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17401129-RR-123 | 155 | ## INDICATION:
year old woman with HFrEF // fluid in lungs
## FINDINGS:
Compared to most recent study of , increased mild pulmonary
edema. Overall similar moderate right, small left pleural effusions and
atelectasis. Unchanged enlargement of the cardiac silhouette. Mildly
increased size of the mediastinum likely representing fluid overload. Stable
positioning of the right IJ central venous catheter and tracheostomy tube.
Double density noted over the left upper lobe likely representing a skin fold,
less likely anterior pneumothorax. Attention on repeat imaging.
## IMPRESSION:
1. Mildly increased pulmonary edema and mediastinal size consistent with fluid
overload state.
2. Similar moderate right, small left, layering effusions and atelectasis.
3. Double density noted over the left upper lobe likely represents a skin
fold, as opposed to an anterior pneumothorax. Repeat imaging is recommended.
## NOTIFICATION:
The findings were discussed with , M.D. by ,
M.D. on the telephone on at 11:33 am, 3 minutes after discovery of
the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17401129", "visit_id": "N/A", "time": "2163-03-05 04:11:00"} |
18003386-RR-13 | 112 | ## INDICATION:
year old woman with likely TGA, but need to rule out stroke
// Likely TGA, restricted diffusion in left hippocampus?
## FINDINGS:
There is no intra or extra-axial mass, acute hemorrhage or infarct. The sulci,
ventricles and cisterns are within expected limits for the patient's age.
There is no suspicious parenchymal FLAIR signal abnormality. The major
intracranial flow voids are preserved. There is minimal mucosal thickening of
the ethmoid air cells. The orbits are unremarkable. The mastoid air cells
are clear. No suspicious marrow signal.
## IMPRESSION:
1. No acute infarct or intracranial hemorrhage. No evidence of punctate
diffusion weighted signal abnormality in the hippocampi.
2. Unremarkable noncontrast MRI brain.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18003386", "visit_id": "25287769", "time": "2148-11-03 16:44:00"} |
13879396-DS-17 | 1,558 | ## HISTORY OF PRESENT ILLNESS:
Mr. is a year old man with a history of
hypertension and polysubstance abuse who was transferred to the
from following a multiday
drug/alcohol binge and now change in mental status. His
girlfriend called EMS on after she went to his apartment
because she hadnt heard from him since when she last
heard from him, he was at his baseline mental status. She
reports that he was in a dark room and was acting very strangely
including laughing inappropriately, shaking, and sweating. He
reported to her that he had smoked crack but couldnt say when
that was; given all of this, she brought him to
. His girlfriend also reports that he
routinely binges on OxyContin (taking mg tablets daily)
and also takes large amounts of Klonopin and Xanax, which he
buys from his neighbor; she is unsure if he was taking these as
well, but assumed that he had been.
.
At where he was initially awake but
confused. He was given IV ondansetron, activated charcoal, and
sorbitol 50 mg. He was noted to vomit and then reportedly
became unresponsive with reported decerebrate posturing on the
left side and decorticate posturing on the right side and so he
was intubated via rapid sequence intubation and put on a
propofol drip. He had a normal CT scan of his head and a
toxicology screen was positive only for benzodiazepines. He was
transferred to for neurologic evaluation.
.
Upon arrival to our , he was afebrile, HR 144, BP 119/69, RR
28, Sat 98% on the ventilator. He extubated himself around 4am
and was able to say that he had not taken any substances for the
past two days or so. He reportedly complained of dyspnea and
was thought to not be protecting his airway and was thus
reintubated. He was given 1000 mg of IV vancomycin, mg of
IV ceftriaxone, mg of IV ampicillin, and 500 mg of IV
acyclovir though, per the resident, there was no concern for
meningitis/encephalitis and so no LP was performed.
.
On questioning now, the patient indicates that it has been
several days since he has taken any substances but is unable to
say exactly when he stopped taking them. He does indicate that
he was taking the drugs to get high.
## PAST MEDICAL HISTORY:
- Hypertension
- Substance abuse
- prior knee injury requiring surgery
- patient has told friends/family that he has mesothelioma or
some sort of cancer but they arent sure if he is making it up
## GENERAL:
intubated and sedated, though opening eyes and
responding appropriately to commands/questioning
## HEENT:
pupils 7 mm à 4 mm bilaterally; no scleral icterus;
impaired gag reflex with copious oral secretions
## NECK:
supple; no cervical/supraclavicular lymphadenopathy
## CHEST:
loud expiratory ronchi; no wheezes or rales
## CV:
tachycardic, regular, no murmurs
## ABDOMEN:
soft, nontender, nondistended, normal bowel sounds, no
HSM
## EXTREMITIES:
no edema, 2+ pulses
## NEUROLOGIC:
sedated but opening eye, following commands, and
answering questions appropriately; PERRL, EOMI, strength in
bilateral deltoids, biceps, triceps, hip flexors/extensors,
ankle flexors/extensors; 2+ patellar reflexes bilaterally
## BRIEF HOSPITAL COURSE:
This is a Male admited for altered mental status presumably
after an Oxycontin/Benzo binge as suicide attempt. At
, the patient recieved charcoal and sorbitol, but
later vomited, became diaphoretic, tachychardic and
unresponsive, with decerebrate posturing on the left and
decorticate posturing on the right. He was intubated. His drug
screen was positive only for benzos. He was trasnferred to the
BI for further care.
.
In the , HR 144, BP 119/69, RR 28 with 02 saturations
98% on ventilator. He was given Thiamine, Veccuronium,
Ceftriaxone, Acyclovir, Ampiciliin, Versed, Fentanyl, as his
course was complicated by self-extubation followed by
re-intubation after the patient became dyspneac. While at first
there was some concern for meningitis (hence the regimen above),
the team subsequently determined that there suspicion was low
and no LP was performed. The patient was trasfered intubated to
the MICU.
.
On arrival to the MICU, the patient showed t98.4, HR 122, BP
148/89, RR 20. After extubation pt halucinated and was tremulous
and was started on a CIWA scale with lorazepam IV. As his mental
status improved he was switched to PO valium with good effect.
Psych and SW were consulted. Once lucid, the patient reported
that this OD was a suicide attempt as further described below.
.
Course otherwise described by problem below:
##
1. SUBSTANCE ABUSE/DEPENDENCE:
It appears that the current
episode was due to snorting of oxycontin and was a suicide
attempt. The patient may have been abusing benzos as well in
the days prior to presentation. No cocaine on current tox
screens, but screen was positive for benzos. SW and psych were
consulted and recommended continuing PO valium per CIWA
protocol. PO thiamine, folic acid, multivitamin also given
during the hospitalizaiton.
Psychiatry consult noted that the patient reports he became
distraught and hopeless after his girlfriend gave him an
ultimatutm that he needed to quit drugs or she and her son
would leave. Over the last two weeks before admission, he
reportedly made statements to his mom and girlfriend that he was
going to kill himslef. + Hopelessness, anhedonia, SI before
hoispitalization, but denied SI in the hospital. Psychiatry aslo
noted that the patient apparently tried to commit suicide at age
. The patient reported trying to OD on "multiple drugs two
weeks ago". The patient was deemed unable to care for himself
and met the criteria for . Although he does not want
to go to a rehab facility, the decision was made that it was in
his best interest to do so, and was filed.
##
2. ALTERED MENTAL STATUS:
very likely from some combination of
withdrawl and/or intoxication. No evidence to suggest
meningitis/encephalitis, LP was not performed. He recieved
Methadone, Haldol and Valium CIWA for delerium, but by , was
alert and oriented, with a much clearer mental status.
## 3. RESPIRATORY FAILURE:
resolved over course. Thought due to
inability to protect airway in the setting of altered mental
status, though CXR showed no signs of aspiration, and patient
was afebrile throughout course. The patient was extubated on
.
.
## 4. HEMOCONCENTRATION:
also resolved over course. Thought
secondary to presumed poor PO intake. Pt reports not eating or
drinking for 4 days prior to admission, just snorting oxycodone
and taking Benzos.
.
## 5. HYPERTENSION/HOME MEDICATIONS:
The patient remained
hypertensive to the 140-150/80's in the unit. The patient's
anti-hypertensive and home mediation regimen was difficult to
establish. Empty bottles prescribed by Dr. of the
following were found at home: Atenolol 50 QD, Lisinopril 5mg QD,
Ambien 10mg HS, Doxepin 50mg QD, Nabumetone 750 mg BID, Percocet
TID PRN. The patient did not recieve anti-hypertensive
medications during his MICU course. Today, we were able to
establish with the patient's pharmacy that on , the
patient filled prescriptions for Atenolol 50QD and Doxepin 50mg
QD. The patient currently has a Clonidine patch .3%; we
recommned that his Atenolol be slowly reintroduced. Depending on
the result, Lisinopril may also be indicated and can be added.
Finally, he may be placed back on his Doxepin, Nabumetone and
Percocet as the admitting team feels is appropriate. Please note
that rapid withdrawal of Clonidine while on a beta blocker is
contraindicated.
.
## PROPH:
The patient was prophylaxed with LMW Heparin, an H2
Blocker.
.
## CODE STATUS:
The patient remained full code throughout the
hospitalization.
## MEDICATIONS ON ADMISSION:
Unclear home regimen; empty bottles of the following were
brought with the patient (prescribed by a Dr. :
- atenolol 50 mg daily
- lisinopril 5 mg daily
- zolpidem 10 mg qhs
- doxepin 50 mg daily
- nabumetone 750 mg bid
- Percocet tid prn
By report, he also takes tablets of 80 mg OxyContin per day
but it's unclear if these are prescribed or not.
## DISCHARGE MEDICATIONS:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every .
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
## 5. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
6. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for CIWA>10.
## DISCHARGE DIAGNOSIS:
Suicide Attempt by overdose
## DISCHARGE INSTRUCTIONS:
You will be discarged to a facility that will seek to help you
with your substance abuse and suicidality.
You were admitted after a suicide attempt by pharmacologic
overdose. You required intubation in the MICU because your
mental status precluded preservation of your airway. You are
being trasnferred to Psychiatry.
.
Please note that because we were unsure of your home medications
when you were admitted yesterday, you have not been receiving
some of the medications that you may previously have been on.
Today, the pharmacy from where you picked up your scripts on
gave us a list of your current medications: Doepin
50mg QD, Percocet TID, and Atenolol 50mg QD. We have not given
you these medications while you have been here. Because your
blood pressure has been moderately high, we recommend that you
ask your doctors on 4 to gradually re-start your
Atenolol. They will be aware that it is important that the
Clonidine not abruptly be discontinued while you are on Atenlol.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13879396", "visit_id": "26997053", "time": "2177-10-16 00:00:00"} |
16782585-RR-42 | 93 | ## INDICATION:
Mr. is a y/o M with a PMH of sarcoidosis, CKD, who presented on
with new onset confusion, tremors, ascites, and jaundice, now with
ileus and increasing tympanic sound on abd exam // eval for
## FINDINGS:
Small bowel loops are mildly dilated with gas and are stacked centrally. The
dilation of small bowel loops are stable. Absence of gas in the colon is
noted. The NG tube is now absent.
## IMPRESSION:
Likely ileus as the small bowel dilation has been stable since ,
however cannot rule-out distal small bowel obstruction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16782585", "visit_id": "27893372", "time": "2121-04-04 10:34:00"} |
19358058-RR-30 | 169 | ## HISTORY:
Cirrhosis, rising total bilirubin and shock. Evaluate for portal
vein thrombus, cholecystitis, or bile duct pathology.
## FINDINGS:
The liver is coarsened in echotexture with nodularity. No focal hepatic
lesion is identified. A tiny hyperechoic area adjacent to the common bile
duct likely represents focal fat. There is no intrahepatic or extrahepatic
biliary duct dilatation. The common bile duct measures 3 mm. There are
multiple gallstones in the gallbladder. No evidence of cholecystitis. Again
seen is reversal of flow in the main portal, left portal, right posterior and
right anterior portal veins. Reversal flow is also seen in the SMV and
splenic vein. There is antegrade flow and normal waveform in the main hepatic
artery. The hepatic veins are not well visualized and likely diminutive. The
spleen is enlarged measuring approximately 13 cm. The pancreas is not well
seen. No ascites.
## IMPRESSION:
1. Unchanged reversal of flow in the portal circulation. No intra or
extrahepatic biliary duct dilatation.
2. Cholelithiasis but no evidence of cholecystitis.
3. Splenomegaly.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19358058", "visit_id": "26195010", "time": "2148-04-14 15:11:00"} |
14809887-RR-13 | 98 | THORACIC SPINE, THREE VIEWS
## FINDINGS:
Thoracic vertebral body height is maintained. The bones are somewhat
osteopenic. Disc height is preserved. There are degenerative changes at all
levels with anterior osteophytes present. There is mildly exaggerated
concavity of the superior endplate of T5 vertebral body which could be
consistent with an impending osteoporotic compression fracture. The remainder
of the thoracic vertebral bodies demonstrate height within normal limits.
## IMPRESSION:
Exaggerated concavity of the superior endplate of T5 vertebral body which
could be consistent with an impending osteoporotic compression fracture.
Remainder of the thoracic vertebral bodies are within normal limits.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14809887", "visit_id": "N/A", "time": "2182-05-20 13:22:00"} |
10165963-RR-59 | 441 | ## INDICATION:
year old man s/p liver transplant.// Right sided PTBD not
draining with elevated LFTs. Detailed cholangiogram with cone beam CT likely
needed.
## OPERATORS:
Dr. Interventional
performed the procedure.
## ANESTHESIA:
Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 85 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
## CONTRAST:
45 ml of OPTIRAY contrast
## PROCEDURE:
1. Post pyloric nasoenteric tube placement
2. Cholangiogram through existing right percutaneous transhepatic biliary
drainage access.
3. Selective catheterization of the left bile duct via the right bile duct
access.
4. Exchange of the existing 12 percutaneous transhepatic biliary
drainage catheter with a new 12 PTBD catheter.
## PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per protocol.
A nasoenteric tube was placed via the right nostril while the patient was
sitting up. The patient was positioned supine and the tube was advanced into
the proximal jejunum. Position was confirmed by contrast injection.
Contrast was injected through the indwelling right biliary drain. Contrast
did not flow smoothly through the indwelling drain. The drain was cut and
exchanged over a stiff Glidewire for a 7 sheath. Antegrade and
pull-back cholangiograms were performed. Multiple attempts were made to
catheterize the left bile duct via the right-sided access. Initial attempts
with a Glidewire, Kumpe catheter, Sos catheter, and 1 glide catheter were
unsuccessful. Ultimately an angled glide cath was used to select the left
bile duct and a left cholangiogram was performed.
A new 12 PTBD catheter was advanced over the wire. The catheter was
locked and secured in place with 0 silk suture and StatLock. The patient
tolerated the procedure well. There were no immediate postprocedural
complications.
## FINDINGS:
1. Partial obstruction of indwelling right biliary drain
2. Persistent visualization of bile leak into the gallbladder fossa from the
mid CBD
3. Selective catheterization of the left bile duct via the right-sided access
showing no unilateral left obstruction
4. Appropriate final position of a right 12 percutaneous biliary drain
## IMPRESSION:
1. Technically successful 12 right percutaneous biliary drain exchange.
2. Persistent visualization of CBD leak into the gallbladder fossa
3. Left cholangiogram shows no need for additional biliary drain.
Findings were discussed via telephone by Dr. with Dr. .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10165963", "visit_id": "20512954", "time": "2157-05-06 09:23:00"} |
12246316-RR-29 | 130 | ## EXAMINATION:
US CHEST WALL SOFT TISSUE LEFT
## INDICATION:
h/o prior suicide attempts presented post suicide attempt(160
Tylenol pills OD) found to have acetaminophen toxicity withresulting acute
liver failure, rhabdomyolysis and kidney failure. Now Left shoulder/
Left upper chest pain and swelling // Left Upper chest swelling, concern for
clot vs bleed
## FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left upper chest. At the site of the patient's palpable lump there is a
complex multiloculated fluid collection with overall measurement of 11.6 x 6.0
x 10.8 cm. Minimal vascularity is seen surrounding this region. Layering
echogenicity is noted. No pseudoaneurysm is detected.
## IMPRESSION:
Complex fluid collection with layering echogenicity likely represents a
hematoma within the left upper chest.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12246316", "visit_id": "26780697", "time": "2184-11-03 10:54:00"} |
15727747-RR-17 | 249 | ## INDICATION:
Worsening radicular symptoms in the upper extremities. Evaluate
for progression from exam.
## FINDINGS:
Normal cervical lordosis is maintained. Vertebral body heights and
alignment are normal. Bone marrow signal is normal. The spinal cord is
normal in caliber and shows normal signal. The cervicomedullary junction is
unremarkable.
Overall, multilevel degenerative changes are not significantly changed since
the study of as detailed below.
## C2-C3:
There is no significant central canal or neural foraminal narrowing.
## C3-C4:
Minimal posterior disc osteophyte complex causes no significant
central canal narrowing. There is no neural foraminal narrowing.
## C4-C5:
Minimal posterior disc osteophyte complex slightly effaces the ventral
thecal sac. Uncovertebral and facet joint hypertrophy result in mild
bilateral neural foraminal narrowing.
## C5-C6:
A more prominent posterior disc osteophyte complex effaces the ventral
CSF in concert with uncovertebral and facet joint hypertrophy. There is
moderate bilateral neural foraminal narrowing.
## C6-C7:
A small posterior disc osteophyte complex effaces the right
paracentral aspect of the thecal sac. There is no significant neural
foraminal narrowing.
## C7-T1:
There is a small posterior disc osteophyte complex without significant
central canal narrowing. There is no neural foraminal narrowing.
The prevertebral and paravertebral soft tissues are unremarkable. There is
mild mucosal thickening of the sphenoid and right maxillary sinuses.
## IMPRESSION:
Stable moderate degenerative changes in the cervical spine,
without appreciable change since the study of . Again, these changes
are most marked at C5-C6 with mild central canal narrowing and moderate
bilateral neural foraminal narrowing.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15727747", "visit_id": "N/A", "time": "2140-06-01 07:46:00"} |
13157308-DS-15 | 1,382 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Transesophageal Echocardiogram
DC cardioversion on
## HISTORY OF PRESENT ILLNESS:
hx of bladder ca s/p resection, HTN who presents w/ SOB.
Patient says symptoms initially started about 1 week before the
. He felt that he was having increase
dyspnea on exertion and chest heaviness. He went to go see his
PCP and an echocardiography was performed, which did not show
any evidence of reduced ejection fraction or valvular disease.
He was told that his symptoms may be related to
"deconditioning". Over the next several weeks, he felt that his
dypsnea was getting worse and started to notice having dyspnea
at rest in addtion to with exertion. He was evaluated by his PCP
and was noted to be 94% O2 at rest with 89% on exertion. PCP
suggested he go to the ED for further evaluation.
In the ED, T98.2 HR64 BP165/95 RR24 satting 97% 4L NP. EKG was
performed which showed new atrial fibrillation without evidence
of ischemic chanes. Rest of labs showed a trop of 0.03, BNP
2557, Chem 10 sig for BUN/Cr , lytes otherwise normal. CBC
was unremarkable. Patient was provided with a dose of enoxaparin
as well as warfarin and transfer to for further evaluation
of his new atrial fibrillation.
Of note, at the initiation of the patient's symptoms when he had
his echo, it was not mentioned that he was in afib.
## ROS:
The patient denies any palpitations although does have
chest pressure. SOB per HPI. Has not had any recent long trips
in the car or a plane. No recent weight loss or hair loss. No
diarrhea. No urinary symptoms. No new rashes. No syncopal or
near syncopal episodes. No history of PE's or blood clots in the
past.
## PAST MEDICAL HISTORY:
vertigo
hypertension
herpes zoster
BPH
skin cancer (basal)
bladder cancer
impaired fasting glucose
## SURGICAL HX:
1. Status post surgical excision, basal cell carcinoma.
2. Status post cataract extraction, both eyes.
3. Status post transurethral resection of bladder tumor
## FAMILY HISTORY:
Positive for CAD, stroke, hypertension, and brain cancer. No
family history of diabetes.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
## NECK:
Supple with flat JVP. No thyromegaly appreciated.
## CARDIAC:
Bounding heart beats. No heave. PMI located in
intercostal space, midclavicular line. Tachycardic with normal
S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. No
accessory muscle use. Bibasilar crackles appreciated.
## ABDOMEN:
Soft, NTND. No HSM or tenderness.
## EXTREMITIES:
No c/c. Trace edema bilaterally. 2+ DPP/RP's.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
damaged skin.
## VS:
afebrile 97.6 107/65 HR 75 sat 94% on RA
## WEIGHT:
77.4 kg (down from 80.5 kg on admission)
## CARDIAC:
NR, RR, no murmur
## FINDINGS:
2 views were obtained of the chest. Lungs are low in
volume but
clear aside from minimal basal scarring/atelectasis. Blunting
of the
costophrenic sulci bilaterally could reflect trace pleural
effusions or
pleural thickening. The heart is top-normal in size with normal
mediastinal and hilar contours aside from a tortuous aorta.
## IMPRESSION:
Low lung volumes without acute intrathoracic
process.
ECHO
Conclusions
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). There
is mild symmetric left ventricular hypertrophy with normal
cavity size. There is moderate global left ventricular
hypokinesis (LVEF = %). Systolic function of apical
segments is relatively preserved. No masses or thrombi are seen
in the left ventricle. Normal right ventricular cavity size with
mild free wall hypokinesis. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION: Mild
symmetric left ventricular hypertrophy with normal cavity size
and moderate global biventricular hypokinesis suggestive of a
diffuse process (toxin, metabolic, etc.).
Compared with the prior study (images reviewed) of ,
global left ventricular systolic function is now depressed
## -TEE :
Mild spontaneous echo contrast is seen in the body
of the left atrium. No mass/thrombus is seen in the left atrium
or left atrial appendage. No thrombus is seen in the right
atrial appendage No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is
moderately depressed (LVEF= 35-40 %). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. IMPRESSION: No intracardiac thrombus. At
least moderate global left ventricular systolic dysfunction.
## -DC CARDIOVERSION :
IMPRESSION: Successful electrical
cardioversion of atrial fibrillation to sinus rhythm.
## BRIEF HOSPITAL COURSE:
Mr. is a M w/ hx HTN who presented one month of
dyspnea due to new acute CHF with reduced EF of 25% with new
AFib who had successful DC cardioversion on followed by
stress test on on showing normal perfusion with global
hypokinesis.
# Atrial Fibrillation: New onset based on prior EKG from
however per attending review of prior echo in was in
AFib at the time as well. Patient had TEE followed by
successful DC cardioversion of atrial fibrillation to sinus
rhythm. Patient started on warfarin which will be followed by
PCP, at . Continue warfarin at 2.5mg daily.
Goal INR 2.0-3.0.
# Acute systolic CHF exacerbation: Responded well to diuresis.
also be having volume overload given diastolic dysfunction
now losing atrial kick from atrial fibrillation leading to
pulmonary edema. Unclear cause of systolic heart failure as
patient has severely depressed EF 25% on admission down from 55%
on prior echo last month. Then found to have EF 35-40% on
when had TEE for successful DC cardioversion. Strict
I/Os, daily weights, sodium and fluid restriction.
Stress test on on showing normal perfusion with global
hypokinesis. Patient will follow up with PCP and heart failure
team at . DRY WEIGHT: 77.4 kg
## # HTN:
Continue lisinopril for goal SBP<140.
#CODE: Full
#CONTACT: Wife
#DISPO: cardiology service to home
### TRANSITIONAL ISSUES ###:
- DRY WEIGHT: 77.4 kg
- Patient started on warfarin for new AFib s/p successful DC
cardioversion. INR will be followed by PCP, at
. Goal INR 2.0-3.0.
- Patient will follow up with PCP and heart failure team at
.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. aspirin *NF* 162 mg Oral qday
2. Lisinopril 10 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. aspirin *NF* 162 mg Oral qday
2. Lisinopril 10 mg PO DAILY
3. Furosemide 40 mg PO DAILY
to treat your heart and to prevent extra fluid.
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp
#*30
## TABLET REFILLS:
*1
4. Metoprolol Succinate XL 50 mg PO DAILY
to treat your heart
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth once daily Disp #*30 Tablet Refills:*1
5. Spironolactone 12.5 mg PO DAILY
to treat your heart and to prevent extra fluid
RX *spironolactone 25 mg one half tablet(s) by mouth once daily
Disp #*15 Tablet Refills:*1
6. Warfarin 2.5 mg PO DAILY16
to thin your blood
RX *warfarin 2.5 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
## 7. OUTPATIENT LAB WORK
INR, CHEM-10
DX:
Atrial fibrillation
Please fax results to:
, MD
## DISCHARGE DIAGNOSIS:
Acute systolic Heart failure
Atrial Fibrillation
## DISCHARGE INSTRUCTIONS:
Mr. , you were admitted to for new heart failure.
While you were here, we performed a stress test which suggests
there is no need for a cardiac catheterization at this time. We
started you on a blood thinner medication called warfarin (also
called Coumadin) for your Atrial Fibrillation. We performed a
procedure called DC cardioversion to convert your heart rhythm
back to normal. It is important that you follow up with your
primary care doctor and the heart failure team at . You
will need lab checks to make sure your warfarin levels are in
the appropriate range.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13157308", "visit_id": "26957610", "time": "2157-02-03 00:00:00"} |
18507581-DS-9 | 836 | ## ALLERGIES:
Penicillins / Nubain / Tylenol / Iodine / Valium / Compazine
## CHIEF COMPLAINT:
Infection of JTUBE insertion site
## HISTORY OF PRESENT ILLNESS:
w/abd pain, swelling, erythema around J-tube site. J-tube
removed at then pt. sent to ER.
## PAST MEDICAL HISTORY:
perforated bezoar, perforated gastric ulcer remote, Crohn's,
needs peptamen TF's, takes only 6 very small meals a day,
pancreatitis, anemia, malnutrition
## ABD:
+BS, soft ND, appropriately TTP around JTUBE
## INCISION:
JTUBE insertion site decreased edema and erythema
## UNDERLYING MEDICAL CONDITION:
w/abd pain, swelling, erythema around J-tube site. J-tube
removed at then pt. sent to ER. Currently
wiyh jejunitis. H/O perforated bezoar, dumping syndrome,
?perforated gastric ulcer remote, Crohn's, needs peptamen TF's,
takes only 6 very small meals a day, pancreatitis, anemia
## REASON FOR THIS EXAMINATION:
Please insert PEG tube for nutrition
## INDICATION:
woman with history of Crohn's disease
who had the jejunostomy tube removed for inflammation. Placement
of the tube was requested, through the existing track.
## IMPRESSION:
Successful insertion of a 12
J-tube through the existing percutaneous track.
.
RADIOLOGY Preliminary Report
PERC G/J TUBE CHECK 11:58 AM
## UNDERLYING MEDICAL CONDITION:
w/abd pain, swelling, erythema around J-tube site. J-tube
removed at then pt. sent to ER. s/p JTUBE
replacement by
## REASON FOR THIS EXAMINATION:
s/p Jtube replacement by here at would like tube study
to assess blockage and please PUSH FARTHER INTO PATIENT
## IMPRESSION:
Successful exchange of a 12
catheter to a 14 modified catheter with tip in the
jejunum.
## BRIEF HOSPITAL COURSE:
Mrs. was transferred to from OSH and evaluated
for JTUBE insertion site infection, inflammation. She was
treated with IV antibiotics, made NPO, and managed with IV fluid
hydration. Pain was controlled with IV Dilaudid and Morphine.
Nausea managed with SL Zofran. The JTUBE had been removed, and
left open to aide in decreasing local inflammation. A new JTUBE
was re-inserted into same opening via Radiology. Procedure was
well tolerated. Diet was advanced to Regular food. Tube feeding
was re-started, Peptamen 1.5 Full Str. Leaking around Jtube
noted once tube feeds started. Tubes held. She was taken back to
Radiology for further advancement of JTube. Tube feeds
re-started, complained of nausea and fullness. Tube feeds
advanced slowly. Plan for new JTUBE site discussed with patient
per Dr. . She decided to return to and have
the local surgeons re-site the JTUBE. In the meantime, she will
continue to increase tubes to goal on her own. She will
follow-up with Dr. as needed.
## MEDICATIONS ON ADMISSION:
methadone 10'''', klonopin 1'''', iron pill"
## DISCHARGE MEDICATIONS:
1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for to affected area for 2 weeks.
Disp:*qs * Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: Tablets PO Q4H (every 4
hours) as needed for pain for 1 weeks.
Disp:*45 Tablet(s)* Refills:*0*
4. Methadone 10 mg Tablet Sig: One (1) Tablet PO four times a
day.
## PRIMARY:
JTUBE site inflammation
Jejunitis
.
## SECONDARY:
Malnutrition-takes only 6 very small meals a day, perforated
bezoar, Crohn's, needs peptamen TF's, pancreatitis, anemia,
chronic pain
## DISCHARGE CONDITION:
Stable
Tolerating regular food, and tube feeds.
Adequate pain control with oral medication
## DISCHARGE INSTRUCTIONS:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
## JTUBE CARE:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Be sure to flush tube at least once a day with 50 ml of water.
Flush tube before and after tubes feeds or medication boluses.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep tube attached safely to body to prevent pulling
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18507581", "visit_id": "28483175", "time": "2137-08-28 00:00:00"} |
11927178-DS-11 | 1,849 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Mr. is a male with history of RLE DVT
initially diagnosed , HIV (CD4 431 in , HTN, COPD,
testosterone deficiency not O2 dependent who presents as a
referral from clinic for dyspnea.
Patient was diagnosed with RLE DVT in in by
US. He was placed on coumadin. A repeat RLE US showed
residual 0.4 cm clot in distal popliteal vein, and he was kept
on coumadin, but he had stopped this in despite being
told to continue through . Over the last 2 weeks, however,
he reports experiencing much worsening dyspnea on exertion. He
has a lot of difficulty walking ~20 feet and cannot really go up
stairs anymore. Therefore on he was evaluated at a clinic
there in and found to have reportedly old residual RLE
DVT. He was since then reinitiated on anticoagulation with
Coumadin 2 mg once daily and enoxaparin.
Currently, he has no chest pain and is not dyspneic at rest. But
very symptomatic even transferring out of bed. He reports LLE
DVT years ago as well
He was then seen in the clinic today on and referred to
ED for evaluation of possible PE. He was found to have hypoxia
to 87% to room air.
In the ED, CT PE study reveals extensive pulmonary emboli
involving the lobar and segmental branches of the right middle
lobe, the basal segmental branches of the right lower lobe, the
subsegmental branches of the left upper lobe, as well as the
segmental and subsegmental branches of the left lower lobe. No
evidence of pulmonary infarct or acute right heart strain.
Troponin 0.04 and proBNP 2202. EKG
Of note, he had been experiencing dyspnea on exertion in
and had PFTs in consistent with emphysema. This
improved.
## PAST MEDICAL HISTORY:
Emphysema diagnosed
Thrush while on Advair resolved
RLE DVT
HIV infection: diagnosed 1990s, CD4 nadir: 105 ( )
ITP; s/p splenectomy in early 1990s
Genital HSV
Cervical and lumbar DJD with stenosis: recurrent RT sciatica
( )
s/p L5/ S1 surgical repair on for lumbar stenosis
Lyme carditis in
s/p permanent pacemaker in
pacemaker removed
osteoarthritis LT mid foot; wrists; hands since
renal stones in (indinavir): 1 cm stone in RT upper pole
and 8 mm stone in RT ueteropelvic junction
s/p RT retrograde cytoscopy with ureteral catheter ( )
actininc keratoses
## MOTHER :
died uterine cancer; osteoarthritis
## DIED:
HTN; h/o emphysema; smoking history
Brother died age : DM; CAD
## PHYSICAL EXAM:
On admission - unchanged at discharge
## GENERAL:
Alert and in no apparent distress
## EYES:
Anicteric, pupils equally round
## ENT:
Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion.
## CV:
Heart regular, no murmur
## RESP:
Lungs clear to auscultation with good air movement
bilaterally. Scant crackle bilateral bases, perhaps worse on
left.
## GI:
Abdomen soft, non-distended, non-tender to palpation
## MSK:
Neck supple, moves all extremities.
## PSYCH:
Very pleasant, appropriate affect
## NEUROLOGIC:
Nonfocal, moves all extremities.
## MENTATION:
Alert and cooperative. Oriented to person and place
and time.
## PERTINENT RESULTS:
Labs on admission
12:15PM BLOOD WBC-4.4 RBC-2.69* Hgb-13.0* Hct-35.1*
MCV-131* MCH-48.3* MCHC-37.0 RDW-15.0 RDWSD-71.8* Plt
12:15PM BLOOD Neuts-48.0 Monos-10.3 Eos-2.3
Baso-1.1* NRBC-8.3* Im AbsNeut-2.09# AbsLymp-1.65
AbsMono-0.45 AbsEos-0.10 AbsBaso-0.05
12:15PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-1+* Microcy-NORMAL Polychr-OCCASIONAL
Target-OCCASIONAL How-Jol-2+*
12:15PM BLOOD PTT-30.8
12:15PM BLOOD Glucose-94 UreaN-17 Creat-0.8 Na-139
K-4.2 Cl-101 HCO3-24 AnGap-14
12:15PM BLOOD proBNP-2202*
12:15PM BLOOD cTropnT-0.04*
05:05AM BLOOD cTropnT-0.03*
12:15PM BLOOD Calcium-9.0 Phos-3.0 Mg-1.7
Labs prior to discharge
06:50AM BLOOD WBC-4.6 RBC-2.84* Hgb-13.6* Hct-36.8*
MCV-130* MCH-47.9* MCHC-37.0 RDW-15.2 RDWSD-74.6* Plt
06:50AM BLOOD PTT-81.2*
05:05AM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-144
K-4.1 Cl-106 HCO3-25 AnGap-13
Imaging this admission
CTA
1. Extensive pulmonary emboli involving the lobar and segmental
branches of the right middle lobe, the basal segmental branches
of the right lower lobe, the subsegmental branches of the left
upper lobe, as well as the segmental and subsegmental branches
of the left lower lobe. No evidence of right heart strain on
CT.
2. No evidence of pulmonary infarction.
3. Mildly ectatic thoracic aorta measuring up to 4.2 cm in
diameter.
Left
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Left leg popliteal ( ) cyst.
Right
No DVT within the right leg.
TTE
Mild global LV systolic dysfunction. Dilated RV with at least
moderate systolic dysfunction. Moderate tricuspid regurgitation
with moderate pulmonary hypertension.
Hip X ray
Degenerative changes involving both hips right greater than
left, most likely secondary to osteoarthritis.
Lumbar spine X ray
Moderate to severe multilevel degenerative changes involving the
lumbosacral spine. Stable mild scoliosis to the right,
unchanged. Mild degenerative changes involving the right hip and
the right SI joint.
## BRIEF HOSPITAL COURSE:
This is a two prior DVTs, most recently diagnosed ,
HIV (CD4 431 in , COPD not on home O2, testosterone
deficiency, who presented with worsening dyspnea and hypoxia to
87% RA, found to have bilateral pulmonary emboli with submassive
features. He stabilized and then improved with therapeutic
anticoagulation. TTE showed pulmonary hypertension, dilated RV,
and he was seen by cardiology/MASCOT who recommended
anticoagulation and outpatient followup.
# Breathlessness, dyspnea
# Acute hypoxic respiratory failure due to
# Extensive bilateral pulmonary emboli on background of
# History of two DVT events, most recently : He was
found to have PE involving the lobar and segmental branches of
the right middle lobe, the basal segmental branches of the right
lower lobe, the subsegmental branches of the left upper lobe, as
well as the segmental and subsegmental branches of the left
lower
lobe. CT with no evidence of acute heart strain, however his
proBNP was 2200 and trop 0.04 (and stable). Bilateral LENIs
negative for residual DVT. On , he maintained ambulatory
saturations of 95% on RA. TTE showed p-HTN and dilated RV,
suggestive of true submassive PE. He was seen by
Cardiology/MASCOT who felt that acute treatment with
experimental advanced therapies for submassive PE was not
warranted at this time.
Aside from PE, he has other potential contributors to his
breathlessness: CAD was considered a possibility given age, HIV
status; COPD/emphysema was considered a possibility; a
contribution from non-VTE associated pulmonary hypertension is
also possible, such as OSA or HIV associated p-HTN. Given
submassive PE and possibility of alternative contributing
diagnoses, close outpatient followup was strongly advised.
- Pulmonary outpatient evaluation with PFTs as scheduled
- Cardiology outpatient re-evaluation with repeat TTE in
weeks for reassessment of RV and p-HTN - he was provided with
contact information for the clinic and strongly advised to make
appointment ASAP for within weeks
- Cardiology also recommended outpatient stress testing after
treatment of PE
- Lifelong anticoagulation with Coumadin (Lovenox bridge to
Coumadin at ) and close outpatient INR monitoring
## # COPD NOT O2 DEPENDENT:
Stable on exam, though could certainly
be contributing to symptoms of breathlessness. Continued home
Spiriva.
- Outpatient pulmonary evaluation as scheduled
## # AORTIC ENLARGEMENT:
Identified on TTE and CTA.
- Requires interval followup imaging
- Cardiology followup as above
# Osteoarthritis
# Hip and back pain: New complaint to me today, but he tells me
that he has had fairly severe discomfort in right hip and low
back, worse in the morning, associated with some stiffness,
worse with ambulation, for quite some time. He previously had
discomfort in his left side and received some sort of "surgery
in that was wonderful." Plain films of hip and back
showed significant osteoarthritis. Continued APAP and ibuprofen
PRN.
- Caution with blood thinners; if frequent use of NSAID, would
likely benefit from acid reducer
## # DRY MOUTH:
He complained of mild dry mouth that has been
present for a few months. This was potentially temporally
associated with his antidepressant/antianxiety medication
initiation. Denied dry eye, submandibular swelling or parotid
swelling. He was encouraged to use lozenges which seem to
mitigate this symptom.
- F/u this symptom and consider adjustment of antidepressant
regimen, with consideration of additional workup/treatment for
sicca syndromes if needed
# HIV (CD4 431 in , UDVL : Stable. Followed by Dr
. Continued home medications including Combvir,
Fos-Amprenavir, Ritonavir and Valtrex.
- F/u HIV VL and CD4 count as requested by Dr
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. LaMIVudine-Zidovudine (Combivir) 1 TAB PO BID
2. Fosamprenavir 700 mg PO Q12H
3. RiTONAvir 100 mg PO BID
4. Tiotropium Bromide 1 CAP IH QHS
5. ValACYclovir 500 mg PO Q24H
6. Warfarin 2 mg PO QHS
7. Enoxaparin Sodium 60 mg SC Q12H
## , FIRST DOSE:
Next Routine Administration Time
8. melatonin 3 mg oral QHS
9. TraZODone 50 mg PO QHS
10. BuPROPion (Sustained Release) 150 mg PO QHS
11. Sertraline 100 mg PO QHS
12. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe
13. Diazepam 5 mg PO QHS
14. Cetirizine 10 mg PO QHS
## DISCHARGE MEDICATIONS:
1. Warfarin 5 mg PO QHS
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth every evening
Disp #*30 Tablet Refills:*0
2. BuPROPion (Sustained Release) 150 mg PO QHS
3. Cetirizine 10 mg PO QHS
4. Diazepam 5 mg PO QHS
5. Enoxaparin Sodium 60 mg SC Q12H
## , FIRST DOSE:
Next Routine Administration Time
RX *enoxaparin 60 mg/0.6 mL 1 syringe SC twice daily Disp #*20
## SYRINGE REFILLS:
*0
6. Fosamprenavir 700 mg PO Q12H
7. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe
8. LaMIVudine-Zidovudine (Combivir) 1 TAB PO BID
9. melatonin 3 mg oral QHS
10. RiTONAvir 100 mg PO BID
11. Sertraline 100 mg PO QHS
12. Tiotropium Bromide 1 CAP IH QHS
13. TraZODone 50 mg PO QHS
14. ValACYclovir 500 mg PO Q24H
15.Outpatient Lab Work
Please draw INR on for titration of Coumadin
dosing. Diagnosis is pulmonary embolism. Please forward results
to patient's PCP:
## DISCHARGE DIAGNOSIS:
Pulmonary embolus
History of DVT x2
COPD/emphysema
HIV asymptomatic
## ACTIVITY STATUS:
Ambulatory - Independent. Ambulatory O2
saturation 95% without supplemental oxygen.
## DISCHARGE INSTRUCTIONS:
You were admitted to with shortness of breath and low
oxygen level. You were found to have multiple blood clots in the
lungs, a condition known as pulmonary embolus or PE. You were
treated with anticoagulation and you improved. You had an
echocardiogram which showed some abnormal right sided heart
function likely related to the embolus.
You are scheduled for followup appointments with your primary
care doctor as well as a Pulmonologist. You also need to see the
Cardiology team in followup and get an echocardiogram (please
make sure to call Dr office to schedule that appointment
as I was unable to schedule that for you). Please follow up with
Dr your usual followup schedule.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11927178", "visit_id": "24619938", "time": "2150-12-24 00:00:00"} |
15416581-RR-10 | 144 | ## INDICATION:
year old man with R testicular mass, question of epididymal
cyst versus new growth.// Characterization of R testicular mass?
## THE RIGHT TESTICLE MEASURES:
3.2 x 2.3 x 3.3 3 cm.
The left testicle measures: 2.6 x 1.5 x 4.3 cm.
The testicular echogenicity is normal. The right testis demonstrates a focal
area of multiple cysts, consistent with rete testis.
The left epididymis appears unremarkable. The right epididymis is near
completely replaced by a right multiloculated hypoechoic cystic lesion with
internal flowing echos, consistent with spermatocele. This measures 4 x 1.4 x
3.3 cm.
Vascularity is normal and symmetric in the testes and epididymides.
## IMPRESSION:
1. Right spermatocele, corresponds to the palpable lesion in the area of
clinical concern .
2. Right sided prominent rete testis.
3. Symmetric size and normal vascularity of bilateral testes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15416581", "visit_id": "N/A", "time": "2137-07-22 15:22:00"} |
14500691-DS-19 | 1,265 | ## HISTORY OF PRESENT ILLNESS:
yoF w/ a h/o metastatic cervical cancer s/p surgery and XRT,
chronic diarrhea radiation enteritis, SBO s/p ileocecectomy
in , AF not on anticoagulation, htn who p/w several episodes
bright red and maroon stools. Patient was in her usual state of
health until last night when she developed LLQ abdominal pain
and then threw up throughout the night. She notes emesis ~ every
30 minutes through the night w/ bilious vomitus mixed with food
but no blood or coffee grounds. This am, the pain and vomiting
subsided. However, starting at ~1pm today, she had multiple
episodes of bloody bowel movements. She denies any fevers,
chills, LH, chest pain, or palpitations. She does have a history
of spotting on the toilet paper for which she had 2
colonoscopies in last year showing only hemorrhoids. She
has had no other h/o GI bleeding.
.
In the ED, 98.0, 137/78, 72, 16, 100% RA. Labs were notable for
a Hct of 25. Her most recent Hct was 32 . Also of note,
her INR was found to be 7.9. LFTs and platelets were
unremarkable. An NG lavage was performed for clear yellow
liquid. She received 1 unit of PRBCs in the ED as well as 2
units of FFP. Repeat Hct prior to transfer to the floor was 28
and repeat INR after FFP was 2.4. She also received 10 mg of
vitamin K. ECG showed rate controlled AF.
.
Upon arrival to the floor, patient continues to feel well. She
denies any bloody bowel movements since her son's house. She
continues to deny LH, SOB, palps, CP, abdominal pain. On ROS,
she denies any chest pain, SOB, LH. She does not DOE w/ heavy
exertion. Also notes edema for which she takes furosemide.
She denies any recent fevers, chills, cough. No change in
chronic diarrhea.
## PAST MEDICAL HISTORY:
Metastatic cervical ca s/p ex-lap and removal of tumor in
, chronic diarrhea secondary to
radiation enteritis, PAF, GERD, partial SBO, gallstones s/p ERCP
, HTN, hypothyroidism, s/p hysterectomy , vein stripping
, ureteral ca s/p ? resection/chemo (Dr.
, femur fracture s/p ORIF
## GEN:
Pleasant, well appearing elderly female in NAD
## HEENT:
Mild conjunctival pallor. No icterus. MMM. OP clear.
## NECK:
Supple, No LAD, JVP of ~ 10 cm.
## CV:
RRR. nl S1, S2. II/VI holosys murmur at apex
## LUNGS:
CTAB, good BS , No W/R/C
## ABD:
NABS. Healed low midline surgical incision. Soft, NT, ND.
## EXT:
WWP, 1+ edema. 2+ DP pulses
## SKIN:
No petechiae. Scattered ecchymoses on UEs
## NEURO:
A&Ox3. Appropriate. CN grossly intact. Moving all
extremities
## PERTINENT RESULTS:
08:20PM PTT-40.3*
06:10PM GLUCOSE-88 UREA N-19 CREAT-0.8 SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
06:10PM estGFR-Using this
06:10PM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-148* TOT
BILI-0.5
06:10PM DIGOXIN-0.4*
06:10PM WBC-4.1 RBC-2.73* HGB-8.1* HCT-25.8* MCV-94
MCH-29.5 MCHC-31.3 RDW-16.6*
06:10PM NEUTS-58.1 MONOS-8.3 EOS-2.4
BASOS-0.4
06:10PM PLT COUNT-252
06:10PM PTT-43.2*
ECG Study Date of 9:48:24
Atrial fibrillation with controlled ventricular response. Right
bundle-branch block. Left anterior fascicular block. Compared to
the previous tracing of the rate is slower.
ABDOMEN (SUPINE & ERECT) PORT
There is severe sclerosis of bilateral sacroiliac joints with
fusion. Air is seen within several colonic segments as well as
within the rectum. There is no obstruction. On the upright film,
air-fluid levels are seen within the colon. No dilated small
bowel segments or fluid levels within the small bowel are
identified.
## IMPRESSION:
Air-fluid levels within the colon. No obstruction
## BRIEF HOSPITAL COURSE:
yoF w/ a h/o metastatic cervical cancer, chronic diarrhea,
SBO, AF not on anticoagulation, htn who p/w painless GI bleeding
and coagulopathy.
.
## 1.GIB:
Patient presented to the emergency department wiht
complaint of painless lower GI bleeding. NG lavage negative.
Patient reports H/o normal colonoscopies in in the past
w/ exception of hemorrhoids. Patient has history of chronic
diarrhea from radiation colitis. In the ED, pt HCT was 25.8 with
an INR of 7.9. She was not on coumadin. She was given 2 units
of PRBC, FFP, Vit K with improvement of HCT. GI team thought
that her bleeding was most likekly from hemarrhoids and given
her history of recent negative colonoscopies, GI team felt that
colonoscopy would be of low benefit to the patient. General
Surgery f/u showed no evidence of acute abdomen and no active
process from her last procedure. HCT stabilized before her
discharge and she did not have any further bleeding. Her INR
also normalized.
.
## 2. COAGULOPATHY:
Patient came in with INR of 7.9. Unclear
source. Not on anticoag as outpt. There was a question of
whether there was an error in medications filled by pharm.
Pharmacy team looked through medications and found no
abnormalities in her pills, however, they were limited given the
fact that her pills were generics not filled locally. Other
hypotheses was that given her history of bowel resection and
radiation enteritis, she could be Vit K deficient. This could be
also contributed because of dietary factors.
.
## 3. ATRIAL FIBRILLATION:
Rate controlled. Not on coumadin. PCP
in contacted, who stated that patient has been off
coumadin given the fact that he believes that the risks of
bleeding given her GI history outweigh the stroke prevention
risks, given that she is a low risk candidate (CHADSII of 2).
Patient had episodes of bradycardia to the upper 30's during
admission. No abnormal rhythms besides a-fib on telemetry.
Patient was asymptomatic during bradycardia episodes.
Metoprolol and digoxin were held initially and then resumed.
## MEDICATIONS ON ADMISSION:
CaCO3 500 mg QID
levothyroxine 100 mcg daily
digoxin 125 mcg daily
lasix 20 mg daily
atenolol 100 mg daily
tylenol#3 prn
cholestyramine 5x/day
KCl 10 meq TID
Immodium prn
asa 81 mg daily
protonix 40 mg daily
## DISCHARGE MEDICATIONS:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
QID (4 times a day).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
## DISCHARGE CONDITION:
Stable. No GI bleeding
## DISCHARGE INSTRUCTIONS:
You were seen in the hospital because you had blood in your
stool. you were given 2 transfusions with improvement of your
blood count. You were given intravenous fluids to keep you
hydrated. You were also found to have thin blood. You were
given medications to improve your blood coagulation.
Please follow-up with Dr. 1 week after
discharge to check your INR and hematocrit.
Continue adequate fluid intake. Please try to sit or lay down
if you feel dizzy.
Please call your primary care physician or return to the
emergency department if symptoms return or worsen.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14500691", "visit_id": "24666346", "time": "2113-02-27 00:00:00"} |
16834349-RR-32 | 122 | ## INDICATION:
man with bilateral wrist pain.
## RIGHT:
There is mild sclerosis with joint space narrowing of the first
carpometacarpal and triscaphe joint. No acute fractures are present. Mild
irregularity along the ulnar styloid process is unchanged compared to the
previous examination. No acute fractures are present. No significant soft
tissue swelling is present either.
THREE VIEWS OF THE LEFT WRIST:
A distal radial plate and screw fixation
transfixes a distal radial fracture with complete obscuration of the
previously noted fracture line. No evidence of loosening or hardware
complications is noted. There is mild joint space narrowing and sclerosis
within the first carpometacarpal and triscaphe joint consistent with mild
osteoarthritis.
## IMPRESSION:
Unchanged mild osteoarthritis of both first carpometacarpal and
triscaphe joints.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16834349", "visit_id": "N/A", "time": "2159-04-01 13:17:00"} |
12517435-RR-170 | 129 | ## EXAMINATION:
MRI OF THE CERVICAL SPINE
## INDICATION:
year old man with left C5/6 cervical radiculopathy. // r/o
disc
## FINDINGS:
At the craniocervical junction and C2-3 levels, no significant abnormalities
are seen.
At C3-4, C4-5, C5-6 and C6-7 levels mild disc bulging identified. At C4-5
mild narrowing of the left foramen seen. At other levels no foraminal
narrowing is identified.
At C7-T1, T1-2 and T2-3 levels no abnormalities are seen.
The spinal cord shows heterogenous signal on T2 and inversion recovery
sagittal images which could not be confirmed on the axial T2 weighted images
and therefore appears artifactual. No definite extrinsic spinal cord
compression is seen.
## IMPRESSION:
Mild degenerative changes without spinal stenosis or high-grade foraminal
narrowing.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12517435", "visit_id": "N/A", "time": "2170-09-21 19:07:00"} |
12546655-RR-41 | 143 | ## EXAMINATION:
UNILAT LOWER EXT VEINS LEFT
## INDICATION:
woman with left calf pain and swelling, postop day 3
after left TKA. Evaluate for DVT. On physical examination, there is tense
swelling, warmth and erythema extending from the mid thigh to just below the
knee.
## FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral and femoral veins. Evaluation of the left popliteal vein was slightly
difficult due to pain and tense swelling over this region, but the vessel
demonstrated normal flow, augmentation and compression. Normal color flow is
demonstrated in the posterior tibial veins. Evaluation of the peroneal veins
is slightly limited.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa ( ) cyst.
## IMPRESSION:
Limited evaluation of the left peroneal veins. No evidence of deep venous
thrombosis in the left lower extremity.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12546655", "visit_id": "25134643", "time": "2134-08-15 09:24:00"} |
13639456-RR-94 | 215 | TWO VIEWS OF THE LUMBAR SPINE,
## HISTORY:
woman, status post fall; ? fractures.
## FINDINGS:
Frontal and limited cross-table lateral views are compared with a
remote examination dated . Allowing for differences in technique and
positioning, there has been no significant interval change. Again
demonstrated is the moderate rotatory dextroscoliosis with apex at the L2-3
level and expected asymmetric degenerative changes. There is most marked disc
space narrowing and left-more-than-right facet arthrosis at the L4-5 and L5-S1
levels. Allowing for the patient's advanced age, there is relatively little
degenerative change elsewhere. There is profound diffuse osteopenia, but
there is no significant progressive loss of vertebral height or evidence of
acute compression fracture or change in alignment. There are symmetric
moderately severe degenerative changes involving the hip joints, as before.
Extensive confluent calcification of the abdominal aorta and its branches,
with no focal aneurysmal dilatation, as well as 2.3-cm round calcification in
the right lower pelvis, presumably related to a uterine leiomyoma, are
redemonstrated. Also noted is fecoloaded colon as well as cardiomegaly with
left ventricular enlargement and the distal portions of dual-chamber cardiac
pacemaker.
## IMPRESSION:
Moderate dextroscoliosis with associated degenerative changes as
well as diffuse osteopenia, but no evidence of compression fracture or other
acute process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13639456", "visit_id": "N/A", "time": "2112-05-04 13:02:00"} |
11441670-RR-26 | 94 | ## INDICATION:
year old man with VV ECMO// interval change interval
change
## IMPRESSION:
Compared to chest radiographs, through . Radiographic
severity of severe global pulmonary consolidation has not improved. No
pneumothorax. Size of pleural effusion is difficult to assess. Mild to
moderate enlargement cardiac silhouette stable.
ET tube in standard placement. Feeding tube ends in the upper stomach.
Nasogastric drainage tube passes into the stomach and out of view. Cannula
traverses SVC and right atrium to the level of the inferior cavoatrial
junction. Left central catheter could be arterial or venous, unchanged in
position.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11441670", "visit_id": "29142856", "time": "2132-03-10 09:08:00"} |
17254880-DS-11 | 961 | ## ALLERGIES:
peanuts / hydrochlorothiazide / chlorthalidone
## HISTORY OF PRESENT ILLNESS:
Ms. is a woman with history of HTN,
HLD who presents with lightheadedness.
History is taken with assistance of patient's friend over the
phone. The telephone interpreter was engaged
multiple times over the language line, however, the interpreter
could not be heard over the phone by either this interviewer or
the patient and ultimately stopped responding.
Briefly, the patient reports that she felt unwell today while at
her doctor's office. She specifically reports that she felt
dizzy. She noticed this while walking. While in the lobby of the
doctor's office, she lied down on the ground and felt a bit
better. She denies head strike or fall. She denies any chest
pain, palpitations, cough, shortness of breath, fevers. She
reports she has been drinking normally but has had a poor
appetite over the past days to week.
Of note, the patient was admitted to the hospital in for
chest pain and syncope and found to have hyponatremia in setting
of thiazide use that improved with isotonic fluids. Her thiazide
diuretic was discontinued at that time. The patient and her
friend both note that this medication resulting in hyponatremia
and she was directed to discontinue it; it was subsequently
listed as an allergy.
The patient saw her cardiologist on and was found to have
poorly controlled hypertension and was started on
chlorthalidone.
## IN THE ED, VITALS:
98.6 79 154/74 16 99% RA
Exam notable for: normal physical and neuro exam
Labs notable for: Na 123->129 (after 500cc NS), UNa 23, UOsm
256,
Urine SpecGrav 1.009, trop<0.01
Patient given: 500 cc NS
On arrival to the floor, the patient reports that her
dizziness/lightheadedness has resolved. She feels thirsty. She
denies any other complaints at this time.
## ROS:
Pertinent positives and negatives as noted in the HPI.All
other systems were reviewed and are negative.
## PAST MEDICAL HISTORY:
HLD
HTN
MEMORY PROBLEMS
H PYLORI
PERIOCULAR ABSCESS
VIT D DEFICIENCY
ADENOMATOUS POLYP (COLONOSCOPY
## SISTER:
colon malaria
Children are healthy
## GENERAL:
Alert and in no apparent distress
## EYES:
Anicteric, pupils equally round, surgical changes s/p
cataract surgery
## ENT:
Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate; moist
mucous membranes
## CV:
Heart regular, no murmur
## RESP:
Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
## GI:
Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
## GU:
No suprapubic fullness or tenderness to palpation
## MSK:
Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; no peripheral edema
## SKIN:
No rashes or ulcerations noted
## NEURO:
Alert, oriented, face symmetric, gaze conjugate with
EOMI,
no nystagmus, speech fluent, moves all limbs, sensation to light
touch grossly intact throughout
## PSYCH:
Very pleasant, appropriate affect
## GENERAL:
Alert and in no apparent distress
## EYES:
Anicteric, pupils equally round, surgical changes s/p
cataract surgery
## ENT:
Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate; moist
mucous membranes
## CV:
Heart regular, no murmur
## RESP:
Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
## GI:
Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
## GU:
No suprapubic fullness or tenderness to palpation
## MSK:
Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; no peripheral edema
## SKIN:
No rashes or ulcerations noted
## NEURO:
Alert, oriented, face symmetric, gaze conjugate with
EOMI,
no nystagmus, speech fluent, moves all limbs, sensation to light
touch grossly intact throughout
## PSYCH:
Very pleasant, appropriate affect
## - EKG ( ):
NSR, NA/NI, no acute ischemic changes
## - CXR ( ):
IMPRESSION: Subtle bibasilar opacities are felt
more likely due to atelectasis, less likely infection.
## BRIEF HOSPITAL COURSE:
Ms. is a woman with history of HTN, HLD
who presents with lightheadedness, found to have hyponatremia.
## # LIGHTHEADEDNESS
# HYPONATREMIA:
She presented with lightheadedness and was found
to be hypnatremic to 123. Suspect due to thiazide-induced
hyponatremia as
patient had thiazide-induced hyponatremia years ago while on
HCTZ and she was started on chlorthalidone one week prior to
presentation. Patient appears euvolemic on exam. By holding her
chlorthalidone and 500 cc NS her sodium improved to 131 on
multiple checks prior to discharge. She has follow up with her
primary care doctor in one week and will also continue to follow
up with her cardiologist.
[] Discontinue chlorthalidone; listed as an allergy
## # HTN:
Held lisinopril initially as she was normotensive on
admission, but was restarted on . She should continue to
have her BP's checked as outpatient and other anti-hypertensives
(other than diuretics) should be considered.
# HLD:
- Continue pravastatin
# GERD:
- Continue ranitidine
# Osteoporosis:
- Continue Ca-Vit D
## TRANSITIONAL ISSUES:
[] Holding chlorthalidone. No other antihypertensive was
initiated due to normotension. Consider other options other than
diuretics as outpatient.
>30 minutes were spent preparing this discharge.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO DAILY
2. Ranitidine 150 mg PO BID
3. Pravastatin 10 mg PO QPM
4. Chlorthalidone 25 mg PO DAILY
5. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg- 250
unit oral DAILY
## DISCHARGE MEDICATIONS:
1. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg-
250 unit oral DAILY
2. Lisinopril 40 mg PO DAILY
3. Pravastatin 10 mg PO QPM
4. Ranitidine 150 mg PO BID
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to because you were feeling weak and had
low sodium. By holding your medication called CHLORTHALIDONE and
giving you fluids, your sodium improved. You should hold this
medication and just continue your lisinopril for blood pressure
as well as your other medications. You should follow up with
your PCP.
We wish you all the best.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17254880", "visit_id": "24454032", "time": "2132-08-16 00:00:00"} |
13948093-DS-14 | 3,199 | ## ALLERGIES:
Evista / Lipitor / Erythromycin Base / lisinopril
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
upper and lower endoscopy - gastritis, no GvHD
## REASON FOR ADMISSION:
Ms. is a woman with
a history of non-Hodgkin's lymphoma, B-cell follicular type and
breast cancer with development of myelodysplastic syndrome, most
likely secondary to her prior treatment, who underwent
allogeneic
cord blood transplant with Fludarabine, Busulfan, and ATG
conditioning in and is being admitted today with fever,
cough and dyspnea.
## :
Day Post Transplant: 190
## POST TRANSPLANT COURSE:
D 0 = . Hospital course
complicated by usual low counts and mucositis requiring Fentanyl
PCA. Developed nonproductive cough without fevers with CT chest
notable for left lower lobe pneumonia, treated with antibiotics.
Bronchoscopy revealed a mucous plug with symptoms resolved after
procedure. Developed increasing lower back pain with noted
enhancement of epidural thecal sac at L3-L4. CT-guided
aspiration without abnormalities. With worsening pain in lower
back and neck, and with increased CRP and ESR, suspected a
delayed serum sickness secondary to ATG. Started on steroids
with improvement of pain. Had increasing blood sugars with
initiation of steroids(previously on Metformin). Started on
Insulin and discharged on NPH.
Discharged to local apartments on . Overwhelmed at all
her medications and trying to do insulin injection with high
blood sugars and not well controlled. Readmitted on .
Required increasing insulin in the hospital but with tapering
off
prednisone as of , had decreased insulin requirements.
Switched to Glipizide 5 mg daily with adequate glycemic control.
Discharged on . With lower blood sugars off
Prednisone,
Glipizide decreased to 2.5 mg on with stable blood
sugars outside of 1 episode of hypoglycemia related to not
eating enough.
## INTERVAL HISTORY:
Now at own home. Had been needing frequent
visits for IV magnesium replacement but this has improved over
time. Occasional issues with loose stool but seemed more
related
to food choices and medications. Magnesium supplementation
decreased. Usual pattern is 1 - 2 stools per day. Now drinking
Lactose-free milk and using Lactaid pills with any dairy
products.
Admission on for fevers and diarrhea. Felt to be
related to viral process. Infectious work up negative.
Discharged on and completed a 7 day course of
Ciprofloxacin and Flagyl. No further fevers or diarrhea.
Admitted on with increasing chest pain radiating to
the
back with difficulty taking a deep breath from the pain. No
fever
or cough. Chest CTA without evidence for PE or pneumonia. No
cardiac etiology. Chest pain resolved but with still noted
shortness of breath at times; has history of breathing issues
with strong perfumes, smoke. Notes a hoarse voice and
"tightness" with breathing. Sent home with inhaler. Also noted
diffuse joint aches and right arm stiffness/pain.
Seen in follow up 1 week ago and was doing relatively well
without significant complaints outside of ongoing joint aches
for
which she takes 1 dose of Tylenol at night. Presents today for
her usual follow up and reports increasing dry cough over the
past week. She has been using the inhaler but lately this has
made her cough worse with vomiting. She has had 3 episodes of
vomiting or dry heaves with the cough. She is more dyspneic
related to her cough as well. On , she noted a
temperature of 100.1 in the evening and last evening, her
temperature was 100.4. She took Tylenol on both occasions and
did not call to report her temperatures. She is feeling more
fatigued and reports eating and drinking in fair amounts only.
Nausea and vomiting related to her cough.
Has also reported increasing right shoulder pain which has been
ongoing. Has continued with joint aches.
## REVIEW OF SYSTEMS:
Outside of above, no bleeding, bruising,
rashes. No diarrhea. Lightheaded this morning. No headaches.
## ONCOLOGIC HISTORY:
1. Left-sided breast cancer diagnosed in , status post
resection, chemotherapy with Adriamycin and Cytoxan, followed by
years of tamoxifen on protocol along with additional
radiation. Completed years of Arimidex.
2. Follicular lymphoma, diagnosed with left neck node biopsy
on revealing non-Hodgkin's lymphoma, B-cell
follicular
type, low-grade, CD20, CD10 and BCL2 positive with MIB1 fraction
of approximately 50%. Chronic urticaria was felt to be an
autoimmune manifestation of her lymphoma.
--Given Rituximab therapy over years, completed .
--Remission until when noted left ear feeling stuck
together when lying on her side. Biopsy of left ear mass on
showed involvement by non-Hodgkin's lymphoma with
follicular center cell derivation. Immunoperoxidase study
showed
positivity for CD20, CD10, BCL2 and BCL6. MIB1 proliferation
index was about 20%. Cells were negative for CD10, CD5, and
CD11c on flow cytometry. Noted for some scalp lesions, which
were felt related to her lymphoma as well.
--Given limited disease, received radioimmunotherapy with
Zevalin on and has remained in remission.
3. , noted for microcytic anemia; not iron deficient.
Bone marrow aspirate and biopsy on noted for
myelodysplasia with complex chromosome abnormalities(Monosomy 5
and 7). Cord donors only.
## PAST MEDICAL HISTORY:
--Hyperparathyroidism, status post parathyroid surgery on
. She continues on vitamin D supplementation with
calcium, followed by endocrine.
--Status post bilateral oophorectomy in due to strong
family history.
--Shingles in and .
--NASH, early disease with no evidence of progression.
Previously followed by Dr. .
--s/p Thyroidectomy in , on thyroid replacement.
--Hypertension.
--Diabetes, was on Metformin.
--Hypercholesterolemia, currently off statin.
## FAMILY HISTORY:
Middle of 5 siblings, with one sister deceased since at age
from breast cancer, and another sister living with
disease. A second sister had breast cancer at age . Parents
are deceased. Mother died of breast cancer at older age. Father
died at the age of with a cerebral hemorrhage from
hypertension. Paternal grandmother had ovarian cancer at , and
her paternal aunt died of breast cancer at .
## GENERAL:
Tired-appearing female, in no acute distress.
## BP:
126/59. Heart Rate: 117. Weight: 122.9. Height:
62.8. BMI: 21.9. Temperature: 98.4. Resp. Rate: 18. Pain Score:
8
(right arm pain). O2 Saturation%: 100. Distress Score: 0.
Performance status: 80%.
## HEENT:
Oropharynx is moist without erythema, lesions, or
thrush.
## LUNGS:
Clear to auscultation bilaterally without wheezing or
rales noted. Decreased breath sounds on left base.
## HEART:
Regular rate and rhythm without murmurs, rubs, or
gallops.
## CHEST:
Tunnelled line with no erythema at exit site; no
tenderness.
## ABDOMEN:
Soft, nontender, nondistended with normal bowel sounds
and without hepatosplenomegaly or other masses appreciated.
## BACK:
No pain along spinal processes.
## SKIN:
Without rashes.
=================
DISCHARGE
=================
## HEENT:
No conjunctival pallor. No icterus. MMM. OP clear.
## LYMPH:
No cervical or supraclav LAD
## CV:
regular rate. Normal S1,S2. No MRG.
## LUNGS:
CTAB. No wheezes, rales, or rhonchi.
## ABD:
+BS. Soft, NT, ND.
## SKIN:
No rashes/lesions, petechiae/purpura ecchymoses.
## IMPRESSION:
No acute intrapulmonary process.
CT Chest without contrast
## IMPRESSION:
1. No new focal consolidations concerning for pneumonia.
2. Unchanged numerous prominent mediastinal lymph nodes compared
to the prior
exam.
3. Slight interval increase in the amount of small pericardial
effusion.
CT sinus
## IMPRESSION:
That the limit of free fluid in the right maxillary sinus;
otherwise,
paranasal sinuses are clear.
MR spine non-con
## IMPRESSION:
Multilevel degenerative spondylosis which is most prominent at
C3-4, C4-5,
C5-6 and C6-7 levels. Moderate canal narrowing at C3-4 with some
deformity on the cord and mild at other levels.
Foraminal narrowing as described above, moderate on the left at
C3-4 and
moderate to severe on the right at C6-7 levels.
No significant change since the prior study of MR shoulder non-con
## IMPRESSION:
1. Moderate tendinosis, bursal surface fraying, and possible
tiny
intrasubstance tears in the supraspinatus tendon. No large
tear. Mild
atrophy and edema in the supraspinatus muscle, which is likely
chronic, and related to the underlying tendinosis.
2. Mild tendinosis and small focal intrasubstance tear in the
infraspinatus
tendon.
3. Mild tendinosis in the subscapularis tendon.
4. Mild subacromial-subdeltoid bursitis.
5. Edema around the axillary recess is nonspecific, though can
be seen in the setting of adhesive capsulitis. Recommend
clinical correlation with symptoms.
6. Moderate degenerative changes in the acromioclavicular
joint.
7. Degenerative changes and fraying of the labrum. No discrete
labral tear is identified on this non-arthrographic study.
8. Low T1 marrow signal likely reflects red marrow hyperplasia.
Please see comment above. Clinical correlation requested.
ECHO
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
Doppler parameters are indeterminate for left ventricular
diastolic function. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ,
findings are similar.
Upper/Lower endoscopy biopsies- gastritis, no evidence of
GvHD
## PET :
1. Small non-FDG-avid left pleural effusion with
associated atelectasis and trace right pleural effusion. 2.
Prominent prevascular mediastinal lymph nodes are not FDG-avid.
3. Left outer breast soft tissue nodule is not FDG-avid.
=================
MICRO
=================
- CMV viral load neg
- BCx no growth - Resp viral panel neg for viruses/antigens
- sputum contaminated
- BCx no growth - Cdiff (+)
- beta glucan, galactomannan negative
- Legionella urine Ag neg, mycoplasma negative
- BCx x2 neg
- BCx x2 neg
- stool O+P neg
- BCx x2 neg
- Adenovirus negative
- EBV, CMV, HHV-6 negative
=====================
DISCHARGE LABS
=====================
12:02AM BLOOD WBC-12.6* RBC-2.51* Hgb-7.6* Hct-23.5*
MCV-94 MCH-30.2 MCHC-32.3 RDW-18.4* Plt
12:02AM BLOOD Neuts-48* Bands-0 Lymphs-45* Monos-4
Eos-1 Baso-1 Atyps-1* Myelos-0 NRBC-1*
12:02AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Schisto-1+
12:02AM BLOOD Plt Smr-NORMAL Plt
12:02AM BLOOD Glucose-202* UreaN-19 Creat-0.8 Na-138
K-4.7 Cl-103 HCO3-27 AnGap-13
12:45AM BLOOD CK(CPK)-46
12:02AM BLOOD Calcium-9.0 Phos-4.2 Mg-1. w/ history of B-cell follicular lymphoma and breast cancer
with development of secondary myelodysplastic syndrome, now
s/p allogeneic double cord blood transplant ( )
with Flu/ATG/Melphalan conditioning who p/w cough and chest
tightness, developed diarrhea and fevers. She completed a 7 day
course of antibiotics for HAP and was also treated for c. diff.
While in the hospital, she developed diffuse tenosynovitis and
was treated with steroids for presumptive GvHD with improvement
of pain.
====================
## ====================
#COUGH VARIANT ASTHMA:
Dx per pulm consult. Pt has cough/chest
tightness, sensation of "irritation" that leads to paroxysms of
coughing and occ nbnb emesis. DDX includes GERD, aspiration,
pneumonia, early fungal infxn, GVHD of lung. CXR neg for acute
cardiopulm process, however, given patient's persistent fevers
in the setting of cord transplant, she was started on an 8 day
course of IV vanc/cefepime for .
Bglucan/galactomannin neg. Trial of inhaled corticosteroid
(Flovent 110mcg, 1 puffs bid) w/ aerochamber spacer did not help
much. Spiriva, albuterol, and symptomatic management with
benzonatate and phenol lozenges improved cough.
## #C DIFF DIARRHEA:
Patient had + c. diff, and was started on IV
flagyl/PO vanc. She will continue PO vanc and be tapered as an
outpatient.
## #FEVER IN CORD TRANSPLANT PT:
Cdiff (+) and was started on PO
vanc, however, her fevers still did not improve. Upper/lower
endoscopy by GI on showed gastritis, but no colitis or GvHD
on biopsy. CT abd/pelvis did not show abscess, but showed edema
of paraspinal muscles. MRI lumbar spine showed nonspecific
myositis. CT chest showed some atelectasis but could not rule
out pneumonia, so she completed a course of IV vanc/cefepime for
HAP. PTLD was a consideration, however, her PET scan was
negative. Her fevers eventually subsided and the exact etiology
is unknown.
## #LOW BACK PAIN:
Patient has history of herniated disks, but
reports that this pain is not the same. Pain is not vertebral in
origin per exam, more paraspinal musculature. CT does not show
abscess, but does show edema of paraspinal muscles. MRI spine
shows nonspecific myositis. Her pain improved with steroids and
this is presumed to be secondary to GVHD.
## #TENOSYNOVITIS:
Patient has developed diffuse asymmetrical
tenosynovitis since this hospitalization. She reports pain on
movement of her right shoulder, right leg at the hip joint, and
pain in her right foot on movement. Ck normal. Improved with
steroids. This is thought to be due to serum sickness. She will
be discharged on a steroid taper.
## #HYPERGLYCEMIA:
She developed hyperglycemia while on taking the
steroids. She was seen by , and was recommended: 20U QAM
for 20mg prednisone, 15U QAM for 10mg prednisone, 10U QAM for
5mg prednisone. She received diabetic/insulin management
teaching while she was in the hospital. also recommended
taking 5 units of Humalog before lunch and dinner if her glucose
is >200, however, the patient is extremely anxious about giving
herself insulin. We came to the decision that the best regimen
for the patient would be to only take NPH as previously
described and to not worry about pre-meal glucose readings as
long as they are less than 300 since she will only be on a one
week course of insulin. She was instructed to call
emergency telephone number if her glucose readings are greater
than 300. She has close follow up at scheduled for
.
====================
## CHRONIC ISSUES:
====================
#Follicular lymphoma s/p allo double cord blood txp: This
patient is on acyclovir (vzv/hsv), bactrim ss (pcp), fluc
(fungal) prophylaxis. She is also on immunosuppressive agents -
Tacrolimus 0.5 mg PO Q12H and Mycophenolate Mofetil 250 mg PO
BID with supplemental FoLIC Acid 4 mg PO/NG DAILY.
## #MDS:
This remaintd stable and she continued her home
mycophenolate and tacro. While in the hospital, her IgG was low
and she received IVIG on
## #ANEMIA:
She requires periodic transfusions since her
transplant. This could be due to pure red blood cell aplasia
given her low retic count.
## #HYPOTHYROIDISM:
She continued her home levothyroxine.
## #DM2:
While in the hospital, we held her glipizide and started
ISS. She was discharged on dose of glipizide.
====================
## TRANSITIONAL ISSUES:
====================
- Patient will be discharged on PO vanc, outpatient taper over
time
- Patient is on Prednisone taper (PredniSONE 30 mg PO/NG DAILY
PredniSONE 20 mg PO/NG DAILY PredniSONE 10
mg PO/NG DAILY , PredniSONE 5 mg PO/NG DAILY
- Patient discharged on U QAM for 20mg prednisone, 15U QAM for
10mg prednisone, 10U QAM for 5mg prednisone
- She should resume her glipizide when she is finished with the
steroids
- has close follow up at for , also has emergency
contact number for low or high glucose readings
- Patient will need to follow up with for PFTs
- Patient should follow up with Dr.
on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Fluconazole 200 mg PO Q24H
3. FoLIC Acid 1 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Mycophenolate Mofetil 250 mg PO BID
8. Pantoprazole 20 mg PO Q24H
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 0.5 mg PO Q12H
11. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
12. GlipiZIDE 2.5 mg PO DAILY
13. Albuterol Inhaler PUFF IH Q6H:PRN chest tightness
14. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
## DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg PO Q8H
2. Albuterol Inhaler PUFF IH Q6H:PRN chest tightness
3. Fluconazole 200 mg PO Q24H
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Mycophenolate Mofetil 250 mg PO BID
8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
9. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
## TABLET REFILLS:
*0
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Tacrolimus 0.5 mg PO Q12H
12. NPH 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [Contour Test Strips] before meals
and before bed Disp #*100 Strip
## REFILLS:
*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL 1 Up to 18
Units QID per sliding scale Disp #*30
## SYRINGE REFILLS:
*0
RX *lancets [Embrace Lancets] 30 gauge before every meal and
before bedtime Disp #*100 Each
## REFILLS:
*0
RX *NPH insulin human recomb [Humulin N KwikPen] 100 unit/mL (3
mL) 1 20 Units before BKFT Disp #*20 Syringe Refills:*0
RX *insulin syringe-needle U-100 [Ins Syringe/Needle 0.5cc/27G]
27 gauge X injust NPH every morning daily Disp #*30 Syringe
Refills:*0
13. PredniSONE 20 mg PO DAILY Duration: 3 Days
Take one daily from
14. PredniSONE 10 mg PO DAILY Duration: 3 Days
Take one daily from
15. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
inhaled daily Disp #*30 Capsule Refills:*2
16. Vancomycin Oral Liquid mg PO Q6H
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every 6
hours Disp #*60 Capsule Refills:*0
RX *vancomycin 1 gram 125 mg by mouth every 6 hours Disp #*30
Syringe Refills:*0
17. PredniSONE 5 mg PO DAILY Duration: 3 Days
Take one daily from
RX *prednisone 5 mg 4 tablet(s) by mouth daily Disp #*17 Tablet
Refills:*0
18. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
19. GlipiZIDE 2.5 mg PO DAILY
Please start taking once the steroids are finished
20. Loratadine 10 mg PO DAILY
21. Benzonatate 100 mg PO TID cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*30 Capsule Refills:*0
22. Voriconazole 200 mg PO Q12H
Please take twice daily for two weeks
RX *voriconazole 200 mg 1 tablet(s) by mouth twice daily Disp
#*14 Tablet Refills:*0
## PRIMARY DIAGNOSIS:
Hospital acquired pneumonia, c. diff
infection, GvHD
## SECONDARY DIAGNOSIS:
B-cell follicular lymphoma, breast cancer,
Secondary MDS
## DISCHARGE INSTRUCTIONS:
Dear ,
were hospitalized on for cough and shortness of
breath. completed a course of antibiotics for pneumonia. The
pulmonary team saw while were here and recommend that
see after are discharged for pulmonary
function testing.
also had diarrhe and were treated with antibiotics for a c.
diff infection. Please continue oral vancomycin, your outpatient
doctors this medication over time.
While were here, developed muscular/tendon pain, which
is most likely due to graft vs. host disease. This pain improved
with steroids. Please continue the steroid (prednisone) taper at
home.
Because of the steroids, your blood glucose levels have been
elevated. Please take 20U NPH for 20mg prednisone, 15U NPH for
10mg prednisone, 10U NPH for 5mg prednisone. We will set up a
to help with this. also have an appointment at
on for follow up.
It was a pleasure meeting and taking care of while were
at the hospital.
-Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13948093", "visit_id": "22069994", "time": "2168-01-30 00:00:00"} |
18652308-DS-6 | 904 | ## CHIEF COMPLAINT:
Left temporal cerebral hypodensity
## HISTORY OF PRESENT ILLNESS:
This is a right handed man with left temporal
hypodensity, discovered after he developed headaches.
He reports these daily headaches for the past several weeks,
bitemporal throbbing headache. He stopped smoking at the end of
, and has been drinking large amount of coffee. He also
became unusually forgetful. He back his USPS truck into a parked
car a few weeks ago, when tried to parallel park, into a space
where the vehicle clearly could not fit. He has been
accident-free for the previous years. He had blank stares on
the job as a . He was searching for words and he was
taken to .
## PAST MEDICAL HISTORY:
1. Left temporal lesion
2. Coronary artery disease
3. Pacemaker
4. DVT on warfarin
5. Tobacco use
6. Thyroid surgery
7. Depression
8. Alcohol and marijuana use
9. Tobacco use
10. Sleep apnea, CPAP
11. Elbow surgery
## SOCIAL HISTORY:
He is married. He has two children and three siblings. His
mother died at with diabetes, and his father died at . He
is a . He has been a smoker, and quit in . He quit
drinking in .
## :
no LNN; supple neck
RRR
no SOB
NTTP
warm peripherals
no CCE
## NEURO:
AAOx3
conversant but clearly with WFDD and several spells int he
inteview;
some blank stares as well; otherwise, cooperative, pleasant
nl affect
## CN:
I) not tested
II) PERLA; no gross visual field abnormalities
III-VI) EOMI
V) symmetric sensation, bite eugnatal
VII) symmetric
VIII) bilaterally intact
IX/X) no swallowing difficulties; phonation intact
XII) tongue midline
## :
no epicritic or protopathic deficit
## REFLEXES:
symmetric 2+
no clonus, no Babinski, no
no extrapramidal signs; eudiadochokinesis
Stable stand and gait; Rhomberg -
## AT TIME OF DISCHARGE:
AAO x 3, PERRL, no pronator drift. Strength throughout.
Sensation intact to light touch.
## PERTINENT RESULTS:
CT head without contrast (pre-op):
Unchanged left temporal lobe hypodensity without calcification,
cystic
regions, or hemorrhage. Differential includes glioma such as
astrocytoma or noncalcified oligodendroglioma
CT head without contrast:
Expected postoperative changes status post left temporal mass
biopsy with no evidence of significant hemorrhage at this time.
## BRIEF HOSPITAL COURSE:
Mr. is a year-old male who was electively
admitted to the Neurosurgery service after he underwent a
stereotactic biopsy on . The patient tolerated the
procedure well. Please see the operative report for further
details. The patient was recovered in PACU and transferred to
the inpatient ward for further management.
On POD 1, Mr. recovered well. He voided without
issue and was tolerating a regular diet. His pain was
well-controlled with oral narcotic and non-narcotic analgesics.
He was written for a decadron taper.
At the time of discharge, the patient was afebrile,
hemodynamically and neurologically stable. A follow-up
appointment with the clinic was provided. The patient was
provided disharge instructions regarding his wound, medication
managment and activity restrictions.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 1000 mg PO BID
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Venlafaxine XR 75 mg PO DAILY
4. Nicotine Patch 21 mg TD DAILY
## DISCHARGE MEDICATIONS:
1. LeVETiracetam 1000 mg PO BID
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Nicotine Patch 21 mg TD DAILY (hand-written prescription
provided)
4. Venlafaxine XR 75 mg PO DAILY
5. Acetaminophen w/Codeine TAB PO Q4H:PRN pain
RX *acetaminophen-codeine 300 mg-30 mg tablet(s) by mouth
every four (4) hours Disp #*40
## TABLET REFILLS:
*0
6. Dexamethasone 4 mg PO QID Duration: 1 Day
RX *dexamethasone 2 mg 1 tablet(s) by mouth as directed Disp #*6
Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
8. Omeprazole 20 mg PO DAILY
## DISCHARGE DIAGNOSIS:
Left temporal brain lesion
## 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.
Dressing may be removed on Day 2 after surgery.
You have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
You may resume your Xarelto on .
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) &
Senna 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 may resume your Coumadin (warfarin) on .
If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
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.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
Fever greater than or equal to 101.5° F.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18652308", "visit_id": "24682604", "time": "2144-04-12 00:00:00"} |
10826309-RR-16 | 140 | ## HISTORY:
male with new right PICC.
## STUDY:
AP portable upright chest radiograph.
## FINDINGS:
There has been interval placement of a right-sided PICC which
courses down the right brachiocephalic vein and then turns upwards into the
left brachiocephalic vein. It travels approximately 4-5 cm of the left
brachiocephalic vein. Heart and mediastinal contours appear unremarkable and
unchanged from prior study. The hila are normal appearing bilaterally. The
lungs are clear of masses or consolidations. There are trace pleural
effusions bilaterally with associated atelectasis. There is no pneumothorax.
The osseous structures did show multiple levels of degenerative changes along
the thoracic spine.
## IMPRESSION:
Right PICC tip within the left brachiocephalic vein,
approximately 4-5 cm beyond the confluence of the right and left
brachiocephalic veins. These findings were discussed with the IV team at the
time of dictation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10826309", "visit_id": "20376564", "time": "2177-07-25 13:10:00"} |
12599033-DS-14 | 833 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
in his usual state of good health until
approximately 1 on th day prior to admission when he
developed a L occipital headache that worsened throughout the
course of the day. He tried taking over the counter pain
medications without any relief. He describes his headache as
"pressure" which spread to the rest of his head by the evening
and was the "worse headache of [his] life". His headache is
worse with movement of his head & neck, and exposure to bright
light. He also complained of concomitant nausea (no vomiting) &
bilateral retro-orbital pain.
In the ED, vital signs were as follows:
## T:
97.6 HR: 75 BP: 145/84 RR: 20 O2: 100% on RA.
The patient was administered empiric treatment for meningitis
with 1 g IV vancomycin & 2 g IV ceftriaxone. He was also given
2.5 L NS, morphine 4mg X 2, IV compazine, & IV zofran, ketorolac
30 mg X 1, & diphenhydramine. He underwent a head CT, which
showed no acute process. LP demonstrated opening pressure 15,
WBC 38, poly 80, lymph 18, protein 44, glucose 61.
.
On the floor, the patient complains of feeling tired. He has a
diffuse headache that he rates at in severity. The
headache is associated with pain behind both eyes.
## PAST MEDICAL HISTORY:
- Concussion in after getting hit in chin while
playing lacrosse. No loss of consciousness. Resumed school the
next day and had no symptoms. Was told not to play lacrosse for
3 weeks after the event and then returned to full activity
without restrictions.
- Wart on right nasal wall that was removed in
## FAMILY HISTORY:
- No history of family illnesses.
## GENERAL:
WNWD young man resting in bed, appears fatigued. Lights
are off.
## COR:
+ S1S2, RRR, no c/w/r.
## PULM:
Good air entry bilaterally. CTAB, no c/w/r.
## :
+NABS in 4Q. Soft, NTND.
## EXT:
MAEE. DP + bilaterally. No c/c/e.
## NO NUCHAL RIGIDITY.
--> CN:
PERRL, EOMI, visual fields full, shoulder shrug intack,
tongue protrusion & palate elevation intact, facial sensation
intact bilaterally. SCMs intact.
--> Strength: bilaterally in upper & lower extremities.
--> Sensation: Intact to light touch bilaterally throughout.
--> Reflexes: Biceps, patellar reflexes intact bilaterally.
## GENERAL:
Well-appearing young male walking around hospital room,
preparing to brush teeth
## :
+ S1S2, RRR, no c/w/r.
## :
soft, NT, ND, NABS.
## EXT:
2+ pulses, no edema.
## NEURO:
CN grossly intact, moving all four extremities and
walking around room
## DISCHARGE LABS:
No microorganisms seen in blood or CSF cultures to date.
## PRIMARY REASON FOR HOSPITALIZATION:
male in his usual state of good health presents with
headache, photophobia, & nausea for one day prior to admission.
## # ASEPTIC MENINGITIS:
The patient's headache with photophobia &
nausea was concerning for meningitis (especially in light of the
fact that he does not usually get headaches). He had a lumbar
puncture in the ED which showed 38 WBCs with 80% neutrophils and
normal protein, glucose, and opening pressure. This was not
diagnostic for either bacterial or aseptic meningitis, but was
felt to represent early aseptic meningitis. He was afebrile on
presentation and remained so throughout his hospital course.
Empiric IV vancomycin and ceftriaxone were initiated for 72
hours to empirically cover for possible bacterial meningitis
(although suspicion for this diagnosis was low, a conservative
approach was favored given the patient's age & early
presentation). The patient's headache improved, with pain
coming only when he moved his neck, then none at all.
Preliminary CSF results showed no bacteria, and CSF and blood
cultures had grown no microorganisms at the time of discharge.
The patient's nausea and pain were well-managed with
prochlorperazine, acetaminophen, and ketorolac during his
admission.
## # FOLLOW-UP:
The patient was instructed to make a follow-up
appointment with his primary care doctor within the next
weeks. He is unsure whether or not he had the meningococcal
vaccine; he should make sure to have the vaccine prior to
starting college in the .
## DISCHARGE INSTRUCTIONS:
Mr. , you were admitted to the hospital because you had a
headache that gave you pressure over the back of your head.
Your pain was worsened by bright light and moving your neck. We
performed testing of your cerebrospinal fluid (CSF), which
showed an increased number of white blood cells that were mostly
neutrophils, which suggested an infection called meningitis.
The relatively normal pressure, glucose, and protein levels in
your CSF made us think that your infection was aseptic
meningitis. You were treated with intravenous antibiotics
because of the lesser possibility that you had bacterial
meningitis. Your headache improved greatly while you were in
the hospital, and you never had a fever while you were here. By
the time you were ready to go home, you were feeling good and
able to tolerate light exposure. You received 3 days of
antibiotics before you left the hospital. Preliminary CSF
results showed no bacteria, and we are waiting to get final CSF
and blood results, but we felt that you were safe to go home.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12599033", "visit_id": "28280542", "time": "2181-07-19 00:00:00"} |
16015533-DS-12 | 1,440 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
with cirrhosis from Hep C and EtOH (last drink one month
ago), ascites, esophageal varices, , presenting with abdominal
pain, jaundice, malaise.
Patient was recently admitted here to for alcholic
hepatitis and upper GI bleed and also to OSH for
pancreatitis. Discharge planning included continuing
methylprednisolone until .
Presented to OSH ED today for nausea, and weakness. Given
Zofran, dilaudid, 2L NS, Reglan IV. Vomited there 50cc bile-like
liquid. Symptoms improved. Transferred to for liver care.
OSH ED US
-Patent PV with hepatopetal flow. 3 main hepatic veins patent.
-Fatty liver
-Ascites
-Dx Tap- 22 WBC, 8% PMNs, gram stain negative
In the ED, initial vitals were 98.0 87 132/73 18 99% RA
- labs significant for: WBC 17 with 84% PMN, h/h 9.8/25.1, Na
128, lipase 98, Tbili 29.6, lactate 2.7
- CXR: no acute intrathoracic abnormality.
- hepatology consulted, recommended full infectious w/u and tox
screens, which were negative
- patient given dilaudid and zofran for symptoms
- vitals on transfer: 97.8 77 118/72 16 98% RA
Upon arrival to the floor patient has no acute complaints. is
entirely unclear of what medications takes. administers
them himself but does not know their names. is unable to say
for sure if has been taking his prednisone.
## ROS:
per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
## PAST MEDICAL HISTORY:
(taken from d/c summary)
ETOH cirrhosis with h/o portal HTN w/gastropathy, grade I
varices
Hepatitis C (patient is uncertain of this diagnosis, or how
got it)
Hepatic Encephalopathy
active ETOH use (h/o withdrawal seizures)
COPD or asthma per patient's report
## FAMILY HISTORY:
Aunt who died of cirrhosis but did not drink alcohol. Father who
passed from an MI at age .
## PHYSICAL EXAM:
>> Admission Physical Exam:
## GENERAL:
jaundiced male, sitting comfortably in bed
## HEENT:
NC/AT, no lymphadenopathy, poor dentition
## LUNGS:
CTAB, no wheezes, rales, or ronchi
## ABDOMEN:
distended with +fluid wave, slightly tense with diffuse
TTP but no rebound or guarding
## EXT:
no edema, DP pulses palpable bl
## NEURO:
AOx3, no asterixis, can backwards
.
>> Discharge Physical Exam:
## GENERAL:
jaundiced male, lying comfortably in bed
## HEENT:
NC/AT, no lymphadenopathy, poor dentition
## LUNGS:
CTAB, no wheezes, rales, or ronchi
## ABDOMEN:
distended with +fluid wave, periumbilical tenderness
## EXT:
no edema, DP pulses palpable bl
## NEURO:
AOx3, could not spell WORLD backward, no asterixis
## PERTINENT RESULTS:
>> Admission Labs:
09:10PM BLOOD WBC-17.0* RBC-2.60* Hgb-9.8* Hct-27.6*
MCV-106* MCH-37.5* MCHC-35.4* RDW-17.9* Plt Ct-40*
09:10PM BLOOD PTT-47.9*
09:10PM BLOOD Glucose-99 UreaN-19 Creat-0.7 Na-128*
K-4.9 Cl-92* HCO3-21* AnGap-20
09:10PM BLOOD ALT-130* AST-121* AlkPhos-112
TotBili-29.6*
11:10PM BLOOD Lactate-2.7*
06:13AM BLOOD Lactate-2.8*
.
>> Pertinent Reports:
(PORTABLE AP): Mid to lower portion of
the stomach. No change in the appearance of the heart
and lungs or evidence of acute cardiopulmonary disease.
.
(PA & LAT): No acute intrathoracic
abnormality.
.
ABDOMEN W/O CONTRAST:
1. Limited, incomplete examination due to patient inability to
breath holdand arm pain.
2. Evidence of portal hypertension including large volume
abdominal ascites,splenomegaly, and innumerable portosystemic
venous collaterals. Chronic liver disease is suspected, but not
well characterized on this examination.
3. Gallbladder wall thickening in the setting of portal
hypertension is
nonspecific. Common bile duct is minimally prominent without
identified
choledocholithiasis, accounting for limitations of this of
partial
examination.
.
CXR
## BRIEF HOSPITAL COURSE:
Mr. is a year old male, withprior history of cirrhosis
ETOH/Hepatitis C cirrhosis, ascites, grade I esophageal
varices, and hepatic encephalopathy, presenting after a recent
admission 1 month prior for alcohol hepatitis, presenting with
several day history of abdominal pain/nausea/hyponatremia,
concerning for acute dempensation.
.
>> ACTIVE ISSUES:
# Acute Decompensated Liver Failure: Upon admission, initial
infectious workup x 1 negative, and viral studies were negative.
AFP done in the setting of cirrhosis also negative. Patient's
LFTs were concerning for acute alcoholic hepatitis (given prior
history), however also notable for more cholestatic picture with
AST=ALT, compared with prior hospital stay with AST > ALT
classic alcoholic pattern. Therefore, concern for cholestatic
picture, patient underwent MRCP which did not reveal any signs
of pancreatitis (slight elev lipase), or chlangitis. Given
history and possible medication compliance concerns with
prednisone course, was restarted on prednisone. As below, with
evidence of falling hyponatremia, was given 2 doses of stress
hydrocortisone, however continued on prednsione 30 mg. His liver
function tests failed to improve with treatent, and patient
elected to shift focus of care to comfort measures. His
medications other than those providing comfort were stopped.
Tube feeds and steroids were stopped. Home Hospice services were
set up prior to discharge.
.
# Hyponatremia: Patient was found to be acutely hyponatremic
during hospital stay (lowest Na 119) without mental status
changes. Thought to volume shifts with intravascular
depletion. TSH and cortisol WNL, and therefore was given stress
dose steroids and albumin. Patient had abrupt improvement, and
diuresis was held.
.
# ETOH/Hepatitis C Cirrhosis: Upon admission, MELD of 31. No
prior history of SBP, and does have a history of hepatic
encephalopathy however was not encephalopathic with
decompensation. Grade I varices on last EGD, and found to have
guiac + stool. Patient was given lactulose TID, and rifaxamin,
and transfused intermittently. was continued on nadolol until
goals shifted to CMO.
## # ALCOHOL ABUSE:
Patient has claimed sobriety for the past 1
month, and this also voiced confirmation by his son. Patient was
continued on home thiamine and folate until goals shifted to
CMO.
.
# COPD: Continued on home albuterol and advair PRN.
.
#GERD: Continued on home omeprazole.
.
>> TRANSITIONAL ISSUES:
- Patient elected to shift focus of care to comfort measures.
His medications other than those providing comfort were stopped.
Tube feeds and steroids were stopped. Home Hospice services set
up prior to discharge.
- Code status: DNR/DNI
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 60 mg PO QAM
4. Lactulose 30 mL PO BID
5. Nadolol 40 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
9. Magnesium Oxide 400 mg PO DAILY
10. Omeprazole 40 mg PO BID
11. Sucralfate 1 gm PO QID
12. Thiamine 100 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Furosemide 40 mg PO QHS
## DISCHARGE MEDICATIONS:
1. Lactulose 30 mL PO BID
RX *lactulose 20 gram/30 mL 30 mL by mouth twice a day
## REFILLS:
*4
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
RX *albuterol sulfate 90 mcg 2 PUFF Q4H:PRN SOB Disp #*1 Inhaler
## REFILLS:
*3
3. Rifaximin 550 mg PO BID
4. Furosemide 40 mg PO QAM
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*3
5. Lorazepam 0.25 mg PO Q6H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
6. Ondansetron mg PO Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN abdominal pain
RX *oxycodone 5 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*0
8. TraZODone 50 mg PO QHS
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
## PRIMARY DIAGNOSIS:
1. Acute Liver Decompensation 2. Hyponatremia
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure taking care of you during your hospital stay
at . You were admitted after
feeling unwell at home, and were found to have severely elevated
liver tests indicating acute liver injury. While here, you
underwent imaging of your liver which did not show any stones or
obstructions in the liver or bile systems. We treated you with
steroids and nutritional supplementation. Since your liver
function tests did not improve much with treatment, you decided
to shift the focus of your care on comfort.
Please continue to take your home medications as prescribed.
Please follow up with your hospice providers if you have any
discomfort or needs after discharge.
We wish you the very best,
Your Team.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16015533", "visit_id": "23560430", "time": "2161-12-30 00:00:00"} |
14960860-DS-12 | 1,256 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Dyspnea following aspiration event
## HISTORY OF PRESENT ILLNESS:
female presenting to the emergency department after
an aspiration event that her nursing facility. The patient is a
DO NOT RESUSCITATE and DO NOT INTUBATE patient. She has history
of severe Alzheimer's dementia.
.
In the ED patient initially was quite dyspnic, however "she
coughed up a pickle in the ED and looks much better".
.
Per her daughter she was in her usual state of health which is
demented but ablke to eat and follow commands at an assisted
living facility. She was eating when she apparently
pickle. The PCAs there performed the heimlich manuver with some
improvement and brought her to the ED. Uncl;ear exactly when and
where the pickle made its exit but she did cough it up and
reportedly felt/appear better. She was given one dose of flagyl
int he ED to cover for asiration PNA and admitted tot he floor
for observation.
.
On arrival to the floor she is resting and arousable but not
oriented place or time. Responds to her name. This is her
baseline. She follows commands well.
.
.
Review of systems:
deferred due to mental status
## PAST MEDICAL HISTORY:
HTN
osteoporosis
depression
Alzheimer's Dementia (most recent MMS was
Hyperthyroidism
Daughter reports history of hiatal hernia
## FAMILY HISTORY:
NO relevant history. Reviewed with Daughter
## GENERAL:
Sleeping but arousable. NAD follows commands. AAOX1
Person
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Poor inspiratory effort with audible breathsounds with
some faint rhonchi.
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## GENERAL:
Eldely woman lying in bed comfortably in NAD. AAOX1
Person
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated
## LUNGS:
Markedly kyphotic but breathing comfortable. Poor
inspiratory effort, but otherwise clear with no wheezes, rales
or rhonchi
## CV:
Regular rate and rhythm, normal S1 + S2, II/VI systolic
cres-decresc murmur heard loudest at base and radiating to
carotids
## ABDOMEN:
soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## MICRO:
Blood Culture, Routine-PENDING INPATIENT
URINE CULTURE-PRELIMINARY INPATIENT
Blood Culture, Routine-PENDING INPATIENT
Blood Culture, Routine-PENDING EMERGENCY WARD
Blood Culture, Routine-PENDING
## IMPRESSION:
Large hiatal hernia or complete gastric herniation
into the
chest. Entities such as gastric volvulus cannot be excluded;
findings were discussed with at 18:30 on
by . A lateral veiw may be helpful in
assessing anterior-posterior positioning.
CXR:
In comparison with the preceding chest examination, at that time
existing
large hiatal hernia that resulted in a compression effect of the
pulmonary structures has been partially relieved. Noteworthy is
that the pulmonary vasculature has now attained a more normal,
non-congestive pattern. There still remains evidence of
eventration on the left base with a high-positioned diaphragm
under which gas-distended colonic loops are seen. Linear
density just above the diaphragm is suggestive of a partial
atelectasis. There is no evidence of other new acute pulmonary
infiltrates and the lateral pleural sinuses remain free from any
major fluid accumulation. Patient's drooping head obscures the
apical areas of both lungs, however, there is no conclusive
evidence for any significant pneumothorax. The lateral view
shows a markedly deformed chest configuration with severely
increased depth diameter related to markedly accentuated
kyphotic curvature in the thoracic spine. Degenerative changes
are seen, but no conclusive evidence for any vertebral body
compression fracture is identified. The lateral view also
discloses extensive aortic wall calcifications throughout the
thoracic aorta including also calcium deposits in the aortic
valve apparatus. Assessment of radiographic heart size is
difficult, but noteworthy is that at the present time, there is
no evidence of significant pulmonary venous congestion.
## BRIEF HOSPITAL COURSE:
YO F with h/o advanced Alzheimer's and known hiatal hernia
presenting after aspiration event and Heimlich maneuver with
hypoxemia and concern for gastric herniation on CXR.
## # LIKELY ASPIRATION PNEUMONITIS:
likely aspirated some food
material during choking event, leading to leukocytosis of 18,000
and mild hypoxia on admission. She was initially given Flagyl
in ED and levofloxacin on admission to cover empirically for
pneumonia, however repeat CXR and WBC in the AM were both
improved, more consistent with aspiration pneumonitis without
ongoing infection. Her hypoxia resolved within the first 24
hours and she continued to appear clinically stable on
discharge. She should be monitored at for any
signs of infection including, fever, cough, or shortness of
breath.
# Aspiration: per history, event sounded like isolated event
associated with choking on her food. No history of chronic
aspirations, has never had aspiration pneumonia before. Per
discussion with daughter, she was not evaluated by SLP, however
nursing and her daughter monitored her eating and did not
witness any trouble with swallowing. She does not need any diet
modifications or direct observation while eating.
# Gastric herniation/Hiatal Hernia: Previously had large hiatal
hernia, presented with likely complete gastric herniation into
chest. It would stand to reason that a sudden increase in
intraabdominal pressure from the Heimlich maneuver in an elderly
woman with known hiatal hernia could have caused this. She did
not show any evidence of incarceration or obstruction. She
complained of mild abdominal pain initially, however this later
resolved. Repeat CXR showed improvement in herniation. Per
discussion with family, the patient would not want any other
invasive procedures to further reduce this herniation. She
should be monitored for any signs of worsening abdominal pain or
reflux symptoms, which would likely be attributable to this
herniation and should be evaluated by the staff MD at rehab.
## # ALZHEIMER'S DEMENTIA:
Stable. Continued home regimen.
## - ASPIRATION PNEUMONITIS:
no evidence of pneumonia, but please
monitor for new or worsening cough, fevers, or shortness of
breath
- Gastric herniation: managing conservatively-- please monitor
for abdominal pain and speak with MD if she complains of
pain. If develops reflux symptoms, would benefit from PPI.
- Blood and urine cultures pending on discharge, will be
followed up and contacted if these are positive
- DNR/DNI this admission
## MEDICATIONS ON ADMISSION:
Preadmission medications listed are correct and complete.
Information was obtained from Nursing home.
1. Duloxetine 50 mg PO DAILY
2. Donepezil 10 mg PO HS
3. Methimazole 2.5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Senna 1 TAB PO BID:PRN constipation
6. Docusate Sodium 100 mg PO BID
## DISCHARGE MEDICATIONS:
1. Docusate Sodium 100 mg PO BID
2. Donepezil 10 mg PO HS
3. Duloxetine 50 mg PO DAILY
4. Methimazole 2.5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
## DISCHARGE DIAGNOSIS:
Primary diagnoses:
Aspiration pneumonitis
Gastric herniation
Secondary diagnoses:
Advanced alzheimer's dementia
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Ms ,
It was a pleasure taking care of you at .
You were admitted to the hospital after you were found to be
choking on food at your living facility. You may have had some
food go down the wrong tube at that time, but this did not cause
any infection or pneumonia in your lungs. Your stomach also
pushed up into your chest from the heimlich maneuver you got,
causing some breathing discomfort, but this has since improved.
We feel you are safe to go back to .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14960860", "visit_id": "21475172", "time": "2175-05-28 00:00:00"} |
17361720-RR-98 | 131 | ## EXAMINATION:
CHEST (PA AND LAT)
## INDICATION:
year old woman with right costal margin pain and constipation
// R/o lung lesion or effusion
## FINDINGS:
PA and lateral views of the chest provided.
Moderate pulmonary interstitial edema and vascular congestion is unchanged
from chest radiograph . More confluent opacities overlying
the right middle lobe and left lower lobe are improved from
and may represent resolving pneumonia. Small bilateral pleural effusions are
unchanged in size. There is no focal consolidation or pneumothorax. There is
no free air below the bilateral hemidiaphragms.
## IMPRESSION:
1. Small bilateral pleural effusions are unchanged as compared to chest
radiograph .
2. Moderate pulmonary interstitial edema and vascular congestion are
unchanged.
3. Confluent opacities overlying the right middle and left lower lobes are
improved from and may represent resolving pneumonia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17361720", "visit_id": "N/A", "time": "2136-06-18 13:40:00"} |
14197637-RR-26 | 163 | ## EXAMINATION:
LEFT DIGITAL DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD
## INDICATION:
Status post biopsy of left breast calcifications in revealing radial scar and papilloma with no atypia. Patient opted for
mammographic observation rather than surgical excision.
## TISSUE DENSITY:
C- The breast tissues are heterogeneously dense which lowers
the sensitivity of mammography. A biopsy clip is seen in the upper central
posterior left breast with no definite residual microcalcifications in this
area. However, there are other scattered punctate calcifications in the
breast tissue. No suspicious mass or area of architectural distortion is
appreciated.
## IMPRESSION:
Status post benign percutaneous core biopsy of the left breast with no
definite residual calcifications at the biopsy site. Dense breast tissues.
No specific mammographic evidence of malignancy in the left breast. Continued
followup imaging in six months seems reasonable at this time given that the
patient did not undergo surgical excision.
## RECOMMENDATION:
Bilateral diagnostic mammography in six months.
## NOTIFICATION:
Findings discussed with the patient at the time of imaging.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14197637", "visit_id": "N/A", "time": "2182-05-18 11:11:00"} |
14257519-RR-24 | 660 | ## CT CHEST:
The thyroid gland is unremarkable in appearance. The trachea is
midline and the airways are patent to the subsegmental level. Multiple
pulmonary metastatic lesions have increased in size. The dominant lesion in
the right upper lobe best visualized on image 2:14 today measures 5.2 x 5.3 cm
which previously measured 4.1 x 4.3 cm. Additional lesions have formed
superior to this main lesion which appears to be contiguous with this main
lesion inferiorly. There best visualized on image 2:10. The more medial
lesion measures 2.8 x 1.7 cm and the more lateral lesion measures
approximately 2.7 x 2.4 cm. Another rounded nodule on the same image today
measures 1 cm where it previously measured 7 mm. Another nodule in the right
middle lobe on image 2:32 measures 1 cm up from 7 mm on the prior exam 2
nodules are seen in the right lower lobe on image 2:39. The paraesophageal
region today measures 2.2 x 2.1 cm up from 2.0 x 1.9 cm and the more lateral
lesion measures 2.0 x 1.4 cm, up from 1.5 x 1.4 cm. A left lower lobe nodule
on image 2:46 measures 9 mm from 7 mm. Ground-glass opacity in the left upper
lobe on image 2:19 today measures 9 mm and is stable.
The heart and pericardium are unremarkable except for an aortic valve
replacement is seen in place. The ascending aorta is ectatic measuring 4.3 cm
in diameter. There is no axillary or supraclavicular lymphadenopathy by CT
size criteria. A 2.5 x 1.3 cm pretracheal lymph node on image 2:17 has
intervally increased in size from 1.8 x 0.9 cm. There is scattered associated
mediastinal lymphadenopathy where all nodes measure slightly larger than on
previous exam.
## CT ABDOMEN:
Multiple subcentimeter hepatic hypodensities are unchanged from prior exam and
too small to fully characterize by CT. The gallbladder is unremarkable
without wall thickening or pericholecystic fluid. There is no intra or
extrahepatic biliary duct dilatation. The portal vein is patent of the
spleen, pancreas and adrenal glands are unremarkable in appearance. There are
2 small splenules seen anterior to the spleen. A small fat containing lesion
in the left lower pole of the kidney is unchanged and likely represents an
AML. The right kidney is surgically absent. The left kidney otherwise
enhances homogeneously.
The stomach, duodenum, small and large bowel are unremarkable in appearance
without focal wall thickening or evidence of obstruction.
The abdominal aorta is of normal caliber with patent celiac axis, SMA,
bilateral renal arteries and . There are no enlarged retroperitoneal or
mesenteric lymph nodes by CT size criteria. There is no ascites,
pneumoperitoneum or hernia is noted.
## CT PELVIS:
There are bilateral lower quadrant soft tissue density lesions
some of which contain air and some of which are new compared to prior exam
which likely represent injection granulomas. The bladder, seminal vesicles,
prostate and rectum are unremarkable in appearance. There is no pelvic free
fluid or air. There are no enlarged inguinal or pelvic wall lymph nodes by CT
size criteria.
## OSSEOUS STRUCTURES:
There multi level degenerative changes of the
thoracolumbar spine most severe at L4-L5 and L5-S1 median sternotomy wires are
observed. There are no focal blastic or lytic lesions in the visualized
osseous structures worrisome for malignancy.
## IMPRESSION:
1. Interval increase in metastatic disease burden with increase in size of all
of pulmonary lesions and mediastinal lymphadenopathy.
2. Multiple indeterminate hepatic hypodensities which are not changed from
prior exam.
3. Fat containing lesion in the left lower pole of the kidney which is stable
likely representing a small angiomyolipoma.
4. Soft tissue densities in the right lower quadrant subcutaneous tissue some
of which contain air and likely represent injection granulomas. Clinical
correlation is advised.
5. Ectatic ascending aorta 4.3cm in diameter.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14257519", "visit_id": "N/A", "time": "2179-08-19 12:12:00"} |
15038366-RR-31 | 136 | ## HISTORY:
morbidly obese male with midline lumbar tenderness s/p MVC
## FINDINGS:
Evaluation is markedly limited due to large body habitus. There are 5
non-rib-bearing lumbar type vertebral bodies. There is no compression
fracture or malalignment. Disk spaces appear preserved with a vacuum disc
phenomenon is noted at L5-S1 suggesting early degenerative disease. Included
portions of the abdomen and pelvis are unremarkable. On series 700 the image
47. There is a subtle lucency involving the right transverse process of L2
which may represent acute fracture in the correct clinical setting. Please
note this abnormality cannot be confirmed on the corresponding axial and
sagittal reformations.
## IMPRESSION:
Possible acute fracture involving the right transverse process of L2.
Otherwise unremarkable though exam markedly limited.
Updated findings were discussed with Dr. at 14:45 on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15038366", "visit_id": "N/A", "time": "2151-04-17 12:39:00"} |
10845188-RR-20 | 363 | ## INDICATION:
Palpable lump felt by the patient, two adjacent masses in the
left breast o'clock and a subtle thickening of the cortex of the left
axillary lymph node. Patient here for ultrasound-guided core biopsy of these
masses and FNA of the axillary lymph node.
ULTRASOUND GUIDED CORE BIOPSY OF TWO MASSES - LEFT BREAST AND FNA OF LEFT
## AXILLARY LYMPH NODE:
After a preprocedure timeout with two patient identifiers and the procedure
identified, a written, informed consent was obtained. The risks and benefits
of the procedure were explained to the patient.
Using standard aseptic technique and 1% lidocaine for local anesthesia,
initially the mass in the left breast at o'clock, 2 cm from the nipple was
targeted. A 13-gauge coaxial needle was placed at the margin of the lesion.
Five cores were obtained with a Bard biopsy device.
## PERCUTANEOUS CLIP PLACEMENT:
A ribbon clip was placed within the mass under
ultrasound guidance.
Subsequently, again using standard aseptic technique and 1% lidocaine for
local anesthesia, a 13-gauge coaxial needle was placed at the margin of the
lesion in the left breast at 7 o'clock, 4 cm from the nipple. Three cores
were obtained with a Bard biopsy device.
## PERCUTANEOUS CLIP PLACEMENT:
A S-shaped clip was placed within this mass
under ultrasound guidance.
FNA OF LEFT AXILLARY LYMPH NODE
Next, attention was diverted towards the left axillary lymph node, which
showed a subtle increased cortical thickness. Fine needle aspiration was
performed with 22- and 25-gauge needles. The aspirate was sent to cytology.
The patient tolerated the procedure well. There were no immediate
post-procedure complications. The patient was sent home with written and
verbal post-procedure instructions after obtaining a two-view mammogram.
GE DIGITAL LEFT DIAGNOSTIC MAMMOGRAM.
The ribbon clip is seen in the anterior mass in the left medial central breast
and the S-shaped clip is seen in the posterior mass in the left medial central
breast.
## IMPRESSION:
Technically successful ultrasound-guided core biopsy of two
masses with clip placement and fine needle aspiration of the left axillary
enlarged lymph node. Pathology is pending. The patient will follow up with
Dr. for results.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10845188", "visit_id": "N/A", "time": "2176-04-13 16:20:00"} |
13990363-RR-48 | 97 | ## EXAMINATION:
BILATERAL DIGITAL DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD
## INDICATION:
History of left breast cancer.
## TISSUE DENSITY:
There are scattered areas of fibroglandular density.
A focal area of architectural distortion in the left upper outer breast is
consistent with previous surgery this is marked with an overlying scar marker.
Surgical clips are noted in the lumpectomy bed. A focal asymmetry in the right
upper deep posterior breast remain stable dating back to . No significant
interval change.
## IMPRESSION:
No evidence of malignancy. Stable postoperative changes.
## NOTIFICATION:
Findings reviewed with the patient at the completion of the
study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13990363", "visit_id": "N/A", "time": "2147-05-31 12:43:00"} |
12444183-DS-5 | 1,103 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Ms. is a pt with hx of gastric carcinoma currently
undergoing chemotherapy presents with a 10 day history of
progressively woresning cough and shortness of breath. Pt
reports initial dyspnea with exertion that progressed to SOB at
rest with cough productive of white sputum. She also reports a 3
day hx of generalized weakness, fevers and chills, diaphoresis,
chest, neck and pack pain and pain with deep inspiration.
denies HAs, sore throat, difficulty swallowing, N/V/D or
constipation, abdominal or extremity pain or rashes. She
endorses a good appetite.
ED course significant for:
-Initial vitals: 96.8 83 99% RA
-Labs: 7.9 > 12.2/39.5 < 178, hypoNa 132, K 4.1, ,
## WNL UA:
WNL
-CXR: Diffuse increased interstitial markings bilaterally with
small bilateral pleural effusions are concerning for mild
interstitial pulmonary edema.
-CTA Chest: No PE/aortic dissecton, bilateral pleural and small
pericardial effusions, interlobular septal thickening c/f
pulmonary edema, vertebral and sternal sclerotic lesions c/f
metastases, ascites in upper abdomen
-ED Resident discussed with oncologist Dr. :
transfer, recommended to stay at to avoid ED-ED transfer
cost. Oncologist also noted that pt has diffuse chest wall
metastases with possible lymphatic spread that may be causing
symptoms.
-The pt received her fentanyl patch, PPI, and naprosyn and was
transferred to the floor.
Upon arrival to the floor, pt endorses that she is feeling a
little bit better. She c/o diffuse back pain assoc. with known
metastases that is at baseline.
## -MOTHER:
breast cancer
-father: prostate cancer
## GENERAL:
Alert, oriented, no acute distress, pleasant
## HEENT:
Sclera anicteric, EOMI, NC/AT
## NECK:
Supple, right supraclavicular LAD
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## LUNGS:
diffuse crackles b/l, fair air movement, decreased breath
sounds
## ABDOMEN:
Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## PSYCH:
appropriate mood and affect
## GENERAL:
AOx3, NAD, able to speak in complete sentences
## LYMPH:
Right supraclavicular node (approximately 1.5 -2.0 cm),
left anterior cervical chain node (approximately 0.5 cm)
## CV:
RRR, no murmurs or rubs or gallops
## LUNGS:
CTAB, no wheezes or crackles
## ABDOMEN:
Soft, non-tender to palpation. BSx4
## EXT:
Non-edematous, no cyanosis or clubbing
## NEURO:
CN grossly intact. Moves all extremities
## SKIN:
No rashes or lesions
## MICROBIOLOGY:
URINE CULTURE (Final :
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood cx (-) x 2
## IMPRESSION:
1. No pulmonary embolism or evidence of acute aortic syndrome.
2. Moderate bilateral pleural effusions and small pericardial
effusion without
evidence for cardiac tamponade.
3. Smooth interlobular septal thickening, most pronounced at the
lung apices, considered more likely pulmonary edema.
4. Sclerotic lesions of multiple vertebral bodies and sternum
compatible with
metastatic disease. No evidence pathologic fracture.
5. Ascites within the imaged upper abdomen.
## TTE:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal diastolic
septal motion/position consistent with right ventricular volume
overload. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate severe pulmonary artery
systolic hypertension. There is a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
## IMPRESSION:
Right ventricular cavity dilation with free wall
hypokinesis. Moderate tricuspid regurgitation with signs of
right ventricular volume overload. Moderate to severe pulmonary
hypertension.
## ECG:
sinus rhythm, ventricular rate 86 bpm, normal axis, TWI
III, AVF, V3, V4.
## #DYSPNEA:
Most likely related to her known gastric cancer with
metastases and lymphangetic spread. Pulmonary edema seen on
chest CT, (is currently being treated with VEGF Ab which may
cause pulmonary edema, usually non-sx) with bilateral pleural
effusions (unchanged from prior CT) and new pericardial
effusion. No PE or consolidation concerning for PNA seen on CT
Chest. TTE w/ RV fluid overload, small pericardial effusion, and
severe pulm HTN. EKG w/ new T-wave inversions, low voltage QRS.
VSS throughout admission, with O2 sats of 93-95% on RA, however
desaturation to 88% with ambulation. Treated with IV lasix 20 mg
x 1 with mild improvement in reported dyspnea. Discharged home
with O2 and benzonate for sx relief.
# Gastric Cancer
Pt followed at oncologist ) who is
aware of her admission and treatment throughout admission.
Currently being treated w/ VEGF Ab, no chemotherapy. Appointment
with oncologist on day of discharge ( ). -cont. fentanyl
patch. Continued home home naprosyn, PPI.
# TWI on EKG
Pt has diffuse TWI on EKG, no complaints of chest pain, no prior
EKG to compare. Troponin < 0.01
## TRANSITIONAL ISSUES:
- Pt discharged with benzonate for symptomatic relief, no hoome
medication changes. consider initiation of lasix for
improvement of dyspnea.
- Pt discharged with home O2 given ambulatory desaturations.
- Severe pulmonary hypertension noted on TTE, would recommend
further appropriate work-up and management
## # CODE STATUS:
FC (confirmed)
# CONTACT: Daughter
on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 250 mg PO Q12H
2. Fentanyl Patch 100 mcg/h TD Q72H
3. Omeprazole 20 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
5. zoledronic acid 4 mg injection QMONTHLY
## DISCHARGE MEDICATIONS:
1. Fentanyl Patch 100 mcg/h TD Q72H
2. Naproxen 250 mg PO Q12H
3. Omeprazole 20 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
5. zoledronic acid 4 mg injection QMONTHLY
6. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID:prn Disp #*90
## CAPSULE REFILLS:
*0
7. Home O2
Please provide patient with home O2 tank and supplies for
ambulatory O2 sat of 88%. ICD-9: 799.02
## PRIMARY DIAGNOSIS:
1. Gastric cancer
2. Pulmonary edema
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure taking care of you at . You were admitted
for increasing shortness of breath and cough. A full workup was
completed and fortunately your results were not significantly
changed from prior reports. You were treated with lasix
(furosemide) to improve your breathing. You remained clinically
stable so we felt comfortable discharging you home with oxygen
available if needed.
Thank you for allowing us to care for you,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12444183", "visit_id": "27979520", "time": "2184-03-27 00:00:00"} |
13190496-RR-18 | 102 | ## INDICATION:
year old woman with right MCA stroke. // Evaluate for safe
swallow
## DOSE:
Fluoro time: 2:20 min.
## FINDINGS:
Examination was somewhat limited given suboptimal patient positioning due to
patient's inability to follow instructions. Barium, administered via syringe,
passes freely through the oropharynx. There is evidence of penetration and
aspiration of thin liquids as well as at least penetration of nectar thick
liquids with possible aspiration.
## IMPRESSION:
Penetration and aspiration of thin liquids and penetration of nectar thick
liquids with possible aspiration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13190496", "visit_id": "29844431", "time": "2151-12-18 13:11:00"} |
12831424-RR-148 | 92 | ## INDICATION:
with reduced O2 sat. Previous study with poor effort //
characterization for consolidation. Emphasize respiratory effort
## FINDINGS:
Apparent increased opacity at the lateral aspect of the left lung base is less
apparent on the current exam and is likely due to overlying soft tissues in
combination with prominent pericardial fat which obscures the left
costophrenic angle. The appearance has not dramatically changed since prior
portable film from . Old thoracolumbar compression deformities again seen
as well as a hiatal hernia.
## IMPRESSION:
No acute cardiopulmonary process, no focal consolidation worrisome for
infection.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12831424", "visit_id": "20581164", "time": "2197-07-25 16:53:00"} |
12851703-RR-64 | 228 | LUMBAR SPINE MRI WITH AND WITHOUT CONTRAST,
## INDICATION:
woman with history of surgeries for scoliosis in
and , who now presents with severe left sciatica and lower back pain.
## FINDINGS:
The L1 vertebral body demonstrates transitional anatomy, with a
small right-sided rib and a left-sided transverse process. There is a small
rudimentary disc separating S1 from S2. Coronal images demonstrate a severe
rotatory levoscoliosis at L1-2, as seen on prior studies. This slightly
limits evaluation of the spine on sagittal and axial images. Posterior
element fusion is again noted from the imaged lower thoracic spine through L4.
Vertebral body height appears preserved. There is no anteroposterior or
lateral subluxation. The distal spinal cord appears unremarkable, with the
conus medullaris terminating at L1. No intrathecal abnormalities are
detected. No pathologic contrast enhancement is seen.
Intervertebral discs maintain normal signal intensity. No disc bulges or disc
herniations are seen. There is no narrowing of the spinal canal or neural
foramina.
There are two small cysts in the imaged portion of the right kidney, measuring
up to 6 mm.
## IMPRESSION:
1. Mild transitional anatomy at L1 and at S1-2, as detailed above. Severe
rotatory scoliosis convex to the left at L1-2. Posterior element fusion from
the imaged lower thoracic spine through L4.
2. No evidence of spinal canal narrowing, neural foraminal narrowing, or
nerve root impingement.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12851703", "visit_id": "N/A", "time": "2165-03-11 14:01:00"} |
15259074-RR-54 | 103 | ## INDICATION:
year old man with acute resp failure // Interval changes
Interval changes
## IMPRESSION:
Compared to chest radiographs through .
New leftward mediastinal shift suggests that much of the increase in
opacification of the left lung is due to severe worsening left lower lobe
atelectasis. Large heart is partially obscured, probably unchanged.
Bilateral pleural effusions are likely moderate on the left small on the
right. No pneumothorax.
Nasogastric drainage tube ends above the diaphragm and would need to be
advanced 15 cm to move all side ports into the stomach. ET tube, left PIC
line, left jugular line are in standard placements respectively.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15259074", "visit_id": "28289161", "time": "2133-05-27 05:06:00"} |
17196429-RR-15 | 194 | ## INDICATION:
RHD w/ h/o bilateral comminuted distal radius fractures (left
side open through volar poke hole) ( ) with right scaphoid fracture
after a fall down 20 steps while carrying a friend's dresser, s/p ORIF of
distal radius fractures and ORIF R scaphoid, fall also c/b mandibular
fracture, left 2nd rib fracture and chin laceration, who now presents with
chronic left wrist pain since the fall. He feels that his right wrist is
healing well, but that his left has "never healed well". He notes swelling at
the volar aspect of the left wrist adjacent to the surgical incisions. Pain is
controlled with motrin at
## FINDINGS:
Since prior plain films, there has been ORIF of the distal right radial
fracture with a volar plate and transfixing screws. No definite evidence of
hardware related complication. Screws at the distal aspect of the right
radius are seen the region of previously seen extensively comminuted and
impacted fracture fragments. Screws obscure visualization of the distal
radius and the radiocarpal joint space. Additional screw seen transfixing
prior right scaphoid fracture. Relative osteopenia seen particularly at the
distal aspect of the scaphoid. No new fractures.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17196429", "visit_id": "N/A", "time": "2135-01-07 19:53:00"} |
14998908-RR-26 | 118 | ## TYPE OF EXAMINATION:
Chest PA and lateral.
## INDICATION:
A female patient with long smoking history, complains
of persistent cough. Evaluate for infiltrates.
## FINDINGS:
The heart size is within normal limits. No typical configurational
abnormality is identified. Thoracic aorta and mediastinal structures are
unremarkable. The pulmonary vasculature is normal. No signs of acute or
chronic parenchymal infiltrates are present, and the lateral and posterior
pleural sinuses remain free. Skeletal structures of the thorax are grossly
within normal limits. Available for comparison is a next preceding chest
examination dated . No significant interval changes can be
identified over these seven and a half years.
## IMPRESSION:
No evidence of acute infiltrates or CHF in female patient with
history of smoking.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14998908", "visit_id": "N/A", "time": "2186-12-21 12:08:00"} |
16381067-RR-23 | 187 | ## INDICATION:
scoliosis and failure of fixation // s/p post fusion T10-S1
assess for stability
## FINDINGS:
6 AP and lateral views of the thoracic and lumbar spine were obtained. The
patient is status post fusion of T10 through S1. Facet screws and
longitudinal rods are intact without evidence of hardware fracture or
periprosthetic lucency. The uppermost screws extend beyond the superior
endplate of T10. This finding is similar in appearance to ;
progressive change is more apparent when compared to the when
these pedicle screws were completely within the vertebral body. In parallel,
there has been increase anterolisthesis and kyphosis of T9 over T10, also
similar in the short interval since but markedly worsened when
compared with .
Limited views of the lungs are clear. There is no focal consolidation,
effusion, pneumothorax. Limited views of the abdomen show cholecystectomy
clips. Limited views of the pelvis show an intact right partial hip
arthroplasty.
## IMPRESSION:
1. T9 over T10 anterolisthesis and kyphosis, similar to ,
progressive since .
2. T10-S1 posterior fusion hardware without evidence of hardware fracture.
The T10 pedicle screws continue to extend beyond the T10 superior endplate.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16381067", "visit_id": "N/A", "time": "2132-11-06 13:15:00"} |
16341313-RR-10 | 140 | ## EXAMINATION:
CT C-SPINE W/O CONTRAST
## INDICATION:
Head injury with altered mental status.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.5 s, 21.3 cm; CTDIvol = 37.2 mGy (Body) DLP = 792.9
mGy-cm.
Total DLP (Body) = 793 mGy-cm.
## FINDINGS:
Alignment is normal. No acute fractures are identified.There is no
significant canal or foraminal narrowing.There is no prevertebral edema.
There are mild multilevel degenerative changes with small anterior and
posterior osteophytes. Small fragments are seen anterior to the C6 and C7
vertebral bodies, which likely represent fragmented osteophytes, particularly
given adjacent to vacuum disc phenomenon at the C6-C7 level.
The thyroid and included lung apices are unremarkable. Endotracheal tube and
upper enteric tube are partially imaged. There is no cervical lymphadenopathy
by size criteria
## IMPRESSION:
No acute cervical spine fracture or malalignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16341313", "visit_id": "22692299", "time": "2151-07-23 00:59:00"} |
19774255-RR-35 | 479 | ## EXAMINATION:
CT abdomen pelvis without contrast
## INDICATION:
year old man with left distal ureteral stone// please assess
for left hydronephrosis and left distal ureteral stone
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 7.2 s, 46.9 cm; CTDIvol = 3.2 mGy (Body) DLP = 147.3
mGy-cm.
Total DLP (Body) = 147 mGy-cm.
## LOWER CHEST:
Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
## HEPATOBILIARY:
The hepatic parenchyma is heterogeneously hypoattenuating,
consistent with hepatic steatosis. There is no evidence of overt mass within
the limitations of an unenhanced scan. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. There is trace layering sludge and/or
small stones in the gallbladder, without gallbladder wall thickening or
evidence of inflammation.
## PANCREAS:
The pancreas is normal in bulk and homogeneous in attenuation.
There is no main 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. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. Previously seen left hydroureteronephrosis on CT from has resolved. There is no nephrolithiasis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The patient is status post
right hemicolectomy. Mild descending and sigmoid sigmoid colonic
diverticulosis, without evidence of acute diverticulitis.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. The
previously seen left UVJ stone on CT from is no longer
visualized. There is no free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate contains central gland calcifications and 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. Mild atherosclerotic disease
is noted.
## BONES:
Multilevel degenerative changes visualized throughout the imaged
portion of the thoracolumbar spine without findings of worrisome osseous
lesions or acute fracture. There is minimal retrolisthesis of L1 on L2 and L2
on L3.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Interval resolution of previously seen left hydronephrosis. No renal or
ureteral calculi.
2. Trace layering sludge and/or small stones in the gallbladder.
3. Colonic diverticulosis without findings of acute diverticulitis.
4. Hepatic steatosis.
## RECOMMENDATION(S):
Radiological evidence of fatty liver does not exclude
cirrhosis or significant liver fibrosis which could be further evaluated by
. This can be requested via the (FibroScan) or the
Radiology Department with either MR or US , in
conjunction with a GI/Hepatology consultation" *
* et al. The diagnosis and management of nonalcoholic fatty liver
disease: Practice guidance from the Association for the Study of
Liver Diseases. Hepatology 67(1):328-357
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19774255", "visit_id": "N/A", "time": "2132-01-30 15:25:00"} |
19845382-RR-15 | 154 | ## INDICATION:
man with abdominal pain.
## FINDINGS:
The liver is diffusely markedly echogenic. No focal lesion is
identified, however, diffuse echogenicity of the liver limits sensitivity for
detection of small lesions. Gallbladder is nondistended. There is no
cholelithiasis or evidence for acute cholecystitis. The main portal vein is
patent with normal hepatopetal flow. The common duct is not dilated measuring
5 mm in the porta hepatis.
The right kidney measures 13.7 cm and the left kidney measures 13.7 cm. There
is no hydronephrosis, mass or calculus in either kidney.
The spleen is not enlarged, measuring 10.6 cm.
The midline structures are not well evaluated due to body habitus and
overlying bowel gas.
There is no abdominal ascites.
## IMPRESSION:
Echogenic liver, consistent with fatty deposition. Other forms of liver
disease and more advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on the basis of this study. No
cholelithiasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19845382", "visit_id": "N/A", "time": "2130-03-09 11:44:00"} |
19437332-RR-97 | 458 | ## HISTORY:
History of right partial nephrectomy for cancer and left renal
tumor. ?Recurrence or growth.
## FINDINGS:
The lesion within the interpolar region of the left kidney has increased in
size since the previous study and now measures 2.3 (CC) x 1.8 (transverse) x
1.9 (AP) cm (previously 1.5 x 1.5 x 1.2 cm). This has a thick wall which is
T2 hypointense (4:13) and is partially T1 hyperintense (12:35). The lesion
also contains areas of T2 hyperintensity within it. Post-contrast, the lesion
demonstrates heterogenous enhancement with marked enhancement of the wall
(21:34). There are also multiple subcentimeter T1 hyperintense cystic lesions
within the left kidney which do not enhance post-contrast, are unchanged since
previous and are consistent with hemorrhagic cysts (11:9, 14, 26 and 31).
There is a single left renal artery which is patent. The left renal vein is
patent.
The patient is status post right partial nephrectomy. There are subcentimeter
cysts at the resection margin in the middle of the right kidney which do not
enhance post-contrast and are unchanged since previous (4:13 and 14). The
residual right kidney measures 5.8 cm in length. No evidence of disease
recurrence within the right kidney or renal bed. There is a single right
renal artery which is patent.
There is a 0.9 cm cystic lesion within the neck of the pancreas (9:20) which
appears similar in size and signal characteristics to previous. No side
branch connection to the main pancreatic duct is identified. The pancreas is
otherwise unremarkable. Normal caliber pancreatic duct.
There are multiple T2 hyperintense cystic lesions within the liver which do
not enhance post-contrast with the largest measuring 0.8 cm in segment VI
(9:15) - these are consistent with biliary hamartomas. The liver is otherwise
unremarkable. The portal vein is patent. No intra or extrahepatic duct
dilatation. The gallbladder is normal. The adrenals and spleen are within
normal limits. Note is made of colonic diverticulosis, most marked in the
descending colon. The visualized small and large bowel is otherwise
unremarkable. No retroperitoneal or mesenteric adenopathy. Bone marrow
signal is normal. No destructive osseous lesions.
## IMPRESSION:
1. Increased size of lesion within the interpolar region of the left kidney,
now measuring 2.3 x 1.8 x 1.9 cm. The signal characteristics and enhancement
are more in keeping with a papillary-subtype renal cell carcinoma rather than
a clear-cell subtype.
2. No evidence of disease recurrence within the right kidney.
3. 0.9 cm cystic lesion within the neck of the pancreas which is unchanged
since the previous MRI and most likely represents a side-branch IPMN.
Follow-up in years is recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19437332", "visit_id": "N/A", "time": "2185-04-03 12:23:00"} |
14780808-RR-57 | 174 | ## INDICATION:
F with metastatic colon cancer s/p T10/11 D F with abdominal
distention, would like to give methylnaltrexone if no concern for perf viscus.
// e/o obstruction or perforation
## FINDINGS:
There is diffuse gaseous distension of the colon.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for an expansile sclerotic lesion in the
posterior eleventh rib measuring 6.5 x 4.2 cm, which is grossly unchanged
compared to CT from . There is a minimally displaced, unhealed
fracture just distal to the mass in the eleventh rib. The patient is status
post extensive thoracolumbar fusion. Anastomotic sutures are noted in the mid
pelvis.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
## IMPRESSION:
1. Diffuse gaseous distention of the colon is nonspecific, and does not appear
obstructive. There is no gross pneumoperitoneum.
2. Expansile sclerotic lesion in the right posterior eleventh rib is
unchanged.
3. Slightly displaced, unhealed right eleventh posterior rib fracture was
present dating back to at least .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14780808", "visit_id": "24842487", "time": "2164-12-21 11:02:00"} |
13669726-RR-100 | 194 | BILATERAL LOWER EXTREMITY DUPLEX ULTRASOUND
## INDICATION:
male with esophageal cancer and multiple pulmonary
emboli found years prior from an infected PICC. Three days of shaking
chills and shortness of breath. Evaluate for deep venous thrombosis in both
lower extremities.
## FINDINGS:
No evidence of acute deep venous thrombosis in the right and left lower
extremities.
Normal wall-to-wall flow and preserved waveform in the left common femoral
vein. There are symmetric waveforms and preserved cardiorespiratory variation
in the right common femoral veins with wall-to-wall flow.
## LEFT:
The left common femoral vein, superficial femoral vein, and popliteal
veins are normally compressible, with expected waveforms and response to
augmentation. The left superficial femoral vein appears to branch in the
deeper larger vein branch and appears to communicate with the popliteal vein
distally. Partially included calf veins are normally compressible.
## RIGHT:
The right common femoral vein, superficial femoral vein, and popliteal
veins are normally compressible, with preserved waveforms and
cardiorespiratory variation. Response to augmentation is maintained.
Partially included calf veins are normally compressible.
## IMPRESSION:
No evidence of acute deep venous thrombosis in the evaluated both
lower extremities. Partially included calf veins appear normally
compressible.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13669726", "visit_id": "29469650", "time": "2172-05-20 08:53:00"} |
16387058-RR-29 | 318 | ## CLINICAL HISTORY:
Cirrhosis, low-grade fevers. Concern for infection,
lymphadenopathy, HCC.
## STUDY:
CT abdomen without and with contrast.
## FINDINGS:
Calcified granuloma seen in the right lower lobe along the diaphragm. There
is minimal atelectasis. Heart size is within normal limits. No effusions.
CT ABDOMEN WITHOUT AND WITH CONTRAST:
The liver is within normal limits in size. There is no nodular contour to the
liver or overt features of cirrhosis. The liver does have diffuse low
attenuation, consistent with fatty deposition. No focal liver lesions are
evident. Portal vein is patent. Hepatic veins are normal in appearance. No
recanalized umbilical vein. No intrahepatic bile duct dilation. The common
bile duct is mildly dilated to 9 mm, unchanged from the MRI in .
Distal CBD tapers slightly down to the papilla where there is a periampullary
duodenal diverticulum, as before. Numerous gallstones are seen within the
gallbladder, but the gallbladder wall is normal in thickness and appearance
without concern for acute cholecystitis. There is fundal adenomyomatosis of
the gallbladder, as before.
The pancreas is normal in appearance with a normal pancreatic duct. Spleen is
normal in size and appearance. Adrenal glands are normal in appearance. Tiny
hypodensity in the right kidney consistent with a cyst is seen on MRI. No
concerning renal lesions. No hydronephrosis. No renal calculi. The major
arteries of the abdomen are widely patent with mild atherosclerotic disease.
The major veins are also widely patent and normal in appearance. No
concerning bowel findings. No adenopathy. No ascites.
## BONE WINDOWS:
No suspicious lytic or sclerotic bone findings.
## IMPRESSION:
1. No cause for fevers. No evidence of infection, lymphadenopathy, or other
concerning finding.
2. No overt features of cirrhosis. Diffuse fatty deposition within the
liver.
3. Cholelithiasis without evidence of cholecystitis. Mild dilation of the
common bile duct, unchanged from . This could be secondary to
sphincter dysfunction or papillary stenosis, though a periampullary duodenal
diverticulum is also noted.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16387058", "visit_id": "20578149", "time": "2168-03-21 07:33:00"} |
17126341-RR-12 | 103 | ## INDICATION:
Fall. Evaluate for fracture.
## FINDINGS:
There is no fracture or malalignment of the cervical spine. The facet joints
are normally aligned. Assessment for prevertebral soft tissue swelling is
limited by the presence of an endotracheal tube. There are mild degenerative
changes of the cervical spine.
Dense calcifications are within the carotid siphons. The included portion of
the thyroid and soft tissues of the neck are unremarkable. The included lung
apices are clear. Intracranial findings, including hemorrhage and
pneumocephalus, are reported separately.
## IMPRESSION:
1. No acute fracture of the cervical spine.
2. Intracranial findings, including hemorrhage and pneumocephalus, are
reported separately.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17126341", "visit_id": "27898346", "time": "2126-08-20 13:13:00"} |
17882272-DS-24 | 796 | ## CHIEF COMPLAINT:
lower abdominal rash and pain
## HISTORY OF PRESENT ILLNESS:
with recent prolonged hospitalization starting with a
perf'd duo ulcer in . She developed a right flank
abscess that required frequent debridement and vac dressing
changes. She was discharged in .
She returns today with increasing pain in her supra-pubic and
RLQ. Her baseline pain is usually but now is . She
has
also been throwing up and having diarrhea. She vented her
g-tube
and more came out than usual. This is not c/w with her previous
epidsodes of ileus. No f/c. She has a known fluid collection
in
her pelvis. No burning upon urination. She doesn't know where
she is on her menstrual cycle because she has a h/o endometrial
ablation.
## PMHX:
- Community-acquired pneumonia
- Gastric bypass , multiple hospitalizations for abdominal
pain, nausea, vomiting
- Recurrent small bowel obstructions secondary to adhesions s/p
multiple adhesiolysis
- Hypertension
- Migraine headaches
- Post traumatic stress disorder
- Obesity
- Chronic pain with narcotic use
- Chronic anemia
- B12 deficiency
- Electrolyte disturbance secondary to dehydration from diarrhea
- poor access, has venous access port in Right chest, states has
been on TPN in past
## FAMILY HISTORY:
Father with hypertension. Mother died of pancreatic cancer.
History of alcohol abuse in sister and brother.
## PHYSICAL EXAM:
97.9 97 128/81 16 99RA
A&Ox4, NAD
RRR
CTAB
R chest port-a-cath, cannulated, no erythema
Abd obese, R flank incision is clearn with granulating sides,
abd
soft, nd, mid line scars, RLQ and suprapubic ttp
Ext - mild edema
##
ABD/PELVIC CT:
1. Decrease in size of fluid collection
at the right abdominal flank.
2. Decrease in size of the loculated fluid collection in the
pelvis, anterior
to the urinary bladder.
## BRIEF HOSPITAL COURSE:
Mrs. was admitted to the hospital, pan cultured and
evaluated by the Infectious Disease service. Her WBC was normal
as was her temperature on multiple occasions. She remained on
all of her home antibiotics.
A CT scan of the abdomen and pelvis was done to rule out any
deep abscesses or other fluid collections and the scan was much
improved from her last one in and the collections though
present are much smaller.
The Dermatology service was also consulted to evaluate the
rash/skin color changes on her lower abdomen and they felt it
was more than likely a panniculitis. A punch biopsy was taken
from the RLQ which was the most painful area and sent to
pathology as well as prep. These studies are pending and
the dermatology service will call her should anything treatable
be uncovered.
Her diet was started at stage 3 and she will self advance over
the next hours.
For now she will continue all of her antibiotics and follow up
with the on . She was discharged to home with
services to assess her abdomen, dressing changes to her
right flank and portacath care.
## MEDICATIONS ON ADMISSION:
cefpod 200'', lovenox , esomeprazole 20'',
fluconazole 200', dilaudid 2'', linezolid , ativan 1 qhs,
robaxin, morphine 15SR'', promethazine 25'', bactrim DS''
.
## DISCHARGE MEDICATIONS:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
2. Enoxaparin 120 mg/0.8 mL Syringe Sig: One Hundred Twenty
(120) mg Subcutaneous Q12H (every 12 hours).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
## 5. LINEZOLID MG TABLET SIG:
One (1) Tablet PO Q12H (every 12
hours).
6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for dsg changes.
9. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*40 Tablet(s)* Refills:*0*
11. Syringe,Safety, Disposal Unit 10 mL Syringe Sig: Two (2) 10
ml syringes Miscellaneous twice weekly.
Disp:*20 syringes* Refills:*2*
## 12. 18 G NEEDLE SIG:
Two (2) 18 g needles twice weekly.
Disp:*20 needles* Refills:*2*
## DISCHARGE INSTRUCTIONS:
* You were admitted to the hospital to have your abdominal rash
and abdominal discomfort assessed. The Ct scan that was done
showed no new fluid collections which is great. The Infectious
Disease service would like you to continue the same antibiotics.
The Dermatology service....
* Continue the same treatment to your right flank incision.
* Srart on a Stage 3 diet and self advance to Stage 5
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17882272", "visit_id": "29464165", "time": "2121-08-08 00:00:00"} |
17827807-DS-6 | 2,005 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
Sudden onset headache, confusion and left arm tingling/weakness.
## HISTORY OF PRESENT ILLNESS:
year old RH man with no transfered from OSH for
intracerebral bleed. This morning around 10 or 11am he developed
sudden onset severe headache and lightheadedness. While driving
at noon, he became disoriented and confused and was driving on
the sidewalk. Police came and found the patient confused and
complaining of left arm numbness and weakness. EMS was called
and took him to .
.
At the patient's vitals were T: 98.7 P: 89 BP:
182/103 RR: 18 O2 Sat: 95% on RA. He had one GTC seizure
observed by the attending and RN and was given 1g fosphenytoin,
2mg Ativan and 10mg labetalol. His head CT at showed a
2.1x1.3x2.5 cm R parietal parenchymal bleed with surrounding
edema but no midline shift or mass effect.
.
He was transferred to the where his vitals were T: 98
## P:
72 BP: 151/80 RR: 20 O2 Sat: 96% on RA and Glucose 109.
.
In the the patient is awake and cooperative, but is slightly
delayed in answering questions. 6 days ago the patient was seen
in the for a fall after tripping on a chain. The
patient fell on his left hand and had an anterior left 9th rib
contusion.
## PAST MEDICAL HISTORY:
Left Knee replacement
Right Knee arthroplasty
Abdominal Hernia Repair
## FAMILY HISTORY:
Brother with diabetes, grandmother with in her .
## PHYSICAL EXAM:
Vital Signs
T 98, HR 72, BP 151/80, RR 20, SpO2 96%
.
General Physical Exam
## HEENT:
NC/AT, moist oral mucosa
## NECK:
No tenderness to palpation, normal ROM, supple, no carotid
bruit
## CV:
RRR, Nl S1 and S2
## LUNG:
Clear to auscultation bilaterally
## ABD:
+BS soft, nontender, nondistended
## EXT:
no edema in , pulses 2+ bilaterally
.
Neurologic examination:
Mental status:
## GENERAL:
alert, awake, normal affect
## ORIENTATION:
oriented to person, place, date, situation
## ATTENTION:
Was able to perform months of the year backwards.
.
Executive function: Able to follow simple axial and appendicular
commands
.
## MEMORY:
registration, recall (5 min).
.
## SPEECH/LANGUAGE:
Patient was fluent with no paraphasic errors.
Able to name objects. Normal prosody. Able to read and write.
Repetition intact.
.
Praxis/ agnosia: Able to acting out brushing teeth with his left
hand.
.
## CALCULATIONS:
Able to calculate 100-7 after some delay.
.
## NEGLECT:
Able to draw clock. Able to identify which side is
touched. Had difficulty describing left side of a picture but
was able to described it when he was prompted. Line bisection
was biased to the right, and did not copy the left side of a
drawing of a cube.
.
## II:
Normal Fundus. Pupils equally round and reactive to light.
Left visual field deficit bilaterally.
## III, IV, VI:
Nystagmus when looking to the left, otherwise
extraocular movements intact bilaterally.
## VII:
Facial movement symmetric. Can keep eyes closed against
resistance, can furrow forehead
## VIII:
Hearing intact to finger rub bilaterally. Symmetric
hearing on Weber test, no conduction hearing loss on test
IX & X: Palate elevation symmetric. Uvula is midline. Gives a
good cough.
## XI:
Sternocleidomastoid and trapezius full strength bilaterally.
## XII:
Good bulk. No fasciculations. Tongue midline, movements
intact.
.
## SENSATION:
Intact to light touch, pinprick, and proprioception
bilaterally. Vibrational sense reduced bilaterally. No
extinction to DSS. Graphesthesia impaired bilaterally. Was able
to identify a quarter in his hand by touch.
.
## COORDINATION:
Able to perform finger-nose-finger; RAMs normal.
Mild pronator drift on the left.
.
## PERTINENT RESULTS:
02:15PM BLOOD WBC-13.6* RBC-4.72 Hgb-14.1 Hct-40.7
MCV-86 MCH-29.9 MCHC-34.7 RDW-13.5 Plt
02:15PM BLOOD Neuts-87.8* Lymphs-7.3* Monos-3.3 Eos-1.2
Baso-0.4
02:15PM BLOOD Plt
02:15PM BLOOD PTT-25.7
02:15PM BLOOD Glucose-98 UreaN-19 Creat-0.8 Na-143
K-4.0 Cl-107 HCO3-26 AnGap-14
06:57AM BLOOD ALT-14 AST-20 AlkPhos-110 TotBili-0.6
06:57AM BLOOD Albumin-4.7 Calcium-9.8 Phos-3.9 Mg-2.2
am Phenytoin 7.2
-----
am phenytoin 8.7
HDL 44 / LDL 112 (TC 193)
HbA1c 5.4%
.
CT HEAD W/O CONTRAST
Prelim Read-
Acute intraparenchymal hemorrhage with adjacent surrounding
edema, may be slightly increased in size from 2 hours prior
study. No mass effect or shift of normally midline structures.
An underlying lesion cannot be excluded. MRI can be considered
for further characterization.
.
CTA HEAD and NECK W&W/O C & RECON
Prelim Read-
No aneurysm or vascular malformation identified, in the region
of the right parietal lobe IPH. However, occult mass or occult
vascular malformation not excluded. Final read pending 3D
recons.
.
CHEST PORTABLE AP
No evidence of pneumonia. If symptoms persist, standard PA and
lateral chest radiograph may be helpful to more fully assess the
lungs.
.
MR HEAD W & W/O CONTRAST
## FINDINGS:
There is again noted a right parietal intraparenchymal
hemorrhage with surrounding edema and mass effect. There is no
associated enhancement. There is no evidence to suggest an
underlying arteriovenous malformation. A small area of chronic
microhemorrhage is seen in left thalamus. Mild changes of small
vessel disease are seen. No acute infarct noted. The midline
structures are central. No other lesions identified.
## IMPRESSION:
Right parietal intraparenchymal hemorrhage with no
evidence of abnormal enhancement to suggest underlying mass.
However, follow up in weeks may help for further
confirmation, if clinically indicated
.
TTE
Conclusions
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
## BRIEF HOSPITAL COURSE:
Mr. is a man with minimal PMH --in particular, no
h/o diabetes or hypertension or hyperlipidemia or CVA/MI-- whose
only medications on arrival were NSAID and narcotic pain meds,
who was was transferred here to from an OSH with a large
right parietal ICH as described above, and a possible GTC
seizure at the OSH before transfer. All his symptoms and exam
findings seem to have resolved over 2d in the hospital. He has
not had any more seizures here, where he has been kept on
phenytoin after he was loaded with fos-phenytoin 1g at the OSH
. This will be continued for at least six months.
His MRI was consistent with the CT findings with the only
addition that there is a tiny spot of hypointensity (old blood
vs. calcium) in the Left thalamus, which is a location most c/w
small vessel / HTN hemorrhage. There is no way to r/o an
underlying mass, so MRI needs to be repeated in about two
months. His TTE did not reveal any cardiac thrombus or PFO to
suggest a cardioembolic problem, and his EF, etc. were normal as
described above. FLP was significant for LDL 112. HbA1c was
normal (5.4%) and the patient had no h/o diabetes.
As his ICH appearance and location is c/w hypertensive disease
(versus less likely an underlying mass or vascular abnormality
or early amyloid angiopathy), and with initial SBPs in the
170s-180s, and with BPs on the floor ranging from the 100s up to
150s, we started a low-dose ACE-inhibitor, which has been
well-tolerated over two days with SBPs in the 100s-120s.
Antihypertensive med titration will be performed by his PCP as
an outpatient. He was also started on low-dose simvastatin with
LDL 112.
PLAN on discharge:
-He needs a f/u MRI in weeks; he needs to call
Radiology to schedule an appointment (it is already ordered in
our electronic system, OMR)
-He will see Dr. in clinic (stroke Neurology) and
follow-up with his PCP as planned
- will continue to take phenytoin (Dilantin) for six months,
starting at 400mg tid dosing) with initially
subtherapeutic blood levels here
-Phenytoin blood levels should be monitored by his PCP (7.2, 8.7
in hospital on
-He should not work with heavy machinery or drive until he is
seizure-free for six months
-He should not work for at least one week after discharge
-He will continue to take an ACE-inhibitor (lisinopril 5mg) and
a statin (simvastatin 20mg)
## MEDICATIONS ON ADMISSION:
Vicodin 3x a day
Prescription NSAID
Ibuprofen 800mg daily (stopped while taking prescription NSAID)
## DISCHARGE MEDICATIONS:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO ONE tablet in the morning and at noon, then TWO tablets in
the evening (100mg, 100mg, 200mg for total daily dose of 400mg)
for 6 months: You need to have your blood level of phenytoin
(Dilantin)monitored by your PCP.
Disp:*120 Capsule(s)* Refills:*2*
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
for your cholesterol.
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for blood pressure control, to prevent recurrent ICH/stroke.
Disp:*30 Tablet(s)* Refills:*2*
## DISCHARGE DIAGNOSIS:
Intracerebral hemorrhage (stroke), Right parietal, centered over
the arm region of the postcentral gyrus.
## DISCHARGE CONDITION:
Normal exam except for mild bilateral graphesthesia (worse in
the right hand, ipsilateral to the ICH) and improved visual
fields, with mild peripheral field cuts bilaterally (possibly
early-stage glaucoma).
## DISCHARGE INSTRUCTIONS:
You were transferred to and admitted to our
stroke-Neurology unit because you had a stroke. The type of
stroke you had was a bleed in your brain, on the Right side.
This caused initially some confusion, some tingling in your left
arm, which has since resolved, and some very mild sensory
deficits in your hands that you might not even notice, and some
mild loss of your peripheral vision. You also had a seizure at
the emergency room of the .
You need to take some medications, which we started in the
hospital, to reduce your risk of another stroke and to prevent
seizures because part of your brain has been irritated by the
blood, which will take months to completely go away.
(1) To reduce the risk of stroke, you will take a medicine
called lisinopril (an ACE-inhibitor) to control your blood
pressure, which was very high when you had your stroke and may
have been the cause of the vessel in your brain starting to
bleed. Your PCP and Dr. will monitor your blood pressure
in the future and make any necessary changes in the dose of
lisinopril.
(2) To reduce your cholesterol, we started you on a "statin"
type of medication called simvastatin. Your LDL cholesterol was
112, which is a little higher than ideal, so you need to keep
taking this medication once every day, and have your LDL
cholesterol level monitored by your PCP.
(3) To prevent additional seizures, you will take a medicine
called phenytoin (old brand name = , three times
every day for six months. Your primary care physician and Dr.
in stroke clinic will monitor the levels of
this drug and make any necessary changes in its dose in the
future. After six months, if you have not had any more seizures,
you can begin driving and operating heavy machinery again, but
until then, you need to take the anti-seizure medicine, not
drive, and not operate any heavy machinery.
You will need a repeat MRI of the brain in weeks (once the
blood has cleared enough to ensure that there is no underlying
lesion or malformation such as a tumor).
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17827807", "visit_id": "23456241", "time": "2115-04-06 00:00:00"} |
10283819-RR-52 | 342 | ## HISTORY:
Tenderness and drainage from surgical wound. Evaluate for abscess.
## FINDINGS:
A small right pleural effusion is unchanged. There is no focal consolidation
or pericardial effusion.
## CT ABDOMEN:
The patient is status post total left hepatectomy, caudate lobe
resection, and extrahepatic bile duct resection secondary to history of
cholangiocarcinoma. Again seen is rim enhancing fluid collection at the
margin of the liver resection now measuring 3.3 x 5.6 cm, decreased in size
from 4.5 x 7.5 cm in . As on prior exam, there are tiny
pockets of gas, which may be slightly increased in size and number.
Superinfection cannot be excluded. There is likely communication (2:28) of
this collection with a new collection of subcutaneous gas and fluid at the
right upper anterior abdominal wall wound site, which measures 3.0 x 3.1 cm.
Again seen is perihepatic fluid, not significantly changed. Infarcts within
the liver and spleen are improved since . An internal biliary
stent extends into the hepaticojejunostomy, and the hepatic artery stent is
unchanged, again without visualization of the hepatic artery distal to the
stent. The SMV thrombus seen on prior exam is not well seen today. Portal
vein is patent.
The pancreas is without focal lesion or peripancreatic stranding or fluid
collection. The kidneys are without focal lesion or hydronephrosis. The
stomach, small bowel, and large bowel are without wall thickening or
obstruction. The aorta is normal in caliber and there are scattered
atherosclerotic calcifications of the aorta and iliac arteries. No
retroperitoneal or mesenteric lymph node enlargement by CT size criteria.
## CT PELVIS:
The urinary bladder is unremarkable. There is is no pelvic wall
or lymph node enlargement by CT size criteria. No pelvic free fluid.
## IMPRESSION:
1. Fluid collection at the margin of the liver resection, decreased in size,
but likely communicating with a new subcutaneous air/fluid collection at the
wound site. Infection of this collection cannot be excluded.
2. Improved hepatic and splenic infarcts.
3. SMV thrombus seen on prior exam is not seen today, likely resolved.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10283819", "visit_id": "20186637", "time": "2161-07-27 08:11:00"} |
14674146-RR-69 | 272 | ## INDICATION:
Nausea, vomiting and left lower quadrant pain in a patient with
history of diverticulitis.
## CT ABDOMEN WITH CONTRAST:
The imaged portions of the lung bases are clear.
Visualized portion of the cardiac apex is normal. The spleen and adjacent
splenules are normal. The patient is status post cholecystectomy. The
pancreas is notable for diffuse ductal dilation up to 4 mm. The common bile
duct is also prominent. Both of these findings are unchanged. Bulky left
adrenal gland and nodule in the right adrenal gland are unchanged from
previous studies. The kidneys enhance and excrete contrast in a symmetric
fashion. The liver is normal. A perihepatic hypodensity is 51 x 28mm (2:18),
unchanged from . There is no free gas or fluid in the abdomen. There is
no retroperitoneal or mesenteric lymphadenopathy. Note is made of dense
atherosclerotic calcification of the abdominal aorta.
## CT PELVIS WITH CONTRAST:
The urinary bladder, distal ureters, uterus, and
rectum are normal. The colon is notable for diverticulosis, without evidence
of diverticulitis. Though the appendix is not distinctly visualized, there
are no secondary signs of appendicitis. There is no free gas or free fluid in
the pelvis. There is no pelvic sidewall or inguinal lymphadenopathy.
## OSSEOUS FINDINGS:
There is no suspicious sclerotic or lytic osseous lesion.
There is a mild levoconvex thoracolumbar scoliosis. Note is made of loss of
intravertebral disc height at L3/L4 and L4/L5 with resultant endplate changes.
## IMPRESSION:
1. No acute intra-abdominal or intrapelvic abnormality to explain the
patient's symptoms.
2. Unchanged right adrenal nodule and thickened left adrenal gland.
3. Unchanged pancreatic ductal dilation.
4. Atherosclerotic disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14674146", "visit_id": "N/A", "time": "2133-01-03 09:44:00"} |
18824198-RR-91 | 180 | ## INDICATION:
Large amount of ascites after common bile duct excision and
hepaticojejunostomy. Evaluate for patency of the portal vein.
LIVER ULTRASOUND WITH DOPPLER.
## FINDINGS:
Liver is coarse in echotexture with a nodular contour and shrunken
appearance. No focal lesions, however, are present. There is a slight
intrahepatic biliary ductal dilatation and the CBD measures 7 mm with PTC
drains in place. Doppler evaluation of the main, right and left portal veins
demonstrate normal flow and waveforms. The flow and waveforms seen within the
right, middle, and left hepatic veins is also normal. Normal arterial
waveforms are seen within the common hepatic artery. Normal flow and
waveforms are seen within the IVC. Midline vessels including the splenic vein
and superior mesenteric vein cannot be visualized due to overlying bowel gas.
There is a moderate amount of intra-abdominal fluid. The spleen is enlarged
measuring 13.7 cm.
## IMPRESSION:
1. Patent hepatic vasculature with normal waveforms.
2. Coarse liver echotexture with mild intrahepatic biliary ductal dilatation.
PTC drains in place.
3. Moderate amount of intra-abdominal ascites.
4. Splenomegaly, mild.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18824198", "visit_id": "26913326", "time": "2159-12-04 09:21:00"} |
16810793-DS-17 | 867 | ## HISTORY OF PRESENT ILLNESS:
He has previously been seen here for
evaluation of a possible prostate nodule, as well as evaluation
of severe lower urinary tract symptoms. Referral of here today
is for microscopic hematuria, which has been noted in ,
and with 5 RBCs and 9 RBCs per high-power field,
respectively. All urine cultures have been negative and the
patient has not had any other known reason for his hematuria.
He
has been evaluated by you with a CT urogram performed on
which noted some benign cysts in the kidney, no
suspicious lesions in the ureter, and a thickened bladder with
an
enlarged prostate with an estimated volume of 50.6 mL. Of note,
the patient is a previous smoker, although he quit in .
Regarding his lower urinary tract symptoms, he is quite bothered
by them. He complains of urgency, dysuria, frequency, weak
stream, and needing to strain when urinates. He is currently on
both finasteride and tamsulosin, but is still significantly
bothered by his urinary symptoms. He mentioned that previous
practitioners have mentioned the possibility of bladder outlet
surgery to help him with his symptoms, but this has not been
followed through. He is interested in this.
## PAST MEDICAL HISTORY:
COPD, Gold stage II.
He also recently underwent an upper endoscopy and biopsy, which
did not note any malignancy.
## PHYSICAL EXAM:
AVSS
NAS
WWP
Unlabored breathing
Abd soft, NT, ND
Foley removed and patient is voiding clear urine. PVR's have
been minimal.
Ext WWP, no edema, or tenderness.
## BRIEF HOSPITAL COURSE:
Patient was admitted to Dr. service after
bipolar transurethral resection of prostate. No concerning
intraoperative events occurred; please see dictated operative
note for details. He patient received antibiotic
prophylaxis. The patient's postoperative course was
uncomplicated. He received intravenous antibiotics and
continuous bladder irrigation overnight. On POD1 the CBI was
discontinued and Foley catheter was removed with an active
vodiding trial. Post void residuals were checked. His urine was
clear and and without clots. He 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. He was given oral pain medications on discharge
along with explicit instructions to follow up in clinic.
## MEDICATIONS ON ADMISSION:
Albuterol, Symbicort, finasteride, fluticasone,
omeprazole, tamsulosin, and tiotropium.
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
4. Lisinopril 30 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4 hours Disp #*30
## TABLET REFILLS:
*0
7. Tamsulosin 0.4 mg PO HS
8. Tiotropium Bromide 1 CAP IH DAILY
9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
## DISCHARGE INSTRUCTIONS:
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-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 until you see your urologist in follow-up AND your foley
has been removed (if not already done)
-Continue taking PROSCAR (Finasteride) AND/OR your other
prostate shrinking medications until you are otherwise advised
.
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine
bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-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.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery. Also, if the Foley catheter and Leg
Bag are in place--Do NOT drive (you may be a passenger).
IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER:
-Please refer to the provided nursing instructions and handout
on Foley catheter care, waste elimination and leg bag usage.
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in 1 week for wound check and Foley removal. DO NOT
have anyone else other than your Surgeon remove your Foley for
any reason.
-Wear Large Foley bag for majority of time, leg bag is only for
short-term when leaving house.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16810793", "visit_id": "26019295", "time": "2180-08-23 00:00:00"} |
16131554-RR-17 | 168 | ## INDICATION:
female with dysmenorrhea leading to iron deficiency,
evaluate for uterine pathology.
## FINDINGS:
Transabdominal and transvaginal ultrasound was performed on the
uterus.
The uterus measures 7.6 x 4.5 x 7.3 cm. A large intramural fibroid is seen in
the posterior aspect of the uterus, measuring 3.4 x 3.4 x 4.7 cm.
The endometrial stripe is unremarkable. An eccentric, echogenic focus within
the endometrium is seen and measures 1.4 x 1 x 0.7 cm. This lesion does not
show definite hypervascularity. There is no fluid seen within the endometrial
canal.
The ovaries are normal in size, both demonstrating normal follicular activity.
There is a 1.2 cm nabothian cyst. There is no free pelvic fluid.
## IMPRESSION:
1. Echogenic focus within the endometrium likely represents a polyp, however,
further characterization with either direct hysteroscopy or a sonohysterogram
is recommended.
2. Fibroid uterus.
These findings were posted to the radiology critical results dashboard at
10:30 a.m. on by Dr. .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16131554", "visit_id": "28190304", "time": "2124-08-20 09:22:00"} |
12513220-RR-22 | 168 | ## INDICATION:
female with kidney stones seen on outside ultrasound.
Further evaluation. Per request, intravenous contrast was not administered.
## FINDINGS:
There is a 6-mm obstructing stone at the left UVJ (2:73). There is
mild hydroureter and mild left hydronephrosis. A 2-mm non-obstructing stone
in the upper pole of the right kidney is also present.
The included portions of the lung bases are clear. The non-contrast
appearance of the liver, spleen, pancreas, gallbladder, and adrenal glands is
unremarkable. Loops of small and large bowel are normal in size and caliber.
Within the pelvis, distal loops of large bowel and rectum are normal in size
and caliber. The uterus is unremarkable. No pelvic free air, free fluid, or
lymphadenopathy is seen.
No concerning osseous lesion is seen.
## IMPRESSION:
1. 6-mm obstructing stone at the left UVJ with mild hydroureteronephrosis.
No significant left perinephric stranding. Evaluation for pyelonephritis is
limited in the absence of intravenous contrast.
2. 2-mm non-obstructing right renal stone.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12513220", "visit_id": "N/A", "time": "2116-01-25 23:57:00"} |
18806770-RR-25 | 297 | ## INDICATION:
Patient with persistent hypoxia, PaO2 of 60. Rule out PE.
## HEART AND GREAT VESSELS:
There is no pulmonary embolism until segmental level but because of motion
artifact the exam is nondiagnostic at subsegmental level especially in lower
lobes. Main pulmonary artery is dilated up to 3.5 cm which could reflect
pulmonary artery hypertension. The heart is moderately dilated. There is no
acute aortic syndrome and ascending aorta is mildly dilated to 4.1 cm.
Coronary arteries are markedly calcified. There is no pericardial effusion.
## MEDIASTINUM:
There is no pathologic supraclavicular, mediastinal or axillary lymph node
enlargement by CT size criteria. 9.6 mm lymph node is new in the prevascular
station (series 3, image 32). Left exophytic inferior thyroid nodule is
stable measuring 15 x 19 mm.
## LUNGS AND AIRWAYS:
There is a lot of breathing artifact throughout the study.
Atelectatic bands in lower lobes are minimal.
Right middle lobe opacities measuring 5 mm (series 3, image 112) could be
atelectasis or a real lung nodule; it was not present in . The airways
are patent to the subsegmental level.
## UPPER ABDOMEN:
This study is not tailored for assessment of intra-abdominal
organs. The liver has fatty infiltration.
## OSSEOUS STRUCTURES:
There is no bony lesion concerning for malignancy or
infection. Left sixth rib fracture is healed. Moderate compression fracture
of T6 is unchanged since chest x-ray of .
## CONCLUSION:
1. There is no pulmonary embolism till segmental level and no acute aortic
syndrome.
2. Main pulmonary artery is moderately dilated to 3.5 cm which could reflect
pulmonary arterial hypertension. There is also moderate cardiac enlargement.
3. 5 mm right middle lobe opacity could be a real nodule or atelectasis. If
needed, this could be followed up with a chest CT in a year.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18806770", "visit_id": "29774612", "time": "2193-05-19 15:31:00"} |
16438215-RR-57 | 209 | ## EXAMINATION:
ABDOMEN US (COMPLETE STUDY)
## INDICATION:
year old woman with weight loss// assess anatomy
## LIVER:
The contour of the liver is smooth. There is no focal liver mass. The
main portal vein is patent with hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CHD measures 2 mm.
## GALLBLADDER:
There is no evidence of stones or gallbladder wall thickening.
## PANCREAS:
Within the body of the pancreas, there is a 3 mm anechoic cystic
lesion without vascularity compatible wit a side-branch h intraductal
papillary mucinous neoplasm (IPMN) for which no further follow-up is
recommended at this age. No pancreatic ductal dilatation demonstrated.
## SPLEEN:
Normal echogenicity, measuring 11.0 cm.
## KIDNEYS:
The right kidney measures 10.0 cm. The left kidney measures 10.0 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of calculi or hydronephrosis in the
kidneys. 1.4 cm simple cyst in the upper pole of the left kidney.
## RETROPERITONEUM:
The visualized portions of aorta and IVC are within normal
limits.
## IMPRESSION:
No hepatic mass demonstrated.
3 mm pancreatic cystic lesion likely a side branch IPMN. Per departmental
policy, no follow-up recommended for this lesion due to small size and age.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16438215", "visit_id": "N/A", "time": "2197-03-16 10:47:00"} |
10684044-DS-10 | 1,046 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## ATTENDING:
Complaint:
transfer from OSH for EP study; A fib w/ RVR found after
syncopal episode
## HISTORY OF PRESENT ILLNESS:
yo old M w/ hx of MI @ age , CABG x 4 in , 3.8cm AAA,
HTN, HLD who was brought to on
after syncopal episode, likely vasovagal. Patient
reports he felt a strong urge to evacuate his bowel, felt warmth
and pressure in his abdomen, got sweaty and saw bright lights
before passing out while trying to pull over his car to use the
restroom. He had bowel incontinence while unconscious. He denied
any chest pain, shortness of breath, or palpitations prior to
this episode. He has never experienced such episode before. EMS
found him in A fib with RVR to 180s. He was started on diltiazem
and lovenox, spontaneously cardioverted with a 4 sec conversion
pause. EEG was negative. CXR was negative. Cardiac enzymes were
negative. Echo showed 40% EF & elevated LVEDP, which was similar
to prior. EKGs showed NSR with RAD, RBBB, LPHB, and long PR
interval (similar to baseline). He continued to have occasional
pauses so CCB was stopped. He was transferred here for EP study
+/- PPM/ICD.
## PAST MEDICAL HISTORY:
CAD s/p MI in , s/p CABG details unknown in , no
coronary intervention since then
Ischemic CMP EF 40-45 % echo
HTN
HLD
AAA at 3.8 cm
OA
Seasonal allergies, Asthma
recently treated for Herpes zoster 3 weeks ago
## FAMILY HISTORY:
No CVA or seizure d/o
CAD/MI - mom and dad in .
Cerebral aneurysm in daughter.
## GEN:
WDWN middle aged male in NAD, Oriented x3. Mood, affect
appropriate.
## HEENT:
NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
## CV:
JVP 4 cm, RRR, normal S1, S2. No m/r/g
## CHEST:
CTAB, no wheezes, crackles, or rhonchi
## ABD:
Soft, NTND, no bruits
## EXT:
No c/c/e, + compression stockings
## PULSES:
radial and DP strong and symmetric
## NEURO:
motor strength throughout, gross sensation intact, CN
grossly intact
## BRIEF HOSPITAL COURSE:
The cause of the patient's syncopal episode was likely vasovagal
given the clinical history. It is highly unlikely to be
secondary to Afib with RVR or bundle branch reentry. Throughout
the hospital stay the patient remained asymptomatic,
hemodynamically stable, and in normal sinus rhythm. His home
medications for his chronic medical problems were continued. On
he underwent an electrophysiologic study to find out
more information about the conduction properties of the AVN and
infranodal system in order to determine need for PPM/ICD, and
also to determine choice antiarryhthmic therapy for rhythm
control in atrial fibrillation. The EP study revealed minimally
prolonged His-Vent interval (infranodal conduction) and
non-sustained ventricular tachycardia only so there was no need
for PPM/ICD. The patient was started on Amiodarone and Coumadin
and set up to follow up with his PCP and primary cardiologist
Dr. labwork (needs baseline TFTs, PFTs, LFTs), INR
monitoring while on Coumadin, and continued management. The rest
of his home medications were continued upon discharge.
## SIMVASTATIN 80 MG TABLET SIG:
One (1) Tablet PO once a day.
Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Pulmicort Flexhaler 180 mcg/Inhalation Aerosol Powdr Breath
## ACTIVATED SIG:
2 puffs Inhalation BID (2 times a day).
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheezing.
## MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Oxycodone-Acetaminophen mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for pain.
## DISCHARGE MEDICATIONS:
1. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 1 weeks: start evening of and stop on .
Disp:*21 Tablet(s)* Refills:*0*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks: Please start on and stop on .
Disp:*14 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please begin on .
Disp:*30 Tablet(s)* Refills:*1*
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. Pulmicort Flexhaler 180 mcg/Inhalation Aerosol Powdr Breath
## ACTIVATED SIG:
2 puffs Inhalation BID (2 times a day).
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheezing.
## 10. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY
(Daily).
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
## 14. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
15. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take
as advised by Dr. . .
Disp:*30 Tablet(s)* Refills:*0*
## DISCHARGE INSTRUCTIONS:
Mr. ,
You were admitted with a fainting spell and palpitations. You
had a cardiac study called an electrophysiologic study to
evaluate your heart conduction system. This showed that your
conduction system was normal. You have been started on a
medication called amiodarone to control your heart rhythm. You
are also started on coumadin to thin your blood. You will need
to follow up with your primary care physician and cardiologist
to get blood work done and for continued follow up. Please go
get your blood work checked at Dr. tomorrow
.
We have started the medications AMIODARONE and COUMADIN. Please
take these as instructed.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10684044", "visit_id": "28910470", "time": "2117-05-27 00:00:00"} |
19340104-RR-19 | 69 | ## HISTORY:
with LLQ and pelvic cramping // eval torsion, other
acute process
## FINDINGS:
The uterus is anteverted and measures 9.1 x 3.1 x 5.0 cm. The endometrium is
homogenous and measures 6 mm.
The ovaries are normal in size and appearance. There is trace free fluid.
Normal arterial and venous waveforms are demonstrated within both ovaries.
## IMPRESSION:
Normal ultrasound appearance of the uterus and ovaries.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19340104", "visit_id": "N/A", "time": "2155-06-19 09:02:00"} |
19106010-RR-107 | 135 | ## EXAMINATION:
FOOT AP,LAT AND OBL RIGHT
## HISTORY:
with foot pain, recent amputation// eval
osteomyelitis
## FINDINGS:
Patient is status post recent resection of the fourth right toe in the context
of prior resection of the first, second, and fifth right toes at the
metatarsophalangeal joints. No lytic/destructive bony lesions. No
subcutaneous gas or apparent skin defects are seen. An os naviculare is again
seen. Moderate size calcaneal spur. Moderate calcific atherosclerotic
vascular changes. No acute fracture or dislocation. There is moderate soft
tissue edema about the forefoot.
## IMPRESSION:
Status post recent resection of the fourth right toe at the
metatarsophalangeal joint. No radiographic evidence of osteomyelitis. No
subcutaneous gas.
## RECOMMENDATION(S):
Please note the sensitivity of radiographs for
osteomyelitis is low, and if clinical suspicion is strong, an MRI should be
performed.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19106010", "visit_id": "N/A", "time": "2140-05-25 04:45:00"} |
15080981-RR-31 | 301 | ## STUDY:
CT abdomen and pelvis with contrast and reconstructions.
## INDICATION:
male with multiple surgeries and cecostomy tube and
recent history for C. diff. colitis with abdominal pain and fever.
## CT ABDOMEN WITH CONTRAST:
There is mild bibasilar atelectasis within the lung
bases. The visualized heart is grossly unremarkable without pericardial
effusion.
There is a nasogastric tube with tip in the duodenal bulb. The fluid
collection between the liver and stomach now measures 6.1 x 2.6 cm which is
slighly smaller in size. The small left subphrenic collection is slightly
larger measuring 3.2 x 2.2 cm. Hypoattenuating ill-defined collection dorsal
to the pancreas is not significantly changed. The gallbladder, and abdominal
loops of small bowel are normal in appearance. There is an IVC filter in an
infrarenal position.
## CT PELVIS WITH CONTRAST:
There is a right anterolateral abdominal wall defect
consistent with previously debrided fasciitis. Streak artifact from bilateral
hip replacements obscures optimal evaluation of the rectum and bladder which
contains an intraluminal Foley. Previously noted colonic wall thickening
within the sigmoid colon and descending colon has resolved. However, in the
loop of bowel which supplies the cecostomy there is continued wall thickening
and mild inflammatory stranding in this bowel loop which extends across the
anterior abdomen. No pericolonic fluid collection or abscess is detected.
## OSSEOUS STRUCTURES:
No suspicious lytic or sclerotic lesion is detected.
There are bilateral hip replacements.
## IMPRESSION:
1. While the majority of the pancolitis previously noted in has
resolved, the segment of bowel feeding the cecostomy site which transverses
the majority of the anterior abdomen continues to demonstrate mild wall
thickening and surrounding inflammatory change. No pericolonic fluid
collections/abscess is detected.
2. No significant change in three intraabdominal fluid collections aside
from mild decrease in perihepatic collection.
3. Bibasilar atelectasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15080981", "visit_id": "26943974", "time": "2120-07-05 03:35:00"} |
16398109-RR-14 | 169 | ## EXAM:
MRA of the neck and MRA of the head.
## CLINICAL INFORMATION:
Patient with neurosix palsy.
## FINDINGS:
NECK MRI:
There is both carotid arteries demonstrate tortuosity in the proximal portion
and normal variation. No evidence of stenosis or occlusion seen.
## IMPRESSION:
Somewhat motion-limited normal MRA of the neck.
## MRA HEAD:
The head MRA demonstrates flow signal in the major arteries around the circle
of . There appears to be an approximately 3-mm aneurysm on the lateral
aspect of the supraclinoid right internal carotid artery.
There is flow signal narrowing of the left middle cerebral artery, the left
supraclinoid internal carotid artery, and basilar artery which could be due to
atherosclerotic disease. These findings can be confirmed with a CTA of the
head if clinically indicated.
## IMPRESSION:
1. 3-mm aneurysm at the lateral aspect of right supraclinoid internal carotid
artery.
2. Flow signal narrowing the left MCA, supraclinoid ICA, and basilar artery
could be due to atherosclerotic disease.
3. CTA can help confirmation of these findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16398109", "visit_id": "21296949", "time": "2168-05-13 08:03:00"} |
17596130-RR-35 | 519 | ## INDICATION:
year old man with metastatic RCC on cabozantinib // eval
interval change
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 9.3 s, 73.6 cm; CTDIvol = 15.7 mGy (Body) DLP =
1,154.9 mGy-cm.
3) Spiral Acquisition 3.8 s, 30.1 cm; CTDIvol = 13.3 mGy (Body) DLP = 401.9
mGy-cm.
Total DLP (Body) = 1,570 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS WITH CONTRAST)
## NECK, THORACIC INLET, AXILLAE:
The visualized thyroid is normal.
Supraclavicular and axillary lymph nodes are not enlarged.
## MEDIASTINUM:
Scattered prominent mediastinal lymph nodes are not enlarged by
CT criteria.
## HILA:
Hilar lymph nodes are not enlarged.
## HEART:
There is moderate coronary arterial calcification. There is no
pericardial effusion.
## VESSELS:
Aortic caliber is normal. The main pulmonary artery is mildly
dilated up to 3.1 cm, which is suggestive of but not diagnostic of pulmonary
arterial hypertension. The right and left pulmonary arteries are normal
caliber.
## PULMONARY PARENCHYMA:
Again seen are innumerable pulmonary nodules,
consistent with metastatic disease. The 1.6 x 1.3 cm right upper lobe
subpleural nodule immediately adjacent to the costochondral junction (series
3, image 66) has increased in size compared to . Otherwise the
remaining pulmonary nodules are grossly unchanged. Some representative
nodules are listed below:
Right upper lobe: 2.9 x 1.8 cm nodule on series 3, image 94
Right middle lobe 1.0 x 0.8 cm nodule on series 3, image 143
Right lower lobe: 1.2 x 0.9 cm nodule on series 3, image 195
Left upper lobe: 2.2 x 1.9 cm subpleural nodule on series 3, image 57
Left lower lobe: 1.4 x 1.3 cm nodule on series 3, image 166
No new pulmonary nodule. No focal consolidation to suggest pneumonia.
## AIRWAYS:
The airways are patent to the subsegmental level bilaterally.
## PLEURA:
There is no pleural effusion.
## CHEST WALL AND BONES:
Left T11 lytic lesion involving the pedicle, lamina,
and costovertebral junction is unchanged. 5.3 x2 0.1 lytic lesion right
posterior seventh rib lesion with soft tissue component is also unchanged.
2.6 x 1.1 cm right posterolateral fourth rib lytic lesion is also unchanged.
2.0 x 1.4 cm anterior left fourth rib lytic lesion and left anterolateral 1.8
x 1.2 cm fifth rib lytic lesion are also unchanged. No new suspicious osseous
lesions. Multilevel degenerative changes are moderate. Sternotomy wires are
intact.
## UPPER ABDOMEN:
Please see separately submitted Abdomen and Pelvis CT report
for subdiaphragmatic findings.
## IMPRESSION:
1. Innumerable pulmonary metastases with 1 lesion in the right upper lobe
adjacent to the costochondral junction demonstrating interval enlargement
currently measuring 1.6 x 1.3 cm. The remaining pulmonary nodules are
unchanged in size. No new pulmonary nodules.
2. Multiple osseous metastases, unchanged compared to . No new
osseous lesions.
3. No acute process within the chest.
4. Please see separate report performed on same day for evaluation of the
abdomen pelvis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17596130", "visit_id": "N/A", "time": "2173-11-13 09:35:00"} |
13446537-RR-21 | 105 | ## INDICATION:
year old man s/p ct pull// eval for ptx
## FINDINGS:
The tip of the right internal jugular central venous catheter projects over
the upper SVC. The endotracheal and gastric tubes as well as a chest tube has
been removed.
There is no pneumothorax identified. Layering bilateral pleural effusions
with subjacent atelectasis/consolidation are unchanged and again are larger on
the right. The size and appearance of the cardiac silhouette is unchanged
including prominence of the mediastinum.
## IMPRESSION:
Interval removal of the endotracheal tube, gastric tube and chest tube. No
pneumothorax.
Bilateral pleural effusions with subjacent atelectasis/consolidation, greater
on the right.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13446537", "visit_id": "26073480", "time": "2128-08-06 11:18:00"} |
13207574-RR-54 | 109 | ## INDICATION:
Ms. is a y/o female with a hx of IDDM, HTN, HLD, OSA,
status post cholecystectomy who presents with pre-syncope and abdominal
pain.// any evidence of perforation or obstruction
## FINDINGS:
There is mild colonic dilatation as noted previously, not significantly
changed. Please note the study is compromised as the right-most and uppermost
abdomen is not included on the radiograph.
Air and stool are seen within the rectum.
Please note the free air cannot be completely excluded on a supine radiograph.
Osseous structures are unremarkable. Vascular calcification is noted.
## IMPRESSION:
Mild colonic dilatation, similar to previous. Air and stool are seen within
the rectum.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13207574", "visit_id": "27590526", "time": "2180-02-29 19:38:00"} |
16906565-RR-137 | 270 | ## EXAMINATION:
DX CERVICAL AND THORACIC SPINES
## INDICATION:
year old woman with S/P C3-T7 LAMI FUSION SURGERY . //
Assess healing
## FINDINGS:
There is posterior spinal fusion hardware spanning C3 through T7. There is
anterior fusion hardware spanning C3 through C5 with interbody spacers. Skin
staples overlie the back. There is no prevertebral soft tissue thickening in
the cervical spine.
Hardware appears intact without evidence of loosening. On today's exam, the
thoracic vertebral body contours are somewhat better seen and one of the lower
most set of posterior screws projects over the posterior aspect of the
adjoining disc.
There is severe diffuse osteopenia, with numerous compression deformities
throughout the thoracic spine. Allowing for obscuration of the uppermost
vertebral bodies on the lateral view, these appear grossly unchanged compared
with targeted review of T-spine CT scan sagittal reformatted images from . Overall alignment appears unchanged, with accentuation of usual
kyphotic angulation. There are healed fractures of left lower ribs.
Compression deformities are also noted in the upper lumbar spine.
Rounded density over the lower right lung is compatible with findings seen on
the chest radiograph from , apparently related to a known
posterior right chest pleural mass.
## IMPRESSION:
Anterior and posterior spinal fusion hardware with unchanged alignment. One
of the 2 lowermost screws projects over the posterior disc space of below,
question the T7/8 disc. Clinical correlation requested.
Multiple compression deformities throughout the thoracic spine, similar to the
T-spine CT from
## NOTIFICATION:
The impression above was entered by Dr. on
at 18:02 into the Department of Radiology critical communications
system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16906565", "visit_id": "N/A", "time": "2158-12-29 11:35:00"} |
13962649-RR-20 | 193 | LUMBAR SPINE RADIOGRAPH PERFORMED ON
## CLINICAL HISTORY:
Back pain, assess for instability.
## FINDINGS:
AP, neutral/flexion/extension lateral views provided. There is a
spinal stimulator projecting over the right hemipelvis and catheter tip
projecting over the right hemisacrum. Clips in the right upper quadrant
noted. Patient has undergone prior laminectomy at L5. Again noted is a
grade anterolisthesis of L5 on S1 measuring approximately 12.5 mm on
neutral positioning which appears stable on flexion and extension positioning.
Please note, however, while the anterolisthesis is stable from most recent
radiograph dated , the degree of anterolisthesis is increased from the
CT of the lumbar spine from . Extensive bony overgrowth is seen along
the posterior facets of the lumbar spine. Mild disc disease is noted with
tiny endplate spurs at L1-2 level. SI joints and hip joints align normally
with only minimal subchondral sclerosis at both hips. There is also note made
of slight uncovering of the femoral heads at the hip joints.
## IMPRESSION:
Grade anterolisthesis of L5 on S1 with no evidence of
instability, though there is increase in overall degree of anterolisthesis
compared with a CT of the lumbar spine dated .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13962649", "visit_id": "N/A", "time": "2149-12-31 14:48:00"} |
18830695-RR-55 | 163 | ## EXAMINATION:
VENOUS DUP UPPER EXT UNILATERAL RIGHT
## INDICATION:
year old woman with subarachnoid hemorrhage, HITT, now with
new significant right upper extremity edema. Please eval for right upper
extremity DVT vs SVT.
## FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
A venous line is noted within the right internal jugular vein, and a partial
thrombus is noted in the right internal jugular vein. There is lack of color
flow within the right subclavian vein reflecting deep vein thrombosis. There
is lack of compressibility in the axillary, brachial and basilic veins
reflecting deep vein thrombosis. Normal compressibility and color flow is
seen in the right cephalic vein.
## IMPRESSION:
Deep vein thrombosis extending from a at least the right subclavian vein into
the axillary, brachial and basilic veins. Partial thrombus seen in the right
internal jugular vein.
## NOTIFICATION:
The findings were discussed by Dr. with Dr.
on the at 10:28 , 5 minutes after discovery
of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18830695", "visit_id": "25124186", "time": "2137-01-21 21:49:00"} |
18234511-RR-116 | 208 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old man with metastatic rectal cancer on apixaban who
fell and hit his head.// Evaluate for intracranial bleed.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 6.0 s, 22.5 cm; CTDIvol = 45.6 mGy (Head) DLP =
1,026.6 mGy-cm.
Total DLP (Head) = 1,027 mGy-cm.
## FINDINGS:
Dental amalgam streak artifact limits study. There is no evidence of acute
territorial infarction, hemorrhage, edema, or large mass. Chronic lacunar
infarct in the left caudate head is again seen. There is prominence of the
ventricles and sulci suggestive of involutional changes. Atherosclerotic
vascular calcifications are noted of bilateral vertebral and cavernous
portions of internal carotid arteries.
There is no evidence of fracture. There is a small left frontoparietal scalp
hematoma. The paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The orbits are unremarkable. Minimal left parietal scalp soft
tissue swelling is noted (see 08:21).
## IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. No acute intracranial abnormality.
3. No evidence acute intracranial hemorrhage or fracture.
4. Minimal left parietal scalp soft tissue swelling.
5. Atrophy, chronic left caudate lacunar infarct, probable small vessel
ischemic changes, and atherosclerotic vascular disease as described.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18234511", "visit_id": "26285637", "time": "2188-03-01 22:30:00"} |
10149722-RR-86 | 117 | ## INDICATION:
with s/p fall right wrist, forearm, elbow, and shoulder pain
with swelling and ecchymosis, +/- headstrike// fx? sdh?
## FINDINGS:
There is deformity of the proximal right humerus which is compatible with old
healed fracture seen in . Differences in the degree of angulation could
be due to differences in projection though clinical correlation will be
necessary. Glenohumeral joint is anatomically aligned. Degenerative changes
again noted at the acromioclavicular joint.
## IMPRESSION:
Deformity of the proximal right humerus compatible with previously seen
fracture. No definite superimposed fracture. Differences in the degree of
angulation of the fracture could be due to differences in projection though if
high clinical concern for acute fracture, cross-sectional imaging could be
considered.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10149722", "visit_id": "N/A", "time": "2207-10-07 18:13:00"} |
17351318-RR-20 | 295 | ## INDICATION:
year old man with trauma to chest/abd with elevated WBC,
fever, and tachycardia and coughing up blood.// Evaluate for
intra-abdominal/chest abscess. Please give PO (Gastrografin contrast).
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 5.5 s, 1.0 cm; CTDIvol = 12.7 mGy (Body) DLP =
12.7 mGy-cm.
3) Spiral Acquisition 17.9 s, 68.7 cm; CTDIvol = 11.9 mGy (Body) DLP =
795.9 mGy-cm.
Total DLP (Body) = 830 mGy-cm.
## HEPATOBILIARY:
The liver is unremarkable except for a few stable hypodense
lesions too small to characterize. Gallbladder is unremarkable.
## GASTROINTESTINAL:
No bowel obstruction or ascites. No extraluminal oral
contrast.
## VASCULAR:
Abdominal aorta is normal in caliber. Major proximal tributaries
are patent.
## PELVIS:
No free pelvic fluid.
## BONES:
Comminuted fracture of the left posterior eleventh rib is
re-demonstrated (05:13). Comminuted fracture of the left anterior fifth rib
is also again noted (05:39).
## SOFT TISSUES:
Small foci of intramuscular/deep soft tissue emphysema are noted
on the left anterolateral chest wall at the site of the comminuted left
anterior rib fracture (5:38 and 39), decreased from prior. Postsurgical
changes are seen along the anterior abdominal wall.
## IMPRESSION:
1. Post splenectomy. No evidence of abdominopelvic fluid collection.
2. Re-demonstration of sequelae of trauma including comminuted fracture of the
left posterior eleventh and left anterolateral fifth ribs. Please see
separate report for intrathoracic findings from same-day CT chest.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17351318", "visit_id": "28544872", "time": "2167-12-08 07:58:00"} |
15205390-DS-12 | 1,939 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## OPERATION:
1. Ultrasound-guided puncture of left common femoral vein.
2. Advancement of catheter to bifurcation of inferior vena
cava.
3. Inferior venacavogram.
4. Deployment of Bard G2 inferior vena cava filter.
5. Ultrasound-guided puncture of right posterior tibial
vein.
6. Serial venogram of right lower extremity.
7. Balloon venoplasty of right posterior tibial vein, right
deep vein of the thigh and common femoral vein.
8. Mechanical/pharmacologic AngioJet thrombolysis of right
deep vein of the thigh and common femoral vein.
9. Placement of thrombolysis catheter.
## OPERATION:
1. Venogram performed through pre-existing right posterior
tibial vein sheath.
2. Balloon venoplasty of right posterior tibial vein,
popliteal vein, and distal deep vein of the thigh.
3. Replacement of thrombolysis catheter.
## OPERATION:
Right lower extremity venogram/lytic f/u
## PROCEDURE:
Drainage of right calf hematoma with drain
placement.
## HISTORY OF PRESENT ILLNESS:
Mr. is a year-old male with
a history of diabetes, HTN, CVA, transferred from with a diagnosis of bilateral PE/RLE DVT and
right lower extremity swelling concerning for compartment
syndrome. Per the patient, he started to notice increasing
shortness-of-breath with exertion approximately 2 weeks prior.
He noticed last some lightheadedness and went to see
his
PCP who found that he had a decline in his breathing capacity by
40% and increased exertional shortness-of-breath after 50 feet
of
walking. His condition continued and on was at the
when he had a sudden
lost-of-consciousness. He does remember any details other than
waking up to EMS personnel who brought him to . At , he underwent a Ct head which was
negative. A V/Q scan demonstrated extensive perfusion defects
in
bilateral lungs consistent with bilateral PEs and a RLE
ultrasound demonstrated a DVT extending from the SFV to the
popliteal. He further had a echocardiogram which showed dilated
RA/RV, moderate pulmonary hypertension, LVEF 55%, and a large RA
thrombus. He was immediately started on a heparin drip and has
been therapeutic as well as starting coumadin. He reports that
2
days ago while in the hospital have severe worsening of his
right
lower leg with inceased pain, swelling, and decreased mobility.
He was transferred from to for
further management of his right lower extremity pain and
swelling.
## VASCULAR RISK FACTORS:
Diabetes, Hypercholesterol, Hypertension,
Obesity.
## PAST MEDICAL HISTORY:
Sleep apnea (on CPAP at night), diabetes,
HTN, BPH, small aleft adrenal mass, CVA (recovered with
left sides hemiplegia), MVC with whiplash symptoms only,
bacteremia from questionable source of bird feces, struck
by lightning in , last colonscopy where 4 polyps
removed.
## PAST SURGICAL HISTORY:
wisdom teeth, tonsillectomy at years
of age, sinusitis surgery
## FATHER:
rheumatic fever with heart murmur
## MOTHER:
deceased from 3 types of cancer at yoa.
## NEURO/PSYCH:
Oriented x3, Affect Normal, NAD.
## NECK:
No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
## NODES:
No clavicular/cervical adenopathy, No inguinal
adenopathy.
## HEART:
Regular rate and rhythm.
## LUNGS:
Clear, Normal respiratory effort.
## GASTROINTESTINAL:
Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, No hernia, No AAA.
## EXTREMITIES:
No popiteal aneurysm, No femoral bruit/thrill, No
LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
## RLE FEMORAL:
P. Popiteal: P. DP: P. : P.
## LLE FEMORAL:
P. Popiteal: P. DP: P. : P.
## DESCRIPTION OF WOUND:
Right lower extremity tense posterior
compartment. needle used to measure compartments:
anterior 24 mm Hg, lateral 14 mm Hg, deep posterior 15 mm Hg,
and
superficial posterior 129, 130, and 131 mm Hg. Decreased
mobility at the ankle and toes. Decreased sensation from level
of
the knee to the toes.
## IMPRESSION:
Large hematoma within the medial head of the
gastrocnemius muscle in the right calf measuring 8.3 cm x 6.9 cm
x 20.3 cm. No evidence of active bleeding within the hematoma.
No evidence of arterial injury.
## BRIEF HOSPITAL COURSE:
Pt admitted on
Started on IV heperin, with PTT goal of 60-80
thought to have compartment sydrome, pressures measued, negative
for compartmetn pressure. CK's followed throughout the hospital
course. 4800 high last one was 2300. noticable down trend
Put on IV nahco3 anf po mucomyst protocol for hydration before
and after each procedure.
Consented for and recieved the below procedures.
## OPERATION:
1. Ultrasound-guided puncture of left common femoral vein.
2. Advancement of catheter to bifurcation of inferior vena
cava.
3. Inferior venacavogram.
4. Deployment of Bard G2 inferior vena cava filter.
5. Ultrasound-guided puncture of right posterior tibial
vein.
6. Serial venogram of right lower extremity.
7. Balloon venoplasty of right posterior tibial vein, right
deep vein of the thigh and common femoral vein.
8. Mechanical/pharmacologic AngioJet thrombolysis of right
deep vein of the thigh and common femoral vein.
9. Placement of thrombolysis catheter.
TPA overnight, fibrinogen levels checked q 4 hrs
heperin through sheath at 500 cc hr, PTT followed
The following day was brought in for lysis check
## OPERATION:
1. Venogram performed through pre-existing right posterior
tibial vein sheath.
2. Balloon venoplasty of right posterior tibial vein,
popliteal vein, and distal deep vein of the thigh.
3. Replacement of thrombolysis catheter.
TPA overnight, fibrinogen levels checked q 4 hrs
heperin through sheath at 500 cc hr, PTT followed
The following day was brought fore the below procedure
## OPERATION:
Right lower extremity venogram / lytic f/u
Sheath pulled without sequele.
IV heparin started, goal ws
Pt calf was continually monitered for compartment syndrome, CK's
were monitered. We decided to get a US which showed hematoma. We
then got a CTA.
We decided to take him to the OR for draiange of hematoma.
Preop'ed and consented
## PROCEDURE:
Drainage of right calf hematoma with drain
placement.
JP in place x two days. When drainage was negative, JP pulled
without sequele.
On Dc IV heparin stopped, started on Lovenox / coumadin bridge.
recommends rehab. Pt stable for rehab.
## MEDICATIONS ON ADMISSION:
metformin 500 mg bid, glipizide 5 mg daily, simvastatin 40 mg
daily, lisinopril 20 mg daily, gemfibrozil 600 mg daily
## DISCHARGE MEDICATIONS:
1. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO BID (2 times a day).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Insulin
Insulin SC
Sliding Scale
Fingerstick q6hr
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units
120-159 mg/dL 2 Units
160-199 mg/dL 4 Units
200-239 mg/dL 6 Units
240-279 mg/dL 8 Units
280-319 mg/dL 10 Units
320-359 mg/dL 12 Units
360-399 mg/dL 14 Units
> 400 mg/dL M.D.
14. Lovenox mg/0.8 mL Syringe Sig: One (1) 110 mg
Subcutaneous twice a day: please waist 10 mg for a dose of 110
mg. Stop when INR is 2.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Coumadin 6 mg Tablet Sig: Two (2) Tablet PO once a day: 12
mg daily, please stop lovenox whrn INR is 2.
## DISCHARGE DIAGNOSIS:
RLE DVT
Calf hematoma
stress incontinance
## DISCHARGE INSTRUCTIONS:
Deep vein thrombosis - discharge
Alternate Names
DVT - discharge; Blood clot in the legs - discharge;
Thromboembolism discharge
Description
Deep venous thrombosis (DVT) is when a blood clot forms in a
vein that is not on the surface of the body.
It mainly affects the large veins in the lower leg and thigh.
The clot can block blood flow. If the clot breaks off and moves
through the bloodstream, it can get stuck in the brain, lungs,
heart, or other area, leading to severe damage.
Self-care
Wear the pressure stockings prescribed by your doctor. They will
improve blood flow in your legs and lower your risk for problems
with blood clots.
Avoid letting the stockings become very tight or wrinkled.
If you use lotion on your legs, let it dry before you put the
stockings on.
Put powder on your legs to make it easier to put on the
stockings.
Wash the stockings each day with mild soap and water, rinse, and
air dry.
Be sure you have a second pair of stockings to wear while the
other pair is being washed.
If your stockings feel too tight, tell your doctor or nurse. Do
not just stop wearing them.
Your doctor may give you medicine to thin your blood. This will
help keep more clots from forming.
Take the medicine just the way your doctor prescribed it.
Know what to do if you miss dose.
You may need to get blood tests often to make sure you are
taking the right dose.
Ask your doctor what exercises and other activities are safe for
you to do.
Do not sit or lie down in the same position for long periods of
time.
Do not cross your legs when you sit.
Do not sit so that you put steady pressure on the back of your
knee.
Prop up your legs on a stool or chair if your legs swell when
you sit.
Keep your legs resting 6 inches above your heart. When sleeping,
make the foot of the bed 4 to 6 inches higher than the head of
the bed.
Do not wear tight clothing on your legs or around your waist. If
your clothes leave a mark in your skin, they are too tight.
## WHEN TRAVELING:
By car -- stop often, and get out and walk around for a few
minutes.
On a plane, bus, or train -- get up and walk around often.
While sitting in a car, bus, plane, or train -- wiggle your
toes, tighten and relax your calf muscles, and shift your
position often.
Do not sit with your legs crossed.
Do not smoke. If you do, ask your doctor for help quitting.
Drink at least 6 to 8 cups of liquid a day, if your doctor says
it is okay.
Try to use less salt.
Do not add extra salt to your food.
Do not eat canned foods and other processed foods that have a
lot of salt.
Read food labels to check the amount of salt (sodium) in foods.
Ask your doctor how much sodium is okay for you to eat each day.
When to Call the Doctor
## CALL YOUR DOCTOR IF:
Your skin looks pale, blue, or feels cold to touch.
You have more swelling in your leg.
You have fever or chills.
You are short of breath (it is hard to breathe).
You have chest pain, especially when it gets worse upon taking a
deep breath in.
You cough up blood.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15205390", "visit_id": "21077917", "time": "2170-08-27 00:00:00"} |
15454044-DS-12 | 996 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
R L3-4 foramenotomy
redo R L3-4 foramenotomy
## HISTORY OF PRESENT ILLNESS:
s/p lumbar lamincectomy with return of right leg pain.
## PAST MEDICAL HISTORY:
- temporal arteritis
- rheumatoid arthritis
- pericarditis
- pericardial effusion
- atrial fibrillation and atrial flutter thought most likely
secondary to atrial irritation with the pericardial effusion
- pleural effusion, left-sided, thought secondary to RA
- CAD s/p remote inferior MI; negative stress test in
- CHF
- HTN
- hypercholesterolemia
- GERD
## FAMILY HISTORY:
Mother with MI in , brother with heart disease in ,
father with MI in .
## PHYSICAL EXAM:
a and 0 x3
lungs:cta
ht rrr
abd soft NT
motor full
sensation intact
## BRIEF HOSPITAL COURSE:
Pt was admitted electively and brought to the OR where
under general anesthesia she underwent right L3-4
foraminotomy/decompression. She tolerated this procedure well,
was extubated, transferred to PACU and then floor when stable.
Post op she continued to complain of right leg pain. Work up
revealed continued compression of nerve root and she returned to
for re-do decompression. Again she tolerated this
procedure well. Post op her leg pain was improved. Her diet and
activity were increased. Her foley was removed. Her incision
was clean and dry. She was evakuated by and recommended for
rehab.
## ALBUTEROL 90 MCG/ACTUATION AEROSOL SIG:
Two (2) Puff Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
## PREGABALIN 75 MG CAPSULE SIG:
One (1) Capsule PO bid ().
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
## MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
Oxycodone 5 mg Tablet Sig: Tablets PO Q3H (every 3 hours)
as needed.
Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
resume once decadron taper is finished.
## DISCHARGE MEDICATIONS:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO bid ().
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
## 9. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
11. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day) as needed for back spasms/pain.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Oxycodone 5 mg Tablet Sig: Tablets PO Q3H (every 3
hours) as needed.
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed for fever or pain.
18. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day) for 3 doses.
19. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 doses.
20. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) for 3 doses.
21. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
23. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): resume once decadron taper is finished.
## DISCHARGE INSTRUCTIONS:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
· Do not smoke
· Keep wound clean / No tub baths or pools until seen in
follow up / begin daily showers
· No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
· Limit your use of stairs to times per day
· Have a family member check your incision daily for
signs of infection
· You are required to wear back brace when out of bed
until see Dr. in follow up.
· You may shower without the back brace.
· Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
· Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for one week.
· Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
· Clearance to drive and return to work will be addressed
at your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
## FOLLOWING:
· Pain that is continually increasing or not relieved by
pain medicine
· Any weakness, numbness, tingling in your extremities
· Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
· Fever greater than or equal to 101° F
· Any change in your bowel or bladder habits
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15454044", "visit_id": "27627668", "time": "2114-07-14 00:00:00"} |
12081472-RR-4 | 111 | ## INDICATION:
Chronic cough and CHF, rule out pneumonia.
There are no prior studies for comparison.
PA and lateral views of the chest: There are no consolidations or pleural
effusions. Heart size is normal. There is an opacified nodular density in
the right mid lung. The aorta demonstrates calcification and tortuosity.
Thoracic spine demonstrates kyphosis and vertebral flattening consistent with
demineralization. There is marked degenerative change in the left
glenohumeral joint.
## IMPRESSION:
No CHF or pneumonia. Nodule in the right mid lung. Kyphosis and
vertebral flattening. Recommend comparison to prior outside films if these
are available, or obtain followup film in three months to evaluate the right
mid lung nodule.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12081472", "visit_id": "N/A", "time": "2161-09-16 10:03:00"} |
17718522-RR-34 | 137 | ## EXAMINATION:
Nasal intestinal tube placement.
## INDICATION:
year old man with h/o malnutrition s/p liver transplant please
replace clogged feeding tube// Please replace clogged feeding tube
## DOSE:
Acc air kerma: 6 mGy; Accum DAP: 106.0 uGym2; Fluoro time: 2:00
## FINDINGS:
The declogging of the existing Dobhoff was unsuccessfully. The right nare was
anesthetized with lidocaine jelly. Under intermittent fluoroscopic guidance,
the new Dobhoff feeding tube was advanced post-pylorically using a guidewire.
10 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in the third
portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
## IMPRESSION:
Successful post-pyloric advancement of a Dobhoff feeding tube. The tube is
ready to use.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17718522", "visit_id": "N/A", "time": "2128-05-30 12:14:00"} |
14737169-RR-84 | 328 | ## INDICATION:
CHF status post mechanical fall with C3 fracture and cord
compression with failed speech and swallow exam.
## RADIOLOGISTS:
Dr. Dr. attending physician, who
performed the procedure. The exam was supervised by Dr. .
## PROCEDURE AND FINDINGS:
The risks and benefits of the procedure were
explained to the patient, and signed informed consent was obtained. A pre-
procedural timeout was performed. The patient was placed supine on the
angiographic table, and the abdomen was prepped and draped in usual sterile
fashion. The stomach was insufflated through NG tube, and no overlying bowel
loops were identified. An adequate position for percutaneous puncture was
assessed, and the skin was anesthetized with 1% local lidocaine. Under
fluoroscopic guidance, a 19 gauge needle was advanced into the stomach. After
gastric air was returned, a T-fastener was deployed and sutured to the skin.
Two additional T- fasteners were placed in similar fashion, forming a 2 cm
apart triangle. A final gastric puncture was then performed at the
the T- fastener configuration and a 0.035 inch Amplatz wire was advanced and
curled in the stomach. The needle was then exchanged for a 5 sheath
and sequentially dilated until a 12 peel-away sheath could be inserted.
A G- tube was then inserted into the gastric antrum. The wire
and sheath were removed, and the catheter tip was curled in the stomach and
secured. 5 ml contrast was injected confirming proper position without
evidence for extravasation. The G tube was sutured to the skin and dressed.
The patient tolerated the procedure well without immediate complication.
Moderate sedation was provided by administering divided doses of Versed and
fentanyl throughout the total intra-service time of 45 minutes during which
the patient's hemodynamic parameters were continuously monitored.
Total fluoroscopy time was approximately three minutes.
## IMPRESSION:
Successful percutaneous G-tube placement. The tube will be ready
for use in 24 hours. The T-fastener skin sutures can be cut and released in
seven days.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14737169", "visit_id": "N/A", "time": "2158-01-16 10:23:00"} |
10750885-RR-38 | 115 | ## INDICATION:
year old woman with h/o fibroids now with pelvic
pain/bloating// eval for fibroids
## FINDINGS:
The uterus is retroflexed and measures 13.1 x 6.5 x 8.4 cm, not significantly
changed from prior. There are multiple fibroids seen including a few which
are subserosal.. The largest is in the left fundal region and measures 4.2 x
3.5 cm enlarged compared to prior when it measured up to 2.6 cm. The
endometrium is homogenous and measures 4 mm.
The ovaries are normal. There is no free fluid.
## IMPRESSION:
1. Enlarged uterus with multiple fibroids. Overall uterine size not
significantly changed. The largest fibroid is increased in size.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10750885", "visit_id": "N/A", "time": "2189-08-25 11:29:00"} |
17937834-DS-3 | 792 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
This is a year with HTN, old Type one diabetic complicated by
gastroparesis, retinopathy and chronic renal disease who
presents after days of not feeling well.
.
Patient reports feeling poorly over the past 3 days and not
taking in much food/fluid. Notes feeling mainly when standing.
Symptoms similar to prior experience when he was too large of a
dose of labetalol and blood pressures got low. Denies symptoms
consistent with his gastroparesis. No N/V/D, fever/chills, no
night sweats. No cough/sob/chest pain/palpitations. No
headache/vision changes/neck stiffness. Patient denies night
sweats, new lumps/bumps. He did note a 20 lbs weight loss a few
weeks back but felt this was during a period when they were
trying to get his gastroparesis regimen improved.
.
Denies sick contacts. Recent travel or new exposures. No bug
bites.
.
In the ED initial vitals, 98.7 73 105/65 18 100. Orthostatic
performed Supine- HR 66, BP 171/97, Sitting- HR 70, BP 139/92,
Standing- HR 84, BP 109/65. Given 2 liters NS. Blood sugars were
in the and the patient was given food, sugar packets to
raise the blood sugar over 100. Prior to transfer the patient's
clonidine patch was removed.
.
On the floor, the patient states while laying down he feels
well.
## TYPE ONE DIABETES YEARS):
Compliated by gastroparesis,
retinopathy, chronic renal disease)
HTN
HLD
Syndrome
Asthma
## FAMILY HISTORY:
Father with CAD/MI. Mother Cancer
## HEENT:
MMM, sclera anicteric, No pharyngeal erythema
## EXT:
No lower extremity edema
## SKIN:
No obvious rashes
.
## BRIEF HOSPITAL COURSE:
Pt is a year HTN, old Type one diabetic complicated by
gastroparesis, retinopathy and chronic renal disease who
presented after days of "not feeling well".
.
#. Orthostatic Hypotension: considered most likely in setting of
poor PO intake and dehydration. Patient had already noticed
improvement in symptoms with one liter IVF. He received further
IVFs and continued to feel even better. His orthostatic symptoms
abated prior to discharge.
.
#. Anemia: continued procrit, Hct stayed at 29 during this
admission
.
#. Acute on Chronic Kidney Failure: Per ED report creatinine
baseline at 3.2. So not a large change on admission, remained
stable during this admission.
.
#. Insulin Dependent Diabetes: stable during his stay on home
lantus and HISS.
.
#. HTN: Pressure elevated on admission: 170/129 - No sign of
hypertensive emergency. His home medications of lisinopril and
catapres were continued and his BP decreased during the day.
.
## MEDICATIONS ON ADMISSION:
Simvastain 20mg QHS
Novolog Sliding Scale with meals
Catapres-TTS-3 0.3mg/24 hr, change weekly
Lantus 7units Am and 7u at bedtime
Erythromycin 250mg TID and before bedtime
Compazine 25mg suppository BID PRN Nausea
Lisinopril 30mg Daily
Vitamin D 1,000 units daily
Metoclopramide one tab TID
Prilosec 20mg TID
Procrit 10,000U every other week
## DISCHARGE MEDICATIONS:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Catapres-TTS-3 0.3 mg/24 hr Patch Weekly Sig: One (1)
Transdermal once a week.
5. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID W/MEALS (3 TIMES A DAY
WITH MEALS).
6. Procrit 10,000 unit/mL Solution Sig: One (1) Injection every
other week.
7. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO three times a day.
8. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
9. Prochlorperazine 25 mg Suppository Sig: One (1) Rectal twice
a day.
10. Insulin Glargine 100 unit/mL Solution Subcutaneous
11. insulin sliding scale
Please resume pre-admission insulin sliding scale.
## DISCHARGE INSTRUCTIONS:
You were admitted to the for
lightheadedness and dizziness. At this time, the most likely
explanation for your symptoms is dehydration secondary to
decreased eating and drinking. We gave you IV fluids and your
blood pressures and overall clinical state improved. You were
deemed stable for discharge home with close follow-up with your
primary care physician. During your stay you were placed on an
insulin regimen that was different than your home regimen. This
caused your blood sugar to drop but quickly increased after you
received juice.
During your stay we changed some of your medications, when you
leave you should continue all your medications as prescribed by
your physician.
You should call your physician or return to the emergency room
if you feel light-headed or dizzy.
Please make sure to drink plenty of fluids especially during hot
days.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17937834", "visit_id": "26028786", "time": "2139-09-13 00:00:00"} |
19010275-RR-83 | 177 | ## INDICATION:
with 2d dizziness, falls with weakness in UMN pattern,
unsteady gait// ?acute vs subacute stroke
## FINDINGS:
Study is mildly degraded by motion. no acute intracranial infarct or
hemorrhage. The intracranial arteries demonstrate normal T2 flow voids. There
is moderate generalized cerebral atrophy with ex vacuo dilatation of the
ventricular system. Mild periventricular deep white matter T2 and FLAIR
hyperintense changes are most likely sequela of microangiopathy.
Approximately 5 mm left CP angle area of increase susceptibility and
isointense T2 signal is again noted (see 4, 5: 6), corresponding to area of
calcification on prior noncontrast head CT (see 2:6 on prior head CT).
Partially empty sella. The orbits are preserved. There is mild mucosal
thickening involving the paranasal sinuses.
## IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute infarct or acute intracranial hemorrhage.
3. 5 mm calcific density in the left cerebellar pontine angle is nonspecific
and may represent a calcified meningioma or dural calcification. If
clinically indicated, consider contrast brain MRI for further evaluation.
4. Paranasal sinus disease , as described.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19010275", "visit_id": "26332263", "time": "2193-01-30 22:06:00"} |
15642566-DS-6 | 4,880 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
y/o F with h/o Afib on Pradaxa s/p mvc, transfer from
. The patient was the restrained rear passenger involved
in an MVC earlier tonight, presumed front air bag deployment;
accident occurred 4 hours PTA. Patient with some swelling,
neck and back pain, as well as L arm tingling. CT C-spine with
C1-2 ligament disassociation with hematoma. Patient with L2 TP
fx, L 3rd rib fx. NCHCT without acute abnormalities. Patient
transferred here for further
management. Denies weakness, numbness, N/V/D, chest pain,
dyspnea, or any other sx at this time.
## PMH:
A Fib on Pradaxa
Stage 2a Breast CA on anastrazole
CAD no known stents or CABG
CHF
## GENERAL:
NAD, A&Ox4
nl resp effort
RRR
## SENSORY:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT
T2-L1 (Trunk)
SILT
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
## NO BEATS
PERIANAL SENSATION:
Normal
Rectal tone: Intact
DISCHARGE PHYSICAL EXAM
=========================
## HEENT:
AT/NC, anicteric sclera, MMM, good dentition
## NECK:
not able to examine due to J-collar
## HEART:
irregularly irregular rhythm, normal rate, normal S1/S2,
no murmurs, gallops, or rubs
## LUNGS:
CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
## ABDOMEN:
nondistended, +BS, nontender, no rebound/guarding
## EXTREMITIES:
no cyanosis, clubbing or edema, left lower
extremity
no longer in splint, left wrist in splint, J-collar on
## SKIN:
no lesions, no rashes
## MICRO
==========
4:07 PM URINE SITE:
NOT SPECIFIED
CHEM RED TOP.
**FINAL REPORT
URINE CULTURE (Final :
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 CFU/mL.
## SENSITIVITIES:
MIC expressed in
MCG/ML
ESCHERICHIA COLI
|
AMPICILLIN
-----
=>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN
-----
=>64 R
CEFEPIME
-----
R
CEFTAZIDIME
-----
4 S
CEFTRIAXONE
-----
=>64 R
CIPROFLOXACIN
-----
=>4 R
GENTAMICIN
-----
<=1 S
MEROPENEM
-----
<=0.25 S
NITROFURANTOIN
-----
<=16 S
PIPERACILLIN/TAZO
-----
<=4 S
TOBRAMYCIN
-----
<=1 S
TRIMETHOPRIM/SULFA
-----
<=1 S
PERTINENT STUDIES
===================
SUPINE AP CHEST XRAY
## FINDINGS:
Lung volumes are low. Heart size is mildly enlarged. Aorta is
unfolded.
Mediastinal and hilar contours are grossly unremarkable. There
is crowding of bronchovascular structures due to low lung
volumes. Mild hazy opacification overlying the peripheral
aspect of the right lung base and projecting over the
costophrenic angle on the left may reflect areas of contusion.
No large pleural effusion or pneumothorax is seen on this supine
exam, though suspect a tiny right-sided pneumothorax. Multiple
bilateral displaced rib fractures are seen, most notably of the
right third, fourth, fifth, and sixth ribs as well as the left
sixth and seventh ribs.
## IMPRESSION:
Multiple displaced bilateral rib fractures with probable small
right
pneumothorax. Hazy opacities overlying the peripheral aspects
of both lung bases are nonspecific, may reflect areas of
pulmonary contusion or small pleural effusion.
CT CHEST ABDOMEN PELVIS WITH CONTRAST
## HEART AND VASCULATURE:
The thoracic aorta is normal in caliber
without
evidence of acute injury. Coronary artery calcifications are
mild. No
pericardial effusion.
## AXILLA, HILA, AND MEDIASTINUM:
No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal hematoma. Trace
locule of air is demonstrated in the left anterior superior
mediastinum (02:40).
## PLEURAL SPACES:
Small right and trace left mildly complex
pleural effusions,likely compatible with hemothorax. Trace
pneumothorax in the right lung apex ( ).
## LUNGS/AIRWAYS:
Diffuse interstitial opacities may reflect a
chronic
interstitial lung abnormality, potentially related to advanced
age. Mild
bibasilar atelectasis. The airways are patent to the level of
the segmental bronchi bilaterally.
## BASE OF NECK:
There are small foci of air seen along the left
anterior
thoracic wall (02:45). 4 mm hypodense nodule in the left
thyroid gland does not require imaging follow-up.
## HEPATOBILIARY:
Probable hepatic steatosis. There is no evidence
of focal
lesion or laceration. 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 lesion or laceration.
## 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. Small bilateral renal hypodensities are too
small fully characterize. No hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal. There is no evidence of
mesenteric injury.
There is no free fluid or free air in the abdomen.
## PELVIS:
The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The endometrial cavity is distended
measuring up to 1.3 cm (608:82). There is a 5.6 x 4.6 x 3.0 cm
mass in the left adnexa
demonstrating coarse calcifications and macroscopic fat (2:199,
608:84)
compatible with a teratoma. No right adnexal abnormalities are
seen.
## LYMPH NODES:
There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
## VASCULAR:
Focus of active extravasation is demonstrated in the
left upper
quadrant in the anterior left pararenal space with associated
soft tissue
stranding and hematoma (2:110, 601:82).There is no abdominal
aortic aneurysm or retroperitoneal hematoma. Moderate
atherosclerotic disease is noted.
## BONES:
Multiple rib fractures as detailed below:
-Nondisplaced fracture of the right C7 transverse process
(03:27).
-Nondisplaced fracture of the right first anterior costochondral
junction
(03:51).
-Mildly displaced fractures of the anterior right second, third,
and fourth ribs.
-Mildly displaced fractures of the lateral right fourth, fifth,
sixth, and
seventh ribs.
-Nondisplaced fractures involving the posterior right third,
fourth, fifth and seventh ribs near the costovertebral junction.
-Displaced fractures involving the lateral left fifth, sixth,
seventh and
eighth ribs. Nondisplaced fractures of the lateral left fourth,
ninth and
tenth posterolateral ribs.
Multilevel degenerative changes of the thoracolumbar spine are
moderate. No suspicious osseous abnormalities are detected.
## SOFT TISSUES:
2.3 x 2.0 cm soft tissue density nodule in the
right breast with clip (3:81).
## IMPRESSION:
1. Active extravasation and hematoma in the left upper quadrant
without
evidence of a solid organ injury.
2. Trace right apical pneumothorax and trace pneumomediastinum.
3. Small right and trace left hemothorax.
4. Nondisplaced right C7 transverse process fracture and
multiple bilateral rib fractures, several which are segmental
fractures on the right, as detailed above.
5. Thickened endometrium measuring up to 1.3 cm. Recommend
pelvic ultrasound once patient's condition stabilizes, and if
clinically indicated.
6. 2.3 cm soft tissue density nodule in the right breast with
clip. Recommend correlation with prior surgical history and
breast imaging.
7. 5.6 cm left adnexal teratoma.
CTA NECK WITH AND WITHOUT CONTRAST
## FINDINGS:
There are moderate atherosclerotic changes affecting major neck
vasculature. Right and left common carotid arteries show
tortuous retropharyngeal course without luminal narrowing,
dissection or thrombosis.
Retropharyngeal course of right internal carotid artery with
mild calcified atherosclerotic plaques at the origin with no
significant stenosis dissection or occlusion. Left internal
carotid artery show no significant stenosis; dissection or
thrombosis. By NASCET criteria, there is no significant
stenosis of the both ICA and.
At included intracranial components of both ICA show
moderate-to-severe
calcified atherosclerotic plaques with about 50% luminal
narrowing at
supraclinoid ICA bilaterally.
Background of moderate noncalcified atherosclerotic changes
affecting both
cervical and included intracranial vertebral arteries with no
significant
stenosis, dissection or occlusion. Hypoplastic left vertebral
artery as
normal variant.
Increased atlantodental interval measuring 8 mm is suggestive of
transverse ligament disruption. There is a hyperdensity
posterior to the dens abutting the spinal cord is concerning for
epidural hematoma (02:147).
Right C5-C7 transverse process fractures are present, but do not
appear to
extend through the transverse foramina (2:104, 95, and 83).
There is a trace left apical pneumothorax. There is trace
pneumomediastinum. Subcutaneous mphysema and hematoma is noted
along the left anterior chest wall. Small bilateral pleural
effusions/hematoma are present. Ground-glass appearance of the
lungs could be related to expiratory phase versus pulmonary
edema.
Additional thoracic findings dictated in the separate chest CT
report.
## IMPRESSION:
1. No acute traumatic injury affecting major neck vasculature on
background of moderate atherosclerotic changes.
2. Moderate-to-severe atherosclerotic changes affecting
supraclinoid internal carotid arteries.
3. Minimally displaced fractures at right transverse process of
C5-C7 as well as left anterior fair rib.
LEFT ANKLE XRAY
## FINDINGS:
No acute fracture or dislocation. Ankle mortise is grossly
symmetric. Talar dome is smooth. No concerning lytic or
sclerotic osseous abnormalities. Moderate-sized dorsal
calcaneal spur. Mild-to-moderate degenerative spurring in the
midfoot. Soft tissue swelling is noted overlying the ventral
aspect of the distal tibia.
## IMPRESSION:
No acute fracture or dislocation.
LEFT KNEE AND TIB/FIB XRAY
## FINDINGS:
No acute fracture or dislocation. Severe degenerative changes
of the left
knee are most pronounced in the patellofemoral and medial
compartments with
bone-on-bone articulation, large osteophyte formation, and
subchondral
sclerosis. A large joint effusion is present. No suspicious
lytic or
sclerotic osseous abnormality. Additionally, marked soft tissue
swelling is
noted ventral and medial to the mid tibia.
## IMPRESSION:
1. No acute fracture or dislocation.
2. Large suprapatellar joint effusion and marked soft tissue
swelling
overlying the ventral and medial aspect of the mid tibia.
3. Severe degenerative changes of the left knee.
SPLENIC EMBOLIZATION
## FINDINGS:
1. Celiac arteriogram demonstrates no focus of extravasation
overlying the
left upper quadrant.
2. Selective splenic arteriogram demonstrates no extravasation
from the main
splenic artery, any of the branches arising from the splenic
artery, or on
delayed filling, from the splenic vein in the site noted on CTA.
No
pseudoaneurysm.
3. Selective GDA arteriogram demonstrates no sites of
extravasation
pseudoaneurysm arising from the GDA territory, including the
right
gastroepiploic artery, which is well seen.
4. SMA arteriogram demonstrates no focus of extravasation,
pseudoaneurysm, or
arterial irregularity.
## IMPRESSION:
Detailed angiography of celiac, splenic, GDA/right
gastroepiploic artery, and
SMA demonstrate no focus of extravasation or pseudoaneurysm
within the left
upper quadrant.
MRI CERVICAL SPINE WITHOUT CONTRAST
## FINDINGS:
There is widening of the atlantodental interval to 6 mm,
unchanged from CT
cervical spine obtained 10 hours prior in a similar measurement.
There is T1
hypointense, mixed T2 hypo/hyper, and stir heterogeneous signal
around the
atlanto-dental interval and extending posteriorly to the dens,
likely
representing posttraumatic edema on a background of chronic
degenerative
change and possible pannus formation. There is a subchondral
cyst in the
posterior dens (3:9). There is trace prevertebral edema at
C2-C3. There is
also edema underlying the alar ligament superior to the dens,
and along the
posterior longitudinal ligament at C2 (3:9). There is no
definite disruption
of the posterior longitudinal ligament.
Right-sided C5 through C7 transverse process fractures are
better evaluated on
prior CT. There is minimal anterolisthesis of C3 on C4. There
is small
scattered areas of focal fat, otherwise marrow signal is within
normal limits.
The visualized portion of the spinal cord is preserved in signal
and caliber.
Apparent linear increased STIR signal at C3-4 and C4-5 is most
consistent with
artifact.
Intervertebral discheightsare narrowed at multiple levels and
there is signal
change consistent with multilevel disc desiccation.
At C2-3 there is no vertebral canalnarrowing but uncovertebral
hypertrophy and
facet osteophytes causing moderate right and mild left neural
foraminal
narrowing.
At C3-4 there is disc bulge with mildvertebral canaland
uncovertebral
hypertrophy and facet osteophytes causing severe bilateral
neural foraminal
narrowing..
At C4-5 there is a posterior disc osteophytes and disc bulge,
causing
effacement of the CSF space and severe vertebral canal
narrowing. There is
uncovertebral hypertrophy causing severe bilateral neural
foraminal
narrowing..
At C5-6 there is disc bulge with moderate to severevertebral
canaland
uncovertebral and facet hypertrophy causing severe bilateral
neural foraminal
narrowing..
At C6-7 there is disc protrusion with mild to moderatevertebral
canal
narrowingand uncovertebral hypertrophy causing severe bilateral
neural
foraminal narrowing..
At C7-T1 there is disc bulge, facet hypertrophy, and ligamentum
flavum
thickening causing mild vertebral canal narrowing and mild
bilateral neural
foraminal narrowing..
## OTHER:
Within the limits of this noncontrast study there is no evidence
of infection
or neoplasm. The visualized portion of the posterior fossa,
cervicomedullary
junction, paranasal sinuses and lung apicesare preserved.
## IMPRESSION:
1. Unchanged widening of the atlantodental interval at 6 mm
compared to prior
CT cervical spine from 10 hours prior. Signal changes at the
craniocervical
junction, as above, likely represent a combination of
posttraumatic edema
about the dens and prevertebral space, on a background of
chronic degenerative
change and pannus formation.
2. Edema underlying the alar ligament and posterior longitudinal
ligament at
C2 without definite ligamentous disruption.
3. Moderate to severe degenerative change in the cervical spine
most severe at
C4-5 and C5-6, as above.
4. Please refer to recent CT cervical spine for better
visualization of
right-sided C5 through C7 transverse process fractures.
LEFT WRIST XRAY
## FINDINGS:
There is a partially visualized displaced fracture of the third
metacarpal.
There is no fracture or dislocation of the radius or ulna.
There are
degenerative changes about the first CMC. Carpal bones are well
aligned.
There are densities within the soft tissues of the forearm which
likely
represent dystrophic calcifications.
## IMPRESSION:
1. Displaced fracture of the base of the third metatarsal.
2. Moderate osteoarthritis of the first CMC joint.
## RECOMMENDATION(S):
Dedicated radiographs of the left hand are
recommended to
further evaluate the third metacarpal fracture and to assess for
other bony
abnormality.
LEFT HAND XRAY
## IMPRESSION:
There is an oblique fracture of the proximal half of the third
metacarpal.
Moderate degenerative changes are seen in the first CMC joint.
CTA CHEST ABDOMEN PELVIS
## LOWER CHEST:
Large bilateral pleural effusions, larger than in prior studies,
associated to
compressive atelectasis of the lower lobes. Stable
cardiomegaly.
## 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. Between the splenic hilum in the
greater curvature
of the stomach there is a hematoma with no evidence of active
extravasation,
more organized as compared to prior study and relatively
unchanged in size
measuring 6.0 x 4.1 cm.
## ADRENALS:
The right and left adrenal glands are normal in size
and shape.
## URINARY:
The kidneys are normal and symmetric in size with
normal nephrogram.
Focal cortical defect noted in the inferior pole of the right
kidney (303:78),
likely sequela from prior infection. There is no perinephric
abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. The visualized
segments of
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.
## LYMPH NODES:
There is no retroperitoneal or mesenteric
lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or new
fracture.
Multiple left rib fractures are re-visualized.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal
limits.
## IMPRESSION:
1. Mesenteric hematoma seen between the greater curvature of the
stomach in
the splenic hilum, relatively unchanged in size with a more
organized
appearance as compared to prior study from . There
is no evidence
of active extravasation.
2. Interval increase in size of the bilateral pleural effusions,
which appear
nonhemorrhagic.
CHEST XRAY
## FINDINGS:
There is no definite pneumothorax on the right or the left. The
previously
seen multiple rib fractures are re-demonstrated. The cardiac
silhouette is
enlarged but stable. There is worsening pulmonary vascular
congestion
compared to prior study on . There is increased
density of the
right lower lobe, which is likely consistent with superimposed
right-sided
pleural effusion. There is no definite pneumonia, although
evaluation is
limited. The right PICC line is seated within the mid-SVC.
## IMPRESSION:
1. Increased pulmonary vascular congestion.
2. Increased right pleural effusion.
ABDOMINAL XRAY
## FINDINGS:
There are distended loops of large bowel without evidence of
small bowel for
large bowel obstruction. There are no pathologically dilated
loops of bowel.
Free intraperitoneal air is better assessed with an upright
radiograph however
on the supine film there is no large volume free intraperitoneal
air.
Osseous structures are notable for left eighth, ninth, and tenth
rib
fractures. There is chondrocalcinosis of the costal
cartilage.
There are multiple rounded radiopacities within the left lower
pelvis which
appear stable in appearance from prior. These may reflect a
calcified
component of a teratoma given the left adnexal mass seen on
recent CT of the
pelvis.
There is blunting of the left and right costophrenic angles with
a left sided
pleural effusion. The stability of this finding would be better
visualized
with a chest radiograph.
## IMPRESSION:
1. No pathologically dilated loops of bowel to suggest
obstruction or ileus.
2. Multiple left-sided rib fractures.
3. Calcific density within the left lower pelvis likely reflects
calcified
components of a teratoma in the setting of the left adnexal mass
seen on
recent CT from
DISCHARGE LABS
=====================
05:30AM BLOOD WBC-15.2* RBC-2.91* Hgb-8.5* Hct-26.6*
MCV-91 MCH-29.2 MCHC-32.0 RDW-14.8 RDWSD-48.5* Plt
05:19AM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-134*
K-4.2 Cl-98 HCO3-27 AnGap-9*
05:19AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0
## SUMMARY STATEMENT:
====================
female with history of atrial fibrillation on
dabigatran, congestive heart failure, coronary artery disease,
recently diagnosed breast cancer (followed at on
neoadjuvant Anastrazole) who presented following motor vehicle
collision, found to have transverse C7 fracture with C1-C2
ligamentous injury, several rib fractures, and oblique fracture
of the proximal left third metacarpal. Due to concern for
splenic hemorrhage her Pradaxa was reversed with idarucizumab
and she had angiography which did not identify any active
extravasation. Her fractures were managed nonoperatively and
she was placed in c-collar as well as left volar splint on
the wrist. Due to hyponatremia and dyspnea, she was transferred
to the medicine service where it was determined this was most
likely due to iatrogenic fluid overload. These issues both
resolved with holding IV fluids and resumption of home
torsemide. She had a UTI treated with 3 days of nitrofurantoin.
She was discharged to rehab facility with orthospine, hand
surgery, and new cardiology follow-up.
## TRANSITIONAL ISSUES:
====================
[] Nonweightbearing left upper extremity, activities of daily
living as tolerated, patient may range the digits gently as well
as the thumb. Continue volar splint until follow-up.
[] Follow up in ortho spine fellow clinic in weeks for
radiographic and clinical re-evaluation.
[] Patient connected with cardiologist on discharge. Consider
just continuation of trend in favor of DOAC as well as
discontinuation of digoxin if feasible. Consider outpatient TTE
to assess global systolic function as well as etiology of atrial
fibrillation.
[] Mildly elevated TSH of 12 identified on evaluation of
hyponatremia, recommend following up with PCP 4 to 6 weeks
for further evaluation. She was not started on thyroid
replacement.
[] Patient received antibiotics from to (ceftriaxone
and nitrofurantoin).
[] Patient noted to have mildly elevated white count throughout
her stay. Is also noted that her baseline was mildly above
normal based on prior labs. Recommend checking CBC as an
outpatient to ensure resolution.
[] Follow-up with oncologist at as needed for
management of recently diagnosed breast cancer.
## ACTIVE ISSUES:
==============
# Motor vehicle collision
# C1-C2 ligamentous injury
# Transverse C5-C7 fractures
# Concern for splenic hemorrhage
# Left metacarpal fracture
Ms. is an s/p MVC, transferred from outside hospital
with multiple bilateral rib fractures, Right hemothorax,
pneumomediastinum, left upper quadrant extravasation status post
non-therapeutic angiography (no active extravasation was
seen), C1-C2 ligamentous injury with possible epidural hematoma,
no vertebral artery injury. MRI cervical spine confirmed no
epidural hematoma. Has history of atrial fibrillation on
dabigatran (was reversed with Praxbind), and recent diagnosis of
breast cancer. She was admitted to the intensive care unit for
frequent neurological monitoring, hematocrit checks, pain
control, and close monitoring. Orthopedic spine was consulted
and recommended hard cervical spine collar and outpatient follow
up.
On HD2 the patient underwent xrays of the left wrist and was
found to have an oblique fracture of the proximal half of the
third metacarpal. Hand surgery was consulted and a left Volar
splint was placed. The patient had a PICC line placed due to
poor venous access for lab draws. Pain was controlled with
dilaudid PCA and Tylenol. She was given 1 unit packed red blood
cells on for hematocrit of 21 with active bleeding seen on
CTA but negative angiogram and post transfusion hematocrit was
25.5.
On HD3 the patient required supplemental oxygenation with nasal
cannula. She ws encouraged to use incentive spirometer. Foley
catheter was removed and she voided spontaneously. Chronic
atrial fibrillation was rate controlled on home diltiazem and
digoxin. She was started on heparin subcu BID for VTE
prophylaxis. Pradaxa was held in setting of concern for
continued bleeding.
On HD4 the patient remained hemodyanmivally stable and was
transferred to the surgical floor for ongoing monitoring.
On HD5 the patient received 1 unit of packed red blood cells for
a hematocrit of 21.5 and post transfusion hematocrit was 26.8.
On HD7 hematocrit remained stable and therefore the patient was
started on a heparin drip for afib. On HD9 the patient became
short of breath over night and chest xray showed pulmonary
edema. The patient was given 5 mg IV Lasix and home torsimide
was restarted. Her respiratory status improved and she was able
to be weaned to room air. The patient had persistent
Hyponatremia that did not respond to fluid restriction. On HD8
the medical service was consulted for assistance in managing
fluid status in setting of hyponatremia in a medically complex
patient with CHF and CAD.
#Hyponatremia
During her time of the surgical service, the patient developed
mild hyponatremia to 128. This is likely due to fluid overload
in the setting of trauma and a mild SIADH. On transfer to the
medical service, IV fluids were held and her home torsemide was
resumed. Her sodium slowly improved to 134 on discharge. On
review of chart, her baseline sodium is on the low
end of normal (low 130s).
#Dyspnea
Patient briefly required supplemental oxygen with NC. Etiology
was thought due to fluid overload from continuous IV fluids.
Her home diuretic was restarted and she was quickly weaned to
room air.
# Atrial fibrillation
CHADSVASC 4. Has taken dabigatran and digoxin for the past
decade as this was prescribed by her prior doctor in per
she has not established care with a cardiologist
here as of yet. On admission due to trauma, anticoagulation was
held. As noted above, due to concern for hemorrhage her
dabigatran was reversed with idarucizumab and she underwent
angiography which did not identify any source of active
extravasation. She was restarted on heparin drip once
stabilized and switched back to home dabigatran shortly
thereafter. Her home rate control with diltiazem and digoxin
was resumed.
# Epigastric pain (resolved)
EKG without concern for ischemia. Normal LFTs/lipase. AXR
showing no concern for free air or ileus. Resolved
spontaneously.
# E. coli UTI
Patient asymptomatic, found incidentally on UA performed for
hyponatremia work-up. Status post 3-day ceftriaxone course,
then urine cultures growing resistant E. coli so switched to
Macrobid on . Course completed .
## CHRONIC ISSUES:
===============
#Chronic heart failure with preserved ejection fraction
Home torsemide initially held in setting of trauma, resumed
later in the hospital course.
#Breast cancer
Patient recently diagnosed with breast cancer, followed at
. Home anastrozole was initially held, and restarted once
patient stabilized.
## CODE STATUS:
full confirmed
>30 minutes spent on DC day planning including face to face
discussion of case with patient and grandson
on :
The Preadmission Medication list is accurate and complete.
1. Anastrozole 1 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Dabigatran Etexilate 110 mg PO BID
4. Torsemide 5 mg PO DAILY
5. Digoxin 0.25 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY
3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID
8. Anastrozole 1 mg PO DAILY
9. Dabigatran Etexilate 110 mg PO BID
10. Digoxin 0.25 mg PO DAILY
11. Diltiazem Extended-Release 120 mg PO DAILY
12. Torsemide 5 mg PO DAILY
## DISCHARGE DIAGNOSIS:
right C5-C6-C7 transverse process fractures
C1-C2 ligamentous injury
Active extravasation in left upper quadrant on CTA
Right sided anterior , lateral , post 3,4,7 rib fractures
Left sided anterior , lat R anterior rib fractures
Atrial fibrillation
Hyponatremia
Pulmonary edema
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the Acute Care Surgery service on
after a motor vehicle crash and found to have multiple injuries
including a fracture and sprain in your neck, bilateral rib
fractures, a left finger fracture. You were seen by the
orthopedic spine doctor who recommended non-operative management
of neck fractures and to wear a hard neck brace at all times
until follow up. You were evaluated by hand surgery for your
finger fracture who placed a splint and recommended elevation
and non-weight bearing. You were seen and evaluated by the
physical therapist who recommend discharge to rehab to continue
your recovery.
You were transferred to the medical team due to shortness of
breath and low blood sodium levels. You were restarted on your
home medications your sodium level improved.
You are now doing better, tolerating a regular diet, and pain is
better controlled. You are now ready to be discharged to rehab
to continue your recovery.
Pleas note the following discharge instructions:
## RIB FRACTURES:
* Your injury caused left and right sided rib fractures which
can cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
## GENERAL 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
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15642566", "visit_id": "23122880", "time": "2135-08-02 00:00:00"} |
18708832-RR-23 | 213 | MRI OF THE LEFT SHOULDER
## CLINICAL INFORMATION:
Moderate left shoulder pain with rotation.
## FINDINGS:
The supraspinatus, infraspinatus, teres minor, and subscapularis tendons are
intact. There is a small amount of fluid in the subacromial/subdeltoid bursa.
The long head of the biceps tendon is seated in the bicipital groove. There
is a large amount of fluid within the bicipital groove surrounding the long
head of the biceps tendon consistent with tenosynovitis. There is a
longitudinal split-thickness tear of the long head of the biceps as it
traverses the bicipital groove. The glenoid labrum appears to be grossly
intact on this non-arthrographic study. However, there is mild bony
irregularity of the anterior inferior glenoid best seen on image 16 series 2.
There is no deformity. The previously described T2 hyperintense
structure at the anteroinferior aspect of the joint is no longer identified.
The acromioclavicular joint and the glenohumeral joint are unremarkable.
There is normal marrow signal. There is a small joint effusion
## IMPRESSION:
1. Rotator cuff is intact.
2. Small amount of fluid in the subacromial/subdeltoid bursa which could
represent mild bursitis.
3. Small joint effusion.
4. Longitudinal split-thickness tear of the long head of the biceps tendon in
the bicipital groove and as it enters the rotator interval.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18708832", "visit_id": "N/A", "time": "2193-09-27 07:32:00"} |
14867461-RR-57 | 97 | ## FINDINGS:
C1 through C7 are visualized on the lateral view. There is no
evidence of prevertebral soft tissue swelling. The vertebral heights are
preserved. There is marked disc space narrowing of C4-C5, C5-C6, and C6-C7.
There are large anterior osteophytes and medium sized posterior osteophytes.
There is uncovertebral hypertrophy with resultant narrowing of the
neural foramena at those levels. The alignment is normal. There are no focal
lytic or sclerotic lesions identified. There are no acute fractures
identified.
## IMPRESSION:
Severe degenerative changes of the mid to lower cervical spine as
described above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14867461", "visit_id": "N/A", "time": "2138-02-09 10:30:00"} |
12632201-RR-81 | 156 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old man with known subdural hematoma from fall, eval for
any residual hematoma, pre op CABG // year old man with known subdural
hematoma from fall (identified on study completed , eval for any residual
hematoma, pre op CABG
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
## FINDINGS:
There is no evidence of fracture, acute large territory
infarction,hemorrhage,edema,or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are normal.
## IMPRESSION:
1. No evidence of acute intracranial process.
2. Left frontal subdural hematoma identified described on outside hospital CT
scan from is not seen on this examination.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12632201", "visit_id": "N/A", "time": "2198-08-19 16:53:00"} |
14132616-RR-24 | 350 | ## CT CHEST:
The airways are patent up to subsegmental level. Vessels are of
normal caliber. There is no evidence of a lung contusion or lung laceration.
There is no pleural effusion or pneumothorax. Cardiac silhouette is normal.
No lymphadenopathy is seen in the mediastinum, or hilum. In the left axilla
there is an abnormal lymph node, measuring 3 x 2.4 cm (301b:25). No evidence
of aortic pseudoaneurysm.
## CT ABDOMEN:
The liver enhances homogeneously. Main portal vein is patent.
Gallbladder appears normal. There is no evidence of extra- or intra-hepatic
biliary duct dilatation.
There is moderate laceration through the spleen, with extracapsular
perisplenic hematoma. There are multiple sites of active extravasation,
(2:44). On delayed images, one of these hyperdense foci remains well defined,
adjacent to the splenic capsule, (2:44), concerning for a pseudoaneurysm.
Along the duodenal wall, below the liver (2:45 and 301B:19), there is
hyperdense material layering blood. Pancreas enhances homogeneously, and there
is no evidence of laceration through the pancreas. Adrenal glands are normal.
The kidneys enhance symmetrically and excrete contrast symmetrically with no
evidence of injury, hydronephrosis, or hydroureter. There is no evidence of
perinephric stranding. Loops of bowel appear unremarkable. There is no
evidence of free air. There is no evidence of retroperitoneal or mesenteric
lymphadenopathy according to CT size criteria.
## CT PELVIS:
Loops of large and small bowel appear normal. The uterus appears
normal. The left ovary is slightly prominent, (2:92), likely a follicule.
There is no lymphadenopathy in the pelvis or inguinal area. There is a Foley
catheter in the urinary bladder, with tiny foci of air, likely from Foley
placement.
## OSSEOUS STRUCTURES:
There is no evidence of fracture.
## IMPRESSION:
1. Laceration through the spleen, with perisplenic hematoma, and several
sites of active extravasation, and a single site concerning for
pseudoaneurysm.
2. Slight prominence of the left ovary, likely a follicle; if concern pelvic
ultrasound in a nonurgent setting can be done.
3. Emlarged lymph node in the left axilla. Further work-up is recommended in
a non-urgent setting including mammography
D/w (surgery).
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14132616", "visit_id": "28214113", "time": "2185-05-21 00:24:00"} |
17198774-RR-66 | 110 | ## INDICATION:
year old woman with concern for stroke, eval for aspiration
pneumonia// eval for aspiration pneumonia
## FINDINGS:
AP portable view of the chest provided.
The left chest port tip ends in the mid SVC. Again seen is dense left apical
opacity, which is concerning for a component of underlying tumor. Adjacent
more nodular opacities are again seen just inferior to the apical opacity.
There may be some resolution of aspiration, however, this may be due to
technical factors. There is no pneumothorax or pleural effusion. The right
lung is clear. The cardiac silhouette is normal.
## IMPRESSION:
1. No significant change in cardiopulmonary findings compared to the prior
exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17198774", "visit_id": "28169235", "time": "2184-05-16 00:44:00"} |
14291493-RR-23 | 260 | ## HISTORY:
Intoxicated with a fall from standing. Evaluate for injury.
## FINDINGS:
Mild hemorrhagic contusion is seen within the right frontal and
temporal lobes. There is a small subdural hematoma within the right middle
cranial fossa, measuring 4.6 mm in maximum thickness . There is no mass
effect or shift of midline structures. The basal cisterns remain patent.
The gray-white matter differentiation is preserved. Small area of
encephalomalacia in the inferior left frontal lobe is noted, likely from a
prior injury. There is no evidence for an acute territorial vascular
infarction. Mild mucosal thickening seen within the ethmoid air cells.
There is a longitudinal fracture of the left temporal bone. The fracture
extends into the middle ear cavity. The malleus and incus do not appear
dislocated. This fracture extends superiorly into the left parietal bone.
Blood is seen within the middle ear cavity. The fracture line likely extends
into the skull base, along the petrous ICA, into the sphenoid sinus. Blood is
seen in the left sphenoid sinus. Additionally, there are tiny foci of
pneumocephalus adjacent to the temporal bone and subcutaneous air.
## IMPRESSION:
1. Right frontotemporal hemorrhagic contusions.
2. Tiny subdural hematoma in the right middle cranial fossa.
3. Left temporal bone fracture with blood in the middle ear cavity and tiny
foci of pneumocephalus. The fracture line extends into the sphenoid sinus,
along the petrous portion of the ICA. CTA would be recommended to exclude
carotid injury.
These findings were discussed with Dr. by Dr. at 20:26 on by telephone at the time of discovery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14291493", "visit_id": "N/A", "time": "2174-05-07 19:00:00"} |
16089455-DS-12 | 1,588 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
y o F w/ PMHx of HTN & CAD s/p IMI & balloon angioplasty of
the distal RCA who presented with substernal "tightness" in her
that she awoke with at 7 am this morning. She describes a
constant central chest tightness, not pain, that is different
than her typical anginal pain with her IMI in . She denies
any assoc nausea or diaphoresis which she experienced with her
prior IMI. She felt is was difficult to take a deep breath but
the pain did not respond to Albuterol. Pt presented to
where she was thought to have dynamic ECG changes. Pt
was started on heparin gtt and transferred to for further
evaluation.
.
In transport, patient received NTGx2 and morphine and SBP
dropped to mid and she also c/o back pain. She received IVF
boluses in transport. In the ED, vitals T 99.3 HR 64 BP
108/50 RR 18 Sating 100% on NRB, then 98% on 2L NC. Pt continued
to complain of chest and back pain upon arrival. Labs remarkable
for anemia at her baseline, an elevated BUN and normal Cr as
well as negative cardiac enzymes x 1. Bedside cardiac ultrasound
performed by the ED physician showed no pericardial fluid. CTA
showed no evidence of PE or dissection but did show diffuse
airspace nodules suggesting an infectious process. Pt denies any
recent fevers, chills, wt loss, sick contacts, cough or SOB. She
reports increased sneezing and feels this is related to seasonal
allergies. While in the ED, pt received 6 mg of IV morphine for
chest pain. SBPs improved to 120s s/p 1 liter of IVF. She
received no further NTG.
.
On arrival to the floor, pt describes ongoing mild chest
tightness but not pain, feeling otherwise comfortable.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, dysuria, hematuria, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Pt denies chest pain on exertion but reports mild baseline
dyspnea when walking uphill. She also reports occais ankle
swelling at end of day. Denies paroxysmal nocturnal dyspnea,
orthopnea, palpitations, syncope or presyncope.
## PAST MEDICAL HISTORY:
# CAD s/p IMI in s/p balloon angioplasty of the distal
RCA.
# HTN
# COPD, emphysema
# asthma
# glaucoma
# seasonal allergies
# s/p bilateral cataract surgery
# s/p cholecystectomy
## FAMILY HISTORY:
father with MI in
## GEN:
WDWN Female in NAD. Oriented x3. Mood, affect appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
## NECK:
Supple with JVP of 6-8cm
## CV:
RRR normal S1, S2. No murmur apprec, +carotid bruits
bilaterally
## CHEST:
No chest wall deformities. Resp were unlabored, no
accessory muscle use. Dec BS but CTAB, no crackles, wheezes or
rhonchi.
## ABD:
Soft, NTND. No HSM or tenderness. No abdominial bruits.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
.
## CTA IMPRESSION:
1. No aortic dissection. No pulmonary embolism.
2. Moderate-to-severe diffuse centrilobular emphysema.
3. Diffuse groundglass pulmonary nodules, most likely reflecting
an infectious process. Atypical infection should be considered.
At least a few contain central areas of low attenuation, raising
possiblity of septic emboli. Followup CT post treatment is
recommended to ensure resolution.
4. Moderate three-vessel coronary artery calcification, mitral
and aortic calcifications, and aortic arch calcification.
5. Small-to-moderate hiatal hernia.
6. Incompletely characterized small hepatic hypodensities. The
larger of these appears to represent a cyst.
7. Right renal cyst
.
CXR PA & Lat
## IMPRESSION:
No acute intrathoracic process.
Bibasilar linear atelectasis. Please refer to subsequent CT for
further findings not evident on this radiograph.
.
CXR PA & Lat IMPRESSION: Small bilateral effusions
without radiographic evidence of pneumonia.
.
## RLE ULTRASOUND:
No evidence of deep venous thrombosis
involving the lower extremities.
.
The left atrium is elongated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is mild aortic
valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
## IMPRESSION:
Normal global and regional biventricular systolic
function. Mild aortic stenosis and mild mitral regurgitation.
Biatrial enlargement.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the report of the prior study (images unavailable
for review) of , the degree of aortic stenosis has
increased slightly. The other findings are similar.
## # CAD:
Pt with h/o IMI and distal RCA angioplasty in presents
now with chest tightness that began on the morning of admission
and was fairly constant at with no relief from nitro or
morphine. Pt ruled out for MI with negative cardiac enzymes,
EKGs were essentially unchanged from prior tracings. Given the
infiltrates on CT, I suspect that this chest pain is not
cardiac, more likely related to the pulmonary process. Pt was
continued on ASA 325mg, Atorvastatin 40mg daily and restarted
Avapro on discharge.
.
# COPD/SOB: Pt has a long h/o COPD/Asthma and presented with
chest tightness that evolved into SOB on day 2 of admission. Pt
had a CTA on admission that showed no evidence of PE or
dissection but revealed diffuse groundglass pulmonary nodules
suggestive of atypical infectious process. ABG was performed and
showed a resp alkalosis with a likely underlying
component of baseline CO2 retention. However, pt maintained sats
well on RA and felt that the SOB improved with Albuterol nebs.
On day 3 of admission, pt developped a left sided back pain with
a pleuritic component. Pt was also noted to have a low grade
temp and repeat CXR showed new small bilateral effusions. PE was
thought very unlikely given lack of tachycardia or hypoxia. The
CTA was negative on and pt was on systemic heparin from
through am. Pt was started Levofloxacin for community
acquired pneumonia and ibuprofen for symptoms. Blood cultures
were negative for growth and pt felt comfortable with discharge
and plan for PCP follow up. radiology report, pt will need
a follow up CT after resolution of infectious process to
re-evaluate pulm nodules seen.
.
# Hypertension: Pt received SL nitro on transfer to and
sbp dropped into but responded to IVF bolus. Pt was given
gentle hydration on the first day of admission and sbp came back
up to 110s. Pt was restarted on Avapro 75mg home regimen prior
to discharge.
.
# Anemia: Pt with baseline hct of 32 since and iron
studies, Vit B12 & folate were all normal. Pt remained at
baseline in house and hct was 33 on discharge.
.
# RLE: Pt noted some right foot swelling on day 3 and reported
that this happens at home but is usually bilateral and possible
related to arthritis. Pt denied pain & RLE ultrasound was
negative for DVT.
## MEDICATIONS ON ADMISSION:
Ecotrin 325 mg DAILY
HCTZ 25mg
Avapro daily
Albuterol Q4H prn shortness of breath.
Ipratropium BID prn shortness of breath.
Flovent daily
Prilosec 20mg daily
Tums 500 mg twice a day as needed for heartburn
Lipitor 40mg daily
## DISCHARGE MEDICATIONS:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Brimonidine 0.15 % Drops Sig: Two (2) Drop Ophthalmic BID (2
times a day).
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation every hours as needed for shortness of
breath or wheezing.
7. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 4 days: Next dose .
Disp:*6 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: puffs Inhalation
every hours as needed for shortness of breath or wheezing.
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Avapro 75 mg Tablet Sig: One (1) Tablet PO once a day.
11. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO three times a day as needed for heartburn.
## PRIMARY:
Chest pain
Upper respiratory tract infection
.
## DISCHARGE INSTRUCTIONS:
You were admitted with chest pain and there has been no evidence
of damage to the heart. You had some findings on a CT scan of
your chest that were suggestive of infection. You have been
started on an antibiotic called Levofloxacin to treat this
infection.
.
You should get a follow up CT scan in the next to follow
up these changes. Please discuss this with your PCP .
.
.
Your hydrochlorothiazide was stopped while you were in the
hospital due to low blood pressures. Please discuss restarting
this medication with your PCP .
.
If you develop any new chest pain, shortness of breath, weakness
or any other general worsening on condition, please call your
PCP or go directly to the ED.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16089455", "visit_id": "22502465", "time": "2166-04-28 00:00:00"} |
19706109-DS-32 | 1,533 | ## ALLERGIES:
Penicillins / Cephalosporins / Ciprofloxacin
## HISTORY OF PRESENT ILLNESS:
This is a yo F with complicated PMH including childhood
astrocytoma s/p resection and radiation, multiple menginomas,
pan-hypopituitarism, refractory seizure disorder and mental
retardation who presents with cough for 3 days and concern for
early pneumonia. Patient is accompanied by her mother, who the
history was obtained from. Patient had non-productive cough
associated with sinus congestion and rhinorrhea for 3 days.
Breathing is now labored. Afebrile, temperatures 96-97. Patient
has also been more fatigued during the same period. She has been
hospitalized multiple times for infections, during which times
she is more hypothermic. She has been hospitalized about 8 this
since Janurary. She was last in the ICU due to hypothermia in
.
The patient presented to outpatient clinic today and they spoke
with her neurologist who recommended that the patient be
admitted due to concern for aspiration pneumonia and that the
patient should receive stress-dose steroids, as she is on
chronic hydrocortisone due to her pan-hypopituitarism.
In the ED, initial VS were: 97.4 76 122/72 18 97% RA. The
patient was given 100 mg hydrocortisone, meropenem, and
azithromycin. The patient had a CXR that showed low lung
volumes, but no clear consolidation. UA was negative. BCx were
sent. The patient was admitted to the floor due to concern of
early infection/sepsis.
On arrival to the floor, the patient has no acute complaints and
history is obtained from her mother.
## REVIEW OF SYSTEMS:
(+) HPI
(-) fever, chills, night sweats, headache, vision changes,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
## PAST MEDICAL HISTORY:
1.) Right parietal astrocytoma- age yrs, s/p resection and
radiation (so baseline left hemiparesis), complicated by
hydrocephalus s/p VP shunt
2.) Refractory seizures on multiple AEDs, s/p VNS; about 5
times per month with a variety of manifestations (turns red in
the face; brief movements of her eyes, brief moments of
non-responsiveness). Swiping the VNS magnet to activate VNS.
Last generalized seizure with post-ictal period noted in OMR
chart was sometime in , preceeded by sometime in .
Last VNS update in Sleep apnea with obese neck; snores/wakes frequently
(including for nocturia); does not tolerate CPAP.
4.) Panhypopituitarism (hypogonadism, adrenal insufficiency,
hypothyroidism); on glucocorticoid and thyroid replacement,
progesterone)
5.) Osteoporosis with unclear h/o knee and shoulder pain
6.) Meningiomas (Right parietal, growing @2cm; RF=XRT@youth)
7.) Developmental Delay / MR following astrocytoma resection
8.) s/p Mohs surgery for a recurrent nodular basal cell cancer
on the left occiput; also s/p BCC Tx with Aldara.
9.) h/o urinary incontinence and nocturia, chronic
10.) h/o VPS in RLV, reportedly removed in (but seen on
current and prior head imaging, with dilated ventricle)
11.) s/p cholecystectomy in
## FAMILY HISTORY:
Adopted. Unknown family history.
## ADMISSION PHYSICAL EXAM:
VS - Temp 97.2F, BP 116/68, HR 83, R 20, O2-sat 93% RA
GENERAL - Cushingoid features, legally blind, arousable to voice
HEENT - PERRLA, MMM, no LAD
NECK - supple, obese
LUNGS - scattered rhonchi and wheezes listened anteriorlly, good
breath sounds bilaterally
HEART - distant heart sounds, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, NT, obese, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, wearing foot brace on left foot
SKIN - no rashes or lesions
NEURO - awake, nonfocal, following commands
## HOSPITALIZATION STATEMENT:
yo F with complicated PMH including mental retardation,
seizure disorder, and pan-hypopituitarism who presented with
cough and fatigue. She was observed for 2 days out of concern
for history of mild infections progressing to sepsis but
remained well-appearing and felt better prior to discharge.
Symptoms were thought to be secondary to viral URI.
## # COUGH/FATIGUE:
Patient presented with URI symptoms including
non-productive cough, sinus congestion and rhinorrhea. Given
relative leukopenia and lymphocytosis, infection was thought to
be viral in nature. She was initially started on meropenem and
azithromycin in the ER (given allergies) but this was stopped
the next morning. CXR, U/A were negative. Lung exam was benign.
WBC improved (though lymphocyte predominance persisted) and the
patient remained non-toxic appearing. Her usual home
hydrocortisone was doubled for 3 days and she is to resume her
usual hydrocortisone dosing (15 mg qAM and 5 mg q4PM) on .
Blood and urine cultures were negative.
.
# Pan-hypopituitarism: The patient is on hydrocortisone at home.
The patient's neurologist recommended increasing the dose in the
setting of possible infection. The patient received 100mg
hydrocortisone in ED. Home dose of hydrocortison 15mg QAM and
5mg QPM. Dose was increased to 30mg QAM, 10mg QPM for 3 days.
Home dose to be resumed on .
## # SEIZURE HISTORY:
We continued keppra, lamictal, and zonegran
with no changes in dosing. No changes were made to the vagal
nerve stimulator. She was scheduled to follow-up with the
epilepsy RN.
## # HYPOTHYROIDISM:
Continued home dose of synthroid.
## TRANSITIONAL ISSUES:
- please verify whether patient needs to be on standing
ibuprofen - inpatient team was not able to determine whether
this should remain a long-term medication given GI/renal risks
- f/u was scheduled in clinic and with the
epilepsy RN
- patient was discharged to continue 1 additional day of double
dose hydrocortisone and is then to resume her usual home regimen
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Hydrocortisone 15 mg PO QAM
2. Hydrocortisone 5 mg PO DAILY16
3. LeVETiracetam 1000 mg PO BID
Keppra, No subsitution
4. Lorazepam 0.5 mg PO HS
5. LaMOTrigine 400 mg PO BID
Lamictal, No subsitution
6. Milk of Magnesia 30 mL PO PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Guaifenesin mL PO PRN cough
9. Levothyroxine Sodium 125 mcg PO DAILY
No Subsitution
10. Calcium Carbonate 1000 mg PO BID
11. Zonisamide 300 mg PO QHS
12. Zonisamide 50 mg PO Q8PM
13. Vitamin D 400 UNIT PO DAILY
14. Ibuprofen 400 mg PO BID
15. Mupirocin Cream 2% 1 Appl TP BID rash
16. progesterone micronized *NF* 100 mg Oral TID
Takes at 8a, 4p, 8p * Patient Taking Own Meds *
17. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
18. Psyllium Wafer 1 WAF PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg PO Q4H:PRN pain or fever
1 tablet by mouth every 4 hours between 8 am and 4 pm, 2 tabs
every 4 hours after 8 pm as needed for headaches or generalized
pain
2. KePPRA 1000 mg PO BID
Keppra, No subsitution
Take 2, 500 mg tablets twice per day.
3. Levothyroxine Sodium 125 mcg PO DAILY
Synthroid No Subsitution
4. Lorazepam 0.5 mg PO HS
5. Vitamin D 400 UNIT PO DAILY
6. Benzonatate 100 mg PO BID Duration: 2 Days
RX *benzonatate 100 mg 1 capsule(s) by mouth two times per day
Disp #*4 Capsule Refills:*0
7. Guaifenesin mL PO PRN cough
8. Ibuprofen 400 mg PO BID
9. Mupirocin Cream 2% 1 Appl TP BID rash
10. Zonegran 300 mg PO QHS
Take 3, 100 mg capules in the evening
11. Zonisamide 50 mg PO Q8PM
Take 2, 25 mg tablets by mouth daily at 8 pm
12. Psyllium Wafer 2 WAF PO DAILY
Take 2 wafers with 8 ounces of water every day as needed for
constipation
13. Prometrium *NF* (progesterone micronized) 100 mg Oral TID
14. Milk of Magnesia 30 mL PO HS:PRN constipation
Take 30 ml by mouth at bedtime as needed for constipation; take
if no bowel movement for more than 48 hours
15. Multivitamins 2 TAB PO DAILY
16. Calcium Carbonate 1000 mg PO BID
Take 2, 500 mg tablets twice per day
17. Hydrocortisone 30 mg PO QAM
Take 3, 10 mg tablets on the morning of (30 mg). On ,
resume the usual home dose (15 mg (or 1.5 tablets) in the
morning and 5 mg (1 tablet) at 4
18. Lamictal 400 mg PO BID
Lamictal, No subsitution
Take 4, 100 mg tablets twice per day (400 mg BID)
19. Hydrocortisone 10 mg PO QPM
Take 1 tablet (10 mg) at 4 on and then resume the normal
home dose (0.5 tablets or 5 mg daily at 4
RX *hydrocortisone 10 mg tablet(s) by mouth twice per day
Disp #*4 Tablet Refills:*0
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Ms. ,
It was a pleasure to participate in your care at the
. You were admitted with a cough, nasal
congestion and runny nose. This was likely a viral upper
respiratory infection. Due to your previous severe respiratory
infections, we observed you overnight. Your temperature and
respiration remained stable.
Please follow up with your physicians as noted below and
continue to take all of your medications as prescribed.
## MEDICATION CHANGES:
STARTED Benzonatate 100mg twice per day for 2 days (last day is
this is a cough suppressant
CHANGED Hydrocortisone from 15mg to 30mg in the morning (only
for 1 day - on .
CHANGED Hydrocortisone from 5mg to 10mg at 4 (only for 1 day
- on .
Please resume your usual dose of Hydrocortisone 15mg every
morning and 5mg at 4 on .
WE MADE NO CHANGES TO THE SEIZURE MEDICATIONS. PLEASE CONTINUE
HER CURRENT REGIMEN.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19706109", "visit_id": "29229063", "time": "2203-12-15 00:00:00"} |
17011637-RR-136 | 86 | ## FINDINGS:
No acute fracture or dislocation is identified. The ankle mortise
is symmetric and the talar dome is smooth. Tiny well-corticated ossific
density inferior to the medial malleolus may reflect the sequela of prior
injury. There are no focal lytic or sclerotic osseous abnormalities. The
bone mineralization is normal. Mild hallux valgus deformity on the right is
unchanged, with degenerative changes of the first MTP again noted. There are
no radiopaque foreign bodies or soft tissue calcifications.
## IMPRESSION:
No acute fracture or dislocation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17011637", "visit_id": "23572273", "time": "2135-11-17 17:18:00"} |
10331875-DS-12 | 1,978 | ## ALLERGIES:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST
## HISTORY OF PRESENT ILLNESS:
M h/o metastatic melanoma and recent cellulitis, enterobacter
bacteremia, and spinal osteomyelitis c/b C diff infection
presenting with failure to thrive at home and ongoing diarrhea.
The patient has had ongoing failure to thrive that has been
gradually worsening since was discharged following a
hospitalization for cellulitis/bacteremia and spinal
osteomyelitis. It is associated with his back pain which has not
changed at all. It was related to his prior long hospitalization
and chronic medical issues, outlined below. was apparently
discharged home with services despite recommending
rehab as no rehab beds became available and the patient reports
was "antsy" to go home. elected to go home with services
with help from his family. Since returning home, reports that
has not been able to get out of bed pretty much at all, and
is limited by back pain whenever you tries to move. continues
to have diarrhea times daily and usually is incontinent due
to inability to get up on his own.
The patient's called his ID physician
reported that has had ongoing weakness and has remained
essentially bedbound since discharge. has had ongoing
diarrhea that was identified with acute onset during last
hospitalization and got slightly better but is now slightly
worse and is related to missing a few doses of po vancomycin.
The was unable to provide adequate care for him at home. Dr.
bringing the patient into the ED for
evaluation of the weakness and rehab placement, which the
patient agreed with.
In the ED, the patient corroborated the above. reported that
the diarrhea has worsened over the past few days and due to his
back pain has had difficulty getting to the bedpan in time,
leading to multiple accidents at home. reported to the ED
that his back pain has not changed in nature and denies any new
weakness or neuro deficits.
I have personally reviewed his past records and to summarize:
The patient has had a long course of metastatic melanoma first
diagnosed in , s/p chemotherapy, immune therapy, cyberknife,
and currently on a study drug through .
has also had recurrent leg cellulitis, enterobacter
bacteremia, and spinal osteomyelitis in the setting of chronic
lymphedema. has been on antibiotics as an outpatient and on
po vanc for concomitant C. Diff infection.
In the ED, The vital signs were stable. Labs were notable for
stable pancytopenia, albumin 1.9, chemistry otherwise wnl. CXR
was notable for low lung volumes and bibasilar atelectasis
without focal consolidation. was given his ertapenem and
other home medications as well as 1 L of fluid.
Patient was seen by who referenced recommendations from
prior admission recommending rehab. Unclear why the patient had
returned home. Case management was unable to find a rehab for
the patient in the ED so decision was made to admit until
placement is confirmed.
On the floor, the patient had no new complaints. was quite
comfortable at rest but with any movement or lifting his back
pain worsens.
## ROS:
Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
## PAST MEDICAL HISTORY:
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on a study drug through
. Dx in
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis, most recently admitted
for cellulitis complicated by GNR bacteremia.
- Recent C. diff infection
- Cirrhosis, possibly secondary to NASH, complicated by varicies
- DM
- HTN
- HLD
## FAMILY HISTORY:
No family history of recurrent infections or autoimmune
disorders.
## VITALS:
Afebrile and vital signs stable (see eFlowsheet)
## GENERAL:
Alert, AOx3, lying flat in bed in NAD. IN visible
distress with any movement of his LLE.
## EYES:
Anicteric, pupils equally round
## ENT:
Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
## CV:
Heart regular, no murmur, no S3, no S4. No JVD.
## RESP:
Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
## GI:
Abdomen obese, slightly distended, non-tender to palpation.
Bowel sounds present.
## GU:
No suprapubic fullness or tenderness to palpation
## MSK:
Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
## SKIN:
Multiple Telangectasias on his face. RLE w/ significant
chronic venous stasis changes and scars from previous
ulcerations but no skin breakdowns or evidence of cellulitis.
LLE slightly edematous as well with chronic venous stasis
changes not as severe as the R.
## NEURO:
Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, sensation to light touch grossly intact
throughout lower extremities. Strength on hip flexoion and
knee flexion on the LLE, on the right
## PSYCH:
pleasant, appropriate affect
EXAM PRIOR TO DISCHARGE
## GENERAL:
Sleeping, resting comfortably, lying flat in bed
## GI:
Abdomen obese, slightly distended, non-tender to palpation.
Bowel sounds present.
## MSK:
Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
## EXT:
Bilateral venous stasis changes fairly advanced, no
erythema, wrapped
## PERTINENT RESULTS:
ADMISSION
02:00AM BLOOD WBC-2.6* RBC-2.70* Hgb-8.6* Hct-26.6*
MCV-99* MCH-31.9 MCHC-32.3 RDW-16.8* RDWSD-59.3* Plt
02:00AM BLOOD Glucose-76 UreaN-22* Creat-0.7 Na-137
K-4.7 Cl-106 HCO3-24 AnGap-7*
02:00AM BLOOD ALT-13 AST-40 AlkPhos-148* TotBili-1.1
02:00AM BLOOD Albumin-1.9* Calcium-7.7* Phos-2.6*
Mg-1.7
PRIOR TO DISCHARGE
06:48AM BLOOD WBC-2.8* RBC-2.57* Hgb-8.3* Hct-26.2*
MCV-102* MCH-32.3* MCHC-31.7* RDW-17.1* RDWSD-63.7* Plt Ct-83*
06:48AM BLOOD
06:48AM BLOOD Glucose-132* UreaN-19 Creat-0.7 Na-140
K-4.7 Cl-108 HCO3-27 AnGap-5*
06:11AM BLOOD ALT-13 AST-41* LD(LDH)-191 AlkPhos-153*
TotBili-0.6
06:48AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.7
06:48AM BLOOD CRP-58.6*
IMAGING STUDIES
MRI L-SPINE
1. Severely limited study due to artifact likely from
combination of motion and body habitus.
2. Compression deformities of L2 and L4, likely due to Schmorl's
nodes.
3. Moderate spinal canal narrowing at L1-L2 and L3-L4.
CXR
1. Right upper extremity PICC tip terminates in the right
atrium, approximately 4 cm beyond the cavoatrial junction.
Please no redundancy in the PICC in the area of the axilla.
2. Low lung volumes. Bibasilar atelectasis without focal
consolidation.
## BRIEF SUMMARY:
This is a with metastatic melanoma and recent spinal
osteomyelitis/ GNR bacteremia c/b C diff infection presenting
with failure to thrive at home and ongoing diarrhea in setting
of missed vanco doses, admitted for rehab placement and workup
of ongoing severe back pain. Workup reassuring, doing well with
nursing care and . Discharged to rehab facility.
## # FAILURE TO THRIVE:
Likely due to being discharged home before
actually was ready to be at home given his tenuous health
status, active issues, and related to ongoing back pain, chronic
illness, and recent hospitalizations. unsurprisingly
recommended rehab.
# Recent osteomyelitis and leg cellulitis: Last admission had
severe sepsis with septic shock, thought due to cellulitis but
then found to have Enterobacter bacteremia. In the context of
back pain, was then found to have diskitis/osteo with
epidural phlegmon. had some ascites and a diagnostic
paracentesis was unremarkable, though had been on antibiotics
for some time, and given the overall picture there was concern
could have had SBP as the primary cause.
- Ertapenem for weeks (D1
- No Bactrim while on other antibiotics. Can question whether
necessary thereafter as diagnosis of SBP is suspect and the
patient is actively having issues with C diff infection so there
is an atypical risk/benefit profile of this medication. Defer to
the OPAT team.
- WEEKLY CBC with diff, BMP, LFT to be faxed to OPAT team - see
their OPAT intake note from last admission for more details
## # BACK PAIN:
MRI on for concern of possible osteomyelitis/
discitis revealed osteo w/o e/o abscess. Continues to have
significant pain, which says worsened in the context of
needing to move around more to try to take care of himself at
home. Neuro exam is confounded by generalized weakness and pain,
though is able to mobilize and there is no obvious
lateralizing deficits, no sensory deficits. MRI was repeated to
assess for interval change but was unfortunately limited by
movement and habitus. ESR CRP downtrending so I think we can get
by without attempting to repeat the MRI for better images.
- Continue standing Tylenol for 2 weeks while at rehab
- Continue low dose oxycodone PRN severe pain and working with
- Avoid NSAIDs given comorbidities
## # C. DIFF COLITIS:
s/p treatment with 14 days ( ) of 125
mg qid with plan to transition to 125 mg bid through end of
ertapenem course.
- Continue treatment dose at 125 mg qid for now, would do
another 2 weeks and then consider transition to BID if no
diarrhea
- Consider probiotic at rehab - none on formulary here
## # PANCYTOPENIA
# COAGULOPATHY
# NASH CIRRHOSIS:
Hx of varices without bleeding. No history of
SBP per patient but does have h/o ascites. Did briefly have some
asterixis concerning for hepatic encephalopathy on last
admission treated with lactulose. S/p vitamin K for mild
coagulopathy, minimal response (but coagulopathy mild).
- Monitor for encephalopathy
- Lactulose titrated to BMs per day has been refusing
and having some diarrhea but this should be monitored closely
for signs of encephalopathy as C diff resolves)
## # METASTATIC MELANOMA:
Stage IIIc melanoma s/p chemotherapy and
cyberknife now on trial drug LOXO-101. This drug is provided for
free by in picks it up but can
apparently have it shipped as well.
- Continue LOXO-101
## # NEUROPATHY:
Stable. Peripheral neuropathy of right thigh.
- Continue home Gabapentin 600 HS
# Mild dehydration in setting of diarrhea: Improved after 1L
NS and resolution of diarrhea.
# Mild hypophosphatemia in setting of diarrhea: Improved/stable
after 15mmol IV sodium phosphate.
# Bilateral venous stasis and some stasis dermatitis: Stable. No
signs of cellulitis. Have been providing ACE wraps to legs.
## BILLING:
>30 minutes spent coordinating discharge to rehab
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Lactulose mL PO BID
3. LOXO-101 Study Med 100 mg PO BID
4. Vancomycin Oral Liquid mg PO QID
5. Nadolol 20 mg PO DAILY
6. Ertapenem Sodium 1 g IV 1X
7. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q8H
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*30
## TABLET REFILLS:
*0
3. Gabapentin 600 mg PO QHS
4. Lactulose 30 mL PO TID
5. Nadolol 40 mg PO DAILY
6. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
Every 24 hours for weeks (D1
7. LOXO-101 Study Med 100 mg PO BID
8. Vancomycin Oral Liquid mg PO QID
Take QID for 2 weeks and then transition to BID until 2 weeks
after last dose ertapenem
## DISCHARGE DIAGNOSIS:
Osteomyelitis of spine
C diff infection
Cirrhosis
Melanoma on study drug
Venous stasis bilateral
Morbid obesity
Failure to thrive in adult
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were admitted with failure at home after a recent hospital
stay for sepsis, osteomyelitis of the spine, and c difficile
colitis on the background of your melanoma and cirrhosis
history.
You were admitted, given some hydration, your usual home
medications including antibiotics, and you were provided with
nursing care. You improved.
You are being discharged to rehab to get stronger so you can go
home and take good care of yourself.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10331875", "visit_id": "27596965", "time": "2168-09-23 00:00:00"} |
15987325-RR-27 | 211 | ## HISTORY:
Brain tumor. CNS lymphoma. Staging.
## FINDINGS:
There is no pathologic enlargement of supraclavicular, axillary or central
thoracic lymph nodes. A 4-mm lucency in the left lobe of the thyroid gland is
too small to warrant further evaluation. The aorta and main pulmonary
arteries are unremarkable. There is no detectable atherosclerotic
calcification in the coronaries or elsewhere in central vasculature in the
chest or neck.
10 mm wide soft tissue nodule at the perimeter of the right apex,
could be a clinically significant mass, particularly if the patient is a
smoker. 2 mm wide crescentic lesion in the right lower lobe, 4:169-171 by
virtue of its shape, is probably an impacted bronchus. Right lung is
otherwise clear.
Tiny pleural nodule at the lateral periphery of the left upper lobe, 4:40 and
41, another along left lower lobe, 4:145 are clinically insignificant, and
aside from mild subpleural atelectasis, left lung is clear. Tracheobronchial
tree is generally unremarkable.
There are no bone lesions in the chest cage suspicious for malignancy.
## IMPRESSION:
1 cm soft tissue nodule, apical periphery, right hemithorax could
be a small mass, unusually located lymph node or lymphoma deposit. Suggest
followup study in three months, unless the diagnosis is ascertained by other
means.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15987325", "visit_id": "22810413", "time": "2139-03-13 17:51:00"} |
17545621-RR-51 | 89 | ## EXAMINATION:
ABDOMEN (SUPINE AND ERECT)
## INDICATION:
year old woman with fevers, bloody diarrhea (from
worsening abdominal pain // acute abdomen, evaluate for obstruction, free
air, fluid levels
## 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. Two right-sided and one left Essure devices
are noted in the pelvis. The visualized osseous structures are unremarkable.No
soft tissue calcifications or radiopaque foreign bodies are detected.
## IMPRESSION:
Normal abdominal radiographs.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17545621", "visit_id": "27382907", "time": "2201-05-23 09:15:00"} |
10627650-RR-70 | 132 | ## EXAMINATION:
FOOT AP,LAT AND OBL BILATERAL
## HISTORY:
with diabetic ulcers// eval for osteomylitits
eval for osteomylitits
## IMPRESSION:
On the left, comparisons made with the study of . Little change in
the previous amputations with old healed fractures of the second and third
metatarsals. No definite gas in soft tissues, though vascular calcifications
consistent with diabetes. If there is serious clinical concern for
osteomyelitis, MRI would be the next imaging procedure.
On the right, comparison is made with the study of . Again
there is evidence of amputation of the third toe at the level of the head of
the proximal phalanx. Deformity about the first interphalangeal joint is
again seen. No definite erosions or gas in soft tissues. MRI could be
obtained if there is a serious clinical concern for osteomyelitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10627650", "visit_id": "29733803", "time": "2165-01-29 14:04:00"} |
16075858-RR-7 | 308 | ## INDICATION:
History: with head bleed. need STAT repeat CTA.// aneurysm?
## FINDINGS:
CT head shows diffuse subarachnoid hemorrhage centered in the bifrontal
convexities, sylvian fissures, and extension inferiorly to the basal cisterns
involving the intrapeduncular, perimesencephalic, and prepontine cisterns.
There is also a small amount of intraventricular hemorrhage, in the occipital
and temporal horns of the left lateral ventricle and fourth ventricle. All of
this is unchanged as compared to outside hospital CT head earlier today. There
is no evidence of worsening hemorrhage. Ventricles and sulci are unchanged in
appearance.
CT angiography of the neck shows bilateral laterally narrowed cervical
internal carotid arteries right greater than left side with extensive
atherosclerotic disease at the bifurcation. The cervical internal carotid
arteries are diffusely narrowed which appears to be secondary to intracranial
occlusive disease. Bilateral cervical vertebral arteries are patent and
robust in appearance. Mild calcification is seen at the origin of left
vertebral artery.
CT angiography of the head extensive calcification of the cavernous and
supraclinoid internal carotid artery. There is occlusive disease affecting
the supraclinoid internal carotid arteries with multiple lenticulostriate
collaterals indicating moyamoya pattern with filling of both middle cerebral
arteries. Irregular vascular structures indicative of collaterals from
external carotid are seen along the orbital frontal region (3:283). A small
left-sided posterior communicating artery is identified. Collaterals from the
posterior lenticulostriate are seen extending anteriorly. There is no
aneurysm identified.
## IMPRESSION:
1. Extensive subarachnoid hemorrhage as described. No hydrocephalus is seen.
2. Extensive supraclinoid internal carotid artery occlusive disease with
calcification of the supraclinoid and cavernous carotid arteries with moyamoya
collaterals through the lenticulostriate vessels, from the external carotid
and posterior circulation providing collateral flow to both middle cerebral
arteries.
3. Bilateral carotid bifurcation atherosclerotic calcification with narrowed
lemon of both internal carotid arteries in the cervical region likely
consequent to intracranial occlusive disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16075858", "visit_id": "20661298", "time": "2186-06-06 21:56:00"} |
15039521-RR-60 | 226 | ## STUDY:
MRI of the head with and without contrast.
## CLINICAL INDICATION:
History of meningioma, treated with CyberKnife, assess
for interval changes.
## FINDINGS:
Again a dural-based extra-axial mass lesion is redemonstrated in
the olfactory groove, with homogeneously avid enhancement, since the most
recent examination, there is interval increase in the pattern of dural
enhancement, extending into the anterior orbital gyrus and lateral to the
olfactory sulcus on the left (image 12, series #12 and coronal image #44,
series #8A), this new area of enhancement demonstrates a nodular configuration
and measures approximately 5 x 3 mm in size in coronal projection and 5 x 4 mm
in transverse dimension. Similar pattern of vasogenic edema is redemonstrated
in the frontal lobes and the midline meningioma demonstrates similar size and
configuration, measuring approximately 31 x 26 mm in transverse dimension and
28 x 21 mm in sagittal projection. Normal flow void signal is identified of
the major vascular structures. The orbits, paranasal sinuses, and mastoid air
cells are grossly unremarkable.
## IMPRESSION:
Extra-axial mass lesion, likely consistent with an olfactory
groove meningioma, which demonstrates a new area of dural enhancement with a
lateral nodule adjacent to the left olfactory sulcus and medial orbital gyrus.
Similar pattern of vasogenic edema and mass effect is redemonstrated, no
diffusion abnormalities are detected to suggest acute or subacute ischemic
changes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15039521", "visit_id": "N/A", "time": "2177-11-30 08:39:00"} |
14248835-DS-7 | 1,507 | ## ALLERGIES:
iodine / Penicillins / codeine / shellfish derived
## HISTORY OF PRESENT ILLNESS:
is an yo woman with CLL, who presents from rehab
with several days of low-grade fever to Tmax 100.6 F, lethargy,
and disorientation.
She was recently admitted to the service for
and
concern for TLS after initiation of bendamustine on . Her
laboratory abnormalities normalized with gentle IV hydration.
Her
course was complicated by e coli UTI and volume overload. A R
POC
was placed on .
After discharge, Ms. was noted to have low grade
temperatures to a Tmax of 100.6 F at STR. In the days prior
to presentation, her daughter noted she was markedly more
lethargic and sleepy. She also had momentary disorientation and
confused daytime with nighttime. She complained of severe pain
at
the R POC site, but STR staff reported the site looked clean and
noninfected.
On arrival to the ED, initial vitals were 99.1 120 130/70 18
100%
4L NC. Exam notable for coarse rhonchi throughout lungs,
bilateral edema, and chronic skin changes. Labs were notable
for WBC 3.6, H/H 8. .2, Plt 47, INR 1.9, Na 140, K 3.3,
BUN/Cr
, lactate 1.8, and UA with negative leuks, 16 WBCs, and
few
bacteria. Blood and urine cultures were sent. CXR concerning for
mild increase in pulmonary edema. Head CT negative for acute
process. Left upper extremity ultrasound was negative for DVT.
Patient was given potassium 40mEq IV and tylenol 1g PO for a
temp
of 100.6F.
She remained in the ED for 26 hrs awaiting an inpatient bed. In
that time, she also weaned from 4L to RA without difficulty.
On the floor, Ms. reports she feels well without any
localizing symptoms for infection including headache, sore
throat, rhinorrhea, sinus pain, ear pain, productive cough,
N/V/D, abdominal pain, dysuria, flank pain. Her daughter reports
that her sensorium has markedly improved and she is now at
baseline.
## PAST MEDICAL HISTORY:
CLL
atrial fibrillation on warfarin
HTN
Pre-DM
OA
Fibromyalgia
Venous insufficiency with venous ulcers
## FAMILY HISTORY:
Father had an unspecified hematologic malignancy.
## GENERAL:
Chronically ill appearing Caucasian woman, resting in
bed comfortably
## NEURO:
Alert and oriented x 3. Gives a clear and cogent history;
able to name specific physicians and nurses who cared for her
during last hospitalization. handgrip bilaterally. Wiggles
toes bilaterally
Pupils equal and reactive to light, EOMI, facial sensation equal
bilaterally, resists eye opening , hearing intact to finger
rub, palate elevates symmetrically, tongue midline, shoulder
shrug 4+/5 bilaterally.
## HEENT:
Oropharynx with moist mucus membranes, scant amount of
white mucus at back of throat which clears with coughing. No
palpable cervical LAD. No sinus tenderness
## CARDIOVASCULAR:
irreg irreg, normal rate
## CHEST/PULMONARY:
Decreased breath sounds at the bases, no
crackles heard.
## EXTR/MSK:
lower extremities are wrapped to the mid calf
bilaterally. patient refused to allow use to remove dressing to
examine ulcers. Reported tenderness to palpation over both legs
which was at baseline.
## SKIN:
One 3-4 cm in diameter ecchymosis over the left shin was
visible over the top of the dressing which appeared old and had
receded 2-3 cm from marker line drawn in ED. Skin was blanchable
and well perfused distal to wrapping
Old ecchymoses over the bilateral forearms
## ACCESS:
R POC site with old appearing overlying ecchymosis,
nontender to palpation, not warm or indurated.
## GENERAL:
Chronically ill appearing woman, resting in bed
comfortably
## NEURO:
Alert and oriented x 3.
## HEENT:
lips, OP slightly dry
## CARDIOVASCULAR:
irreg irreg, normal rate. III/VI tricuspid
regurgitation murmur
## CHEST/PULMONARY:
decreased at bases o/w clear
## EXTR/MSK:
BLE edema nearly resolved. chronic venous stasis
changes of the skin.
## SKIN:
extensive chronic venous stasis changes w/ marked xerosis
over bilat tibias
## ACCESS:
R POC site with old appearing overlying ecchymosis,
non-tender to palpation, not warm or indurated.
## DISCHARGE LABS:
:12AM BLOOD WBC-3.2* RBC-2.46* Hgb-7.9* Hct-24.0*
MCV-98 MCH-32.1* MCHC-32.9 RDW-21.8* RDWSD-75.3* Plt Ct-82*
05:12AM BLOOD Neuts-68 Bands-0 Lymphs-13* Monos-16*
Eos-2 Baso-0 Myelos-1* AbsNeut-2.18
AbsLymp-0.42* AbsMono-0.51 AbsEos-0.06 AbsBaso-0.00*
05:12AM BLOOD Glucose-117* UreaN-16 Creat-0.6 Na-138
K-3.5 Cl-97 HCO3-29 AnGap-12
05:12AM BLOOD ALT-10 AST-11 LD(LDH)-170 AlkPhos-201*
TotBili-1.1 DirBili-0.5* IndBili-0.6
05:12AM BLOOD Albumin-3.1* Calcium-9.4 Phos-3.5 Mg-2.1
UricAcd-2. year old female with CLL, who presents from
rehab with low-grade fever (Tmax 100.6 F), lethargy, and
disorientation initially c/f delirium in s/o occult infection
now
with continued fluid overload management.
ACUTE ISSUES
-----
#Chronic Lymphocytic Leukemia:
Diagnosed years ago and lost to follow up years ago.
Presented w/ year of worsening lymphedema, FTT. BMBx
and imaging concerning for bulky disease w/ marrow involvement.
-- Started bendamustine and with plan for
rituximab after 2 weeks. After two doses of bendamustine, she
developed and TLS, was managed with IVF which ultimately
worsened her pulmonary edema.
-Continue allopurinol daily
#Pancytopenia
infiltration of CLL in her marrow and/or from recent
benadmustine-effects. counts now improving
-Transfuse for hct <24 (due to heart disease) and/or plts < 10K
-neupogen daily, last dose given
-Initiated acyclovir prophylaxis
-IgG low at 301 patient currently refusing IVIG, will continue
to
discuss outpatient
#Volume Overload:
#Pulmonary Edema:
#Venous insufficiency with venous months per
patient}
Improved significantly. TTE showed normal LV systolic
function, dilated RV with preserved RV systolic function and
evidence of pressure overload as well as moderate to severe
functional tricuspid regurgitation in addition to moderate to
severe pulmonary hypertension.
- weight now down >20lb since admission
-decreased to 40mg po Lasix daily
-lyte checks now daily
- wrap legs bilaterally with ACE bandage
## #HYPERBILIRUBINEMIA:
RESOLVING. Unclear etiology. primarily
indirect. RUQ
U/S consistent with some sludge. ? for hepatosplenic
candidiasis in the setting of neutropenia so she was treated
partially with micafungin pending workup which was largely
unrevealing. She has declined MRI for further eval. Cont to
downtrend
-AFT blood culture NTD
-Fungal markers negative
-off Micafungin (D1 with neg work up
-Monitor and trend Daily LFTs
## #EOSINOPHILIA:
now normalized. noted at time of count recovery.
-F/U Strongyloides
-O & P neg
## #ELECTROLYTE IMBALANCES:
most notably hypokalemia &
hypophosphatemia, likely consequence of severe malnutrition,
vitamin deficiency with exacerbation from aggressive diuresis as
above. Needing frequent K+ repletions.
-Monitor and trend lytes now daily will increase if needed
## #SEVERE PROTEIN-CALORIE MALNUTRITION:
Nutrition consulted on
admission but patient refused. After discussion on ,
patient was amenable to nutrition so re-consulted for
recommendations.
-Encourage PO intake and adequate protein at all meals
-Oral nutrition supplement: Prosource Gelatein 20 TID
-Continue multivitamin
-Continue to monitor lytes and replete PRN
-Check zinc: replete w/ 220 mg zinc sulfate/day x14 days if
found to be deficient
-Trend weights daily
-Nutrition following
## #VITAMIN D DEFICIENCY:
Initiated Vitamin D 50,000U x 8WKs.
## #ELEVATED INR, COAGULOPATHY:
Stable, improving.
#Ecchymoses
-Monitor & Trend LFTs
## #AFIB:
CHADS2VASC 4
-Holding atenolol 50 mg /25 mg due to lower pressures on high
dose lasix
-will resume warfarin on discharge with plt count recovery, held
with thrombocytopenia and coagulopathy
CORE MEASURES
-----
## FEN:
Regular diet, electrolyte repletions
## EMERGENCY CONTACT:
Elects Dtr as HCP:
## DISPO:
back to rehab f/u Dr
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Allopurinol mg PO DAILY
2. Atenolol 25 mg PO QPM
3. Atenolol 50 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5. Potassium Chloride 20 mEq PO DAILY
6. Simethicone 80 mg PO TID:PRN gas
7. Ondansetron ODT 8 mg PO Q8H:PRN nausea
8. Lactic Acid 12% Lotion 1 Appl TP ASDIR
9. Iron Polysaccharides Complex mg PO DAILY
10. Furosemide 40 mg PO BID
11. Warfarin 4 mg PO DAILY16
## DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg PO Q12H
2. Vitamin D UNIT PO 1X/WEEK ( ) Duration: 8 Weeks
3. Furosemide 40 mg PO DAILY
4. Allopurinol mg PO DAILY
5. Iron Polysaccharides Complex mg PO DAILY
6. Lactic Acid 12% Lotion 1 Appl TP ASDIR
7. Ondansetron ODT 8 mg PO Q8H:PRN nausea
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
9. Potassium Chloride 20 mEq PO DAILY
10. Simethicone 80 mg PO TID:PRN gas
11. Warfarin 4 mg PO DAILY16
12. HELD- Atenolol 25 mg PO QPM This medication was held. Do
not restart Atenolol until outpatient team tells you to do so
13. HELD- Atenolol 50 mg PO DAILY This medication was held. Do
not restart Atenolol until outpatient team tells you to do so
## FACILITY:
Diagnosis:
CLL
CHF
Pulmonary HTN
## DISCHARGE INSTRUCTIONS:
Ms. ,
You were admitted due to fever and too much fluid. This improved
with antibiotics adjusting your heart medications and time. You
will follow up in the clinic as stated below. It was a pleasure
taking care of you.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14248835", "visit_id": "25060451", "time": "2154-06-15 00:00:00"} |
17103939-DS-12 | 1,728 | ## HISTORY OF PRESENT ILLNESS:
is a man with DLBCL on DA-EPOCH who is
admitted from the ED after presenting with palpitations, found
to have AFib with RVR and now s/p cardioversion.
Patient awoke in the middle of the night
withpalpitations. He called his neighbor who checked his HR,
andnoted it to be in the 90's. He went back to sleep but his
palpitations progressed to the point that his chest was
pounding' so he drove himself to the ED.
In the ED, initial VS were T 97.8, HR 50, BP 106/62, RR 15, O2
95%RA. Recheck VS shortly after triage were HR 170 and BP
85/63. EKG showed AFib with RVR. He was also increasingly
lightheaded, so he was cardioverted with 100J syncrochized DCCV
after sedation with 10mg tomidate and 50mcg fenankyl. He had
return to spontaneous rhythm. Initial labs notable for WBC 10.7,
HCT 28.4, PLT 112, TSH 1.9, Na 140, K 3.7, HCO3 25, CR 0.7,
lactate 1.7, UA negative, flu swab negative. CXR showed no acute
process. He received 2L NS, IV vancomycn and meropenem along
with his home meds. VS prior to transfer were T 97.9, HR 88, BP
104/61, RR 21, O2 100%RA.
On arrival to the floor, patient reports feeling back to normal,
although is quite tired. He denies any fevers or chills. No
chest pain. Chronic mild cough unchanged. NO SOB. No N/V/D.
Normal bowel movements. No dysuria. No new leg pain or swelling.
No rashes. He has no known cardiac history, but reports somewhat
similar episodes earlier in his treatment course, which were
sinus tachycardia. He did have a POC placed a few weeks ago. He
is taking lovenox for DVT/PE and hasn't missed any doses.
## REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
## ~ :
Develops dyspnea and a non-productive cough. This is
treated with empiric prednisone by his PCP 1 week, without
improvement in his symptoms.
- : Presents to with ongoing
symptoms, with CT imaging of the chest revealing a large
anterior mediastinal mass, a right-sided pleural effusion, and
segmental right-sided pulmonary emboli. He was transferred
promptly to for further evaluation and management.
- : Core biopsy of the mediastinal mass from
reveals diffuse large B cell lymphoma, positive for CD20, PAX5,
BCL6, MUM1, and CD10 (subset dim, <30%). FISH is negative for
the high-grade lymphoma panel, but is positive for three copies
of JAK2, CKDN2A, and the centromere of chromosome 9 (i.e. not
consistent with primary mediastinal B cell lymphoma or gray zone
lymphoma). Flow cytometry is consistent with involvement by a
kappa-restricted B cell lymphoma which is CD5 negative and CD10
negative. Thoracentesis on that same day is positive for
malignant cells, which are morphologically consistent with
DLBCL.
- : Upper extremity ultrasound demonstrates right axillary
and right subclavian deep venous thromboses. He is initially
anticoagulated with a heparin gtt for the PE and DVTs, and this
is transitioned to therapeutically-dosed enoxaparin.
- : CT of the abdomen and pelvis shows no evidence of
infradiaghragmatic disease.
- : Bone marrow biopsy is negative for involvement of
DLBCL. Final staging is Stage IV (given involvement of pleural
effusion), with R-IPI: 1 indicating good prognosis.
- : C1D1 da-EPOCH-R.
- : Discharged to home.
- : Initial outpatient hematology/oncology visit.
- : Develops rash consistent with drug side effect.
- : Rash persistent, so Bactrim and allopurinol held.
- : Prescribed triamcinolone topical for rash.
- : Rash still present but improved, resumes Bactrim.
- : Near baseline PET reveals the FDG avid soft tissue in
the anterior mediastinum (significantly decreased in size since
, a 1.2 cm medial right lower lobe nodule that could be
infectious/inflammatory in nature (but another site of disease
could not be excluded), and right vocal cord uptake.
- : Admitted for C2 of da-EPOCH-R, dose level 2,
with vincristine reduced by 50% because of peripheral
neuropathy.
- : C3 rituximab.
- : Admitted for C3 da-EPOCH, dose level 3, with
vincristine reduced by 50% because of peripheral neuropathy.
- : C4 rituximab.
- : Admitted for C4 da-EPOCH, dose level 4, with
vincristine reduced by 50% because of peripheral neuropathy.
## PAST MEDICAL HISTORY:
- DLBCL, as above
- PE and right upper extremity DVTs, as above
- Anxiety
## FAMILY HISTORY:
Father died of multiple myeloma at age . Father was a native
of . Mother is alive and well at age . Two sisters are
without medical problems. Maternal grandfather had colon and
prostate cancer in his .
## VS:
T 98.0 HR 83 BP 111/71 RR 16 SAT 96% O2 on RA
## GENERAL:
Pleasant, lying in bed comfortably. Somewhat anxious.
## EYES:
Anicteric sclerea, PERLL, EOMI;
## ENT:
MMM, JVD not elevated
## CARDIOVASCULAR:
Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
## RESPIRATORY:
Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
## GASTROINTESTINAL:
Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
## MUSKULOSKELATAL:
Warm, well perfused extremities without lower
extremity edema; Normal bulk
## NEURO:
Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
## LYMPHATIC:
No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
## GENERAL:
Pleasant, lying in bed comfortably.
## EYES:
Anicteric sclerea, PERLL, EOMI
## ENT:
MMM, known white ulcer on left side of tongue--no
surrounding erythema.
## CARDIOVASCULAR:
RRR, nl S1 S2, no m/r/g
## RESPIRATORY:
On RA, no increased work of breathing, no wheezes,
rales or ronchi.
## GASTROINTESTINAL:
nBS, NT, ND, no masses, no hepatomegaly
## NEURO:
AOx3, facial symmetry, moving all extremities with intent
## IMAGING:
==========================
CXR:
Since , there has been interval removal of a right
IJ central
venous catheter in placement of a dual lumen right IJ central
venous port with
its tip projecting over the expected location of the superior
cavoatrial
junction. Lungs are fully expanded and clear. No pleural
abnormalities. Heart size is
normal. Cardiomediastinal and hilar silhouettes are normal.
## IMPRESSION:
No evidence of an acute cardiopulmonary abnormality.
ECHO
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. Normal left ventricular wall thickness, cavity
size, and regional systolic function. Global function is low
normal (biplane LVEF = 55 %). The estimated cardiac index is
normal (>=2.5L/min/m2). There is no ventricular septal defect.
Right ventricular chamber size is top normal with borderline
normal free wall function. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
## IMPRESSION:
Normal biventricular cavity sizes with preserved
regional and low normal global biventricular systolic function.
No valvular pathology or pathologic flow identified.
Compared with the prior study (images reviewed) of ,
biventricular systolic function is less vigorous, and now low
normal.
## CLINICAL IMPLICATIONS:
Based on AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
## :
UA, FLU, RESP PANEL, BLOOD CX - NEG
## BRIEF HOSPITAL COURSE:
is a man with DLBCL on DA-EPOCH who was
admitted
from the ED after presenting with palpitations, found to have
AFib with RVR and now s/p cardioversion due to hypotension with
return to sinus rhythm. His echo and EKG in sinus rhythm were
reassuring.
## # ATRIAL FIBRILLATION
# S/P DCCV:
Etiology of Afib unclear, though potentially related
to
DA-EPOCH-R. He was cardioverted in the ED due to blood pressures
in 80's/50's. No obvious infectious source, was briefly treated
with antibiotics but they were discontinued shortly after
admission. TSH normal. He has remained in sinus rhythm on
telemetry and was already on therapeutic lovenox for DVT. His
TTE was normal. He was started on metoprolol 12.5 mg po Q6H
which was consolidated to succinate 50 mg daily. Per cardiology,
he may develop atrial fibrillation again with another round of
chemotherapy but intent of metoprolol is to control rates and
can go up on dose as indicated. He will with
cardiology in 2 weeks with a Zio patch until then.
## # DLBCL:
S/P 4 cycles of DA-EPOCH-R, last dose , thus 15
days out. Has come out of nadir, and is off neupogen (last dose
. Plan for reimaging prior to C5. He was continued on home
acyclovir, Bactrim prophylaxis.
## # HISTORY OF DVT PE:
He was continued on home lovenox 70mg q12
hours.
## TRANSITIONAL ISSUES:
[ ] Zio patch (patch for heart rate monitoring) to be applied on
[ ] Cardiology f/u on
[ ] f/u oral ulcer, no erythema or significant pain (no longer
neutropenic)
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Clindamycin 300 mg PO Q8H
3. Enoxaparin Sodium 70 mg SC Q12H
## , FIRST DOSE:
Next Routine Administration Time
4. Filgrastim 300 mcg SC ASDIR
5. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Cetirizine 10 mg PO DAILY:PRN allergies; bone pain with
neupogen
## DISCHARGE MEDICATIONS:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*1
2. Acyclovir 400 mg PO Q8H
3. Cetirizine 10 mg PO DAILY:PRN allergies; bone pain with
neupogen
4. Enoxaparin Sodium 70 mg SC Q12H
## , FIRST DOSE:
Next Routine Administration Time
5. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. HELD- Filgrastim 300 mcg SC ASDIR This medication was held.
Do not restart Filgrastim until told by your oncologist.
## PRIMARY:
Atrial Fibrillation s/p cardioversion
Diffuse Large B-Cell Lymphoma
History of Deep Vein Thrombosis
## DISCHARGE INSTRUCTIONS:
Mr. ,
You were admitted after you had a pounding sensation (found to
be an abnormal heart rhythm called atrial fibrillation) and
required being shocked in order to stop that rhythm. Your heart
has been in a normal rhythm since being shocked. Cardiology saw
you while you were here who recommended wearing a monitor for 2
weeks. You were also started on a new medication called
metoprolol to help control you heart rate.
Please keep your appointments and take your
medications as listed below.
-Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17103939", "visit_id": "23343548", "time": "2176-10-11 00:00:00"} |
11671471-RR-73 | 138 | ## INDICATION:
woman with new unexplained abnormal LFTs.
## FINDINGS:
Liver demonstrates no focal or textural abnormalities. There is no intra- or
extra-hepatic biliary dilatation. The common bile duct measures approximately
3 mm. Gallbladder contains numerous small gallstones as well as a few tiny
polyps. There is no pericholecystic fluid, wall thickening, or sludge. The
right kidney measures 10.1 cm in length. The left kidney measures 9.9 cm in
length. There is no stone, mass, or hydronephrosis. The spleen is
unremarkable in appearance and measures 9.3 cm in length. The abdominal aorta
is normal in caliber throughout. The main portal vein is patent. There is no
ascites. Pancreatic head and body are unremarkable. The tail is not well
visualized due to overlying bowel gas.
## IMPRESSION:
1. Numerous small gallstones. Small polyps.
2. Normal liver.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11671471", "visit_id": "N/A", "time": "2138-07-24 07:31:00"} |
19766760-RR-26 | 106 | ## EXAMINATION:
PELVIS (AP AND FROG HIPS)
## FINDINGS:
There remains mild widening of the pubic symphysis, unchanged to , may
represent sequela prior diastasis, with secondary mild degenerative changes.
Better appreciated on CT, there is subtle bony fragmentation/avulsion, at the
tenoperiosteal junction adductor and abdominal aponeurosis, may relate to
athletic pubic allergy.
The hips are maintained, without erosive or degenerative changes. No
fracture, osteonecrosis, or suspicious bone lesion. Mineralization is
symmetric.
SI joints maintained.
## IMPRESSION:
Mild widening of the pubic symphysis, and degenerative changes/bony
fragmentation, may represent sequela prior diastasis, and/or athletic
pubalgia. If clinically warranted, this could be further evaluated by MRI.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19766760", "visit_id": "N/A", "time": "2128-09-28 10:05:00"} |
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