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17135164-RR-39 | 411 | ## INDICATION:
History of HCC, status post CyberKnife and RFA. Re-staging.
## FINDINGS:
The visualized portions of the lung bases are unremarkable.
Coronary artery calcifications are noted.
The patient is status post right hepatic lobe CyberKnife therapy and
radio-frequency ablation for multifocal HCC. Within the segment V
radio-frequency ablation treatment zone, there is a 3.1 x 2.9 cm lesion
(previously 2.2 x 1.9 cm) with arterial phase nodular/rim enhancement that
becomes isointense to the liver parenchyma on delayed phase imaging (4:33).
Centrally there is a region of hypoattenuation reflecting RFA treatment
(4:30).
Superior to the segment VIII CyberKnife treatment zone, again seen is a focus
of arterial enhancement with incomplete washout on delayed images (4:22).
This measures 3.1 x 2.6 cm (previously 1.9 x 1.7 cm) and given the increase in
size likely represents hepatocellular carcinoma. There is no intrahepatic
biliary ductal dilatation. The main portal vein is either diminutive or
chronically occluded with evidence of cavernous transformation, as before.
The spleen is markedly enlarged, measuring 19.6 cm, slightly increased in size
compared to the prior study from . The pancreas, adrenal
glands, and kidneys are unremarkable. The stomach and visualized loops of
small and large bowel are unremarkable. There is no free fluid or free air in
the abdomen. Multiple tiny mesenteric and retroperitoneal lymph nodes do not
meet CT size criteria. The abdominal aorta is normal in caliber. A 2.3 cm
aneurysm at the bifurcation of the celiac axis is not significantly changed.
Similarly, a 1.2 cm right hepatic artery aneurysm (4:31) and 2.7 cm splenic
artery aneurysm with thrombus (4:37) are not significantly changed in size.
Large perisplenic varices are again noted.
## BONE WINDOW:
No suspicious lytic or blastic lesions are identified. Loss of
height of the L1 vertebral body is not significantly changed with a superior
endplate Schmorl's node.
## IMPRESSION:
1. Increased size of segment V lesion at the site of prior RFA with
peripheral and slightly nodular arterial phase enhancement, concerning for
residual tumor.
2. Increased size of focus of arterial enhancement adjacent to the segment
VIII CyberKnife treatment zone which may represent a focus of hepatocellular
carcinoma.
3. Diminutive or obliterated portal vein with cavernous transformation, not
significantly changed compared to the prior study.
4. Splenomegaly.
5. Right hepatic artery aneurysm, splenic artery aneurysm, and aneurysm at
the celiac axis bifurcation, not significantly changed.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17135164", "visit_id": "N/A", "time": "2118-04-25 09:59:00"} |
10198884-RR-13 | 327 | ## INDICATION:
Abdominal pain with thickening of jejunum seen on previous MRA.
Evaluate for inflammatory bowel disease.
## CHEST BASE:
The bases of the lungs are unremarkable. There is no pleural
effusion or mass or thickening.
CT OF THE ABDOMEN WITH IV CONTRAST:
## LIVER:
The liver is not enlarged. There are two hypodense foci, less than 3
mm, peripherally which are too small to characterize. No focal mass or nodule
or cyst seen. No diffuse abnormality. There is no bile duct dilatation and
the gallbladder is unremarkable.
## PANCREAS:
The pancreas is not enlarged with no focal mass or nodule. No
abnormal calcifications. There is no peripancreatic stranding.
## SPLEEN:
Not enlarged and appears homogeneous.
## ADRENAL GLANDS:
Both adrenal glands are normal.
## KIDNEYS:
The kidneys are not enlarged. They excrete contrast symmetrically.
There is no cortical renal solid or cystic mass. There are no cysts seen.
There is no perinephric stranding or other abnormality.
RETROPERITONEUM AND MESENTERY. There is no retroperitoneal or mesenteric
lymph node enlargement or other mass.
## GI TRACT:
The stomach appears normal. There is no hiatal hernia. The
duodenum appears normal as well. The jejunum is also normal with no evidence
of wall thickening on the CT scan. The ileum is also normal with normal
mucosal pattern and no evidence of wall thickening. There is no mesenteric
stranding and the terminal ileum is normal. The colon shows no mucosal
abnormality and there is no obstructing mass. There is mild fecal load in the
left colon. The sigmoid is normal.
CT OF THE PELVIS WITH IV CONTRAST:
There is no pelvic lymph node enlargement or other mass. The urinary bladder
is unremarkable. A small remnant of uterus is seen, status post partial
hysterectomy. Both ovaries are well visualized and there is follicular
activity. The right ovary measures 0.9 x 1.6 cm and the left 0.3 x 4.2 cm.
## IMPRESSION:
Normal CT of the abdomen and pelvis. In particular, normal GI
tract by CT.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10198884", "visit_id": "N/A", "time": "2151-09-08 15:55:00"} |
11986799-RR-16 | 183 | ## INDICATION:
Right MCA territory stroke.
## CT HEAD:
There is an established infarct in the posterior half of the right
MCA territory. There is no evidence of hemorrhagic conversion. There is no
hydrocephalus or midline shift or mass effect seen. Atherosclerotic
calcifications are seen along bilateral intracranial vertebral arteries and
bilateral cavernous internal carotid arteries. Visualized orbits, paranasal
sinuses, and mastoid air cells are unremarkable. No fracture is seen.
## CTA HEAD:
Bilateral intracranial internal carotid arteries, vertebral
arteries, basilar artery and their major branches are patent with no evidence
of stenosis, occlusion, dissection, or aneurysm formation.
## CTA NECK:
Atherosclerotic changes are seen in the aortic arch and visualized
descending thoracic aorta. Bilateral common carotid arteries, internal
carotid arteries in the neck are patent with no evidence of stenosis,
occlusion, dissection or pseudoaneurysm formation. Streak artifacts from the
pacemaker and leads are seen. Visualized neck soft tissues are unremarkable.
Bilateral vertebral artery origins are patent.
## IMPRESSION:
1. Acute/subacute right MCA territory infarct with no evidence of hemorrhage.
There is no hydrocephalus or midline shift.
2. Unremarkable CTA of the head and neck.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11986799", "visit_id": "22079625", "time": "2119-04-26 17:07:00"} |
14039438-RR-81 | 90 | ## CHEST:
Frontal and lateral views
## HISTORY:
with reflux symptoms// plz eval for acute
intrathoracic abnormality
## FINDINGS:
Right lung base opacity may represent atelectasis but difficult to exclude
aspiration or pneumonia. This may conform to an parent or simulated cavity
seen on the lateral view projecting over the lowest fully visible thoracic
vertebral body. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unchanged from prior.
## IMPRESSION:
Right lung base opacity may represent atelectasis but difficult to exclude
aspiration or pneumonia. Oblique views are recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14039438", "visit_id": "22008246", "time": "2169-05-20 00:37:00"} |
18032895-RR-17 | 454 | ## INDICATION:
year old woman with pancreatic cancer metastatic to liver,
screening for clinical trial// please evaluate disease prior to starting
chemotherapy
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen following intravenous contrast administration with split
bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## LOWER CHEST:
Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
## HEPATOBILIARY:
There are multiple hepatic metastases with some of them the
progressed in size another new as described below (series 3 close):
-Segment 2 lesion measuring 3.8 x 4.9 cm, previously 3.8 x 3.3 cm (image 113).
-Segment 7 lesion measuring 3.2 x 3.1 cm previously 2.3 x 2.2 cm (image 105).
-Lesion segment 4 B measuring 1.7 x 3.4 cm previously 1.7 x 2.7 cm (image 117)
-New segment 5 lesion measuring 1.3 by 1.1 cm (image 130).
- New caudate lesion measuring 1.8 x 1.3 cm.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
## PANCREAS:
Again seen is a hypodense mass at the body of the pancreas measuring
2.6 x 3.7 cm (series 3, image 122). There is secondary main duct dilatation
reaching 5 mm. This mass encases the splenic vein with complete occlusion and
secondary perigastric varices. It abuts the distal part of the celiac trunk
and abuts also the portal splenic confluence. There is no peripancreatic
stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. Trace of
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The uterus is retroverted and contains multiple fibroids
with the largest measuring 2.3 cm.
## LYMPH NODES:
Few perigastric, peripancreatic and porta hepatic lymph nodes are
again seen. No new abdominal pelvis adenopathy. No peritoneal nodule.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Interval increase in size and number of metastatic liver lesions.
2. Please refer to separate chest CT for thoracic findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18032895", "visit_id": "N/A", "time": "2138-02-12 10:38:00"} |
14577519-RR-25 | 145 | ## EXAMINATION:
CHEST PORT. LINE PLACEMENT
## INDICATION:
year old woman s/p MVR/TVR/Left Atrial Appendage Ligation //
FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Contact name: ,
:
## FINDINGS:
A moderate left apical pneumothorax is noted. A left pleural effusion cannot
be excluded. The right lung is clear.
Postsurgical changes are noted. The left atrial appendage clip is noted. A
Swan-Ganz catheter is noted entering the right internal jugular and
terminating at the main pulmonary artery. A pleural drain is noted. The heart
is moderately enlarged. Median sternotomy wires are intact.
The endotracheal tube terminating in the right mainstem bronchus.
## IMPRESSION:
Moderate left apical pneumothorax.
Endotracheal tube terminates in the right mainstem bronchus. Should be pulled
back 5-6 cm.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 5:36 , 20 minutes
after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14577519", "visit_id": "23324194", "time": "2171-05-30 13:39:00"} |
13166135-RR-20 | 170 | ## EXAM:
MRI of the brain.
## CLINICAL INFORMATION:
Patient with history of melanoma in with recent
cervical spine MRI showing suspicious lesion in the pons.
## FINDINGS:
There are FLAIR hyperintensities in the subcortical and
periventricular white matter including pons indicative of small vessel
disease. Following gadolinium, no abnormal enhancement is seen in the brain
parenchyma or in the pons to indicate parenchymal metastatic disease.
There is an approximately 2 x 1.5 cm mass in the inferior frontal lobe region
in the midline. The mass is centered in the region of the cribriform plate
and is suggestive of an olfactory groove meningioma. The mass has
characteristics of extra-axial lesion and shows homogeneous enhancement.
Vascular flow voids are maintained.
## IMPRESSION:
1. 2 x 1.5 cm olfactory groove meningioma is noted.
2. No intraparenchymal metastatic disease is seen.
3. Mild changes of small vessel disease.
4. The subtle hyperintensity previously noted in the pons on MRI of the
cervical spine appears to be due to a small vessel disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13166135", "visit_id": "N/A", "time": "2121-08-14 10:23:00"} |
12629944-RR-27 | 106 | ## INDICATION:
with RLQ pain radiating to vagina s/p essure placement with
hysteroscopy // ? abnormality, abscess
## FINDINGS:
LMP on . Essure placement on
The uterus is anteverted and measures 8.8 x 4.9 x 4.6 cm. Bilateral Essure
device noted entering the uterine fundus in appropriate position. The
endometrium is homogenous and measures 4 mm. The ovaries are normal. Note is
made of a 2.6 x 1.4 x 2.6 cm hemorrhagic cyst within the right ovary There is
minimal free fluid.
## IMPRESSION:
2.6 cm hemorrhagic cyst within the right ovary. Minimal free fluid in the
pelvis. Essure device in place.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12629944", "visit_id": "N/A", "time": "2160-07-07 22:47:00"} |
14249055-RR-25 | 126 | ## INDICATION:
male with new onset mental status changes and
suicidal ideation. Rule out mass or bleed.
## FINDINGS:
There is no acute intracranial hemorrhage, major vascular
territorial infarction, mass effect, or edema. Evaluation for mass is limited
on this non-contrast-enhanced CT. The gray-white matter differentiation is
preserved. Ventricles and sulci are normal in size and appearance. Basilar
cisterns are preserved. Globes and lenses are intact. Aerosolized secretions
are noted in the right sphenoid sinus is noted, but the remainder of the
visualized paranasal sinuses and mastoid air cells are well aerated. No
osseous abnormality is identified.
## IMPRESSION:
1. Limited evaluation for mass on non-contrast-enhanced CT, but no evidence
of acute intracranial abnormality.
2. Right sphenoid sinus disease. Clinical correlation recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14249055", "visit_id": "22375753", "time": "2154-08-01 16:56:00"} |
14620815-RR-56 | 386 | ## INDICATION:
History: with acute on chronic epigastric pain//ischemia?
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 4.9 s, 53.0 cm; CTDIvol = 16.8 mGy (Body) DLP = 889.9
mGy-cm.
Total DLP (Body) = 901 mGy-cm.
## LOWER CHEST:
Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is surgically absent.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
There is a moderate to large hiatal hernia. The stomach and
small bowel are normal in caliber. The appendix appears normal. The colon is
normal in caliber and there is no evidence of colitis. There are several
sigmoid diverticula, but no evidence of diverticulitis. There is no free air
or free fluid in the abdomen.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The uterus and bilateral adnexae are within normal
limits.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There are multilevel degenerate changes in the lower thoracic and lower
lumbar spine. No acute fracture or concerning osseous lesion.
## SOFT TISSUES:
A small umbilical hernia contains fat.
## IMPRESSION:
1. Moderate to large hiatal hernia, not significantly changed from .
2. No acute pathology in the abdomen or pelvis. Normal caliber small and
large bowel loops.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14620815", "visit_id": "N/A", "time": "2155-07-13 20:01:00"} |
18209122-RR-19 | 170 | ## INDICATION:
male with history of alcohol abuse now with
epigastric and right upper quadrant pain, here to assess for acute biliary
pathology.
## FINDINGS:
The liver is diffusely echogenic consistent with hepatic steatosis.
No focal liver lesions are identified. The main portal vein is patent with
normal hepatopetal flow. No intra or extrahepatic biliary ductal dilatation
is seen with the common bile duct measuring 5 mm. The gallbladder is normal
without evidence of stones, distention or wall thickening. The spleen is
normal, measuring 11.3 cm. There is no ascites seen.
The body of the pancreas is partially visualized and unremarkable. The head,
distal body and tail of the pancreas are obscured by overlying bowel gas. The
visualized portions of the inferior vena cava are unremarkable.
## IMPRESSION:
1) Diffusely echogenic liver consistent with hepatic steatosis. Other forms
of advanced liver disease including fibrosis or cirrhosis cannot be excluded
on this study. No focal liver lesions are identified.
2) Unremarkable gallbladder without stones, wall thickening, or distention.
3) No ascites.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18209122", "visit_id": "21536487", "time": "2118-10-31 13:07:00"} |
16017987-RR-13 | 583 | ## INDICATION:
year old man with multiple stab wounds and GSW // Eval for
active bleeding
## CHEST, ABDOMEN, AND PELVIS CTA:
Non-contrast and multiphasic
post-contrast images were acquired through chest, abdomen, and pelvis.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
## VASCULAR:
The thoracic aorta and proximal great vessels are well opacified
and normal in caliber, however evaluation of the aortic arch somewhat limited
by motion artifact. The mid and distal thoracic aorta appear normal. The
abdominal aorta and iliac arteries are normal in caliber and well opacified.
The celiac trunk and main branches, SMA and bilateral renal arteries are
patent. The is patent.
At the site of small bowel anastomosis in the mid abdomen there is a
high-density blush of contrast within the lumen which appears on the arterial
phase and becomes larger and less dense on the portal venous and 3 minute
delayed phase sequences matching blood pool on all sequences.
The IVC appears more normal in caliber since the prior study.
## CHEST:
Enteric tube courses through the esophagus. The partially visualized
thyroid is unremarkable. There is no lymphadenopathy. Heart size is normal.
Pneumopericardium is compatible with recent pericardial window.
There is a small nonhemorrhagic left pleural effusion with overlying
atelectasis at the left base. Atelectasis at the right base is moderate.
There is a tiny left anterior pneumothorax. The lungs are otherwise well
expanded and clear. The airways are patent to the subsegmental level.
There are several sites of suture and admixed subcutaneous gas in the left
upper back, and partially visualized left arm compatible with recent closure
of traumatic injuries.
## ABDOMEN:
The liver enhances normally without focal lesions. There is no intra
or extrahepatic biliary duct dilation. The gallbladder is normal without wall
thickening or evidence of stones. There is generalized nonhemorrhagic free
fluid in the abdomen also seen around the gallbladder.
The spleen, pancreas, and adrenal glands are normal. The kidneys excrete
contrast symmetrically without hydronephrosis or evidence of injury. The
ureters normal in caliber throughout their visualized course.
Enteric tube terminates in the stomach which appears normal. There is
anastomosis of small bowel following resection in the mid abdomen. The
anastomosed segment of small bowel is mildly distended with wall thickening,
likely postoperative. Suspected intraluminal bleeding at the site of
anastomosis is detailed above in the vascular section.
There is no free air or free fluid adjacent to the anastomosis to suggest
anastomotic leak. Small locules of gas seen elsewhere in the abdomen or
compatible with recent surgery.
There is a very high density focus causing significant streak artifact in the
left mid abdomen lying just anterior to the quadratus lumborum muscle (02:47)
compatible with bullet. There is subcutaneous edema in stranding in the right
mid abdominal wall (02:50).
## PELVIS:
The urinary bladder is drained by a Foley catheter. There is moderate
amount of nonhemorrhagic pelvic free fluid. The rectum appears normal.
## BONES AND SOFT TISSUES:
There are anterior abdominal skin staples. Surgical
packing is seen in the left upper abdominal wall/lower chest wall (02:30).
## IMPRESSION:
1. Active extravasation of contrast into the lumen at the site of small bowel
anastomosis.
2. Tiny left anterior pneumothorax is unchanged.
3. No other significant change from the study 3 hr prior with small volume
nonhemorrhagic ascites and scattered locules of gas in the abdomen compatible
postoperative state.
## RECOMMENDATION(S):
Consider consultation with interventional radiology
## NOTIFICATION:
The findings were telephoned to Dr. By at
09:50, , 5 min after discovery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16017987", "visit_id": "28430460", "time": "2132-11-07 08:15:00"} |
16178757-DS-21 | 2,413 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
This is an woman with a pmhx. significant for PMR,
degenerative joint disease, and HTN who presented to
with one day of abdominal pain radiating to her back, found to
have obstructing CBD stone on CT scan, now transferred to
for ERCP in the morning.
Patient was in her usual state of health until day of admission
when she developed excruciating epigastric pain, which radiated
to her back and right flank. Ms. complained of loss of
appetitie, but no nausea or vomiting. After pain lasted for 3
hours, patient decided to go to ED at . At ,
labs were notable for WBC 6.8, Tbili 3.4, ALT 210, AST
183, Alk Phos 171 and Lipase 99. A CT scan was performed, which
demonstrated CBD dilatation and obstructing stone. Patient was
given levofloxacin, flagyl, and morphine and transferred to
for evaluation for ERCP. Patient denies chest pain,
shortness of breath, vomiting, diarrhea, blood in stools, or
other concerning signs or symptoms.
In the ED, initial vitals were: 99.7 94 103/58 20 98% 2L NC.
Patient was given morphine and zofran. Patient was evaluated by
surgery who will follow along. Plan is for ERCP in the morning.
## ROS:
A 12-point review of systems is negative aside from what
is described.
## PAST MEDICAL HISTORY:
HTN
Osteoporosis c/b vertebral compression fractures & kyphosis
PMR/GCA
GERD
## FAMILY HISTORY:
No family history of biliary problems. Mother died of a blood
clot. Father died of a bowel obstruction.
## GENERAL:
Elderly lady, no acute distress, kyphotic
## CHEST:
Clear to auscultation bilaterally but dullness at bases
## ABDOMEN:
+BS, well-healed scar, epigatstrum is tender to
palpation
## NEURO:
Alert and oriented x3, patient is moving all 4
extremities
## DISCHARGE PHYSICAL EXAM:
VSS, HR in the high (metoprolol tartrate decreased from
12.5mg bid to 6.25mg bid)
## CHEST:
Crackles in right lower lung base
## ABDOMEN:
+BS, soft, non-tender, non-distended
## U/A:
ketones 15, ublg 50
09:10PM URINE COLOR-Yellow APPEAR-Clear SP
09:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-NEG
ercp:
Normal major papilla.
Cannulation of the pancreatic duct was successful with a
sphincterotome using a free-hand technique. Cannulation of the
biliary duct was successful and deep with a sphincterotome using
a free-hand technique. Contrast medium was injected resulting in
complete opacification.
The intrahepatics were normal. The common bile duct was 8 mm.
There was a filling defect within the CBD. The cystic duct and
gallbladder filled.
While attempting to cannulate the bile duct, the pancreatic duct
was cannulated and injected. The pancreatic duct was normal but
had a more vertical orientation than usual.
Given the cholangiogram findings, a sphincterotomy was performed
in the 12 o'clock position using a sphincterotome over an
existing guidewire.
One large stone was extracted successfully using a balloon
catheter.
There was excellent flow of bile and contrast.
Otherwise normal EGD to third part of the duodenum
## RECOMMENDATIONS:
Return to the Hospital floor for ongoing care.
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
If any fever, worsening abdominal pain, or post procedure
symptoms, please call the advanced endoscopy fellow on call
/ pager .
No aspirin, NSAIDs, coumadin for 5 days.
ERCP
Evidence of a previous sphincterotomy was noted in the major
papilla.
A small blood clot was noted at the sphincterotomy site. No
active bleeding was seen
Cannulation of the biliary duct was successful and deep with a
sphincterotome
Limited cholangiogram showed normal CBD
A 5cm by double pig tail biliary stent was placed to help
cauterization around the sphincterotomy site
Gold probe was used to cauterize the area at the sphincterotomy
site for hemostasis
Otherwise normal EGD to third part of the duodenum
## RECOMMENDATIONS:
Return to floor
Continue to keep NPO.
IVF as tolerated.
Repeat Hct after transfusion.
Avoid NSAIDs, anti-platelets, coumadin.
Repeat ERCP in stent-pull and
re-evaluation
Follow-up with Dr. as needed
ECHO
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ( ) mitral regurgitation is seen.
Due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (Coanda effect). The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
## IMPRESSION:
Normal regional and global biventricular systolic
function. Severe calcific aortic stenosis with mild mitral
regurgitation. At least mild-to-moderate mitral regurgitation.
Mild to moderate dilation of the ascending aorta. Mild elevation
of pulmonary artery systolic pressu
06:40AM BLOOD WBC-7.3 RBC-2.78* Hgb-9.4* Hct-27.2*
MCV-98 MCH-33.9* MCHC-34.7 RDW-17.5* Plt
06:40AM BLOOD Glucose-97 UreaN-13 Creat-0.5 Na-140
K-3.5 Cl-100 HCO3-33* AnGap-11
06:40AM BLOOD ALT-54* AST-30 AlkPhos-91 TotBili-1.0\
## ERCP :
Evidence of a previous sphincterotomy was noted in the major
papilla.
A small blood clot was noted at the sphincterotomy site. No
active bleeding was seen
Cannulation of the biliary duct was successful and deep with a
sphincterotome
Limited cholangiogram showed normal CBD
A 5cm by double pig tail biliary stent was placed to help
cauterization around the sphincterotomy site
Gold probe was used to cauterize the area at the sphincterotomy
site for hemostasis
Otherwise normal EGD to third part of the duodenum
## RECOMMENDATIONS:
Return to floor
Continue to keep NPO.
IVF as tolerated.
Repeat Hct after transfusion.
Avoid NSAIDs, anti-platelets, coumadin.
Repeat ERCP in stent-pull and
re-evaluation
Follow-up with Dr. as needed
## ECHO :
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ( ) mitral regurgitation is seen.
Due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (Coanda effect). The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
## IMPRESSION:
Normal regional and global biventricular systolic
function. Severe calcific aortic stenosis with mild mitral
regurgitation. At least mild-to-moderate mitral regurgitation.
Mild to moderate dilation of the ascending aorta. Mild elevation
of pulmonary artery systolic pressure.
06:50AM BLOOD WBC-5.7 RBC-2.67* Hgb-8.9* Hct-26.8*
MCV-100* MCH-33.3* MCHC-33.2 RDW-17.8* Plt
06:50AM BLOOD Neuts-50.8 Monos-7.2 Eos-5.5*
Baso-0.8
06:50AM BLOOD Plt
06:50AM BLOOD Glucose-91 UreaN-20 Creat-0.5 Na-142
K-3.8 Cl-104 HCO3-34* AnGap-8
06:50AM BLOOD ALT-37 AST-25 LD(LDH)-178 AlkPhos-74
TotBili-0.7
06:50AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.7
## BRIEF HOSPITAL COURSE:
This is an woman with a pmhx. significant for HTN,
osteoporosis, compression fractures, GCA/PMR (on low-dose
prednisone) who is admitted with abdominal pain, elevated LFTs,
and CT scan showing obstructing stone in common bile duct.
## # CHOLEDOCHOLITHIASIS:
Patient with symptoms, labs, and
imaging concerning for obstructing stone. Had ERCP in which
stone was extracted, and sphincterotomy done. She developed
post ERCP pancreatitis after first ERCP and also had post
sphincterotomy bleed, so she went for repeat ERCP in which a
clot was seen at the sphincterotomy site. Cautery was applied
at the site of sphincterotomy site and a stent was placed.
Patient will need repeat ERCP in weeks for stent removal.
This will be arranged by ERCP team. Of note, patient cannot
take aspirin or NSAIDs until due to sphincterotomy and
bleed. Ms. will remain on cipro 500mg BID through
.
## # GCA/PMR:
During hospitalization, prednisone was increased to
5mg QD due to clinical symptoms and labs (elevated ESR)
consistent with PMR flare. This dose should be tapered down as
an outpatient.
## # ANEMIA:
Baseline hematocrit of 24, decreased to 21 after
post sphincterotomy bleed. Received one unit prbcs and blood
count increased appropriately. However, patient *does* have an
elevated MCV, which should be further investigated. A B12 level
was sent on admission, but was not back at time of discharge.
This should either be followed up or a repeat B12 should be
drawn as an outpatient.
## # NECK PAIN:
Patient developed severe neck pain after days of
hospitalization. Also with very tight sternocleidomastoid
muscles. She has this pain intermittently, but was
dramatically worsened by hospitalization. She could not receive
NSAIDS because of post sphincterotomy bleed, so she was given
tylenol and low doses of ativan for relief. Patient also
continued on a fentanyl patch. Prednisone was increased, which
helped with symptoms as well.
# PULMONARY EDEMA AND SEVERE AS: Patient developed pulmonary
edema after receiving low doses of IVF at low rates after ERCPs.
ECHO done to assess, and severe aortic stenosis was found.
Patient was started on low-dose metoprolol (she was bradycardic
at doses of 12.5mg BID and this was decreased to 6.25mg BID) and
should have close follow-up with her PCP. Moreover, patient's
PCP help arrange follow-up with cardiology for further
evaluation.
## # METABOLIC ALKALOSIS:
Patient with bicarb of 34 on discharge.
She was given lasix during hospitalization but did not receive
any on the days prior to discharge. Concern for hypercapnia at
night due to marked kyphosis. Would recommend rechecking bicarb
and perhaps doing sleep study as an outpatient.
## # HTN, BENIGN:
Patient's blood pressures were well-controlled,
and lisinopril was decreased to 5mg QD in context of starting
metoprolol.
## # OSTEOPOROSIS:
Continue fortical, reclast, calcium and
vitamin D. Patient with marked kyphosis, presumed secondary to
compression fractures.
## # CODE STATUS:
Patient remained full code in the hospital
Transitional issues:
--Severe aortic stenosis, started on metoprolol, scattered
crackles at bases
--Decreased lisinopril from 10mg to 5mg QD
--Increased prednisone to 5mg QD for PMR flare, will need to be
decreased
--Needs repeat ERCP in weeks (will be scheduled by ERCP
office at
--Needs evaluation by surgery for possible cholecystectomy
--Outpatient and
--Bicarb was creeping up during admission: recheck and consider
sleep study
--Anemia: stable but needs to be followed. MCV is elevated
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcitonin Salmon 200 UNIT NAS DAILY
2. Fentanyl Patch 25 mcg/h TP Q72H
3. Lisinopril 10 mg PO DAILY
Please hold for SBP <100.
4. PredniSONE 1 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Calcium Carbonate 500 mg PO QID
8. Vitamin D 800 UNIT PO DAILY
9. Reclast *NF* (zoledronic acid-mannitol&water) Dose is Unknown
Unknown Injection Q year
. Multivitamins 1 TAB PO DAILY
## DISCHARGE MEDICATIONS:
1. Calcitonin Salmon 200 UNIT NAS DAILY
2. Calcium Carbonate 500 mg PO QID
3. Fentanyl Patch 25 mcg/h TP Q72H
4. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg One tablet(s) by mouth Once a day Disp #*30
## TABLET REFILLS:
*0
5. PredniSONE 5 mg PO DAILY
RX *prednisone 1 mg 5 tablet(s) by mouth Once a day Disp #*90
## TABLET REFILLS:
*0
6. Ciprofloxacin HCl 500 mg PO Q12H
Please take through .
RX *ciprofloxacin [Cipro] 500 mg One tablet(s) by mouth Twice a
day Disp #*12 Tablet Refills:*0
7. Lorazepam 0.5 mg PO BID:PRN Neck pain
Do not drink alcohol or drive while taking this medication.
RX *lorazepam [Ativan] 0.5 mg One tablet by mouth Twice a day
Disp #*20 Tablet Refills:*0
8. Metoprolol Tartrate 6.25 mg PO BID
RX *metoprolol tartrate 25 mg (total of 6.25mg) tablet(s) by
mouth twice a day Disp #*30 Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Do not start taking this medication until .
11. Reclast *NF* (zoledronic acid-mannitol&water) 0 Unknown
INJECTION Q YEAR
. Vitamin D 800 UNIT PO DAILY
13. Multivitamins 1 TAB PO DAILY
## DISCHARGE DIAGNOSIS:
Choledocholithiasis
Bleeding at sphincter site
Pancreatitis
Aortic stenosis
Polymyalgia Rheumatica Flare
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure taking care of you on this admission. You
were transferred to in the setting of abdominal pain. You
underwent an ERCP, which showed an obstructing stone, and a
sphincterotomy (small incision of the bile duct sphincter) was
performed. You subsequently developed pancreatitis
(inflammation of the pancreas) and a small bleed at the site of
the sphincterotomy. You underwent another ERCP and a stent was
placed. You will need to have this stent removed in weeks.
You were also seen by the surgeons who would eventually like to
take out your gallbladder.
During this hospitalization, we noticed some fluid in your
lungs. We did an echocardiogram of your heart, which showed
severe aortic stenosis. You will need to see a cardiologist (to
be arranged by your PCP) about this issue. We also started you
on a medication called metoprolol 6.25mg twice a day to slow
your heart rate. Stop taking this medication if you get dizzy
or lightheaded and call your PCP. We decreased your lisinopril
to 5mg once a day as your blood pressure was well-controlled.
You can start taking your aspirin and ibuprofen on . You
will also be on an antibiotic called ciprofloxacin 500mg twice a
day through to treat a possible infection in your
biliary system.
While you were here, you had symptoms and labwork consistent
with a PMR flare. We increased your prednisone to 5mg once a
day. This dose can be tapered down by your rheumatologist.
Please keep all of your appointments and take your medications
as prescribed.
It was really wonderful caring for you!
-- , MD
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16178757", "visit_id": "20168752", "time": "2183-04-21 00:00:00"} |
12898150-DS-13 | 1,086 | ## ALLERGIES:
Keflex / Penicillins / Sulfa (Sulfonamide Antibiotics) /
clindamycin
## CHIEF COMPLAINT:
Right upper quadrant discomfort, fever, weakness
## HISTORY OF PRESENT ILLNESS:
Mr. is an male who is recently s/p
laparoscopic cholecystectomy on , discharged home the same
day in good condition. He returns to the ED today with RUQ
discomfort and a fever to 103. He reports having felt quite well
in the first two days post-operatively, with controlled and
decreasing pain, good tolerance of POs, no nausea/vomiting, and
having bowel function. For the past hours, however, he
reports feeling an increasing RUQ discomfort and nausea, but no
emesis. His son who accompanies him reports that the patient has
also seemed much more fatigued than usual today. He also
developed a fever to 103. He reports no CP/SOB, no urinary
symptoms, and no BRBPR/melena. He has been passing flatus and
tolerating POs despite this discomfort, although with a
decreased
appetite.
## PAST MEDICAL HISTORY:
Chronic cholecystitis, atrial fibrillation
(previously on Eliquis, stopped recently), TIA, hypertension
## PAST SURGICAL HISTORY:
Laparoscopic cholecystectomy
Dr.
, L knee surgery ( )
## FAMILY HISTORY:
Father lived until
Mother with heart issues
## GEN:
A&O, NAD, interactive and cooperative
## PULM:
Clear to auscultation b/l
## ABD:
Soft, non-distended, tender in RUQ, no
rebound/rigidity/guarding, no palpable masses, surgical scars
healing well with steri-strips in place
## LUNGS:
Clear, diminished BS right lateral chest
## ABDOMEN:
soft, non-tender, ecchymosis around
area, steri-strips to port sites
## EXT:
no calf tenderness bil., no pedal edema bil
## NEURO:
alert and oriented x3, speech clear
## CXR:
1. Bibasilar atelectasis. Underlying consolidation cannot be
ruled out.
2. Small right pleural effusion
## CT A/P:
1. Heterogenous ill-defined collection with internal foci of air
measuring up to 6.3 cm in the gallbladder fossa that likely
represents Surgicel.
2. Free intraperitoneal air and mild mesenteric fatty stranding
in the right upper quadrant is likely postsurgical given recent
cholecystectomy. No evidence of abscess
3. Appendix measures up to 10 mm without adjacent fatty
stranding or
hyperemia.
4. T11 compression deformity is worse since and
compatible with a compression fracture.
## BRIEF HOSPITAL COURSE:
Mr. is an year old male admitted to the Acute Care
Surgery Service on with right upper quadrant pain and
febrile to 103 status post laparoscopic cholecystectomy 3 days
prior. Admission labs revealed no leukocytosis but
hyperbilirubinemia (Tbili 1.9). CT abdomen pelvis and ultrasound
imaging showed no evidence of biliary leak or biliary ductal
dilation. He was admitted to the surgical floor for IV
antibiotics and further assessment. The patient was started on a
course of ciprofloxacin and flagyl.
During his hospital course, his vital signs remained stable and
he was afebrile. His white blood cell count was normal and
liver function tests trended downward. Blood cultures were
drawn with results pending. He was voiding without difficulty
and ambulatory. The patient was discharged home on HD #3 in
stable condition on a 3 day course of ciprofloxacin and flagyl.
Follow-up appointments were made with the acute care surgery
clinic, and his primary care provider. The patient was
instructed to follow-up with his cardiologist to discuss
resuming his Eliquis. Discharge instructions were reviewed and
questions answered.
## MEDICATIONS ON ADMISSION:
oxycodone PRN
-aspirin
-flecainide
-diltiazem
(Was on Eliquis, now held?)
## DISCHARGE MEDICATIONS:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
last dose
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*5 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
hold for diarrhea
3. MetroNIDAZOLE 500 mg PO Q8H
last dose
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*8 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
hold for diarrhea
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Aspirin 325 mg PO DAILY
7. Diltiazem Extended-Release 180 mg PO DAILY
8. Flecainide Acetate 100 mg PO Q12H
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to the Acute Care Surgery Service on
with fevers after having your gallbladder removed 3 days prior.
You had a CT scan and ultrasound that showed normal post
operative changes and no evidence of bile leak. You had blood
cultures and urine cultures that showed an infection and you
were given antibiotics. You symptoms resolved and you were able
to tolerate a regular diet without nausea or abdominal pain. You
fevers and abdominal discomfort was most likely caused by a
gallstone that passed and therefore your symptoms resolved. You
are now ready to be discharge to home to continue your recovery
from surgery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
## INCISION CARE:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips days after surgery.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12898150", "visit_id": "28674778", "time": "2117-08-10 00:00:00"} |
14129581-RR-19 | 162 | ## HISTORY:
Unwitnessed fall. Evaluate for cervical spine fracture.
## FINDINGS:
There is no fracture. Minimal retrolisthesis of C5 on C6 and
anterolisthesis of C7 on T1 are likely degenerative. There is multilevel
degenerative change with neural foraminal narrowing, worst at C5-C6 due to
uncovertebral and facet arthrosis. Tiny osteophytes at C4-C5 and C5-C6 mildly
narrow the spinal canal. There is no paravertebral hematoma. Prevertebral
soft tissue thickness is maintained. A left maxillary mucous retention cyst
and small right sphenoid sinus air-fluid level are seen. Mastoid air cells
and middle ear cavities are clear.
The lung apices demonstrate biapical pleural parenchymal scarring. The left
thyroid is heterogeneous, nodular, and enlarged. The upper esophagus is
dilated.
## IMPRESSION:
1. No cervical spine fracture. Minimal spondylolistheses as detailed above
are likely degenerative.
2. Heterogenous nodular left thyroid. Recommend correlation with physical exam
and possibly labs.
3. The upper esophagus is dilated, which puts the patient at risk for
aspiration. Correlate clinically.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14129581", "visit_id": "27735200", "time": "2129-05-30 14:42:00"} |
17846323-RR-15 | 234 | ## INDICATION:
year old woman with abd pain and weight loss and diarrhea// ?
abd pain and weight loss and diarrhea
## MR ENTEROGRAPHY:
Oral contrast adequately distends the small bowel loops. The small bowel is
normal without bowel wall thickening, mucosal hyperenhancement or submucosal
edema to suggest acute inflammatory disease. No submucosal fatty infiltration
to suggest chronic inflammation. There is no stricturing or proximal bowel
dilatation. No abscess or fistula collection.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Liver demonstrates normal morphology and signal characteristics. No worrisome
enhancing hepatic mass lesions within the visualized portions of the liver.
The gallbladder is normal. No intrahepatic or extrahepatic biliary duct
dilatation. The spleen is top-normal in size measuring 13 cm in maximal
diameter. It otherwise enhances homogeneously without focal mass lesions.
The pancreas, adrenal glands and kidneys are normal. Abdominal aorta is
normal in caliber and its major branches are patent.
No mesenteric or retroperitoneal lymphadenopathy by size criteria. No
suspicious osseous or soft tissue mass lesions.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
Bladder and distal ureters are normal without focal mass or wall thickening.
Uterus is anteverted. There is a 2.6 cm right ovarian follicle. No adnexal
mass lesions.
Physiological free fluid in the pelvis. No pelvic lymphadenopathy. No
suspicious osseous or soft tissue mass lesions
## IMPRESSION:
Normal small bowel without evidence of active or chronic inflammatory disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17846323", "visit_id": "N/A", "time": "2132-08-09 07:48:00"} |
15766332-RR-41 | 111 | ## EXAMINATION:
KNEE (3 VIEWS) RIGHT
## INDICATION:
year old woman with right knee pain. // Assess right knee
pain. Assess right knee pain.
## RIGHT KNEE:
There is no fracture or dislocation. Again seen is mild
tricompartmental degenerative change of the right knee with small osteophytes.
A sclerotic focus in the distal femur likely reflects an enchondroma and is
stable. The soft tissues are prominent and there is mild prepatellar soft
tissue prominence as well.
## LEFT KNEE:
Limited assessment on single AP standing view demonstrates mild
degenerative change of the left knee.
## IMPRESSION:
Mild degenerative change of the right knee.
Stable appearing chondroid lesion likely an enchondroma.
Mild prepatellar soft tissue swelling.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15766332", "visit_id": "N/A", "time": "2135-07-04 10:35:00"} |
11910993-RR-137 | 181 | ## EXAM:
Abdomen, supine and left side down decubitus views.
## CLINICAL INFORMATION:
female with history of abdominal
distention, vomiting.
## FINDINGS:
AP supine and left side down decubitus views of the abdomen were
obtained. The ascending colon is dilated, measuring 8.5 cm in diameter and
demonstrating air-fluid level on the decubitus view. Additional loops of
distended bowel seen in the abdomen, most likely represent colon, although
mildly dilated small bowel is not excluded. Air is seen at least the level of
the sigmoid colon and possibly in the rectum. No evidence of free air is
seen. There are vascular calcifications, including along the aorta, which
seemed to be aneurysmally dilated on prior CTs. Minimal left base
atelectasis/scarring is seen. Surgical clips are noted projecting over the
medial left lower hemithorax. The patient is status post bilateral hip
replacement with prostheses are partially imaged. Degenerative changes are
seen along the spine.
## IMPRESSION:
1. Dilated descending colon with air-fluid level, evolving colonic
obstruction cannot be entirely excluded. Findings can be further evaluated on
CT. No evidence of free air.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11910993", "visit_id": "24927755", "time": "2145-07-01 11:32:00"} |
11959088-RR-33 | 97 | ## CHEST:
Frontal and lateral views
## HISTORY:
with cough x 3 weeks with fevers // Please obtain
lateral film
## FINDINGS:
Bibasilar atelectasis is seen. Streaky retrocardiac opacity on the lateral
view most likely represents atelectasis with possible chronic lung disease,
less likely focal consolidation from pneumonia. Underlying aspiration is also
possibility. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are stable.
## IMPRESSION:
Bibasilar atelectasis. Streaky retrocardiac opacity on the lateral view most
likely represents atelectasis with possible chronic lung changes, less likely
focal consolidation from pneumonia, but pneumonia or aspiration is not
excluded.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11959088", "visit_id": "22921213", "time": "2135-05-10 20:17:00"} |
15865261-DS-29 | 1,571 | ## ALLERGIES:
Sulfonamides / Codeine / Nsaids/Anti-Inflammatory Classifier /
Penicillins / Zosyn / Vancomycin / Levaquin / Unasyn /
Cephalosporins / Neurontin
## CHIEF COMPLAINT:
Hip sores and cellulitis
## HISTORY OF PRESENT ILLNESS:
The patient is an y.o. F with h/o cognitive impairment NOS,
HTN, who lives at home who was referred to the ED by
her son when she developed a red open sore on the L hip "the
size of a man's hand". NO trauma that anyone is aware of. Aide
noticed red area yesterday and since then it has increased in
size. VS on presentation: 98.1, 71, 16, 99% on RA.
Received clindamycin 600 mg IV x T. Found to have an
erythematous, swolen RLE on exam thus dx with cellulitis.
negative for clot.
<br>
Currently reports chills x days- cannot quantify for how long.
No overt fevers. No cough. + tenderness at sites fo skin
breakdown on her hip. No n/v/cp/sob/cough/rhinorrhea/+chronic
arthralgias/no abdominal pain. + diarrhea with lactose rich
food. No fevers. Cannot remember how this lesion occured.
<br>
Spoke with her son who also confirms above story. He does
not understand how this wound occured. She has had the same
for years without incident. He thinks that she is happy and well
cared for at home and rehab would set her back.
## PAST MEDICAL HISTORY:
1. Hypertension.
2. Chronic Kidney Disease with baseline creatinine 1.2-1.4
3. Chronic diarrhea/Irritable Bowel Syndrome
4. History of transient ischemic attack.
5. Gastroesophageal reflux disease.
6. Anemia
7. History of MRSA wound infection.
8. Osteoporosis.
9. Polymyalgia rheumatica
10. Rheumatoid arthritis
11. Spinal stenosis status post multiple spine surgeries.
12. s/p cholecystectomy
. s/p TKR
14. s/p TAH
15. Cellulitis of the RLE treated with clindamycin in
## GENERAL:
Elderly female laying in bed/
## EYES:
NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
## EARS/NOSE/MOUTH/THROAT:
MMM, no lesions noted in OP. Poor
dentition.
## NECK:
supple, no JVD or carotid bruits appreciated
## RESPIRATORY:
Decreased BS at the bases.
## CARDIOVASCULAR:
RRR, nl. S1S2, no M/R/G noted
## GASTROINTESTINAL:
soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
## SKIN:
L hip with erythematous excoriated lesion measured 2-3cm
in diameter.
no rashes or lesions noted. RLE with erythema/swelling/warmer
than L. 2+ DPP pulse. No sign of skin break down between toes.
## EXTREMITIES:
No C/C/E bilaterally, 2+ radial, DP and pulses
b/l.
## LYMPHATICS/HEME/IMMUN:
No cervical, supraclavicular, axillary or
inguinal lymphadenopathy noted.
## -MENTAL STATUS:
Alert, oriented x 3. Able to relate history
without difficulty. No evidence of delirium on exam. Able to
relate DOYB.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
## RLE US:
No DVT.
<br>
Echo
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
4. There is moderate pulmonary artery systolic hypertension.
<br>
## BRIEF HOSPITAL COURSE:
This is an y.o. F with cognitive impairment NOS, HTN, chronic
edema, HTN, who presented with RLE swelling, chills along
with new skin lesions on her L arm/hip/abdomen.
.
# Cellulitis of RLE: The patient was noted to have erythema and
swelling of her right lower shin. Ultrasound of her RLE was
negative for DVT. She has numerous allergies to antibiotics, and
has been treated in the past with clindamycin. She was started
on IV clindamycin on admission, and the following day after
initiation both pt and son noted decreased swelling. She was
discharged home and will complete a total of 6 days of
clindamycin (primarily to treat her left hip infection as her
cellulitis had nearly resolved by time of discharge).
.
# L arm/abdomen/hip lesion: The pt had a large area of
ulceration over the left hip with apparent superinfection. Her
lesions were described well in the wound care note from
## :
On the left hip--" The superior wound is a macular red
rash, measuring 4 x 2 cm, with 2 1 cm circular lesions covered
with yellow slough in the center. The inferior wound is a red
rash, measuring 8 x 10 cm, with scattered areas of epidermal
skin loss with a red, moist base. The skin surrounding this
lesion is intact. In addition, Mrs. has a left
posterior forearm red rash with intact skin, irregularly shaped
and measuring 4 x 2 cm. In addition, she has a red superficial
rash under her left elbow, measuring 4 x 2 cm. Finally, she has
a red macular lesion on her left abdomen, measuring 4x6 cm of
intact skin." For her wound care they recommended "Cleanse with
commercial wound cleanser. Pat dry. Cover wound with adaptic
non-adherent dressings. Cover with dry gauze and ABD pad,
secured with cloth tape." Dermatology was consulted and felt the
lesions looked mostly like either traumatic injury (ie fall vs
burn) vs. irritant contact dermatitis. The pt was started on
clindamycin for this superinfected left hip lesion in addition
to her RLE cellulitis. She will complete a 6 day course of
clindamycin as per above. will come to home to assist
with wound care.
.
# Cognitive impairiment NOS/depression: Continued zyprexa 15 mg,
zoloft 200 mg qd, ativan prn
.
# Chronic renal failure, stage : Creatinine was at baseline
of 1.2 Continued lasix
.
# HTN, benign: Continued Toprol 250 mg qd. Given SBP elevation
to 150 nd 190 with exertion, her norvasc was increased
from 5 mg daily to 10 mg daily. She will need her blood pressure
followed up with her PCP.
.
# Anemia: Admission hct of 30 was lower than her baseline of
33-36. Iron studies were normal. Folate was normal. B12 level
was pending at time of discharge.
.
# Code status: Confirmed with son and patient. DNR/DNI.
## MEDICATIONS ON ADMISSION:
15 mg zyprexa
10 mg oxycontin qpm
ranitidine 150 mg bid
calcium 600 mg
20 mg oxycontin qam
folic acid 1 mg
zoloft 200 mg qd
lasix 20 mg
norvasc 5 mg
250 toprol
600 mg caclicum
ASA 81 mg
percocet prn
1 mg ativan prn
## DISCHARGE MEDICATIONS:
1. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Three (3) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
3. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO QPM (once a day (in the
evening)).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO QAM (once a day (in the
morning)).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Furosemide 20 mg Tablet
## SIG:
One (1) Tablet PO DAILY (Daily).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
## SIG:
2.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
9. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical DAILY
(Daily): apply thin layer over left hip/buttock ulcer daily.
Disp:*1 tube* Refills:*2*
12. Os-Cal 500 + D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO three times a day.
## 13. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
One (1) Tablet
PO once a day as needed for pain.
14. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
## DISCHARGE DIAGNOSIS:
Cellulitis of the right lower extremity
Infected ulcer of the left buttock
.
## SECONDARY:
Cognitive deficit
Chronic Kidney Disease
Hypertension
## DISCHARGE INSTRUCTIONS:
You were admitted with cellulitis of your right lower leg and
infection of the ulcer on your left hip. The ulcer on your left
hip may be due to either pressure, a burn, or an irritant (like
a chemical).
.
You should try to minimize sitting down as much as possible. If
you are sitting, try to shift your weight onto your right
buttock. When sleeping you should try to sleep on either your
back or your left side until the ulcer on your hip/buttock has
resolved. You should look at all of your products that you use
at home and make sure that no caustic chemicals (like bleach)
are touching your skin. Make sure that you are not using any new
skin care products on your skin either.
.
Your blood pressure was elevated up to SBP 155 nd 190
with exertion. We increased your norvasc to 10 mg a day. You
should have your blood pressure checked when you follow up with
on .
.
You should apply bactroban to the ulcer, cover it with adaptec
dressing, and then cover with a guaze. Nursing will help you
care for your wound.
.
It is important you complete your full course of antibiotics
(clindamycin).
.
Call your doctor or return to the ER for any fevers, worsening
of your cellulitis, diarrhea, abdominal pain, vomiting,
worsening of your left hip ulceration, new ulcers that form, or
any other concerning symptoms.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15865261", "visit_id": "20511084", "time": "2161-08-03 00:00:00"} |
11151861-RR-8 | 222 | ## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN)
## INDICATION:
woman with cholecystectomy years ago, complaining of
persistent RUQ abdominal pain. Evaluate liver as well as biliary tree.
## LIVER:
The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
## BILE DUCTS:
The common bile duct is dilated, measuring up to 1 cm but appears
to taper towards the liver and could be secondary to postcholecystectomy
status. There is suggestion of mild central intrahepatic biliary ductal
dilation which could also be related to postcholecystectomy status.
## GALLBLADDER:
The patient is status post cholecystectomy.
## PANCREAS:
The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
distal body and tail obscured by overlying bowel gas.
## SPLEEN:
Normal echogenicity, measuring 8.4 cm.
## KIDNEYS:
The right kidney measures 10.5 cm. The left kidney measures 11.2
cm. Limited views of the kidneys show no hydronephrosis.
## RETROPERITONEUM:
The visualized portions of aorta and IVC are within normal
limits.
## IMPRESSION:
1. Normal hepatic echotexture without evidence of a focal hepatic mass.
2. Dilated common bowel duct to 1 cm with mild central intrahepatic biliary
ductal dilation, nonspecific and could be related to postcholecystectomy
status.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11151861", "visit_id": "27404709", "time": "2155-03-29 15:25:00"} |
11414573-RR-77 | 113 | CT HEAD WITHOUT CONTRAST.
## HISTORY:
Subdural hematoma status post bur holes with right-sided headache.
Evaluate for acute intracranial hemorrhage.
## FINDINGS:
There is no evidence of acute intracranial hemorrhage or shift of
normally midline structures. The ventricles and sulci are normal in
appearance. There is no evidence of hydrocephalus. The basilar cisterns are
preserved. Mild calcifications of the anterior and posterior circulations are
noted. There is mild bifrontal extra-axial prominence, unchanged. Patient is
status post right frontal burr holes, similar in appearance. There is no
evidence of acute fracture. The visualized paranasal sinuses are clear except
to note mild aerosolized secretions in the sphenoid sinus, unchanged.
## IMPRESSION:
No acute intracranial hemorrhage.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11414573", "visit_id": "N/A", "time": "2186-12-19 11:08:00"} |
10554112-RR-13 | 376 | ## INDICATION:
Small left renal mass. Assess for interval growth.
## FINDINGS:
The visualized portions of the lung bases are clear. The imaged
aspect of the liver is normal. The main portal vein and visualized
intrahepatic branches are patent. There is no intrahepatic biliary duct
dilatation. The spleen is unremarkable. The imaged portions of the adrenal
glands are normal. In the head of the pancreas, there is a 5 mm coarse
calcification, not significantly changed in size compared to the prior CT from
. A previously seen surrounding hypodense lesion within the
pancreatic head is no longer appreciated, likely due to interval
endoscopic-guided fine-needle aspiration. The pancreas is otherwise normal in
appearance, without dilatation of the main pancreatic duct.
Within the left lower renal pole, there is a heterogeneously enhancing 2.3 x
2.0 cm soft tissue mass, increased in size compared to the MRI dated , previously measuring 1.7 x 1.5 cm. Non-contrast imaging does not
demonstrate any internal fatty component to this lesion. Within the posterior
aspect of the left interpolar region, there is a 2 mm hypodense lesion, not
significantly changed in size compared to the MRI from , too small
to characterize, but statistically a simple cyst. There are also scattered
subcentimeter hypodensities within the right kidney, not significantly changed
in size or number compared to the prior MRI, statistically simple cysts. The
kidneys are otherwise unremarkable. The renal veins are patent. There is no
free fluid or free air in the abdomen. There is redemonstration of
retroperitoneal, aortocaval and left paraaortic soft tissue density material
and/or mild lymphadenopathy, not significantly changed compared to the prior
CT from (8:11). The abdominal aorta is normal in caliber.
Scattered aortic calcifications are seen.
## BONE WINDOW:
No suspicious lytic or blastic lesions are identified.
## IMPRESSION:
1. Slight increase in size of 2.3 cm solid mass in the left lower renal pole.
While this lesion remains concerning for renal cell carcinoma, a lipid-poor
angiomyolipoma is not excluded.
2. No significant change in soft tissue density material/mild lymphadenopathy
within the retroperitoneum, as discussed above.
2. Marked decrease in size of cystic component of a pancreatic head lesion
compared to the prior CT from , status post endoscopic fine-needle
aspiration.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10554112", "visit_id": "N/A", "time": "2152-04-12 10:41:00"} |
17394379-DS-9 | 920 | ## ALLERGIES:
recorded as having No Known Allergies to Drugs
## ATTENDING:
Complaint:
lower gastrointestinal bleeding
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
flexible sigmoidoscopy x 2
central line placement
## HISTORY OF PRESENT ILLNESS:
This is an yo female who presented with 2
episodes of BRBPR and called EMS. She was found to have an SBP
of nd brought to the ED. She was given 1 liter
LR, 1500 cc NS, 1 U pRBC and transferred to the ICU. Per the
interpreter, she denied any abdominal pain, but has
had recent weakness. She has a hx of liver disease and
hepatocellular carcinoma and has been followed by Dr. at
was admitted to the MICU where she was observed to have
BM c BRBPR on . She underwent flexible sigmoidoscopy without
any intervention. subsequently had additional episodes
of bleeding with BMs on and became hypotensive. She was
transfused packed red blood cells and and was rescoped. This
time she had derma-bond to two bleeding lesions. has not
had any additional bowel movements since that time. Hct has
remained stable and she has remained hemodynamically stable.
## PAST MEDICAL HISTORY:
-Type II Diabetes Mellitus
-Hypertension
-Hepatocellular Carcinoma, followed by Dr. at . Per
PCP not interested in treatment
-Cryptogenic Cirrhosis
-Knee Osteoarthritis
-Asthma
## PHYSICAL EXAM:
Exam on Admission To Hepatorenal Floor from MICU
## GEN:
well appearing, no acute distress
## LUNGS:
CTAB, no wheezes or crackles
## ABD:
+BS, soft, non-tender, non-distended
## EXT:
no edema, cyanosis or clubbing
## HEPATITIS PANEL:
09:15PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
09:15PM BLOOD HCV Ab-NEGATIVE
-----
-----
## 3:57 AM STOOL CONSISTENCY:
SOFT Source: Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Pending at time of
discharge)
-----
-----
## IMPRESSION:
1. Left hepatic mass measuring 2.9 x 2.4 x 2.5 cm is compatible
with the
reported history of hepatocellular carcinoma.
2. Cholelithiasis without evidence of cholecystitis.
3. Normal hepatic arterial and venous waveforms without evidence
of
thrombosis.
## BRIEF HOSPITAL COURSE:
This is an year old female with a history of cryptogenic
cirrhosis, hepatocellular carcinoma who presented with bright
red blood per rectum found to be secondary to bleeding rectal
varices.
## # RECTAL VARICEAL BLEED:
observed to have bowel
movements with bright red blood per rectum on . She
underwent flexible sigmoidoscopy by the liver service which on
first flex sig did not observe active bleeding and no
interventions performed. On had additional episodes
of bright red blood per rectum and had a repeat flex sig. On the
second flex sig two large rectal varices with hemocystic spots
were observed and injected with dermabond. had no
additional episodes of bleeding after this intervention. In
total the was transfused 6 units of packed red blod
cells given she presented with a Hct of 20. was on an
octreotide drip and ciprofloxacin for 72 hours. should
follow up for repeat flex sigmoidoscopy in weeks. Team to
discuss whether will follow up at or with
outpt PCP who is at and will contact with this
information.
## # HEPATOCELLULAR CARCINOMA:
followed by Dr.
oncologist at . Per PCP has not been
interested in undergoing treatment for her known cancer. We
suggested that the make sure she understand all
available treatment options and discuss these options with her
oncologist and PCP.
## # HISTORY OF HYPERTENSION:
Diovan and Diltiazem were held
initially given blood loss and episode of hypotension while in
the MICU. Medications were not restarted given that
blood pressure was in a normotensive range. has PCP
follow up on at which time she should have her blood
pressure rechecked.
## # ASTHMA:
Respiratory status remained stable. atrovent
and albuterol inhalers were continued. Theophylline was held
given that was on cipro. may restart
theophylline on discharge.
## # DM:
Blood sugars remained stable. Per PCP,
is no longer on treatment for her diabetes.
## DISCHARGE MEDICATIONS:
1. 3 in 1 commode
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheezing.
## 4. HYDROCODONE-ACETAMINOPHEN MG TABLET SIG:
One (1) Tablet
PO Q6H (every 6 hours) as needed for pain: Do not take more than
4 per day since this medication takes acetaminophen which could
be toxic to your liver.
5. Loratadine Oral
6. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO twice a day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. diabetic boost 1 can TID
## PRIMARY:
Lower gastrointestinal bleeding secondary to rectal
variceal bleed
## SECONDARY:
Hepatocellular carcinoma, Asthma, Hypertension
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with lower gastrointestinal
bleeding. We determined that you have rectal varices, that are
related to your chronic liver disease, were responsible for the
bleeding. You bleeding resolved after we did a procedure that
put applied a material to the varices to make them stop
bleeding. Following this procedure you did not have any further
bleeding and your red blood cell counts remained stable.
You should have this procedure repeated within the next
weeks in order to prevent further rectal bleeding. We will
discuss setting up this procedure with your primary care
provider to determine whether it would be more convenient for
you to have this procedure done at
versus .
## STOP TAKING:
Diltiazem
Diovan
If you experience any additional episodes of rectal bleeding,
not chest pain, shortness of breath or dizziness please contact
your primary care physician immediatley or come to the emergency
department for evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17394379", "visit_id": "25249717", "time": "2158-12-21 00:00:00"} |
18962557-RR-111 | 502 | ## INDICATION:
year old woman with limited walking distance, known neurogenic
claudication, years of incontinence, last MRI years ago. Please evaluate
stenosis.// year old woman with limited walking distance, known neurogenic
claudication, years of incontinence, last MRI years ago. Please evaluate
stenosis.
## FINDINGS:
In comparison with the prior MRI of the lumbar spine dated , again
there is mild retrolisthesis at L5-S1 level, the visualized aspect of the
lower thoracic spinal cord is unremarkable, conus medullaris is normal and
terminates at the level of L1. The signal intensity in the bone marrow is
heterogeneous at the inferior endplate of L3 and superior endplate of L4,
likely consistent with a combination of bone edema bone marrow replacement for
fat type 1 and type 2 endplate changes)
At T11-T12 level, there is a grossly unchanged mild posterior disc bulge
causing mild right-sided neural foraminal narrowing (image 73, series 100).
There is no evidence of central spinal canal stenosis.
At T12-L1 level, there is unchanged mild disc bulge causing mild anterior
thecal sac deformity with no evidence of neural foraminal narrowing or spinal
canal stenosis.
At L1-L2 level, there is unchanged disc bulge causing mild anterior thecal sac
deformity, with no evidence of neural foraminal narrowing or spinal canal
stenosis, there is mild bilateral articular joint facet hypertrophy which is
also unchanged.
At L2-L3 level, there is unchanged disc bulge causing mild anterior thecal sac
deformity with no evidence of nerve root compression or spinal canal stenosis,
unchanged articular joint facet hypertrophy is seen.
At L3-L4 level, there is interval progression in the disc degenerative
changes, with slightly more pronounced diffuse disc bulge, causing anterior
thecal sac deformity and bilateral neural foraminal narrowing, bilateral
articular joint facet hypertrophy and mild ligamentum flavum thickening
results in severe spinal canal stenosis (image 34, series 100).
At L4-5 level, there are relatively stable disc degenerative changes
consistent with disc protrusion, causing bilateral neural foraminal narrowing
and severe spinal canal stenosis, bilateral articular joint facet hypertrophy
and ligamentum flavum thickening also remain unchanged.
At L5-S1 level, there is unchanged grade 1 retrolisthesis as described above,
with similar degree of spinal canal narrowing, posterior disc protrusion
causing anterior thecal sac deformity and bilateral neural foraminal stenosis,
the disc bulge is contacting the traversing nerve roots bilaterally. Mild
articular joint facet hypertrophy remains unchanged.
The sacroiliac joints are unremarkable. The left adrenal gland remains
enlarged, grossly unchanged since the prior abdominal CT in ,
suggestive of adrenal adenoma. The previously described cystic formation
noted in the left kidney is not seen in this examination.
## IMPRESSION:
1. There is interval progression in the disc degenerative changes identified
at L3-L4, with a slightly more pronounced posterior disc bulging producing
anterior thecal sac deformity and bilateral neural foraminal narrowing as
described detail above.
2. Unchanged grade 1 retrolisthesis at L5 upon S1 level.
3. Other multilevel, multifactorial degenerative changes throughout the
lumbar spine remain relatively stable since the prior exam.
4. Unchanged left adrenal adenoma.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18962557", "visit_id": "N/A", "time": "2161-05-30 17:22:00"} |
18110592-RR-8 | 195 | CTA HEAD WITHOUT AND WITH CONTRAST,
## HISTORY:
Right occipital arteriovenous malformation, planning study for
CyberKnife radiosurgery.
Continuous axial images were obtained through the brain before contrast
administration. Subsequently, imaging was performed during infusion of 70 cc
of Omnipaque intravenous contrast. The images were reconstructed on a
separate workstation. The CTDIvol was 181, the DLP was 3338.
Comparison to a cerebral arteriogram of and a CTA of .
## FINDINGS:
There have been no significant changes since the prior study.
There is no evidence of hemorrhage on the CT examination. Again seen is a
collection of dilated veins in the right occipital region adjacent to the
tentorium and the falx. Some of these are calcified. After contrast
administration, the massively dilated veins are seen to drain both into the
superior sagittal sinus and into the transverse sinus. The lesion is well
localized for CyberKnife planning.
Again seen is mucosal thickening and small amounts of fluid in the maxillary
sinuses and partial opacification of the ethmoid and frontal sinuses.
Overall, this appears slightly more prominent than on the study of .
## CONCLUSION:
CyberKnife planning study reveals right occipital arteriovenous
malformation with no evidence of changes since the study of .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18110592", "visit_id": "N/A", "time": "2180-01-30 14:36:00"} |
17624772-RR-23 | 143 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
year old woman with 2 months fevers, malaise, muscle aches;
opacities on CXR // e/o malignancy, other acute process
## FINDINGS:
The thyroid is enlarged. Supraclavicular, axillary, mediastinal and hilar
lymph nodes are not enlarged. Aorta and pulmonary arteries are normal size.
Cardiac configuration is normal and there is no appreciable coronary
calcification. There is no pleural or pericardial effusion. Left lower lobe
perifissural nodule measures 3 mm (4:93). There are multifocal platelike
atelectasis in the lower lobes right middle lobe and lingula
This examination is not tailored for subdiaphragmatic evaluation. The upper
abdomen is unremarkable.
There are no bone findings of malignancy
## IMPRESSION:
Enlarged thyroid please correlate with concurrent thyroid ultrasound
Multifocal platelike atelectasis in the lower lobes, right middle lobe and
lingula with no central obstructing lesions identified. No worrisome lung
nodules.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17624772", "visit_id": "21722856", "time": "2127-09-16 09:48:00"} |
19001598-RR-37 | 115 | ## HISTORY:
A man with abdominal pain. Assess for free air.
## PA AND LATERAL CHEST RADIOGRAPH:
The most inferior of the 6 midline
sternotomy wires is fractured, which is new in the interval. The left-sided
dual-chamber pacemaker is seen with leads in the expected location of the
right ventricle and right atrium. The cardiomediastinal silhouette, hilar
contours, and pulmonary vasculature are within normal limits. The lungs are
clear without pleural effusion or pneumothorax. The underlying osseous
structures are normal. No free air under the diaphragms.
## IMPRESSION:
1. No acute intrathoracic process. No pneumoperitoneum.
2. Fracture of the most inferior midline sternotomy wire, without significant
displacement.
3. No free air under the diaphragms.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19001598", "visit_id": "22126296", "time": "2184-02-27 11:18:00"} |
11930011-RR-11 | 124 | ## INDICATION:
Hemi sensory loss and right leg pain concerning for infarct.
Evaluate for infarct.
## FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There are a few scattered punctate foci of subcortical white
matter T2/FLAIR hyperintensity, nonspecific, likely reflecting the sequela of
chronic small vessel ischemic disease. There is no abnormal focus of slowed
diffusion. The principal intracranial vascular flow voids are preserved.
The paranasal sinuses are grossly clear. The orbits are grossly unremarkable.
## IMPRESSION:
1. No acute intracranial abnormality including hemorrhage, infarct, or
suggestion of mass.
2. Few, nonspecific foci of subcortical white matter signal abnormality, most
likely reflecting chronic small vessel ischemic disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11930011", "visit_id": "24565987", "time": "2121-08-03 01:37:00"} |
16748938-DS-19 | 1,064 | ## CHIEF COMPLAINT:
Elective admission for high-dose MTX
## HPI:
Ms. is a year old woman with h/o stage IV DLBCL
diagnosed s/p 2 cycles of R-CHOP (last cycle , who
is admitted from home for high-dose MTX treatment. She has been
feeling well this week without any complaints or problems. She
had a headache the week before which is now resolved. She has
no fatigue and is able to carry out all of her normal
activities.
.
## ROS:
She has mild parasthesias in her fingers. She denies
F/C/S, N/V, headache, visual/hearing changes, dizziness, neck
pain, chest pain, dyspnea, cough, abdominal pain, constipation,
diarrhea, hematochezia, hematuria, other urinary symptoms, rash,
or focal weakness. All other ROS are negative.
## FROM EPIC:
Ms. is a yo F s/p L oophorectomy in due to a
hemorrhagic cyst and she had 9 week miscarriage on . She
presented to ED on t her left chest and
epigastric region, fever 100.4 and dry cough. CT showed a large
8.3 x9.3 cm anterior mediastinal mass with enlarged
paraesophageal and left pericardial LNs, likely representing
lymphoma. Her PET scan showed a 6 x5.9cm intensely FDG-avid
(SUV max 12.3) mass in the anterior mediastinum with central low
attenuation, with mediastinal and epicardial lymphadenopathy.
PET also showed separate masses likely along the left inferior
pleural surface and moderately avid left adrenal nodule which
may represent metastasis. Atelectasis within the LUL, with
surrounding ground glass opacity, likely postobstructive. She
was treated with Levaquin x 4 days and then started on
Amoxicillin for 2 weeks. She had CT guided biopsy of the
mediastinal mass on which showed large majority of the
cells are CD20-positive B cells and no definitive
immunoreactivity for CD30, highly suspicious for involvement by
a B cell lymphoma. CT chest on showed interval
development of extensive nodular airspace opacification within
the left upper lobe, in association with the large anterior
mediastinal mass, representing lymphoma rather than infection.
Dr. performed mediastinal biopsy at on
which confirmed diffuse B cell lymphoma. Bm biopsy is
suspicious but not diagnostic of lymphoma involvement. was
consulted on for Left adrenal biopsy. Per fellow,
team decided Pt is very thin and it might not be safe to perform
adrenal biopsy. MRI abd on suggested left adrenal nodule
is likely lymphomatous deposit, not adenoma. She was seen by
Dr. at fertility clinic for Lupron monthly. Planned for
R-CHOP21 x6 cycles plus high-dose MTX for CNS prophylaxis at D15
of cycle 2,4,6 per regimen et al, Cancer,
. R-CHOP was started on .
.
Current treatment:
Cycle 1 R-CHOP
Cycle 2 R-CHOP
MTX 3.5gm/m2
.
.
## PAST MEDICAL HISTORY:
s/p L oophorectomy in due to a hemorrhagic cyst
HTN
.
## FAMILY HISTORY:
Prostate cancer in paternal uncles. grandmother had
throat cancer. A great aunt had cancer in her abd. She states
most of her family members died of cancer.
## GENERAL:
NAD, sitting in bed
## SKIN:
warm and well perfused, no excoriations or lesions, no
rashes
## HEENT:
AT/NC, EOMI, anicteric sclera, pink conjunctiva, patent
nares, MMM, good dentition, nontender supple neck, no LAD, no
JVD
## CARDIAC:
RRR, S1/S2, no mrg
## ABDOMEN:
nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
## M/S:
moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
## PULSES:
2+ DP pulses bilaterally
## NEURO:
CN II-XII intact grossly
## PSYCH:
cooperative, pleasant
On Discharge
No significant change
## URINE:
10:21PM URINE Color-Yellow Appear-Clear Sp
10:21PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-
NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
09:26AM URINE Color-Straw Appear-Clear Sp
09:26AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
09:53AM URINE UCG-NEGATIVE
## BRIEF HOSPITAL COURSE:
PRINCIPLE REASON FOR ADMISSION
year old woman with DLBCL diagnosed who is admitted
for C1 high-dose methotrexate.
## ACTIVE PROBLEMS
# HIGH DOSE METHOTREXATE:
Patient was administered high-dose MTX
with leucovorin rescue, per protocol. She was supported with
D51/2NS and HCO3 and urine pH was monitored and maintained >8.
Patient was provided antiemetics prn, and tolerated treatment
well. MTX level 0.05 day of discharge. Pregnancy was ruled out
with urine HCG prior to initiation of therapy.
## # DLBCL:
Initially diagnosed in after presenting to
ER with postobstructive PNA and large anterior mediastinal mass
was found on CT. Also with possible left adrenal and BM
involvment. Per outpatient oncologist, Dr. , she is planned
for R-CHOP21 x6 cycles plus high-dose MTX for CNS prophylaxis at
D15 of cycle 2,4,6. Patient is s/p 2 cycles R-CHOP, now s/p
cycle of HD-MTX. Patient was maintained on allopurinol and
acyclovir ppx.
## # HTN:
Previously treated with metoprolol 12.5 and was recently
tapered off. Patient was normotensive without treatment.
OUTSTANDING STUDIES
None
TRANSITIONAL ISSUES
None
## MEDICATIONS ON ADMISSION:
Trazodone 50mg PO qhs prn
Zofran 8mg PO q8h prn
Acyclovir 400mg PO q12h
Ativan 0.5mg PO qhs prn
Dilaudid 2mg PO q3h prn
Leuprolide 3.75mg IM monthly (Has not started yet)
Allopurinol PO daily
Calcium
Vitamin C
## DISCHARGE MEDICATIONS:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea.
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
4. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
5. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
## 6. ALLOPURINOL MG TABLET SIG:
One (1) Tablet PO BID (2 times
a day).
7. Calcium 500 Oral
8. Vitamin C Oral
## DISCHARGE DIAGNOSIS:
High dose methotrexate for diffuse large B cell lymphoma.
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the hospital to receive high dose
methotrexate, a chemotherapy used to treat your lymphoma. You
tolerated the infusion well, and we gave you plenty of IVF's and
monitored your blood levels for a few days, until you cleared
the chemotherapy. We made no changes to your medications. Please
follow up with your primary oncologist for further management.
It has been a pleasure taking care of you.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16748938", "visit_id": "29762008", "time": "2152-03-04 00:00:00"} |
14416327-RR-74 | 110 | ## INDICATION:
Previous history of renal mass. Follow up.
## FINDINGS:
The patient has previously undergone radiofrequency ablation of a
left renal lesion in . The ablated site appears somewhat heterogeneous in
echotexture, with a focus of increased echogenicity centrally. There are no
new masses. There is no hydronephrosis.
Right kidney is unremarkable and measures approximately 11.6 cm in length.
Left kidney measures 10.4 cm in length. Incidental note is made of increased
echogenicity of the liver parenchyma, which is commonly seen with diffuse
fatty infiltration.
## IMPRESSION:
1. The previously described renal lesion has undergone radiofrequency
ablation. No new lesions are identified.
2. Probable fatty infiltration of the liver.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14416327", "visit_id": "N/A", "time": "2121-09-22 14:08:00"} |
11354492-RR-55 | 104 | ## HISTORY:
Fatigue, chills. Rule out pneumonia.
## FINDINGS:
There is redemonstration of a pleural-based opacity in the right lower lung
which appears stable from prior examination and likely reflects a loculated
pleural effusion. There is rightward shift of midline structures likely due to
chronic atelectasis and continued volume loss at the right lung base. There is
a new small left sided pleural effusion. The heart is mildly enlarged and
there is new mild pulmonary vascular congestion.
## IMPRESSION:
New small left pleural effusion and mild pulmonary vascular
congestion. Stable posteriorly loculated moderate size right pleural effusion
and atelectasis of the right lung base.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11354492", "visit_id": "29037616", "time": "2131-03-09 08:32:00"} |
19685967-RR-24 | 117 | ## INDICATION:
year old woman with osteopenia // bone loss
## FINDINGS:
The bone mineral density of the left forearm, radius 33%, is 0.46 g/cm2. This
corresponds to a T-score of -3.5 and a Z-score of -1.3.
The bone mineral density of the femoral necks is 0.73 g/cm2. This corresponds
to a T-score of -2.2 and a Z-score of -0.2. When compared to the most recent
study from , this represents a nonsignificant decrease in bone
density of -1.5%.
## IMPRESSION:
According to the World Health Organization criteria, the patient has
osteoporosis of the lumbar spine and osteopenia of the femoral necks.
Overall, the patient has osteoporosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19685967", "visit_id": "N/A", "time": "2122-03-13 13:26:00"} |
11506801-RR-14 | 130 | ## INDICATION:
year old man with chest surgery, central line palcement// eval
line positino
## IMPRESSION:
There has been interval placement of a left subclavian central venous catheter
terminating in the mid to lower SVC, satisfactory. There has been interval
placement of thoracic fusion hardware. Endotracheal tube and upper enteric
tube are satisfactory. Bilateral chest tubes remain in place.
Cardiomediastinal silhouette is unchanged. There has been some redistribution
of a right-sided pleural effusion, appearing small in volume. There is no
large left-sided effusion. There remains central pulmonary vascular
congestion with at least mild to moderate edema, grossly similar to the prior
examination. Given the background edema, a superimposed consolidation would
be difficult to exclude. Postsurgical changes are noted along the right chest
wall. There is no appreciable pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11506801", "visit_id": "29280112", "time": "2139-04-19 16:12:00"} |
11926993-RR-29 | 111 | ## INDICATION:
Inconclusive hysterosalpingogram. Status post Essure devices.
IUD removed. Confirm tubal blockage.
## OPERATORS:
Dr. under the supervision of Dr.
( ).
## PROCEDURE:
After the risks and benefits of the procedure were explained to
the patient, written informed consent was obtained. A preprocedure timeout was
performed per protocol.
The patient was placed in the lithotomy position and prepped in the usual
fashion. With aseptic technique, an attempt to introduce a 5
hysterogram catheter was done, but this was unsuccessful as the patient had
severe cervical pain. After multiple attempts, the decision was made to stop
the procedure given the persistent pain.
The findings were E-mailed to Dr. after the procedure on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11926993", "visit_id": "N/A", "time": "2152-10-28 13:05:00"} |
16253574-DS-20 | 1,134 | ## ALLERGIES:
Penicillins / Cephalosporins / latex / Banana / kiwi / Cucumber
/ Green pepper / Watermelon
## HISTORY OF PRESENT ILLNESS:
Mr. is a yo gentleman with a h/o proximal left tibia
fracture on
who presents for a PICC line evaluation. Much of the
details of the post-op course are taken from ID OPAT note by Dr.
. He fractured his left proximal tibia/fibula requiring
a staged repair with I&D and ORIF on and further external
fixation on . He became septic on and returned to the
OR to undergo an incision and drainage of his left leg infection
again on and . He was discharged on
empiric Vancomycin and ertapenem with a PICC line because the
intra-op cultures were negative (as well as universal PCR
negative). He noted purulence and erythema at his PICC line site
and given concern for PICC line infection was referred to the
ED. He has been followed by Infectious Disease and Orthopedics.
He denies currently fevers, chills, CP, sob, n/v, knee
swelling/pain.
In the ED, initial vs were: 98, 80, 121/85, 16, 97% RA. Labs
were remarkable for no leukocytosis and slight increased
creatinine. His PICC line was removed and blood and catheter tip
were sent for culture. Vitals on Transfer: T 98.6 P 70 BP
120/75 RR 14 O2 sat 99% RA.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
## PAST MEDICAL HISTORY:
# Adrenal Insufficiency -- during recent admission
# Pancreatitis -- during recent admission
# Motorcycle Accident ( )
-- left rib fracture and left tib/fib fracture
-- s/p ORIF left tibia and external fixator
# Chronic Back Pain -- vertebral fracture age
# GERD
## # MOTHER:
Passed away in her with dementia.
# Father: and drug issues, passed away in his .
# Siblings: Brother with stomach cancer at age . Eight
siblings, several with drug and alcohol problems.
## GENERAL:
alert and oriented x 3, NAD
## ABDOMEN:
soft, NT, ND, no HSM
## EXT:
Extensive tattoos, no edema. Left knee has well-healed
surgical scar without purulence or tenderness. Prior site of
PICC on left upper extremity is clean and dry with rectangular
area of erythema at the site where tegaderm was.
## NEURO:
sensation intact in bilateral feet, strength
## SKIN:
No rashes or signs of endocarditis
ON DISCHARGE
## GENERAL:
Alert and oriented x 3, NAD
## ABDOMEN:
Soft, NT, ND, no HSM
## EXT:
Extensive tattoos, no edema. Left knee has well-healed
surgical scar without purulence or tenderness. Prior site of
PICC on left upper extremity is clean and dry with rectangular
area of erythema at the site where tegaderm was, slightly
reduced erythema since admission.
## SOURCE:
LEFT SIDED PICC LINE REMOVED BY NURSE.
**FINAL REPORT
## BLOOD CULTURE :
No growth to date
## BRIEF HOSPITAL COURSE:
Mr. is a yo man with h/o proximal left tibia fracture
on requiring ORIF and then revision with post-op course
complicated by sepsis, being treated empirically with
vanc/ertapenem because no cultures were positive, who presents
for a line evaluation.
## # PICC LINE:
Mr. presented due to concern for PICC line
infection when he noticed purulence and erythema at the
site at home. The PICC was removed on admission, blood cultures
were drawn, and the PICC tip was sent for culture. On exam,
there was a rectangular area of erythema where his tegaderm
previously was. The area was nonpurlent, non-tender,
non-indurated, with no palpable cord to suggest a
clot/phlebitis. His blood cultures remained negative, the PICC
tip culture was negative, he did not have a leukocytosis, and
remained afebrile. The likely cause for his symptoms is thought
to be contact dermatitis from tegaderm and the area of his
erythema improved once his tegaderm was removed.
## # PREVIOUS SURGICAL SITE INFECTION:
Mr. has a history of
proximal left tibia fracture on requiring ORIF and
revision with a post-operative course complicated by sepsis. He
was started on Vancomycin and ertapenem empirically given no
cultures were positive. His wound appeared to be healing very
well without pain or induration around the site. There was no
evidence of osetomyelitis on plain films. He was admitted on
Vancomycin and Ertapenem, and continued on Vancomycin and
Meropenem while in-house. He was evaluated by Dr.
in-house, who has been following him for his infection. She
determined that it was appropriate for him to be switched from
Vancomycin and Ertapenem to Levofloxacin. He is discharged on
Levofloxacin 500 mg daily.
## # ADRENAL INSUFFICIENCY:
Stable blood pressure while in-house
and no signs of infection on exam to suggest need for stress
dose steroids.
- Continued home Hydrocortisone 20 Qam, 5Q pm
## # ACUTE KIDNEY INJURY:
Mr. baseline Creatinine is 1.0,
though he was found to have rising Creatinine during his
hospital stay. His FeNa was consistent with intrinsic renal
injury, thought possibly secondary to his Vancomycin. He was
evaluated by Dr. , as noted above, who determined it was
appropriate to stop his Vancomycin and Ertapenem and discharge
him on Levofloxacin 500 mg daily.
## TRANSITIONAL ISSUES:
Blood cultures x2 (No growth to date)
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Paroxetine 20 mg PO DAILY
5. Senna 1 TAB PO DAILY
6. Hydrocortisone 20 mg PO QAM
7. Hydrocortisone 5 mg PO QPM
8. Vancomycin 1250 mg IV Q 12H
9. ertapenem 1 gram Injection q24hours
10. Hydrochlorothiazide 25 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Docusate Sodium 100 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Hydrocortisone 20 mg PO QAM
5. Hydrocortisone 5 mg PO QPM
6. Omeprazole 40 mg PO DAILY
7. Paroxetine 20 mg PO DAILY
8. Senna 1 TAB PO DAILY
9. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*14
## DISCHARGE DIAGNOSIS:
Contact dermatitis secondary to tegaderm
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted because there was concern for an infection of
your PICC line. We removed your PICC line and sent the tip for
cultures, which was negative. Your blood cultures also show no
growth. You were seen by Dr. determined that we can
switch you to oral antibiotic therapy and that you no longer
require the PICC for IV antibiotics. In addition, we believe
that the reason for the irritation around your PICC site was a
contact reaction rather than an infection. This allergy will be
added to your medical records to prevent further complications.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16253574", "visit_id": "24834842", "time": "2129-05-25 00:00:00"} |
13863107-RR-72 | 230 | ## HISTORY:
Suburethral mass, evaluate for a diverticulum versus suburethral
cyst.
## FINDINGS:
The uterine junctional zone is mildly thickened, measuring up to 15 mm, with
associated loss of the zonal anatomy (2:16), suggestive of adenomyosis. An
IUD is seen within the endometrial canal, with both struts penetrating deeply
into the myometrium, one of which extends anterosuperiorly along the midline
and the second of which projects laterally to the right. The endometrial
thickness is normal. Nabothian cysts are seen within the cervix. The vagina
is grossly unremarkable. There are bilateral simple ovarian cysts, measuring
up to 4.0 cm on the right and 1.6 cm on the left. The bladder is normal. The
urethra is unremarkable. No periurethral mass or diverticulum is identified.
The visualized loops of small bowel and colon are grossly normal. There are
no pathologically enlarged pelvic lymph nodes. No free fluid is seen in the
pelvis.
## IMPRESSION:
1. No evidence of a periurethral mass or ureteral diverticulum.
2. Intrauterine IUD within both struts penetrating deeply into the myometrium,
as described above. Further evaluation could be performed with ultrasound,
preferably with 3D capabilities.
3. Bilateral simple ovarian cysts, measuring up to 4 cm. Given that this
patient is premenopausal, no followup imaging is recommended.
4. Adenomyosis.
Pertinent findings were discussed with Dr. by Dr. at 16:50 via
telephone on the day of the study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13863107", "visit_id": "N/A", "time": "2194-11-23 09:05:00"} |
17304051-DS-11 | 1,804 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
Transferred from with after acute coronary syndrome
(likely STEMI) for catheterization
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Cardiac catheterization with thrombectomy and drug eluting stent
to LAD
## HISTORY OF PRESENT ILLNESS:
yo M with DMII, HTN, HLD and no prior cardiac history awoke
from sleep with chest pain at 1am on . It was initially
associated with SOB and then involved nausea and diaphoresis.
This lasted until 3:45am at which time he went back to sleep. He
had only had one episode of chest pain prior to this which had
occured 3 wks prior at rest lasting only minutes. He awoke in
the morning with no overt chest pain or pressure, but still with
an odd substernal 'sensation.' He presented to the b/c
his wife told him that he looked unwell.
.
On arrival to , he was given SLNTG x1 which resolved the
lingering discomfort in his chest. His initial EKG was notable
for Q-waves V1/V2/V3 with subtle STE (~1mm) in those leads.
Initial troponinI=16 (CKMB not checked). He was started on
heparin and integrillin drips, given 80mg lipitor, 25mg po
metoprolol, & 325mg ASA, loaded with 600mg plavix and
transferred to for cath. Vitals stable throughout course
at .
.
On arrival to , he is pain free, stating that he has not
had chest pain or pressure since 3:45am (18hrs prior) and has
not had chest 'discomfort' since given SLNTG at at
4:30pm. He has never had exertional chest pain; has noticed some
increase in DOE over past few months.
.
## 2. CARDIAC HISTORY:
none
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
DMII on metformin and insulin
Dylipidemia on statin
HTN controlled
Depression
## FAMILY HISTORY:
1out of 9 uncles & aunts had CAD
## GENERAL:
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 NO APPRECIABLE JVP.
## CARDIAC:
RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
## ABDOMEN:
Soft, NTND. No HSM or tenderness.
## EXTREMITIES:
No c/c/e. No femoral bruits.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## FINDINGS:
Normal lung volumes. Moderate cardiomegaly without
signs of
overhydration. No pleural effusions. No focal parenchymal
opacity suggesting
pneumonia. No pulmonary edema.
.
Cardiac catheterization:
## COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated 2
vessel CAD. The LMCA was patent. The LAD had a 95% stenosis
after a high
diagonal branch and first septal with large associated thrombus.
The LCx
had a 30% proximal stenosis. The RCA had a 50-60% stenosis in
the RPL
branch.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension with an SBP of 133 mmHg.
3. Successful manual aspiration thrombectomy, PTCA and placement
of a
3.0x18mm Promus drug eluting stent, post-dilated using a 3.25mm
balloon
were performed in the proximal LAD. Final angiography showed
normal
flow, no apparent dissection, and no residual stenosis. (See
PTCA
comments.)
4. The right common femoral arteriotomy was successfully closed
using a
Fr Angioseal VIP device.
## FINAL DIAGNOSIS:
1. Two vessel CAD.
2. Anterior MI with thrombotic LAD occlusion.
3. Placement of a drug eluting stent in the proximal LAD.
.
echo:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with severe hypokinesis of
the distal half of the anterior septum and anterior walls. The
apex is akinetic but not aneurysmal. (LVEF= 40 %). No
intraventricular thrombus is seen. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
promient fat pad.
## IMPRESSION:
Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (mid-LAD
distribution). Dilated aortic root.
## BRIEF HOSPITAL COURSE:
yo M transferred to for catheterization after presented
with resolved STEMI vs NSTEMI.
.
# Acute coronary syndrome: It was initially unclear if the
patient had suffered a STEMI or a Non-STEMI because his
biomarkers were elevated and he had Q waves on EKG, but he had
presented so late that there were no ST segment elevations. The
patient was taken for catheterization where a thrombus was found
in the LAD artery. This was aspirated and a dug eluting stent
was placed. The patient was kept on integrellin for 18 hrs post
catheterization. He was also continued on aspirin 325 mg,
plavix 150 mg, and lipitor 80 mg. He will need to take 150 mg
plavix Q day for one week before changing to 75 mg Q day. A
follow up echocardiogram was obtained and showed an akinetic
apex so the patient was also started on coumadin. He will need
to have his INR checked and plans to go to is primary care
doctor's office for this. He was also found to be tachycardic
overnight and the following morning so his metoprolol tartrate
was uptitrated to 50 mg BID, which had good effect on his heart
rate. He was converted to metoprolol succinate 100 mg prior to
discharge. Lisinopril was decreased from 40 mg to 10 mg q day
due to hypotension from the metoprolol. The lisinopril will
need to be titrated up as an outpatient with a goal of 40 mg Q
day if blood pressure can tolerate it. It was also thought that
the patient would benefit from cardiac rehab and he was given a
patient handout. He plans to talk with his PCP to find
cardiac rehabilitation center near his home. He worked with
physical therapy prior to discharge and was found to have no
additional needs. He will also need a repeat echo in
weeks. He plans to establish care with a cardiologist near
.
.
# Diabetes II: The patient's metformin was held and he was given
LANTUS + SSI humalog. He was restarted on his metformin upon
discharge.
.
# Depression: The patient's home dose paroxeteine was continued.
.
## FEN:
regular, heart healthy, diabetic diet.
.
## DISPOISITION:
the patient was provided with two prescriptions of
his new medications so he can mail one copy for cheeaper
medications and fill the other right away.
.
FULL CODE
## MEDICATIONS ON ADMISSION:
ASA 81 Q once a day
Metformin Q once a day
simvastatin 80 Q once a day
lantus 48U QHS
humalog SS
paroxeteine 20 Q once a day
lisinopril 40 Q once a day
## DISCHARGE MEDICATIONS:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*4*
3. Metformin 1,000 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Simvastatin 80 mg Tablet
## SIG:
One (1) Tablet PO once a day.
5. Lantus 100 unit/mL Solution
## SIG:
(48) units
Subcutaneous at bedtime.
6. Humalog 100 unit/mL Solution Subcutaneous
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: please
take two pills a day (150 mg) for one week, then decrease to 75
mg (one pill) once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*4*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*4*
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
.
Disp:*30 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Primary diagnosis:
acute coronary syndrome - Likely STEMI
Thrombotic occlusion of LAD - extracted
Drug eluting stent to proximal LAD
Secondary diagnosis
Diabetes
Hyperlipidemia
## DISCHARGE INSTRUCTIONS:
You came to the hospital because you had a heart attack. You
had a cardiac catheterization which showed that you had a clot
in your major heart artery (LAD artery). This clot was removed
and you had a stent placed to open the artery and provide good
blood flow to the rest of your heart. You did well during the
procedure. Unfortunately, you had already lost some function
from the tip of your heart from the heart attack. Because this
puts you at a higher risk of having a clot that could cause a
stroke, you will need to take coumadin as well as plavix and
aspirin. You will need to have your blood monitored because of
the coumadin and will need to get labs drawn at your primary
care doctor's office on . You will also benefit from
participating in cardiac rehab and should talk to your primary
care doctor about this.
You were also noted to have a fast heart rhythm. Your
metoprolol was increased to slow your heart down to a healthier
rate. This may cause some low blood pressure so your lisinopril
was decreased. you should talk to your doctor about increasing
this dose in the future.
Please note the following changes to your medications:
** Increase aspirin to 325 mg once a day
** Decrease lisinopril to 10 mg once a day; you will need to
talk to your doctor about increasing this dose. You may ask
your doctor to write you a prescription for your mail in
medications at your appointment with the new dosage that he
wants you to take.
** START Plavix 150 mg once a day for a week then decrease to 75
mg once a day (take two of the 75 mg pills once a day for the
first week)
** START coumadin 5 mg once a day; you were only given one
prescription. Please ask your doctor what dosage he wants you to
be on and ask him to write you a mail in prescription for this.
** START metoprolol succinate 100 mg once a day
Please continue to take all of your other medications as
prescribed.
It was a pleasure taking part in your care.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17304051", "visit_id": "29710807", "time": "2119-12-29 00:00:00"} |
10193237-RR-48 | 136 | ## REASON FOR EXAMINATION:
Evaluation of the patient with volume overload and
coronary artery disease.
Portable AP chest radiograph was compared to .
ET tube tip is 2.4 cm above the carina. Left internal jugular line and right
internal jugular line are in unchanged appropriate positions. The NG tube tip
is in the proximal stomach and may be advanced. The appearance of partially
imaged post-surgical abdomen is unchanged.
There is still present bibasilar atelectasis and bilateral pleural effusions,
right most likely more than left. There is slight interval improvement of the
pulmonary edema component and no evidence of worsening of any of the process
within the chest has been demonstrated within the limitations of this study
technique.
The left PICC line tip is most likely in the distal portion of the left
subclavian vein.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10193237", "visit_id": "22853314", "time": "2111-11-25 05:01:00"} |
19000380-RR-14 | 69 | ## INDICATION:
year old woman with left shoulder pain // Steroid injection
left sub acromial bursa for pain control
## FINDINGS:
The rotator cuff is intact. There is no significant fluid in the
subacromial/subdeltoid bursa. Subsequent images demonstrates filling of the
bursa with fluid medication.
## IMPRESSION:
1. Imaging Findings-as above
2. Procedure - Uneventful ultrasound-guided injection of long-acting
anesthetic and steroid into the left subacromial/subdeltoid bursa.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19000380", "visit_id": "N/A", "time": "2159-10-29 08:30:00"} |
18481070-RR-11 | 88 | ## INDICATION:
year old woman with post op hw // post op
## FINDINGS:
T2-3 disc space loss and endplate destruction. Again demonstrated, with
transpedicular screw placement and longitudinal rods. At levels proximal and
distal to this, most likely extending from T1 through T5. Background
degenerative changes are present in the thoracic spine. Overlying skin
staples and soft tissue gas. Surgical clips also project over the left
axillary region.
## IMPRESSION:
Persistent endplate destruction and disc space loss at T2-3, with postsurgical
changes of upper thoracic spine fusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18481070", "visit_id": "22663882", "time": "2168-12-29 09:32:00"} |
12499622-RR-15 | 60 | ## HISTORY:
woman, with confusion. Has history of cirrhosis.
Assess for portal vein thrombosis and the amount of ascites.
## IMPRESSION:
1. Patent portal veins, without evidence of portal venous thrombosis.
2. Known cirrhotic liver, without focal lesions. Marked splenomegaly.
3. Only a small amount of perihepatic ascites, not sufficient for therapeutic
paracentesis.
4. Moderate-to-large bilateral pleural effusions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12499622", "visit_id": "21024122", "time": "2177-03-01 09:31:00"} |
19744711-RR-22 | 233 | ## REASON FOR EXAM:
Assess for pulmonary embolism.
## FINDINGS:
There is satisfactory contrast opacification of the pulmonary arteries, no
pulmonary embolism or acute aortic pathology. Small bibasilar pleural
effusions are present, slightly larger on the right than the left side with
mild linear atelectasis throughout the lower lungs which are otherwise clear.
Post-CABG surgical changes in the mediastinum are present with diffuse
calcification of the native coronary arteries. The central and hilar
mediastinal lymph nodes are significantly enlarged up to 14 mm in the anterior
mediastinum, 16 mm in the precarinal region and conglomerate lymphadenopathy
extends throughout the hila bilaterally. The pulmonary artery is top normal at
30 mm, heart size is normal with no pericardial effusion. The central airways
are widely patent to subsegmental level bilaterally.Diffuse circumferential
thickening of the lower esophagus with a small hiatal hernia.
Although this examination was not designed for subdiaphragmatic evaluation,
the abdominal structures are unremarkable.
A tiny focal area of sclerosis within a right lateral rib, is most likely a
bone island, no destructive or sclerotic bone lesions are concerning for
malignancy. Recent median sternotomy wires are intact.
## IMPRESSION:
No pulmonary embolism or acute aortic pathology.
Diffuse mediastinal and hilar lymphadenopathy should be amenable to
transbronchial biopsy, differential diagnosis would include lymphoma, less
likely sarcoidosis.
Diffuse circumferential thickening of the lower esophagus should be further
evaluated with an EGD.
Small bibasilar pleural effusions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19744711", "visit_id": "26613911", "time": "2134-03-21 15:07:00"} |
16906224-DS-6 | 2,800 | ## CHIEF COMPLAINT:
BLE pain with ambulating
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
BILATERAL L2-5 LAMINECTOMY AND NON-INSTRUMENTED
FUSION with Dr.
Coronary Angiography
Percutaneous Coronary Intervention with Impella VAD
(3 DES to LAD, 1 DES to RCA)
## HISTORY OF PRESENT ILLNESS:
Ms. is an female who presents with a chief
complaint of neurogenic claudication secondary to lumbar spinal
stenosis. She describes having bilateral dull pain in her low
back and buttock area with weakness mainly in her left lower
extremity in the past year and a half. She states that her
symptoms get worse with walking and standing. Sometimes, the
pain radiates into her left lower extremity. She does have
bilateral sensation of pins and needles as well throughout her
lower extremities. She states that at times she needs to sit due
to the pain becoming too severe while she is walking. She has
had prior epidural steroid injections x 2 to her in the past,
which were of no help. She did have physical therapy, which was
of no help with her symptoms. She has not had any other spine
procedures done to her. She does take Tylenol No. 3 to alleviate
her pain at times. She has not had any bowel or bladder
incontinence. She is able to ambulate independently still. She
does use a walker at times when she is traveling long distances.
On POD2 patient developed waxing/waning mental status,
significant nausea, nonbloody emesis x2, leukocytosis to 16, and
persistent anemia (to a nadir of 6.6) requiring 1uPRBC. Due to
these abnormalities she was transferred to medicine.
At time of transfer to medicine, Pt feels well. She does not
recall being confused, but states that her back pain is better
compared to prior to the procedure (used to be bilateral, now is
unilateral on the left). Pt has been passing gas, but has not
had a bowel movement since prior to her operation 4 days ago.
She notes a productive cough (with tan sputum). She denies
fevers, chills, chest pain, SOB, dysuria, hematuria, frequency,
abdominal pain, numbness/tingling in the extremities, and focal
weakness.
## PAST MEDICAL HISTORY:
CAD s/p stent in
Hypothyroidism
Sigmoid diverticulitis
Osteochondropathy
HTN
Anti-Fya, Anti-S, and Anti-E antibodies -- risk for hemolytic
transfusion reactions
## PAST SURGICAL HISTORY:
Partial hysterectomy and appendectomy
## FAMILY HISTORY:
Family history of diabetes (one grandparent). Son with
anticardiolipin antibody.
## PHYSICAL EXAM:
==============
ADMISSION EXAM
==============
AVSS
Well appearing, NAD, comfortable
All fingers WWP, brisk capillary refill, 2+ distal pulses
## BLE:
SILT L1-S1 dermatomal distributions
## BLE:
All toes WWP, brisk capillary refill, 2+ distal pulses
==============
DISCHARGE EXAM
==============
## HEENT:
No icterus or injection. PERRL, EOMI.
## LUNGS:
Non-labored breathing on RA. No crackles.
## ABDOMEN:
Soft, nontender, nondistended. no rebound or guarding.
+BS.
## GU:
No suprapubic or CVA tenderness. Foley removed.
## EXT:
Warm, trace edema. Right femoral cath site CDI with no
hematoma or bruit.
## NEURO:
Normal mental status. CN intact. Strength
symmetric throughout.
## TTE ( ):
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= %) with infero-lateral and distal
LV/apical akinesis. The mid to distal anterior wall and
are hypokinetic (? Multivessel CAD?). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. Right ventricular chamber size is normal with
borderline normal free wall function. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion
HEST W/O CONTRAST
1. Moderate aortic arch calcification. No significant ascending
thoracic
aortic calcification.
2. Possible lingular nodule versus nodular scar measuring 8 x 7
mm. Recommend
six (6)-month follow-up chest CT.
3. Pulmonary interstitial edema with mild superimposed perihilar
alveolar
edema.
4. Bilateral layering nonhemorrhagic moderate right small left
pleural
effusions.
5. Mild focal subpleural fibrosis with traction bronchiolectasis
in the
anterior mid- and upper lungs raises the possibility of prior
hypersensitivity
pneumonitis or other prior lung injury.
6. Dilated main pulmonary artery measuring 3.5 cm raises the
possibility of
pulmonary hypertension.
7. Moderate global cardiomegaly.
8. Severe three-vessel coronary artery calcification.
9. Aortic and mitral valvular calcification.
## RECOMMENDATION(S):
6-month followup chest CT.
Possible lingular nodule versus nodular scar measuring 8 x 7 mm.
Recommend
six (6)-month follow-up chest CT.
-----
CATH REPORT ( )
Procedure(s)
* Arterial Access
* Arterial Access
* Percutaneous Coronary Intervention
* Percutaneous Coronary Intervention
* VAD Placement (Impella)
## IMPRESSIONS:
1. Successful PCI of LAD (3 DES) and RCA (1 DES) with DES using
Impella support.
2. Blood loss from access site stabilized resulting in transient
hypotension.
Recommendations
1. ASA 81 mg a day.
2. Plavix 75 mg a day.
3. Secondary prevention CAD.
=====================
OTHER IMAGING & STUDIES
=====================
DIFFICULT CROSSMATCH AND/OR EVALUATION OF IRREGULAR ANTIBODIES
## DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS:
Ms. has a
history of
Anti-Fya, Anti-S and Anti-E antibodies (Anti-Fya and Anti-S
identified
for this workup). The , S-antigen and E-antigen are
members
of the , MNS, and Rh blood group systems, respectively.
Anti-Fya,
Anti-S, and Anti-E antibodies are all clinically significant and
are
capable of causing hemolytic transfusion reactions.
In the future, Ms. should receive , S-antigen
and
E-antigen negative products for all red cell transfusions.
Approximately
11% of ABO compatible blood will be , S-antigen and
E-antigen
negative. A wallet card and a letter stating the above will be
sent to
the patient.
-----
## CXR ( ):
There are no prior chest radiographs available
for review. Combination of moderate cardiomegaly, with a
configuration favoring left atrial enlargement, pulmonary and
mediastinal vascular engorgement suggests that widespread
interstitial abnormality with prominent septal lines is could be
due to congestive heart failure alone. Pleural effusions are
presumed, but small.
-----
## ABDOMINAL XR ( ):
1. Non-obstructive bowel gas pattern.
2. Cardiomegaly and interstitial thickening, suggestive of
pulmonary edema.
-----
CT ABDOMEN/PELVIS W/O CONTRAST ( ):
1. Focal area of linear high density along the course of the
right external iliac artery may represent a focal area of
dissection and retained contrast versus calcification of the
vessel. Correlate with intraprocedural findings during arterial
access.
2. No evidence of retroperitoneal hematoma.
3. Small bilateral pleural effusions right greater than left.
-----
## BLOOD CULTURE, ROUTINE (PENDING):
3:30 am BLOOD CULTURE Source: Line-PICC 1 OF 2.
## 12:59 PM URINE SOURCE:
Catheter.
**FINAL REPORT
URINE CULTURE (Final :
YEAST. >100,000 CFU/mL.
9:00 am BLOOD CULTURE
**FINAL REPORT
## BLOOD CULTURE, ROUTINE (FINAL :
NO GROWTH.
5:40 am BLOOD CULTURE
**FINAL REPORT
## BRIEF HOSPITAL COURSE:
Ms. is an with CAD s/p PCI ( ) and hypothyroidism,
admitted for L2-L5 laminectomy for spinal stenosis. On
POD1 she developed severe acute anemia (Hb 11->6.6) requiring
transfusion (1u pRBC). On POD2 she developed delirium, hypoxemic
respiratory failure (requiring supplemental O2 and ICU), NSTEMI
with ST depressions but no chest pain (peak trop 2.8), new acute
decompensated heart failure (LVEF , multiple wall motion
abnormalities, 3+ MR), and leukocytosis. NSTEMI was treated
with aspirin, Plavix, heparin, and nitroglycerin infusion during
IV diuresis. She was transferred out of the ICU early to
the Heart Failure service with ongoing HF exacerbation,
delirium, and anemia, and was diuresed to euvolemia. She
redeveloped dynamic ECG changes associated with chest
discomfort, and was found to have severe three-vessel CAD on LHC
( ). She declined open heart surgery but agreed to undergo
high-risk PCI with Impella support, and had 3 DES to LAD and 1
DES to RCA ( ). She then developed hypotension due to
hemorrhage from right radial cath site requiring dopamine and
second CCU stay. She recovered quickly on the floor and was
discharged pain free and euvolemic on optimal CAD and
medical regimens.
=============
DETAILED COURSE
=============
Patient was admitted to the Spine Surgery Service and
taken to the Operating Room for L2-L5 laminectomy for spinal
stenosis. The surgery was without complication (EBL 300cc,
received 2675cc IVF, UOP 385cc).
On POD1 patient developed severe acute anemia (Hb 11->6.6)
requiring transfusion (1u pRBC). On POD2 she developed delirium,
significant nausea/emesis, leukocytosis and her anemia
persisted. Due to these abnormalities she was transferred to
Medicine.
## MEDICINE/CARDIOLOGY COURSE:
Pt was transferred from Medicine to
Cardiology for worsening SOB, EKG with ST depressions in the
precordial leads and troponin elevation to 2.37 concerning for
NSTEMI. Was started on hep gtt, received metop tartrate, plavix
and continued on ASA. Bedside echo found EF of with
apical hypokinesis c/w ischemic cardiomyopathy from NSTEMI.
Diuresed with Lasix 20mg x2, then 40mg IV x1, then triggered in
AM for low urine output. Was briefly given NS, but stopped
as thought to be hypervolemic in setting of acute systolic heart
failure w/ crackles on lung exam, JVP 12-15cm at 45 degrees, and
cool LEs. Stopped metop, loaded with IV Lasix 40mg, then Lasix
gtt 5mg/hr, started nitro gtt and transferred to CCU for
worsening respiratory status.
## CCU COURSE:
Transferred to CCU for oliguria and increasing
hypoxia. Lasix gtt was increased to 20 mg/hr with 80 mg IV
boluses and she was placed on a nitroglycerin gtt for
augmentation of diuresis. The nitro gtt was weaned off. Her
urine output and respiratory status improved. In addition, she
was started on ceftriaxone for a positive UA in the setting of
delirium and leukocytosis she had no fevers or chills. H/H
continued to downtrend with no signs of hemorrhage, and she was
transfused 1U PRBCs, along with 80 mg IV Lasix. She was
transferred to the floor in a stable condition and ceftriaxone
was discontinued.
## CCU ( ):
After PCI, BP declined as low as systolic
so put on dopamine. Echocardiogram showed no effusion. Aortogram
was unrevealing as as well. Per report, the patient bled from
her right radial cath site and lost up to half liter of blood
requiring 2u pRBC. An impella was placed for support. Dopamine
gtt was as high as 10 but weaned off prior to transfer back to
floor.
## DISCHARGE PRELOAD:
Furosemide 40 mg PO/NG DAILY
## DISCHARGE AFTERLOAD:
Lisinopril 5 mg PO/NG DAILY, Metoprolol
Succinate XL 12.5 mg PO
## DISCHARGE ANTI PLT:
Aspirin 81 mg PO/NG DAILY, Clopidogrel 75 mg
PO/NG DAILY
## NEW HFREF DIAGNOSIS:
EF on pre-PCI TTE
## DRUG-ELUTING STENTS:
3 to LAD and 1 DES in RCA on
## RECOMMENDATION(S):
6-month followup chest CT.
Possible lingular nodule versus nodular scar measuring 8 x 7 mm.
Recommend
six (6)-month follow-up chest CT.
## PER BLOOD BANK:
"Ms. has a history of Anti-Fya, Anti-S
and Anti-E antibodies (Anti-Fya and Anti-S identified for this
workup). Anti-Fya, Anti-S, and Anti-E antibodies are all
clinically significant and are capable of causing hemolytic
transfusion reactions. In the future, Ms. should receive
, S-antigen and E-antigen negative products for all
red cell transfusions."
## PPI:
Started this admission in case slow upper GI bleed
contributing to anemia. Consider discontinuing.
## SPINE PRECAUTIONS:
TLSO brace, F/U in spine clinic
Patient given dilaudid 2mg q6h for discomfort from cath.
Morphine not used given prior intolerance
Patient received Ferric Gluconate 125 mg IV x1 on given
her anemia and heart failure. Please consider additional future
dosing
## CODE STATUS:
DNR OK TO INTUBATE
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 40 mg PO DAILY
5. LORazepam 0.5 mg PO BID:PRN anxiety
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. Acetaminophen 1000 mg PO Q8H
8. Polyethylene Glycol 17 g PO DAILY
9. Gas-X (simethicone) 62.5 mg oral QID:PRN
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY
4. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Days
Take through day
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Furosemide 40 mg PO DAILY
8. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*8 Tablet Refills:*0
9. Lisinopril 5 mg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Senna 8.6 mg PO BID
12. Aspirin 81 mg PO DAILY
13. Gas-X (simethicone) 62.5 mg oral QID:PRN
14. Levothyroxine Sodium 88 mcg PO DAILY
15. LORazepam 0.5 mg PO QHS:PRN anxiety or insomnia
16. Multivitamins 1 TAB PO DAILY
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
18. Omeprazole 40 mg PO DAILY
19. Pantoprazole 40 mg PO Q12H
20. Polyethylene Glycol 17 g PO DAILY
## DISCHARGE DIAGNOSIS:
Primary Diagnoses
==================
Lumbar spinal stenosis
Degenerative scoliosis
Non-ST segment elevation myocardial infarction
Multivessel coronary artery disease
Acute ischemic systolic heart failure
Acute hypoxemic respiratory failure
Hypovolemic shock
Acute posthemorrhagic anemia
Secondary Diagnoses
========================
Acute renal failure
Catheter-associated urinary tract infection
Delirium
Anti-Fya, Anti-S and Anti-E antibodies
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to for back
surgery. Unfortunately you had a heart attack after your
surgery.
What happened while you were in the hospital:
- You were transferred to the Intensive Care Unit and the Heart
Failure service
- We gave you medications to protect your heart and remove
excess fluid from your body
- You had 4 stents placed in your heart to open the blocked
blood vessels that caused your heart attack
- You had several blood transfusions to replace the blood you
lost during your surgery and your stent procedure
-You had a urine infection which was treated with antibiotics
Instructions for when you leave the hospital:
- Please take all of your medications as prescribed
- Weigh yourself every morning. Call your doctor if your weigh
goes up by more than 3 pounds.
- Avoid salty foods (including bread, canned soups, fast food).
Limit yourself to 2 grams of sodium each day.
- Follow up with your primary care doctor, ,
and your spine surgeons. See below for details.
- Please see below for detailed instructions from your surgeons.
We wish you a speedy recovery!
Sincerely,
Your Care Team
=============================
INSTRUCTIONS FROM YOUR SPINE SURGEONS
=============================
You have undergone the following operation: Lumbar Decompression
With Fusion
## ACTIVITY:
You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without getting up and
walking around.
## REHABILITATION/ PHYSICAL THERAPY:
times a
day you should go for a walk for minutes as part of your
recovery. You can walk as much as you can tolerate. Limit any
kind of lifting.
## DIET:
Eat a normal healthy diet. You may have
some constipation after surgery. You have been given medication
to help with this issue.
## BRACE:
TLSO Brace when out of bed
## WOUND CARE:
If the incision is draining cover
it with a new sterile dressing. If it is dry then you can leave
the incision open to the air. Once the incision is completely
dry (usually days after the operation) you may take a
shower. Do not soak the incision in a bath or pool. If the
incision starts draining at anytime after surgery, do not get
the incision wet. Cover it with a sterile dressing. Call the
office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on . We are not allowed to call in or fax
narcotic prescriptions (oxycontin,oxycodone,percocet) to your
pharmacy. In addition, we are only allowed to write for pain
medications for 90 days from the date of surgery.
## FOLLOW UP:
Please call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your incision,
take baseline X-rays and answer any questions.We may at that
time start physical therapy
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16906224", "visit_id": "23023865", "time": "2177-12-10 00:00:00"} |
17612019-DS-15 | 1,443 | ## ALLERGIES:
Menthol / oxaliplatin / Amoxicillin
## CHIEF COMPLAINT:
elective admission for chemotherapy
## HISTORY OF PRESENT ILLNESS:
yo female with a history of colon cancer and an allergic
reaction to oxaliplatin who is admitted for oxaliplatin
desensitization. only complaint is some back pains/spasms at
home. says she has been taking ibuprofen she got from a friend.
no more than 800mg per day
## REVIEW OF SYSTEMS:
+chronic nasal congestion. She denies any nausea, fevers, cough,
shortness of breath, pain, diarrhea, or dysuria. No bleeding
## PAST ONCOLOGIC HISTORY:
Reconciled in OMR.
Colon cancer stage IV (T3N2bM1b) KRAS mutated, MSI stable
- Had a few episodes where she felt hot and dizzy,
for
which she was seen in urgent care.
- She experienced a similar episode with dizziness,
lightheadedness, nausea, vomiting, and abdominal pain and
presented to the ED.
- CT abdomen/pelvis showed abnormal thickening of the
terminal ileum and cecum. A left adnexal hypodense tubular area
was also seen.
- Pelvic US showed a 5.4 x 5.5 x 6.3 cm solid and
cystic
mass arising from the left ovary. Colonoscopy found a large
friable mass in the proximal portion of the ascending colon,
which the scope could not pass. Biopsy revealed low grade
adenocarcinoma. CEA on was 10.
- CT chest was negative.
- Underwent a right colectomy and left
salpingo-oophorectomy. Intraoperatively, the small bowel was run
and no lesions were found. At the conclusion of the case the
amount of remaining gross disease included a 1-cm nodule on the
bladder serosa as well as a small rind of tumor on the left
pelvic sidewall overlying the ureter. Pathology revealed
low-grade adenocarcinoma, pT3, pN2b (13 of 28 positive lymph
nodes), pM1 based on involvement of the left ovary. Margins from
the colectomy were negative. Lymphovascular invasion and
perineural invasion was seen. KRAS was mutated and MMR proteins
were intact by IHC.
- : CT a/p with interval increase in left paraaortic
lymph node, now 2.5 cm. Focally prominent lymph nodes along the
course of the SMV. At surgical staple line from right colectomy
there is a 1.6 x 1.7 cm soft tissue density mass within the
proximal most portions of residual colon. 4.8 x 4.2 cm mass in
the left adnexal surgical bed concerning for residual or
recurrent disease. In the right ovary there is a 2.4 x 1.3 cm
enhancing structure with an area of central low density with
more
solid enhancing components than would be expected for a corpus
luteal cyst, concerning for a new metastatic lesion.
- : C1D1 FOLFOX
- : C2D1 FOLFOX-avastin
- : C3D1 FOLFOX-avastin given after two week delay for
neutropenia. bolus held. Neulasta given.
- : CT torso: no intrathoracic disease. 13 x 11 mm soft
tissue density adjacent to anastomosis decreased from prior
(previously 17 x 16 mm). 19 x 14 mm left retroperitoneal lymph
node decreased, previously 26 x 28 mm. 3.7 x 3.0 cm left adnexal
soft tissue mass decreased in size, previously 4.8 x 4.2 cm.
Right adnexal mass no longer seen, may have been corpus luteum.
- : C4D1 FOLFOX-avastin, bolus restarted. Neulasta
given.
- : C5D1 FOLFOX-avastin. Reacted to oxaliplatin,
discontinued from further treatments.
- C6D1 with Neulasta
- CT torso showed, "Minimal interval decrease in size
of the soft tissue density lesion in the ascending colon
adjacent to the anastomosis, which may represent malignant
disease. Interval decrease in size of the left paraaortic lymph
node. Interval decrease in size of the left adnexal soft tissue
density mass."
- C7D1 with Neulasta
- C8D1 with Neulasta
- C9D1 with Neulasta
- CT torso with slight interval progression of
disease
- C1D1 irinotecan 350 mg/m2 Q21 days
- C2D1 irinotecan 350 mg/m2 Q21 days
- C3D1 irinotecan 350 mg/m2 Q21 days
- CT torso showed progression of her adnexal mass and
multiple small pulmonary nodules
- C1D1 FOLFIRI + Avastin
- C2D1 FOLFIRI + Avastin
- C3D1 FOLFIRI + Avastin
- CT torso showed slight decrease in lung mets but
slight increase in size of a left adnexal mass. CEA rising.
- C1D1 Regorafenib 120 mg D1-21 - held after D12 or so
- C2D1 Regorafenib 80 mg D1-14 of a 21 day cycle
delayed
for vacation
- C3D1 Regorafenib 80 mg D1-14 of a 21 day cycle
- C4D1 Regorafenib 80 mg D1-14 of a 21 day cycle
- CT torso showed growth of lung mets and possible 2
new
small mets, increase of left adnexal mass, new right adnexal
mass, enlarging left periaortic lymph node, and new right
pericolic gutter implant all consistent with metastatic disease.
There is also a new anterior uterine lesion, which may also
represent a metastasis.
- C5D1 Regorafenib 80 mg D1-14 of a 21 day cycle
- CT torso showed progression of liver mets
- Skin testing for oxaliplatin sensitivity negative.
- C1D1 FOLFOX6 with 3 bag desensitization
- C2D1 FOLFOX6 with 3 bag desensitization
- C2D15 dose of FOLFOX6 with 3 bag desensitization
delayed for cytopenias
- CT torso showed decrease in metastatic disease
- C3D1 FOLFOX6 with 3 bag desensitization plus
Neulasta
- C3D15 FOLFOX (ci5FU 1800 mg/mg) with 3 bag
desensitization plus Neulasta
- CT torso showed progression of lung mets
- C10D1 FOLFOX (ci5FU 1800 mg/mg) with 3 bag
desensitization plus Neulasta
## FAMILY HISTORY:
Mother died at of breast cancer, HTN
No breast cancer in female siblings, colon cancer in male
relatives.
No FH of Crohn's, UC, IBD.
Father- HTN, DM, ESRD on HD
## HEENT:
MMM, no OP lesions
## CV:
RR, NL S1S2 no S3S4 MRG
## ABD:
Soft, NTND, no masses or hepatosplenomegaly
## LIMBS:
No edema, clubbing, tremors, or asterixis
## SKIN:
No rashes or skin breakdown
## NEURO:
Alert and oriented, no focal deficits.
## LIVER:
The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD
measures 3 mm.
## GALLBLADDER:
There is no evidence of stones or gallbladder wall
thickening.
## PANCREAS:
Imaged portion of the pancreas appears within normal
limits, without masses or pancreatic ductal dilation, with
portions of the pancreatic tail obscured by overlying bowel
gas.
## SPLEEN:
Normal echogenicity, measuring 11.7 cm.
## KIDNEYS:
The right kidney measures 10.9 cm. The left kidney
measures 11.1 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones, or hydronephrosis in the
kidneys.
## RETROPERITONEUM:
Visualized portions of aorta and IVC are within
normal
limits.
## BRIEF HOSPITAL COURSE:
yo female with a history of colon cancer and an allergic
reaction to oxaliplatin who is admitted for oxaliplatin
desensitization.
#Colon cancer - metastatic to omentum. received C11 oxaliplatin
w/ desensitization per protocol . Tolerated well without
signs of allergic
reaction but developed hemolysis as below. infusion held on
given elevated LFTs/bili which rapidly improved,
bolus given and pump set up prior to
discharge.
#Hemolysis - new indirect hyperbili, elevated LD and
undetectable hapto following oxaliplatin infusion. coags normal
thus not c/w DIC. DAT is +. hemolytic anemia is listed as rare
side effect. appears to be self-limiting HCT did not drop and
bilirubinemia improved the following day. currently
asymptomatic. Will need to monitor w/ next oxaliplatin infusion
#Hypertension - persistently elevated BP despite home atenolol.
would likely benefit from but receives contrast
frequently for staging thus risk of nephropathy. changed to
labetalol during admission w/ better control, will continue on
discharge, may need to increase to TID or add agent if
remains elevated patient will monitor at home
#Leukocytosis - prior neupogen after last cycle, now
downtrending. no infectious symptoms at this time
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO ASDIR
2. Atenolol 100 mg PO QHS
## DISCHARGE MEDICATIONS:
1. Cetirizine 10 mg PO ASDIR
2. TraMADol 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg tablet(s) by mouth every 4 hours as
needed Disp #*30
## TABLET REFILLS:
*1
3. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
## DISCHARGE DIAGNOSIS:
Colon cancer
Oxaliplatin hypersensitivity
Hemolysis
Hypertension
## DISCHARGE INSTRUCTIONS:
Dear Ms , it was a pleasure caring for you during your
stay at . You were admitted for your next cycle of
oxaliplatin which you tolerated well. You did experience some
back spasms which may be a side effect but did not have any
signs of allergic reaction. However you did have elevated
bilirubin and were found to have hemolysis of red blood cells.
We monitored this to make sure it was a dangerous form of
hemolysis and your blood counts remained stable without
intervention. You were also given a new medication for elevated
blood pressure which you will now need to take twice a day.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17612019", "visit_id": "20742225", "time": "2130-10-08 00:00:00"} |
18132130-RR-30 | 360 | ## HISTORY:
Bilateral shoulder pain and weakness status post .
## LEFT SHOULDER MRI WITHOUT CONTRAST:
There is mild AC joint arthropathy. Note is made of an os acromiale variant.
There is trace fluid in the subacromial-subdeltoid bursa.
There is mild tendinosis and intrasubstance edema in the distal supraspinatus
tendon over a length of approximately 6.7 mm (4:9). The possibility of a tiny
intrasubstance tear in this location cannot be excluded. In addition, the
sagittal images suggests the presence of a small rim-rent tear along the
anterior fibers of the distal supraspinatus tendon measuring approximately 2.9
mm in the sagittal plane and 2.7 mm in the coronal plane (5:6, 4:7). This is
associated with small area of subcortical marrow edema. No definite surfacing
component is seen in this area. No tendon retraction is identified.
The infraspinatus tendon shows mild tendinosis, with possible minimal distal
fraying, but is otherwise intact. The teres minor tendon is intact, within
normal limits. The subscapularis tendon shows mild tendinosis, without
discrete tear.
The glenohumeral joint is grossly congruent, with mild cartilage thinning
along THE glenoid, but without other evidence of degenerative change. Limited
assessment of the labrum on this non-arthrographic exam reveals no displaced
tear.
The long head biceps tendon shows mild-to-moderate intra-articular tendinosis,
but is well seated in the intertubercular groove, without surrounding
tenosynovitis.
There is scattered red marrow. No focal marrow edema to suggest bone
contusion or fracture is detected. No evidence of osteonecrosis.
Muscles about the shoulder girdle are within normal limits in signal intensity
and morphology.
Scattered axillary lymph nodes are noted, none enlarged by short axis
criteria.
## IMPRESSION:
1. Tendinosis of the supraspinatus, infraspinatus, subscapularis and
intra-articular biceps tendons.
2. Small intrasubstance tear of the distal supraspinatus tendon and tiny
rim-rent tear of the anterior fibers of the distal supraspinatus tendon.
Doubt full-thickness tear. No tendon retraction or muscle atrophy.
3. Mild AC joint arthropathy, with note made of a normal variant os
acromiale. Trace fluid in the subacromial-subdeltoid bursa, consistent with
trace bursitis.
4. Suspect mild degenerative narrowing of hyaline cartilage along the
glenoid.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18132130", "visit_id": "N/A", "time": "2131-11-02 16:22:00"} |
17333529-RR-17 | 171 | ## STUDY:
CT head without contrast.
## INDICATION:
Status post evacuation of subdural hematoma, please evaluate for
interval change.
## FINDINGS:
Little overall change since prior study is demonstrated. Previously
noted intracranial drains have been removed. No change is demonstrated to
size or appearance of small, mixed-attenuation bifrontal extra- axial
collections with small amount of pneumocephalus within. The right extra-axial
collection measures 7 mm, and the left, 8 mm in maximal thickness. Punctate
calcifications within the left extra-axial collection suggest dystrophic
calcification within an old extra-axial hemorrhage. No new shift of normal
midline structures, hemorrhage, mass lesions, or evidence for acute major
territorial infarct is apparent. The normal gray-white matter differentiation
is preserved. The major basal cisterns are preserved.
There has been bilateral lens replacement. There is dense calcification of
the carotid siphons bilaterally. Visualized paranasal sinuses and mastoid air
cells remain clear.
## IMPRESSION:
Little change from prior study with thin bifrontal extra-axial
collections, status post intracranial drain removal. No new intracranial
hemorrhage or mass effect.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17333529", "visit_id": "21631677", "time": "2158-05-26 11:16:00"} |
14650130-RR-85 | 291 | ## INDICATION:
year old woman with right shoulder pain post injury ( )
// r/o RC re-injury
## FINDINGS:
This examination is limited by motion artifact.
## ACROMIO-CLAVICULAR JOINT:
Mild degenerative changes are seen at the
acromioclavicular joint, with adjacent marrow edema and hypertrophy of the
joint capsule. The subacromial fat plane is preserved, without MR evidence of
impingement.
## SUBACROMIAL-SUBDELTOID BURSA:
There is a moderate amount of fluid within the
subacromial-subdeltoid bursa, consistent with bursitis.
## SUPRASPINATUS TENDON:
There is increased signal, irregularity, and fraying at
the bursal surface of the anterior supraspinatus tendon near its insertion,
with small fissure like partial thickness tears (7:8).
Infraspinatus tendon: Intact.
Teres minor tendon: Intact.
Subscapularis tendon: There is no discrete tear, however there is increased
intrasubstance signal near the insertion point, consistent with moderate
tendinosis.
## GLENOHUMERAL JOINT:
The humeral head is well seated within the glenoid.
Joint effusion: There is no joint effusion.
Hyaline cartilage: No macroscopic cartilage defect was seen.
Glenoid labrum: There is no evidence of displaced labral tear on this non
arthrographic examination.
## BICEPS TENDON:
The biceps tendon is not well-visualized due to positioning
and technical factors. Within these limitations, no evidence of biceps tear.
## WITHIN NORMAL LIMITS.
BONE MARROW:
Within normal limits.
No evidence of mass within the suprascapular, spinoglenoid, or quadrilateral
space is. No evidence of axillary lymphadenopathy.
## IMPRESSION:
1. Limited examination due to motion artifact, patient positioning, and
technical factors. Within these limitations, no full-thickness rotator cuff
tear is seen. Irregularity and fraying of the bursal surface of the anterior
supraspinatus tendon near its insertion with small fissure like partial
thickness tears.
2. Tendinosis of the subscapularis tendon, but no tear.
3. Moderate subacromial-subdeltoid bursitis.
4. Mild degenerative changes at the acromioclavicular joint.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14650130", "visit_id": "N/A", "time": "2183-09-26 18:00:00"} |
19104291-DS-13 | 1,615 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
female patient presenting to the ED as a transfer
from an outside hospital for altered mental status and
hyponatremia. Serum sodium level was 108 at OSH. Pt's husband
reportedly called EMS when he noticed the pt was altered (also
reportedly the pt's husband was intoxicated when he called). Pt
was found disheveled, covered in feces, and with multiple old
hospital bracelets (from on her wrists.
## IN THE ED, INITIAL VITALS:
97.6 88 96/55 18 97% RA
Exam notable for:
Ulcers on buttock will likely need wound care
Labs notable for:
Na 111
## IMAGING:
None
Patient received:
IV NS
IV folic acid
IV Mag sulfate
## CONSULTS:
None at this time.
Upon arrival to , the pt reports she is having pain in her L
ankle and her back. She explains that she fell recently and
this is why her ankle hurts. She denies any other complaints,
including SOB, chest pain, abdominal pain, dizziness, or feeling
confused. She does report that at home she felt dizzy which is
why she fell. She walks with a walker but does not get up
often. When asked, she reports that she does get up and walk to
the bathroom when she has a bowel movement.
She reports that she has not eaten any food in over 2 weeks.
She says she has plenty of food in her home, but that she just
"doesn't feel like eating" and she has trouble getting up and
going to the kitchen. She explains that her husband brings her
several glasses of water a day. She had 2 beers today, which is
about her normal daily amount. She reports her husband drinks
alcohol as well. She states that she feels safe at home and no
one is hurting her. She sees a primary care doctor,
in . She does not know the last time she saw him.
She cannot recall any of her medications or her medical
problems.
## PAST MEDICAL HISTORY:
Pt unable to report.
Denies heart problems, liver problems, or kidney problems when
asked.
According to OSH records, also has history of:
Colon poyps
GI Bleed
L femoral neck fracture
Alcoholism
## FAMILY HISTORY:
Pt does not know of any medical problems in her family members.
## GENERAL:
Disheveled, poorly-kept woman who appears older than
stated age.
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
## ABD:
soft, 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
## SKIN:
On the bilateral groin and buttocks there are erythematous
patches with surrounding macules of erythema. Over the sacrum
there is an eroded area of skin with hemorrhagic crust. The
toenails are thickened, yellow, and long. There are red to
violaceous patches on the bilateral shins c/w ecchymoses. There
are several other areas of lighter ecchymoses, including the R
hip area and the R rib area.
## NEURO:
AAOx3. Flat affect. CN grossly intact.
## RUQ US:
1. Markedly limited study due to diffuse hepatic steatosis.
Evaluation for
focal lesion is limited due to difficulty penetrating. Echogenic
liver is most likely from steatosis. More advanced liver disease
including steatohepatitis, hepatic fibrosis, and cirrhosis
cannot be excluded on this study.
2. Trace ascites.
## TTE:
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. No significant
valvular disease.
CXR:
There are low bilateral lung volumes. There is a left pleural
effusion with
subjacent atelectasis, new since prior. Additionally, new
opacities in the
right mid to lower lung may reflect atelectasis or pneumonia. No
pneumothorax is identified. The size of the cardiac silhouette
is within normal limits.
CXR:
New pulmonary vascular congestion and mild pulmonary edema with
bilateral
effusions, is new compared to most recent prior.
CXR
Comparison to . Minimal decrease in extent of
the
pre-existing pleural effusions. Improvement of the pre-existing
pulmonary
edema. Borderline size of the cardiac silhouette and mild
retrocardiac
atelectasis persist. Stable position of the right PICC line.
## UGI SERIES
PRELIM READ:
No evidence of leak or obstruction; contrast
passes freely through esophagus and stomach. ? of antral ulcer.
## BRIEF HOSPITAL COURSE:
with h/o GI bleed ( ), L fem neck fx ( ), ETOH use
disorder, transferred from where she presented with acute
altered mental status and was found to have severe hyponatremia
(na 108), signs of neglect, transaminitis, malnutrition, and
hypotension.
# Hyponatremia: Serum sodium on arrival to 111, urine
sodium <20 and osmolality 210, indicating that this is an
appropriate dilution of her urine. In this patient the most
likely cause is poor diet/low dietary solute intake from not
eating food for 2 weeks and only drinking beer. Na eventually
improved to the 130s with improved PO intake and later diuresis
(see below). Would f/u sodium every few days, especially if
Lasix dose is adjusted.
# Hypoxia:
# Pneumonia:
Developed 4L oxygen requirement. CXR was unable to rule out
pneumonia and she was febrile with leukocytosis. She was treated
with CTX + doxy (not azithro given prolonged QTc). She was seen
by speech and swallow who recommended nectar thick liquids due
to likely aspiration but she adamantly refused. Patient also
has long standing smoking history and likely has underlying
emphysema. She needs outpatient followup with pulmonology.
# Decompensated congestive heart failure, diastolic, given
normal EF on ECHO: BNP greater than 1000 and she has pleural
effusions. She initially tolerated IV Lasix boluses, but she
developed signs of hypovolemia from this so she was transitioned
to low dose oral Lasix 10 mg. As she increases her oral intake,
Lasix dose can be increased. CXR does show improving pulmonary
edema and improving effusions.
## # NAUSEA/VOMITING:
Patient experienced some intermittent n/v in
the hospital. She initially told me that it had not been
occurring at home, but her husband states that it has been going
on for the past few months. She had a prior endoscopy which
she tells me showed "gastritis". Upper GI series here showed ?
of antral ulcer but no obstructive lesions. She was started on
high dose PPI and H pylori serum antigen sent and is pending at
the time of discharge. She is not inclined to have endoscopy
at this time, but is open to the idea of discussing at
outpatient hepatology f/u.
## # MALNUTRITION:
Severe, with albumin of 1.8, evidence of
anasarca on exam, Zn of 23, low vitamin D. She met with
nutrition, started on supplements, zn supplement started and MVI
given as well.
# Neglect/poor condition/concern for abuse
# Depression:
Presented with significant bruising, including hip, rib area.
Past L hip fracture. She denied any element of abuse or feeling
unsafe at home and stated that she falls a lot. She was found
covered in feces. Groin and buttock area with rash due to
maceration/likely pt wetting self in bed. Evaluation for
reversible causes of dementia was done (TSH, RPR, HIV) were
negative. Social worker spoke with her extensively. Patient is
defensive regarding her and her husband's alcohol use, does not
appear to recall her being found in squalor.
# Transaminitis
RUQUS was a limited study but was consistent with diffuse
hepatic steatosis. LFTs abnormalities were likely related to
alcohol ingestion prior to admission and resolved without
intervention. However, she has INR elevation to 1.6; this,
coupled with steatosis, ? of ascites on exam raises concern for
underlying cirrhosis. Hepatology followup scheduled.
## # URINARY RETENTION:
She had urinary retention, unclear
etiology, failed voiding trial in hospital. Would repeat
voiding trial at rehab in one week. Urology f/u made.
# EtOH use
Reportedly drinks 2 beers/day for the past month, but her
typical daily intake is beers a day. Her husband also
consumes alcohol with her. Has had withdrawal symptoms in the
past on admission at . She was tremulous
on initial exam but did not develop additional symptoms of
withdrawal. CIWA High dose IV thiamine, folate, and MVI were
started as above.
## TRANSITIONAL ISSUES:
1. PICC line left in place for lab draws; once blood draws are
not necessary, PLEASE REMOVE PICC LINE ASAP.
2. Needs close f/u with hepatology/urology.
3. If vomiting persists despite high dose PPI, please contact
her outpatient GI physicians to see if they will repeat
endoscopy.
4. Once she improves in regards to walking, rehabilitation and
is ready for d/c home, please consider involvement of SW,
protective services, given that her husband also appears to
drink and that she was found in squalor.
## MEDICATIONS ON ADMISSION:
Pt unable to report.
According to medication refill inquiry:
Recent refills:
Trazodone 50mg qhs
KCl 10meq
Furosemide 20mg daily
## DISCHARGE MEDICATIONS:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze
2. Mirtazapine 15 mg PO QHS
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Omeprazole 40 mg PO BID
5. Ramelteon 8 mg PO QHS:PRN insomnia
6. Vitamin D 1000 UNIT PO DAILY
7. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
## PRIMARY:
Hyponatremia
Pneumonia
Fall
Aspiration
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You came in after a fall. You were found of dangerously low
sodium levels. You were initially monitored in the ICU, and
your sodium levels were corrected.
You also developed a pneumonia and you were treated with
antibiotics. You were also given diuretics to help remove fluids
from your lungs. It is important that you attend your followup
appointments and that you stop drinking alcohol completely.
It was a pleasure taking care of you, and we're happy that you
are feeling better!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19104291", "visit_id": "27450533", "time": "2189-10-24 00:00:00"} |
11696876-RR-12 | 238 | ## FINDINGS:
Again seen is a fracture of the body of C2 with anterior displacement of the
fracture fragment and posterior displacement of C2 on C3. There is rotation
with posterior subluxation of the right C2 lateral mass on C3. These findings
are unchanged since the previous study. There is minimal sclerosis at the
fracture line, suggesting probable early healing, but there is no evidence of
osseous , and there remains several mm of distraction of the fracture
site. Again seen is anterior subluxation of C5 on C6 without evidence of
fracture. This is likely on a degenerative basis.
There are multiple hypodense foci in the vertebral bodies that may be related
to focal fat deposition or osteoporosis. The margins appear sclerotic, making
metastatic disease less likely. However, if the etiology of this finding is
unknown, correlation with an MR examination may be helpful.
There are minimal degenerative changes with left-sided facet osteophyte
formation greater than right, but no evidence of spinal canal or neural
foraminal compromise. Again incompletely imaged, there appears to be
enlargement of the thyroid gland, perhaps with nodules. If clinically
indicated, this may be further pursued with ultrasound.
## IMPRESSION:
Slight evidence of healing at the C2 fracture site, with continued distraction
of fragments, and posterior subluxation of C2 upon C3.
Multiple lucent lesions in the vertebral bodies as described above. MR of the
cervical spine may be helpful if further evaluation is indicated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11696876", "visit_id": "N/A", "time": "2133-10-30 08:31:00"} |
14228992-DS-3 | 1,307 | ## ALLERGIES:
Compazine / Allegra / Penicillins / Amoxicillin / morphine
## CHIEF COMPLAINT:
Left breast ca w/ lymph involvement
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Left axillary lymph node dissection
## HISTORY OF PRESENT ILLNESS:
is a very pleasant female who is status
post left breast total skin-sparing mastectomy with immediate
breast reconstruction with expander/implant placement with left
axillary sentinel node biopsy performed
. Her surgical pathology report showed
multiple foci of invasive lobular carcinoma, grade 2, withthe LV
I, ER positive, PR negative, HER-2 negative. Four sentinel
lymph nodes were identified and 1 lymph node had a
micrometastatic focus of carcinoma. Thus, she has a pathologic
stage P T1,N1, MIC M0 invasive lobular carcinoma. We discussed
performing a completion left axillary lymph node dissection.
Risks, benefits and alternatives of the aforementioned surgical
plan were discussed with the patient. She voiced understanding
and wished to proceed. She did sign informed consent for the
procedure.
## PAST MEDICAL HISTORY:
1. Right breast carcinoma with recurrence with oligometastatic
disease to the right femur as noted above.
2. Positive BRCA2 gene mutation status.
3. Osteopenia.
4. GERD.
5. Recurrent sinus infections.
6. Depression.
7. Left nose skin cancer.
## PAST SURGICAL HISTORY:
1. Right breast lumpectomy followed by mastectomy for
recurrence
as noted above.
2. Three left breast excisional biopsies, which the patient
reports have benign pathology. However, I do not have these
reports for my review at this time.
3. TAH/BSO in .
4. Excision of left nose skin cancer.
5. I and D of left neck abscess.
6. Facelift.
## FAMILY HISTORY:
1. Sister with breast cancer (age of ), negative BRCA
mutation.
2. Maternal aunt with breast cancer (age .
3. Father with breast cancer ( ), colon cancer.
4. Two paternal aunts with breast cancer (age .
5. Two paternal cousins breast cancer (age . One paternal
cousin positive for the BRCA2 gene mutation.
## CV:
RRR, nl S1 and S2
## PULM:
CTA b/l, no resp distress
## WOUND:
Left breast reconstruction well healing, left axillary
drain with serosanguinous fluid, well secured with sutures,
dressings clean and dry without evidence of hematoma or seroma.
## EXT:
No c/c/e, left upper extremity 2+ radial pulse,
strenght, sensation grossly intact, no swelling or lymphadema.
## BRIEF HOSPITAL COURSE:
The patient presented to pre-op on . Pt was
evaluated by anaesthesia and taken to the operating room for a
left axillary lymph node dissection
for surgical management of her left breast ca w/ lymph
involvement. There were no adverse events in the operating
room; please see the operative note for details. Pt was taken to
the PACU until stable, then transferred to the ward for
observation. The patient arrived on the floor on a diet as
tolerated with IVF and oral pain medications. The patient was
hemodynamically stable.
## NEUROLOGICAL:
Post-operatively, the patient had good pain
control on oral narcotics.
## CARDIOVASCULAR:
The patient was stable from a cardiovascular
standpoint; vital signs were routinely monitored.
## PULMONARY:
The patient was stable from a pulmonary standpoint;
early ambulation and incentive spirometry was encourage.
## GI/GU:
Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. She was also started on a bowel
regimen to encourage bowel movement. The patient voided
spontaneously after surgery.
## PROPHYLAXIS:
The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. The
incision site remained clean, dry and intact, with no signs of
infection or hematoma. There was a JP drain intact with serous
sanguineous output. The patient was discharged home in good
condition with for drain care.
## MEDICATIONS ON ADMISSION:
calcium, vitamin D, pepcid, lexapro, serax, multivitamin,
oxazepam
## DISCHARGE MEDICATIONS:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*30 Tablet(s)* Refills:*2*
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. oxazepam 10 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day) as needed for anxiety.
5. temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
6. hydromorphone 2 mg Tablet Sig: Tablets PO Q4H (every 4
hours) as needed for pain not relieved with tylenol .
Disp:*20 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Left Breast Cancer with Postive Lymph Node Involvement
Possible lymphoma of left breast nodes
## DISCHARGE INSTRUCTIONS:
You were admitted after undergoing a left axillary lymp node
dissection for management of your left breast cancer ans
suspcicious nodes. You are recovering well and ready for
discharge home.
1. Leave your left mastectomy/chest incision open to air. You
may cover with a clean, dry dressing daily if this is more
comfortable
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s)
times per day.
4. A written record of the daily output from your drain should
be brought to every follow-up appointment. Your drain will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower daily. No baths until instructed to do so by
Dr.
6. You may wear a soft, non-restrictive camisole but no tight or
underwire bras.
## ACTIVITY:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr.
## :
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
4. Take prescription pain medications for pain not relieved by
tylenol.
5. Take your antibiotic as prescribed.
6. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
7. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Call the office IMMEDIATELY if you have any of the following:
## 1. SIGNS OF INFECTION:
fever with chills, increased redness,
welling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14228992", "visit_id": "20193813", "time": "2139-05-06 00:00:00"} |
14623586-DS-23 | 537 | ## HISTORY OF PRESENT ILLNESS:
Asked to see this year old male who was transferred from
with concerns for an SBO. He was in his usual state of health
until 9am yesterday. He started having sharp, stabbing lower
abdominal pain that increased throughout the day. Pain became
this morning, so he presented to the ED. + bilious emesis
x
2. Last bowel movement 11pm on . No flatus x 24 hrs. He
denies fevers, chills, shortness of breath, or any urinary
symptoms. Reports he had a colonoscopy and biopsy in that showed Crohn's disease, however he is not on
medication. Denies hematemesis. Reports occasional bright red
blood in bowel movements, but none recently.
## PMH:
-Small bowel injury after motor vehicle colision
-Crohn's disease
-History of etoh and drug abuse
## PSH:
-Exploratory laparotomy, small bowel resection after motor
vehicle colision
-Splinting of right calcaneal fracture
-Repair of undescended testicle as a child
## PHYSICAL EXAM:
99.0 72 123/69 18 97% RA
A&O x 3, NAD, NGT in place draining 500 cc of brown,
feculent-appearing fluid
PERRL, EOMI, anicteric
RRR
CTAB
Abdomen soft, nontender, mildly distended, hypoactive bowel
sounds. Old midline laparotomy incision well healed. No
incisional or inguinal hernias appreciated
warm, no edema
## RECTAL:
guaiac +, no masses, normal tone
## BRIEF HOSPITAL COURSE:
The patient was transferred from the
on due to a small bowel obstruction in the mid
ileum with a dilated loop of bowel in the mid abdomen seen on CT
scan. The patient was subsequently admitted to the Acute Care
Service.
The patient was initially managed with intravenous fluids, a
tube to continuous suction and NPO status until a
repeat CT scan showed contrast flow through to the rectum.
Therefore, the tube was discontinued, the diet was
advanced sequentially to regular, and the abdominal exam
improved. At time of disharge the patient was passing flatus
and stool, voiding adequately and ambulating the hallways
independently.
## DISCHARGE INSTRUCTIONS:
You were admitted to the acute care surgery service for small
bowel obstruction which resolved with gastric decompression and
bowel rest.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
## GENERAL DISCHARGE INSTRUCTIONS:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any new
medications as prescribed.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Please also follow-up
with your primary care physician.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14623586", "visit_id": "23345707", "time": "2164-10-26 00:00:00"} |
13235606-DS-19 | 1,589 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Altered mental status + convulsion
## HISTORY OF PRESENT ILLNESS:
This is a woman with a history of anxiety/depression,
recent hospitalization for self-injurious behavior, recent life
stressors (broke up with boyfriend) and genital herpes who
presents to the ED as a referral from NP. Apparently, in the
midst of recent issues with poor mental health, she had been
recently doing well. She woke up this morning and felt that she
had no clear memory of the events of the past two days. She also
reported a poorly described headache, together with numbness in
the back of tongue. She could not remember if she had taken
any medications or had anything to eat or drink. She also
complained of "dizziness" without vertigo or lightheadednes.
NP referred to the ED.
Here, she was initially seen by the ED resident who found the
patient to be a little sleepy and slow to respond, but otherwise
largely well appearing. She provided the history above, and had
a nonfocal neurological examination. She was able to walk to the
bathroom and provide a urine sample for analysis. She appeared
to be answering questions reliably and appropriately. Psychiatry
had been consulted to address the possibility of this episode
being a possible dissociate state or fugue state. Several hours
into ED stay, she had a generalized convulsion which I
happened to observe from a distance. She was on the phone with
mother when all of a sudden, she started to yell and shake
all extremities rhythmically. voice undulated with the
shaking. This stopped spontaneously after and did not have
any lateralizing signs. Following the event, she was
administered IV ativan and she was sleepy and difficult to
arouse. Neurology was consulted.
When I returned an hour later, she was more arousable. She was
complaining of significant headache and malaise. She was
surprised to know that she had had a seizure. She once again
could not give me any details about the past two days. She
allowed me to obtain the phone number of friend
( ) and mother in ( ). noted
that the patient was doing well on (three days prior)
when in class (she is a student at the )
and did in fact call and speak with this morning and relayed
concerns. felt that she was having a panic attack.
mom relayed also that the patient has been calling home
everyday now for a few days, and psychiatric issues seem to
have improved somewhat in the recent few weeks. She denied any
history of brain/meninges infections or significant head trauma,
but did report that had one febrile seizure as a child.
was able to make colposcopy appointment two days
prior without difficulty, and the report from that appointment
does not note any abnormal behavior. did suspect that the
patient had perhaps overdosed on lamotrigine (prescribed for
mood): she reported that she has not been taking medications
recently because she ran out (?), although the referral from
NP did not raise these concerns.
Review of systems was negative for cough, chest pain or
congestion. She has been taking 50mg of benadryl at night to
help with poor sleep over the past two days.
## PAST MEDICAL HISTORY:
Notable for depression, anxiety, a
suicide
attempt (see recent ED Consult psychiatry note for more
details), herpes, positive pap smear with LG squamous
hyperplasia. Genital herpes.
## PAST SURGICAL HISTORY:
Notable for laparoscopy for pelvic pain,
adhesions were noted.
## FAMILY HISTORY:
Per mom, "2 of sisters are on because after a car
accident with head trauma, they both have seizures
## PHYSICAL EXAM ON ADMISSION:
ital signs were 98.2, 87, 104/72, 16, 98%. She is a thin young
woman who was lying on side in bed. She had limited
cooperation throughout the examination. Neck was supple, head
was NCAT. Chest examination was normal. Extremities were warm,
and without cyanosis. No lower extremity edema noted. No unusual
rashes noted.
Neurologically, she was sleepy but easy to arouse. She mostly
just preferred to stay asleep during the interview. She would
not answer simple orientation questions. She appeared to
comprehend my questions and responses were appropriate. She
followed commands. Pupils were large, equal and reactive. Eye
movements were full. Facial sensation and strength were
symmetric. Tongue was midline. Bilateral traps were . She was
able to provide full strength in all major muscle groups without
any asymmetry. Sensation was intact to light touch throughout.
Reflexes were symmetric and 2+ throughout with downgoing toes.
She refused to walk for my examination. Finger-nose was not
dysmetric.
## PHYSICAL EXAM ON DISCHARGE:
afebrile, normotensive
awake, alert, speech fluent
cranial nerve, motor, sensory exam normal
## LABS ON ADMISSION:
04:00PM WBC-12.9* RBC-4.64 HGB-13.8 HCT-43.7 MCV-94
MCH-29.6 MCHC-31.5 RDW-12.9
04:00PM PLT COUNT-336
04:00PM GLUCOSE-91 UREA N-8 CREAT-0.7 SODIUM-140
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12
04:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
03:50PM URINE UCG-NEGATIVE
03:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
03:50PM URINE COLOR-Yellow APPEAR-Clear SP
03:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
03:50PM URINE RBC-4* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-3
## IMAGING STUDIES:
EEG
This is an abnormal EEG due to the presence of bursts of
generalized discharges suggestive of a primary generalized
epilepsy, or a
frontal epilepsy with rapid electrographic spread. At times,
eye-blinking
may have occurred as a clinical correlate.
MRI brain w/ and w/o contrast
No evidence of mesial temporal sclerosis or cortical
malformation.
The ventricles are slightly prominent for age , likely a
developmental
variant, no obstructive lesion seen.
## BRIEF HOSPITAL COURSE:
woman with a history notable for depression with recent
life stressors and a short hospitalization for suicidal
act/behavior, who presented to college's NP for complaints
of headache, dizziness, numbness in tongue and the inability
to remember any events for the past two days.
# Neuro:
She woke up on morning of admission with "blood on bra" and
a tongue bite. She was confused upon waking up. Of note, she
took 4 tabs of Benadryl the night prior for insomnia. mother
and college friend report that she has been doing relatively
well recently, from a psychiatric standpoint. She has been going
to see therapist, and she has been taking a low dose of
lamotrigine for mood (25mg daily). While in the ED awaiting a
psychiatric consultation, she had a generalized convulsion
lasting approximately that spontaneously resolved and had no
obvious focal features. Following the event, she was sleepy and
slow to respond. neurological examination one hour after the
event identified no obvious focal features, but was largely
limited by poor cooperation on the part of the patient, in that
she was sleepy, nauseous and was complaining of headache. In
terms of risk factors for epilepsy, mother did report that
had one febrile convulsion as a child. After speaking
with mother, discovered that she was in a car accident many
years ago during which the car "flipped over 6 times." 2 of
sisters were also in the car and they now have seizures and are
on Keppra. and are unsure whether or not she hit
head at that time. Today, neuro exam is normal.
An EEG was obtained which showed generalized spike and wave
complexes that were frontally predominantly, having runs up to
10 seconds long with normal background. This is concerning for
a primary generalized epilepsy. MRI brain was wnl, no evidence
of mesial temporal sclerosis. Perhaps she had a seizure
provoked by large dose of Benadryl night prior as this lowers
seizure threshold. Discussed results with patient and mother
who were agreeable to starting an anti epileptic medication.
Started Keppra 500mg bid with plan to gradually uptitrate
Lamictal to AED dose and stop Keppra given psych history.
Increased Lamictal from 25mg qd to bid on discharge.
## # PSYCH:
Patient seen by psychiatry who recommend no medication
changes and that she continue to follow up with outpatient psych
providers. Do not feel she is a safety risk needing inpatient
psych hospitalization. Mom will stay with for the next
week, so feel that she is safe. She will continue to follow up
with outpatient providers.
## TRANSITIONS OF CARE:
- will follow up in neurology clinic
## MEDICATIONS ON ADMISSION:
OCPs, lamotrigine 25mg daily, ativan PRN.
## DISCHARGE MEDICATIONS:
1. ValACYclovir 500 mg PO Q24H
2. LaMOTrigine 25 mg PO BID
RX *lamotrigine [Lamictal] 25 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
3. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the hospital because you were confused at
home and then had a seizure in the emergency room. We did an
EEG to look at your brain waves which showed that you have a
seizure disorder or epilepsy. We started you on medications to
treat it. An MRI of your brain was done and was normal.
We have made the following changes to your medications:
START
Keppra 500mg twice per day
INCREASE lamictal to 25mg BID
On dicharge, please call to schedule an appointment with Drs.
in neurology clinic.
It was a pleasure taking care of you, we wish you all the best!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13235606", "visit_id": "24097994", "time": "2167-12-31 00:00:00"} |
13440918-RR-24 | 547 | CT OF THE ABDOMEN AND PELVIS, :
## HISTORY:
Right lower quadrant abdominal pain.
## ABDOMEN:
The lung bases are clear. The liver is normal in size and contour.
The patient status post cholecystectomy with metallic surgical clips seen at
the porta hepatis. The common extrahepatic duct measures 8 mm at the level of
the head of the pancreas, which is within normal limits status post
cholecystectomy. A 6 mm hypodensity seen just posterior to the left hepatic
vein branch in the lateral segment of the left lobe of the liver is unchanged
compared to . Just anterior to the ligamentum teres, a 1.5 x 1 cm well-
defined ovoid hypodensity in the liver is larger than seen in but has
been evaluated with ultrasound as a cyst with some internal echoes. It
measures approximately 20 Hounsfield units in density. Further inferiorly in
the right lobe of the liver (axial image 31), is a very vague 9 mm subcapsular
hypodensity which appears to represent an area of aberrant vascularity.
The pancreas and spleen are normal in appearance, though the tail of the
pancreas is somewhat obscured by isodense small bowel loops immediately
adjacent to it. The portal vein is patent. The abdominal aorta is not
dilated and shows no significant atherosclerotic plaque. The visceral
arteries are patent. No ascites or adenopathy is seen.
Evaluation of the kidneys shows a less than 4 mm hypodensity at the junction
of the cortex and medulla on the right laterally, possibly a simple cyst but
too small to accurately characterize. It was not seen in . On the left,
a 5 mm inferior pole hypodensity is unchanged compared to .
## PELVIS:
Oral contrast has reached through to distal colon at time of scanning
and this area of the cecum is well opacified showing normal appearance to the
terminal ileum. The appendix is not definitely identified, but there is a few
millimeters of soft tissue density adjacent to the medial wall of the cecum
inferiorly possibly, but not likely representing the appendix. There is no
inflammation in this area. The appendix is not identified even
retrospectively on the study. No fluid is seen in the pelvis.
There is stable asymmetry of lower rectus abdominus, thicker on the right. The
uterus and ovaries are absent. The urinary bladder is normal in appearance and
contrast opacifies the distal left ureter, but there is no contrast seen in
the distal right ureter at time of scanning. On axial images, 71, a less than
1 mm calcification is seen just proximal to the expected region of the right
ureterovesical junction, but this appears to be external to the ureter.
Bones are normal in appearance.
## CONCLUSION:
1. Hepatic hypodensities as described, the left lateral segment hypodensity
unchanged compared to , the anterior well-defined lesion slightly
increased but previously identified on ultrasound as nonsimple cyst and the
inferior most right lobe vague hyperdensity probably related to an area of
aberrent vascularity.
2. Small bilateral renal hypodensities unchanged on the left and too small to
accurately characterize on the right.
3. No definite abnormality to account for right lower quadrant pain. Note
minimal soft tissue density inferior medial cecum (3-4 mm) of unclear
significance, possibly non-inflamed appendix.
4. Status post hysterectomy and bilateral salpingo- oophorectomy.
4. Sable lower abdominal muscular asymmetry.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13440918", "visit_id": "N/A", "time": "2174-03-01 13:45:00"} |
10465643-DS-7 | 1,587 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Mr. is a year old gentleman with a history of
seizure disorder with a recent admission for who
presents with blood cultures notable for GPCs. He had a recent
hospitalization ( ) for s/p craniotomy and
resection of dural AVF, EVD placement, trach/PEG, with hospital
course complicated by UTI and lower extremity DVT treated with
heparin gtt with plan to transition to Coumadin. He was
discharged with a PICC line placed for access (for heparin gtt)
now transferred back from rehab after positive blood cultures
noted in bottles.
Infectious Disease was consulted via phone and they
recommended removing the PICC, reculturing and starting the
patient on Vancomcyn while awaiting speciation of the blood
cultures. This was communicated to the covering Physician at
who felt that it was in the patient's best
interest to be transferred to BI.
In the ED initial vitals were: 98.6 HR 100 BP 124/86 RR 16 96%
RA
- Labs were significant for WBC 12.6 Hct 34.9 Plt 179. Lactate
1.0. INR 1.3. Normal chemistry panel. UA notable for large leuk
est, negative blood, negative nitrite, WBC 109, bacteria few,
Epi 0.
- Patient was given Vancomycin 1 g, 1L NS, and started on a
heparin gtt. Ceftriaxone ordered but not given prior to
transfer.
- He was seen by neurosurgery in the ED who noted that there are
no acute neurosurgical issues at this time.
Vitals on transfer: 98.3 143/94 96 20 97% RA
On the floor, he is comfortable and without complaints.
## REVIEW OF SYSTEMS:
Endorses sense that his UTI "is not fully
treated," though cannot describe symptoms due to word finding
difficulties. Denies headache, vision changes, numbness,
tingling, congestion, sore throat, cough, dyspnea, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia.
## PMHX:
Subarachnoid Hemorrhage
Left Temporal Intraparenchymal Hemorrhage
Seizure disorder (last seizure was years ago).
Hypertension
Sleep apnea
Tetanus
Kidney stones
## PSH:
Angiogram for embolization and L craniotomy with
resection of dural AVF
R EVD
Trach and PEG
## FAMILY HISTORY:
Denies knowledge of any family medical conditions.
## GENERAL:
Lying in bed in NAD
## HEENT:
AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
thrush on tongue, good dentition
## NECK:
nontender supple neck, no LAD, no JVD
## CARDIAC:
RRR, S1/S2, no murmurs, gallops, or rubs
## LUNG:
CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
## ABDOMEN:
nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. PEG in place, c/d/i.
## EXTREMITIES:
no cyanosis, clubbing or edema, moving all 4
extremities with purpose
## PULSES:
2+ DP pulses bilaterally
## NEURO:
CN II-XII intact, strength in the upper and lower
extremities bilaterally, sensation grossly intact. Oriented to
self but not hospital or date. Severe word finding difficulties
and occasional garbled speech
## SKIN:
Erythema surrounding previous trach site
## GENERAL:
Obese gentleman lying in bed, appears comfortable
## HEENT:
AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
thrush on tongue, good dentition
## NECK:
Supple, no LAD, no JVD
## CARDIAC:
RRR, S1/S2, no murmurs, gallops, or rubs
## LUNG:
CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
## ABDOMEN:
Nondistended, +BS, nontender, no rebound/guarding, no
hepatosplenomegaly. PEG in place with overlying dressing, c/d/i.
## EXTREMITIES:
No cyanosis, clubbing or edema, moving all 4
extremities with purpose
## PULSES:
2+ DP pulses bilaterally
## NEURO:
Oriented to self and "hospital." Word finding
difficulties and occasional garbled speech. CN II-XII intact,
strength in the upper and lower extremities bilaterally,
sensation grossly intact.
## SKIN:
Erythema surrounding previous trach site, no induration or
drainage, nontender.
## MICROBIOLOGY:
Blood Culture, Routine (Final :
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
OF TWO COLONIAL MORPHOLOGIES.
Aerobic Bottle Gram Stain (Final :
Reported to and read back by . ON AT 2300.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final :
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
## 9:00 PM CATHETER TIP-IV SOURCE:
PICC line.
WOUND CULTURE (Final : No significant growth.
## URINE CULTURE (FINAL :
NO GROWTH.
Blood cultures from , and pending
## TTE :
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are mildly thickened. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. Physiologic
mitral regurgitation is seen (within normal limits). No masses
or vegetations are seen on the tricuspid valve, but cannot be
fully excluded due to suboptimal image quality. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
## IMPRESSION:
Limited study. No vegetations or
clinicall-significant regurgitant valvular disease seen.
## CXR :
PA and lateral views of the chest provided. A right upper
extremity PICC line is again seen with its tip extending into
the low SVC. Lung volumes are somewhat low without focal
consolidation, effusion or pneumothorax. Cardiomediastinal
silhouette is stable. Bony structures are intact. No free air
below the right hemidiaphragm is seen.
## BRIEF HOSPITAL COURSE:
Mr. is a gentleman with a history of
seizure disorder and recent admission for /IPH s/p craniotomy
who presents with GPC bacteremia.
## # GPC BACTEREMIA:
Patient was called back to the hospital after
cultures from site (drawn on last admission as part
of infectious work-up for persistent tachycardia) grew GPCs in
bottles; bottles drawn peripherally from the same day
showed no growth to date. He was asymptomatic, vital signs were
stable, and leukocytosis resolved (though WBC increased to 12.3
on discharge). PICC was removed. Patient was started on
vancomycin, but this was discontinued after speciation returned
coag-negative staph as this was thought to represent a
contaminant. A TTE revealed no evidence of vegetation. Daily
surveillance blood cultures showed no growth to date.
## # UTI:
Patient was continued on ceftriaxone for a UTI (started
on , which was switched to cefpodoxime on discharge.
Urine culture sent on admission was negative (but this was in
the setting of 2 days of antibiotics). Patient should continue
cefpodoxime through to complete a 7 day course for
complicated cystitis.
## # DVT:
Patient's recent hospital course was complicated by RLE
DVT. He was started on heparin as a bridge to Coumadin during
his last admission (Coumadin 5 mg daily was started on .
Patient was continued on a heparin gtt, which was switched to
Lovenox on day prior to discharge. INR was therapeutic on
discharge so Lovenox was discontinued.
## # SINUS TACHYCARDIA:
Patient's last hospital course was notable
for sinus tachycardia, possibly related to autonomic
dysfunction. CTA had showed no evidence of pulmonary embolism.
Patient was continued on metoprolol during this admission and
heart rate was .
## # HYPERGLYCEMIA:
Patient was put on a Humalog sliding scale for
hyperglycemia. Blood sugars were well-controlled. (Patient had
been discharged on NPH with a regular insulin sliding scale
during his last admission, likely in the setting of tube feeds.)
## # S/P SAH/IPH:
Patient has residual expressive aphasia and mild
dysarthria from his SAH. He was evaluated in the ED by
neurosurgery, who believed that he remained neurologically
stable (neuro exam unchanged from discharge). Patient will
follow-up with neurosurgery as scheduled in .
## TRANSITIONAL ISSUES:
[ ] Patient should continue cefpodoxime through (give
one dose tonight and last dose tomorrow morning)
[ ] Patient was continued on Coumadin 5 mg daily and INR was
therapeutic on discharge (2.4).
[ ] Patient's blood sugar was well-controlled on a Humalog
sliding scale. Please continue to monitor.
[ ] Patient was started on tamsulosin but failed a voiding trial
so Foley was reinserted.
[ ] was 12.3 on discharge. Recommend rechecking CBC in one
week to ensure resolution of leukocytosis.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. LaMOTrigine 200 mg PO BID
5. Valsartan 320 mg PO DAILY
6. Senna 17.2 mg PO QHS
7. Nystatin Oral Suspension 5 mL PO QID
8. LeVETiracetam Oral Solution 1000 mg PO BID
9. Acetaminophen 650 mg PO Q6H:PRN pain/fever
10. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheeze
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
12. Docusate Sodium 100 mg PO BID
13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
14. Glucose Gel 15 g PO PRN hypoglycemia protocol
15. OxycoDONE Liquid mg PO Q4H:PRN pain
16. Warfarin 5 mg PO DAILY16
17. CeftriaXONE 1 gm IV Q24H
18. Metoprolol Succinate XL 150 mg PO DAILY
## DISCHARGE DIAGNOSIS:
Primary diagnoses:
Coagulase-negative staphylococcus bacteremia
Urinary tract infection
Secondary diagnoses:
Deep vein thrombosis
Tachycardia
Hyperglycemia
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure taking care of you during your stay at .
You were admitted because bacteria was growing in your blood.
You were started on antibiotics but these were stopped after the
bacteria was thought to be a contaminant (not harmful). You
remained clinically stable without symptoms and it was
determined that you were safe to return to rehab. Please
continue to take your medications as prescribed and keep your
follow-up appointments.
Sincerely,
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10465643", "visit_id": "26231639", "time": "2169-02-01 00:00:00"} |
16199313-RR-6 | 402 | ## INDICATION:
yo s/p oocyte retrieval on and culdocentesis on
admitted with OHSS and SOB.// Please eval for PE, pleural effusion
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4
mGy-cm.
2) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 10.6 mGy (Body) DLP =
2.1 mGy-cm.
3) Spiral Acquisition 3.7 s, 24.1 cm; CTDIvol = 7.5 mGy (Body) DLP = 175.9
mGy-cm.
4) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4
mGy-cm.
5) Stationary Acquisition 2.0 s, 0.2 cm; CTDIvol = 26.5 mGy (Body) DLP =
5.3 mGy-cm.
6) Spiral Acquisition 3.9 s, 25.1 cm; CTDIvol = 7.4 mGy (Body) DLP = 181.1
mGy-cm.
Total DLP (Body) = 367 mGy-cm.
## FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
Central filling defect is identified in the right pulmonary artery extending
into the right lower lobe superior segmental pulmonary artery (12:36),
concerning for pulmonary embolus. A separate pulmonary embolus is identified
in right upper lobe posterior segmental pulmonary artery (12:23). Additional
multiple pulmonary emboli are identified in the segmental and subsegmental
arteries of the right lower lobe (13:88, 91), right middle lobe (13:83) and in
multiple left lower lobe superior segmental arteries (13:65, 102, 104).
The main and right pulmonary arteries are normal in caliber, and there is no
evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Trace left pleural effusion is
noted.
Platelike right lower lobe opacity measuring 3.7 x 0.8 cm is suspicious for
pulmonary infarct (12:45). Atelectasis in bilateral lower lobes are mild.
the airways are patent to the segmental level.
Limited images of the upper abdomen is notable for small to moderate ascites..
No lytic or blastic osseous lesion suspicious for malignancy is identified.
## IMPRESSION:
1. Multifocal pulmonary embolism, involving right pulmonary artery, multiple
segmental arteries of right upper, middle, and lower lobes, and left lower
lobe.
2. Platelike right lower lobe opacity is suspicious for pulmonary infarct.
3. Small to moderate ascites.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16199313", "visit_id": "23859596", "time": "2121-03-27 04:00:00"} |
18690929-RR-15 | 97 | ## INDICATION:
History: with knee pain after fall// eval for fracture
## FINDINGS:
Exam is limited as the patient was unable to straighten the knee. A
comminuted fracture involving the mid patella is demonstrated with distraction
of fracture fragments by approximately 5 cm and evidence of a fat fluid level
within the ventral aspect of the knee compatible with lipohemarthrosis. No
dislocation is seen on the provided views. There are no concerning lytic or
sclerotic osseous abnormalities. Ventral soft tissue swelling about the knee
is noted.
## IMPRESSION:
Comminuted and distracted fracture of the patella with associated
lipohemarthrosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18690929", "visit_id": "28647447", "time": "2157-10-28 09:42:00"} |
19712945-RR-19 | 86 | ## EXAMINATION:
CT T-SPINE W/O CONTRAST Q321 CT SPINE
## INDICATION:
female restrained passenger in the back seat in a
motor vehicle accident with tenderness over the thoracic spine. Evaluate for
fracture.
## FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling. There is no evidence of infection or neoplasm. The partially
visualized lungs are unremarkable.. The partially visualized bilateral
kidneys are unremarkable.
## IMPRESSION:
No fracture or malalignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19712945", "visit_id": "N/A", "time": "2118-09-06 14:25:00"} |
15999575-DS-21 | 2,075 | ## CHIEF COMPLAINT:
Chest pain and fatigue
## HISTORY OF PRESENT ILLNESS:
year old gentleman with ischemic heart disease, HFpEF (ECHO
w/ EF >60%), poorly controlled T1DM, stage IV CKD, TBI, and
chronic pain syndrome presenting with chest pain and fatigue.
In the ED the patient endorsed substernal chest pain radiating
to the arm, relieved by sublingual nitroglycerin. The pain is on
the right side of his chest, radiating to the right shoulder.
The pain has been occuring intermittently since , and
nitroglycerin sometimes helps his pain. Also has been
complaining of pain in back, abdomen and legs.
The patient also endorses nausea, and a fever to 100.0 that
resolved on its own 5 days ago. His blood sugars have also been
elevated to 1000 recently and he has been using his sliding
scale insulin to
adjust.
He also c/o recent difficulty swallowing over the past two
months. He lost 15 lbs a few weeks ago when he was in jail and
was not being properly taken care of. Since returning home he
has gained weight. He also reports that while in jail he was
taken to an OSH for chest pain where he was found to have a "bad
infection," and it is unclear what diagnosis was made. Also
reports having been treated for a leg infection during this
time.
He also c/p increasing abdominal pain exacerbated by eating, and
muscle pain secondary to increased exertion as he has been
packing for an upcoming move.
Of note, the patient was last admitted in for chest pain.
During this admission, Tn were negative x2, and his pain
was managed with morphine. Sublingual nitro and nitroglycerin
derivatives were held given concerns for hypotension. His blood
sugars were also difficult to control and was consulted.
In the ED initial vital signs: 97.6 72 127/65 99% RA. Labs were
notbale for wbc 7.3, H/H 12.7/36.6 (near recent baseline), BUN
87, Cr 2.5 (baseline 2.4-2.9) Tn 0.03, lactate 0.9, ALT 42, AST
25, Alkp 198, T bili 0.2, Lip 15, BNP 372.
A CXR showed no acute cardiopulmonary abnormality. A CT A/P
preliminary report showed moderate fecal loading, no
appendicitis, and irregularity/sclerosis at the L4/L5 levels. A
CT head prelim read showed no acute abnormality.
An EKG showed sinus rhythm, ventricular rate of 67 bpm, normal
axis, T wave flattening in III, no significant ST depressions or
elevations, unchanged prior. The patient received aspirin,
morphine, and insulin, and was admitted to the floor.
Cardiac workup on the floor notable for neg trops, stable on
telemetry.
On the floor, the patient's c/o chest, abdominal, leg, back
pain. He states that though he is on a sliding dose of Torsemide
depending on his weight, he has been taking 20mg daily. Of
note, the patient carries a diagnosis of chronic pain on
methadone.
Hospital course also notable for FSBG 40, patient was noted to
be somnolent. He received dextrose with increase in FSBG to
300s. He remained somnolent, but had recently received IV
morphine. Subsequently his mental status improved without
incident.
Given likely noncardiac nature of pain he was transferred to the
general medicine service for further management.
## PAST MEDICAL HISTORY:
HLD
HTN
H/O stent placement
Heart failure with preserved EF
Traumatic brain injury in
Chronic kidney injury
GERD
Chronic pain syndrome
Hypothyroidism
Seizure disorder
Substance misuse
Chronic back pain status post L4-L5 laminectomy
Degenerative joint disease
Peripheral vascular disease
Status post multiple hip fractures requiring surgeries
Right wrist fracture in
## FAMILY HISTORY:
Mother has diabetes .
## GENERAL:
NAD, alert, oriented, fatigued
## HEENT:
AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva
## NECK:
nontender supple neck, no LAD
## CARDIAC:
RRR, S1/S2, no murmurs, gallops, or rubs
## LUNG:
CTAB, decreased breath sounds however no wheezes, rales or
rhonchi appreciated
## ABDOMEN:
some TTP around umbilical region, nondistended, +BS, no
rebound or guarding
## EXTREMITIES:
no cyanosis, clubbing or edema, moving all 4
extremities with purpose, bilateral fingers are contracted
## SKIN:
warm and well perfused, 2x2 cm wound on patient's head
with some blood but no active bleeding.
## GENERAL:
Sittin up eating breakfast in NAD.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
## NECK:
Supple without appreciable JVP.
## CARDIAC:
PMI located in intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Tender to palpation on R side of chest.
## ABDOMEN:
Soft, NTND. Mildly distended. Diffusely tender to
palpation. Abd aorta not enlarged by palpation.
## EXTREMITIES:
No c/c/e. LUE av fistula with thrill
## PULSES:
2+ radial pulses b/l
## SKIN:
Contractures noted in bilateral fingers. Tender indurated
hypopigmented nodules noted over the skin, prominent on lower
extremities. Areas of prior superficial bleeding / excoriation
noted over scalp and abdomen.
## IMAGING:
Blateral hand, 3 views:
The study is limited by patient in ability to extend the
fingers. Severe contractures are visualized bilaterally, with
flexion deformities at the proximal and distal interphalangeal
joints. This is most marked in the third fourth and fifth
phalanges bilaterally is but also present in the first and
second phalanges. It is difficult to assess the joint spaces due
to the hand positioning.
## CT HEAD:
1. New area of encephalomalacia involving the anterior and
inferior aspect of the left temporal lobe as described in detail
above, suggestive of sequela of prior insult from stroke or
trauma, please correlate.
2. There is no evidence of acute intracranial hemorrhage.
3. Slightly prominent ventricles and sulci for the patient's
age.
## CT ABD/PELVIS WITHOUT CONTRAST:
1. Moderate fecal loading without evidence of obstruction.
2. Tiny appendicolith within an otherwise normal appendix. No
appendicitis.
3. Endplate irregularity and sclerosis at the L4-L5 level
crossing the disc space. Findings of discitis and osteomyelitis
at this level were already noted on the prior MR dated , and now appears progressed, but chronicity is
indeterminate. Clinical correlation is recommended and if
indicated, MRI could be considered.
CXR:
No acute cardiopulmonary abnormality.
ECG:
Sinus rhythm with baseline artifact. Possible left atrial
abnormality. Slow R wave progression in leads V1-V2 which is
non-diagnostic. Compared to the previous tracing of no
diagnostic change.
IntervalsAxes
## BRIEF HOSPITAL COURSE:
Mr. is a year old gentleman with ischemic heart
disease, last EF on echo >60%, poorly controlled type
1 diabetes, stage IV CKD, TBI, and chronic pain syndrome
presenting with diffuse pain and fatigue.
# Skin findings:
He had subtle scattered tender nodules which raised concern for
dermatologic etiology of his chronic pain. He was evaluated by
dermatology service. There was low suspicion for scleroderma or
dermatomyositis but given severity of symptoms, laboratory
workup was sent. Unlikely calciphylaxis given unremarkable
Ca/Phos product. Scl70, aldolase and anti-centromere ab pending
at time of discharge.
# Chest Pain:
He presented with right sided chest pain with radiation to right
arm. Trops inconclusive given CKD. EKG unchanged. His pain was
felt to be unlikely cardiac in origin. Continued aspirin,
plavix, and rostuvastatin. Also continued home methadone and
Imdur.
# Chronic heart failure with preserved EF:
Appeared euvolemic on exam. No evidence of pulmonary edema on
CXR. Continued torsemide daily. Given polyuria in the setting of
intermittent hyperglycemia, fluid restriction was relaxed during
his admission.
# Abdominal Pain:
Patient endorsed abdominal pain exacerbated by eating. He does
have a hx of GERD on a PPI and carafate. CT A/P showed no acute
process, but some fecal loading. No leukocytosis or abscess on
CT concerning for infection. He was given bowel regimen for
constipation with senna/colace/miralax. Home carafate and PPI
were continued.
# Weakness:
Patient complained of new weakness. Still able to ambulate.
States that his weakness may be associated with increased
exertion due to a lot of packing recently in preparation for a
move as he has decreased resources. He had head CT without new
acute process, but demonstrating encephalomalacia which per
neurology was consistent with known history of TBI.
# Type 1 DM:
Has difficult to control blood sugars requiring consult
in the past. Recent home FSBG have been elevated. He is able to
recount his insulin regimen. He had episode of hypoglycemia to
41, and was subsequently hyperglycemic. was consulted
for management of labile FSBGs.
# ESRD not on HD, s/p AVF placement:
Cr at recent baseline. No urgent indication for dialysis during
current admission.
# Depression/Anxiety:
Continued home sertraline and alprazolam.
# Chronic pain syndrome:
The patient's chronic pain syndrome has been managed by an
outside
pain center. Continued home methadone/gabapentin
## TRANSITIONAL ISSUES:
- He had CT abdomen/pelvis demonstrating endplate irregularity
and sclerosis at the L4-L5 level, progressed from prior. CRP was
0.5 suggesting no active discitis/osteomyelitis. This finding
may be further investigated by MRI if indicated in the
outpatient setting.
- He will need close management of his labile type 1 diabetes.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO QPM
3. Glargine 20 Units Bedtime
NPH 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Klor-Con M20 (potassium chloride) 1 tab oral TID:PRN only if
taking Torsemide
5. Terbinafine 1% Cream 1 Appl TP BID
6. ProAir HFA (albuterol sulfate) Puffs inhalation TID:PRN
wheeze, SOB
7. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
EVERY OTHER WEEK
8. ammonium lactate 12 % topical DAILY:PRN dry skin
9. Clopidogrel 75 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Gabapentin 600 mg PO TID
12. Ferrous Sulfate 325 mg PO BID
13. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
14. Levothyroxine Sodium 112 mcg PO DAILY
15. Lorazepam 1 mg PO BID:PRN anxiety
16. Methadone 10 mg PO QID
17. Nitroglycerin SL 0.4 mg SL PRN chest pain
18. Omeprazole 20 mg PO BID
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Sertraline 150 mg PO DAILY
21. Sucralfate 1 gm PO TID
22. Tamsulosin 0.4 mg PO QHS
23. Torsemide 20 mg PO DAILY:PRN wt >183 lbs
24. TraZODone 150 mg PO QHS:PRN insomnia
25. urea 40 % topical DAILY
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Gabapentin 600 mg PO TID
5. Glargine 20 Units Bedtime
NPH 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Lorazepam 1 mg PO BID:PRN anxiety
9. Methadone 10 mg PO QID
10. Omeprazole 20 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Rosuvastatin Calcium 20 mg PO QPM
13. Sertraline 150 mg PO DAILY
14. Sucralfate 1 gm PO TID
15. Tamsulosin 0.4 mg PO QHS
16. Torsemide 20 mg PO DAILY:PRN wt >183 lbs
17. TraZODone 150 mg PO QHS:PRN insomnia
18. ammonium lactate 12 % topical DAILY:PRN dry skin
19. Ferrous Sulfate 325 mg PO BID
20. Klor-Con M20 (potassium chloride) 1 tab oral TID:PRN only if
taking Torsemide
21. Nitroglycerin SL 0.4 mg SL PRN chest pain
22. ProAir HFA (albuterol sulfate) Puffs inhalation TID:PRN
wheeze, SOB
23. Terbinafine 1% Cream 1 Appl TP BID
24. urea 40 % topical DAILY
25. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
EVERY OTHER WEEK
## PRIMARY DIAGNOSIS:
Chest pain, chronic pain
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to with diffuse pain and chest pain. We
investigated the cause of your pain and fortunately did not find
any concerning causes like a heart attack that require treatment
at this time. Therefore, it is safe to you to be discharged.
Your blood sugars were difficult to control while you were
hospitalized. We consulted your team (Dr. who
recommended that you continue the regimen we have been using in
the hospital for you as detailed in your medication worksheet.
Even though your blood sugars have been high, Dr.
not to change your regimen at this time to ensure you do
not get too low. Please call him tonight as planned to ensure
your blood sugars are controlled.
Sincerely,
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15999575", "visit_id": "29579273", "time": "2138-11-03 00:00:00"} |
14067009-RR-85 | 100 | ## INDICATION:
year old woman with ARDS, RLL pna, intubated at 330am //
patient was just intubated, check tube position
## FINDINGS:
AP upright portable chest radiograph demonstrates interval placement of an
endotracheal tube. This appears approximately 2.5 cm above the level of the
carina. Bilateral opacities, right greater than left, are perihilar in
distribution, not significantly changed. Bilateral pleural effusions, left
greater than right are noted. Cardiac borders are obscured. There is no
pneumothorax.
## IMPRESSION:
Endotracheal tube terminates 2.5 cm above the level of carina. Patient
appears to be looking down and endotracheal tube is probably appropriately
positioned.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14067009", "visit_id": "29103179", "time": "2150-05-20 03:35:00"} |
13311285-DS-17 | 937 | ## ALLERGIES:
Bactrim / Diprivan / Morphine / Penicillins / Tetracycline /
Hibiclens / Terazol 7 / Dilaudid / flu shot / ketamine / tape
placed over betadine
## CHIEF COMPLAINT:
low back and groin pain
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Posterior revision fusion L4-Ilium
## HISTORY OF PRESENT ILLNESS:
Mrs. presented to Dr. office with complaints of
low back and groin pain. After review of the patients history
and physical examination in the office, as well as radiographic
studies, it was determined they would be a good candidate for
posterior revision fusion from L4-ilium. The patient was in
agreement with the plan and consent was obtained and signed.
## PAST MEDICAL HISTORY:
scoliosis, bronchitis, rheumatoid arthritis, osteoarthritis, s/p
cervical laminectomy/fusion
left knee scope, left heel skin graft, LEFT achilles tendon
replacement, C3-C5 cervical laminectomy, TAH-BSO, cataract
removal
## PHYSICAL EXAM:
On examination the patient is well developed, well nourished,
A&O x3 in NAD. AVSS.
Range of motion of the lumbar spine is somewhat limited on
flexion, extension and lateral bending due to pain.
Ambulating well with the assistance of a walker.
A lumbar corset brace is used for support when OOB.
Gross motor examination reveals good strength throughout the
bilateral lower extremities.
There is no clonus present.
Sensation is intact throughout all affected dermatomes.
The posterior lumbar incision is clean, dry and intact without
erythema, edema or drainage.
The patient is voiding well without a foley catheter.
## PERTINENT RESULTS:
05:40PM BLOOD WBC-9.7 RBC-3.63* Hgb-10.1* Hct-30.4*
MCV-84 MCH-27.9 MCHC-33.3 RDW-14.9 Plt
05:40PM BLOOD Plt riefly, the patient was admitted to the Spine Surgery
Service and taken to the Operating Room on for posterior
revision and fusion L4-ilium. Refer to the dictated operative
note for further details. The surgery was performed without
complication, the patient tolerated the procedure well, and was
transferred to the PACU in a stable condition. TEDs/pneumoboots
were used for postoperative DVT prophylaxis. Intravenous
antibiotics were continued for 24hrs postop per standard
protocol. Initially, postop pain was controlled with a fentanyl
PCA (allergy to diluadid and morphine). Diet was advanced as
tolerated. The patient was transitioned to oral meperidine for
pain when tolerating PO diet. Foley was removed on POD#2 and
the patient was voiding well. Post-operative labs were grossly
stable. A hemovac drain that was placed at the time of surgery
was also removed on POD#2. Physical therapy was consulted for
mobilization OOB to ambulate. A lumbar corset brace was fitted
for the patient. Hospital course was otherwise unremarkable. On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Estrogens Conjugated 0.425 mg PO DAILY
2. Mobic (meloxicam) 155 mg oral qd
3. Xyzal (levocetirizine) 5 mg oral qd
4. levothyroxine 75 mcg oral qd
5. Hydroxychloroquine Sulfate 200 mg PO DAILY
6. Gabapentin 600 mg PO QID
7. Meladox (melatonin) 6 mg oral 2 tab hs
8. Cyanocobalamin 50 mcg PO DAILY
9. Spironolactone 50 mg PO 2 TAB QD
## DISCHARGE MEDICATIONS:
1. Gabapentin 600 mg PO QID
2. Acetaminophen 650 mg PO Q4H:PRN fever, pain
3. amitriptyline-chlordiazepoxide 12.5-5 mg oral QID
4. Betamethasone Valerate 0.1% Cream 1 Appl TP TID rash
5. DiphenhydrAMINE mg PO Q6H:PRN itching
6. Meperidine 50 mg PO Q4H:PRN pain
7. Docusate Sodium 100 mg PO BID
8. Cyanocobalamin 50 mcg PO DAILY
9. Estrogens Conjugated 0.425 mg PO DAILY
10. Hydroxychloroquine Sulfate 200 mg PO DAILY
11. levothyroxine 75 mcg oral qd
12. Meladox (melatonin) 6 mg oral 2 tab hs
13. Spironolactone 50 mg PO 2 TAB QD
14. Xyzal (levocetirizine) 5 mg oral qd
15. Mobic (meloxicam) 155 mg oral qd
## ACTIVITY:
DO NOT lift anything greater than 10 lbs for 2 weeks.
times a day you should go for a walk for minutes as
part of your recovery. You can walk as much as you can tolerate.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
## BRACE:
You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
## WOUND:
Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
## MEDICATIONS:
You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at Spine
Specialists, . We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery.
Posterior revision fusion L4-Ilium
## ACTIVITY:
Out of bed w/ assist
Thoracic lumbar spine: when OOB
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13311285", "visit_id": "23488614", "time": "2185-05-03 00:00:00"} |
17444901-RR-19 | 97 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## BLEED? HISTORY:
with headache, altered mental status //
bleed?
## FINDINGS:
There is no evidence of infarction, hemorrhage, edema, mass effect, midline
shift. The ventricles and sulci are prominent likely due to atrophy. There is
an old right frontal burr hole. There is mucosal thickening in the ethmoid air
cells and maxillary sinuses. The sphenoid sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable. Coils causing
artifact anterior to the pons, limiting assessment.
## IMPRESSION:
No acute intracranial hemorrhage or mass effect within the limitations of
artifacts
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17444901", "visit_id": "N/A", "time": "2134-01-04 03:04:00"} |
16582674-RR-68 | 546 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
year old woman with loculated pleural effusion, ongoing Afib
// Eval effusion and r/o bowel ischemia/infectious source
## SINGLE PHASE CONTRAST:
MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.1 s, 67.2 cm; CTDIvol = 15.8 mGy (Body) DLP =
1,059.7 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 4.8 s, 0.5 cm; CTDIvol = 26.9 mGy (Body) DLP =
13.4 mGy-cm.
Total DLP (Body) = 1,075 mGy-cm.
## LOWER CHEST:
Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no suspicious focal lesion. There is mild-to-moderate intrahepatic
biliary dilatation. The common bile duct is dilated measuring 1.4 cm. The
gallbladder is surgically absent.
## PANCREAS:
The pancreas is atrophic, without evidence of focal lesions. There
is no pancreatic ductal dilatation or peripancreatic stranding.
## SPLEEN:
The spleen is enlarged measuring 13.4 cm. Normal size and attenuation
throughout, without evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions. Left renal cyst measuring 1.5 cm
with fluid fluid level likely a hemorrhagic cyst (series 2, image 57).
Additional cysts subcentimeter cysts, too small to characterize. There is no
perinephric abnormality. There is no hydronephrosis or hydroureter.
Intraluminal air within the bladder likely due to previous catheterization.
## GASTROINTESTINAL:
A gastrostomy tube is noted which is unremarkable. Small
bowel loops demonstrate normal caliber, wall thickness, and enhancement. The
colon and rectum are within normal limits. There is thickening of the
descending colon consistent with colitis. A rectal tube is noted.
-----
appendix
-----
## PELVIS:
There is no free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
There is an enlarged, fibroid uterus. No adnexal
abnormality is seen.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy.
There is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
The major branches off the abdominal aorta are patent the limits of
this portal venous phase study. Moderate atherosclerotic disease is present.
There is no abdominal aortic aneurysm.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
rods are noted from T10-L1.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits. Edema in
the surrounding soft tissues of the abdominal wall.
## IMPRESSION:
1. Wall thickening of the descending colon consistent with colitis.
Differential includes infectious, inflammatory and ischemic causes.
2. Unremarkable gastrotomy tube. No evidence of discrete fluid collection in
the abdomen or pelvis.
3. Dilated common bile duct measuring up to 1.4 cm with mild-to-moderate
intrahepatic biliary duct dilation. Status post cholecystectomy.
4. Splenomegaly
5. Please see dedicated CT of the chest for thoracic findings.
## NOTIFICATION:
The findings were discussed with , M.D. by ,
M.D. on the telephone on at 4:06 pm, 5 minutes after discovery of
the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16582674", "visit_id": "26691544", "time": "2126-07-27 13:52:00"} |
18305480-RR-78 | 112 | ## REASON FOR EXAMINATION:
Hemoptysis with history of recent pneumonia.
PA and lateral upright chest radiographs were reviewed in comparison to obtained 08:40 a.m. and .
Heart size is normal. Left retrocardiac opacity is persistent, potentially
may be slightly increased. This opacity in part may reflect the neo-esophagus
and overall appears to be unchanged since . There is
questionable potential slight additional opacity that might reflect interval
development of aspiration or pneumonia, but in the absence of patient's
symptoms most likely reflects changes in the distention of the neo-esophagus.
Left upper lung nodular relatively dense opacity, unchanged since multiple
prior studies, represents rib abnormality, benign, most likely fibrodysplasia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18305480", "visit_id": "23736124", "time": "2172-04-17 17:21:00"} |
11896259-RR-108 | 106 | ## EXAMINATION:
DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
## INDICATION:
year old man s/p DDLT// evaluate line Contact name: ,
## IMPRESSION:
As compared to the previous radiograph, the patient is now intubated. The tip
of the endotracheal tube projects approximately 4.5 cm above the carinal. The
patient has also received a right-sided Swan-Ganz catheter. The tip of the
catheter projects over the outflow tract of the right ventricle. The feeding
tube shows a normal course but the tip is not included on the image. No
pleural effusions but signs of mild pulmonary edema are present. Mild
cardiomegaly. No pneumonia. No pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11896259", "visit_id": "25245946", "time": "2127-12-30 04:41:00"} |
14745006-DS-14 | 637 | ## HISTORY OF PRESENT ILLNESS:
This is a year-old gentleman with history of malignant
salivary duct carcinoma of the left parotid gland, diabetes
mellitus, and tobacco abuse with a month history of right
lower extremity claudication. Since that time, patient endorses
pain over the posterior aspect of his lower leg upon ambulation
of blocks which improves with rest. However, last week he
noticed that the pain persisted for longer than usual, even
after
rest. As part of his outpatient workup, he underwent RLE
ultrasound earlier today, which revealed a likely thrombosed
popliteal artery aneurysm measuring 1.74 x 1.79 x 3.65 cm. Given
such findings, he was advised to present to the ED for
evaluation. Patient otherwise denies fevers, chills, nausea,
emesis, chest pain, or shortness of breath. He has decreased
sensation on his bilateral feet, as well as tingling in his
fingers, all of which he assures that has been going on for many
years and is attributed to diabetic peripheral neuropathy. He
also endorses chronic diffuse abdominal pain which waxes and
wanes, attributed to IBS and diverticulosis (recently in
hospital
for management of ?acute diverticulitis).
## - :
laparoscopic cholecystectomy
-L partial nephrectomy
-Nasal polypectomy
-Penile surgery (x 2)
## FAMILY HISTORY:
CAD
Renal disease
Mother- cirrhosis of unknown etiology
## R:
/ /d/d
Feet warm, well perfused. No open areas
## BRIEF HOSPITAL COURSE:
The patient presented with right leg pain, found to have
thrombosed popliteal aneurysm on CTA. He will need to follow up
with vascular surgery as outpatient for further evaluation. He
underwent noninvasive vascular studies with vein mapping as
inpatient. Following his scheduled surgery for parotid tumor and
recovery, patient will follow up with vascular surgery in clinic
as directed. No surgical intervention this admission. His
Pravastatin was changed to 80mg daily. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
with h/o DM and tobacco abuse with month history of RLE
claudication found to have R thrombosed popliteal artery
aneurysm.
## ANTIPLATELET:
ASA
Start Pravastatin 80mg daily
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Calcium Carbonate 500 mg PO QHS:PRN heartburn
3. Gabapentin 300-600 mg PO QHS:PRN pain, sleep
4. Witch 50% Pad SDIR
5. Atenolol 25 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO DAILY
7. Pravastatin 20 mg PO QPM
8. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
## DISCHARGE MEDICATIONS:
1. Pravastatin 80 mg PO QPM
RX *pravastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
## TABLET REFILLS:
*2
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Calcium Carbonate 500 mg PO QHS:PRN heartburn
5. Gabapentin 300-600 mg PO QHS:PRN pain, sleep
6. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Witch 50% Pad SDIR
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital and were found to have
symptoms of peripheral vascular disease and claudication. On
further evaluation, we found that you have a clot in your
popliteal artery in the right leg. You will need to be followed
by vascular surgery for future treatment.
Please follow up in Vascular Surgery clinic in after
your scheduled parotid surgery and recovery. You can call the
office at
Please give us a call sooner if your pain becomes worse or you
have any questions.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14745006", "visit_id": "24367550", "time": "2145-01-31 00:00:00"} |
12699927-RR-21 | 428 | ## EXAMINATION:
CT abdomen/ pelvis without contrast.
## INDICATION:
with s/p unwitnessed fall, reports abd pain,ttp, contrast
allergy. Assess for infectious process, evidence of trauma
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 4.5 s, 49.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 325.2
mGy-cm.
Total DLP (Body) = 325 mGy-cm.
## LOWER CHEST:
Visualized lung fields are notable for bibasilar heterogeneous
opacities. A trace pericardial effusion is noted. The heart is normal in
size. No pleural effusion.
## HEPATOBILIARY:
The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall thickening or
evidence of inflammation. The gallbladder is mildly distended.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size. 4.3 x 4.3 cm right
lower pole renal cyst is noted. There is no evidence of worrisome renal
lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
## GASTROINTESTINAL:
Small hiatal hernia. The stomach is decompressed. Small
bowel loops demonstrate normal caliber and wall thickness throughout. Distal
transverse colonic wall thickening involving approximately 10 cm of colon. No
adjacent fat stranding. Large amount of stool is seen throughout the colon.
The appendix is not visualized.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The uterus is not visualized. No large adnexal mass.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
## BONES:
Mild anterolisthesis of L2 on L3 is noted. Chronic left inferior pubic
rami fracture is noted. There is no evidence of worrisome osseous lesions or
acute fracture.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Mild distal transverse colonic wall thickening might be seen with early
colitis.
2. Large fecal load. No obstruction.
3. Cholelithiasis with mildly distended gallbladder. No additional signs of
acute cholecystitis.
4. Bilateral lower lobe pneumonia/aspiration pneumonia.
## RECOMMENDATION(S):
Clinical and laboratory data correlation is recommended
for acute cholecystitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12699927", "visit_id": "22881592", "time": "2121-07-31 02:29:00"} |
14042958-RR-11 | 572 | ## EXAMINATION:
CTA HEAD AND CTA NECK Q16 CT NECK.
## HISTORY:
with intermittent L eye visual changes and MRI
concerning for IC occlusion// eval occlusion other acute process.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 98.0 mGy (Head) DLP =
49.0 mGy-cm.
3) Spiral Acquisition 5.0 s, 39.7 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,231.1 mGy-cm.
Total DLP (Head) = 2,083 mGy-cm.
## CT HEAD WITHOUT CONTRAST:
The ventricles, sulci, and cisterns appear normal. Areas of low attenuation
within the subcortical and periventricular white matter are nonspecific, but
likely reflect the sequela of chronic small vessel disease. A more prominent
small area of low density within the region of the left postcentral gyrus and
adjacent superior parietal lobule may reflect an old infarct. There is no
large infarct, acute intracranial hemorrhage, or mass effect.
There is mild mucosal thickening within the bilateral maxillary sinuses. The
paranasal sinuses are otherwise clear. The middle ear cavities and mastoid
air cells are clear.
There is erosion of the crown in most of the root of the first right maxillary
premolar tooth.
## CTA HEAD:
There is moderate atherosclerotic plaque within the cavernous and supraclinoid
segments of the bilateral internal carotid arteries, without stenosis. The
anterior cerebral and middle cerebral arteries are patent CT stenosis.
The posterior cerebral arteries are patent without stenosis. The posterior
communicating arteries are patent.
There is atheromatous and atherosclerotic plaque within the proximal V4
segment of the left vertebral artery with severe narrowing, and an area of
moderate narrowing within the distal left V4 segment. There are areas of mild
narrowing within the right V4 segment and basilar artery due to atheromatous
plaque. The vertebral arteries and basilar artery are otherwise patent.
No aneurysm or high-flow vascular malformation is identified.
## CTA NECK:
There is a 2 vessel aortic arch, with a common origin of the brachiocephalic
trunk and left common carotid artery. There is mild atherosclerotic plaque
within the aortic arch.
There is mild atheromatous plaque within the right common carotid artery.
There is moderate atheromatous atherosclerotic plaque at the right carotid
bulb, with less than 50% stenosis by NASCET criteria.
There is mild atheromatous and atherosclerotic plaque within the left common
carotid artery. There is severe atheromatous and atherosclerotic plaque at
the left carotid bulb with 50-70% stenosis by NASCET criteria.
There is atheromatous plaque within the left vertebral artery with areas of
moderate narrowing in the V2 and V3 segments.
## OTHER:
There is a 3 mm pulmonary nodule within the left upper lobe (series 3, image
53). There are subcentimeter pulmonary nodules within the thyroid gland.
There is moderate cervical degenerative disc disease, without high-grade
spinal canal narrowing. Uncovertebral and facet joint hypertrophy result in
severe neural foraminal narrowing at left C4-5 and left C5-6, and bilateral
C6-7.
## IMPRESSION:
1. No large infarct, acute intracranial hemorrhage, or mass effect.
2. Moderate intracranial atherosclerosis, with severe narrowing of the
proximal and moderate narrowing of the distal V4 segment of the left vertebral
artery.
3. Moderate extracranial atherosclerosis, with 50-70% stenosis of the left
carotid artery at the carotid bulb by NASCET criteria. There is less than 50%
stenosis of the by NASCET criteria.
4. Dental caries. Recommend nonemergent dental consultation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14042958", "visit_id": "28492553", "time": "2124-06-30 04:21:00"} |
17788664-RR-22 | 151 | CT NECK WITHOUT CONTRAST
## HISTORY:
Nocturnal dyspnea. Assess for airway compromise.
Contiguous axial images were obtained through the neck. No contrast was
administered. Comparison to a neck CT of .
## FINDINGS:
Again identified is a nodule in the right lobe of the thyroid
gland. This contains two small calcifications and appears unchanged in size
and density characteristics since the study of . Also again noted is a
small nodule in the left parotid gland. This likely represents a node.
The numerous prominent nodes throughout the level 2 and 3 locations
bilaterally appear somewhat smaller than on the study of .
There is no evidence of airway compromise. Although there is a thyroid
nodule, it does not encroach on the larynx or trachea.
## CONCLUSION:
No evidence of airway compromise. Right thyroid nodule unchanged
since . Left parotid nodule, likely a lymph node, unchanged since .
Scattered adenopathy again demonstrated, but the nodes are smaller than in
.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17788664", "visit_id": "N/A", "time": "2163-02-08 14:14:00"} |
17347275-RR-21 | 289 | ## INDICATION:
man with mid epigastric abdominal pain, vomiting, and
diarrhea for three days. Elevated lactate to 7.2.
## CT PELVIS WITH IV CONTRAST:
Multiple loops of large and small bowel are
within normal limits, with scattered diverticulosis of the distal colon. The
small bowel and colon enhance normally. There is no bowel wall thickening or
bowel distention. There is no evidence of bowel ischemia.
The lumen of the right proximal superficial artery is markedly narrowed with a
"string sign", indicating very high grade stenosis.
The prostate gland remains markedly enlarged and heterogeneous, again
protruding into the base of the urinary bladder. The bladder and distal
ureters are unremarkable. There is no free fluid in the pelvis. There is no
pelvic or inguinal lymphadenopathy by size criteria.
## OSSEOUS STRUCTURES:
There is no fracture or worrisome bony lesion.
Degenerative changes are mild, with a large Schmorl's node in the L3 vertebral
body.
## IMPRESSIONS:
Small bilateral pleural effusions, right greater than left.
Distended gallbladder with multiple gallstones, including one in the
gallbladder neck. Trace pericholecystic fluid and gallbladder wall edema,
although without definite gallbladder free wall thickening. Cholecystitis is
a concern. This can be further evaluated via ultrasound or hepatobiliary
scan.
Extensive atherosclerotic calcifications throughout the aorta and major
mesenteric branches, although mesenteric arteries are without stenosis or
thrombosis evident. Due to suboptimal contrast administration, venous
structures are not opacified. However, there are no secondary signs of venous
thrombus. There is no evidence of bowel ischemia.
Very high grade stenosis of the proximal right superficial femoral artery.
Stable appearance of simple and hyperdense renal cysts.
Diffusely enlarged prostate gland with prominent median lobe, with multiple
proteinaceous/hemorrhagic nodules. This is consistent with BPH, although
tumor is not definitively excluded.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17347275", "visit_id": "26125985", "time": "2172-12-10 12:19:00"} |
13308637-DS-17 | 2,242 | ## ALLERGIES:
atenolol / Lipitor / Zocor / diltiazem / codeine / atorvastatin
/ simvastatin
## HISTORY OF PRESENT ILLNESS:
w/ PMHx of Afib/flutter (on eliquis), CAD, HTN, HLD, PVD,
AAA and CKD3 who p/w several days of orthopnea, weight gain, and
orthopnea found to be in Afib with RVR.
Pt had recent admission at for a brief episode
of Lt neck pain and blurry vision felt to be headache
syndrome. During that admission he was also started on
prednisone 60 mg daily for possible temporal arteritis which he
was on from until the temporal artery biopsy returned
negative at which time he was instructed to taper the pred now
on 40mg.
Pt states that since discharge (worse over the past week), he
has been having SOB, and weight gain 192 to 202 lbs. He also
endorses a cough and nasal congestion for which he received
azithromycin for 5 days on , and was prescribed levofloxacin
as well, which he took on . Last night, he had orthopnea
while lying in bed.
He was seen at an OSH where he was found to be in Afib with rate
in the 170s-180s. He was given 500 cc of normal saline and
transferred to .
Of note, he has a listed anaphylaxis allergy to atenolol and a
serious allergic reaction to diltiazem as well as amiodarone.
However, he does not recall any of these reactions. He has been
taking apixaban as prescribed but missed 4 doses on ,
for temporal artery biopsy, as well as a dose this AM given
his acute illness. In the ED, pt endorses history above.
- Initial VS: 97.9 20 98% 2L NC
- Exam: crackles at the bilateral lung bases
- Labs:
- CBC: WBC 17.7, Hgb 12.0, plt 117
- CHem: BUN 32, Cr 1.4, bicarb 27
- Coags: INR 1.2, PTT WNL
- BNP 6700
- TropT 0.05 @ 1630
- Lactate 1.7
- UA WNL
- cx pending
- Bld cx pending
## - STUDIES NOTABLE FOR:
- ECG:
Afib w/ HR 169, 2mm STD V4-V5 ECG in NSR)
- CXR at OSH: Vascular congestion and hilar fullness, small
b/l pleural effusions, no frank pulm edema (my read)
- Patient was given:
17:58 IV Digoxin 0.5 mg
17:58 IV Furosemide 40 mg
- Consults:
## CARDIOLOGY:
HD stable and mentating well. Could trial digoxin
load. Would prefer not to DCCV unless clinically unstable given
he has only been on eliquis since and would need TEE to r/o
clot.
- Digoxin load and verapamil for rate control
- DCCV only if clinically unstable (started eliquis on ,
less than one month)- same applies to amio given risk of
chemical cardioversion
- 40 IV Lasix now
- admit to
to arriving on the floor, he had 1.6L urine output after
Lasix.
On arrival to the CCU, patient denies chest pain, palpitations,
SOB while resting in bed. No recent fevers, chills, but
continues to have a cough productive of yellow/green sputum.
Since he started prednisone, his headaches have improved.
## PAST MEDICAL HISTORY:
- Atrial flutter, s/p ablation
- Mild AS
- CAD, s/p PCIx4 , not on beta blocker due to fatigue and
history of changes in mental status
- Hypertension
- Dyslipidemia
- Abdominal aortic aneurysm s/p endovascular repair in
- Vasculogenic claudication s/p angioplasty/stent of Lt external
iliac artery and right SFA
- CKD Stage 3
## FAMILY HISTORY:
Diabetes in mother and sister.
## GENERAL:
NAD, lying comfortably in bed
## HEENT:
NCAT, EOMI, PERRL, oropharynx clear
## NECK:
supple, JVP elevated to 8-9 cm at 30 degrees
## CARDIAC:
tachycardic, irregular, no murmurs
## LUNGS:
crackles at the bases, no wheezing
## ABDOMEN:
Soft, nt/nd, no HSM
## EXTREMITIES:
WWP, trace edema bilaterally, non-tender
## NEUROLOGIC:
A&Ox3, strength symmetric, sensation intact to
light touch
## SKIN:
No rash, no open lesions
## GENERAL:
No distress, resting comfortably in bed
## HEENT:
NCAT, EOMI, PERRL, oropharynx clear
## NECK:
supple, JVP not elevated
## LUNGS:
CTAB, no wheezing or crackles
## EXTREMITIES:
WWP, no edema bilaterally, non-tender
## NEUROLOGIC:
Alert, answering questions appropriately
## SKIN:
No rash, no open lesions
## IMAGING:
==================
CHEST XRAY
Lungs are low volume with bibasilar atelectasis.
Cardiomediastinal silhouette is stable. There is no pleural
effusion. No pneumothorax is seen.
TTE
The left atrial volume index is normal. The estimated right
atrial pressure is mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is mild
regional left ventricular systolic
dysfunction with basal inferior/inferolateral akinesis (see
schematic). Global left ventricular systolic function is low
normal. Quantitative biplane left ventricular ejection fraction
is 54 %. There is no resting left ventricular outflow tract
gradient. There is Grade I diastolic dysfunction. Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.5-1.9 cm2). There is no aortic regurgitation. The mitral
leaflets appear structurally normal with no mitral valve
prolapse. There is an eccentric, inferolateral directed jet of
mild to moderate [ ] mitral regurgitation.
Due to the Coanda effect, the severity of mitral regurgitation
could be UNDERestimated. The tricuspid valve leaflets appear
structurally normal. There is trivial tricuspid regurgitation.
The estimated pulmonary artery
systolic pressure is normal. There is a trivial pericardial
effusion.
## IMPRESSION:
1) Mild symmetric left ventricular hypertrophy with
low normal LV systolic function as measured by LVEF and regional
wall motion abnormalities suggesting myocardial infarction
in RCA territory. Global longitudinal strain ranged from 7 - 11%
depending on view (due to arrhythmia global averaging was not
available) suggesting presence of a diffuse cardiomyopathic
process as well. 2) Mild aortic stenosis and mild to moderate
mitral regurgitation.
TEE
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is mildly depressed. Global left ventricular
systolic function is mildly
depressed. There are simple atheroma in the descending aorta.
The aortic valve leaflets (3) are moderately thickened. No
masses or vegetations are seen on the aortic valve. No abscess
is seen. There is no aortic regurgitation. The mitral leaflets
are mildly thickened with no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve. No abscess is seen.
There is moderate [2+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation.
## IMPRESSION:
No spontaneous echo contrast or thrombus in the left
atrium or left atrial appendage. Mildly
depressed left ventricular systolic function. Moderate mitral
regurgitation. Mild tricuspid regurgitation.
## SOURCE:
Expectorated.
**FINAL REPORT
GRAM STAIN (Final :
>25 PMNs and <10 epithelial cells/100X field.
2+ per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
2+ per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final :
MODERATE GROWTH Commensal Respiratory Flora.
6:53 pm URINE
**FINAL REPORT
URINE CULTURE (Final :
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
4:25 pm BLOOD CULTURE
## BLOOD CULTURE, ROUTINE (PENDING):
No growth to date.
## DISCHARGE LABS:
==================
07:45AM BLOOD WBC-12.2* RBC-3.86* Hgb-12.2* Hct-37.4*
MCV-97 MCH-31.6 MCHC-32.6 RDW-14.1 RDWSD-48.5* Plt
07:45AM BLOOD Glucose-91 UreaN-28* Creat-1.4* Na-141
K-4.3 Cl-101 HCO3-28 AnGap-12
07:45AM BLOOD Calcium-8.7 Phos-3.1 Mg-2. history of Afib/flutter (on apixaban), CAD, HTN, HLD, PAD
s/p recent angioplasty/stenting x2 , AAA, CKDIII, who
presented with several days of orthopnea, weight gain, and lower
extremity edema found to be in Afib with RVR. He was admitted to
the CCU given persistent Afib with RVR in light of limited
treatment options due to reported allergies to atenolol,
diltiazem, and amiodarone.
# Afib/flutter with rapid ventricular response: Hx of
Afib/flutter s/p ablation , last ECG in NSR. He
presented in atrial fibrillation with RVR with rates 170s at
OSH. Trigger felt to be most likely acute on chronic HFpEF
possibly secondary to initiation of prednisone for suspected
giant cell arteritis (biopsy negative). He was admitted to the
CCU given limited treatment options due to documented allergies
to atenolol, diltiazem, and amiodarone. He was initially treated
with digoxin and verapamil without improvement, and both were
ultimately discontinued to discharge. He underwent
TEE/DCCV x3 without conversion to sinus rhythm (after TEE
neg for thrombus). Patient was challenged with amiodarone load,
which he tolerated without significant issues and he continues
on amiodarone po after discharge. He was continued on apixaban 5
mg BID.
## # ACUTE ON CHRONIC HFPEF:
Patient presented with evidence of
volume overload, consistent with acute on chronic HFpEF. Likely
etiology is secondary to prednisone initiation (as above) and
dietary indiscretion on background of chronic hypertension and
mildly stiff left ventricle. He was diuresed with IV Lasix and
ultimately euvolemic off po diuretics by time of discharge
## # NSTEMI:
Patient presented with troponin elevation and EKG with
STD V4-V5. Likely type II demand in the setting of high heart
rates. Troponin peaked at 0.09. He remained medically managed on
aspirin, statin, and is on Plavix for his PVD
## #SUSPECTED GCA:
to admission, patient had been placed on
prednisone for suspected GCA. However, when bx resulted as
negative, his prednisone taper was initiated by rheumatology.
Given concern for HFpEF exacerbation with prednisone, this taper
was accelerated this admission. He was placed on 20 mg po x3
days with plan to transition to 10 mg x3 days then stop
prednisone. See transitional issues below for details.
## #CHRONIC KIDNEY DISEASE, STAGE III:
Admission Cr 1.4 near recent
baseline 1.3. baseline 1.0-1.2 in . Persistent
possibly secondary to diuresis, but more likely some ATN in the
setting of acute heart failure exacerbation. Cr remained near
baseline by time of discharge
## # HYPERTENSION:
Home amlodipine 5 mg was held initially but
resumed to discharge. Lisinopril resumed at reduced dosing
to discharge
## # CAD:
Hx of CAD s/p remote PCI in for stable angina.
Continued home Rosuvastatin and Aspirin 81 mg. Notably pt is on
Plavix as for PVD as below.
# Peripheral Vascular Disease s/p angioplasty/stenting x2:
On he underwent angioplasty/stent of the left external
iliac artery and right superficial femoral artery. Continued
home plavix (30 days post-op as well as statin and
asa.
# Cerebral amyloid angiopathy:
MRI/MRA showing evidence of multiple chronic infarcts suggesting
cerebral amyloid angiopathy.
## TRANSITIONAL ISSUES:
- Patient is on altered prednisone taper plan as above. Patient
planned for prednisone 10 mg x3 days ( ), then stop
prednisone.
- Please note that patient was initiated on amiodarone this
admission. Baseline TSH 1.2, LFTs wnl ( ), and CXR with
Ill-defined hazy opacities of the bilateral lung apices known.
Please continue to monitor LFTs, TFTs, and CXR with amiodarone
use and consider baseline PFTs.
- Please note that last day of Plavix for recent PVD s/p
stent to current admission)
- Patient has a number of listed allergies (atenolol, diltiazem,
and amiodarone) to admission. However, these are
questionable. He tolerated amiodarone and so this was removed
from allergy list. Atenolol listed allergy is anaphylaxis; he
did notably receive metoprolol at in
without reported issue. Please consider allergy follow up
for skin testing to confirm BB allergy; if he can tolerate BB,
this would be a helpful allergy to test. Finally, diltiazem
specifically was tolerated at as well.
- please resume Lisinopril 20 mg from discharge 10 mg dosing if
BP allows
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Oxybutynin 10 mg PO DAILY extended release
5. Rosuvastatin Calcium 10 mg PO QPM
6. amLODIPine 5 mg PO DAILY
7. PredniSONE 40 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
## TABLET REFILLS:
*0
2. Lisinopril 10 mg PO DAILY
3. PredniSONE 10 mg PO DAILY Duration: 5 Days
Take from
Tapered dose - DOWN
RX *prednisone 5 mg tablet(s) by mouth daily Disp #*7 Tablet
## REFILLS:
*0
4. amLODIPine 5 mg PO DAILY
5. Apixaban 5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Oxybutynin 10 mg PO DAILY extended release
9. Rosuvastatin Calcium 10 mg PO QPM
## DISCHARGE DIAGNOSIS:
Atrial fibrillation with sustained ventricular response
Non ST elevation myocardial infarction
Acute on chronic heart failure with preserved ejection fraction
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure caring for you at !
Why did you come into the hospital?
- You came into the hospital due to shortness of breath and
cough.
What happened while you were in the hospital?
- You were found to have a fast heart rate called atrial
fibrillation, which is similar to atrial flutter, which you
previously had.
- You had attempted cardioversions to shock your heart into a
normal rhythm. However, this was not successful and you remained
in atrial fibrillation.
- You were started on amiodarone, which is a drug that treats
abnormal heart rhythms.
- Your heart rate improved.
What should you do when you leave the hospital?
- Please follow up with the appointments we have arranged.
- Please take all medications as prescribed. Note the plan in
your prednisone course and your new amiodarone medications. Your
prednisone will be 10 mg x 3 days ( ), then stop
prednisone.
- Please note that you are NOT allergic to amiodarone.
We wish you the best.
Sincerely,
Your care team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13308637", "visit_id": "28618856", "time": "2159-09-14 00:00:00"} |
15641430-RR-28 | 173 | ## EXAMINATION:
ABDOMEN US (COMPLETE STUDY)
## INDICATION:
year old woman with OIC and bloating with abdominal pain //
Abdominal pain and constipation
## LIVER:
The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD measures 3 mm.
## GALLBLADDER:
There is no evidence of stones or gallbladder wall thickening.
## PANCREAS:
The pancreas is obscured by overlying bowel gas and cannot be
evaluated.
## SPLEEN:
Normal echogenicity, measuring 10.0 cm.
## KIDNEYS:
The right kidney measures 11.3 cm. The left kidney measures 10.3 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. Simple appearing parapelvic and cortically based renal cysts are
noted bilaterally. There is no evidence of solid masses, stones, or
hydronephrosis in the kidneys.
## RETROPERITONEUM:
Visualized portions of aorta and IVC are within normal
limits.
## IMPRESSION:
1. Bilateral simple parapelvic and cortical renal cysts.
2. Otherwise, unremarkable abdominal ultrasound.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15641430", "visit_id": "N/A", "time": "2184-11-30 14:23:00"} |
17393842-RR-34 | 191 | ## INDICATION:
Hepatitis B virus. Rule out HCC.
## FINDINGS:
The liver demonstrates a coarse echotexture. There are again two
right hepatic lobe hemangiomas noted. The first one measures 12 x 14 x 15 mm
(image 26) and the second one measures 12 x 13 x 11 mm (image 47). They are
unchanged in size allowing for different measurement techniques. Previously
described cluster of cysts within the liver is not visualized on the current
study. There is no intra- or extra-hepatic biliary tree dilatation. The main
portal vein is patent with hepatopetal flow. The gallbladder is present
without any stones, wall thickening or pericholecystic fluid. The spleen has
a normal appearance and measures 7.8 cm. There is a simple cyst in the lower
pole of the left kidney measuring 1.4 x 1.8 x 1.4 cm, which is unchanged when
compared to the prior examination. Left kidney measures 9.7 cm and the right
kidney measures 9.2 cm. There is no hydronephrosis or stones identified. No
ascites.
## IMPRESSION:
1- Stable right hepatic hemangiomas with no new focal liver lesion identified.
2- Unchanged simple left renal cyst.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17393842", "visit_id": "N/A", "time": "2188-02-16 08:01:00"} |
14960641-RR-14 | 100 | ## INDICATION:
year old woman with SCC, recent fem port placement // r/o ptx
r/o ptx
## IMPRESSION:
In comparison with the study of , the right femoral catheter is
not definitely seen, though it could be in the IVC just beneath the
hemidiaphragms. Repeat radiograph with abdominal technique and upper border at
the hilum could be obtained. No evidence of pneumothorax.
The left hemidiaphragm is not as sharply seen, raising the possibility of its
left effusion and mild atelectatic changes. Otherwise, little overall change
in appearance of the heart and lungs except for some decrease in pulmonary
vascular congestion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14960641", "visit_id": "21107484", "time": "2142-09-29 17:49:00"} |
14508231-RR-313 | 159 | ## EXAMINATION:
Left shoulder CT arthrogram
## INDICATION:
year old woman with persistent l shoulder pain with activity
after tsr // rc tear ??? subscap tear ???
## AC JOINT:
There is mild degenerative change of the acromioclavicular joint
with marginal spurring.
## SUBACROMIAL SUBDELTOID BURSA:
There is no contrast in the subacromial
subdeltoid bursa.
## ROTATOR CUFF:
Supraspinatus and infraspinatus are grossly intact. Although
very poorly visualized there is contrast in the expected location of the
subscapularis worrisome for complete or near complete tear (10:22 and 25).
The subscapularis muscle is severely atrophied.
## GLENOHUMERAL JOINT:
Patient is status post total left shoulder arthroplasty.
Artifact from metal hardware partially limits the evaluation. Hardware
appears intact without evidence of loosening or periprosthetic fracture.
Alignment appears satisfactory.
Included portions of the left axilla show morphologically normal non enlarged
lymph nodes.
## IMPRESSION:
Although poorly visualized there is contrast in the expected location of the
subscapularis worrisome for high grade tear. The subscapularis muscle is also
severely atrophied.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14508231", "visit_id": "N/A", "time": "2144-04-14 10:34:00"} |
11845313-RR-33 | 65 | ## HISTORY:
man, 17 days status post liver transplant, with
elevating AST/ALT. Assess for hepatic vessels for patency.
## IMPRESSION:
1. Major intrahepatic vasculature patent. Portal veins with normal antegrade
flow. Resistive indices of hepatic arteries range from 0.53 to 0.63, within
normal limits.
2. Similar increased echogenicity in the transplanted liver, compatible with
fatty infiltrate.
3. No ascites or fluid collection.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11845313", "visit_id": "N/A", "time": "2124-07-31 09:17:00"} |
15862493-RR-110 | 271 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
year old man with hodgkins p/w hypercalcemia, possible pna on
cxr// r/o pna, sarcoid
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.4 s, 34.9 cm; CTDIvol = 5.8 mGy (Body) DLP = 198.5
mGy-cm.
Total DLP (Body) = 199 mGy-cm.
## FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL:
Thyroid is normal. Right sided
chest port is in place with tip terminating at cavoatrial junction.
## UPPER ABDOMEN:
Limited evaluation demonstrates that there is mild-to-moderate
ascites, new since prior. There are multiple hypodense lesions within the
liver, stable since . Partially seen is upper adenopathy, more
prominent since prior. Mild to moderate intrahepatic biliary duct dilation
with a biliary catheter in place.
## MEDIASTINUM:
Mildly prominent mediastinal lymph nodes have grown since prior,
largest measures 1.1 cm today series 5, image 71, compared with 0.9 cm on
prior. No axillary adenopathy..
## HILA:
No obvious adenopathy or mass noting lack of contrast
## HEART AND PERICARDIUM:
Normal size heart. No pericardial effusion
## PLEURA:
Small right pleural effusion. No significant left effusion.
## 1. PARENCHYMA:
No air space opacification. There is mild compressive right
lower lobe subsegmental atelectasis. Minimal left basilar atelectasis.
## 3. VESSELS:
Mid ascending aorta is enlarged, measures 4.2 cm, stable.. Main
pulmonary artery is of normal size.
## CHEST CAGE:
No lytic or blastic concerning osseous lesion
## IMPRESSION:
No airspace opacification. There is a small right pleural effusion with mild
basilar atelectasis.
Mediastinum, and partially visualized upper abdominal adenopathy has worsened.
Ascites. Intrahepatic bile duct dilatation is partially seen, there is
biliary catheter in place. Recommend LFT correlation if indicated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15862493", "visit_id": "24138206", "time": "2190-12-15 18:43:00"} |
14564547-DS-12 | 1,265 | ## HISTORY OF PRESENT ILLNESS:
Ms. is a woman with history of
ulcerative colitis s/p J-pouch with history of
pouchitis/cuffitis
now presenting with diarrhea.
The patient reports that her typical stool pattern is stools
per day. She normally takes loperamide tablets per day and
Metamucil powder. She reports that 1 week prior to admission she
developed profuse, watery, diarrhea of up to 30 bowel movements
per day. The stool is nonbloody. This was associate with nausea
and poor appetite but no vomiting. No fevers or chills. She has
mild diffuse abdominal discomfort, but states that this pain is
very different from her typical pain with pouchitis.
She traveled to , of this year. She felt
well
throughout the trip and after. She subsequently went to in . No other recent travel. No sick contacts. No
contacts with similar symptoms. No unusual foods that she could
identify. No recent changes in medications or dosages. Of
additional note, she reports that she had an EGD and pouchoscopy
within he last year ( ) that was "fine" at .
She increased her immodium to 8 tablets per day and increased
her
Metamucil intake without effect on her stools. She took
ciprofloxacin for 5 days preceding the admission without effect.
Given her ongoing severe symptoms, she referred to the ED by her
surgeon (Dr. for further evaluation.
##
IN THE ED, VITALS:
97.4 58 140/70 16 100% RA
Exam notable for: Abd: Soft, nondistended. Mild tenderness to
palpation of periumbilical region
Labs notable for: WBC 5.6, Hb 13.8, plt 221; BMP wnl; lactate
1.2; CRP 36; C. diff negative
## CT A/P:
No abscess or bowel obstruction
Patient given: Loperamide 2 mg, Zofran 4 mg IV, LR at 100cc/hr
On arrival to the floor, the patient reports ongoing profuse
watery diarrhea (she reports over 30 bowel movements on day of
admission). Denies any abdominal pain at present. No other
complaints at this time.
## PAST MEDICAL HISTORY:
- Ulcerative colitis s/p colostomy and ileoanal J-pouch
- GERD
- Depression/anxiety
- Bilateral avascular necrosis
- Placenta previa
- Seasonal allergies
## FAMILY HISTORY:
Distant relative with ulcerative colitis.
## 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, erythema or exudate
## 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
## SKIN:
No rashes or ulcerations noted
## NEURO:
Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
## PSYCH:
Very pleasant, appropriate affect
## CV:
RRR, +S1, S2, no murmurs, rubs or gallops
## RESP:
CTA B/L with good inspiratory effort
## AB:
Soft, NT, ND, normoactive BS
## MICRO:
FECAL CULTURE (Final :
SALMONELLA SPECIES.
Presumptive identification pending confirmation by
Laboratory.
Reported to and read back by @
1453.
SENSI REQUESTED PER . ( ) ON .
Intermediate TO CIPROFLOXACIN MIC = 0.25 MCG/ML, test
result
performed by Etest.
## SENSITIVITIES:
MIC expressed in
MCG/ML
SALMONELLA SPECIES
|
AMPICILLIN
-----
<=2 S
CEFTRIAXONE
-----
<=1 S
CIPROFLOXACIN
-----
I
TRIMETHOPRIM/SULFA
-----
<=1 S
## CAMPYLOBACTER CULTURE (FINAL :
NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final :
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final : NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final : NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final :
No E. coli O157:H7 found.
## IMAGING:
CT ABDOMEN/PELVIS
1. The patient is status total colectomy with an ileal pouch and
anal
anastomosis which is intact. No evidence of a fistulous
connection or
abscess.
2. No evidence of bowel obstruction.
06:29AM BLOOD WBC-4.3 RBC-4.03 Hgb-12.2 Hct-38.1 MCV-95
MCH-30.3 MCHC-32.0 RDW-12.5 RDWSD-43.6 Plt
05:05AM BLOOD Glucose-102* UreaN-17 Creat-0.9 Na-141
K-4.7 Cl-105 HCO3-22 AnGap-14
## BRIEF HOSPITAL COURSE:
Ms. is a woman with history of ulcerative
colitis s/p J-pouch with history of pouchitis/cuffitis now
presenting with profuse diarrhea, found to have salmonella
infection on stool culture.
# Salmonella gastroenteritis:
Presented with 1-week of profuse, watery diarrhea. CT A/P with
IV contrast ( ) grossly normal. Pouchoscopy ( ) performed
by GI with normal mucosa in the pouch and neo-TI. Stool cultures
returned positive for Salmonella infection. As per ID
recommendations, initiated on Azithromycin for a 5-day course
(last dose . Patient was instructed to hold
anti-diarrheal agents until after completing the antibiotic
course. She will follow-up with ID on for repeat stool
testing.
# Mild (RESOLVED)
Cr up to 1.0 at admission, trended down to 0.7 with IV fluids.
## # DEPRESSION/ANXIETY:
Continued home citalopram
# GERD: C/w raniditine and PPI
Transitional care issues
[ ] ID f/u after completion of Azithromycin (to end to test
for clearance of Salmonella infection
> 30 minutes spent in discharge planning and counseling
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. azelastine 0.05 % ophthalmic (eye) BID
2. Cetirizine 10 mg PO BID
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Citalopram 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Ranitidine 150 mg PO QHS
7. LOPERamide mg PO QID:PRN Diarrhea
8. Psyllium Powder 1 PKT PO TID:PRN Loose stool
9. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
10. LORazepam 0.5 mg PO Q8H:PRN Anxiety
11. Melatin (melatonin) 3 mg oral QHS:PRN Insomnia
12. Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg
oral DAILY
13. Vitamin D Dose is Unknown PO DAILY
## DISCHARGE MEDICATIONS:
1. Azithromycin 500 mg PO Q24H Duration: 2 Days
Last dose
RX *azithromycin [Zithromax] 500 mg 1 tablet(s) by mouth once a
day Disp #*2 Tablet
## REFILLS:
*0
2. Diphenoxylate-Atropine 1 TAB PO TID
Do not start until
RX *diphenoxylate-atropine [Lomotil] 2.5 mg-0.025 mg 1 tablet(s)
by mouth three times a day Disp #*90 Tablet Refills:*0
3. Psyllium Wafer 2 WAF PO TID
RX *psyllium 2 WAF by mouth three times a day Disp #*90 Wafer
Refills:*0
4. Vitamin D 1000 UNIT PO DAILY
5. azelastine 0.05 % ophthalmic (eye) BID
6. Cetirizine 10 mg PO BID
7. Citalopram 20 mg PO DAILY
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
9. LOPERamide mg PO QID:PRN Diarrhea
RX *loperamide [Imodium A-D] 2 mg tab by mouth four times a
day Disp #*120 Tablet Refills:*0
10. LORazepam 0.5 mg PO Q8H:PRN Anxiety
11. Melatin (melatonin) 3 mg oral QHS:PRN Insomnia
12. Pantoprazole 40 mg PO Q12H
13. Ranitidine 150 mg PO QHS
14. HELD- Probiotic (S.boulardii) (Saccharomyces boulardii) 250
mg oral DAILY This medication was held. Do not restart
Probiotic (S.boulardii) until until discussion with Infectious
Disease
## DISCHARGE INSTRUCTIONS:
You came to the hospital with diarrhea and were found to have a
salmonella infection. You were started on an antibiotic called
azithromycin to treat this. Please take this medication until
and including . Please follow-up with your primary care
doctor, Infectious Disease team, and Gastroenterology doctor in
the coming weeks. You can start Imodium and Lomotil starting
.
It was a pleasure taking care of you at !
-- Your medical team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14564547", "visit_id": "21973427", "time": "2170-03-15 00:00:00"} |
11486456-RR-17 | 136 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## HISTORY:
with headstrike. no loc. no blood thinners. tx from
osh without imaging of head. known l femur fx // eval for bleed
## FINDINGS:
There is no acute hemorrhage, edema, mass effect or acute large vascular
territorial infarction. Prominent ventricles and sulci are consistent with
age-related involutional change. Periventricular hypodensities are consistent
with chronic small vessel ischemic disease. The basal cisterns appear patent
and there is preservation of gray-white matter differentiation.
No acute fracture is identified. Deformity of the nasal septum and nasal
bones is likely chronic. The mastoid air cells, middle ear cavities, and
visualized paranasal sinuses are clear. The globes are unremarkable.
## IMPRESSION:
1. No acute intracranial process.
2. Deformity of the nasal septum and nasal bones is likely chronic.
Recommend correlation with physical exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11486456", "visit_id": "N/A", "time": "2122-12-18 22:46:00"} |
12055218-RR-9 | 381 | ## NO PO CONTRAST; HISTORY:
with hx of appendectomy p/w RUQ abd
rib pain. NO PO contrast // Patient with RUQ rib and abd pain, negative US.
Please eval for cholecystitis, liver pathology.
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 5.0 s, 54.5 cm; CTDIvol = 16.2 mGy (Body) DLP = 882.4
mGy-cm.
Total DLP (Body) = 898 mGy-cm.
## LOWER CHEST:
Minimal atelectasis involves the left lung base. There is no
pleural or pericardial effusion.
## HEPATOBILIARY:
The liver is homogeneous in attenuation. There is no focal
lesion. There is no intrahepatic duct dilation. The portal veins are patent.
There is no radiopaque cholelithiasis. The gallbladder wall is not thickened.
There is no pericholecystic fluid.
## PANCREAS:
The pancreas is homogeneous in attenuation without a focal lesion or
pancreatic duct dilation. There is no peripancreatic stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not definitely visualized,
clips in the right upper quadrant noted.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The visualized reproductive organs are unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. There are no significant
atherosclerotic calcifications.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
Diastasis of the rectus muscles of the anterior abdominal wall
midline is noted.
## IMPRESSION:
No acute intra-abdominal or pelvic abnormality to explain patient
symptomatology. Normal appearing gallbladder.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12055218", "visit_id": "N/A", "time": "2144-12-19 11:43:00"} |
19955908-RR-28 | 412 | ## EXAMINATION:
MR ORBIT ANDW/O CONTRAST T9123 MR
## INDICATION:
Resolving sinusitis and orbital cellulitis with extension to the
meninges. Evaluate for interval change and for abscess.
## MRI ORBITS:
Compared the prior MR examination, there has been progression of
left-sided proptosis. There has been progression of left orbital cellulitis,
with increasing edema and enhancement of the intraconal fat. Again, there is
extension of inflammatory fat stranding and enhancement abutting the optic
nerve, with edema and enhancement of the optic nerve sheath. There is
extraconal extension of inflammatory fat stranding and enhancement with
similar degree of periorbital soft tissue involvement. There is involvement
of the left superior and medial rectus and superior oblique musculature. The
left globe itself is unremarkable.
There has been interval progression of left frontal pachymeningeal
enhancement, with a new 8 x 6 mm left frontal epidural rim enhancing fluid
collection (17:1).
Again, there is extensive paranasal sinus disease with moderate left and mild
right frontal sinus mucosal thickening, near complete opacification of the
left-sided ethmoid air cells, and moderate mucosal thickening in the right
ethmoid air cells, opacification of the right frontoethmoidal recess, and mild
mucosal wall thickening in the bilateral maxillary sinuses which demonstrate
enhancement. There are postsurgical changes from right ethmoidectomy and
maxillary antrostomy. Extent of paranasal sinus disease appears mildly
progressed compared the prior MR examination.
There is no evidence of cavernous sinus thrombosis.
The right orbit and preseptal soft tissues are unremarkable. The right globe
is normal. The right optic nerve complex appears normal. The right
extraocular muscles are normal. The right lacrimal apparatus is normal. The
right retrobulbar soft tissues are normal.
## MRI BRAIN:
There is left frontal pachymeningeal thickening and enhancement as
well as a small epidural abscess, as described above. There is no evidence of
hemorrhage, edema, masses, mass effect, midline shift or infarction. The
ventricles and sulci are normal in caliber and configuration.
## IMPRESSION:
1. Progressive left orbital cellulitis with worsening proptosis and
periorbital extension with involvement of the extraocular musculature and left
optic nerve, as described.
2. Progressive left frontal pachymeningeal thickening and enhancement
consistent with meningitis from direct extension of orbital cellulitis with
interval development of an 8 x 6 mm epidural abscess.
3. Progressive extensive paranasal sinus disease, the likely infectious
source.
4. No evidence of cavernous sinus thrombosis.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 23:28, 5 minutes after
discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19955908", "visit_id": "23511709", "time": "2176-03-16 21:33:00"} |
17002060-RR-22 | 282 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old woman with IPH and contusions s/p fall. Evaluate for
hemorrhage or infarct.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.8 cm; CTDIvol = 47.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
## FINDINGS:
Compared to , there is overall similar appearance of several
areas of intraparenchymal hemorrhage involving the right frontal and parietal
lobes near the vertex. A small focus of hemorrhage in the left frontal lobe
(02:23) is unchanged. A large area of encephalomalacia in the right frontal
lobe is unchanged.
There is no evidence of acute large territorial infarction,new hemorrhage,or
mass effect. There is prominence of the ventricles and sulci suggestive of
involutional changes. Periventricular white-matter hypodensities are
nonspecific, but likely represent sequela of chronic small vessel ischemic
disease. Atherosclerotic vascular calcifications are noted of bilateral
cavernous portions of internal carotid arteries.
There is no evidence of fracture. There is opacification of the right ethmoid
air cells. Aerosolized secretions are seen in the right maxillary sinus. The
visualized portion of the other paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable. Subcutaneous edema over the right parietal bone is similar to
prior (03:44).
## IMPRESSION:
1. Grossly stable intraparenchymal hemorrhage involving the right
frontoparietal and left frontal lobes compared to prior exam.
2. No evidence of new hemorrhage.
3. Grossly stable large right frontal encephalomalacia.
4. Atrophy, probable small vessel ischemic changes, and atherosclerotic
vascular disease as described.
5. Grossly stable paranasal sinus disease as described.
6. Stable right parietal scalp soft tissue swelling.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17002060", "visit_id": "21100520", "time": "2117-08-24 06:13:00"} |
15287289-RR-11 | 372 | ## NO PO CONTRAST; HISTORY:
with metastatic melanoma s/p TACE on
now with recurrent fevers and negative culturesNO PO contrast // r/o
infectious process in abdomen following TACE procedure
## DOSE:
DLP: 736 mGy-cm (abdomen and pelvis.
## LOWER CHEST:
Visualized lung fields are within normal limits. There is no evidence of
pleural or pericardial effusion.
## HEPATOBILIARY:
Patient is status post right-sided chemo embolization. The
residual chemo embolization material is seen throughout the right lobe. Masses
in segment 6 measures 14 mm, decreased in size. One of two lesions in the
liver dome has also decreased in size. Tiny focal soft tissue density lesion
in the gallbladder may represent a small polyp or stone measuring 5 mm.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
## GASTROINTESTINAL:
Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon is within normal limits. In the right lower
quadrant, there is an ill-defined soft tissue density which is partially
visualized with some adjacent fat stranding, not seen on CT from .
## RETROPERITONEUM:
There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. There is mild calcium burden
in the abdominal aorta and great abdominal arteries.
## BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
## IMPRESSION:
Decrease in size of the known liver lesions in segments 6 and 7. Residual
chemo embolization material seen throughout the right lobe. No abscess in the
liver.
Ill-defined soft tissue density in the right lower quadrant, partially
visualized and indeterminate, recommend CT pelvis for further evaluation.
5 mm gallbladder polyp or stones, unchanged.
## NOTIFICATION:
These findings were discussed with Dr. by Dr. at
20:40 on by telephone at time of discovery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15287289", "visit_id": "29152580", "time": "2110-11-11 19:00:00"} |
12733064-RR-34 | 258 | ## INDICATION:
woman with flank pain shortness of breath status post
drainage of a suprarenal abscess with flank pain and shortness of breath.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 14.2 s, 0.2 cm; CTDIvol = 242.8 mGy (Body) DLP =
48.6 mGy-cm.
3) Spiral Acquisition 6.2 s, 69.1 cm; CTDIvol = 7.6 mGy (Body) DLP = 521.3
mGy-cm.
Total DLP (Body) = 572 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS WITH CONTRAST)
## FINDINGS:
The thyroid is normal. Supraclavicular, axillary, mediastinal and hilar lymph
nodes are not enlarged. Aorta and pulmonary arteries are normal size. Cardiac
configuration is normal and there is no appreciable coronary calcification.
The airways are patent to the subsegmental level. There is no pericardial
effusion. There is no worrisome pulmonary nodule. Moderate left greater than
right dependent atelectasis is noted. There is a trace left pleural effusion.
This study is not tailored for evaluation of subdiaphragmatic structures,
please see separately submitted report of the CT abdomen and pelvis.
## IMPRESSION:
1. Moderate dependent atelectasis at the left lung base with a trace
associated pleural effusion. Otherwise normal chest CT.
2. Please see the separately submitted report of the same day CT Abdomen and
Pelvis for findings below the diaphragm.
## NOTIFICATION:
The findings were discussed by Dr. with Dr.
on the telephone on at 4:00 , 2 minutes after the
discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12733064", "visit_id": "N/A", "time": "2126-02-08 14:28:00"} |
12695005-RR-86 | 85 | ## HISTORY:
female status post intubation, to assess for the
position.
## FINDINGS:
The patient is signifcantly rotated. The ET tube has its tip approximately 37
mm from the carina. The NG tube is projected over the stomach. There is a
right- sided central line with the tip projected over the right atrium. There
are bibasal (L>R) effusions along with pneumonic consolidation in the left
lower lobe.
## CONCLUSION:
Bibasal effusions with a pneumonic consolidation in the left lower lobe.
Please ensure followup to clearance.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12695005", "visit_id": "24869134", "time": "2117-11-04 16:56:00"} |
13585703-RR-33 | 116 | CT ABDOMEN AND PELVIS WITH IV CONTRAST
## INDICATION:
woman with renal cell carcinoma, reevaluate for
clinical trial. Please generate oncology table.
CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST
## IMPRESSION:
1. Increase in size of several lung nodules that are depicted at the lung
bases. Please note that a full chest CT was not requested.
2. No new lesions identified. No evidence for retroperitoneal
lymphadenopathy.
Please note that an oncology table cannot be performed on this study since
multiple of the target lesions are only seen on the chest portion of the
examination and not depicted on this study of the abdomen and pelvis (only
lesion number 5 is included in the present study).
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13585703", "visit_id": "N/A", "time": "2129-07-30 11:51:00"} |
15309754-DS-16 | 996 | ## CHIEF COMPLAINT:
Desire for revisions s/p left flap surgery
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
1. Left breast reconstruction revision including re-positioning
of the flap, fat necrosis excision, redundant skin
excision,
repositioning of the infra mammary fold
2. Right breast reduction for symmetry, Wise pattern inferior
pedicle
3. Revision of right abdominal donor site skin contour
irregularity.
## HISTORY OF PRESENT ILLNESS:
year old female who is s/p Left immediate flap
reconstruction following left skin-sparing mastectomy
/ / ) on . She has since undergone and
completed chemotherapy. She is now ready for revisions which
will be completed in 2 stages. Today is stage 1 including;
Right lateral abdomen dog ear revision, L breast reconstruction
revision and fat necrosis excision and Right breast reduction
for symmetry.
## PAST MEDICAL HISTORY:
varicoise veins, rhinitis, breast cancer, colonic adenoma,
hypercholesterolemia, hypothyroid
## FAMILY HISTORY:
mother with breast cancer
## PHYSICAL EXAM:
Physical exam per PRS post op check note :
VSS
## GEN:
NAD, A&Ox3, lying on stretcher.
## R:
Breathing comfortably on NC. No wheezing.
## BREASTS:
Bra in place. R breast wise pattern incisions cdi w
dermabond, NAC well perfused pink. No oozing. L breast circular
incision well approximated, no oozing. Drain SS. nitropaste to
bl breasts.
R abdomen incis cdi w steris intact.
## BRIEF HOSPITAL COURSE:
The patient was admitted to the plastic surgery service on
and had a R lateral abdomen dog ear revision, L breast
revision with fat necrosis excision, and R balancing reduction
mammoplasty. The patient tolerated the procedure well.
.
## NEURO:
Post-operatively, the patient received IV pain
medication with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
.
## CV:
The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
## PULMONARY:
The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
## GI/GU:
Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. Intake and output were closely
monitored.
.
## PROPHYLAXIS:
The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
At the time of discharge on POD#1, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. Incisions intact, no evidence of hematoma, JP x 1
with serosang fluid, surgibra in place.
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*1
## DISCHARGE DIAGNOSIS:
1. Previous left breast cancer treated with lumpectomy and
radiation
2. Second left breast cancer, s/p skin sparing mastectomy and
immediate autologous reconstruction with flap
3. Asymmetry between the reconstructed left breast and the
native
right breast, with the right breast being significantly larger
4. Abdominal flap donor site contour irregularity requiring
revision
5. flap fat necrosis, superior and medial hollowing, ptosis
## PERSONAL CARE:
1. You may leave your incisions open to air or you may cover
them with a clean, dry dressing daily.
2. Clean around the drain site, where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s)
times per day.
4. A written record of the daily output from your drain should
be brought to every follow-up appointment. Your drain will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower daily. No baths until instructed to do so by
Dr. .
6. Continue to wear your surgibra for support. You may remove
for laundering and showering.
.
## ACTIVITY:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. .
.
## MEDICATIONS:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate
to severe pain. You may switch to Tylenol or Extra Strength
Tylenol for mild pain as directed on the packaging.
3. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
4. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
## 1. SIGNS OF INFECTION:
fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or
drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms
that concern you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15309754", "visit_id": "28868639", "time": "2143-08-15 00:00:00"} |
10383113-RR-29 | 137 | ## INDICATION:
Patient is a male status post line placement. For
interval evaluation.
## FINDINGS:
Material external to the patient overlies the mid abdomen obscuring
the radiograph at this level. There has been interval placement of a right
subclavian approach central venous catheter with tip terminating within the
right atrium. Extensive bibasilar opacification is redemonstrated that likely
represents a combination of atelectasis and effusion, though underlying
pneumonia is not excluded. Mild pulmonary vascular congestion. Stable
cardiomediastinal silhouette. Multilevel degenerative change.
Known pneumoperitoneum as seen on concurrent CT examination.
## IMPRESSION:
1. Known pneumoperitoneum as seen on concurrent CT examination.
2. Central venous catheter with tip terminating likely within the right
atrium.
3. Bibasilar opacification likely representing of atelectasis and effusions
though pneumonia is not excluded. Mild uplmonary interstitial edema.
These findings were discussed with Dr. at 5:30AM.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10383113", "visit_id": "N/A", "time": "2143-03-25 23:01:00"} |
18951529-DS-7 | 889 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
woman with frequent falls and generalized weakness, with
particular difficulty climbing out of a chair or getting out of
bed. She notes this has been gradually progressive over about
the last 6 months but particularly worse in the last several
weeks. She says her legs feel "like jello," and she has to sit
down from standing but then cannot get up. Yesterday she fell
twice in one day, so she called her life alert line. She also
reports mild muscle soreness in her upper thighs. She has had
chronic right shoulder pain, and her rheumatologist at told
her she has a "frozen shoulder" and is treating her with a
lidocaine patch. She lives independently and reports eating and
drinking normally. She denies fever, chills, chest pain,
dyspnea, nausea, vomiting, diarrhea, melena, hematochezia, or
rash. She reports dysuria x6 weeks after a pessary was removed.
She also has constipation.
## IN THE ED:
VS: 97.9 52 130/55 18 98% on RA. She was given
aspirin 325mg.
## ROS:
10 point review of systems negative except as noted above.
## DM2:
was on glyburide which was recently d/c'd, not on meds
Hypothyroid
Hypercholesterolemia
OA
Hiatal hernia
Cholecystectomy
TAH
cataract surgery
pelvic organ prolapse, pessary removed due to pain
## VS:
T 97.2 HR 43 BP 93/54 RR 18 Sat 96% RA
## GEN:
elderly woman in NAD
## EYE:
extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
## ENT:
mucus membranes dry, no ulcerations or exudates
## NECK:
no thyromegally, JVD: flat
## CARDIOVASCULAR:
brady but regular rhythm, normal s1, s2, no
murmurs, rubs or gallops
## RESPIRATORY:
Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
## ABD:
Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
## EXTREMITIES:
thigh muscles tender on palpation, no cyanosis,
clubbing, edema, joint swelling
## NEUROLOGICAL:
Alert and oriented x3, CN II-XII intact, hip
flexion, else , DTR's 1+ bilaterally
## INTEGUMENT:
Multiple scattered ecchymosis related to falls,
otherwise warm, moist, no rash or ulceration
## PSYCHIATRIC:
appropriate, pleasant, not anxious
## HEMATOLOGIC:
no cervical or supraclavicular LAD
## MICROBIOLOGY:
Urine Cx - mixed bacterial flora
## STUDIES:
CT C spine -
1. No evidence of fracture or malalignment with normal
prevertebral soft
tissues.
2. Severe degenerative changes with mild encroachment on the
ventral spinal canal - if cord injury is a clinical concern, MR
is recommended.
CT Head -
1. No acute intracranial process.
2. Age-related atrophy.
## BRIEF HOSPITAL COURSE:
yo woman with generalized weakness (proximal > distal),
recurrent falls, mildly elevated CPKs, and hypovolemic
hyponatremia.
##
1. HYPOVOLEMIC HYPONATREMIA:
Improved with isotonic saline.
Patient was advised to increase her daily fluid intake. She
should have her sodium rechecked on to ensure stability.
2. Proximal muscle weakness, with mildly elevated CPK: Ddx
includes polymyalgia rheumatica or polymyositis, vitamin D
deficiency, adverse effect of statin. Rheumatology was consulted
and did not think she has a rheumatologic disorder. Her
lovastatin was discontinued and she was started on vitamin D
empirically. Physical Therapy was consulted and they recommended
rehab.
##
3. PRESUMED URINARY TRACT INFECTION:
treated with cipro x 3 days
4. DM type II, uncontrolled without complications: Patient
reported being diet-controlled after her doctor stopped her
glyburide. On the first hospital day, her glucose was >200.
HbA1C was 7.2%, and glyburide was restarted at 2.5mg once daily.
##
5. RIGHT SHOULDER ADHESIVE CAPSULITIS:
diagnosed by her primary
rheumatologist (Dr. at , treated with lidoderm
patch.
## MEDICATIONS ON ADMISSION:
levothyroxine 75mcg 5 days/wk, 112 2 days/wk
lidoderm patch to right shoulder
lovastatin 10mg daily
## DISCHARGE MEDICATIONS:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
( ).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,FR).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Outpatient Lab Work
Please have your chem 7 (sodium, potassium, chloride,
bicarbonate, BUN, Creatinine, and glucose) checked on
.
## DISCHARGE DIAGNOSIS:
1. Probable vitamin D deficiency
2. Hypovolemic hypovolemia
## 3. URINARY TRACT INFECTION:
treated with ciprofloxacin x 3 days
4. Diabetes mellitus type II, uncontrolled without complications
5. GERD
6. Osteoarthritis
7. Hypothyroidism
8. Hyperlipidemia
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were admitted with generalized weakness and recurrent falls.
You reported mild soreness in your legs, and as your muscle
enzymes were mildly elevated, we discontinued your lovastatin,
as this may be an adverse effect of this medication. We also
consulted the Rheumatology doctors for opinion about a
possible disorder causing your symptoms, but they do not think
you have one. We started you on vitamin D, as vitamin D
deficiency is very common and causes weakness and falls
especially in the elderly. You were also quite dehydrated, and
this was corrected with IV fluids. Please try to drink plenty of
water and non-caffeinated beverages every day, especially in the
hot weather as dehydration can also make you weak and prone to
falls. Lastly, your blood sugar was mildly elevated, and we
started you back on low-dose glyburide. Please follow-up with
your primary care doctor on these issues.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18951529", "visit_id": "25248258", "time": "2123-12-26 00:00:00"} |
13114102-RR-30 | 361 | ## EXAMINATION:
CT PELVIS W/O CONTRAST
## HISTORY:
with concern for nec fasc L labia*** WARNING ***
Multiple patients with same last name!// eval for SubQ gas
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.3 s, 41.6 cm; CTDIvol = 14.0 mGy (Body) DLP = 582.2
mGy-cm.
Total DLP (Body) = 582 mGy-cm.
## PELVIS:
No bowel obstruction within the partially visualized small large
bowel. There is a partially seen left lower quadrant bowel anastomosis. The
urinary bladder and distal ureters are unremarkable. There is trace free fluid
in the pelvis.
## REPRODUCTIVE ORGANS:
The uterus and bilateral adnexae are grossly within
normal limits.
## LYMPH NODES:
There is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
No atherosclerotic disease is noted. A right-sided femoral line
terminates in the right common femoral vein.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
Severe anasarca diffusely. There is thickening and stranding
the left pleural near the posterior left labia (series 2, image 44). An area
of density consistent with fluid is seen along the inferior left groin
extending into the perineum measuring 3.4 x 1.3 cm (series 2, image 44).
There is asymmetric thickening of the left perennial compared to the right
which could reflect phlegmonous change or cellulitis (series 2, image 48).
Several small locules of air are seen along the subcutaneous fold without any
definite subcutaneous emphysema. There is a tiny locule of gas along the
superficial soft tissues which appears to be located at a wound site (series
601, image 22), may represent a tract.
## IMPRESSION:
1. 3.4 x 1.3 cm fluid collection within the left groin with surrounding soft
tissue thickening and edema which extends into the left perineum, suggestive
of an overlying cellulitis.
2. No subcutaneous emphysema within the deep fascia to indicate necrotizing
fasciitis, however this finding is inconsistent. There is no substantial
thickening of the superficial fascial layers within the limits of diffuse
background anasarca. A tiny focus of air along a break in the left inferior
labial skin likely represents ulceration or a wound track.
3. Trace free fluid in the pelvis, otherwise no acute intrapelvic findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13114102", "visit_id": "23387876", "time": "2168-04-28 02:06:00"} |
15439394-DS-22 | 1,101 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## ATTENDING:
Complaint:
Left shoulder osteoarthritis
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
left total shoulder arthroplasty
## HISTORY OF PRESENT ILLNESS:
with advanced left shoulder osteoarthritis who failed
conservative management.
## PAST MEDICAL HISTORY:
# HTN
# Atypical chest tightness - nml P-MIBI in
# OA
# Hypothyroidism
# Right TKR
# ?restrictive lung disease (no PFTs, on albuterol)
# Acute cholecystitis
# Chronic pain (hands/back/knees)
# Lumbar spondylosis and spinal canal stenosis
# Synovitis
# Possible SLE
# Elevated LFT's - no hepatitis, hemochromatosis, negative
but positive, diffuse fatty infiltration on US (likely )
## PHYSICAL EXAM:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
## NEUROLOGIC:
Intact with no focal deficits
## MUSCULOSKELETAL UPPER EXTREMITY:
* Incision healing well with staples - no erythema, warmth,
or drainage
* Scant serosanguinous drainage
* mild to moderate dependent edema and ecchymosis
* sensory/motor intact to m/u/r nerve distributions
* axillary n. intact
* 2+ radial pulse
## BRIEF HOSPITAL COURSE:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for a left total shoulder
arthroplasty. Please see operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Pain was initially controlled with a PCA
followed by a transition to oral pain medications on POD#1. The
patient received IV antibiotics for 24 hours postoperatively.
The foley was removed on POD#2 and the patient was voiding
independently thereafter. The surgical dressing was changed on
POD#2 and the surgical incision was found to be clean and intact
without erythema or abnormal drainage.
While in the hospital, the patient was seen daily by physical
and occupational therapy. Labs were checked throughout the
hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. On POD#1 became febrile to 102. Fever work-up, to
include blood and urine cultures, and a chest xray, was
negative. At discharge, the patient was afebrile with stable
vital signs. The patient's hematocrit was acceptable and pain
was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
The patient progressed well with physical therapy.
Post-operative Xrays demonstrated hardware in good position. The
patient was discharged in stable condition. The patient's
nonweightbearing to the LUE with sling at all times except for
pendulums.
## MEDICATIONS ON ADMISSION:
amlodipine 5 QD, prevpac (amox/clarithro/lansopraz ,
hctz 25, hydroxycloroquine 400 qd, levothyroxine 50mcg qd,
metformin 500 BID, prilosec 40 EC QD, oxybutynin 10 EC QD PRN,
simvastatin 20qd, diovan 320 qd, aspirin 81 qd
## DISCHARGE MEDICATIONS:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) as needed for spasms.
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
## 10. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY
(Daily).
11. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
## 12. HYDROCODONE-ACETAMINOPHEN MG CAPSULE SIG:
Tablets
PO Q6H (every 6 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
## DISCHARGE INSTRUCTIONS:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool
softener (such as colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
days after surgery, but no tub baths or swimming for at least
four weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by the visiting nurse or rehab facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
## 9. WOUND CARE:
Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four week
checkup. Please place a dry sterile dressing on the wound each
day if there is drainage, otherwise leave it open to air. Check
wound regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
11. (once at home): Home , dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Nonweightbearing in Left upper extremity. Sling at
all times. Pendulums only.
## PHYSICAL THERAPY:
Nonweightbearing of left arm. Sling at all times. Pendulums
## TREATMENTS FREQUENCY:
Please keep your incision clean and dry. It is okay to shower
five days after surgery but no tub baths, swimming, or
submerging your incision until after your four week checkup.
Please place a dry sterile dressing on the wound each day if
there is drainage, otherwise leave it open to air. Check wound
regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15439394", "visit_id": "28333561", "time": "2198-11-24 00:00:00"} |
18558396-RR-30 | 422 | ## INDICATION:
year old woman with possible vesico-uterine fistula // ?
bladder leak or fistula
## BOWEL:
The partially visualized small and large bowel are unremarkable.There
is no free fluid in the pelvis.
## BLADDER AND URETERS:
A Foley catheter is noted in the urinary bladder. There
is no distal hydroureter. The increased soft tissue seen along the posterior
aspect of the bladder is decreased since the CT. Several small
calcifications are now within the bladder, which are new. There is an oblong
area of calcification just posterior to the main part of the bladder and
anterior to the uterus, which has a decreased volume of calcification compared
to the preoperative CT, measuring 1.9 x 0.9 x 3.1 cm now and
previously 2.0 x 1.3 x 2.8 cm (series 6: Image 27 and series 753b: Image 17).
This is likely a collection of stones in a pseudodiverticulum or diverticulum
present before the surgery with some of the stones having entered the main
part of the bladder after the surgery. Contrast administered through the
Foley catheter is in direct contact with the calcifications that appear
posterior to the bladder again suggesting that these calcifications are in
communication with the bladder. No contrast is seen posterior to the
calcification between the bladder and the uterus or vagina. There is a small
amount of contrast noted at the urethral orifice.
## REPRODUCTIVE ORGANS:
There are several calcified fibroids in the uterus.
Contrast material administered through the Foley catheter is seen in the
vagina. There is no distinct connection between the vagina or uterus and
bladder to suggest fistula formation.
## LYMPH NODES:
There is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
Mild atherosclerotic disease is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Interval decrease in the size of oblong calcifications along the posterior
aspect of the bladder and anterior to the uterus, likely stones in a
pseudodiverticulum or diverticulum of the bladder as it has decreased in size,
there are new stones in the bladder postoperatively with decreased soft tissue
on the posterior bladder wall, and the contrast administered through the Foley
cathater contacts the calcifications that appear posterior to the bladder.
2. No definite contrast seen extending between the vagina or uterus and
bladder to suggest fistula formation, though there is contrast in the vagina.
This may be due to retrograde reflux of contrast that passed around the Foley
catheter out the urethra.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18558396", "visit_id": "23922390", "time": "2140-10-20 09:19:00"} |
10866343-DS-14 | 1,303 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Intoxication, s/p assault, hypoxia
## HISTORY OF PRESENT ILLNESS:
w/ hx of ETOH abuse, pancreatitis brought in by EMS for
intoxication and complaining of assault on . States
that he has had "too much to drink" today, and that he states he
was jumped last night in . Complains of
intermittent headache.
Of note, patient has had multiple recent ED visits for
intoxication, but has not expressed interest in alcohol
cessation.
In the ED, initial vitals were: 96.8 72 119/72 17 97% 2L Nasal
Cannula. Labs significant for WBC 4.9, unremarkable
electrolytes, mild transaminitis, normal lactate. CT head
unremarkable. CT without evidence of fracture. CXR with
RLL infiltrate concerning for pneumonia. given poor social
support and chronic homelessness, patient admitted for eval and
treatment. Patient given IV levofloxacin in ED.
On the floor, patient reports that he has had increased dyspnea
and productive cough for the past month following an upper
respiratory infection. He reports progressive shortness of
breath to the point where he can no longer climb a flight of
stairs without stopping. He denies fevers, although he does
report periodic chills. Denies chest pain, chest pressure,
orthopnea, leg swelling. Feels that he is starting to withdraw
from alcohol, and reports nausea and tremulousness. He does
report that he has had withdrawal seizures, which have been new
over the past year. He drinks about a pint of vodka per day, and
his last drink was this morning. He reports that he previously
quit drinking for about a year when he had a job; he does not
think that it would be possible for him to quit now because "I'm
homeless, what else would I do?".
## 1. ALCOHOL ABUSE:
1 pint/day. reports hx of 2 withdrawal
seizures.
## 2. TOBACCO ABUSE:
PPD
3. Bilateral foot fungal cellulitis
4. Appendectomy as teen
5. Pancreatitis
6. Rash
7. Left shoulder fracture with persistent left shoulder pain
trauma years ago
## GENERAL:
Disheveled but pleasant, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear. poor dentition.
healed scrapes on head.
## LUNGS:
breathing comfortably. poor inspiratory effort on exam
but faint crackles in RLL. no wheezes appreciated
## CV:
mildly tachycardic but regular, normal S1 + S2, no murmurs,
rubs, gallops
## ABDOMEN:
soft, . tender to palpation in RUQ and
epigastrium, no rebound or guarding, mild hepatomegaly
## SKIN:
flaking of skin on feet
## NEURO:
A and O x3. PERRL, EOMI, face symmetric, strength
grossly symmetric.
## GENERAL:
Pleasant, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear. poor dentition.
Healed scrapes on head.
## LUNGS:
CTAB, good respiratory effort.
## CV:
RRR, normal S1 + S2, no murmurs, rubs, gallops
## ABDOMEN:
soft, . tender to palpation in RUQ and
epigastrium, no rebound or guarding, mild hepatomegaly
## EXT:
Trace lower extremity edema
## NEURO:
AAOx3. PERRL, EOMI, face symmetric, strength grossly
symmetric.
## IMAGING:
============
CXR
Vague opacity in the right lower lung adjacent to the cardiac
silhouette is new since . No pulmonary edema, pleural
effusion or pneumothorax. The cardiac and mediastinal contours
are normal. There are old left rib fractures.
## IMPRESSION:
Right lower lung opacity is concerning for pneumonia in the
correct clinical setting.
CT head
No acute intracranial hemorrhage or mass effect.
## CT CHEST :
Small airway infection at the right lung base with focal area of
consolidation within right middle lobe compatible with pneumonia
in the right clinical setting.
## RENAL ULTRASOUND :
A cyst with a single thin septation is located in the upper pole
of the right kidney. Otherwise, normal renal ultrasound. No
is required.
## :
Blood cx x 2 NGTD
## DISCHARGE LABS:
================
No labwork day of discharge.
## BRIEF HOSPITAL COURSE:
y/o homeless male with history of ETOH abuse brought in with
intoxication and history of assault, with 1 month of productive
cough and worsening dyspnea on exertion, RLL opacity on CXR and
CT scan found to be a likely bacterial pneumonia.
# RLL pneumonia:
Patient with progressively worsening cough and dyspnea. CXR and
CT scan indicative of a RLL pneumonia. Given risk factors for
community acquired pneumonia, he was started on Levofloxacin
750mg daily for a total of a 5 day course that was started on
. He responded well to the antibiotics, with
improvement of his oxygen saturation. Prior to discharge, his
ambulatory oxygen saturation was 95%, greatly improved from
admission. Patient also noted subjective decrease in his cough.
# ETOH abuse:
Patient has self reported history of 2 withdrawal seizures from
alcohol. He is dependent on alcohol, and drinks daily with no
breaks in his drinking. He takes a MVI at home, but in the
hospital was provided thiamine, folate, and multivitamin along
with adequate nutrition and electrolyte repletion. The patient
was offered social work assistance and refused it. He was
counseled extensively on the importance of both alcohol and
tobacco cessation, but was for both of these
conversations. He was maintained on CIWA precautions and
provided with Diazepam for CIWA>10. At the time of discharge he
was taking less than 10mg of Diazepam daily for withdrawal sx
and so was provided a 2 day course of 10mg Diazepam after
discharge.
# Transaminitis:
Likely related to ETOH abuse. Hepatitis serologies last checked
in , negative at that time. CT abdomen showed likely hepatic
steatosis . Patient's LFTs were trended as an inpatient,
and should be at his next PCP .
# Anemia:
Mild, macrocytic. His anemia is likely related to folate
deficiency alcohol abuse. Supplemental folate was provided
as noted above.
# Thrombocytopenia
Not present in . Currently stable, and likely alcohol
and/or splenic sequestration. Was stable during hospitalization,
and should also be followed up as an outpatient. If no
improvement after discharge would consider further workup such
as repeat HIV/Hepatitis serologies.
# Right upper pole renal cortical hypodensity:
Seen on CT abdomen on prior hospitalization in . Was
better characterized with a renal ultrasound and found to be a
benign cyst. No further imaging indicated as per radiology.
## TRANSITIONAL ISSUES:
====================
- Follow up with PCP
- ultrasound shows benign cyst, no further imaging needed
- LFTs at next PCP
- 2 day course of Diazepam provided for alcohol withdrawal
FULL CODE
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Ibuprofen 400 mg PO Q8H:PRN left shoulder pain
## DISCHARGE MEDICATIONS:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX 1 capsule(s) by mouth once a day
Disp #*30 Capsule Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30
## TABLET REFILLS:
*0
4. Ibuprofen 400 mg PO Q8H:PRN left shoulder pain
5. Levofloxacin 750 mg PO DAILY Duration: 2 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet
## REFILLS:
*0
6. Diazepam 10 mg PO QD Duration: 2 Days
RX *diazepam 10 mg 1 tablet by mouth once a day Disp #*2 Tablet
Refills:*0
## PRIMARY:
Bacterial Pneumonia
Alcohol Abuse
Transaminitis
Anemia
Thrombocytopenia
## DISCHARGE INSTRUCTIONS:
Mr. ,
You came to due to a severe
cough. You were found to have pneumonia, and treated with
antibiotics. Your cough improved prior to discharge, and during
your stay you had no fevers or chills. After leaving the
hospital it is important that you complete your entire course of
medication.
During your hospitalization a social worker offered to speak
with you, but you were not interested in meeting with them. In
addition, you were counseled extensively on the importance of
alcohol cessation. After leaving the hospital if you would like
to seek assistance with your alcoholism, then please call
, a free assistance line run by the state of
.
It has been a pleasure caring for you, and we wish you all the
best.
Kind regards,
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10866343", "visit_id": "28981708", "time": "2167-11-29 00:00:00"} |
12602264-RR-74 | 111 | ## INDICATION:
Right breast asymmetry/distortion identified on screening .
## RIGHT DIGITAL DIAGNOSTIC MAMMOGRAM:
True lateral, MLO spot, CC spot and ML
spot views were obtained. The distortion identified within the posterior
upper slightly inner right breast on the screening mammogram does not persist
with the additional imaging. No dominant mass, architectural distortion, or
suspicious microcalcifications are noted. Benign vascular calcifications are
identified. There has been no significant change from .
## RIGHT BREAST ULTRASOUND:
The upper right breast was examined. No solid or
cystic lesions are identified.
## IMPRESSION:
No evidence of malignancy. Findings on the screening mammogram
due to superimposed normal breast parenchyma. Annual screening mammography is
recommended.
BI-RADS 2 - benign.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12602264", "visit_id": "N/A", "time": "2146-07-16 08:52:00"} |
15889331-RR-66 | 262 | ## INDICATION:
year old man with stoke requiring GJ tube // routine GJ tube
exchange
## OPERATORS:
Dr. , attending radiologist,
performed the procedure. Dr. supervised the trainee
during the key components of the procedure and has reviewed and agrees with
the trainee's findings.
## ANESTHESIA:
Lidocaine jelly was used for local anesthesia
## CONTRAST:
20 ml of Optiray
## PROCEDURE:
18 MIC gastrojejunostomy exchange.
## PROCEDURE DETAILS:
Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient's proxy. The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
protocol. The tube site was prepped and draped in the usual sterile
fashion.
The stay suture was cut and a 0.035 stiff Glidewire wire was introduced
through the gastric port and negotiated along side the jejunal portion of the
catheter. The balloon was taken down and removed over the wire. A new, 18
MIC gastrojejunostomy tube was advanced over the Glidewire into
position under fluoroscopy. The balloon was inflated and pulled back against
the anterior wall of the stomach. The wire was removed. Contrast was
administered through the jejunostomy and gastrostomy lumens to confirm
appropriate positioning. Fluoroscopic images were stored. The lumens were
flushed and capped. The tube was then secured and dressed. The patient
tolerated the procedure well without any immediate complications.
## FINDINGS:
1. Appropriately positioned new 18 MIC gastrojejunostomy tube.
## IMPRESSION:
Successful exchange of a gastrojejunostomy tube for a new 18 MIC
gastrojejunostomy tube. The tube is ready to use.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15889331", "visit_id": "N/A", "time": "2155-02-26 12:58:00"} |
19341663-RR-85 | 58 | GE DIGITAL LEFT DIAGNOSTIC MAMMOGRAM WITH COMPUTER-AIDED DETECTION:
## INDICATION:
Patient is status post left lumpectomy for DCIS in .
Mammogram is performed to assess presence of residual calcifications.
## IMPRESSION:
No residual calcifications seen in the left retroareolar region.
Findings were discussed with the patient and her daughter.
BI-RADS 6 - Known carcinoma. Appropriate action should be taken.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19341663", "visit_id": "N/A", "time": "2131-08-22 09:37:00"} |
13313653-RR-9 | 211 | ## INDICATION:
female with pelvic pain times several months,
intermittent nausea and emesis with increased right lower quadrant pain and
vaginal discharge x5 days.
## FINDINGS:
The lung bases are clear. There are no pleural effusions. The
heart is normal in size, without pericardial effusion.
## ABDOMEN:
The liver enhances homogeneously on this single phase examination.
Gallbladder is partially collapsed. The pancreas is normal. There is no
intra- or extra-hepatic biliary ductal dilation. The spleen is normal in
size.
The adrenals are normal. Kidneys enhance and excrete contrast promptly and
symmetrically, without masses or hydronephrosis.
The stomach and small bowel are normal.
## PELVIS:
In the left ovary, there is a 2.6 x 2 cm peripherally enhancing and
crenulated cyst. Small amount of layering simple free fluid is present in the
pelvis. The uterus and right ovary are normal. There is no free air.
The appendix is nondilated and filled with air. There is a moderate amount of
retained fecal material throughout the colon. The bladder and distal ureters
are normal.
There is minimal retrolisthesis and moderate loss of disc height at L5-S1,
with broad-based posterior disc bulge that abuts the ventral thecal sac.
## IMPRESSION:
1. Crenulated left ovarian cyst with free fluid, suggesting recent rupture.
2. Normal appendix.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13313653", "visit_id": "N/A", "time": "2139-02-28 00:02:00"} |
12836543-RR-13 | 353 | ## INDICATION:
with RLQ abd pain evaluate for appendicitis or perforation.
## DOSE:
Study was performed at an outside hospital. Reported total DLP =
380.93 mGy-cm.
## LOWER CHEST:
Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
Multiple renal hypodensities bilaterally are too small to fully characterize
but likely represent simple cysts. There is no perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is markedly enlarged measuring
up to 2.8 cm in greatest axial diameter (2:100). There is extensive
associated mucosal hyperemia and surrounding fat stranding with reactive
adenopathy. There are focal areas of nonenhancing mucosa worrisome for
ischemia of (2:105, 103). There is no associated drainable fluid collection
or pneumoperitoneum.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is
small volume free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The visualized reproductive organs are unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
An umbilical hernia containing fat is noted.
## IMPRESSION:
Acute appendicitis with periappendiceal phlegmon and findings worrisome for
ischemia of the wall. No drainable fluid collection or pneumoperitoneum.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 1:01 pm, 2 minutes after
discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12836543", "visit_id": "28116548", "time": "2118-05-20 01:10:00"} |
19230021-RR-161 | 177 | ## EXAMINATION:
BILATERAL SCREENING BREAST MRI WITH AND WITHOUT INTRAVENOUS
CONTRAST
## INDICATION:
year old woman with personal hx DCIS status post lumpectomy in
, breast ca, dense breast tissue (C) on // baseline high risk
screening r/o malignancy
## AMOUNT OF FIBROGLANDULAR TISSUE:
Heterogeneous fibroglandular tissue.
The right breast is smaller than the left breast. There are posttreatment
changes in the right breast. There is no suspicious enhancing mass, non-mass
enhancement, architectural distortion, nipple retraction or skin thickening.
No axillary or internal mammary lymphadenopathy is present.
There is an irregular pleural-based 1.7 x 1.6 cm area of enhancement in the
right anterior chest which displays washout kinetics on delayed phase. No
abnormality is identified in the visualized upper abdomen.
## IMPRESSION:
1. Indeterminate 1.7 cm area of pleural-based enhancement in the right chest.
2. No evidence of malignancy in the breasts.
## RECOMMENDATION(S):
1. Chest CT.
2. Age and risk appropriate breast screening.
## NOTIFICATION:
The findings and recommendations were communicated to
by via telephone at 2:18 on Chest CT scan is
recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19230021", "visit_id": "N/A", "time": "2175-11-28 16:22:00"} |
19533730-RR-46 | 106 | ## INDICATION:
Mucus plug, obesity, evaluation.
## FINDINGS:
As compared to the previous radiograph, there is a new subcomplete
opacification of the left hemithorax, with only a minimal portion of left lung
parenchyma remaining ventilated. The displacement of the mediastinum towards
the left is strongly suggestive of an atelectatic process, potentially caused
by a mucus plug. In the right lung, the pre-existing opacities are not
substantially changed and likely represent a combination of pulmonary edema
and infection.
At the time of dictation and observation, 7:41 a.m., on , the
referring physician was paged for notification. Findings were
discussed over the telephone one minute later.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19533730", "visit_id": "24894429", "time": "2192-08-04 03:57:00"} |
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