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11775105-RR-22 | 264 | CT HEAD WITHOUT CONTRAST, .
## HISTORY:
male with left thalamic "hemorrhage"; follow-up.
## FINDINGS:
The study is compared with the NECT of and non-enhanced
cranial MRI/MRA of . The small somewhat comma-shaped hyperattenuating
focus in the lateral aspect of the left thalamus is completely unchanged in
size, configuration and attenuation. It demonstrates no adjacent edema or
mass affect. This lesion demonstrates heterogeneous internal signal,
including a central T1-hyperintense focus, with substantial "blooming"
susceptibility artifact on the MR study, imaging characteristics strongly
suggestive of cavernous angioma. Its stability over this nearly three-month
interval would support this diagnosis.
There is no intra- or extra-axial hemorrhage at this site or elsewhere, the
midline structures are in the midline and the ventricles and cisterns are
unchanged in size and configuration, with slight asymmetric prominence of all
components of the left lateral ventricle, likely on a congenital/developmental
basis. The gray-white matter differentiation is maintained throughout with no
evidence of cerebral edema or other space-occupying lesion, and the posterior
fossa structures are grossly unremarkable. There is a small likely
mucus-retention cyst in the region of the left spheno-ethmoidal recess, but
the included paranasal sinuses, as well as the mastoid air cells and middle
ear cavities are otherwise clear. Incidentally noted is atherosclerotic mural
calcification involving the cavernous and supraclinoid carotid arteries.
## IMPRESSION:
Stable 8.5 mm hyperattenuating focus in the lateral aspect of the left
thalamus likely represents an "occult" cavernous angioma, with no evidence of
associated acute hemorrhage. Unless additional symptoms supervene, no further
imaging follow-up is recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11775105", "visit_id": "N/A", "time": "2174-12-28 15:42:00"} |
19598699-RR-43 | 175 | ## INDICATION:
male with cirrhosis and ascites awaiting transplant.
Please do ultrasound-guided therapeutic paracentesis and send fluid for cell
count and culture.
## PROCEDURE:
Following explanation of the risks, benefits, and alternatives to
the procedure, written informed consent was obtained. A preprocedure timeout
was performed, verifying patient identity with three patient identifiers.
Preprocedure ultrasound demonstrated a moderate amount of ascites in the lower
quadrants bilaterally and a suitable spot was chosen for diagnostic and
therapeutic paracentesis in the left lower quadrant. Overlying skin and
subcutaneous tissues were anesthetized with 1% lidocaine, following
preparation of the area in standard sterile fashion. An catheter was
advanced into the pocket of ascites and 20 cc of straw- colored ascitic fluid
was aspirated and sent for cell count and culture as requested by the clinical
team. An additional 3.5 liters of ascitic fluid was drained into vacuum-sealed
containers.
The patient tolerated the procedure well and there were no immediate
complications.
Dr. attending radiologist, was present and supervising throughout.
## IMPRESSION:
Successful ultrasound-guided diagnostic and therapeutic
paracentesis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19598699", "visit_id": "N/A", "time": "2127-03-10 14:12:00"} |
16882192-RR-100 | 95 | ## EXAMINATION:
DUP EXTEXT BIL (MAP/DVT)
## INDICATION:
year old man with chronic lower extremity edema // ?DVT,
?venous insufficiency
## FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins. There is one
area of reflux within the distal left tibial vein.
There is normal phasic respiratory variation in the common femoral veins
bilaterally.
No evidence of medial popliteal fossa ( ) cyst.
## IMPRESSION:
No evidence of DVT or reflux in the bilateral lower extremity veins.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16882192", "visit_id": "N/A", "time": "2158-05-31 11:00:00"} |
16024297-RR-50 | 795 | ## EXAMINATION:
CT abdomen and pelvis with contrast
## INDICATION:
man with a history of Hodgkin's lymphoma, non-small
cell lung cancer, status-post resection, and recently status-post Cyberknife
for a right lower lobe nodule that was suspicious for new primary /metastatic
disease. Assess response to CyberKnife and rule out disease recurrence.
## ONCOLOGY 2 PHASE:
Multidetector CT of the abdomen and pelvis was
performed as part of CT torso with intravenous contrast. A single bolus of
intravenous contrast was injected and the abdomen and pelvis were scanned in
the portal venous phase, followed by scan of the abdomen in the equilibrium
(3-min delay) phase. Coronal and sagittal reformations were performed and
reviewed on PACS.
## IV CONTRAST:
150 mL Omnipaque.
Oral contrast was administered.
## LOWER CHEST:
Please refer to the dedicated CT chest report from the same day
for description of the thoracic findings, including calcified pleural plaques
consistent with prior exposure to asbestos, as well as emphysematous changes.
## 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 nondistended with
calcified, nonobstructing stone/s (series 2, image 66).
## PANCREAS:
Diffuse fatty atrophy of the pancreas is unchanged. The pancreas
has normal attenuation throughout, without evidence of focal lesions or
pancreatic ductal dilatation. No peripancreatic stranding.
## SPLEEN:
The spleen is normal in size. A 4-mm subcapsular hypodensity is too
small to accurately characterize on CT, but is unchanged since at least
and most likely a hemangioma or small cyst (series 2, image 54; series 601b,
image 51). No suspicious focal splenic lesion. The remaining spleen
parenchyma is homogeneous in attenuation.
## ADRENALS:
Diffuse thickening of the bilateral adrenal glands is overall
unchanged since (series 601b, image 51; series 2, image 50, 62), possibly
reflecting cortical hyperplasia. Apparent thickening of the right adrenal
gland may be from partial volume averaging.
## URINARY:
The kidneys are of normal and symmetric in size with normal
nephrograms. Multiple, bilateral hypodense renal cortical lesions, are
unchanged, and are most likely. The largest cyst is in the right upper renal
pole and measures 5.7 x 5.7 cm (series 2, image 61). No perinephric
stranding. No suspicious focal renal lesion. No hydronephrosis. The
partially distended urinary bladder is unremarkable.
## GASTROINTESTINAL:
A hiatal hernia is small. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Scattered colonic
diverticulosis is demonstrated. The rectum are within normal limits. No
bowel obstruction, intra-abdominal fluid collection, peritoneal masses, or
free air.
## PELVIS:
No free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate is normal in size.
## LYMPH NODES:
Several retroperitoneal lymph nodes are larger and more conspicuous from the
prior exam, the largest measuring 1.2 cm in maximum dimension in the
para-aortic region (series 2, 84). The next largest node measures
approximately 1 cm, also periaortic (series 2, image 79).
A right pelvic sidewall lymph node measures approximately 4 mm and
demonstrated mildly increased FDG avidity on PET in (series 2, image
115). A left pelvic sidewall node measures approximately 6 mm and also
demonstrated mildly increased FDG and dated in (series 2, image 115).
These nodes are not enlarged by CT size criteria.
No inguinal lymphadenopathy by CT size criteria.
## VASCULAR:
The patient is status-post EVAR of an infrarenal abdominal aortic
aneurysm that now measures 4.3 x 3.9-cm, unchanged from (series 2,
image 81; series 602b, image 44). The EVAR extends from the renal arteries to
both common iliac arteries. No evidence of endoleak or periaortic fluid.
Extensive atherosclerotic disease is overall unchanged.
## BONES:
No evidence of worrisome osseous lesions or acute fracture.
Multilevel, degenerative changes with Schmorl's nodes, are mild-to-moderate
and overall unchanged.
## SOFT TISSUES:
A right-sided fat-containing inguinal hernia is small (series
2, image 119). The abdominal and pelvic wall is otherwise within normal
limits.
## IMPRESSION:
1. New retroperitoneal lymphadenopathy, the largest a 1.2-cm paraaortic node.
The distribution favors recurrent lymphoma, and appears less typical for lung
cancer metastasis.
2. Bilateral pelvic side wall lymph nodes that had FDG avidity on the PET-CT
in are redemonstrated but are not enlarged by CT size criteria.
Attention on follow-up recommended.
3. Bilateral adrenal gland thickening, unchanged from .
4. Status-post EVAR of an infrarenal abdominal arotic aneurysm, measuring 4.3
x 3.9 cm and similar to . No endoleak.
5. Diverticulosis.
6. Small hiatal hernia. Small fat-containing right umbilical hernia.
7. Cholelithiasis.
9. Please refer to the dedicated CT chest report from the same day for
thoracic findings.
## NOTIFICATION:
The impression and recommendation above was entered by Dr.
on at 12:26 into the Department of Radiology critical
communications system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16024297", "visit_id": "N/A", "time": "2180-02-07 06:58:00"} |
17316172-DS-9 | 1,311 | ## ALLERGIES:
Codeine / Tetracycline / heparin
## CHIEF COMPLAINT:
Invasive squamous cell carcinoma mid-back.
## :
Wide-excision of squamous cell carcinoma mid-back,
split thickness skin graft (right thigh donor site), wound vac
placement. The wound vac was removed on POD 6.
## HISTORY OF PRESENT ILLNESS:
is a man who developed a large ulcerated
lesion of the mid back over an unclear period of time. Shave
biopsy was perforemd on . He
appeared to have a moderately differentiated invasive squamous
cell carcinoma of at least 2 mm in depth.
On , a punch biopsy was performed that showed moderately
differentiated invasive squamous cell carcinoma which extended
to the deep dermal subcutaneous junction. The peripheral
margins were involved with tumor.
## PAST MEDICAL HISTORY:
HIV (dx , undetectable viral load but low CD4 - 114 in , COPD, HSV-2 infection, urethral gonococcal infection,
anal condylomata (pap smears showing LSIL and HSIL, condylomata
diagnosed in and treated x 3 with cryo), possible hepatitis
B (no serologies in OMR), PCP pneumonia in , CMV retinitis
in , chronic low back pain with radiculopathy.
Past surgical history:
past surgical history is significant for high-grade PIN
found at the time of anorectal biopsies in year . In ,
he had negative biopsies. In , he underwent what he
describes as an ERCP for a "block bile duct." He also has
undergone placement of a cardiac drug-eluting stent at an
outside hospital in approximately year .
## FAMILY HISTORY:
Pt reports his mother had lung cancer (was a smoker). No other
history of heart disease, CA, diabetes, or autoimmune disease.
## INCISION:
right thigh donor site dsg c/d/i
mid back recipient site with partially taken split thickness
skin graft, dressed
## EXTREMITIES:
warm well perfused, no edema
## PERTINENT RESULTS:
08:37PM BLOOD WBC-6.1 RBC-3.74*# Hgb-11.7*# Hct-35.9*#
MCV-96 MCH-31.2 MCHC-32.5 RDW-14.2 Plt
10:30PM BLOOD Na-137 K-4.6 Cl-100
08:37PM BLOOD Glucose-96 UreaN-15 Creat-0.7 Na-133
K-7.1* Cl-103 HCO3-19* AnGap-18
08:37PM BLOOD Calcium-8.4 Phos-4.1 Mg-1. year old male with significant PMH of HIV,chronic COPD who
presents with a large mid-back squamous cell carcinoma, now s/p
wide-excision SCC of mid back, STSG (donor site right thigh),
vac placement. Patient tolerated the procedure well and was
transferred to PACU and admitted to surgical ward for
postoperative care.
## NEURO:
Postoperatively pain was controlled with IV pain
medication(morphine,toradol).Once tolerating a diet patient was
transitioned to oral pain medication(oxycodone,tylenol).
## CARDIOVASCULAR:
Postoperatively patient triggered for hypotension
(SBP 80's), and recieved IV fluid bolus and responded well. (SBP
110).
## PULMONARY:
Postoperatively,patient's oxygen desaturated to 89%
on RA and was placed on 3L NC. Chest xray showed no acute
pulmonary process.Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
Patient received nebulizer breathing treatment PRN. His oxygen
was subsequently weaned over the next few days.
## GI/GU/FEN:
Diet was advanced as tolerated and fluids were
discontinued. Postoperatively patient voided without any issues
and maintained good urine output.
## ID:
The patient's white blood count and fever curves were
closely watched for signs of infection of which there were none.
## WOUND:
Right thigh donor site dressing changes were performed as
needed under direction of Dr. . No signs of infection was
noted. Recipient site (mid back) had wound vac for low
continuous suction at 100 mmHg.
## HEMATOLOGY:
Hematocrit was stable;no transfusions were required.
## DVT PROPHYLAXIS:
Subcutaneous heparin and venodyne boots were
used during this stay. Pt ambulated following his surgery with
use of cane.
At time of discharge,the patient was tolerating a regular diet,
ambulating,voiding well, and pain was well-controlled. The
patient received discharge teaching and follow-up instructions.
## :
acyclovir 400'', albuterol sulfate 0.083% neb q4h prn,
aulbuterol sulfate 90mcg 1 puff prn,
emtricitab-rilpivirine-tenofov (Complera) 200-25-300',
fluticasone-salmoterol 500-50'', furosemide 20', gabapentin
300''', lisinopril 2.5', naproxen 500 prn, raltegravir 400'',
bactrim DS', terazosin 5', tiotropium bromide 2 inh', trazodone
100 325
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth three times per day Disp #*50 Tablet Refills:*0
2. Acyclovir 400 mg PO/NG Q12H
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet by mouth two times per day
Disp #*40 Tablet Refills:*0
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Furosemide 20 mg PO DAILY
7. Gabapentin 300 mg PO TID
8. OxycoDONE (Immediate Release) mg PO Q3H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth every hours Disp
#*50 Tablet Refills:*0
9. PredniSONE 5 mg PO EVERY OTHER DAY
10. PredniSONE 10 mg PO EVERY OTHER DAY
11. Raltegravir 400 mg PO BID
12. rilpivirine 25 mg ORAL DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
14. Terazosin 5 mg PO
15. Tiotropium Bromide 1 CAP IH DAILY
16. TraZODone 100 mg PO
17. Aspirin 325 mg PO DAILY
18. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth two times per
day Disp #*40 Tablet Refills:*0
## DISCHARGE DIAGNOSIS:
Mid-back invasive squamous cell carcinoma
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to following your surgery on .
You have tolerated a regular diet and have adequate pain control
and may now return home to continue your recovery. The following
is a summary of discharge instructions.
MEDICATIONS
1. Please resume all home medications, unless specifically
advised not to take a particular medication. Please take any new
medications as prescribed.
2. Please take all pain medications as prescribed, as needed.
You may not drive or operate heavy machinery while taking
narcotic pain medications. You may also take acetaminophen
(Tylenol) as directed, but do not exceed 4000 mg in one day.
3. An over-the-counter stool softener such as Colace (100 mg
twice daily) is recommended to prevent constipation while you
are taking narcotic pain medication.
WOUND CARE
1. Please keep your surgical dressing clean, dry and intact
until after your follow-up appointment. A nurse come to
change the dressing on your back daily. The dressing on your
right thigh should only be changed by if it becomes
saturated or soiled.
2. Monitor your wounds for signs of infection, including redness
that is spreading, increasing drainage, or pain that is not
relieved by medications. Please call Dr. if you
experience any of these symptoms, or your may call the main
number of the hospital ( ) and request for Dr.
to be paged (pager .
ACTIVITY
1. You may walk several times a day.No strenuous activity until
cleared by Dr. .
2. You may have sponge baths only (i.e., no showering, keeping
your dressing dry) until you follow-up with Dr. discuss
this with him.
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).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Please go 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.
Thank you for allowing us to participate in your care.
Your Team.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17316172", "visit_id": "29843408", "time": "2176-11-16 00:00:00"} |
10456993-DS-13 | 1,407 | ## ALLERGIES:
Sulfa (Sulfonamide Antibiotics) / Pentasa / Entocort EC /
Tetracycline / Shellfish Derived / Penicillins
## CHIEF COMPLAINT:
chron's disease with ileo-colonic stricture
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Open ileocecectomy Dr.
of Present Illness:
Ms. , with PMH of ileo-colonic stricturing Crohn's
Disease (currently on single-agent infliximab, recent increase
to 10mg/kg in every 6 weeks) with recent hx of partial
SBO and ongoing active ileitis who presented with lower
abdominal pain and persistent nausea consistent with
Crohn's flare on . She was treated with empiric IV
cefepime and PO flagyl and discharged home on with plan
for close outpatient GI and colorectal surgery follow up and 4
week course of abx.
She presented today to clinic with continued abd pain,
presistent n/v. She has been unable to tolerate liquids or
solids without vomiting. She does have 1 small bowel movement
per day and is still have good urine output. Denies any fevers,
complains of some chills. Denies any bloody or dark stools.
ROS other wise negative, no cp, sob, ha.
## PAST MEDICAL HISTORY:
# Stricturing ileo-colonic Crohn's Disease
Crohn's disease summary:
Year at diagnosis:
Extent of disease: ileo-colonic
Disease type: stricturing, 1x enteroenteric fistula on
MRE
Current medications: infliximab 7.5mg/kg every six weeks -
recent increase to 10mg/kg in (not yet started on this
dose)
Last endoscopies:
Last imaging:
GI surgeries: None
Prior Crohn's medications:
6-mp - stopped given problems with insurance per pt.
Prednisone
Entecort
Pentasa
# Back Pain
# Asthma - well controlled on advair, rare albuterol use
# Tobacco Abuse
# Marijuana Use
## FAMILY HISTORY:
Mother with hx. of Crohn's disease. Otherwise,
non-contributory.
## PHYSICAL EXAM:
On discharge:
VS T 99.8 HR 84 BP 106/66 RR 16 SaO2 93 RA
## HEENT:
neck supple, no LAD
## CARD:
RRR, S1 and S2 no r/m/g
## ABD:
soft, appropriately TTP around incision, some edema at
inferior pole of midline incision closed with absorbable
subcuticular suture and dermabond intact. No drainage or
erythema. non-distended. no guarding or rebound tenderness.
## BRIEF HOSPITAL COURSE:
Ms. presented to holding at on
after she was directly admitted to the hospital from clinic
for progressively worsening ileo-colonic stricturing
related to her known chron's disease. Her fluid status was
optimized prior to surgery. She tolerated the procedure well
without complications (Please see operative note for further
details). After a brief and uneventful stay in the PACU, the
patient was transferred to the floor for further post-operative
management.
## NEURO:
Her pain was initially managed by our acute pain service
colleagues, who placed an epidural. Her epidural was split for
improved pain control and then discontinued on POD1. She
continued on dilaudid PCA with adequate, but not excellent
analgesia, and pain control improved when she was transitioned
to PO dilaudid on POD2.
## CV:
Ms. was initially tachycardic on admission, and
remained mildly tachycardic until POD3, when her pain control
improved.
## PULM:
Ms. did use her albuterol inhaler several times
after surgery. She used her incentive spirometer early and
frequently.
## GI:
Initially, she was kept NPO with IVF, and then advanced to
sips for comfort. When she had return of bowel function with
flatus and bowel movement, she was started on a clear liquid
diet, and she did well with this and was tolerating a regular
diet by POD3.
## GU:
Ms. had a foley catheter placed at the time of
surgery and this was removed on POD2 without incident. She
voided afterward.
## HEME:
Postop hematocrit stable, no significant intraoperative
blood loss.
On , the patient was discharged to home. At discharge,
she was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. She will follow-up in the
clinic in weeks. This information was communicated to the
patient directly prior to discharge.
## POST-SURGICAL COMPLICATIONS DURING INPATIENT ADMISSION:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
## MEDICATIONS ON ADMISSION:
Medications - Prescription
Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
FOLIC ACID - folic acid 1 mg tablet QD
LORAZEPAM 0.5 mg PO QD PRN anxiety
Cefepime 2g IV q12H
Flagyl 500mg PO q8h
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet q6h PRN pain
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q6H
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. HYDROmorphone (Dilaudid) mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg tablet(s) by mouth q3h
Disp #*40 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
6. Hyoscyamine 0.125 mg SL TID:PRN bloating
## DISCHARGE DIAGNOSIS:
1. Acute Exacerbation of Crohn's Disease with ileo-colonic
stricturing
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital after an open ileocectomy for
surgical management of your chron's disease with ileo-colonic
stricturing. You have recovered from this procedure well and you
are now ready to return home. Samples from your ileum and colon
were taken and this tissue has been sent to the pathology
department for analysis. You will receive these pathology
results at your follow-up appointment. If there is an urgent
need for the surgeon to contact you regarding these results they
will contact you before this time. You have tolerated a regular
diet, passing gas and your pain is controlled with pain
medications by mouth. You may return home to finish your
recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You have a vertical incision on your abdomen that is closed with
sutures. This incision can be left open to air or covered with a
dry sterile gauze dressing. The sutures will re-absorb on their
own with time. Please monitor the incision for signs and
symptoms of infection including: increasing redness at the
incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run over
the incision line and pat the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by your surgeon. You may gradually increase
your activity as tolerated but clear heavy exercise with your
surgeon.
You will be prescribed a small amount of the pain medication
(dilaudid). Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10456993", "visit_id": "23904396", "time": "2192-10-01 00:00:00"} |
12251773-RR-13 | 95 | ## INDICATION:
year old man with left lateral mass fracture C2 // Assess
healing
## FINDINGS:
C1 through C6 are visualized on the lateral view. There is multilevel
moderate degenerative discogenic change. Slight asymmetric sclerosis of the
left lateral aspect of the body of C2 at its articulation with the lateral
mass of C1 may reflect some callus formation related to known fracture, which
was better depicted on recent CT. Lung apices appear unremarkable.
## IMPRESSION:
Some callus formation likely reflects early healing of the C2 fracture.
Fracture line is difficult to appreciate, better depicted on CT.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12251773", "visit_id": "N/A", "time": "2139-03-12 09:49:00"} |
10581736-RR-90 | 83 | ## FINDINGS:
There is no intracranial hemorrhage, edema, shift of normally
midline structures, or acute major vascular territorial infarction. The
ventricles and sulci are prominent, likely reflective of age-related atrophy.
Visualized paranasal sinuses are normally aerated, with several left mastoid
air cells opacified. A deformity noted within the left lamina papyracea
likely reflects sequela of prior trauma. posttraumatic. A rounded sclerotic
focus within the right frontal bone (2:11) is unchanged from as far back as
.
## IMPRESSION:
No acute intracranial process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10581736", "visit_id": "21498420", "time": "2141-04-25 21:23:00"} |
14261437-RR-11 | 88 | ## INDICATION:
patent tubes, normal ovaries
## FINDINGS:
The uterine cavity appears normal. There was rapid filling of the left
fallopian tube with free spill of contrast into the peritoneal cavity. The
proximal right tube was present, however the distal aspect could not be
assessed and there is no free spill. Intravasation was noted.
## IMPRESSION:
Patent left fallopian tube. The proximal right tube was present, however
given rapid filling and spill via the left fallopian tube there was likely
inadequate pressure to assess the distal right fallopian tube.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14261437", "visit_id": "N/A", "time": "2179-01-14 14:56:00"} |
16117084-RR-64 | 104 | ## INDICATION:
year old woman with new R PICC// R DL Power PICC 40cm MB
Contact name: MB, :
## FINDINGS:
There has been interval placement of a right PICC line which terminates in the
distal SVC. There is no pneumothorax. A right hemodialysis catheter
terminates in the right atrium. An enteric tube descends inferiorly below the
diaphragms, with the tip out of the field of view.
Lung volumes are low, unchanged. Moderate right and small left pleural
effusion with compressive atelectasis is unchanged. Cardiomediastinal and
hilar contours are unchanged.
## IMPRESSION:
The tip of the right PICC line terminates in the distal SVC. No pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16117084", "visit_id": "25107291", "time": "2137-03-29 13:00:00"} |
13999982-RR-129 | 130 | ## EXAM:
MRI of the brain.
## CLINICAL INFORMATION:
Patient with right arm numbness.
## BRAIN MRI:
There is no acute infarct seen. There are moderate changes of small vessel
disease and moderate brain atrophy seen. There is no midline shift or
hydrocephalus. No evidence of microhemorrhages. Vascular flow voids
maintained.
## IMPRESSION:
Mild-to-moderate changes of small vessel disease and brain
atrophy. No mass effect, hydrocephalus, or acute infarct.
## MRA HEAD:
Head MRA demonstrates normal flow in the arteries of anterior and posterior
circulation. No evidence of stenosis, occlusion, or aneurysm greater than 3
mm in size seen.
## IMPRESSION:
No significant abnormalities on MRA of the head.
## MRA NECK:
Neck MRA demonstrates normal flow in the carotid and vertebral arteries
without stenosis or occlusion.
## IMPRESSION:
Normal MRA of the neck.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13999982", "visit_id": "N/A", "time": "2151-05-19 15:17:00"} |
16269879-DS-18 | 1,269 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
yo hx of BPH with urinary retention, NIDDM (on Metformin),
HTN
(Lisinopril, Atenolol, HCTZ), high cholesterol (Atarvostatin),
s/p colon cancer with surgery and chemotherapy (in , per pts
report) with a hx of subacute decline in function in the context
of medical issues related to urinary retention and possible UTI,
presenting with AMS and unresponsiveness.
He has hx of repeated hospital presentations since .
He was admitted to medical service on with concerns for
subacute decline in function in the context of medical issues
related to urinary retention and concerns for delirium. C-L
psychiatry was consulted paranoid delusions, confusion, and
SI. Per OMR (e.g., note of Dr. , pt was taking meds
incorrectly at home (e.g., higher dose of lorazepam). While on
medical floor, pt remained anxious, confused, paranoid despite
being on Zyprexa in high moderate dose.
He was transferred from medical floor after initial medical work
up was non revealing. Per psych, pt's current clinical
presentation could be summarized as anxious-delusional syndrome.
Pt appears to have paranoia about security officer on the unit.
While he is oriented to time, person, and situation, he exhibits
decreased attention. Considering above, delirium remains high on
diff diagnosis list. Additionally, pt c/o depression.
While in the psych unit, over the last few days prior to
transfer, he noted to the nursing staff he was "not feeling like
himself." In the afternoon of , patient became
hypotensive/orthostatic when BP was being checked with a drop to
66/40s and became unresponsive, so a code blue was called.
Patient did not lose a pulse. Patient's BP normalized while
lying
in bed but remained unresponsive to commands. Glucose was 70, so
given amp of D5W along with 2 L of fluid, then transferred
to
the MICU for further care.
Upon arrival to the ICU, patient reports no complaints. His
mental status is improved and he is able to follow commands.
Shakes his head no to any pain.
## PAST MEDICAL HISTORY:
DM (on metformin)
HL
HTN
BPH and urinary retention requiring self-cath at home.
stage IIIA colon adenocarcinoma in
treated by rectosignmoid resection, chemo; now disease free.
## FAMILY HISTORY:
Significant for cancer in sister (lung; was long
term smoker, now deceased), brother (multiple myeloma,
surviving); remainder reviewed and found to be not relevant to
this illness/reason for hospitalization.
## GENERAL:
Resting in bed comfortably.
## PULMONARY:
lungs clear to auscultation
## CHEST:
no tenderness to palpation
## ABDOMEN:
soft and non-distended. Non-tender to palpation
## EXTREMITIES:
Gross motor and sensory exam normal.
## SKIN:
No bruises or rashes.
## NEURO:
Does not respond verbally but able to follow commands to
a
limited extent. Able to open eyes, raise eyebrows, squeeze
hands,
wiggle toes. No appreciable focal neurologic deficits.
Down-going
Babinski, 2+ reflexes in upper extremity and lower extremity.
## GENERAL:
Frail, lying down in bed, flat affect, talks in quiet
voice
## PULMONARY:
Normal work of breathing on RA
## SKIN:
No rashes or lesions noted.
## ==========
-MENTAL STATUS:
Awake, alert, answering questions after a long
pause, speaking slowly and in short phrases
-Cranial Nerves: bilateral cataracts/post-surgical, EOMI, no
facial asymmetry, tongue midline
-Motor: Decreased bulk, increased tone most prominent in LUE
with
distraction. No adventitious movements, such as
tremor or asterixis noted. Able to lift all limbs antigravity.
## CT
CTA HEAD AND NECK:
Normal 3 vessel takeoff. Moderate
atherosclerotic
calcifications of the aortic arch, common origin of the head and
neck vessels, carotid bifurcations, and cavernous carotid
arteries bilaterally. No evidence of large vessel occlusion,
aneurysm, or dissection. The moderate to severe of
a left M 2 branch, inferior division (series 3, image 243).
Dural venous
sinuses are patent. Final read pending 3D reformats.
Periapical lucencies and marked erosion involving left maxillary
central
incisor with adjacent soft tissue density (series 3, image 191),
which should be correlated with any evidence of active
infection.
CXR
No acute cardiopulmonary abnormality.
## BRIEF HOSPITAL COURSE:
yo hx of BPH with urinary retention, NIDDM (on Metformin),
HTN
(Lisinopril, Atenolol, HCTZ), high cholesterol (Atarvostatin),
s/p colon cancer with surgery and chemotherapy , admitted to
DEAC
4 initially with SI, then transferred to the ICU for orthostatic
hypotension and AMS. His mental status quickly recovered with
improvement his blood pressures. He was likely hypotensive
given poor p.o. intake and improved with fluids. After he became
stable medically, he was transferred back to psychiatry Deac 4.
## ACTIVE ISSUES:
===============
#AMS
Patient altered in the setting of orthostatic hypotension on
, code stroke called, CTA performed and was normal, mental
status now back at baseline after fluids and improvement in BP.
He was then called out to the neurology service for evaluation
of organic causes of cognitive decline. EEG was performed and
normal. LP was performed with basic studies normal, no evidence
of inflammation or encephalitis. His exam and history were not
consistent with rapidly progressive dementias. It was felt
likely that olanzapine had unmasked a small degree of latent
parkinsonism (L>R tone) and this improved over several days
after this had been held.
- Avoid olanzapine and most other antipsychotics except
quetiapine, which may be used if needed and least likely to
elicit parkinsonism.
- He was started on sertraline 50mg for mood issues and Seroquel
25mg qhs
#Orthostatic hypotension
Suspect most likely to poor PO intake per report of nursing.
Also was on BB, blunting tachycardic response. His vitals have
improved with
fluids, encouraging PO, and holding beta blockade.
## CHRONIC ISSUES:
===============
#Hyperlipidemia:
Continued Aspirin 81 mg PO/NG DAILY, Atorvastatin 20 mg PO/NG
QPM
#HTN
Holding Atenolol 50 mg PO/NG DAILY and Hydrochlorothiazide 25 mg
PO/NG in the setting of orthostatic hypotension
#T2DM -
Holding MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY with ISS
on the floor if hyperglycemic
#BPH/Urinary retention -
Continued Tamsulosin 0.4 mg PO QHS. Scheduled for outpatient
appointment in the clinic. Continued with foley in place
## TRANSITIONAL ISSUES:
====================
[ ] F/u with clinic for chronic urinary retention
## MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Hydrochlorothiazide 25 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. OLANZapine 5 mg PO QHS
9. OLANZapine 5 mg PO DAILY:PRN Anxiety/Agitation/Insomnia
10. Donepezil 5 mg PO QHS
11. Ramelteon 8 mg PO QHS sleep/wake regulation
12. Sertraline 100 mg PO DAILY depression
13. Thiamine 100 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. QUEtiapine Fumarate 25 mg PO QHS
3. Senna 8.6 mg PO BID:PRN Constipation
4. Sertraline 50 mg PO QAM
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Thiamine 100 mg PO DAILY
11. HELD- Donepezil 5 mg PO QHS This medication was held. Do
not restart Donepezil until instructed by your doctor
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr ,
You presented to because you were seeing
things that were not there.
While in the hospital, you had an episode of low blood pressure
that resolved with lying down. You received a lumbar puncture
which was normal. You were also monitored on EEG; this showed no
seizures.
Since you continued to feel anxious and continued to see things
that were not there, you were then transferred to inpatient
psychiatry.
We wish you the best,
Your team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16269879", "visit_id": "21728754", "time": "2174-02-17 00:00:00"} |
16667528-RR-50 | 109 | ## EXAMINATION:
SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
## INDICATION:
year old woman with L shoulder fx/dislocation// assess
fx/reduction
## FINDINGS:
No acute fractures or dislocations are seen.The left humeral head is well
seated within the glenoid fossa.Re-demonstrated is the marked deformity of the
superolateral humeral head in keeping with large lesion.There is a
prominent ossific density measuring up to 2.8 cm in length projecting
posterior to the glenohumeral space which likely represent residual bone
fragments from the fracture and heterotopic bone formation.
## IMPRESSION:
1. No acute fracture or dislocation of the left shoulder. Persistent large
lesion with adjacent prominent bone fragments.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16667528", "visit_id": "N/A", "time": "2182-04-17 10:44:00"} |
10150279-DS-7 | 1,962 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
exploratory laparotomy; abdominal perineal resection;
repair of ventral hernia with mesh, placement of the
fuducials.V-Y advancement flap closure
## PER DR. :
Rectal bleeding for a couple of years without any pain or any
other symptoms that she ascribed to hemorrhoids and then about
three to four months ago, she started having some discomfort and
difficulty sitting that progressed
over time with some urgency up to three to four small bowel
movements a day; however, without any clear difficulties
evacuating or constipation. She did have some abdominal
discomfort that she also noted. She noted also increased
bleeding and also some mucusy discharge. She denies any trouble
with continence to gas or stool. The symptoms have been getting
progressively worse. She eventually had a colonoscopy, which
revealed a very low lying rectal cancer confirmed by the biopsy
and the follow up workup revealed a mass in the liver, which has
now also been confirmed by biopsy to be colon cancer. The
patient recieved neoadjuvant treatment and was again evaluated
by Dr. in clinic. Surgical arrangments were made for APR.
## PMH:
morbid obesity, hypertension, hyperlipidemia, GERD,
osteoporosis, and restless leg syndrome, rectal cancer s/p
neoadjuvant therapy, port-associated venous thrombosis (on
arixtra)
## PSH:
laparoscopic appendectomy for acute appendicitis in ,
right knee surgery in , and a laparoscopic cholecystectomy
in the 1990s.
## GENERAL:
Patient appears well, ambulating without issue, pain
controlled with medications by mouth. Pleasant and agreeable
with discharge plan.
## RESP:
No increased work of breathing
## ABD:
obese, appropriately tender, soft, ostomy pink with stool
and gas from os
## LOWER EXTREMITIES:
No significant edema. Equal strength and
range of motion bilaterally
## BRIEF HOSPITAL COURSE:
The patient was admitted to the Colorectal Surgery Service for
surgical treatment of her rectal cancer and incisional hernia.
On , the patient underwent abdominal perineal resection
with end colostomy and flap closure as well as an incisional
hernia repair with mesh. The procedure went well without
complication. See operative note for further details. After a
brief, uneventful stay in the PACU, the patient arrived on the
floor NPO, on IV fluids, with a foley catheter, and dilaudid PCA
for pain control. The patient was hemodynamically stable.
## NEURO:
The patient intially was on a dilaudid PCA
postoperatively but this was not adequately controlling pain
because she kept falling asleep. We stopped the PCA and put her
on PRN dilaudid bye mouth along with Toradol. Epidural was
considered but deferred because of her recent arixtra use.
## CV:
The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
## PULMONARY:
The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
## GI/GU/FEN:
Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. She has an
ostomy and on post-operative demonstarted bowel function in the
late afternoon of . She was continued on Colace by mouth
to prevent consitpation as she has an ostomy. At the time of
discharge, she was tolerating a regular diet without issue.
## ID:
The patient's white blood count and fever curves were
closely watched for signs of infection and remained stable.
## ENDOCRINE:
The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
## HEMATOLOGY:
The patient's complete blood count was examined
routinely; no transfusions were required. She was started on
subcutaneous heparin then transitioned to Lovenox on POD 2. She
recieved her first dose of Coumain in the afternoon of .
Outpatient care was arranged through Dr. office
who manages her Coumadin as an outpatient.
## PROPHYLAXIS:
The patient received venodyne boots were used
during this stay; was encouraged to get up and ambulate as early
as possible.
## SKIN:
The patient maintained on peritoneal precausions for the
flap and Kinair matress. Instructions were given for
discharge to prevent pressure on flap. Follow-up with plastice
surgery was arranged as appropriate.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
## MEDICATIONS ON ADMISSION:
Atenolol 25', Simvastatin, Potassium, Magnesium, Arixtra 5',
arixtra 40', Maxzide 25'
## DISCHARGE INSTRUCTIONS:
were admitted to the hospital after an abdominal perineal
resection for surgical management of your rectal cancer.
have recovered from this procedure well and are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact
regarding these results they will contact before this time.
have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. may return home
to finish your recovery.
.
*****IMPORTANT******
will be on "perineal precautions" until follow up with
Plastic Surgery. This means that may not sit on your bottom
until that time. are allowed to sit on the toilet. If
are riding in a car, must place a pillow under your bottom
on top of the chair to cushin your bottom and protect your
wound. can lay down on your back and on either side.
.
Please monitor bowel movement prior to your discharge which is
acceptable. If have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation.
.
will be on Coumadin when get home. This means that
will need to have your INR followed by your PCP with regular
blood draws. Until your INR is high enough, will be on
Lovenox to keep your blood thin.
.
-What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
-How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
-What should contact your healthcare provider :
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if
hit your head. Talk with healthcare provider even if feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleeding, or rash.
-Call your doctor if are unable to eat for several days, for
whatever reason. Also call if have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your dosage.
.
-Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what eat
while taking this medication.
Until recently, doctors advised taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
.
-These foods contain vitamin K:
Fruits and vegetables, such as: kiwi, blueberries, broccoli,
cabbage, sprouts, green onions, asparagus, cauliflower,
peas, lettuce, spinach, turnip, , and mustard greens,
parsley, kale, endive. Meats, such as: beef liver, pork liver.
## OTHER:
mayonnaise, margarine, canola oil, soybean oil, vitamins,
soybeans and cashews.
-Limit alcohol. Alcohol can affect your
dosage but it does not mean must avoid all alcohol. Serious
problems can occur with alcohol and when
drink more than 2 drinks a day or when change your usual
pattern. Binge drinking is not good for . Be careful on
special occasions or holidays, and drink only what usually
would on any regular day of the week.
-Monitoring:
The doctor decides how much need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, might be at risk for
bleeding problems. If it is too low, might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for . The blood test used for monitoring
is called an INR.
-Use of Other medications:
When is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way works. It is very important to
talk with your doctor about all of the other medicines that
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
.
have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse.
.
Please monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if develop a
fever. Please call the office if develop these symptoms or
go to the emergency room if the symptoms are severe. may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. Dr. may
gradually increase your activity as tolerated but no heavy
exercise until cleared by your surgeon.
.
will be prescribed a small amount of the pain medication
Dilaudid. Please take this medication exactly as prescribed.
may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
.
have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. should have
bowel movements daily. If notice that have not had any
stool from your stoma in days, please call the office.
may take the stool softeners we prescribe or an over the
counter stool softener as needed to avoid constipation from
narcotic pain medications.
.
Please watch the appearance of the stoma, it should be beefy
red/pink, if notice that the stoma is turning darker blue or
purple, or dark red please call the office for advice. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as have been instructed by
the wound/ostomy nurses. will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery.
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until are comfortable caring
for it on your own.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10150279", "visit_id": "23303646", "time": "2143-07-10 00:00:00"} |
18131667-RR-108 | 166 | ## INDICATION:
year old woman with S/p kidney transplant // increasing
creatinine.
## FINDINGS:
The left iliac fossa transplant renal morphology is normal. Specifically, the
cortex is of normal thickness and echogenicity, pyramids are normal, there is
no urothelial thickening, and renal sinus fat is normal. There is no
perinephric fluid collection. Minimal fullness is demonstrated and is stable
from prior exam.
The resistive index of intrarenal arteries ranges from 0.7 to 0.79, within the
normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 91. Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform.
The urinary bladder was empty during the exam with catheter seen in place. A
trace amount of free fluid was demonstrated in the pelvis.
## IMPRESSION:
Normal renal transplant ultrasound morphology. Minimal renal fullness stable
from prior exam. Normal intrarenal resistive indices and normal main renal
artery and vein waveforms.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18131667", "visit_id": "N/A", "time": "2191-05-16 09:41:00"} |
16700532-RR-18 | 503 | ## INDICATION:
with multiple falls, quite positive black stool, C2 fracture,
tenderness over thoracic and lumbar spine.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 9.9 s, 78.1 cm; CTDIvol = 23.1 mGy (Body) DLP =
1,800.4 mGy-cm.
Total DLP (Body) = 1,800 mGy-cm.
## HEART AND VASCULATURE:
Heart size is normal. Trace pericardial fluid is
within physiologic limits. Coronary artery calcifications are severe. The
thoracic aorta is normal in caliber. The main pulmonary artery is normal in
caliber.
## AXILLA, HILA, AND MEDIASTINUM:
No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
## PLEURAL SPACES:
No pleural effusion or pneumothorax.
## LUNGS/AIRWAYS:
The airways are patent to the subsegmental level. There is
mild right lower lobe predominant bronchial wall thickening. There are
diffuse right upper, right middle, right lower, and left lower lobe
centrilobular pulmonary nodules and a right lower lobe posterior and lateral
basal segment consolidation. There is apical paraseptal emphysema.
## HEPATOBILIARY:
The liver demonstrates diffusely decreased attenuation
throughout with focal sparing adjacent to the gallbladder. There is no
evidence of focal lesion or laceration within the limitation of an unenhanced
scan.There is no perihepatic free fluid. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreatic head is mildly atrophic. There are punctate
calcifications in the uncinate process. No focal lesions or pancreatic ductal
dilation identified. There is no peripancreatic stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration within the limitation of an unenhanced
scan.
## ADRENALS:
There is diffuse nonspecific bilateral adrenal gland thickening.
## URINARY:
The kidneys are of normal and symmetric size. There is an exophytic
simple cyst arising from the lower pole of the left kidney punctate
nonobstructing right nephrolithiasis measures up to 2 mm. No hydronephrosis.
Nonspecific bilateral perinephric fat stranding/edema.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber. Diverticulosis of the sigmoid colon is noted, without
evidence of wall thickening and fat stranding. The appendix is normal. There
is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate is not enlarged.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
## BONES:
There is no acute fracture. No focal suspicious osseous abnormality.
Chronic appearing L1 compression deformity. There are multiple chronic
bilateral rib deformities. Mild thoracolumbar spine and bilateral
degenerative changes.
## SOFT TISSUES:
Moderate bilateral fat containing inguinal hernias.
## IMPRESSION:
1. An L1 compression deformity appears chronic, but recommend correlation with
physical examination and symptoms. Bilateral rib deformities are chronic.
2. Centrilobular pulmonary nodules and right lower lobe consolidation
concerning for aspiration and/or multifocal pneumonia.
3. Additional incidental findings include hepatic steatosis, colonic
diverticulosis, and severe calcified coronary atherosclerosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16700532", "visit_id": "N/A", "time": "2156-01-25 21:25:00"} |
13385656-RR-20 | 232 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
Cerebrovascular accident due to occlusion pf cerebral arterypr to
occlusion of cerebral artery. * Auth # *cerebral artery//
Cerebrovascular accident due to occlusion of cerebral artery e
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
## FINDINGS:
Hypoattenuation involving the left thalamus and posterior limb of the left
internal capsule is noted, which extends into the corona radiata. There is
hyperdensity in the left sylvian fissure on image 15 of series 2 which could
reflect dense middle cerebral artery branch vessels. There is no evidence of
large acute vascular territory infarction,hemorrhage,edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
## IMPRESSION:
1. Infarct in the left thalamus and adjacent white matter could be subacute.
In addition, there are densities in the left sylvian fissure which could
reflect dense vessels in the MCA distribution, of uncertain chronicity.
## NOTIFICATION:
The findings were discussed by telephone by Dr. with
Dr. at 16:50 on . Per discussion, the patient has a known
history of recent stroke in but no acute new symptoms.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13385656", "visit_id": "N/A", "time": "2143-04-23 14:55:00"} |
12867993-DS-20 | 1,366 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
epigastric pain, decreased PO intake
## HISTORY OF PRESENT ILLNESS:
Mr. is a yo man who presented to the
ED with N/V, bloating, and epigastric abdominal pain x
weeks. He was recently seen at with
similar complaints, where he had an EGD with biopsy (results
still pending). Over recent days, he has continued to have
decreased PO intake with dizziness, feeling like he was going to
pass out today. This morning, he had two episodes of nausea and
abdominal pain. Pain is worse with eating. In previous days, his
pain has been relieved after vomiting, but today's episodes were
refractory after vomiting with persistent severe abdominal pain.
Thus, he felt the need to present for further evaluation and
pain management. He reported melena with occasional
constipation, though his stool was guiaic negative in the ED. He
denies any change in urinary habits.
.
In the ED, VS were 98.4, 86 130/88 19 96%RA. The ED staff spoke
with the patient's PCP who said he has pancreatic mass per OSH
MRCP. The PCP spoke with the patient today to share the news of
possible pancreatic CA; it sounds like he has not shared this
with his wife yet, but his nephew may know. He has had a 10- 20
lbs loss in recent weeks, no F/C. Guiaic negative in the ED.
.
On the floor, he reports that his pain has subsided from a
down to a , but that the nausea persists. He continues to
deny fever/chills.
## GEN:
alert, awake, appears fatigued, thin
## HEENT:
EOMI grossly, PERRL, no scleral icterus, no LAD, mucous
membranes dry, no erythema/exudate in oropharynx
## ABD:
soft, bs+, TTP epigastric and LUQ, no rebound tenderness,
no guarding, mildly tympanic, minimal distension
## EXT:
no c/c/e, DP pulses 2+
## FINDINGS:
Supine and upright abdominal radiographs are reviewed
without
comparison. There is no sign of free intraperitoneal air. There
is overall
paucity of abdominal bowel gas, with a few foci of air seen
within non-dilated
loops of colon. Degenerative changes are noted in the lower
lumbar spine.
## IMPRESSION:
Non-obstructive bowel gas pattern.
.
Radiology Report CTA ABD W&W/O C & RECONS Study Date of
4:42
## IMPRESSION:
1. A heterogeneous enhancing irregular 3.8 x 3.5 cm mass is seen
at the
head/uncinate process. Most likely diagnosis is pancreatic
adenocarcinoma.
2. Pancreatic mass encases the third portion of the duodenum
resulting in
distended stomach and proximal duodenum. Contrast does get by
this obstruction
to some extent.
3. Partial encasement of superior mesenteric artery by the
pancreatic mass,
complete occlusion of superior mesenteric vein.
4. Occlusion or significant narrowing of celiac artery at the
origin of
abdominal aorta, this is unrelated to the pancreatic mass.
However, the celiac
distribution is fed primarily by the partially encased SMA.
.
Radiology Report CHEST (PRE-OP PA & LAT) Study Date of
10:30 AM
## BRIEF HOSPITAL COURSE:
Mr. is a yo man who presented to the
ED with N/V, bloating, and epigastric abdominal pain x
weeks. He was recently seen at with
similar complaints, where he had an EGD with biopsy (results
still pending).
.
#Abdominal pain: likely related to pancreatic origin, given
recent work-up at OSH. Pending records, but conversation between
OSH and ED noted possible pancreatic mass. This is consistent
with patient's symptoms (nausea/vomiting, epigastric pain, pain
with meals.) However, differential also includes GERD, gastric
ulcer, small bowel obstruction, pancreatitis. Mildly elevated
WBC on admission (12.4).
.
#Nausea/vomiting: most likely related to abdominal pain
etiology. Pain worse with eating, and pt unable to tolerate PO
at present.
- Follow-up on pancreatic work-up from OSH
.
#Hyperlipidemia: pt on home Gemfibrozil 600mg PO bid. Has been
unable to keep down PO meds over past week.
- Re-start home med with trial of PO intake
.
#PTSD: stable.
- Re-start Mirtazapine 30mg PO qhs
- Will clarify Depakote dose with PCP tomorrow .
.
#FEN: pt physically unable to keep down, will continue to look
for potential obstruction.
.
==================================================
He was transferred to the surgery service. A workup for this
including a CT scan shows an invasive malignant appearing mass
at the third and fourth portion of
the duodenum involving the pancreas itself. This mass is clearly
unresectable due to vascular encasement of the SMA as it courses
lateral to this. He has a massively distended stomach which goes
down to his pelvis.
He went to the OR on for:
1. Exploratory laparotomy.
2. Gastroenterostomy.
3. Placement of gold fiducial seeds for CyberKnife.
4. Pancreatic head biopsies x2.
## PAIN:
He had a PCA for pain control. Once tolerating a clear
diet, he was started on PO pain meds.
## GI/ABD:
He was NPO, with a NGT and IVF. The NGT, per the
pathway, was removed on POD 3. His diet was slowly advanced as
she had return of bowel function. He was tolerating clears
liquids by POD 5. He reported +BM on POD 7. He then had some
emesis starting around POD 7. He was having intermittent emesis
on POD . A UGI swallow study showed narrowing at the
gastrojejunal anastomosis with barium flowing freely post-
anastomosis. This narrowing may be accentuated by postsurgical
edema and may account for patient's symptomatology. There is no
ileus noted.
He received a NGT on POD 10 and started on TPN. After several
days of TPN, a PO diet was again restarted. He needs continued
encouragement with PO intake.
His abdomen was soft, nondistended and the incision with staples
was C/D/I. The staples were removed prior to discharge and steri
strips placed.
He was tolerating regular food and reported +flatus and +BM
prior to discharge.
## ONCOLOGY:
He was seen by Radiation Oncology for discussion
regarding Cyberknife therapy.
He will follow-up with Oncology on .
## MEDICATIONS ON ADMISSION:
Gemfibrozil 600mg PO bid
Depakote 250mg PO ?daily
Mirtazipine 30mg PO qhs
Nexium 40mg PO daily
Tylenol #3 PRN pain
## DISCHARGE MEDICATIONS:
1. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
## 5. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Gastric Outlet Obstruction
Pancreatic Mass - adenocarcinoma
Delayed Gastric Emptying
Malnutrition
## DISCHARGE INSTRUCTIONS:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* 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.
* Continue to increase activity daily
* Monitor your incision for signs of infection.
* You may shower and wash, no tub baths or swimming.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12867993", "visit_id": "22016665", "time": "2111-04-23 00:00:00"} |
19058546-RR-27 | 118 | ## INDICATION:
female with new onset severe vertigo. Rule out
intracranial bleed or evidence of stroke.
## NON-CONTRAST HEAD CT:
There is no hemorrhage, hydrocephalus, shift of
normally midline structure or evidence of major vascular territorial
infarction. The gray-white matter differentiation is generally preserved, with
scattered hypoattenuating foci in the subcortical and periventricular white
matter reflecting chronic microvascular infarction. Prominence of the
ventricles and sulci are consistent with generalized atrophy. The cavernous
internal carotid arteries are calcified, bilaterally. The paranasal sinuses
and mastoid air cells are normally aerated. Bilateral lens replacements are
noted.
## IMPRESSION:
No hemorrhage. If there is further concern regarding ischemia,
particularly in the posterior fossa, MRI with diffusion-weighted imaging is
more sensitive.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19058546", "visit_id": "25788685", "time": "2167-01-02 00:35:00"} |
10275551-RR-5 | 298 | ## CLINICAL INDICATION:
man with history of ethanol abuse, status
post fall with cervical and pelvic fractures with back pain and lower
extremity weakness. Evaluate for cord compression.
## FINDINGS:
There is no abnormal signal intensity in the vertebral bodies, cauda equina or
spinal cord.
There is a small posterior annular tear at the L1-2 intervertebral disk.
At L2-3, mild retrolisthesis of L2 on L3 with adjacent edema of the
endplates which likely represents degenerative change. There are mild facet
arthropathy and mild disc bulge without central canal stenosis but with mild
bilateral foraminal stenosis.
At L3-4, a right small disc osteophyte complex and mild facet degenerative
changes without canal stenosis. There is mild foraminal stenosis
bilaterally but on the right there is contact of the right nerve root by a
small osteophyte. A synovial cyst is noted posterior to the right facet
joint.
At L4-5, there is a mild broad-based central bulge without evidence of central
canal stenosis. There is mild foraminal stenosis bilaterally. Synovial cysts
are noted posterior to both facet joints.
At L5-S1, there is a dysplastic left lamina noted. There is an small annular
tear of the posterior intervertebral disc. There is no evidence of central or
foraminal narrowing. Synovial cysts are noted bilaterally.
There is small T1 and T2 hypointense linear area in the left sacrum (7:18) may
represent the left sacral fracture seen on plain films dated ,
although there is no adjacent bone marrow edema. Minimal presacral T2
hyperintensities may represent edema or blood, would recommend correlation
with outside imaging.
## IMPRESSION:
1. Suggestion of left sacral fracture as seen on pelvic plain films.
2. Minimal posterior spondylolisthesis of L2 on L3 but without canal
stenosis.
3. Degenerative changes with bilateral foraminal stenoses as described above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10275551", "visit_id": "29306218", "time": "2146-05-21 22:12:00"} |
15718233-RR-16 | 189 | ## INDICATION:
year old woman with anastomotic leak after sigmoid
anastomosis. has had an anastomotic leak// Does the leak persist?
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.0 s, 26.4 cm; CTDIvol = 15.1 mGy (Body) DLP = 401.7
mGy-cm.
2) Spiral Acquisition 3.3 s, 3.6 cm; CTDIvol = 18.7 mGy (Body) DLP = 68.4
mGy-cm.
Total DLP (Body) = 470 mGy-cm.
## FINDINGS:
Please note that no rectal contrast was administered. Post sigmoid colectomy
changes are again seen. The distal colonic anastomosis is redemonstrated and
there is an elongated pocket of gas coursing from the anastomosis extending
superiorly, posterior to the uterus, at the site of the prior leakage of
rectal contrast. This is compatible with a persistent contained leak
containing gas. No drainable fluid collections.
No free intraperitoneal air. A right lower quadrant ileostomy is again seen.
There is no colonic obstruction. There is no distal ureteral dilatation. The
uterus and adnexa are unremarkable for age.
No pelvic adenopathy. No worrisome osseous lesions. Postoperative changes
are again seen in the anterior pelvic wall.
## IMPRESSION:
Persistent contain perianastomotic leak without drainable fluid collection.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15718233", "visit_id": "N/A", "time": "2110-09-05 12:51:00"} |
17451713-RR-185 | 234 | ## INDICATION:
year old woman with failure to thrive, feeding tube dependent
with Fr Sheety Transgastric J tube presenting for routine exchange //
Routine exchange
## OPERATORS:
Dr. , attending radiologist, performed
the procedure.
## ANESTHESIA:
1% lidocaine was used for local anesthesia
## CONTRAST:
10 cc ml of Optiray
## PROCEDURE DETAILS:
Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per
protocol. The tube site was prepped and draped in the usual sterile fashion.
The existing tube was injected with contrast and showed opacification of the
small bowel. The stay sutures were cut and a Amplatz wire was introduced into
the stomach. The existing feeding tube was then removed. A 14
gastrojejunostomy catheter was advanced over the wire into position. The
sheath was then peeled away.
The catheters retaining loop was formed in the proximal duodenum and locked in
the stomach after confirming the position of the catheter with a contrast
injection. The catheter was then flushed, capped and secured. Sterile
dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
## FINDINGS:
1. Appropriately positioned new 14 gastrojejunostomy tube.
## IMPRESSION:
Successful exchange of a gastrojejunostomy tube for a new 14
gastrojejunostomy tube. The tube is ready to use.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17451713", "visit_id": "N/A", "time": "2202-04-12 11:00:00"} |
11545787-RR-163 | 139 | ## EXAMINATION:
ART DUP EXT LO UNI;F/U
## INDICATION:
year old man with s.p angio plasty RLE and ucers// please eval
occlusion s.p angioplasty
## FINDINGS:
Right peak systolic velocities:
Distal superficial femoral artery: 70 centimeters/second with slight delayed
upstroke
Proximal popliteal artery: 54 centimeters/second
Distal popliteal artery: 59 centimeters/second with slight delayed upstroke
Proximal posterior tibial artery: 40 centimeters/second with delayed upstroke
Mid posterior tibial artery: 56 centimeters/second with delayed upstroke
Distal posterior tibial artery at the ankle: 58 centimeters/second with
significantly delayed upstroke
Peroneal artery poorly visualized in the mid calf
Peroneal artery distal calf: 62 centimeters/second with delayed upstroke
Peroneal artery at the ankle: 80 centimeters/second with delayed upstroke
## IMPRESSION:
Patent distal superficial femoral artery, popliteal, posterior tibial and
peroneal artery without focal stenosis identified.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11545787", "visit_id": "N/A", "time": "2138-06-22 08:28:00"} |
10685798-RR-22 | 119 | ## INDICATION:
year old man with dysphagia // ngt placement
## FINDINGS:
The endotracheal tube has been removed. A nasogastric tube extends below the
level the diaphragms but beyond the field of view of this radiograph. The
side port however still likely lies within the distal esophagus and further
advancement is recommended.
New bilateral airspace opacities, greater on the right likely reflect
underlying pulmonary edema. No large pleural effusion or pneumothorax
identified. The size the cardiac silhouette is enlarged but unchanged.
## IMPRESSION:
The tip of the gastric tube projects beyond the field of view of this
radiograph however the side port is visualized within the distal esophagus.
Further advancement is recommended.
The endotracheal tube has been removed.
New pulmonary edema.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10685798", "visit_id": "23559866", "time": "2141-11-22 18:28:00"} |
13237465-RR-28 | 168 | ## HISTORY:
Treated liver metastases for pancreatic neuroendocrine tumor.
## IMPRESSION:
1. 4 mm and 6 mm arterially-enhancing foci within hepatic segments VIII and V,
respectively, are nonspecific, but warrant short-term followup given prior
history of metastatic neuroendocrine tumor.
2. 1.7 x 1.5 cm enhancing nodule along the medial aspect of the right breast
appears enlarged in comparison to CT examinations from through ,
although detailed direct comparison is difficult owing to differences in
imaging technique. This may relate to reported prior breast reduction
surgery, but comparison against recent and future scheduled mammograms (no
comparisons at is recommended.
3. Post distal pancreatectomy, splenectomy, and right adrenalectomy. No local
tumor recurrence detected.
4. Two 2-mm cystic lesions within the pancreatic body, likely representing
side branch IPMN. Continued attention to this region is recommended on
subsequent followup MR examinations.
5. Pancreas divisum.
6. Midthoracic vertebral body hemangioma.
7. Small duodenal diverticulum.
The breast and liver findings were placed in the critical notification
dashboard by Dr. on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13237465", "visit_id": "N/A", "time": "2144-02-19 09:34:00"} |
16361542-DS-4 | 996 | ## CHIEF COMPLAINT:
Unwated ileostomy related to prior surgical procedure.
## HISTORY OF PRESENT ILLNESS:
A woman who underwent extensive resection of stage
IV serous papillary carcinoma with colorectal anastomosis and
diverting loop ileostomy and presented for elective ileostomy
takedown with Dr. .
## PAST ONCOLOGIC HISTORY:
- CT abd/pelvis on revealed a large mass centered in
the sigmoid colon with pelvic lymphadenopathy, retroperitoneal
lymphadenopathy, and peritoneal carcinomatosis.
- A colonoscopy revealed a fungating, ulcerated mass within
the sigmoid colon causing a partial obstruction. The biopsy of
this mass revealed adenocarcinoma with papillary formation,
suggestive of an ovarian primary.
- underwent exploratory laparotomy, hysterectomy,
bilateral salpingo-oophorectomy, rectosigmoid resection with
colorectal re-anastomosis and diverting loop ileostomy. This was
a suboptimal tumor debulking. Intra-operatively, the uterus and
bilateral adnexal were unremarkable. Extensive firm
retroperitoneal lymphadenopathy was appreciated. There was no
evidence of carcinomatosis. The tumor was noted to involve
the sigmoid colon and rectum. Pathology examination revealed
serous carcinoma involving full thickness of the rectal wall.
Seven of eight lymph nodes were positive for malignancy. Uterus,
cervix, fallopian tubes, and ovaries were negative for
malignancy.
- start chemotherapy with Carboplatin q21d and weekly Taxol
- Cycle 3 Carboplatin and Taxol
.
## UNCLE:
diabetes. Mother and father lived in to , she denies
family history of cancer, CAD, hypertension.
## GENERAL:
Appears well, ambulating independently, pain controlled
with oral pain medications, tolerating a regular diet. +BM,
+flatus, voiding after foley removal.
## ABD:
flat, nondistended, appropriately tender, old ileostomy
site intact, no sign of infection, draining small amounts of
sero-sang fluid, no sign of infection, covered with dry sterile
gauze dressing.
## LOWER EXTREMITIES:
No significant edema noted.
## BRIEF HOSPITAL COURSE:
The patient was admitted to the inpatient colorectal surgery
service after ileostomy takedown. The patient was stable
overnight into post-operative day one. Her pain was controlled
with intravenous pain medications and she was hydrated
intravenously. Post-operative day one the patient tolerated a
clear liquid diet, ambulated, and pain control was transitioned
to pain medications by mouth. The patient was doing well, her
old ileostomy site was packed with gauze packing strip until
post-operative day two when the strip was removed and the wound
was covered with a dry sterile gauze dressing. On post-operative
day two, the patient passed flatus and tolerated a regular diet.
The Foley catheter was removed and the patient voided without
issue. Post-operatively the patient's hematocrit was 26.3, the
patient's past values were low as well and she has been treated
for anemia, hemodynamically the patient was stable.
Post-operative day two the patient's hematocrit was unchanged.
The patient was discharged home with appropriate discharge
instruction. The patient voided later in the afternoon on
post-operative day two. The patient was stable for discharge but
requested to stay in house until the morning of post-operative
day three when the daughter could provide transportation.
## DISCHARGE MEDICATIONS:
1. oxycodone 5 mg Tablet Sig: Tablets PO Q4H (every 4 hours)
as needed for pain for 5 days: Do not drink alcohol or drive a
car while taking this medicatoin.
Disp:*35 Tablet(s)* Refills:*0*
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) for 7 days: Do not drink alcohol while taking
this medication. Do not take more than 4000mg of Tylenol daily.
.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
## DISCHARGE DIAGNOSIS:
Ovarian cancer, diverting loop ileostomy.
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital after an ileostomy takedown.
You have recovered from this procedure well and you are now
ready to return home. You have tolerated a regular diet,
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are expected however, if you notice that you are passing bright
red blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you have any of the following
symptoms please call the office for advice or go to the
emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonged loose stool, or
constipation. It is important that if you are having loose stool
you do not become dehydrated. Please take increased amounts of
fluid during this time such as gatoraide.
You have a wound on your abdomen where the ileostomy once was.
This no longer requires packing. You should shower daily, let
the warm water run over the wound, pat dry, and cover with a dry
sterile gauze dressing. It is expected that the wound will drain
small amounts of pick/yellow drainage, the wound should not
drain infected appearing drainage (green/yellow/white/grey, foul
smelling). Please call the office if you develop infected
appearing draingae from the wound, or these other symptoms of
infection: swelling at the site, increased pain, or increased
redenss at the site.
Please restart all of your home medications. You will be given a
prescription for the pain medication oxycodone. Please take this
as prescribed. Do not drink alcohol or drive a car while taking
this medication. You may also take Tylenol as written. Do not
take more than 4000mg of Tylenol daily.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16361542", "visit_id": "22740128", "time": "2111-08-04 00:00:00"} |
13661098-RR-61 | 287 | ## INDICATION:
female with epigastric pain.
## FINDINGS:
Note that this is a limited study due to the patient's body
habitus. The liver is diffusely echogenic consistent with fatty infiltration.
No focal liver lesion is identified. No biliary dilatation is seen and the
common duct measures 0.4 cm. The portal vein is patent with hepatopetal flow.
The patient is reported to be status post cholecystectomy. The pancreas is
unremarkable, but is only partially visualized. The spleen is unremarkable
and measures 11.2 cm. The aorta is of normal caliber throughout. The IVC is
only minimally visualized but is otherwise unremarkable.
The right kidney measures 14.2 cm and the left kidney measures 15.3 cm. There
is a simple cyst seen in the right kidney measuring 4.0 x 4.0 x 3.9 cm. A
small non-obstructing stone is seen at the lower pole of the right kidney
measuring 7 mm. A simple cyst is seen in the left kidney measuring 6.0 x 5.3
x 2.7 cm. Additional known renal cysts are not appreciated due to the
limitations of this study. Two small non-obstructing renal stones are seen in
the left kidney. A 9-mm stone is seen at the upper pole and a 7-mm stone is
seen in the interpolar region.
## IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other forms of liver
disease and more advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Bilateral renal cysts. Additional renal cysts which were seen on the
abdominal CT of are not appreciated on today's exam due to the limited
nature of this study.
3. Small bilateral non-obstructing renal stones.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13661098", "visit_id": "N/A", "time": "2187-06-19 08:58:00"} |
10425516-RR-16 | 201 | ## INDICATION:
man with pain and weakness.
## FINDINGS:
There is a near-complete tear of the supraspinatus tendon with a
few intact bursal surface fibers. It is suspected that there are occult full-
thickness components. There is no tendon retraction or muscle atrophy. The
infraspinatus and teres minor tendons and muscles are unremarkable. There is
tendinosis and slit like longitudinal intrasubstance tears within the
subscapularis muscle. There is a moderate amount of fluid in the
subacromial/subdeltoid bursa. There are moderate hypertrophic changes at the
acromioclavicular joint as well as a mild amount of edema.
The biceps labral anchor is intact and the biceps tendon courses in the
bicipital groove surrounded by a moderate amount of fluid. The intra-
articular biceps tendon demonstrates severe tendinosis and probable
longitudinal split tear (series 6:10). There is no displaced labral tear.
There is a small-to-moderate sized joint effusion. There are subchondral
cystic changes at the infraspinatus tendon insertion.
## IMPRESSION:
1. High-grade near-complete tear of the supraspinatus tendon with a few
bursal surface fibers remaining.
2. Tendinosis and longitudinal split tear of the intra-articular biceps
tendon.
3. Tendinosis and intrasubstance slit-like longitudinal tears of the
subscapularis tendon.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10425516", "visit_id": "N/A", "time": "2142-01-23 18:43:00"} |
11787740-RR-64 | 761 | ## EXAMINATION:
CT-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY
CT-GUIDED ASPIRATION
## INDICATION:
year old man with cirrhosis s/p TIPS c/b hemorrhagic shock s/p
embolization of R. hepatic artery, now with increasing pressor requirements
and white count, imaging c/f gallbladder ? hematoma vs rupture ? // perc
chole tube placement
## PROCEDURE:
CT-guided percutaneous cholecystostomy and CT-guided aspiration of
right porta hepatis hematoma and perihepatic ascites.
## OPERATORS:
Dr. , radiology trainee and Dr. ,
attending radiologist. Dr. supervised the trainee during the
key components of the procedure and reviewed and agrees with the trainee's
findings.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 6.4 s, 19.7 cm; CTDIvol = 12.8 mGy (Body) DLP = 235.0
mGy-cm.
2) Stationary Acquisition 1.8 s, 1.4 cm; CTDIvol = 19.0 mGy (Body) DLP =
27.3 mGy-cm.
3) Stationary Acquisition 11.9 s, 1.4 cm; CTDIvol = 198.5 mGy (Body) DLP =
285.8 mGy-cm.
4) Spiral Acquisition 9.9 s, 30.2 cm; CTDIvol = 14.7 mGy (Body) DLP = 423.6
mGy-cm.
Total DLP (Body) = 980 mGy-cm.
## SEDATION:
Not applicable. Patient sedated prior to the procedure. Pain
medication administered throughout the procedure by unit nurse.
## FINDINGS:
A limited post-procedure CT is performed in the portal venous phase. This CT
confirms adequate position of the cholecystostomy tube within the gallbladder
lumen. The gallbladder lumen remains distended to some degree.
The porta hepatis hematoma is redemonstrated, and is smaller when compared to
the study performed earlier today, now measuring approximately 5.3 x 16.5 cm
in AP and transverse dimension. Locules of air within the hematoma are
related to instrumentation.
Note is made of a jejuno-jejunal intussusception in the left hemiabdomen. This
jejuno-jejunal intussusception was present on the CT performed earlier today,
but was shorter, and considered transient at the time. It now measures
approximately 6.8 cm, previously 2.3 cm. No associated upstream obstruction
is noted.
Additional note is made of high density intraluminal material within the
jejunum, fairly distal to the site of intussusception (series 6, image 123).
This high density material was not visualized on the CT performed earlier
today. As the study was performed with administration of intravenous contrast,
this is suspicious for extravasation contrast, as no oral contrast has been
administered on the study performed earlier today or the study performed more
remotely on . It is unclear why this patient would have
extravasation of contrast in the jejunum, and one which would have presumably
developed in a period of 6 hours.
Additional findings are unchanged from the study performed earlier today, and
pertain to known liver cirrhosis and stigmata of portal hypertension. There
remains moderate volume ascites. There is additionally diffuse subcutaneous
fat stranding/fluid, suggestive of anasarca.
## IMPRESSION:
1. Successful CT-guided placement of 10 pigtail catheter into the
gallbladder lumen. Old hematoma aspirated. No purulent characteristics.
Sample sent for microbiology evaluation. On the post-procedure CT scan,
appropriate cholecystostomy tube position is confirmed. Gallbladder remains
distended to some extent.
2. A porta hepatis hematoma is aspirated, again yielding old blood without
purulent characteristics. Sample sent for microbiology evaluation and for
bilirubin sampling, to evaluate for gallbladder source.
3. 170 cc of perihepatic ascites aspirated and sent for microbiology
evaluation. Ascites is serosanguineous in appearance. No purulent
characteristics.
4. On the post-procedure CT scan performed with intravenous contrast, there
is a jejuno-jejunal intussusception in the left hemiabdomen. This
jejuno-jejunal intussusception was present on the CT performed earlier today,
but was significantly shorter, and considered transient at the time. It now
measures approximately 6.8 cm, previously 2.3 cm. No associated upstream
obstruction is noted. The significance of this finding is indeterminate.
5. Additional note is made of high density intraluminal material within the
jejunum, separate from and distal to the site of intussusception described
above. This high density material was not visualized on the CT acquired
earlier today. As the study was performed with the administration of
intravenous contrast, this is suspicious for contrast extravasation, as no
oral contrast has been administered on the study performed earlier today or
the study performed . It is unclear why this patient would
have extravasation of contrast in the jejunum, and one which would have
presumably developed in a period of 6 hours.
## NOTIFICATION:
Findings reviewed with Dr. , MICU resident,
immediately following procedure. Specifically, findings pertaining to the
small bowel are communicated and emphasized. If bloodwork is suggestive of
evolving hemorrhage, a formal multiphasic CT angiogram of the abdomen and
pelvis should be performed to assess for active contrast extravasation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11787740", "visit_id": "N/A", "time": "2125-04-15 16:42:00"} |
12415668-RR-38 | 124 | PA AND LATERAL CHEST AT 19:44 HOURS.
## HISTORY:
Slurred speech and cough.
## FINDINGS:
As previously noted, there is either thickening or chronic fluid
within the minor fissure. Linear ill-defined opacities are evident at the
left lung base. Given the relative volume loss, atelectasis is suspected.
Linear atelectasis is identified in the right lung base as well. Marked
aortic tortuosity is noted accentuated by low lung volumes. Calcified plaque
is seen throughout. The cardiac silhouette remains borderline enlarged with a
left ventricular configuration. No effusion or pneumothorax is noted. The
osseous structures are unremarkable.
## IMPRESSION:
Ill-defined opacity in the lingula and left lower lobe. Atelectasis is
favored, although an early developing pneumonia is difficult to entirely
exclude particularly given clinical context.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12415668", "visit_id": "27615495", "time": "2180-08-16 19:43:00"} |
14351952-DS-19 | 1,225 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
"I am going to jump off a bridge."
## HISTORY OF PRESENT ILLNESS:
Mr. is a homeless man with an unknown
psychiatric history who is BIB EMS after being found walking
towards ambulance with a ranger reported suicidal ideation
without specific plans in the setting of self-discontinuation of
his psychiatric medications and ongoing homelessness.
On interview, the patient is lying in bed with his eyes closed
and gives only few-word responses. When asked about his mood, he
states "I am fucking depressed." When asked about any plans, he
states "I will jump in front of a car or jump into a river."
Reports his ongoing homelessness and limited supports as his
primary stressor. Denies any current psychiatric medications
(discontinued 1 month ago). Reports that he has a PCP at
but denies any psychiatric treaters. Reports drinking a pint
daily but denies any other illicit use. Reports depressed mood
and poor sleep due to homelessness. States multiple times that
he
would attempt to kill himself if he was discharged. When asked
if
the patient could sit up and elaborate on his history, he
becomes
irritable and states "I am fucking tired" and refuses to answer
further questions.
Per BEST, the patient was medically admitted at and
seen by BEST team; he was admitted to . Patient
has had 8 BEST evals at since . Last inpatient psych was
at . He was diagnosed with alcohol dependence
and depressive disorder at the time. BEST reports 7 previous
dual
diagnosis admission at . BEST documentation confirms
a
previous SA in by jumping into river.
## PAST MEDICAL HISTORY:
Hyperlipidemia
History of withdrawal seizures
## FAMILY HISTORY:
No known family history of psychiatric illness
## APPEARANCE:
age-appearing male with poor hygiene, wearing
hospital gown, resting comfortably in bed
## SPEECH:
decreased content, monotoned, slowed rate
## CONSTRICTED
THOUGHT PROCESS/ASSOCIATIONS:
linear/intact
Thought content: Focused on killing himself. No overt
delusions/paranoia.
## -ORIENTATION:
Oriented to person, place, time and situation.
-Attention: minimally attentive to interview
-Memory: refused to engage in cognitive testing
-Fund of knowledge: unable to assess
-Speech/Language: no paraphasic errors
## -STATION AND GAIT:
not tested
-tone and strength: not tested
## BRIEF HOSPITAL COURSE:
#Psychiatric
Patient was admitted to inpatient psychiatry for treatment of
depression and alcohol dependence.
For alcohol dependence, given history of withdrawal seizures,
patient was placed on standing valium which was tapered over
several days. Other than poor sleep, he did not note any
withdrawal symptoms.
On admission he noted poor mood and a constant feeling of
wanting to die due to his recurrent drinking, homelessness, and
current life situation (having lost all clothes, IDs, wallet,
etc). He expressed frustration at people in his life who were
supposed to help him, and on exam exhibited marked irritability
and lack of self efficacy in bringing about change and recovery
in his life.For depression, once LFTs were downtrending (see
below), patient was restarted on his depakote and titrated up to
1000 mg ER daily, as he noted that this medication had been
quite helpful for him in the past. He had run out of the
medication a few weeks ago.
He was noted early in admission to spend most of the day in bed
and needed strong encouragement to even meet with the treatment
team; however, as the hospitalization progressed, he was noted
to be less irritable and more active in the millieu. He reported
mood improvement with depakote, and by discharge reported that
his thoguths of wanting to die had resolved and he was feeling
more optimistic about the future. He was also noted on discahrge
to be more proactive in pursuing further care and housing,
making several calls to various organizations in the days
leading to discharge and taking an active roll in asking
questions about his care.
The patient was provided with several options for aftercare,
including further residential substance abuse treatment programs
through the and dual diagnosis partial hospital treatment
options. He elected to pursue a dual diagnosis partial hospital
program while living at a shelter, and a referall was made to
outpatient mental health services at the as well as a dual
diagnosis hospital program at .
On the day of discharge, patient was anxious about the task of
putting his life back together but was forward looking and
future oriented. He noted improvement in depression from the
time of admission and had no thoughts, plans, or intent to harm
himself or others. He was well groomed, eating and sleeping
well, was no longer irritable, was well organized, and had a
good understanding of the resources and treament options
available to him. He understood his long struggle with addiction
recovery and his need for intensive supports through time. He
appeared to have the capacity to make treatment decisions for
himself and to seek additional help in the future if needed. At
time of discharge, he did not present as an acute risk to
himself. He did remain a chronic risk of relapse into alcohol
use and associated mood symptoms, suicidal thoughts, or self
injurious behavior. He understood this risk and demonstrated a
desire for ongoing care and good knowledge of how to seek
emergency help again in the future if needed.
The patient declined contact with his family over the course of
the admission. He does view his sister in as an emotional
support. He is considering a future move back to , but
remains contemplative about this.
#Meidcal
a) Transaminitis- patient had elevation in LFTs (ALT = 195, AST
= 236) on presentation, though these were noted to downtrend by
. This elevation was attributed to alcoholic hepatitis. LFTs
should be repeated after several weeks of sobriety to insure
resolution.
b) Hyperlipidemia- Patient noted he had been on simvastation in
the past, and this was restarted at a dose of 10 mg daily. He
will follow up with his PCP for further care
#Legal
Patient signed a CV on admission and remained on a voluntary
status through out his hospitalization.
#Safety
Patient was in good behavioral control on the unit and was
maintained on 15 minute checks throughout his stay. He
demonstrated no signs of aggression, impulsivity, psychosis or
mania through out his admission. He does not have access to
weapons and he denies a history of violence. He had no self
injurious behaviors through out his stay and was quite motivated
to work to rebuild his life and ultimately secure housing and
employment again in the future.
## DISCHARGE MEDICATIONS:
1. Divalproex (EXTended Release) 1000 mg PO HS
RX *divalproex [Depakote ER] 500 mg 2 tablet(s) by mouth at
bedtime Disp #*28
## TABLET REFILLS:
*0
2. Simvastatin 10 mg PO DAILY
RX *simvastatin 10 mg 1 tablet(s) by mouth Daily Disp #*14
## TABLET REFILLS:
*0
3. TraZODone 50 mg PO HS
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
## DISCHARGE DIAGNOSIS:
Depressive Disorder NOS
Alcohol Dependence
## DISCHARGE CONDITION:
Future oriented, no evidence of suicidal thoughts. Pleasant, no
longer irritable. Knoweldgeable about resources in the area.
Motivated to work to rebuild. No psychosis, no mania, no
impulsivity.
## MR. :
You were admitted to inpatient psychiatry for treatment of
depression and alcohol dependence. We treated you with valium
for alcohol dependence and restarted Depakote to help with your
mood. Please take all of your medications as prescribed and
attend all follow-up appointments.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14351952", "visit_id": "21874191", "time": "2145-02-07 00:00:00"} |
18539987-DS-16 | 687 | ## HISTORY OF PRESENT ILLNESS:
w/GERD, chronic constipation presents with nausea. Pt was
seen in ED for dysphagia, was found to have UTI and Rx
Bactrim. Pt reports poor PO intake, anorexia but denies emesis,
dysphagia, abd pain. No relief with metoclopramide at home. Son
reports that nausea and anorexia are chronic but have been worse
over the last 3 days. He is requesting GI consult as well as
psych eval as he feels her depression is contributing to her
lack of eating. Last BM yesterday.
In ED pt found to still have pyuria, now also with worsened
hyponatremia and . Given CTX and 500cc NS.
On arrival to floor pt confirms history. Denies nausea
currently. No other complaints.
## ROS:
+as above, otherwise reviewed and negative
## PAST MEDICAL HISTORY:
HTN
ANXIETY
DEPRESSION
ATYPICAL CHEST PAIN
CHRONIC CONSTIPATION
HYPERLIPIDEMIA
CXR in showed mild COPD with "uncoiling" of the aorta
STRESS INCONTINENCE
GERD
## ESOPHAGEAL STRICTURE?:
per pt had EGD with dilation
## ABDOMEN:
bowel sounds present, soft, nt/nd
## PERTINENT RESULTS:
03:30PM WBC-6.2 RBC-3.06* HGB-9.8* HCT-30.2* MCV-99*
MCH-31.8 MCHC-32.3 RDW-13.2
03:30PM NEUTS-74.9* LYMPHS-15.6* MONOS-8.5 EOS-0.7
BASOS-0.4
03:30PM PLT COUNT-178
03:30PM cTropnT-<0.01
03:30PM LIPASE-30
03:30PM ALBUMIN-4.1
03:30PM ALT(SGPT)-14 AST(SGOT)-23 ALK PHOS-44 TOT
BILI-0.2
03:30PM GLUCOSE-125* UREA N-22* CREAT-1.2*
SODIUM-126* POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-22 ANION GAP-15
04:00PM URINE COLOR-Yellow APPEAR-Clear SP
04:00PM URINE RBC-1 WBC-20* BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
04:00PM URINE HYALINE-3*
04:00PM URINE MUCOUS-RARE
**FINAL REPORT
URINE CULTURE (Final : <10,000 organisms/ml.
UGI SGL CONTRAST W/ KUB IMPRESSION:
Limited study. No evidence of narrowing or stricture within the
esophagus.
Tertiary contractions suggest underlying motility abnormality.
## BRIEF HOSPITAL COURSE:
F w/GERD, chronic constipation presents with nausea,
and hyponatremia.
## HYPONATREMIA:
Improved with holding hctz. This should continue
to be held as this is the patient's second hospitalization for
hyponatremia due to this medication.
## DEPRESSION:
Seen by psychiatry. Started on a low dose of
mirtazepine.
## NAUSEA AND EPISODIC ABDOMINAL PAIN:
Remained stable. Barium
study revealed no evidence of stricture. Pt was able to tolerate
a regular diet while hospitalized. She has undergone an
extensive GI workup with Dr. at including
a recent small bowel enteroscopy which was normal. She should
continue to follow with him.
## CODE STATUS:
DNR, DNI, HCP is son. Confirmed with patient and
son.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO HS
2. Bisacodyl 5 mg PO DAILY:PRN constipation
3. Dipyridamole-Aspirin 1 CAP PO BID
4. Docusate Sodium 100 mg PO BID
5. Metoclopramide 5 mg PO BID:PRN nausea
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Zolpidem Tartrate 2.5 mg PO HS:PRN insomnia
10. HydrALAzine 50 mg PO TID
11. Vitamin D 800 UNIT PO DAILY
12. lisinopril-hydrochlorothiazide mg oral BID
13. Sucralfate 1 gm PO BID
## DISCHARGE MEDICATIONS:
1. Metoclopramide 5 mg PO BID:PRN nausea
2. Mirtazapine 15 mg PO HS
3. Vitamin D 800 UNIT PO DAILY
4. Sucralfate 1 gm PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. Omeprazole 20 mg PO BID
7. Metoprolol Succinate XL 100 mg PO DAILY
8. HydrALAzine 50 mg PO TID
9. Docusate Sodium 100 mg PO BID
10. Dipyridamole-Aspirin 1 CAP PO BID
11. Bisacodyl 5 mg PO DAILY:PRN constipation
12. Amlodipine 10 mg PO HS
## DISCHARGE INSTRUCTIONS:
You were admitted with nausea, abdominal pain and low sodium.
Your HCTZ was stopped and your sodium improved. You were seen by
psychiatry. You were started on a low-dose antidepressant.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18539987", "visit_id": "20003946", "time": "2170-01-14 00:00:00"} |
13447286-RR-31 | 116 | ## INDICATION:
year old man with and history of obstructive uropathy.
Rule out hydronephrosis.
## FINDINGS:
The right kidney measures 8.5 cm. The left kidney measures 11.4 cm. In the
lower pole the left kidney, there is an exophytic 2.5 x 2.2 x 1.8 cm
avascular, isoechoic structure, grossly unchanged allowing for differences in
measurement technique and image selection. Simple cysts in the right kidney
measure up to 1.5 cm in the interpolar region (image 10). There is no
hydronephrosis or stones bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and unremarkable in appearance.
## IMPRESSION:
No evidence of hydronephrosis or renal stones.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13447286", "visit_id": "N/A", "time": "2164-03-28 16:18:00"} |
19647994-RR-37 | 431 | ## INDICATION:
male with significant vascular disease presenting
with worsening abdominal pain. Evaluate for mesenteric ischemia.
## FINDINGS:
The visualized portion of the heart is unremarkable. Increased interstitial
reticular markings in the lung bases are compatible with interstitial lung
disease, consistent with a UIP pattern.
## ABDOMINAL CTA:
Assessment of the vasculature is limited due to lack of 3D
reformats. Severe atherosclerotic calcifications are present along the
abdominal aorta with several significant regions of mural thrombus and
ulcerated plaque. No aneurysm or dissection is present. There is severe
stenosis of the celiac axis (>90%) due to an atherosclerotic plaque at its
base, but it is distally well opacified. An accessory left hepatic artery is
present, arising from the gastric artery. The celiac axis arterial anatomy is
otherwise conventional. There is moderate-to-severe stenosis (75%) of the SMA
origin, and severe stenosis (>90%) of the . Both main renal
arteries have 50% stenosis. Accessory renal arteries are present bilaterally
and are of small caliber and likely also diseased. Severe atherosclerotic
disease involves the bilateral common iliac artery origins and extends through
the internal iliac arteries. The bilateral external iliac arteries are patent
with moderate atherosclerotic disease at the level of the common femoral
arteries.
## ABDOMEN:
The liver, gallbladder, intra- and extra-hepatic bile ducts, pancreas, spleen,
and adrenal glands are normal. The kidneys enhance symmetrically and excrete
contrast promptly. Subcentimeter renal hypodensities are too small to further
characterize. The ureters are normal in course and caliber.
The stomach is unremarkable. The small and large bowel have a normal course
and caliber. There is no pneumatosis of the bowel, abnormal bowel dilation, or
free fluid to suggest mesenteric ischemia. The appendix is normal.
The portal vasculature is unremarkable. No retroperitoneal or mesenteric
lymphadenopathy. No free abdominal fluid or pneumoperitoneum. Two small fat
containing ventral hernias are present.
## PELVIS:
The bladder and terminal ureters are unremarkable. The prostate
gland and seminal vesicles are unremarkable. No free pelvic fluid or inguinal
hernia. No inguinal or pelvic sidewall lymphadenopathy.
## OSSEOUS STRUCTURES:
A mixed lucent-sclerotic lesion is present in the right
iliac bone adjacent to the SI joint with some calcific density may represent
an enchondroma or other non-aggressive bone lesion.
## IMPRESSION:
1. Severe atherosclerotic disease of the abdominal aorta with >90% stenosis
of the celiac origin, 75% stenosis of the SMA, and >90% stenosis of the .
No overt vascular occlusion. No CT evidence of bowel ischemia.
2. Mixed lucent-sclerotic lesion in the right iliac bone may represent an
enchondroma or other non-aggressive bone lesion.
3. Bilateral lung base fibrosis, compatible with UIP pattern.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19647994", "visit_id": "N/A", "time": "2129-01-21 00:04:00"} |
18896980-RR-90 | 439 | ## INDICATION:
male with persistent left upper quadrant pain status
post gastric bypass surgery.
## CT ABDOMEN:
Visualized lung bases are clear. There is no consolidation or
effusion. The liver, gallbladder, biliary tree are normal. There is no
intra- or extra-hepatic biliary ductal dilatation. Gallbladder is normal with
no wall thickening or pericholecystic fluid and no gallstones identified. The
spleen, pancreas, adrenal glands, and kidneys are unremarkable. There is no
hydronephrosis, renal mass lesion or perinephric stranding identified. A
peripelvic cyst is seen in the left kidney. There is symmetric renal
parenchymal enhancement and contrast excretion bilaterally.
The patient is status post gastric bypass surgery. Orally administered
contrast passes from the gastric pouch into the efferent Roux limb and
ultimately into the colon. There are no dilated bowel loops to suggest
obstruction. A patulous segment of jejunum adjacent to the jejunojejunal
anastomosis is within normal limits for a side-to-side anastomosis ( ).
The excluded stomach and duodenum are decompressed. There is no contrast
identified within these structures. In the left upper quadrant, there are
multiple loops of decompressed bowel, some with acute angulation, unchanged in
appearance compared to the prior study, suggesting the presence of adhesions
or possibly a internal hernia. However, there is no evidence for
transmesocolic herniation.
There is no mesenteric or retroperitoneal adenopathy. There is no free fluid
or free air. The aorta is normal in caliber and configuration. The major
mesenteric vessels are patent.
## CT PELVIS:
There are unchanged hyperattenuating lesions within the uterus,
likely fibroids. In the right adnexa, there are likely two simple cystic
lesions, one measuring 4.4 x 2.2 cm in the axial plane and the second
measuring 2.2 x 2.6 cm in the axial plane. Alternatively, this may represent
a single lobulated cystic structure or a hydrosalpinx. Further evaluation
with pelvic ultrasound is recommended. There are no left adnexal cysts or
masses identified. There is no pelvic adenopathy or free fluid. The distal
ureters and bladder are normal. The rectum and sigmoid colon appear normal.
## BONE WINDOWS:
There are no suspicious lytic or sclerotic lesions.
## IMPRESSION:
1. In the left upper quadrant, there is acute angulation of multiple
decompressed loops of small bowel. This appears unchanged retrospectively
from prior study in , and suggest the presence of adhesions or possibly an
internal hernia.
2. There is no evidence for obstruction. Patulous segment of small bowel at
the jejunojejunal anastomosis is within normal limits following side-to-side
anastomosis. Contrast passes freely into the colon.
3. Right adnexal cystic lesions as described above. Follow up with pelvic
ultrasound to better characterize these findings is recommended.
4. Uterine fibroids.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18896980", "visit_id": "N/A", "time": "2153-05-19 08:54:00"} |
15593062-RR-17 | 85 | ## EXAMINATION:
GLENO-HUMERAL SHOULDER (W/ Y VIEW) BILATERAL
## INDICATION:
History: with bilateral shoulder pain.
## RIGHT SHOULDER:
There is inferomedial dislocation of the humeral head with
respect to the glenoid. No evidence of osseous injury. No clavicular or
scapular fracture. Imaged right ribs and right lung are normal.
## LEFT SHOULDER:
There is inferomedial dislocation of the left humeral head
with respect to the glenoid. No evidence of fracture. Imaged left ribs and
along are normal.
## IMPRESSION:
Bilateral anterior shoulder dislocation. No evidence of fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15593062", "visit_id": "21288347", "time": "2155-07-14 11:28:00"} |
13158011-RR-68 | 421 | ## EXAMINATION:
MR WAND W/O CONTRAST
## INDICATION:
with right hand numbness//Evaluate for nerve injury.
## FINDINGS:
Study is mildly degraded by motion.
Vertebral body alignment is grossly preserved. Vertebral body heights are
preserved. C6 inferior endplate probable type changes without definite
evidence of epidural collection are seen.
The visualized portion of the spinal cord is preserved in signal.
There is loss of intervertebral disc height and signal throughout the cervical
spine. There is no evidence of prevertebral soft tissue swelling.
At C2-3, there is asymmetric left disc bulge with no spinal canal or neural
foraminal narrowing.
At C3-4, there is disc bulge with no spinal canal or neural foraminal
narrowing.
At C4-5, there is disc bulge, uncovertebral hypertrophy, central disc
protrusion, deformation of the ventral thecal sac and spinal cord without
definite associated cord signal abnormality, mild-to-moderate spinal canal and
mild bilateral neural foraminal narrowing.
At C5-6, there is disc bulge, uncovertebral hypertrophy, facet joint
hypertrophy, deformation of the ventral thecal sac and spinal cord without
definite associated cord signal abnormality, mild vertebral canal and moderate
left neural foraminal narrowing.
At C6-7, there is disc bulge resulting with mild spinal canal and no neural
foraminal narrowing.
At C7-T1, there is no spinal canal or neural foraminal narrowing.
## OTHER:
A 1.8 cm predominantly T2 hyperintense right thyroid nodule and a 0.8 cm T2
hyperintense left thyroid nodule are not significantly changed since .
## IMPRESSION:
1. Study is mildly degraded by motion.
2. Multilevel cervical spondylosis as described, most pronounced at C4-5,
where there is deformation of the ventral thecal sac and spinal cord without
definite associated cord signal abnormality, mild-to-moderate vertebral canal
and mild bilateral neural foraminal.
3. Within limits of study, no definite evidence of cervical spinal cord lesion
or abnormal enhancement.
4. Bilateral cystic thyroid nodules measuring up to 1.8 cm on the right,
similar appearance since . Thyroid ultrasound evaluation is recommended
if not previously worked up.
## RECOMMENDATION(S):
Thyroid nodule. Ultrasound follow up recommended.
College of Radiology guidelines recommend further evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under age or 1.5
cm in patients age or older, or with suspicious findings.
## SUSPICIOUS FINDINGS INCLUDE:
Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J
12:143-150.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13158011", "visit_id": "N/A", "time": "2136-04-19 03:01:00"} |
15295974-DS-10 | 1,514 | ## HISTORY OF PRESENT ILLNESS:
yof with history of Asthma, HIV (last CD4 22 in ,
variable compliance with HAART and bactrim prophy) presented to
ER with shortness of breath for one week. Initially started
with a "constriction" and difficulty breathing one week ago.
Also had a non prodcutive cough and low grade fevers over the
past week. SOB progressively got worse and today had sob with
minimal exertion, so came into the ER for evaluation. + DOE,
denies PND. She denies recent travel, denies sick contacts.
+fever to 101 at home. Denies any hemoptysis. Of note has not
taken HAAART/bactrim or fluc prophy for >1month.
.
In the ER, 100.4 Hr 71 BP 132/71 RR 26 O2 92%RA placed on
supplemental O2. She was given Given Albuterol/ipratropium
nebs, tylenol mg, levofloxacin 750 mg and decadron 10 mg IV
X 1. Written for bactrim for PCP but not yet.
.
At time of transfer to the floor, she feels improved sob.
Denies any chest pain. On ROS + nausea, denies vomiting,
diarrhea, chest pain, abdominal pain. denies change in weight,
denies visual symptoms.
## PAST MEDICAL HISTORY:
- HIVdx CD4 22 in , VL 1,250 copies/ml in .
- h/o cryptococcal meningitis, complicated by elevated ICP
requiring vP shunt. Which malfunctioned and needed to be
removed.
- h/o C. diff
- STDS (Chlamydia, gonorrhea, trich, HSV)
- recurrent sinusitis
- 2x aseptic meningitis
- migraines
- asthma
- depression
- hx zoster
## FAMILY HISTORY:
Htn- mother and fathers side; DM MGM, maternal aunt; PGM
CA Cervical CA mother, aunt. Also
depression/psych.
## GEN:
Well appearing comforatble female able to speakin full
sentences.
.
## HEENT:
MMM, PERRL, OP clear
## RESP:
CTABL, prolonged exp phase. no wheezing or crackles.
## CVR:
rrr, nl s1, s2, no r/m/g
## EXT:
No C/C/E, warm, 2+DP pulses b/l
## NEURO:
A&Ox3, no focal deficits
## CXR:
. New bilateral airspace opacities, probably involving the
lower lobes and possibly additionally the middle lobe/lingula,
highly concerning for atypical infection in this
immunocompromised patient.
.
2. Removal of ventriculoperitoneal shunt and right PIC line.
.
## ECG:
ST at 100, nl axis, nl intervals. no sig st-t changes
compared to prior from
.
## IMPRESSION:
Diffuse poorly defined ground-glass opacities seen
scattered throughout the lungs bilaterally, with lower lobe
predominance. Findings are consistent with multifocal pneumonia.
Although no cavitary lesions are identified, comment on possible
organism is not possible in the setting of patient's CD4 count
of 22, and tuberculosis cannot be excluded radiographically.
.
10:00 am SPUTUM Source: Induced.
GRAM STAIN (Final :
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final :
TEST CANCELLED, PATIENT CREDITED.
## LEGIONELLA CULTURE (PENDING):
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
## :
NEGATIVE for Pneumocystis jirvovecii
(carinii).
## ACID FAST CULTURE (PENDING):
<br>
CRYPTOCOCCAL ANTIGEN (Final :
POSITIVE FOR CRYPTOCOCCAL ANTIGEN.
QUANTITATIVE CRYPTOCOCCAL ANTIGEN (Final :
POSITIVE FOR CRYPTOCOCCAL ANTIGEN AT A TITER OF >=1:64 .
<br>
## HEAD CT ( ):
There is asymmetric soft tissue in the left nasopharynx which
may represent lymphoid tissue but a focal lesion in this locale
cannot be excluded. Recommend correlation with direct
visualization.
There is no evidence for acute intracranial hemorrhage or acute
transcortical infarction. In the absence of contrast, subtle
leptomeningeal disease cannot be excluded.
There is no evidence of hydrocephalus.
The tonsils appear somewhat low lying but unchanged compared to
prior study.
Visualized paranasal sinuses and mastoid air cells are clear.
## IMPRESSION:
No acute intracranial abnormality.
There is a right frontal burr hole.
Possible mass in the left nasopharynx, recommend correlation
with direct visualization.
<br>
7:15 am SPUTUM Site: INDUCED Source: Induced.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
:
POSITIVE FOR PNEUMOCYSTIS JIROVECII (CARINII).
Test
-----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
-----
-----
>500 pg/ml Negative Less than
60 pg/ml
Indeterminate 60 - 79
pg/ml
Positive Greater
than or equal to
80 pg/ml
<br>
8:20 am Influenza A/B by
## SOURCE:
Nasopharyngeal aspirate. R/O RESPIRATORY VIRUSES
AND HSV.
Rapid Respiratory Viral Antigen Test (Final :
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
## SPECIMEN SCREENED FOR:
ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
<br>
9:54 am CSF;SPINAL FLUID # 3.
GRAM STAIN (Final :
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
## FUNGAL CULTURE (PRELIMINARY):
NO FUNGUS ISOLATED.
<br>
6:00 am IMMUNOLOGY
**FINAL REPORT
HIV-1 Viral Load/Ultrasensitive (Final :
Greater than 100,000 copies/ml.
.
Sputum AFB ( ) - concentrated smear negative
## BRIEF HOSPITAL COURSE:
yo woman with h/o HIV (h/o low CD4 count, not on HAART or
prophylaxis w/ h/o cryptococcal meningitis requiring VP shunt)
presents with shortness of breath.
.
1. Pneumonia/SOB/Cough
Patient found to have PCP . Was in respiratory isolation and
was ruled out for TB. Was covered with Bactrim (2 DS q8h) for
PCP empirically prior to diagnosis of PCP. Although she was
given a single dose of steroids in the ED, this was not
continued since she was not hypoxic. She was briefly on
for possible CAP, however once PCP DFA positive and
Chest CT w/ findings c/w PCP came back, was stopped.
Sputum gram stain stains/cx and fungal cultures showed extensive
contamination. Cryptococcal PNA possibility, however unable to
make this diagnosis based on samples received. She will receive
a nd then go on bactrim prophylaxis.
Please see below for dosage adjustments secondary to impaired
renal function.
2. HIV/AIDS w/ h/o cryptococcal meningitis requiring VP shunt
and now cryptococcemia
Had positive cryptococcal Ag in blood. Unclear etiology of
this. Given h/o meningitis and concern for meningitis, patient
was empirically treated with Amphotericin B and Flucytosine.
The patient developed severe rigors with Amphotericin B despite
pre-hydration and Tylenol. This was ultimately changed to
Ambisome which she tolerated well. Multiple attempts at lumbar
puncture were attempted at the bedside without success. She
ultimately underwent an LP by fluoro-guidance, performed by .
This had the results as above. No evidence of bacterial
meningitis. Cryptococcal Ag was negative in the CSF. Based on
further input from ID, Ambisome and Flucytosine stopped and
patient placed on Fluconazole.
Patient off ARVs and prophylaxis because she reports financial
difficulties with medicaitons. Social work met with patient
about financial aspects of medications as well as coping with
disease. Restarting ARVs will be discussed at the next
outpatient ID follow up.
3. Asthma
Initially received nebs and steroids in ED. Subsequently, not
wheezing, and clinically improved. Continued with nebulizers.
4. Pancytopenia
Suspect secondary to HIV. Anemia consistent w/ chronic disease
picture. Counts stable (platelets now normal)
5. Question of nasopharyngeal mass
Unclear about etiology. New since last imaging. Seen by ENT,
who did not think there was any evidence of malignancy or need
for further imaging/biopsies during this stay but should have a
repeat CT in weeks for further evaluation. There was no
respiratory distress or signs of airway compromise during her
stay.
6. Metabolic Acidosis
Appears to have non-anion gap metabolic acidosis. Would
consider Type 1 RTA (given hyperchloremia, decreased K, and high
urine pH) vs. HIV-associated Fanconi's syndrome. Bicarb in
range, which remained constant despite cessation of IV
hydration.
7. Depression
The patient appeared extremely depressed during the course of
this hospitalization. Seen by SW as above. Would benefit from
being plugged into outpatient counseling.
## MEDICATIONS:
(patient has not taken any meds in the past month
due to inability to afford meds, prior to that taking it when
she could afford it).
Lamivudine 300 mg once daily
Norvir 100 mg once daily
Tenofovir Disoproxil Fumarate 300 mg once daily
Atazanavir 300 mg once daily
Bactrim DS 160 mg-800 mg once daily
Compazine 10 mg once every six hours prn
Fluconazole 400 mg once daily
Azithromycin 600 mg q
Acyclovir 400 mg three times a day
Ferrous Sulfate
## DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed for headache.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every hours as needed for shortness
of breath or wheezing.
MDI* Refills:*0*
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 14 days.
Disp:*84 Tablet(s)* Refills:*0*
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*0*
5. Azithromycin 600 mg Tablet Sig: One (1) Tablet PO once a
week.
Disp:*12 Tablet(s)* Refills:*2*
## DISCHARGE DIAGNOSIS:
PNEUMONIA, PNEUMOCYSTIS CARINII (PCP)
HIV/AIDS, SYMPTOMATIC
PANCYTOPENIA
ASTHMA, W/ ACUTE EXACERBATION
CRYPTOCOCCOSIS
ACIDOSIS
DEPRESSION
## DISCHARGE CONDITION:
Afebrile, vital signs stable.
## DISCHARGE INSTRUCTIONS:
You were diagnosed with PCP . You will need to take
Bactrim at the treatment dose for 21 days total. After that,
you will need to take Bactrim for prophylaxis. It is very
important that you take all your medications as prescribed and
come to all of your medical visits.
.
Please call your doctor or return to the emergency room if you
should have worsening headache, neck stiffness, fever, increased
shortness of breath or chest pain.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15295974", "visit_id": "28755410", "time": "2162-11-10 00:00:00"} |
14904554-RR-68 | 275 | CERVICAL SPINE MRI WITHOUT CONTRAST,
## INDICATION:
Left-sided neck pain radiating to the left upper extremity and
left chest.
## FINDINGS:
Vertebral body height and alignment are normal. Bone marrow signal
is within normal limits.
At C2-3, no significant abnormalities are seen.
At C3-4, there is a small central disc protrusion which does not contact any
nerve roots. There are also small uncovertebral osteophytes, minimally
narrowing the neural foramina.
At C4-5, there is a small central disc protrusion, which does not contact the
spinal cord or cause any significant spinal canal narrowing. There is no
evidence of neural foraminal narrowing.
At C5-6, there are very small right uncovertebral osteophytes without any
significant neural foraminal narrowing. There is no spinal canal narrowing.
At C6-7 and C7-T1, no significant abnormalities are seen.
The spinal cord is normal in morphology and signal intensity. The imaged
portion of the posterior fossa is unremarkable.
There is a small mucous retention cyst in the left maxillary sinus. A 6-mm
oval lesion with high signal on T2-weighted images and intermediate signal on
T1-weighted images in the nasopharynx to the left of midline (image 3:6) could
represent a mucus retention cyst, though it is incompletely evaluated in the
absence of intravenous contrast.
## IMPRESSION:
1. Mild cervical spondylosis without evidence of neural impingement.
2. Nonspecific 6 mm lesion in the left nasopharynx could represent a mucous
retention cyst, but it is incompletely evaluated in the absence of iv
contrast. A solid lesion cannot be excluded, and direct visualization should
be considered. This was entered into the critical results dashboard on
at 3:17 pm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14904554", "visit_id": "N/A", "time": "2133-11-08 07:04:00"} |
10509294-RR-52 | 695 | ## INDICATION:
male with total colectomy and ileostomy for Crohn's,
recurrent abdominal pain.
.
## FINDINGS:
Mild atelectasis is noted at the lung bases. There are no pleural
effusions. The heart is normal in size.
## ABDOMEN:
There is diffuse fatty infiltration of the liver. The gallbladder
is normal. There is mild atrophy of the pancreas. There is no intra- or
extra-hepatic biliary ductal dilatation. The spleen is mildly enlarged at
15.3 cm. The adrenals are normal. The kidneys enhance and excrete contrast
promptly and symmetrically, without masses or hydronephrosis.
## PELVIS:
The bladder and distal ureters are normal. The prostate is mildly
enlarged. A small left inguinal hernia is present.
## GASTROINTESTINAL:
The stomach and proximal duodenum are normal.
Again seen are multiple small bowel-containing incisional ventral hernias.
Three dominant hernias are identified in the right lateral abdominal wall,
midline abdominopelvic wall, and left lower quadrant (parastomal region).
The first hernia in the right lateral abdominal wall is relatively
narrow-necked, and contains multiple loops of collapsed distal duodenum and
jejunum. There is associated acute angulation of the duodenum as it enters
the hernia. Associated mesenteric swirling, fat stranding, and regional
lymphadenopathy in the right upper quadrant (10-14 mm) appear increased from
prior examination. There appears to be new superolateral retraction of a
proximal branch of the superior mesenteric artery. These changes likely
reflect venolymphatic obstruction, although other inflammatory processes (such
as mesenteric panniculitis) remain in the differential.
The second hernia is wide-necked and located in the mid-abdominopelvic wall.
A prominent jejunal loop in the superior and left lateral portion of this
hernia measures up to 3.5 cm, and courses inferolaterally to reenter the first
(right lateral wall) hernia. There are relative transition points at the
entry (2:40 and 300B:11) and exit (300B:16) sites of this bowel loop from the
hernia. Although this could be secondary to peristalsis, focal ileus or
partially obstructing adhesions could also have this appearance. The jejunum
then courses medially back into the midline hernia, with a relative transition
point as it re-enters the peritoneum (2:63 and 300B:20).
Distal to this point, there are multiple decompressed jejunal and proximal
ileal loops which course superiorly through the right abdomen, just lateral to
the region of mesenteric tethering; pass medially through the superior
abdomen (2:37); descend along the left anterior abdomen; and reverse course
to again pass superiorly (2:54 and 300B:19). This unusual course of bowel
loops is suggestive of postoperative adhesions and/or internal hernias.
Prominent contrast-filled loops of ileum in the left upper quadrant measure up
to 2.5 cm. Ileal loops then course inferiorly down into the pelvis, where
they normalize in caliber. Bowel loops enter the left inferior aspect of the
second (midline abdominopelvic) hernia, without evidence of caliber change,
and exit on the right side of this hernia. Multiple additional loops cluster
in the pelvis, before finally exiting through an ileostomy site in the left
lower quadrant (2:62 and 300B:22). There is an associated fat-containing
parastomal hernia. Enteric contrast is seen progressing to the level of the
stoma, ruling out complete obstruction at all levels.
There are no extraluminal air or fluid collections to suggest perforation.
There is no abnormal bowel wall thickening or enhancement to suggest active
inflammation. No pneumatosis, portal or mesenteric venous gas is seen to
suggest ischemia.
The colon and rectum are surgically absent. A surgical clip is seen in the
posterior pelvis.
Multiple prominent retroperitoneal nodes are present, measuring up to 7-8 mm
in the left paraaortic region.
The bones are diffusely demineralized. The sacroiliac joints are normal.
There are no suspicious lytic or sclerotic osseous lesions.
## IMPRESSION:
1. Status post total colectomy, with multiple small bowel-containing
incisional ventral hernias.
2. Increased mesenteric swirling, fat stranding, and regional lymphadenopathy
in the right upper quadrant, suggestive of progressive mesenteric torsion with
venolymphatic obstruction. Close clinical follow-up is recommended.
3. Several areas of small bowel caliber change and acute angulation,
suggestive of postoperative adhesions and/or internal hernias. No evidence of
high-grade obstruction, active inflammation, or ischemia.
4. Fatty liver.
5. Mild splenomegaly.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10509294", "visit_id": "N/A", "time": "2134-05-12 20:02:00"} |
17613792-RR-15 | 78 | ## EXAMINATION:
MR HEAD W AND W/O CONTRAST
## FINDINGS:
There is no intracranial mass, mass effect, or midline shift. Scattered
T2/FLAIR subcortical white matter hyperintensities are nonspecific and may
reflect evidence of gliosis secondary to chronic small vessel disease.
Ventricles and sulci are age-appropriate. There is no pathologic intracranial
enhancement. Intracranial flow voids are maintained. Visualized paranasal
sinuses and mastoid air cells are clear.
## IMPRESSION:
Unremarkable brain MRI with no evidence of metastatic disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17613792", "visit_id": "N/A", "time": "2160-03-24 16:09:00"} |
12461014-RR-14 | 166 | MR EXAMINATION OF THE LUMBAR SPINE WITHOUT CONTRAST,
## HISTORY:
female with urinary incontinence; ? "cord compression"
(sic).
## FINDINGS:
There is no comparison study on record. The distal spinal cord is
normal in caliber and intrinsic signal intensity, as is the conus medullaris,
which is normal in morphology and terminates at the mid-L1 level. There is a
normal distribution of cauda equina nerve roots within the thecal sac. The
sagittal STIR sequence is unremarkable, with no paravertebral soft tissue,
vertebral bone marrow or distal spinal cord pathologic hyperintense focus.
The T11-12 through L5-S1 discs are preserved in height and signal intensity,
without significant bulge or focal herniation, and the spinal canal and neural
foramina are widely patent, throughout. There is an unremarkable appearance
to the paraspinal and limited included retroperitoneal soft tissues;
specifically, there is no evidence of paraspinal or other regional muscular
atrophy.
## IMPRESSION:
Normal study, with unremarkable appearance to the distal spinal
cord, the conus medullaris and the cauda equina nerve roots.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12461014", "visit_id": "N/A", "time": "2175-05-07 20:34:00"} |
10010440-RR-26 | 97 | ## HISTORY:
Status post fall, now with right foot pain. Evaluation for
fracture.
## FINDINGS:
There is no evidence of acute fracture or dislocation within the
right foot. Calcaneal spurring is noted, representing mild degenerative
changes. Otherwise, no lytic or sclerotic lesion is identified. On the
oblique view, there is question of an old healed medial malleolar fracture
which is not well seen on the other views. Enthesopathy is noted at the
insertion point of the Achilles tendon. No radiopaque foreign body is
identified.
## IMPRESSION:
No acute fracture or dislocation within the right foot. Mild
degenerative changes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10010440", "visit_id": "26812050", "time": "2173-08-09 09:46:00"} |
10551843-RR-10 | 94 | ## INDICATION:
with h/o ovarian cysts and mittleschmerz presenting with 1
day of acute periumbilical abdominal pain, nausea, diarrhea, and anorexia.//
Evaluate for ovarian torsion vs hemorrhagic cyst vs appendicitis
## FINDINGS:
The uterus is anteverted and measures 5.9 x 2.4 x 3.9 cm. The endometrium is
homogenous and measures 3 mm.
The ovaries are normal. There is no free fluid. There was normal arterial
and venous flow demonstrated within the ovaries.
Right lower quadrant focused ultrasound failed to demonstrate appendix.
## IMPRESSION:
1. Normal pelvic ultrasound.
2. Appendix not visualized.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10551843", "visit_id": "N/A", "time": "2176-03-18 21:12:00"} |
15708357-RR-36 | 194 | ## EXAMINATION:
Duplex Doppler evaluation of the arterial and venous structures
in both upper extremities.
## HISTORY:
male requiring evaluation for dialysis access.
## RIGHT:
The right subclavian vein is phasic, an indirect indicator of central venous
patency. The right cephalic vein is patent with calibers ranging from 0.47 cm
to 0.58 cm .
The right basilic vein is also patent with calibers ranging measuring 0.29 cm
to 0.47 cm.
The right brachial artery measures 0.51 cm and the right radial artery
measures 0.22 cm. Mural calcifications are identified.
## LEFT:
The left subclavian vein demonstrates a phasic waveform, an indirect indicator
of central venous patency. The left cephalic vein has calibers ranging from
0.22 cm to 0.49 cm. The left basilic vein has calibers ranging from 0.33 cm
to 0.64 cm.
The left brachial artery measures 0.47 cm, the left radial artery measures
0.21 cm, with scattered mural calcifications.
## IMPRESSION:
1. Phasic subclavian veins bilaterally, an indirect indicator of central
venous patency.
2. Patent cephalic and basilic veins bilaterally as described.
3. Patent brachial and radial arteries with calibers as described, with mural
calcifications.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15708357", "visit_id": "26157806", "time": "2115-03-03 09:17:00"} |
17262521-RR-36 | 116 | ## EXAMINATION:
ELBOW (AP, LAT AND OBLIQUE) LEFT
## HISTORY:
with assault, arm pain, shortness of breath// ?
Fracture? Rib fracture? Pneumonia ? Fracture? Rib fracture?
Pneumonia
## FINDINGS:
No acute fractures or dislocations are seen. Joint spaces are preserved
without significant degenerative changes. No joint effusion is seen. No soft
tissue calcifications or radiopaque foreign bodies are detected. Triceps
enthesophyte. Minimal degenerative change of the ulnar trochlear joint.
Moderate soft tissue swelling along the medial aspect of the elbow and distal
arm. Rounded density projecting over the soft tissues posterior to the
humerus are consistent with snaps on patient's gown.
## IMPRESSION:
No fracture. Moderate soft tissue swelling along the medial aspect of the
elbow and distal arm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17262521", "visit_id": "21820380", "time": "2155-12-13 00:11:00"} |
16502473-DS-22 | 1,120 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Ms. is a year old G1P0 at 30w1d with
tri-tri triplets.
She was noted to have mild range BPs 140-150/80s in the office,
and so collected a 24 h urine protein which contained 466 mg
( ). Serum labs have been normal except for stable anemia.
On evaluation here, she reports feeling well. She does endorse a
mild retro-orbital headache that is mild; no photophobia or
phonophobia, visual changes, or other neurologic symptoms. Also
denies ctx, VB, LOF. Endorses +FM.
## ROS:
Denies fevers/chills or recent illness. Denies HA, vision
changes, RUQ/epigastric pain. Denies chest pain, shortness or
breath, palpitations. Denies abd pain. Denies recent falls or
abd trauma. Denies any nausea, vomiting, diarrhea.
## PNC:
- by 11 week US (redated from LMP
- Labs: Rh+ /Abs- /RubImm /RPRnr /HBsAg- /HIV- /GBS unk
- Screening: SMA neg; MaterniT21 testing "non-reportable" due to
inadequate fetal fraction
- FFS normal x 3
- GLT 91
- U/S
> Fetus 1 930 g (33%), Fetus 2 1133 (57%), 1019 (44%)
> : normal amniotic fluid x 3, no previa, cervix long
- Issues:
*) spontaneous tri-tri triplet pregnancy
*) hepatitis C, not treated
*) Opioid use disorder on methadone maintenance
*) genital HSV
*) recent RUE DVT on lovenox
*) obesity, early pregnancy BMI 44
## - LAST PAP:
Pap and HPV unsatisfactory-plan repeat
- History of abnormal Paps at age , with normal pap in
interim
- STIs: genital HSV; negative GC/CT testing this pregnancy
## PMH:
- Upper GI bleed secondary to duodenal mass, s/p ICU stay and
transfusion, s/p resection of mass with pathology showing
hamartomatous polyp with superficial foci of low-grade
dysplasia;
negative for high grade dysplasia or malignancy ( )
- Opioid use disorder, on methadone maintenance therapy
- Right upper extremity DVT noted during
hospitalization
for pneumonia
- Hepatitis C, Diagnosed in , not treated
- h/o IV opioid use x years: tox screen positive for fentanyl
( ), on maintenance therapy
- Asthma: hospitalized as child; currently mild intermittent
with
rare albuterol use
- Obesity, early pregnancy BMI 44
## PSH:
- EGD and duodenal mass biopsy
- Transduodenal resection of adenoma
- Open cholecystectomy
## FAMILY HISTORY:
Denies history of cervical, uterine, ovarian, colon or breast
cancers
## EXT:
no calf tenderness, trace peripheral edema
## FHT
A- 140/MOD VAR/+ACCELS/-DECELS:
AGA
B- 135/mod var/+accels/-decels: AGA
C- 120/mod var/+accels/- decels: AGA
Toco no distinct contractions
## TAUS:
presenting triplet is vertex
-----
On discharge:
24 HR Data (last updated @ 809)
##
98.4 (TM 98.4), BP:
108/74 (99-130/56-86), HR: 106
(88-109), RR: 18, O2 sat: 97% (95-98), O2 delivery: ra
Fluid Balance (last updated @ 2245)
Last 8 hours No data found
Last 24 hours Total cumulative -510ml
## IN:
Total 1440ml, PO Amt 1440ml
## OUT:
Total 1950ml, Urine Amt 1950ml
## ABD:
soft, nontender, fundus firm below umbilicus
Incision clean/dry/intact, nontender, no surrounding erythema or
drainage
Lochia minimal
## BRIEF HOSPITAL COURSE:
yo G1 with tri-tri triplets admitted at 30w1d with
preeclampsia. On admission, she had mostly normal range blood
pressures and normal preeclampsia labs. Fetal testing was
reassuring. She was admitted to the service for close
surveillance. She underwent close blood pressure monitoring and
weekly labs. In regards to fetal testing, she was monitored with
daily NSTs and weekly BPPs. She was made betamethasone complete
on . In regards to her opioid use disorder, she was
continued on daily methadone and clonidine/benadryl as needed
for withdrawal symptoms. The Addictions team followed along and
assisted with uptitration of her medications to keep her
comfortable. Prior to delivery, her methadone regimen was 110mg
in am and 25mg at night. She agreed to periodic toxicology
screens. Social services met with her frequently given her
complicated social stressors. At 32w1d, a routine ultrasound
revealed minimal interval growth and elevated UA dopplers for
each triplet (not IUGR). At that point, her testing was
increased to twice weekly BPPs with dopplers and testing
remained reassuring. She remained clinically stable until 33w1d
when she developed sudden onset of SOB, tachycardia, and a
fever. Fetal monitoring at that time was also concerning for
decelerations. She was transferred to labor and delivery for
further evaluation and monitoring. She had findings on CXR
concerning for pulmonary edema, with a possible evolving
pneumonia. She was given broad spectrum IV antibiotics. The
decision was made to move forward with delivery. Please see
operative report for details.
For her postpartum course, she received magnesium for 24 hours
postpartum. She received antibiotics for 24 hours to treat a
potential pneumonia as the cause of the shortness of breath.
Infectious disease was consulted who was less convinced this was
pneumonia and more likely pulmonary edema, so her antibiotics
were discontinued after 24 hours. Her blood cultures were
negative. Her methadone was switched back a daily dose of 135 mg
daily. Her blood pressures were well controlled without needing
any medications. By postpartum day 5, she was tolerating a
regular diet, voiding, ambulating, and pain was well controlled
and thus was discharged home with plan for close follow up. She
was followed closely by social work as well.
## MEDICATIONS ON ADMISSION:
PNV
Methadone 110 mg qAM (clinic in
Pantoprazole 40 mg PO q24h
Acetaminophen PRN
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*1
2. Enoxaparin Sodium 60 mg SC DAILY
RX *enoxaparin 60 mg/0.6 mL 60 mg SC once a day Disp #*40
## SYRINGE REFILLS:
*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*1
4. Methadone 135 mg PO QAM
5. OxyCODONE (Immediate Release) mg PO Q4H:PRN Pain -
Severe
may cause sedation. do not drink alcohol or drive while taking
oxycodone
RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
## DISCHARGE INSTRUCTIONS:
Congratulations on the birth of your baby! You have recovered
well and the team now feels that you are ready to go home.
Please follow these instructions below.
Please refer to your discharge packet and the instructions
below:
- Nothing in the vagina for 6 weeks (No sex, douching, tampons)
- No heavy lifting for 6 weeks
- Do not drive while taking narcotics (i.e. Oxycodone, Percocet)
- Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs
- Do not take more than 2400mg ibuprofen in 24 hrs
Please call the on-call doctor at if you develop
headache, vision changes, chest pain, upper abdominal pain,
shortness of breath, dizziness, palpitations, fever of 100.4 or
above, pelvic pain, increased redness or drainage from your
incision, nausea/vomiting, heavy vaginal bleeding, or any other
concerns.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16502473", "visit_id": "21623473", "time": "2142-02-27 00:00:00"} |
13437614-RR-23 | 292 | ## INDICATION:
Intoxicated patient status post fall with head pain.
## FINDINGS:
There is no fracture. There is no prevertebral edema. There is a dextroconvex
curvature centered in the region of the craniocervical junction and a
levoconvex curvature centered in the upper thoracic spine, not completely
evaluated. There is mild anterolisthesis of C3 on C4, minimal retrolisthesis
of C4 on C5, minimal retrolisthesis of C5 on C6, and mild anterolisthesis of
C7 on T1, which are likely related to advanced facet arthropathy. There is
disk space narrowing with endplate sclerosis and large endplate osteophytes
from C4-5 through C6-7. There is moderate spinal canal narrowing from C3-4
through C5-6, and milder spinal canal narrowing at C6-7. There is multilevel
neural foraminal narrowing by uncovertebral and facet osteophytes. There is
mild ligamentous thickening and calcification posterior to the odontoid
process without mass effect on the thecal sac.
There is partially calcified pleural/ parenchymal scarring at both lung
apices. Large paraseptal bullae are partially visualized at both lung apices.
There is calcification at bilateral internal carotid artery origins.
Right mastoid air cells are partially opacified. Left mastoid air cells are
clear. There is mild mucosal thickening in the visualized portions of the
maxillary sinuses and ethmoid air cells, as well as minimal mucosal thickening
in the left sphenoid sinus. Concurrent head CT is reported separately.
## IMPRESSION:
1. No acute fracture.
2. Mild spondylolisthesis at multiple levels is likely degenerative, though
there are no prior exams for comparison.
3. Moderate spinal canal stenosis, which predisposes the spine cord to injury
with minor trauma. If there is clinical evidence for myelopathy, then MRI may
be obtained.
4. Large paraseptal bullae at the imaged lung apices.
5. Partial right mastoid air cell opacification.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13437614", "visit_id": "21362162", "time": "2188-12-11 00:38:00"} |
10441476-RR-25 | 82 | BILATERAL BREAST MRI WITH AND WITHOUT INTRAVENOUS CONTRAST
## INDICATION:
woman, high-risk screening, dense breast tissue,
family history of breast cancer in sister at age , mother at age .
## FINDINGS:
There is minimal background parenchymal enhancement. There is no
suspicious enhancement or architectural distortion in either breast. There is
no skin thickening or nipple retraction. There is no internal mammary or
axillary adenopathy. Incidental note is made of a small hiatal hernia.
## IMPRESSION:
No MR evidence of malignancy.
BI-RADS 1 - negative.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10441476", "visit_id": "N/A", "time": "2197-06-01 11:23:00"} |
12330994-RR-67 | 197 | ## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN)
## FINDINGS:
This examination is limited by the bowel gas pattern.
## LIVER:
Cirrhotic appearing liver. No focal liver lesions are identified.
There is moderate ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 4 mm.
## GALLBLADDER:
The gallbladder is not well visualized.
## PANCREAS:
The pancreas is obscured by overlying bowel gas.
## SPLEEN:
The spleen demonstrates normal echotexture, and measures 13 1.1 cm.
## DOPPLER EVALUATION:
The main portal vein is patent, with intermittent reversed (hepatofugal) flow.
Right and left portal veins are not well visualized.
The main hepatic artery is patent, with appropriate waveform.
The middle hepatic vein is patent. The right and left hepatic veins are not
well visualized.
A patent umbilical vein is demonstrated. There is a right pleural effusion.
## IMPRESSION:
1. This examination is limited by bowel gas resulting in markedly reduced
acoustic access. Cirrhotic liver without focal liver lesion.
2. The main portal vein is patent, however there is intermittent reversed flow
with a to and fro pattern.
3. Sequela of portal hypertension include mild splenomegaly, moderate volume
of ascites, and a patent umbilical vein.
4. Right pleural effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12330994", "visit_id": "25832142", "time": "2177-03-03 00:39:00"} |
18209469-RR-32 | 86 | ## INDICATION:
A man with persistent dizziness. Evaluate for
intracranial abnormality.
## FINDINGS:
There is no evidence of acute intracranial hemorrhage, shift of
normally midline structures, or acute major vascular territory infarction.
Ventricles and sulci are normal in size and configuration. Multiple calcified
densities are noted scattered throughout the brain parenchyma, likely
representing remote infection such as neurocysticercosis.
There is no evidence of sclerotic or lytic osseous lesion. The mastoid air
cells are well aerated bilaterally.
## IMPRESSION:
No acute intracranial hemorrhage or major vascular territory infarction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18209469", "visit_id": "N/A", "time": "2152-05-14 07:28:00"} |
17851173-RR-15 | 115 | ## INDICATION:
Status post fall. Evaluate for hemorrhage.
## FINDINGS:
There is no evidence of hemorrhage, edema, mass, mass effect, or
large vascular territorial infarction. The ventricles and sulci are
prominent, most consistent with age-related volume loss. Periventricular
confluent white matter hypodensities are consistent with chronic small vessel
ischemic disease. Basal cisterns are patent.
No fractures are identified. The patient is status post bilateral burr holes
in the posterior occipital bone. The visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. There is a small scalp hematoma
overlying the left occiput with cutaneous staples.
## IMPRESSION:
1. No acute intracranial abnormality.
2. Age-related volume loss and chronic small vessel ischemic disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17851173", "visit_id": "28899520", "time": "2149-04-30 12:19:00"} |
16060192-DS-5 | 1,265 | ## HISTORY OF PRESENT ILLNESS:
The pt is a year-old right-handed man with a past medical man
with PMH s/f NIDDM, CAD, HTN, hyperlipidemia, Prostate CA, and
hx of TIA who presents with blurry vision, gait difficulty, and
dysequilibrium now transferred from after being
discovered to have a small deep right cerebral hemorrhage.
He felt fairly normal when woke up early this morning and first
noticed deficit when he got on the eliptical trainer as he does
every day at 7:45am. He noticed that he couldn't read the
calorie display and stopped his usual 3. fter 10
minutes. He felt a little dizzy and somewhat unsteady on his
feet. His visual difficulty was in all visual fields and
present with either eye closed. He took a brief nap, waking up
at 9am to walk mile to and from the corner store to get the
paper. He took a second nap. At 11am his son in law asked him
how he was feeling, and again he reported blurry vision and
shakyness. They called the PCP who asked the son to bring the
patient to the ED at .
A head CT showed a small right intraparenchymal hemorrhage
without shift. Coags there were PTT:29.9 INR:1.2.The
patient was transferred here for further management.
The patient noted two weeks of loose stool.Besides what is noted
above the patient endorsed being hungry and fatigued. He has
had long standing bilateral hearing loss for which he has been
advised to get hearing aids. He has nocturia.
## PAST MEDICAL HISTORY:
Type 2 diabetes mellitus
HTN
Hyperlipidemia
Gout
Pancytopenia
Prostate CA
Hypothyroid
SInus Allergy
hx of TIA (slurred speech)
## HEENT:
NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
## NECK:
Supple, no carotid bruits appreciated. No nuchal rigidity
## PULMONARY:
Lungs CTA bilaterally without R/R/W
## CARDIAC:
RRR, nl. S1S2, no M/R/G noted
## ABDOMEN:
soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
## EXTREMITIES:
No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
## SKIN:
no rashes or lesions noted.
## -MENTAL STATUS:
Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
## -CRANIAL NERVES:
Olfaction not tested. PERRL 3 to 2mm and
brisk.
Predominantly a left inferior homonymous quadrananopsia with a
questionable mild superior deficit. There is no ptosis
bilaterally. Funduscopic exam revealed no papilledema, exudates,
or hemorrhages. EOMI without nystagmus. Normal saccades. Facial
sensation intact to pinprick. No facial droop, facial
musculature symmetric. Hearing diminished but intact to
finger-rub
bilaterally. Palate elevates symmetrically. strength in
trapezii and SCM bilaterally. Tongue protrudes in midline.
## -SENSORY:
No deficits to light touch, pinprick, cold sensation,
proprioception throughout. Vibratory sense was diminished in the
lower extremities even at the knees. No extinction to DSS.
## -COORDINATION:
No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
## - REFLEX:
No clonus
Bi Tri Bra Pat An Toes
C5 C7 C6 L4 S1 CST
Ltr 2 2 tr tr down
tr tr down
## -GAIT:
Good initiation. Narrow-based, normal stride and arm
swing. Romberg mildly positive with extra steps, but patient
doesn't fall.
## NEUROLOGICAL EXAMINATION:
virtually unchanged from the initial
examination.
## PERTINENT RESULTS:
and MRA of the head and neck
1. Acute hemorrhage in the right thalamus and basal ganglia,
with no definite underlying lesion identified.
2. All appearance, including chronic microvascular infarction,
isolated left frontal and occipital subcortical and bilateral
basal ganglia lacunar
infarcts, all suggest underlying hypertensive hemorrhage.
3. Unremarkable cranial MRA, with no flow-limiting stenosis.
CT head
Acute intraparenchymal hemorrhage within the right thalamus and
second adjacent focus of hemorrhage extending to insular cortex.
No mass
effect.
Labs
05:30PM GLUCOSE-72 UREA N-26* CREAT-1.3* SODIUM-140
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-29 ANION GAP-10
05:30PM WBC-3.9* RBC-3.65* HGB-11.5* HCT-32.8* MCV-90
MCH-31.5 MCHC-35.2* RDW-13.4
05:30PM NEUTS-71.8* MONOS-3.8 EOS-4.2*
BASOS-0.3
05:30PM PLT COUNT-114*
05:30PM PTT-29.1
05:55AM TSH 0.067* B12 729 Fol 19.3 HbA1c 6.4
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
05:55AM 90 651 26 3.5 51
## BRIEF HOSPITAL COURSE:
Mr was observed for over 24 h. He had two readings of
a systolic blood pressure of over 150, and therefore his
lisinopril dose was doubled. His creatinine is 1.2, and he is
also on an HCTZ/Trimaterene preparation, therefore, his
creatinine will need to be followed. In addition, his TSH was
low, therefore his dose was adjusted. He was assessed by
occupational therapy, who felt that he did not require their
input currently. In addition, he was seen by physiotherapy, who
felt that he needed supervision with ambulation, and they
suggested walks three times a day. We have advised him not to
use his elliptical trainer, due to the hypertension. In
addition, we have told him that he cannot drive until he has a
follow-up with his neurologist. Apart from loose stools which he
had been admitted with, there were no events. Due to the issues
with his bowels, and after further discussion with Dr ,
decided to stop the colchicine. In addition, if indicated
from a cardiovascular stand-point, he could potentially start on
a dose of baby aspirin in a week's time.
## MEDICATIONS ON ADMISSION:
Aggrenox - 1 dialy
Lipitor. 10mg daily
aspirin 81mg daily
Iron 65mg po daily
Senna/colace daily
Lisinopril 10mg po daily
Ramipril 5mg daily
HCTZ 50/triamterene 75 - daily
Glyburide - 5 daily
Levothyroxine - 125mcg daily
Colchicine - 0.6mg BID
Januvia - 100mg daily
Repaglinide - 0.5 BID
## DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: Two
(2) Cap PO DAILY (Daily).
## DISCHARGE DIAGNOSIS:
Right intraparenchymal hemorrhagic stroke
Hypertension
## DISCHARGE CONDITION:
Left inferior homonymous quadrantanopia with a mild superior
deficit.
## DISCHARGE INSTRUCTIONS:
You have had a hemorrhagic stroke due to high blood pressure. If
you have sudden onset weakness, or worsening visual problems,
please go to your nearest emergency room. Please avoid taking
aggrenox, aspirin and other non-steroidal anti-inflammatory
medication such as ibuprofen, unless your PCP recommends
otherwise. However, Tylenol is fine.
You cannot drive, please follow-up with your neurologist, Dr
further advice.
Do not use the elliptical trainer until your blood pressure is
better controlled. However, you should continue to go for walks,
initially with supervision.
Your blood pressure medication has been increased, and your
thyroid medication dose has been decreased due to your blood
test results.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16060192", "visit_id": "22590929", "time": "2140-03-03 00:00:00"} |
16051228-DS-21 | 966 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
restrained driver of MVC versus tree with prolonged
extrication of 25 minutes. ETOH last night, though denied this
morning. On imaging found to have small splenic laceration and
small left renal laceration. Hemodyndamically stable. Acetabular
and pubic rami fractures on left with sacral alar fracture. Labs
notable for an EtOH level of 193 and urine tox positive for
amphetamines.
## HEENT:
Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Neck is nontender
## CHEST:
Clear to auscultation, chest wall is nontender
## CARDIOVASCULAR:
Regular Rate and Rhythm, Normal first and
second heart sounds
## ABDOMINAL:
Soft, diffuse abdominal tenderness but no
peritoneal signs
## EXTR/BACK:
Back is nontender. There is no evidence of
extremity trauma. His extremity pulses are intact. There is
no deformity or lacerations
## NEURO:
Speech fluent he is awake alert and oriented x2.
Normal motor normal sensory normal DTRs toes
## CT C-SPINE - IMPRESSION:
Slightly motion limited study without
acute fracture or malalignment
CT head - IMPRESSION: No acute intracranial process with motion
limited evaluation of the skullbase.
CT torso - IMPRESSION:
1. 2.3 cm splenic laceration with a small amount of subcapsular
splenic perisplenic fluid and multiple left upper pole renal
lacerations measurinng up to 3.7 cm without significant
intraperitoneal or retroperitoneal fluid.
2. Left minimally displaced inferior pubic ramus fracture with
nondisplaced superior pubic ramus fracture extending into the
acetabulum and minimally displaced left sacral fracture.
3. Ground-glass opacity right middle lobe could reflect
aspiration or
atelectasis, less likely contusion.
4. Left testis in the inguinal canal could reflect undescended
or retractile testis.
Bilateral lower extremity duplex study
No evidence of DVT in the right or left leg
## BRIEF HOSPITAL COURSE:
Mr. was evaluated immediately upon arrival by the trauma
team, and subsequently admitted to the when CT revealed
small spleen and left renal lacerations. He remained
hemodynamically stable thereafter. He was given ativan for
anxiety and the chronic pain service was consulted for pain
management given suboxone use: they recommended dilaudid PCA
with 1mg bolus x 3 initially for pain control.
On , Mr. continued to be stable, tolerating a
regular diet with a stable hct. He was transferred to the
surgical floor for further care. and SW were consulted for
d/c planning and substance abuse counseling. He was
transitioned to oral pain medication per CPS recommendations and
remained TDWB on the LLE per ortho trauma recs, and bedrest for
his splenic and renal lacerations until . Due to ongoing
tachycardia and fever, there was concern for a deep vein
thrombus. Lower extremity doppler studies were conducted, which
were negative for DVT.
Mr. continued to do well with physical therapy. He will
be discharged home with the use of crutches. He will follow-up
with orthopedics in approximately 4 weeks where his pelvic
fractures can be assessed. Occupational therapy has also
recommended that the patient follow up with cognitive neurology
due to poor test results during their examination.
In regards to his pain management, Mr. will be discharged
with a week's worth of oxycontin and PRN oxycodone. He has been
instructed to call his psychiatrist immediately when he returns
home and request a follow-up appointment within one week. At
that time, the psychiatrist could work on resuming the patient
on suboxone therapy.
At the time of discharge, Mr. was hemodynamically stable,
afebrile and in no acute distress. His weight bearing status
was re-confirmed and the patient was now instructed to bear
weight as tolerated on both legs (per MD note, .
## MEDICATIONS ON ADMISSION:
Suboxone 8mg-2mg tab BID, Buspar 10mg BID, buproprion 300mg
daily, amphetamine salt 20mg BID
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*6 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) mg PO Q3H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
5. Oxycodone SR (OxyconTIN) 20 mg PO TID
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth three times
a day Disp #*21 Tablet Refills:*0
6. Senna 1 TAB PO BID:PRN constipation
7. Sodium Chloride Nasal SPRY NU QID:PRN Dry nares
8. BuPROPion (Sustained Release) 300 mg PO DAILY
## DISCHARGE DIAGNOSIS:
- Spleen laceration
- Left renal laceration
- Left superior and inferior pubic rami fractures
- Sacral alar fracture
- Acute pain
## DISCHARGE INSTRUCTIONS:
You were admitted to on
after you were involved in a motor vehicle accident. On
further evaluation, you were found to have the following
injuries:
- Spleen laceration
- Left renal laceration
- Left superior and inferior pubic rami fractures
- Sacral alar fracture
In terms of your pelvic fractures, those injuries were
non-operative. You are able to bear weight on your legs as
tolerated. You were seen by physical therapy and they feel you
are ready to go home with the use of crutches.
You were also evaluated by Occupational Therapy. Based on their
exam, it is their recommendation that you follow-up with Dr.
with cognitive neurology (see below).
Your spleen and kidney lacerations were stable. You needed no
surgical procedures to repair them. You will follow up in the
clinic in 2 - 3 weeks (see below). In the meantime, you
should not participate in any contact sports until your
follow-up appointment.
* Continue to utilize your crutches as needed. Based on the
type of fracture you have, you can place weight on both legs as
tolerated.
* Take any medication you were prior to hospital admission.
Also, take the prescribed medication as directed.
* Do not drive or operate heavy machinery while taking narcotic
pain medications as they can cause drowsiness and a decrease in
your mental status.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16051228", "visit_id": "27873084", "time": "2120-06-21 00:00:00"} |
17432869-RR-4 | 361 | ## HISTORY:
with history of kidney stone LLQ pain *** WARNING
*** Multiple patients with same last name! // eval for kidney stone and
diverticilutis
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.2 s, 57.0 cm; CTDIvol = 15.6 mGy (Body) DLP = 885.6
mGy-cm.
Total DLP (Body) = 886 mGy-cm.
## LOWER CHEST:
There bibasilar atelectasis. No pleural or pericardial effusion
is seen.
## HEPATOBILIARY:
The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesion or intra or extrahepatic biliary duct
dilation, within the limitations of a noncontrast exam. The gallbladder is
within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilation or peripancreatic stranding or fluid collection.
## SPLEEN:
The spleen is homogeneous and normal in size.
## ADRENALS:
The adrenal glands are normal in caliber and configuration
bilaterally.
## URINARY:
The kidneys are symmetric and normal in size. There is mild
perinephric stranding of the left kidney and mild hydroureter. There is no
evidence of focal renal lesions within the limitations of an unenhanced scan.
There is no nephrolithiasis.
## GASTROINTESTINAL:
The stomach is distended with ingested material, without
obvious wall thickening or mass within the limitations of a noncontrast exam.
Small bowel loops are normal in caliber without wall thickening or evidence of
obstruction. The colon and rectum are within normal limits. A normal
air-filled appendix is visualized.
## PELVIS:
A 3 mm stone is seen within the urinary bladder. Given the
nondependent position, it is felt to still be located at the left UVJ. There
is no free fluid in the pelvis.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
## BONES:
There is no focal lytic or sclerotic osseous lesion to suggest neoplasm
or infection.
## SOFT TISSUES:
There is a fat containing right inguinal hernia.
## IMPRESSION:
3 mm stone at the left UVJ, with mild left hydroureter and mild perinephric
stranding of the left kidney.
## NOTIFICATION:
The updated impression was emailed to the ED QA nurses by Dr.
at 0954 on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17432869", "visit_id": "N/A", "time": "2146-11-25 02:28:00"} |
14440470-RR-55 | 218 | ## HISTORY:
woman with 6 weeks of diarrhea, weight loss, and
abdominal pain.
## FINDINGS:
The lower chest is unremarkable.
## ABDOMEN:
The liver enhances homogeneously and is without concerning focal
abnormality. There is a tiny hypodensity in the dome of the liver which is
too small to characterize (2:7). The gallbladder and biliary tree appear
normal. The pancreas, spleen, and adrenal glands appear normal. The kidneys
enhance normally and excrete contrast symmetrically. There is a 1 cm simple
cyst in the mid left kidney. The stomach, duodenum, and abdominal loops of
small and large bowel are of normal caliber, without wall thickening, or
associated mass. The appendix is normal. There is no ascites, fluid
collection, or pneumoperitoneum.
The portal, splenic, and mesenteric veins are patent. The abdominal aorta is
not enlarged and its main branches are patent. There is no retroperitoneal,
periportal, or mesenteric lymphadenopathy.
## PELVIS:
The rectum and sigmoid are normal. The bladder, uterus, and ovaries
are normal. There is no pelvic free fluid or mass. There is no pelvic or
inguinal lymphadenopathy.
## MUSCULOSKELETAL:
There are no lytic or sclerotic osseous lesions concerning
for malignancy.
## IMPRESSION:
1. Essentially normal CT of the abdomen and pelvis. No abdominal or pelvic
process to explain patient's symptoms is identified on this study.
2. Incidental findings as described above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14440470", "visit_id": "N/A", "time": "2175-09-30 07:39:00"} |
13369196-DS-24 | 2,409 | ## ALLERGIES:
Depakote / Dilantin / phenobarbital / Hydromorphone / Kefzol
## CHIEF COMPLAINT:
"Are you getting this from the news channel that's broadcasting
about me?"
## HISTORY OF PRESENT ILLNESS:
This is a year old woman, reported history of BPAD, with no
reported prior psychiatric hospitalizations or suicide attempts,
medical history significant for tracheomalacia s/p
tracheobronchoplasty, IgG2 deficiency, who was BIBA after
running from her father's car claiming that he was lacing her
gatorade with crack cocaine.
On arriving to the floor, the patient refused to be interviewed
stating that she didn't understand where she was going earlier
today. She asked to be sent to one of the regular floors,
repeating over and over that she did not want to be here anymore
and demanding to be discharged stating that she just wanted to
go home and be with her sons.
Per initial evaluation by note on :
Ms reports feeling somewhat more depressed recently and
endorses decreased sleep, decreased appetite and is up at night
with increased energy in the setting of medication
non-compliance. During her recent surgery, she reports her
medication was disrupted. She also reports that she is being
cross-tapered on Abilify and Latuda by her psychiatrist. This
could not be verified with the outpatient psychiatrist earlier
today and message was left today and not returned. The patient
reports she was diagnosed with BPAD years ago and reportedly
had been doing well, controlled on medications. She is unable
to
elaborate on the conditions surrounding her initial diagnosis
and
suggests that perhaps she was feeling more depressed.
Per collateral from the father gathered in the ED by NP , the patient has not been sleeping or eating for the past
few days. The night prior to presentation, she threatened to
burn down the house. On the day of presentation, her father
reports that he was driving her to a follow-up surgical
appointment when she became verbally aggressive, grabbed the
steering wheel and began yelling that he was trying to kill her.
She reportedly told her father that she would kill him and then
jumped out of the car approaching a trooper and reporting
that her father had kidnapped her and was trying to kill her.
Per collateral from her father, she previously owned a home in
, was working as a and was married with two
children. He relayed that she has had a rapid recent decline
and
is now homeless and has been staying with her father in
for
the last 2 months.
Of note, the patient was assessed earlier today and at that time
thought to be in a manic state though behaviorally
well-controlled and cooperative with interview. Psychiatry
recommendations from NP recommended holding the
patient's venlafaxine. Per the patient received 300 mg of
venlafaxine at 17:00.
Below History derived from NP note on :
Ms reports feeling somewhat more depressed recently and
endorses decreased sleep, decreased appetite and is up at night
with increased energy in the setting of medication
non-compliance. During her recent surgery, she reports her
medication was disrupted. She also reports that she is being
cross-tapered on Abilify and Latuda by her psychiatrist. This
could not be verified with the outpatient psychiatrist earlier
today and message was left today and not returned. The patient
reports she was diagnosed with BPAD years ago and reportedly
had been doing well, controlled on medications. She is unable
to
elaborate on the conditions surrounding her initial diagnosis
and
suggests that perhaps she was feeling more depressed.
Per collateral from the father gathered in the ED by NP , the patient has not been sleeping or eating for the past
few days. The night prior to presentation, she threatened to
burn down the house. On the day of presentation, her father
reports that he was driving her to a follow-up surgical
appointment when she became verbally aggressive, grabbed the
steering wheel and began yelling that he was trying to kill her.
She reportedly told her father that she would kill him and then
jumped out of the car approaching a and reporting
that her father had kidnapped her and was trying to kill her.
Per collateral from her father, she previously owned a home in
, was working as a and was married with two
children. He relayed that she has had a rapid recent decline
and
is now homeless and has been staying with her father in
for
the last 2 months.
## PAST MEDICAL HISTORY:
- Asthma
- IgG2 subclass deficiency
- Eosinophilic bronchitis
- Recurrent pneumonias since
- Post-nasal drip s/p rhinoplasty in
-GERD
-Tracheal bronchomalacia s/p right thoracotomy and tracheo
bronchoplasty with mesh, bronchoscopy with lavage
-Hypersensitivity reaction to Cefazolin
## FAMILY HISTORY:
* Father with PSA, PTSD was in
* Mother alcoholic now sober
* Paternal grandfather alcohol and drugs
* 7 half siblings all with drug, alcohol and emotional problems
## *STATION AND GAIT:
WNL
*tone and strength: good strength and tone
cranial nerves: not assessed
abnormal movements: tremor L foot
frontal release: Not assessed
## WAKEFULNESS/ALERTNESS:
Alert
*Attention (digit span, MOYB):MOYB
*Orientation:" the Unit" " I
don't know the date is it the US.Pres."Obama"
Executive function (go-no go, Luria, trails, FAS):not assessed
*Memory:registered 3, recalled 2
*Fund of knowledge: wnl
## ABSTRACTION:
Glass Houses "they shouldn't throw stones you could
be doing the same thing"
## MENTAL STATUS:
yo female, with adequate hygiene and grooming,
dressed in hospital gown, sitting on a stretcher, with good eye
contact, tatoo on R leg
## BEHAVIOR:
in good behavioral control
*Mood and Affect:"totally overwhelmed" affect labile, crying
and
hypomanic
*Thought process / *associations:loose , disorganized but
redirectable with racing thoughts
*Thought Content: paranoid, believes her family has been mixing
drugs in her Gatorade, denies AH but reports that sometimes she
sees bugs and has had the sensation that bugs are crawling on
her
arms, denies si or hi, reports that she is not sleeping, eating,
with increased energy and is up at night with various activities
*Judgment and Insight:impaired/impaired
## PERTINENT RESULTS:
Initial Results for
Import 10:44AM URINE HOURS-RANDOM
Import 10:44AM URINE HOURS-RANDOM
Import 10:44AM URINE UCG-NEGATIVE
Import 10:44AM URINE GR HOLD-HOLD
Import 10:44AM URINE bnzodzpn-NEG barbitrt-NEG
opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG
Import 10:44AM URINE COLOR-Straw APPEAR-Clear SP
Import 10:44AM URINE BLOOD-NEG NITRITE-NEG
PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG
PH-6.5 LEUK-SM
Import 10:44AM URINE RBC-1 WBC-4 BACTERIA-NONE
YEAST-NONE EPI-3
Import 09:10AM GLUCOSE-113* UREA N-5* CREAT-0.8
SODIUM-136 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
Import 09:10AM estGFR-Using this
Import 09:10AM LITHIUM-0.7
Import 09:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Import 09:10AM WBC-11.7* RBC-4.33 HGB-13.4 HCT-41.0
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.7
Import 09:10AM NEUTS-72.0* MONOS-4.9
EOS-2.3 BASOS-0.7
Import 09:10AM PLT COUNT-439
## BRIEF HOSPITAL COURSE:
PSYCHIATRIC
#)On admission, patient was acutely psychotic, stating that she
was "being broadcast on News." Patient exhibited behavioral
dysregulation, including attempts to elope and tapping on other
patient's doors, as well as reporting visual hallucinations of
deceased relatives in setting of recent surgery, marginal
medication compliance, and marijuana use.
Upon initial hospitalization, patient was kept on constant
observation to ensure safety. Patient was started on lurasidone
40mg PO BID with good effect on psychotic symptoms.
Additionally, patient's Effexor was stopped without
complication. Patient received ativan PRNs for anxiety with good
effect. Within 48 hours of admission, the patient's behavior was
significantly better regulated and she was oriented to person,
place, time, and situation. Patient was then restarted on home
lithium 300mg PO TID (level 1.0 on admission) and klonopin 1mg
PO BID, with klonopin 0.5mg PO PRNs for anxiety. We uptitrated
her lurasidone to 60mg PO BID and uptitrated her lithium to
300mg BID plus 600mg QHS. She began to report improvement in
anxiety, with resolution of psychotic symptoms; however,
depressed mood persisted. Patient requested to try ECT
treatments, in setting of many failed antidepressant trials in
the past. She was medically cleared for ECT by internal
medicine, anesthesia, and thoracic surgery (given recent
tracheobronchoplasty). She began receiving unilateral ECT ,
without complication other than some confusion following
treatments. We thus decreased her lithium, to just 600mg QHS,
with less confusion following treatments. Patient began to
report improvement in mood, but still complained of some mental
"fogginess," for which she requested her home Ritalin. She
received Ritalin 5mg PO BID with self-reported improvement in
ability to focus. She continued to receive ECT x8 treatments
with good tolerability and improvement in mood. No apparent
cognitive side effects on exam. On discharge, mood was euthymic.
## SAFETY:
The patient remained in good behavioral control
throughout the remainder of the hospitalization and did not
require any additional physical or chemical restraints. The
patient then remained on 15 minute checks, which is our lowest
acuity level of checks.
## GENERAL MEDICAL CONDITIONS
#)HYPOTHYROIDISM:
It was noted on presentation that the patient
had a goiter; she was subsequently found have elevated TSH with
decreased T4 and positive anti-TPO Ab. She was started on
Synthroid 75mcg, with dose being lower than would be predicted
by weight due to propensity for mania, per endocrine recs.
-Continue Synthroid 75mcg PO QD
-Recommend f/u with outpt providers as clinically indicated
#)Asthma
-Continue Albuterol nebs
-Continue Advair BID
-Continue Ipratropium nebs
-Recommend f/u with outpt providers as clinically indicated
#)GERD
-Continue Ranitidine 150mg PO QHs
-Recommend f/u with outpt providers as clinically indicated
#)HTN
-Hold Verapamil SR 120mg PO Q24h. Patient's home medication
verapamil was held before discharge due to holding
parameters of SBP<110.
-Patient was encouraged to follow up with her primary care
doctor after discharge
#)Gastroenteritis, now resolved. During this admission, the
patient had one day of fever with multiple episodes of watery
diarrhea and mild nausea without vomiting. She met criteria for
norovirus precautions, and thus was kept on contact precautions
for several days, before they were taken off due to being
asymptomatic for 72 hours.
PSYCHOSOCIAL
#) MILIEU/GROUPS
The patient was euthymic, and intermittently participatory in
the milieu. The patient was visible on the unit and frequently
had conversations with her peers. She intermittently attended
some groups.
#) FAMILY CONTACTS
Family meeting was held with the patient's mother , father
. They understand and are in agreement with the current
treatment and discharge plan.
#) COLLATERAL
We spoke with the patient's parents, father and mother
.
LEGAL STATUS
The pt remained on a CV throughout the duration of this
admission.
## RISK ASSESSMENT:
This patient does not report abusing substances, is not suicidal
or homicidal, is feeling well, euthymic, and some what
participatory in the milieu, all of which indicate a
low-moderate immediate risk of harm.
Despite recent episodes of agitation and active psychosis,
current risk of harm to others is moderate given resolution of
psychotic symptoms and improvement in mood and behavioral
regulation.
Static risk factors include severe mental illness, history of
trauma/abuse, family history of suicide, chronic medical
illness, impulsive/aggressive tendencies
Modifiable risk factors include evidence of impulsivity, acute
major mood episode, limited outpatient/social support, sense of
isolation, financial stressors, unemployment, lack of day
structure, family history of mental illness, and medical
comorbidities,
We modified this risk by uptitrating the patient's mood
stabilizing medications, antipsychotic, anxiolytic, and
stimulant. Patient was started on zolpidem to assist with sleep
maintenance.
Protective factors include children, patient trust in current
outpatient providers, strong family support, education level,
motivation to obtain treatment, and ability to clearly
articulate possible future challenges. Current risk is moderate
for intentional and unintentional self-harm given that pt denies
suicidal ideation, intent and plan, is accepting of treatment,
is currently sober and is future oriented with plans to restart
her life; however, patient continues to demonstrated evidence of
disordered thought processes and inclination towards impulsivity
on exam.
INFORMED CONSENT
I discussed the indications for, intended benefits of, and
possible side effects and risks of this medication, and risks
and benefits of possible alternatives, including not taking the
medication, with this patient. We discussed the patient's right
to decide whether to take this medication as well as the
importance of the patient's actively participating in the
treatment and discussing any questions about medications with
the treatment team, and I answered the patient's questions. The
patient appeared able to understand and consented to begin the
medication.
## PROGNOSIS:
Fair due to the fact that .
## MEDICATIONS ON ADMISSION:
Adderall
Advair diskus
Venlafaxine
Ranitidine
Lurasidone
Albuterol
Benztropine
Clonazepam
Lithium
Pantoprazole
Verapamil
## DISCHARGE MEDICATIONS:
Lithium carbonate 600 mg by mouth at bedtime for mood
stabilization
Lurasidone 60 mg by mouth twice daily for mood stabilization
Clonazepam 1 mg by mouth twice daily for anxiety
Clonazepam 0.5 mg by hour every 4 hours as needed for anxiety
and insomnia
Methylphenidate 5 mg by mouth twice daily (before breakfast and
lunch) for attention and impulsivity
Zolpidem tartrate 10 mg by mouth at bedtime for sleep
Levothyroxine Sodium 75 mcg by mouth every morning (to be taken
on empty stomach) for hypothyroidism
Verapamil SR 120 mg by mouth daily for high blood pressure
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH twice daily for
asthma
Ipratropium Bromide Neb 1 NEB IH four times daily as needed for
shortness of breath and wheezing (for asthma)
Albuterol 0.083% Neboln 1 NEB IH four times daily as needed for
wheezing (for asthma)
Pantoprazole 40 mg by mouth twice daily for GERD
Ranitidine 150 mg by mouth at bedtime for GERD
## DISCHARGE DIAGNOSIS:
Bipolar disorder, mixed episode
## DISCHARGE INSTRUCTIONS:
Discharge Instructions
-Please follow up with all outpatient appointments as listed
-take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
*It was a pleasure to have worked with you, and we wish you the
best of health.*
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13369196", "visit_id": "25691652", "time": "2111-07-10 00:00:00"} |
19653772-RR-11 | 511 | ## EXAMINATION:
MR FOOT CONTRAST RIGHT
## INDICATION:
year old woman with erythema and pain around first metatarsal
head // eval tibial sesamoid for osteo vs. soft tissue infetion
## FINDINGS:
Images are targeted to the forefoot from the proximal metacarpals through the
distal tufts.
A skin marker is identified just distal to and subjacent to the medial
sesamoid bone. The medial sesamoid bone is increased in signal intensity on
STIR sequences consistent with mild bone marrow edema. The lateral sesamoid
is normal in signal intensity. No discrete fracture line is present within
either sesamoid bones.
Trace edema along the plantar aspect of the first metatarsal head (4:21) at
its articulation with the medial sesamoid suggests mild arthritic changes.
There are no erosions. There is a small joint effusion within the first
metatarsal phalangeal joint, relatively common finding. Edema within the
subcutaneous fat subjacent to the sesamoid bones is noted. No cutaneous
ulceration is appreciated. Susceptibility artifact within the subcutaneous
fatty tissues medial to the sesamoid bones is without a radiopaque correlate
on radiograph dated .
The plantar plate is intact. There is trace fluid about the flexor hallucis
longus tendon (04:14) consistent with tenosynovitis. Trace fluid is also
present about the extensor hallucis longus tendon consistent with
tenosynovitis (04:14). The medial and lateral heads of the flexor hallucis
brevis muscle are unremarkable and normal in bulk.
There is no evidence of a neuroma. Trace fluid in the first and
third intermetatarsal bursae is within physiologic limits. Extensor digitorum
longus tendons appear within normal limits. Trace fluid is noted in several
MTP joints, also relatively common finding. There is mild diffuse
subcutaneous and interstitial edema in the forefoot.
Tiny focus of edema at the base of the first metacarpal adjacent to the
tarsometatarsal joint (06:17 8:9) is compatible with a tiny focus of
osteoarthritis.
## IMPRESSION:
1. Trace non-specific bone marrow edema within the medial sesamoid bone
without a discrete fracture line in without bone erosion. The differential
includes osteomyelitis, however, given subtle changes in the adjoining first
metatarsal, this could reflect the presence of osteoarthritis.
2. Patchy non-specific soft tissue edema in the plantar subcutaneous fat
subjacent to the sesamoid bones of the first ray. This is non-specific, but
given its relatively focal nature and location, the differential could include
early changes associated with an adventitial bursa. In the appropriate
clinical setting, cellulitis could have a similar appearance. No obvious skin
ulceration is seen in this area, but that is best correlated clinically. No IV
contrast was administered. Allowing for this, there is no focus of dense
edema to suggest an abscess collection. Mild diffuse subcutaneous and
interstitial edema is also seen in the elsewhere in the forefoot. No
significant muscle edema.
3. Mild tenosynovitis of the flexor and extensor hallucis longus muscles.
4. Small first metatarsal phalangeal joint effusion, relatively common
finding.
5. Focus of susceptibility artifact within the subcutaneous tissues medial to
the sesamoid bones without a radiopaque correlate identified on the radiograph
dated . Correlate with history of prior surgical
instrumentation or penetrating injury.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19653772", "visit_id": "N/A", "time": "2180-03-31 13:38:00"} |
19655386-RR-111 | 460 | ## INDICATION:
Persistent back pain radiating down the right leg. Evaluate for
right-sided disc herniation.
## FINDINGS:
Alignment is preserved. Vertebral body heights are preserved. Areas of
endplate degenerative signal are noted from the L1-L2 through L5-S1 levels.
Scattered areas of fatty marrow placement are seen. A few Schmorl's nodes are
seen. There is otherwise no suspicious focal bone marrow signal abnormality.
There is no prevertebral soft tissue edema.
There is loss of T2 signal of the intervertebral discs, a manifestation of
degenerative disc disease. There is moderate intervertebral disc height loss
from the L1-L2 through L5-S1 levels.
The distal visualized spinal cord is preserved in signal and caliber. The
conus medullaris terminates at the distal L1 level.
Mild facet degenerative changes are noted at multiple levels.
Limited sagittal view of the T11-T12 level demonstrates trace disc bulge
without significant spinal canal or neural foraminal narrowing.
At T12-L1 level, there is desiccation and minimal diffuse disc bulge with no
evidence of neural foraminal narrowing or spinal canal stenosis.
At L1-L2, there is mild disc bulge and endplate osteophyte formation indenting
the ventral thecal sac without significant spinal canal narrowing. Endplate
osteophytes produce minimal right neural foraminal narrowing. The left neural
foramina is patent. A perineural cyst is seen on the left.
At L2-L3, there is disc desiccation, diffuse disc bulge with left paracentral
disc protrusion, and small amount of disc material extruded inferiorly on the
left (image 18, series 5, and image 13, series 2),endplate osteophytes more
prominent on the left and ligamentum flavum thickening are present indenting
the ventral thecal sac without significant spinal canal narrowing. Facet and
endplate osteophytes produce moderate left neural foraminal narrowing. There
is mild right-sided neural foraminal narrowing.
At L3-L4, there is mild disc bulge and endplate osteophyte formation without
significant spinal canal narrowing. Facet and endplate osteophytes produce
mild left-greater-than-right neural foraminal narrowing.
At L4-L5, there is trace disc bulge, slightly eccentric to the right,
contacting the traversing nerve roots, without significant spinal canal
narrowing. Facet and endplate osteophytes produce moderate right and mild
left neural foraminal narrowing.
At L5-S1, there is no significant spinal canal narrowing. Facet and endplate
osteophytes produce mild left-greater-than-right neural foraminal narrowing.
An unchanged perineural cyst (Tarlov cyst), is identified at S2 level on the
right.
Overall degree of degenerative change appears minimally progressed compared to
, mainly with progression of degenerative disc disease.
The visualized retroperitoneum is grossly unremarkable.
## IMPRESSION:
Minimal progression of degenerative disc disease compared to ,
with most notable findings at L2/L3 level with left paracentral disc
protrusion, and moderate neural foraminal narrowing at the right L4-L5 level.
No significant spinal canal narrowing.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19655386", "visit_id": "N/A", "time": "2171-06-02 18:32:00"} |
17694771-DS-5 | 1,091 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
cold-like symptoms, nonproductive cough, fevers, and confusion.
## HISTORY OF PRESENT ILLNESS:
Ms. is a y.o. woman with advanced dementia, dependent
of IADLs and needs assistance w/
eating/toileting/dressing/bathing and lives in an assisted
living dementia unit. She has a history of PAfib (on A/C),
hypothyroidism, and hypertension who presents with cold-like
symptoms, nonproductive cough, fevers, and confusion. She was
seen by her PCP for upper respiratory symptoms, thought was
likely viral given a number of other residents had similar
symptoms. The main reason for transfer to the hospital was a
fever and confusion. Patient is alert but unable to provide a
history given her advanced dementia.
In the ED, she spiked a temperature up to 103.8, tachycardic to
low 100s, stable BP. A CXR was negative for pneumonia, and a UA
was grossly positive. She has a history of UTIs, Klebsiella
which was pansensitive and Proteus also
pansensitive. WBC was 6.3, with a left shift of N 75%.
Creatinine 0.8, and LA 1.3. Flu swab was negative. Medications
she received in the ED, Tylenol PR x 1, Zosyn IV and
Vancomycin IV. She was given 1L of NS on the floor and remained
stable overnight.
I spoke to the patient's daughter and HCP this morning
on the phone. She has noticed a decline of her mom over the last
month. Having more difficultly eating, "having trouble finding
her own mouth" (requiring assistance). More lethargic lately.
Saw her on , and thought she was more lethargic but was
not concerned about an infection. At baseline, Mrs. uses a
, but uses only minimally (eg to bathroom, to kitchen).
She does not speak normally or very rarely. Daughter describes,
"she is not in the moment with us." Family had planned to get a
private aid to assist her during the day, specially to help her
eat. She had conversations with her mother about her wishes for
her end of life care. She does not want aggressive life saving
measures such as CPR or intubation or HD. Will fill out a Molst
this admission. She is currently a DNR, with form in the chart.
Patient has 3 children in the area that visit with her often.
is her HCP. She said her brother would be the
"second in charge," if she wasn't available to make decisions.
## PAST MEDICAL HISTORY:
Advanced dementia
PAF
hypothyroidism
hearing loss
hypertension,
osteoarthritis
cystocele pessary previously, was removed
## GENERAL:
Makes eye contact, nonverbal, not following commands,
elderly appearing in NAD
## HEENT:
Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
## CV:
Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
## LUNGS:
Clear to auscultation bilaterally however poor effort,
no wheezes, rales, rhonchi
## ABDOMEN:
Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
## EXT:
Hyperpigmented venous stasis changes on legs, otherwise,
warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
## NEURO:
Moving all extremities with purpose, no facial
asymmetry, gait deferred.
## CAM:
Difficult to obtain given patient's dementia
1) Acute onset and fluctuating course: no
2) Inattention: yes but baseline
3) Disorganized thinking: unable to obtain
4) Altered level of consciousness: arousable
If yes to criteria 1 and 2 AND either 3 or 4, then positive for
delirium
## MINICOG:
Unable to obtain given patient's baseline dementia
## GENERAL:
pleasant thin elderly woman, sleeping but arousable to
voice
## HEENT:
sclera anicteric, MMM, oropharynx clear
## LUNGS:
clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
## EXT:
warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## NEURO:
CNs2-12 intact, motor function grossly normal. Oriented x
0.
## SENSITIVITIES:
MIC expressed in
MCG/ML
ESCHERICHIA COLI
|
AMPICILLIN
-----
=>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN
-----
<=4 S
CEFEPIME
-----
<=1 S
CEFTAZIDIME
-----
<=1 S
CEFTRIAXONE
-----
<=1 S
CIPROFLOXACIN
-----
<=0.25 S
GENTAMICIN
-----
<=1 S
MEROPENEM
-----
<=0.25 S
NITROFURANTOIN
-----
<=16 S
PIPERACILLIN/TAZO
-----
<=4 S
TOBRAMYCIN
-----
<=1 S
TRIMETHOPRIM/SULFA
-----
=>16 R
Imaging
-----
## CXR :
IMPRESSION:
No focal consolidation to suggest pneumonia
## BRIEF HOSPITAL COURSE:
Ms. is a year old woman with a history of
advanced dementia who presented with fever and confusion. She
initially met criteria for sepsis with fever and tachycardia.
Workup for infectious sources revealed a urinary tract infection
with urine culture growing >100,000 E. coli. She was initially
treated with broad-spectrum antibiotics, and then based on
sensitivities this was narrowed to cefpodoxime for a planned 7
day course. The rest of her home medications were continued.
=================
CHRONIC ISSUES
=================
## # PAROXYSMAL ATRIAL FIBRILLATION:
Continued home Rivaroxaban 15
mg PO QDaily, Propafenone mg PO BID
## # HYPOTHYROIDISM:
Continued home Levothyroxine 100 mcg PO QDaily
## # CONSTIPATION:
Continued home senna and Colace.
## # GOALS OF CARE:
A MOLST was completed with the patient's
daughter/HCP indicating her preference for DNR/DNI, no
artificial hydration or nutrition, no dialysis, but ok for
re-hospitalization and noninvasive ventilation.
=================
CHRONIC ISSUES
=================
-continue cefpodoxime 200mg po BID for a planned 7 day course
(Day 1:
# CODE: DNR/DNI (confirmed)
# CONTACT: (HCP) - (h),
(c)
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Propafenone HCl 225 mg PO BID
3. Rivaroxaban 15 mg PO DAILY
4. Acetaminophen 1000 mg PO Q12H:PRN Pain - Moderate
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 200 mg PO DAILY
7. Senna 17.2 mg PO QHS
8. GuaiFENesin ER 600 mg PO Q12H
9. Cyanocobalamin 1000 mcg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
## DISCHARGE MEDICATIONS:
1. Cefpodoxime Proxetil 200 mg PO/NG Q12H Duration: 5 Days
2. Acetaminophen 1000 mg PO Q12H:PRN Pain - Moderate
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 200 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Propafenone HCl 225 mg PO BID
8. Rivaroxaban 15 mg PO DAILY
9. Senna 17.2 mg PO QHS
10. Vitamin D 1000 UNIT PO DAILY
## PRIMARY DIAGNOSIS:
-sepsis due to complicated urinary tract infection
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were hospitalized at
because of a urinary tract infection. You were treated with
antibiotics, and you improved.
You will be discharged with antibiotics to take by mouth for
another 5 days.
We wish you all the best!
-Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17694771", "visit_id": "21140468", "time": "2180-06-21 00:00:00"} |
18433771-RR-3 | 175 | ## HISTORY:
woman with abdominal pain, CT showing a 2.5 cm ovarian
cyst. Evaluate for torsion.
## FINDINGS:
Transvaginal examination was performed for better evaluation of the
endometrium and adnexa, a transabdomial exam was not performed since the
bladder was empty. The uterus appears normal in echotexture measuring 7 x 2.7
x 4.6 cm. The endometrium is normal in echotexture measuring 4.5 mm. The
right ovary measures 3.9 x 4.5 x 3.2 cm. Within the right ovary is an
anechoic cyst measuring 2.6 x 3.5 x 3.4 cm. There is no internal vascularity
within the cyst. Within the periphery of the right ovary is normal ovarian
tissue demonstrating normal venous and arterial waveforms. The left ovary
could not be identified. There is no fluid in the pelvis.
## IMPRESSION:
1. Right adnexal cyst. Normal venous and arterial waveforms in the right
ovary. Left ovary cannot be visualized. Please note that a normal ultrasound
examination does not exclude the possibility of torsion.
2. Normal uterus and endometrium.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18433771", "visit_id": "N/A", "time": "2185-02-28 02:08:00"} |
17257616-RR-13 | 122 | ## EXAMINATION:
BILAT LOWER EXT VEINS
## INDICATION:
seizure disorder, hx of right pyelonephritis here for
scheduled laparoscopic nephrectomy, converted to open aorta/cava
transection, s/p interposition grafting of IVC/aorta. CTA torso: Nonocclusive
central filling defect in the left common femoral vein// Please evaluate
bilateral for DVT, signs of filling defect on CTA L CFV. Thanks.
## FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa ( ) cyst.
## IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17257616", "visit_id": "26006242", "time": "2169-12-20 13:49:00"} |
12318994-RR-35 | 350 | ## EXAMINATION:
CTA CHEST WITH CONTRAST
## INDICATION:
year old woman with Right-sided aortic arch with aberrant
left subclavian.
## HEART AND VASCULATURE:
A right-sided aortic arch with retroesophageal aberrant
left subclavian artery is unchanged. Mass effect on the adjacent esophagus
appears similar, without proximal esophageal distension. The diameter of the
left subclavian artery at its origin is unchanged since and measures 2.3
cm. More distally, the left subclavian artery is normal in caliber. Distal
to the origin of the aberrant left subclavian, the arch measures 3.1 cm.
Prior to the origin of the aberrant left subclavian, the arch measures 2.7 cm.
The descending aorta continues to efface the right mainstem bronchus, less
pronounced than the prior examination (series 3, image 61).
The left brachiocephalic vein has an aberrant course posterior to the
ascending thoracic aorta, but without evidence of compression. Coronary
anatomy is normal with no significant atherosclerosis visualized.
The right subclavian and bilateral internal carotid arteries are normal in
caliber. No significant aortic atherosclerosis. No evidence of penetrating
ulcer or dissection. Heart size is normal. The main pulmonary artery is
normal in caliber. No pulmonary embolus to the subsegmental level.
## AXILLA, HILA, AND MEDIASTINUM:
No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
## PLEURAL SPACES:
No pleural effusion or pneumothorax.
## LUNGS/AIRWAYS:
Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
## BASE OF NECK:
Visualized portions of the base of the neck show no abnormality.
## ABDOMEN:
A 1.6 cm hepatic segment VII lesion with peripheral nodular
enhancement is compatible with a hemangioma (series 3, image 114), unchanged
since .
## BONES:
No suspicious osseous abnormality is seen.? There is no acute fracture.
## IMPRESSION:
1. Right-sided aortic arch with aberrant retro-esophageal left subclavian
artery. Mass effect on the adjacent esophagus is unchanged. No proximal
esophageal dilation to suggest significant obstruction.
2. Effacement of the right mainstem bronchus by the descending thoracic aorta
is less conspicuous than on the prior examination.
3. Aberrant left brachiocephalic vein without evidence of compression.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12318994", "visit_id": "N/A", "time": "2110-11-29 09:23:00"} |
15245319-RR-47 | 139 | ## INDICATION:
eval for LIJ line change over wire
year old man s/p emergent AAA // eval for LIJ line change over wire
Contact name: , PA, :
## EXAMINATION:
CHEST PORT. LINE PLACEMENT
## FINDINGS:
The ET tube terminates 9 cm above the carina. Right IJ dialysis catheter
terminates at mid SVC. Left IJ venous line terminates in right
brachiocephalic vein. Transesophageal tube terminates in the stomach.
Severe pulmonary edema and moderate to large bilateral pleural effusions are
similar to prior. Cardiac silhouette is borderline enlarged.
## IMPRESSION:
1. Left IJ venous line terminates in right brachiocephalic vein.
2. ET tube terminates 9 cm above the carina. Recommend advancing it by 5 cm.
3. Severe pulmonary edema and moderate to large bilateral pleural effusions
are similar to prior.
## NOTIFICATION:
The findings were discussed by with on
the telephone on at 1:25 .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15245319", "visit_id": "23614906", "time": "2184-02-05 12:46:00"} |
18998366-RR-32 | 397 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## HISTORY:
with neutropenic fever, diarrhea and anemia.
Evaluate for abscess or colitis.
## SINGLE PHASE CONTRAST:
MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 16.8 mGy (Body) DLP = 874.0
mGy-cm.
Total DLP (Body) = 888 mGy-cm.
## LOWER CHEST:
Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon is
predominantly fluid-filled throughout with diffuse mild mural wall thickening
and hyperemia. No drainable fluid collection is seen. No pneumoperitoneum or
ascites.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate is unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
The infrarenal abdominal aorta is mildly ectatic measuring up to 2.7
x 2.5 cm (02:41), stable compared to . Extensive atherosclerotic
disease is noted.
## BONES:
Compression deformity of the T12 vertebral body appears similar to
prior exam performed . No aggressive osseous lesions are
identified.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Diffusely fluid-filled colon with mild mural wall thickening and
enhancement compatible with provided history of diarrhea. Findings may
reflect a mild pancolitis.
2. Stable ectatic infrarenal abdominal aorta.
3. Unchanged T12 compression deformity.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18998366", "visit_id": "23465587", "time": "2175-06-27 22:40:00"} |
12777045-RR-29 | 98 | ## INDICATION:
with uretral stents// eval stents
## FINDINGS:
Projection of the right ureteral stent is similar compared to prior CT scan
with lower pigtail projecting over the pelvis in the right superior pigtail
over the renal shadow. IVC filter projects over the right mid abdomen.
Surgical clips and chain sutures seen in the pelvis as well as in the right
upper quadrant. There are no dilated loops of air-filled small bowel. No
abnormal air-fluid levels. No free intraperitoneal air.
## IMPRESSION:
Right ureteral stent is in similar position compared to scout image from CT
scan from .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12777045", "visit_id": "N/A", "time": "2172-02-17 15:38:00"} |
10754991-RR-131 | 468 | ## HISTORY:
Failed rotator cuff repair. Pain.
## FINDINGS:
Surgical anchors are present within the humeral head. There has been
development of marked marrow edema within the humeral head and to a lesser
extent within the superior aspect of the glenoid.
The supraspinatus tendon has increased in thickness and heterogeneous T2
signal. In addition, there is articular surface fraying. There is a small
amount of increased adjacent fluid within the subacromial / subdeltoid bursa.
The infraspinatus tendon has increased in heterogeneous T2 signal as well
without evidence of a discrete tear and articulate surface fraying.. There is
unchanged muscle atrophy of the supraspinatus and infraspinatus muscles. The
teres minor is intact and normal in signal.
The subscapularis tendon is somewhat lax in appearance and heterogeneous in
signal indicative of moderate tendinosis. There is a partial tear of the
superior fibers of the subscapularis tendon.
There is marked heterogeneous signal within the long head of the biceps tendon
indicative of severe tendinopathy and partial tearing, status post biceps
tendon debridement. The intra-articular portion of the long head of the
biceps is medial displaced suggestive of a biceps pulley injury as well as a
partial tear of the subscapularis.
There is minimal subchondral sclerosis with joint fluid of the left
acromioclavicular joint. There is subacromial osseous spurring.
There is a small joint effusion. There is prominent synovitis within the
axillary pouch.
The superior labrum is heterogeneous and T2 signal indicative of degeneration.
The anterior and posterior aspects of the labrum are diminutive in appearance,
however appear intact. The inferior aspect of the labrum appears intact.
There is full-thickness articular cartilage loss of the superior aspect of the
humeral head and glenoid indicative of severe degenerative joint disease.
The left axilla demonstrates multiple subcentimeter benign-appearing lymph
nodes. Incidental note is made of an intramuscular lipoma within the deltoid
measuring 3.3 cm CC x 0.8 cm TRV x 1.0 cm AP (5:15, 7:8).
## IMPRESSION:
1. Severe tendonopathy and articular surface fraying of the surgically
repaired supraspinatus tendon without evidence of a discrete tear.
2. Moderate tendinosis of the intact infraspinatus tendon and articular
surface fraying.
3. Partial tear of the superior fibers of the subscapularis tendon.
4. Degeneration of the superior labrum.
5. Severe tendinopathy and partial tearinglongtime long head of the biceps
tendon. Medial subluxation of the intra articular biceps tendon.
6. Severe degenerative joint disease of the glenohumeral joint with marked
interval increase in prominence of edema within the humeral head and to a
lesser extent the superior aspect of the glenoid, may be degenerative and / or
post-operative in etiology. However, infection could result in this MR
appearance, recommend clinical correlation.
7. Small glenohumeral joint effusion with concomitant synovitis.
8. Incidental note is made of an unchanged intramuscular lipoma within the
deltoid.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10754991", "visit_id": "N/A", "time": "2132-11-03 17:44:00"} |
17434443-RR-68 | 125 | ## EXAMINATION:
CHEST (AP AND LAT)
## HISTORY:
with shortness of breath, chest pain// Pneumonia,
Pneumothorax
## FINDINGS:
Heart size appears moderately enlarged, slightly increased in the interval.
The aorta is unfolded. Crowding of bronchovascular structures is noted with
mild pulmonary vascular congestion. More focal opacity along the periphery of
the left midlung field may reflect post radiation changes. Bibasilar patchy
opacities likely reflect atelectasis. Elevation of the right hemidiaphragm
was seen on the previous CT. No pleural effusion or pneumothorax is present.
The osseous structures are diffusely demineralized with multiple compression
deformities again noted including evidence of prior kyphoplasty of multiple
lumbar vertebral bodies.
## IMPRESSION:
1. Mild pulmonary vascular congestion.
2. Probable post radiation changes in the left lateral mid lung field.
3. Bibasilar atelectasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17434443", "visit_id": "25492706", "time": "2186-11-17 15:44:00"} |
17216679-RR-30 | 189 | ## INDICATION:
s/a.// eval for AAA pt with PAD and CAD
## FINDINGS:
The proximal aorta cannot be measured due to overlying bowel gas.
The aorta measures 2.0 x 1.4 cm in the mid portion and 1.8 x 1.6 cm in the
distal portion. There is moderate calcified atherosclerotic plaque.
Wall-to-wall color flow is seen within the aorta with appropriate arterial
waveforms.
The right common iliac artery measures 1.3 x 0.9 cm and the left common iliac
artery measures 1.3 x 1.2 cm.
The right kidney measures 11 cm and the left kidney measures 11.9 cm. Limited
views of the kidneys demonstrate cortical thinning and increased cortical
echogenicity, in keeping with chronic renal disease. There is suggestion of
multiple peripelvic cysts in both kidneys, as seen on renal ultrasound from and scout images from MRI of the lumbar spine from .
## IMPRESSION:
1. Evaluation of the proximal aorta is limited due to overlying bowel gas. No
evidence of aneurysmal dilatation of mid or distal abdominal aorta.
## RECOMMENDATION(S):
A dedicated renal ultrasound can be obtained for further
evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17216679", "visit_id": "N/A", "time": "2168-12-22 13:03:00"} |
16960594-RR-71 | 206 | ## INDICATION:
year old man with reintal hemorrhages// r/o occlusions
## RIGHT:
The right carotid vasculature has mild to moderate atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 99 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 47, 57, and 69 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 35 cm/sec.
The ICA/CCA ratio is 0.7.
The external carotid artery has peak systolic velocity of 108 cm/sec.
The vertebral artery is patent with antegrade flow.
## LEFT:
The left carotid vasculature has mild to moderate atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 107 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 49, 61, and 55 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 25 cm/sec.
The ICA/CCA ratio is 0.6.
The external carotid artery has peak systolic velocity of 90 cm/sec.
The vertebral artery is patent with antegrade flow.
## IMPRESSION:
Atherosclerotic plaque bilaterally with no hemodynamically significant carotid
stenosis, similar to prior carotid ultrasound in .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16960594", "visit_id": "N/A", "time": "2192-01-08 10:17:00"} |
10394039-RR-86 | 355 | ## EXAMINATION:
CT abdomen and pelvis without intravenous contrast.
## INDICATION:
female with abdominal pain in bloating. Evaluate for
obstruction.
## LOWER CHEST:
There is mild dependent atelectasis in the bilateral lower lobes.
Ill-defined linear opacities in the lingula likely represent atelectasis. The
heart is top normal in size. Aortic valvular calcifications are moderate.
There is no pleural pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates low attenuation throughout, compatible
with hepatic steatosis. 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 is within normal limits.
## PANCREAS:
There is mild fatty atrophy of the pancreas. There is no 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. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is not delineated though no inflammatory changes
noted in the right lower quadrant.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The uterus and ovaries 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. Minimal atherosclerotic
disease is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
There is a hemangioma in the L2 vertebral body. Moderate multilevel
degenerative changes of thoracolumbar spine are noted.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits. Surgical
clips noted in the lateral aspect of the left breast.
## IMPRESSION:
No acute abnormality in the abdomen or pelvis. No evidence of obstruction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10394039", "visit_id": "N/A", "time": "2190-04-23 17:07:00"} |
13622149-RR-29 | 100 | ## HISTORY:
female, left lower quadrant pain and tenderness, concern
for diverticulitis or mass.
## BONE WINDOWS:
No concerning lesions are seen.
## IMPRESSION:
1. No evidence of diverticulitis.
2. Fecalization of small bowel similar to suggests possible
underlying hypomotility. There is equivocal irregular wall thickening of the
terminal ileum but no adjacent inflammatory change. Gastroenterological
consultation and/or small bowel follow through examination are recommended.
3. Fibroid uterus.
ER dashboard wet read placed at 11:15 p.m. on . Findings related to
small bowel / terminal ileum and suggestions for followup care were
communicated to the ED QA nurse via email .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13622149", "visit_id": "N/A", "time": "2190-11-15 22:49:00"} |
14129767-RR-58 | 421 | ## EXAMINATION:
CTA CHEST WITH CONTRAST
## INDICATION:
with tachycardia, dyspnea, ESRD// ? PE
## HEART AND VASCULATURE:
Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The right atrium is enlarged with reflux of contrast
into the IVC and hepatic veins. Otherwise, the heart, pericardium, and great
vessels are within normal limits. There is a moderate nonhemorrhagic
pericardial effusion, increased in size compared to .
## AXILLA, HILA, AND MEDIASTINUM:
No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
## PLEURAL SPACES:
No pleural effusion or pneumothorax.
## LUNGS/AIRWAYS:
Mild upper lobe predominant centrilobular emphysema. Mosaic
attenuation of the bilateral lungs likely reflects air-trapping. Mild
bilateral septal and bronchial wall thickening likely represents mild fluid
overload. Multiple calcified granulomas are visualized. There also multiple
solid pulmonary nodules, some of which are subpleural/perifissural location
(series 3, image 77, 103, 149, 174, 209). The largest is within the right
upper lobe and is subpleural in location measuring 6 mm. No focal
consolidations. The airways are patent to the level of the segmental bronchi
bilaterally.
## BASE OF NECK:
Visualized portions of the base of the neck show no abnormality.
## ABDOMEN:
Note is made of ascites. Otherwise, the included portion of the
upper abdomen is unremarkable.
## BONES AND SOFT TISSUES:
Diffuse sclerotic appearance of the bones compatible
with renal osteodystrophy. Degenerative changes within the bilateral
glenohumeral joints. No suspicious osseous abnormality is seen.? There is no
acute fracture. Diffuse subcutaneous edema.
## IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Moderate nonhemorrhagic pericardial effusion, increased in size compared to
. Right atrium is enlarged with reflux of contrast into the IVC
and hepatic veins. Please correlate with echocardiography for any tamponade
physiology.
3. Mild bilateral septal thickening, likely mild fluid overload.
4. Multiple solid pulmonary nodules measuring up to 6 mm. Follow-up CT is
recommended.
5. Ascites, incompletely assessed.
6. Diffuse sclerotic appearance of the bones compatible with renal
osteodystrophy.
## RECOMMENDATION(S):
For incidentally detected multiple solid pulmonary nodules
measuring 6 to 8mm, a CT follow-up in 3 to 6 months is recommended in a
low-risk patient, with an optional CT follow-up in 18 to 24 months. In a
high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months
is recommended.
See the Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14129767", "visit_id": "24602326", "time": "2155-04-22 20:58:00"} |
16320691-RR-77 | 430 | ## INDICATION:
Lymphoma, main disease in neck. Evaluate interval change.
## FINDINGS:
CT OF THE CHEST WITH IV CONTRAST:
There is no axillary, mediastinal, or hilar
lymphadenopathy present. A 6-mm hypodensity persists in the isthmus of the
thyroid, minimally changed over many studies. A 5-mm hypodensity is also seen
in the right lobe of the thyroid. Incidental note made of an aberrant right
subclavian artery. Minimal vascular calcifications are seen at the aortic
arch. The heart and pericardium appear unremarkable.
Examination of lung windows demonstrates patency of the central airways to the
segmental bronchi bilaterally. Multiple sub-5 mm pulmonary nodules are again
noted, which, based on their stability since examinations back to , appear
benign. Minimal dependent atelectasis is present.
Note is made of a heterogeneous appearance of the soft tissue surrounding the
left shoulder, with equivocal lucency in the region of the acromial tip
adjacent to the acromioclavicular joint. However, in general this has a
similar appearance to the prior CT of , with the subsequent MR of
demonstrating degenerative and atrophic changes without otherwise
concerning features.
CT OF THE ABDOMEN WITH IV CONTRAST:
Previously described vague hypodensity in
the central aspect of segment IV-B (series 2, image 60) is unchanged since
, likely representing a hemangioma but nonspecific on this single
examination. The gallbladder, pancreas, spleen, adrenal glands appear
unremarkable. A 9-mm hypodensity is seen in the interpolar aspect of the
right kidney, nonspecific and unchanged since . A large exophytic cyst is
seen arising off the lateral upper pole of the left kidney. A 1 cm cyst is
also seen arising from the lower pole of the left kidney. No abdominal
adenopathy or free fluid, or mesenteric abnormalities evident.
CT OF THE PELVIS WITHINTRAVENOUS CONTRAST:
The prostate is mildly enlarged.
Diffuse diverticulosis is seen involving the sigmoid and descending colon,
without evidence of associated inflammatory changes. Scattered diverticula
are also seen in the region of the hepatic flexure. Remainder of large and
small bowel loops appear unremarkable. There is no pelvic lymphadenopathy or
free fluid. Intermuscular lipoma is seen within the left iliopsoas muscle.
Aside from the changes at the left shoulder (described above), no concerning
osseous lesions are detected. Marked degenerative changes are seen involving
the lower lumbar spine. Note is also made of marked fatty atrophy of the right
subscapularis muscle. Incidental note is made of a grade I anterolisthesis of
L4 on L5.
## IMPRESSION:
1. No evidence of recurrent disease.
2. Heterogeneous appearance of the left shoulder, previously characterized on
MRI as severe degenerative changes.
3. Pulmonary nodules essentially unchanged since , suggesting benignity.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16320691", "visit_id": "N/A", "time": "2192-05-29 12:00:00"} |
12081271-RR-21 | 180 | ## EXAMINATION:
CT C-SPINE W/O CONTRAST
## INDICATION:
with fall/headstrike. Evaluate for cervical spine injury.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.0 s, 19.3 cm; CTDIvol = 36.8 mGy (Body) DLP = 711.3
mGy-cm.
Total DLP (Body) = 711 mGy-cm.
## FINDINGS:
Alignment is normal. Mild multilevel degenerative changes with intervertebral
disc space narrowing and minimal osteophytic spurring are noted at C5-6 and
C6-7. No fractures are identified.There is no significant canal or foraminal
narrowing. There is no prevertebral edema.
Multiple nodules are noted in the thyroid gland bilaterally which is
heterogeneous, the largest measuring 1.6 cm in the right thyroid lobe. Mosaic
attenuation of the partially visualized left lung apex is nonspecific.
## IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment.
2. Multiple bilateral thyroid nodules, the largest measuring 1.6 cm in the
right thyroid lobe. If previous workup has not been performed, recommend
further evaluation with thyroid ultrasound.
3. Mosaic attenuation of the left lung apex, a nonspecific finding.
## RECOMMENDATION(S):
Thyroid ultrasound, if not done previously.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12081271", "visit_id": "21993162", "time": "2137-12-17 13:56:00"} |
17079941-RR-34 | 87 | ## HISTORY:
Altered mental status and change in neurological function (upgoing
plantars). Assess for acute intracranial process.
## FINDINGS:
There is no evidence of hemorrhage or territorial infarct. There is no
evidence of midline shift, mass effect, or hydrocephalus. The ventricles and
extra-axial CSF spaces are mildly prominent.
There is no evidence of skull fracture.
There are aerosolized secretions in the left sphenoid sinus. Otherwise, the
paranasal sinuses are clear. The mastoid air cells are clear.
## IMPRESSION:
Unremarkable examination. No evidence of hemorrhage or territorial infarct.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17079941", "visit_id": "22427703", "time": "2138-09-12 11:13:00"} |
14276893-RR-26 | 863 | ## INDICATION:
woman with coronary artery disease, status post
coronary artery bypass on , with graft occlusion on cardiac cath; CTA
to assess for patency of the vein graft to diagonal.
## CORONARY CT ANGIOGRAPHIC QUALITY:
The overall quality of CT angiographic
examination is excellent.
## RIGHT CORONARY ARTERY:
RCA is heavily calcified and completely occluded just
beyond its proximal segment.
## LEFT MAIN CORONARY ARTERY:
LMC artery demonstrates mild-to-moderate amount of
calcification at its origin with approximately around 30% narrowing.
## LEFT ANTERIOR DESCENDING:
The LAD is heavily calcified with multisegmental
stenosis. Distally, near the cardiac apex, LAD is reformed by the LIMA branch
arising from the saphenous graft as a Y-shaped configuration. Beyond this LAD
shows adequate flow. There are two diagonal branches arising from the LAD,
first diagonal branch being smaller and shows mild calcification in its
proximal segment. The second bigger diagonal branch is moderately calcified
but with maintained flow distally.
## LEFT CIRCUMFLEX CORONARY ARTERY:
The left circumflex artery in its proximal
segment is heavily calcified and occluded. There is a single obtuse marginal
branch arising from it, which reformats distally with the saphenous graft and
demonstrates the entire course.
## GRAFT 1:
Graft 1 appears to be a saphenous venous graft to the OM1 branch
arises anteriorly from ascending aorta at 12 o'clock position. This graft
demonstrates a short-segment stenosis at its origin extending over length of
8-10 mm.
It is well separated from the sternum.
## GRAFT 2:
Graft 2 appears to be LIMA graft arising from the proximal saphenous
graft in the Y-shaped configuration and is well separated from the sternum. It
courses anteroinferiorly on the left side to join the left anterior descending
artery. Graft is patent without any stenosis.
There are two tiny nipple-like projections arising from the anterior wall of
the ascending aorta (303:140 and 303:137), which may be the anastomotic site
of the two other potential grafts that are occluded. There are two focal
areas of contrast enhancement anterior to the ascending aorta (303:105 and
303:76), which are nonspecific.
## CARDIAC MORPHOLOGY:
The cardiac chambers are not dilated. Papillary muscle
calcification in the left ventricle suggests prior ischemic event.
Mild-to-moderate calcification of the aortic valve is present. There is no
pericardial abnormality. Cardiac valves appear unremarkable.
## PULMONARY ARTERIES:
The main pulmonary artery measures 23 mm before
bifurcation and normal. There is no evidence to suggest pulmonary arterial
hypertension.
## AORTA:
The ascending aorta at the level of the intrapericardial portion of
the right pulmonary artery measures up to 32 mm. The arch and descending
thoracic aorta demonstrate mild-to-moderate intimal atherosclerotic
calcification. Just beyond the origin of the left subclavian artery there is
calcified plaque causing hemodynamically significant narrowing up to 80-90%
over a length of 9-10 mm. In the proximal left common carotid artery just
beyond its origin, there is a non-calcified plaque causing up to 50-60%
narrowing of the lumen.
## EXTRACARDIAC FINDINGS:
Airways are patent to subsegment bronchi. An 8 x 7.8
mm solid perifissural nodule is present on the right side (303:182). A
sub-3-mm nodule is seen in the subpleural region in the left apex ( ). In
addition, there is a non charactaristic opacity in the left perifissural
region within the superior segment of the left lower lobe measuring up to 10.4
x 8.9 mm. There are no pathologically enlarged mediastinal or axillary lymph
nodes. Imaged sections of upper abdomen are unremarkable.
## BONES:
Patient is status post median sternotomy for prior CABG. There is a
sternal dehiscence with separation of sternal fragments for up to 15 mm in the
upper sternal region (302:5). In addition, in the left upper hemisternum,
there is a lytic area with bone demineralization and presternal and anterior
mediastinal fat stranding; however, there is no obvious fluid collection.
These findings are concerning for sternal osteomyelitis with inflammatory
stranding extending to the presternal and anterior mediastinal compartment.
Clinical correlation is suggested.
Degenerative changes are present at multiple vertebral body levels.
## IMPRESSION:
1. Saphenous venous graft to the obtuse marginal branch from the ascending
aorta with short-segment severe stenosis at its origin. The LIMA branch to
left anterior descending artery arising from the saphenous graft is patent.
2. Right coronary and left circumflex arteries are heavily calcified with
complete occlusion. Mild calcification in the left main and moderately to
severe calcification in the left anterior descending and the second diagonal
branch with multisegmental stenosis.
3. Calcified plaque in left proximal subclavian artery and soft plaque at
proximal left common carotid which are hemodynamically significant.
4. Mild sternal dehiscence up to 15 mm with destruction and lytic areas in
the left upper hemisternum with presternal and anterior mediastinal fat
stranding; features are concerning for osteomyelitis.
4. 8-mm solid non-calcified right perifissural nodule, sub-3-mm left apical
subpleural nodule, and 10.4 x 8.9 mm non-characteristic opacity in the left
perifissural region of the superior segment of the left lower lobe. Followup
CT is again recommended at three-month interval to assess for interval
changes.
Dr. pertinent findings with Dr. on at
2:50 p.m.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14276893", "visit_id": "25495156", "time": "2129-04-15 09:48:00"} |
16884961-RR-19 | 124 | ## INDICATION:
year old woman with right groin and lower abdominal pain;
fibroids// evaluate pelvic anatomy
## FINDINGS:
The uterus is anteverted and measures 6.7 x 2.9 x 4.4 cm. Uterine fibroids
are present. The largest fibroid is intramural measuring 2.7 x 1.9 x 2.3 cm.
The endometrium is distorted due to fibroids however, where seen appears
heterogeneous and measures 7 mm in thickness.
The ovaries are normal with a 0.5 cm simple left ovarian cyst. There is no
free fluid.
## IMPRESSION:
1. Heterogenous, thickened endometrium measuring 7 mm. Endometrial distortion
due to fibroids.
2. Uterine fibroids.
3. Normal ovaries. 0.5 cm simple left ovarian cyst. Per current size
guidelines, no further follow-up is required.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16884961", "visit_id": "N/A", "time": "2122-04-03 07:49:00"} |
18708010-RR-11 | 105 | ## INDICATION:
Patient is a female status post motor vehicle
accident with positive fluid in Morison's pouch. Please evaluate for possible
fracture.
## EXAMINATION:
CT of the cervical spine without contrast.
## FINDINGS:
There is no sign of a fracture or abnormal alignment. There is no
disc, vertebral, or paraspinal abnormality seen. The prevertebral soft
tissues are unremarkable. CT is not able to provide intrathecal detail
comparable to MRI. The visualized outline of the thecal sac appears
unremarkable. There is a nodular scarring in the right lung apex. There is
partial opacification of the right mastoid air cells.
## IMPRESSION:
No evidence of fracture or malalignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18708010", "visit_id": "23485861", "time": "2134-03-22 09:58:00"} |
15297415-RR-133 | 170 | ## INDICATION:
year old man with h/o of recent right native kidney bleed with
hemmhoragic shock (refer CTA), with perinephric and subcapsular renal
hematoma, incresaed pain. please eval native kidney // please eval for
hematoma, capsular stretch, interval size change in hematoma?
## FINDINGS:
The right kidney measures 9.9 cm.
The right kidney is surrounded by a perinephric hematoma, ranging from 0.8 x
1.5 cm in thickness and almost completely surrounding the right kidney. Also,
below the lower pole, there is a more discrete hematoma below the kidney
measuring 6.7 x 3.9 x 4.7 cm. There is no hydronephrosis.
Limited views of the left kidney, which measures 8.9 cm in length, show a 9 mm
stone in the lower pole but no evidence of hydronephrosis no perinephric
collections.
The bladder is partially distended and normal in appearance.
## IMPRESSION:
Extensive right perinephric hematoma, with the a second large component below
the lower pole of the right kidney.
Incidental nonobstructive left lower pole renal stone.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15297415", "visit_id": "29873294", "time": "2119-02-24 13:13:00"} |
10930413-RR-54 | 150 | ## INDICATION:
Mechanical fall with left upper quadrant pain two days ago.
## FINDINGS:
The spleen is 10.3 cm. There is no evidence of splenic mass.
Vascular structures at the splenic hilum are unremarkable. At the periphery
of the spleen is a linear echogenic area, that is overall nonspecific possibly
representing the appearance of a lobulated contour of the spleen alternatively
vascular calcification. There is no adjacent hypoechogenicity nor parenchymal
distortion to suggest a splenic laceration. Additionally, there is no
perisplenic fluid collection.
## IMPRESSION:
Linear echogenic focus at the periphery of the spleen as above,
overall nonspecific, possibly a calcified vascular structure. There are no
secondary signs to suggest splenic trauma. If clinical concern persists for a
splenic injury, would recommend further investigation with a CT of the
abdomen.
These results and recommendations were discussed over the telephone by Dr.
with Dr. at approximately 5:45 p.m. on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10930413", "visit_id": "N/A", "time": "2170-09-01 17:07:00"} |
16533040-RR-3 | 248 | ## EXAM:
CTA of the head and neck.
## CLINICAL INFORMATION:
Patient with right-sided weakness, clinical question of
intracranial hemorrhage or stroke.
## CT HEAD:
There are no prior studies. There is a chronic left basal ganglia
infarct identified extending to the periventricular region. No hemorrhage
seen.
## CT ANGIOGRAPHY OF THE NECK:
The CT angiography of the neck demonstrates no
vascular occlusion or stenosis.
## CT ANGIOGRAPHY OF THE HEAD:
The CT angiography of the head demonstrates
markedly attenuated left middle cerebral artery and its sylvian branches. The
right middle cerebral artery and the arteries of the posterior circulation are
well maintained. Both anterior cerebral arteries are also well maintained.
No evidence of vascular occlusion or aneurysm seen in the arteries of anterior
and posterior circulation.
The CT perfusion of the head demonstrates somewhat diminished blood volume in
the left basal ganglia region at the site of infarct noted on the head CT.
Otherwise, no perfusion abnormalities are seen.
## IMPRESSION:
1. Head CT shows a chronic left basal ganglia infarct.
2. CT angiography of the head demonstrates markedly attenuated left middle
cerebral artery indicative of chronic occlusive disease in the left middle
cerebral artery. Otherwise, arteries of the anterior and posterior
circulation are maintained except for mild calcification at the carotid
bifurcations.
3. No definite perfusion abnormalities are seen on the perfusion study. Low
blood volume in the left basal ganglia likely represents the infarct seen on
the CT.
4. MRI can help for further assessment if clinically indicated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16533040", "visit_id": "29035176", "time": "2113-11-19 19:16:00"} |
12350239-RR-11 | 211 | ## INDICATION:
Right intraparenchymal hemorrhage, transfer from outside
hospital.
## FINDINGS:
There is a 3.3 x 2.8 cm lobulated area of hyperdensity in the right
parietal lobe (3, 19), consistent with intraparenchymal hemorrhage. There is
mild surrounding hypodensity consistent with edema, and mild mass effect on
adjacent sulci and occipital horn of the right lateral ventricle. There are
scattered foci of subarachnoid hemorrhage in the right parietal sulci, and
similar sulcal hyperdensity is also seen in the left parietal lobe, also
consistent with subarachnoid hemorrhage. There is a small amount of
intraventricular blood layering in the bilateral occipital horns.
There is no shift of normally midline structures. Basal cisterns are not
effaced. Calcifications in the bilateral basal ganglia are stable. There is
no sign of acute vascular territorial infarction. Visualized osseous
structures are unremarkable. Partial opacification of the left maxillary
sinus is not significantly changed. Visualized paranasal sinuses are
otherwise normally aerated.
## IMPRESSION:
3.3 cm area of right parietal intraparenchymal hemorrhage, with mild edema and
mass effect, small foci of associated subarachnoid hemorrhage, and
intraventricular blood. While this appearance could result from hypertensive
hemorrhage with intraventricular extension, the recurrent bleeding raises
concern for a possible underlying etiology for hemorrhage, and despite prior
negative workup, reinvestigation should be considered.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12350239", "visit_id": "N/A", "time": "2124-05-22 20:41:00"} |
10564151-RR-193 | 124 | ## EXAMINATION:
CHEST (PA AND LAT)
## INDICATION:
year old man with AML, dyspnea. // year old man with AML,
dyspnea. year old man with AML, dyspnea.
## IMPRESSION:
In comparison with the study , there is increasing opacification at
the left base consistent with pleural fluid an substantial volume loss in the
left lower lobe. In the appropriate clinical setting, it would be very
difficult to exclude superimposed pneumonia in this region.
On the right, the hemidiaphragm now sharply seen with mild blunting of the
costophrenic angle, consistent with decrease in the pleural effusion on this
side. Cardiac silhouette remains within normal limits and there is no
evidence of vascular congestion. The tip of the Port-A-Cath again is in the
right upper right atrium.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10564151", "visit_id": "N/A", "time": "2163-02-17 10:21:00"} |
16948354-RR-18 | 845 | MR EXAMINATION OF THE ENTIRE SPINE WITHOUT AND WITH CONTRAST,
## HISTORY:
female with fever, back pain; evaluate for epidural
abscess.
## FINDINGS:
The study is compared with the bedside AP radiograph of the chest,
obtained roughly 3 hours earlier; there is no previous imaging of the spine on
record.
The sagittal T2-weighted and STIR sequences demonstrate no pathologic
hyperintensity, and there is no abnormal enhancement, involving the
intervertebral discs, vertebral endplates or adjacent paraspinal tissues to
suggest spondylodiscitis or epidural or paraspinal abscess/phlegmon. The
post-contrast imaging demonstrates no pathologic paraspinal or epidural soft
tissue, leptomeningeal, intramedullary or radicular focus of enhancement.
There is multilevel multifactorial degenerative disease involving,
particularly the cervical spine, associated with abnormal angulated kyphosis
with apex at the C3-4 level. The combination of degenerative disc disease
with broad-based disc-endplate spondylotic ridges, as well as ligamentum
flavum infolding, results in narrowing of the ventral canal with remodeling of
that aspect of the spinal cord at the C3-4 and C4-5 levels with less marked
narrowing of the right ventral canal at the C5-C6 level. At C4-5, the
combination of the above factors results in a "confined" appearance to the
spinal cord. However, there is no abnormal focal hyperintensity within the
cervical cord substance, including on the STIR sequence. There is also
multilevel at least moderate neural foraminal stenosis, most marked at C3-4 on
the left, C4-5 bilaterally, and C5-6 on the right, with likely corresponding
exiting neural impingement. There is less marked degenerative disease at the
C6-7 level with only mild ventral canal narrowing and no cord contact, and no
significant neural foraminal stenosis. The limited imaging of the surrounding
cervical soft tissues is notable for the presence of endotracheal and
nasogastric tubes with abundant surrounding fluid in the oro- and hypopharynx.
The thyroid gland is notable for several small T2-hyperintense foci,
particularly in its left lobe, which may represent nodules or cysts. There is
no cervical lymphadenopathy and the principal intravascular flow voids appear
preserved.
The thoracic spinal cord is normal in caliber and intrinsic signal intensity
through the conus medullaris, which is normal in morphology and intrinsic
signal intensity and terminates at the L1-2 level. Again, there is no
pathologic focus of enhancement. Though there is desiccation of the T2-3
through T6-7 discs with some loss of height and mild bulging, there is no
significant spinal canal or neural foraminal compromise. The limited imaging
of the surrounding thoracic soft tissues is notable for posteriorly-layering
pleural effusions with associated subsegmental atelectasis,
better-demonstrated on the chest radiograph.
The lumbar vertebrae are normal in height and alignment, and the normal lumbar
lordosis is maintained. The lumbar vertebral bone marrow signal is also
overall maintained, other than moderate 2 discogenic change involving,
particularly the left lateral aspect of the L5 inferior and S1 superior and,
to a lesser extent, S1 superior endplates, associated with disc degeneration,
below.
The T12-L1 and L1-2 discs are relatively maintained in height and signal
intensity with normal intranuclear clefts.
There is some desiccation of the L2-3 disc with mild-moderate bulging, but
widely patent spinal canal and neural foramina.
There is more marked degeneration of the L3-4 disc with relatively mild
bulging. This, in combination with congenitally short pedicles, facet
arthrosis and ligamentum flavum thickening, narrows both subarticular zones
without definite traversing L4 neural impingement.
There is fairly marked degeneration of the L4-5 disc with moderate bulging,
markedly eccentric to the right. In combination with eccentric L4 inferior
endplate spondylosis, this significantly narrows the right subarticular zone,
likely impinging upon the traversing right L5 nerve root. These factors, as
well as facet arthrosis also produce significant narrowing of that neural
foramen with likely impingement upon the exiting right L4 nerve root; there is
no significant left neural foraminal narrowing at this level.
There is degeneration of the L5-S1 disc, with asymmetric bulging to the left
which, in combination with eccentric L5 inferior endplate and facet
spondylosis, significantly narrows the left neural foramen and may impinge
upon the exiting left L5 nerve root.
Limited imaging of the surrounding lumbar paravertebral soft tissues is
notable only for a small round T2-hyperintense lesion in the medial aspect of
the lower pole of the right kidney, likely a simple cyst. There is no
retroperitoneal fluid collection in the included imaging volume.
## IMPRESSION:
1. No evidence of spondylodiscitis, epidural or paraspinal abscess/phlegmon
throughout the entire spine.
2. No pathologic focus of enhancement.
3. Severe multifactorial degenerative disease of the mid-cervical spine with
secondary kyphosis, ventral canal narrowing, and cord "confinement" and
remodeling; however, there is no abnormality of spinal cord signal.
4. Degenerative disc disease in the lower lumbosacral spine with subarticular
zone and neural foraminal stenosis and resultant neural impingement, as
detailed above.
5. Bilateral pleural effusions with apparent associated subsegmental
atelectasis, incompletely imaged; correlate with dedicated chest radiography.
## COMMENT:
A preliminary interpretation to this effect was posted to RISweb at
12:04 p.m. on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16948354", "visit_id": "24477934", "time": "2111-02-01 08:10:00"} |
11354762-RR-44 | 260 | ## INDICATION:
year old woman with uterine sarcoma with lung metastasis, post
four cycles of chemotherapy and surgical resection of the primary and lung
metastasis.// metastatic uterine sarcoma, surveillance scan following
chemotherapy treatment and resection of primary uterine tumor and lung
metastasis. Compare with recent scans.
## DOSE:
DLP: Given in abdominal CT report.
## FINDINGS:
No incidental thyroid findings. Stable right pectoral Port-A-Cath. No
supraclavicular, infraclavicular or axillary lymphadenopathy. Multiple normal
sized mediastinal lymph nodes and hilar lymph nodes. Stable normal appearance
of the large mediastinal vessels. No incidental pulmonary embolism. There is
new surgical material at the level of the right hilus (5, 30). No pericardial
effusion. No abnormalities of the posterior mediastinum. The upper abdomen is
reported in detail in the dedicated abdominal CT report. No osteolytic
lesions at the level of the ribs, the sternum, or the vertebral bodies.
Moderate degenerative vertebral disease. No vertebral compression fractures.
Since the previous examination, a previous 4 mm left upper lobe nodule (6, 56)
has grown and is now approximately 6 mm in diameter. There has been right
lung surgery with removal of a large metastasis on the right (6, 145) And
subsequent postoperative right lung changes with respect to the lung
parenchyma, the pleura and the right hilus. Minimal areas of atelectasis at
the posterior aspect of the lung parenchyma. No other pulmonary nodules are
visualized. The airways are patent.
## IMPRESSION:
Status post removal of a right lung metastatic mass, with expected right
postoperative changes.
Mild interval growth of a pre-existing left upper lobe pulmonary nodule.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11354762", "visit_id": "N/A", "time": "2171-08-02 08:28:00"} |
13519869-RR-25 | 106 | ## HISTORY:
male with chest tube draining frank red blood, status
post sternal rewiring and CABG.
Comparison is made to prior chest radiograph dated and prior CT
dated .
UPRIGHT PORTABLE CHEST RADIOGRAPH
## FINDINGS:
Postoperative widening of the superior mediastinum is not significantly
changed, and there is unchanged appearance to sternal wires and multiple
mediastinal drains. Diffuse peripheral ground-glass opacity/subpleural
fibrosis is better appreciated on recent CT examination but appear stable.
Mild left lower lobe atelectasis is identified with no focal parenchymal
infiltrates seen. No evidence of pulmonary edema or pneumothorax.
## IMPRESSION:
No etiology for blood draining from chest tube site identified on radiograph.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13519869", "visit_id": "N/A", "time": "2135-11-01 21:42:00"} |
10772962-RR-10 | 525 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
year old woman with new severe colitis and abdominal pain, now
with new leukocytosis to 14, thrombocytopenia to , concern for
microperforation given severe inflammation and ongoing pain.
## 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 28.9 s, 0.2 cm; CTDIvol = 493.1 mGy (Body) DLP =
98.6 mGy-cm.
3) Spiral Acquisition 7.9 s, 51.4 cm; CTDIvol = 16.1 mGy (Body) DLP = 815.7
mGy-cm.
Total DLP (Body) = 916 mGy-cm.
## LOWER CHEST:
There is mild bibasilar atelectasis. Otherwise, visualized lung
fields are within normal limits. There is no evidence of pleural or
pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid 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. There is
redemonstration of diffuse colonic and rectal wall thickening, pericolonic
stranding, and mucosal hyperenhancement, not significantly changed compared to
prior study dated . The appendix is mildly dilated and
fluid-filled measuring up to 8 mm. Extensive pericolonic stranding and
fascial thickening in the right lower quadrant is likely secondary to colonic
inflammation and unlikely acute appendicitis.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is a
small amount of simple free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
An intrauterine device is seen within the endometrial
cavity in stable position. Otherwise, the visualized reproductive organs are
unremarkable.
## LYMPH NODES:
There is redemonstration of multiple scattered subcentimeter
mesenteric and retroperitoneal lymph nodes measuring up to 9 mm (05:35),
unchanged. There is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. No evidence of colonic perforation or intra-abdominal abscess.
2. Redemonstration of pancolitis extending from the rectum to the cecum,
unchanged compared to prior study, and compatible with an inflammatory or
infectious etiology. Small amount of simple free intraperitoneal fluid is new
from prior study.
3. Mildly dilated and fluid-filled appendix measuring 8 mm with extensive
stranding and fascial thickening in the right lower quadrant. Findings are
likely secondary to adjacent cecal inflammation and less likely to represent
acute appendicitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10772962", "visit_id": "20820585", "time": "2150-10-08 16:23:00"} |
18907826-DS-6 | 679 | ## CHIEF COMPLAINT:
Chronic cholecystitis, pancreatic duct stricture
## :
Laparoscopic cholecystectomy and removal of the
percutaneous cholecystostomy tube.
## HISTORY OF PRESENT ILLNESS:
The patient is a female with history of chronic
aculculos cholecystitis and pancreatic cystic mass. She
underwent placement of percutaneous cholecystostomy tube,
several ERCP/EUS with FNA. Her cytology was negative for
malignancy. Today she present for elective interval
cholecystectomy and perc. chole tube removal.
## PAST MEDICAL HISTORY:
- HTN
- CAD s/p CABG ( )
- T2DM
- HL
- obesity
- glaucoma
- wet macular degeneration (L eye)
- CVA residual right sided weakness ( ) - primarily in
leg, some in hand
- ICH ( )
- PVD
- CKD
- s/p cataract surgery
- appendectomy
- Osteoarthritis
## FAMILY HISTORY:
Mother with a history of CAD and a "leaky heart."
Father without known medical conditions.
## BRIEF HOSPITAL COURSE:
The patient with history of chronic cholecystitis was admitted
to the HPB Surgical Service for elective laparoscopic
cholecystectomy. On , the patient underwent laparoscopic
cholecystectomy and cholecystostomy tube removal, which went
well without complication (reader referred to the Operative Note
for details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor on clear liquid diet, on IV fluids,
and IV Morphine for pain control. The patient was
hemodynamically stable.
Post-operative pain was initially well controlled with IV
Morphine, which was converted to oral pain medication when
tolerating clear liquids. The patient voided without problem.
Diet was advanced to regular on POD 1 and IVF was discontinued.
Patient was admitted from Rehab and she was evaluated by
service for possible discharge home. however recommended
rehab for further physical therapy.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Allopurinol mg PO BID
2. Amlodipine 10 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Lovastatin 40 mg oral daily
5. Metoprolol Tartrate 25 mg PO BID
6. Aspirin 81 mg PO DAILY
7. HydrALAzine 25 mg PO BID
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Dipyridamole-Aspirin 1 CAP PO BID
4. Docusate Sodium 100 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Lidocaine 5% Patch 2 PTCH TD QAM:PRN back pain
7. Metoprolol Tartrate 25 mg PO BID
8. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4-6 hours
Disp #*20 Tablet Refills:*0
9. Senna 17.2 mg PO HS
10. Allopurinol mg PO BID
11. HydrALAzine 25 mg PO BID
12. Lovastatin 40 mg oral daily
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were admitted to the surgery service at for surgical
resection of your gallbladder. You have done well in the post
operative period and are now safe to return home to complete
your recovery with the following instructions:
.
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
## INCISION CARE:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have 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": "18907826", "visit_id": "23946661", "time": "2185-08-28 00:00:00"} |
12679447-RR-88 | 103 | ## INDICATION:
woman presenting with cough and sore throat and
basilar crackles. Evaluate for pneumonia or volume overload.
## FINDINGS:
No diffusion, edema, focal consolidation, or pneumothorax. The heart size is
top-normal in size, slightly increased since . The mediastinum is not
widened. The hila and pleura are normal. The descending thoracic aorta is
slightly tortuous, similar to the prior exam.
The patient has bilateral cervical ribs. No osseous lesions suspicious for
malignancy are infection. Degenerative changes and dextroconvex scoliosis of
the thoracic spine are mild.
## IMPRESSION:
1. No pneumonia or evidence of volume overload.
2. Top-normal heart size, slightly increased since .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12679447", "visit_id": "N/A", "time": "2183-02-08 23:46:00"} |
10029291-RR-6 | 142 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
with AMS, massive PE, on heparin, evaluate for intracranial
hemorrhage.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.8 cm; CTDIvol = 47.7 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 4.0 s, 4.2 cm; CTDIvol = 47.7 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
## FINDINGS:
The study is somewhat motion degraded. Given this limitation, there is no
evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci
are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
## IMPRESSION:
1. Somewhat motion degraded study. This limitation, no acute intracranial
process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10029291", "visit_id": "22205327", "time": "2123-02-20 00:12:00"} |
18116280-RR-21 | 94 | ## REASON FOR EXAM:
Status post motor vehicle accident.
## FINDINGS:
For findings within the brain, please refer to report on CT head
done on the same date. Straightening of the cervical spine is noted, likely
positional. There is no evidence of fracture or subluxation. NG tube and
endotracheal tube are seen. Prevertebral soft tissues are not thickened.
Imaged soft tissues are unremarkable. Increased mucosal secretions in the
oropharynx are likely related to intubation. There is a small tracheal
diverticulum at the thoracic inlet.
## IMPRESSION:
No evidence of acute injury to the cervical spine.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18116280", "visit_id": "24339689", "time": "2187-10-07 20:15:00"} |
19759225-DS-31 | 968 | ## ALLERGIES:
Phenergan / Reglan / Vancomycin / Prochlorperazine Maleate
## HISTORY OF PRESENT ILLNESS:
male with history of chronic pancreatititis and alcohol
abuse was admitted from the ED with abdominal pain and rectal
bleeding.
He reports that several days ago he developed blood-streaked
stool after straining with hard bowel movement. He reports that
was the last time he had blood in his stools. His last bowel
movement was on the day prior to admission and was notable for
diarrhea. With these changes in his bowel movements, he has
developed worsened abdominal pain, which he describes as the
following: character is dull, onset was sudden worsening
days ago, location is in his epigastrium, and duration has been
constant. His last drink was on the day prior to admission, and
he drank pint of vodka.
Upon arrival to the ED, temp 97.3, HR 108, BP 137/82, RR 16, and
pulse ox 99% on room air. Exam was notable for abdominal
tenderness and guiac positive. There was concern about blood
streaked emesis, and NG lavage was performed and negative. Labs
are notable for Hct 32.2. He received dilaudid 2mg IV x 1 with
some improvement in his abdominal pain. Upon arrival to the
floor, he reports abdominal pain that is "off the charts." He
says that he is thirsty and would like to drink ginger ale. He
is requesting IV dilaudid for pain control. When I said that
there was no clear indication for IV pain medication and would
try oral pain medication, he suggested oxycontin. Of note, he
was found by nursing to have percocet hidden in his socks.
Regarding his social situation, he is homeless. He spent last
night in the ED due to pain for his broken heel, and the
previous three nights in a hotel. He drinks approximately 1 pint
of vodka per day.
Review of systems:
(+) Per HPI. abdominal pain, nausea, vomiting, bloody stools,
recently broke his left foot and is in a cast
(-) Denies fever, chills, night sweats, weight loss, headache,
sinus tenderness, rhinorrhea, congestion, cough, shortness of
breath, chest pain or tightness, palpitations, constipation,
change in bladder habits, dysuria, arthralgias, or myalgias.
## 1. PANCREATITIS:
lipase has ranged normal level to 433. CT
abd/pelvis x 2 has shown no evidence of acute or chronic
pancreatitis, but has shown diffuse fatty infiltration of the
liver.
2. Chronic pain secondary to pancreatitis, narcotics use
3. Alcohol abuse, starting at age multiple attempts at detox
w/ h/o DT's
4. Gastritis
5. Hepatitis C (not documented in this system)
6. Iron-deficiency Anemia
7. Prosthetic left eye
8. Positive H. pylori serology,
9. Panic disorder
## FAMILY HISTORY:
Father - EtOH
Mother - EtOH
## GEN:
no acute distress, speaking clearly, pleasant
## NECK:
Supple, No LAD, No JVD
## CV:
RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
## LUNGS:
CTA, BS , No W/R/C
## ABD:
+ BS, soft, tender to soft / deep palpation, no rebound,
voluntary guarding
## EXT:
No edema. left lower extremity cast.
## NEURO:
A&Ox3. Appropriate. strength throughout. Normal
coordination. Gait assessment deferred
## PSYCH:
Listens and responds to questions appropriately, pleasant
## DISCHARGE LABS:
07:05AM BLOOD WBC-6.1 RBC-3.74* Hgb-9.9* Hct-30.6*
MCV-82 MCH-26.4* MCHC-32.2 RDW-18.8* Plt male with chronic pancreatitis and alcoholism was admitted
with reported history of lower GI bleeding and abdominal pain.
.
## 1. PRESUMED HEMORRHOIDAL BLEED:
Patient described intermittent
BRBPR after hard bowel movements with associated pain. He did
not describe red flags for other processes. His Hct remained
stable in house with only one small episode of BRBPR. This was
most consistent with hemorrhoidal bleed, which he endorses in
the past. The decision was made to defer further work up to the
outpatient setting given his priority to enter detox. GI
referral should be considered.
.
## 2. ABDOMINAL PAIN:
No clear evidence of medical pathology.
Consistent with prior pain episodes. His home regimen was
continued.
.
## 3. ALCOHOL ABUSE, ALCOHOL WITHDRAWAL:
He did not exhibit true
signs of withdrawal while in house. Social work assisted the
patient. Arrangements were made to enter on
discharge.
.
5. Anxiety: Stable. Continued home ativan
.
## ON ADMISSION:
1. Folic Acid 1 mg PO daily
2. Multivitamin 1 tab PO daily
3. Thiamine HCl 100 mg PO daily
4. Ativan 1 mg PO qid prn anxiety
5. Percocet mg qid prn pain
6. Ferrous Sulfate 300 mg (60 mg Iron) PO daily
## DISCHARGE MEDICATIONS:
1. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
## 4. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety: do use with alcohol or driving.
## 6. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
One (1) Tablet
PO four times a day as needed for pain: do not use with alcohol
or driving.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Bisacodyl 5 mg Tablet Sig: Tablets PO once a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: until
having soft bowel movements.
Disp:*60 Tablet(s)* Refills:*2*
## DISCHARGE DIAGNOSIS:
Presumed hemorrhoidal bleeding
Chronic pancreatitis
Anxiety
Substance dependence
## DISCHARGE INSTRUCTIONS:
You were admitted with abdominal pain and rectal bleeding. The
most likely cause of your abdominal pain was your chronic
pancreatitis. Your bleeding was likely due to hemorrhoids and
constipation. You must take stool softeners going forward and
follow up closely with your PCP and gastroenterologist. Please
take all medications as prescribed.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19759225", "visit_id": "28847565", "time": "2141-05-06 00:00:00"} |
13751863-RR-72 | 106 | ## CLINICAL INFORMATION:
Assess hip for sacroiliac pathology.
AP view pelvis, three views right hip.
## FINDINGS:
Bowel gas obscures fine osseous detail. There are severe degenerative changes
in the lumbar spine. There is mild degenerative change of bilateral
sacroiliac joints and also femoroacetabular joints. There is joint space
narrowing. The femoral heads are spherical and well seated in the acetabula.
In the right hip, coned-down views demonstrate enthesopathy about the greater
trochanter. No osteonecrosis or stress fracture.
In addition, there is focal cortical thickening of the lateral cortex in the
subtrochanteric region. This could represent the sequela of prior stress
fracture or prior trauma.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13751863", "visit_id": "N/A", "time": "2179-03-08 11:31:00"} |
12685261-RR-20 | 272 | ## INDICATION:
year old man with newly diagnosed pancreatic adenocarcinoma.
// Please evaluate for metastasis to complete staging.
## FINDINGS:
The thyroid gland is unremarkable. There are no pathologically enlarged
supraclavicular, mediastinal, hilar or axillary lymph nodes.
Heart size is normal with no pericardial effusion. Coronary artery and aortic
valvular calcifications are extensive. There is no pericardial effusion. The
main pulmonary artery is normal caliber. There is mild fusiform dilatation of
the ascending thoracic aorta to 4.2 cm. No incidental large central pulmonary
embolus is identified. Moderate calcific atherosclerosis diffusely involves
the thoracic aorta and its branches.
Elevation of the right hemidiaphragm is incidentally noted. Punctate pulmonary
nodules measuring no more than 2 mm in the right upper lobe are identified (4:
41, 53, 59, 86). A punctate calcified left lower lobe granuloma is
incidentally noted. There is no endobronchial lesion or pleural effusion.
Airways are patent to the subsegmental level. Mild subpleural bandlike
scarring adjacent to multiple spinal osteophytes is likely due to fibrosis.
For a detailed discussion of the upper abdomen, including the partially imaged
pancreatic mass, please refer to the report of the prior CTA dated .
Moderate multilevel spinal degenerative changes are present. There are no
bone lesions in the thorax worrisome for infection or malignancy. The bones
are osteopenic.
## IMPRESSION:
Indeterminate punctate pulmonary micronodules measuring up to 2 mm in the
right upper lobe warrant a three-month followup chest CT. .
Extensive aortic valve calcifications with fusiform aneurysmal dilatation of
the ascending thoracic aorta to 4.2 cm suggests aortic stenosis.
Echocardiographic correlation is advised.
Extensive coronary artery calcifications.
## RECOMMENDATION(S):
Echocardiography to evaluate for possible aortic stenosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12685261", "visit_id": "N/A", "time": "2160-05-22 15:02:00"} |
11826880-RR-26 | 103 | ## HISTORY:
Severe transaminitis, history of hepatitis C. Earlier diagnostic
ultrasound demonstrating hepatomegaly and findings raising concern for acute
congestive hepatopathy.
## FINDINGS:
All of the visualized vessels including the hepatic, portal, splenic, and
superior mesenteric veins as well as the visualized celiac, SMA, and
proper/right/left hepatic arteries are widely patent and demonstrate normal
spectral waveforms. The IVC is also widely patent with normal appearing
waveform. Note is again made of an enlarged liver with diffusely increased
echogenicity. The IVC and hepatic veins also are again noted to be dilated.
## IMPRESSION:
Normal Doppler analysis of the hepatic and superior mesenteric vasculature.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11826880", "visit_id": "27658232", "time": "2141-07-17 13:18:00"} |
12749568-RR-89 | 120 | ## INDICATION:
Status post liver transplant.
## LIVER TRANSPLANT ULTRASOUND:
The liver is heterogeneous in echotexture
without focal lesion. The common bile duct is stably distended measuring 13
mm. Fluid collection in the inferior aspect of the liver measures 4 x 2 cm
and is not significantly changed. Small amount of subcapsular fluid is also
unchanged.
The main, right, and left hepatic veins are patent with appropriate waveforms
and directional flow. The main, right, and left portal veins are patent. The
main, right, and left hepatic arteries are patent, with appropriate
directional flow, but mild dampening of the velocity.
## IMPRESSION:
1. Patent hepatic vasculature.
2. Heterogeneous liver parenchyma which could be seen in the setting of
failure, but is nonspecific.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12749568", "visit_id": "29852579", "time": "2136-04-19 05:37:00"} |
13188070-DS-21 | 1,790 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
and therapeutic paracentesis by
## HISTORY OF PRESENT ILLNESS:
This is a yo M with h/o HIV and HCV cirrhosis (Childs C, on
transplant list) recent MELD 26 with two readmissions in the
past few weeks for increased confusion, global distention and
general failure to thrive in the outpatient setting. On most
recent admission, he was started on sofosbuvir and ribavirin for
his hepatitis C. His most recent VL was HCV 2,640
During the previous admission, the pt two negative diagnostic
paracentesis as well as large volume paracenteses. He also had
an NG tube placed for nutrition, which he later removed. His
pain regimen was also adjusted for right foot pain.
Pt states since his last admission his abdomen has become more
distended and confused. He states he has been having confusion
with dates and conversations. He denies any fevers or chills at
home. Denies abdominal pain, nausea or vomiting. Had 5 BM
yesterday with lactulose and denies any bloody BMs. His foot
pain has been controlled with 2.5 mg oxycodone which he has
taken doses per days. He also c/o cough which has been
chronic although slightly worse. He states he has been complaint
with his medications (his partner helps him) and has been
following a low salt diet.
Pt was seen in liver clinic today and direct admitted for workup
of worsening confusion and ascites.
## ROS:
per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematu
## PAST MEDICAL HISTORY:
# HCV (genotype 1) cirrhosis, complications: HE, variceal bleed
s/p banding. Previously treated with interferon and ribarin but
stopped due to variceal bleed. Reactivated on transplant list
# HIV on HAART. CD4 nadir: 25. No history of OI.
# Depression
# GERD
# Colonic adenoma- removed in colonoscopy
# Diabetes type 2
# Maxillary sinus mass: Seen by ENT
## FAMILY HISTORY:
Sister with DM and steatosis of the liver, mother with CAD.
## HEENT:
icteric sclera, dry MM, EOMI
## CV:
systolic ejection murmur, tachycardiac, regular rhythm
## LUNGS:
Fine crackles at bases bilaterally otherwise clear
## ABDOMEN:
distended, +BS, firm but nontender to palpation, no
rebound or guarding, tympanic to percussion
## EXT:
2+ pitting edema to sacrum
## NEURO:
AOx3, able to spell WORLD forwards and backwards,
+asterixis, mental slowing noted
## SKIN:
erythema of dorsum of R foot
## HEENT:
icteric sclera, dry MM, EOMI, small amount of blood
over gums
## CV:
systolic ejection murmur, tachycardiac, regular rhythm
## LUNGS:
Fine crackles at bases bilaterally otherwise clear
## ABDOMEN:
improved distension, +BS, soft and nontender to
palpation, no rebound or guarding, tympanic to percussion
## EXT:
2+ pitting edema to sacrum
## NEURO:
AOx3, +asterixis, mental slowing noted
## SKIN:
erythema of dorsum of R foot
##
======
HCV VIRAL LOAD (FINAL :
HCV RNA detected, less than
1.50E+01 IU/mL.
URINE CULTURE (Final : <10,000 organisms/ml.
3:17 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final :
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
## REPORTS:
========
CXR
Compared to the previous radiograph, the nasogastric tube has
been
removed. The lung volumes remain low with areas of plate-like
atelectasis at
the left and right lung bases. No pulmonary edema. No
pneumonia, no larger
pleural effusions.
RUQ US . Nodular cirrhotic liver Heaptic cyst. No other focal
lesions are
identified. The known enhancing lesions seen on the MRI are not
well
evaluated by ultrasound.
2. Patent portal veins with normal direction of flow, though
evaluation of
the right and left branches of the portal vein are somewhat
limited.
3. Moderate-to-large amount of ascites.
4. Splenomegaly.
## # HYPONATREMIA:
Pt's Na 128 on admission, similar to previous
discharge labs. His hyponatremia was likely secondary to
hypervolemia hyponatremia in setting of cirrhosis. It was
unlikely this was contributing to mental status as had been
chronic. Diuretics had previously been stopped secondary to
hyponatremia. His diuretics were held and Na was trended and
remained stable during this admission.
## #ASCITES:
Pt with worsening ascites since previous discharge.
His diuretics had been stopped previous admission in setting of
worsening hyponatremia. RUQ showed patent portal flow. Pt had
diagnostic and therapeutic para on that did not show
evidence of SBP. 5L were removed and his distension improved.
## # HEPATIC ENCEPHALOPATHY:
Pt was admitted with complaints of
worsening confusion. Pt stated he had been having frequent BMs.
On exam on admission, he was AOx3 but did have asterixis.
Infection was ruled out with diagnostic para, urine cx, blood cx
and CXR. He did not have evidence of a GI bleed
contributing to encephalopathy. Pt's lactulose was increased to
q2 and his mental status improved with frequently BMs. He was
also continued on home rifaxamin.
# HCV cirrhosis: Pt has a history of cirrhosis which has been
complicated by hepatic encephalopathy, portal gastropathy s/p
banding, ascites, and peripheral edema. He is currently on the
transplant list. On last admission, cause of decompensation had
been attributed to worsening hep C and treatment was started on
treatment with ribavirin and sofosbuvir. This admission
infection was ruled out as a cause of worsening decompensation
with urine cx, blood cx, CXR as well as diagnostic paracentesis
which was negative for SBP. Pt was continued on home ribavirin
and Sofosbuvir as well as nadolol. His LFTs were trended daily.
His MELD on admission and discharge was 27.
## #THROMBOCYTOPENIA:
Pt been had chronic thrombocytopenia, likely
secondary to worsening liver function and portal hypertension.
He reported continued gingiveal bleeding since last admission.
SC heparin was held and pneumoboots were used for DVT ppx.
## # RT FOOT PAIN:
Pt with neuropathic pain, possibly secondary
to cryo. Last admission his gabapentin and duloxetine doses were
increased and he was also started on low dose oxycodone (2.5
mg). Pt's pain was well controlled on this regimen during this
admission.
## #ANEMIA:
Pt with chronic macrocytic anemia previously attributed
to cirrhosis. Pt hct remained stable except for when hct
feel from 29-> 25, likely dilutional from receiving albumin. Pt
did not have signs of bleeding. His hct was rechecked and was
stable.
## #NUTRITION:
Pt briefly had feeding tube last admission but had
pulled out during an episode of encephalopathy.
Pt had a doboff successfully placed and advanced by on
but removed it overnight. He was recommended placement of
another NGT by nutrition and the medical team but pt refused.
CHRONIC MEDICAL
# HIV: Pt's last CD4 ct in was 388. He was continued on
home Emtricitabine-Tenofovir (Truvada), Raltegravir as well as
prophylaxis with bactrim and acyclovir
## #DM:
Pt's last HbA1c was 5.3 in . His blood sugars last
admission were uncontrolled at times and he was sent home with a
glucometer. Pt was continued on insulin sliding scale while
inpatient and encouraged to monitor blood sugars at home upon
discharge.
## # GERD:
Pt was continued on home Omeprazole 20 mg PO BID
## # DEPRESSION:
Pt was continued on home BuPROPion 75 mg PO BID
and duloxetine 60 mg
## TRANSITIONAL ISSUES:
[ ] Pt's diuretics continued to be held in setting of
hyponatremia. His Na on discharge was 129 and should continue to
be monitored as an outpatient
[ ] Pt was recommended tube feeds by nutrition but did not
tolerate an NGT and refused placement of second NGT
[ ] Pt will need continued treatment of HCV with ribavirin and
sofosbuvir
[ ] Pt should be encouraged to continue to follow low Na diet
[ ] Pt's blood sugars continued to be elevated this admission.
The previous admission he was discharged with a glucometer to
measure his blood sugars while at home and he should continue to
do this
[ ] MELD 27 on discharge
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 800 mg PO DAILY
2. Albuterol-Ipratropium PUFF IH Q4-6H PRN sob
3. BuPROPion 75 mg PO BID
4. capsaicin 0.1 % topical BID pain
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Duloxetine 60 mg PO DAILY
7. Lactulose 60 mL PO QID
8. Lidocaine 5% Patch 2 PTCH TD QPM pain
9. Nadolol 60 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. Raltegravir 400 mg PO BID
12. Rifaximin 550 mg PO BID
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
15. sofosbuvir 400 mg oral daily
16. calcium-vitamins B6-B12-FA 1 tab oral daily
17. Lanacane Anti-Itch (benzocaine-benzethonium) %
topical BID pain
18. Senna 8.6-17.2 mg PO HS:PRN constipatoin
19. Gabapentin 600 mg PO Q8H
20. Ribavirin 200 mg PO BREAKFAST
21. Ribavirin 400 mg PO DINNER
## DISCHARGE MEDICATIONS:
1. Acyclovir 800 mg PO DAILY
2. BuPROPion 75 mg PO BID
3. capsaicin 0.1 % topical BID pain
4. Duloxetine 60 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Gabapentin 600 mg PO Q8H
7. Lactulose 60 mL PO QID
8. Lidocaine 5% Patch 2 PTCH TD QPM pain
9. Nadolol 60 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*20 Tablet Refills:*0
12. Raltegravir 400 mg PO BID
13. Rifaximin 550 mg PO BID
14. Senna 8.6-17.2 mg PO HS:PRN constipatoin
15. sofosbuvir 400 mg oral daily
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Albuterol-Ipratropium PUFF IH Q4-6H PRN sob
18. calcium-vitamins B6-B12-FA 1 tab oral daily
19. Lanacane Anti-Itch (benzocaine-benzethonium) %
topical BID pain
20. Ribavirin 400 mg PO DINNER
21. Ribavirin 200 mg PO BREAKFAST
22. outpatient rehab
Pt will need outpatient rehab for ICD9 code: Cirrhosis of
liver without mention of alcohol. Outpatient hepatologist: Dr.
( ).
## DISCHARGE DIAGNOSIS:
primary:
ascites
hepatic encephalopathy
secondary:
hcv cirrhosis
HIV
## DISCHARGE INSTRUCTIONS:
Dear Dr. was a pleasure taking care of you during your
stay at . You were admitted for confusion and
abdominal distension. You had a therapeutic paracentesis to help
relieve your abdominal distension. You lab tests did not show
any signs of infection. We continued your home medications and
your symptoms improved. We also placed a feeding tube to help
with nutrition but you accidently removed it. We would recommend
a feeding tube to help with your nutrition but you preferred not
to have another feeding tube placed. Please remember to follow a
low salt diet and take your medications as directed. Please also
remember to monitor your blood sugars with the glucometer you
were given last admission. Please follow up with Dr. in
the .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13188070", "visit_id": "26347014", "time": "2122-01-21 00:00:00"} |
12379861-DS-18 | 850 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Mr is a year old man with a history of atrial
fibrillation s/p prior on sotalol and aspirin, mitral
regurgitation, trigeminal neuralgia, transferred from
for management of atrial fibrillation and
potential cardioversion.
Originally presented to for concerns of sinus infection. He
complained of 2 days of left sinus pressure and tenderness,
difficulty opening mouth, feeling feverish, and odynophagia.
No cough or coryza. At , pt was found to be tachycardic and
had mild leukocytosis; EKG showed Afib. Was started on dilt gtt
at 5mg/hr as he was tachycardic to 130-140s, w/HRs subsequently
down to low 100s. Pt denying any symptoms related to A-fib; no
chest pain, palpitations, lightheaded/dizziness, dyspnea,
diaphoresis, orthopnea, abd pain, n/v/d/c, chills/ns. Pt
endorses drinking 3x EtOH last night.
Normally has very good functional capacity, walks miles
daily and swims 1 mile daily. Walked up the to today
without problem.
In the ED, initial vitals were T 97.5, HR 94-105, BP 114/74, RR
18, SPO2 97% on RA.
## EKG:
Atrial fibrillation, rate 105, LAFB, no ST segment or T
wave changes.
labs:
--troponin T <0.03
--WBC 13.4, creatinine 1.0
Labs/studies notable for:
--WBC 12.3, Hgb 16.1 (MCV 101), Plt 172
--INR 1.0 PTT 27.5
--Na 136, K 3.7, HCO3 20, creat 0.8
Patient was given: 1000mL normal saline and rivaroxaban 20mg PO.
He was seen by cardiology who recommended admission to for
planned TEE/ tomorrow, as well as continuing him on his
sotalol, and starting rivaroxaban for anticoagulation.
## VITALS ON TRANSFER:
98.2 HR100 BP 146/99 98%RA
On the floor patient appeared stable.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
## PAST MEDICAL HISTORY:
-Trigeminal neuralgia
-R knee meniscal tear, s/p 5 surgeries
-h/o afib with RVR s/p
## FAMILY HISTORY:
Mother died of "exploded heart" in .
No other family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
## GENERAL:
well appearing man in NAD
## HEENT:
EOMI, no scleral icterus, MMM, TTP over L paranasal
sinus
## CV:
irregular rhythm, regular rate, no MRG
## LUNGS:
CTAB, normal respiratory effort
## EXTR:
warm, well perfused, no edema
## NEURO:
AOx3, able to move all extremities grossly, able to
ambulate
## SKIN:
no rashes or ulcerations noted
=======================
## GENERAL:
well appearing gentleman in NAD
## HEENT:
EOMI, no scleral icterus, MMM
## NECK:
Supple with JVP of 8 cm.
## LUNGS:
CTAB, normal respiratory effort
## EXTREMITIES:
warm, well perfused, no edema
## SKIN:
No stasis dermatitis, ulcers.
## # AFIB WITH RVR:
Presented asymptomatically to urgent care
because of issues of sinus congestion. Given diltiazem at OSH
with good effect on rate. On arrival to , was still in
atrial fib but rates ~100. Required no other rate control
agents, continued on sotalol and spontaneously converted before
DCCV could be attempted. Discharged on sotalol and rivaroxaban
with follow up with home cardiologist.
## #SINUS CONGESTION:
no fevers, short duration of symptoms.
Recommended symptomatic management with nasal saline,
antihistamine. IF symptoms persist more than days,
recommended f/u for consideration of antibiotics.
## TRANSITIONAL ISSUES:
-started on rivaroxaban, continue d/c after one month because of
low CHADS-VASc score
-holding aspirin while on rivaroxaban
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Sotalol 80 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. Aspirin 81 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Atorvastatin 40 mg PO QPM
2. Sotalol 80 mg PO BID
3. Rivaroxaban 20 mg PO DINNER
continue for 1 month at least, duration to be determined by your
cardiologist
RX *rivaroxaban [ ] 20 mg 1 tablet(s) by mouth at DINNER
Disp #*30 Tablet Refills:*1
## DISCHARGE DIAGNOSIS:
Primary diagnosis:
Afib with RVR
Secondary diagnosis:
sinus congestion
## DISCHARGE CONDITION:
AOx3
Able to ambulate independently
Cardiovascular exam unremarkable
Respiratory exam unremarkable
## DISCHARGE INSTRUCTIONS:
Mr. ,
You were admitted because your heart was in a rhythm called
atrial fibrillation and it was beating very quickly which can be
dangerous, although you were asymptomatic. You have had this
before but this time your heart spontaneously converted back to
a normal rhythm. You required no procedure but we will start you
on a blood thinning medication for at least a month in order to
prevent stroke. You should follow up with your outpatient
cardiologist to determine long term need for this medicine,
called rivaroxaban. You can stop taking your aspirin while you
take this.
For your sinus congestion you should use the nasal spray
times a day and you can take an antihistamine like zyrtec. A
humidifier can also be useful at home.
Be well,
Your team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12379861", "visit_id": "22107381", "time": "2163-06-18 00:00:00"} |
13515075-DS-11 | 876 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Patient transferred from outside intubated and sedated
after being involved in a single vehicle motor vehicle collision
overnight. By report patient was initially alert on scene,
however his mental status subsequently deteriorated and he was
intubated in the field. He was taken to
were he underwent CT scan of his head, C-spine and
torso. He was noted to have multiple spinal fractures including
C-spine facet fractures and T/L spine transverse process
fractures. Upon arrival to the ED he is intubated and sedated
therefore unable to provide any meaningful history. He was noted
by ED staff to be spontaneously moving all extremities when the
sedation weaned.
## PHYSICAL EXAM:
A&O X 3; NAD
Large laceration on scalp
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - , reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
## BRIEF HOSPITAL COURSE:
Mr. was admitted to the Acute Care Service on and
was given a head CT, an MRI/MRA of the head and neck and a CT
torso. He was noticed to have a large scalp laceration and
multiple cervical fractures. He was stabilized in the T/SICU
and subsequently taken to the Operating Room for an anterior
cervical fusion. Please refer to the dictated operative note for
further details. The surgery was without complication and the
patient was transferred to the T/SICU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were given per standard protocol. On
HD#5 he returned to the operating room for a scheduled C5-T1
decompression with PSIF as part of a staged 2-part procedure.
Please refer to the dictated operative note for further details.
The second surgery was also without complication and he was
transfered to Dr. . Post-operativley he
developed a ventilator associated pneumonia and H. flu was
cultured. He was started on broad spectrum antibiotics with
subsequent change to Augmentin. He developed a prevertebral
hematoma and a Speach and Swallow consult was obtained. They
recommended NPO until his swelling subsided. The patient was
transitioned to oral pain medication when tolerating a PO diet.
On he experienced a vasovagal episode while working with
. A stat CT scan of the head was obtained which was negative.
He was fitted with a lumbar warm-n-form brace for comfort.
Physical therapy was consulted for mobilization OOB to
ambulation. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q6H
2. Amoxicillin-Clavulanic Acid mg PO Q12H
Last dose to be given on .
3. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg capsule(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
4. Senna 1 TAB PO BID:PRN c
## DISCHARGE DIAGNOSIS:
Multiple cervical fractures
Pneumonia
## DISCHARGE INSTRUCTIONS:
You have undergone the following operation: ANTERIOR/POSTERIOR
Cervical 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:
o2-3 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.
oLimit 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:
You have been given a collar. This is to be worn when
you are walking. You may take it off when sitting in a chair or
while lying in bed.
## -WOUND CARE:
Remove the dressing in 2 days. 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. No
NSAIDs.
-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
2. 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.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
## PHYSICAL THERAPY:
As tolerated; collar for ambulation.
## TREATMENTS FREQUENCY:
Please continue to change the dressings daily.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13515075", "visit_id": "26441595", "time": "2112-12-21 00:00:00"} |
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