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11677801-DS-38 | 1,746 | ## HISTORY OF PRESENT ILLNESS:
with a complex cardiac history including CABG ×4 at age
in
the early , multiple stenting procedures since then for
repeated occlusions of coronary/CABG associated vasculature, who
was transferred from for evaluation of chest
pain consistent with unstable angina.
He is followed by Dr. as his primary cardiologist. He has
had overall good functional status at baseline over the last few
months, walking up to 4 miles a day. However, in the past week,
he has developed episodes of chest tightness and numbness
radiating down his left arm, and associated perceived shortness
of breath. He reports these initially occurred in the context of
walking, starting a week ago. However in the past days,
these
have been occurring at rest. He went to 2 days
ago, had 2 sets of cardiac enzymes and was observed, and a
cardiology consultation was obtained, during which it was noted
that he had had some abdominal distention and abdominal pain
with
fullness progressing into his chest, and it was felt that 3 sets
of serial enzymes could be obtained and if negative he could
follow-up with his outpatient cardiologist as his discomfort was
likely noncardiac. He was discharged home yesterday, however
last
night he awoke from sleep at about 2 AM with severe chest
pressure and symptoms in his left arm, felt a bit better after
about a half hour and went back to sleep. This morning, he woke
up chest pain-free, however while sitting and reading, he
developed chest pressure which was worse than any previous
episodes this week, was associated with a tingling/numbness
sensation in his left arm. He went to his car to drive to the
hospital, chest pain resolved for about a half hour at his he
sat
in his car warming up as it was covered in ice, and then chest
pain returned, severe, and he drove to . At , his EKG was similar
prior, without ischemic changes, cardiac enzyme testing was
negative, and he received a full dose aspirin. His chest pain
resolved by 9 AM, and has not recurred. He was transferred to
for further care, given his complex cardiac history
and multiple ED visits in the past week for same complaint.
Review of records from also indicates patient
had a troponin T of less than 0.01 on ,
and at about 5 AM on (today). He had a chest x-ray
this morning which did not show any acute process per ED
physician at .
In the ED, initial VS were: 98.1 63 139/77 16 97% RA
## EXAM:
Midline sternotomy scar is well-healed, multiple abdominal
surgery scars are well-healed, abdomen soft and nontender, no
cardiac murmur, lungs are clear, patient is not tachycardixc,
patient does not appear to be in acute distress at this time
EKG at 10:45 AM today at : Sinus at 56 with normal
axis, axis normal intervals, there is no ST elevation or
depression, there are T-wave inversions in V1 and 3 and aVF,
these features are similar to those seen on the EKG from 4 AM
today at , and are similar to those
seen on an EKG from of this year at
## SHOWED:
CBC, cardiac enzymes, BMP and lactate all wnl
Patient received no medications
Transfer VS were: 98.1 53 136/64 12 100% RA
On arrival to the floor, patient reports pain has been absent
since this morning. But it frequently is provoked by food, and
just had dinner a few minutes ago. Pain usually radiates to left
arm or jaw. No other acute complaints, denies SOB or chills.
## PAST MEDICAL HISTORY:
-CAD/ CABG 3V
-Stents - BMS to mid SVG-RPL, Promus to distal
SVG-RPL, Resolute distal SVF-RPL ISR ,
Resolute
for bilayer restenosis, - Promus for ISR RPL
-Restenosis of Promus from , restenosis of the
quadralayer in the SVG-RPL/RPDA Stenting of SVG-RPL ISR
complicated by perforation of the SVG - treated with covered
.
-DES to ISR of RPL ( )
-Hypertension
-Hyperlipidemia
-muscle invasive urothelial bladder ca s/p cystectomy and
creating of neobladder ( )
-intraductal papillary mucinous neoplasm s/p Whipple procedure
( )
-ventral hernia s/p repair
-Ulcer s/p cautery ( )
-pulmonary embolus (was on coumadin for 6 mo)
## FAMILY HISTORY:
Mother CAD, CHF, Tremor
Father CAD,
Brother CAD, EtOH abuse
Brother Living TREMOR, CAD
Aunt LUNG CANCER
## GENERAL:
Adult male in NAD
## HEENT:
AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
## NECK:
supple, no LAD, no JVD
## HEART:
RRR, S1/S2, no murmurs, gallops, or rubs
## LUNGS:
CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
## ABDOMEN:
nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
## EXTREMITIES:
no cyanosis, clubbing, or edema
## PULSES:
2+ DP pulses bilaterally
## NEURO:
A&Ox3, moving all 4 extremities with purpose
## SKIN:
warm and well perfused, no excoriations or lesions, no
rashes
## GENERAL:
Adult male in NAD
## HEENT:
AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
## NECK:
supple, no LAD, no JVD
## HEART:
RRR, S1/S2, no murmurs, gallops, or rubs
## LUNGS:
CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
## ABDOMEN:
nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
## EXTREMITIES:
no cyanosis, clubbing, or edema
## PULSES:
2+ DP pulses bilaterally
## NEURO:
A&Ox3, moving all 4 extremities with purpose
## SKIN:
warm and well perfused, no excoriations or lesions, no
rashes
## DOMINANCE:
Right
* Left Main Coronary Artery
The has an unchanged from before stenosis in the
distal vessel into both LAD and LCx.
* Left Anterior Descending
The LAD is fully occluded in its mid portion. It fills through
the LIMA.
* Circumflex
The Circumflex has some diffuse disease.
* Right Coronary Artery
The RCA is patent and has a 90% ISR in the origin of the RPL
with a stenosis in the orgin of the
RPDA.
LIMA-LAD patent and lands in a very small LAD.
SVG-RPL-RPDA is occluded.
Interventional Details
Based on the diagnsotic coronary angiogram we decided to proceed
with PCI to the -RPL. Heparin
boluses were given prophylactically and the patient was already
on DAPT. A Fr JR-4 guide provided
good support for the procedure. A short Prowater wire crossed
into the RPL easily and then a short
Terumo Runthrough wire crossed into the RPDA. We then
pre-dilated both branches with a 2.5*12
balloon at 14 ATM and then performed IVUS showing mild area of
under-expanded in the RPL and
some neo-intima hyperplasia. We then pre-dilated with a 2.5*10
mm Cutting balloon at 12 ATM and then
delivered a 2.75*15 mm Onyx DES into the -RPL at 18 ATM. We
then post-dilated with a 3.0 NC at
24 ATM and then performed kissing balloon inflation with a NC
2.75 into the RPDA. We performed IVUS,
which still showed an under-expanded area in the RPL and thus
performed further post-dilation. Final
angiogram revealed no residual and TIMI 3 flow and no visible
evidence of dissection.
## BRIEF HOSPITAL COURSE:
This is a with history of CAD s/p 3V CABG , HTN, HLD,
bladder Ca s/p cystectomy, pancreatic Ca s/p Whipple who
presented to an OSH with chest pain and was transferred to the
for cath.
During his hospital stay the patient continued to have typical
chest pain at rest and at night associated with ST segment
depression in the high lateral leads. The chest pain responds to
nitro and sitting up right. On the patient underwent
a LHC with
Based on the diagnostic coronary angiogram we decided to proceed
with PCI to the -RPL. A Onyx DES was placed into the
-RPL. We then post-dilated with a 3.0 NC and then performed
kissing balloon inflation into the RPDA. We performed IVUS,
which still showed an under-expanded area in the RPL and thus
performed further post-dilation. Final angiogram revealed no
residual and TIMI 3 flow and no visible evidence of dissection.
Transitional issues:
[ ] The patient received a and require not
alteration in his DAPT for a least 18 months.
[ ] Monitor chest pain with exercsion and at rest.
[ ] Advice echo as an outpatient to eval LV function
[ ] Also consider a ETT for assessment of symptoms and residual
ischemia.
[ ] On discharge the patient had anemia and hb of 11.1 and plt
of 132, please repeat a CBC in 1 week to trend h/h.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Prasugrel 10 mg PO DAILY
7. Aspirin EC 81 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
## DISCHARGE MEDICATIONS:
1. Metoprolol Tartrate 75 mg PO BID
RX *metoprolol tartrate [Lopressor] 50 mg 1.5 tablet(s) by mouth
twice a day Disp #*90 Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Cyanocobalamin 1000 mcg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Prasugrel 10 mg PO DAILY
8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your cardiologist
## PRIMARY DIAGNOSIS:
Unstable angina
Secondary diagnosis:
Hypertension
hyperlipidemia
history of pancreatic cancer
## DISCHARGE INSTRUCTIONS:
Dear
was a pleasure taking care of you at the
!
Why was I admitted to the hospital?
-You were admitted because you had new chest pain concerning for
low blood supply to one of your coronary arteries.
What happened while I was in the hospital?
- We placed a rent in our of your coronary arteries without
complications. You were kept on the same home medications.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
-It is very important to take your aspirin and prasugrel every
day.
-These two medications keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack.
-If you stop these medications or miss dose, you risk causing
a blood clot forming in your heart stents, and you may die from
a massive heart attack.
-Please do not stop taking either medication without taking to
your heart doctor.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11677801", "visit_id": "21390868", "time": "2203-07-10 00:00:00"} |
13878847-DS-16 | 1,734 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
left internal jugular central line
## HISTORY OF PRESENT ILLNESS:
with history of previous stroke (flacid on left which is at
baseline from previous stroke), seizures, diabetes, end-stage
renal disease on hemodialysis presenting from an outside
hospital for evaluation of intracranial hemorrhage. The patient
apparently had an episode of hypotension during dialysis today
(SBP 80, got 1. atheter). With the pressure covered
she did remain altered for a period of time. At the outside
hospital, he had a CT scan of the head that showed a small
petechial hemorrhage in the left occipital lobe. Chest x-ray was
reportedly normal. Labs are pending at time of his transfer.
Currently the patient through an interpreter states that he
feels well and has no complaints including headache, chest pain,
shortness of breath, abdominal pain.
In the ED, initial VS were:13:12 0 96.8 80 127/68 16 98%
CT Head was repeated in the ER:
1. There is a 3 x 3 mm hyperdense focus in the left occipital
lobe posterior to the occipital horn of the left lateral
ventricle. This focus is indeterminate and may represent a
punctate hemorrhage versus other etiologies. An MRI with and
without contrast is recommended for further evaluation.
2. Cortical atrophy and evidence of likely prior small vessel
ischemic changes.
Neurology was consulted regarding the finding. Impression was
shows tiny hyperdense focus in left occipital lobe
posterior to temporal horn. Hemorrhage quite unlikely, not a
typical location for this. Recommended non-urgent MRI to better
characterize the lesion, can be done as outpatient.
Patient's episode of unresponsiveness during HD was very likely
due to his hypotension at the time. Incidental finding on head
CT would not explain his clinical picture.
## RECS:
1. Non-urgent MRI with/without contrast to characterize
hyperdensity on (can be performed as an outpatient)
2. If admitted, we will follow on West consult service
Labs were performed:
- CBC showed WBC 13.3 Hgb 12.3 Plt 62 (new)
- Otherwise chem panel within normal limits except for Cr
ECG showed v-pacing with ? underlying atrial fibrillation. No
Sgarbossa criteria meet.
VS on transfer: 18:46 0 98.2 64 145/67 18 98%
On the floor, patient denies any compliants or concerns. He
states that he "feels fine." He has no other questions or
concerns.
## REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
## PAST MEDICAL HISTORY:
1. Chronic kidney disease of several years duration stage IV
with greater than 1 g proteinuria/albuminuria for quite some
time per Dr. Dr. thought to be due to
diabetes and hypertension.
2. Diabetes mellitus, the patient on treatment for the last four
to years
3. Hypertension.
4. Recurrent cerebrovascular accidents, most notably in , an acute right MCA stroke with residual left-sided
weakness.
5. History of atrial fibrillation and question of heart block
requiring permanent pacemaker placement. He is on Coumadin.
6. Anemia secondary to chronic kidney disease
## PAST SURGICAL HISTORY:
Status post hernia repair, status post
permanent pacemaker placement, questionable history of TURP.
## FAMILY HISTORY:
Questionable history of a father having renal disease. His
father also had a CVA. No other family history of renal disease.
## HEENT:
NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
## LUNGS:
CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
## HEART:
RRR, no MRG, nl S1-S2
There is a temp HD line on right precordium with redness (?
granulation tissue). There is also a fistua with bruit and
thrill on RUE (appears new)
## ABDOMEN:
normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
## EXTREMITIES:
no edema, 2+ pulses radial and dp
## NEURO:
AAOx2, left facial droop (at baseline)
.
## PULM:
clear to auscultation bilaeterally
## CT HEAD W/O CONTRAST:
1. No change in calcification in the left occipital lobe
adjacent to the occipital horn of the left lateral ventricle.
2. Unchanged small vessel ischemic changes and chronic basal
ganglia and right pontine lacunes.
LEFT UPPER EXT VEINS US: No evidence of left upper
extremity deep venous thrombosis.
CT HEAD W/O CONTRAST:
1. 3 x 3 mm hyperdense focus in the left occipital lobe medial
and posterior to the occipital horn of the left lateral
ventricle, possibly representing a punctate intraparenchymal
hemorrhage, though a hemorrhagic mass is not excluded. An MRI
with contrast is recommended for further evaluation.
2. Cortical atrophy, chronic basal ganglia and right pontine
lacunes, and evidence of small vessel ischemic changes.
## ASSESSMENT/PLAN:
with history of previous stroke, seizures,
DM, ESRD on HD presenting from an outside hospital for
evaluation of intracranial hemorrhage and relative hypotension
during HD, found to have thrombocytopenia secondary to HIT.
.
# Thrombocytopenia/HIT: Patient was started on argatroban drip
to goal PTT for anticoagulation in the setting of a
subtherapeutic INR on admission (needs anticoagulation for
Afib). Platelet counts slowly recovered from 62 on admission to
145 on discharge. Serotonin release assay pending. Patient was
also maintained on Coumadin with goal INR of with 2 days of
overlap with agratroban. Argatroban was stopped on . INR OFF
argatroban was 5.1. Coumadin was held on day of discharge and
should be resumed at alternating daily starting on .
Check INR regularly, next check due on .
.
# AMS/hypotension: While at dialysis at OSH, patient had episode
of confusion and hypotension to SBP , both of which resolved
with 1.5L normal saline (likely due to fluid shifts during HD).
Patient had no AMS or episodes of hypotension during admission.
Home amlodipine and lopressor were continued.
.
# Occipital lobe lesion: Repeat head CT showed no change in
lesion, low suspicion for hemorrhage per neuro. No MRI because
of pacemaker.
.
# ? Cellulitis surrounding Right subclavian HD catheter: No
bacteremia, but erythema and intermittent pain around port site.
Was treated with IV vancomycin started on , should be
continued for 10 days through . If cellulitis is not
improving after 10 days, it should be continued for 1 more week.
.
# CKD on HD: been on HD for a few weeks , last HD
. RUE fistula created , stitches removed by
transplant surgery team.
.
# DM: Well-controlled on HISS.
.
# HTN: Well-controlled on home amlodipine and lopressor
.
# History of atrial fibrillation and ? heart block s/p PPM. We
continued coumadin.
.
# Anemia secondary to chronic kidney disease: at baseline.
.
# Seizure disorder. Continued keppra 500mg BID. Received extra
500mg dose post-HD
.
## TRANSITIONAL ISSUES:
- Patient was on Amantadine 100mg daily on admission, per
records. Our attempts to Med rec with family were unsuccesful.
Unclear indication for this. Regardless, Hemodialysis dosing for
this medication is 200mg Q7days. We switched to this dosing
prior to discharge.
## RESULTS OF SEROTONIN RELEASE ASSAY:
SEROTONIN RELEASE ASSAY
PLATELET AND NEUTROPHIL IMMUNOLOGY
Unfractionated Heparin-Dependent Platelet Antibody (SRA)***
## UNFRACTIONATED HEPARIN RESULT:
Borderline Positive
A positive result requires release of serotonin from target
platelets in
the presence of patient serum and low concentration of heparin
of >20%,
together with inhibition of release (<20%) when a higher
concentration of
heparin (100 U/ml) is present. The reaction obtained with this
patient's serum
does not meet our criteria for a positive result. However, it is
a boderline
reaction and if the clinical presentation indicates
Heparin-Induced
Thrombocytopenia, it may be helpful to repeat testing on another
sample
collected hours later.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Amantadine 100 mg PO DAILY
2. Lactulose 30 mL PO BID
3. Docusate Sodium 200 mg PO BID
4. Bisacodyl 10 mg PR HS
5. Tamsulosin 0.8 mg PO HS
6. LeVETiracetam 500 mg PO BID
7. Metoprolol Tartrate 100 mg PO BID
8. Amlodipine 10 mg PO DAILY
9. Oxycodone SR (OxyconTIN) 10 mg PO HS
10. Senna 2 TAB PO BID
11. Acetaminophen 650 mg PO HS
12. Pravastatin 40 mg PO HS
13. Calcitriol 0.25 mcg PO DAILY
14. Epoetin Alfa 10,000 units SC EVERY WITH HD Start: HS
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO HS
2. Amantadine 100 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Bisacodyl 10 mg PR HS
5. Docusate Sodium 200 mg PO BID
6. Calcitriol 0.25 mcg PO DAILY
7. Lactulose 30 mL PO BID
8. Metoprolol Tartrate 100 mg PO BID
9. Oxycodone SR (OxyconTIN) 10 mg PO HS
10. Pravastatin 40 mg PO HS
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Senna 2 TAB PO BID
13. Tamsulosin 0.8 mg PO HS
14. Exelon *NF* (rivastigmine) 1.5 mg Oral BID Reason for
## ORDERING:
Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
15. Lidocaine 5% Patch 1 PTCH TD DAILY left scapula
16. Sodium CITRATE 4% 10 mL DWELL ASDIR
17. Vancomycin 1000 mg IV HD PROTOCOL
18. Epoetin Alfa 10,000 units SC EVERY WITH HD
19. LeVETiracetam 500 mg PO BID
20. Nephrocaps 1 CAP PO DAILY
21. Sodium CITRATE 4% 1 mL DWELL ASDIR
22. Warfarin 2 mg PO 4X/WEEK ( ) PLEASE GIVE NEXT DOSE
ON (do NOT give a dose)
23. Warfarin 3 mg PO 3X/WEEK ( )
## FACILITY:
Diagnosis:
Heparin induced thrombocytopenia
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure taking care of you at the
. You were transferred to this hospital
because your platelet levels were low (platelets are a type of
blood cell). Your labwork showed that you have antibodies that
bind with a drug called heparin and causes your platelets to be
destroyed. You likely were receiving heparin with dialysis,
which was started in the past few weeks. We continued warfarin,
which is an anticoagulation medicine that you take at home, and
started you on an intravenous anticoagulation medication called
Argatroban until your warfarin levels were therapeutic. Your
platelet levels increased while you were in the hospital.
You were also found to have a lesion in your brain. We spoke
with neurology who felt that this was NOT a bleed. We performed
a cat scan of your brain twice (a few days apart) and the lesion
had not changed.
In the future you should avoid all heparin products. You might
have an allergy to it. For your tunnel line, you should make
sure people use citrate locks.
You had an infection of your tunnel line. You were started on
vancomycin and should continue for ay 1 is
.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13878847", "visit_id": "25738645", "time": "2165-03-02 00:00:00"} |
13051530-RR-98 | 164 | ## INDICATION:
Pain after fall. Patient has a history of lung and breast
cancer.
## FINDINGS:
According to size criteria, there are no pathologically enlarged
supraclavicular, axillary, or mediastinal lymph nodes. There are dense
atherosclerotic calcifications of the aorta, coronary arteries, as well as the
mitral and aortic annuli. The heart is moderately enlarged.
The patient has undergone interval wedge resection left lower lobe. Chain
sutures are now present there. However, just adjacent to this is a 3.9 x 1.7
cm lobulated mass (4:131). Two tiny nodules in the right apex are also noted,
the more superior is stable since (4:21, 37). There is no
pleural effusion. Although not tailored for subdiaphragmatic evaluation, the
imaged portions of the upper abdomen are noteworthy only for an atraumatic
left kidney.
## IMPRESSION:
1. 3.8 cm mass adjacent to left lower lobe resection, consistent with local
recurrence.
2. No fracture. Two tiny right apical nodules can be assessed at the time of
followup.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13051530", "visit_id": "N/A", "time": "2176-03-31 17:38:00"} |
15788461-DS-19 | 1,577 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
worsening headaches, concerning imaging findings for ?vasculitis
## HISTORY OF PRESENT ILLNESS:
is a woman R handed who presented to
neurology clinic with Dr. on for evaluation
of predominantly L sided headaches and MRIs in and showing multiple T2 hyperintense lesions (non-enhancing) in
a subcortical distribution. Work-up for her persistent L sided
headaches after her neurology visit with Dr. MRI
and an MRA head to evaluate for any vasculitis or
cadasil phenomenon.
During her clinic visit with Dr. on , Ms
complained of severe headaches for the last . She
described them as having a sharp character, typically always
located on the L side but can occasionally occur on the R. She
has associated nausea without emesis, and also
photo/phonophobia. At that time, they were occuring a few times
per week and the headaches lasted minutes at a time.
Tylenol only helped minimally. Triggers included poor sleep and
stress. Menses also worsened the headaches. In addition, she
described having intermittent numbness in her face/ head, and
then stated that she also recently had intermittent R leg
numbness and weakness that would come and go. She did not report
double vision or other changes in vision, however today she
reports that she has horizontal double vision from time to time
for the past few months.
As part of work-up for her headaches, she underwent an MRI brain
with and without contrast on which showed bilateral
T2/Flair hyperintensities located sub cortically and
periventricularly without enhancement. Compared to MRI brains
done in these lesions were stable. Given the concern for
migraines and T2 lesions on MRI, there was concern for possible
vasculitis/ cadasil or migraines. Exam at the time was notable
for L sided hemibody sensory deficits. Given the broad
differential, an MRI and MRA head was ordered. In
addition, she was ordered for a CBC, BMP, LFT, TSH, Lyme,
Vitamin B12, Ace, ESR, and CRP. Of these tests, only ACE came
back elevated to 68, all others were negative/normal.
MRA was performed on and was found to show
multifocal areas of stenosis in different vascular territories.
As the imaging was concerning for vasculitis the patient was
advised to present to the hospital for further evaluation.
On arrival to the ER today, the patient is having a significant
headache located on the R side not L. She states that after
seeing Dr. headaches worsened to the point of
happening almost daily. In addition, for the past two days she
has been having significant R neck pain that is described as
stabbing in quality. In addition, she describes intermittent R
leg numbness that has been coming and going for the past 3
weeks, associated with her headache. No speech or language
difficulties. She also has been having night sweats but no
documented fevers. Lastly, she describes sharp stabbing chest
pain in the her chest that began 2 weeks ago and lasts
between minutes at a time. Occuring rather infrequently
last happening yesterday.
On neuro ROS, the pt denies loss of vision, blurred vision,
dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. No
bowel or bladder incontinence or retention. Denies difficulty
with gait.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
## PAST MEDICAL HISTORY:
Headaches
Depression
Lower back surgery,
## FAMILY HISTORY:
No family history of multiple sclerosis or aneurysm
## VITALS:
T 98.4, HR 61, BP 150/90, RR 16, RA
## GENERAL:
awake, cooperative, crying due to pain
## HEENT:
NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
## NECK:
supple, tenderness to palpation of neck, crying with
minimal movements of neck
## PULMONARY:
breathing comfortably on room air
## SKIN:
no rashes or lesions noted
## -MENTAL STATUS:
Alert, oriented x self, date, location. Able to
relate history without difficulty.Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands.
## II, III, IV, VI:
PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoycopic
exam revealed no papilledema, exudates, or hemorrhages.
## V:
Facial sensation intact to light touch.
## VII:
No facial droop, facial musculature symmetric.
## VIII:
Hearing intact to finger-rub bilaterally.
## XI:
strength in trapezii and SCM bilaterally.
## XII:
Tongue protrudes in midline.
## -MOTOR:
Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA
L 5 5 5 5 5 5 5 5 5
5 5
R 5 5 5 5 5 5 5 5 5
5 5
## -SENSORY:
decreased sensation to light touch, temperature, and
pinprick in R foot only. Otherwise intact elsewhere. Intact
vibration in toes.
-DTRs:
Bi Tri Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
## -COORDINATION:
No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
## DISCHARGE EXAMINATION:
Patient refused neurologic examination due to pain on motor
testing of her right upper extremity (deltoid), and refused any
further interaction with the team thereafter and did not want to
answer any questions anymore and wanted to be left alone.
## IMPRESSION:
No acute intrathoracic process.
CTA head/neck :
Noncontrast head CT:
No acute intracranial process.
CTA neck:
No evidence of occlusion, dissection, or flow limiting stenosis.
CTA head:
Mild narrowing of the M1 segment of the right middle cerebral
artery, similar in appearance to recent MRA. Otherwise no
occlusion, large aneurysm, or flow limiting stenosis.
Final read pending 3D reformats.
## IMPRESSION:
No intracranial mass, hemorrhage or acute infarct.
Predominantly deep and subcortical white matter T2 and FLAIR
hyperintense
changes with relative sparing of the periventricular white
matter is
nonspecific.
No abnormal enhancing lesions.
For evaluation of the vessels please refer to CTA done (4 hours prior).
## BRIEF HOSPITAL COURSE:
Patient is a year old woman with history of chronic headaches
and neck pain, who was admitted for incidental findings of
possible multi-vessel stenosis on outpatient MRA brain without
contrast most prominently in the right MCA stem, concerning for
possible vasculitis.
Upon admission, she underwent CTA head/neck, which demonstrated
only mild right MCA focal narrowing, but no diffuse narrowing
that would be concerning for vasculitis. MRI head w/wo contrast
was repeated which was stable compared to prior MRI head in
and , without evidence of any new infarcts or
contrast-enhancing lesions. In addition, inflammatory markers
were reviewed, with most recent ESR in negative, as well
as extensive workup including CBC, BMP, LFTs, TSH, Lyme, vitamin
B12, and ACE in the past by her neurologist. ESR and CRP were
repeated here; CRP was negative at 0.8, with ESR pending.
Overall picture inconsistent with active vasculitis or any other
ongoing inflammatory process. Rheumatology had initially been
consulted but given the results of above studies, the consult
was canceled. This may be addressed as an outpatient.
Of note, on hospital day 1 upon Stroke team interviewing and
assessing the patient, she had significant pain on motor
examination of the right deltoid and subsequently refused to
complete the remainder of the examination or comply with further
questions or testing. She was also upset in regards to a member
of the Rheumatology team who had evaluated her earlier that day
and she did not wanted to answer the same questions and do the
same parts of the exam that the student/resident on the
rheumatology team had already done. She later refused to speak
or engage with the on-service attending.
Transitional issues:
She will require continued outpatient follow up for management
of her headache and nonspecific MRI white matter findings, which
may include lumbar puncture. For her focal narrowing, we suggest
obtaining a lipid panel as an outpatient and weighing risk
benefit ratio of starting aspirin for primary stroke and
cardiovascular prevention.
She has an appointment scheduled with Dr. . It is
unfortunate that she was not willing to be examined by us and
that the ultimately refused to interact with us or answer any of
other questions. There are no acute issues going on currently
that would have required her to stay hospitalized. Thus, we felt
comfortable to discharge her and then follow-up with her
Neurologist within a few days.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide 500 mg PO BID
2. Cyclobenzaprine 5 mg PO HS:PRN pain
3. Escitalopram Oxalate 5 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Cyclobenzaprine 5 mg PO HS:PRN pain
2. Escitalopram Oxalate 5 mg PO DAILY
3. Magnesium Oxide 500 mg PO BID
## DISCHARGE DIAGNOSIS:
Mild focal arterial narrowing of right MCA
Chronic headaches
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were hospitalized due to an imaging finding concerning for
possible vasculitis, which is an inflammatory condition.
Fortunately, you underwent repeat testing with more sensitive
imaging studies, which were NOT consistent with vasculitis or
any other acute, dangerous condition, such as infection.
You should follow up with your neurologist to continue
evaluation for your chronic symptoms, as well as your PCP.
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15788461", "visit_id": "26271502", "time": "2179-04-21 00:00:00"} |
19406064-DS-17 | 2,123 | ## CHIEF COMPLAINT:
"I want to start life over."
## HISTORY OF PRESENT ILLNESS:
Mr. is an year old Caucasian man with onset
of mental illness at age years old with multiple diagnoses
(affective and psychotic) who was BIB security
for concern of suicidal ideation.
Patient has had "a tough life," which he felt had finally begun
to improve. He experience one year of happiness which lasted
through . However, since that time, he has lost his
girl friend, been dismissed from and felt he had to prove
he was not violent by going into an inpatient psychiatric
hospital in . He was hopeful that he would be able to
fulfill his dreams by successfully completing .
, he was notified that he failed his Freshman year and
could no longer attend . He perseverated on feeling
hopeless and wanting to end his life yesterday. He acknowleges
that he called friends to say goodbye and told them he had
cardiomyopathy because he knows from television that the
prognosis is poor. He denies developing a plan, but received
comfort from his friend and now developed a
plan to work until he can move to and "start [his life]
over."
He reports that he has always had a difficult life with a
dysfunctional family environment including a physically abusive
older brother and a mother who is a "victimized sociopath unable
to keep relationships," and stated that if he has to return home
with his mother he would probably end up in jail or dead. He
continually repeated that he wanted to "start over" and that
getting away was the best option.
When asked about his current mood he again stated that he's had
"a tough life" and avoids answering the question. He endorsed
feeling hopeless and guilty last night but was no longer having
those feelings in the ED since he and his friend had come
up with a plan for his future. He reported 12 hours of sleep a
night from 8pm-7pm but that he was not able to get a full nights
sleep last night as he woke up multiple times and had a
nightmare (from prior trauma). He denies anhedonia, lack of
motivation, decreased appetite and weight loss. Reports normal
energy level. He has not noticed a decline in memory or
concentration. Denies having homicidal ideation, but "sometimes
I wish I was a psychopath." He denies symptoms consistent with
mania. Denies psychotic symptos of AVH, IOR, TC and paranoia.
Denies anxiety, panic attacks, compulsions or eating disorders.
## ROS:
Positive for lumbar back pain x several months. Recent
headaches - not currently.
## MOM:
Phone: . Patient has been
deteriorating for several weeks. He asked if he could stay at
home starting this week because the dorms were closing and asked
if a friend could come live with them. They arrived at
s on and patient would not eat any food
despite not having money and the cafeteria being closed. Patient
returned to with the understanding that he would return
home to live, however, he never returned. He was not answering
his phone and family became concerned when on a high
school teacher contacted them saying, is the worst he
has ever been" and he has said "he has nothing to live for" and
that he will "end his life." The high school teacher described
him to his mother as despondent and incoherent. Friend's of the
family contacted them saying they had received goodbye messages
from . On , mother came into town to search for
patient. The eventually found him on his own in a
building, where he was not supposed to be. Patient was
allegedly verbally aggressive with mother and with the father by
phone. Security ultimately decided to bring patient into ED
given his threats of suicidality. Is concerned about AVHs. She
reflects that he is very smart and can pull himself together; he
knows what to say and what not to say. However, he always gets
the same look on his face and his eyes drift to the side when he
is having hallucinations, so she knows he is having them now
even though he will not admit to it. Patient has been diagnosed
with various disorders including acute psychotic disorder, BPAD,
psychosis NOS, aspergers, depression and anxiety.
## ( ) - PHONE:
-
Patient told that he had no place to stay and was
invited to stay with her on . He appeared down and was
eating at least once daily until when he learned he
failed out of school. He was crying, described life as pain and
stated that he wanted life to end. He called people to tell
them goodbye. He talked about loosing everything (family, home,
ROTC, school) and when he tried to find a place to stay with his
friend , he was told no. He said "I want to die," he
contemplated harming himself with knives, guns or poisoning
himself. He was crying, holding his knife and staring at it.
She took the knife away from him and hid all her medications out
of concern that he would harm himself. Stated that maybe his
death would mean something, but he didn't want it to be painful.
They arranged for an emergent psychiatry appointment, but he
did not go. Feels God has abandoned him. Reflects he did drink
yesterday. Agrees that he has been looking around as if
hallucinating.
## -DIAGNOSES:
Reports multiple diagnoses, but has never identified
with any of them.
-Hospitalizations: Multiple hospitalizations starting at age
for psychosis and homicidal ideation. Including ,
in and for 6 days starting . Twice
in .
-Current treaters and treatment: Therapist Dr.
. Prior psychiatrist Dr. , prior therapist
Dr. .
-Medication and ECT trials: Perphenazine/cogentin (stopped when
started . Trialed on risperdal, geodon, abilify,
seroquel, asenapine, haldol, tegretol, depakote, lithium, &
zoloft, and experienced significant side effects, particularly
sedation
-Self-injury: Denies
-Harm to others: Reports h/o aggression when in a physical fight
with elder brother (self defence per parents); ED visit after
verbally yelling at a girl on campus, no physical violence
## DYSLEXIA
* PCP:
Dr. at
* Denies history of seizures and head injuries.
## SOCIAL HISTORY:
Patient was born and raised in and for a short time in
. Parents divorced when patient was approximately year
old. He was in settings of care when growing up but cannot
elaborate. Has 4 siblings, he's the oldest. Education:
Failed and was dismissed from Freshman year at
in . Supports: Does not view family as supports. His
girlfriend of one year left him during . He
has a close friend . Religion: Raised . Trauma:
?neglect when in psychiatric treatment settings (states he was
locked in room in a facility without food). Alleges primary
domestic violence from older brother. : Previously living
on campus, but most recently staying with friend and family.
## EMPLOYMENT:
but has yet to do orientation. Legal: Denies. Access to weapons:
Knife, no guns.
## MARIJUANA:
tried once in the past. Stimulants
(adderall, concerta and vyvanse): Abused in the .
## ETOH:
Reports several beers on the weekend. Denies blackouts
and withdrawal. "I had a problem with alcohol" at age but
not currently. Tobacco: < 1 ppd. Denies: Cocaince, opiates,
benzodiazepines, PCP, , meth, speed and .
## FAMILY HISTORY:
Brother- substance abuse. Sister- SA (patient states he
witnessed her s/p OD on NSAIDs + EtOH). Paternal uncle was
institutionalized for life and suffered from addiction.
Maternal cousin successfully committed suicide.
## VS:
130/75 58 98 99% on RA 149.4 lbs 72"
General- NAD. NCAT.
Skin- No rashes. No jaundice. Warm, dry, pink.
HEENT- No erythema or exudate on palate. No ocular injection nor
scleral icterus.
Neck and Back- No LAD. No tender to palpation.
Lungs- CTAB.
CV- RRR without M/R/G.
Abdomen- Soft. NT, ND. Active BS.
Extremities- No swelling or tenderness. MAEW.
Neuro-
## CRANIAL NERVES- I:
Deferred. II: Grossly intact. PERRL. III, IV,
## EOMI. V, VII:
Intact to touch. Symmetric. VIII: Intact to
finger rub. IX, X: Equal palatal elevation. XI: SCM intact. XII:
Midline.
## SENSATION:
Intact to light touch.
## COORDINATION:
Finger-nose-finger: Mildly dysmetric on left.
## ALERT.
*ATTENTION:
MOYB.
*Orientation: Oriented to self, , to 9)/
*Memory: registration and five minute recall.
*Fund of knowledge: Past three Presidents. wrote
## ABSTRACT INTERPRETATION OF APPLE/FALL/TREE
*SPEECH:
Regular volune, tone, prosody and rate.
*Language: Fluent .
## *APPEARANCE:
Young, thin, caucasian man in his own shirt and
scrub pants. Behavior: Fair eye contact. Orients towards
interviewer. No PMA. Focusing on examiners paper whenever
writing.
*Mood and Affect: "It doesn't matter now" / Dysphoric.
*Thought process / *associations: Circumferential, somewhat
disorganized.
*Thought Content: Disappointed to be going inpatient again,
denying current SI, but cannot explain how circumstance has
changed from yesterday when active SI. Denies HI. Denies
psychotic symptoms.
*Judgment and Insight: Poor/Poor.
## BRIEF HOSPITAL COURSE:
--LEGAL:
--PSYCHIATRIC:
Patient was admitted to hospital after making phone calls to
multiple family and friends saying "goodbye" or telling them he
was dying of cardiomyopathy. In the emergency department and
while on the unit patient consistently denied SI; he confirmed
that he was suicidal for approximately hours while he was
processing all of his losses (most recently failing out of
with intent however he did not have a plan. He has no
hx of self harm or SA. During hospitalization he denied sx of a
mood or psychotic episode, and denied sx of anxiety. He did
demonstrate some Cluster B personality traits, namely narcisstic
and histrionic, though he doesn't carry such a dx and would
require more monitoring through time to see if this truly
applies to him. Psychological testing was notable for
relatively low level of complaints suggesting minimizing of sx.
He scored highly on scales of trauma and aggressiveness stance.
His answers suggested a paranoid view of others as well as
concerns regarding the effects of substances in his life. During
hospitalization, he initially appeared bright and was eager and
happy to talk to staff and other patients about various topics.
He did have a tendency to speak about his emotions or current
mental state superficially and did prefer to not discuss
depressing aspects of his current situation or his emotional
reaction for too long. When his was close to
expiration, he agreed to sign CV with the plan that his father
would return home from (there on a work trip) in a few
days and after a family meeting he would be discharged into his
father's care. After signing CV patient began showing
significantly more anger and resentment towards inpatient team,
though maintained behavioral control and did not act out. He
eventually submitted a 3d notice, and given that there were no
acute safety concerns at that point he was discharged home with
his friends with the plan for him to enter his father's care
subsequently. During hospitalization he was future oriented and
his plans for now include finding a job. He continues to find
his father an emotional support and will continue to talk with
him about his struggles. Given lack of evidence of major
psychiatric illness amenable to psychopharmacologic management,
no medications were initiated. At time of discharge, he denies
SI/HI/AVH; he is psychiatrically stable for outpatient
follow-up.
--MEDICAL:
Healthy young male, no medical issues while on unit.
--SOCIAL/MILEU:
Attended some groups, visible in the mileu, social with peers.
No issues during hospitalization, no physical or chemical
restraints.
--RISK ASSESSMENT:
Risk factors for self harm include numerous recent losses,
recent SI and communication of goodbye messages prior to
admission, and male gender. Protective factors include denial of
SI, no h/o SAs or SIB, help-seeking nature, established
therapist, family and friends supportive and aware of current
situation, no e/o acute affective or psychotic episode, no e/o
substance use at this time. At this time patient does not pose
an acute risk of harm to self though he's at moderately elevated
risk in the future given his numerous losses, however this risk
will not be improved by further time in hospital.
--DISPOSITION:
Home with outpatient follow-up.
## DISCHARGE DIAGNOSIS:
Adjustment disorder with depressed mood
## MENTAL STATUS:
Clear and coherent. Denies SI/HI,
future-oriented.
## DISCHARGE INSTRUCTIONS:
During your admission at , you were diagnosed with
adjustment disorder and treated with individual and group
therapy. Please follow up with all outpatient appointments as
listed. 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. If you need to talk to a Staff
Member regarding issues of your hospitalization, please call
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19406064", "visit_id": "27443968", "time": "2128-05-22 00:00:00"} |
14099440-RR-45 | 204 | ## EXAMINATION:
CT SPINE WITHOUT CONTRAST
## HISTORY:
with osteoporosis, mechanical fall, with complaint
of left sided pelvis and back pain. // rule out fracture rule out
fracture
## FINDINGS:
There is redemonstration of known acute/subacute fracture of the T11 vertebral
body, not fully imaged. Mild compression deformity of the L5 vertebral body is
again seen and appears similar to prior MRI examination. There is moderate
levoscoliosis of the lumbar spine. No acute fracture or subluxation
identified in the lumbar spine. There is minimal retrolisthesis of L4 over L5.
Visualized portions of the small and large bowel are grossly unremarkable.
There is severe calcifications of the intra-abdominal aorta and its branches.
Bilateral hypodensities within the kidneys could reflect cysts, however these
are not fully imaged in this examination.
## IMPRESSION:
1. No acute fracture or subluxation in lumbar spine. Levoscoliosis.
Multilevel, multifactorial degenerative changes, with moderate canal narrowing
at L3-4 and bilateral moderate to severe foraminal narrowing from L2-S1
levels.
Correlate clinically.
2. Redemonstration of known acute/subacute fracture of the T11 vertebral body
with mixed density, not fully imaged this examination. Further workup as
needed
3. Mild compression deformity of the L5 vertebral body appears similar to the
appearance on MRI from .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14099440", "visit_id": "28997848", "time": "2134-10-12 14:01:00"} |
12497762-RR-9 | 104 | ## HISTORY:
with unwitnessed trauma, please eval for fracture//
with unwitnessed trauma, please eval for fracture
## FINDINGS:
Patient's overlying hand obscures the right ilium and portion of the proximal
right femur. No evidence of acute fracture is seen elsewhere. The pubic
symphysis and sacroiliac joints are intact. There are mild to moderate
bilateral hip degenerative changes and degenerative changes along the
partially imaged lower lumbar spine. Extensive vascular calcifications are
seen.
## IMPRESSION:
Patient's overlying hand obscures the right side of the pelvis, including the
right ilium and right femoral head and neck. No evidence of acute fracture
seen elsewhere. No dislocation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12497762", "visit_id": "N/A", "time": "2160-10-28 12:20:00"} |
11239965-RR-30 | 288 | ## INDICATION:
M with recent diagnosis of right occipital GBM, s/p
resection with Dr. , presenting to on transfer from OSH for
lethargy, headache, and diffuse weakness. // eval for brain abscess
## FINDINGS:
Within the right parietal occipital lobe, a mass is seen measuring
approximately 2.2 cm x 2.5 cm by 4.1 cm, abutting the superior sagittal sinus
and demonstrating restricted diffusion, concerning for recurrence of the
patient's malignancy. Adjacent right inferior parietal post surgical cavity
is seen, demonstrating resolution of the previously noted blood products from
. Extensive surrounding FLAIR signal is seen extending inferiorly
along the right occipital lobe and anteriorly into the right temporal lobe.
The extent of this FLAIR signal has not significantly changed compared to the
prior exam. Punctate foci of microhemorrhage are seen in the surgical
resection bed.
Right periventricular FLAIR hyperintensity, series 12, image 17 is likely
secondary to a focus of chronic small vessel disease. The globes are
unremarkable. Aside from right parietal craniotomy changes, the marrow signal
is unremarkable. The visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The globes are unremarkable.
## IMPRESSION:
1. 4.1 cm enhancing mass within the right parieto-occipital lobe abutting the
superior sagittal sinus and demonstrating restricted diffusion, is concerning
for recurrence of patient's GBM. Extensive surrounding FLAIR signal extending
inferiorly along the right occipital lobe and anterior along the right
temporal lobe, is similar to the prior exam.
2. On the sagittal post gadolinium MP rage images continue NG of the superior
sagittal sinus is not seen mass which may indicate invasion and obliteration
of the sinus (14:10 8).
3. Appropriate post surgical changes status post right parietal craniotomy,
with foci of microhemorrhage.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11239965", "visit_id": "28935387", "time": "2131-07-15 22:52:00"} |
16912219-RR-44 | 95 | ## CHEST:
Frontal and lateral views
## HISTORY:
with s/p fall, ?b/l rib pain, no obvious
crepitus or deformity // ?obvious fx
## FINDINGS:
No obvious acute fracture is seen although clinical concern is high, CT is
more sensitive. Chronic deformities at the bilateral distal clavicles. There
is minor basilar atelectasis without definite focal consolidation. No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are
stable. No overt pulmonary edema is seen.
## IMPRESSION:
No significant interval change. No obvious acute fracture identified although
if clinical concern is high, CT is more sensitive.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16912219", "visit_id": "28931466", "time": "2177-07-16 17:31:00"} |
16889304-RR-21 | 301 | ## EXAMINATION:
CT ORBIT, SELLA AND IAC W/O CONTRAST Q115 CT HEADSUB
## INDICATION:
year old man with R IPH, L Temporal bone fx // Please
evalauate temporal bone fracture and obtain with thin cuts. Please assess for
involvement of: (1) otic capsule (2) facial nerve (3) skull base/tegmen
(4)carotid canal
## DOSE:
This study involved 3 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral
Acquisition 6.0 s, 12.4 cm; CTDIvol = 139.0 mGy (Head) DLP = 1,717.7 mGy-cm.
Total DLP (Head) = 1,718 mGy-cm.
## LEFT:
Transversely oriented nondisplaced temporal bone fracture extends inferiorly
into the mastoid air cells. Mastoid air cell opacification is likely due to
blood products. The middle ear cavity contains high density fluid, presumably
blood. The ossicles and tegmen are intact. There is no evidence for enlarged
vestibular aqueduct or superior semicircular canal dehiscence. The facial
nerve follows a normal course through the middle ear. There is no evidence for
inner ear dysplasia.
## RIGHT:
There is fluid in the mastoid air cells, unchanged. There is air in the
middle fossa adjacentto the mastoid air cells, unchanged. High-density fluid
in the middle ear is presumably blood products. The ossicles and tegmen are
intact. No definite temporal bone fracture is seen. There is no evidence for
enlarged vestibular aqueduct or superior semicircular canal dehiscence. The
facial nerve follows a normal course through the middle ear. There is no
evidence for inner ear dysplasia.
## OTHER:
Right temporal lobe edema, pneumocephalus and blood products are re-
demonstrated.
## IMPRESSION:
1. Air in the right middle cranial fossa and fluid in the right mastoid air
cells are presumably due to fracture, however no fracture is seen.
2. Stable left temporal bone fracture. No otic capsule involvement.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16889304", "visit_id": "21747997", "time": "2118-04-12 10:56:00"} |
19638455-RR-87 | 758 | ## :
Cardiology Staff: , MD
## GENDER:
Female Radiology Staff: , MD
## RACE:
Other Technologist: , RT
## WEIGHT (LBS):
160 Injection Site: left antecubital vein
## RHYTHM:
Sinus rhythm Creatinine (mg/dl): 0.9
## INDICATION:
Myocarditis vs infiltrative disease
## CMR MEASUREMENTS:
Measurement Normal Range
Left Ventricle
LV End-Diastolic Dimension (mm) 44 <55
LV End-Diastolic Dimension Index (mm/m2) 24 <33
LV End-Systolic Dimension (mm) 28
LV End-Diastolic Volume (ml) 97 <143
LV End-Diastolic Volume Index (ml/m2) 52 <78
LV End-Systolic Volume (ml) 41
LV Stroke Volume (ml) 56
LV Stroke Volume Index (ml/m2) 30
LV Ejection Fraction (%) 58 >=56
LV Mass (g) 84
LV Mass Index (g/m2) 45 <60
Basal wall thickness (mm) *10 <10
Basal infero-lateral wall thickness (mm) *9 <9
Q-Flow Aortic Net Forward Stroke Volume (ml) 45
Q-Flow Aortic Total Stroke Volume (ml) 50
Q-Flow Aortic Cardiac Output (l/min) 4
Q-Flow Aortic Cardiac Index (l/min/m2) 2.2
LV Effective Forward Ejection Fraction (%) *51 >=56
Right Ventricle
RV End-Diastolic Volume (ml) 95
RV End-Diastolic Volume Index (ml/m2) 51 47-103
RV End-Systolic Volume (ml) 36
RV Stroke Volume (ml) 59
RV Stroke Volume Index (ml/m2) 32
RV Ejection Fraction (%) 62 >=49
Q-Flow Pulmonary Net Forward Stroke Volume (ml) 56
Q-Flow Pulmonary Total Stroke Volume (ml) 58
Qp/Qs 1.24 0.8-1.2
Atria
Left Atrial Dimension (Axial) (mm) 28 <40
Left Atrial Length (4-Chamber) (mm) 40 <52
Left Atrial Length (2-Chamber) (mm) 47
Right Atrial Dimension (4-Chamber) (mm) 39 <50
Great Vessels
Ascending Aorta Diameter (mm) 27 <35
Ascending Aorta Diameter Index (mm/m2) 15 <21
Transverse Aorta Diameter (mm) 16
Transverse Aorta Diameter Index (mm/m2) 9
Descending Aorta Diameter (mm) 20 <25
Descending Aorta Index (mm/m2) 11 <15
Abdominal Aorta Diameter (mm) 19
Abdominal Aorta Diameter Index (mm/m2) 10
Main Pulmonary Artery Diameter (mm) 25 <27
Main Pulmonary Artery Diameter Index (mm/m2) 14 <15
Valves
Aortic Valve Regurgitant Volume (ml) 4
Aortic Valve Regurgitant Fraction (%) *9 <5
Mitral Valve Regurgitant Volume (ml) 6
Mitral Valve Regurgitant Fraction (%) *11 <5
Pulmonary Valve Regurgitant Volume (ml) 1
Pulmonary Valve Regurgitant Fraction (%) 2 <5
Tricuspid Valve Regurgitant Volume (ml) 2
Tricuspid Valve Regurgitant Fraction (%) 3 <5
Pericardium
Pericardial Thickness (mm) 2 <4
* Mildly abnormal | ** Moderately abnormal | *** Severely abnormal
## STRUCTURE
" T1-WEIGHTED (BLACK BLOOD):
Dual-inversion T1-weighted fast spin echo images
were acquired in 5-mm contiguous axial slices to evaluate cardiac and vascular
anatomy.
" T2-Weighted: T2-weighted fast spin echo images were acquired to evaluate
edema/inflammation.
## FUNCTION
" CINE SSFP:
Breath-hold SSFP cine images were acquired in 8-mm slices in the
4-chamber, 3-chamber, 2-chamber, and short axis orientations.
" Cine SSFP (Additional Aortic Valve Views): A short-axis series was acquired
at the level of the aortic valve.
## FLOW
" AORTIC VALVE FLOW:
Phase-contrast cine images were acquired transverse to
the proximal ascending aorta to quantify through-plane flow.
" Pulmonary Valve Flow: Phase-contrast cine images were acquired transverse
to the main pulmonary artery to quantify through-plane flow.
##
VIABILITY
" LGE (3D):
Late gadolinium enhancement (LGE) images were acquired using a
navigator-gated 3D ultrafast gradient echo inversion-recovery sequence with
spectral fat saturation pre-pulses 15 minutes after injection of a total of
0.1 mmol/kg (15 mL) Gd-BOPTA (Multihance).
" EGE: Early gadolinium enhancement (EGE) images were acquired using an
ultrafast gradient echo inversion-recovery sequence with spectral fat
saturation pre-pulses 5 minutes after injection of a total of 0.1 mmol/kg (15
mL) Gd-BOPTA (Multihance).
## LEFT VENTRICLE
" LV CAVITY SIZE:
Normal
" LV ejection fraction: Normal
" LV mass: Normal
" Basal wall thickness: Mildly increased
" Basal infero-lateral wall thickness: Mildly increased
## RIGHT VENTRICLE
" RV CAVITY SIZE:
Normal
" RV ejection fraction: Normal
" Intra-cardiac shunt: None present
## ATRIA
" LA SIZE:
Normal
" RA size: Normal
## GREAT VESSELS
" ASCENDING AORTIC DIAMETER:
Normal
" Main pulmonary artery diameter: Normal
## VALVES
" AORTIC REGURGITATION:
Mild
" Mitral regurgitation: Mild
## ADDITIONAL INFORMATION/FINDINGS:
None.
## NON-CARDIAC FINDINGS:
Two liver cysts, dominant measures 1.4 cm
## IMPRESSION:
The left atrium is normal. The right atrium is normal. Normal left
ventricular cavity size with top-normal wall thickness. Normal right
ventricular cavity size. Normal bi-ventricular global and regional systolic
function. No late delayed enhancement seen in the LV myocardium. Ascending
aorta and descending aorta diameters were normal. The main pulmonary artery
dimension was normal. No aortic stenosis. Mild aortic regurgitation. Mild
mitral regurgitation. Trivial circumferential pericardial effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19638455", "visit_id": "22687885", "time": "2202-08-04 07:39:00"} |
19557250-DS-14 | 2,245 | ## ALLERGIES:
Iodinated Contrast Media - IV Dye
## CHIEF COMPLAINT:
shortness of breath, hypertension
## HISTORY OF PRESENT ILLNESS:
Mr. is a y/o male with a past medical history of HTN,
recent MVC c/b rib fractures and pneumomediastinum who presented
to the ED with dyspnea and chest pain. Patient was recently
admitted to the hospital for trauma after suffering 3 left sided
rib fractures, left lung contusion and pneumomediastinum. He
underwent a flex bronch which revealed a right bronchus
intermedius posterior wall mucosal defect. This was managed
conservatively.
The patient was discharged recently in early and since that
time he has had worsening shortness of breath. Patient also
reports worsening lower extremity edema. Today he went to the
surgery clinic for a followup appointment and was found to be
markedly hypertensive (unknown SBPs given no note) and hypoxic
to the . He was sent to the ED for further evaluation.
In the ED, initial VS were T 96.9, BP 225/126, HR 106, RR 24,
86% RA. Patient was placed on a nitro gtt and received Lasix 40
mg IV. He was placed on BiPAP. NIPPV was transitioned to 4L NC.
Surgery was consulted and recommended CTA chest, diuresis and
CAD workup. Blood pressure was controlled and improved to
123/59. Labs were notable for a BNP 2152, D-dimer 2756, Cr 0.9,
lactate 1.9. was negative for DVT. CXR was performed and
showed no acute process though very low lung volumes.
On arrival to the floor, T 98.7, BP 154/88 on nitro gtt, HR 114,
96% 5L NC, RR 26. He triggered on the floor for dyspnea
requiring increase of O2 requirement to 6L. Repeat CXR showed
low lung volumes and some vascular congestion. He was noted to
have 700 cc in his foley from 40 mg IV Lasix and then got
another 60 mg IV Lasix with good UOP (300 cc initially). VBG was
7.35/60/76, lactate 1.2. He was still on the nitro gtt to the
floor. Later into the evening, he was briefly off nitro gtt and
then by morning was acutely short of breath and requiring face
mask. He received another 60 mg IV Lasix with 600 cc output.
Repeat ABG was , so decision was made to transfer the
patient to the ICU for BiPAP.
## PAST MEDICAL HISTORY:
HTN
S/p MVC c/b pneumomediastinum s/p bronch
Lower extremity edema
Chronic anxiety
HTN urgency resulting in pulmonary edema
OSA (presumed)
Chronic venous stasis
Obesity
Anxiety
## SOCIAL HISTORY:
Pt is married and lives with his wife in . Pt
has twin adult dtrs who live locally, an adult son with MS who
resides at Home, two grandsons, and a loving dog. Pt
described feeling very well-supported by his family and shared
that his dtr has already gone to the tow-lot to retrieve
personal belongings from his totaled car. Pt's wife has been in
phone
contact but is planning to stay home today due to her own
injuries.
Pt described having a fear of doctors and thus being fairly
non-compliant with his blood pressure medications. Pt
acknowledged his need to do better so he can continue to be
healthy for his family. Pt expressed some anxiety related to
being in the hospital but actually appeared to be coping with it
relatively well.
Married, spouse
tobacco, none current
No IVDU
Occasional EtOH
## FAMILY HISTORY:
Mother - HTN
Father - HTN
## GENERAL:
A+Ox3, tachypneic, not speaking in full sentences due
to BiPAP mask
## HEENT:
AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
## NECK:
nontender supple neck, no LAD, unable to appreciate JVD
due to habitus; no crepitus
## CARDIAC:
mildly tachycardic, distant heart sounds, S1/S2, no
murmurs, gallops, or rubs
## LUNG:
poor effort, diminished throughout, unable to appreciate
crackles or wheezes
## ABDOMEN:
obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding
## EXTREMITIES:
no cyanosis; marked 3+ pitting edema to knees b/l
with lymphedema and erythema bilaterally up to knees, no calf
tenderness
## PULSES:
2+ DP pulses bilaterally
## SKIN:
warm and well perfused, venous stasis changes
## VS:
98.2 BP 90-145/53-75 HR RR22 on RA
## HEENT:
AT/NC, EOMI, PERRL, , MMM,
## NECK:
nontender supple neck, no LAD, unable to appreciate JVD
due to habitus
## CARDIAC:
distant heart sounds, S1/S2, no murmurs, gallops, or
rubs
## LUNG:
poor effort, diminished breath sounds diffusely, no
crackles
## ABDOMEN:
obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding
## EXTREMITIES:
no cyanosis; decreased 2+ edema to knees b/l with
lymphedema and erythema bilaterally up to knees
## PULSES:
2+ DP pulses bilaterally
## SKIN:
warm and well perfused, venous stasis changes
## IMAGING:
========
CXR
No acute intrathoracic process, though low lung volumes limits
detection of focal consolidation.
B/L VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
CXR
There are low lung volumes. Cardiomediastinal silhouette is
within normal limits allowing for the technique and poor
inspiratory effort. No definite consolidation or pulmonary edema
is seen. There are no pneumothoraces.
TTE
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.6cm2). No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is trivial
mitral regurgitation.The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
## IMPRESSION:
Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild aortic valve stenosis. Increased PCWP.
Compared with the study (images reviewed) of ,
left ventricular systolic function has improved and the severity
of mitral regurgitation is decreased.
DISCHARGE LABS
================
06:25AM BLOOD WBC-6.1 RBC-4.52* Hgb-11.9* Hct-38.0*
MCV-84 MCH-26.3 MCHC-31.3* RDW-15.2 RDWSD-46.0 Plt
06:25AM BLOOD Glucose-146* UreaN-83* Creat-1.6* Na-136
K-4.5 Cl-96 HCO3-32 AnGap-13
05:55AM BLOOD ALT-15 AST-17 AlkPhos-74 TotBili-0.3
06:25AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.7*
## BRIEF HOSPITAL COURSE:
with a past medical history of HTN, recent MVC c/b rib
fractures and pneumomediastinum who presented to the ED with
dyspnea and chest pain, secondary to hypertensive emergency
which caused pulmonary edema.
## INVESTIGATIONS/INTERVENTIONS:
-For HTN urgency causing pulmonary edema, pt required nitro gtt
and BiPAP, was transferred to the CCU, aggressively diuresed
w/tight BP control including nitro gtt then was switched to
amlodipine/metoprolol regimen which maintained normotension
thereafter.
- hospital stay, pt developed perhaps to
overaggressive diuresis and BP control. Diuretics were held and
Cr improved to 1.6 at time of discharge. Pt was not discharged
on diuretics as it is not clear that he needs it, but needs
daily weights, and consideration of Lasix initiation if he gains
>3lbs in 1 day or 5lb in 1 week.
-Pt also developed diarrhea, stool was positive for C Diff,
treated w/PO Flagyl with plan for nding .
## #HYPERTENSION:
Patient had a long standing history of
hypertension and reported compliance with medications. Patient
has had a significant amount of pain recently from rib
fractures, likely contributing to his hypertensive episodes.
Patient had a hypertensive emergency, an Aline was placed for
closer monitoring and managed with nitro gtt, BiPAP and Lasix in
the ED with initial improvement. He was weaned off nitro drip
along with diuresis. Pt was started on Captopril low doses
uptitrated and consolidated to Lisinopril 20mg, though needed to
decrease and eventually stop ACEI to development of . Pt
was restarted on Amlodipine for BP control, 5 mg daily. Pt's BPs
were labile, most likely related to anxiety, pt was started on
Klonopin 0.5mg BID w/Ativan PRN and Sertraline 25mg to be
uptitrated as outpatient. Pt also started on Metop XL 50mg. Pain
was controlled w/tylenol and oxycodone PRN.
##
#ACUTE KIDNEY INJURY:
Pt's creatinine increased from baseline
1.1-1.2 to 2.0, likely in setting of overaggressive diuresis and
current self-diuresis. Diuretics and ACEI were held on due
to and Cr improved to 1.6 on discharge. Was not discharged
on diuretics as unclear that he needs daily dosing as overload
may have only been uncontrolled HTN. Needs repeat CHEM on
to ensure that Cr has returned to baseline.
# Hypoxemic and hypercarbic respiratory failure: Most likely
secondary to pulmonary edema as a result of hypertensive
emergency. Lung volumes were poor on CXR so also could be
component of atelectasis. He appeared to have some chronic
retention given VBG showing pCO2 of 51 with normal pH,
perhaps obesity hypoventilation syndrome and probable OSA
component. Pt initially improved with BiPAP and diuresis, then
w/better diuresis was transitioned off BIPAP to CPAP at night,
which pt tolerated well. Patient had an elevated D-Dimer, which
was likely due to recent trauma and not PE, TTE when euvolemic
w/o signs of Rt heart strain and LENIs were negative. Pt will
require sleep study as outpatient to evaluate for OSA and was
scheduled for sleep followup. Patient was scheduled for follow
up with cardiology. Patient was about 90-92% on room air, and
was given CPAP for sleep at night.
# Acute on chronic diastolic/systolic CHF: Patient had a recent
TTE with EF 45-50%. Reported chronic lower extremity edema which
worsened over the past few days before admission. The pt was
recently started on Lasix (unknown dose). TTE showed LVH but
with overall improved function w/EF >55% after aggressive volume
and BP control. Pt was initially on ACEI, though this was held
. Also started on Metop, consolidated to 50mg XL qd, and
ASA 81mg qd. If weight gain over 3 lbs in 1 day or 5 lbs in a
week, would initiated Furosemide 60 mg PO daily.
## #DIARRHEA:
Pt developed diarrhea toward the end of his
admission, stool C diff sent though w/o recent Abx use. Pt was
started on PO Flagyl 500mg q8 on with plan for nding .
# Hx of Rib fracture, pneumomediastinum, lung contusion: Pt
injuries from MVC treated by ACS. Pain was controlled
w/oxycodone, concern for PE w/elevated Ddimer and recent trauma
though LENIs/TTE neg per above.
TRANSITIONAL ISSUES
=====================
-Discharge weight:120 kg
-If weight gain more than 3 lbs in a day or 5 lbs in a week,
please start PO 60 Lasix daily, trend weights and ins/outs and
obtain Cr.
-Please obtain CHEM 10 on to evaluate Cr (On discharge
1.6, but baseline 1.1)
-Patient's baseline appears to be 90-92% on Room air, may need
nasal cannula PRN
-We recommend outpatient psychiatry consideration for
significant anxiety, pt started on 0.5mg BID Klonopin and 25mg
Sertraline, please uptitrate as outpatient
-Recommend outpatient sleep study for CPAP at night
-Unknown etiology to , thought to be uncontrolled HTN
which has since resolved, but would consider outpatient cath for
ischemic source. Also needs close , with titration of
meds as needed.
-Metronidazole course for is 2 weeks total ending .
-Needs to be evaluated for home O2 at rehab as may need it with
ambulation
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
4. Senna 8.6 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
6. Furosemide Dose is Unknown PO DAILY
## DISCHARGE MEDICATIONS:
1. Docusate Sodium 100 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth q4h:prn Disp #*30
## TABLET REFILLS:
*0
4. Senna 8.6 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Sertraline 25 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
9. Amlodipine 5 mg PO DAILY
10. ClonazePAM 0.5 mg PO BID
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*20
## PRIMARY:
HTN Emergency
Acute Hypoxemic Respiratory Failure
Acute on Chronic Systolic/Diastolic Heart Failure
C Diff Diarrhea
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to after you were found to have very
high blood pressures and were short of breath at your surgery
follow up. You were transferred to the CCU the morning after
your admission because you needed a BiPAP machine to assist with
your breathing. We gave you strong medications to control your
blood pressure and aggressively removed water from your body
with diuretic pills. Your breathing and blood pressures improved
and you were transferred back to the floor where you were much
more stable.
You also required help from a sleep machine at night, so we set
up follow up for you to get evaluated for possible need for this
at home.
Lastly, you were found to have an infection of your intestines
called Clostridium Difficile ("C Diff"), for which you will need
to continue antibiotics for 14 days.
It was a pleasure taking care of you!
Your CCU Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19557250", "visit_id": "23748032", "time": "2169-01-05 00:00:00"} |
10303503-RR-55 | 107 | CT OF THE HEAD WITHOUT CONTRAST, .
## HISTORY:
year-old female with altered mental status; rule out acute
process.
## FINDINGS:
The study is compared with NECT of . There is no intra- or
extra-axial hemorrhage, the midline structures are in the midline and the
ventricles and cisterns are normal in size and in contour for age. Allowing
for the artifact, above, the gray-white matter differentiation is maintained,
throughout, with no evidence of cerebral edema or space-occupying lesion. The
posterior fossa structures are grossly unremarkable. The mastoid air cells,
middle ear cavities and included portions of the paranasal sinuses are clear.
## IMPRESSION:
No acute intracranial process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10303503", "visit_id": "28278201", "time": "2146-06-04 16:31:00"} |
18357972-RR-47 | 141 | ## INDICATION:
scaphoid pain // scaphoid pain
## FINDINGS:
On the AP clenched fist comparison view, there is mild prominence of the
scapholunate interval on both sides, measuring approximately 3.0 mm on the
right and 4.2 mm on the left.
No definite scaphoid fracture is detected. On the lateral view of the left
wrist, there is linear lucency traversing the distal radial corner of the
scaphoid bone, though this could represent artifact due to overlying soft
tissues.
## IMPRESSION:
Mild prominence of left-greater-than-right scapholunate interval.
Linear lucency along the left scaphoid --question artifact due to overlying
soft tissues. If clinically indicated, cross-sectional imaging could help for
further assessment.
## NOTIFICATION:
The impression and recommendation above was entered by Dr.
on at 10:39 into the Department of Radiology critical
communications system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18357972", "visit_id": "N/A", "time": "2149-09-02 08:56:00"} |
10189338-RR-12 | 184 | ## INDICATION:
man with nausea, vomiting, and diarrhea, on
interferon and ribavirin. Has allergy to p.o. and possibly IV contrast.
Assess for colitis.
## CT ABDOMEN:
The lung bases are clear bilaterally. The non-contrast
appearance of the spleen, liver, gallbladder, pancreas, stomach, adrenal
glands, and kidneys are within normal limits. There is no retroperitoneal or
mesenteric lymphadenopathy. There is no free air or free fluid. Although
evaluation is limited of the colon without IV or oral contrast, there is no
evidence of colitis. The transverse, descending, and sigmoid colon are
collapsed. A small amount of stool is present within the right colon.
## CT PELVIS:
Non-contrast appearance of the rectum, prostate, and bladder are
within normal limits. Intrapelvic loops of bowel appear within normal limits.
There is no inguinal or pelvic lymphadenopathy. There is no free fluid within
the pelvis.
## BONE WINDOWS:
A small sclerotic focus within the vertebral body L4 is likely a
small bone island. No concerning osseous lesions are identified.
## IMPRESSION:
Suboptimal evaluation given the lack of IV and oral contrast.
However, no evidence of colitis on this study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10189338", "visit_id": "N/A", "time": "2119-08-19 19:07:00"} |
17356318-RR-47 | 107 | ## INDICATION:
man with cough, fever, evaluate for infiltrate.
## FINDINGS:
Subtle interstitial opacities in the right upper and right lower lung
correlate with the locations of peribronchial nodules seen on prior CT chests,
most recently . Otherwise, there is no evidence of new focal
consolidation. The cardiomediastinal silhouettes are stable, within normal
limits. The bilateral hila are unremarkable. There is no pulmonary vascular
congestion or pulmonary edema. There is no pneumothorax or pleural effusion.
## IMPRESSION:
Subtle interstitial nodular opacities, most conspicuous in the right upper and
lower lung are unchanged and correlate with previously demonstrated
peribronchial nodules seen on prior exams. No evidence of new focal
consolidation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17356318", "visit_id": "21945440", "time": "2139-08-18 04:40:00"} |
19960743-RR-47 | 112 | ## INDICATION:
year old woman with takutsubo now s/p NGT// Eval location of
NGT
## FINDINGS:
There is an abnormal course of the Dobhoff which is likely within the left
bronchial tree.
The tip of the right PICC line projects over the mid SVC.
The lungs are hyperexpanded. Opacities in both lower lung zones likely
reflect atelectasis. There is no pneumothorax identified. A small left
pleural effusion is unchanged.
## IMPRESSION:
The tip of the Dobhoff is likely within the left bronchial tree and removal is
recommended. At the time of this dictation, a follow-up chest radiograph is
performed demonstrating removal of the Dobhoff.
Unchanged cardiopulmonary findings. No pneumothorax is identified.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19960743", "visit_id": "28131106", "time": "2141-08-14 20:39:00"} |
11501805-RR-77 | 167 | ## MUSCULOSKELETAL:
Bones are osteopenic. There is no suspicious osteolytic or
osteoblastic lesion. Multilevel spinal degenerative changes are seen. There
is a ventral hernia with gas-filled bowel lying just beneath the skin surface.
## IMPRESSION:
1. Closed loop obstruction with two transition points one in the terminal
ileun close to the ileocecal valve and one in the sigmoid colon. This is most
likely due to an adhesion crossing over those bowel loops. While there is
some twisting of the mesenteric vessels to suggest a component of volvolus,
there are no signs of ischemia such as lack of bowel wall enhancement or
thickening, portal venous air or pneumatosis
2. Distended bladder.
3. Enlarged prostate.
4. Ventral hernia with dilated loops of bowel just beneath the skin surface.
5. Patulous esophagus with fluid.
6. Bibasilar opacification with a suggestion of nodularity on the left, non-
specific for an infectious inflammatory process.
## COMMENT:
Results posted to the ED dashboard and discussed with Dr
surgery by Dr at 9:45a
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11501805", "visit_id": "23205678", "time": "2140-04-13 03:42:00"} |
14123835-RR-81 | 384 | ## EXAMINATION:
CT abdomen and pelvis without intravenous contrast.
## INDICATION:
w h/o sigmoid diverticulosis p/w GIB, now s/p subtotal
colectomy and end ileostomy . with increasing wbc in the presance of abx
// With PO contrast, eval for fluid collection
## DOSE:
DLP: 574.3 mGy-cm (abdomen and pelvis.
## LOWER CHEST:
There are trace bilateral pleural effusions. There are extensive coronary
artery calcifications. Midline sternotomy wires are present.
## ABDOMEN/PELVIS:
Evaluation of abdominal and pelvic structures is limited due to lack of
intravenous and oral contrast.
There is been increase in size of perihepatic fluid collection with trace foci
of air, likely postsurgical in etiology. This fluid collection as L of high
density material suggestive of hematoma. Liver is grossly unremarkable without
evidence of intrahepatic or extrahepatic biliary ductal dilatation. There are
dense gallstones within the gallbladder. Spleen is not enlarged. There is a
moderate amount of perisplenic fluid. Adrenal glands and kidneys are grossly
unremarkable. The pancreas is not well visualized. There is extensive
atherosclerotic calcification of abdominal and pelvic vasculature.
There is a percutaneous catheter in the right paramidline pelvis within an
anterior fluid and air containing collection. There is no additional
collection deep to this collection and anterior to surgical sutures. Within
the right pelvis, (03:58) there is a similar-appearing 5.6 x 6.8 cm collection
with dependent higher density material suggestive of hematoma. There is a
right lower quadrant ileostomy. Oral contrast from prior CT examination is
seen within the loops of small bowel continuing through the ostomy. There is
mild dilatation of midline upper abdominal small bowel loops.
There is extensive atherosclerotic calcification of the abdominal aorta
without evidence of aneurysmal dilatation. There are no enlarged inguinal,
iliac chain, or retroperitoneal lymph nodes. There is diffuse anasarca. There
is no suspicious osseous lesion. There are degenerative changes of the lower
lumbar spine.
.
## IMPRESSION:
1. Increase in size of perihepatic fluid collection with areas of increased
density suggestive of hematoma.
2. Pigtail catheter in the right pelvis within grossly unchanged appearing
anterior air and fluid containing collection. There is an additional pelvic
collection deep to this catheter. Communication of these collections is
uncertain.
3. Grossly unchanged right lower quadrant hematoma
4. Minimal dilatation of midline upper abdominal small bowel loops may be
secondary to ileus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14123835", "visit_id": "21427560", "time": "2171-11-14 10:16:00"} |
12206709-RR-8 | 115 | ## HISTORY:
female with worsening shortness of breath. Question
effusion. History of sarcoidosis, status post left upper lobectomy.
## FINDINGS:
AP and lateral views of the chest. No prior. There is a
moderate-sized right-sided pleural effusion with possible underlying
atelectasis versus possible consolidation. There is some pleural thickening
seen laterally at the left lung base without definite consolidation or
evidence of pulmonary vascular redistribution. Cardiomediastinal silhouette
is within normal limits. Surgical chain sutures seen at the left hilum
compatible with history of left upper lobectomy. Osseous and soft tissue
structures are unremarkable.
## IMPRESSION:
Moderate-sized right-sided pleural effusion and underlying
atelectasis; however, consolidation is not excluded. Postoperative changes of
left upper lobectomy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12206709", "visit_id": "25001614", "time": "2153-04-10 15:54:00"} |
16146107-RR-4 | 207 | RIGHT UPPER QUADRANT ULTRASOUND WITH DUPLEX DOPPLER EVALUATION OF HEPATIC
VESSELS.
## HISTORY:
man with metastatic prostate cancer with elevated LFTs
and thrombocytopenia, evaluate for portal vein thrombosis, splenomegaly,
please perform Doppler.
## FINDINGS:
Multiple heterogeneous echogenic masses seen throughout the liver
parenchyma, with significant distortion of the parenchyma, consistent with
multiple diffuse liver metastases. Partially visualized body of pancreas
appears unremarkable. Normal-appearing right kidney measuring 11.9 cm in
length. Normal-appearing gallbladder without evidence of cholelithiasis,
gallbladder wall thickening, or pericholecystic fluid. Normal-appearing
common bile duct measuring 4 mm in diameter. Partially visualized aorta and
IVC appear unremarkable. Normal-appearing spleen measuring 11.3 cm in length.
Normal left kidney measuring 11.8 cm in length. Trace ascites.
DOPPLER EVALUATION OF THE HEPATIC VASCULATURE. Normal hepatopetal flow within
the main, right, and left portal veins. Normal hepatofugal flow with normal
phasicity of the right, mid, and left hepatic veins. Normal hepatopetal flow
with normal Doppler waveform of the main hepatic artery. Preserved flow
within the splenic vein away from the spleen.
## IMPRESSION:
1. Diffuse multiple liver metastases, unusual for prostate primary. Biopsy
may be helpful.
2. Normal Doppler evaluation of the hepatic vasculature.
Findings discussed with patient's physician at 4:00 pm on
.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16146107", "visit_id": "20281420", "time": "2187-02-01 08:35:00"} |
14020151-RR-37 | 100 | ## INDICATION:
Headache status post fall.
## FINDINGS:
There is straightening of the cervical lordosis, which could be due
to patient positioning or muscle spasm. The atlanto-occipital, atlantoaxial,
and bilateral facet articulations are normal. There are no fractures. There
is mild DJD with anterior osteophytosis and minimal loss of intervertebral
disc space at C5-C6.
The pre- and paravertebral soft tissues are unremarkable. There is a right
subclavian catheter, partly visualized. The imaged lung apices are within
normal limits. The mid to lower cervical esophagus is mildly distended but
thin walled.
## IMPRESSION:
No acute fracture of the cervical spine.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14020151", "visit_id": "20146298", "time": "2151-07-30 12:44:00"} |
17325109-RR-77 | 309 | ## INDICATION:
Progression of known portal hypertension. Comparison was
performed to the previous MR examination from .
## FINDINGS:
Liver is enlarged. It is 19 cm long with heterogeneous "nutmeg"
appearance with reticular non-enhancing bands throughout the liver between the
regenerative tissue. No change has been seen in size and appearance of the
liver since the last examination.
Intrahepatic IVC is relatively narrow. The right hepatic vein drains into
suprahepatic IVC and the mid and left hepatic vein drain into big
subdiaphragmatic collateral that continues along the left anterior border of
the heart upwards.
Portal veins, SMV, splenic vein are normal.
Hepatic artery is normal.
Spleen is enlarged. Its length 13.8 cm, similar to the previous examination.
On the posterior surface of the spleen, there are two peripheral somewhat
triangular structures that do not enhance after gadolinium injection and they
have not been changed since previous examination. Their appearance is not
specific and may represent old infarct.
A number of small peripheral tubular structures are seen in the segment VII in
the right liver lobe. They probably represent hepatic venous collaterals.
Intercostal and lumbar vessels and azygos vein are very prominent and they
represent systemic collaterals.
Small amount of ascites and left pleural effusion is seen.
Minimal size lesions of low signal intensity on T1- and T2-weighted images are
seen in both kidneys and they are not enhancing after gadolinium injection.
They are more prominent on the right. Their appearance is not specific. They
may represent minimal hemorrhagic cysts.
Multiplanar 2D and 3d reformations delineated the dynamic series
in multiple pespectives and facilitated assessemnt of liver
parenchyma and vasculature.
## IMPRESSION:
1. Known Budd-Chiari syndrome with systemic collaterals due to probably
thrombosis of intrahepatic inferior vena cava. No change has been seen since
the previous examination.
2. Small amount of ascites and left pleural effusion is seen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17325109", "visit_id": "N/A", "time": "2169-05-02 10:01:00"} |
18738985-RR-25 | 192 | ## STUDY:
MRI of the sella turcica with and without contrast.
## CLINICAL INDICATION:
woman with family history of
hyperparathyroidism, rule out pituitary macroadenoma.
## FINDINGS:
The size and configuration of the sella turcica appears within
normal limits, there is no evidence of abnormal enhancement, the pituitary
stalk appears midline, the suprasellar cistern appears normal. The optic
chiasm and parasellar regions are unremarkable. On the T2-weighted sequences,
there are multiple foci of high signal intensity, distributed in the
subcortical white matter, which are nonspecific and may represents chronic
microvascular ischemic changes, however, a dedicated MRI of the brain is
recommended for further assessment. The visualized elements of the posterior
fossa and craniocervical junction are unremarkable.
## IMPRESSION:
Essentially normal MRI of the sella turcica, there is no evidence
of pituitary enlargement or areas with abnormal enhancement to suggest
pituitary adenoma.
Multiple foci of high signal intensity are identified on the T2-weighted
sequence, distributed in the subcortical and periventricular white matter,
which are nonspecific and may represent chronic microvascular ischemic
changes, however, other entities cannot be completely excluded including
demyelination, correlation with a dedicated MRI of the brain is recommended
if clinically warranted.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18738985", "visit_id": "N/A", "time": "2193-02-07 17:31:00"} |
14112934-RR-39 | 105 | ## EXAMINATION:
C-SPINE NON-TRAUMA VIEWS IN O.R. IN O.R.
CLINICAL HISTORY year old woman with cervical myelopathy now s/p fusion//
s/p fusion anterior and posterior s/p fusion anterior and posterior
## FINDINGS:
The patient is status post laminectomy and placement of bilateral rods and
screws posteriorly at C5 C6 and T1. There is minimal anterior
spondylolisthesis of C3 on C4 and mild anterior spondylolisthesis of C4 on C5.
Alignment appears stable.
## IMPRESSION:
Status post laminectomy and fusion as described. There is no evidence of
hardware related complication. Mild anterior spondylolisthesis of C 4 on C5
as demonstrated previously.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14112934", "visit_id": "21920630", "time": "2177-08-06 09:46:00"} |
16736195-RR-24 | 157 | ## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN)
## INDICATION:
year old man with congenital hepatic fibrosis and cirrhosis //
r/o focal liver lesion
## 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 a large patent umbilical vein unchanged in
appearance from prior examinations. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. There is mild ductal
ectasia of the common bile duct measuring up to 6 mm, mildly increased from
prior.
## GALLBLADDER:
There is no evidence of stones or gallbladder wall thickening.
## PANCREAS:
The pancreas is poorly visualized secondary to overlying bowel gas.
## SPLEEN:
Normal echogenicity, measuring 18.8 cm.
## IMPRESSION:
1. No suspicious liver lesion.
2. Splenomegaly and large patent umbilical vein consistent with portal
hypertension.
3. Common bile duct ectasia up to 6 mm of uncertain clinical significance.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16736195", "visit_id": "N/A", "time": "2145-08-16 13:36:00"} |
16564743-RR-106 | 177 | ## HISTORY:
Right hip pain.
AP PELVIS AND TWO VIEWS OF THE RIGHT HIP.
The patient is status post Girdlestone procedure on the right, with proximal
retraction of the femoral shaft. There is a wire with methyl methacrylate
beads extending into the femroal medullary canal. Compared with , the
write appears to have fractured at the intertrochanteric line. The proximal
fragment of the wire-and-beads project over the expected site of the hip
joint. There may also be some bony fragmentation of the upper edge of the
trochanter itself or of the lateral edge of the acetabulum versus heterotopic
bone formation. The methyl methacrylate femoral head "prosthesis" is seated
in the acetabulum, similar to prior.
The patient is also status post ORIF of an old healed left proximal femur
fracture with three pins extending along the femoral neck.
## IMPRESSION:
S/p girdlestone procedure. Interval fracture of beaded wire. Possible small
fracture fragment vs heterotopic ossification arising from the lateral edge
of the acetabulum or the upper edge fo the greater trochanter. No new bony
osteolysis detected.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16564743", "visit_id": "N/A", "time": "2160-11-02 13:43:00"} |
15619878-DS-3 | 2,849 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
- rectal nodule resection with anastomosis
- wash out and diverting ileostomy
## HISTORY OF PRESENT ILLNESS:
man with history of macular degeneration,
hyperthyroidism s/p excision and cholangiocarcinoma diagnosed
years ago s/p right hepatectomy was found to have a rectal
nodule on follow up consistent with metastasis. Extensive
workup did not reveal any other site of metastases so he was
admitted for resection. He is now status post low anterior
resection on with colorectal surgery. After uncomplicated
surgery he was admitted to the floor for monitoring and was
advancing his diet slowly. He was taking in clears when today
he started vomiting. His white blood cell count was noted to be
downtrending to a nadir of 2.0. CT scan of the abdomen showed
large anastomotic leak. He therefore went to the OR on
for washout and diverting ileostomy. There was noted to be
copious amounts of stool in his abdomen during the surgery. Now
with new onset a-fib with RVR, s/p 10 IV metop and 10 IV of
dilt. He was started on a diltiazem drip at 10 and his rates
came down to 110s from 130-140s with stable BPs. He was
extubated successfully, started on daptomycin and Zosyn given
his vancomycin allergy transferred to the FICU for ongoing
monitoring on diltiazem drip.
His hospital course was further complicated by with with
creatinine elevated to 1.5 from baseline of 0.9. His pain is
being controlled with the Dilaudid PCA and IV Tylenol.
Upon arrival to , the patient appears well, is alert and
oriented, and states that his pain is well controlled.
## PAST MEDICAL HISTORY:
Hyperthyroidism
Macular drusen
Nuclear cataract
Osteopenia
Vitamin D deficiency
Rotator cuff rupture
Labral tear of long head of biceps tendon
Meibomianitis
Postablative hypothyroidism
Cholangiocarcinoma
History of SCC (squamous cell carcinoma):
R forearm, L lower leg
DVT (deep venous thrombosis)
Macular degeneration, dry
PVD (posterior vitreous detachment)
Colonic adenoma
Macular pucker
Non-toxic multinodular goiter
Follicular mucinosis without alopecia
Myxoma of right thigh
Achilles tendon disorder
Lichen planus
History of basal cell cancer: R shin, L upper arm
Cataract, post subcapsular polar senile
Basal cell carcinoma, L maxilla
## FAMILY HISTORY:
Maternal grandmother died of brain cancer, maternal grandfather
died of unknown cancer. No family history of cardiac disease or
colon cancer.
## VITALS:
T max 99.1, HR 73-80, BP 86/48-103/55, RR , O2
95-96% on 2 L NC
## GENERAL:
Well-appearing man lying in bed in no apparent distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
## ABD:
Soft, mildly distended, mild diffuse tenderness to
palpation. Drain in left lower quadrant with dressing c/d/i.
Ostomy right middle quadrant with clear output no stool
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## NEURO:
No focal deficit, cranial nerves grossly intact, moving
all extremities
Discharge physical exam
## ABDOMEN:
soft, non-tender. Well-healing incisions. Ostomy pink
with loose output.
## 5:45 PM ABSCESS SITE:
ABDOMEN Source: abdomen.
**FINAL REPORT
GRAM STAIN (Final :
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final :
ESCHERICHIA COLI.
Identification and susceptibility testing performed on
culture #
- .
ANAEROBIC CULTURE (Final :
BACTEROIDES FRAGILIS GROUP. RARE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # .
## 5:30 PM ABSCESS SOURCE:
abdomen.
**FINAL REPORT
GRAM STAIN (Final :
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final :
ESCHERICHIA COLI. SPARSE GROWTH.
## SENSITIVITIES:
MIC expressed in
MCG/ML
ESCHERICHIA COLI
|
AMPICILLIN
-----
=>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN
-----
16 R
CEFEPIME
-----
<=1 S
CEFTAZIDIME
-----
<=1 S
CEFTRIAXONE
-----
<=1 S
CIPROFLOXACIN
-----
<=0.25 S
GENTAMICIN
-----
<=1 S
MEROPENEM
-----
<=0.25 S
PIPERACILLIN/TAZO
-----
<=4 S
TOBRAMYCIN
-----
<=1 S
TRIMETHOPRIM/SULFA
-----
=>16 R
ANAEROBIC CULTURE (Final :
BACTEROIDES FRAGILIS GROUP. RARE GROWTH. BETA
LACTAMASE POSITIVE.
## IMAGING:
==============
BD & PELVIS WITH CO
## IMPRESSION:
1. Evidence of anastomotic leak from the recent colorectal
anastomosis on the right side with large amount of
intraperitoneal contrast, fluid and air.
2. Remainder of the findings as above.
Imaging ABD SUPINE & LAT DECUB
## IMPRESSION:
Known free intraperitoneal air, possibly decreased when compared
to the prior CT scan from .
Imaging CHEST PORT. LINE PLACEMENT
## IMPRESSION:
Right-sided PICC line projects to the cavoatrial junction. The
NG tube
projects below the left hemidiaphragm and out of field-of-view.
There is a small to moderate left pleural effusion and a small
right pleural effusion. Cardiomediastinal silhouette is stable.
No pneumothorax is seen
CT scan IMPRESSION:
-Multiple rim-enhancing fluid collections throughout the abdomen
are
concerning for developing abscesses. The largest fluid
collection in the
right paracolic gutter measures 3.1 x 4.1 x 10.7 cm. A
subdiaphragmatic fluid
collection in the left upper quadrant between the liver and
spleen measures
4.3 x 7.3 x 5.1 cm. A 5.1 x 6.7 x 4.7 cm fluid collection lies
inferior to
the remaining right hepatic lobe with a smaller 2.8 x 2.4 x 2.0
fluid
collection without clear communication posteroinferiorly.
-Small hyperdense focus posterior to the rectum could be
residual extraluminal
contrast, from prior CT.
-Increasing bilateral pleural effusions with compressive
atelectasis, moderate
on the left and small on the right.
tube check
## IMPRESSION:
1. Likely interval resolution of right upper quadrant collection
in
correlation with postprocedure CT exam from .
2. Unchanged size of left upper quadrant collection when
compared to post
procedure CT examination from .
08:00AM BLOOD WBC-10.1* RBC-3.70* Hgb-10.8* Hct-33.8*
MCV-91 MCH-29.2 MCHC-32.0 RDW-12.6 RDWSD-42.0 Plt
08:00AM BLOOD Plt
## ICU COURSE ( ):
===============================
Mr. was admitted to the ICU for monitoring and atrial
fibrillation with RVR that was a new diagnosis after his washout
with diverting ileostomy. He initially can on a diltiazem drip
and converted to sinus rhythm upon arrival to the ICU with HR in
the . He was mildly hypotensive with systolic pressures in
the high to so the diltiazem drip was reduced from 10mg
to 2.5mg gradually. the drip was stopped the morning of
with hopes that after this acute illness his atrial fibrillation
would resolve. Unfortunately, he reverted back into atrial
fibrillation and required diltiazem drip again for a short
period of time before reverting back into sinus rhythm.
Cardiology was consulted and suggested stopping the diltiazem
drip again with close observation in hopes that as he improved
he would remain in sinus. The drip was stopped again the evening
of and he remained in sinus rhythm without complications.
He was continued on daptomycin and zosyn (start date for
anastomotic leak with recent procedure. His ileostomy was
initially draining clear/red fluid and his abdominal distention
was not improving so a nasogastric tube was placed and put to
low intermittent suction. He also had a PICC line inserted on
and TPN was started for nutrition as he was kept NPO
until adequate stool production from the ostomy. Once stable
from a cardiac and hemodynamic perspective he was transferred to
the floor for further management.
## FLOOR COURSE:
=================
On a CT scan was obtained for elevated WBC which showed
multiple abdominal collections. He was taken for drainage by
and 2 drainage catheters were placed, one in the LUQ and one in
the RUQ. See their note for procedural details. His WBC improved
and his daptomycin was discontinued on . His diet was
advanced slowly as tolerated and his TPN was discontinued on
at which time his antibiotics were switched to PO
ciprofloxacin and flagyl. He was started on Lovenox on that same
day and his RUQ drain was removed for low output. He
ambulated early and often in his floor course. His pain was
managed with Tylenol alone. His surgical drain was removed on
the day of discharge. At the time of discharge the patient's
vital signs were stable. He was voiding spontaneously and had
adequate pain control. He was discharged to home with the LUQ
drain in place, 14 days of cipro/flagyl, 30 day total course of
lovenox. His PICC line was removed prior to discharge. The
discharge plan was discussed with the patient who expressed
understanding and agreement.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
4. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES QID
5. diclofenac sodium 0.1 % ophthalmic (eye) DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Multivitamins 1 TAB PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 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 #*14 Tablet
## REFILLS:
*0
3. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*30 Syringe
## REFILLS:
*0
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
5. Psyllium Wafer 1 WAF PO BID
RX *psyllium 1 wafer by mouth twice a day Disp #*30 Package
Refills:*3
6. Sodium Chloride 0.9% Flush 20 mL IV BID drain flush
Flush drain with 20cc lock syringe of saline twice daily
RX *sodium chloride 0.9 % 0.9 % 20 ml per draiin twice a day
Refills:*2
7. syringe (disposable) miscellaneous BID
Please provide 10cc lock syringes for drain flushing
RX *syringe (disposable) Flush with 20 cc saline BID twice a
day Disp #*30 Syringe Refills:*1
8. diclofenac sodium 0.1 % ophthalmic (eye) DAILY
9. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES QID
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
13. Tamsulosin 0.4 mg PO QHS
14. Vitamin D 1000 UNIT PO DAILY
## DISCHARGE DIAGNOSIS:
Metastatic cholangiocarcinoma to the
rectum.
Anastomotic leak.
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital after a low anterior resection
for surgical management of your cancer. You have recovered from
this procedure well and you are now ready to return home.
Samples of tissue were taken and this tissue has been sent to
the pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you regarding these
results they will contact you before this time. You have
tolerated a regular diet, are passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
If you have any of the following symptoms please call the office
for advice :
fever greater than 101.5
increasing abdominal distension
increasing abdominal pain
nausea/vomiting
inability to tolerate food or liquids
prolonged loose stool
extended constipation
inability to urinate
## INCISIONS:
You have laparoscopic surgical incisions on your abdomen
which are closed with internal sutures. These are healing well
however it is important that you monitor these areas for signs
and symptoms of infection including: increasing redness of the
incision lines, white/green/yellow/malodorous drainage,
increased pain at the incision, increased warmth of the skin at
the incision, or swelling of the area.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips), these will fall off
over time, please do not remove them. Please no baths or
swimming until cleared by the surgical team.
Pain
It is expected that you will have pain after surgery and this
pain will gradually improved over the first week or so you are
home. You will especially have pain when changing positions and
with movement. You should continue to take 2 Extra Strength
Tylenol ( ) for pain every 8 hours around the clock and you
may also take Advil (Ibuprofen) 600mg every hours for 7 days.
Please do not take more than 3000mg of Tylenol in 24 hours or
any other medications that contain Tylenol such as cold
medication. Do not drink alcohol while or Tylenol. Please take
Advil with food. If these medications are not controlling your
pain to a point where you can ambulate and preform minor tasks,
you should take a dose of the narcotic pain medication. Please
take this only if needed for pain. Do not take with any other
sedating medications or alcohol. Do not drive a car if taking
narcotic pain medications.
Activity
You may feel weak or "washed out" for up to 6 weeks after
surgery. No heavy lifting greater than a gallon of milk for 3
weeks. You may climb stairs. You may go outside and walk, but
avoid traveling long distances until you speak with your
surgical team at your first follow-up visit. Your surgical team
will clear you for heavier exercise and activity as the observe
your progress at your follow-up appointment. You should only
drive a car on your own if you are off narcotic pain medications
and feel as if your reaction time is back to normal so you can
react appropriately while driving.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
## HIGH ILEOSTOMY OUTPUT:
Goal Ileostomy output is 500-1200cc in 24 hours. Here are
general guides. If this does not work for you, please call the
office with any questions or concerns. BE SURE REGLAN IS
DISCONTINUED, this can elevate output. Ileostomy output can be
slowed just by eating a reg diet of breads, potato, peanut
butter or other thickening food. Try this first. If still
elevated after eating food, follow the following guidelines: 1)
Start with 2mg of Loperamide BID for ileostomy output >500cc by
noon if patient's taking a regular diet, if by noon you have
greater than 1000cc you can take 2mg of loperamide 4 times a
day, 2) If the 2 loperamide 4 times a day does not slow down the
output to be on tract for <1200cc in 24 hours, please add 2
psyllium wafers three times a day 4) If the loperamide and
wafers do not work, you can increase your loperamide to 4
tablets 4 times a day. Do not exceed 16mg in 24 hours. You can
then add lomotil. 3) If this does not work, you can add opium
Max 100/day. You will not be prescribed this at discharge, but
should call the office if despite 4mg 4 times a day of
loperamide and 2 wafers 3 times a day your output is above
1200cc per day. start with 1 drop 3 times a day. You can advance
by 1 drop a day (1 drop three times a day--> 2 drops three times
a day--> 3 drops three times a day). Please titrate slowly so
that you do not get too thick of output and your output drops
below 500cc per day.
4) Patients should continue to drink enough fluids to replace at
minimum what is coming out of your ostomy. So if having 1500cc
out of your ostomy, you need to drink at least 1.5L of fluids.
However, drinking too much fluid can increase output and the
fluid should be around the time of meals ideally if this is a
cause of the elevated output.
5) check daily weights during this time.
You will be discharged home on Lovenox injections to prevent
blood clots after surgery. You will take this for 30 days after
your surgery date. This will be given once daily. Please follow
all nursing teaching instruction given by the nursing staff.
Please monitor for any signs of bleeding: fast heart rate,
bloody bowel movements, abdominal pain, bruising, feeling faint
or weak. If you have any of these symptoms please call our
office for advice or seek medical attention if there is an
emergency. Avoid any contact activity while taking Lovenox.
Please take extra caution to avoid falling.
You are being discharged with a drain placed by the
Interventional Radiology service at .
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, , or nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15619878", "visit_id": "21443142", "time": "2166-12-04 00:00:00"} |
15612368-RR-122 | 465 | ## HISTORY:
Status post bilateral salpingo-oophorectomy, partial hysterectomy,
bilateral mastectomy with reconstruction and abdominal flap. BRCA2 positive.
Presenting with persistent abdominal pain and elevated inflammatory markers.
?Presence of abdominal mass or fluid collection. ?Evidence of inflammation of
bowel or peritoneum.
## ABDOMEN:
The liver is diffusely low in attenuation, consistent with hepatic steatosis.
There are focal areas of higher attenuation in the periportal region (5:22)
and the gallbladder fossa (5:27) consistent with areas of focal fatty sparing.
No concerning liver lesions are identified. The portal and hepatic veins are
patent. No intra or extrahepatic duct dilatation. The gallbladder is
contracted but is otherwise unremarkable.
Similar to the previous study, there is a 1.1 cm nodule within the medial limb
of the left adrenal gland that is unchanged in size and appearance since but was not present on the previous study in . This has
not been fully characterized. The right adrenal gland is within normal
limits. There is a 1 cm simple cyst within the upper pole of the left kidney.
The kidneys are otherwise unremarkable. No hydronephrosis. The spleen is
within normal limits. The pancreas is unremarkable.
Note is again made of a gastric diverticulum arising from the fundus of the
stomach (5:15). The small and large bowel are unremarkable. The appendix is
normal. No mesenteric or retroperitoneal adenopathy. The abdominal aorta is
of normal caliber. There are multiple surgical clips in the rectus abdominus
muscles bilaterally and there is stranding within the subcutaneous fat of the
anterior abdominal wall, consistent with postsurgical change and is unchanged
since previous (5:56).
The lung bases are clear. The visualized portion of the heart and pericardium
is unremarkable. Multiple surgical clips are noted within the both breasts
consistent with previous surgery.
## PELVIS:
The patient is status post partial hysterectomy and bilateral
salpingo-oophorectomy. The cervix and vagina are unremarkable. The bladder
is within normal limits. No pelvic adenopathy. No free air or fluid within
the abdomen or pelvis.
## OSSEOUS STRUCTURES:
There is a well-defined area of mixed sclerosis and lucency within the right
iliac bone that is unchanged since and has no concerning features. Mild
scoliosis of the lower thoracic and lumbar spine convex to the left is again
identified. No concerning sclerotic or lytic lesions are identified within
the osseous structures of the abdomen or pelvis.
## IMPRESSION:
1. No abdominal mass or fluid collections.
2. Severe hepatic steatosis with areas of sparing in the gallbladder fossa
and in the periportal region. No concerning liver lesions.
3. 1.1 cm nodule within the medial limb of the left adrenal gland which is
unchanged since but was not present on the oldest previous CT in
. Further assessment with dedicated CT or MRI of the adrenal glands is
recommended.
4. Unchanged gastric diverticulum.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15612368", "visit_id": "N/A", "time": "2155-07-11 17:04:00"} |
17082938-DS-19 | 1,396 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Crohn's flare for 2.5 weeks not responding to PO prednisone
## HISTORY OF PRESENT ILLNESS:
Patient is a with a h/o Crohn's disease who present with
2.5 weeks of right sided abdominal pain and diarrhea, consistent
with his past Crohn's flares. Patient said current flare
started shortly before the - had intermittent
stabbing right sided abdominal pain and 5BMs/day which were
non-bloody and mucousy. He was seen in on
where a CT showed ilial inflammation with a phlegmanous
collection surrounding it. They sent him home with 4 days of PO
prednisone of unknown dose. He made an appt. with a new
gastroenterologist who he saw on the . Dr. him on
60mg PO prednisone daily as well as PO flagyl. The patient did
not fill the flagyl prescription becuase he was going to a party
that weekend and wanted to be able to drink alcohol. In
contrast he has been compliant with the PO prednisone, without
relief of symptoms. Over the weekend his symptoms changed to
become a midline squeezing feelig in addition to the stabbing
right sided pain. He started the PO flagyl the day PTA, without
relief of symptoms, and came to the due to worsening of his
pain and encouragement by the nurses at his gastroenterologist's
office.
The patient was first diagnosed with Crohn's at the age of .
He presented with RLQ abd pain and underwent surgery for
presumed appendicits, but had a 6 inch bowel resection for
Crohn's disease instead. Since the age of , he has had flares
approximately every years. Most of these are treated with 4
days of PO prednisone as an outpatient, though he has required
inpatient admissions for IV steroids, bowel rests and IVF in the
past (unsure of date of last admission).
In the , initial vitals were 98.8, 107/61, 100, 16, 99% on RA.
Labs were notable for WBC of 24.6 with 95% neutrophills. A
lactate was 1.8. A repeat CT scan showed ileitis without
phlegmonous collection. The patient was treated with IV
cipro(1365)/flagyl(1500). Pain was controlled with
oxycodone-acetaminophen 10mg-650mg PO at 1300 and oxycodone 10mg
PO at 1330. He was given IV zofran 4mg x1 for nausea.
Vitals prior to transfer were 98.3, 64, 16, 133/64, 98% on RA,
pain. On the floor the patient was hungry, compalining of
slight nausea since he hadn't eaten for a while. He had
right sided belly pain, an no other complaints.
## ROS:
per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, nausea, vomiting, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
## PAST MEDICAL HISTORY:
MEDICAL & SURGICAL HISTORY:
Crohn's disease, as above
Depression
Polysubstance abuse
## FAMILY HISTORY:
No family history of IBD, autoimmune disease, HLA-B27 associated
diseases.
## ADMISSION PHYSICAL EXAM:
VS - Temp 98.3, BP 149/83, HR 64, R 20, O2-sat 98% RA, Pain
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - hyperactive bowel sounds, soft, non-distended, TTP in
RLQ>epigastrium, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, diffuse tattoos
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
throughout, sensation grossly intact throughout, cerebellar
exam intact, steady gait
## DISCHARGE PHYSICAL EXAM:
unchanged except for decreased abdominal tenderness to
palpation.
## HEPATITIS SEROLOGIES:
07:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
## MICROBIOLOGY:
STOOL OVA + PARASITES
OVA + PARASITES (Final :
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
STOOL **FINAL REPORT
C. difficile DNA amplification assay (Final :
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final :
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final : NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final :
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O YERSINIA (Final : NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final :
NO E.COLI 0157:H7 FOUND.
URINE CULTURE- no growth
BLOOD CULTURE -PENDING
BLOOD CULTURE -PENDING
## IMAGING:
CT ABD/PELVIS Prelim report-
## IMPRESSION:
Focal segment of thickening of the distal ileum
consistent with Crohn's disease. No signs of abscess or
phlegmon. Correlation with outside imaging is recommended. MR
can be more sensitive for acute inflammation of the bowel.
## BRIEF HOSPITAL COURSE:
with h/o Crohn's disease, here with Crohn's flare
refractory to 2 weeks of PO prednisone.
## # CROHN'S FLARE:
Patient's abdominal pain was considered to be
most likely a Crohn's flare, given that it felt similar to his
flares in the past. Infectious stool studies were sent to be
thorough and were pending at the time of discharge. A repeat CT
scan done in the showed ileitis without phlegmon. ESR and
CRP were normal. He was seen by gastroenterology and was
started on IV Cipro/Flagyl and 20mg q 8hr IV Solu-Medrol, with
an improvement in his symptoms. He was discharged on HD#2
(patient was unwilling to stay in the hospital any longer) on PO
budesonide, Cipro and Flagyl for 10 days, with instructions to
follow up with his outpatient gastroenterologist as soon as
possible. Unfortunately, we were not able to make this
appointment for him over the weekend.
## #H/O POLYSUBSTANCE ABUSE:
The patient's pain was controlled with
4mg PO Dilaudid Q6H. When he complained of continued
discomfort, but not frank pain, he was offered acetaminophen
650mg. He was not discharged on any standing oral narcotics,
given his history of opiate addiction, but was provided several
doses of oral opiates as an emergency supply only to reach his
followup appointment within several days. He was maintained on
a nicotine patch and his home gabapentin while in house.
## CHRONIC ISSUES:
# Depression: Chronic stable issue, not on any current therapy.
## TRANSITIONAL ISSUES:
#Patient requires an outpatient follow up appointment with his
gastroenterologist, which we were unable to schedule for him
over the weekend.
#Blood cultures, stool studies and urine cultures were still
pending at the time of discharge.
# CT scan final read was still pending at time of discharge.
## MEDICATIONS ON ADMISSION:
1. Gabapentin 600 mg PO TID
## DISCHARGE MEDICATIONS:
1. Gabapentin 600 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *Cipro 500 mg 1 tablet(s) by mouth Twice a day Disp #*20
## TABLET REFILLS:
*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 10 Days
RX *Flagyl 500 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
4. Budesonide 9 mg PO DAILY Duration: 10 Days
RX *budesonide 3 mg 3 capsule by mouth Once a Day Disp #*30
## CAPSULE REFILLS:
*0
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 6hrs Disp #*5
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure taking care of you at . You came to the
hosptial becuase of a Crohn's Flare. A cat scan done in the
emergency department showed inflammation in your small
intestine. We drew blood cultures and took stool samples to rule
out infectious causes of your bowel inflammation - these were
still pending at the time of discharge. You were treated with
steroids and antibiotics through your veins, which improved your
symptoms. You were discharged on steroids and antibiotics by
mouth.
Please call your gastroenterologist to make an outpatient
appointment with him as soon as possible. We were unable to
make an appointment for you over the weekend.
## MEDICATION CHANGES:
START budesonide 9mg daily x 10 days
START ciprofloxacin 500 mg by mouth twice a day for 10 days
START flagyl 500 mg by mouth three times a day for x 10 days
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17082938", "visit_id": "20709091", "time": "2163-04-07 00:00:00"} |
10561929-RR-44 | 297 | CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST
## INDICATION:
woman with locally advanced pancreatic cancer,
evaluate for progression.
CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST TECHNIQUE:
Multidetector
scanning is performed from the diaphragm through the symphysis during dynamic
injection of 150 cc of Omnipaque. Comparison is made to . For full
description of the lung bases, please refer to chest CT from the same day.
The liver is without focal lesions. The intrahepatic bile ducts are prominent
and contain air. There is a stent within the common bile duct. The spleen is
normal in size. The pancreas is atrophic. A dilated pancreatic duct is seen.
There is a 2.1 x 2.1 cm mass in the head of the pancreas. This is stable in
size. The soft tissue extends to approximately 50% of the circumference of
the portal vein as well as along the hepatic artery and portal vein
anteriorly. There is also soft tissue which is noted posterior to the stents
in the common bile duct and this is unchanged. The adrenal glands are
unremarkable. The kidneys are normal in size. Again noted are subcentimeter
hypodense lesions in the mid and lower pole of the left kidney and these are
stable in size.
CT OF THE PELVIS WITH IV CONTRAST:
The bladder is unremarkable. There is
artifact from a total hip prosthesis on the left. There is no free fluid in
the pelvis. There is no pelvic or inguinal lymphadenopathy.
On bone windows, there are no concerning osteolytic or osteosclerotic lesions.
Degenerative changes of the spine are noted.
## IMPRESSION:
Stable size of the pancreatic head mass with vascular encasement
as described above. No evidence of metastatic disease. Stable hypodense
lesions in the lower pole of the left kidney are consistent with cysts.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10561929", "visit_id": "N/A", "time": "2140-03-16 11:57:00"} |
14823400-RR-40 | 295 | ## EXAMINATION:
BILATERAL DIGITAL DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD AND
RIGHT BREAST ULTRASOUND
## INDICATION:
woman recalled from screening mammography for
bilateral increasing coarse heterogeneous calcifications and a 1 cm right
breast mass, likely a sebaceous cyst.
## TISSUE DENSITY:
C - The breast tissue is heterogeneously dense which may
obscure detection of small masses.
A circumscribed mass in the medial right breast measuring 9 mm appears to be
located in the skin. Two amorphous groups of calcifications located in the
inner lower right breast and the central upper left breast
areprobably/possibly benign but have increased in number since . Multiple
additional bilateral groups of heterogeneous coarse calcifications are benign
in appearance. There is no dominant mass or unexplained architectural
distortion.
## BREAST ULTRASOUND:
Targeted ultrasound in the right breast at 3 o'clock 13 cm
from the nipple shows an oval circumscribed predominantly hypoechoic mass with
posterior through transmission which is based in the dermis and contains a
tract to the skin surface, consistent with an epidermoid cyst/sebaceous cyst.
This corresponds to the circumscribed mass in the medial right breast seen on
mammography.
## IMPRESSION:
1. Bilateral amorphous groups of calcifications located in the inner lower
right breast, probably benign and the central upper left breast, possibly
benign, have increased in number since . Six-month follow-up bilateral
diagnostic mammogram seems reasonable, as the patient is likely unable to
tolerate a stereotactic core biopsy.
2. The right breast nodule corresponds to an epidermoid cyst. No additional
follow-up imaging is needed for this finding.
## RECOMMENDATION(S):
Bilateral diagnostic mammogram in 6 months.
## NOTIFICATION:
Findings and recommendation were reviewed with the patient who
agrees with the plan. She was given information to schedule her follow-up. In
addition, findings and recommendations were emailed to Dr. by Dr.
on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14823400", "visit_id": "N/A", "time": "2181-07-01 13:17:00"} |
17078350-RR-120 | 83 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
with ams// ? acute process
## DOSE:
DLP: 802.73 mGy cm
## FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles, sulci, and extra-axial CSF space suggestive of
involutional changes.
There is no evidence of fracture. Small mucous retention cyst is noted in
left sphenoid sinus. Mastoid and middle ear cavities are clear bilaterally.
The visualized portion of the orbits are unremarkable.
## IMPRESSION:
No acute intracranial process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17078350", "visit_id": "N/A", "time": "2180-07-08 16:16:00"} |
17921134-RR-34 | 244 | ## INDICATION:
female with diffuse abdominal pain, vomiting and
diarrhea, which is worse after eating. Most tender in the left lower
quadrant. Evaluate for diverticulitis.
## CT ABDOMEN WITH IV CONTRAST:
There is dependent subsegmental atelectasis, but
the lung bases are otherwise clear. There is a 5-mm hypodensity in the dome
of the right lobe of the liver (2:14) which is too small to further
characterize but likely a cyst or small hemangioma. There is no intra- or
extra-hepatic biliary ductal dilatation. The gallbladder is surgically
absent. The pancreas, spleen, and bilateral adrenal glands are normal. The
kidneys enhance and excrete contrast symmetrically without evidence of
hydronephrosis or hydroureter. Bilateral renal hypodensities are too small to
further characterize, but likely simple cysts. The non-opacified stomach and
intra-abdominal loops of small bowel are normal. There is colonic
diverticulosis without evidence of acute diverticulitis. There is no free air
or fluid in the abdomen. No mesenteric or retroperitoneal lymphadenopathy is
noted.
## CT PELVIS WITH IV CONTRAST:
The urinary bladder, distal ureters, adnexa, and
rectum are normal. There is sigmoid diverticulosis without evidence of acute
diverticulitis. A dropped surgical clip is noted in the pelvis. There is no
free fluid in the pelvis. No pelvic or inguinal lymphadenopathy is noted.
## BONE WINDOWS:
No suspicious lytic or sclerotic osseous lesion is identified.
## IMPRESSION:
1. No acute intra-abdominal or pelvic finding to the patient's symptoms.
2. Diverticulosis, without evidence of acute diverticulitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17921134", "visit_id": "N/A", "time": "2156-10-02 21:07:00"} |
13687044-DS-8 | 2,540 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
The patient is an year old male with HTN,
chronic CHF, and COPD who presented with sudden onset SOB since
last night. He tried to ambulate to the bathroom but was too
short of breath to make it and sat down. Per EMS, he appeared
"terrible" and was reportedly hypertensive, tachycardic, RR ,
and SpO2 on RA. Diffuse rales bilaterally. He was
placed on CPAP and the patient improved rapidly. His HR
improved to , RR to , O2sat in mid-90s on CPAP. He was
given 8 nitro sprays en route.
.
On arrival to the ED, the patient was afebrile with P 90, SBP
190, RR , O2sat 100% on CPAP. He was continued on a CPAP for
a period of time then titrated down to 4L NC. He was briefly on
a nitro drip which was discontinued after 20 minutes. He was
given Furosemide 40 mg IV with 400cc of UOP. He appeared fairly
comfortable and chest pain free. EKG without ST-T changes. CXR
shows fluid overload, BNP 10000s. His Lactate was initially 6
but was repeated and improved to 2.1. ABG 7.31/55/129/29. He
complained of bilateral pain with edema so LENIs were done
which were negative. On transfer to floor, he was afebrile, P
54, BP 173/75, RR 23, O2sat 100% 4LNC.
.
On the floor, he denied chest pain, pressure, palpitations,
syncope or presyncope. He does report dyspnea on exertion,
orthopnea, chronic asymmetric edema (left more than right),
cough, and wheezing. He denied any recent GI or urinary
symptoms.
.
On further review of systems, he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, hemoptysis, black stools, or
red stools. He denies recent fevers, chills or rigors. All of
the other review of systems were negative.
.
## # CARDIAC RISK FACTORS:
Diabetes, Dyslipidemia, Hypertension
# Diastolic CHF -- Echo in with EF 60%
# Mitral regurgitation
# Chronic edema -- worse in the summer and after walking
# DOE -- Stress test with mild inferior wall fixed
defect, mild LVH; repeat stress echo no ischemic
changes, mild MR
# Carotid ultrasound -- less than 40% occlusion
# Hyperlipidemia
# COPD -- on inhalers
# Prostate cancer (presumptive diagnosis)
-- refused Urology workup for elevated PSA : PSA 30.9)
# Primary hyperparathyroidism
-- s/p resection in for right superior adenoma
-- parathyroid tissue implanted into left forarm
-- hypocalcemia on Ca and Vit D supplementation
# Depression
# Anxiety -- Sertraline and tapering Lorazepam
# Anemia -- declines colonoscopy
# Gout
# Obesity
# H/o MVC
## FAMILY HISTORY:
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
# Mother -- died at age , patient unsure of cause
# Father -- died at age , patient unsure of cause
# Siblings -- One sibling deceased of unknown type cancer.
## GEN:
Elderly male in NAD. Oriented x3. Mood,
affect pleasant and appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. Somewhat dry MM, halitosis, OP clear.
## NECK:
Supple, full ROM. JVP of 12 cm. No cervical
lymphadenopathy. No carotid bruits noted.
## CV:
Distant heart sounds. RRR with normal S1, S2. No M/R/G
appreciated, but limited by body habitus and breath sounds.
## CHEST:
Increased work of breathing but able to speak in full
sentences. Wheezes in all lung fields. Diffuse bibasilar
crackles.
## ABD:
Normal bowel sounds. Soft, obese NT, ND. No organomegaly
detected. Abdominal aorta not enlarged by palpation.
## EXT:
WWP. Digital cap refill ~2 sec. No cyanosis or clubbing.
Amputation of distal left first digit. Pitting edema L>>R to
knees, but not tense. Distal pulses radial 2+ and DP 1+.
## SKIN:
Stasis dermatitis. No ulcers, rashes, or other lesions
noted.
## NEURO:
CN II-XII grossly intact. Moving all four limbs.
.
## VS:
T 98.9, BP 169/74, HR 87, RR 28, SpO2 96 on RA, Wt 113.8 kg
## GEN:
Elderly male in NAD. Oriented x3. Mood,
affect pleasant and appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. Somewhat dry MM, halitosis, OP clear.
## NECK:
Supple, full ROM. Unable to assess JVP. No cervical
lymphadenopathy.
## CV:
RRR with normal S1, S2. Harsh systolic murmur at RUSB.
## CHEST:
Mildly increased work of breathing but able to speak in
full sentences. Coarse breath sounds. Wheezing improved from
admission. Minimal crackles, improved from admission.
## ABD:
Normal bowel sounds. Soft, obese, NT, ND. No organomegaly.
## EXT:
WWP. Digital cap refill ~2 sec. No cyanosis or clubbing.
Amputation of distal left first digit. Pitting edema L>R,
improved from admission. Distal pulses radial 2+ and DP 1+.
## SKIN:
Stasis dermatitis. No ulcers, rashes, or other lesions
noted.
## NEURO:
CN II-XII grossly intact. Moving all four limbs.
Bilateral hip flexion and plantarfexion limited by leg and lower
back pain. No tenderness over spinous processes or paraspinal
muscles.
.
## FINDINGS:
There is moderate-to-severe cardiomegaly with mild
pulmonary edema. There is no pleural effusion and no
pneumothorax.
## IMPRESSION:
Moderate cardiomegaly with mild pulmonary edema.
.
# BILAT LOWER EXT VEINS at 3:52 AM):
## FINDINGS:
Normal compressibility, flow and augmentation of
bilateral common femoral, superficial femoral, popliteal and
calf veins.
## IMPRESSION:
No DVT.
.
# ECG at 2:42:28 AM):
Sinus rhythm. Normal tracing. Compared to the previous tracing
of no definite change.
.
# TTE at 3:59:23 :
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Doppler parameters are most consistent with
Grade II (moderate) left ventricular diastolic dysfunction. The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The diameters of aorta at the sinus,
ascending and arch levels are normal. There are three aortic
valve leaflets. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to increased
stroke volume due to aortic regurgitation. Mild to moderate
( ) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ( ) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
## IMPRESSION:
Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function.
Moderate diastolic LV dysfunction. Mild to moderate aortic and
mitral regurgitation. Moderate pulmonary hypertension.
.
.
## BRIEF HOSPITAL COURSE:
The patient is an year old male with HTN,
chronic diastolic CHF, and COPD who presented with sudden onset
SOB consistent with a CHF exacerbation.
.
# Pump: His presentation was consistent with a CHF exacerbation
based on symptoms, physical exam, and proBNP elevation to .
He had recent dietary indiscretion, and his poorly controlled
hypertension is likely contributing as well. He was kept on a
low sodium, cardiac diet with a fluid restriction of 1500 ml
daily. He had good urine output with Lasix 40 mg IV BID on
admission, reaching his goal fluid balance of -2L. However, his
Cr rose from 1.7 on admission to a peak of 2.5 the next day, and
his Lasix was held for several doses. His Cr returned to 1.7
and he continued to diuresis fairly well without Lasix. His
echo on showed LVEF 55-60%, diastolic dysfunction, and
mild to moderate AR and MR. discharge, he was started on
Lasix 40 mg PO daily (previously 20 mg BID).
.
# COPD: He has a history of COPD and continues to smoke
cigars daily. He uses Aerobid and Albuterol inhalers at home,
and reports that he has a nebulizer. His Aerobid was exchanged
for Fluticasone, since Aerobid is no longer available. His
current respiratory symptoms are likely due to a combination of
his CHF and COPD. His pulmonary exam improved after diuresis,
with significantly less crackles, but continued wheezing and
coarse breath sounds. He was discharged on Fluticasone
Propionate 110 mcg 2 PUFF IH BID and Albuterol inhaler PRN.
Given his COPD, he should have further outpatient evaluation of
his pulmonary status with PFTs and possibly start a long acting
anticholinergic bronchodilator such as Tiotropium.
.
# ARF: His Cr was 1.7 on admission from a recent baseline of
1.1-1.2 over the last few years, and 1.3 on at a recent
PCP . His Cr rose from 1.7 on admission to a peak of 2.5
during diureses, but returned to 1.7 after holding Lasix for
several doses. His UA on was unremarkable except for
some blood, and cultures were negative. His FEUrea was
unrevealing at 41%. Repeat urinalysis and urine culture from
were also unremarkable except from the continued
presence of blood, likely from minor Foley trauma.
.
# Back Pain: He complained of bilateral lower back and leg pain
the morning before discharge, as well as subjective quad
weakness. He has had similar symptoms intermittently in the
recent past. He was able to ambulate with later in the day.
He has not had any urinary retention, incontinence, or bowel
symptoms. His PSA was elevated to 30.9 on , but the
patient has reportedly declined further workup for prostate
cancer. His current symptoms are somewhat concerning given this
history, and will need close followup with his PCP as an
outpatient.
.
# Hypocalcemia: He has a history of hypocalcemia after resection
of a parathyroid adenoma. He takes Calcitriol at home and was
continued on his home Calcitriol 0.25 mcg PO BID.
.
# Coronaries: He has no known history of CAD, but several
significant risk factors including hypertension, hyperlipidemia,
and smoking. He was not on Aspirin or a statin on admission.
His Troponin increased to 0.04 the morning of , but was
otherwise negative. He was started on Aspirin 81 mg PO daily
and Simvastatin 20 mg PO daily. His Metoprolol Tartrate 50 mg
PO BID was continued.
.
# Hypertension: He has a history of hypertension treated with
Clonidine and Telmisartan. He was continued on his Clonidine
patch and Valsartan was exchanged during his stay for the
nonformulary Telmisartan. His BP was poorly controlled at the
time of admission and reached SBP 180-200. He was started on
Isosorbide mononitrate and Hydralazine on with some
improvement. These may have additional benefit given his CHF.
Because of continued hypertension, he was also started on
Amlodipine 5 mg PO daily on . His SBP remained in the
150s-170s overnight, and he was increased to Amlodipine 10 mg PO
daily. He was discharged on a regimen of Clonidine,
Telmisartan, Amlodipine, Isosorbide mononitrate, and
Hydralazine.
.
# Hyperlipidemia: His home medication regimen did not include a
statin. His lipid panel on showed TC 191, 118, HDL
55, and LDL 112. He has no known coronary disease, but an LDL
goal of 100 is recommended given his multiple cardiac risk
factors. He was started on Simvastatin 20 mg PO daily.
.
# Depression / Anxiety: He was continued on his home regimen of
Sertraline 50 mg PO daily and Lorazepam 0.5 mg PO daily.
.
# Gout: His home Colchicine 0.6 mg PO daily was held while his
creatinine was elevated during diuresis.
.
# DVT Prophylaxis: Heparin 5000 units SC TID
.
# Followup: He has a number of chronic medical issues which will
require close outpatient followup including his hypertension,
COPD, and elevated PSA.
-- Recommend outpatient PFTs to assess COPD severity
-- Recommend reevaluation of BP in home setting and potential
scale back of his antihypertensive regimen at discharge
-- Recommend further discussion of his PSA elevation and
potential implications
.
## MEDICATIONS ON ADMISSION:
Metoprolol tartrate 50 mg BID (QAM and 11am)
Clonidine 0.3 mg/24 hour Patch Weekly
Telmisartan 80 mg PO daily
Furosemide 20 mg PO BID
Aeorobid -- Dosage uncertain
Albuterol -- Dosage uncertain
Calcitriol 0.25 mcg PO BID
Sertraline 50 mg PO daily
Lorazepam 0.5 mg PO daily
Colchicine 0.6 mg PO daily
## DISCHARGE MEDICATIONS:
1. metoprolol tartrate 50 mg Tablet
## SIG:
One (1) Tablet PO BID
(2 times a day).
2. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every .
4. telmisartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO twice a
day.
6. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
9. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
Disp:*1 inhaler* Refills:*2*
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
## PRIMARY DIAGNOSES:
Diastolic Congestive Heart Failure (Acute on Chronic)
Chronic Obstructive Pulmonary Disease
Hypertension
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital for shortness of breath,
weakness, and leg swelling. At the hospital, you were found to
be having an acute worsening of your congestive heart failure
(CHF) and possibly your chronic obstructive pulmonary disease
(COPD). Your blood pressure was also elevated quite high.
Tests on your heart showed that you were not having a heart
attack. Your body was overloaded with excess fluid, which was
causing your leg swelling and breathing problems.
You were treated with medications to help remove the excess
fluid from your body. Your breathing and leg swelling improved
with this treatment. Your blood pressure was quite high, which
puts strain on your heart. Several changes were made to your
medications to get your blood pressure under better control.
Several changes were also made to your inhalers for COPD to
improve your breathing. These medication changes are shown
below and on your discharge medication sheet.
## START:
Isosorbide mononitrate 30 mg by mouth daily
## START:
Hydralazine 50 mg by mouth three times daily
## START:
Amlodipine 10 mg by mouth daily
## START:
Fluticasone 110 mcg inhaler, two puffs twice daily
In order to prevent similar episodes in the future, it is
important that you limit the amount of sodium in your diet.
Instructions on how to do this were provided by the
nutritionists in the hospital. You should weigh yourself every
morning after urinating and call your doctor if your weight goes
up more than 3 lbs. You should also call your doctor if your
leg swelling or breathing is getting worse, since this may
indicate excess fluid building up again.
Because of your deconditioning and decreased strength, it was
recommended that you go to a rehab facility after discharge in
order to have intensive physical therapy. However, you declined
rehab and decided to be discharged home.
A followup appointment with your PCP has been scheduled for you.
The appointment details are listed below.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13687044", "visit_id": "20365873", "time": "2166-07-18 00:00:00"} |
17708877-RR-22 | 364 | ## EXAMINATION:
MR HEAD W AND W/O CONTRAST
## INDICATION:
year old man with metastatic cancer to the brain, s/p
radiation. // assess response to radiation, rule out progression or new
lesions
## FINDINGS:
Numerous new supratentorial enhancing lesions are identified in both cerebral
hemispheres as follows:
A new 4 x 4 mm in transverse dimension, punctate lesion is noted on the left
frontal convexity (image 20, series 13).
A new lesion measuring approximately 8 x 9 mm in transverse dimension is noted
on the right parietal lobe (image number 17, series 13).
A new 8 x 7 mm focal nodular lesion is noted on the head of the caudate
nucleus on the right (image 15, series 13).
A new 6 x 8 mm in transverse dimension enhancing lesion is noted on the
anterior aspect of the left insula (image 14, series 13.
A new 11 x 12 mm in transverse dimension slightly heterogeneous enhancing
lesion is noted lateral to the straight gyrus of the left frontal lobe(image
number 12, series 13).
There is a hemorrhagic slightly larger right temporal lobe enhancing lesion
with associated slow diffusion and susceptibility changes suggestive of
metastasis, measuring approximately 11 x 10 mm in transverse dimension and
previously 9 x 10 mm (Image 11, series 13).
A new focus of abnormal enhancement is noted in the anterior tip of the left
temporal lobe some flow related artifacts are also seen in this area (Image
10, series 13), however the enhancing lesion is also visible on the axial
FLAIR image (10, series 11).
Few scattered foci of high signal intensity are visualized in the subcortical
white matter with no evidence of enhan. Cement, which are nonspecific and may
reflect changes due to small vessel disease. There is no evidence of
hydrocephalus or shifting of the normally midline structures. There is no
evidence of enhancing lesions in the posterior fossa.
The major vascular flow voids are present and demonstrate normal distribution
the orbits are unremarkable, the paranasal sinuses and mastoid air cells are
clear.
## IMPRESSION:
Numerous new supratentorial enhancing lesions as can detail above, suggestive
of metastatic disease. Slightly larger hemorrhagic lesion is identified in the
right temporal lobe.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17708877", "visit_id": "23775827", "time": "2156-01-11 13:51:00"} |
15364266-DS-16 | 936 | ## HISTORY OF PRESENT ILLNESS:
year old male resident of of with
Alzheimer's who presents with hematuria and increased agitation
after traumatic Foley placement. He had a traumatic foley
insertion last week and has had ongoing hematuria since then.
Today he was more confused and agitated than his baseline. He
is normally alert and oriented . He tried to pull out his
foley and has been having more hematuria. He also developed new
scrotal swelling. He has been afebrile. He was found to have a
WBC of 18 today.
In the ED, initial VS were: 99.2 74 128/90 18 98. Labs were
notable for WBC 9.6, Cr 1.7. U/A is positive. The patient
received cefepime. Vitals prior to transfer to the floor were:
100, 84, 169/60, 20, 99RA.
## REVIEW OF SYSTEMS:
Limited given patient's dementia--denies
pain, headache, chest pain, palpitations, cough, SOB, n/v/d,
abdominal pain.
## PAST MEDICAL HISTORY:
HTN
Sick sinus syndrome, s/p pacemaker years ago
Hyperlipidemia
Alzheimer Dementia
Previous stroke yo ago mild deficits
Peripheral vascular disease with claudication
Mild carotid disease
Persistent left vertebral artery occlusion
Gout
BPH
Glaucoma
## GEN:
NAD, alert, oriented to self, can answer direct questions,
likes to talk about nothing in particular but easily
redirectable
## HEENT:
PERRLA, EOMI, MM dry, sclera anicteric, not injected
## CARDIOVASCULAR:
RRR normal s1, s2, IV/IV sysotlic murmur
## RESPIRATORY:
Clear to auscultation bilaterally
## ABD:
normoactive bowel sounds, soft, non-tender, non distended
## GU:
R sided inguinal hernia at least partially reducible,
scrotal edema, nontender testes, blood in urine
## EXTREMITIES:
No edema, 2+ DP pulses
## PSYCHIATRIC:
appropriate, pleasant, not anxious
## SINGLE FRONTAL CHEST RADIOGRAPH:
There are low lung volumes.
Bibasilar
opacities likely represent bronchovascular crowding and
bibasilar atelectasis. There is no definite focal airspace
consolidation. No pleural effusion or pneumothorax is noted. The
left dual-chamber pacemaker is noted with leads in the right
ventricle and right atrium respectively. A subtle linear opacity
projects over the left heart, likely external to the patient.
## 10:35 PM URINE SITE:
CATHETER
**FINAL REPORT
URINE CULTURE (Final :
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
## SENSITIVITIES:
MIC expressed in
MCG/ML
ENTEROCOCCUS SP.
|
AMPICILLIN
-----
<=2 S
NITROFURANTOIN
-----
<=16 S
TETRACYCLINE
-----
<=1 S
VANCOMYCIN
-----
1 S
12:07 am BLOOD CULTURE x 2
## BRIEF HOSPITAL COURSE:
year old male resident of of with
Alzheimer's who presents with hematuria and increased agitation
after traumatic Foley placement, found to have leukocytosis at
Epoch.
## HEMATURIA:
Initiated with traumatic Foley placement. Urine
cytology pending at the . Given BPH and foley placement,
clots and significant hematuria the foley catheter was initially
left in to hopefully tamponade the suspected prostatic bleed.
Eventually the patient developed a catheter associated UTI with
enterococcus (ampicillin sensitive) and his hematuria cleared.
He had been on finasteride for a long time and started on flomax
x 1 week. The foley was removed and the patient was
subsequently incontinent. Currently most of the time he is
incontinent, this is new for him and may be related to recent
foley and infection. Multiple bladder scans were performed and
at most revealed 200cc or less. Overflow incontinence is
unlikely. The patient should follow up with urology in 2 weeks,
this will allow enough time to pass from his UTI treatment and
his from his foley trauma.
## URINARY TRACT INFECTION:
enterococcal. 5 days remaining, last
day of treatment on . On ceftriaxone initially on unti
when it was switched to augmentin.
##
ACUTE ON CHRONIC RNEAL FAILURE:
Baseline Cr 1.4. Admission Cr
1.7, improved with hydration to 1.2.
## HYPERTENSION:
Home enalapril and metoprolol continued but HCTZ
discontinued due to urinary issues. BP remained stable.
## MEDICATIONS ON ADMISSION:
ASA 325 mg daily (d/c'ed
metoprolol 50 mg bid
Finasteride 5 mg daily
Tamulosin 0.4 mg qhs
Mirtazapine 7.5 mg qhs
Simvastatin 20 mg daily
Timolol 0.5% eye drops bid
Enalapril 10 mg bid
Colace 200 mg daily
HCTZ 25 mg daily
Lorazapem 0.5 mg whs prn
MTV
## DISCHARGE MEDICATIONS:
1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 5 days: last day .
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
8. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
## 9. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Lorazepam 2 mg/mL Syringe Sig: 0.25 mg Injection BID PRN ()
as needed for agitation.
## PRIMARY DIAGNOSIS:
Hematuria
Urinary tract infection
## DISCHARGE INSTRUCTIONS:
You were admitted with blood in your urine and confusion and
weakness. You were found to have a urinary tract infection.
You were treated with antibiotics. The blood in your urine
improved and you were not obstructed, but following the removal
of the foley catheter you were incontinent of urine, this is not
uncommon after the removal of a catheter and with an infection
and I have hopes this will improve. I also suggest you follow
up with a urologist to further address this issue and your
enlarged prostate.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15364266", "visit_id": "22432318", "time": "2139-12-09 00:00:00"} |
15820477-DS-5 | 1,352 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
s/p laparoscopic appendectomy at
s/p JP drainage
## HISTORY OF PRESENT ILLNESS:
year old female presenting as a transfer from
for the management of a recurrent
intra-abdominal/pelvic collection.
Ms. presented to on with the
chief complaint of abdominal pain; imaging performed was
consistent with ruptured appendicitis, and the patient was taken
to the operating room for a laparoscopic appendectomy, and
discharged on POD6 on an antibiotic regimen and pain control.
The
patient re-presented to on due to
abdominal pain, and work-up revealed a large pelvic loculated
abscess, in addition to leukocytosis. The patient was started on
antibiotics at that time, and an attempt at drainage of the
abscess was unsuccessful. A second attempt at drainage on
expressed about 60cc of pus, however no drain was placed. The
patient was subsequently taken to the OR on for an abdominal
washout and placement of a JP drain. Due to continued abdominal
discomfort, repeat imaging on showed a new fluid collection
in the anterior pelvis, at which point transfer to was
initiated.
On evaluation, the patient appears comfortable, and in no acute
distress. She complains of stable low mid-abdominal pain,
described as a cramping sensation, and in severity. She has
been passing gas, but hasn't had a bowel movement in the last
several days. She further denies nausea, vomiting, subjective
fevers or chills. She currently has a mid-line wound which is
healing well, with no surrounding erythema, or necrosis.
## PAST MEDICAL HISTORY:
Diabetes, hypertension and asthma
## PHYSICAL EXAM:
Prior to admission physical exam
## GENERAL:
alert, oriented X3, in no acute distress
## HEENT:
normocephalic, atraumatic, oral mucosa moist
## RESP:
clear breath sounds bilaterally
## CV:
RRR, no murmurs, rubs, or gallops
## ABD:
soft, non-tender, global distention; mid-line surgical
incision healing well, clean edges
## ABDOMEN:
soft, tender, lower abd. wound 4" x 2", depth 2",
tissue red, JP bulb left side abd.(minimal old blood tinged
drainage)
## EXT:
no pedal edema, no calf tenderness bil
## NEURO:
alert and oriented x 3, speech clear
## IMPRESSION:
1. Ill-defined 7.7 x 3 cm fluid collection noted in the anterior
right pelvic region. This appears to be new since the prior
study.
2. Drainage catheter noted. Previously noted ill-defined fluid
collections within the pelvis appear to be essentially resolved.
Small fluid collection adjacent to the tube may remain measuring
2.7 x 2 cm.
3. Left adnexal cystic collection which may represent an ovarian
cyst. Overall this cystic area has decreased in size since the
prior study.
CT Abdomen/Pelvis
## IMPRESSION:
1. Ill-defined 7.7 x 3 cm fluid collection noted in the anterior
right pelvic region. This appears to be new since the prior
study.
2. Drainage catheter noted. Previously noted ill-defined fluid
collections within the pelvis appear to be essentially resolved.
Small fluid collection adjacent to the tube may remain measuring
2.7 x 2 cm.
3. Left adnexal cystic collection which may represent an ovarian
cyst. Overall this cystic area has decreased in size since the
prior study.
## BRIEF HOSPITAL COURSE:
year old female presented to with recurrent
intra-abdominal/pelvic collection on . Imaging was
obtained which revealed ruptured appendicitis for which the
patient underwent a laparoscopic appendectomy. The patient
returned to on with increased
abdominal pain for which a large pelvic loculated abscess was
found with leukocytosis. The patient received antibiotics and an
attempt at an placement was unsuccessful. A second attempt
for an placement was done on where 60 cc of pus was
drained without placement of an . The patient was taken to the
OR on for abdominal washout and a JP drain was placed at
that time. Repeat imaging done for increased abdominal pain
revealed a new fluid collection in anterior pelvic at which time
she was transferred to .
When first evaluated at the patient appeared comfortable.
She reported continued abdominal pain that was cramping
pain. The patient had passed gas but had not had a bowel
movement. The patient was admitted to the surgical floor, she
was made NPO and given intravenous fluids. Her pain was
controlled with a PCA pump. On the day of admission she was
given a regular diet and her intravenous fluid was discontinued.
A wound vac was placed on her abdominal wound. The patient
reported pain with dressing changes and was using her PCA for
pain control. She was transitioned from IV to oral agents on HD
#1. The was contacted for insulin
recommendations and better control of her diabetes.
In preparing for discharge, case management had been involved
for home care planning related to her wound vac. She has been
provided with a wound vac and home care services on a limited
basis. She has a follow-up appointment in the acute care clinic
for inspection of the wound on .
At the time of discharge, the patient's vital signs were stable
and she was afebrile. She was tolerating a regular diet. Her
blood sugar was maintained at 93-107. Her pain was controlled
with oral analgesia. She was given prescriptions for
ciprofloxacin and flagyl for completion of a 2 week course. The
Vac dressing was changed prior to discharge on .
## MEDICATIONS ON ADMISSION:
Hydrochlorothiazide 25 mg PO daily
Lantus 30 units at night
Novolog 20 units with meals
Lisinopril 20 daily
Albuterol PRN
## DISCHARGE MEDICATIONS:
1. Ciprofloxacin HCl 500 mg PO Q12H
stop
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*24 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
stop
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*36 Tablet Refills:*0
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
8. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
9. HYDROmorphone (Dilaudid) mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg tablet(s) by mouth Q3H
Disp #*50 Tablet Refills:*0
10. Glargine 17 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 17 Units before
BED; Disp #*1 Vial Refills:*0
11. FreeStyle Lite Strips (blood sugar diagnostic)
miscellaneous ASDIR
RX *blood sugar diagnostic [FreeStyle Lite Strips] as directed
Disp #*100 Strip Refills:*1
12. FreeStyle Lancets (lancets) 28 gauge miscellaneous ASDIR
RX *lancets Tier Unilet ComforTouch] 28 gauge as directed
Disp #*1 Package Refills:*0
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with abdominal pain. You
underwent a laparoscopic appendectomy. A fluid collection was
found and the wound was left open with a wound vac as well as a
JP drain. Your vital signs have been stable and you are now
preparing for discharge with the following instructions.
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.
VAC dressing change every 72 hours, 125mm hg, black sponge
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15820477", "visit_id": "29040355", "time": "2159-08-21 00:00:00"} |
18376342-DS-57 | 2,225 | ## ALLERGIES:
Sulfonamides / Shellfish / Iodine Containing Agents Classifier /
Codeine / Morphine / Heparin Agents / Levaquin
## CHIEF COMPLAINT:
shortness of breath, cough, fatigue
## HISTORY OF PRESENT ILLNESS:
Ms. is a with h/o ESRD on HD, CAD s/p PCI, chronic
abdominal pain, PVD s/p aorto-femoral bypass, diastolic heart
failure, asthma,and recent hospitalization - with FICU
stay) for abdominal pain and hypoxic respiratory failure CHF
exacerbation and was treated with HD for diuresis and levoquin x
6 days for presumed CAP, who p/w 7 days of shortness of breath
and cough productive of green sputum. She reports that she
began feeling nauseous and coughing on and the cough
has become worse over the past several days. Endorses
orthopnea. Low grade fever (reports maximum temperature 99.3 on
the AM of admission). Denies hemoptysis, chest pain, shaking
chills, arthralgias, myalgias, numbness or tingling. Endorses
abdominal pain and nausea. No vomitting or change in bowel or
bladder habits. No sick contacts.
.
In the ED, initial VS were: Temp:97.5 HR:80 BP:142/75 Resp:21
## O(2)SAT:
95. She received a duoneb, ceftriaxone 1g IV x1,
percocet, aspirin, levoquin 750 mg IV was started and stopped
due to hives, which resolved with 25 mg IV benadryl. She was
sent to hemodialysis where 3L of fluid were taken off and she
reports improvement in her breathing after HD.
## PAST MEDICAL HISTORY:
- "About 20" hospitalizations over the past years for
epigastric pain that has eluded definitive diagnosis. According
to her primary care physician, she carries a diagnosis of
chronic pancreatitis, although this has not been confirmed.
Multiple attempts to have her seen in the outpatient GI unit
have failed because she has not been able to keep her
appointments.
- Coronary artery disease; s/p MI in (received stent to
RCA and right PDA at )
- ESRD diagnosed years ago"; has received hemodialysis since
that time. Receives HD on , and . Last dialysis
was yesterday. Baseline creatinine is in range.
- Peripheral vascular disease: s/p aorto-femoral bypass with
atherectomy in after near total occlusion; multiple
revisions of her aorto-bifemoral and cross femoral grafts since
then
- Possible chronic mesenteric ischemia with known occlusion of
inferior mesenteric artery.
- Exploratory laparotomy for pancreas divisum with
sphincterectomy of her minor duct in
- Asthma
- Schizoaffective disorder
- Hypertension
- Insulin-independent diabetes mellitus (last measured HbA1c
6.6% in
- History of DVT and clots in aorto-femoral bypass
- Lumbar disc disease (with associated back pain)
- Hyperlipidemia
- Gastroesophageal reflux/gastritis EGD)
- Chronic pancreatitis
- s/p exploratory laparotomy for pancreas divisum with
sphincterotomy of her minor duct in
- Benign pelvic mass, s/p R oophrectomy and hysterectomy
- s/p cholecystectomy
- s/p arthroscopy of right knee and medial meniscectomy in
- Heparin-induced thrombocytopenia (positive antibody)
## FAMILY HISTORY:
siblings passed away from CAD/heart attacks
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MM dry, geographic tongue, oropharynx
clear
## NECK:
supple, JVP not elevated, no LAD appreciated
## LUNGS:
Expiratory wheezes, coarse crackles and diffuse rhonchi
bilaterally
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
soft, TTP in epigastrum, non-distended, bowel sounds
present, no rebound tenderness or guarding
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis, no
edema
## NEURO:
CN III-XII wnl, no focal deficits
## PERTINENT RESULTS:
08:00AM BLOOD WBC-10.8# RBC-4.24 Hgb-10.3* Hct-32.7*
MCV-77* MCH-24.4* MCHC-31.6 RDW-19.4* Plt
04:30AM BLOOD WBC-6.1 RBC-4.35 Hgb-10.7* Hct-33.7*
MCV-77* MCH-24.5* MCHC-31.6 RDW-19.3* Plt
08:00AM BLOOD Glucose-138* UreaN-31* Creat-5.1* Na-135
K-5.6* Cl-93* HCO3-28 AnGap-20
07:00PM BLOOD Glucose-246* UreaN-8 Creat-2.4*# Na-135
K-3.2* Cl-90* HCO3-36* AnGap-12
04:30AM BLOOD Glucose-76 UreaN-16 Creat-3.3* Na-137
K-3.7 Cl-92* HCO3-36* AnGap-13
08:00AM BLOOD cTropnT-0.05*
08:00AM BLOOD Calcium-8.3* Phos-6.2*# Mg-2. HF:
Prior to admission, Ms. received hemodialysis where 3 L
of fluid was removed with marked improvement in breathing.
During this hospitalization she was further diuresed during
dialysis, but with little additional improvement in her
breathing. She was continued on her home lasix, beta-blocker,
and angiotensin receptor blocker for CHF. On the night of
she slept nearly flat without difficulty.
#Bronchitis/pneumonia/asthma:
Given cough with sputum production, low grade fevers, and
fatigue, was started on 1 g of ceftriaxone and 500 mg of
azithromycin for empiric treatment of community acquired
pneumonia, though pre-test probability was relatively low.
Expectorated sputum on of unclear quality showed gram
positive cocci in pairs. She improved most with
albuterol/ipratropium nebs, then with the addition of prednisone
on , and felt improved enough to be discharged on .
O2 sats remained stable in the mid-high on room air.
#ESRD:
Ms. was maintained on her home hemodialysis regimen of
three times/week, nephrocaps, low phosphorus diet, and home
supplements.
#Troponin elevation:
On admission Ms. troponin was found to be slightly
elevated at 0.05 with no change in chest pain (baseline chronic
pain). ECG with lateral ST-T changes, inferior infarct of
undetermined age, unchanged from prior. Troponin repeated and
was stable at 0.06.
## HTN:
Ms. was continued on her home medications with
systolic blood pressures in the 130s-140s.
## DM2:
sugars well controlled on ISS
## MEDICATIONS ON ADMISSION:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
inhalation Inhalation every hours as needed for
shortness of breath or wheezing.
2. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO three
times a day.
8. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Darbepoetin Alfa In Polysorbat 60 mcg/0.3 mL Syringe Sig:
One (1) injection Injection every other week.
11. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
12. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain: You will
get your next prescription on .
Disp:*5 Patch 72 hr(s)* Refills:*0*
13. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1)
inhalation Inhalation twice a day.
14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day):
(Advair).
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
18. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
19. Ipratropium Bromide 0.02 % Solution
## SIG:
One (1) inhalation
Inhalation 4 times a day.
20. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
21. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
## SIG:
Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
22. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
## 23. PERCOCET MG TABLET SIG:
One (1) Tablet PO every six
(6) hours as needed for pain: You will get your next
prescription on .
Disp:*60 Tablet(s)* Refills:*0*
24. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
three times a day.
25. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
27. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
28. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
29. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
30. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) application
Topical twice a day.
31. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO every six (6) hours as needed for gas or
indigestion.
32. Acetaminophen 325 mg Tablet Sig: Tablets PO every eight
(8) hours as needed for pain: Do not exceed 4 grams of
acetaminophen (Tylenol) especially if you are taking Percocet.
33. B Complex Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
34. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
35. Ferrous Sulfate 324 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a
day.
36. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO
three times a day: Please take with meals.
37. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
38. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: 12 hours on 12 hours off.
## DISCHARGE MEDICATIONS:
1. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization Sig:
Inhalation every six (6) hours as needed for dyspnea or
wheezing.
2. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
## 9. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas or
indigestion.
11. insulin lispro 100 unit/mL Solution Sig: One (1) unit
## SUBCUTANEOUS ASDIR (AS DIRECTED):
per home sliding scale.
12. clopidogrel 75 mg Tablet
## SIG:
One (1) Tablet PO DAILY
(Daily).
13. zolpidem 5 mg Tablet
## SIG:
One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. senna 8.6 mg Tablet Sig: Tablets PO BID (2 times a day)
as needed for constipation.
15. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day) as needed for nausea.
20. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
21. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
22. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation BID (2 times a day).
24. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
25. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
26. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
27. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
28. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
29. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
30. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
31. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
32. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
## PRIMARY:
1. CHF exacerbation
2. Bronchitis
3. Asthma exacerbation
## SECONDARY:
4. ESRD
5. CAD s/p PCI
6. chronic abdominal pain
7. NIDDM2
## DISCHARGE CONDITION:
Stable, mentating, ambulating, taking good PO.
## DISCHARGE INSTRUCTIONS:
You were admitted to the for a congestive heart failure
exacerbation and bronchitis. You were also treated for a
pneumonia. Please continue to take all of your medications as
prescribed. Please continue to attend hemodialysis three
times/week as directed by your nephrologist. Weigh yourself
every morning, call MD if weight goes up more than 3 lbs.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18376342", "visit_id": "21236560", "time": "2156-04-05 00:00:00"} |
10108199-RR-37 | 97 | PA AND LATERAL CHEST ON
## HISTORY:
woman with left lower lobe segmental resection and
recurrent pleural effusion.
## IMPRESSION:
PA and lateral chest compared to through :
Moderate left pleural effusion displacing the mediastinum to the right is
unchanged since , following thoracentesis on that day. There is no
pneumothorax. Small amount of left pleural fluid enters the left major
fissure. Osteotomy noted in the left posterior sixth rib. The base of the
post-operative left lung is partially atelectatic, unchanged. Right lung is
clear. Heart size is top normal but unchanged and there is no pulmonary
vascular abnormality.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10108199", "visit_id": "N/A", "time": "2143-03-18 14:41:00"} |
16591395-RR-87 | 82 | ## INDICATION:
year old man with a LLL pneumonia and changes on CT c/w
chronic aspiraiton // r/o chronic aspiraiton
## FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was penetration with all consistencies of barium. There was
silent gross aspiration with thin liquids.
## IMPRESSION:
1. Penetration with all consistencies of barium.
2. Silent aspiration with thin barium.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16591395", "visit_id": "24364115", "time": "2160-01-30 09:17:00"} |
12362110-RR-26 | 427 | ## EXAMINATION:
CTA CHEST WITH CONTRAST
CTA chest
## INDICATION:
with respiratory distress// Please evaluate for PE
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.6
mGy-cm.
2) Spiral Acquisition 4.1 s, 32.6 cm; CTDIvol = 8.1 mGy (Body) DLP = 263.7
mGy-cm.
Total DLP (Body) = 268 mGy-cm.
## HEART AND VASCULATURE:
Pulmonary vasculature is well opacified to the
subsegmental level. There is significant motion artifact which obscures
evaluation of the segmental and subsegmental branches at the right lung base
and the distal segmental and subsegmental branches at the left lung base. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Dense coronary artery calcifications are noted. The
heart, pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
## AXILLA, HILA, AND MEDIASTINUM:
Mediastinal adenopathy is noted, soft tissue
density which is felt to be separate from the esophagus though inseparable
from in the subcarinal region measures 1.5 cm AP (02:47). A 1.4 cm node is
seen anterior to the carina. There is right hilar adenopath measuring 1.3 x
1.3 cm(02:48).
## PLEURAL SPACES:
No pleural effusion or pneumothorax.
## LUNGS/AIRWAYS:
Vague area of ground-glass noted in the right lower lobe.
There is some centrilobular nodular opacities in the superior segment of the
right lower lobe (3:99). And likely involving the left upper and left lower
lobes as well. There is extensive peribronchial wall thickening throughout
the airways as well as mucous plugging in the distal airways as seen
previously.
## BASE OF NECK:
Visualized portions of the base of the neck show no abnormality.
## ABDOMEN:
There is a small hiatal hernia. Hypodense right renal lesion is
likely a cyst. Included portion of the upper abdomen is otherwise
unremarkable.
## BONES:
No suspicious osseous abnormality is seen.? There is no acute fracture.
Limited images of the upper abdomen demonstrate a 2.2 x 1.4 cm
well-circumscribed hypodense lesion in interpolar region of the left kidney
likely a renal cyst.
## IMPRESSION:
1. No evidence of pulmonary embolism noting suboptimal evaluation of the
segmental and subsegmental branches of the right lung base and the distal
segmental and subsegmental branches of the left lung base. No acute aortic
abnormality.
2. Extensive bronchial wall thickening and mucous plugging suggesting chronic
bronchial inflammation. Scattered ground-glass opacities and centrilobular
nodules could represent small airways disease, aspiration or developing
infection.
3. Mediastinal adenopathy, potentially reactive though should be followed on
subsequent exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12362110", "visit_id": "29724002", "time": "2118-06-02 18:53:00"} |
10072890-DS-16 | 1,699 | ## ALLERGIES:
Morphine Sulfate / Shellfish Derived / Cortisone
## CHIEF COMPLAINT:
NSTEMI, for cardiac catheterization
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Cardiac catherization
redo Coronary artery bypass graft x 3 (LIMA>LAD, SVG>OM,
SVG>PDA)
## HISTORY OF PRESENT ILLNESS:
y/o gentleman with h/o IMI s/p CABG approx years ago, HTN,
hyperlipidemia, chronic systolic heart failure had right total
knee replacement on at .
Nuclear stress on showed EF of 49% with large
inferior MI with mild to moderately reduced LV function and mild
residual inferolateral hypoperfusion. nausea and
diaphoresis on night and was diagnosed with NSTEMI and
acute heart failure. was treated with ASA, metoprolol,
plavix and nitrates. Coumadin was held for possible cardiac
catheterization.
was transfered here for cardiac catheterization.
## PAST MEDICAL HISTORY:
- Inferior MI s/p CABG at to RCA, left saphenous vein graft to OM1, OM2 and LAD
- Acute on chronic systolic heart failure
- Hypertension
- Hyperlipidemia
- S/p right total knee replacement on
- Fatty liver
- Benign kidney tumor
- Depression
## GEN:
Alert and awake, NAD
## HEENT:
PERRL, MMM, OP clear, JVP 9 cm
## EXTREMITIES:
healing right knee scar, WWP, no edema, DP 2+
## NEURO:
Answers questions appropriately, spontaneously moves all
4 extremities
.
## REASON:
evaluate sternal wires - sternal drainage
Final Report
## PROCEDURE:
Chest PA and lateral on .
## HISTORY:
man status post CABG, evaluate for sternal
wires and
sternal drainage.
## FINDINGS:
The small right pleural effusion has increased on today's
examination. A new
small to moderate left pleural effusion with associated left
lower lobe
atelectasis is new on today's examination. The is redo
status post
CABG with new sternotomy wires, none of which are broken or
displaced. There
is no pneumothorax. The heart size is mildly enlarged but
stable.
## IMPRESSION:
1. Status post redo CABG with a small to moderate left pleural
effusion and
adjacent left lower lobe atelectasis.
2. Small right pleural effusion.
3. Unremarkable sternal wires.
The study and the report were reviewed by the staff radiologist.
.
.
## MRN:
Portable TTE
(Complete) Done at 3:00:40 FINAL
Referring Physician
.
Division of Cardiothoracic Surg
## INDICATION:
Coronary artery disease. Left ventricular function.
## TYPE:
Portable TTE (Complete) Sonographer: ,
## DOPPLER:
Full Doppler and color Doppler Location: 6
## NONE TECH QUALITY:
Suboptimal
Tape #: -0:18 Machine: Vivid
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.7 m/s
Left Atrium - Peak Pulm Vein D: 0.6 m/s
Left Atrium - Peak Pulm Vein A: *0.5 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.9 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm
## LEFT VENTRICLE - DIASTOLIC DIMENSION:
*5.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 35% >= 55%
Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.25
Mitral Valve - E Wave deceleration time: 182 ms 140-250 ms
Findings
This study was compared to the prior study of .
## LEFT VENTRICLE:
Mild symmetric LVH. Mildly dilated LV cavity.
Moderate regional LV systolic dysfunction. No resting LVOT
gradient.
## RIGHT VENTRICLE:
Normal RV chamber size and free wall motion.
## AORTA:
Mildly dilated aortic sinus. Normal ascending aorta
diameter. Normal aortic arch diameter.
## AORTIC VALVE:
Mildly thickened aortic valve leaflets (3). No AS.
No AR.
## MITRAL VALVE:
Mildly thickened mitral valve leaflets. No MVP.
Trivial MR.
## VALVE:
Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
## PULMONIC VALVE/PULMONARY ARTERY:
Pulmonic valve not well seen.
## GENERAL COMMENTS:
Suboptimal image quality - poor echo windows.
## REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is moderate regional left ventricular systolic
dysfunction with inferior hypokinesis and inferolateral
akinesis. There is mild hypokinesis of the remaining segments
(LVEF = 35%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
## IMPRESSION:
Dilated left ventricle with moderate regional
systolic dysfunction, c/w CAD.
Compared with the prior study (images reviewed) of ,
significant tricuspid regurgitation is no longer appreciated.
The other findings are similar.
Electronically signed by , MD, Interpreting
physician 15:56
M
Cardiology Report ECG Study Date of 7:25:28
Sinus rhythm
Consider left atrial abnormality
Inferior ( and ? lateral) myocardial infarction, age
indeterminate
ST-T wave changes - are nonspecific but cannot exclude in part
ischemia -
clinical correlation is suggested
Since previous tracing of , ST-T wave changes are
decreased
Read by: .
Axes
Rate PR QRS QT/QTc P QRS T
75 148 90 y/o gentleman with h/o IMI s/p CABG approx years ago, HTN,
hyperlipidemia, chronic systolic heart failure had right total
knee replacement on at .
had NSTEMI on . Cath showed 3VD, occluded RIMA
and all vein grafts. He was seen by cardiac surgery. He had
several runs of AIVR and was seen by EP, he will need follow up
with EP after surgery for re-evaluation for an ICD. Viability
showed some reversibility. Coumadin was held in preparation
for surgery and he remained on lovenox 30 bid.
He was taken to the operating room on where he
underwent a redo CABG x 3. He was transferred to the ICU in
stable condition. He was given IV vancomycin as he was in the
hospital preoperatively. He was extubated on POD #1. He was
transferred to the floor on POD #1. Chest tubes and wires were
discontinued without incident. He was restarted on coumadin and
lovenox for his recent knee replacement. He remained in the
hospital for sternal drainage, chest xray revealed left effusion
and he was diuresised. The drainage was minimal and he was
discharged home with keflex seven day course and wound check
. In relation to coumadin, discussed with Dr
- , at 10am, lower extremity ultrasound
completed and was negative for DVT, he was discharged on aspirin
325mg daily, no further need for anticoagulation. Plan for
follow up with EP in months for evaluation of AIVR.
## HOME MEDICATIONS:
Toprol 25 mg daily
Ecotrin 81 mg daily
Zetia 10 mg daily
Cardizem Cd 120 mg daily
Prilosec 20 mg daily
Tylenol
Paxil 20 mg daily
MVI
KDur 20 mEq bid
Lyrica 25 mg bid
Ambien 5 mg daily
Coumadin
.
## MEDICATIONS ON TRANSFER:
Plavix 75 mg daily
Ezetimibe 10 mg daily
Aldacotone 25 mg daily
Enalapril 5 mg bid
Furosemide 40 mg daily
Paroxetine 20 mg daily
Omeprazole 20 mg daily
Tylenol mg q6h prn
Oxycodone mg q3h prn
Milk of magnesia
MVI
Methylprednisolone 60 mg IV once at at 5pm
Diphenhydramine 25 mg PO q6h
Ranitidine 300 mg PO once at at 5 pm
Vitamin K SC 2 mg once at at 5 pm
.
## DISCHARGE MEDICATIONS:
1. Docusate Sodium 100 mg Capsule
## SIG:
One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
## SIG:
1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): for
dose of 75mg daily.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Coronary Artery Disease s/p CABG
Acute on chronic systolic heart failure
Accelerated idioventricular rhythm
NSTEMI
Depression
Hypertension
Hyperlipidemia
Inferior MI s/p CABG at
s/p R TKR on
Fatty liver
Benign kidney tumor
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
There is currently a small amount of serous drainage from the
sternal incision please call if the color changes or increase in
amount
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10072890", "visit_id": "21097169", "time": "2116-08-03 00:00:00"} |
12078372-RR-20 | 98 | ## EXAMINATION:
CHEST PORT. LINE PLACEMENT
## INDICATION:
year old man with MSSA bacteremia and new RIJ // eval RIJ
placement Contact name: : eval RIJ placement
## IMPRESSION:
Bibasilar atelectasis has improved since today. The persistent region of
consolidation in the lower lobe medially could be another focus of atelectasis
or pneumonia, increased since . There is no pleural effusion.
Cardiomediastinal silhouette is normal. ET tube is in standard placement.
Nasogastric tube ends in the upper stomach and should probably be advanced 5
cm to move all side ports beyond the GE junction. Right jugular line ends in
the low SVC.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12078372", "visit_id": "21290547", "time": "2144-01-16 04:14:00"} |
11911069-RR-57 | 353 | MRI LIVER WITH AND WITHOUT GADOLINIUM
## HISTORY:
Cirrhosis and two areas of suspicious abnormalities consistent with
HCC. Follow up.
## FINDINGS:
Liver cirrhosis is again identified. A small amount of ascites is
again noted and not significantly changed from the prior examination. Central
hepatic arteries and hepatic veins are patent. Spleen is stable in size.
Within segment IVb, the previously identified T1 hypointense, T2 isointense
arterially enhancing mass lesion is noted and is slightly increased in size
now measuring 2 cm in maximal diameter. Lesion demonstrates washout on
delayed phase imaging with an associated peripheral rim enhancement. Findings
are suggestive of hepatocellular carcinoma.
A segment VI lesion is again noted measuring approximately 1.5 cm in maximal
diameter. This lesion also demonstrates wash out with peripheral rim
enhancement and also suggestive of hepatocellular carcinoma. Lesion does not
appear to have significantly changed in size. Within the far inferior aspect
of segment VI, an additional hyper-enhancing lesion is noted which
demonstrates washout and is concerning for an additional focus of
hepatocellular carcinoma. This lesion measures approximately 1.3 cm in
diameter and is not appreciated on the prior examination. Additional wedge-
shaped peripheral areas of arterial enhancement are noted in segment II and VI
and appear similar to prior examinations dated and . This is
of uncertain clinical significance and likely represents a perfusion anomaly.
Bilateral renal cysts are again noted and unchanged. A nonenhancing focus
within the pancreatic body is again present measuring up to 3 mm which
demonstrates T2 hyperintensity and is unchanged. Adrenal glands are
unremarkable. There are no enlarged retroperitoneal lymph nodes.
## IMPRESSION:
1. Arterially enhancing lesion in segment IVb of the liver with washout and
rim enhancement on delayed phases consistent with hepatocellular carcinoma. At
2.2 cm in diameter it is slightly increased in size from .
2. Arterially enhancing focus within segment VI also concerning for
hepatocellular carcinoma is not significantly changed in size.
3. An additional 1.3 cm arterially enhancing lesion with delayed washout in
the far inferior aspect of segment VI is also suggestive of hepatocellular
carcinoma. This is not appreciated on the prior examination.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11911069", "visit_id": "N/A", "time": "2191-03-23 11:11:00"} |
14777714-RR-16 | 222 | ## HISTORY:
History are intubation in the setting of status epilepticus. Please
evaluate.
## CHEST:
The heart size is normal. The hilar and mediastinal contours are
normal. The lungs are clear without evidence of focal consolidations
concerning for pneumonia. ET tube terminates appropriately above the carina.
There is an enteric tube which extends below the diaphragm with the tip likely
in the body of the stomach. There is no pleural effusion or pneumothorax.
## ABDOMEN:
The bowel gas pattern is unremarkable. There is no pneumatosis or
free air. There is mild to moderate fecal loading. There is a baclofen pump
in the right lower quadrant. Note is also made of a dense linear foreign body
projecting lateral to the L4 vertebral body. Apparent irregularity of the
right femoral head may be projectional.
## IMPRESSION:
1. ET tube terminates appropriately above the carina.
2. Apparent irregularity of the right femoral head may be projectional. If
there is further clinical concern for injury to the right hip, a dedicated
view of the pelvis and right hip can be obtained.
3. Dense linear foreign body projects in the lower right abdomen, adjacent to
the L4 vertebral body. It is unclear if this is within, or external to the
patient. Please correlate clinically.
Updated findings and recommendations were d/w Dr. by Dr. by
phone at 10am on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14777714", "visit_id": "29932786", "time": "2143-01-02 03:43:00"} |
15525470-RR-51 | 134 | ## EXAMINATION:
Chest radiograph, portable AP upright.
## INDICATION:
Internal jugular venous catheter placement.
## FINDINGS:
A right internal jugular venous catheter terminates in the lower superior vena
cava. Allowing for technique and decreased lung volumes, cardiac, mediastinal
and hilar contours appear stable. At each lung base, there are patchy
opacities most suggestive of atelectasis. Left hemidiaphragm is mildly
elevated compared to the right, which is probably a baseline finding to some
extent but also exacerbated by atelectasis. Visible small pleural effusion is
found on the right. Small left-sided subpulmonic effusion is not excluded.
There is no pneumothorax noting limitation that the medial right lung apex is
partly excluded.
## IMPRESSION:
Right internal jugular catheter terminating in the lower superior vena cava.
Decreased volumes with atelectasis at each lung base. Small right-sided
pleural effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15525470", "visit_id": "25092297", "time": "2142-01-09 18:22:00"} |
18600028-RR-158 | 855 | ## EXAMINATION:
CT abdomen pelvis with contrast
## INDICATION:
T12 paraplegic w/ complex surgical history on trial drains +
extended antibiotics for non-surgical management of multiple abdominal wall
and retroperitoneal collections. Evaluate for response of collections to
non-surgical management. Additionally, patient is status post failed spinal
fusion with history of osteomyelitis discitis.
## 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.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 13.7 s, 0.2 cm; CTDIvol = 233.2 mGy (Body) DLP =
46.6 mGy-cm.
3) Spiral Acquisition 8.2 s, 53.4 cm; CTDIvol = 19.9 mGy (Body) DLP =
1,048.8 mGy-cm.
Total DLP (Body) = 1,097 mGy-cm.
## LOWER CHEST:
There is bibasilar atelectasis. There is no evidence of pleural
or pericardial effusion. There are coronary artery calcifications, as before.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
Again seen are multiple sub cm hypodense lesions, too small to characterize.
Unchanged 1.6 cm hyperdense lesion in segment 2 ( ), which again may
represent a flash-filling hemangioma. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
There is a 0.6 cm hypodense lesion in the uncinate process ( ).
This lesion is unchanged from at least (see MRI, series
from that date) and may also represent a side branch IPMN as described
on prior imaging. No pancreatic ductal dilatation. There is no
peripancreatic stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right gland is normal in size and shape. The left adrenal gland
is poorly visualized due to beam hardening artifact due to adjacent hardware.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There are multiple unchanged sub cm hypodense lesions in the right kidney, too
small to characterize. No hydronephrosis. There is no perinephric
abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
## PELVIS:
Compared to , no significant change in a large
heterogeneous retroperitoneal fluid collection extending along both the psoas
muscles with multiple foci of air, as before. For example, the right sided
collection lateral to the right psoas measures 7.8 x 5.8 cm ( ) at the
level of the sacroiliac joint, previously 7.6 x 5.8 cm. A small loculation of
fluid along the inferior/lateral aspect of the psoas has essentially involuted
since the prior examination (series 2, image 72 on the prior CT from .
A lobulation of the complex fluid collection in proximity to a previously
placed left-sided pigtail catheter, anteriomedial to the left psoas muscle and
anterolateral to the vertebral bodies has also decreased in size (series 2,
image 62 on the prior CT).
Interval removal of left lower quadrant pigtail catheter.
Interval decrease in size of a right posterior rim enhancing fluid collection
at the site of prior midline skin staples, measuring 2.6 x 0.8 cm ( ),
previously 5.0 x 1.7 cm.
As before, there is extensive fat stranding throughout the abdomen, pelvis and
proximal legs.
## BLADDER AND DISTAL URETERS:
The bladder wall is thickened, which could in
part be secondary to underdistention. Recommend correlation for cystitis. The
distal ureters are unremarkable. As before, the there is extension inferiorly
to the iliopsoas muscles.
## REPRODUCTIVE ORGANS:
There are prostatic calcifications. The visualized
reproductive organs are otherwise unremarkable.
## LYMPH NODES:
Evaluation for retroperitoneal lymphadenopathy is limited by beam
hardening artifact due to adjacent hardware. Again seen are multiple,
unchanged enlarged lymph nodes in the abdomen and pelvis, including multiple
nodes along the bilateral iliac chains. Index nodes:
- 1.3 cm left para-aortic lymph node ( )
- 1.2 cm aortocaval lymph node ( )
- 1.2 cm right caval lymph node ( )
## VASCULAR:
There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted. Unchanged IVC filter.
## BONES:
No acute fractures. No significant change in extensive hardware
involving the lower thoracic and lumbar spine as well as the sacrum. No
significant change in multiple osseous destructive/resorptive changes of the
lower lumbar spine and sacrum. Again seen is presumed cement in the right hip
joint with surrounding bony and soft tissue changes. Again seen are multiple
healed rib fractures.
## SOFT TISSUES:
Compared to , there has been interval healing of a
sacral decubitus ulcer with new soft tissue posterior to the coccyx. The
abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Compared to , minimal improvement in extensive retroperitoneal
fluid collection containing air, fluid and phlegmon surrounding the lower
spine and extending along both psoas muscles. No new intraperitoneal or
retroperitoneal fluid collections.
2. No significant change in extensive postsurgical and osseous changes
throughout the spine.
3. Healing sacral decubitus ulcer.
4. The bladder wall is thickened, which could in part be secondary to
underdistention. Recommend correlation for cystitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18600028", "visit_id": "N/A", "time": "2151-08-14 09:40:00"} |
17940101-RR-45 | 136 | ## EXAMINATION:
US AXILLA, SOFT TISSUE RIGHT
## INDICATION:
year old man with supraglottic SCC s/p chemo/XRT with prior
right axillary lymph node on PET from concerning for possible
metastatic disease.// Please evaluate for right axillary lymphadenopathy that
would be amendable to biopsy.
## FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right axilla. In the area of concern, there is a bilobed hypoechoic mass
measuring 2.3 x 1.2 x 2.2 cm with internal vascularity correlating with the
mass seen on prior PET-CT, which is amenable to ultrasound guided biopsy. An
additional normal appearing lymph node measuring 4 mm is seen adjacent to the
mass.
## IMPRESSION:
A 2.3 cm bilobed hypoechoic mass with internal vascularity identified in the
right axilla, minimal to ultrasound-guided biopsy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17940101", "visit_id": "25962291", "time": "2180-12-07 14:34:00"} |
12862888-RR-150 | 152 | ## INDICATION:
year old woman with abdominal abscess// US guided drainage
## PROCEDURE:
Ultrasound-guided drainage of left anterior abdominal wall
collection.
## OPERATORS:
Dr. , radiology fellow and Dr.
radiologist. Dr. supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
## SEDATION:
Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of
15 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
## FINDINGS:
Limited preprocedural planning ultrasound again demonstrates a hypoechoic
subcutaneous fluid collection along the left mid abdominal wall. Intra
procedural ultrasound demonstrates the drainage catheter in appropriate
position within this collection.
## IMPRESSION:
Successful US-guided placement of pigtail catheter into the
collection. The catheter was secured using a 0-silk suture and a StatLock.
60 cc of purulent fluid was aspirated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12862888", "visit_id": "26333772", "time": "2131-04-11 10:15:00"} |
10650001-RR-49 | 104 | ## INDICATION:
Evaluation of patient with syncopal episode for pneumonia.
## FINDINGS:
Single AP chest radiograph was obtained. Left lower lobe
opacification as well as a small left pleural effusion are unchanged in
comparison to prior study from , and raise concern for
pneumonia. The right lung remains well aerated. There is mild haziness of
the pulmonary vasculature consistent with mild pulmonary vascular engorgement.
The cardiomediastinal and hilar silhouettes appear stable with cardiomegaly
and tortuosity of the thoracic aorta. Pulmonary vasculature is normal.
## IMPRESSION:
1. Lower lobe opacity and small left pleural effusion appear stable and remain
concerning for pneumonia.
2. Mild pulmonary vascular congestion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10650001", "visit_id": "22338692", "time": "2136-03-14 13:29:00"} |
13146802-DS-15 | 1,435 | ## HISTORY OF PRESENT ILLNESS:
male history of ischemic cardiomyopathy with sCHF, recent
NSTEMI in the setting of PNA, DM, CKD, afib, and recent
brain IPH after fall while on coumadin ( ) who was sent from
his cardiologist's office due to EKG changes as well as chest
pain, SOB for roughly 1 week.
The patient was seen by his cardiologist, Dr. , on
who found him to hve ST depression V4-V6, which were
increased compared with and had an initial troponin of
0.13. He was chest pain free but was sent in for consideration
of a cardiac cath as well as further neuro evaluation given his
history of ICH and the likelihood for heparinization. Of note,
at the outside hospital he was given levofloxacin IV for
question of a pneuumonia and aspirin 325.
Outside record hx:
- presented w/ seizure after fall, found to have ICH
- had another ICH after anticoagulation was attempted
again after DVT
- admitted to w/ acute resp failure
pneumonia, MI with trop 6.19. Echo at that admission w/ dilated
LV, contractile dsfx, EF , hypokinetic; did not
recommend further cardiac testing
Initial CABG
PCI - last
Has ICD model , "Protecta" - dual chamber
pacing, defibrillation, ATP
## PAST MEDICAL HISTORY:
Fall with brain IPH and seizure-like activity
right foot drop
Type 2 diabetes
Hypertension
Atrial fibrillation
CHF LVEF 20%
Hyperlipidemia
Coronary artery disease s/p stenting
ICD implanted ( )
## NECK:
thick neck, no JVD
## CV:
irregularly irregular, no murmurs, rubs or gallops
## ABDOMEN:
obese, nontender, no rebound or guarding
## NEURO:
AOx3, able to perform backwards, CN II-XII intact,
upper extremity strength, R foot drop
## GENERAL:
NAD, sitting comfortably, walking comfortably with
walker
## NECK:
thick neck, no JVD
## CV:
RRR, no murmurs, rubs or gallops
## ABDOMEN:
obese, nontender, no rebound or guarding
## NEURO:
AOx3, CN II-XII intact, upper extremity strength, R
foot drop
## FINDINGS:
Left ventricular cavity size is severely enlarged. Rest and
stress perfusion images reveal moderate fixed defects in the
anterior, anterolateral, inferolateral, and inferior walls.
Gated images reveal global hypokinesis. The calculated left
ventricular ejection fraction is markedly depressed at 25%
No prior studies for comparison.
## IMPRESSION:
Abnormal myocardial person study with moderate
fixed defects in the anterior, anterolateral, inferolateral, and
inferior walls. There is global hypokinesis. Markedly
decreased function with a LVEF of 25%.
## IMPRESSION:
ECG uninterpretable for accurate ischemia evaluation
in the setting of intermittent V pacing. No anginal type
symptoms. Appropriate hemodynamic responses to Persantine.
Echo
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Right ventricular chamber size is
normal. with depressed free wall contractility. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of
CXR
1. No evidence of left lower lobe pneumonia or pulmonary edema.
2. Cardiomegaly is consistent with known history of ischemic
cardiomyopathy
and systolic CHF.
EKG
Sinus rhythm. Leftward axis. Predominantly lateral ST-T wave
abnormalities. Compared to the previous tracing the rate is
slightly faster but ventricular pacing is no longer present.
Precordial ST-T waves are now improved.
EKG
Baseline artifact. Sinus rhythm with a period of ventricular
pacing at a rate of 70. Generalized low voltage. ST-T wave
abnormalities. Compared to the previous tracing of there
is now more artifact. ST-T wave abnormalities are difficult to
compare because of differences in the artifact pattern. Clinical
correlation is suggested.
## BRIEF HOSPITAL COURSE:
On arrival to the ED, his initial VS were 98.1 91 133/79
20 97% 3L. He was chest pain free on arrival. Of note, his labs
from the outside hospital were notable for a WBC of 11 and a
Trop I of 0.13. His labs at were notable for WBC 15.6, Hgb
13.6, Hct 38.7, Plt 150, BUN 46 and Cr 2.0. proBNP was 3504. His
initial TnT at 6AM was 0.13 and was 0.36 at 12:30 .
Neurosurgery was consulted given the concern regarding his
previous ICH. A prior CT Head from (faxed from his PCP)
showed a ?retracted thrombus. A CT head was ordered and the
prelim read showed a "hyperdensity in the right parietal vertex
slightly less conspicuous when compared to , given
the persistence of this finding for over year, findings are
consistent with dystrophic calcification in the region of prior
hemorrhage. No acute intracranial hemorrhage." He was given his
home doses of calcitriol, keppra and lyrica. His diuretic and BP
meds were held at this time. He was seen by cardiology and the
decision was made to defer anticoagulation at pt was
assymptomatic.
# NSTEMI - supported by symptoms, EKG and labs. Dipyrimadole
MIBI showed fixed disease with no new ischemia so
catheterization was not performed. He was free of chest pain
while walking and not desatting. Downtrending troponins.
Continued home medications for medical optimization with
increased dose of Atorvastatin (to 80 mg daily).
## # ?PNEUMONIA:
abnormal lung exam and an elevated WBC at OSH, CXR
noted to have left lower lobe pneumonia by report at outside
hospital so given levothyroxine. Pt denied any fevers or coughs
c/w pneumonia, WBC came down and no fever, so did not continue
treatment.
## ON CKD:
Cr 2.0 on admission. Most recent baseline appears
to be 1.5-1.8. Unclear etiology as pt denies any recent decrease
in PO intake supporting pre-renal etiology. No recent new
offending medications such as NSAIDs or abx. Appears relatively
euvolemic, making cardio-renal less likely.
## #CHF:
Pt appears evuolemic on exam. Initially held home lasix in
setting of , restarted on discharge. Continued BB.
#AF: Currently rate controlled. Not on coumadin given ICH on
coumadin. Continued metoprolol.
## #DM:
Continued home glargine, ISS
#HTN: Continued hydralazine (BID dosing) and Imdur. Aldactone
had initially been held with the and realatively low
BP at discharge it was restarted at daily, but pressures are
likley to come up so if potassium normal at follow-up can go to
BID.
#HL: Continued Atorvastatin
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Calcitriol 0.5 mcg PO DAILY
3. Furosemide 40 mg PO DAILY
4. HydrALAzine 25 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. LeVETiracetam 500 mg PO BID
7. Metoprolol Succinate XL 100 mg PO BID
8. Pregabalin 25 mg PO QAM
9. Spironolactone 25 mg PO BID
10. Docusate Sodium 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Ascorbic Acid mg PO BID
13. Pregabalin 75 mg PO QHS
14. Atorvastatin 20 mg PO QPM
15. Glargine 44 Units Bedtime
16. Tiotropium Bromide 1 CAP IH DAILY
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30
## TABLET REFILLS:
*3
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 40 mg 2 tablet(s) by mouth daily Disp #*60
## TABLET REFILLS:
*3
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. LeVETiracetam 500 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Pregabalin 25 mg PO QAM
7. Pregabalin 75 mg PO QHS
8. Ascorbic Acid mg PO BID
9. Calcitriol 0.5 mcg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Furosemide 40 mg PO DAILY
12. HydrALAzine 10 mg PO BID
RX *hydralazine 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
13. Metoprolol Succinate XL 100 mg PO BID
14. Spironolactone 25 mg PO DAILY
15. Outpatient Lab Work
Please draw chemistry panel (chem 7 + Mg) on and fax result
to , MD at .
## ICD-9:
428.2
16. Glargine 44 Units Bedtime
17. Tiotropium Bromide 1 CAP IH DAILY
## PRIMARY:
Non ST elevation myocardial infarction
## SECONDARY:
Acute kidney injury
Congestive heart failure
Atrial fibrillation
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to the hospital with chest pain and a concern
for damage to your heart. We determined that there was not a
need for further intervention with surgery or a stent. We
optimized your medications to treat your heart disease to help
prevent further chest pain.
It was a pleasure to take care of you.
Sincerely,
Your cardiology team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13146802", "visit_id": "29275349", "time": "2165-12-21 00:00:00"} |
17096560-DS-12 | 2,760 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
yo F with h/o HTLV assocaited lymphoma p/w fatigue for 1
week. Pt reports feeling run down and "not herself" for the past
week. She has had less energy than usual with malaise and poor
appetite. She notes that she has also had worsened dyspnea on
exertion. She denies cough, CP. She denies f/c. She was seen in
clinic today and noted to have an INR 6.9 and Ca . Pt
given zometa and 2L NS and referred to BI for eval by team.
.
## ROS:
Pt currently reports feeling much better after the
zometa/ivf. Her complete ROS otherwise is negative.
## PAST MEDICAL HISTORY:
LUE DVT on livelong anti-coagulation
HTLV-1 associated T-cell leukemia/lymphoma, diagnosed in .
Followed by Dr. s/p thyroid nodule resection
Alopecia
Overweight
S/p hysterectomy with oophorectomy
Hypertension
Cataracts
## FAMILY HISTORY:
Father with CAD, mother with glaucoma, Sisters with ovarian and
breast cancer.
## ON ADMISSION:
====================================
t98.4 118/54 93 16 94% ra
NAD
eomi, perrl, mmm
neck supple
chest clear
rrr
abd benign
ext w/wp without edema
no rash
neuro non-focal
## PERTINENT MICRO:
=======================================
Immunology (CMV) CMV Viral Load- 17,200 IU/mL
BLOOD CULTURE Blood Culture, Routine-NEGATIVE
BLOOD CULTURE Blood Culture, Routine-NEGATIVE
SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-Non-Reactive
BLOOD CULTURE Blood Culture, Routine-NEGATIVE
URINE URINE CULTURE-NEGATIVE
## STUDIES:
=================================================
CXR ( )
As compared to the previous radiograph, the distribution of the
left pleural effusion is slightly changed, but the overall
extent is not. The bases of the right lung are better
ventilated than on the previous image. The size of the cardiac
silhouette continues to be enlarged. No evidence of
pneumothorax. Unchanged left pectoral Port-A-Cath.
ECHO ( )
The left atrial volume is normal. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is a very small
echodense pericardial effusion.
## IMPRESSION:
Very small pericardial effusion.
CT CHEST ( )
Stable disease with bulky lymph nodes in the thoracic inlet, the
chest wall and the axillary regions as well as in the
mediastinum. Stable pericardial effusion. Minimally
progressive bilateral pleural effusions.
CT ABD ( )
1. Extensive lymphadenopathy involving the porta hepatis,
mesentery,
retroperitoneum, inguinal region, and iliac chains with new
necrotic
appearance to multiple nodes.
2. Apparent filling defect of the of the left common femoral
and superficial femoral vein which may represent
non-opacification however, DVT is also a possibility, recommend
ultrasound to assess findings.
3. Diverticulosis of the sigmoid colon without evidence
diverticulitis.
LOWER EXT US ( )
1. No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
2. Multiple enlarged lymph nodes in the right and left groin,
similar to prior CT.
CXR ( )
As compared to the previous radiograph, no relevant change is
seen.
A pre-existing small left pleural effusion is smaller than on
the previous image. Mild cardiomegaly without pulmonary edema.
No pneumonia. No pneumothorax. The left pectoral Port-A-Cath
is in unchanged position.
LUE US ( )
No evidence of DVT in the left upper extremity veins. The left
subclavian vein was not completely visualized due to Port-A-Cath
with
overlying bandage.
ART EXT ( )
Triphasic Doppler waveforms at all levels from the femoral
through
the ankle. The ankle-brachial indices at rest were 1.03/0.99.
Pulse volume recordings were likewise obtained and they were
globally diminished but remained normally phasic throughout the
thigh, calf, ankle and metatarsal levels.
## IMPRESSION:
Essentially normal arterial Doppler and pulse
volume recording studies.
ECHO ( )
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is mild posterior leaflet mitral valve
prolapse. Mild to moderate ( ) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is a very
small pericardial effusion. There is an anterior space which
most likely represents a prominent fat pad. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ,
image quality is better. Mitral valve prolapse was probably
present on prior study also. The severity of mitral
regurgitation has increased in comparison to prior echoes.
Amount of pericardial fluid is similar.
CT CHEST ( )
1. No good evidence for intrathoracic infection.
2. Mild progression of generalized adenopathy, more pronounced
in the axillae than intrathoracic.
3. Interval decrease in bilateral pleural effusion, despite
small pleural tumor implants. Stable pericardial effusion. No
evidence of tamponade.
CT ABDOMEN ( )
1. No evidence of occult infection.
2. Extensive lymphadenopathy, with increased number of necrotic
lymph nodes in the inguinal regions.
3. New gallbladder wall edema. The gallbladder itself is
collapsed, however.
CT HEAD ( )
No acute intracranial abnormality. However, if concern for
ischemia, MR is more sensitive.
TTE ( )
All left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is unusually small. with normal free
wall contractility. The estimated pulmonary artery systolic
pressure is normal. There is a small to moderate sized
pericardial effusion. There are no echocardiographic signs of
tamponade.
## IMPRESSION:
Small to moderaet amount of pericardial fluid mostly
over the right ventricle and apex. While the right ventricle is
relatively small, there are no echo signs of tamponade.
( )
No evidence of deep venous thrombosis in the left lower
extremity.
TTE ( )
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a very small pericardial effusion.
Compared with the prior study (images reviewed) of ,
the pericardial effusion is likely smaller, though apical views
in which the effusion was best seen on the prior study are
technically suboptimal on the current study.
EKG ( )
Limb lead reversal. Baseline artifact. Sinus tachycardia.
Occasional atrial premature beats. Non-specific ST-T wave
changes. Compared to the previous tracing of there is no
significant diagnostic change.
## IMMUNOPHENOTYPING :
Three color gating is performed (light scatter vs. CD45) to
optimize
lymphocyte yield. CD45-bright, low side-scatter gated
lymphocytes comprise 9% of total analyzed events.
Abnormal/lymphoma cells comprise of total gated events.
(accurate estimation is limited by the short panel selected). T
cells comprise 76% of lymphoid gated events. T-cells have an
increased helper-cytotoxic ratio of 5:1 (usual range in blood
0.7-3.0). There is a partial loss of CD7 (6-7% total events.
There is an
expanded population of double-negative (~2%). No abnormal events
are identified in the "blast gate."
## BRIEF HOSPITAL COURSE:
==============================================
with progressive HTLV-1 associated T cell lymphoma
leukeomia who presents for progression of disease despite
outpatient chemotherapy.
## ACTIVE ISSUES:
==============================================
# HTLV-1 associated T cell leukemia lymphoma:
The patient presented with relapsed/refractory disease, which
has not been responsive to outpatient chemotherapy. Her
pre-admission labs and peripheral smear were suggestive of
transformation to the leukemic phase of this disease. CT torso
showed stable disease with the exception of increased necrotic
lymph nodes in the abdomen. The type of chemotherapy regime was
discussed with oncologist, Dr. the
family friend and oncologist Dr. . The patient began
treatment with arsenic/interferon/zidovudine on . Tumor
lysis labs were trended frequently along with LDH. EKGs were
trended to evaluate for QTc prolongation. The patient was also
started on prophylaxis with bactrim and fluconazole. 3 days
after starting treatment, the patient developed tachycardia and
respiratory distrss. CXR was unchanged from prior. EKG revealed
sinus tachycardia versus atrial flutter with 2:1 block. QTc was
increased to 450 from baseline of 380. The patient was diuresed
with lasix and started on metoprolol for rate control. Given QTc
prolongation, it was felt that the patient could not tolerate
arsenic, interferon, and zidovudine. Upon further discussion
with the patient and family, the patient decided to undergo
further chemotherapy with EPOCH as a last resort. She started
chemo with EPOCH on . The patient continued to do poorly and
it was discontinued on but mental status and strength
improved somewhat and EPOCH restarted on and finished night
of . Started neupagen and completed 10d course. Given
that counts and functional status recovered, pt was restarted on
EPOCH and completed 5 day cycle thereafter. Post-discharge,
pt will f/u w/ Dr. week) and Dr. at
(thereafter) for further care.
# Leukocytosis:
The WBC strated to rise on day 3 of hospitalization.
Peripheral smear showed a neutrophil predominance. The patient
underwent an infectious workup including cultures and CT torso.
CT torso was only notable for increased necrosis of the
lymphadenopathy. The patient denied any localized
infectious symptoms. She was never febrile. The patient was
continued on prophylactic bactrim and acyclovir.
# Sinus tachycardia:
Patient noted to have short non-sustained episodes of sinus
tachycardia. She was otherwise asymptoamtic and hemodynamically
stable. Her Hct was stable. She did not show any signs of
infection. She was started on metoprolol for rate control. This
was later switched to diltiazem to avoid masking hypoglycemia.
By time of discharge, hr was better controlled, and pt remained
asymptomatic on dilt.
# Hypercalcemia:
Commonly seen in HTLV-1 associated leukemia lymphoma. The
patient was treated with one dose of zoledronic acid in the
clinic prior to admission. She was also given calcitonin and
IVF. Despite these therapies, the calcium continued to
increase. on gave pamidronate. Ca downtrended to normal as a
result
# Hypoglycemia:
Early in hospital course, pt's morning labs were notable for
hypoglycemia. The patient was completely asymptomatic - no
diaphoresis, tremors, nausea, and vomiting. She denied any
history of diabetes or difficulty with blood glucose. AM
cortisol at the time was within normal limits (though was later
low - see adrenal insufficiency for further details). It was
felt that her hypoglycemia was secondary to liver disease given
concurrent transaminitis and coagulopathy. Shortly after in her
hospital course this issue resolved.
# Transaminitis:
Unclear etiology, could be EPOCH or could be
fluconazole. Hepatitis serologies negative. Switched to
micafungin on . LFTs downtrended since then, and micafungin
dc'ed once counts normalized.
# Coagulopathy:
The patient presented on lifelong anticoagulation due to history
of DVTs in the setting of malignancy. INR on admission was 6.9.
Coagulopathy likely secondary to coumadin and poor PO intake.
She was also on on levofloxacin prior to admission for presumed
pneumonia. The coumadin was restarted when her INR was
therapeutic. However due to concern of liver disease, this was
later discontinued. Given the difficulties in maintaining an
appropriate INR, pt was switched to daily lovenox shots prior to
discharged, and was instructed to continue them at home. Her
platlets are to be followed by Dr. be
notified to stop lovenox once they are noted to be below 50.
# Hypertension:
Blood pressures remained within normal limits despite
discontinuing lisinopril and verapamil being held. Accordingly,
such medications were held upon discharge
# Hypothyroidism:
TSH was checked when the patient had an episode of sinus
tachycardia vs atrial flutter. Patient found to have
hypothyroidism. She was started on levothyroxine 100mcg. She
will need to have her TSH checked in 6 weeks and dose adjusted
as needed.
#Cool Lower Left Extremity
Pt had intact pulse (doppler verified), motor, and sensory of L
lower leg, but was cool to touch. Arterial disease felt unlikey
given adeqaute pulses on doppler. venous ultrasound did not
identify DVT. Pt was on lovenox as above. Since patient was able
to ambulate well, did not investigate issue further.
## TRANSITIONAL ISSUES:
1. Repeat TSH 6 wks (Started on
2. Trend platelet count and discontinue lovenox once levels
decline
3. Ensure that pt completed prednisone taper. Starting at 40mg
daily on , decreasing by 10mg q2d until 10mg which she
should continue thereafter unless directed otherwise.
4. Pt will need to follow closely w/ Dr. as an
outpatient to have her labs trended and appropriate infusions
given.
5. Pt will need to continue Nystatin Swish and Swallow for
several days until oral thrush clears
6. Pt will need to be monitored for e/o CMV disease, and be
treated if it occurs given known viremia.
7. Pt would benefit from advance directive discussion including
code status
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 5 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
4. ValACYclovir 1000 mg PO Q24H
5. Verapamil SR 240 mg PO Q24H
6. Warfarin Dose is Unknown PO Frequency is Unknown
## DISCHARGE MEDICATIONS:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
## REFILLS:
*5
2. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8h:prn Disp #*15
## TABLET REFILLS:
*1
3. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90
## TABLET REFILLS:
*5
4. Bisacodyl 10 mg PO DAILY:PRN Constipation
RX *bisacodyl 5 mg tablet(s) by mouth daily:prn Disp #*60
## TABLET REFILLS:
*2
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*5
6. Levothyroxine Sodium 100 mcg PO DAILY
RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30
## TABLET REFILLS:
*2
7. Neutra-Phos 2 PKT PO BID
RX *potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250
mg 2 (Two) powder(s) by mouth daily Disp #*100 Packet Refills:*1
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
9. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily:prn Disp #*30 Packet Refills:*2
10. PredniSONE 40 mg PO DAILY Duration: 2 Days
## , FIRST DOSE:
Next Routine Administration Time
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*50 Tablet
## REFILLS:
*1
11. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*5
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*30
## TABLET REFILLS:
*2
13. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
14. Allopurinol mg PO DAILY
RX *allopurinol mg 2 tablet(s) by mouth daily Disp #*60
Tablet
## REFILLS:
*2
15. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day
Refills:*0
16. PredniSONE 30 mg PO DAILY Duration: 2 Days
## START:
After 40 mg tapered dose
17. PredniSONE 20 mg PO DAILY Duration: 2 Days
## START:
After 30 mg tapered dose
18. PredniSONE 10 mg PO DAILY Duration: ongoing Days
## START:
After 20 mg tapered dose
19. Diltiazem Extended-Release 120 mg PO DAILY
20. Enoxaparin Sodium 40 mg SC DAILY
## START:
, First Dose: Next Routine Administration Time
## PRIMARY DIAGNOSIS:
HTLV-1 associated leukemia lymphoma
Liver failure
Hypercalcemia
Transaminitis
Adrenal Insufficiency
Hypothyroidism
SVT
HTN
## ACTIVITY STATUS:
Ambulation w/ rolling walker
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure caring for you at
. As you recall, you were admitted for inpatient
chemotherapy because your disease was progressing. We started
you on chemotherapy (with arsenic, interferon, and zidovudine),
but you were unable to tolerate these medications. Therefore, we
switched you to another type of chemotherapy. Fortunately, you
tolerated the second treatment (EPOCH) well and were able to
recieve a second cycle prior to discharge.
You came with low blood sugar levels. Please avoid prolonged
period of fasting, and have some snack available for
lightheadedness.
It is extremely important that you take your medications as
prescribed and call us immediately if you are confused regarding
your medications. If you have a fever or feel unwell in anyway
you should also call the clinic immediately for further
instructions.
We wish you the best!!!!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17096560", "visit_id": "24324489", "time": "2178-04-29 00:00:00"} |
19860377-RR-30 | 100 | ## FINDINGS:
As compared to the previous radiograph, a newly appeared parenchymal
opacity is seen in the right lung. The opacity is subtle and mainly located in
the right perihilar areas. Their predominant pattern is micronodular. Parts of
the opacity extend into the right suprahilar areas. In the left lung apex,
subtle peribronchial opacities are seen. Overall, in the context of fever, an
infection must be suspected.
The referring physician was notified by telephone at the time
of dictation.
The size of the cardiac silhouette is at the upper range of normal, there is
no evidence of pleural effusions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19860377", "visit_id": "26171481", "time": "2119-07-17 16:55:00"} |
13291351-RR-27 | 122 | ## INDICATION:
year old woman with non healing ulcer in Lt // venous
mapping for potential bypass
## RIGHT:
The great saphenous vein is patent with diameters ranging from 0.64
proximally to 0.22 cm distally. Of note is that there are GSV varicosities in
the distal calf. The right small saphenous vein is patent with diameters
ranging from 0.35 to 0.44 cm.
## LEFT:
The great saphenous vein is patent with diameters ranging from 0.69
proximally to 0.33 cm distally. There are varicosities at the mid calf level.
The left small saphenous vein is not visualized.
## IMPRESSION:
The great saphenous veins are patent bilaterally but have areas varicosity.
Please see digitized image on PACS for formal sequential measurements.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13291351", "visit_id": "24445945", "time": "2189-09-24 10:06:00"} |
19375035-RR-18 | 76 | ## CLINICAL HISTORY:
MS, on Tysabri. ? interval disease activity.
## FINDINGS:
There is no interval change in the appearances of multiple T2 hyperintensities
in the subcortical, deep and periventricular white matter, including the
corpus callosum. There are no infratentorial lesions. There are no new or
enhancing lesions. There are no lesions with slow diffusion. The ventricles
and sulci are stable in size without evidence of volume loss.
## IMPRESSION:
Stable appearance of demyelinating disease. No new lesions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19375035", "visit_id": "N/A", "time": "2143-11-18 19:31:00"} |
18562129-DS-9 | 1,255 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
sternotomy, aortic valve replacement with a 23 mm
Bicor epic tissue heart valve.
## HISTORY OF PRESENT ILLNESS:
year old male s/p coronary artery bypass surgery with aortic
stenosis who has been followed by Dr. with serial
echocardiograms. Patient has noticed worsening symptoms of
dyspnea on exertion with some fullness in
his chest with exertion. His most recent echo showed severe
aortic stenosis. In preparation for surgery he underwent a
cardiac cath which showed native coronary disease and occluded
saphenous vein graft to obtuse marginal. He presents today after
randomizing to surgical arm of CORE valve study for redo
sternotomy/AVR/?CABG.
## PAST MEDICAL HISTORY:
Atrial fibrillation
Hyperlipidemia
Diabetes Mellitus
Hypertension
BPH
Prostate Ca s/p TURP/XRT , receiving testosterone shots
Sleep apnea on CPAP
Coronary artery disease s/p coronary artery bypass graft x 4,
s/p 2 stents to SVG to RCA , s/p stent at anastomosis of SVG
to LAD and stent to proximal SVG to LAD , s/p LCx/?OM stent
and LM stenting
s/p coronary artery bypas graft x4
Cholecystectomy
Nephrolitiasis
## SURGERY:
coronary artery bypas graft x 4
- Dr :
## GENERAL:
Well-developed male in no acute distress
## NECK:
Supple [X] Full ROM [X]
## CHEST:
Lungs clear bilaterally [X]
## HEART:
RRR [X] Irregular [] Murmur [X] grade
## EXTREMITIES:
Warm [X], well-perfused [X] -open incision from
vein
harvest healed on RLE
## PRE-BYPASS:
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (estimated LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. There are simple atheroma in the ascending aorta and
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are focal calcifications throughout the
aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area calculated 0.7cm2). Trace aortic
regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
Post-Bypass
The patient is A-V paced on a phenylephrine infusion.
There is a well seated bioprosthetic valve in the aortic
position. Two paravalvular leaks persist after protamine
administration, one where the noncoronary cusp would have been,
and one at the former commissure between left and non-coronary
cusps. Peak and mean gradients through the valve are with a
calculated cardiac output of 3.4L/min.
Left ventricular function is preserved with estimated EF > 55%.
There is no echocardiographic evidence of an aortic dissection
after de-cannulation.
The mitral regurgitation remains trace. The remainder of the
exam is unchanged.
05:49AM BLOOD WBC-7.0 RBC-3.46* Hgb-10.4* Hct-30.6*
MCV-89 MCH-30.1 MCHC-34.0 RDW-15.7* Plt
01:03AM BLOOD PTT-33.6
03:31AM BLOOD PTT-41.1*
05:49AM BLOOD
05:49AM BLOOD Glucose-85 UreaN-16 Creat-1.1 Na-138
K-3.6 Cl-101 HCO3-28 AnGap-13
12:47AM BLOOD ALT-8 AST-36 AlkPhos-29* Amylase-24
TotBili-0.6
05:49AM BLOOD Mg-2. year old male s/p coronary artery bypass surgery now with
aortic stenosis. His most recent echo showed severe aortic
stenosis. In preparation for surgery he underwent a cardiac cath
which showed native coronary disease and occluded saphenous vein
graft to obtuse marginal. He was randomized to surgical arm of
CORE valve study for redo sternotomy AVR/ possible CABG.
On the patient went to the operating room where the he
underwent Redo sternotomy, aortic valve replacement with a 23 mm
Bicor epic tissue
heart valve. Please see operative note for further details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition. He arrived paced over slow junctional rhythm, on
pressors, hematocrit was low and he was transfused two units of
cells. He was hypoxic and confused and remained intubated until
POD#1. He extubated without difficulty. His confusion resolved
and narcotics were minimized. He remained weak after surgery but
neurologically intact. Chest tubes and pacing wires were
discontinued without difficulty. While in the unit he returned
to sinus rhythm with first degree atrial block and proceeded to
developed rapid afib that was difficult to control. He was
started on amiodarone and lopressor was increased. He remain
aystomatic and hemodynamically stable. He was also started on
coumadin and his INR was found to increase quickly even after
low doses of it. He was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD six the patient was ambulating with
assistance, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to
in good condition with appropriate follow up
instructions.
## MEDICATIONS ON ADMISSION:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/CaregiverwebOMR.
1. Amoxicillin 500 mg PO PRN dental prophylaxis
2. fosinopril *NF* 40 mg Oral daily
3. ketotifen fumarate *NF* 0.025 % bid
2 gtts
4. Leuprolide Acetate 7.5 mg IM MONTHLY
5. Amlodipine 5 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Sertraline 100 mg PO DAILY
10. GlipiZIDE XL 10 mg PO DAILY
11. Metoprolol Tartrate 50 mg PO BID
12. Nitroglycerin SL 0.3 mg SL PRN angina
## DISCHARGE MEDICATIONS:
1. Aspirin EC 81 mg PO DAILY
2. GlipiZIDE 10 mg PO DAILY
3. Rosuvastatin Calcium 10 mg PO DAILY
4. Acetaminophen 650 mg PO Q4H:PRN pain/fever
5. Amiodarone 400 mg PO DAILY
taper to 200mg daily on
6. Bisacodyl AILY:PRN constipation
7. Cepacol (Menthol) 1 LOZ PO PRN sore throat
8. Diltiazem 60 mg PO QID
9. Docusate Sodium 100 mg PO BID
10. Furosemide 20 mg PO BID
11. Milk of Magnesia 30 ml PO HS:PRN constipation
12. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
13. MD to order daily dose PO DAILY
goal INR 1.8-2.0
very sensitive to coumadin dosing
14. Amlodipine 2.5 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. ketotifen fumarate *NF* 0.025 % bid
2 gtts
17. Leuprolide Acetate 7.5 mg IM MONTHLY
18. Sertraline 100 mg PO DAILY
## DISCHARGE DIAGNOSIS:
Critical symptomatic aortic
stenosis, status post coronary artery bypass surgery.
Critical symptomatic aortic
stenosis, status post coronary artery bypass surgery.
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating, with assit of one
Sternal pain managed with oral analgesics
sternal incision: cleam and dry without drainage
## EXTREMITIES:
trace lower extremity edema
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
## FEMALES:
Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18562129", "visit_id": "21924784", "time": "2135-03-19 00:00:00"} |
18068167-DS-8 | 910 | ## HISTORY OF PRESENT ILLNESS:
Ms. is a woman
with
past medical history significant for pulmonary nodules,
bronchiectasis, and recent fundoplication presenting with
hemoptysis.
Patient reported feeling in her normal state of health when she
had onset of coughing with coughing up multiple episodes of
blood
starting day prior to admission. The patient denied any previous
hemoptysis.
Notable, the patient has known pulmonary nodules and
bronchiectasis which have been monitored in the past but have
not
progressed. She has been followed at since
for these. Last month, she presented to Thoracic Surgery
for a second opinion on management, which recommendation to
continue CT screening.
This admission, the patient initially presented to
, where she continued to have mild hemoptysis. She
underwent CT scan, which per ED note showed:
"Patient's CT shows nonopacification of the right middle lobe
and
lingular pulmonary arteries about focal thrombus suggesting
shunting rather than embolism as etiology. He should also found
to have chronic bronchiectasis mucus plugging in the right
middle
lobe and lingual suggesting chronic infectious or inflammatory
process such as am II complex.
There are multiple do pulmonary opacities geographic groundglass
opacities in the right upper lobe may be infectious inflammatory
or hemorrhagic. New 1.7 cm left upper lobe nodule with
surrounding groundglass density which indicate superimposed
hemorrhage. Neoplasm is not excluded here in correlation."
The patient was given azithromycin and ceftriaxone, and
transferred to in stable condition for further evaluation.
At time of arrival to the E, the patient denies any chest pain,
vomiting, diarrhea, fevers, chills.
In the ED, initial VS were: 98.6 71 125/75 16 98% RA
## PATIENT RECEIVED:
Acetaminophen 1000 mg
On arrival to the floor, patient reports that she feels quite
well. She is still coughing up very small spots of blood, but
nothing like yesterday's episode. No dyspnea, chest pain.
## REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
## PAST MEDICAL HISTORY:
Hiatal Hernia
Hypothyroidism
Osteopenia
Lung Nodules
Mitral Valve Prolapse
## HEENT:
AT/NC, EOMI, PERRL, no blood in oral cavity
## HEART:
RRR, S1/S2, no murmurs, gallops, or rubs
## LUNGS:
CTAB, no wheezes, rales, rhonchi, breathing comfortably
## ABDOMEN:
nondistended, nontender in all quadrants
## EXTREMITIES:
no cyanosis, clubbing, or edema
## NEURO:
A&Ox3, moving all 4 extremities with purpose
## SKIN:
warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
## HEENT:
AT/NC, EOMI, PERRL, no blood in oral cavity
## HEART:
RRR, S1/S2, no murmurs, gallops, or rubs
## LUNGS:
CTAB, no wheezes, rales, rhonchi, breathing comfortably
## ABDOMEN:
nondistended, nontender in all quadrants
## EXTREMITIES:
no cyanosis, clubbing, or edema
## NEURO:
A&Ox3, moving all 4 extremities with purpose
## SKIN:
warm and well perfused, no excoriations or lesions, no
rashes
## IMPRESSION:
No overt effusions or new consolidation. Known left pulmonary
mass,
right-sided granuloma, and right apical lung mass are best
visualized on prior
CT chest.
BRONCHOSCOPY
The vocal cords were normal appearing. Lidocaine was
administered
at the level of the vocal cords. The bronchoscope was advanced
into the trachea which was unremarkable in appearance. Lidocaine
was administered at the level of the carina and then the scope
was passed through to the RUL. Scant bleeding was noted at the
apical segment of the RUL and the bronchoscope was advanced to
this subsegment. A small nodule was noted on the posterior
membrane (see picture). Distal to this there were small amounts
of fresh blood. A BAL was obtained in this area which was
notable
for bright red return. The bronchoscope was then withdrawn to
examine the RML. There was old blood in RML. A BAL was performed
in this segment with initial bloody return which cleared with
subsequent aliquots. Left airways normal
## BRIEF HOSPITAL COURSE:
Ms. is a woman with past medical history
significant for treated TB (latent), pulmonary nodules,
bronchiectasis, and recent fundoplication presenting with
hemoptysis. Problems addressed during this hospitalization are
as follows:
## # HEMOPTYSIS:
Patient presenting with mild-moderate hemoptysis
with stable hemoglobin. Per CT, patient with known chronic
inflammatory changes along with bronchiectasis and a new 1.7 cm
left upper lobe nodule with superimposed hemorrhage. No evidence
of upper airway/nose bleeding or GI bleeding. s/p bronchoscopy
and BAL: small nodule was noted on the posterior membrane less
likely source of hemoptysis. AFB from BAL negative, PJP
negative. Completed azithromycin for 3 day course ( ),
ceftriaxone for 5 day course ( ). Pathology of nodule
pending.
CHRONIC ISSUES
==============
# Depression
Continued FLUoxetine
# Hypothyroidism
Continued Levothyroxine
# Anxiety
Continued LORazepam
## TRANSITIONAL ISSUES:
======================
[ ] f/u pulmonary nodule pathology
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 20 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. LORazepam 0.5 mg PO QPM at night as needed for sleep
## DISCHARGE MEDICATIONS:
1. FLUoxetine 20 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. LORazepam 0.5 mg PO QPM at night as needed for sleep
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure to care for you at .
You came to the hospital because you were coughing up blood. We
evaluated you and looked at your lungs more closely with a
"bronchoscopy" procedure and did not find a clear reason why you
were coughing up blood. We determined that you do not have
tuberculosis. We believe it is safe for you to return home with
outpatient follow-up.
Please continue to take your home medication and follow-up with
your doctors as .
We wish you all the best,
Your care team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18068167", "visit_id": "29465148", "time": "2138-04-21 00:00:00"} |
14984923-DS-3 | 791 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
yo G3P1101 at 37 weeks 1 day by patient reported estimated
due date with vaginal bleeding concerning for
abruption. Her first episode of vaginal bleeding was which
she describes as spotting for which she presented to
and was evaluated. She then reports being at her
son's football game today where she felt her blood dripping down
her leg. She denies abdominal pain or painful contractions,
denies headache or vision changes, denies shortness of breath or
chest pain. She denies cocaine or tobacco use.
## ROS:
Denies fevers/chills or recent illness. Denies HA, vision
changes, RUQ/epigastric pain. Denies chest pain, shortness or
breath, palpitations. Denies abd pain. Denies recent falls or
abd trauma. Denies any unusual foods/undercooked foods, nausea,
vomiting, diarrhea.
## PNC:
- ?? per patient report
** Records of prenatal care unavailable***
## PMH:
- Asthma, mild intermittent (denies hospitalizations,
intubations)
- denies hypertension
## PULM:
CTAB, nl work of breathing
## ABD:
soft, gravid, nontender
EFW 5#by Leopolds
## SSE:
closed cervix, no bleeding, normal discharge
## TAUS:
vertex, Single IUP, EFW 2342g +/- 351g c/w 33w4d GA (FL
6.60cm, 34w0d), MVP 4.2cm, active movement
FHT 125 /mod var/+accels/-decels
## ON DISCHARGE:
pt left Against Medical Advice
## PERTINENT RESULTS:
WBC-12.3 RBC-3.45 Hgb-10.3 Hct-31.0 MCV-90 Plt-234
WBC-12.9 RBC-3.75 Hgb-10.9 Hct-33.9 MCV-90 Plt-276
PTT-23.1 BLOOD PTT-UNABLE TO Glucose-128* UreaN-6 Creat-0.5 Na-134* K-5.2 Cl-105
HCO3-19* AnGap-10
ALT-14 AST-35
Calcium-8.4 Phos-3.4 Mg-1.8 UricAcd-2.8
HBsAg-NEG
HIV Ab-NEG
HCV Ab-NEG
URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG*
URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-5
RenalEp-<1
URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG oxycodn-NEG mthdone-NEG marijua-POS*
OTHER BODY FLUID CT-NEG NG-NEG
SMEAR FOR BACTERIAL VAGINOSIS (Final :
GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS.
1+ (<1 per 1000X FIELD): BUDDING YEAST
YEAST VAGINITIS CULTURE (Final :
YEAST. SPARSE GROWTH
R/O GROUP B BETA STREP (Final :
Negative for Group B beta streptococci.
URINE CULTURE (Final :
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
SKIN AND/OR GENITAL CONTAMINATION
## BRIEF HOSPITAL COURSE:
y/o with hx of IUFD in prior pregnancy admitted at
32w5d with vaginal bleeding. Ms presented to labor and
delivery reporting of (which would make her 37+
weeks) with vaginal bleeding. On speculum exam, no blood was
seen and her cervix appeared closed. Fetal testing was
reassuring. Her records were obtained from and her was
noted to be , which was 32w5d. She received a course of
betamethasone (complete and the NICU was consulted. She
was transferred to the antepartum floor for observation due to
concern for abruption. Formal ultrasound in the
Maternal Fetal Medicine was reassuring with appropriate growth.
There was no sonographic evidence of abruption.
.
Ms continued to report intermittent bleeding and pain.
Repeat speculum exams were again negative for any blood and Ms
declined to wear a pad. She was felt to have made small
cervical change (closed -> 1cm) while she was here, but then
remained unchanged and appeared comfortable. Over the course of
her admission, Ms became increasingly anxious and admitted
to feeling fearful that she would suffer another intrauterine
demise. She was forthcoming about hoping to get delivered. She
was counseled that delivery would only be recommended if she had
a significant amount of bleeding, pain, nonreassuring fetal
testing, or by 36-37 weeks. Continued inpatient surveillance was
strongly recommended given the reported bleeding. Ms opted
to leave Against Medical Advice on . She agreed to present
to the on for testing.
## DISCHARGE MEDICATIONS:
Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma
Fluticasone Propionate 110mcg 2 PUFF IH TID
Prenatal Vitamins 1 TAB PO DAILY
## DISCHARGE DIAGNOSIS:
Concern for placental abruption
## DISCHARGE INSTRUCTIONS:
Dear. Ms. ,
You were admitted to the hospital with vaginal bleeding
concerning for abruption. You have complained of ongoing
intermittent bleeding and cramping but you have decided to leave
the hospital against medical advice.
You received betamethasone for fetal lung maturity and you were
counseled by the NICU team. All of your fetal testing have been
reassuring.
Please follow the instructions below:
- Attend all appointments with your obstetrician and all fetal
scans
- Monitor for the following danger signs:
- headache that is not responsive to medication
- abdominal pain
- increased swelling in your legs
- vision changes
- Worsening, painful or regular contractions
- Vaginal bleeding
- Leakage of water or concern that your water broke
- Nausea/vomiting
- Fever, chills
- Decreased fetal movement
- Other concerns
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14984923", "visit_id": "22090142", "time": "2112-12-02 00:00:00"} |
13087122-RR-88 | 285 | ## INDICATION:
Patient is an female status post fall from standing
with ecchymosis around left orbit. Please evaluate for facial fracture.
## EXAMINATION:
CT of the facial bones.
## FINDINGS:
There are displaced fractures of the anterior and medial walls of
the left maxillary sinus. There is associated high-density fluid within the
left maxillary sinus consistent with associated hemorrhage. There is a
nondisplaced fracture of the inferior wall of the left orbit. There is no
evidence of associated left intraconal or extraconal hematoma. There is
superficial soft tissues swelling surrounding the left orbit. The
intracranial hemorrhage characterized on dedicated head CT is again
visualized. Please refer to dedicated head CT for further characterization
and recommendations. There is an extraconal lateral and inferior right
orbital soft tissue density best seen on images (3:51) and (41B 25). The
differential diagnosis for this soft tissue density includes a venolymphatic
malformation, a sequela of prior trauma, a hemangioma, or possible lymphoma.
Recommend dedicated MRI of the orbits when clinically feasible for further
evaluation. The temporomandibular joints are well aligned. The nasal septum
is midline. The osteomeatal complexes are patent. The bilateral frontal
sinuses, the right maxillary sinus, and the sphenoid sinuses are well aerated.
The visualized portions of the mastoid air cells are well aerated. There is
mild ethmoid mucosal thickening.
## IMPRESSION:
1. Anterior and medial wall fractures of the maxillary sinus with associated
hemorrhage within the maxillary sinus. Non-displaced fracture of the inferior
wall of the left orbit with no associated orbital hematoma.
2. Extraconal right inferolateral soft tissue density that either represents
a venolymphatic malformation, post-traumatic sequela, a hemangioma, or
possible lymphoma. Recommend dedicated MRI of the orbits when clinically
feasible for further evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13087122", "visit_id": "29072003", "time": "2159-04-23 14:14:00"} |
11150876-RR-47 | 253 | ## INDICATION:
year old woman with acute L2-L5 fracture. Assess for pelvic
fracture
## DOSE:
Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.7 s, 28.1 cm; CTDIvol = 24.8 mGy (Body) DLP = 697.4
mGy-cm.
Total DLP (Body) = 697 mGy-cm.
## PELVIS:
The partially visualized small bowel is unremarkable. There is
sigmoid diverticulosis, without evidence of diverticulitis. The urinary
bladder and distal ureters are unremarkable. There is no free fluid in the
pelvis.
## REPRODUCTIVE ORGANS:
The uterus is of normal size and enhancement. There is no
evidence of adnexal abnormality bilaterally.
## LYMPH NODES:
There is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
Extensive atherosclerotic disease is noted. Ectasia of the
infrarenal abdominal aorta is present and the known aneurysm is not imaged on
this exam.
## BONES:
Nondisplaced fractures are seen through the anterior aspects of the
sacral ala bilaterally (2:28). As seen previously, nondisplaced left L5
transverse process fracture is again. Compression fracture of the L5
vertebral body is also unchanged with mild retropulsion and at least 50% loss
of height, as seen previously. Moderate degenerative changes are also seen at
L4-5 and L5-S1 with endplate irregularity, posterior disc bulges and facet
hypertrophy.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Nondisplaced fractures of the anterior aspect of the sacral ala
bilaterally.
2. Re- demonstration of left L5 transverse process fracture and L5 vertebral
body compression fracture with mild retropulsion.
3. Diverticulosis without evidence of diverticulitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11150876", "visit_id": "29278258", "time": "2137-12-07 17:20:00"} |
10860177-RR-55 | 161 | ## EXAMINATION:
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
## INDICATION:
year old woman with right hip pain// right hip pain
## FINDINGS:
Again, positioning is suboptimal due to external rotation. Re-demonstrated is
a transverse, transcervical fracture of the right femoral neck. As before,
the fracture fragments are likely mildly displaced. There is no significant
change in alignment compared to prior. It is difficult to assess whether
there has been interval callus formation due to positioning. There is
moderate medial narrowing of the right hip joint and mild narrowing on the
left. There is no suspicious lytic or sclerotic lesion. Again seen are
extensive vascular calcifications.
## IMPRESSION:
Again, there is suboptimal positioning due to external rotation of the right
hip. Otherwise, no significant change in the mildly displaced right femoral
neck fracture. It is difficult to assess whether there has been interval
bridging callus formation. If there is concern regarding healing, a CT can be
obtained for further evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10860177", "visit_id": "N/A", "time": "2146-01-10 08:56:00"} |
10677866-RR-17 | 96 | ## EXAMINATION:
BILAT LOWER EXT VEINS
## INDICATION:
woman with a history of miscarriage who presents with
stroke, found to have a patent foramen ovale, concern for paroxysmal embolism,
evaluate for deep venous thrombosis.
## FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa ( ) cyst.
## IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10677866", "visit_id": "23193525", "time": "2158-06-02 19:29:00"} |
17792436-RR-11 | 212 | ## EXAMINATION:
CT-guided right lung lesion biopsy
## INDICATION:
year old woman with RUL lung mass concerning for lung cancer
// Biopsy of RUL lung mass. Discussed with team while she was inpatient,
but biopsy could not be performed due to holiday weekend, so opted to get it
done as an outpatient
## PROCEDURE:
CT-guided right upper lobe lung lesion biopsy.
## OPERATORS:
Dr. trainee and Dr.
radiologist. Dr. supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 4.9 s, 14.9 cm; CTDIvol = 3.6 mGy (Body) DLP = 48.7
mGy-cm.
2) Stationary Acquisition 14.5 s, 1.4 cm; CTDIvol = 109.2 mGy (Body) DLP =
157.3 mGy-cm.
Total DLP (Body) = 217 mGy-cm.
## SEDATION:
Moderate sedation was provided by administering divided doses of
1.75 mg Versed and 75 mcg fentanyl throughout the total intra-service time of
40 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
## FINDINGS:
1. 3 x 2.5 cm right upper lobe mass identified
2. 5 18 gauge core biopsies were obtained and sent to pathology
## IMPRESSION:
Successful CT guided biopsy of a right upper lobe lung lesion
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17792436", "visit_id": "N/A", "time": "2171-02-06 13:12:00"} |
16388704-DS-20 | 1,815 | ## ALLERGIES:
Asacol / Pentasa / Imuran / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Bactrim / Compazine / Tagamet / Vancomycin /
Remicade / Tetracycline / Salsalate / Ciprofloxacin Hcl / Flagyl
/ Clindamycin / Keflex
## HISTORY OF PRESENT ILLNESS:
w/ Crohn's disease s/p multiple bowel surgeries and
otherwise complex PMH including anxiety who presents with one
day of right arm pain. RN came into home on to
change dressing, which was larger than previous dressings. Later
in day on noted RUE swelling and throbbing pain.
AM called company, surgery clinic, and GI clinic
and was advised to go to ED but she declined but eventually was
brought in by a friend as pain became unbearable. She reports no
difficulty with PICC prior to and otherwise has no new
complaints. She feels TPN is "her only chance to get her life
back" and is very upset about the possibility of not
re-initiating TPN.
Of note, the patient was admitted for three weeks in
with increased ostomy output, malnutrition, and
improved with IVF. She was found to have campylobacter stool
infection and treated with 7 day course of IV azithromycin. She
also completed this course for a pneumonia seen on CXR after
hydration. She was started on tincture of opium per Dr.
titrated up until stool output decreased. She was found to have
a non-occlusive DVT in the R arm associated with PICC site on
. Given her high ostomy output, she was made NPO and a
double lumen PICC line was placed by on in the R arm for
TPN, which was initiated. She was also clinically hyperthyroid,
likely from oversupplementation, during that admission.
In the ED, initial VS: 97.2 77 132/73 16 100% RA. GI was
consulted and recommended medicine admission, they will follow.
Exam notable for intact radial pulse on the right. RUE
showed dampened waveform in the R subclavian suggestive of more
central thrombus but prior to subclavian/IJ confluence and also
showed sluggish flow in distal RUE veins but no definitive DVT.
PICC line was pulled and she refused PIV access attempt or stick
for lab draw, requesting replacement of PICC first. UA notable
for large leuks, 35 WBC, few bacteria, 1 epi. She was given
oxycodone 10mg x2, tincture of opium 0.6mg, and hydroxyzine 25mg
x1. VS at transfer: 98.2 75 136/71 16.
On arrival to the medical floor, she is nauseaous and anxious
and requesting zofran and xanax.
## REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
## PAST MEDICAL HISTORY:
1. Crohns disease
2. Thyroid cancer, now hypothyroid
3. Secondary hyperparathyroidism per records
4. Fatty liver disease with likely cirrhosis
5. Possible vertebral compression fracture
6. Diabetes
7. Inflammatory joint disease related to the Remicade infusions
and resultant lupus
8. History of
- Pulmonary nodule
- Pancreatitis
- DVT
- Cystoscopy and urethral dilation
- RSD
- Vitamin D deficiency.
- Iritis
Surgical history
1. Cholecystectomy ( )
2. Mammoplasty ( )
3. Splenectomy ( )
4. Left ovarian cystectomy ( )
5. TAHBSO, incisional hernia repair ( )
6. Multiple abdominal surgeries including
- terminal ileum & cecal revision ( )
- ileocolectomy ( )
- resection of distal terminal ileum, partial colectomy
( )
- excision of anal ulcer and lateral internal sphincterotomy
( )
## FAMILY HISTORY:
Mother - Cancer
Father - Heart Problems, Kidney failure, strokes
No family history of Crohn's disease.
## PHYSICAL EXAM:
VS - Temp 98.6F, BP 122/66, HR 61, R 18, O2-sat 98% RA
GENERAL - Alert, interactive, anxious female in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP non-elevated, no carotid
bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, ostomy bag in
place
EXTREMITIES - WWP, trace RUE edema, 1+ peripheral pulses, incl.
R radial, drsg over former site c/d/i
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, moving all extremities, strength in
hands b/l
## PSYCH:
tangential thinking and somewhat pressured speech at
times
## PERTINENT RESULTS:
12:06AM URINE COLOR-Yellow APPEAR-Clear SP
12:06AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
12:06AM URINE RBC-2 WBC-35* BACTERIA-FEW YEAST-NONE
EPI-1 RENAL EPI-<1
12:06AM URINE GRANULAR-1*
12:06AM URINE WBCCLUMP-RARE
Radiology W/O PORT Study Date of 1:20
## IMPRESSION:
Uncomplicated ultrasound and fluoroscopically guided
double lumen PICC line placement via the left basilic venous
approach. Final internal length is 45 cm, with the tip
positioned in SVC. The line is ready to use.
## BRIEF HOSPITAL COURSE:
HOSPITAL COURSE
with extensive PMH including Crohn's and recent PICC
placement for TPN who presents with RUE pain and swelling found
to have evidence of RUE DVT on ultrasound.
ACTIVE ISSUES
# DVT: Patient presented with symptoms consistent with RUE DVT
in the setting of right sided PICC line. Ultrasound did not
visualize a clot however there was evidence that was consistent
for clot. PICC line was removed. Given her history of prior DVT
in that arm (diagnosed in and was untreated, she was
started lovenox for anticoagulation. She will need at least 3
months of anticoagulation. Initially patient was very hesitant
to start therapy because she did not want to inject into her
abdomen, which is the only authorized location of delivery
according to drug insert. After long discussion she ultimately
decided on treatment.
## # CROHN'S DISEASE:
Patient with history of severe disease
resulting severe diarrhea. She requires TPN for nutrition. Right
PICC line was removed given DVT and patient had left sided PICC
placed. She uses opium tincture for control of diarrhea.
## # POSITIVE UA:
Patient had positive UA on arrival to ED however
was completely asymptomatic. She was asked to provide another
urine sample however refused.
## # ANXIETY:
Patient was anxious throughout her stay about her
TPN. At times this impeded on the ability to properly care for
her.
## INACTIVE ISSUES
- HYPOTHYROIDISM:
continued 2x/week IM levothyroxine. Outpatient
endocrinologist was contacted about dose given TSH however did
not want to change her dose.
- NAFLD: continued ursodiol
- Inflammatory arthritis: Continued hydroxychloroquine
- Diabetes: continued glargine and sliding scale
## - PENDING:
none
- Code Status: full code
## MEDICATIONS ON ADMISSION:
ALPRAZOLAM - 0.5 mg Tablet - Tablet(s) by mouth at bedtime
and prn
BENZONATATE - 100 mg Capsule - 1 Capsule(s) by mouth three times
a day as needed
CALCITRIOL - (Prescribed by Other Provider) (Not Taking as
## PRESCRIBED:
taking 0.5mcg--2/day) ) - 0.25 mcg Capsule - 2
Capsule(s) by mouth twice a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - 1ml
subcutaneous every month Use a 1 ml vial
EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector -
one injection IM for anaphylaxis one time as needed
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - 50,000 unit Capsule -
one Capsule(s) by mouth once weekly on
ESTRADIOL [VIVELLE-DOT] - 0.05 mg/24 hour Patch Semiweekly - one
application twice weekly on tues and fri
FLUOROMETHOLONE - (Prescribed by Other Provider) - 0.1 % Drops,
Suspension - 1 drop in each eye every tues
HYDROXYCHLOROQUINE - (Prescribed by Other Provider) - 200 mg
Tablet - 1 (One) Tablet(s) by mouth once daily
HYDROXYZINE PAMOATE - 25 mg Capsule - 1 Capsule(s) by mouth four
times a day With oxycodone if still pain.
INSULIN GLARGINE [LANTUS] - 10 units at bedtime
INSULIN LISPRO [HUMALOG KWIKPEN] - 100 unit/mL Insulin Pen -
dosing per endo
LANSOPRAZOLE [PREVACID SOLUTAB] - 30 mg Tablet,Rapid Dissolve,
- 1 Tablet(s) by mouth twice a day
LEVOTHYROXINE - (Prescribed by Other Provider) (On Hold from
to unknown for thyrotoxic) - 150 mcg Tablet - 2
Tablet(s) by mouth qd, 30 min prior to breakfast, 2X/WK (SA,
LEVOTHYROXINE - (Prescribed by Other Provider) - 200 mcg Recon
Soln - 150mcg IM twice a and
LEVOTHYROXINE [LEVOTHROID] - (Prescribed by Other Provider) (On
Hold from to unknown for thyrotoxic) - 150 mcg Tablet
- 4 Tablet(s) by mouth qd, 30 min prior to bed,5x/wk
( )
ONDANSETRON HCL - 8 mg Tablet - Tablet(s) by mouth three
times a day as needed - No Substitution
OPIUM TINCTURE - 10 mg/mL Tincture - 0.4-0.6 mg by mouth at
bedtime
OXYCODONE - 5 mg Tablet - 1- Tablet(s) by mouth four times
a day as needed
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
URSODIOL - 250 mg Tablet - 2 Tablet(s) by mouth twice a day
LOPERAMIDE - (Not Taking as Prescribed: not using now) - 1 mg/5
mL Liquid - mg by mouth tid - qid
## DISCHARGE MEDICATIONS:
1. alprazolam 0.5 mg Tablet Sig: Tablets qhs and as
needed for insomnia.
2. benzonatate 100 mg Capsule Sig: One (1) Capsule TID (3
times a day) as needed for cough.
3. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule twice a
day.
4. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) cc Injection once a month.
5. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule once a week.
6. fluorometholone 0.1 % Drops, Suspension Sig: One (1) drop
Ophthalmic once a week.
7. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet once
a day.
8. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet four
times a day as needed for prior to oxycodone dose.
9. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
10. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous per endo.
11. lansoprazole 30 mg Tablet,Rapid Dissolve, Sig: One (1)
Tablet,Rapid Dissolve, (2 times a day).
12. levothyroxine 100 mcg Recon Soln Sig: One Hundred Fifty
(150) mg Intravenous 2X/WEEK ( ).
13. ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet Q8H
(every 8 hours) as needed for nausea.
14. opium tincture 10 mg/mL Tincture Sig: 0.5-1.0 mL every
six (6) hours as needed for loose stools.
Disp:*116 mL* Refills:*0*
15. ursodiol 250 mg Tablet Sig: Two (2) Tablet BID (2 times a
day).
16. trazodone 50 mg Tablet Sig: One (1) Tablet HS (at
bedtime).
17. oxycodone 5 mg Tablet Sig: 1.5 Tablets QID (4 times a
day) as needed for pain.
18. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
Disp:*60 syringe* Refills:*2*
## DISCHARGE DIAGNOSIS:
Deep Venous Thrombosis of Right Upper Extremity
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital because you had right arm
pain. An ultrasound detected evidence of a deep vein clot in
that arm. It is probably related to your PICC line. Your PICC
line was subsequently removed and another one placed on the left
side. You were started on lovenox.
The following changes were made to your medications:
-- START Lovenox 60mg subcutaneously twice a day
No other changes were made to your medications. Please be sure
to take them as directed.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16388704", "visit_id": "20500676", "time": "2179-04-28 00:00:00"} |
10784877-DS-18 | 1,306 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Nausea, vomiting, abdominal pain
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
EGD and Colonoscopy with biopsy of esophagus and colon
## HISTORY OF PRESENT ILLNESS:
Patient is a woman with stage 4 lung cancer with metastases
to the brain, history of SBO requiring ex lap with LOA in
who presents with nausea, vomiting, and abdominal pain similar
to prior presentation of SBO. Her pain started around midnight,
waking her up. The pain was in the LLQ, described as dull
background with sharp pains, no known aggravating factors. She
has been feeling nauseous, vomited once this morning, nonbloody,
nonbilious. Her last bowel movement was morning, normal,
no brbpr, no melena. No history of constipation, diarrhea. No
fevers, chills, nightsweats.
Patient first presented to . CT there showed mild
R-sided hydronephrosis and hydroureter without clear evidence of
an obstructing renal stone; thickening of the descending and
rectosigmoid colon walls; and possible sbo.
In the ED, initial VS were: 98.5 72 129/80 18 98% RA. Labs were
notable for K 3.0. Re-read of CT here: "1. Mural thickening of
descending and sigmoid colon suggesting colitis; could reflect
infectious, inflammatory or ischemic etiologies. 2. No small
bowel obstruction." Surgery was consulted, will follow. The
patient received cipro, flagyl. Vitals prior to transfer to the
floor were: 98.3 79 105/66 12 97%.
## REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies cough, shortness of breath. No
dysuria, urinary frequency. Denies arthralgias or myalgias.
Denies rashes. All other review of systems negative.
## PAST MEDICAL HISTORY:
1. Stage IV (T4 N3 M1b) non-small-cell adenocarcinoma of the
lung with brain metastases, status post nine cycles of therapy.
2. Cervical cancer at age , status post total abdominal
hysterectomy and unilateral salpingo-oophorectomy, followed by
pelvic radiation therapy at in
, stable.
3. Persistent radiation enteritis following treatment,
characterized by four-to-five bowel movements per day, managed
with a low-fiber diet and Imodium.
4. Status post salpingo oophorectomy of her other ovary at the
age of due to a large ovarian cyst, stable.
5. History of right knee lateral meniscus repair at
.
6. Attention deficit hyperactive disorder, stable.
## FAMILY HISTORY:
- Father with diabetes, coronary artery bypass, percutaneous
interventions, heart disease clinically evident by or
- Mother with breast cancer, dying at
## HEENT:
PERRL, EOMI, MMM, sclera anicteric, not injected
## NECK:
no LAD, no JVD
## CARDIOVASCULAR:
RRR normal s1, s2, no murmurs appreciated
## RESPIRATORY:
decreased breath sounds at bases, no wheezes, rales
or rhonchi
## ABD:
normoactive bowel sounds, diffuse mild guarding, diffuse
tenderness, no rebound, non distended
## EXTREMITIES:
No edema, 2+ DP pulses
## NEUROLOGICAL:
CN II-XII intact, normal attention, sensation
normal, MS in BUEs and BLEs, intention tremor with finger to
nose on R only, heel to shin intact
## INTEGUMENT:
Warm, moist, no rash or ulceration
## PSYCHIATRIC:
appropriate, pleasant, not anxious
## BLOOD CULTURE:
No growth to date.
## EKG:
Sinus rhythm. Borderline low QRS voltage. Biphasic T wave
in lead V2.
Findings are non-specific. Clinical correlation is suggested.
Since the
previous tracing of there may be no significant change
but baseline artifact in the right precordial leads on
previously tracing makes comparison difficult.
.
GI biopsy of esophagus and colon: Pending.
.
## EGD:
Question of linear furrowing and feline esophagus, very
mild/subtle, possibly suggestive of eosinophilic esophagitis.
## COLONOSCOPY:
There was a tight twist in the sigmoid colon that
could not be traversed with the colonoscope, but could be
traversed easily with the gastroscope. The mucosa there appeared
normal, there was no obvious stricture or lesion. Polyp in the
transverse colon. Grade 1 internal hemorrhoids.
## BRIEF HOSPITAL COURSE:
yo F with metastatic lung CA, SBO in admitted with
nausea, vomiting and abdominal pain.
The patient presented from an OSH with the above complaints. CT
read at that facility raised concern for a possible colitis and
mild right sided hydronephrosis. Both of these findings were not
seen on local radiologist review at - the possible colitis
was felt to be more likely underdistention of the bowel and the
bilateral kidneys appeared normal. The patient had no fevers or
leukocytosis. She was transiently on IV Cipro/Flagyl but these
were discontinued. An infectious work-up was negative including
stool C Diff testing and blood cultures. Both the surgery and GI
consult teams followed the patient. She underwent endoscopy and
colonoscopy with no concerning findings. She did have very mild
changes in the esophagus that could be consistent with
eosinophilic esophagitis - biopsies were taken and she continues
on a PPI until those results come back. Colonoscopy revealed a
tight turn in the sigmoid colon though this could be traversed
with the gastroscope and per surgery and GI was not consistent
with a partial obstruction or other pathology finding. Biopsy of
this area was taken and is pending. With bowel rest, IV fluids
and pain control, the patient had moderate improvement in her
symptoms. She continues to have some left lower quadrant
tenderness and pain but this is well controlled on oral
oxycodone and she is able to tolerate a full liquid diet though
still with a poor appetite. Part of the pain seemed to be gas
pain as she had relief with passing gas. The patient will
continue on a full liquid diet with caloric supplement drinks.
She had moderate malnutrition and was transiently on TPN but her
oral intake improved such that this was discontinued. She was
seen by the nutrition consult regarding caloric supplementation.
The patient has a leukopenia. She should have a repeat CBC in 5
days after discharge at her primary care doctor's office.
She will follow-up with her oncologist for ongoing management of
metastatic lung cancer.
## MEDICATIONS ON ADMISSION:
Folic acid 1 mg daily
Gabapentin 100 mg tid
Levetiracetam 1000 mg bid
Ativan 0.5 mg q6 hrs prn
Concerta 36 mg daily
Zofran, compazine
Temazepam 30 mg qhs
Colace, Senna
## DISCHARGE MEDICATIONS:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
5. Concerta 36 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. oxycodone 5 mg Tablet Sig: Tablets PO Q4H (every 4 hours)
as needed for Pain for 15 doses.
Disp:*15 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Abdominal pain
Stage IV lung cancer to the brain
H/o cervical cancer age
Malnutrition - Severe
H/o persistent radiation enteritis with frequent bowel
movements, managed with immodium and fiber
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with abdominal pain. The
work-up was reassuring - there were no signs of infection,
inflammation, obstruction or other concerning finding to explain
your symptoms. Continue to take a full liquid diet with caloric
supplement drinks and follow-up with your oncologist and primary
care doctor for further care.
Please have your blood drawn in 5 days at your primary care
doctor's office to monitor your blood counts.
Follow-up with your primary care doctor within 1 week. At that
time, have your primary care doctor assist you in following up
the results of your esophagus and colon biopsy. If your
esophagus biopsy is normal you can stop taking pantoprazole.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10784877", "visit_id": "23562045", "time": "2169-04-04 00:00:00"} |
19213219-DS-11 | 1,401 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Ms. is a y/o female with a hx of diastolic
congestive heart failure (EF 55%), atrial fibrillation/flutter,
HTN and DM2 who was sent in from her colonscopy when she was
noted to be hypoxic ( ) and tachycardic. She states that she
did not feel short of breath and did not feel uncomfortable. She
notes that she has been taking in a lot of salt including
chicken broth recently due to her only being able to take in
liquids. She denies any fevers, chills, nausea or vomiting. She
has been compliant with her medications however she did not take
her meds this morning due to the procedure. She has chronic
orthopnea but denies any recent changes. She states that she has
home O2 but notes that she rarely uses it (only when she feels
SOB). Her dry weight is around 210 lbs and her ECHO in
showed grade I diastolic dysfunction with a preserved EF of 55%.
.
In the ED, initial vs were: T 97.6 P 96 BP 146/73 O2 sat 100 4L.
Patient was given 10mg IV lasix and 25mg of metoprolol.
.
On the floor, she states that she is doing well. She denies any
chest pain, shortness of breath or discomfort. She states that
she feels well and never felt short of breath.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
## PAST MEDICAL HISTORY:
Hypertension
H/o arrythmia
Diabetes diagnosed in
Degenerative joint disease (left knee, large popliteal cyst)
Tinnitus
## FAMILY HISTORY:
Mom - died of MI in y.o., dad - died from brain cancer in
.
## GENERAL:
Alert, oriented, no acute distress
## NECK:
supple, JVP elevated to the angle of the jaw, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
ronchi
## CV:
Irregular, no murmurs, rubs, gallops
## ABDOMEN:
soft, non-tender, slighlty distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
## EXT:
trace edema, warm, well perfused, 2+ pulses, no clubbing,
cyanosis
## NEURO:
CNs2-12 intact, motor function grossly normal
## FINDINGS:
Moderate-to-severe cardiomegaly appears unchanged. No
focal
opacity to suggest pneumonia is seen. No pleural effusion,
pneumothorax or
overt pulmonary edema is seen.
.
## BRIEF HOSPITAL COURSE:
Ms. is a y/o female with a hx of diastolic
congestive heart failure (EF 55%), atrial fibrillation/flutter,
HTN and DM2 who was sent in from her colonscopy when she was
noted to be hypoxic ( ) and tachycardic.
# Acute on Chronic Diastolic Heart Failure: She has a history of
grade 1 diastolic heart failure with multiple exacerbations in
the past. It appears that she has not been compliant with her
strict salt diet. There is also question of her consistency in
taking her lasix. She states that her dry weight is around 210
lbs but was 9 lbs over weight on admission. She has chronic
orthopnea but denies any worsening PND. She was also noted to be
tachycardic (possible atrial fibrillation) which may have
precipitated by her heart failure exacerbation. Ruled out for MI
with negative cardiac enzymes and no ischemic EKG changes. No
evidence of infection. Patient was diuresed over three days with
IV lasix (between 40 and 60 mg) with reduction down to her dry
weight of 210 lbs on discharge. She was transitioned to oral
lasix, and her oral dose was increased to 40 mg BID prior to
discharge. She was continued on her home dose of lisinopril and
metoprolol tartrate. She was counseled by nutrition on a healthy
low sodium heart healthy diet and fluid restriction to 1.5 L
daily. She has scheduled follow-up appointment with her PCP;
Cardiology f/u was recommended on discharge.
## # HYPOXIA:
Patient continued to be hypoxic through her
admission, likely in the setting of her CHF. Baseline O2 sats
were 94% on RA. Patient was 85% on room air prior to discharge,
satting 95% on 2 L NC. She already was set up with home oxygen
at home and was counseled to wear her oxygen nasal cannula
prongs continuously until follow-up with her PCP.
## # HYPERTENSION:
Well controlled on current home regimen of
lisinopril and metoprolol
## # ATRIAL FIBRILLATION:
She was noted to be tachycardic and
potentially in atrial fibrillation with rapid ventricular rate
or atrial flutter during her colonoscopy. It is likely her heart
failure exacerbated her atrial fibrillation. She is currently
anticoagulated on coumadin with a CHADS2 score of 3 (CHF, HTN,
DM2). She was monitored on telemetry and diuresed, and her
heart rate was stable in the on discharge. She was kept on
her home dose of coumadin, and metoprolol.
## # DM2:
Her last A1c in out system was in which was 6.9. Per
her outside records last A1c in was 6.7. Continued on her
insulin sliding scale with a long acting insulin (Glargine 10 U
QHS). Glyburide held during hospitalization but restarted on
discharge.
## MEDICATIONS ON ADMISSION:
Bupropion HCl 150 mg Tablet Sustained Release
1 (One) Tablet(s) by mouth twice a day
Ergocalciferol (vitamin D2) [Drisdol] 50,000 unit Capsule
1 (One) Capsule(s) by mouth once a week
Furosemide 20 mg Tablet
2 (Two) Tablet(s) by mouth once a day (Prescribed by Other
Provider)
Glyburide 5 mg Tablet
1 Tablet(s) by mouth daily
Glargine [Lantus Solostar] 100 unit/mL (3 mL) Insulin Pen
10u as directed hs
Ipratropium bromide [Atrovent HFA]
Lansoprazole 30 mg Capsule, Delayed Release(E.C.)
1 (One) Capsule(s) by mouth twice a day (Prescribed by Other
Lisinopril 2.5 mg Tablet
1 (One) Tablet(s) by mouth once a day (Prescribed by Other
Provider)
Metoprolol tartrate 25 mg Tablet
1 (One) Tablet(s) by mouth twice a day (Prescribed by Other
Provider)
nr Potassium chloride 20 mEq/15 mL Liquid
20meq by mouth once a day (Prescribed by Other Provider)
Pravastatin 80 mg Tablet
1 (One) Tablet(s) by mouth once a day (Prescribed by Other
Provider)
Tiotropium bromide [Spiriva with HandiHaler] 18 mcg Capsule,
w/Inhalation Device 18 mcg inhal daily
Verapamil 240 mg Cap,24 hr Sust Release Pellets
1 Cap(s) by mouth daily (Prescribed by Other Provider)
Warfarin 2.5 mg Tablet 3 (Three) Tablet(s) by mouth once a day
as directed (Prescribed by Other Provider)
## DISCHARGE MEDICATIONS:
1. lisinopril 5 mg Tablet Sig: 0.5 Tablet DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet BID
(2 times a day).
3. pravastatin 20 mg Tablet Sig: Four (4) Tablet DAILY
(Daily).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. verapamil 120 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release Q24H (every 24 hours).
6. warfarin 2.5 mg Tablet Sig: Three (3) Tablet Once Daily at
4 .
7. lansoprazole 30 mg Tablet,Rapid Dissolve, Sig: One (1)
Tablet,Rapid Dissolve, a day.
8. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release BID (2 times a day).
9. furosemide 40 mg Tablet Sig: One (1) Tablet BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Lantus 100 unit/mL Cartridge Sig: Ten (10) U Subcutaneous at
bedtime.
11. insulin regular human 100 unit/mL (3 mL) Insulin Pen Sig:
One (1) as directed Subcutaneous four times a day: per sliding
scale.
12. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule once a week.
13. glyburide 5 mg Tablet Sig: One (1) Tablet once a day.
14. potassium chloride 20 mEq Packet Sig: One (1) once a
day.
## DISCHARGE DIAGNOSIS:
Primary Diagnosis
Acute on Chronic Diastolic Heart Failure
## DISCHARGE INSTRUCTIONS:
You were admitted because you were noted to have low oxygen
saturations and an elevated heart rate after your colonoscopy.
This was most likely due to the increased salt you were eating
resulting in some fluid to build up in your lungs. You received
IV lasix which you responded well to. You were discharged on an
increased dose of lasix. Your oxygen levels remained low, so you
were also dishcarged on home oxygen therapy.
## MEDICATIONS CHANGED DURING YOUR ADMISSION:
Lasix was INCREASED from 40 mg once daily to 40 mg twice a day
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19213219", "visit_id": "27148845", "time": "2168-05-26 00:00:00"} |
19111671-RR-66 | 487 | ## INDICATION:
year old woman with known colon adeno, recent increase in
bowel wall thickening, stranding and progressive lymphadenopathy with
worsening abdominal pain and distention. // r/o obstruction
## 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.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 25.4 s, 0.2 cm; CTDIvol = 433.2 mGy (Body) DLP =
86.6 mGy-cm.
3) Spiral Acquisition 5.0 s, 55.6 cm; CTDIvol = 11.4 mGy (Body) DLP = 624.1
mGy-cm.
Total DLP (Body) = 713 mGy-cm.
## LOWER CHEST:
Lower lung bases, pleural spaces and lower mediastinal structures
are grossly normal.
## HEPATOBILIARY:
The liver demonstrates normal signal intensity with no focal
liver lesions. There remains mild central intrahepatic ductal prominence,
with the common bile duct measuring up to 13 mm, unchanged from the prior
study. The gallbladder has been removed. The hepatic vasculature is patent.
## PANCREAS:
The pancreas demonstrates homogeneous signal intensity with no main
duct dilatation or focal mass per
## SPLEEN:
The spleen is normal in size and appearance
## ADRENALS:
Both adrenal glands are normal in size and appearance
## URINARY:
No dilatation of the renal collecting system. No perinephric
abnormalities.
## GASTROINTESTINAL:
The patient is status post Roux-en-Y gastric bypass. Again
noted are mildly prominent loops of small bowel leading up to the JJ
anastomosis, however these loops of bowel demonstrate no wall thickening or
pneumatosis. No extraluminal contrast is identified.
Minimally improved in appearance is the previously noted inflammatory changes
within the ileocolic mesentery, characterized by wall thickening involving the
cecum and ascending colon. The degree of bowel wall thickening involving the
distal and terminal ileum has improved. There remains inflammatory fat
stranding within the ileocolic mesentery, with increased thickening of the
right lateral Conal fascia. Multiple small lymph nodes are again noted,
unchanged. These inflammatory changes continued to extend superiorly towards
the root of the mesentery. Multiple enlarged retroperitoneal lymph nodes,
largest measuring up to 1.5 cm (series 5, image 38) is unchanged.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. Small volume
of free fluid is seen within the pelvis, unchanged
## VASCULAR:
There is no abdominal aortic aneurysm.
## 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. Previously-seen bowel wall thickening has minimally improved from the
comparison study, however the degree of inflammatory changes within the right
lower quadrant has minimally progressed. Differential considerations remain
that of infectious/inflammatory etiology.
2. Mildly prominent loops of small bowel approaching the JJ anastomosis is
re- demonstrated, however there is no bowel wall thickening or pneumatosis.
3. Trace pelvic free fluid.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19111671", "visit_id": "20720007", "time": "2131-01-13 19:06:00"} |
12136446-RR-88 | 202 | ## HISTORY:
Patient with altered mental status, pre-MRI assessment to exclude a
pacemaker or metallic foreign body within the orbits/soft tissues.
## FINDINGS:
The AP and lateral radiographs of the skull do not show any lytic or sclerotic
lesions. The bones are osteopenic.
The AP radiograph of the cervical spine demonstrates multilevel degenerative
changes and osteophytes. The bones are osteopenic. No worrisome lytic or
sclerotic lesion is identified.
AP radiograph of the chest demonstrates calcification of the aortic arch.
There is mild prominence of the right paratracheal stripe which may be
projectional. The lungs otherwise appear clear. Deformity of the left
proximal humerus is most consistent with prior healed fracture. There are no
lytic or sclerotic bony lesions.
The radiograph of the abdomen demonstrates multilevel degenerative changes
throughout the lumbar spine. There is extensive atherosclerosis present in
the abdominal vasculature. The bowel gas patterns are unremarkable. There is
cortical irregularity of the right superior pubic ramus which may be related
to old trauma
## IMPRESSION:
1. No metallic foreign body within the soft tissues and no evidence of a
pacemaker.
2. No lytic or sclerotic bony lesions.
3. Old healed fracture through the proximal left humerus and right inferior
pubic ramus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12136446", "visit_id": "22203020", "time": "2146-01-06 15:59:00"} |
12618932-RR-67 | 169 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
s/p fall with posterior head trauma. Had prior fall in
with subdural hematoma that has resolved on CT scan from .
## FINDINGS:
There is no acute intracranial hemorrhage, edema, mass effect, or loss of
gray/ white matter differentiation. Previously noted left subdural hematoma
has resolved. Ventricles and sulci are normal in size for age. Mild
periventricular white matter hypodensity is nonspecific could be either
age-related or related to mild chronic small vessel ischemic disease.
There is a subgaleal hematoma at the right parietal vertex with an overlying
skin laceration, status post staple repair. There is minimal left frontal
scalp soft tissue thickening, unchanged and likely related to scarring from a
prior injury. No fracture is seen. Visualized paranasal sinuses and mastoid
air cells are well aerated.
## IMPRESSION:
1. No evidence of acute intracranial abnormalities.
2. Resolution of prior left frontal subdural hematoma.
3. Right parietal subgaleal hematoma with overlying laceration, status post
staple repair. No evidence for a fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12618932", "visit_id": "N/A", "time": "2132-01-05 08:14:00"} |
19310445-RR-29 | 483 | ## INDICATION:
New asymptomatic hematocrit drop to 22. Generalized weakness.
Evaluate for retroperitoneal bleed.
## LUNG BASES:
There is a moderate-sized right nonhemorrhagic pleural effusion.
There is a small nonhemorrhagic left pleural effusion. There is associated
bibasilar atelectasis. There is no focal consolidation, nodule, or
pneumothorax. The base of the heart is mildly enlarged. Atherosclerotic
calcifications are noted along the aortic valve and coronary arteries.
Multiple stents are also present within the coronary arteries. There is no
pericardial effusion.
## ABDOMEN:
The liver is normal in shape and contour. There are no focal
hepatic lesions. There is no intra- or extra-hepatic biliary duct dilation.
The gallbladder is not distended, and normal in appearance. The portal vein
is patent. The spleen is normal in size. There are no focal splenic lesions.
The pancreas is unremarkable. The left adrenal gland is minimally thickened
without a discrete nodule. The right adrenal gland is normal. Within the
left kidney, there is a 16 mm hypodense lesion. No other focal renal lesions
are identified. There is no evidence of hydronephrosis, pyelonephritis, or
perinephric stranding.
The stomach is collapsed. There is a curvilinear density which appears to be
within the first portion of the duodenum (2, 26). This may be a partially
digested pill. The remainder of the small bowel is unremarkable without focal
inflammatory changes. There is no evidence of obstruction. There is no free
air or free fluid.
The abdominal vasculature is normal in course and caliber without evidence of
aneurysm or dissection. Severe atherosclerotic calcifications are noted along
its course. There is no mesenteric, retroperitoneal, or abdominal
lymphadenopathy.
## PELVIS:
The colon is normal in course and caliber. There is diverticulosis,
without definite evidence of diverticulitis. This is most severe in the
sigmoid colon, where there is some mild wall thickening which is likely
chronic. There is no surrounding stranding. No discrete colonic mass is
identified. There are no surrounding inflammatory changes. A metallic object
in the cecum is likely a pill (2, 44). Small lymph nodes around the right
colon do not meet criteria for pathologic enlargement. The appendix appears
normal. The bladder is moderately distended and within normal limits. The
uterus is unremarkable. There are no adnexal masses. There is no pelvic or
inguinal lymphadenopathy.
## OSSEOUS STRUCTURES:
There is a levoscoliosis of the thoracic spine with
severe degenerative changes. There is anterolisthesis of L4 on 5. There is
some asymmetric vertebral body height loss, but no evidence of an acute
fracture. There is diffuse osteopenia. There are no concerning lytic or
sclerotic lesions. Calcifications within the soft tissues of the left
buttocks are of uncertain etiology, but likely from an old injury or injection
granulomas. There is no associated soft tissue mass.
## IMPRESSION:
1. No evidence of a retroperitoneal hematoma.
2. Moderate right and small left non-hemorrhagic pleural effusions.
3. Diverticulosis without evidence of diverticulitis.
4. Severe degenerative changes of the thoracic spine.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19310445", "visit_id": "29957152", "time": "2184-09-29 00:06:00"} |
13404476-DS-13 | 1,049 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CC:
pt called EMS saying she was out of methadone and ultram;
c/o not being able to control her body
## HISTORY OF PRESENT ILLNESS:
HPI (obtained from ED records and OMR; pt unable to cooperate):
Ms. is a yo F with PMH of depression/bipolar DO and
narcotic abuse, on methadone, who presented to the ED last night
asking for help. Per ED staff, she ran out of her methadone ~2
days ago.
.
In the ED, VS were HR 150's initially, BP 140/70, T 98.7, RR 24.
Pupils are 2 mm; she had minimal diaphoresis; she was extremely
agitated in the ED. Urine tox is positive for methadone, but the
ED staff have also considered w/d, tylenol tox,
serotonin withdrawal and other substances as possible substances
of withdrawal/intoxication. In the ED, she received multiple
doses of valium 9approaching 100 mg IV). Of note, she has had
prior admissions for self-tapering of narcotics, at which point
she has had consults with social work and the addiction team,
refusing rehab placement.
## PAST MEDICAL HISTORY:
Narcotic abuse
Depression
Bipolar d/o
.
Past Surgical History (per discharge summary): - B/L mammoplasty s/p revision
## FAMILY HISTORY:
GF CAD in , s/p CABG in , with diabetes
## PE:
V/S 98.3 82 130/74 17 100% RA
GEN - alert, alternatingly agitated and calm
EENT - downward/inward gaze, sclera anicteric, pupils 3 mm,
reactive, no nystagmus OP clear
CV - RRR no m/r/g
PULM - CTAB no w/r/r
ABD - soft NTND +BS no hepatomegaly
EXT - WWP +PP
NEURO - moves all 4 ext equally, nl tone
## LIP:
19
Serum Acetmnphn 26.2
Serum ASA, EtOH, , Tricyc Negative
Urine Mthdne Pos
Urine Benzos, Barbs, Opiates, Cocaine, Amphet Negative
.
12.6
8.2 >
-----
< 335
36.2
.
## EEG:
Abnormal EEG due to focal slowing and sharp transient
phase
reversals about the left mid-temporal and left posterior
temporal
regions with associated focal excessive beta. This would suggest
an
area of recent increase in irritability involving the left
temporal
region broadly. This activity was seen more in wakefulness than
in the
brief drowsy portions. Some pre-central beta was also seen
related to
the benzodiazepine prescribed for the patient
.
## HEAD CT:
Technically limited study due to extensive patient motion. No
gross abnormality appreciated. However, if there is truly
concern for an
intrinsic brain lesion, a followup MR study should be
considered, but only if the patient can remain still. Perhaps to
achieve successful imaging, such an endeavor would require
premedication
## BRIEF HOSPITAL COURSE:
yo F on methadone for SA, admitted with agitation and c/f
substance withdrawal/intoxication. Hosp course by problem:
.
#Delirium/agitation - Initial presentation suggested
intoxication or drug overdose and was supported by patient's
known history of substance abuse. Other considerations in the
differential diagnosis included withdrawal state (although
clinical picture is not entirely consistent with either alcohol
or narcotic withdrawal), tylenol ingestion (high-normal level
initially), anticholinergic or serotonin syndrome (seroquel
would be the possible culprit), infection (although unlikely in
the absence of fever or leukocytosis), nonconvulsive status
epilecticus. Neurology and toxicology were consulted.
Noncontrast CT scan of head was negative for intracranial bleed
or mass. EEG was performed (results as stated in report).
Tylenol levels trended downward in first 24 hours.
Valium was given prn for agitation. Motrin, clonidine, and IVF
were given prn for muscle cramps and withdrawal symptoms.
Nausea and vomiting persisted and were treated with zofran and
compazine.
Patient became more responsive throughout the day. Pt was able
to tell us that she called EMS after she had taken 3 tylenol pm
pills and 3 seroquel pills that she had gotten from a friend.
She stated that she had run out of methadone two days earlier
and wanted relief from her withdrawal symptoms. Pt was unclear
where she got her methadone from. Pt denied any attempt to take
her life.
On day 2 of admission patient's symptoms of somnolence and
agitation returned acutely. A small empty plastic bag was found
next to her open purse. It was suspected that patient ingested
an unknown medication. Psychiatry and social services were
consulted. Psychiatry did diagnose substance abuse disorder but
did not find the patient to be a harm to herself or others at
this time. Social services contacted to report her
persistent drug abuse while living her son. At this time pt
decided to leave AGAINST MEDICAL ADVICE. Pt was provided a list
of resources for counseling and treatment for her addiction.
Patient was provided no medications on discharge. She was
instructed to return to the Emergency Department if symptoms
progress.
#Bipolar d/o: origin of diagnosis unclear. With the exception
of valium and clonidine psych meds were held.
.
#Contact: (friend)
.
Code status: Presumed full
## MEDICATIONS ON ADMISSION:
reportedly (but non confirmed:
methadone 40-80mg
seroquel - stolen from friend
:
none
## PRIMARY:
- Polysubstance overdose. Pt admits she ran out of methadone
and was having difficulty sleeping. She reports taking 3
pills and 3 seroquil pills to help her sleep before
she called EMS.
- altered mental status: head ct normal. improved
- agitation
## DISCHARGE INSTRUCTIONS:
You were admitted to the ICU for altered mental status and
agitation which we believe was the result of drug overdose. As
expected, during the first 24 hours of your admission you became
more alert and responsive. However, because your agitation and
unresponsiveness returned we consulted the psychiatry service.
Psychiatry diagnosed substance abuse but did not believe you
were a harm to yourself or others at this time.
The decision was then made to discharge you from the hospital
AGAINST MEDICAL ADVICE. You were not sent home on any new
medications and we have no records of any home medications. If
you are on home medications we urge you to tell your primary
care physician.
We strongly recommend that you refrain from using any
medications that are not prescribed to you by your primary care
physician. Please follow up with you primary care doctor within
the next two weeks to verify your full recovery.
If you develop fever, chills, or confusion please return to the
Emergency Department. If when you return home you feel you are a
threat to yourself or others please call or return to the
Emergency Department.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13404476", "visit_id": "26177761", "time": "2150-11-28 00:00:00"} |
19128980-RR-18 | 98 | ## HISTORY:
male with cerebellar AVM and a new left IJ line placed.
## STUDY:
Portable AP semi-upright chest radiograph.
## FINDINGS:
There has been interval placement of a left-sided IJ venous
catheter with its tip at the left brachiocephalic. The cardiomediastinal
silhouette appears unchanged. The lung volumes are low with bibasilar and
particularly retrocardiac opacities consistent with atelectasis. There is no
evidence of pneumothorax. The endotracheal tip remains 4.5 cm above the
carina. An endogastric tube tip and side port projects over the stomach.
## IMPRESSION:
Interval placement of left IJ line without evidence of
complication.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19128980", "visit_id": "22087237", "time": "2136-09-10 13:21:00"} |
17967137-RR-44 | 254 | ## INDICATION:
woman with metastatic lung cancer, status post
resection. Followup exam.
## FINDINGS:
The patient is status post left parietal craniotomy with stable
post-operative changes including enhancement and thickening of the left
posterior parietal dura. There is unchanged appearance of the left parietal
resection cavity with peripheral hemosiderin staining and somewhat
heterogeneous T1 hypo, T2 hyperintense contents related to blood products and
fluid. While there is intrinsic T1 hyperintensity along its margins, no
additional nodular enhancement is identified that may suggest local
recurrence. Likewise, there are no new enhancing lesions of the brain
parenchyma. There is a small developmental venous anomaly in the left
cerebellar hemisphere.
The right frontal ventriculostomy catheter demonstrates unchanged position
with its tip in the area of the foramen of . Prominent cerebral sulci,
stable enlargement of the ventricular system likely reflect global cerebral
volume loss. Extensive periventricular and deep white matter confluent
FLAIR/T2 signal abnormality likely relate to sequela of small vessel ischemic
disease and post XRT changes. Flow voids of the major intracranial vessels
are preserved.
Since the prior study, there is a new fluid level in the right maxillary sinus
and sphenoid sinus.
The bilateral mastoid air cells have diffuse mucosal thickening and fluid.
## IMPRESSION:
1. Stable appearance of left parietal resection cavity with no evidence of
local recurrence.
2. No new metastatic lesions.
3. Unchanged position of right frontal ventriculostomy catheter with stable
configuration of ventricular system with moderate ventricular dilation.
4. Small left cerebellar developmental venous anomaly.
5. Paranasal sinus and mastoid disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17967137", "visit_id": "N/A", "time": "2126-08-04 09:56:00"} |
18892635-RR-237 | 110 | AP CHEST, 6:27 P.M. ON
## HISTORY:
Fever, chest pain and cough. Rhonchi.
## IMPRESSION:
AP chest compared to , mild interstitial
pulmonary edema is new. Progressive distention of the azygous vein and hila
suggest volume overload or biventricular cardiac decompensation. Bibasilar
consolidation is more pronounced today than on which could be due
to worsened atelectasis, but pneumonia is certainly possible. The intended
left internal jugular line still passes peripherally toward the left axilla
either in the subclavian vein or even a smaller branch.
Right subclavian dual-channel catheter ends at the superior cavoatrial
junction. Feeding tube passes below the diaphragm and out of view. Heart
size normal. No pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18892635", "visit_id": "23554680", "time": "2191-07-17 18:11:00"} |
19414987-RR-82 | 179 | ## INDICATION:
History: with pain, swelling// fx
## FINDINGS:
The bones are diffusely osteopenic. Well corticated appearing 3 mm ossific
structure just adjacent to the medial base of the fifth proximal phalanx could
represent a small avulsed fragment of indeterminate age. 0.4 x 0.3 cm well
corticated ossific structure projects dorsal to the proximal carpal row and
may represent a triquetrum fracture of indeterminate age, more likely old. No
evidence of acute fracture seen elsewhere. There are mild to moderate
degenerative changes at the first carpometacarpal joint, triscaphe joint, and
at the DIP joints. Mild ulnar minus variance is noted. There are vascular
calcifications.
## IMPRESSION:
Diffuse osseous demineralization. Well corticated appearing 3 mm ossific
structure just adjacent to the medial base of the fifth proximal phalanx could
represent a small avulsed fragment of indeterminate age, probably old.
0.4 x 0.3 cm well corticated ossific structure projecting dorsal to the
proximal carpal row on the lateral view may represent a triquetrum fracture of
indeterminate age, but likely old. No acute fracture seen elsewhere.
Multilevel degenerative changes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19414987", "visit_id": "N/A", "time": "2193-07-10 17:45:00"} |
10806814-RR-5 | 209 | ## FINDINGS:
The aorta and great vessels are normal in caliber and contour. There is no
evidence of dissection. Pulmonary vasculature demonstrates no filling defects
to suggest a pulmonary embolism. The heart is normal in size without
pericardial effusion. The thyroid gland appears heterogenous and enlarged.
Airways are patent to the subsegmental levels bilaterally. There are mild
bibasilar atelectatic changes along with a small non-hemorrhagic left pleural
effusion. Otherwise, the lungs are clear with no evidence of a consolidation
or pneumothorax.
This study is not tailored for evaluation of subdiaphragmatic structures;
however, the visualized portions of the abdomen demonstrate multiple hypodense
foci within the liver likely representative of cysts, the largest of which is
located in segment , measures 5.6 x 5.5 cm (2:46). Additionally, a
hypodense lesion is noted with surrounding centripetal enhancement following
the administration of contrast in segment VIII and most likely representative
of a hemangioma (3:57).
## OSSEOUS STRUCTURES:
There are no lytic or sclerotic osseous lesions
suspicious for malignancy.
## IMPRESSION:
1. No evidence of acute aortic injury or pulmonary embolism.
2. Thyroid gland is diffusely enlarged. A dedicated thryroid ultrasound is
recommended for further characterization.
3. Multiple cysts and a hemangioma are noted in the visualized portions of
the liver.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10806814", "visit_id": "29220055", "time": "2128-05-20 23:26:00"} |
12621575-RR-8 | 103 | ## HISTORY:
Left elbow point tenderness, bruising status post fall, question
fracture.
LEFT ELBOW THREE VIEWS. No elbow films on PACS record for comparison.
No fracture, dislocation, degenerative change, or joint effusion is detected
about the left elbow. There may be mild soft tissue swelling posterior to the
elbow near the triceps insertion site of the olecranon bursa. No radiopaque
foreign body is detected.
## IMPRESSION:
No fracture detected. If there is continuing elbow pain, then
repeat elbow radiographs in days are recommended to assess for interval
change.
The case was discussed by Dr. with Dr. at
approximately 2:40 p.m. on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12621575", "visit_id": "N/A", "time": "2123-01-23 14:19:00"} |
16720629-RR-11 | 256 | ## EXAMINATION:
FETAL BPP WITH MEASUREMENTS
## INDICATION:
year old woman pregnant// ?leaking fluid post dates
## FINDINGS:
There is a live in cephalic presentation. The placenta is anterior.
There is no evidence of previa. There is a normal amount of amniotic fluid
with an amniotic fluid index of 9 cm. No fetal morphologic abnormalities are
detected. The uterus is normal. No adnexal masses are seen.
The following biometric data were obtained:
BPD 91 mm, 37 weeks 0 days.
HC 341 mm, 39 weeks 2 days.
AC 340 mm, 38 weeks 0 days, n/a %.
FL 75 mm, 38 weeks 3 days.
## AGE BY US:
38 weeks 2 days.
Age by Dates: 40 weeks 3 days.
EFW 3378 g, 47% (based on LMP)
Compared to the prior exam there has not been appropriate interval growth.
The biophysical profile score is with 2 points each for breathing in fluid
volume 0 point each for movement and tone.
In the left lower uterine segment, there is a 6.7 x 5.1 x 6.4 cm fibroid,
unchanged allowing for differences in measurement technique.
## IMPRESSION:
1. The biophysical profile score is with 0 points for movement and tone.
2. Compared to the prior exam, there has not been appropriate interval growth
with size now 2 week behind dates. However, the weight is at the 47th
percentile.
3. The amniotic fluid index is 9 cm.
4. A lower uterine segment fibroid is unchanged.
## NOTIFICATION:
Written preliminary findings were given to Dr. at the time
of examination by the sonographer, Tiara .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16720629", "visit_id": "21485615", "time": "2174-08-31 07:48:00"} |
14296716-RR-16 | 141 | ## INDICATION:
man with ulcerated mixed 3 cm mass found on
colonoscopy within the proximal rectum.
## DOSE:
Reported separately on same day abdomen/pelvic CT.
## NECK/ CARDIOMEDIASTINUM:
The imaged thyroid is unremarkable. There is no
supraclavicular or axillary lymphadenopathy. There is no mediastinal or hilar
lymphadenopathy. The heart is normal in size. The aorta and main pulmonary
artery are normal in caliber. The right brachiocephalic and left common
carotid arise from a single trunk. There is no pericardial effusion.
## AIRWAYS/LUNGS:
The tracheobronchial tree is patent to the subsegmental level. There are no
suspicious pulmonary nodules. There is no focal consolidation.
## ABDOMEN:
Please see same-day abdomen/pelvic CT report.
## CARDIAC THORACIC CAGE/SOFT TISSUES:
There are no suspicious lytic or blastic
lesions.
## IMPRESSION:
No evidence of cardiothoracic metastasis. Please see same-day abdomen/pelvic
CT for infra diaphragmatic findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14296716", "visit_id": "N/A", "time": "2133-02-19 08:29:00"} |
17091758-RR-29 | 443 | ## HISTORY:
Status post recent CABG now with clinical concern for sternal wound
infection, here to evaluate for focal fluid collection.
## FINDINGS:
The patient is status post median sternotomy with multiple intact sternal
wires. A small hypodense collection at the sternal notch and subjacent to the
manubrium with an internal density of 35 Hounsfield U, which most likely
represents a small postoperative hematoma. There is no evidence of dehiscence
in the lower sternum and no focal fluid collections elsewhere. There are
minimal midline postsurgical changes including subcutaneous fat stranding but
no subcutaneous fluid collection is seen.
The central tracheobronchial tree is patent to the subsegmental levels
bilaterally. There is mild centrilobular emphysema in the upper lobes and
mild bronchiectasis in the right lower lobe. Focal cystic areas in the right
lower lobe (4: 124) was likely represent sequelae from prior infection. Mild
atelectasis of is seen in the left lower lobe. There is a 6 fissural
pulmonary nodule in the right lower lobe (4: 144). No other suspicious
pulmonary nodules are identified.
The thyroid gland is unremarkable. Multiple small fatty replaced axillary
lymph nodes are noted bilaterally, which are not pathologically enlarged.
Small mediastinal lymph nodes measuring up to 7 mm in short axis in the
precarinal region (4: 83) do not meet CT size criteria for lymphadenopathy.
The esophagus is unremarkable.
The thoracic aorta and pulmonary arterial trunk are normal in caliber. Mild
calcification of the aortic arch and ostia of the aortic arch vessels is
noted. The heart is top-normal in size with moderate calcification of the
aortic valve annulus. Trace pericardial fluid is physiologic. The patient is
status post CABG with multi-vessel calcified coronary artery disease.
Although this study is not tailored for the evaluation of subdiaphragmatic
contents, the imaged upper abdomen demonstrates a scar along the splenic
capsule. There is an indeterminate 20 x 14 mm left adrenal nodule (4: 233)
with an internal density of 29 Hounsfield U. The imaged upper abdomen is
otherwise within normal limits.
No osseous destructive lesions concerning for malignancy are detected.
## IMPRESSION:
1. Status post median sternotomy with a small postoperative hematoma at the
sternal notch and subjacent to the manubrium without dehiscence or focal fluid
collection lower in the sternum.
2. 6 mm right lower lobe pulmonary nodule for which a followup CT is
recommended in 12 months if the patient is low risk for pulmonary malignancy
or months if the patient is at high risk for pulmonary malignancy.
3. Mild centrilobular emphysema in the upper lobes and mild right lower lobe
bronchiectasis.
4. Indeterminate 20 mm right adrenal nodule. If desired MR can be performed
for further characterization.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17091758", "visit_id": "23384946", "time": "2126-10-19 15:02:00"} |
12974812-RR-10 | 986 | ## EXAMINATION:
MRI THORACIC AND LUMBAR PT6 MR SPINE
## *** CODE CORD *** HISTORY:
with back pain, thigh thumbness
and urinary retentionIV contrast to be given at radiologist discretion as
clinically needed // eval cauda equine or cord compression
## FINDINGS:
Study is moderately degraded by motion.
Absence of IV contrast limits the evaluation. There are multiple T2/stir
hyperintense and T1 hypointense lesions in the thoracic and lumbar spine
suggestive of metastases. For example, there is a lesion involving the left
pedicle and lamina of T2 extending to the the vertebral canal and displacing
the spinal cord, which demonstrates increased signal in T2/stir at this level.
Another example includes a lesion involving the posterior aspect of T3
vertebral body. A lesion involving the left most aspect of T10 vertebral body
is also noted. T2/stir hyperintense and T1 hypointense foci in T6 and T11
are also concerning for additional metastatic lesions.
There is a compression fracture in L3 vertebral body, likely pathologic, with
approximately 80% height loss, associated with diffuse hyperintensity on STIR
suggesting bone marrow edema with retropulsion of the posterior aspect of the
vertebral body into the vertebral canal causing severe vertebral canal
stenosis, compressing the nerves of the cauda equina at this level. There is
also a lesion involving the right pedicle of L4 and the vertebral body of L5
with extensive epidural involvement at the latter level. Note is made of a
T2 and T1 hyperintense and STIR hypointense focal lesion in L2 vertebral body
that could represent a hemangioma. There are also metastatic lesions an S1
and S2 vertebral bodies and bilateral iliac bones.
Limited evaluation of the ribs shows an expansile destructive lesion involving
the left posterior tenth rib (09:29) also suggestive of metastasis.
There is multilevel disc desiccation with decreased intervertebral disc height
in L2-L3.
At T1-T2 there is a mildly T2 hyperintense tissue along the left
posterolateral aspect of the vertebral canal extending into the left neural
foramina (8:6) concerning for an epidural lesion, causing moderate left-sided
neural foraminal narrowing.
At T2-T3 there is moderate to severe vertebral canal stenosis and severe left
neural foraminal stenosis secondary to the above-mentioned lesion involving
the left pedicle and lamina of T2 which extends into the left side of the
vertebral canal. The spinal cord is displaced and demonstrates increased
signal intensity in STIR, suggesting edema.
At T3-T4 there is moderate vertebral canal stenosis with moderate bilateral
neural foraminal narrowing secondary to extension of the bony lesion involving
T3 into the vertebral canal. There is increased signal intensity in T2/stir
within the spinal cord at this level.
At T4-T5 there is no vertebral canal or neural foraminal stenosis.
At T5-6 there is no vertebral canal or neural foraminal stenosis.
At T6-7 there is no vertebral canal or neural foraminal stenosis.
At T7-8 there is no vertebral canal or neural foraminal stenosis.
At T8-T9 there is no vertebral canal or neural foraminal stenosis.
At T9-T10 there is no vertebral canal or neural foraminal stenosis.
And T11-T12 there is no vertebral canal or neural foraminal stenosis.
At T12-L1 there is no vertebral canal or neural foraminal stenosis.
At L1-2 there is no vertebral canal or neural foraminal stenosis.
At L2-3 there is no vertebral canal or neural foraminal stenosis.
At L3-4 there is severe vertebral canal stenosis and severe bilateral neural
foraminal narrowing secondary to the above-mentioned probable pathologic
fracture involving L3 with retropulsion of the posterior aspect of the
vertebral body into the vertebral canal. The thecal sac is compressed at this
level.
At L4-5 there is mild diffuse disc bulge with mild bilateral neural foraminal
narrowing andno vertebral canal stenosis.
At L5-S1 there is moderate to severe vertebral canal stenosis and severe right
and mild left neural foraminal narrowing secondary to anterior epidural
lesion, which is compressing the thecal sac at this level..
Limited images of the of lungs demonstrates a left upper lobe lung mass,
measuring approximately 3.4 x 3.0 cm (09:16).
Limited evaluation of the abdomen shows a probable liver mass measureing
approximately 4.2 cm (13:13). A 1.8 cm T2 hyperintense lesion in the lower
pole of the left kidney could represent a cyst (13:25).
## IMPRESSION:
1. Multiple lesions throughout the thoracic and lumbar spine as well sacrum
and iliac bones are concerning for metastatic disease, some of which extend
into the vertebral canal and neural foramina.
2. Probable pathologic acute/ subacute fracture involving L3 vertebral body
with associated bone marrow edema and retropulsion of the posterior aspect of
the vertebral body causing severe vertebral canal stenosis and severe
bilateral neural foraminal narrowing, compressing the thecal sac at this
level.
3. Moderate to severe vertebral canal stenosis along with moderate left-sided
neural foraminal narrowing at T2-T3 secondary to a metastatic lesion and
epidural involvment as described above, with associated edema of the spinal
cord at this level.
4. Moderate vertebral canal stenosis along with moderate bilateral neural
foraminal stenosis at T3-4, secondary to a metastatic lesion as described
above, with associated edema of the spinal cord at this level.
5. Absence of IV contrast limits the evaluation for epidural lesions, however
epidural involvement is seen at least in L5-S1 causing moderate to severe
vertebral canal stenosis and severe right neural foraminal narrowing and at
T1-T2 causing moderate left neural foraminal narrowing.
6. Limited evaluation of the ribs demonstrates an expansile lesion within the
left posterior tenth rib concerning for metastasis.
7. Limited evaluation of the lungs demonstrates a left upper lobe lung mass
concerning for a lung cancer.
8. Limited evaluation of the abdomen demonstrates a liver mass concerning for
metastasis.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 11:18 AM, to communicate
the final read.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12974812", "visit_id": "20714176", "time": "2176-02-23 18:43:00"} |
19370314-RR-36 | 152 | ## INDICATION:
female for annual mammogram with most recent prior
mammogram dated , at which time a six month follow up mammogram and US was
recommended for probable cysts. Patient was previously lost to follow up at
.
## LEFT BREAST ULTRASOUND:
Targeted left breast ultrasound of the left upper
outer quadrant demonstrates three well-circumscribed anechoic lesions with
increased through transmission and no internal vascularity, consistent with
simple cysts. Two of these lesions are located at 2 o'clock 6 cm from the
nipple, measuring 7mm x 7mm x 4mm and 10mm x 4mm x 11mm and a third is located
at 3 o'clock, 5 cm from the nipple, measuring 4mm x 4mm x 6mm. No additional
sonographic abnormalities are identified.
## IMPRESSION:
No evidence of malignancy. Three simple cysts within the left
upper outer quadrant.
These findings were communicated to the patient by Dr. on at
11:55pm.
BIRADS 2- Benign findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19370314", "visit_id": "N/A", "time": "2168-02-11 09:56:00"} |
16538698-RR-13 | 518 | ## INDICATION:
year old man with CKD and nephrolithiasis and recurrent UTIs
presenting with fevers, leukocytosis, worsening renal function//
?nephrolithiasis ? pyelonephritis ? PCN tube position
## 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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 3.4 s, 54.7 cm; CTDIvol = 4.6 mGy (Body) DLP = 251.4
mGy-cm.
Total DLP (Body) = 251 mGy-cm.
## LOWER CHEST:
New bilateral multiple patchy areas of ground-glass scattered
throughout all bases of lung fields. There is pericardial effusion as well as
mild bilateral pleural effusions
## HEPATOBILIARY:
The lower has low-density throughout. Subcentimeter
hypodensity is again seen in the periphery of the right hepatic lobe, likely
representing a hepatic cyst or biliary hamartoma (2; 54). There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
contains small gallstones, similar to prior.
## PANCREAS:
Atrophic pancreas. No pancreatic ductal dilatation. There is no
peripancreatic stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. There is borderline high-normal splenomegaly.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The left kidney is atrophic. There is no evidence of focal renal
lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. One stone is visualized in the left kidney and measures 2.5
mm. A percutaneous nephrostomy tube is seen within the renal pelvis.
Punctate renal stones seen in the right kidney. There is bilateral
perinephric stranding, which extends to surround bilateral proximal ureters.
There is extensive atherosclerosis in right renal artery.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is
diverticulosis the sigmoid colon without evidence of wall thickening and fat
stranding. The appendix is not visualized. There are calcified appendages
throughout the colon.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The visualized reproductive organs are unremarkable. A
Foley catheter is in place.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Severe atherosclerotic
disease is noted.
## BONES:
There is no evidence of worrisome osseous lesions. The patient is
status post posterior spinal fusion from L3-L5. Degenerative changes are seen
throughout the thoracolumbar spine. A fixation rod is seen within the left
femur within an old fracture. Old right-sided posterior rib fractures..
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Percutaneous nephrostomy tube is seen within the left renal pelvis. There
are bilateral punctate nonobstructive renal stones, without evidence of
hydronephrosis.
2. New bilateral multiple patchy areas of ground-glass scattered throughout
bases of lung fields. Rapid recurrence of this appearances most suggestive of
infectious cause. Recommend dedicated CT of chest for full evaluation of
extent if clinically indicated.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Cirrhotic liver.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16538698", "visit_id": "28035366", "time": "2190-01-06 15:40:00"} |
15442918-RR-100 | 145 | ## HISTORY:
Abdominal pain, diarrhea and vomiting. Evaluate for underlying
colitis or diverticulitis.
## BONE WINDOWS:
Slight deformity of the L5 left transverse process is noted,
likely reflective of prior trauma with scattered moderate multilevel
degenerative joint and disc disease noted with disc osteophyte complexes noted
at L4-L5 and L5-S1. No aggressive appearing osseous lesions are identified.
## IMPRESSION:
1. Loops of bowel are slightly fluid-filled which may reflect underlying
enteritis. Incidentally noted is mild induration of the mesentery which can
also be seen with underlying enteritis.
2. Probable fibroid uterus. Can consider more definitive evaluation with a
pelvic ultrasound on a non-emergent basis as clinically indicated.
3. 4 to 5 mm left lower lobe pulmonary nodule. In abscence of prior exams
and in a patient with prior history of breast cancer, a dedicated full chest
CT would be recommended in months.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15442918", "visit_id": "29534693", "time": "2175-09-11 18:46:00"} |
12812885-RR-32 | 84 | ## INDICATION:
man with an obstructive right ureteral calculus
causing mild to moderate right hydroureteronephrosis.
## FINDINGS:
6 intraoperative images were acquired without a radiologist present.
Images show a filling defect in the right mid ureter that likely represents
the known right ureteral calculus and subsequent images demonstrate right
ureteral stent placement.
## IMPRESSION:
Intraoperative images were obtained during retrograde urography and
demonstrate a right mid ureteral calculus with subsequent right ureteral stent
placement. Please refer to the operative note for details of the procedure.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12812885", "visit_id": "24514211", "time": "2201-07-17 17:21:00"} |
11498783-RR-13 | 475 | ## INDICATION:
year old man with bilateral DVTs, spiculated lung lesion on CT
chest, multiple cranial neuropathies // ?cancer
## 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.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 5.5 s, 1.0 cm; CTDIvol = 12.7 mGy (Body) DLP =
12.7 mGy-cm.
3) Spiral Acquisition 18.8 s, 72.3 cm; CTDIvol = 14.3 mGy (Body) DLP =
1,010.8 mGy-cm.
Total DLP (Body) = 1,045 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 homogenous attenuation throughout. A
few subcentimeter hypodense lesions are noted in the liver in segment and
2, too small to definitively characterize but likely represent hepatic cysts
or biliary hamartomas. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, 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.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
Heterogeneous enhancement of the kidneys is demonstrated. There are
normal size and symmetric. A small hypodense lesion is noted in the lower
pole of the left kidney, too small to definitively characterize. There is no
perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding. The appendix is normal.
## PELVIS:
The urinary bladder contains hyperdense material dependently layering
which likely represents mixing of contrast material. There is no free fluid
in the pelvis.
## REPRODUCTIVE ORGANS:
The visualized reproductive organs are unremarkable.
## LYMPH NODES:
A borderline enlarged left paraaortic lymph node is noted
measuring 1.1 cm. Multiple right inguinal lymph nodes are demonstrated
measuring up to 1.3 cm.
## VASCULAR:
There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted. There is central hypodensity in the right common femoral vein
extending from the deep femoral artery and is distended. Marked surrounding
inflammatory stranding is demonstrated.
## 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 in the abdomen or pelvis.
2. Hypodense and distended right deep femoral vein extending into the common
femoral vein is consistent with known DVT.
3. This preliminary report was reviewed with Dr.
radiologist.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11498783", "visit_id": "25157516", "time": "2123-07-31 18:00:00"} |
13938919-DS-16 | 246 | ## HISTORY OF PRESENT ILLNESS:
yo G0 w/ hx of fibroid uterus, menorrhagia, and anemia
requiring IV iron infusions p/w acute episode of heavy vaginal
bleeding. Pt states that she has been soaking several tampons
per
hour and passing large clots since yesterday evening. Presented
to Dr. this afternoon and was subsequently
referred to gyn triage for further evaluation. Pt currently
endorses mild lightheadedness. No CP, SOB, palpitations.
## ABDOMEN:
mildy tender, non-distended, no r/g
## GU:
scant dried blood on pad
## ADMISSION:
Gen NAD
CV regular rate
Pulm nl respiratory effort
Abd soft, minimal LLQ TTP, no R/G
Pelvic NEFT, tampon in vault completely saturated (was placed
approx. 30min prior), 3 scopettes dark blood in vault, cervical
os closed. no cervical/vaginal lesions
## BRIEF HOSPITAL COURSE:
On , Ms. was admitted to the gynecology service for
management of heavy vaginal bleeding secondary to a large
intrauterine fibroid complicated by anemia. On hospital day 1,
she was started on oral estrogen therapy and IV iron infusion.
By hospital day 2, her bleeding had improved and hematocrit had
stabilized. She was transition to oral Provera to take at home
and scheduled for close follow-up with her primary gynecologist.
She was stable and discharged home.
## DISCHARGE MEDICATIONS:
1. MedroxyPROGESTERone Acetate 10 mg PO BID
RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
## DISCHARGE DIAGNOSIS:
menorrhagia
anemia
uterine fibroid
## DISCHARGE INSTRUCTIONS:
pelvic rest until follow up visit
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13938919", "visit_id": "20550876", "time": "2154-08-06 00:00:00"} |
12234376-RR-41 | 120 | ## HISTORY:
male with HIV and altered mental status.
## FINDINGS:
There has been interval dilatation of the ventricles and sulci
consistent with cerebral atrophy our of proportion to age. Additionally,
there is periventricular white matter hypodensity which has progressed from
prior. There is no acute intracranial hemorrhage, extra-axial collection, or
mass effect.
The soft tissues appear normal. There is mucosal thickening and aerosolized
mucus within the right sphenoid sinus, and there is minimal mucosal thickening
of the posterior ethmoid air cells on the right. The remainder of the
visualized paranasal sinuses are clear. The mastoid air cells and middle ear
cavities are clear.
## IMPRESSION:
No acute process. Significant interval progression of white
matter disease and cerebral atrophy since .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12234376", "visit_id": "27233093", "time": "2162-02-13 17:52:00"} |
10960463-RR-36 | 92 | ## INDICATION:
Ms. is a year old woman with recent diagnosis of
highgrade serous ovarian CA c/b partial bowel obstruction from sigmoid mass
and malignant ascites and pleural effusion (with morganella superinfection,
s/p abx course). Now with worsening abdominal pain, nausea, and distension//
Eval SBO. Eval perf/ air under diaphragm
## FINDINGS:
Nonobstructive bowel gas pattern with relative paucity of bowel gas
identified. No residual oral contrast. Unchanged right central venous
catheter with tip projecting over the right atrium.
## IMPRESSION:
Nonobstructive bowel-gas pattern with interval passage of oral contrast.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10960463", "visit_id": "28835226", "time": "2156-07-27 04:27:00"} |
18036964-RR-58 | 101 | ## HISTORY:
female with recent fall to assess for a bony injury.
## FINDINGS:
The bones are osteopenic which makes assessment of fractures difficult. Within
these limitations, there is a minimally displaced fracture through the radial
head. There is an associated joint effusion present.
There are degenerative changes present at the left glenohumeral and left
acromioclavicular joint. There is no acute fracture seen. The visualized
left rib cage and left lung appear unremarkable.
## CONCLUSION:
Bones are osteopenic. Within these limitations, there is a minimally
displaced fracture seen through the radial head along with an associated joint
effusion at the left elbow.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18036964", "visit_id": "27343038", "time": "2167-11-14 12:32:00"} |
15026018-RR-50 | 126 | ## EXAMINATION:
KNEE (AP, LAT AND OBLIQUE) LEFT
## INDICATION:
Left knee pain times several months no injury rule out pathology
## FINDINGS:
Compared with , Bone and hardware alignment is unchanged.
Again seen is a lateral buttress plate and screws extending into the proximal
tibia. Scalloping of the lateral tibial plateau is unchanged, suggestive of
an old healed tibial plateau fracture. No hardware loosening or displacement
detected.
No new superimposed fracture and no dislocation identified. No joint
effusion.
Mild degenerative spurring is present in the patellofemoral and lateral
femorotibial compartments. Equivocal slight narrowing of the patellofemoral
joint. Femorotibial joint space preserved. No joint effusion.
## IMPRESSION:
No acute fracture or dislocation detected.
Old healed lateral tibial plateau fracture.
Mild degenerative spurring. Equivocal slight narrowing of the patellofemoral
compartment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15026018", "visit_id": "N/A", "time": "2147-06-22 10:47:00"} |
10412483-RR-73 | 485 | ## INDICATION:
year-old male with history of CHF, HTN, Afib on
Eliquis,chronic LBBB, aortic stenosis, falls, and dementia who presented s/p
fall with R pelvic fractures, retroperitoneal hematoma, acute on chronic HF,
right pleural effusion.// Etiology of right exudative pleural effusion
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 2.6 s, 40.7 cm; CTDIvol = 13.9 mGy (Body) DLP = 566.6
mGy-cm.
Total DLP (Body) = 567 mGy-cm.
## FINDINGS:
Thyroid is unremarkable.
Heart size is borderline with trace pericardial effusion. There are severe
coronary artery calcifications. Thoracic aorta is normal caliber with
moderate atherosclerotic calcifications. Pulmonary arteries are top normal in
caliber without centralized filling defect.
There is no supraclavicular, axillary, hilar, or mediastinal lymphadenopathy
by CT size criteria. There are numerous densely calcified mediastinal and
bilateral hilar lymph nodes suggestive of prior granulomatous insult.
There are moderate right and small left-sided nonhemorrhagic pleural
effusions. There is associated adjacent mild compressive atelectasis. There
is also mild streaky atelectasis in the right middle lobe. Minimal areas of
linear scarring or atelectasis are noted in the bilateral upper lobes. There
is a somewhat spiculated 3 mm nodule in the right upper lobe (302:112) which
appears unchanged since . Another punctate 1 mm subpleural
nodule in the right middle lobe is noted (302:173). This is also unchanged.
Few punctate scattered calcified granulomas are identified. Subtle areas of
peribronchial ground-glass attenuation are noted in the left upper lobe. This
component appears unchanged compared the prior examination. Additional
peribronchial nodules are noted in the left lower lobe with the
largest nodular component measuring up to 5 mm (302:101). These appear
significantly decreased compared the prior examination, with the largest
nodule previously measuring up to 1.5 cm. Otherwise no suspicious focal
consolidation is seen.
Central airways are patent.
Although this study is not tailored for subdiaphragmatic analysis, the
visualized upper abdomen demonstrates no gross acute abnormality. There is a
punctate nonobstructing stone in the right interpolar kidney along with
bilateral renal cyst. There is also borderline prominence of the bilateral
renal collecting systems without frank hydronephrosis of the visualize
component. Few colonic diverticula are noted.
Thoracic cage is intact without suspicious focal bone lesion or acute
fracture. There is moderate thoracic dextroscoliosis with moderate multilevel
degenerative changes.
## IMPRESSION:
1. New moderate right and small left-sided nonhemorrhagic pleural effusions,
source unclear.
2. Interval decrease in size and conspicuity of peribronchial
nodules in the left lower lobe, likely representing sequela of infectious or
inflammatory insult.
3. Stable peribronchial ground-glass attenuation in the left upper lobe, which
may represent the residua of prior infection/inflammation or improving airway
mucous inspissation.
4. Stable 3 mm right upper lobe and 1 mm right middle lobe pulmonary nodules.
Otherwise no new or growing pulmonary nodule.
5. Unchanged numerous densely calcified mediastinal and hilar lymph nodes
suggesting prior granulomatous insult.
6. Punctate nonobstructing right renal calculus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10412483", "visit_id": "27477495", "time": "2132-11-25 16:21:00"} |
12456241-RR-94 | 251 | ## INDICATION:
with metastatic pancreatic cancer and lung cancer, restarting
treatment// baseline
## DOSE:
Total DLP (Body) = 1,515 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS WITH CONTRAST)
## FINDINGS:
Port-A-Cath resides over the right chest wall with right IJ insertion and tip
residing in the cavoatrial junction. The imaged base of neck including the
partially visualized thyroid is unremarkable. Thoracic aorta is mildly
calcified and normal in course and caliber. The heart is normal in size and
shape. Main pulmonary artery is normal in size with patent central branches.
There is no axillary, hilar or mediastinal lymphadenopathy. Several small
lymph nodes in the paratracheal station do not meet size criteria for
pathological enlargement and are stable when compared with several prior CT
exams.
The right suprahilar opacity is unchanged when compared with multiple priors,
measuring 7.4 x 3.2 x 2.2 cm containing a fiducial. No new or growing
pulmonary nodule, mass, or consolidation. There is mild bronchial wall
thickening which likely reflects sequelae of airways inflammation. No pleural
effusion is seen.
Please refer to separately dictated CT abdomen pelvis performed same day.
## BONES:
There are no worrisome lytic or blastic osseous lesions.
## IMPRESSION:
1. Right suprahilar opacity containing a fiducial is size stable compared
with multiple priors.
2. No new or growing pulmonary nodules.
3. Mild bronchial wall thickening likely reflect airways inflammation
Please refer to same-day separately dictated CT abdomen pelvis for findings
below the diaphragm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12456241", "visit_id": "N/A", "time": "2182-12-28 16:39:00"} |
10841093-RR-19 | 112 | ## EXAMINATION:
CT L-SPINE W/O CONTRAST Q331 CT SPINE
## INDICATION:
with lumbar spinal midline pain, evaluate for fracture.
## DOSE:
Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 6.9 s, 27.1 cm; CTDIvol = 32.1 mGy (Body) DLP = 868.9
mGy-cm.
Total DLP (Body) = 869 mGy-cm.
## FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling. There is no evidence of infection or neoplasm. The partially
imaged retroperitoneal and intra-abdominal solid or hollow viscous organs are
unremarkable.
## IMPRESSION:
Normal CT lumbar spine. No fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10841093", "visit_id": "N/A", "time": "2131-08-18 00:21:00"} |
18605997-RR-58 | 110 | ## INDICATION:
year old man with left kidney dx is pain rule out lesion//
left kidney dx is pain rule out lesion
## FINDINGS:
The right kidney measures 10.6 cm. The outline is slightly irregular and the
parenchyma somewhat thinned. No hydronephrosis stones or mass seen on this
kidney.
The left kidney measures 10.9 cm and also shows some thinning of the cortex.
A cyst is present the medial upper aspect which measures 3 cm. It is simple.
No hydronephrosis stones or mass seen..
Bladder outline is normal. The prostate was not enlarged.
## IMPRESSION:
No evidence of lesion within the left kidney. No stones or hydronephrosis are
present.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18605997", "visit_id": "N/A", "time": "2171-01-23 13:50:00"} |
17846933-RR-5 | 199 | ## INDICATION:
Abdominal pain. Rule out gallstones.
## FINDINGS:
The liver is diffusely echogenic. No worrisome liver lesion is
noted. There is a small cyst located in the right liver lobe measuring 6 x 6
x 5 mm. The gallbladder is present without any gallstones, wall thickening or
pericholecystic fluid. There is no intra- or extra-hepatic biliary tree
dilatation. The CBD is not enlarged measuring 4 mm. The pancreas is not well
seen secondary to overlying bowel gas and cannot be fully evaluated. The
right kidney measures 10.6 cm, and the left kidney measures 13.3 cm. There is
a large simple cyst within the central portion of the right kidney measuring
7.3 x 6.4 x 7 cm. There is no hydronephrosis, stones or masses. The spleen
measures 13.8 cm and has homogeneous echotexture. The visualized portions of
the aorta and IVC are unremarkable. There is no ascites.
## IMPRESSION:
1. Echogenic liver consistent with fatty deposition. Other forms of liver
disease and more advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Simple right liver lobe cyst and simple right renal cyst.
3. Mild splenomegaly.
4. No cholelithiasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17846933", "visit_id": "N/A", "time": "2175-09-24 07:04:00"} |
10173966-DS-9 | 904 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
OPEN HERNIORRHAPHY INCISIONAL WITH MESH
## HISTORY OF PRESENT ILLNESS:
with history of knife wound to the left lower abdomen,
exploratory laparotomy, and subsequent incisional hernia
development. He has had recent pain and discomfort with his
umbilical hernia. He states that he has had the hernia for many
years, but that over the past month it has become more
uncomfortable and sometimes painful. Him and his wife note that
it has gotten bigger through the years, although it is still
reducible. Mr. would like to have this hernia fixed.
## PMH:
-sickle cell trait and a heart murmur
## PSH:
-ex lap in the 1990s for an abdominal stab wound
-rotator cuff repair
## GEN:
well appearing, no apparent distress
## ABD:
soft, nontender, nondistended, no masses palpable, no
hernia
## CARDIO:
regular rate and rhythm
## PULM:
clear to ascultation bilaterally
## EXT:
warm and well perfused, noncyanotic, nonedematous
## WOUND:
clean,dry,intact with sutures and steristrips; no
drainage, no erythema
## BRIEF HOSPITAL COURSE:
The patient was admitted to the Surgical Service for
evaluation and treatment. On , the patient underwent
open incisional hernia repair with mesh, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor in stable condition.
.
## NEURO:
The patient initially required IV Dilaudid for pain
control, but then was transitioned to oxycodone and PO Tylenol.
This regimen was adequate to control his pain. Suboxone was
held, and the patient was instructed not to resume this
medication until he was no longer taking the oxycodone.
.
## 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.
.
## GI/GU/FEN:
Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated.
.
## PROPHYLAXIS:
The patient received subcutaneous heparin and was
encouraged to get up and ambulate as early as possible.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
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.
## MEDICATIONS ON ADMISSION:
buprenorphine-naloxone
clonidine [Catapres] 0.1 mg tid prn
quetiapine 25 mg tablet tablet(s) by mouth qhs PRN as needed
for insomnia
nicotine 21 mg/24 hr daily Patch
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q6H:PRN pain RX *acetaminophen [8
HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth q6hrs prn Disp
#*60 Tablet
## REFILLS:
*2
2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace]
100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule
Refills:*2
3. Nicotine Patch 21 mg TD DAILY
4. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain do not
drive or drink alcohol or take suboxone while usint this
medication
RX *oxycodone 5 mg tablet(s) by mouth q4hrs prn Disp #*60
## TABLET REFILLS:
*0
5. Senna 1 TAB PO BID:PRN constipation RX *sennosides [senna]
8.6 mg 1 tablet by mouth BID PRN Disp #*60 Tablet Refills:*2
## DISCHARGE INSTRUCTIONS:
You were seen and evaluated by the Surgery Service for
treatment and evaluation of your hernia. We took you for a
surgery and repaired your hernia. You are now safe to return
home and continue your recovery there.
.
## IMPORTANT:
-You must wear your abdominal binder daily when you are up and
out of bed and moving around. You can take it off at night and
while you are in the shower. You must continue wearing this
until your follow up visit with Dr. .
-Do not lift any objects over 10 pounds until your follow up
appointment with Dr. .
-You were taking Suboxone at home, but you must NOT resume this
medication until you are NO LONGER TAKING OXYCODONE for pain
control. You can take tylenol along with the oxycodone but you
should gradually be able to decrease the amount of oxycodone you
use and transition to using only tylenol for pain control. You
will need to take a stool softener while taking the oxycodone to
prevent constipaton. You can stop taking these if you develop
loose stools or diarrhea.
.
Please resume all regular home medications unless specifically
advised not to take a particular medication (see above for
instructions regarding when to resume suboxone). 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 staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips days after surgery.
.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10173966", "visit_id": "25544795", "time": "2118-06-27 00:00:00"} |
12850832-RR-24 | 133 | ## INDICATION:
year old man with BP // r/o L4-5 instability r/o L4-5
instability
## FINDINGS:
5 non-rib-bearing lumbar vertebral bodies are present. Mild dextro convex
curvature, apex at L2. There is mild multilevel degenerative change.
Degenerative changes are most marked at L4-5, where there is asymmetric
moderate to severe disk space narrowing on the right. There is grade 1
anterolisthesis of L4 with respect to L5, measuring 8 mm in neutral position.
This does not demonstrate substantial dynamic instability. There is also
moderate to severe L4-5 and L5-S1 facet joint degeneration. Mild L3-4 facet
joint degeneration.
There is mild right hip joint degenerative change.
## IMPRESSION:
Degenerative changes as above, with grade 1 anterolisthesis of L4 with respect
to L5, but no dynamic instability.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12850832", "visit_id": "N/A", "time": "2126-10-03 10:22:00"} |
16859288-RR-43 | 142 | ## HISTORY:
male, with known right parietal enhancing lesion, now
status post right parietal brain biopsy, with worsening weakness.
## FINDINGS:
There is no evidence of large hemorrhage including hematoma. There is a trace
amount of subarachnoid hemorrhage, following the course of the biopsy tract.
There is no evidence of acute vascular territorial infarction. There is
unchanged of expected tiny pneumocephalus at the biopsy site. There is
residual pneumocephalus at the extra-axial space subjacent to the
parietovertex burr hole.
There is no mass, mass effect, or significant edema. There is no shift of
normally midline structures. Other than the noted burr hole, there is no
other skull abnormlity or acute fracture.
## IMPRESSION:
1. No evidence of large hemorrhage including hematoma at biopsy site.
2. No evidence of large territorial infarct.
3. Expected tiny pneumocephalus and subarachnoid hemorrhage along the biopsy
tract.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16859288", "visit_id": "26433405", "time": "2169-03-27 11:55:00"} |
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