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10087981-DS-4 | 1,321 | ## ALLERGIES:
cephalexin / doxycycline / Furazolidone / morphine / naproxen /
Macrobid / Oxycodone / prednisone / prochlorperazine /
Sulfasalazine / ondansetron / mesalamine / nitrofuran / sulfur
dioxide / Benadryl / tramadol
## HISTORY OF PRESENT ILLNESS:
year old female with h/o osteoporosis and ulcerative colitis
presents with one month of progressive low back pain, increased
in severity over the past 3 days. Patient's daughter reports she
has a history of multiple compression fractures (followed at
and bent over last month to retrieve recycling materials
when she had sudden onset of low back pain. Three days ago, the
pain became severe, limiting patient's ability to ambulate. She
denies any numbness, weakness, urinary or fecal incontinence,
and denies fever or chills.
She was seen at this evening where CT was obtained and
showed an L1 compression fracture
In the ED, initial vitals were 97.9 110 100/80 19 97% RA. At
, count was 10.6, creatinine was 1.1. Neurosurgery
was consulted and stated that the patient has multiple
compression fractures, including L1, L4, and will need pain
control and vertebroplasty. They recommended admission to
Medicine, and would follow along and consult with for
procedure. Vitals on transfer were 97.4 82 129/65 16 100% RA.
On the floor, the patient reports no current back pain. There
is no current numbness or weakness, retention or incontinence.
She has been constipated for two days.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea or abdominal
pain. No recent change in bladder habits. No dysuria. Denies
arthralgias or myalgias. Ten point review of systems is
otherwise negative.
## PAST MEDICAL HISTORY:
Primary sclerosing cholangitis
Ulcerative colitis
Osteoporosis
Diverticulosis
Costochondritis
Hypertension
Tuberculosis
## FAMILY HISTORY:
No history of cancer, heart disease, diabetes
## GEN:
Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
## HEENT:
NCAT, Pupils equal and reactive, sclerae anicteric, o/p
clear, MMM.
## SUPPLE, NO JVD
LYMPH NODES:
No cervical, supraclavicular LAD.
## CV:
S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
## RESP:
Good air movement bilaterally on anterior exam, no rhonchi
or wheezing.
## ABD:
Soft, non-tender, non-distended, + bowel sounds.
## EXTR:
No lower leg edema, no clubbing or cyanosis
## NEURO:
muscle strength in all major muscle groups in lower
extremities, sensation to light touch intact, toes downgoing
bilaterally, non-focal.
## PSYCH:
Appropriate and calm.
Discharge exam:
afebrile, VSS
## GEN:
Alert, oriented to name, place and situation
## HEENT:
NCAT, Pupils equal and reactive, sclerae anicteric, o/p
clear, MMM.
## SUPPLE, NO JVD
LYMPH NODES:
No cervical, supraclavicular LAD.
## CV:
S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
## RESP:
Good air movement bilaterally on anterior exam, no rhonchi
or wheezing.
## ABD:
Soft, non-tender, non-distended, + bowel sounds.
## EXTR:
No lower leg edema, no clubbing or cyanosis
## NEURO:
muscle strength in all major muscle groups in lower
extremities, sensation to light touch intact, toes downgoing
bilaterally, non-focal.
## MSK:
no midline tenderness over spinous processes, mild point
tenderness over left SI joint
## CONCLUSION:
1. Lower L1 compression fracture, slight posterior wall
retropulsion,
which may be acute or early subacute; new since CT .
Clinical
correlation needed. Chronic L3, L4 compression fractures
unchanged.
2. Fluid density contrast, liquid in the large bowel, which
might be
due to mild enterocolitis, correlate clinically with respect to
diarrhea. Suggestion of wall thickening, of rectosigmoid,
possibly
mild proctocolitis.
3. Uncomplicated gallstone. Limited, uncomplicated colonic
diverticulosis. Normal appendix.
4. Other incidental findings listed above.
HIP XRAY
## FINDINGS:
Comparison is made to the CT scan from .
Contrast material is seen throughout the colon. There are
severe degenerative changes of the lower lumbar spine with
numerous compression deformities, better assessed on the recent
CT scan. Since the prior study, compression deformity of L4 was
severe. Bilateral hip joint spaces demonstrate mild
degenerative changes with some minimal joint space narrowing and
spurring superolaterally. There are also proliferative changes
of pubic symphysis. No focal lytic or blastic lesions are
identified. There is some calcification adjacent to the left
greater trochanter which may represent calcific
tendinitis.
Discharge labs:
RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
9.0 3.46 11.5 34.9 101 33.3 33.0 13.2 189
Glucose UreaN Creat Na K Cl HCO3
84 20 1.0 137 4.1 101 24
## ECG:
sinus, rate , normal axis/intervals, no ST-T wave
changes
## BRIEF HOSPITAL COURSE:
year old female with h/o osteoporosis and ulcerative colitis
presents with one month of progressive low back pain.
## # BACK PAIN:
On imaging pt had evidence of chronic L3, L4
compression fractures and a more recent L1 compression fracture.
No evidence of cord compromise. She was transfered to for
neurosurgical evaluation. The neurosurgical service recommended
conservative management with pain control and TLSO brace for
comfort. There is no need for neurosurgical follow up. The brace
made the patient more uncomfortable, and was discontinued.
Her exam was more consistent with left SI joint
sprain/inflammation, as there was point tenderness in this area,
and not over the spinous processes. She received standing
acetaminophen, ibuprofen, lidocaine patch, and heat pads PRN,
and was able to work with physical therapy. She was seen by the
chronic pain service, and if she needs a left SI joint
corticosteroid injection, this can occur on as
scheduled. If patient needs more pain control than current
regimen, would recommend tramadol 50 mg PO Q4H PRN pain. plan
in page 1 worksheet.
# HTN- atenolol
# Osteoporosis/compression fractures- pain control as above,
nasal calcitonin, vitamin D
# Hypothyroidisim- Synthroid
# Anxiety- at times uncontrolled, continuing triazolam TID PRN
# Glaucoma- eye drops
Full code
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 25 mg PO HS
2. Atenolol 50 mg PO QAM
3. Lisinopril 10 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Calcitonin Salmon 200 UNIT NAS DAILY
7. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QHS
8. Hydrocortisone Acetate Suppository AILY PRN UC
flare
9. Mesalamine Enema AILY:PRN UC flare
10. Clorazepate Dipotassium 3.75 mg PO HS:PRN insomnia
11. TRIAzolam 0.25 mg PO QHS:PRN insomnia
12. Vitamin D 4000 UNIT PO DAILY
13. Ascorbic Acid mg PO DAILY
14. Cyanocobalamin 50 mcg PO DAILY
15. Calcium Carbonate 500 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Atenolol 25 mg PO HS
2. Atenolol 50 mg PO QAM
3. Calcitonin Salmon 200 UNIT NAS DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. TRIAzolam 0.125 mg PO TID:PRN anxiety, insomnia
8. Vitamin D 4000 UNIT PO DAILY
9. Acetaminophen 1000 mg PO TID
10. Ibuprofen 400 mg PO TID Duration: 4 Days
11. Lidocaine 5% Patch 1 PTCH TD QAM
to left SI joint
12. Omeprazole 20 mg PO DAILY Duration: 14 Days
13. Ascorbic Acid mg PO DAILY
14. Calcium Carbonate 500 mg PO DAILY
15. Cyanocobalamin 50 mcg PO DAILY
16. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QHS
17. Hydrocortisone Acetate Suppository AILY PRN UC
flare
18. Mesalamine Enema AILY:PRN UC flare
19. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
## FACILITY:
Diagnosis:
Primary diagnosis:
left SI joint sprain/inflammation
Secondary diagnoses:
anxiety
osteoporosis
lumbar compression fractures
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were admitted with back pain. You had imaging at
that showed lumbar spinal compression fractures. You
were evaluated by neurosurgery, who suggested a back brace for
comfort. Your exam was more consistent with joint inflammation
in the left lower back, and the brace made you uncomfortable, so
this was stopped.
Your pain gradually improved with medications, and you will
continue physical therapy at rehab.
Please see below for your follow up appointments and
medications.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10087981", "visit_id": "26111029", "time": "2159-04-15 00:00:00"} |
19661755-RR-8 | 87 | ## INDICATION:
year old man with COPD, HTN, here with sepsis
cholecystitis.// Perc Chole Drain.
## OPERATORS:
Dr. , radiology trainee and Dr.
radiologist. Dr. supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
## SEDATION:
No moderate sedation was delivered. 1% lidocaine solution was
given for local anesthesia, as above.
## FINDINGS:
Unchanged distended gallbladder, as on prior ultrasound. No cholelithiasis
identified.
## IMPRESSION:
Successful ultrasound-guided placement of pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19661755", "visit_id": "26721629", "time": "2151-02-18 14:17:00"} |
10553449-RR-11 | 92 | ## EXAMINATION:
EARLY OB US <14WEEKS
## INDICATION:
year old woman with positive, known pregnancy and continued
spotting. Evaluate dates and viability.
## FINDINGS:
An intrauterine gestational sac is seen and a single living embryo is
identified with a crown rump length of 37 mmrepresenting a gestational age of
10 weeks 5 days. This corresponds satisfactorily with the menstrual dates of
10 weeks 2 days. The uterus is normal. A corpus luteum within the right
ovary measures 1.9 cm. The left ovary is unremarkable.
## IMPRESSION:
Single live intrauterine pregnancy with size = dates.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10553449", "visit_id": "N/A", "time": "2134-01-20 11:21:00"} |
10584187-RR-59 | 165 | ## INDICATION:
hx DM, HTN s/p fall from flight of stairs p/w LUE pain, ?LOC
w/ L. SDH/SAH, b/l IVH, L. scapular fx, b/l rib fx, T3/7 vertebral body fx.
Triggering for RR 38// pleas eval for interval changes from prior CXR
## FINDINGS:
In comparison with the study of again noted are prominent
lung markings and redemonstration of patchy opacifications at the lung bases,
overall similar the previous exam. The position of the right apical chest
tube is unchanged. There is no pneumothorax or pleural effusions. Vertebral,
ribs, and left scapular fractures are better characterized on the previous CT.
There is an impacted fracture at the left humeral neck of unknown chronicity.
## IMPRESSION:
Prominent lung markings with redemonstration of patchy opacifications at the
lung bases, largely unchanged from the previous exam. Right apical chest tube
is similarly positioned. There is no pneumothorax or pleural effusions.
There is an impacted fracture of the left humeral neck of unknown chronicity.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10584187", "visit_id": "20489414", "time": "2206-03-15 00:17:00"} |
17194276-DS-48 | 1,433 | ## HISTORY OF PRESENT ILLNESS:
Ms. is a female with a history of
secondary sclerosing cholangitis and biliary cirrhosis
complicated by recurrent hepatic encephalopathy, ascites, portal
hypertension with varices, portal hypertensive gastropathy, who
has had upper GI bleeding from polyps s/p thermal therapy (with
a port-a-cath bc of frequent transfusion need) as well as portal
vein thrombosis seen on recent CT scans, presents with FUO.
Patient notes history of intermittent fever, particularly in the
evening, initiating the week prior to admission. Patient had
intermittent fevers and diarrhea earlier in the week. No
exacerbating or relieving factors. Has been avoiding tylenol
because of liver disease, although she did take one 650 mg dose.
Over the last 2 days, because of outpatient workup, has had 8
total blood cultures drawn. NGTD on these to date. CT scan
abdomen also performed on , which was largely unrevealing
(detailed read below). Patient without additional complaints.
In the ED, initial vitals were 99.5 78 97% RA. Labs
were notable for WBC 2.3, Hgb 9.4, Plt 23 (all of which are
stable); INR 1.5, AP 109. Lactate was 1.4, troponin <0.01, UA
negative. Blood and urine cultures were sent. Exam notable for
normal mental status, no asterixis, no localizing source of
infectionn, port site c/d/i, abdomen soft with fluid wave but
without rebound, guarding, or tenderness. CXR negative. Patient
had a bedside ultrasound in the ED that showed no obvious
ascites that could be safely tapped for diagnostis paracentesis.
She was started empirically on ceftriaxone and flagyl and
admitted to for further workup of fever.
## PAST MEDICAL HISTORY:
Suspected Non-alcoholic Steatohepatitis (NASH)
S/p Cholecystectomy ( )
Hepaticojejunostomy ( )
Secondary Biliary Cirrhosis
Hepatic Encephalopathy
Esophageal Varices, grade 1
Hemorrhoids, grade 1
Diverticulosis, complicated by diverticular abscess
Desmoid tumor, unresectable, 2 cycles chemotherapy with
Adriamycin and Dacarbazine
Hyperplastic Colonic Polyps (colonoscopy
C. difficile colitis ( )
GERD
Multinodular thyroid goiter, s/p FNA : biopsy shows
microfollicular neoplasm; needs thyroidectomy
Obstructive Sleep Apnea
Type II Diabetes
Spinal Stenosis
Peripheral Neuropathy
## FAMILY HISTORY:
Her mother has diabetes and hypertension. Her father died at the
age of from congestive heart failure. Maternal aunt died at
the age of from pancreatic cancer.
## HEENT:
Sclera anicteric. PERRL, EOMI.
## CARDIAC:
RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
## ABDOMEN:
Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly.
+Fluid wave
## MICROBIOLOGY:
4:04 pm STOOL CONSISTENCY: NOT APPLICABLE
## SOURCE:
Stool.
C. difficile DNA amplification assay (Final :
Reported to and read back by 9:45AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
## FECAL CULTURE (FINAL :
NO SALMONELLA OR SHIGELLA
FOUND.
## CAMPYLOBACTER CULTURE (FINAL :
NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O YERSINIA (Preliminary):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final :
NO E.COLI 0157:H7 FOUND.
## IMPRESSION:
1. Cirrhotic liver with signs of portal hypertension including
splenomegaly and multiple portosystemic venous collaterals
within the mesenteries, not significantly changed compared to
prior study.
2. Non-occlusive filling defect within the main portal vein,
consistent with thrombosis and partial occlusion is unchanged.
3. Soft tissue mesenteric mass remains stable. This was biopsied
in and was shown to be a desmoid.
4. Small loculated fluid collection at the liver hilum is
unchanged in amount and appearance compared to the prior study.
There are no clear signs of choliangitis, but it cannot be
completely excluded on this study.
5. Stable left hydrosalpinx.
EGD
## LUMEN:
A sliding medium size hiatal hernia was seen.
Protruding Lesions 1 cords of grade II varices were seen in the
lower third of the esophagus. The varices were not bleeding.
## MUCOSA:
Localized discontinuous erythema and congestion of the
mucosa with no bleeding were noted in the stomach body and
fundus. These findings are compatible with mild portal
gastropathy.
Protruding Lesions Many sessile bleeding polyps with recent
stigmata of bleeding of benign appearance were found in the
stomach body. An Argon-Plasma Coagulator was applied for
hemostasis successfully.
Other Prior GAVE in the antrum treated with APC improved
## IMPRESSION:
Varices at the lower third of the esophagus
Medium hiatal hernia
Erythema and congestion in the stomach body and fundus
compatible with mild portal gastropathy
Polyps in the stomach body (thermal therapy)
Prior GAVE in the antrum treated with APC improved
Otherwise normal EGD to third part of the duodenum
CXR (PA/Lat)
## FINDINGS:
Frontal and lateral views of the chest. As on prior, there is
elevation of the right hemidiaphragm. Region of consolidation
at the right lung base laterally is most suggestive of
atelectasis, similar to prior CT scan. The lungs are otherwise
clear. Cardiomediastinal silhouette is within normal limits.
Right chest wall port is seen with catheter tip in the lower
SVC. Osseous and soft tissue structures are unremarkable.
## IMPRESSION:
No acute cardiopulmonary process.
## BRIEF HOSPITAL COURSE:
with hx of secondary sclerosing cholangitis and biliary
cirrhosis complicated by recurrent hepatic encephalopathy,
ascites, portal hypertension with varices, portal hypertensive
gastropathy, who has had upper GI bleeding from polyps, s/p
thermal therapy as well as portal vein thrombosis seen on recent
CT, who presented with fever.
## # C DIFF:
Pt presented with report of fevers and increased
stools and was placed on empiric abx with ceftriaxone and flagyl
to cover SBP vs. acute hepatobiliary infection. There was
insufficient ascites on ultrasound for paracentesis.Pt's
indwelling port-a-cath was considered as an infectious source,
but blood cultures were negative. Urine cultures were also
negative. Stool studies revealed positive c diff PCR and
patient was switched to PO vancomycin given prior episode of C
diff in . Stool frequency decreased and patient was
discharged with plan to complete 10 day course PO vancymycin.
## # SECONDARY BILIARY CIRRHOSIS:
Complicated by varices, hepatic
encephalopathy and SBP and recently found to have likely chronic
portal vein thrombosis. Home lasix and aldactone were continued
as was home nadolol given h/o grade 2 varices. Bactrim
prophylaxis was held while patient on ceftriaxone/flagyl, but
restarted at discharge. She was discharged with plan to
follow-up with Dr. have MRI in for portal vein
evaluation.
## # HEPATIC ENCEPHALOPATHY:
Patient had a history of recurrent
hepatic encephalopathy, but without signs of HE this admission.
Home lactulose and rifaximin were continued.
## # ANEMIA:
Iron deficiency anemia as well as anemia of chronic
disease. Iron supplementation was continued.
## TRANSITIONAL ISSUES:
-Pt scheduled for follow-up of stomach polyps discovered on EGD
in
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Furosemide 80 mg PO DAILY
3. Lactulose 15 mL PO BID
4. Nadolol 40 mg PO DAILY
give after EGD, hold for hr<55 sbp<90
5. Rifaximin 550 mg PO BID
6. Spironolactone 100 mg PO BID
7. Sucralfate 1 gm PO QID
8. Vitamin D 800 UNIT PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Calcium Carbonate 500 mg PO BID
11. Omeprazole 20 mg PO BID
## DISCHARGE MEDICATIONS:
1. Calcium Carbonate 500 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Furosemide 80 mg PO DAILY
4. Lactulose 15 mL PO BID
5. Nadolol 40 mg PO DAILY
give after EGD, hold for hr<55 sbp<90
6. Omeprazole 20 mg PO BID
7. Rifaximin 550 mg PO BID
8. Spironolactone 100 mg PO BID
9. Sucralfate 1 gm PO QID
10. Vitamin D 800 UNIT PO DAILY
11. Vancomycin Oral Liquid mg PO Q6H Duration: 10 Days
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every 6
hours Disp #*36 Capsule Refills:*0
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
## SECONDARY DIAGNOSES:
Secondary biliary cirrhosis
Anemia
Diabetes mellitus
## MS. :
It was a pleasure to take care of you. You were admitted to the
because of fevers. We treated you with antibiotics and
performed many studies to evaluate you for potential sources of
fever and you were found to have an infection called Clostridium
difficile which was causing diarrhea. We treated this with an
antibiotic called vancomycin, which you should continue to take
for a total of 10 days.
Weigh yourself every morning, and call your primary care doctor
if your weight goes up more than three pounds.
Please start:
VANCOMYCIN 125 mg by mouth every 6 hours, take through
*Prescription has been faxed to pharmacy on .*
Please see below for your follow-up appointments.
Wishing you all the best!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17194276", "visit_id": "20557856", "time": "2148-07-18 00:00:00"} |
12863021-RR-14 | 118 | ## NOTE:
This study was performed emergently and therefore evaluation of the
fetus is limited.
## FINDINGS:
There is a single live intrauterine gestation with a fetal heart
rate of 150 BPM. The fetus is in cephalic position. The placenta is
anterior. There is no evidence of previa. Cord insertion appears to be along
the inferior margin of the placenta. There is a normal amount of amniotic
fluid. The cervix is closed and the length is normal. The remainder of the
uterus is normal. The following biometric data were obtained:
## IMPRESSION:
1. Single live intrauterine pregnancy. Size equals dates.
2. Findings suggestive of marginal cord insertion. This can be reassessed
during the patient's dedicated full fetal survey.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12863021", "visit_id": "N/A", "time": "2143-01-25 08:20:00"} |
11548046-RR-75 | 91 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## HISTORY:
with fall, head strike, neck pain // evaluate for
acute pathology
## DOSE:
Total exam DLP: 852 mGy-cm.
## FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
## IMPRESSION:
1. No acute intracranial pathology.
2. No evidence of fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11548046", "visit_id": "N/A", "time": "2176-12-23 12:24:00"} |
17696678-DS-20 | 2,174 | ## HISTORY OF PRESENT ILLNESS:
Mr is a y/o male with widely metastatic,
hormone-refractory prostate CA with known metastatic disease to
pelvis, abdomen, bone, and pleura, recently admitted for
management of bilateral malignant effusions s/p left sided
thorascopy and pleurodesis on , found to have new liver
mets and initiated on Docetaxel, now C1D9, who returns from
clinic with febrile neutropenia.
.
The patient was doing well at home after discharge 1 week ago
until the day prior to admission. He had gone outside for the
first time, and when he got back inside he started having
chills. Later yesterday evening, the patient had a fever of 102,
which came down to 101.6 with some ice chips. His temperature
continued to trend downward to 99 overnight. He did not take any
Tylenol. He notes that he has had some L posterior and anterior
sharp chest wall pain that is worse than prior. He was short of
breath yesterday, but better now after his PleurX catheter was
drained in clinic. They have been draining 200-500cc/day at
home, but were only able to get out 75cc yesterday despite
positional maneuvers. The patient did not have any other new
symptoms. Nausea/vomiting has been controlled with Zofran and
Compazine. He has a persistent dry cough, but no sputum
production. He did not call anyone last night regarding the
fever since he already had an appointment scheduled with Dr.
. At the clinic appointment, the patient was noted
to be neutropenic ( 630), so he was admitted for febrile
neutropenia. He was afebrile in clinic T97.5.
.
On the floor, initial VS: 98.3 105/59 93 16 99%RA. The patient
has some L sided chest wall pain and nausea. No shortness of
breath.
.
## REVIEW OF SYSTEMS:
(+) Per HPI
(-) Review of Systems: HEENT: No headache, sinus tenderness,
rhinorrhea or congestion. CV: No chest tightness, palpitations.
## GI:
No diarrhea. No recent change in bowel habits, no
hematochezia or melena. GUI: No dysuria or change in bladder
habits. MSK: No arthritis, arthralgias, or myalgias. NEURO: No
numbness/tingling in extremities. PSYCH: No feelings of
depression or anxiety. All other review of systems negative.
.
## /10:
Initially presented with several weeks of chest
and abdominal pain; abdominal/pelvic CT scan showed abdominal
lymphadenopathy mainly retroperitoneal, involving the
periaortic, retrocrural and bilaterally iliac regions. Many
hyperenhancing and a few necrotic nodes were present. Findings
highly suggestive of neoplastic disease.
## :
underwent a surgical excision of a retroperitoneal
lymph node. Pathology was notable for a poorly-differentiated
adenocarcinoma consistent with prostate origin.
Immunohistochemical staining was (+) for cytokeratin cocktail,
prostate specific antigen and prostate acid phosphatase, and
(-)for cytokeratin 7, cytokeratin 20, S100, MART-1, HMB-45, and
CD30.
## :
PSA of 111.
TREATMENT COURSE
## :
PSA further increased to 173.3, with testosterone of
401. Pt started degarelix the same day. He underwent Chest CT
which was
unrevealing and bone scan which showed focal tracer uptake in
mid
c-spine and left of L4-5 probably representing degenerative
changes. Shortly thereafter pt developed scrotal swelling,
testicular ultrasound ultrasound showed a left varicocele.
## :
PSA the next month was 169.3 with testosterone 270, he
received a second dose of degarelix.
PSA was 73.8, testosterone 166, the following week PSA
was 73.8 and testosterone 58.1.
## :
switched to Lupron/Casodex with improvement in his
PSA down to 14.2
## :
testosterone at the time was 7. He has continued on
Lupron subsequently, receiving monthly injections apart from
3-month dose as pt was travelling to . His PSA began to
rise to 32.5
which prompted addition of ketoconazole, hydrocortisone and
dutasteride. PSA again declined down to nadir of 13.0 on
.
## :
pt developed leg swelling, work-up for DVT was
negative. This was felt to be due to obstructive lymphadenopathy
and he began radiation therapy to pelvis from .
He
travelled to with his wife from through
. PSA in in was reportedly 12.
.
pt noted abdominal bloating and back pain. A
chest/abdomen/pelvis CT on showed extensive bulky
adenopathy in the retrocrural space extending through the
retroperitoneum with some increase in extent of lymphadenopathy.
Lymphadenopathy appeared more prominent. Within the pelvis,
there was also extensive bulky adenopathy, which appeared
slightly decreased in size. Distal loops of large bowel and
rectum were of normal sizeand caliber. There was loss of disk
space at L5-S1. Bone scan on showed new activity at T10
corresponding to a lucent and sclerotic lesion as well as a new
linear focus of activity in the fourth left posterior rib. MRI
of the T and L-spine on showed involvement of T6 and T7
posteriorly, T10 with moderate loss of height due to endplate
irregularity, T12 and L1 without cortical breakthrough or
disease within the epidural space. He
began radiation therapy to T9- T11 spine and retroperitoneal
nodes . He presented shortly after finishing radiation
therapy
with worsening shortness of breath,
.
Chest CT showed new bilateral pleural effusions. He
underwent a left sided thoracentesis on for 600cc,
cytology was positive for malignant cells. He then travelled to
and after returning
underwent a right sided thoracentesis on , 850cc were
removed. It was noted that his left sided effusion had
reaccumulated and plan was for left thorascopy with pleurodesis
on .
.
Repeat CT abdomen on showed progression of disease.
Patient was started on Docetaxel .
.
## OTHER PAST MEDICAL HISTORY:
S/P tonsillectomy
History of degenerative joint disease
Asthma
Dupuytren contracture involving his hands
Hypercholesterolemia
## FAMILY HISTORY:
Father died of metastatic lung cancer. Maternal grandfather had
throat cancer. Mother is otherwise alive and well.
## HEENT:
PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
## CARDS:
RR S1/S2 normal. no murmurs/gallops/rubs.
## PULM:
decreased breath sounds at the bases R>L, no wheezes
## ABD:
BS+, soft, distended, diffusely tender, no
rebound/guarding, no HSM, no sign
## EXTREMITIES:
2+ edema to groin bilaterally
.
On discharge:
## HEENT:
PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
## CARDS:
RR S1/S2 normal. no murmurs/gallops/rubs.
## PULM:
decreased breath sounds at the bases R>L, no wheezes;
stitch removed from pleurex site.
## ABD:
BS+, soft, distended, diffusely tender, no
rebound/guarding, no HSM, no sign
## EXTREMITIES:
2+ edema to groin bilaterally
## IMAGING:
CXR PA and Lateral
## HISTORY:
Metastatic prostate cancer after chemotherapy, now with
fever.
## FINDINGS:
In comparison with the study of , there is improved
aeration at
the right base consistent with resolution of some of the
atelectasis. Small
persistent right effusion. Mild residual pleural effusion on the
left.
No evidence of vascular congestion or definite acute focal
pneumonia.
## BRIEF HOSPITAL COURSE:
Mr is a y/o male with widely metastatic
hormone-refractory prostate CA (metastatic to pelvis, abdomen,
bone, and pleura) with course complicated by persistent
bilateral malignant pleural effusions; s/p left sided thorascopy
and pleurodesis on , now C1D9 of Docetaxel, presented
from clinic with febrile neutropenia.
.
#. Febrile Neutropenia: Patient with temperature spike to 102 on
day prior to admission. On admission patient without localizing
signs or symptoms of infection. CXR with evidence of
reaccumulation of effusion however without focal infiltrate.
Urine and blood cultures on admission: NGTD. Pleurex site
without tenderness, erythema or drainage. Patient broadly
covered with cefepime and vanc (in the setting of the pleurex).
Patient continued on IV regimen for 3 days. Concurrently he was
administered 2 doses of Neupogen. Counts recovered by hospital
day 4 and patient transitioned to PO Levofloxacin for ppx
antibiotics in setting of recent febrile neutropenia of unknown
source. Patient administered one dose of levofloxacin prior to
discharge to ensure lack to side effect. Of note patient
remained afebrile throughout admission and at time of discharge
patient hemodynamically stable, afebrile with stable CBC.
## OUTPATIENT ISSUES:
-- Consider use of neupogen with next dose of taxotere to
prevent neutropenia.
.
# Metastatic prostate cancer with known mets to pelvis, abdomen,
bone, and pleura with evidence of new liver metastasis
reflective of disease progression on last admission. Patient has
previously completed radiation therapy to his pelvic and
retroperitoneal lymphadenopathy as well as thoracic spine. On
this admission he was Cycle1Day9 of taxotere. PSA 132. Overall
patient tolerated taxotere well with limited side effects though
did become neutropenic which was treated with Neupogen. In house
pain regimen transitioned from oxycontin to morphine XR with
good relief. Patient was supported with anti-emetic as needed.
Social work continued to work with the family with coping and
grieving.
## OUTPATIENT ISSUES:
-- Close outpatient follow-up with primary oncologist to
determine next schedule of next chemo cycle.
.
# Malignant effusions s/p pleuroscopy and pleurodesis. On
admission CXR with evidence of persistent right sided effusion.
Pleurex drained daily in house with average output ~250-500
daily. Catheter site was monitored daily with daily dressing
changes. Prior to discharge pleurex stitch removed. Surrounding
skin appeared well healed with no sign of infection. Per IP plan
for catheter removal when output is less than 50cc for 3
consecutive days.
## OUTPATIENT ISSUES:
-- Daily monitoring of pleurex drainage with plan to follow-up
with IP when drainage slows to less than 50cc daily x3 days for
possible removal.
.
# Hyponatremia. Chronic problem thought secondary to SIADH in
setting of known lung/pleural pathology as well as some degree
of intravasculature repletion. Patient placed on a 1500cc total
fluid restriction; 1000cc free water restriction. Transfused
2units of pRBCs with improvement in Na to 128. Na stable at 126
on discharge.
## OUTPATIENT ISSUES:
-- Continue free water restriction
-- Continue monitoring of sodium levels
.
# Thrombocytopenia. Admission 65. Likely multifactorial in
setting of recent chemo, likely malignant marrow involvement and
chronic DIC in setting of underlying malignany. Platelet count
monitored daily; counts remained stable with no need for
transfusion in house.
.
# Anemia. HCT nadired at 22. Patient was transfused 2u of pRBCs
with appropriate elevation in HCT. HCT stable (33) at time of
discharge.
# Constipation. Likely secondary to narcotic use. Patient
continued on liberal laxatives with bowel movement daily to
every other day.
.
# Lower extremity edema of back/legs/scrotum. Likely
multifactorial in setting of lymphatic obstruction, low albumin,
decreased mobility. US demonstrated enlarged inguinal
lymphadenopathy bilaterally however was without evidence of DVT
in lower extremities. Edema managed supportively with
compression stockings, elevation, and OOB with mobilization as
tolerated. Stable 2+ edema at time of discharge.
.
## MEDICATIONS ON ADMISSION:
Doxazosin 3mg PO qhs
Benzonatate 200mg PO TID
Neurontin 300mg PO q24h
Zofran 8mg PO q8h prn nausea
Oxycodone PO q4h prn pain
Compazine 10mg PO q6h prn
Crestor 10mg PO daily
Colace 100mg PO BID
MVI 0.5tab PO BID
Miralax 1pkt PO daily
Senna 1tab PO BID
Flovent 2puffs INH BID
.
## DISCHARGE MEDICATIONS:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. oxycodone 5 mg Tablet Sig: Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: Tablets PO BID (2 times a day).
4. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release(s)* Refills:*0*
6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
7. doxazosin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
11. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
## 12. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY
(Daily).
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. guaifenesin 100 mg/5 mL Syrup Sig: MLs PO Q6H (every 6
hours) as needed for cough.
## DISCHARGE INSTRUCTIONS:
Dear Mr it was a pleasure taking care of you.
.
You were admitted for treatment and evaluation of fever in the
setting of low white blood cell. You were started on IV
antibiotics and your blood counts and fever curve closely
monitored. You remained afebrile in house. You were given a
medication, Neupogen, to help stimulate white blood cell
production. You received 2 doses and your counts rose to an
appropriate level. You were transitioned to PO antibiotics on
the day of discharge.
.
Prior to discharge the suture around your pleurex catheter was
removed; you should call to schedule a follow-up appt with
Interventional Pulmonary Department when pleurex drainage
becomes less than 50cc/day x3 consectutive days or if you have
any problems with pleurex.
.
## CHANGES TO YOUR MEDICATIONS:
START taking Levofloxacin 750mg tablets. Take one tablet daily
for a total of 7 days.
.
To control pain:
START taking Morphine XR (in lieu of oxycontin)
CONTINUE taking Oxycodone 5mg tablets. Take every 4hrs as
needed for pain.
.
Again it was a pleasure taking care of you. Please contact with
any questions or concerns.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17696678", "visit_id": "23555807", "time": "2128-09-03 00:00:00"} |
18979146-DS-24 | 1,739 | ## CHIEF COMPLAINT:
chest pain, flank pain, abdominal pain
## HISTORY OF PRESENT ILLNESS:
with a history of alcohol use disorder complicated by
withdrawal, hepatic steatosis, hypertension, tobacco use, and
GERD who presents with chest pain and flank pain found to have
hyperbilirubinemia and AST predominant transaminitis concerning
for alcoholic hepatitis and/or decompensated cirrhosis.
He reports two weeks of increasing abdominal distention. He
denies any fevers/chills. He has had intermittent
nausea/vomiting. He also noted some specks of bright red blood
in
his stools but no black tarry stools. Starting two days prior to
presentation he noted bilateral flank pain, but denies dysuria
or
hematuria. In the ED, he says he drinks about 3 alcoholic
beverages per day.
He has been noted to have alcoholic steatosis of his liver since
at least years ago. He has had persistently elevated AST but
has never had a liver biopsy or Fibroscan, and has never been
seen by a liver doctor at .
## PMH:
HTN, HLD, Eczema, GERD, alcoholic steatosis, Alcohol abuse c/b
withdrawal s/p hospitalization x2, MVA c/b thoracic back
pain
## FAMILY HISTORY:
Father is with diabetes, mother passed at for unknown
cause (?stroke vs. head bleed); reports his siblings are all
healthy; reports no one in family has alcohol-related issues
## GENERAL:
Alert and interactive. In no acute distress.
## HEENT:
PERRL, EOMI. Sclera anicteric and without injection. MMM.
## NECK:
No cervical lymphadenopathy. No JVD.
## CARDIAC:
Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
## LUNGS:
Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
## ABDOMEN:
Distended abdomen, tender in epigastrium.
## EXTREMITIES:
Trace pitting edema in shins. Pulses DP/Radial 2+
bilaterally.
## SKIN:
Warm. Cap refill <2s. No rashes.
## NEUROLOGIC:
AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. No Asterixis.
## GENERAL:
Alert and interactive. In no acute distress.
## HEENT:
PERRL, EOMI. Icteric sclera and without injection. MMM.
NGT in place on R nostril.
## NECK:
No cervical lymphadenopathy. No JVD.
## CARDIAC:
Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
## LUNGS:
Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
## ABDOMEN:
Distended abdomen, positive fluid wave with some mild
tenderness in epigastrum to deep palpation. No guarding, no
rebound tenderness.
## EXTREMITIES:
wwp, no edema b/l. Pulses DP/Radial 2+ bilaterally.
## SKIN:
Warm. Cap refill <2s. No rashes.
## NEUROLOGIC:
AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. No Asterixis.
## URINE:
contaminated
peritoneal fluid: no growth to date
peritoneal fluid in blood culture bottle: no growth to date
blood cx: no growth to date
blood cx: no growth to date
## CHEST (PA & LAT) IMPRESSION:
Bibasilar opacities, presumably due to atelectasis given low
lung volumes.
Possibility of infection would be difficult to exclude entirely.
## LIVER OR GALLBLADDER US IMPRESSION:
1. The liver is heterogeneously hyperechoic, which may be due to
areas
regional areas of fat. Thus, given patient's history of
hepatitis, recommend
further evaluation with the liver MRI to evaluate for underlying
lesion.
2. The portal vein is patent.
ECG Sinus rhythm
compared to previous ECG
then also tds
the rate has decreased
## DX CHEST PORT LINE/TUBE IMPRESSION:
2 sequential images demonstrate advancement of a Dobhoff into
the stomach.
There are low bilateral lung volumes however no focal
consolidation, pleural
effusion or pneumothorax is identified. The size of the cardiac
silhouette is
within normal limits.
## MRI LIVER W&W/O CONTRAS IMPRESSION:
1. Exam is limited by non breath hold technique.
2. Patchy moderate hepatic steatosis.
3. Increased diffusion signal in the remainder of the hepatic
parenchyma, may
be due to acute hepatitis.
4. No focal suspicious hepatic lesions.
5. Sequela of portal hypertension including a recannulized
paraumbilical vein
and small ascites. No splenomegaly.
6. Small right pleural effusion.
## BRIEF HOSPITAL COURSE:
with a history of alcohol use disorder complicated by
withdrawal, hepatic steatosis, hypertension, tobacco use, and
GERD who presented with chest pain and flank pain found to have
hyperbilirubinemia and AST predominant transaminitis consistent
with alcoholic hepatitis.
TRANSITIONAL ISSUES
===================
[] Vaccinate for HBV
[] Will need EGD screening for varices as outpatient
[] Consider re-introduction of furosemide and spironolactone as
outpatient. This was held at discharge as patient with
unclear follow up due to his leaving prematurely
[] Will need intensive nutrition rehabilitation to manage his
alcoholic hepatitis
[] Patient counseled to avoid alcohol and should continue to
receive support for this
## ACUTE/ACTIVE ISSUES:
====================
# Alcoholic hepatitis
# Concern for decompensated cirrhosis
## DF:
30.5
He has a history of alcohol use disorder and steatosis, never
followed up in liver clinic. He presented with abdominal pain,
AST predominant transaminitis, and elevated bilirubin concerning
for alcoholic hepatitis. Otherwise, workup was only notable for
HAV positive. He also has underlying cirrhosis given his
thrombocytopenia. He is currently decompensated by ascites and
coagulopathy as well. Liver MRI showed patchy moderate hepatic
steatosis and parenchyma showing acute hepatitis. He has ascites
on exam and imaging and received diuresis with Lasix and
spironolactone. Ascitic fluid studies were negative for SBP, and
a pan-infectious w/u was unrevealing. There is currently no EGD
on record, and he will eventually need screening for varices as
outpatient. He will also need intensive nutritional support
for his alcoholic hepatitis. Consider re-introduction of
furosemide and spironolactone as outpatient. This was held at
discharge as patient with unclear follow up due to his leaving
prematurely.
# Patient leaving despite medical recommendation to continue
inpatient care
Unfortunately the patient cited multiple reasons for leaving the
hospital despite medical recommendations. He understood the
risks associated with leaving and communicated that if he became
ill would seek medical attention. was unable to tolerate this
and subsequently cut his NG tube. He left the floor and was
found and returned to the floor without incident. The medical
team had hour long discussion with him with interpreter.
He was adamant about leaving the hospital because he needed to
go to work to earn money. He said that he felt fine and that he
felt that since he had stopped drinking alcohol, his liver would
be fine. We explained to him that although he felt like he was
healthy, his liver function was acutely worsening and that he
would need to continue the nutrition through the NG to help,
since his PO intake was so poor. We explained to him that the
nutrition team had recommended tube feeds because his PO intake
was not adequately satisfying his nutritional needs. We
explained the risks of leaving the hospital without nutrition
and observation of his liver function tests and overall clinical
status many times, but the patient continued to want to leave.
We explained how a social worker may be able to help with his
job situation, because he mentioned that his boss wanted him to
come back to work. He declined these interventions.
# Urinary urgency
Pt described some nocturia and increased urinary frequency. A UA
was negative. Unlikely due to BPH given his age. He was not
retaining based on post-void residual monitoring.
Could be related to his ascites.
# Alcohol use disorder
This is longstanding with previous efforts at sobriety. He
currently is expressing a desire to quit. Pt seems to be showing
some signs of withdrawal on admission including tremors and
diaphoresis, and was placed on CIWA monitoring which he never
scored on. Social work was consulted for his alcohol use, and
his nutrition was supplemented with folate, thiamine, and
multivitamins.
# Macrocytic anemia
This is likely from alcohol use and liver disease. CBC was
trended daily.
# Thrombocytopenia
This is likely from sequestration from splenomegaly. CBC was
trended daily.
# Coagulopathy
This is likely synthetic liver dysfunction I/s/o likely
underlying
cirrhosis. His INR was trended and he was given vitamin K.
# Hypertension
He continued home Amlodipine. His and HCTZ was held upon the
initiation of diuretics.
## # CODE:
full
# CONTACT: (sister) -- she was contacted after
the patient left and will try to convince him to return
## MEDICATIONS ON ADMISSION:
1. amLODIPine 10 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
## PRIMARY DIAGNOSIS:
alcoholic hepatitis with decompensated
cirrhosis, severe malnutrition, alcohol use disorder
## SECONDARY DIAGNOSIS:
tobacco use disorder, coagulopathy
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure caring for you at
.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for chest pain, side pain,
and abdominal pain and you also had a very sick liver
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- To help your liver heal, you required nutrition and vitamins,
and we gave this to you through a tube
- We put a tube through your nose that went into your stomach to
help your liver
- You removed the tube because it was making you sneeze and
cough
- We explained that it is very important for you to have this
tube in through your nose to help your nutrition
- You were very concerned about your employment status and your
children, and you wanted to go to work even though we said it
was very dangerous to leave the hospital
- You communicated your understanding of the risks associated
with your liver disease and understand that you need to avoid
alcohol and focus on nutrition to recover
- With all the information we gave you, you decided to leave the
hospital despite our recommendation
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Please avoid drinking alcohol as it is extremely harmful to
your liver
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
- It is very important to keep track of your health.
- If you notice your skin or your eyes turning yellow, you need
to go to the hospital
- If you start feeling nauseous or start vomiting, you need to
go to the hospital
- If you notice your belly becoming bigger or you have trouble
breathing, you need to go to the hospital
We wish you the best!
Sincerely,
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18979146", "visit_id": "25506996", "time": "2191-08-02 00:00:00"} |
15770461-DS-20 | 1,967 | ## ALLERGIES:
Augmentin / oxycodone / timolol
## HISTORY OF PRESENT ILLNESS:
is a with a history of CVA, HTN, RA on MTX,
ulcerative colitis and conservatively managed DLBCL/MALT
previously restricted to left parotid s/p parotidectomy in
who presents with PO intolerance, RUQ abdominal pain found to
have likely diffusely metastatic lymphoma, possible
cholecystitis, and anasarca, now admitted for conservative
management.
Caretaker called Atirus:
=================================
Live telephone call with , visiting nurse with
while she was in the house with the patient who requires
visit at home today due to abdominal pain.
History of extremely elevated LFTs in - no known etiology
apparent in chart. Have generally normalized since then.
Pt and aide reports abdominal pain in upper right hand quadrant
for days. Tender to palpation. Pt screams out when touched,
moaning and groaning when not touched- unable to rate pain or
characterize due to baseline mental status. Has been affecting
ability to eat, has not eaten well in the past few days. Has
had a couple cans of ensure but that's it. Hydration baseline,
however, at baseline her intake is notably poor.
Denies headache, nausea, vomiting, diarrhea, constipation. Most
recent BM today.
## VS:
BP sitting 120/62
Heartrate 95
O2 Sat 97%
Temp 100 TA
## CONSTITUTIONAL:
Appears very uncomfortable. Moaning without
being touched. Yells out when touched.
## ABD:
exquisite tenderness with palpation of RUQ
:
===========================
MD:
w/ h/o HLD, CAD, HTN, CVA w/ RUE/RLE weakness, heart
disease, lymphoma, dementia, presenting with her caretaker with
increased RUQ pain for the past 3 days, waxing/waning, without
vomiting but with greatly dec PO intake, not tolerating any food
and losing interest in it. No chest pain, shortness of breath,
dysuria, frequency, fevers, chills, diarrhea or constipation,
though limited by patient mental status. Caretaker called
nursing staff to evaluate who recommended evaluation.
##
:
NURSE
arrived via EMS transport from home w/ caregiver. Pt has had
1.5 weeks of poor PO intake and RUQ pain x2 days, Tylenol given
last night w/ minimal relief, pt no longer yelling out in pain.
Hx received from carvegiver. Pt has hx of CVAx2, pt is alert
intermittently spontaneously, consistently reactive to
voice/name. R sided weakness and L facial droop. Per caregiver
pt is verbal w/ slurred speech at baseline. All consistent w/
baseline. Per caregiver pt previously denied any CP. RR even,
unlabored, NAD noted. Per caregiver, pt has had poor POs for 1.5
weeks. RUQ pain, guarding at home PTA, pain w/ palpation noted.
No n/v/d. Minimal flatus, but LBM of formed stool today.
In the , initial vitals were: 17:16 UNABLE 97.5 98 115/68 22
98% RA
Exam notable for patient appearing being Aox1 comfortable, weak,
dehydrated with RUE flexed against the body, and abd focally
very ttp RUQ, RLQ, +rebound +bs. Also no peripheral edema.
Labs notable for
## FLUBPCR:
Negative
Color Yellow / Appear Clear / SpecGr 1.015 /pH 6.0/ Urobil
0.2 / Bili Neg / Leuk Tr / Bld Neg / Nitr Neg / Prot 100 /
Glu Neg / Ket Neg / RBC 1 / WBC 6 / Bact Few / Yeast None / Epi
0
## :
Lip: 22
96
9.2 \ 10.
/ 32.1 \
N:82.4 L:7.2 M:8.3 E:0.9 Bas:0.4 : 0.8
Imaging notable for CT Abd/Pel with
. Findings of fluid overload including periportal edema,
gallbladder wall edema, mesenteric congestion, ascites, and body
wall edema.
2. Marked splenomegaly, increased since the previous PET-CT with
mass effect upon the left kidney. This may be reflective of
lymphoma.
3. Ill-defined hypodense lesions within the liver and spleen may
be reflective of lymphoma given the patient's history, or other
metastases, but are incompletely characterized on this study and
appear new from the previous PET-CT. If further evaluation of
these hepatic and splenic lesions are desired, MRI with contrast
can be obtained or alternatively, consider direct sampling.
4. Equivocal wall thickening of the descending colon may be
secondary to underdistention, however mild colitis cannot be
excluded.
Patient was given
19:06 IVF NS
20:00 IV Ketorolac 10 mg
20:00 PR Acetaminophen 650 mg
20:00 IV CefePIME 2 g
20:01 IVF NS
20:32 IV Vancomycin
22:04 IV Vancomycin 1 mg
23:47 IV Thiamine 100 mg
00:17 IV Ketorolac 10 mg
07:03 IVF NS
Patient was seen by ACS who felt that she would not be a CCY
candidate now or in the future, and that she may benefit from
perc-chole placement.
Decision was made to admit for cholecystitis, failure to thrive.
Vitals notable for Today 06:13 97.8 93 120/68 21 98% RA
On the floor, patient is AOx1, denies pain. She asks, "Am I
okay." She is told we are going to call her family and she says,
"okay."
## PAST MEDICAL HISTORY:
- Ulcerative colitis, chronic
- Venous stasis
- Hyperlipidemia
- HTN (hypertension)
- CVA (cerebral vascular accident)
- nerve palsy
- Dry eyes
- DLBCL (diffuse large B cell lymphoma) / Extranodal marginal
zone B-cell lymphoma of mucosa-associated lymphoid tissue
(MALT): found to have growing L parotid mass. She underwent left
parotidectomy with facial nerve dissection and preservation on
at with Dr . Found to have diffuse large
B cell lymphoma of germinal center origin arising in
association with extranodal marginal zone lymphoma of
mucosa-associated lymphoid tissue. Followed by Dr.
from Oncology ( )
- Vascular dementia with behavioral disturbance
- Edentulism
- Iron deficiency anemia
- Contracture of muscle, right upper arm
- Dysphagia following other cerebrovascular disease
- Pressure ulcer, stage 1
## FAMILY HISTORY:
- Diabetes - Type II in her father; in her mother.
- Daughter is HCP
- Son
- 4 grandchildren
## GEN:
cachectic, bedbound older woman lying in bed with eyes
closed, interactive
## HEENT:
Temporal wasting, MM appear dry, poor dentition
## NECK:
Palpable L submandibular and R anterior cervical LNs
## CV:
S1, S2 no m/r/g appreciated
## PULM:
Limited by participation, poor effort
## ABD:
Abdominal fullness in RUQ and L hemi-abdomen diffusely, no
tenderness to palpation, hypoactive bowel sounds
## EXT:
R hand and arm contracture, multiple arthritic joints,
chronic venous stasis changes; R foot is externally rotated
## SKIN:
Limited by positioning, chronic venous stasis
## NEURO:
Limited testing, but does not follow gaze superiorly or
inferiorly; some L handgrip strength; unable to assess R arm;
moves LLE but not RLE; reflexes deferred
## PSYCH:
AOx1, long term memory intact
## GEN:
cachectic, bedbound older woman lying in bed with eyes
closed, interactive
## CV:
S1, S2 flow murmur appreciated
## PULM:
Limited by participation, poor effort
## ABD:
Abdominal fullness in RUQ and L hemi-abdomen diffusely, no
tenderness to palpation, hypoactive bowel sounds
## EXT:
R hand and arm contracture, multiple arthritic joints,
chronic venous stasis changes; R foot is externally rotated
## SKIN:
Limited by positioning, chronic venous stasis
## PSYCH:
AOx1, long term memory intact, expresses desire to go
home
## MICRO:
======
8:00 pm BLOOD CULTURE
## BLOOD CULTURE, ROUTINE (PRELIMINARY):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final :
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by , , ON
AT
4:30 ..
7:35 pm URINE
## URINE CULTURE (PRELIMINARY):
ENTEROCOCCUS SP.. >100,000 CFU/mL.
## ========
9:
BD & PELVIS WITH CONTRAST
## IMPRESSION:
1. Findings of fluid overload including periportal edema,
gallbladder wall edema, mesenteric congestion, ascites, and body
wall edema.
2. Marked splenomegaly, increased since the previous PET-CT with
mass effect upon the left kidney. This may be reflective of
lymphoma.
3. Ill-defined hypodense lesions within the liver and spleen may
be reflective of lymphoma given the patient's history, or other
metastases, but are incompletely characterized on this study and
appear new from the previous PET-CT. If further evaluation of
these hepatic and splenic lesions are desired, MRI with contrast
can be obtained or alternatively, consider direct sampling.
4. Equivocal wall thickening of the descending colon may be
secondary to underdistention, however mild colitis cannot be
excluded.
9:20
CHEST (SINGLE VIEW)
## IMPRESSION:
Mild bibasilar atelectasis. No focal consolidation to suggest
pneumonia.
## BRIEF HOSPITAL COURSE:
with a history of CVA, HTN, RA on MTX, ulcerative colitis
and conservatively managed DLBCL/MALT previously restricted to
left parotid s/p parotidectomy in who presents with PO
intolerance, RUQ abdominal pain found to have likely diffusely
metastatic lymphoma, possible cholecystitis, and anasarca,
admitted for conservative management.
## # GOALS OF :
Spoke w/ patient's daughter and confirmed
form available via Web, that patient is DNR/DNI.
Spoke w/ patient's son at 13:25 and he stated his mother's goals
were to remain at home, just want to treat pain. Both son and
daughter are amenable to hospice. Goals are to not have pain.
Completed new w/ DNR/DNI/DNH. Patient discharged to home
hospice.
# Massive Splenomegaly
# Liver/Spleen lesions
# DLBCL (diffuse large B cell lymphoma) / Extranodal marginal
zone B-cell lymphoma of mucosa-associated lymphoid tissue
(MALT): Imaging on admission consistent with progression of
disease. This would explain her subacute decline as well
including RUQ abdominal pain and anorexia. On admission,
contacted on-call Oncologist who agrees with assessment.
No cytotoxic chemotherapy indicated. Outpt oncologist notified.
## # PO INTOLERANCE:
Likely multifactorial including mass effect of
spleen, abdominal pain, possibly cholecystitis. Patient
reportedly greatly enjoys Ensure, so diet liberalized to soft
solids to maximize quality of life at risk of aspiration
chronic dysphagia.
## # :
History consistent with prerenal etiology, supported by
hypernatremia and improvement w/ IVF. Other consideration is
intrinsic injury. Less likely obstructive as mass effect is
exerted only on the L kidney, without hydronephrosis, and
patient draining clear urine.
## # HYPERNATREMIA:
history consistent with inadequate free water
intake. Improved with IVF
## # FEVERS:
Differential includes infection, malignancy-related.
Less likely related to RA. Received acetaminophen and pain
management.
## # ANASARCA:
Multifactorial including poor nutrition, , heart
failure.
## # TRANSAMINITIS:
Imaging concerning for hepatic lymphoma, as
below. Pattern not consistent w/ cholestasis. Also with AMS.
However, INR 1.2, did not meet criteria of fulminant liver
failure.
## # THROMBOCYTOPENIA:
differential includes sequestration
splenomegaly, poor production from low epo (transaminitis) or
possibly marrow involvement of lymphoma.
## # DYSPHAGIA:
for comfort-focused , liberalized diet as
patient requesting Ensure, water
## ==========================
# CVA:
known deficits including memory, RUE and RLE
# Left hip fracture s/p IMN
For #Atherosclerosis, # Ulcerative colitis, # HTN, # HLD, #
Anemia holding home meds given and transition
to hospice
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO DAILY
2. Methotrexate 25 mg IM WEEKLY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. FoLIC Acid 1 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Losartan Potassium 50 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q4H:PRN
Pain - Severe
4. Senna 17.2 mg PO HS
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. HELD- Methotrexate 25 mg IM WEEKLY This medication was held.
Do not restart Methotrexate until speak with your hospice
team about the risk-benefit of pain relief
7. HELD- Ranitidine 150 mg PO DAILY This medication was held.
Do not restart Ranitidine until speak with your hospice
team
## PRIMARY DIAGNOSIS:
=================
Acute kidney injury
Bacteremia
Failure to thrive
Massive splenomegaly
Thrombocytopenia
## SECONDARY DIAGNOSES:
====================
History of CVA w/ residual deficits
Diffuse large B cell lymphoma
Rheumatoid arthritis, on methotrexate
Sacral pressure ulcer
## DISCHARGE INSTRUCTIONS:
Dear ,
were admitted to the hospital with fevers and acute kidney
injury.
What was done for during this hospitalization?
- received intravenous fluids and your kidney function
improved
- were connected with hospice services and your goals of
were clarified
What should do now that are leaving the hospital?
- Refer medical questions to your hospice team
- If anyone tries to bring to the hospital, show them your
updated form that clearly states your goals of
It was a pleasure taking of . Wishing the best.
Sincerely,
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15770461", "visit_id": "26291897", "time": "2156-04-04 00:00:00"} |
18886241-RR-38 | 126 | ## INDICATION:
year old man with fever// eval for pneumonia
## FINDINGS:
Low lung volumes. Interval diffuse increased opacity at the left lung base
which could reflect moderate left effusion versus new infiltrate, aspiration
or atelectasis. Mild vascular congestion with mild increased perihilar
interstitial opacities in the right lung could reflect mild asymmetric edema.
No pneumothorax.
Moderate cardiomegaly stable.
The feeding tube has been advanced, and although the tip is off the film, the
tube appears at least in the stomach. Right sided dialysis catheter in the
mid SVC as before. Left IJ catheter in the mid SVC stable.
## IMPRESSION:
Interval increased opacity at the left lung base which may reflect new
moderate left effusion, pneumonia or aspiration, or atelectasis.
Possible mild right-sided pulmonary edema
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18886241", "visit_id": "22554453", "time": "2141-03-08 05:52:00"} |
11527917-RR-19 | 459 | ## INDICATION:
year old woman with right UPJ stone and right lower pole
cluster of stones measuring 2-3 cm. Patient with right hydronephrosis and
pain but otherwise stable, no evidence of infection at this time.// Please
place right nephroureteral stent if possible
## OPERATORS:
Dr. ,
performed the procedure.
## ANESTHESIA:
Moderate sedation was provided by administrating divided doses of
150mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 29 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
## MEDICATIONS:
Fentanyl and Versed for moderate sedation as above, 1% local
lidocaine,,
## CONTRAST:
10 ml of Optiray contrast
## FLUOROSCOPY TIME AND DOSE:
Unavailable at the time of dictation
## PROCEDURE:
1. Right ultrasound and fluoroscopic guided renal collecting
system access .
2. Right nephrostogram.
3. Right PCNU tube placement.
## PROCEDURE DETAILS:
Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per
protocol. The right flank was prepped and draped in the usual sterile fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the right renal collecting system was initially attempted to be access through
the stone, however wires were unable to be passed around the stone in the
lower pole. Therefore, and upper pole access was chosen under ultrasound
guidance. A wire was able to easily curl into the lower pole indicating that
these could easily be use for PCNL access. Additionally, the wire was able to
be passed around the UPJ stone. After a skin , the needle was exchanged
for an Accustick sheath. Once the tip of the sheath was in the collecting
system; the sheath was advanced over the wire, inner dilator and metallic
stiffener. The wire and inner dilator were then removed and diluted contrast
was injected into the collecting system to confirm position. A Amplatz wire
was advanced through the sheath and coiled in the bladder. The sheath was
then removed and a 8 PCNU tube was advanced into the bladder. The wire
was then removed and the pigtail was formed in the collecting system. Contrast
injection confirmed appropriate positioning. The catheter was then flushed and
secured with a Stat Lock device and sterile dressings. The catheter was
attached to a bag.
## FINDINGS:
1. Large radiopaque stones in the lower pole of the right kidney as well as
at the UPJ
2. Successful access through an upper pole calyx for future PCNL
## IMPRESSION:
Successful placement of 8 PCNU on the right.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11527917", "visit_id": "24704112", "time": "2173-10-21 11:56:00"} |
18322508-RR-30 | 129 | ## EXAMINATION:
VENOUS DUP EXT UNI (MAP/DVT) LEFT
## INDICATION:
year old woman with a history of metastatic breast cancer with
meningeal carcinomatosis now with left lower extremity pain, evaluate for DVT
or cyst.
## FINDINGS:
There is normal compressibility, flow, and augmentation of the left 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.
In the medial left popliteal region, there is an irregularly-shaped 2.6 x 2.1
x 0.6 cm avascular hypoechoic focus consistent with cyst.
## IMPRESSION:
1. Left-sided 2.6 x 2.1 x 0.6 cyst.
2. No evidence of deep venous thrombosis in the left lower extremity veins.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18322508", "visit_id": "21802571", "time": "2162-01-28 08:40:00"} |
10342727-DS-17 | 1,301 | ## ALLERGIES:
Sulfa (Sulfonamide Antibiotics) / Gentamicin / Amoxicillin /
codeine / OxyContin
## CHIEF COMPLAINT:
LLE wound & pain x 1 week
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
L fem-Tib artery bypass graft w/ propatan graft
Diagnostic LLE angio w/ occluded SFA and pop.
## HISTORY OF PRESENT ILLNESS:
Ms. is a F with PMH T2DM, CAD, HTN, and long
history of PVD with surgical history including left fem-AKpop
bypass with PTFE , c/b occlusion in ,
all requiring open or endovascular thrombectomies,
who presents to the ED on with a wound to the LLE. She
reports that
the wound started 1 week ago as a fluid-filled blister.
She
does not remember any trauma.
## PAST MEDICAL HISTORY:
hyperlipidemia
hypertension
CAD s/p LAD stent
PVD s/p stents to left SFA x 4
Hearing impaired in left ear-wears a hearing aide
h/o ankle fracture
GERD
fasciitis s/p fasciotomy
tonsillectomy
appendectomy
s/p Total abdominal hysterectomy
## :
Left common fem-AK pop bypass with PTFE complicated by
occlusion requiring thrombolysis, 4 compartment fasciotomies
## :
lysis to left fem-pop graft, stent to native AT
## FAMILY HISTORY:
Father and brother both died from MIs at age
## PHYSICAL EXAM:
Neuro; awake alert oriented conversational
## LUNGS:
CTA
ABd soft NT ND + BS
Ext LLE staple lines CDI / no drainage. DP dopplerable. Left
great toe with dry gangrene to medial aspect
## BRIEF HOSPITAL COURSE:
Ms. is a with PMH T2DM, CAD, HTN, DM and long history
of PVD with surgical history including left fem-AKpop bypass
with PTFE , c/b occlusion in
all requiring open or endovascular thrombectomies, who
presents to the ED on with left leg pain and a wound to
the left great toe which has been present x1 week. She was
admitted and placed on heparin drip and antibiotics because of
worsening erythema of her foot.
She underwent a Diagnostic LLE angiogram on which showed:
Complete occlusion of the superficial femoral and popliteal
artery in the left lower extremity.
Due to the long segment occlusion of the entirety of the
superficial femoral and popliteal artery as well as the
patient's nonhealing wound, decision was made to proceed with
common femoral to anterior tibial bypass via a lateral approach.
in view of her low EF and h/o CAD with stents She was seen and
cleared by cardiology for the pprocedure. The heparin drip was
discontinue on and her eliquis started.
She ha sbeen followed by Pod and I&D of her left great toe was
done. Foot Xray was neg. Left leg became swollwen with pain,
neg for DVT. She requested to go to rehab and she has been
evaluated for that on .
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 3.125 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. GlipiZIDE 5 mg PO DAILY
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Apixaban 5 mg PO BID
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q6H
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Glucose Gel 15 g PO PRN hypoglycemia protocol
6. HYDROmorphone (Dilaudid) mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
7. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q4H:PRN Pain -
Moderate
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
9. lansoprazole 30 mg oral DAILY
10. Minocycline 100 mg PO BID Duration: 10 Days
11. Ondansetron 4 mg IV Q8H:PRN Nausea/Vomiting - First Line
12. Prochlorperazine 10 mg IV Q6H:PRN Nausea/Vomiting - Second
Line
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
14. GlipiZIDE 10 mg PO BID
continue with your previously scheduled dosing parameters
according to fsbs
15. Apixaban 5 mg PO BID
16. Atorvastatin 80 mg PO QPM
17. CARVedilol 3.125 mg PO BID
18. Clopidogrel 75 mg PO DAILY
19. Furosemide 40 mg PO DAILY
20. Gabapentin 800 mg PO TID
21. Lisinopril 10 mg PO DAILY
22. MetFORMIN (Glucophage) 1000 mg PO BID
23. Metoprolol Succinate XL 25 mg PO DAILY
## DISCHARGE DIAGNOSIS:
PVD,
DM
HTN, Hypercholesterolemia, CAD
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Ms ,
It was a pleasure taking care of you. You are now being
discharged after undergoing bypass surgery. This was performed
to improve your circulation. You are recovering well. Please
follow the below instructions for an uncomplicated recovery:
## WHAT TO EXPECT:
You may feel tired. This might last for weeks.
You are expected to have some swelling of the leg you were
operated on. Elevate your leg above the level of your heart
(use pillows or a recliner) every hours throughout the
day and at night.
Avoid prolonged periods of standing or sitting without your
legs elevated. You should wear an ACE wrap to this leg each
day. You can remove the ACE bandage for sleeping.
You are expected to have a decreased appetite. You might lose
some weight. Your appetite should return with time.
Eat small frequent meals.
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing.
You are expected to have some constipation, especially if
taking Narcotic pain medication. To avoid constipation, eat a
high fiber diet and drink plenty of water. You may use an
over-the-counter stool softener such as Colace or Docusate
Sodium 100mg twice daily and an over-the-counter laxative such
as Senna 2 tabs twice daily as needed for constipation. You
should be using these while taking narcotic pain medication.
## MEDICATION:
Follow your discharge medication instructions below. These
have been carefully reviewed by your providers.
For pain, you may use Tylenol (Acetaminophen) 1000mg every 8
hours. Be aware that there are some over-the-counter and
prescription medications that contain acetaminophen. Be sure
never to consume more than 3000mg of Tylenol/Acetaminophen in
one day.
Use narcotic pain medication sparingly, if at all. You should
require smaller amounts and doses less often as time goes on.
NEVER DRIVE OR OPERATE MACHINERY WHILE ON NARCOTIC PAIN
MEDICATION.
If you are taking narcotics, keep in mind that you may easily
become constipated. You can take over-the-counter stool
softeners or laxatives to prevent or treat this.
## ACTIVITIES:
You should get up out of bed every day and gradually increase
your activity each day, as you can tolerate. Do not do too much
right away!
Unless you were told not to bear any weight on operative foot,
you may walk and you may go up and down stairs.
No driving until post-op visit and until you are no longer
taking narcotic pain medications.
You may up and down stairs, go outside and ride in a car.
Increase your activities as you can tolerate!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit.
You may shower. Avoid direct spray on incision. Let the soapy
water run over incision, rinse and pat dry.
Your incision may be left uncovered, unless you have drainage
from the wound. If there is drainage, place a dry dressing over
the incision and notify the clinic at . You staples
will remain in place until about 3 weeks after your surgery.
Staples will be removed at post clinic visit by your vascular
surgery team.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10342727", "visit_id": "28660807", "time": "2165-05-02 00:00:00"} |
16567789-DS-9 | 606 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
transferred from hospital after apparently fell down in
hallway at her apartment building. Neighbors heard noise and
found her in hallway approximately half hour later. Went to OSH
with EtOH reportedly 398, had large right posterior scalp
laceration stapled. Head CT showed left parafalxine SDH with
layering on left tentorium and she was transferred here for
further management. Abdominal CT and c-spine CT both negative
at OSH. Transported here in hard collar.
## GEN:
WD/WN, asleep on strecther in ED but easily arousable, NAD.
## HEENT:
Pupils: 4->3 EOMs full
## NECK:
In hard collar, some pain with posterior palpation
## NEURO:
Mental status: Awake and alert, cooperative with exam.
## ORIENTATION:
Oriented to person, place, and date.
## LANGUAGE:
Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
## II:
Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
## III, IV, VI:
Extraocular movements intact bilaterally without
nystagmus.
## V, VII:
Facial strength and sensation intact and symmetric.
## VIII:
Hearing intact to voice.
## XI:
Sternocleidomastoid and trapezius normal bilaterally.
## XII:
Tongue midline without fasciculations.
## MOTOR:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power throughout. No pronator drift
## SENSATION:
Intact to light touch bilaterally.
Toes downgoing bilaterally
## CT:
1. Acute SDH along the falx cerebri and the left
tentorium
cerebelli.2. Acute SAH in the left quadrigeminal cistern,
interpeduncular fossa and left cerebellopontine cistern.
3. Right nasal bone fx of indeterminate age.4. Large right
occipitotemporoparietal subgaleal hematoma.
## LABS:
Na 139 Cl 104 BUN 9 Glu 107 AGap=15
K 3.8 HCO3 24 Cr 0.4
Serum EtOH 178
Serum ASA, Acetmnphn, , Tricyc Negative
## BRIEF HOSPITAL COURSE:
Patient was admitted to the neurosurgery service for traumatic
SDH. She was monitored closely on the floor and did not require
any intervention. She had staples placed to a laceration on the
back of her head. She was started on keppra for seizure
prophylaxis. Her repeat head CT was stable She was seen in
consultation by social work who felt that she would benefit from
AA meetings and gave her information regarding meetings in her
area. She was ambulatory in the halls and neurologically
intact. She was seen by who cleared her and she was
discharged to home without services.
## MEDICATIONS ON ADMISSION:
"something for my nerves"
## DISCHARGE MEDICATIONS:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
## DISCHARGE INSTRUCTIONS:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring. Please take this medicine for
7 days
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16567789", "visit_id": "26882246", "time": "2159-06-08 00:00:00"} |
13844538-RR-27 | 96 | ## HISTORY:
Unwitnessed fall, left chest wall tenderness. Evaluate for fracture
or bleed.
## FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect,
edema, or vascular territorial infarction. Prominent ventricles and sulci are
likely secondary to age-related atrophy. Periventricular and deep white
matter hyperdensities are likely sequelae of chronic small vessel ischemic
disease. There is preservation of normal gray-white matter differentiation,
and the basilar cisterns appear patent. No fracture is identified. The
visualized portions of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear.
## IMPRESSION:
No acute intracranial abnormality.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13844538", "visit_id": "26871337", "time": "2173-05-27 11:54:00"} |
19328152-RR-49 | 242 | ## INDICATION:
year old man with lung cancer and brain mets, s/p resection of
2 larger lesions. // CALL TO CANCEL OR RESCHEDULE, assess response to
radiation
## FINDINGS:
The patient is status post left parietooccipital craniotomy for resection of
underlying mass, with unchanged chronic hemorrhage product. Mild residual
dural thickening and enhancement is unchanged from prior exam. No areas of
growing nodular enhancement. Associated T2/FLAIR white matter edema pattern
of the left parieto-occipital lobe is unchanged. Mild encephalomalacia and
FLAIR hyperintense white matter edema of the left frontal lobe and right
occipital lobe is unchanged.
No new enhancement. No acute infarct or intracranial hemorrhage. Lacunar
infarcts of the bilateral cerebellar hemispheres are re-identified. The major
intracranial flow voids are preserved. The dural venous sinuses are patent.
There is mild mucosal thickening of the paranasal sinuses. The orbits are
unremarkable. Trace fluid signal is seen in the right mastoid tip. No
suspicious marrow signal.
## IMPRESSION:
1. Status post left remote parietooccipital craniotomy, with unchanged chronic
hemorrhage product as well as underlying mild dural thickening and
enhancement. Associated white matter edema pattern of the left
parietooccipital lobe is unchanged. Additional regions of encephalomalacia
and FLAIR white matter edema pattern of the left frontal lobe and right
occipital lobe are unchanged. There is no evidence of disease progression or
new abnormal enhancement.
2. No acute infarct or intracranial hemorrhage.
3. Chronic bilateral cerebellar lacunar infarcts.
4. Additional findings as described above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19328152", "visit_id": "N/A", "time": "2166-05-01 12:17:00"} |
17259397-RR-61 | 229 | ## INDICATION:
female patient with current lymphoma status post
chemotherapy.
## FINDINGS:
CT OF THE CHEST WITH IV CONTRAST:
The lungs are clear bilaterally without
pulmonary nodules. There is no mediastinal, hilar, or axillary
lymphadenopathy. A left-sided Port-A-Cath is seen terminating in the
cavoatrial junction. The heart size is normal.
CT OF THE ABDOMEN WITH IV AND ORAL CONTRAST:
The spleen, adrenal glands,
stomach, pancreas, gallbladder, and intra-abdominal loops of bowel are within
normal limits. A renal cyst is seen at the upper pole of the right kidney,
unchanged. The left kidney is normal. Within the left lobe of the liver is a
small hepatic cyst, also unchanged. Otherwise, the liver is normal without
any other lesions identified.
A few small lymph nodes are identified retroperitoneally, the largest
measuring approximately 7 mm in short-axis diameter. This is stable since the
prior PET CT of . A few tiny scattered mesenteric lymph nodes
are seen, none meeting CT criteria for pathologic enlargement. There is no
free air or free fluid.
CT OF THE PELVIS WITH IV AND ORAL CONTRAST:
The rectum, uterus, bladder, and
intrapelvic loops of bowel are within normal limits. There is no pelvic or
inguinal lymphadenopathy. There is no free fluid.
## BONE WINDOWS:
No suspicious osseous lesions are identified.
## IMPRESSION:
Small lymph nodes seen retroperitoneally, stable in size since
the . No new lymphadenopathy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17259397", "visit_id": "N/A", "time": "2169-11-14 09:26:00"} |
13263522-RR-28 | 127 | ## INDICATION:
Status post anterior craniotomy. Please evaluate postoperative
change.
, 1342 hours, and MRI from , 1324 hours.
## FINDINGS:
Patient is status post left frontal craniotomy, and excision of
left frontal lobe metastasis, with expected post-surgical change seen in the
left frontal lobe, and moderate pneumocephalus throughout the brain. There is
no sign of large intracranial hemorrhage. Vasogenic edema in the vicinity of
resected left frontal lobe mass is not significantly changed. There is no
shift of normally midline structures. Ventricles and sulci are grossly
unchanged in size and configuration. A small air-fluid level in the right
maxillary sinus is unchanged.
## IMPRESSION:
Status post resection of left frontal lobe mass via left frontal
craniotomy, with expected post-surgical change and pneumocephalus. No large
intracranial hemorrhage.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13263522", "visit_id": "23611886", "time": "2136-05-24 21:59:00"} |
15549843-RR-112 | 148 | CERVICAL SPINE, TWO VIEWS, AT 1301 HOURS
## HISTORY:
Significant degenerative disease with radicular pain. Please
compare to radiograph.
## FINDINGS:
Diffuse disc space narrowing is seen throughout the cervical spine,
particularly from C3-C4 through to the cervicothoracic junction. The worse
affected levels are C5-C6 and C6-C7. Marginal osteophytes are noted at
multiple levels. A grade 1 anterolisthesis of C4 on C5 is noted as well and
was commented upon previously. The lower cervical spine is relatively
straightened with a kyphotic angulation noted at C4-C5. The prevertebral soft
tissues are unremarkable. Multilevel uncovertebral joint hypertrophy is also
present at the affected levels.
## IMPRESSION:
Diffuse degenerative disc disease. Qualitatively, the findings
noted are similar to those previously described, although progression of
disease is impossible without direct comparison. Given the apparent
radiculopathy noted, MRI is indicated to assess for disc pathology and cord
and nerve root impingement.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15549843", "visit_id": "N/A", "time": "2198-01-08 12:39:00"} |
17801698-RR-13 | 261 | ## HISTORY:
Rule out empyema or abscess. Previous left lower lobe pneumonia,
now with bilateral pleural effusion.
## FINDINGS:
Small-to-moderate, non-hemorrhagic, largely layering bilateral pleural
effusion is new. Parietal, costal pleural enhancement is relatively mild.
Severe heterogeneous consolidation in the left lung has worsened appreciably,
and there is now widespread ground-glass opacification and new basal
consolidation in the right lung, lower lobe greater than upper and middle
lobes, and new mild nodulation in the left upper lobe. Overall, findings
suggest dramatic progression of pneumonia. A component of pulmonary
hemorrhage could be present.
Mild but multifocal central lymph node enlargement has been stable except for
growth of 14 x 17 mm right hilar lymph node, previously 12 x 15 mm. No lymph
nodes impinge on vital structures. There is no pericardial effusion. Severe
splenomegaly has worsened. Just above the upper pole of the left kidney,
maximum orthogonal diameters have increased from 80 x mm to 94 x mm,
2:61.
## IMPRESSION:
1. Severe progression of widespread pneumonia, now accompanied by the small
layering non-hemorrhagic pleural effusion. There is no direct radiographic
evidence that this represents empyema, but if the fluid volume continues to
increase, sampling is recommended to distinguish pleural infection from
reactive exudate.
2. Although mild-to-moderate central adenopathy has been relatively stable
(with the exception of enlarging right hilar node), moderate splenomegaly has
progressed substantially.
Diagnostic considerations of advancing multifocal consolidationi include
Legionnaires disease and similar infections. Dr. I discussed the
findings and their clinical significance over the telephone at the time of
dictation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17801698", "visit_id": "29544420", "time": "2173-04-24 17:36:00"} |
13863911-RR-8 | 118 | ## EXAMINATION:
CAROTID SERIES COMPLETE
CLINICAL HISTORY year old woman with cad// please eval for carotid
stenosis please eval for carotid stenosis
## FINDINGS:
Duplex was performed of bilateral carotid arteries. There is mild
heterogeneous plaque in the proximal ICA bilaterally.
## RIGHT:
Peak velocities are 121, 72 and 95 centimeters/second in the ICA, CCA
and ECA respectively. The ICA CCA ratio is 1.6. This is consistent with
40-59% right ICA stenosis.
## LEFT:
Peak velocities are 119, 94 and 88 centimeters/second in the ICA, CCA
and ECA respectively. The ICA CCA ratio is 1.2. This is consistent with
40-59% left ICA stenosis.
Vertebral flow is antegrade bilaterally.
## IMPRESSION:
Bilateral 40-59% carotid stenosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13863911", "visit_id": "N/A", "time": "2138-09-09 12:41:00"} |
19229684-RR-38 | 457 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## HISTORY:
with abd pain, dysuria and hx of kidney stones// r/o
stones, infection
## SINGLE PHASE CONTRAST:
MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 23.5 mGy (Body) DLP =
11.7 mGy-cm.
2) Spiral Acquisition 6.8 s, 52.3 cm; CTDIvol = 20.2 mGy (Body) DLP =
1,057.2 mGy-cm.
Total DLP (Body) = 1,069 mGy-cm.
## LOWER CHEST:
Right pleural thickening versus small right pleural effusion is
seen in the dependent portion of the right hemithorax, and has been seen on
prior studies, similar. Mild, dependent, subsegmental atelectasis of the left
lung. No pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout. A
millimetric, focal hypodensity within the spleen (02:18) is too small to
characterize.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
Subcentimeter bilateral renal hypodensities are too small to characterize. A
nonobstructing right renal stone measures 3 mm. There is 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:
The bladder appears unremarkable. There is no free fluid in the
pelvis.
## REPRODUCTIVE ORGANS:
The uterus is not seen. A cystic structure adjacent to
the right ovary measures 0.8 cm (2:72) and is stable since .. No
left adnexal masses.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes are seen at the lumbosacral junction with disc space
narrowing, vacuum phenomenon and posterior disc osteophyte with mild to
moderately narrows the central canal.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Nonobstructing 3 mm right renal stone. No hydronephrosis.
2. Right pleural thickening versus small right pleural effusion.
3. 0.8 cm cystic structure within the right adnexa, adjacent to the right
ovary, possibly a paraovarian or ovarian cyst and stable since .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19229684", "visit_id": "N/A", "time": "2130-05-28 18:00:00"} |
18282193-DS-6 | 1,194 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
yr old F w/ PMH of hypothyroidism, anxiety, Breast CA (on wk
#1, day #7 of taxol/herceptin) who called in to Heme/Onc service
reporting fever to 101.7 in am and was directed to ED for w/u of
possible neutropenic fever. Pt reported 2 days of diffuse aches
(hips/neck), HA, and fatigue when walking that preceeded the
fever.
In ED,pt did not meet any SIRS criteria (WBC 4.6, afebrile, nml
Hr/RR) but recieved empiric Abx (Cefipime/Vanc) Tylenol for HA.
On presentation SBP was in 90's, dropped transiently to 87/46,
recieved 3L NS. Of note, pt took 0.5mg Ativan PO just prior to
arrival in ED. Pt was transferred to MICU for further mgmt.
On arrival to the MICU, pt was comfortable, vital signs stable
Review of systems:
Pt endorsed rhinorrhea and minor urinary urgency but denied
chills, night sweats, vision changes, neck stiffness, cough,
SOB, sore throat, nausea, vomiting, diarrhea, dysuria, or rash.
## PAST MEDICAL HISTORY:
Breast CA (dx , R breast, invasive ductal/DCIS on biopsy,
had lumpectomy on w/o complication, 4 cycles of
Adriamycin/Cytoxan started in , BRCA1/2 neg, heme/onc
provider is
Hypothyroid - on Levothyroxine
Anxiety - on Ativan
## PSH:
Inguinal Hernia Repair
Carpal tunnel release L hand
## FAMILY HISTORY:
Father died CA
Mother living CA x2, HTN, Arrythmia
Sister living CA
## GENERAL:
Well appearing female in no acute distress, sitting
comfortably
## HEENT:
Mucous membs moist, no erythema/discharge/swelling in
nares,
## CV:
S1/S2 Regular Rate and Rhythm, no murmurs/gallops
appreciated
## LUNGS:
Clear to auscultation bilaterally, no
wheezes/rales/ronchai
## ABDOMEN:
Soft, nontender, normoactive bowel sounds, no skin
lesions
## EXT:
Warm, no peripheral edema
## GENERAL:
Well appearing, thin female wearing scarf on head,
comfortable
## HEENT:
Mucous membranes moist, oropharynx clear
## PULM:
Clear to auscultation bilaterally, no wheezes/rales/ronchi
## CV:
Regular rate and rhythm, no murmurs
## ABDOMEN:
normoactive bowel sounds, soft, nontender, nondistended
## EXTREMITIES:
Warm, well perfused, no edema
## PERTINENT LABS RESULTS:
08:30AM BLOOD Ret Aut-2.1
08:30AM BLOOD LD(LDH)-198 TotBili-0.7
10:10AM BLOOD ALT-38 AST-26 AlkPhos-80 TotBili-0.5
08:30AM BLOOD Hapto-200
07:20AM BLOOD HIV Ab-NEGATIVE
07:20AM BLOOD QUANTIFERON-TB GOLD-PND
08:30AM BLOOD BABESIA ANTIBODIES, IGG AND IGM-PND
08:30AM BLOOD BABESIA MICROTI DNA PCR-PND
10:10AM BLOOD LYME DISEASE ANTIBODY, IMMUNOBLOT-Test
Name
06:10PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
## MICRO:
Urine-1.005, clear, negative leuks/nitrite/blood
## BLOOD CX :
Pending
URINE Legionella Urinary Antigen -Negative
## STOOL VIRAL CULTURE :
Pending
LYME SEROLOGY (Final :
EIA RESULT NOT CONFIRMED BY WESTERN BLOT.
POSITIVE BY EIA.
NEGATIVE BY WESTERN BLOT.
## IMAGES:
CXR PA/Lateral (Final)
Subtle patchy opacity is seen in the right mid lung, could be
due to
atelectasis or infection. Attention at follow-up
CXR PA/Lateral (Final)
Normal heart, lungs, hila, mediastinum and pleural surfaces. No
evidence
currently of pneumonia. Focal region of lung abnormality have
cleared since .
## IMPRESSION:
yr old F w/ PMH of hypothyroidism, anxiety,
Breast CA (on wk #1, day #7 of taxol/herceptin) admitted with
fever.
## # FEVER:
Patient admitted with fever, malaise and myalgias. Her
fevers were not thought to be due to recent chemotherapy as they
had initially occured prior to starting taxol. Patient was not
neutropenic so not related to neutropenic fever. She received
Cefepime and Vanc initially for concern for sepsis and blood and
urine cultures were drawn. At discharge, urine cultures were
negative and blood cultures pending. CXR was performed on
admission which showed changes concerning for atypical pneumonia
and she was started on doxycycline. Her xray changes resolved
while on doxycycline and she was discharged with plan to
complete a 7 day course of doxycycline. Patient has exposures to
tick so tick borne illness was suspected and panel was sent.
Because she continued to have fevers initially on antibiotics,
infectious disease was consulted for further recommendations on
of fevers. This was thought to most likely be due to
viral illness but given the patient's current chemotherapy,
additional testing was sent. She was negative for lyme disease,
HIV and respiratory viral antigen. Quantiferon gold, viral stool
studies, babesia, erlichia and blood cultures were all pending
at discharge. Patient's fever had defervesced for >24 hours at
time of discharge.
# Anemia - Patient found to have normocytic anemia on admission
with hematocrit of 23.8. Hemolysis labs were sent given concern
for tick borne illnesses but were negative. Given her ongoing
chemotherapy with taxol which suppresses RBC production, patient
was transfused 1unit packed RBCs on . She tolerated this
well and her crit bumped significantly from 24 to 30.8.
## # HYPOTENSION:
Patient transiently hypotensive in ED to 87/46.
Concern for sepsis so patient given 3L NS, cefepime and
vancomycin. Likely hypotension was related to ativan which she
took prior to coming to the ED. Blood pressure was otherwise
stable throughout her admission.
#Hypothyroidism - Pt was continued on home dose of Levothyroxine
50mcg qd.
#Breast CA - Patient currently on Taxol/Herceptin admitted on
Week 1 day 7. Chemo was held while inpatient. She was seen by
Dr. while in hospital. She will plan to return for
chemotherapy on with Dr. continued resolution
of fevers.
#Anxiety - Patient's home ativan 0.5mg prn: anxiety was
continued in the hospital.
## TRANSITION OF CARE ISSUES:
[ ] f/u Bcx, Quantiferon gold, babesia antibodies, babesia PCR,
anaplasma IgG & IgM, stool viral cultures, respiratory viral
culture
[ ] Ongoing anemia will need to be monitored in setting of
continued chemotherapy
[ ] Continue Doxycycline for 7 day course
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Lorazepam 0.5 mg PO Q6H:PRN anxiety
3. Ibuprofen 400 mg PO Q8H:PRN pain
## DISCHARGE MEDICATIONS:
1. Ibuprofen 400 mg PO Q8H:PRN pain
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
4. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Q12H (every
12 hours) Disp #*10 Tablet Refills:*0
## DISCHARGE INSTRUCTIONS:
Dear ,
were admitted to with
fevers, fatigue and body aches. were found to have changes
on your chest xray concerning for infection. were treated
with doxycycline and the chest xray improved. should plan to
complete a total of 7 day course of doxycycline.
Because continued to have fevers initially on antibiotics,
infectious disease was consulted and a more extensive infectious
workup was performed. This was all negative at time of
discharge. have several outstanding tests which should
talk to Dr. about at your next appointment.
On discharge, had not had a fever in >24 hours. If your
fevers return, please contact Dr. further .
were also found to be anemic on admission. Labs were done to
test whether your blood was hemolyzing (breaking down) and were
all negative meaning are not hemolyzing. Because are
continuing chemotherapy which can make anemic, were
transfused 1 unit of blood without any reactions. Your
hematocrit increased nicely with the transfusion.
It was a pleasure taking care of during your admission.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18282193", "visit_id": "22459955", "time": "2165-07-11 00:00:00"} |
19659653-RR-152 | 128 | ## EXAMINATION:
SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA BILATERAL
## INDICATION:
year old woman with Bilateral Shoulders pain// Bilateral
Shoulders pain
## LEFT SHOULDER:
No acute fractures or dislocations are seen.There are severe
degenerative changes of the glenohumeral joint with loss of joint space and
prominent spurs. There is a small subacromial spur.Dystrophic calcification
along the superolateral humeral head can be consistent calcific tendinitis of
the rotator cuff. Visualized left lung apex is grossly clear.
## RIGHT SHOULDER:
Port-A-Cath is seen. No acute fractures or dislocations are
seen. There are moderate degenerative changes of the glenohumeral joint with
inferior spurring. Mild degenerative changes the AC joint are seen. There is
slight demineralization.
## IMPRESSION:
Bilateral degenerative changes as described above. Calcific tendinitis of the
left rotator cuff.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19659653", "visit_id": "N/A", "time": "2194-04-06 12:20:00"} |
12397019-RR-31 | 278 | ## INDICATION:
year old woman with resected pelvic sarcoma, restaging scan
s/p 2 cycles of chemotherapy treatment. Also with lung nodules // re staging
of sarcoma s/p 2 cycles of chemotherapy
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.0 s, 65.7 cm; CTDIvol = 15.4 mGy (Body) DLP =
1,011.6 mGy-cm.
2) Spiral Acquisition 2.3 s, 30.1 cm; CTDIvol = 13.4 mGy (Body) DLP = 402.6
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 37.0 mGy (Body) DLP =
18.5 mGy-cm.
Total DLP (Body) = 1,434 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS WITH CONTRAST)
## THORACIC INLET:
The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes.
## BREAST AND AXILLA:
There are no enlarged axillary lymph nodes
## MEDIASTINUM:
There are no enlarged mediastinal hilar lymph nodes. Heart size
is normal. The there is no pericardial effusion. The aorta and pulmonary
arteries are normal in caliber.
## PLEURA:
There is no pleural effusion.
## LUNG:
There are multiple bilateral pulmonary metastasis are again seen the
largest in the right lower lobe measures 6.9 mm it previously measured 5.9 mm.
Similarly all the other metastasis a minimally more prominent than on the
prior study.
## BONES AND CHEST WALL:
Review of bones is unremarkable
## UPPER ABDOMEN:
Limited sections through the upper abdomen are also
unremarkable
## IMPRESSION:
Multiple bilateral pulmonary metastasis slightly increased in size since the
prior study.
Please refer to dedicated report on abdomen which has been dictated separately
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12397019", "visit_id": "N/A", "time": "2192-02-03 14:10:00"} |
13071917-RR-53 | 124 | ## EXAMINATION:
Chest radiographs, PA and lateral.
## INDICATION:
Chest pain. Query pneumothorax.
## FINDINGS:
Cardiac, mediastinal and hilar contours appear stable. There is a similar
eventration of the anterior right hemidiaphragm as well as a medium sized
hiatal hernia. There is likely a trace left-sided pleural effusion, no
definite 1 on the right. No pneumothorax. No displaced rib fracture is
found. A left posterolateral fifth rib fracture appears old and healed.
Irregularity along the course of the posterolateral right eighth rib appears
new and may indicate a nondisplaced fracture of subacute or longer acuity..
## IMPRESSION:
No definite evidence of acute abnormality. Suspected nondisplaced right
posterolateral eighth rib fracture, probably of subacute or older acuity.
Correlation with clinical Findings is recommended. No pneumothorax found.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13071917", "visit_id": "N/A", "time": "2199-02-09 16:43:00"} |
11293444-RR-47 | 216 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
History: with altered mental status// eval for ICH
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.7 cm; CTDIvol = 48.4 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
## FINDINGS:
There is no evidence of acute territorial infarction,hemorrhage,edema, or
mass. Periventricular and subcortical white matter hypoattenuation with
encephalomalacia in both frontal lobes is compatible with history of prior
traumatic brain injury. Focal hypodensity in the right basal ganglia is also
unchanged, and compatible with encephalomalacia from prior area of hemorrhage.
Chronic fractures of the right zygomatic arch and left temporal bone are
unchanged. There is no evidence of acute fracture. Mild mucosal thickening
is seen within the ethmoid air cells and left frontal ethmoidal recess.
Minimal fluid is seen within the inferior mastoid air cells bilaterally. The
visualized portion of the remaining paranasal sinusesand middle ear cavities
are clear. Extensive streak artifact from a left orbital overlying structure
obscures assessment of the left orbit. The right orbit appears unremarkable.
## IMPRESSION:
1. No acute intracranial abnormality.
2. Redemonstration of bifrontal and right basal ganglia encephalomalacia, the
sequela of prior traumatic brain injury.
3. Redemonstration of chronic fractures of the left temporal bone and right
zygomatic arch.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11293444", "visit_id": "24221696", "time": "2133-04-12 17:23:00"} |
18898288-RR-18 | 306 | MRI BRAIN, MRA BRAIN AND MRA NECK: .
## HISTORY:
male with first-time seizure and hypodensity in the
right caudate. Question malignancy or infection.
## FINDINGS:
There are few scattered periventricular and subcortical white
matter T2/FLAIR hyperintensities, nonspecific but commonly due to chronic
small vessel disease. There is no region of restricted diffusion to suggest
acute infarct. Ventricles and sulci are symmetric and unremarkable. No other
parenchymal signal abnormalities identified. There is no abnormal
susceptibility artifact or other evidence of hemorrhage. Prominent sulcus
versus possible 1.7 x 0.8 cm arachnoid cyst overlies the left frontal lobe.
Major intravascular flow voids, including the major dural venous sinuses are
preserved. Post-contrast images demonstrate no abnormal parenchymal or
meningeal enhancement.
Mucosal thickening seen within the maxillary sinuses. No abnormal signal seen
in the remaining paranasal sinuses or mastoids. Just medial to the right
temporomandibular joint, abutting the deeper portion of the left parotid
tissue is a 10 x 9 mm T2-hyperintense lesion without enhancement. It may be
associated with the left temporomandibular joint and represent a synovial
cyst.
There is mild irregularity at the carotid siphons, right greater than left,
which is likely due to atherosclerotic calcification as opposed to aneurysm.
Overall, the degree of narrowing is relatively mild. The bilateral MCAs,
ACAs, vertebral arteries, basilar artery, and PCAs are unremarkable. Small
posterior communicating arteries are identified bilaterally. There is no
hemodynamically significant stenosis, aneurysm or occlusion within the
anterior or posterior circulations.
MRA of the neck demonstrates normal origin of the great vessels with minimal
narrowing identified at the origin of the right vertebral artery. There is no
hemodynamically significant stenosis within the common or internal carotid
arteries by NASCET criteria.
## IMPRESSION:
1. No acute intracranial process. No evidence of territorial infarction. No
mass identified.
2. Essentially unremarkable MRA of the head and neck.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18898288", "visit_id": "N/A", "time": "2141-05-21 19:53:00"} |
18032787-DS-12 | 1,349 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
L Arm bunch biopsy
## HISTORY OF PRESENT ILLNESS:
female presenting with left arm erythema since
concerning for cellulitis, who developed reaction to
vancomycin in ED.
She reports erythema which started over left posterior arm near
elbow. The area was itchy at first and not particularly painful.
She thought it was a bug bite, but there was no obvious wound or
cut. On she went to and was started on
Keflex and Bactrim for presumed bacterial cellulitis. her arm
then started to blister last night and this morning and spread
outside of markings, with significant itchiness. She returned to
on for follow up and worsening of rash was noted
despite having taken around 3 or 4 doses of antibiotic so she
was referred by PCP to the ED. Of note the patient was
treated for a very similarly appearing blistering rash on her
middle L toe staring on , which improved with
Of note, per ED documentation; while in the ED the patient was
started on Vancomycin infusion. After 2 hours, patient had Red
Man's syndrome. Was given 50 mg IV Benadryl with improvement.
Vanc was then given without premedication over 3 hours, which
she tolerated well, then developed pruritic erythematous rash
over the b/l chest/neck concerning for Red Man's, received 25 mg
IV Benadryl. Dermatology consult was called and biopsy was taken
of the skin.
## IN THE ED, INITIAL VITALS:
99.3 (tmax 100.4) 98 133/70 18 100%
RA
- Exam notable for: blistering cellulitis over posterior aspect
of left arm above elbow initially, then developed face, chest
rash with administration of vancomycin. No wheezing or SOB.
## - LABS NOTABLE FOR:
WBC 8.6, Hgb 13.6, Plt 264, Cr 0.9,
electrolytes within normal limits otherwise. UA negative and UCG
negative.
## - IMAGING NOTABLE FOR:
CXR forearm and humerus with diffuse left
upper extremity soft tissue swelling without subcutaneous gas.
- Pt given:
19:03 IV Vancomycin
19:03 IVF NS
20:14 IV DiphenhydrAMINE 50 mg
22:53 IV Vancomycin 1 mg
22:53 IVF NS
08:54 IV Vancomycin
13:45 IV DiphenhydrAMINE 25 mg
18:24 IV DiphenhydrAMINE 25 mg
## - VITALS PRIOR TO TRANSFER:
97.8 92 110/52 18 100% RA
On the floor, the patient reports that her arm swelling went
down significantly after receiving vancomycin. She still feels
significantly itchy especially on face, chest and back. She
reports that the pain in her arm is now gone. She denies IV drug
use, history of STIs. She is sexually active with one partner.
## FAMILY HISTORY:
No history of autoimmune disease
migraines, strokes - mother
Father passed away in from fungemia (aspergillosis)
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclerae anicteric, MMM without lesions, oropharynx clear,
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## ABDOMEN:
Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## SKIN:
L arm with ruptured blisters near elbow and on medial
aspect of forearm. Erythema with mild induration but no areas of
fluctuance and mild to moderate erythema which lies within the
boundaries of skin marking. Full range of motion in arm. Chest,
stomach, back and face are covered with a diffuse maculopapular
erythematous rash, excoriations.
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclerae anicteric, MMM without lesions, oropharynx clear,
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## ABDOMEN:
Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## SKIN:
L arm with ruptured blisters near elbow and on medial
aspect of forearm. Erythema is significantly reduced from
yesterday. No fluctuance. Full range of motion in arm. Chest,
stomach, back and face are covered with a diffuse maculopapular
erythematous rash, excoriations.
## PATHOLOGY:
Skin, left dorsal arm, biopsy:
- Eosinophil-rich superficial to deep dermal and upper
pannicular interstitial and perivascular
infiltrate with histiocytes and rare neutrophils (see note).
## NOTE:
Brown-Brenn and PAS stains are negative for bacteria and
fungi. No arthropod puncta are
found. The abundance of eosinophils, interstitial pattern of
inflammation, and presence of flame
figures most suggests eosinophilic cellulitis. Due to the
presence of rare admixed neutrophils, clinical
follow-up is suggested.
## BRIEF HOSPITAL COURSE:
woman who presented with for arm rash. She says two weeks PTA
she developed itching and pain over her third L toe, which
blistered after putting antibiotic ointment on it. She went to
her PCP and received course of Keflex with resolution of rash.
Then 3 days PTA she had a similar episode of redness and itching
on her L posterior arm. This was predominantly itchy and swelled
rapidly, so she presented to her PCP who prescribed
for cellulitis. She took these for 1 day and
developed blistering on rash and extension of erythema and
represented to her PCP who referred her to ED.
In our ED her arm was evaluated by dermatology, who felt it most
likely represented cellulitis, though itchiness and blistering
unusual with ddx of eosinophilic dermatitis, bug bite reaction,
and erythema migrans. Lyme serologies were sent and a skin
biopsy was performed. She received Vancomycin with rapid
improvement of her arm. However, she developed Red Man Syndrome
which persistent despite premedication and dose reduction of
Vancomycin infusion. She also developed a diffuse itchy
maculopapular rash concerning for true allergy to Vancomycin.
She received one dose of linezolid IV with significant
improvement in rash and was switched to Bactrim DS 2 tabs.
The patient's biopsy results showed Eosinophilic cellulitis. Her
antibiotics were discontinued and she was started on oral
prednisone ( ) and topical Fluocinonide.
=========================
Transitional issues:
=========================
[] Started prednisone on . 40mg PO QD x7 days, then 20mg PO
QD x 7 days
[] outpatient follow up with dermatology and allergy
[] Vancomycin reaction likely secondary to Red Man syndrome.
[] follow up lyme serologies
[] L Arm bunch biopsy sutures to be removed
Per Dermatology Note regarding Vancomycin reaction
" Her manifestations with this medication were most consistent
with "red man syndrome",
developing a red rash on the upper trunk during infusion, that
on repeat slowed infusion was less severe. Close monitoring
should obviously be undertaken using this medication, but in the
event of a life-threatening MRSA infection this medication
should not
be strictly contraindicated."
- Full code presumed
- Emergency contact: mom
on Admission:
The Preadmission Medication list is accurate and complete.
1. Norethindrone-Estradiol 1 TAB PO DAILY
## DISCHARGE MEDICATIONS:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
Do not drive or operate heavy machinery after taking. Do not mix
with alcohol.
RX *diphenhydramine HCl 25 mg 1 capsule(s) by mouth q6h PRN Disp
#*20 Capsule Refills:*0
2. Fluocinonide 0.05% Ointment 1 Appl TP BID
RX *fluocinonide 0.05 % As directed twice a day Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 7 Doses
## , FIRST DOSE:
Next Routine Administration Time
This is dose # 1 of 2 tapered doses
RX *prednisone 20 mg tablet(s) by mouth once a day Disp #*21
## TABLET REFILLS:
*0
4. PredniSONE 20 mg PO DAILY Duration: 7 Doses
## START:
After 40 mg DAILY tapered dose
This is dose # 2 of 2 tapered doses
5. Norethindrone-Estradiol 1 TAB PO DAILY
## DISCHARGE DIAGNOSIS:
PRIMARY DIAGNOSIS
Cellulitis
Red Man Syndrome
Drug eruption
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure taking care of you during your hospital stay.
You came to the hospital because you were having a rash. We
initially thought this was from an infection and you were given
antibiotics to which you had a reaction. You were seen by our
dermatologists who did a biopsy of your skin. It showed
something called eosinohillic cellulitis". This is not an
infection, therefore you do not need to take antibiotics. You
will be treated with oral and topical steroids.
Your discharge follow up appointments and medications are
detailed below.
We wish you the best!
Your Care team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18032787", "visit_id": "24017967", "time": "2164-05-17 00:00:00"} |
12990431-RR-8 | 345 | CT ABDOMEN AND PELVIS WITH CONTRAST
## INDICATION:
male recently diagnosed with metastatic melanoma;
status post resection of mesenteric mass. Evaluate for recurrence.
## CONTRAST:
Oral contrast and intravenous nonionic contrast was administered
for this study.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:
There is a small 7-mm hyperdense
nodule in the right middle lobe of the lung of indeterminate origin. No
pleural effusions are noted in the lung bases. There is a 1.5cm area of low
density in the dome of the liver (segment 8), This shows rim enhancement and
is of fluid density. There are scattered hypodense lesions in the liver, the
larger of which are consistent with cysts. The smaller ones are too small to
characterize. There is a 2-cm mass in the omentum (2:38) concerning for
metatstatic disease. The gallbladder, pancreas, spleen, kidneys, and ureters
are unremarkable. Evidence of prior bowel resection and jejunal anastamosis is
noted. The remainder of the small and large bowel are unremarkable. There is
no free air or fluid in the abdomen. No mesenteric or retroperitoneal
lymphadenopathy is present.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST:
There is a 4 x 2.5 cm homogeneous
ovoid mass in the anterior portion of the true pelvis. The rectum, sigmoid
colon, bladder, prostate, and seminal vesicles are unremarkable. There is no
free fluid and no pelvic or inguinal lymphadenopathy noted.
Mild DJD at the L5-S1 level is noted.
## CT RECONSTRUCTIONS:
Coronal and sagittal reconstructions were essential in
delineating the anatomy and pathology.
## IMPRESSION:
1. Several lesions are identified that are concerning for metastatic disease,
including a lung nodule, an omental mass and a pelvic mass. Correlation with
prior outside studies is recommended to evaluate for interval growth.
2. Hypodense lesion in the dome of the liver may represent postsurgical change
if there is a history of metastasectomy. In the absence of such history this
is concerning for metastatic disease and could be further evaluated with MRI
if clinically warranted.
3. Multiple liver lesions consistent with cysts. Other small liver lesions
too small to characterize.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12990431", "visit_id": "N/A", "time": "2139-03-17 11:56:00"} |
17804681-RR-11 | 109 | ## EXAMINATION:
SHOULDER VIEWS NON TRAUMA BILATERAL
## INDICATION:
year old man with post-traumatic seizure and complaint of
bilateral shoulder pain.// ?Shoulder injury
## FINDINGS:
No fracture or dislocation is detected involving either the right or left
shoulder the AC and glenohumeral joints are congruent bilaterally.
Small rounded focal density overlying the upper edge of the left greater
tuberosity on one view probably represents artifact outside of the patient.
## IMPRESSION:
No acute fracture or dislocation detected involving the right or left
shoulder.
Question artifact overlying right greater tuberosity. If clinically
indicated, a repeat view could be obtained at no additional charge the patient
to confirm that this represents artifact.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17804681", "visit_id": "26508139", "time": "2118-03-17 11:09:00"} |
18048184-RR-40 | 369 | CT ANGIOGRAM OF THE ABDOMEN AND PELVIS
## HISTORY:
Abdominal aortic aneurysm; status post EVAR.
## CT OF THE ABDOMEN:
A few small pulmonary nodules appear stable at the lung
bases. There are no pleural effusions. Emphysema is noted. A right
epicardial lymph node measuring 10 mm in diameter is borderline in size but
stable.
The liver is low in density suggesting fatty infiltration of the liver. The
gallbladder, pancreas, spleen, and adrenal glands appear within normal limits.
The stomach, small and large bowel are unremarkable.
## CT OF THE PELVIS:
The prostate is mildly enlarged. The seminal vesicles and
bladder appear within normal limits. There is no lymphadenopathy or ascites.
Small periaortic lymph nodes are unchanged and probably reactive, not enlarged
by size criteria. The major mesenteric arteries and veins appear patent.
## CT ANGIOGRAPHY:
The patient is status post endovascular repair of an
abdominal aortic aneurysm. There is no evidence for an endoleak. The
aneurysm measures 51 mm in coronal, also 51 mm in sagittal, and 40 mm in axial
, which measures 1-2 mm of previous assessment, probably within
measurement error. Mild ectasia of the left common iliac artery is stable.
Widely patent distal runoff is present.
The stent begins 23 mm superior to the more inferior renal artery, which is
the left. The length of the stent from the apex to the right distal margin
mesaures 214 mm. The length of the stent graft measures 206 mm on the left.
From the end of the stent in the right common iliac artery to the iliac
bifurcation measures 11 mm. From the end of the stent in the left common iliac
artery to the iliac bifurcation measures 19 mm.
The estimated volume of the aneurysm measures 117 cm3. The aortic volume from
the inferior renal artery to the aortic bifurcation measures 158 cm3. The
volume from the inferior renal artery to the iliac bifurcation measures 210
cm3.
## BONE WINDOWS:
Moderate degenerative changes are present along the lower
thoracic spine. The L5-S1 interspace is slightly narrowed with mild
retrolisthesis. Degenerative changes associated with abutment among lower
lumbar spinous processes appear unchanged.
## IMPRESSION:
1. Stable aneurysm following repair without evidence for endoleak.
2. Fatty infiltration of the liver.
3. Emphysema.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18048184", "visit_id": "N/A", "time": "2171-12-04 13:27:00"} |
10530041-RR-72 | 116 | PA AND LATERAL CHEST,
## HISTORY:
woman after VATS lobectomy.
## IMPRESSION:
PA and lateral chest compared to through .
## FINDINGS:
Consolidation in the upper aspect of the postoperative right lung continues to
clear. Smaller irregular opacities have developed laterally at the level of
the second rib, perhaps the residual of previous extensive pneumonia. If
patient has referable symptomatology, I would repeat a chest radiograph in two
weeks, but if not, re-evaluation can wait until regularly scheduled chest CT
scan in the surgical followup. Volume of pleural fluid at the apex and base
of the right hemithorax, is unchanged. Left lung is clear. Heart size is
normal. A right subclavian infusion port ends low in the SVC.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10530041", "visit_id": "N/A", "time": "2117-01-27 11:30:00"} |
16259953-DS-18 | 1,027 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
is a year old female who presented with
progressively worsening right lower quadrant pain that began 2
days prior to presenting to the hosptial. The pain initially
began a few weeks prior when running, but was not constant until
2 days prior to her coming to the hospital. She had not
experienced any nausea or vomiting, but did experience loss of
appetite. She had had no fevers.
## FAMILY HISTORY:
No h/o Crohn's or UC. Father w/ diverticulitis.
## GEN:
NAD, A&O x 3, nontoxic appearance
## ABD:
soft, ND, NT, incisions c/d/i
## EKG ( ):
Baseline artifact. Sinus rhythm. Within normal
limits.
## BRIEF HOSPITAL COURSE:
Patient was admitted to the hospital with symptoms of
abdominal pain and decreased appetite and was found to have
acute appendicitis on CT scan. She was taken to the OR for a
laparoscopic appendectomy on . Pain was well controlled
postoperatively, and the pt was advanced to regular diet. Pt
was discharged once she was tolerating regular diet, her pain
was controlled with oral pain medications, and she was
ambulating. The patient will return in 2 weeks for a postop
check with the acute care service. Postoperative instructions
were reviewed with the patient.
## MEDICATIONS ON ADMISSION:
Wellbutrin 300', Celexa 40', Adderall 40', Seasonique
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Adderall *NF* (dextroamphetamine-amphetamine) 40 Oral daily
5. BuPROPion 300 mg PO DAILY
6. Citalopram 40 mg PO DAILY
## DISCHARGE DIAGNOSIS:
Laparoscopic appendectomy for acute appendicitis
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
## ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than lbs for weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
## HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
## YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
## YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
## PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
## MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16259953", "visit_id": "20554050", "time": "2183-02-18 00:00:00"} |
13855132-RR-25 | 151 | ## INDICATION:
year old man with ?PNA // Line placement Contact name:
:
## FINDINGS:
There is been significant progression of confluent left lower lobe airspace
opacities. Right upper and lower lobe opacities are essentially unchanged.
An endotracheal tube terminates approximately 4.5 cm superior to the carina.
An enteric tube side port projects below the GE junction. There has been
interval placement of a right sided IJ central venous catheter, which
terminates within the mid SVC. No pneumothorax. Apparent widening of the
right paratracheal stripe is likely positional and not significantly changed.
Possible small bilateral pleural effusions. Severe cardiomegaly and moderate
pulmonary edema are unchanged.
## IMPRESSION:
1. Multifocal airspace opacities likely reflect worsening multifocal
pneumonia, most pronounced in the left lower lobe.
2. Moderate pulmonary edema.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 12:07 , approximately
30 minutes after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13855132", "visit_id": "28064016", "time": "2147-04-06 06:16:00"} |
16623708-RR-19 | 117 | ## FINDINGS:
Right chest tube remains in place. Previously identified right
pneumothorax is no longer visible at the apex, but unusually sharp contour of
right hemidiaphragm may reflect a residual small basilar component.
Additionally, there is a small lucency along the right hemidiaphragm contour
for which free intraperitoneal air cannot be excluded, as discussed with Dr.
on , and for which a dedicated left lateral decubitus
radiograph may be helpful. Cardiomediastinal contours are unchanged.
Worsening airspace opacities in the left perihilar and right basilar regions,
as well as worsening atelectasis of left lower lobe with apparent
near-complete collapse of this region. Unchanged small left effusion and
decrease of right pleural effusion which is no longer evident.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16623708", "visit_id": "23086337", "time": "2168-02-19 04:19:00"} |
15868318-RR-24 | 130 | ## INDICATION:
female with urine hCG elevated at on
, was told she may have an ectopic pregnancy. Records not available.
GA by LMP 4 weeks 3 days. Please evaluate for ectopic. No relevant prior
imaging for comparison.
## FINDINGS:
There is fluid within the endometrial cavity without yolk sac or
embryonic pole. The uterus is otherwise normal.
The ovaries are normal bilaterally. There is a small amount of fluid within
the pelvis.
## IMPRESSION:
No IUP. The differential diagnosis is early pregnancy, too early
to see, miscarriage, cannot rule out ectopic. F/u with HCG testing and
ultrasound is advised.
The referring physician, was contacted regarding this
result by Dr. by telephone at 4:10 p.m. on . Dr.
directly with the patient following the examination and is arranging for
followup.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15868318", "visit_id": "N/A", "time": "2195-03-27 14:57:00"} |
14406977-RR-22 | 110 | PA AND LATERAL CHEST AT 1246 HOURS.
## FINDINGS:
The lungs are clear without consolidation or edema. Scattered
densely calcified nodules are present consistent with prior granulomatous
disease. Nipple shadows are also evident and marked on the images on PACS.
The mediastinum is unremarkable. The cardiac silhouette is within normal
limits for size. No left effusion is noted. There is blunting of the right
costophrenic angle, similar to the prior exam, which may represent scarring or
possibly a chronic effusion. No pneumothorax is seen. The osseous structures
are unremarkable.
## IMPRESSION:
No acute pulmonary process. Scarring versus chronic effusion at
the right costophrenic angle. Evidence of prior granulomatous infection as
above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14406977", "visit_id": "N/A", "time": "2150-11-19 12:48:00"} |
17351502-RR-8 | 436 | ## HISTORY:
man with history of cholangitis and cholecystitis
recently treated with ERCP stone removal and sphincterotomy complicated by
bleeding. He was brought back to the endoscopy suite for epinephrine
injection and electrocautery but has continued to bleed.
## PROCEDURE:
Selective mesenteric arteriography and coil and gelfoam
embolization of distal GDA branches.
## OPERATORS:
Dr. and Dr. . Dr. is the
attending radiologist, who was present for and participated in the entire
procedure.
## ANESTHESIA:
The patient was brought down, intubated and on a propofol drip
which was augmented throughout the study with additional boluses of propofol
as well as fentanyl. He was on continuous hemodynamic monitoring with the
unit nurse was present during the entire exam. 1% buffered lidocaine was also
used locally at the right groin access site.
## FINDINGS:
The common hepatic arteriogram showed brisk reflux of contrast into
the large splenic artery. There was some resistance to antegrade flow in the
hepatic arteries noted and intrahepatic arteries were attenuated and irregular
consistent with either edema or possibly changes related to infection and/or
ischemia. A plastic stent was seen in the right upper quadrant and arterial
phase of the gastroduodenal opacification shows active extravasation from the
distal branches of the pancreaticoduodenal arcade. This corresponds with the
expected site of the ampulla and corresponds to findings at the ERCP. With
the microcatheter out distally, active extravasation was not seen, but Gelfoam
and coil embolization were performed and final images shows coils proximal and
distal to the site of extravasation. The initial post-embolization showed
antegrade flow at the level of the extravasation though no active bleeding was
seen at that time, however therefore additional embolization was performed and
the final post-embolization arteriogram taken from the level of the proximal
GDA showed no further antegrade flow in anterior and posterior branches. In
addition, post-embolization study of the superior mesenteric arteries showed
no anterograde flow or extravasation at the area embolized. More detailed
study of the SMA was not performed.
Incidental note is made of pacer wires and tortuosity of the lower abdominal
aorta and iliac arteries.
## CONCLUSION:
1. Mesenteric arteriography is showing active contrast extravasation
(bleeding) from the distal branches of the gastroduodenal artery corresponding
to the site of the ampulla.
2. Successful microcoil and Gelfoam embolization proximal and distal to the
site of extravasation with post-embolization imaging showing no further
anterograde flow in this region.
3. Note made of of abnormal hepatic arterial supply the branches of which are
attenuated and mildly tortuous distally suggesting some combination of edema,
possible underlying cirrhosis and/or changes related to known recent
infection/ischemia.
4. Aortoiliac atherosclerosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17351502", "visit_id": "20161768", "time": "2119-06-19 14:50:00"} |
13140362-RR-74 | 135 | ## EXAMINATION:
FOOT WEIGHTBEARING AP,MO,LAT BILATERAL
## INDICATION:
year old woman with hindfoot pain// hindfoot pain
## RIGHT:
No acute fractures or dislocation are seen. Mild degenerative changes of the
first TMT and MTP joints. Small plantar calcaneal spur. Small posterior
calcaneal enthesophyte. An os supranaviculare is incidentally noted.
Mineralization is normal. There are no erosions.
## LEFT:
No acute fractures or dislocation are seen. Mild degenerative changes of the
first TMT and MTP joints. Small plantar calcaneal spur. Small posterior
calcaneal enthesophyte. Os trigonum. Pes planus. Mineralization is normal.
There are no erosions.
## IMPRESSION:
1. Pes planus of the left foot.
2. Small, bilateral plantar calcaneal spurs and posterior calcaneal
enthesophytes.
3. No acute fracture or dislocation.
4. Mild degenerative changes of the bilateral feet, most pronounced within the
first TMT and MTP joints.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13140362", "visit_id": "N/A", "time": "2148-11-22 09:19:00"} |
19560960-DS-18 | 881 | ## ALLERGIES:
Pentazocine / Lisinopril / Meperidine / Leflunomide
## CHIEF COMPLAINT:
End-stage renal disease with need for dialysis access
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Right upper extremity AV graft
## HISTORY OF PRESENT ILLNESS:
w/ESRD, currently on dialysis through a right-side
tunneled dialysis catheter. She previously had a LUE AV graft,
which failed, as well as peritoneal dialysis, which resulted in
a colon perforation. She presents this admission for formation
of a RUE AV graft.
## PMH:
ESRD on HD, failed kidney txp, BK virus infxn, sickle
cell anemia, sarcoidosis, seizures neurosarcoidosis, HTN,
dyslipidemia, C. diff colitis
## PSH:
ccy, colostomy for perforated colon
## PHYSICAL EXAM:
Vitals 98.2, 85, 122/71, 18, 93RA
Gen - alert and oriented x3, nad
CV - rrr, no murmur
Resp - cta bilaterally
Abd - soft, NT, ND, +bs
Extr - RUE w/faintly palpable thrill, audible bruit, radial
pulse 2+, hand sensation intact and warm
## BRIEF HOSPITAL COURSE:
Ms was admitted to the Transplant surgery service after
her RUE AV graft formation. Her pain was well-controlled with
oral medications. She was given a regular diet, which she
tolerated well. Her vital signs were monitored routinely and
stayed within normal parameters. At the time of discharge on
POD 1, she was tolerating a regular diet, had adequate pain
control, and felt comfortable with discharge.
## MEDICATIONS ON ADMISSION:
Nephrocaps', buspirone 10", PhosLo 3 caps''', citalopram 30',
Aranesp 1 mL qweek, diltiazem 120', lactulose 1 tablespoon
prn, lansoprazole 30', levatiracetam 250", metoclopramide 10"",
metoprolol 50", oxycodone 5 prn, polyethylene glycol, prednisone
2.5', senna
## DISCHARGE MEDICATIONS:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet Q 8H
(Every 8 Hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
.
5. buspirone 10 mg Tablet Sig: One (1) Tablet BID (2 times a
day).
6. calcium acetate 667 mg Capsule Sig: Three (3) Capsule TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. citalopram 20 mg Tablet Sig: 1.5 Tablets .
8. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release .
9. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML
( ).
10. lansoprazole 30 mg Tablet,Rapid Dissolve, Sig: One (1)
Tablet,Rapid Dissolve, .
11. levetiracetam 250 mg Tablet Sig: One (1) Tablet BID (2
times a day).
12. metoclopramide 10 mg Tablet Sig: One (1) Tablet QIDACHS
(4 times a day (before meals and at bedtime)).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet BID
(2 times a day).
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet .
15. prednisone 2.5 mg Tablet Sig: One (1) Tablet
( ).
16. senna 8.6 mg Tablet Sig: One (1) Tablet BID (2 times a
day) as needed for constipation.
## DISCHARGE DIAGNOSIS:
End stage renal disease with need for dialysis access.
## DISCHARGE INSTRUCTIONS:
You were admitted to the Transplant surgery service after your
AV graft. Please contact our office if you experience pain in
your right hand, or numbness/tingling.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
## GENERAL DISCHARGE INSTRUCTIONS:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
## INCISION CARE:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips days after surgery
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19560960", "visit_id": "20165194", "time": "2118-10-19 00:00:00"} |
11336547-RR-27 | 435 | ## INDICATION:
year old lady with metastatic NSCLC// cycle 3 restaging CT
scan following study treatment for NSCLC
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.1 mGy (Body) DLP = 1.4
mGy-cm.
2) Stationary Acquisition 8.1 s, 0.2 cm; CTDIvol = 132.1 mGy (Body) DLP =
26.4 mGy-cm.
3) Spiral Acquisition 9.8 s, 63.4 cm; CTDIvol = 10.6 mGy (Body) DLP = 663.9
mGy-cm.
4) Spiral Acquisition 4.5 s, 28.9 cm; CTDIvol = 9.7 mGy (Body) DLP = 274.0
mGy-cm.
Total DLP (Body) = 966 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS WITH CONTRAST)
## CHEST PERIMETER:
No thyroid findings warrant any further imaging.
Supraclavicular and axillary lymph nodes are not enlarged. Breast evaluation
is reserved for mammography. Elsewhere in the chest wall there are no soft
tissue abnormalities concerning for malignancy. Findings below the diaphragm
will be reported separately.
## CARDIO-MEDIASTINUM:
Esophagus is unremarkable. Atherosclerotic calcification
is mild in head and neck vessels, not apparent coronary arteries. Aorta and
pulmonary arteries and cardiac chambers are normal size. Small pericardial
effusion is is slightly different in distribution but unchanged in overall
size since .
## THORACIC LYMPH NODES:
No lymph nodes in the chest are pathologically enlarged.
Fluid filled upper pericardial recesses slightly smaller today than in .
Should not be mistaken for mediastinal adenopathy.
## LUNGS, AIRWAYS, PLEURAE:
14 x 19 mm spiculated suprahilar soft tissue mass,
right upper lobe, was 19 x 24 mm on and had a longer interface with
mediastinal pleura. Today there only linear projections to costal,
paraspinal, and mediastinal pleura. Tumor extension inferiorly to the upper
pole of the right hilum persists but previous infiltrative hilar lymph node
enlargement has substantially decreased. Region of peribronchial ground-glass
opacification in the right upper lobe is less radiodense. Centrally it
contains a new small 7 mm long irregularly shaped opacity. I suspect this was
either an area of hemorrhage due to bronchoscopic biopsy, or, infection,
rather than malignant extension.
Left lung is grossly clear and the tracheobronchial tree is normal to
subsegmental levels.
## CHEST CAGE:
Sclerosis has appeared in several previously entirely or
predominantly lytic chest cage metastases, including the largest in the T7
vertebral body, as well as several ribs. There is no loss of height in that
vertebra, any compression fractures elsewhere in the thoracic spine, new large
destructive bone lesions or pathologic fractures elsewhere.
## IMPRESSION:
Substantial interval involution since in the right suprahilar primary
bronchogenic carcinoma, previous right hilar adenopathy, multiple lytic
osseous metastases, now more substantially blastic.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11336547", "visit_id": "N/A", "time": "2152-08-08 11:53:00"} |
16268804-RR-15 | 98 | ## INDICATION:
year old man with COPD, intubated and sedated with marked
agitation undergoing work-up // interval change in PNA
## FINDINGS:
Severe cardiomegaly stable. Improved bilateral pulmonary edema. Large
bilateral pleural effusions stable. Bibasilar atelectasis unchanged. Left
retrocardiac consolidation unchanged, likely atelectasis but cannot exclude
pneumonia, correlate clinically. No pneumothorax.
Right HD catheter terminates in the upper right atrium. ET tube 2.0 cm above
the carina. NG tube traverses beyond the diaphragm and beyond the inferior
margins of this film, all likely in the stomach.
## IMPRESSION:
Improved bilateral pulmonary edema. No significant interval change compared
to
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16268804", "visit_id": "29219847", "time": "2180-05-05 04:15:00"} |
17966332-RR-128 | 131 | ## INDICATION:
Nephrotic proteinuria, prior history of renal cysts.
## FINDINGS:
The right kidney measures 12.1 cm.
The left kidney measures 14.1 cm.
There are multiple renal cysts visualized, distorting the structure of the
right kidney. The largest cyst measures 5.1 x 4.7 x 4.5 cm. On correlation
with prior CT, this does not appear to be significantly changed in size. The
left kidney is also distorted by multiple large cysts. The largest is located
in the upper pole and measures 4.0 cm in greatest dimension. On correlation
with prior CT, this does not appear significantly larger.
There is no hydronephrosis, stones or masses in either kidney.
The bladder is moderately well seen and appears normal.
## IMPRESSION:
1. Stable bilateral renal cysts.
2. Normal bladder.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17966332", "visit_id": "N/A", "time": "2124-09-14 13:59:00"} |
14698539-RR-43 | 227 | ## INDICATION:
Status post recent exploratory laparotomy with elevated white
blood cell count
## DOSAGE:
TOTAL DLP reported separatelymGy-cm
## FINDINGS:
Since , bilateral pleural effusions have reaccumulated, with
small left and trace right pleural effusions, both dependent in location with
simple fluid attenuation.
Assessment of the lungs is limited by respiratory motion and inadvertent
expiratory phase of respiration. With these limitations in mind, multifocal
pulmonary opacities are relatively similar to the recent study with the
exception of slight progression of consolidative opacities in the inferior
lingula and left lower lobe. Multifocal opacities consistent with
small airways disease show possible slight decrease in extent within the
lingula and left lower lobe, although direct comparison is limited by above
described artifacts.
No new or enlarging thoracic lymph nodes are evident. Heart is upper limits
of normal in size, and there is no evidence of pericardial effusion.
Skeletal structures of the thorax demonstrate healing left posterior lateral
rib fractures.
## IMPRESSION:
1. Evolving bronchopneumonia with progressive consolidation in the inferior
lingula and adjacent left lower lobe and slight decrease in the extent of
small airways disease in these regions.
2. Other pre-existing pulmonary opacities are not appreciably changed since .
3. Reaccumulation of pleural effusions, small on the left and trace on the
right.
4. Please see separately dictated CT of the abdomen and pelvis for complete
description of subdiaphragmatic findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14698539", "visit_id": "29305781", "time": "2144-08-24 10:59:00"} |
15540055-RR-79 | 328 | CHEST CT WITH CONTRAST
## INDICATION:
Patient with cough and abnormal chest x-ray.
## MEDIASTINUM:
The patient has multiple bilateral calcified pleural plaque corresponding to
the nodule described on the chest x-ray consistent with prior asbestos
exposure.
There is no pathologic superclavicular, mediastinal or axillary lymph node
enlargement by CT size criteria.
The aorta is severely atheromatous with penetrating ulcer on the anterior wall
of descending aorta (series 2, image 21) measuring 9 mm. The aorta is not
dilated.
Prior sternotomy was done for CABG with calcification of native coronary
artery and a stent in one of the venous graft. Thinning of the inferior wall
of the mid portion of the myocardium with subendocardial hypodensity is
consistent with prior myocardial infarct.
There is no pleural or pericardial effusion. Residual epicardial wires are
seen.
## LUNGS AND AIRWAYS:
The airways are patent to the subsegmental level. Small, less than 6 mm lung
nodules are seen. They are in series 4, image 74, 88, 101, 106, 120, 128,
131, 146, 166, 167, 198. The dominant one is in the right upper lobe
measuring 6 mm, image 88, with ill-defined ground-glass opacity around it:
they could be infectious or inflammatory but they remain indeterminate.
## UPPER ABDOMEN:
This study is not tailored for assessment for intra-abdominal
organs. Except for uncomplicated colonic diverticulum, the remaining of the
upper abdomen is unremarkable.
## OSSEOUS STRUCTURES:
There is no bony lesion concerning for malignancy.
## CONCLUSION:
1. Calcified bilateral pleural plaques correspond to the nodule described on
the left lung on chest x-ray consistent with prior asbestos exposure. There is
no related interstitial lung disease.
2. Considering the risk factor (asbestos), less than 6 mm lung nodules that
are nonspecific will have to be followed up with a chest CT in six months.
3. Prior CABG was done for coronary artery disease with sequela of infarct in
inferior mid portion of the left ventricle.
4. Descending aorta is severely atheromatous with penetrating ulcer.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15540055", "visit_id": "N/A", "time": "2173-10-13 14:19:00"} |
14391494-RR-116 | 176 | ## INDICATION:
female with dizziness on Coumadin. Evaluate for
intracranial hemorrhage.
## FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large territorial
infarction. Ill-defined calcified density within the right frontal lobe gyri
(2:21) is slightly more defined than on , and may represent a
dural calcification or meningioma. Marked ventriculomegaly involving the
lateral and third ventricles is similar to . The basal cisterns appear
patent and there is preservation of gray-white matter differentiation.
A 2.8 x 1.4 cm lesion containing macroscopic fat along the right scalp
overlying the temporal region is similar to prior and compatible with lipoma.
No acute fracture is identified. A small mucous retention cyst is present in
the right sphenoid sinus. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are otherwise clear. There is right phthisis
bulbi, similar to . The left globe is unremarkable.
## IMPRESSION:
1. No intracranial hemorrhage.
2. Stable moderate lateral and third ventriculomegaly, similar to .
3. Small ill-defined right frontal lobe calcification, compatible with dural
calcification or small meningioma.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14391494", "visit_id": "N/A", "time": "2171-03-06 19:09:00"} |
13863357-RR-37 | 108 | ## FINDINGS:
Extensive gas collections in the soft tissues, both at the plantar
and dorsal aspect of the foot. Increasing assessment of cortical structures
in the region of the calcaneus (where a non-recent fracture line has newly
appeared), in the talus and at the distal metatarsal bone of the first digit.
Known extensive hallux valgus deformity with degenerative changes. Healing
fracture deformities of the third to fifth metatarsal bones. Pes planus
deformity.
Overall, the changes are consistent with ongoing multifocal osteomyelitis,
complicated by a pathologic calcaneal fracture and gas collections in the soft
tissues.
The referring physician, was notified by telephone at the time of
dictation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13863357", "visit_id": "28758073", "time": "2121-02-19 09:44:00"} |
19919588-RR-16 | 478 | ## EXAMINATION:
CT abdomen and pelvis with contrast
## INDICATION:
year old man with hernia and prolapsing stoma // ? anatomy
post ileostomy and
## 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 27.5 s, 0.2 cm; CTDIvol = 469.0 mGy (Body) DLP =
93.8 mGy-cm.
3) Spiral Acquisition 7.6 s, 49.4 cm; CTDIvol = 10.2 mGy (Body) DLP = 495.5
mGy-cm.
Total DLP (Body) = 591 mGy-cm.
## LOWER CHEST:
There is a 7 mm nodule in the left lower lobe, seen on image 3 of
series 5. Linear atelectasis noted at the left lung base. Lung bases are
otherwise unremarkable.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, 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:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
Post-surgical changes are seen from partial colectomy,
ileostomy and mucous fistula. There is a large parastomal hernia, containing
loops of small bowel, without evidence for obstruction. Additionally, there
is a large herniation at the site of the patient's mucous fistula, containing
approximately 10 cm of colon.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. Small, 2.3
cm fluid collection adjacent to the left inguinal canal likely represents a
postoperative seroma vs lymphocele.
## REPRODUCTIVE ORGANS:
The visualized reproductive organs are unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
Bilateral inguinal hernias containing fat are noted.
## IMPRESSION:
1. Parastomal hernia at the site of patient's right lower quadrant ileostomy,
containing small bowel, without evidence for obstruction.
2. Prolapsing mucous fistula, containing approximately 10 cm of colon.
3. 7 mm pulmonary nodule in the left lower lobe.
## 7 MM PULMONARY NODULE:
For low risk patients, initial
follow-up
CT at months and then at months if no change. For high risk
patients - initial follow-up CT at months and then at and 24 months
if no change.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19919588", "visit_id": "N/A", "time": "2118-03-31 13:25:00"} |
17400167-RR-49 | 121 | ## INDICATION:
A female with upper abdominal pain.
## FINDINGS:
The hepatic architecture is normal in appearance. No focal liver
lesion is identified and no biliary dilatation is seen. The common duct
measures 0.3 cm. The portal vein is patent with hepatopetal flow. The
gallbladder is normal with no gallstones identified. The pancreas is
unremarkable, but is partially obscured from view by overlying bowel. The
spleen is unremarkable and measures 9.1 cm. No hydronephrosis is seen. The
right kidney measures 10.7 cm and the left kidney measures 10.1 cm. The
visualized portion of the IVC is unremarkable. The aorta is of normal caliber
throughout.
## IMPRESSION:
Unremarkable abdomen ultrasound with no findings to explain the
patient's pain.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17400167", "visit_id": "N/A", "time": "2157-08-16 13:37:00"} |
16716185-RR-30 | 162 | ## INDICATION:
year old man with thyroid nodule in the right lobe, recent FNA
is suspicious for malignancy// evaluate neck adenopathy for surgical planning.
## FINDINGS:
In the right lobe of the thyroid 2 nodules are present 1 lies posteriorly in
mid to upper pole and measures 9 x 7 x 9 mm. The other lies in the mid to
lower pole and lies anteriorly and measures 11 x 9 x 6 mm. Elsewhere the
right lobe appears normal.
The left lobe contains an anterior nodule measuring 5 x 6 x 4 mm this is
well-defined and has no concerning features. Elsewhere the the left lobe of
the thyroid remains normal.
Evaluation of the neck anteriorly and more posteriorly was made. No evidence
of abnormal lymph nodes seen on either side in particular the lymph nodes
adjacent to the lower pole of the right lobe appeared normal
## IMPRESSION:
No evidence of abnormal lymph nodes in the right or the left side
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16716185", "visit_id": "N/A", "time": "2125-07-19 11:14:00"} |
18873784-RR-8 | 145 | ## INDICATION:
Right hip pain, unable to ambulate. Assess for occult fracture.
## FINDINGS:
There are non-displaced fractures through the medial aspects of the
superior and inferior pubic rami. There is no dislocation. There is diffuse
demineralization. Degenerative changes are seen at both femoroacetabular
joints. There are also degenerative changes of the pubic symphysis and along
the lower lumbar spine.
There are bilateral iliac artery calcifications. There is colonic
diverticulosis without evidence of diverticulitis. There is no free fluid in
the pelvis. No pathologically enlarged pelvic lymph nodes are seen. The
uterus is not identified and may be surgically absent. No adnexal
abnormalities are seen.
## IMPRESSION:
Non-displaced fractures through the medial aspects of the
superior and inferior pubic rami.
The preliminary report stated no acute fracture. An updated report was
discussed with Dr. by Dr. at 9:24 a.m. via telephone on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18873784", "visit_id": "23351857", "time": "2188-02-24 04:02:00"} |
15292838-RR-18 | 187 | ## EXAMINATION:
DX HUMERUS AND ELBOW
## INDICATION:
with marked RUE right upper extremity swelling, evaluate for
fracture.
## FINDINGS:
Irregular radiodensity just posterolateral to the humeral head on the second
of 2 provided images of the humerus, with the patient in internal rotation,
may represent periarticular calcification, suboptimally evaluated on this
study. Otherwise, the humerus is intact without evidence of fracture or
dislocation. The imaged right ribs are normal. The right scapula is within
normal limits. No evidence of right clavicular injury. There is suggestion
of irregularity about the medial right humeral epicondyle, without a clearly
delineated fracture or focal injury. No definite elbow effusion. The radius
and ulna are intact on limited evaluation. Limited evaluation of the right
wrist demonstrates no evidence of acute injury.
## IMPRESSION:
1. Radiodensity seen adjacent to the right humeral head may be periarticular
in nature. Recommend dedicated shoulder radiographs for further evaluation.
2. Irregularity about the medial right humeral epicondyle is suboptimally
evaluated. Recommend dedicated elbow radiographs for further evaluation.
3. Otherwise, no focal osseous abnormality involving the right humerus or
forearm.
## RECOMMENDATION(S):
Dedicated shoulder and elbow radiographs, as above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15292838", "visit_id": "N/A", "time": "2181-09-29 04:31:00"} |
16033805-RR-40 | 124 | ## HISTORY:
Metastatic melanoma, rule out recurrence in the right neck.
## FINDINGS:
Incompletely evaluated are postoperative changes in the right
cerebellum. There is no mass or pathologic adenopathy in the neck.
Previously noted right-sided pre- and postauricular lymph nodes show no
evidence for recurrence. There is skin thickening in the right parotid region
which is likely related to prior partial parotidectomy. This likely
represents scar tissue. A tiny node is seen medial to the
sternocleidomastoid, which does not appear pathologic by imaging criteria.
There is no exophytic mucosal mass.
No thyroid lesion is seen.
There are nodular densities in both lung apices, for which recommend
correlation with the concurrent CT torso.
## IMPRESSION:
No evidence for recurrence of right pre- and postauricular adenopathy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16033805", "visit_id": "N/A", "time": "2131-10-15 13:00:00"} |
19515421-DS-19 | 610 | ## ALLERGIES:
Egg Yolks / Shellfish
## HISTORY OF PRESENT ILLNESS:
year-old woman with a history of acute pancreatitis one year
prior to admission that was related to a pancreatic duct
stenosis s/p pancreatic duct sphincterotomy and temporary stent
placement who was transferred from with
acute pancreatitis.
Her current course begins 3 weeks ago when she had diffuse,
severe abodminal pain radiating to her back that led to her
admission to for nearly a week. She had
an elevated lipase and was treated supportively and sent
home on a diet of clears/bland food, which she tolerated. She
was set up to have ERCP at on . THe night prior to
admission she developed acute onset constant and at times sharp
diffuse abdominal pain similar to these episodes of
pancreatitis. She went to the ED where a lipase was >4000
and she was sent to .
She had stable vitals in the ED and was given IV dilaudid. SHe
currenly has abdominal pain and has not received dilaudid
in >2hrs.
## ROS:
eating a bland low fat diet recently, no weight loss, no fevers,
no chest pain, no diarrhea, ++Nausea, no bloody stools, no new
meds. Unless noted above 13pt review is otherwise negaive.
Of note, she does not consume alcohol and is s/p cholecystectomy
years ago.
## PAST MEDICAL HISTORY:
- Acalculous cholecystitis
- S/p Cholecystectomy
- Spincter of Oddi dysfunction
- ERCP : Severe stenosis of the pancreatic sphincter was
noted with resistance to the passing of the sphincterotome.
sphincterotomy of biliary and pancreatic ducts and pancreatic
duct stent placement , PD stent removed 7 days later.
## FAMILY HISTORY:
No history of pancreatitis.
## ADMISSION EXAM:
97.5 114/71 50 18 99 RA
appears very uncomfortable, lying in bed
heent: unremarkable
neck: unremarkable
regular s1 and s2
clear breath sounds without wheeze
intense to palpation of mid-epigastric region and RUQ, guarding,
+BS, non-distended, no flank echymosis
no peripheral edema
AOX3, speech fluent
## VS:
Afebrile, normal vital signs
## NEURO:
Ambulatory, alert, oriented x3, fluent speech
## BRIEF HOSPITAL COURSE:
year-old woman presents with recurrence of acute
pancreatitis; prior episodes of pancreatitis were due to
pancreatic duct stenosis.
## # ACUTE PANCREATITIS:
Pt underwent CT on admission that showed
mild inflammatory changes in the pancreas. Primary team
discussed pt with Dr. that stated pt should not go
urgently to ERCP this admission but rather receive supportive
care and then when she is well return for ERCP. She received IV
fluids, IV dilaudid and zofran. Her pain gradually improved.
IV pain medications were titrated down and eventually converted
to oral pain medication for only one day. Diet was started only
when she did not require any further opiod pain medication.
She will have a repeat ERCP scheduled with Dr. 2
weeks after discharge.
## # ACTIVE SMOKER:
Nicotine patch. The patient is interested in
quitting.
## MEDICATIONS ON ADMISSION:
Promethazine PRN
Dilaudid 2mg PRN
Tramadol 50mg PRN
## DISCHARGE MEDICATIONS:
1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 2 weeks: after 2 weeks at this dose,
work with your PCP to taper the dose.
Disp:*14 patch* Refills:*0*
2. acetaminophen 500 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed for pain.
## DISCHARGE DIAGNOSIS:
Acute pancreatitis
Tobacco use
## DISCHARGE INSTRUCTIONS:
You were admitted with acute pancreatitis. Please avoid alcohol,
or fatty meals. You are encouraged to stop smoking.
## MEDICATION INSTRUCTIONS:
1. Nicotine Patch 14 mg patch daily. You should work with your
primary care doctor about tapering down the strength of the
patch over the next couple of weeks.
2. Acetaminophen (Tylenol) to 1000 mg by mouth every 6 hours
as needed for pain. Maximum 4000 mg per day.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19515421", "visit_id": "26717905", "time": "2150-12-26 00:00:00"} |
14648756-RR-97 | 168 | ## REASON FOR EXAMINATION:
Evaluation of NG tube placement.
Portable AP chest radiograph compared to .
The NG tube currently is continuing to the left of the midline with its tip at
the level of the mid portion of the left main bronchus. It could be in the
upper esophagus although it can be within the airways with its tip in the left
main bronchus, the precise location is difficult on this slightly rotated
radiograph. The findings were discussed with the clinical team, Dr.
phone and the NG tube has been subsequently removed.
Bibasilar atelectasis is present, progressed since the previous study,
especially on the left with bilateral pleural effusion, left most likely
larger than right. The bilateral perihilar opacities are mild, representing
mild pulmonary edema/volume overload. There is no change in the position of
the pacemaker with right and left leads terminating into the right and left
ventricle accordingly.
The retrocardiac opacities might represent atelectasis, but also might
represent aspiration pneumonia, given the patient's history.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14648756", "visit_id": "29579513", "time": "2172-07-11 16:54:00"} |
13030379-RR-45 | 122 | ## CLINICAL INFORMATION:
man with upper GI bleeding and large
gastric varix with suspected cirrhosis. Request is made for transjugular
liver biopsy.
## RADIOLOGISTS:
Dr. , Dr. , Dr. , Dr.
, who was the attending physician and present for the entire
procedure.
## PROCEDURE AND FINDINGS:
During the initial steps of the requested TIPS
procedure, after the portosystemic gradient was found to be relatively low,
request was made for transjugular liver biopsy. However, the hepatic vein
anatomy was not conducive for this procedure as the hepatic vein confluence
came off the IVC at an acute angle. Despite numerous attempts, the biopsy
access sheath could not be safely advanced into the hepatic vein. The
procedure was terminated.
## IMPRESSION:
Unsuccessful transjugular liver biopsy due to hepatic vein
anatomy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13030379", "visit_id": "24705959", "time": "2158-12-24 15:30:00"} |
15063316-RR-50 | 565 | ## EXAMINATION:
CT abdomen and pelvis without intravenous contrast
## INDICATION:
s/p incisional hernia ( ) repair presenting with ileus//
CT abdomen w/ PO contrast. please rule out intrabd collection
## LOWER CHEST:
There are punctate calcified granulomas in the left lower lobe
(series 2:8) and right lower lobe (series 2:5).
## HEPATOBILIARY:
The liver demonstrates homogeneous attenuation throughout.
There is a hypoattenuated focus in the caudate lobe measuring 3.6 x 2.6 cm
(series 2:20) likely representing a simple cyst or biliary hamartoma,
unchanged from CT . 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 within the limitations of an unenhanced scan. There is 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 and left adrenal glands are normal in size and shape.
## URINARY:
The bilateral native kidneys are atrophic. There is a hypoattenuated
focus in the upper pole of the transplant kidney in the right iliac fossa
which measures 2.1 cm (series 2:50), unchanged from CT .
There is no hydronephrosis or perinephric abnormality the transplant kidney.
## GASTROINTESTINAL:
Patient is status post incisional hernia repair in the right
lower quadrant. There is significant fatty stranding adjacent to bowel loops
near the hernia repair site likely postoperative given recent surgery. Small
bowel loops are mildly dilated measuring up to 3.3 cm across maximal diameter
(series 2:30) without a discrete transition point likely representing a
postoperative ileus. There is mild sigmoid diverticulosis without evidence of
diverticulitis. There is no evidence of obstruction. There is no evidence of
an fluid collection in the abdomen or pelvis.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate is unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
Patient is status post incisional hernia repair in the right
lower quadrant. In the subcutaneous tissues adjacent to the repair site,
there is a poorly organized fluid collection which measures approximately 2.0
x 10.4 x 4.4 cm (series 2:85 and series 602:37) with a fat fluid level. A
right lateral approach drainage catheter terminates at the periphery of this
fluid (series 2:55). There is also subcutaneous stranding and foci of air
within the subcutaneous tissues. Skin staples are noted in this area.
## IMPRESSION:
1. No evidence of a collection in the abdomen or pelvis.
2. Fatty stranding adjacent to bowel loops in the right lower quadrant
adjacent to the hernia repair site which is likely reactive from recent
surgery. There are prominent small bowel loops measuring up to 3.3 cm across
maximal diameter without a transition point likely representing an ileus. No
evidence of a mechanical obstruction.
3. In the subcutaneous tissues in the right lower quadrant at the site of
hernia repair, there is poorly organized fluid measuring 2.0 x 10.4 x 4.4 cm
likely representing postoperative fluid. A surgical drainage catheter
terminates along the periphery but outside of this fluid (series 2:55).
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15063316", "visit_id": "24300666", "time": "2136-01-21 12:44:00"} |
12469540-DS-4 | 1,478 | ## HISTORY OF PRESENT ILLNESS:
year old F diagnosed with SLE in complicated by
pericarditis and pleural effusion as well as lupus nephritis who
is now admitted due to increasing weight gain and edema. Pt
previously followed at since initial diagnosis. She had
biopsy proven nephritis and was treated with Cytoxan and
prednisone in followed by prednisone and MMF for years.
In , due to increasing proteinuria, she was treated with
high dose steroids and Rituximab x 2. She had an episode of
chest tightness attributed to rituximab. She was kept on
prednisone and MMF post RTX and went into remission. In ,
she stopped all immunosuppressants and went with holistic
treatment. She did well clinically until the end of of
this years when she developed worsening edema and found to
have nephrotic range proteinuria. She was treated as an
outpatient with IV solumedrol 1000 x 2, followed by 60 mg
prednisone and MMF 1g bid and PO Lasix. A week later, she had
worsening edema and increase in Lasix dosing to 60, 40, 60 mg
did not help so she was admitted to . She had a renal
biopsy that showed stage 4 glomerulonephritis and was treated
with plasmapheresis on and followed by 30hour
treatment with RTX. Pt discharged on on prednisone 40 daily
and MMF 1g bid. During that admission, her losartan was stopped
due to increasing creatinine, and amlodipine was started.
She came to for a game on and was
tachycardic with symptomatic edema, so she was admitted to
from the medical tent. She was discharaged a day later with no
significant intervention to follow up in clinic. Pt seen
in clinic on and was noted to be 189lb compared to
180lb at discharge, her heart rate was also in the 110's. Pt
sent to the ED for evaluation due to persistent tachycardia to
rule out pulmonary embolus in the setting of her nephrotic
syndrome. MMF increased to 1500 bid.
In the ED, negative. She was started on empiric heparin
gtt and admitted for VQ scan.
## PAST MEDICAL HISTORY:
- SLE c/b lupus nephritis
- HTN
- pericarditis / pleural effusions secondary to SLE requiring
ICU admission at in
## FAMILY HISTORY:
Biologic mother with h/o +ANCA and polysubstance abuse
Biologic father with depression and bipolar disorder
## PHYSICAL EXAM:
VSS except BP 140s-150s/80s-90s, HR 96-110
## ABD:
palpable subQ edema, slightly full
## EXTREM:
1+ pitting edema to just below knees, warm and
well-perfused
## NEURO:
alert and oriented, conversant, nonfocal
## RENAL U/S:
1. No hydronephrosis.
2. Unremarkable Doppler ultrasound with no findings to suggest
renal artery stenosis.
## ECHO:
The left atrium is elongated. The estimated right atrial
pressure is mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF =
70%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
## IMPRESSION:
No evidence of acute pulmonary embolism. Normal
ventilation and perfusion scans
## CXR:
IMPRESSION:
Compared to chest radiographs
Lungs are fully expanded and clear. Cardiomediastinal and hilar
silhouettes and pleural surfaces are normal
## EKG:
sinus tachycardia, normal axis, no ST/T changes, no S1Q3T3
## BRIEF HOSPITAL COURSE:
Pt is a y.o woman with SLE complicated by nephritis and prior
pericarditis, pleural effusion with recent admissions to
and (please see HPI for further details) who was
readmitted with lower extremity edema/anasarca and tachycardia.
Lupus with nephritis stage IV
#proteinuria/edema-nephrotic syndrome
#HTN
Nephrology and rheumatology were consulted. Pt was recommended
to continue her already prescribed prednisone taper, and current
doses of MMF and hydroxychloroquine. She was recommended to
start PO Bactrim DS for PCP ppx while on steroids. Her edema was
initially treated with BID IV Lasix which was converted to PO
torsemide 40mg. Although her edema was not completely resolved
upon discharged, it had improved enough that she was deemed
stable to continue to diurese at home. She was given a range
dose of mg of torsemide to take depending on her morning
weight. Her potassium was 3.7 without supplementation and she
was not given a supplement to take. She should have electrolytes
rechecked on .
Her amlodipine was discontinued as it could be contributing to
her edema. Losartan was resumed at 50mg daily as per renal and
rheumatology recommendations, then titrated up to 100 mg due to
persistent hypertension.
Weight on discharge was 82.5 kg (181.5 kg). Pt thinks her
baseline is ~180lbs.
She is to see rheumatology on and renal on - if
possible, she should have labs drawn on for availability
during her renal visit.
#tachycardia-ddx with concern for pericarditis, pericardial
effusion. Pt was on empiric heparin for DVT/PE. This was
discontinued after negative and V/Q scans. TTE was
unrevealing for an acute process including pericardial effusion.
TSH WNL, and multiple EKGs showed only sinus tachycardia. Anemia
could be contributing. Patient also demonstrated significant
anxiety about marital situation (possible separation from wife),
which likely contributed.
#anemia. Pt with evolving anemia during admission. Iron studies
and hemolytic work up sent which showed a low haptoglobin but
otherwise no definitive evidence of hemolysis. No signs of
active bleeding noted, and a stool guaiac was negative x2.
Hematology was consulted, and agreed that hemolysis was
unlikely. Most likely a combination of anemia of inflammation
plus phlebotomy-induced anemia.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PredniSONE 40 mg PO DAILY
2. Hydroxychloroquine Sulfate 200 mg PO BID
3. Mycophenolate Mofetil 1500 mg PO BID
4. OxyCODONE--Acetaminophen (5mg-325mg) TAB PO Q4H:PRN Pain
- Moderate
5. Vitamin D3 (cholecalciferol (vitamin D3)) units oral
5XWEEK
6. amLODIPine 10 mg PO DAILY
7. LORazepam 0.5-1 mg PO Q4H:PRN anxiety
8. Furosemide 100 mg PO BID
## DISCHARGE MEDICATIONS:
1. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
## REFILLS:
*0
2. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*30
## TABLET REFILLS:
*0
3. Torsemide 10 mg PO DAILY
Take 1 tablet if no weight gain. Take 2 tablets if weight gain.
RX *torsemide 10 mg tablet(s) by mouth daily Disp #*45
Tablet Refills:*0
4. Hydroxychloroquine Sulfate 200 mg PO BID
5. Mycophenolate Mofetil 1500 mg PO BID
6. PredniSONE 40 mg PO DAILY
continue prednisone taper as previously recommended.
7. Vitamin D3 (cholecalciferol (vitamin D3)) units oral
5XWEEK
## DISCHARGE DIAGNOSIS:
SLE
Lupus nephritis
Tachycardia
Edema
## DISCHARGE INSTRUCTIONS:
You were admitted because of a significant weight gain with
swelling in your legs and abdomen, which was a result of your
uncontrolled kidney disease. We switched the medications that
you had been discharged on from your last hospitalization:
- Stopped amlodipine
- Started torsemide
- Restarted losartan
After this, your swelling significantly improved. It seems that
you are still above your baseline (or "dry") weight because you
have a bit of swelling, but it is much improved and can be
treated at home.
You had chest pain and a fast heart rate when you arrived. For
this, you had studies of your heart and lungs (including an
echocardiogram, multiple EKGs, blood testing of your thyroid,
and a V/Q scan of your lungs) that did not show any serious
problems that are causing this.
You were evaluated by the rheumatology and nephrology teams, and
you will have follow up with them when you leave. The
rheumatology team recommended that you start taking Bactrim to
prevent infections while on your immune suppressing medications.
You were also seen by the hematology team for anemia. Your
anemia was likely due to a combination of your lupus and
repeated blood draws.
You are being given a prescription of torsemide 10 mg tablets.
Please weigh yourself as soon as you get home, and then every
morning after that. Take torsemide according to this plan:
- If your weight is the same in the morning as it is tonight
when you leave the hospital, take 10 mg (one tablet) of
torsemide.
- If your weight goes up above the weight that you record upon
leaving the hospital, take 20 mg (two tablets) of torsemide.
- If your weight is more than 3 pounds above the weight that you
record upon leaving the hospital, call your doctor's office or
come back to the emergency room.
It is important to weigh yourself at the same time every day
wearing the same amount of clothing, to maintain accuracy.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12469540", "visit_id": "25914784", "time": "2127-12-11 00:00:00"} |
18568518-DS-7 | 1,599 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Drainage of Cystic Pelvis Mass ( )
## HPI:
Mrs. is a year old female with past medical
history significant for advanced stage small cell lung cancer
with metastasis to the brain s/p whole brain radiation, recently
started on etoposide and carboplatin, who is presenting with
uncontrollable diarrhea and generalized weakness. She has had
episodes of diarrhea for the last 3 days. She also feels
weaker than she normally does. She last received
etoposide/carboplantin a week and a half ago. She has a
chronically poor appetite and denied having nausea, vomiting,
melena, or hematochezia. She claims that she has lost about 80
pounds since her cancer was first diagnosed six months ago. In
addition to her diarrhea and weakness, she has chronic shortness
which she uses 2L of oxygen at home for. She states that her
shortness of breath is no worse than her baseline. She denied
recent antibiotic use, lightheadedness, and chest pain.
In the ER, her vitals were 98.4 76 127/64 20 97%1L NC. Her labs
were remarkable for a hematocrit of 25.3 from 34.3 on ,
WBC count 0.4, and a sodium of 131. Physical exam in the ER
revealed that she had good rectal tone, brown stool that was
guaiac positive. CT scan of the abdomen was performed to look
for a source of GI bleeding and to rule out an intrabdominal
process. The CT scan showed no acute intra-abdominal process.
Urine analysis was unremarkable and blood cultures were sent.
Upon arrival to the floor, she was hemodynamically stable and in
no acute distress.
## PAST ONCOLOGIC HISTORY:
Briefly, pt started feeling unwell in the . She was
having a cough, nausea/vomiting, and a 20 lb weight loss. This
eventually led to a CT scan on which showed a right
inferolateral hilar mass. Subsequent bronchoscopy with biopsies
at were nondiagnostic. She was subsequently seen by
Dr. as well as by Dr. . On , Dr.
a mediastinoscopy with biopsies. Path
revealed small cell lung cancer in multiple lymph node stations.
Pt was seen as a new pt in on at which time
staging
workup was ordered, including CT torso and MRI head. On ,
MRI head was performed and it revealed several metastases and a
small amount of midline shift. The on-call oncologist called pt
and referred her to the ED for steroid therapy and expediated
consults. During that admission, pt was started on whole brain
radiation. Therapy started on for a total of 10
fractions, with completion date of .
- C1D1
## PAST MEDICAL HISTORY:
SCLC as above
COPD
hyperlipidemia
diverticulosis
hemorrhoids
ruptured appendix yrs ago
glaucoma
## FAMILY HISTORY:
Brother with stage IV colon cancer, sister died of "brain
cancer", another sister died from MI.
## GENERAL:
NAD, cachectic appearing woman who looks older than her
stated age
## HEENT:
AT/NC, EOMI, PERRLA, anicteric sclera, no cervical LAD
## CARDIAC:
RRR, S1/S2, III/VI systolic ejection murmor, no
gallops, or rubs
## LUNG:
Tachypnic, Clear, no wheezes, rales, rhonchi, decreased
breath sounds throughout
## ABD:
nondistended, +BS, nontender in all quadrants, no
rebound/guarding
## EXT:
moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
## PULSES:
2+ DP pulses bilaterally
## NEURO:
CN II-XII intact, strength is and symmetric in the
lower extremity muscle extensors and flexors, sensation intact
to light touch in the upper and lower extremities
## SKIN:
warm and well perfused, no excoriations or lesions, no
rashes
.
## GENERAL:
NAD, cachectic appearing woman who looks older than her
stated age
## HEENT:
AT/NC, EOMI, PERRLA, anicteric sclera, no cervical LAD,
no oral thrush
## CARDIAC:
RRR, S1/S2, III/VI systolic ejection murmor, no
gallops, or rubs
## LUNG:
Tachypnic, Clear, no wheezes, rales, rhonchi, decreased
breath sounds throughout
## ABD:
nondistended, +BS, nontender in all quadrants
## EXT:
moving all extremities well, no cyanosis, clubbing or edema
## PULSES:
2+ DP pulses bilaterally
## NEURO:
CN II-XII intact, strength is and symmetric in the
lower extremity muscle extensors and flexors, sensation intact
to light touch in the upper and lower extremities
## SKIN:
warm and well perfused, no excoriations or lesions, no
rashes
## PATHOLOGY:
None.
# Pevlic Mass Cytology ( ): Negative for malignant cells.
## # CT ABD/PEL ( ):
1. No acute intra-abdominal process. 2. 9
mm hypodense nodule in the left adrenal gland concerning for
metastasis
3. Indeterminate left hyperdense renal lesion which is
increased in size
compared to the prior study may reflect hemorrhage into a cyst.
Could be
further evaluated with renal ultrasound if clinically indicated.
4. Large cystic mass in the pelvis not significantly changed
from 1 month
prior likely originating from the ovary remains concerning for
malignancy. Again further evaluation with pelvic ultrasound or
MRI could be performed to further characterize.
# Pelvic US ( ): Large 11 cm complex cystic mass within the
pelvis with internal septations. The bilateral ovaries are not
definitely visualized. This likely originates from the ovary and
remains concerning for malignancy. Consultation with
gynecooncology is recommended.
# Drainage of Pelvic Cystic Mass ( ): Technically
successful ultrasound guided drainage of pelvic cystic mass.
Cytology negative.
## BRIEF HOSPITAL COURSE:
Mrs. is a year old female with past medical history
significant for advanced stage small cell lung cancer with
metastasis to the brain s/p whole brain radiation, recently
started on etoposide/carboplantin, who is presenting with
uncontrollable diarrhea and generalized weakness.
## # DIARRHEA/WEAKNESS:
She felt weak and had about 9 episodes of
diarrhea following her last chemotherapy infusion. Her symptoms
were likely secondary to chemotherapy induced pancytopenia (see
below). CT abdomen was unremarkable. She was found to be guaiac
positive on admission. She did not have a bowel movement for
several days after being admitted and actually felt constipated
(likely secondary to a cystic pelvic mass as detailed below).
Her fatigue improved after receiving blood. She had two solid
bowel movements after the cystic pelvic mass was drained.
## # PANCYTOPENIA:
Her hematocrit dropped to 24.3 from 34.3 on
. Her platelets continued to be low. Anemia labs were
sent. She was found to have a reticulocyte count of 0.2 and her
iron studies revealed an elevated ferritin and TIBC. She was
transfused 2 units of pRBCs on and her HCT improved. One
unit of platelets was transfused on . Her WBC count was
uptrending at the time of discharge. This was likely secondary
to receiving Neupogen during chemotherapy at the end of .
# Urinary retention/incontinence: Likely secondary to large
cystic mass in pelvis causing overflow incontinence. A Foley
catheteter was placed after 900cc of urine was seen on bladder
scan. One liter of urine drained from her bladder after the
Foley was placed. Gynecology-Oncology was consulted. Pelvic
ultrasound showed an 11cm cystic pelvic mass. Interventional
radiology drained 600cc of greenish fluid from mass on
and cytology was obtained. The Foley was discontinued and she
was able to void spontaneously. She complained of dysurea and UA
showed many bacteria. She will complete a 7 day course of
ciprofloxacin for a UTI. Urine culture was pending at the time
of discharge.
# Small Cell Lung Cancer with brain mets s/p whole brain
radiation. She recently started carboplatin/etoposide. Chest
x-ray obtained on admission showed that her tumor has decreased
in size. She received chemo on without issue. Her
dexamethasone was tapered to 2 grams every other day on
discharge.
## # COPD:
Continued Albuterol, Symbicort, and Supplemental oxygen.
# Hyponatremia: Likely to SIADH. This should improve as her
tumor shrinks.
## # GLAUCOMA:
Continued home Timolol eye drops.
===============================================
## TRANSITIONAL ISSUES:
# She will to have her urine culture sensitivities followed up
as an outpatient.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler PUFF IH Q6H:PRN shortness of breath
2. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
3. Dexamethasone 2 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Simvastatin 20 mg PO DAILY
7. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
## DISCHARGE MEDICATIONS:
1. Albuterol Inhaler PUFF IH Q6H:PRN shortness of breath
2. Dexamethasone 2 mg PO EVERY OTHER DAY
3. Omeprazole 40 mg PO DAILY
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Simvastatin 20 mg PO DAILY
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
8. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
## REFILLS:
*0
9. Docusate Sodium 100 mg PO BID:PRN constipation
Hold for loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 8.6 mg by mouth twice a day Disp
#*60 Tablet Refills:*0
11. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*13 Tablet Refills:*0
## PRIMARY:
Pancytopenia (likely chemotherapy induced) and cystic
pelvic mass
## SECONDARY:
Small Cell Lung Cancer, Hyponatremia, COPD,
Hyperlipidemia, Glaucoma, GERD
## DISCHARGE INSTRUCTIONS:
Dear ,
were admitted to the hospital after had a couple days of
diarrhea and felt weak after receiving chemotherapy. Your blood
counts were low and were transfused some red blood cells and
some platelets. felt better after your transfusion. It was
also noticed that had a large cyst in your pelvis. The cyst
was drained and felt it was easier to go to the bathroom.
The studies from the cyst are still pending. will resume
your chemotherapy as an outpatient. will take antibiotic for
fourteen days for a urinary tract infection.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18568518", "visit_id": "25683415", "time": "2179-03-06 00:00:00"} |
16363439-DS-19 | 1,555 | ## CHIEF COMPLAINT:
Mr. presented with a chief complaint of 2 recent unprovoked
seizures.
## HISTORY OF PRESENT ILLNESS:
Mr. is a right-handed man with recent onset
seizures, now admitted for differential diagnosis and
clarification of his epilepsy syndrome. He reports that he was
well until , and he had a seizure as a passenger in
the car. A witness stated that he turned to the left and his
left arm elevated, followed by stiffening of his body,
generalized shaking, and foaming of saliva for about 12 minutes.
He bit his lip, but did not bite his tongue or have urinary
incontinence. He did not injure himself during this event. He
was taken to , where head CT was unremarkable
and he was discharged home without medications. He denied any
clear precipitating factors for the seizure. He was then well
until , in an airport in , when he again had an
episode of stiffening of his body, fall, and generalized
shaking.
He hit his face and sustained a laceration over his left
eyebrow.
He again did not bite his tongue or have urinary incontinence.
He was taken to a local emergency room, head CT was
unremarkable,
and he was again discharged. Here, he saw Dr. ,
obtained an EEG which showed a single generalized spike, and a
normal MRI. He was started on Dilantin with a plan to
transition
him to Lamictal.
He says that he has not fully returned to his baseline since the
initial seizure. He complains of problems with memory and
attention. He notes that his vision is somewhat blurred and
that
he is more anxious and irritable. He also describes episodes of
staring and loss of awareness, which his girlfriend has also
witnessed. She says that he appears to be "daydreaming" without
change in facial expression or face or limb automatisms or other
abnormal movements. She may need to call his name 3 or 4 times
before he answers, but does not seem to be confused after the
staring. These episodes occur nearly daily.
## PAST MEDICAL HISTORY:
Bipolar Disorder
Social anxiety disorder
Benzodiazepine abuse
Alcohol abuse
Risk factor for seizure:
At the age of he had a minor injury where a small rock hit his
head but no LOC or long term effect from injury. No other
significant trauma history.
No surgical history.
Taking Xanax in the past years on a regular basis, off the
meds since a week ago, took 0.5 mg on the night prior to
admission.
Birth and developmental history:
Mom describes possible difficulty at birth, though details
unclear and no description of prolonged hospitalization or ICU
stay. Pregnancy was ok without complication. Walked and talked
at right time and did well at school by mom's report. Describes
himself as a " ".
## FAMILY HISTORY:
anemia, father with MI at age related to drug use, poor diet.
Grandparents with heart disease, diabetes, high cholesterol. One
cousin with seizures beginning at age , unclear history. No
other known history of seizures.
## HEENT:
NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
## NECK:
Supple, no carotid bruits appreciated. No nuchal rigidity.
Full range of motion OR decreased neck rotation and
flexion/extension.
## PULMONARY:
Lungs CTA bilaterally without R/R/W
## CARDIAC:
RRR, nl. S1S2, no M/R/G noted
## ABDOMEN:
soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
## EXTREMITIES:
No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
## SKIN:
no rashes or lesions noted.
## MENTAL STATUS:
ORIENTATION - Alert, oriented x3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register objects and recall at 5
minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
## CRANIAL NERVES:
I: Olfaction not tested.
## II:
PERRL 3 to 2mm and brisk. VFF to confrontation. Blinks to
threat bilaterally. Funduscopic exam reveals no papilledema,
exudates, or hemorrhages.
## III, IV, VI:
EOMI without nystagmus. Normal pursuits and
saccades.
## V:
Facial sensation intact to light touch. Good power in muscles
of mastication.
## VII:
No facial weakness, facial musculature symmetric.
## VIII:
Hearing intact to finger-rub bilaterally.
## XI:
strength in trapezii and SCM bilaterally.
## XII:
Tongue protrudes in midline with normal velocity movements.
## MOTOR:
Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
SAbd SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
## SENSORY:
No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE and . No
extinction to DSS.
## DTRS:
BJ SJ TJ KJ AJ
L 2 1
R 2 1
There was no evidence of clonus.
negative. Pectoral reflexes absent.
Plantar response was flexor bilaterally.
## COORDINATION:
No intention tremor, normal finger tapping. No
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
## GAIT:
Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
## BRIEF HOSPITAL COURSE:
is a man with recent onset seizures of
unclear etiology who was admitted to the inpatient
neurology unit on for differential diagnosis and
characterization of his seizures. On admission, it was not
clear whether he has epilepsy or whether his seizures were
precipitated by a combination of sleep deprivation, alcohol use,
and benzodiazepine withdrawal. He was admitted with the goal of
trying to record his typical events, or at least record
additional interictal epileptiform discharges to confirm a
diagnosis of epilepsy. His dilantin was weaned from 250mg to 100
mg and then off completely, and he placed on continuous EEG
monitoring. He was offered a nicotine patch numerous times, but
refused to use this during his hospital stay, noting that he did
not plan to go out for a cigarette during this admission but
rather would attempt to quit and continue to not smoke after
discharge without help from the patch. Throughout his
admission, he was followed closely for any signs of withdrawal
from alcohol and/or benzodiazepines.
Overnight on , his EEG recorded abnormal generalized
waveform changes, though no clinical events were recorded.
These findings indicate that he most likely has a primary
generalized epilepsy, likely exacerbated by intermittent sleep
deprivation, alcohol use, and benzodiazepines use.
On , Mr. became irritable and expressed an interest
in leaving the hospital, as he did not believe there was good
reason to keep him admitted. Although we had not yet recorded
his typical episodes of staring and brief loss of awareness, he
said that he was not willing to remain in the hospital to
attempt to record these events. He initially insisted that he
was going to sign out against medical advice, but after
extensive discussion, he agreed to stay overnight so that we
could restart his Dilantin at full dose. He was kept on EEG
monitoring overnight, taken off the morning of , and
discharged later that morning without having recorded any of his
typical events.
At the time of discharge (and throughout his hospital stay), he
had no current signs of withdrawal from alcohol or
benzodiazepines (no hypertension, tachycardia, or tremor).
## MEDICATIONS ON ADMISSION:
Current medications are Xanax he buys on street and marijuana.
He
smokes "excessive amounts" of marijuana he states to control
anxiety. He states he has been abusing Xanax since age ,
mg
every day, stopped taking that a week ago.
## DISCHARGE MEDICATIONS:
1. Phenytoin Sodium Extended 250 mg PO QHS
Continue as directed by outpatient physician.
2. LaMOTrigine 25 mg PO LAMOTRIGINE 25 MG PO AT NIGHT FOR 2
WEEKS, THEN 50 MG AT NIGHT FOR A WEEK. THEN TAKE PER
RX *lamotrigine [Lamictal] 25 mg 1 tablet(s) by mouth
LaMOTrigine 25 mg PO AT NIGHT FOR 2 WEEKS, THEN 50 MG AT NIGHT
FOR A WEEK. THEN TAKE PER Disp #*60
## DISCHARGE DIAGNOSIS:
Abnormal EEG without documented clinical event.
Seizure Disorder not otherwise specified.
## DISCHARGE INSTRUCTIONS:
Dear ,
It was our pleasure to take care of you during this admission.
You have been admitted regarding seizure-like episodes for
characterizing events.
During this hospital stay you had an abnormal EEG without any
clinical event.It means that the possibility of another seizure
is high. We did these changes to your medication .
1. Add lamictal to your medications.
This is a medication that can cause skin rash that can be
intense.
Please call your doctor as soon as you develop the rash.
To decrease the risk of this reaction we started you on 25 mg of
lamictal at night for 2 weeks, then you should take 50 mg at
night for a week. At this point you have an appointment with
your epileptologist and she will adjust the medication for you
to the goal dose.
Please continue your other medication per instructed.
Please do not start driving befor your neurology apointment. Per
MA law you should avoid driving for 6 months after seizure.
Please avoid swimming alone, or lying in bathtub.
Please drink enough amount of fluid and avoid skiping your meals
and snacks.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16363439", "visit_id": "29718953", "time": "2167-07-07 00:00:00"} |
15863802-DS-33 | 1,581 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
Mrs. is a year old female with a history of CLL s/p
treatment with Campath in , history of recurrent c.diff
colitis in , and hospitalization for PCP pneumonia in
complicated by readmission for aseptic meningitis thought to be
related to Bactrim. She was also admitted in late for
neutropenic fever complicated with SIRS at which time no source
of infection was found. She was most recently discharged from
the hospital on after being admitted for recurrence of
fevers, severe abdominal distention, and pain. During that
admission, she underwent palliative radiation therapy to the
spleen, abdominal paracentesis (with 4L of fluid removed), and
had IV cefepime given for persistent low grade fevers
(?non-cirrhotic SBP). Her pain was controlled with lidoderm
patches, oxycontin and po oxycodone. With palliative radiation
and paracentesis, her pain and abdominal distention largely
resolved. She was hospitalized again from to ,
admitted with acute renal failure (Cr 2.5 at clinic, baseline
1.0) and also with ascites - paracentesis done by on .
Patient on arrival to the floor endorses abdominal fullness and
discomfort. She feels nauseous (has not vomited), short of
breath, and endorses b/l leg swelling. Denies fever/chills,
chest pain, rash, muscle aches. Has low back pain. Easily feels
full, so has been eating small meals (including breakfast this
morning). Having bowel movements, without diarrhea/constipation;
denies dysuria. Without difficulty ambulation.
.
## ONCOLOGIC TREATMENT HISTORY:
She completed two cycles of R-CVP (rituxan, cytoxan,
vincristine, prednisone) back in as part of her initial
treatment for CLL. She did not have a significant response to
treatment though her white count did normalize after treatment.
However, the patient remained with a predominance of
lymphocytes. She continued to have bulky lymphadenopathy both
above and below the diaphragm following this treatment, did have
slight interval decrease overall with the exception of a slight
increase in the size of her lymph nodes in the right
supraclavicular chain. She has remained with massive
splenomegaly. She had an extended hospitalization in for
further workup for fever and night sweats. Her disease status
was reassessed with a bone marrow biopsy, which confirmed her
known history of CLL. She also had a lymph node biopsy of the
right supraclavicular node in order to rule out transformation
of her disease, which was also consistent with CLL without any
evidence of transformation. However, there was note of caseating
granuloma concerning for TB. She did have a PPD placed, which
was positive. Of note, she also developed a rash in this
setting, which eventually resolved. However, it was thought to
be related to TB, noted to be granuloma annulare on biopsy.
Ultimately, it was felt that she had extrapulmonary TB. She was
ultimately started on TB medication regimen with rifampin, INH,
ethambutol, and pyrazinamide. The patient was started on that at
the time of discharge from hospital on . At that
point, she was still having high fevers. After a few days of
being on this regimen, her high fevers improved. Of note, due to
a poor tolerability with anorexia, nausea, weight loss, and
fatigue, we switched her regimen. The ethambutol and
pyrazinamide were discontinued on and moxifloxacin
was added. She completed a six-month course of her TB medicines,
which she completed back in . The patient refused to take
the medications any longer. She then had a slowly rising white
blood count over the past couple of months. Also has had a
depressed platelet count. Her CT scans have overall been stable,
but remained with persistent bulky disease above and below the
diaphragm with massive splenomegaly. Our recommendation had been
to proceed with a fludarabine-based regimen given her bulky
disease, but until recently the patient refused any treatment
and we had been monitoring her off treatment. She noted at the
beginning of of her plans to go to in for
five or six months. As a result, she agreed to receive treatment
with FCR regimen, which she began on . The goal of
this was to cytoreduce her disease before she left for .
.
## PAST MEDICAL HISTORY:
====================
1. CLL. Please refer to note for extensive details.
2. Extrapulmonary TB diagnosed , now s/p 6 months of therapy
with rifampin, INH, and moxifloxacin.
3. Hypothyroidism
4. Osteoarthritis
5. Status post ERCP with sphincterotomy for gallstone
pancreatitis and cholangitis, . Status post cholecystectomy
7. History of C. difficile
8. Recurrent ascites
## GEN:
NAD, resting comfortably in bed.
## ABD:
distended, regionally tympanitic versus dull to percussion,
+BS, uncomfortable to palpation, unable to assess
hepatosplenomegaly given the distention
## EXTR:
pitting edema bilateral, 1+DP pulses
## IMPRESSION:
Successful therapeutic paracentesis yielding 4
liters of clear
brown fluid.
.
CT torso :
## IMPRESSION:
1. Small-to-moderate layering left pleural effusion with
underlying left
lower lobe atelectasis, slightly increased from .
2. Unchanged lymphadenopathy of the chest and abdomen
lyphadenopathy and
hepatosplenomegaly related to CLL.
3. Slightly increased abdominal and pelvic ascites from .
.
CXR:
## PA AND LATERAL CHEST RADIOGRAPHS:
Cardiac size is stable and is
within normal limits. Widened mediastinum, due to the known
mediastinal or hilar
lymphadenopathy. A linear right lower lobe atelectasis is noted.
Stable large left pleural effusion with left lower lobe
atelectasis is again noted. No significant change in the left
pleural effusion, with interval progression of the left lower
lobe atelectasis compared to the prior radiograph and is stable
since the CT done yesterday. Pulmonary vasculature is not
engorged.
## BRIEF HOSPITAL COURSE:
Mrs. is a yo female with CLL, presenting with
recurrent ascites.
1. Recurrent ascites - believed secondary to lymphadenopathy and
splenomegaly from CLL. Patient presented with abdominal
discomfort, nausea, and shortness of breath due to the ascites.
Following a therapeutic paracentesis (ultrasound-guided) by
Radiolgoy, the patient's symptoms improved significantly. The
next day, she was ambulating comfortably, breathing on room air,
and tolerating food. Patient still with abdominal distention at
discharge.
.
## 2. ACUTE RENAL FAILURE:
Cr decreased from most recent
hospitalization as sign of improving ARF, but still elevated
above baseline. Unclear whether ATN versus pre-renal as etiology
or likely a mixed picture, from previous hospitalization.
Patient hydrated with IVF's (gently however, given volume
overload in the setting of ascites), and Cr improved during
hospitalization. Patient continued on allopurinol.
.
## 3. CLL:
Mrs. cycle 1 of Campath ended . She is
noted to have increasing ascites, likely secondary from
increasing lymphadenopathy and splenomegaly seen on recent
restaging PET CT during a previous admission; s/p being treated
with palliative radiation therapy. CT torso done during this
hospitalization demonstrated relatively stable disease.
Discussion regarding further radiation versus bendamustine
versus EPOCH treatment for the CLL will be continued as an
outpatient via discussion with Dr. .
.
## 4. SHORTNESS OF BREATH:
Improved following paracentesis.
Decreased breath sounds at the left lung base prompted CXR on
, which showed stable left pleural effusion (albeit with
increased atelectasis). Patient comfortable on room air - safe
for discharge.
.
## 5. ANEMIA:
Mrs. HCT on admission was 26.1,
approximately at her baseline. She had a Hct decrease that
prompted transfusion of 1 unit pRBC on the morning of discharge.
.
## 6. HYPERURICEMIA:
Likely due to tumor lysis s/p radiation.
Patient continued on allopurinol. Acute renal failure improved.
.
## 7. HYPERKALEMIA:
Hyperkalemia may be due to tumor lysis s/p
radiation; or due to renal failure. Hydrated with NS, then saw
that K had decreased to within normal range. Resolved on
discharge.
.
## FEN:
NPO until s/p paracentesis and then regular diet.
.
Patient stable for discharge - improved abdominal discomfort,
breathing well on room air.
## MEDICATIONS ON ADMISSION:
ACYCLOVIR - (Prescribed by Other Provider) - 200 mg Capsule - 1
Capsule(s) by mouth every twelve (12) hours
ALLOPURINOL - 100 mg Tablet - 1 (One) Tablet(s) by mouth every
other day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
Capsule(s) by mouth twice monthly
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
LEVOTHYROXINE - (Dose adjustment - no new Rx) - 100 mcg Tablet
-
1 (One) Tablet(s) by mouth once a day Dispense Mylan Generic
please - No Substitution
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime
PENTAMIDINE [NEBUPENT] - (Dose adjustment - no new Rx; LAST
DOSE
GIVEN - 300 mg Recon Soln - 300 mg(s) inh monthly last
dose given as inpatient.
## DISCHARGE MEDICATIONS:
1. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
## 2. ALLOPURINOL MG TABLET SIG:
One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
Disp:*24 Tablet(s)* Refills:*1*
## DISCHARGE CONDITION:
Stable, afebrile, vital signs stable, abdominal discomfort
improved, on room air.
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with abdominal
distention/discomfort, nausea, and shortness of breath. You had
a paracentesis to removed fluid from the abdomen, and then your
symptoms improved. You had low blood levels and so you were
transfused 2 units of red blood cells. For a low white blood
cell count you were given a dose of Neupogen on the day of
discharge.
.
Please call your doctor or return to the hospital if you develop
worsening abdominal pain or distention, shortness of breath,
worsening of your leg swelling, fevers, chills, or other
symptoms that concern you.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15863802", "visit_id": "28502308", "time": "2123-10-25 00:00:00"} |
11481397-RR-42 | 71 | ## EXAMINATION:
BILATERAL DIGITAL SCREENING MAMMOGRAM INTERPRETED WITH CAD AND
3D DIGITAL BREAST TOMOSYNTHESIS
## INDICATION:
Screening. Right breast biopsy.
## TISSUE DENSITY:
There are scattered areas of fibroglandular density.
There is no dominant mass, unexplained architectural distortion or suspicious
grouped microcalcifications. A clip is present in the right upper outer
quadrant. Scattered calcifications are stable.
There is no significant change.
## IMPRESSION:
No specific evidence of malignancy.
## RECOMMENDATION:
Annual mammography is recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11481397", "visit_id": "N/A", "time": "2132-10-15 10:40:00"} |
10601565-DS-15 | 751 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Fever and Abdominal pain
## HISTORY OF PRESENT ILLNESS:
yo F with no PMH who presented to the ED on for abdominal
pain and fever (100.2F at home). The abdominal pain is located
on the right side. The pain was described as dull with
occasional throbbing and worse with movement. Currently rated
, although it was rated on presentation. Patient also
complained of nausea and NBNB vomiting x3. Patient also reports
poor appetite, chills, lightheadedness, and increased urinary
frequency. She denies dysuria.
In the ED, initial vitals were: Temp: 99.0 HR: 121 BP: 124/65
## 16 O(2)SAT:
98. She had an elevated WBC with left shift
and UA revealed pyuria and bacteriuria. She was started on IVF
and Cipro IV. However, because patient continued to complain of
nausea and pain, she was admitted to medicine for further
management.
## FAMILY HISTORY:
Denies FH of cardiovascular disease and DM. PGF with bladder
cancer, PGM with breast cancer. Maternal uncle, aunt, and 2
cousins with stomach cancer.
## GENERAL:
Thin, appears stated age. Non-toxic appearing. NAD.
## HEENT:
PERRL, EOMI. Oropharynx without erythema or edmema.
## NECK:
Supple, no cervical lymphadenopathy.
## CV:
RRR, normal S1, S2. No S3, S4 or murmurs.
## LUNGS:
Clear to auscultation bilaterally. No crackles or
wheezes.
## ABDOMEN:
+ Bowel sounds. Pain with palpation of right upper and
lower quadrant.
## BACK:
+ CVA tenderness on right side.
## EXT:
Peripheral 2+ and symmetrical. No edema.
## NEURO:
CN II-XII grossly intact. Strength in upper and lower
extremities .
## GENERAL:
Thin, appears stated age. Non-toxic appearing. NAD.
## HEENT:
PERRL, EOMI. Oropharynx without erythema or edmema.
## NECK:
Supple, no cervical lymphadenopathy.
## CV:
RRR, normal S1, S2. No S3, S4 or murmurs.
## LUNGS:
Clear to auscultation bilaterally. No crackles or
wheezes.
## ABDOMEN:
+ Bowel sounds. Pain with palpation of right upper and
lower quadrant, better compared to yesterday's exam.
## BACK:
+ CVA tenderness on right side.
## EXT:
Peripheral 2+ and symmetrical. No edema.
## NEURO:
CN II-XII grossly intact. Strength in upper and lower
extremities .
## URINE CULTURE (PRELIMINARY):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
## SENSITIVITIES:
MIC expressed in
MCG/ML
ESCHERICHIA COLI
|
AMPICILLIN
-----
=>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN
-----
<=4 S
CEFEPIME
-----
<=1 S
CEFTAZIDIME
-----
<=1 S
CEFTRIAXONE
-----
<=1 S
CIPROFLOXACIN
-----
<=0.25 S
GENTAMICIN
-----
<=1 S
MEROPENEM
-----
<=0.25 S
NITROFURANTOIN
-----
<=16 S
PIPERACILLIN/TAZO
-----
<=4 S
TOBRAMYCIN
-----
<=1 S
TRIMETHOPRIM/SULFA
-----
=>16 R
## BRIEF HOSPITAL COURSE:
F with no PMH who presents with fever and abominal pain
found to have pyelonephritis.
# Pyelonephritis:
Patient was extremely nauseous and could not tolerate PO. She
was given IVF. She was started on Ciprofloxacin IV and
transitioned to PO when she was able to tolerate food. She will
continue Cipro for a total of 14 days ( ) Patient's
fever was treated with Tylenol, nausea treated with Zofran, and
pain treated with oxycodone. Blood cultures grew E. coli, with
sensitivities only showing resistance to Ampicillin. Urine
culture pending on discharge.
# Birth control:
Pt currently on generic form of yaz. Because she will be on a
long course of abx, she was counseled to stop taking it this
month, and re-start with her next menstrual cycle. We counseled
her on barrier protection.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. YAZ 28 *NF* (drospirenone-ethinyl estradiol) mg-mcg Oral
Daily
2. Claritin *NF* 5 mg Oral Daily Seasonal Allergies
## DISCHARGE MEDICATIONS:
1. Claritin *NF* 5 mg Oral Daily Seasonal Allergies
2. YAZ 28 *NF* (drospirenone-ethinyl estradiol) mg-mcg Oral
Daily
3. Acetaminophen 650 mg PO Q6H:PRN Fever
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 8 hours Disp #*10
## TABLET REFILLS:
*0
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 13 Days
Last Day is
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*26 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*30
## CAPSULE REFILLS:
*0
7. Senna 1 TAB PO BID:PRN Constipation
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure taking care of you at . You were admitted
to the hospital with a kidney infection. You improved with
antibiotics, medicine for nausea, and pain medications. You will
need to continue the antibiotics for a total duration of 14 days
( ).
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10601565", "visit_id": "29230575", "time": "2147-12-06 00:00:00"} |
18008337-RR-53 | 150 | ## EXAMINATION:
BILATERAL SCREENING BREAST MRI WITH AND WITHOUT INTRAVENOUS
## INDICATION:
High risk screening for woman with history of right
breast DCIS status post breast conservation therapy diagnosed at age .
## AMOUNT OF FIBROGLANDULAR TISSUE:
Heterogeneous fibroglandular tissue.
Postsurgical changes related to lower outer right breast lumpectomy are again
noted. A 13 mm T2 hypointense well-circumscribed mass in the left breast is
stable since at least , compatible with a benign fibroadenoma (03:17).
There is no suspicious enhancing mass, non-mass enhancement, unexplained
architectural distortion, nipple retraction or skin thickening. No axillary or
internal mammary lymphadenopathy is present.
No abnormality is identified in the visualized chest and upper abdomen. The
previously described T2 hyperintense structure anterior to the right kidney
seen on the prior MRI from is not imaged, and was not seen on
dedicated ultrasound from , suggesting benign or artifactual
in etiology.
## IMPRESSION:
No MRI evidence of malignancy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18008337", "visit_id": "N/A", "time": "2171-07-07 11:55:00"} |
16076355-DS-4 | 1,099 | ## CHIEF COMPLAINT:
Right Carotid Body Tumor- Pathology pending
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Right Carotid Body Tumor Removal
## HISTORY OF PRESENT ILLNESS:
yo woman has a history of anxiety and
tachycardia, who had been well until , when she was doing
sit-ups and developed severe headaches and noted to have
hypertensive urgency and was evaluated in the ER. She had a
CTA head/neck showing a 1.2 x 1 x 0.7 cm right carotid body
paraganglioma and 3.5 x 1.9 x 2 cm right glomus vagale tumor.
She also had a 24 hour urine collection showing
a slightly high urine norepinephrine level. She was then sent to
vascular surgery, but because of tachycardia and hypertension,
she was hospitalized 10 days ago and started on prazosin and
labetalol which improved her BP. She denies any further
episodes of palpitations and denies any chest pain or
lightheadedness. She had a PET scan that showed two right sided
paragangliomas. She is scheduled for a right carotid body tumor
resection with Dr. .
## PAST MEDICAL HISTORY:
Esophagitis c/b by Esophagus diagnosed by endoscopy,
monitored w/ EGD every years
Asthma (post URI)
SVT s/p ablation
## PAST SURGICAL HISTORY:
Appendectomy
Tubal Ligation
Irregular Z line, small hiatal hernia
## FAMILY HISTORY:
Father had CHF, MI x4. Mother had 4v CABG. Grandmother had CHF.
A lot of people in her family have diabetes. Half brother had
carotid body tumor surgically removed. Aunt had "throat cancer"
(unclear if esophageal or thyroid). Uncle had blood clot.
## PHYSICAL EXAM:
Exam on Discharge
===================================
## GEN:
middle aged woman in no acute distress
## HEENT:
MMM, EOMI, normocephalic, atraumatic
## NECK:
R sided incision c/d/I, w/ steri strips in place.
## CV:
RRR, nl S1, S2, no m/r/g
## ABD:
soft, NTND, no masses, no rebounding
## EXT:
warm and well perfused
## NEURO:
CN II-XII intact, no focal deficits noted. no upper or
lower extremity weakness.
## PERTINENT RESULTS:
LABS
=
=
================================================================
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
04:04AM 7.8 4.11 11.7 36.5 89 28.5 32.1 12.7 41.4
167
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
04:04AM 117* 13 0.6 140 3.8
## BRIEF HOSPITAL COURSE:
Ms. was admitted to the Vascular Surgery team under Dr.
at on
after she underwent a R carotid body tumor resection.
Post-operatively she was stable, extubated, and transferred to
the PACU. During her hospitalization there were no
complications. She was restarted on her home meds later that
evening, given a regular diet, and encouraged to ambulate. Her
neurologic exam was intact throughout her course. Her blood
pressure remained with in normal limits; SBP 110-120 post
operatively, her HR was in the 80's to 90's. Her home dose of
prazosin and labetalol was not restarted post operatively and
was not re-started upon discharge. She will follow up with her
endocrinologist to determine if she should be restarted on any
BP medications.
Upon discharge, she was ambulating independently, tolerating a
regular diet, voiding and stooling normally, and her pain was
controlled.
## MEDICATIONS ON ADMISSION:
LABETALOL - labetalol 200 mg tablet. 1 tablet(s) by mouth twice
a
day - (Prescribed by Other Provider)
PANTOPRAZOLE - pantoprazole 40 mg tablet,delayed release. 1
tablet(s) by mouth once a day - (Prescribed by Other Provider)
PRAZOSIN - prazosin 1 mg capsule. 1 capsule(s) by mouth twice a
day - (Prescribed by Other Provider)
TRAZODONE - trazodone 50 mg tablet. 0.5 (One half) tablet(s) by
mouth at bedtime as needed for insomnia - (Prescribed by Other
Provider)
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 tablet(s) by mouth Q6H:PRN Disp #*20
## TABLET REFILLS:
*0
2. OxyCODONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth Q4H:PRN Disp #*12
## DISCHARGE DIAGNOSIS:
Right Carotid Body Tumor-Pathology Pending
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to and
underwent Carotid Body Tumor Removal. You have now recovered
from surgery and are ready to be discharged. Please follow the
instructions below to continue your recovery:
## WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
## MEDICATION:
Take all of your medications as prescribed in your discharge
## ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications. Do not go back to work until cleared by your
endocrinologist.
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
## CALL THE OFFICE FOR:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16076355", "visit_id": "27959692", "time": "2176-07-25 00:00:00"} |
16940921-RR-32 | 199 | ## INDICATION:
yo man with small cell lung cancer with know brain metastases
now s/p chemo, chest RT// Re-eval brain metastases.
## FINDINGS:
There is interval growth of all previously identified intracranial metastasis.
The largest lesions are located within the right occipital lobe and measures
12 mm in diameter, left cerebellar hemisphere measuring 7 x 7 mm, mid aspect
of the left occipital lobe measuring approximately 7 by 7 mm, head of the
caudate nucleus on the left measuring approximately 3 x 4 mm, and left
parietal convexity measuring approximately 8 x 8 mm, no new intracranial
metastasis are identified. No leptomeningeal enhancement.
Ventricles, sulci, and cisterns appear normal. No acute infarct or
intracranial hemorrhage. The major vascular flow voids are preserved.
There is mucosal thickening within the left frontal sinus, within the
bilateral anterior posterior ethmoid air cells, with the left maxillary sinus,
and bilateral sphenoid sinuses.
The orbits are grossly unremarkable.
## IMPRESSION:
1. Interval growth of all the previously identified parenchymal metastasis.
The interval growth is most consistent with disease progression given the lack
of whole-brain radiation. No new intracranial metastasis are identified.
2. No acute infarct or intracranial hemorrhage.
3. Paranasal sinus disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16940921", "visit_id": "N/A", "time": "2151-06-14 11:26:00"} |
12357823-RR-23 | 165 | ## INDICATION:
History: with motor vehicle collision and hip deformity
## FINDINGS:
Patient is status post right total hip arthroplasty with dislocation of the
femoral component superiorly and posteriorly relative to the acetabular
component, as seen on the previous CT. Comminuted fracture of the greater
trochanter of the right proximal femur is also again noted. No hardware
loosening is detected.
Patient is status post left total hip arthroplasty without evidence of
hardware complications.
Heterotopic ossification is noted about both proximal femurs. Diffuse
vascular calcifications are noted. Degenerative changes are noted within the
lower lumbar spine. No diastases of the pubic symphysis or sacroiliac joints.
Contrast from recent CT is noted within the right collecting system and
bladder. No concerning lytic or sclerotic osseous abnormalities are present.
## IMPRESSION:
1. Status post right total hip arthroplasty with the femoral component
dislocated superiorly and posteriorly relative to the acetabular component.
2. Comminuted right proximal femoral greater trochanter fracture.
3. Status post left total hip arthroplasty without hardware complications.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12357823", "visit_id": "N/A", "time": "2158-05-03 18:46:00"} |
18377554-RR-22 | 232 | ## EXAMINATION:
MRI of the Abdomen
## INDICATION:
year old woman with 6 wks pregnant, acute RLQ abd pain and
tenderness// appendicitis?
## LIVER:
The imaged portion of the liver is normal in signal intensity. No
focal lesions. Smooth contour.
## BILIARY:
No intrahepatic or extrahepatic biliary ductal dilation. The
gallbladder is surgically resected.
## PANCREAS:
The pancreas is normal in signal intensity and enhancement. No
focal lesions.
## SPLEEN:
The imaged portion the spleen is normal in signal intensity. No focal
lesions. There is a small accessory spleen.
## ADRENAL GLANDS:
The adrenal glands are normal in size and shape. No nodules.
## KIDNEYS:
There are tiny T2 hyperintense cysts. Kidneys are otherwise
symmetric in size. No concerning lesions. No hydronephrosis.
## GASTROINTESTINAL TRACT:
The stomach and partially imaged loops of large and
small bowel are unremarkable. The appendix is normal.
## PELVIS:
There is a single intrauterine pregnancy better assessed on same-day
ultrasound. The uterus is otherwise unremarkable. The bilateral ovaries are
normal. There is trace free fluid adjacent to the right ovary.
## LYMPH NODES:
No retroperitoneal or mesenteric lymphadenopathy.
## VASCULATURE:
No abdominal aortic aneurysm.
## OSSEOUS AND SOFT TISSUE STRUCTURES:
No suspicious osseous lesions. There are
postsurgical changes in the anterior abdominal wall with a small, fat
containing umbilical hernia present.
## IMPRESSION:
1. Normal caliber appendix. No acute appendicitis.
2. Trace fluid along the right adnexa, likely physiologic.
3. No hydronephrosis.
4. Patient is status post cholecystectomy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18377554", "visit_id": "N/A", "time": "2186-04-12 04:25:00"} |
19668264-DS-2 | 973 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
LLQ and Left flank pain
## HISTORY OF PRESENT ILLNESS:
year-old male with history of recurrent uric acid
nephrolithiasis and Grave's disease who presents with left sided
flank and lower quadrant pain and found to have ARF in the ED.
.
Patient states that he began experiency left lower
back pain. At that time he was seen in the ED at , a CT
abdomen/pelvis showed moderate left perirenal and periureteral
stranding, without overt hydronephrosis and without obstructing
renal or ureteral calculi, and labs were notable for Cr of 1.1.
He was treated with morphine and toradol for likely passed
calculus and discharged with percocet and ibuprofen. He reports
taking 600mg ibuprofen bid for two days and percocet with
resolution of his flank pain. On he returned for upper
back pain, at that time he had a Cr of 1.1.
.
One day prior to admission at 1pm patient re-experienced similar
pain. Pain is along LLQ and left lower back. It is described
as colicky, , non-radiating, and with minimal relief with
percocet. Patient also describes noticing reduced urine output
and darker urine over the past 4 days. He also endorses low
pelvic and penile pain on urination, increased urgency, and
sensation of incomplete voiding. He denies any penile
discharge, frank hematuria, fevers, nausea, vomiting, changes in
bowel habit. Of note patient takes 1 aleeve once a day
times a week when exercising, and 325mg aspirin. He denies
further ibuprofen intake since . He denies any other
changes in his medications, such as antibiotic use. He states
that he keeps himself hydrated, drinks 1 gallon of fluids daily.
He has had a 20lb intentional weight loss over the past month.
.
In the ED, initial vs were: T 97.1 P 75 BP 132/78 R 16 O2 sat
100. Labs were notable for elevated Cr 1.8 from 1.1 ( ).
Urine analysis notable for blood and RBC, low pH. A bedside US
was done and not evident for urinary retention. Patient was
given morphine 4mg x 3, ketorolac 30mg x1, 2L NS and 1L D5W w/
bicarb. Repeat Cr after ivfs was 1.9. Urology was consulted, a
foley was placed to evaluate for urethral obstruction with only
100cc of urine output. Patient was admitted for further work up
for his renal failure.
.
On the floor, patient states his pain is currently .
.
Review of sytems:
(+) Per HPI
(-) Denies fever, night sweats. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel habits. Denied arthralgias or myalgias.
## PAST SURGICAL HISTORY:
1. Appendicitis
2. Knee surgery
## FAMILY HISTORY:
Mother with DM and HTN, who passed away of
breast cancer. No CAD.
## GENERAL:
Laying comfortably in bed. Alert, oriented, no acute
distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
ronchi
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
Obese, soft, TTP at LLQ w/o guarding or RT, bowel
sounds present, no organomegaly, well healed scar at RLQ. TTP
at suprapubic area. No CVA tenderness
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## SKIN:
No jaundice, no rash
## RENAL US ( ):
Non-obstructing bilateral renal calculi as in previous CT.
08:37PM URINE HOURS-RANDOM UREA N-518 CREAT-110
SODIUM- year-old male with recurrent uric acid nephrolithiasis
presents with left sided flank and ARF.
.
# Acute Renal Failure: Patient hydrated in ED and continued to
receive iv fluids on the floor. Urine sediments did not show
casts and was negative for eos. FeNa was less than 1%
consistent. On further discussion with urology, felt that
obstructive process less likely as little urine output obtained
with placement of foley in the ED. Patient's Cr trended down to
1.3 on discharge and he continued to make good urine with fluid
hydration and holding of nephrotoxic agents. Patient was
discharged with PCP and follow up for Cr check. He was
advised to avoid further NSAID use given his presentation.
.
# Nephrolithiasis: Renal US evident for bl nonobstructing
stones. Patient initially treated w/ D5W w/ bicarb for urine
alkalinazation. He was started on flomax per urology recs and
discharged with urology follow up. He was treated with iv
morphine then percocet for pain control.
.
# Graves Disease: Continued home methimazole
## MEDICATIONS ON ADMISSION:
Methimazole 5mg daily
Aspirin 325mg daily
Percocet prn
Aleeve prn
Ibuprofen prn
## DISCHARGE MEDICATIONS:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) for 2 weeks.
Disp:*14 Capsule, Sust. Release 24 hr(s)* Refills:*0*
2. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
## 3. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
Tablets PO
Q6H (every 6 hours) as needed for pain for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
## PRIMARY:
Acute Renal Failure
Nephrolithiasis
## DISCHARGE INSTRUCTIONS:
We had the pleasure of taking care of you at
. You were admitted because of pain and renal
failure. Your renal failure improved with iv fluids. We think
the renal failure was from dehydration and likely excessive
NSAID use (aleve and ibuprofen) and the pain was from passing
kidney stones.
You should avoid NSAIDs which include: aleve, ibuprofen, advil.
These can be toxic to the kidneys.
We have started you on Flomax for your kidney stones.
We have given you Percocet for pain control. This is a sedating
medication, please do not take while driving a vehicle or with
alcohol. We are starting you on stool softner called colace
while you are taking Percocet.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19668264", "visit_id": "20406517", "time": "2119-06-26 00:00:00"} |
18759022-DS-18 | 1,468 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Endoscopy with endoscopic ultrasound and biopsy on
## HISTORY OF PRESENT ILLNESS:
with DM2, ESRD on HD, CAD, CHF, who presented to
with 4 months of worsening abdominal pain, weight loss,
and jaundice, and found to have multiple hepatic lesions on CT
concerning for malignancy. He underwent ERCP on with stent
placement despite no notable stricture or obstruction. However
bili continued to rise. Repeat CT a/p showed possible posterior
duodenal wall thickening. Thus the patient was transferred to
for EUS with biopsy of duodenal thickening. Also, patient
underwent guided liver biopsy on with path results
pending on admission to .
En route to from , the patient experienced 2
minutes of fleeting substernal chest pain. It was associated
with diffuse abdominal pain as well and improved spontaneously.
He was taken to nonetheless, where EKG was c/w
prior and troponins were 0.05 (in the setting of ESRD). He was
rerouted to through the emergency department, where CP was
noted to be resolved, EKG was again stable, and troponins were
lower at 0.03 with an MB of 2. He was then admitted to the
medicine service.
On arrival, he endorsed nausea and continued abdominal pain,
although he is hungry. He reported that prior to transfer he was
tolerating clears. He endorseed watery diarrhea, although OSH
documentation documents resolution by the end of his hospital
course.
## FAMILY HISTORY:
None per patient. No cancers in the family.
## PHYSICAL EXAM:
Admission exam:
Vitals- 98.3, 145/53, 97, 20, 97% on RA
General- Alert, oriented to person and place but not time, no
acute distress
HEENT- NCAT. EOMI. L surgical pupil. Sclera icteric. MM dry. OP
clear.
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-distended, bowel sounds present. TTP in the
left and right lower quadrants. no rebound tenderness or
guarding, no organomegaly
GU- no foley
Ext- R BKA. warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro- CNs2-12 intact, strength. full sensation.
Skin - jaundiced. shallow ulceration of the left dorsal foot
without purulence or surrounding erythema.
Discharge exam:
Vitals not checked as patient is CMO.
General- AAOx1, jaundiced
HEENT- NCAT. EOMI. L surgical pupil. Sclera icteric. MMM. OP
clear.
Lungs- Clear to auscultation anterolaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-distended, bowel sounds present. nontender.
Ext- R BKA. warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema. L foot ulcer bandaged.
Neuro- CNs2-12 intact, strength. full sensation. Mild
asterixis
## GASTROINTESTINAL MUCOSAL BIOPSIES, TWO:
1. Gastric polyp:
- Fragments consistent with gastric hyperplastic polyp with
focal erosion.
- Additional levels are examined.
2. "Edematous fold, duodenum":
- Duodenal mucosa with focal chronic mildly active duodenitis.
- No deeper/submucosal tissue present for evaluation. Additional
levels are examined.
Liver, targeted needle core biopsy ( ):
- Neuroendocrine carcinoma (grade 3) involving the liver, see
note.
- Lymphovascular invasion is present
- Adjacent liver parenchyma with marked cholestasis, bile
ductular proliferation and mixed
inflammatory infiltrate.
## NOTE:
The tumor cells are immunoreactive for pan-cytokeratin,
synaptophysin, CD56 and focally
positive for villin and CDX2. Tumor cells are negative for CK7,
CK20, PSA and TTF-1. The tumor
shows increased mitotic rate HPF). These results were
conveyed via telephone to Dr. by Dr. on .
## IMAGING:
From
-----
ERCP
1. Dilated ducts
2. No evidenceof masses or stricture
## PLAN:
follow LFTs, remove stent in weeks, consider liver bx
## CT A/P:
1. Persistent multiple hypoenhancing lesions in the R and L
hepatic lobes. Findings could represent persistent multiple
metastatic tumors or dysplastic nodules in hepatic cirrhosis.
2. Persistent unchanged marked splenomegaly with multiple
hypoenhancing lesions. Differential diagnosis can include
multiple metastatic tumors from unknown primary, infiltration
with malignant lymphoma or leukemia, or multiple septic emboli.
3. Persistent unchanged s/p CCY, dilated common hepatic duct,
but interval placement of plastic common bile duct.
4. The current examination with oral constrast shows a possible
filling defect in upper descending duodenum posterior wall. Even
though findings could represent redundant mucosa, duodenal tumor
cannot be excluded. Correlation with endoscopy findings during
ERCP is recommended.
5. No intestinal or colonic obstruction or abdominal
inflammation or pneumoperitoneum is seen.
6. Persistent unchanged markedly atrophic kidneys with probably
multiple renal cortical cysts.
7. No pelvic mass, lesions, abscess, or LAD is seen.
CT CHEST
1. Fan shaped right middle lobe atelectasis and tiny focal
anterior medial left lingular lobe atelectasis are seen.
2. No focal lung mass lesion or mediastinal LAD is seen.
3. No thoracic aortic aneurysm or dissection is seen.
## BRIEF HOSPITAL COURSE:
with DM, ESRD on HD, CAD, CHF, who presented to
with 4 months of worsening abdominal pain, weight loss,
and jaundice, and found to have multiple hepatic lesions on CT
A/P concerning for malignancy. He underwent ERCP at in
with stent placement. Bilirubin continued to rise post
procedurally. Repeat CT A/P was then done, which confirmed
proper stent placement and noted continued presence of
multifocal lesions in the liver, as well as duodenal wall
thickening. On pt underwent guided liver biopsy. He was
transferred to for duodenal wall biopsy and to workup for
a primary malignancy. Of note, GI was consulted at , who
delayed inpatient colonoscopy pending the above biopsy results.
At , pt underwent Endoscopy with US and biopsy of the
duodenum showing duodenitis. Liver biopsy from came
back on , showing neuroendocrine carcinoma. Pt was
presented at Tumor Board Conference on . Hepatology,
Oncology, pathology, and radiology all agreed that the patient
was a poor candidate for further intervention given his multiple
comorbidities, the aggressive nature of the carcinoma, and the
stage. Multiple discussion with the patient and his sons
revealed that the patient values his independence and
cognitition and would not want to prolong a life of
hospitalization and illness. Palliative care was consulted, and
the patient was transitioned to focused care.
Of note, many preadmission medications were stopped. Celexa was
continued for depression and omperazole for any pain related to
gastritis/duodenitis. Rifaximin and lactulose were started to
improve hepatic encephalopathy, which was within pt's goals of
care. He received oral dilaudid for abdominal pain throughout
the hospitalization with good effect, and on the day of
discharge was transitioned to oxycodone elixir for ease of
administration. He appeared comfortable on day of discharge.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO BID
2. Aspirin 81 mg PO DAILY
3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
4. Cinacalcet 30 mg PO BID
5. Citalopram 30 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Amitriptyline 50 mg PO HS
8. CloniDINE 0.3 mg PO BID
9. Glargine 42 Units Breakfast
Insulin SC Sliding Scale using UNK Insulin
10. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO ONCE:PRN
dialysis
## DISCHARGE MEDICATIONS:
1. Citalopram 30 mg PO DAILY
2. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet
## REFILLS:
*3
3. Lactulose 30 mL PO QID
RX *lactulose 10 gram/15 mL 30 ML by mouth four times a day
Refills:*1
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Apply 1 Patch Daily Disp #*90
## PATCH REFILLS:
*1
5. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg tablet(s) by mouth Daily Disp #*90
## TABLET REFILLS:
*1
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60
## TABLET REFILLS:
*0
7. Omeprazole 40 mg PO BID
8. Lorazepam 0.5-1 mg PO Q2H:PRN anxiety or dyspnea
RX *lorazepam 0.5 mg tabs by mouth every two hours Disp #*40
Tablet Refills:*0
9. OxycoDONE Liquid mg PO Q1H:PRN pain or dyspnea
RX *oxycodone 5 mg/5 mL mg by mouth every hour Refills:*0
## DISCHARGE DIAGNOSIS:
PRIMARY DIAGNOSES
==================
Neuroendocrine carcinoma
Jaundice
Hyperbilirubinemia
Hepatic encephalopathy
End stage renal disease
Type 2 diabetes mellitus
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure caring for you at . You were admitted for
further evaluation of lesions on your liver found on a CT scan.
The liver biopsy done at came back on
and showed evidence of cancer. After extensive discussions with
the oncology and liver service as well as with you and your
family about your preferences, it was decided to discharge you
to an facility for comfort focused care. We wish you
the best and if we can do anything at all to make you more
comfortable please let us know.
We wish you the best,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18759022", "visit_id": "24915370", "time": "2144-06-13 00:00:00"} |
14123203-RR-42 | 162 | ## DOSE:
DLP: Given in abdominal CT report.
## FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. No enlarged lymph nodes in the hilar or mediastinal
areas. Normal appearance of the large mediastinal vessels. No incidental
pulmonary embolism. No coronary calcifications, no valvular calcifications,
no pericardial effusion. The posterior mediastinum is unremarkable. The
upper abdomen is reported in detail in the dedicated abdominal CT report. No
osteolytic lesions at the level of the ribs, the sternum, and the vertebral
bodies. Mild degenerative vertebral disease. No vertebral compression
fractures. The left upper lobe postoperative changes are stable. Currently
there is no evidence of suspicious pulmonary nodules or masses. No pleural
effusions. No diffuse lung disease. A small focal left lower lobe pleural
thickening (302, 186) is stable. The lung parenchyma shows no evidence of
micro nodularity.
## IMPRESSION:
No micro nodularity on today's CT examination. The postoperative situs in the
left upper lobe is stable. No adenopathy. No pleural effusions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14123203", "visit_id": "N/A", "time": "2183-08-21 10:44:00"} |
15736859-RR-25 | 100 | ## INDICATION:
male with vertigo since 9 a.m.
## MRI BRAIN, WITHOUT IV CONTRAST:
There is redemonstration of large cisterna
magna. Otherwise, there is no evidence of acute intracranial hemorrhage,
edema, mass effect, hydrocephalus, or acute infarct. The brain has normal
signal and morphology. Normal vascular flow voids are demonstrated in the
major intracranial arteries. The visualized orbits, paranasal sinuses and
mastoid air cells have normal signal. Also there is normal appearance to the
craniocervical junction and the visualized upper cervical spine.
## IMPRESSIONS:
Large cisterna magna redemonstrated, a normal variant. No
findings to account for the patient's symptoms.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15736859", "visit_id": "N/A", "time": "2153-09-25 06:23:00"} |
13085401-RR-21 | 100 | ## EXAMINATION:
LUMBO-SACRAL SPINE (AP AND LAT)
## INDICATION:
with new TLSO brace placement. Evaluate placement.
## FINDINGS:
5 non-rib-bearing lumbar vertebral bodies are present. There is re-
demonstration of the known compression fracture of the superior endplate of
the L1 vertebral body. A TLSO brace has been placed, without evidence of
lumbar spinal malalignment. No suspicious lytic or sclerotic lesion is
identified.
Incidental note of a partially imaged right hip hardware.
## IMPRESSION:
Interval placement of a TLSO brace, without evidence of lumbar spinal
malalignment. Re- demonstration of the known compression fracture of the
superior endplate of L1.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13085401", "visit_id": "22451981", "time": "2188-04-29 15:14:00"} |
19015535-RR-80 | 146 | ## HISTORY:
with hx of SCC of lung, now with worsening pain in
right hip. // Does this patient have evidence of hip fracture?
## FINDINGS:
No acute fracture or dislocation. Minimal lateral acetabular spurring of the
left femoroacetabular joint. Hips and sacroiliac joints are otherwise
preserved. No diastases of the pubic symphysis or sacroiliac joints. Known
lytic lesions within the iliac bones bilaterally are better assessed on prior
PET-CT and are somewhat obscured due to overlying bowel gas. No suspicious
lytic or sclerotic osseous abnormality identified on the current radiograph.
Aspherical appearance of the right femoral head suggests underlying
femoroacetabular impingement.
## IMPRESSION:
1. No acute fracture or dislocation.
2. Known lytic lesions in both iliac bones are better assessed on prior
PET-CT.
3. Aspherical appearance of the right femoral head suggests underlying
femoroacetabular impingement which can be better assessed with MRI, if
clinically indicated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19015535", "visit_id": "N/A", "time": "2196-05-20 19:24:00"} |
19270701-DS-20 | 1,601 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
y/oM w/ PMH of HTN, HLD, Obesity, CAD who
presented to ED c/o spontaneous lightheadedness at work the day
of admission. At work, he reported several presyncopal spells,
lasting seconds at a time, occurring at rest, that was a/w
palpitations, but not a/w
diaphoresis/syncope/nausea/vomiting/chest pain/SOB. Accordingly,
he called EMS and was brought to the ED. Of note, pt also c/o 3
wk hx of fatigue, cough, thought to be viral
bronchitis by PCP, tx with tylenol/codeine for cough
suppression.
In ED, pt VS were T98.9 , BP93/66, R16, 97%RA. Exam findings
included irregularly irregular HR, , w/ BP 90's/50's.
Labs significant for normocytic anemia 12.5/37.8, and nml WBC w/
neutrophilic predominance 80%.
Pt given ASA 81mg. Pt remained asymptomatic while in ED. Given
hemodynamic stability, pt transfered to for w/u of new
onset and possible DCCV.
On review of systems, he denied any vision changes, wt loss,
change in appetite, skin changes.
##
1. CARDIAC RISK FACTORS:
CAD, HTN, HLD, obesity
2. CARDIAC HISTORY:
-Pt had ETT for sx in , it was positive
(ST depression , so then had perfusion testing performed
which identified a perfusion defect of anterior wall. Pt then
had subsequent cath
-Cath , showed no flow limiting disease but diffuse CAD.
The had a 20% stenosis. The LAD had a diffuse 30% proximal
stenosis and a diffuse 60% stenosis in its distal portion. A
small diagonal branch had 90% stenosis. The ramus intermedius
had a 70% stenosis. The LCx was ectatic and had diffuse
stenosis. The RCA had a 30% stenosis and a 70% origin PLSA
stenosis.
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
GOUT
HYPERLIPIDEMIA
HYPERTENSION
LABYRINTHINE DYSFUNCTION
LFT VERICOSE VEIN STRIIPPING
VENOUS INSUFFICIENCY
APPENDECOMY and mucocele removal
TONSILLECTOMY
## FAMILY HISTORY:
Father had CAD, died of MI @
Daughter has arrhythmia of unknown type
## GENERAL:
Pleasant, sitting comfortably in bed, NAD
## HEENT:
PERRL, MMM, OP/nares clear, no LAD, no JVD, no palpable
thyroid abnormalities
## CV:
Irregular rate, nml S1/S2, no m/r/g
## LUNGS:
CTA b/l, no wheezes/rales/rhonchi, no abnormalities on
percussion
## ABDOMEN:
Soft, NT, Distended obesity, midline vertical
suprapubic scar, BS+
## EXT:
Warm, no peripheral edema
## SKIN:
Warm, Dry, no e/o rash
## GENERAL:
Pleasant, sitting comfortably in bed, NAD
## HEENT:
PERRL, MMM, OP/nares clear, no LAD, no JVD, no palpable
thyroid abnormalities
## CV:
Irregular rate, nml S1/S2, no m/r/g
## LUNGS:
CTA b/l, no wheezes/rales/rhonchi, no abnormalities on
percussion
## ABDOMEN:
Soft, NT, Distended obesity, midline vertical
suprapubic scar, BS+
## EXT:
Warm, no peripheral edema
## SKIN:
Warm, Dry, no e/o rash
## ADMISSION LABS:
11:20AM BLOOD
Plt
06:58AM BLOOD
Plt
11:20AM BLOOD
11:20AM BLOOD
11:20AM BLOOD
## EKG:
Irregular Rhythym @105, normal intervals (QRS, QTc), rSr'
in V1 (normal variant), no ST elevations
## CXR :
The lungs however are grossly clear. Blunting of
the left lateral costophrenic angle may be due to overlying soft
tissues. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities detected.
## BRIEF HOSPITAL COURSE:
BRIEF HOSPITAL COURSE
======================
Mr. is a y/o M w/ PMH of HTN, HLD, Obesity,
CAD who presented to ED c/o several episodes of
lightheadedness at work and was found to be in new . Given
that he was asymptomatic while still in atrial fibrillation, it
was felt duration was unknown. As such, he was started on
dabigatran (guaiac negative), and discharged to home on
increased metoprolol dose (remained hemodynamically stable) for
planned outpatient TEE and cardioversion with EP on .
===============================================================
## ===============
#. ATRIAL FIBRILLATION:
He presented to the ED c/o several
episodes of lightheadedness and was subsequently found to be in
Afib, though it is unclear when the abnormal rhythm began.
Etiology also unclear but may be related to diffuse CAD noted
during cardiac catheterization in . He has no known
history of valvular, ETOH abuse, thyrotoxicosis, sympathomimetic
drug use, PE, or pulmonary disease. CXR on admission showed no
e/o pulmonary edema or infection. MI unlikely given
hospital course, hemodynamic stability, and EKG w/ no e/o acute
ST changes. Subsequent TSH/LFTs were found to be normal.
Cardiology recommended starting Dabigatran with plan for
immediate DCCV, as pt's presyncopal sx were believed to be
, and it was felt that cardioversion would be the best
method for reducing the occurrence of future episodes. He agreed
to be discharged home on Dabigatran with an outpatient
appointment booked for for elective outpatient
TEE/cardioversion.
During remainder of hospital course, pt's regimen was
reduced to a single agent (Metoprolol) and was uptitrated for
ideal HR/BP control. Of note, pt remained asymptomatic
throughout the hospital course and did not have any episodes of
lightheadedness or RVR identified on telemetry. Also of note, pt
CHADS score = 1, so he is recommended to continue ASA 325 mg
daily after to reduce future stroke risk.
#. HTN - Normotensive during this admission. His
meds were reduced to a single agent
(Metoprolol), which was uptitrated for ideal HR/BP control.
Given such changes to his regimen, he will likely require
evaluation/titration by PCP 1 wk .
## # DRY COUGH:
Several weeks ago he was evaluated as an outpatient
for dry cough, which was felt to be due to viral syndrome. He
continued to have a dry cough without evidence of febrile
illness. This could be secondary to Acei (which was stopped to
allow more room for rate control with metoprolol), vs viral
cough. CXR was negative for pulmonary edema. Other etiologies
could be related to GERD as well. As this was very upsetting to
the patient, please follow up on resolution of cough. He was
discharged on short course of tylenol with codeine which he felt
helped symptomatically.
=====================================================
## CHRONIC ISSUES:
1. CAD - Pt has well established history of CAD,
identified on cardiac catheterization in . Of note, he did
not have any episodes of CP or EKG changes suggestive of
ischemia during this admission. Accordingly, he was continued on
home regimen of ASA and Simvastatin. Metoprolol was titrated up
for ideal HR/BP control. He did not require any NTG during this
admission
2. HLD - As per most recent lipid panel on (Chol 129
Trig 124 HDL 46 LDLcalc 58), pt is well controlled on current
dose of Simvastatin. Accordingly, it was continued at home dose
during this hospitalization.
3. Normocytic anemia - Noted to have a normocytic anemia on
admission with a Hemoglobin of 13.5, down from apparent baseline
of 15. His CBC remained stable throughout the hospital course
and he was asymptomatic, breathing comfortably on RA, in no
acute distress, speaking in full sentences. His stool was tested
for occult blood, and was found to be negative prior to starting
(Dabigatran) in preparation for . Pt will
need further workup of this problem as an outpatient.
4. BPH - known history of BPH, causing intermittent hesitancy
when urinating, so home dose tamsulosin was given.
=
=
=
================================================================
## - CODE STATUS:
Full code, confirmed.
- Studies pending on discharge: TSH.
- Emergency contact: (daughter, HCP, .
- needs outpatient w/u of his normocytic anemia
- Pt needs evaluation of HR/BP in 1wk following discharge for
titration of Metoprolol (to achieve HTN and rate control)
- Pt to have outpatient cardioversion on
- Stopped ramipril; please BP on and at f/u and
consider whether it is necessary to restart (of note, patient
has new dry cough; consider ACEi side effect, as well as post
viral cough).
- started vitamin D per PCP note
- discharged on Dabigatran 150mg BID (covered by his insurance)
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
please hold for HR<60 or SBP<100
2. Ramipril 10 mg PO DAILY
please hold for SBP<100
3. Simvastatin 80 mg PO HS
4. Tamsulosin 0.4 mg PO DAILY
5. Aspirin 81 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 80 mg PO HS
3. Tamsulosin 0.4 mg PO DAILY
4. Dabigatran Etexilate 150 mg PO BID
RX *dabigatran etexilate [Pradaxa] 150 mg one capsule(s) by
mouth every 12 hours Disp #*60 Capsule Refills:*0
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
6. Acetaminophen w/Codeine TAB PO QHS:PRN cough
do not take if driving/operating machinery/drinking alcohol.
RX #3] 300 mg
tablet(s) by mouth at night Disp #*10 Tablet Refills:*0
7. Vitamin D 1000 UNIT PO DAILY
## PRIMARY:
New onset atrial fibrillation of unclear duration
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure taking part in your care at ! You were
admitted because you were feeling symptomatic for an abnormal
heart rhythm called "atrial fibrillation." We started you on a
blood thinning medication called "dabigatran" which decreases
your risk of clotting during this abnormal heart rhythm. You
should follow up on for an echo, with subsequent
intervention called a "cardioversion" which will help your heart
return to normal rhythm.
Instructions for AM procedure:
Please make sure not to take anything by mouth after
at midnight.
Please report to at 6:45 AM on
.
Please take all your medications that morning.
## MED CHANGES:
We increased your metoprolol to control your heart
rate. We stopped your ramipril in the meantime. You should start
vitamin D3 1000 units daily (your PCP sent you letter re: low
vitamin D a month ago). You should start dabigatran. We also
wrote a small script for tylenol with codeine.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19270701", "visit_id": "24071624", "time": "2128-03-30 00:00:00"} |
10992229-RR-34 | 150 | ## FINDINGS:
There has been interval placement of a right PICC which projects
over the right atrium. To be appropriately positioned at the approximate
cavoatrial junction, this should be pulled back by no less than 6 cm.
Again demonstrated is the enteric tube in the stomach as well as bilateral
pleural effusions and bibasilar atelectasis. The fluid in the minor fissure
has decreased since the prior study, and may be due to patient positioning.
Since the prior study, there has been interval partial reinflation of the
right middle lobe. Again noted is a possible small left apical pneumothorax,
which is unchanged since the prior study.
## IMPRESSION:
Interval placement of right PICC line which projects into the
right atrium. To be appropriately placed at the approximate cavoatrial
junction, this should be retracted by approximately 6 cm.
The PICC team was initially paged at 115PM, on the day of the examination.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10992229", "visit_id": "23656295", "time": "2115-12-09 12:53:00"} |
10377016-RR-29 | 278 | ## EXAMINATION:
ABDOMEN US (COMPLETE STUDY)
## INDICATION:
year old man with history of alcoholic cirrhosis and stable
liver nodule // interval change in liver nodule
## LIVER:
The hepatic parenchyma is diffusely nodular in echogenicity. The
contour of the liver is nodular. 7 x 9 x 6 mm left hepatic lobe cyst is
similar in appearance to prior examinations. Along the subcapsular aspect of
segment II a 8 x 6 x 10 mm hypoechoic nodule is re-identified. There is no
focal liver mass, however sensitivity is limited due to diffusely nodular
pattern of parenchymal echogenicity. The main portal vein is patent with
hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD measures 5 mm.
## GALLBLADDER:
There is no evidence of stones or gallbladder wall thickening.
## PANCREAS:
Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
## SPLEEN:
Normal echogenicity, measuring 12.0 cm.
## KIDNEYS:
The right kidney measures 11.6 cm. The left kidney measures 11.5 cm.
Normal cortical echogenicity and corticomedullary differentiation are present
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
imaged kidneys, however the inferior pole of the right kidney is not well
visualized due to artifact from overlying structures.
## RETROPERITONEUM:
Visualized portions of aorta and IVC are within normal
limits.
## IMPRESSION:
1. Sonographic findings consistent with provided history of cirrhosis.
2. Diffusely nodular hepatic parenchymal echogenicity makes exact comparison
with prior examination difficult, however left subcapsular nodule appears
similar measuring 8 x 6 x 10 mm. Given diffuse nodularity, additional
evaluation with MRI should be considered.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10377016", "visit_id": "N/A", "time": "2154-07-19 14:01:00"} |
15404950-RR-157 | 96 | ## INDICATION:
with SOB // ?consolidation or other acute process
## FINDINGS:
AP portable upright view of the chest. Shunt tubing is seen overlying the
chest as on prior. Volumes are low limiting assessment. Patient's chin
overlies the upper chest. There is new hazy opacity at the left lung base
which silhouettes the left hemidiaphragm which could represent a developing
pneumonia and or small effusion. Elsewhere lungs appear relatively clear. No
large pneumothorax. Cardiomediastinal silhouette is stable. Bony structures
are intact.
## IMPRESSION:
New hazy opacity at the left lung base could represent layering effusion
versus pneumonia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15404950", "visit_id": "N/A", "time": "2159-12-24 21:03:00"} |
17069955-DS-33 | 2,766 | ## ALLERGIES:
Penicillins / adhesive tape / Cephalosporins / Carbapenem /
lactose intolerance / azithromycin
## HISTORY OF PRESENT ILLNESS:
Mr. is a with h/o MDS Decitabine x2 in and
reduced-intensity MUD SCT (Flu/Bu/ATG) in , , CAD
CABG in , HTN/HLD, IDDMII, and iatrogenic adrenal
insufficiency who was transferred from after presenting
there on from rehab after complaining of abdominal pain.
He was recently d/c from on after prolonged
hospitalization for GVHD, PNA, line-associated bacteremia (CON).
On arrival to , he was febrile 102.1, HR 125 BP 74/50.
Labs were notable for WBC 19.2, HCT 23.9 (down from 28 on
, PLT 97, Cr. 1.7 (baseline 0.76), Lactate 3.3, INR 1.4.
ABG 7.37/40/ , Troponin 0.08, CK-MB negative. CXR showed
right pleural effusion. He had a CT abdomen/pelvis that was
negative for any intraabdominal process, but showed a right lung
consolidation and pleural effusion c/w PNA. He was subsequently
noted to have increased O2 requirement and was started on
vanc/moxifloxacin and BiPAP . Repeat ABG 7.36/37/101/22.
He was given morphine because of increased respiratory rate and
was then noticed to be hypotensive with systolics in the , he
was transferred to the MICU, given 1L NS and Narcan 0.4mg after
which he became more arousable and responsive but had persistent
hypotension. Given his tachycardia, hypotension, hypoxia there
was concern for PE, but he did not have CTPA given he had IV
contrast w/last 24h and evidence on admission.
showed left soleil vein thrombosis. Given findings on
and hx of SCT he was started on heparin gtt. Neo-synephrine was
started with increased MAPs in the , which was subsequently
switched to Levophed HTN. Aztreonam was also started for
PNA, and he received one dose of Tobramycin. He was also
transfused 2U PRBCs for his acute HCT drop. As most of his care
is via , he was transferred here for further management.
On arrival to the MICU, VS 126 102/61 28 98%. He was sleepy but
arousable and responsive to commands.
## PAST MEDICAL HISTORY:
PAST ONCOLOGIC HISTORY (adapted from discharge summary :
- ITP rituximab x1 cycle (weekly x4) in
- MDS Dacogen x2 cycles in and reduced-intensity MUD
SCT (Flu/Bu/ATG) D0
PAST MEDICAL/SURGICAL HISTORY (adapted from discharge summary
:
- CAD CABG c/b significant bleeding
- HTN/HL
- Diastolic/systolic HF (LVEF 45-50% on
- IDDMII (last HA1c 12.8 in
- RA
- BPH c/b urinary incontinence
- Diverticulosis
- LGIB in rectosigmoid resection with colostomy
formation (reversed in
- CCY in
- H/o steroid-induced psychosis
- bilateral inguinal hernia repair in
- L distal radius fracture MVA in
## FAMILY HISTORY:
Mother with h/o DMII, CAD, and neck surgery c/b aspiration.
Father with h/o RA and stomach ulcer.
## GENERAL:
sleepy but arousable, oriented x 2.
## HEENT:
Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
## NECK:
supple, cannot assess JVP body habitus, no LAD
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## LUNGS:
Coarse breath sounds bilaterally, with scattered rhonchi
## ABDOMEN:
soft, obese abdomen, non-tender, non-distended, +BS,
lower abdominal surgical scare well healed no organomegaly
## EXT:
warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## PATH/CYTOLOGY:
Pleural fluid
Pleural fluid, cell block,:
Negative for malignant cells.
Fibrinous material and inflammatory cells.
No fungal organisms seen on PAS and GMS stains.
## CXR :
As compared to the previous radiograph, the lung volumes have
decreased. The left PICC line is in correct position, the tip
projects over the mid SVC. On the right, there is a massive
newly appeared pleural
effusion, with a strong intrafissural component, as well as
resulting
atelectasis at the right lung base. Multiple healed right rib
fractures.
CXR
In comparison with the study of , there is little overall
change. Residual opacification at the right base is again
consistent with
fluid and some volume loss in the right lower lung. Continued
enlargement of the cardiac silhouette with elevation of
pulmonary venous pressure. Central catheter remains in place.
CXR
In comparison with study of , there has been removal of a
substantial amount of fluid from the right pleural space with a
catheter
remaining in place. A substantial residual opacification at the
right base is
consistent with fluid and continued collapse of the right lower
lobe.
KUB
Two views of the abdomen show barium contrast within the
transverse and
descending colon. No dilated loops of bowel are present. Coils
from an
embolization are noted in the left-sided pelvic vessels.
## IMPRESSION:
No dilated loops of bowel or evidence of the ileus.
CT chest without contrast
## IMPRESSION:
1. Bilateral opacities are consistent with multifocal
pneumonia.
2. Moderate nonhemorrhagic pleural effusion without pleural
enhancement.
3. Right pleural tube is in the chest wall, and not within the
pleural fluid.
CXR
In comparison with the study of , there is some increasing
opacification in the left mid and upper zones with continued
opacification in the left mid zone. The appearance is worrisome
for bilateral pneumonia, associated with some elevated pulmonary
venous pressure and enlargement of the cardiac silhouette.
CXR
Right chest tube is in place and there is no evidence of
pneumothorax. Patchy opacifications persist bilaterally,
worrisome for
pneumonia. Continued enlargement of the cardiac silhouette in a
patient with previous CABG procedure. Mild indistinctness of
pulmonary vessels is
consistent with some elevated pulmonary venous pressure.
CXR
Right chest tube is in place and there is no evidence of
pneumothorax. Patchy opacifications persist bilaterally,
worrisome for
pneumonia. Continued enlargement of the cardiac silhouette in a
patient with previous CABG procedure. Mild indistinctness of
pulmonary vessels is
consistent with some elevated pulmonary venous pressure.
## CXR :
The pigtail portion of the catheter again is at the lower
portion
of the right hemithorax. Patchy opacifications are again seen
bilaterally,
worrisome for areas of pneumonia. No evidence of pneumothorax.
## PORTABLE CXR :
Since the prior chest x-ray, there has been some clearing of the
patchy
pneumonia present on the prior film. This is more marked on the
right than the left. There is no evidence of intrathoracic
bleeding.
CT abd pelvis without contrast
1. No retroperitoneal hematoma.
2. Interval decrease in right pleural fluid with pigtail
catheter in place.
Tiny right pneumothorax.
3. Bilateral pulmonary opacities persist, but are improved from
,
likely due to multifocal pneumonia.
4. Lumbar spine vertebral body compression deformities as
above.
CT CHEST without contrast
## IMPRESSION:
1. No retroperitoneal hematoma.
2. Interval decrease in right pleural fluid with pigtail
catheter in place. Tiny right pneumothorax.
3. Bilateral pulmonary opacities persist, but are improved from
,
likely due to multifocal pneumonia.
4. Lumbar spine vertebral body compression deformities as
above.
.
## ASSESSMENT/PLAN:
Mr. is a M with multiple medical problems including
MDS Decitabine x2 in and reduced-intensity MUD SCT
(Flu/Bu/ATG) in , with evidence of persistent MDS by
, dCHF (EF 55%), CAD CABG in , HTN/HLD, IDDMII,
and iatrogenic adrenal insufficiencyv who p/w septic shock.
## #) DIARRHEA/WBC COUNT:
Had positive C. Diff antigen Assay and
diarrhea, was started on PO Vancomycin 125mg q6H and is to
continue it until 14 days after stopping all other antibiotics.
He should remain on PO vancomycin .
## #) SEPTIC SHOCK:
Patient presented to OSH with fever,
leukocytosis with bandemia, tachycardia and was found to be
hypotensive with evidence of PNA on CXR and end-organ damage
with elevated Lactate to 3.3 and with Cr elevated from
baseline. Therefore, meeting criteria for septic shock with
likely source being PNA with RML infiltrate on CXR, but other
possible etiologies are BSI given recent hx of line-associated
bacteremia and CON with last day of antibiotics being .
He presented with abdominal pain raising concern for an
intraabdominal process, however, CT scan at OSH was negative.
Urinary tract infection also possible, but urine culture at OSH
reportedly negative. Rapid H. flu negative. Blood cultures were
negative x2 from OSH. He was continued on abx with
vanc/cefepime/cipro to double cover pseudomonas spp. and for
atypical PNA. Repeat CXR showed a massive newly appeared
pleural effusion, with a strong intrafissural component, as well
as resulting atelectasis at the right lung base. CM were
negative x 2. Source of sepsis was found to be bilateral pleural
effusion. He was treated with antibiotics as noted below. His
Chest tube was removed on without any difficulty.
1. Vancomycin
2. Cefepime
3. Levofloxacin
## 5. CIPROFLOXACIN:
6. Acyclovir PPx
7. Fluconazole PPx
8. Vancomycin PO
## # RESPIRATORY DISTRESS:
Patient presented with hypoxemia
respiratory distress. Causes of his respiratory distress were
thought to be PNA vs PE. Pt had RML infiltrate on CXR. There
was also concern for PE with evidence of isolated soleil vein
DVT on at OSH. He also has hx of with pulmonary
edema on exam making CHF exacerbation possible. Certainly,
onset of hypotension with his hx could have precipitated
exacerbation of CHF resulting in pulmonary edema. Due to concern
of DVT leading to PE he was started on heparin gtt. Pt had CT
chest which demonstrated multifocal PNA with b/l opacities and a
moderate R effusion (w/o enhancement not consistent with
empyema. IP placed a pigtail catheter and infused tpa/dnase
which resulted in drainage of the parapneumonic effusion. Pt's
pneumonia was treated with cefepime and vancomycin. Pt's
respiratory distress is likely multifactorial including COPD
exacerbation, empyema, pulmonary edema, and OSA physiology
worsening his status during sleep. Pt was given BIPAP and
diuresed with good urine output and overall improvement in labor
of breathing. Pt was weaned of BiPAP and is now on Room air.
## # HYPOTENSION:
He was found to be hypotensive to systolics of
on presentation to that was not fluid responsive
requiring a short course of pressor support prior to transfer
and is currently off pressors. His hypotension is potentially
multifactorial and related to sepsis vs. known adrenal
insufficiency vs. vs. hypovolemia. Certainly he had
evidence of sepsis with end organ damage which can potentiate
hypotension. He has known adrenal insufficiency on chronic
hydrocortisone and in the setting of acute stress, he may not
respond appropriately to maintain increased BP in the setting of
an acute insult. He has a hx of CHF with preserved EF and has
crackles and rhonchi on exam, with evidence of pulmonary edema
on most recent CXR. Lastly, his hypotension may be compounded
by insensible losses fevers with increased metabolic demand.
Anti-hypertensives were initially held and was started on
stress dose steroids with Hydrocortisone IV with improvement in
his BPs. CM were negative x 2.
## # ATRIAL FIBRILLATION WITH RVR:
During day #2 of this admission
he went into AF with RVR. All other vital signs were stable and
he was mentating well w/o complaints. He was treated with
Metroprolol 5mg IV and his home dose of PO metoprolol was
reinitiated. He then became tachycardic again and so PO
metoprolol was uptitrated resulting in a heart rate in low
100's.
## # ATRIAL TACHYCARDIA:
Pt continued to to episodes of
tachycardia, which were at time irregular and other times
regular thought to be atrial tachycardia. He often became tachy
multiple consecutive albuterol nebulizer treatments. He also
became tachy independent of nebs. When he was tachy to 140-160s
which appeared regular on EKG, vagal maneuvers including
Valsalva and carotid sinus massage were attempted without
relief. Beta blockade was attempted and not initially
successful. After consulting with cardiology, decision was made
to allow him to remain tachy as long as he is hemodynamically
stable and otherwise asymptomatic. Pt's tachy subsequently
spontaneously resolved.
## # MDS/ANEMIA:
Dacogen x2 in and reduced-intensity MUD
SCT (Flu/Bu/ATG)in (~D120) found to have persistent disease
with poor cytogenetics (del 13q) with on recent admission
currently on hydrocortisone. It is possible that the acute drop
in HCT from to is secondary to persisent MDS.
HCT increased appropriately to 28 from 23 after 2U PRBCs
although his increased percentage of bands and 15% Other are
concerning for RAEB.
## # :
initially Cr elevated to 1.4 from baseline 0.7 which
improved at OSH to 1.2 with IVF and was 0.9 on arrival to .
Likely pre-renal/ATN in etiology hypotension. This resolved
and at time of transfer out of the MICU his Cr was 0.8.
## #HYPOGAMMAGLOBULINEMIA:
Pt was found to have low IgG and IgM
which contributed to patient susceptibility to infection. He was
given IVIG on which was well tolerated.
## #PSYCH:
was seen by psychiatry and given olanzapine during
previous hospitalization. His delirium improved so it was
discontinued on discharge. He should follow up with psychiatry
as an outpatient to have his anti-depressants re-addressed. His
Citalopram was increased to 20mg.
## # CHRONIC THROMBOCYTOPENIA:
pt initially thought to have ITP in
tx rituxmab x 1, but then dx with MDS by with baseline
platelet counts ranging 97-102. Rejection also thought to be
playing a role during previous hospitalization and this is
currently being followed by his Hematologist Dr. .
Currently, his PLT is at baseline and monitored throughout this
hospital stay.
# Depression: Pt with history of depression on citolopram 10 mg
daily at home. Pt reported increased symptoms of depression and
asked to speak with a psychiatrist. He was diagnosed with
depression secondary to medical illness and so the citolpram
dose was increased to 20 mg/day.
# Neuropathy: hold gabapentin now given his sedation, can resume
when more alert
# GERD: continue home pantoprazole.
# RA: continue oxycontin 10 mg PO daily
## TRANSITIONAL ISSUES:
-He should be seen by his HEME-ONC provider (Dr. within
2 weeks of his discharge.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Budesonide 3 mg PO Q 8H
4. Citalopram 10 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
Rinse mouth after use
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Atovaquone Suspension 1500 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Fluconazole 400 mg PO Q24H
11. Gabapentin 200 mg PO Q8H
12. MethylPHENIDATE (Ritalin) 2.5 mg PO QAM
13. Vancomycin 1000 mg IV Q 12H
14. Glargine 45 Units Breakfast
Glargine 15 Units Bedtime
Humalog 12 Units Breakfast
Humalog 14 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
15. Metoprolol Tartrate 75 mg PO Q6H
Hold for SBP<90, HR<60
16. calcium citrate *NF* 950 mg ORAL TID Reason for Ordering:
Recommended by endocrine given poor absorption of Ca carbonate
in setting of PPI use
17. Hydrocortisone 10 mg PO QAM
18. Hydrocortisone 5 mg PO QPM
19. Testosterone Cypionate 200 mg IM Q2 WEEKS
20. Simethicone 40-80 mg PO QID
21. OLANZapine 2.5 mg PO HS
22. Vitamin D 50,000 UNIT PO DAILY Duration: 7 Doses
23. Oxycodone SR (OxyconTIN) 10 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg PO Q8H
2. Atovaquone Suspension 1500 mg PO DAILY
3. Budesonide 3 mg PO Q 8H
4. Citalopram 20 mg PO DAILY
5. Fluconazole 400 mg PO Q24H
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 200 mg PO Q8H
8. Hydrocortisone 10 mg PO QAM
9. Hydrocortisone 5 mg PO QPM
10. Glargine 60 Units Breakfast
Glargine 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Metoprolol Tartrate 100 mg PO Q6H
12. Multivitamins 1 TAB PO DAILY
13. OLANZapine 2.5 mg PO HS
14. Pantoprazole 40 mg PO Q24H
15. Simethicone 40-80 mg PO QID
16. Vitamin D 50,000 UNIT PO DAILY Duration: 7 Doses
17. Vancomycin Oral Liquid mg PO Q6H Duration: 13 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth q6 Disp #*52 Capsule
## REFILLS:
*0
18. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
19. calcium citrate *NF* 950 mg ORAL TID Reason for Ordering:
Recommended by endocrine given poor absorption of Ca carbonate
in setting of PPI use
20. Fluticasone Propionate 110mcg 2 PUFF IH BID
Rinse mouth after use
21. MethylPHENIDATE (Ritalin) 2.5 mg PO QAM
22. Oxycodone SR (OxyconTIN) 10 mg PO DAILY
23. Testosterone Cypionate 200 mg IM Q2 WEEKS
## DISCHARGE DIAGNOSIS:
Septic Shock
Pneumonia
Empyema
Clostridium Difficile Colitis
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to for trouble breathing and found to
have an infection in your chest. You required a chest tube and
antibiotics. While you were here, you developed C. Diff, a gut
infection which also requires antibiotics. You should continue
to take Vancomycin (oral antibiotic) until for C.
Diff. Please keep your appointments and take all your
medications.
MD
Completed by:
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17069955", "visit_id": "20185564", "time": "2183-01-10 00:00:00"} |
19970158-DS-5 | 2,054 | ## :
AVNRT ablation c/b pericardial bleed/tamponade
## HISTORY OF PRESENT ILLNESS:
YOF, AVNRT on atenolol, s/p ablation c/b
pericardial tamponade now s/p pericardial drain placement.
Patient was in his until and presented for elective AVNRT
ablation. Following procedure while still in the lab became
tachycardic to 130s and hypotensive to systolic. TTE showed
pericardial effusion, c/w tamponade. Pt underwent emergent
pericardiocentesis (aspiration of 210cc of blood). Pericardial
drain was placed successfully. Subsequently hemodynamically
stable and with improved heart rates in the 100s.
Of note, patient also had femoral Aline placed during event.
Femoral venous sheath is still in place.
On interview following the procedure, the patient complained of
sharp chest pain which is worse with inspiration. No
lightheadedness / dizziness. Had nausea earlier requiring
Zofran, but currently asymptomatic.
## PAST MEDICAL HISTORY:
IDDM type II
HLD
SVT
GERD
Generalized anxiety disorder
Recurrent major depressive disorder
Beta thalassemia trait
Migraines
Fatty liver
Endometriosis
Left foot plantar fasciitis
## FAMILY HISTORY:
Maternal grandmother with SVT. No sudden cardiac death.
## VS:
Reviewed in records. Notable for BP of 125/80, HR 100.
Pulsus <5.
## HEENT:
Normocephalic, atraumatic. Sclera anicteric. pupils
equally round. OP clear
## CARDIAC:
Tachycardic. No murmurs, rubs, or gallops.
## LUNGS:
Normal effort. Clear anteriorly bilaterally.
## ABDOMEN:
Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
## EXTREMITIES:
Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
## SKIN:
No significant lesions or rashes.
## PULSES:
Distal pulses palpable and symmetric.
## NEURO:
AAOx3, face symmetric, normal speech, moving all
extremities with purpose.
## GEN:
lying in bed in NAD
## NEURO:
A&Ox4, cooperative with care. Speech clear,
appropriate and comprehensible. MAE equal and strong. Ambulated
with steady gait to BR.
## CV:
RRR. No friction rub appreciated
## CHEST:
no erythema or pain at drain site, dressing C,D,I
## PULM:
clear b/l on auscultation, no use of accessory or
abdominal muscles noted
## GROIN:
femoral access sites soft, no hematoma or bruit, scant
ecchymosis left groin
## EXTR:
WWP, no clubbing, cyanosis, or peripheral edema.
## PERTINENT STUDIES:
==================
EP ABLATION
Patient entered the EP lab in sinus rhythm ~100-110 bpm. AH 75
ms; HV 34 msec. There was evidence of dual AV nodal physiology
during A pacing the Wenckebach. conduction was concentric and
decremental. SVT was induced with 2 AES from the CS in teh
setting of isuprel at 1 mcg/min. SVT morphology was c/w AVNRT.
His refractory PVCs did not advance the A. SVT was entrained
from the RVA and PPITCL = 220 msec c/w AVNRT. Slow pathway
ablation was performed with F curve Biosense 4 mm catheter.
Junctional rhythm with conduction was obtained during RF
ablation. There was a single fleeting period of junctional
rhythm with block and RF was turned off immediately upon this
event. No AV block was observed at any time. Following ablation,
there was no evidence of conduction over the slow AVN pathway
and no inducible SVT or echoes. Femoral sheaths were removed and
while pressure was being applied over the access sites, the
patient became hypotensive with SBP ~70 mmHg with sinus rates
~135 bpm. A stat echo showed a large circumferential pericardial
effusion with evidence of tamponade. Interventional Cardiology
was called stat to the EP Lab and performed emergent
pericardiocentesis with drainage of 210 mL for blood from the
pericardium. Immediately following pericardiocentesis, her SBP
improved to 130 mmHg and her sinus rate decreased to ~90-100
bpm. A right femoral arterial line was placed and a left
femoral venous line was also placed. The patient left the EP Lab
in stable condition to the PACU.
INTERVENTIONAL CARDIOLOGY
- Lidocaine 1 % was administered. Moderate sedation was provided
with appropriate monitoring performed by a member of the nursing
staff. Estimated blood loss <50cc. No specimens were obtained. A
total of 180 mL of blood of pericardial fluid was obtained and
delivered to the clinical laboratory for further testing.
- Pericardial Drain Placement: Under US and X-ray guidance
wusing the kit needle we access the pericardial space
emergently. Given patient was vomiting and with severe
hypotension (SBP in we did not obtain pericardial pressure
and proceeded to drain 180 cc of frank blood. At the end of the
procedure the drain was sutured in place and TTE showed
completer resolution of the pericardial effusion (see separate
report). Patients BP immediately improved to ~150/70 mmHg.
- Venous access: Given poor IV access we proceeded to obtaining
further femoral access (and for autotransfusion in case it was
needed). Access was obtained by percutaneous entry of the left
femoral vein using ultrasound imaging guidance using a
MicroPuncture needle and sheath, and subsequently using a 5
10 cm introducing sheath. At the conclusion of the
procedure, the venous sheath was sutured in place for IV access.
- Femoral Artery Access: Arterial access was obtained by
percutaneous entry of the right femoral artery using ultrasound
imaging guidance using a Micro Puncture needle and sheath and
subsequently using a/an 4 10 cm introducing sheath. At
the end of the procedure the sheat was sutured in place for
hemodynamic monitoring (as a-line).
- There were no clinically significant complications.
Successful pericardiocentesis draining 180 cc of bloody fluid
and drain placement. Successful LCFV Fr sheath placement.
Successful RCFA Fr arterial sheath placement.
TTE
## CONCLUSION:
There is normal left ventricular wall thickness with
a normal cavity size. Overall left ventricular systolic function
is normal. Normal right ventricular cavity size with normal free
wall motion. There is a normal descending aorta diameter. The
aortic valve leaflets (?#) appear structurally normal. The
mitral valve leaflets appear structurally normal. There is no
pericardial effusion.
## IMPRESSION:
No pericardial effusion. Normal left ventricular
wall thickness and biventricular cavity sizes and global
systolic function.
TTE
## CONCLUSION:
The estimated right atrial pressure is mmHg.
Overall left ventricular systolic function is normal.
Quantitative 3D volumetric left ventricular ejection fraction is
60 %. The right ventricle has low normal free wall motion. There
is abnormal interventricular septal motion. There is a very
small circumferential pericardial effusion. The effusion is echo
dense, c/w blood, inflammation or other cellular elements. There
is increased respiratory variation in transmitral/transtricuspid
inflow but no right atrial/right ventricular diastolic collapse.
Compared with the prior TTE (images reviewed) of , a
very small pericardial effusion is seen with variation in
tricuspid valve inflow and abnormal septal motion that may be
consistent with effusive constrictive physiology. The right
ventricular free wall systolic motion appears somewhat
restricted vs prior that appeared normal.
## CONCLUSION:
The estimated right atrial pressure is >15mmHg.
There is normal left ventricular wall thickness with a normal
cavity size. There is normal regional left ventricular systolic
function. Quantitative
biplane left ventricular ejection fraction is 66 %. Normal right
ventricular cavity size with normal free wall motion. The aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse.
There is trivial mitral regurgitation. There is no pericardial
effusion.
Compared with the prior TTE (images reviewed) of , the
findings are similar.
## DISCHARGE LABS:
===============
08:08AM BLOOD WBC-8.2 RBC-3.58* Hgb-11.0* Hct-34.0
MCV-95 MCH-30.7 MCHC-32.4 RDW-12.9 RDWSD-44.6 Plt
08:08AM BLOOD Glucose-101* UreaN-16 Creat-0.9 Na-142
K-4.4 Cl-104 HCO3-27 AnGap-11
08:08AM BLOOD Calcium-8.8 Phos-3.8 Mg-1. SSESSMENT AND PLAN:
=====================
with PMH of AVNRT on atenolol, presented for elective
ablation, now s/p successful ablation on course c/b
pericardial tamponade/bleed, s/p pericardial drain placement
which was removed . She was transferred to cnp service night
of .
## #CORONARIES:
unknown
#PUMP: normal biventricular function
#RHYTHM: sinus rhythm.
#PERICARDIAL BLEED
#TAMPONADE
Likely complication of AVNRT ablation with either CS or RV
injury. S/p pericardial drain placement with drainage of 210cc
of
blood on , 100cc on , none on . Currently
hemodynamically stable. Repeat TTE without reaccumulation.
- Start colchicine 0.6mg BID , for 2 weeks)
- Tylenol mg q 6 hours prn for pain management
- oxycodone 5mg q6prn for pain management at home for total of 6
doses
- No ASA per Dr.
- F/U with Dr. on
#AVNRT s/p ABLATION
Successful ablation with EP .
- Continue atenolol at half-dose x1 week until ,
then decrease by another 50% x1 week until , then
discontinue
- F/U with Dr. as above
#ANXIETY
Has h/o anxiety and takes 0.5-1mg PO Ativan q2-3 days PRN at
home.
- continue home at PRN
- SW consult appreciated: Pt sees a therapist once weekly at
in . She also sees a
psychiatrist and is involved with two grief groups.
## #IDDM TYPE II:
On glargine 50u qbreakfast and qPM at home as
well as metformin
1000mg BID and victoza 1.2mg SC daily.
- continue home regimen of glargine currently 50 AM & ,
metformin, and victoza
#THALASSEMIA TRAIT
S/p 1u PRBC despite Hb 11, prophylactic iso bleed as above. H/H
11.0/34.0 at discharge.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Glargine 50 Units Breakfast
Glargine 50 Units Bedtime
2. Vitamin D UNIT PO 1X/WEEK (WE)
3. FLUoxetine 40 mg PO DAILY
4. Atorvastatin 80 mg PO QAM
5. Victoza 2-Pak (liraglutide) 1.2 mg subcutaneous DAILY
6. Atenolol 25 mg PO DAILY
7. Sumatriptan Succinate 25 mg PO ONCE:PRN headache
8. LORazepam 0.5-1 mg PO ONCE EVERY DAYS PRN anxiety
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. BuPROPion XL (Once Daily) 300 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q6H
Do NOT exceed more than 4000mg (4 grams) in 24 hours due to risk
of liver failure.
2. Colchicine 0.6 mg PO BID Duration: 2 Weeks
Last dose
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Please take over the counter laxatives daily (Miralax 17grams)
for duration of narcotic use.
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
5. Atenolol 12.5 mg PO DAILY Duration: 5 Days
Continue current dose until decrease dose by 50% to
6.25 mg x one week, then stop.
6. Atorvastatin 80 mg PO QAM
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. FLUoxetine 40 mg PO DAILY
9. Glargine 50 Units Breakfast
Glargine 50 Units Bedtime
10. LORazepam 0.5-1 mg PO ONCE EVERY DAYS PRN anxiety
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Sumatriptan Succinate 25 mg PO ONCE:PRN headache
13. Victoza 2-Pak (liraglutide) 1.2 mg subcutaneous DAILY
14. Vitamin D UNIT PO 1X/WEEK (WE)
## DISCHARGE DIAGNOSIS:
1) Cardiac Tamponade
2) AVNRT s/p ablation
## DISCHARGE INSTRUCTIONS:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ,
It was a pleasure taking care of you at
.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You were admitted to after a planned procedure to correct
your abnormal heart rhythm
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- The heart rhythm was corrected successfully
- Unfortunately, you had a small bleed which caused blood to
accumulate around your heart
- We placed a drain to remove the blood
- We gave you pain medication and monitored you
- The bleeding stopped and we were able to remove the drain
- Your repeat echocardiogram (ultrasound of heart) did not show
any evidence of effusion/blood around your heart.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- You have been given 6 oxycodone pills to use for moderate to
severe pain; Try Tylenol first and use Oxycodone for
breakthrough pain. Take Miralax 17 grams once daily for duration
of oxycodone use to prevent constipation.
- Follow up with your doctors as listed below
- Activity restrictions and information regarding care of the
access sites in the groin are included in your discharge
instructions.
If you have any urgent questions that are related to your
recovery from your procedure or are experiencing any symptoms
that are concerning to you and you think you may need to return
to the hospital, please call the HeartLine at
to speak to a cardiologist or cardiac nurse
practitioner.
It has been a pleasure to have participated in your care and we
wish you the best with your health!
Your Cardiac Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19970158", "visit_id": "29114710", "time": "2189-01-28 00:00:00"} |
14590709-RR-50 | 131 | ## INDICATION:
man with COPD, HCC, cirrhosis, with altered mental
status, evaluate for bleed, CVA, or mass.
## FINDINGS:
There is no evidence of hemorrhage, edema, mass, mass effect, or
acute infarction. Two small hypodensities in the left pons that were seen on
prior study on likely represent old lacunar infarcts. The
ventricles and sulci are mildly prominent consistent with atrophy. There are
vascular calcifications of the left vertebral artery and carotids bilaterally.
There is a defect in the left lamina papyracea. The visualized paranasal
sinuses and mastoid air cells are well aerated.
## IMPRESSION:
1. No acute intracranial process.
2. Two small hypodense lesions in the left pons that may represent old
lacunar infarcts. This is unchanged compared to study on .
3. Sulci and ventricles are mildly prominent consistent with atrophy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14590709", "visit_id": "26583785", "time": "2124-04-12 16:03:00"} |
11485288-RR-29 | 159 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
with Brbpr, fall evaluate for bleed or colitis.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.0 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 3.0 s, 6.2 cm; CTDIvol = 48.7 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
## FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of age-appropriate
involutional changes. Nonspecific periventricular white matter hypodensities
most likely represent mild chronic small vessel ischemic disease.
There is no evidence of fracture. Aside from minimal mucosal thickening of
the right maxillary sinus, the visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable. The carotid siphons are calcified.
## IMPRESSION:
No evidence of acute intracranial process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11485288", "visit_id": "21146621", "time": "2178-12-15 06:15:00"} |
13927903-RR-9 | 622 | ## EXAMINATION:
MRI CERVICAL, THORACIC, AND LUMBAR
## INDICATION:
year old woman with s/p fall down steps, diffuse spine
tenderness // eval for traumatic injury .
## FINDINGS:
MRI of the cervical spine. The visualized elements of the posterior fossa and
the craniocervical junction are unremarkable, the cervical spine alignment is
maintained, multilevel multifactorial degenerative changes are present
throughout the cervical spine call, consistent with mild disc bulging at
C3/C4, C5/C6 and C6/C7 levels. The signal intensity throughout the cervical
spinal cord is normal with no evidence of focal or diffuse lesions. Note is
made of a small focus of high T2 signal intensity identified on the right
thyroid lobe, measuring approximately 4 x 5 mm in transverse dimension,
partially evaluated in this examination (image 29, series 7), most likely
likely consistent with small cyst.
MRI of the thoracic spine. The alignment of the thoracic vertebral bodies
appears maintained, the signal intensity throughout the thoracic spinal cord
is normal with no evidence of focal or diffuse lesions. Mild degenerative
changes are visualized in the lower thoracic spine, consistent with articular
joint facet hypertrophy ligamentum flavum thickening at T10/T11 (image 29,
series 8), causing posterior thecal sac deformity on the right. The conus
medullaris is normal and terminates at the level of T12. .
MRI of the lumbar spine. Multilevel multifactorial degenerative changes are
visualized throughout the lumbar spine, there is mild anterolisthesis at L4
upon L5 level.
At T12/L1 level, there is a biconvex disc bulge, causing mild bilateral neural
foraminal narrowing.
At L1/L2 level, there is disc desiccation and disc bulging, causing mild
bilateral neural foraminal narrowing with no frank evidence of nerve root
compression.
At L2/L3 level, there is disc desiccation and diffuse disc bulging, causing
bilateral neural foraminal narrowing, apparently contacting the traversing
nerve roots, additionally articular joint facet hypertrophy and ligamentum
flavum thickening are present, resulting in mild spinal canal narrowing.
At L3/L4 level, there is disc desiccation and diffuse disc bulge, causing
bilateral neural foraminal narrowing, contacting the traversing nerve roots
bilaterally, moderate articular joint facet hypertrophy and ligamentum flavum
thickening are present, resulting in moderate spinal canal stenosis (image 37,
series 9).
At L4/L5 level, there is disc desiccation and uncovering disc, and related
with mild anterolisthesis as described above, the disc bulging is producing
anterior thecal sac deformity of bilateral neural foraminal narrowing, right
greater than left, contacting the traversing nerve roots and apparently the
right exiting nerve root (image 23, series 15), moderate articular joint facet
hypertrophy and ligamentum flavum thickening are present at this level,
producing moderate spinal canal narrowing.
At L5/S1 level, there is disc desiccation and diffuse disc bulge, causing
bilateral neural foraminal narrowing, moderate articular joint facet
hypertrophy is present, note is made of possible area of edema in the anterior
aspect of the endplates at L5/S1 level, suggesting degenerative changes,
however bone contusion is also a consideration. The sacroiliac joints are
unremarkable. Note is made of small amount of fluid surrounding the right
perirenal space (image number 12, series 15). Additionally gallstones are
visualized in the gallbladder.
## IMPRESSION:
1. Multilevel multifactorial degenerative identified in the cervical spine
with no evidence of focal or diffuse lesions in the spinal cord.
2. Mild to moderate degenerative changes throughout the thoracic spine, more
significant at T10/ T11 level, consistent with articular joint facet
hypertrophy and ligamentum flavum thickening.
3. Multilevel multifactorial degenerative changes throughout the lumbar
spine, more significant at L1/L2 level, there is mild anterolisthesis at L4
upon L5 level. Edema at the endplates of L5/S1 levels suggest degenerative
changes, however, bone contusion is also a consideration.
4. Small amount of fluid is noted in the right pre renal space, gallstones.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13927903", "visit_id": "27726176", "time": "2136-09-28 10:18:00"} |
11071173-DS-10 | 758 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
biliary plasty with placement of internal/external
PTBD
## HISTORY OF PRESENT ILLNESS:
M with PSH significant for lap CCY on at
complicated by high bile duct injury, transferred to
and underwent ex lap, RNY hepaticojejunostomy. His course has
been complicated by recurrent cholangitis secondary to a CHD
stricture, requiring multiple drain placements, last removed
. He was last seen in clinic by Dr. found to be
doing well. He was found to have an incisional hernia that he
would manage with a binder.
He comes in today with 48 hours of fevers as high as 103.5,
malaise and nausea. He reports these symptoms are very similar
to
his prior episodes of cholangitis. Denies abdominal pain, chest
pain, shortness of breath, changes in bowel movements frequency,
color or consistency, urinary symptoms.
In the ED, he was febrile but otherwise vital signs have been
stable and mental status is normal. His labs showed WBC 9.5,
elevated transaminases as well as Tb 1.4 (baseline 0.4). RUQ US
showed mild dilation of the Mild intrahepatic biliary ductal
dilatation, predominantly in the left hepatic lobe, similar to
prior studies.
## ROS:
(+) per HPI
(-) Denies night sweats, unexplained weight loss, lethargy,
changes in appetite, trouble with sleep, pruritis, jaundice,
rashes, bleeding, easy bruising, headache, dizziness, vertigo,
syncope, weakness, paresthesias, nausea, vomiting, hematemesis,
bloating, cramping, melena, BRBPR, dysphagia, chest pain,
shortness of breath, cough, edema, urinary frequency, urgency.
## PMH:
acute cholecystitis, cholangitis, nephrolithiasis
## PSH:
L inguinal hernia repair, lap cholecystectomy c/b CBD
injury ex-lap with RNY hepatojejunostomy and
biliary stent x2 ( )
## FAMILY HISTORY:
no history of liver cancer
## ADMISSION PE:
T 102.6 HR 97 BP 133/77 RR 18 SatO2 100% RA
NAD
No jaundice
Alert and oriented
RRR
CTA bil
Abdomen soft, non-tender, non-distended
Small incisional hernia, reducible, non-tender
Extremities no edema
Labs
## RUQ US:
1. Mild intrahepatic biliary ductal dilatation, predominantly in
the left hepatic lobe, similar to prior studies.
2. No evidence of CBD stone.
## WT:
165.2 lb/74.93 kg
Fluid Balance (last updated @ 535)
Last 8 hours Total cumulative -975ml
## IN:
Total 345ml, PO Amt 220ml, IV Amt Infused 125ml
## OUT:
Total 1320ml, Urine Amt 1300ml, PTBD 20ml
Last 24 hours Total cumulative -1760ml
## IN:
Total 1620ml, PO Amt 1140ml, IV Amt Infused 480ml
## OUT:
Total 3380ml, Urine Amt 3270ml, PTBD 110ml
## DRAINS:
PTBD drain to gravity, non-purulent sanguinous/bilious
output
## BLOOD CULTURE, ROUTINE (PENDING):
No growth to date.
## BRIEF HOSPITAL COURSE:
s/p RNYHJ for CBD injury during lap CCY, c/b recurrent
cholangitis secondary to biliary stricture presented with fever
## MED/SURG ISSUES ADDRESSED:
An MRCP was performed noting multiple
stones in the right posterior hepatic duct and common hepatic
duct, mild cholangitis and mild/moderate intrahepatic biliary
dilation.
Unasyn was started and he felt better the next day. He remained
afebrile. Urine culture was negative from . Blood
cultures from were negative to date (unfinalized). On
, performed a cholangiogram noting a stricure of the
hepaticojejunostomy. This area was plastied and a Fr
internal/external PTBD was placed. LFTs improved overnight. The
PTBD was capped on . Unasyn was changed to Augmentin on
. The plan was to continued Augmentin for 5 days. He was
discharged to home with plan to have repeat cholangiogram on
. He was just taking Tylenol for discomfort at the drain
site with good relief.
## TRANSITIONAL ISSUES:
f/u unfinalized blood cultures from
and return for f/u cholangiogram on
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
## DISCHARGE MEDICATIONS:
1. Acetaminophen 500 mg PO Q6H
do not take more than 2000mg per day. Decrease or stop as pain
lessens
2. Amoxicillin-Clavulanic Acid mg PO Q12H Duration: 5 Days
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
## DISCHARGE INSTRUCTIONS:
Please call Dr. office at for fever
of 101 or greater, chills, nausea, vomiting, diarrhea,
constipation, increased abdominal pain, pain not controlled by
your pain medication, swelling of the abdomen or ankles,
yellowing of the skin or eyes, inability to tolerate food,
fluids or medications, the PTBD biliary drain site has redness,
drainage or bleeding, or any other concerning symptoms.
You may shower. Allow water to run over the PTBD drain site. Do
not apply lotion or powder to the drain insertion site. Apply a
new dry gauze dressing daily.
Keep the PTBD drain capped.
No lifting more than 10 pounds
No driving if taking narcotic pain medication
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11071173", "visit_id": "25576273", "time": "2180-12-13 00:00:00"} |
14517206-RR-75 | 117 | ## INDICATION:
female status post multiple abdominal surgeries
presenting with right lower quadrant pain.
## ABDOMEN, SUPINE AND ERECT VIEWS:
There is a non-specific bowel gas pattern
with mildly gas distended loops of small bowel present in the mid abdomen. Air
and stool seen throughout the colon to the level of the rectum. No free air is
seen beneath the hemidiaphragms. Surgical clips are again noted in the right
upper abdominal quadrant. There is mild convex scoliosis. Ovoid
calcifications, likely phleboliths, project over the pelvis.
## IMPRESSION:
Non-specific bowel gas pattern with central loops of mildly gas
distended small bowel. No evidence of obstruction or free intraperitoneal
air. Correlate clinically and with follow up as needed.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14517206", "visit_id": "N/A", "time": "2135-06-09 11:12:00"} |
14318402-RR-13 | 91 | ## INDICATION:
Right chest discomfort. Evaluate for effusion.
## FINDINGS:
There is no significant change compared with the prior radiograph.
The lungs are well expanded. Chain suture is seen in the right upper lung,
compatible with prior resection. Mild elevation of the right hemidiaphragm is
likely due to volume loss in the right. There are no focal opacities. There
is a prominent epicardial fat pad with partial obscuring the left heart apex,
unchanged. There is no pleural effusion or pneumothorax. Cardiomediastinal
and hilar contours are unremarkable.
## IMPRESSION:
No evidence of pneumonia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14318402", "visit_id": "N/A", "time": "2187-02-14 10:30:00"} |
12298542-RR-38 | 442 | ## EXAMINATION:
CT abdomen and pelvis with contrast
## INDICATION:
year old man with recurrent abdominal pain post colonoscopy in
left side// abd pain cause
## 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) Spiral Acquisition 3.2 s, 51.2 cm; CTDIvol = 19.4 mGy (Body) DLP = 991.1
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.8 mGy (Body) DLP = 1.4
mGy-cm.
3) Stationary Acquisition 5.6 s, 0.5 cm; CTDIvol = 30.7 mGy (Body) DLP =
15.4 mGy-cm.
Total DLP (Body) = 1,008 mGy-cm.
## LOWER CHEST:
Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, 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:
The kidneys are of normal and symmetric size with normal nephrogram.
Subcentimeter cortical hypodensities in the right kidney are too small to
characterize, however not significantly changed from prior, likely
representing cysts. Again seen is a 4 mm nonobstructing stone in the lower
pole of the left kidney. There is no hydronephrosis. There is no perinephric
abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Extensive
diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding. The appendix is not visualized, however there
are no secondary signs of acute appendicitis.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate and seminal vesicles are normal.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
Bilateral inguinal hernias containing fat are noted.
## IMPRESSION:
-No acute process in the abdomen or pelvis, to explain patient's left sided
abdominal pain.
-Extensive sigmoid diverticulosis, with no evidence of acute diverticulitis.
-4 mm nonobstructing calculus in the lower pole of the left kidney.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12298542", "visit_id": "N/A", "time": "2165-06-27 09:27:00"} |
17891678-RR-30 | 95 | ## INDICATION:
year old woman with recent ground level fall 4 days ago, chest
and thoracic back pain// r/o rib fracture
## FINDINGS:
Mild cardiomegaly is unchanged compared to the prior exam. Small bilateral
pleural effusions are seen, left greater than right. Bibasilar atelectasis is
seen. There is no evidence of pneumothorax. No definite focal consolidations
concerning for pneumonia identified. No definite displaced rib fracture is
identified.
## IMPRESSION:
-Small bilateral pleural effusions.
-No definite displaced rib fracture identified. If there is further clinical
concern, dedicated rib series radiograph may be helpful for further
evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17891678", "visit_id": "N/A", "time": "2208-09-19 13:24:00"} |
17497258-RR-11 | 211 | ## EXAMINATION:
LEFT UNILATERALDIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD AND
## FINDINGS:
LEFT DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD:
## TISSUE DENSITY:
There are scattered areas of fibroglandular density.
There is a tubular opacity in the left retroareolar region which on same day
ultrasound corresponds to dilated ducts. There is persistent circumscribed
mass in the left upper central quadrant. This opacity ultrasound corresponds
to a simple cyst.
## LEFT BREAST ULTRASOUND:
The upper central and retroareolar region was scanned. Prominent ducts are
seen in the retroareolar region without any intraductal mass. A duct measuring
up to 5 mm in diameter and felt to correspond to the tubular opacity seen on
mammogram. No solid or cystic mass is seen.
In the 1 o'clock 10 cm from the nipple there is an oval circumscribed anechoic
mass which measures 0.5 x 0.5 x 0.4 cm and demonstrates good through
transmission and no internal vascularity. This is consistent with a simple
cyst and is felt to correspond to the mass seen on mammogram.
## IMPRESSION:
No evidence of malignancy. Prominent ducts which is an expected finding in
this patient who recently discontinued breastfeeding.
## RECOMMENDATION:
Age and risk appropriate screening is recommended.
## NOTIFICATION:
Findings and recommendation were reviewed with the patient at
the completion of the study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17497258", "visit_id": "N/A", "time": "2146-12-20 07:10:00"} |
12251785-DS-50 | 1,357 | ## ALLERGIES:
Keflex / Penicillins / Dicloxacillin / Morphine / Compazine /
Reglan / Amicar / Verapamil
## HISTORY OF PRESENT ILLNESS:
female with history of SLE, ESRD on HD who presents
with weakness consistent with prior episodes of hyperkalemia.
The patient was in her usual state of health and went to
dialysis. She noted that she became progressively weak at
dialysis and had difficulty standing. She felt that this was
consistent with her prior episodes of hyperkalemia. She decided
to present to the hospital instead of undergoing dialysis as an
outpatient. She denies any changes in her diet or medications.
In the ED, initial VS were: T 97.7, HR 87, BP 148/76, RR 16,
SvO2 97% RA. Potassium was 7.4. EKG showed peaked T waves. She
was given calcium gluconate 2g, dextrose and insulin, Sodium
Polystyrene Sulfonate (30g) and sodium bicarbonate. Nephrology
was consulted and recommended MICU admission and dialysis.
On arrival to the MICU, dialysis nurse already at bedside. She
notes some abdominal distension with mild discomfort. She also
had some nausea today. Otherwise she feels okay.
## PAST MEDICAL HISTORY:
- ESRD TMA s/p failed graft in , previously on PD,
switched to HD on (tunneled catheter placed ,
s/p right transplant nephrectomy
- Thrombotic microangiopathy s/p renal transplant in
- Antiphospholipid antibody syndrome
- SLE
- deficiency
- OSA on CPAP
- Depression
- Anxiety
- ?bipolar disorder
- H/o malignant HTN c/b hypertensive encephalopathy and PRES
- Hyperlipidemia
- Raynaud's phenomenon in
- GERD
- Gastritis in
- Migraine headaches (remote)
- s/p TAH-BSO at for heavy menses and bleeding ovarian cysts
- H/o aspiration pneumonia, pulmonary hemorrhage and
- H/o gout, on chronic prednisone
- H/o seizures with dialysis
- Diplopia thought to be due to lamotrigine, followed by
neurology
- s/p cholecystectomy
- Left brachiocephalic fistula
- H/o T7 compression fracture
- H/o tarditive dyskinesia
## FAMILY HISTORY:
father with anti-phospholipid syndrome, HTN, DM. Sister with MS.
siblings with asthma, HTN.
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
## NECK:
supple, unable to assess JVD
## CV:
soft, RR, nl rate, no murmurs, rubs or gallops appreciated
## LUNGS:
Clear to auscultation bilaterally, limited anterior
examination, no wheezes, crackles
## ABDOMEN:
soft, mild distention, diffuse tenderness, bowel sounds
present, no rebound or gaurding
## EXT:
warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, unable to assess JVD
## CV:
soft, RR, nl rate, no murmurs, rubs or gallops appreciated
## LUNGS:
Clear to auscultation bilaterally, no wheezes, crackles
## ABDOMEN:
Normoactive bowel sounds, soft, mild distention, mild
reported tenderness without guarding or rebound
## EXT:
warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## IMAGING:
EKG
Sinus rhythm. Left axis deviation. R wave reversal in leads
V2-V3. Loss
of R wave may represent lateral myocardial infarction but also
consider lead placement. Probable Q waves in leads III and aVF.
Consider inferior
myocardial infarction. Since the previous tracing of
small R waves in leads III and aVF are now less apparent. T wave
amplitudes are more prominent. Limb lead voltage is less
prominent but may still represent left ventricular hypertrophy.
Clinical correlation is suggested.
EKG
Sinus rhythm. Consider inferior myocardial infarction, age
undetermined. Left ventricular hypertrophy by voltage in lead
aVL. R wave reversal in
leads V2-V4. Since the previous tracing of T wave
amplitudes are
less. QRS voltage is more prominent in the limb leads.
## BRIEF HOSPITAL COURSE:
Patient is a female with history of SLE, ESRD on HD
who presents with hyperkalemia with weakness and EKG changes.
## # HYPERKALEMIA:
She was admitted to the MICU for emergent
dialysis after she was found to have K 7.8 with EKG changes. She
was transferred to the floor the following day. She has had
multiple admissions for hyperkalemia in the past with negative
workup (including dietary fasting to identify food sources). She
denies any clear precipitating factors. Patient has been taking
Kayexalate as outpt twice per week on non-HD days to combat this
but per Renal should be taking this on every non-HD day (or 4
times per week). Patient was instructed to increase frequency of
Kayexalate at home and to follow up with her nephrologist Dr.
.
## # ESRD ON HD:
Her home medications including calcitriol,
sevelamer carbonate and calcium carbonate were continued. She
underwent HD on and . Patient had a brief
episode of hypotension and bradycardia with transient
unresponsiveness at the end of the session on that
responded to bolus of IV fluid. She had no further episodes of
hypotension overnight on and was stable at discharge.
## # HTN:
She was continued on amlodipine and hydralazine.
## # OSA:
She was continued on CPAP.
## # GOUT:
She is on chronic prednisone with difficulty weaning
(per OMR records). We continued her home prednisone taper.
## # DEPRESSION/ANXIETY/QUESTIONABLE BIPOLAR:
She was continued on
her home seroquel, lamictal and mirtazapine.
## MEDICATIONS ON ADMISSION:
- amlodipine 10 mg PO daily
- B complex-vitamin C-folic acid 1 mg PO daily
- butalbital-acetaminophen-caff 50 mg-325 mg-40 mg tabs q6
hours PRN
- calcitriol 0.5 mcg PO daily
- fluticasone 50 mcg Spray sprays per nostril daily
- hydralazine 50 mg PO TID prn
- lamotrigine 25 mg PO BID
- latanoprost 0.005 % 1 gtt daily
- levetiracetam 500 mg PO daily
- lidocaine-prilocaine 2.5 %-2.5 % Cream apply cream topically
one hour before HD
- mirtazapine 45 mg Tablet 0.5 Tabs PO qHS
- mupirocin 2 % Ointment apply to left hand daily
- omeprazole 20 mg PO BID
- oxycodone-acetaminophen 5 mg-325 mg Tablet Tablets PO q4H
prn
- prednisone 10 mg PO daily
- quetiapine 100 mg Tablet tabs PO qHS prn insomnia
- sevelamer carbonate 1600 mg Tablet PO TID mg with snacks)
- sodium polystyrene sulfonate 15g Powder(s) PO on non dialysis
days
- aspirin 81 mg PO daily
- calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg)
Tablet
2 Tablets PO TID
- ibuprofen [Motrin] Dosage uncertain
## DISCHARGE MEDICATIONS:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): with additional dose after HD.
5. mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. butalbital-aspirin-caffeine 50-325-40 mg Capsule Sig:
Caps PO every six (6) hours as needed for headache.
8. hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for hypertension.
## 9. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
Tablets PO
every four (4) hours as needed for pain.
10. quetiapine 100 mg Tablet Sig: Tablets PO at bedtime as
needed for insomnia.
11. sodium polystyrene sulfonate Powder Sig: Fifteen (15)
grams PO Every nonHD day.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
15. mupirocin 2 % Ointment Sig: One (1) Topical once a day:
please apply to left hand daily.
16. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
day.
18. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO
three times a day: with meals.
## PRIMARY:
- Hyperkalemia
- End stage renal disease on hemodialysis
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was pleasure taking care of you during your admission to
. You were admitted to the
hospital with elevated potassium. This was corrected with
dialysis and medications. Previous workups for this problem
have yet to find a cause but to prevent this from happening
again, it is important that you take Kayexalate every day that
you do not have dialysis. Please follow-up with your Primary
care provider and Dr. .
The following changes were made to your medications:
1. Increase kayexalate to every day that you do not have
dialysis.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12251785", "visit_id": "29984287", "time": "2179-01-13 00:00:00"} |
19037640-RR-94 | 160 | ## INDICATION:
year old woman with hx SAH while on // follow up
resolution
## FINDINGS:
There is interval resolution of previously identified left frontal sulcal
FLAIR hyperintensity likely related to left frontal convexal subarachnoid
hemorrhage. There is residual increased susceptibility on T2 star sequence
along same left frontal region related to hemosiderin deposition (series 10,
image 17 and 16).
There is no evidence of acute hemorrhage, edema, masses, mass effect, midline
shift or infarction. There are essentially unchanged few small punctate
bilateral frontal and parietal white matter nonenhancing T2 FLAIR
hyperintensities; nonspecific in appearance. The ventricles and sulci are
normal in caliber and configuration. There is no abnormal enhancement after
contrast administration.
Both orbits are normal. Paranasal sinuses and mastoid air cells are
essentially clear.
## IMPRESSION:
1. No acute intracranial abnormality or abnormal intracranial enhancement.
2. Interval resolution of previously identified left frontal sulcal FLAIR
hyperintensity likely related to left frontal convexity subarachnoid
hemorrhage with subtle residual changes as described.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19037640", "visit_id": "N/A", "time": "2137-04-04 17:41:00"} |
17414827-RR-62 | 190 | ## REASON FOR EXAMINATION:
Evaluation of patient with asthma.
## FINDINGS:
Aorta and pulmonary arteries are normal in diameter. Coronary calcifications
are present. There is no pericardial or pleural effusion. Imaged portion of
the upper abdomen reveals no abnormality.
There are no bone lesions worrisome for infection or neoplasm. Assessment of
the airways demonstrates irregularity at the level of the subvocal cord with
unchanged since prior study area of stenosis, 4:39, approximately 120 mm2.
Rest of the imaged portion of the trachea and airways demonstrate no
abnormality during inspiration. During dynamic expiration, there is no
evidence of substantial tracheobronchomalacia. Narrowing of the bronchus
intermedius is demonstrated, unchanged since the prior study, clinical
significance of this finding is unclear.
Multiple pulmonary nodules scattered throughout the lungs are unchanged in the
right upper lobe, superior segment of left lower lobe, 4:123, 147, with no new
nodules, masses, or consolidations demonstrated.
## IMPRESSION:
1. Unchanged mild-to-moderate subglottic stenosis.
2. No evidence of tracheobronchomalacia. Relatively prominent decrease in
the area of bronchus intermedius, clinical significance is unclear.
3. Unchanged mild right upper and left lower lobe areas of scarring/nodular
atelectasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17414827", "visit_id": "N/A", "time": "2168-09-12 09:05:00"} |
11449781-RR-21 | 285 | ## INDICATION:
female with left-sided subdural hematoma of unknown
etiology. Assessment for vascular abnormality.
## MRI HEAD:
There is no interval change with regard to the subdural collections
overlying both convexities, measuring 5 and 9 mm in maximal right or left
hemisperic thickness. While the collection on the right side is predominantly
CSF isointense and homogeneously enhancing, the left subdural fluid is large
composed of blood products, hypointense on T2 and hyperintense on T1,
suggesting an early subacute chronicity with mostly intracellular
methemoglobin. Trace amounts of subdural blood are moreover seen overlying
the right frontal lobe. There is mild mass effect on the adjacent sulci with
effacement.
The gray-white matter differentiation is well preserved. Scattered deep white
matter FLAIR/T2 signal abnormalities are in keeping with sequelae of chronic
small vessel ischemic disease. There is no evidence of acute ischemic
infarct, intraparenchymal hemorrhage, or space-occupying lesion. The flow
voids of the major intracranial vessels are preserved. The paranasal sinuses
and mastoid air cells are clear. Incidental note is made of a right frontal
osseous lesion, that might represent a hemangioma.
## MRA HEAD:
The intracranial internal carotid, vertebrobasilar, and anterior,
middle, and posterior cerebral arteries demonstrate normal flow-related
enhancement and branching pattern. There is no evidence of occlusion,
hemodynamically significant stenosis, or arteriovenous malformation.
## IMPRESSION:
1. Stable subdural collections overlying both convexities with right and left
maximal thickness of 5 or 9 mm. While there is predominantly hygroma on the
right side with some traces of blood, the left subdural collection containts
largely blood products of early subacute origin. Mass effect is mild and
limited to effacement of the sulci.
2. No evidence of vascular malformation, underlying space-occupying lesion, or
infarct.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11449781", "visit_id": "20695984", "time": "2182-08-20 17:30:00"} |
11224076-DS-12 | 1,175 | ## HISTORY OF PRESENT ILLNESS:
year old Female who presents with a single episode of
witnessed syncope. The patient states that she was sitting at
the dinner table with her family when she lost consciousness for
about 3 minutes per the family. The family denies tonic clonic
activity. She was never placed on the floor, but awoke 3 minutes
later, with normal mental status.
.
She notes some nausea prior to fainting, but denies any other
associated symptoms. She had been complaining of dizziness
during dinner, but not immediately prior to losing
consciousness. She denies any positional change or symptoms, or
other associated symptoms including headache, diaphoresis,
palpitations, weakness, change in vision, tinnitus, seizure-like
activity, tongue-biting, or loss of bladder or bowel continence.
.
She has had intermittent short episodes of dizziness over the
last few days to a month. She has not been drinking much in the
way of fluids, but has had a normal appetite and has been eating
well. She also had a fall 2 days prior, without any LOC or head
trauma, and she was caught by her grandson. She does note some
chest discomfort since the fall, but the grandson denies that
she hit her chest during the fall. At baseline, she walks with a
cane and with the help of another person (in this case it was
her grandson). She has not had any significant changes to her
medications, with the exception of the addition of colace for
constipation in early . She says she has been
urinating a lot recently, and has no idea why.
.
In the ED, VS - Temp 97.2F, BP 126/84, HR 68, R 18, SaO2 100%
RA. Physical exam was notable for some mild inferior sternal
chest wall tenderness but was otherwise normal without any focal
neurologic signs. She was Guaiac negative. Labs revealed mild
ARF (Cr 1.5), troponin at baseline, and negative UA. NCHCT
showed no acute findings, and parenchymal atrophy and chronic
small vessel disease. ECG showed old TWI but was at baseline.
CXR showed no acute cardiopulmonary abnormality, and a large
hiatal hernia and elevation of the right hemidiaphragm, both of
which are chronic findings. She received IVF NS 500cc and is
being admitted for syncope work-up.
## PAST MEDICAL HISTORY:
CAD s/p NSTEMI
Atrial fibrillation in but NSR since
Type 2 Diabetes
Benign Hypertension
Mild dementia
Legally blind due to glaucoma
B12 deficiency anemia
## GEN:
- fevers, - Chills, - Weight Loss
## EYES:
- Photophobia, - Visual Changes
## CARDIAC:
- Chest Pain, - Palpitations, - Edema
## GI:
- Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
## MSK:
- Myalgia, - Arthralgia, - Back Pain
## HEENT:
Blind, Dry MM, - OP Lesions
## NEURO:
CAOx3, alert and oriented to person, place. strength
in all 4 extremities. No pronator drift. No facial droop, Able
to stand without assistance. Walks with cane and assistance at
baseline. 2+ patellar reflexes bilaterally.
## URINE:
08:45PM URINE Color-Yellow Appear-Clear Sp
08:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
CHEST (PA & LAT) Study Date of 6:46
## IMPRESSION:
No acute cardiopulmonary abnormality. Large hiatal
hernia and
elevation of the right hemidiaphragm, both of which are chronic
findings.
.
CT HEAD W/O CONTRAST Study Date of 7:11
## IMPRESSION:
1. No acute intracranial pathology.
2. Parenchymal atrophy, and small vessel chronic ischemic
disease.
## 1. SYNCOPE, ORTHOSTATIC HYPOTENSION:
Thought to be vasovagal in
etiology complicated by mild hypovolemia secondary to history of
low PO intake. Hydrochlorothiazide and imdur may have
contributed to episode. Was found to be orthostatic positive
and was given IV fluids. Was without any worrisome findings on
telemetry or EKG, and cardiac biomarkers were negative. Also, a
lethal arrythmia that causes syncope rarely self resolves. She
has no evidence of bradyarrythmia or heart block. Patient feels
subjectively well, and syndrome makes a neurologic cause
unlikely given rapid recovery. Also without any focal
neurologic deficits to demonstrate a stroke. Should syncope
recur, may consider an event monitor as an outpatient.
Encouraged to increase fluid intake as an outpatient.
.
2. Acute Renal Failure, CKD Stage III. Creatinine was found to
be elevated from baseline on admission, but returned to baseline
with gentle IV hydration. All medications were renally dosed.
HCTZ and imdur were held, but will consider reinitiation as an
outpatient should creatinine and blood pressures remain stable.
.
## 3. CAD NATIVE VESSEL:
Was continued on outpatient metoprolol,
statin, ASA.
.
## 4. ATRIAL FIBRILLATION:
ECG in sinus rhythm and telemetry
without arrythmias.
.
5. Type 2 Diabetes Controlled with Complications: Was stable
during hospital admission. Controlled on diet. No concern for
hypoglycemia.
## 6. BENIGN HYPERTENSION:
Was continued on metoprolol and BP was
labile. Held imdur and hydrochlorothiazide, as these
medications may be responsible for orthostatic hypotension.
.
## 7. MILD DEMENTIA:
Patient lives with daughter and is dependent
on ADL's.
.
8. legally blind due to glaucoma: Stable, was placed on fall
precautions.
## MEDICATIONS ON ADMISSION:
- HCTZ 12.5mg PO daily
- Imdur 120mg PO daily
- Metoprolol 12.5mg PO BID
- NTG SL 0.4mg PRN
- Omeprazole 40mg PO daily
- Simvastatin 10mg PO QHS
- Trazodone 25mg PO QHS
- Aspirin 81mg PO daily
- Cyanocobalamin 1000mcg PO daily
- Ferrous sulfate 325mg PO BID
- ? Colace
## DISCHARGE MEDICATIONS:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
## DISCHARGE DIAGNOSIS:
Syncope
Acute on chronic renal failure
Coronary artery disease
Hypertension
Diabetes mellitus type 2
Anxiety
Glaucoma
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane)
## DISCHARGE INSTRUCTIONS:
It was a pleasure taking care of you at
. You were admitted to the hospital after losing
consciousness. It appears that you have not been consuming
enough fluids by mouth and your blood pressure may have been
low. You were also on several medications that may have lowered
your blood pressure even further. You did not have any
worrisome changes on EKG and your heart rhythm was monitored on
a machine without any events. Your blood work demonstrated that
you did not have a heart attack. You were given IV fluids and
your blood pressures were monitored. Your hydrochlorothiazide
and imdur have been held. You are medically cleared to return
home.
.
We have made the following CHANGES to your medications:
- HOLD hydrochlorothiazide
- HOLD imdur
.
Please continue all other medications as previously directed
prior to your hospitalization.
.
Please seek medical attention if you have any chest pain,
shortness of breath, loss of consciousness, palpitations.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11224076", "visit_id": "28965155", "time": "2200-02-21 00:00:00"} |
14270780-RR-57 | 146 | ## EXAMINATION:
CHEST (PA AND LAT)
## INDICATION:
year old woman cirrhosis with dyspnea // acute
intrathoracic process?
## FINDINGS:
The previously seen left pigtail catheter is no longer visualized. There has
been interval accumulation of a small to moderate size left pleural effusion
with some degree of underlying collapse and/or consolidation, though there is
relative translucency of the left lung base itself. Air bronchograms are seen
in the retrocardiac region. There is upper zone redistribution, without overt
CHF. The cardiomediastinal silhouette is probably unchanged. Minimal
atelectasis at the right base, but, in the right lung, no focal infiltrate,
consolidation, or effusion. No pneumothorax detected.
## IMPRESSION:
Left lung base pigtail catheter no longer visualized. Interval development of
small to moderate left effusion with underlying collapse and/or consolidation.
If clinically desired, a left-side-down decubitus view a help to better
quantify the amount of pleural fluid.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14270780", "visit_id": "22592328", "time": "2117-09-29 14:38:00"} |
16108683-RR-36 | 174 | ## INDICATION:
Burkitt's lymphoma. Re-intubated for respiratory distress.
Assess endotracheal tube placement.
## FINDINGS:
The tip of the endotracheal tube appears to be approximately 5.5 cm proximal
to the carina and could be advanced somewhat. There is a nasogastric tube in
situ. The tip of the nasogastric tube is, however, projected over the right
lower lobe.
There has been interval increase in opacity in the right lower lobe compatible
with consolidation. There is a small pleural effusion.
The left lung demonstrates no significant change from prior study. There is
some atelectasis at the left lower lobe.
There is a right internal jugular central venous catheter in situ. The tip of
this is projected over the superior aspect of the right atrium.
## IMPRESSION:
1. Endotracheal tube position is slightly proximal.
2. Nasogastric tube is malpositioned, the tip of which is projected over the
right lower lobe. I note that a subsequent radiograph was performed and that
the nasogastric tube has been pulled back and repositioned (see radiograph
performed at 05:06 on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16108683", "visit_id": "21607477", "time": "2120-11-22 02:21:00"} |
14042274-RR-31 | 274 | ## EXAMINATION:
MRI of the Abdomen
## INDICATION:
year old man with IPMN. Assess for stability of size//
year old man with IPMN. Assess for stability of size
## LOWER THORAX:
The lower thorax is unremarkable. There is no pericardial or
pleural effusion.
## LIVER:
The liver is normal in size. No focal hepatic lesions are seen.
## BILIARY:
There is cholelithiasis without evidence of acute cholecystitis.
There is no intrahepatic or extrahepatic biliary ductal dilatation.
## PANCREAS:
The pancreas is normal in signal intensity without pancreatic ductal
dilatation or peripancreatic fluid. Mild diffuse fatty atrophy is noted.
There are several stable subcentimeter T2 hyperintense foci within the
pancreatic parenchyma, with the largest measuring 7 mm in the uncinate, most
likely representing side-branch IPMNs.
## SPLEEN:
The spleen is normal in size and signal intensity without focal lesion
seen.
## ADRENAL GLANDS:
The adrenal glands are normal in shape and size.
## KIDNEYS:
The kidneys demonstrate normal corticomedullary differentiation and
are symmetric and normal in size without hydronephrosis.T2 hyperintense
subcentimeter focus in the inferior pole of the right kidney is compatible
with a cyst, unchanged. No suspicious renal lesions are seen.
## GASTROINTESTINAL TRACT:
The visualized large and small bowel demonstrate
normal thickness and caliber.
## LYMPH NODES:
There is no lymphadenopathy.
## VASCULATURE:
The abdominal aorta is normal in size.
## OSSEOUS AND SOFT TISSUE STRUCTURES:
No suspicious osseous lesions are seen.
The body wall is within normal limits.
## IMPRESSION:
1. Stable appearance of several subcentimeter T2 hyperintense foci within the
pancreatic parenchyma, with the largest measuring 7 mm in the uncinate
process, most likely representing side-branch IPMNs. Follow-up in years
is recommended.
2. Cholelithiasis without evidence of acute cholecystitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14042274", "visit_id": "N/A", "time": "2191-05-22 06:59:00"} |
14839583-DS-8 | 1,561 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
LHC after positive nuclear stress
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
1. Coronary artery bypass graft x 4, Total arterial
revascularization.
2. Skeletonized left internal mammary artery sequential
grafting to diagonal and the left anterior descending artery.
3. Skeletonized right internal mammary artery to obtuse
marginal artery.
4. Left radial artery grafting to posterior descending
artery.
5. Endoscopic harvesting of the left radial artery.
## HISTORY OF PRESENT ILLNESS:
This is a y.o. with history of CAD
s/p RCA Velocity stenting in , family history of premature
CAD ,
HTN, HLD, diabetes, atrial flutter on Xarelto, who presents for
LHC. The patient is followed by Dr. as an outpatient. Due
to multiple risk factors and a strong family history, he has had
several screening stress tests as an outpatient. He denies any
history of CP, SOB, DOE, PND or orthopnea. He had a positive
stress in that resulted in a LHC and RCA stent. Since that
time has been feeling well and has no new symptoms. He underwent
a stress test in the of which was mildly abnormal.
He
was referred for a surveillance nuclear stress which
demonstrated epression in V4-V6. Gated SPECT
demonstrates Inferoposterolateral and inferoapical ischemia. He
was then
referred for coronary angiogram which shows 3VD. Surgery was
recommended to reduce pts risk of future MI or death.
Of note, the patient has a history of atrial flutter and had a
successful DCCV in . He notes no further episodes of AF
and has remained on Xarelto.
## PAST MEDICAL HISTORY:
Hypertension, hyperlipidemia,CAD s/p RCA
Hepacoat Velocity 3.5 x 13 mm , Aflutter - on Xarelto with
LD pre cath , s/p DCCV , type 2 DM
## FAMILY HISTORY:
Father and brother with MI in the . Two uncles had MI
around age . Another uncle had a stroke in his early . No
family history of arrhythmias, cardiomyopathies, or
sudden/unexpected death
## NECK:
Supple [x] Full ROM [x]
## CHEST:
Lungs clear bilaterally [x]
## HEART:
RRR [x] Irregular [] Murmur [x] grade none
## ABDOMEN:
Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
## RIGHT:
none Left: none
.
## LUNGS:
CTA [x] No resp distress []
## EXTREMITIES:
no CCE[x] Pulses doppler [] palpable [x]
## STERNAL:
CDI [x] no erythema or drainage []
Sternum stable [x] Prevena []
## LEG:
Right [] Left[x] CDI [x] no erythema or drainage []
## DOMINANCE:
Right
* Left Main Coronary Artery
The LMCA is normal
* Left Anterior Descending
The LAD has a long segment of calcified stenosis to 70%
involving
a large D1. This was interrogated
with a pressure wire with IFR 0.80 consistent with significant
disease.
* Circumflex
The Circumflex has 70% stenosis involving a bifurcation into 2
OM
branches.
* Right Coronary Artery
The RCA has proximal 60% stenosis. There is a patent stent in
the
mid RCA with a hazy 80% eccentric stenosis just distal to the
stent.
The Right PDA is normal
## OTHER DIAGNOSTICS:
none
.
TEE intra-op
Conclusions
## PRE-BYPASS:
The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-50 %). The right ventricular free wall thickness is
normal. 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
simple atheroma in the aortic root. There are simple atheroma in
the ascending aorta. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.
## BRIEF HOSPITAL COURSE:
Pt was admitted and was taken to the operating room on
and underwent CABG X4. Please see operative note for
full details. Pt tolerated the procedure well and was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
Pt was weaned from sedation, awoke neurologically intact, and
was extubated on POD 1. Pt was weaned from inotropic and
vasopressor support. Beta blocker was initiated and pt was
diuresed toward his preoperative weight. Pt remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. Xarelto resumed for h/o AFib.
Lisinopril resumed- developed hypotension w - Lisinopril
d/c'd. Oral Diabetes meds resumed. Pt was evaluated by the
physical therapy service for assistance with their strength and
mobility. By the time of discharge on POD 5 pt was ambulating
freely, all wounds were healing, and pain was controlled with
oral analgesics. Pt was discharged home with in good
condition with appropriate follow up instructions.
## MEDICATIONS ON ADMISSION:
Medications at home:
DORZOLAMIDE - dorzolamide 2 % eye drops. 1 drop in the left eye
twice a day - (Prescribed by Other Provider)
GLIMEPIRIDE - glimepiride 2 mg tablet. 1 tablet(s) by mouth
daily/AM - (Prescribed by Other Provider)
LATANOPROST - latanoprost 0.005 % eye drops. 1 drop in each eye
daily/HS - (Prescribed by Other Provider)
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth daily
- (Dose adjustment - no new Rx)
METFORMIN - metformin ER 500 mg tablet,extended release 24 hr. 2
tablet(s) by mouth twice a day - (Prescribed by Other Provider)
METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg
tablet,extended release 24 hr. 0.5 (One half) tablet(s) by mouth
twice a day - (Dose adjustment - no new Rx)
NITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet. 1
Tablet(s) sublingually 1 po PRN - (Dose adjustment - no new Rx)
RIVAROXABAN [XARELTO] - Xarelto 20 mg tablet. 1 tablet(s) by
mouth last dose pre cath - (Prescribed by Other
Provider)
SAXAGLIPTIN [ONGLYZA] - Onglyza 5 mg tablet. 1 tablet(s) by
mouth
daily/AM - (Prescribed by Other Provider)
SIMVASTATIN - simvastatin 80 mg tablet. 1 Tablet(s) by mouth 1
po
qd - (Dose adjustment - no new Rx)
Medications - OTC
ASCORBIC ACID (VITAMIN C) [VITAMIN C] - Vitamin C 500 mg tablet.
1 tablet(s) by mouth daily - (Prescribed by Other Provider)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000
unit tablet. 1 tablet(s) by mouth daily - (Prescribed by Other
Provider)
CHROMIUM PICOLINATE - chromium picolinate 200 mcg capsule. 1
Capsule(s) by mouth 1 po qd - (Prescribed by Other Provider)
FISH,BORA,FLAX OILS-OM3,6,9NO1 [OMEGA - Dosage uncertain
-
(daily )
VITAMIN B COMPLEX [VITAMINS B COMPLEX] - Vitamins B Complex
tablet. 1 Tablet(s) by mouth 1 po qd - (OTC)
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
## REFILLS:
*1
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Doc-Q-Lace] 100 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule
## REFILLS:
*0
4. Furosemide 40 mg PO DAILY
## DURATION:
7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*1
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
## DURATION:
6 Months
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*5
6. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
7. Potassium Chloride 40 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*1
8. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*1
9. Ascorbic Acid mg PO DAILY
10. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID
11. glimepiride 2 mg oral DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
14. Onglyza (sAXagliptin) 5 mg oral DAILY
15. Rivaroxaban 20 mg PO DAILY
16. Simvastatin 80 mg PO QPM
17. Vitamin B Complex 1 CAP PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
## DISCHARGE DIAGNOSIS:
CAD
Hypertension
hyperlipidemia
Aflutter - on Xarelto
type 2 DM
## DISCHARGE CONDITION:
Alert and oriented x3 non-focal
Ambulating with steady gait
Incisional pain managed with Tylenol
## INCISIONS:
Sternal - healing well, no erythema or drainage
No Edema
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the
chart.
****call MD if weight goes up more than 3 lbs in 24 hours or 5
lbs over 5 days****.
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns . Answering service will contact on call
person during off hours**
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14839583", "visit_id": "24416174", "time": "2119-07-16 00:00:00"} |
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