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11205949-RR-25 | 167 | ## EXAMINATION:
RIB UNILAT, W/ AP CHEST LEFT
## INDICATION:
year old woman with left sided focal rib pain, worse under the
left breast and over left lateral sternum// evaluate for rib injury
## CHEST:
Extreme right costophrenic angle excluded from the film. There is an
electronic device overlying the upper left chest, obscuring a small portion of
the underlying rib and lung. Allowing for this, the cardiomediastinal
silhouette is within normal limits. No CHF, focal infiltrate, pleural
effusion, or pneumothorax is detected.
## LEFT RIBS:
As noted above, a small portion of the ribs in the upper chest are
obscured by the electronic device. A marker was placed and overlies the lower
left ribs, in particular, the left tenth rib posterolaterally. No lucent or
sclerotic fracture line, displaced fracture fragment, or obvious lytic or
sclerotic lesion is detected involving the visualized left ribs.
## IMPRESSION:
Electronic device noted overlying left upper chest.
No acute pulmonary process identified.
No rib fracture and no obvious lucent or sclerotic rib lesion detected.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11205949", "visit_id": "N/A", "time": "2166-10-01 09:10:00"} |
10860467-RR-56 | 421 | ## EXAMINATION:
CT NECK W/CONTRAST (EG:PAROTIDS)
## INDICATION:
year old woman with neck lymphadenopathy and multinodular
goiter experiencing rapidly progressive voice loss and lymphadenopathy.
## DOSE:
DLP: 423.37 mGy-cm; CTDI: 14.92 mGy
## FINDINGS:
Again noted is a large multinodular goiter extending into the superior
mediastinum conglomerate centrally hypo-attenuating superior mediastinal lymph
node mass measuring approximately 4.5 x 2.8 x 5.6 cm (series 2, image 75 and
series 601 the, image 31; AP, TRV, CC), similar in size from prior exam , exerting rightward mass effect on the trachea as well as
compressing the esophagus. There are multiple adjacent enlarged lymph nodes
which are also essentially unchanged in size. The largest of these include 2.1
x 1.7 cm and 2.8 x 1.9 cm right and left level lymph nodes respectively
adjacent to the thyroid (series 2, image 66). Additional level 5 lymph nodes
are similar in size to prior exam. Paratracheal and subcarinal lymphadenopathy
is also essentially unchanged in appearance from prior exam .
Paramediastinal radiation fibrosis is also essentially unchanged.
There is no cervical lymphadenopathy by size criteria of levels 1, 3 and 5a.
Parotid and submandibular glands are unremarkable.
There is pneumatization of the left vocal cord as well as asymmetric
enlargement of the left laryngeal ventricle and piriform sinus. In addition,
there is asymmetric atrophy of the left posterior cricoarytenoid muscle
(series 2, image 48). Previously described esophageal varices a better
evaluated on prior exams. The cervical vessels are patent although the left
supraclavicular mass does compress the left internal jugular vein (series 2,
image 65).
There is a small right-sided pleural effusion with mild compressive
atelectasis. Paramediastinal radiation fibrosis is also essentially unchanged.
Polypoid mucosal thickening of the left maxillary sinus is noted. The
remainder of the paranasal sinuses are essentially clear. The visualized
orbits are unremarkable. The mastoid air cells and middle ear cavities are
well pneumatized and clear. There are no suspicious blastic or lytic osseous
lesions.
## IMPRESSION:
1. Again noted large multinodular goiter, larger on the left, exerting
rightward mass effect on the trachea and compressing the esophagus.
2. Findings compatible for left vocal cord paralysis is noted, as described.
Potentially, there is compression of the left recurrent laryngeal from the
multinodular goiter.
3. Diffuse mediastinal and level the lymphadenopathy is again noted,
similar in appearance to prior exam.
4. There is no lymphadenopathy by CT size criteria of levels 1, 3 and 5a.
5. Mild interval increase size of right-sided pleural effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10860467", "visit_id": "N/A", "time": "2154-12-10 14:11:00"} |
18857829-RR-22 | 76 | ## INDICATION:
man with new right PICC.
## IMPRESSION:
1. Right-sided PICC ends in the right atrium and should be pulled back
approximately 3 cm. These findings were discussed with , IV
therapy, at 3:40 p.m. on .
2. Bilateral lower lobe consolidations, most consistent with
pneumonia/aspiration, have increased since the chest radiograph,
are likely stable in size when compared to the CT torso of ,
given differences in technique.
3. Small bilateral pleural effusions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18857829", "visit_id": "29879076", "time": "2183-12-02 15:14:00"} |
17990124-RR-76 | 143 | ## EXAMINATION:
SINUSES, COMPLETE MIN 3 VIEWS
## INDICATION:
year old man with ;chronic rhinitis/congestion w persistent
cough ? evidence for persistent sinusitis; s/p course antibx not resovling sx
// chronic rhinitis/congestion w persistent cough ? evidence for persistent
sinusitis; s/p course antibx not resovling sx chronic
rhinitis/congestion w persistent cough ? evidence for persistent sinusitis;
s/p course antibx not resovling sx
## FINDINGS:
No radio-opaque foreign body is detected over the orbits. The frontal,
maxillary, and mastoid sinuses as symmetric aeration without air-fluid levels
or soft tissue densities within them.
## IMPRESSION:
Symmetric aeration of the frontal, maxillary, and mastoid sinuses. CT or MRI
would be more sensitive for the detection of sinus mucosal disease.
## NOTIFICATION:
The findings were discussed with Dr. . by ,
M.D. on the telephone on at 10:38 AM, 5 minutes after discovery of
the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17990124", "visit_id": "N/A", "time": "2149-03-20 10:02:00"} |
18193888-RR-12 | 138 | ## EXAMINATION:
DX HAND AND WRIST
## INDICATION:
man with pain after a fall.
## FINDINGS:
There is no acute fracture or dislocation involving the left hand or wrist.
There are severe degenerative changes involving the first interphalangeal
joint as well as the fourth digit DIP. More mild degenerative changes affect
the second DIP and first CMC joint. There are no bony erosions. Subjective
osseous mineralization is normal. There is no worrisome focal lytic or
sclerotic osseous lesion. Vascular calcifications are noted in the volar left
wrist. Otherwise, there is no worrisome soft tissue calcification or
unexpected radiopaque foreign body.
## IMPRESSION:
1. No acute fracture or dislocation in the left hand or wrist.
2. Severe osteoarthritis affecting the first interphalangeal joint as well as
the fourth DIP joint, with more mild degeneration in the second DIP and first
CMC.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18193888", "visit_id": "23806957", "time": "2151-08-20 17:31:00"} |
19243807-RR-83 | 142 | ## INDICATION:
year old man with brain lesion, evaluate for primary
malignancy.
## DOSE:
Total DLP (Body) = 1,108 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS WITH CONTRAST)
## FINDINGS:
The thyroid gland is unremarkable. There is no supraclavicular, axillary,
mediastinal, or hilar lymphadenopathy. The heart is normal in size.
Atherosclerotic calcifications are seen at the coronary arteries. The caliber
of the aorta as well as the pulmonary arteries are normal. There is no
pericardial effusion.
The airways are patent to the subsegmental level. There is atelectasis at the
left lung base. Scattered calcified granulomas are identified. No suspicious
focal lesion is seen. There is no focal consolidation, pleural effusion, or
pneumothorax.
No suspicious lytic or sclerotic osseous lesion is seen. Subdiaphragmatic
findings are reported separately.
## IMPRESSION:
No evidence of malignancy within of the chest.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19243807", "visit_id": "21552634", "time": "2133-07-17 11:42:00"} |
15107377-DS-7 | 1,133 | ## ALLERGIES:
Sulfa (Sulfonamide Antibiotics) / steriods / Rocephin
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
s/p AVR(21mm tissue)
s/p permanent pacermaker placement
## HISTORY OF PRESENT ILLNESS:
recently found to have heart murmur on exam in .
Echo revealed severe aortic stenosis. She subsequently
developed chest discomfort with exertion. She previously walked
6x a week and now is unable to do so because of the chest pain.
Cardiac cath at did not reveal any
significant CAD. She is transferred for evaluation of AVR.
Additional workup done includes CXR and CT scan for RUL
pulmonary nodule, with recommendations to repeat CT chest in 6
months.
She denies shortness of breath, chest pain. No history of
syncope.
## PAST MEDICAL HISTORY:
Aortic Stenosis
Hypothyroidism
Lyme disease- reports diagnosed in ; has left arm weakness;
history of "brain lesions" seen on CT scan in ; has been
intermittently on antibiotics for years
Psoriasis
## PAST SURGICAL HISTORY:
Open cholecystectomy
Lap Tubal Ligation
L neck Lymph Node resection
## FAMILY HISTORY:
Father - lung cancer
## NECK:
Supple [X] Full ROM [X]
## CHEST:
Lungs clear bilaterally [X]
## HEART:
RRR [X] Irregular [] Murmur [X] grade 5/6 SEM
## RIGHT ATRIUM/INTERATRIAL SEPTUM:
Normal RA size. No ASD or PFO
by 2D, color Doppler or saline contrast with maneuvers.
## LEFT VENTRICLE:
Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
## RIGHT VENTRICLE:
Normal RV chamber size and free wall motion.
## AORTA:
Mildly dilated ascending aorta. Focal calcifications in
ascending aorta. Normal descending aorta diameter. Focal
calcifications in descending aorta.
## AORTIC VALVE:
Severely thickened/deformed aortic valve leaflets.
Severe AS (area <1.0cm2). Trace AR.
## MITRAL VALVE:
Mildly thickened mitral valve leaflets. Mild (1+)
MR.
## COMMENTS:
Informed consent was obtained. The patient was
under anesthesia throughout the procedure. The TEE probe
was passed with assistance from the anesthesioology staff using
a laryngoscope. No TEE related complications.
## REGIONAL LEFT VENTRICULAR WALL MOTION:
Basal InferoseptalBasal AnteroseptalBasal Anterior
Basal InferiorBasal InferolateralBasal Anterolateral Mid
InferoseptalMid AnteroseptalMid Anterior
Mid InferiorMid InferolateralMid Anterolateral Septal
ApexAnterior Apex
Inferior ApexLateral Apex Apex
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
## CONCLUSIONS
PRE BYPASS:
The left atrium is normal in size. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.58 cm2 using VTI). Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
## POST BYPASS:
1. On PE, AV pacing
## 2. AV:
no perivalvular leak appreciated, tissue leaflets seen
opening on AoSAX, peak and mean gradients .
3. Global RV/LV systolic function unchanged.
4. Remainder of pre bypass exam unchanged.
5. Results diuscused with surgical team.
## BRIEF HOSPITAL COURSE:
The patient was brought to the Operating Room on
where the patient underwent tissue AVR with 21 mm
Valve via median sternotomy. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. The patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Her post operative
course was complicated by complete heart block and the EP
service was consulted. The decision was made to place a dual
chamber pacer and this was placed on (see details
below). Beta blocker was initiated after permanent pacemaker
placement and the.Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 6 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. of note, her surgery was postponed due a rash under
her breasts and she was seen by Infectious disease, who felt
that this was her psoriasis. Dermatology was then consulted and
they felt the rash was consistent with inverse psoriasis, with
very low concern for infectious etiology. They recommended
calcipotriene cream BID to plaques and she was restarted on her
dicloxacillin and fluconazole.
## CHB FOLLOWING AVR
DEVICE BRAND/NAME:
/ :
A lead date: MDT / /
RV lead date: MDT / /
## MEDICATIONS ON ADMISSION:
acidophilus daily
armour thyroid 60mg daily
cholecalciferol 800 units daily
fish oil 1200mg daily
levothyroxine 50mcg daily
magnesium oxide 500mg daily
melatonin 10mg hs
omeprazole 20mg hs
quetiapine 100mg daily
Vit B12 500mcg daily
Aspirin 81
*dicloxacillin 500mg bid
*fluconazole 100mg daily
*stopped on admission to - no clear indication
## DISCHARGE MEDICATIONS:
1. Acetaminophen mg PO Q6H:PRN Pain - Mild
2. Clindamycin 300 mg PO Q6H
## DURATION:
1 Day
3. DiCLOXacillin 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Fluconazole 100 mg PO Q24H
6. Furosemide 20 mg PO DAILY Duration: 5 Days
7. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN Pain - Moderate
## DURATION:
3 Days
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q3h PRN
Disp #*20 Tablet Refills:*0
8. Metoprolol Tartrate 12.5 mg PO BID
9. Senna 17.2 mg PO BID:PRN constipation
10. Aspirin EC 81 mg PO DAILY
11. Atorvastatin 10 mg PO QPM
12. Calcipotriene 0.005% Cream 1 Appl TP BID
13. Cyanocobalamin 500 mcg PO DAILY
14. Levothyroxine Sodium 50 mcg PO DAILY
15. QUEtiapine Fumarate 100 mg PO QHS
16. Thyroid 60 mg PO DAILY
17. Vitamin D 800 UNIT PO DAILY
## FACILITY:
Diagnosis:
Aortic Stenosis
Hypothyroidism
Lyme disease- reports diagnosed in 1990s; has left arm weakness;
history of "brain lesions" seen on CT scan in 1990s; has been
intermittently on antibiotics for years
Psoriasis
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
**Please call cardiac surgery office with any questions or
concerns . Answering service will contact on call
person during off hours**
## FEMALES:
Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15107377", "visit_id": "20790254", "time": "2125-08-25 00:00:00"} |
14071842-RR-126 | 261 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
year old woman with dyspnea, cough.// Evidence of pneumonia?
Interstitial infiltrates?
## FINDINGS:
The examination is compared to . Stable small right thyroid
calcification (2, 4). No supraclavicular, infraclavicular or axillary
lymphadenopathy. Aberrant right subclavian artery as anatomical variant.
Multiple normal to borderline sized lymph nodes are noted in the mediastinum.
The size has not changed since the previous examination. A small right
pleural effusion continues to be present and has slightly decreased in extent
since the previous examination. Mild dilatation of the main pulmonary artery.
Severe coronary calcifications, severe aortic valve calcifications. Mild
cardiomegaly. No pericardial effusion. The posterior mediastinum is
unremarkable. No acute abnormalities in the upper abdomen. Moderate
degenerative vertebral disease. No vertebral compression fractures. The
morphological changes in the lung parenchyma have substantially progressed.
The pre-existing ground-glass opacities are more widespread than on the
previous examination and the edges con fluid to larger consolidated areas,
notably in the middle lobe and at the lung bases. There also are increased
interstitial markings, likely reflecting interstitial fluid accumulation. No
suspicious pulmonary nodules are present. No pleural thickening.
## IMPRESSION:
Substantial progression of the pre-existing ground-glass opacities that are
now diffuse and aggregate 2 consolidated areas at the bases of the middle lobe
and the bilateral lower lobes. The changes likely reflect pneumonia. In
addition, signs of interstitial pulmonary edema are seen. The also have
progressed since the previous examination. No relevant change in extent of a
pre-existing right pleural effusion and in the borderline sized mediastinal
lymph nodes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14071842", "visit_id": "26460351", "time": "2193-05-28 09:56:00"} |
14052090-RR-34 | 259 | ## EXAMINATION:
MR CERVICAL SPINE W/O CONTRAST
## INDICATION:
year old woman with history of Bells palsy and cervicalgia,
now with posterior headache and right face spasms.
## FINDINGS:
The vertebral body heights within the cervical spine are maintained. The bone
marrow signal of the cervical spine appears normal.
The cervical spine is normal in signal. There is no cerebellar tonsillar
ectopia.
The paraspinal and prevertebral soft tissues appear unremarkable.
At the C2-C3 level, the spinal canal and neural foramina appear normal.
At the C3-C4 level, the spinal canal and neural foramina appear normal.
At the C4-C5 level, there is a broad-based posterior disc protrusion causing
mild spinal canal narrowing. The neural foramina appear normal.
At the C5-C6 level, the spinal canal and neural foramina appear normal.
At the C6-C7 level, there is a posterior disc extrusion, migrating inferiorly
along the posterior aspect of the C6 vertebral body, which causes moderate
spinal canal narrowing with contact of the ventral surface of the spinal cord.
There is no clear spinal cord signal abnormality or edema.
At the C7-T1 level, the spinal canal and neural foramina appear normal.
Within the limits of this noncontrast study there is no evidence of infection
or neoplasm. There is no prevertebral soft tissue swelling.. The visualized
portion of the posterior fossa, cervicomedullary junction, paranasal sinuses
and lung apicesare preserved.
## IMPRESSION:
1. C6-C7 disc extrusion which contacts the ventral surface of the spinal cord,
with no definite cord signal abnormality.
2. Additional minimal multilevel spondylosis as described above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14052090", "visit_id": "N/A", "time": "2173-03-30 19:32:00"} |
18900753-DS-5 | 958 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
man with active alcohol use, otherwise no known medical
history who presented to with progressive weakness,
found to have hyperbilirubinemia, leukocytosis, and hypotension
transferred for ongoing management of suspected alcoholic
hepatitis.
Patient reports that he has been progressively weaker for the
last few weeks, to the point where he is unable to get out of
bed. He is a long-time alcohol drinker, approximately beers
a day. No history of withdrawal or prior hospitalizations for
alcohol. Denies chest pain, abdominal pain, nausea, vomiting,
diarrhea. No headaches. No fevers or chills. He does endorse
some shortness of breath over the last few weeks.
At , he was given ceftriaxone for possible UTI, was
found to have markedly elevated bilirubin and LFTs. RUQUS showed
no evidence of biliary dilation, mass, but did show fatty liver
disease. He was transferred here for further evaluation and
management of his acute illness by hospital that has hepatology
service. Upon arrival to our ED, he was hypotensive in the
over .
## GENERAL:
alert, confused, cachetic, jaundiced
## HEENT:
Sclera icteric, MM dry
## LUNGS:
Clear to auscultation in anterior fields, patient
declined further examination
## CV:
tachycardic, distant heart sounds, no mrg
## ABD:
firm, distended, no apparent fluid wave, +BS
## EXT:
jaundiced, warm, no peripheral edema
## NEURO:
AOx1.5 (self, hospital in , face symmetric,
moving all limbs, unable to participate further to eval for
asterixis etc
## DISCHARGE PHYSICAL EXAM:
Patient passed away on .
## CXR :
small bilateral pleural effusions. Hazy opacity of
the right lung base could relate to a right-sided pleural
effusion, but consolidation due to pneumonia or aspiration is
not excluded.
## CT ABD/PEL :
1. In the absence of signs of advanced cirrhosis, hepatic
steatosis with
moderate volume ascites is suggestive of acute hepatitis,
presumably alcohol related.
2. Bilateral nonhemorrhagic pleural effusions, small to moderate
on the right and small on the left, with mild subjacent
atelectasis. No focal findings of pneumonia.
3. Mild compression deformity of the L2 vertebra vertebral body
is of
indeterminate age but appears chronic. Comparison with prior
studies is
recommended to ensure stability.
## BRIEF HOSPITAL COURSE:
This is a year old man with a PMH of ETOH use disorder who
presents with weakness, found to have cholestatic and
hepatotoxic pattern of liver injury consistent with alcoholic
hepatitis. INR 1. .3.
#Leukocytosis
#Shock
#HCAP
On admission, he was briefly on NE overnight for BP with
wbc 22 on
admission. He was started on broad spectrum abx
(Vanc/ctz/flagyl) and transitioned to CTX/flagyl day of
admission. CTAP w/o contrast negative, no tappable pocket on US,
UA was not indicative of UTI. While on the floor, he maintained
low SBPs and HR 100s, he triggered multiple times due to
hypotension, tachypnea, tachycardia and low urine output. On
trigger, CXR found hydrothorax and possible left ligula
PNA. Chest tube place on drew off 0.8L of transudate and
tube was removed on . Vanc was added back and CTX was
broadened to cefepime as patient was clinically unstable - at
times he was responsive to questions and other times not.
Vancomycin was then held again following a trough of 39 and new
onset . He required multiple rescusitations with 25% albumin
during this period as well. Ultrasound ruled out biliary
infection on . Per discussion with wife on , he was made
DNR/DNI but CMO not started then as hopeful for response to
antibiotics. Overnight on , he was transferred to the ICU.
After a discussion with his wife, , he was made CMO on
and passed away on .
# Alcoholic hepatitis
Abdominal pain, emesis, leukocytosis, AST > ALT,
hyperbilirubinemia concerning for acute alcohol hepatitis. Serum
tox negative. RUQUS with evidence fatty liver infiltration. He
was started on lactulose and broad spectrum Abx. EGD ( )
found 3 cords of grade I varices in distal esophagus with no
active bleeding. TTE were attempted but had limited views which
made interpretation difficult. Diagnostic paracentesis was
completed on and all of which were not
concerning for SBP. On , he started having large volume
stools at which point lactulose was titrated to 1L stool output.
On this date, he began declining overall. It was thought that he
had an infection which he was struggling to fight iso the
alcoholic hepatitis.
# Alcohol Use Disorder
Per wife, he had been drinking particularly heavy over the past
few years (lost job, home foreclosure and lost dog). Over
and , he became too weak to get ambulate far from bed and
chair. At the end of , he was dependent on his wife to get
him his alcohol. She started to wean him down, during the
weeks prior to admission, he was vomiting in the morning but did
not have any seizures. His last drink was approximately , 5
days prior to admission.
Increase in Cr 1.1->1.8 ( ) which then continued to trend up
to 2.4 by time of ICU transfer. Likely due to vanc injury
(trough of 39 on which was then held) iso of hypovolemia.
Hypovolemia due to large stool output (C. dif negative) and poor
PO fluid intake despite dobhoff in place. ATN was suspected give
that UOP began declining and did not respond to fluids, as well
as casts and pyuria in UA.
# Troponin elevation and new LBBB
Trop 0.02 in ED, Sgarbossa negative for ACS. Unknown coronary
status and unknown if new, however denied any chest pain. EKG w/
LBBB. TnT peak 0.11, but flat MB. PP low, concerning for
cardiomyopathy. TTE w/ poor windows, but no signs of systolic
dysfunction.
#Severe Malnutrition
Temporal wasting, muscle wasting, and severe cachexia on
admission exam. He was continued on dobhoff tube feeds (pureed
diet with 2 Ensures for each meal) until at which point he
was made NPO due to aspiration concern.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18900753", "visit_id": "25506146", "time": "2178-07-21 00:00:00"} |
14546998-DS-9 | 760 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
with UC and and PSC with stage 2 fibrosis on a liver biopsy
in , with recurrent cholangitis most recently treated with
Levaquin 500 qd - then subsequently with Cipro
500 bid x 14 days ( ), s/p Roux-en-Y
hepaticojejunostomy, cholecystectomy, with extrahepatic biliary
duct excision in for a biliary stricture. He was most
recently seen in Liver Clinic on at which point it was
decided to continue the Cipro on for another 2 weeks,
and he has been scheduled for an MRCP to assess the biliary
anatomy. he reports that he's had continued fevers, chills, and
nausea. he denies abdominal pain, vomiting, jaundice, rash,
hematochezia, melena. He also reports intense pruritus that has
been refractory to cholestyramine, benadryl, and naltrexone.
.
Patient denies any HA, change in vision, dysphagia, odynophagia,
CP, SOB, diarrhea, constipation, hematochezia, melena,
hematuria, change in urinary habits, skin rash, joint pain
## PAST MEDICAL HISTORY:
UC
Roux-en-Y hepaticojejunostomy
CCY
extrahepatic biliary duct excision in
recent R trigger finger release
## GENERAL:
laying in bed, NAD, cast on r hand
## SKIN:
warm and well perfused, excoriations on r shoulder or
lesions, no rashes, well healed scar on abdomen
## HEENT:
AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, supple neck, no LAD, no JVD
## CARDIAC:
RRR, S1/S2, no mrg
## ABDOMEN:
nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
## M/S:
moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
## PULSES:
2+ DP pulses bilaterally
## IMAGING:
=========
MRI ABDOMEN W/O & W/CON Study Date of 7:09 AM
## IMPRESSION:
1. Increasing intrahepatic ductal dilatation as noted above.
Intrahepatic biliary ductal enhancement is again identified.
Recommend close interval followup in four to six weeks including
delayed post-gadolinium images as cholangiocarcinoma cannot be
definitively excluded on this imaging examination.
2. Stable appearing hemangioma again identified.
3. Simple-appearing bilateral cysts noted.
.
MRCP (MR ABD Study Date of 7:39
## IMPRESSION:
1. Slightly less dilatation of intrahepatic bile ducts in
patient with known
primary sclerosing cholangitis and choledochojejunostomy.
2. Unchanged 2-cm hemangioma in segment VII.
3. Bilateral renal cysts.
.
colonoscopy
Erythema, granularity and ulceration in the cecum (biopsy)
Polyp in the cecum (biopsy)
Ulcerations, erythema and friability in the transverse colon and
distal rectum compatible with Colitis (biopsy)
## BRIEF HOSPITAL COURSE:
1. Cholangitis - Patient had failed outpatient oral treatment
for his colangitis. Recent MRI with increased ductal dilation
and evidence of new stricture developing. He was treated with 3
days of IV antibiotics and sent home with a course of oral
antibiotics to total 10 days. If he again fails antibiotic
therapy he will likely need dilation of the strictures.
Continued Ursodiol and Naltrexone for pruritus
.
## 2.UC:
Continue Asacol & canasa
.
## MEDICATIONS ON ADMISSION:
Actigall 300 mg 3 tabs twice a day
Asacol 400 mg 12 tabs daily
Canasa 1000 mg rectal suppository daily
levothyroxine 300 micrograms 1 tab daily lisinopril 10 mg daily
TUMS 500 mg p.o. twice daily
vitamin E 800 units p.o.
## DISCHARGE MEDICATIONS:
1. Naltrexone 50 mg Tablet Sig: One (1) Tablet PO qd ().
2. Ursodiol 300 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
twice a day.
8. Vitamin E 800 unit Capsule Sig: One (1) Capsule PO once a
day.
9. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Please draw CBC with differential, BUN, Cr, and LFTs (including
ALT, AST, Alk Phos, Total Bili, LDH). Fax results to Dr.
at .
## DISCHARGE DIAGNOSIS:
Colangitis
Primary Sclerosing Colangitis
Ulcerative Colitis
## DISCHARGE CONDITION:
Stable, tolerating PO well, afebrile, on oral antibiotics
## DISCHARGE INSTRUCTIONS:
You were seen in the hospital for treatment of cholangitis. You
were given IV antibiotics and after doing well were switched to
oral antibiotics. You should complete the entire course of
moxifloxacin.
.
Either return to the emergency room of call the liver clinic if
you have any fevers, chills, abdominal pain, nausea, vomiting or
other symptoms of concern to you.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14546998", "visit_id": "28239352", "time": "2166-01-17 00:00:00"} |
18855412-RR-37 | 877 | ## :
Cardiology Staff: , MD
## GENDER:
Male Radiology Staff: , MD
## STATUS:
Outpatient Nursing Support: , RN
## WEIGHT (LBS):
170 Injection Site: right antecubital vein
## RHYTHM:
Sinus rhythm Creatinine (mg/dl): 1.6
## INDICATION:
Evaluation for cardiac amyloid.
## CMR MEASUREMENTS:
Measurement Normal Range
Left Ventricle
LV End-Diastolic Dimension (mm) 54 <62
LV End-Diastolic Dimension Index (mm/m2) 28 <32
LV End-Systolic Dimension (mm) 43
LV End-Diastolic Volume (ml) *201 <196
LV End-Diastolic Volume Index (ml/m2) *105 <95
LV End-Systolic Volume (ml) 144
LV Stroke Volume (ml) 57
LV Stroke Volume Index (ml/m2) 30
LV Ejection Fraction (%) ***28 >=54
LV Mass (g) 442
LV Mass Index (g/m2) ***230 <80
Basal wall thickness (mm) ***23 <12
Basal infero-lateral wall thickness (mm) ***20 <11
Late Gadolinium Enhancement Positive
Distal anterior late gadolinium enhancement
Distal inferior late gadolinium enhancement
Q-Flow Aortic Net Forward Stroke Volume (ml) 58
Q-Flow Aortic Total Stroke Volume (ml) 59
Q-Flow Aortic Cardiac Output (l/min) 3.7
Q-Flow Aortic Cardiac Index (l/min/m2) 1.9
LV Effective Forward Ejection Fraction (%) ***29 >=54
Right Ventricle
RV End-Diastolic Volume (ml) 125
RV End-Diastolic Volume Index (ml/m2) 65 58-114
RV End-Systolic Volume (ml) 76
RV Stroke Volume (ml) 49
RV Stroke Volume Index (ml/m2) 26
RV Ejection Fraction (%) *39 >=46
Q-Flow Pulmonary Net Forward Stroke Volume (ml) 53
Q-Flow Pulmonary Total Stroke Volume (ml) 54
Qp/Qs 0.91 0.8-1.2
Atria
Left Atrial Dimension (Axial) (mm) 37 <40
Left Atrial Length (4-Chamber) (mm) ***74 <52
Left Atrial Area (4-Chamber) (mm) 30
Right Atrial Dimension (4-Chamber) (mm) *58 <50
Great Vessels
Ascending Aorta Diameter (mm) 38 <39
Ascending Aorta Diameter Index (mm/m2) 20 <20
Transverse Aorta Diameter (mm) 30
Transverse Aorta Diameter Index (mm/m2) 16
Descending Aorta Diameter (mm) **39 <28
Descending Aorta Index (mm/m2) **20 <14
Abdominal Aorta Diameter (mm) 30
Abdominal Aorta Diameter Index (mm/m2) 16
Main Pulmonary Artery Diameter (mm) *34 <29
Main Pulmonary Artery Diameter Index (mm/m2) *18 <15
Valves
Aortic Valve Morphology Bioprosthetic AVR
Aortic Valve Excursion Normal
Aortic Valve Regurgitation (Visual) Present
Aortic Valve Regurgitant Volume (ml) 1
Aortic Valve Regurgitant Fraction (%) 2 <5
Mitral Valve Regurgitation (Visual) None present
Pulmonary Valve Regurgitation (Visual) None present
Tricuspid Valve Regurgitation (Visual) None present
Pericardium
Pericardial Effusion None present
* Mildly abnormal | ** Moderately abnormal | *** Severely abnormal
## STRUCTURE
" T1-WEIGHTED (BLACK BLOOD):
Dual-inversion T1-weighted fast spin echo images
were acquired in 5-mm contiguous axial slices to evaluate cardiac and vascular
anatomy.
## FUNCTION
" CINE SSFP:
Breath-hold cine images were acquired in 8-mm slices in the
4-chamber, 3-chamber, 2-chamber, and short axis orientations.
" Cine SSFP (Additional Aortic Valve Views): A short-axis series was acquired
at the level of the aortic valve.
" Tagged Cine: Breath-hold tagged cine images were acquired to evaluate
myocardial function and/or sliding motion of the pericardium.
## FLOW
" AORTIC VALVE FLOW:
Phase-contrast cine images were acquired transverse to
the proximal ascending aorta to quantify through-plane flow.
" Pulmonary Valve Flow: Phase-contrast cine images were acquired transverse
to the main pulmonary artery to quantify through-plane flow.
##
VIABILITY
" LGE (3D):
Late gadolinium enhancement (LGE) images were acquired using a
navigator-gated 3D ultrafast gradient echo inversion-recovery sequence with
spectral fat saturation pre-pulses 15 minutes after injection of a total of
0.1 mmol/kg (15 mL) Gd-BOPTA (Multihance).
" EGE: Early gadolinium enhancement (EGE) images were acquired using an
ultrafast gradient echo inversion-recovery sequence with spectral fat
saturation pre-pulses 5 minutes after injection of a total of 0.1 mmol/kg (15
mL) Gd-BOPTA (Multihance).
## LEFT VENTRICLE
" LV CAVITY SIZE:
Mildly increased
" LV ejection fraction: Severely depressed
" LV mass: Severely increased
" Basal wall thickness: Severely increased
" Basal infero-lateral wall thickness: Severely increased
" Late gadolinium enhancement: Positive
" Distal anterior late gadolinium enhancement:
" Distal inferior late gadolinium enhancement:
## RIGHT VENTRICLE
" RV CAVITY SIZE:
Normal
" RV ejection fraction: Mildly depressed
" Intra-cardiac shunt: None present
## ATRIA
" LA SIZE:
Severely enlarged
" RA size: Mildly enlarged
## GREAT VESSELS
" ASCENDING AORTIC DIAMETER:
Normal
" Descending aortic diameter: Moderately dilated
" Main pulmonary artery diameter: Mildly dilated
## VALVES
" AORTIC VALVE MORPHOLOGY:
Bioprosthetic AVR
" Aortic regurgitation jet: Present
" Mitral regurgitation jet: None present
" Pulmonary regurgitation jet: None present
" Tricuspid regurgitation jet: None present
## ADDITIONAL INFORMATION/FINDINGS:
None.
## NON-CARDIAC FINDINGS:
Multiple simple left renal cysts are small. Bilateral airspace disease likely
reflects a combination of pulmonary edema and atelectasis.
## IMPRESSION:
Severe left atrial and mild right atrial enlargement. Severely increased
symmetric left ventricular wall thickness with severely increased mass. Mild
left ventricular cavity dilation with severe global systolic impairment.
Subendocardial and midwall early and late gadolinium enhancement most
prominently in the anterior, lateral, and inferior walls. Normal right
ventricular cavity size with mild RV free wall hypokinesis. Moderately
dilated descending aorta. Normal ascending aorta and aortic arch diameters.
Mildly dilated main pulmonary artery. Mild aortic regurgitation. No
pericardial effusion.
## IMPRESSION:
Severely left ventricular hypertrophy with severe global left
ventricular systolic impairment. Subendocardial and midwall early and late
gadolinium enhancement throughout anterior, lateral, and inferior walls.
Findings are most compatible with hypertrophic cardiomyopathy with cardiac
amyloidosis being less likely.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18855412", "visit_id": "N/A", "time": "2119-09-08 08:52:00"} |
14231762-RR-23 | 120 | ## STUDY:
Bilateral lower extremity venous duplex.
## REASON:
Status post ORIF in the right ankle with right calf pain and
swelling. Rule out DVT.
## FINDINGS:
Duplex evaluation was performed of bilateral lower extremity veins.
On the right, there is normal compression of the common femoral, superficial
femoral, and popliteal veins. The posterior tibial veins are noncompressible.
The peroneal veins are compressible. There is no flow seen in the posterior
tibial veins. This is consistent with posterior tibial thrombus.
On the left, there is normal compression and augmentation of the common
femoral, superficial femoral, popliteal, posterior tibial, and peroneal veins.
There is normal phasicity of the common femoral veins bilaterally.
## IMPRESSION:
There is thrombosis of the right posterior tibial veins.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14231762", "visit_id": "N/A", "time": "2113-08-27 13:36:00"} |
18785047-DS-15 | 664 | ## ALLERGIES:
Remicade / Sulfa(Sulfonamide Antibiotics)
## CHIEF COMPLAINT:
Right Upper Quadrant Pain
## HISTORY OF PRESENT ILLNESS:
with RUQ pain that started 3 days ago. The pain is
located in her RUQ and radiates around to her back. It is sharp
and intermittent and is brought on by food intake. No fevers or
chills. No nausea or emesis. No jaundice. She was first seen
2
days ago at an Urgent Care Clinic where a RUQ U/S was reportedly
normal. 8 hours later she had recurrent pain and underwent a CT
scan that showed "hepatic flexure diverticulitis". She was
given
Cipro and discharged home. The pain recurred once again and
this
time she was advised to come to for evaluation. A CT scan
here shows a dilated gallbladder with wall thickening and
pericholecystic fluid with a dependent gallstone consistent with
cholecystitis. She states that she has been having similar
attacks over the past few months but not this severe. When
eating she is having normal BMs and passing flatus. Her last BM
was 2 days ago.
## PAST MEDICAL HISTORY:
Crohn's disease, hypothyroidism, adrenal "fatigue"
## PHYSICAL EXAM:
AAOX3 NAD
RRR
CTAB
Soft, RUQ/mid epigastric tenderness, no rebound, guarding or
tenderness
No edema
## IMPRESSION:
Distended gallbladder with severe wall edema;
although
gallbladder wall edema can occur for multiple reasons including
hydration and
third spacing, in the setting of right upper quadrant pain and
elevated WBC
count this is concerning for cholecystitis.
## BRIEF HOSPITAL COURSE:
presented to the ED on with three day history of RUQ
pain, focal tenderness and CT scan evidence of ongoing acute
cholecystitis. she did current systemic signs of sepsis.
Patient was offered cholecystectomy, but refused. She wished to
maintain on antibiotics alone.
Dr. spoke with the patient at length re: the risks and
benefits of surgical intervention, including the specific risks
of delaying definitive treatment: ongoing infection, sepsis,
death. She was told that we would again offer her
cholecystectomy,
especially if her clinical condition should deteriorate. She
claimed to understand that delayed cholecystectomy in this
fashion increases the risks of complications from surgery and
likelihood of open procedure. She was very coherent, well
informed and chose to defer surgery.
She was admitted on for serial abdominal exams and
measurements. She was made NPO and get intravenous antibiotics.
Her leukocytosis seemed to improve over the course of her stay.
Her diet was advanced on . Her pain also improved. On ,
she was advanced to regular diet and discharged home tolerating
it, having bowel movements. Her abdominal pain was improved but
not completely absent. She was discharged home on augmentin for
10 days.
## MEDICATIONS ON ADMISSION:
amour thyroid 45mg daily, isocort, , other herbal
supplements
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
hold for sedation or RR<10
RX *oxycodone 5 mg 1 tablet(s) by mouth every four ( ) hours
Disp #*20 Tablet Refills:*0
4. Thyroid 45 mg PO DAILY
5. Amoxicillin-Clavulanic Acid mg PO Q8H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab(s) by mouth
every 8 hours Disp #*21 Tablet Refills:*0
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab(s) by mouth
every eight (8) hours Disp #*30 Tablet Refills:*0
## DISCHARGE INSTRUCTIONS:
You were admitted for acute cholecystitis. This diagnosis was
made by your clinical picture and CT scan. You were started on
antibiotics and pain control. You were offered an operation and
told that this is the definitive treatment for your condition,
but refused it due to personal reasons. You are tolerating a
regular diet and your pain is improved. You will be discharged
on augmentin for 10 days.
Please call your PCP or go to the emergency department if you
have worsening pain, nausea, vomiting, diarrhea, jaundice,
yellowing of your skin or eyes.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18785047", "visit_id": "28376062", "time": "2137-11-20 00:00:00"} |
13318171-RR-103 | 110 | ## REASON FOR EXAMINATION:
Followup of a patient with HIV after aortic valve
replacement and mitral valve replacement and history of endocarditis.
Portable AP chest radiograph was compared to .
The patient was extubated in the meantime interval with removal of the NG
tube. The pacemaker lead is presumably in the right ventricle, unchanged. The
cardiomediastinal silhouette is stable. There is interval progression of
bilateral perihilar and lower lobe opacities especially in the left perihilar
area in right lower lobe, findings that might represent progression of
pulmonary edema, although worsening of infectious process cannot be excluded.
Bilateral pleural effusions are seen, small but might be underestimated on
this supine radiograph.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13318171", "visit_id": "22065711", "time": "2137-01-27 03:31:00"} |
19638958-DS-6 | 1,447 | ## ALLERGIES:
Codeine / Shellfish / Motrin / naproxen / Augmentin / yellow dye
/ morphine / lorazepam
## CHIEF COMPLAINT:
Transfer from hospice s/p fall
## HISTORY OF PRESENT ILLNESS:
Ms. is a year-old woman with PMH significant for widely
metastatic lung adenocarcinomc , chronic pain, IBS,
depression and anxiety started on inpatient hospice who
presents s/p fall at facility.
Regarding patient's relevant oncologic history, she was
diagnosed with stage IV KRAS-mutant adenocarcinoma of the lung
in , already metastatic to brain and adrenals at the time
of diagnosis. Treated thus far with WBXRT through , no
systemic therapy.
Of note, the patient was recently admitted /DFCI admission
. At that time, she was diagnosed with bilateral
PEs for which she was started on therapeutic Lovenox. She also
suffered demand NSTEMI in the setting of prolonged tachycardia.
She was noted to have declining swallowing function, and though
found to have aspiration pneumonitis/pneumonia, antibiotics were
deferred in the setting of overall picture. Overall, patient's
performance status deemed too poor to warrant further treatment
and she was discharged to 's Hospice.
The patient was at 's Hospice for
approximately 12 hours. There, she was found by nursing staff
on her hands and knees and floor screaming that she broke her
back, after which she was sent to ED.
In the ED, initial VS were 98.9 122 115/68 12 92% Nasal Cannula.
Labs
Labs were notable for Chem-7 with HCO3 23 and Cr 0.2 otherwise
wnl, CBC with WBC 12.7 and H/H 7.9/26.7, Trop 0.02 with 7hr
recheck of <0.01, lactate 1.0, coags with PTT 52.0 and INR 2.9.
UA neg, UCx/BCx x2 pending. CT Head w/o con negative for acute
process but showed stable brain metastases. CT CTL Spine without
acute fracture. CT Torso "metastatic lung cancer causing severe
narrowing of the right mainstem bronchus extending into the
lobar bronchi with postobstructive pneumonia" with extensive
metastases in thorax and abdomen (adrenals and kidneys). The
patient was started on Vanc/Cefepime for palliative treatment of
post-obstructive pneumonia. For pain, she was administered IV
dilaudid 1mg x7 over the course of 12 hours, lorazepam IV 2mg
then 1mg, and Zydis 5mg x1. The patient is now admitted to
for further treatment and management. VS prior to transfer 98.4
120 131/70 18 96% Nasal Cannula.
On arrival to the floor, VS 99.5 128/60 128 16 94%4L. The
patient is lethargic, responds to voice, reports pain.
## PAST MEDICAL HISTORY:
PAST ONCOLOGIC HISTORY
Diagnosed with stage IV KRAS-mutant adenocarcinoma of the lung
in , already metastatic to brain and adrenals at the time
of diagnosis. Treated thus far with WBXRT through , no
systemic therapy. During recent /DFCI admission, patient
placed on hospice as performance status too poor to warrant
further treatment.
## PAST MEDICAL HISTORY:
Irritible bowel syndrome
cervical spondylosis s/p spinal fusion
Chronic pain syndrome on narcotics contract
Depression/Anxiety/Hyperthymic disorder
## FAMILY HISTORY:
Mom died lung ca age , dad died glioblastoma age , no other
fam hx cancer of any kind including colon, breast, ovarian
cancer.
Three brothers alive at this time, one with heart problems. One
sister died of suicide at age , and another brother died of
complications from heroine addiction.
## PHYSICAL EXAM:
ADMISSION PHYSICAL EXAM
=======================
## GENERAL:
Lethargic, cachectic woman, lying in bed, appears
uncomfortable
## HEENT:
NC/AT, EOMI, pupils pinpoint but reactive, dry MM
## CARDIAC:
Regular rhythm, tachycardic, normal S1 & S2, without
murmurs, S3 or S4
## LUNG:
Diffusely rhonchorous, decreased breath sounds on R
## ABD:
+BS, soft, NT/ND, no rebound or guarding
## EXT:
Trace/1+ pitting edema bilaterally
## NEURO:
Lethargic, unable to assess to mental status
## SKIN:
Warm and dry, without rashes
*******PATIENT EXPIRED AT 9:47PM********
## PERTINENT RESULTS:
ADMISSION LABS
==============
06:00AM BLOOD WBC-12.7* RBC-3.53* Hgb-7.9*# Hct-26.7*#
MCV-76*# MCH-22.4*# MCHC-29.6* RDW-15.9* RDWSD-43.5 Plt
06:00AM BLOOD Neuts-77.9* Lymphs-8.2* Monos-11.2
Eos-1.7 Baso-0.4 Im AbsNeut-9.91*# AbsLymp-1.05*
AbsMono-1.43* AbsEos-0.22 AbsBaso-0.05
06:00AM BLOOD PTT-52.0*
06:00AM BLOOD Glucose-101* UreaN-12 Creat-0.2* Na-141
K-3.7 Cl-101 HCO3-34* AnGap-10
12:40PM BLOOD cTropnT-<0.01
06:00AM BLOOD cTropnT-0.02*
06:00AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.6
06:11AM BLOOD Lactate-1.0
REPORTS
=======
CT Torse w/ con
1. Interval progression of metastatic lung cancer causing severe
narrowing of the right mainstem bronchus extending into the
lobar bronchi with postobstructive pneumonia. 2. Interval
increase in multiple supraclavicular, mediastinal, and hilar
necrotic lymphadenopathy. 3. Interval replacement of the thyroid
gland by metastatic disease with narrowing of the proximal
trachea. 4. Evaluation of intra-abdominal structures limited due
to motion artifact but no definite retroperitoneal or
intra-abdominal hematoma is identified. 5. Striated nephrogram
to the right kidney concerning for pyelonephritis. 6. Bilateral
adrenal gland metastatic disease. New hypodense lesions within
both kidneys concerning for metastatic disease with the largest
measuring 2 cm in the interpolar region of the left kidney.
NCHCT
1. No acute intracranial abnormality. Specifically, no acute
hemorrhage or fracture. 2. Multiple foci of hypodensity
correspond to edema at related to multiple metastatic lesions,
better evaluated on MR from . No new focus of
hyperdensity identified.
CT C-spine
1. No acute fracture, malalignment, or prevertebral soft tissue
abnormality. 2. Anterior fixation of the C4 through 7 vertebral
bodies, without evidence of hardware malfunction. 3. 5 mm
sclerotic focus of the right T1 lamina, unchanged from prior MRI
of , likely representing a bone island.
CT L-spine
No acute fracture, malalignment, or prevertebral soft tissue
abnormality of the lumbar spine.
CXR
Opacification of the majority of the right hemi thorax,
concerning for pneumonia or aspiration. Other possibilities
include asymmetric pulmonary edema and hemorrhage, but are
considered less likely. Small to moderate right pleural
effusion. Clinical correlation is recommended.
*******PATIENT EXPIRED AT 9:47PM********
## BRIEF HOSPITAL COURSE:
with widely metastatic lung adenocarcinoma NSCLC recently
started on inpatient hospice who presents s/p fall at
facility. She was recently admitted BWH/DFCI admission
. At that time, she was diagnosed with bilateral
PEs for which she was started on therapeutic Lovenox. She also
suffered demand NSTEMI in the setting of prolonged tachycardia.
She was noted to have declining swallowing function, and though
found to have aspiration pneumonitis/pneumonia, antibiotics were
deferred in the setting of overall picture. Overall, patient's
performance status deemed too poor to warrant further treatment
and she was discharged to . The patient was at
Hospice for approximately 12 hours.
There, she was found by nursing staff on her hands and knees and
floor screaming that she broke her back, after which she was
sent to ED. In ED, imaging showed known extensive
metastases as well as post-obstructive pneumonia. There, she was
administered IV dilaudid for pain and given one dose of
palliative antibiotics. The patient was admitted to OMED
service at 7pm. Patient's goals of care and code status
was confirmed with her healthcare proxy
(sister-in-law) . The patient was placed on
palliative regimen as prescribed her discharge
paperwork, which included hydromorphone PCA pump. MD was called
to bedside for apena, and the patient was pronounced at 9:47pm
(see death note). Patient's brother ,
sister-in-law , and primary care physician were notified.
*******PATIENT EXPIRED AT 9:47PM********
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Venelex (balsam oil) 87-788 mg/gram topical
## BID:
PRN dry skin
2. Bisacodyl AILY:PRN constipation
3. Artificial Tears DROP BOTH EYES TID:PRN dry eyes
4. Glycopyrrolate 0.2 mg IV Q6H:PRN increased respiratory
secretions
5. Lorazepam 0.5-1 mg IV Q6H:PRN anxiety
6. HYDROmorphone (Dilaudid) mg IVPCA Lockout Interval:
minutes Basal Rate: 1.2 mg(s)/hour 1-hr Max Limit: 2 mg(s)
## START:
@ 1800
7. OLANZapine (Disintegrating Tablet) 5 mg PO BID
8. OLANZapine 5 mg PO Q6H:PRN nausea
9. Prochlorperazine 5 mg IV Q6H:PRN nausea
10. sodium chloride 0.9 % inhalation Q4H:PRN respiratory
distress
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Nicotine Patch 21 mg TD DAILY
13. Acetaminophen 325 mg PO Q4H:PRN mild pain
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
15. Benzonatate 100 mg PO TID:PRN cough
16. Citalopram 50 mg PO DAILY
17. Enoxaparin Sodium 70 mg SC Q12H
##
, FIRST DOSE:
Next Routine Administration Time
18. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
## START:
, First Dose: Next Routine Administration Time
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19638958", "visit_id": "22808887", "time": "2172-11-20 00:00:00"} |
14005113-RR-21 | 93 | ## INDICATION:
man with neck pain, CT showing atlantoaxial distance
widening, evaluate for ligamentous injury.
## FINDINGS:
There is no evidence of fracture or malalignment. There is no
abnormal signal within the spinal cord. There is no evidence of ligamentous
injury. There is disc space narrowing with endplate sclerosis from C2 to C7.
Specifically, there is mild posterior disc bulge and bilateral neural
foraminal narrowing at C3/4. There is no prevertebral soft tissue
abnormality. There is no evidence of spinal canal narrowing.
## IMPRESSION:
No post traumatic changes. No evidence of ligamentous injury.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14005113", "visit_id": "29241594", "time": "2182-07-10 09:05:00"} |
11128113-DS-8 | 1,284 | ## ALLERGIES:
Penicillins / Sulfa (Sulfonamide Antibiotics)
## HISTORY OF PRESENT ILLNESS:
y/o F with history of disease and CAD, admitted
for diarrhea. The patient reports diarrhea with dark loose
stools for one day. She reports nausea but denies vomiting.
She reports mild abdominal pain in LQ. She denies fevers.
She does not recall any infections circulating at her assited
living, however she was aware of "norovirus" early this year.
She also reports being treated for pneumonia in the last few
months, but does not remember when. Confirmed with pharmacy
that levaquin was given in , no other antibiotics since.
She is still not interested in a CT scan, however, will think
about it. In the meantime, she is willing to entertain a KUB to
rule out obstruction. She was started on cipro/flagyl overnight
for suspected diverticulitis and stool studies were sent,
including c diff.
.
Currently, she reports one episode of diarrhea overnight, and
continues to have mild abdominal pain and distention.
.
## ROS:
Denies fever, chills, cough, shortness of breath, chest
pain, vomiting, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
## PAST MEDICAL HISTORY:
- Disease (dx x yrs, Neurologist is Dr.
- in
-cataracts s/p surgery bilaterally
-melanoma on the L ankle, surgically resected over years ago
## FAMILY HISTORY:
+CVA +CAD Sister with diverticulosis.
## GENERAL:
in NAD, pleasant, appropriate.
## HEENT:
NC/AT, EOMI, sclerae anicteric, MMM, OP clear.
## LUNGS:
CTA bilat, poor effort.
## HEART:
RRR, no MRG, systolic murmur at LUSB.
## ABDOMEN:
Distended with dilated veins on the abdomen, markedly
TTP LQ, + BS, guaiac positive in the ED.
## EXTREMITIES:
WWP, no c/c/e, 2+ peripheral pulses.
## SKIN:
No rashes or lesions.
## GENERAL:
in NAD, pleasant, appropriate with dyskinesias
improving
## HEENT:
NC/AT, EOMI, sclerae anicteric, MMM, OP clear.
## LUNGS:
CTA bilat, no rhonchi or crackles
## HEART:
RRR, no RG, systolic murmur at .
## ABDOMEN:
Distended with dilated veins on the abdomen, softer
than prior, non tender.
## EXTREMITIES:
WWP, no c/c/e, 2+ peripheral pulses.
## SKIN:
No rashes or lesions.
## FECAL CULTURE (FINAL :
NO SALMONELLA OR SHIGELLA
FOUND.
## CAMPYLOBACTER CULTURE (FINAL :
NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final :
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
OVA + PARASITES (Final :
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
KUB Dilated small and large bowel loops compatible with
obstruction; Moderate amount of fecal matter within the
descending and rectosigmoid colon.
.
KUB Two views of the abdomen compared to the prior study
from demonstrate mildly decreased distention of the
colon and small bowel, but still remains quite distended,
consistent with ileus. Large amount of fecal debris within the
rectum and ascending colon, could also represent obstruction.
## BRIEF HOSPITAL COURSE:
y/o F with PMHx of disease and CAD admitted for
diarrhea, found to have obstruction
.
# Bowel obstruction: Initially, the patient was thought to
have an infectious cause of diarrhea given leukocytosis,
tachycardia and low grade temps. She refused CT scan to
evaluate for diverticulitis, so levo/flagyl was used to treat
her empirically which resulted in decreased pain, leukocytosis
and resolution of tachycardia. However, the patient on
admission likely had liquid stool leaking around a bowel
obstruction. She was treated with 2 tap water enemas to attempt
to dislodge hard stool. However, the patient was guaiac
positive on exam and has a history of colon polyps years ago,
so concerning for additional malignant process causing
obstruction. The patient was reluctant to have a CT or
colonscopy to diagnosis this process. She understood the
possibility of a malignant process, but expressed that she would
like to attempt symptomatic treatment first then maybe in the
future entertain diagnostic testing. She reports even if she
was found to ahve a malignancy, she would not be interested in
chemotherapy or surgical treatment. Her symptoms improved with
a bowel regimen, however repeat KUB revealed persistence of the
obstruction. She will continue levo flagyl on discharge in
addition to resuming stool softners and daily lactulose. TSH
wnl. She will discuss with her outpatient NP, ,
further workup of the obstruction.
.
# HTN: The patient's BP was low on admission likely secondary
to infectious process and poor PO intake. The patient was
restarted on carvedilol 25 BID. However lisinopril was held
during the hospitalization with instructions to restart with her
outpatient provider as needed.
.
# : Complicated outpatient regimen, confirmed with
outpatient pharmacist and neurologist. She takes 1 tab of ER
carbidopa/levodopa at 6am, 9am, 12pm, 3pm, 6pm. With additional
carbidopa/levodopa .25 or .5 as needed (.25 additional during
the day, .5 at night as needed). Continued azilect
## MEDICATIONS ON ADMISSION:
Lisinopril 5 mg daily
Azilect 1 mg daily
Carvedilol 25 mg BID
Pravastatin 20 mg weekly
Vitamin D 400 IU daily
Duonebs BID and PRN
Mucinex PRN
Florastor 250 mg capsule
Lactulose 2 tablespoons daily
Clotrimazole for abdominal rash
Carbidopa/Levodopa ER , 1 tab at 6a, 9a, 12, 3p, 6p
Carbidopa/Levodopa tab during the day and tab at
night as needed up to 8 times a day
## DISCHARGE MEDICATIONS:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
2. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day) as needed for for constipation .
4. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 4 days.
Disp:*14 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
## 8. CARBIDOPA-LEVODOPA MG TABLET SIG:
0.25-0.5 Tablet PO 5
X DAY () as needed for Parkinsons symptoms: 6am, 9am, noon,
3pm, 6pm
.
## 9. CARBIDOPA-LEVODOPA MG TABLET SIG:
0.5-1.0 Tablet PO HS
(at bedtime) as needed for Symptoms.
10. AZILECT 1 mg Tablet Sig: One (1) Tablet PO daily ().
11. carbidopa-levodopa mg Tablet Extended Release Sig:
One (1) Tablet Extended Release PO five times a day: 6am, 9am,
12noon, 3pm, 6pm .
12. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
13. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
## NEBULIZATION SIG:
One (1) Neb Inhalation twice a day as needed
for shortness of breath or wheezing.
## DISCHARGE DIAGNOSIS:
Primary diagnosis:
bowel obstruction
.
## DISCHARGE INSTRUCTIONS:
You were admitted to for evaluation of diarrhea. You were
found to have a bowel obstruction. You were treated with stool
softeners, laxatives and enemas. We discussed getting at CT
scan or a colonoscopy and you are not interested in getting
these studies currently. You should discuss this with your
outpatient provider, .
.
## MEDICATION CHANGES:
START Colace 100 mg twice per day
START Senna, 1 tablet twice per day
START Lactulose 15 mg Three times per day
START Bisacodyl suppository every day as needed for severe
constipation.
HOLD Lisinopril until you see your doctor this week. Your blood
pressure was initially low and became normal prior to your
discharge. If it continues to increase, your doctor can help
decide whether this medicine should be restarted.
INCREASE Vitamin D to 1000 units daily
Please confirm your drug regimen with your doctor
when you return to your assisted living. Further management and
dose adjustment should be assessed when you see your doctor this
week.
Continue other home medications as prescribed
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11128113", "visit_id": "28349479", "time": "2161-04-30 00:00:00"} |
14599803-RR-17 | 252 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
year old man with history of PE, s/p EKOS, persistent fevers
// eval for pulmonary infarct, signs of infection or fluid collection
## FINDINGS:
The thyroid is normal. Supraclavicular, axillary, mediastinal and hilar lymph
nodes are not enlarged. Of note increasing number of axillary lymph nodes is
stable as well as increasing number of mediastinal lymph nodes, they are
stable and not meeting CT criteria for pathologic enlargement. Aorta and
pulmonary arteries are normal size. Previously seen extensive pulmonary
embolism cannot be assess in this nonenhanced study. There is trace
pericardial effusion minimally increased from prior. Trace right pleural
effusion is stable. Small left effusion has markedly increased. Cardiac
configuration is normal and there is moderate calcification in all coronary
arteries.
Extensive consolidation in the left lower lobe is worrisome for pneumonia.
New subpleural triangular ground-glass opacities in the upper lobes could
represent infarcts. Other more denser nodular subpleural nodular opacities in
the lower lobes (4:149) are of unclear etiology could be infection or
infarcts. Have increased from prior study.
This examination is not tailored for subdiaphragmatic evaluation there is
fatty infiltration of the liver
There are no bone findings of malignancy
## IMPRESSION:
Extensive consolidation in the left lower lobe is consistent with pneumonia
Multiple ground-glass opacities throughout the lungs in subpleural location
likely represent infarcts
Denser nodular subpleural opacity in the lower lobes could represent infection
or infarcts
Mediastinal lymphadenopathy is reactive
Increased left pleural effusion
Coronary calcification
Fatty liver
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14599803", "visit_id": "25997121", "time": "2122-01-27 12:40:00"} |
15662315-RR-37 | 100 | ## INDICATION:
year old man with cirrhosis, severe malnutrition // Replaced
dislodged Post pyloric feeding tube. Hepatology will come and bridle the tube
after it is placed. Page her at when completed
## FINDINGS:
The preliminary scout film shows no abnormality. A tube was
placed into the stomach via the left nares. The tube was advanced into the
inferior duodenal flexure. Final placement was confirmed by injection of 5 cc
of Optiray contrast. The tube was secured in place with a bridle.
## IMPRESSION:
Appropriate position of a post pyloric feeding tube in theinferior duodenal
flexure. The tube is ready to use.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15662315", "visit_id": "N/A", "time": "2176-11-22 12:44:00"} |
19561278-RR-49 | 126 | ## REASON FOR EXAM:
Superficial PICC-related clot in the left cephalic vein with
palpable clot in the forearm. Clinical concern for deep venous thrombosis.
## FINDINGS:
Left subclavian vein demonstrates normal color and Doppler flow.
The left internal jugular vein demonstrates normal color and Doppler flow and
normal compressibility. The left axillary, brachial veins demonstrate normal
compressibility and color and Doppler flow. Again seen is a thrombosed left
cephalic vein. At the location of palpable nodular structure in the left
forearm, a tubular structure with no flow is demonstrated which may represent
a superficial vein which is thrombosed.
## IMPRESSION:
No evidence of left upper extremity deep venous thrombosis.
Stable thrombosis of the left cephalic vein and likely thrombosis of the
superficial vein in the forearm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19561278", "visit_id": "N/A", "time": "2146-01-10 22:13:00"} |
10278608-RR-19 | 108 | ## INDICATION:
man with trauma to the right fourth and fifth toe.
Rule out fracture.
## EXAMINATION:
Three views of the right foot.
## FINDINGS:
There is an oblique, slightly displaced fracture through the shaft
of the proximal phalanx of the fifth toe, without intra-articular involvement.
There is associated soft tissue swelling of the fifth toe. There are no other
fractures or dislocations. There is no soft tissue calcification or
radiopaque foreign body. Joint spaces are well preserved.
## IMPRESSION:
Oblique fracture through the mid shaft of the proximal phalanx of
the fifth toe.
These findings were discussed with , NP by Dr. at 10
a.m. on , via telephone.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10278608", "visit_id": "N/A", "time": "2136-11-12 09:24:00"} |
15693883-DS-6 | 1,530 | ## HISTORY OF PRESENT ILLNESS:
Ms. is a y/o woman with history of primary biliary
cirrhosis and autoimmune hepatitis (MELD 27), IPMN, and
hyperlipidemia presenting for chest pain.
Patient states she was lying down when she started having chest
pain this morning around 10:30am. The pain was insidious in
onset. It was left sided with radiation to her left arm. Has
been mostly constant throughout the day, described as a pressure
sensation and not improving. She has not tried anything for
pain. No fevers, chills, cough. No N/V. No worsening abdominal
pain from baseline.
In the ED, initial VS were pain of 7, T 97.7, HR 70, BP 101/64,
RR 18, 100% RA.
Exam notable for comfortable appearing with scleral icterus,
jaundiced, telangiectasias. Mild abdominal tenderness diffusely.
Lungs with crackles at bases.
Labs showed Trop-T: <0.01, AST 127, ALT 57, AP 283, Tbili 36.7,
Lipase 141, : 17.4, PTT: 40.1 INR: 1.6, moderate bili in
urine. BUN 37, Creatine 1.2.
Imaging with CXR showed COPD, no new focal consolidation is
seen. EKG with normal sinus rhythm 73 PR hanges normal axis.
Received Oxycodone 5 mg PO ONCE Duration, Aspirin 324 mg PO
ONCE.
Transfer VS were T 97.4, HR 66, BP 108/50, RR 16, 98% RA
Dr. Atrius cards and transplant hepatology were
consulted.
Given worsening bili and hypoxemia to 90% O2 recently in
clinic, decision was made to admit to medicine for
further management and work up of chest pain.
On arrival to the floor, patient confirms the above history. No
difficulty breathing and pain is not worse with inspiration. She
did not have any worsening chest pain with ambulation. Since
receiving oxycodone in the ED, pain is much improved.
## PAST MEDICAL HISTORY:
-PBC with autoimmune hepatitis overlap
-Non-melanoma skin cancer
-Hypercholesterolemia
-Osteoporosis
-Gastric and colonic polyps
-Cervical carcinoma in situ status post cone procedure
## FAMILY HISTORY:
Mother had colon cancer at age and CHF, father drank and had
CHF with kidney problems, and she has one healthy brother.
## GENERAL:
Adult female in NAD
## HEENT:
Scleral icterus, MMM, PERRL.
## CV:
RRR. Normal S1+S2, no murmurs, rubs, gallops.
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## ABDOMEN:
Soft with mild distention, no fluid wave, nontender
## EXT:
WWP with trace edema bilaterally
## NEURO:
CNII-XII intact, moving all ext, neg asterixis
## GENERAL:
very pleasant, Jaundiced and very thin lady in NAD
## HEART:
RRR, S1/S2, no m/r/g
## ABDOMEN:
soft, NT, ND, no palpable ascites
## NEURO:
grossly intact , mild asterixis
## SKIN:
warm and well perfused, jaundiced, no significant rash
## IMPRESSION:
COPD. No new focal consolidation is seen.
RUQ US
## IMPRESSION:
Cirrhotic liver with sequela of portal hypertension including
splenomegaly, patent umbilical vein, and reversal of flow in the
main and right anterior portal veins. There is antegrade flow
in the left portal vein and the right posterior portal vein is
thrombosed. Compared to the prior ultrasound from ,
there is no significant change, aside from the fact that the
posterior right portal vein was not visualized on the prior
study and is seen,
demonstrating no flow on the current study.
## IMPRESSION:
1. Cirrhosis with portal hypertension. No lesion meeting OPTN-5
criteria.
Evaluation is limited due to diffuse and extensive parenchymal
nodularity as
described above.
2. The entirety of the portal venous system opacifies with
contrast, including
the posterior right portal vein, which is attenuated but patent.
3. Multiple cystic lesions in the pancreas are stable in size
from but increased in size from to , compatible
with
side-branch IPMNs. The largest lesion measuring 1.9 cm in the
head of the
pancreas previously measured 1.1 cm in but
compared to , there is new internal hemorrhage/proteinaceous debris,
compatible with
recent fine-needle aspiration on with cytology
compatible with
IPMN. Six-month follow-up is recommended.
## RECOMMENDATION(S):
6 month follow up MRCP recommended for
follow-up of
pancreatic IPMNs
## INTERVAL AND DISCAHRGE LABS:
:35AM BLOOD WBC-8.8 RBC-3.03* Hgb-9.1* Hct-26.1*
MCV-86 MCH-30.0 MCHC-34.9 RDW-21.6* RDWSD-65.1* Plt
07:10AM BLOOD PTT-45.5*
07:35AM BLOOD PTT-44.1*
07:10AM BLOOD Glucose-88 UreaN-38* Creat-1.3* Na-137
K-3.3 Cl-97 HCO3-23 AnGap-20
07:43AM BLOOD Glucose-91 UreaN-31* Creat-1.1 Na-136
K-3.5 Cl-99 HCO3-22 AnGap-19
08:40AM BLOOD Glucose-162* UreaN-26* Creat-0.9 Na-132*
K-4.4 Cl-96 HCO3-18* AnGap-22*
07:35AM BLOOD Glucose-85 UreaN-26* Creat-1.1 Na-134
K-4.4 Cl-98 HCO3-19* AnGap-21*
07:10AM BLOOD ALT-51* AST-110* AlkPhos-228*
TotBili-32.2*
07:43AM BLOOD ALT-56* AST-129* LD(LDH)-308*
AlkPhos-238* TotBili-31.5*
08:40AM BLOOD ALT-55* AST-121* LD(LDH)-292*
AlkPhos-235* TotBili-33.2*
07:35AM BLOOD ALT-54* AST-115* LD( )-315*
AlkPhos-231* TotBili-34.0*
03:00PM BLOOD Lipase-141*
03:30AM BLOOD CK-MB-1 cTropnT-<0.01
07:35AM BLOOD Albumin-3.6 Calcium-10.3 Phos-3.5 Mg-2. with history of primary biliary cirrhosis, autoimmune
hepatitis and hyperlipidemia who presented with chest pain and
. EKG with no ischemic changes, cardiac enzymes negative x2,
and chest pain resolved on day of admission with oxycodone. Did
not return during admission, and no clear cause was identified.
Bilirubin was slightly elevated on admission, prompting RUQUS
that was concerning for posterior right portal vein thrombus.
This was further evaluated with MRCP that showed patent portal
venous vasculature. Had mild on admission that was thought
to be overdiuresis, and renal function improved with holding
diuretics. MELD was 28 on day of discharge.
TRANSITIONAL ISSUES
-consider outpatient stress test as further workup of chest pain
-consider repeat MRI in 3 months to assess portal venous
patency, particularly if patient develops abdominal symptoms or
has worsening liver function tests. Patient is a liver
transplant candidate.
-consider outpatient EGD to assess varices, especially as may
need anticoagulation if develops thrombus in future
-At Hepatoloy appointment on , consider restarting
home diuretics (torsemide, spironolactone) on a schedule of
every other day. Patient has had on multiple recent
admissions
-Nadolol recently dc'd for hypotension. consider restarting
pending outpatient blood pressure and risk/benefit for variceal
bleeding prophylaxis.
-6 month follow up MRCP recommended for follow-up of pancreatic
IPMNs, increased in size from
# CODE: full (presumed)
# CONTACT:
Name of health care proxy:
## :
Husband
Phone number:
Cell phone:
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1500 mg PO BID
2. Citalopram 10 mg PO QHS
3. Desonide 0.05% Cream 1 Appl TP AS DIRECTED
4. Gabapentin 200 mg PO QHS
5. Lactulose 30 mL PO TID
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Spironolactone 50 mg PO DAILY
9. Torsemide 10 mg PO EVERY OTHER DAY
10. Ursodiol 600 mg PO BID
11. Acyclovir Ointment 5% 5 % topical ASDIR
12. Denosumab (Prolia) 60 mg SC 2X/YEAR
. estradiol 0.01 % (0.1 mg/gram) vaginal ASDIR
14. LORazepam 0.5 mg PO DAILY:PRN procedures
15. Vitamin A UNIT PO DAILY
16. Vitamin D UNIT PO 1X/WEEK (WE)
17. Vitamin E 1000 UNIT PO QDAILY
## DISCHARGE MEDICATIONS:
1. Acyclovir Ointment 5% 5 % topical ASDIR
2. Calcium Carbonate 1500 mg PO BID
3. Citalopram 10 mg PO QHS
4. Denosumab (Prolia) 60 mg SC 2X/YEAR
5. Desonide 0.05% Cream 1 Appl TP AS DIRECTED
6. estradiol 0.01 % (0.1 mg/gram) vaginal ASDIR
7. Gabapentin 200 mg PO QHS
8. Lactulose 30 mL PO TID
9. LORazepam 0.5 mg PO DAILY:PRN procedures
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Ursodiol 600 mg PO BID
13. Vitamin A UNIT PO DAILY
14. Vitamin D UNIT PO 1X/WEEK (WE)
15. Vitamin E 1000 UNIT PO QDAILY
16. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until appointment on
17. HELD- Torsemide 10 mg PO EVERY OTHER DAY This medication
was held. Do not restart Torsemide until appointment on
## DISCHARGE INSTRUCTIONS:
Dear ,
were seen at for chest pain.
WHILE WERE IN THE HOSPTIAL
-Based on your EKG and blood tests, it was unlikely that
were having a heart attack. Your chest pain resolved.
-We did an ultrasound of your belly because your bilirubin went
up. We were worried there could be a clot in one of the veins
going to the liver. To further evaluate this, we did an MRI of
your abdomen that did not show any blood clots.
- also had a slight decrease in kidney function, but this
recovered after we stopped your diuretic (water pill)
medications.
WHAT SHOULD DO NOW
-We stopped your torsemide and spironolactone medications.
should ask your doctor about restarting these medications on
.
-Weigh yourself every day. If gain more than 2 pounds in one
day call your doctor.
- call your doctor if your chest pain returns.
We wish the best!
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15693883", "visit_id": "26721351", "time": "2162-04-19 00:00:00"} |
10827205-RR-43 | 103 | ## HISTORY:
Trigeminal neuralgia status post microvascular decompression.
## FINDINGS:
On this limited study with only one sequence obtained, there is a
normal and symmetric appearance of the trigeminal nerves bilaterally.
Post-surgical changes are noted following a left suboccipital craniectomy,
with areas of susceptibility likely reflective of post-surgical changes,
better assessed on the dedicated complete MRI performed on . The
visualized cranial nerves VII and VIII are normal in course and appearance. A
right globe deformity is again noted and unchanged.
## IMPRESSION:
1. Limited study, with a symmetric appearance of the trigeminal nerves
bilaterally.
2. Postoperative changes following a suboccipital left craniectomy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10827205", "visit_id": "24982524", "time": "2187-02-13 14:12:00"} |
14336116-RR-11 | 297 | ## EXAMINATION:
MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
## INDICATION:
year old man with MS // eval for new lesions, activity
eval for new lesions, activity
## CERVICAL:
Cervical alignment is anatomic. Vertebral body and intervertebral disc signal
intensity appear normal.There are multiple nonenhancing T2/STIR hyperintense
lesions of the cord and visualized brain stem, unchanged in configuration from
prior exam of allowing for technical differences. There is no
evidence of spinal canal or neural foraminal narrowing, allowing for mild
degenerative changes. There are scattered bilateral perineural cysts sub cm
in size, unchanged from prior exam. There is no abnormal enhancement after
contrast administration. Visualize prevertebral and paraspinal soft tissues
are unremarkable.
## THORACIC:
Thoracic alignment is anatomic. Vertebral body and intervertebral disc signal
intensity appear normal.Re-identified are scattered nonenhancing T2/STIR
hyperintense lesions of the thoracic spine, most prominent at the T10-T11
level. No definitive new lesions are identified. There is no abnormal
enhancement. There is no evidence of spinal canal or neural foraminal
narrowing. Visualize prevertebral and paraspinal soft tissues are
unremarkable.
## LUMBAR:
Lumbar alignment is anatomic. Vertebral body and intervertebral disc signal
intensity appear normal.T2/STIR nonenhancing hyperintense signal at the level
of the conus and T11-T12 cord are similar in appearance to prior exam of . Node no definitive lesions are identified. There is no
abnormal postcontrast enhancement. There is no evidence of significant spinal
canal or neural foraminal narrowing. Visualize prevertebral and paraspinal
soft tissues are unremarkable.
## IMPRESSION:
1. Essentially unchanged nonenhancing T2/STIR hyperintense cord lesions in a
pattern compatible with history of multiple sclerosis spanning the cervical,
thoracic and lumbar spine from prior examinations, allowing for technical
differences. No new enhancement to suggest active process.
2. There is no significant spinal canal or neural foraminal narrowing.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14336116", "visit_id": "N/A", "time": "2158-10-14 07:16:00"} |
13109002-RR-11 | 303 | ## INDICATION:
woman with rapidly enlarging abdomen over the past
two months.
Comparison was performed with prior CT study from .
## FINDINGS:
The liver demonstrates normal echogenicity throughout. There is a
single echogenic lesion measuring 0.7 cm in segment V of the liver. No
corresponding lesion was seen on the prior CT from . There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder
demonstrates thin wall but sludge within. The pancreas could not be evaluated
due to presence of mass and gas. The right kidney measures 9.4 cm. There is
no evidence of hydronephrosis or stones. The spleen measures 8 cm, and there
is no evidence of focal lesions throughout. The left kidney measures 9.6 cm.
There is no evidence of hydronephrosis or stones.
In the midline of the abdomen, there is a large mass, at least 20 x 20 cm with
echogenic homogenous contents, multiple septa and nodularity along the septa.
Flow can be demonstrated along the septa. The mass is seen spanning from the
liver edge to the uterus. Ovaries could not be identified on the current
study. Transvaginal approach was not attempted.
## IMPRESSION:
1. At least 20 x 20 cm complex cystic mass with septa and nodularity and
abnormal flow. Further evaluation is recommended by MRI. Findings were
discussed with referring physician, on the phone by Dr. at
the time of discovery of the findings on at 3:30 p.m.
2. A single 0.7 cm echogenic lesion in segment V of the liver which could not
be identified on the prior CT study from . This may represent hemangioma
or less likely secondary lesion. Further evaluation can be performed at the
time of the MRI.
3. Sludge in the gallbladder.
Findings 2 and 3 were emailed to Dr by Dr on at 21.29.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13109002", "visit_id": "N/A", "time": "2125-10-05 15:01:00"} |
10742902-DS-11 | 1,710 | ## ALLERGIES:
Peanut / Warfarin / heparin / tramadol
## HISTORY OF PRESENTING ILLNESS:
Mrs. is a pleasant w/ IDDM, HTN, DL, port-associated
DVT c/b HIT, and colorectal adenocarcinoma (met to b/l lungs and
R temporal lobe) unfortunately w/ progression of disease despite
multiple lines of chemo, now presenting with weakness,
uncontrolled diabetes, and concern for new hemorrhagic foci
The history was obtained from the patient and her son. He states
that she was recently doing well at rehab where she was for
several days prior to being discharged to home where she lives
w/
her two sons. Her sugar in the morning was around yesterday
and they called who recommended juice. She left to visit her
father and did not have an appetite, and felt weak. Her sugars
there were elevated in high 200s. She did not have any new
symptoms aside from generalized weakness which is acutely worse
from her baseline weakness. She did not have any F/C, no N/V.
She
called her son who called an ambulance because he was not able
to
get home to be with her. Ambulance took to OSH ED. EMS reported
sugar 300 range.
## OSH ED WORK-UP SIGNIFICANT FOR:
-CBC:
10.7> 11.2 <250
-Chemistry: 138/3.8 | 103/29 |
-CT head: "new 2mm high attenuation focus in the superior
aspect
of the right frontal lobe at the gray-white junction which may
represent a tiny IPH"
-CXR: "concern for pneumonia and worsening lung metastases"
OSH transferred to .
ED initial vitals were 98.4 22 100% RA
Prior to transfer vitals were 97.9 88 151/99 17 99% RA
## EXAM IN THE ED SHOWED:
"cachectic, tired-appearing, CV/lung
exam
normal, no skin rashes, abdomen soft/NT/ND, CN intact,
strength x 4"
ED work-up: UA 1WBC
## ED MANAGEMENT SIGNIFICANT FOR:
-MEDICATIONS:NONE
-CONSULT:
Neurosurgery - exam unchanged, no neurosurgical
intervention indicated
On arrival to the floor, patient reports feeling better and
requesting to go home.
## PAST MEDICAL HISTORY:
Ms. is a female who was
initially diagnosed with colon cancer in . She had a
colonoscopy at which showed a near obstructing
mass at 40 cm, and biopsy showed invasive adenocarcinoma. She
underwent a rectosigmoid resection at in by Dr.
showed a 3.5 cm ulcerated mass with
metastasis
in one out of 17 lymph nodes with a high-grade tumor, staged as
T3 N1. It was KRAS wild type.
- : initially treated with Xeloda and oxaliplatin -->
stopped due to skin darkening, rashes, eye irritation and
headache
- referred to Dr. at
- : PET showed mass in RUL and a new nodule in LLL, ? mets
- elevated and biopsy was advised --> pt deferred
- moved to for years
- : returned to , evaluated by 's pulmonary service
due to ongoing respiratory symptoms --> found to have
progression
of metastatic disease
- began on single-agent irinotecan
- : began FOLFIRI --> stopped mouth sores and fatigue
- : switched to Xeloda, then Xeloda plus irinotecan, then
Xeloda, irinotecan and Avastin
- : dropped Xeloda, continued irinotecan and Avastin alone
## - :
progression
- : switched to FOLFIRI + Avastin
- : switched to irinotecan, Avastin and Xeloda again
- : progression
- : back to FOLFIRI plus Avastin
- : back to FOLFOX due to progression
- : added Avastin + FOLFOX --> developed significant
mouth
sores
- then rose --> imaging = increase in pulmonary metastasis
- developed pain in the right breast/right scapular region -->
met
- - : treated with palliative radiation to R lung
mass/metastatic colon carcinoma to the lung, 3000 cGy total in
10
fx
- : C1D1 Cetuximab 250mg/m2 weekly - 25%
- : C2D1 Cetuximab 250mg/m2 weekly - changed to 15%
- : C3D1 Cetuximab 500mg/m2 D1, D15 - 15%
- : C4D1 Cetuximab 500mg/m2 D1, D15 - 15% restaging
scan = improved disease
- : C5D1 Cetuximab 500mg/m2 D1, D15 - 15%
- : C6D1 Cetuximab/irinotecan D1, D15 - due to rising
- : C6D15 Cetuximab/irinotecan D1, D15 - scans confirmed
progression of disease
- : C7D1 Cetuximab/irinotecan D1, D15
- : C7D15 Cetuximab ALONE, irinotecan HELD; rising
(1205)
- : C1D1 panitumumab
- : C2D1 panitumumab --> rose ( ), switched to
Lonsurf
- : C1D1 Lonsurf
- : C2D1 Lonsurf 1569, then 2288)
- : admitted at for chest pain, diagnosed
with pneumonia, treated with Levaquin
- : C1D1 FLOX at 15% 6722)
- transferred care to under care of Dr.
chemo on
- : C3D1 FLOX at had completed 2 cycles of FLOX with
downtrending but wanted treatment break
- : seen by Dr. , on treatment break, planned to
resume FLOX the following week at another 5% to 20%)
per
pt preference
- : brought to ER by ambulance after being found
unresponsive at home; found to have large 2.9cm right temporal
lobe mass on head CT w/ edema and midline shift; given mannitol,
keppra, steroids, Kcentra; seen by who recommended
surgery;
ultimately able to be extubated and stabilized
- : transferred care back to --> stat MRI confirmed
mass; seen by Dr. Dr. decision made for CK
(rather than surgery)
- : CK x3 to right temporal lobe brain met
- : C1D1 FLOX
- : C2D1 FLOX
- : C3D1 FLOX
- : CT Torso with progression of disease (mediastinal
adenopathy, pancreatic tail mass, right adnexal mass, new left
adrenal mass).
- : Given progression of disease patient referred to
hospice
- : Transition from hospice to services at patient's
request
PAST MEDICAL HISTORY
-Heparin-induced thrombocytopenia
-Port associated DVT
-Hyperlipidemia
-Hypertension
-Depression
-Osteoarthritis
-Diabetes
## FAMILY HISTORY:
No known family history of CRC.
## :
NAD, Resting in bed comfortably
## HEENT:
MMM, no OP lesions, no cervical/supraclavicular
adenopathy
## CV:
RR, NL S1S2 no S3S4 No MRG
## PULM:
CTAB, No C/W/R, No respiratory distress
## ABD:
BS+, soft, NTND, no palpable masses or HSM
## LIMBS:
WWP, no , no tremors
## SKIN:
No rashes on the extremities
## NEURO:
CN III-XII intact, Strength b/l upper and lower ext
w/
L pronator drift w/ L side neglect, thought per they noted
in the ED before admission she had with neglect"
## PERTINENT RESULTS:
10:10AM BLOOD WBC-10.5* RBC-3.42* Hgb-10.8* Hct-33.8*
MCV-99* MCH-31.6 MCHC-32.0 RDW-17.0* RDWSD-61.7* Plt
10:10AM BLOOD Glucose-271* UreaN-6 Creat-0.3* Na-140
K-3.8 Cl-101 HCO3-26 AnGap-13
10:10AM BLOOD ALT-13 AST-31 LD(LDH)-615* AlkPhos-89
TotBili-0.6
10:10AM BLOOD Albumin-2.9* Calcium-8.5 Phos-2.3* Mg-2. w/ IDDM, HTN, DL, port-associated DVT c/b HIT, and
colorectal
adenocarcinoma (met to b/l lungs and R temporal lobe)
unfortunately w/ progression of disease despite multiple lines
of
chemo, now presenting with weakness, uncontrolled diabetes, and
concern for new hemorrhagic foci
## # WEAKNESS:
Likely multifactorial from progressive disease and
poor po intake. NO localizing symptoms and CXR/UA
non-contributory. Hyperglycemia could lead to dehydration
causing
weakness and hypoglycemia on its own can cause weakness.
Steroids
can also cause muscular weakness and mental/emotional changes
that can be reported as weakness. She improved very quickly with
gentle hydration and now feeling like she is "alive again."
[ ] pt back to physical baseline, recommend outpatient PRN
# Concern for new small intraparenchymal hemorrhage
Evaluated by who recommended continuing decadron and close
monitoring w/ neuro checks and no acute surgical intervention
needed. She had neuro checks every 4 hours and continued to
improve
neurologically inpatient. She refused a repeat NCHCT and
demanded to
return home asap which we accommodated. Do not suspect this IPH
is causing
her symptoms of weakness and likely incidental finding.
[ ] Hold fondaparinux until she sees Dr in clinic (
will arrange f/u)
# CNS metastatic disease
# CNS post-radiation necrosis and edema
During previous admission was seen by neuro-oncology and
radiation oncology. Per radiation oncology unclear whether
progression of CNS disease and concern for worsening radiation
necrosis if patient received radiation. Per neuro-oncology
recommended to continue high dose steroids for the foreseeable
future.
[ ] continue Dex 4mg q6h
# History of VTE
# History of Heparin-induced thrombocytopenia
[ ] Hold fondaparinux 7.5mg and fish oil until she sees
outpatient
# Type 2 DM:
She is having labile sugars (60-300 range) at home likely in
part to erratic diet. She does have hyperglycemia and AM
hypoglycemia so we changed her lantus to the morning time.
[ ] changed Glargine 6u qhs to qAM w/ breakfast
[ ] titrated lispro SS
[ ] instructed to f/u w/ PCP
# Hypertension:
[ ] continued her home hydralazine bid
## # METASTATIC COLORECTAL CANCER:
Widely metastatic to lung,
brain,
pancreas, adnexa and now adrenals in spite of treatment. No
additional treatment options.
[ ] pt clearly articulated she will discuss further plans w/ her
oncology team this week
## DISPO:
Home w/ (she vehemently refused rehab)
## BILLING:
>30 min spent coordinating care for discharge
, D.O.
Heme/ Hospitalist
p:
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Fondaparinux 7.5 mg SC DAILY
4. HydrALAZINE 10 mg PO BID
5. LevETIRAcetam 500 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Headache
8. Dexamethasone 4 mg PO Q6H
9. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
## DISCHARGE MEDICATIONS:
1. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 650 mg PO Q6H:PRN Headache
3. Ascorbic Acid mg PO DAILY
4. Dexamethasone 4 mg PO Q6H
5. HydrALAZINE 10 mg PO BID
6. LevETIRAcetam 500 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. HELD- Fish Oil (Omega 3) 1000 mg PO DAILY This medication
was held. Do not restart Fish Oil (Omega 3) until discussed with
your neurosurgeon (as this can cause increased bleeding)
9. HELD- Fondaparinux 7.5 mg SC DAILY This medication was held.
Do not restart Fondaparinux until discussed with your
neurosurgeon
## FACILITY:
Diagnosis:
Intraparenchymal Hemorrhage
Uncontrolled Insulin Dependent Diabetes Mellitus
Generalized Weakness
Metastatic Colorectal Cancer
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear
was a pleasure caring for you in the hospital. You were found
to have a small head bleed. You were admitted and had close
observation. Thankfully your neurological exam was stable and
you felt much stronger with some hydration and glucose control.
You will need to follow up with your oncologist to discuss the
plans for your cancer. You also need to follow up with your PCP
for your diabetes management. The neuro-surgery team will call
you to make an appointment within the next week or two to
discuss when you can start taking your Arixtra injection again
(which we stopped while you were here).
Regards,
Your team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10742902", "visit_id": "29490093", "time": "2155-02-23 00:00:00"} |
14087022-RR-66 | 123 | ## INDICATION:
woman with multinodular goiter.
## FINDINGS:
The right thyroid lobe measures 5.1 x 2.1 x 1.4 cm, and the left
thyroid lobe measures 1.7 x 1.1 x 4.6 cm. The thyroid echotexture remains
heterogeneous with multiple nodules. Spongy nodule in the mid pole of the
right thyroid lobe measures 1.4 x 0.8 x 1.5 cm and the largest spongy right-
sided nodule in the right aspect of the isthmus measuring 1.9 x 1.3 x 0.8 cm,
compared to 2.0 x 0.8 x 1.0 cm.
## IMPRESSION:
Multiple thyroid nodules, which do not demonstrate concerning
sonographic characteristics, and are similar in size and appearance, suitable
for routine followup.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14087022", "visit_id": "N/A", "time": "2188-11-19 10:59:00"} |
17744182-RR-15 | 124 | ## INDICATION:
Diabetes mellitus with a left foot ulcer. Evaluate for
osteomyelitis.
## RIGHT FOOT, THREE VIEWS:
There is marked soft tissue swelling with
subcutaneous air at the fifth metatarsophalangeal joint compatible with known
cellulitis and ulceration. There is also mild demineralization of the distal
aspect of the fifth metatarsal with associated irregularity. Although this
could be related to patient's underlying demineralization and osteoarthritis,
osteomyelitis is not excluded.There is diffuse degenerative disease involving
all the metatarsophalangeal joints and to some extent the interphalangeal
joint. No fractures are present. An os peronei is noted. The hardware is
partially visualized in the distal fibula.
## IMPRESSION:
Findings equivocal for right metatarsophalangeal osteomyelitis.
Overlying soft tissue swelling and subcutaneous gas compatible with known
cellulitis and ulceration.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17744182", "visit_id": "24366994", "time": "2132-03-31 14:41:00"} |
12722407-DS-4 | 1,773 | ## HISTORY OF PRESENT ILLNESS:
with hepatitis C is transferred from
after presenting with abdominal pain. Symptoms started 3 weeks
ago with worsening pain, which is severe and constant in the
RUQ. He has associated nausea and vomiting and reports weight
loss of 20lbs from poor PO intake. The patient was previously
treated for HCV in . He was recently seen in
Liver Tumor Clinic on .
In the ED, initial vitals were: T 97.5 HR 53 BP 143/97 RR 16 O2
100%RA Pain .
Labs were normal for CHEM7, LFT, and CBC with diff.
Preliminary CT abdomen showed "interval decrease in size of 1.8
cm hypodensity within segment 7 of the liver consistent with
known abscess."
GI service thought patient unlikely to have cirrhosis given labs
and imaging and recommended admission for IV antibiotics and
consult regarding aspiration of abscess.
The patient received morphine sulfate 5 mg IV x2, 1L NS,
ampicillin-sulbactam 3g, and ondansetron 4mg IV x1.
On the floor, the patient reports that he is having increased
pain since his last dose of IV morphine, which helps a lot with
his pain. He says that he has been vomiting 20 times a day since
the onset of symptoms a month ago. He was admitted ~a month ago
for suicidal ideation, at which time he was found to have this
3x2cm liver mass incidentally. At the time of discovery, the
patient did not have any pain from the mass, but he developed
pain shortly after. He was taken off of his regular psychiatric
medications given concern for liver disease; these included
lithium and olanzepine. He reports no focal back pain or neck
stiffness. He does not have difficulty going to the bathroom,
but has had 2 episodes of fecal incontinence with diarrhea. He
reports no numbness or tingling in his extremities. Last, his
last tattoo was from last and has had no recent
procedures. He has never used IV drugs.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. No
dysuria. Denies arthralgias or myalgias.
## PAST MEDICAL HISTORY:
Hepatitis C
Depression/Anxiety (Prior hospitalizations for SI)
Hypertension
Chronic Low Back Pain
## FAMILY HISTORY:
Maternal grandmother with ?liver/gastric cancer, no other GI
malignancy history.
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear, poor dentition
with many missing teeth, EOMI
## NECK:
Supple, JVP not elevated, no LAD
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## ABDOMEN:
Soft, non-distended, tenderness with light touching in
the RUQ extending down to RLQ, bowel sounds present, no
organomegaly, no rebound or guarding
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## NEURO:
No overt neurological deficits, moves all extremities
well, no facial asymmetry, speech intact
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear, poor dentition
with many missing teeth, EOMI
## NECK:
Supple, JVP not elevated, no LAD
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## ABDOMEN:
Soft, mildly distended, tenderness with deep palpation
of RUQ, RLQ and R flank, bowel sounds present, no organomegaly,
no rebound or guarding
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## NEURO:
No overt neurological deficits, moves all extremities
well, no facial asymmetry, speech intact
## RADIOLOGY
=========
5:
BD & PELVIS WITH CONTRAST
## CHEST:
Limited assessment of the lung bases demonstrates mild
bilateral lower lobe ground-glass opacities most consistent with
atelectasis however differential includes infection in the
appropriate clinical setting. No pleural effusion. The
visualized heart is normal in size without pericardial effusion.
## ABDOMEN:
The liver is homogeneous in enhancement. Ill-defined
1.8 x 1.2 cm (02:27) hypodensity within segment 6 of the liver
has mildly decreased in size (previously 2.5 x 2.3 cm).No
intrahepatic or extrahepatic biliary dilatation. The gallbladder
is normal without calcified gallstones. The portal vein, SMV,
and splenic vein are patent. The spleen is normal. The
pancreas enhances homogenously and is without focal lesions,
peripancreatic fat stranding, or focal fluid collection. The
adrenal glands are unremarkable. The kidneys display symmetric
nephrograms and excretion of contrast. No focal renal lesions.
No hydronephrosis or hydroureter identified. No renal or
proximal ureter calculi. The distal esophagus is normal
without hiatal hernia. The stomach is grossly unremarkable in
appearance. The small bowel is normal in caliber without wall
thickening. The large bowel is normal in caliber without wall
thickening, fat stranding, or focal mass lesion. Colonic
diverticulosis is present without evidence of acute
diverticulitis. The appendix is not visualized however no
evidence of acute appendicitis. The abdominal aorta is normal
in caliber without aneurysmal dilatation. The celiac axis, SMA,
and are patent . Small amount of atherosclerotic
calcification noted. The iliac arteries are normal in course and
caliber. No retroperitoneal or mesenteric lymph node
enlargement by CT size criteria. No free abdominal fluid,
abdominal wall hernia, or pneumoperitoneum.
## PELVIS:
The bladder is well distended and normal. No pelvic
side-wall or inguinal lymph node enlargement by CT size
criteria. No free pelvic fluid seen. The prostate and seminal
vesicles are unremarkable.
## OSSEOUS STRUCTURES:
Multilevel, multifactorial degenerative
changes are seen within the visualized thoracolumbar spine. No
focal lytic or sclerotic lesion concerning for malignancy.
## IMPRESSION:
1. Interval decrease in size of 1.8 cm hypodensity within
segment 6 of the liver consistent with liver abscess.
2. Bilateral lower lobe ground-glass opacities most consistent
with atelectasis.
7:32 ABDOMEN (SUPINE & ERECT)
## FINDINGS:
The bowel gas pattern is nonspecific and nonobstructive. There
are no abnormally dilated loops of small or large bowel. There
is no evidence of pneumatosis or pneumoperitoneum. The
visualized osseous structures are unremarkable.No radiopaque
foreign bodies are detected. The imaged lung bases are
unremarkable.
## IMPRESSION:
No evidence of obstruction or perforation.
8:17 AM LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP
ABD/PEL)
## LIVER:
The liver is normal in size and the hepatic architecture
is normal in appearance. There is associated heterogeneous
region in the posterior right lobe a likely correlating with the
abnormality seen on the recent CT (see image number 38). The
main portal vein is patent with hepatopetal flow. There is no
ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD
measures 0.2 cm.
## GALLBLADDER:
No gallstones are visualized.
## PANCREAS:
The pancreas is unremarkable but is only minimally
visualized due to overlying bowel gas.
## DOPPLER EXAMINATION:
The main, right and left portal veins are
patent with hepatopetal flow. The hepatic veins and IVC are
patent.
## IMPRESSION:
1. Patent portal veins.
2. Vague heterogeneity in the posterior right lobe of the liver
likely correlating with the resolving focal hepatic abnormality
seen on the recent CT.
## SUMMARY:
with hepatitis C transferred from
after presenting with RUQ abdominal pain most likely
related to his liver abscess.
## # LIVER ABSCESS:
Most likely bacterial infection. Biopsy results
from OSH records ruled out malignancy, and patient has normal
AFP. Patient was afebrile throughout stay with no signs of
bacteremia. Blood cultures from prior hospitalization were
negative and negative at the time of discharge here. The abscess
was deemed too small to drain by . Liver ultrasound ruled out
portal vein thrombosis. He was started on Unasyn with transition
to PO ciprofloxacin and metronidazole for a 4 week planned
course given concern for having a indwelling line (see below).
He was instructed to have Liver Clinic follow up in weeks.
## # DRUG ABUSE:
The patient's PCP reported that patient has had
issues with drug abuse in the past. The patient was discharged
with a short course of oxycodone to get him to his PCP
. Because of this concern of drug abuse, IV
antibiotics as outpatient was deferred in favor of PO.
## # HEPATITIS C:
No signs of cirrhosis at this point on
radigraphic or laboratory testing. Previously treated with
interferon and ribavirin with subsequent undetectable viral
load, last in . Viral load checked this admission was
again undetectable.
## # DEPRESSION:
Patient reported not being on any medications.
After discussing with PCP, it appears patient was purposefully
discontinued on his psychiatric medications with good subsequent
follow up.
## TRANSITIONAL ISSUES
- ANTIBIOTICS:
ciprofloxacin and metronidazole ,
- Patient will need clinic follow up
- Medication titration for psychiatric conditions
- Patient needs repeat colonoscopy this year to follow up on
polyps seen on prior years ago
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Gabapentin 800 mg PO TID
3. ClonazePAM 1 mg PO TID:PRN Anxiety
4. Levothyroxine Sodium 75 mcg PO DAILY
## DISCHARGE MEDICATIONS:
1. Gabapentin 800 mg PO TID
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. ClonazePAM 1 mg PO TID:PRN Anxiety
5. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30
## CAPSULE REFILLS:
*0
6. OxycoDONE (Immediate Release) mg PO Q8H:PRN Pain
RX *oxycodone 5 mg tablet(s) by mouth three times a day Disp
#*45 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*14 Packet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Capsule Refills:*0
9. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*52 Tablet Refills:*0
10. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*78 Tablet Refills:*0
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were transferred to
from after presenting there with abdominal
pain. We performed a CT scan of your abdomen that showed a 1.8
cm abscess in your liver. It is decreasing in size from the
original abscess seen at . You likely have a bacterial
infection that is getting better, but you will need to take
antibiotics for 4 weeks to make sure that the infection fully
goes away.
Last, on review of your records, we found that you had many
polyps seen on your last colonoscopy. We recommend that you have
a repeat colonoscopy within this year for follow up. You can ask
for it to be arranged with your primary care doctor.
Please take your medications as directed and keep the
recommended appointments below with your doctors. not
hesitate to contact us with questions or concerns.
Sincerely,
Your Medicine Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12722407", "visit_id": "20554371", "time": "2156-02-24 00:00:00"} |
17163115-RR-172 | 95 | ## INDICATION:
cirrhotic with shock, screening for infectious causes (no
localizing symptoms) // ?pneumonia, infection screening
## FINDINGS:
Low lung volumes with chronic elevation of the right hemidiaphragm. The
cardiac silhouette is enlarged, stable. There is diffuse interstitial
prominence with perihilar vascular congestion, suggestive of mild pulmonary
edema. Small right pleural effusion, whereas the left costophrenic angle is
not completely visualized. No pneumothorax. There is a left PICC line that
terminates in the lower SVC.
## IMPRESSION:
Vascular congestion and interstitial prominence suggestive of mild pulmonary
edema. In the appropriate clinical setting, cannot exclude superimposed
aspiration/pneumonia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17163115", "visit_id": "N/A", "time": "2168-03-30 11:31:00"} |
10934106-RR-14 | 758 | ## EXAMINATION:
CTA HEAD AND CTA NECK Q16 CT NECK
## INDICATION:
year old man with congestive heart failure, pulmonary
embolism, new evidence of multiple embolic strokes. Etiology of embolic
infarcts?
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 5.1 s, 40.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 537.2
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 38.6 mGy (Body) DLP =
19.3 mGy-cm.
Total DLP (Body) = 558 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
## CT HEAD WITHOUT CONTRAST:
Small hypodensities in the left frontal and parietal corona radiata,
corresponding to acute infarctions on the MRI, have increased
in conspicuity compared to the CT. Small hypodensity in the
posterior right caudate, image 2:19, also corresponds to recent infarction on
the preceding MRI. Other periventricular, deep, and subcortical white matter
hypodensities are not significantly changed compatible with chronic small
vessel disease. No large new infarct is identified. No significant mass
effect. No acute hemorrhage. Prominence of the ventricles and cerebral sulci
are compatible with age related involutional changes.
There are multiple dental caries and periapical lucencies in the bilateral
maxilla, with mild mucosal thickening along the floors of the maxillary
sinuses and a small mucous retention cyst on the right. There also multiple
dental caries and periapical lucencies in the mandible bilaterally. Mastoid
air cells are well aerated. The orbits appear unremarkable.
## CTA NECK:
There is mild calcified plaque in the visualized proximal descending aorta.
There is a 3 vessel aortic arch with widely patent great vessel origins.
Right common carotid and internal carotid arteries appear widely patent
without stenosis by NASCET criteria. There is mild noncalcified plaque in the
proximal left internal carotid artery, best seen on image 304:11, without
stenosis by NASCET criteria.
Small focus of calcified plaque in the proximal left subclavian artery near
the left vertebral artery origin does not extend into the left vertebral
artery lumen. There is a small focus of mixed plaque in the V3 segment of the
left vertebral artery, images 3:221 and 305:53, with mild luminal narrowing.
Right vertebral artery is widely patent, forming a loop between the transverse
foramina C4 on C5.
## CTA HEAD:
There are calcifications of the carotid siphons without flow-limiting
stenosis. Bilateral middle cerebral arteries are diffusely irregular. There
is mild narrowing of the proximal left MCA M1 segment (3:280). There is a
short segment of severe stenosis of the distal left MCA M2 segment with distal
reconstitution, though the distal branches appear irregular there is mild
irregular narrowing of the right M1 segment, images (3:278,
302:27, 309:25). There is also mild narrowing of the proximal right M2
branches.
Mild irregularity of the P2 segment of the left posterior cerebral artery,
images 3:270 , is likely atherosclerotic. Right complexes are
normal variant.
1 mm hyperdensity along the medial wall of the cavernous right internal
carotid artery on image 3:265 is consistent with either calcified plaque or
infundibular origin of a branch vessel. No evidence for an aneurysm is
otherwise seen.
The dural venous sinuses are patent.
## OTHER:
There are moderate bilateral pleural effusions (right greater than left),
similar to the recent chest CT. Motion artifact limits evaluation of the
included upper lungs. Multiple nonenlarged mediastinal lymph nodes are again
seen, likely reactive. The thyroid appears unremarkable.
## IMPRESSION:
1. Increased conspicuity of small hypodensities in the left corona radiata
compared to the CT, corresponding to acute to early subacute
infarcts on the MRI . Unchanged CT appearance of the small
subacute infarct in the right posterior caudate.
2. Short-segment severe stenosis of the left MCA M2 segment with distal
reconstitution. Mild stenoses of bilateral MCA M1 segments and proximal right
M2 branches. Mild irregularity of the left PCA P2 segment. These findings
are likely atherosclerotic.
3. Small focus of mixed plaque causes mild narrowing of the V3 segment of the
left vertebral artery.
4. Moderate bilateral pleural effusions (right greater than left) are again
partially visualized.
5. Multiple bilateral dental caries and periapical lucencies in the maxilla
and mandible. Please correlate with dental exam regarding any active
inflammation.
## NOTIFICATION:
The cerebral infarctions and severe left MCA stenosis were
discussed with , M.D. by , M.D. on the telephone
on at 11:02 am, 5 minutes after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10934106", "visit_id": "28010768", "time": "2121-09-22 18:47:00"} |
12431541-DS-19 | 922 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Abdominal pain, right lower quadrant
## HISTORY OF PRESENT ILLNESS:
yo G0 w/ UC, (last episode > a few yrs ago, no current meds,
asx) with RLQ pain x 24 hrs. Started yesterday and was initially
mild but has increased in intensity. Constant dull discomfort
with intermittent sharper pain, worse w/ standing, associated w/
nausea, no vomiting. Pain slightly better sitting and lying down
but can't find completely comfortable position. Normal BM
yesterday, no diarrhea, fevers. LMP 2 weeks ago, has never been
sexually active. Pain level sitting , standing, "worse."
Sent to from PCP for evaluation including CT, r/o
appy, colitis.
Received Zofran and Morphine IV x1 in ED at .
Labs at :
neg
WBC 12.2
Hct 42.1
CT at showing no appy, 11x11cm right ovarian cyst c/w
dermoid
Received Zofran and Morphine IV x 1 in ED.
## PMH:
UC not on meds, depression recently started in wellbutrin,
broken arm
## MEDS:
Wellbutrin 300mg daily x 1.5months
## PHYSICAL EXAM:
T 98.4 HR 73 BP 125/71 RR 16 O2 100%RA
NAD, well appearing
RRR
CTAB
Abd soft, very minimal tenderness to deep palpation of RLQ,
?fullness on right, no rebound or guarding, s/p morphine
Ext NT, no edema
Pelvic exam: cervix nl appearing, no blood or abnl discharge in
vault, no CMT, fullness of right adnexa, no definable mass
abdominal muscle tone, no rebound or guarding, pt with only mild
tenderness one exam of lower abdomen, R>L
## INDICATION:
Enlarged dermoid cyst on CT at . Assess for
torsion.
## COMPARISONS:
abdomen and pelvis from earlier the
same date.
## FINDINGS:
Transabdominal and transvaginal pelvic sonography was
performed,
the latter to better visualize the endometrium and adnexa. The
uterus
measures 7.2 x 3.7 x 3.8 cm. The endometrium is normal
measuring 6 mm. The left ovary contains a 4.6 x 4.6 x 3.7 cm
cyst with internal reticulations compatible with a hemorrhagic
cyst. Peripheral ovarian tissue demonstrates normal arterial
and venous waveforms. The right ovary contains a large
multiseptated cyst, portions of which are anechoic, but other
portions of which are echogenic and shadowing compatible with
the known large dermoid cyst seen on the CT, measuring 11.1 x
6.5 x 10.9 cm. Normal venous and arterial waveforms are seen.
Trace free fluid is identified.
## IMPRESSION:
4.6-cm left ovarian hemorrhagic cyst and 11-cm
right ovarian
dermoid cyst, with normal arterial and venous waveforms
bilaterally.
Intermittent torsion remains difficult to exclude. Trace free
fluid.
## BRIEF HOSPITAL COURSE:
Ms. was admitted to the gynecology service from the
emergency department because of new-onset right lower quadrant
pain, concerning for intermittent torsing of ovary in the
setting of a newly found 11-cm right ovarian cyst. Overnight her
exam was benign and reassuring, and there was adequate flow seen
to the ovary on ultrasound. The patient was sleeping
comfortably without narcotic medications and,
therefore, she was admitted for observation, given that she was
not thought to be torsing her ovary on admission. However, on
hospital day #1, she developed right lower quadrant pain again
associated with movement and, therefore, the decision was made
to proceed with laparoscopy. She underwent an uncomplicated
right salpingo-oophorectomy. Please see operative report for
details.
Immediately post-op, her pain was controlled with oral pain
medication and she was tolerating a regular diet and ambulating
independently. She was planned to be discharged on
post-operative day 0, but she had urinary retention, with
250-400cc post-void residual on bladder scan. Her foley was thus
replaced overnight. She passed a trial of voiding on
post-operative day #1 and thus was discharged without a Foley
catheter, in stable condition and with outpatient follow-up
scheduled.
## DISCHARGE MEDICATIONS:
1. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every hours Disp
#*40 Tablet Refills:*0
2. Oxycodone-Acetaminophen (5mg-325mg) TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every 4 hours Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID
RX *erythromycin 5 mg/gram (0.5 %) apply small amount to
affected area four times a day Disp #*1 Tube Refills:*0
## DISCHARGE DIAGNOSIS:
Right ovarian cyst, likely dermoid. Ovarian torsion
## DISCHARGE INSTRUCTIONS:
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* Remove outer dressing on
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12431541", "visit_id": "28582963", "time": "2137-03-17 00:00:00"} |
15953943-RR-29 | 112 | ## HISTORY:
female with shortness of breath, to rule out a
cardiopulmonary process.
## FINDINGS:
The lungs are of low volume, most likely due to poor inspiratory effort.
There is mild CHF. There is stable appearance to the left retrocardiac
opacity, atelectasis in the left lower lobe as well as a left basal effusion.
There is atelectasis in the right mid-zone. The patient is status post
sternotomy. The bones are osteopenic.
## CONCLUSION:
Retrocardiac opacity along with atelectasis and left basal effusion, likely a
combination of atelectasis and pneumonic consolidation. Atelectasis is also
seen in the right mid-zone. Superimposed mild CHF. Followup AP and lateral
radiographs are recommended for further evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15953943", "visit_id": "22034065", "time": "2176-10-29 19:58:00"} |
16934035-RR-81 | 186 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
man with a history of meningeal lymphoma, now with
altered mental status, fever, and abdominal pain. Evaluate for acute
intracranial hemorrhage or large territorial infarct.
## FINDINGS:
A right frontal approach ventriculostomy catheter ends in the third ventricle,
unchanged from prior. Pericatheter hypodensity within is also unchanged.
Overall ventricular size and configuration is stable dating back to at least
, with ventriculomegaly. There is no large territorial infarct,
mass, or mass effect. There is no intracranial hemorrhage.
There is no evidence of acute fracture. Postsurgical changes related to prior
right lateral orbital wall fracture repair are again noted. The visualized
portion of the mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. Minimal bilateral frontal
sinuses ethmoid air cell mucosal thickening is present.
## IMPRESSION:
1. No acute intracranial abnormality.
2. Stable position of right frontal approach ventriculostomy catheter with
grossly stable ventriculomegaly.
3. Please note MRI of the brain is more sensitive for the detection of acute
infarct and intracranial metastatic disease.
4. Paranasal sinus disease as described.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16934035", "visit_id": "26464134", "time": "2160-12-26 03:22:00"} |
17218341-DS-9 | 430 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
L AKA L flank fasciotomy
abdominal debridement fasciotomy
## HISTORY OF PRESENT ILLNESS:
hx PVD/nonhealing lower extremity ulcers, s/p left-to-right
fem-fem PTFE BPG L fem-AKpop NRSVG s/p thrombectomy x2, bovine
patch angioplasty to proximal anastomosis now with ~24hr
LLE pain and erythema, presented to OSH, febrile, hypotensive,
hypoxic, "pulseless" LLE, sensory asymmetry,
leukocytosis/bandemia, concern for ischemic limb with
superimposed soft tissue infection and sepsis. Received CTX 1g,
4L IVF, transferred to .
In ED, afebrile, hypotensive SBP , mentating, hypoxic.
Nonhealing bilateral plantar ulcers LLE ~4cm with purulence,
cool left foot, paresthetic to mid-calf, motor intact. Pulse
exam notable for nonpalp L fem, monophasic popliteal, absent
.
## PMH:
DM2, COPD/asthma, hx severe PNA requiring tracheostomy 09
removed , AF (on coumadin), hyperlipidemia, MDD, Chronic
anemia, Osteomyelitis LLE, PVD, Mediastinal adenopathy, Charcot
foot deformity
## PSH:
- I&D Left foot ulcer - Right Toe amputation and heel ulcer debridement
- RLE toe ray amp
- LtoR fem-fem PTFE BPG, LLE Fem-AKpop NRSVG BPG
( )
- thrombectomy fem-fem, bovine patch angioplasty
anastomosis ( )
- Sartorius flap L groin ( )
## FAMILY HISTORY:
brother, sister, father with DM
## ABD:
obese, nontender, no peritoneal signs
## EXT:
chronic venous stasis changes bilaterally. RLE - 2cm ulcer
medial plantar surface without erythema/fluctuance/purulence.
LLE
- 4.5cm linear ulceration defect with erythematous changes,
purulent drainage, no crepitus. well-healed L fem-AKpop BPG
incisional scar. LLE mottled/paraesthetic to midcalf, cool to
touch, 2+ pitting edema.
## DERM:
as above
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
## RLE FEMORAL:
P, Popliteal: D, DP: D, : D
## LLE FEMORAL:
N, Popliteal: P, DP: N, : N graft: N
## BRIEF HOSPITAL COURSE:
On the day of presentation Mrs. was taken emergently to
the operating room for left above knee guillotine amputation,
left flank incision and debridement. Postoperatively she was
admitted to the CVICU in unstable condition with a substantial
pressor requirement. Her abdomen was debrided, infectious
disease, nephrology and acute care surgery consults were
obtained. She was continued on broad spectrum antibiotics and
wound cultures grew out group A strep. She had repeated
debridements of both her abdomen and LLE wounds but failed to
improve. Her acidosis and pressor requirement persistent and she
was placed on renal replacement therapy with mild improvement.
On hospital day 4 a discussion was held with the family given
her worsening condition and dismal prognosis. They decided that
in this circumstance the patient would have wished to be CMO.
Pressor support was withdrawn and she expired soon thereafter.
## DISCHARGE DIAGNOSIS:
necrotizing soft tissue infection
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17218341", "visit_id": "27914462", "time": "2113-04-03 00:00:00"} |
18070061-RR-119 | 259 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD.
## HISTORY:
with known brain mets from rectal ca, s/p fall with
headache// eval for hemorrhage, trauma.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
## FINDINGS:
Patient is status post right suboccipital craniotomy with stable
encephalomalacia of the right cerebellum. No acute intracranial hemorrhage.
No large vascular territory infarction. Multiple metastatic lesions are
again demonstrated centered in the cerebellum and right putamen. The left
cerebellar lesion measures 1.7 x 2.4 cm, similar to prior (2; 6). The right
putamen lesion measures 1.4 cm similar to prior. Extensive adjacent vasogenic
edema with mass effect on the fourth ventricle and on the right lateral
ventricle are similar to prior. 3 mm leftward midline shift is similar to
prior. Effacement of the sulci in the right frontoparietal lobe is similar
to prior.
Basal cisterns appear patent. Size and configuration of the ventricles are
similar to prior.
There is no evidence of acute 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 hemorrhage.
2. Redemonstration of multiple metastatic lesions in the right basal ganglia,
left cerebellum, with stable vasogenic edema and mass effect on the right
lateral ventricle, and fourth ventricle. Stable 3 mm leftward midline shift.
3. Status post right suboccipital craniotomy with stable right cerebellar
encephalomalacia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18070061", "visit_id": "28548972", "time": "2123-12-09 13:04:00"} |
12083456-RR-44 | 411 | ## HISTORY:
male with metastatic cancer presenting with pleural
effusions, pericardial effusions. New oxygen requirement of 4 liters.
Question PE.
.
## FINDINGS:
The aorta opacifies normally without evidence of dissection. The
pulmonary arteries opacify normally without intraluminal filling defects to
suggest pulmonary embolism. The heart is normal in size. A new pericardial
effusion is moderate in severity, causing straightening of the ventricular
septum and distortion and attenuation of the right atrium, concerning for
tamponade physiology. No pericardial nodularity is identified. Multiple
mediastinal lymph nodes are new or enlarged including a 14-mm lower right
paratracheal lymph node which is new. Numerous non-pathologically enlarged
upper paratracheal and thoracic inlet lymph nodes are new. A right hilar
lymph node is mildly enlarged measuring 11 mm, previously measuring 9 mm.
Previously identified pleural thickening and nodularity have rapidly
progressed within the right hemithorax with numerous new pleural metastases
identified and involving both the minor and major fissure. Several areas of
loculated pleural fluid are noted, most prominent along the paramediastinal
pleural surface and within the major and minor fissures. A new left pleural
effusion is moderate in severity. No pleural thickening or nodularity is
noted within the left hemithorax.
Right lower lobe airspace consolidation is attributed to atelectasis.
Multiple new pulmonary nodules are identified including a 6-mm left lower lobe
nodule (400B:36), a 3-mm right lower lobe nodule (3:52), a ground glass 9-mm
nodule in the right upper lobe (3:39), a 4-mm right upper lobe nodule (3:34)
and a 4-mm right upper lobe nodule, consistent with pulmonary metastases.
There are no bony lesions suspicious for malignancy. Multilevel degenerative
changes noted throughout the spine.
Although the study was not designed for subdiaphragmatic evaluation, numerous
low-density lesions within the liver have increased in size, most consistent
with worsening hepatic metastases.
Findings are better characterized on prior CT abdomen dated .
## IMPRESSION:
1. No evidence of pulmonary embolism.
2. Moderate pericardial fluid causing attenuation and distortion of the right
atrium, concerning for tamponade physiology. Clinical correlation is
essential, as reported in preliminary reading on and discussed with
Dr. at 12:10 a.m. by Dr. .
3. Marked interval progression of extensive pleural metastases in the right
hemithorax, bilateral pulmonary nodules and mediastinal and hilar
lymphadenopathy, all of which is consistent with worsening metastatic disease.
4. Moderate left pleural effusion; no pleural nodules.
5. Partially imaged numerous low-density lesions in the liver, demonstrating
interval increase in size.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12083456", "visit_id": "22751521", "time": "2145-08-20 23:43:00"} |
14008937-RR-25 | 110 | ## INDICATION:
year old female with right-sided weakness, ataxia, sensory
loss. Question infarction.
## FINDINGS:
There are multiple subcortical, periventricular and deep white matter FLAIR/
T2 hyperintensities. A linear band of restricted diffusion is seen along the
ventral lateral aspect of the thalamus/posterior limb of the left internal
capsule. There is no evidence of hemorrhage, edema, masses, mass effect or
midline shift. The ventricles and sulci are normal in caliber and
configuration.
## IMPRESSION:
1. Acute infarction of the left ventral lateral aspect of the thalamus with no
acute hemorrhage.
2. Superimposed nonspecific T2/FLAIR periventricular subcortical white matter
hyperintensities, which are commonly seen in setting of chronic
microangiopathy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14008937", "visit_id": "22123992", "time": "2114-12-31 21:03:00"} |
13635902-RR-18 | 111 | ## CLINICAL INFORMATION:
History of left breast DCIS in , status post
lumpectomy. No current complaints.
## FINDINGS:
Routine views of both breasts were performed using GE digital
mammography. A wire was placed over the inferior lateral left breast
indicating the lumpectomy scar. Routine views of both breasts were performed.
Comparison made with , and film screen exam from .
Both breasts demonstrate scattered fibroglandular densities. No dominant
mass, significant clustered calcifications, or architectural distortion is
seen. Stable benign intramammary lymph nodes in the upper outer right breast
and in the upper left breast are noted.
## IMPRESSION:
No radiographic evidence of malignancy. Annual exam recommended.
Results discussed with the patient.
BI-RADS 2 - benign.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13635902", "visit_id": "N/A", "time": "2119-07-22 12:56:00"} |
14679110-RR-26 | 283 | ## EXAMINATION:
MR CERVICAL SPINE W/O CONTRAST MR SPINE
## INDICATION:
year old man with MVA followed a few days later by stuttering
Extensor plantars // ? cord compression ? cord compression
## FINDINGS:
Study is moderately degraded by motion.
Vertebral body alignment is preserved. Vertebral body heights are preserved.
There is no focal marrow signal abnormality. Question overall low marrow
signal.
The visualized portion of the spinal cord is grossly preserved in signal and
caliber.
Intervertebral disc heights and signal are preserved.
Within the limits of this noncontrast study there is no evidence of infection
or neoplasm. There is no prevertebral soft tissue swelling..
At C2-3 there is disc bulge, uncovertebral hypertrophy, novertebral canal or
neural foraminal narrowing.
At C3-4 there is disc bulge, uncovertebral hypertrophy, mildvertebral canal
and severe bilateral neural foraminal narrowing.
At C4-5 there is disc bulge, uncovertebral hypertrophy, mildvertebral
canalmoderate right and mild leftneural foraminal narrowing.
At C5-6 there is disc bulge, uncovertebral hypertrophy, ligamentum flavum
hypertrophy, mild to moderatevertebral canal, moderate left and mild
rightneural foraminal narrowing.
At C6-7 there is uncovertebral hypertrophy, novertebral canal and mild
bilateral neural foraminal narrowing.
At C7-T1 there is no vertebral canal or neural foraminal narrowing.
## IMPRESSION:
1. Study is moderately degraded by motion.
2. Multilevel cervical spondylosis as described, most pronounced at C5-6,
where there is mild-to-moderate vertebral canal, moderate left and mild right
neural foraminal narrowing.
3. Within limits of study, no definite evidence of cervical spinal cord
lesion.
4. Nonspecific low marrow signal, which may be seen in the setting of anemia.
If clinically indicated, consider correlation with CBC.
5. Please see concurrently obtained MRI brain report for description of
cranial structures.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14679110", "visit_id": "N/A", "time": "2190-08-09 19:48:00"} |
19921471-RR-132 | 530 | ## EXAMINATION:
CT ABD AND PELVIS W/O CONTRAST
## INDICATION:
year old man with recurrent bladder cancer s/p 12+ TURBTs
(resulting low-volume bladder), RCC s/p L nephrectomy, recurrent
UTI/pyelonephritis, present with urinary sx and RLQ/back pain.// with
recurrent bladder cancer s/p 12+ TURBTs (resulting low-volume bladder), RCC
s/p L nephrectomy, recurrent UTI/pyelonephritis, present with urinary sx and
RLQ/back pain. Please assess for kidney stone/pyelo.
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen following intravenous contrast administration with split
bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## LOWER CHEST:
Severe emphysema in the visualized lower lungs is
re-demonstrated. Suture material/surgical clips is again seen at the right
lung base. Multiple surgical clips along the left hemidiaphragm are again
seen and unchanged.
## 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 contains gallstones without
wall thickening or surrounding inflammation.
## 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:
A 1.4 cm low-density left adrenal nodule is re-demonstrated and
unchanged. The right adrenal gland is normal in size and shape.
## URINARY:
Patient is status post left nephrectomy. The right kidney is
dysmorphic in appearance with cortical scarring and moderate
hydroureteronephrosis which tapers in the proximal ureter and enlarges in the
mid and distal ureter to the level of the ureterovesicular junction. Multiple
cortical renal cysts are again seen measuring up to 1.8 cm. There is no
perinephric abnormality. Multiple nonobstructing punctate renal
calcifications are demonstrated.
The bladder contour is irregular in appearance with bladder diverticula and
hyperdense thickening of the posterior bladder wall though new nodularity is
demonstrated measuring up to 14 mm (06:44) with associated calcifications
which may represent recurrent malignancy.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding. There is extensive fecal loading throughout the colon the appendix
is normal.
## PELVIS:
There is no free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate is enlarged and contains calcifications.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
Vascular clips along the retroperitoneum and left pelvic wall are
re-demonstrated and unchanged. There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Moderate right hydroureteronephrosis to the level of the bladder with
posterior bladder wall thickening and new nodularity measuring up to 14 mm
with associated calcifications concerning for recurrent malignancy.
2. No obstructing renal, ureteral, or bladder stones identified. Multiple
punctate nonobstructing renal stones demonstrated.
3. Cholelithiasis without findings to suggest cholecystitis.
4. Diverticulosis without findings of diverticulitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19921471", "visit_id": "29068055", "time": "2154-05-21 18:32:00"} |
12481481-RR-153 | 178 | ## INDICATION:
History of right carotid bruit.
## BILATERAL CAROTID ULTRASOUND:
Gray-scale and color Doppler sonography was
performed of the right and left ICA, ECA, CCA, and vertebral arteries.
On the right, mild homogenous plaque is seen within the carotid bulb and
proximal right ICA. Antegrade flow is seen within the vertebral artery. The
following velocity measurements were obtained: Proximal ICA 68/17 cm/sec, mid
ICA 63/16 cm/sec, distal ICA 71/24 cm/sec, CCA 72 cm/sec, ECA 97 cm/sec,
vertebral artery 44/15 cm/sec, right ICA/CCA ratio 1.0.
On the left, there is mild homogenous plaque within the proximal left ICA and
carotid bulb. Antegrade flow is seen within the left vertebral artery. The
following velocity measurements were obtained: Proximal ICA 38/10 cm/sec, mid
ICA 71/22 cm/sec, distal ICA 63/24 cm/sec, CCA 86 cm/sec, ECA 70 cm/sec,
vertebral artery 65/15 cm/sec, left ICA/CCA ratio 0.7.
## IMPRESSION:
Findings are consistent with less than 40% bilaterally stenosis
bilaterally.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12481481", "visit_id": "N/A", "time": "2172-08-21 11:00:00"} |
11354313-DS-26 | 1,249 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
Mr. is a man with a history of CAD s/p multiple
stents, not adherant with his Plavix regimen x 2 weeks, and a
tentative diagnosis of idiopathic recurrent pancreatitis, who
presents with 2 weeks of epigastric pain.
.
Regarding his history of pancreatitis, for seven or years
now he has been experiencing initially episodic and now more
frequent upper abdominal pain escalating to and located in
the mid abdomen radiating to the back. There are no specific
triggers and it does not seem to be worse with food. Bowel
movements are unchanged. His weight has been unchanged.
.
In , a CT scan of the abdomen and pelvis done to evaluate
these symptoms revealed mild expansion and edema of the pancreas
consistent with a mild pancreatitis. There was no evidence of
collections or pancreatic necrosis. Subsequently, he was
admitted to to and also thought to have CT
findings consistent with pancreatitis. The patient does not
drink alcohol, but he is a heavy cigarette smoker. There is no
strong family history of pancreatitis or pancreatic neoplasia.
Triglycerides have been normal in the past.
.
Of note, the patient had a recent admission
through
with a chief complaint of upper abdominal pain with
nausea and no vomitting, fevers, or chills. US was without
evidence of gallbladder disease. Amylase and lipase were normal,
but his GI doctor has noted that these can be normal in patients
with recurrent pancreatitis/chronic pancreatitis. He was started
on ranitidine and felt that his symptoms were somewhat improved.
.
For the past 2 weeks, Mr. as again been experiencing
abdominal pain. The pain gradually increased. The day of
admission he experienced an episode of acutely worsened
abdominal pain associated with nausea without vomitting lasting
one hour. He activated EMS. He received ASA 325 mg in the
ambulance.
.
In the ED, VS initially: T 98, HR 66, BP 135/69, RR 16, O2 Sat
99% RA. EKG showed new TWI in V3 but was otherwise unchanged
from baseline. He received SL nitro with no relief of pain.
Cardiology was consulted and thought this was likely secondary
to lead placement. CXR WNL. Labs notable for normal cardiac
enzymes x 1 and lipase elevated >3000. He received a total 12 mg
of IV morphine with moderate relief as well as 1 L IVF. PO was
not tried. VS prior to transfer: HR 61, BP 104/50, RR 15, O2 Sat
96% RA
.
On the floor, patient says his pain has improved but still
present, now a . Upon further review of his history, he
admits to not taking any of his medications for the past
months because he fears that his meds prompt bouts of epigastric
pain. He restarted all meds this AM (although pain started
yesterday). Patient apparently came to ED last night but left
after finding out the wait was 2 hours and tried to self
medicate with a bottle of mag citrate and gas-x. Pain initially
subsided but returned this afternoon after eating some mashed
potatoes. He had a "tiny" amount of nausea but no vomiting,
fevers or chills.
## - CORONARY ARTERY DISEASE:
s/p LAD and RCA stenting in
followed by two episodes of LAD restenosis and one episode of
RCA re-stenosis; beta brachytherapy in
- Patient states that he has had an MI in
- Hypertension
- Hypercholesterolemia
- Left lung nodule - discovered incidentally on CT at
in 6mm as per pt. report.
- Septated kidney cyst
- Pancreatitis: recurrent acute episodes of unclear etiology;
gallbladder evaluation reportedly normal, no h/o alcohol use
- hx of tib/fib fx
## CAD:
Grandfather died at of an MI; uncle had CABG in his
. His mother has a history of Crohn's disease. His father
died from complications of colon cancer.
## GENERAL:
Obese gentleman in NAD. Oriented x3.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Clear oropharynx
## CARDIAC:
RRR, normal S1, S2. No m/r/g.
## LUNGS:
Decreased breath sounds bilaterally although clear
bilaterally
## ABDOMEN:
Normoactive bowel sounds, obese, mildly distended,
marked epigastric tenderness with guarding, no rebound, mild
hepatomegaly, negative sign.
## EXTREMITIES:
No c/c/e. 2+ radial and DP bilaterally
## IMAGING:
CXR:
Lungs are clear. There is no pneumonia. There is no pleural
effusion or pneumothorax. Hilar, mediastinal, and cardiac
silhouettes are
within normal limits.
Please note that the right costophrenic angle was cut off from
projection.
## BRIEF HOSPITAL COURSE:
Mr. is yo man with a history of CAD and recurrent
idiopathic pancreatitis who presents with sudden onset abdominal
pain starting the day prior to admission.
# Epigastric pain: The source of his abdominal pain remains
unclear although it is chronic and idiopathic in nature.
Suspect it is idiopathic pancreatitis but partial SBO or ulcer
disease is in differential. Workup for other etiologies
including triglycerides and gallbladder evaluation have been
normal in the past. Pt just had outpt MRCP with an essentially
normal apppearing pancreas. Trigs 219 in . He had an
elevated lipase on admission and was fluid resuscitated with
2.5L NS given history of grade I diastolic dysfunction seen in
. Patient was told to be NPO over night but ate some soup
and crackers brought in from home without pain. While NPO the
morning of discharge, he ate a sandwich without pain and
said his pain was only . He is scheduled for endoscopy at
the end of this month with his GI physician .
# CAD: History of multiple stents to the LAD, RCA stents in ,
with multiple episodes of restenosis, MI in . He has not
been taking Plavix x months and was educated in the
importance of resuming all of his medications including beta
blocker, ACE-I and statin.
## # HYPERCHOLESTEROLEMIA:
Continued simvastatin
# Hypertension: His systolic blood pressures were all in the low
100s. He takes a beta blocker and ACEI at home.
# ARF: Creatinine elevated to 1.3 with baseline 1.1. Suspect
this may have been prerenal secondary to poor PO intake.
## MEDICATIONS ON ADMISSION:
(patient says he had not taken these for months)
Aspirin 325 mg Daily
Clopidogrel 75 mg Daily
Ranitidine HCl 150 mg BID
Simvastatin 80 mg Tablet Daily
Nitroglycerin 0.4 mg SL PRN
Metoprolol Tartrate 50 mg BID
Lisinopril 20 mg BID
## DISCHARGE MEDICATIONS:
1. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual asdir as needed for chest pain.
## DISCHARGE CONDITION:
stable, pain improved, tolerating POs
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital for severe epigastric pain.
Your pain was controlled with morphine, and you were told to not
eat or drink. Your pain improved, and you tolerated some food
and liquids. You should have a low fat, bland diet at home.
Please follow-up with your PCP and Dr. .
No changes were made to your medications. If your insurance
does not fill Ranitidine, you can take Zantac over the counter.
If you experience worsening abdominal pain, nausea, vomiting,
fevers, chills, chest pain or difficulty breathing, please call
your doctor or come to the ED.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11354313", "visit_id": "20308777", "time": "2173-01-19 00:00:00"} |
18588433-RR-92 | 176 | ## REASON:
year old man with visual symptoms ? TIA. History of heart disease
## FINDINGS:
Duplex evaluation was performed of bilateral carotid arteries. On
the right there is no plaque seen in the ICA. On the left there is no plaque
seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 49/14, 67/19, 61/21, cm/sec. CCA peak systolic
velocity is 77 cm/sec. ECA peak systolic velocity is 49 cm/sec. The ICA/CCA
ratio is .87 These findings are consistent with no stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 66/17, 66/27, 69/22, cm/sec. CCA peak systolic
velocity is 107 cm/sec. ECA peak systolic velocity is 86 cm/sec. The ICA/CCA
ratio is .64. These findings are consistent with no stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
## IMPRESSION:
Right ICA with no stenosis.
Left ICA with no stenosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18588433", "visit_id": "N/A", "time": "2139-11-17 13:59:00"} |
13512565-DS-20 | 734 | ## ALLERGIES:
Sulfa (Sulfonamide Antibiotics) / Keflex
## HISTORY OF PRESENT ILLNESS:
This is a y/o female with a history notable for
nephrolithiasis, h/o cdiff keflex), and depression,
who presents with acute epigastric abdominal pain, nausea and
vomiting x 2 days. Patient reports that her pain began
yesterday afternoon as sharp, epigastric pain without radiation
, with continuous episodes of nausea and vomiting
(non-bloody, non-bilious). The vomiting helped with her
abdominal pain slightly. She had chills, but no fevers or
sweats. No diarrhea.
.
She presented to this morning due to persistent
symptoms, where exam was significant for epigastric TTP,
negative sign. Labs were notable for a lipase of 737
and AST/ALT in the 200s. A RUQ u/s demonstrated small
gallstones in the gallbladder with 4mm wall thickening of the
GB, no fluid - ? acute vs. chronic cholecystitis. She was given
IVF, zofran 4 mg IV x 1, and dilaudid 1 mg x 1. She was
subsequently transferred to for possible ERCP.
.
In the ED here, VS 99.2, 124/60, 88, 18, SaO2 98/RA. She did
not receive any medications or IVF. She reports she has not had
any further pain or vomiting since transfer from . Pain
is currently . She denies any new complaints. No changes
in urination or stool.
.
## ROS:
10-point ROS is otherwise negative except for noted as
above.
Ms. is a F with a medical history notable for
Began to note epigastric and left-sided abdominal pain on .
She . Her evaluation in
was notable for a lipase of 700 and an ultrasound that revealed
cholelithiasis
Vital signs on arrival to ED: T 99.2, P 88, BP 124/60, 98%
on RA. In the ED she received IV fluids.
## PAST MEDICAL HISTORY:
Hyperlipidemia
Depression
Allergic rhinitis
h/o nephrolithiasis
h/o cdiff colitis
s/p tubal ligatgion
## FAMILY HISTORY:
CAD s/p CABG in both parents
## GENERAL:
Pleasant, well-appearing female in NAD, AO x 3.
## HEENT:
NC/AT, PERRL, EOMI. Anicteric sclerae. MM slightly dry,
OP clear.
## CV:
RRR s1 s2 normal, no m/g/r
## ABD:
soft, NT/ND, NABS. No HSM. Negative
## NEURO:
AO x 3, non-focal exam
## IMPRESSION:
1. Cholelithiasis and choledocholithiasis with distal 3mm CBD
stone. Common duct is not abnormally dilated.
2. No MR evidence of pancreatitis or complications from
pancreatitis.
3. Renal haemorrhagic or proteinaceous cysts.
## BRIEF HOSPITAL COURSE:
y/o female with minimal medical history who was admitted with
nausea, vomiting and abdominal pain that was likely due to
gallstone pancreatitis. Her symptoms actually spontaneously
resolved at the outside hospital. By hospital day 2, she denied
any abdominal pain, nausea, vomiting or any symptoms at all with
teh exception of a headache which she experiences when she
misses her paroxetine (held because she was NPO). Her diet was
advanced to sips and a MRCP was performed, which revealed a ile duct stone without any dilation of the common bile
duct. This result was discussed with the ERCP fellow who stated
that the patient did not need an ERCP during this admission but
would need one prior to her cholecystectomy. The ERCP will be
arranged for early next week as an outpatient. She will also
need a cholecystectomy at some point in the near future.
Remainder of hospital course per problem:
1. Gallstone pancreatitis - as above. She was managed
conservatively with bowel rest and NPO and IVF. She quickly
improved and her lab values normalized very quickly. She will
need ERCP prior to CCY. This will be performed as an
outpatient.
2. Cholecystitis - She was treated with Unasyn while in house
but was not discharged on any antibiotics.
3. Hyperlipidemia - Her simvastatin was held during this
admission but can be restarted at this time.
4. Depression - She was continued on her paroxetine.
## MEDICATIONS ON ADMISSION:
Confirmed with patient:
Simvastatin 20 mg daily
Paxil 20 mg daily tabs daily, currently on 45 mg daily)
Flonase 50 mcg 1 spray to each nostril twice daily
Miralax 2x/weekly
## DISCHARGE INSTRUCTIONS:
You were admitted with gallstone pancreatitis. Your symptoms
improved spontaneously. You had a MRCP that showed a 3 mm stone
in the common bile duct. You will need to follow-up with GI to
have an ERCP performed early next week. You were also noted to
have gall bladder wall thickening and likely cholecystitis. You
were treated with antibiotics while hospitalized but do not need
to continue these after discharge.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13512565", "visit_id": "20449835", "time": "2113-07-14 00:00:00"} |
16800364-RR-13 | 94 | ## HISTORY:
Falls and altered mental status.
## FINDINGS:
There is no acute fracture or malalignment. Minimal unchanged
retrolisthesis is seen of C5 on C6 with accompanying degenerative changes at
this level resulting in mild to moderate canal narrowing due to disc
osteophyte complex. Prevertebral soft tissues are difficult to assess due to
intubation but appear unremarkable. Soft tissues of the neck including the
thyroid gland are normal. The imaged lung apices demonstrate postsurgical
changes on the right and are otherwise clear. Old left clavicular fracture is
noted.
## IMPRESSION:
No acute fracture or malalignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16800364", "visit_id": "27037153", "time": "2133-06-15 17:13:00"} |
17984725-RR-18 | 103 | BONE DENSITOMETRY EXAM PERFORMED ON .
## FINDINGS:
The bone mineral density measurement of L1 through L4 of the lumbar
spine is 0.956 g/cm2, which corresponds with a T-score of -1.9 and a Z-score
of -0.3. This measurement corresponds within the osteopenic range by WHO
criteria. Within the femoral necks bilaterally, there is a mean bone mineral
density measurement of 0.776 g/cm2 corresponding to a T-score of -1.9 and a
Z-score of -0.4. Findings correspond within osteopenic range.
## IMPRESSION:
By WHO criteria, patient has osteopenia within the femoral necks
and lumbar spine.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17984725", "visit_id": "N/A", "time": "2129-06-01 13:12:00"} |
13724605-RR-113 | 116 | ## INDICATION:
year old man with AMS, hypercarbic respiratory failure, and
now new urinary retention and . Previously noted to have bladder stones and
ureteral stones, nonobstructing.// eval for hydronephrosis and bladder stones
## FINDINGS:
There is no hydronephrosis, stones, or solid masses bilaterally. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally. There is a 0.9 cm cyst in the right kidney. 2 small syone are
present in he lower pole of the left kidney measuring 5.4 mm and 9.8 mm
Right kidney: 9.1 cm
Left kidney: 11.1 cm
The bladder is moderately well distended and contains a 1.8 cm stone..
## IMPRESSION:
Non obstructing sub-cm renal stones.
Bladder calculus..
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13724605", "visit_id": "29628073", "time": "2158-12-05 12:52:00"} |
14761652-RR-11 | 131 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
with fall w/headstrike, no loss of consciousness, evaluate
for intracranial injury.
## FINDINGS:
There is no evidence of acute major infarction, hemorrhage, edema, orlarge
mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. Mild periventricular hypodensities are noted,
nonspecific but likely reflect mild chronic small vessel disease. There is no
evidence of fracture. Left periorbital soft tissue swelling is present.
There is minimal mucosal thickening in the bilateral ethmoid air cells. The
remaining visualized portion of the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. A left lens replacement is noted.
Atherosclerotic calcifications of the carotid siphons are present.
## IMPRESSION:
1. No acute intracranial process.
2. Left periorbital soft tissue swelling without underlying calvarial
fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14761652", "visit_id": "N/A", "time": "2132-04-17 17:17:00"} |
12916974-RR-29 | 149 | ## HISTORY:
Line placement.
Shortly after the study, a preliminary interpretation was provided by A.
, which stated " new left subclavian line extends to upper SVC, tip
positioned against the right lateral SVC wall. Prior right subclavian line
unchanged, tip in SVC as well. Small bore feeding tube and tracheostomy
unchanged. Distended stomach. Retrocardiac opacity appears improved favoring
atelectasis. No pneumothorax."
## CHEST, SEMI-UPRIGHT AP:
There is a new left subclavian central venous
catheter terminating in the upper superior vena cava. A right subclavian
venous catheter is unchanged, terminating in the lower superior vena cava. A
feeding tube again courses into the stomach, its inferior extent not
visualized. The patient also has a tracheostomy. The patient is status post
posterior fusion of the cervicothoracic junction. The cardiac and mediastinal
contours are unchanged. Left lower lobe opacification has improved, as has
minor right mid lung atelectasis. There is no pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12916974", "visit_id": "23183828", "time": "2162-07-09 17:02:00"} |
14631974-RR-26 | 434 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
year old man with metastatic esophageal cancer evaluate for
response to treatment.
## ONCOLOGY 2 PHASE:
Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV contrast was
injected and the abdomen and pelvis were scanned in the portal venous phase,
followed by scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## LOWER CHEST:
A right pleural effusion is present. Please refer to separate
report of CT chest performed on the same day for description of the thoracic
findings.
## HEPATOBILIARY:
Perihepatic ascites is present. The liver demonstrates
homogenous attenuation throughout. There are unchanged punctate focal
calcifications. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder wall is prominent due to fluid status.
## 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. There are
unchanged punctate focal calcifications.
## 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 hydronephrosis. In the lower and mid poles of the
right kidney are round hypodensities, the largest of which measures 1.5 x 1.7
x 1.8 cm, which are unchanged from previous examination and consistent with
simple cysts. 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 not visualized.
There is mild omental thickening.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis. Enhancing peritoneum is seen the pelvis which is
unchanged from prior examination.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy by CT
size criteria. There is no pelvic or inguinal lymphadenopathy by CT size
criteria.
## VASCULAR:
An infrarenal abdominal aortic aneurysm is unchanged from prior
examination, measuring 3.2 cm, maximally. Moderate atherosclerotic disease is
noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Mild omental thickening and enhancing peritoneum in the pelvis, unchanged
from prior examination.
2. No pathologic lymphadenopathy by CT size criteria.
3. Moderate ascites.
4. Stable abdominal aortic aneurysm.
5. Splenic and hepatic calcifications consistent with prior granulomatous
disease, unchanged.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14631974", "visit_id": "28649966", "time": "2114-04-05 14:47:00"} |
15488784-DS-2 | 909 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
The pt is a y/o woman who was diagnosed with dementia
Alzheimer's type by Dr she was seen . The history was gathered from the son but unfortunately he
himself was a bit stressed and scattered so the history is a bit
sparse at this time. From what is gathered though is that her
problems started about years ago, I think a personality change
was what was noticed first, agitation was the main thing but
also memory issues. Over the last years it seems that her
problems have worsened over a gradual non-step like process. The
son had a list of things that have been going on his phone. He
states that she gets agitated, confrontational, occasionally
with the use of a knife. She has also been hoarding thins saying
she is OCD and would frequently be found going out of the house
with multiple items. She will frequently think people are
harassing her and will accuse people of things. She frequently
leaves the stove on and places plates over the stove until they
et hot. Her symptoms
seem to get worse at night. I asked what medications she was
tried on but he was not really able to say. Per Dr
note the GP tried Ativan but this made things worse. I
mentioned this to the son but he was not sure. The son overall
feels very overwhelmed and does not feel safe managing her
further at home.
The patient herself has no complaints.
ROS was negative to SOB, CP, headache, changes to vision,
trouble with walking, dysuria, vertigo, or muscle or joint pain.
## PAST MEDICAL HISTORY:
Dementia
HTN - not on any medications
Depression
GERD
## FAMILY HISTORY:
Her daughter recently passed away from a and the patients
mother also passed away from a .
## EXTREMITIES:
No edema or deformities.
## SKIN:
no rashes or lesions noted.
## NEUROLOGIC:
Alert but not oriented. Very distractible and tangential thought
process. Only oriented to self, was not able to tell me where
she was at, what type of place this is. Would call her son
husband and sometimes self correct. She was able to tell me her
age. her language was often empty. + logorrhea. Would make
inappropriate comments towards the examiner including saying I
was very good looking. She would grab my hand and kiss it and at
one time tried to kiss my face. She had difficulty with one step
commands most of the time and was not able to complete a two
step command. Was able to read a sentence on the card but
on naming was only able to name the key, and chair. Called the
glove a PAD, the feather hair and was not able to name the other
items. Not able to test praxis.
## II:
PERRL 3 to 2mm and brisk.
## XI:
strength in trapezii bilaterally.
## XII:
Tongue protrudes in midline.
## - MOTOR:
Normal bulk, tone throughout. Strength was full
bilaterally in the upper and lower extremities given the limited
exam.
## -SENSORY:
unable to test
-DTRs:
Bi Tri Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was equivocal bilaterally.
====================
## GEN:
patient lying in bed, appears comfortable. large ecchymosis
on right bicep.
## MENTAL STATUS:
alert, awake, more attentive than admission but
unable to formally test. not oriented to place (thinks she is at
home) or time (states "i don't know"). appears calmer and less
distracted than previously today. Answers simple questions and
follows simple directions.
## MOTOR EXAM:
able to ambulate on her own.
## MICRO:
03:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
03:30PM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
UCx contaminated
## BRIEF HOSPITAL COURSE:
yo woman with progressive dementia characterized by worsening
behavioral issues/agitation at home, who was brought into ED by
her family for increasing agitation. Toxic metabolic work up was
done and she was treated with IV ceftriaxone for likely urinary
tract infection. Unfortunately, patient continued to be agitated
in the hospital, with likely component of acute hyperactive
delirium, which could be from being in a new strange
environment, concurrent infection (UTI) or reversed sleep-wake
cycle. She was started on low dose rivastigmine for her
dementia, and was evaluated by psych given family's concerns.
She was started on low dose seroquel for sleep, and zyprexa prn
for agitation with some improvement. Psychiatry recommended
starting celexa for ?depression.
## MEDICATIONS ON ADMISSION:
trazodone (unknown dosage, taking it during the day)
prilosec
## DISCHARGE MEDICATIONS:
1. Bisacodyl 10 mg PO/PR BID:PRN constipation
2. Citalopram 10 mg PO DAILY
3. Glycerin Supps AILY:PRN constipation
4. Omeprazole 20 mg PO DAILY
5. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN agitation
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Quetiapine Fumarate 25 mg PO QHS
8. rivastigmine *NF* 1.5 mg Oral Daily Reason for Ordering:
Starting medication in house
## PRIMARY DIAGNOSIS:
likely frontotemporal dementia, urinary tract
infection, constipation
## MENTAL STATUS:
Confused - most of the time.
## MENTAL STATUS:
Confused - most of the time.
## DISCHARGE INSTRUCTIONS:
Dear were admitted to the hospital because of the worsening
dementia and behavioral issues at home. were managed with
medications to control agitation. Your urinary tract infection
was treated with antibiotics.
are being transferred to inpatient geriatric psychiatric
unit for further management of your dementia and behavioral
issues.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15488784", "visit_id": "25833206", "time": "2189-03-29 00:00:00"} |
18194969-DS-56 | 1,047 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Ms. is a pleasant w/ CNS lymphoma admitted for C34
methotrexate. The patient states she has been feeling well and
has not have any illnesses since her last admission. She denies
any fever, cough, sore throat, dizziness, shortness of breath,
nausea, diarrhea, or dysuria. She admits to word finding
difficulty which she expressed to her neuro-oncologist. SHe was
started on keppra for possible seizures but this did not improve
and her word finding difficulty has not been interfering with
her
ability to live life to her fullest and hence keppra was
discontinued.
She has otherwise felt well and has no other neurological
deficits. She notes she has been working out at the gym every
day. She presented on for HD MTX but had worsening URI and
so returned today.
## PAST ONCOLOGIC HISTORY (PER OMR):
Reading problems started
Difficulty speaking
MRI showed left temporal brain mass
Brain biopsy by Dr. : DLBCL, highly atypical lymphoid infiltrate composed
of large cells with blastic chromatin and scant cytoplasm,
perivascular preservation of tumor viability with significant
apoptosis and necrosis away from vascular structures. Mitotic
figures, including atypical mitoses, are prominent. CD20, CD45,
and BCL-6 positive, and CD3, GFAP, TdT, BCL-1, CD10 and Kappa
and lambda light chain negative. A LMP-1 stain is equivocal,
MIB-1
>90%. EBV encoded RNA stain pending.
Admission, port placement
Slit lamp examination negative
CSF negative
C1 MTX 8g/m2 dose reduced by 29% GFR 71 ml/min
MTX 8g/m2 dose reduced by 29% GFR 81 ml/min
C3 MTX 8g/m2 dose reduced by 20% GFR 83 ml/min
C4 MTX 8g/m2 dose reduced by 30% GFR 77 ml/min
Brain MRI showed CR
C5 MTX 8g/m2 dose reduced by 30% GFR 85 ml/min
C6 MTX 8g/m2 dose reduced by 30% GFR 93 ml/min
C7 MTX 8g/m2 dose reduced by 30%
Brain MRI stable
Endovascular repair of port
C8 (C5) MTX 8g/m2 dose reduced by 37 %
C9 MTX 8g/m2 dose reduced by 37% GFR 75 ml/min
Slit lamp examination negative
Brain MRI stable
C10 MTX 8g/m2 dose reduced by 60% GFR 41 ml/min
C11 MTX 8g/m2 dose reduced by 60% GFR 83 ml/min
Brain MRI stable
C12 MTX 8g/m2 dose reduced by 20% GFR 89 ml/min
C13 MTX 8g/m2 dose reduced by 34% GFR 66 ml/min
Brain MRI stable
C14 MTX 8g/m2 dose reduced by 20% GFR 86 ml/min
C15 MTX 8g/m2 dose reduced by 20% GFR 80 ml/min
Brain MRI stable
C16 MTX 8g/m2 dose reduced by 20% GFR 80 ml/min
C17 MTX 8g/m2 dose reduced by 20% GFR 92 ml/min
C18 MTX 8g/m2 dose reduced by 20% GFR 124 ml/min
Brain MRI stable
C19 MTX 8g/m2 dose reduced by 20% GFR 90 ml/min
Brain MRI stable
C20 MTX 8g/m2 dose reduced by 20% GFR 76 ml/min
Brain MRI stable
C21 MTX 8g/m2 dose reduced by 20% GFR 61 ml/min
Brain MRI stable
C22 MTX 8g/m2 dose reduced by 20% GFR 92 ml/min
Brain MRI stable
C23 MTX 8g/m2 dose reduced by 20% GFR 76 ml/min
Brain MRI stable
C24 MTX 8g/m2 dose reduced by 20% GFR 74 ml/min
Brain MRI stable
C25 MTX 8g/m2 dose reduced by 20% GFR 73 ml/min
Brain MRI stable
C26 MTX 8g/m2 dose reduced by 20% GFR 72 ml/min
Brain MRI stable
C27 MTX 8g/m2 dose reduced by 20% GFR 73 ml/min
Brain MRI stable
C27 MTX 6.4g/m2 dose reduced by 20%
C28 MTX
C29 MTX
C30 MTX
C31 MTX
- C32 MTX
- C33 MTX
admit for C34 MTX
## PAST MEDICAL HISTORY:
1. Depression, anxiety
2. Bilateral knee replacements
3. Left hip replacement
4. Right hemi-thyroidectomy
5. Reported having an inflammatory bowel disease, treated with
meselamine
6. Diverticulosis
7. Lumbar scoliosis
8. Hiatal hernia
9. Umbilical hernia
10. Pectus excavatum
11. Spleen rupture
## FAMILY HISTORY:
Mother had colon cancer in her .
Father deceased at young age from cardiac disease.
## CV:
RR, NL S1S2 no S3S4
## SKIN:
No rashes on extremities
## NEURO:
Alert and oriented, no focal deficits.
## PRELIMINARY READ:
1. Stable FLAIR hyperintensity in the left periventricular white
matter
surrounding the occipital and temporal lobes with mild volume
loss. This is most likely posttreatment in etiology. No new/
residual area of enhancement.
2. Age-related involutional changes and findings of small vessel
ischemic.
## BRIEF HOSPITAL COURSE:
with a history of left temporal CNS lymphoma who was
admitted for q4 month C34 HD MTX.
CNS Large B-cell Lymphoma
She received C34 HD MTX at . She tolerated
chemotherapy well but within hours of her chemo infusion, she
developed profound nausea. This improved well with lorazepam as
well as zofran. She had expected mild transaminitis and
hypokalemia which were improving by the time of discharge. She
had a brain MRI which showed no obvious changes on the
preliminary read and should the final read should be followed up
as an outpatient. She will return on for her next cycle
of methotrexate.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 75 mg PO BID
2. LORazepam 0.5 mg PO QHS:PRN insomnia
3. Aspirin 81 mg PO DAILY
4. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN rash
## DISCHARGE MEDICATIONS:
1. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN rash
2. LORazepam 0.5 mg PO QHS:PRN insomnia
3. Venlafaxine XR 75 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
## DISCHARGE INSTRUCTIONS:
You were admitted for high dose methotrexate. You tolerated this
well but you had a lot of nausea on your first night. Please
discuss with your doctor on the next admission taking ativan
right away every hours to help avoid the wave of nausea. In
addition, you should not take aspirin the morning of your next
admission. You should talk to your primary care doctor Dr.
you should be taking this medication.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18194969", "visit_id": "28969993", "time": "2192-03-14 00:00:00"} |
10433204-RR-143 | 309 | ## EXAMINATION:
LEFT BREAST VACUUM-ASSISTED TOMOSYNTHESIS-GUIDED CORE BIOPSY
WITH CLIP PLACEMENT; AND POST-PROCEDURE LEFT DIGITAL MAMMOGRAM
## INDICATION:
woman with subtle architectural distortion in the
left breast. Request for stereotactic core biopsy.
## FINDINGS:
Subtle distortion in the outer left breast at posterior depth was targeted for
biopsy.
## CONSENT:
The procedure, risks, benefits and alternatives were
discussed with the patient and written informed consent was obtained.
Time-out certification: Performed using three patient identifiers, with
confirmation of side and site.
Allergies / Medications: The patient's medication list and history of
allergies were reviewed prior to beginning the procedure.
## CLINICIANS:
, M.D. , M.D.. The procedure was supervised
by , M.D. (attending).
## DESCRIPTION:
The lesion was localized with tomographic guidance on the upright unit from
the lateral approach. Using standard aseptic technique and local anesthesia, a
small skin incision was made and a standard 9-g needle was advanced to the
architectural distortion. Pre- and post-fire images confirmed the needle was
at the target, and 8 core biopsies were obtained using a vacuum-assisted
biopsy device while additional anesthesia was given. Next, a HydroMark coil
clip was deployed at the biopsy site. The needle was removed and hemostasis
was achieved.
## SPECIMENS:
Sent to pathology, labeled with and without calcifications.
## POST-PROCEDURE MAMMOGRAM:
CC and ML views demonstrate that the clip is
approximately 1 cm lateral to the expected location. There are expected post
biopsy changes with no significant hematoma.
## IMPRESSION:
Technically successful vacuum-assisted tomographic-guided core biopsy of the
left breast distortion. Pathology is pending.
The patient expects to hear the pathology results from Dr. in
business days. Standard post care instructions were provided to the patient.
As the Attending radiologist, I personally supervised the Fellow during the
key components of the above procedure and I reviewed and agree with the
Fellow's findings and dictation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10433204", "visit_id": "N/A", "time": "2159-08-21 12:30:00"} |
10503925-DS-13 | 1,798 | ## :
Exchange of a jejunostomy tube for a new 16 MIC
jejunostomy tube
## :
Cholangiogram; R anchor drain removed with
embolization of tract
## :
10 mm CBD stent placed; right Fr anchor drain; 12
Fr J-tube placement
## :
Right Fr int/ext PTBD placed
## HISTORY OF PRESENT ILLNESS:
Mr is a with hx of gastric adenocarcinoma (s/p
total gastrectomy/Roux-en-Y in at w/liver mets, on
palliative nivolumab) p/w abd pain/nausea to , found to
have transaminitis mets obstruction, transferred to
for
further management
Per Summary, "The patient had been on MS 30
mg
twice a day and oxycodone at home which was not controlling the
pain as well as due to the ongoing nausea and vomiting, he came
into the ER. On workup here he was noted to have transaminitis
with his AST and ALT in the 500-600 range, Alk phosphatase
increased to 930 s bilirubin being elevated to 3.4. His
most recent LFTs few weeks ago were fairly normal. It was
unclear
if this was related to his new immunotherapy ordered this could
be related to obstructive jaundice from the malignancy. He was
seen by gastroenterology, they recommended MRCP which was
performed and this showed multiple intrahepatic metastasis as
well as a extrahepatic mass at the porta hepatis causing
compression and obstruction of the distal CBD. GI recommended
him
to be transferred to for further management given he had
the surgery done there few months ago."
Initially, plan for ERCP w/stent placement, however, upon GI
review of imaging, thought diff anatomy, so plan for guided
stenting. Pt was kept NPO over most of admission, pain control
w/MS-contin and IV dilaudid. Heme-Onc, GI, and Palliative care
teams were consulted. Of note, pt reports that he was started on
Nivolumab ~1wk prior. Pt was seen by Dr as second
opinion, follows oncology at .
Upon arrival to the floor, the patient states that he was
admitted to for worsening nausea since last
week. Nausea is associated with NBNB vomiting.
Pt has had diffuse, constant, dull abdominal pain for
approximately one month which is being treated with oxycodone
and
well controlled.
No fevers/chills. Intermittent constipation but no diarrhea. No
blood in urine or stool. No SOB/CP/cough. Intermittent mild
frontal HA. c/o new dysuria today.
## PAST MEDICAL HISTORY:
1. H. pylori gastritis.
2. History of GERD.
3. Iron deficiency anemia.
4. History of hemorrhoids.
5. Deep venous thrombosis and pulmonary embolism after shoulder
surgery, treated with six months of Coumadin three to years
ago.
## FAMILY HISTORY:
No family history of colon, gastric, esophageal cancer, or IBD
## GENERAL:
Alert and interactive. comfortable
## HEENT:
Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera icteric
and without injection. Oral thrush, MMM
## NECK:
Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
## CARDIAC:
Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
## LUNGS:
Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
## BACK:
No spinous process tenderness. No CVA tenderness.
## ABDOMEN:
+BS, RUQ and LUQ TTP, no guarding or rebound
## EXTREMITIES:
No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
## NEUROLOGIC:
CN2-12 intact. strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated @ 931)
## GENERAL:
Cachectic and chronically ill appearing, appeared
uncomfortable and sad this morning
## HEENT:
Icteric sclera, dry mucosa
## CARDIAC:
Regular rhythm, normal rate.
## LUNGS:
Scattered rhonchi posteriorly, breathing comfortably on
room air
## EXTREMITIES:
No clubbing, cyanosis, or edema. BLE warm.
## NEUROLOGIC:
moving all extremities spontaneously
## FINDINGS:
1. Moderate right intrahepatic biliary dilatation and common
bile duct
dilatation secondary to low CBD obstruction. Cone beam CT
confirms moderate right anterior intrahepatic biliary duct
dilatation with paucity of biliary ducts in the right posterior
and left biliary system secondary to hepatic metastases.
Catheterization of the segment 2 biliary ducts demonstrates mild
dilatation peripherally with long segment stricturing secondary
to central hepatic metastasis. Based on the findings the
decision was made not to obtain left biliary duct access.
## IMPRESSION:
Successful placement of the right anterior internal-external
biliary
drain.
## FINDINGS:
1. Right 10 percutaneous transhepatic internal external
biliary
drainage catheters.
2. Cholangiogram showing distal CBD obstruction. Post stent
deployment and
cholangioplasty demonstrates brisk antegrade flow of contrast
into the
duodenum through the common bile duct stent.
3. Successful exchange of right 10 percutaneous
transhepatic biliary
internal external drainage catheters with new 10 anchor
drain.
## IMPRESSION:
1. Infiltrative soft tissue mass encasing the remnant stomach
extending along the gastrohepatic ligament to the hepatic hilum
and involving the celiac axis, portal vein, SMV, splenic vein
and pancreas as detailed above consistent with invasive local
disease recurrence.
2. Significant interval progression of hepatic metastases as
described. In
particular, there is diffuse metastatic infiltration in the left
lobe with
occlusion of the lateral branch of the left portal vein and
distal branches of the left hepatic vein.
3. New 1.3 cm hyperattenuating focus within the right hepatic
lobe along the periphery of the large hepatic lesion suspicious
for a focal bleed versus pseudoaneurysm. Further evaluation
with a multiphasic CT scan of the abdomen is recommended.
4. 2.5 cm nodule in the region of the left adrenal gland is
suspicious for
left adrenal metastasis.
5. Multiple peritoneal and omental nodules as described are
consistent with
peritoneal carcinomatosis.
6. Enlarged retroperitoneal and mesenteric lymph nodes
consistent with
metastatic lymphadenopathy.
7. Splenic infarct from tumor involvement of the splenic artery.
8. New nodular and ill-defined opacities in the visualized lower
lung fields concerning for metastatic involvement although
superimposed infectious etiologies could also be considered.
## CHOLANGIOGRAM:
1. Right 10 external percutaneous transhepatic biliary
drainage
catheter.
2. Cholangiogram showing patent common bile duct stent with
brisk antegrade
flow. No biliary ductal dilatation.
3. Successful removal of right 10 external percutaneous
transhepatic
biliary drainage catheter with embolization of tract.
## BRIEF HOSPITAL COURSE:
Mr. is a year old man with metastatic HER-2
negative gastric adenocarcinoma s/p neoadjuvant ECF and then EOX
followed by gastrectomy/Roux-en-Y in recently initiated on nivolumab early ,
who presented with nausea, acute on chronic abdominal pain, and
LFTs markedly above baseline secondary to metastatic CBD
obstruction and worsening of disease burden. After discussions
with the patient, his wife and his niece, patient is CMO and
DNR/DNI.
#Acute on chronic abdominal pain
#Nausea
#Hiccups
Patient has chronic abdominal pain and nausea from his
underlying metastatic malignancy. His pain and nausea were not
well controlled at home, and worsened with spread of his
disease. Initially there was hope that biliary
decompression/drainage would help his symptoms, but this was not
the case. Palliative care was consulted for symptom management.
He was on Zofran, metoclopramide, Ativan, morphine pca,
oxycodone and methadone. He was discharged to a hospice center
to focus on pain and symptom management.
#Goals of care
On patient expressed that he wants to focus on being
comfortable, and not undergo aggressive care because it will not
make the cancer better and not help his pain. He asks to be
comfortable, and he and family explicitly do not want lab draws,
imaging or anything that is not going to improve comfort.
Palliative care was consulted during his hospitalization for
symptom management. He was discharged to hospice.
#Obstructive jaundice:
#Metastatic gastric cancer:
Patient is followed by Dr. . He presented as a
transfer from with elevated LFTs/AP/T bili along with
imaging consistent with common bile duct obstruction from
metastatic disease. Imaging also showed worsening
intra-abdominal metastases. Patient underwent cholangiogram with
PTBD placement on , with repeat cholangiogram on with
CBD stent placed. Then on right anchor drain was removed
and tract was emblazed. Labs initially improved with PTBD done
, then uptrended and then remained stable. Palliative care
was consulted for symptom control as above. Dr. was
updated during his hospital stay.
#Leukocytosis
Uptrended his last week of hospitalization, without increase in
LFTs, other focal symptoms or fevers. Differential included
infection vs worsening metastatic disease. No intervention was
done as patient was transitioned to CMO.
#Severe malnutrition
Patient underwent J-tube placement for tubefeeds, but also so
pain medications could be given with less nausea. Tube feeds
were stopped when transitioned to CMO, out of concern that they
may precipitate pain or nausea.
## TRANSITIONAL ISSUES:
#Patient comfort measures only at discharge
#Discharged to
#Code: DNR/DNI, CMO
#Contact: Wife, : Niece, :
on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE Liquid mg PO Q4H:PRN pain
2. Morphine SR (MS 30 mg PO Q8H
3. Pantoprazole 40 mg PO Q12H
4. Polyethylene Glycol 17 g PO DAILY
5. Nivolumab 240 mg IV EVERY TWO WEEKS
6. LORazepam 0.5 mg PO Q6H:PRN anxiety
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Nystatin Oral Suspension 5 mL PO QID
10. Senna 8.6 mg PO BID:PRN constipation
## DISCHARGE MEDICATIONS:
1. ChlorproMAZINE 12.5 mg IV QHS PRN hiccups
RX *chlorpromazine 25 mg/mL 12.5 mg IV PRN Disp #*10 Ampule
## REFILLS:
*0
2. HYDROmorphone (Dilaudid) 0.2-1 mg IVPCA Lockout Interval: 10
minutes Basal Rate: 0.2-1 mg(s)/hour 1-hr Max Limit: 0 mg(s)
## REFILLS:
*0
3. LORazepam 0.5 mg IV Q4H:PRN anxiety, agitation
RX *lorazepam 2 mg/mL 1 mg iv prn agitation Disp #*10 Vial
Refills:*0
4. Methadone 5 mg IV Q8H
RX *methadone 5 mg/0.5 mL 5 mg IV three times a day Disp #*10
## SYRINGE REFILLS:
*0
5. Ondansetron 4 mg IV Q4H PRN nausea/vomiting
6. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
7. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
## DISCHARGE DIAGNOSIS:
Metastatic gastric cancer
Malignant biliary obstruction
Pain and nausea secondary to gastric cancer
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure caring for you during your hospitalization at
the .
WHY WAS I ADMITTED TO THE HOSPITAL?
===========================================
- You were having worsening pain and also elevation in your
liver tests.
WHAT WAS DONE FOR ME IN THE HOSPITAL?
===========================================
- You had a CT scan that unfortunately showed worsening spread
of the cancer.
- You were seen by the interventional radiology doctors, who
placed a stent (like a drainage pipe) to help drain some of the
blockage in the liver caused by the cancer.
- You were seen by the palliative care team, who helped to find
medications to help with your pain and nausea.
- You were discharge to a hospice center, which is a place that
will focus on making sure your pain and nausea are well
controlled.
We wish you the best.
Warmly,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10503925", "visit_id": "25092449", "time": "2147-03-25 00:00:00"} |
15250909-DS-21 | 1,669 | ## CHIEF COMPLAINT:
admitted for venetoclax ramp up
## HISTORY OF PRESENT ILLNESS:
Mr. is an year-old gentleman with relapsed mantle
cell lymphoma. He originally presented in with R axillae
adenopathy and found to have diffuse involvement throughout
chest torso and bone marrow. He underwent 6C of Rituximab &
Bendamustine followed by Rituximab maintenance but noted for
progressive disease in . He then switched to Ibrutinib
which he tolerated well for years now with progressive
disease based on PET imaging. During recent admission for a
pseudomonas POC infection, he underwent a left inguinal LN
biopsy ( ) to confirm disease progression. Unfortunately,
biopsy was only sent for flow and not diagnostic. Flow cytometry
showing mantel cell lymphoma. He presents again
for continued venetoclax ramp up and close monitoring for tumor
lysis syndrome.
## INTERVAL HISTORY:
NAE. Reports feeling well since recent
discharge. Continue with hip pain - did take oxycodone and
tylenol intermittently at home with improvement. No discomfort
at previous POC site though has some pain on deep palpation.
Denies fevers, chills, rigor, CP, palpitations, SOB, DOE, cough,
headache, dizziness, lightheadedness, nausea, vomiting, diarrhea
constipation (LBM , urinary sxs, rashes and lesions.
## REVIEW OF SYSTEMS:
A complete 10 point ROS was obtained and
negative unless stated above.
## ONCOLOGIC HISTORY
============================
- :
Diagnosed with mantle cell lymphoma with right
axillary biopsy and found to have diffuse involvement on CT
imaging--retroperitoneal, iliac, and inguinal lymphadenopathy as
well as adenopathy in the chest. MCL also found in bone marrow
aspiration and biopsy at the time of diagnosis
## - :
PET CT
1. Extensive lymphadenopathy extending from the right
supraclavicular region and into the right axilla demonstrating
intense FDG avidity, compatible with lymphoma.
2. Small right retrocrural lymph nodes demonstrating mildly
increased FDG avidity up to an SUV max of 4.5, suspicious for
lymphomatous involvement.
3. Increased FDG avidity within the left hip joint is likely due
to inflammation given the extensive sclerotic and cystic changes
involving the left femoral head and adjacent acetabulum.
4. Other incidental findings include cholelithiasis, mild
diverticulosis, and prostatomegaly.
## - :
PET CT
1. Significant interval decrease in size and FDG avidity of
right supraclavicular and right axillary lymph nodes but with
SUV max values remaining higher than the liver, thus
4.
2. Interval resolution of retrocrural lymph nodes.
## - :
PET CT
1. Resolution of right supraclavicular lymphadenopathy and FDG
avidity, and near resolution of right axillary lymphadenopathy
and FDG avidity suggests treatment response without evidence of
new lesions.
2. Cholelithiasis.
3. Diverticulosis.
## - :
Admission for fevers and viral URI symptoms with
EKG and TTE consistent with acute viral pericarditis. He had a
small L pleural effusion and associated atelectasis that was
likely just spill-over from his pericardial effusion. Treated
with a 5-day CAP antibiotic course.
## - :
PET
1. No FDG avid lymphadenopathy within the abdomen or pelvis.
1.
2. Mild pericardial thickening is slightly improved in
comparison to .
3. Layering left pleural effusion is slightly increased in size
from the prior CT chest with associated compressive atelectasis
in the left lower lobe.
## TREATMENT HISTORY:
-BR X 6 cycles
-Maintenance rituximab q3 months
-Progressive disease: Started ibrutinib
-Progressive disease via PET
PAST MEDICAL HISTORY
===========================
-MCL
-BPH
-Hypothyroidism
-OA
-Diffuse joint pain after MVA
-PPD Positive
-Vitamin D deficiency
-Pericarditis
-Iron deficiency
-s/p hip fracture
-Bilateral foot/ankle surgery
- : Left hip surgery after MVA and had further surgery
(details unclear)
-Left wrist and forearm surgery after MVA
## FAMILY HISTORY:
No family history of hematologic or oncologic conditions
## GEN:
Sitting up at side of bed in NAD
## HEENT:
MMM. No OP lesion. No palpable cervical, supraclavicular,
or axillary LAD
## CV:
Regular, normal S1 and S2. No S3, S4, or murmurs
## PULM:
Clear to auscultation bilaterally
## ABD:
BS+, soft, non-tender/non-distended, no masses or HSM
## LIMBS:
Trace BLE edema, no inguinal adenopathy. Hyperpigmented
skin on bilateral shin (not new).
## SKIN:
Left CW site of prior POC-CDI, no bleeding or drainage.
Non-tender on palpation.
## NEURO:
Grossly non-focal, alert and oriented x3
## GEN:
Sitting up at side of bed in NAD
## HEENT:
MMM. No OP lesion. No palpable cervical, supraclavicular,
or axillary LAD
## CV:
Regular, normal S1 and S2. No S3, S4, or murmurs
## PULM:
Clear to auscultation bilaterally
## ABD:
BS+, soft, non-tender/non-distended, no masses or HSM
## LIMBS:
Trace BLE edema, no inguinal adenopathy. Hyperpigmented
skin on bilateral shin (not new).
## SKIN:
Left CW site of prior POC-CDI, no bleeding or drainage.
Non-tender on palpation.
## NEURO:
Grossly non-focal, alert and oriented x3
## PERTINENT RESULTS:
ADMISSION LABS
========================
WBC-5.7 RBC-3.84* Hgb-9.0* Hct-30.5* MCV-79* MCH-23.4*
MCHC-29.5* RDW-16.7* RDWSD-47.6* Plt Neuts-63.5
Monos-12.8 Eos-0.5* Baso-0.5 Im
AbsNeut-3.61 AbsLymp-1.27 AbsMono-0.73 AbsEos-0.03* AbsBaso-0.03
Plt Glucose-78 UreaN-14 Creat-1.0 Na-144 K-4.5 Cl-106
HCO3-25 AnGap-13 ALT-10 AST-20 LD(LDH)-208 AlkPhos-59
TotBili-0.4 Albumin-3.8 Calcium-8.7 Phos-3.4 Mg-1.8 UricAcd-3.9
DISCHARGE LABS
===========================
07:15AM BLOOD WBC-4.4 RBC-3.69* Hgb-8.6* Hct-29.3*
MCV-79* MCH-23.3* MCHC-29.4* RDW-16.5* RDWSD-47.5* Plt
Neuts-46.6 Monos-14.7* Eos-1.1 Baso-0.5 Im
AbsNeut-2.06 AbsLymp-1.63 AbsMono-0.65 AbsEos-0.05 AbsBaso-0.02
Plt Glucose-79 UreaN-17 Creat-1.0 Na-143 K-4.1 Cl-109*
HCO3-24 AnGap-10 ALT-10 AST-18 LD(LDH)-170 AlkPhos-50
TotBili-0.4 Albumin-3.2* Calcium-7.9* Phos-3.4 Mg-1.6
UricAcd-3. n year-old male with relapsed mantle cell lymphoma currently
on ibrutinib and venetoclax and admitted for venetoclax ramp up
and close TLS monitoring.
Acute Conditions
=======================
#Relapsed Mantle Cell Lymphoma:
#Encounter for Chemotherapy:
Progressive disease based on PET . Currently, he is not a
candidate for CAR-T trial. Underwent left inguinal LN biopsy
( ) to confirm disease progression. Unfortunately, biopsy
was only sent for flow and is not diagnostic. Flow cytometry
showing mantle cell lymphoma. He presents for continued
initiation of venetoclax with close monitoring for TLS and
continued ibrutinib 560mg PO daily per primary oncologist. He
had no evidence of TLS. He will re-admitted on for dose
ramp up of venetoclax as outlined below.
Treatment Plan
-Venetoclax schedule as follows:
-Week 1: 50mg daily x7D (D1:
-Week 2: 100mg x7D ( )
-Week 3: 200mg x 12D ( ) as week 4 will be
delayed
-Week 4 was to start on but due to scheduling constraint
with his HCP, plan to start 400mg dosing on (patient
will be readmitted on for dose ramp-up)
-Continue Ibrutinib 560mg PO daily
-Continues on allopurinol for TLS prevention
-Continue acyclovir for infectious prophylaxis
## #CINV:
No acute vomiting. Likely venetoclax and ibrutinib
combination. He was managed with zofran.
Chronic/Resolved/Stable Conditions
========================================
## #PSEUDOMONAS POC INFECTION:
Resolved. Noted for acute pain upon
accessing PORT on . There was also evidence of
surrounding erythema. POC removed in on . Initiated
Vancomycin empirically (D1: but discontinued
when wound culture grew pseudomonas. His abx was transitioned to
cefepime
(D1: . ID consulted. Noted for persistent
swelling at site of POC removal. Obtained left chest wall US
which showed an encapsulated seroma. He underwent aspiration per
of the content on . Culture data from revealed
no growth. Given clinical stability and sensitivities, he was
switched to ciprofloxacin on and completed a 2 week
course on .
## #PERICARDITIS:
Resolved. Likely idiopathic vs. viral. also
have been related to concurrent pneumonia
malignant although repeat PET scan w/o evidence of recurrence of
lymphoma. Decreased colchicine to 0.3mg BID per primary
cardio-oncologist but discontinued completely during recent
admission as felt not needed at this point. Plan to follow up in
4 months.
## #L HIP PAIN:
OA after trauma/car accident. No acute
exacerbation. Has prescription for Oxycodone mg PO q6hrs
but uses medication intermittently.
## #ANEMIA:
Likely disease vs. treatment related. Transfuse if hgb
< 7. No evidence of acute bleeding. He did not require blood
products during his hospital course.
## #HYPOTHYROIDISM:
Continue home dose of levothyroxine.
## #BPH:
Continue home dose of tamsulosin and finasteride.
## CORE MEASURES
================
#ACCESS:
None
#Contact: . Son
on :
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol mg PO DAILY
3. Artificial Tears DROP BOTH EYES PRN dry eyes
4. Finasteride 5 mg PO DAILY
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Tamsulosin 0.4 mg PO QHS
8. venetoclax 100 mg PO QPM
9. ibrutinib 560 mg oral DAILY
10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
## DISCHARGE MEDICATIONS:
1. venetoclax 200 mg PO DAILY
Continue medication until at which point you will be
readmitted for dose increase
2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
3. Acyclovir 400 mg PO Q12H
4. Allopurinol mg PO DAILY
5. Artificial Tears DROP BOTH EYES PRN dry eyes
6. Finasteride 5 mg PO DAILY
7. ibrutinib 560 mg oral DAILY
8. Levothyroxine Sodium 112 mcg PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
10. Senna 8.6 mg PO BID:PRN constipation
11. Tamsulosin 0.4 mg PO QHS
## DISCHARGE DIAGNOSIS:
PRIMARY DIAGNOSIS
=====================
RELAPSED MANTLE CELL LYMPHOMA
ENCOUNTER FOR CHEMOTHERAPY
CINV
ANEMIA
SECONDARY DIAGNOSIS
=========================
HISTORY OF PSEUDOMONAS PORT-A-CATH INFECTION
PERICARDITIS
HYPOTHYROIDISM
BPH
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Mr. ,
You were admitted to continue your incremental dose increase of
venetoclax as part of your treatment for your mantle cell
lymphoma. You were monitored vrey closely for tumor lysis
syndrome (a potential complication of treatment) and you showed
no signs of tumor lysis, are feeling well and will be discharged
home today. Please continue to take all medications as
prescribed and return for admission to continue the dose
escalation on .
Sincerely,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15250909", "visit_id": "29879447", "time": "2111-10-15 00:00:00"} |
12577153-RR-19 | 187 | ## HISTORY:
Advanced maternal age complicating pregnancy.
## FINDINGS:
There is a live in cephalic presentation. The placenta is
anterior. There is no evidence of previa. There is a normal amount of
amniotic fluid with an AFI of 16.4. No fetal morphologic abnormality is
detected. The uterus is normal. No adnexal mass is seen.
The following biometric data were obtained:
## BPD:
86 mm, corresponding to 34 weeks 6 days.
## HC:
311 mm, corresponding to 34 weeks 5 days.
## AC:
298 mm, corresponding to 33 weeks 6 days, 66 percentile based on LMP.
## FL:
64 mm, corresponding to 33 weeks 2 days.
## EFW:
2282 g, 58% based on LMP.
Compared to the prior studies, there has been appropriate growth.
Doppler assessment of the umbilical cord artery shows an S/D ratio of 2.5 with
a normal waveform.
## BPP:
The fetus received 2 points each for breathing, movement, tone, and
amniotic fluid volume for a total score of .
## IMPRESSION:
1. Size 7 days greater than dates. Appropriate growth.
2. BPP . Normal cord Doppler.
The sonographer provided a preliminary report to , NP at time of
patient's appointment .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12577153", "visit_id": "N/A", "time": "2174-12-22 09:43:00"} |
12657083-RR-14 | 122 | ## STUDY:
Bilateral lower extremity veins ultrasound.
## INDICATION:
male with right leg pain, edema, and recent knee
surgery.
## FINDINGS:
Grayscale, color, and pulsed Doppler sonography was performed on
bilateral common femoral, superficial femoral, and popliteal veins.
## RIGHT LOWER EXTREMITY:
The right common femoral vein is patent with normal
compression and flow. A small amount of echogenic thrombus is detected within
the proximal superficial femoral vein which becomes completely occlusive from
the mid superficial femoral vein to the popliteal vein.
## LEFT LOWER EXTREMITY:
Normal flow, compression, augmentation, and waveforms
are demonstrated. No intraluminal thrombus detected.
## IMPRESSION:
Echogenic thrombus within the proximal right superficial femoral
vein which is completely occlusive in the mid right superficial femoral vein
extending into the right popliteal vein.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12657083", "visit_id": "N/A", "time": "2178-11-22 22:38:00"} |
19768190-RR-36 | 87 | ## INDICATION:
Focal asymmetry in the right upper outer breast, prominent on the
mammogram of . Patient here for six-month followup.
GE DIGITAL RIGHT DIAGNOSTIC MAMMOGRAM WITH COMPUTER-AIDED DETECTION:
## IMPRESSION:
Stable asymmetry in the right upper breast. Given six-month
stability, a followup mammogram is recommended in six months at which time the
patient is due for a bilateral mammogram. Findings discussed with the
patient.
BI-RADS 3 -- probably benign. Short-interval followup recommended in six
months and scheduling slip handed out to the patient.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19768190", "visit_id": "N/A", "time": "2149-09-23 13:55:00"} |
12872503-RR-17 | 118 | ## CLINICAL INDICATION:
female with right shoulder fracture
dislocation.
## FINDINGS:
There is an anterior shoulder dislocation with the humeral head dislocated
anteriorly and inferiorly with respect to the glenoid fossa. There is
impaction of the posterior lateral humeral head with the anterior inferior
glenoid consistent with deformity. Osseous fragmentation is seen
lateral to the posterior lateral humeral head from a greater tuberosity
fracture. There is irregularity of the cortex of the anterior inferior
glenoid raises concern for osseous Bankart lesion. The acromioclavicular
joint is preserved. No definite acute rib fractures are seen. Visualized
right lung is grossly clear.
## IMPRESSION:
Anterior shoulder dislocation with deformity, fracture
of the proximal humerus involving the greater tuberosity and possible bony
Bankart.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12872503", "visit_id": "24929324", "time": "2172-06-14 21:21:00"} |
14513439-RR-62 | 163 | ## HISTORY:
Patient on depo with bleeding for 3 months.
## FINDINGS:
Transabdominal and transvaginal ultrasound examinations were performed, the
latter for better visualization of uterine and adnexal structures. The uterus
measures 7.9 x 3.8 x 5.0 cm,enlarged in comparison to the prior study when it
measured 6.6 x 3.1 x 5.5 cm. Fibroids are again visualized with the dominant
posterior fibroid measuring 1.8 x 1.7 x 1.7 cm, enlarged in comparison to the
prior study when it measured 1.0 x 0.8 x 1.0 cm. A right lateral fibroid is
also visualized measuring 1.2 x 0.8 x 1.1 cm. The endometrium is distorted by
the posterior fibroid but non-thickened measuring 7 mm. The ovaries are
normal. There is no free fluid.
## IMPRESSION:
Enlarged fibroid uterus with an interval enlargement of dominant posterior
fibroid. The endometrium is distorted by the posterior fibroid but without
focal abnormalities otherwise.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14513439", "visit_id": "N/A", "time": "2167-01-14 09:26:00"} |
12660864-DS-15 | 1,339 | ## ALLERGIES:
Sulfa (Sulfonamide Antibiotics) / Penicillins / tb test /
morphine
## HISTORY OF PRESENT ILLNESS:
Mrs is a w/ hx of unresectable cholangiocarcinoma s/p
stent on who presents w/ chills, generalized weakness, temp
of 100.2 since yesterday. No vomiting, + nausea and mild
epigastric "sensitivity" without pain. Feels that this is
similar to previous times when she has been admitted for "a
blocked stent".
In the , initial vs were pain score 2 98.7 100 126/78 18 99%
ra. Labs were remarkable for transaminitis, elevated tbili and
alk phos, WBC 12.6 with L shift. EJ was placed as peripheral
access was difficult. Pt refused RUQ US. Blood cultures were
sent. She was given metronidazole and cipro. Vitals on transfer
were 98.7 97 135/91 18 100%
On the floor, pt complains of fatigue, ongoing chills and nausea
nausea. Mild pain around IV site. C/o epigastric sensitivity
without pain. Pt is concerned about her husband as she is his
primary caretaker and he is currently in the awaiting
placement while she is in house.
Review of sytems:
(+) Per HPI
(-) + recent wt loss. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Ten point review of systems is otherwise negative.
## PAST MEDICAL HISTORY:
(per chart, confirmed with pt):
# Cholangiocarcinoma:
-s/p laparoscopic ccy , pathology demonstrated
moderately-differentiated adenocarcinoma involving the cystic
duct.
-Cancer was found to be non-resectable after ex-lap by surgery
in . Ex-lap was c/b wound infection. She had 3 biliary
wall stents by in .
- Previous ERCP-
# Hypertension
# Hypothyroidism
# Gallstone pancreatitis
# Constipation
## FAMILY HISTORY:
(per chart, confirmed with pt):
Daughter passed away of metastatic breast cancer.
Mother passed away from old age, lived to be years old.
Father passed away from a young age, had some disease of the
stomach.
## GENERAL:
Alert, sleepy, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, EJ in place, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
ronchi
## CV:
Regular rate and rhythm, normal S1 + S2, SEM loudest at
RUSB, rubs, gallops
## ABDOMEN:
soft, mild epigastric tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## SKIN:
no lesions or ecchymoses
## NEURO:
aaox3. CNs intact. Strength and sensation grossly
intact
## ERCP:
A 5cm double pigtail biliary stent was placed successfully in
the right intrehepatic system at the completion of the case.
## IMPRESSION:
A metal stent and a double pigtail plastic stent
were found at the major papilla. The plastic stent was removed
with a snare. Multiple overlapping metal biliary stents were
also seen on film
Successful biliary cannulation was achieved with a balloon
catheter and the wire passed easily into the right intrahepatic
system though the multiple overlapping metal stents. Minimal
contrast opacification was used given the evidence of
cholangitis. Multiple balloon sweeps were performed and a
moderate amount of sludge was extracted from the right
intrahepatic system and CBD. Attention was then turned to the
left intrahepeatic system, which is more difficult to access due
to stent overlap. Wire passage was ultimately possible into the
left intrahepatic system, but a biliary dilating balloon and
Oasis stent introducer could not be passed through the stent
interstices in order to allow for dilation. A 5cm double pigtail
biliary stent was placed successfully in the right intrehepatic
system at the completion of the case.
MRCP
## IMPRESSION:
1. Interval increase in the intrahepatic biliary ductal dilation
from likely inspissated bile resulting in biliary obstruction,
with more inspissated material on the left than right. Hepatic
edema, affecting predominantly segments , and IVB with
increased early and delayed enhancement, along with biliary wall
thickening and enhancement suggests ongoing cholangitis in these
regions with less seen in the right lobe. Portal vein is patent.
## NOTE:
It is difficult to demarcate the border of the
inflammatory bile duct
from the site of the cholangiocarcinoma, as there appears to be
continuous
enhancement from within the pancreas to around the intrahepatic
ducts.
2. Stable position of the two right and one left biliary stents,
with the tip of the left biliary stent terminating in the
duodenum.
07:42AM BLOOD TotBili-1. yo F hx of unresectable cholangiocarcinoma admitted with
chills, elevated temp concerning for cholangitis.
# Cholangitis, biliary obstruction, recurrent: Patient
presented with no abd pain however given chills, leukocytosis hx
blocked stent, concerning for recurrent biliary
obstruction/infection. Patient was initially NPO, started on
antibiotics (which she refused) and evaluated by ERCP team. The
ERCP team was concerned that further stenting would not be
helpful and recommended a permanent percutaneous biliary drain
by interventional radiology. Interventional radiology requested
MRCP to further evaluate the patient's anatomy prior to drain
placement and this was obtained. MRCP showed an increase in
biliary ductal diltation and persistent biliary obstruction. The
patient's bilirubin improved and she was afebrile off
antibioitcs. She therefore underwent an abdominal CT scan which
showed persistent obstruction. She underwent guided
percutaneous drain placement on with imoprovement in
LFTs. She did not recieve antibiotics. Her drain was capped and
LFTs continued to improve. She was discharged with the drain
capped. After discussion with interventional radiology, it was
determined that she was not a candidate for internalization of
her drain.
She was advised to leave the drain capped. If she develops dark
urine, she should have her bilirubin checked. If bilirubin is
elevated, she develops fever, increasing draining from around
the tube site or worsening pain she should open the drain. She
will then need to follow up with interventional radiology
or call the main operator and have the fellow
on call paged). Consideration should also be given to starting
antibiotics. If she remains asymptomatic, tube will need to be
changed in 3 months. If she has recurrent cholangitis, she would
benefit from evalation with MRCP given her complicated anatomy
and previous drain placement.
## # CHOLANGIOCARCINOMA:
Radiation and chemo on hold per pt
request. Followed by Dr. ( .
## # SOCIAL:
Each time the patient is admitted her elderly husband
is also admitted and discharged to rehab, as the patient is his
primary caregiver. He is currently at in . The
patient also expressed anxiety at returning to the emergency
department as she has had a difficult time with IV placment in
the past. Patient relations was involved and an alert was placed
in POE.
## # CONSTIPATION:
Continued PRN fleets
.
## # HYPERTENSION:
Continued losartan.
# CODE: DNR/DNI, confirmed with pt
# CONTACT: pt, , step daughter, ,
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Thyroid 60 mg PO DAILY
3. Ursodiol 250 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Fleet Enema AILY:PRN constipation
## DISCHARGE MEDICATIONS:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Fleet Enema AILY:PRN constipation
4. Losartan Potassium 25 mg PO DAILY
5. Thyroid 60 mg PO DAILY
6. Ursodiol 250 mg PO DAILY
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were admitted with pain and chills that you thought might be
a recurrence of your cholangitis. You were seen by the
specialists, who recommended a radiology evaluation to clarify
whether a percutaneous biliary drain would be a better way to
manage your recurrent biliary obstructions.
You had a drain placed into your bile ducts. This drain is
currently capped.
If you notice your urine is getting darker, develop abdominal
pain or fevers, please uncap the drain and attach the bag, since
those are all signs that the drain may be blocked internally.
You then need to see interventional radiology to have the tube
exchanged. In addition, if you notice fluid leaking from around
the tube, please call interventional radiology (number provided
below)
You need to have the tube changed in 3 months.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12660864", "visit_id": "20732648", "time": "2172-03-21 00:00:00"} |
12503315-RR-16 | 96 | ## INDICATION:
year old woman with recurrent R pleural effusion s/p R chest
tube x2 today. // Please assess pleural effusions. Please perform prior to
7AM as results are crucial to determining whether or not to re-tap effusion.
Thank you!
## IMPRESSION:
As compared to chest radiograph, right-sided chest tubes and
pleural catheter remain in place, with a moderate right pleural effusion and a
small right apical hydro pneumothorax. Worsening atelectasis in the right mid
and lower lung. Left lung is remarkable for improving left basilar
atelectasis and slight decrease in small pleural effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12503315", "visit_id": "28320719", "time": "2152-02-25 06:18:00"} |
10862025-RR-10 | 83 | ## FINDINGS:
Lung volumes are low. Heart size is mild to moderately enlarged with a left
ventricular predominance. The aorta is tortuous and diffusely calcified.
There is mild pulmonary edema, similar compared to the most recent exam.
Small left pleural effusion is likely present. There is no pneumothorax
identified. Evaluation of the extreme lung apices is obscured due to the
patient's chin overlying this region. No acute osseous abnormalities are
visualized.
## IMPRESSION:
Mild congestive heart failure and small left pleural effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10862025", "visit_id": "23180260", "time": "2139-01-14 14:20:00"} |
12611327-DS-16 | 766 | ## HISTORY OF PRESENT ILLNESS:
Mrs. is an yo f with h/o breast cancer, anemia and
osteopenia. She presented to her PCP today after experiencing a
brief episode of lightheadedness and palpitations yesterday
after getting off an airplane on her way home from .
She denied any nausea, vomiting, diaphoresis, chest pain,
shortness of breath or loss of consciousness with this episode.
Her symptoms resolved with drinking two glasses of water and
eating lunch. During her evaluation today at her PCP's office
she was found to have new t-wave inversions on her EKG in leads
V3-4. She was advised to go to the Emergency Department for
further evaluation.
## IN THE ED, VS:
T 97.7 HR 60 SpO2 190/78 RR 19 SpO2 98%. She
denied any complaints. Troponin was found to be 0.03 with no
baseline troponin on record and no evidence of renal impairment.
She received aspirin 81 mg po x 4 prior to transfer to the
medicine floor.
Currently, she denies any lightheadedness or dizziness. Her only
complaint is thirst, constipation, and a slight headache which
she attributes to thirst and hunger.
## ROS:
Denies fever, chills, vision changes, recent illness, sick
contacts, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, dysuria.
## PAST MEDICAL HISTORY:
1) Breast Cancer cx s/p excision/xrt/fumara
2) HTN
3) Osteoporosis
4) Primary hyperparathyroidism
5) Cyst at head of pancreas
## GENERAL:
NAD, ao x 3, pleasant, conversant
## HEENT:
NCAT, anicteric sclera, no conjunctival pallor, mmm, no
oral lesions
## LUNG:
CTA B, nonlabored breathing
## ABDOMEN:
soft, ntnd, + bs
## EXT:
warm, dry, no c/c/e, 2+ distal pulses
## NEURO:
no focal deficits, CN grossly intact
## DERM:
no rashes, ulcers, or lesions
.
## EKG:
Sinus bradycardia. Compared to the previous tracing no
diagnostic change.
## CXR:
. Borderline heart size.
2. No focal consolidation or pleural effusion.
## BRIEF HOSPITAL COURSE:
year old female with history of breast cancer, anemia, and
osteopenia presents 24 hours after a presyncopal episode.
##
1. PRESYNCOPE:
Isolated episode of dizziness and
lightheadedness during travel (after long plane flight) in hot
climate after decreased po intake. Presyncopal event was most
likely vasovagal or orthostatic in setting of baseline
bradycardia. Cardiac etiology such as arrhythmia or acute
cardiac syndrome was much less likely. Although patient had
nonspecific EKG findings (new t-wave inversion in V3-4), repeat
EKG showed no interval change and cardiac enzymes were negative
x 3 (0.03 -> 0.03 -> 0.01). Only cardiac risk factors are age
and hypertension, patient had normal stress echo in .
Throughout hospitalization, patient was monitored on telemetry
with no acute events. She had no recurrence of any symptoms.
As an outpatient, patient is scheduled for 24 hour holter
monitor to further assess for arrhythmia. Recommendation for
primary care physician to get repeat Echo is symptoms recur or
cardiac etiology is suspected.
##
2. HTN:
Stable on home medication lisinopril 20 mg po daily.
##
3. ANEMIA:
Hct at baseline 34.9, continued home multivitamin
with iron supplement
## 4. FEN:
Maintained on regular diet
## 5. PPX:
heparin SQ, bowel regimen as needed, fall precautions
## CONTACT:
son
on Admission:
LISINOPRIL 20 mg po daily
ASPIRIN E.C. 81 mg po daily
CALCIUM CARBONATE-VITAMIN D3 (600-400mg) po bid
MULTIVITAMIN WITH IRON-MINERAL [CENTRUM] daily
## DISCHARGE MEDICATIONS:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
## 5. MULTIVITAMIN,TX-MINERALS TABLET SIG:
One (1) Tablet PO
DAILY (Daily).
## DISCHARGE INSTRUCTIONS:
You were admitted after an episode of palpitations and
lightheadedness that occurred while you were traveling. These
symptoms were most likely a manifestation of dehydration and had
resolved at the time of hospitalization. You did not have any
evidence of an abnormal heart rhythm or heart attack. At time of
discharge, you were feeling well with no complaints of further
dizziness, shortness of breath or palpitations.
Please continue to take all of your medications as preciously
prescribed.
Return to the emergency department if you experience any
shortness of breath, chest discomfort, nausea/ vomiting or any
other concerning symptoms.
We recommend that you follow up with your primary care physician
as indicated below, please discuss the possibility of repeating
an echocardiogram. You also have an appointment for a temporary
heart monitor to ensure you are not experiencing transient
abnormal heart rhythms.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12611327", "visit_id": "20872489", "time": "2175-04-26 00:00:00"} |
10191971-DS-9 | 1,969 | ## HISTORY OF PRESENT ILLNESS:
Mr. is a male with past medical history of
COPD, HTN, hypothyroidism, OSA (not on home O2 or CPAP), with
recently diagnosed peripheral T-cell lymphoma who presented with
cough and SOB.
Patient noted approximately day history of progressive
shortness of breath and dry cough. He had a temp of 100.3 a few
days PTA, but otherwise denied f/c/s. Was seen in clinic on DOA
for the above noted concerns, CT chest showed thickening of
bronchial walls, c/f lymphomatous spread. Initial plan was for
direct admit for bronchoscopy. However, while in waiting room in
clinic while waiting for bed, became hypoxic, desatted to in
RA, low on 4L by NC. Sent to ED for emergent eval.
Of note, patient was diagnosed with peripheral T-cell in
of this year after presenting for evaluation erythematous rash,
shortness of breath, lower extremity edema and diffuse bulky
cervical and inguinal lymphadenopathy. He was initiated on
dose-adjusted EPOCH from through the and
received Neulasta on . Patient denies recent sick
contacts.
In ED, initally noted to by hypoxic 86% on RA, tachypneic 24;
set of full vitals (1hr after triage): 98.8 HR 130 BP
144/78, RR 30, 96% on Bipap, last set of ED vitals HR 119, BP
130/72, RR 21, 95% on NC. Meds received: ASA 325mg, Lasix,
methylpred 125mg x2, Duonebs, SL nitro 0.4 mg. EKG with sinus
tachycardia, c/w prior.
On arrival to the MICU, initial vitals were T:98.1 BP:120/81
P:112 R:23 SaO2:86% on 5L. Patient switched to venturi mask with
improvement in sats. Was in NAD, reported his SOB had improved.
Started on vanc, cefepime, and levaquin for empiric HCAP
treatment, and standing nebs/steroids for possible COPD
exacerbation. Was able to be weaned to 1L by NC with sats in
upper on first night in the MICU.
## PAST MEDICAL HISTORY:
- Periphearl T Cell Lymphoma
- Hypothyroidism
- HTN
- COPD
- OSA
- Bilateral cataract surgery
- H/o hepatitis B (core Ab +, viral load negative per report)
## -BROTHER:
Cancer (unknown type) at years of age
-Sister's son: at age
-Mother: DM
## PHYSICAL :
ADMISSION PHYSICAL EXAM
========================
## VITALS:
T 98.1 BP 120/81 P R 20 SaO2 100% on 35% shovel mask
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Bibasilar crackles, worse at right lung base
CV- tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, mild diffuse tenderness/soreness to palpation,
mildly distended, tympanic, bowel sounds present, no rebound
tenderness or guarding, no rigidity, no organomegaly
GU- foley in place draining clear yellow urine
Ext- warm, well perfused, 1+ DP and raidal pulses, no clubbing,
cyanosis; 2+ pitting edema to the knees bilaterally; enlarged
right supraclavicular lymph node, enlarged left inguinal lymph
node
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARG PHYSICAL EXAM
=======================
## GENERAL:
Sitting up in chair, NAD, appears comfortable
## HEENT:
MMM, no OP lesions
## CV:
RRR, nl S1 and S2, no MGR
## PULM:
Improved RLL crackles, otherwise CTAB
## ABD:
BS+, soft, NT, ND
## NEURO:
Alert and oriented x 3
## SKIN:
No rashes or skin breakdown
## MICRO
======
URINE CULTURE (FINAL :
NO GROWTH.
URINE CULTURE (Final : NO GROWTH.
## BLOOD CULTURE, ROUTINE (FINAL :
NO GROWTH.
Blood Culture, Routine (Final : NO GROWTH.
Blood Culture, Routine (Final : NO GROWTH.
Respiratory Viral Culture (Final :
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final :
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
ASPERGILLUS AG,EIA,SERUM Not Detected
B-D-Glucans 45 pg/mL (Negative=Less than 60 pg/mL)
IMAGING
========
## EKG :
Sinus tachycardia with occasional PVCs.
CXR
Right lower lobe consolidation, concerning for early pneumonia.
CT CHEST . New extensive air wall thickening is concerning for diffuse
metastatic disease involving the airways; also with
post-obstructive atelectasis, as in the lingula.
2. There are also multiple bilateral lung nodules, some larger
since which are likely metastasis.
3. Interval response of peripheral and central lymphadenopathy,
which is smaller since .
4. No signs of PE or bone involvement.
CT A/P . Diffuse widespread lymphadenopathy in the abdomen and pelvis,
most of which are stable or smaller in size compared to scan
from .
2. Splenomegaly with old splenic infarct.
CXR
Improvement in right perihilar opacity consistent with improving
infection.
## BRIEF HOSPITAL COURSE:
male with past medical history of COPD, HTN,
hypothyroidism and OSA who was diagnosed with peripheral T-cell
lymphoma, NOS, CD30 negative, in who is now s/p C1
EPOCH and s/p neulasta who presented to
clinic on DOA with cough and SOB found to be hypoxic.
# Hypoxic respiratory distress, now resolved: At the time of
admission, the patient was noted to be significantly hypoxic on
room air. He subsequently worsened and required BiPAP and brief
ICU stay. In terms of the cause of his hypoxic respiratory
distress, the differential included interval worsening of
malignancy vs pneumonia, +/- COPD exacerbation. It was felt to
be unlikely that his acute change in his respiratory status was
due to interval worsening of disease, although it may have
contributed some. His decompensation was more likely thought to
be due to pneumonia, which caused an acute COPD exacerbation
resulting in hypoxemic respiratory distress.
On arrival to MICU, patient was started on empiric antibiotics
with vanc/cefepime/levofloxacin for possible HCAP. Patient was
also started on treatment for possible COPD exacerbation with
standing duonebs and prednisone. Overnight in the MICU, the
patient's oxygen requirement decreased and shortness of breath
improved. He was subsequently transferred from the ICU to the
floor and at that time was able to maintain oxygen saturations >
94% on RA. Once on the service, the patient was switched
from vanc/cefepime/levofloxacin to zosyn and levofloxacin. At
that point, the plan had been to proceed with bronchoscopy, but
as patient had improved significantly, bronchoscopy would not
have contributed much information and was, therefore, not done.
Nasopharyngeal swab and cultures had returned negative. B-glucan
and galactomannan were also negative. The patient remained on
zosyn and levofloxacin throughout the remainder of his stay, and
his respiratory status remained stable. The patient did not
endorse any further SOB and his cough resolved by the time of
discharge. Upon discharge, the patient was instructed to
continue levofloxacin through , to complete a two-week
course.
## # T-CELL LYMPHOMA:
Stage IV with an IPI score of 3
(high-intermediate risk group). Patient has had a substantial
response to EPOCH based on decrease in LAD seen on current CT
scan. In general, the plan from the patient's primary oncologist
was to give the patient a total of six cycles of dose-adjusted
EPOCH with plan to obtain a PET-CT scan after the second cycle.
In terms of CNS prophylaxis, the patient will likely receive
intrathecal methotrexate starting with the third cycle. At the
time of admission, the patient was scheduled to receive his
second cycle of EPOCH. Given his respiratory status, however,
chemotherapy was initially held. Once the patient's respiratory
status improved (discussed further below), the patient received
his second cycle of EPOCH on without complications. He was
continued on allopurinol for tumor lysis prevention. For
infection prophylaxis, the patient was continued on lamivudine
(Hepatitis B Core Ab positive, VL negative consistent with
resolved infection), fluconazole for fungal ppx, and acyclovir
for viral ppx. The patient was not on PCP ppx, as he had
developed a rash after taking Bactrim SS daily prior to
admission. During this admission his G6PD level was checked and
was 21, which is not deficient, so the patient was started on
dapsone for PCP . The patient was discharged with
instructions to follow-up with Dr. on . At that
time he will receive Neulasta. Discussion should also be had at
that time about timing of port placement.
## # ANEMIA:
Patient with normocytic anemia on admission, which was
at baseline. During the course of his hospital stay, the
patients H/H slowly down-trended, but the patient did not
require any transfusions. Patient was tachycardic, but without
any signs of bleeding and with stable blood pressures throughout
his stay. Hemolysis labs were checked and were negative. Anemia
was thought to be secondary to chemotherapy and will be
monitored as an outpatient.
# Hyponatremia: Patient was hyponatremic on admission to 131.
Thought to potentially be from diuretic use. No mental status
changes were noted. The patient sodium level normalized without
any intervention and was 135 at the time of discharge.
## CHRONIC ISSUES
# HYPERTENSION:
Stable.
# Hypothyroidism: Stable. Continue levothyroxine.
TRANSITIONAL ISSUES
- Patient was admitted in hypoxic respiratory distress thought
to be secondary to atypical pneumonia. The patient was started
on zosyn and levofloxacin during his admission and quickly
improved. He will be discharged on levofloxacin to complete a
two week course on .
- Once the patient improved from an infectious standpoint, he
was able to complete cycle two of his EPOCH chemotherapy during
this admission.
- Med changes:
1. Started dapsone for PCP .
2. Started levofloxacin for atypical pneumonia - to be continued
through .
## 3. STARTED ON PREDNISONE TAPER:
60 mg PO , 40 mg PO ,
and 20 mg PO , then stop.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Allopurinol mg PO DAILY
2. Ipratropium bromide 17 mcg/actuation inhalation Q4:prn
sob/wheezing
3. LaMIVudine 100 mg PO DAILY
4. Fluconazole 400 mg PO Q24H
5. Furosemide 40 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Nystatin 1,000,000 UNIT PO BID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Acyclovir 400 mg PO Q8H
10. Albuterol sulfate 90 mcg/actuation inhalation Q4:PRN
SOB/Wheezing
## DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg PO Q8H
2. Allopurinol mg PO DAILY
3. Fluconazole 400 mg PO Q24H
4. Furosemide 40 mg PO DAILY
5. LaMIVudine 100 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Dapsone 100 mg PO DAILY
8. Levofloxacin 750 mg PO DAILY
9. Albuterol sulfate 90 mcg/actuation inhalation Q4:PRN
SOB/Wheezing
10. ipratropium bromide 17 mcg/actuation inhalation Q4:prn
sob/wheezing
11. Tiotropium Bromide 1 CAP IH DAILY
12. PredniSONE 60 mg PO ONCE Duration: 1 Day
## START:
Tomorrow - - First Routine Administration Time
Please take 60 mg , 40 mg , 20 mg , then stop.
13. PredniSONE 40 mg PO ONCE Duration: 1 Day
## START:
After 60 mg tapered dose
Please take 60 mg , 40 mg , 20 mg , then stop.
14. PredniSONE 20 mg PO ONCE Duration: 1 Day
## START:
After 40 mg tapered dose
Please take 60 mg , 40 mg , 20 mg , then stop.
## PRIMARY:
- Pneumonia
- Hypoxic respiratory distress
- T-cell lymphoma
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure taking care of you at .
You were admitted to the hospital from clinic because you were
found to be extremely short of breath and your oxygen levels had
decreased significantly. You needed to stay in the intensive
care unit (ICU) for a brief period before you were stable enough
to come to the floor. Once your breathing improved, you were
able to be transferred to the Hematology service.
We believe that you likely had either a bacterial infection in
your lungs, called pneumonia, or a non-specific viral syndrome
that caused your symptoms. You were started on antibiotics and
you quickly improved. You should continue taking an antibiotic,
called levofloxacin, until .
During your hospitalization, you also received your second cycle
of chemotherapy for your T-cell lymphoma. You tolerated this
very well.
Please follow-up at your scheduled appointments, as below.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10191971", "visit_id": "29690819", "time": "2133-10-07 00:00:00"} |
15573918-RR-21 | 109 | CHOLANGIOGRAM IN THE OR
## INDICATION:
male for open cholecystectomy and cholangiogram for
recurrent pancreatitis.
## FINDINGS:
Four fluoroscopic images obtained in the OR without the presence of
a radiologist are submitted for review. These images demonstrate cannulation
of the cystic duct and opacification of the duodenum and partial opacification
of the common biliary and hepatic ducts as well as intrahepatic ducts. Detail
of the distal extrahepatic ducts is limited by contrast within the duodenum.
## IMPRESSION:
Normal intrahepatic and extra hepatic bile ducts, part of
the distal common bile duct is obscured by contrast within the duodenum. For
further details, please refer to the operative report from the same date.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15573918", "visit_id": "N/A", "time": "2139-08-13 18:14:00"} |
14871394-RR-22 | 547 | ## EXAMINATION:
CT of the abdomen and pelvis.
## INDICATION:
year old woman presents with nausea, vomiting, inability to
tolerate po intake and weight loss. RUQ US concerning for metastatic cancer.//
Please evaluate for etiology of symptoms. Pt has a contrast allergy and is
thus being premedicated prior to the study.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.2 s, 33.9 cm; CTDIvol = 27.3 mGy (Body) DLP = 906.5
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 22.2 s, 0.2 cm; CTDIvol = 377.8 mGy (Body) DLP =
75.6 mGy-cm.
4) Spiral Acquisition 10.5 s, 67.9 cm; CTDIvol = 25.8 mGy (Body) DLP =
1,736.6 mGy-cm.
5) Spiral Acquisition 5.2 s, 33.9 cm; CTDIvol = 27.3 mGy (Body) DLP = 906.5
mGy-cm.
Total DLP (Body) = 3,627 mGy-cm.
## FINDINGS:
Chest is reported separately.
Several small to medium size liver masses are most suggestive of metastatic
neoplastic neoplastic disease. One of the larger solid on lesions is located
in segment VI and measures up to 71 x 63 mm in axial (06:59). The
largest lesion is in segment VIII and measures up to 72 x 65 mm (06:47). This
one demonstrates a fluid fluid level with dependent hyperdense content
suggesting subacute hemorrhage in the lesion or proteinaceous debris
associated with necrosis. Background liver is hypoattenuating consistent with
steatosis.
Although there is mild intrahepatic and extrahepatic biliary dilatation, this
is most likely due to prior cholecystectomy. Mass effect from very large
retroperitoneal lymph nodes may contribute to some extent, however. There is
pneumobilia in ducts of the left lobe in addition to reflux of oral contrast
into the distal common bile duct strongly implying patency, however.
Pancreatic head is partly obscured by lymphadenopathy but no intrinsic
pancreatic abnormality is suspected.
The spleen is normal in size and appearance. The lateral limb of the left
adrenal is slightly thickened including a nodule that may measure up to 11 mm.
Despite the context this is indeterminant, adenoma versus possibility of
metastasis, not clearly visible on the remote prior study. There is no
evidence for stones, solid masses or hydronephrosis involving either kidney.
Stomach and small bowel appear normal. Enteric contrast has passed through
the whole small bowel and as far as the mid descending colon. No evidence of
colonic or rectal abnormality.
Uterus, adnexa and bladder appear normal. Major vascular structures appear
widely patent.
There are number of very large retroperitoneal lymph nodes. The largest is a
left periaortic lymph node cluster measuring up to 98 x 59 mm in axial
(6:75). Some of these nodes show central low-attenuation areas
that are most compatible with necrosis. There is also a poorly defined left
retrocrural mass seems to which possibly involves are may cross the medial
crura of the left hemidiaphragm to some extent (06:55).
There are no suspicious bone lesions.
## IMPRESSION:
Findings suggest metastatic liver masses and retroperitoneal lymphadenopathy
with no definite primary lesion. Largest liver mass shows central hemorrhage
and/or necrosis. Mild biliary dilatation, although most likely due to prior
cholecystectomy. Fatty liver.
## NOTIFICATION:
Findings discussed with Dr. at 6:30 pm by telephone on
.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14871394", "visit_id": "26506775", "time": "2178-05-03 15:57:00"} |
16146005-DS-9 | 1,489 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Exertional dyspnea and occassional chest pain
## :
1. Aortic valve replacement with a 21-mm
Magna Ease aortic valve bioprosthesis. Model number .
Serial number .
2. Coronary artery bypass grafting x1 with left internal mammary
artery to left anterior descending coronary artery.
## HISTORY OF PRESENT ILLNESS:
year old active gentleman with
history of aortic stenosis which has been followed by serial
echcardiograms. More recently he has noticed increased symptoms
of exertional dyspnea and mild chest pain. He has also noticed
that he is considerably more fatigued. A recent echocardiogram
revealed critical aortic stenosis with mild left ventricular
hypertrophy with a normal left ventricular ejection fraction. He
was admitted today after catherization for AVR/CABG
## PAST MEDICAL HISTORY:
AVR CABG x 1 LIMA->LAD
## PAST MEDICAL HISTORY:
Aortic stenosis
GERD
Depression
Hypertension
Eosinophilia since
Pruritis
BPH
## PAST SURGICAL HISTORY:
Hemicolectomy c/b infection and prolonged recovery
Multiple bowel surgeries for adhesions/obstruction
Right knee arthroscopy
MOH's surgery x2 on head for Basal cell
Recent varicose vein repair after trauma
## FAMILY HISTORY:
Father died at age of heart disease
## GENERAL:
AAO x 3 in NAD
## SKIN:
Warm, Dry and intact. Multiple well healed abdominal
incisions. Infraumbilical incisional hernia.
## HEENT:
NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Missing
multiple teeth - poor repair
## NECK:
Supple [X] Full ROM [X]
## CHEST:
Lungs clear bilaterally [X]
## HEART:
RRR [X] IV/VI Systolic Murmur
## ABDOMEN:
Soft[X] non-distended[X] non-tender [X] + bowel
sounds[X]
## EXTREMITIES:
Warm [X], well-perfused [X] Trace Edema
## VARICOSITIES:
Right below knee grossly varicosed laterally. No
appreciable varicosities in thigh.
## RADIAL RIGHT:
2 Left:2
Carotid Bruit Transmitted vs. Bruit bilaterally
## PREBYASS:
-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.
-There is mild symmetric left ventricular hypertrophy with
normal cavity size. Regional left ventricular wall motion is
normal.
-Doppler parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction.
-Right ventricular chamber size and free wall motion are normal.
-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 are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen.
-The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
-The left ventricular inflow pattern suggests impaired
relaxation.
-The tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
## POSTBYPASS:
The patient is AV paced on low dose phenylephrine infusion.
There is a well seated prosthetic valve in the aortic position.
Peak Gradient=48mmHg. There is trace AR. Biventricular function
remains intact. The aorta remains intact.
06:43AM BLOOD WBC-14.5* RBC-4.16* Hgb-12.3* Hct-35.0*
MCV-84 MCH-29.5 MCHC-35.0 RDW-13.6 Plt
06:43AM BLOOD
05:33AM BLOOD
01:58AM BLOOD
06:43AM BLOOD Glucose-102* UreaN-28* Creat-0.9 Na-131*
K-4.5 Cl-99 HCO3-29 AnGap-8
05:33AM BLOOD Glucose-116* UreaN-32* Creat-1.0 Na-134
K-4.9 Cl-99 HCO3-27 AnGap-13
## BRIEF HOSPITAL COURSE:
Mr has known aortic stenosis, he was admitted one day
prioor to for cardiac catheterization. On he was
brought to the operating room for aortic valve replacement and
coronary bypass grafting, please see operative report for
details. In summary he had: Aortic valve replacement with a
21-mm Ease aortic valve bioprosthesis. Model number .
Serial number .
And coronary artery bypass grafting x1 with left internal
mammary artery to left anterior descending coronary artery. His
bypass time was 110 minutes with a crossclamp time of 89
minutes. He tolerated the operation and was brought from the
operating room to the cardiac surgery ICU on Neosynephrine and
Propofol. Post-operatively he experienced significant bleeding
and requiried multiple units of fresh frozen plasma, platelets
and packed red blood cells. He stopped without returning to the
operating room but was kept sedated on the day of surgery.
His chest xray showed moderate pulmonary conjestion requiring
aggressive diuresis prior to weaning from the ventilator. He
finally extubated on POD3, he remained somewhat lethargic after
extubation and failed a speech and swallow evaluation. A feeding
tube was placed on POD 5. His mental status improved slowly and
steadily. He was evaluated at the bedside by speech and swallow
pathology and was cleared for ground solids and thin liquids. He
continued to progress and a video swallow was done and he was
cleared for soft solids and thin liquids. His appetite remains
fair with patient consuming ~50% meals and supplements were
ordered. He pulled his dobhoff multiple times and it was decided
that it would left out with encouragement with meals. He
continued to need supervision and assistance with meals. He
remains on calorie counts.
He experienced post-operative afib which was managed with
lopressor and amiodarone. While on Lopressor 25 BID and
Amiodarone 400 BID he developed complete heart block with a
stable blood pressure. He was transferred back to the for
closer monitoring. Electrophysiology was consulted and
recommended decreasing the Amiodarone to 200 . Once rhythm
was stable, his Lopressor was added back and titrated up to 25
mg BID. He remained in a sinus rhythm with PAC's in the 70-80's
throughout the remainder of his hospital course. Coumadin was
initiated for Atrial fibrillation with mg doses for INR goal
2.0-2.5. He will need coumadin follow up arranged post
discharge from rehab. He is discharged to the
on POD 16 in stable condition. All follow up appointments were
arranged.
## MEDICATIONS ON ADMISSION:
Active Medication list as of :
Amoxicillin 2grams dental prophylaxis
LEXAPRO - 10MG Tablet - ONE TABLET EVERY DAY
LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth once a day
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth twice a
day
TRIAMCINOLONE ACETONIDE - 0.5 % Ointment - apply to affected
area
twice a day # 30 gm
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day - No Substitution
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - 1
Tablet(s) by mouth once a day
## DISCHARGE MEDICATIONS:
1. Outpatient Lab Work
## LABS:
for Coumadin indication afib
Goal INR 2.0-2.5
First draw
Results to phone fax: plaese arrange coumadin follow up with
PCP upon discharge from rehab
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) .
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet Q4H (every
4 hours) as needed for fever/pain.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML HS (at bedtime) as needed for constipation.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
as needed for constipation.
6. losartan 50 mg Tablet Sig: Two (2) Tablet .
7. amiodarone 200 mg Tablet Sig: One (1) Tablet once a day.
8. escitalopram 10 mg Tablet Sig: One (1) Tablet
( ).
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet
( ).
10. lansoprazole 30 mg Tablet,Rapid Dissolve, Sig: One (1)
Tablet,Rapid Dissolve, .
11. amlodipine 5 mg Tablet Sig: One (1) Tablet .
12. furosemide 20 mg Tablet Sig: One (1) Tablet
for 7 days.
13. potassium chloride 20 mEq Packet Sig: One (1) Packet once
a day for 7 days.
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet BID
(2 times a day).
15. warfarin 2 mg Tablet Sig: One (1) Tablet once a day: MD
to dose for goal INR , dx: afib.
16. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) BID (2
times a day).
## DISCHARGE DIAGNOSIS:
AVR CABG x 1 LIMA->LAD
## PMH:
Aortic stenosis, GERD, Depression, Hypertension, Eosinophilia
since , Pruritis, BPH, Hemicolectomy c/b infection and
prolonged recovery, Multiple bowel surgeries for
adhesions/obstruction, Right knee arthroscopy, 's surgery x2
on head for ?Basal cell, Recent varicose vein repair after
trauma
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Transfers from bed to chair with assistance, deconditioned
Incisional pain managed with tylenol
## INCISIONS:
Sternal - healing well, no erythema or drainage
## DISCHARGE INSTRUCTIONS:
Please shower including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
**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": "16146005", "visit_id": "27977003", "time": "2165-12-03 00:00:00"} |
17239652-RR-40 | 96 | ## INDICATION:
year old woman with AML on enasidenib, now with fever and
neutropenia, ? pneumonia// year old woman with AML on enasidenib, now with
fever and neutropenia, ? pneumonia
## FINDINGS:
Mild cardiomegaly is unchanged compared to the prior exam. Hilar and
mediastinal contours are normal. Small bilateral pleural effusions are seen.
A subtle opacity is seen at the left lung base. There is no pleural effusion
or pneumothorax. Visualized osseous structures are grossly unremarkable.
## IMPRESSION:
Subtle opacity at the left lung base could be seen in the setting of an
infectious process. Persistent small bilateral effusions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17239652", "visit_id": "20861943", "time": "2165-10-08 14:15:00"} |
19132877-RR-33 | 260 | ## INDICATION:
year old woman s/p open chole now in now with
elevated ALk phos and RUQ pain // biliary system
## FINDINGS:
The patient is status post cholecystectomy with susceptibility artifact
associated with the cholecystectomy clips as well as along the anterior
abdominal wall of the right upper quadrant. There is a small pocket of fluid
within the gallbladder fossa with diameter of 2.3 cm. This may be postsurgical
in nature. An ongoing leak is thought to be unlikely given lack of surrounding
inflammatory change.
The extrahepatic biliary tree and the left intrahepatic bile ducts are normal
in caliber without filling defects. The right biliary tree is prominent,
particularly on posterior branches serving as segment 5. These are dilated to
the periphery (8:3). . The centrally, there is lack of communication with the
common hepatic duct (8:2). This may be on the basis of stricturing, focal
edema, or potentially inadvertent ligation of right posterior duct during
cholecystectomy. Further evaluation with ERCP may be useful. There is no
surrounding parenchymal signal or enhancement abnormality to suggest
cholangitis.
The pancreas, spleen, adrenal glands and kidneys are unremarkable. There is no
lymphadenopathy or free fluid. Osseous structures are unremarkable in
appearance.
## IMPRESSION:
Segmental bile duct dilation involving segment 5 duct with truncation cyst
centrally and lack of communication with the extrahepatic biliary tree. This
appearance may be on the basis of stricture, focal edema or potentially
inadvertent ligation during cholecystectomy. ERCP may be helpful in further
characterization
## NOTIFICATION:
Findings were communicated via phone by Dr to Dr.
on , at 1120am.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19132877", "visit_id": "N/A", "time": "2127-04-15 07:10:00"} |
17493391-RR-35 | 115 | ## REASON FOR THE EXAMINATION:
This is a man with hepatitis B. The
request is to rule out hepatoma.
## FINDINGS:
The liver is mildly echogenic and demonstrates mild coarse
echotexture. No focal liver lesions are identified. There is no intra- or
extra-hepatic biliary duct dilatation, the CBD measures 0.3 cm.
The gallbladder is normal without evidence of stones.
The portal vein is patent showing hepatopetal flow.
Both right and left kidneys are normal without hydronephrosis or stones.
The pancreas is not well visualized.
The spleen measures 8.3 cm and is unremarkable.
No ascites is detected.
## IMPRESSION:
1. Mild echogenic liver with mild coarse echotexture.
2. No focal liver lesions are identified.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17493391", "visit_id": "N/A", "time": "2170-01-30 13:08:00"} |
16873272-RR-39 | 367 | ## EXAMINATION:
MR HEAD W AND W/O CONTRAST
## INDICATION:
year old woman with transient facial numbness and paresthesias
in the lower extremities that ascended. MRI spine normal. Evaluate for
demylenation.
On the MRI intake form, the patient reports current tingling in the right lead
and prior facial tingling which has passed.
## FINDINGS:
There are multiple foci of high T2 signal in the subcortical, deep, and
periventricular white matter of the cerebral hemispheres, some of which are
globular or ovoid, measuring up to 10 mm in the left periatrial white matter
on image 304:77. There is 1 small lesion in the left genu of the corpus
callosum, images 303:47 and 3:83. There is 1 small right frontal pericallosal
lesion, images 304:45 and 3:101.
In the infratentorial compartment, there is a 6 mm ovoid lesion with fluid
signal intensity in the right superior cerebellar hemisphere, images 3:106 and
7:8.
None of the lesions demonstrate contrast enhancement or slow diffusion.
Parenchymal volume is within normal limits for age, with normal size of
ventricles and sulci.
There is no evidence for an intracranial mass, edema, acute diffusion
abnormality, or blood products. Major arterial flow voids are grossly
preserved. Major dural venous sinuses appear patent on postcontrast MP RAGE
images.
There is mild mucosal thickening in the ethmoid air cells and maxillary
sinuses, as well as in the inferolateral left sphenoid sinus.
## IMPRESSION:
1. Multiple T2 hyperintense foci in the supratentorial white matter with 1
small left callosal genu lesion and 1 small right frontal pericallosal lesion,
without contrast enhancement. While similar findings are most commonly
related to chronic small vessel ischemic disease in this age group, the size
and morphology of the larger lesions are somewhat atypical for sequela of
chronic small vessel ischemic disease. Other diagnostic considerations
include demyelinating disease, sequela of infection/ inflammation including
Lyme disease and sarcoidosis, and sequela of vasculitis. CSF testing could be
pursued, if clinically indicated.
2. 6 mm ovoid fluid signal intensity lesion in the right superior cerebellar
hemisphere is nonspecific but most likely a chronic infarct, and less likely a
"black hole" " secondary to demyelination.
3. No evidence for intracranial mass. No acute infarction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16873272", "visit_id": "N/A", "time": "2189-11-21 15:28:00"} |
10281634-DS-8 | 1,487 | ## GEN:
NAD, A&O x 3
## RESP:
no acute respiratory distress
## ABD:
soft, minimally TTP, no rebound/guarding
## EXT:
mild b/l calf TTP. no palpable cords, erythema, or edema
## BLOOD CULTURE, ROUTINE (PENDING):
8:20 pm BLOOD CULTURE
## BLOOD CULTURE, ROUTINE (PENDING):
Time Taken Not Noted Log-In Date/Time:
9:27 pm
URINE
**FINAL REPORT
URINE CULTURE (Final :
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
2:50 pm SEROLOGY/BLOOD
**FINAL REPORT
RAPID PLASMA REAGIN TEST (Final :
NONREACTIVE.
## REFERENCE RANGE:
Non-Reactive.
IMAGING
==================
CT Scan
Final Report
## INDICATION:
with LLQ abdominal pain, feverNO PO contrast//
evaluate for
diverticulitis or other intra-abdominal proces
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images
were acquired
through the abdomen and pelvis following intravenous contrast
administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
## 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
surgically absent.
## 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:
There is a small hiatal hernia. The stomach
is otherwise
unremarkable. Small bowel loops demonstrate normal caliber,
wall thickness,
and enhancement throughout. Scattered diverticular noted in the
colon,
particularly the sigmoid without evidence of acute
diverticulitis. The
appendix is normal.
## PELVIS:
The urinary bladder and distal ureters are unremarkable.
There is
trace free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
IUD is identified within the uterus. The
right adnexae is unremarkable. There is an oblong cystic
structure in the left adnexum measuring 5.6 by 2.9 by 3.4 cm.
Given oblong configuration, this may represent a hydrosalpinx.
The left adnexae is otherwise unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. No
atherosclerotic disease is noted.
## BONES:
There is no evidence of worrisome osseous lesions or
acute fracture. Sclerosis surrounding the SI joints, more
exuberant on the iliac side bilaterally. Moderate degenerative
changes seen at the hips bilaterally.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal
limits.
## IMPRESSION:
1. Oblong cystic structure in the left adnexa which given
configuration may represent a hydrosalpinx. Consider dedicated
exam with pelvic ultrasound, the acuity of which can be
determined clinically.
2. Diverticulosis without diverticulitis.
3. Sclerosis abutting the SI joints bilaterally which may
represent
sacroiliitis of versus osteitis condensans ilii.
Pelvic US
Final Report
## INDICATION:
year old woman with abdominal pain, fevers//
evaluate oblong
structure seen on CT a/p, ?evidence of PID
Has a Mirena IUD, distant LMP
## TECHNIQUE:
Grayscale ultrasound images of the pelvis were
obtained with
transabdominal approach followed by transvaginal approach for
further
delineation of uterine and ovarian anatomy.
## COMPARISON:
CT of the abdomen and pelvis from at
20:55
## FINDINGS:
The uterus is anteverted and measures 7.8 x 3.9 x 5.5 cm. The
endometrium is
homogenous and measures 4 mm. The IUD was demonstrated within
the endometrial
cavity. The IUD appears satisfactorily placed.
The left ovary measures 5.3 x 3.2 x 3.0 cm. In the left adnexa,
two cysts
which measure 3.3 x 2.6 x 2.6 cm and 2.0 x 1.7 x 1.8 cm are not
seen to
definitely communicate, one of which may contain some debris and
a represent a
hemorrhagic cyst.
The right ovary measures 3.0 x 1.9 x 1.5 cm an appears normal.
There is a
trace amount of free fluid.
## IMPRESSION:
Left ovary containing physiologic cysts, one containing
debris/hemorrhage..
LENIS
Final Report
## EXAMINATION:
BILAT LOWER EXT VEINS
## INDICATION:
G1P1 who presented with worsening abdominal
pain, N/V/D,
fevers, admitted for tx of presumed left pyosalpinx, now w/ calf
pain// eval
for DVT
## TECHNIQUE:
Grey scale, color, and spectral Doppler evaluation
was performed
on the bilateral lower extremity veins.
## FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the tibial veins.
Evaluation of the
peroneal veins bilaterally was limited.
There is normal respiratory variation in the common femoral
veins bilaterally.
## IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
## BRIEF HOSPITAL COURSE:
Ms. is a yo G2P1 who presented with 3 days of
abdominal pain, pelvic cramping,
nausea/vomiting/diarrhea/fevers, and was found to have a left
adnexal dilated structure on CT scan, with adnexal tenderness on
CMT. She was admitted for treatment of a presumed left
pyosalpinx.
## *) LEFT PYOSALPINX:
Pt defervesced after her initial
presentation, with first afebrile time 18:20 on . She was
started on IV Gentamicin/Clindamycin ( ). Her WBC
downtrended from 11 ( ) to 9.4 ( ). Given that pt remained
afebrile and her pain improved, she was transitioned to PO
Levofloxacin/Flagyl on . Her STI panel was negative for HIV,
RPR, Hepatitis B, Hepatitis C, gonorrhea, and chlamydia.
## *) BILATERAL LOWER EXTREMITY TENDERNESS:
On , pt reported
bilateral calf tenderness. She underwent lower extremity venous
ultrasounds which did not demonstrate any evidence of DVT.
## *) GBS UTI:
Pt's urine culture grew group B strep. She was
started on a 3-day course of amoxicillin ( -) to treat her
UTI.
## *) CONTRACEPTION:
Pt underwent removal of her IUD at the
bedside. She elected to use the patch for contraception. Pt was
made aware of decreased efficacy of the patch for contraception
in the setting of obesity. She remained interested in the patch
as she uses this method primarily for cycle control. She is not
currently sexually active.
By hospital day #3, Ms. was afebrile, her
abdominal pain was minimal, she was tolerating a regular diet
without nausea/vomiting, and she was ambulating independently.
She was discharged home in stable condition with outpatient
follow-up scheduled.
## DISCHARGE MEDICATIONS:
1. Acetaminophen mg PO Q6H:PRN Pain - Mild
do not exceed 4000mg in 24 hours
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*30
## TABLET REFILLS:
*1
2. Amoxicillin 500 mg PO Q12H
RX *amoxicillin 500 mg 1 tablet(s) by mouth twice daily Disp #*5
Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*1
4. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*14 Tablet Refills:*0
5. MetroNIDAZOLE 500 mg PO BID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice
daily Disp #*28 Tablet Refills:*0
6. Xulane (norelgestromin-ethin.estradiol) 150-35 mcg/24 hr
transdermal 1X/WEEK
RX *norelgestromin-ethin.estradiol [ ] 150 mcg-35 on the skin once a week Disp #*4 Patch Refills:*2
## DISCHARGE DIAGNOSIS:
Pyosalpinx
Urinary tract infection
## DISCHARGE INSTRUCTIONS:
Dear ,
You were admitted to the Gynecology Service with abdominal pain
and fevers. You were treated for a pyosalpinx (infection of the
fallopian tubes) with IV antibiotics, and have been transitioned
to oral antibiotics. Your IUD was removed.
You were found to have a urinary tract infection. Please take
the amoxicillin as prescribed to treat this infection.
You have overall recovered well and are ready for discharge.
Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
## CONTRACEPTION:
* You elected to start the patch for birth control and are
provided a prescription. Please change the patch once a week.
* You may use the patch for three weeks in a row and then take
one week off for a period, or you may elect to continuously use
the patch.
* You are eligible for another IUD should you choose one in 3
months.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10281634", "visit_id": "26131119", "time": "2141-12-22 00:00:00"} |
14263099-DS-7 | 692 | ## ALLERGIES:
Ambien / bee stings
## HISTORY OF PRESENT ILLNESS:
Mr. is a year old male is s/p CABG x 2 on . He
had an uneventful postoperative course and was discharged to
rehab on . He did well at rehab and was discharged to
home on . He has been active at home and doing well. He
did have some intermittent dizziness the past 2
days and had an appointment with his PCP today where he was
found to be in atrial fibrillation/flutter. He was sent to the
ED for further care.
## HYPERLIPIDEMIA
GOUT
BPH
ETOH ABUSE:
sober since
Right cervical radiculitis C5-C6
Basal cell carcinoma and squamous cell chest, face and legs
Dry eye syndrome
Removal of basal and squamous cell carcinoma
Right knee replacement
Renal lithiasis
Cataract removal with implants
Cervical spine fusion C6
## FAMILY HISTORY:
Premature coronary artery disease- non contributory
## GENERAL:
well-developed, well-nourished white-Caucasian male.
Pleasant, cooperative.
## NECK:
Supple [x] Full ROM [x]
## CHEST:
Lungs clear bilaterally [x]sternal incision healing well,
sternum stable
## HEART:
RRR [] Irregular [x] Murmur [] grade
## ABDOMEN:
Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x] Well-healed RLQ incision c/w prior appendectomy
## EXTREMITIES:
Warm [x], well-perfused [x] Edema []
L saphenectomy site C/D/I
## PERTINENT RESULTS:
TEE No definite thrombus, but with dense
spontaneous echo contrast and borderline empyting velocities.
Normal biventricular cavity size and systolic function. Trivial
mitral regurgitation. Simple atheroma in the descending thoracic
aorta.
## BRIEF HOSPITAL COURSE:
Mr. is a year old man, now POD s/p CABG x2
(LIMA-LAD, SVG-PDA). He was initially discharged to rehab on
, and then discharged from there to home on ,
. He had been doing well with the exception of mild
orthostatic lightheadedness. He saw his primary care MD, Dr.
, and was found to be in atrial fibrillation. He
was readmitted and found to be back in sinus rhythm. He had no
significant lab abnormalities. Today, he had TEE which showed
no definite thrombus. Mr. is very reluctant to start
coumadin and had extensive discussion with Dr.
atrial fibrillation/stroke risk. Given that he has remained in
sinus rhythm this admission, he will be discharged home today
without coumadin. However, if his atrial fibrillation recurs, he
will then be started on coumadin and patient agrees with this
plan.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Allopurinol mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Cialis (tadalafil) unknown mg oral PRN
4. Tamsulosin 0.4 mg PO HS
5. Aspirin EC 81 mg PO DAILY
6. Magnesium Oxide 400 mg PO DAILY
7. saw 500 mg oral daily
8. Ibuprofen 600 mg PO Q8H:PRN pain
9. Metoprolol Tartrate 25 mg PO BID
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
## DISCHARGE MEDICATIONS:
1. Allopurinol mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Ibuprofen 600 mg PO Q8H:PRN pain
4. Magnesium Oxide 400 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
7. Docusate Sodium 100 mg PO BID
8. Metoprolol Tartrate 25 mg PO BID
9. Aspirin EC 81 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Oxycodone
## INCISIONS:
Sternal - healing well, erythema at upper pole, no drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
**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": "14263099", "visit_id": "28954108", "time": "2150-09-15 00:00:00"} |
15364978-RR-30 | 121 | ## EXAMINATION:
BILATERAL DIAGNOSTIC BREAST MRI WITH AND WITHOUT INTRAVENOUS
CONTRAST
## INDICATION:
woman with newly diagnosed multifocal DCIS in the
right breast, with diagnostic mammogram from demonstrating
residual calcifications at sites of prior biopsy.
## AMOUNT OF FIBROGLANDULAR TISSUE:
Heterogeneous fibroglandular tissue.
Non-diagnostic examination as no post-contrast images were obtained. T2
weighted sequences demonstrate post biopsy changes in the upper inner right
breast.
No abnormality is identified in the visualized chest and upper abdomen.
## IMPRESSION:
Non diagnostic examination as no post contrast imaging was obtained.
## RECOMMENDATION(S):
Further management will be based on clinical decisions.
## NOTIFICATION:
Dr. was emailed by Dr. on at
09:30, 5 minutes after the discovery of findings.
## BI-RADS:
6 Known Biopsy-Proven Malignancy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15364978", "visit_id": "N/A", "time": "2127-12-07 07:02:00"} |
14954759-RR-43 | 677 | ## TYPE OF THE EXAM:
CT of the torso.
REASON FOR THE EXAM AND MEDICAL HISTORY:
Recent MRI to pericardial effusion
showing atypical cells concerning for carcinoma, workup for unknown primary.
## CHEST:
Thyroid gland is unremarkable in appearance. There is no axillary or
supraclavicular lymphadenopathy. There are multiple mediastinal lymph nodes,
the largest one located in the right pretracheal region, measuring 1.3 cm in
larger dimension. A right hilar lymph node is also noted (2:21 and 2:25).
There is a filling defect at the distal aspect of the right lower interlobar
artery which extends into multiple segmental pulmonary emboli within the right
lower lobe with associated peripheral consolidation, most likely consistent
with an infarct. There is a small right-sided pleural effusion. A tiny left
pleural effusion is also noted. There is again seen a ground glass spiculated
nodular opacity within the right upper lobe (2:14), which has not changed
significantly from the prior studies. There is a newly seen, left upper lobe
ground-glass nodule (2:14) , measuring 4 mm). The thoracic aorta demonstrates
atherosclerotic calcification at the arch level. There is no evidence of
residual pericardial effusion.
## ABDOMEN:
There is a contour deforming abnormality within the segment IV of
the liver with a vague, more central hypoenhancing area (2:60) which measures
approximately 2 cm in the largest dimension.
This morphology is new from the prior CTs of the chest, the most recent one
dated on and not clearly seen on the MRI of .
The gallbladder is unremarkable in appearance. Spleen, bilateral adrenal
glands, pancreas is unremarkable. There is evidence of recent left partial
nephrectomy with some post-treatment changes and heterogeneous enhancement in
the left upper pole. There are multiple tiny hypodensities involving both
kidneys with two large cystic areas within the right lower pole which were
previously characterized as simple and hemorrhagic cyst. There is an enlarged
lymph node within the gastrohepatic ligament, measuring 1.3 cm. Smaller lymph
nodes are seen at the celiac axis level as well as in the retroperitoneum in
the left paraaortic region.
The small and colonic loops of bowel in the upper abdomen are unremarkable in
appearance without evidence of obstruction. There is a small, wide aperture
left flank hernia, likely post-laparoscopic procedure containing colonic
bowel loops without evidence of obstruction or strangulation.
## PELVIS:
Extensive sigmoid diverticulosis without imaging evidence of
diverticulitis. There is a small, right cystic adnexal structure (2:105).
The left ovary is not visualized. There is no lymphadenopathy in the pelvis.
There is no free fluid. There is no pneumoperitoneum.
## VASCULAR STRUCTURES:
There is heavy atherosclerotic calcification of the
abdominal aorta, with moderate stenosis of bilateral common iliac arteries,
worse on the left.
## OSSEOUS STRUCTURES:
There is again seen a hemangioma in the lumbar spine,
otherwise there are no worrisome destructive osseous lesions or acute
fractures.
## IMPRESSION:
Acute pulmonary embolism involving the distal right lower pole interlobar
artery and multiple segmental pulmonary arteries in the right lower lobe with
associated peripheral consolidation, most likely represent an infarct.
Stable appearance of the spiculated, ground-glass nodular consolidation in
the right upper lobe with a new 4-mm ground-glass left upper lobe nodule.
Continued surveillance with CT in 12 months is recommended.
Multiple mediastinal lymph nodes, borderline enlarged by CT criteria, the
largest one in the pretracheal station, measuring 1.3 cm in the short axis.
Contour deforming, slightly hypoenhancing apparent nodule within the segment
IV of the liver, measuring approximately 2 cm, which appears new from prior
CTs and the prior MRI of . Further evaluation with
ultrasound and potentially MRI, depending on the US results is recommended for
better characterization, to assess for primary or metastatic disease.
Enlarged, 1.3-cm lymph node within the gastrohepatic ligament with smaller
mesenteric and retroperitoneal lymph nodes.
Status post partial left nephrectomy with heterogeneous enhancement within the
left upper pole of the kidney which may be post-treatment in nature.
Surveillance MRI would be beneficial.
Findings discussed with Dr. at 11:47 AM, 20 minutes after the images
were reviewed.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14954759", "visit_id": "28366292", "time": "2144-10-20 19:38:00"} |
11170354-RR-15 | 125 | ## INDICATION:
man with past medical history significant
forlaryngeal mass in the left supraglottis (T3N0 M0 SCC), CAD s/pmultiple
stents, atrial fibrillation on warfarin (Heparinpreoperatively) and emphysema
who was evaluated in preopclinic for surgical resection of supraglottic
laryngeal mass andfound to have hypokalemia and hypotension believed to be
fromoverdiuresis, admitted for medical optimization prior toscheduled surgery
on . // video swallow eval
## DOSE:
Fluoro time: 02:19 min.
## FINDINGS:
There is penetration and aspiration with nectar consistency liquids. Patient
is unable to clear airways with cough.
## IMPRESSION:
Aspiration with nectar consistency liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11170354", "visit_id": "21826324", "time": "2162-06-24 13:47:00"} |
13048571-RR-10 | 86 | ## INDICATION:
year old man with new decreased pO2 in the setting of newly
discovered mediastinal mass. // pls assess for fluid, opacity
## FINDINGS:
Redemonstration of a large anterior mediastinal mass, largely obscuring the
heart borders. Subtle opacity at the right lung base with not definitely seen
on prior study may represent atelectasis. No pneumothorax. No large pleural
effusions. No pulmonary edema.
## IMPRESSION:
1. New subtle opacities at the right lung base likely represent atelectasis or
edema.
2. Redemonstration of a large anterior mediastinal mass, unchanged.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13048571", "visit_id": "21779078", "time": "2133-11-27 00:25:00"} |
15690806-DS-9 | 2,859 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Mr is a yoM with PMH IDDM, CKD, HTN, and HLD who
presented to ED on as a transfer from
with DKA after his home health aide found him somnolent
at home. He had nausea and vomiting for the past several days
and stopped taking insulin due to decreased PO intake. He was
found to have a lactate of 7, pH 7.04, BS 1500, gap 34,
hypothermia . He was given 1g vanc, ceftaz, calcium
gluconate, sodium bicarb, and IVF. He was also started on an
insulin drip at 9U/hr
and transferred to .
Upon arrival to , he was lethargic but able to answer basic
questions. Head CT at was concerning for ?mastoiditis
and the patient had visible purulent drainage from the R ear.
ENT
was consulted and he was given vanc/zosyn for empiric coverage
in the setting of hypothermia and hypotension. UA showed blood,
pyuria, ketones, glucosuria. EKG showed nonspecific T wave
inversions and STD. Troponin was elevated to 0.13 and he was
started on heparin. Cardiology was consulted and he was given
full dose aspirin, then transferred to MICU for further
management.
In the MICU, he was continued on IVF, insulin gtt (then
transitioned to insulin boluses). was consulted regarding
management of his DM. He was also started on levophed for
hypotension, shock of unclear etiology. Heparin gtt was stopped
after troponin downtrended. His BP and gap improved, and he was
called out of the ICU on .
## PAST MEDICAL HISTORY:
HTN
HLD
IDDM
GERD
CKD
Gout
## PHYSICAL EXAM:
ADMISSION PHYSICAL EXAM
=======================
## GENERAL:
lethargic, following commands, AOx1 to person only
## HEENT:
dry MM, Sclera anicteric, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
## ABD:
soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## DISCHARGE PHYSICAL EXAM
=======================
0735 TEMP:
97.9 PO BP: 146/66 L Lying HR: 61 RR: 18 O2
sat: 97% O2 delivery: Ra FSBG: 101
## GENERAL:
NAD, pleasant, lying in bed with slightly bent knees
## RESP:
CTAB. Normal resp effort.
## CHEST/CV:
Regular rate and rhythm.
## MSK:
Right wrist with greater ROM, almost able to make fist
though still painful on closing. Left and right knee pain
but able to bend more than previously.
## EXT:
2+ pitting edema to mid-calves bilaterally, improved from
prior.
## PERTINENT RESULTS:
ADMISSION AND OTHER PERTINENT LABS
==================================
12:44PM BLOOD WBC-15.8* RBC-5.20 Hgb-13.3* Hct-41.0
MCV-79* MCH-25.6* MCHC-32.4 RDW-15.5 RDWSD-43.8 Plt
12:44PM BLOOD Neuts-87.7* Lymphs-8.9* Monos-2.4*
Eos-0.0* Baso-0.1 Im AbsNeut-13.87* AbsLymp-1.41
AbsMono-0.38 AbsEos-0.00* AbsBaso-0.02
12:44PM BLOOD PTT-20.1*
12:44PM BLOOD Glucose-1377* UreaN-106* Creat-6.2*
Na-132* K-6.4* Cl-84* HCO3-9* AnGap-39*
12:44PM BLOOD ALT-42* AST-57* AlkPhos-92 TotBili-0.2
12:44PM BLOOD ALT-42* AST-57* AlkPhos-92 TotBili-0.2
12:44PM BLOOD Lipase-6170*
12:44PM BLOOD CK-MB-77*
12:44PM BLOOD cTropnT-0.13*
08:30PM BLOOD CK-MB-112* cTropnT-0.35*
02:29AM BLOOD CK-MB-95* MB Indx-1.9 cTropnT-0.41*
12:23PM BLOOD CK-MB-81* cTropnT-0.34*
06:29PM BLOOD CK-MB-66* MB Indx-1.5 cTropnT-0.28*
12:44PM BLOOD Albumin-3.7 Calcium-8.9 Phos-7.6* Mg-4.2*
08:35PM BLOOD %HbA1c-16.2* eAG-418*
12:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
12:51PM BLOOD pO2-39* pCO2-27* pH-7.23*
calTCO2-12* Base XS--15
12:51PM BLOOD Glucose-GREATER TH Lactate-3.3*
IMAGING
=======
CXR
Retrocardiac opacity, likely atelectasis given left
hemidiaphragm elevation.
However, superimposed infection is a consideration if clinically
relevant.
Mild pulmonary vascular congestion and mild cardiomegaly.
ECHO
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Doppler parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. There is a mild resting left
ventricular outflow tract obstruction. The gradient increased
with the Valsalva manuever. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve VTI
= 50 cm. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
## IMPRESSION:
Suboptimal image quality with these limitations in
mind the following observations can be made.
1) Mild symmetric left ventricular hypertrophy with normal
biventricular regional/global systolic function.
2) Minimal to mild aortic stenosis. Mean gradient/Peak velocity
high due to high stroke volume rather then valvular aortic
stenosis..
3) Grade I LV diastolic dysfunction.
RENAL U/S
No hydronephrosis. Unremarkable sonographic appearance of the
kidneys, noting
a 2.3 cm simple cyst in the interpolar region of the left
kidney.
CXR Preliminary report.
## FINDINGS:
Lungs are mildly hypoinflated with crowding of vasculature and
bibasilar atelectasis. New heterogeneous right lower lobe
opacity noted. No pleural effusion. No pneumothorax. Heart size,
mediastinal contour, and hila are unremarkable.
Osseous structures are unremarkable.
## IMPRESSION:
Findings worrisome for early right lower lobe pneumonia,
aspirated contents, or aspiration pneumonia.
XR Left Knee
## FINDINGS:
No fracture or dislocation seen. There is mild medial
compartment narrowing
with small medial and lateral joint line osteophytes. Small
patellofemoral
osteophytes. There is a moderate joint effusion. No
destructive lytic or
sclerotic bone lesions seen. Vascular calcification noted.
Incidental noteis made of a fabella.
## IMPRESSION:
Mild tricompartmental degenerative changes. Moderate joint
effusion.
KUB
## IMPRESSION:
Mild gaseous distension of the stomach and small bowel with air
within the
colon. This is a nonspecific bowel gas pattern and appears
similar to the
previous study from .
CXR
## IMPRESSION:
In comparison with the study of , the patient has taken
a better
inspiration. The areas of increased opacification at the bases
are less
prominent than on the previous study. Dense streak of
atelectasis is seen in the left mid zone.
US Abdomen
## IMPRESSION:
Mild increased echogenicity of the liver parenchyma could be
related to mild steatosis. Otherwise unremarkable abdominal
ultrasound.
Cardiac Angiography
Coronary Anatomy
## DOMINANCE:
Right. The LMCA, LAD, Cx had mild plaquing. The RCA
had mild disease with a distal PDA cutoff that appeared embolic
in nature.
## IMPRESSIONS:
1. Branch vessel disease.
Recommendations
1. Medical management.
TTE with bubble study
No atrial septal defect or patent foramen ovale is seen by
saline contrast with maneuvers. No late contrast is seen in the
left heart (suggesting absence of intrapulmonary shunting).
## IMPRESSION:
No evidence of a right-to-left shunt (atrial septal
defect/patent foramen ovale).
MICRO DATA
===========
EAR FLUID CULTURES
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN
-----
<=4 S
CEFEPIME
-----
<=1 S
CEFTAZIDIME
-----
<=1 S
CEFTRIAXONE
-----
<=1 S
CIPROFLOXACIN
-----
<=0.25 S
GENTAMICIN
-----
<=1 S
MEROPENEM
-----
<=0.25 S
PIPERACILLIN/TAZO
-----
<=4 S
TOBRAMYCIN
-----
<=1 S
TRIMETHOPRIM/SULFA
-----
<=1 S
## JOINT ASPIRATION:
=================
Joint Fluid Specimen Results
## RBC, JOINT FLUID:
3510
Polys99%
Lymphocytes0%
Monocytes1%
Joint Crystals, ShapeNEEDLE
Joint Crystals, Location Extracellular
Joint Crystals, BirefringenceNEG
Joint Crystals, Comment
c/w monosodium urate crystals
Joint culture - negative
## BRIEF HOSPITAL COURSE:
Mr is a yoM with PMH IDDM, CKD, HTN, and HLD who
presented to ED on as a transfer from
after his home health aide found him somnolent at home.
He had nausea and vomiting for the past several days, and
stopped taking insulin due to decreased PO intake. On admission,
he was found to be in DKA. He was found to have otitis externa.
He was started on an insulin drip and admitted to the ICU.
In the MICU, he was started on pressors for hypovolemic shock.
His DKA was treated with an insulin gtt and IV fluids. His BP
and anion gap improved, and he was called out of the ICU to the
Medical Floor on . His hospital course is as below by
problem:
# DKA
# Type 1 diabetes:
Triggers of DKA include noncompliance and infection. On
admission, A1C 16.2% (previously 9.8% per PCP note in
. In the MICU, his DKA was managed with IVF and
insulin gtt. was consulted regarding management of his DM
and followed along throughout the hospital course. Initially, he
was continued on a basal bolus regimen. There was concern for
compliance with this regimen at home and he was trialed on a
mixed regimen. However, it was difficult to control his
sugars on this regimen, and he was ultimately transitioned to a
basal-bolus regimen. He is being discharged with long-acting
glargine twice daily, as well as Humalog with mealtimes and
sliding scale insulin.
# Otitis externa:
Head CT at was concerning for ?mastoiditis and the
patient had visible purulent drainage from the R ear. ENT was
consulted and he was given vanc/zosyn for empiric coverage in
the setting of hypothermia and hypotension. This was further
narrowed to Ciprofloxacin ear drops and Unasyn after Klebsiella
grew out of fluid cx's. He was transitioned to Augmentin PO and
completed a 10 day course while in house.
## # ON CKD:
Admission Cr was 7.7. Per outpatient providers,
baseline is around 2.0 (last recorded in . This
was believed to be multifactorial, with a component of pre-renal
azotemia in the setting of infection and hypotension, as well as
ATN (later in course of hospitalization, urine sediment analysis
revealed granular casts). Home diuretics and nephrotoxic
medications were held initially. With IVF and over time, his
kidney function improved and at discharge Cr was 1.2. HTN
medications were restarted as below. Diuretics were ultimately
restarted at a lower dose.
# Demand NSTEMI
# H/o CAD
# Distal PDA cutoff, ?embolic:
Found to have likely type 2 demand ischemia given initial
presentation, electrolyte abnormalities and DKA, with elevated
troponins but no chest pain, EKG with non-specific T wave
inversions. An initial TTE showed no acute changes. Later in his
hospital course, he underwent cardiac angiography ( )
which demonstrated a distal PDA cutoff, no other significant
CAD, and no intervention was done. He was continued on Aspirin
81mg, Atorvastatin 80mg. He was restarted on home Metoprolol
Succinate 200mg daily at discharge . A follow up TTE to
evaluate for a PFO was negative for any sign of PFO.
# HTN
Initially his home blood pressure medications were held given
hypotension and . However, they were slowly restarted and
retitrated. He is being discharged on
Metoprolol Succinate 200 mg PO daily, Amlodipine 10 mg daily,
Hydralazine 50mg q8h, and lisinopril 40 mg daily.
#Acute exacerbation of diastolic HF
The patient was found to be largely fluid overloaded with
significant peripheral edema on exam. Though no baseline dry
weight was known, diuretics were restarted once the patient's
resolved. He was diuresed with Lasix 40 mg BID, with net
goal of -1L daily over several days. His discharge weight was
113.1 kg (249.34 lb), with plans to continue diuresis during
acute rehabilitation.
# Polyarticular Gouty flare
The patient developed a flare of known baseline gout while in
hospital, affecting primarily his right wrist and hand, and both
knees. Rheumatology was consulted and tapped the left knee
joint, confirming the presence of urate crystals consistent with
gout. He was originally treated with colcichine. Due to
persistent symptoms, he began a steroid course (40 mg x 2 days,
30 mg x2 days, 20 mg x2 days, 10 mg x1 day) which he completed
in hospital. He will seen Rheum as an outpatient.
# Elevated LFT's
Found to be elevated, but down-trending over the hospital
course. RUQUS did not demonstrate an acute issue, but did show
evidence of steatosis. Recommend repeat LFT's as outpatient.
# Electrolyte repletion:
Required frequent repletion of electrolytes including Phosphate
and Magnesium. Received Neutraphos tablets while in house for
low Phosphate. Given repeated need for IV Mg repletion over
several days, started Mg Oxide 400 mg PO daily at discharge.
# Chronic anemia:
Hgb and low MCV. Iron studies suggestive of chronic disease,
but also with low Fe/TIBC ratio. Would benefit from repeat iron
studies as outpatient to evaluate for component of iron
deficiency.
TRANSITIONAL ISSUES
==============================
- Please recheck Chem 10 in days to ensure stable Cr and
Electrolytes. He was started on daily Magnesium repletion for
low Magnesium levels. Discharge Cr 1.2. Discharge K 4.1.
- Recommend repeat iron studies as an outpatient. This
admission, they showed picture consistent with anemia of chronic
inflammation, as well as low iron/TIBC ratio. Ferritin 435, TIBC
134, serum Iron 11.
- Recommend repeat CBC as outpatient to ensure continued
normalization. Discharge WBC 12.8, discharge Hgb 7.7.
- SSRI was discontinued this hospital stay. If needed as an
outpatient, can restart his Fluoxetine 20mg daily
- Please continue to monitor weights daily. Check weight as soon
as he arrives to get a baseline. He is being discharged on
Furosemide 40mg BID which he responds well to, but this can be
adjusted as an outpatient depending on how he does.
- Please continue to monitor blood pressures. Consider
increasing Hydralazine dose, or restarting his home Clonidine,
if he remains persistently elevated
- Outpatient Rheum follow up has been scheduled for Gout
management
- Uric acid elevated >6, consider allopurinol as an outpatient
(not until wks post flare)
- Recommend repeat LFT's in 2 weeks to ensure stability. Last
ALT 110, AST 93, AP 135, Tbili 0.2.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Bumetanide 2 mg PO 3X/WEEK ( )
4. Calcitriol 0.25 mcg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Metolazone 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. CloNIDine 0.2 mg PO BID
9. HydrALAZINE 100 mg PO TID
10. Metoprolol Tartrate 50 mg PO BID
11. Bumetanide 1 mg PO 4X/WEEK ( )
12. Ranitidine 150 mg PO QHS
13. Vitamin D UNIT PO DAILY
14. Glargine 78 Units Bedtime
Humalog 26 Units Breakfast
Humalog 44 Units Lunch
Humalog 48 Units Dinner
15. FLUoxetine 20 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Furosemide 40 mg PO BID
4. Magnesium Oxide 400 mg PO DAILY
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Senna 8.6 mg PO BID constipation
7. Atorvastatin 80 mg PO QPM
8. HydrALAZINE 50 mg PO Q8H
9. Glargine 26 Units Breakfast
Glargine 20 Units Bedtime
Humalog 6 Units Breakfast
Humalog 10 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Ranitidine 150 mg PO DAILY
11. amLODIPine 10 mg PO DAILY
12. Calcitriol 0.25 mcg PO DAILY
13. Lisinopril 40 mg PO DAILY
14. Vitamin D UNIT PO DAILY
## DISCHARGE DIAGNOSIS:
#DKA
#Klebsiella Otitis externa
#NSTEMI
on CKD
#Diastolic HF exacerbation
#Polyarticular gout flare
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
Why was I here?
- You were admitted to the hospital because you were found down
at home. In the hospital you were then found to have dangerously
high blood sugar levels and an infection in your ear.
What was done for me here?
- You received treatment to control your blood sugars.
- Your ear infection was treated with antibiotics.
- You were found to have a flare of your gout and received
medications to reduce inflammation.
- You were found to have excess fluid in your body and you
received diuretics to reduce this.
- You underwent angiography to look at the vessels in your heart
and found to have a small blockage in one of the blood vessels
in your heart.
- We also did imaging studies of your liver and your heart and
these did not show significant changes.
What should I do when I go to rehab and then home?
- Your medications will continue to be adjusted during your
rehabilitation stay
- You should work with the staff at the rehab and rebuild your
strength
- You should follow-up with your primary care provider 1 week
after discharge from rehab. You should also follow-up with your
outpatient Nephrologist and your outpatient Cardiologist.
- You have a follow-up appointment scheduled with Rheumatology
(Dr. on at 9:00 AM
Please call your primary care doctor if you have any fevers,
chills, chest pain, shortness of breath, nausea/vomiting,
swelling or pain in your joints, or if you feel very thirsty or
are peeing a lot.
It was a pleasure taking care of you! We wish you the best of
luck in the coming weeks.
Your Inpatient Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15690806", "visit_id": "23321044", "time": "2124-08-20 00:00:00"} |
11888962-RR-20 | 640 | ## INDICATION:
male patient with persistent left lateral knee pain,
radiating to the toes, to evaluate for stenosis. Has MRI compatible heart
valve.
## FINDINGS:
The numbering used for the present study is depicted on series 2, image 12;
series 3, image 12.
Lumbar vertebral bodies are grossly normal in height, signal intensity, and
alignment. Mild reduction in the height of L3 to L5 is noted and likely
relates to the concavity of the endplates from mild disc bulges
intravertebrally. This also correlates with the appearance noted on the plain
radiograph of the lumbar spine where there is associated osteopenia.
Disc desiccation is noted at multiple levels. Small anterior and posterior
osteophytes, related to spondylosis, are noted at multiple levels.
At T12-L1 level, prominent anterior osteophytes are noted along with disc
desiccation and mild diffuse disc bulge and mild facet degenerative changes.
There is mild indentation on the ventral thecal sac. There is no significant
spinal canal stenosis.
At L2-3, the disc is unremarkable. There are mild-moderate degenerative
changes noted in the facet joints on both sides and ligamentum flavum
thickening, indenting the roots of the cauda equina posteriorly.
At L3-4, there is diffuse disc bulge, asymmetric to the left side, causing
severe neural foraminal narrowing and deformity of the left L3 nerve root.
There are also degenerative changes noted in the facet joints and the
ligamentum flavum thickening on both sides, moderate, contributing to the
neural foraminal narrowing, left more than right. There is moderate-to-severe
spinal canal stenosis, causing moderate compression of the roots of the cauda
equina. A small focus of annular tear is noted anteriorly on the right side.
At L4-5, there is disc desiccation, narrowing of the disc space, and diffuse
disc bulge, more prominent on the right side. Moderate facet degenerative
changes and ligamentum flavum thickening are also noted. Overall, there is
severe spinal canal stenosis, with severe compression of the roots of the
cauda equina and severe neural foraminal narrowing on the right and moderate
on the left, with severe compression on the right L4 nerve root.
Moderate degenerative changes are noted in the facet joints, along with
ligamentum flavum thickening. There are also type changes related to
marrow edema, noted in the adjacent endplates.
At L5-S1, there is mild diffuse disc bulge along with moderate facet
degenerative changes, without spinal canal stenosis. No nerve root
compression is noted.
The spinal cord ends at T12-L1 level. No pre- or para-vertebral soft tissue
swelling or masses are noted.
There is a small subcentimeter T2 hyperintense lesion in the anterior aspect
of the left kidney.
The renal hilum on the right side appears to be oriented anteriorly rather
than medially. However, the kidneys are not completely assessed on the
present study.'
There is mural thickening of the aortic wall in the visualized portions, not
adequately assessed on the present study.
## IMPRESSION:
1. Multilevel degenerative changes in the lumbar spine, in the discs, facet
degenerative changes, and ligamentum flavum thickening along with spondylosis,
causing severe spinal canal stenosis at L3-4, L4-5 - moderate at L3/4 and
severe at L4/5 level with severe compression of the roots of the cauda equina
at L4-5 level. Findings were communicated to , Admin Assistant at
the office of Dr. by on at around 2 Pm.
2. Increased signal in the adjacent endplates at L4-5 level likely relates to
changes, related to marrow edema. However, if there is concern for any
superimposed infection based on clinical symptoms, further evaluation with
contrast and correlation with labs can be considered.
3. Subcentimeter T2 hyperintense lesion in the left kidney, with anterior
orientation of the right renal hilum, which need further evaluation with
ultrasound of the kidneys.
4. Thickening of the abdominal aortic wall, not adequately assessed on the
present study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11888962", "visit_id": "N/A", "time": "2133-09-06 07:55:00"} |
17238343-RR-25 | 102 | ## INDICATION:
female with enlarged left thyroid lobe, status post
right hemithyroidectomy many years prior. Please evaluate for concerning
thyroid nodules.
## FINDINGS:
Again demonstrated is a grossly enlarged left thyroid lobe with
dominant internal nodule measuring approximately 4.9 cm. Foci of tiny
internal cystic spaces is demonstrated also seen on recent MRI. A remnant
right lobe measures 4 x 2 x 1.3 cm after remote partial hemilobectomy. No
concerning perithyroid lymphadenopathy is identified.
## IMPRESSION:
Grossly enlarged left thyroid lobe with dominant nodule measuring
4.9 cm in greatest dimension. If clinically indicated, this nodule would be
amenable to FNA.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17238343", "visit_id": "N/A", "time": "2141-12-08 12:37:00"} |
11830275-RR-31 | 125 | ## FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass,
mass effect, or large vascular territorial infarction. The ventricles and
sulci are mildly prominent, reflective of diffuse cortical atrophy. Punctate
hypodensities in the region of the basal ganglia bilaterally likely reflect
lacunes. There is no shift of normally midline structures. An acute
nondisplaced fracture of the right lateral mass of C1 is present (3:4). The
dens appears intact. The middle ear cavities and mastoid air cells are clear.
There is mild mucosal thickening within the ethmoid and maxillary sinuses.
Mild soft tissue swelling is noted overlying the right posterior vertex.
## IMPRESSION:
1. Acute nondisplaced C1 right lateral mass fracture.
2. No acute intracranial process.
3. Mild ethmoid and maxillary sinus disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11830275", "visit_id": "25644593", "time": "2152-07-08 20:02:00"} |
14639458-RR-10 | 149 | ## HISTORY:
man with head pain status post motor vehicle collision.
Evaluate for fracture.
## CT C-SPINE:
Helical imaging was performed through the cervical spine without
IV contrast. Sagittal and coronal reformats were prepared.
## FINDINGS:
There is no fracture or subluxation. There is straightening of the
normal cervical lordosis, likely secondary to patient's positioning within a
cervical restraint collar or related to muscle spasm. There is no
prevertebral soft tissue swelling. At C2/3 and C2/3, there are left posterior
endplate osteophytes slightly indenting the left aspect of the thecal sac.
There is patchy ground glass attenuation at the visualized lung apices, of
uncertain etiology, possible due to expiratory phase of respiration.
There are non-enlarged but unusually numerous level 1, 2, and 5 lymph nodes.
## IMPRESSION:
1. No fracture or subluxation.
2. Mild spondylosis.
3. Non-enlarged but numerous cervical lymph nodes. Clinical correlation
suggested.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14639458", "visit_id": "N/A", "time": "2138-10-10 19:23:00"} |
14767095-RR-50 | 140 | ## INDICATION:
year old man with Hx left thyroid 8 mm nodule, evaluate for
interval change.
## THE RIGHT LOBE MEASURES:
(transverse) 2.7 x (anterior-posterior) 2.6 x
(craniocaudal) 4.5 cm.
The left lobe measures: (transverse) 1.9 x (anterior-posterior) 2.2 x
(craniocaudal) 4.6 cm.
Isthmus anterior-posterior diameter is 0.4 cm.
The thyroid parenchyma is homogenous and has normal vascularity. Multiple
simple cysts are redemonstrated, measuring up to 2 cm on the right and 4 mm on
the left. The previously seen hyperechoic nodule within the left lower pole
measures 9 x 5 x 5 mm, not significantly changed from the prior study which
time it measured 8 x 5 x 5 mm.
## IMPRESSION:
Unchanged left lower pole hyperechoic nodule.
## RECOMMENDATION(S):
Follow-up ultrasound years is recommended to evaluate
for stability.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14767095", "visit_id": "N/A", "time": "2152-10-10 14:37:00"} |
14922593-DS-21 | 1,714 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
colonscopy with biopsies on
## HISTORY OF PRESENT ILLNESS:
with stage IV DLBCL of the left breast, presenting during
pregnancy, s/p six cycles of R-CHOP, HD MTX as CNS ppx, then
relapse in the CNS, s/p 4C of HD MTX (8g/m2)s/p 2C of HD
MTX(4g/m2)/Ifosfamide complicated by recent VZV
infection of cranial nerve V. Then consolidated with 1C of CYVE
followed by 1 cycle of HiDAC followed by autologous stem cell
transplant with ByCy/Thiotepa regimen. Currently on protocol
, which includes pembrolizumab after auto transplant in
Hodgkins lymphoma s/p auto transplant and s/p C2 pembrolizum now
admitted with worsening diarrhea, + C diff .
## -- :
About 15 weeks' pregnant. begins feeling
unwell
with decreased energy. Development of asymmetry, swelling, and
pain in her left breast
-- : Breast ultrasound reveals no evidence of
malignancy -- . Breast punch biopsy reveal:
"lymphangiectasias with dermal edema and scant superficial to
mid
dermal perivascular lymphoplasmacytic infiltrate. No carcinoma
was seen."
-- breast core biopsy with results showing high-grade
lymphoma. Mib fraction of 100%, MUM1 and BCL2 positivity; BCL6
gene positive by cytogenetics. By cytogenetics, BCL2 and MYC
are
negative
-- : Admitted for expedited work-up; MRI head
(without contrast) shows no evidence of disease, MRI abdomen
pelvis with soft tissue infiltration in the left breast,
extending into the axilla, consistent with biopsy proven
lymphoma. Infiltrating soft tissue in the left renal hilum,
highly concerning for lymphomatous involvement. Mild upper and
lower pole calyceal dilation as a result. Findings concerning
for diffuse splenic, liver and bilateral ovarian lymphomatous
involvement. No retroperitoneal, mesenteric or pelvic
lymphadenopathy.
-- : CSF negative for lymphoma
-- : Delivers 6lb baby boy via C-section named . Baby initially in NICU with low apgar scores, intubated,
but quickly improves clinically. Placenta is calcified and
small, but no evidence of lymphoma on path review.
-- : PET reveals no evidence of disease aside from slight
uptake in left breast
-- : PET reveals, slightly asymmetric FDG uptake within
the
left breast is not significantly changed relative to prior study
with a more focal area of increased uptake seen in the upper
inner quadrant.
-- : PET reveals, FDG avidity of a focal area in the left
breast, slightly decreased in avidity from the most recent prior
study. FDG avidity in the axial skeleton, also reduced compared
to the most recent prior study, compatible with treatment
effect.
Resolution of focal area of increased FDG avidity in the
cutaneous tissues of the left back. Persistent prominence of
the
right renal pelvis without hydronephrosis on ultrasound, which
may represent an extrarenal pelvis.
-- : Left breast biopsy, no evidence of B cell lymphoma
-- PET: Interval increase in focal FDG uptake in the
left inner breast with SUVmax now 4.4. No new FDG-avid focus.
- : complains of left numbness, no
herpetic lesion, giving Valtrex empirically and will
re-evaluate,
also with likely De Que 's tenosynovitis (referral to PCP
and
OT)
-- : Admitted for worsening left numbness,
tongue numbness, mandibular numbness. MRI reveals, thickening
and enhancement in the left trigeminal nerve. CSF with evidence
of lymphoma by histopathology.
-- : MRI head shows slightly decreased enhancement and
thickening of the left trigeminal nerve cisternal and cavernous
portions. No enhancing brain lesions.
-- : The previously described area of focal FDG uptake
within the medial left breast appears less conspicuous. No new
foci of abnormal FDG uptake identified.
-- : VZV involvement of right CNV, patient admitted for IV
acyclovir and discharged on valacyclovir
-- : Profoundly neutropenic on C1D11 of CYVE, started on
cipro/flagyl for prophylaxis
##
-- :
C1D1 CHOP (dosed per actual body weight)
cyclophosphamide at 750 mg/m2, doxorubicin 50 mg/m2, vincristine
1.4 mg/m2 and prednisone 100 mg for five days.
-- : First dose rituximab
-- : C2D1 R-CHOP
-- : C3D1 R-CHOP
-- : Admitted for transaminitis, likely drug induced
(Neupogen vs. LMWH vs. chemo vs. acyclovir)
-- : C4D1 R-CHOP (given on day ), LFTs are still elevated
but trending down.
-- : C5 R-CHOP (Q2 weeks)
-- : C6 R-CHOP (Q2 weeks)
-- : C1 HD MTX for CNS prophylaxis
-- : C2 HD MTX for CNS prophylaxis
-- : C3 HD MTX for CNS prophylaxis
-- : C4 HD MTX for CNS prophylaxis
CNS RECURRENCE
## -- :
IT Depocyt (had headache, vomiting)
****************
Auto SCT preparation :
--We then prepared for high dose chemotherapy with autologous
stem cell rescue.
--Stem cells were mobilized with Neupogen and Mozobil and
collected with four apheresis sessions with a total yield of 4.9
x 10^6.
--Consents for transplant was signed on . Performance
status at time of consent was 80%.
Bone marrow biopsy on showed hypercellular marrow
without
evidence of lymphoma. PET scan on revealed: No evidence
of FDG avid disease or lymphadenopathy.
--As we geared up for transplant in early ,
began complaining of worsening headaches (L>>R) and left eye
pain
and pressure.
## --MRI BRAIN/ORBITS/MRA :
Mild persistent enhancement of
the left trigeminal secondary lesion identified in the foramen
rotundum but otherwise no new mass lesion identified. Earlier
mass and enhancement in relation with left trigeminal nerve has
resolved. No intraorbital masses identified. Mild increased
signal along both upper eyelids on diffusion images is likely
artifactual but clinical correlation is recommended.
Ms. also underwent dilated eye exam by Ophthalmology
without evidence of occular lymphoma.
Her headache was treated supportively with triptans,
dexamethasone, compazine, fioricet, and dilaudid prn. She was
admitted on due to worsening headache.
-- , an LP was performed, which revealed: four WBCs, 1
RBC, 5% polys, 71% lymphs, 19% monos, 1% plasma cells and 4%
others. Total protein was 45 and glucose was 64. Cytogenetics
from CSF returned with: FISH: LOW POSITIVE for BCL6
REARRANGEMENT.
Decision made to proceed
## :
Thiotepa/Busulfan/Cytoxan auto transplant complicated
by neutropenic fever and c.diff infection.
## :
LP with FISH negative for BCL6 rearrangement, flow
non-diagnostic, MRI with no significant change since the MRI of
. Mild persistent enhancement of the left
trigeminal nerve as well as in the region of foramen rotundum
are
again noted. No new mass lesion identified. No abnormal brain
parenchymal enhancement.
## PET :
1. No evidence of FDG avid disease.
## :
Admitted with worsening headache. MRI head negative
for recurrent disease. LP with FISH negative for BCL6.
Trial , pembrolizumab after auto transplant in HL and NHL:
## -- :
C1D1
-- : Diagnosed with recurrent c.diff
## HEENT:
PERRL, MMM, OP clear, no vesicles or ulcers seen
## CV:
RRR, good S1, S2, no M/R/G
## LUNGS:
CTA , no w/r/rh
## ABDOMEN:
soft, NT, ND, no HSM
## SKIN:
3 crusted lesions on R cheek, and R side of scalp healing
appropriately
## NEURO:
CNII-XII grossly intact, muscle strength symmetric and
full in both extremities.
## I/O:
3080/2200; 1 soft stool this morning
## HEENT:
PERRL, MMM, OP clear, no vesicles or ulcers seen
## CV:
RRR, good S1, S2, no M/R/G
## LUNGS:
CTA , no w/r/rh
## ABDOMEN:
soft, NT, ND, no HSM
## SKIN:
3 crusted lesions on R cheek, and R side of scalp healed
appropriately
## NEURO:
CNII-XII grossly intact, muscle strength symmetric and
full in both extremities.
## BRIEF HOSPITAL COURSE:
#Stage IV DLBCL with CNS recurrence: most recent MRI on
showed a significant response to therapy no active disease. most
recently received C2 (dose 2) of pembrolizumab on , due
again approx. every 3 weeks but may need to hold PND
diarrhea work up.
## #DIARRHEA:
+ C diff and , currently remains on po
vanc 125mg q6, repeat sample negative so advised patient to
decrease t 125mg q8 on , further stool studies PND at
discharge. sent CMV vL--neg. concern of colitis in setting of
study drug, completed colonoscopy with biopsies for
definitive
diagnosis, clinically bowel was unremarkable with mild erythema,
final path PND but prelim w/ nonspecific changes, initiated
methylpred 50mg IV in setting of neg C diff and concern
of chemical colitis due to pembrolizumab. Received 60mg of
prednisone x1 on with plan to take 50mg daily from
and 40mg daily from . Dr to give
further taper instructions at outpatient appointment on .
## #VZV:
The patient was recently admitted for VZV of the
trigeminal nerve. Had crusted lesions on right pinna and
temporal scalps that have since resolved, continues on
valacyclovir
## #DEPRESSION:
continue sertraline
#Insomnia Ativan 1mg @hs per Dr.
#EMERGENCY CONTACT: (Cell)
#DISPO: Discharged with follow up appointment on with
Dr.
on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen-Caff-Butalbital TAB PO Q8H:PRN Headache
2. FoLIC Acid 1 mg PO DAILY
3. LORazepam 1 mg PO QHS:PRN insomnia
4. norethindrone (contraceptive) 0.35 mg oral DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. Sertraline 25 mg PO DAILY
7. Topiramate (Topamax) 25 mg PO BID
8. ValACYclovir 500 mg PO Q12H
9. Vancomycin Oral Liquid mg PO Q6H
10. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
11. Cyanocobalamin 1000 mcg PO DAILY
## DISCHARGE MEDICATIONS:
1. LOPERamide 2 mg PO QID:PRN loose stool
RX *loperamide 2 mg 2 mg by mouth every 6 hours as needed Disp
#*30 Capsule
## REFILLS:
*0
2. Pantoprazole 40 mg PO Q24H
3. PredniSONE 50 mg PO DAILY
50mg daily on and . If feeling better, decrease dose to
40mg daily on and .
Tapered dose - DOWN
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*42 Tablet
Refills:*0
4. Vancomycin Oral Liquid mg PO Q8H
start decreased dose on . Acetaminophen-Caff-Butalbital TAB PO Q8H:PRN Headache
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
7. Asmanex HFA (mometasone) 400 mcg IH BID
8. Cyanocobalamin 1000 mcg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. LORazepam 1 mg PO QHS:PRN insomnia
11. norethindrone (contraceptive) 0.35 mg ORAL DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. Sertraline 25 mg PO DAILY
14. Topiramate (Topamax) 25 mg PO BID
15. ValACYclovir 500 mg PO Q12H
## DISCHARGE DIAGNOSIS:
DLBCL with CNS Disease
Diarrhea
## DISCHARGE INSTRUCTIONS:
Ms. ,
You were admitted due to worsening diarrhea. You underwent
colonoscopy. The final results are not back yet but preliminary
results are reassuring. Your most recent C diff test on this
admission was negative. You will start tapering your vancomycin
on . You were started on steroids as it is thought that
your colitis/diarrhea may be secondary to the study drug and you
will continue steroids until Dr. you to do so. Your
symptoms continue to improve you and you will be discharged home
today. You will follow up in clinic as stated below. It was a
pleasure taking care of you.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14922593", "visit_id": "23824402", "time": "2144-05-27 00:00:00"} |
18196126-RR-14 | 124 | ## EXAMINATION:
CT C-SPINE W/O CONTRAST Q311 CT SPINE
## INDICATION:
year old man found down w/ AMS, coagulopathy of unknown
etiology found to have intraparenchymal hemorrhage // eval for cspine fx,
able to take of cspine precautions?
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.0 s, 19.6 cm; CTDIvol = 36.8 mGy (Body) DLP = 720.3
mGy-cm.
Total DLP (Body) = 720 mGy-cm.
## FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling.Known pneumonia involving the right upper lobe is noted.
## IMPRESSION:
1. No acute fracture, malalignment, or prevertebral soft tissue abnormality.
2. Known pneumonia is incompletely visualized in the right lung apex.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18196126", "visit_id": "22916352", "time": "2186-05-06 06:37:00"} |
17267800-DS-7 | 1,674 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
: Percutaneous endoscopic gastrostomy
## HISTORY OF PRESENT ILLNESS:
s/p AVR/CABG p/w gallstone panc, perforated duodenal ulcer
c/b massive UGI bleed from duodenal ulcer and diverticulum s/p
GDA/SPDA/IPDA embolization and repair of duodenal perforation,
ccy. B/l pleural effusions with pigtail placement. Drainage (OR
and for VRE in and retroperitoneal
collections.
Patient discharged yesterday ( ) to rehab and is now
transferred from after developing tachycardia
to 120s and subjective fevers at his rehabilitation center. New
leukocytosis of 20k, non tender abdomen w/ opaque serous
drainage, wet cough and altered mental status. Patient is
oriented to self only. Concern for pneumonia or intra-abdominal
process for recent change.
Recent antibiotic course includes vancomycin ( ), Flagyl
( ), and Fluconzole ( ), patient's duodenal
collection grew VRE and was started on linezolid on on
which patient was discharged and planned course through .
## PMH:
HTN, HLD, DMII, verterbral aortic stenosis s/p aortic valve
replacement, h/o Alcohol Abuse, B12 Deficiency, BPPV, BPH, hx GI
Bleed, H. pylori, vertebral artery stenosis, mild dementia,
hearing loss, vitamin D Deficiency
## PSH:
- Aortic valve replacement (23 tissue) and
CABG
x1
- cataract surgery
- bilateral inguinal hernia repair - unclear TEP vs TAP years
ago,
## FAMILY HISTORY:
Father - died at age of myocardial infarction, history of
diabetes.
Brother - history of myocardial infarction in his , history
of CABG
## GEN:
Oriented to self only, responsive, follows commands
## HEENT:
mucus membranes dry, DHT in nostril w/ bridle. Sinuses
nontender to palpation
## PULM:
b/l air movement, no frank crackles, overt wheezing; bases
diminished laterally
## ABD:
soft, non distended, midline incision healing well w/ steri
strips in place, dry w/o discharge or evidence of infection.
Anterior JP drain to suction and lateral small catheter drain
with opaque serous drainage in bulbs.
## GEN:
Alert, sitting up in bed. Interactive.
## HEENT:
no deformity. PERRL, EOMI. Mucus membranes moist. neck
supple, trachea midline.
## PULM:
Clear to auscultation, diminished in the bases.
## ABD:
Soft, non-distended, mildly tender at peg site to palpation
as anticipated. Open are due to bumper rubbing on skin. Right
lower quadrant drain in place.
## EXT:
Warm and dry. 2+ pulses. No edema.
## NEURO:
A&O to person and place. Follows commands and moves all
extremities equal and strong. Speech is clear and fluent.
## SOURCE:
Stool.
**FINAL REPORT
C. difficile DNA amplification assay (Final :
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay. (Reference Range-Negative).
04:15PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
04:15PM URINE RBC-37* WBC-7* Bacteri-FEW Yeast-NONE
Epi-<1
04:15PM URINE Color-Yellow Appear-Clear Sp
3:25 pm BLOOD CULTURE #1.
**FINAL REPORT
Blood Culture, Routine (Final : NO GROWTH.
4:15 pm URINE
**FINAL REPORT
URINE CULTURE (Final : NO GROWTH.
**FINAL REPORT
## WOUND CULTURE (FINAL :
No significant growth.
IMAGING
CT Abdomen/Pelvis
1. Interval placement of drainage catheter in the right
perinephric fluid
collection with slight decrease in overall size of this
collection.
2. Small residual pleural effusions with right basal
atelectasis.
3. Otherwise, no significant change.
Bilateral duplex study
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins.
2. Bilateral cysts.
CXR
1. New faint right lung base opacities in a peribronchial
distribution,
concerning for interval aspiration.
2. Trace bilateral pleural effusions.
CT Abdomen/Pelvis
1. Minimal possible increase in size of the complex loculated
right
perinephric fluid collections with unchanged position of a
pigtail catheter partially uncurled and incompletely residing in
an inferior fluid pocket, which has increased minimally in size.
2. Interval increase in small right pleural effusion.
3. Diverticulosis.
4. Extensive atherosclerosis.
## BRIEF HOSPITAL COURSE:
s/p AVR/CABG p/w gallstone panreatitis with massive upper GI
bleed secondary to perforated duodenal ulcer who underwent
GDA/SPDA/IPDA embolization and operative repair of duodenal
diverticular bleed and perforation w/ post-operative course
complicated by VRE abscesses represents with tachycardia and
leukocytosis. He had a CT abdomen and pelvis reassuring for
overall decreased size of abdominal fluid collections. He was
admitted to the surgical floor for hemodynamic monitoring.
Given concern for a new leukocytosis of 20K, his antibiotics
were broadened to ciprofloxacin, metronidazole, and linezolid.
Infectious Disease was consulted and helped formulate antibiotic
coverage. His white blood cell count trended down. He had a
repeat CT scan on HD9 that showed interval decrease in his fluid
collection.
Due to poor PO intake, a dobhoff was replaced during the
hospitalization but was accidentally self-removed by the patient
on HD11. Due to the need for long term enteral nutrition, a PEG
was placed on HD12. The patient tolerated the procedure well. On
HD13, tubefeeds were started and advanced to goal.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating tubefeeds at
goal, out of bed with assist, voiding without assistance, and
was denying pain. The patient was discharged to rehab, to
continue oral antibiotics until his follow-up in the surgery
clinic. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
## MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium (Liquid) 100 mg PO BID
3. Metoprolol Tartrate 12.5 mg PO TID
4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
5. Diltiazem 90 mg PO Q6H
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. NPH 15 Units Breakfast
NPH 15 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Linezolid mg IV Q12H
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
13. OxycoDONE Liquid 2.5-5 mg PO Q4H:PRN pain
14. Senna 8.6 mg PO BID:PRN constipation
15. Cyanocobalamin 1000 mcg IM/SC MONTHLY
16. Bisacodyl AILY:PRN constipation
17. Donepezil 5 mg PO QHS
18. Furosemide 20 mg PO DAILY
19. Atorvastatin 80 mg PO QPM
## DISCHARGE MEDICATIONS:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Ciprofloxacin HCl 500 mg PO Q12H
5. Diltiazem 90 mg PO Q6H
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Donepezil 5 mg PO QHS
8. Heparin 5000 UNIT SC BID
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Linezolid mg PO Q12H
12. Metoprolol Tartrate 12.5 mg PO TID
13. MetroNIDAZOLE 500 mg PO Q8H
14. OxycoDONE Liquid 2.5-5 mg PO Q6H:PRN pain
15. Sodium Chloride 1 gm PO TID
## DISCHARGE DIAGNOSIS:
Right perinephric fluid collection
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to the Acute Care Surgery Service on
fever, increased white blood cell count, and a fast heart rate.
You had a CT scan that showed a fluid collection in your
abdomen. You were given antibiotics and had a tube placed to
help drain the infection. You had a poor appetite and were
unable to take in enough food so a PEG tube placed to help meet
your nutritional needs.
You are now tolerating tube feed, heart rate is improved, and
your infection is controlled. You are now ready to be discharged
to rehab to continue your recovery. Please note the following
discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
## INCISION CARE:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips days after surgery.
## JP DRAIN CARE:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, , or nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17267800", "visit_id": "21850596", "time": "2183-08-09 00:00:00"} |
11089687-RR-31 | 323 | DIGITAL DIAGNOSTIC BILATERAL MAMMOGRAM AND LEFT BREAST ULTRASOUND:
## HISTORY:
Palpable abnormality in the lower inner quadrant for a couple of
months. Now for evaluation. Family history of breast cancer in patient's
mother, probably premenopausal.
## FINDINGS:
Routine digital mammography of both breasts marked with a BB marker
indicating the palpable abnormality in the lower inner quadrant were
performed. Additional 90-degree lateral views of both breasts, as well as CC
and MLO spot compression views of the left breast were performed with special
attention to the area of the lower inner left breast palpable abnormality.
Comparison made with , and .
The breasts are heterogeneously dense, limiting the sensitivity of
mammography. The area of asymmetry in the upper outer right breast is seen
which on the 90-degree lateral view demonstrates pliable breast tissue.
Corresponding to the BB marker in the lower inner quadrant, there is no focal
abnormality seen. Targeted ultrasound was performed.
## LEFT BREAST ULTRASOUND:
Ultrasound targeted to the palpable abnormality which
the patient had difficulty locating in the lower inner quadrant reveals a
superficial 0.5 x 0.1 x 0.5 cm circumscribed hypoechoic nodule in the dermal
layer at 7 o'clock, 6 cm from the nipple, consistent with an epidermal
inclusion cyst/sebaceous cyst. No significant abnormality is seen in the
breast tissue at this location. Patient was asked to follow up with Dr.
clinical evaluation, as well as consider genetic counseling and
MRI given dense breasts and family history of breast cancer.
## IMPRESSION:
No radiographic evidence of malignancy. Superficial dermal
lesion in the left breast at 7 o'clock, 6 cm from the nipple at the site of
palpable abnormality indicated by the patient, although patient had alot of
difficulty identifying the palpable abnormality. Clinical followup with Dr.
is recommended. Consider genetic counseling and MRI evaluation given
patient's family history of breast cancer in her mother, probably
premenopausally.
BI-RADS 2 -- benign; clinical management also recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11089687", "visit_id": "N/A", "time": "2110-02-17 15:56:00"} |
15261821-DS-19 | 1,003 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Cystoscopy, right ureteroscopy and stent placement
## HISTORY OF PRESENT ILLNESS:
w/ 5mm R ureteral stone.
- denies fevers, chills, sweats
- + nauesa, emesis
- not tolerating PO
- admitted directly from Dr clinic
## PAST MEDICAL HISTORY:
- kidney stones
- thoracic aneurysm
## PHYSICAL EXAM:
NAD, AVSS
Abd soft nt/nd
No CVA tenderness bilaterally
Ext wwp
## PERTINENT RESULTS:
10:22PM URINE COLOR-Straw APPEAR-Clear SP
10:22PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
## BRIEF HOSPITAL COURSE:
Ms. was admitted to the Urology Service under Dr
with right flank pain, nausea, emesis. On admission, she was
made NPO, given IV fluids and medication to control her pain and
nausea. On the morning of HD1 she had persistent right sided
pain with nausea. She was, therefore, taken to the operating
room for ureteroscopy and right ureteral stent placement. No
concerning intraoperative events occurred; please see dictated
operative note for details. The patient received
antibiotic prophylaxis. The patient's postoperative course was
uncomplicated. She remained a-febrile throughout his hospital
stay. At discharge, the patient had pain well controlled with
oral pain medications, was tolerating regular diet, ambulating
without assistance, and voiding without difficulty. She was
given bactrim for prophylaxis and oral pain medications on
discharge along with explicit instructions to follow up in
clinic. She did report right lower quadrant pain on POD1 that
worsened with voiding (producing increased dysuria) and was
reassured given the ureteral stent placement.
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q6H Duration: 8 Doses
2. Atenolol 25 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Meclizine 25 mg PO TID dizziness
5. NexIUM (esomeprazole magnesium) 40 mg oral qhs
6. Polyethylene Glycol 17 g PO DAILY
7. Rosuvastatin Calcium 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth at bedtime Disp #*30 Capsule Refills:*0
9. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
take with stool softener. Do not drink/drive after taking
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q4-6 hrs
Disp #*25 Tablet Refills:*0
1. Acetaminophen 650 mg PO Q6H Duration: 8 Doses
2. Atenolol 25 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Meclizine 25 mg PO TID dizziness
5. NexIUM (esomeprazole magnesium) 40 mg oral qhs
6. Polyethylene Glycol 17 g PO DAILY
7. Rosuvastatin Calcium 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth at bedtime Disp #*30 Capsule Refills:*0
9. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
take with stool softener. Do not drink/drive after taking
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q4-6 hrs
Disp #*25 Tablet Refills:*0
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Duration: 3 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*3 Tablet Refills:*0
1. Acetaminophen 650 mg PO Q6H Duration: 8 Doses
2. Atenolol 25 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Meclizine 25 mg PO TID dizziness
5. NexIUM (esomeprazole magnesium) 40 mg oral qhs
6. Polyethylene Glycol 17 g PO DAILY
7. Rosuvastatin Calcium 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth at bedtime Disp #*30 Capsule Refills:*0
9. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
take with stool softener. Do not drink/drive after taking
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q4-6 hrs
Disp #*25 Tablet Refills:*0
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Duration: 3 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*3 Tablet Refills:*0
## DISCHARGE INSTRUCTIONS:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin if you were previously taking it until your urine is
clear
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Continue on your miralax that you take at home. We ask that you
take it to avoid post surgical constipation and constipation
related to narcotic pain medication. Discontinue if loose stool
or diarrhea develops. Miralax is a stool softener,and available
over the counter. The generic name is glycol. It is
recommended that you use this medication.
-Bactrim has been prescribed to you to take once daily for 3
days. This is antibiotic prophylaxis after placement of your
stent. Begin taking is on .
-Do not eat constipating foods for weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15261821", "visit_id": "23926943", "time": "2186-03-26 00:00:00"} |
17867595-DS-2 | 1,087 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
intoxicated and fell down approx 15 steps. At OSH he was
found to have RR 8 intubated. ETOH 350. Was found to have R
frontoparietal SDH with traumatic SAH.
## HEENT:
L side parietal lac. Pupils:5->2 EOMs UTA
## MENTAL STATUS:
Intubated on propofol. Propofol held. Moves all
extremities spont. Appears to attempt to follow commands. Face
symmetric
## MENTAL STATUS:
Alert and Oriented x 3. Appears to attempt to
follow commands.
## PUPILS:
5-->3 bilaterally
No pronator drift
## MOTOR:
Moves all extremities spont. Face symmetric, tongue
midline
## SENSATION:
intact to light touch
## FINDINGS:
There are extensive foci of subarachnoid hemorrhage
throughout the right frontotemporal region with a thin right
hemispheric subdural hemorrhage measuring up to 4 mm. Subdural
hemorrhage also layers along the tentorium with a thin layer
along the falx cerebri. Multiple foci of right temporal
intraparenchymal hemorrhage measure up to 3.8 x 1.4 cm with
surrounding vasogenic edema. There is mild mass effect on the
right lateral ventricle with 3 mm of leftward shift of
normally-midline structures. The basilar cisterns appear grossly
patent. The calvaria appear intact. There is a moderate left
frontoparietal subgaleal hematoma, presumably, the site of
"coup." Moderate mucosal thickening involves the maxillary
sinuses and ethmoid air cells bilaterally, as well as the right
sphenoid and bifrontal air cells. There may be a few opacified
right
mastoid air cells.
## IMPRESSION:
Multiple foci of right temporal intraparenchymal
hemorrhage with multifocal right frontoparietal subarachnoid
hemorrhage. A small amount of subdural blood layer along the
right cerebral convexity, as well as along the tentorium and
falx cerebri. 3-mm of leftward shift of midline structures is
associated.
## NOTE ADDED IN ATTENDING REVIEW:
Comparison with the
NECT,
performed some 2.5 hrs earlier (and since uploaded into PACS)
demonstrates
significant interval evolution of, particularly, the multifocal
right temporal hemorrhagic contusions with surrounding edema, as
well as the multifocal SAH and slight generalized edema
involving the right hemisphere, which could reflect underlying
. The slight shift of normally-midline structures is also new
over the short-interval.
CT Chest/Abd/Pelvis
negative for acute traumatic injury
## CT C-SPINE :
No fracture or acute alignment abnormality. Prominent posterior
osteophyte at C6 could cause cord injury with the appropriate
traumatic mechanism, though evaluation of intrathecal details is
limited on CT.
## BRIEF HOSPITAL COURSE:
The patient was admitted to the hospital for eval of
intraparenchymal and diffuse right frontoparietal subarachnoid
hemorrhage. intoxicated and fell down approx 15 steps. At
OSH he was found to have RR 8 intubated. ETOH 350. Was found to
have R
frontoparietal SDH with traumatic SAH. He receieved cerebrex
and transferred to for further evaluation.
On hospital day number one, , the pt underwent a head CT w/o
contrast which demonstrated multifocal right temporal
hemorrhagic contusions, multifocal SAH
and slight generalized edema. He was admitted to the trauma ICU
and started on phenytoin. Later that day, a repeat CT was stable
and the patient was extubated and transferred to the
neurosurgery service.
On , the patient was transferred to the stepdown unit. The
patient was started on a CIWA scale.
On and the patient's neuro exam remained stable. He had
episodes of asymptomatic bradycardia into the . The
patient's cardiac medications were held. A cardiology consult
was obtained. The patient was cleared by cardiology to go home
with the recommendation that beta blockers are discontinued
until further outpatient evaluation.
The rest of his hospital stay was uneventful with his lab data
and vital signs within baseline values, and his pain controlled.
He is being discharged today in stable condition.
## DISCHARGE MEDICATIONS:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 3 days.
Disp:*9 Capsule(s)* Refills:*0*
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): to start when 500 BID doses are complete .
Disp:*120 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
## 8. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
## SIG:
Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily):
Medication should be held/reviewed secondary to bradycardia.
13. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO daily ().
## 14. ALLOPURINOL MG TABLET SIG:
One (1) Tablet PO DAILY
(Daily).
15. Hydromorphone 2 mg Tablet Sig: Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
right intraparenchymal and subarachnoid hemorrhages s/p fall
## DISCHARGE INSTRUCTIONS:
General 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 prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCPs
office, but please have the results faxed to .
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": "17867595", "visit_id": "29196316", "time": "2141-03-05 00:00:00"} |
16803592-RR-32 | 353 | ## INDICATION:
year old woman with small pleural effusion on CT in .
She has persistent R back/chest wall pain.// Is the effusion still there, and
is there anything to account for her R sided thoracic pain?
## DOSE:
Found no primary dose record and no dose record stored with the
sibling of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
## FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL:
No evidence of supracervical or
axillary lymphadenopathy. The esophagus is normal. The thyroid is normal.
## UPPER ABDOMEN:
The upper abdomen is unremarkable.
## MEDIASTINUM:
No evidence of mediastinal lymphadenopathy or mass.
## HILA:
No evidence of hilar lymphadenopathy or mass.
## HEART AND PERICARDIUM:
No evidence of pericardial effusion. Cardiac size is
normal.
## PLEURA:
No evidence of pleural effusion or pneumothorax.
## 1. PARENCHYMA:
No evidence of focal consolidation. There is a new pulmonary
nodule in the left lower lobe measuring 2.4 mm (series 15, image 206). Right
upper lobe pulmonary nodule measuring 4 mm is unchanged (series 15, image 40).
Mild bibasilar atelectasis.
## 2. AIRWAYS:
The airways are patent to the segmental level without evidence of
bronchiectasis or obstruction.
## 3. VESSELS:
The pulmonary artery measures 2.8 cm suggests pulmonary arterial
hypertension. No evidence of pulmonary embolism to the segmental level.
## CHEST CAGE:
Moderate to severe ankylosis of the right anterior spinal
vertebrae spanning from T3-T11. Unchanged focus of sclerosis along the
lateral third and second rib. No evidence of fracture.
## IMPRESSION:
1. Moderate to severe ankylosis of the right anterior spinal vertebrae
spanning T3-11. No evidence of acute fracture.
2. New left lower lobe pulmonary nodule measuring up to 2 mm. Right upper
lobe pulmonary nodule is unchanged.
## RECOMMENDATION(S):
For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16803592", "visit_id": "N/A", "time": "2161-01-29 08:46:00"} |
14222247-DS-19 | 766 | ## ALLERGIES:
benzalkonium chloride / ciprofloxacin / edetic acid / Quinolones
## HISTORY OF PRESENT ILLNESS:
The patient is a male with history of prostate
cancer s/p radiation , HLD, AAA s/p endovascular repair
, peptic ulcer s/p vagotomomy 1960s presents with GIB after
colonoscopy with polypectomy.
The patient had a routine screening colonoscopy . The
colonoscopy found a 2 cm sigmoid polyp at 30 cm, removed
without complication. Also revealed diverticulosis and
hemorrhoids. The colonoscopy was uneventful and the patient
went home that evening. The morning of the patient had
BRBPR x1, about 200ccs. He called his GI physician who referred
him to .
At another colonoscopy was performed on which showed
a clot formed at the base of the polyp. The base was injected
with epinephrine. The patient had about 5 more episodes of
BRBPR, about 100-200 ccs each. His hematocrit on admission was
42.3, and at transfer it had dropped to 32. No hemodynamic
instability; his BP this AM was 108/66, heart rate 71. He
received 1 L fluid overnight at 125ml/hr and another liter today
before transfer.
The patient was transferred to due to concern about
persistent bleeding with possible need for for colonoscopy and
possible endoscopic cauterization or clipping if appropriate.
The patient has a past history of a GIB in the due to a
gastric ulcer s/ vagotomy. Denies any bleeding since.
On arrival to the MICU, the patient's vitals are 147/74, 73, 17,
96% RA. He feels well and denies lightheadedness, dizziness,
CP, palpitations, nausea, vomiting, abd pain, edema. C/o mild
headache and stomach distension.
## PAST MEDICAL HISTORY:
- hyperlipidemia
- hx prostate CA treated with radiation
- hx colonic polyps
- BPH
- PUD s/p vagotomy 1960s
- s/p AAA repair endovascular with type 2 Endoleak s/p
repair
- peripheral neuropathy
- DJD
- vitamin D deficiency
## FAMILY HISTORY:
Colon cancer and AAA.
## GEN:
Well appearing male, NAD, comfortable
## CV:
RRR, systolic murmur heard best at RUSB
## ABD:
Soft, non-tender, non-distended, NABS
## EXT:
No edema, warm, well perfused
## SKIN:
intact, no rashes noted
## COLONOSCOPY :
Large adherent clot that was not actively
bleeding was seen in the sigmoid colon ~30cm from the anal
verge. This clot did not come off after vigorous washing.
(injection, injection). Diverticulosis of the sigmoid colon.
Polyp in the sigmoid colon (polypectomy). Otherwise normal
colonoscopy to splenic flexure
## BRIEF HOSPITAL COURSE:
male with history of prostate cancer s/p radiation
, HLD, AAA s/p endovascular repair , peptic ulcer s/p
vagotomomy 1960s presents with GIB after colonoscopy with
polypectomy.
## # GI BLEED:
The patient on admisison had one episode bloody
bowel movement. His hematocrit remained stable in the low .
GI consulted and recommended a repeat colonoscopy. The patient
underwent a colonoscopy on that showed an adherent clot
at the site of polypectomy. Epinephrine was injected at the base
of the clot. The patient did well post-procedure and was
transferred to the floor. He had no further episodes of
bleeding. His hematocrit was stable. His diet was advanced and
he was discharged home. His aspirin will be temporarily held for
the next two weeks and he follows up with his primary care
physician. He will follow up with his PCP this week for repeat
CBC check. Of note, a polyp was biopsied during the colonoscopy
and pathology is pending at the time of discharge.
.
#Hematochezia: The patient initially underwent screening
colonoscopy for a history of blood in stool. Colonoscopy on
showed diverticula, hemorrhoids and polyp that was biopsied. The
pathology appears to be an adenoma. He was given contact
information of GI at to schedule follow up appointment.
.
## TRANSITIONAL:
[ ]pathology of polyp biopsied at pending at time of
discharge. Pt given contact info for GI if does not hear about
results in 1 week.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D UNIT PO DAILY
## DISCHARGE MEDICATIONS:
1. Vitamin D UNIT PO DAILY
## DISCHARGE DIAGNOSIS:
GI bleed after polypectomy
## DISCHARGE INSTRUCTIONS:
It was a pleasure to participate in your care. You were admitted
after having bleeding following your recent screening
colonoscopy. You were found to have evidence of recent bleeding
from the site a polyp was removed. This area was injected with a
medication to prevent further bleeding. You were monitored
closely over the next two days and did well. Your blood counts
remained stable. You were discharged home.
A polyp was removed during your colonoscopy at . You will
be contacted with the results of this biopsy. If you do not hear
back from us in one week, please call (Dr.
to obtain the results.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14222247", "visit_id": "22463760", "time": "2177-06-07 00:00:00"} |
17814256-RR-6 | 162 | ## INDICATION:
with AMS, gait unsteadiness, evaluate for acute process.
## FINDINGS:
There is no intracranial hemorrhage. Ventricles and sulci are prominent
suggesting a age-related atrophy. Prominence of the temporal horns suggest
median temporal atrophy. Extensive periventricular white matter hypodensities
as well as encephalomalacia of the right frontal (02:14), left frontal
(02:22), right temporal (2: 9), are likely sequela of prior trauma or less
likely ischemia. A hypodensity involving the right cerebellum (2:6, 601b:79),
is likely a prominent sulci. The basal cisterns are patent and there is
preservation of gray-white matter differentiation.
There is no acute fracture. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
## IMPRESSION:
1. No evidence of intracranial hemorrhage.
2. Multiple regions of hypodensity involving the right frontal, left frontal,
and right temporal lobes are likely sequela of prior trauma and less likely
due to ischemia. If concern for acute stroke, MR is more sensitive.
3. Cerebral atrophy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17814256", "visit_id": "21453015", "time": "2138-06-06 09:45:00"} |
11038896-RR-21 | 372 | ## INDICATION:
year old woman with vaginal discharge and pelvic pain// ?
endometritis vs PID
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 20.1 mGy (Body) DLP =
1,048.4 mGy-cm.
Total DLP (Body) = 1,059 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.
There is no evidence of focal renal lesions or 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 unremarkable.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
Uterus appears subtly heterogeneous, but without focal
lesion. The ovaries are grossly unremarkable. No evidence of hydrosalpinx.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
Fat containing umbilical hernia. Otherwise unremarkable.
## IMPRESSION:
1. No obvious evidence of hydrosalpinx. Please correlate with clinical and
laboratory findings for further assessment of pelvic inflammatory disease.
2. Uterus appears subtly heterogeneous, with no focal myometrial finding seen
on preceding ultrasound.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11038896", "visit_id": "N/A", "time": "2157-06-27 19:59:00"} |
11360447-DS-24 | 1,400 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
The patient is a with h/o CAD, HTN, HL, Afib on coumadin,
CAS s/p CEA, and breast CA in remission x yrs who presented
to outpatient clinic after episode of lightheadedness this AM,
Na found to be 122. According to clinic note, the patient stood
up after drinking a cup of coffee and suddenly fell down. The
patient endorsed lightheadedness and nausea at the time of the
fall. There was no loss of consciousness associated with the
event. The patient denies vomiting, diarrhea, diuretic use, or
other fluid losses. Denies fevers, chills SOB, CP, abdominal
pain, HA, vision changes, numbness/weakness,
hematochezia/melena, or dysuria. She does have a dry cough, but
states that this has been ongoing for years without clear
etiology. ROS also positive for recent constipation. Pt had Na
of 132 at recent PCP visit in with no obvious cause found,
but suspicion was hypovolemia.
In the ED, initial VS were: 98.0 60 169/57 16 100% RA. Labs were
significnat for Na 122, INR 3.8. Urine sodium was 61. Patient
was given 1L normal saline. On arrival to the floor, the patient
reports that she has no current complaints. She denies any
current symptoms of lightheadedness, dizziness, CP, SOB, or
palpitations.
## REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.
## PAST MEDICAL HISTORY:
1. breast cancer s/p lumpectomy and XRT , 1.6 cm grade
II infiltrating ductal cancer, nodes were not taken, ER
positive, ?LVI; followed by Dr.
2. carotid stenosis s/p left CEA x 2 (most recently
3. hypertension
4. hyperlipidemia
5. anemia, b12 deficiency on monthly injections
6. chronic renal insufficiency (baseline Cre )
7. coronary artery disease (last echocardiogram w/ EF 65%,
aortic sclerosis, and trace MR; P-MIBI with preserved EF,
normal perfusion and wall motion)
8. atrial fibrillation on coumadin
9. osteopenia
10. sick sinus syndrome s/p dual chamber pacemaker ( )
11. recent c. diff infection completed course PO flagyl
12. peripheral arterial disease s/p bilat fem-pop bypass ,
13. h/o CVA (followed by Dr.
14. h/o fecal incontinence
15. h/o recurrent UTIs
## GENERAL:
well appearing elderly female
## HEENT:
PERRL, EOMI, mucous membranes dry
## NECK:
no carotid bruits, no elevation of JVP, no LAD
## LUNGS:
CTAB, no wheezing rhochi or rales
## HEART:
RRR, normal S1 S2, no MRG
## ABDOMEN:
Soft, NT, NABS, no organomegaly
## NEUROLOGIC:
A+OX3, CN II-XII grossly intact
.
## GENERAL:
well appearing elderly female
## NECK:
no carotid bruits, no elevation of JVP, no LAD
## LUNGS:
CTAB, bibasilar crackles L>R
## HEART:
RRR, normal S1 S2, no MRG
## ABDOMEN:
Soft, NT, NABS, no organomegaly
## NEUROLOGIC:
A+OX3, CN II-XII grossly intact
## IMPRESSION:
No acute intrathoracic process.
## BRIEF HOSPITAL COURSE:
The patient is a with h/o CAD, HTN, HL, Afib on coumadin,
CAS s/p CEA, and breast CA in remission x yrs who presented
to outpatient clinic after episode of lightheadedness this AM,
Na found to be 122.
.
ACUTE
# Hyponatremia: Patient was admitted with Na of 122. It
initially trended up yesterday with 1L IV NS, but remained
dropped slightly with an additional 500 cc IV NS. Her initial
BUN was < 10, uric acid < 4, and urine Na > 25. These lab
values and lack of continued improvement with an additional
500cc bolus, suggested that this represented SIADH. However, it
appears that she was likely hypovolemic on admission as her Ha
did improve somewhat with IV NS initially. She was started on a
1L fluid restriction and salt tab with meals and her sodium
gradually improved. Renal was consulted and suggested that she
should continue 1L fluid restriction, salt tabs, and start
eating more protein in her diet to induce urea-mediated free
water diuresis. Renal did not recommend any further evaluation
for SIADH other than consideration of stopping SSRI, which can
cause SIADH in older females. On the day of discharge, she her
sodium had trended up to 129 with these interventions, which
appears to be near her baseline. She was instructed to get labs
drawn early next week, has follow up in clinic,
and schedule f/u with nephrology.
.
# Lightheadedness: Patient had episode of presyncope the day
prior to admission. Orthostatics were positive on admission and
she was bolused with 1L NS. She initially was found to have
hypovolemic hyponatremia, consistent with dehydration being a
cause of her presyncope. She was instructed to take in ~ 1L of
fluid daily in an effort to balance her SIADH and her tendency
to be dehydrated and be related to hypovolemia. No CP, SOB,
or palpitations to suggest cardiac cause.
.
CHRONIC
# Hypertension: Losartan, diltiazem, and metoprolol were
continued during admission.
.
# A.Fib on coumadin: In NSR during admission. INR was
supratherapeutic initially. Coumadin was held and then
restarted prior to discharge once INR normalized.
.
# Hyperlipidemia: She was continued on home dose of
atorvastatin.
.
#. CRI (baseline Cr ~1.1): She was encouraged to hydrate with
up to 1L of fluid daily. Her Cre remained near baseline during
her entire admission.
.
# CAD: She was continued on her home dose of metoprolol, asa,
and statin.
.
# Depression: She was continued on her home dose of citalopram
.
TRANSITIONAL
# Would consider stopping citalopram given its possible link to
SIADH
# Will need f/u with nephrology
# Will need Na check early next week
## MEDICATIONS ON ADMISSION:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Atorvastatin 20 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Cyanocobalamin 1000 mcg IM/SC MONTHLY
5. Diltiazem Extended-Release 300 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Warfarin 2.5 mg PO ASDIR
9. Aspirin 81 mg PO DAILY
10. Vitamin D Dose is Unknown PO Frequency is Unknown
11. FoLIC Acid Dose is Unknown PO DAILY
12. Psyllium Dose is Unknown PO Frequency is Unknown
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Alendronate Sodium 70 mg PO WEEKLY
6. Cyanocobalamin 1000 mcg IM/SC MONTHLY
7. Diltiazem Extended-Release 300 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Psyllium 1 PKT PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Warfarin 2.5 mg PO ASDIR
13. Bisacodyl AILY:PRN constipation
RX *Bisac-Evac 10 mg 1 Suppository(s) rectally at bedtime Disp
#*30 Suppository
## REFILLS:
*0
14. Senna 2 TAB PO HS
Hold if patient has loose stools.
RX *senna 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet
Refills:*0
15. Sodium Chloride 1 gm PO TIDAC
please give 1st dose now even though she has already eaten
RX *sodium chloride 1 gram 1 tablet(s) by mouth with meals Disp
#*90 Tablet Refills:*0
16. TwoCal HN *NF* (nut.tx,spec.frm,l-fr,iron-fos)
gram-kcal/mL Oral BID
with breakfast and dinner
RX *TwoCal HN 0.08 gram-2 kcal/mL 1 can by mouth twice a day
Disp #*60 Bottle Refills:*0
17. Outpatient Lab Work
Hyponatremia 276.1
Atrial fibrillation 427.31
Please check BMP and INR on results:
,
## DISCHARGE INSTRUCTIONS:
Dear Ms ,
It was a pleasure taking care of you during your recent
admission to . You were admitted because of low blood
sodium. We believe you were somewhat dehydrated so we gave you
fluid through your IV. In addition, we think you have an
abnormal level of a hormone in your blood which causes you to
retain water, which then makes your sodium low. We restricted
your fluid to 1 liter per day and started you on salt tabs. You
will need to continue the salt tabs with meals, as well as the
fluid restriction. In addition, you should try to increase your
protein intake, which will also help you get rid of excess
water.
You should continue all of your home meds as before.
Start
salt tabs 1 g with each meal
1 liter fluid restriction.
You will also need to have a lab draw on or at
your primary care doctor's office.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11360447", "visit_id": "20720796", "time": "2158-09-18 00:00:00"} |
15146455-RR-38 | 218 | ## INDICATION:
year old man with left > right carotid bruit for further
evaluation// Left > right carotic bruit vs transmitted AS murmur
## RIGHT:
The right carotid vasculature has mild heterogeneous atherosclerotic plaque,
greatest within the proximal ICA.
The peak systolic velocity in the right common carotid artery is 48 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 40, 55, and 78 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 20 cm/sec.
The ICA/CCA ratio is 1.6.
The external carotid artery has peak systolic velocity of 63 cm/sec.
The vertebral artery is patent with antegrade flow.
## LEFT:
The left carotid vasculature has mild heterogeneous atherosclerotic plaque,
greatest within the proximal ICA.
The peak systolic velocity in the left common carotid artery is 45 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 54, 52, and 67 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 18 cm/sec.
The ICA/CCA ratio is 1.4.
The external carotid artery has peak systolic velocity of 39 cm/sec.
The vertebral artery is patent with antegrade flow.
## IMPRESSION:
Less than 40% stenosis in the bilateral carotid systems.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15146455", "visit_id": "N/A", "time": "2160-12-11 10:11:00"} |
15831709-RR-43 | 272 | ## EXAMINATION:
CT-guided drainage and drain placement
## INDICATION:
year old woman with hepatic abscesses
## PROCEDURE:
CT-guided drainage of hepatic collection.
## 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.
## DOSE:
Acquisition sequence:
Total DLP (Body) = 748 mGy-cm.
## SEDATION:
Moderate sedation was provided by administering divided doses of 0
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 47
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
## FINDINGS:
Small bilateral low-density pleural effusions are noted. The visualized lung
bases are otherwise clear. The previously seen hepatic abscesses in segment
VIII measure 2.5 x 2.9 cm and 1.0 cm, respectively (previously 2.6 x 1.3 cm
and 1.0 cm). There is interval increase in size of the more inferior
component the dominant collection.
A prominent gas-filled focus near the dome of the liver (series 2, image 9)
measures 7 mm (previously 9 mm), possibly representing a third abscess. No
definite new abscesses appreciated.
A CBD stent is in unchanged position and there is moderate intrahepatic
biliary ductal dilatation and pneumobilia, which appears overall similar to
prior.
Moderate low density ascites is again visualized.
Sequential images demonstrate drain placement in the dominant abscess in the
medial aspect of segment VIII.
Postprocedure imaging demonstrates the drain successfully placed within the
medial aspect of segment VIII.
## IMPRESSION:
Successful CT-guided placement of an pigtail catheter into the
dominant hepatic abscess. Samples were sent for microbiology evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15831709", "visit_id": "28649181", "time": "2179-01-18 12:37:00"} |
18662737-DS-15 | 804 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Left retromastoid craniectomy for trigeminal neuralgia
## HISTORY OF PRESENT ILLNESS:
right-handed female who presents with facial pain
involving the left side of her face, which started about
years ago. The pain was
radiating along the jaw and was like electric shock-like
sensation. She was initially told it was an eustachian tube
dysfunction and was referred to ENT and then to Oral Surgery.
She was finally seen by a neurologist at , Dr.
now she has transferred her care to Dr. .
Her
last episode of pain was in . She has tried
Klonopin, baclofen and gabapentin. She is very sensitive to
pain
medications. She is currently on Trileptal 300 mg once daily,
earlier it was as high as 1200 mg per day. She had good relief
from the pain with this regimen however the pain has become
intractable.
## PAST MEDICAL HISTORY:
chronic back pain,
COPD, history of methadone use, hepatitis C, former IV drug use
and alcohol abuse
## PHYSICAL EXAM:
awake, alert, oriented x3. Her speech
was fluent. Extraocular movements are intact. Face is
symmetric. Tongue was in the midline. Motor strength is in
all four extremities. She has mild facial droop on the right
side. Hearing is intact bilaterally.
## EXAM ON DISCHARGE:
A&OX3, PERRL, EOMI, Face symmetrical, L face numbness,
Corneal intact
No drift, MAE
## BRIEF HOSPITAL COURSE:
Patient presented electively on for a left retromastoid
craniectomy for decompression of trigeminal neuralgia. She
tolerated the procedure well, her intraoperative course was
uneventful. Please refer to the operative note for more
information. She was transferred to the ICU for close
monitoring. She remained neurologically and hemodynamically
intact and was transferred to the neurosurgical floor on .
Her dressing was removed on , her incision was clean dry and
intact with sutures. On , she was remained neurologically
stable, she expressed readiness to go home. She was discharged
home in stable conditions. All discharge instructions and follow
up were given prior to discharge.
## MEDICATIONS ON ADMISSION:
albterol, atrovent, flovent, methadone, oxcarbazepine, spiriva
## DISCHARGE MEDICATIONS:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
## REFILLS:
*0
3. Dexamethasone 2 mg PO Q8H Duration: 24 Hours
RX *dexamethasone 2 mg 1 tablet(s) by mouth Q8hrs Disp #*3
## TABLET REFILLS:
*0
4. Dexamethasone 2 mg PO Q12H Duration: 24 Hours
RX *dexamethasone 2 mg 1 tablet(s) by mouth Q 12hrs Disp #*2
## TABLET REFILLS:
*0
5. Dexamethasone 2 mg PO DAILY Duration: 24 Hours
RX *dexamethasone 2 mg 1 tablet(s) by mouth Daily Disp #*1
## TABLET REFILLS:
*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
7. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*10
## TABLET REFILLS:
*0
8. Methadone 10 mg PO QID
9. Oxcarbazepine 300 mg PO BID
10. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
this medication.
RX *oxycodone 5 mg tablet(s) by mouth Q 4hrs Disp #*60
## DISCHARGE INSTRUCTIONS:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
**Your wound was closed with sutures. You may wash your hair
only after sutures have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to .
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18662737", "visit_id": "29664514", "time": "2158-07-20 00:00:00"} |
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