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17687876-DS-16 | 1,424 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
h/o pulm hypertension, DM2, AR, htn, presents with
substernal chest pain, hypotension, and hypoxia.
Family reports pt has been having fever, yellow productive
sputum and flu-like symptoms. Seen by PCP , CXR showed
RUL infiltrates. who prescribed her with 10 day course of
levoflox. She presented to c/o substernal CP and was
found to be hypotensive. Because of CP, checked EKG, which
showed infereior ST depression. Pt was also hypoxic. For airway
protection, pt was intubated at OSH. She was started on dopa
and epi. Transferred to for further eval.
At , pt was taken to cath lab, and RHC showed cleaned
coronaries EF > 55%, baseline AR (Moderate to severe (3+) aortic
regurgitation). RHC findings were consistent with cardiovascular
collapse with low systemic vascular resistance and high cardiac
output. Pt was transferred to CCU for further management
## PAST MEDICAL HISTORY:
pulmonary hypertension
DM2
aortic regurgitation
Hypertension
## CV:
RRR, S1S2, diastolic murmur, no r/g
## ABDOMEN:
soft, NTND, NABS, no HSM
## NEURO:
sedated w/ RASS -1, PERRLA
## GENERAL:
well appearing, no distress
## CV:
RRR, S1S2, diastolic murmur, no r/g
## ABDOMEN:
soft, NTND, NABS, no HSM
## NEURO:
sedated w/ RASS -1, PERRLA
## IMAGING:
============================
##CHEST X-RAY
ET tube is present approximately 1.8 cm above the carina. An
enteric tube is present with tip and side hole is in the
stomach. The cardiomediastinal and hilar contours are normal
aside from aortic valve calcifications. There is no pneumothorax
or pleural effusion. The lungs are well expanded with
interstitial changes, likely chronic. There is no finding
concerning for pneumonia or pulmonary edema.
##CTA chest
1. Bilateral pulmonary emboli, including a saddle embolus of the
superior segment of the right upper lobe pulmonary artery. 2.
Several subcentimeter solid pulmonary nodules for which followup
chest CT is recommended in months in the setting of risk
factors for malignancy, and in 12 months in the absence of risk
factors. 3. Several hypodense liver lesions, and a soft tissue
abnormality in the left upper abdomen for which dedicated CT of
the abdomen is recommended.
##CT abd/pelvis with contrast
Enlarged right ovary with apparent solid and cystic component.
Further evaluation with pelvic ultrasound on a non-emergent
basis should be performed.. Air within the bladder.
Correlation with recent instrumentation and urinalysis is
recommended. Nodule at the right lung base measures 6 mm.
Follow-up CT in 6 months is recommended. Two hypodense lesions
in the right lobe of the liver are not fully characterized on
this single phase CT scan, however, the imaging characteristics
are most consistent with simple cysts.
##BILATERAL LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND
Exam is limited on the right side due to bandage on the groin.
Color flow is preserved in the right common femoral, proximal
femoral and mid femoral veins. There is normal compressibility,
flow and augmentation of the right distal femoral, and popliteal
veins. Normal color flow and compressibility is demonstrated in
the right posterior tibial and peroneal veins. There is normal
compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Normal color
flow and compressibility are demonstrated in the left posterior
tibial veins. The left peroneal veins were not visualized.
There is normal respiratory variation in the common femoral
veins bilaterally. No evidence of medial popliteal fossa
( ) cyst.
##RIGHT AND LEFT HEART CATHETERIZATIN
Hemodynamic Measurements (mmHg)
Baseline
SiteSysDiasEndMeanA WaveV WaveHR
PC
RA 12
LV
AO
Resistance Results (Metric Units)
PVR (dsc-5) SVR (dsc-5)PVR-I SVR-I (dsc-5*m2) TPR (dsc-5)
Resistance Results (Wood Units)
PVR ( ) SVR ( ) PVR-I ( ) SVR-I ( ) TPR ( )
1.18 7.10 1.85 11.09 2.96
The PCWP was 18 mmHg and the LVEDP was
20 mmHg after 5 Liters of volume resuscitation. There was no
evidence of constriction/restrictive physiology. There was no
evidence of an intracardiac shunt by oximetry.
## LAD:
Normal. There was a medium sized diagonal branch.
## LCX:
Normal. The LCx gave rise to a large OMB1 without disease.
## RCA:
Normal. The RCA gives rise to a PDA and a cascade of
posterolateral branches. The RCA was normal.
Interventional details
The patient presented with chest pain, a markedly abnormal EKG,
and cardiovascular collapse. She was stabilized on two pressors
and referred to the cardiac catheterization laboratory. The
patient had a history of known pulmonary hypertension, aortic
sclerosis and moderate aortic regurgitation.
The clinical picture is consistent with distributive shock with
a
SVR 568 dynes-cm-sec-5. Cannot exclude aortic dissection or PE.
ASSESSMENT
1. Cardiovascular collapse with low systemic vascular resistance
and high cardiac output
2. Normal coronary arteries
3. No evidence of an intracardiac shunt
## BRIEF HOSPITAL COURSE:
#Hypotension and hypoxia:
Patient was admitted to the hospital with complaints of
subjective fever, yellow productive sputum and flu-like symptoms
at home. She presented to an outside hospital and was
hypotensive with SBP in the , and she received IV fluid
resuscitation, was intubated for airway protection, and was
started on pressure support with dopamine and epinephrine. She
was transfered to . In the she was found to have
infereior ST depression on EKG and hypoxia. She was taken to
cath lab, where left and right heart catheterization showed
cleaned coronary arteries, EF > 55%, baseline AR (Moderate to
severe (3+) aortic regurgitation). Catheterization findings were
consistent with cardiovascular collapse with low systemic
vascular resistance and high cardiac output, indicative of
distributive shock. Patient had been seen by her PCP recently
with symptoms and chest x-ray consistent with pneumonia, and
with cardiac catheter evidence of distributive shock she was
initially felt to have septic shock from a pulmonary source, and
was started on vancomycin and cefepime. She was able to be
extubated without complication following catheterization. Given
her chest pain and hypoxia, she underwent CTA chest and was
found to have bilateral PEs and was therefore started on
apixaban. Antibiotics were discontinued. Patient showed rapid
and steady improvement, and on discharge, patient was breathing
comfortably and afebrile without chest pain.
## ====================
#DIABETES MELLITUS:
home anti-hyperglycemics were held and she
was treated with insulin sliding scale
## #HYPERTENSION:
Home antihypertensives were held due to low blood
pressure on presentation, and were not restarted on discharge
due to normal BP. restart medications as outpatient per her
primary care doctor's recommendation.
## TRANSITIONAL ISSUES:
====================
#Pulmonary embolism-patient started on 10mg BID dosing of
apixaban on . Apixaban should be dosed at 10mg BID x7 days
and then transition to 5mg BID
## #OVARIAN CYST:
Workup for malignancy was started at and CT
abdomen revealed right ovarian cyst, abnormal for her age, for
which outpatient transvaginal ultrasound is recommended in next
few weeks as well as a 6mm lung nodule in RLL for which a 6
month follow-up CT is recommended.
#HCTZ and Labetolol were held for normal blood pressures (had
been hypotensive on admission); may be restarted if patient
becomes hypertensive at follow up with PCP
on :
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
2. Famotidine 20 mg PO DAILY
3. Labetalol 300 mg PO BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fexofenadine 180 mg PO DAILY
7. Aspirin 81 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Apixaban 10 mg PO BID Duration: 7 Days
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*26 Tablet Refills:*0
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
3. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*42 Capsule Refills:*0
4. Aspirin 81 mg PO DAILY
5. Famotidine 20 mg PO DAILY
6. Fexofenadine 180 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the hospital after you were having trouble
breathing. You were found to have clots in your lungs and were
started on a new medicine to treat the clots. Please take the
new medication -- Apixaban -- after you go home as directed. It
is very important to follow up with your primary family doctor
after discharge.
We held your antihypertensive medications due to normal blood
pressures while off them. As you recover, these medications may
need to be restarted by your PCP.
It was a pleasure taking care of you while you were in the
hospital,
Your care team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17687876", "visit_id": "22849383", "time": "2144-10-24 00:00:00"} |
14391494-RR-109 | 136 | ## FINDINGS:
The liver is unremarkable in appearance, but no focal liver lesion
identified. No biliary dilatation is seen and the common duct measures 0.6
cm. The portal vein is patent with hepatopetal flow. The patient is status
post cholecystectomy. The pancreas is unremarkable but is only minimally
visualized due to overlying bowel gas. The spleen is enlarged measuring 16.2
cm. No hydronephrosis is seen. The right kidney measures 10.7 cm and the
left kidney measures 8.1 cm. A small non-obstructing stone is seen in the
right kidney measuring 5 mm. The visualized portion of the IVC is
unremarkable. The proximal portion of the aorta is unremarkable; however, the
distal aorta is not visualized.
## IMPRESSION:
1. Splenomegaly.
2. Tiny non-obstructing stone in the right kidney. Otherwise unremarkable
abdomen ultrasound.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14391494", "visit_id": "21302421", "time": "2170-07-22 09:38:00"} |
19394671-RR-26 | 97 | CHEST RADIOGRAPH PERFORMED ON .
## CLINICAL HISTORY:
woman with inability to tolerate p.o., question
acute process.
Compared with a prior study from .
## FINDINGS:
AP and lateral views of the chest are obtained. Overall, no change
from prior study on this limited exam with low lung volumes again noted. No
large pleural effusion or pneumothorax is seen. Heart size is mildly
enlarged. Mediastinal contour is stable with atherosclerotic calcification of
the knob. Bones are diffusely demineralized, with kyphotic angulation of the
T spine. Coils are noted in the upper abdomen.
## IMPRESSION:
No change since . No acute findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19394671", "visit_id": "25818464", "time": "2162-09-07 14:55:00"} |
16290929-DS-42 | 1,729 | ## ALLERGIES:
Cefepime / ciprofloxacin / Levofloxacin
## CHIEF COMPLAINT:
UTI, blisters on knees
## HISTORY OF PRESENT ILLNESS:
man diagnosed with AML in s/p matched
unrelated allogeneic stem cell transplant with busulfan and
cyclophosphamide as his conditioning regimen in . Was
in recently discharged from rehab in for paraplegia
which developed secondary to spinal cord injury during a prior
hospitalization. In addition to his paraplegia his course has
been complicated chronic GVHD of the lungs and liver for which
he has been receving IVIG infusions and steriods.
In the last few days his wife has noted a new discharge from the
area where his foley inserts into his penis.
Additionally she has noted that his urine has been foul smelling
and cloudy appearing. He denies any dysuria or blood in the
urine.
Six days prior to admission he noted the developement of a small
blister on his R knee. In the following days his blisters
enlarged and he noted the involvement of his L knee. Today he
notes the possible formation of new blister on his L elbow.
Theses blisters are not painful or actively draining. He was
seen in the outpatient clinic today where the blisters were
noted to be tense. He was sent to outpatient Dermatology where
a blister was aspirated -- this fluid was sent for culture. Per
Derm outpatient clinic, the blisters are more likely related to
truama/friction vs infection.
## ONCOLOGIC HISTORY:
- diagnosed with AML in .
- underwent unrelated allogeneic stem cell transplant
with busulfan and cyclophosphamide as his conditioning regimen.
## POST TRANSPLANT COMPLICATIONS:
*GVHD of the liver and skin. Question of pulmonary cGVHD as
often requires oxygen and steroids in the setting of respiratory
infections (h/o RSV, parainfluenza)
*Chronic lower extremitiy edema, refractory to lasix, suspected
to be GVHD
*Avascular necrosis (bilateral hips and left shoulder)
*Multiple compression fractures of the spine with chronic pain
*Type 2 DM
*Pulmonary embolus in and , on lifelong
anticoagulation
*s/p L5 vertebroplasty
*Ruptured left calf hematoma ( ) complicated by MRSA wound
infection
*Influenza A
*bilateral Achilles tendon rupture ( attributed to
levoflox).
OTHER PAST MEDICAL HISTORY (From ):
*CKD with baseline Cr 1.1
*Pericardial effusion s/p drainage.
*Hyperlipidemia, no meds.
*HTN, on metoprolol.
*Nephrolithiasis, lithotripsy and previous nephrostomy tube and
emergent surgery to repair ureteral damage.
*Left interpolar renal lesion, followed with MRs
*Basal cell carcinoma, resected.
*Squamous cell carcinoma left cheek, s/p Mohs' .
*Multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical
spine fusion (bone graft, no hardware).
*Anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
- Dr. .
*Chronic numbness, neuropathic pain in left upper extremity.
*Sleep Apnea, planned BIPAP, followed by Dr. .
*Lower extremity wound, s/p debridement by plastics, grew
pseudomonas
## FAMILY HISTORY:
Mother died suddenly in . Father died of unknown cancer. One
sister with thyroid cancer. One brother has diabetes. One sister
has .
## HEENT:
Pupils dilated but equally reactive to light, EOMI, MMM,
no thrush, no OP erythema or lesions
## NECK:
supple, no LAD, no JVD
## CHEST:
phresis cathether without erythema/tenderness/induration
## :
Distant heart sounds, otherwise Regular rate and rhythm
## LUNGS:
reg resp rate, breathing unlabored, no accessory muscle
use, diffuse rhonchorious bs throughout with transmitted
upper airway sounds
## SOFT, DISTENDED, NT, ND
EXT:
2+ pulses, no c/c/e,
## SKIN:
blisters wrapped in gauze
## NEURO:
CN intact, strength in UE; paralyzed from the
waist down.
## GEN:
Awake and alert, watching TV.
## HEENT:
EMOI, PERRL, OP clear.
## PULM:
bronchial breath sounds bilaterally; reduced breath sounds
bilaterally; no wheezing or rhonchi
## ABD:
+BS. Soft. Non-tender, non-distended.
## EXT:
trace bilateral lower extremity edema.
## NERUO:
A&Ox3. CN II-XII intact. No movement in bilateral
## SKIN:
no erythema or rashes noted today. healing skin blisters
on L knee
## BRIEF HOSPITAL COURSE:
man diagnosed with AML in s/p matched
unrelated allogeneic stem cell transplant in . His
course has been complicated chronic GVHD of the lungs and liver
for which he has been receving IVIG infusions and steriods. Was
in recently discharged from rehab in for paraplegia
which developed secondary to spinal cord injury during a prior
hospitalization. Admitted for blisters on his knee and foul
smelling urine concerning for UTI, and subsequently found to
have bactermia (Staph Epi x2 bottles).
## ACTIVE ISSUES:
# AML s/p MUD SCT in : Daily CBCs were checked and there was
no evidence of reoccurance. He was continued on bactrim,
acyclovir, and voriconazole prophylaxis during this admission.
## # BACTEREMIA:
Blood cultures obtained on in clinic were
positive for coagulase negative staphylococcus, later determined
to be staph epidermidis. The patient was treated with 14 days
of vanocmycin -- 6 days in the hospital followed by IV infusions
at home with a . Sensitivies demonstrated suspectibilty to
vancomycin. Vancomycin was initially dosed at 1000mg q12hours
-- however on the day of discharge the dose was reduced to
vancomycin 750mg q12hours due to an elevated vancomycin troph.
## # CHRONIC GVHD:
In the past his chronic GVHC has primarily
involved liver and lungs. His LFT's were mildly elevated during
this admission (AST: 49, ALT: 43). He was continued on
prednisone 10 mg and azithromycin 250 mg daily. His last IVIG
infusion was approximately 1 month prior to this admission so he
was given IVIG in the hospital. Respiratory function was stable
during this admission.
# Skin blisters on L knee: He was seen by outpatient dermatology
on (day of admission) who suggested that the blisters
were most likely due to trauma/friction vs contact dermatitis.
One of the blisters was aspirated and it grew coagulase negative
staph. He was seen by the dermatology consult service who
recommended basic wound care with gauze dressing. He was
treated with vancomycin (14 days) and aztrenam (5 days).
## # UTI:
In the days prior to admission his wife reported noting
foul smelling urine and discharge around the site of his chronic
foley. A U/A was positive for bacteria, nitrates and leuk
esterase. A urine culture was negative. He was empirically
treated with vancomycin and 5 days of acetrenam.
## # PARAPLEGIA:
Stable during this admission. A spine consult was
called regarding further management. Per Spine, lumbar and
thoracic spine x-rays were ordered -- these showed no
significant interval change.
# Type 2 DM on insulin: Stable during this admission. He was
placed on an ISS and continued on his home doses of NPH.
## TRANSITIONAL ISSUES:
[ ] will f/u with Dr. on please check vancomycin
troph
## MEDICATIONS ON ADMISSION:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Acyclovir 400 mg PO Q8H
2. Atorvastatin 10 mg PO DAILY
3. Azithromycin 250 mg PO Q24H
4. Duloxetine 30 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 300 mg PO TID
9. Heparin 5000 UNIT SC BID
10. Hydrocortisone Cream 1% 1 Appl TP QID
apply to affected areas
11. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
12. NPH 15 Units Breakfast
NPH 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Ipratropium Bromide Neb 1 NEB IH Q6H
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
15. MethylPHENIDATE (Ritalin) 5 mg PO NOON
16. MethylPHENIDATE (Ritalin) 5 mg PO QAM
17. Metoprolol Tartrate 12.5 mg PO BID
18. Montelukast Sodium 10 mg PO DAILY
19. Oxycodone SR (OxyconTIN) 40 mg PO BID
20. Pantoprazole 40 mg PO Q24H
21. PredniSONE 10 mg PO DAILY
22. Sulfameth/Trimethoprim SS 0.5 TAB PO DAILY
23. Voriconazole 200 mg PO Q12H
24. Bisacodyl 10 mg PO DAILY constipation
25. Bisacodyl 10 mg PR HS
26. Docusate Sodium 100 mg PO BID
27. Guaifenesin 10 mL PO Q6H:PRN cough
28. Multivitamins 1 TAB PO DAILY
29. Senna 2 TAB PO HS
30. Sodium Chloride Nasal SPRY NU QID:PRN nasal congestion
31. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
## DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3. Atorvastatin 10 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Bisacodyl 10 mg PO DAILY constipation
6. Bisacodyl 10 mg PR HS
7. Duloxetine 30 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 300 mg PO TID
12. Guaifenesin 10 mL PO Q6H:PRN cough
13. Hydrocortisone Cream 1% 1 Appl TP QID
apply to affected areas
14. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
15. NPH 15 Units Breakfast
NPH 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. Ipratropium Bromide Neb 1 NEB IH Q6H
17. MethylPHENIDATE (Ritalin) 5 mg PO NOON
18. Metoprolol Tartrate 12.5 mg PO BID
19. Montelukast Sodium 10 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. MethylPHENIDATE (Ritalin) 5 mg PO QAM
22. Oxycodone SR (OxyconTIN) 40 mg PO BID
23. Pantoprazole 40 mg PO Q24H
24. PredniSONE 10 mg PO DAILY
25. Senna 2 TAB PO HS
26. Sodium Chloride Nasal SPRY NU QID:PRN nasal congestion
27. Sulfameth/Trimethoprim SS 0.5 TAB PO DAILY
28. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
29. Docusate Sodium 100 mg PO BID
30. Voriconazole 200 mg PO Q12H
31. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth every 8 hours as
needed for muscle spasms Disp #*60 Tablet
## REFILLS:
*1
32. Vancomycin 750 mg IV Q 12H
RX *vancomycin 750 mg 750 mg IV every 12 hours Disp #*16 Unit
Refills:*0
## PRIMARY:
Urinary tract infection, bacteremia
## DISCHARGE INSTRUCTIONS:
It was a pleasure to participate in your care at . You
were admitted to the hospital because of blisters on your knees
and concerns about a urinary tract infection. At the hospital
we also found that you have a blood infection. We treated you
with antibiotics which will need to be continued at home.
You were seen by the Dermatology team who recommended keeping
the sites of you blisters wrapped with gauze until the skin is
healed.
You were seen by the Spine team who order images of your back
which showed no significant change from the previous images.
Please keep all follow up appointments. Please take all
medications as prescribed.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16290929", "visit_id": "26107257", "time": "2192-05-23 00:00:00"} |
16339049-RR-130 | 109 | ## INDICATION:
man with end-stage renal disease on peritoneal
dialysis with clotting of dialysis catheter, could not be cleared with TPA.
## PHYSICIAN:
, M.D., fellow performed the procedure with Dr. .
, M.D., attending supervising and present.
## MEDICATIONS:
None apart from 20 mL contrast injected into the peritoneal
cavity.
## RADIATION DOSE:
0.8 minutes of fluoro time, 30 mGy total dose.
## PROCEDURE:
Injection of peritoneal dialysis catheter with passage of wire
through the catheter.
## DETAILS:
Initial contrast injection demonstrated widely patent peritoneal
dialysis catheter. A wire was passed through the length of the
catheter without difficulty. Repeat contrast injection confirmed patency of
the catheter. There were no complications.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16339049", "visit_id": "27105912", "time": "2157-06-12 15:56:00"} |
18427420-RR-16 | 206 | ## INDICATION:
History of colon cancer with new rectal mass found at
colonoscopy. Restaging examination.
## FINDINGS:
The liver is diffusely hypodense consistent with fatty deposition.
However, there is a focal 1.7 x 1.5 cm mass in segment VI (4:67). Only focal
fatty sparing is seen on . The hepatic and portal veins are
patent. The gallbladder, pancreas, spleen, and adrenals are normal. The
kidneys enhance symmetrically and excrete contrast without evidence of
hydronephrosis or mass. The stomach and small bowel are unremarkable. There
is no portacaval, mesenteric, or retroperitoneal lymphadenopathy. There is no
free air or free fluid.
## CT PELVIS:
The appendix is normal. There are scattered diverticula
throughout the colon. Circumferential mucosal thickening in the rectum is
just adjacent to the anastomotic sutures (4:123). There are no pathologically
enlarged pelvic lymph nodes by size criteria. There is no pelvic free fluid.
The seminal vesicles and urinary bladder are normal. The prostate is mildly
enlarged.
## OSSEOUS STRUCTURES:
There is no lytic or blastic lesion worrisome for
metastasis.
## IMPRESSION:
1. New 1.7 cm hepatic lesion in segment VI is worrisome for metastasis and
amendable to biopsy.
2. Circumferential mucosal thickening of the rectum concerning for local
recurrence especially given findings on colonoscopy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18427420", "visit_id": "N/A", "time": "2142-08-21 10:12:00"} |
11459120-RR-73 | 239 | ## INDICATION:
female with urinary tract infection and PICC line
request.
## OPERATORS:
Drs. and , attending. Dr.
was supervising the procedure.
## PROCEDURE:
The patient was brought to the angiography suite and ultrasound
evaluation of the arm veins was performed bilaterally, demonstrating patent
brachial and basilic veins within the left arm, which was prepped and draped
in standard sterile fashion. A preprocedure timeout and huddle were
performed. Under sonographic guidance and following generous local lidocaine,
a micropuncture needle was used to access the left brachial vein. A
microcatheter wire was advanced through the needle, however, stopped 3-4 cm
central to the insertion site in the left brachial vein. Ultrasound evaluation
of the upstream veins demonstrated severe narrowing, likely venospasm.
Attempts were also performed of the left basilic vein with similar
cosequences. Access was obtained however, there was venospasm more centrally.
During both punctures, the patient expressed extreme pain and could not
tolerate any further manipulation. It was decided at this time to stop the
procedure due to the extreme pain and venospasm. Reattempt could be performed
either at higher level of anesthesia.
## IMPRESSION:
Unsuccessful attempt at placement of PICC line via the left
brachial and left basilic veins which were initially patent, however,
demonstrated venospasm. Due to patient's inability to tolerate due to the
extreme pain the patient expressed, it was decided to stop the procedure.
Reattempt can be performed with a higher level of anesthesia if necessary.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11459120", "visit_id": "23062717", "time": "2136-11-30 15:11:00"} |
10680436-RR-10 | 125 | ## EXAMINATION:
SHOULDER VIEWS NON TRAUMA LEFT
## INDICATION:
year old man with ALS with left shoulder pain// eval for
fracture eval for fracture
## FINDINGS:
There is no evidence of fracture or dislocation involving the glenohumeral or
acromioclavicular joints. There are mild degenerative changes involving the
acromioclavicular joint. There is no periarticular calcification or
radiopaque foreign body. There is an ovoid soft tissue density projecting
over the proximal humerus, which may be secondary to overlying soft tissues.
No radiopaque foreign body.
## IMPRESSION:
1. There is no acute fracture or dislocation. Mild degenerative changes
involving the acromioclavicular joint.
2. Nonspecific ovoid soft tissue density projecting over the proximal humerus,
seen on only one view. Dedicated humeral radiographs could be obtained for
further evaluation as clinically indicated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10680436", "visit_id": "N/A", "time": "2112-06-24 10:50:00"} |
13906745-RR-75 | 84 | ## CLINICAL INFORMATION:
Mental status changes post-brain surgery in .
.
## FINDINGS:
The patient is status post right parietal craniotomy. No evidence
of acute intracranial hemorrhage is seen. Gray-white matter differentiation
is preserved. Prominence of ventricles and sulci are again seen, consistent
with global atrophy. There is mucosal thickening/a possible small fluid level
in the left sphenoid sinus. The remainder of the paranasal sinuses is clear.
The mastoid air cells are clear. No acute fracture is seen.
## IMPRESSION:
No acute intracranial process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13906745", "visit_id": "N/A", "time": "2149-04-15 15:48:00"} |
18851806-RR-17 | 652 | MR OF THE ABDOMEN AND PELVIS:
## CLINICAL HISTORY:
Patient with known metastatic renal cell carcinoma, for
restaging.
## MR OF THE ABDOMEN:
There is diffuse fatty infiltration of the liver which is unchanged since the
prior study. A 2 mm cyst is noted in the posterior aspect of the right
hepatic lobe. No focal suspicious hepatic lesions are identified. There is no
intrahepatic or extrahepatic biliary dilatation. The gallbladder is
unremarkable.
The pancreas demonstrates diffuse homogeneous enhancement. There are several
focal tiny cystic dilatations of the side branches of the pancreatic duct
that are not significantly changed since the prior examination.
The spleen and adrenal glands are stable in appearance. The patient is status
post right nephrectomy. No focal masses or pathologically enlarged lymph
nodes are seen in the nephrectomy bed. The left kidney demonstrates normal
enhancement. There is no hydronephrosis. Several 2-3 mm cysts are seen in the
left kidney. No suspicious renal lesions are identified.
There are several small stable lymph nodes in the root of the mesentery. The
largest lymph node measures approximately 6 mm in short axis and 9 mm in long
axis.
There are multiple small paraaortic lymph nodes that not significantly changed
since the prior examination. The largest lymph node is seen in the left
paraaortic region and measures 5 mm in short axis and 13 mm in long axis
(series 200, image 73).
The abdominal aorta is normal in caliber and measures approximately 2.2 cm at
the level of the renal arteries. There is extensive atherosclerotic disease
involving the abdominal aorta with multiple areas of eccentric, irregular
plaque.
Note again is made of a 1.5 x 3.0 cm fluid- and gas-filled structure abutting
the proximal duodenum likely representing a diverticulum.
There is no ascites.
## MR OF THE PELVIS:
There has been overall decrease in size of several enlarged lymph nodes along
the left pelvic side wall. For example, the previously noted largest lymph
node designated as target #1 measures 0.7 cm in short axis and 1.0 cm in long
axis (series 400, image 43). This previously measured 1.9 x 1.4 cm. On the
current study the largest pelvic lymph node is now seen along the left pelvic
side wall and measures 07.x1.2 cm (Series 400, image 34). This lymph node
previously measured 0.9 x 1.5 cm.
Additional multiple small lymph nodes are noted along both pelvic side walls,
all of which measure less than 1 cm in short axis and overall appear less
conspicuous when compared with the prior examination. There is no significant
free pelvic fluid. No focal pelvic masses are identified. The urinary
bladder is unremarkable. There is sigmoid diverticulosis.
There is a large hernia with a wide neck containing multiple loops of bowel
protruding trought the lower abdominal wall. There is no dilatation of bowel
loops to suggest an element of bowel obstruction. The hernia is not
significantly changed when compared with the prior examination from .
The visualized osseous structures are unremarkable. Mild enhancement is
evident in soft tissues adjacent to both greater trochanters which may be
related to bursitis (left greater than right). Additionally, as before, there
is persistent soft tissue expansion, stranding and abnormal enhancement
between the left femur and the ischium seen on previous CT and MRI. It is
difficult to assess for interval change as this region was not completely
included on all sequences of this examination. A dedicated hip MRI is
recommended for further evaluation.
## IMPRESSION:
1. No evidence of tumor recurrence in the right nephrectomy bed.
2. Interval improvement in some of the left pelvic adenopathy with
others unchanged.
3. Soft tissue abnormality in the region of the left hip which is not
completely evaluated on this study. A dedicated hip MRI is recommended for
further evaluation.
4. Hepatic steatosis.
5. Large lower abdominal wall hernia containing bowel.
6. Colonic diverticulosis. Duodenal diverticulum.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18851806", "visit_id": "N/A", "time": "2139-07-26 08:24:00"} |
14400773-RR-33 | 127 | ## EXAMINATION:
KNEE (3 VIEWS) BILATERAL
## INDICATION:
year old woman with R>L knee pain. // extent of DJD
extent of DJD
## FINDINGS:
Right knee.
There is mild patellofemoral marginal spurring compatible with mild
degenerative change. The femorotibial joint spaces are preserved. No
concerning bone lesion. No acute fracture is seen. No effusion. Small
curvilinear density in the lateral tibial metaphysis of uncertain
significance, possibly sequela of prior injury.
Left knee.
Minimal patellofemoral marginal spurring is seen compatible with mild
degenerative change. No concerning bone lesion or acute fracture is seen. No
effusion.
## IMPRESSION:
Mild bilateral patellofemoral degenerative change.
Small curvilinear area of increased density in the lateral right tibial
metaphysis may be due to prior injury in the absence of current features
concerning for fracture clinically.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14400773", "visit_id": "N/A", "time": "2177-02-27 10:54:00"} |
12501533-DS-15 | 983 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
with a history of DMII and HTN who presents with rigors and
fever, transfer from OSH for evaluation. The patient was in his
usual state of health until this AM, when he developed rigors at
home and presented to for evaluation. In the ED, he was
noted to be febrile to 103.4, with labs notable for a WBC of
13.7and lactate of 2.4. Baseline Cr appears to be around 1.3,
1.5 at time of presentation. The patient complained of
additional symptoms, including mild headache and cough, but
denied any abdominal complaints including nausea, emesis,
abdominal pain.
On my evaluation, the patient confirms the above. He has not had
rigors or chills since this AM. He reports new constipation over
the past few months but continues to have a bowel movement every
days. He denies change in PO intake or weight loss. His last
colonoscopy was years ago and he does not recall any
significant findings. He denies a personal or family history of
inflammatory bowel disease. CT at the OSH showed a 5cm
inflammatory mass in the cecum.
He denies sick contacts, recent travel. He reports a bug bite a
few days prior on his left calf but denies any symptoms or
sequelae.
## PAST MEDICAL HISTORY:
DMII, HTN, HLD, prostate cancer
## PULM:
normal excursion, no respiratory distress
## ABD:
soft, NT, ND, no mass, no hernia
## EXT:
WWP, no CCE, 2+ B/L radial
## NEURO:
A&Ox3, no focal neurologic deficits
## PSYCH:
normal judgment/insight, normal memory, normal
mood/affect
## PERTINENT RESULTS:
07:15AM BLOOD -6.5 RBC-4.44* Hgb-13.5* Hct-40.6
MCV-91 MCH-30.4 MCHC-33.3 RDW-12.5 RDWSD-41.9 Plt
03:55PM BLOOD WBC-7.8 RBC-4.21* Hgb-12.8* Hct-38.3*
MCV-91 MCH-30.4 MCHC-33.4 RDW-12.7 RDWSD-42.1 Plt
12:26AM BLOOD WBC-8.3 RBC-4.46* Hgb-13.6* Hct-41.5
MCV-93 MCH-30.5 MCHC-32.8 RDW-13.1 RDWSD-44.4 Plt
12:26AM BLOOD Neuts-84.9* Lymphs-7.2* Monos-7.2
Eos-0.0* Baso-0.2 Im AbsNeut-7.04* AbsLymp-0.60*
AbsMono-0.60 AbsEos-0.00* AbsBaso-0.02
07:15AM BLOOD Glucose-150* UreaN-12 Creat-1.3* Na-143
K-3.8 Cl-104 HCO3-26 AnGap-13
03:55PM BLOOD Glucose-133* UreaN-15 Creat-1.3* Na-140
K-3.7 Cl-101 HCO3-26 AnGap-13
03:55PM BLOOD ALT-16 AST-11 AlkPhos-78 TotBili-0.6
12:26AM BLOOD ALT-20 AST-18 AlkPhos-87 TotBili-1.0
07:15AM BLOOD Calcium-9.0 Phos-2.4* Mg-1.9
12:26AM BLOOD Albumin-4.2 Calcium-9.6 Phos-2.5* Mg-1.6
12:39AM BLOOD Lactate-1.4
07:15AM BLOOD WBC-6.5 RBC-4.44* Hgb-13.5* Hct-40.6
MCV-91 MCH-30.4 MCHC-33.3 RDW-12.5 RDWSD-41.9 Plt
07:15AM BLOOD Glucose-150* UreaN-12 Creat-1.3* Na-143
K-3.8 Cl-104 HCO3-26 AnGap-13
03:55PM BLOOD ALT-16 AST-11 AlkPhos-78 TotBili-0.6
07:15AM BLOOD Calcium-9.0 Phos-2.4* Mg-1. with fever and rigors and new inflammatory mass of the
cecum. AT , the patient is clinically stable, AVSS with a
benign exam. Review of imaging shows inflammation of the cecum
with increased fluid density within the bowel wall,
although no free fluid, free air or enlarged lymph nodes. The
appendix is not definitively visualized but findings do not
appear consistent with abscess formation.
Given fevers patient was admitted to colorectal service and
treated for infectious process with bowel rest, resuscitation
and IV antibiotics. HD 2 patient was clinically doing well,
passing gas and having bowel movements. Patient was given a diet
which was tolerated well. Continued on antibiotics, Cipro and
Flagyl changed to oral antibiotics. Patient discharged home on
HD #2 with followup CT scan in 2 weeks and colonoscopy with GI
as an outpatient for definitive diagnosis
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO QAM
2. Losartan Potassium 25 mg PO QPM
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*18 Tablet Refills:*0
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Losartan Potassium 50 mg PO QAM
6. Losartan Potassium 25 mg PO QPM
7. Metoprolol Succinate XL 50 mg PO DAILY
## DISCHARGE DIAGNOSIS:
Terminal Ileitis of Unknown Etiology
## DISCHARGE INSTRUCTIONS:
Mr. ,
You were admitted to the hospital for a inflammation in your
bowels, the CT scan showed an Ileitis (inflammation of the end
of your small bowel). You were given bowel rest, intravenous
fluids, and IV antibiotics. Your inflammation subsequently has
improved after conservative management. You are tolerating a
regular diet, passing gas and your pain is controlled with pain
medications by mouth. You will still need a colonosco
If you have any of the following symptoms, please call the
office or go to the emergency room (if severe): increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or extended constipation.
Thank you for allowing us to participate in your care, we wish
you all the best!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12501533", "visit_id": "20514924", "time": "2117-12-29 00:00:00"} |
17522005-RR-25 | 166 | CT OF THE LUMBAR SPINE
## HISTORY:
Sudden onset of low back pain, point tenderness at thoracolumbar
junction.
## FINDINGS:
The lumbar spine alignment is maintained. There is no fracture or
subluxation. There is no significant central canal stenosis or neural
foraminal narrowing. Mild multilevel degenerative changes are seen, with
vacuum disc phenomenon at T12-L1 and L1-L2 levels. Schmorl's node is seen in
the inferior endplate of L4. CT is not able to provide intrathecal detail
comparable to MRI.
No abnormal fluid collection is seen in the posterior soft tissues. The
paraspinal soft tissues are unremarkable. There is a small subcentimeter left
renal lower pole hypodense lesion, likely cyst. Atherosclerotic calcification
noted at origins of celiac, superior mesenteric and renal arteries.
## IMPRESSION:
1. No fracture or subluxation in the lumbar spine.
2. No evidence for osteomyelitis or abscess. If clinically warranted, MRI may
be obtained to evaluate for discitis, osteomyelitis, or epidural abscess.
The results were discussed with resident at the time of study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17522005", "visit_id": "N/A", "time": "2143-03-19 15:28:00"} |
12174941-AR-47 | 124 | ## HISTORY:
Evaluate for subq air.
Please note that this is an addendum to this clip number. The existing report
under this number is for an unrelated study and an unrelated patient. A wet
reading for these films was provided at 7:03 p.m. on as indicated.
TWO VIEWS OF THE RIGHT FEMUR AND RIGHT LOWER LEG. There is probable diffuse
soft tissue swelling, best correlated with physical exam. No subcutaneous
emphysema is identified. No focal bone erosion, osteolysis, or sclerosis is
detected. Allowing for surrounding soft tissue swelling, no definite knee
effusion. Minimal degenerative changes of the right hip are noted. Limited
assessment of the right knee and ankle is grossly unremarkable.
## IMPRESSION:
Probable soft tissue swelling. No subcutaneous emphysema
identified.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12174941", "visit_id": "24793786", "time": "2145-03-18 18:16:00"} |
15053067-RR-72 | 123 | ## INDICATION:
year old woman with history of dysfunctional bleeding and
pelvic pain after trauma. // Evaluate for pelvic pathology
## FINDINGS:
The uterus is retroverted and measures 7.6 x 5.1 x 7.1 cm. A nabothian cyst
with internal debris is once again demonstrated appears similar. Uterine
fibroids are present. The largest fibroid is intramural on the right
measuring 3.6 x 2.5 x 2.6 cm, previously 3.9 x 3.6 x 3.5 cm. The endometrium
is mildly distorted due to fibroids however, where seen appears homogeneous
and measures 4 mm.
The ovaries are normal. There is no free fluid.
## IMPRESSION:
1. Fibroid uterus. Similar to prior exam.
2. Endometrial distortion due to fibroids.
3. Normal ovaries.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15053067", "visit_id": "N/A", "time": "2132-08-15 13:42:00"} |
18793288-RR-33 | 270 | ## INDICATION:
year old man with colon cancer in remission // eval for
recurrent colon cancer
## CT ABDOMEN:
For full description of the lung bases please see chest CT report
from the same day. The visualized portions of the heart pericardium are
normal. The liver enhances homogeneously and there is a subcentimeter
hypodense lesion on series 2, 59. This is not definitely previously noted
but is too small to characterize The hepatic and portal veins are patent. The
gallbladder is contracted. , the pancreas, spleen, and adrenals are normal.
The kidneys enhance symmetrically and excrete contrast without evidence of
hydronephrosis or mass. An extrarenal pelvis is noted in the left kidney.
The stomach and small bowel are unremarkable. There is no portacaval,
mesenteric and retroperitoneal lymphadenopathy. There is no free air or free
fluid.
## CT PELVIS:
The appendix is normal. The patient is status post right
hemicolectomy, the rectum, urinary bladder and are normal. There is no pelvic
lymphadenopathy or free fluid.
## OSSEOUS STRUCTURES:
There is no lytic or blastic lesion worrisome for
malignancy. There is a sclerotic lesion in in the right iliac wing on series
2, 96. Is stable and most consistent with a bone island. A similar focus
is seen in the right ischial tuberosity on series 2, 132. Again this is
stable.
## IMPRESSION:
1. 0.5 cm hypodense lesion in segment 2 of the liver is too small to
characterize and not definitely previously seen, which may be due to small
size of the lesion, a new lesion cannot be excluded however. This could be
further evaluated with MRI. Alternatively close attention on follow-up is
recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18793288", "visit_id": "N/A", "time": "2173-02-16 14:25:00"} |
16491344-DS-13 | 1,289 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
neurogenic claudication, LLE weakness
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
-L2-S1 LAMINECTOMIES with Dr.
of Present Illness:
Mr. is a pleasant gentleman who is seen today
with complaints of neurogenic claudication along with left lower
extremity radiculopathy along L4 dermatome with the foot drop.
Examination shows presence of left-sided tibialis anterior and
weakness which is and numbness along L4 and L5
dermatome. He is unable to walk on the heels. Straight leg
raising test is negative. His MRI shows presence of severe
spinal stenosis from L2-L5 and moderate bilateral lateral recess
stenosis at L5-S1. Considering his symptoms and presence of foot
drop Dr. like to offer treatment in the form of
surgery which would include L2-S1 laminectomy.
## PAST MEDICAL HISTORY:
Past medical history is positive for Guillain-Barré syndrome,
hypertension, COPD, type 2 diabetes, history of colon cancer
Past surgical history is positive for colonectomy and knee
replacement
## MEDICATIONS:
Xarelto 20 mg once a night
2. Simvastatin 40 mg once a night
3. Metoprolol succinate 50 mg oral tablet extended release once
a day
4. Digoxin 125 mg oral tablet
5. Tramadol hydrochloride 50 mg tablet 1 p.o. nightly
Metformin hydrochloride 500 mg oral oral tablet 2 tablets twice
daily
7. Pro-air HFA 108 mcg
8. Gabapentin 300 mg capsule
## FAMILY HISTORY:
Family history is positive for heart disease, COPD and liver
disease
## PHYSICAL EXAM:
Last 24h:No acute events overnight. HR remains stable 80's-90's.
## PE:
VS99.0 PO 104 / 62 R Lying 86 18 93 Ra
NAD, A&Ox4
nl resp effort
RRR
HVAC 40cc, d/c'd. dsg changed with mepilex ag
## SENSORY:
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
## :
Na: 139 (New reference range as of : K: 4.1 (New reference range as of : Cl: 99
## :
Glucose: 125* (If fasting, 70-100 normal, >125
provisional diabetes)
## A/P:
with neurogenic claudication and LLE radiculopathy with
severe spinal stenosis L2-S1. Now s/p L2-S1 LAMINECTOMIES
with Dr. . Post op course complicated by afib rvr 160s on
this is now resolved with stable vitals. HR remains
80's-90's. We will restart Plavix today now that his drain has
been removed. evaluation today for discharge to home with
services REHAB.
## ACTIVITY:
as tolerated, no lifting, twisting or bending,
consult
## ABX:
ancef x24 h post op
## ANALGESIA:
oxycodone, diazepam PRN, Tylenol, gabapentin
## DISPO:
evaluation for discharge to home with services
REHAB.
## FOLLOW-UP:
in Spine Clinic in 2 weeks
## BRIEF HOSPITAL COURSE:
Patient was admitted to the Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.
Post op course complicated by afib rvr 160s on Home
digoxin and metoprolol were restarted and was given one dose of
IV metoprolol with moderate effect. NS was given and HR
improved to mid 80's. This is now resolved with stable vitals.
HR remains 80's-90's. We will restart Plavix today now that his
drain has been removed. Lisinopril was held due to normotension
post op.
Hospital course was otherwise unremarkable.On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
## MEDICATIONS ON ADMISSION:
Simvastatin
Metoprolol
Digoxin
Gabapentin
Glimeperide
Lisinopril
Metformin
Xarelto
Simvastatin
Tramadol
Spiriva
Vitamin B12, Folic Acid
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. Diazepam 5 mg PO BID:PRN Pain, Spasm
may cause drowsiness
RX *diazepam 5 mg 1 tablet by mouth twice a day Disp #*30 Tablet
## REFILLS:
*0
3. Docusate Sodium 100 mg PO BID
please take while taking narcotics
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
4. OxyCODONE (Immediate Release) mg PO Q4H:PRN Pain -
Moderate
please do not operate heavy machinery, drink alcohol or drive
RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours
Disp #*65 Tablet Refills:*0
5. Cyanocobalamin 100 mcg PO DAILY
6. Digoxin 0.125 mg PO DAILY Home Dose
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 900 mg PO TID Home Dose
10. Lisinopril 10 mg PO DAILY Home Dose
Please hold off on restarting this medication until you follow
up with your pcp
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Rivaroxaban 20 mg PO DAILY
restart on . Tiotropium Bromide 1 CAP IH DAILY
## DISCHARGE DIAGNOSIS:
1. L2 to S1 lumbar spinal stenosis.
2. Neurogenic claudication.
3. Bilateral lower extremity radiculopathy, left more than
right.
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Lumbar Decompression Without Fusion
You have undergone the following operation: Lumbar Decompression
Without Fusion
## IMMEDIATELY AFTER THE OPERATION:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without moving around.
Rehabilitation/ Physical times a
day you should go for a walk for minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet:Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace, this brace is to be worn when you are
walking.You may take it off when sitting in a chair or lying in
bed.
## WOUND CARE:
Remove the dressing in 2 days.If
the incision is draining cover it with a new sterile dressing.If
it is dry then you can leave the incision open to the air.Once
the incision is completely dry (usually days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Cover it with a sterile
dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on 2.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
## FOLLOW UP:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your incision,
take baseline X-rays and answer any questions.We may at that
time start physical therapy.
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16491344", "visit_id": "26442039", "time": "2169-03-10 00:00:00"} |
12179055-RR-36 | 469 | ## INDICATION:
Acute on chronic kidney disease, needs tunneled HD line.
## OPERATORS:
Dr. , Dr. , and Dr. .
## ANESTHESIA:
Moderate sedation was provided by administering divided doses of
fentanyl and Versed throughout the total intraservice time of 47 minutes
during which time, the patient's hemodynamic parameters were continuously
monitored. Total fentanyl dose was 150 mcg. Total Versed dosage was 2 mg.
## PROCEDURE:
After the risks and benefits of the procedure were explained to
the patient, written informed consent was obtained. The patient was brought
to the angiography suite and placed supine on the imaging table. The left
neck and chest were prepped and draped in the usual sterile fashion. A
preprocedure timeout and huddle were performed per protocol.
Under ultrasound guidance, the patent left internal jugular vein was accessed
with a micropuncture needle. Hard copy ultrasound images were obtained. A
microwire was then advanced through the micropuncture needle, into the
superior vena cava under fluoroscopic guidance. A small skin incision was
made at the venipuncture site. The needle was then exchanged for a
micropuncture sheath. The inner dilator and microwire were removed and a
wire was advanced into the right atrium. This was used to measure the
appropriate catheter length. The wire was then advanced into the
inferior vena cava. The wire and sheath were then secured to the overlying
drapes.
Attention was then turned towards creating the chest wall tunnel. Appropriate
access site was marked, and the length of the planned tract was anesthetized
with 1% lidocaine and epinephrine. A small skin incision was then made at the
exit site. A 27-cm tip-to-cuff hemodialysis catheter was then attached to the
tunneling device and tunneled from the access site in the left chest wall to
the venipuncture site in the left neck. The cuff was then positioned in the
mid portion of the tract.
Attention was then returned to the left internal jugular venipuncture site.
Over the wire, the micropuncture sheath was removed and the tract was
progressively dilated to 14 , followed by insertion of a peel-away
sheath. The wire and inner dilator were then removed, and the hemodialysis
catheter was advanced through the peel-away sheath into the final position
with tip in the upper right atrium. The peel-away sheath was then removed.
Final spot fluoroscopic image of the chest confirmed appropriate catheter
position. The catheter was then sutured to the skin with 0 silk sutures and
the incision over the venipuncture site was closed with absorbable sutures. A
sterile dressing was applied. The patient tolerated the procedure and there
were no immediate post-procedure complications.
## IMPRESSION:
Successful placement of a tunneled hemodialysis catheter from a
left internal jugular approach. The catheter length is 27-cm tip-to-cuff.
The tip is in the upper right atrium. The catheter is ready to use.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12179055", "visit_id": "26018138", "time": "2162-12-06 07:37:00"} |
16930174-RR-89 | 119 | ## DOSE:
Total DLP: 1783 mGy-cm
## FINDINGS:
The trachea enhances homogeneously. There is no axillary, supraclavicular,
mediastinal, or hilar lymphadenopathy.
The heart is normal size. No significant coronary calcifications appreciated.
There is no pericardial effusion. The great vessels are within normal limits.
The airways are patent to subsegmental level. Mild biapical scarring and a 5
mm left apical nodule (5:42) are stable since . No new pulmonary
nodules concerning for malignancy are identified. No pleural effusion or
pneumothorax.
No lytic or sclerotic osseous lesion concerning for malignancy identified.
## IMPRESSION:
1. No evidence of intrathoracic metastatic disease.
2. Please refer to separately dictated CT abdomen and pelvis report from the
same day for full description of subdiaphragmatic findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16930174", "visit_id": "N/A", "time": "2192-09-13 10:55:00"} |
14522429-DS-6 | 1,156 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Aortic Valve replacement (25mm and
ascending aorta replacement (28mm Gelweave graft)
## HISTORY OF PRESENT ILLNESS:
year old male with a history of bicuspid aortic valve and
aortic stenosis. He has been followed in the past with serial
echocardiograms but was lost to follow up until his recent
cardiology visit is . He has noted a slight decrease
in his exercise tolerance. Echocardiogram on
demonstrated a mildly dilated left ventricle with mild
concentric left ventricular hypertrophy. Estimated ejection
fraction was 45%. The aortic valve appeared bicuspid and was
moderately thickened. There was mild to moderate aortic
regurgitation. There was moderate aortic stenosis with an aortic
valve area of 1.3cm2. The aortic root and ascending aorta were
dilated, measuring 4.0cm and 4.9cm, respectively. CTA of the
chest was obtained to further evaluate the aortic .
The study demonstrated the ascending aorta at the sinus of
Valsalva was 54 x 47mm. The ascending aorta at the level of the
main pulmonary artery measured 53 x 47 mm.
## PAST MEDICAL HISTORY:
Aortic stenosis
Bicuspid aortic valve
Aortic aneurysm
Depression
Dysphagia
Elevated Liver Function Test
Hyperlipidemia (pt denies)
Hypertension (pt denies)
Impaired Glucose Tolerance
Myocardial Infarction - clean coronaries on cath
Obesity
Osteoartritis
Total Knee Replacement (right),
Appendectomy, remotely
## FAMILY HISTORY:
Premature coronary artery disease- Mother - died of myocardial
infarction at age , Father - died of liver disease ,
Brother - recent myocardial infarction, age
## GENERAL:
NAD, appears stated age
## NECK:
Supple [x] Full ROM [] JVD []
## CHEST:
Lungs clear bilaterally [x]
## HEART:
RRR [x] Irregular [] Murmur [] Grade
## EXTREMITIES:
Warm [x], well-perfused [x], Edema - none
## VARICOSITIES:
None [] Minimal varicosities
## UNDERLYING MEDICAL CONDITION:
year old man S/P.CABG
## REASON FOR THIS EXAMINATION:
yo M S/P.CABG. Please evaluate for any progression in left
apical
pneumothorax noted on CXR on
Final Report
PA AND LATERAL CHEST,
## IMPRESSION:
PA and lateral chest compared to :
No pneumothorax, and only small bilateral pleural effusions
layering
posteriorly. Heart is mildly enlarged and the widening of the
mediastinum are stable compared to the two prior chest
radiographs. It would be important to see if the mediastinum
was widened preoperatively to see if there is need to
investigate the possibility of adenopathy.
## BRIEF HOSPITAL COURSE:
Mr. was a same day admit and was brought directly to the
operating room where he underwent an aortic valve replacement
and ascending aorta replacement. Please see operative note for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. He was
transferred to the floor on POD#1 and started on coumadin. His
chest tubes were discontinued and on POD#2 his epicardial pacing
wires were discontinued as well. He went into atrial
fibrillation on POD# 3 and was started on amiodorone and his
beta blocker was increased. He converted to sinus rhythm and
continued to progress with physical therapy. He started on a
heparin drip on POD #3 and it was discontinued on POD#4. He was
discharged to home in stable condition on POD#5 with appropriate
follow up appointments.
## MEDICATIONS ON ADMISSION:
Aspirin 81mg daily
Atenolol 50mg HS
Lisinopril 5mg HS
Metformin 250mg daiy HS (not ER)
Simvastatin 40mg SH
Trazodone 25mg HS
Venlafaxine XR 75mg daily
Omeprazole 20 mg BID
Multivitamin 1 tablet daily
## DISCHARGE MEDICATIONS:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,chewable(s) by mouth once a day Disp
#*30
## TABLET REFILLS:
*0
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed by
mouth once a day Disp #*30 Capsule Refills:*0
4. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*0
5. TraZODone 100 mg PO HS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
6. Venlafaxine XR 75 mg PO DAILY
RX *venlafaxine 75 mg 1 tablet(s) by mouth once a day Disp #*30
## CAPSULE REFILLS:
*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
8. Metoprolol Tartrate 75 mg PO TID
RX *metoprolol tartrate 50 mg 1.5 tablet(s) by mouth three times
a day Disp #*70
## TABLET REFILLS:
*0
9. Oxycodone-Acetaminophen (5mg-325mg) TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg tablet(s) by mouth
every six (6) hours Disp #*50
## TABLET REFILLS:
*0
10. Warfarin 2.5 mg PO ONCE Duration: 1 Dose
RX *warfarin 2.5 mg 1 tablet(s) by mouth once a day Disp #*50
## TABLET REFILLS:
*0
11. MetFORMIN (Glucophage) 250 mg PO DAILY
RX *metformin 500 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*20
## TABLET REFILLS:
*0
12. Amiodarone 400 mg PO BID Duration: 3 Days
400 mg PO daily for 7 days after dose completed, then decrease
dose to 200 mg PO daily.
RX *amiodarone 200 mg 2 tablet(s) by mouth once a day Disp #*40
## TABLET REFILLS:
*0
13. Furosemide 40 mg PO DAILY Duration: 10 Days
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
14. Potassium Chloride 40 mEq PO DAILY Duration: 10 Days
RX *potassium chloride 20 mEq 2 by mouth once a day Disp #*10
Tablet Refills:*0
15. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
## DISCHARGE DIAGNOSIS:
Aortic stenosis, Bicuspid aortic valve and aortic aneurysm s/p
Aortic valve replacement and ascending aorta replacement
Past medical history:
Depression
Dysphagia
Elevated Liver Function Test
Hyperlipidemia (pt denies)
Hypertension (pt denies)
Impaired Glucose Tolerance
Myocardial Infarction - clean coronaries on cath
Obesity
Osteoartritis
Total Knee Replacement (right),
Appendectomy, remotely
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
## INCISIONS:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
## FEMALES:
Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns . Answering service will contact on call
person during off hours**
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14522429", "visit_id": "29242237", "time": "2146-03-03 00:00:00"} |
18843156-RR-26 | 505 | ## HISTORY:
History of piriform sinus surgery with retroesophageal abscess,
status post incision and drainage. Evaluate for extension of abscess into the
mediastinum.
## FINDINGS:
The visualized portion of the thyroid gland is unremarkable. The thoracic
aorta is normal in caliber. Scattered aortic and coronary artery
calcifications are seen. The right ventricular outflow tract is normal in
caliber. The heart is mildly enlarged. There is a trace pericardial. There
are no pathologically enlarged mediastinal, hilar, or axillary lymph nodes.
Minimal pneumomediastinum and surrounding fat stranding is seen within the
right posterior aspect of the middle mediastinum, directly to the right of the
mediastinal drain, which terminates approximately 4 cm above the level of the
carina (2: 14). The degree of mediastinal air, fluid, and fat stranding has
dramatically decreased compared to the recent outside hospital neck CT dated
. There is no residual drainable fluid collection.
The endotracheal tube is appropriately positioned, ending 3.7 cm above the
level of the carina. The tracheobronchial tree is patent to the segmental
level bilaterally. Mild to moderate bilateral lower lobe compressive
atelectasis relates to small bilateral non-hemorrhagic pleural effusions.
There is also bandlike atelectasis extending across both the right upper and
lower lobes as well mild dependent bilateral upper lobe atelectasis. There
is minimal left apical scarring versus a 5 mm nodule (4: 33). There is also a
7 mm right middle lobe nodule (4:129).
This study was not optimized for evaluation the subdiaphragmatic contents.
Limited assessment of the upper abdomen is unremarkable.
## SOFT TISSUES AND BONES:
Subcutaneous air along the right anterior aspect of
the thorax has decreased compared to the outside hospital study from . There has also been a marked decrease in the degree of
subcutaneous air along the right greater than left cervical regions,
incompletely imaged on this dedicated chest CT.
A relatively well-defined 12 mm lucency is seen within the T3 vertebral body
(602: 80). There is no associated cortical erosion or loss of the vertebral
body height. Marked multilevel degenerative changes are seen throughout the
thoracic spine.
## IMPRESSION:
1. Marked decrease in degree of pneumomediastinum and mediastinal
fluid/fat-stranding compared to the outside hospital CT from ,
status post incision and drainage. No remaining drainable fluid collection.
2. Small bilateral moderate pleural effusions with associated mild to
moderate lower lobe compressive atelectasis.
3. 7-mm right middle lobe nodule warrants CT follow-up in 6 months if this
patient is a non-smoker and has no history of malignancy. Otherwise, a
follow-up CT in 3 months is recommended. An additional 5-mm left apical
nodular opacity could be reassessed on this follow-up study, although is
likely an area of focal scarring.
4. Nonspecific 12 mm lucent lesion within the T3 vertebral body, incompletely
assessed on the current study, but not a typical appearing hemangioma.
Further assessment should be performed with MRI.
5. Mild cardiomegaly.
Findings were discussed with Dr. by Dr. at 4:41 p.m. via
telephone on the day of the study, 20 minutes after discovery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18843156", "visit_id": "23556893", "time": "2118-02-13 14:51:00"} |
16420873-RR-29 | 137 | ## HISTORY:
female with advanced maternal age, history of mild fetal
ventriculomegaly, and size greater than dates.
## FETAL BIOPHYSICAL PROFILE WITH MEASUREMENTS:
LMP was on .
There is a single live intrauterine gestation. The fetus is in cephalic
position. The placenta is anterior, without evidence of previa. There is a
normal amount of amniotic fluid, with AFI of 19.1 cm. S/D ratios were normal
at 2.0. The BPP score was . Fetal heart rate was 140 BPM. The estimated
fetal weight is 3689 grams, which corresponds to 87th percentile based on
of which was confirmed by early ultrasound. No fetal morphologic
abnormalities are detected on the limited views of the fetal anatomy; the
intracranial structures are not well seen secondary to late gestation and
fetal position.
## IMPRESSION:
Appropriate interval growth. BPP and AFI of 19.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16420873", "visit_id": "N/A", "time": "2117-08-21 14:05:00"} |
12604599-RR-11 | 331 | ## HISTORY:
female with history of right vertebral dissection on
with reported right cerebellar stroke at that time; six days ago had
right PCA territory stroke. Evaluate for interval change.
## MRI BRAIN WITHOUT CONTRAST:
There is restricted diffusion in the
posterolateral quadrant of the medulla, the right inferior cerebellar
peduncle, and the right cerebellar tonsil (8:4, 8:5). These are quite focal
in the right paramedian region, with sparing of the remainder of the posterior
fossa. There is no correlate of low signal on ADC, and these regions
demonstrate hyperintensity on FLAIR imaging, suggesting early subacute
duration. In the mid-right cerebellar hemisphere, a punctate focus of
hyperintensity seen on T2 and FLAIR imaging (4:3, 3:3) has no correlate on DWI
or ADC, and is consistent with the reported recent right cerebellar CVA.
Although only sagittal T1-weighted imaging was obtained, in the right
parasagittal sections, the distal right vertebral artery demonstrates high
signal intensity (2:13, 2:12). This correlates with lack of flow-void in this
segment, as well as non-opacification of the right V3 and V4 segments of the
right vertebral artery seen on CTA the previous evening. No dedicated MRA
study was performed.
The remaining vascular flow voids appear unremarkable. There is no intra- or
extra-axial hemorrhage. The ventricles and sulci are normal in size and
configuration for the patient's age.
Visualized paranasal sinuses and soft tissues are unremarkable.
## IMPRESSION:
1. Early subacute infarction in the distribution of the right territory,
consistent with distal embolization from known right vertebral dissection.
2. Loss of normal V3 and V4 segmental flow-voids of right vertebral artery,
with high signal intensity within this segment on T1-weighted imaging,
consistent with dissection and intramural hematoma (and/or slow intraluminal
flow).
3. Older right cerebellar hemispheric lacunar infarction, likely related to
prior embolic event.
## COMMENT:
If outside cross-sectional imaging is obtained and uploaded into
PACS, a comparison can be made and an addendum issued.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12604599", "visit_id": "21716831", "time": "2114-02-21 08:17:00"} |
19299056-RR-62 | 361 | ## INDICATION:
year old man with AML s/p alloSCT with subacute confusion, new
fevers.// Eval for intracranial infectious or malignant process
## FINDINGS:
Motion artifact degrades the diagnostic quality of the imaging. The T2
imaging is rendered uninterpretable. The T1 MP rage imaging is moderately
compromised.
Small solid nodular, and rim enhancing lesions with associated FLAIR
abnormality are seen in the bilateral cerebral hemispheres. 1 lesion is in
the posterior aspect of left medial orbital gyri (series 7, image 11),
enhancement is measuring 7 mm in diameter demonstrating rim enhancement
postcontrast. Additional lesion abutting lateral aspect of the probable left
postcentral gyrus focus of enhancement measures 0.3 cm, adjacent or coursing
artery.
Additional small enhancing lesion involving posteromedial right temporal lobe,
superior left frontal gyrus, on the upper margin of the left insula.
Two 3 mm foci of high signal on diffusion weighted imaging present in the
right middle frontal gyrus, right occipital lobe, without definite enhancement
Above lesions are new since MRI brain .
Generalized cerebral atrophy with ex vacuo dilatation of the ventricular
system. The craniocervical junction is normal. The pituitary is normal. The
dural venous sinuses are patent. Mild chronic small vessel ischemic changes.
Fairly diffuse and heterogenous decrease in bone marrow signal intensity in
keeping with history of AML.
## IMPRESSION:
1. Multiple small foci of enhancement involving bilateral cerebral
hemispheres, 1 has rim enhancement, largest lesion measures 0.7 cm. These
lesions have developed since , and appearance favors
infectious process, possibly from systemic disseminated infection, with
possible component of septic emboli. Some of the tiny lesions may represent
subacute infarcts. Metastatic disease, lymphoproliferative disorder is less
likely. No abscess.
2. 1 small nodular enhancement at left inferior parietal lobe is adjacent to a
coursing artery, mycotic aneurysm cannot be excluded, MRA brain recommended
further evaluation.
## RECOMMENDATION(S):
MRA brain without contrast to cover entire convexity.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 9:38 am, 10 minutes after
discovery of the findings.
The findings were discussed with , M.D. by
, M.D. on the telephone on at 10:02 pm, 10 minutes after
discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19299056", "visit_id": "26714126", "time": "2187-04-11 18:52:00"} |
17193983-DS-3 | 591 | ## CHIEF COMPLAINT:
partial amputation right digits s/p lawnmower
accident
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
s/p right and digits washout, revisional amps, and
closure
## HISTORY OF PRESENT ILLNESS:
Pt is an transfered from with traumatic
partial amputations after lawnmower accident today at 3pm. Pt
states that he was mowing the lawn this afternoon, fell
backwards
after tripping and right foot was runover by lawnmower. He was
taken to where he was given tetanus, ancef and
dilaudid for pain. He was then transfered to for podiatry
evaluation. He states that he has been NPO since 10am today for
a
cavity removal. Pt was taken to the OR for washout, debridement,
revision of traumatic amputations and closure. He will be
admitted post-op for pain control, abx. Pts mother was present
during HPI
## INTEGUMENT:
Open traumatic partial amputations at Right distal hallux and
distal to PIPJ with obvious comminution and skin loss
dorsally
## PATHOLOGY TISSUE:
RIGHT FOOT BONE AND SOFT: Pending
RADIOLOGY
Radiology FOOT AP,LAT & OBL RIGHT: There has been
amputation of the first digit at the level of the mid distal
phalanx and of the second digit at the level of the distal
aspect of the middle phalanx. Several osseous fragments are
noted about the amputation sites. No fracture or dislocation is
otherwise visualized elsewhere within the foot. There are no
radiopaque foreign bodies.
Radiology FOOT AP,LAT & OBL RIGHT: Three views of the
right foot show surgical amputation of the first and second toes
at or near the PIP joints since preoperative exam
(one day ago). Exam otherwise normal.
## BRIEF HOSPITAL COURSE:
transfered from to BI ED with Right foot
traumatic and digit amputations following lawnmower
accident at 3pm on . Pt had been NPO since 10am that
morning. He was given tetanus, ancef and pain medication prior
to transfer. In BI ED, he was given gentamycin and ancef. Foot
xray revealed traumatic amputation with comminution to mid
distal phalanx of Right hallux and to middle phalanx digit.
He was continued on antibiotics and taken to OR that night for
washout, revision amputation right digits and closure.
He tolerated the procedure and anesthesia well. See operative
report for further details.
Antibiotics were continued x 24hrs. He was started on Toradol
and PO pain meds with pain well controlled. He was instructed to
remain NWB RLE.
On onsult was obtained and pt was cleared for home
NWB RLE with crutches. A CBC was noted to be WNL. Pain was well
controlled with PO dilaudid
On , pt was DC home with PO pain medication and toradol. He
was instructed to remain NWB RLE in crutcheds. He is to leave
dressing intact f/u appointment in 1 week
## DISCHARGE MEDICATIONS:
1. Hydromorphone 2 mg Tablet Sig: Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Ketorolac 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Traumatic partial amp right digit secondary to
lawnmower accident.
## DISCHARGE INSTRUCTIONS:
Please resume all pre-admission medications. If you were given
new prescriptions, please take as directed.
Keep your dressing clean and dry at all times. You do not need
any dressing changes.
You can be NONWEIGHT BEARING on your RIGHT foot in a surgical
shoe.
Call your doctor or go to the ED for any increase in RIGHT foot
redness, swelling or purulent drainage from your wound, for any
nausea, vomiting, fevers greater than 101.5, chills, night
sweats or any worsening symptoms.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17193983", "visit_id": "27934552", "time": "2166-01-28 00:00:00"} |
19244736-RR-37 | 83 | ## INDICATION:
year old woman with L distal radius fx s/p reduction **keep in
splint** // assess fx
## FINDINGS:
There is a cast overlying the left forearm limiting evaluation of fine bone
and soft tissue detail. There is redemonstration of a fracture through the
distal radius with dorsal tilting of the distal fracture fragments. No new
fracture is seen. There is dorsal tilting of the lunate.
## IMPRESSION:
Distal radial fracture, not significantly changed from the prior exam.
Dorsal tilting of the lunate.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19244736", "visit_id": "N/A", "time": "2157-01-14 13:56:00"} |
14120635-RR-188 | 229 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
63 with recent intraparenchymal, subarachnoid, intraventricular
hemorrhage in, now with new bradycardia, hypotension, hypothermia // f/u
interval change
## DOSE:
Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 5.4 s, 19.4 cm; CTDIvol = 49.1 mGy (Head) DLP =
954.0 mGy-cm.
Total DLP (Head) = 954 mGy-cm.
## FINDINGS:
There is no evidence of new hemorrhage or infarct. There has been continued
evolution of the previously identified intraparenchymal, subarachnoid, and
intraventricular hemorrhages with mild redistribution of blood products.
Bilateral hypoattenuating subdural collections appear stable to minimally
decreased in comparison to 3 days prior. No mass-effect.
Periventricular and subcortical white matter hypodensities are nonspecific but
likely sequelae of chronic small vessel ischemic disease. A hypodensity in
the right corona radiata (03:19) is stable and consistent with a prior lacunar
infarct.
There is no evidence of fracture. Partial opacification of the mastoid air
cells is unchanged, possibly due to prolonged supine position positioning.
The visualized portion of the paranasal sinuses and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
## IMPRESSION:
1. Stable to minimally decreased subdural fluid collections, possibly
hygromas. No mass-effect.
2. No evidence of new hemorrhage or other acute intracranial abnormalities.
3. Continued evolution of intraparenchymal, subarachnoid, and intraventricular
hemorrhage as described above
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14120635", "visit_id": "24808740", "time": "2156-01-07 13:37:00"} |
19396598-RR-23 | 325 | ## EXAMINATION:
CT ABDOMEN PELVIS WITHOUT CONTRAST
## INDICATION:
year old woman with abdominal symptoms and decompensating
status who presented to ICU with hypotension, fatigue, presumed GI
process/bleed// r/o intrathoracic intrabdominal/pelvic process to explain
worsening status, weakness, malnutrition
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 9.1 s, 59.4 cm; CTDIvol = 10.5 mGy (Body) DLP = 619.4
mGy-cm.
2) Spiral Acquisition 2.9 s, 18.9 cm; CTDIvol = 5.3 mGy (Body) DLP = 96.9
mGy-cm.
Total DLP (Body) = 716 mGy-cm.
## LOWER CHEST:
Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
## HEPATOBILIARY:
The liver demonstrates homogeneous attenuation throughout. A
subcentimeter calcification is seen in the posterior right lobe, likely
representing a granuloma (05:56). There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is unremarkable.
## PANCREAS:
The pancreas is grossly unremarkable.
## SPLEEN:
The spleen is normal in size. There are scattered calcified
granulomas in the spleen.
## ADRENALS:
The bilateral adrenal glands are not well visualized.
## URINARY:
The kidneys are symmetric in size. No hydronephrosis or
nephrolithiasis.
## GASTROINTESTINAL:
The stomach is unremarkable. Small and large bowel loops
are normal in caliber.
## PELVIS:
The urinary bladder is unremarkable.
## REPRODUCTIVE ORGANS:
The uterus is not visualized. A 2.0 cm right adnexal
cyst is noted.
## LYMPH NODES:
No pathologically enlarged abdominopelvic lymph nodes.
## VASCULAR:
There is no abdominal aortic aneurysm. Severe, diffuse vascular
calcification is noted.
## BONES:
Bones are severely demineralized. There is no aggressive osseous
lesion or acute fracture.
## SOFT TISSUES:
There is anasarca of the body wall. Injection granulomas are
noted in the bilateral gluteal regions.
## IMPRESSION:
1. No acute findings or source of infection identified in the abdomen or
pelvis, within the limitations of an unenhanced study.
2. Anasarca of the body wall.
3. Please refer to the separate report of CT chest performed on the same day
for description of the thoracic findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19396598", "visit_id": "29760254", "time": "2137-02-08 11:59:00"} |
10669050-RR-47 | 393 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
year old woman with sq cell ca distal esophagus, cT2N1M0
completed pre-op chemo, RT had esophagectomy resection of
brain metastasis , post-op CK completed // Esophageal cancer
restaging, with PO and IV contrast
## ONCOLOGY 2 PHASE:
Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV contrast was
injected and the abdomen and pelvis were scanned in the portal venous phase,
followed by scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## LOWER CHEST:
Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
## HEPATOBILIARY:
The liver demonstrates unremarkable attenuation throughout.
Small area of hypodensity adjacent to the falciform ligament. Tthere is no
evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout and is mildly
atrophic, without evidence of focal lesions or pancreatic ductal dilatation.
There is no peripancreatic stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. There is a small accessory spleen.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
Patient is post esophagectomy and gastric pull-through.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The appendix is
normal.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The uterus and bilateral adnexae are unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. No evidence of malignancy or metastatic disease in the abdomen and pelvis.
2. Please refer to dedicated CT chest report of the same date for the
intrathoracic findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10669050", "visit_id": "N/A", "time": "2128-06-11 12:56:00"} |
16839169-RR-40 | 244 | ## HISTORY:
woman with unexplained tachycardia. Evaluate for PE.
## CHEST WITH CONTRAST:
A cardiac pacemaker is in position soft tissue of the
left anterior thorax. The tip terminates in the right ventricle anteriorly.
No pericardial effusions are present. Residual thymic tissue is noted in the
anterior mediastinum. The aorta is unremarkable with no evidence for
dissection thrombosis or significant mural calcification. The coronary
arteries are patent. No enlarged lymph nodes present in the right hilum. The
remaining left and right as well as segmental pulmonary arteries all widely
patent with no persistent intraluminal filling defect. No enlarged
mediastinal lymphadenopathy is identified no axillary adenopathy is present.
Nodular pleural thickening is noted in the left and right lung apices. No
discrete pulmonary nodules are identified. No areas of consolidation are
identified focal area of some ground glass opacities noted in the chest left
chest anteriorly which may represent some platelike atelectasis. This is best
shown on series 3 image 58. No pleural effusions are present. Platelike
atelectasis is also noted in the left lung base. This is best shown on series
3 image 81.
## BONE WINDOWS:
No concerning lytic or blastic abnormalities are seen in the
bones of the thorax.
## REFORMATTED SEQUENCES:
The obliques sagittal and axial as well as coronal
images demonstrate widely patent aorta and pulmonary arteries.
## IMPRESSION:
1. No acute aortic syndrome or pulmonary embolus.
2. Plate-like atelectasis in left lower lobe.
3. Residual thymic tissue in the anterior mediastinum.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16839169", "visit_id": "25428722", "time": "2152-10-30 21:29:00"} |
14478167-RR-98 | 311 | ## INDICATION:
w cirrhosis PSC s/p DDLT ( ) s/p re-do DDLT with
RNY HJ and kidney txp s/p washout/closure with redo RNYHJ, now with concern
for acute humoral rejection undergoing plasmapheresis // Please perform
cholangiogram through Roux tubeThank you!
## OPERATORS:
Dr. Interventional and Dr.
fellow performed the procedure. The
attending(s) personally supervised the trainee during any key components of
the procedure where applicable and reviewed and agrees with the findings as
reported below.
## CONTRAST:
10 ml of Optiray contrast
## PROCEDURE:
1. Hand injection cholangiogram via silastic pediatric feeding tube through
roux limb into the intrahepatic left bile duct.
## PROCEDURE DETAILS:
A scout image of the abdomen was obtained.
A hand injection of approximately 10 cc of dilute contrast was injected into
the silastic pediatric feeding tube coursing through the Roux limb into the
left intrahepatic bile ducts. Multiple fluoroscopic and spot radiographic
images of the abdomen were obtained.
## FINDINGS:
1. Silastic pediatric feeding tube courses from the Roux limb through the
choledochal jejunostomy into the left intrahepatic bile ducts.
2. Initial contrast injection demonstrates filling of the left and right
intrahepatic bile ducts and the common bile duct. There is contrast flowing
into the Roux jejunum limb. Contrast extravasation is noted at approximately
the level of the choledochojejunostomy, likely from the Roux limb.
3. Contrast fills both the right and left intrahepatic bile ducts.
## IMPRESSION:
1. Cholangiogram demonstrates contrast flow from the intrahepatic bile ducts,
through the choledochojejunostomy, and into the Roux jejunal limb with a large
bile leak/contrast extravasation at the level of the choledochal jejunostomy,
likely from the Roux limb.
2. Contrast fills both the right and left intrahepatic bile ducts.
These findings were discussed with Dr. the phone at the time of the
procedure, 4:10 p.m. on .
## RECOMMENDATION(S):
Noncontrast CT of the abdomen for better localization of
bile leak.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14478167", "visit_id": "N/A", "time": "2138-12-13 15:18:00"} |
16120968-RR-35 | 150 | ## INDICATION:
man with fall, syncope, evaluate for head bleed.
## FINDINGS:
There is no intra- or extra-axial hemorrhage, mass effect, edema,
or shift of normally midline structures. Bilateral periventricular white
matter hypoattenuation is again noted and likely reflects small vessel
ischemic changes. The ventricles and sulci are mildly prominent appropriate
for age-associated involutionary changes. There are no acute major vascular
territorial infarcts. The relative area of hypoattenuation in the left
cerebellum is also unchanged. The gray and white matter differentiation is
preserved. The (periapical) lucency in the right maxilla is again noted and
appears unchanged. Otherwise, the osseous and soft tissue structures are
unremarkable. Bilateral scleral bands are noted.
## IMPRESSION:
1. No acute intracranial process.
2. Unchanged lucency in the right maxilla, may be periapical. Correlate with
dental exam.
3. Stable small vessel ischemic changes in periventricular white matter and
area of hypoattenuation in the left cerebellum.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16120968", "visit_id": "N/A", "time": "2150-11-17 22:11:00"} |
10450914-DS-5 | 1,007 | ## HISTORY OF PRESENT ILLNESS:
Ms. is a yo F with PMH significant for asthma,
constipation, endometriosis, PID, head and neck cancer s/p
chemoradiation and g tube placement, and remote diagnostic
laparoscopy and open myomectomy who had acute onset of diffuse
sharp abdominal pain around 10PM last night after eating a
sandwich, and associated nausea and bloating. She did not take
any medication for the pain, and it increased in severity over
the next few hours, so she presented to the ED for evaluation.
Upon arrival to the ED, she began to have nonbloody emesis. Her
pain is now improved, s/p dilaudid. She has not passed flatus
since the pain began. Last bowel movement was 2 days ago, and
was normal. She has no shortness of breath or chest pain, no
fevers, chills, no urinary symptoms. She has never had pain like
this before, and no history of bowel obstructions.
## PAST MEDICAL HISTORY:
endometriosis
fibroids
asthma
constipation
head and neck cancer s/p chemotherapy and radiation
Pelvic inflammatory disease following IVF treatment
hiatal hernia
## PAST SURGICAL HISTORY:
Diagnostic laparoscopy
Open myomectomy
G tube placement
## FAMILY HISTORY:
Adopted. Son is healthy, yo.
## HEENT:
No scleral icterus, mucus membranes moist
## PULM:
Clear to auscultation b/l, No W/R/R
## ABD:
Soft, minimally distended, nontympanic, tender to palpation
in the LLQ, no rebound or guarding, hyperactive bowel sounds, no
palpable masses or hernias. Well healed infraumbilical scar.
Well-healed low transverse incision.
## EXT:
No edema, warm and well perfused
## HEENT:
No scleral icterus, mucus membranes moist
## CV:
RRR, No M/R/G, WWP
## PULM:
No W/R/C, normal WOB
## ABD:
Soft, non-distended, non-tender to palpation, no rebound or
guarding.
## FINDINGS:
The lungs are well-expanded and clear. The cardiomediastinal
silhouette is unremarkable. The hilar pleural surfaces are
normal. There is no subdiaphragmatic free air.There is a small
hiatal hernia.
## CT A/P IMPRESSION:
1. Findings compatible with small bowel obstruction, with
transition point in the right lower quadrant.
2. Moderate volume abdominopelvic free fluid.
3. Extensive diverticulosis, with no evidence of diverticulitis.
4. Moderate hiatal hernia.
5. Fibroid uterus.
6. Prominent pancreatic duct, with no obstructing lesion
identified.
## BRIEF HOSPITAL COURSE:
The patient presented to Emergency Department on . Pt was
evaluated by ACS upon arrival to ED. Given findings on history,
exam, and imaging suggestive of SBO, the patient was admitted to
for observation and monitoring. She was managed
conservatively with bowel rest and IV fluids. She responded
well and had return of bowel function HD 1. By HD 2 she was
tolerating a regular diet.
## NEURO:
The patient was alert and oriented throughout
hospitalization.
## CV:
The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
## PULMONARY:
The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
## GI/GU/FEN:
The patient was initially kept NPO on IV fluids. On
HD 1, the diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored
## ID:
The patient's fever curves were closely watched for signs of
infection, of which there were none.
## HEME:
The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
## PROPHYLAXIS:
dyne boots were used during this stay and was
encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
On CT patient has a prominent pancreatic duct, measuring up to 5
mm in diameter, no evidence of focal lesion identified and no
peripancreatic stranding. She should follow-up with a
gastroenterologist for possible MRCP and/or ERCP to rule-out
neoplastic process. Her PCP's office, . at
, was contacted with this information on at
10:58am.
## MEDICATIONS ON ADMISSION:
Colace
senna
occasional claritin, zyrtec
asthmanex qd
albuterol prn
## DISCHARGE MEDICATIONS:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Docusate Sodium 100 mg PO BID
do not take if you are having diarrhea or nausea/vomiting
3. Senna 8.6 mg PO BID:PRN constipation
do not take if you are having diarrhea or nausea/vomiting
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to with a
small bowel obstruction. You were managed conservatively with
bowel rest and IV fluids. You are recovering well and are now
ready for discharge. Please follow the instructions below to
continue your recovery:
Re-introduces foods slowly into your diet. Eat small, frequent
meals.
Please follow-up with your primary care physician and
gastroenterologist about the finding on CT of a prominent
pancreatic duct which needs further investigation.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10450914", "visit_id": "27558167", "time": "2183-06-15 00:00:00"} |
16917124-DS-8 | 1,213 | ## CHIEF COMPLAINT:
Oozing and erythema at pacemaker site
## HISTORY OF PRESENT ILLNESS:
This year old patient has a history of sick sinus syndrome
and persistent atrial fibrillation, s/p VVIR PPM generator
change on who is admitted today for pacer pocket site
drainage and erythema. Patient was discharge from the hospital
on on Keflex PO TID for total of 5 days. Two days
ago, she noticed a small amount of brownish, non-purulent
drainage from the site. She also noted the site getting slightly
erythmatous. She then went to an OSH ER yesterday to get the
steri-strips removed and she noticed more brownish drainage
today. She states to be feeling well and denies having any
fever, chills, malaise, shortness of breath, pain in site or any
other complaints since the procedure on .
She is underwent pacemaker placement initially in .
Her pacemaker was noted to be at ERI in and has
now
reverted to VVI mode at 65 bpm. She was referred for elective
generator change. She was discharge home on with 5 day
course of Keflex
In our ER her BP at arrival was 181/76, HR 85, Temp 97.6. She
had blood cultures x 2 and wound site cultures. She was started
on Vancomycin 1000mg IV.
.
## PAST MEDICAL HISTORY:
- atrial fibrillation (on warfarin) s/p pacemaker placement in
for sick sinus syndrome; s/p elective generator change
on
- hypothyroidism
- hypertension
- hyperlipidemia
- s/p appendectomy
- s/p stripping of leg veins
## FAMILY HISTORY:
Sister has AAA and another sister had a CABG
## GENERAL:
WDWN in NAD. Alert and Oriented x3.
## HEENT:
NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
## NECK:
Supple, no JVD noted
## CARDIAC:
RRR, No murmurs noted, normal S1 and S2
## LUNGS:
no accessory muscle use. CTAB bilaterally, no crackles,
wheezes or rhonchi
## ABDOMEN:
Soft, NT/ND. No HSM or tenderness. No abdominial
bruits.
## EXTREMITIES:
no edema, +pulses in all extremeties
## SKIN:
left anterior chest wall surgical site wound healing with
small area of serous drainage medially, non-odorous,
non-purulent. Mild erythema around the site, non tender to
palpation and with a small area that is soft to palpation
(appears to be small amount of fluid under dermis).
## :
36.0 PTT: 30.4 INR: 3. year old patient has a history of sick sinus syndrome
and persistent atrial fibrillation, s/p VVIR PPM generator
change on who is admitted today for pacer pocket site
drainage and erythema, questionable infection.
## ##INFECTION:
Upon arrival her Mrs. BP was 181/76, HR
85, Temp 97.6. Her left anterior chest wall surgical wound had a
small amount of serous drainage with very mild erythema, and
appeared that she had a very small amount of fluid accumulation
under her dermis on the medial end of the incision. The rest of
the incision appears to be healing well. Her WBC was 7.8. Blood
cultures x 2 and wound site cultures were done. She was started
on Vancomycin 1000mg IV Q 12hrs (received total of 2 doses).
During her hospitalization, she remained afebrile with stable
vitals signs. In the morning of discharge, her left anterior
chest wall surgical wound had a scant amount of serous drainage,
and a scab was now forming over the site. It no longer appeared
erythmatous and no fluid accumulation was noted. The site was
non-tender to touch.
Cultures results are pending and patient was sent home on Keflex
PO QID and she was instructed to follow-up with
in one week.
##Afib: Patient was on continuous telemetry monitoring which
showed paced rythm with underline A-Fib, HR ranging from
. Patient on Coumadin 5mg Po Qday except for which
she takes 2.5mg PO. Her INR was supratherapeutic at 3.7.
Coumadin was held on . Another level was ordered to
be done today, however patient wanted to leave and didn't want
to wait to for lab draws. She was instructed to hold coumadin
today and restart it tomorrow. She was also instructed to
follow-up in her clinic on for a and INR.
##HTN: Patient was hypertensive at admission with BP 181/76, she
states that she has been very worry and anxious about risk of
developing an infection which could have contributed to elevated
BP. Her BP this AM 142/72. Patient instructed to continue all
her antihypertensives, verapamil
## ##ANXIETY:
Very anxious during hospitalizaton. She became very
upset because she was couldn't go out to smoke since she was on
continuos telemetry monitor. Patient refused to have nicotine
patch. She continue Oxazepam 10 mg PO BID PRN anxiety as
previously ordered.
## ## HYPERLIPIDEMIA:
continue statin: Atorvastatin 20 mg PO HS
## ##ANXIETY:
Very anxious during hospitalizaton. She became very
upset because she was couldn't go out to smoke since she was on
continuos telemetry monitor. Patient refused to have nicotine
patch. She continue Oxazepam 10 mg PO BID PRN anxiety as
previously ordered.
## HOME MEDICATIONS:
- digoxin 0.25 mg daily
- levothyroxine 88 mcg daily
- atorvastatin 20 mg daily
- oxazepam 10 mg bid prn
- verapamil 80 mg tid
- warfarin 5 mg daily (except 2.5 mg on
- calcium plus vitamin D
- Citrucel 500 mg daily
- vitamin E 400 units daily
- multivitamin
- fish oil one capsule daily
## DISCHARGE MEDICATIONS:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO BID PRN () as
needed for anxiety.
5. Verapamil 80 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Every day except
for . HOLD TODAY, RESTART tomorrow.
7. Warfarin 5 mg Tablet Sig: half Tablet PO Every .
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
## 11. KEFLEX MG CAPSULE SIG:
One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Questionable pacemaker pocket infection
## DISCHARGE INSTRUCTIONS:
You were admitted to for drainage and redness at your
pacemaker surgical site. You had blood cultures and a wound
culture done. The results for these tests are still pending. You
were also given two doses of IV antibiotics.
.
Your surgical wound does not appear to be infectected, but until
we have the final culture results we will give you a
prescription to continue taking antibiotics at home.
.
Please continue all your medications as previously prescribed.
We only added the antibiotic:
-Keflex mg four times per day for a total of 7 days.
-Hold Coumadin today and restart tomorrow
You should also follow-up with the clinic this
week so they can measure your INR levels.
.
You should keep the surgical would site clean and dry. Please
call your doctor or come to the emergency room if you develop a
fever (tempture greater than 101.3 F), chills, chest pain,
shortness of breath, or if the surgical site has increase
drainage, becomes red or swollen, or if you have any other
concerns.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16917124", "visit_id": "27220260", "time": "2159-04-07 00:00:00"} |
13907704-DS-23 | 1,088 | ## CHIEF COMPLAINT:
L Hip pain and OA
## PMH:
anxiety, urinary retention requiring straight cath after
back surgery, BPH, GERD
## PSHX:
bilateral inginual hernia repair, CCY, Open right hernia
repair with mesh, laminectoy and microdiscectomy
## PHYSICAL EXAM:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
## NEUROLOGIC:
Intact with no focal deficits
## MUSCULOSKELETAL LOWER EXTREMITY:
* Incision healing well with staples
* Thigh full but soft
* No calf tenderness
* strength
* SILT, NVI distally
* Toes warm
## BRIEF HOSPITAL COURSE:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
## POD1:
Labs stable, no overnight issues, drain pulled, worked
with
## POD2:
Cleared , labs stable, discharged home with services.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Aspirin 325 mg twice
daily for DVT prophylaxis starting on the morning of POD#1. The
foley was removed and the patient was voiding independently
thereafter. The surgical dressing was changed on POD#2 and the
surgical incision was found to be clean and intact without
erythema or abnormal drainage. The patient was seen daily by
physical therapy. Labs were checked throughout the hospital
course and repleted accordingly. At the time of discharge the
patient was tolerating a regular diet and feeling well. The
patient was afebrile with stable vital signs. The patient's
hematocrit was acceptable and pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior precautions.
Patient is discharged to home with services in stable condition.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Cephalexin mg PO ASDIR
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
3. DULoxetine 60 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. Tamsulosin 0.4 mg PO QHS
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*100
## TABLET REFILLS:
*0
2. Aspirin 325 mg PO BID Duration: 30 Days
RX *aspirin 325 mg 1 tablet(s) by mouth twice a day Disp #*60
## TABLET REFILLS:
*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. OxyCODONE (Immediate Release) mg PO Q4H:PRN Pain
RX *oxycodone 5 mg tablet(s) by mouth every 4 to 6 hours
Disp #*84 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tab by mouth
once a day Disp #*30 Tablet Refills:*0
7. Cephalexin mg PO ONCE 30 to 60 minutes prior to dental
procedures/cleanings Duration: 1 Dose
8. DULoxetine 60 mg PO DAILY
9. Finasteride 5 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. Tamsulosin 0.4 mg PO QHS
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician 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 drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
## 7. SWELLING:
Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
## 8. ANTICOAGULATION:
Please continue your Aspirin 325 twice daily
with food for four (4) weeks to help prevent deep vein
thrombosis (blood clots). Continue Pantoprazole daily while on
Aspirin to prevent GI upset (x 4 weeks). If you were taking
Aspirin prior to your surgery, take it at 325 mg twice daily
until the end of the 4 weeks, then you can go back to your
normal dosing.
## 9. WOUND CARE:
Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. 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. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
## 10. (ONCE AT HOME):
Home , dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
## 11. ACTIVITY:
Weight bearing as tolerated on the operative
extremity. Posterior precautions. No strenuous exercise or heavy
lifting until follow up appointment. Mobilize frequently.
## PHYSICAL THERAPY:
WBAT RLE
Posterior hip precautions x 2 months
Wean assistive device as able
Mobilize frequently
## TREATMENTS FREQUENCY:
daily dressing changes as needed for drainage
wound checks daily
ice
staple removal and replace with steri-strips on POD14-17 at
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13907704", "visit_id": "28330870", "time": "2124-09-16 00:00:00"} |
18206330-RR-74 | 319 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
year old man with above// pulmonary nodule
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 6.1 s, 39.9 cm; CTDIvol = 6.8 mGy (Body) DLP = 266.4
mGy-cm.
Total DLP (Body) = 266 mGy-cm.
## CHEST PERIMETER:
Thyroid is unremarkable. Supraclavicular and axillary lymph
nodes are not enlarged and there is no soft tissue abnormality in the imaged
chest wall concerning for malignancy. This study is not appropriate for
subdiaphragmatic diagnosis but shows no abnormalities in the adrenal glands.
Several small calcified gallstones are unchanged since . There is no
suggestion biliary obstruction or cholecystitis.
## CARDIO-MEDIASTINUM:
Esophagus is unremarkable. Atherosclerotic calcification
is moderately heavy in head and neck vessels and extensive in the left
coronary artery and its branches and distal branches of the right coronary
artery. Aorta and pulmonary artery and cardiac chambers are normal size.
Small pericardial effusion is unchanged since , though larger than it
was in , could still be physiologic.
## LUNGS, AIRWAYS, PLEURAE:
4 mm nodule superior segment left lower lobe
retracting the major fissure is unchanged since and .
There are no lung nodules concerning for malignancy.
Widespread cylindrical bronchiectasis in the lower lobes, which persisted in
after clearing of pneumonia in is little changed.
Wall thickening in some areas is slightly more pronounced but there is no
retention of secretions. There is a slight increase in peribronchial
ground-glass opacification deep in the right lower lobe, and peripheral
interstitial abnormality. Both of these could be inflammatory sequelae to
chronic, inflammatory, but not necessarily suppurative bronchiectasis.
## CHEST CAGE:
No compression or pathologic fractures or destructive bone
lesions. No evidence of infection or malignancy. Chronic disc degeneration is
responsible for vacuum discs and osteophytes in the lumbar spine.
## IMPRESSION:
Widespread bibasilar bronchiectasis, probably actively inflamed, not
necessarily suppurative.
4 mm left lower lobe nodule stable since can be considered
benign. There is no indication for imaging follow-up.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18206330", "visit_id": "N/A", "time": "2166-06-08 10:50:00"} |
13865397-RR-91 | 182 | ## FINDINGS:
The right kidney measures 10.6 cm. There is well-defined exophytic
simple renal cortical cyst measuring 0.8 cm in the lower pole of the right
kidney. A 5 mm echogenic area in the upper pole of the right kidney without
definite posterior acoustic shadowing, may represent a tiny cyst. There is no
hydroneprhosis, stones or masses in the right kidney.
The left kidney measures 10.3 cm. An 8-mm stone is again seen in the upper
pole of the left kidney. There is a well-defined hyperechoic lesion
measuring 2.5 x 2.1 x 1.5 cm in the upper pole of the left kidney, unchanged
since prior study and corresponds to the prior RF ablation site. There is no
hydronephrosis or new renal mass in left kidney.
The bladder is partially distended and is not fully evaluated.
## IMPRESSION:
1. Unchanged appearance of the RF ablation site in the left kidney, without
new mass lesions or hydronephrosis. 8-mm stone in the left kidney.
2. Unremarkable right kidney, except for a simple renal cortical cyst.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13865397", "visit_id": "N/A", "time": "2138-08-14 09:11:00"} |
13907061-RR-21 | 236 | ## EXAMINATION:
CTA HEAD AND NECK WITH PERFUSION
## INDICATION:
An woman found unresponsive, concern for CVA.
## HEAD CT:
No evidence of hemorrhage or infarct. Ventriculomegaly out of
proportion to sulcal enlargement, which raises the possibility of
communicating hydrocephalus. There is opacification of the right maxillary
sinus with adjacent sclerosis of bony wall, indicating chronic inflammation.
## HEAD AND NECK CTA:
There is mild narrowing at the origin of the left common
carotid artery; distal to this, the bilateral carotid and vertebral arteries
and their major branches are patent. There are atherosclerotic mural
calcifications at the right and left common carotid bifurcations, and in the
proximal right ICA, however there is no evidence of occlusion or significant
stenosis by NASCET criteria. The distal cervical internal carotid arteries
measure 4 mm in diameter on the left and 4 mm in diameter on the right.
The circle of vasculature is patent without evidence of stenosis,
occlusion, dissection or aneurysm. There are bilateral, right greater than
left, atherosclerotic mural intracranial ICA calcifications without
significant stenosis.
Incidentally noted is thyromegaly.
## CT PERFUSION:
No evidence of ischemia or infarction by perfusion scanning.
## IMPRESSION:
1. No evidence of hemorrhage or infarct. Ventriculomegaly out of proportion to
sulcal enlargement, raising the possibility of communicating hydrocephalus.
2. Patent carotid and vertebral arteries and circle of vasculature
without evidence of significant stenosis, occlusion, aneurysm, or dissection.
3. No evidence of ischemia or infarction by perfusion scanning.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13907061", "visit_id": "27227599", "time": "2155-11-18 11:28:00"} |
10361028-RR-33 | 94 | ## INDICATION:
History of urolithiasis, with recent history of gross hematuria.
## FINDINGS:
The right kidney measures 11.3 cm and the left kidney measures 10.4
cm. A nonobstructing 5-mm calculus is present within the lower pole of the
left kidney. No masses are detected. The prostate measures 4.6 x 3.9 x 4.2
cm, corresponding to a volume of 39 ml. The predicted PSA of 4.7. The
bladder appears normal.
## IMPRESSION:
1. 5 mm non-obstructing calculus within the lower pole of the left kidney.
2. Enlarged prostate.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10361028", "visit_id": "N/A", "time": "2183-04-22 09:31:00"} |
13778055-DS-22 | 2,062 | ## CHIEF COMPLAINT:
"I've reached a breaking point."
## HISTORY OF PRESENT ILLNESS:
This is a yo caucasian woman who presents to the ED at the
urging of her family after she admits to SI with a plan to
overdose on headache medications. Her family moved one year
prior
to a new single-family dwelling house and the patient noticed
the
beginnings of severe headaches, of pulsatile nature, on the
pain scale, in the back of her head which became a daily
occurance. She has no history of such headaches or a migraine
disorder. She also reports the development of debilitating
depressive symptoms, which the patient thinks stems from her
chronic headaches. Her family became suspicious when her
daughter
experienced similar headaches after returning from a study
abroad
trip to live at the home. They have since moved out and have
come
to find out, reportedly from EPA analyses, that there were
chemicals in the basement that Ms. was most likely
being
exposed to. Apparently the basement was a site for making meth
some years prior and had been vacant for a few years before her
family moved in. She noticed that her headache symptoms would
periodically get better if she were to leave home for an
extended
time, for instance when she went to visit her family for a week.
However, since moving to a new house in a few weeks ago,
she has not experienced a decrease in her headaches, she
attributes this to the chemicals possibly staying in the moved
furniture/bedding.
She says she has reached a "breaking point" and has been
preoccupied with thoughts of killing herself by overdosing on
her
headache medications. At her house, she has access to percocet,
gapapentin, fioicet, topiramate, lorazepam, and codeine. She has
had these thoughts periodically over the course of the year, and
once her husband took away the medications when she told him
about these thoughts. She battles herself in her thoughts over
these suicidal dispositions, and attributes this to her strong
faith. Regarding her depressive symptoms, she says she has
always
been the "one to get my family going in the morning" but now
feels guilty for not being able to help anyone. She had to quit
her job of years at a in because
of
the pain. She notes increasing hopelessness. She is not able to
sleep soundly but instead spends most of the night laying in her
bed and dozing off periodically. She has decreased interest in
things she used to enjoy such as walking, running, and cooking.
Her appetite is down and she has lost pounds. She is not
able to concentrate on things like movies, and has times where
her memory fails her such as when she was trying to teach a
lesson for a bible study.
Ms. does have a history of suicide attempt in . She
was in a physically abusive first marriage, the abuse lasted for
about years and consisted of her husband "beating the
out of me." She attempted to kill herself by driving her car
into
a truck. She was hospitalized but it ended up that she did not
retain many injuries from that suicide attempt. At the time she
was 7 months pregnant and had two other children and she left
her
abusive relationship to move back to (her home
). She engaged in therapy briefly after this period in her
life, but didn't feel like she really wanted to talk about the
abusive experience. She also tried taking wellbutrin and zoloft
but said that "they kept me in a no-zone" meaning neither happy
nor sad and she didn't like having that feeling so she
discontinued those medications.
## TOBACCO:
pack per day, years
## MARIJUANA:
occasionally, last use 1 week prior, helps her
appetite
## FAMILY HISTORY:
father- depression (never hospitalized)
sister- bipolar (never hospitalized)
## GENERAL:
Thin caucasian female in no apparent distress, appears
comfortable seated in exam room, alert and oriented x3.
Interactive and appropriate.
## HEENT:
Normocephalic, atraumatic. Pupils 2 mm, round and
reactive to light. Oropharynx clear.
## NECK:
Soft, supple, no lymphadenopathy.
## CHEST:
Clear to auscultation bilaterally, no crackles, no
wheezing.
## HEART:
Regular rate and rhythm, S1, S2 normal, no murmurs.
## ABDOMEN:
Soft, nontender, nondistended, no rebound or guarding.
## EXTREMITIES:
Full range of motion of bilateral upper
extremities, no pain on range of motion of extremities. No
lower
extremity edema.
## NEUROLOGIC:
No focal deficits. Ambulatory with normal gait.
Cranial nerves II through XII intact, strength intact and
equal on bilateral upper and lower extremities at all joints
grossly.
## SKIN:
No skin changes, no bruising or rashes.
## *APPEARANCE:
thin caucasian woman, dressed in hospital
with additional wrapped around her, with stylish hair and
nails, poor dentition. Slumped in chair.
## BEHAVIOR:
slightly guarded but cooperative. no pma. Some pmr
noted as all movements were slowed and speech was slowed.
Appropriate eye contact.
*Speech: volume is very low. rate is slowed. tone is
monotonous.
*Mood and Affect: mood is "tired" affect is dysphoric,
restricted, stable, congruent
*Thought process: linear, logical, goal oriented
*Thought Content: patient continues to endorse SI with plan
to
overdose on headache medications "to make it all go away". She
does not have plans to harm herself on unit. Denies HI. Denies
AVTH. Denies delusions.
*Judgment and Insight: insight fair as patient acknowledges
being depressed but views depression only as a result of
headaches, judgement fair as she endorses suicidal thought with
plan but is help seeking
## *ATTENTION, *ORIENTATION, AND EXECUTIVE FUNCTION:
alert,
oriented x 3, can do MOYB without difficulty
*Memory: can register and recall at five minutes
## CALCULATIONS:
can calculate 7 quarters in $1.75
## ABSTRACTION:
apple and orange= fruit.
## BRIEF HOSPITAL COURSE:
PSYCHIATRIC
#) DEPRESSION
Ms. was admitted to psychiatry after suicidal
thoughts in the context of worsening depression exacerbated by
intractible headaches.
We believe that Ms. has long-standing depression based
upon her report of a long h/o depression following an abusive
first marriage, where she made a plan to suicide once her
children were adults. She now has grown children, but she said
that things were looking more hopeful as she felt pride in
raising them, was enjoying watching their accomplishments, and
had met and married a new man recently.
Although depression and SI had resolved, they returned after she
and her new husband were exposed to toxic chemicals in a house
they had been renting.
Due to subseqeunt h/a, she was feeling depressed and started to
become hopeless as the h/a were not resolving, and she was
stressed with having to move again and to get rid of many
belongings that were exposed to chemicals. Her daughter also
became ill from the chemicals, and the pt had significant guilt
around this.
Upon arrival to the unit, she was depression, anhedonia,
guilt, poor concentration, anergia, pmr, and suicidal thoughts
with a plan to overdose on medications. She spent the first day
in bed, but afterwards was visible on the unit and engaging with
peers. Ms. accepted medication in the form of celexa
which was titrated to 30mg QD, and was aware of the r/b/se incl
but not limited to; irritability, sexual dysfunction, inc'd
energy, and delayed onset of action for mood relief. She also
took Mirtazapine 7.5mg for insomnia and help with her appetite.
Ms. had been taking significant ativan as an outpatient
(up to /day) and she tolerated a taper down to 0.5mg BID
prn for anxiety and 0.5mg QHS prn. By the time of her d/c, she
was rarely taking the prn benzos and was educated about the
risks of dependency, somnolence, and dec'd cognition on these
meds. We advised her that the benzos should be tapered off in
the near future. We have given her a prescription for 1 weeks
worth of 0.5mg BID and have informed the patient that we would
recommend her outpatient psychiatrist not c/w this medication if
possible. Due to her anxieties about transitioning home and
recent multiple signficant psychosocial stressors, we felt it
was reasonable to supplement her antidepressants with a short
treatment of Ativan upon discharge from the hospital.
GENERAL MEDICAL CONDITIONS
#) HEADACHE
Ms. h/a upon arrival to our unit. We treated
her with Fiorocet TID prn and tylenol. Her h/a subsided with
the Fiorcet. Due to her anxiety about the h/a returning, we
agreed to supply 1 week of the above medication with
instructions to seek help if the h/a continued or became
intolerable via her nearest ED.
To further assist with pain control, we have strongly advised
Ms. to f/u with the Body
at for help coping with h/a without medication.
PSYCHOSOCIAL
#) FAMILY INVOLVEMENT
3 family meetings were held with the pt's husband, . He
shared his concerns over her depression and the pt revealed her
long-standing depression to him. He was very supportive and
visited frequently. We educated pt and husband about the nature
and severity of her depression, need for cont'd meds, and
ongoing therapy and outpt care. On we had a meeting
with the pt and her husband, the day before d/c, and he agreed
that she had signficantly improved and was ready for d/c.
#) COLLATERAL PROVIDERS
pt has been f/u by Dr. as an outpatient. He was made
aware of the nature of her hospital admission.
LEGAL STATUS
The patient remained on a CV throughout the duration of her
admission
RISK ASSESSMENT
Ms. has a moderately elevated risk for self harm.
Non-modifiable risk factors include:
-race, recent suicidal thoughts, exposure to toxic chemicals in
her home
Modifiable risk factors include:
-headache, depression
Protective factos include:
-supportive husband, children, agreement to f/u with outpatient
care, current lack of suicidal thoughts/intent/plan
We worked with the pt to diminish her risk of self-harm
significantly by treating her depression with medication and
therapy. She had a notable resolution in her low mood and was
more optimistic about the future by the time of discharge.
Several family meetings were held where the pt's husband was
made aware of her risk, and he is actively involved in
supporting her in the community and aware of risk factors
requiring immediate attention. Ms. has no guns or
other weapons. Significantly contributing to her depression is
pain from severe headaches incurred after exposure to toxic
chemicals. Her pain was minimized by pharmacological treatment,
and she has f/u with several outpatient providers to address her
psychiatric issues and pain. At this time, Ms. is
appropriate for d/c to the outpatient setting which is currently
the least restrictive for care.
## PSYCHIATRIC:
citalopram 20mg tab daily
lorazepam 0.5mg qHS:PRN
## NON-PSYCHIATRIC:
vitamin D2
acetaminophen-codeine 300mg/30mg q8h:PRN
calcium carbonate
multivitamin
## DISCHARGE MEDICATIONS:
1. Citalopram 30 mg PO DAILY depression
RX *citalopram [Celexa] 10 mg 3 tablet(s) by mouth once a day
Disp #*42
## TABLET REFILLS:
*0
2. Mirtazapine 7.5 mg PO HS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet
## REFILLS:
*0
3. Acetaminophen-Caff-Butalbital TAB PO TID PRN pain and
headaches
RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-325 mg-40 mg
1 tablet(s) by mouth three times a day Disp #*21 Tablet
Refills:*0
4. Lorazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 by mouth twice a day Disp #*14
## DISCHARGE DIAGNOSIS:
AXIS I
Major depressive d/o, moderate and recurrent
AXIS II
defer
AXIS III
headache
AXIS IV
recent move, exposure to toxic chemicals, new marriage
AXIS V
55
## DISCHARGE CONDITION:
Stable
Pt is alert, oriented, and cooperative with care. Mood is
'better' and affect is bright and reactive. No disorders of
thought process/content/speech. No longer having suicidal
thoughts/intent/plans and no homicidal thoughts. Insight and
judgment are good.
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the psychiatry unit for treatment of your
depression and suicidal thoughts. You have shown signficant
signs of improvement during your stay here. We have been giving
you medications and therapy to help with your mood. Upon
discharge, it is highly recommended that you continue with
medication management and attend a step-down program via partial
hospitalization. Please also follow-up with your doctors as
directed below.
It has been a pleasure working with you and we wish you the very
best of .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13778055", "visit_id": "22490935", "time": "2136-10-19 00:00:00"} |
12779994-DS-11 | 658 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HPI:
yo M h/o HTN untreated presented with dyspnea x 1 month
with significant worsening x 1 week with productive cough. Pt
reports associated achiness and subjective fevers, no chills.
Denies chest pain. Pt has a h/o HTN treated in the past on an
unknown med but has not taken that med for years. Pt has a
daughter and son with flu symptoms.
.
In the ED: 97.8 24 97%. Pt given ntg in the ED with
relief of dyspnea. CXR: possible mild pulm edema and left mid
lung opacity. Pt given asa, ctx, and levofloxacin. EKG per
report showed "ST @ 129, LBBB (new versus prior), sgarbossa's
negative but with discordant STE less than 5mm," though not yet
in cmoputer and hardcopy unavailable. Cardiology consulted and
reportedly were unconcerned by the findings.
.
## ROS:
Pt denies n/v/d/abd pain/dysuria/hematuria. +mild bifrontal
HA off and on.
## PAST MEDICAL HISTORY:
htn (untreated, as above)
gerd
## FH:
denies any family h/o heart dz
## PHYSICAL EXAM:
t98.1, 180/110, 116, 18, 95%ra
appears comfortable, speaking in complete sentences
tachy regular sem at , non-radiating
chest: bibasilar crackles
abd soft/nt/nd +bs
ext w/wp trace pedal edema
## PERTINENT RESULTS:
10:04AM PLT SMR-NORMAL PLT COUNT-274#
10:04AM WBC-7.6 RBC-5.50# HGB-15.5# HCT-45.5# MCV-83#
MCH-28.1# MCHC-34.0# RDW-15.1
10:10AM LACTATE-1.8 K+-4.6
10:10AM LACTATE-1.8 K+-4.6
07:30PM CK(CPK)-238
07:30PM CK-MB-3 cTropnT-<0.01
11:40AM PTT-30.9 yo M history untreated hypertension admitted with
cough/dyspnea found to have significant heart failure.
.
cough/dyspnea: On admission it was initially felt that the
patient had pneumonia given the CXR findings and that heart
failure may also be contributing. However, a CTA demonstrated
that the suspected infiltrate was in fact a complete herniation
of the stomach through the diaphragm. An echo showed severe
hypokinesis of the left ventricle (EF 25%). The patient had an
episode of flash pulmonary edema on , which resolved with iv
lasix, SL nitroglycerin, and iv hydralazine. The patient was
seen by cardiology and his heart failure was adjusted with their
assistance. They are recommending outpatient cardiac MRI and
further medication optimization after discharge.
.
hiatal hernia: This was demonstrated on CTA as above and barium
swallow, though there was no evidence of obstruction. Surgery
saw the patient in-house and recommended ongoing cardiac
optimization before surgery.
## MEDICATIONS ON ADMISSION:
prevacid occasionally (dose unknown)
## DISCHARGE MEDICATIONS:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
## REFILLS:
*0
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate [Imdur] 30 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet
## REFILLS:
*0
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 200 mg 1 tablet(s) by mouth
daily Disp #*30
## TABLET REFILLS:
*0
5. Pravastatin 20 mg PO DAILY
RX *pravastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
## DISCHARGE DIAGNOSIS:
congestive heart failure
hypertension
hiatal hernia
## DISCHARGE CONDITION:
The patient is ambulatory with a normal mental status.
## DISCHARGE INSTRUCTIONS:
You were admitted with shortness of breath. You were diagnosed
with heart failure. You should continue the lifestyle
modifications as we discussed including improved diet and
exercise.
You were diagnosed as having a significant hiatal hernia. You
will need optimization of your
Please take all medications as prescribed.
Please go to all of your appointments as below.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12779994", "visit_id": "29270965", "time": "2139-12-18 00:00:00"} |
18127146-RR-68 | 96 | ## INDICATION:
year old man with hx HTN, CVA, CAD, SSS s/p PPM, CHF, COPD
with syncope , now with worsening leukocytosis // Please eval for PNA vs
edema Please eval for PNA vs edema
## IMPRESSION:
Comparison to . Lung volumes remain low. Stable correct
position of the right pectoral pacemaker. In almost unchanged manner, the
vascularity of the lung parenchyma is enlarged, the size of the cardiac
silhouette is increased, and the peribronchial interstitium is thickened.
Given the symmetry and nature of the changes, pulmonary edema is more likely
than pneumonia. No pleural effusions. No pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18127146", "visit_id": "22349604", "time": "2144-05-25 08:41:00"} |
15527241-RR-47 | 248 | ## INDICATION:
Stage IIIb lung cancer, status post left pneumonectomy in for lung cancer surveillance.
## FINDINGS:
The visualized thyroid enhances homogenously. There is no axillary
pathologic lymphadenopathy. The patient is status left pneumonectomy with
fluid now filling the left hemithorax. Fluid and soft tissue density in the
left pneumonectomy site as well as pleural thickening is probably within
normal limits. Surgical clips are seen. There has been expected leftward
shift of the mediastinum, status post pneumonectomy. The pulmonary artery
measures 2.6 cm, normal. The left main pulmonary artery is surgically
ligated. The heart is normal in size. There is a small pericardial effusion,
simple in attenuation.
Central airways are patent to the level of subsegmental bronchi on the right.
A 2-mm right upper lobe nodule (series 4, image 46) appear stable from prior.
There is no right pleural effusion or pneumothorax.
This study is not optimized to evaluate the abdomen. Within this limitation,
the liver, pancreas, and visualized kidneys appear normal. A hyperattenuating
focus in the spleen is stable, likely a hemangioma. An 8-mm left adrenal
nodule is indeterminate by CT but unchanged. There is no suspicious
osteolytic or osteoblastic lesion. Surgical rib fractures are seen on the
left, status post pneumonectomy.
## IMPRESSION:
1. Status post left pneumonectomy with no new pulmonary nodules or
lymphadenopathy detected. Pleural thickening can be seen s/p pneumonectomy
but attention to this area in follow up is recommended to assure stability.
2. Indeterminate left adrenal nodule is unchanged.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15527241", "visit_id": "N/A", "time": "2114-07-29 14:52:00"} |
17774003-RR-32 | 124 | ## EXAMINATION:
LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
## INDICATION:
year old man with mediastinal B cell lymphoma, needs
intrathecal chemo on // needs access for IT chemotherapy.
## FLUOROSCOPY TIME:
25 seconds. Two images were saved.
## FINDINGS:
8 mls of CSF were collected in 4 tubes.
## IMPRESSION:
1. Lumbar puncture at L4-L5 without complication.
2. 8 mls of CSF were collected in 4 tubes and sent to the lab for requested
analysis.
3. Intrathecal chemotherapy was administered by the hematology/oncology team.
I, Dr. supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
## RECOMMENDATION(S):
The patient should lie flat in the supine position for 1
hour post procedure.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17774003", "visit_id": "24655800", "time": "2148-04-28 15:04:00"} |
16657198-RR-120 | 104 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
with headstrike // ICH?
## FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Periventricular white matter hypodensities are noted compatible
with chronic microvascular ischemic disease. Ventricles and sulci are normal
in overall size and configuration. The imaged paranasal sinuses are clear.
Mastoid air cells and middle ear cavities are well aerated. The bony calvarium
is intact. A subgaleal hematoma is noted at the right parietal vertex.
## IMPRESSION:
No acute intracranial process. Small subgaleal hematoma at the right vertex.
Small vessel disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16657198", "visit_id": "27395071", "time": "2151-01-18 18:12:00"} |
19325755-DS-23 | 1,136 | ## PERTINENT RESULTS:
ADMISSION LABS
==============
01:30PM BLOOD Neuts-87.9* Lymphs-3.7* Monos-7.7
Eos-0.0* Baso-0.3 Im AbsNeut-9.15* AbsLymp-0.39*
AbsMono-0.80 AbsEos-0.00* AbsBaso-0.03
07:24AM BLOOD WBC-8.9 RBC-4.38* Hgb-13.3* Hct-38.7*
MCV-88 MCH-30.4 MCHC-34.4 RDW-12.7 RDWSD-41.1 Plt
01:30PM BLOOD Glucose-110* UreaN-24* Creat-1.2 Na-139
K-4.1 Cl-100 HCO3-25 AnGap-14
07:24AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.1
07:24AM BLOOD CRP-114.8*
07:24AM BLOOD HIV Ab-NEG
07:24AM BLOOD Trep Ab-PND
IMAGING
=======
CT SINUS/MANDIBLE/MAX
1. Motion and dental artifact limits study.
2. Right preseptal and right maxillary soft tissue swelling with
some fat
stranding, and soft tissue thickening of right pinna concerning
for
cellulitis.
3. Question thickening of bilateral tympanic membranes and of
right external auditory canal versus cerumen.
4. Within limits of study, no definite evidence of abscess.
5. Lymphadenopathy and additional scattered subcentimeter
nonspecific lymph
nodes, as described.
6. Paranasal sinus disease , as described.
7. Additional findings as described above.
MICROBIOLOGY
=============
7:24 am BLOOD CULTURE X 1.
## BRIEF HOSPITAL COURSE:
Mr. is a year old man with a history of HLD and
HTN who presented with a 3-day history of R facial and ear
erythema, found to have facial erysipelas and preseptal
cellulitis that improved after initial therapy with IV
antibiotics. He was transitioned to PO antibiotics on for
a planned 10 day course.
TRANSITIONAL ISSUES
=====================
[ ] F/u treponemal antibody
[ ] Ensure improvement of cellulitis on PO antibiotics--(Bactrim
DS 2 tablets twice daily and Augmentin 875 mg twice daily for
planned 10-day; course with end date inclusive).
[ ] We typically recommend that patients stay in the hospital
for monitoring after transitioning from IV to PO antibiotics, to
ensure an adequate response to the oral medications. Because the
patient felt strongly about going home, and had improved so
significantly, we ultimately discharged him on , the same
day that we had transitioned him from IV to PO antibiotics. It
will be extremely important to have close PCP , to
ensure adequate response to new medications.
[ ] Blood pressure medications: Blood pressure medications were
initially held in the setting of soft/normal blood pressures.
These were also held on discharge, his blood pressures remain
normal at that time. He will need close PCP to
determine when his most appropriate to restart his
hydrochlorothiazide and lisinopril.
## ACUTE ISSUES:
=============
#Preseptal cellulitis
#Facial erysipelas
Swelling and erythema of pinna, periorbital and maxillary
regions most consistent w/ preseptal cellulitis and facial
erysipelas given involvement of the ear. Orbital cellulitis and
mastoiditis unlikely d/t lack of pain w/ eye movements,
proptosis, tenderness over mastoid process, or headache.
Received cefepime in ED, started Vancomcyin on for MRSA
coverage. Maxillofacial CT w/contrast showed right preseptal and
right maxillary soft tissue swelling with some fat stranding,
and soft tissue thickening of right pinna concerning for
cellulitis but no evidence of abscess or deep tissue infection.
He was transitioned to oral antibiotics on (Bactrim DS 2
tablets twice daily and Augmentin 875 mg twice daily for planned
10-day; course with end date inclusive).
#Thrombocytopenia
Presented with platelet count of 126 from baseline 173 in
, likely d/t infection. No evidence of bleeding. HIV ab
negative. Plts improved on discharge to 143.
#
Presented with Cr 1.2 which improved to 0.9 with fluids c/w
prerenal.
# Essential hypertension
Held home HCTZ and lisinopril d/t SBP 102 and Cr 1.2. On
discharge these medications were held, as blood pressures
remained normal.
## CHRONIC ISSUES:
===============
#HLD
Continue home atorvastatin
#Sinus bradycardia
Asymptomatic and known prior.
#Gout - Continue home allopurinol
#BPH - Continue home finasteride, tamsulosin
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Allopurinol mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
## DISCHARGE MEDICATIONS:
1. Amoxicillin-Clavulanic Acid mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*19 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice a day Disp #*38 Tablet Refills:*0
3. Allopurinol mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Finasteride 5 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was
held. Do not restart Hydrochlorothiazide until you see your PCP
8. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your PCP
:
Home
## DISCHARGE DIAGNOSIS:
Primary diagnosis:
Erysipelas/preseptal cellulitis
Secondary diagnoses:
Thrombocytopenia
Hypertension
Hyperlipidemia
Sinus bradycardia
Gout
BPH
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a privilege taking care of you at the
.
Why was I admitted to the hospital?
=================================
- You were admitted because you had a skin infection.
What happened while I was in the hospital?
====================================
- You were started on IV antibiotics.
- You had a CT scan of your head that showed you have a skin
infection (cellulitis) but did not have an abscess or more
serious deep tissue infection.
- You were transitioned to oral antibiotics on to
complete a 10-day course.
What should I do after leaving the hospital?
====================================
- Please call your primary care provider on to make an
appointment to be seen that same day or the next. It is
essential to be evaluated by her primary care provider on
or of next week in order to make sure that you are
infection is improving on oral antibiotics.
- Note that we typically recommend that patients stay in the
hospital after transitioning from IV to PO antibiotics, to
ensure an adequate response to the oral medications. Because
you felt strongly about going home, and had improved so
significantly, we ultimately discharged you on , the same
day that we had transition you from IV to PO antibiotics. It
will be extremely important for you to with your
primary care providers very closely to ensure that you are
responding to these new medications.
- If you experience fever, chills, headache, changes in your
vision, painful eye movements, ear pain, nausea/vomiting,
confusion, general malaise, worsening skin rash, changes in your
hearing, or have any other concerns please come back to the ED
immediately to be evaluated.
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best.
Sincerely,
Your Healthcare Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19325755", "visit_id": "23785490", "time": "2130-06-04 00:00:00"} |
14843335-RR-36 | 130 | ## HISTORY:
Right sciatica, question abnormality.
LUMBAR SPINE, TWO VIEWS. No previous L-spine radiographs on PACS record for
comparison.
There are five non-rib-bearing vertebral bodies. Lordosis is preserved.
Vertebral body heights are preserved. There is mild disc space narrowing at
multiple levels and moderately severe narrowing at L5/S1, where there may also
be minimal retrolisthesis. Prominent marginal spurs are seen anteriorly at
L5/S1. There is moderate facet arthrosis, worse from L4 through S1. Moderate
aortic calcification. Surgical clips noted in the right upper quadrant and
upper right pelvis. At the periphery of these films, degenerative changes in
both hips are suggested.
## IMPRESSION:
Multilevel degenerative changes in the lumbar spine, including
moderately severe discogenic degenerative change at L5-S1 and lower lumbar
spine facet arthrosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14843335", "visit_id": "N/A", "time": "2174-05-28 14:52:00"} |
17218141-RR-22 | 91 | ## EXAMINATION:
GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT
## INDICATION:
with recent arthroplasty// eval for hardware
## FINDINGS:
Patient is status post total left shoulder arthroplasty, in near anatomic
alignment. There is mild cortical discontinuity adjacent to the distal and of
the humeral components. This appears similar to the prior study, and likely
reflects the insertion of the deltoid muscle on the humerus. There is no
evidence of hardware loosening or fracture. The imaged portion of the left
lung is clear.
## IMPRESSION:
Status post left reverse shoulder arthroplasty in unchanged alignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17218141", "visit_id": "N/A", "time": "2182-09-07 10:51:00"} |
19390913-RR-33 | 100 | ## EXAMINATION:
EARLY OB US <14WEEKS
## INDICATION:
year old woman with uncertain LMP, new pregnancy// dating,
viability
## FINDINGS:
An intrauterine gestational sac is seen and a single living embryo is
identified with a crown rump length of 10 mm representing a gestational age of
7 weeks 1 days. This is less than dates by menstrual age of 8weeks 5 days.
The uterus and ovaries are normal. Again demonstrated is a thick-walled cyst
measuring 3.3 cm consistent a corpus luteum in the right ovary.
## IMPRESSION:
Single live intrauterine pregnancy with weeks size dates discrepancy.
The by ultrasound is .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19390913", "visit_id": "N/A", "time": "2121-07-19 14:01:00"} |
19337695-RR-30 | 102 | ## EXAMINATION:
US INTRA-OP MINS PORT
## INDICATION:
year old man with pancreatic cancer.// IOUS, WEST, ,
estimated start of 9:30 AM, scheduled for exploratory laparoscopy, possible
bx.
## FINDINGS:
Intraoperative ultrasound was provided to Dr. during the performance
of a robotic assisted laparoscopic pancreas surgery for resectability of
pancreatic mass.
Ultrasound demonstrated a hypoechoic mass located in the head of the pancreas
with hypoechoic soft tissue encasing the celiac artery and common hepatic
artery respectively.
## IMPRESSION:
Intraoperative ultrasound evaluation of hepatic vasculature and celiac artery
for evaluation of resectability. Extensive hypoechoic soft tissue was noted
encasing these vessels on intraoperative ultrasound.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19337695", "visit_id": "26072592", "time": "2121-03-16 06:46:00"} |
11068310-RR-21 | 147 | ## FINDINGS:
There is a single live intrauterine gestation. The fetus is in
cephalicposition. The placenta is anterior. There is no evidence of previa.
There is a normal amount of amniotic fluid. Views of the fetal head, face,
heart, outflow tracts, stomach, kidneys, cord insertion site, bladder, spine,
3 vessel cord, and extremities were normal. No fetal morphologic abnormalities
are detected. The uterus is normal. No adnexal abnormalities are seen.
The following biometric data was obtained:
BPD 4.1cm, 18 weeks 4 days.
HC 15.0cm, 18 weeks 1 days.
AC 12.7cm, 18 weeks 2 days.
FL 2.6cm, 17 weeks 6 days.
## AGE BY US:
18 weeks 2 days.
Age by Dates: 18 weeks 3 days.
EFW 220 g
Compared to the prior exam there has been appropriate interval growth.
## IMPRESSION:
Single, live fetus measuring size equals dates. No fetal morphologic
abnormalities are detected.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11068310", "visit_id": "N/A", "time": "2157-11-02 15:28:00"} |
15103783-RR-86 | 233 | ## DOSE:
DLP: Given in abdominal CT report.
## FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. All visible lymph nodes in the mediastinum are
normal in size. Stable aortic wall calcifications, stable moderate to severe
coronary calcifications. No pericardial effusions. No abnormalities in the
posterior mediastinum, with the exception of a small hiatal hernia. Upper
abdominal findings are described in detail in the dedicated abdominal CT
report. The sagittal reconstructions show a wedge-shaped deformity of L1 as
well as a mild progression of the increased attenuation at the level of T9
(602, 40). Vertebral fixation devices in the lower aspect of the lumbar
spine. No osteo destructive rib lesions. Stable bilateral apical scarring.
The pre-existing upper lobe ground-glass opacities (302, 42) have decreased in
extent and severity. Some of them have completely resolved. The pre-existing
paramediastinal right lower lobe consolidation with a partially nodular
appearance (302, 141) has substantially decreased in size. No new or
suspicious lesions or nodules. Stable subpleural left lower lobe scarring
(302, 219). No pleural effusions.
## IMPRESSION:
Decrease and partially complete resolution in extent and number of the
pre-existing upper lobe ground-glass opacities. Decrease in size of a right
lower lobe paramediastinal consolidation. No new consolidations or opacities.
No suspicious lung nodules or masses. Wedge-shaped deformity of L1,
progression of the attenuation increase at the level of T9.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15103783", "visit_id": "N/A", "time": "2152-10-26 08:32:00"} |
12877392-RR-158 | 168 | ## INDICATION:
Cervical spine pain. Please evaluate for fracture or
degenerative disease.
## FINDINGS:
There is no evidence of fracture or malalignment. Multilevel
degenerative change is identified with endplate sclerosis and disc space
narrowing, worst at the C5-C6 and C6-C7 levels. Also noted are posterior
broad-based disc bulges with no significant narrowing of the spinal canal at
C2-3 and C3-4. Although CT is not able to provide intrathecal detail
comparable to MRI, there does not appear to be any critical central canal
stenosis.
No prevertebral soft tissue swelling identified. The left thyroid lobe is
asymmetrically enlarged with multiple nodular hypodensities evident (3:56).
The minimally visualized lung apices demonstrate interseptal thickening,
possibly reflecting a degree of pulmonary edema. The minimally visualized
esophagus is somewhat patulous and contains debris.
## IMPRESSION:
1. No evidence of fracture or malalignment. Multilevel degenerative changes
without significant spinal canal narrowing.
2. Asymmetric enlargement of left thyroid lobe with nodular hypodensities.
Could be further evaluated with non-urgent thyroid ultrasound.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12877392", "visit_id": "21673488", "time": "2155-02-12 16:40:00"} |
15112602-RR-11 | 488 | CT OF THE MAXILLOFACIAL STRUCTURES at 1430 hours.
## HISTORY:
Fall from two stories with extensive facial trauma.
## FINDINGS:
1. There is a right basal skull fracture extending through the right
occipital condyle and the more medial aspects of the horizontal portion of the
carotid canal in the petrous right temple bone. The fracture terminates
within the lateral wall of the right sphenoid sinus which is filled with fluid
and debris, presumably blood.
2. There is a fracture through the base of the right pterygoid plate
extending in a linear fashion through the maxillary superior alveolar ridge
through the root of the right superior second molar and terminating through
the anterior wall of the right maxillary sinus involving the infraorbital
foramen. That sinus is filled with fluid and debris as well, presumably blood.
There is no herniation of intraorbital contents. The right globe is intact
and the lens in place. No vitreous hemorrhage is noted.
3. There is a fracture through the lateral aspect of the left pterygoid
plate. Non-displaced fracture is also evident in the left zygomatic arch.
There is comminuted fracture and buckling of the lateral orbital wall at the
zygomatico-sphenoid suture. This fracture extends along the lateral aspects
of the left frontal bone, terminating within the more cephalad aspect of the
coronal suture. There is a fracture at the lateral aspect of the orbital apex
as well. Please note there is a medial extension of the fracture of the
medial wall of the left orbit (lamina papyracea), which extends through the
left frontal sinus. No definite inner table involvement is noted. This
fracture then terminates to involve the left nasal bone fracture described
above.
4. There is extensive left- sided exophthalmus. No definite vitreous
hemorrhage is identified, although there is beam hardening artifact in the
region which may compromise the sensitivity. The lens is not dislocated. There
is extensive preseptal soft tissue swelling. There is intraorbital air
predominantly in the extraconal retrobulbar soft tissues admixed with soft
tissue density likely hematoma from the various orbital wall fractures.
5. There is a distracted fracture involving the left nasal bone. There is a
minimally displaced fracture through the mid substance of the nasal septum.
6. The mandible is intact. The mandibular condyles are appropriately
located.
7. Tiny locules of pneumocephalus are identified adjacent to the lateral left
frontal bone fracture and the site of a small known subdural hematoma.
## IMPRESSION:
Extensive facial fractures detailed above. In summary, there is
a basal skull fracture on the right involving the right occipital condyle and
right carotid canal, there is bilateral pterygoid plate involvement with an
atypical distribution. These features suggestive of a right hemi-LeFort II
and a left hemi-LeFort III fracture pattern. In addition, the left sided
fracture extends along the left frontal bone with a component of underlying
pneumocephalus and small subdural hematoma known from the accompanying head CT
examination. Please see details above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15112602", "visit_id": "26355294", "time": "2151-03-18 14:06:00"} |
16050305-DS-21 | 1,687 | ## ALLERGIES:
Lipitor / Tetracycline / Ampicillin / Sulfa (Sulfonamide
Antibiotics) / Levaquin / Aspirin / Chicken Derived /
Pravastatin / Simvastatin / lovastatin / clonazepam /
rosuvastatin / Salicylates / valacyclovir / Atarax / Cardia
## CARDIOVERSION:
200 J external biphasic synchronized energy with
prompt return to sinus rhythm followed by a 27 second episode of
AIVR at 90 bpm
## PRE-DCCV ECG:
Atrial fibrillation, 134 bpm
## POST-DCCV ECG:
Sinus rhythm, 86 bpm
## HISTORY OF PRESENT ILLNESS:
Ms. if a with a history of CHF, HTN,
syndrome, and atrial fibrillation on Coumadin who
presents with worsening shortness of breath. She was recently
hospitalized at for several days and found to
have atrial fibrillation and was subsequently started on
dilitiazem, metoprolol, digoxin, and warfarin. Due to side
affects that the patient attributed to both digoxin and
dilitiazem, they were both discontinued.
Since her hospitalization she has been feeling progressively
worse. Her weight has been increasing, currently 10 lbs up from
baseline and worsening lower extremity edema. She has also
noticed her blood pressure and heart rate frequently
fluctuating. She denies any CP and only feels short of breath
with exertion. Denies fevers, chills, night sweats, cough,
dysuria.
In the ED, initial VS were 97.4 111 130/95 18 94% RA. Labs were
significant for WBC 9.1, Hgb 12.8, plts 222, BNP 2803, Cr 1.2
Trop <0.01, XRay showed mild to moderate pulmonary edema.
## 1. CONGESTIVE HEART FAILURE:
LVH, diastolic dysfunction, mild
AS
2. Diabetes mellitus
3. Hypertension
4. Hyperlipidemia
5. GERD
## 6. SYNDROME:
asthma, nasal polyps, and salicylate
allergy
7. Mild restrictive lung disease
8. Obesity
9. OA knees
10. Panic attack
11. Hysterectomy for endometrial cancer in
.
## - LIPITOR/PRAVASTATIN:
myalgia
- Salicylate: anaphylaxis
- Tetracycline, ampicillin, Sulfa, Levaquin
- ACE inhibitors: cough
## - FATHER DIED AT :
CAD; first MI at age
- Mother died at from cancer
- Brother: age , healthy.
- Daughter PCOS
- Daughter with obesity, hypothyroidism, and asthma
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death
.
## GEN:
NAD, breathing comfortably, speaking in full sentances
## CV:
RRR, systolic ejection murmur
## RESP:
airmovement throughout, crackles lower loves, greater
right side
## :
edema bilaterally with venous changes and dermatitis
of anterior lower extremities
## NEURO:
AAOx3, MAE, no gross deficit
## VS:
T= 97.2 BP: 134/72 HR= 66-122 RR= O2 sat= 94-98% RA
## GENERAL:
NAD. Oriented x3. Mood, affect appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL. no pallor or cyanosis of
the oral mucosa.
## NECK:
Unable to assess JVP due to patient need to remain sitting
(joint/muscle discomfort). thyroid mildly enlarged
## CARDIAC:
HRRR, normal S1, S2. systolic murmur best
appreciated at right upper sternal border.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. End expiratory wheezes
throughout, faint bibasilar crackles
## EXTREMITIES:
No c/c/e. Diminished radial pulses. 2+ pitting
edema
## SKIN:
red rash 3x4 cm bilaterally on anterior lower legs
## LEFT ATRIUM:
Moderately increased LA volume index.
## LEFT VENTRICLE:
Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
## RIGHT VENTRICLE:
Normal RV chamber size and free wall motion.
## AORTA:
Normal aortic diameter at the sinus level. Normal aortic
arch diameter.
## AORTIC VALVE:
Moderately thickened aortic valve leaflets. Mild
AS (area 1.2-1.9cm2). Trace AR.
## MITRAL VALVE:
Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. Mild functional MS due to MAC. Mild (1+) MR.
## VALVE:
Mild [1+] TR. Mild PA systolic hypertension.
## GENERAL COMMENTS:
The rhythm appears to be atrial fibrillation.
Conclusions
Echocardiogram found LVEF>55%, symmetric LVH with normal global
and regional biventricular systolic function, mild aortic
stenosis, mild calcific mitral stenosis, mild pulmonary
hypertension.
CXR
Evidence of a large hiatal hernia is seen in the retrocardiac
region. The
cardiac silhouette is markedly enlarged. There is also
persistent prominence of the mediastinum in this patient with
mediastinal lipomatosis. The lungs are hyperinflated. No
definite focal consolidation is seen. There is no large pleural
effusion or pneumothorax. There is mild to moderate pulmonary
edema.
## IMPRESSION:
Marked enlargement of the cardiac silhouette. Mild to moderate
pulmonary
edema. Hiatal hernia.
ECG
Arial fibrillation with a wider beat that is probably
ventricular. There is borderline low limb lead voltage. Late R
wave progression. ST-T wave
abnormalities. Compared to the previous tracing of the
wider complex beat is now present. Differences in R wave
progression may be related to lead position.
Axes 0 -6 151
Rate PR QRS QT QTc ( ) P QRS T
117 92 344 443
ECG
Borderline P-R interval prolongation. Sinus rhythm. Poor R wave
progression may be a normal variant. Low precordial QRS
voltages. Compared to the previous tracing of the
findings are similar.
Axes 33 -15 27
Rate PR QRS QT QTc ( ) P QRS T
63
ECG
No significant change compared to tracings #2 and #3 except for
premature
atrial contractions.
Axes
Rate PR QRS QT QTc ( ) P QRS T
62 194 92 460 463
## BRIEF HOSPITAL COURSE:
Ms. is a old woman with a history of CHF, HTN,
syndrome, and atrial fibrillation on Coumadin who
presented with worsening shortness of breath and was found to
have acute on chronic diastolic heart failure, atrial
fibrillation with RVR with heart rate to 140s, and acute kidney
injury with creatinine = 1.2.
Diastolic heart failure: Due to volume overload likely
exacerbated by poorly controlled afib. Patient was diuresed with
80 mg Lasix daily to euvolemic status, dry weight = 96.5 kg.
Transitioned to PO torsemide, dose: 80 mg daily. This dose was
chosen with some expected active diuresis. I spoke with Dr.
will see her 6 days post discharge check a 6
and adjust dose as needed
## ATRIAL FIBRILLATION:
Patient had RVR with tachycardia to 150s. 3
months prior to hospitalization, diltiazem and digoxin had been
stopped due to side effects, and patient complained of
difficulty tolerating metoprolol, so cardioversion was performed
on . Patient was started on Sotalol.
Continued on her home Coumadin.
## :
The patient presented with , creatinine of 1.3 from
baseline of 0.9, likely elevated due to cardiorenal dysfunction
given CHF exacerbation. Losartan was held during the admission.
Creatinine declined to 1.1.
## TRANSITIONAL ISSUES:
DHF:
Will need close follow-up of weights (discharge 96.5 kg),
volume status. Will likely benefit from nutrition education.
Dosing of diuretics may need modification.
Atrial fibrillation: On discharge patient was in NSR. Was
started on new medications Sotalol. Will need follow up to
monitor rate and rhythm, as well as potential medication side
effects.
Will continue to monitor INR at clinic with Dr. .
Recheck electrolytes on follow-up
Patient discharged with for rhythm monitoring
Dry weight: 96.5 kg
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
1 pill oral BID
2. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Furosemide 40 mg PO DAILY
4. Nasonex (mometasone) 50 mcg/actuation nasal DAILY
5. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
7. Vitamin D 1000 UNIT PO BID
8. coenzyme Q10 300 mg oral DAILY
9. desoximetasone 0.25 % topical BID as needed
10. Losartan Potassium 25 mg PO DAILY
11. Metoprolol Tartrate 100 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO BID
14. Omeprazole 20 mg PO DAILY
15. Warfarin 5 mg PO DAILY16
16. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
17. Ascorbic Acid mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
7. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
8. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth DAILY Disp #*120 Tablet
## REFILLS:
*0
9. Sotalol 80 mg PO BID
RX *sotalol 80 mg 1 tablet(s) by mouth twice a day Disp #*60
## TABLET REFILLS:
*0
10. Ascorbic Acid mg PO DAILY
11. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B
complex) 1 pill oral BID
12. coenzyme Q10 300 mg ORAL DAILY
13. desoximetasone 0.25 % topical BID as needed
14. Losartan Potassium 25 mg PO DAILY
15. Nasonex (mometasone) 50 mcg/actuation nasal DAILY
16. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
17. Vitamin D 1000 UNIT PO BID
18. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride [Klor-Con] 20 mEq 1 packet(s) by mouth
DAILY Disp #*30 Packet Refills:*0
## DISCHARGE DIAGNOSIS:
Primary diagnosis:
Acute on chronic diastolic heart failure.
Secondary diagnosis
Atrial fibrillation with rapid ventricular response.
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure to participate in your care at
.
You came to the hospital because you were feeling short of
breath when walking. We found that you had fluid backed up in
your lungs that was making it difficult to breathe. This was
caused by heart failure. Also you were in atrial fibrillation
that was causing your heart to beat fast.
You were given Lasix intravenously to help you take off the
extra fluid in your body. Your heart rhythm was changed to a
normal rhythm with electrical cardioversion. To keep your heart
from going into atrial fibrillation again, you started to take
the medication sotalol.
There are several things you can do to manage your heart failure
and avoid having fluid back up in your lungs again:
1. Weigh yourself every morning. Call your doctor if your weight
goes up more than 3 lbs.
2. You expressed a strong commitment to cutting down on the salt
in your diet. If you can keep your sodium intake down to less
than 2 grams per day, this will help keep the water weight off.
The best thing you can do to avoid more problems with atrial
fibrillation is to take your sotalol every day as prescribed and
to continue to take your Coumadin.
New medications were started at this visit. They are:
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16050305", "visit_id": "26777020", "time": "2157-11-04 00:00:00"} |
15649228-RR-12 | 131 | ## EXAMINATION:
CHEST (PA AND LAT)
## INDICATION:
year old man with ILD, on 30/d pred and 750 bid cellcept and 1
wk of increased SOB and cough// assess for worsening of ILD or pneumonia
## FINDINGS:
PA and lateral views of the chest provided. Coarsened lung markings reflect
known interstitial lung disease better assessed on the prior CT chest exam.
Prominence of the cardiac silhouette in part reflect prominent epicardial fat
pads. Mediastinal contour is stable. No definite signs of a superimposed
pneumonia though given background fibrosis, a subtle infectious process is
impossible to exclude. No large effusion, pneumothorax or signs of edema.
Bony structures are intact. No free air below the right hemidiaphragm.
## IMPRESSION:
Similar overall pattern of interstitial lung disease. No definite signs of
superimposed pneumonia or edema.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15649228", "visit_id": "N/A", "time": "2135-01-20 13:44:00"} |
14417931-DS-12 | 2,198 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
EGD and clipping of mucosal tear
## HISTORY OF PRESENT ILLNESS:
is a year old women with a history of esophageal
strictures s/p dilatation, HTN who came into the ED to visit her
husband, developed chest pain and was ultimately found to have a
large linear mucosal tear of the esophagus that was partially
closed with clips given that some tissue was too denuded for
approximation.
Patient reports that at baseline she occasionally experiences
dysphagia for solids, feeling like food is getting stuck in her
esophagus, although this is mild and intermittent. She was
otherwise well until yesterday afternoon. While in the ED she
was
eating a muffin and felt like it became caught in her esophagus.
She subsequently regurgitated some of it and developed
sub-sternal tearing non-radiating chest pain. She had several
episodes of regurgitating bloody material. She denies any
difficulty breathing, cough, subjective fevers, chills,
light-headedness, abdominal pain, vomiting, diarrhea,
hematochezia, melena, dysuria, rash, or swelling.
While in the ED, she underwent EGD on revealed a linear
tear
from 26 to 38cm below the incisors, s/p clipping (10 clips).
She was febrile this AM to 102, but remained hemodynamically
stable, and subsequently has been afebrile. Her labs are notable
for a leukocytosis to 12.8. Her imaging included a CT chest and
a
barium esophagram - both negative for perforation and
mediastinitis, notably performed after the EGD. She was started
on Zosyn and Fluconazole, PPI, and strict NPO. Barium esophagram
was negative for perforation. She was admitted for further
management of esophageal tear without perforation.
On arrival to the floor, the patient feels well and denies any
current pain. She does feel that her throat is very dry since
she
has been NPO. She denies current subjective fevers, chills,
light-headedness, chest pain, SOB, cough, n/v/d, abdominal pain,
dysuria, or rash.
## PAST MEDICAL HISTORY:
PAST MEDICAL HISTORY
-Esophageal strictures
-Short segment
-Multilevel cervical arthropathy
-Lumbar arthropathy lumbar with neurogenic claudication
-Ménière's disease
-Hypertension
-Homocystinemia
-Hyperlipidemia
-Melanoma in situ status post resection
-CVA in
-Anemia
PAST SURGICAL HISTORY
-Bougie dilation of esophageal strictures
-Cervical spine decompression
-Multiple lumbar decompressive surgeries
## FAMILY HISTORY:
-Mother with disease, thyroid cancer
-Father with hypertension
-Daughter with hypothyroidism
## ADMISSION PHYSICAL EXAM
1611 TEMP:
98.6 PO BP: 164/82 L Sitting HR: 74 RR: 18
O2
sat: 98% O2 delivery: Ra
## GENERAL:
WDWN older woman in NAD
## HEENT:
NCAT, sclerae anicteric, normal conjunctivae, PERRLA,
EOMI, oropharynx clear
## CARDIAC:
RRR, normal S1/S2, no m/r/g. No chest wall tenderness.
No chest wall or supraclavicular crepitus.
## LUNGS:
CTAB, no increased work of breathing
## ABDOMEN:
Soft, non-tender, non-distended, normoactive BS
## EXTREMITIES:
Warm, DP pulses 2+ bilaterally, no edema
## NEUROLOGIC:
A&Ox3, CN grossly intact
DISCHARGE PHYSICAL EXAM
## GENERAL:
Lying comfortably in bed in NAD
## HEENT:
NCAT, sclerae anicteric, normal conjunctivae, PERRLA,
EOMI, oropharynx clear, no erythema or exudate
## CARDIAC:
RRR, normal S1/S2, no m/r/g. No chest wall tenderness.
No chest wall or supraclavicular crepitus.
## LUNGS:
CTAB, no increased work of breathing
## ABDOMEN:
Soft, non-tender, non-distended, normoactive BS
## EXTREMITIES:
Warm, DP pulses 2+ bilaterally, no edema
## NEUROLOGIC:
A&Ox3, CN grossly intact
## HEART AND VASCULATURE:
The thoracic aorta is normal in caliber
without
evidence of dissection or intramural hematoma. The main
pulmonary artery is
enlarged measuring up to 3.7 cm (4:105), which can be seen in
pulmonary artery
hypertension. There is no central pulmonary embolus. The heart
is mildly
enlarged. Pericardium and remaining great vessels are within
normal limits.
Trace pericardial effusion is seen.
## AXILLA, HILA, AND MEDIASTINUM:
Oral contrast is seen layering in
a patulous
esophagus without evidence of extraluminal extension to indicate
esophageal
perforation. There is a small amount of fluid tracking along
the right aspect
of the mid to distal esophagus (601:50), and a small amount of
fluid and fat
stranding are seen along the left posterolateral aspect of the
mid esophagus
(2:2 26). There is mild circumferential wall thickening
involving the mid and
distal esophagus. Several intraluminal hemoclips are seen along
the posterior
wall of the mid esophagus and within the distal esophagus, near
the
gastroesophageal junction. There is no evidence of
pneumomediastinum. There
is no organized mediastinal fluid collection.
No axillary, mediastinal, or hilar lymphadenopathy is present.
No mediastinal
mass.
## PLEURAL SPACES:
There are trace bilateral pleural effusions. No
pneumothorax.
## LUNGS/AIRWAYS:
There are diffuse scattered centrilobular
nodular
and ground-glass opacities in the right upper lobe, right lower
lobe, and left
upper lobe lungs, suggestive of aspiration. No focal
parenchymal
opacification is seen. The airways are patent to the level of
the segmental
bronchi bilaterally.
## BASE OF NECK:
Note is made of anterior cervical fusion
hardware, unchanged.
Limited upper abdomen is remarkable for a partially seen 1.1 cm
left upper
pole renal cyst and a mildly complex right renal upper pole 1.3
cm cyst.
There is a sclerotic lesion in the right aspect of the T9
vertebral body,
possibly a bone island, although not definitely seen on a prior
MR
from .
## IMPRESSION:
1. No oral contrast extravasation to suggest esophageal
perforation. No
pneumomediastinum.
2. Multiple hemoclips within the mid and distal esophagus. Mild
esophageal
wall thickening in the mid and distal esophagus suggestive of
mild esophagitis
with small amount of fluid and fat stranding about the left
posterolateral
aspect of the mid esophagus, and a small amount of fluid
tracking along the
right mid and distal esophagus. No organized fluid collection
identified.
3. Diffuse scattered centrilobular nodular opacities
in both upper
lobes and right lower lobe indicative of aspiration.
4. Trace bilateral pleural effusions.
5. Mildly complex 1.3 cm right upper pole renal cyst for which
nonemergent
renal ultrasound is suggested for further assessment.
6. A sclerotic lesion is noted in the T9 vertebral body,
possibly bone island
although not definitely seen on a prior MR from . If
there is any history of malignancy, consider further assessment
with a bone
scan.
7. Mildly dilated pulmonary artery can be seen in the setting of
pulmonary
artery hypertension, but clinical correlation is needed.
## RECOMMENDATION(S):
1. Dedicated nonemergent renal ultrasound can be obtained for
further
evaluation of the right upper pole renal cyst.
2. Bone scan can be obtained for further assessment of the
sclerotic focus in
the T9 vertebral body if there is a history of malignancy.
EGD ( )
Upon entry to the esophagus, moderate amount of mucus and blood
was seen. After irrigation, a large linear mucosal tear was
noted, starting at approximately 26cm from the incisors, and
continuing to approximately 38cm. The submucosal space was in
fact more patent than the esophageal lumen, but the scope could
be carefully advanced into the stomach, and no discrete luminal
narrowing or mass is seen.
resolution clips were used to approximate the
mucosa starting at the distal edge of the tear. Closure was
possible for about 6-8cm using approximately 8 clips, however,
above this, there mucosa along the left edge of the tear was too
denuded for approximation. An additional 2 clips were placed at
the proximal edge of the tear.
CXR ( )
## FINDINGS:
Again demonstrated, are multiple posterior mediastinal clips
unchanged.
Lung volumes are better ventilated. Bibasilar opacities likely
represent
atelectasis. There is persistent small right pleural effusion.
There is
interval decrease in the small left pleural effusion. No frank
pulmonary
edema. The cardiomediastinal silhouette is enlarged but
unchanged. No
appreciable pneumothorax. No evidence of pneumomediastinum.
## IMPRESSION:
Better lung ventilation. Persistent small right pleural
effusion with
improvement of small left pleural effusion. No evidence of
pneumomediastinum.
Barium Swallow ( )
## FINDINGS:
Scout radiograph demonstrates numerous clips in the distal
esophagus related
to the recent procedure.
Contrast passes through the esophagus without evidence of a
perforation.
Note is made of an absent peristaltic wave and featureless
esophagus. The
caliber of the distal of the esophagus is mildly narrowed,
possibly the
site of the known recently dilated stricture.
## IMPRESSION:
No extravasation of orally ingested contrast to suggest
leak/perforation.
## BRIEF HOSPITAL COURSE:
Ms. is a F w/ esophageal strictures who came into
the ED to visit her husband, developed chest pain and was
ultimately found to have a large linear mucosal tear of the
esophagus that was partially closed with clips, now stabilized
post-EGD advancing diet as tolerated.
## ACUTE ISSUES:
============
#Esophageal mucosal tear s/p clipping #Esophageal strictures
## ESOPHAGUS:
Patient presented with acute onset chest
pain, found on EGD to have linear esophageal tear s/p clipping.
Barium swallow negative for perforation, no pneumomediastinum on
CXR. Chest CT not suggestive of mediastinitis, but with evidence
of aspiration, small bilateral pleural effusions. No current
pulmonary symptoms to suggest active pneumonia. Patient
currently afebrile, hemodynamically stable, will continue
empiric antibiotics. GI and thoracic surgery following.
Tolerated clear liquids for breakfast AM of without
increase in pain or difficulty swallowing. Diet was slowly
advanced from NPO to clear to full liquids and soft solids.
Covered empirically with Zosyn 4.5MG IV q8H, fluconazole 200MG
IV q24H per thoracic surgery and discontinued AM of .
Received Pantoprazole 40MG IV q12H which was transitioned to PO
omeprazole 40 BID upon discharge. Also received IV fluids.
## #NORMOCYTIC ANEMIA:
Patient reports long-standing history of
anemia of unclear etiology. Unclear prior work-up based on OMR
review. Per patient not thought to be secondary to GI bleeding.
Unclear recent baseline. Iron studies consistent with iron
deficiency anemia with transferrin sat ~5%. Unlikely hemolysis
given haptoglobin is not low (sensitive test for hemolysis).
Received IV ferric gluconate 125mg x1.
#Sclerotic T9 vertebral body lesion #Weight loss: Per radiology
report "Bone scan can be obtained for further assessment of the
sclerotic focus in the T9 vertebral body if there is a history
of malignancy". Noted incidentally on chest CT. Patient endorses
25lb unintentional weight loss over recent months. Last
colonoscopy in w/sessile polyp s/p polypectomy, recommended
for repeat in years.
## #RENAL CYST:
Noted incidentally on chest CT. Consider renal US
as outpatient
## ===============
#HTN:
Resumed home HCTZ, held amlodipine but resumed on
discharge
## #ANXIETY:
resumed home citalopram
#Cervical Spondylosis #Lumbar Spinal Stenosis #Neurogenic
## CLAUDICATION:
Patient w/gait instability, limited mobility at
baseline. was consulted.
## #MENIERE'S DISEASE:
Patient reports positional vertigo at
baseline.
## TRANSITIONAL ISSUES:
===================
[ ] Patient will require GI follow-up and repeat endoscopy in
weeks with primary gastroenterologist Dr.
at Endoscopy .
[ ] Patient was discharged on omeprazole 40 BID which will need
to be continued for at least 8 weeks; can discuss with primary
gastroenterologist about transitioning back to home dose
(omeprazole 20 daily).
[ ] Recommend repeat renal ultrasound as outpatient to evaluate
right upper pole renal cyst seen incidentally on chest CT
(mildly complex 1.3 cm right upper pole renal cyst).
[ ] Recommend repeat outpatient bone scan and further malignancy
work-up (e.g. colonoscopy) as outpatient given sclerotic lesion
noted in the T9 vertebral body seen incidentally on chest CT,
possibly bone island although not definitely seen on a prior MR
from .
[ ] Recommend age appropriate screening for further workup of
iron deficiency anemia and consider treatment with PO/IV iron as
able.
## #CODE:
Full Code (confirmed)
#CONTACT: (husband, HCP)
on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Rosuvastatin Calcium 5 mg PO QPM
5. Citalopram 30 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
## CAPSULE REFILLS:
*1
2. amLODIPine 5 mg PO DAILY
3. Citalopram 30 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Rosuvastatin Calcium 5 mg PO QPM
## PRIMARY DIAGNOSIS:
================
Esophageal mucosal tear
## SECONDARY DIAGNOSIS:
===================
Esophageal strictures
Esophagus
Pleural effusion
Normocytic Anemia
Sclerotic T9 vertebral body lesion
Renal cyst
Hypertension
Hyperlipidemia
Cervical Spondylosis
Lumbar Spinal Stenosis
Neurogenic Claudication
Meniere's Disease
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure to care for you at the
.
Why did I come to the hospital?
-You had pain in your chest after eating.
What happened while I was in the hospital?
-An endoscopy found a mucosal tear in your esophagus which was
repaired with clips.
-You underwent chest x-ray and chest CT, which showed some signs
of aspiration and trace pleural effusions
-Barium swallow showed no signs of perforation
-You were given IV antibiotics and IV fluids
-At first you were kept NPO but starting , you
were slowly advanced from clear liquid to full liquid to soft
diet, which you tolerated.
What should I do once I leave the hospital?
- Please continue taking all your medications as prescribed.
- If you experience worsening if chest pain, nausea, vomiting,
or vomit blood, please come to the emergency department
immediately to be evaluated.
- Please attend any outpatient appointments you have upcoming.
You will need a repeat endoscopy in weeks.
- Please take omeprazole 40mg twice a day (instead of omeprazole
20 daily). You will need to take this for at least 8 weeks.
Please ask your GI doctor about how long you should remain on
this higher dose.
- Please continue to eat a soft diet for at least 1 week after
discharge or unless otherwise instructed by your outpatient GI
doctor
wish you the best!
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14417931", "visit_id": "29941411", "time": "2189-04-28 00:00:00"} |
10454216-RR-145 | 234 | ## INDICATION:
year old man with hemorrhagic areas w/ edema biopsy necrosis ?
interval change // ? interval change
## FINDINGS:
Again seen is extensive edema in the temporal and parietal lobes as well
as the occipital and posterior parietal robust bilaterally. Again seen is
edema in the cerebellar hemisphere. There is hemorrhage in each of
these locations with evidence of new hemorrhage since the prior studies.
There is abnormal enhancement without hemorrhage in the hippocampus.
There is a small focus of enhancement in the dorsal midbrain.
There is striking enhancement of all of the abnormal areas with a
predominantly cortical pattern. Overall, the degree of enhancement appears
somewhat greater than on the study of . cerebellar mass
effect and deformity of the fourth ventricle are more prominent than on the
prior brain MR. hemispheric mass effect now with mild
midline shift is increased since the prior brain MR.
are postoperative changes after craniectomy for biopsy. A small
postoperative epidural hematoma appears unchanged since the head CT of
.
There are new areas of signal abnormality, hemorrhage or enhancement.
## IMPRESSION:
Progressive edema and enhancement since the prior brain MR.
evidence of new lesions or new hemorrhage.
The progressive edema and enhancement argue against a simple infarction as the
etiology. Although the timing of onset of the process appears uncertain, the
continued increase in enhancement and edema would raise a concern of
superimposed infection if infarction is the underlying process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10454216", "visit_id": "29763497", "time": "2164-09-09 00:47:00"} |
13798580-DS-15 | 2,272 | ## ALLERGIES:
Ace Inhibitors / colchicine / Bactrim / trimethoprim /
vancomycin
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Transesophageal echocardiogram
Skin biopsy
## HISTORY OF PRESENT ILLNESS:
with PMH afib on Coumadin, rheumatic heart disease s/p
MVR/AVR (mechanical), lung adenocarcinoma s/p resection c/b vent
necessity ( ), HTN, HLD, CHB s/p dual-chamber
pacemaker, presenting from with pain and rash to
hands and feet.
Of note, patient had a recent prolonged hospitalization from
to after being admitted for worsening SOB after a CT guided
lung biopsy. He was found to have a large hemothorax requiring
CT
placement and ICU admission. His ICU course was c/b PEA arrest
attributed to hypoxic respiratory failure prompting intubation.
He was unable to be extubated and a trach/PEG was placed. He
required multiple blood transfusions throughout the
hospitalization, was cautiously restarted on anticoagulation
prior to discharge, transitioned to home Coumadin, and
discharged
to .
At , patient was reportedly doing well. He completed
a course of levofloxacin and vancomycin for citrobacter/MRSA
tracheobronchitis c/b citrobacter bacteremia which the patient
completed 2 days prior to admission. He was evaluated by the
physician at the rehab and noted to have He has had raised, red
lesions on his hands and dark lesions on his feet were notably
new. The rash on his hands were pruritic while those in his
lower
extremities were reported to be painful. Wound cultures from his
leg (unclear where) grew MRSA. Patient otherwise denies any
hemoptysis, hematochezia, neck pain, congestion, dyspnea, chest
pain, abdominal pain, diarrhea, joint pains or stiffness,
fevers,
weight loss, or vision changes.
Patient has been on stable vent settings at 5/5/50% since his
discharge from the hospital and was intermittently able to
tolerate TM trials.
In the ED,
## GENERAL:
chronically ill appearing elderly male on vent. NAD.
## SKIN:
scattered punctate hemorrhages to the soles of the feet,
hemorrhagic bullae to the right first toe. Scattered purpura to
the upper extremities.
## ABDOMEN:
protuberant, soft, non-tender, no HSM
## LABS:
WBC 13.7, Hgb 7.7 (at baseline), AP 150s, BNP 1443, trop
0.02, UA w/ 7
## IMPRESSION:
1. New hazy opacification of the right lung base suggesting a
right pleural effusion. Associated right basilar parenchymal
opacity concerning for acute infectious process versus
substantial atelectasis.
2. Similar appearance of left lower lung with underlying pleural
effusion and likely atelectasis.
## PAST MEDICAL HISTORY:
Rheumatic heart disease w/ MS & AS s/p MVR/AVR ( )
CAD s/p stent
HTN
HLD
Afib
CHB s/p dual-chamber pacemaker
COPD
Severe pulmonary hypertension
Hyperprolactinemia ( )
Drug-induced vs. idiopathic thrombocytopenia
Invasive lung adenocarcinoma s/p wedge resection
PEA arrest/hypoxic respiratory failure s/p trach/PEG
Leukocytoclastic vasculitis
Positive hepatitis B core antibody
## FAMILY HISTORY:
Per chart review, father had prostate cancer, 2 uncles with
unknown malignancy.
## GENERAL:
Pleasant man sitting in bed in NAD
## HEENT:
PERRL, EOMI. Sclera anicteric and without injection. MMM.
## CARDIAC:
Regular rhythm, normal rate. Mechanical click.
## LUNGS:
Clear to auscultation bilaterally. L basilar crackles, No
increased work of breathing. Dressing on back c/d/I
without evidence of hematoma,
## ABDOMEN:
Normal bowels sounds, mildly distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
## SKIN:
chronic venous stasis changes to the bilaterally,
scattered punctate hemorrhages to the soles of the feet,
hemorrhagic bullae to the right first toe. Scattered purpura in
the dorsal hands bilaterally.
## NEUROLOGIC:
Alert and oriented, moving all extremities with
purpose.
## GENERAL:
Pleasant man sitting in bed in NAD
## HEENT:
PERRL, EOMI. Sclera anicteric and without injection. MMM.
## CARDIAC:
Regular rhythm, normal rate. Mechanical click.
## LUNGS:
Clear to auscultation bilaterally. L basilar crackles, No
increased work of breathing. Dressing on back c/d/I
without evidence of hematoma,
## ABDOMEN:
Normal bowels sounds, mildly distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
## SKIN:
chronic venous stasis changes to the bilaterally,
scattered punctate hemorrhages to the soles of the feet,
hemorrhagic bullae to the right first toe and plantar aspect of
foot. Scattered purpura in
the dorsal hands bilaterally.
## NEUROLOGIC:
Alert and oriented, moving all extremities with
purpose.
## IMPRESSION:
Well seated, normal functioning bileaflet AVR with
normal gradient and trace aortic regurgitation. Well seated,
normal functioning bileaflet MVR with normal gradient and no
mitral
regurgitation. Moderate to severe pulmonary artery systolic
hypertension. Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global systolic
function. Mildly dilated ascending aorta. No discrete vegetation
identified.
LUENI
## IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
TEE
## IMPRESSION:
No discrete vegetation or abscess seen. At least
moderate to severe tricuspid
regurgitation.
Skin biopsy pathology
- Small vessel vascular injury with focal fibrin deposition,
associated neutrophilic inflammation,
leukocytoclasia, and extravsated erythrocytes consistent with
leukocytoclastic vasculitis, see note.
## NOTE:
The findings are consistent with leukocytoclastic
vasculitis. The degree of inflammation is
more than usually observed in septic vasculitis or a thrombotic
vasculopathy and no thrombi are
identified. Of note, rarely lesions of infective endocarditis
may show a leukocytoclastic vasculitis;
however, this is not the usual histopathologic pattern observed.
Gram stain is negative for bacteria.
PAS and GMS stains are negative for fungi. No fibrin thrombi are
seen with CD42. Preliminary
results were sent to Dr. via internal email on
.
CLINICAL
## BRIEF HOSPITAL COURSE:
with PMH afib on Coumadin, rheumatic heart disease s/p
MVR/AVR (mechanical), lung adenocarcinoma s/p resection c/b vent
necessity ( ), HTN, HLD, CHB s/p dual-chamber
pacemaker, presenting from with pain a purpuric
rash on his hands and feet, which was consistent with
leukocytoclastic vasculitis on biopsy. He had recently been
treated with multiple antibiotics for tracheitis
# Leukocytoclastic vasculitis:
Noted to have palpable, pruritic purpuric rash in the dorsal
upper extremities with painful purpura and hemorrhagic blisters
on the feet bilaterally. Dermatology consulted and biopsied a
lesion on his left hand, with biopsy showing leukocytoclastic
vasculitis. He had a panel of labs sent which were either
unrevealing or pending at discharge including hepatitis panel,
cyroglobulins, ANCA, , RF, complement and PEP.
Regarding the offending agent, he had recently received multiple
antibiotics at rehab for citrobacter/MRSA tracheobronchitis, as
well as citrobacter bacteremia. He received vanc/zosyn around
. On isolate returned zosyn resistant so switched to
vanc/cefepime. This was ultimately narrowed to vanc/levofloxacin
which finished on . The most likely offending agents were
the levofloxacin or the vancomycin, with levofloxacin seemingly
more likely to cause leukocytoclastic vasculitis. Warfarin was
held initially on admission due to concern it could be the
culprit but this was felt unlikely so he was restarted prior to
discharge.
Due to concern that the lesions could be related to
endocarditis, he underwent a TTE that showed no vegetations and
a TEE On which showed no vegetations. He had no positive
blood cultures and ultimately it was felt most likely this was
related to drug reaction as above.
## #ACUTE ON CHRONIC RESPIRATORY FAILURE:
Patient with chronic
ventilator dependence on trach mask trials at his facility. He
was continued on home bumex and was table to tolerate 3 hours
off the vent on before becoming hypoxic and going back on
the vent.
## #LUE SWELLING:
Likely chronic lymphedema. US negative for DVT.
## # BLOODY SECRETIONS:
Suspected that this is a result of some
pulmonary
edema causing increased hydrostatic pressure with some bleeding
given anticoagulation, vs. tracheal trauma from suctioning. CXR
with only increased pulmonary edema; sputum cx with GPR.
Improved with additional diuresis with Bumex gtt. He received 2x
dose of home bumex 2 mg BID on day of discharge and likely can
be transitioned back to home dose when he is euvolemic.
## #TROPONINEMIA
#ELEVATED BNP:
Mildly elevated trop 0.02. EKG V-paced, without
obvious STTW changes. Echo without new ischemic changes.
## #LEUKOCYTOSIS:
Likely residual from recently treated infection.
CXR with possible opacity though patient without respiratory
symptoms or increased vent requirements. UA bland. No abdominal
symptoms. Cultures had no growth and endocarditis workup
negative as above.
#Lung adenocarcinoma
#Chronic respiratory failure s/p trach/PEG: Pall care team
following patient at . On minimal vent settings currently.
# Afib
# Mechanical AVR/MVR on warfarin
Has a history of rheumatic heart disease s/p mechanical AVR and
MVR, as well as afib and complete heart block s/p pacemaker. His
Coumadin was held as above as initial concern it could be
culprit for the leukocytoclastic vasculitis, and was bridged
with heparin. It was felt the antibiotics were more likely
culprit so warfarin restarted prior to discharge. He was dosed
with warfarin and was discharged with heparin gtt as bridge
until he is back to therapeutic level for warfarin. Home
metoprolol continued.
## # CHRONIC NORMOCYTIC ANEMIA:
Required 1u pRBC trasnfusion for
hgb 6.8 but overall was near his baseline. Acute on chronic
anemia due to bloody secretions per above.
# CAD
# HTN
# HLD
# Peripheral vascular disease
- Continued home metoprolol, atorvastatin, aspirin, losartan,
bumex
# COPD
- Continued home duonebs, albuterol PRN
# Pain
- Continued home Tylenol. Gabapentin was increased due to pain
in his feet from the lesions. He preferred gabapentin over
narcotics.
## ISSUES:
[] FOR PATIENT'S PROBLEM LIST:
patient has a positive hepatitis
B core antibody and surface antibody
[] He should continue to work with but will need boot and
pain control as he has significant pain from the foot lesions
[] gabapentin increased for foot pain, he did not want opiates
and Tylenol was not adequate
[] Avoid vanc or levaquin if able given possibly triggered LCV,
but reasonable to trial if needed
[] Diuresis increased to 4 mg PO BID given pulmonary edema on
CXR, please de-escalate to regular dose of 2 mg PO on or
pending volume status exam.
[] Patient transfused 1 U pRBC prior to discharge for Hgb 6.7 on
day of discharge. His anemia is chronic and no clear source of
blood loss was identified besides some bloody secretions likely
trauma from TEE. Please check CBC on and trend PRN.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PR PRN Constipation - Second Line
2. Gabapentin 300 mg PO BID
3. Gabapentin 600 mg PO QHS
4. Lactulose 15 mL PO DAILY:PRN constipation
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Metoprolol Tartrate 25 mg PO Q6H
7. Polyethylene Glycol 17 g NG DAILY
8. Simethicone 80 mg PO TID
9. Aspirin 81 mg NG DAILY
10. Warfarin 10 mg PO DAILY
11. Losartan Potassium 25 mg PO BID
12. Albuterol Inhaler 2 PUFF IH Q6H
13. Pulmicort (budesonide) 0.25 mg/2 mL inhalation Q12H
14. Acetylcysteine 20% mL NEB Q4H:PRN secretions
15. Bumetanide 2 mg PO BID
16. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
17. Vitamin D 1000 UNIT NG DAILY
18. Ipratropium Bromide MDI 2 PUFF IH Q6H
19. melatonin 5 mg oral QHS
20. Mirtazapine 7.5 mg PO QHS
21. Pravastatin 40 mg PO QPM
22. TraZODone 100 mg PO QHS
23. Creon 12 2 CAP PO PRN declog feeding tube
24. Sodium Bicarbonate 650 mg PO PRN declog feeding tube
25. Docusate Sodium (Liquid) 100 mg NG BID
26. Acetaminophen (Liquid) 975 mg NG TID:PRN Pain - Mild/Fever
27. budesonide 0.25 mg/2 mL inhalation Q12H
28. omeprazole magnesium 40 mg oral DAILY
29. Senna 17.2 mg NG QHS
## DISCHARGE MEDICATIONS:
1. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
2. Heparin IV Sliding Scale
No Initial Bolus
Start infusion with rate of: 1550 units/hr
## THERAPEUTIC/TARGET PTT RANGE:
60 - 99.9 seconds
3. Bumetanide 4 mg PO BID
4. Acetaminophen (Liquid) 975 mg NG TID:PRN Pain - Mild/Fever
5. Acetylcysteine 20% mL NEB Q4H:PRN secretions
6. Albuterol Inhaler 2 PUFF IH Q6H
7. Aspirin 81 mg NG DAILY
8. Bisacodyl 10 mg PR PRN Constipation - Second Line
9. Budesonide 0.25 mg/2 mL inhalation Q12H
10. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
11. Creon 12 2 CAP PO PRN declog feeding tube
12. Docusate Sodium (Liquid) 100 mg NG BID
13. Gabapentin 300 mg PO BID
14. Gabapentin 600 mg PO QHS
15. Ipratropium Bromide MDI 2 PUFF IH Q6H
16. Lactulose 15 mL PO DAILY:PRN constipation
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Losartan Potassium 25 mg PO BID
19. melatonin 5 mg oral QHS
20. Metoprolol Tartrate 25 mg PO Q6H
21. Mirtazapine 7.5 mg PO QHS
22. omeprazole magnesium 40 mg oral DAILY
23. Polyethylene Glycol 17 g NG DAILY
24. Pravastatin 40 mg PO QPM
25. Pulmicort (budesonide) 0.25 mg/2 mL inhalation Q12H
26. Senna 17.2 mg NG QHS
27. Simethicone 80 mg PO TID
28. Sodium Bicarbonate 650 mg PO PRN declog feeding tube
29. TraZODone 100 mg PO QHS
30. Vitamin D 1000 UNIT NG DAILY
31. Warfarin 10 mg PO DAILY
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure treating you at !
Why was I admitted to the hospital?
-You were admitted because you had a rash, and we were concerned
that it was caused by a medication or an infection.
What happened while I was admitted?
-You had a biopsy of the rash that showed a process called
leukocytoclastic vasculitis, which may have been an reaction to
one of the medications.
-You had an ultrasound of your heart that did not show any
evidence of infection on the heart valves.
-We gave you a blood transfusion because your blood levels were
low.
-We increased your diuretic medicines to help take fluid off of
your body.
What should I do when I return home?
-Please attend all of your follow-up appointments, and take your
medications as directed.
We wish you the best!
Your care providers
:
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13798580", "visit_id": "25988418", "time": "2186-01-18 00:00:00"} |
12373064-RR-10 | 108 | ## HISTORY:
Ulcerative colitis with left lower extremity pain.
## FINDINGS:
Grayscale, color, and spectral Doppler evaluation was performed of the
bilateral lower extremity veins. There is normal phasicity of the common
femoral veins bilaterally. There is normal compression and augmentation of
the bilateral common femoral, proximal femoral, mid femoral, distal femoral,
popliteal, posterior tibial, and peroneal veins. Targetted sonographic
examination of the right posterolateral mid-thigh in the region of concern
demonstrates a 1.5 x 0.7 x 2.1 cm hyperechoic lesion with minimal posterior
acoustic shadowing consistent with a lipoma.
## IMPRESSION:
No evidence of DVT in either the right or the left lower extremity.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12373064", "visit_id": "23743503", "time": "2143-10-04 22:38:00"} |
15565801-RR-14 | 246 | ## INDICATION:
year old man with w/ aggressive typebilateral
hemispheric cerebral presentation of multiple sclerosis who presented to ED
with altered mental status, confusion, and psychosis// We would like to know
if his MS has progressed since the patient's last MRI on
## FINDINGS:
There is evidence of acute intracranial infarction or hemorrhage. mass
effect. Again seen are multiple bilateral, areas confluent, white matter
T2/FLAIR hyperintense lesions in a periventricular distribution and involving
the splenium of the corpus callosum (for example, 101:81), as well as a
similar lesion in the left mid brain (101:37). A few of these lesions within
the centrum semiovale demonstrate marked T1 hypointensity (03:18). These are
most consistent with demyelinating lesions. There is evidence of an
enhancing lesion. Overall, this appearance is stable from prior study of . A right occipital developmental venous anomaly is unchanged
(13:11).
Prominence of the ventricles and sulci are consistent with cortical volume
loss, unchanged since the prior exam, however, significantly advanced for
patient's age. Major intracranial vascular flow voids are preserved. Major
dural venous sinuses are patent. The globes are unremarkable. There is mild
left maxillary sinus mucosal thickening (12:1).
## IMPRESSION:
1. Stable appearance of demyelinating lesions predominantly seen in the
bilateral periventricular white matter but also involving the corpus callosum
and brainstem, consistent with stated history of MS. enhancing lesions.
2. Otherwise, acute intracranial abnormality.
3. Global involutional change which is significantly advanced for this
patient's age.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15565801", "visit_id": "27425726", "time": "2149-03-21 10:37:00"} |
13876205-RR-10 | 327 | ## INDICATION:
year old man with newly identified brain lesion //
Prognostication of brain lesion.
## FINDINGS:
Within the left frontal lobe, a large complex enhancing mass is seen measuring
approximately 3.3 cm x 6.5 cm by 3.7 cm, with internal T2 hyperintense
components suggestive of necrosis and susceptibility artifact within this
lesion suggestive of blood products. Mild vasogenic edema is seen surrounding
this lesion, which demonstrates mass effect on the superior surface of the
body of the left lateral ventricle. As well as superior midline shift to the
right by approximately 8 mm, overall unchanged compared to the prior exam.
There is slight extension of this mass crossing midline. The mass appears to
invade into the body of the left corpus callosum and appears to extend
inferiorly to the level of thalamus. The left anterior cerebral artery
appears to traverse this mass. A slightly linear enhancing focus is seen
within the right frontal lobe measuring up to 6 mm, series 100, image 79.
No marrow signal abnormalities are identified. The principal flow voids are
otherwise well preserved. Subtle areas of restricted diffusion along the
margin of this mass could be secondary to the hyper cellularity or local mass
effect.
## IMPRESSION:
1. Large complex enhancing mass within the left frontal lobe measuring up to
6.5 cm with evidence of internal necrosis and blood products resulting an
surrounding vasogenic edema and mass effect on the superior margin of the body
of the left lateral ventricle, invasion into the left corpus callosum with
extension to the left thalamus. The left A4 and A5 segments of the anterior
cerebral artery appears to traverse this mass. There is midline shift to the
right as well as possible extension of this mass across midline.
2. Linear enhancing focus within the right frontal lobe measures up to 6 mm,
series 100, image 79, could be secondary to a satellite lesion.
## NOTE:
Differential considerations include a glial neoplasm or metastatic
disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13876205", "visit_id": "20547499", "time": "2176-02-06 02:14:00"} |
12076472-RR-41 | 138 | ## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN)
## INDICATION:
female with intermittent abdominal pain and new liver
function abnormality.
## LIVER:
The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD measures 3 mm.
## GALLBLADDER:
There is no evidence of stones or gallbladder wall thickening.
Within the gallbladder, there is evidence of layering sludge. Distention of
the gallbladder is thought likely to be sequela of remote last meal.
## PANCREAS:
Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
## IMPRESSION:
Sludge within the gallbladder without evidence of cholelithiasis or
cholecystitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12076472", "visit_id": "N/A", "time": "2137-10-01 03:03:00"} |
16904821-RR-20 | 284 | ## INDICATION:
Lumbago // Lumbago ** Per .: was called
and patient doesn't need auth until after . ** Lumbago, ** Per .: care was called and p
## FINDINGS:
Alignment is normal. Vertebral body signal intensity appear normal. The
spinal cord appears normal in caliber and configuration, conus terminates at
mid L2 level.
Advanced degenerative changes lumbar spine. Multilevel diffuse disc bulges.
Multilevel disc space narrowing, most prominent at L3-L4 level, were there is
probable osseous fusion across disc space. Severe lower lumbar facet
arthritis at L4-5 level. Mild posterior element edema L4-5, likely
degenerative. Small synovial cyst about posterior left L4-5 facet joint,
largest measures 0.7 cm extending along the paraspinal process.
L1-L2 level: Mild central canal narrowing. Mild right, mild to moderate left
foraminal narrowing.
L2-L3 level: Moderate central canal narrowing, preserved CSF within thecal
sac. Tiny right paramedian, inferior disc protrusion. Left far lateral,
extra foraminal prominent osteophyte, diffuse disc bulge contacts exited left
L2 nerve. . Moderate to severe bilateral foraminal narrowing.
L3-L4 level: Partial effacement right lateral thecal sac from facet
arthropathy, endplate osteophyte, partial encroachment on traversing
intrathecal right L4 nerve. Mild central canal narrowing. Moderate to severe
right, moderate left foraminal narrowing.
L4-5 level: Moderate central canal narrowing. Prominent ligamentum flavum.
Preserved CSF within thecal sac. Encroachment upon bilateral traversing L5
nerves. Severe bilateral foraminal narrowing.
L5-S1 level: Patent central canal. Mild-to-moderate bilateral foraminal
narrowing.
Bilateral cystic lesions in the kidneys, likely benign simple cysts.
## IMPRESSION:
1. Advanced degenerative arthritis lumbar spine.
2. Moderate central canal narrowing L2-L3, L4-5 levels.
3. Multilevel foraminal narrowing, severe at bilateral L4-5 foraminal.
4. Cystic lesions bilateral kidneys, likely benign simple cysts.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16904821", "visit_id": "N/A", "time": "2136-11-22 17:43:00"} |
15810905-RR-15 | 467 | ## EXAMINATION:
CTA HEAD AND CTA NECK PQ147 CT HEADNECK
## INDICATION:
year-old male with right upper extremity and right facial
weakness 4 days ago evaluate for hemorrhage or infarct.
## DOSE:
This study involved 6 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) CT Localizer
Radiograph 4) Sequenced Acquisition 8.0 s, 20.0 cm; CTDIvol = 56.1 mGy (Head)
DLP = 1,121.4 mGy-cm. 5) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3
mGy (Head) DLP = 32.7 mGy-cm. 6) Spiral Acquisition 5.2 s, 40.9 cm; CTDIvol =
31.9 mGy (Head) DLP = 1,303.7 mGy-cm. Total DLP (Head) = 2,458 mGy-cm.
## CT HEAD WITHOUT CONTRAST:
No hemorrhage, edema, or mass is identified. There is a hypodensity in the
right anterior limb of the internal capsule which likely represents a subacute
lacunar infarct or evolution of prominent chronic periventricular small vessel
ischemic changes (4:22). No major vessel territory acute infarct is seen and
no dense MCA sign is seen. The ventricles and sulci are normal in size for
age. The basal cisterns are patent. The visualized orbits and internal
auditory canal are normal in appearance. Bilateral maxillary sinus mucosal
thickening is present. Vascular calcifications are noted in the bilateral
internal carotids.
## CTA HEAD:
The vessels of the circle of and their principal intracranial branches
appear normal without stenosis, occlusion or aneurysm formation. The dural
venous sinuses are patent.
## CTA NECK:
The carotid and vertebral arteries and their major branches are tortuous
without evidence of stenosis or occlusion. There is no evidence of internal
carotid stenosis by NASCET criteria. There is a right dominant vertebral
artery. The left vertebral artery originates from the aortic arch which is a
normal variant.
## OTHER:
The ascending aorta is ectatic measuring 4.4 cm without evidence of
dissection. The visualized portion of the lungs are clear. The visualized
portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria. There are degenerative changes in the
cervical spine.
## IMPRESSION:
1. No acute intracranial process on head CT.
2. Subacute right lacunar infarct vs evolving prominent periventricular small
vessel ischemic changes.
3. Patent anterior and posterior circulation without evidence of stenosis,
occlusion, or aneurysm.
4. Ascending aorta is ectatic measuring 4.4 cm. Dedicated evaluation of the
ascending aorta with transthoracic echocardiogram is recommended. Screening
for possible connective tissue disease should be performed.
## RECOMMENDATION(S):
Ascending aorta is ectatic measuring 4.4 cm. Dedicated
evaluation of the ascending aorta with transthoracic echocardiogram is
recommended. Screening for possible connective tissue disease should be
performed.
## NOTIFICATION:
The wet read was discussed by Dr. with Dr. on the
telephone on at 4:32 , 2 minutes after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15810905", "visit_id": "N/A", "time": "2121-10-02 12:17:00"} |
12395625-RR-36 | 112 | LUMBOSACRAL SPINE, TWO VIEWS, AT 1623 HOURS.
## HISTORY:
History of metastatic squamous cell cancer of the tongue who
presents with low back and groin pain with urinary retention.
## FINDINGS:
Catheter tubing overlies the medial left abdomen with a pigtail in
the mid abdomen and numerous side holes along the course of the distal
catheter in the region of the left renal fossa. There are five
non-rib-bearing lumbar-type vertebrae in normal alignment. Vertebral body
heights are intact. Disc spaces are maintained. No pedicle destruction is
identified. The sacrum and sacroiliac joints are unremarkable.
## IMPRESSION:
No radiographic evidence of pathologic or other compression
fracture of the lumbar spine. Normal alignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12395625", "visit_id": "21153589", "time": "2166-04-11 16:19:00"} |
11004012-RR-14 | 543 | ## NO PO CONTRAST; HISTORY:
with elevated white count in the
setting of pancreatic and abdominal pain. NO PO contrast// eval for migrated
stent or other infection
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## LOWER CHEST:
There is bibasilar dependent atelectasis. A filling defect is
seen in the pulmonary artery at the right lung base concerning for pulmonary
embolism. A similar finding may be seen on the left.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
Multiple cysts are again demonstrated throughout the liver measuring up to 3.9
x 3.8 cm. Additional hypoattenuating lesion throughout the liver better
characterized on prior MR as metastatic disease, are unchanged. There is
interval exchange of CBD stent with associated pneumobilia air in the
gallbladder, consistent with stent patency. The gallbladder contains a stone
without wall thickening or distension. Air in the gallbladder is likely
secondary to the CBD stent.
## PANCREAS:
Again seen is a 2.2 x 1.6 cm hypoattenuating lesion in the uncinate
process of the pancreas with market dilatation of the upstream pancreatic
duct. When compared to outside hospital CT from , these are
grossly stable. There is mild increased peripancreatic stranding, which could
represent post ERCP pancreatitis.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis in either kidney. Scattered hypoattenuating is
throughout the kidneys with the largest measuring 1.5 cm are most likely
representing cysts. There is no perinephric abnormality.
## GASTROINTESTINAL:
There is a moderate size hiatal hernia. The small and large
bowel demonstrate no obstruction. There is diverticulosis throughout the
colon without diverticulitis. The appendix is unremarkable.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate and seminal vesicles unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
There are multilevel degenerative changes of the thoracolumbar spine.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Filling defects in the pulmonary arteries in the right lung base and
possibly left lung base are concerning for pulmonary embolism. CTA of the
chest is recommended for further evaluation.
2. The CBD stent is in appropriate position with associated pneumobilia.
3. Overall similar appearance of the mass in the uncinate process of the
pancreas with markedly dilated pancreatic duct and extensive hepatic
metastases which is better evaluated on MR.
4. Interval mild increase peripancreatic stranding. In the setting of recent
ERCP and stent placement, this could represent post ERCP pancreatitis.
5. Cholelithiasis without cholecystitis.
6. Diverticulosis throughout the colon without diverticulitis.
## NOTIFICATION:
The updated wet read was discussed with ,
M.D. by , M.D. on the telephone on at 9:14 am, 5 minutes
after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11004012", "visit_id": "28668188", "time": "2119-06-02 01:19:00"} |
15352059-RR-22 | 86 | ## INDICATION:
year old man s/p CABG// Fast track early extubation cardiac
surgery Contact name: , Phone: 1
## FINDINGS:
There are low lung volumes with crowding of the vascular markings. The
endotracheal tube is in good position. The right IJ tip is in the distal SVC.
An enteric tube extends below the left hemidiaphragm, the tip is not
visualized. Postoperative changes are evident. Sternal wires appear intact.
The aorta is atherosclerotic and tortuous. There is mild cardiomegaly.
## IMPRESSION:
Mild cardiomegaly. Postoperative changes. Low lung volumes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15352059", "visit_id": "20653346", "time": "2157-12-16 16:54:00"} |
14709865-RR-43 | 98 | ## INDICATION:
year old woman with cough, chest congestion, recent
hospitalization at BI // R/O pneumonia
## FINDINGS:
The lungs are well expanded without evidence focal consolidation. Left
midlung density is unchanged. Mediastinal contours, cardiac borders, and hila
are normal. No pleural effusions.
## IMPRESSION:
1. No evidence of pneumonia.
2. Left mid lung density unchanged since . If clinical concern for
malignancy, a CT could be obtained for further evaluation.
## NOTIFICATION:
The impression and recommendation above was entered by Dr.
on at 17:40 into the Department of Radiology critical
communications system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14709865", "visit_id": "N/A", "time": "2144-02-20 14:36:00"} |
12492854-RR-72 | 247 | ## EXAMINATION:
BILATERAL DIGITAL 2D DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD
AND LEFT BREAST ULTRASOUND
## INDICATION:
man presents for diagnostic evaluation of clinical
gynecomastia, left breast mass at 7:00 position, and left-sided axillary pain.
## TISSUE DENSITY:
A- The breast tissue is almost entirely fatty.
A triangle marker is seen over the upper left breast, denoting location of
pain. No suspicious finding is seen to correlate to the triangle marker.
There is no suspicious mass, architectural distortion, or suspicious grouped
microcalcifications.
## BREAST ULTRASOUND:
Targeted ultrasound was performed in the area of pain, as
indicated by the patient, o'clock, 14 cm from the nipple, which was
without any discrete suspicious solid or cystic mass. Further management of
the patient's symptoms at this time should be based on the clinical
assessment.
Additional targeted ultrasound was performed in the area of palpable concern,
as indicated on the requisition, from 6 to 8 o'clock, 0-10 cm from the nipple,
which was without any discrete suspicious solid or cystic mass. Any decision
to biopsy at this time based on the clinical assessment
## IMPRESSION:
No focal mammographic or sonographic abnormality identified in an area of pain
as indicated by the patient in area of concern as indicated by the
requisition. Further management of patient's symptoms at this time and any
decision to biopsy at this time should be based on the clinical assessment.
## NOTIFICATION:
Findings and recommendations reviewed with the patient at the
completion of the study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12492854", "visit_id": "N/A", "time": "2128-09-21 14:09:00"} |
13620449-RR-46 | 138 | ## INDICATION:
year old man with CHF, vtach s/p ICD, s/p episode of
vtach/hypotension, now with progressive renal failure // eval for underlying
renal disease
## FINDINGS:
The right kidney measures 10.8 cm. The left kidney measures 10.2 cm. There is
no stone or suspicious mass bilaterally. A large cystic structure measuring
4.6 x 4.1 x 6.9 cm is seen in the pelvis of the right kidney likely
representing a parapelvic cyst. This cyst appears to be causing minimal
caliectasis however no frank hydronephrosis is seen. No hydronephrosis is seen
in the left kidney. A simple cortical cyst in the left kidney measures 3.0 by
3.1 x 2.4 cm.
The bladder is moderately well distended and normal in appearance.
## IMPRESSION:
Bilateral renal cysts. No suspicious renal mass visualized.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13620449", "visit_id": "23701947", "time": "2156-07-22 16:08:00"} |
13375158-RR-13 | 87 | ## EXAMINATION:
LUMBAR SINGLE VIEW IN OR
## FINDINGS:
There is interval placement of a posterior pedicular fusion device, fusing
T11-L1. The hardware appears in good position with near anatomic alignment.
Suture anchors are noted in the vertebral endplates on either side of T10.
The branching dense material seen to the right of midline at the thoracolumbar
junction presumably relates to the recent spinal artery embolization
procedure.
## IMPRESSION:
Intraoperative images of posterior fusion of T11-L1. For details of the
procedure, please consult the operative report.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13375158", "visit_id": "25392892", "time": "2125-10-23 08:43:00"} |
16149168-DS-7 | 1,308 | ## ALLERGIES:
Penicillins / Tequin / amoxicillin / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / aspirin
## CHIEF COMPLAINT:
1. Diabetes mellitus type 2.
2. Morbid obesity.
3. Hyperlipidemia.
4. Asthma.
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
1. Laparoscopic Roux-en-Y gastric bypass.
2. Endoscopy.
## HISTORY OF PRESENT ILLNESS:
woman with longstanding morbid obesity refractory to
attempts at weight loss by nonoperative means. Her preoperative
weight is 315.3 pounds. Given her height, this translates to a
body mass index of 54.1 kg/m2. She has been considering weight
loss surgery for years. She prefers gastric bypass sighting
longer term outcomes. She does not like the idea of a foreign
body aspect of the gastric band. Her previous unsuccessful
attempts at weight loss have included Weight Watchers, Slim
Fast, over-the-counter green tea and phentermine as well as
24-day AdvoCare Challenge. Using the 24-day AdvoCare Challenge
and changes in diet, she recently has been able to lose 15
pounds since . She suffers from comorbidities including
diabetes mellitus type
2, hyperlipidemia, asthma, depression and knee pain. She has
been evaluated by our Multidisciplinary Bariatric Service and
deemed a suitable candidate in accordance with National
Institutes of Health Consensus Statement. She presents for
Laparoscopic Roux-en-Y gastric bypass.
## PAST MEDICAL HISTORY:
1. Progesterone autoimmune dermatitis.
2. Asthma; it has been greater than a year since she has
required steroids. She quit smoking eight weeks ago and her
asthma has dramatically improved.
3. Depression.
4. Migraine headaches, occasional.
5. Lactose intolerance.
6. Infertility.
7. Borderline diabetes mellitus type 2.
8. Hyperlipidemia.
## FAMILY HISTORY:
Paternal grandmother with breast cancer, paternal aunt with
thyroid cancer, grandmother with GYN cancer, mother with asthma
and question of COPD.
## HEENT:
No scleral icterus, mucus membranes moist
## PULM:
Clear to auscultation b/l, No W/R/R
## ABD:
Soft, nondistended, nontender, incisions c/d/i, no rebound
or guarding Ext: No edema, warm and well perfused
## UPPER GI ( ):
No evidence of leak from the gastrojejunostomy anastomosis
## KUB ( ):
Gastric outlet obstruction with contrast pooling in gastric
remnant and esophagus may be risk of aspiration
## KUB ( ):
Interval movement of contrast out of the esophagus and into the
bowel distally. There is still contrast pooling within the
stomach.
## KUB ( ):
Less contrast within the stomach
## BRIEF HOSPITAL COURSE:
Ms presented to holding at on for
Laparoscopic Roux-en-Y gastric bypass. She tolerated the
procedure well without complications (Please see operative note
for further details). After a brief and uneventful stay in the
PACU, the patient was transferred to the floor for further
post-operative management.
## NEURO:
The patient received morphine PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
## CV:
The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
## PULMONARY:
The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
## GI:
Post-operatively, the patient was made NPO with IV fluids.
An upper GI study was performed on POD#1 which revealed no leak.
Initially she was started on a Bariatric Stage 1 diet but
because the contrast had not passed she was reverted back to
NPO. On POD#2 a KUB was done which revealed passage of contrast
this was confirmed by KUB on POD#3. Diet was again advanced on
POD#3, which was well tolerated. Patient's intake and output
were closely monitored, and IV fluid was adjusted when
necessary. Electrolytes were routinely followed, and repleted
when necessary.
## GU:
The patient had a foley catheter placed in the OR, which was
removed on POD#1. After the foley was removed, the patient
voided without difficulty.
## ID:
The patient's white blood count and fever curves were
closely watched for signs of infection, of which there were
none.
## HEMATOLOGY:
The patient's complete blood count was examined
routinely. JP appeared sanguinous on POD#2 serial hematocrits
were ordered and found to be stable.
## SKIN:
The incision sites were well approximated and intact.
## PROPHYLAXIS:
The patient received subcutaneous heparin. Patient
wore venodyne boots and was encouraged to get up and ambulate as
early as possible following surgery
On , the patient was discharged to home. At discharge,
she was tolerating a Satge III bariatric diet, passing flatus,
stooling, voiding, and ambulating independently. She will
follow-up in clinic. This information was communicated to the
patient directly prior to discharge with verbalized
understanding and agreement.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
2. Beclomethasone Dipro. AQ (Nasal) 80 mcg Other BID
3. Loratadine 10 mg PO DAILY
4. Vitamin D 1000 UNIT PO 2X/WEEK (MO,TH)
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN asthma
6. Albuterol Inhaler PUFF IH Q6H:PRN asthma
## DISCHARGE MEDICATIONS:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN asthma
2. Albuterol Inhaler PUFF IH Q6H:PRN asthma
3. Beclomethasone Dipro. AQ (Nasal) 80 mcg Other BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
5. Loratadine 10 mg PO DAILY
6. Vitamin D 1000 UNIT PO 2X/WEEK (MO,TH)
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg/20.3 mL 1 solution(s) by mouth every
six (6) hours
## REFILLS:
*0
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. Ursodiol 300 mg PO BID
RX *ursodiol [Actigall] 300 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule
## REFILLS:
*0
10. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 1 by mouth every four (4) hours
Refills:*0
11. Ranitidine (Liquid) 150 mg PO BID
RX *ranitidine HCl 15 mg/mL 10 ml by mouth twice a day
Refills:*0
## DISCHARGE DIAGNOSIS:
1. Diabetes mellitus type 2.
2. Morbid obesity.
3. Hyperlipidemia.
4. Asthma.
## DISCHARGE INSTRUCTIONS:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
## GENERAL 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 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 steri-strips, they will fall off on their own.
Please remove any remaining strips days after surgery.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16149168", "visit_id": "21178690", "time": "2114-10-26 00:00:00"} |
15098714-RR-14 | 140 | ## EXAM:
Chest frontal and lateral views.
## CLINICAL INFORMATION:
An female with history of end-stage renal
disease, coronary artery disease, pre-op chest radiograph.
## FINDINGS:
Frontal and lateral views of the chest were obtained. A dual-lead
right-sided pacer device is seen with leads in the expected position of the
right atrium and right ventricle. Patient is status post median sternotomy
and CABG. Slight blunting of the left costophrenic angle may be due to a
trace effusion. be minimal pulmonary vascular congestion. No focal
consolidation or pneumothorax is seen. A cardiac and mediastinal silhouettes
demonstrate a top normal heart size. The aorta is calcified and tortuous. A
tubular structure is partially imaged projected over the mid to upper abdomen,
which may represent patient's J-tube.
## IMPRESSION:
Possible small left pleural effusion and minimal pulmonary
vascular congestion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15098714", "visit_id": "22322277", "time": "2172-08-10 20:45:00"} |
11539240-RR-130 | 127 | PA AND LATERAL CHEST ON
## HISTORY:
woman with cough, severe cardiomegaly.
## IMPRESSION:
PA and lateral chest compared to through :
Small region of heterogeneous opacification has developed at the base of the
right lung extending into the posterior pleural sulcus. Lateral view does not
support diagnosis of appreciable pleural effusion. Therefore, I think this is
pneumonia in the right lower lung. Severe cardiomegaly and pulmonary vascular
engorgement are chronic, but there is no good evidence for pulmonary edema.
Patient has had aortic and tricuspid valve replacement. Transvenous right and
left ventricular pacer leads are in standard placements. A right ventricular
pacer defibrillator lead tip projects over the floor of the right ventricular
apex, proximal electrode spanning the SVC and upper right atrium. No
pneumothorax.
Dr. was paged.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11539240", "visit_id": "N/A", "time": "2135-06-24 11:05:00"} |
15152711-AR-58 | 171 | ADDENDUM This patient had a subsequent chest CT dated .
Taking the chest CT findings into consideration, the numerous nonenhancing
rounded discrete lesions in the liver and spleen could represent granulomatous
disease such as sarcoidosis.
## IMPRESSION:
1. 2 arterially enhancing lesions in segment V and VIII measuring 0.7 cm and
0.6 cm respectively do not meet OPTN 5 criteria, however remains suspicious
and close attention on follow-up recommended.
2. Hepatomegaly and splenomegaly with numerous hypoenhancing discrete rounded
lesions distributed throughout the liver and spleen measuring up to 1 cm in
diameter. The hepatic and splenic lesions were first discretely visualized on
the CT abdomen dated and appear more numerous on today's exam.
These could represent granulomatous disease such as sarcoidosis especially
given the laboratory findings and the chest CT findings.
3. Moderate ascites, small right pleural effusion, patent TIPS.
The impression and recommendation above was entered by Dr.
on at 10:57 into the Department of Radiology critical
communications system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15152711", "visit_id": "24500283", "time": "2119-12-23 15:01:00"} |
18756393-RR-103 | 443 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
with pancreatic cancer s/p procedure p/w w 5days of
abdominal pain and distension// ?obstruction, infection
## SINGLE PHASE CONTRAST:
MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.Coronal and sagittal reformations were
performed and reviewed on PACS.
## LOWER CHEST:
With the exception of bibasilar atelectasis, the lung bases are
clear. No pleural or pericardial effusion.
## HEPATOBILIARY:
There is heterogeneous enhancement of the liver parenchyma,
most prominent in segment 5. No focal hepatic lesions are seen. No drainable
fluid collection. There is expected pneumobilia following Whipple procedure.
Periportal edema is noted. Gallbladder is surgically absent. No intrahepatic
biliary dilation.
## PANCREAS:
Patient is status post Whipple procedure. The remnant pancreatic
tail parenchyma is atrophic. The duct is not dilated. There is
re-demonstration of ill-defined soft tissue encasing the celiac, SMA and
extending into the porta hepatis, which is not significantly changed compared
to . Re-demonstrated cavernous transformation of the main portal
vein.
## SPLEEN:
Splenomegaly is again noted, measuring 16 cm in length.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
A right upper pole simple cyst is re-demonstrated. No suspicious solid renal
lesions or hydronephrosis. There is no perinephric abnormality.
## GASTROINTESTINAL:
There is a small hiatal hernia. Multiple paraesophageal
varices are re-demonstrated. Postsurgical changes following Whipple procedure
are again seen. There is no bowel obstruction. There is colonic
diverticulosis without evidence of diverticulitis. Re-demonstration of soft
tissue nodularity throughout the omentum, which is overall similar to . Large volume ascites is increased.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate gland is mildly enlarged.
## LYMPH NODES:
Numerous nonenlarged retroperitoneal lymph nodes measuring up to
8 mm are similar. There is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes of the lumbar spine are noted.
## SOFT TISSUES:
There is a ventral hernia containing a small amount of fluid
(2:63). Fat containing left inguinal hernia is present.
## IMPRESSION:
1. Heterogeneous enhancement of the liver, particularly the right lobe, is
nonspecific. There is no drainable fluid collection.
2. Re-demonstration of soft tissue encasing the celiac artery and SMA,
extending into the porta hepatis, as well as occlusion of the main portal vein
with cavernous transformation.
3. Similar appearance of extensive peritoneal carcinomatosis. Interval
increase in large volume ascites.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18756393", "visit_id": "22496531", "time": "2162-03-26 22:11:00"} |
18697563-RR-5 | 103 | CHEST RADIOGRAPH PERFORMED ON .
## CLINICAL HISTORY:
Altered mental status, assess infectious process in the
chest.
## FINDINGS:
AP upright and lateral views of the chest are provided. Lung
volumes are markedly low, which limits the evaluation. Allowing for this;
however, there is no overt consolidation, effusion, or pneumothorax. No signs
of CHF. The heart size appears top normal, though this is likely due to
projection and technique. Mediastinal contour likewise is prominent though
this also likely reflects technique. The bony structures appear intact.
Degenerative spurring in the mid-to-lower thoracic spine noted. No free air
below the right hemidiaphragm.
## IMPRESSION:
Limited negative.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18697563", "visit_id": "N/A", "time": "2110-06-10 18:29:00"} |
15390529-DS-10 | 1,038 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
From nightfloat admitting resident presents w/ concern
for alcohol withdrawal. Reports a h/o prior withdrawal seizure.
Drinks 16 drinks of vodka daily, today has had 6, last at . Also complaining of insomnia, seeing flashes of "demonic
faces" and dreams of being levitated by devils. No auditory
hallucinations. No SI or HI. No h/o prior psych diagnoses. He
has poor sleep hygiene at baseline and has not been sleeping
well recently. He noted after beginning to drink today that he
was having dry heaves, relieved with Pepto Bismol. He continued
to not tolerate PO and his case worker was concerned that he
might have a withdrawal seizure at home unwitnessed (his
roommate was inpatient at for detox at the time) and
advised he come to the ED which he did.
Of note, the patient was admitted to for EtOH withdrawal
seizure in . He was treated with benzos and had no
further seizures in the hospital. He has struggled with
alcoholism since he was yo. He has had at least for detox.
In the ED, initial VS: 99.4 16 100% RA. Labs notable
for AG 18, PLT 78, EtOH 157, ALT 152, AST 176, Tbili 2.2, neg
Utox, UA with trace leuks, 40 ketones, 20 WBC, few bacteria, no
epis. Psychiatry was consulted and they felt he did not meet
admission for psych inpatient admission or dual diagnosis
program and recommended observation. His roommate left the
inpatient side AMA to be with him in the ED. He was given Valium
30mg PO, Ativan 2mg PO, Zofran 4mg, Thiamine 100mg, MVI, 1g
Tylenol, 1 Tums, Cipro 500mg PO, 1L NS. VS at transfer: 98.7
129/92 91 21 100% RA.
Currently, he has no complaints. Denies SI, HI, vivid images
## PAST MEDICAL HISTORY:
Alcohol abuse with history of withdrawal seizures in the past
Foot/Hand surgery
## FAMILY HISTORY:
Grandfather with alcoholism, many other family members with
alcoholism
## PHYSICAL EXAM:
Admission exam documented by admitting resident;
VS - Temp , BP 135/90, HR 86, R 18, O2-sat 100% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, poor
dentition, thrush on tongue
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, fast but regular rhythm, no MRG, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, trace fine tremor, slightly anxious at
times
.
## DISCHARGE:
VS - 98.3 119/80 84 18 100/RA
Gen - thin male, wearing street clothes, lying in bed in NAD
HEENT - MMM
Heart - RRR, normal S1/S2
Lungs - clear b/l, no rales/rhonchi/wheezes
ext - no edema
skin - no new lesions
## IMPRESSION:
Increased liver echogenicity, compatible with fatty
deposition. No discrete hepatic lesion.
## SUMMARY:
year old man with alcohol abuse admitted for
detoxification.
## # ALCOHOL WITHDRAWAL:
Patient is high risk for seizures given
high EtOH intake and history of withdrawal seizures. Was
monitored on CIWA scale. Received IV thiamine for 24 hours,
followed by daily thiamine in addition to MVI and folic acid.
Social work was consulted, and the patient was provided a
detailed list of outpatient treatment centers. He is to start
ad care within one week of discharge, and plans to be seen at
for counseling within several days of discharge.
THe importance of aggressive outpatient compliance and
counseling was stressed to the patient. Mr. refused
inpatient alcohol abuse treatment.
## # LEUKOPLAKIA:
Patient noted to have mild leukoplakia at the
back of his tongue. Was treated with 5 day course of nystatin.
HIV test was negative.
## # THROMBOCYTOPENIA:
Likely secondary to heavy alcohol abuse,
with improving trend at discharge.
## # TRANSAMINITIS:
Evidence for fatty deposition noted on
ultrasound, likely steatohepatitis from alcohol use. Trend was
improving at time of discharge. HCV was negative, HIV negative,
and HBV tested in was notable for HBV core and surface
antibody positive.
.
=========
## TRANSITIONAL ISSUES:
=========
-Encourage sobriety
-Patient strongly encouraged to obtain treatment at outpatient
alcohol treatment center and was provided with an appointment
for intake at program by Social Work.
## MEDICATIONS ON ADMISSION:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Bismuth Subsalicylate 15 mL PO QID:PRN dyspepsia
## DISCHARGE MEDICATIONS:
1. Bismuth Subsalicylate 15 mL PO QID:PRN dyspepsia
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 Tablet(s) by mouth daily Disp #*30 Capsule
## REFILLS:
*0
3. Multivitamins 1 TAB PO DAILY
RX *Daily Multi-Vitamin 1 Tablet(s) by mouth daily Disp #*30
## CAPSULE REFILLS:
*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 Tablet(s) by mouth daily Disp #*30
## CAPSULE REFILLS:
*0
5. Nystatin Oral Suspension 5 mL PO QID Duration: 5 Days
RX *nystatin 100,000 unit/mL ml by mouth three times daily
Disp #*1 Bottle Refills:*0
## DISCHARGE INSTRUCTIONS:
You were admitted for alcohol detoxification. We treated you
with medicines to prevent dangerous withdrawal symptoms and side
effects.
We also had out social worker and addiction specialists work
with you to come up with a safe plan for discharge to keep you
sober. As you know, it is extremely important that you stop
drinking to prevent the many terrible effects alcohol can have
on the body. As we discussed, this will be difficult, but with
the proper social supports it is something that you have the
capability to do. By continuing to drink, you are only
increasing the chances of death at a young age.
.
We also tested you for HIV and Hepatitis C, both of which were
negative. You had some findings in your mouth that may have
been thrush (a mild infection), so you should finish 5 days of
nystatin to treat this. We have also started you on some
vitamins, which you should continue to take.
.
Please note the following medication changes:
-Please START thiamine
-Please START multivitamin
-Please START folic acid
-Please START nystatin for 2 more days
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15390529", "visit_id": "20448301", "time": "2134-11-28 00:00:00"} |
16386570-RR-57 | 157 | ## INDICATION:
A woman with cirrhosis and abdominal pain.
## FINDINGS:
The liver has diffusely coarsened echotexture consistent with the patient's
known cirrhosis. No focal liver lesions are seen. No biliary duct
dilatation. The portal vein is patent with normal hepatopetal flow. The
gallbladder is surgically absent. No biliary duct dilatation seen, there is
an echogenic focus seen superiorly within the right kidney. While there is no
definite shadowing seen, this could represent either a small calculus or
crystal deposition. No hydronephrosis. The left kidney is unremarkable in
appearance. The spleen measures 10 cm and is unremarkable in appearance. The
aorta is unremarkable in caliber throughout. The visualized portions of the
inferior vena appear normal. There is a trace of free fluid seen along the
liver margin. This disappears with respiration.
## IMPRESSION:
Coarse hepatic echotexture consistent with the patient's known cirrhosis. A
trace of ascites. Possible small calculus in the right kidney measuring 3 mm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16386570", "visit_id": "N/A", "time": "2151-06-20 13:07:00"} |
18682902-RR-133 | 131 | ## INDICATION:
Bilateral calf pain and shortness of breath. Evaluate for deep
vein thrombosis.
## FINDINGS:
There is normal symmetric respiratory variation in the bilateral
common femoral veins. The bilateral common femoral veins, superficial femoral
veins, and popliteal veins show normal compressibility, flow, and
augmentation. The bilateral peroneal and posterior tibial veins show normal
color flow.
In the right popliteal fossa, there is a small 3.2 x 3.1 x 1.6 cm hypoechoic
fluid collection, most consistent with a small cyst. In the left
popliteal fossa, there is a tiny 1.8 x 1.0 x 1.4 cm mostly anechoic fluid
collection, also consistent with a cyst.
## IMPRESSION:
1. No evidence of a right or left lower extremity deep vein thrombosis.
2. Small right and tiny left cysts.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18682902", "visit_id": "N/A", "time": "2185-11-04 13:18:00"} |
19650185-RR-30 | 244 | ## INDICATION:
year old man years s/p RUL lobectomy for stage 1B
squamous cell carcinoma // check interval change
## FINDINGS:
Right upper paratracheal lymph node is stable, series 2, image 10, not
pathologically enlarged. Right lower paratracheal lymph nodes, series 2,
image 21 has slightly increased in size from 10 x 7.7 mm to 11 by out 12.8 mm.
Bronchial wall thickening surrounding the right main bronchus, series 2, image
25 is similar to previous examination as well as a right hilar lymph node,
series 2, image 28, 12 mm in diameter. No new mediastinal hilar or axillary
lymph nodes demonstrated.
Aorta and pulmonary arteries are well enhanced. The patient is after CABG.
Heart size is normal. Coronary calcifications are extensive. There is no
pericardial pleural effusion.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
Postsurgical changes after right upper lobectomy are stable. There are no new
abnormalities in the side degenerative changes the skeleton is unremarkable.
Airways are patent to the subsegmental level bilaterally. No new pulmonary
nodules masses or consolidations seen.
Image portion of the upper abdomen demonstrate left kidney stone, series 2,
image 63 . Sludge in the gallbladder is present. No other abnormalities in
the image portion of the upper abdomen demonstrated
## IMPRESSION:
Stable appearance of the chest with no evidence of new pulmonary nodules O
local or remote recurrence.
Left kidney stone.
Status post CABG with extensive calcifications of the native Coronary
arteries.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19650185", "visit_id": "N/A", "time": "2177-05-03 09:16:00"} |
11084285-RR-210 | 614 | ## HISTORY:
man with recurrent HCC after liver transplant, to assess
interval change.
## FINDINGS:
A 4.7 x 4.5 cm treated lesion in the segment II (16:43) and 3.3 x 3.2 cm
treated lesion in segment III of the liver (16:53, show mild T1 hyperintense
signal on the precontrast images, with no definite arterial hyperenhancement /
delayed washout to suggest recurrent tumor.
A 2.2 x 1.9 cm T2 hyperintense lesion in segment IV A (13:31), demonstrating
arterial hyperenhancement / delayed washout and pseudocapsule, slightly larger
since , 2.0 x 1.7 cm, meets criteria for HCC (OPTN 5B).
A 1.9 x 1.8 cm T2 hyperintense lesion in segment II (13:38) demonstrating
arterial hyperenhancement/ delayed washout, and a pseudocapsule, is little
changed in size since the prior study 1.9 x 1.5 cm, with washout less well
seen on the prior outside hospital study. This lesion meets criteria for
(OPTN 5A).
A 1.4 x 1.1 cm lesion in segment IVB (13:48) demonstrating arterial
hyperenhancement, delayed washout and a pseudocapsule is consistent with a HCC
(OPTN 5A). This lesion is slightly larger compared to the prior study, 1.0 x
0.8 cm.
A 1.1 x 1.3 cm lesion in the segment VI (16:71) and 1.1 x 0.9 cm lesion in
segment VI (16:75) both demonstrate arterial hyperenhancement, delayed washout
and suggestion of a pseudocapsule, worrisome for OPTN-5A. These lesions
were not definitively seen on the prior outside hospital MRI study.
All of the above described nodules contain intravoxel fat.
An ill-defined focus of arterial hyperenhancement is seen at the junction of
segment IVB and V (13:55), without definite delayed washout. A 9 mm focus in
segment VIII (15:32), a 14 mm focus in the segment (15:40), and poorly
defined areas in segment II/III (14:48) show hypoenhancement on the delayed
phase, but do not have a definite correlate on arterial phase images, and are
indeterminate.
The hepatic veins and IVC are patent. The portal, splenic and superior
mesenteric veins are patent. Hepatic artery is patent. The abdominal aorta
has mild atherosclerotic disease, without aneurysmal dilation. The hepatic
arteries are patent.
The adrenal glands and pancreas are normal. The spleen remains enlarged
measuring 18.5 cm. The left kidney is unremarkable. Few tiny simple renal
cysts are seen in the right kidney. A 6 mm exophytic enhancing lesion in the
lower pole of right kidney (16:101), slightly larger since , is worrisome
for malignancy.
The stomach, small and large bowel loops in the upper abdomen are normal.
There is no ascites. Few periportal lymph nodes relate to the underlying
liver disease. Few scattered retroperitoneal lymph nodes are likely reactive.
There is no ascites. Portosystemic collaterals include a large splenorenal
shunt and perisplenic collaterals.
A 3.7 x 2.8 cm enhancing T2 hyperintense lesion in L3 vertebral body (16:78),
larger in size compared to the prior study of , is worrisome for
metastasis.
## IMPRESSION:
1. At least 5 lesions with arterial hyperenhancement and delayed washout are
worrisome for HCC and meet OPTN 5 criteria. Of these, at least 2 lesions are
slightly larger since the prior study of .
2. Post treatment sites in segment II and III show no evidence of recurrent
tumor.
3. Moderate splenomegaly.
4. 6-mm enhancing lesion in the lower pole of the right kidney is worrisome
for malignancy.
5. Enhancing lesion in L3 vertebral body, larger since , is not
completely evaluated on this study and a dedicated lumbar spine MRI/bone scan
is recommended to evaluate for metastasis.
Findings added to radiology critical reports dashboard.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11084285", "visit_id": "N/A", "time": "2203-10-10 18:43:00"} |
14449139-RR-187 | 259 | ## INDICATION:
year old woman with ENMZL. No w.p resection and Rituxan.
Evaluate for local recurrence// H.o ENMZL now s.p surgery. Evaluate recurrence
## FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. No enlarged lymph nodes in the hilar or mediastinal
compartments. All visible mediastinal lymph nodes (2, 69)
Are normal in size. No incidental pulmonary embolism. Severe coronary
calcifications are unchanged. Mild aortic valve calcifications. No
pericardial effusion. Tortuosity of the descending aorta. No osteolytic
lesions at the level of the ribs, the sternum, or the vertebral bodies.
Moderate degenerative vertebral disease. No vertebral compression fractures.
Moderate scarring in the upper lobes. Multiple nodular opacities in the left
upper lobe (4, 35), surrounding the surgical staple line, have minimally
increased in size. Moreover, nodular soft tissue structure adjacent to the
staple line (4, 54) has increased in size. Also increased in size are 2
nodular structures (4, 57) Located lateral to the anterior portion of the
staple line. In para-aortic location in the left lower lobe, a soft tissue
nodule has minimally increased in size. Micronodules in the right lung,
notably in perifissural location, are overall stable. Non characteristic
scarring at the bases of the left and right lower lobe. No pleural effusions.
No pleural thickening.
## IMPRESSION:
Progression of disease with increase of lung nodules on or around the left
upper lobe surgical staple line. Minimal increase in size of a left lower
lobe para-aortic nodule. Multiple predominantly perifissural micro nodules in
the right lung are stable. No pleural effusions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14449139", "visit_id": "N/A", "time": "2162-04-18 15:36:00"} |
19916340-DS-14 | 1,889 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CC:
"I just wanted to sleep"
Presented to ED after ingesting 30 tablets of Ibuprofen, denies
it was a suicide attempt.
## HISTORY OF PRESENT ILLNESS:
is a year-old freshman at with
no past psychiatric or medical history who presented to the ED
today complaining of abdominal pain. The pain started after she
ingested about 30x 200 mg tablets of ibuprofen. She is unable to
clearly explain why she did this, but the story is as follows
(aided by her friend, who prods the patient to give more details
when she says "I don't know"):
She recently moved from her home town of to
in order to start studying at . She has a
long-distance boyfriend who is lives in . Recently, he
has been voicing concerns about being able to sustain their
distance relationship. They saw each other during a week
vacation that ended ~ 10 days ago. Sometime after returning, he
decided to end the relationship. They continued talk on the
phone, but during a conversation last night, he hung up on her
(occurred around midnight); he was irritated when she tried to
call him back. She was upset and crying about it when she
learned
that her roommate had broken a glass doll that her great
grandmother had given her (her great grandmother, to whom she
was
close, past away in . This made her more upset,
which led to a headache, for which she took 4 ibuprofen. She
didn't feel much better so she went upstairs and started taking
tablets by the handful. She took about 30 tablets in total, but
didn't finish the entire bottle; she stopped because her stomach
hurt. She then sought her friend for support, but didn't tell
her
that she had ingested the pills until much later in the day.
After the friend learned about what had happened, she took the
patient to a counselor at so they could get a
cab voucher in order to come to the ED.
When pressed on why she took the pills and what her intent was,
says she took the pills because "some people do that" when
they're upset. She said "just wanted to take the pills and go to
sleep." She denied actively wanting to commit suicide, though
she
knew that taking those pills would harm her. She fails to give a
convincing or reassuring explanation for the incident. It was an
impulsive decision, but she denies having made similarly
impulsive, harmful decisions in the past. However, she states
she
was required to take anger management classes for years while
in high school. She doesn't know why -- she typically bottles up
her anger and thinks no one sees it. However, one of her
teachers
thought she had anger issues. She says they helped her stay
calm.
Over the past days, she notes difficulty sleeping, poor
appetite, difficulty concentrating, and a labile mood and
affect.
She denies perceptual disturbances and SI/HI.
## NONE
CURRENT TREATERS AND TREATMENT:
none
Medication and ECT trials: none
## AS IN HPI
HARM TO OTHERS:
denies
Access to weapons: no
Patient did do "anger management" classes in high school at the
suggestion of her teachers which she found helpful.
## PAST MEDICAL HISTORY:
No significant past medical history, no home medications
## - GENERAL:
Young female in NAD. Well-nourished, well-developed.
Appears stated age.
- HEENT: Atraumatic. EOMI. Oropharynx clear.
- Neck: Supple.
- Back: No significant deformity.
- Lungs: CTA . No crackles, wheezes, or rhonchi.
- CV: RRR, no murmurs/rubs/gallops.
- Abdomen: +BS, soft, nontender, nondistended. No palpable
masses or organomegaly.
- Extremities: No edema.
- Skin: No rashes or lesions.
## - MOTOR:
Normal bulk and tone bilaterally. No abnormal
movements, no tremor, no asterixis.
- Strength: full power throughout.
- Gait: Steady. Normal stance and posture. No truncal ataxia.
- Romberg: Negative.
## - WAKEFULNESS/ALERTNESS:
awake and alert
- Attention: intact to interview
- Orientation: oriented to person, time, place, situation
- Memory: intact to recent and past history and three object
recall
- Fund of knowledge: consistent with education
- Calculations: nine quarters = $2.25
- Abstraction:
-- "Don't cry over spilt milk" = "don't stress over things you
can't fix."
-- "The grass is always greener on the other side" = "There's
always something better to look forward to."
-- Apple and orange are similar because they are "round"
-- Watch and ruler are similar because they "tell time"
- Speech: normal rate, volume, and tone
- Language: native speaker, no paraphasic errors,
appropriate to conversation
## - APPEARANCE:
No apparent distress, appears stated age, well
groomed, dressed in hospital gown
- Behavior: Calm, cooperative, engaged, friendly, pleasant,
appropriate eye contact, no psychomotor agitation or retardation
- Mood and Affect: "Mellow" / euthymic, full range, appropriate
to situation, congruent with mood
- Thought Process: linear, coherent, goal-oriented. No LOA.
- Thought Content: denies SI, no evidence of delusions or
paranoia
- Judgment and Insight: poor/poor
## - CBC:
WBC 12.8, Hgb 12.2, Hct 38.1, Plt 334
- BMP: Notable for Glucose 126, HCO3 21, Na 142, and K 4.1
- UA: WBC 11, No Bacteria, Neg Leuks
- Urine tox: Negative for benzos, barbituates, opiates,
cocaine,
amphetamine, and methadone.
- Serum tox: Negative for aspirin, benzos, barbituates,
ethanol,
TCAs and acetaminophen.
## PERTINENT RESULTS:
03:10PM URINE UCG-NEGATIVE
03:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
03:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
03:10PM URINE RBC-<1 WBC-11* BACTERIA-NONE YEAST-NONE
EPI-0
01:05PM GLUCOSE-126* UREA N-10 CREAT-1.1 SODIUM-142
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-21* ANION GAP-20
01:05PM ALT(SGPT)-16 AST(SGOT)-15 ALK PHOS-77 TOT
BILI-0.2
01:05PM LIPASE-25
01:05PM ALBUMIN-4.2
01:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
01:05PM WBC-12.8* RBC-4.74 HGB-12.2 HCT-38.1 MCV-80*
MCH-25.7* MCHC-32.0 RDW-14.4 RDWSD-41.8
01:05PM NEUTS-81.0* LYMPHS-12.4* MONOS-5.3 EOS-0.2*
BASOS-0.5 IM AbsNeut-10.34* AbsLymp-1.58 AbsMono-0.68
AbsEos-0.03* AbsBaso-0.06
01:05PM PLT COUNT- . LEGAL & SAFETY:
On admission, the patient signed a conditional voluntary
agreement (Section 10 & 11) and remained on that level
throughout her admission. They were also placed on 15 minute
checks status on admission and remained on that level of
observation throughout while being unit restricted.
2. PSYCHIATRIC:
#) Adjustment disorder
Patient endorsed that she took 30 tablets of Ibuprofen because
she was upset, had a headache and wanted to sleep. She denied
that it was a suicide attempt. She was feeling overwhelmed by
being away from her family, recently breaking up with her
boyfriend and loss of a sentimentally significant object. She
was not having suicidal thoughts prior to the overdose and her
choice to take the pills was impulsive. She Reports her mood
has been "up and down" and she has trouble falling asleep. She
doesn't have trouble with sleep every night, but sometimes when
she has a lot of things on her mind she can't fall asleep and
ends up looking at her phone which makes it more difficult to
sleep. Once asleep, she tends to stay asleep. However, she
still enjoys hanging out with her friends and is doing well in
school. She feels that she has a difficult time expressing her
feels and keeps them inside. She doesn't have anyone at present
that she discusses her feelings with, though she would like to.
She did not meet criteria for a mood disorder.
3. SUBSTANCE USE DISORDERS:
#) Denies illicit substances, occasional alcohol use and
occasional smoking
4. MEDICAL
#) Denies, patient's blood pressure was elevated to 140's at
times. Recommended following up with her school's
.
5. PSYCHOSOCIAL
#) GROUPS/MILIEU:
The patient was encouraged to participate in the various groups
and milieu therapy opportunities offered by the unit. The
patients primary team met with them daily and various
psychotherapeutic modalities were utilized during those times.
#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT
Patient's mother was contacted by phone after patient gave
permission. She was updated on patient's admission, team's
thoughts about patient's condition and likely discharge plans.
Patient's family visited and are very supportive of her and want
to help her. They discussed her finishing the semester at
and having the possibility of transferring to a
college closer to home if she would like.
## #) INTERVENTIONS
- MEDICATIONS:
Patient was given Vistaril PRN for sleep, team
did not feel she required an antidepressant or other psychiatric
medication.
- Psychotherapeutic Interventions: Individual, group, and milieu
therapy.
- Coordination of aftercare: Patient will go to her school
mental health office for initial follow up.
## INFORMED CONSENT:
The team discussed the indications for,
intended benefits of, and possible side effects and risks of
starting this medication, and risks and benefits of possible
alternatives, including not taking the medication, with this
patient. We discussed the patient's right to decide whether to
take this medication as well as the importance of the patient's
actively participating in the treatment and discussing any
questions about medications with the treatment team, and I
answered the patient's questions. The patient appeared able to
understand and consented to begin the medication.
RISK ASSESSMENT
On presentation, the patient was evaluated and felt to be at an
increased risk of harm to herself given the impulsiveness of her
actions in response to several stressors. Their static factors
noted at that time include age, marital status (recent breakup
with boyfriend). The modifiable risk factors included lack of
outpatient providers and poor coping skills. During the
admission, the patient attended groups to help develop coping
skills and was agreeable to continuing with an outpatient
therapist. Finally, the patient is being discharged with many
protective risk factors, family support,lack of suicidal
ideation, no history of substance use disorder, no history of
abuse. Overall, based on the totality of our assessment at this
time, the patient is not at an acutely elevated risk of
self-harm nor danger to others.
Our Prognosis of this patient is good based on her resilience,
wiliness to engage with providers and her insight into her
condition.
## GENERAL:
NAD, good hygiene, appears stated age
## BEHAVIOR:
Cooperative, good eye contact
## MOOD/AFFECT:
'Good', mood congruent, full range, bright and
hopeful
## SPEECH:
Fluent, regular rate, volume and tone
Thought content: Linear, goal directed, denies SI, no delusions
or paranoia endorsed, plans for future
## DISCHARGE INSTRUCTIONS:
You were hospitalized at for an overdose of ibuprofen. We
adjusted your medications, and you are now ready for discharge
and continued treatment in partial program.
-Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
It was a pleasure to have worked with you, and we wish you the
best of health.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19916340", "visit_id": "24360853", "time": "2112-04-07 00:00:00"} |
10674535-RR-14 | 137 | ## EXAMINATION:
CHEST (PA AND LAT)
## INDICATION:
year old woman with cough, fatigue x one week. Decreased LLL
breath sounds. Evaluate for abnormality.
## FINDINGS:
The heart size and mediastinal silhouettes are normal. The lungs are without
focal consolidation or pleural effusion. No pneumothorax detected. Patient
is post prior vertebroplasty.
Notably, a spiculated or reticular opacity projecting over the anterior left
second rib is present.
## IMPRESSION:
1. No focal consolidation concerning for pneumonia.
2. Incidental note of a spiculated or reticular opacity projecting over the
anterior left second rib. Correlation with prior radiographs, if they can be
obtained, is advised. If not available, then consider further evaluation with
repeat PA and apical lordotic radiographic views.
## NOTIFICATION:
The above findings were entered by Dr. the
Imaging Findings Dashboard for communication to the ordering
clinician at 14:08 on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10674535", "visit_id": "N/A", "time": "2153-10-24 12:07:00"} |
13869491-RR-156 | 267 | ## INDICATION:
woman with end-stage renal disease with displaced
hemodialysis line, now hypotensive with abdominal pain.
## FINDINGS:
Partially imaged lung bases are notable for minimal dependent atelectasis.
There is no pleural effusion.
## CT ABDOMEN:
The liver enhances homogeneously without concerning lesions. The
spleen, pancreas and adrenal glands are unremarkable. The patient is status
post cholecystectomy. Native kidneys are atrophic and contain numerous
rounded hypodensities, the larger ones are compatible with simple cysts and
the majority is too small to characterize.
The stomach is decompressed and non-dilated loops of small bowel are within
normal limits. The colon is notable for diverticulosis without
diverticulitis. Anastomotic sutures are noted. There is no mesenteric or
retroperitoneal lymphadenopathy. There is no intra-abdominal free air or
fluid. Abdominal aorta demonstrates moderate atherosclerotic calcification,
but no aneurysmal dilatation.
## CT PELVIS:
The bladder is partially decompressed. The uterus contains
multiple calcified fibroids. A multiseptated right adnexal cystic mass
measures 6.5 x 8.4 x 6.8 cm (TRV x AP x CC) (601b:36), previously 5.6 x 7.5 x
5.7 cm. The left ovary contains a focus of coarse calcification. There is no
pelvic free fluid or lymphadenopathy.
No concerning lytic or sclerotic osseous lesion is identified. Degenerative
changes are present in the lumbosacral spine with grade 1 anterolisthesis of
L4 on L5.
## IMPRESSION:
Enlarging 6.5 x 8.4 x 6.8 cm (TRV x AP x CC) multiseptated right adnexal
cystic mass concerning for neoplasm as also mentioned on the prior ultrasound
from and again Gyn consultation is recommended. Again, surgical
excision should be considered.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13869491", "visit_id": "24312462", "time": "2140-11-21 21:47:00"} |
10052277-RR-52 | 538 | ## FINDINGS:
There is grade 1 anterolisthesis of L3 on L4 and L4 on L5, new compared to the
prior examination, likely degenerative, without definite pars defects
identified. Vertebral body alignment is otherwise preserved. Vertebral body
heights are preserved. A Schmorl's node is seen at the superior endplate of
L3. Focal fat is noted in the L2 vertebral body. There is no other focal
bone marrow signal abnormality.
There is loss of T2 signal of the intervertebral discs, a manifestation of
degenerative disc disease. There is minimal intervertebral disc height loss
at L2-L3, L3-L4 and L4-L5, slightly progressed compared the prior examination.
The terminal spinal cord is preserved in signal and caliber. The conus
medullaris terminates at the mid L2 level.
There is nonspecific superficial lumbar soft tissue edema, likely hydrostatic.
At T11-T12, there is trace disc bulge without significant spinal canal or
neural foraminal narrowing.
At T12-L1, there is mild disc bulge without significant spinal canal or neural
foraminal narrowing.
At L1-L2, there is mild disc bulge without significant spinal canal or neural
foraminal narrowing.
Prominent epidural fat compatible with epidural lipomatosis from the levels of
L2-L3 through L5-S1 contribute to the degree of thecal sac narrowing, as on
the prior examination.
At L2-L3, mild disc bulge and epidural fat produce moderate thecal sac
narrowing with crowding of the traversing cauda equina nerve roots. There is
bilateral facet joint hypertrophy which has also progressed in the interim.
The neural foramina are patent. Degree of epidural lipomatosis at the L2-3
level has progressed on prior. In there had been no significant canal
narrowing.
At L3-L4, disc bulge, anterolisthesis and prominent epidural fat produce
severe thecal sac narrowing with crowding and compression of the traversing
cauda equina nerve roots. Foraminal component of disc bulge and ligament
thickening produce mild bilateral neural foraminal narrowing which is not
dramatically changed. Extensive bilateral facet joint hypertrophy is
unchanged.
At L4-L5, disc bulge appears marginally increased. Anterolisthesis and
prominence of the epidural fat contribute to severe thecal sac narrowing with
crowding and compression of the traversing cauda equina nerve roots (06:11),
slightly worse when compared to prior. Foraminal component of disc bulge and
facet osteophytes produce mild left and moderate right neural foraminal
narrowing, progressed on the right compared to prior.
At L5-S1, disc bulge and prominent epidural fat produces severe thecal sac
narrowing, similar compared to prior. The neural foramina are patent. Facet
joint hypertrophy is unchanged.
Overall findings have progressed since .
The visualized retroperitoneum is grossly unremarkable with the exception of a
millimetric T2 hyperintense right upper pole renal lesion, likely representing
a cyst.
## IMPRESSION:
1. Multilevel lumbar spondylosis, progressed since , as
described, with most notable findings including epidural lipomatosis
contributing to thecal sac narrowing at multiple levels. Specifically, new
moderate narrowing at L2-L3 compared to and progressive, severe canal
narrowing at L3-L4, L4-L5, and L5-S1. Up to mild to moderate neural foraminal
narrowing at the right L4-L5 level which is worse compared to prior. Other
details as above.
2. Grade 1 anterolisthesis of L3 on L4 and L4 on L5 is new, likely
degenerative. No definite pars defects seen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10052277", "visit_id": "N/A", "time": "2151-06-05 10:11:00"} |
13515178-RR-65 | 343 | ## EXAMINATION:
CT ABDOMEN W/O CONTRAST Q421
## INDICATION:
year old woman s/p CABG// eval for PEJ tube placement in
patient with bile exuding from insertion site
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 2.6 s, 34.2 cm; CTDIvol = 10.7 mGy (Body) DLP = 365.9
mGy-cm.
Total DLP (Body) = 366 mGy-cm.
## FINDINGS:
Opacities at each lung base have mostly resolved leaving only platelike minor
atelectasis at the left lung base. There are no persistent pleural effusions.
Mildly hyperdense gallbladder content may potentially indicate presence of
sludge. There is no biliary dilatation. The pancreas appears normal. Spleen
is normal in size. Adrenals are unremarkable. No definite stones or
hydronephrosis involving either kidney. Instead, calcifications in each renal
hilum are thought to be vascular, also noting that vascular calcification is,
more generally, widespread among medium-sized arteries.
A gastrojejunostomy tube is seated in the stomach. The jejunal limb
terminates in the third portion of the duodenum, previously in the proximal to
mid jejunum. There is some hyperdense material in the stomach probably
recently administered barium. Along the subcutaneous route of the tube there
are many gas bubbles in addition to dense fat stranding although without any
organized collection. Some retention of barium in the stomach over the past 6
hours may indicate some slow emptying, but most of the barium has passed into
the visualized small bowel and colon. Gastric obstruction seems doubtful.
There is no lymphadenopathy, free air or free fluid.
There are no suspicious bone lesions. Bones are probably demineralized.
## IMPRESSION:
Dense stranding and gas bubbles along the subcutaneous root of the gastro
jejunostomy tube. In the early post-procedure course this is nonspecific but
possibility of a leakage of air and/or fluid from the stomach in subcutaneous
fat or even the possibility of active infection cannot be excluded by this
examination. Correlation with clinical findings is recommended. Tube has
migrated proximally and now terminates in the third portion of the duodenum
with redundancy in the stomach, previously having terminated in the proximal
to mid jejunum.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13515178", "visit_id": "20762918", "time": "2154-02-17 16:39:00"} |
11176843-DS-11 | 853 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
Mr. is a year old male with a of alcohol
abuse,
hypertension, hyperlipidemia, pancreatic lesion who presented on
to ED with disorganized behavior. He had
previously been admitted on for delirium with psychosis
which resolved spontaneously after one day. A full workup was
negative. He was subsequently admitted to the medical service
on
and was cleared medically for transfer to psychiatry.
Patient and patients daughter state he went back to work after
discharge from and was initially fine. The next day he
was
having difficulty with calculations, was anxious, and paranoid
about surveillance cameras watching him. He denies any AH or VH
at that time. After admission to , he states that he had
visual hallucinations, seeing "Jesus Christ" and Superman. He
also believed that the toxicologist was "not normal". He has
not
had any AH or VH since then. He denies SI or HI (though as per
Dr. note Mr. has says that he
"cannot live this way" or "does not wnat to live this way").
Patients daughter states that he was "completely normal" before
his first presentation to on and has no psychiatric
history.
Psych Consult followed Mr. while he was on the medical team.
He was started on Risperdal 0.5mg po bid.
## PAST MEDICAL HISTORY:
Past psychiatric history:
Patient denies any history of psychiatric diagnoses. Per OMR,
pts family questions whether he has a history of depression.
Denies prior psych hospitalizations. No prior SA.
Past medical history:
hypertension
hyperlipidemia
pancreatic lesion ("most likely IPMN" as per Dr.
## FAMILY HISTORY:
As per OMR, his brother died in his from a "dementing
illness".
## PHYSICAL EXAM:
Physical and Neuropsychiatric Examination:
## GA:
pleasant male, sitting in chair, in NAD, daughter at
bedside
## :
NC/AT, PERRL, EOMI, oral mucosa pink and moist, good
dentition
## NECK:
no LAD, no thyromegaly
## ABD:
soft, NT, ND, +BS
## *STATION AND GAIT:
gait balanced and steady
*tone and strength: normal tone, strength throughout
cranial nerves: CN II-XII grossly intact
abnormal movements: no PMR or PMA
*Appearance: fairly groomed male, wearing hospital gown
## COOPERATIVE
*MOOD AND AFFECT:
"i feel fine", flat affect
*Thought process (including whether linear, tangential,
circumstantial and presence or absence of loose *associations):
linear
*Thought Content (including presence or absence of
hallucinations, delusions, homicidal and suicidal ideation, with
details if present): denies AH or VH; denies SI/HI
*Judgment and Insight: limited
## *ATTENTION, *ORIENTATION, AND EXECUTIVE FUNCTION:
A+Ox3
*Speech: normal rate and tone, flips between and
*Language: fluent
## LABS:
from
BMP wnl, CBC wnl except Hct 37.2. ALT 55, AST 25, ALP 68
serum tox was negative
UDS was negative
U/A was negative
RPR nonreactive
CSF was unremarkable and culture did not grow anything
## MRI BRAIN ( ):
few punctate foci of high signal intensity
in subcortical white matter, c/w chronic microvasc ischemic
changes, no abnormal enhancement
## EEG:
left temporal slowing, more c/w subcortical abnormalities.
no seizure activity noted
## BRIEF HOSPITAL COURSE:
1. Psychiatric
Patient was transferred from medicine and signed a CV. He was
initially quite irritated and angry about being on inpatient
psychiatry. Patient was interviewed with interpreter and
he perseverated and anchored on the legal forms and would not
agree with clinical evaluation. On his second hospital night, a
behavioral trigger was called when patient barricaded his room.
Patient received chemical and physical restraints included 10 mg
IM Olanzapine. The following day, he was apologetic and agreed
to cooperate with the treatment team. Risperdal was added and
titrated up to 2 mg qhs without side effects. There were no
other overt signs of psychosis or thought disorder. Neuropsych
testing was performed and patient was given outpatient
behavioral neurology referral. He showed no signs of cognitive
impairment while inpatient.
2. Psychosocial
Multiple family meetings were held with patient and his
wife/daughter. They were kept abreast of treatment plan and
agreeable.
3. Medical
Patient had one medical trigger, when he become mild hypotensive
in context Risperdal titration and BP meds. He felt dizzy but
had no other sequelae. His BP meds were divided and his BP
stabilized. PCP was contacted and care coordinated.
4. Legal, CV, signed 3 day, retracted.
## MEDICATIONS ON ADMISSION:
Simvastatin 20 mg qhs
Nifedipine SR 60 mg po qam
Lisinopril 40 mg qhs
## DISCHARGE MEDICATIONS:
1. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
## DISCHARGE DIAGNOSIS:
Axis I Delirium/ Acute onset of Dementia / R/o Psychosis NOS
Axis II Def
Axis III HTN, Hyperlipedemia
Axis IV Unclear
Axis V -30
## DISCHARGE CONDITION:
fair; improved.
MSE
A Ox3
Disheveled in hosp gown
Cooperative. Good rapport.
Cognition grossly wnl
Speech Normal
## MOOD:
ok. Restricted range.
No overt delusions, overvalued ideas. No FOI, LOA, TT/TB.
## DISCHARGE INSTRUCTIONS:
Please take medications as prescribed.
Please make follow up appointments.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11176843", "visit_id": "27674119", "time": "2153-02-18 00:00:00"} |
13997024-RR-16 | 90 | ## FINDINGS:
Emphysema. No pneumonia. No pleural effusion, or pneumothorax.
9-mm nodular opacity at the right mid lung, concerning for pulmonary nodule
seen only on frontal view. Hilar, mediastinal, and cardiac silhouettes are
within normal limits. Nodular opacity at the right lung base likely nipple.
## IMPRESSION:
1. No pneumonia. Emphysema.
2. 9-mm nodular opacity at the right mid lung, concerning for pulmonary
nodule, seen only on frontal view. CT chest is recommended for evaluation in
a nonurgent setting.
Finding posted on the ED dashboard; ED attending aware.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13997024", "visit_id": "23253595", "time": "2121-05-24 03:56:00"} |
12809118-RR-25 | 130 | ## INDICATION:
year old woman PPD#8 with R flank pain, chills, and dysuria.
Also with significant fundal and adnexal tenderness. UA w/ large leuks, neg
bacteria // ? rPOCs?
## FINDINGS:
The uterus is anteverted and measures 12.8 cm x 5.1 cm x 10.5 cm. The
endometrium is homogenous and measures 3 mm. No evidence of vascularized
retained products of conception. An intrauterine device is noted with the
cross bars at the level of the lower uterine segment.
The ovaries are normal. There is no free fluid.
## IMPRESSION:
1. No evidence of vascularized products conception.
2. Low lying position of an intrauterine device with the cross bars at the
level of the lower uterine segment as described above.
3. Unremarkable appearance of the ovaries. No free pelvic fluid.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12809118", "visit_id": "N/A", "time": "2135-10-23 15:58:00"} |
11005133-DS-7 | 993 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
Large duodenal adenoma
Gallstones
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
1. Duodenotomy for large adenoma resection.
2. Open cholecystectomy.
3. Intraoperative diagnostic/therapeutic upper endoscopy of
esophagus, stomach and duodenum.
## HISTORY OF PRESENT ILLNESS:
Mr. is a man well-known to me with a sizeable
duodenal adenoma. He has been found to not have a lesion
amenable to endoscopic
resection. This was determined by our expert endoscopy team.
Biopsies revealed adenoma tissue, however. I went ahead,
therefore, and met with him and discussed the goals, risks and
objectives of an operative exploration and duodenotomy with
tumor resection and whatever else would be necessary.
## PAST MEDICAL HISTORY:
bladder and prostate CA, DM, depression, chronic alcohol abuse
(reports stopped yr ago), tonic clonic seizure during EGD
## SOCIAL HISTORY:
Lives with wife on the
depression which was being treated at time of
procedure with Wellbutrin and a history of chronic alcohol
abuse.
All three factors may have contributed to this event.
## GEN:
well appearing and in no acute distress. Pleasant and
cooperative.Alert and
oriented. Attenion, language, praxis normal.
BP 1340/72. HR 66 and regular.
Chest CTA.
is RRR. No bruits.
## ABD:
nontender, nondistended. +BS. No masses.
PERRL. EOMI. No nystagmus.
## SPECIMEN SUBMITTED:
gallbladder, duodenal adenoma.
Procedure date Tissue received Report Date Diagnosed
by
.
Previous biopsies: DUOD. POLYP...1 JAR.
DUOD. 2 ND PART...1 JAR.
## I. GALLBLADDER (A-B):
1. Chololithiasis, mixed-type.
2. Mild chronic cholecystitis.
## II. DUODENUM (C-H):
1 Adenoma with focal high grade dysplasia, completely excised.
2. Small acute ulcer.
3. No carcinoma.
## BRIEF HOSPITAL COURSE:
This is a man well-known to me with a sizeable
duodenal adenoma.
He went to the OR on for:
1. Duodenotomy for large adenoma resection.
2. Open cholecystectomy.
3. Intraoperative diagnostic/therapeutic upper endoscopy of
esophagus, stomach and duodenum.
## PAIN:
He had a PCA for pain control. Due to some confusion, the
PCA was D/C'd and he was ordered for IV pain meds PRN. Once the
confusion passed, he was restarted on his PCA. His pain was well
controlled. He was transitioned to oral pain medications once
tolerating a diet.
## GI/ABD:
He was NPO, with a NGT and IVF. The NGT was removed on
POD 3. His diet was slowly advanced as he had return of bowel
function. He was tolerating clears liquids by POD 5. On POD 6,
the JP was subsequently removed the next day.
His abdomen was soft, nondistended and the incision with staples
was C/D/I. The staples were removed prior to discharge and steri
strips placed.
He was tolerating regular food and reported +flatus and +BM
prior to discharge.
## POST-OP HYPERTENSION:
He received IV Hydralazine for HTN with
good effect.
## MEDICATIONS ON ADMISSION:
Plavix 75', Flomax 0.4'', Actose 30', ASA 81', Ambien 10',
Vitamin D, Insulin 13am/7pm, HCTZ 25', Detrol, B12, Wellbutrin,
Fe 325'
## SIG:
One (1) Drop Ophthalmic
QID (4 times a day).
2. Hydromorphone 2 mg Tablet Sig: Tablets PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
10. Bupropion 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
16. Ambien 10 mg Tablet Sig: One (1) Tablet PO once a day.
## DISCHARGE INSTRUCTIONS:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting lbs) for 6 weeks.
* You may shower and wash. No tub baths or swimming.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11005133", "visit_id": "25312036", "time": "2112-09-30 00:00:00"} |
16006839-RR-5 | 78 | ## INDICATION:
Gallstone pancreatitis, LFTs and pain, improving. Concern for
passed stone.
## IMPRESSION:
1. No ductal stones.
2. Cystic changes and mild increased T2 signal intensity throughout segments
V and VIII are nonspecific, but warrant further evaluation with intravenous
contrast once renal function has improved.
3. Incompletely-characterized 5.4 x 3.8 cm T2-hypointense left paramedial
mesenteric mass warrants further evaluation with contrast-enhanced study
following improvement of renal function.
4. Moderate-sized hiatal hernia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16006839", "visit_id": "24570601", "time": "2189-09-25 18:43:00"} |
11551927-RR-56 | 346 | ## INDICATION:
year old man with severe pancreatitis, multiorgan failure //
evaluate pancreas, intrabdominal abscess
## FINDINGS:
Opacities in the bilateral lung bases consistent with atelectasis have
increased from prior exam. The visualized lung bases are otherwise clear.
Probable gynecomastia is noted.
## LIVER:
Evaluation of the abdominal organs is somewhat limited on
this non-contrast exam. The liver demonstrates a decreased density and a
heterogeneous texture, consistent with fatty deposition.
## GALLBLADDER:
The gallbladder his normal in appearance.
## PANCREAS:
Extensive hypodense fluid collections and fat stranding are seen in
the area of the pancreas, unchanged in overall extent compared to prior exam
and consistent with known severe pancreatitis. The pancreas cannot be
evaluated for necrosis on this noncontrast exam. There may be a small focus of
blood products in the fluid collection in the right pelvis (2:81).
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The adrenal glands are unremarkable bilaterally.
## KIDNEYS:
The left kidney is again noted to be hypoplastic. The right kidney is
hypertrophic. The right kidney demonstrates and dilated collecting system
without cortical thinning, which may represent hydronephrosis or possibly
congenital UPJ obstruction.
## GI:
The patient is status post gastric surgery. The stomach, duodenum, and
intra-abdominal loops of bowel are normal in caliber and otherwise
unremarkable.
## VASCULAR:
The abdominal aorta is normal in appearance.
## PELVIS:
The sigmoid colon and rectum are normal in appearance. The distal
ureters and bladder are normal. Free fluid is seen in the pelvis.
## BONES AND SOFT TISSUES:
No focal lytic or sclerotic osseous lesions
suspicious for infection or malignancy are seen.
## IMPRESSION:
1. Overall unchanged extent of intra-abdominal and pelvic hypodense fluid
collections centered around the pancreas, consistent with known severe
pancreatitis. A possible small focus of blood products is seen fluid
collection in the right pelvis, unchanged. Cannot evaluate for abscess on this
noncontrast exam.
2. Dilated right kidney collecting system without cortical thinning, which may
represent congenital UPJ obstruction given it is longstanding and there is no
evidence of parenchymal loss c/w anUS from ..
3. Fatty liver.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11551927", "visit_id": "29654387", "time": "2171-05-22 13:48:00"} |
16339701-DS-13 | 2,077 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Esophagogastroduodenoscopy, argon plasma coagulation ( )
## HISTORY OF PRESENT ILLNESS:
Ms. is a with chronic anemia GAVE, requiring
transfusions ~Q3 months, CKD, DM2, HTN, PVD who initially
presented for a kidney biopsy for proteinuria, but was admitted
to us for pallor and low hematocrit. Pt has had chronic anemia
from GAVE, with baseline hct from . She has underwent
banding procedures for the GAVE, and requires blood transfusions
~Q3 months. She was most recently admitted to in
for a transfusion. She reports lightheadedness while walking,
but not at rest, and denies SOB. She reports regular black
stools, but no BRBPR. She denies vaginal bleeding.
Pt has been noted to have proteinuria. Pt's nephrologist, Dr.
that this is likely DM2, HTN, and PVD. She
presented today for a kidney biopsy, but was found to be pale. A
CBC revealed a hematocrit of 17.3, hgb 5.4. The biopsy was
cancelled, and she was admitted for a blood transfusion.
Upon arriving to the ED, her vitals were T 98.2, BP 150/40, HR
58, RR 18, O2 sat 98% on RA. She felt weak and tired, but was
not lightheaded or SOB. She received 2 units of pRBC's. GI was
consulted. She was transferred to the floor, with no acute
complaints.
Of note, pt FOOSH'ed on , with subsequent swelling and
pain of her L wrist. She also has echymosis of a R toe. She had
an X-ray today in the ED which showed no evidence of fracture.
She has pain with palpation or movement of the wrist.
.
## ROS:
- Lightheadedness as above. No headaches or LOC.
- No changes in vision or hearing.
- No chest pain, palpitations
- No SOB, dyspnea, cough
- Melena as above. No dysphagia, abdominal pain, diarrhea,
constipation, BRBPR
- No dysuria or hematuria
- No myalgia or arthralgia
- No new skin rashes
## PAST MEDICAL HISTORY:
-Pericardial effusion
-Mitral stenosis
-Moderate pulmonary hypertension
-GAVE c/b iron deficiency anemia s/p banding procedures
-HLD
-DM2, with neuropathy, last A1C 5.6 ( )
-PVD with claudication, s/p b/l SFA angioplasties and stent
placement
-CKD (baseline Cr ~3 since , mid 1's in ,
normal in
-obesity
-gout
-s/p left and partial right salpingo-oophrectomy for ovarian
cyst c/b premature ovarian failure
-s/p lap CCY
-s/p ventral hernia repair
## FAMILY HISTORY:
Father died at yo from MI
Mother died of MI in
1 sister died at from lung CA
1 sister with ?kidney cancer, but still alive
1 brother healthy
2 daughters - 1 health, 1 has menstrual problems, is getting
hysterectomy
1 son - healthy
## ADMISSION PHYSICAL EXAM:
Vitals- T 98.1 BP 143/31 HR 64 RR 19 O2 sat 100% on RA
General- Alert, oriented, no acute distress
HEENT- Conjunctival pallor, sclera anicteric, MMM, oropharynx
clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, SEM over the
upper sternal borders, no rubs or gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- There is pitting edema over the L wrist extending into the
hand. Pt wears a splint, beneath which there is ecchymosis.
toe of the R foot has echymosis, with mild swelling. warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro- CNs2-12 intact, motor function intact and symmetric
throughout. Decreased vibratory sensation in the lower
extremities to the knees bilaterally.
## DISCHARGE PHYSICAL EXAM:
Vitals- T 98.3, BP 173/58, HR 59, RR 18, O2 sat 100% on RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Lungs- CTAB, no wheezes, rales, ronchi
CV- Regular rate and rhythm, normal S1 + S2, SEM over the
upper sternal borders, no rubs or gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- There is pitting edema over the L wrist extending into the
hand. Pt wears a splint, beneath which there is ecchymosis.
toe of the R foot has echymosis, with mild swelling and
tenderness to touch. Warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema otherwise.
Neuro- Motor function grossly intact.
## IMAGING:
Foot X-ray:
Three views of the right third through fifth toes were obtained.
The toes are somewhat flexed and thus not optimally evaluated.
There is also diffuse osteopenia. There is limited evaluation
of the middle and distal phalanges. Slight irregularity of the
distal fifth proximal phalanx is of indeterminate age.
## IMPRESSION:
Suboptimal study due to flexed position of the
third through fifth toes, difficult to exclude a subtle
fracture. Slight irregularity of the distal aspect of the fifth
proximal phalanx is of indeterminate age. Correlate clinically
for acuity.
## LEFT HAND:
No acute fracture or dislocation is seen. There is
relative diffuse osteopenia. Extensive vascular calcifications
are seen. There is a 4 mm ovoid calcific/ossific structure
located between the scaphoid and triquetrum which appears old,
but could relate to a nonspecific soft tissue calcification or
loose body. There is amorphous calcification projecting over
the dorsal aspect of the lateral wrist which does not appear
acute.
## LEFT WRIST:
No definite acute fracture or dislocation. There
are extensive vascular calcifications. Soft tissue
calcifications as described above including 4-mm dense
ossific/calcific structure between the scaphoid and triquetrum
as well as amorphous calcification projecting over the lateral
dorsum of the wrist are nonspecific but are unlikely acute.
## IMPRESSION:
No evidence of acute fracture or dislocation. Soft
tissue calcifications as described above.
CXR:
Frontal and lateral radiographs the chest demonstrate well
expanded lungs. There is minimal blunting of the bilateral
costophrenic angles. There is no pneumothorax. The
cardiomediastinal and hilar contours are unchanged. No acute
displaced rib fracture is identified. A chronic compression
fracture is present at the thoraco-lumbar junction.
## IMPRESSION:
1. No acute cardiopulmonary process.
2. No acute displaced rib fracture is identified. If clinical
suspicion remains high, dedicated rib films could be performed
for additional evaluation of rib fracture.
EGD:
Normal mucosa in the whole esophagus
GAVE that was actively oozing. Successful hemostasis with APC.
(thermal therapy)
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
## BRIEF HOSPITAL COURSE:
Ms. is a with chronic anemia GAVE, requiring
transfusions ~Q3 months, CKD, DM2, HTN, PVD who initially
presented for a kidney biopsy for proteinuria, but was admitted
for a low hematocrit in the setting of melena. She was initially
administered 2 units of pRBC's. On EGD, she was found to have
ectasia, and underwent argon plasma coagulation. She received
another 2 units of pRBC's. These transfusions were complicated
by hypertension, with SBP's in the 190's, requiring home
anti-hypertensives. She was stable at time of discharge.
## # ANEMIA GAVE AND CKD:
Pt's hct was 17.3 on admission, down
from baseline of . She was administered 2 units of pRBC's,
after which hct rose to 23.5. She underwent an EGD, which
revealed ectasia consistent with GAVE, and completed argon
plasma coagulation to achieve hemostasis. She was administered
another 2 units of pRBC's, with hct goal of 30. Plan was for
kidney biopsy for which she was originally scheduled however she
decided not to undergo it and chose to reschedule it at a later
date. She was maintained on sucralfate (1g daily in
liquid/crushed-pill form QID for 2 weeks, then BID) and
pantroprazole BID. She was scheduled for a repeat EGD in 6 weeks
for banding.
## # CKD:
CKD likely DM and HTN. Nephrotic range proteinuria,
suggestive of diabetic/vascular glomerulonephropathy. All meds
renally dosed. NSAID's avoided. Kidney biopsy to be rescheduled
with Dr. .
## # HTN:
Pt has refractory HTN at baseline. We initially held her
anti-hypertensives given concern for GIB. However, after a unit
of pRBC's, her BP rose, with SBP as high as 190's. She was
administered furosemide and restarted on home antihypertensives.
## # LEFT WRIST SPRAIN:
4 days prior to admission, pt fell onto an
outstretched hand, with pain and swelling of the L wrist, as
well as the R toe. X-rays were negative for fracture in
either location. The wrist pain was attributed to a sprain, and
was maintained in a splint. Pain was controlled with Tylenol and
tramadol. We appreciated OT consultation with help with further
treatment and brace fitting.
## #DM2:
Blood sugars were well controlled, though home insulin
regimen (per pt's report) has been inappropriately high for her
current blood sugars. Pt reports that she typically does not
control her carb intake at home to the extent here. Standing
insulin doses held; home sliding scale continued. She will go
home on her home insulin as she has a less controlled diet.
## - CODE STATUS:
Confirmed Full
- Contact: (husband)-
- to reschedule kidney biopsy with Dr.
- pt request, possibly arranging for outpatient management
of anemia to try to minimize admissions. Balance of transfusions
is potential alloimmunization.
- Continue sucralfate 1g 4x/day, as liquid or as crushed-pill in
liquid, for at least 2 weeks after the procedure ( )
- Continue pantoprazole 40 mg PO Q12H
- Repeat EGD in 6 weeks for banding
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Labetalol 300 mg PO BID
3. HydrALAzine 50 mg PO TID
4. Sucralfate 1 gm PO BID
5. Klor-Con M10 (potassium chloride) 10 mEq oral DAILY
6. Diltiazem Extended-Release 240 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Zolpidem Tartrate 10 mg PO HS:PRN Insomnia
10. Humalog 18 Units Breakfast
Humalog 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Citracal Regular (calcium citrate-vitamin D3) 250-200
mg-unit oral BID
12. Torsemide 20 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Atorvastatin 80 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. HydrALAzine 50 mg PO TID
5. Labetalol 300 mg PO BID
6. Losartan Potassium 100 mg PO DAILY
7. Sucralfate 1 gm PO QID
Please take in liquid form, or as crushed-pill in water.
RX *sucralfate 1 gram/10 mL 1 suspension(s) by mouth 4 times
daily Disp Milliliter Milliliter Refills:*0
8. Torsemide 20 mg PO DAILY
9. Zolpidem Tartrate 10 mg PO HS:PRN Insomnia
10. Citracal Regular (calcium citrate-vitamin D3) 250-200
mg-unit oral BID
11. Klor-Con M10 (potassium chloride) 10 mEq oral DAILY
12. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
You may take up to 2 doses per day. Please stop taking if you
develop diarrhea.
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
14. Humalog 18 Units Breakfast
Humalog 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
## DISCHARGE DIAGNOSIS:
Anemia
Gastric antral vascular ectasia
Chronic kidney disease
Proteinuria
Wrist sprain
Diabetes
Hypertension
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure taking care of you at
. Though you initially presented for a kidney
biopsy, your blood levels were found to be too low, and you were
admitted to the medicine service. Here, we gave you blood
through your IV. You underwent an endoscopy, which found that
your GAVE was causing some recurrent bleeding. The bleeding
sites were cauterized. After receiving additional blood, you
underwent a biopsy of your kidney.
Once you return home, continue to take omeprazole (twice a day)
and sucralfate (1 gram, 4 times a day, in liquid form or as
crushed-pills in water; you may return to your usual home dose
of twice a day starting on these will help to reduce
irritation of your stomach. You may take 1 dose a day of Miralax
(up to 2 doses per day) for constipation; please stop taking
this if you have diarrhea.
Please follow-up with your primary care doctor, , on
at 11:00am.
Please follow-up with the GI doctor on at 10:30am, who
will repeat the endoscopy to band the bleeding vessels in your
stomach.
You may hear from Dr. office to reschedule your kidney
biopsy. If you do not hear from them in the next 2 business
days, please call his office at .
We wish you the best!
Sincerely,
The SIRS 4 Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16339701", "visit_id": "23587124", "time": "2131-05-16 00:00:00"} |
15768560-RR-9 | 352 | CTA CHEST PERFORMED ON
Comparison with a chest radiograph from earlier today as well as a CTA chest
from .
## CLINICAL HISTORY:
man with hemoptysis, mold exposure, fever to
102, question PE or fungus.
## FINDINGS:
The pulmonary arterial tree is suboptimally opacified, though there
is no evidence of filling defect within the main, lobar and segmental
branches. Subsegmental branches are difficult to assess, given the suboptimal
opacification. The thoracic aorta is normal in course and caliber without
evidence of dissection or atherosclerosis. The heart is normal in size and
shape. There is no pleural or pericardial effusion. Small mediastinal lymph
nodes do not meet size criteria for pathological enlargement.
There is stable atelectasis at the left lung base. The previously noted tiny
left pleural effusion has resolved. The nodule in the inferior lingula is
again seen, measuring approximately 7 mm. There is only minimal residual
scarring/atelectasis in the region of previous consolidation in the anterior
aspect of the left lung base. There is a 4-mm right middle lobe nodule seen
on series 4, image 62, which is more conspicuous than on prior study, though
appears grossly stable in size.
The imaged portion of the upper abdomen is unremarkable aside from a minimally
prominent periportal lymph node, which measures approximately 10 mm in short
axis.
## BONES:
The imaged osseous structures appear intact without focal lytic or
sclerotic lesion of concern. There is interval resolution of the previously
noted subcutaneous fluid collection in the anterior mid chest with residual
skin thickening and subcutaneous fat stranding in this location (series 501B,
image 37).
## IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic process.
2. Pulmonary nodules, stable from CT scan, measuring 4 mm in
the right middle lobe and up to 7 mm in the lingula. Please correlate
clinically and if needed, a followup CT in one year may be obtained to assess
for resolution or stability.
3. Minimal residual skin thickening and subcutaneous fat stranding in the
anterior chest wall at the site of prior subcutaneous fluid collection.
4. Stable left basilar atelectasis with interval resolution of trace left
pleural effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15768560", "visit_id": "22429778", "time": "2142-04-09 17:39:00"} |
19525287-DS-4 | 2,163 | ## ALLERGIES:
Clindamycin / Neomycin / Penicillins /
triamterene-hydrochlorothiazid / Sulfa (Sulfonamide Antibiotics)
/ Ace Inhibitors
## CHIEF COMPLAINT:
Aspiration; AF with RVR; old C2 fracture
## HISTORY OF PRESENT ILLNESS:
yo woman with HTN, AF, depression, C2 fracture recently
admitted to for afib RVR treated with dronedarone
and C2 fracture treated conservatively with cervical collar due
to high surgical risk who is now transferred from for
management of AF with RVR and ? aspiration PNA. She was recently
admitted to for AF with RVR and dronedarone was
discontinued due to prolonged Qt and patient was started on
diltiazem. This admission to ICU ( ), she was
admitted for AF with RVR and hypoxia. Daughter also concerned
that patient aspirated due to coughing and choking after PO
intake on and wanted her to receive antibiotics. She was
treated with Aztreonam, Vancomycin. CT Chest was obtained which
revealed bibasilar atelectasis and ? infiltrate. CT Head/neck
revealed chronic fracture. She was traneiently on dilt drip then
transitioned to IV dilt. She remained NPO due to concern for
aspiration. She was transferred from ICU per daughter's
request for further management.
.
On arrival to the floor, she is screaming "I have a headache!
Give me pain medications!". She states she has had HA for weeks
and denies current CP, cough or SOB. She is not cooperative with
exam and is pulling on my arm and grabbing my coat. History
mostly obtained from daughter who states pt awoke approx 1.5
weeks ago with neck in laterally flexed position to L that she
has been "stuck in" for last week. Since this time, she has been
choking on food more than usual and had episode approx days
ago where she had witnessed aspiration resulting in subsequent
tachycardia that prompted admission to . She would like to
see if neck can be fixed so she can stop aspirating but did not
want to have this done without involvement of ortho spine. She
is aware that patient would be at high risk of death with any
surgical procedure but also is concerned that she would also die
if she is unable to eat and patient has stated she would not
want feeding tube.
## PAST MEDICAL HISTORY:
Hypertension
Depression
Hyponatremia
C2 Vertebral fracture
Osteoporosis
Migraine
AF not anticoagulated due to recurret falls
Gait disorder
Recurrent falls
Aspiration
## FAMILY HISTORY:
Daughter with grave's disease and grandson with tourette's and
ocd.
## GENERAL:
Chronically ill-appearing woman, screaming as above,
apears uncomfortable but falls asleep when left alone.
## HEENT:
NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear.
## NECK:
Laterally rotated to left so ear and side of head touching
shoulder with palpable muscle spasm. In cervical soft collar.
Unable to appreciate JVD
## HEART:
Irreg irreg. Tachy. No MRG, nl S1-S2.
## LUNGS:
Coarse rhonchorous breath sounds anteriorly on R and
bilateral bases with transmitted upper airway sounds. No
wheezes, resp unlabored
## ABDOMEN:
Soft/NT/ND, no masses or HSM, no rebound/guarding.
## EXTREMITIES:
WWP, no c/c/e, 2+ peripheral pulses. Able to wiggle
toes and lift legs off bed
## SKIN:
No rashes or lesions.
## NEURO:
Awake, A&Ox to place and self, didn't know date,
otherwise minimally cooperative, CNs II-XII grossly intact.
## GEN:
elderly, chronically ill appearing female, head slightly
laterally flexed position with soft collar in place.
## CV:
irreg rhythm, reg rhythm, normal S1, S2, no m/r/g
## PULM:
CTAB on anterior chest
## ABD:
BS+, NT, ND, no HSM
## EXT:
warm, trace edema, 2+ pulses bilaterally
## NEURO:
strength in RUE (decreased grip strength), in
LUE, CNII-XII grossly intact but neuro exam limited by
inattention, AAOx person, more interactive and appropriate
## URINALYSIS:
01:43PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
01:43PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
## ECG :
Atrial flutter with rapid ventricular response. Left anterior
fascicular block. Delayed R wave progression with late
precordial QRS transition is
non-diagnostic. Anterolateral lead T wave changes are
non-specific. Clinical correlation is suggested. Since the
previous tracing of atrial flutter has replaced sinus
rhythm and ST-T wave changes are present.
MRI HEAD
## FINDINGS:
The parenchymal gray-white matter differentiation is
maintained. There is considerable susceptibility artifact over
the right frontal and parietal lobes on the diffusion-weighted
sequence. With that limitation, there is no evidence of abnormal
diffusion. No intracranial hemorrhage, edema or mass effectis
seen. There are multiple periventricular and subcortical white
matter T2 hyperintensities, most likely representing the sequela
of chronic small vessel ischemic disease. The ventricles and the
sulci are prominent, likely related to atrophic change. There is
no extra-axial fluid collection. The major intracranial flow
voids are present. Fluid is present within the left mastoid air
cells, and in the nasopharynx.
Concurrent cervical spine MRI is reported separately.
## IMPRESSION:
Allowing for artifacts on diffusion weighted images, there is no
evidence of acute intracranial abnormalities.
## MRI CERVICAL SPINE:
1. The chronic type 2 dens fracture has not significantly
changed showing
possible evidence of chronic arthrodesis at the fracture site.
Unchanged
moderate spinal canal narrowing at the level of the dens, mostly
due to
prominent epidural soft tissues.
2. Unchanged degenerative spinal canal stenosis, severe at C3-C4
and moderate to severe C4-C5.
## BRIEF HOSPITAL COURSE:
Patient is a yo female with PMH of HTN, AF, chronic C2
fracture, osteoposis, lateral neck flexion and spasm x 1.5 weeks
who presented with with aspiration and a. fib with RVR.
## #ASPIRATION:
Patient presented after witnessed aspiration
causing tachycardia, a.fib with RVR and hypoxia. CT chest did
not show definitive pneumonia. She had no leukocytosis and no
fever and did not appear to have pneumonia clinically and
antibiotics started at were discontinued. She was
evaluated by speech and swallow and she tolerated pureed foods
with thin liquids as well as crushed meds in applesause or ice
cream. Please make sure to have speech and swallow re-evaluation
if there are any concerns.
## #A. FIB:
Patient was admitted in a. fib with RVR. While she was
NPO, her rate was difficult to control with iv metoprolol and
she did have an increase in her heart rate, particularly when
being moved or agitated. Once she was able to tolerate oral
medications per speech and swallow, she was restarted on her
home po metoprolol and diltiazem. Her heart rate was still high
and her dose of metoprolol was increased from 100mg BID to
. Her heart rate has been better controlled on
. Given that patient's medications need to be crushed, we
could not place the patient on extended release meds.
.
#Lateral neck flexion and spasm: unclear trigger- though may
have been related to fracture, neck brace or medication effect
(haldol vs ciprofloxacin). This was thought to be contributing
to her apsiration. She passed speech and swallow while her neck
was still held in laterally flexed position. Ortho spine was
consulted who recommended that her head be manually manipulated
to the right. She was also placed in cervical collar. There was
an attempt to place patient on a cervical traction, but she was
unable to tolerate this. She was able to move her head to the
right and her spasm had improved by the time of discharge. She
has also improve range of motion of her RUE, although continues
to have mild weakeness of her R arm. Work up was negative for
CVA or other causes of her R arm weakness. Patient was placed on
tylenol every 8 hours and oxycodone 2.5mg as needed for
pain. Her pain has improved and is now well controlled mainly
with Tylenol.
## #C2 FRACTURE:
per recent notes, not a surgical candidate. She
was seen by ortho spine who again recommended keeping her neck
in the soft cervical collar and cervical traction, however she
was unable to tolerate the cervical traction. She will need to
follow-up with ortho as listed on the discharge instructions.
#Hypertension: Patient had several episodes of hypertension
during her admission with SBP in 150s, low 160s but was better
controlled once back on her home metoprolol and diltizem.
## #HEADACHES:
Chronic issue for patient. Patient complained of
headaches thoughout her admission and was treated with tylenol.
She had a degative CT head at and negative MRI head.
## .
# CONSTIPATION:
Pt had no BM for days. She was given
dulcolax suppository with + BM on . She then had liquid
stools today. Rectal exam + for hard stool on rectal vault and
pt was mannually disimpacted. Please continue w/ bowel regimen
daily w/ additional meds as needed.
## #CODE:
Full (patient and daughter would like time to think about
it)
## MEDICATIONS ON ADMISSION:
Ultram 50mg PO TID prn
Oxycodone 2.5mg PO q4 hours pnr
Vitamin D 1000 units PO qam
Cipro 500mg PO BID start on for 7 days
Florastor 250mg PO BID for 7 days
Aspirin 325mg P odaily
Calcium/Vitamin D
Duonebs prn
Trazodone 12.5mg PO BID
Bowel regimen
Ensure 240ml PO TID
Metoprolol 100mg PO BID
Prevacid 30mg PO daily
Cardizem 180mg PO daily
Pureed diet
Robitussin prn
## DISCHARGE MEDICATIONS:
1. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every four (4) hours
as needed for pain: Please hold for sedation and Respiratory
rate<12.
2. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
3. Calcium 500 500 mg calcium (1,250 mg) Tablet, Chewable Sig:
One (1) Tablet, Chewable PO three times a day.
## 4. ENSURE LIQUID SIG:
One (1) PO three times a day.
5. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day.
8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
## NEBULIZATION SIG:
One (1) neb Inhalation every hours as
needed for shortness of breath or wheezing.
9. Robitussin Chest Congestion 100 mg/5 mL Liquid Sig: Five (5)
ml PO three times a day as needed for cough.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: Give one tablet in the morning and the second dose
in the evening. PLEASE HOLD FOR SBP<100 and HR<60.
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q
afternoon: Please give 8 hours apart from yesterday morning.
15. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation: As needed for constipation.
## 16. ENSURE LIQUID SIG:
One (1) can PO three times a day.
## 17. TRAZODONE (BULK) POWDER SIG:
12.5 mg Miscellaneous at
bedtime as needed for insomnia: AS need for insomnia. Please
hold for sedation and respiratory rate <12.
18. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a
day.
## PRIMARY:
Aspiration
Atrial Fibrillation with rapid ventricular rate
C2 fracture
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the hospital after you aspirated some of
you food at your extended care facility. This may have been
related to your neck spasm. You were seen by the spine
specialists who helped us manage your care. You attemped to
place you on spinal traction and you did not tolerated it. You
had a soft collar placed and your neck is getting better. It is
very important that you keep the soft collar on at all times,
until your told by your doctor that this is okay to be removed.
You were also found to be atrial fibrillation with a very fast
heart rate. This was thought to be related to an aspiration
event that you had. You were given a medication to help control
your blood pressure.
You were also seen by our speech and swallow therapists who
helped us determine a safe way for you to eat and drink.
You were constipated and had to be mannually disimpacted. IT is
very important that you continue to take stool softners and
laxatives as needed to help prevent this problem.
The following changes were made to your medications:
- STOPPED Ciprofloxacin (you had already finished your course of
antibiotics)
- STOPPED Florastor
- Changed Trazadone twice daily to the evening prior to bed time
- CHANGED Diltiazem from 180 mg once a day to 30 mg every 6
hours
- INCREASED Metoprolol from 100mg twice daily to 100mg in the
AM, 50mg at lunch time and 100mg in the evening.
- STARTED on tylenol every 8 hours for the pain. You
SHOULD NOT exceed 4000mg per day. This dose should be reassess
by your primary care doctor as the pain in your neck starts to
improve.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19525287", "visit_id": "23347190", "time": "2119-01-14 00:00:00"} |
11219036-RR-12 | 190 | ## EXAMINATION:
ABDOMEN US (COMPLETE STUDY)
## INDICATION:
year old man with uptrending liver enzymes// eval for
hepatic/biliary process
## LIVER:
The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation.
## GALLBLADDER:
The gallbladder is not visualized.
## PANCREAS:
The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas. An elongated hypoechoic/anechoic
structure seen at the anterior aspect of the pancreatic body on a few images
likely represents the splenic artery.
## KIDNEYS:
Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is a 6.5 cm cortical cyst arising at the lower pole
of the right kidney. There is no evidence of solid masses, stones, or
hydronephrosis in the kidneys.
Right kidney: 14.6 cm
Left kidney: 10.3 cm
## RETROPERITONEUM:
The visualized portions of aorta and IVC are within normal
limits.
## IMPRESSION:
No cause for elevated liver enzymes is identified.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11219036", "visit_id": "28099682", "time": "2153-05-29 15:16:00"} |
11882807-DS-14 | 1,331 | ## ALLERGIES:
Cephalosporins / Penicillins / Iodine Containing Agents
Classifier
## CHIEF COMPLAINT:
DM1 and ESRD here for combined kidney/pancreas transplant
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
kidney/pancreas transplant : line placement
## HISTORY OF PRESENT ILLNESS:
y/o AA male with history of Type 1 DM since age and
HTN who has been on hemodialysis x years now presents for
combined kidney/pancreas transplant.
The patient currently dialyzes at using a
Right tunneled dialysis catheter. He is s/p removal of an
infected graft approximately 3 months ago but currently is not
on
any antibiotics for this. He states his recent HD sessions are
marked by some cramping, and they are increasing his EDW.
He denies fever, chills, recent sick contacts, chest pain,
shortness of breath, abdominal pain, diarrhea, rectal bleeding,
headache. He states he has low energy but attributes that to the
HD.
He reports a minimal urine output, probably less than 100 cc
daily. He reports some peripheral neuropathy but no sores or
infections related to the diabetes.
His primary nephrologist called to report that patient was
hospitalized in at with a partial SBO that was
resolved with medical management. The patient denies ever
having
abdominal surgery, and the GI service there was recommending an
enterography to rule out small bowel mass in the absence of
other
causes for obstruction. He has not as yet had this study. Also
of
note the nephrologist mentioned the patient has not required
epogen therapy while on HD.
## PAST MEDICAL HISTORY:
DM1 since age , HTN, depression, hypercholesterolemia,
retinopathy, neuropathy, erectile dysfunction and cocaine abuse.
## FAMILY HX:
DM and HTN both sides of family, brother with recent
of DM
## GENERAL:
NAD, lying in bed comfortable but sl anxious
## HEENT:
no LAD, anicteric sclera, full upper denture, missing
lower teeth, no evidence of infection
## ABDOMEN:
Soft, non-tender, non-distended, no scars, + BS
## EXTR:
left upper arm scar where graft removed, no edema, 1+
femoral pulses bilaterally, 1+ DPs, feet dry but no cracks/sore
noted
## ON ADMISSION:
WBC-5.0 RBC-4.68 Hgb-13.7* Hct-42.2 MCV-90 MCH-29.2 MCHC-32.4
RDW-17.5* Plt PTT-23.6
Glucose-257* UreaN-23* Creat-9.3*# Na-133 K-5.9* Cl-93* HCO3-27
AnGap-19
ALT-16 AST-28 LD(LDH)-196 AlkPhos-76 Amylase-173* TotBili-0.2
Lipase-62*
Albumin-4.3 Calcium-8.5 Cholest-138
%HbA1c-9.0* eAG-212*
On Discharge
WBC-4.8 RBC-3.06* Hgb-8.9* Hct-27.3* MCV-89 MCH-29.2 MCHC-32.7
RDW-17.3* Plt
Glucose-105* UreaN-13 Creat-2.3* Na-137 K-5.3* Cl-107 HCO3-22
AnGap-13
Amylase-85 Lipase-41
Calcium-9.5 Phos-1.9* Mg-1.7
tacroFK-14. y/o male admitted for pancreas/kidney transplant. After CT
clearance for question of small bowel mass related to a
hospitalization this at (Concern due to
no previous abdominal surgery and medically managed possible
SBO) The CT did not demonastrate any concerning massess, and it
was determined he could go ahead with the transplant.
The patient was taken to the OR with . The pancreas
transplant was performed first without complication. A two-layer
bowel anastomosis was accomplished. The kidney was then placed,
it reperfused very well and immediately. There were no ureteral
issues. The patient tolerated the surgery without complication
and was transferred to the PACU in stable condition.
He received routine induction immunosuppression to include
solumedrol with taper, cellcept and Thymoglobulin, first dose
intra-op with 5 doses total of 100 mg. Prograf was started on
the morning of POD 2.
Blood sugar values were well controlled by the new pancreas,
amylase and lipase values were normal. The kidney was noted to
have a drop in urine output immediately post transplant and an
ultrasound was performed showing No hydronephrosis of transplant
kidney. Satisfactory arterial and venous waveforms on Doppler
imaging. Following the initial drop, he gained function with
excellent urine output and creatinine 9.3 on admission dropped
daily to an apparent baseline of 2.3 at discharge.
On was otherwise progressing well until POD 4 his temp was 100.2
and on POD 5 his TMax was 101.5.
Urine culture from showed E coli, >100,000 colonies. Initial
blood cultures from were negative, but new sets were sent on
as the low grade fever had not subsided, and the blood
cultures came back also with E coli. The patient has significant
allergies (anaphylaxis) reported with PCN and cephalosporins. He
was initially started on Vanco, Levaquin and Flagyl, and after
the initial pathway Fluconazole was given immediately post op,
he was restarted on the fluconazole on POD3 and then continued
through POD 10. Once the sensitivities were returned, the
patient, who had been followed by ID consult, was started on
Aztreonam.
A PICC line was placed once he was afebrile and the Aztreonam
will be continued through .
The patient had a CT of abdomen and pelvis on when he was
febrile which showed Status post renal and pancreas transplant
with expected post surgical changes. No fluid collections are
noted.
He was slow to regain bowel function, and required several
enemas and suppositories before good bowel function was
restored.
By day of discharge he was tolerating diet, but without a good
appetite, he was ambulatory.
Due to fluconazole being stopped day before discharge, his
prograf level was increased to 3 mg BID with labs to be drawn
.
He will be staying with his mother initially and receiving his
IV aztreonam via line, services have been arranged.
## MEDICATIONS ON ADMISSION:
Renal Caps daily, Cinacalcet 60 mg daily, Clonidine patch
0.3 weekly ( ), Benadryl hs,
Glargine 18 units 8 , Humalog SS, Renvela 3 Tabs q meal,
Diovan, unsure of dose daily, Nifedipine 90 mg BID, Metoprolol
50
Mg BID, Mirtazapine 15 mg hs, Pantoprazole 20 mg daily, Aspirin
(has not taken for a few months) Colace 100 mg PRN
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every .
Disp:*4 Patch Weekly(s)* Refills:*2*
11. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
12. Aztreonam in Dextrose(Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q8H (every 8 hours) for 12 days.
Disp:*36 gram* Refills:*0*
13. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation: Over the counter for
constipation.
## DISCHARGE DIAGNOSIS:
DM I
ESRD
Now s/p combined pancreas/kidney transplant
Bacteremia
## ACTIVITY STATUS:
Ambulatory - Independent. (requested cane)
## DISCHARGE INSTRUCTIONS:
Please call the Transplant office if you experience
any of the warning signs listed below.
You will need to have labs drawn every and at
building
Check you blood sugar twice daily, record. Call if 200 or
greater
You may shower, pat incision dry and leave open to air. No tub
baths
No heavy lifting/straining/swimming
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11882807", "visit_id": "21619296", "time": "2129-09-08 00:00:00"} |
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