fractures an MRI T and L spine showed no source. A RUQ ultrasound was obtained in setting of right upper extremity edema and pain on palpation of the axilla revealed evidence of a non occlusive clot. In setting of atopic dermatitis, multiple skin lesions and recent knee injury with slow healing wound, skin source entertained. A picc line was placed and 4-6 weeks of vancomycin will be continued at discharge dose of 750mg [Hospital1 ]. . # ACUTE RENAL FAILURE: Patient with creatinine of 3.3 up from a baseline of 1.5. On admission, patient was 89 kg, down from 94.9kg on [2143-12-16]. He appeared hypovolemic with increased thirst, and BUN/creatinine ratio is >20. Urine lytes demonstrated FeUrea < 34 (25) consistent with pre-renal etiology. After administration of IVF, renal function improved with discharge creatinine 1.1. AIN possibly contributed given recent treatment with Nafcillin. Urine eosinophils were positive. Valsartan and lasix were initially held. Valsartan was restarted prior to discharge and lasix was restarted at a lower dose 40mg. . # HYPERKALEMIA: Likely in the setting of dehydration, renal failure, and valsartan. With fluids and kayexalate, patient's potassium trended down. . # SHORTNESS OF BREATH: Differential includes asthma exacerbation vs. pneumonia vs. bronchitis vs. volume overload. Mr. [Known lastname 19829] was given a prednisone burst ( 5 days of 40mg prednisone) with significant improvement in his symptoms. His Advair was increased to 500/50 and he was started on Singulair. . INACTIVE ISSUES: # AFIB WITH RVR: Metoprolol, diltiazem and coumadin were continued during admission. . # HTN: Metoprolol and dlitiazem was continued. . # ATOPIC DERMATITIS: Hydroxyzine and clobetasol were continued during admission. . TRANSITIONAL ISSUES: - PCP [Last Name (NamePattern4) 702]: basic metabolic panel - OPAT follow-up: Vancomycin trough at discharge was 22 - Code Status: Full Medications on Admission: fluticasone-salmeterol 250-50 mcg/dose Disk - 1 puff [Hospital1 ] hydroxyzine HCl 25 mg qhs simvastatin 40 mg daily clobetasol 0.05 % Ointment [Hospital1 ] valsartan 80 mg daily ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler every 6-7 hours prn cholecalciferol 400 unit daily multivitamin Tablet daily metoprolol succinate 200 mg daily albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler q4h prn Lasix 60 mg Tablet daily warfarin 5 mg Tablet daily for 7 days dilt 120mg ER daily oxycodone-acetaminophen 5-325 mg Tablet q6h prn pain Discharge Medications: 1. vancomycin 750 mg Recon Soln Sig: One (1) Intravenous twice a day for 6 weeks. Disp:qs Refills:0 2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 6. valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every four (4) hours. 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 15. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home With Service Facility: Primary home care specialists Discharge Diagnosis: Acute on chronic kidney injury Bacteriemia Atrial fibrillation Congestive heart failure Asthma Atopic dermatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you. You came because of high potassium. Your potassium was high because your kidneys were not functioning as they usually do. We gave you fluid and held diuretics for few days and your kidney function came back to the baseline. While you were in the hospital we found a bacteria in your blood. Therefore we had to give you intravenous antibiotics that you have to continue at home for 6 weeks. We have done the following changes to your medication: TAKE VANCOMYCIN 750 mg intarvenously through the PICC line twice a day. Home service will come to help you. CHANGE furosemide 60 mg daily to furosemide 40 mg daily Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2144-1-7] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 647], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: [Hospital3 249] When: TUESDAY [2144-1-7] at 2:20 PM With: [First Name11 (Name Pattern1) 198] [Last Name (NamePattern4) 199], M.D. [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: INFECTIOUS DISEASE When: WEDNESDAY [2144-1-22] at 10:30 AM With: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage ICD9 Codes: 5849, 2762, 5180, 4168, 4280, 2767, 4240, 5859, 2720, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2215 }	Medical Text: Admission Date: [2197-11-10] Discharge Date: [2197-11-24] Date of Birth: [2121-3-19] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: 76 year old female with history of CABG in [2185] transferred from [Hospital6 3105] with evidence of recurrent AVR/MVR and recent chest discomfort with ambulation Major Surgical or Invasive Procedure: [2197-11-13] redo sternotomy aortic valve repair #21 CE pericardial, mitral valve repair #26 annuloplasty band, aortic endarterectomy and patch. History of Present Illness: 76 year old female status post CABG [2185] with evidence for AVR/MVR, chest discomfort after walking in mall prior to outside hospital admission. Admitted on [11-10] and referred to Dr. [Last Name (STitle) ] for surgery. Past Medical History: CABG x2 [2185], Appendectomy, TAH, cataract surgery, tonsillectomy NIDDM HTN gout lymphoma in remission bilat. renal art. stenosis obesity Social History: denies tobacco, alcohol, or recreational drug use Family History: noncontributory Physical Exam: WDWN white female NAD AVSS AA&ox3 EOMI, anicteric supple without bruits B/S CTAB S1/S2 Abd obese scars present soft NT/ND EXT [1-22]+ edema, at ankles Pertinent Results: [2197-11-23] 06:00AM BLOOD Hct-32.7* [2197-11-22] 06:05AM BLOOD WBC-9.8 RBC-3.83* Hgb-11.2* Hct-33.6* MCV-88 MCH-29.4 MCHC-33.5 RDW-14.5 Plt Ct-239 [2197-11-23] 06:00AM BLOOD PT-14.3* PTT-56.1* INR(PT)-1.4 [2197-11-22] 06:05AM BLOOD Glucose-94 UreaN-40* Creat-1.4* Na-140 K-3.7 Cl-100 HCO3-31 AnGap-13 [2197-11-24] 06:10AM BLOOD WBC-10.4 RBC-3.68* Hgb-10.6* Hct-32.4* MCV-88 MCH-29.0 MCHC-32.9 RDW-14.5 Plt Ct-285 [2197-11-24] 06:10AM BLOOD PT-15.8* PTT-59.6* INR(PT)-1.7 [2197-11-24] 06:10AM BLOOD Plt Ct-285 [2197-11-24] 06:10AM BLOOD Glucose-107* UreaN-30* Creat-1.4* Na-141 K-4.0 Cl-101 HCO3-29 AnGap-15 [2197-11-11] 01:40AM BLOOD ALT-15 AST-21 LD(LDH)-215 AlkPhos-88 Amylase-70 TotBili-0.4 [2197-11-11] 01:40AM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE Brief Hospital Course: Admission date: [2197-11-10], Shortness of Breath, Pre-Op AVR/MVR Discharge date: [2197-11-24], Aortic Stenosis, Mitral Regurgitation 76 year old female admitted with the above who underwent redo sternotomy/AVR/MVRepair with Dr. [Last Name (STitle) ] on [2197-11-13], she was transferred to PACU in stable condition with A-pacing at 80bpm. One unit PRBC's transfused, wean epinephrine drip, lasix 40mg [Hospital1 ]. On POD 2 the patient was awakened, sedatives weaned, patient extubated on early POD #2, CT's d/c'don POD #3, weaned nitroprusside. Diuresis continued throughout her postop course.Patient went into Afib on after first degree AVB. Natrecor was also started briefly. Amiodarone was started when she went back into Aflutter. Creatinine remained mildly elevated postop.Coumadin and heparin were started on POD #7 for Aflutter., and amiodarone was discontinued for wenckebach rhythm. Seen by cardiology consult and transferred to the floor on POD #7.Patient continued to improve her activity tolerance level, but still requires additional rehab. Screening begun on [11-21].Beta blockade started, held for bradycardia while sleeping , and restarted at low dose on [11-24]. INR 1.7 on [11-24], and heparin DCed. Cleared for discharge on [11-24] and rehab bed avail. Medications on Admission: lasix 40 mg daily plavix 75 mg daily lipitor 20 mg daily nexium 40 mg daily atenolol 12.5 mg daily allopurinol 100 mg daily Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). [Month/Day (4) ]:28 Capsule, Sustained Release(s) Refills:1 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. [Month/Day (4) ]:60 Capsule(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [Month/Day (4) ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. [Month/Day (4) ]:1 Refills:0 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). [Hospital1 ]:1 Refills:2 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [Hospital1 ]:30 Tablet, Delayed Release (E.C.)(s) Refills:1 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. [Hospital1 ]:14 Tablet(s) Refills:0 9. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. [Hospital1 ]:40 Tablet(s) Refills:0 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. ML(s) 11. Lopressor 50 mg Tablet Sig: [1-24] tablet Tablet PO twice a day. 12. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. [Month/Day (4) ]:30 Tablet(s) Refills:2 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1 doses: today [11-24] only; further dosing by INR/rehab MD. [Last Name (Titles) ]:1 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Location (un) 582] - [Location (un) 7658] Discharge Diagnosis: s/p redo AVR/MVrepair/ aortic endarterectomy NIDDM HTN CAD AS gout lymphoma (remission) Bil renal art. stenoses Aflutter/fib Discharge Condition: stable Discharge Instructions: no lotions , creams or powders on incisions may shower and pat wounds dry no driving for one month no lifting greater than 10 pounds for 10 months Followup Instructions: see Dr. [Last Name (STitle) 5017] in [1-22] weeks See Dr. [Last Name (STitle) 6352] in [1-22] weeks follow- up with Dr. [Last Name (STitle) ] in the office in 4 weeks ([Telephone/Fax (1) 170]) goal INR 2.0-2.5- coumadind dosing after [11-24] and INR followup by rehab MD Completed by:[2197-11-24] ICD9 Codes: 4019, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2216 }	Medical Text: Admission Date: [2117-8-11] Discharge Date: [2117-8-21] Date of Birth: [2055-10-24] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 695] Chief Complaint: 61 yo M w/ h/o ETOH cirrhosis s/p piggyback orthotopic liver transplant [2117-7-11] now p/w tachycardia and hypotension. Major Surgical or Invasive Procedure: Cardiac catheterization and ablation of aberrant focus of atrial pacemaker. History of Present Illness: 61 yo M h/o ETHO cirrhosis s/p piggyback orthotopic liver transplantion in [2117-7-11]. Discharged in good condition to [Hospital3 7] for Rehab. He has done well there, had wound opened on [8-4] and vac placed. Seen by Dr. [Last Name (STitle) 816] in clinic on Monday prior to hospitalization c/o lower abdominal pain. A CT scan was ordered that showed mild fluid density intra-abdominal ascites and constipation. No intra-abdominal or Sub Q fluid collections were identified. He presented on [2117-8-11] to [Hospital ] hospital after he had an epidsode of tachycardia to 160 at [Hospital1 ] followed by hypotension after treatment with IV lopressor. He was given a 1 L fluid bolus, to which his pressure responded. Questionable episode of atrial fibrillation. Upon presentation he was in normal sinue rhythym but denies dizziness, SOB, or CP. Currently he is asymptomatic with the exception of lower abdominal discomfort. Past Medical History: -ESLD s/p OLT (piggyback in [2117-7-11]) -IDDM since [2101] -CAD s/p stenting in [2115] -H/o postop acute renal failure -anemia, thrombocytopenia, HIT+ -s/p cholecystectomy -LIH repair spring [2115] Social History: Lives in [Hospital3 ]. Family History: non-contributory Physical Exam: 98.3 87 187/86 20 100 RA A&0 x 3 NAD, comfortable MMM no scleral icterus, PERRLA EOMI Lungs CTA bilaterally RRR no MRG 2+ carotids bilaterally, no bruits Round, tympanic bowel sounds, distanded vac in place. Tenderness to deep palpation throughout. No guarding or rebound. no c/c/e, distal pulses, 1+ Pertinent Results: Coags: [2117-8-21] 06:25AM BLOOD Plt Ct-88* [2117-8-20] 06:45AM BLOOD Plt Ct-82* [2117-8-18] 05:45AM BLOOD Plt Ct-107* [2117-8-15] 05:25AM BLOOD PT-18.0* INR(PT)-2.1 [2117-8-11] 08:15PM BLOOD PT-13.6* PTT-25.7 INR(PT)-1.2 Tacrolimus: [2117-8-19] 06:20AM BLOOD FK506-4.4* [2117-8-18] 05:45AM BLOOD FK506-8.5 [2117-8-15] 05:26AM BLOOD FK506-13.5 [2117-8-14] 02:08PM BLOOD FK506-15.8 [2117-8-13] 09:20AM BLOOD FK506-13.4 Chemistry: [2117-8-21] 06:25AM BLOOD Glucose-166* UreaN-45* Creat-1.7* Na-135 K-4.9 Cl-106 HCO3-19* AnGap-15 Brief Hospital Course: He presented on [2117-8-11] to [Hospital ] hospital after he had an epidsode of tachycardia to 160 at [Hospital1 ] followed by hypotension after treatment with IV lopressor. He was given a 1 L fluid bolus, to which his pressure responded. Questionable episode of atrial fibrillation. Upon presentation he was in normal sinue rhythym but denies dizziness, SOB, or CP. Currently he is asymptomatic with the exception of lower abdominal discomfort. Pt admitted to [Hospital Ward Name 121] 10 for observation. On hospital day #2 pt was monitored on telemetry. Cardiology was consulted, and pt was started on diltiazem 30mg PO QID and Lopressor 25 PO TID for better rate control. He was transfered to the ICU for monitoring of recurrent Atrial flutter. His Digoxin was discontinued. Pt initially declined to undergo cardiac catheterization procedure to ablate aberrant pacemaker focus and was continually monitored by telemetry. On [2117-8-16] pt decided to undergo cardiac catheterization procedure. His amiodarone was discontinued and his coumadin was discontinued to get his INR<2.0 for the ablative procedure by electrophysiology. On [2117-8-19], Pt was given 1 unit FFP and taken to electrophysiology labs for ablation of aberrant atrial focus. Pt did well post-procedure and remained in normal sinue rhythym. He was discharged to home w/ VNA services on [2117-8-21] on Coumadin 1mg, FK506 1mg PO BID, and rapamycin 4mg qday. Per Cards his INR is to remain [1-28] and he is to follow-up in cardiology clinic. Medications on Admission: ASA Plavix Diflucan Lasix Prevacid Metoprolol Colace CEllcept [Pager number ]'''' Prednisone 20' Bactrim Flomax Valcyte Prograf 4' Insulin Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed. Disp:60 Suppository(s) Refills:3 2. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Will need a level drawn on Monday [8-23] and adjust dose accordingly to keep INR [12-27]. Disp:30 Tablet(s) Refills:3 3. Pantoprazole Sodium 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:3 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). Disp:105 Tablet(s) Refills:2 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 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. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO every other day. Disp:30 Tablet(s) Refills:2 10. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Sirolimus 4 mg Tablet Sig: Two (2) Tablet PO once a day: Will need a trough level on Monday [8-23] and adjust dose accordingly. Disp:60 Tablet(s) Refills:2 12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Will need a trough level on Monday [8-23] and adjust dose accordingly. Disp:60 Capsule(s) Refills:2 13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please hold for SBP <100 or HR <55. Disp:90 Tablet(s) Refills:2 15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 16. Aspirin EC 81 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 17. Outpatient Lab Work FK level, Rapamycin level, Coumadin level on Monday [2117-8-23] 19. Insulin 70/30 70-30 unit/mL Suspension Sig: One (1) Subcutaneous three times a day: 25 Units with breakfast. 22 Units with lunch. 25 units with dinner. Disp:qs qs Refills:2 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Atrial flutter Discharge Condition: stable Discharge Instructions: Patient to call transplant surgery immediately at [Telephone/Fax (1) 673] if any feves, chills, nausea, vomiting, abdominal pain, decrease energy, change in bowel movements or urine output. Also if there are changes in skin color, or questions about her medications. Patient needs to have labs drawn every Monday and Thursday in which: CBC, CHEM 10,ALT, alk phosp, PO4, albumin, AST, T. bili, U/A and RAPAMUNE LEVEL. PLEASE FAX RESULTS TO [Telephone/Fax (1) 697]. Followup Instructions: Patient to follow up with Transplant surgery at [Telephone/Fax (1) 673] in [1-28] weeks. Call to make an appt. Follow-up with Dr. [Last Name (STitle) 911] in Cardiology clinic as outpatient in [1-28] weeks. Please call clinic to schedule. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2117-8-21] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2217 }	Medical Text: Admission Date: [2144-5-14] Discharge Date: [2144-5-18] Date of Birth: [2144-5-13] Sex: F Service: NBB HISTORY OF PRESENT ILLNESS: This infant was transferred on day of life number one from [Hospital3 3583] to the [Hospital1 1444] for evaluation and treatment of neonatal abstinence syndrome. She was born at 37 and 3/7 weeks to a 29 year old gravida IV, now para IV mother, by cesarean section with [Name (NI) ] scores of eight at one minute and nine at five minutes, respectively. Her birth weight was 2690 grams. PRENATAL SCREENS: O negative, positive anti-[Doctor Last Name ] antibody, RPR nonreactive, rubella immune, hepatitis surface antigen negative, HIV negative, group B Strep unknown, hepatitis C positive. ANTEPARTUM COURSE: The maternal history and pregnancy were notable for: Placenta previa, history of polydrug substance abuse including opiates and benzodiazepines. Currently, mother is on Ativan 4 mg per day and Methadone 180 mg per day. Mother reports using Cocaine at least once during the pregnancy. Positive hepatitis C - history of intravenous drug abuse, no intravenous drug use for past one and one half years per mother's report. Positive tobacco use. History of colectomy post motor vehicle accident - multiple lysis of adhesions for small bowel obstruction. Status post cholecystectomy, status post chronic pancreatitis. Gastroesophageal reflux disease treated with Zantac, Prilosec, and possibly Protonix. PHYSICAL EXAMINATION: The patient was active and alert on admission to the Neonatal Intensive Care Unit. Her weight was 2600 grams (five pounds fourteen ounces), just below the 25th percentile, length 50 centimeters, just above the 75th percentile, and head circumference 31 centimeters, just above the 10th percentile. The baby was transferred to the [Name (NI) ] Nursery. Breath sounds were clear to auscultation bilaterally. Her heart rate was regular with no murmur and femoral pulses were two plus. The red reflex was present bilaterally. The abdomen was benign without hepatosplenomegaly. Neurologically, she was alert moving all extremities and reflexes were symmetric. Her head size was lower than expected for the rest of her growth measurements. HOSPITAL COURSE: Respiratory - No issues. Breath sounds were clear and equal bilaterally. Cardiovascular - No issues. Heart rate was regular, no murmur, femoral pulses two plus and symmetric. Fluids, electrolytes and nutrition - She is tolerating ad lib feedings of Enfamil well. Her weight on day of discharge is 2555 grams. Infectious disease - No issues. Studies from [Hospital3 3583] reported a complete blood count of 12.0, 23 neutrophils, 3 bands, hematocrit 46.9, platelet count 263,000. Gastrointestinal - The initial bilirubin on [2144-5-15], was 8.3/0.3/8.0. Her subsequent bilirubins were 10.1/0.3/9.8 and 12.0/0.3/11.2. The baby is O negative, [Name (NI) 36243] negative. Neurology - The baby has maintained a normal neurological examination during admission with. Her head circumference is lower than expected for the rest of her growth measurements. An evaluation for relative microcephaly with a head ultrasound was normal. The baby's neonatal abstinence scores have been in the range of [4-3] over the 24 hours prior to transfer. Neonatal opium solution was begun on Saturday [5-23] for scores . Mother is currently on Methadone 180 ne 26th for scores of 10. SHe has remained on a stable dose Sensory - Audiology - Hearing screening was performed with automated auditory brain stem responses. The baby passed hearing test on [2144-5-16]. Psychosocial - [Hospital1 69] social work involved with the family. The contact social worker is [Name (NI) ] [Name (NI) 47799] or [First Name8 (NamePattern2) 5036] [Name (NI) 4467] and they can be reached at [Telephone/Fax (1) 36390]. Mother denies current abuse from father of baby. She has three other living children and none are in her custody. She denies contact with them. They live with their father, but she denies a DFS history. A 51-A has been filed with DFS in the [Location (un) 3320] office, telephone [Telephone/Fax (1) 55774]. Hepatitis B vaccine was given on [2144-5-13]. CONDITION ON DISCHARGE: Stable. DISPOSITION: Transfer to [Hospital3 3583]. Care of Dr [Last Name (STitle) 46439]. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) ] [Name (STitle) ], [Location (un) 55775], [Location (un) 3320], [Numeric Identifier 55776], telephone [Telephone/Fax (1) 55777]. CARE RECOMMENDATIONS: Feeding - Ad lib feedings of Enfamil 20. Medications - Neonatal Opium Solution (0.4 mg/ml) 0.5 ml every 4 hours. State [Telephone/Fax (1) ] Screening - Sent on [2144-5-17]. Immunizations Received - Hepatitis B vaccine on [2144-5-13]. Immunizations Recommended - Synagis RSV prophylaxis should be administered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: Born at less than 32 weeks, 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 with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW UP: Pediatrician appointment within one day of discharge. Dr. [Last Name (STitle) ] [Name (STitle) ], telephone [Telephone/Fax (1) 55778]. VNA. [Last Name (LF) 780], [First Name5 (NamePattern1) 12130] [Last Name (NamePattern1) ]-[Location (un) 3320], telephone [2144]. Fax [Telephone/Fax (1) 55779]. DISCHARGE DIAGNOSES: Term average for gestational age female. Narcotic Exposure R/O Neonatal Abstinence Syndrome [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Doctor Last Name 55781] MEDQUIST36 D: [2144-5-17] 12:07:29 T: [2144-5-17] 14:25:00 Job#: [Job Number 55782] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2218 }	Medical Text: Admission Date: [2120-6-1] Discharge Date: [2120-6-6] Date of Birth: [2048-7-9] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old gentleman who presented with right-sided visual loss. He woke up with normal vision and noted to his wife at 7:15 a.m. that he was not able to see out of the right side and complained of a slight headache. His son reports that he had normal speech on the telephone, but primary care physician called and reported the patient had slurred speech. No nausea or vomiting. No chest pain or shortness of breath. No weakness. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Temporal lobe epilepsy. MEDICATIONS ON ADMISSION: Tegretol and Lipitor. ALLERGIES: PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, he was in no acute distress. He had some difficulty following commands. His pupils were equal, round, and reactive to light. The extraocular movements were full. There was no nystagmus. The neck was supple. The chest was clear to auscultation. Cardiovascular examination revealed a regular rate and rhythm. The abdomen was soft, nontender, and nondistended. Extremity examination revealed 1+ edema. The skin was normal and dry. Cranial nerves II through XII were intact. Right-sided visual deficit. Motor strength was [6-12]. Sensation was intact. PERTINENT RADIOLOGY/IMAGING: The patient had a magnetic resonance imaging that showed a left temporal lobe mass extending to the parietal area with a large hemorrhage. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was therefore to the operating room and had a left occipital lobe hematoma evacuated without intraoperative complications. The patient was monitored in the Intensive Care Unit postoperatively. He was awake and alert. Pupils were equal, round, and reactive to light. His speech continued to be garbled. He was following commands times four with no motor deficits. His vital signs were stable. On postoperative day one, the patient was alert, awake, and oriented to name. He was following simple commands. He was moving all extremities with some right-sided neglect. The patient was transferred to the regular floor. He continued to remain neurologically stable. The incision was clean, dry, and intact. The patient was seen by the Physical Therapy Service and Occupational Therapy and found to be safe for discharge to home. A repeat head computed tomography postoperatively showed good evacuation of the hematoma. The patient continued to have a right dense homonymous visual field cut on the right side. His vital signs remained stable. DISCHARGE DISPOSITION: He was assessed by Physical Therapy and Occupational Therapy and felt to be safe for discharge to home. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 10 days for staple removal and thereafter in three weeks for a repeat head computed tomography. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tablets by mouth q.4h. as needed. 2. Pravastatin 20 mg by mouth once per day. 3. Colace 100 mg by mouth twice per day. 4. Lansoprazole 40 mg by mouth q.24h. 5. Metoprolol 25 mg by mouth twice per day. 6. Carbamazepine 200 mg by mouth twice per day (for seizures). CONDITION AT DISCHARGE: Stable. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2120-6-6] 10:48 T: [2120-6-6] 10:55 JOB#: [Job Number 11682] ICD9 Codes: 431, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2219 }	Medical Text: Admission Date: [2163-6-20] Discharge Date: [2163-6-22] Date of Birth: [2090-1-9] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 73 year old woman with history of ESRD on HD, hypertension, severe PVD s/p bilateral BKA, and LVH with LVOT who is presenting with acute shortness of breath. She was in her usual state of health until earlier this evening when she noticed that she "just didn't feel right." When she went to lay down, she noted the onset of shortness of breath. She denied chest pain or palpitations. She had her last HD session on Friday. She denies eating salty food or missing medications . In the ED her initial vital signs were 220/110 120 RR 40 and 100% on BIPAP. She continued on BIPAP with improvement in her oxygenation. An EKG was interpreted as unchanged from prior. Nitro-paste was administered for blood pressure control. A left femoral central line was placed for IV access. Both cardiology and nephrology were consulted who recommended urgent dialysis for volume control. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . * Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: - Diastolic CHF with LVOT obstruction at rest - Chronic 2L NC at night - Hypertension - Diabetes - Peripheral vascular disease status post bilateral knee amputations in [2146] (L) and [2157] (R) - GERD - Hypercholesterolemia - ESRD on hemodialysis M,W,F. Receives dialysis at [Location (un) ] hemodialysis center in [Location (un) ]. - Paroxysmal atrial flutter, s/p failed ablation with subsequent a. fib - Peptic ulcer disease - Hypertrophic obstructive cardiomyopathy - Mild mitral stenosis (MVA 1.5-2.0 cm2) - Secondary Hyperparathyroidism - Diastolic Congestive Heart Failure Social History: Social history is significant for the presence of current tobacco use (1 pack per week), and [12-22] PPD x 50 years. There is no history of alcohol abuse. Lives in [Hospital3 ] facility and uses a mobile wheelchair or a walker. Family History: Her father died in his 90s and mother at the age of 102. Patient unable to specify cause of death. She has one living sister and 6 sisters and one brother who passed away. Her family history is significant for coronary artery disease, cancer, and diabetes. Physical Exam: VS: T 97.3, BP 121/69, HR 78, RR 18, O2 99% on 4L Gen: thin elderly, African American female. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. right pupil 2mm->1, left surgical pupil, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP to angle of jaw. gauze in place from LIJ line placement w/o hematoma CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. II/VI holosystolic murmur at LLSB/apex Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles and rhonchi to [12-22] way up back. Abd: flat, soft, NTND, No HSM or tenderness. No abdominal bruits. Ext: No c/c/e. No femoral bruits. b/l BKA. left femoral TLC Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit Left: Carotid 2+ without bruit; Femoral 2+ without bruit Pertinent Results: [2163-6-20*] 12:00AM BLOOD WBC-16.1# RBC-4.34 Hgb-12.5 Hct-41.2 MCV-95 MCH-28.9 MCHC-30.4* RDW-18.8* Plt Ct-350 [2163-6-22] 04:54AM BLOOD WBC-7.8 RBC-4.16* Hgb-12.0 Hct-38.9 MCV-93 MCH-29.0 MCHC-31.0 RDW-17.8* Plt Ct-324 [2163-6-20] 12:00AM BLOOD PT-17.6* PTT-94.2* INR(PT)-1.6* [2163-6-22] 04:54AM BLOOD PT-27.2* PTT-38.1* INR(PT)-2.7* [2163-6-20] 12:00AM BLOOD Glucose-182* UreaN-74* Creat-8.1# Na-140 K-5.6 Cl-100 HCO3-26 AnGap-20 [2163-6-20] 11:30AM BLOOD K-6.4* [2163-6-22] 04:54AM BLOOD Glucose-100 UreaN-65* Creat-6.9# Na-135 K-5.0 Cl-98 HCO3-27 AnGap-15 [2163-6-20] 12:00AM BLOOD CK(CPK)-49 [2163-6-20] 06:24AM BLOOD CK(CPK)-53 [2163-6-20] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.05 [2163-6-20] 06:24AM BLOOD CK-MB-NotDone cTropnT-0.05* [2163-6-20] 06:24AM BLOOD Calcium-8.7 Phos-6.4* Mg-2.7* [2163-6-20] 08:00PM BLOOD Calcium-8.6 Phos-2.8# Mg-2.0 [2163-6-22] 04:54AM BLOOD Calcium-8.7 Phos-5.6# Mg-2.5 Brief Hospital Course: The patient is a 73 year old woman with history of ESRD on HD, severe PVD, LVH with LVOT obstruction presenting with shortness of breath and pulmonary edema. . # CAD: Although patient has with multiple CAD risk factors, prior non-invasive and invasive testing showed no significant obstructive coronary disease. A troponin of 0.04 in the context of normal CK and EKG with no ST-T changes was likely demand ischemia secondary to hypertensive heart disease. Admission EKG did not show signs of active ischemia and the patient was monitored on telemetry and continued on aspirin and statin. . # CHF: The pt's hypoxia was attributed to CHF and not pneumonia as she denied any cough, and was afebrile and lacking a consolidate on chest xray. Pulmonary embolism was also unlikely as the patient is on chronic anticoagulation. Due to chronic diastolic congestive heart failure and a physiologic HOCM that leads to hypotension during dialysis sessions, it is most likely that the patient developed pulmonary edema in the setting of volume status change while receiving dialysis. Her oxygenation status improved significantly following blood pressure and rate control and a dialysis session. There are no PFT's to support the diagnosis of COPD, but marked hyperinflation on CXR and notable smoking history indicated strong possibility of COPD contributing to patient's symptoms so patient was treated with home dose of spiriva and albuterol as needed. The patient was weaned on BiPap and began to breathe comfortably on room air following dialysis. . # Atrial fibrillation: The pt was anticoagulated with coumadin and rate controlled with metoprolol and diltiazem for her history of atrial fibrillation. . # Hypertension: The patient's hypertension was also controlled with diltiazem and metoprolol and following a successful dialysis session her lisinopril and irbesartan were restarted. . # Diabetes: For her diabetes the patient was continued on her home dose of NPH with an insulin sliding scale. . # Hyperkalemia: The patient has end stage renal disease and receiving HD. The patient was orginally volume overloaded and on day two of admission developed hyperkalemia to a K of 6.7. She had no peaked T waves or QT prolongation on EKG and received calcium carbonate and D5/insulin as well as dialysis. Her electrolytes were monitored closely with subsequent K between 4.1 and 5.0. # Heme: On admission labs the patient was erythrocytotic. Prior evaluations had not shown renal mass that could contribute to over production of erythropoietin and on [2163-5-30] the epo level was low normal which would suggest a MPD such as [Initials (NamePattern4) ] [Last Name (NamePattern4) ]. Patient would benefit from heme follow up as an outpatient. Medications on Admission: Nephro-cap 1 capsule daily Warfarin 2 mg Daily Brimonidine 0.15 % Drops DAILY Latanoprost 0.005 % Drops HS Tiotropium 18 mcg DAILY Ranitidine HCl 150 mg DAILY Lisinopril 30 mg DAILY Insulin NPH 4 [Hospital1 ] Albuterol 90 mcg 1 puff:q6hours Aspirin 325 mg daily Simvastatin 80 mg daily Diltiazem HCl SR 120 mg DAILY Irbesartan 150 mg daily Metoprolol Tartrate 100 mg [Hospital1 ] Sevelamer HCl 800 mg TID Discharge Medications: 1. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily (). 13. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4) units Subcutaneous twice a day. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: [Location (un) 86] [Location (un) 269] Discharge Diagnosis: Primary: Acute diastolic Heart Failure End stage renal disease on hemodialysis . Secondary: Peripheral Vascular disease Atrial Fibrillation on Coumadin Hypertension Discharge Condition: stable Discharge Instructions: You were admitted with shortness of breath and acute diastolic heart failure. This has been treated with dialysis & aggressive blood pressure control. . We have not made any changes to your medications, please make sure to adhere to a low salt diet and keep all your follow up appointments as shown below. . If you develop any worsening shortness of breath, chest pain, weakness or any other general worsening of condition, please call your PCP or come directly to the ED. . It is very important that you adhere to a low sodium diet. Followup Instructions: 1. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2163-7-14] 12:40 . 2. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2163-8-29] 11:40am . 3. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2163-12-7*] 1:40pm ICD9 Codes: 5856, 4280, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2220 }	Medical Text: Admission Date: [2138-8-29] Discharge Date: [2138-9-11] Date of Birth: [2089-4-2] Sex: M Service: [Doctor First Name 147] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 57094]-renal shunt History of Present Illness: 49 yo man with h/o binge drinking and remote intravenous drug use who has not seen a physician in over 30 years initially presented to an OSH ED [8-28] with nausea, hematemesis, lightheadedness, and diaphoresis. The pt was never hemodynamically unstable in the OSH ED (HR 81-96, BP 111-150/67-80). In the ED there he received PPI IV, ondansetron, and lorazepam, and he was started on an octreotide gtt. An EGD done on the day of admission there showed blood with clots in the stomach but no active bleed; a 3-4 cm submucosal mass was seen in the fundus of the stomach with overlying clot consistent with a recent bleed. The duodenum was normal. These findings were thought to be consistent with varices vs. leiomyoma vs. submucosal tumor. A CT scan of the abdomen showed splenomegaly and prominent varices clustered in the area of the fundus and GE junction. Given these findings, the pt was transferred here for further evaluation and treatment for portal hypertension. Past Medical History: 1. tobacco abuse 2. binge EtOH use 3. remote intravenous and intranasal drug abuse 4. excision of benign cyst on L anterior chest wall Social History: The patient lives with his family in an apartment in [Location (un) ]. He has six children. He works as a landscaper and general handyman. He has no pets. Family History: The patient's father died at age 72 from complications of Alzheimer's disease. There is a history of diabetes on his father's side of the family. His mother is in her 70s and is well. He has four brothers and three sisters, all of whom are well. The patient has six children, the youngest of whom has asthma. Physical Exam: Temp 98.0 BP 131/64 HR 77 RR 12 SpO2 97% room air Gen: Pleasant man lying flat in bed, appearing his stated age and in no acute distress HEENT: NCAT, no sinus tenderness, conjunctivae pink and non-icteric, OP clear, MMM, no sublingual jaundice, poor dentition Neck: Soft, supple, no LAD CV: RRR, normal S1 and S2, no m/r/g. Pulm: CTA bilaterally Abd: Soft, non-tender, non-distended, active bowel sounds, no palpable hepatosplenomegaly, liver span 6 cm on scratch test Back: No CVA or paraspinal tenderness Ext: 2+ DP pulses, no edema, no teres nails Neuro: Alert, oriented, appropriate, no focal deficits Skin: No rashes, no lesions, no telangiectasias, normal skin tone without jaundice, no caput medusae Pertinent Results: [2138-8-29] 04:11AM BLOOD WBC-7.0 RBC-3.46* Hgb-11.6* Hct-31.4* MCV-91 MCH-33.4* MCHC-36.8* RDW-14.0 Plt Ct-68* [2138-8-30] 06:07AM BLOOD WBC-4.6 RBC-3.26* Hgb-10.7* Hct-29.6* MCV-91 MCH-32.9* MCHC-36.3* RDW-14.3 Plt Ct-67* [2138-8-31] 05:04AM BLOOD WBC-4.5 RBC-3.32* Hgb-11.2* Hct-29.8* MCV-90 MCH-33.7* MCHC-37.5* RDW-14.1 Plt Ct-87* [2138-9-1] 08:50AM BLOOD WBC-5.2 RBC-3.60* Hgb-12.0* Hct-32.5* MCV-90 MCH-33.3* MCHC-36.9* RDW-14.7 Plt Ct-101* [2138-9-2] 08:55AM BLOOD WBC-4.5 RBC-3.38* Hgb-11.6* Hct-30.8* MCV-91 MCH-34.2* MCHC-37.5* RDW-14.8 Plt Ct-97* [2138-9-3] 05:10AM BLOOD WBC-4.3 RBC-3.27* Hgb-11.1* Hct-30.6* MCV-94 MCH-34.1* MCHC-36.4* RDW-15.1 Plt Ct-83* [2138-9-5] 03:50AM BLOOD WBC-3.6* RBC-3.07* Hgb-10.3* Hct-28.2* MCV-92 MCH-33.6* MCHC-36.6* RDW-15.0 Plt Ct-88* [2138-9-5] 12:51PM BLOOD WBC-8.7# RBC-3.39* Hgb-11.5* Hct-31.4* MCV-93 MCH-33.9* MCHC-36.6* RDW-15.3 Plt Ct-125* [2138-9-6] 05:30AM BLOOD WBC-13.0* RBC-3.60* Hgb-12.4* Hct-33.3* MCV-92 MCH-34.5* MCHC-37.3* RDW-15.4 Plt Ct-107* [2138-9-8] 04:58AM BLOOD WBC-10.3 RBC-3.05* Hgb-10.2* Hct-27.9* MCV-92 MCH-33.5* MCHC-36.6* RDW-15.2 Plt Ct-98* [2138-8-29] 04:11AM BLOOD PT-13.9* PTT-28.9 INR(PT)-1.2 [2138-8-29] 11:15AM BLOOD PT-13.8* PTT-29.1 INR(PT)-1.2 [2138-8-31] 05:04AM BLOOD PT-13.6 PTT-27.8 INR(PT)-1.2 [2138-9-5] 03:50AM BLOOD PT-14.4* PTT-30.7 INR(PT)-1.3 [2138-9-7] 04:39AM BLOOD PT-14.1* PTT-34.8 INR(PT)-1.3 [2138-8-29] 04:11AM BLOOD Glucose-132* UreaN-19 Creat-0.9 Na-138 K-4.2 Cl-106 HCO3-25 AnGap-11 [2138-8-31] 05:04AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-139 K-4.0 Cl-106 HCO3-26 AnGap-11 [2138-9-3] 05:10AM BLOOD Glucose-95 UreaN-11 Creat-0.9 Na-137 K-3.8 Cl-103 HCO3-24 AnGap-14 [2138-9-6] 05:30AM BLOOD Glucose-124* UreaN-12 Creat-1.3* Na-138 K-4.1 Cl-105 HCO3-27 AnGap-10 [2138-9-8] 04:58AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-136 K-3.8 Cl-102 HCO3-26 AnGap-12 [2138-8-29] 04:11AM BLOOD ALT-88* AST-80* LD(LDH)-192 AlkPhos-79 Amylase-55 TotBili-1.7* [2138-9-1] 08:50AM BLOOD ALT-81* AST-69* AlkPhos-85 TotBili-1.7* [2138-9-3] 05:10AM BLOOD ALT-66* AST-54* AlkPhos-77 TotBili-1.4 [2138-9-5] 03:50AM BLOOD ALT-49* AST-43* AlkPhos-70 TotBili-1.3 [2138-9-5] 12:51PM BLOOD ALT-52* AST-54* AlkPhos-68 Amylase-76 TotBili-2.0* [2138-9-7] 04:39AM BLOOD ALT-47* AST-60* AlkPhos-67 Amylase-58 TotBili-2.5* [2138-9-8] 04:58AM BLOOD ALT-42* AST-52* AlkPhos-67 TotBili-2.6* [2138-9-9]: Alkphos 115, T Bili 1.4, ALT 39, AST 50 [2138-8-29] 04:11AM BLOOD calTIBC-263 VitB12-540 Folate-13.1 Ferritn-509* TRF-202 Iron-246* [2138-8-29] 04:11AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.8 Mg-1.9 [2138-8-31] 05:04AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.6 [2138-9-5] 12:51PM BLOOD Albumin-3.1* Calcium-8.6 Phos-5.1* Mg-1.4* [2138-9-7] 04:39AM BLOOD Calcium-8.1* Phos-2.4# Mg-1.8 [2138-9-8] 04:58AM BLOOD Albumin-2.7 Calcium-8.0* Phos-2.2* Mg-1.6 [2138-8-29] 04:11AM BLOOD AFP-17.1* [2138-8-29] 04:11AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE [2138-8-29] 04:11AM BLOOD HCV Ab-POSITIVE [2138-8-29] 04:11AM BLOOD TSH-0.44 RADIOLOGY: [8-29] U/S abdomen: 1) Coarsely echogenic liver texture without evidence of focal lesions. 2) Small amount of sludge without evidence of acute cholecystitis. 3) Splenomegaly. 4) No evidence of ascites. Normal Doppler flow. [8-30] CT abdomen: 1. Splenomegaly and large gastric varices, consistent with portal hypertension. 2. Conventional liver anatomy and blood flow with patent hepatic veins and portal vein. [9-2] Celiac angiogram: 1) Enlarged left-sided renal vein with possible small splenorenal shunt. However, this shunt is not seen on the splenic venogram. 2) Widely patent portal vein, splenic vein, and superior mesenteric vein. Varices identified off of the splenic vein. 3) PRESSURES: Left renal vein 9 mmHg, IVC 6 mmHg, hepatic vein 7 mmHg, wedged hepatic 20 mmHg. [9-10] venogram study: No shunt stenosis, with pressures of 31 mmHg in the splenic vein, 25 mmHg in the renal vein, and 15 mmHg in the IVC. Brief Hospital Course: This patient was a 49 yo man with remote history of alcohol abuse, ongoing binge alcohol use, and remote intravenous and intranasal drug abuse who has not seen a physician in over thirty years was transferred to the [Hospital1 18] from an OSH for further evaluation of hematemesis and gastric varices. The patient had an abdominal ultrasound and CT scan, as well as celiac angiogram as part of a workup of portal hypertension. He also had Hepatitis C serologies drawn which showed a positive Hep-C antibody and Hep C viral load of >700,000 by PCR; Hepatitis B serologies were only remarkable for positive core antibody. He had an abdominal ultrasound on [8-29] which demonstrated a coarsely echogenic liver texture without evidence of focal lesions, a small amount of sludge in the gall bladder, and splenomegaly. A CT scan on [8-30] demonstrated similar findings as well as conventional liver anatomy. His celiac angiogram on [9-2] demonstrated an enlarged left-sided renal vein with possible small splenorenal shunt, as well as idely patent portal vein, splenic vein, and superior mesenteric veins. [Pressures of : Left renal vein 9 mmHg, IVC 6 mmHg, hepatic vein 7 mmHg, wedged hepatic 20 mmHg]. Varices were identified off of the splenic vein. With regards to his hematemesis, the patient was noted to be hemodynamically stable throughout his hospital course and did not have any episodes of hematemesis during his hospital stay. He had an anemia workup which was unremarkable with a normal serum Folate, B12, TIBC, and transferrin on [8-29]. His hematocrit remained stable in the 27 to 33 range throughout his hospitalization. After thorough discussion of risks and benefits, the patient underwent [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) 57094]-renal shunt for treatment of severe portal hypertension on [2138-9-5]. The patient was noted to do remarkably well in his post-operative course, with good pain control and tolerating a regular diet by POD 4. He had a venogram study on post-operative day 5 which demonstrated no shunt stenosis, with pressures of 31 mmHg in the splenic vein, 25 mmHg in the renal vein, and 15 mmHg in the IVC. Medications on Admission: 1. octreotide gtt 2. pantoprazole 40 mg IV BID 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). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:10 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Portal Hypertension Discharge Condition: Fair Discharge Instructions: Please call the office or come to the emergency room with any worsening of abdominal pain, new-onset jaundice, or fever. You may shower but no baths/swimming for 2 weeks. No heavy lifting for 5 weeks. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in on [2138-9-17], 9:20 am. Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] CENTER (NHB) Where: LM [Hospital 5628] CLINIC Phone:[Telephone/Fax (1) 673] Date/Time:[2138-9-17] 9:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2138-9-11] ICD9 Codes: 2875, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2221 }	Medical Text: Admission Date: [2184-9-30] Discharge Date: [2184-10-4] Date of Birth: [2143-1-25] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 2009] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 41 yo male with a PMH of a fall off a ladder [2179] with multiple MSK injuries requiring T10-L3 fusion, iliac crest bone graft, ORIF of right femur, and eventual total left hip replacement [5-11] with multiple infectious complications of his left hip replacement (including MRSA septic arthritis) which was finally removed with spacer placed. He presented on [2184-9-30] with asymptomatic hypotension and ? sepsis. Please see MICU [Location (un) ] H&P for full HPI, PMH, home meds, SH, FH. Briefly, after his septic arthritis, he required a prolonged course of vanc, but unfortunately became [Last Name (LF) 60810], [First Name3 (LF) ] it was changed to dapto in [Month (only) ]. He was subsequently doing well up until this admission. . Because of hypotension and tachycardia, he was sent to MICU 6. He had a nl lactate, and he was on transient pressors while awaiting fluid management, but was ultimately fluid responsive. His VS have since been stable. He was initially placed on dapto/zosyn. His BCx have grown out enterococcus and his urine is growing GNRs. Despite joint fluid from his left hip showing WBC of 1800, ortho felt this was not a septic joint. ID was consulted bc they are following him as an outpatient. Their latest recs were to stop dapto bc they felt enteroccus would respond to ampicillin (not VRE). A TTE was negative, but a TEE is recommended. His PICC was removed and cultured (no signficant growth). He has one PIV, refusing another. . In addition to the above, he has had bradycardia with HRs in 40s-50s, thought to be related to vagal tone. His PR has been wnl and the bradycardia has been asymptaomtic. He has a hx of svt, on dilt, which is being held for the bradycardia. . He has also had ARF to 2.8, bl 0.9. This is felt likely ATN after hypoperfusion [1-5] to hypotension. He is making urine and has gotten roughly 6L of IVF, + 2.5L LOS. . Finally, he has been disruptive in the ICU. He has a hx of depression and polysubstance abuse. Today, upon talking with psychiatry, he was verbally abusive to him. He apparently was nearing code purple, but he calmed down spontaneously. Psych felt he is compitent to make dnr/dni and to make medical decisions, including AMA. Past Medical History: 1) L THR [2184-5-20] (due to traumatic osteoarthritis [2179] - fell off ladder), L hip MRSA prosthetic joint infection with bacteremia, s/p explant [6-9], multiple washouts, spacer placement, 2) ex-lap with resection of his small bowel, 3) ORIF R femur, 4) T10-L3 fusion, transpedicular decompression, at T12, multiple laminotomies, 5) right Iliac Crest Bone Graft, 6) h/o polysubstance abuse, etoh, cocaine 7) depression, s/p multiple suicide attempts: cocaine binge, radial artery laceration/percocet overdose 8) SVT after washouts, responded to dilt 9) h/o GI bleed in the setting of thrombocytopenia from Vancomycin, improved with stopping Vanco, refused colonoscopy Social History: Mom died while pt hospitalized for initial fall. h/o incarceration Disability. Tobacco 1.5 ppd. ETOH, crack cocaine, opiate use in past. Denies IVDU. Last EtOH and drug use in [1-12]. Family History: NC Physical Exam: Tm/c 96.8 HR 65, 56-83 114/72, 87-120/45-75 RR 20 93-99%RA PHYSICAL EXAM GENERAL: NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP=12cm on left LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No c/c/e SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Grossly nonfocal Pertinent Results: [2184-9-29] 11:50PM BLOOD WBC-14.7# RBC-3.33 Hgb-9.3* Hct-27.3* MCV-82 MCH-28.1 MCHC-34.2 RDW-16.3* Plt Ct-186 [2184-9-30] 06:34AM BLOOD WBC-9.6 RBC-2.99* Hgb-8.1* Hct-25.2* MCV-85 MCH-27.1 MCHC-32.0 RDW-15.9* Plt Ct-164 [2184-9-30] 02:38PM BLOOD WBC-6.0 RBC-2.90* Hgb-8.0* Hct-24.4* MCV-84 MCH-27.7 MCHC-32.8 RDW-16.3* Plt Ct-169 [2184-10-1] 03:25AM BLOOD WBC-6.5 RBC-3.17* Hgb-8.9* Hct-26.8* MCV-85 MCH-28.0 MCHC-33.1 RDW-16.3* Plt Ct-217 [2184-10-2] 05:40AM BLOOD WBC-6.2 RBC-3.35* Hgb-9.1* Hct-28.4* MCV-85 MCH-27.1 MCHC-31.9 RDW-16.0* Plt Ct-257 [2184-10-3] 06:45AM BLOOD WBC-6.7 RBC-3.15* Hgb-9.0* Hct-26.6* MCV-85 MCH-28.6 MCHC-33.8 RDW-16.3* Plt Ct-286 [2184-10-4] 07:10AM BLOOD WBC-8.9 RBC-3.42* Hgb-9.6* Hct-28.4* MCV-83 MCH-28.0 MCHC-33.7 RDW-16.3* Plt Ct-333 [2184-9-29] 11:50PM BLOOD Neuts-86* Bands-2 Lymphs-5* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2184-10-1] 03:25AM BLOOD Neuts-51 Bands-2 Lymphs-32 Monos-8 Eos-6* Baso-1 Atyps-0 Metas-0 Myelos-0 [2184-9-29] 11:50PM BLOOD PT-13.5* PTT-24.2 INR(PT)-1.2* [2184-9-30] 06:34AM BLOOD PT-13.3 PTT-27.3 INR(PT)-1.1 [2184-10-4] 07:10AM BLOOD Plt Ct-333 [2184-9-29] 11:50PM BLOOD ESR-99* [2184-9-29] 11:50PM BLOOD UreaN-33* Creat-2.9# [2184-9-30] 06:34AM BLOOD Glucose-136 UreaN-31* Creat-2.7* Na-137 K-3.2* Cl-103 HCO3-23 AnGap-14 [2184-9-30] 02:38PM BLOOD UreaN-30* Creat-2.7* Na-142 K-3.4 Cl-109* HCO3-23 AnGap-13 [2184-10-1] 03:25AM BLOOD Glucose-108* UreaN-31* Creat-2.8* Na-144 K-4.0 Cl-110* HCO3-24 AnGap-14 [2184-10-2] 05:40AM BLOOD Glucose-85 UreaN-24* Creat-2.5* Na-145 K-3.6 Cl-111* HCO3-23 AnGap-15 [2184-10-3] 06:45AM BLOOD Glucose-93 UreaN-18 Creat-2.2* Na-144 K-3.4 Cl-109* HCO3-24 AnGap-14 [2184-10-4] 07:10AM BLOOD Glucose-93 UreaN-13 Creat-2.0* Na-145 K-3.3 Cl-110* HCO3-26 AnGap-12 [2184-9-30] 06:34AM BLOOD ALT-9 AST-17 LD(LDH)-201 AlkPhos-86 TotBili-0.5 [2184-9-30] 02:38PM BLOOD LD(LDH)-199 TotBili-0.3 [2184-9-30] 06:34AM BLOOD Albumin-2.8* Calcium-7.5* Phos-3.9 Mg-1.6 [2184-10-4] 07:10AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.7 [2184-9-30] 02:38PM BLOOD calTIBC-195* Hapto-285* Ferritn-380 TRF-150* [2184-9-29] 11:50PM BLOOD CRP-235.2* [2184-9-30] 06:34AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2184-9-29] 11:55PM BLOOD Glucose-129* Lactate-1.3 Na-133* K-3.3* Cl-93* calHCO3-24 [2184-9-30] 04:53AM BLOOD Lactate-1.0 [2184-9-30] 04:53AM BLOOD Hgb-9.1* calcHCT-27 ECHO ([2184-9-30])- The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Chest X-ray ([2184-9-30])- IMPRESSION: No acute intrathoracic process. CT Pelvis ([2184-9-30])- IMPRESSION: 1. Redemonstration of methyl methacrylate beads, wire and spacing device in the left acetabulum/proximal femur with proximal migration of the femur. 2. No frank joint effusion identified. High density soft tissue in region of hip joint, may represent granulation tissue. 3. Bilateral fat-containing inguinal hernias. ECG ([2184-9-30])- Sinus bradycardia. Incomplete right bundle-branch block. Prolonged Q-T interval. Compared to the previous tracing of [2184-7-6] an RSR' pattern is now present in lead V1 with a slight increase in the QRS duration. The sinus rate is slower. Premature atrial beats are no longer present. Chest X-ray for line placement ([2184-10-4])- FINDINGS: Radiodense wire of left PICC terminates in the lower superior vena cava just above the junction with the right atrium. Heart size is normal, and lungs are grossly clear. Brief Hospital Course: #. Septic shock - Patient was hypotensive on admission and was admitted to the MICU. It was determined this was most likely SIRS/sepsis that was fluid responsive (received 2L NS in MICU). He was transferred to the floor on [2184-10-1]. Hypotension has since resolved. BP on discharge was 144/80. Patient treated for bacteremia, initially with ampicillin and zosyn. Zosyn was discontinued after urine cultures returned (showed GNRs). He was switched to PO cipro 500mg PO q12hr. Ampicillin continued at 2gm IV q4hr. Patient had PICC line placed on [10-4]- chest x-ray showed tip in lower SVC. Please apply heat to LUE 4 times a day for 2-3 days. #. Bacteremia: Patient currently on ampicillin and cipro for enterococcus and GNR coverage. Joint fluid, PICC culture and blood cultures have not grown anything to date. Joint fluid thought not septic by ortho. TTE was negative for endocarditis. ID team did not feel like patient needed a TEE also given negative TEE. Urine culture grew pan-sensitive klebsiella (MIC <.25 for cipro). Patient remained afebrile with normal WBC. ID followed patient- regarding discharge planning, they recommended ampicillin 2gm q 4hr for total of 14 days (day 1- [10-1]). They said if IV access is lost again, then to give PO linezolid. Patient is to also continue cipro 500mg PO BID x 7 days (day 1- [10-2]). #. Anemia - Patient has a history of normocytic anemia secondary to chronic inflammation with negative DIC/TTP labs on previous hospitalization. Hct trended up while here (24.4 on admission and 28.4 on discharge). He did not require any blood transfusions while in the hospital. No signs of active bleed or hematoma at surgical site. #. Acute Renal Failure - Admissions creatinine up to 2.8 from baseline of 0.9. An FENA was 0.5 suggesting prerenal etiology. Patient maintained excellent UOP while in the hospital. Creatinine trended down daily (was 2.0 on discharge). #. Bradycardia - HR was down to high 30s in ED. Patient was on CCB at home- his diltiazem was held while here. Patient had normal PR interval. It was felt bradycardia was secondary to vagal tone. Diltiazem was held on discharge. HR upon discharge was 60. Patient denied any headache, dizziness, or syncope. #. Depression- Patient on fluoxetine 40mg daily. Currently has no outpatient psychiatrist at this time. He had no suicidal ideation while here. Patient was seen by psych in the ICU and felt he had capacity for code status and AMA decisions. Patient did nearly code purple on [10-1] but he calmed down on his own. However, he was code purpled on [10-2] after altercation with IV nurse. Patient threatened to leave AMA but decided to stay after it was explained to him that he needed antibiotics. IV was placed later on that evening. After that he remained calm and appropriate. #. S/p left hip arthroplasty- Orthopaedics saw patient while here. They aspirated the joint fluid and determined it was not septic. They recommended patient be NWB LLE. #. Polysubstance abuse - Last use of cocaine/EtOH was [1-12]. #. CODE STATUS: DNR/DNI confirmed in ICU . # Follow up: Will need ID, ortho and pcp follow up, as well as BMP this week. Medications on Admission: Heparin 5000 UNIT SC TID Ampicillin 1 g IV Q6H Calcium Carbonate 500 mg PO/NG QID:PRN Nicotine Patch 21 mg TD DAILY Docusate Sodium 100 mg PO/NG [Hospital1 ] Piperacillin-Tazobactam 2.25 g IV Q8H Fluoxetine 40 mg PO/NG DAILY Simethicone 40-80 mg PO QID:PRN indigestion Gabapentin 300 mg PO/NG TID HYDROmorphone (Dilaudid) 8 mg PO/NG Q4H:PRN pain Discharge Medications: 1. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q4H (every 4 hours). 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion/GERD. 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 8. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: Rosscommons Discharge Diagnosis: Primary: Bacteremia Secondary: S/p left hip replacement Discharge Condition: Good, vital signs stable Discharge Instructions: You were admitted to the hospital with an infection in your blood. While here, you were treated with antibiotics and did well. You remained afebrile with normal white blood cell count. Tests showed that you did not have any infection on your heart valves. Upon discharge, you were afebrile and stable. The following changes were made to your medications: 1. Please continue ampicillin 2mg IV every 4 hrs for a 14 day course (day 1- [10-1]) 2. Please continue ciprofloxacin 500mg by mouth every 12hrs for a 7 day course (day 1- [10-2]) 3. Please discontinue your diltiazem If you experience any fevers, chills, chest pain, shortness of breath, headaches, or any other medically concerning symptoms, please contact your primary care physician or go to the emergency department immediately Followup Instructions: Please follow-up with infectious disease ([First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288], MD- [Telephone/Fax (1) 457]) on [2184-10-15] at 9:00am Please follow-up with your [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN on [2184-10-20] at 2:40pm. Completed by:[2184-10-5] ICD9 Codes: 5845, 5990, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2222 }	Medical Text: Admission Date: [2139-1-29] Discharge Date: [2139-2-12] Date of Birth: [2088-4-5] Sex: F Service: CARDIOTHORACIC Allergies: Zestril / Fioricet / Codeine / Ibuprofen Attending:[First Name3 (LF) 1283] Chief Complaint: MRSA sternal wound infection and prosthetic valve endocatditis Major Surgical or Invasive Procedure: s/p sternal wound debridement and pectoral flaps History of Present Illness: Ms [Known lastname ] is s/p MVR [12-27], now presented with several days of sternal drainage, fever and lethargy Past Medical History: s/p MVR sternal wound infection prosthetic valve endocarditis s/p sternal debridement and pectoral flaps Type I DM HTN depression Social History: Patient lives alone, smoke 1 pack/day, no alcohol or recreational drug use. Family History: Father died from MI at age 45 Physical Exam: [2-12] Tm 98.7 P95 BP 130/60 RR20 SpO298% on RA Neuro:awake, alert, orientedx3 CV:RRR, I-II/VI SEM Resp:BS clear bilat sternal incision with sutures in place, clean, dry. JP draining serosangunous drainage Abd:+bowel sounds, soft, non-tender, non-distended lower extremities warm, well perfused, 1+ edema Pertinent Results: [2139-2-12] 03:55AM BLOOD WBC-14.1* RBC-3.10* Hgb-8.7* Hct-26.8* MCV-87 MCH-28.1 MCHC-32.5 RDW-16.3* Plt Ct-424 [2139-2-12] 03:55AM BLOOD Plt Ct-424 [2139-2-12] 03:55AM BLOOD Glucose-143* UreaN-13 Creat-0.8 Na-127* K-3.8 Cl-90* HCO3-32* AnGap-9 [2139-2-10] 06:48PM BLOOD ALT-25 AST-27 LD(LDH)-536* AlkPhos-199* TotBili-0.6 [2139-2-12] 04:11AM BLOOD Vanco-25.5* Brief Hospital Course: Ms [Known lastname ] was admitted on [1-29] with several days of purulent drainage from her sternal incision. On admission she was febrile, lethargic and hypotensive with large amounts of purulent sternal drainage. She was taken to the operating room that evening for debridemnt. Plastic surgery was consulted and it was decided to close the wound at a later time. She was in the intensive care unit sedated and intubated until her wound closure. Her hemodynamics stabilized post operatively. In the operating room, a trans esophageal echocardiogram was performed and it was noted that the patient had a 0.5 x 1.0 cm vegetation on the posterior leaflet of the mitral valve. Her cultures from her sternal wound and blood grew MRSA. She was seen by infectious disease and started on vancomycin, rifampin and gentamycin. On [2-4] she was taken to the operating room by plastic surgery team for pectoral flap closure. [2-5] her sedation was weaned and she was extubated from mechanical ventillation. She was transfered to the floor on [2-6]. She had a persistently elevated WBC, she was pan cultured, had a repeat echocardiogram which showed persistent vegetaion. She had a PICC line placed for long term antibiotics and her central line removed and her WBC began to decrease. On [2-12] she was cleared for discharge to rehab Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sertraline HCl 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QOD (). 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 12. Rifampin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 19. Gentamicin in Normal Saline 80 mg/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 7 days: please check gentamycin peak and trough and BUN/creatinine q 3 days while on gentamycin. 20. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours): please check trough after 3rd dose. 21. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [Doctor Last Name ] TCU at [Location (un) ] [Hospital 1459] Hospital Discharge Diagnosis: s/p MVR MRSA sternal wound infection prosthetic mitral valve endocarditis s/p sternal wound debridement and pectoral flaps Type I DM chronic hyponatermia depression HTN Discharge Condition: good Discharge Instructions: Fluid Restriction:1200 do not apply anything to your incision Followup Instructions: Provider: [Name10 (NameIs) ] surgery clinic Where: [Hospital6 29] SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 274] Date/Time:[2139-2-20] 1:30. Please call [Telephone/Fax (1) 274] with any questions. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Where: [Hospital6 29] [Hospital ] Phone:[Telephone/Fax (1) 250] Date/Time:[2139-3-3] 9:00 follow up with Dr. [Last Name (STitle) ] in 1 month follow up with Dr. [First Name4 (NamePattern1) 8516] [Last Name (NamePattern1) 17444]/ID follow up with Dr. [First Name8 (NamePattern2) 1312] [Last Name (NamePattern1) 10088]/[Hospital ] Clinic in 1 month Completed by:[2139-2-12] ICD9 Codes: 7907, 3572, 2761, 4019, 2720, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2223 }	Medical Text: Admission Date: [2141-1-2] Discharge Date: [2141-1-8] Date of Birth: [2073-3-25] Sex: F Service: OME HISTORY OF PRESENT ILLNESS: Ms. Ms. [Known lastname 84593] is a 67-year-old female with metastatic renal cell carcinoma, admitted today to begin cycle 1, week 1, high-dose IL-2 therapy. Her oncologic history began in [2134], after she underwent an MRI to evaluate back pain was incidentally found to have a left kidney mass. She underwent left nephrectomy at that time. A small liver lesion was noted during her yearly followup CT scans for which she underwent an ultrasound which did not reveal metastatic disease. During an annual mammogram on [2140-7-8], she was discovered to have a new density in her right breast. An ultrasound guided biopsy of this mass was performed on [2140-8-11], and pathology revealed the presence of an invasive carcinoma with clear cell features concerning for metastatic renal cell carcinoma. PET CT performed on [2140-8-26], showed the presence of a lesion in the medial right hepatic lobe, worrisome for a growing neoplasm. An additional low attenuation lesion on the lateral right hepatic lobe was also seen. No liver lesion was biopsied on [2140-9-12], with pathology consistent with renal cell carcinoma. She was referred here to discuss treatment options. She was planned for liver and breast resection on [2140-10-28], but her liver lesion was more extensive than thought prior to surgery and could not be resected. She underwent right partial mastectomy with pathology from the breast and a repeat liver biopsy confirming metastatic kidney cancer. Systemic options were discussed and she wanted to consider high-dose IL-2 therapy. She passed eligibility testing and presents today to begin cycle 1, week 1, high- dose IL-2 therapy. PAST MEDICAL HISTORY: Thyroid cancer [2131], status post thyroidectomy and radioiodine treatment; renal cell cancer as above; status post tonsillectomy in [2091]; bladder surgery in [2099]; status post hysterectomy and bladder repair in [2101]; cholecystectomy in [2118]; multiple bladder repairs including a sling in [2136], and multiple rectocele repairs from [2137]-[2139]; arthroscopic left knee surgery in [2127]. ALLERGIES: Levofloxacin, morphine, and tape. MEDICATIONS: Evista 60 mg p.o. daily, Effexor 37.5 mg p.o. daily, Toprol XL 75 mg daily on hold, Synthroid 150 mcg daily with additional 75 mcg on Wednesdays, temazepam 30 mg p.o. at bedtime, Estrace cream every other day, vitamin D 1000 units daily, calcium 600 mg p.o. b.i.d. PHYSICAL EXAMINATION: GENERAL: Well-appearing female, no acute distress. Performance status 1. VITAL SIGNS: 96 9, 78, 20, 142/70, O2 sat 96% on room air. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Moist oral mucosa with areas of erythema on her bilateral lower mandible. NECK: Supple. Lymph nodes. No cervical, supraclavicular or bilateral axillary lymphadenopathy. HEART: Regular rate and rhythm, S1, S2. CHEST: Clear bilaterally. ABDOMEN: Rounded, soft, nontender, no HSM or masses. EXTREMITIES: No edema. NEUROLOGIC: Exam nonfocal. SKIN: Right upper quadrant right breast scars are well-healed. LAB RESULTS: White blood count 6.4, hemoglobin 12.8, hematocrit 37.1, platelet count 274,000, INR 1, BUN 16, creatinine 1, sodium 140, potassium 4.3, chloride 105, CO2 26, glucose 111, ALT 64, AST 54, LDH 209, CK 119, total bili 0.3, albumin 4.0. HOSPITAL COURSE: Ms. [Known lastname 84593] was admitted and underwent central line placement to begin therapy. Her admission weight was 91 kg and she received interleukin-2, 600,000 units per kg based on adjusted ideal body weight, equaling 40.1 milliunits IV every 8 hours x14 potential doses. During this week she received of [11-9] doses, with 2 doses held due to development of shock on day 5, and 2 doses held due to fatigue on days 4 and 5. Side effects during this week included diarrhea improved with antiemetic therapy; mild nausea improved with Ativan; an erythematous pruritic skin rash; mucositis and fatigue. On treatment day #5, after her 10th dose of IL-2, she became hypotensive and was placed on dopamine to a max of 6 mcg per kilogram per minute. At that time her blood pressure was in the high 50s. She was placed in Trendelenburg with Neo- Synephrine added and titrated up to 3.5 mcg of Neo with continued hypotension. She was given a liter of normal saline. She initially stabilized with blood pressure in the high 90 to low 100s, and then again developed hypotension to the 70-80 range with additional IV fluids given. She was hypoxic to the 80s requiring non-rebreather, and there was concern for pulmonary edema given recent IL-2 dosing, capillary leak and fluid boluses. She was also noted to be lethargic with difficulty staying awake. Decision was made to transfer her to the ICU, given maximum Neo and dopamine dosing currently on the floor, with associated hypoxia and lethargy concerning for CO2 retention. She was transferred to the unit where she improved from a mental status perspective. She was slowly weaned off vasopressor therapy and was transferred out of the unit the following day doing well. Her hypoxia improved and she was treated with Lasix on treatment day #6 once her systolic blood pressure stabilized. She had no further hypotension throughout her hospitalization. During this week she developed acute renal failure with a peak creatinine of 3.3 improved to 2.9 at the time of discharge. She had associated oliguria and metabolic acidosis with a minimum bicarb of 18 improved with bicarbonate replacement intravenously. Electrolytes were monitored and repleted per protocol. Strict I's and O's, serum chemistries were maintained. Intravenous fluids were initially continued at maintenance and increased when she developed hypotension. During this week she developed transaminitis with a peak ALT of 55 and a peak AST of 71, both improved at the time of discharge. She developed hyperbilirubinemia with a peak bilirubin of 3.2, improved to 1.9 at the time of discharge. She was anemic without need for packed red blood cell transfusion. She developed thrombocytopenia with a platelet count low of 103,000 without evidence of bleeding. She had no coagulopathy or myocarditis noted. By [2141-1-8], she had recovered from side effects to allow for discharge to home. CONDITION ON DISCHARGE: Alert, oriented and ambulatory. DISCHARGE STATUS: To home with her husband. DISCHARGE DIAGNOSIS: Metastatic renal cell carcinoma - status post cycle 1, week 1, high-dose IL-2 complicated by shock, pulmonary edema and acute renal failure. DISCHARGE MEDICATIONS: Lasix 20 mg p.o. daily x5 days or until you reach pretreatment weight, Tylenol 1-2 tablets q.i.d. p.r.n. fever or pain, Zantac 150 mg p.o. b.i.d. p.r.n. indigestion, lorazepam 0.5 mg t.i.d. p.r.n. nausea/vomiting, Benadryl 25-50 mg q.i.d. p.r.n. pruritus, Compazine 10 mg t.i.d. p.r.n. nausea/vomiting, Keflex 500 mg p.o. b.i.d. x5 days, Lomotil 1-2 tabs q.i.d. p.r.n. diarrhea, Eucerin cream topically, Sarna lotion topically, levothyroxine 750 mcg p.o. daily, venlafaxine 37.5 mg p.o. daily, Gelclair 15 ml t.i.d. p.r.n. mucositis, Nystatin 5 ml p.o. q.i.d. p.r.n. thrush, Percocet 1-2 tablets t.i.d. p.r.n. pain. FOLLOWUP PLANS: Ms. [Known lastname 84593] will return in 1 week for week number 2 of therapy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [MD Number(1) 7782] Dictated By:[Last Name (NamePattern1) 18853] MEDQUIST36 D: [2141-2-22] 16:20:11 T: [2141-2-23] 15:05:46 Job#: [Job Number 84594] ICD9 Codes: 5849, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2224 }	Medical Text: Admission Date: [2124-3-24] Discharge Date: [2124-3-31] Date of Birth: [2090-9-22] Sex: F Service: MEDICINE Allergies: Cisatracurium / penicillin G / morphine Attending:[First Name3 (LF) 30] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation, mechanical ventilation History of Present Illness: 33F w/muscular dystrophy, OSA on CPAP, Cushings s/p pituitary resection, DMII, hypothyroid p/w SOB. . Presented from home. Was in USOH until last night when she developed a sore throat and then URI symptoms with cough. This progressed to include nausea, vomitting and diarrhea. Per her husband, she took one dose of narcotic cough syrup (likely vicodin containing). . Presented to [Doctor Last Name 1495] Medical Center where came in with lethargy, SOB, AF with RVR. Appeared pale, cool, dusky, RR 12, sat 68% RA.Given Dilt f/b Dilt gtt, and autoconverted back to sinus rhythm. CPAP initiated. CT chest with contrast reportedly unremarkable, not sent over. Trop (X) 0.196 at OSH. ABG 7.21 / 77 /110 on NRB. +opiates on tox screen. Did have transient improvement of mental status and vomited with 2 mg Narcan at OSH. . Pt denied any complaints (including fevers, CP, SOB, palps, abd pain, N/V, HA), [Last Name (un) ] arousable to voice, but quickly falls back asleep. Endorsed taking cough syrup last few days, unsure if contains codeine, o/w denied any drug use. EMS gave supplemental O2 but not PPV. In our ED: arousable to voice then falls back to sleep, pupils 4 mm, moving all extremities. Vomiting lethrgic on arrival afib co2 retention to 75- on CPAP- ? response to narcan? maybe [Hospital1 ] gen? - Initial vitals: 97.4 90 129/77 30 96% 15L - EKG: SR@90 NA NI - diltiazem gtt d/c'd - Trop-T 0630 - 0.08 - BiPAP initiated - ABG a few min after started BiPap: resp acidosis, improved from prior at OSH (pH 7.28 pCO2 63 pO2 229 HCO3 31 BaseXS 1) - repeat ABG 0810 - 7.27 pCO2 64 pO2 88 HCO3 31 BaseXS 0 - cxr: Poor film, AP, large heart, crowded, looks fluid overload - head ct - - Additional Narcan 0.4 mg --> improved mental status - ED thinking - possible unifying diagnosis would be opiate overdose leading to respiratory depression leading to hypoxia leading to NSTEMI and AFib - 99, HR 80-90, BP 100/60, Sat 99% on 50%, [11-10] Past Medical History: Myotonic dystrophy type 1 - per husband no Cardiac structural abnormalities, high normal QRS and mild bradycardia. [Month/Day (1) ] wants her to take mexiletine and modafinil. Cushings s/p pituitary resection OSA uses CPAP, tonsillectomy that did not change CPAP settings [12-15] - admitted for pneumonia and discharged on O2 (Multilobar PNA) [2122-8-6] - admitted for LUL pneumonia to Saints and discharged on O2. Continued shortness of breath attributed to hibiscus plant with fungal spores Gout Hypothyroidism last talked to PCP in [Name9 (PRE) 216] about hair loss Social History: She is [Name8 (MD) ] RN with VNA of [Location (un) 3307]. Husband works in respiratory at [Hospital1 18]. - Tobacco: none - Alcohol: none - Illicits: none Family History: non-contributory Physical Exam: Admission Physical: Initial 97.4 90 129/77 30 96% 15L Vitals at 1000: 108/72, HR 80, 99% on 50% BIPAP General: Lethargic but arousable to voice, no acute distress HEENT: NCAT, Sclera anicteric, BIPAP Neck: supple, JVP not elevated, no LAD Lungs: Air movement to bases with crackles on left side to midlevel CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ edema to knees Discharge Physical: Pertinent Results: ADmission labs: Discharge labs: Micro: MRSA SCREEN (Final [2124-3-26]): No MRSA isolated. SPutum: GRAM STAIN (Final [2124-3-24]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2124-3-26]): RARE GROWTH Commensal Respiratory Flora. [2124-3-24] 8:24 pm Influenza A/B by DFA Source: Nasopharyngeal swab. FINAL REPORT [2124-3-27] DIRECT INFLUENZA A ANTIGEN TEST (Final [2124-3-25]): Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by DFA testing Interpret all negative results from this specimen with caution. Negative results should not be used to discontinue precautions. Refer to respiratory viral culture results. Recommend new sample be submitted for confirmation. Reported to and read back by DR [Last Name (NamePattern4) 92318] [2124-3-25] 1125AM. DIRECT INFLUENZA B ANTIGEN TEST (Final [2124-3-25]): Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by DFA testing Interpret all negative results from this specimen with caution. Negative results should not be used to discontinue precautions. Refer to respiratory viral culture results. Recommend new sample be submitted for confirmation. Respiratory Viral Culture (Final [2124-3-27]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [Telephone/Fax (1) 6182] within 1 week if additional testing is needed. [2124-3-24] 9:35 pm BLOOD CULTURE Source: Line-central. Blood Culture, Routine (Pending): [2124-3-25] 5:54 pm SPUTUM Source: Endotracheal. FINAL REPORT [2124-3-27] GRAM STAIN (Final [2124-3-25]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2124-3-27]): NO GROWTH. Images: TTE [2124-3-24]: Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a borderline mild resting left ventricular outflow tract systolic gradient. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Tricuspid regurgitation is present but cannot be quantified. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. CT head w/o [3-24]: IMPRESSION: 1. Global loss of [Doctor Last Name 352]-white matter differentiation may be secondary to hypoxic injury. For further evaluation, could consider an MRI if not contraindicated. 2. No evidence of hemorrhage. CTA [3-24]: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Scattered ground-glass and more consolidative opacities throughout the lungs, with a bilateral lower lobe predominance, thought to be infectious in etiology. Prominence of bilateral hilar lymph nodes is likely reactive. 3. Moderate bilateral lower lobe atelectasis. 4. Diffuse hepatic fat deposition. CXR [2124-3-27]: IMPRESSION: 1. The right subclavian PICC line now has its tip in the mid SVC in satisfactory position. The right internal jugular central line continues to have its tip in the right atrium. A nasogastric tube is seen coursing below the diaphragm with the tip not identified. Endotracheal tube continues to have its tip approximately 4 cm above the carina. 2. Relatively low lung volumes with crowding of the vasculature and likely residual perihilar edema. Left basilar airspace process appears slightly worsened and may reflect worsening lower lobe atelectasis. Pneumonia should also be considered. No large right effusion. No large pneumothorax on the supine film. Brief Hospital Course: Mrs. [Known lastname 8529] is a 33 F with Myotonic dystrophy type 1, remote history of multilobar pneumonia, and new rapid respiratory failure in the setting of URI symptoms and recent history of presents with lethargy and sob. She was admitted to the MICU and intubated for respiratory failure. # Hypercapneic Respiratory Failure: The patient was intubated in the ED, and transferred to the ICU. Etiology was thought to be due to her underlying neuromuscular disorder in combination with pneumonia and/or possible viral bronchitis and use of opioid-based cough suppressants. Her CXR showed opacities concerning for pneumonia, and she was treated with Ceftriaxone and Levofloxacin for a total of a 7 day course. Her respiratory viral screen was negative. CTA done on [3-25] and was negative for PE's, but did show ground glass opacities concerning for infection versus atelectasis. Her ventilation was weaned, and she was extubated on HD #4. The extubation was complicated by laryngeal edema treated with a steroid [Doctor Last Name 2949] and was nearly resolved by discharge. She was transferred to the medical floors on HD#5 and continued to improve and was discharge on HD# 7 after her last dose of antibiotics. She was instructed to follow up with her neuro muscular specialist and to avoid opioid-based cough suppressants. # Somnolence: Thought in part due to narcotics and hypercapnea in setting of respiratory failure. Thought that narcotics may have contributed to respiratory depression, leading to hypercarbia and worsening somnolence. The patient's mental status improved on HD#2 and she was following commands. Pt's mental status back to baseline by extubation. # R thigh pain: patient endorses burning R thigh pain, which has been unchanged for 2 weeks prior to presentation. Patient was told to follow up with her PCP for further evaluation and management. # Hypothyroid: continued on Levothyroxine. # Elevated liver enzymes: Nonspecific pattern potentially related to MD, likely NAFLD/NASH, given CT findings. Would recommend follow-up for further evaluation as an outpatient. # Elevated Troponin: Elevated on admission to 0.08, potentially related to initial afib, and down trended with flat CK-MB. # Afib: Single episode on arrival to ED, likely triggered by hypoxia, resolved in the ICU. Not started on anti-coagulation and the patient remained in sinus rhythm from HD#1 until discharge. # diarrhea- The patient developed watery non-bloody on HD#5, which was C.diff negative thought to be secondary to antibiotic use. She was able to maintain adequate hydration to replace the diarrheal losses. Medications on Admission: Levoxyl 127 HISTORICAL MEDS Allopurinol 100 Lasix 20 prn Albuterol Advair 250 Cal-D, vitamin, new cough syrup Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [2-7] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 3. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO once a day. 4. Home Oxygen Supplement Oxygen (1-3L) via nasal canula to titrate oxygen saturation to greater than 95% during the day time. Please exclusively use Bi-PAP with supplement Oxygen at night. Discharge Disposition: Home Discharge Diagnosis: hypercarbic respiratory failure pneumonia muscular dystrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname 8529], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for respiratory distress and required intubation. We believe you had respiratory distress due to both an underlying neuromuscular disorder and from pneumonia. You have been treated with antibiotics and have complete treatment for the pneumonia. You continue to require supplemental oxygen, which you should continue after you are discharge until no longer needed. Please continue to use the Bi-PAP as prescribed. Please also follow up with your primary care doctor and your [Hospital1 850]. While in the hospital, you developed diarrhea, we tested the stool for c. difficile which was negative. The diarrhea is likely related to recent antibiotic use and is unlikely to be infectious. Medication Changes: Please take albuterol [2-7] puff every 4-6 hours as needed for shortness of breath or wheezing Please continue to take levothyroxine as prescribed Please take imodium up to 4 times daily as needed for diarrhea Followup Instructions: Please follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 850] within 2 weeks of discharge ICD9 Codes: 486, 2449, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2225 }	Medical Text: Admission Date: [2195-8-28] Discharge Date: [2195-9-2] Date of Birth: [2120-3-18] Sex: M Service: MEDICINE Allergies: Omeprazole Attending:[First Name3 (LF) 10593] Chief Complaint: hyponatremia Major Surgical or Invasive Procedure: none History of Present Illness: 75 y/o M with a history significant for COPD with 2L home O2 requirement, CHF, A-fib and recent hospitalization at [Hospital1 18] in [Month (only) 205] for PNA and hyponatremia, from which he left AMA, who presented to PCP the morning PTA for evaluation of vomitting and was referred to [Hospital1 18] ED after labs revealed Na 111. N.B. the patient and his wife speak primarily Italian but together are able to provide a coherent history. . He is here with his wife who explains that he has "not been himself" for the past week--low energy, no appetite. Mr. [Known lastname 13858] confirms that he has not been eating much, and is unsure why. Reports an 8-10lb weight loss over the past [2-26] weeks. Admits also to cough and SOB, with "doubling" of his home O2 requirement to be comfortable. He has also had nausea and vomiting for two days, and also admits to thirst. Denies fevers/chills, CP, palpitations, abdominal pain, diarrhea and constipation. . Notably, during his prior admission, he presented with hyponatremia to the mid 120??????s which corrected with 50mg hydrocortisone x7 days. He was not discharged home on steroids. . On presentation to the ED VS T98 HR73 BP151/75 RR18 O2Sat100% (FiO2 unclear). [Name2 (NI) ] in the ED he had a CT head which was WNL, a CXR with evidence of hyperinflation but no evidence of PNA. Labs were significant for serum Na 111 BUN 9 Cr 0.8, urine Na 37, and Uosm 272. He was started on IVF at 125 cc/hr and also received vancomycin 1g and levofloxaacin 750mg IV for presumed pneumonia. Given the severity of the hyponatremia, he was admitted to ICU for further management. Past Medical History: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (on [2-25].5L O2 by NC at home) ATRIAL FIBRILLATION CONGESTIVE HEART FAILURE (EF 30%), class 3 HEADACHE TINNITUS HYPERCHOLESTEROLEMIA ESOPHAGITIS, REFLUX IMPOTENCE, ORGANIC ORIGIN [2182-10-3] CARDIOMYOPATHY [2184-10-18]. Non-infarct related cardiomyopathy, status post dual-chamber ICD in [2187] VENTRICULAR ECTOPY BACK PAIN GOUT Social History: Lives in [Location (un) ] with wife. Denies alcohol intake and tobacco in the past 10 years. 50py history. Has sons who live nearby and are involved in his care. Family History: Denies FH of heart disease, cancer, diabetes. Physical Exam: Admission Physical Exam: VS: T95.2 BP123/64 HR78 RR15 O2Sat96% on 2L NC Gen: Cachectic, barrel-chested, pursed-lip breathing HEENT: Dry mucus membranes, PERRL Neck: JVD 7cm Pulm: Poor air movement, no wheezing. Trace RLL crackles. CV: Faint heart sounds Abd: Soft, NT/ND. Active BS. Extrem: B/l 1+ pitting ankle edema. Skin: Warm and well-perfused. . Discharge Physical Exam: Pertinent Results: Admission Labs: [2195-8-27] 10:54PM WBC-4.8 RBC-4.30* HGB-12.3* HCT-35.3* MCV-82# MCH-28.7 MCHC-35.0 RDW-15.4 [2195-8-27] 10:54PM NEUTS-74* BANDS-2 LYMPHS-13* MONOS-7 EOS-3 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2195-8-27] 10:54PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL ELLIPTOCY-1+ [2195-8-27] 10:54PM PT-17.3* PTT-39.5* INR(PT)-1.5* [2195-8-27] 02:15PM UREA N-9 CREAT-0.8 SODIUM-111* POTASSIUM-3.8 CHLORIDE-68* TOTAL CO2-33* ANION GAP-14 [2195-8-27] 02:15PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-75 AMYLASE-84 TOT BILI-1.3 [2195-8-27] 10:54PM GLUCOSE-144* UREA N-10 CREAT-0.8 SODIUM-109* POTASSIUM-4.3 CHLORIDE-67* TOTAL CO2-31 ANION GAP-15 [2195-8-27] 02:15PM DIGOXIN-<0.2* [2195-8-27] 10:54PM CK(CPK)-84 [2195-8-27] 10:54PM CK-MB-4 cTropnT-<0.01 . Microbiology: Blood cultures ([8-28]): pending . Imaging: CHEST, PA AND LATERAL VIEWS ([8-28]): Evaluation is limited by exclusion of the right costophrenic sulcus. Lungs are hyperexpanded with flattened diaphragms and widening of the AP diameter. There is relative hyperlucency of the lungs suggesting chronic obstructive lung disease. Small left pleural effusion is present as well as a residua of a prior infection in LLL. Heart size is enlarged as before. There is tortuosity of the thoracic aorta and enlargement of the pulmonary arteries. Two leads follow a normal course from the left-sided battery pack terminating in the expected region of the right atrium and right ventricle. There is no overt edema. . CT head ([8-28]): IMPRESSION: No acute intracranial abnormality. . Discharge Labs: [2195-8-31] 07:45AM BLOOD WBC-4.4 RBC-4.11* Hgb-12.2* Hct-36.0* MCV-88 MCH-29.6 MCHC-33.8 RDW-15.5 Plt Ct-232 [2195-9-2] 03:20AM BLOOD PT-22.7* INR(PT)-2.1* [2195-9-2] 03:20AM BLOOD Glucose-103* UreaN-21* Creat-0.9 Na-135 K-4.5 Cl-93* HCO3-39* AnGap-8 Brief Hospital Course: 75M with history significant for COPD, CHF, recent admission for PNA and hyponatremia from which he left AMA, who presented with hyponatremia in the setting of two days of n/v and ~1 week of poor PO intake. . # Hyponatremia: The patient's history and physical exam was consistent with volume depletion, with Na of 107. Following hydration, the Na did not entirely correct, indicating a possible component of SIADH secondary to COPD and recent PNA. In addition, the patient had recently been on steroids and there was concern for adrenal insufficiency. The final diagnosis is a combination of dehydration, SIADH, and adrenal insufficiency. Resolved with hydration and steroids. . # Adrenal Insufficiency: Per Endocrinology, recent Cosyntropin stimulation testing revealed a mildly suppressed hypothalamic-pituitary-adrenal axis, with a low baseline cortisol level and an insufficient response to ACTH stimulation. This is most likely secondary to chronic inhaled steroid therapy, though recent treatment with Prednisone (last given on [2195-8-4]) may have contributed. The presenting symptoms of nausea, vomiting, weight loss, and hyponatremia were considered to be partially due to this insufficiency. He was treated with hydrocortisone at tapering doses. He was discharged with instructions to take hydrocortisone 20 mg qam and 10 mg qpm. He was also given a script for 100 mg im, in case he is unable to take po doses. He will follow-up in the [Hospital 6091] clinic on [9-9]. . # COPD: Severe, with home O2 requirement and use of multiple nebs. No exacerbation during this admission. During the admission, the patient did not have an increased O2 requirement. Home regimen continued. His oxygen saturation with ambulation dropped to 80%, though he was not dyspneic. His serum bicarbonate level rose to 39, though his venous pH was 7.35. . # A-Fib: AICD in place. Chronically on coumadin with INR 1.5 on admission. EKG shows he is ventricularly paced, no ischemic changes. Coumadin was continued through his stay and his INR was therapeutic at the time of discharge. Home amiodarone and digoxin were continued. He did have an episode of higher rates, for which diltiazem 30 mg po q6h was started. As his HRs remained stable during the rest of the admission, diltiazem was stopped at the time of discharge, to avoid excessive nodal blockade and interaction with other medications. . # CAD # CHF, chronic, systolic: No sign of volume overload on exam or CXR. His home furosemide was initially held, then restarted. His weight at the time of discharge was 127.5 lbs. He is not on a beta blocker. His [Last Name (un) ] has been held recently due to relative hypotension. He had frequent PVCs and NSVT, including a 19 beat run of NSVT (asymptomatic). Electrolyte levels were normal. Cardiac biomarkers were negative. These runs were likely from myocardial scar. . # Hyperlipidemia: continued statin . # Anemia: Hct was stable during this admission, though has been lower recently than previously. Defer further work-up to outpatient setting with PCP. Medications on Admission: 1. Atorvastatin 20 mg daily 2. Colchicine 0.6 mg daily 3. Digoxin 125 mcg 4. Fluticasone-salmeterol 250/50mcg 1 whif INH [Hospital1 ] 5. Furosemide 20 mg daily 6. Ipratropium-albuterol 18mcg/90mcg 2 puff INH QID 7. Nitroglycerin 0.3 mg SL prn 8. Pantoprazole 40 mg daily 9. Tiotropium bromide 10. Valsartan 160 mg daily 11. Warfarin 2.5 mg daily 12. Amiodarone 200mg PO daily 13. Aspirin (dose uncertain) 14. Guaifenesin prn Discharge Medications: 1. hydrocortisone Sig: One Hundred (100) MG Intramuscular ONCE as needed for if unable to take oral hydrocortisone for 1 doses. Disp:1 DOSE Refills:2 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) PUFFS Inhalation four times a day as needed for shortness of breath or wheezing. 8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM: take every morning. Disp:30 Tablet(s) Refills:0 15. hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO QPM: take 10 mg every evening. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Art of Care Discharge Diagnosis: Hyponatremia Adrenal insufficiency CHF, chronic, systolic COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You were admitted with a potentially life-threatening electrolyte abnormality (low sodium). Please take your medications exactly as prescribed and ask your physician what to do if you miss a dose or have to change any doses. -Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. -You should continue to take hydrocortisone (steroid medicine), 20 mg every morning, and 10 mg every evening. If you are unable to take this medicine by mouth, then you can inject 100 mg of hydrocortisone in your muscle. You will be given scripts for both. You have an appointment to see Dr. [Last Name (STitle) ] of Endocrinology on Wed [9-9], at which point adjustments to the dose will be determined. -You should see your primary care doctor, Dr. [Last Name (STitle) 58], on Mon [9-7]. -Lightheadedness may be a sign that your blood pressure is too low, and that you need more steroid medicine. If this happens, please call Dr. [Last Name (STitle) 58] or Dr. [Last Name (STitle) ]. -You should continue to use supplemental oxygen at home. -If you develop fever, chest pain, shortness of breath, worsening cough, lightheadedness, nausea, abdominal pain, or any other concerning symptoms, please call Dr. [Last Name (STitle) 58] or go to the emergency department. Followup Instructions: Department: BIDHC [Location (un) ] When: MONDAY [2195-9-7] at 4:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5080], MD [Telephone/Fax (1) 3329] Building: [Location (un) 3966] ([Location (un) 55], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: MEDICAL SPECIALTIES When: WEDNESDAY [2195-9-9] at 12:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2164], 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: CARDIAC SERVICES When: TUESDAY [2195-10-20] at 10:30 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: TUESDAY [2195-10-20] at 11:20 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4511], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 4271, 4254, 4280, 496, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2226 }	Medical Text: Admission Date: [2120-8-14] Discharge Date: [2120-8-18] Date of Birth: [2046-5-21] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[Known firstname 922] Chief Complaint: chest pressure and shortness of breath with mild exertion Major Surgical or Invasive Procedure: [2120-8-14] - Coronary bypass grafting x4: Left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the second diagonal coronary artery; reverse saphenous vein single graft from the aorta to the third diagonal coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery. History of Present Illness: This 74 year old man has a history of hyperlipidemia, prior tobacco abuse, mild COPD and prostate cancer, s/p radiation. He reports that several months ago he began to notice mid sternal chest pressure and shortness of breath with mild exertion, ie. Walking up a slight incline. Because of these symptoms, his primary MD referred him for a stress echo which revealed new akinesis of the lower anterior septum and apex. The patient also reports a history of intermittent GI bleeding, particularly noticed in the past when he was constipated. He recently underwent a colonoscopy on [2120-7-16]. This revealed mild radiation proctitis and diverticulosis. GI recommended proceeding with cardiac catheterization. On [2120-7-18] the patient was evaluated by Dr. [Last Name (STitle) ] in cardiology who prescribed him Aspirin, Plavix and Diovan/HCT. About one week following his colonoscopy, the patient reported a moderate amount of BRBPR. A repeat Hematocrit was found stable and he has not had any further evidence of bleeding. With regard to symptoms, the patient reports that over the past three to four weeks he has been feeling better with no significant symptoms, although he has remained quite sedentary. Past Medical History: Hyperlipidemia Prostate cancer, s/p radiation in [2118] Right hip osteoarthritis s/p right total hip replacement Back pain s/p lumbar surgery [2114] [7-23] GIB- colonoscopy revealing proctitis from prior radiation therapy and diverticulosis Glaucoma Remote hydrocele repair Mild COPD [2-23] Pneumonia Social History: Patient is widowed and lives alone. He does not have children. Occupation: Retired truck driver and mechanic ETOH: rare Family History: No family history of premature CAD Physical Exam: blood pressure was 139/60. Veins are flat. Venous pressure approximately 5 cm of water. He has upper and lower dentures. Tongue was papillated. Carotids show normal upstroke. There is no cervical adenopathy. Chest is clear. Heart sounds are distant. PMI is not palpable. S1 is normal. S2 showed normal splitting. No murmurs are heard. There is no enlargement of liver or spleen. Extremities show full pulses. There are no peripheral skin lesions. Pertinent Results: [2120-8-14] ECHO PRE CPB No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) 914] was notified in person of the results in the operating room at the time of the study. POST CPB Normal biventricular systolic function. Thoracic aorta appears intact. Mild mitral regurgitation remains. No other changes from pre-bypass findings. [2120-8-14] CXR In comparison with the study of [8-5], there has been placement of an endotracheal tube with its tip approximately 7 cm above the carina. Right Swan-Ganz catheter extends to the outer edge of the mediastinal aspect of the right pulmonary artery. Nasogastric tube extends to the stomach. Left chest tube is in place and there is no pneumothorax. Substantial atelectatic changes are seen at the left base. Brief Hospital Course: Mr. [Known lastname ] was admitted on [2120-8-14] for elective surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. Within 24 hours, he awoke neurologicall intact and was extubated. Beta blockade, aspirin and a statin were resumed. He was then transferred to the [Doctor Last Name 6552] down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He has progressed well from a PT standpoint, has remained hemodynamically stable, and is ready for discharge to home. Medications on Admission: Plavix 75', Diovan 160/12.5', Zocor 20', Vit B, MVI, Pilocarpine 0.5% 1gtt both eyes [Hospital1 ], Flovent 110mcg [Hospital1 ], Albuterol, ASA 325', Oxycontin 10', 20', 40'. Discharge Medications: 1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:14 Packet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Pilocarpine HCl 0.5 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). Disp:1 vial Refills:2 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 MDI Refills:2 8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:1 MDI Refills:2 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day: Resume as per pre-op regimen. Disp:90 Tablet Sustained Release 12 hr(s) Refills:0 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: CAD s/p CABGx4 Hyperlipidemia Prostate cancer, s/p radiation in [2118] Right hip osteoarthritis s/p right total hip replacement Back pain s/p lumbar surgery [2114] [7-23] GIB- colonoscopy revealing proctitis from prior radiation therapy and diverticulosis Glaucoma Remote hydrocele repair Mild COPD [2-23] Pneumonia Discharge Condition: Stable 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) 4044]. 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. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 914] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Follow-up with Dr. [Last Name (STitle) 66650] in [2-18] weeks. [Telephone/Fax (1) 19980] Completed by:[2120-8-18] ICD9 Codes: 496, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2227 }	Medical Text: Admission Date: [2109-4-24] Discharge Date: [2109-4-25] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: hypotension Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. [Known lastname 805] is an 87 year old female with a h/o dementia, anemia and R toe ulcer s/p recent toe amputation who presents from [Hospital3 1186] with hypotension and bradycardia. Per notes, pt was more fatigued and diaphoretic today and then unresponsive at [Hospital3 ]. Vitals were checked and HR was 40 and BP was 70/50. Per report, vitals had been normal earlier in the day. EMS was called and noted BP to be 60-102/40-56 and HR in the 40s. . Upon arrival to the ER, the pt was noted to be responsive. Her HR was in the 40s-50, and EKG showed atrial flutter. SBP did drop to the 60s and pressures improved to the 80s-90s with 1 L of IVF. Her pressures then dropped again, so she was given 1 mg of atropine with improvement in her HR to the 70s and SBPs to the 100s. Her hct was stable at 30 and she was guaiac negative. . Upon arrival to the ICU the pt is comfortable. Past Medical History: - R 3rd toe ulcer: last seen by Dr. [Last Name (STitle) ] on [2109-3-5], when toe was described as gangrenous - Atrial tachycardia - rate-controlled with diltiazem and metoprolol as outpatient - R. hip fracture in [7-/2107], managed conservatively - Alzheimer's dementia - Pre-syncope/syncope - s/p admission in [4-14] where w/u was negative - Rheumatoid Arthritis - Hypertension - Lower back pain - S/p appendectomy - Osteoarthritis - Anemia - patient is Jehovah's witness and cannot receive transfusions. Social History: Lives in [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ]. No blood products, Jehovah's witness. No tobacco or EtOH. Family History: Brother has DM, unclear of any other significant fhx. Physical Exam: VS: T: 98.8 HR: 73 BP: 114/68 O2 sat: 100% on RA RR: 29 (later 18) Gen: well appearing, thin, elederly female in NAD HEENT: anicteric sclera, PERRL, dry MM Pulm: CTAB Cardio: irreg irreg, nl S1 S2, no m/r/g Abd: soft, NT, ND, hypoactive BS Ext: trace b/l edema, 3rd toe on right foot amputated, previous incision site appears c/d/i Neuro: awake, alert, moving all extremities, unclear how oriented she is as she answers "uh [Doctor Last Name 10290]" to many questions Pertinent Results: [2109-4-24] 05:30PM BLOOD WBC-8.2 RBC-3.21* Hgb-9.7* Hct-30.0* MCV-93 MCH-30.3 MCHC-32.4 RDW-13.5 Plt Ct-208 [2109-4-25] 04:13AM BLOOD PT-20.9* PTT-30.9 INR(PT)-2.0* [2109-4-25] 04:13AM BLOOD Glucose-89 UreaN-32* Creat-1.0 Na-137 K-4.6 Cl-111* HCO3-18* AnGap-13 [2109-4-24] 05:30PM BLOOD ALT-21 AST-21 CK(CPK)-33 AlkPhos-65 TotBili-0.3 [2109-4-24] 05:30PM BLOOD cTropnT-<0.01 [2109-4-24] 05:30PM BLOOD TSH-8.3* [2109-4-25] 04:13AM BLOOD Free T4-0.90* Brief Hospital Course: 87 yo female with h/o anemia, dementia and afib presents with bradycardia and hypotension that improved with atropine. . Bradycardia: This is likely due to high doses of 2 nodal blocking agents, the doses of which have been increased in the past few weeks. She was hypotensive on admission, this was likely due to her bradycardia and resolved with normalization of her heartrate. Dig level not elevated, cardiac enzymes negative, potassium level was normal. Her diltiazem was discontinued and the dose of her metoprolol was cut in half. The doses of these medication will need to be titrated at rehab. . Afib: Pt with history of afib but EKG c/w aflutter with variable conduction on admission. Medication doses adjusted as above. Coumadin continued with goal INR [2-10] . * Renal insufficiency: Cr elevated at 1.4 from baseline of 0.8-1 on admission; this resolved with improvement in heartrate overnight and was back to baseline at 1.0 on discharge. . * Hypothyroidism: On levothyroxine. TSH elevated and Free T4 slighly low. Levothyroxine dose increase. Needs repeat TFT's in [4-14] weeks. . Code Status: DNR/DNI confirmed with family tonight Medications on Admission: Levothyroxine 25 mcg PO 4x/wk (q [Doctor First Name ]/Tu/Th/Sa) Levothyroxine 37.5 mcg PO 3x/wk 9qM/W/F) ASA 81 mg daily Ferrous gluconate 324 mg daily Folic acid 1 mg daily plavix 75 mg daily prilosec 20 mg daily vitamin D 400 unit dialy MVI daily prostat awc 30 ml by mouth [Hospital1 ] Coumadin Metoprolol 50 mg TID Diltiazem 75 mg PO TID eye gtts calcium carbonate 1000 mg [Hospital1 ] Ultram 25 mg TID Ultram 25 mg q4 hours prn pain Discharge Medications: Levothyroxine 25 mcg Tablet Sig: 1.5 Tablets daily Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. Tramadol 50 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] Discharge Diagnosis: Symptomatic bradycardia. Discharge Condition: Stable Discharge Instructions: DUring this admission you were treated for low heart rate (bradycardia). This was likely a side effect of your medications. Therefore we have changed your medications: we lowered the dose of your metoprolol and discontinued your diltiazem. PLease continue to take all medications as prescribed; your doctors [Name5 (PTitle) ] likely need to continue to adjust the doses of your medications over the next few days. Follow up with your PCP this week. Seek immediate medical care if you develop chest pain, palpatations, fainting, shortness of breath or other concerning symptoms. Followup Instructions: Follow up with your PCP this week: [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 608] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2109-4-26] 11:00 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292*] ICD9 Codes: 5849, 2449, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2228 }	Medical Text: Admission Date: Discharge Date: Date of Birth: [2132-9-25] Sex: M Service: UROLOGY NOTE: An addendum will be dictated as a stat by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] regarding events after this date. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old gentleman who presented to [Hospital1 188] via Medivac after being diagnosed with Fournier's gangrene on [2193-8-20]. On presentation, it was noted that he had three days of swelling and pain in the scrotal perineal region. PAST MEDICAL HISTORY: The past medical history was significant for a myocardial infarction in [2187], noninsulin dependent diabetes, hypertension and hypercholesterolemia. MEDICATIONS ON ADMISSION: The patient was noncompliant with all medications and therefore was on none at home. ALLERGIES: The patient had no known drug allergies that we could ascertain. LABORATORY DATA: Upon admission, the Chem 7 revealed a sodium of 128, potassium of 4.3, chloride of 92, bicarbonate of 25, BUN of 25, creatinine of 1.2 and glucose of 525. Liver function tests included an ALT of 12, AST of 13, total bilirubin of 0.5 and alkaline phosphatase of 95. Coagulation studies revealed a prothrombin time of 13.9, partial thromboplastin time of 24.9 and INR of 1.3. CBC revealed a white blood cell count of 11,200, hematocrit of 38.3 and platelet count of 198,000. A negative urinalysis was obtained from this gentleman. HOSPITAL COURSE: Stat cultures were sent off from the swab and the patient was emergently taken to the operating room for emergency scrotal debridement. Please see the operative report for full details. Postoperatively, the patient was admitted to the surgical intensive care unit team for immediate postoperative care at least overnight. During the course of the night, a central venous line was inserted into the right subclavian vein and a unit of blood was transfused. The patient remained n.p.o. and required several corrections as to his electrolytes as needed for both magnesium and potassium. On postoperative day #1, [2193-8-21], the patient was transferred to the vascular intensive care unit, where he was noted to have respiratory distress. He had an arterial blood gas with a pH of 7.42, a pCO2 of 36 and a pO2 of 50. He was emergently ruled out. An electrocardiogram was done as well as a chest x-ray and arterial blood gases. An arterial line was placed. A cardiology consultation was called, which stated the possibility of fluid overload. He was started on Lasix and he was diuresed out. The patient was made n.p.o. The patient was taken back to the operating room on postoperative day #3 for further debridement of his scrotum and perineum. He was also given a diverting colostomy. Please see the operative note for full details regarding that procedure. Postoperatively, he was admitted to the surgical intensive care unit and was ruled out for a myocardial infarction again, which came back negative. The patient was requiring ventilatory support at this time. The patient required ventilatory support until postoperative days #5 and #3, [2193-8-25], at which time he was switched over to nasal cannula. His laboratory studies and electrolytes were repleted as necessary. His hematocrit was stable. On postoperative days #6 and #4, [2193-8-26], the patient was stable and in the medical intensive care unit. The possibility of total parenteral nutrition was started and the infectious disease service was asked to come in. His antibiotics were changed to Flagyl 500 mg every eight hours, levofloxacin 500 mg once a day and vancomycin 1 gm every 12 hours. Originally, the patient had been started on Ampicillin 2 gm every six hours, gentamicin 80 mg every eight hours and Flagyl 500 mg q.d. The patient had remained on this regimen until the infectious disease service recommended a change on [2193-8-26]. On [2193-8-27], the patient was still in the intensive care unit and he pulled out his central line. However, in consultation with the surgical intensive care unit team, the patient was transferred to the floor on [2193-8-28]. Whereupon, the [Last Name (un) ] service was called and they recommended Glyburide being added to his medication profile at 10 mg p.o. b.i.d. for better control of his blood sugar. The patient was stable at this point and had an hemoglobin A1c which came back at 15.1 and a vancomycin peak and trough of 29.8 and 10.2. His cultures will be dictated at the end of his dictation summary. The patient remained in [Apartment Address(1) 36335] on [Hospital Ward Name 36336] in stable condition. On [2193-8-29], it was noted that the patient was growing some yeast and a urinalysis sent off showed 5 epithelial cells, 6 to 8 red blood cells, 290 white blood cells and moderate yeast. Yeast was also shown going down the sides. On [2193-8-30], the Flagyl was discontinued and the patient was started on fluconazole, initially on 200 mg p.o. times one day to be followed by 100 mg p.o. for six days. On [2193-8-31], the patient had repeat laboratory studies which showed his electrolytes and his hematocrit to be in balance and his liver function tests to be normal. On [2193-8-31], his chemistries came back with a sodium of 137, potassium of 4.4, chloride of 102, bicarbonate of 28, BUN of 12, creatinine of 1.1 and glucose of 107. AST was 10 and ALT was 15. CBC had a white blood cell count of 11,700 with a hematocrit of 30.7 and a platelet count of 452,000. On [2193-9-1], with vancomycin and levofloxacin being #6 and fluconazole being day #3, the patient was stable. The plastic surgery service's chief resident was consulted, as well as the general surgery service. His CBC came back with a white blood cell count of 11.7, hematocrit of 33.4 and platelet count of 468,000. DISPOSITION: A PICC line is to be inserted today and his blood sugar is back under control. The phone number for the plastic surgery service is [Telephone/Fax (1) 274]. The patient is to have follow up and have an appointment for [2193-9-10]. The patient is also to be seen by the general surgery service on the same day. DISCHARGE MEDICATIONS: The patient will most likely be discharged on Vancomycin 1 gm every 12 hours with fluconazole 100 mg p.o. q.d. and levofloxacin 500 mg p.o. q.d., to complete a two week antibiotic course. CONDITION ON DISCHARGE: On discharge, the patient is stable. NOTE: The addendum with complete discharge information and medications will be dictated by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], when the patient finally goes to rehabilitation. FINAL COMMENTS REGARDING MICROBIOLOGY: Swabs taken intraoperatively and cultures showed that the patient was growth alpha streptococcus and Monilia as well as coagulase negative staphylococcus in addition to the yeast that he grew postoperatively. The vancomycin and Levaquin will cover for that and the fluconazole is covering for the yeast. The alpha streptococcus was sensitive to clindamycin, erythromycin and levofloxacin. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8916] Dictated By:[Name8 (MD) 16758] MEDQUIST36 D: [2193-9-1] 15:04 T: [2193-9-1] 15:12 JOB#: [Job Number 36337] ICD9 Codes: 9971, 4280, 5185
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2229 }	Medical Text: Admission Date: [2195-12-1] Discharge Date: [2195-12-7] Date of Birth: [2167-5-15] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: SOB with exertion, heart murmur since 25y/o Major Surgical or Invasive Procedure: Mitral valve replacement(25mm CE tissue) [2195-12-1] History of Present Illness: 28y/o female with known MVP who was diagnosed with a heart murmur at age 25. She was evaluated with serial TTE's which showed worsening MR. Echo showed LVEF 27% with Mitral valve regurgitant fraction of 52%. She denies any symptoms. Past Medical History: Hyperlipidemia, MVP/MR, Depression, Obesity Social History: social Etoh, live with mother, denies IVDA or tobacco use Family History: noncontributory Physical Exam: 28y/o F in bed NAD Neuro AA&Ox3, nonfocal Chest CTAB resp unlab median sternotomy stable, c/d/i no d/c, RRR no m/r/g chest tubes and epicardial wires removed. Abd S/NT/ND/BS+ EXT warm with trace edema Pertinent Results: RADIOLOGY Preliminary Report CHEST (PA & LAT) [2195-12-7] 9:48 AM CHEST (PA & LAT) Reason: assess LLL atelectasis [Hospital 93] MEDICAL CONDITION: 28 year old woman with fever atelectasis seen on prio film REASON FOR THIS EXAMINATION: assess LLL atelectasis INDICATION: Fever, atelectasis seen on prior film. COMPARISONS: [2195-12-6]. PA and lateral chest radiographs show stable cardiac and mediastinal silhouettes. Again seen are median sternotomy wires and prosthetic mitral valve. There has been interval improvement in the previously seen left retrocardiac opacity suggesting improving atelectasis. No focal opacities are seen. No pleural effusions are seen. IMPRESSION: Improved left retrocardiac opacity suggestive of improving atelectasis. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [2195-12-4] 05:45AM BLOOD WBC-9.3 RBC-3.08* Hgb-8.8* Hct-24.5* MCV-80* MCH-28.5 MCHC-35.8* RDW-14.3 Plt Ct-154 [2195-12-3] 03:01AM BLOOD PT-13.9* PTT-24.4 INR(PT)-1.3 [2195-12-4] 05:45AM BLOOD Glucose-118* UreaN-12 Creat-0.6 Na-135 K-4.3 Cl-98 HCO3-26 AnGap-15 [2195-12-3] 03:01AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0 [2195-12-2] 03:33AM BLOOD Type-ART pO2-125* pCO2-43 pH-7.39 calHCO3-27 Base XS-1 [2195-12-5] 11:40 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): Cardiology Report ECHO Study Date of [2195-12-1] * Report not finalized * PRELIMINARY REPORT PATIENT/TEST INFORMATION: Indication: Intra op for MVR Height: (in) 48 Weight (lb): 178 BSA (m2): 1.51 m2 Status: Inpatient Date/Time: [2195-12-1] at 11:17 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW578-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) 412] [Last Name (Prefixes) 413] MEASUREMENTS: Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Valve Level: 1.7 cm (nl <= 3.6 cm) Aorta - Ascending: 1.6 cm (nl <= 3.4 cm) INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Top normal/borderline dilated LV cavity size. Mild global LV hypokinesis. Mildly depressed LVEF. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal descending aorta diameter. AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous mitral valve leaflets. Moderate/severe MVP. Mild mitral annular calcification. No MS. Moderate (2+) MR. Eccentric MR jet. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the for the patient. Conclusions: Pre-CPB The left atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed EF about 50%. . Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are small in diameter and free of atherosclerotic plaque. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. Trace to mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is moderate/severe posterior mitral valve leaflet prolapse. Mild anterior leaflet prolapse. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is a trivial/physiologic pericardial effusion. Post CPB Normal RV systolic function. LV with continued mild global hypokinesis, EF about 50%. Mitral bioprosthesis is well seated, normal leaflet function. There is trace valvular and perivalvular MR. [First Name (Titles) ] [Last Name (Titles) ]. [Name13 (STitle) ] other changes from pre-CPB. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD on [2195-12-1] 12:20. Cardiology Report ECG Study Date of [2195-12-1] 12:30:56 PM Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous tracing of [2195-11-24] the rate has increased. Read by: [Last Name (LF) ],[First Name3 (LF) ] Intervals Axes Rate PR QRS QT/QTc P QRS T 107 118 84 338/400.85 131 92 -14 Brief Hospital Course: Ms. [Known lastname 47766] was admitted to the [Hospital1 18] on [2195-12-1] for further management of her dyspnea on exertion. She was taken to the catheterization lab where she was found to have no significant CAD, severe MVP and regurgitation with moderate pulmonary hypertension, LVEF 51%. Given the severity of her disease, the cardiac surgical service was consulted for surgical repair of her valve disease. She was worked-up in the usual preoperative manner including an echocardiogram which revealed trace Aortic insufficiency, 4+ mitral regurgitation with myxomatous leaflets, and an LV ejection fraction of 61%, RVEF 58%, bilateral atrial enlargement. On [2195-12-1], Ms. [Known lastname 47766] was taken to the operating room. She underwent a mitral valve replacement using a 25mm [Last Name (un) ] [Doctor Last Name ] pericardial model 2800 bioprosthesis. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, she awoke neurologically intact and was extubated. Beta blockade and aspirin were resumed. She was gently diuresed towards his preoperative weight. On POD 2 Her pressors were weaned, chest tubes were removed, and she was transferred to the cardiac stepdown unit. Beta blockade and aspirin were resumed. She was gently diuresed towards his preoperative weight. On POD 3 her epicardial wires were removed without incident. The physical therapy service was consulted to assist with her postoperative strength and mobility. Her oxygen saturations improved to 100% on room air. The physical therapy service was consulted to assist with her postoperative strength and mobility. On POD 6 Ms. [Known lastname 47766] was 5kg above her preop weight with good exercise tolerance, no SOB, or Chest pain. Her blood pressure was stable. Her sternotomy incision was clean, dry, and intact without evidence of infection. She was discharged home on POD 6 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with her PCP and cardiologist in [11-16] weeks. She will follow up with Dr. [Last Name (STitle) 1290] in four weeks. Medications on Admission: Paxil 20 mg qday Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:14 Packet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 3 days: When dose is finished, decrease dose to 400 mg PO daily for 7 days, then decrease dose to 200 mg PO daily. Disp:40 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Mitral regurgitation Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for sternal drainage, temp.>101. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 48276] for 1-2 weeks [Telephone/Fax (1) 6820]. Make an appointment with Dr. [Last Name (STitle) 1290] for 4 weeks [Telephone/Fax (1) 170]. Make an appointment with your cardiologist 1-2 weeks. Completed by:[2195-12-7] ICD9 Codes: 4240, 4168, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2230 }	Medical Text: Admission Date: [2136-6-5] Discharge Date: [2136-6-8] Date of Birth: [2053-6-7] Sex: F Service: MEDICINE Allergies: Cymbalta / Penicillins Attending:[First Name3 (LF) 1515] Chief Complaint: CP and shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 82F with DM and hypertension presenting with intermittent chest pain, shortness of breath and ankle edema. Pt notes that one week ago started to have dyspnea on exertion and chest pressure when running up the stairs. Last week had left-sided chest pressure while lying in bed. After taking some tylenol pain remitted. However, this am, had additional episode of chest pressure at rest. Also noted worsening orthopnea and ankle edema. Has 3 pillow orthopnea. . Pt called PCP requesting lasix and referred in to ED. Nausea, decreased appeitite, no vomiting. . In the ED, initial vitals were 97.5 140/67 67 22 93% RA. Speaking in 10 word sentences in ED. Initially got 20mg lasix and SL Nitro. Got heparin 4000 unit bolus and ASA. BNP elevated to 7175. Per report, sats in high 80s on arrival bumped to low 90s on NRB. Received a total of 60mg lasix. Chest x-ray showed mild cardiomegaly with moderate interstitial pulmonary edema and small bilateral pleural effusions. . ROS: + cough Past Medical History: Diabetes Mellitus Peripheral Neuropathy Pulmonary Embolus [3-5] post-partum right leg thrombophlebitis in [2093] s/p Appendectomy Hypertension Hyperlipidemia Osteoarthritis - bilateral hips and lumbosacral spine Bilateral Hip Replacements [12/2127] Left Thumb Paronychia s/p I&D '[30] Left Foot Cellulitis s/p I&D '[30] Peripheral Vascular Disease Peripheral Neuropathy Social History: Married, 6 living children. Lives in [Location 745]. -Tobacco history: Never -ETOH: None -Illicit drugs: None Family History: Father - Deceased, MI at 50 Mother - Deceased, MI at 65 3 brothers died of [Name (NI) 5290] in 60s and 70s. Physical Exam: 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 * cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [2136-6-5] 02:58PM BLOOD WBC-10.7 RBC-4.31 Hgb-13.0 Hct-39.3 MCV-91 MCH-30.2 MCHC-33.1 RDW-13.2 Plt Ct-515# [2136-6-5] 02:58PM BLOOD Neuts-85.2 Lymphs-11.7* Monos-1.8* Eos-1.0 Baso-0.4 [2136-6-5] 02:58PM BLOOD PT-14.3* PTT-30.2 INR(PT)-1.2* [2136-6-5] 02:58PM BLOOD Glucose-190* UreaN-21* Creat-1.0 Na-135 K-4.6 Cl-100 HCO3-20* AnGap-20 [2136-6-5] 02:58PM BLOOD CK(CPK)-520* [2136-6-5] 02:58PM BLOOD CK-MB-18* MB Indx-3.5 proBNP-7175* [2136-6-6] 06:30AM BLOOD Calcium-8.8 Phos-4.7* Mg-1.7 [2136-6-5] 10:29PM BLOOD Mg-1.9 Cholest-228* [2136-6-5] 02:58PM BLOOD %HbA1c-7.1* [2136-6-5] 10:29PM BLOOD Triglyc-164* HDL-50 CHOL/HD-4.6 LDLcalc-145* . Cardiac enzymes: [2136-6-5] 02:58PM BLOOD CK(CPK)-520* [2136-6-5] 10:29PM BLOOD CK(CPK)-432* [2136-6-6] 06:30AM BLOOD CK(CPK)-250* [2136-6-5] 02:58PM BLOOD cTropnT-0.27* [2136-6-5] 10:29PM BLOOD CK-MB-17* MB Indx-3.9 cTropnT-0.34* [2136-6-6] 06:30AM BLOOD CK-MB-12* MB Indx-4.8 cTropnT-0.32* . ECHO (TTE): The left atrium is mildly dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [2136-2-11] , the severity of mitral regurgitation has increased. . Chest X-ray: In comparison with the study of [6-5], there is poor due to poor definition of the right hemidiaphragm with increased opacification at the right base, consistent with increasing pleural effusion. Less prominent effusion with the basilar atelectasis is seen on the left. Enlargement of the cardiac silhouette persists. Elevation of pulmonary venous pressure is again noted. The patient has taken a relatively better inspiration. IMPRESSION: Continued cardiomegaly with bilateral pleural effusions and elevated pulmonary venous pressure. . Left Foot X-ray: No radiographic evidence of osteomyelitis or bone destruction. Hallux valgus. Degenerative change at interphalangeal joints. . Persantine Stress: STAGE TIME SPEED ELEVATION [Doctor Last Name 10502] HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 1 0-4 0.142MG/ KG/MIN 68 [Telephone/Fax (1) 111462] TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 50 SYMPTOMS: NONE ST DEPRESSION: NONE INTERPRETATION: This 82 year old type 2 NIDDM woman with a positive stress test [2136-2-11] was referred to the lab for evaluation of chest pain and shortness of breath. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were NSSTTW changes during the near peak infusion and in early recovery. The rhythm was sinus with rare isolated apbs. Appropriate hemodynamic response to the infusion. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or significant ST segment changes. Nuclear report sent separately. . Nuclear stress report: The image quality is satisfactory following the application of a motion correction algorithm to both rest and stress images, although there remains attenuation by the patient's left arm. Left ventricular cavity size is normal with an EDV of 80 ml. Rest and stress perfusion images reveal reduced photon counts in the inferior wall which resolves with attenuation. However, there is a moderate, reversible perfusion abnormality in the inferolateral wall, persistent following attentuation correction. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 56%. IMPRESSION: 1. Moderate, reversible inferolateral wall defect consistent with ischemia. 2. Normal LV cavity size with ejection fraction of 56%. . Non-invasive Lower extremity Arterial: Doppler tracings demonstrate triphasic waveforms at the femoral levels bilaterally and at the left superficial femoral level. All other waveforms are monophasic. At the tibial level on the right, no Doppler tracings could be identified involving either the DP or PT arteries. The volume recordings are in [Location (un) ] with the Doppler tracings. On the left the ABI is 0.68 based on the PT artery and 0.61 based on the DP artery. IMPRESSION: Findings as stated above which indicates: 1. Right-sided SFA disease and significant tibial disease. 2. Distal left SFA versus proximal popliteal disease and tibial disease. Brief Hospital Course: ASSESSMENT AND PLAN: 82F with PMH of DM, and HTN presenting with chest pressure, shortness of breath and ankle edema. BNP in ED, markedly elevated at 7100. . # Acute Congestive Heart Failure- Last ECHO in [2-10] showed EF of >55%. However, given patient's presentation, concern for diastolic dysfunction leading to acute heart failure exacerbation. She was intially admitted to CCU for diuresis and symptomatically improved. She was continued on aspirin, statin, BBlocker and ACE inhibitor. She was discharged on lasix which is a new medication for her. . # Elevated troponin: Thought related to demand ischemia in setting of acute decompensated heart failure however patient also had recent positive stress test. She was referred for cardiac catheterization to evaluate coronaries, but refused. Patient did consent to persantine stress however that showed moderate, reversible inferolateral wall defect. She was again offered therapeutic catherization but refused. She was started on plavix for medical management of her CAD as well as conitnued on aspirin, beta blocker, ACE inhbitor and statin. . # Diabetes Mellitus - On glyburide and metformin at home, however metformin was held while in-house given possibility of cardiac catherization. Home regimen was resumed prior to discharge with no changes in medications or doses . # Foot ulcer: Patient had 1cm ulcer on dorsum of left foot on admission. Podiatry was consulted for recommendations for management and requested plain films of the foot that showed no osteomyelitis. Nonivasive doppler studies were performed that showed right-sided SFA disease and significant tibial disease. as well as distal left SFA versus proximal popliteal disease and tibial disease. She will follow up as an outpatient with podiatry for further management . # Hypertension - Well-controlled on home regimen of BBlocker, ACE inhibitor, and Isosorbide Mononitrate . # Hyperlipidemia - Continued home statin Medications on Admission: Amlodipine 10mg daily ([Hospital1 ] per the patient) Atenolol 50mg daily Atorvastatin 80mg daily Glyburide 10mg [Hospital1 ] Norvasc 30mg daily Metformin 1000mg [Hospital1 ] (daily per the patient) Moexipril 15mg [Hospital1 ] (daily per the patient) Aspirin 81mg daily Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual take 5 minutes apart x3: If you still have chest pain after 3 tablets, call 911. Disp:1 bottle Refills:2 11. Furosemide 20 mg Tablet Sig: [2-3] Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Acute on Chronic Diastolic congestive Heart Failure Coronary Artery Disease with Cardiac Ischemia Hypertension Diabetes Mellitus Type 2 Hyperipidemia Discharge Condition: stable Discharge Instructions: You had chest pain and trouble breathing at home. During your hospital stay it was determined that you had poor blood flow to your heart and congestive heart failure. You were continued on your home medicines and were given intravenous diuretics to get rid of the extra fluid. You will be at risk for reaccumulation of the fluid so your sill continue on low dose furosemide to prevent fluid buildup. 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. You will see Dr. [Last Name (STitle) ] as an outpatient. Please discuss cardiac rehabilitation with him. . New medicines: 1. Furosemide 10 mg daily: to prevent fluid buildup 2. Metoprolol 37.5 mg twice daily to lower your heart rate 3. Clopodigrel: to prevent blood clots that could cause a heart attack. 4. STOP taking Atenolol . Please call Dr. [Last Name (STitle) ] or Dr. [First Name (STitle) ] if you have any further chest pain, trouble breathing, a new cough, swelling in your legs, trouble breathing at night, fevers, chills, trouble urinating or any other concerning symptoms. Followup Instructions: Cardiology: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 62] Date/Time: [2136-6-12] 11:40 [Hospital Ward Name 23] Clinical Center, [Location (un) 436], [Hospital Ward Name 516], [Hospital1 18]. . Podiatry: Dr. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 543] Date/time: please call the office to set up an appt in 2 weeks. . Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]: phone: [Telephone/Fax (1) 250] Date/time: [2136-6-18] 1:40 Completed by:[2136-6-10] ICD9 Codes: 4280, 4240, 4019, 3572, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2231 }	Medical Text: Admission Date: [2155-11-20] Discharge Date: [2155-11-23] Date of Birth: [2155-11-20] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname 1557] is a newborn male infant who was admitted to the NICU with hypoglycemia. He was [Known lastname ] at 5:09 a.m. and was 4.255 gm. He was a product of a 40 6/7 weeks gestation pregnancy to a 31 year old G1 now P1 mother with an estimated date of confinement of [2155-11-14]. Prenatal laboratory studies included blood type A positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B surface antigen negative, Group B strep negative. The pregnancy was complicated by gestational hypertension leading to induction of labor. There was no evidence of gestational diabetes. In the intrapartum period, mother developed a low grade temperature under 100.3. There were no maternal antibiotics and artificial rupture of membranes occurred 12 hours prior to delivery. The baby was [Name2 (NI) ] vaginally with vacuum assistance through light meconium stained amniotic fluid emerging vigorously with apgars of 8 and 8. Initial blood sugars over the first three hours of life were 35, 33 and 35 in spite of feeding [2-6] of an ounce in the Recovery Area. He was brought to the Nursery where he was fed 2 ounces but his follow-up glucose screen was then 29. He was admitted to the NICU for further evaluation and management of hypoglycemia. PHYSICAL EXAMINATION: Physical examination on admission revealed a weight of 4255, greater than the 90th percentile. Head circumference was 37 cm, greater than the 90th percentile and length was 53 cm, greater than the 90th percentile. Vital signs were a temperature of 98.3, heart rate 140's, respiratory rate 40, blood pressure 79/47 with a mean of 53. Oxygen saturation was 99 percent in room air. In general, he was a well-developed large for gestational age infant in no distress and vigorous with exam. Skin was pale pink, warm with brisk capillary refill and no rashes. HEENT was notable for molding, anterior fontanelle soft and flat, red reflex present bilaterally, oropharynx clear, palate intact and mucous membranes were moist and pink. Chest was clear with no grunting, flaring or retracting. Cardiac - regular rate and rhythm, Grade 2/6 systolic murmur left upper sternal border, no gallop. Pulses are plus 2 and equal. Abdomen is soft with no hepatosplenomegaly, no masses, active bowel sounds, three vessel cord. GU - normal male, testes palpable, anus patent. Extremities - warm, well-perfused. Hips and back are normal. Neurologic - tone and activity are appropriate. Moro grasp and suck is intact, not jittery, two to three beats of clonus noted. Deep tendon reflexes are 2 plus and equal. HOSPITAL COURSE BY SYSTEMS: Respiratory - [Doctor Last Name 916] remained comfortable in room air and has a resting respiratory rate in the 40's. Cardiovascular - continues with an intermittent soft systolic murmur with APs 110-150, maybe representative of a closing ductus arteriosus. No murmur appreciated over past 12 hours.Blood pressure ranged from 69/45 with a mean of 52 to a systolic of 72/46 with a mean of 59. The baby has remained hemodynamically stable. FEN - [Doctor Last Name 916] was started on IV fluids peripheral of D10W at 80 cc per kg to achieve euglycemia with blood sugar ranges 42-53 in the first 24 hours of age. He required a bolus of D10W with increased glucose infusion rate utilizing D12 [12-6] percent glucose IV in addition to enteral feeds of 24 calorie breast milk or Similac. Blood sugar ranges have been 60's to 80's subsequent to that and IV fluids were weaned to maintain blood sugars greater than 60. On day of discharge, [11-23], [Doctor Last Name 916] is off of his IV fluids and is taking breast milk or Similac 22 calories per ounce with blood sugars greater than 60. He has been breastfeeding and has been supplementing as well with 22 calorie formula. Electrolytes were checked at 24 hours of age and were in the normal range. His urine output has been good and he is passing meconium stool. There is no evidence of hyperbilirubinemia. Weight at discharge is 4.185 gm. There is no change in head circumference or length. Hematology - CBC and blood culture were drawn upon admission in view of persistent hypoglycemia. White count was 14.1 with 71 polys, 0 bands, 21 lymphs and hematocrit was 43 percent. Platelets were 273,000. Blood culture has remained negative to date. There were no antibiotics given to the baby. [Name (NI) ] has remained clinically well throughout his stay. Neurology - the baby has an appropriate neurologic exam, is vigorous with appropriate tone and reflexes. Sensory - Audiology - hearing screen was performed on [11-22] and there was a refer on the right ear with the automated auditory brainstem responses and they recommend re-screen prior to discharge and referral for follow-up testing. Ophthalmology - the patient is not a candidate for an eye exam at term. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home with family. The name of primary pediatrician is [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of [Location (un) 47], [Hospital1 59714], [Location (un) 47], [Numeric Identifier 59715]. The phone number is [Telephone/Fax (1) 43144]. DISCHARGE INSTRUCTIONS: Medications at discharge - none. Feeds at discharge - breastfeeding ad lib demand with supplementation as needed with Similac currently at 22 calories per ounce. Car seat position screening is not indicated at term. Immunizations received - hepatitis B vaccine was administered on [11-23]. State screen was also performed on [11-23] and the results of which are pending at this time. Immunizations recommended - Synergist RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria - 1) [Month (only) ] at less than 32 weeks, 2) [Month (only) ] between 32 and 35 weeks with two of the following risk factors - day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, or 3) infants 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 hours of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. Follow-up appointments are with primary pediatrician. Mother has this appointment scheduled for the week of discharge. DISCHARGE DIAGNOSES: Term infant, large for gestational age, hypoglycemia, rule out sepsis. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] M.D [MD Number(1) 43886] Dictated By:[Last Name (NamePattern1) 54678] MEDQUIST36 D: [2155-11-23] 05:01:03 T: [2155-11-23] 07:39:16 Job#: [Job Number 59716] ICD9 Codes: V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2232 }	Medical Text: Admission Date: [2162-7-8] Discharge Date: [2162-7-13] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 85yo woman with h/o CAD s/p MI in [2134] and HTN who presents with complaint of chest pain. The patient reports episodes of substernal chest pain over the last week. She describes shooting pain that "pulled from side to side," not associated with exertion. She thought the pain was indigestion and did not seek care. The night prior to admission, she was feeling stressed after seeing her husband at rehab, where he has been staying since an MI treated at [Hospital1 18] in the CCU 02/[2162]. She went home and ate a hot dog with relish, then had a chocolate bar and fried [Last Name (un) 106277]. When she went to bed, she started having severe right-sided chest pain, which she variably describes as being under her right breast vs just to the right of her sternum. No associated nausea, dyspnea, or diaphoresis. Not pleuritic. She tried some tylenol and then smoked a cigarette, but without any relief. After taking some nasal spray (azelastine), she began feeling palpitations and shortness of breath. In the morning, she called her daughter, who brought her to see her PCP. [Name10 (NameIs) ] her PCP's office at 10:30am, she felt fine; the chest pain and dyspnea had resolved on their own. Her PCP noted EKG changes and sent her to the ED. In the ED, initial VS were: 97.1 67 146/76 19 95% on ??. There were no acute EKG changes noted, and she was given ASA 324mg, SL NTG. She was going to be admitted to [Hospital Unit Name 196] for rule out when she developed acute respiratory distress with SBP up to 170s and sat's down into the 80s. CXR demonstrated significant pulmonary edema, and she was given lasix 40mg IV as well as put on a nitro gtt. She was placed on CPAP at 8 and admitted to the CCU. Upon arrival to the CCU, she was breathing comfortably on 4L by nasal cannula and chest pain free. Nitro gtt at 0.78. The patient reports having poor energy for the last couple of months. She has also had poor appetite. She has 4 pillow orthopnea but denies PND. She endorses some minor LE edema x 1 week but no weight gain. Past Medical History: CAD s/p MI in the [2134]; reports she had a second minor MI shortly after, both medically managed. HTN GERD h/o Choledocholithiasis [2153] s/p ERCP and sphincterotomy h/o Acute cholecystitis [2156] s/p cholecystostomy tube, followed by open CCY c/b wound infection, epigastric hernia Gout h/o GI bleed in [2148], ?? due to diverticulosis h/o transfusion reaction s/p appendectomy s/p Open reduction and internal fixation of left hip. s/p C section. PCP: [Name10 (NameIs) ],[Name11 (NameIs) 569] [Name Initial (NameIs) ]. [Telephone/Fax (1) 133] ALLERGIES: NKDA Social History: Social history is significant for the presence of current tobacco use. She has smoked 1 pack per week x 70 years. She denies alcohol abuse. She had been living with her husband until [Month (only) 956], when he had his MI. He has been in and out of hospitals/rehab since then. She has 2 children in [Location (un) 86] and in [Hospital1 614]. She walks with a cane since a hip fracture. She does not have a visiting nurse, but a woman comes to help clean from time to time. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 97.1, BP 143/80, HR 96, RR 26, O2 96% on 4L Gen: Pleasant elderly woman, mildly tachypneic when talking but able to complete full sentences; somewhat tearful when talking about changes in her life. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 5cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +systolic murmur at apex. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Faint crackles at bases b/l, no wheeze or rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: Left > right LE edema. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Carotids 2+ without bruit; distal pulses dopplerable b/l Pertinent Results: EKG on admission demonstrated NSR with normal axis and incomplete BBB with old inferior Q waves and T wave flattening in I, aVL, and V5-V6. As compared with prior from [2161], prominent R wave in V2 has disappeared and lateral T wave flattening is new. CXR [2162-7-8] (dictated): Lateral right hemithorax cut off. No definite pneumonia. Central hilar prominence suggestive of congestion. No large pleural effusion on left [Month/Day/Year ] [11/2160] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal inferior and inferolateral akinesis. 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, without prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Mild regional left ventricular systolic dysfunction. Moderate mitral regurgitation. Bedside TTE in CCU [2162-7-8]: The left atrium is normal in size. There is severe regional left ventricular systolic dysfunction with extensive inferior, inferolateral and lateral akinesis (LCx distribution). There is mild hypokinesis of the remaining segments (LVEF = 25-30%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w CAD. Severe mitral regurgitation. Moderate pulmonary hypertension. pMIBI [2161-5-13]: 84 yo woman (h/o MI) was referred to evaluate an atypical chest discomfort and fatigue. Due to a limited ability to exercise (prior hip fx) and limited hemodynamic response to exercise without ECG changes or symptoms, a persantine-MIBI was performed. The patient was administered 0.142 mg/kg/min of persantine over 4 minutes. No chest, back, neck or arm discomforts were reported by the patient during the procedure. No significant ST segment changes were noted from baseline. The rhythm was sinus with frequent aea and infrequent vea. The hemodynamic response to the persantine infusion was appropriate. Three min post-MIBI, the patient was administered 125 mg aminophylline IV. IMPRESSION: Limited functional exercise tolerance secondary to orthopedic limitations; persantine MIBI performed. No anginal symptoms or ECG changes from baseline. Nuclear report sent separately. Laboratory Data [2162-7-13] WBC-5.2 RBC-3.20* Hgb-10.0* Hct-29.3* MCV-92 MCH-31.3 MCHC-34.1 RDW-16.6* Plt Ct-184 [2162-7-8] Glucose-111* UreaN-41* Creat-2.5* Na-137 K-4.7 Cl-107 HCO3-17* AnGap-18 [2162-7-13] Glucose-104 UreaN-62* Creat-3.2* Na-134 K-4.3 Cl-104 HCO3-18* AnGap-16 [2162-7-13] Calcium-8.3* Phos-4.3 Mg-2.0 [2162-7-9] TSH-1.8 [2162-7-8] 12:05PM BLOOD CK(CPK)-90 [2162-7-8] 08:44PM BLOOD CK(CPK)-114 [2162-7-9] 06:04AM BLOOD CK(CPK)-83 [2162-7-10] 05:52AM BLOOD CK(CPK)-62 [2162-7-12] 07:00AM BLOOD CK(CPK)-44 [2162-7-8] 12:05PM BLOOD CK-MB-NotDone proBNP-[Numeric Identifier 106278]* [2162-7-8] 12:05PM BLOOD cTropnT-1.90* [2162-7-8] 08:44PM BLOOD CK-MB-21* MB Indx-18.4* cTropnT-2.09* [2162-7-9] 06:04AM BLOOD cTropnT-1.86* [2162-7-10] 05:52AM BLOOD cTropnT-1.88* [2162-7-12] 07:00AM BLOOD CK-MB-5 cTropnT-1.42* [2162-7-9] Triglyc-127 HDL-35 CHOL/HD-5.0 LDLcalc-115 Brief Hospital Course: Mrs. [Known lastname 1557] is an 85 yo woman with CAD s/p remote MI admitted with chest pain and acute pulmonary edema, found to have new inferolateral wall motion abnormality and 4+ MR [First Name (Titles) ] [Last Name (Titles) ] concerning for subacute ischemic event. . # CAD/Ischemia [Last Name (Titles) ] was found to have new inferolateral wall (LCx distribution) motion abnormality, EF of 25-35% in remaining areas, and 4+ MR (increased from 2+) on [Last Name (Titles) 113] since [2160]. Pt likely had MI in past week or so leading up to admission since at presentation, troponins were elevated but trending down, CKs negative, non-evolving EKGs. During hospital course, the pt complained of "chest soreness" associated with episodes of acute pulmonary edema, but her EKGs were unchanged from baseline and her cardiac markers continued trending down so a new ischemic event is not likely. The pt was managed medically rather than invasively in light of her age and comordities; home aspirin was continued and she was started on a statin. Metoprolol was increased as tolerated instead of giving home nifedipine for increased cardiac benefit. She was not started on an ACE I during this admission due to acute renal failure but would benefit from it once her renal function stabilizes. She was also given a nicotine patch for tobacco cessation. The need for tobacco cessation was readressed at discharged. . # Acute Systolic Heart Failure (EF 25-35%) Patient likely had acute pulmonary edema due to transient stiffening of her LV vs worsening mitral regurgitation. Her respiratory status improved with lasix, nitro gtt, and oxygenation in the ED. Her nitro gtt was weaned off and hydralazine and imdur were started for afterload reduction. The pt had acute pulmonary edema several more times which was triggered by exertion and possibly elevated BP. This resolved with lasix prn. Patient was subsequently started on a standing dose of lasix 40 mg po daily . # Acute renal failure on chronic renal insufficiency: Baseline Cr 1.8-2.1. The pt noted to have decreased urine output at admission. She had urine lytes with a FeUrea of 30.5, an unremarkable UA, and urine output that was responsive to increased po fluid intake all of which suggest a prerenal etiology. This was most likely due to poor forward flow in setting of heart failure. Nephrotoxic agents, including ACE I, were avoided. However, as the patient continued to develop acute pulmonary edema, she was gently diuresed with lasix while her fluid status was closely monitored. She had a Cr of 3.5 on discharge. . # Anemia: Her Hct was stable at 29.3 on discharge. She has a baseline Hct of 33-38. The pt has a h/o BRBPR in [2148]. Her stool was guiac negative. She reports a recent outpatient colonoscopy (in past 6mos) as normal. . # Gout: The pt was on home med of allopurinol 300 mg daily for gout prophylaxis. As pt had ARF her dose was decreased to 100 mg daily. Medications on Admission: Atenolol 100mg Isosorbide 20mg daily Nifedical XL 60mg daily Allopurinol 300mg daily Prilosec Azelastine nasal spray Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:100 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 5. Outpatient Lab Work For visiting nurse to draw: Please draw BUN, creatinine and CBC on [7-15] and forward results to Dr. [Last Name (STitle) 172] 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Azelastine Nasal Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: 1. Coronary artery disease s/p Myocardial Infarction 2. Acute systolic heart failure Secondary Diagnoses: 1. Acute systolic heart failure 2. Acute pulmonary edema 3. Mitral regurgitation 4. Acute renal failure 5. Chronic renal insufficiency 6. Hypertension Discharge Condition: Stable vital signs. Ambulating with wheeled walker. Tolerating oral medication and nutrition. Discharge Instructions: You were admitted with chest pain and shortness of breath. We found evidence for a recent heart attack and adjusted your medications to optimize your heart function. 1. Please take all medications as prescribed. *Medication changes:* New medications: - Aspirin 325 mg daily - Atorvastatin 80 mg at night - Hydralazine 50 mg three times a day - Furosemide 40 mg daily Changed medications: - Isosorbide was increased to 30 mg daily - Allopurinol was decreased to 100 mg daily - Atenolol was changed to Toprol XL (metoprolol succinate) 100 mg daily Discontinued medications: - Nifedical XL 60mg daily 2. Please attend all follow-up appointments listed below. The two new doctors [First Name (Titles) ] [Last Name (Titles) 32607] in the heart and kidney disease. 3. Please call your doctor or return to the hospital if you develop chest pain, shortness of breath, palpitations, lightheadedness, fevers, or any other concerning symptom. 4. Please stop smoking. Information was given to you on admission regarding smoking cessation. 5. Please weigh yourself every day and tell Dr. [Last Name (STitle) 172] if you gain more than 3 pounds in 1 day or 6 pounds in 3 days. Please follow a low sodium diet. Information was given to you regarding heart failure, diet and exercise on discharge. Followup Instructions: 1. PCP: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 172] [2162-7-22] at 9:30am. Please call [Telephone/Fax (1) 133] with questions. 2. Cardiology clinic: You have a follow up appointment with Dr. [Last Name (STitle) ] on Monday [7-26] at 3:20pm 3. [Hospital 10701] Clinic: Dr. [First Name4 (NamePattern1) 429] [Last Name (NamePattern1) 118] on [2162-8-3] at 11:30am in the [Hospital Ward Name 23] Center [Location (un) 436]. Please call [Telephone/Fax (1) 60] with questions. Completed by:[2162-7-21] ICD9 Codes: 5849, 4280, 5859, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2233 }	Medical Text: Admission Date: [2183-6-10] Discharge Date: [2183-6-18] Date of Birth: [2109-11-11] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain/Myocardial Infarction Major Surgical or Invasive Procedure: [2183-6-11] - Cardiac Catheterization [2183-6-12] - CABGx4 (Interal mammary to Left anterior descending artery, Vein to Diagonal artery, vein to obtuse marginal artery, vein to posterior descending artery) History of Present Illness: 73M with h/o HTN, DMII, hyperlipidemia, GERD presents with 3 days of escalating exertional chest pressure. He clearly states that he has been having the sensation of chest pressure/not pain, over his anterior chest, non radiating which started with exertion when he was mowing the lawn on Saturday. The pressure is associated with bilateral elbow/arm muscular pain. He had a prolonged episode today relieved with burping and pressing on his stomach. He tells me that these symptoms started about three months ago, off/on and getting progressively worse. The pressure usually occurs with exertion and is relieved with drinking cold water or sitting down. He is unclear how long these episodes last but always resolve with the above measures. He denies any nausea/vomiting/diaphoresis although may have been a little sweaty on saturday during that episode. Also denies any abd pain. He has normal bowel movements brown/tan color, never black or frank blood. He has his last colonoscopy a few years ago at [Hospital1 ] [Location (un) ] (no recors here). Currently he is CP free since he has been lying down/sitting. ROS also negative for fever/chills, +frequent cough with "upper respiratory problems". [Name2 (NI) ] orthopnea/pnd, but often sleeps with pillows due to GERD. GERD symptoms are more burning in nature compared to these symptoms. Effort tolerance unlimited although pressure sensation can occur with minimal exertion, a few years ago walked 12 miles. . In the ED VS 97.7 77 147/96 16 98% RA. Given metoprolol 12.5 mg po x 1, heparin per weight based protocol, ASA 81 mg x 1. EKG NSR at 69, nl axis, nl intervals, S1Q3T3 pattern, no other ST-T changes. (no old for comparison). Guaiac + clear mucus on rectal. . He is now admitted for a cardiac catheterization and further management of his cardiac disease. Past Medical History: - Diabetes--on metformin, recently decreased dose to 500 mg daily due to rash; HbA1C 7.0 [1-19] - Hypertension - Hyperlipidemia. - Arthritis of hands - GERD - HOH - Myocardial Infarction - Anxiety Social History: Lives with wife and daughter, still working for school with disabled children, used to be in air force and worked for the goverment. Quit smoking 7 years ago (prior smoked 2 ppd x 40 yrs), occasional etoh (1 drink every 2 weeks), no drugs. Family History: There is no family history of premature coronary artery disease or sudden death. Father's side of family with CAD but all lived to 80-90's. Mother's side died from stomach ulcers that became cancerous (several members with same diagnosis). No other cancer in family. Physical Exam: VS: T 98.2 BP 133/78 HR 62 RR 12 O2 96% RA Wt 183 lbs Gen: elderly male in NAD, lying flat in bed, heavy beard, frequently coughing. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with flat JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Distant heart sounds. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [2183-6-10] 08:00PM WBC-9.1 RBC-4.97 HGB-15.2 HCT-43.5 MCV-88 MCH-30.6 MCHC-34.9 RDW-13.3 [2183-6-10] 08:00PM GLUCOSE-120* UREA N-20 CREAT-1.1 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17 [2183-6-10] 08:00PM CK-MB-6 [2183-6-10] 08:00PM cTropnT-0.06* [2183-6-10] 08:00PM CK(CPK)-110 [2183-6-10] 09:30PM D-DIMER-1501* . EKG [6-10]: NSR at 69, nl axis, nl intervals, S1Q3T3 pattern, no other ST-T changes. (no old for comparison). . CXR [6-10]: No acute cardiopulmonary process identified. . CTA [6-11]: No PE. [2183-6-11] Cardiac Catheterization 1. Selective coronary angiography of this right dominant system demonstrated severe three (3) vessel coronary artery disease. The left main demonstrated no angiographic evidence of any flow limiting lesions. The left anterior descending artery was diffusely calcified including a 70% proximal and 80% distal stenosis. The left circumflex was diffusely diseased including an 80% lesion at the origin of the vessel. The right coronary artery demonstrated a hazy 80-90% lesion in the proximal portion of the vessel along with mild diffuse disease throughout the remainder of the vessel. 2. LV ventriculography demonstrated a preserved left ventricle function with an ejection fraction of approximately 60%. The mitral valve appeared structurally normal without any significant regurgitaition. There was no significant pressure gradient across the aortic valve upon pullback from the left ventricle to the aorta.an elevated left heart filling pressure (LVEDP 24 mm Hg) along with a normal central aortic pressure (124/70 mm Hg). [2183-6-11] ECHO The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Preserved global and regional biventricular systolic function. Mild mitral regurgitation with normal valve morphology. [2183-6-13] - CXR: The pulmonary artery catheter has been removed with the right internal jugular vascular sheath persisting. Mediastinal and chest tubes have also been removed. Patient is status post sternotomy and CABG with no significant change in the appearance of the mediastinum. Lung volumes remain low and there is no evidence of pneumothorax. Right upper lung field linear atelectasis is unchanged. Layering left pleural effusion and atelectasis persists. No evidence of overt failure. Brief Hospital Course: Mr. [Known lastname 16745] was admitted to the [Hospital1 18] on [2183-6-10] for further management of his chest pain. He underwent a cardiac catheterization which revealed severe three vessel disease. Given these findings, the cardiac surgical service was consulted for surgical management. Mr. [Known lastname 16745] was worked-up in the usual preoperative manner and deemed suitable for surgery. On [2183-6-12], Mr. [Known lastname 16745] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname 16745] [Last Name (Titles) 5058] neurologically intact and was extubated. Pressors were slowly weaned as tolerated. On postoperative day two, Mr. [Known lastname 16745] developed atrial fibrillation which converted back to normal sinus rhythm with intravenouos beta blocker and repletion of his electrolytes. On postoperative day three, he was treansferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. By post-operative day six he was ready for discharge to home. Medications on Admission: HYDROCHLOROTHIAZIDE 12.5 mg--1 capsule(s) by mouth once a day take w/ oj or banana LIPITOR 10 mg--1 tablet(s) by mouth once a day LISINOPRIL 40 mg--1 tablet(s) by mouth once a day METFORMIN 500 mg--2 tab(s) by mouth q.day PAXIL 20 mg--1 tablet(s) by mouth once a day RANITIDINE HCL 150 mg--1 tablet(s) by mouth b.i.d. RHINOCORT AQUA 32MCG--One spray/nostril every day TRIAMCINOLONE ACETONIDE 0.1 %--apply twice a day as needed for rash Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while taking percocet. Disp:60 Capsule(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: CAD s/p CABG MI Hypercholesterolemia HTN Diabetes Mellitus Type II Anxiety GERD Pleurisy Hearing Impaired Discharge Condition: Stable 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. 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. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month Follow-up with Dr. [Last Name (STitle) ] in [2-15] weeks. [Telephone/Fax (1) 4775] Follow-up with cardiologist Dr. [Last Name (STitle) ] in 2 weeks. Call all providers for appointments. Completed by:[2183-6-18] ICD9 Codes: 9971, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2234 }	Medical Text: Admission Date: [2189-3-18] Discharge Date: [2189-3-26] Date of Birth: [2111-12-25] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1481] Chief Complaint: back pain Major Surgical or Invasive Procedure: Right chest tube thoracostomy History of Present Illness: 77 year old man withh/l HTN, prostate ca, early Parkinson's disease who presented toBIDMC from [Hospital6 302] after a MVA. Patient was reportedly out at [Company ] in the mid afternoon and reversed at high speed into a tree in the parking lot. He sustained multiple traumas, including R hemothorax, R scapular fx, C7 non displaced spinous process fx, multiple thoracic spine fx's, R 6-8th rib fx, and SDH. Past Medical History: `PMH 1. Hypertension 2. Parkinson's Disease 3. Dementia 4. Prostate cancer Social History: Single, lives alone on [Location (un) ] of a duplex house. Friend/HCP, [Name (NI) ], lives on the [Location (un) 448] and has been his tenant x 36 years. Retired owner of several nightclubs. No services at home, takes care of self-care independently. Drives. [Doctor Last Name ] is very involved in his care and accompanies him to all doctor's appointments. Has h/o alcohol use, but [Doctor Last Name ] cannot quantify his current usage. States that last week his cousin died and Mr. [Known lastname ] took the news badly. He was visibly intoxicated last week. Mr. [Known lastname ] occasionally has alcohol on his breath, but [Doctor Last Name ] is unaware if he drinks daily. Family History: non contributory Physical Exam: O: T: 99 BP: 114/53 HR: 83 R 17 O2Sats 100% CMV Gen: intubated and sedated HEENT: Pupils: L 2->1; R 4, unresponsive with a small defect in the [Doctor First Name 2281]; opens eyes to name Neck: Supple. Lungs: CTA bilaterally; CT in place on R Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Opens eyes to command, but does not follow commands Orientation: Intubated and sedated Recall: Intubated and sedated Language: Intubated and sedated Cranial Nerves: I: Not tested II: L pupil 2->1; [Initials (NamePattern4) ] [Last Name (NamePattern4) 2281] defect superiorly, pupil 4, nonreactive III-XII: patient intubated and sedated, does not follow commands Motor: Moves extremities spontaneously and in response to pain, but does not localize Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 1+---- 2+ 1+ Left 1+---- 2+ 1+ Toes downgoing bilaterally Coordination: Unable to assess at this point Pertinent Results: [2189-3-17] 10:30PM WBC-19.3* RBC-2.93* HGB-10.1* HCT-29.4* MCV-100* MCH-34.6* MCHC-34.6 RDW-13.6 [2189-3-17] 10:30PM PLT COUNT-227 [2189-3-17] 10:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2189-3-17] 10:30PM UREA N-26* CREAT-0.9 [2189-3-17] 10:40PM GLUCOSE-157* LACTATE-2.0 NA+-140 K+-3.8 CL--104 TCO2-22 [2189-3-17] Head CT : There is a small subdural hematoma along the falx, best seen on images 23-24 [2189-3-17] CT C Spine : Minimally displaced C7 spinous process fracture. Large posterior osteophytes and PLL ossification at C3-C4 causing significant narrowing of the spinal canal in the setting of trauma, cord contusion cannot be excluded and if focal neurologic deficit, a MR for further evaluation is recommended. NOTE ADDED AT ATTENDING REVIEW: There has been resection of the left lamina of C6 and C7. There is sever spinal canal narrowing at multiple levels. In the setting of trauma these can lead to cord contusions. [2189-3-18] Cardiac echo : The left atrium is elongated. 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [2189-3-18] CT Abd/pelvis : 1. Slight interval increase in hematoma abutting the right posterior pleura. 2. Interval increase in bilateral pleural effusions. The density of the right effusion is suggestive of a hematoma or hemothorax. 3. Stable appearance to thoracic and posterior right rib and transverse spinous process fractures. Right superior scapular fracture is now evident, but was not imaged on the prior examination. Otherwise no new fractures. 4. ET tube 1.5 cm from carina. 5. Horseshoe kidney configuration. 6. Diverticulosis without diverticulitis. [2189-3-18] MRI C/T/L spine : 1. Severe narrowing of the spinal canal at C3-4 and C4-5. Additional variable multilevel spinal canal and neural foraminal narrowing of the cervical spine as described above. 2. Acute compression of the T3, T5, T6, T7, and T12 vertebral bodies. Questionable acute bone marrow edema involving the T11 vertebral body. 3. Multilevel degenerative changes of the lumbar spine without high-grade neural foraminal or spinal canal narrowing. [2189-3-19] Head CT : 1. Slight decrease in small perifalcine SDH. 2. Moderate paranasal sinus disease. Brief Hospital Course: Mr. [Known lastname ] was evaluated in the Emergency Room by the Trauma service then admitted to the Trauma ICU for close monitoring, frequent neuro checks and pulmonary toilet as well as pain control. His GCS on admission was 15 however he soon became very agitated and eventually required intubation and sedation to keep him calm. His chest xray showed a large right pleural effusion and he had a chest tube placed which drained about 1 liter of blood. He was oxygenating well but did require 2 blood transfusions during his initial resuscitation. The Neurosurgery service and Orthospine service followed him closely as well. He had a small subdural hematoma and subsequent head Ct's showed no increase. After he was weaned and extubated from the respirator he was able to follow simple commands but unfortunately his episodes of agitation were treated with Ativan and this seemed to cause over sedation. The geriatric service was consulted to assist in balancing his medications in light of his Parkinson's disease. They recommended treating him with Seroquel instead on benzo's or Haldol and this over time was effective. The Orthospine service recommended a TLSO brace with a cervical extension for his multiple thoracic vertebral fractures and his C7 fracture. He was fitted for a TLSO brace and required another revisement. His chin developed a stage 1 pressure ulcer and that prompted a consult to the skin care nurse. See recommendations on referral sheet. His TLSO brace may be removed for chest PT however he must maintain logroll precautions when it is off. Following extubation from the respirator on [2189-3-19] his chest tube was removed and he was kept in the ICU for persistent episodes of agitation and delirium. Due to a possible history of ETOH he was placed on a CIWA scale. Within 24 hours he was improving enough to be followed on the Trauma floor. He had a speech and swallow evaluation and failed secondary to aspiration therefore a dobhoff feeding tube was placed and remains in place, Hopefully as his mental status improves the study can be repeated. Mr. [Known lastname ] was making some progress and his agitation is controlled with increased doses of Seroquel at HS and a low dose in the AM. His pain is controlled with Oxycodone and Tylenol and he has been able to get out of bed to a chair with Physical Therapy as long as his pain is controlled. Nutritional recommendations were made today to change his formula to Boost glucose control at 80cc/hr however given the transfer to rehab I elected not to change the preparation prior to transfer. His foley catheter was removed on [2189-3-25] but replaced the same day due to urinary retention. He was also started on Flomax. A voiding trial should occur [2189-3-27]. Hopefully after a successful stay in rehab he will be able to return home independently with necessary services. Please call with any questions. Medications on Admission: 1. Requip 2. "blood pressure pill" - [Doctor Last Name ] does not recall name Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection TID (3 times a day). 2. Ropinirole 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2 times a day). 8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 9. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 11. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 12. 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: [Hospital 5503] rehab Discharge Diagnosis: Discharge Worksheet-Discharge Diagnosis-Last Updated by: [Last Name (LF) ],[First Name3 (LF) 278], PA on [2189-3-26] @ 1111 Primary diagnosis S/P MVC 1. C7 non displaced spinous process fracture 2. T3 pedicle and transverse process fracture 3. T5 & T6 Right transverse prcoess fracture 4. T6 & T7 vertebral body fracture 5. T4-8 spinous process fractures 6. T12 & L1 Left transverse process fractures 7. Right [7-14] rib fractures 8. Right scapular fracture 9. SDH 10. Acute blood loss anemia Secondary diagnoses 1. Hypertension 2. Parkinson'sisease 3. Dementia 4. Prostate Cancer Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Lethargic but arousable Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. TLSO brace with cervicle extension at all times ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. . CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Call the [Hospital 85876] Clinic at [Telephone/Fax (1) 1669] for a follow up appointment in 4 weeks with a non contrast head CT prior. The secretary can arraange this for you. Call Dr. [Last Name (STitle) 363] at [Telephone/Fax (1) 3573] for a follow up appointment in 4 weeks. Completed by:[2189-3-26] ICD9 Codes: 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2235 }	Medical Text: Admission Date: [2194-6-12] Discharge Date: [2194-6-24] Date of Birth: [2194-6-12] Sex: M Service: Neonatology HISTORY: [Known lastname ] [Known lastname 48353] was born at 34-5/7 weeks gestation to a 33-year-old gravida 9 para 2 now 3 woman. Her past obstetrical history is notable for an ectopic pregnancy in [2185], SAB at 12 weeks in [2186], a blighted ovum in [2186], a intrauterine fetal demise at 20 weeks with severe preeclampsia in [2186], SAB in [2187] at nine weeks, a 34 week infant delivery for severe preeclampsia in [2189], another blighted ovum in [2191], and a 34 week infant in [2193]. Her previous medical history is notable for antiphospholipid antibody syndrome, treated with aspirin during the pregnancy. She also has a history of deep venous thrombosis in [2184] and is currently on Lovenox. Her prenatal screens are blood type O+, DAT negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative and group B Strep negative. This pregnancy was also complicated by an abnormal triple screen and with a decline of amniocentesis, but a level II ultrasound was normal. She has been on aspirin and enoxaparin. No other medications until the week prior to delivery. Pregnancy was also complicated by hypertension leading to bed rest in the week prior to delivery with blood pressure controlled initially on labetalol, then required magnesium sulfate. Worsening blood pressure led to the repeat cesarean section. Rupture of membranes occurred at delivery yielding clear amniotic fluid with no maternal fever, no labor, no fetal tachycardia or evidence of chorioamnionitis. No antibiotics were delivered to the mother prior to delivery. The infant emerged vigorous. Apgars were 8 at one minute and 9 at five minutes. Birth weight is 2,020 grams and the birth length was 44 cm and the birth head circumference was 30 cm. PHYSICAL EXAMINATION: Admission physical exam reveals an active nondysmorphic preterm infant. Anterior fontanel is soft and flat, mild nasal flaring. Chest with mild-to-moderate intercostal and subcostal retractions, good breath sounds bilaterally, no crackles, mild grunting respirations. Heart with regular, rate, and rhythm. A grade 1/6 systolic ejection murmur at the left upper sternal border without radiation. Abdomen is soft, nondistended, no masses, three vessel umbilical cord, normal preterm male genitalia. Testes descended bilaterally. Active, alert, responses to stimulation. Tone appropriate for gestational age. HOSPITAL COURSE BY SYSTEMS: Respiratory status: The infant initially started on nasopharyngeal continuous positive airway pressure on day of life #1, required intubation for increasing respiratory distress. He received three doses of surfactant, and weaned back to nasopharyngeal continuous positive airway pressure on day of life #5 and weaned to room air on day of life #6, where he has remained. He had rare episodes of apnea and bradycardia never requiring any treatment for those. On examination now, his respirations are comfortable. His lung sounds are clear and equal. Cardiovascular status: The murmur that was present on admission persisted. Cardiology evaluation was done day of life #6. The infant had an electrocardiogram that had right ventricular predominance which was normal for age and passed a hyperoxia test. He has normal four extremity blood pressures and a chest x-ray with a normal cardiothymic silhouette. He was seen by Dr. [Last Name (STitle) 48354] of [Hospital3 1810] of Cardiology, and this was felt to be most likely an innocent murmur. On examination, he is pink and well perfused. He continues at the time of discharge to have a grade [1-27] murmur. Fluids, electrolytes, and nutrition status: At the time of discharge, his weight is 2,120 grams. His length is 44.5 cm. His head circumference is 32 cm. Enteral feeds were begun on day of life #6 and advanced without difficulty to full volume feedings. At the time of discharge, he is taking formula feeding of 20 cal/ounce of Enfamil on an adlib schedule. Gastrointestinal status: [Known lastname ] was treated with phototherapy for hyperbilirubinemia of prematurity from day of life #4 until day of life #7. His peak bilirubin occurred on day of life #4 and was total 12.5, direct 0.4. Hematology: The hematocrit at the time of admission was 45. The infant has never received any blood product transfusions during his NICU stay. Infectious disease status: [Known lastname ] was started on ampicillin and gentamicin at the time of admission for sepsis risk factors. He did complete seven days of antibiotics. His blood culture did remain negative. He has remained off antibiotics since that time. Sensory: Audiology. Hearing screen was performed with automated auditory brain stem responses and the infant passed in both ears. Psychosocial: Parents have been very involved in the infant's care throughout his NICU stay. CONDITION ON DISCHARGE: The infant is discharged in good condition. DISPOSITION: The infant is discharged home with his parents. PRIMARY PEDIATRICIAN: Primary pediatric care will be provided by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 42720], telephone #[Telephone/Fax (1) 42721]. CARE AND RECOMMENDATIONS AFTER DISCHARGE: 1. Feedings: Formula feeding of 20 calorie per ounce formula on an adlib schedule. 2. The infant is discharged on no medications. 3. A car seat position screening test was passed prior to discharge. 4. A State Newborn Screen was sent on [6-17] and again on [6-24], the day of discharge. 5. The infant received his first hepatitis B vaccine on [2194-6-22]. 6. Follow-up appointments: [Hospital3 1810] Cardiology, Dr. [Last Name (STitle) 48354], telephone #[Telephone/Fax (1) 37115]. DISCHARGE DIAGNOSES: 1. Prematurity 34-5/7 weeks. 2. Status post respiratory distress syndrome. 3. Status post apnea of prematurity. 4. Status post presumed sepsis. 5. Status post exaggerated physiologic hyperbilirubinemia. 6. Heart murmur most likely a flow murmur. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 37333] MEDQUIST36 D: [2194-6-23] 23:09 T: [2194-6-24] 06:05 JOB#: [Job Number 48355] ICD9 Codes: 769, 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2236 }	Medical Text: Admission Date: [2118-3-20] Discharge Date: [2118-3-26] Date of Birth: [2063-8-9] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6021] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Abdominal port placement [2118-3-21] History of Present Illness: 54 y/o woman with metastatic ovarian cancer complicated by ascites requiring frequent paracentesis who is admitted to the [Hospital Ward Name 332] ICU after presenting to the emergency department with dyspnea. . Her ascites has been a [Last Name 12785] problem of late, and has required 2 paracentesis last week alone. She was in fact scheduled to have IR place a peritoneal port on [2118-3-21]. She underwent her last recieved chemo on [2118-3-15]; and was transfused 2U PRBC for HCT 26 that day. She last underwent paracentesis on [2118-3-18]. . She awoke on the day of admission (Sunday [2118-3-20]) feeling short of breath, and with abdominal distension, and noted that this was similar to how she feels prior to paracentesis. She has not had any acute abdominal pain, but notes a bloating and a tightness sensation. She vomited once last night after eating and has had poor PO intake at baseline. She also reports feeling increasingly weak. She has had no chest pain. . In the ED, she was afebrile 99.5, with BP 110/60, HR 120, 18, O2 sat 98% on RA. She was found to have a Hct of 16 (down from 26 on [2118-3-16]) and WBC of 1.0. A CT torso was performed in the ED which demonstrated no PE/dissection, but progression of omental/peritoneal disease with pockets of hyperdense ascites in LUQ and mid line lower abdomen which likley represent intraperitoneal hemmorhage mixed with ascites. Surgery was consulted and felt that there was no need for surgical intervention. She was admitted to the [Hospital Unit Name 153] for further monitoring. Past Medical History: 1. Ovarian Cancer Diagnosed with Stage I in [2115-7-11] with good surgical resection. Ascites has been positive. Received adjuvant with carboplatin and taxol with avastin Received 6 cycles. Had recurrent disease in [2116-10-10] and had gemcitabine, 7 cycles taxol, 4 cycles doxil, and started Alimta on [2118-2-23]. 2. Anxiety disorder followed by a psychiatrist 3. Hypertension after treatment with Avastin 4. DVT and bilateral subsegmental PE diagnosed [2-17] Social History: Worked as a schoolteacher. Does not smoke or drink. Family History: She has one uncle who had prostate cancer. Both her sister and brother have had basal cell carcinoma of the nose. There is no history of any breast, ovarian, uterine, or colorectal cancer. Physical Exam: VS 98.5 76 118/80 28 99%4L GEN: NAD HEENT: ATNC, HEENT, EOMI HEART: RRR, no m/r/g LUNGS: CTAB, no r/r/w ABD: Distended, soft, nt, nd EXTREM: No c/c/e Neuro: nonfocal Pertinent Results: On Admission: [2118-3-20] 10:35AM GLUCOSE-126* UREA N-26* CREAT-0.5 SODIUM-130* POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-24 ANION GAP-12 [2118-3-20] 10:35AM ALT(SGPT)-13 AST(SGOT)-21 CK(CPK)-12* TOT BILI-0.2 [2118-3-20] 10:35AM cTropnT-<0.01 [2118-3-20] 10:35AM CK-MB-NotDone [2118-3-20] 10:35AM TOT PROT-4.0* CALCIUM-7.1* PHOSPHATE-3.2 MAGNESIUM-1.9 [2118-3-20] 10:35AM WBC-1.0# RBC-1.76# HGB-5.5# HCT-16.0# MCV-91 MCH-30.9 MCHC-34.1# RDW-18.6* [2118-3-20] 10:35AM NEUTS-30* BANDS-0 LYMPHS-70* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-6* . Imaging: CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST [2118-3-20]: 1. No evidence of aortic dissection or pulmonary embolism. 2. Interval disease progression involving the peritoneum and omentum within the abdomen and pelvis with increased ascites. Pockets of ascites appear to display hyperdense components within it, noted within the left upper quadrant and lower midline abdomen which are suggestive of regions of intraperitoneal hemorrhage. No findings of active extravasation. 3. Unchanged intrathoracic and abdomen/pelvic lymphadenopathy. 4. Slightly prominent air- and fluid-filled loops of transverse colon without any secondary signs to suggest bowel obstruction. . CT Abdomen [2118-3-23]: 1. No evidence of active extravasation. 2. Stable appearance of known extensive metastatic disease with ascites, peritoneal and omental implants. Stable appearance of high attenuation components in left upper quadrant within the ascites suggestive of regions of intraperitoneal hemorrhage. 3. Interval development of small-to-moderate right pleural effusion. 4. Dilated loops up to 7 cm of air and fecal material filled transverse and ascending colon, and cecum that is compatible with ileus. Brief Hospital Course: [Hospital Unit Name 153] and Oncology course according to problem list. . # Anemia: Patient presented with a hematocrit of 16 in the setting of recent chemotherapy and no clear source of acute bleeding. An abdominal CT was performed and demonstrated ascitic fluid consistent with focal areas of hemorrahage from metastatic disease. This was thought to be the etiology of the patient's acute anemia and she was admitted to the [Hospital Unit Name 153] for close monitoring. She was transfused a total of four units of blood and had a post-transfusion Hct of 34, suggesting that her initial Hct of 16 was erroneous. Lovenox, which she takes because of a history of DVT/PE, was held. Her Hct remained stable and she was subsequently transferred to the medical floor for further management. On the floor patient had 1 L of fluid drained from abdominal port for comfort - the next day she had > 15 pt HCT drop (30.4 -> 15.7). Hemodynamics were stable. CTA was performed which demonstrated no active source of bleeding from vessels. However, abdominal port was draining frank blood. Patient was transfused 2 units, and HCT increased to 28.6. Again it was felt 15 HCT was erroneous and perhaps due to dilution (port draw). Regardless patient is suffering from intraperitoneal bleeding demonstrated by frank blood (drained from abdominal port). CTA ruled out treatable vascular source, most likely bleeding is from metastatic peritoneal disease. There is some concern that removing fluid for comfort increases peritoneal bleeding due to decreased pressure/tamponade. HOwever, prior to discharge 500 cc X 2 was drained with no significant drop in HCT or change in hemodynamics. Plan is to discontinue lovenox, transfuse based on symptoms only and drain ascities for comfort. . # Ascities: The patient has significant ascites and has undergone multiple therapeutic paracentesis to relieve dyspnea and abdominal discomfort. IR placed guided port on [2118-3-21]. Abdominal port is currently draining frank blood (see above), but does provide significant comfort. Patient was briefly started on antibiotics (Vanc, Ceftrioxone) for possible intrapertineal infection based on PMN 249 ([2118-3-22]), however culture returned negative and antibiotics were discontinued. - Drain prn for comfort . # History of DVT/PE: Lovenox discontinued in setting of intraperitoneal hemorrhage. # Metastatic ovarian cancer: Patient discharged home with hospice. - Morphine prn - Paracentesis via port for comfort - Transfusions based on symptoms # FEN: Encourage po intake # CODE: DNR/DNI Medications on Admission: 1. Lovenox 100mg sq daily (of note did not take AM of sunday [2118-3-20]) 2. senna 8.6mg daily 3. Reglan 5mg po q6hrs prn nausea 4. clonazepam 0.5mg [Hospital1 ] prn anxiety 5. proAir HFA 90mcg 1-2puffs q6-8 hrs prn cough 6. dexamethasone 8mg [Hospital1 ] the day before, of and day after chemo 7. famotidine 40mg [Hospital1 ] prn 8. vitamin B-12 9. colace 100mg [Hospital1 ] 10. desipramine 50mg daily 11. folic acid 1mg daily 12. zofran 8mg TID prn nausea 13. Alimta q3 weeks, last dose [2118-3-15]. Discharge Medications: 1. [Doctor Last Name ] needles 4p/week 19 gauge, 1 inch For abdominal port access 2. Port a cath access kits Please provide 3 kits/week 3. Saline and Heparin flush Use PRN with abdominal port 4. 3 way stop cock Please provide 3 per week 5. 30 cc syringe - [Last Name (un) ] lock Please provide 3 per week 6. ETOH wipes, dressing materials, and needle bucket Please provide enough for one month supply Indication: abdominal port 7. Nephrostomy drainage bag Please provide 6 bags per month 8. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO q1hr as needed for pain. Disp:30 ml Refills:0 9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for nausea. Disp:30 Tablet, Chewable(s) Refills:0 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 13. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. Disp:30 Tablet(s) Refills:0 17. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:30 Tablet(s) Refills:0 18. Desipramine 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 19. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. Disp:30 suppository Refills:0 Discharge Disposition: Home With Service Facility: Hospice of the Good [Doctor Last Name 9995] Discharge Diagnosis: Ovarian cancer Refractory ascites Intraperitoneal hemorrhage Discharge Condition: Good, pain well controlled. Discharge Instructions: You were admitted for low blood counts. You stabilized with blood transfusions. Your lovenox was discontinued. An abdominal port was placed to allow frequent paracentesis. . Attend all your follow-up appointments. You will have an appointment with Dr. [Last Name (STitle) 4149] and [Doctor Last Name ] [0-0-] on Friday (not tuesday). . Follow your medication list, we have changed some of your medications. . Call your doctor if you experience dizziness, chest pain, fever, chills, nausea, vomiting, pain or any other concerning symptoms. Followup Instructions: You will have an appointment with Dr. [Last Name (STitle) 4149] and Dr. [Last Name (STitle) ] [0-0-] on Friday Febuary 20th. They will call you with the time. Your appointment on Tuesday [3-29] has been cancelled. Completed by:[2118-3-25] ICD9 Codes: 2761, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2237 }	Medical Text: Admission Date: [2171-12-29] Discharge Date: [2171-12-30] Service: TRAUMA [Last Name (un) ] HISTORY OF PRESENT ILLNESS: This is a [Hospital1 190] admission for this 83 year old man who was found down in his apartment four hours being last seen. He was unresponsive to voice, but by report was moving extremities. He was brought to the emergency room where he was intubated to protect the airway. PAST MEDICAL HISTORY: Remarkable for Parkinson's, CAD. MEDICATIONS: Proscar, isosorbide, Norvasc, propranolol, enalapril, Cardura. PHYSICAL EXAMINATION: On exam he was intubated. Heart regular rate and rhythm. Chest was clear. Abdomen was soft. Extremities were warm. LABORATORY DATA: Hematocrit was 34.5, white count 9.3. CT scan showed right parieto-occipital, intraparenchymal hemorrhage. HOSPITAL COURSE: He was admitted to the ICU. It was felt that he should not have an operation on his head at the moment. The rest of his workup was essentially negative. CT of his abdomen and pelvis was negative. CT of his C-spine showed also negative results. He did not follow commands on exam. Minimally opening his eyes to deep sternal rub. On [12-30] he was made comfort measures and the DNR order was instituted. Subsequently he expired at 18:17 with his daughter at the bedside on [12-30]. DISCHARGE STATUS: Approved. FINAL DIAGNOSIS: Intraparenchymal parieto-occipital bleed. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 11889] Dictated By:[Last Name (NamePattern4) 12891] MEDQUIST36 D: [2172-3-10] 03:23 T: [2172-3-12] 19:16 JOB#: [Job Number 32160] ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2238 }	Medical Text: Admission Date: [2187-8-7] Discharge Date: [2187-8-14] Date of Birth: [2121-6-12] Sex: F Service: NEUROSURGERY Allergies: Latex Attending:[First Name3 (LF) 2724] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Evacuation of a postoperative wound hematoma. History of Present Illness: 66 yo female who presents with a deterioration of function since a recent discharge from [Hospital1 18]. Patient was admitted from [2187-7-22] to [2187-7-31] for new onset numbness from breast level to feet, urinary retention, and fecal incontinence. Patient has a longstanding history of metastatic melanoma and imaging showed a lesion at T4-T5. Palliative surgery was conducted to decompress these lesions. Postop course included some improvement of function. On discharge, the patient continued to have left lower extremity paralysis but had sensation and her right leg was 4 to 4/5 strength. Since that time, she was able to bend her right leg at the knee, and to wiggle her left foot on her bed. About a week ago, she experienced some changes in pain in her middle back. In rehab, it was determined that the patient had a elevated WBC to the 42, and a positive UA. She was started on PO vancomycin, and levoquin. She was transferred to [Hospital1 18]. Past Medical History: 1. Spina bifida 2. melanoma (left forearm) - with metastatic involvement in [5-3] - refused treatment initially 3. Chronic tinnitis Social History: Lives with husband, retired translator. Non smoker. Family History: Non-contributory Physical Exam: O: T: 97.2 BP: 141/64/ HR: 94 R 16 O2Sats 99% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4-2mm EOMs intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [Last Name (un) 938] G R 5 5 5 wiggles foot L 5 5 5 uable to move foot Sensation: Not intact to light touch on legs, no propioception of bilateral great toes, vibration bilaterally. Reflexes: B T Br Pa Ac Right 2+ - Left 2+ - Toes upgoing bilaterally CT/MRI: Pertinent Results: [2187-8-13] 05:45AM BLOOD WBC-13.5* RBC-3.96* Hgb-11.8* Hct-35.1* MCV-89 MCH-29.7 MCHC-33.5 RDW-14.8 Plt Ct-223 [2187-8-7] 05:20PM BLOOD Neuts-92* Bands-1 Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2187-8-7] 05:20PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ [2187-8-13] 05:45AM BLOOD Plt Ct-223 [2187-8-8] 01:34PM BLOOD Fibrino-281 [2187-8-8] 07:47PM BLOOD FacVIII-214* [2187-8-8] 07:47PM BLOOD VWF AG-185* VWF CoF-276* [2187-8-13] 05:45AM BLOOD UreaN-18 Creat-0.6 Na-130* K-3.8 Cl-97 HCO3-26 AnGap-11 [2187-8-13] 05:45AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 Brief Hospital Course: Mrs [Known lastname ] is a 66 yo woman with a h/o cutaneous melanoma on forearm (excised [12-2]) and spina bifida who initially presented 3 weeks ago ([7-22]) with a complaint of 4 days of increasing lower extremity weakness and numbness and fecal and urinary incontinence. She initially presented to an OSH and MRI was performed, showing an intermedullary cord lesion. She was transferred to the [Hospital1 ], and CT demonstrated diffuse metastatic disease from malignant melanoma including lungs, mediastinum, gallbladder, liver, left ureter with moderate hydronephrosis,cervix with uterine obstruction and ischiorectal fossa. A thoracic MRI done at [Hospital1 18] demonstrated 2 enhancing spinal masses most likely metastasis with leptomeningeal involvement- 1 intramedullary mass posterior to the T3-T4 disc space measuring 2 cm, and a second small possible intradural metastasis just posterior to L2. There was associated spinal cord edema. On [7-25] whe underwent laminectomy at T3-T4 and resection of an intradural intramedullary tumor to improve her neurological symptoms. She was discharged to rehabilation [7-31]. In rehab, on [8-4], she began to feel a very painful 'a lump' in her upper back at the site of her surgical excision. The pain was diffuse throughout her upper back, but did not radiate elsewhere. It was significantly worse with pressure, almost unbearable. It continued to worsen, and on [8-5] she states that she was 'in and out of consciousness'. Labs from the rehab facililty indicated that she had an elevated WBC to 42, and a positive UA. She was started on PO vancomycin 125 mg q6h and levoquin 500 mg qday. She was transferred to [Hospital1 18]. On admission, her hct was 18.9 and CT chest showed a large hematoma the right posterior back measuring 18 cm x 4.9 cm x 25 cm, and a new R pleural effusion. She was transfused five units PRBC and two units FFP, and Hct increased to 29%. She was taken to the OR on [8-8] and the hematoma was evacuated and washed out, using the old incision. She remained in the ICU for 2 days she had some slow improvement of her right leg and no change (plegic in left leg)A hematology consult was obtained for cause of her hematoma and bleeding during surgery they felt it would be unlikely for her to have a primary factor deficiency or [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease and not to have had prior bleeding problems. [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease and more rarely FXIII deficiciency, however, can occur in the setting of normal coagulation studies. She may have acquired platelet dysfunction, and vancomycin is known to cause platelet dysfuction. Regarding her systemic disease they felt her malignant melanoma was so advanced that she unfornately she did not qualify for any type of treatment. From an ID perspective she was only treated for 7 days with Cipro other antibiotic were dc'd. She developed anal ulcers from diahrrea. The left aspect has a full thickness ulcer approx. 2 x 3 cm, right aspect has a full thickness ulcer approx. 1.5 x 1 cm-each site has yellow brown tissue with irregular wound edges. The periwound tissue is erythemic extending posteriorly along the intergluteal cleft where the epidermis is denuded. Our wound care specialist recommended: Keep perianal tissue clean and dry. Check patient every 1-2 hours for fecal incontinence. Cleanse perianal tissue with Foam cleanser and disposable washcloths wet with warm water. Pat the tissue dry (Please no facecloths or towels and no rubbing of the tissue) Apply a thin layer of Critic Aid Clear Moisture Barrier Ointment to the perianal tissue, covering the ulcers and extending posteriorly along the intergluteal tissue daily and prn or every 3rd cleansing. Neurologically she has some antigravity movement on her right leg 3-4/5 strength. She has no movement of her left leg. She has normal strength in his arms. Her incision is dry and clean. She is eating a regular diet. A foley is in place due to the anal ulcers. She will go to rehab and return to the brain tumor clinic for radiation planning on [9-3]. Medications on Admission: Bisacodyl 10 mg PO/PR DAILY:PRN Senna 1 TAB PO BID:PRN Docusate Sodium (Liquid) 100 mg PO BID Pantoprazole 40 mg PO Q24H Multivitamins 1 TAB PO DAILY Oxycodone SR (OxyconTIN) 20 mg PO Q12H Acetaminophen 500 mg PO Q6H:PRN Oxycodone (Immediate Release) 15 mg PO Q3H:PRN Lorazepam 1 mg PO Q4H:PRN Lactulose 15 mL PO BID Zolpidem Tartrate 5 mg PO HS Insulin SC (per Insulin Flowsheet) Hydromorphone (Dilaudid) 0.5 mg IV Q2H:PRN postop pain Dexamethasone 4 mg PO Q8H Ciprofloxacin HCl 500 mg PO Q12H Heparin 5000 UNIT SC TID Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q3H (every 3 hours) as needed. 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 10. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day). 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. 15. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day: Start after 4mg dose-Continue on this dose until follow up at brain tumor clinic. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Malignant Melanoma Wound Hematoma Discharge Condition: Neurologically stable with left leg paralysis and right leg weakness Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery ?????? ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Dr [Last Name (STitle) 548] on [9-3] at 9:30 am (this will be confirmed) 2. with Dr [Last Name (STitle) ] [Last Name (NamePattern4) 724] (Neuro-Onc) and Dr [First Name (STitle) 13014] (Rad-Onc) on [9-3] at 10:30 am [Hospital Ward Name 23] [Location (un) ] 3. with Dr [Last Name (STitle) ] on [9-3] at 1 pm for the [Hospital 11884] clinic [Hospital Ward Name 23] 9 reception area A Have your sutures removed next Monday at your rehab facility Completed by:[2187-8-14] ICD9 Codes: 5990, 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2239 }	Medical Text: Admission Date: [2174-5-26] Discharge Date: [2174-5-28] Date of Birth: [2115-8-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 458] Chief Complaint: AICD firing Major Surgical or Invasive Procedure: None History of Present Illness: 58 yo man with CAD s/p IMI and subsequent systolic dysfuntion (EF 25-30%), HTN, hyperchol, OSA, VT s/p ICD implantation presents with AICD shocks. On Sunday, he had VT that was not terminated by AVP and his ICD shocked him. He sent tele to Dr.[Last Name (STitle) ] which showed 12 VT episodes. No intervention was planned at that time. Of note, he recently stopped his carvedilol himself about 3 weeks ago because he thought is was making him tired though he's been on this medication for a long time. He was recently admitted in [Month (only) 547] for elective VT ablation. He states that prior to [Month (only) 547] he his AVP sucessfully terminted his VT and he had not had a shock in over a year. More recently in the past 3 weeks, he's had a total of 4 shocks (one Sunday, one at work today and 2 here in the ED). He's unclear if this correlates with stopping his carvedilol. Today, at work, he again went into VT and AVP was unsucessful at converting and it shocked him. He had no CP or SOB at the time. He called EMS and was brought here. In ER, VS 98.0 86 156/95 18 100%RA. EKG with old RBBB otherwise unremarkable for ischemia. He had another episode of VTach, which the ICD attempted twice to ATP and then fired. EP was consulted and witnessed a second failed ATP and AICD firing. He was admitted to the CCU for further monitoring. Currently, he feels well and has no complaints. He states that when he goes into VT he does not have chest pain or shortness of breath - states that it feels like his heart is being 'tickled'. Denies blurred vision or lightheadedness during these episodes. Past Medical History: CAD s/p inferoposterior MI with PTCA [2159], [2173] Dyslipidemia Hypertension Chronic Systolic Heart Failure, EF 25-30%. Nonsustained ventricular tachycardia with ICD [8-/2170] S/p VT ablation [4-/2174] Hypertension Hyperlipidemia Obstructive sleep apnea H/o vitamin B12 deficiency Nephrolithiasis Peripheral neuropathy Remote history of peptic ulcer disease GERD Status post tonsillectomy and adenoidectomy. Social History: Social history is significant for the presence of current tobacco use (40 pack year history). There is no history of alcohol abuse.Pt lives at home with his wife and daughter. [Name (NI) ] is on disability but still works part time in management for the [Location (un) 86] retirement board. Family History: There is no family history of premature coronary artery disease or sudden death. Father had atrial fibrillation. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: On Admission: VS: T:98.3 HR:78 BP:126/74 RR:17 SpO2:94% General Appearance: Well nourished, No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL, Pupils dilated Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur: Systolic), distant heart sounds thoughout Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : , Bronchial: throughout, Wheezes : scant, Diminished: bilaterally) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: No(t) Muscle wasting Skin: Warm Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to): person, place, time and purpose, Movement: Purposeful, Tone: Normal Pertinent Results: ADMISSION LABS: - WBC-8.1 RBC-4.61 HGB-14.0 HCT-41.1 MCV-89 MCH-30.3 MCHC-34.0 RDW-15.7* - PLT COUNT-245 - NEUTS-63.2 LYMPHS-30.2 MONOS-4.5 EOS-1.4 BASOS-0.7 - CALCIUM-9.9 PHOSPHATE-3.9 MAGNESIUM-2.2 - CK-MB-5 - cTropnT-<0.01 - CK(CPK)-147 - GLUCOSE-97 UREA N-13 CREAT-1.4* SODIUM-140 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-30 ANION GAP-17 - CALCIUM-9.7 MAGNESIUM-2.1 Brief Hospital Course: 58 yo man with CAD s/p IMI and subsequent systolic dysfuntion (EF 25-30%), HTN, hyperchol, OSA, VT s/p ICD implantation presents with recurrant VT after self discontinuation of carvedilol. # RHYTHM, VT: Patient has VT s/p multiple ablations. Patient recently stopped his Carvediolol, which likely contributed to new failure of ICD to terminate VT. Carvedilol restarted and patient had no further episodes of VT. Was observed for 24 hours and discharge home with EP follow up on home medications of mexilitine and quinidine. # CAD: Not an active issue. Patient is s/p IMI with PCI in 08/[2173]. ETT on [2174-4-28] showing stable severe fixed defects involving the inferior and lateral walls, and the apex, with associated akinesis. Cardiac enzymes were negative in ED, has had no chest pain. Did not ROMI given low clinical suspicion. Continued atorvastatin, aspirin, and restarted BB as above. Also restarted Diovan which was stopped during last admission [2-7] renal failure and never restarted as out patient. # CHRONIC SYSTOLIC HEART FAILURE: Stable, not actively managed whie in patient. EF 20-25% on last echo in [8-13]. Continued home po lasix 60mg [Hospital1 ] and restarted BB as above. [Last Name (un) ] restarted as above. # HYPERLIPIDEMIA: Continued atorvastatin and niacin. # CHRONIC RENAL INSUFFICIENCY: On admission, Cr 1.4. Baseline Cr 0.9 to 1.3 but recently ranging up to 2.2. [Last Name (un) ] restarted as above. # PERIPHERAL NEUROPATHY: Unknown cause, not a diabetic per prior notes. Continued home gabapentin and oxycodone for pain. # OSA: Known complex OSA per out patient sleep note. Used home CPAP # Code: FULL Medications on Admission: 1. Allopurinol 150 mg qd 2. Atorvastatin 80 mg qd 3. Carvedilol 12.5 mg PO BID --- prescribed but not taking at home 4. Duloxetine 60 mg qd 5. Gabapentin 600 mg tid 6. Gabapentin 900 Q9 P.M. 7. Aspirin 325 mg qd 8. Omega-3 Fatty Acids Capsule qd 9. Mexiletine 150 mg Q8H 10. Niacin 500 mg qhs 11. Quinidine Gluconate 648 q8h 12. Acetaminophen-Codeine 300/30 [1-7] Tab q4h prn 13. Pramipexole 0.125 mg qhs 14. Furosemide 60 mg [Hospital1 ] 15. Vitamin B Complex 1 tab qd 16. Melatonin 3 mg qhs 17. Nicotine 14 mg/24 hr Patch 18. Oxycodone 5-10 mg qhs prn pain 19. Lorazepam 0.5 mg q6h prn anxiety 20. Magnesium 250 mg qd Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q9PM (). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 10. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q8H (every 8 hours). 11. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs (). 13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 14. B-Complex with Vitamin C Tablet Sig: One (1) Cap PO DAILY (Daily). 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 16. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO HS (at bedtime). 17. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Ventricular tachycardia Secondary: CAD, Dyslipidemia, HTN, OSA, GERD Discharge Condition: stable, pain free, afebrile Discharge Instructions: You were admitted to the hospital for AICD firing. It was felt that you had a heart arrhythmia secondary to stopping our carvedilol. This medication was restarted and you heartrate was much improved. Please continue this medication in the future. In addition, your diovan was restarted at discharge at one half your prior dose. Please seek immediate medical attention if you experience chest pain, shortnss of breath, palpitations, dizziness, fevers, chills or any change from your baseline health status. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please call Dr.[Name (NI) 62432] office on Tuesday to make a follow up appointment in [7-15] days [Telephone/Fax (1) 62]. ICD9 Codes: 4271, 4280, 5859, 412, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2240 }	Medical Text: Admission Date: [2102-6-20] Discharge Date: [2102-6-25] Date of Birth: [2051-12-21] Sex: M Service: MEDICINE Allergies: Cephalosporins / Penicillins / Vancomycin / Gentamicin Attending:[First Name3 (LF) 3556] Chief Complaint: Alcohol withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: 50M with PMH ETOH abuse and withdrawal but no prior h/o DTs or sz, h/o UGIB [1-2] esophagitis [2098], infective aortic endocarditis [2100] course c/b AIN, C diff, embolic CVA, sarcoidosis, ? hemochromatosis, recently escalating ETOH abuse transferred from [Hospital1 46] for pancytopenia, elevated LFTs and GIB with HCT 23 at OSH, trasnfused 1 unit. History obtained from patient and girlfriend x 18 years. She reports emesis x 2 weeks with coffee grounds emesis and bloody emesis 2 days prior to admission. Per girlfriend, pt has been drinking more than usual, approx 3 half gallons of vodka per week. Pt reports he drinks 1 glass of wine and 3 [Location 71221] per day which has been unchanged for years. Last drink 2 mornings prior to admission ([6-19]). He has been drinking on daily basis x > 2 months. Pt has also had increased violent behavior per girlfriend. [Name (NI) ] has not been taking Tylenol or using other drugs. Also has noted decreased PO intake, UOP, and appetite, yellowing of skin last week. . In the ED, initial vs were: 98.3 110 149/94 16 100. HCT 30 after transfusion 1 unit at [Hospital1 46]. Rectal exam revealed light brown stool and was trace guaiac positive. He was given 45mg Valium for agitation and withdrawal. Liver was consulted and will see in am, recommended steroids if discriminant function >32. Abdominal ultrasound obtained with no evidence of cholecystitis. . On arrival to the floor, pt combative, agitated, hallucinating. denies any complaints of pain. He reported weight loss last month but denied fever, chills, cough, shortness of breath, CP, abd pain, confusion, numbness, weakness, thirst. Past Medical History: - Alcohol abuse and withdrawal - Alcoholic hepatitis - Sarcoidosis - Cutaneous T-cell lymphoma right flank s/p XRT - Strep sanguis IE [2101-7-1] c/b embolic CVA with occasional residual stuttering, word finding difficulty, no other focal weakness. also c/b AIN [1-2] beta-lactams, biopsy proven at [Hospital1 34], started on steroids [2100] - UGIB and EGD [7-6]: Reflux esophagitis likely source of bleeding HTN - h/o C. diff Social History: Lives with girlfriend of 18 years in [Location (un) ]. No pets, no kids. Retired 8-9 years ago from being stockbroker. Denies Tob/Illicits. Never IVDU. ETOH use as above. Has been drinking on and off since [07] years old. No prior h/o formal detox. Has mother who is 88 and ill and lives with brother. Pt is very stressed out and overwhelmed by the responsibilities of taking care of family members. Family History: Father with calcified AV s/p porcine valve Mother healthy Physical Exam: General: Alert, agitated, restrained in bed, pulling at restraints. oriented to year, not month ([Month (only) ]), not place (on a boat), grabbing at air HEENT: Sclera icteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 and prominent S2, [1-6] systolic murmur LLSB rubs Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, spleen palpable just below costal margin Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: CN 2-12 grossly intact. MAE. Skin: Flaking scaling lesions right flank and thigh Pertinent Results: LABORATORIES: [2102-6-20] 08:50PM BLOOD WBC-3.6# RBC-3.35 Hgb-10.7* Hct-30.8* MCV-92 MCH-31.9 MCHC-34.7 RDW-17.5* Plt Ct-80# [2102-6-20] 08:50PM BLOOD Neuts-49.1 Lymphs-42.4* Monos-5.9 Eos-1.8 Baso-0.7 [2102-6-20] 08:50PM BLOOD PT-14.7* PTT-25.3 INR(PT)-1.3* [2102-6-20] 08:50PM BLOOD Glucose-103 UreaN-10 Creat-1.4# Na-134 K-3.0 Cl-96 HCO3-26 AnGap-15 [2102-6-20] 08:50PM BLOOD CK-MB-5 [2102-6-20] 08:50PM BLOOD cTropnT-<0.01 [2102-6-21] 02:06AM BLOOD Albumin-3.5 Calcium-7.8* Phos-1.0# Mg-2.0 Iron-119 [2102-6-21] 02:06AM BLOOD calTIBC-152 TRF-117* [2102-6-20] 09:00PM BLOOD Lactate-1.4 [2102-6-20] 08:50PM BLOOD ALT-112* AST-240* CK(CPK)-245* AlkPhos-181* TotBili-10.0* DirBili-7.4* IndBili-2.6 [2102-6-20] 08:50PM BLOOD Lipase-54 GGT-2720* [2102-6-25] 05:30AM BLOOD ALT-61* AST-80* LD(LDH)-221 AlkPhos-143* TotBili-4.4* [2102-6-20] 08:50PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2102-6-20] 08:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2102-6-20] 08:50PM BLOOD HCV Ab-NEGATIVE ==================== IMAGING: Abdominal U/S [6-20]: No evidence of cholecystitis or cholelithiasis. Portal vein flow hepatopedal. Liver echogenic consistent with diffuse fatty liver but could not exclude cirrhosis. No ascites. No intra or extrahepatic bile duct dilatation. . CXR [6-20]: No acute intrathoracic process. Possible enlarged ascending aorta; baseline PA and lateral radiographs should be obtained. . CT head [6-21]: There is no evidence of hemorrhage, edema, mass, mass effect, or infarct. The ventricles and sulci are prominent suggestive of mild atrophy. No fractures are identified. Soft tissues are unremarkable. Please note, the study is somewhat limited secondary to movement artifact. IMPRESSION: No evidence of hemorrhage or trauma. ==================== EKG ([6-21]): Sinus rhythm. Non-specific intraventricular conduction delay. Compared to the previous tracing of [2102-6-20] no significant change. Brief Hospital Course: This is a 50 year old man with history of ETOH abuse admitted for alcohol withdrawal and elevated LFTs consistent with alcoholic liver disease. . # ETOH withdrawal/agitation: Pt admitted to ICU from the ED for presumed alcohol withdrawal. On the floor patient was agitated, tremulous, hallucinating, and confused, with CIWA scores in the 30's. He required >120 mg of Valium the night of admission for agitation and tremor. He had a head CT to assess anisicoria, that was noted on admission. This study was unremarkable and his pupils normalized. Patient continued receiving benzodiazepines per q1hr CIWA [Doctor Last Name ]. By day 2, his agitation decreased and he was transitioned to oral medications. He redeveloped agitation and halucinations on day 3. He attempted to leave and was restrained by security. He was seen by Psychiatry to help clarify withdrawal from intoxication. Psych recommended Benzos only for CIWA, haldol for agitation. Over the next evening, his CIWA scores fell to zero. He was transferred to the floor on [6-24] for social work, PT, and psych evaluations. Patient had no more sx of withdrawal on the floor. He was on MVI, folic acid, thiamine, and was seen by SW. Patient was given AA information. . # Elevated LFTs: The acute elevation of LFT is most likely due to EtOH hepatitis given 2:1 AST:ALT ratio and increased alcohol intake, but pt does have ? hemachromatosis which could give him chronic transaminitis. Tylenol level negative and no recent use per report. Patient was seen by the liver service when in MICU. Patient's LFT continued to trend down on the floor. On the day of discharge, he continued to have elevated LFTs, but significantly improved. . # GIB/Anemia: ddx include varices and [Doctor First Name 329] [Doctor Last Name ] tear, or minor mucosal tear [1-2] vomiting. Pt received IV PPI, his hct was stable. No more transfusion was required at [Hospital1 18]. . # Pancytopenia: Likely secondary to bone marrow suppression associated with chronic liver disease. Patient's blood counts were stable during this hospital stay. . # Hypertension: Likely multifactorial related to withdrawal and known history of hypertension with recent med noncompliance. Home atenolol was continued. . # New lesion on upper thigh: emailed Dr. [Last Name (STitle) ] since he was Oncologist 2 years ago: [First Name8 (NamePattern2) 50269] [Last Name (NamePattern1) 71222] can arrange follow-up in Cutaneous Oncology. Her contact information is: ([Telephone/Fax (1) 52205]. Patient was told to follow up as outpatient. . Patient received IVF, electrolytes repleted. He had full code (confirmed by MICU team), contact: girlfriend [Name (NI) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 71223] who is HCP, confirmed with pt. Medications on Admission: Atenolol 25mg PO BID B12 1000mcg PO daily B6 50mg tab PO qd folic acid 1g PO qd Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 5. B-12 DOTS 500 mcg Tablet Sig: Two (2) Tablet PO once a day. 6. Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:28 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Alcohol abuse - Alcohol withdrawal - Alcoholic hepatitis Secondary diagnoses: - Sarcoidosis - Cutaneous T-cell lymphoma right flank s/p XRT - Strep sanguis IE [2101-7-1] c/b embolic CVA with occasional residual stuttering, word finding difficulty, no other focal weakness. also c/b AIN [1-2] beta-lactams, biopsy proven at [Hospital1 34], started on steroids [2100] - UGIB and EGD [7-6]: Reflux esophagitis likely source of bleeding HTN - h/o C. diff Discharge Condition: Stable, no more withdrawal symptoms. Afebrile, ambulating well. Discharge Instructions: You were hospitalized to [Hospital1 69] for alcohol withdrawal and acute liver disease secondary to your alcohol use. You were initially in the ICU, being treated aggressively for your withdrawal symptoms. After you were transferred to regular floor, you haven't had any withdrawal. Your liver function tests are normalizing on discharge. You were also seen by Social Work during this hospital stay. You should not drink alcohol again in the future. Your medications have been changed. The following medications have been added: - omeprazole - multivitamin - thiamine If you develop vomiting, especially if you have bloody vomiting or have coffee-ground colored vomitus, become more jaundiced, have abdominal pain becomes, become severely agitated, notice bloody stools or have any symptom that concerns you, please call your doctor or come to the Emergency Department immediately. Followup Instructions: You should follow-up for the rash which is getting worse on your right thigh. You can see Dr. [Last Name (STitle) ] in Oncology. [First Name8 (NamePattern2) 50269] [Last Name (NamePattern1) 71222] can arrange an appointment. Her contact information is: ([Telephone/Fax (1) 71224]. Please see your primary care doctor Dr. [Last Name (STitle) ],[First Name3 (LF) ] F. [Telephone/Fax (1) 17753] for followup within one week after discharge. You are interested in going to AA meetings. Please call you local AA for further information. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560] ICD9 Codes: 2851, 5789, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2241 }	Medical Text: Admission Date: [2156-11-5] Discharge Date: [2157-2-16] Date of Birth: [2156-11-5] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname ] [Known lastname 47549] was born at 25-6/7 weeks gestation and is currently being discharged at 102 days of age. [Known lastname 47549] was born to a 36-year-old gravida 1, para 0 now 1 woman whose past medical history was noncontributory and pregnancy was uncomplicated preterm contractions. The mother's prenatal screens are blood type A positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, and group B Strep unknown. The rupture of membranes occurred 14 hours prior to delivery and the mother received one dose of betamethasone prior to chorioamnionitis as evidenced by leukocytosis. Mother proceeded to spontaneous vaginal delivery under epidural anesthesia. Infant emerged hypotonic, apneic, and bradycardic. She required bagged mask ventilation and intubation. Apgars were two at one minute and seven at five minutes. The infant's birth weight was 807 grams (25-50th percentile), birth length was 33.6 cm (25-50th percentile), and head circumference 24 cm (25-50%). Baby's physical exam reveals an extremely premature infant. Anterior fontanel is soft and flat, nondysmorphic features, intact palate, moderate subcostal and intercostal retraction with spontaneous breaths. Fair breath sounds with scattered-coarse crackles. Pink and well perfused. Femoral pulses normal, no murmur present. Soft and nondistended abdomen. No organomegaly. Active bowel sounds. Patent anus. Normal female preterm genitalia, active infant, tone decreased, but appropriate for gestational age. HOSPITAL COURSE BY SYSTEMS: Respiratory status: The infant was intubated in the delivery room. She extubated to nasopharyngeal continuous positive airway pressure on day of life 46, and then weaned successfully to nasal cannula oxygen on day of life #56, where she remains in 75 cc/minute flow of 100% oxygen by nasal cannula. She was treated with caffeine citrate for apnea of prematurity from day of life 22 to day of life 58. Her last episode of desaturation occurred on [2157-2-3], and it was associated with a feeding. Diuril was begun on day of life 35 for chronic lung disease, and she continues on that medication at the time of discharge at a dose of 20 mg/kg/day in two doses with potassium chloride supplementation. An arterial blood gas on [2157-2-15] was a pH of 7.4, pCO2 46, pO2 80, bicarbonate 30, and a base access of +3. Cardiovascular status: Infant required fluid bolus for blood pressure support and then dopamine infusion for the first 48 hours of life. She was treated with indomethacin empirically due to a presumed patent ductus on day of life #1. An echocardiogram on day of life #7 revealed a patent ductus arteriosus, and she was again treated with a second course of indomethacin. Her murmur persisted and a followup echocardiogram on day of life #12 showed no patent ductus, but left peripheral pulmonary stenosis. Continued respiratory symptoms prompted another echocardiogram on [11-30] again showed a small to moderate PDA and a patent foramen ovale. She was treated with a third course of indomethacin at that time. A followup echocardiogram on [12-3] showed a small 1-1.5 mm patent ductus. Followup echocardiogram on [2156-12-10] showed again a small patent ductus with left-to-right flow. Her last echocardiogram on [2-3] again showed a small persistent patent ductus arteriosus. She was seen in consultation by the Cardiology team from [Hospital3 1810]. They felt that there was little flow through this PDA and it was therefore unlikely to be a significant factor in her continued pulmonary symptoms and did not require treatment. Cardiology followup is recommended. Consideration of the need for SBE prophylaxis would need to be considered if the patient requires relevant surgical or dental procedures before the PDA is documented to be closed. She currently has a grade 1-2/6 systolic ejection murmur. She is pink and well perfused. Fluids, electrolytes, and nutrition status: Enteral feeds were begun on day of life #14, and increased to full volume feedings by day of life 21. She was then increased to a maximum calorie enhanced feeding of 32 calories per ounce of added ProMod. Her current feedings are breast milk 26 calories per ounce with added Enfamil powder and corn oil. She is breast feeding two times a day and feeding every four hours during the day and a five hour maximum at night. Her measurements at the time of discharge are a weight of 3,080 grams, length 47.5 cm, and head circumference 33.5 cm. Her electrolytes on [2157-2-15] were a sodium of 136, potassium of 5.2, chloride 98, and bicarbonate 30. She is receiving potassium chloride supplementation of 3 mEq 3x a day. Gastrointestinal status: She was treated with phototherapy for hyperbilirubinemia of prematurity from day of life one until day of life 19. Her peak bilirubin on day of life #1 was total 5 and direct 0.3. She does have a moderate sized soft umbilical hernia. Hematological status: She received six transfusions of packed red blood cells during her NICU stay, her last one on [2156-12-26]. Her hematocrit on [2157-2-15] was 32.8 with a reticulocyte count of 4.2. She is receiving supplemental iron of 3 mg/kg/day of elemental iron. Infectious disease status: [Known lastname 47549] was started on ampicillin and gentamicin at the time of admission to the NICU for sepsis risk factors. She completed seven days for presumed sepsis, blood and cerebrospinal fluid cultures remained negative from that time. On day of life #8, she had a clinical decompensation and was started on Vancomycin and gentamicin. She completed seven days for presumed sepsis. Her blood cultures from that time remained negative. She remained off antibiotics until day of life 22, when she again had a clinical decompensation and was started on Vancomycin and gentamicin. Antibiotics were discontinued after 48 hours when her clinical change was felt to be due to a patent ductus. She has remained off antibiotics since that time. Neurology: On day of life #7, her first head ultrasound showed a grade I germinal matrix hemorrhage and bilateral periventricular cysts. Followup head ultrasound revealed a resolution of the germinal matrix hemorrhage. On [2157-12-7], her head ultrasound showed that the periventricular cysts were will present and there was a slight prominence of the left lateral ventricle. Her last head ultrasound on [2157-1-31] showed normal ventricular size and only one remaining 1.6 mm left periventricular cyst. No other parenchymal abnormalities and extra axial fluid normal. Appropriate neurodevlopmental follow-up is suggested. Sensory: Audiology. Hearing screening was performed with automated auditory brain stem responses and [Known lastname 47549] passed in both ears. Ophthalmology: Eyes were examined most recently on [2157-2-15] revealing regressing retinopathy of prematurity as compared with her previous examination which was Stage I retinopathy O.U. [4-12] o'clock hours. As this current examination shows that the vessels are crossing the demarcation line, a follow up examination is recommended in two to three weeks.. Psychosocial: [Hospital1 ] social worker, [Name (NI) 46381] [Name2 (NI) 6861], [Hospital3 ] beeper #[Numeric Identifier 36451] has been following this family. The parents have been very involved in the infant's care throughout the NICU stay. At the time of this infant's birth, the parents were planned to relocate to [State 108]. The father has been employed there throughout the NICU stay, and they are very thrilled with finally having this baby discharged and moving to [Name (NI) 108]. CONDITION ON DISCHARGE: The infant was discharged in good condition. DISPOSITION: The infant is discharged home with her parents with plans for them to fly with the infant to [State 108] on Thursday, [2-17]. Supplemental oxygen has been arranged for both her time here in [Location (un) 86], on the airline flight and in [State 108]. PRIMARY PEDIATRIC PHYSICIAN: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 47550] [Last Name (NamePattern1) ], address is 927 45th Street, [Apartment Address(1) 47551], West Palm [Last Name (LF) ], [Numeric Identifier 47552], and fax #[Telephone/Fax (1) 47553], telephone #[Telephone/Fax (1) 47554]. CARE AND RECOMMENDATIONS AT DISCHARGE: Feedings: 26 calorie/ounce of breast milk, 4 calories/ounce of Enfamil powder that is one teaspoon per 100 cc of breast milk, and corn oil 2 calories per ounce made with 1 cc of corn oil per 100 cc of breast milk. Infant is feeding every four hours during the day with a maximum limit of five hours during the night, and the infant is breast feeding twice a day without supplementation after breast feeding. MEDICATIONS: 1. Diuril 55 mg po bid. 2. Potassium chloride supplement 3 mEq po tid. 3. Ferrous sulfate (25 mg/ml of elemental iron) 0.35 cc po q day. 4. Poly-Vi-[Male First Name (un) ] 1 cc po q day. The infant failed a car seat oxygenation test, and is being discharged with a car bed for automobile travel. The parents plan to hold the baby during their airplane flight. The last State Newborn Screen was sent on [2156-12-20] and was within normal limits. The main number of the [State 350] Newborn Screening Program is [Telephone/Fax (1) 47555] Infant has received the following immunizations: Hepatitis B #1 on [2157-1-13], hepatitis B #2 on [2157-2-14], DtaP on [2157-1-13], HIB on [2157-1-14], IPV on [2157-1-14], and pneumococcal 7-valient conjugate vaccine on [2157-1-14] and Synagis on [2157-2-14]. Recommended immunizations: 1. In [Location (un) 86], 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. Tailoring of these recommendations to the rleevant ones for [State ] will be done by the pediatrician. FOLLOW- UP APPOINTMENTS: 1. Primary pediatric care with Dr. [Last Name (STitle) ]. Parents have an appointment for the same day they arrive in [State 108], which is Thursday, [2-17]. 2. Early intervention will be provided by Developmental Associates, telephone number [Telephone/Fax (1) 47556]. 3. Home oxygen will be provided by [Hospital1 5065] Oxygen of West Palm [Last Name (LF) ], [First Name3 (LF) 108], telephone number [Telephone/Fax (1) 47557]. Followup is also recommended: 1. Cardiology for followup of patent ductus arteriosus. 2. Ophthalmology followup in six months. 3. Pulmonology with Dr. [Last Name (STitle) 47558]. Oxygen will be by nasal cannula oxygen [12-15] to 1/16 cc of a liter flow. Oxygen saturations will be set with pulse oximeter limits being a low saturation of 90 and a high saturation of 99. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Status post respiratory distress syndrome. 3. Status post pulmonary interstitial emphysema. 4. Status post apnea of prematurity. 5. Bronchopulmonary dysplasia. 6. Status post hypotension. 7. Patent ductus arteriosus. 8. Status post exaggerated hyperbilirubinemia. 9. Anemia of prematurity. 10. Retinopathy of prematurity. 11. Status post presumed sepsis x2 courses. 12. Umbilical hernia. 13. Status post right germinal matrix hemorrhage. 14. Resolving periventricular cyst. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 37333] MEDQUIST36 D: [2157-2-16] 02:22 T: [2157-2-16] 06:03 JOB#: [Job Number 47559] ICD9 Codes: 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2242 }	Medical Text: Admission Date: [2159-3-1] Discharge Date: [2159-3-12] Date of Birth: [2089-6-16] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Right temporal bleed vs mass Major Surgical or Invasive Procedure: 1. Right-sided frontotemporal craniotomy. 2. Subdural hematoma evacuation. 3. Temporal lobectomy. 4. Evacuation of hematoma. 5. Microscopic dissection. 6. Onlay duraplasty. History of Present Illness: 73 year old right handed male with hypertension, hypercholesterolemia, developed severe headache at approximately 17:00 followed by several bouts of emesis through 21:00 at which time he apperantly passed out on the bathroom floor. EMS called and found patient with minimal speech and Left hemiparesis. Patient transported to [Hospital1 18] where BP=220/130. Acute stroke protocol was activated. Patient brought to CT at 22:00 which revealed large Right temporal bleed with uncal herniation and also small lesion in Right frontal, Right cerebellum, and Right occipital regions. CT chest revealed hilar mass. Moreover, patient continued to be hypertensive and increasingly bradycardic with signs of increased ICP and herniation therefore Neurosurgery called. Past Medical History: 1. Hypertension 2. Hypercholesterolemia Social History: Lives with girlfriend and there is significant smoking history. Family History: unknown Physical Exam: Physical exam at admission 180s/100s hr80s 15 regular General: obtunded MS: eyes open, minimal responsiveness to voice, intermittent posturing with LUE to deep stim; minimal speech output CN: I not tested, II,III R pupil 4-5mm, min reactive, L 2mm reactive to 1mm; III,IV,VI sl R gaze preference; V- corneals intact; VII L facial weakness/asymmetry; VIII + OCR bilat; IX,X +gag; XII tongue appears midline, no atrophy or fasciculations Motor: Deltd Bicep Tricp ECR/U ExDig FlDig DorsI OppPB Axill mscut [Hospital1 21443] [Name6 (MD) 21443] [Name8 (MD) 21443] md/ul ulnar medin C5 C5-6 C7 C6-7 C7 C8 T1 C8-T1 L hemiparesis R w/d briskly Ilpso Qufem Hamst TibAn [First Name9 (NamePattern2) 2778] [Last Name (un) 938] Femor femor [First Name9 (NamePattern2) 21444] [Last Name (un) 18709] tibil dpper L1-2 L3-4 L5-S2 L4-5 S1-2 L5 L dense paresis R w/d briskly DTRs: [Name2 (NI) ] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar L brisk up R brisk up Sensory: w/d purposefully to pinch on R, postures with L. Coord: no focal incoordination, ataxia, dysmetria noted. Gait: did not assess. Pertinent Results: CTA NECK W&W/OC & RECONS [2159-3-1] 10:00 PM IMPRESSION: 1) Multiple hemorrhagic lesions seen throughout the brain as above, with large mediastinal nodal masses and multiple pulmonary nodules. These findings are highly suspicious for metastatic disease (perhaps RCC or melanoma). Correlate with biopsy results and/or CT Torso if warranted. Please see subsequent brain MRI for better evaluation of the smaller lesions. 2) Left orbital enhancing lesion intimately associated with the superior rectus muscle, likely a metastasis. 3) No aneurysm or significant stenosis, involving the vasculature of the head and neck. Vessels in the right MCA distribution are displaced by the large right temporal mass. Minimal bilateral carotid bulb atherosclerotic disease. 4) Advanced emphysema. . CT PELVIS and CT Abdomen [2159-3-2] 4:13 PM CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Multiple nodules are demonstrated in both lung bases measuring up to 24 x 11 mm. Centrilobular emphysema is also identified. Within the liver, multiple hypodense ill-defined lesions are identified, the largest of which is within segment VII of the liver and measures 24 x 11 mm, suspicious for metastases. Multiple innumerable subcentimeter hypodensities are also seen diffusely throughout the liver, which could represent tiny metastases versus biliary hamartomas. There is no intra- or extra- hepatic biliary duct dilatation. The portal vein is patent. Within the left adrenal gland, a 22 x 18 mm enhancing mass is demonstrated most consistent with metastasis. The right adrenal gland is unremarkable. The spleen and pancreas are within normal limits. The splenic artery is heavily calcified. Both kidneys contain multiple well-circumscribed hypodense lesions, many of which appear to be cysts. However, within the inferior pole of the left kidney, a 28 x 26 mm hypodense lesion appears to demonstrate mild enhancement after contrast administration and is not clearly a simple cyst. Both kidneys enhance symmetrically and excrete normally. Proximal ureters are unremarkable. Abdominal aorta is normal in caliber but demonstrates calcified atherosclerotic plaque. Enlarged retroperitoneal lymph node within the left periaortic region measuring up to 16 mm wide is identified. There is no free air or free fluid. There is no evidence of bowel obstruction. Multiple subcutaneous nodules are demonstrated within the abdomen and pelvis, the largest of which is within the subcutaneous fat of the right pelvis measuring up to 7 mm. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Foley catheter is seen within the bladder which contains air within it. Coarse prostatic calcifications are identified. Small bowel-containing, large, left inguinal hernia is demonstrated. The bowel appears non-obstructed without evidence of bowel wall thickening. A large, fat-containing right inguinal hernia is also demonstrated. No inguinal or pelvic lymphadenopathy is identified. There is no free fluid. Multiple small subcutaneous nodules are demonstrated within the subcutaneous fat as well as adjacent to the left gluteus maximus muscle measuring up to 10 mm wide. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. Widespread metastatic disease involving the lungs, liver, left adrenal gland, and subcutaneous tissues. 2. Innumerable subcentimeter hypodense lesions within the liver may represent innumerable tiny metastases versus biliary hamartomas. 3. Multiple hypodense lesions in both kidneys, the majority of which are cysts. One hypodense lesion in the left kidney, however, demonstrates mild enhancement and does not meet criteria for simple cyst. 4. Large, small bowel-containing, left inguinal hernia. . MR HEAD W & W/O CONTRAST [2159-3-2] 5:44 PM CLINICAL INFORMATION: Patient for postoperative MRI following evacuation of right-sided hematoma and evidence of multiple metastasis. TECHNIQUE: T1 axial, sagittal and coronal images of the brain were obtained following gadolinium. MP-RAGE axial images were also acquired. FINDINGS: There are postoperative changes identified in the right frontotemporal region. There is mild mass effect seen on the right lateral ventricle. Multiple hyperintense masses, indicating enhancing lesions are identified predominantly in the posterior fossa and right cerebral hemisphere. There are at least three enhancing lesions seen in the right cerebellar hemisphere, and one in left cerebellar tonsillar region. There is a faint area of enhacement in the left side of the pons. Additional 3 small enhancing lesions are seen in the right occipital lobe and at least two small enhancing lesions are seen in the right frontal lobe. The lesions in the right frontal lobe and right cerebellum measure approximately 1 cm in size with an additional 5-10 mm lesion in the right cerebellum. Most of the other lesions measure 5 mm or smaller. A faint enhancement is also identified in the left temporal lobe anteriorly which is suggestive of an additional metastasis. At the site of surgery in the right temporal region, some marginal enhancement is identified at the surgical cavity. In absence of pre-gadolinium images, the assessment is limited. IMPRESSION: Multiple enhancing lesions are identified for therapy planning in the supra and infratentorial regions as described above. . TEMPORAL LOBE TUMOR (RIGHT)-FS, TEMPORAL LOBE TUMOR (RIGHT) Procedure date Tissue received Report Date Diagnosed by [2159-3-1] [2159-3-2] [2159-3-5] DR. [Last Name (STitle) ] [Known firstname ]/jtj?????? DIAGNOSIS: #1, RIGHT TEMPORAL LOBE HEMORRHAGIC TUMOR BIOPSY (including intraoperative smear and frozen section): METASTATIC MALIGNANT MELANOMA. #2, RIGHT TEMPORAL LOBE HEMORRHAGIC TUMOR RESECTION: METASTATIC MALIGNANT MELANOMA. NOTE: Intermixed within the blood clot are frequent small clusters of highly malignant cells having large nuclei, a prominent nucleolus, and fine cytoplasmic pigment. These cytologic features are diagnostic of metastatic melanoma. Clinical: Intracranial hemorrhage. Right temporal tumor hematoma for evacuation; suspect underlying malignancy. Gross: The specimen is received fresh labeled with "[Known firstname 122] [Known lastname 72376]" and the medical record number. Part 1 is additionally labeled "right temporal lobe tumor, frozen section" and consists of 3.3 x 1.5 x 1.2 cm aggregate of maroon red recently clotted blood and scant fragments of pink white tissue. Intraoperatively, the frozen section diagnosis by Dr. [Last Name (STitle) ] reads: "Right temporal lobe tissue: Pigmented malignant epithelioid cell aggregate present within blood clot. Final diagnosis pending permanent section." It is entirely submitted as follows: A = frozen section remnant, B-E = remaining tissue. Part 2 is additionally labeled "right temporal lobe tumor" and consists of an aggregate of red brown blood clot with scant fragment of tan tissue, measuring 4.1 x 3.4 x 0.9 cm. The specimen is entirely submitted in F-J. Brief Hospital Course: Mr. [Known lastname 72376] was emergently taken to the CT scanner after being evaluated by the neurology stroke team. The head CT showed a large right sided temporal hemorrhage, measuring approximately 5 x 5 cm with uncal herniation, incipient midline shift, transfalcine herniation. The patient was emergently taken to the operating room for decompression. The patient tolerated the procedure well and was extubated POD 1. Oncology was consulted because the pathology from the brain mass came back metastatic melanoma. Their recommendations was CT scan of the chest, abdomen and pelvis for metastatic workup, possible role of temodar, and derm consult to look for primary lesion on the skin. The derm consult they recommended a biopsy of the a lesion on the foot which turned out to be a dyplastic nevus and to get any old records of his possible history of melanoma. His PCP was [Name (NI) 653] but she did not have any history of his having melanoma in the past. On POD 1 he failed bedside swallow evaluation so a dobhoff was placed and he was started on tubefeeds. His steriods were also started on a taper to 2mg dexamethasone [Hospital1 ]. On POD 2 he went into rapid atrial fibrillation so he was started on an amiodarone drip. On POD 3 he was converted to IV amiodarone to PO amiodarone and started on a beta blocker to rate control him. He was also started on Keppra and the dilantin was continued until he was therapeutic on his Keppra then it was discontinued. On POD 4 he was transferred to the floor once his atrial fibrillation was rate controlled. He was also seen by radiation oncology who felt that he may be a candidate for radiation but wanted to see the post-op MRI before final recommendations. On POD 5 he pulled out his dobhoff and he was re-evaluatated by speech and swallow which he passed. He was then able to advance his diet as tolerated to a regular diet. Physical therapy also saw him and felt that he would be better served by going to rehab for at least one week. On POD 6 it was noted that he had a left inguinal hernia so general surgery was consulted and it was decided due to life expectancy and that this is a chronic problem with no signs of obstruction that surgery was not an opition at this time. He did need a sitter occasionally but each day he has been improving and by POD 7 he was sitter free for more than 24 hours. He has been neurologically stable and awaiting a rehab bed. On POD#10, he walked in the hallway with assistance. His surgical staples are removed without difficulty. Medications on Admission: 1. Atenolol Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Insulin SC per sliding scale. Patient should remain on when taking steroids. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Metastatic melanoma Discharge Condition: Neurologically Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have your incision checked daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Please keep your Brain [Hospital 341] Clinic with Dr. [First Name (STitle) ] [Name (STitle) 4253] at [2159-3-19] at 11:30am. Call [Telephone/Fax (1) 44] if you have any questions or concerns. Completed by:[2159-3-12] ICD9 Codes: 4019, 2720, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2243 }	Medical Text: Admission Date: [2140-7-31] Discharge Date: [2140-8-4] Date of Birth: [2085-12-29] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1515] Chief Complaint: epigastric/back pain, and nausea/vomiting Major Surgical or Invasive Procedure: cardiac catheterization with bare metal stent to the diagonal artery History of Present Illness: Ms. [Known lastname 3234] is a 54 yo F with HIV and Bipolar Disorder who presented to the [Hospital1 18] ED with epigastric/back pain, and nausea/vomiting. . The pt states she initially had N/V yesterday around 11 am. She continued to have nausea into today, but then at 2 pm she started to get severe [11-6] pain that felt like it would "explode" in her back which radiated to her epigastrium. She tried a lidocaine patch, percocet, and icy hot, but none of that helped. The pain started to radiate to her jaw and neck. Associated with the pain, the pt states she had tightness with her breathing and diaphoresis. Her vitals in the ED upon arrival were: T After she arrived, she was found to have concerning changes on EKG (ST elevations in V5 and V6 with reciprocal changes in the inferior leads (II, III, avF) for a STEMI. The ED started a heparin drip, integrillin, ASA 325 mg PO, and 5 mg of IV metoprolol x 1. She was loaded with 600 mg of plavix, and was sent to the cath lab. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: - HIV - diagnosed in [2118], most recent CD4 count 488 in [Month (only) ] [2139] - Bipolar disorder - Fibromyalgia x 20 yrs - Secondary Cushings--[3-1] steroid injection ([4-4]) - Scoliosis - Cervical radiculopathy - Gastric ulcers - Hiatal hernia - Seasonal allergies - Uterine fibroids - Abnormal PAP smears - s/p tubal ligation [2113] - s/p lumpectomy [2104] - history of syphillis - history of varicella - history of peri-rectal HSV2 Social History: Immigrated to US in [2117] from [Male First Name (un) 1056] and has lived in the [Location (un) 86] area since then. She does not use EtOH, illicit drugs, or tobacco. . Per previous d/c summary [2139-5-6]: The patient lives with her son and partner in [Location (un) 686]. Per OMR, partner is apparently HIV positive and has a lot of health issues. Patient used to be very involved in HIV community outreach work but not anymore, which she believes is due to depression. She is currently not married. She has been married twice in the past. Her first husband was HIV positive and they were diagnosed at the same time. He was an IV drug abuser. Her second husband was also HIV positive, who committed suicide in [2134]. She has a GED. Family History: Father had prostate CA, Mother- cervical CA Two brothers with AIDS Grandmother had DM, HTN Son with bipolar disorder, daughter with schizophrenia Physical Exam: VS: T=96.9 BP=129/80 HR=93 RR= 25 O2 sat= 97% on GENERAL: WDWN F in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills. No S3 or S4. LUNGS: No chest wall deformities. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: radial 2+ Femoral 2+ DP 2+ PT 2+ Left: radial 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [2140-8-4] 06:10AM BLOOD WBC-7.8 RBC-3.92* Hgb-11.4* Hct-33.4* MCV-85 MCH-29.0 MCHC-34.0 RDW-16.6* Plt Ct-221 [2140-8-4] 06:10AM BLOOD Glucose-97 UreaN-12 Creat-1.0 Na-142 K-4.1 Cl-101 HCO3-29 AnGap-16 [2140-8-3] 02:15AM BLOOD CK(CPK)-397* [2140-8-2] 05:38PM BLOOD CK(CPK)-506* [2140-8-2] 05:38PM BLOOD CK(CPK)-506* [2140-7-31] 10:28PM BLOOD CK(CPK)-2871* [2140-8-2] 05:38PM BLOOD CK-MB-7 cTropnT-2.55* [2140-8-4] 06:10AM BLOOD Calcium-9.8 Phos-4.5 Mg-2.0 [2140-8-2] 05:27AM BLOOD %HbA1c-5.8 eAG-120 . Cardiac catheterization [2140-7-31]: COMMENTS: 1. Coronary angiography in this right dominant system demonstrated single and branch vessel CAD. The LMCA was patent. The LAD had a distal tubular 70% stenosis. There was a thrombotic total occlusion in a large proximal first diagonal branch with few collaterals from the RCA. The LCx was small without obstructive disease. The RCA had minimal disease. 2. Limited resting hemodynamics revealed elevated left sided filling pressures with an LVEDP of 32 mmHg. There was mild systemic arterial systolic hypertension with an SBP of 140 mmHg. 3. There was no pressure gradient on left heart pullback from left ventricle to ascending aorta to suggest aortic stenosis. 4. Successful PTCA and stenting of D1 with a 2.5x23 mm Mini Vision bare metal stent which was postdilated with a 2.5x20mm NC quantum balloon. 5. Successful closure of right femoral arteriotomy with 6F angioseal. FINAL DIAGNOSIS: 1. Single and branch vessel CAD with STEMI due to D1 occlusion. 2. Left ventricular diastolic dysfunction. 3. Successful PCI of D1 with bare metal stent. 4. Successful deployment of 6F angioseal at right femoral arteriotomy. . ECHO [2140-8-2]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mid anterior/anterolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . ECG [2140-8-4]: Sinus rhythm. There is an early transition which is non-specific. Compared to the previous tracing there is no signifciant change. Brief Hospital Course: ASSESSMENT AND PLAN: 54yoF with h/o HIV, fibromyalgia/spinal scoliosis and chronic pain who presented today to the [Hospital1 18] ED with a cc of nausea and vomiting. She was found to have + cardiac enzymes in the ED with ST elevations on EKG and is now s/p cardiac catheterization. . # STEMI/CAD: Pt with no previous CAD hx presents with STEMI now s/p cath. The pt was Plavix loaded with 300 mg, was given ASA 325 mg, as well as a high dose statin, metoprolol 5 mg IV x 1, SLNTG, Integrillin. ASA 325 mg po daily and Plavix 75 mg po daily were continued throughout admission. Atorvastatin was decreased to 40 mg po QHS as HAART affects the cytP450 that metabolizes statins. She had an episode of CP responsive to SLNG and morphine after cath. She also had chest pain that varied with position and inpiration that responded to indomethacin; however, no pericardial effusion noted on Echo. She was started on metoprolol tartrate 12.5mg [Hospital1 ], which was titrated up to 25mg [Hospital1 ], and she was discharged on 50mg of metoprolol succinate. However, while she was bale to tolerate BBlockade well, her SBPs, which were in the 90s, did not tolerate addition of an ACEi. Pt developed a small inguinal hematoma after cath. Hct was closely followed. She received 1 unit pRBCs after which her Hct/Hgb bumped appropriately and was stable throughout the rest of admission. . # PUMP: Pt has no prior Dx of CHF. Echo showed EF 45-50% and mild regional LV systolic dysfunction. BBlocker started as noted above. ACEi held as noted above. . # RHYTHM: Pt monitored on tele throughout hospital stay. No arrhythmia noted. . # HIV: Home HAART regimen continued throughout admission: Lopinavir-Ritonavir 200-50 mg [Hospital1 ] and Emtricitabine-Tenofovir 200-300 mg daily. Last known CD4 is 488 from [2139-6-29]. Atorvastatin dose adjusted as noted above. . # Gastric Ulcers: Pt is on omeprazole at home. Pt was initially started on pantoprazole 40 mg IV BID for now. She was switched to po ranitidine given the potential interaction between Plavix and PPIs. . # Bipolar Disorder: Home sertraline and bupropion continued throughout admission. Medications on Admission: Bupropion HCl 200 mg Sustained Release PO BID 2. Emtricitabine-Tenofovir (Truvada) 200-300 mg Daily 3. Darunavir (Prezista) 400 mg tabs, 2 tabs PO daily 4. Ritonavir 100 mg PO daily 5. Lamotrigine 200 mg PO QHS 6. Lidoderm 5 %(700 mg/patch) Q24H 7. Levothyroxine 25 mcg PO daily 8. Lorazepam 1 mg PO HS 9. Pregabalin 100 mg PO BID 10. Promethazine 12.5 mg TID with meals 11. Omeprazole 20 mg PO daily 12. Sertraline 200 mg Daily 13. Zolpidem 10 mg PO HS 14. Oxycodone 10 mg PO BID 15. Loratadine 10 mg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 weeks: Then decrease to one tablet daily. Do not stop taking or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) ] tells you to. . Disp:37 Tablet(s) Refills:2 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: Take 5 minutes apart for chest pain, do not take more than 3 tablets at one time!!!. Disp:25 Tablet, Sublingual(s) Refills:0 4. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO at bedtime. 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. 13. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 15. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 16. Promethazine 25 mg Tablet Sig: 0.5 Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 17. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for insomnia. 18. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 20. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: ST Elevation Myocardial Infarction HIV Bipolar disorder Fibromyalgia Pericarditis Anemia Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and needed a cardiac catheterization and a bare metal stent to open a clogged artery. It is extremely important that you take Plavix every day for at least one month to prevent the stent from clotting off and causing another heart attack. You will take 2 tablets of Plavix every day for one week, then decrease to one tablet daily. Do not stop taking Plavix unless Dr. [Last Name (STitle) ] tells you to, even if you have bleeding. You will also need to be on the following medicines to help your heart recover from the heart attack. These medicines are: 1. Aspirin, enteric coated, 325 mg daily to take with the Plavix. Do not stop taking this medicine unless Dr. [Last Name (STitle) ] tells you it is OK. 2. Metoprolol to slow your heart rate and help your heart recover 3. Atorvastatin to help prevent further blockages in your arteries. You will need to have liver function tests in 6 weeks and every 6 months to make sure it is not affecting your liver. 4. Plavix: as noted above 5. Nitroglycerin tablets to take under your tongue if your chest pain that brought you to the hospital returns. Sit down, take one tablet under your tongue and wait 5 minutes. If you still have chest pain you can take one more tablet but pls call 911 so you can get to the hospital. 6. Stop taking Omeprazole, it interferes with Plavix. . You will see Dr. [Last Name (STitle) ] in 5 weeks and will probably have a stress test to see if the other blocked heart artery needs to be fixed as well. You should continue taking your other medicines as before. Followup Instructions: Dr [Last Name (STitle) 92962] [University/College 92963] [Location (un) 686], [Numeric Identifier 92964] Phone: ([Telephone/Fax (1) 17612] Fax: ([Telephone/Fax (1) 92965] [8-18] at 3pm The office will try to get you an earlier appt and will call you at home. . Department: CARDIAC SERVICES When: TUESDAY [2140-9-13] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2140-8-10] ICD9 Codes: 2875, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2244 }	Medical Text: Admission Date: [2176-2-9] Discharge Date: [2176-2-10] Date of Birth: [2120-1-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: Alcohol intoxication Major Surgical or Invasive Procedure: None History of Present Illness: This is a 54 M who was found down outside a restaurant where he reportedly works as a dishwasher and was brought to the ED. BAL was 509. He had stepped outside about five minutes before he was found unresponsive. Pt was noted to be posturing and foaming at the mouth per EMS. No signs of trauma. C-collar was placed. FSBG normal per EMS. In the ED, vitals on presentation were T 98 HR 90 BP 133/70 RR 15 100%NRB. Head CT was negative. CT C-spine revealed grade 1 retrolisthesis of C4 on C5 and disc bulge at C4-5 causing moderate canal narrowing. He was given a banana bag and 325 mg PR ASA. Weaned to 2L NC, 100% sats. EKG revealed ST at a rate of 111, normal axis, normal intervals, and STD in V3-V6, II. Upon arrival to the ICU, pt was able to spell his name but he had no identification on him. He could not remember any of his PMH or his medications. Pt clearly states when asked who is PCP [Last Name (NamePattern4) ], "Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]." After further investigation, his full name and MR#[Medical Record Number ]were able to be obtained. Past Medical History: Alcohol abuse HTN Hyperlipidemia Tobacco abuse Depression Social History: Alcohol abuse, unclear at this time how much pt drinks. Several [Last Name (un) 20934] in the past. Also smokes, unclear amount. He denies any illicit drug use. Family History: He is adopted. Physical Exam: Vitals: Per Metavision GEN: Appears unkempt, NAD. HEENT: NC/AT. MMM. OP clear. NECK: No JVD. CV: RRR, no M/G/R, normal S1 S2, radial pulses +2. PULM: Lungs CTAB, no W/R/R. ABD: Soft, NT, ND, +BS, no HSM, no masses. EXT: No C/C/E, no palpable cords. NEURO: Oriented to person and place. Able to move all four extremities. Sensation grossly intact. Pertinent Results: [2176-2-9] 01:45AM GLUCOSE-122* UREA N-17 CREAT-0.9 SODIUM-141 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-20* ANION GAP-20 [2176-2-9] 01:45AM CK(CPK)-180* [2176-2-9] 01:45AM CK-MB-5 cTropnT-<0.01 [2176-2-9] 01:45AM ASA-NEG ETHANOL-509* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2176-2-9] 01:45AM WBC-9.3 RBC-4.33* HGB-14.9 HCT-42.1 MCV-97 MCH-34.5* MCHC-35.4* RDW-14.1 [2176-2-9] 01:45AM NEUTS-76.6* LYMPHS-18.4 MONOS-3.5 EOS-1.1 BASOS-0.5 [2176-2-9] 01:45AM PT-11.9 PTT-25.3 INR(PT)-1.0 [2176-2-9] 04:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2176-2-9] 04:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2176-2-9] 08:21AM TRIGLYCER-122 HDL CHOL-68 CHOL/HDL-3.7 LDL(CALC)-161* [2176-2-9] 08:21AM ALT(SGPT)-33 AST(SGOT)-37 CK(CPK)-218* ALK PHOS-56 TOT BILI-0.2 [2176-2-9] 08:21AM CK-MB-7 cTropnT-<0.01 [2176-2-9] 08:21AM CALCIUM-7.7* PHOSPHATE-3.8 MAGNESIUM-1.9 CHOLEST-253* [2176-2-9] 02:26PM CK(CPK)-240* [2176-2-9] 02:26PM CK-MB-8 cTropnT-0.05* [2176-2-9] 08:06PM CK(CPK)-252* [2176-2-9] 08:06PM CK-MB-7 cTropnT-0.07* Imaging: CT C-spine [2-9]: No evidence of acute fracture or mal-alignment, however grade 1 retrolisthesis of C4 on C5 is of unknown chronicity and and disc bulge at C4-5 causes moderate canal narrowing. MRI is recommended for further evaluation if concern for cord injury persists. Head CT [2-9]: No acute intracranial process. MRI C-spine [2-9]: (prelim) Central disc protrusion at C4-C5 with mild central canal stenosis. There is no significant cord compression or cord contusion. Brief Hospital Course: 54 M who was found down acutely intoxicated, found to have a BAL of 509, and admitted to the ICU for alcohol intoxication. # Alcohol intoxication - The patient was found down acutely intoxicated. Unclear the amount that patient drank although can estimate based on BAL. Pt with known history of alcohol abuse. He was monitored overnight in the ICU on telemetry without event. He had no signs of alcohol withdrawal. He was alert and oriented the morning after admission and wished to be discharged home. He was counceled to refrain from alcohol and will follow up with his primary doctor, Dr. [First Name (STitle) ]. # EKG changes - No baseline available for comparison. Lateral ST changes may be [2-26] to profound alcohol intoxication. No symptoms of CP or SOB. His CE's were cycled and his CK's were mildly elevated in the 200's (likely due to muscle break down from his fall) and his troponins ranged between <0.01 to 0.07. On recheck, his EKG changes had resolved. Due to concern for possible cardiac disease he was started on 25 mg of metoprolol [Hospital1 ] and his zocor was increased to 40 mg daily. He was continued on his outpatient ASA. He was ordered for an outpatient stress test and will follow up with his primary doctor after the stress test. # CT C-spine findings: The patient underwent a C-spine CT given his history of a fall which was re-read as showing a large midline protrusion of the intervertebral disk at C4-5 with concern for cord compression so neurosurgery was called to evaluate the patient in the ED. He underwent a MRI of his C-spine which showed Central disc protrusion at C4-C5 with mild central canal stenosis and no significant cord compression or cord contusion. Neurosurgery stated that he did not need to wear a collar or have follow up with them as an outpatient. # Code: Full code Medications on Admission: HCTZ 25 mg PO daily Percocet PRN Zocor 20 mg PO daily Trazodone 50 mg PO QHS PRN insomnia ASA 81 mg PO daily Colace MVI Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Colace Oral 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Primary - Alcohol Intoxication Mild central cervical spinal canal stenosis Secondary - Hypertension Hyperlipidemia Discharge Condition: Stable, detoxed. Discharge Instructions: You were admitted to the hospital because you were found to have fallen while intoxicated with alcohol. You had imaging of your head and spine which showed no injury. Neurosurgery evaluated you in the ED and felt that you had no spinal injury. While you were evaluated in the emergency room your EKG (imaging of the forces in your heart) showed changes concerning for cardiac disease. These resolved when your heart rate decreased. You will need to undergo a stress test as an outpatient. You should refrain from drinking alcohol in the future. Medication changes: 1. You were started on metoprolol 25 mg twice daily. 2. Your zocor was increased to 40 mg daily. Otherwise continue to take your outpatient medications as prescribed. Go to the emergency room or call your primary doctor if you experience fevers, chills, chest pain, shortness of breath, blood in your stool, black stool, new onset numbness, tingling, or weakness. Followup Instructions: You will need to follow up with with your primary doctor, Dr. [First Name (STitle) ]. Call [Telephone/Fax (1) 250] to schedule this appointment. Appointment should be in [8-2] days You will also need to follow up with your social worker, [Name (NI) ] [Name (NI) 41140]. Call [Telephone/Fax (1) 250] to schedule this appointment. Appointment should be in [8-2] days Call [Telephone/Fax (1) 62] to schedule your stress test. Please try to complete this test before following up with Dr. [First Name (STitle) ]. It is very important that you undergo this test to see if their is problems with the vessels in your heart. Completed by:[2176-2-10] ICD9 Codes: 4019, 2724, 3051, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2245 }	Medical Text: Unit No: [Numeric Identifier 73111] Admission Date: [2198-5-10] Discharge Date: [2198-5-29] Date of Birth: [2198-5-10] Sex: F Service: Neonatology HISTORY: This is a 19 day old former 32-0/7 week female who is being transferred to the [Hospital1 2436] Special Care Nursery. The infant was born to a 38-year-old G3-P1 to 2 woman. Her prenatal labs were A negative, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, GBS unknown and rubella equivocal. Past medical history remarkable for ovarian cystectomy in [2198-2-1]. Her pregnancy was, otherwise, remarkable for gestational diabetes and the eventual development of pregnancy induced hypertension. The decision was made to deliver this baby because of decreased fetal growth in the setting of severe pregnancy induced hypertension. The mother was treated with magnesium sulfate and she was betamethasone complete at the time of delivery. The infant emerged vigorous. There was blood leaking from the umbilical cord and it was manually occluded before reclamping. The infant required 10-15 seconds of positive pressure ventilation and had Apgars of 7 at 1 and 9 at 5 minutes. FAMILY HISTORY: Remarkable for a healthy adolescent boy with a prior partner. Mother and father are [Name (NI) 16042] Witnesses. The father has a history of epilepsy. Family and social history are, otherwise, noncontributory. PHYSICAL EXAMINATION: At discharge, the physical examination was remarkable for a well appearing preterm infant with a nasal cannula with a head circumference of 30 cm, length 43 cm and a weight of 2075 grams. Skin is pink. The anterior fontanel is flat and soft. There is no grunting, flaring or retracting. Breath sounds are clear. The palate is intact. The abdomen is flat, soft, nontender. There is no hepatosplenomegaly. The hips are stable. The tone and activity are normal. The external genitalia are normal female. HOSPITAL COURSE: Respiratory: The infant had grunting, flaring and retracting soon after delivery. The infant was placed on CPAP and received CPAP until the second hospital day, at which time she was weaned to nasal cannula O2 and eventually to room air on day 5. The course was consistent with mild hyaline membrane disease. The blood gases were reassuring. The infant has not had a problem with apnea of prematurity. The infant has been hemodynamically stable throughout her hospitalization. Four days prior to transfer, the infant developed a mild oxygen requirement and has required intermittent low flow cannula at 13 ml per minute. Her respiratory rates remained in the 30-60 range. Fluid, electrolytes and nutrition: The infant was initially n.p.o. She was started on feeds on day two and advanced. She is currently on breast milk 24 with human milk fortified or special care 24. She occasionally has saturation drifts with feeding. At this point, she requires intermittent gavage feeding but is about 50% p.o. feeds. Hematologic: The infant's initial hematocrit was 56. The following day, her hematocrit was 53. Another hematocrit was obtained on day 17 and this was 38.8 with a retic of 2.1%. The infant is on ferrous sulfate at 0.3 ml daily. Gastrointestinal: Maximum bilirubin was 7.6. The infant required phototherapy for 4 hospital days. There has been no evidence of gastrointestinal intolerance with feeds. The baby's blood type is A positive and the DAT was negative. Infectious disease: The infant had a blood culture on the day of birth and this was no growth. The infant was treated with ampicillin and gentamicin for 48 hours pending cultures. Neurology: There have been no neurologic issues. Sensory: Part 1 audiology: The infant has not had hearing screen at this point. Ophthalmology: The infant's eyes were examined on [5-28] and were immature to zone 3. Suggested followup was 3 weeks. Psychosocial: The [Hospital1 18] social worker was involved with this family. The contact social worker can be reached at [Telephone/Fax (1) 55529]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to the [Hospital1 2436] special care nursery. PRIMARY PEDIATRICIAN: The family is considering [Hospital 8985] Pediatrics at this point. CARE AND RECOMMENDATIONS: Feeds at discharge: 24 calorie breast milk or special care nursery p.o., p.g. MEDICATIONS ON DISCHARGE: 1. Ferrous sulfate (25 mg per ml 0.3 ml daily). 2. 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 ([Month (only) 116] be provided as a multivitamin preparation) daily until 12 months corrected age. Car seat position screening has not been performed. State newborn screening status: State screens were sent on [5-14] and [5-25]. Immunizations received: None. 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 2 of the following: Daycare 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 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. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Respiratory distress syndrome. 3. Hypoglycemia. 4. Hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (NamePattern4) 58323] MEDQUIST36 D: [2198-5-29] 13:57:25 T: [2198-5-29] 14:41:40 Job#: [Job Number 73112] ICD9 Codes: 769, 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2246 }	Medical Text: Admission Date: [2180-5-10] Discharge Date: [2180-6-8] Date of Birth: [2100-5-15] Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Procainamide / Cephalosporins Attending:[First Name3 (LF) 31014] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 79-year-old male with ischemic CHF NYHA IV (EF 30%) BiV ICD, pAFIB on coumadin, CKD (Cr 1.6-1.8), hx of LGIB (angioectasia colonoscopy [2179]) with down trending Hct from the low 30s-> 27.5 with progressive fatigue, DOE with any activity. . Patient complained of dyspnea with minimal exertion that was worsening over the last few weeks. He could only walk ~10 feet before feeling short of breath. He stated that his lasix has been increased over the last 2 weeks and he was on 160mg [Hospital1 ], without symptomatic relief or resolution of significant lower extremity edema. He was also on spirolactone and metolazone. His stated that his weight has been stable at ~205lbs. He also complained of orthopnea. . He denied having any chest pain or other respiratory symptoms. He had darker stools since he was started on iron pills, but denied having any blood on stool or black tarry stools. . In the ED, initial vitals were 98.4 67 107/56 18 99% RA. He overall appeared comfortable. His EKG showed a ventricular-paced rythm, bigeminy with rate in the 70s. His labs were notable for creatine at 1.8 (trending up for the last 2-3 months, but at his baseline), proBNP: 765, Hct at 27.3. Guaiac +. His chest X-ray showed pulmonary congestion. The patient was then admitted for further evaluation. . On the arrival to the floor, pt appears slightly uncomfortable. He states to have increased dyspnea on exertion. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CHF (NYHA class IV, ACC/AHA stage D) - Atrial Fibrillation - CABG: Yes - PERCUTANEOUS CORONARY INTERVENTIONS: None. - PACING/ICD: Cardiac defibrillator in place 3. OTHER PAST MEDICAL HISTORY: - Peripheral vascular disease - Long-term anticoagulation - Anemia - Obesity - Sleep apnea - Osteomyelitis - Ankle/Foot (Acute) - Restless legs syndrome - Colonic Polyp - Gout - Lumbar spinal stenosis - Nephrolithiasis Social History: Occupation: Retired security guard, worked at a pharmaceutical company with chemical exposure. Family: Married Tobacco history: Smoked from age 6-35; quit at 35. ETOH: 1-2 drinks per month. Illicit drugs: Denies. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam 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 to Jaw CARDIAC: RR, with + holysystolic loudest on LUSB. LUNGS: Bil crackles up to mid lung fields. No chest wall deformities, scoliosis or kyphosis. Resp w/ mild increase in wOB, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: +3 pitting edema up to thigh w/ LE hyperpigmentation PULSES: + 1 on bil LE Discharge Exam Gen: alert, oriented, NAD HEENT: supple, JVD at 5 sitting on edege of bed CV: irreg irreg, 1/6 systolic murmur at RUSB, RESP: No crackles or wheezes. ABD: firm, NT, pos BS EXTR: 1+ peripheral edema to 1/2 up calf, skin is wrinkled near ankles. NEURO: A/O Extremeties: none Pulses: Right: DP 1+ PT trace Left: DP 2+ PT trace Skin: intact Pertinent Results: LABS ON ADMISSION [2180-5-10] 12:40PM GLUCOSE-115* LACTATE-2.1* K+-3.6 [2180-5-10] 12:30PM GLUCOSE-122* UREA N-46* CREAT-1.8* SODIUM-138 POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-33* ANION GAP-14 [2180-5-10] 12:30PM ALT(SGPT)-14 AST(SGOT)-18 ALK PHOS-179* TOT BILI-1.0 [2180-5-10] 12:30PM LIPASE-34 [2180-5-10] 12:30PM cTropnT-0.02* [2180-5-10] 12:30PM proBNP-765 [2180-5-10] 12:30PM ALBUMIN-3.9 CALCIUM-8.4 PHOSPHATE-2.5* MAGNESIUM-2.8* [2180-5-10] 12:30PM DIGOXIN-1.5 [2180-5-10] 12:30PM WBC-6.6 RBC-3.00* HGB-8.6* HCT-27.3* MCV-91 MCH-28.8 MCHC-31.7 RDW-19.2* [2180-5-10] 12:30PM NEUTS-79.0* LYMPHS-12.4* MONOS-6.5 EOS-1.4 BASOS-0.7 [2180-5-10] 12:30PM PLT COUNT-284 [2180-5-10] 12:30PM PT-27.3* PTT-38.5* INR(PT)-2.6* . LABS ON DISCHARGE: [2180-6-8] 05:16AM BLOOD WBC-7.1 RBC-2.90* Hgb-8.3* Hct-25.9* MCV-89 MCH-28.5 MCHC-31.9 RDW-19.5* Plt Ct-305 [2180-6-8] 05:16AM BLOOD PT-28.2* INR(PT)-2.7* [2180-6-8] 05:16AM BLOOD Glucose-92 UreaN-46* Creat-1.8* Na-141 K-4.0 Cl-100 HCO3-33* AnGap-12 . ECG ([2180-5-10] 12:27:36 PM) Demand ventricular paced rhythm with frequent ventricular premature beats. Q-T interval prolongation. No previous tracing available for comparison. . ECG ([2180-5-15] 2:30:34 PM) Ventricular pacing with wide complex native beats, probably ventricular in origin. Since the previous tracing of [2180-5-10] the ventricular bigeminal pattern is not seen but ventricular premature beats persist. . CHEST (PA & LAT) ([2180-5-10] 1:33 PM) IMPRESSION: 1. Ill-defined bibasilar opacities, possible aspiration or pneumonia in the appropriate clinical setting. Underlying mild interstitial lung disease is also possible. 2. Intact pacemaker/ICD leads in standard position. 3. Stable mild cardiomegaly. 4. Possible small effusions or pleural thickening. . CHEST (PA & LAT) ([2180-5-14] 9:26 AM) IMPRESSION: 1. Probable background COPD. 2. Cardiomegaly, with sternotomy and ICD device. 3. Bibasilar opacities, ? infectious, inflammatory or aspiration. Suspect some background more diffuse interstitial abnormality. If there is clinical concern for an infectious process, followup imaging to confirm resolution is recommended. Chest CT may be useful to evaluate the background parenchymal pattern. 4. Bilateral pleural thickening. 5. ?increased soft tissue density adjacent to right paratracheal region, not fully assessed here. Attention to that area at the time of CT scan is recommended. . CT CHEST W/O CONTRAST ([2180-5-14] 4:32 PM) IMPRESSION: Fibrotic lung changes with a pattern corresponding to NSIP, of overall mild-to-moderate severity. Further pulmonologic workup is strongly suggested. Mild-to-moderate mediastinal lymphadenopathy, with partly calcified lymph nodes, that might suggest previous exposure to granulomatous disease and also might be related to the fibrotic lung changes. Status post CABG, left pectoral pacemaker in correct position. No evidence of pulmonary nodules or masses. Minimal bilateral pleural effusions. No pericardial effusions, no osteodestructive lesions. . Cardiac Cath ([2180-5-15]) 1. Markedly elevated left and right heart filling pressures. 2. Severe pulmonary hypertension. Video swallow study ([2180-6-8]) 1. Aspiration of thin liquids with moderate residue 2. Barium reflux to nasopharynx 3. large osteophyte in C3 Brief Hospital Course: 79-year-old male with ischemic CHF NYHA IV (EF 30%) BiV ICD, pAFIB on coumadin, CKD (Cr 1.6-1.8), hx of LGIB (angioectasia colonoscopy [2179]) with down trending Hct from the low 30s-> 27.5 with progressive fatigue, DOE with any activity who was admitted for CHF exacerbation. # CORONARIES: Pt has hx of 3 vessel disease with CABG in [2172], he denied having any chest pain on admission. ASA, BB, statin were continued on admission. He was started on losartan but due to his acute kidney injury in setting of diuresis, his [Last Name (un) ] was discontinued. It will need to be restarted as outpatient. # Acute on Chronic Systolic CHF: Pt with hx of CHF last echo showed EF of 30%, fluid overloaded on exam. He appears to not be responding appropriate to home dose of lasix, spironolactone and metolazone. He was treated with IV lasix/metolazone and assessed for further diuresis on a daily basis. However, his BP was often too low and his daily lasix was held on numerous occasions. On [2180-5-14] he was transfused w 2 Units of blood over 4 hours each (for dropping Hct) but his pressures remained low. On [2180-5-15], he underwent a R-sided cardiac cath that revealed PCWP of 30 and he was placed on lasix gtt but this was quickly stopped as SBPs were in the 70s. He was transfered to the CCU for augemented diuresis on a dopamine and lasix gtt. In the CCU patient with brisk diuresis of greater than 5L with noted subjective improvement of symptoms, and dopamine was stopped on [5-17]. He was transitioned to torsemide 100mg PO daily and metolazone 2.5 mg PO daily was started. He was continued on Torsemide 100mg PO daily on the floor for several days, however hypotension with SBP in low 80s-90s prevented further increase in diuresis. Patient was significantly orthostatic during this time with SBP 60s and lightheadeness while sitting up and an inability to work with PT given his symptoms. Over this period, several doses of metoprolol were held given his hypotension. He has worsened volume overload in this setting with uptrending weight, creatinine. His weight was 94kg and Cr. 3.3 prior to his transfer to the CCU for augmented diuresis. In the CCU, he was restarted on dopamine and lasix gtt and diuresed well with BPs in the 90s-100s/50s-60s. From [5-26] to [6-4], he diuresed an additional 19L. Dopamine was weaned off on [6-3] and the patient was transferred to the floor on [6-4] with a lasix gtt. [6-6] Lasix gtt was dced and pt was started on torsemide 80mg [Hospital1 ]. Torsemide was decreased to 80 mg po qdaily on [2180-6-8] as he was net negative on qdaily dose. His dry weight upon discharge was 182 lbs and BNP was 1117. # RHYTHM: Pt w/ biventricular pacer, v paced at this time. Hx of A-fib on coumadin at therapeutic range. On dig and on metoprolol. His coumadin was held for Cardiac cath on [2180-5-15] (at which point it was 2.2). Given he was CHADS2 of at least 2, ASA 81mg daily was started for AF anti-coag, considering carefully the presence of concomitant GI bleed. He was then briefly heparin gtt- bridged to coumadin with uptitrated dose of coumadin, his INR was 1.7 prior to his transfer to the CCU, and was therapeutic while in the CCU. His INR Was 2.7 on discharge. His goal INR is 2.0-2.5. Counadin was held on [6-8] to decrease INR slightly. [Month (only) 116] consider 1mg alternating wtih 0.5 mg dosing in the future. # Anemia: Likely contributing to symptoms of fatigue. Patient with known hx of angioectasia to the mid jejunum. Guaiac positive in the ED. Hct 3 points lower than baseline. Currently taking iron. Last colonoscopy in [2179]. GI was consulted and recommended clarifying cardiac situation prior to any GI studies. They also recommended supportive care with blood transfusions; patient was transfused 1 unit of pRBCs in the CCU with appropriate Hct elevation. GI was reconsulted when the patient returned to the floor and he underwent an enteroscopy on [5-22] which showed "Normal esophagoscopy; Normal stomach. Normal duodenum with bile present. The enteroscope was advanced to 120cm into the jejunum and there was no bleeding identified and not AVM seen." GI signed off at that point and indicated that they did not believe he was having a significant GI bleed and that further workup should be defered to the outpatient setting. His HCT downtrended to nadir of 23.4 on [2180-5-26] without transfusion. He was transfused 1U PRBC on [2180-6-2]. His iron studies were consistent with iron deficiency anemia. He was startd on iron 325 mg po BiD. His hematocrit on [2180-6-8] was 25.9. Our transfusion threshold for him was adjusted to > 22. # Dysphagia: He was noted to have dysphagia to solid food on [2180-6-7]. Speech and swallow study noted obstructive pattern due to large C3 osteophyte. He was encourage to regain his strength and placed on soft liquid diet with protein shakes for nutrition. # Fibrotic Lung changes. Patient without h/o of known restrictive lung disease. CT chest on [5-14] with extensive fibrotic lung changes with a pattern corresponding to NSIP, of overall mild-to-moderate severity. Pulmonary impression was that he had underlying restrictive lung disease and severe pulmonary hypertension, likely significant causative factors for his progressive DOE. # UTI: On [5-29], the patient complained of dysuria. Urine cx grew > 100k E.coli. He completed 7 days of ciprofloxacin 500 mg [Hospital1 ]. # Acute on Chronic Kidney Disease. Per report baseline creatinine 1.6-1.8. In house elevated to 2.7 on admission. FeUrea 27; consistent with pre-renal in setting of intravascular volume depletion vs poor forward flow in setting of heart failure. Creatinine improved in the setting of augmented diuresis. Transitioned to carvedilol to aid in forward flow (which was changed to low dose metoprolol on the floor). His creatinine reached a nadir of 1.9 on [2180-5-22] in the CCU while on pressors and then trended up to 3.3 over the next 4 days as hypotension, orthostasis and inability to further diurese limited his renal perfusion. With augmented diuresis with dopamine, Cr improved to baseline and was 1.8 on discharge. # RESTLESS LEGS SYNDROME: Continued on Mirapex # SLEEP APNEA: Continued on home CPAP machine. # Rehab issues 1. Please check hematocrit, creatinine and electrolytes on [2180-6-11] and [2180-6-14] and twice a week if he stays longer than a week. Please arrange for transfusion if HCT is less than 22. Please call physician on call if creatinine > 2.5, sodium < 130 or potassium > 5.0 2. His dry weight is 182 lbs. Please check weight daily, if his weight is greater than 185 lbs please give him extra dose of torsemide. OUTPATIENT ISSUES: - Pulmonary follow-up needed with PFTs - Consider surgical biopsy which is usually necessary for confirmation of dx of NSIP - Consider capsule endoscopy / EGD / Colonoscopy - Will need daily swallow therapy with speech therapist Medications on Admission: MEDICATIONS (Home): - Furosemide (LASIX) 80 mg Oral take 2 tablets (160mg) twice a day - Potassium Chloride 20 mEq Oral Tablet, ER 2 tablet daily - Metolazone 2.5 mg Oral Tablet - Betamethasone Dipropionate (DIPROSONE) 0.05 % Topical Cream Apply twice daily to legs - Digoxin 125 mcg Oral Tablet TAKE ONE TABLET DAILY EVERY EVENING - Lorazepam 1 mg Oral Tablet TAKE [1-2] TO 1 TABLET AT BEDTIME AS NEEDED FOR INSOMNIA - Ferumoxytol (FERAHEME) 510 mg/17 mL (30 mg/mL) Intravenous Solution feraheme 510mg conc:30mg/ml=17ml=510mg delivered in syringe - Magnesium Oxide 400 mg Oral Tablet TAKE ONE TABLET DAILY EVERY EVENING - Metoprolol Succinate 25 mg Oral Tablet Sustained Release 24 hr - Lorazepam 1 mg Oral Tablet TAKE 1 TABLET AT BEDTIME AS NEEDED - Simvastatin 10 mg Oral Tablet 1 tablet every evening for cholesterol - Allopurinol 300 mg Oral Tablet TAKE ONE TABLET DAILY - Spironolactone 25 mg Oral Tablet take [1-2] tablet DAILY - Ferrous Sulfate 325 mg (65 mg Iron) Oral Tablet 1 tablet qd - Warfarin 1 mg Oral Tablet None Entered - Omeprazole 20 mg Oral CpDR TAKE 2 CAPSULE DAILY - Fluocinolone 0.025 % TOPICAL CREAM 0.025 % Top Crea apply TWICE DAILY to legs as needed - Docusate Sodium Capsule 100MG PO takes one [Hospital1 ] - Mirapex tablet 0.125MG PO (PRAMIPEXOLE DI-HCL) . MEDICATIONS (on transfer): - Metolazone 2.5 mg PO DAILY - Allopurinol 100 mg PO/NG DAILY - Metoprolol Tartrate 12.5 mg PO/NG [Hospital1 ], hold for SBP<100 and HR<60 - Digoxin 0.125 mg PO/NG DAILY - Pantoprazole 40 mg PO Q12H - Docusate Sodium 100 mg PO BID - Fluocinolone Acetonide 0.025% Cream 1 Appl TP [Hospital1 ] - Simvastatin 10 mg - Furosemide 5-20 mg/hr IV DRIP INFUSION - Senna 1 TAB PO/NG [Hospital1 ]:PRN Spironolactone 12.5 mg PO/NG DAILY - Lorazepam 1 mg PO/NG HS:PRN anxiety - Pramipexole NF 0.625 mg Oral QHS Restless leg syndrome - Losartan Potassium 25 mg PO/NG DAILY hold for SBP<100 Discharge Medications: 1. betamethasone dipropionate 0.05 % Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. metoprolol tartrate 25 mg Tablet [Hospital1 ]: 0.25 Tablet PO BID (2 times a day): may crush in applesauce. 3. torsemide 20 mg Tablet [Hospital1 ]: Four (4) Tablet PO DAILY (Daily): can crush in applesauce. 4. spironolactone 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO DAILY (Daily): can crush in applesauce. 5. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [Hospital1 ]: Five (5) cc PO BID (2 times a day). 6. lorazepam 0.5 mg Tablet [Hospital1 ]: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: please give under tongue or crush in applesauce. 7. simvastatin 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily): crush in applesauce. 8. allopurinol 100 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day: please crush in applesauce. 9. Outpatient Lab Work Please check hematocrit, creatinine, INR and electrolytes on [2180-6-11] and [2180-6-14] and twice a week if he stays longer than a week. Please arrange for transfusion if HCT is less than 22. Please call physician or NP on call if creatinine > 2.5, sodium < 130 or potassium > 5.0. INR goal 2.0-2.5. 10. acetaminophen 650 mg/20.3 mL Solution [Month/Day/Year ]: Twenty (20) ml PO Q6H (every 6 hours) as needed for pain. 11. aspirin 81 mg Tablet, Chewable [Month/Day/Year ]: One (1) Tablet, Chewable PO DAILY (Daily): may crush in applesauce. 12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily): do not crush, can dissolve in mouth . 13. pramipexole 0.25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO QHS (once a day (at bedtime)) as needed for Restless leg syndrome: may crush in applesauce. 14. senna 8.8 mg/5 mL Syrup [Last Name (STitle) ]: Five (5) ml PO BID (2 times a day) as needed for constipation. 15. docusate sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Five (5) cc PO BID (2 times a day). 16. 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. 17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: Life Care Center at [Location (un) 2199] Discharge Diagnosis: Primary: acute on chronic congestive heart failure: ACE held because of renal failure. Acute Blood Loss anemia interstitial lung disease Acute on Chronic Kidney disease Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had an acute exacerbation of your congestive heart failure and needed to be admitted to the CCU twice for intravenous diuretics and medicines to help your heart pump better. Your discharge and "dry" weight is 182 pounds. This is your ideal weight and you will need to increase or decrease the torsemide to stay at this weight. Weigh yourself every morning before breakfast, call [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 107826] NP if weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. You also continued to have bleeding from the malformations in your intestinal tract. You will need to have blood transfusions on a regular basis and continue to take iron supplements to keep your blood count more than a hematocrit of 22. Your blood count this morning is 26. Your kidneys worsened with the diuresis temporarily but have now recovered. You have a bony deformity on your spine that is impinging on your throat and causing trouble with swallowing. We think that weakness is making this worse and hope that it will improve with swallowing therapy and general physical therapy. In the meantime, we will give you only shakes to drink and liquid or crushed medicines. We made the following changes to your medicines: 1. Discontinue furosemide, metolazone, digoxin and magnesium 2. Change metoprolol to tartrate formulation so the medicine can be crushed. 3. Start torsemide 80 mg daily to prevent fluid accumulation. This will need to be titrated up or down to maintain a weight of 182 pounds 4. Decrease allopurinol to 100 mg daily 5. Increase iron to twice daily 6. change omeprazole to lansoprazole so that it can be given in liquid form Followup Instructions: Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 107827], MD Specialty: Cardiology Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2258] We are working on a follow up appointment with Dr. [Last Name (STitle) ] within the next week. You will be called with the appointment. Since you are going to an Extended Care Facility they will call your home number to speak to your spouse but they also have the phone number of your daughter. If you have not heard within 2 business days or have questions, please call the number above. ICD9 Codes: 5789, 5990, 5849, 2851, 4168, 4280, 5859, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2247 }	Medical Text: Admission Date: [2163-10-8] Discharge Date: [2163-10-25] Service: [Hospital1 ] HISTORY OF PRESENT ILLNESS: This is an 89-year-old male with history of hypertension, diabetes mellitus, end stage renal disease on hemodialysis who presented to an outside hospital with hypoglycemia. Apparently, on the morning of presentation he had a reported glucose of 10, though did not have the typical symptoms of hypoglycemia such as diaphoresis. Family members reported decreased p.o. at that time. He went to the dialysis as scheduled, however post dialysis he had six episodes of emesis, non-bloody containing food material. His fingersticks at this point had improved, however his blood pressure was found to be low with a systolic between 90 and 100 with his baseline being about 150 to 160. His fingerstick at that point was in the 700s. He therefore received 10 units of regular insulin three times and then started on insulin drip. At that point, he also had an anion gap of 24 and was believed in DKA. His EKG showed new ST depressions in leads V3 through V6. He was therefore heparinized and started on aspirin. The patient, himself, denied any chest pain, shortness of breath, diaphoresis, fevers, abdominal pain, polydipsia. He makes minimal urine at baseline. He was transferred to the [Hospital1 1444] Medical Intensive Care Unit because lack of ICU beds at the outside hospital. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. End stage renal disease on dialysis. 3. Hypertension. 4. Polycythemia [Doctor First Name ]. 5. Nephrolithiasis. 6. Status post transurethral resection of prostate. MEDICATIONS UPON TRANSFER: 1. Adalat 60 b.i.d. 2. Phos-Lo two tabs b.i.d. 3. Nephrocaps one q. day. 4. Aspirin 81 p.o. q.d. 5. Colace 100 b.i.d. 6. Tylenol #3 as needed. 7. Insulin 75/25 30 units in the morning and 10 units in the evening. SOCIAL HISTORY: He is widowed. Functioning relatively independently. He is a pastor at a local church and very active socially. PHYSICAL EXAMINATION: Temperature 96.4 F, blood pressure 101/42, heart rate 100, respiratory rate 16, saturating 100% on nonrebreather. In general awake, alert and appropriate in no acute distress. Head, eyes, ears, nose and throat: Pupils equal and reactive to light. Oropharynx clear. Neck: No jugular venous distention. Chest: Clear to auscultation bilaterally. Cardiovascular: Tachycardia, but regular, S1, S2 with no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities reveal no cyanosis, clubbing or edema. Neurological exam: He is grossly nonfocal. LABORATORY DATA ON ADMISSION: Include white count of 20.2, hematocrit 39, platelets 356. Sodium 131, potassium 3.8, chloride 89, bicarbonate 18, BUN 31, creatinine 3.3, glucose 764. His LFTs were unremarkable. He has an albumin of 2.9, positive acetones and INR of 1.2. HOSPITAL COURSE: 1. ENDOCRINE: Upon initial presentation, the patient was believed to be in DKA. This is evident by his anion gap acidosis, ketones in blood and urine as well as extremely elevated glucose. He was started on insulin drip and aggressive hydration which lead to quick resolution of his symptoms. A consultation with the [Last Name (un) ] Service was obtained and the impression was that this most likely is not true DKA. There thoughts were that he probably had hyperglycemia as well as concomitantly occurring metabolic acidosis which could have been out of starvation or other metabolic processes. He had no further episodes of hypoglycemia and only occasional episodes of glucose between 300 and 400. He responded very well to 14 units of Humalog q. two hours until blood pressure was normalized. In the hospital he was left on NPH insulin 20 units in the morning and 8 units at night with very good glucose control, however he did occasionally require encouraging intakes of p.o. as his sugars were several times in the 60s to 80s. 2. CARDIOVASCULAR: During his MICU stay, the patient had an episode of several hypotension with blood pressure about 70/palp. A set of cardiac enzymes at this point revealed a troponin of 50 and the patient was taken for catheterization to the Cardiac Lab. The catheterization there revealed a stenotic lesion in the LDA about 90% which was stented. It also revealed an RCA lesion of 70 to 80% which was nothing to intervene upon on. A following bedside echo following the MI revealed an ejection fraction of about 20%. A consultation with the Heart Failure Service was obtained and their recommendations included continuing beta blocker and ACE inhibitor as started by the patient as well as aspirin and Plavix. The discussion was initiated about the possible options given the RCA lesion. It was felt that at this point, given the patient's overall condition, it would be best not to intervene upon those lesions. There are several options in the future such as doing a stress test to see whether the patient has symptomatic pain from the defects versus purely medical management versus cardiac catheterization in the future if the patient improves symptomatically. We decided to obtain on the day of discharge, another cardiac echocardiogram now that his cardiac function has somewhat stabilized to assess his ejection fraction and to determine the for systemic coagulation if he has a low ejection fraction. 3. GASTROINTESTINAL: Patient remained relatively stable from a gastrointestinal standpoint. He continued to complain of abdominal pain, however those are believed to be due to urinary obstruction which was relieved after straight catheterizing him and finding 1000 cc in his bladder. He had diarrhea during hospital course, but numerous samples were sent for Clostridium difficile and all of those were negative. We obtained several imaging studies of his belly all of which revealed no evidence of obstruction or lesions to explain abdominal pain. It must be noted that abdominal pain waxed and wane together with his mental status. Additionally, consultation was obtained with Speech and Swallowing Service. They performed a video swallow which revealed possible aspiration with some liquids, therefore their recommendation included thick and nectar consistency type diet while awaiting for improvement in his mental status and overall function before advancing to thin liquids. 4. INFECTIOUS DISEASE: On initial presentation, the patient had occasional fevers as well as a white count, however search for infectious source was unrevealing. He received a full seven day course of Ceftriaxone for possible pneumonia during his stay on the regular medical floor. The only evidence of infection was an equivocal urinalysis which revealed some white blood cells and bacteria. The urine culture is negative. He received a short course of Ciprofloxacin for potential urinary tract infection. There was no other source of an infectious process and his fevers resolved. 5. MUSCULOSKELETAL: During his stay on the Medical Floor, the patient was found to have a significant amount of right shoulder pain. An x-ray revealed no signs of fracture or dislocation. The consultation with the Orthopedic Service was obtained and their opinion was that this is most likely a chronic rotator cuff injury. Would of liked to obtain a MRI of his shoulder to further characterize this, but given patient's mental status, this is an unrealistic test at this point. 6. NEURO: Patient's mental status remained somewhat altered following his MICU stay. Apparently he receives very high doses of benzodiazepine, Haldol and other medications effecting his mental status. Also such medications were discontinued on the Medical Floor and he had mild improvement in mental status. A consultation with the .................... Service was obtained and there feeling is that this is most likely medication induced contusion and delirium which will hopefully resolve as time goes by. An EEG was obtained which showed changes consistent with toxic metabolic picture and no evidence of seizures. 7. RENAL: Patient continued to receive hemodialysis while in the hospital. His electrolytes remained well-controlled and there are no acute issues from a renal standpoint. Note, patient makes small amounts of urine, but has somewhat reluctant to void and had required Foley catheter for this purpose. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Diabetes mellitus. 2. Metabolic acidosis, now recovered. 3. Status post acute myocardial infarction. 4. Right shoulder rotator cuff chronic injury. 5. Hypertension. 6. End stage renal disease on hemodialysis. DISCHARGE MEDICATIONS: 1. Insulin 20 units NPH AM, 8 units q.h.s. 2. Insulin sliding scale. 3. Lipitor 10 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. for the next 20 days. 5. Lansoprazole 30 mg p.o. q.d. 6. Nephrocaps one cap p.o. q.d. 7. Aspirin 81 mg p.o. q.d. 8. Lopressor 25 mg p.o. b.i.d. 9. Lisinopril 2.5 mg p.o. q.d. 10. Colace 100 mg p.o. b.i.d. 11. Senna two tabs p.o. q.h.s. 12. Dulcolax 10 mg p.o. p.r. p.r.n. 13. Lactulose 30 mg p.o. q.h.s. p.r.n. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Name8 (MD) 5094] MEDQUIST36 D: [2163-10-25] 13:33 T: [2163-10-25] 14:03 JOB#: [Job Number 24499] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2248 }	Medical Text: Unit No: [Numeric Identifier 69381] Admission Date: [2188-8-25] Discharge Date: [2188-9-4] Date of Birth: [2188-8-25] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 5850] was the 3.115 kg product of a 35 and [4-11] week gestation, born to a 27 year- old, Gravida II, Para 0 now I. Blood type A positive, antibody negative, hepatitis surface antigen negative, Rubella immune, RPR nonreactive, GBS positive. Mother followed at [Name (NI) ] Clinic for diabetes, diagnosed in [2176]. Has a history of mild diabetic retinopathy. Mother admitted to [Hospital1 18] due to preterm rupture of membranes for clear fluid. Given gestational age, mother's labor was induced with Pitocin. Labor progressed well. One hour prior to delivery, fetal tachycardia was noted. Vaginal delivery required low forceps assistance. Report of mild shoulder dystocia. Initially, infant was floppy, dusky, no immediate spontaneous cry and then onset of crying within 30 seconds. On warmer, infant stimulated, continued crying, and received blow-by oxygen. Left arm noted to have decreased spontaneous movements. Perfusion and tone improved. Apgars were 7 and 8. Infant admitted to newborn ICU. PHYSICAL EXAMINATION: Weight 3.115 kg. Length 50 cm. Head circumference 31.5 cm. Large for gestational age. Significant molding with bruising on caput. No evidence of fullness in back of head or along neck. Anterior fontanel soft and flat. Mild bruising of left forehead and left cheek, due to forceps placement. Eyes: No trauma of lids. External exam of eye appears within normal limits. No evidence of trauma. Red reflexes bilaterally. Nose within normal limits. Ears within normal limits. Mild asymmetry and cry with the mouth. Palate within normal limits. Clavicles within normal limits to palpation. Chest clear and equal breath sounds, good air entry. Cardiovascular: Normal heart sounds. No murmur. Regular rhythm. Pulses 2+ to 4 extremities. Abdomen soft, nondistended, nontender, no masses, no hepatosplenomegaly. Genitourinary: Normal preterm female. Anus patent. Extremities with symmetric spontaneous movement. HOSPITAL COURSE BY SYSTEMS: Respiratory: [Known lastname ] was admitted to the Neonatal Intensive Care Unit for management of prematurity. On admission, she had intermittent grunting which resolved within the first few hours of life. She has remained stable in room air throughout her hospital course. She was having occasional desaturations with feeding. Last documented episode (with feeding) was on [2188-9-1]. Cardiovascular: She has been stable throughout her hospital course with no cardiovascular concerns. Fluids, electrolytes and nutrition: Birth weight was 3.115 kg. Discharge weight is 3000 grams. Infant was initially started on 60 cc/kg/day of D-10-W. Enteral feedings were initiated on day of life #1 and infant has been ad lib feeding since that time, taking in adequate amounts, demonstrating good weight gain. Gastrointestinal: Peak bilirubin was on day of life #7, 12.2. She has not required any intervention. Hematology: Hematocrit on admission was 48. She has not required any blood transfusions. Infectious disease: CBC and blood culture were obtained on admission. CBC was benign with a white count of 16.9; platelet count of 143,000. 23 polys, 3 bands. Infant received 48 hours of Ampicillin and Gentamycin at which time they were discontinued due to a negative blood culture. Neuro: Infant has been appropriate for gestational age. Sensory: Hearing screen was performed with automated auditory brain stem responses and the infant passed bilaterally. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Initials (NamePattern4) ] [Last Name (NamePattern4) ], telephone number [Telephone/Fax (1) 47371]. FEEDS AT DISCHARGE: Continue ad lib breast feeding. MEDICATIONS: Not applicable. CAR SEAT POSITION SCREENING: Infant was placed in a car seat for a 90 minute screening and the infant passed. STATE NEWBORN SCREENS: Have been sent per protocol and have been within normal limits. Infant received hepatitis B vaccine on [2188-8-30]. DISCHARGE DIAGNOSES: 1. Prematurity born at 35 and [4-11] week gestation. 2. Transitional respiratory distress. 3. Rule out sepsis with antibiotics. 4. Mild hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2188-9-3] 23:30:08 T: [2188-9-4] 05:15:22 Job#: [Job Number 69382] ICD9 Codes: 7742, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2249 }	Medical Text: Admission Date: [2187-12-26] Discharge Date: [2187-12-31] Date of Birth: [2125-11-20] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2187-12-27] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending, with vein grafts to the obtuse marginal and PDA. History of Present Illness: This is a 62 yo male with PMH signififcant for hypertension and hypercholesterolemia. Patient admits to experiencing chest tightness with left hand numbness and diaphoresis for the first time 4 days prior to admission while carrying a load up a flight of stairs. The chest pain was relieved with ASA after 20 minutes. His chest pain recurred with attempts at shoveling and walking upstairs. Each episode lasted 20-30 minutes. Patient eventually went to [Location (un) ] Hopital ER and ruled in for non-STEMI with a troponin of 0.68. Cardiac catheterization revealed severe three vessel coronary artery disease. He was subsequently transferred to the [Hospital1 18] for surgical revascularization. Past Medical History: Hypertension Dyslipidemia History of Arrhythmia, possible SVT 15 years ago Social History: Quit tobacco 15 years ago. Social ETOH, denies history of abuse. Family History: Denies premature coronary artery disease Physical Exam: Preop Exam Pulse: 58 Resp: 18 O2 sat: 96% BP 124/70 Height: 6 feet Weight: 276 pounds General: WDWN male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None 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 none Pertinent Results: [2187-12-26] WBC-5.7 RBC-4.15* Hgb-12.9* Hct-36.4* RDW-13.8 Plt Ct-106* [2187-12-26] PT-12.3 PTT-21.6* INR(PT)-1.0 [2187-12-26] Glucose-101* UreaN-14 Creat-0.9 Na-140 K-4.4 Cl-106 HCO3-26 [2187-12-26] ALT-33 AST-25 AlkPhos-76 TotBili-0.9 [2187-12-26] %HbA1c-6.2* eAG-131* . [2187-12-27] Intraop Echocardiogram PRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50%). 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. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is decreased mobility and a severe focal calcification of the non and right cardiac cusps. There is mild to moderate aortic valve stenosis (valve area 1.4cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results in the operating r0oom at the time of the study. POST BYPASS Normal right ventricular systolic function. Left ventricular systolic function improved - EF now 55-60%. Valvular function unchanged from pre-bypass exam. Thoracic aorta intact after decannulation. . [2187-12-29] WBC-6.3 RBC-2.95* Hgb-9.1* Hct-26.1* RDW-13.8 Plt Ct-78* [2187-12-30] WBC-5.0 RBC-2.74* Hgb-8.5* Hct-24.3* RDW-13.5 Plt Ct-71* [2187-12-31] WBC-5.3 RBC-2.84* Hgb-8.6* Hct-25.5* RDW-13.7 Plt Ct-122# [2187-12-29] Glucose-123 UreaN-28* Creat-1.1 Na-140 K-4.3 Cl-106 HCO3-29 [2187-12-30] Glucose-126* UreaN-26* Creat-1.0 Na-142 K-4.1 Cl-105 HCO3-30 [2187-12-31] Glucose-135* UreaN-23* Creat-1.0 Na-137 K-3.8 Cl-104 HCO3-29 . [2186-12-30] Chest x-ray: Stable cardiomegaly. Stable left base atlectesis. No pneumothorax. Minimal plueral effusions. Brief Hospital Course: Mr. [Known lastname ] was admitted and underwent routine preoperative evaluation. He remained pain free on medical therapy. Workup was uneventful and he was cleared for surgery. The following day, Dr. [Last Name (STitle) ] performed coronary artery bypass grafting. Of note, intraoperative echocardiogram was notable for mild to moderate aortic stenosis. For surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Given outside hospitalization, Vancomycin was utilized for perioperative antibiotic coverage. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. All drains and wires were removed without complication. Platelet count dropped as low as 71K. HIT assay was negative, and by discharge his platelet count improved. He remained in a normal sinus rhythm and beta blockade was advanced as tolerated. Over several days, he continued to make clinical improvements and was discharge to home on postoperative day four. At discharge, all surgical wounds were clean, dry and intact. Medications on Admission: Metoprolol 50 twice daily, Simvastatin 80mg daily, Folic Acid, Aspirin 325 daily, Plavix loaded on [2187-12-26] Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:50 Tablet(s) Refills:0 2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:11 5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: take for 7 days then stop..please take with KCL. Disp:7 Tablet(s) Refills:0 7. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 7 days: please take for 7 days then stop....please take with Lasix. Disp:7 Packet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 932] Area VNA Discharge Diagnosis: Coronary artery disease, s/p CABG Hypertension Dyslipidemia Mild to moderate Aortic Stenosis Sleep Apnea Postop Thrombocytopenia, Improved by discharge and HIT negative 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 - healing well, no erythema or drainage 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: Surgeon: Dr. [Last Name (STitle) ] [2188-1-24] 1PM [Telephone/Fax (1) 170] Primary Care: Dr. [Last Name (STitle) 40075] - appt pending at discharge 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:[2187-12-31] ICD9 Codes: 2875, 4241, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2250 }	Medical Text: Admission Date: [2188-11-16] Discharge Date: [2189-1-12] Date of Birth: [2121-1-11] Sex: F Service: SURGERY Allergies: Meropenem Attending:[First Name3 (LF) 148] Chief Complaint: abdominal pain, hypotension, sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 67F w/ who initially presented to an OSH in [Month (only) 359] with acute onset of abdominal pain. She was diagnosed with biliary pancreatitis. She was transferred to [Hospital1 18] for an [Hospital1 ] on [10-9], but she could not undergo sphincterotomy because of ampullary and duodenal wall edema. A biliary stent was inserted and she was transferred back to the OSH. Over the following days, the patient developed respiratory distress and renal failure and was intubated and transferred back to [Hospital1 18] for further management. Given ongoing leukocytosis, a C. diff toxin was checked and was positive, and she was started on p.o. metronidazole. She was extubated [10-21]. On [11-4] she had abrupt onset of pain with an increase in her WBC to 43.8. A repeat CT at the time demonstrated worsening areas of pancreatic necrosis and increased mesenteric omental phlegmon, but no evidence of colitis. She had a colonoscopy demonstrating no colitis, and was treated conservatively with meropenem and oral C. diff therapy starting the evening of [11-4]. Micafungin was added on [11-6] thereafter as empiric therapy. She slowly improved, with WBC trending downward to 30-40K. All antibiotics were stopped on [11-12], and she was discharged to rehab off antibiotics on [11-14]. WBC at that time was 30K. She was readmitted with abdominal pain and hypotension (BP 60/40) on [11-16] Past Medical History: obesity, seasonal allergies tonsillectomy, cesarean section, appendectomy Social History: no tobacco, rare EtOH Family History: neg for pancreatic or liver diseases Physical Exam: Patient expired Pertinent Results: imaging: [11-16] CT ABD/PELVIS: 1. Severe, necrotizing pancreatitis with large areas of pancreatic necrosis, in addition to retroperitoneal inflammatory change and multiloculated peritoneal fluid (particualrly pelvic and peri-hepatic) which have increased in volume. 2. Bilateral pleural effusions and basal atelectasis. 3. Calcified cholelithiasis. [11-16] CT-guided drainage of abdominal fluid collection: 8Fr catheter placed w/ drainage of 600cc grey-brown fluid [11-20] ABD U/S: 1. Cholelithiasis. 2. No extra- or intra-hepatic biliary duct dilatation. 3. Small amount of perihepatic free fluid. 4. Small bilateral pleural effusions [11-23] CXR: Large bilateral pleural effusions, increased in the interim. Pulmonary edema + [11-24]: CXR:Consolidation persisting at the left lung base could be atelectasis or pneumonia. On the right is a new large relatively round radiopacity in the suprahilar right lung; bilateral pleural effisuons. [11-27]: Extubated (intubated [11-24] with PEA) [11-27]: Pulled LEFT pigtail catheter. RIGHT pleural effusion - thoracentesis 1.1L. Repeat CXR with improved effusion on RIGHT after thoracentesis 1.1L but reaccumulation on LEFT. [11-29]: CXR: In comparison with the study of [11-28], the right pneumothorax is not definitely appreciated on this limited study that is degraded by patient motion. Continued enlargement of the cardiac silhouette with bilateral pleural effusions and volume loss involving both lower lungs. Monitoring and support devices remain in place. The engorgement of pulmonary vessels is less prominent on the current study. [12-2] RUQ U/S: Complex multiseptated collection centered over L hepatic lobe not present on prior u/s ([10-31]). Sm simple fluid collection ant to the R hepatic lobe. No biliary dilatation. Patent portal vein. Cholelithiasis w/no sign of cholecystitis. [12-3] [Month/Day (4) ]: small stones and slugde in CBD. Replaced stent. [12-3] CT Abd/Pelvis - (wetread): interval decr size of multilobulated a/p fluid collections being drained by two pigtail catherers--residual fluid remains present; new 15x8cm L subdiaprhagmatic fluid collection; overall stable apperarance to extensive fatty pancreatic necrosis, no vessel compromise; L gallstone in gallbladder, lg b/l pleural effusion w/atlectesis. [12-8]: CT Abd/Pelvis: Improved bilateral pleural effusions. Severe necrotizing pancreatitis with minimal residual normal appearing pancreatic tissue. Multiple intra-abdominal fluid collections with three drains in situ. Interval decrease in fluid collections containing drains. Other fluid collections are stable. Large calcified gallstone. Biliary stent in place. No evidence of cholecystitis or biliary tree dilatation. [12-16] CXR: No significant change with redistribution of bilateral pleural effusions. [12-17] CT chest: (wet read) RLL, RML and LLL bronchi are occluded, probably with secretions. bilateral lower lobe collapse, RML collapse. Only the upper lobes are aerated, with focal atelectasis of medial RUL. RUL with nonspecific ground glass opacities, nonspecific (could be infection/aspiration/hemorrhage). Small right pneumothorax. Chest tube in right pleural space. Small bilateral pleural effusions. [2189-1-11] U/S - 1. Abdominal fluid collection measuring up to 10.4 cm and appears to communicate with previously placed abdominal drain. 2. No intrahepatic biliary dilation. CBD measures 8 mm with stent in place. 3. Small amount of perihepatic free fluid. MICRO: [11-26] BAL: GS: budding yeast, GNR, STENOTROPHOMONAS [12-14]: urine - enterococcus (>100,000), sensitive to vancomycin [12-14]: BAL - stenotrophomonas maltophilia, sensitive to bactrim [12-17]: BAL - 3+ PMNs, 4+ GNRs, 2+ GPCs [2188-12-27]: Left pleural fluid - enterococcus+, stenotrophomonas [2189-1-4]: urine - ENTEROBACTER CLOACAE [2189-1-10]: HD line - GNRs Brief Hospital Course: The patient was readmitted with abdominal pain and hypotension (BP 60/40) on [11-16]. WBC ranged 48-72K on the day of admission, and CT scan showed increased, loculated intraabdominal fluid collections and retroperitoneal inflammatory changes. She was admitted to the SICU and started on norepinephrine, and CT-guided drainage of one of her fluid collections was done, yielding 600 cc of cloudy, grey-brown fluid. Pressors were weaned off [11-17] pm. She has been afebrile, but was hypotensive [11-16] to 94.1. On the morning of [11-23], the patient had a witnessed aspiration event and immediately had sustained desaturations to the 60s. She was emergently intubated but developed PEA arrest. She recovered after just one round of epi and was transferred to the TSICU for further management. [11-23]: witnessed aspiration event w/ subsequent resp distress and desat to 60s, PEA arrest. rhythm restored after 1 round of epinephrine. tx'd to TSICU. bedside echo performed. pt initially unresponsive but later awake and appropriate, following commands. renal consult obtained. free water increased per their recs. family updated. hypotensive requiring neo. [11-24]: Diuresis. L CT guided thoracentesis. Bronch. [11-25]: Continued to wean her from the vent; pigtail clamped at 6 pm; CXR at 6 am; free water flushes-100cc q6h [11-26]: Pt. was bronched after L pleural tube clamped. She was put on a SBT, but gas still showed PCO2 > 60, Bicarb 41. In consultation with primary team we DC'd lasix drip and switched to diamox due to concern for contraction alkalosis. [11-27]: Extubated / OOB to chair [11-27]: Removed Left pleural pigtail catheter. Later w/ acute SOB found to have RIGHT pleural effusion on CXR. Thoracentesis for 1.1L with brief hypotension - given 25g Albumin. [11-28]: Persistant and worsening respiratory distress --> thoracentesis 1.1L on RIGHT and reintubated, grade 2 view. post intubation CXR showed b/l pleural effusion; USG chest done- no fluid on the left and minimal fluid on the right; Dophoff advanced to post pyloric position under IR; tube feeds started; Lasix 40 mg IV given; Bed changed. [11-29]: had difficulty diuresing patient and remained alkalotic with elevated bicarb. Diamox was increased to 500 and she was started on a lasix drip once more. After the lasix drip was started, she did start to diurese although overall she remained positive. [11-30]: persistent metabolic alkalosis with respiratory compensation [12-1]: diuresis not successful, but improved hypernatremia, worsening metabolic alkalosis and respiratory acidosis, somewhat increased lethargy, all antibiotics stopped [12-2]: Added spironolactone for hypokalemia and had decreased free water flushes, but then increased them due to worsening hypernatremia back to 400 cc q4h. RUQ U/S showed new loculated fluid collection. [12-3]: [Month/Day (4) ] - small stones and slugde in CBD. Replaced stent by GI. [12-4]: To IR for CT-guided placement L pigtail and hepatic collection drain [12-5]: Trach and R sided CT placed at bedside. Pt. transfused 2 units PRBCs and given albumin for low BPs. [12-8]: CT showed improvement of abdominal fluid collections. [12-9]: R SC CVL placed (removed and cultured L IJ); Bumex gtt increased 0.5->0.75 [12-10]: continued diuresis, transitioned to trach mask, electrolytes normalized [12-12]: placed PICC, d/c'ed R subclavian CVL, Passy-muir valve trial - not phonating, voicing only [12-14]: RIGHT CT to suction (new leukocytosis, worsening CXR); bronched [12-15]: Became hypotensive 80's/40's on the way to IR for G-tube -aborted - pneumosepsis ([12-14] GNRs) vs urosepsis ([12-14] Enterococcus). s/p 1L LR and 2U pRBCs, Vanc/Zosyn, low dose Levo gtt; bedside echo low filling with good contraction [12-15]: Bilious liquid in mouth. ? ileus in setting of sepsis. Abdomen soft. NGT placed and 350ml bilious fluid return initially - 700cc overnight. KUB showed dobhoff no longer post-pyloric. [12-18]: Worsening ARF, CRT 1.6. Rising bilirubin, ASL, ALT stable. Rising INR. [12-19]: transfused 2u pRBC for low Hct [2188-12-30]: R chest tube was placed by IP for worsening effusions on CXR [2188-12-31] - [2189-1-12]: The patient remained on low dose levophed requirement to keep BP elevated. Intermittent CVVH was performed as her kidney function had completely deteriorated. She became more septic as her PNA continued despite several different antibiotic regimens per infectious disease and multiple chest tubes in place. Her liver function began to decrease as the patient became more sick. Her liver enzymes were trending upward, and she became more jaudinced. Due to persistent PNA, patient was unable to be weaned off the ventilator. Her pancreatic collections appeared to improve during this time, and her abdominal drains were putting out decreasing amounts of fluid. Her HD line and central lines were pulled as potential sources of infections and grew out GNRs. Ultimately the patient had enterococcus in her blood, urine, and chest along with stenotrophomas in her chest as well. The patient's nutritional status was maintained via tube feeds, but patient had become very weak and deconditioned. Per renal, the patient would require life-long dialysis for her damaged kidneys. Due to the extent of her multi-organ failure it was felt that patient was unlikely to recover from her current state of health. A family meeting was held on [1-10] and [1-11] to discuss goals of care for the patient. The family ultimately decided to make the patient CMO. On [2189-1-12] all medications were discontinued including pressors. The vent was also stopped, and the patient expired two hours later. Ultimately the patient succumbed to overwhelming sepsis and multi-system failure. Medications on Admission: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 8. insulin regular human 100 unit/mL Cartridge Sig: insulin sliding scale Injection qid. 9. TPN, TPN via PICC Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Death due to sepsis, multi-organ failure Discharge Condition: expired Completed by:[2189-1-12] ICD9 Codes: 2875, 5845, 5856, 5990, 2760, 5119, 2930, 4275, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2251 }	Medical Text: Admission Date: [2113-5-2] Discharge Date: [2113-5-8] Date of Birth: [2045-8-16] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [2113-5-2]: Aortic valve replacement with 27-mm Biocor Epic tissue heart valve Resection of the ascending aortic aneurysm and the ascending aortic repair with 26 mm Gelweave graft under deep hypothermic circulatory arrest History of Present Illness: 67 year old gentleman known to our service with a vague cardiac history which began roughly 15 years ago when he was diagnosed with paroxysmal atrial fibrillation. He was treated with several antiarrythmics but has been most improved as far as his symptoms of palpitations with amiodarone. He was recently switched from flecanide due to his left ventricular hypertrophy and continued palpitations. More recently, he claims he was diagnosed with aortic valve stenosis in [2111-12-20]. An echo at that time showed severe aortic valve stenosis with a dilated aortic root. A repeat echocardiogram this [Month (only) 956] revealed worsening disease however the report of this echocardiogram is unavailable. A cardiac catheterization was performed which revealed normal coronary arteries, severe tricuspid aortic valve stenosis and a markedly dilated aortic root. He presented as same day admission for surgery. Past Medical History: Aortic Stenosis dx 1 year ago per patient Dilated Aortic Root/asc. arch Paroxsymal Atrial Fibrillation - First occurred 15 years ago Hypertension ? Chronic obstructive pulmonary disease Hyperlipidemia Past Surgical History Right knee surgery (Pt unsure but likely arthroscopy) Appenedectomy Social History: Race: Caucasian Last Dental Exam: dental clearance received [2113-3-27] Lives with: Wife in [Name2 (NI) 392], MA Occupation: Retired Tobacco: 1.5ppd x 25 years. Quit [1-24]. ETOH: 2 glasses of wine daily Family History: Mother died of stroke at 49. Father died of AAA at 73. Physical Exam: Pulse: 69 SR Resp: 16 O2 sat: 95% B/P Right: 148/84 Left: 145/86 Height: 75" Weight: 219 General: Well-devloped male in no acute distress Skin: Dry [X] intact [X]. Multiple nevi and actinic keratosis. HEENT: NCAT, PERRL, Sclera anicteric OP benign. Teeth in fair repair. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2, III-IV/VI SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Ventral hernia Extremities: Warm [X], well-perfused [X] No Edema Varicosities: None [X] Some mild chronic venous stasis changes of lower extremities. 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 Transmitted murmur to bilateral carotids. Pertinent Results: [2113-5-7] 10:00AM BLOOD WBC-11.8* RBC-3.66* Hgb-10.7* Hct-32.9* MCV-90 MCH-29.3 MCHC-32.6 RDW-14.9 Plt Ct-325# [2113-5-6] 09:30AM BLOOD WBC-11.8* RBC-3.25* Hgb-9.9* Hct-29.6* MCV-91 MCH-30.5 MCHC-33.6 RDW-15.4 Plt Ct-199 [2113-5-8] 05:15AM BLOOD PT-30.9* INR(PT)-3.1* [2113-5-7] 10:00AM BLOOD PT-28.8* INR(PT)-2.8* [2113-5-6] 04:44PM BLOOD PT-28.3* INR(PT)-2.8* [2113-5-2] 03:54PM BLOOD PT-15.7* PTT-46.4* INR(PT)-1.4* [2113-5-7] 10:00AM BLOOD Glucose-84 UreaN-40* Creat-1.1 Na-144 K-4.2 Cl-101 HCO3-30 AnGap-17 [2113-5-6] 09:30AM BLOOD Glucose-72 UreaN-40* Creat-1.2 Na-139 K-4.0 Cl-98 HCO3-30 AnGap-15 [2113-5-2]: TTE PRE-BYPASS: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. There is a well-seated bioprosthetic valve in the aortic position with good leaflet excursion. There is trace, central transvalvular regurgitation. There was initially a very small paravalvular regurgitant jet eccentrically directed towards the anterior mitral leaflet, but was not viewed in later imaging. There is no residual aortic stenosis. There is a normal appearing ascending aorta tube graft. Biventricular systolic function is preserved and all other findings are consistent with pre-bypass findings. All findings communicated to the surgeon intraoperatively. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [5-2] where the patient underwent an aortic valve replacement with 27-mm Biocor Epic tissue heart valve and resection of the ascending aortic aneurysm and the ascending aortic repair with 26 mm Gelweave graft under deep hypothermic circulatory arrest. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. He was kept in the intensive care unit for pulmonary issues and required aggressive pulmonary toilet. EP service was consulted regarding evaluation and management of atrial fibrillation. They recommended continuing beta blockers and titrating up as tolerated, starting amiodarone at 200mg [Hospital1 ] x 1 week, then 200mg daily and continue warfarin for anticoagulation. He was anticoagulated to goal INR of [12-21] and will be followed by [Hospital ] Medical [Hospital 197] clinic for further dosing instructions for atrial fibrillation. The patient was gently diuresed toward the preoperative weight and pulmonary issues slowly resolved with sats 91-92% on room air at discharge. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. His Lopressor was increased to 50 mg TID on day of discharge as the patient went into an atrial fibrillation prior to discharge with a rate in the 90's. The patient was discharged home with VNA services in good condition with appropriate follow up instructions. Medications on Admission: Amiodarone 200 mg qd Verapamil 240 mg qd HCTZ 25mg daily Lisinopril 10 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks: 1 week then decrease to 200 mg daily and then continue per further instructions Disp:35 Tablet(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 10. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff Inhalation four times a day. Disp:1 1 Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Critical symptomatic aortic stenosis and ascending aortic aneurysm. Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage + LE Edema Bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon Dr [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 83686] in [11-19] weeks Cardiologist Dr. [Last Name (STitle) 83686] in [11-19] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation Goal INR 2.0-3.0 First draw [2113-5-9] Results to [Hospital ] Medical [Hospital 197] Clinic phone [Telephone/Fax (1) 85180] fax [Telephone/Fax (1) 7165] Completed by:[2113-5-8] ICD9 Codes: 4241, 5185, 5180, 496, 2724, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2252 }	Medical Text: Admission Date: [2154-7-1] Discharge Date: [2154-7-12] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: exertional angina/NSTEMI Major Surgical or Invasive Procedure: cabg x3 [2154-7-5] (LIMA to LAD, SVG to OM, SVG to RCA) History of Present Illness: 81 yo male presented to [Hospital3 ] with exertional chest pain and elev. troponin. transferred to [Hospital1 18] for cardiac cath which revealed heavily calcified coronaries, LM 30%, LAD aneurysmal 80%, diag 3 60%, CX 80%, RCA 80%, RPL and AM disease. Referred to Dr. [Last Name (STitle) ] for cabg. Past Medical History: NSTEMI esoph. dilat. 30 years ago asthma TIA elev. chol. ulcerative colitis HTN GERD OA hiatal herniorrhaphy tonsillectomy Social History: owns farm lives with wife no tobacco for 7 years no ETOH use Family History: father with angina age 60 Physical Exam: HR 68 RR 20 BP 135/65 5'[58]" 70.3 kg NAD skin/HEENT unremarkable neck supple, no carotid bruits CTAB RRR no murmur soft, NT, ND extrems warm and well-perfused, no edema bilat. LE varicosities left greater than right neuro grossly intact 2+ fem/radial pulses; NP PT/DPs Pertinent Results: [2154-7-11] 07:10AM BLOOD WBC-11.3* RBC-3.25* Hgb-9.1* Hct-27.8* MCV-86 MCH-28.1 MCHC-32.8 RDW-14.9 Plt Ct-377# [2154-7-11] 07:10AM BLOOD PT-14.0* INR(PT)-1.2* [2154-7-11] 07:10AM BLOOD Plt Ct-377# [2154-7-11] 07:10AM BLOOD Glucose-102 UreaN-15 Creat-0.7 Na-140 K-4.2 Cl-101 HCO3-29 AnGap-14 [2154-7-1] 01:35PM BLOOD ALT-18 AST-24 AlkPhos-75 TotBili-0.5 [2154-7-8] 02:00AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.1 [2154-7-1] 01:35PM BLOOD %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE [2154-7-1] 01:35PM BLOOD Triglyc-114 HDL-49 CHOL/HD-3.2 LDLcalc-87 Brief Hospital Course: Admitted [7-1] to cardiology and underwent cath. Was given large loading dose of plavix on [6-30] with additional dose on [7-1]. Dr. [Last Name (STitle) ] elected to wait several days to let the plavix wear off prior to cabg. Carotid US performed in the interim showed significant left carotid dz. He underwent cabg x3 on [7-5] and was transferred to the CSRU in stable condition on titrated propofol and phenylephrine drips. Extubated successfully that evening and remained on a phenylephrine drip on POD #1 in SR with a BBB. Weaned off neo on POD #2 and chest tubes were removed. He was transferred to the floor to begin increasing his activity level. Beta blockade and gentle diuresis were started. Had rapid AFib that evening and was transfused one unit PRBCs. Amiodarone was started and he converted to SR. Pacing wires removed on POD #4 and he was encouraged to increase his pulm. toilet and ambulation. He developed left forearm phlebitis with a pustule on POD #5 and was started on abx and seen by vascular. It was also noted he had some sacral breakdown(HD #11). Ultrasound of his left arm revealed no fluid collection, he has remained stable hemodynamically, and he is ready to be discharged home today. Medications on Admission: Ventolin MDI protonix lipitor 80 mg daily ASA 325 mg every other day at home, 81 mg daily on transfer lopressor 25 mg [Hospital1 ] flovent 2 puffs [Hospital1 ] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:1 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 3 days: then 400 mg daily for 7 days, then 200 mg daily ongoing. Disp:40 Tablet(s) Refills:1 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:2 MDI Refills:1 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:28 Capsule, Sustained Release(s) Refills:0 11. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 7 days. Disp:28 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1376] Discharge Diagnosis: s/p cabg x3 [2154-7-5] HTN elev. chol L carotid dz. TIA OA MI asthma GERD ulcerative colitis remote esoph. dilatation phlebitis Discharge Condition: good Discharge Instructions: may shower over incisions and pat dry no lotions, creams or powders on any incision may drive if one month if off narcotics no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness or drainage Followup Instructions: follow up with Dr.[Last Name (STitle) 25471] in [1-14] weeks follow up with Dr. [Last Name (STitle) 4469] in [2-15] weeks follow up with Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Completed by:[2154-7-12] ICD9 Codes: 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2253 }	Medical Text: Admission Date: [2163-12-31] Discharge Date: [2164-1-3] Date of Birth: [2110-8-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1145] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Right and left cardiac catheterization with thrombectomy of left circumflex and placement of bare metal stent to left circumflex artery. History of Present Illness: Mr. [Known lastname 70972] is a 53 yo with PMH significant for hyperlipidemia who was in his USOH until 2 evenings ago when he began feeling "washed out" and short of breath; decided to go to bed early and sleep in. He was feeling well the next day until yesterday evening around 7:15 when he was standing in his garage and began feeling SOB and "woozy." This resolved by sitting; then at 8:40 he was sitting in the living room watching TV with friends and began feeling woozy, SOB, with [2167-3-11] substernal chest pressure that was not resolved by laying down on the floor. He also endorsed nausea, vomiting, and cold sweats. His wife called EMS and he was brought to [Hospital6 33] where his CP continued; urelieved by NTG, morphine, or dilaudid. He was also given lovenox. Initial EKG showed NSR with 1-1.5 mm II, III, aVF with loss of ST segment. This was not initially interpreted as an STEMI until this morning at 6am when CE's turned positive and Q waves appeared in the inferior leads; at this point he was started on integrellin; loaded with plavix and transferred to [Hospital1 18] for urgent cath. He was taken to the cath lab at 10am and was found to have total occlusion of proximal LCX; thrombectomy was performed and a BMS was placed with resultant TIMI 3 flow. He was started on a nitro drip in the cath lab for HTN. On transfer to the CCU he is chest-pain free and [Hospital1 ] dyspnea but is complaining of fatigue/nausea. . Upon further questioning Mr [Known lastname 70972] [Last Name (Titles) ] any h/o CP or dyspnea. He routinely walks 1 mi at lunch w/o difficulty. He does smoke [12-6] ppd for 40yrs and has an extensive FH of early MI. He sleeps on 2 pillows but [Month/Day (2) ] orthopnea/PND, LE edema, or any other problems. Past Medical History: Hypercholesterolemia Social History: smokes [12-6] PPD since age 15. drinks 6 beers 1 night/week. no drugs. works as chief probation officer Family History: father died of MI at age 57; grandfather with [Name2 (NI) ] in 50's. Physical Exam: T 99 HR 60 BP 168/81, RR 15, 98% 5L n/c; wt 225lbs Gen: A&O, NAD skin: pink CV: RRR no m/r/g; no carotid bruits; JVD unasssessable Pulm: CTA anteriorly/laterally Abd: S/ND/NT Groin: R groin w/ sheath in place Ext: no edema; 2+ DP pulses Pertinent Results: WBC 16.9, Hct 44, plt 281 CK 3357, trop 10.72 Cr 0.7 . Cath findings CI 2.61 RAP 16 mean PCWP 20 PA 49/19, mean 30 RV 49/7, . LMCA: clean LAD 40% lesion at origin, diffuse dz after D1 with up to 70% stenosis; D1 focal 80% LCX TO prox; BMS placed RCA diffuse dz with 70% mid lesion . Echo: EF 55-60%; no WMA noted; mild LVH Brief Hospital Course: Mr [Known lastname 70972] is a 53 yo who was transferred from [Hospital3 ] with an inferior STEMI. He was taken acutely to the cath lab where he was found to have an acute occlusion of LCX which was intervened with thrombectomy and BMS; also with diffuse CAD involving RCA, LAD, D1. Of note the The LMCA was patent. He was started on a nitro drip in the cath lab for htn and transferred to the CCU. In the CCU he was weaned of the nitro drip and started on captopril and metoprolol which was switched to atenolol 50mg daily for discharge. He was also begun on lipitor 80. Echo showed no wall motion abnormality and a preserved EF of 55-60% with mild LVH. He had no clinical signs of heart failure. He stayed in normal sinus rhythm. He was transferred out to the floor the following day where he met with physical therapy and did well. He was counseled about smoking cessation and he states he plans to quit smoking. Because of his 3 vessel disease he will likely need CABG within the next few months as an outpatient and he will be followed by Dr. [Last Name (STitle) ] here for cardiology. Medications on Admission: none 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). 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:30 Tablet, Sublingual(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: ST segment elevation myocardial infarction with acute occlusion of left circumflex artery and diffuse coronary artery disease but no left main coronary artery disease. . hyperlipidemia. Discharge Condition: Good. Discharge Instructions: Please take all medications as prescribed, please keep all follow-up appointments. Please call your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 36589], your cardiologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], or return to the Emergency room if you experience chest pain, shortness of breath, nausea, vomiting, light-headedness, sweating, abdominal pain, fevers, chills, or any symptoms that concern you. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2164-1-9] at 2:00pm. Please call ([Telephone/Fax (1) 7236] if questions regarding this appointment. ICD9 Codes: 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2254 }	Medical Text: Admission Date: [2116-1-18] Discharge Date: [2116-1-18] Date of Birth: [2116-1-18] Sex: M HISTORY: Baby [Name (NI) ] [Known lastname 13469] is the product of a 33-5/7 week triplet gestation born to a 34 year old Gravida 2, Para now 4 mother. RPR nonreactive, rubella nonimmune, Hepatitis surface antigen negative. GBS unknown. IUI conception for a tri-tri triplet gestation. Estimated date of confinement [2116-3-2]. Spotting until nine weeks gestation. Pressure until 16 weeks gestation. Admitted to the [Hospital3 ] on [2115-11-5], at 22-4/7 weeks sulfate and bed rest. On [11-11], magnesium sulfate changed to nifedipine, changed back to magnesium sulfate on [11-16] until [2116-1-10], when tocolysis was discontinued. Mother also received a 14 day course of ampicillin started on [2115-12-10], for a urinary tract infection. Received a complete course of betamethasone on [11-15] and [11-16]; no further betamethasone given. Biophysical profile on [1-14] was 8 out of 8. Mother developed mild pregnancy-induced hypertension on [2116-1-17], which progressed prompting delivery by cesarean section on the 19th. At delivery, this infant emerged with a spontaneous cry, received blow-by O2, dried, suctioned, stimulated. Apgars were at 8 and 8. Transferred to the Newborn Intensive Care Unit for prematurity. PHYSICAL EXAMINATION: On admission, birth weight 1845, 35th percentile, head circumference of 30.5, 35th percentile; length 43.5, 35th percentile. Non-dysmorphic overall appearance consistent with known gestational age. Grunting, flaring and retracting prior to intubatation. Regular rate and rhythm without murmur. Abdomen benign. Three-vessel cords. Skin pink and well perfused, active and alert with appropriate tone and strength. HISTORY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: In light of respiratory distress including grunting, flaring and retracting, infant was intubated and given exogenous surfactant times one. Was transferred to [Hospital 8503] on SIMV 24/6 with a rate of 20 and 40% O2. 2. Cardiovascular: Stable during hospital course. 3. Fluid and electrolytes: Birth weight was 1845 grams. Started on D10W at 80 cc per kilo per day, NPO 4. Infectious Disease: CBC and blood culture were obtained. Ampicillin and Gentamicin were intitated pending clinical course and lab results . Initial CBC was benign and blood cultures remained negative at 48 hours of age. CONDITION AT DISCHARGE: Guarded. DISCHARGE DISPOSITION: To a Level III [Hospital 10908] due to lack of available beds at [Hospital1 18]. DISCHARGE DIAGNOSES: 1. Premature triple III born at 33-5/7 weeks gestation. 2. Mild respiratory distress syndrome. 3. Rule out sepsis with antibiotics. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 38532], M.D. [MD Number(1) 38533] Dictated By:[Last Name (NamePattern1) 37156] MEDQUIST36 D: [2116-1-31] 11:18 T: [2116-1-31] 11:28 JOB#: [Job Number 11512] ICD9 Codes: 769, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2255 }	Medical Text: Admission Date: [2135-3-8] Discharge Date: [2135-3-12] Date of Birth: [2066-2-16] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Initiation of Milrinone Major Surgical or Invasive Procedure: Right heart catheterization History of Present Illness: 69 yo M history of idiopathic dilated cardiomyopathy with moderately dilated left ventricle (last EF 10%) now with 4+ MR, 3+ TR and resultant pulmonary hypertension, NYHA class III heart failure presenting for milrinone initiation. . Per Dr.[Name (NI) 3536] last clinic note dated [2135-3-7], the patient has had progressive and marked reduction in his functional capacity over the last few months. Over this period of time, the patient has developed pulmonary hypertension. His most recent ECHO in [7-23] demonstrated tricuspid regurgitation pressure gradient of 50 mmHg indicating a pulmonary artery systolic pressure of 60 mmHg to 70 mmHg. Currently, he is unable to walk more than a few yeards or a few stairs without dyspnea. He also complains of orthopnea, paroxysmal nocturnal dyspnea and occasional lightheadedness. His symptoms were thought to be representative of NYHA class III symptoms. . Weight in clinic on [2135-3-7] was 241 pounds, which is not far from what has been considered in the past to be his dry weight. . It was felt that the patient was doing poorly at this time now with orthopnea, paroxysmal nocturnal dyspnea and dyspnea during ordinary activities of daily living. ECHO was performed in clinic showing left ventricle is more dilated and there has been a substantial further reduction of ejection fraction (LVEF 10 %). In addition his mitral regurgitation is markedly increased. Lasix apparently made him lightheaded and it was discontinued recently. . Patient underwent right heart cath before admission. Results: Baseline PCWP 28 Mean PA 57 Mixed Veinous p02 42 CO 3.11 CI 1.4 [Doctor Last Name ] unit [Unit Number ].333 (Transpulmonary gradient/CO 57-28 = 29/3.11 L) Post-Milrinone 0.5 mcg/kg/min (with large amount of ectopy) PCWP 15 Mean PA 34 Mixed Veinous p02 60 CO 4.75 CI 2.15 [Doctor Last Name ] unit [Unit Number ].6 Post-Milrinone 0.375 mcg/kg/min PCWP 14 Mean PA 33 Mixed Veinous p02 60 CO 5.21 CI 2.35 [Doctor Last Name ] unit [Unit Number ].7 # gastric bypass 25 years ago # cholecystectomy # non-ischemic cardiomyopathy, EF 10% # [Company 1543] dual chamber ICD placement for primary prevention of sudden cardiac death in the setting of nonsustained VT and class III heart failure # hypertension # gout # Obstructive sleep apnea Last seen by Dr. [Last Name (STitle) ] on [2135-3-7] for OSA follow-up. He utilizes an Adapt SV machine. His pressure was change to expiratory pressure of 9 and pressure support 3 and 10. # Diabetes # CKD - evaluated by renal, baseline creatinine ~1.2-1.4 # Hyperlipidemia Past Medical History: # gastric bypass 25 years ago # cholecystectomy # non-ischemic cardiomyopathy, EF 10% # [Company 1543] dual chamber ICD placement for primary prevention of sudden cardiac death in the setting of nonsustained VT and class III heart failure # hypertension # gout # Obstructive sleep apnea Last seen by Dr. [Last Name (STitle) ] on [2135-3-7] for OSA follow-up. He utilizes an Adapt SV machine. His pressure was change to expiratory pressure of 9 and pressure support 3 and 10. # Diabetes # CKD - evaluated by renal, baseline creatinine ~1.2-1.4 # Hyperlipidemia Social History: Married and retired police officer. He cares for his 19 and 12 year old grandchildren. He denies tobacco or illicit drug use. History of extensive EtOH use, however he has cut back. Last alcoholic drink 1 month ago. Family History: Grandmother with CAD but no premature CAD in family. Mother with cancer, sister with DM Physical Exam: Admission weight 109 kg VS: 97.6 97 146/87 14 93% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: moist mucus membranes NECK: Supple with flat JVP. CARDIAC: RRR with normal S1/S2, occasional PVCs. No murmurs rubs gallops LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2135-3-9] ECHO Left ventricular cavity size is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %). The right ventricular cavity is mildly dilated with normal free wall contractility. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-13]+) mitral regurgitation is seen. Compared with the prior study (images reviewed) of [2135-3-7], right ventricular function is more vigorous. The severity of mitral and tricuspid regurgitation is reduced. Left ventricular ejection fraction appears slightly improved and cavity size is smaller. [2135-3-7] ECHO The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis (LVEF = 10 %). The estimated cardiac index is depressed (<2.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of at least moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2134-7-21], the left ventricle is more dilated and there has been a substantial further reduction of ejection fraction. Mitral regurgitation is markedly increased. [2135-3-12] 05:42AM BLOOD WBC-3.6* RBC-4.19* Hgb-11.1* Hct-35.7* MCV-85 MCH-26.5* MCHC-31.1 RDW-16.2* Plt Ct-170 [2135-3-12] 05:42AM BLOOD Glucose-141* UreaN-22* Creat-1.5* Na-140 K-3.9 Cl-107 HCO3-24 AnGap-13 [2135-3-9] 03:46AM BLOOD CK-MB-2 cTropnT-<0.01 [2135-3-12] 05:42AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9 Brief Hospital Course: 69 yo M history of idiopathic dilated cardiomyopathy with moderately dilated left ventricle (last EF 10%) now with 4+ MR, 3+ TR and resultant pulmonary hypertension, NYHA class III heart failure presenting for milrinone initiation. Started on milrinone in cath lab with excellent response. . # Milrinone Initiation He has had significantly worsening functional status and LVEF to 10% over the last few months. He underwent right heart cath, showing elevated wedge and PA pressures. He was started on milrinone during right heart catheterization, with impressive response. Wedge and PA pressures both dropped by almost half. Cardiac index doubled. Milrinone was decreased from 0.5mcg/kg/min to 0.375 mcg/kg/min due to ectopy. He was admitted to the CCU to monitor infusion. He continued to have some ectopy and tachycardia. Carvedilol was restarted at an increased dose of 25mg [Hospital1 ] (he was on Coreg 20mg daily at home). This helped to control his heart rate and ectopy. A repeat echo the following day showed increased RV and LV squeeze. The swan catheter was pulled and his milrinone was continued via PICC line. He was transferred to the floor. He had occasional episodes of hypotension to the 70s and 80s intermittently throughout his hospital stay. The carvedilol was switched to metoprolol to avoid the hypotension. He was also felt to be dry, so the torsemide was stopped. His valsartan was also decreased to 120mg daily. He continued to have occasional dizziness, and was advised to avoid standing up too quickly. . # CHF/HTN LVEF of 10% as above. This improved to about 20% with repeat echo. His anti-hypertensives were titrated as above. He was discharged home on metoprolol succ 200mg daily, valsartan 120mg daily, aspirin 81mg, rosuvastatin 40mg daily and eplerenone 25mg daily. He was provided a prescription for torsemide to take if he had weight gain. . # OSA Uses a CPAP machine at home. His O2 sats were monitored in house. . # DM - Continued glipizide 2.5mg daily. . # Gout - continued allopurinol 100mg daily . # BPH - continued finasteride and tamsulosin daily TRANSITIONAL ISSUES - Patient is being discharged off diuretics, with a prescription for PRN torsemide. If at follow-up, he appears volume overloaded, then restart torsemide 10mg daily. Medications on Admission: Allopurinol 100mg tablet daily Calcitriol 0.25 mcg weekly Carvedilol (Coreg CR) 20mg daily Eplerenone 25mg daily Finasteride 5mg daily Folic acid 1mg daily Furosemide 40mg daily Glipizide 5mg [12-13] tablet daily Omeprazole 20mg [Hospital1 ] Rosuvastatin (Crestor) 40mg daily Tamsulosin (Flomax) 0.4mg daily Valsartan (Diovan) 320mg [12-13] tablet daily Aspirin 81mg daily Calcium Carbonate - Vitamin D3 - 600mg (1500mg) - 400 unit Cholecalciferol (Vitamin D3) 1000unit daily Cyanocobalamin (Vitamin B12) 500mcg daily MVI Discharge Medications: 1. milrinone in D5W 200 mcg/mL Piggyback Sig: 0.375 mcg/kg/min Intravenous INFUSION (continuous infusion). Disp:1 bag Refills:10 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a week. 4. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. 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. 6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. valsartan 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:2 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 17. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for weight gain. Disp:30 Tablet(s) Refills:0 18. 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:0 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Acute on Chronic Systolic congestive heart failure Hypotension Acute on Chronic Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had trouble breathing and an echocardiogram showed that your heart function was very poor. You were admitted to start a medicine called milrinone that you will have infused continuously into your IV. Weigh yourself every morning, call Dr. [First Name (STitle) 437] if weight goes up more than 3 pounds in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. START milrinone to help your heart pump better 2. DECREASE valsartan to 120 mg daily 3. STOP taking furosemide, take torsemide if you notice your weight is increasing 4. STOP taking carvedilol, take metoprolol instead to lower your heart rate and help your heart pump better. Followup Instructions: Name: [Last Name (LF) 7726],[First Name3 (LF) 177] A. Address: [Street Address(2) 7727],2ND FL, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 7728] Appointment: Wednesday [2135-3-16] 3:00pm Department: CARDIAC SERVICES When: MONDAY [2135-4-4] at 10:00 AM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: Nutrition Phone: [Telephone/Fax (1) 3681]. A message was left for an outpatient nutritionist to schedule an appt with you in the next few weeks. They should be contacting you at home. Please call the number next week if you do not hear from them. Department: WEST [Hospital 2002] CLINIC When: WEDNESDAY [2135-4-6] 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 ICD9 Codes: 4168, 4254, 5849, 4280, 2749, 5859, 2724, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2256 }	Medical Text: Admission Date: [2146-12-22] Discharge Date: [2146-12-23] Date of Birth: [2070-11-25] Sex: M Service: MEDICINE Allergies: Aleve / Lisinopril Attending:[First Name3 (LF) 8404] Chief Complaint: Lip swelling Major Surgical or Invasive Procedure: None History of Present Illness: 76yoM with h/o HTN, HL recently started on Lisinopril [11-30] who woke up this morning and felt swelling on upper L side of lip. He is unsure exactly when he started taking Lisinopril but states it was in the past several weeks. Thought it was a cold sore, but saw no skin break, got bigger and bigger through the day so presented to ED by noontime. . He never felt SOB, stridor, wheezes, or swelling elsewhere. He's never had this before, but does relate a history of other allergic reactions (documented in OMR, he has seen Allergy) that consist of facial and body erythema, flushing, and pruritis after an exposure to Lovenox; and also to exposure to "red sauces" like spaghetti sauce, and possibly to pork. Of note, pt is also taking Niacin, and this has been noted in most recent Allergy note. . In the ED: 97.6 78 136/89 18 99%RA. He was noted to have good airway, talking in full sentences, no stridor. He got 125 mg IV Solumedrol, 50 IV Benadryl, Pepcid 20 mg IV x1, and 1L NS. No OP swelling was noted, but his upper lip didn't appear to be improving. Admitted to ICU for further observation. . In the [Name (NI) 153], pt is without complaint, ROS is negative for all systems except lip swelling. Past Medical History: 1. HTN 2. HL 3. Seen by Allergy for h/o facial flushing, pruritis with negative allergy testing to date and unclear etiology; however also notes pt is on Niacin Social History: Lives at home with wife, daughter and her husband and [Name2 (NI) 7337]. Is retired from Federal Bank job, but still currently working and is still very active without use of [Last Name (LF) ], [First Name3 (LF) ], etc. No smoking history, drugs, or EtOH. Family History: DM on father's side Physical Exam: 96 140/84 20 97% RA Much younger than stated age, pleasant, good historian, no stridor. EOMI, no scleral icterus Mouth moist, tongue not swollen, crowded OP with difficult to visualize OP, but no apparent edema or swelling noted. Upper lip is grossly edematous and swollen with no broken skin. Not tender. Lower lip is grossly normal. No gross swelling of face or any other area. Neck is supple and normal appearing CTAB no w/c/r/r RRR no m/g Abd soft NT ND BS+ No BLE edema CN 2-12 grossly intact, no focal neuro deficits noted Pertinent Results: [2146-12-22] 01:28PM GLUCOSE-81 UREA N-17 CREAT-1.3* SODIUM-136 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-30 ANION GAP-12 [2146-12-22] 01:28PM estGFR-Using this [2146-12-22] 01:28PM WBC-5.0 RBC-5.16 HGB-15.6 HCT-46.5 MCV-90 MCH-30.3 MCHC-33.6 RDW-13.2 [2146-12-22] 01:28PM NEUTS-40.6* LYMPHS-46.1* MONOS-7.4 EOS-2.1 BASOS-3.8* [2146-12-22] 01:28PM PLT COUNT-208 [2146-12-22] 01:28PM PT-13.0 PTT-27.2 INR(PT)-1.1 Brief Hospital Course: [Hospital Unit Name 153] course 76yoM with HTN, HL, recently started Lisinopril and now with upper lip swelling consistent with angioedema. . 1. Angioedema: Admitted to MICU for monitoring. Satting well on RA, no respiratory distress, no stridor or wheezes, appears comfortable, no swelling other than on upper lip, BP stable. Likely due to recent Lisinopril use, i.e. inhibition of bradykinin degradation pathways, as opposed to mast cell degranulation pathways. Given pts documented history of flushing, pruritis with a variety of other exposures, was monitored for potential hypersensitive phenotype. [Month (only) 116] also be due to the fact he has been taking Niacin while having these flushing/pruritis episodes. He was continued on Prednisone 20 mg daily, Pepcid 20 mg PO bid was delivered on HD#1 but DC'd, and Benadryl was delivered on HD#1 but dc'd. D/C'd Lisinopril. Would recommend pt get Epi pen on d/c given allergy issues. His PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 2903] was notified of patient's admission. Was placed on amlodipine for alternative HTN management. Should continue steroids for a total of 5 day course (day 1 = [2146-12-22]). [Month (only) 116] want to transition to [Last Name (un) ] for BP control as less cross over reaction with comparable benefits to ACE-I. . 2. Chronic renal insufficiency: Cr of 1.3 not far from his apparent baseline of 1.2. S/p 1L NS in the ED. F/u Cr was still 1.3. [Month (only) 116] be due to initation of Lisonorpil. No acute issues regarding management in the ICU. . 3. HTN: DC'd Lisinopril on admission. Continued home meds HCTZ, Spironolactone, and added Amlodipine 5 mg daily for better control in the absence of Lisinopril. . 4. Hyperlipidemia: Home Niacin and Atorvastatin were continued as wel as daily full strength aspirin. . . Access: PIC PPx: Pepcid, subQ Hep Comm: wife is HCP, [Name (NI) ] [Name (NI) ] [Last Name (NamePattern1) 7092]: Full, discussed with pt and ICU consented Medications on Admission: 1. Atorvastatin 10 mg daily 2. HCTZ 25 mg daily 3. Lisinopril 20 mg daily 4. Niacin 500 mg SR q evening 5. Spironolactone 50 mg daily 6. ASA 325 daily (recorded) Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO q6 hr prn as needed for fever, pain. 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 8. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:4 Tablet(s) Refills:0 9. epinephrine (PF) 1 mg/mL Solution Sig: One (1) Injection prn: Use in the event of presumed allergic reaction leading to airway/breathing compromise. Place autoinjector with direct contact on thigh muscle, depress, and follow up with immediate medical attention (call 911 or report to your nearest emergency room). Disp:1 1 pen Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Angioedema . Secondary: Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dr. [Last Name (STitle) ]. [Known lastname ], You were admitted to the hospital due to upper lip swelling. This was thought to be due to recently starting your new medication, lisinopril, which is a type of medication known as an "ACE inhibitor". One of the known side effects of this medication is upper lip swelling. You were admitted to the Instensive Care Unit to monitor your airway for any respiratory compromise, but did not have any. You received doses of Benadryl, prednisone (a steroid to decrease inflammation) as well as another medication called Famotidine which is also a medication to help reduce swelling. After 24 hours, you remained stable without any respiratory distress. We changed your lisinopril to a different blood pressure medication called amlodipine (aka NORVASC). It was felt you can follow up with your PCP regarding this issue and further changes in your anti-hypertensive medications. You should continue to take prednisone for the next 4 days to assure no further swelling of your lips or airway occur. If you experience recurrent/worsening swelling, shortness of breath, or difficulty breathing, please report to the nearest emergency department for further management. It has been a pleasure taking care of you Mr. [Known lastname ]! Followup Instructions: You have an appointment with a colleague of Dr. [Last Name (STitle) 2903], Dr. [Last Name (STitle) 104630]. Please keep this appointment for follow up evaluation of your lip swelling and hypertension. Date: [2146-12-29] 11:30 AM Phone # [State 104631]. 100, [Location (un) ] MA [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 8405] ICD9 Codes: 2724, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2257 }	Medical Text: Admission Date: [2144-12-7] Discharge Date: [2144-12-14] Date of Birth: [2058-12-29] Sex: M Service: OTOLARYNGOLOGY Allergies: Bee Pollens / Lisinopril Attending:[First Name3 (LF) 7729] Chief Complaint: squamous cell carcinoma of tongue Major Surgical or Invasive Procedure: 1. Direct laryngoscopy and biopsy of left lateral tongue 1. tumor and left anterior tonsillar pillar. 2. Left modified radical neck dissection. 3. Hemiglossectomy. History of Present Illness: 85 year old man with T2(possibly T4 if invading into base of tongue musculature) probable N2c (bilateral uptake) squamous cell carcinoma of the left lateral tongue and newly identified mid-esophageal squamous cell carcinoma at least in situ. For left SCC of tongue patient underwent left partial glossectomy, left neck dissection and direct laryngoscopy [2143-12-8] by ENT. . As patient is currently intubated history obtained through OMR. Patient first noticed a painful swollen tongue in [2144-8-5] - progressed to difficulty swallowing accompanied by a 25-pound weight loss over the course of three months. This prompted an evaluation at the [Hospital 882] Hospital where he had a biopsy performed of the left lateral tongue on [2144-9-4] that revealed squamous cell carcinoma in situ extending to the specimen margins. There was no invasive carcinoma identified in the biopsy specimen. PEG tube placed [2144-9-25] in preparation for treatment of tongue cancer. As part of work-up patient had EGD [2144-3-5], [2144-9-25] that demonstrated no abnormalities however EGD [10-21] which revealed a visible abnormality in his mid-esophagus with biopsy consistent with at least in situ squamous cell carcinoma. This EGD was preformed on recent admission [2144-10-19] for weight loss and fatigue felt to be secondary to malignancy and PMR flare was consequently started on course of prednisone. Past Medical History: Squamous cell carcinoma of the left lateral tongue Squamous cell carcinoma of the esophagus Hypertension GERD Polymyalgia rheumatica: Diagnosed about 2.5 years ago for the symptoms of hand swelling/stiffness. Started on steroid 15-20 mg daily and was slowly tapered off over couple years. Pt was on 1mg prednisone until [Month (only) 359] - then recently re-started last [Month (only) ] admission. . Social History: The patient performs his own ADL's. He used to drink about 4oz of alcohol a day and smoke a pipe, but quit both when he was diagnosed with cancer. He began smoking a pipe at the age of 17. . Family History: No family history of oral or GI cancers Physical Exam: On discharge: AVSS GEN: eldery male, NAD HEENT: PERRL, anicteric, dry mucosa, tongue s/p left partial glossectomy. Neck: Left neck wound with steri-strips over incision, c/d/i RESP: CTA b/l with good air movement throughout anteriorly CV: S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, + PEG in use EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters . Pertinent Results: [2144-12-9] 04:16AM BLOOD WBC-11.8* RBC-3.89* Hgb-12.0* Hct-36.3* MCV-93 MCH-30.8 MCHC-33.0 RDW-15.3 Plt Ct-218 [2144-12-9] 04:16AM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-141 K-4.0 Cl-103 HCO3-29 AnGap-13 [2144-12-9] 04:16AM BLOOD Albumin-3.3* Calcium-8.5 Phos-2.4* Mg-2.3 [2144-12-12] 09:45AM OTHER BODY FLUID Triglyc-1475 . CXR: [12-7] FINDINGS: In comparison with the study of [10-19], there has been placement of an endotracheal tube with its tip approximately 7.5 cm above the carina. Hyperexpansion of the lungs persists suggestive of chronic pulmonary disease. However, no acute focal pneumonia, vascular congestion, or pleural effusion. CXR: [12-9] Aside from mild left basal atelectasis lungs are clear. Heart size top normal, increased since [12-7], but no pulmonary vascular congestion or edema. Small left pleural effusion may be present. No pneumothorax. . Micro: URINE CULTURE (Final [2144-12-9]): NO GROWTH. Brief Hospital Course: A/P: 85 yo male PMH oral SCC s/p left partial hemiglossectomy, left neck dissection. The patient was admitted to the ENT Service on [2144-12-7] for treatment. On [2144-12-7], the patient underwent left partial hemiglossectomy, left neck dissection and direct laryngoscopy, which went well without complication (reader referred to the Operative Note for details). The patient remained intubated after the procedure due to concern for postoperative edema, and was kept in the ICU. The patient was hemodynamically stable. He was extubated on POD#1. The patient was hemodynamically stable. He was transferred to the floor on POD#2, where speech and swallow service saw the patient, and he was transitioned to thin liquids on POD#3 and also began supplemental tube feeds. His Foley catheter was D/Ced on POD#4, and he voided without difficulty. His diet was advanced further to pureed solids on POD#4, and his tube feeds were cycled overnight. The patient tolerated these well, however on POD#4 developed cloudy output from his JP drain which was found to contain elevated triglycerides and a chyle leak was suspected. His diet was reduced to clear liquids, and his tube feeding formula changed. By POD#7, his drain output became serosanguinous again, and his drain and staples were removed. The remainder of the [Hospital 228] hospital course was uneventful. Post-operative pain was initially well controlled with IV pain medications, which was converted to oral pain medication when tolerating clear liquids. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. At the time of discharge on [2144-12-14], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a clear liquid diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with services for tube feeding. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: ATENOLOL - 50 mg Tablet - 1Tablet(s) by mouth daily PREDNISONE - 30 mg daily MS CONTIN - 15 mg [Hospital1 ] EPINEPHRINE [EPIPEN] - Dosage uncertain OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day OXYCODONE-ACETAMINOPHEN [ROXICET] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 3. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. morphine 10 mg/5 mL Solution Sig: [4-13] mL PO Q4H (every 4 hours) as needed for pain. Disp:150 mL Refills:0 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: squamous cell carcinoma of the left lateral tongue Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-13] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 1837] as scheduled: Provider: [First Name4 (NamePattern1) 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 41] Date/Time:[2144-12-18*] 10:40 ICD9 Codes: 5185, 4019, 2749, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2258 }	Medical Text: Admission Date: [2162-1-18] Discharge Date: [2162-1-23] Date of Birth: [2083-2-25] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4748] Chief Complaint: ischemic heel ulcer with toe gangrene and rest pain Major Surgical or Invasive Procedure: 1. Right femoral and profunda endarterectomy, and Dacron patch profundoplasty. 2. Exploration of above-the-knee popliteal artery. History of Present Illness: Mr. [Known lastname 47487] is a 78-year-old male, who is status post an aortobifemoral bypass graft and a failed femoral to dorsalis pedis bypass graft performed 6 months ago. The patient now presents with an ischemic heel ulcer as well as toe gangrene with rest pain. A diagnostic arteriogram demonstrated extensive SFA disease with a calcified popliteal artery but yet a patent peroneal and anterior tibial. For that reason, he was admitted to undergo a femoropopliteal bypass. Past Medical History: Stress Test ([2157-1-24] - stress MIBI normal,LVEF 58%.) Echo (Post CABG echo - LVEF 30%) Congestive Heart Failure Dyslipidemia Hypertension Ischemic Heart Disease Hx of Myocardial Infarction Hx of CABG (x1 [3-/2161] at [Hospital3 2358]) Peripheral Vascular/Arterial Disease (s/p aortobifem in [2157]) Pulmonary Chronic Obstructive Pulmonary Disease DM 2 (with retinopathy,neuropathy) hypothyroidism Gastrointestinal Reflux Chronic Renal Insufficiency(Baseline Cr= 1.5) prostate CA s/p seed implantation polycythemia [Doctor First Name ] s/p phlebotomy s/p Aorta bifemoral bypass graft ([2156]) s/p Cholecystectomy s/p left Carotid Endarterectomy([7-16]) Social History: Nonsmoker/No EtOH Family History: Noncontributory Physical Exam: PHYSICAL EXAM: General: no acute distress,Awake,Alert,& Oriented x 3 HEENT: neck supple, PERRLA,EOMI Heart: regular rate and rhythm, without murmurs, rubs, or gallops Lungs: clear to auscultation bilaterally, Abdomen: soft, nontender, nondistended, +bowel sounds Extremities: no clubbing, cyanosis, or edema, capillary refill< 2 seconds,sensation intact to light touch Pulses: fem [Doctor Last Name ] PT DP R palp palp dop dop L palp palp dop dop Pertinent Results: [2162-1-18] 08:20PM GLUCOSE-50* UREA N-27* CREAT-1.6* SODIUM-138 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-31 ANION GAP-13 [2162-1-18] 08:20PM estGFR-Using this [2162-1-18] 08:20PM ALT(SGPT)-17 AST(SGOT)-21 ALK PHOS-138* TOT BILI-0.7 [2162-1-18] 08:20PM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.5 [2162-1-18] 08:20PM %HbA1c-6.7* [2162-1-18] 08:20PM WBC-5.7# RBC-3.10* HGB-11.4* HCT-34.7* MCV-112# MCH-36.9# MCHC-32.9 RDW-16.9* [2162-1-18] 08:20PM TSH-0.39 [2162-1-18] 08:20PM PLT COUNT-606* [2162-1-18] 08:20PM PT-13.5* PTT-27.3 INR(PT)-1.2* [2162-1-19] 6:17:04 Cardiology Report ECG: Sinus rhythm. Left atrial abnormality. Intraventricular conduction delay - may be incomplete left bundle-branch block. Consider left ventricular hypertrophy and possible biventricular hypertrophy. ST-T wave abnormalities with probable prolonged QTc interval, although is difficult to measure - are non-specific but could be due to intraventricular conduction delay, left ventricular hypertrophy, drug/electrolyte,metabolic effect or possible ischemia. Clinical correlation is suggested. Since the previous tracing of [2161-7-22] the rate is slower and ST-T wave changes are less prominent [2162-1-19] 12:39 AMCHEST (PRE-OP PA & LAT) Study Date of:Stable cardiomegaly. Small left pleural effusion. No evidence of pneumonia or CHF. [2162-1-22] ECHOCARDIOGRAM:The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. Left ventricular function is depressed EF 20-25%. Septal a nd inferior walls are hypokinetic.There is no pericardial effusion. Brief Hospital Course: 1.ISCHEMIC HEEL ULCER WITH TOE GANGRENE & REST PAIN [2162-1-18] -Admit to Dr.[Name (NI) 1392] service (Vascular Surgery) -Preop'ed patient for OR (consent,type/screen,) [2162-1-19] - a.m. labs -CXR -EKG -To OR for Right femoral and profunda endarterectomy,and Dacron patch profundoplasty. -Pulmonary Artery(Swanz-Ganzth)Catheter placed -Foley placed -pain control [2162-1-20] -ruled out an MI with 3 sets of cardiac enzymes -advance diet as tolerated -out of bed to a chair [2162-1-21] -Pulmonary Artery(Swanz-Ganzth)Catheter Removed [2162-1-22] -Physical Therapy Consult [2162-1-23] -Discharged home today Medications on Admission: Acetylcysteine (Mucomyst, Mucosil) Albuterol Aerosol ASA (Aspirin) Atorvastatin [Lipitor] Carvedilol [Coreg] Cipro (Ciprofloxacin) Flagyl (Metronidazole) Folic acid (Folvite) Heparin (SC TID) Insulin (Humulin, Novolin, Lente Iletin, Semilente Iletin, Velosulin, Ultralente (70/30 and sliding scale) Lasix (Furosemide) Lisinopril [Prinivil, Zestril] Percocet (Oxycodone/Acetaminophen) (prn) Plavix (Clopidogrel) Protonix Vancocin (Vancomycin) Other (hydroxyurea, montelukast Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO 1X/WEEK ([Doctor First Name ]). 3. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. Disp:28 Tablet(s) Refills:0 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN for 30 days. Disp:60 Capsule(s) Refills:0 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: 1. Right foot gangrene with ischemic rest pain. 2. Urinary retention Discharge Condition: good pain controlled w/ oxycodone d/c'ed with a foley catheter in place Discharge Instructions: Please call your physician or go to the emergency room 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. Please do not get your incisions wet until your follow-up appointment. If there is clear drainage from your incisions, cover with a dry dressing. Please leave staples in until your follow-up appointment. Activity: You may resume activity as tolerated Medications: Resume your home medications. You have been prescribed an antibiotic called Bactrim,please take as directed. You have also been given a pain medication called oxycodone (prescription in OMR). This is a narcotic pain medication,so please use with caution. Please do not drive while taking oxycodone. You will also be given a stool softener, as oxycodone can cause constipation. You are being sent home with a foley catheter in place and leg bag training. Please at the [Hospital 159] Clinic (([Telephone/Fax (1) 10797]) to be evaluated and to have the foley catheter removed. Followup Instructions: Please follow up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391], M.D. in 2 weeks. Please call his office at ([Telephone/Fax (1) 4852] to make an appointment 2. Please call the [Hospital 159] Clinic @([Telephone/Fax (1) 10797] on Monday [1-25] for an appointment to be evaluated and have the foley catheter removed Please follow up with your PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ] [Telephone/Fax (1) 28612] in 1 week. Completed by:[2162-7-30] ICD9 Codes: 2724, 412, 496, 5859, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2259 }	Medical Text: Admission Date: [2198-8-27] Discharge Date: [2198-9-1] Date of Birth: [2164-4-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [2198-8-27] Aortic Valve Replacement utilizing a 29mm CE Perimount Magna Pericardial Valve. Replacement of Ascending Aorta utilizing a 26mm Gelweave Graft. History of Present Illness: Mr. [Known lastname 68695] is a 34 year old male who first presented with chest discomfort and tingling sensation in his left shoulder in [Month (only) 216] [2197]. Then in [2198-8-3], after playing tennis, developed vague chest discomfort associated with dyspepsia and nausea. Echocardiogram revealed a bicuspid aortic valve with moderate to severe aortic insufficiency. His ascending aorta was dilated, measuring 4.5 centimeters. His aortic root measured 2.9 centimeters. LVEF estimated at 55-60%. Subsequent cardiac catheterization confirmed moderate aortic insufficiency and dilated ascending aorta. His coronary arteries were normal and his LVEF was measured at 65%. Based on the above results, he was referred for cardiac surgical intervention. Past Medical History: Biscupid Aortic Valve, Aortic Insufficiency, Dilated Ascending Aorta, History of Seizure Disorder as an infant, ?[Doctor Last Name 13621] Syndrome as a child Social History: Denies tobacco. Admits to only occasional ETOH. He is married and works as a software engineer. Family History: Father underwent CABG at age 61 Physical Exam: Vitals: BP 130/80, HR 84, RR 12 General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, [2-5] diastolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: alert and oriented, nonfocal Pertinent Results: [2198-9-1] 04:55AM BLOOD WBC-5.7 RBC-2.61* Hgb-8.2* Hct-22.9* MCV-88 MCH-31.4 MCHC-35.7* RDW-13.9 Plt Ct-159 [2198-9-1] 04:55AM BLOOD Glucose-112* UreaN-11 Creat-0.8 Na-140 K-4.1 Cl-100 HCO3-32 AnGap-12 RADIOLOGY Final Report CHEST (PRE-OP PA & LAT) [2198-8-30] 4:01 PM CHEST (PRE-OP PA & LAT) Reason: AORTIC INSUFFICIENCY\BENTAL PROCEDURE /SDA [Hospital 93] MEDICAL CONDITION: 34 year old man s/p CABGx3/ASD REASON FOR THIS EXAMINATION: ?pneumonia CHEST, TWO VIEWS, PA AND LATERAL History of CABG and AVR. Status post median sternotomy and AVR. There is slight cardiomegaly. No evidence for CHF. There is a small left pleural effusion with minimal atelectasis at the left lung base. Mediastinal emphysema is present anteriorly in the substernal region, presumed post-surgical. No pneumothorax. DR. [First Name8 (NamePattern2) 4075] [Last Name (NamePattern1) 5999] Cardiology Report ECHO Study Date of [2198-8-27] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for AVR, asc. Aorta repair, Height: (in) 75 Weight (lb): 180 BSA (m2): 2.10 m2 Status: Inpatient Date/Time: [2198-8-27] at 10:27 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW03-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) 412] [Last Name (Prefixes) 413] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) Aorta - Ascending: 4.4 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: 1.9 cm (nl <= 2.5 cm) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Low normal LVEF. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aortic root. Moderately dilated ascending aorta. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic valve leaflets. Systolic doming of aortic valve leaflets. No AS. Moderate (2+) AR. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Normal mitral valve leaflets. No MS. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: PRE-BYPASS: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler, but can not completely rule out a very small PFO. 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 low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is moderately dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are mildly thickened. There is systolic doming of the aortic valve leaflets. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. POST-BYPASS Normal RV systolic function. Low normal LV systolic function. EF 50-55%. A bioprosthesis is located in the aortic position. It is well seated and displays normal leaflet function. There is no aortic stenosis. There are two jets of trace aortic regurgitation. The first is clearly valvular. There is a second jet that emanates from the region of the native right coronary cusp that is directed perpendicularly to the LVOT. The nature of this jet suggests a likely perivalvular source but this can not be confirmed on 2D imaging. This jet decreased somewhat in intensity after protamine administration. Graft material is seen in the ascending aorta. The thoracic aorta is intact post-CPB. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD on [2198-8-27] 14:31. Brief Hospital Course: Mr. [Known lastname 68695] was admitted and underwent replacement of his aortic valve and ascending aorta by Dr. [Last Name (STitle) 1290]. The operation was uneventful and he transferred to the CSRU for invasive monitoring. For further surgical details, please see seperate dictated operative note. He initially experienced postoperative coagulopathy which required fresh frozen plasma and platelets. With blood products, his bleeding quickly improved and no further intervention was required. Within 24 hours, he awoke neurologically intact and was extubated. Beta blockade was initiated on postoperative day one. His CSRU course was otherwise uncomplicated and he transferred to the SDU on postoperative day two. Over several days, beta blockade was advanced as tolerated. He remained in a normal sinus rhythm. He continued to make clinical improvments with diuresis and made steady progress with physical therapy. Given his pericardial tissue valve, he will need to remain on Aspirin therapy. He was medically cleared for discharge to home on postoperative day 5.Prior to discharge, his chest x-ray showed only a small pleural effusions and no evidence of heart failure. Medications on Admission: Lisinopril Pepcid Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:50 Tablet(s) Refills:0 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:50 Tablet(s) Refills:0 4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). Disp:180 Tablet(s) Refills:2 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. 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 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:20 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: Dilated Ascending Aorta, Bicuspid Aortic Valve, Aortic Insufficiency - s/p Aortic Valve Replacement and Replacement of Ascending Aorta, Postoperative Coagulopathy, History of Seizures Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) 1290] in [3-7] weeks - call for appt. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 68568] in [1-5] weeks - call for appt. Local cardiologist, Dr. [Last Name (STitle) 1295] in [1-5] weeks - call for appt. Completed by:[2198-9-1] ICD9 Codes: 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2260 }	Medical Text: Admission Date: [2155-5-9] Discharge Date: [2155-5-16] Date of Birth: [2155-5-9] Sex: M Service: ADMISSION DIAGNOSES: 1. Newborn ex-34-0/7 week male infant. 2. Sepsis screen. DISCHARGE DIAGNOSES: 1. Day of life number eight ex-34-0/7 week male infant. 2. Sepsis ruled out status post 48 hours of antibiotics. 3. Status post hyperbilirubinemia. 4. History of one episode involving oxygen desaturation, resolved. IDENTIFICATION: Baby [Name (NI) ] [Known lastname 47893] is now a day of life number eight ex-34 week male infant who was admitted to [Hospital1 346] Neonatal Intensive Care Unit secondary to prematurity and rule out sepsis. HISTORY: Baby [Name (NI) ] [Known lastname 47893] is now a day of life number eight ex-34-0/7 week male infant who was delivered on [2155-5-9] to a 34-year-old gravida 3, para 0 now 1 mother whose pregnancy was complicated by preterm labor beginning four to five days prior to delivery. She was initially seen at [Hospital1 346] with urinary tract infection symptoms with a negative culture and she was treated with ampicillin. Mother represented to [Hospital1 190] on [2155-5-8] with uterine contractions. She was admitted, started on betamethasone, and given magnesium sulfate. Mother progressed to delivery despite tocolysis and proceeded to delivery by stat cesarean section on the afternoon of [2155-5-9] in the setting of the question of a possible abruption. Cesarean section was performed under general anesthesia. Mother's prenatal screen was remarkable for blood type O+, antibody screen negative, HBsAg negative, RPR nonreactive, rubella immune and GBS unknown. There were no sepsis risk factors outside of the GBS unknown status and preterm labor. Mother was apparently a healthy woman with an uncomplicated pregnancy prior to the above noted history. Baby [Name (NI) ] [Known lastname 47893] was vigorous at the time of delivery. He was given blow-by oxygen and was warmed, dried, suctioned and stimulated. He was brought to the Neonatal Intensive Care Unit after visiting with his father and mother in the Labor and Delivery room secondary to prematurity and rule out sepsis. ADMISSION EXAMINATION: Birth weight 2,330 grams. Head circumference 30.5 cm, 25th-50th percentile. Length 46.5 cm, 50th-75th percentile. HEENT: Normocephalic, atraumatic, anterior fontanel open, flat and soft, normal facies, normal set ears. Neck: Supple. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, normal S1 and S2 without murmurs. Abdomen: Soft and benign. Genitalia: Normal male with testes descended bilaterally. Neurological: Nonfocal and age appropriate. Spine intact. Hips normal. HOSPITAL COURSE: 1. Cardiovascular: Baby [Name (NI) ] [Known lastname 47893] was cardiovascularly stable throughout his admission and had no episodes of hypotension or hypertension or cardiovascular instability with dysrhythmia. He was discharged to home without any concerns regarding his cardiovascular status. 2. Respiratory: Baby [Name (NI) ] [Known lastname 47893] remained on room air throughout his admission and had no episodes of increased work of breathing. On the weekend of [5-10] he was noted to have one episode of oxygen desaturation and thus a spell count was started. He was discharged to home without any subsequent episodes of oxygen desaturation, apnea or bradycardia. 3. Fluids, electrolytes and nutrition: Initially Baby [Name (NI) ] [Known lastname 47893] was placed on intravenous fluids at 80 cc per kg per day. He was started on feeds as well. He had an initial hypoglycemia which was treated with two D10 boluses and his IV fluids were increased to 100 cc per kg per day. There was no history of gestational diabetes in the mother. The infant was started on feeds shortly after being admitted and was taking PE 20. He was p.o. feeding well enough such that by [2155-5-10] his IV was heparin locked and he was placed on p.o. feeds with a minimum. His p.o. feeding volumes increased such that by [2155-5-13] he was at approximately 100 cc per kg per day and then increased such that by the time of his discharge for two days in a row he had 140 to 150 cc per kg per day of p.o. intake. He has had no difficulties with electrolyte instability or with voiding or stooling and he is discharged to home without any concerns regarding fluids, electrolytes and nutrition. 4. Hematologic/infectious disease: Baby [Name (NI) ] [Known lastname 47893] was started on a rule out sepsis pathway secondary to the mother's history of a possible urinary tract infection as well as preterm labor. He was started on ampicillin and gentamicin and blood culture was drawn and a complete blood count was also obtained at the time of admission. His complete blood count was benign. His blood culture remained no growth at 48 hours and his ampicillin and gentamicin were discontinued after 48 hours of therapy. He was noted to be jaundiced and by [2155-5-13] his total bilirubin had reached 10.6 and he was started on phototherapy. His phototherapy was discontinued on [2155-5-14] and his total bilirubin was checked on [5-15] and was found to be 8.1 followed by a total bilirubin on [5-16] of 7.2. He was thus discharged home without any concerns regarding hyperbilirubinemia as well. Of note, Baby [Name (NI) ] [Known lastname 47893] was noted to have a monilial rash on [2155-5-14] and he was started on Nystatin as well as Desitin therapy. By the morning of [2155-5-16] his rash had notably improved and he was to be discharged to home with instructions to continue Nystatin therapy with Nystatin cream 100,000 units per gram until the rash has completely disappeared. 5. Sensory: Baby [Name (NI) ] [Known lastname 47893] has passed audiological screening with automated auditory brainstem responses. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 47894] at [Telephone/Fax (1) 37887] or [Telephone/Fax (1) 45059]. The parents are to follow up with Dr. [Last Name (STitle) 47894] on Tuesday, [2155-5-20]. FEEDINGS AT DISCHARGE: Ad lib Enfamil 20 with iron. DISCHARGE MEDICATIONS: Nystatin cream 100,000 units per gram to diaper rash q.i.d. p.r.n. CAR SEAT POSITION SCREENING: Passed. STATE NEWBORN SCREENING STATUS: Pending. IMMUNIZATIONS RECEIVED: Hepatitis B #1. PROCEDURES PERFORMED: Baby [Name (NI) ] [Known lastname 47893] underwent circumcision by mother's primary care obstetrician on the morning of [2155-5-16] and has passed urine without problem. The circumcision site looks good. There is minimal bleeding and the baby appears to be quite comfortable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Last Name (NamePattern1) 47895] MEDQUIST36 D: [2155-5-16] 12:32 T: [2155-5-16] 14:30 JOB#: [Job Number 47896] ICD9 Codes: 7742, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2261 }	Medical Text: Admission Date: [2112-2-4] Discharge Date: [2112-2-10] Date of Birth: [2033-2-26] Sex: F Service: CV MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old female, with a past medical history significant for metastatic breast carcinoma with stable metastases to the lung, as demonstrated on a CT scan in [11/2111], who presents with a 1-month history of progressive dyspnea on exertion. She also states that she has shortness of breath at rest, and reports mild chest pressure with exertion and at rest. She also reports bilateral lower extremity edema increasing over the last 1 month. For work-up of this, her primary care provider had the patient undergo a cardiac stress test on [2112-2-2] which was negative for reversible perfusion defects. However, the patient did experience atrial fibrillation at that time. She also did have an echocardiogram done on [2112-2-4], which showed a moderate pericardial effusion which had increased slightly since her previous echo. The patient denied any symptoms suggestive of lightheadedness or syncope. She denies fevers and cough. PAST MEDICAL HISTORY: 1. New atrial fibrillation. 2. Pericardial effusion status post echo [2112-2-4], which showed moderate pericardial effusion, no tamponade physiology, ejection fraction of 60%, mild MR, moderate TR. 3. History of metastatic breast cancer, status post CT in [2111-11-23] which showed stable lung metastases, and at that time stable pericardial effusion. 4. Status post Persantine-MIBI [2112-2-2], which showed no reversible perfusion defects. 5. Chronic renal insufficiency, status post nephrectomy. 6. Hypertension. 7. Hypothyroidism. 8. Hypercholesterolemia. 9. Gout. 10.Glaucoma. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Levoxyl. 2. Allopurinol. 3. Amaryl. 4. Arimidex. 5. Avandia. 6. Colace. 7. Iron. 8. Folate. 9. Protonix. 10.Lipitor. 11.Vitamin B12. 12.Norvasc. SOCIAL HISTORY: The patient denies tobacco or alcohol. She lives with her husband in [Name (NI) 86]. She does have a daughter in [Name (NI) 86] who is involved in her care. The patient does have stressors at home, including her husband who has bipolar disease longstanding. VITALS ON ADMISSION: Temperature 97.6, blood pressure 127/56, pulse 70, respiratory rate 22, satting 100% on 2 liters. HEENT: Her extraocular movements were intact. Her oropharynx was clear. NECK: She had JVD to the midneck. CHEST: She had bilateral crackles, left greater than right. CARDIAC EXAM: She was irregularly irregular with a II/VI harsh systolic murmur at the left lower sternal border. ABDOMEN: Benign. EXTREMITIES: 2+ edema. Of note, she had no pulses paradoxus on exam. LABORATORIES ON ADMISSION: White count 4.4, hematocrit 33.7, platelets 198. Her chem-7 was normal. She had a UA which was negative. Chest x-ray showed right heart border was obscured with possible infiltrate. EKG was irregular with poor R wave progression, which was new. HOSPITAL COURSE: The patient was admitted for pericardial drain procedure. She went to the cardiac catheterization laboratory where under fluoro guidance she had a pericardiocentesis and drain placement, and 450 cc of straw-colored fluid was removed. Micro on pericardial fluid was negative. However, cytology was still pending. The patient did have follow-up echocardiogram. Her systolic function was normal with an LV-EF of 55%. Ventricular wall thickness and cavity size were also normal. She still had moderate TR. She also had mild to moderate pulmonary artery systolic hypertension, and she showed only a small pericardial effusion. No tamponade. This echo was performed after her pericardial drain was pulled. A total of approximately 460 cc of pericardial fluid was collected in the drain post her pericardiocentesis for a total of approximately 900 cc of straw-colored fluid removed. Her drain was pulled 24 hours after placement. The patient was sent to the CCU for observation post pericardial drain placement. There, she did have atrial fibrillation. Coumadin therapy was not started secondary to her known metastatic disease. The patient also had a temperature to 101. This was most likely attributable to her right infiltrate which was seen on her admission chest x-ray, and she was started on Levofloxacin for presumed pneumonia. She will complete a 7-day course of Levofloxacin. The patient did not spike any further fevers after that initial temperature of 101. The patient also had increasing oxygen requirement during the end of her hospital stay. It was believed this was secondary to pneumonia, but more importantly signs of congestive heart failure. She had serial x-rays which showed worsening pulmonary congestion. She was treated with IV lasix 20 mg po bid with good urine output. On the day of discharge, her oxygen saturation improved. Initially, the patient was satting 92% on 5 liters. On discharge, she was satting 95% on 2 liters. The CCU team also felt that her hypoxia could be attributable to either obstructive sleep apnea, or hypoxia secondary to obesity, considering that a number of her oxygen desaturations occurred at night. The patient will continue lasix therapy for heart failure. She did have improved exam and oxygen saturation on the day of discharge. She will be continued on lasix 40 [Hospital1 ] at [Hospital ] Rehabilitation. In terms of her breast cancer, the patient was seen by Dr. [Last Name (STitle) ], her primary oncologist. No therapy was initiated for this during her hospital stay. She was continued on her Arimidex which she was on as an outpatient, and she will follow-up with Dr. [Last Name (STitle) ] on [2-16]. The patient was continued on her Vitamin B12 for her anemia, and for her atrial fibrillation no Coumadin was started, again because of her known metastatic disease. However, she was started on Lopressor 37.5 mg po bid. The patient was also depressed during the course of her hospital stay. Social work was involved. The patient did not want to see psychiatry. She was on an SSRI previously as an outpatient; however, she self-discontinued this and was not interested in pharmacologic therapy. Social work provided services, and also helped her in terms of estate planning for the future. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: [Hospital ] Rehabilitation facility. DISCHARGE DIAGNOSES: 1. Pericardial effusion, status post pericardiocentesis and drain placement. 2. Atrial fibrillation. 3. Congestive heart failure. 4. Pneumonia. 5. Metastatic breast cancer. DISCHARGE MEDICATIONS: 1. Allopurinol 100 mg po qd. 2. Arimidex 1 mg po qd as treatment for breast cancer. 3. Colace 100 mg po bid. 4. Ferrous sulfate 325 mg po bid. 5. Levothyroxine 50 mcg po qd. 6. Folic acid 1 mg po qd. 7. Atorvastatin 10 mg po qd. 8. Protonix 40 mg po qd. 9. Vitamin B12 1,000 mcg po qd. 10.Amlodipine 5 mg po qd. 11.Lopressor 37.5 mg po bid. 12.Miconazole powder tid prn. 13.Lasix 40 mg po bid. 14.Senna 1 tablet po bid. 15.Levofloxacin 250 mg po q 24 h, continue through [2112-2-13], then stop for a full 7-day course. 16.Amaryl 1 mg po qd. 17.Avandia 4 mg po qd. FOLLOW-UP: 1. The patient will follow-up with Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] on [2-16] at 2:30. 2. She will also see Dr. [First Name8 (NamePattern2) 5045] [Last Name (NamePattern1) ] on [2-16] at 3:30. 3. The patient will also receive an echocardiogram in 1 month's time to reevaluate for pericardial effusion. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-661 Dictated By:[Last Name (NamePattern1) 11207] MEDQUIST36 D: [2112-2-10] 10:58 T: [2112-2-10] 11:09 JOB#: [Job Number 95445] cc:[Last Name (NamePattern4) 95446] ICD9 Codes: 4280, 486, 2749, 2449, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2262 }	Medical Text: Admission Date: [2193-3-22] Discharge Date: [2193-3-28] Date of Birth: [2193-3-22] Sex: M Service: Neonatology HISTORY: The patient is a 2,470 gram male product of a 34-5/7 week gestation pregnancy born to a 35-year-old gravida 2, para 1, now 2 woman. Estimated date of confinement was [2193-4-28]. Prenatal screens: O+, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, GBS unknown. Pregnancy was notable for mild fetal hydronephrosis. Prior delivery at term, vacuum assisted. That infant was treated in the Neonatal Intensive Care Unit for hypoglycemia and respiratory distress. This pregnancy was uncomplicated until 0100 on [2193-3-21] with premature rupture of membranes, clear fluid, onset of contractions eight hours later. Mother was admitted to [Hospital1 1444] and had Pitocin augmentation of labor, treated with IV antibiotics for 12 hours prior to delivery. There was no maternal fever or other sepsis risk factors. The infant was born by spontaneous vaginal delivery, nuchal cord at delivery, cut prior to delivery of body. The infant emerged with spontaneous cry, dried, bulb suctioned, blow-by O2. Apgar scores were 8 at one minute and 9 at five minutes. The infant was held by parents and then admitted to the Neonatal Intensive Care Unit. In the NICU O2 saturations were 97-100% on room air. There were sternal retractions and tachypnea. There was also an irregular heartbeat by auscultation and by monitoring. Complete blood count and blood culture were obtained. The D stick on admission was 72. PHYSICAL EXAMINATION: Weight 2,470 grams (75th percentile), length 49 cm (90th percentile), head circumference 31.5 cm (60th percentile). HOSPITAL COURSE BY SYSTEMS: 1. Cardiovascular: An EKG was obtained that demonstrated normal sinus rhythm with normal intervals and segments. There was no evidence of irregular heart rate. There was also no further irregular heart rate noted beyond 12 hours of life. Most likely these were PACs that tend to appear perinatally and are benign and resolve spontaneously. 2. Respiratory: The patient remained stable in room air. During his first few days of life the patient did have mild desaturations to the high 80s with feedings. These spontaneously resolved with no further events for the past 48 hours. 3. Fluids, electrolytes and nutrition: The patient was immediately started on p.o. ad lib feedings and did well with these. He continues to p.o. bottle well in addition to breast-feeding. His discharge weight was 2510gms, L 48.25 cm, and HC 32.5 cm. 4. Infectious disease: Initial complete blood count was as follows: White count 14.8 with 33 polys and 1 band, hematocrit 58 and platelet count 207. The patient was observed off antibiotics. The blood culture drawn on admission remained sterile. 5. Hematology: The patient was treated for physiologic hyperbilirubinemia with phototherapy. The peak bilirubin was on day of life four and was 13.6. The phototherapy was discontinued on day of life 5 for a level of 11.4. Rebound bilirubin the following day was 12. 6. Sensory: The patient had hearing screening and passed in both ears bilaterally. Hepatitis B was administered on [2193-3-27]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home. PRIMARY CARE PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [Location (un) 14840], [State 350]. CARE AND RECOMMENDATIONS: 1. Feeds at discharge: p.o. ad lib, E20 and breast milk. 2. Medications: None. 3. Car seat position screening was performed on two different occassions and the infant failed to pass; he desaturated below 90% within a 90 minute period. As a result he was discharge to home in a car seat. 4. State newborn screening status: State screen sent [2193-3-25] with no abnormal results to date. 5. Immunizations received: Hepatitis B vaccine was given [2193-3-23]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks; 2. Born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or with preschool siblings; 3. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. DISCHARGE DIAGNOSES: 1. Prematurity at 34-5/7 weeks. 2. Rule out sepsis off antibiotics. 3. Prenatal diagnosis of mild hydronephrosis which can be followed up by postnatal ultrasound at around two to three weeks of age. 4. Physiologic hyperbilirubinemia, resolved. [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) 44694] MEDQUIST36 D: [2193-3-28] 08:34 T: [2193-3-28] 08:46 JOB#: [Job Number 49310] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2263 }	Medical Text: Admission Date: [2112-11-10] Discharge Date: [2112-12-16] Date of Birth: [2049-3-2] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4358] Chief Complaint: hypoglycemia; seizure Major Surgical or Invasive Procedure: Tunneled dialysis line placement Central venous line placement and removal Peripherally-inserted central catheter placement History of Present Illness: Mr. [Known lastname ] is a 63 year-old man with a PMH notable for ESRD on HD (MWF), chronic aspiration, seizure disorder, history of CVA with residual left-sided weakness and dysarthria, who presented to the ED s/p seizure. Patient denies having seizure activity though brought in after [2-25] witnessed seizures at his day program. Unclear what day nurses saw at the rehab or if he fell. Patient denies headache, blurry vision, numbness, tingling, weakness of his extremities. He is a poor historian as he does not speak much at baseline. Patient states he's been taking his Keppra as prescribed. . In the ED, initial VS: 97.5 58 131/78 18 100%. Exam notable for left sided deficits, speech slow and minimal (reported baseline). EKG: NSR at 58, LAD, TWI II, [Month/Day (3) 1105], AVF, V4-V6, c/w prior. Lytes showed K 5.4, Cr 8.4, lactate 0.9. CBC with WBC 3.0 (mildly decreased from baseline), Hct 38 (up from baseline mid 30s) plts 104 (at baseline). A left central line was placed for access. In the ED, line was placed given BG dropped to 35, given 1 amp dextrose, and BG improved to 130. Per ED d/w daughter, pt has no h/o diabetes and has multiple episodes of hypoglycemia in the past that has reportedly been worked up by endocrinology without known etiology. CXR showed no acute process, and CT head without acute process. Per Epilepsy attending, recommended change Keppra to 1500mg [Hospital1 ] abd 500mg after HD, and recommended sending a Keppra level. Blood cultures were sent x1, no urine sent as pt does not make urine. VS prior to transfer 97.9, 59, 118/61, 16, 96%r/a. . On the floors, pt triggered for hypoglycemia with FS 47. Please see trigger note for further details. Pt denies lightheadedness, nausea, vomiting, diaphoresis. He denies having a seizure today and cannot recall and falls or shaking episodes. He says that he has been feeling well. He is unsure of the last time he ate, but knows he did not have dinner. He says his daughter helps him eat at home. . Attempted to call daughter, but no answer initially. Eventually able to contact her, and reportedly had seizure today per daycare, [Last Name (un) 35689] House in Endleson Day care. Unsure if they checked his BG there. On no hypoglycemics. She recalls that all his food is pureed given his dysphagia. . Pt had a recent admission from [Date range (3) 63593] for possible seizure and found to have RLL, discharged on Levofloxacin. . ROS: Per HPI. Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia. Past Medical History: - ESRD on HD (M/W/F at [Location (un) ]) - h/o multiple prior CVAs - per last dc summary ambulates at home, has residual left-sided weakness - Seizure disorder - Chronic hepatitis B - Chronic aspiration with failed speech and swallow eval - family wants him to continue eating despite risks - HTN - CAD - h/o MSSA bacteremia after manipulation of fistula - hospitalization in [12-30] for incarcerated inguinal hernia complicated by ESBL Klebsiella bacteremia and PNA - Hyperlipidemia - GERD - S/p SBO [2109] - Hernia repair - Hypoglycemia Social History: Patient lives in [Location ] with his daughter, [Name2 (NI) ], who is a former [Hospital1 18] employee. He denies any recent use of alcohol, tobacco, illicit drugs, or herbal medications. He has a distant, but considerable smoking history per his daughter. [Name (NI) ] uses the toilet himself, but needs help cleaning himself, and does not cook or manage his finances. He is at HD on MWF and spends TU and [Doctor First Name ] in an adult day program. His daughter does not leave him alone by himself. Family History: Mother died at 45 with hypertension. Father died at 60 of unknown causes. He has eight living siblings, many of whom have hypertension. He has six children who are all healthy. Physical Exam: ADMISSION EXAM VS - Temp 97.8F, BP 140/83, HR 60, R 18, O2-sat 100% RA FS 47 GENERAL - pleasant male, appears comfortable, NAD [Doctor First Name 4459] - NC/AT, left-sided facial droop (old per pt), EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, left IJ with dried blood on gauze LUNGS - no use access mm, fair air movement due to effort, no wheezes or crackles HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - right upper extremity with AVG +thrill, LE's dry without edema, 2+ DP pulses NEURO - awake, oriented to person, states "hospital", "[Month (only) 359] [2112]", answers questions appropriately in few words, CNs II-XII grossly intact with left-sided facial droop, 5/5 strength in UE's, 4+/5 bilaterally in lower extermities, gait not assessed . DISCHARGE EXAM: More [Year (4 digits) 3584], able to eat breakfast and drink milk with supervision. RUE AVG thrombosed and no longer functional. Still minimally conversant. RRR, no m/r/g, CTAB. Line sites: Tunneled dialysis line with some oozing; PICC line with improving oozing as well, due to elevated PTT. Pertinent Results: ADMISSION LABS [2112-11-10] 05:35PM BLOOD WBC-3.0* RBC-3.53* Hgb-12.8* Hct-38.5* MCV-109* MCH-36.2* MCHC-33.3 RDW-14.5 Plt Ct-104* [2112-11-10] 05:35PM BLOOD Neuts-46.4* Lymphs-38.0 Monos-8.9 Eos-6.2* Baso-0.6 [2112-11-10] 05:35PM BLOOD PT-22.6* PTT-38.8* INR(PT)-2.1* [2112-11-9] 08:40AM BLOOD Na-141 K-3.8 Cl-99 [2112-11-10] 05:35PM BLOOD Glucose-130* UreaN-35* Creat-8.4# Na-135 K-5.4 Cl-95* HCO3-30 AnGap-15 [2112-11-11] 06:31AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8 [2112-11-13] 06:09AM BLOOD VitB12-1735* Folate-GREATER TH [2112-11-10] 05:48PM BLOOD Lactate-0.9 . PERTINENT LABS AND STUDIES: . [2112-11-16] 05:21AM BLOOD WBC-5.3 RBC-3.05* Hgb-10.8* Hct-32.5* MCV-106* MCH-35.4* MCHC-33.3 RDW-14.1 Plt Ct-118* [2112-11-18] 04:35AM BLOOD WBC-8.1 RBC-3.37# Hgb-10.9# Hct-29.8* MCV-89# MCH-32.3* MCHC-36.5* RDW-18.5* Plt Ct-110* [2112-12-1] 01:48PM BLOOD WBC-11.5* RBC-2.61* Hgb-8.4* Hct-24.1* MCV-93 MCH-32.2* MCHC-34.8 RDW-15.6* Plt Ct-408 [2112-12-12] 07:35AM BLOOD WBC-6.5 RBC-2.31* Hgb-7.0* Hct-21.1* MCV-92 MCH-30.4 MCHC-33.2 RDW-15.2 Plt Ct-197 [2112-12-14] 05:06AM BLOOD WBC-6.8 RBC-2.16* Hgb-6.6* Hct-19.9* MCV-92 MCH-30.4 MCHC-33.0 RDW-15.4 Plt Ct-184 [2112-12-16] 01:34PM BLOOD WBC-6.8 RBC-2.88* Hgb-8.6* Hct-26.0* MCV-90 MCH-29.8 MCHC-33.2 RDW-16.3* Plt Ct-147* [2112-12-14] 05:06AM BLOOD PT-15.2* PTT-119.9* INR(PT)-1.3* [2112-12-15] 03:40AM BLOOD PT-19.9* PTT-150* INR(PT)-1.8* [2112-12-16] 06:44AM BLOOD PT-13.8* PTT-53.2* INR(PT)-1.2* [2112-11-14] 06:24AM BLOOD Glucose-113* UreaN-56* Creat-10.9# Na-130 K-7.3* Cl-90* HCO3-28 AnGap-19 [2112-11-17] 01:08AM BLOOD Glucose-170* UreaN-23* Creat-6.7# Na-142 K-4.5 Cl-99 HCO3-29 AnGap-19 [2112-11-23] 03:00AM BLOOD Glucose-122 UreaN-52* Creat-8.4# Na-137 K-4.8 Cl-92 HCO3-32 AnGap-18 [2112-12-13] 02:07PM BLOOD Glucose-161* UreaN-29* Creat-7.1# Na-137 K-3.9 Cl-96 HCO3-27 AnGap-18 [2112-12-16] 06:44AM BLOOD Glucose-87 UreaN-38 Creat-8.4# Na-137 K-5.3 Cl-98 HCO3-28 AnGap-16 [2112-11-28] 11:51AM BLOOD ALT-81* AST-62* LD(LDH)-473* AlkPhos-130 TotBili-0.7 [2112-12-1] 04:10AM BLOOD ALT-40 AST-34 AlkPhos-121 TotBili-0.8 [2112-11-16] 05:21AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9 [2112-11-22] 03:10AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.9 [2112-12-3] 05:48AM BLOOD Calcium-9.0 Phos-4.1# Mg-2.2 [2112-12-14] 05:06AM BLOOD Calcium-9.5 Phos-5.4* Mg-1.7 [2112-11-13] 06:09AM BLOOD VitB12-1735* Folate-GREATER TH [2112-11-17] 04:14AM BLOOD Hapto-169 [2112-11-25] 05:19AM BLOOD Cortsol-21.8* [2112-11-12] 02:36PM BLOOD C-PEPTIDE- 3.12 H [2112-11-12] 02:36PM BLOOD SULFONAMIDES-normal [2112-11-12] 02:36PM BLOOD INSULIN, FREE (BIOACTIVE)- normal [2112-11-12] 02:36PM BLOOD INSULIN- normal [2112-11-12] 02:36PM BLOOD BETA-HYDROXYBUTYRATE- high [2112-11-11] 06:31AM BLOOD LEVETIRACETAM (KEPPRA)- 69.8 (normal) MICROBIOLOGY: [2112-12-7] 4:29 pm CATHETER TIP-IV Source: right IJ. FINAL REPORT [2112-12-10] WOUND CULTURE (Final [2112-12-10]): KLEBSIELLA PNEUMONIAE. >15 colonies. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 63594], [2112-12-7]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. <15 colonies. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. 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 _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMIKACIN-------------- =>64 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 16 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S [2112-12-8] 4:50 pm BLOOD CULTURE - same 2 organisms as above All other cultures - negative IMAGING: CT head w/o [2112-11-10]: No acute intracranial process. Stable bilateral encephalomalacia. . CT Neck [2112-11-10] 1. No fracture or subluxation. 2. Apparent degenerative changes at C5-6 with probable endplate Schmorl's nodes which appear similar, although somewhat progressed since the prior MR study. Posterior disc osteophyte complex at C5-6 and disc bulge at C6-7 slightly indent the thecal sac. Anterior disc space widening at C6-7 is chronic. 3. Right thyroid enlargement which slightly indents the trachea. . CXR [2112-11-10]: FINDINGS: AP and lateral upright radiographs of the chest were obtained. There are moderately low lung volumes. The previously seen right lower lung opacity has improved, but not completely resolved and may reflect residual atelectasis or infection. The previously described right paratracheal fullness is stable and is attributable to tortuous vessels as seen on prior CT studies. Trachea is stably narrowed at the level of the thoracic inlet and is attributable to tortuous vessels as noted on CT torso. There is stable cardiomegaly. There is no pleural effusion or pneumothorax. IMPRESSION: Improvement in right lower lung opacity which has not completely resolved and may reflect residual atelectasis or infection. . CXR line placement [2112-11-10]: FINDINGS: There is a newly placed left internal jugular catheter with the tip positioned in the upper SVC. No pneumothorax is present. Bibasilar atelectasis is present. The cardiac silhouette, hilar, and mediastinal contours appear stable. . IMPRESSION: Satisfactory central line position without pneumothorax. Bibasilar atelectasis. . CT-torso ([2112-11-22]): IMPRESSION: 1. Unchanged right perinephric and retroperitoneal hematoma. 2. Small right pleural effusion with consolidated portions of the right middle and lower lobes containing hyperdense material suggesting aspiration as a possible etiology. . CT-head ([2112-11-24]): FINDINGS: There is no evidence of acute intracranial hemorrhage. Again noted are large, bilateral ares of encephalomalacia in the MCA territory is present since [2107], likely due to old infarcts. A small right cerebellar hypodensity is again noted. The ventricles and sulci are enlarged, likely due to a combination of age-related atrophy and prior infarctions. No fractures are identified. Line placements by IR ([2112-12-15]): IMPRESSION: 1. Successful placement of a 4 French single-lumen PICC via the left basilica vein approach, terminating at the cavoatrial junction. The line is ready for use. 2. Successful conversion of a temporary catheter for a tunneled 15.5 French dual-lumen hemodialysis catheter via the left IJ approach, with the tip terminating within the right atrium. The line is ready for use. 3. Left arm venogram demonstrating marked tortuosity at the basillic-axillary junction and a diminutive cephalic vein. All visualized veins are patent Brief Hospital Course: Mr. [Known lastname ] is a 63 year-old man with a PMH notable for ESRD on HD (MWF), chronic aspiration, seizure disorder, history of CVA with residual left-sided weakness and dysarthria, who presented to the ED s/p seizure and hypoglycemia. Course was complicated by RP bleed, s/p IR embolization of R renal artery [2112-11-17], PNA s/p course of Vanc/Zosyn/Tobra, and inability to clear his own secretions with subsequent recurrent mucus plugging and chronic aspiration, leading to episodes of hypoxic respiratory distress. . # Seizures: The patient had a witnessed event in which he had whole-body shaking and was non-responsive. DDx for seizure precipitant includes metabolic etiology such as [2-24] hypoglycemia vs. infection vs. medication non-compliance. Not likely acute intracranial process as no changed on CT head w/o. No reason to believe that the patient has been missing his medications, per family and daycare. He has no complaints, and no s/s of infection (no fever, symptoms, and CXR w/no focal infiltrate), which could also precipitate seizures. Per reviewing [Name (NI) ], pt has been admitted frequently for these seizures every few months. The ED [Name (NI) 653] pt's outpt Neurologist who recommended increasing Keppra dose to 1500mg [Hospital1 ] and continuing 500mg after HD and checking a level. Keppra level was obtained but pending as it is a send out. Oxcarbazepine 150mg [Hospital1 ] continued. Treatment of hypoglycemia as below. . # Hypoglycemia: Pt presented with significant hypoglycemia of unknown etiology. There is no evidence of iatrogenic cause of hypoglycemia. Workup included fasting C-peptide and insulin level, which were non-diagnostic given the venous glucose for the specimen was not less than 50. There was no evidence of adrenal insufficiency. His hypoglycemia resolved after RP bleed for unclear reasons. . # Aspiration: Pt has a documented history of chronic aspiration likely secondary to his CVA, and has been evaluated by speech and swallow multiple times in the past. Pt was found to be at increased risk for aspiration. However, family in the past had insisted on continued feeding, regardless of aspiration risk. In [Month (only) ], speech and swallow commented that "As aspiration risks are similar across consistencies, pt comfort should be deciding factor in diet order". Pt was placed on mechanical soft diet/dysphagia diet on admission, as quality of life was considered to be the number one priority by the family. During this admission, pt was found to have significant worsening aspiration, manifested by copious secretions in airway. He had multiple episodes of desatting both in the MICU and on the regular floor. He collapsed his right lung several times in the setting of mucus plugging. For all these episodes, he responded well with suction and chest PT. After lengthy discussion with family, decision was made to feed the patient despite the aspiration risk. A PEG tube was deferred given successful eating without obvious aspiration. . # Fistula thrombosis/Access: Following his stay in the ICU the patient had a thrombosed fistula. The level of thrombosis was too much for vascular or for IR to open the fistula. He had a temporary line placed that was converted to a tunneled catheter for dialysis and IR was able to place a PICC for further access via venogram. He will be discharged on a heparin drip-to-warfarin bridge for this thrombosis and a catheter-associated thrombus in the right IJ. . # Line infection: The patient had pus noted around his right IJ following his time in the ICU. Cultures subsequently grew resistant Klebsiella and coagulase negative gram positive cocci, along with confirmation from 1 subsequent blood culture. He will be treated for a total of two weeks with vancomycin and cefepime, to be completed on [2112-12-20]. # Retroperitoneal bleed with subsequent anemia: Pt was found to have tachycardia and hypotension on HD#7, with a 9-point HCT drop. He underwent CTA, and was found to have multifocal retroperitoneal bleed in the right kidney. He was admitted to MICU and intubated for airway protection. Pt had a total of 9 units pRBC. Transcatheter embolization of the right kidney was performed and hemodynamic stability was achieved. Subsequently, his hematocrit continued to run low, requiring intermittent transfusions of RBCs at dialysis, with a nadir of 19.9. Nephrology will be assessing whether he should be started on Epogen at dialysis. . # Pneumonia: Pt was found to have pneumonia on MICU day 4, with leukocytosis and fever. The etiology of pneumonia was HCAP vs VAP. He was treated with vanco, zosyn and tobra for a total of 9 days. His WBC and fever resolved s/p antibiotics treatment. . CHRONIC ISSUES: # ESRD on HD: MWF, received dialysis on schedule. Access is now a tunneled line, given AVG thrombosis and he should be continued on sevelamer and nephrocaps. . # Pancytopenia: Pt with macroycytic anemia and thrombocytopenia prior. However, WBC mildly decreased at presentation to 3.0, which is a change from prior. No s/s infection, CXR without focal infiltrate as above. B12 and folate were high. . # CAD/CVA history: ECG unchanged from prior. We initially continued home aspirin, statin, metoprolol, and coumadin, but the RP bleed complicated this regimen. Once embolization was done and hematocrit was deemed stable, multiple thromboses were discovered in right IJ and RUE AVG. Therefore, a heparin drip was started and he was bridged to coumadin. . # Depression: on fluoxetine as listed discharge med but held on discharge as it causes hypoglycemia and it can lower the seizure threshold. . ISSUES OF TRANSITIONS IN CARE: # CODE: FULL - confirmed HCP daughter # CONTACT: patient; [Telephone/Fax (1) 63591] [Name2 (NI) ]/ Daughter's cell: (h) [Telephone/Fax (1) 63580]. Adult Day Care Program is [Last Name (un) 35689] House in [Telephone/Fax (1) 63595] # PENDING STUDIES AT TIME OF DISCHARGE: none # ISSUES TO ADDRESS AT FOLLOW UP: please see page 1 Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD (): M W Fri after HD. 8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO three times a day. 14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Coumadin 3 mg Tablet Sig: Three (3) Tablet PO once a day: Until you get your INR checked. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 4. levetiracetam 500 mg/5 mL Solution Sig: 1500 (1500) mg Intravenous twice a day. 5. LeVETiracetam 500 mg IV MWF Dose after HD 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day: hold if SBP<90, HR<55. 7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) PO once a day as needed for constipation. 8. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 9. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO three times a day. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. heparin (porcine) 1,000 unit/mL Solution Sig: see below Injection PRN (as needed) as needed for line flush: 4000-[Numeric Identifier 2249] UNIT DWELL PRN line flush Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: please titrate to INR, goal [2-25]. 13. heparin (porcine) 1,000 unit/mL Solution Sig: see below Injection PRN (as needed) as needed for dialysis: Heparin Dwell (1000 Units/mL) [2101]-8000 UNIT DWELL PRN dialysis Dwell to catheter volume . 14. lacosamide 200 mg/20 mL Solution Sig: Fifty (50) mg Intravenous [Hospital1 ] (2 times a day). 15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g Intravenous HD PROTOCOL (HD Protochol) for 4 days. 16. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 4 days. 17. heparin (porcine) in NS Intravenous 18. 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: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: primary diagnosis: hypoglycemia, seizure disorder, end stage renal disease secondary diagnosis: hypertension, coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: [Hospital1 ] and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname ], You were admitted for seizure, which was likely in the setting of hypoglycemia. You have often become hypoglycemic in the past and it is unclear why this keeps happening. You were evaluated for this but the results of the studies can be discussed in outpatient follow up. Because you continue to be hypoglycemic, it was felt that you might be best served by placement in a long term care facility. While in the hospital, you received hemodialysis per your normal schedule. You will continue to get hemodialysis as an outpatient while you are in the long term care facility. Please note the following changes to your medications: STOP aspirin, since you will be on coumadin STOP fluoxetine, as it can contribute to hypoglycemia START coumadin, with dosing to be adjusted per your MDs START heparin IV, dosing to be adjusted per your MDs START cefepime and vancomycin to help fight bacteria in your blood Please be sure to follow up with your physicians as below. Followup Instructions: You will be seen by the doctors at the [Name5 (PTitle) ]-term care facility. Dr. [Last Name (STitle) ], your primary care doctor, will see you if you are discharged from this facility. Please feel free to call him with any questions - [Telephone/Fax (1) 250]. You should see your outpatient neurologist to continue managing your anti-seizure medications. Appointment information is below: Department: NEUROLOGY When: [Telephone/Fax (1) ] [2113-1-6] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7025], MD [Telephone/Fax (1) 3294] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage You will continue getting dialysis at your regular location. ICD9 Codes: 5070, 2930, 5856, 2762, 2851, 7907, 2761, 5180, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2264 }	Medical Text: Admission Date: [2100-8-6] Discharge Date: [2100-8-11] Date of Birth: [2100-8-6] Sex: F Service: Neonatology HISTORY: Baby Girl [Known lastname ] ([Name2 (NI) ]) was admitted to the Newborn Intensive Care Unit for management of hypoglycemia. She was born at 36 3/7 weeks weighing 4.85 kilograms. Her mother is a 33 year-old gravida III, para I whose prenatal screens included blood type B positive, antibody negative, group B strep unknown, hepatitis B surface antigen, RPR nonreactive. Had benign antepartum with the exception of insulin dependent diabetes mellitus. Mother was admitted in labor and delivery was by repeat cesarean section under spinal anesthesia. Apgars of 8 and 9 were given at one and five minutes. Baby was noted to have grunting, flaring and retracting in the delivery room and was brought to the Newborn Intensive Care Unit for further evaluation. Initial d- stick was 16. Spent approximately 48 hours in NICU and then transferred to [Location (un) 13248] Newborn Service on postpartum floor. PHYSICAL EXAMINATION: On admission remarkable for a large for gestational age infant born preterm in no acute distress. Color is pink. Head, eyes, ears, nose and throat: Anterior fontanelle open, flat, symmetric sutures, normal facies, intact palate. Chest is clear, equal, minimal work of breathing. Appears comfortable. Cardiovascular: Grade II/VI systolic murmur at the left lower sternal border, no gallop. Intact femoral pulses, normal perfusion. Abdomen is flat and soft, nontender, active bowel sounds without hepatosplenomegaly. Hips were stable. Neurologic: Tone and activity are appropriate for gestational age. HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Baby remained in room air with O2 saturations greater than 99, breathing 40s to 50s. Transitional respiratory distress resolved quickly after birth. Remains comfortable in room air at time of discharge. CARDIOVASCULAR: A murmur on admission, AP 110 to 150, blood pressure 64/36 with a mean of 52. She remained hemodynamically stable; murmur resolved consistent with transitional circulation. IV access was via peripheral IV. FLUID, ELECTROLYTES AND NUTRITION: Total fluids were initiated at 80 ml per kilo per day. Initial D-stick was noted to be 16. Was given a D10 bolus, changed to D12 and 1/2% glucose infusing at 80 per kilo with glucose ranges from 50 to 84. IV fluids were weaned over the course of 24 hours with blood glucose noted to be in the 70s while off IV fluids. In the meanwhile ad lib p.o. feeds were initiated with formula which were well tolerated with documented weight gain prior to discharge. Baby at time of discharge is feeding ad lib p.o., cow milk protein based term formula. Discharge weight 4140 grams (9 lbs 2 oz). HEME/INFECTIOUS DISEASE: CBC and blood culture were checked upon admission due to symptomatic infant. A white blood cell count of 12.1 with 57 polys and 0 bands were noted. Hematocrit 56.8% and 247,000 platelets. Blood culture has remained negative. There were no antibiotics given to the baby and baby remained asymptomatic. Baby developed hyperbilirubinemia with peak bilirubin of 16.4 total and 0.3 direct at 5:30am [8-10], 87 hours of life. Phototherapy was initiated at 7:15 am [8-10] and continued through 10am [8-11] with good response. Last bilirubin level was 13.6/0.3 at 6am [8-11]. Blood type is AB+, Coombs test negative. SENSORY: Hearing screen with brainstem audioevoked response passed prior to discharge on [8-11]. Red reflex noted bilaterally. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home with parents. Site of primary pediatric care is [Hospital ] Pediatrics in [Location (un) 3844], name of pediatrician not available at this time. MEDICATIONS: None. CAR SEAT POSITION SCREENING: Is indicated at under 37 weeks; baby passed on [8-9] prior to discharge. STATE NEWBORN SCREEN: Sent to [Location (un) 511] Regional Newborn Screening Lab [8-10] prior to discharge. HEPATITIS B VACCINE given in R thigh [2100-8-10]. DISCHARGE DIAGNOSES: Prematurity at 36 3/7 weeks. Large for gestational age. Infant of a diabetic mother. Hypoglycemia, resolved. Delayed transition, resolved. Rule out sepsis without antibiotics. Hyperbilirubinemia, status post phototherapy with good response. [First Name11 (Name Pattern1) 6177] [Last Name (NamePattern4) ], [MD Number(1) 61488] Dictated By:[Last Name (NamePattern1) 62776] MEDQUIST36 D: [2100-8-11] 11:03:36 T: [2100-8-11] 12:10:56 Job#: [Job Number 62777] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2265 }	Medical Text: Admission Date: [2183-10-26] Discharge Date: [2183-11-2] Date of Birth: [2183-10-26] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: [Known lastname 2331] [Known lastname 57571] was born at full term to a 43 year old gravida 2, para 0, now 1 woman. The mother's prenatal screens were blood type 0 positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis surface antigen negative and Group B Streptococcus positive. This was an intrauterine insemination pregnancy. Mother had had a previous spontaneous loss with a diagnosis of Trisomy 15. The mother has been taking throughout her pregnancy Celexa 30 mg per day for depression. This was a spontaneous onset of labor, rupture of membranes occurred 15 hours prior to delivery. There were no interpartum sepsis risk factors. The infant was delivered by vacuum-assisted vaginal delivery due to a nonreassuring fetal heart rate. The infant emerged limp, apneic and blue. Apgars were 2 at one minute and 5 at five minutes and 7 at ten minutes. The infant required bag mask ventilation in the Delivery Room. PHYSICAL EXAMINATION: The weight was 3,070 gm. The length was 47 cm, and head circumference was 31.5 cm. The admission physical examination revealed a term appearing infant. Anterior fontanelles were soft and flat, nondysmorphic. Palate intact. Moderate occipital caput, no nasal flaring. Positive bilateral red reflex. Comfortable respirations. Breath sounds were clear and equal. Heart was regular rate and rhythm. Femoral pulses were normal, no murmur. The infant was pale with decreased perfusion. Normal female genitalia. Hyperalert, slightly jittery. Tone initially decreased, and generalized distribution moving all limbs symmetrically. Initially suck, root and gag reflexes intact. Grasp and Moro initially disconjugate, but not full. HOSPITAL COURSE: Respiratory status - The infant was on room air for most of her neonatal course. She received facial CPAP for the first 30 minutes of age and has been on room air since that time. She did have an episode of posturing, and subsequent episode of desaturation that were not obviously accompanied by apnea on day of life No. 2 and 3. Due to her initial perinatal depression and these other events, she had an electroencephalogram on [10-27], to evaluate for seizure activity. The electroencephalogram showed no seizure activity but did reveal episodes of apnea lasting 10 and 20 seconds. The infant had a head computerized tomography scan on [2183-10-31]. Head CT was within normal limits for the brain image, but did reveal a Right-sided parietal linear skull fracture, with no displacement of the skull. Her last episode of desaturation occurred on day of life No. 3. On examination her respirations are comfortable. Lung sounds are clear and equal. Due to the prolonged time for the baby to initiate oral feedings, plus the episode of bradycardia (and apnea noted during resp monitoring during EEG, and the growing concern re: exposure to SSRIs (Medwatch from FDA, [2183-7-24]), the mother was asked to discontinue breastfeeding due to the concerns that the medication might be contributing to the infant's apnea, bradycardia, and poor feeding. Infant began to feed better after switching to formula. There was no further bradycardia or apnea noted on CVR monitoring. We discussed at length with the parents regardiitoring. We discussed our concerns re: cardiovascular instability, abnormal neurological behavior including poor feeding in infants born to mothers taking SSRIs. We acknowledged that, at this time, there is limited information on which to base recommendations regarding breast feeding of babies by mothers on SSRIs. However, in light of increasing neonatal reports, our own observations, and the recent FDA Medwatch report regarding postnatal signs/symptoms of infants with intrauterine exposure to SSRI, we advised the mother to continue her treatment with SSRI, but to not breast feed. We also acknowledged that the perinatal distress may have contributed to the bradycardia, apnea, poor po feeding (although the baby's neurological exam otherwise improved quickly within the first several hours after birth). Cardiovascular status - She did receive one normal saline bolus a the time of admission for poor perfusion. She has remained normotensive throughout her Neonatal Intensive Care Unit stay. Her heart has a regular rate and rhythm and no murmur. Fluids, electrolytes and nutrition status - He weight at discharge is 3005 gm. She has been feeding 20 calorie formula and takes that well with a well coordinated suck and swallow. Gastrointestinal status - She had one bilirubin level drawn on day of life No. 1 and the total was 5.6, direct 0.4. She never required phototherapy. Hematological status - Her admission hematocrit was 33, at that time a Kleihauer-Betke test was done on the mother's blood and no fetal cells were detected. Her hematocrit on [2183-10-28], was 32 with a reticulocyte count of 16 percent. She has received no blood product transfusions during her Neonatal Intensive Care Unit stay. Anemia at birth is attributed to placental pooling of blood during period of perinatal distress. No other identifiable etiology of anemia. Infectious disease status - She was started on Ampicillin and Gentamicin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours when the infant was clinically well and the blood cultures were negative. Neurology status - Neurology findings were as discussed in the respiratory status section. Newborn neurological exam was wnl at the time of discharge. Sensory - Audiology, a hearing screening was performed with automated auditory brain stem responses. The infant referred in one ear, and I will have that test repeated prior to discharge. Psychosocial - Parents have been very involved in the infant's care throughout her Neonatal Intensive Care Unit stay. The infant is discharged in good condition. She is discharged home with her parents. Her primary pediatric care provider will be Dr. [First Name8 (NamePattern2) 698] [Last Name (NamePattern1) ] in [Hospital1 2436], [State 350]. RECOMMENDATIONS AFTER DISCHARGE: Feeding - The infant is discharged eating formula 20 cal/oz on an ad lib schedule. Medications - She is discharged on no medications. Carseat position screening - She passed the carseat position screening test. State newborn screen - Her state newborn screen was sent on [2183-10-29]. Immunizations given - She received her first hepatitis B vaccine on [2183-10-28].. Immunizations recommended - Synagis respiratory syncytial virus prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks; 2. Born between 32 and 35 weeks with two of the following, daycare during respiratory syncytial virus season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or 3. With chronic lung disease. Influenza Immunizations recommended annually in the fall for all infants once they reach six months of age, before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers. DISCHARGE DIAGNOSIS: Term newborn female. Sepsis, ruled out. Status post perinatal depression. Status post apnea of unclear etiology. Anemia. [First Name8 (NamePattern2) 1154] [Last Name (NamePattern1) ], MD [MD Number(2) 56585] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2183-11-2] 06:46:45 T: [2183-11-2] 07:38:04 Job#: [Job Number 57572] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2266 }	Medical Text: Admission Date: [2190-5-14] Discharge Date: [2190-5-19] Date of Birth: [2124-2-12] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3200] Chief Complaint: Trauma: rollover MVC Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 66 year old male who is transferred by med flight from outside hospital for MVC. He was an unrestrained driver in a rollover at 1 PM. Windshield was starred and airbag deployed. At OSH he was initially intoxicated and agitated and refused a trauma evaluation, but eventually was talked into it. He has pelvic fractures, lumbar spine fracture, left supraclavicular hematoma and manubrium fractures. He complains of trouble swallowing and mild trouble breathing and vomited twice in transfer. Timing: Sudden Onset Duration: 6 Hours Context/Circumstances: MVC Associated Signs/Symptoms: chest, pelvis, back injuries Past Medical History: Past Medical History: hyperchol, HTN, reflux Social History: Social History: Positive for Alcohol Family History: NC Physical Exam: PHYSICAL EXAMINATION HR: 83 BP: 158/94 Resp: 11 O(2)Sat: 98% Normal Constitutional: Comfortable HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact Left ear ecchymosis but no blood from canal, no stridor, able to swallow secretions Chest: Clear to auscultation, large soft hematoma over left clavicle that does not extend into the neck Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema, right hand ecchymosis Skin: Warm and dry Neuro: Speech fluent Psych: Normal mentation Heme/[Last Name (un) ]/[Last Name (un) ]: No petechiae Pertinent Results: [2190-5-16] 08:30PM BLOOD WBC-7.6 RBC-2.90* Hgb-10.0* Hct-28.5* MCV-98 MCH-34.4* MCHC-35.1* RDW-14.1 Plt Ct-169 [2190-5-16] 05:00AM BLOOD WBC-7.5 RBC-2.84* Hgb-9.5* Hct-27.3* MCV-96 MCH-33.6* MCHC-34.9 RDW-14.1 Plt Ct-166 [2190-5-15] 12:06PM BLOOD Hct-29.9* [2190-5-14] 11:08PM BLOOD Neuts-93.2* Lymphs-3.9* Monos-2.5 Eos-0.1 Baso-0.3 [2190-5-16] 08:30PM BLOOD Plt Ct-169 [2190-5-16] 05:00AM BLOOD Plt Ct-166 [2190-5-14] 11:08PM BLOOD PT-13.1 PTT-23.8 INR(PT)-1.1 [2190-5-14] 07:40PM BLOOD Plt Ct-257 [2190-5-14] 07:40PM BLOOD Fibrino-267 [2190-5-16] 08:30PM BLOOD Glucose-150* UreaN-8 Creat-0.8 Na-134 K-4.2 Cl-96 HCO3-28 AnGap-14 [2190-5-15] 05:26AM BLOOD Glucose-117* UreaN-8 Creat-0.7 Na-132* K-4.2 Cl-95* HCO3-21* AnGap-20 [2190-5-17] 03:20PM BLOOD CK(CPK)-230 [2190-5-17] 09:20AM BLOOD CK(CPK)-217 [2190-5-17] 03:20PM BLOOD CK-MB-4 cTropnT-0.02* [2190-5-17] 09:20AM BLOOD CK-MB-4 cTropnT-0.02* [2190-5-17] 03:27AM BLOOD CK-MB-5 cTropnT-0.04* [2190-5-16] 08:30PM BLOOD Calcium-9.4 Phos-2.0# Mg-1.8 [2190-5-14] 07:40PM BLOOD ASA-NEG Ethanol-180 Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2190-5-14] 11:48PM BLOOD Lactate-3.0* [2190-5-14]: EKG: Sinus rhythm. T wave abnormalities. No previous tracing available for comparison [2190-5-14]: chest x-ray: Widened mediastinum raises concern for a mediastinal hematoma. Further evaluation with a chest CT is recommended. [2190-5-14]: CT of c-spine: IMPRESSION: 1. Large left neck/supraclavicular hematoma. Please refer to CTA of the chest which includes this region performed concurrently. No acute fractures. 2. Prominent pre-vertebral tissues could represent hematoma tracking medially or be the sequalae of ligamentous injury. An MRI is recommended for further evaluation. [2190-5-14]: cat scan of the abdomen: IMPRESSION: 1. Fracture of the menubrium with adjacent small hematoma. 2. Fractured left superior and inferior pubic rami with associated small hematoma. 3. Large left supraclavicular hematoma with active extravasation. 4. Left fourth and fifth posterior rib fractures. 5. Compression fracture of the superior end plate of the L1 vertebral body without retropulsion. [2190-5-14]: left ankle x-ray: IMPRESSION: No definite fracture or dislocation. [2190-5-16]: chest x-ray: Lung volumes have improved. Mediastinal contours are less abnormal due to the change in chest volume. The prior torso CT showed no mediastinal arterial bleeding and the decrease in caliber suggests that the small volume of mediastinal blood may have been due to venous bleeding or manubrial fracture, has not worsened. Lungs are clear. There is no pneumothorax or pleural effusion. Any rib fractures are non-displaced. [2190-5-17]: L-spine x-ray: Overlying brace partially obscures the L-spine, particularly L1. There is a wedge compression deformity of L1 with marked depression of the superior endplate. there is no spondylolisthesis. The remaining lumbar vertebral body heights are preserved. Moderate distention of multiple loops of small bowel. Brief Hospital Course: 66 year old gentleman involved in a motor-vehicle roll-over admitted to the acute care service. Upon admission, he was made NPO, given intravenous fluids and underwent radiographic imaging. He was reported to have fractures of his chest, pelvis, and back. Because of the extent of his injuries, he was evaluated by plastics, neurosurgery, and orthopedics. Imaging of his cervical spine did demonstrate a large left supra-clavicular hematoma with tracheal deviation. satisfactory oxygenation. For this reason, he was admitted to the Trauma intensive care unit for airway assessment and monitoring. He maintained adequate oxygenation and his airway was not compromised. He was reported to have an L1 compression fracture. His cervical spine was clinically cleared. He was evaluated by neurosurgery and recommendations made for a TLSO brace which he will need to wear for 8 weeks. He was maintained on bedrest with log-roll precautions until the TLSO brace was made available. He also sustained a pelvic hematoma and left rami fracture. His pelvic fractures were reported to be non-operative. During the accident he sustained a left auricular hematoma. It was surgically drained by Plastics and sutures applied. His hospital course has been stable. He did report an increase in sputum production especially noted while lying supine. Nebulizers and expectorants were added to his medical regimen and seems to have decreased the sputum viscosity. He has been evaluated by physical therapy and they have instructed him in applying the TLSO brace and have made recommendations for his discharge. Social service has met with him and his family to provide additional support. His vital sign are stable and he is afebrile. His hematocrit is stable. He is tolerating a regular diet. He has been out of bed with the assistance of physical therapy. He is preparing for discharge to a rehabilitation facility to help him further increase his endurance. He has follow-up appointments with plastics, neurosurgery, orthopedics, and with the acute care service. The patient was cared for by the acute care surgical services. Medications on Admission: [Last Name (un) 1724]: simvastatin, verapamil, prilosec, benicar Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. verapamil 180 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QBEDTIME (). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily (). 10. guaifenesin 600 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO TID (3 times a day). 11. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for secretions. 12. acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs Miscellaneous Q6H (every 6 hours) as needed for secretions. 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily): as needed constipation. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: s/p Motor vehicel crash Injuries: Manubrium fracture Anterior mediastinal hematoma Supraclavicular hematoma Left acetabular fractures Left inferior/superior rami fractures L1 compression fractures Left pinna hematoma Left nondisplaced [3-16] rib fractures Left pelvic hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane) ( TLSO brace when head of bed greater than 30 degrees), and when out of bed. Discharge Instructions: You were admitted to the hospital after you were involved in a motor-vehicle accident. You sustained pelvic fractures, lower back fracture, and a bruise around your left collar bone and rib fractures. You are now preparing for discharge to a rehabilitation facility with the following instructions: Because of the extent of your back injuries you will need to wear the TLSO brace when you are out of bed or if your head of bed is greater than 30 degrees. Please report: increased numbness lower ext. increased weakness lower ext. inability to urinate Additional discharge instructions include: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. You also sustained left [3-16] non-displaced rib fracture. These may also be uncomfortable with breathing and coughing. Please follow these instructions: Your injury caused left [3-16] rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke Followup Instructions: Please follow up with the Acute care service in 2 weeks. You can scheudule your appointment by calling # [Telephone/Fax (1) 600]. Follow-up with Orthopedics, Dr. [Last Name (STitle) ] in 4 weeks. The telephone number is #[Telephone/Fax (1) 1228]. Please let them know that you will need an AP film of your pelvis prior to your visit. You will also need to follow-up with Plastics on [5-21] in clinic. The teleophone number is #[Telephone/Fax (1) 5343]. Please follow up with Neurosurgery in the clinic with Dr. [Last Name (STitle) ] in 8 weeks with a CT scan. Appointment can be arranged by calling [Telephone/Fax (1) 1669]. Completed by:[2190-5-25] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2267 }	Medical Text: Admission Date: [2172-10-14] Discharge Date: [2172-10-19] Service: [Hospital Unit Name 196] IDENTIFICATION/CHIEF COMPLAINT: This is a [Age over 90 ]-year-old male with a history of coronary artery disease, re-do coronary artery bypass grafting and hypertension, who presented to an outside hospital with unstable angina. PAST MEDICAL HISTORY: 1. Coronary artery disease: a) The patient had coronary artery bypass grafting with a saphenous vein graft to the left anterior descending artery, a saphenous vein graft to the first obtuse marginal artery, a saphenous vein graft to the third obtuse marginal artery and a saphenous vein graft to the right coronary artery. b) He had re-do coronary artery bypass grafting in [2170] with a saphenous vein graft to the left anterior descending artery with no bypass grafts to total occlusions of right coronary artery and obtuse marginal artery grafts. c) In [2172-3-5], the patient had a stent of the saphenous vein graft to the left anterior descending artery with a cardiac catheterization showing a left ventricular end diastolic pressure of 17, an ejection fraction of 42% and mid inferior akinesis and anterolateral akinesis/hypokinesis. d) In [2172-6-2], the patient had a percutaneous transluminal coronary angioplasty of a saphenous vein graft to the left anterior descending artery with a left ventricular end diastolic pressure of 19. 2. Hypercholesterolemia. 3. Hypertension. 4. Chronic renal insufficiency with a baseline creatinine of 1.9. 5. Hernia repair. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d. Enalapril 10 mg p.o. b.i.d. Metoprolol 25 mg p.o. b.i.d. Lipitor 20 mg p.o. q.d. Amlodipine 5 mg p.o. q.d. Sublingual nitroglycerin p.r.n. ALLERGIES: There were no known drug allergies. HISTORY OF PRESENT ILLNESS: The patient was doing well post percutaneous transluminal coronary angioplasty in [2172-6-2]. On [2172-10-11], he developed back pain while sitting. This involved radiation to his left arm and also some retrosternal chest pain. He also described some slight shortness of breath with nausea and diaphoresis. This episode of chest pain was not initially relieved with sublingual nitroglycerin and the patient presented to [Hospital6 18075]. At [Hospital6 2561], the patient was found to have no acute electrocardiogram changes and laboratory investigation showed a CBC with a white blood cell count of 10.7, a hematocrit of 36.6, a platelet count of 291 and a Chem 7 which was within normal limits with a BUN of 50 and a creatinine of 1.9. His CK, MB and troponin I were noted to be 64, 2.6 and 0.2. His second set of enzymes were also normal. The patient was admitted and his chest pain was treated with nitroglycerin and heparin drips. He was also noted to have an asymptomatic run of ventricular tachycardia of 27 beats without any hemodynamic compromise. The patient was started on a lidocaine infusion at that time. The patient was transferred to [Hospital1 188] on [2172-10-14] and was taken straight to the cardiac catheterization laboratory. There, he was found to have a cardiac output and cardiac index of 3.1 and 1.8 respectively. His right ventricular end diastolic pressure was 16 and his pulmonary artery pressures were 48/28 with a mean of 39. His wedge pressure was noted to be 29 and his mixed venous oxygen saturation was 42. No left ventricular angiography was done. Examination of the coronary arteries showed a right dominant system with a normal left main coronary artery. There was a 99% lesion at the first obtuse marginal artery and a 100% lesion at the second obtuse marginal artery. His posterolateral ventricular branch was noted to be occluded at 30%. The right coronary artery, which had a previous known occlusion, was not injected. The patient's saphenous vein graft to left anterior descending artery stent was found to be 98% occluded and the patient underwent balloon percutaneous transluminal coronary angioplasty and subsequent brachytherapy with a residual occlusion of 10%. SOCIAL HISTORY: The patient denied any history of tobacco use. He consumed alcohol socially and currently lived alone without support. The patient was capable of doing his own shopping, cooking, cleaning and driving. He did have a health care proxy by the name of [Name (NI) 1743] [Name (NI) 7049], who resided at 74 [Hospital1 36830]in [Hospital1 2436]. FAMILY HISTORY: The family history was noncontributory. PHYSICAL EXAMINATION: On examination, the patient was in no apparent distress with vital signs showing a temperature of 96.9??????F, a blood pressure of 138/63, a heart rate of 87, a respiratory rate of 20 and an oxygen saturation of 96% on a nonrebreather mask. The neurological examination was unremarkable. The patient was awake, alert and oriented times three. On head and neck examination, the pupils were equal and reactive to light. The extraocular movements were intact. The oropharynx was moist. On cardiovascular examination, the patient's jugular venous pressure was 8-10 cm above the sternal angle. He had a normal S1 and S2 with an S3 and S4. He did not have any audible murmurs. The respiratory examination showed diffuse crackles half way up his chest bilaterally with no wheezes. The abdominal examination was unremarkable. The extremities showed palpable bilateral dorsalis pedis pulses with no edema. He had a right groin pulmonary artery catheter line in place and his arterial sheath site was clean, dry and intact with no bruit or hematoma. LABORATORY DATA: The patient's cardiac care unit laboratory values showed a white blood cell count of 14,200, hematocrit of 27.6 and platelet count of 211,000. Chem 7 showed a sodium of 129, potassium of 4.1, chloride of 97, bicarbonate of 18, BUN of 46, creatinine of 2.1 and glucose of 217. CK was 555, calcium was 9.0 and magnesium was 1.6. Arterial blood gases showed a pH of 7.33, a pCO2 of 29 and a pO2 of 90. ELECTROCARDIOGRAM: The patient's electrocardiogram on [2172-10-12] showed him to be in sinus rhythm at 60 with a prolonged P-R interval, a normal P wave and a QRS axis of -60 to -90. He also had a right bundle branch block with a left anterior hemiblock. He had Q waves noted in leads III and aVF. He also had some premature ventricular contractions. There were T wave inversions in leads V1 to V4, which appeared unchanged from his electrocardiogram from [2172-7-1]. RADIOLOGY DATA: The patient's chest x-ray showed significant pulmonary vascular redistribution cephalad. HOSPITAL COURSE: Following cardiac catheterization, the patient was continued on Plavix and received aggressive diuresis for his elevated pulmonary capillary wedge pressure. On [2172-10-15], the patient was noted to have continued runs of nonsustained ventricular tachycardia and an echocardiogram was done, which showed the patient to have a moderately depressed left ventricular function with 1+ aortic insufficiency, 2+ mitral regurgitation and 1+ tricuspid regurgitation. He also was noted to have inferior and inferoseptal hypokinesis. The pulmonary artery catheter was removed along with the introducer on that day. On [2172-10-16], the patient was noted to be in atrial bigeminy in the morning and also continued to have short runs of nonsustained ventricular tachycardia of three to four beats. The patient continued with his intravenous diuresis with 80 mg of Lasix q.d. and was subsequently transferred to the floor. On [2172-10-17], the electrophysiology department was informally consulted and the patient's metoprolol dose was increased. The patient's rhythm continued to be monitored. On [2172-10-19], the patient was in stable condition with adequate diuresis. His nonsustained ventricular tachycardia continued to improve and the patient continued to show no further episodes of nonsustained ventricular tachycardia. The patient was discharged home on [2172-10-19] in stable condition. DISCHARGE MEDICATIONS: Plavix 75 mg p.o. q.d. Enteric coated aspirin 325 mg p.o. q.d. Lipitor 20 mg p.o. q.d. Metoprolol 37.5 mg p.o. q.d. Enalapril 10 mg p.o. q.d. Amlodipine 5 mg p.o. q.d. Lasix 40 mg p.o. q.d. Colace 100 mg p.o. b.i.d. Nitroglycerin 0.4 mg sublingual every five minutes p.r.n. times three. Protonix 40 mg p.o. q.d. FOLLOW UP: The patient was instructed to follow up with his primary cardiologist, Dr. [Last Name (STitle) 1391], at [Hospital3 ] in the upcoming week. [First Name8 (NamePattern2) 2053] [Last Name (NamePattern1) 2052], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 26201] MEDQUIST36 D: [2172-10-20] 14:46 T: [2172-10-20] 14:59 JOB#: [Job Number 36831] ICD9 Codes: 4111, 4271, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2268 }	Medical Text: Admission Date: [2108-8-8] Discharge Date: [2108-8-11] Date of Birth: [2043-7-13] Sex: F Service: CHIEF COMPLAINT: Delirium. Suspected TCA overdose. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old retired Orthopedic surgeon at [Hospital3 1810] with a history of chronic back pain and depression who presented on [2108-8-8] in an agitated and confused state. Patient was found by her housekeeper who found her sleeping on the floor earlier this morning. Many items in the house were destroyed such as broken lamps. The patient was surrounded by numerous pill bottles which were found opened. Amitriptyline 50 mg tablets were filled on [2108-8-7] with only 29 pills out of 40 remaining. The patient also filled amitriptyline 50 mg tablets on [2108-7-16] with only 3 out of 50 pills remaining. Numerous bottles of Darvocet, Wellbutrin, Robitussin, Ultram and multiple antibiotics including clindamycin, Ciprofloxacin and Levaquin were also found around patient. EMS vitals revealed systolic blood pressure of 60 with a heart rate of 100 to 115. Upon arrival to the Emergency Room, patient's blood pressure rose to a systolic blood pressure of 120s without intervention. Patient appeared distressed and agitated. Initial toxicology screen at that time revealed a positive for benzodiazepines, positive for opiates, positive for methadone, positive for tricyclics. Urinalysis revealed 40 ketones. Chest x-ray revealed small left pleural effusion. The patient was given 2.5 liters of intravenous fluid, charcoal 50 grams, Ceftriaxone for a questionable pneumonia. The patient was also given Haldol and Ativan. Electrocardiograms revealed no QRS changes. The patient had recently returned from a trip from [Country 532]. Patient supposedly had a pneumonia at that time per friend. Details were unknown. PAST MEDICAL HISTORY: 1. The patient is status post golf cart accident six years ago in which she broke 26 bones and has had chronic low back pain since. 2. Depression: Patient is followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 109800], phone number [Telephone/Fax (1) 109801]. 3. Patient has a sleep disorder. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Amitriptyline. 2. Darvocet. 3. Wellbutrin SR. 4. Robitussin AC. 5. Ultram. 6. Clindamycin. 7. Ciprofloxacin. 8. Levaquin. FAMILY HISTORY: The mother died recently. SOCIAL HISTORY: The patient is a retired Orthopedic surgeon at [Hospital3 1810]. The patient's closest friend is [Name (NI) 501] [Name (NI) 4135]. Phone number is [Telephone/Fax (1) 109802]. Patient was never married and does not have children. PHYSICAL EXAMINATION UPON PRESENTATION: Temperature 97.8. Heart rate 100. Blood pressure 120s/70s. Oxygen saturation: 98% on two liters. General appearance: Patient is a disheveled 65-year-old female with mumbled speech. Head, eyes, ears, nose and throat examination: Normocephalic, atraumatic. Pupils equal, round and reactive. Mucous membranes appear very dry. Neck is supple. Lungs: Clear to auscultation anteriorly. Cardiovascular exam: No murmurs, rubs or gallops appreciated. Abdomen soft, nontender, nondistended, no hepatosplenomegaly, positive bowel sounds. Extremities: No edema and no calf tenderness. Neurological examination: Cranial nerves grossly intact, moving all extremities spontaneously. LABORATORIES UPON ADMISSION: White blood cell count 12.6, hematocrit 34.4, platelets 615,000. 85.2 neutrophils, 109 lymphocytes. Sodium was 142, potassium 4.0, chloride 102, bicarbonate 27, BUN 9, creatinine 0.5, glucose 8.0. CK 191. Albumin 3.1, TSH 0.34. Urinalysis revealed ketones at 40, negative for nitrates, negative for bacteria. Serum tox screen revealed positive for tricyclics. Urine tox screen revealed positive for benzodiazepines, positive for opiates, positive for methadone. Chest x-ray revealed blunting of left costophrenic angle, old fractures. HOSPITAL COURSE: The patient was transferred to the Surgical Intensive Care Unit and patient was managed with Haldol 2 mg intravenously q. 30 minutes to achieve calmness. Patient was also given benzodiazepines. The patient remained agitated and confused in the Surgical Intensive Care Unit. Patient was placed on monitoring to measure QTC prolongation as well as numerous 12 lead electrocardiograms which revealed no problems with rhythm abnormalities. Patient was also sent to have a head CT. Patient could not undergo the procedure since she was quite agitated even after being given versed and Haldol. Patient was seen by Psychiatry in the Surgical Intensive Care Unit who suggested only to continue the patient on Haldol with no further benzodiazepine administration since this may have worsened her delirium. Patient was transferred to Five South on the second day after admission. The patient's mental status on the first day on the floor remained agitated and confused. Patient had a 1:1 sitter. Patient did undergo a CT scan on the second day of admission which revealed no intra or extracranial hemorrhage. The CT scan also revealed no edema or infarction. Patient's mental status continued to improve greatly. By the second day of admission, patient became far less agitated. Haldol 2 mg q. 30 minutes was not needed. The patient was given only Haldol on only two or three occasions. By the third day of admission, patient's mentation appeared excellent and at near baseline. Patient continued to have no QT segment changes on telemetry on the floors. Electrocardiograms q.d. also revealed no rhythm abnormalities. Patient's pain was controlled with Toradol intravenously, as well as Darvocet 100 mg tablets every four hours, which patient states that she took at home. The patient was also seen by the Cast Service who re-fitted her for a lower back brace cast which patient states decreased her pain as well. Psychiatry saw the patient once again and decided that the patient did not need a 1:1 sitter and was safe for discharge. Patient stated at this time with clear mentation that there was absolutely no suicide attempt. Patient states that she had been self-medicating in order to help relieve her symptoms of the pneumonia. She states no suicidal ideation or plan. Patient states that she will follow-up with her primary care physician within one week at which time greater care would be given to her pain regimen. DISCHARGE DIAGNOSIS: Tricyclic overdose. No suicidal intent. DISCHARGE CONDITION: Stable. FOLLOW-UP PLAN: The patient is to follow-up with patient's primary care doctor, who will go over pain protocol. MEDICATIONS UPON DISCHARGE: 1. Amitriptyline.2 2. Darvocet. 3. Wellbutrin SR. 4. Robitussin AC. 5. Ultram. Please note: No new medication refills were administered upon time of discharge. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[First Name3 (LF) 109803] MEDQUIST36 D: [2108-8-15] 21:57 T: [2108-8-15] 21:57 JOB#: [Job Number 109804] ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2269 }	Medical Text: Admission Date: [2155-7-16] Discharge Date: [2155-7-22] Date of Birth: [2071-11-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 83 YO M w AF/FLUT (not anticoagulated), bioprosthetic AVR for AS, prior colon Ca s/p hemicolectomy presenting from [Hospital 745] Health Center Rehab with increased confusion, lethargy and cloudy urine. The patient is a very poor historian so his history was obtained largely from his daughter and HCP. She reports that the patient was largely independant prior to a [Month (only) 116] admission to [Hospital1 18] for MRSA bacteremia. He was treated with 4 weeks of abx and discharged to rehab. While at rehab he was doing well until approximately 2 weeks ago. He began to develop some mild confusion and had a fall. He reportedly did not have any sequelae after the fall and it is not clear if the patient had any secondary trauma although his changes in mental status have also occurred over the past couple of weeks. Over the past week, he has become more fatigued and lethargic, not getting out of bed as he usually does. At one point, he did pull out his foley. Over the past day, the patient's confusion became much more severe. He developed some diarrhea and his family was concerned that his confusion was [3-4] a UTI. His rehab noted that the patient had a leukocytosis and so he was brought into the ED for further evaluation. . Upon presentation to the ED, his initial VS were: 101.8 110 105/47 18 95%. Shortly after arrival his SBP decreased to 84. Exam was reportably notable for mild confusion (normally oriented times 3, but not oriented to time in the ED) a LUSB ejection murmur and cloudy urine. Labs were notable for a leukocytosis with left shift but no bands, a lactate of 1.4 and a u/a with >50 WBCs and positive leuks. EKG was notable for new ST segment depressions in V4-V6 with a rate of 117. Two 18g PIVs were placed and less than 1L NS were given. Blood and urine cultures were sent and the patient was given cefepime 2g, levoflox 750mg IV once and APAP 325mg. VS prior to transfer were: 107 22 97/52 95%. . Upon arrival to the floor, the patient reports recent confusion and possibly some chest pain within the past few days although he denies active chest pain and is unable to provide any additional information. . Review of sytems: (+) Per HPI, otherwise patient unable to provide . Past Medical History: * severe AS, s/p valvuloplasty [3-8], then AVR [4-5] (19 mm [Last Name (un) 3843]-[Known firstname ] bovine pericardial prosthesis), repair [5-6]. * CHF [3-4] AS EF 45-50% * atrial fibrillation/atrial flutter * colon adenoCA s/p R colectomy [3-8] * Chronic indwelling foley with several UTIs * Zenkers diverticulum s/p surgical repair [4-3] * h/o splenomegaly and thrombocytosis * Anemia iron deficiency * pulmonary asbestosis diagnosed by CT scan in [2142] * jejunal microperforation diagnosed by barium swallow in [2144] * manic depression/anxiety * b/l inguinal hernia repair, right inguinal hernia [2146] * decreased hearing * esophageal stenosis * left rotator cuff partial tear * C diff [2151] Social History: Was living with family but was recently discharged to an extended care facility after hospitalization for bacteremia. No tobacco or alcohol use. Patient walks with a cane or walker. Family History: unable to obtain Physical Exam: Vitals: 96.8 119/69 16 98 2L Gen: NAD, Oriented to hospital, person, not date. HEENT: Mouth open, dry MM Neck: JVP flat Cardiovascular: Irregularly irregular no murmurs, rubs or gallops Respiratory: Clear to auscultation anteriorly. Scant rales at right base. Abd: Soft, non-tender, non distended, no heptosplenomegally, bowel sounds present. Extremities: No edema Pertinent Results: [2155-7-16] 05:30PM WBC-18.2# RBC-3.75 HGB-11.2* HCT-34.2* MCV-91 MCH-29.8 MCHC-32.7 RDW-15.8* [2155-7-16] 05:30PM CK(CPK)-44* [2155-7-16] 05:30PM CK-MB-2 [2155-7-16] 05:30PM cTropnT-0.04* [2155-7-16] 05:30PM GLUCOSE-126* UREA N-32* CREAT-0.9 SODIUM-137 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-29 ANION GAP-15 [2155-7-16] 05:55PM URINE RBC-[4-4]* WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 [2155-7-16] 05:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [2155-7-16] 11:45PM TYPE-ART PO2-70* PCO2-41 PH-7.41 TOTAL CO2-27 BASE XS-0 MICRO: [2155-7-16] Blood and Urine Culture: PROTEUS MIRABILIS \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2155-7-19] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2155-7-18] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2155-7-18] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2155-7-17] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT [2155-7-17] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2155-7-17] URINE URINE CULTURE-FINAL INPATIENT [2155-7-16] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [Hospital1 ] [2155-7-16] CXR: Left basal scarring of the lung; no acute cardiopulmonary process. [2155-7-22] 05:10AM BLOOD WBC-5.6 RBC-3.56* Hgb-10.3* Hct-32.3* MCV-91 MCH-29.0 MCHC-31.9 RDW-15.6* Plt Ct-398 [2155-7-18] 03:39AM BLOOD PT-13.6* PTT-36.4* INR(PT)-1.2* [2155-7-22] 05:10AM BLOOD Glucose-87 UreaN-23* Creat-0.4* Na-144 K-4.5 Cl-104 HCO3-33* AnGap-12 [2155-7-16] 05:30PM BLOOD CK(CPK)-44* [2155-7-17] 05:57AM BLOOD CK(CPK)-19* [2155-7-16] 05:30PM BLOOD CK-MB-2 [2155-7-16] 05:30PM BLOOD cTropnT-0.04* [2155-7-17] 05:57AM BLOOD CK-MB-2 cTropnT-0.04* [2155-7-22] 05:10AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.0 Brief Hospital Course: Mr. [Known lastname ] is an 83 YO M with CHF EF 45-50%, aortic stenosis s/p biprosthetic AVR, prior colon CA s/p hemicolectomy, chronic indwelling foley for urinary retention and recent hospitalization for MRSA bacteremia admitted with septicemia from urinary source with pansensitive proteus mirabilis on blood and urine cultures. # Sepsis secondary to ascending urinary tract infection Blood and urine cultures from admission with pan-sensitive proteus mirabilis. Presented with pyuria, fevers, altered mental status and leukocytosis to 18.2. Became hypotensive and tachycardic shortly after arrival, which improved with fluid boluses. Initially treated with vancomycin, cefepime and ciprofloxacin. Changed to meropenem/ciprofloxacin. Narrowed to ciprofloxacin alone once sensitivities available. Fevers, pyuria and leukocytosis resolved within a couple days, and his mental status slowly cleared to his baseline. He was discharged to complete 14 day course of ciprofloxacin and he will follow up in [Hospital 159] clinic. # Altered mental status Acute delirium in the setting of dementia. Most likely secondary to infectious process. He came in mildly confused and persistently did not know why he was brought to the hospital. His confusion slowly improved; he became more coherent and interactive over the course of his stay. He became mildly agitated at times but could be reoriented. No focal neurologic signs or symptoms. On discharge he was alert, oriented to person and place. He was able to count from 10 to 1 backward. He was at his baseline on discharge. # EKG changes When he became tachycardic to 117 in the setting of sepsis, he had new ST segment depressions V4-V6. Improved when his heart rate normalized with fluid resuscitation. Negative cardiac enzymes and lack of chest pain or symptoms suggestive of anginal equivalent. EKG changes were likely secondary to demand with tachycardia. # Hypernatremia On the day prior to discharge, he became mildly hypernatremic (146), likely from poor PO intake and restarting his home dose of 10 mg Lasix. His lasix was held on discharge to be restarted at rehab once back to baseline oral intake. # Urinary retention He chronically has in indwelling foley catheter for his urinary retention. Likely source of his proteus urosepsis. He had pulled out his prior foley, and a new foley was placed on admission. He was continued on his home dose of tamulsulosin. He has been discharged with a foley and he will follow up with Dr. [Last Name (STitle) 770] in urology clinic. #Loose Stools - during his admission he had several loose stools per day with small amount of urgency and fecal incontinence. He was tested for C. difficile which was negative x2. On the day of discharge he was placed on a lactose free diet to see if this would improve his symptoms and his bowel regimen was held. # CHF He showed no signs or symptoms of acute CHF. His home dose of Lasix (10 mg daily) was stopped on admission in the setting of sepsis. It was held during his hospitalization given decreased po intake. His intake and weights should be monitored with lasix restarted for weight gain or signs of fluid accumulation. # Atrial fibrillation/flutter Irregularly irregular rhythm, but rate is well-controlled. Treated with 325 mg aspirin daily. On review of note from his cardiologist Dr. [Last Name (STitle) 1016] he is not on coumadin due to increased fall risk. # Dementia - stable. Continued outpatient donepezil. Medications on Admission: Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID prn Cholecalciferol (Vitamin D3) 800mg daily Calcium Carbonate 500 mg Tablet, Chewable TID Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID Omeprazole 20 mg Capsule, Delayed Release(E.C.) daily Ferrous Sulfate 325 mg Tablet daily Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Heparin (Porcine) 5,000 unit/mL TID Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID Acetaminophen 1000 mg Tablet Q6H Tamsulosin 0.4 mg PO daily Furosemide 10 mg (half-tab of 20mg) PO daily Vitamin B12 100 mcg PO daily Lidoderm patch 5% to bilateral knee 12 hours on 12 hours off Discharge Medications: 1. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 10 days: Last doses on [7-30]. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital 745] Health Care Center Discharge Diagnosis: Primary diagnoses: UTI c/b bacteremia (pan-sensitive Proteus Mirabilis) Orthostasis Secondary diagnoses: Atrial fibrillation/flutter Dementia Hypocalcemia s/p aortic valve replacement CHF Discharge Condition: Mental Status: Oriented to person. Occasionally oriented to place. Not oriented to date. Able to count backward from 10 to 1. Delirium mostly resolved prior to discharge. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane) due to high fall risk. Discharge Instructions: You were admitted because you had an infection in your urinary tract and blood that gave you fevers, lowered your blood pressure and made you more confused. We treated your infection with antibiotics, and we treated your low blood pressures by giving you IV fluids. Your fevers resolved, your blood pressures stabilized and your mental status became more clear. Please complete your full 14 day course of ciprofloxacin, which is the antibiotic that treats your infection. Your foley catheter was changed during your hospitalization. Changes to your medications: -ciprofloxacin 500mg PO twice daily (last day [7-30]) -HOLD furosemide, can be restarted by rehab when no longer hypernatremic. Otherwise no changes were made to your medications. Please take all medications as prescribed. Please follow up with all of your appointments. It was a pleasure taking care of you, Mr. [Known lastname ]. Followup Instructions: 1. You have an appointment to follow up in [Hospital 159] clinic given your recurrent urine infections and foley catheter. You will be seeing one of the nurse practitioners that works with Dr. [Last Name (STitle) 770]. Department: SURGICAL SPECIALTIES When: THURSDAY [2155-8-7] at 1:30 PM With: PELVIC FLOOR UNIT [Telephone/Fax (1) 274] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage 2. You have an appointment scheduled to see Dr.[Name (NI) 3733] who is the cardiologist that is taking over your care from Dr. [Last Name (STitle) 6558] since he is retiring. You will have an echocardiogram at 9:00 am prior to your appointment with Dr.[Doctor Last Name 3733]. ECHOCARDIOGRAM Phone:[Telephone/Fax (1) 62] Date/Time:[2155-10-31] 9:00 [Name6 (MD) ] [Last Name (NamePattern4) 6559], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2155-11-18] 9:20 3. Please follow up with your primary care doctor within two weeks of discharge from rehab. ICD9 Codes: 2760, 2930, 5990, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2270 }	Medical Text: Admission Date: [2185-1-25] Discharge Date: [2185-2-18] Date of Birth: [2126-2-16] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Aspirin / Motrin Attending:[First Name3 (LF) 165] Chief Complaint: fever, back pain Major Surgical or Invasive Procedure: ERCP w/stent [1-26] Liver bx [2-1] History of Present Illness: 58 yo F with h/o TV annuloplasty in [2159] and TV replacement in [2171] who pressented to OSH [1-21] with 4 day history of fever to 103, back pain, nausea cough and diarrhea. Initial blood cultures were positive for MSSA and enterococcus and she was started on antibiotics. She developed hypotension and was transferred to the CCU. Abdominal CT [1-22] showed ? of pancreatitis/GB sludge, and RUQ ultrasound showed dilated CBD. She continued to have a rising WBC and TEE showed 2.3 x 1.3 irregular mobile mass on TV annulus with severe TR. She was transferred to [Hospital1 ] for further management. Past Medical History: s/p TV repair '[59], s/p TVR/PFO closure '[69] c/b CVA/cardiac arrest,Breast CA s/p lumpectomy/Chemo/XRT '[78], sepsis related to Portacath, atrial arrhythmias, multiple spinal surgeries, h/o spinal stimulators-?removal, COPD, Left ing hernia repair. Social History: lives with fiance and granddaughter + tobacco - about [11-17] ppd, none for ~ 1 week prior to transfer denies current etoh/drug abuse Family History: Mother- Diabetes/HTN Physical Exam: Admission HR 80s BP 101/49 RR 30s 95% on 100% NRB Neuro [Last Name (LF) ], [First Name3 (LF) 2995], grip/plantar flexion/extension [2-18] equal bilaterally; pupils 2-3 mm equal/reactive bilat. CV irreg 3/6 systolic murmur Resp course breath sounds anteriorly; clear at post. bases GI hypoactive bowel sounds, soft. RUQ tenderness GU foley draining [Location (un) 2452] urine Extrem 2+ pulses throughout, 2+ pitting edema in LE, RUE edema > LUE, right radial [Doctor Last Name ] test with + ulnar flow Discharge VS T 98 HR 80 SR BP 149/63 RR 20 O2sat 97% RA Gen NAD Neuro A&Ox3, nonfocal exam Pulm CTA bilat CV RRR Abdm soft, NT/+BS Ext warm, well perfused. Trace pedal edema bilat Pertinent Results: [2185-2-10] 06:16AM BLOOD WBC-13.1* RBC-2.89* Hgb-8.9* Hct-27.2* MCV-94 MCH-30.7 MCHC-32.6 RDW-17.5* Plt Ct-248 [2185-2-10] 06:16AM BLOOD UreaN-8 Creat-1.1 K-2.9* [2185-1-25] 09:56PM GLUCOSE-78 UREA N-21* CREAT-0.8 SODIUM-138 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-18* ANION GAP-15 [2185-1-25] 09:56PM ALT(SGPT)-18 AST(SGOT)-24 LD(LDH)-431* CK(CPK)-12* ALK PHOS-162* AMYLASE-17 TOT BILI-12.6* DIR BILI-10.4* INDIR BIL-2.2 [2185-1-25] 09:56PM LIPASE-11 [2185-1-25] 09:56PM CK-MB-NotDone cTropnT-<0.01 [2185-1-25] 09:56PM ALBUMIN-2.5* CALCIUM-8.2* PHOSPHATE-3.3 MAGNESIUM-2.2 URIC ACID-3.5 [2185-1-25] 09:56PM TSH-1.3 [2185-1-25] 11:58PM LACTATE-1.2 [2185-1-25] 09:56PM WBC-20.8* RBC-3.40* HGB-10.7* HCT-31.9* MCV-94 MCH-31.5 MCHC-33.5 RDW-15.3 [2185-1-25] 09:56PM NEUTS-94* BANDS-2 LYMPHS-1* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2185-1-25] 09:56PM PLT SMR-LOW PLT COUNT-76* [2185-1-25] 09:56PM PT-14.5* PTT-30.0 INR(PT)-1.3* [2185-1-25] 09:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.5 LEUK-TR [2185-1-25] 09:50PM URINE RBC-329* WBC-8* BACTERIA-FEW YEAST-NONE EPI-0 [2185-2-7] 06:18AM BLOOD WBC-7.8 RBC-2.49* Hgb-7.7* Hct-23.9* MCV-96 MCH-31.0 MCHC-32.4 RDW-17.2* Plt Ct-219 [2185-2-7] 06:18AM BLOOD Plt Ct-219 [2185-2-7] 06:18AM BLOOD PT-17.2* PTT-28.5 INR(PT)-1.6* [2185-2-7] 06:18AM BLOOD Glucose-95 UreaN-6 Creat-1.0 Na-140 K-2.6* Cl-114* HCO3-17* AnGap-12 [2185-2-7] 06:30AM BLOOD ALT-17 AST-23 AlkPhos-111 Amylase-62 TotBili-1.6* [2185-2-7] 06:30AM BLOOD Lipase-48 [2185-2-7] 06:30AM BLOOD Albumin-2.4* RADIOLOGY Final Report CHEST (PA & LAT) [2185-2-5] 12:37 PM CHEST (PA & LAT) Reason: pna [Hospital 93] MEDICAL CONDITION: 58 year old woman with RHONCHOUROUS bs THROUGHOUT / requiring increase in oxygen REASON FOR THIS EXAMINATION: pna CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [2185-2-2]. FINDINGS: As compared to the previous radiograph, the nasogastric tube and the endotracheal tube have been removed. Both lungs have increased in transparency, however the pre-existing bilateral extensive parenchymal opacities are still very prominent. No evidence of pleural effusion. The size of the cardiac silhouette is unchanged. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 59947],[Known firstname ] M [2126-2-16] 58 Female [Numeric Identifier 59948] [Numeric Identifier 59949] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) 59950] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ], [Doctor Last Name 15785],[Doctor First Name ]/mtd SPECIMEN SUBMITTED: LIVER CORE BX...1 JAR. Procedure date Tissue received Report Date Diagnosed by [2185-2-1] [2185-2-1] [2185-2-3] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/stu DIAGNOSIS: Liver, needle core biopsy: Portal tracts: Mild peri-ductular acute inflammation. Lobules: No hepatocellular necrosis or apoptosis. No steatosis. No cholestasis noted. Trichrome stain: No increase fibrosis seen. Iron stain: Mild iron deposition in Kupffer cells. Note: If findings are not specific, but may be seen in early biliary obstruction, ascending cholangitis, sepsis or drug reaction. Clinical correlation is suggested. Clinical: Elevated LFT, patient with endocarditis, ? cirrhosis. Gross: The specimen is received in one formalin container, labeled with the patient's name, "[Known lastname ], [Known firstname ] M" and the medical record number. It consists of tan-yellow tissue core measuring 0.5 x 0.1 cm in diameter, entirely submitted in cassette A. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 59951] (Complete) Done [2185-1-28] at 3:31:07 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2126-2-16] Age (years): 58 F Hgt (in): 67 BP (mm Hg): 104/69 Wgt (lb): 200 HR (bpm): 71 BSA (m2): 2.02 m2 Indication: Endocarditis. ICD-9 Codes: 424.90 Test Information Date/Time: [2185-1-28] at 15:31 Interpret MD: [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD Test Type: TEE (Complete) Son[Name (NI) 930]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2008W000-0:00 Machine: Vivid i-3 Echocardiographic Measurements Results Measurements Normal Range Findings Pt maintained in ICU with paralytics and fentayl/versed drips during procedure. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Bioprosthetic tricuspid valve (TVR). Large vegetation on tricuspid valve. No TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was monitored by a nurse in [Last Name (Titles) 9833] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). No TEE related complications. Conclusions Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 30 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. A bioprosthetic tricuspid valve is present. There is a large vegetation on the septal leaflet of the tricuspid valve measuring approximately 2cm by 1cm. IMPRESSION: Large vegetation on tricuspid valve as described above. No tricuspid regurgitation. No abscess identified. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2185-1-28] 16:22 Brief Hospital Course: She was admitted to the cardiac surgery ICU. She was seen by general surgery and hepatobiliary services. She was intubated for respiratory failure and for an emergent ERCP/no obstruction was found but a biliary stent was empirically placed and she will require repeat ERCP for stent removal in 8 weeks. She was also seen by Cardiology & Infectious diseases. ID recommended tx with rifampin, vancomycin and gentamycin for 6 weeks. She initially required paralasis and sedation to be ventilated. She also required multiple pressors for hemodynamic support. Liver biopsy on [2-1] was negative for cirrhosis. A TEE revealed TV endocarditis with no TR. Gradually her sepsis resolved, the vent and pressors were weaned, she was extubated and her pressors were weaned to off on [2-2]. She was transferred to the floor on [2-3]. Over the next week she continued on triple antibiotics and gradually recovered her strength. On [2-8] overnight she developed a fever and was pancultured, these cultures are currently no growth to date. By hospital day 17 it was decided she could be transferred to rehabilitation to complete a 6 week antibiotic course prior to surgical replacement of her tricuspid valve. Medications on Admission: Percocet 10/375 QID/prn Albuterol Robaxin 750''' Discharge Medications: 1. Docusate Sodium 100 mg Capsule [Month/Year (2) ]: One (1) Capsule PO twice a day. 2. Nystatin 100,000 unit/mL Suspension [Month/Year (2) ]: Five (5) ML PO QID (4 times a day) as needed. 3. Nystatin 100,000 unit/g Cream [Month/Year (2) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Rifampin 150 mg Capsule [Last Name (STitle) ]: Three (3) Capsule PO Q12H (every 12 hours): thru [3-8]. 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Month/Year (2) ]: 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily MLs Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily . 9. Vancomycin 500 mg Recon Soln [Month/Year (2) ]: Seven [Age over 90 1230]y (750) mg Intravenous Q 12H (Every 12 Hours). 10. Oxycodone 5 mg Tablet [Age over 90 ]: One (1) Tablet PO every six (6) hours as needed for pain. 11. Gentamicin in Saline (Iso-osm) 100 mg/50 mL Piggyback [Age over 90 ]: One Hundred (100) mg Intravenous Q24H (every 24 hours): thru [3-8]; check peak and trough [2-11]. Discharge Disposition: Extended Care Facility: [Hospital ] Health Care - [Hospital1 ] Discharge Diagnosis: Tricuspid valve endocarditis PMH: s/p TV repair '[59], s/p TV replacement '[69], breast CA s/p lumpectomy/rads/XRT '[78], s/p PFO closure, s/p CVA '[69], cervical radiculopathy s/p cervical laminectomy &lumbar fusion, hx R&L spinal stimulator-?L side removed, COPD, Atrial tachycardia, sepsis from portacath'[80], s/p L ing hernia repair Discharge Condition: Stable. Discharge Instructions: Take all medications as prescribed. Keep all scheduled appointments, call for all other f/u appointments. Followup Instructions: repeat ERCP for stent removal (Biliary Service- Dr [Last Name (STitle) ]8 weeks from [1-26] Dr [First Name (STitle) ] in 3 weeks([Telephone/Fax (1) 1504]) Dr [Last Name (STitle) 7443] ([Hospital ] clinic) on [2-21] @12noon [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2185-2-10] ICD9 Codes: 486, 2762, 496, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2271 }	Medical Text: Admission Date: [2169-4-30] Discharge Date: [2169-5-5] Date of Birth: [2123-11-17] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 45 year-old man wtih a history of narcotic and benzodiazepine abuse status post multiple attempts to detox who decided three days ago to stop all of his narcotics and benzodiazepines, because he was tired of being dependent on these medications. The patient [Hospital6 17459] on [4-28] who placed him on a combination of medications for withdraw. The patient saw this physician again on the day of admission in his office, checked a tox screen with a urine screen negative for narcotic and gave him a test dose of Naltrexone by mouth [2-22] of a 50 mg tablet at 1:00 p.m. Twenty minutes later the patient became acutely confused, agitated, hypertensive, without back pain and without headache. On further questioning the patient admitted to taking one Percocet earlier on the day of admission. In the Emergency Room the patient's blood pressure was 220/100 with a pulse of 127, respirations 28, very agitated and placed on four point restraints. The patient received 8 mg of Ativan and 111 mg of morphine over a several hour period with improvement in his mental status and diminishment of his blood pressure to 166/110 and his pulse was diminished to 97. SOCIAL HISTORY: One half pack per day of smoking times 17 years, occasional alcohol, history of intravenous drug abuse, no cocaine. The patient was disabled with past profession as a boxer. He lives with his fiance. MEDICATIONS AT ADMISSION PRIOR TO [4-28]: The patient was taking Percocet 7.5 mg tablets prn roughly 120 tablets per month, Fentanyl patch 100 micrograms for the last seven years, Xanax 1.5 mg b.i.d. for the last seven years, Prozac and Tums. After seeing the withdraw specialist the patient was on Neurontin 1600 mg q.i.d., Robaxin 750 mg t.i.d., Celebrex 200 mg q.d., Quinine 260 mg b.i.d., Baclofen 20 mg b.i.d., Ambien 10 to 20 mg q.h.s., Librium 25 mg q.i.d., Valium 10 mg q.o.d., Risperdal 1 mg prn, Clonidine 0.1 mg patch q week, Doxepin 100 mg q.h.s., Tizanidine 4 mg q.h.s. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 166/110. Heart rate 97. The patient is [Age over 90 ]% on room air. Pupils were 3 mm equal and reactive to light. Extraocular movements intact. Oropharynx was clear. JVP was difficult to evaluate. Neck was supple. The patient had a regular rate and rhythm with no murmurs, rubs or gallops. Lungs were clear to auscultation bilaterally. Abdomen was obese, well healed midline scar, diffuse tenderness, no edema. 2+ pedal pulses. The patient had a nonfocal cranial nerves examination with cranial nerves II through XII intact. HOSPITAL COURSE: The patient was initially observed in the MICU for signs of acute withdraw and management of the patient's hypertension. The patient was started on 60 mg of intravenous morphine prn signs of withdraw q 6 hours. The patient was also given up to 4 mg of po Ativan q 4 to 6 hours. The patient was weaned aggressively off these narcotics and was followed by the toxicology service who recommended keeping him on short acting agents for 72 hours after his ingestion due to the 72 hour duration of Spironolactone in the circulation. Therefore long acting agents were discouraged and not used in this patient although the patient did get one dose of methadone prior to this decision being made. The patient was weaned off of his intravenous medications and switched to oral. At the time of discharge the patient was receiving 30 mg of MSIR q 6 hours prn and 2 mg po Ativan q 6 hours prn. On the day prior to discharge the patient got 10 mg total of po Ativan and roughly 120 mg po of MSIR. The plan was to continue to wean these medications completely off with acute inpatient detox patient. The patient had been followed by social work, psychiatry, toxicology and general medicine. All services agreed that the patient would require inpatient detoxification. An outpatient taper was discussed, however, the patient's narcotic requirements were too high for any of the physicians involved in his care to feel comfortable prescribing him with medications. Also it was thought that he should be receiving these medications and this detoxification under an observed setting with administration of these medications by a third party. The patient was agitated throughout his hospitalization, but on the last 48 hours of his hospitalization showed no objective signs of withdraw. The patient was normotensive. The patient had no signs of tachycardia. The patient's pupils remained normal with normal reactivity at the last day of admission. The patient was afebrile throughout his hospitalization. The patient was combative at times, but was never physically aggressive or threatening. PLEASE SEE OMR NOTE DATED [2169-5-12] BY DR. [Last Name (STitle) ] FOR DETAILS OF THE REMAINDER OF THIS HOSPITALIZATION. DISCHARGE DIAGNOSES: 1. Acute narcotic withdraw. 2. Narcotic dependence. 3. Benzodiazepine dependence. 4. Depression. 5. Anxiety. 6. Complex regional pain syndrome. 7. Chronic low back pain. 8. Gastroesophageal reflux disease. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2506] Dictated By:[Last Name (NamePattern1) 7942] MEDQUIST36 D: [2169-5-5] 11:08 T: [2169-5-5] 11:18 JOB#: [Job Number 17460] ICD9 Codes: 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2272 }	Medical Text: Admission Date: [2138-2-11] Discharge Date: [2138-3-3] Date of Birth: [2138-2-11] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname 59275] is a former 1.93 kg product of a 36 and 2/7 weeks gestation pregnancy, second born of twin to a 42 year old G1, P0 woman. Prenatal screens - blood type A positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group Beta strep status unknown. The pregnancy was notable for in [Last Name (un) 5153] fertilization with diamniotic, dichorionic twin. The pregnancy was otherwise uncomplicated. The mother was delivered by cesarean section after spontaneous rupture of membranes for known breech and transverse lies. This twin, No. 2, emerged with Apgars of 8 at 1 minute, and 9 at 5 minutes. She was in good condition and admitted to the Newborn nursery. At 17 hours of age she was admitted to the Neonatal Intensive Care Unit for poor feedings, bilious emesis and hypothermia. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit, weight 1.93 kg, length 42.5 cm, head circumference 30 cm, all 10th percentile for gestational age. GENERAL: Sleepy, pink, preterm infant in no apparent distress. HEENT: Anterior fontanel soft and flat. Intact palate, poor suck, positive red reflexes bilaterally. CHEST: Lungs clear to auscultation. Equal breath sounds. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. 2+ femoral pulses. ABDOMEN: Full but soft and nontender. Positive bowel sounds. GENITOURINARY: Normal female. Anus patent. SPINE: Straight with normal sacrum. EXTREMITIES: Hips stable. Fit and well perfused digits. NEUROLOGIC: Tone and reflexes consistent with gestational age. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LAB DATA: RESPIRATORY: [Known lastname ] was in room air for her entire Neonatal Intensive Care Unit admission. She did not have any episodes of spontaneous apnea during admission. CARDIOVASCULAR: [Known lastname ] has maintained normal heart rates and blood pressures. No murmurs had been noted. FLUIDS, ELECTROLYTES AND NUTRITION: [Known lastname ] was made NPO upon admission to the Neonatal Intensive Care Unit. Due to her abdominal distention there was concern for possible gastrointestinal obstruction. She had an upper gastrointestinal series and a contrast enema performed at [Hospital3 1810] on [2138-2-11], when she finally began to pass stool on day of life No. 1. The abdominal distention resolved and feedings were initiated on day of life No. 2. She was gradually advanced to full volume without problems. At the time of discharge she was taking breast milk or Similac fortified to 24 calories per ounce of breast milk with 4 calories of Similac powder. Weight on the day of discharge is 2.335 kg with a length of 46 cm and head circumference of 32 cm. Serum electrolytes were checked in the first week of life and were within normal limits. INFECTIOUS DISEASE: Due to the hypothermia, and the abdominal distention, [Known lastname ] was evaluated for sepsis upon admission to the Neonatal Intensive Care Unit. Complete blood count was within normal limits. Intravenous ampicillin and gentamycin were started after procurement of blood culture. Blood culture showed no growth at 48 hours and [Known lastname 59278] clinical condition had improved and the antibiotics were discontinued. GASTROINTESTINAL: As previously noted, there was concern for possible gastrointestinal obstruction. The upper gastrointestinal series showed no bowel malrotation. The contrast enema showed meconium plug which did not allow contrast to pass beyond the sigmoid colon. She was returned back to the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] from [Hospital3 1810] Radiology Suite. She spontaneously passed stool within the next 24 hours and the abdominal distention resolved. She tolerated feeds well from that point on. She also required treatment for unconjugated hyperbilirubinemia with phototherapy. Her peak serum bilirubin occurred on day of life No. 3 with a total of 10 mg/ dL over 0.3 mg per dL direct. She received approximately 48 hours of phototherapy with rebound bilirubin on day of life No. 6 was 5.8. Total over 0.2 mg per dL direct. NEUROLOGY: [Known lastname ] has maintained a normal neurological examination. During admission there are no neurological concerns at the time of discharge. SENSORY: Hearing screening was performed with automated auditory brain stem responses. [Known lastname ] passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 5279] [Last Name (NamePattern1) 43699] Centre Pediatric Associates, 10NE [Location (un) ] Place, [Apartment Address(1) 50442], [Location (un) ], [Numeric Identifier 59279]. Phone No. [Telephone/Fax (1) 43701]. Fax No. [Telephone/Fax (1) 59280]. CARE RECOMMENDATIONS: 1. Feedings, ad lib breast feeding or bottle feeding Similar 24 calorie per ounce or expressed breast milk fortified to 24 calories per ounce with Similac powder. 2. No medications. 3. Car Seat Position Screening was performed. [Known lastname ] was observed for 90 minutes in her car seat without any episodes of bradycardia or oxygen desaturations. 4. State Newborn Screens were sent on [2-14], and [2138-2-25] with no notification of abnormal results to date. 5. Immunizations received: Hepatitis B vaccine was administered on [2138-2-19]. 6. Immunizations Recommended: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: A. Born at less than 32 weeks. B. Born between 32 and 35 weeks with two of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings, C. With chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. Follow up appointments recommended: Appontment with Dr. [Last Name (STitle) 43699], primary pediatrician within 2 days of discharge. DISCHARGE DIAGNOSIS: 1. Prematurity at 36 and 2/7 weeks. 2. Twin No. 2 of twin gestation. 3. Suspicious for sepsis ruled out. 4. Suspicious for intestinal obstruction ruled out. 5. Meconium plug syndrome. 6. Unconjugated hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2138-3-2] 22:56:05 T: [2138-3-2] 23:44:17 Job#: [Job Number 59281] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2273 }	Medical Text: Admission Date: [2184-12-27] Discharge Date: [2185-1-3] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Gastrointestinal bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: HPI: [Age over 90 ] y/o lady with CAD multiple PCI, chronic diastolic heart failure, hypertension, hypothyroidism, chronic renal failure presents after a syncopal episode and melena. Patient is a poor historian with memory trouble per family. Most of the history was obtained from grand daughter and daughter over the phone. Patient daughter visited her this morning and found her to be in usual health. Her grand daughter went during the evening and patient was in bath room. She took her to the bedroom and patient felt week. Patient slipped along her bed to the floor but without trauma to the head or body. She had breif episodes of loss of consciousness for 7-10secs and family decided to call EMS. Patient was noted to be cold, clammy with stiffened extremities during this episode. When they moved her, found to have really dark stool. She also vomitted once, very dark coloured vomit. Patient denied any chest pain or shortness of breath. In the ED vitals were: T 95.7 HR 71 BP 134/44 RR 19 100% in RA. Patient received 80 mg IV pantoprozole. Patient was found to have left retrocardiac opacity and was given 1 gm of IV ceftriaxone and levofloxacin 750 mg IV. On arrival to MICU her vitals were T 97.2 HR 73 BP 111/80 RR 18 100% in RA. Patient is asymptomatic. Patient and family denied any recent fever, chills, nightsweats, cough, cold, abdominal pain, diarrhea, constipation, dysuria, hematuria, focal numbness or weakness. Past Medical History: CAD s/p multiple PCIs, stenting and restenting of LCx Chronic diastolic heart failure HTN Hyperlipidemia CRI: creatinine 2.0 on [5-3] (while reportedly on ACEi) Hypothyroidism Social History: hx: Lives alone; former seamstress; widowed; Has children that live close by and assist her with foodshopping; otherwise she is totally independent. Never smoker, no ETOH Family History: NC Physical Exam: Vital: T 97.2 HR 73 BP 111/80 RR 18 100% in RA. Patient is asymptomatic. Gen: Alert and oriented to person and place. NAD. Pleasant lady following commands. HEENT: EOM-I, MM dry, JVP not elevated Heart: S1S2 II/VI holosystolic murmur heard throughout the precordium but best at RUSB. Lungs: crackles at left base. Abdomen: BS present, soft NTND. Ext: WWP, no edema Neuro: Following commands. CNII-XII grossly intact. Strength [5-31] bilaterally. Pertinent Results: [2184-12-27] 08:10PM BLOOD WBC-14.4# RBC-3.39 Hgb-10.8* Hct-31.6* MCV-93 MCH-31.8 MCHC-34.1 RDW-13.2 Plt Ct-401# [2184-12-28] 12:56AM BLOOD WBC-13.4* RBC-3.13* Hgb-10.1* Hct-28.7* MCV-92 MCH-32.4* MCHC-35.3* RDW-13.3 Plt Ct-366 [2184-12-27] 08:10PM BLOOD Neuts-89.5* Lymphs-6.2* Monos-3.4 Eos-0.7 Baso-0.3 [2184-12-27] 08:10PM BLOOD PT-14.7* PTT-23.3 INR(PT)-1.3* [2184-12-27] 08:10PM BLOOD Plt Ct-401# [2184-12-27] 08:10PM BLOOD Glucose-176* UreaN-161* Creat-4.5# Na-137 K-5.2 Cl-99 HCO3-22 AnGap-21* [2184-12-28] 12:56AM BLOOD Glucose-170* UreaN-162* Creat-4.6* Na-137 K-5.1 Cl-101 HCO3-22 AnGap-19 [2184-12-27] 08:10PM BLOOD CK(CPK)-50 [2184-12-28] 12:56AM BLOOD CK(CPK)-48 [2184-12-27] 08:10PM BLOOD CK-MB-NotDone [2184-12-27] 08:10PM BLOOD cTropnT-0.07* [2184-12-27] 08:10PM BLOOD Calcium-8.8 Phos-5.6* Mg-2.7* [2184-12-28] 12:56AM BLOOD Calcium-8.4 Phos-5.5* Mg-2.5 [2184-12-28] 01:20AM URINE Hours-RANDOM UreaN-706 Creat-114 Na-10 [2184-12-27] 10:20PM URINE RBC-0-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-0-2 [2184-12-27] 10:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR . Radiographic studies: [12-27] CXR: IMPRESSION: Increased left retrocardiac opacity suspicious for pneumonia or aspiration. Correlate clinically. . EKG [2184-12-27]: sinus rhythm. rate 60s. PVC. Borderline left axis deviation. Mildly prominent q waves in I and aVL with biphasix T wave in I and TWI in aVL. No sig change since [2184-12-13]. . EGD ([12-28]): Schatzki's ring Medium hiatal hernia Ulcers in the stomach body and antrum Erosions in the fundus Ulcers in the first part of the duodenum and second part of the duodenum Otherwise normal EGD to second part of the duodenum . [2184-12-31] 07:30AM BLOOD WBC-11.7* RBC-3.59* Hgb-11.1* Hct-32.6* MCV-91 MCH-31.0 MCHC-34.1 RDW-14.7 Plt Ct-320 [2184-12-31] 07:30AM BLOOD Glucose-102 UreaN-118* Creat-3.7* Na-144 K-4.3 Cl-113* HCO3-18* AnGap-17 [2184-12-31] 07:30AM BLOOD CK(CPK)-62 [2184-12-28] 12:19 pm SEROLOGY/BLOOD Source: Venipuncture. FINAL REPORT [2184-12-29] HELICOBACTER PYLORI ANTIBODY TEST (Final [2184-12-29]): POSITIVE BY EIA. (Reference Range-Negative). [2184-12-31] CXR FINDINGS: In comparison with the study of [12-27], there is further increase in opacification at the left base with slight silhouetting of the hemidiaphragm. The appearance is suggestive of aspiration or pneumonia. [2185-1-2] UA SpecGr 1.013 pH 5.0 Urobil Neg Bili Neg Leuk Tr Bld Neg Nitr Neg Prot Tr Glu Neg Ket Neg RBC 1 WBC 7 Bact Few Yeast None Epi 1 Brief Hospital Course: Assessment and Plan: [Age over 90 ] yo F with CAD, chronic distolic heart failure, hypertension, hypothyroidism, chronic renal failure presents after a gastrointestinal bleeding, syncope and acute renal failure. . 1. GIB: Baseline HCT > 34. On admission 31 in the setting of dehydration. Remained hemodynamically stable. Repeat hct of 26.2 prompted transfusion of 1U PRBCs. EGD on [12-28] showed multiple gastric and duodenal ulcers, not actively bleeding. H pylori was positive. Patient was started on [Hospital1 ] PPI, Clarithromycin, and Amoxicillin. HCT stable at 32 on discharge. Aspirin and Plavix were held. GI recommended holding plavix for total of 2 weeks, and Aspirin for 4-5 days. Restarted ASA on discharge. Plavix to be resumed on [1-11]. Please monitor HCT. Please continue PPI [Hospital1 ] for total of 6 weeks (started [12-28]). Patient was found to be H. pylori positive, and was started on Amoxicillin and clarithromycin on [2184-12-30]. . 2. Left retrocardiac opacity: Crackles on exam and elevated white count. T 96.6, has been low for several days, with HCO3 of 17. CXR [12-31] showed worsening infiltrate. -continue amoxicillin and clarithromycin from H.pylori therapy for pneumonia. Patient's GFR is 7. . 3. Syncope: Thought to be secondary to GI bleed and dehydration. EKG without any acute ischemic changes. Three sets of cardiac enzymes negative. . 4. Acute on chronic renal failure: Cr up to 4.5 but recent baseline 1.7-2.2. However has been slowly trending up. Nephrology was consulted. Thought to be prerenal. Seemed to be improving on discharge, with creatinine down to 2.9 with IV fluids. This will need continuous monitoring as an outpatient. Continues to have good urine output. - send urine lytes . 5. UTI: Developed urinary urgency and frequency, UA consistent with UTI. Started on 7 day course of ciprofloxacin on [1-3]. 6. CAD: Known CAD s/p multiple PCI. Inferior NSTEMI on [2184-12-11]. Last PCI in [2179]. Held Asa and plavix in the setting of GI bleed. Carvedilol was held briefly, and restarted prior to discharge. Medications on Admission: Current Medications: Confirmed with family Levothyroxine 75 mcg daily Aspirin 325 mg daily Nitroglycerin 0.3 mg prn Atorvastatin 80 mg daily Docusate Sodium 100 mg [Hospital1 ] prn Clopidogrel 75 mg daily Carvedilol 12.5 mg [Hospital1 ] Furosemide 20 mg [Hospital1 ] Indomethacin 75 mg daily Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 4. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily) for 10 days. Disp:20 Capsule(s) Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every 6-8 hours as needed for nausea. Disp:20 Tablet, Rapid Dissolve(s) Refills:0 7. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Location (un) 169] in [Last Name (un) ] [Doctor Last Name ] Discharge Diagnosis: Primary diagnosis: 1. Gastric and duodenal ulcers 2. H. pylori infection 3. Syncope 4. Acute renal failure 5. Urinary tract infection 6. Aspiration pneumonia Secondary diagnosis: Coronary artery disease Chronic diastolic heart failure Hypertension Hyperlipidemia Chronic kidney disease Hypothyroidism Discharge Condition: Stable. HCT 32.6. Discharge Instructions: You were admitted because you were passing blood in your stool. You had an endoscopy performed that showed ulcers in your stomach. You are on a medication and several antibiotics to treat this. You received several blood transfusions because your blood count was low. We have stopped your plavix and Aspirin temporarily because they can increase GI bleeding. Your indomethacin was stopped, as this can worsen ulcers. Your Carvedilol was stopped while you were in the hospital. Next time you see Dr. [Last Name (STitle) ], you can discuss restarting it. Your kidneys weren't functioning well during your hospitalization. We are closely monitoring your kidney function, and this will need to be monitored in clinic as an outpatient. If you have lightheadedness, fevers, bright red blood in your stools, black stools, or vomiting blood, please call your primary doctor or go to the emergenc room. Followup Instructions: You have an appointment with Dr. [Last Name (STitle) ] Thursday [1-6] at 3:15pm. You will need to have some labs checked on Monday. You have an appointment with Dr. [Last Name (STitle) 80026] on [2-15] at 1pm. The clinic number is [Telephone/Fax (1) 9557]. Completed by:[2185-1-3] ICD9 Codes: 5789, 5849, 2762, 486, 4280, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2274 }	Medical Text: Admission Date: [2189-9-24] Discharge Date: [2189-9-30] Date of Birth: [2119-2-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Bronchopleural Fistula Major Surgical or Invasive Procedure: [2189-9-25] Rigid bronchoscopy using Dumon black bronchoscope. Flexible bronchoscopy, Placement of covered metal stent [95] x 40 mm in the left main stem covering the left upper lobe bronchus, Balloon dilation of the metal stent. History of Present Illness: Mr [Known lastname 84248] is a 70 year old man with a history of non-small cell lung CA s/p R thoractomy with en bloc wedge resection in [2184], who, on [2189-7-28] at [Hospital6 8432] Center, underwent left thoracotomy, left upper lobectomy with wedge resection of left lower lobe for two new lung lesions identified on surveillence CT chest in [5-28]. Post-operatively, the patient remained intubated and had a mild elevation in his troponins which later trended down. He underwent tracheostomy on [2189-8-11] and G-tube placement. He subsequently developed ventilator associated PNA (MSSA and enterobacter) and has been treated with Zosyn and remained ventilaor dependant. He eventualy recovered well but had a had a persistant air leak and on his discharge to a [Hospital 5442] rehab ([Hospital1 ]) his chest tube remained in place. The chest tube then fell out at rehab and he was then transferred to [Hospital3 ] Medical Center for replacement and managament of the chest tube. He underwent bronchoscopy and it was thought he had a bronchopleural fistula. He was planned to undergo a Eloesser procedure, but was felt to be too high risk and was transferred to [Hospital1 18] for bronchoscopy and possible endobronchial glue to treat likely bronchopleural fistula. Has been afebrile at [Hospital3 84249], WBC normalized. last BM today. Was complaining of LLQ pain during admission, underwent Abd CT [9-19] that was normal. Past Medical History: LULobectomy/LLlobe wedge for lung CA via L thoractomy [2189-7-28] NSCL Ca [2184] s/p R thoracotomy, en bloc resection portions of RUL/RLM/RLL ETOH GERD Depression L knee OA h/o PE Social History: Lives in [State 1727]. Ex-smoker. + EtOH Family History: unknown Physical Exam: PHYSICAL EXAM: T 97.5 HR 99 BP 131/69 RR 26 02 94% CMV 450x14 peep 5 GENERAL [x] NAD [x] AAO to person HEENT [x] EOMI [x] PERRL/A [x] Anicteric [x] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [ ] Abnormal findings: tracheostomy tube in place, no drainage RESPIRATORY hyperesonent left chest, decreased BS right base, no crackles Left chest tube in place to WS, +airleak CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD GI Soft, ND, No mass/HSM, tender per patient w deep palpation, no rebound or guarding. Peg in place, capped. GU- foley in place, deep yellow urine in bag EXT: warm, well-perfused, 2+ edema, RUE PICC line in place. no erythema. Pertinent Results: [2189-9-30] 02:33AM BLOOD WBC-9.3 RBC-2.91* Hgb-7.4* Hct-23.8* MCV-82 MCH-25.6* MCHC-31.3 RDW-19.1* Plt Ct-282 [2189-9-30] 02:33AM BLOOD Glucose-115* UreaN-16 Creat-0.5 Na-140 K-4.0 Cl-96 HCO3-39* AnGap-9 [2189-9-30] 03:45AM BLOOD Hct-24.1* [2189-9-30] 09:17AM BLOOD Hct-26.0* Brief Hospital Course: Pt was admitted to SICU on [2189-9-24] and had CT Chest done which demonstrated the following. CT Chest with Contrast ([2189-9-24]): 1. Likely bronchopleural fistula from the left upper lobe stump. 2. Ground-glass opacification, peribronchial consolidation and pleural effusion, most consistent with multifocal pneumonia and mild pulmonary edema. 3. Enlarged hyperdense paratracheal nodes that may relate to patient's diagnosis of NSCLC or be reactive. 4. Severe emphysema. 5. Pattern of interstitial disease suggestive of usual interstitial pneumonia which may be secondary to idiopathic pulmonary fibrosis, collagen vascular disease, or drug reaction. 6. Lung loculated effusion on the left with apparenelty thickened consistent with intection/inflammation. 7. Aortic and mild coronary artery calcification. 8. Defects the ribs on the right may be due to respiratory motion or fractures. Correlate clinically. Patient underwent rigid bronchoscopy with stent placement on [2189-9-25]. Plans were made to transfer him back to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1727] Medical Center for further surgical treatment ([Last Name (un) 72968] procedure) with his thoracic surgeon there. After communication with his thoracic surgeon it was determined that they were unable to provide him with [Location (un) ] transportation to his facility. Plans were then made to transfer to him back to [Hospital ] Rehab with follow-up with his thoracic surgeon in [State 1727]. Medications on Admission: Lopressor 25mg PO BID Nexium 40 mg PO DAILY Lorazepam 0.25mg PO q 8 Trazadone 50mg PO Daily Colace 100mg PO BID Fentanyl patch 50mcg topical q72hrs Nicotine Patch 21mg topical DAILY Zosyn 2.2.5mg IV q 6 Day #11 or 14 Tylenol 650 q 4 prn fever albuterol nebs q 4 prn SOB Dulcolax 10mg PO/PR prn Daily Haldol 2mg PO q 4 prn agitation Ativan 1 mg IV q 12 prn agitation Morphine 2mg IV q12 prn pain Morphine 1 mg IV q 2 prn severe pain Zofran 4mg IV q 8 prn nausea Oxycodone 10mg PO q 4 prn pain Lovenox 40mg SC DAILY ProMod w Fiber at 75cc/hr + 200cc free H20 down g-tube [Hospital1 ] Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 2. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous Membrane [Hospital1 ] (2 times a day). 4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Lung cancer with respiratory failure and bronchopleural fistula. Discharge Condition: Fair Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: Please follow up with your thoracic surgeon at [State 48444] Center in [12-24] weeks [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 2762, 496, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2275 }	Medical Text: Admission Date: [2155-6-9] Discharge Date: [2155-6-13] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2195] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD through ostomy bag at [Hospital ] Hospital with suture placed at ostomy site at [Location (un) ]. [Hospital1 18]: NG lavage and Ileoscopy through ostomy site [2155-6-10] History of Present Illness: [Age over 90 ] year old man with history of PUD, recurrent diverticulitis s/p illeostomy with history of illioconduit in [2145] then colostomy in [2152], recent history of GI bleed 5 weeks ago complicated by retained small bowel camera who presents with an acute GI bleed. 3-5 days prior to admission he noticed blood filling his ileostomy bag. The bag actually filled up with blood three times over the past week. He and his wife tried to apply pressure to the bleeding on the day of admission ([2155-6-9]), which only temporarily helped. He denied any abdominal pain, nausea, vomitting, chest pain, shortness of breath, fevers, chills. When the bleeding did not stop, he decided to come to the ED. . He arrived at [Hospital ] Hospital and underwent an EGD through the ileostomy stoma which only revealed blood and no obvious source of bleeding. He then underwent an a repeat EGD through the ileostomy stoma that did not reveal the source of bleed. He did get fent/versed and for unclear reasons sux/etom (although not intubated) for sedation for this procedure. He also was given phenylephrine and levoquin during the procedure. This procedure also did not reveal the bleed. He had a suture placed at the stoma entry site. He remained hemodynamically stable throughout his stay and he was given 4 units of PRBCs, 2 units of FFP during his hospital stay, and his HCT rose from 23 at 9am to 28 at 9pm on [2155-6-9]. He also was on protonix 40mg IV BID and an ocreotide gtt. Because both scopes were unrevealing, he was transferred to [Hospital1 ] for unstable blood volume and evaluation for IR guided intervention. His access was 2 #20 PIVs. . Of note, patient had a recent hospital stay for GI bleed at [Hospital ] Hospital with a small bowel camera retained in small bowel from [Date range (1) 89310] for N/V and ?GI bleed c/b retention of small bowel camera c/b SVT and fever. It is unclear if this camera was ever removed. Past Medical History: 1. Diverticulitis 2. Performated Meckel's diverticulum requiring surgery 3. S/p subtotal colectomy in [2152] for diverticulosis 4. S/p partial small bowel resection with ileostomy and ileal conduit in [2145] for diverticulosis 5. CKD baseline Cr 1.5 6. H/o prosate CA s/p radiation in [2134] 7. PVD 8. Peripheral neuropathy 9. Macular degeneration of R eye 10. PUD 11. AS 12. S/p hemorrhoidectomy 13. Migraines 14. S/p cholecystectomy [2151] 15. Last echo EF 55% Social History: Lives with his wife in [Name (NI) ], MA. He does not currently smoke, drink, or use drugs. Family History: Noncontributory. Physical Exam: On admission: GEN: Pale, confused, elderly man in NAD, AOx2 HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no jvd, no RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no r/g, 4+ crescendo/decrescendo SM, with loss of S2, +pulsus parvus et tardus, not late peaking ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, ileostomy bag with active exsanguination and + clots that resolved after 30m, stoma without any obvious bleeding lesions with fresh suture in place EXT: no c/c/e, trace LLE edema, none on RLE SKIN: no rashes/no jaundice/no splinters NEURO: AAOx2. On discharge: GEN: elderly gentleman in NAD, alert and oriented to person, year (thinks he is in [Hospital1 ] still; knows the year but thinks it's [Month (only) 958]) HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no jvd, no RESP: CTA b/l with good air movement throughout CV: S1 and S2, 4+ crescendo/decrescendo SEM, with loss of S2, +pulsus parvus et tardus, not late peaking ABD: (+)bowel sounds, ileostomy in place with 300cc of maroon fluid, urostomy with light yellow urine; soft, nt, no masses or hepatosplenomegaly, stoma without any obvious bleeding lesions Pertinent Results: ADMISSION LABS [2155-6-9] 10:54PM BLOOD WBC-8.8 RBC-3.46* Hgb-10.1* Hct-28.2* MCV-82 MCH-29.1 MCHC-35.7* RDW-16.1* Plt Ct-113* [2155-6-9] 10:54PM BLOOD PT-13.4 PTT-27.6 INR(PT)-1.1 [2155-6-9] 10:54PM BLOOD Glucose-129* UreaN-25* Creat-1.0 Na-141 K-4.3 Cl-109* HCO3-23 AnGap-13 [2155-6-10] 03:05AM BLOOD ALT-9 AST-17 LD(LDH)-181 AlkPhos-60 TotBili-2.0* [2155-6-9] 10:54PM BLOOD Calcium-7.1* Phos-4.3 Mg-1.6 DISCHARGE LABS [2155-6-13] 07:50AM BLOOD WBC-4.4 RBC-3.36* Hgb-9.9* Hct-28.1* MCV-84 MCH-29.5 MCHC-35.4* RDW-15.5 Plt Ct-163 [2155-6-13] 11:00AM BLOOD Hct-30.4* [2155-6-13] 07:50AM BLOOD Glucose-87 UreaN-18 Creat-1.2 Na-138 K-3.6 Cl-107 HCO3-26 AnGap-9 [2155-6-12] 07:40AM BLOOD TotBili-0.6 DirBili-0.2 IndBili-0.4 [2155-6-13] 07:50AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.8 EKG [2155-6-9] Sinus rhythm with premature ventricular complexes. Probable left anterior fascicular block with right bundle-branch block. Diffuse baseline artifact on the first half of the tracing marring interpretation of ST segments for ischemia but no gross abnormalities appreciated. No previous tracing available for comparison. CTA ABDOMEN/PELVIS [2155-6-10] 1. Multiple bowel surgeries, with right lower quadrant ileostomy. No evidence of vascular extravasation, obstruction, or leak. 2. Rectal Hartmann pouch, with apparent mild wall thickening that could reflect proctitis. 3. Ileal conduit and urostomy in the left lower quadrant. Renal atrophy and mild bilateral hydroureteronephrosis, likely reflecting chronic reflux. 4. Cholecystectomy, with moderate intrahepatic and common biliary ductal dilation. 5. Emphysema and moderate bilateral pleural effusions. CXR [2155-6-10] 1. Bibasilar opacities are likely atelectasis although pneumonia or aspiration pneumonitis cannot be excluded. 2. Pulmonary vascular congestion without evidence of pulmonary edema. 3. Small left pleural effusion. CXR [2155-6-11] As compared to the previous radiograph, there is a progression of the pre-existing parenchymal opacities. The pattern and distribution of the changes suggest pulmonary edema of moderate severity. In addition, the pre-existing retrocardiac atelectasis and right basal parenchymal opacity persists Ileoscopy [2155-6-10] Normal mucosa in the ileum without blood. Otherwise normal colonoscopy to ileum (20cm examined) Brief Hospital Course: BRIEF HOSPITAL COURSE Mr. [Known lastname 6632] is a [Age over 90 ]y/o gentleman with history of PUD, recurrent diverticulitis s/p illeostomy with history of illioconduit in [2145] then colostomy in [2152], recent history of GI bleed 5 weeks ago complicated by retained small bowel camera who presented with an acute GI bleed. This may have been due to a stomal tear, which was repaired at the OSH. During this admission his Hct was stable and he was discharged home. . 1. Acute GI bleed: Resolved. Lower GI source most likely given that he was briskly bleeding with clots yet remaining hemodynamically stable. Possibly from a stomal tear. At OSH a tear was visualized and he underwent stoma revision. Since he has been here, he has had no active bleeding. No clear source identified on CTA. He did require 3u pRBCs and his Hct remained stable after that. GI scoped through ileostomy with no clear source and given stability, Surgery signed off. Next step would be capsule endoscopy, which Pt declined due to his h/o obstruction from retained camera. He was advised to follow up as an outpatient and to continue his PPI. He was d/c'd home with PT and GI follow-up. . 2. Hypoxia: Pulmonary edema, resolved. Occurred while in ICU, most likely due to pulmonary edema from volume resuscitation. He was diuresed with Lasix 20mg IV x1, successfully. He was subsequently euvolemic. . 3. [Last Name (un) ] on CKD: Cr peaked at 1.4, was likely prerenal in the setting of acute blood loss. Resolved quickly after blood transfusions and his Cr returned to his baseline (1.2). . 4. AS: Moderate to severe based on exam. Unclear why not on diuretics or antihypertensives, although fludricortisone suggests h/o orthostasis. He was set up with an appointment to follow up with his Cardiologist. . 5. Depression: Chronic. He was continued on Celexa. . 6. PVD: stable. Unclear why not on aspirin or statin. He was told to follow up with his Cardiologist. . Code Status: DNR/DNI Medications on Admission: 1. Celexa 20mg PO daily 2. Rabeprazole 20mg PO daily 3. Fludrocortisone 0.1mg PO daily 4. Gabapentin unknown dose PO BID 5. Vitamin B12 600mcg PO daily Discharge Medications: 1. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. rabeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary diagnosis this admission: Gastrointestinal bleeding of unclear source. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 18] from another hospital with bleeding into your ostomy pouch. You received several blood tranfusions to maintain your blood levels and the bleeding eventually slowed down such that your blood levels were stable for several days. Our gastroenterologists and surgeons felt comfortable discharging you from the hospital given that you blood levels were stable, and you did not want to have any further workup at this time. Therefore, it is important for you to follow up closely with the gastroenterologist doctors [Name5 (PTitle) 7974]. If you notice any further bleeding, return to the hospital immediately. We did not make any changes to your medications. Followup Instructions: PRIMARY CARE Name: [Doctor Last Name ],[Last Name (un) 49339] V. MD Address: [Street Address(2) 89311]., [Location ],[Numeric Identifier 26374] Phone: [Telephone/Fax (1) 13745] Appointment: Thursday [2155-6-26] 11:00am CARDIOLOGY Name: [Last Name (LF) ],[Name8 (MD) ] MD Address: [Street Address(2) ] SUITE #4930, [Location (un) ],[Numeric Identifier 7023] Phone: [Telephone/Fax (1) 89312] Appointment: Tuesday [2155-7-1] 11:20am GASTROENTEROLOGY [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) 1437] [Name8 (MD) ], MD S W Gastroenterological Assoc [State 89313], SW Gastro Assoc [Location (un) ], [Numeric Identifier 23881] Phone: ([Telephone/Fax (1) 89314] We are working on a follow up appointment in Gastroenterology with Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) 1437] within 2 weeks. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call [Telephone/Fax (1) 25843]. ICD9 Codes: 5789, 2851, 5849, 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2276 }	Medical Text: Admission Date: [2112-6-11] Discharge Date: [2112-6-15] Date of Birth: [2062-5-23] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[First Name3 (LF) 2291] Chief Complaint: seizure Major Surgical or Invasive Procedure: You were initially intubated and admitted to the ICU during this hospitalization. History of Present Illness: 50 yoM found unaccompanied on a park bench by police/EMS seizing. No sign of trauma at the scene. Fingerstick glucose at the site was 142. En route to the ED, the patient was post-ictal but able to tell EMS his name ([Known firstname ]) and that he was a drinker. . In the ED, initial vs were: T 98.4 P 128 BP 145/77 R 24-30 O2 sat 99% on NRB. Upon arrival to the ED, the patient seized again; he had 1 tonic-clonic seizure and received 1mg Ativan x2. After his seizure in the ED, the patient remained non-responsive and started the gurgle. He was intubated for protection of his airway. CT scan of the head showed no acute ICH or acute intracranial pathologic process. Encephalomalacia in the L frontal lobe, and there was evidence of prior craniotomy. A foley was placed with good uop and an OGT was also placed. . On the floor, the patient arrived intubated and sedated. Initial VS were: T 37.7 P 101 BP 127/79 R 15 O2 Sat 97%; vent settings: CMV/Assist, FiO2 100%, RR 14, TV 500, PEEP 5. He was finishing his third liter of NS. An ABG was obtained on presentation to the ICU. . Review of systems: Unable to obtain. Past Medical History: # EtOH abuse with hx of withdrawl seizures and DT's # seizure disorder [12-30] traumatic brain injury # hypertension # Hyperlipidemia # Essential tremor Social History: currently homeless unemployed incarcerated in the past daily EtOH - [11-29] quart of vodka daily hx of cocaine use [11-29] PPD smoker has daughter that lives in [Name (NI) 1727] Family History: pt denies any known family history Physical Exam: Admission Exam: Vitals: T: 37.7 BP: 127/79 P: 101 R: 15 O2: 97% on vent. General: Sedated, intubated. HEENT: Sclera anicteric. Pinpoint pupils, minimally reactive to light. ETT and OGT in place. Scar over the left frontal-temporal area. Neck: No LAD. Lungs: Clear to auscultation bilaterally. No wheezes or crackles. CV: Regular rate and rhythm. Normal S1 + S2. No murmurs, rubs, gallops Abdomen: Soft, NT/ND. Bowel sounds +. No HSM. GU: Foley in place. Ext: WWP. 2+ DPs. No clubbing, cyanosis or edema Skin: multiple tattoos with dry skin. Neuro: Arousable to name. Able to squeeze right hand on command. Unable to squeeze left hand on command. Pertinent Results: [2112-6-11] 11:45PM TYPE-ART TEMP-38.7 PO2-120* PCO2-43 PH-7.40 TOTAL CO2-28 BASE XS-1 COMMENTS-AXILLARY T [2112-6-11] 11:45PM LACTATE-1.4 [2112-6-11] 08:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2112-6-11] 08:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2112-6-11] 08:15PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [2112-6-11] 08:15PM URINE HYALINE-3* [2112-6-11] 08:15PM URINE MUCOUS-RARE [2112-6-11] 07:33PM LACTATE-27.7* [2112-6-11] 07:20PM GLUCOSE-150* UREA N-10 CREAT-1.0 SODIUM-145 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-8* ANION GAP-38* [2112-6-11] 07:20PM ALT(SGPT)-84* AST(SGOT)-102* LD(LDH)-343* CK(CPK)-550* ALK PHOS-97 TOT BILI-0.4 [2112-6-11] 07:20PM LIPASE-62* [2112-6-11] 07:20PM ALBUMIN-5.0 [2112-6-11] 07:20PM WBC-9.9 RBC-4.46* HGB-14.4 HCT-45.6 MCV-102* MCH-32.4* MCHC-31.6 RDW-14.6 [2112-6-11] 07:20PM NEUTS-47* BANDS-1 LYMPHS-32 MONOS-16* EOS-0 BASOS-0 ATYPS-4* METAS-0 MYELOS-0 [2112-6-11] 07:20PM PLT SMR-NORMAL PLT COUNT-266 Discharge labs: [2112-6-14] 06:15AM BLOOD WBC-6.0 RBC-4.41* Hgb-14.5 Hct-41.5 MCV-94 MCH-32.8* MCHC-34.9 RDW-13.6 Plt Ct-247 [2112-6-14] 06:15AM BLOOD Glucose-114* UreaN-4* Creat-0.8 Na-136 K-3.7 Cl-100 HCO3-28 AnGap-12 [2112-6-14] 06:15AM BLOOD ALT-45* AST-35 LD(LDH)-200 CK(CPK)-176 AlkPhos-72 TotBili-0.5 [2112-6-14] 06:15AM BLOOD Albumin-3.8 Blood cultures ([6-13] and [6-12]): no growth to date, final results pending. Urine culture (([6-12]): no growth - FINAL. MRSA screen ([6-12]): no MRSA - FINAL. CT Head ([6-11]): TECHNIQUE: Non-contrast MDCT images were acquired through the brain. Multiplanar reformatted images were obtained for evaluation. FINDINGS: The study is slightly limited by patient's motion. Allowing for the limitations, there is encephalomalacia in the left frontal lobe, with adjacent old left frontotemporal craniotomy, compatible with prior injury with surgical intervention. There is otherwise no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct. Apart from the ex vacuo effect from the left frontal encephalomalacia, there is no shift of normally midline structures. The ventricles and sulci are prominent, representing age-advanced global atrophy. There is no evidence of acute fracture. Scattered anterior ethmoidal opacification is noted with minimal aerosolized fluid in the right maxillary sinus. The remaining visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Evidence of old left frontotemporal craniotomy, with severe left frontal encephalomalacia, compatible with old injury with surgical intervention. Recommend clinical correlation. 2. No evidence of acute intracranial pathologic process. Specifically, no intracranial hemorrhage. Brief Hospital Course: 40yoM with no known significant PMHx with a known history of EtOH use found by police/EMS seizing and who had one tonic-clonic seizure in the ED. #seizure disorder: The patient was intubated for airway protection after seizure in the ED and admitted to the ICU. The patient did well in the ICU and was extubated the following morning and transferred to the regular medical floor. He has a known history of seizure disorder due to traumatic brain injury several years prior and also has a history of EtOH withdrawl seizures. He admits to being non-compliant with his outpatient regimen of Keppra and has been non-compliant with [Hospital 878] Clinic follow-up at [Hospital1 2177] as well. Following transfer to the floor, he was kept on oral standing and PRN benzos for EtOH withdrawl and then seen by Neurology Consult regarding the etiology and treatment of his seizures. Neurology Consult felt that the most likely etiology of his seizures is his underlying epilepsy due to prior TBI. They recommended restarting him on his Keppra, and he received an IV Keppra load and was started on maintenance Keppra as an antiepileptic. At this time, the patient is amenable to restarting anti-seizure medications and states he will continue the medication and follow-up with [Hospital 878] Clinic at [Hospital1 2177] in 2 days. #EtOH depedence: The patient has a long-standing history of EtOH abuse and has been through treatment programs multiple times. On this admission, he was initially placed on IV benzos standing in the ICU, then transitioned to standing and PRN PO benzos, then PRN PO benzos only. He has not required any benzos in the past 24 hours and remains stable and without signs and symptoms of withdrawl. After discussion with Social Work, he has indicated that he is not interested in EtOH cessation at this time. He was started on multi-vitamin, thiamine and folate, and will be discharged with these prescriptions as well. #Code status: Full code #Pending lab work: Pt's blood cultures drawn during this admission are negative thus far, but final results still pending. Medications on Admission: none Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Seizure disorder, epilepsy. EtOH dependence. Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to the hospital after presenting via ambulance with seizures. You were initially admitted to the ICU, after being intubated and connected to a ventilator machine. You did well in the ICU and was then transferred to the floor after being removed from the ventilator and breathing on your own. You were seen by the Neurology Consult service given your history of seizures and restarted on your prior anti-epileptic medication (Keppra). Please continue to take your medications as prescribed and please follow-up with your outpatient [Hospital 878] Clinic appointment. Your blood cultures drawn during this admission are negative thus far, but final results are still pending. Followup Instructions: Name: [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] --Neurology Address: Dept of Neurology-[Hospital1 2177], [First Name8 (NamePattern2) ] [Hospital Ward Name 23] Bldg, Ste 7B, [Location (un) 86], [Numeric Identifier 89923] Phone: [Telephone/Fax (1) 25666] Appt: [6-17] at 10am NOTE: If you are unable to keep this appt, please give 24 hours notice. ICD9 Codes: 2762, 4019, 2724, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2277 }	Medical Text: Admission Date: [2123-8-21] Discharge Date: [2123-8-25] Date of Birth: [2076-3-31] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 3298] Chief Complaint: Hematochezia, Abdominal Distension Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy Colonoscopy with biopsies Ultrasound guided paracentesis History of Present Illness: 47F with PMH of chronic depression, hemorrhoids x 20+ years presents with BRBPR for past 2 weeks. Patient states that 2 weeks ago, she drank tap water, which she normally does not do, and began to have diarrhea. Since then, she has been going to the bathroom every hour, with small amounts of loose stool, until two days ago, when she became more constipated. She has noticed her hemorrhoids more recently, in the sense that when she uses the bathroom, she can feel them popping out from her sphincter, and finds blood on the toilet paper when she wipes. There is no pain associated with her hemorrhoids. At the same time, she has noticed worsened abdominal distension and her clothes no longer fit. She denies abdominal pain, nausea, or vomiting. Yesterday, she had a fever of 100F with some sweats, but has not noticed any fevers since. She was also complaining of reflux symptoms over the past three days for which she had been taking an over the counter anti-acid. In the ED, initial vs were: 98.8, 106, 116/80, 18, 100% RA. Labs were notable for an HCT of 24.5 with an MCV of 122, Plt of 109, AP of 204, t-bili of 3, AST of 62, ALT of 18, amylase of 219, lipase of 123, INR of 1.7 and negative serum/urine tox screens. A CT of her abdomen/pelvis with contrast was notable for a thickened colonic wall consistent with colitis and a moderate amount of free fluid in the pelvis/paracolic gutters. She was given levofloxacin, with plans to start flagyl but did not receive this in the ER. She was given 4g of Mg and 40meq of potassium. GI was consulted with possible plans for a colonoscopy on Monday, she had two 18 gauge IV's placed but was not transfused any PRBC's in the ER. She was admitted to the ICU for frequent HCT monitoring. VS on transfer were: T 98.4, BP 118/86, RR 17, O2 sat 100% RA. On arrival to the ICU her initial VS were: T98, Hr99, BP129/88, RR20, Sat 100% (RA). She looks comfortable with no abdominal pain, nausea/vomiting. She does feel somewhat lightheaded, but no chest pain or SOB. Review of Systems: Positive per HPI. Other review checked and unremarkable. Past Medical History: Hemorrhoids Depression (hx of SI, insomnia) ETOH abuse, in remission (last drink > 1 year ago, last heavy use approximately 4 years ago) anemia secondary to folate deficiency asthma Hyperthyroidism s/p ablation, now hypothyroid HTN Low back pain secondary to DJD s/p tubal ligation s/p fibroidectomy Social History: unemployed, social support from mother but serious financial limitations - Tobacco: 1 pack/day for 20 years - Alcohol: former alcohol abuse (up to [1-3] pink whisky/night), quit using alcohol last year, reports much less alcohol over the past four years - Illicits: none Family History: Diabetes mellitus and cancer in members. No inflammatory bowel disease she knows about. Physical Exam: Admission Physical Exam: Vitals: T:98 BP:129/88 P:99 R:20 O2:100%(RA) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, very distended, liver edge 4cm below costophrenic margin, tympanic to percussion, no tenderness to palpation GU: no foley Ext: warm, well perfused, no edema Discharge Physical Exam: All vital signs stable and within normal limits. Pt appeared comfortable. Mild jaundice. Heart and lung exam within normal limits. Abdominal exam notable for significantly diminished distension after U/S guided paracentesis. Abdomen nontender and liver edge no appreciated. Bowel sounds positive. No masses. Otherwise exam notable for no asterixis. Pertinent Results: =================== LABORATORY RESULTS =================== Admission Labs: WBC-6.0 RBC-2.02# HGB-8.4# HCT-24.5# MCV-122# RDW-15.2 PLT COUNT-109* --NEUTS-75.5* LYMPHS-15.1* MONOS-8.3 EOS-0.7 BASOS-0.4 PT-18.6* PTT-32.7 INR(PT)-1.7* GLUCOSE-92 UREA N-5* CREAT-0.7 SODIUM-139 POTASSIUM3.0* CHLORIDE-98 TOTAL CO2-29 ALT(SGPT)-18 AST(SGOT)-62* LD(LDH)-204 CK(CPK)-103 ALK PHOS-204* AMYLASE-219* TOT BILI-3.0* ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-2.7 MAGNESIUM-1.3* LIPASE-123* cTropnT-<0.01 CK-MB-2 Serum Tox: ASA-NEG ACETMNPHN-NEG ETHANOL-NEG UCG neg, UA: BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-SM RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-33 Urine Tox: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Discharge Labs: WBC-7.9 RBC-2.52* Hgb-9.8* Hct-29.0* MCV-115* RDW-18.3* Plt Ct-85* PT-18.8* PTT-36.2* INR(PT)-1.7* Glucose-83 UreaN-2* Creat-0.6 Na-133 K-3.6 Cl-101 HCO3-23 Other Important Labs calTIBC-221* Ferritn-176* TRF-170* VitB12-1123* Folate-7.4 TSH-33* HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE HCV Ab-NEGATIVE Anti Smooth Muscle Antibody- POSITIVE * [Doctor First Name ]-NEGATIVE Paracentesis: WBC-270* RBC-25* Polys-3* Lymphs-16* Monos-73* Mesothe-8* TotPro-3.1 Albumin-1.8 ============== MICROBIOLOGY ============== Urine Culture [2123-8-21]: No growth Stool Culture and C diff toxin assay: negative Peritoneal Fluid culture [8-24]: GRAM STAIN (Final [2123-8-24]): 1+ (<1 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 (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): ============== OTHER STUDIES ============== ECG [2123-8-21]: Sinus rhythm. Poor R wave progression with low QRS voltage in the precordial leads and the limb leads. Compared to the previous tracing of [2112-8-9] the QRS voltage has decreased and there is poor R wave progression. CT Abdomen and Pelvis W/ Contrast [2123-8-21]: IMPRESSION: 1. Heterogeneously enhancing liver with a gastroesophageal varix and ascites; consider an acute inflammatory process of the liver. Correlate for clinical presence of hepatitis. 2. Thickened right colonic wall, with lesser thickening of the left colon wall and transverse colon sparing; this finding may be nonspecific in the setting of ascites; another consideration is colitis (infectious versus inflammatory etiologies). Liver/ GB U/S [2123-8-22]: IMPRESSION: 1. Heterogeneous liver with patchy areas of increased echogenicity, finding suggestive of steatosis or possibly acute inflammation. No definite hepatic lesion is identified. 2. Diffuse gallbladder wall edema, likely secondary to edema and/or underlying liver disease. No signs of acute cholecystitis. 3. No intra- or extra-hepatic biliary ductal dilatation. 4. Moderate ascites, largest pocket in the right lower quadrant. Brief Hospital Course: 47F with PMH of chronic depression, hypothyroidism, and alcohol abuse presenting with hematochezia and abdominal distension and signs of acute liver injury with secondary portal hypertension/ascites. 1) Portal hypertension complicated by ascites due to acute or chronic hepatitis: Pt presented with thromobocytopenia, increased transaminases with AST>ALT, elevated bilirubin, and elevated INR that did not normalize with vitamin K. She also had ascites that was eventually revealed to have a SAAG of 1.3 suggestive of being due to portal hypertension. Imaging revealed heterogeneous liver. Overall picture is somewhat confusing. Possible patient has chronic portal hypertension due to cirrhosis (most likely due to previous alcohol abuse) but imaging not strictly typical and though SAAG met criteria for being due to portal hypertension ascites albumin was relatively high. Other possibility would be an acute hepatitis causing acute portal hypertension. Most likely etiology of this would be alcoholic hepatitis but patient vehemently denies continued alcohol use to multiple individuals. Extensive work up for causes of liver disease was unremarkable except for positive low titre anti-smooth antibody but with negative [Doctor First Name ]. She remained with an elevated bili, INR, and low platelets suggesting chronic cirrhosis but given she was otherwise stable she was discharged to follow up in liver clinic for further management and work up. She was cautioned about other manifestations of decompensated cirrhosis (i.e. encephalopathy) and warned to have a low threshold to seek medical care. She was started on 20 mg PO lasix daily at time of discharge to help control ascites. 2) Hematochezia: On presentation patient had bright red blood per rectum with major concern being for a hemorrhoidal bleed vs diverticular bleed vs bleeding from colitis (as CT seemed to suggest inflammation). Never had large volume of blood and never with dark blood suggesting more likely from a lower GI source. The patient's Hct on presentation was 24.5 and increased to around 30 after transfusion of one unit with stability thereafter. Upper and lower endoscopy failed to reveal a clear source of bleeding though there were hemorrhoids, which could certainly explain blood that was seen. To complete work up should get a capsule endoscopy to evaluate for small bowel AVMs. GI elected to arrange this as an outpatient. At time of discharge Hct stable >48 hrs w/o any transfusion. 3) ? Fevers: Pt reported low grade fevers prior to presentation. ED CT scan concerning for colitis so she was started on cipro/metronidazole though never febrile here. Colonoscopy did not show any colitis and C diff negative so metronidazole stopped. SBP was also entertained as a source of fever but by time of paracentesis (deferred due to bedside procedure being technically infeasible and the deferred for endoscopies) she had received four days of antibiotics. Therefore she completed five days of ciprofloxacin for possible SBP. No prophylaxis was started as diagnosis never confirmed and seemed unlikely. 4) Anemia. Patient has hx of anemia from folate deficiency. Hct on presentation at 24.5 likely reflects baseline anemia with component of GI bleeding. Labs suggested no current deficiencies. Possible some degree of sequestration due to portal hypertension. She felt considerably better after transfusion and with higher Hct. She will follow up for Hct rechecks. 5) Hypothyroidism: Pt acknowledged taking levothyroxine irregularly at best. TSH 33 suggestive of very poor adherence. Levothyroxine restarted in hospital. She will follow up with PCP for TSH rechecks. 6) Depression. pt with significant history of depression and had not been taking meds regularly. She was restarted on fluoxetine and aripiprazole in house. 7) Poor adherence: Discussed with social work and largely due to very limited income and large debts for housing. Patient discussed and reassured her that the infrastructure at [Hospital ] Clinic where she plans to be seen should be very helpful in working with financial issues and helping to make sure she does not miss care. Patient was reassured. Need for close follow up, particularly for hepatic issues was repeatedly emphasized. Transitional Issues: -Pt will follow up with PCP to assess for signs of dehydration, tolerance of daily furosemide regime -Pt will follow up with PCP and liver to assess resolution of ascites -Pt will follow up with liver to discuss further work up of liver disease, trend labs, and discuss need for biopsy -Pt will follow up with PCP to recheck anemia and trend as well as platelet count -Final ascites culture results and serum ceruloplasmin pending at time of discharge. Medications on Admission: Levothyroxine 200mcg daily - not taking everyday Metoprolol 100mg daily - not taking HCTZ 50mg daily Amlodipine 5mg daily Fluoxetine 60mg daily - not taking regularly Abilify 20mg daily - not taking everyday but thinks she should be calcium 1000mg Vitamin D Iron Melatonin 3mg Discharge Medications: 1. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:1 2. aripiprazole 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Acute decompensated cirrhosis complicated by ascites Acute GI bleed (source unclear) Secondary Diagnoses: Depression Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with GI bleeding and swelling of your abdomen. We think the swelling in the abdomen was due to liver disease, likely due to your previous heavy alcohol use (we have excluded viruses and some other common causes though the liver doctor you follow up might perform other investigations). Despite using a camera to look at significant portions of your upper and lower GI tract we did not pinpoint a source of bleeding. Nevertheless, the bleeding resolved on its own and it is likely a slow source so GI feels it can be worked up as an outpatient. Your medications have been changed. You have been started on an acid blocking medication to help prevent further episodes of bleeding. Your blood pressure medicines have been held as your blood pressure is normal without them. Finally, you have been started on a diuretic called furosemide (lasix) to help you get rid of excess fluid on the body. Followup Instructions: Department: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] When: THURSDAY [2123-9-2] at 9:00 AM With: Dr [First Name4 (NamePattern1) 1060] [Last Name (NamePattern1) 1520] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] South [Hospital ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage NOTE: 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: THURSDAY [2123-9-9] at 10:15 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage ICD9 Codes: 2875, 2851, 2768, 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2278 }	Medical Text: Admission Date: [2132-12-14] Discharge Date: [2132-12-30] Date of Birth: [2066-5-26] Sex: F Service: MEDICINE Allergies: Bactrim / Augmentin Attending:[First Name3 (LF) 983] Chief Complaint: dyspnea, anemia Major Surgical or Invasive Procedure: EGD Colonscopy Capsule endoscopy History of Present Illness: Mrs [Known lastname 103573] is a pleasant 66F with history of COPD, afib, mitral valve replacement presenting from group home with worsening dyspnea on exertion x 3 days. She denies chest pain, cough, shortness of breath, lower extremity swelling, headache, nausea, vomiting, or fever. She has orthopnea at rest and sleeps with 2 pillows at baseline, this has not worsened recently. . In the ED, she was noted to be hypotensive to the 70s, however manual BP was 100/70 and pt was mentating well. Physical exam was notable for loud murmur not previously documented. EKG was done and notable for hypertrophy and ST depressions, unchanged from prior. Labs were notable for mildly elevated lactate of 2.4, hyponatremia to 132, elevated creatinine to 2.4 (baseline 2.0), mildly elevated BNP, and crit of 21.5, down from a baseline of 30. Pt was guiac negative on exam. CXR showed retrocardiac opacity, possibly pleural effussion. . On the floor, pt is comfortable without any complaints. She states that she feels improved since she arrived in the hospital, with improvement in her weakness. . Review of systems: (+) Per HPI. Pt states she has 1 BM daily, no blood recently however did have blood in stools 1 wk prior which she attributed to her hemorrhoids. + lightheadedness. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -Rheumatic heart disease s/p mitral & aortic valve replacement -COPD -Asthma -Hypothyroid -CRI, baseline creatinine 2.0 -urinary incontinence -Anxiety -Depression -Afib -psychoaffective disorder -hx ascending aortic anuerysm 5.4x 4.9 cm [6-/2132], appropriate for resection Social History: Lives in group home. No tobacco/No Etoh, very unstable family life according to PCP Family History: Mother and father with CAD, dad died of MI Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T:98.2 BP:100/46 P:63 R:17 O2:98% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, conjunctiva pale Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregular rate, 2/6 SEM, mechanical s1, s2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: aaox3, CNs [3-22] intact, strength and sensation grossly nl. . DISCHARGE PHYSICAL EXAM VS: 97.3, 77, 103/52, 16, 96% on RA GEN: A&OX3 HEENT: MM dry, oropharynx clear, anicteric conjunctiva NECK: supple, JVP not elevated, no LAD HEART: irregularly irregular rhythm, high pitched S1, S2, [3-16] systolic murmur best heart at LUSB LUNG: CTA Bl ABD: soft, NT/ND, positive BS, no rebound/guarding EXT: warm, no pitting edema, nontender over left MTP Pertinent Results: ADMISSION LABS [2132-12-14] 02:50PM WBC-9.5 RBC-2.34# HGB-6.9# HCT-21.5# MCV-92# MCH-29.6 MCHC-32.2 RDW-20.5 [2132-12-14] 02:50PM NEUTS-84.1* BANDS-0 LYMPHS-9.8* MONOS-5.3 EOS-0.7 BASOS-0.1 [2132-12-14] 02:50PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [2132-12-14] 02:50PM PLT SMR-NORMAL PLT COUNT-273 [2132-12-14] 02:50PM PT-33.2* PTT-77.7* INR(PT)-3.3* [2132-12-14] 02:50PM proBNP-2838* [2132-12-14] 02:50PM GLUCOSE-100 UREA N-69* CREAT-2.4* SODIUM-132* POTASSIUM-3.5 CHLORIDE-91* TOTAL CO2-28 ANION GAP-17 [2132-12-14] 02:50PM cTropnT-0.02* [2132-12-14] 03:00PM LACTATE-2.4* K+-3.5 [2132-12-14] 05:35PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.006 [2132-12-14] 05:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2132-12-14] 11:34PM HCT-23.3* [2132-12-14] 11:34PM CK-MB-2 cTropnT-0.01 [2132-12-14] 11:34PM CK(CPK)-24* . DISCHARGE LABS [2132-12-30] 07:05AM BLOOD WBC-2.9* RBC-3.06* Hgb-8.8* Hct-27.1* MCV-89 MCH-28.9 MCHC-32.6 RDW-17.0* Plt Ct-146* [2132-12-30] 07:05AM BLOOD PT-28.0* INR(PT)-2.7* [2132-12-30] 07:05AM BLOOD Glucose-96 UreaN-13 Creat-1.4* Na-141 K-4.2 Cl-105 HCO3-28 AnGap-12 [2132-12-30] 07:05AM BLOOD ALT-31 AST-24 AlkPhos-21* TotBili-0.4 [2132-12-30] 07:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1 . PERTINENT LABS [2132-12-14] 02:50PM BLOOD proBNP-2838* [2132-12-15] 04:52AM BLOOD calTIBC-369 Hapto-33 Ferritn-23 TRF-284 [2132-12-19] 07:25AM BLOOD VitB12-455 Folate-19.4 . Beta-2-Glycoprotein 1 Antibodies IgG Test Result Reference Range/Units B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU . [2132-12-16] 07:30AM BLOOD tTG-IgA 1 [2132-12-20] 07:00AM BLOOD Inh Screening POS [2132-12-20] 07:00AM BLOOD Lupus anti-coagulant POS [2132-12-22] 07:05AM BLOOD ACA IgG-2.2 ACA IgM-7.2 Anticardiolipin Antibody IgG 2.2 0 - 15 GPL 0-15 GPL: NEGATIVE;15-20 GPL: INDETERMINATE; >20 GPL: POSITIVE Anticardiolipin Antibody IgM 7.2 0 - 12.5 MPL . PERTINENT STUDIES [12-14] CT chest/abd/pelvis IMPRESSION: 1. Stable appearance of thoracic aortic aneurysm without evidence of hematoma in the chest, abdomen, or pelvis, as questioned. 2. Splenomegaly and prominence of the left hepatic lobe, findings that suggest the possibility of background liver disease. Correlation with LFTs is recommended. 3. Biapical and left lower lobe nodular pulmonary densities, for which followup with chest CT is recommended in one year if there are risk factors for lung cancer. 4. Aortic and mitral valve replacement with biatrial enlargement and findings again consistent with pulmonary artery hypertension. 5. Fat-containing umbilical and left inguinal hernias. . [12-16] EGD [Doctor First Name ]-[Doctor Last Name ] tear Blood in the body of stomach Erythema in the stomach Normal mucosa in the duodenum (biopsy) Otherwise normal EGD to third part of the duodenum . [12-16] Colonoscopy Melanosis coli in the colon Polyp in the colon . [12-16] Duodenal biopsy Duodenum, biopsy (A): Duodenal mucosa within normal limits. . [12-24] CXR FINDINGS: In comparison with the study of [12-14], there is continued enlargement of the cardiac silhouette in a patient with aortic and mitral valve replacement and CABG procedure. Opacification at the base posteriorly is consistent with pleural effusion, more prominent on the left. Volume loss is again seen in the region of the left lower lobe. No evidence of acute focal pneumonia. . [12-26] single ballon enteroscopy Normal esophagus. Normal stomach. Normal duodenum. There was one small area with active bleeding seen in the proximal jejunum. The base of the bleeding was not able to be well visualized because of the active bleeding and clots. It is suspicious for AVM or Dieulafoy lesion. It was first treated with cauterization with a gold probe. Then it was injected with 1:10,000 epinephrine. Three hemoclips were placed successfully with good hemostasis. SPOT tattoo was applied on either side of the bleeding area for future localization . [12-29] KUB IMPRESSION: Single focally dilated loop of small bowel with wall thickening and two clips within the lumen, which likely represents a focal ileus in the area of the recent AVM clipping. Brief Hospital Course: 66 yo woman with h/o rheumatoid heart disease s/p MVR and AVR, A-fib on coumadin, admitted for DOE, found to have new anemia. . ACTIVE ISSUES: # Jejunal AVM: Pt presented with 10 pt crit drop. There was no evidence of hemolysis or BM suppression. She was treated with PPI gtt. Her EGD revealed [Doctor First Name 329] [Doctor Last Name ] tear, but no active source of bleeding. Her colonoscopy showed benign polyp and melanosis coli . However, capsule endoscopy showed jejunal AVM. Pt was treated medically with blood transfusion, while awaiting optimization of anticoagulation status. She received endoscopic cauterization on [12-26]. She was hemodynamically stable afterwards. We discontinued her aspirin given she is already on warfarin. WE continued her homedose omeprazole given there is no evidence gastric ulcer disease. . # Coagulation abnormality: Pt has chronically elevated PTT. Current workup is notable for positive mixing test, inhibitor screening, and lupus anticoagulant. The test was done > 48 hrs after cessation of heparin, therefore unlikely false positive from presence of heparin. Her anti-cardiolipin and beta2-glycoprotein were negative. The clinical suspicion for anti-phospholipid syndrome was high, however, pt does not formally meet the diagnostic criteria for antiphospholipid syndrome, and she is already on anti-coagulation treatment. A FOLLOW UP APPOINTMENT WITH HEMATOLOGY ON [2132-3-6] WITH DR. [First Name (STitle) ] HAS BEEN MADE FOR FURTHER WORKUP AND MANAGEMENT. . # Ileus: Pt complained of abdominal bloating and mild discomfort on the last few days of this admission. She tolerated food intake well with no nausea/vomiting. Her abdominal exam was always reassuring. She did not have bowel movement for three days. KUB showed evidence of ileus likely in the location of AVM clipping. . # Hx prosthetic valve: Pt has documented h/o MVR and AVR secondary to rheumatic heart disease. We kept her INR at goal of 2.5 - 3.5 with heparin gtt for procedure. No thromboembolic events were observed during this admission. She was discharged with INR 2.7. . # Gout: Pt developed left MTP pain. The location and nature of pain is concerning for gout. She was empirically treated with low dose colchicine once, and her symptoms improved significantly in the following days. . # [Last Name (un) ]: Pt presented with acute kidney injury in the setting of significant GIB. Her creatinine improved after correcting her anemia. . # CHF: Pt has a documented history of diastolic CHF. We held her diuretics temporarily in the setting of hypovolemia. An the time of discharge, pt tolerated half dose of her lasix well. We recommend restarting spiralactone and half dose of her potassium supplement, and titrating up as tolerated. . CHRONIC ISSUES # A-fib: Pt has documented a-fib. She was in a-fib rhythm throughout this hospitalization. We started her diltiazem after the procedure, and she tolerated well. Pt was anticoagulated throughout this hospitalization. . # Psychoaffective disorder/depression: We continued her home medication. . # COPD: Pt has documented history of COPD. She did well on her home medication Spiriva and Advair. . # Hyperlipidemia: We continued her home dose statin. . TRANSITIONAL ISSUES # CODE STATUS: Full code # COMMUNICATION: [Doctor First Name ] at group home [Telephone/Fax (1) 103574] (pt designated person of contact), daugher is official HCP, but not in [Name (NI) 86]. # PENDING STUDIES AT DISCHARGE: none # MEDICATION CHANGES: - STOPPED aspirin in the setting of GIB. Will consider restarting after stabilization, as there are evidence that aspirin and coumadin is superior than coumadin monotherapy in mortality of patients with mechanical valves. - RESTARTED furosemide at half dose. - STOPPED Metolazone. - CONTINUED at home dose with alternating 5 mg and 4.5 mg. - RESTARTED half dose of potassium supplement # FOLLOWUP: - Will need early follow-up with PCP/Cardiology - Recommend follow-up with hematology - Recommend maintenance treatment for gout as outpatient. Medications on Admission: Priloesec 20 mg qam diltiazem 240 mg q am spiriva 1 cap inh qhs aspirin 81 mg daily pramipexole 1 mg PO qhs bupropion 150 mg po qam zocor 10 mg po qhs iron sulfate 325 po q am aldactone 25 mg po qam nephrocaps 1 cap po q day advair 5/500 puff inh [Hospital1 ] senna 2 tabs PO bid colace 100 mg PO BID albuterol nebs 1 vial neb q 4hr prn sob tylenol 650 mg po q 6h procrit 40,000 un sc q month, hold for hgb 12 levothyroxine 125 mcg po qam zaroxolyn 1 tab 2.5 po mon/wed/fri 1/2 hr prior to lasix kcl 20 mcg po bid lasix 40 mg PO bid coumadin 4.5 alternating with 5 mg MoM 30 mL po prn constipation Discharge Medications: 1. pramipexole 1 mg Tablet Sig: One (1) Tablet PO qHS (). 2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Diltia XT 240 mg Capsule,Ext Release Degradable Sig: One (1) Capsule,Ext Release Degradable PO once a day. 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization Sig: One (1) neb treatment Inhalation q4h prn as needed for shortness of breath or wheezing. 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 14. Procrit 40,000 unit/mL Solution Sig: One (1) injection Injection once a month: Hold for Hgb > 12. 15. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: alternate 4.5mg and 5mg doses every other day. 17. FerrouSul 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 18. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) cc PO once a day as needed for constipation. 19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 20. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 21. potassium chloride 20 mEq Packet Sig: One (1) PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 2251] Nursing and Rehabilitation - [Location (un) 2251] Discharge Diagnosis: Primary Diagnosis - A-V malformation in jejunum Secondary Diagnosis - Atrial fibrillation - Asthma - anti-phospholipid syndrome (high suspicion) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 103573], You came to our hospital for shortness of breath, and was found to have a significant drop in blood count, concerning for bleeding from your gut. You were initially treated in the MICU, and received multiple units of blood products. You underwent upper and lower endoscopy, as well as a capsule endoscopy. We found that you have a large malformed vessel in your small intestine. Our gastroenterologist corrected that bleeding vessel through endoscopy. During this hospitalization, we also found that you have an unusual blood clotting pattern, that will require further followup. You had a small gout flare, that has largely resolved. . Please note that the following medication has changed: - Please STOP taking aspirin, until further instruction by your PCP. [Name Initial (NameIs) ] Please TAKE a reduced dose of furosemide at 20 mg tablet, one tablet by mouth twice a day. Please remind your doctor that this is half of your previous dose, and should be increased if needed. - Please STOP taking Metolazone until further notice by your PCP. [Name Initial (NameIs) ] Please CONTINUE to take warfarin 5 mg daily and have your INR checked regularly. - There is no further changes to your medication. INR monitoring will be extremely important moving forward due to the propensity of your blood to clot. We have arranged followup with your PCP/Cardiologist Dr. [Last Name (STitle) ], and with our hematologist. Please make sure that you make to these appointments. It has been a pleasure taking care of you here at [Hospital1 18]. We wish you a speedy recovery. Followup Instructions: Name: [Last Name (LF) 7726],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 4094]: INTERNAL MEDICINE/CARDIOLOGY Address: [Street Address(2) 7727],2ND FL, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 7728] Appointment: THURSDAY [1-29] AT 2PM Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2133-3-6] at 11:00 AM With: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 5056], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5849, 2761, 2851, 4589, 4280, 2749, 5859, 2449, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2279 }	Medical Text: Admission Date: [2127-10-9] Discharge Date: [2127-11-5] Date of Birth: [2094-10-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3918] Chief Complaint: fatigue Major Surgical or Invasive Procedure: Central Line Placement History of Present Illness: 32 Year-old male with h/o asthma was under his usual status of health until the end of [Month (only) 216] when he developed sore throat. He had intermittent sore throat and running nose and fatigue since the end of [Month (only) 216]. He denied fever, chill, rash, blurry vision, dizzy, CP, cough, and SOB. In the morning of [2127-10-8], he suddenly felt discomfort in his LUQ which was not pain. He made urgent appointment with his PCP who checked his CBC. his CBC showed significant increase WBC counts. He was called to ED yesterday. He denied Abd pain, n/v, BRBPR, melena, or diarrhea. In [Name (NI) ], pt's VS: T 99.9 P 89 BP 155/88 R 20 SaO2 100. He received one dose of Allopurinol 100mg ROS: no fever, chill, dizzy, CP, SOB, cough, wheezing, dysuria, urgency, dysphagia, odynophagia, Abd pain, reflux, diarrhea, constipation, BRBPR, or melena, no N/V. no weakness, numbness. rash. He gain 7 lps. Past Medical History: asthma ERECTILE DYSFUNCTION Hypertriglyceridemia Seasonal allergies PSH: none Social History: He is smoking one to two cigarettes a day. He is unclear if this hurts his asthma. He works in a financial company. He has no pets. Unmarried. No regular alcohol. Family History: father died from RCC in his 40s, maternal grandmother had melanoma, his mother is healthy. He has 2 half siblings (from his father side) that he doesn't know about their health status. Physical Exam: Vitals: T 98.6 BP 124/79 P 78 RR 18 O2 Sat 100% General: Alert, oriented, no acute distress. Pleasant. HEENT: Sclera anicteric, MMM, oropharynx clear no lesions or thrush. Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A+O x 3, CN grossly intact, upper and lower extremity strength 5/5, sensory intact, normal gait. Cerebellar Function: Rapid hand movements, finger to nose wnl, heel to shin wnl, normal gait. Pertinent Results: ADMISSION LABS: [2127-10-9] 03:00AM URINE HOURS-RANDOM [2127-10-9] 03:00AM URINE GR HOLD-HOLD [2127-10-9] 03:00AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.012 [2127-10-9] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2127-10-9] 02:31AM PT-13.1 PTT-24.5 INR(PT)-1.1 [2127-10-9] 02:31AM FIBRINOGE-377 [2127-10-9] 02:28AM D-DIMER-583* [2127-10-9] 12:21AM LACTATE-1.1 [2127-10-9] 12:10AM GLUCOSE-106* UREA N-21* CREAT-1.4* SODIUM-142 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15 [2127-10-9] 12:10AM ALT(SGPT)-31 AST(SGOT)-33 LD(LDH)-900* ALK PHOS-83 TOT BILI-0.5 [2127-10-9] 12:10AM ALBUMIN-5.1 URIC ACID-9.8* [2127-10-9] 12:10AM WBC-55.6* RBC-4.08* HGB-13.3* HCT-36.1* MCV-89 MCH-32.7* MCHC-36.9* RDW-15.3 [2127-10-9] 12:10AM NEUTS-6* BANDS-0 LYMPHS-22 MONOS-34* EOS-2 BASOS-1 ATYPS-5* METAS-0 MYELOS-0 OTHER-30* [2127-10-9] 12:10AM I-HOS-AVAILABLE [2127-10-9] 12:10AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL [2127-10-9] 12:10AM PLT COUNT-54* [2127-10-8] 04:45PM WBC-57.1# RBC-3.98# HGB-13.0* HCT-35.8# MCV-90 MCH-32.6# MCHC-36.3# RDW-14.1 [2127-10-8] 04:45PM NEUTS-4 BANDS-0 LYMPHS-23 MONOS-44* EOS-4 BASOS-4* ATYPS-3* METAS-0 MYELOS-0 OTHER-18* [2127-10-8] 04:45PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2127-10-8] 04:45PM PLT SMR-VERY LOW PLT COUNT-56# . DISCHARGE LABS: [2127-11-5] 05:25AM BLOOD WBC-5.3 RBC-3.80 Hgb-12.1* Hct-31.7* MCV-84 MCH-31.8 MCHC-38.0* RDW-14.1 Plt Ct-711* [2127-11-5] 05:25AM BLOOD Neuts-23* Bands-1 Lymphs-30 Monos-19* Eos-0 Baso-0 Atyps-2* Metas-5* Myelos-15* Promyel-1* Blasts-4* NRBC-3* Other-0 [2127-11-5] 05:25AM BLOOD Plt Smr-VERY HIGH Plt Ct-711* [2127-11-5] 05:25AM BLOOD Gran Ct-2931 [2127-11-5] 05:25AM BLOOD Glucose-83 UreaN-14 Creat-1.1 Na-140 K-4.9 Cl-102 HCO3-31 AnGap-12 [2127-11-5] 05:25AM BLOOD ALT-59* AST-30 LD(LDH)-286* AlkPhos-85 TotBili-0.3 [2127-11-5] 05:25AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.3 Brief Hospital Course: Mr. [Known lastname 27628] is a 32y/o gentleman with new diagnosis of AML who has recently undergone 7+3 therapy. . #AML: The patient was diagnosed with AML on BMB, and has tolerated 7+3 therapy without complaint. Patient was started on an aggressive hydration regimen with bicarbonate as well as hydroxyurea and allopurinol in order to bring down the WBC burden as well as prevent tumor lysis syndrome. Bone Maroow Biopsy at Day 14 showed a clean bone marrow. Patient's counts began to slowly recover around Day 20 and was discharged on Day + 27. . #Hypoxia: On [10-11] pt spiked a fever and had need for supplemental O2 to maintain sats. On [10-12] he continued to have fevers and had increase in oxygen demand requiring a non-rebreather in order to keep sats in the 90s and was accordingly transfered to the [Hospital Unit Name 153] for hypoxia. His CXR at the time showed moderate-severe new pulmonary edema. Pt was given 2 doses of 20mg IV lasix with good urine response. Vancomycin and cefepime had been started (see below) and levofloxacin was started to cover atypicals. Pt was supported in the evening on a non-rebreather but then O2 was tapered as pt showed improvement in saturations. CXR on [10-13] showed significant improvement in pulmonary edema s/p lasix diuresis. Another 20mg IV lasix was given with good response and pt transferred back to floor on 2L NC. ECHO was perfomred to look for signs of cardiotoxicty and decrased EF [2-25] chemotherapy, but was unrevealing; inital concerns about an ASD were put to rest after a ubble study was negative for ASD. . # Neutropenic Fever: When pt spiked initial fever Cefepime was started although not technically neutropenic at the time. Vanco had been added as well at time of ICU transfer. Levofloxacin was started to cover possible atypical PNA organisms. ID was consulted, and he completed 5 days of coverage with Levofloxacin for atypical organisms. Vancomycin was subsequently DC'ed, and the patient continued on Cefepime, Acyclovir, and fluconazole. Patient subsequently began to have 4 consecutive days of low grade fever to 99-100. He was restarted on IV Vancomycin. CT Scan of the chest showed several lung nodules that may represent new area of infection. As his ANC increased, his fevers began to fade. He was transitioned to PO Levofloxacin for 7 days on discharge to cover the likely infection in his lungs. . # [Last Name (un) ]: Creatinine was slightly elevated upon admission, and rose even further prior to tranfser tot he ICU. It has since normalized [2-25] diuresis both within the ICU and on the floor. . # Anemia: Patient has become transfusion dependent for both RBC and plts during admission, and was supported with multiple transfusions. . # ? Aneurysm: Patient had an MRI head with contrast to explore possible CNS involvement of the AML as he was having 2 days worth of headaches. The headaches subsequently faded and decision was made to not to an LP. The MRI showed a possible anueurysm in the internal carotid artery; however, the read was that it was a likely artifact. MRA was done, which showed the finding was an artifact from the tourtuous nature of the internal carotid artery. Medications on Admission: ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 Puffs(s) inhaled Q 4 hr as needed for sob or wheezing Loratadine 10 mg Tab 1 Tablet(s) by mouth once a day allergies Fluticasone 50 mcg/Actuation Nasal Spray, Susp [1-25] sprays(s) each nostril daily as needed for allergy season Discharge Disposition: Home Discharge Diagnosis: Primary: AML Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital for high-dose chemotherapy to treat your leukemia. . We made the following changes to your medications: 1. ADDED Levofloxacin 500 mg daily for 5 days 2. ADDED Acyclovir 400 mg three times a day Followup Instructions: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2127-11-7] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12633], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2127-11-7] 10:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], RN, [Name8 (MD) 16569], [MD Number(3) 1240]:[Telephone/Fax (1) 1579] Date/Time:[2127-11-10] 10:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 3922] ICD9 Codes: 5849, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2280 }	Medical Text: Admission Date: [2173-8-7] Discharge Date: [2173-8-7] Date of Birth: [2117-2-1] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 13489] Chief Complaint: swollen lips Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 56 y.o male with h.o HTN, DM who presents with L.maxillary Lip swelling and pruritis below the L.eye. Pt states that swelling began around 1hr after eating chinese food/vegetable lomain (~1130pm), which he has eaten before without difficulty. At that time, pt took 25mg of benedryl. PT denies tongue swelling, dyspnea, SOB, dysphagia, odynophagia, inability to handle secretions, difficulty speaking, hives, or rash. He took 25mg of benedryl at 2345 without relief. . Pt reports that an episode similiar to this, but with predominately itching rather than swelling occurred 23yrs ago after eating an apple, but resolved at home within 5 days. Pt states this episode was predominately swelling. He denies any other history of this occurrance or any other anaphylactoid type reaction. He denies any new medications, has taken lisinopril for ~8yrs and ASA for 3yrs. Denies f/c/headache/LH/blurred vision/ST/cough/URI/CP/palp/SOB/abd pain/n/v/d/c/brbpr/melena/dysuria/hematuria/skin rash/joint pain. . In the ED, initial vs were-01:49 T98 HR59 BP127/80 RR14 sat100. Pt was given solumedrol 125, pepcid 20mg and benedryl 50mg IV. 1L of NS, Last vitals-97.5 65 119/80 16 98%. . Currently, pt feels that swelling has improved. Past Medical History: DM2 HTN R.knee pain Social History: WOrks for NSTAR, lives at home with his 29 y.o daughter. Denies smoking, ETOH or drug use. Family History: denies allergic rxns Physical Exam: Vitals: HR 66, BP 115/74, RR 14, sat 99% on RA General: Alert, oriented, no acute distress, speaking in full sentences. HEENT: NC/AT, perrla, EOMI, Sclera anicteric, MMM, prominent L.maxillary swelling and in the nasolabial fold. No rash. Minor swelling present on the R.side. Neck: supple, JVP not elevated, no LAD, no stridor. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no rash neuro: AAOx3 Pertinent Results: [2173-8-7] 05:15AM BLOOD WBC-8.9 RBC-4.66 Hgb-15.1 Hct-44.1 MCV-95 MCH-32.3* MCHC-34.1 RDW-12.6 Plt Ct-232 [2173-8-7] 05:15AM BLOOD Plt Ct-232 [2173-8-7] 05:15AM BLOOD Glucose-147* UreaN-17 Creat-1.0 Na-140 K-4.2 Cl-109* HCO3-22 AnGap-13 . CXR: The heart is not enlarged. The aorta is minimally unfolded. No CHF, focal infiltrate or effusion. Within the limits of plain film radiography, no hilar or mediastinal lymphadenopathy is identified. No focal infiltrate, effusion, CHF, or pneumothorax identified. IMPRESSION: No acute pulmonary process identified. Brief Hospital Course: Pt is a 56 y.o male with h.o DM, HTN who presents with facial itching and lip swelling after dinner. . #eye itching/lip swelling-likely secondary to an allergic rxn. Pt denied any SOB/difficulty swallowing/throat swelling. Pt denied any h.o anaphylaxis. ACEI started 8 yrs ago, ASA 3 yrs ago. Pt received 125mg solumedrol, famotidine and benedryl in the ED. Pt reports improvement in swelling. We continued solumedrol and famotidine while on the floor, and then transitioned him to PO prednisone, with dose of 40 mg x3 days, 20 mg x3 days, then 10 mg x3 days. He will also complete 7 days of prevacid. He was advised not to eat chinese food and stop his acei and aspirin. Allergy was called and the case was discussed with plan for outpatient follow up. He was hemodynamically stable throughout and had no airway compromise. He was discharged home with an epi pen. . #HTN- stable off the lisinopril, he should follow up as outpatient to have BP checked and see if new [Doctor Last Name 360] needs to be added. . #DM- held metformin while inpatient, did sliding scale; restarted on discharge. . Prophylaxis: Subutaneous heparin, pneumoboots Access: peripheralsx2 Code: Full Medications on Admission: Calcium 600 + D(3) 600 mg-400 unit Tab-[Hospital1 ] ASA 81mg Lisinopril 30 mg Tab daily Metformin 1,000 mg Tab [Hospital1 ] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day for 7 days: please take 4 tabs (for total of 40 mg) for 2 days; then take 2 tabs (for a total of 20 mg) for 3 days; then take 1 tab (10 mg) for 3 days; then stop. Disp:17 Tablet(s) Refills:0 3. Pepcid 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 4. Benadryl 25 mg Capsule Sig: [1-8] Capsules PO every eight (8) hours: as needed for itching. 5. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) pen Intramuscular once: as needed for shortness of breath and wheezing in setting of allergic reaction. Disp:1 pen Refills:2 6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Angioedema 2. Hypertension Discharge Condition: stable, unobstructed airway, no stridor, swollen upper lip Discharge Instructions: You were admitted to the hospital with swelling of your lips after eating chinese food. The swelling is likely an allergic reaction either from the food you ate, or possibly from either your lisinopril or aspirin. You should stop taking both lisinopril and aspirin until you have allergy testing. You should also avoid chinese food and apples until you have allergy testing. . Please continue all your other medications. We have added a week of prednisone and pepcid to treat the swelling. The prednisone will be tapered. Starting tomorrow, take 4 tabs daily for 2 days; then 2 tabs daily for 3 days; then 1 tab daily for 3 days and then stop. You can also take benadryl as needed for comfort. . Please also get an epipen from the pharmacy. You can use this if you get short of breath and are feel like your throat is closing up. . Please return to the hospital for any shortness of breath, increased swelling, tongue swelling, feeling like your throat is closing up, or any other concerns. Followup Instructions: Please follow up with the allergy clinic. Please call [Telephone/Fax (1) 9316] on Monday morning to make an appointment. They will be expecting your call. Please follow up with your primary care doctor. Please call Dr. [Name (NI) 13490] office on Monday morning at [Telephone/Fax (1) 7976]. You will have to have your blood pressure rechecked and maybe have some new medications in place of your lisinopril. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13491] MD, [MD Number(3) 13492] Completed by:[2173-8-7] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2281 }	Medical Text: Admission Date: [2124-10-10] Discharge Date: [2124-10-14] Date of Birth: [2085-2-11] Sex: F Service: HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old state trooper, who was diagnosed with squamous cell carcinoma of the left neck, which was resected. She did well for approximately a year and about nine months started developing progressive sensory symptoms over the left neck and jaw. Initially started with some numbness over the left earlobe above the surgical site followed by burning sensation in the jaw. She then noticed when she brushed her hair behind her ear, it felt raw. Pain that went down the neck to the chest and shoulder area. For the past month, these symptoms have been relatively stable without progression. On direct questioning, she and her husband, who is here with her cooberates some difficulty with short-term memory which has worsened in the past year or so. A MRI scan of the head shows a third ventricle hyperintense lesion in T1 weighted images, which does not enhance causing mild-to-moderate increased size in the lateral ventricles. There is no significant transependymal fluid noted on T2 weighted images, and the cerebellar tonsils are a little bit low lying, but just at the level of the foramen magnum. The fourth ventricle was normal in size and the corporis callosum is thin throughout relatively uniformly. PHYSICAL EXAMINATION: On physical exam, she is awake, alert, and fully oriented. Speech is normal and fluent. Cranial nerves are normal. Strength is normal throughout. Gait is normal. Sensory examination reveals some decreased touch sensation over the left neck posterior to the ear and the occipital areas as well as along the neck to the upper part of the anterior chest. Left neck neuropathic symptoms concerning for a perineural invasion. On MRI scan of the head, the third ventricles tumor is an incidental finding. Dr. [First Name (STitle) ] felt that this was most likely a colloid cyst, and the patient was given an option for VP shunt and watching colloid cyst or drainage. Patient opted for resection of the colloid cyst. Patient underwent transcallosal resection of the third ventricle colloid cyst without intraoperative complication. Postoperatively, the patient was monitored in the ICU without complication. Postoperatively, she was monitored in the Surgical ICU. There were no intraoperative complications. Postoperatively, patient was alert, awake, oriented, following commands. Motor strength is [5-15] in all muscle groups. Face is symmetric. Pupils are equal, round, and reactive to light. EOMs were full. Tongue was midline, good language skills. Patient had ventricular drain in place that was level 10 meters about the tragus draining 45 cc to 10 cc over postoperative day #2. Head CT was performed on [2124-10-11]. CT scan showed no hemorrhages, showed good size of ventricles with decompression of the ventricles. The vent drain was removed on [2124-10-13], and the patient after having it clamped which showed no evidence of hydrocephalus, the patient was transferred to the regular floor on [2124-10-13]. She remained neurologically stable. The patient was discharged home on [2124-10-14] for followup with staple removal on postoperative day #10 and follow up in the Brain [Hospital 341] Clinic in two weeks. MEDICATIONS AT TIME OF DISCHARGE: 1. Nicotine patch once a day. 2. Percocet 1-2 tablets p.o. q.4h. prn for pain. 3. Dilantin 100 mg p.o. t.i.d. for seven days and then discontinue. CONDITION ON DISCHARGE: Stable at the time of discharge. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2124-12-20] 11:18 T: [2124-12-22] 11:01 JOB#: [Job Number 51200] ICD9 Codes: 496, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2282 }	Medical Text: Admission Date: [2131-5-24] Discharge Date: [2131-6-2] Date of Birth: [2073-8-19] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3376] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: [5-28] Exam under anesthesia, control of internal hemorrhoidectomy bleeding History of Present Illness: 57F with rectal bleeding pod 13 from hemorrhoidectomy for bleeding internal hemorrhoids by Dr. [Last Name (STitle) 1120]. She said the week after her surgery she was fine. However this last week she has had increasing spotting and bleeding with bms. Earlier this week her inr was 4.5. Her goal is 2.5 - 3.5. This last day it has been fairly constant and she has to keep changing pads. She feels occasionally lightheaded. Past Medical History: Significant for alcohol abuse Status post AVR and MVR in [2123] (due to rheumatic HD) Migraines Depression Hepatitis C Status post hysterectomy Hypertension Anemia with a baseline hematocrit in the low 30s to mid 30s Social History: Works in a multidisciplinary clinic on [Hospital Ward Name ] for patients with melanoma. Married, no children. - Tobacco: 1 pack per week - EtOH: Couple of drinks every night but hasn't drank in a week, has been in detox in the past - Illicits: Denies Family History: Mom had breast cancer in her 50s. No h/o abdominal/GI diseases. Family h/o DM. Physical Exam: On Admission: 98.2 94 117/68 16 100 NAD RRR CTAB Abd soft Rectal - no external hemorrhoids, small amount of bleeding from anus, unable to pass an anoscope due to patient discomfort. Ext - no edema Pertinent Results: [2131-5-25] 02:09AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.3* [2131-5-29] 10:33PM BLOOD Calcium-7.8* Phos-3.9 Mg-1.2* [2131-5-24] 04:00AM BLOOD Glucose-210* UreaN-15 Creat-1.5* Na-141 K-3.6 Cl-108 HCO3-23 AnGap-14 [2131-5-29] 10:33PM BLOOD Glucose-107* UreaN-6 Creat-0.8 Na-139 K-3.3 Cl-107 HCO3-26 AnGap-9 [2131-5-24] 04:00AM BLOOD PT-92.5* PTT-50.0* INR(PT)-11.4* [2131-5-24] 04:00AM BLOOD Plt Ct-336 [2131-5-24] 11:08AM BLOOD PT-34.9* PTT-46.4* INR(PT)-3.6* [2131-5-24] 11:08AM BLOOD Plt Ct-186 [2131-5-24] 01:52PM BLOOD PT-21.1* INR(PT)-2.0* [2131-5-24] 05:15PM BLOOD PT-19.6* INR(PT)-1.8* [2131-5-25] 02:09AM BLOOD PT-15.5* PTT-67.5* INR(PT)-1.4* [2131-5-25] 02:09AM BLOOD PT-15.5* PTT-67.5* INR(PT)-1.4* [2131-5-25] 02:09AM BLOOD Plt Ct-125* [2131-5-25] 08:36AM BLOOD PT-13.4 PTT-52.2* INR(PT)-1.1 [2131-5-25] 03:08PM BLOOD Plt Ct-178 [2131-5-25] 03:20PM BLOOD PT-13.0 PTT-59.2* INR(PT)-1.1 [2131-5-25] 10:00PM BLOOD PTT-73.1* [2131-5-26] 04:00AM BLOOD PT-13.9* PTT-62.2* INR(PT)-1.2* [2131-5-26] 05:20PM BLOOD PT-13.6* PTT-56.8* INR(PT)-1.2* [2131-5-27] 02:06AM BLOOD PT-14.5* PTT-82.2* INR(PT)-1.3* [2131-5-27] 08:40AM BLOOD PT-14.3* PTT-41.2* INR(PT)-1.2* [2131-5-27] 09:15PM BLOOD PTT-82.2* [2131-5-28] 04:30AM BLOOD PT-15.7* PTT-67.0* INR(PT)-1.4* [2131-5-28] 04:30AM BLOOD Plt Ct-161 [2131-5-28] 10:20AM BLOOD PTT-37.8* [2131-5-29] 09:22AM BLOOD PT-14.7* PTT-33.5 INR(PT)-1.3* [2131-5-29] 10:33PM BLOOD PTT-97.3* [2131-5-30] 07:00AM BLOOD PT-14.2* PTT-46.2* INR(PT)-1.2* [2131-5-30] 03:30PM BLOOD PTT-150* [2131-5-30] 09:47PM BLOOD PTT-40.8* [2131-5-30] 09:47PM BLOOD PTT-40.8* [2131-5-31] 05:53AM BLOOD PT-17.6* PTT-108.9* INR(PT)-1.6* [2131-5-31] 06:57AM BLOOD PT-17.4* PTT-86.4* INR(PT)-1.6* [2131-5-31] 01:24PM BLOOD PTT-119.6* [2131-5-31] 09:40PM BLOOD PTT-75.0* [2131-6-1] 06:16AM BLOOD PT-20.2* PTT-61.1* INR(PT)-1.9* [2131-5-24] 04:00AM BLOOD WBC-8.0# RBC-2.62* Hgb-7.5* Hct-23.9* MCV-91 MCH-28.5 MCHC-31.3 RDW-17.2* Plt Ct-336 [2131-5-24] 11:08AM BLOOD WBC-8.0 RBC-2.00* Hgb-6.1* Hct-18.0* MCV-90 MCH-30.7 MCHC-34.1 RDW-16.9* Plt Ct-186 [2131-5-24] 01:52PM BLOOD Hct-28.4# [2131-5-24] 05:15PM BLOOD Hct-28.1 [2131-5-25] 02:09AM BLOOD WBC-5.6 RBC-3.18# Hgb-9.5# Hct-26.9* MCV-85 MCH-29.8 MCHC-35.2* RDW-16.5* Plt Ct-125* [2131-5-25] 08:36AM BLOOD Hct-26.7* [2131-5-25] 03:08PM BLOOD WBC-6.7 RBC-3.71* Hgb-10.8* Hct-32.3* MCV-87 MCH-29.0 MCHC-33.3 RDW-16.6* Plt Ct-178 [2131-5-25] 10:00PM BLOOD Hct-29.3* [2131-5-26] 04:00AM BLOOD WBC-5.7 RBC-3.10* Hgb-9.3* Hct-27.2* MCV-88 MCH-29.9 MCHC-34.1 RDW-15.6* Plt Ct-155 [2131-5-26] 03:10PM BLOOD Hct-28.0* [2131-5-27] 02:06AM BLOOD Hct-26.5* [2131-5-27] 08:40AM BLOOD Hct-27.2* [2131-5-27] 05:00PM BLOOD WBC-4.8 RBC-2.89* Hgb-8.5* Hct-25.5* MCV-88 MCH-29.5 MCHC-33.4 RDW-15.8* Plt Ct-174 [2131-5-28] 04:30AM BLOOD WBC-4.4 RBC-2.48* Hgb-7.4* Hct-21.9* MCV-89 MCH-29.7 MCHC-33.5 RDW-15.6* Plt Ct-161 [2131-5-28] 04:30AM BLOOD WBC-4.4 RBC-2.48* Hgb-7.4* Hct-21.9* MCV-89 MCH-29.7 MCHC-33.5 RDW-15.6* Plt Ct-161 [2131-5-28] 03:30PM BLOOD Hct-28.9# [2131-5-28] 09:35PM BLOOD Hct-28.6 [2131-5-29] 03:30AM BLOOD Hct-26.6* [2131-5-29] 09:55AM BLOOD Hct-28.5* [2131-5-29] 10:33PM BLOOD Hct-25.6* [2131-5-30] 06:54AM BLOOD Hct-28.7* Brief Hospital Course: [2131-5-24] - Admitted to SICU for rectal bleeding, decreased hematocrit and elevated INR.; Foley catheter, A-line placed, transfused 3 units of PRBC's and 1U FFP, surgi-cel rectal tampon placed, ICU consent obtained. Hct stable, INR decreased to <2, heparin gtt initiated. [2131-5-25] - Low electrolytes, repleated per sliding scale, Serial hematocrits were checked and coumadin was held. Patient was transferred to the floor after Hct, BP, UOP and coagulopathy were stabilized. [5-28] patient underwent exam under anesthesia control of internal hemorrhoidectomy bleeding [5-29] coumadin restarted and hematocrits continued to be checked and stable in mid to upper 20's. heparin drip continued to bridge patient to warfarin given the AVR and MVR. [6-2] INR was therapeutic at 2.7 By time of discharge the INR was therapeutic and the patient's Hct was stable. Medications on Admission: amlodipine 2.5', fioricet q6 prn, premarin cream, anusol supp'', lisinopril 80', metoprolol 100'', mirtazapine 45', percocet prn, trazodone 200 qhs, coumadin as dir. Discharge Medications: 1. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Trazodone 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime) as needed for insomnia. 4. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain for 1 weeks. Disp:30 Tablet(s) Refills:0 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: AFTER your dose tonight, and your dose Sunday, you are to GO TO [Hospital Ward Name ] ONE ON MONDAY MORNING [2131-6-4] FOR an INR Draw. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: rectal bleeding from internal hemorrhoidectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call if you notice further rectal bleeding. Call if fevers >101. Call if light headed, dizzy, bleeding, chest pain, change in mental status, sudden weakness or slurring of speech. Call with any concerns or questions. You were admitted to the hospital due to rectal bleeding and elevated INR. On [5-28] you had an exam under anesthesia with control of internal hemorrhoidectomy bleeding. After bleeding was adequately controlled you were restarted on coumadin and heparin drip as a bridge to coumadin. Your therapeutic goal INR is 2.5 to 3.5. It is very important that you follow up in coumadin clinic for frequent INR checks and appropriate adjustmenjt of your coumadin. Followup Instructions: On Monday MORNING you are to go to [Hospital Ward Name ] 1 for a blood draw and INR check, at which your comadin dose will be adjusted by the doctor on-call. Then later that week, we ask that you please follow-up with Dr. [First Name (STitle) ] for INR checks and coumadin dose adjustment. Phone: [Telephone/Fax (1) 250] Please call Dr. [Last Name (STitle) 1120] to schedule follow up in [2-3] weeks ICD9 Codes: 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2283 }	Medical Text: Admission Date: [2140-11-15] Discharge Date:[2140-11-18] Date of Birth: [2140-11-15] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname ] was the 3.145 kg product of a 39 and [6-5] week gestation, admitted for evaluation of prenatally diagnosed hydrocephalus, absence of corpus callosum and hydronephrosis. Infant was born to a 31 year-old, Gravida III, Para I now II woman. Prenatal screens: 0 positive, antibody negative, RPR nonreactive, rubella immune, hepatitis surface antigen negative, GBS negative, CF negative, quad screen normal. Pregnancy complicated by fetal ultrasound with agenesis corpus callosum, colpocephaly, mild bilateral ventricular dilatation, tear dropped shape frontal [Doctor Last Name 534] and mild bilateral hydronephrosis with renal pelvic dilatation. The remainder of fetal survey, including cardiac anomaly, was normal. Fetal MRI of the brain confirmed the findings. A fetal echocardiogram was normal. Care transferred from [Hospital 1474] Hospital to [Hospital3 ] with these findings on ultrasound. AFCC consultation with Drs. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 36469] and Dr. [First Name4 (NamePattern1) 622] [Last Name (NamePattern1) 36467]. They also met with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968], neonatology. Amniocentesis was declined. Induced vaginal delivery with epidural anesthesia. Apgars were 9 and 9. FAMILY HISTORY: Paternal first cousin with autism and mental retardation. SOCIAL HISTORY: Parents are married. Two year old healthy sister. PHYSICAL EXAMINATION: Weight 3.145 kg, 25th to 50th percentile. Length 54 cm, greater than 90th percentile. Head circumference 35.5 cm, 90th percentile. Anterior and posterior fontanel soft, flat, positive molding. Sutures are closed. Eyes: Slightly close set. Ears with mild posterior rotation but normally set. Mild retrognathia. Intact palate. Red reflex not done. Clear breath sounds. S2 over 6 systolic murmur in the left lower sternal border. Normal pulses. Soft abdomen. 3 vessel cord. No hepatosplenomegaly. No masses. Bilateral undescended testes. Normal penis. Patent anus. No hip click, no sacral dimple, warm and well perfused. Skin peeling on hands and feet. Active normal tone. Symmetric moro on response to exam. HOSPITAL COURSE: Respiratory: [Doctor First Name ] has been stable in room air throughout his initial hospital stay in the NICU. He was transferred to the Newborn Nursery on the night of [11-16]. He initially did well by report with slow feeding. On theearly morning of [11-18] he was transferred back to NICU for persistent hypothermia reqiring warming lights and lethargy. Weight was 9% below BW at the time of NICU readmission. This Cardiovascular: [Doctor First Name ] was noted to have an audible murmur after birth. Prenatal echocardiogram was within normal limits. He was seen by cardiology because of the murmur. His CXR showed normal herat size and configuration. His four extremity BPs were normal. . His pre and post ductal saturation were 98-100% in RA. Echo done [11-18] showed muscular VSD and ASD., Aortic arch said to be at lower normal of size. No restriction seen. PDA closed. Cardiology team to follow. Fluids, electrolytes and nutrition: Birth weight was 3.145 kg. Infant has been ad lib breast feeding and taking in adequate amounts. Started on IV D10w on morning of [11-18] after receiving NS bolus for MBP 39. Subsequent BPs normal. BS 49 this am. Subsewquently in 100-150 range on IVF. Na 147 with NaHCO# 12 noted on lytes done [11-17]. This am noted to be hyperventilating. Repeat CBG and lytes showed pH 7.44 HCO3 7. Given NaHCO3 2 meq/kg and begun on NaHCO3 drip at 1 meq/k/h. Following drip for several hours serum HCO3 increased to 17 then 21. A serum ammonia from this morning was 540, however there was a delay in processing fo this specimen for several hours. A repeat specimen that was promptly run showed NH3 of 240. A serum lactae was 2.4. AHs been seen by Metabolism team from CH. Newborn screening specimen has been sent and received by State lab. Director there has been contact[Name (NI) ] by Metabolism team. A urine organic aa screen has been sent to CH lab. Lactate/Pyruvate sent here. Endocrine: He was seen and evaluated by the endocrine team because of bilateral undescended testes. He had TSH 14 T4 10.7 Cortisol 11.6. 11 DOC and 17 OHP pending. Gastrointestinal: No issues. His bilirubin prior to discharge was 9.6/1.6. DIRECT FRACTION HAS INCREASED FROM 1.2 EALIER IN DAY. ALT 24. AST 87. AP 188. Genitourinary/renal: An abdominal ultrasound was obtained on [11-16], demonstrating normal kidneys with no hydronephrosis, no testes in canal or scrotal sac. No female inetrnal genitalai noted. Urology was consulted, they plan outpatient followup. Infectious disease: Was restarted on AMpicillin and gentamicin this morning after repeat BC was obtained. Neuro: Head ultrasound was obtained on admission to the Neonatal Intensive Care Unit and the findings include: Complete agenesis of corpus callosum. Mild accompanying colpocephaly, left greater than right. The degree of occipital [Doctor Last Name 534] dilatation is quite modest. No other structural abnormalities evident. In particular, the posterior fossa is normal appearing with no evidence of arachnoid cyst or Dandy-Walker spectrum of abnormality. Extra axial fluid spaces are normal. Neonatal neurology was consulted, Dr. [Last Name (STitle) 36469], was consulted prenatally and postnatally. Recommended follow-up with the neonatal neurology program after discharge. Genetics: Genetics was consulted because of the bilaterally undesended testes. They would like to follow-up with the patient after his neurology follow-up. Opthalmology consult has been requested but not completed at this time. Sensory: Audiology: Hearing screening has not [Female First Name (un) ] been performed. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], telephone number [Telephone/Fax (1) 69092]. FOLLOW UP CARE AND RECOMMENDATIONS from previous evaluations 2) Day of life # 10 he should have testosterone, LH, and FSH levels drawn. 3) He should follow up with [Hospital3 1810] Endocrinology one month of life. Please call [Telephone/Fax (1) 69093] to arrange appointment. Should endocrine questions arise, please page Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 53567] pager id [Pager number ]. 4) His neurology appointment is scheduled for [2140-12-21] at 8 am. The appointment is at [Hospital3 1810] [Last Name (un) 9795] 8. Please plan to arrive 15-20 minute prior to appointment. Telephone number is [Telephone/Fax (1) 36468]. 5) He needs to have an MRI prior to the neurology appointment. Please call [First Name8 (NamePattern2) 803] [Last Name (NamePattern1) 69094] to arrange appointment [Telephone/Fax (1) 36468]. 6) He will need follow up with genetics Dr. [Last Name (un) 69095] [Name (STitle) ]. Please call [Telephone/Fax (1) 37200]. FEEDS AT DISCHARGE: Ad lib breast feeding. MEDICATIONS: None. STATE NEWBORN SCREENING: . IMMUNIZATIONS: He hjas not received his Hep B vaccine. DISCHARGE DIAGNOSES: 1. Absence of corpus callosum, mild dilatation of occipital [Doctor Last Name 534]. 2. Bilaterally undescended testes. 3. Cardiac murmur. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2140-11-17] 02:53:33 T: [2140-11-17] 05:24:36 Job#: [Job Number 69096] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2284 }	Medical Text: Admission Date: [2172-10-9] Discharge Date: Date of Birth: [2132-4-12] Sex: M Service: CHIEF COMPLAINT: Increased seizures and fever. HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with a history of tuberous sclerosis, mental retardation, and seizure disorder. The patient was in his usual state of health on [2172-10-8], when he received a flu shot at his outpatient physician's office. He was also okay on the morning of [10-9], and then at his group home had a seizure, and this seizure repeated later in the day. Emergency Medical Service was called. They noted tonic-clonic motions and gave 5 mg of Valium intravenously with cessation of the seizure. The patient has been unresponsive after the seizure. He was taken to [Hospital3 1196] Emergency Room where a urine culture was done, and the patient was started on ciprofloxacin 400 mg intravenously when the urinalysis was positive. He was than transferred to [Hospital1 190] because of lack of bed space and because he has received his prior care here. Emergency Medical Service noted in the field that the patient's oxygen saturation was 99%. He had a slightly low blood pressure of 92/60. His pulse was 107. In the [Hospital1 69] Emergency Room temperature was 102. He was covered empirically for meningitis with ampicillin and ceftriaxone. A systolic blood pressure of 72 was noted. The patient was given intravenous fluids and treated briefly with dopamine. This was titrated up to 7.5 and then weaned off as soon as he got to the Medical Intensive Care Unit on the [Hospital Ward Name ]. In the Emergency Room, however, his abdomen was noted to "rigid." Therefore, an abdominal CT was performed, and this showed intussusception of the duodenum into the jejunum without local mass and without obstruction as contrast reached the colon. Therefore, Surgery got involved and recommended nasogastric tube and a follow-up CT. The patient received a total of 4.5 liters of fluid in the Emergency Room. He reportedly denied fever, chills, cough, sputum, change in mental status, headache, and nausea, and vomiting. Head CT was negative. Lumbar puncture was negative. The patient had a couple of episodes of diarrhea while in the Medical Intensive Care Unit. These were Clostridium difficile colitis negative. His temperature maximum while in the Medical Intensive Care Unit was 100.3. The patient's antibiotics were trimmed to ceftriaxone only secondary to the negative cerebrospinal fluid samples, and this was continued for his urinary tract infection. Also, while in the Medical Intensive Care Unit, he was continued on his anti-seizure medications and decreased hematocrit and platelets were noted. He had no seizures while in the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Tuberous sclerosis with angiomyolipomas of the kidney, eye, and brain. 2. Hypertension. 3. Depression. 4. History of increased NH4. 5. Seizure disorder with a baseline of one to two seizures per week, up to every other day. 6. Violent behavior toward nursing in the past, throwing food at them, attributed to Lamictal. 7. Questionable history of gastritis per past discharge summaries. 8. Mental retardation. SOCIAL HISTORY: The patient lives at a group home. His contact there is [Name (NI) ] and that number is [Telephone/Fax (1) 94768]. Reportedly, the patient wonders at the group home at baseline, speaks a few words of Portuguese and Spanish, sometimes English, and some made up words. He draws pictures and eats on his home. Per his outpatient neurologist, his functional status is poor. He has refused to wear a helmet, and therefore he has had large amounts of anti-seizure medications which have produced some sedation. The patient also has multifocal seizures, and therefore surgery is not an option. The patient's guardian is his brother. Phone number for the brother is [Telephone/Fax (1) 94769] and [Telephone/Fax (1) 94770]. The patient's father can be reached at [Telephone/Fax (1) 94771]. His primary care physician is [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216], and his primary neurologist is Dr. [Last Name (STitle) 851]. FAMILY HISTORY: Not able to be obtained. MEDICATIONS ON ADMISSION: Valproic acid 750 mg p.o. t.i.d., Trileptal 600 mg p.o. b.i.d. (it was increased to 765 mg p.o. b.i.d. in the Intensive Care Unit), Topamax 200 mg p.o. b.i.d., Prozac 20 mg p.o. q.d., folate, and multivitamin, Tums 750 mg p.o. b.i.d., Miacalcin 1 spray q.d. alternating nostrils, Ensure supplement p.r.n. MEDICATIONS ON TRANSFER: On transfer to the floor, the patient was also receiving Ativan 1 mg p.o. q.8h., and ceftriaxone 1 g q.24h., as well as Protonix 40 mg intravenously q.d., and normal saline, and potassium chloride 40 mEq. ALLERGIES: LAMICTAL causes agitation, NEURONTIN causes "toxicity." REVIEW OF SYSTEMS: Review of systems was not able to be obtained. LABORATORY DATA ON PRESENTATION: Laboratories on admission at the outside hospital were white blood cell count 18.8, hematocrit 38.6, platelets of 135. Depakote level was 146.8. Differential of 67 neutrophils, 13 bands, 2 lymphocytes, 21 monocytes. Urinalysis showed 115 ketones, was negative for nitrites but showed 313 white blood cells in clumps. Laboratories also notable for a sodium of 134, a potassium of 3.3, bicarbonate of 23, BUN of 13, creatinine of 1. RADIOLOGY/IMAGING: The CT in the Emergency Department showed intussusception of the duodenum into the jejunum in the left upper quadrant as well as angiomyolipomas in multiple sites, atelectasis of the lung bases versus early pneumonia, and a left adrenal mass 3.5 cm in dimension. Chest x-ray showed no free air and no infiltrate in the lungs. HOSPITAL COURSE BY SYSTEM: On transfer to the floor, the patient was hemodynamically stable and had a stable hematocrit and platelet count. 1. INFECTIOUS DISEASE: The patient was continued on his ceftriaxone intravenously. Repeat urinalysis showed marked decrease in white cells to 3 from an initial greater than 50, and repeat urine culture was negative. The outside hospital urine culture results, however, showed a Pseudomonas aeruginosa sensitive to all antibiotics tested except for cefotaxime. The patient was therefore switched to ciprofloxacin before discharge, and he was to complete a 10-day course of this antibiotic. Note that the one dose of ciprofloxacin the patient received as an outpatient apparently caused substantial reduction of his urine white cells, resolution of all fevers, and decline in his white count, and this course should be sufficient to cover Pseudomonas. 2. GASTROINTESTINAL: After the patient's abdominal rigidity resulted in his abdominal CT he was followed by Surgery and Medicine clinically given the intussusception shown on CT. The patient had a soft abdomen throughout, although he would periodically tense when palpate. He tolerated p.o. throughout his stay, especially after Ativan was discontinued, and he had increased alertness. At discharge he was tolerating p.o. well. Another concern was a low hematocrit in the setting of a questionable history of gastritis. However, his hematocrit was stable throughout. He never had any episodes of bright red blood per rectum or melena, and his initial decline in hematocrit seemed to be related to a large amount of fluid administration in the Emergency Room. At one point, the patient's father indicated he thought his son might be having some odynophagia; however, the patient was tolerating p.o. well enough that the team did not feel it was necessary to pursue this pain with esophagogastroduodenoscopy or barium swallow. 3. HEMATOLOGY: Throughout his stay, the patient had a low hematocrit and low platelet count; however, these were stable. Consideration was made for DIC; however, laboratories for this were negative. Hemolysis laboratories were also negative. Iron studies showed an anemia of chronic disease pattern. Consideration was also given to bone marrow suppression related to his antiepileptics; however, he had been on all of these for a long time, and it was thought that none of them were causing acute bone marrow suppression. In review of his past counts, it seemed that his hematocrit had been declining rather slowly since [2171-6-8], and that his platelets had done the same and are now remaining stable. Therefore, a workup was deferred as an outpatient. A B12 and folate were sent which were still pending. The patient requires outpatient Hematology/Oncology follow up to evaluate his depressed counts. Also of note, his white blood cell count declined from the 20s to a normal range of 5 during his stay, consistent with resolution of infection. 4. NEUROLOGY: Per Neurology curbside opinion, his Trileptal was increased from 600 mg b.i.d. to 675 mg b.i.d. He was also covered through the acute febrile phase of his illness with Ativan 1 mg p.o. q.8h. which was discontinued after this illness had largely resolved. The patient had no seizures while on the floor or while in the Medical Intensive Care Unit, and no changes were contemplated for his antiseizure regimen. 5. MUSCULOSKELETAL: The patient's father indicated he thought his son might have right shoulder pain; however, on examination, the patient had full range of motion of both shoulders, and while he did grimace while the right shoulder was manipulated, he grimaced to nearly any physical examination intervention. Therefore, this was only followed clinically. If there is further evidence that something is going on in the right shoulder, this should be worked up as an outpatient. 6. LABORATORY: Laboratory results were notable for a decline of white count from 20.3 to 5.1 with treatment of his infection. Hemoglobin and hematocrit have remained stable in the range of 10.4 and 31 throughout his stay, and were actually improved on the day of discharge. Platelet count was 116 at discharge which represented an improvement. Coagulation studies were sent with a question of DIC given his decline in hematocrit and platelets; these were normal with a PT of 13, a PTT of 34.9, and an INR of 1.2. D-dimer was sent, and this was 500 to 1000 which represented a minimal elevation. Fibrinogen was sent; this was 611, which was elevated and inconsistent with DIC. A reticulocyte count was low at 0.8. Urinalyses were nitrite negative. Large blood was noted after the patient self discontinued his Foley catheter with the balloon inflated; however, the white count in his urine declined from 50 to 3 with treatment. Cerebrospinal fluid showed 0 white blood cells, 0 red blood cells. Culture was negative. Chemistry was remarkable only for slightly low potassium which was repleted, and a mild anion gap acidosis with a bicarbonate of 15 and anion gap of 15, which resolved with feeding. At discharge, anion gap was 10 and bicarbonate was 20. LDH was 231. For unclear reasons, the patient was ruled out for myocardial infarction while in the Medical Intensive Care Unit. Troponin and creatine kinases were 0.3 to 0.8 and 109 to 159, respectively. Calcium was 8.5 and 7.9 on the day before discharge. Iron was 32. B12 and folate were pending. TIBC was 202. Haptoglobin was 140. Ferritin was 299. Transferrin was 155. Repeat valproic acid level was 82. Initial urine culture was negative. Repeat urine culture was pending. Clostridium difficile assay was negative. Sputum culture showed oral contamination only. Blood cultures were no growth to date. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE FOLLOWUP: Follow up with the patient's primary care physician within one week; arranged at his group home. Followup should be initiated with Hematology to evaluate his low hematocrit and platelets, and B12 and folate levels sent here should be reviewed. His questionable odynophagia and right shoulder pain should be followed as an outpatient. DISCHARGE DIAGNOSES: 1. Pseudomonas urinary tract infection. 2. Tuberous sclerosis. 3. Mental retardation. 4. Depression. 5. Anemia. 6. Thrombocytopenia. 7. Seizure disorder. 8. Intussusception. MEDICATIONS ON DISCHARGE: 1. Depakote 750 mg p.o. t.i.d. 2. Topamax 200 mg p.o. b.i.d. 3. Trileptal 675 mg p.o. b.i.d. 4. Calcitonin nasal spray 1 spray q.d. alternating nostrils. 5. Prozac 20 mg p.o. q.d. 6. Multivitamin p.o. q.d. 7. Tums 750 mg p.o. b.i.d. 8. Folate 1 mg p.o. q.d. 9. Tylenol 650 mg p.o. q.4-6h. p.r.n. for pain. 10. Ensure dietary supplements p.r.n. 11. Zantac 150 mg p.o. b.i.d. 12. Ciprofloxacin 500 mg p.o. b.i.d. times 10 days (nursing should alert physicians if the patient is not taking this medication as it is required to treat his Pseudomonas urinary tract infection). [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2172-10-13] 13:41 T: [2172-10-13] 14:43 JOB#: [Job Number 94772] (cclist) ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2285 }	Medical Text: Admission Date: [2126-12-6] Discharge Date: [2126-12-8] Date of Birth: [2075-3-1] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 8404] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [Known lastname 74626] is a 51 year old gentleman with stage IIa esophageal adenocarcinoma s/p chemoradiation, HCV with ?cirrhosis, and EtOH abuse who presented to the [Hospital1 18] ED for abdominal pain and distension now transferred to the [Hospital Unit Name 153] for hyperbilirubinemia and SBP. The patient reports that he has had worsening jaundice over the past several weeks with an increasing hyperbilirubinemia measured at an outside hospital who presented to the ED today for progressively worsening abdominal pain and distension. Per the patient's wife, the patient had a CTAP performed at [Hospital1 1474] over the past 2 weeks, and was originally scheduled for ERCP at [Hospital 1474] Hospital today. The patient's wife states that over the past 2 weeks, his bilirubin has increased from 9 two weeks ago to 20 5 days ago, to 40 on initial presentation to the ED. Per the patient's wife, he has not had any f/c/s, diarrhea, or recent medication changes. . With regard to the patient's oncologic history, he was diagnosed with stage IIa esophageal adenocarcinoma in [5-30] and underwent 5-FU chemoradiation completed on [2126-10-10]. He has been followed by Dr. [First Name (STitle) ] of Oncology here at [Hospital1 18]. . In the [Hospital1 18] ED, initial VS 140 210/120 28 99%. He had a CXR and KUB that were unremarkable. A RUQ U/S was performed with interpretation pending at the time of transfer. A diagnostic and therapeutic paracentesis was performed with 3L removed, with a white count of 19k with diff pending. He received 1L IVF, pip/tazo, vanco, and he was admitted to the [Hospital Unit Name 153] for further management. . Currently, the patient is confused and in severe abdominal pain. . ROS: As above, otherwise negative. Past Medical History: ONCOLOGIC HISTORY: [2126-6-14] EGD showed a 1.5 cm GE junction mass, biopsy positive for poorly differentiated adenocarcinoma with signet ring cells (stage IIA (T3 N0 M0) [2126-7-2] endoscopic ultrasound at [Hospital1 ] by Dr. [Last Name (STitle) ], which revealed a 3-cm mass of malignant appearance at the GE junction, staged as T3 by US criteria. No lymph node was noted in the peri-esophageal mediastinum. He was deemed to not be a surgical candidate due to his poor functional status, ongoing alcohol and tobacco use, and history of chronic hepatitis C. [2126-7-22]: Planned to start chemotherapy concurrent with radiation with cisplatin and 5-FU. Thrombocytopenia was noted on [2126-7-22], only 5-FU and radiation was started. 5-FU and radiation were discontinued on [2126-7-24] for a platelet count of 42. Workup for thrombocytopenia revealed no reversible causes, with likely contributions from his liver disease and splenomegaly. [2124-1-21]: Received 4500 cGy with photons, followed by boost of [2095] cGy in 11 fractions. Total radiation administered with 6480 cGy from [2126-7-22] to [2126-10-10], given over a total of 80 days, with treatment interruptions due to the patient not showing up. . PAST MEDICAL HISTORY: 1. Chronic hepatitis C, diagnosed 30 years ago; [7-9] viral load: 3,890,000, stable 2. Alcoholism. 3. Right above the knee amputation status post motor vehicle accident at the age of 17, stable. 4. Bullet fragment in the left foot as a result of an accident that the patient does not wish to elaborate upon. 5. Chronic lower extremity edema in left leg, stable 6. Umbilical hernia, stable 7. Chronic neck and back pain presumably due to degenerative joint disease, stable 8. Narcotic dependence. 9. Splenomegaly. Social History: He previously worked as a landscaper, but has not been working since [2122] secondary to poor fitting prosthesis and not being able to ambulate. He is married and has one son who is in the military. He continues to smoke one pack per day of cigarettes since about [2110]. He previously was drinking 10 to 15 beers per day, and briefly stopped drinking, but he reports that he currently drinks one day per week, about six or seven beers per session. Family History: NC Physical Exam: VS: 97.8 118 117/63 13 92%6L nc Gen: Splinting in severe abdominal pain, rapid shallow breathing HEENT: Jaundiced, +scleral icterus. MM dry CV: Tachy S1 + S2 Pulm: Low lung volumes, CTAB ABD: Distended, tense. -BS. Ext: Chronic stasis dermatitis. Neuro: Oriented to person. otherwise non-focal. -asterixis. Pertinent Results: [2126-12-8] 04:51AM BLOOD WBC-22.7# RBC-3.37 Hgb-11.9* Hct-35.4* MCV-105* MCH-35.4* MCHC-33.7 RDW-17.9* Plt Ct-106* [2126-12-7] 04:15PM BLOOD WBC-11.3# RBC-3.56 Hgb-12.4* Hct-35.6* MCV-100* MCH-35.0* MCHC-34.9 RDW-17.9* Plt Ct-72* [2126-12-7] 03:42AM BLOOD WBC-3.1* RBC-3.83* Hgb-13.5* Hct-37.9* MCV-99* MCH-35.3* MCHC-35.7* RDW-17.4* Plt Ct-68* [2126-12-6] 09:28PM BLOOD WBC-2.3* RBC-3.84* Hgb-13.6* Hct-39.1* MCV-102* MCH-35.3* MCHC-34.7 RDW-17.0* Plt Ct-68* [2126-12-6] 12:50PM BLOOD WBC-3.1# RBC-4.39# Hgb-15.3# Hct-44.1# MCV-100# MCH-34.9 MCHC-34.8 RDW-17.3* Plt Ct-79# [2126-12-6] 12:50PM BLOOD Neuts-85 Bands-8* Lymphs-2* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2126-12-6] 12:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL [2126-12-8] 04:51AM BLOOD PT-33.5* PTT-55.0* INR(PT)-3.4* [2126-12-7] 04:15PM BLOOD PT-27.2* PTT-56.7* INR(PT)-2.6* [2126-12-7] 03:42AM BLOOD PT-22.7* PTT-45.6* INR(PT)-2.1* [2126-12-6] 09:28PM BLOOD PT-22.7* PTT-49.8* INR(PT)-2.1* [2126-12-6] 12:50PM BLOOD PT-19.6* PTT-40.9* INR(PT)-1.8* [2126-12-8] 04:51AM BLOOD Glucose-86 UreaN-29* Creat-2.1* Na-137 K-4.7 Cl-104 HCO3-19* AnGap-19 [2126-12-7] 04:15PM BLOOD Glucose-59* UreaN-26* Creat-1.8* Na-138 K-4.2 Cl-109* HCO3-15* AnGap-18 [2126-12-7] 03:42AM BLOOD Glucose-73 UreaN-19 Creat-1.4* Na-138 K-3.6 Cl-105 HCO3-17* AnGap-20 [2126-12-6] 09:28PM BLOOD Glucose-88 UreaN-15 Creat-1.2 Na-135 K-2.7* Cl-100 HCO3-18* AnGap-20 [2126-12-6] 12:50PM BLOOD UreaN-14 Creat-0.9 [2126-12-8] 04:51AM BLOOD ALT-60* AST-202* LD(LDH)-422* AlkPhos-47 TotBili-31.4* [2126-12-7] 03:42AM BLOOD ALT-38 AST-83* LD(LDH)-141 AlkPhos-81 TotBili-33.0* [2126-12-6] 09:28PM BLOOD ALT-38 AST-78* LD(LDH)-149 AlkPhos-94 TotBili-33.9* DirBili-24.6* IndBili-9.3 [2126-12-6] 12:50PM BLOOD ALT-44* AST-92* LD(LDH)-210 AlkPhos-135* TotBili-41.7* DirBili-29.4* IndBili-12.3 [2126-12-6] 12:50PM BLOOD Lipase-25 [2126-12-8] 04:51AM BLOOD Albumin-3.5 Calcium-7.9* Phos-8.1# Mg-2.8 [2126-12-7] 03:42AM BLOOD Albumin-2.5* Calcium-7.9* Phos-4.2 Mg-2.5 [2126-12-6] 09:28PM BLOOD Hapto-12* [2126-12-6] 12:55PM BLOOD Ammonia-96* [2126-12-6] 12:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2126-12-8] 05:27AM BLOOD Type-ART Temp-37.8 Rates-14/2 Tidal V-500 PEEP-20 FiO2-80 pO2-108* pCO2-74* pH-7.00* calTCO2-20* Base XS--14 AADO2-392 REQ O2-69 Intubat-INTUBATED [2126-12-8] 01:18AM BLOOD Type-ART Temp-37.8 Tidal V-500 PEEP-20 FiO2-80 pO2-75* pCO2-77* pH-6.96* calTCO2-19* Base XS--17 AADO2-422 REQ O2-73 Intubat-INTUBATED [2126-12-7] 10:41PM BLOOD Type-ART Temp-38.3 Rates-14/12 Tidal V-500 PEEP-20 FiO2-80 pO2-81* pCO2-63* pH-7.02* calTCO2-17* Base XS--16 AADO2-430 REQ O2-74 -ASSIST/CON Intubat-INTUBATED [2126-12-7] 08:23PM BLOOD Type-ART Temp-37.6 Rates-14/10 Tidal V-550 PEEP-10 FiO2-80 pO2-69* pCO2-45 pH-7.11* calTCO2-15* Base XS--15 AADO2-460 REQ O2-78 -ASSIST/CON Intubat-INTUBATED [2126-12-7] 06:33PM BLOOD Type-ART Temp-38.1 Rates-/24 Tidal V-550 PEEP-10 FiO2-80 pO2-86 pCO2-40 pH-7.16* calTCO2-15* Base XS--13 AADO2-463 REQ O2-76 -ASSIST/CON Intubat-INTUBATED [2126-12-7] 04:22PM BLOOD Type-ART pO2-141* pCO2-39 pH-7.22* calTCO2-17* Base XS--11 [2126-12-7] 01:11PM BLOOD Type-ART Temp-37.6 PEEP-10 pO2-106* pCO2-41 pH-7.19* calTCO2-16* Base XS--11 -ASSIST/CON Intubat-INTUBATED [2126-12-6] 09:33PM BLOOD Type-ART pO2-89 pCO2-33* pH-7.36 calTCO2-19* Base XS--5 [2126-12-8] 05:27AM BLOOD Lactate-6.6* [2126-12-8] 01:18AM BLOOD Lactate-7.0* [2126-12-7] 10:41PM BLOOD Lactate-7.4* [2126-12-7] 08:23PM BLOOD Lactate-7.9* [2126-12-7] 04:22PM BLOOD Lactate-6.3* [2126-12-7] 01:11PM BLOOD Lactate-7.3* [2126-12-7] 04:10AM BLOOD Lactate-6.0* [2126-12-6] 09:33PM BLOOD Lactate-7.3* [2126-12-6] 12:57PM BLOOD Glucose-90 Lactate-4.1* Na-135 K-3.4* Cl-97* calHCO3-24 [2126-12-7] 04:22PM BLOOD freeCa-1.09* [2126-12-7] 01:11PM BLOOD freeCa-1.10* [2126-12-6] 12:57PM BLOOD freeCa-1.05* [2126-12-6] 03:20PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-LG Urobiln-4* pH-7.0 Leuks-NEG [2126-12-6] 03:20PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [2126-12-6] 03:20PM URINE CastGr-[2-22]* CastHy-0-2 [2126-12-7] 10:10AM URINE Hours-RANDOM UreaN-70 Creat-99 Na-94 K-30 Cl-90 [2126-12-7] 10:10AM URINE Osmolal-303 [2126-12-6] 03:29PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG [2126-12-6] 03:13PM ASCITES WBC-[Numeric Identifier 24587]* RBC-5000* Polys-93* Bands-2* Lymphs-0 Monos-5* [2126-12-6] 03:13PM ASCITES TotPro-0.8 Glucose-0 LD(LDH)-110 Amylase-25 Albumin-LESS THAN [2126-12-6] 12:50 pm BLOOD CULTURE SET#1. Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) \| AMIKACIN-------------- S AMPICILLIN------------ S AMPICILLIN/SULBACTAM-- S CEFEPIME-------------- S CEFTAZIDIME----------- S CEFTRIAXONE----------- S CIPROFLOXACIN--------- R GENTAMICIN------------ S MEROPENEM------------- S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ S Aerobic Bottle Gram Stain (Final [2126-12-7]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] @ 6:08A [2126-12-7]. GRAM NEGATIVE RODS. Anaerobic Bottle Gram Stain (Final [2126-12-7]): GRAM NEGATIVE RODS. [2126-12-6] 3:13 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [2126-12-6]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 85252] ON [2126-12-3] AT [2115]. FLUID CULTURE (Preliminary): ESCHERICHIA COLI. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Abd u/s IMPRESSION: No free intraperitoneal air or evidence of small bowel obstruction. RUQ u/s IMPRESSION: Limited evaluation of the right upper quadrant due to patient's inability to cooperate with the study. 1. No focal hepatic lesions. Patent main portal vein with hepatopetal flow. 2. Minimal ascites not amenable to paracentesis. 3. Splenomegaly CTAP IMPRESSION: 1. Extensive intrahepatic biliary dilatation and irregularity involving the right lobe of the liver of uncertain etiology for which differential includes infection (ascending cholangitis with pericholangitic phlegmon), primary neoplasm such as cholangiocarcinoma, or metastasis. Overall MRCP/ERCP is recommended for further evaluation. 2. Distended gallbladder without other CT evidence of acute cholecystitis. Clinical correlation to this site is recommended and if acute cholecystitis is of clinical concern, HIDA can be considered. 3. Small amount of intra-abdominal ascites in the setting of a cirrhotic liver with sequela of portal hypertension including splenomegaly and varices. 4. Likely bibasilar atelectasis of the lungs, though pneumonia is not excluded. Brief Hospital Course: Mr. [Known lastname 74626] is a 51 year old gentleman with stage IIa esophageal adenocarcinoma s/p chemoradiation, HCV cirrhosis, and EtOH abuse who presented to the [Hospital1 18] ED for abdominal pain and distension now transferred to the [Hospital Unit Name 153] for hyperbilirubinemia and SBP. The pt was found to have Ecoli in his peritoneal fluid, with fluid analysis consistent with SBP, and GNR's in his blood. He was started on Zosyn and given albumin. ERCP, Hepatology, and Transplant surgery were consulted. However, pt began to clinically decompensate very rapidly and was intubated. He had CTAP to evaluate for secondary source of infection, i.e. ? ascending cholangitis, however by this time was becoming anuric with worsening renal function, WBC count was rising, becoming more coagulopathic, liver enzymes rising, and becoming very acidemic with elevated lactate. Consulting services evaluated the pt and felt him far too sick to survive any intervention and gave him a grim prognosis. He was bolused IVF's and eventually started on pressors, however his BP's continued to fall despite 3 pressors at max doses, and FiO2 100% with 20 PEEP to maintain sats in the 80's. Initial discussion with pt's ex-wife, who was present through this course, was to continue pressors and mechanical ventilation, but not escalate care, and he was initially made DNR. Eventually he was made CMO given futility of further medical management. He passed away in the am of [2126-12-8]. Medications on Admission: Ativan 1 mg po tid prn Oxycodone 30 mg QID prn Ambien 10 mg qhs prn Colace Omeprazole 20 mg daily Discharge Medications: N/a Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 8405] Completed by:[2126-12-8] ICD9 Codes: 5849, 2762, 2875, 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2286 }	Medical Text: Admission Date: [2155-7-16] Discharge Date: [2155-7-25] Date of Birth: [2081-10-8] Sex: F Service: CHIEF COMPLAINT: Disabling leg claudication, left greater than right. HISTORY OF THE PRESENT ILLNESS: The patient is a 73-year-old nondiabetic white female with hypertension, hypercholesterolemia, mesenteric ischemia, status post mesenteric artery bypass in [2154-7-8] complicated by respiratory failure, pleural effusions, esophageal Candidiasis, and gallbladder disease requiring gallbladder decompression and anorexia requiring the placement of a PEG, complained of severe, disabling bilateral claudication and left foot rest pain. The patient had outpatient arteriogram which showed aortoiliac disease. However, because of the patient's pulmonary disease and recent postoperative complications following mesenteric artery bypass an axillobifemoral bypass graft was recommended. The patient had no ulcerations on her feet. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Mesenteric ischemia. 4. Gastritis. 5. Migraines. 6. GERD. 7. Esophageal Candidiasis during hospitalization in [2154-7-8]. 8. Postoperative respiratory failure requiring reintubation in [2154-7-8]. 9. Left pleural effusion, status post thoracentesis times two in [2154-8-8]. 10. Gallbladder disease requiring percutaneous cholecystotomy for gallbladder decompression. 11. Anorexia requiring the placement of a PEG in [2154-8-8] hospitalization. PAST SURGICAL HISTORY: 1. Mesenteric artery bypass graft on [2154-8-6] by Dr. [Last Name (STitle) ]. 2. Left thoracentesis on [2154-8-15] and [2154-8-17]. 3. Percutaneous cholecystotomy. 4. PEG placed on [2154-9-3]. 5. Tonsillectomy at age 6. ALLERGIES: 1. Penicillin causes red blotching, rash. 2. Erythromycin base: Reaction unknown. ADMISSION MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Aspirin 81 mg p.o. q.d. 3. Lasix 20 mg p.o. q.d. 4. Pravachol 20 mg p.o. b.i.d. 5. Folic acid 1 mg p.o. q.d. 6. Senokot C two tablets q.d. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is a former cigarette smoker, does not drink alcohol. She lives with an elderly female roommate. She ambulates independently. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Pulse 85, blood pressure 184/85, height 5' 2", weight 132 pounds. General: The patient was an alert, cooperative, frail white female, mildly dyspneic on ambulation to examination room. HEENT: The pupils were equal and round. The sclerae were anicteric. Neck: Range of motion was within normal limits. No lymphadenopathy or thyromegaly. Chest: Lungs were clear bilaterally. Heart: Regular rate and rhythm without murmur. Abdomen: Bowel sounds present. Mild tenderness in the epigastric area at the proximal pole of the surgical incision with some hypertrophy and puckering noted. Rectal: Deferred. Extremities: No ankle edema. Right first toenail absent. Left foot ruborous without ulceration. Pulse examination: Femoral pulses diminished bilaterally. Distal pulses nonpalpable. Neurologic: Nonfocal. LABORATORY/RADIOLOGIC DATA: On [2155-7-8], WBC 11.6, hemoglobin 12.5, hematocrit 39.2, platelets 360,000. PT 12.7, PTT 24.8, INR 1.1. Sodium 147, potassium 4.0, chloride 107, bicarbonate 20, BUN 29, creatinine 1.2, glucose 96. EKG showed a normal sinus rhythm at a rate of 70. Normal tracing compared to previous tracing of [2154-9-17]. Chest x-ray showed no acute pulmonary disease. HOSPITAL COURSE: The patient was admitted to the hospital on [2155-7-16] following an uneventful right axillary artery to right common femoral bypass and right femoral to left common femoral bypass with PTFE graft. At the end of surgery, the patient had warm feet with Dopplerable right pedal pulses and no Doppler signals in the left pedal pulse initially but within several hours Doppler signals were found. On postoperative day number one, the patient was transferred from the VICU to a floor bed. Later that same evening, the patient had two episodes of nausea and vomiting. She complained of epigastric pain. EKGs were normal. She was kept n.p.o. Her heart rate was approximately 115 and was treated with IV Lopressor. The patient's hematocrit was found to be 26 after having been 32 on postoperative day number one. She was transfused 2 units of packed red blood cells. She was started on IV heparin and IV nitroglycerin. Her second set of cardiac isoenzymes were positive and she was transferred to the SICU for treatment of her evolving myocardial infarction. The Cardiology Service started the patient on Imdur, Lopressor, and hydralazine which was then changed to an ACE inhibitor. The goal heart rate was 60 and goal systolic blood pressure was 115-125. The patient was continued on heparin. The patient continued to have several more episodes of nausea and vomiting without any EKG changes. This was thought to be continued demand ischemia. Persantine MIBI study was planned; however, because of repeated episodes of nausea, the patient was taken for a cardiac catheterization on [2155-7-21]. Catheterization showed one vessel coronary artery disease, preserved ventricular function with an ejection fraction of 55%, a successful PTCA/drug eluding stent of the midcircumflex was placed and a PTCA of OM1. Cardiology also recommended starting Zestril 5 mg q.d. if the patient's systolic blood pressure continued to be higher than 130 on Lopressor, Captopril, and Imdur. The patient's left hand became somewhat cooler following cardiac catheterization and revealed the left brachial artery. Heparin was continued to prevent thrombosis during arterial vasospasm. The arm was also edematous since the patient had gained 10 kilograms postoperatively in fluid. The patient's hematocrit was noted to be 28 and she was transfused 1 more unit of packed red blood cells. The patient returned to [Hospital Ward Name ] 9 from the Postcatheterization Unit on [2155-7-23]. Her hand was somewhat warmer. She had a triphasic left ulnar pulse and a biphasic left radial pulse. The IV heparin was stopped. Physical Therapy consult was requested for full weightbearing ambulation. Short-term cardiac rehabilitation was recommended. At the time of dictation, the patient's incisions are clean, dry, and intact. She has Doppler signals of her axillo and femoral-femoral grafts. Her pedal pulses are all Dopplerable. She will follow-up with Dr. [Last Name (STitle) ], covering for Dr. [Last Name (STitle) ], in one weeks time or per further instructions at the time of discharge. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q.d.; nine months following PTCA/stent placement. 2. Aspirin 325 mg p.o. q.d. 3. Lopressor 50 mg p.o. t.i.d. 4. Lasix 20 mg p.o. q.d. 5. Pravastatin 20 mg p.o. b.i.d. 6. Folic acid 1 mg p.o. q.d. 7. Isordil 10 mg p.o. t.i.d. 8. Protonix 40 mg p.o. q.d. 9. Colace 100 mg p.o. b.i.d. 10. Senna tablet one p.o. b.i.d. p.r.n. 11. Dulcolax suppository, one per rectum q.d. p.r.n. 12. Milk of magnesia 30 cc p.o. q. six hours p.r.n. 13. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n. 14. Hydromorphone 2-4 mg p.o. q. four hours p.r.n. pain. 15. Ambien 5 mg p.o. q.h.s. DISPOSITION: To [Hospital ] Rehabilitation, possibly cardiac rehabilitation. CONDITION ON DISCHARGE: Satisfactory. PRIMARY DIAGNOSIS: 1. Severe disabling claudication, left greater than right. 2. Axillobifemoral bypass graft on [2155-7-16]. SECONDARY DIAGNOSIS: 1. Postoperative myocardial infarction. 2. Left arm arterial vasospasm, resolved. 3. Blood loss anemia, status post transfusions. 4. Postoperative fluid retention, treated with IV Lasix. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 3954] MEDQUIST36 D: [2155-7-24] 03:22 T: [2155-7-24] 19:05 JOB#: [Job Number 42960] ICD9 Codes: 9971, 2851, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2287 }	Medical Text: Admission Date: [2124-10-2] Discharge Date: [2124-10-3] Date of Birth: [2068-5-18] Sex: F Service: MEDICINE Allergies: Ampicillin Attending:[Last Name (NamePattern4) 290] Chief Complaint: Vomiting coffe ground like stuff Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [Known firstname 553] [Known lastname 23957] is a 56 year old woman with a history of ITP s/p splenectomy and recently diagnosed DM2 who presents from her PCP office with new onset coffee ground emesis. . Ms. [Known lastname 23957] describes waking up this morning and feeling unwell while running errands. On return back to the house she felt extremely fatigued and lightheaded after walking up the four stairs from her driveway to the front door and had to sit down. She described the sensation of sudden fevers and chills. She reports having sudden sharp substernal chest pain while seated that lasted a few minutes. She was concerned that this chest pain might be a heart attack so she went inside to take aspirin. On the way to the kitchen she vomited dark brown coffee grounds. She took two baby aspirin and called her spouse. She did not want to go to the Emergency Department so her spouse called her PCP who instructed her to come in. On her walk into the office she had another episode of coffee ground emesis. In clinic she was found to be tachycardic and was instructed to go immediately to the Emergency Department for concern for a GI bleed. . In the ED, initial vs were: T 96.4 P 111 BP 115/73 R 18 O2 sat 100% RA. NG lavage was positive for coffee grounds. Her rectal exam revealed melanotic guaiac positive stools. EKG showed sinus tachycardia with [Street Address(2) 4793] depression I and aVL. CXR was negative for an acute process. Her initial hct returned at 36 down from recent 43 on [2124-9-13]. Repeat hct, however, fell to 26. GI services was consulted. During her evaluation she had one transient episode of hypotension to 79/54 which quickly responded to IV fluids. Patient received protonix bolus and continuous drip, 2 u pRBC, and 3 L IV NS prior to transfer to the ICU. . On the floor, patient reports feeling much better since receiving her blood transfusions in the Emergency Department. She is no longer light headed and fatigued. She reports only having two episodes of coffee ground emesis which both occured prior to arrival to the ED. On further questioning she admits to one day of dark tarry stools but has not had any further bowel movements since her arrival. She denies any history of GI bleeding or ulcers. She denies use of alcohol or anticoagulation. She denies recent GI illness or repeated emesis or heaving. When asked about NSAID use she does report a significant increase in her NSAID use after a recent dental procedure. She describes taking 3 Advil tablets at time up to every four hours. She states she probably averages 12 pills per day over the last two weeks. She also reports starting a prescription strength NSAID that she took in addition to the Advil after her dental procedure. She was also given a prescription for Percocet and often alternated her Advil doses with 2 extra strength Tylenol. Patient reports taking up to 8 extra strength Tylenol each day (4 grams). Past Medical History: 1) Hypertension: Toprol XL 50mg. 2) High cholesterol/triglycerides: Zocor 3) Irritable Bowel Syndrome: with constipation alternating with diarrhea and lower abdominal pain. 4) Migraine headaches: several times monthly 5) ITP s/p laparoscopic splenectomy ([12/2112]): initially relapsed following splenectomy but has had stable, normal platelet levels for last 10 years. 6) Diabetes Mellitus Type 2: last hemoglobin A1C of 8.3 [2124-9-13]. started metformin. 7) Serologies: neg hepatitis w/u '[11], neg [Doctor First Name ], RF '[13] Social History: Social History: Patient lives with her spouse. She is unemployed. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies . Family History: Family History: Mother - cerebral aneurysm Physical Exam: Physical Exam: Vitals: T: 98.5 BP: 141/85 P: 109 R: 16 O2: 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no hepatomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes . Pertinent Results: [2124-10-2] 02:47PM BLOOD WBC-9.6 RBC-3.74* Hgb-11.4* Hct-36.1 MCV-97 MCH-30.6 MCHC-31.7 RDW-12.8 Plt Ct-338 [2124-10-2] 05:55PM BLOOD WBC-8.1 RBC-2.74# Hgb-8.7 Hct-25.8# MCV-94 MCH-31.7 MCHC-33.6 RDW-12.7 Plt Ct-245 [2124-10-3] 04:42AM BLOOD WBC-10.6 RBC-3.74# Hgb-11.2# Hct-34.1 MCV-91 MCH-29.9 MCHC-32.8 RDW-14.9 Plt Ct-207 [2124-10-2] 02:47PM BLOOD Neuts-64.4 Lymphs-30.5 Monos-3.6 Eos-0.6 Baso-0.9 [2124-10-3] 04:42AM BLOOD PT-12.4 PTT-22.2 INR(PT)-1.0 [2124-10-2] 02:47PM BLOOD Glucose-178* UreaN-38* Creat-0.6 Na-137 K-4.6 Cl-103 HCO3-24 AnGap-15 [2124-10-3] 04:42AM BLOOD Glucose-84 UreaN-15 Creat-0.5 Na-142 K-3.4 Cl-113* HCO3-21* AnGap-11 [2124-10-3] 04:42AM BLOOD ALT-47* AST-35 CK(CPK)-91 AlkPhos-50 TotBili-0.9 [2124-10-3] 04:42AM BLOOD CK-MB-2 cTropnT-<0.01 [2124-10-3] 02:04PM BLOOD CK-MB-2 cTropnT-<0.01 [2124-10-3] 04:42AM BLOOD Phos-2.4* Mg-1.9 [2124-10-2] 02:52PM BLOOD Glucose-179* Lactate-2.9* K-4.4 Brief Hospital Course: #GI Bleed: Patient with hematocrit drop 17 pts (43-->26) since PCP [Name Initial (PRE) ] [2124-9-13]. She had two witnessed episodes of coffee ground emesis on the day of admission as well as one of day of dark tarry bowel movements. In the ED she was noted to have no known history of GI bleeding or PUD. She denies history of recent GI illness, upper endoscopy, or liver disease. She has a history of ITP which has been in remission for 10 years and presents today with normal platelet count. Patient does admit to significant increase in NSAID use due to recent dental procedures. She is not able to quantify the exact amount of NSAIDs but reports taking 3 Advil tablets at one time multiple times each day over the last two weeks. She also states she was started on a prescription strength NSAID that she took in addition to the Advil over the last two weeks. She was without hemodynamic compromise. Since her transfusion in the ED, her lightheadedness, shortness of breath, or sharp chest pain resolved. Pt Hct was stable overnight and EGD did not show any areas of active bleeding. She was on a pantoprazole drip, and was switched to PO BID. She remained asymptomatic throughout the day and her diet was advanced from NPO to regular. Pt tolerated her diet and was ready for discharge to home. She was instructed to avoid NSAIDs for at least the next 6-8 weeks as well as to not get an MRI for one month. She was given tramadol for 1 month and her outpatient physician said he would manage her pain thereafter. . # Chest pain: Clinical history is unlikely to represent ACS with unstable plaque. Given her active bleed this may represent demand ischemia. The sharp sudden nature of the pain is more consistent with GI or musculoskeletal pain. Her chest discomfort may be related to gastritis or ulcer. No evidence of mediatinal widening to suggest esophageal perforation. Repeat EKG showed no concerning findings. Her cardiac enzymes were negative x2. Her aspirin was held in the setting of GI bleed. The patient was advised to follow up with a cardiologist for an exercise stress test. . #Transaminitis: AST/ALT mildly elevated. Unclear etiology. Negative hepatitis work-up in the past. Slightly more elevated than expected for NASH. She does admit to taking acetaminophen 1 gram q4 hours in addition to Perocet over the last two weeks. LFTs were trended and they were trending back to normal at the time of discharge. . #Diabetes Mellitus Type 2: Hold metformin while inpatient. Pt was put on an insulin sliding scale during her admission and was discharged to home on her oral hypoglycemics. # Hypertension: Blood pressure currently well controlled. Hold home antihypertensives. . Pt was discharged to home with instructions to follow up with her PCP [Last Name (NamePattern4) ] 6 weeks or [Name (NI) 23958] if she had any change in clinical status or any medical concerns that needed to be addressed. Medications on Admission: Metformin Toprol XL 50mg, Zocor 40mg, Vitamin D Levsin (Hyoscyamine) prn Maxalt (Rizatriptan) prn Hydrocortisone 2.5 % Ibuprofen 200 mg three daily Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:2 2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. ketoconazole 2 % Cream Sig: One (1) Topical PRN as needed for Rash. 6. hydrocortisone valerate 0.2 % Ointment Sig: One (1) Topical once a day. 7. hydrocortisone 2 % Lotion Sig: One (1) Topical once a day. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Upper Gastrointestinal Bleed Secondary Diagnosis: Hypertension High cholesterol/triglycerides Irritable Bowel Syndrome. Migraine headaches: several times monthly ITP s/p laparoscopic splenectomy Diabetes Mellitus Type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged from [Hospital1 18]. You were admitted to the hospital because you woke up feeling unwell. You were lightheaded, weak, had fevers/chills, tachycardia and vomited coffe ground color vomit two times before seeing your Primary Care Physician. [Name10 (NameIs) ] sent you straight to the hospital as you physician was concerned about bleeding from your stomach or in that area. You presented to the emergency department and you had a drop in your red blood cells compared to previously. You were transfused 2 units of packed red blood cells and given fluids. Your blood levels stabilized after those two transfusions and further transfusions were not required. It is believed that the bleeding occurred because of the NSAID's that you were taking. It seems that you were taking a lot of advil and ot her anti-inflammatories that aggrevate the stomach lining and can cause it to bleed. It is important that you do not take NSAIDs in the next 6-8 weeks and try to avoid them in the future. You should follow up with Dr. [First Name (STitle) 679] regarding pain management. Do not have an MRI done for 1 month after being discharged from the hospital. The following medication was added: Omeprazole 40mg by mouth daily. Tramadol every 6 hours as needed for pain. The following medications were stopped: Ibuprofen 200 mg three daily Other NSAID's Followup Instructions: Please call Dr. [First Name (STitle) ] at [Telephone/Fax (1) 682]. You should follow up with Dr. [First Name (STitle) 679] 6 weeks after leaving the hospital. NO MRI FOR ONE MONTH. DISCUSS WITH DR. [First Name (STitle) ] ABOUT FOLLOWING UP FOR A CARDIAC STRESS TEST. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 5789, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2288 }	Medical Text: Admission Date: [2114-7-20] Discharge Date: [2114-8-7] Date of Birth: [2038-2-16] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / aspirin / Codeine Attending:[First Name3 (LF) 1505] Chief Complaint: Progressive lower extremity edema Major Surgical or Invasive Procedure: [2114-7-30] Mitral Valve Replacement ([First Name8 (NamePattern2) 11599] [Male First Name (un) 923] Tissue) History of Present Illness: 76 year old female with a past medical history pertinent for Rheumatic heart disease with mitral valve stenosis and severe pulmonary hypertension, atrial fibrillation-on Coumadin, type II Diabetes Mellitus,Hypertension, hyperlipidemia, COPD, Transient ischemic attack, A-V malformation with recurrent GI bleeds, who was admitted to an outside hospital for exacerabation of hear failure, worsening lower extremity edema, shortness of breath and hyponatremia. Past Medical History: anemia secondary to arterio-venous Malformation, bleed 2' Coumadin use, congestive heart failure, Atrial fibrillation, type 2 diabetes mellitus, depression, hypertension, hypothyroidism, peripheral neuropathy, hyponatremia, glaucoma, chronic obstructive pulmonary disease, vascular disease-s/p carotid endarterectomy, obstructive sleep apnea-sleep study x2-does not use recommended CPAP at home, irritable bowel syndrome w/ chronic constipation/diarrhea Social History: Lives with:her daughter [Name (NI) 1139]: intermittent tobacco x 60yr, [7-17] cigs/day x last 2 months -pt states last cigarette prior to admission at OSH ETOH:+2 beers/day:pt states last beer ~ 1mo ago Family History: non-contributory Physical Exam: Pulse:75, Resp: 18, O2 sat: 98% B/P 125/60 Height:148 Weight:63.5" General:A&Ox 3, NAD Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: CTA Heart: RRR [] Irregular [x] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities:superficial varicosities None [] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right:1+ Left:1+ PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit-none Right: 2+ Left:2+ Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: 6.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: 0.33 >= 0.29 Left Ventricle - Ejection Fraction: 65% >= 55% Left Ventricle - Stroke Volume: 91 ml/beat Left Ventricle - Cardiac Output: 6.01 L/min Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 2.9 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 29 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - Mean Gradient: 7 mm Hg Mitral Valve - E Wave: 2.0 m/sec Mitral Valve - E Wave deceleration time: 300 ms 140-250 ms TR Gradient (+ RA = PASP): 68 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. RIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity. RV function depressed. Abnormal systolic septal motion/position consistent with RV pressure overload. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated, with normal leaflet/disc motion and transvalvular gradients. TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild to moderate [[2-11]+] TR. Severe PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with depressed free wall contractility. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Transferred in from outside hospital after presenting with increased edema and shortness of breath for re evaluation for surgical intervention. She was on heparin for atrial fibrillation and underwent preoperative evaluation. Hepatology was consulted, she had abdominal ultrasound that revealed normal liver and spleen, and she was cleared for surgery. Additional preoperative workup included dental, pulmonary function test and echocardiogram. She had discomfort at her catheterization site and had vascular ultrasound that revealed no hematoma or pseudoaneurysm. She was brought to the operating room on [7-25] for surgery however due to increased tenderness at the catheterization site her surgery was cancelled and she was started on ancef for potential cellulitis. Vascular surgery was consulted and felt there was no evidence of infection or vascular issues. However her creatinine increased to 1.6, her ace inhibitor and lasix were stopped and the ancef was discontinued. Additionally her digoxin was stopped due to increased creatinine and bradycardia. Over the next few days her creatinine trended down to baseline 1.1-1.3. She developed diarrhea which resolved within twenty four hours with WBC remaining normal. On [2114-7-30] she was brought to the operating room and underwent mitral valve replacement. See operative report for further details. She received vancomycin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. That evening, she was weaned from sedation, awoke neurologically intact, and was extubated without complications. However later she was noted to have increasing pulmonary and systolic pressures with no response to milirone, nipride, and nicardipine. Her medications were adjusted and on post operative day one she was started on diuretics, ace inhibitor, and beta blocker. On post operative day two her pulmonary catheter was removed and she remained in the intensive care unit for hemodynamic management. Her epicardial wires and chest tubes were removed per protocol. She continued to have betablockers adjusted for heart rate management and lasix for diuresis. Additionally she was treated for hyponatremia with free water restriction and sodium tablets. She was restarted on coumadin for atrial fibrillation and then on post operative day four was transferred to the floor for the remainder of her care. Physical therapy worked with her on strength and mobility. On post operative day eight she was ready for discharge to rehab - [Hospital3 ] in [Hospital1 ] [Location (un) ]. Medications on Admission: Coumadin 2.5 mg Fri-Wed/5 mg Thurs Digoxin 0.125mg daily Glucophage 500 mg [Hospital1 ] Lasix 80 mg daily Omeprazole 20 mg daily Synthroid 150 mcg daily Zocor 20 mg daily Lisinopril 20 mg daily B-12 injections Ambien 5 mg HS 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. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: received 4 mg on [8-7] - to have INR checked [8-8] for further dosing - see coumadin referral form for dosing and INR . 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 5. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): give with lasix daily . 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 11. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 15. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs puffs Inhalation every six (6) hours. 16. amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): 7.5 mg daily . 17. Lantus 100 unit/mL Solution Sig: Twelve (12) untis units Subcutaneous at bedtime: 12 units at bedtime . 18. Insulin Sliding scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2 Units 2 Units 2 Units 2 Units 160-199 mg/dL 4 Units 4 Units 4 Units 4 Units 200-239 mg/dL 6 Units 6 Units 6 Units 6 Units 240-279 mg/dL 8 Units 8 Units 8 Units 8 Units Also note to receive lantus at bedtime 19. potassium chloride 10 mEq Capsule, Extended Release Sig: [2-11] Capsule, Extended Releases PO once a day. 20. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation Goal INR 2.0-2.5 First draw [2114-8-8] Please check PT/INR Monday, Wednesday, and Friday for two weeks then decrease as instructed by physician Coumadin to be managed by rehab physician then please arrange for follow up with PCP when discharged from rehab 21. Outpatient Lab Work Please check Chem 7 to evaluate once a week due to lasix/zaroxlyn/lisinopril/potassium Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Mitral valve stenosis s/p MVR Atrial Fibrillation Diabetes Mellitus type 2 Hyponatremia Rheumatic heart disease Pulmonary hypertension Hypertension Hyperlipidemia Chronic obstructive pulmonary disease Transient ischemic attack A-V malformation with recurrent GI bleeds Depression Hypothyroidism Peripheral neuropathy Hyponatremia Glaucoma Carotid disease Osteoarthritis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with 1 assist Incisional pain managed with tylenol as needed Incisions: Sternal - healing well, no erythema or drainage Edema +1 lower extremity Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [8-23] at 1:30pm Cardiologist: Dr. [Last Name (STitle) 4783] [Telephone/Fax (1) 5424] on [9-5] at 10:45am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] [Telephone/Fax (1) 83705] in [5-15] 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 Goal INR 2.0-2.5 First draw [2114-8-8] Please check PT/INR Monday, Wednesday, and Friday for two weeks then decrease as instructed by physician Coumadin to be managed by rehab physician then please arrange for follow up with PCP when discharged from rehab Completed by:[2114-8-7] ICD9 Codes: 2761, 496, 4168, 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2289 }	Medical Text: Unit No: [Numeric Identifier 70625] Admission Date: [2154-12-20] Discharge Date: [2154-12-23] Date of Birth: [2154-12-20] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Patient is a 3-day-old full-term infant with tachypnea and cyanosis admitted to the neonatal intensive care unit for further evaluation. Patient was born at 41 weeks to a 41-year-old G1 woman. She was A+, antibody negative, GBS negative, hepatitis B surface antigen negative and was RPR nonreactive. PAST MEDICAL HISTORY: Crohn disease treated with Azulfidine. Unremarkable antepartum course. Admitted for induction. Patient was a C-section for failure to progress. Apgars of 9 and 9. SOCIAL HISTORY: Noncontributory. FAMILY HISTORY: Noncontributory. HOSPITAL COURSE: Patient was admitted to the newborn nursery. Vital signs were remarkable for tachypnea, poor feeding and repeated evaluation. Today patient had increasing tachypnea with murmur noted. Patient was referred to NICU for further evaluation. PHYSICAL EXAMINATION: Term infant in mild respiratory distress with temperature of 98.0, pulse of 138, respiratory rate of 52, oxygen saturation of 87% in room air and failure to increase with supplemented nasal cannula oxygen. Blood pressure 62/45 with a mean of 51, weight 3970 grams. Color pink. Soft anterior fontanel. Normal facies. Mild retractions. Clear breath sounds. A II-III/VI harsh systolic murmur at left lower sternal border. No gallop. Abdomen: Soft, flat, nontender. Liver 2.5 cm below right costal margin. Normal perfusion. Hips stable. Normal tone and activity. Normal phallus, testes and scrotum. Four extremity blood pressures showed no differential between upper and lower pressures. Chest x-ray showed normal cardiac silhouette with possible mild pulmonary edema. EKG showed normal sinus rhythm at rate of 150 with intervals and axes notable for right axis deviation and increased voltages in the right-sided precordial leads. ABG notable for pressure of oxygen of 42 with 200 ml of nasal cannula, otherwise pH of 7.43, paco2 of 36. Preliminary echo results from [Hospital3 1810] pediatric cardiology showed likely total or partial pulmonary venous anomalus pulmonary venous return. Cardiology recommendations followed. Total fluids assessed at 60 ml/kg per day. Lasix administered 1/kg x1. Infant is on p.o. and IV fluids of dextrose D10W. Blood culture was sent. Ampicillin and gentamicin initiated upon obtaining a blood culture. Parents were updated both by neonatology and cardiology. Awaiting bed at 8 South. Dr. [Last Name (STitle) ] updated. DIAGNOSIS: 1) Congenital Heart Disease- Partial/Total Anomalous Pulmonary Venous Return 2) Term infant DISPOSITION: Transfer to [Hospital3 1810] 8 South [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Name8 (MD) 68276] MEDQUIST36 D: [2154-12-23] 18:03:38 T: [2154-12-23] 19:56:07 Job#: [Job Number 70626] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2290 }	Medical Text: Admission Date: [2130-6-9] Discharge Date: [2130-6-15] Date of Birth: [2057-8-18] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[First Name3 (LF) 165] Chief Complaint: Shortness of breath, chest pressure Major Surgical or Invasive Procedure: coronary artery bypass grafting x 2 (LIMA-LAD, SVG-OM) [2130-6-11] History of Present Illness: This is a 72 year old male with past medical history significant for angioplasty and stenting of his circumflex artery, posterior left ventricular artery and right coronary artery in [2129-7-11]. He returned to the cath lab later that month due to recurrent angina and underwent stenting of his left anterior descending artery. He was doing well until this past [Month (only) 958] when he developed chest pressure with associated shortness of breath while carrying trash up a flight of stairs. He has also noted some mild chest pressure when he is on the treadmill during cardiac rehab sessions, this also resolves when he either slows his pace or stops walking. A stress test was performed on [2130-5-3] which showed inferolateral ischemia and was stopped due to fatigue. He underwent a cardiac catheterization which revealed single vessel coronary artery disease involving the left main coronary artery and proximal left anterior descending artery detected by IVUS. The former left anterior decending, circumflex and right coronary artery stents were widely patent. Given the anatomy of his disease, he has been referred to Dr. [Last Name (STitle) ] for surgical evaluation. Past Medical History: Coronary artery disease s/p multiple drug eluting stents in [7-19] Hypertension Hypercholesterolemia gastroesophageal reflux History of Basal Cell Carcinoma Social History: Occupation: Pastor at a church in [Location 15289]. Tobacco: Quit [2090] ETOH: one drink daily. Family History: [Name (NI) ] brother with HTN. Most of his family died early, but of cancer. No premature coronary disease. Physical Exam: admission: temp 98, HR 82, BP 154/77, RR 16, 98%RA Height: 66" Weight: 155 General: Elderly male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] - poor dentition Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none Abdomen: Softly distended; asymetrical - larger on left than right; non-tender [x] bowel sounds+ [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 bilateral femoral bruits DP Right: 2 Left: 2 PT [Name (NI) 167]: 2 Left: 2 Radial Right: 2 Left: 2 Carotid Bruit Right: none Left: none Pertinent Results: [2130-6-14] 10:53AM BLOOD UreaN-21* Creat-1.1 K-4.5 [2130-6-13] 03:21AM BLOOD WBC-12.0* RBC-3.62* Hgb-11.4* Hct-33.4* MCV-92 MCH-31.4 MCHC-34.1 RDW-13.8 Plt Ct-221 [2130-6-11] 10:16AM BLOOD PT-13.8* PTT-32.8 INR(PT)-1.2* [2130-6-13] 03:21AM BLOOD Glucose-122* UreaN-16 Creat-1.0 Na-138 K-4.2 Cl-103 HCO3-28 AnGap-11 [2130-6-12] 03:28AM BLOOD Glucose-103* UreaN-18 Creat-1.1 Na-140 K-4.5 Cl-107 HCO3-25 AnGap-13 [2130-6-14] 10:53AM BLOOD WBC-9.2 RBC-3.84* Hgb-12.1* Hct-35.7* MCV-93 MCH-31.5 MCHC-33.9 RDW-14.0 Plt Ct-291 [Hospital1 18] ECHOCARDIOGRAPHY REPORT BP (mm Hg): 110/75 Wgt (lb): 155 HR (bpm): 81 BSA (m2): 1.80 m2 Indication: Coronary artery disease. ICD-9 Codes: 786.05, 786.51 Test Information Date/Time: [2130-6-11] at 09:24 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW001-0:00 Machine: ie33 Echocardiographic Measurements Results Measurements Normal Range Findings LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. Biventricular systolic function is preserved. There is 1+ tricuspid regurgitation. The aorta is intact post-decannulation. All findings communicated to the surgeon intraoperatively. Brief Hospital Course: The patient was brought to the Operating Room on [2130-6-11] where he underwent coronary artery bypass grafting x 2 with Dr. [First Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis given the patient's inpatient stay of 24hours preoperatively. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Fr. [Known lastname 60285] was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued in a timely fashion, without complication. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD# the patient was ambulating freely, the wounds were healing well and pain was controlled with oral analgesics. Fr.[Known lastname 60285] was cleared by Dr.[First Name (STitle) ] for discharge to home on POD# 4 in good condition with appropriate follow up instructions advised. Medications on Admission: Amlodipine 2.5mg qd Plavix 75mg daily- LAST DOSE [2130-6-4] Imdur 60mg Daily Lopressor 50mg twice daily Sublingual nitroglycerin as needed 0.3mg Benicar 20/12.5mg daily zantac 150mg [Hospital1 ] Crestor 20mg daily Aspirin 325mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:50 Tablet(s) Refills:0 7. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: coronary artery disease s/p Coronary artery bypass grafting x 2 (LIMA-LAD, SVG-OM) [2130-6-11] s/p multiple drug eluting stents in [7-19] Hypertension Hypercholesterolemia gastroesophageal reflux History of Basal Cell Carcinoma Left shoulder arthritis Past Surgical History: Resection of skin cancers Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2130-7-17] 1:45 Please call to schedule appointments PCP/Cardiologist Dr. [Last Name (STitle) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 8725] in [2-11] 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 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2130-6-15] ICD9 Codes: 2859, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2291 }	Medical Text: Admission Date: [2116-10-22] Discharge Date: [2116-11-12] Date of Birth: [2096-8-1] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: Headache Major Surgical or Invasive Procedure: Tunnelled catheter placement Hemodialysis History of Present Illness: 20 F with Type I Diabetes, complicated by ESRD on HD for the last year. Recently hospitalized here 2-3 weeks ago for uncontrolled hypertension. . States that she has bifrontal headaches associated with her hypertension. This was controlled for only a few days after her discharge. Since then, she has had recurrent headaches at least daily, sometimes lasting up to all day. They have been relatively stable these past weeks. She denies associated CP, SOB. No signs of infection including fevers, chills, new rash, nausea, vomiting or diarrhea. . Was seen at endocrine clinic for her parathyroid adenoma, at which time she was referred to the ED for her elevated blood pressure to SBP > 200 and associated headache. Past Medical History: * Type I DM - since [2098] * ESRD on HD (MWF in [Hospital1 789]) * Pulmonary embolism on coumadin (diagnosed 1 month prior per patient) * Hypertension * Hyperlipidemia * Retinal detachment L eye * Bilateral cataracts Social History: The patient lives at home with her parents and younger sister. She denies any alcohol or tobacco use. Family History: No history of headaches or migraines. Father and grandparents with hypertension. Two grandparents are diabetic. Physical Exam: Physical Examination VS - 98.1 bp 160/110 HR 91 RR 18 96%RA GEN: NAD HEENT - R pupil reactive; L globe scarred; OP clr, MMM CV - RRR, no m/r/g RESP - R anterior chest tunnelled HD line c/d/i; lungs CTAB ABD - NABS, soft, NT/ND, EXT - no edema Pertinent Results: [2116-10-22] 03:30PM GLUCOSE-188* UREA N-39* CREAT-6.3* SODIUM-140 POTASSIUM-6.3* CHLORIDE-96 TOTAL CO2-27 ANION GAP-23* [2116-10-22] 09:03PM K+-5.7* . [2116-10-22] 03:30PM WBC-6.4 RBC-3.86* HGB-11.8* HCT-38.0# MCV-98 MCH-30.6 MCHC-31.1 RDW-18.6* NEUTS-54.5 LYMPHS-21.0 MONOS-3.3 EOS-17.6* BASOS-3.6* . [2116-10-22] 03:30PM PT-33.2* PTT-37.7* INR(PT)-3.6* . CXR [10-22]. IMPRESSION: Findings consistent with volume overload. Repeat radiography following diuresis recommended. Brief Hospital Course: In summary, Ms. [Known lastname ] is a 20 yo female with Type I DM, ESRD on HD, h/o PE in [8-11] on coumadin, parathyroid adenoma, admitted for hypertensive urgency. . HTN. Patient was initially treated in the MICU on a nitroglycerin drip. Her BP improved. She was then transferred to the floor after one day. She was resumed on her home BP meds (labetolol and losartan and nifedipine). It remained unclear if hypertension was due to medication noncompliance (patient says she reliably takes all meds) versus chronic underdializing and fluid overload. She was then transferred back to the ICU for hypertensive urgency again. She required labetolol gtt on and off to control her BP. She received daily ultrafiltration and hemodialysis to regain fluid balance. She was also started on additional oral BP meds including hydralazine and minoxidil (avoided clonidine for concern over reflex hypertention if there is medication non-compliance). Once transferred back to the floor, minoxidil was uptitrated to 7.5mg daily. Hydralazine was dosed at 25mg po BID, was briefly treated with QID dosing but both patient and her mother thought this would be difficult to maintain while outpatient. Upon discharge her BP ranged from SBP 120-130s directly after dialysis to SBP 140-180 on non-dialysis days. When she did exceed SBP > 200, or DBP > 120, she was given hydralazine 5mg IV with appropriate effect. Discharged on labetolol, losartan, nifedipine, minoxidil and hydralazine. . Line infection/bacteremia. At HD on [10-26] she was noted to have rigors and subsequently developed a ACINETOBACTER BAUMANNII bactermia and growth from her tunnelled cath tip (after it was removed). She was treated with gentomycin until the sensitivities returned and she was switched to ciprofloxacin. A temporary line was briefly used and then a new tunneled catheter was placed once surveillance cultures returned negative. She completed a 14 day course of Cipro and then the medication was discontinued. . HA. Patient reports unilateral throbbing headache associated with photophobia and nausea. It was not clear if her headache was due to hypertension or if she was having a migraine. Throughout her course, her HA occurred nearly daily and had no clear association with her blood pressure. She was treated also with Dilaudid and morphine IV for pain which generally controlled her pain. She was started on a trial of sumatriptan for headaches which was moderately helpful, she was discharged with a limited number of this medication. Fioricet was tested and did provide moderate relief. She was discharged on a limited number of this medication. . Parathryoid adenoma. Parathyroid scan on [2116-10-2] showed anterior mediastinal parathyroid adenoma. Patient will need surgical removal of adenoma in future given that hypercalcemia likely contributes to both her headache and recurrent nausea. Dr. [Last Name (STitle) 26030] was consulted while inpatient and planned on removing her adenoma while inpatient. The day of the proposed operation, however, her blood pressure was so poorly controlled that anesthesiology thought it unsafe to proceed with surgery. She was recommended to follow-up with Dr. [Last Name (STitle) 26030] as an outpatient with an appropriate anesthesiology pre-operative evaluation given the severity of her hypertension. . History of PE. Patient had PE at OSH in [8-11] and is on Coumadin. She was continued on coumadin in the hospital with her INR within goal range of [2-8]. Her coumadin was briefly held while inpatient and she was transitioned to a heparin drip in preparation for her parathyroid adenomectomy. Once it became clear that her surgery could not be obtained while inpatient, she was restarted on coumadin. The day of discharge she had a therapeutic INR x 48 hours. . ESRD on HD: followed by renal consult. Continued on HD and ultrafiltration. Also treated with Sevelamer and Cinacalcet per Renal recommendations. Discharged with follow-up at prior hemodialysis facility. Also instructed INR monitoring during HD. . DM1. Long standing history on uncontrolled type 1 diabetes. She was hyperglycemic initially with her infection, but then was better controlled in the MICU. Continued on glargine [Hospital1 ] and humalog with meals. Maintained fair control while inpatient from 100-200. Was continuously difficult to control given erratic eating patterns, poor diet compliance and refusal by patient & mother to adhere to prescribed insulin dosing at various intervals. Discharged with glargine 15u at breakfast and 12u at supper and a humalog insulin sliding scale. Also set-up with VNA services given the complexity of her medical issues. . Hyperkalemia. Intermittently hyperkalemic in the setting of ESRD. Never symptomatic. No EKG changes. Treated intermittently with kayexelate when K > 5. . Abdominal Pain - Intermittent abdominal pain described as vague and diffuse. C/w with constipation in addition to possible gastritis. Continued on PPI and an aggressive bowel regimen. Resolved with these interventions. Was discharged without abdominal pain x 48 hours. . H/O glaucoma. On multiple medications, eye drops consistent with glaucoma. Additionally on prednisone gtts of unclear reasoning. Patient insisted on continued drops during inpatient stay. On discharge was recommended to follow-up with ophthalmologist to better define course of prescribed medications. . Discharged home with moderately controlled hemodynamic stability, afebrile. VNA services set-up on discharge for family support given complexity of her medical problems. Medications on Admission: 1. B Complex-Vitamin C-Folic Acid 1 mg DAILY 2. Prednisolone Acetate 1 % Drops, One Drop Daily 3. Dorzolamide-Timolol 2-0.5 % Drops 1 Drop DAILY 4. Brimonidine 0.15 % Drops 1 Drop DAILY 5. Butalbital-Acetaminophen-Caff 50-325-40 mg One Tablet PO Q8h PRN 6. Labetalol 800 mg PO TID 7. Prochlorperazine 10 mg PO Q8h prn nausea 8. Pantoprazole 40 mg PO Q24H 9. Sevelamer 1600 mg PO TID W/MEALS 10. Warfarin 5 mg PO at bedtime Mon, Wed, Fri, Sat; 2.5 mg Tues, [Last Name (LF) 5929], [First Name3 (LF) ] 11. Insulin Glargine 12 units with breakfast, 10 units at bedtime 12. Humalog sliding scale 13. Cinacalcet 90 mg PO once a day 14. Losartan 100 mg PO once a day 15. Nifedipine 30 mg PO Q8h Discharge Medications: 1. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day): 1 DROP BOTH EYES DAILY . 2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): 1 DROP BOTH EYES DAILY . 3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): 1 DROP BOTH EYES DAILY . 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Q MWFSAT (). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Q TUETHURSUN (). 6. Imitrex 25 mg Tablet Sig: One (1) Tablet PO once a day as needed for migraine: Please take within 2 hours of onset of headache. Disp:30 Tablet(s) Refills:0 7. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 11. Sevelamer 800 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:150 Tablet(s) Refills:2 12. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 16. Butalbital-Aspirin-Caffeine 50-325-40 mg Capsule Sig: One (1) Cap PO every eight (8) hours as needed for headache. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 18. Minoxidil 2.5 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:90 Tablet(s) Refills:1 19. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:60 Tablet(s) Refills:1 20. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:60 Tablet Sustained Release(s) Refills:1 21. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache for 20 doses: Do not exceed more than 3gm of Acetamenophen (Tylenol) in one day. This medication contains 325mg per tablet. Disp:20 Tablet(s) Refills:0 22. VNA port maintenance Heparin Flush Port (10 units/mL) 5 ml IV each visit with 10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units heparin) each lumen, each visit. Inspect site each visit. 23. Outpatient Lab Work Please check INR at each Hemodialysis visit and forward information to Dr. [First Name (STitle) 29653] Z [First Name (STitle) ] at [Telephone/Fax (1) 40070] so that he may adjust her coumadin dosing. 24. Lantus 100 unit/mL Solution Sig: 12-15 units Subcutaneous twice a day: Take 15 units at breakfast and 12 units at bedtime . 25. Humalog 100 unit/mL Solution Sig: As directed by insulin sliding scale units Subcutaneous four times a day. Discharge Disposition: Home With Service Facility: VNA Care [Location (un) 511] Discharge Diagnosis: Primary: Hypertension, Diabetes Mellitis type I Secondary: ESRD, parathyroid adenoma, hypercalcemia, hyperlipidemia, prior pulmonary embolism on Coumadin Discharge Condition: Good, moderate hemodynamic control and afebrile Discharge Instructions: You were admitted for hypertension and associated headache. Your blood pressure was controlled by increasing your medications and your headache was controlled with agressive pain relief. You additionally had an infection in your blood while you were in the hospital. You have been treated for this infection. On discharge you will have the continued VNA services. You should also have hemodialysis every Monday, Wednesday and Friday with monitoring of your INR while there. You also need to schedule a follow-up appointment with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. at ([Telephone/Fax (1) 9011] for removal of your parathyroid adenoma. . Please take all your medications as prescribed in the following medication sheet. There have been several modifications concerning your blood pressure medications but it is important that you take all these medications as prescribed. . If you have worsening headache, blurry vision, nausea/vomiting, shortness of breath, chest pain, or any other concerning symptoms, please call your physician or come to the emergency department. . Please keep all your outpatient appointments. Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 40069], in 1 to 2 weeks. Please schedule an appointment by callling [Telephone/Fax (1) 40070]. . Or, if you prefer to have your primary care physician transferred to [Hospital3 ], you may call [Hospital6 733] at [Telephone/Fax (1) 250] to make an appointment to establish care. . Please contact [Name (NI) ] [Name (NI) ], M.D. at ([Telephone/Fax (1) 9011] to schedule a follow-up appointment for surgical removal of your parathyroid adenoma. You will also need a preoperative anesthesiology visit prior to this operation. You should discuss this with Dr. [Last Name (STitle) ]. . Continue to follow-up closely with your gynecologist at Women & Infant's Hospital. . Follow-up with your [Hospital 197] Clinic 3-5 days post-discharge for a INR check and dose adjustment. ICD9 Codes: 2768, 0389, 5856
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2292 }	Medical Text: Admission Date: [2166-7-13] Discharge Date: [2166-8-14] Date of Birth: [2135-2-7] Sex: F Service: EMERGENCY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2565] Chief Complaint: seizure, hypoglycemia Major Surgical or Invasive Procedure: trans-esophageal echocardiogram bronchoscopy History of Present Illness: 31yoF w/ h/o DM1, HTN, s/p left sided hemorrhagic CVA (3 yrs ago) s/p trach/PEG/chronically indwelling catheter presents to ED from [Hospital ] rehab today after having had witnessed "tonic clonic" activity at which time her BS was found to be 30. NH staff had also noted decreased alertness today prior to her seizure activity and hypoglycemia. She has reportedly been spiking temps since [7-8] at rehab. In review of her med list, she was started on ceftriaxone, vancomycin and inhaled tobramycin on [7-10] (planned for 2 wk course); abx were changed from levaquin/vanco when sputum grew cipro resistant klebsiella (sensitive to ceftriaxone). . Of note, pt. was recently hospitalized [Date range (1) 6957] for sepsis (presumed pulmonary source). Course was c/b probable VAP and she is s/p tracheostomy recannulation during last hospitalization as well as s/p PEG placement as she had been having increasing dysphagia at home. Also during this past hospitalization, she was noted to be persistently febrile without clear e/o of persistet infection and in the absence of clear medication causes. . In the ED, initial VS revealed T 101.6 BP 110/71 HR 100 RR 20 O2 sat 100% on AC (Vt 450, rr 14, FiO2 0.60, PEEP 5). A CXR was obtained and did not show e/o infiltrate. UA showed moderate bacteria, but only 0-2 WBCs and she has a chronic indwelling foley. She received ceftriaxone and vancomycin in addition to approximately 2L IV NS. . ROS: Unable to obtain from patient Past Medical History: # Diabetes Mellitus type 1 (dx at age 3), hx of hypoglycemic episodes # CVA (hemorrhagic) at 27 with residual aphasia and Right hemiparesis, tracheostomy post CVA now recannulated during recent [6-/2166] admission # Blindness in one eye # History of aspiration pneumonia # Although patient is on valproate, no reported history of seizures # Depression # Hyperthyroidism # Anemia (BL hct 22-25) # HTN # Gastroparesis # LV dysfunction . Social History: Remote smoking history in her teens, lived in CA previously and has lived at the Greenery since coming to MA. Family History: healthy brother/sister. Maternal family history of DM. Physical Exam: T 94.2 BP 120/62 HR 83 RR 15 O2sat 100% (Vt 450, rr 14, FiO2 0.60, PEEP 5) Gen: Pt. with trach on ventilator, in NAD HEENT: Right pupil round and reactive to light, Left eye w/ what appears to be scar tissue overlying inferior [Doctor First Name 2281] Neck: Supple CV: RRR, no mrg Resp: Coarse BS anteriorly, unable to appreciate post. BS Abd: +BS, soft, ND, no rebound/gurding Ext: Left arm able to move spontaneously, hand in [University/College ], right hand with contraction. Neuro: Moves LUE, does not follow commands, but opens eyes to voice/name. Pertinent Results: [2166-7-12] CXR: wet read without clear evidence of infiltrate. . [2166-7-13] sputum: sparse coag +staph = MRSA. S: gen, rifampin, tetracycline, bactrim, vanco; R: clinda, erythromycin, penicillin, and oxicillin . [7-13], [7-14], [7-15] stool neg. for c. diff . [7-14] UCx: yeasts > 100K . [2166-7-15] UA: +yeasts, mod leuk, no bact . [2166-7-15] EEG: This is a mildly abnormal portable EEG in the waking and drowsy states due to the disorganized and poorly sustained background. There was no clear electrographic correlate for clinically observed episodes of eye fluttering or leg tremor. There were no clearly focal, lateralized, or epileptiform features noted. There were no electrographic seizures. . [2166-7-16] CT head: no significant change since [2166-6-27]. no new IC bleed or infarct . [2166-7-16] CT abd/ pelvis: pneumonic infiltrate of RLL, no perinephric abscess, 4.5cm soft tissue mass in R breast (rec f/u with US) . [2166-7-18] CT head: no significant interval change. no new IC bleed . [2166-6-12] Echo: LVEF 30-40% [1-10] to severe hypokinesis/akinesis of the apical half of the left ventricle, mild pulmonary htn. . [2166-7-19] Echo: Mild mitral leaflet thickening but without discrete vegetation or pathologic flow. Low normal left ventricular systolic function. Compared with the prior study (images reviewed) of [2166-6-12], left ventricular systolic function is improved with lack of regional dysfunction. The focal thickening of the anterior mitral leaflet was also present on review of the prior study. . [2166-7-20] MRI/MRA: IMPRESSION: 1. Severe bilateral athermatous disease of the intracranial internal carotid arteries. 2. Similar encephalomalacic changes in the left frontal lobe. 3. Extensive T2 signal abnormality in the cerebral white matter, probably due to widespread chronic small vessel infarction. 4. Marked brain atrophy. 5. No evidence of brain abscess or abnormal meningeal enhancement. . [2166-7-25] RLE US: neg for DVT . [2166-7-28] CT head/ sinus: IMPRESSION: Similar appearance of cystic encephalomalacia and other atrophic changes in the brain. No acute intracranial hemorrhage or mass effect. Clear sinuses. . [2166-7-28] CT chest/ abd/ pelvis: CONCLUSION: 1. Interval improvement in extent of right lower lobe atelectasis, and development of small airspace opacity, that may represent pneumonia vs. reexpansion changes. 2. Right lower lobe airspace consolidation, likely representing atelectasis, underlying infection cannot be entirely excluded. 3. Arteriosclerosis. 4. No drainable fluid collection. . [2166-7-30] EEG: intermittent sharp wave, as well as spike and slow wave discharges, seen in a multifocal fashion arising sometimes in a generalized distribution but also were seen independently in the bifrontal regions and the left temporal region. Also noted were broad-based, high amplitude, blunted triphasic waves in the region of the left anterior temporal and temporal regions. Discharges were not repetitive and there were no electrographic seizures noted. These multifocal regions of discharges suggest areas of cortical irritability with potential for epileptogenesis. Also persistent slowing over the left temporal regions in the setting of a persistent slow and disorganized background. The slowing over the left hemisphere - subcortical dysfunction. The otherwise slow and disorganized background rhythm suggests a more global and diffuse process consistent with an encephalopathy likely due to deeper midline or bilateral subcortical dysfunction. Medications, metabolic disturbances, infections, and anoxia are among the most common causes of encephalopathy. . [2166-7-30] TEE: could not be done as probe could not be passed . [2166-7-31] TTE: could not be done as study is technically difficult - no additional information would be provided from previous . [2166-8-1] EGD: . [2166-8-1] GJ tube exchange . [2166-8-3] CT chest/abd/pelvis: IMPRESSION: 1. Multifocal pneumonia with new left upper lobe and lingular infiltrates and no significant change to left lower lobe air bronchogram containing infiltrate. Near complete resolution of previously identified patchy right lower lobe opacities. No evidence of intra-abdominal abscess. 2. Unchanged atherosclerotic disease involving the aorta and its branches as well as the coronary circulation much more prominent than expected for patient's age. . [2166-8-3] Bronchoscopy: LLL and RLL with some purulent secretions. no evidence of bronchial obstruction. Sent LLL BAL. . [8-7] Bilat LE u/s: IMPRESSION: No evidence of DVT in both lower extremities. . [8-5] Trans esophageal echo Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A very small secundum atrial septal defect is present. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No valvular vegetations identified. Mildly thickened mitral and aortic valve leaflets. Trivial aortic and mitral regurgitation. Mild tricuspid regurgitation. Small secundum atrial septal defect. . [8-11] CXR: Increased consolidation at left lung base which could represent pneumonia. New development of left pleural effusion, small. [2166-7-12] 09:10PM URINE RBC-[2-10]* WBC-0-2 BACTERIA-MOD YEAST-OCC EPI-0 [2166-7-12] 09:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2166-7-12] 09:10PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.020 [2166-7-12] 09:10PM PT-13.6* PTT-26.3 INR(PT)-1.2* [2166-7-12] 09:10PM PLT COUNT-655* [2166-7-12] 09:10PM NEUTS-77.1* LYMPHS-15.5* MONOS-6.7 EOS-0.1 BASOS-0.5 [2166-7-12] 09:10PM WBC-13.7# RBC-3.06 HGB-9.6* HCT-28.0* MCV-92 MCH-31.2 MCHC-34.1 RDW-15.5 [2166-7-12] 09:10PM VALPROATE-44* [2166-7-12] 09:10PM estGFR-Using this [2166-7-12] 09:10PM GLUCOSE-217* UREA N-45* CREAT-1.7* SODIUM-135 POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-24 ANION GAP-22* [2166-7-12] 09:12PM %HbA1c-5.8 [2166-7-12] 09:20PM COMMENTS-GREEN TOP [2166-7-13] 06:12AM PT-13.4* PTT-36.9* INR(PT)-1.2* [2166-7-13] 06:12AM NEUTS-68.5 LYMPHS-22.0 MONOS-8.8 EOS-0.2 BASOS-0.4 [2166-7-13] 06:12AM VANCO-8.1* [2166-7-13] 06:12AM OSMOLAL-293 [2166-7-13] 06:12AM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.5 [2166-7-13] 06:12AM GLUCOSE-38* UREA N-40* CREAT-1.2* SODIUM-138 POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 [2166-7-13] 08:30AM URINE OSMOLAL-398 [2166-7-13] 08:30AM URINE HOURS-RANDOM UREA N-595 CREAT-72 SODIUM-29 [2166-7-13] 01:48PM GLUCOSE-78 UREA N-33* CREAT-1.1 SODIUM-139 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2166-8-14] 04:39AM 8.7 3.02* 9.6* 27.9* 92 31.8 34.4 16.4* 462* [2166-8-13] 04:14AM 7.7 3.17* 10.0* 28.9* 91 31.6 34.7 16.1* 422 [2166-8-12] 04:33AM 7.1 2.80* 9.1* 25.2* 90 32.7* 36.3* 16.3* 397 Source: Line-CVC [2166-8-11] 05:18AM 5.7 2.80* 8.7* 25.7* 92 31.2 34.0 16.4* 378 Source: Line-L sc [2166-7-17] 10:57PM 14.6* 3.97* 12.2 36.0 91 30.7 33.9 16.1* 342 Source: Line-Left subclavian [2166-7-17] 04:00AM 10.4 3.50* 11.1* 31.7* 90 31.6 35.0 16.0* 244 [2166-7-16] 05:54AM 8.9 3.60#1 11.4#1 32.8#1 91 31.5 34.6 17.0 310 Source: Line-L subclavian 1 VERIFIED [2166-7-15] 06:20AM 7.7 2.21* 7.1* 21.0* 95 32.0 33.6 15.8* 326 . DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2166-8-14] 04:39AM 51.5 33.3 4.2 10.8* 0.2 [2166-8-13] 04:14AM 67.5 18.7 5.5 7.9* 0.4 [2166-8-12] 04:33AM 44.4* 38.9 4.4 11.9* 0.4 Source: Line-CVC [2166-8-11] 05:18AM 40.5* 42.9* 3.9 12.5* 0.2 Source: Line-CVC [2166-8-10] 04:41AM 34.5* 49.6* 4.7 10.8* 0.4 Source: Line-CVC [2166-8-9] 04:30AM 56.4 32.1 3.5 7.8* 0.2 [2166-8-2] 04:21AM 74.9* 20.8 3.7 0.4 0.2 Source: Line-A line [2166-7-28] 04:56AM 69.8 24.4 4.6 0.9 0.4 Source: Line-picc [2166-7-22] 03:16AM 51.9 39.8 7.6 0.5 0.1 Source: Line-central [2166-7-19] 03:10AM 55.4 35.5 7.3 1.5 0.3 Source: Line-lsc tlcl [2166-7-15] 06:20AM 53.2 34.8 8.0 3.4 0.6 Source: Line-TLC [2166-7-13] 06:12AM 68.5 22.0 8.8 0.2 0.4 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2166-8-14] 04:39AM 161* 13 0.6 135 4.0 102 26 11 [2166-8-13] 04:14AM 56* 16 0.6 138 4.7 103 28 12 [2166-8-12] 04:33AM 153* 11 0.5 136 4.4 104 28 8 . [2166-8-5] 04:30AM 84 10 0.7 138 3.7 110* 19* 13 Source: Line-left IJ [2166-8-4] 04:10AM 71 9 0.8 139 3.9 112* 18* 13 [2166-8-3] 04:06AM 64* 11 0.9 141 3.4 112* 17* 15 . [2166-7-14] 06:29AM 63* 20 1.0 143 4.0 111* 23 13 Source: Line-tlc; Vancomycin @ Trough [2166-7-13] 01:48PM 78 33* 1.1 139 4.9 108 22 14 Source: Line-groin line [2166-7-13] 06:12AM 381 40 1.2* 138 2.61 101 23 17 . LFTs ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2166-7-28] 04:56AM 14 15 143 67 146 0.1 . Ft4 1.4 on [8-11] 2.0 on [7-31] PTH 25 on [7-21] . ANCA neg [Doctor First Name ] neg dsDNA neg Brief Hospital Course: # Fever: Febrile to 101.6 in ED where she received IV ceftriaxone and vancomycin without clear infiltrate on CXR but has extensive h/o aspiration pneumonia and was recently treated for VAP for which she completed a course of meropenem and vancomycin prior to d/c on [7-4]. On admission, with temp. and tachycardia she met criteria for SIRS with no definitive source. Blood and urine cultures were sent in the ED. Did have elevated WBC count to 13.7, but no notable left shift and all cell lines appeared to be up suggesting hemoconcentration. In discussion w/ RN at [Hospital1 ], she had been spiking temperatures there since [7-8] at which time she was started on levofloxacin and vancomycin. Her vancomycin level was noted to be elevated so was held while levels resolve. Levaquin was reportedly discontinued on [7-10] when her sputum was found to be growing klebsiella resistant to ciprofloxacin, but sensitive to ceftriaxone. Thus she was started on ceftriaxone and tobramycin neb at that time. She was started on vanco/zosyn for ?LLL pna here but then these were stopped given negative infectious workup and no significant LLL infiltrate on repeat CXR. However, fever spikes continued (Tm 104.6 on [7-19], 104.2 on [7-21]) with negative cultures. TTE and TEE showed no vegitations, CT abd showed no abscess. LP negative for meningitis, cryptococcus negative, viral culture still pending. Sputum grew Klebsiella pneumonia on [7-19] which was sensitive to Zosyn and she was treated with a full course of zosyn. She continued to spike fevers after she was treated, ID was consulted, review of culture data showed that she has a sub-population of ESBL resistant klebsiella and so she was subsequently treated with meropenem. She should continue treatment until [8-25]. She was also found to have pseudomonas in her sputum which was sensitive only to amikacin. She was started on amikacin and should continue until [8-28]. Amikacin dosing switched to 750mg q24 dosed at 4pm on day of discharge. She should have amikacin levels draw just prior to administration of third dose (on [8-16]). Goal trough is <4, if >4 can increase dosing interval to q36hrs. She had diarrhea of unclear etiology - it may have been due to tube feedings and she was given banana flakes to good effect. Because of fevers and prolonged antibiotics, C. diff was a concern. C.diff toxin assay was negative, however given concern a B-toxin was sent which is currently pending. She should continue flagyl for another 7 days (until [8-21]) or until B-toxin is negative. Patient grew MRSA in sputum which was initially treated with vancomycin then linezolid as there was concern for drug-fever with vancomycin. Linezolid then stopped because of eosinophilia (see below). Although CXR on [8-11] was read as having consolidation in left lower lobe, she was clinically much improved with fever curve trending down. Given much improved respiratory status, MRSA was felt to be a chronic colonizer. She had a UTI with [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 563] which was treated with voriconazole. During her hospitalization, non-infectious sources of fever were considered as well. Vancomycin was thought to be causing a drug fever as above given that she was febrile to 106F. Vasculitis panel was negative. Neurology consulted to consider autonomic dysfunction/central causes of fevers but did not feel this would explain fevers. She does have hyperthyroidism, but this also was not though to explain fevers. At discharge she had been afebrile x4 days. She should have a repeat CXR in a few weeks to assess for resolution of pneumonia. Overall antibiotic regimen included: vancomycin [Date range (1) 6958]; [7-28] - [8-6] zosyn [Date range (1) 6959]; [Date range (1) 6960]; [8-2] - [8-4] meropenem 1g IV q8h [8-4] - [8-18] (planned) amikacin [8-8] - [8-21] (planned) Flagyl [7-14] - [7-16]; [8-2] - [8-21] (planned) fluconazole [7-16] - [7-19] Vori 200 PO BID [8-4] - [8-8] cipro [7-28]- [7-28] CTX [7-13] - [7-13] Bactrim [7-17] - [7-21] Linezolid [8-8] - [8-11] . # Seizure: Reportedly no h/o seizures previously despite having been maintained on depakote (presumably started post CVA). ?seizure on day of admission seems more likely [1-10] to severe hypoglycemia as opposed to structural abnormalities post CVA acting as epileptiform nidus. A [2166-6-11] EEG did not reveal e/o seizure/epileptiform activity. Pt now with increased resting tremor of LUE. [2166-7-15] EEG results neg. for epileptiform activity; no clear electrographic correlate for clinically observed episodes of eye fluttering or leg tremor. CT head r/o acute IC process/ new stroke since [6-27]. LFTs WNL. Neurology believes tremor in hand is likely action tremor due to stroke affecting basal ganglia. MRI/MRA neg. On [7-21] depakote changed to keppra because it may be contributing to fevers. She was continued on keppra with no further evidence of seizure activity - she has a resting tremor of the left hand which was not felt to represent epilectic activity. . # DM1/ Hypoglycemia: In review of her records, has h/o labile BS and, as above, was found to be hypoglycemic to the 30s when found to seize. Diabetes management service consulted. Initially euglycemia maintained on insulin drip. Once patient tolerating consistent tube feeds, she was transitioned to glargine (currently 24 units) and QID insulin sliding scale. Blood sugars still fairly variable, however given that she presented for hypoglycemia, we erred on the side of higher blood sugars. Josline diabetes service had been considering switching to [Hospital1 ] lantus regimen at discharge but as blood sugars currently stable she was not changed. This could be considered if blood glucose is variable in the future. . # ARF: Baseline creatinine is 0.7-1.0 and was found to be elevated to 1.7 on ED presentation (while it was normal on d/c on [7-4]). Given it appears that she is hemoconcentrated by CBC, most likely reflects prerenal azotemia. U lytes consistent with prerenal ARF. She initially had a low bicarbonate (low of 17) and urine electrolytes suggested renal tubular acidosis. This had resolved on discharge. . # Respiratory failure: Has reportedly not attempted wean at [Hospital1 ] per limited progress notes sent w/ patient. Respiratory distress has been complicated by tremors, apears to be a central process with cyclical periods of tacchypnea that had made weaning difficult. Once respiratory infection treated she was transitioned to trach collar and has stayed on that with 40% FiO2 for 4 days prior to discharge. . # Coughing Patient had intermittent paroxysms of coughing that persisted even once respiratory infection was mostly treated. Interventional pulmonology performed bronchoscopy which showed that the trach was in good position but did show largyngeal inflammation suggestive of GE reflux. She was started on [Hospital1 ] PPI and sucralfate (for possible element of gastritis), sucalfate stopped prior to discharge. . #Aggitation she has been receiving standing clonazepam for aggitation/anxiety and occasional ativan IV with good effect. . # Hyperthyroidism: free t4 3.9 on admission, hyperthyroidism treated with PTU, free t4 normalized to 1.4. She should continue PTU until she follows up with her outpatient endocrinologist in [Location (un) 620] in the next few months. Free t4 should be rechecked in [3-14] weeks. . # HTN: antihypertensives initially held for hypotension and ARF. Metoprolol restarted at low doses and blood pressure began to increase in the week before discharge. She was started on captopril and metoprolol increased to 100mg [Hospital1 ]. Outpatient regimen was metoprolol 175mg PO bid, lisinopril 20mg daily, and Lasix 40 mg daily. These medications should be restarted slowly at rehab to control hypertension. . # Corneal opacity Patient is blind in left eye from diabetic retinopathy. Eye noted to have corneal opacity in inferior aspect of cornea for at least a month. Ophthalmology consulted who felt this was unlikely to be a corneal ulcer but that there may be some abrasion for which they recommended erythromycin ophthalmic ointment. This was stopped for concern of systemic absorption causing eosinophilia. She should have her left eye kept closed to prevent drying out of the cornea. . # Anemia: Baseline hct appears to be 22-25. Recent iron studies during last hospitalization are c/w AOCD w/ low TIBC, elevated ferritin. Patient transfused intermittently when HCT fell below 21. No evidence of bleeding. . # Eosinophilia Eosinophils rose to 7/8 on [8-9] and a maximum of 12.5 on [8-11]. Although she was afebrile at the time, this was thought to perhaps be another representation of tendency towards drug fever. linezolid and erythromycin ophthalmic ointment stopped and eosinophilia began trending down. She should have a repeat eosinophil count in a few days to confirm that it has gone down. . # Depressed LVEF: 40% on recent echo. On lasix, BB, ACEI as outpatient (see HTN above) . # ?DVT: given cool extremities with decreased pulses noted [7-25] but doppler U/S was negative on two occassions. . # FEN: Tube feed continued, electrolytes repleted as needed. Reglan stopped for diarrhea. . # R breast mass: US evaluation as outpatient . Access: PICC placed [8-13] Medications on Admission: Meds (obtained from [7-4] d/c summary): Ferrous sulfate 300mg liquid daily Ceftriaxone 1g IV BID (started [7-10]) Cholestyramine/sucrose 4g daily Reglan 10mg PO daily ASA 81mg daily MVI Docusate Senna Folate 1mg daily Diltiazem 120mg PO qid (on d/c summary from [7-4], but not on med list from [Hospital1 ]) SC heparin Artificial tears Albuterol prn SOB/wheezing Ipratropium Metoprolol Tartrate 175 mg PO bid Miconazole Nitrate 2 % Powder qid prn rash Ranitidine 150 mg q12h Lantus 30U hs, 25 qam Novolog SS Propylthiouracil 100 mg PO Q8h Lidocaine HCl 5 % Ointment [Hospital1 ]: One (1) Appl Topical Q6h prn Lisinopril 20mg daily Lasix 20mg IV daily Lasix 80mg PO bid Valproate 1g q6h Ativan 1mg q4h prn Morphine 15mg PO q4h prn pain Acetaminophen q4h prn Beneprotein Tobramycin neb q12h (started on [7-10]) . All: NKDA Discharge Medications: 1. Propylthiouracil 50 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO Q8H (every 8 hours). 2. Metronidazole 500 mg Tablet [Month/Day (2) ]: One (1) Tablet PO TID (3 times a day): last day [8-21]. 3. Meropenem 1 g Recon Soln [Month/Year (2) ]: One (1) Recon Soln Intravenous Q8H (every 8 hours): last day [8-25]. 4. Outpatient Lab Work amikacin level before third dose of 750mg on [8-16] to be drawn just prior to administration at 4pm. goal is less than 4. if greater than 4 can increase interval to q36 5. Levetiracetam 100 mg/mL Solution [Month/Day (4) ]: Ten (10) mL PO BID (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day (4) ]: One (1) inj Injection TID (3 times a day). 7. Miconazole Nitrate 2 % Powder [Month/Day (4) ]: One (1) Appl Topical QID (4 times a day) as needed. 8. Acetaminophen 160 mg/5 mL Solution [Month/Day (4) ]: 650-975 mg PO Q6H (every 6 hours) as needed. 9. Clonazepam 0.5 mg Tablet [Month/Day (4) ]: .5 Tablet PO BID (2 times a day). 10. Lidocaine HCl 1 % Solution [Month/Day (4) ]: Three (3) ML Injection Q4-6H (every 4 to 6 hours) as needed. 11. Lidocaine HCl 2 % Gel [Month/Day (4) ]: One (1) Appl Mucous membrane PRN (as needed). 12. Codeine Sulfate 30 mg Tablet [Month/Day (4) ]: 0.5 Tablet PO Q6H (every 6 hours) as needed. 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 14. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 15. Lisinopril 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 16. Albuterol 90 mcg/Actuation Aerosol [Last Name (STitle) ]: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 17. Ipratropium Bromide 17 mcg/Actuation Aerosol [Last Name (STitle) ]: Two (2) Puff Inhalation QID (4 times a day). 18. Lorazepam 2 mg/mL Syringe [Last Name (STitle) ]: 1-2 mg Injection Q2H (every 2 hours) as needed for agitation. 19. Amikacin 250 mg/mL Solution [Last Name (STitle) ]: Seven [Age over 90 1230]y (750) mg Injection Q24H (every 24 hours): day 1=[8-8] last day =[8-28] (current dosing started [8-14]) Should be given at 4pm Please follow trough, should be less than 4. 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Month/Day (4) ]: Two (2) ML Intravenous DAILY (Daily) as needed. 21. Lantus 100 unit/mL Cartridge [Month/Day (4) ]: Twenty Four (24) units Subcutaneous at bedtime. 22. Insulin Regular Human Injection Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Hospital1 ] Discharge Diagnosis: Primary: ventilator-associated pneumonia with pseudomonas, klebsiella, and MRSA Yeast UTI hypoglycemic seizures DM type I Hyperthyroidism . secondary Hypertension Discharge Condition: Fair - stable on trach collar with 40% FiO2. afebrile x4 days. Discharge Instructions: You were admitted for a low blood sugar, seizures, and fevers. You low blood sugars were likely due fevers and to changes in your tube feeding regimen and resolved with steady tube feed intake and close monitoring of your blood sugars. You had an extensive workup for your fevers. We believe the fevers were due to infections in your lungs with two bacteria and in your urine with yeast. These were treated with antibiotics and antifungals. You should continue the antibioitics as indicated below. You are also being treated for an infectious diarrhea associated with antibiotic use called Clostridium difficile. Also, you were treated for hyperthyroidism, which is a high level of thyroid hormone. You should follow up with your outpatient endocrinologist regarding this. Please return to the hospital if you have recurrent high fevers, increased sputum production, seizures, or any other new or concerning symptoms. Followup Instructions: Please follow-up with your outpatient endocrinologist and your primary care doctor ICD9 Codes: 5849, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2293 }	Medical Text: Admission Date: [2129-8-8] Discharge Date: [2129-8-15] Date of Birth: [2072-11-11] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Lisinopril / Aloe / Shellfish Attending:[First Name3 (LF) 165] Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: 1. Off-pump coronary artery bypass graft x2: Left internal mammary artery to left anterior descending artery and saphenous vein graft to right coronary artery. 2. Endoscopic harvesting of the long saphenous vein. History of Present Illness: Ms. [Known lastname ] is a 56 year old female with dyslipidemia, HTN, and known CAD, who was scheduled to see CT surgery as an outpatient tomorrow for possible CABG, who presents now with chest pain and SOB since yesterday. Patient underwent recent cardiac cath on [2129-7-26] which was notable for proximal tubular 90% stenosis in the LAD and proximal 50% stenosis in the RCA. She was scheduled to see CT surgery tomorrow in consult for possible CABG, but yesterday developed shortness of breath and left anterior chest pain radiating to left arm after going up 2 flights of stairs. Reports this pain was different from her typical anginal pain, which is more substernal in nature and often radiates to the back. The chest pain was not associated with any dizziness, diaphoresis, or nausea. It would last for about 5-30 minutes at a time and intermittently resolve, though overall she has not been feeling well. Was not able to go into work today. Called the Cardiology office, and was referred to ED for further evaluation. In the ED, initial vitals were 98.1 64 142/120 14 98% RA. She was AAOx3, and in NAD. Received SL nitro x1 with relief of CP. Per report, EKG showed mildly flattened T waves laterally. Trop negative x2. Cardiology was consulted, and recommended heparin gtt and admission to Cardiology. CT surgery also to be notified. Vitals prior to transfer: 98.3 61 134/61 21 98% RA. On arrival to floor, patient comfortable and chest pain free. On review of systems, she reports recent headaches secondary to her isosorbide mononitrate. Has occasional palpitations. Also reports occasional orthopnea and PND, though attributes some of this to her body habitus and sleep apnea. Typically has dyspnea with 2 flights of stairs, therefore limits her activity. Reports mild abdominal discomfort and loose stool yesterday, now resolved. Denies fevers, chills, diaphoresis, nasal congestion, sore throat, current N/V, abdominal pain, constipation, bloody or dark tarry stools, dysuria, or hematuria. No lower extremity edema. Has had myalgias in past when on a statin. All of the other review of systems were negative. Past Medical History: Coronary Artery Disease Hypertension Irritable bowel syndrome GERD Esophageal spasms Lyme disease OSA - CPAP at home but does not use Obesity Hearing loss L>R Memory problems Sarcoidosis Meningioma (calcified) Past Surgical History: Tonsillectomy D&C x 2 Right breast lumpectomy x 2 (Lipomas) Social History: She lives with her husband and two teenaged sons. [Name (NI) ] son is about to start college and she's looking forward to moving him into a dorm. She has never smoked. She drinks one or two alcoholic beverages per week. She has no history of ilicit drug use or intravenous drug use. She works as a fertility lab manager at [Company 2274]. Family History: Father: sudden death due to MI age 60 paternal uncle: sudden death due to MI age 61 brother: h/o cad s/p cabg in his 40s mother died of pancreatic cancer Physical Exam: ADMISSION VS: 98.6 140/84 62 18 98% RA GENERAL: obese female, resting comfortably, oriented, NAD, mood and affect appropriate HEENT: NC/AT, PERRL, EOMI, sclera anicteric, conjunctiva pink, MMM, OP clear NECK: supple, no JVD or cervical LAD CARDIAC: RRR, normal S1, S2, no r/m/g LUNGS: CTAB, no crackles/wheezes/rhonchi, respirations unlabored, no accessory muscle use ABDOMEN: obese, soft, NTND, no organomegaly appreciated, no guarding or rebound tenderness, normoactive bowel sounds EXTREMITIES: warm, well-perfused, 2+ DP pulses, no edema SKIN: No stasis dermatitis or ulcers NEURO: CN II-XII grossly intact, strength 5/5 throughout Pertinent Results: [2129-8-10] TEE Conclusions PRE GRAFTING The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. 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. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST GRAFTING There is normal biventricular systolic function. There is no change in valvular function. The thoracic aorta is unchanged. Chest X-Ray [2129-8-13]: FINDINGS: In comparison with study of [8-11], there are continued low lung volumes. Opacification at the left base is consistent with pleural effusion and volume loss in the left lower lobe. Some increasing opacification at the right base most likely represents atelectasis with crowding of vessels in the region of the cardiophrenic angle. Mild blunting of the costophrenic angle is seen. No evidence of vascular congestion. [2129-8-15] 02:45AM BLOOD WBC-11.1* RBC-3.37* Hgb-10.0* Hct-29.5* MCV-88 MCH-29.8 MCHC-34.0 RDW-12.6 Plt Ct-227# [2129-8-13] 06:20AM BLOOD WBC-12.0* RBC-3.10* Hgb-9.5* Hct-27.2* MCV-88 MCH-30.5 MCHC-34.8 RDW-12.8 Plt Ct-132* [2129-8-12] 05:55AM BLOOD WBC-15.2* RBC-3.66* Hgb-10.9* Hct-32.4* MCV-89 MCH-29.8 MCHC-33.7 RDW-13.0 Plt Ct-123* [2129-8-15] 02:45AM BLOOD Glucose-139* UreaN-19 Creat-0.9 Na-135 K-4.3 Cl-101 HCO3-27 AnGap-11 [2129-8-14] 06:01AM BLOOD Glucose-118* UreaN-18 Creat-0.8 Na-139 K-4.2 Cl-103 HCO3-29 AnGap-11 [2129-8-13] 06:20AM BLOOD UreaN-17 Creat-0.9 Na-140 K-3.9 Cl-103 Brief Hospital Course: The patient was brought to the Operating Room on [2129-8-10] where the patient underwent Off-Pump CABG with Dr. [First Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. She was started on beta blockers and was gently diuresed toward the preoperative weight. Both lopressor and lasix was decreased due to mild hypotension. The patient transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD5 the patient was ambulating freely, her wounds were healing well and her pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Donnatol 1 tablet PO QID abdominal pain 4. Verapamil SR 240 mg PO Q24H 5. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain/fever 2. Aspirin EC 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #60 Tablet Refills:0 3. Atorvastatin 10 mg PO DAILY RX atorvastatin 10 mg 1 tablet(s) by mouth once a day Disp #60 Tablet Refills:1 4. Clopidogrel 75 MG PO DAILY off-pump RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #90 Tablet Refills:1 5. Docusate Sodium 100 mg PO BID 6. Metoprolol Tartrate 25 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:2 7. Miconazole Powder 2% 1 Appl TP QID:PRN rash 8. Omeprazole 20 mg PO DAILY Duration: 1 Months RX omeprazole [Prilosec] 20 mg 1 capsule(s) by mouth once a day Disp #60 Capsule Refills:0 9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol [Ultram] 50 mg 1 tablet(s) by mouth every six (6) hours PRN Disp #40 Tablet Refills:0 10. Furosemide 20 mg PO DAILY Duration: 5 Days RX furosemide [Lasix] 20 mg 1 tablet(s) by mouth once a day Disp #5 Tablet Refills:0 11. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K > RX potassium chloride [K-Tab] 10 mEq 20 mEq by mouth once a day Disp #5 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Coronary Artery Disease Hypertension Irritable bowel syndrom GERD Esophageal spasms Lyme disease OSA - CPAP at home but does not use Obesity Hearing loss L>R Memory problems Sarcoidosis Meningioma (calcified) Past Surgical History: Tonsillectomy D&C x 2 Right breast lumpectomy x 2 (Lipomas) Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 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 Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac [Doctor First Name ] Office [Telephone/Fax (1) 170] [2129-8-23] at 10:00 am Surgeon Dr. [First Name (STitle) ] [Telephone/Fax (1) 170] on [2129-9-13] at 1:15p Cardiologist: Dr. [Last Name (STitle) 911] [2129-9-7] at 10:20am [First Name8 (NamePattern2) ] [Location (un) 1439], MA [Telephone/Fax (1) 9347] Please call to schedule the following: Primary Care Dr. [First Name (STitle) ] in [3-24] weeks [Telephone/Fax (1) 2010] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2129-8-15] ICD9 Codes: 4111, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2294 }	Medical Text: Admission Date: [2194-1-28] Discharge Date: [2194-2-5] Date of Birth: [2107-6-29] Sex: F Service: MEDICINE Allergies: Scopolamine Attending:[First Name3 (LF) 3565] Chief Complaint: Malaise, weakness, reduced appetite . Reason for MICU transfer: cholangitis / pancreatitis / ARDS Major Surgical or Invasive Procedure: Intubation, mechanical ventilation ERCP with two stent placed Arterial lines X2 Right IJ line placement History of Present Illness: HPI gleaned from [Hospital1 ] [Location (un) 620] notes and daugther since Pt is intubated. . Pt is a 86 year old female w/ PMH of hypertension, hyperlipidemia, and insulin-dependent diabetes mellitus who complains of generalized malaise and weakness. According to family she has had a six-month decline in her general function including mobility, ability to communicate and mental status. At baseline, she can transfer wheelchair to toilet with assistance and some walking at home with physical therapy, but is "quite confused". According to the family, 2 days ago she had an episode of hypoglycemia related to a insulin dose it was late in the evening administered by her husband. Shortly afterwards, she became combative and needed to be restrained by her son. They called 911 and EMS found her blood sugars to be in the 40s. Her mental status cleared after admin of D50 and glucagon. Since that episode, she has had increased lethargy and weakness. She has been refusing to get out of bed at all and she has been moaning. No vomiting, no diarrhea, no fever. She did have episode of incontinence however that was in the setting of not getting out of bed. She always is a poor eater reported to family however she's had much nothing to eat for the last 24 hours. Her husband states her blood sugars have been normal and has been giving her her insulin as usual the last couple of days. Pt was brought to [Hospital1 ] [Location (un) 620] ED for evaluation by family for continued "moaning" and reduced responsiveness. At BIDN, initial vitals were Temp: 100.6 HR: 98 BP: 120/46 Resp: 20 O(2)Sat: 94. Pt complained of L chest pain and R wrist pain. Troponins were negative, no concerning ECG changes. Plain CXR did not show any fractures of the chest or R wrist. Pt's lipase was elevated to [2122] and Pt developed a fever to 102F. She had a CT abdomen w/ contrast, which showed a common bile duct dilated to 2.8 cm w/ multiple stones and a question of obstructing ampullary stone. Plan was made to transfer Pt to [Hospital1 ] [Location (un) 86] for ERCP, and Pt received a dose of Zosyn. Before transport, the patient became unstable with SBP in 70's. She was given 2L IVF and her BP remained low, and she was started on peripheral levophed. [Hospital1 ] [Location (un) 620] ED placed a R IJ without complications, however she developed hypoxia just afterwards and needed to be intubated for airway control. She was intubated on second attempt with a 7.0 ETT. Her ETT and CVL appear to be in correct position on CXR and [Hospital1 ] [Location (un) 620] feels she may have developed ARDS. Pt was then transferred to [Hospital1 ] [Location (un) 86] ED. . In the [Hospital1 ] [Name (NI) 86] [Name (NI) ], Pt was stable. CXR showed diffuse bilateral infiltrates R > L and blunting of R costophrenic angle, ?ARDS. Pt was on midaz/fent. On norepi 0.21. IJ + 2PIVs. Received a dose of Vanc. Vent settings on transfer were FiO2 50% TV 420 RR 20 PEEP 5. Vitals were 76, 107/49, 98%. Pt was finishing 6th liter of IVF. . On arrival to the ICU, Pt's vital signs were 37.2C, HR 73, BP 109/46, RR 17, Sat 100% on FiO2 50%, intubated and sedated. . Review of systems: Unable to confirm due to intubation. Per [Hospital1 ] [Location (un) 620] records and daughter, Pt did not have fevers / chills. No nausea or vomiting. No diarrhea. Reports malaise and reduced appetite for several months, but especially so for the last two days. No urinary symptoms. Past Medical History: insulin-dependent diabetes hypertension hyperlipidemia benign stricture of the pylorus and duodenum s/p dilation [2187] ampullary stenosis s/p sphincertotomy in [2187] peptic ulcer disease rheumatic heart dz Mixed aortic valve disease (mild) Mixed mitral valve disease (mild) History of breast cancer; status post bilateral mastectomy osteoporosis chronic hip and leg pain peripheral neuropathy R hip "plate" L carotid artery stenosis ? TIA Social History: Former smoker, quit decades ago. Denies EtOH. She lives with her husband in their home. Has visiting PT 2x weekly. Family History: Alzheimer dementia in sisters Physical Exam: Vitals: 37.2C, HR 73, BP 109/46, RR 17, 100% on FiO2 50%. General: intubated elderly woman HEENT: pupils pinpoint, dry mucous membranes Neck: R IJ Lungs: Clear to auscultation bilaterally except for L base, no wheezes or ronchi CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic and diastolic murmurs, no rubs Abdomen: soft, non-distended, bowel sounds present, no organomegaly GU: foley present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [1-28] 1.45a ABG: 7.26/42/87/20 on FiO2 50%. [1-27] 11.50p Lactate 1.3 Lipase [2122] [1-27] CBC: WBC 10.6, Hct 40.9, Plt 174. [1-27] 4pm LFTs: AST 68, ALT 34, T bili 0.57, AP 82. [1-27] Chem7: 138, 4.6, 102, 26.1, 19, 0.8, 112, Lactate 1.4. [1-27] UA bland, troponin < 0.01 . [2194-1-27]: CXR showed diffuse bilateral infiltrates R > L and blunting of R costophrenic angle, ?ARDS [2194-1-27]: CT abdomen w/ contrast: common bile duct dilated to 2.8 cm w/ multiple stones and a question of obstructing ampullary stone. L1 impression fracture of uncertain age. Small right upper lobe opacity consistent with resolving infection. . EKG: no prior available. NSR, normal axis, normal intervals, no PQ or ST changes, T waves tall. Brief Hospital Course: 86 yo F w/ PMH diabetes, hypertension, ampullary stenosis s/p sphincterotomy who presented with increasing lethargy, fevers, and hypotension, found to have septic [Month/Day/Year ] from likely cholangitis and gallstone pancreatitis. She initially appeared to respond well to ERCP and antibiotics, initially coming down on pressors and appeared close to extubation. Then, however, her pressures began to drop and she was put back on pressors. Her mental status was poor, even off sedation, and she persistently failed her spontaneous breathing trials. Leukocytosis and fevers increased, and it appeared her sepsis and overall clinical status was worsening. At this point, her family felt that she would not want to continue with this level of treatment if it did not appear she would return to her baseline. After a meeting with the entire family (including daughter/HCP [Doctor First Name 4134], Dr. [Last Name (STitle) ], and the rest of the ICU team, her care was transitioned to comfort focused care. Her pressors and antibiotics were stopped on [2-4], but she remained intubated and ventillated, as the family did not want her to feel air hunger. She passed away peacefully with family at her side at 4:05pm on [2194-2-5]. Please see below for more detailed summary of main hospital problems. PRIMARY PROBLEMS: # [Name2 (NI) 21020]: Thought to be septic in nature [2-27] cholangitis. Echo showed significant multi-valve dysfunction, however there was no evidence of cardiogenic component. Patient was intubated and started on norepinephrine on arrival in the ICU. For source control, she was sent to ERCP (see below) and started on empiric vancomycin and zosyn. Blood pressure was originally reasonably responsive to fluids, so patient was intermittently bolused and weaned off pressors after 3 days. She then, however, began to drop her pressures again requiring uptitration with pressors. Leukocytosis increased and she developed new fevers, raising concern for worsening of sepsis. No new source identified, nothing grew on blood or urine cultures. UOP decreased despite maintenance of MAPs. She began developing pleural effusions due to administered fluid and leaky capillaries, worsening her respiratory status. Given her overall worsening septic picture despite aggressive interventions, her family decided to focus on comfort and stop the antibiotics and pressors. # Respiratory distress: Pt was intubated for hypoxia and dyspnea at [Hospital1 ] [Location (un) 620]. She initially met criteria for ARDS w/ acute onset, bilateral infiltrates, PaO2:FiO2 of 174 on admission. Likely cause was acute infectious process cholangitis vs pancreatitis. Patient was difficult to extubate due to poor gag, AMS and agitation as well as subsequent volume overload with fluid administration which did not resolve with diuresis. She continued to fail her SBTs daily and ultimately could not be extubated. # Cholangitis: OSH CT abdomen showed common bile duct dilated to 2.8cm w/ multiple stones. Given her presentation with fevers and hypotension, it was thought that she developed septic [Location (un) ] from cholangitis or possibly gallstone pancreatitis (see below), although LFTs were never singificantly elevated. Started on vancomycin and zosyn. ERCP on [2194-1-28] showed 2 strictures, both dilated, and an 8mm irregular stone which was not evacuated. 2 stents were placed. Initially she seemed to be improving after this intervention and antibiotics, with WBC count and fever coming down, weaned off pressors. After 5 days, however, her leukocytosis and fevers began to climb again while on seemingly adequate coverage with vanco/zosyn. # Gallstone pancreatitis: Pt's lipase elevated to [2122] by report at OSH, now down in the 100s. Given presence of multiple stones in CBD, pancreatitis thought to be very likely due to gallstones. ERCP done with stents placed in CBD, stone was not removed. Serum TG 68. Given IVFs given aggressively and bowel rest initially. Patient started on tube feeding several days into ICU stay, however she did not tolerate these. # Arrhythmias: On the morning of admission, she went into numerous runs of ventricular tachycardia, which were sustained for [11-7] secs but spontaneously resolved without intervention. Later in her course, she developed atrial fibrillation with RVR that was not responsive to control with diltiazem 5mg x 2, metoprolol 5mg x2 plus 10mg x1. Started amiodarone drip w/ bolus. Hemodynamically unstable requiring increased pressor dose at that time. After about one day, spontaneously converted back to sinus after changing pressor to neosynephrine from levophed. Amio drip was stopped. Remained in normal sinus after that until she passed away. # Myoclonus: On the morning of admission, started having twitching of left shoulder and leg concerning for seizure activity. Neuro consulted and felt abnormal movements were not seizure activity, believes it is more consistent with myoclonus. EEG according to neuro shows no signs of seizure (even during marked periods of movements), just diffuse slowing consistent with encephalopathy Medications on Admission: Atenolol 12.5 mg daily Aggrenox 1 tablet twice a day calcium 600 mg daily vitamin D 1000 units a day. Insulin - 70/30, 10 units before supper B12 1000mcg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Septic [Month/Year (2) ] Cholangitis Gallstone pancreatitis Hypoxic respiratory failure Atrial fibrillation with RVR Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired ICD9 Codes: 0389, 4271, 4019, 2724, 3572, 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2295 }	Medical Text: Admission Date: [2148-7-8] Discharge Date: [2148-7-15] Service: SURGERY Allergies: Penicillins / Optiray 350 / Lactose Attending:[First Name3 (LF) 371] Chief Complaint: s/p fall with multiple right sided rib fractures Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [Age over 90 ] yo male s/p fall. Patient attempted to sit into chair and fell backwards onto coffee table. no LOC. Past Medical History: Parkinson's disease DM2 c/b neuropathy on neurontin diplopia x one year, horizontal, no clear etiology per patient, followed by ophtho HTN Migraines s/p MI [57] yrs ago s/p cataract [Doctor First Name ] bilat s/p laminectomy in [2089] Social History: Recent move to [Location (un) 86] from NY 10 days ago. lives with wife in senior citizen home, + tob 30yrs x 1ppd, quit 30 yrs ago, no etoh, no drugs, has 2 sons Family History: Father with strokes, no seizures, no parkinsons, sons are healthy Brief Hospital Course: [Age over 90 ] y.o. male with multiple right sided rib fracture after fall on [7-8]. He was admitted to the surgery service and taken to the regular floor and because of his age, poor pain control and multiple rib fractures he was transferred to Trauma SICU. Acute Pain Service was consulted and an epidural catheter was placed for better pain control; oral analgesics were eventually introduced and his pain is currently under much better control. He has required nasal oxygen since admission with saturations in low 90's. He is on scheduled nebulizer treatments as well and using the incentive spirometer much more effectively pulling volumes of ~1200-[Numeric Identifier 20476] cc's. He was seen by Neurology at the request of his family due to his tremors. A head CT was recommended which showed no evidence of acute intracranial abnormalities or interval change. He was continued on his home meds which include carbidopa/levodopa, Aricept/namenda; following his discharge from rehab he should follow up with his PCP and primary movement disorder specialist for any adjustments of his meds. With regards to his PMH he has known chronic kidney disease and appears to have a baseline creatinine around 2.5. His home medications for his type II DM were continued. He has a recent community acquired pneumonia (completed Levaquin) and UTI treated with Bactrim which has been stopped. He was evaluated by Physical therapy and is being recommended for acute level rehab after his hospitalization. Medications on Admission: aricept, nameda, glipizide, neurontin, allopurinol, simvistatin, lisinopril, amlodipine, atenolol, mirtazapine, carbidopa-levadopa Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Amlodipine 5 mg Tablet Sig: 1 [12-23] Tablet PO DAILY (Daily). 13. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation DAILY (Daily). 15. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection [Hospital1 ] (2 times a day). 17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 18. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to chest wall over rib fracture sites . 20. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 22. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 24. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 25. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: s/p Fall Right rib fractures [6-30] Urinary tract infection Secondary diagnosis: Pneumonia (resolving was being treated for this prior to his fall) 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 hospitalized following a fall where you broke many ribs on your right side. These injuries did not require any operations; an epidural catheter was placed to deliver pain medication to help with managing the discomfort associated with rib fractures. Once your pain was better controlledthe catheter was removed and you were started on oral pain medications. It is important that you continue to do your breathing exercises and use the spirometer t least 10x every hour you're awake. You were also seen by Neurology while here in the hospital per request of your family due to your tremors, there were no major recommendations other than some minor adjustments of your Parkinson medication which they have deferred to your primary movment disorder specialist. Followup Instructions: Follow up in [1-24] weeks in [Hospital 2536] clinic for your rib fractures; call [Telephone/Fax (1) 600] for an appointment. You will need an end expiratory chest xray for this appointment. Follow up with your primary providers after discharge from rehab. Completed by:[2148-7-15] ICD9 Codes: 5849, 5990, 3572, 412, 5859, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2296 }	Medical Text: Admission Date: [2140-10-7] Discharge Date: [2140-10-10] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Fatigue, melena Major Surgical or Invasive Procedure: EGD Angiography with chemoembolization to L gastric artery History of Present Illness: 87 yo F with h/o CAD s/p MI [2135], CHF EF 30-40%, AR, MR, TR, GERD, remote history of breast cancer who presented with 4 episodes of melena. The patient reported feeling fatigued for several days, and then having first episode of melena on the evening of [10-6] and then had additional 3 episodes. She denies any prior episodes of melena or bright red blood per rectum. On presentation, vital signs were stable and the patient's initial hematocrit was 26.6. NG lavage did not clear with 1000 cc NS, clots present. She denied nausea, vomiting and abdominal pain. She also denied any NSAID use or additional aspirin use (takes 1 full dose aspirin/day). Past Medical History: 1. CAD, QWMI [2135]. Subsequent P-MIBI with slightly rev [First Name (Titles) ] [Last Name (Titles) 99599]t in distal anterior/inferior walls and apex. EF 30-40% at that time. 2. MR, TR, AI 3. Breast cancer [2125] s/p excision/radiation/tamoxifen 4. Depression 5. Gout Social History: Widow. Lives in [Hospital3 4634]. Family History: Non-contributory Pertinent Results: [2140-10-7] 01:30AM BLOOD WBC-15.7# RBC-2.69 Hgb-8.5* Hct-26.7* MCV-99* MCH-31.8 MCHC-32.1 RDW-17.1* Plt Ct-295 [2140-10-7] 01:30AM BLOOD Plt Ct-295 [2140-10-7] 01:30AM BLOOD Neuts-76.6* Bands-0 Lymphs-18.8 Monos-3.3 Eos-0.8 Baso-0.4 [2140-10-7] 01:30AM BLOOD PT-13.2 PTT-22.7 INR(PT)-1.1 [2140-10-7] 01:30AM BLOOD Glucose-155* UreaN-57* Creat-0.9 Na-142 K-4.5 Cl-106 HCO3-23 AnGap-18 [2140-10-7] 01:30AM BLOOD CK(CPK)-42 [2140-10-7] 01:30AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2140-10-7] 06:00AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.7 [2140-10-7] 01:30AM BLOOD VitB12-435 Folate-GREATER TH EKG: Normal sinus rhythm. Q waves in leads V1-V3 suggest prior anterior myocardial infarction. Q waves in leads III and aVF consistent with prior inferior myocardial infarction. Non-specific ST-T wave flattening. Compared to the previous tracing of [2140-4-7] the ST segment elevations in leads V2-V3 are no longer present. Otherwise, no diagnostic interval change. Brief Hospital Course: 87 yo female with history of CAD, HTN, CHF and breast cancer admitted with melena. 1. UGIB- The patient presented with fatigue and melena. Her initial hematocrit was 26. An NG lavage in the ED did not clear with >1 liter saline. GI and surgery were consulted and recommended urgent EGD. Her initial EGD showed diffuse red blood in the fundus and body of the stomach with no identifiable source. She was then taken emergently to IR for angiography. Angiogram showed no obvious source of bleeding; however, the left gastric artery was prophylactically emoblized with gel foam. The patient subsequently had no further bleeding episodes and her hematocrit stablilized. Her aspirin was discontinued. She received a total of 4units of PRBCs and was started on protonix. An H.pylori was sent and is pending at the time of discharge. She had a re-look EGD on [10-10] which showed severe diffuse gastritis with contact bleeding. She will need outpatient GI follow-up. 2. CAD: The patient denied chest pain however given her history of CAD she was ruled out for MI with serial cardiac enzymes. She had no events on telemetry. Her aspirin and beta blocker were held on admission; however, once her hematocrit stabilized her beta blocker was restarted. 3. HTN: Restarted on beta blocker. 4. Depression: The patient was continued on celexa and remeron with trazadone prn at night. 5. Access: 2 large bore IVs were maintained at all times. 6. Px- Pneumoboots, PPI 7. Code: Full, HCP: daughter-[Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 99600]. 8. Dispo: She is being discharged to home with PCP and GI [Name9 (PRE) 702]. VNA services have been arranged for a hematocrit check 2-3 days after discharge. Medications on Admission: lopressor 25 [Hospital1 ] lasix 20 every other day ecasa 325 daily mvi celexa 20 daily remeron 15 daily trazadone 25 daily Discharge Medications: 1. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Primary diagnosis: UGIB Secondary diagnosis: CAD Depression HTN Discharge Condition: No further episodes of melena. HD stable. Hct stable x 48 hours. Discharge Instructions: Please take your medications as prescribed and keep all scheduled appointments. Call your doctor or return to the ER if you experience worsening fatigue, abdominal pain, chest pain, black stools or bloody stools. Do not take any aspirin or NSAIDs until further notice. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name12 (NameIs) ] Where: [Name12 (NameIs) ] Date/Time:[2140-10-20] 1:30 Completed by:[0-0-0] ICD9 Codes: 2851, 412, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2297 }	Medical Text: Admission Date: [2162-2-15] Discharge Date: [2162-3-6] Date of Birth: [2101-7-7] Sex: M Service: MEDICINE Allergies: Influenza Vaccine,Trival [2159] Attending:[First Name3 (LF) 13256] Chief Complaint: s/p TACE Major Surgical or Invasive Procedure: Transarterial chemoembolization [2162-2-15] mechanical intubation History of Present Illness: This 60-year-old gentleman with h/o chronic HCV and cirrhosis who has been followed with regular u/s and MRIs and recently found to have two less than 1 cm nodules that subsequently progressed to numerous nodules. He was referred to [Hospital1 18] and underwent targeted liver biopsy, which confirmed HCC in three of the five nodules, making him no longer transplant eligible. Today he underwent his first chemoembolization. For his HCV, he had been treated with ribavirin and interferon, without response. He is followed closely for this and was diagnosed with varices in the past but recent endoscopy did not show any varices. He has no histopry of encephalopathy, ascites or GI bleed. Pt underwent chemoembolization today and during procedure became very uncomfortable with epigastric abd pain [8-25], requiring dilaudid, toradol. His BP was increased to SBP 200s, and required also hydralazine. At this time, the patient is feeling better, his pain has decreased to [2159-12-19]. He denies any associated n/v/fever, chills, rigors, lightheadedness, palpitations. ROS: pt denies HA, weight chamges, fatigue, cough, SOB, CP, dysuria, constipation. Full ten point ROS was otehrwise negative. Past Medical History: 1. HCV cirrhosis complicated by portal hypertension, esophageal varices, hepatoma. 2. Diabetes. 3. COPD. 4. Orbit repair Social History: Social History: Half-pack-per-day smoker. No ETOH, no IVDA, occasional marijuana use. lives with his wife and dog. He has three grown children. He works as a postal clerk. Family History: Family History: His mother was diagnosed with breast cancer at the age of 84. He has never been in contact with his father. Physical Exam: Exam on admission: VS T current 96.6 BP 120/84 HR 52 RR 16 O2sat 95%RA Gen: In NAD. HEENT: PERRL, EOMI. No scleral icterus. No conjunctival injection. Mucous membranes moist. No oral ulcers. Neck: Supple, no LAD, no JVP elevation. Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal respiratory effort. CV: RRR, no murmurs, rubs, gallops. Abdomen: soft, NT, ND, NABS, no HSM. well healed surgical scars at the umbilicus and right upper quadrant Extremities: warm and well perfused, no cyanosis, clubbing, trace pedal edema B. R leg immobilizer in place, adequate B pulses peripherally, no bruits in R femoral puncture site Neurological: alert and oriented X 3, CN II-XII intact. Skin: No rashes or ulcers. Psychiatric: Appropriate. GU: deferred. Discharge exam: PHYSICAL EXAM: VS: 97.3 112/55 63 18 94%RA General: no acute distress, jaundiced, a+ox3 HEENT: +scleral icterus, MMM Neck: supple, unable to assess JVP, no LAD Lungs: CTA, no wheezes or rales appreciated CV: Regular rate and rhythm, no murmurs appreciated Abdomen: soft, mild distended, bowel sounds present, no rebound tenderness or guarding, no ascites Ext: warm, well perfused, 2+ pulses, 1+edema, scrotal edema Pertinent Results: MRI performed on [2161-11-24] showed at least four hepatic lesions up to 1 cm in size, two of which have slightly increased and demonstrate washout and two with borderline washout; all concerning for HCC. Several additional nodules which are subcentimeter in size, are also concerning for HCC but too small for definitive imaging diagnosis. . ADMISSION LABS: [2162-2-15] 08:14AM WBC-4.1 RBC-4.31* HGB-13.8* HCT-43.9 MCV-102# MCH-32.0 MCHC-31.4# RDW-14.8 [2162-2-15] 08:14AM PLT COUNT-100 [2162-2-15] 08:14AM PT-12.8* PTT-36.5 INR(PT)-1.2* [2162-2-15] 08:14AM GRAN CT-2140* [2162-2-15] 08:14AM ALBUMIN-3.0* CALCIUM-8.5 [2162-2-15] 08:14AM ALT(SGPT)-45* AST(SGOT)-70* ALK PHOS-129 TOT BILI-1.8* [2162-2-15] 08:14AM UREA N-7 CREAT-0.8 SODIUM-142 POTASSIUM-3.5 CHLORIDE-106 [2162-2-15] 08:14AM AFP-11.6* [2162-3-6] 05:20AM BLOOD WBC-6.3 RBC-3.07* Hgb-11.0* Hct-35.6* MCV-116* MCH-35.8* MCHC-30.9* RDW-19.1* Plt Ct-95* [2162-3-6] 05:20AM BLOOD PT-21.2* PTT-53.3* INR(PT)-2.0* [2162-3-6] 05:20AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-135 K-4.0 Cl-102 HCO3-33* AnGap-4* [2162-3-6] 05:20AM BLOOD ALT-85* AST-167* LD(LDH)-499* AlkPhos-199* TotBili-8.6* [2162-3-6] 05:20AM BLOOD Albumin-2.0* Calcium-7.8* Phos-2.6* Mg-1.9 SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Status post TACE treatment, complicating by pneumonia and hepatic coma. New oxygen requirement. Comparison is made with prior study, [2-24]. Right lower lobe opacity has markedly increased, a combination of pleural effusion and adjacent consolidation. Left lower lobe opacities have increased, could be due to atelectasis or pneumonia. There is no pneumothorax. Cardiac size is normal. Right PICC tip is in the lower SVC. LIMITED ABDOMINAL ULTRASOUND DATE: [2162-2-26]. COMPARISON: Liver ultrasound [2162-2-18], CT abdomen and pelvis [2162-2-20], chemoembolization [2162-2-15]. CLINICAL INDICATION: 60-year-old man with hepatitis C status post TACE procedure, elevated and rising bilirubin of unclear etiology. Question obstruction. TECHNIQUE: Multiple son[Name (NI) 493] grayscale images of the abdomen were obtained with select images supplemented with color Doppler and spectral waveform analysis. FINDINGS: The liver demonstrates coarsened echotexture consistent with known cirrhosis. Echogenic foci within the right hepatic lobe are consistent with sequelae of recent TACE procedure. This examination was not tailored to evaluate for liver lesions. The gallbladder is nondistended and demonstrates diffuse gallbladder wall thickening measuring up to 3 mm, stable from prior CT examination. There is no intra- or extra-hepatic biliary dilation with the common hepatic duct measuring 4 mm. The main portal vein is patent, but demonstrates persistent hepatofugal flow. Visualized portions of the pancreas are within normal limits with the pancreatic head, uncinate process and tail non-visualized secondary to shadowing from overlying bowel gas. There is a small amount of ascites seen in the right lower quadrant and perihepatic locations. The spleen measures approximately 13.2 cm. Representative images of the kidneys demonstrate no hydronephrosis. IMPRESSION: 1. No evidence of biliary obstruction. Circumferential gallbladder wall thickening, stable from recent CT, which likely relates to underlying liver disease. 2. Sequelae of recent TACE. Coarsened, heterogeneous liver consistent with cirrhosis with stable reversal of flow in the patent main portal vein. 3. Small amount of perihepatic and right lower quadrant ascites. The study and the report were reviewed by the staff radiologist. Radiology Report MR HEAD W & W/O CONTRAST Study Date of [2162-2-24] 8:44 PM [Last Name (LF) 2437],[First Name3 (LF) ] [First Name3 (LF) ] [Hospital Unit Name 153] [2162-2-24] 8:44 PM MR HEAD W & W/O CONTRAST Clip # [Clip Number (Radiology) 91738] Reason: evaluate for cause of obtunded state [Hospital 93] MEDICAL CONDITION: 60 year old man with HCC who is obtunded s/p TACE REASON FOR THIS EXAMINATION: evaluate for cause of obtunded state CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Altered mental status, status post chemoembolization procedure. COMPARISON: CT head from [2162-2-22]. TECHNIQUE: MRI of the head was obtained before and after administration of contrast per department protocol. FINDINGS: There is no evidence of hemorrhage, infarction, edema, mass, or mass effect. Ventricles and sulci are age appropriate. Few scattered T2/FLAIR hyperintensities are seen in the periventricular white matter, which are nonspecific and may represent small vessel ischemic disease. Visualized orbits, paranasal sinuses are unremarkable. There is minimal fluid signal in bilateral mastoid air cells. The post-contrast images are degraded by motion. IMPRESSION: Post-contrast images are markedly degraded by motion artifact. There are several nonspecific FLAIR signal abnormalities may represent small vessel ischemic disease. This limited study is otherwise normal. Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of [2162-2-20] 4:11 PM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] 11R [2162-2-20] 4:11 PM CT ABD & PELVIS WITH CONTRAST Clip # [Clip Number (Radiology) 91739] Reason: ? infarct or infection Contrast: OMNIPAQUE Amt: 130 [Hospital 93] MEDICAL CONDITION: 60 year old man with hepatic encephalopathy post TACE REASON FOR THIS EXAMINATION: ? infarct or infection CONTRAINDICATIONS FOR IV CONTRAST: post TACE Final Report INDICATION: 60-year-old male with hepatic encephalopathy status post TACE. Question liver infarct or abscess. COMPARISON: CT dated [2162-2-16] and MR dated [2161-11-24]. TECHNIQUE: MDCT images were acquired from the lung bases through the pubic symphysis following administration of intravenous contrast with multiplanar reformations. CT ABDOMEN: An enteric tube is in place with tip extending to the stomach. There is a small right pleural effusion with compressive atelectasis. Mild dependent atelectasis is present on the left. The heart is normal in size without pericardial effusion. Multivessel coronary arterial disease is present. A 1-cm saccular enhancing structure at the gastroesophageal junction (300A, 27 and 2, 8) likely represents a paraesophageal varix. A small perihepatic ascites is present. The liver is shrunken and nodular, consistent with cirrhosis. The portal veins are attenuated but appear patent. The patient is status post TACE with hyperdense Ethiodol accumulating in known lesions in segments V, VI and VII. The remainder of the liver demonstrates no evidence of infarct. Two subcentimeter hypodense lesions are seen within liver, segments [Doctor First Name 690] (2, 14) and IVb (2, 21), too small to fully characterize. Additional lesions demonstrated on preceding MRI are not evident on current single phase exam. The gallbladder demonstrates circumferential mural edema, likely reflecting underlying liver disease. The spleen is enlarged to 17 cm and associated with prominent splenorenal and gastrosplenic varices. The pancreas and adrenal glands are unremarkable. Bilateral kidneys enhance symmetrically without hydronephrosis or hydroureter. A 2-cm lower pole exophytic left renal cyst is present. Additional subcentimeter renal hypodensities are too small to fully characterize. The small and large bowel loops are normal in caliber. Scattered tiny retroperitoneal and mesenteric lymph nodes do not meet size criteria for adenopathy. Moderate atherosclerotic calcifications are seen in the infrarenal aorta extending into common iliac arteries. CT PELVIS: The bladder is partially collapsed, containing a Foley catheter and probably post-instrumentation air. The prostate appears unremarkable. A rectal tube is in place. There is no inguinal or pelvic sidewall adenopathy. Trace free fluid is in the pelvis. BONE WINDOW: No focal concerning lesion. Remote right posterior rib fractures are seen in ribs 9 and 10. A hemangioma is noted in L4 vertebral body. IMPRESSION: 1. No evidence of intra-abdominal or intrapelvic abscess. 2. Cirrhosis, splenomegaly, varices, and small ascites, consistent with portal hypertension. 3. TACE treated liver, without evidence of infarct. 4. Two subcentimeter hypoattenuating liver lesions within segments [Doctor First Name 690] and IVb, too small to fully characterize. Additional known liver lesions are better depicted on preceding MRI dated [2161-11-24]. 5. Small right pleural effusion with compressive atelectasis. 6. Bilateral renal cysts, some of which are too small to fully characterize. 7. Remote right ninth and tenth chronic appearing posterior rib fractures. Brief Hospital Course: REASON FOR HOSPITAL ADMISSION 60 y/o M with recently diagnosed multifocal HCC, s/p selective segment VI + right lobar TACE [2162-2-15]. . HOSPITAL COURSE: # hepatic encephalopathy: s/p selective segment VI and right lobar TACE [2-15] for hepatic carcinoma. He became hypertensive at the the end of the procedure, thought to be due to pain with BP up to SBP 200, controlled with dilaudid, toradol for pain and hydralazine. Slowly became obtunded and altered following the procedure. His bilirubin and LFTs trended up. non-contrast CT of liver done showed ethidiol in most of R hepatic lobe and additional mass, no extravasation. Pt with persistent nausea/vomiting/pain post procedure and marked increase in transaminases and bilirubin and developed encephalopathy and hypoxia, see below. Pt was transferred to the [Hospital Unit Name 153] for unresponsiveness. C/f infection given pt was febrile to 101 on [2-21]. Source of infection unclear. [Name2 (NI) ] evidence of abscess or liver infarct on [2162-2-20] CT ab/pelvis. RUQ u/s was negative. No ascites to tap. BCx and Ucx are no growth to date. CXR x 2 concernign for RLL opacification. Head CT w & w/o was neg [2-18]. Pt started on vanc/ctx/flagyl initially, then broadened to vanc/zosyn. Amonia level was 177. Pt was unresponsive to sternal rub, off sedation. EEG did not show signs of epileptic activity. Head CT stable without evidence of bleed. MRI head was performed which showed only nonspecific signal abnormalities likely from small vessel ischemic disease, nothing acute. RUQ u/s with doppler obtained but did not suggest significant hepatic artery or portal vein obstruction. Tube feeds were started via NG. After 3 days in the [Hospital Unit Name 153] with aggressive lactulose therapy and rifaxamin transaminases and bili were trending down, and pt regained consciousness. Amonium level went down to 70. It was felt this had been a toxic-metabolic encephalopathy likely [12-17] elevated ammonium levels. He was extubated and slowly re-oriented, making jokes with his family. Subsequently bilirubin went up to 10.8 and pt developed severe jaundice. Pt did not complain of RUQ pain at this time but given elevated bili RUQ u/s obtained without evidence of obstruction. While on the hepatology floor Tbili stabilized 7-8 range. He was started on ursodiol 600 mg [Hospital1 ]. # Hypoxia: Patient developed new O2 requirement on the floo following the TACE procedure with O2 sat down to 86% on RA -> 92% on 3L shovel mask. Given hepatic encephalopathy/coma, patient had increasing difficulty clearing his secretions and developed diffuse rhonchi on exam. c/f aspiration pneumonia as he also had a fever to 101.2. Vanc/zosyn initiated, pt transferred to the [Hospital Unit Name 153] and was intubated. After 3 days in the [Name (NI) 153] pt was extubated and regained significant neurologic function. Hypoxia resolved. A 13 days course of vanc/zosyn for HAP was finished on [3-6]. # Volume overload: Likely combiniation of hepatic failure and IVF. Patient started on spironolactone and furosemide. . # Coagulopathy: Pt with INR 3.3, thrombocytopenia, fibrinogen 64, concern for DIC. Most likely secondary to hepatic decompensation and poor synthetic function. No schistocytes on smear. Pt was given IV vitamin K and this remained stable. . # Hypernatremia: Likely secondary to decreased free water intake given mental status, as well as hypovolemia from diarrhea ([12-17] lactulose for hepatic encephalopathy). While intubated pt without access to free water. Pt was given slow rate D5W with careful monitoring of electrolytes. No issues after resolution and patient taking PO. # Fever: Source unclear, although concern for respiratory process given new hypoxia and O2 requirement in the context of high risk for aspiration. Blood/urine cultures unrevealing. Vanc/zosyn was continued for 13 day course for possible HAP. # Hepatocellular carcinoma s/p TACE: s/p selective segment VI and right lobar TACE. Patient had marked increase in transaminases and bili with development of hepatic encephalopathy as above. Per oncologist, prognosis for HCC alone would be about 1year. # Thrombocytopenia: baseline 100s due to portal hypertension. PLTs in the 50s while in the [Hospital Unit Name 153]. Pt without signs of active bleeding and it was felt appropriate to monitor; no transfusions were given. Remained stable while on the floor. # DM2: Initially getting D5W for hypernatremia. Post extubation pt began taking PO. Insulin sliding scale was continued. . # Portal HTN: controlled on home nadolol . # Communication: wife [Name (NI) 2048]: cell [Telephone/Fax (1) 91740], H [Telephone/Fax (1) 91741] . Pt was maintained as FULL CODE throughout the course of this hospitalization. . TRANSITIONAL ISSUES: # Patient will need LFT monitoring including Tbili for the next 5 days to evaluate stability. If stable at this point no need to continue to check unless otherwise indicated. # Patient will need Chem7 monitoring for the next 5 days to evaluate for hypokalemia or worsening renal function. If stable at this point no need to continue to check. Medications on Admission: NADOLOL - (Prescribed by Other Provider) - 40 mg Tablet - 3 Tablet(s) by mouth once a day Discharge Medications: 1. nadolol 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 3. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 4. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 5. insulin lispro 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: per insulin sliding scale. 6. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical twice a day as needed for [Female First Name (un) ]: apply to groin area. 9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital 38] Rehab, [Location (un) 38], MA Discharge Diagnosis: Hepatoma s/p chemoembolization Hepatic Coma/Encephalopathy Pneumonia HCV cirrhosis Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], You were admitted for transarterial chemoembolization of your liver cancer. Unfortunately, the procedure was complicated by injury to the normal liver cells as well as the cancer cells which led you to have decompensation requiring intubation. You were also found to have a pneumonia, for which you were treated with IV antibiotics. You were extubated several days later and have remain stable on room air. We have continued to treat you with diuretics as well as lactulose and rifaximin. We also had the nutritionist meet with you and your family to help you with your caloric intake and dietary choices. We wish you a fast recovery and hope you make it home soon. The following changes have been made to your medications: START Simethicone 80 mg up to 4 times a day as needed for gas (take separate from other meds by at least 1 hr) START Insulin glargine 12 units at bedtime START Insulin lispro per sliding scale START Spironolactone 150 mg daily START Furosemide 40 mg daily START Lactulose 30 mL TID (can increase or decrease but titrate to [1-17] bowel movements daily) START Miconazole powder to groin as needed for rash START Rifaxamin 550 mg twice a day START Ranitidine 150 mg twice a day START Ursodiol 600 mg twice a day Followup Instructions: You have the following appointments: Department: LIVER CENTER When: THURSDAY [2162-3-18] at 1:40 PM With: [Name6 (MD) ] [Name8 (MD) ], 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 [2162-4-2] at 1:40 PM With: XMR [Telephone/Fax (1) 590] Building: CC [Location (un) 591] [Hospital 1422] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2162-4-16] at 2:30 PM With: [Last Name (LF) 3150],[Name8 (MD) ] MD [Telephone/Fax (1) 11133] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5070, 2760, 496, 2768, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2298 }	Medical Text: Admission Date: [2124-10-20] Discharge Date: [2124-11-21] Date of Birth: [2066-9-2] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient was a 58-year-old man who was admitted to the Neurology Service on [10-20]. He initially presented to [Hospital ] Hospital on [10-18] with the acute onset of left-sided weakness. A right .................... hemorrhage was diagnosed by noncontrast head CT. While at [Hospital ] Hospital, the patient fell, and the thalamic hemorrhage expanded. It was not clear whether the hemorrhage resulted in the fall or the fall resulted in expansion of the hemorrhage. He was transferred to the [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) ] on [2124-10-20]. The initial exam documented that he was awake, obeying commands, had a right gaze preference, and that he had left arm ................... and face weakness. He was witnessed to have three generalized tonic clonic seizures on admission. Ativan and Dilantin were started at that time. Although it was felt that his hemorrhage was a typical occasion for hypotensive bleed ...................., rapid increase in size despite control of blood pressure and increased right temporal edema suggested the possibility of an AVM or dual sinus thrombosis. Conventional angiogram as normal. The patient blood pressure was controlled with IV drips in the unit, and Labetalol was discontinued on [10-24]. He did require intermittent Hydralazine and Lopressor for blood pressure control. His exam was fluctuating, but he had no overt seizures since presentation. For this reason, an EEG was obtained that showed generalized background slowing. While in the Intensive Care Unit, the patient had an induced sputum which showed gram-positive cocci. He was treated initially with Vancomycin and then with Oxacillin. Mannitol was started on [10-24] for the fear of increased intracranial edema, and noncontrast head CT showed increased edema. Mannitol was discontinued the next day. Since that time, the patient had reasonable control of his blood pressure. He has been transferred to the Neurology Floor for further management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Alcohol abuse. 3. Atrial fibrillation times five years off Coumadin for two years. 4. Depression. 5. Question of history of myocardial infarction 6. Hiatal hernia. MEDICATIONS ON ADMISSION: Digoxin, Paxil, Tagamet, Aspirin, Albuterol inhaler. MEDICATIONS ON TRANSFER TO NEUROLOGY: Tylenol p.r.n., Paxil 20 mg p.o. q.d., Digoxin 0.25 mg p.o. q.d., Albuterol inhaler, Dilantin 200 mg IV q.8 hours, Colace, Insulin sliding scale, Zantac 150 mg IV b.i.d., Oxacillin 2 g IV q.6 hours, Neutra-Phos, Hydralazine 20 mg IV q.6 hours, Lopressor 75 mg p.o. b.i.d. ALLERGIES: SULFA. SOCIAL HISTORY: Unable to be obtained. FAMILY HISTORY: Unable to be obtained. PHYSICAL EXAMINATION: Vital signs: The patient was afebrile, blood pressure 132/68, heart rate 96, oxygen saturation 100%. General: He appeared older than stated age. Difficult to arouse. HEENT: Dry mucous membranes. Neck: No thyromegaly or carotid bruits. Pulmonary: Coarse breath sounds throughout. Cardiovascular: Atrial fibrillation. No murmurs. Abdomen: Soft and nontender. Positive bowel sounds times four. Extremities: There were 1+ peripheral pulses. No edema. [Month (only) ]: He was sleeping but aroused by name being called loudly. He kept his eyes open for a minute before falling back asleep. He did not attempt to communicate. He blinks to threat. Right-sided gaze preference. Pupils equal and reactive. He had ................... strength in right hand. He could squeeze with good effort. He moved right leg back and forth. Left side was flaccid. Toes upgoing in the left, and downgoing in right. Reflexes 3 in the upper extremities, 1+ at the patella, no ankle jerks. LABORATORY DATA: White count 13.5, hematocrit 35.5 platelet count 220; sodium 140, potassium 3.7, chloride 110, bicarb 26, BUN 19, creatinine 0.5, glucose 141, calcium 8.0, magnesium 1.8, phosphate 3.0. Head CT showed a large right .................. hemorrhage. HOSPITAL COURSE: As noted above, the patient was initially admitted to the Neurology [Month (only) ]. After being transferred to the Neurology floor on [10-28], he was continued on Mannitol with an osmolality of 308. The patient's mental status did not improve on Mannitol. His edema did not resolve on CT. He was therefore tried on an empiric course of Decadron, a 10 mg bolus followed by 4 mg p.o. q.6 hours. The patient's alertness improved on the Decadron, and follow-up head CT demonstrated somewhat less edema with decreased flattening of the ventricle. The patient became more alert, and the Decadron was tapered over two weeks. The patient's Oxacillin was discontinued after a ten-day course. He has had no further issues with pneumonia. The patient continue to make progress. He was more alert, although still not moving the left side of his body which has remained hemiplegic. He was not taking adequate oral intake, so he was evaluated by Gastroenterology for placement of PEG tube. The PEG tube could not be placed because of his ascites which was noted on ultrasound, and gastroesophageal varices which was seen on EGD. His current examination shows that he is awake and alert. He does not know the date but knows that he was in [Hospital6 1760]. His eye movements are full to both sides. His pupil are equal. He has a left facial droop, and his head was turned to the right. He is hemiplegic on the left side. His toes are upgoing in the left. The patient will be discharged to rehabilitation on [2124-11-21]. DISCHARGE DIAGNOSIS: 1. Right .................. hemorrhage. 2. Hypertension. 3. Portal hypertension complicated by varices. DISCHARGE MEDICATIONS: Lopressor 75 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., Paxil 20 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., Digoxin 0.25 mg p.o. q.d., Lactulose 30 cc p.o. q.6 hours, Nadolol 20 mg p.o. b.i.d. FOLLOW-UP: The patient will follow-up with myself, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1206]. CONDITION ON DISCHARGE: He is discharged in fair condition. DR [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 13.140 Dictated By:[Last Name (NamePattern1) 5476] MEDQUIST36 D: [2124-11-20] 18:04 T: [2124-11-20] 18:17 JOB#: [Job Number 45082] ICD9 Codes: 431
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 2299 }	Medical Text: Admission Date: [2159-2-14] Discharge Date: [2159-2-21] Date of Birth: [2100-12-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1711] Chief Complaint: chest pressure Major Surgical or Invasive Procedure: cardiac catheterisation History of Present Illness: 58M hx CAD s/p 2 stents 9 years prior to unknown artery, hep C, HTN, HLP who presented to OSH today for elective L hip ORIF. He was off his plavix and aspirin since [2-5] in preparation for the procedure. Arrived to PACU @ 12:56pm today c/o chest pressure with lateral ST elevations & HR in the 120s 127/80. He received Plavix 600mg, [Year (2 digits) ] 325 mg, IV ntg @ 20 mcg, heparin @ 1300 units/hr no [Year (2 digits) 1868], lipitor 80mg, IV lopressor 5mg x2. HR down to 72, BP 107/78 with 6/10 chest pressure. He was transferred to [Hospital1 18] for urgent cath. . In cath lab, he underwent thrombectomy and DES to the LAD. He underwent the procedure without complication, suffering only some nausea. On transfer to the floor, he was hemodynamically stable, awake and alert without complaints. . During the first few hours of his CCU course, he experienced an episode of nausea with loss of conciousness and was found to be pulseless. CPR was begun and stopped quickly after patient regained conciousness. IO and central line access were obtained as was epinephrine given during the code, with dopa and neo afterward. Labs showed HCT of 24 from 32 at OSH prior to ORIF. 2L IVF were given and he was stabilized. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: ?MI in past, s/p multiple stents 9 years prior 3. OTHER PAST MEDICAL HISTORY: Hep C HTN HLP Social History: - Tobacco history: Quit 15yrs prior - ETOH: 1-2 drinks per day - Illicit drugs: none Family History: - Brother with cardiac disease, sister "on LVAD" Physical Exam: On admission: VS: Pulse 97 BP 108/56 100%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, JVD unable to be appreciated due to habitus. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, heart sounds distant. 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. IO line in place on the right tibial tuberosity. 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+ At discharge: 98.9, 125/78, 90, 20 98% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Central line in place. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVD unable to be appreciated due to habitus. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, heart sounds distant. 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. Left hip bandaged, taut, tender to palpation. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2159-2-14] 05:32PM BLOOD WBC-10.7 RBC-2.76* Hgb-7.8* Hct-23.9* MCV-87 MCH-28.4 MCHC-32.8 RDW-13.1 Plt Ct-188 [2159-2-14] 09:53PM BLOOD Hct-30.8# Plt Ct-152 [2159-2-15] 01:37AM BLOOD Hct-30.2 [2159-2-15] 06:13AM BLOOD WBC-9.2 RBC-3.38* Hgb-9.8# Hct-28.8 MCV-85 MCH-29.0 MCHC-34.0 RDW-13.9 Plt Ct-172 [2159-2-15] 11:03AM BLOOD Hct-26.4* [2159-2-15] 04:01PM BLOOD Hct-23.1* [2159-2-15] 11:28PM BLOOD Hct-25.7* [2159-2-16] 03:15AM BLOOD WBC-8.4 RBC-2.94* Hgb-8.6* Hct-24.7* MCV-84 MCH-29.3 MCHC-34.9 RDW-13.5 Plt Ct-138* [2159-2-16] 08:43AM BLOOD Hct-23.8* Plt Ct-142* [2159-2-16] 03:20PM BLOOD Hct-25.9* [2159-2-16] 09:08PM BLOOD Hct-22.6* [2159-2-17] 06:21AM BLOOD WBC-9.7 RBC-2.98* Hgb-8.8* Hct-24.8* MCV-83 MCH-29.7 MCHC-35.6* RDW-13.7 Plt Ct-138* [2159-2-17] 05:30PM BLOOD Hct-26.4* [2159-2-17] 11:28PM BLOOD Hct-25.0* [2159-2-18] 05:34AM BLOOD WBC-10.5 RBC-2.94* Hgb-8.6* Hct-24.6* MCV-84 MCH-29.2 MCHC-34.9 RDW-13.1 Plt Ct-179 [2159-2-18] 03:00PM BLOOD Hct-24.1* [2159-2-19] 03:59AM BLOOD WBC-11.4* RBC-2.86* Hgb-8.2* Hct-24.0* MCV-84 MCH-28.9 MCHC-34.4 RDW-13.3 Plt Ct-230 [2159-2-20] 05:10AM BLOOD WBC-12.2* RBC-2.98* Hgb-8.6* Hct-25.4* MCV-85 MCH-28.7 MCHC-33.6 RDW-12.9 Plt Ct-313 [2159-2-20] 05:10AM BLOOD Neuts-68.7 Lymphs-15.1* Monos-10.5 Eos-5.3* Baso-0.4 [2159-2-14] 05:32PM BLOOD Plt Ct-188 [2159-2-14] 05:32PM BLOOD PT-16.7* PTT-46.9* INR(PT)-1.6* [2159-2-14] 09:53PM BLOOD Plt Ct-152 [2159-2-15] 06:13AM BLOOD Plt Ct-172 [2159-2-16] 03:15AM BLOOD PT-14.4* PTT-28.3 INR(PT)-1.3* [2159-2-16] 03:15AM BLOOD Plt Ct-138* [2159-2-16] 08:43AM BLOOD Plt Ct-142* [2159-2-17] 06:21AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.3* [2159-2-14] 05:32PM BLOOD Glucose-208* UreaN-19 Creat-0.9 Na-140 K-3.6 Cl-111* HCO3-18* AnGap-15 [2159-2-14] 09:53PM BLOOD Na-137 K-4.4 Cl-108 [2159-2-15] 06:13AM BLOOD Glucose-162* UreaN-25* Creat-1.2 Na-138 K-4.8 Cl-108 HCO3-24 AnGap-11 [2159-2-16] 03:15AM BLOOD Glucose-126* UreaN-17 Creat-0.7 Na-135 K-3.8 Cl-106 HCO3-23 AnGap-10 [2159-2-16] 03:20PM BLOOD Glucose-139* Na-135 K-4.3 Cl-103 HCO3-23 AnGap-13 [2159-2-17] 06:21AM BLOOD Glucose-121* UreaN-10 Creat-0.8 Na-137 K-3.7 Cl-104 HCO3-27 AnGap-10 [2159-2-17] 05:30PM BLOOD Na-136 K-3.9 Cl-102 [2159-2-18] 05:34AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-137 K-3.8 Cl-103 HCO3-26 AnGap-12 [2159-2-18] 03:00PM BLOOD Na-135 K-4.3 Cl-101 [2159-2-19] 03:59AM BLOOD Glucose-127* UreaN-16 Creat-0.8 Na-137 K-4.1 Cl-103 HCO3-26 AnGap-12 [2159-2-20] 05:10AM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-138 K-4.4 Cl-103 HCO3-23 AnGap-16 [2159-2-14] 05:32PM BLOOD CK(CPK)-1709* [2159-2-15] 01:37AM BLOOD CK(CPK)-1718* [2159-2-15] 06:13AM BLOOD CK(CPK)-1279* [2159-2-15] 11:03AM BLOOD CK(CPK)-924* [2159-2-14] 05:32PM BLOOD CK-MB-174* MB Indx-10.2* cTropnT-3.94* [2159-2-14] 09:53PM BLOOD CK-MB-241* [2159-2-15] 01:37AM BLOOD CK-MB-191* MB Indx-11.1* cTropnT-6.80* [2159-2-15] 06:13AM BLOOD CK-MB-129* MB Indx-10.1* cTropnT-6.77* [2159-2-15] 11:03AM BLOOD CK-MB-85* MB Indx-9.2* cTropnT-5.64* [2159-2-14] 05:32PM BLOOD Calcium-6.8* Phos-3.4 Mg-1.4* [2159-2-15] 06:13AM BLOOD Calcium-7.8* Phos-3.9 Mg-2.3 [2159-2-16] 03:15AM BLOOD Calcium-7.7* Phos-1.5# Mg-2.0 [2159-2-16] 03:20PM BLOOD Calcium-8.0 Phos-3.1# Mg-2.0 [2159-2-17] 05:30PM BLOOD Calcium-8.1* Mg-1.8 [2159-2-18] 05:34AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9 [2159-2-18] 03:00PM BLOOD Mg-2.2 [2159-2-19] 03:59AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9 [2159-2-20] 05:10AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2 . Discharge labs: [2159-2-21] 19 122 AGap=14 4.8 25 0.8 Ca: 8.5 Mg: 2.0 P: 3.8 13.6>8.2/24.5<353 PT: 13.9 PTT: 29.9 INR: 1.3 . [2159-2-14] CARDIAC CATHETERISATION 1. Selective coronary angiography of this right-dominant system demonstrated severe 2 vessel CAD. The LMCA had no significant stenosis. The mid LAD had a large occlusive thrombus in the prior stent. The LCX had 60% stenosis at the origin. A large OM1 branch had 60% stenosis. The dominant RCA had 80% stenosis in the mid RPDA branch. 2. Limited resting hemodynamics revealed normal systemic arterial pressures with a measure central aortic pressure of 114/80/83. 3. Left ventriculography was deferred. 4. Very late stent thrombosis in the LAD (previous stent deployed in [2149]) with acute antero-lateral MI. 5. LAD stenosis successfully treated by aspiration thrombectomy and deployment of a 3.0 x 12 mm Promus drug-eluting stent. . FINAL DIAGNOSIS: 1. Acute anterior [Year (4 digits) ]. 2. 3 vessel CAD. 3. Very late stent thrombosis in the LAD treated successfully with aspiration thrombectomy and deployment of a 3.0 x 12 mm Promus drug-eluting stent. 4. [Year (4 digits) ] 325mg/day; plavix 75mg/day for minimum 1 year. . [2159-2-14] HIP XRAY WITH PELVIS Left total hip arthroplasty in satisfactory alignment with no evidence of immediate post-surgical complications. . [2159-2-15] ECHOCARDIOGRAPHY The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with moderate anterior septal hypokinesis and mild inferior septal hypokinesis. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Moderate hypokinesis of the anterior septum, mild hypokinesis of the inferior septum. No significant valvular abnormality seen. . [2159-2-16] CT Abdomen/Pelvis without contrast 1. No retroperitoneal hematoma. 2. Expected soft tissue edema and subcutaneous air, consistent with post-surgical changes from left total hip arthroplasty. 3. Bilateral fat-containing inguinal hernias. . [2158-2-19] CXR No evidence of pneumonia. Brief Hospital Course: 58M hx CAD with LAD and ?other stents 9 years prior, hep C, HTN, HLP who presented to OSH for elective L hip ORIF. In PACU, developed substernal chest pressure, was found to have ST elevations in V2-V4 and transferred for cath. . # CAD: Unclear history of cardiac disease, has had at least one stent to the LAD ~9 years prior. Post-operatively had ST elevations in the precordial leads. Was plavix loaded, put on hep gtt without [Last Name (LF) 1868], [First Name3 (LF) ] 325, atorva 80, was on a nitro gtt for hypertension and received lopressor 5 IV x2. Cath showed large LAD thrombus in the old stent, s/p thrombectomy with [Name Prefix (Prefixes) ] [Last Name (Prefixes) 5175]. EKG after stent showed resolution of ST elevations. He will continue on aspirin, plavix, atorvastatin, metoprolol and lisinopril following discharge. . # PEA: On [2158-2-14], patient experienced a PEA arrest. Likely vagal episode (nausea prior to event) versus hypovolemia (blood loss into RP versus into hip). Stabilized after short course of CPR and epinephrine, transiently on dopamine/neo. s/p 2L IVF. HCT 24 from 32 at OSH. Currently stable. No further PEA episodes. . # L hip ORIF: s/p elective surgery. Possible site of bleeding for PEA etiology. Unfortunately due to [Date Range ] and DES, will require [Date Range ]/plavix. ongoing bleeding, likely into left hip. Ortho was not concerned for compartment syndrome currently. Hematocrit was currently stable. CT [Last Name (un) 103]/pelvis was not concerning for RP bleed. He received a total of 6 units PRBCS and 1 unit FFP. His hemotcrit subsequently stabilised and was trending up at the time of discharge. He will continue lovenox for DVT prophylaxis for a total of 4 weeks. . # Leukocytosis: WBCs up to 12.2 currently from 8.4 on [2158-2-16]. Etiology unclear. [Name2 (NI) ] localizing symptoms. LIkely [3-15] inflammation from recent hip surgery and cardiac manipulation. cx ngtd. UA and CXR were negative for infection. . # CHF: No history of CHF. Appears hemodynamically stable without evidence of pulmonary congestion. In setting of volume resuscitation/blood and anterior [Last Name (LF) ], [First Name3 (LF) ] monitor fluid status and oxygenation. We restarted ACE inhibitor and he will followup with cardiology as an outpatient. . # HTN: Restarted home lisniopril one Hct was stable. . # HLD: increased atorvastatin to 80 daily. Medications on Admission: Toprol XL 50 Atorvastatin 40 Plavix 75 (held on [2-5] for procedure) Lisinopril 10 Aspirin 81 (held on [2-5] for procedure) MVI Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 24 days. Disp:48 Refills:0 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. 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:0 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours: please hold for sedation, do not take if you are drowsy or are having difficulty breathing. Please do not drive while you are taking this medication. . Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Primary: ST Elevation Myocardial Infarction, PEA Arrest Secondary: s/p Open Reduction Internal Fixation, Acute Blood Loss Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at the [Hospital1 771]. You were admitted with a heart attack following your hip surgery. We performed a cardiac catheterisation and found some blockage to the blood flow to your heart, which we repaired by placing a stent. During your stay in our intensive care unti, you transiently lost your pulse. We performed CPR and were able to rapidly restore your pulse. This episode was probably due to some blood loss during your surgery, and you had no further episodes during your hospitalization. We monitored your hematocrit (a measure of your blood levels) and found that it was dropping, probably due to slow ongoing bleeding into your left hip. We gave you blood transfusions and your hematocrit level was stable by the time of discharge. We made the following changes to your medications. -INCREASED Metoprolol XL to 200 mg daily -INCREASED Atorvastatin to 80 mg daily -INCREASED Lisinopril to 20 mg daily -INCREASED Aspirin to 325 mg daily -STARTED Enoxaparin -STARTED Percocet Please continue taking your other medications as usual. Please followup with your doctors, see below. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 251] T. Location: [Hospital3 ] INTERNAL MEDICINE ASSOCIATES Address: [Street Address(2) 4472], [Apartment Address(1) 4473], [Hospital1 ],[Numeric Identifier 9331] Phone: [Telephone/Fax (1) 4475] Appointment: TUESDAY [2-27] AT 2:45PM Department: CARDIAC SERVICES When: MONDAY [2159-3-26] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage You will also need to followup with your orthopedic surgeon at [Hospital3 ]. Please call his office to make a followup appointment regarding your hip. Completed by:[2159-2-21] ICD9 Codes: 4275, 2851, 2724, 4019, 412

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