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17750991-RR-86 | 298 | ## INDICATION:
Bilateral shoulder pain with severe left osteoarthritis and mild
right glenohumeral osteoarthritis and right rotator cuff arthropathy.
Corticosteroid injection of both shoulders is requested. Because the right
shoulder bothers the patient more than her left, given that she uses the right
arm more due to her severe left shoulder osteoarthritis, she requested that
only the right shoulder be injected at this time. The patient declined to
have an injection of the left shoulder.
## PHYSICIANS:
Dr. (resident) and Dr. (attending)
performed the procedure. Dr. was present for and supervised the
entire procedure.
## PROCEDURE:
After discussing the risks, benefits and alternatives to the
procedure, written informed consent was obtained. A preprocedure timeout was
performed using three unique patient identifiers per protocol.
Under fluoroscopic guidance, an adequate spot on the right shoulder was
marked. The area was prepped and draped in the usual sterile fashion. 1%
lidocaine was used to anesthetize the skin and subcutaneous tissues. A
20-gauge spinal needle was advanced into the right glenohumeral joint. Needle
position was confirmed with a 2 mL injection of Optiray. Subsequently, a
mixture of 40 mg Kenalog and 4 mL 0.25% bupivacaine was injected into the
right glenohumeral joint.
The needle was removed, hemostasis achieved and a dry sterile dressing
applied. The patient tolerated the procedure well without immediate
post-procedure complications.
## FINDINGS:
Fluoroscopic images demonstrate mild degenerative change of the
right glenohumeral joint. Contrast is seen within the right glenohumeral
joint after Optiray injection.
## IMPRESSION:
1. Status post right glenohumeral joint injection of 40 mg Kenalog and 0.25%
bupivacaine.
2. The patient declined left shoulder corticosteroid injection at the present
visit and would prefer to consider having that procedure performed potentially
at a later date. An email regarding this was sent to Dr. at 2pm
on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17750991", "visit_id": "N/A", "time": "2151-10-30 12:50:00"} |
11704969-RR-19 | 443 | ## INDICATION:
year old man with right forehead biopsy showing metastatic
adenocarcinoma// evaluate for primary cancer, ? immunohistochemistry suggests
GI or pancreatobiliary tract, hx smoking
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 2.4 s, 31.7 cm; CTDIvol = 22.1 mGy (Body) DLP = 700.3
mGy-cm.
2) Spiral Acquisition 5.6 s, 74.7 cm; CTDIvol = 20.9 mGy (Body) DLP =
1,560.8 mGy-cm.
3) Spiral Acquisition 2.4 s, 32.2 cm; CTDIvol = 22.3 mGy (Body) DLP = 715.8
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.3 mGy (Body) DLP =
20.1 mGy-cm.
Total DLP (Body) = 2,999 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
## FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla or
thoracic inlet. No abnormalities on the chest wall. Mild atherosclerotic
calcifications in the head and neck arteries.
## HEART AND VASCULATURE:
The heart is normal in size and shape. No pericardial effusion. Mild
atherosclerotic calcifications in the coronary arteries and aorta, none in the
cardiac valves. The pulmonary arteries and aorta are normal in caliber
throughout.
## MEDIASTINUM AND HILA:
Small hiatal hernia. An heterogeneous mostly hypodense mass is noted in the
lower esophagus measuring approximately 3.5 x 3.3 x 3.1 cm. This mass is very
well defined, showing a fatty plane is still noted between the esophagus and
the aorta. No periesophageal lymph nodes are seen. Small mediastinal lymph
nodes none pathologically enlarged by CT size criteria. No hilar
lymphadenopathy.
## PLEURA:
No pleural effusions. No apical scarring bilaterally.
## LUNGS:
The airways are patent to the subsegmental levels. No bronchial wall
thickening, bronchiectasis or mucus plugging. Punctate nodule in the left
upper lobe (302: 173). No suspicious lung nodules or masses. No
consolidations or atelectasis.
## CHEST CAGE:
Moderate dorsal spondylosis. No acute fractures. No suspicious lytic or
sclerotic lesions.
## UPPER ABDOMEN:
Please refer to same day abdominal CT report for subdiaphragmatic findings.
## IMPRESSION:
Esophageal mass sitting atop of a small hiatal hernia is concerning for a
primary esophageal malignancy, for which an endoscopy with tissue sampling is
recommended. There are no local periesophageal lymph nodes. Given the non
locally aggressive appearance of this mass, alternative diagnosis of GIST or
leiomyoma are also possibilities.
## NOTIFICATION:
Pertinent critical findings were posted by Dr.
on at 10:29 to the Department of Radiology online critical
communications system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11704969", "visit_id": "N/A", "time": "2176-01-23 08:35:00"} |
14541028-RR-16 | 141 | ## EXAMINATION:
MR KNEE W/O CONTRAST RIGHT
## INDICATION:
year old woman with recurrent right knee mass // recurrent
right knee mass
## FINDINGS:
There is a lobulated, mildly septated mass along the anteromedial subcutaneous
soft tissues of the knee demonstrating bright signal on fluid sensitive
sequences and T1 hypointensity with peripheral and some internal septal
enhancement on post-contrast imaging. This measures 1.3 x 3.1 x 3.2 cm. There
is overlying skin abnormality consistent with prior incision.
There is no joint effusion.
A varicose vein is noted within the posterior soft tissues at the distal
thigh.
There is mild degenerative signal abnormality within the posterior horn of the
medial meniscus without evidence for tear. No gross internal derangement of
the knee is visualized on limited non dedicated sequences.
## IMPRESSION:
Recurrent ganglion cyst within the anteromedial subcutaneous soft tissues.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14541028", "visit_id": "N/A", "time": "2173-02-01 15:16:00"} |
17018658-RR-8 | 116 | ## INDICATION:
male with fall and seizure, evaluate for intracranial
hemorrhage.
## FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect,
or shift of normally midline structures. The ventricles and sulci are normal
in size and configuration. Prominent posterior fossa CSF space posteriorly
may relate to cisterna magna. The mastoid air cells are well aerated
bilaterally. There is deviation of the nasal septum with with a small bony
spur; mild mucosal thickening the ethmoid air cells, left greater than right.
## IMPRESSION:
No evidence of acute hemorrhage or shift of normally midline
structures. Mild ethmoid mucosal thickening. Correlate with EEG and if there
is cocnern for aprenchymal abn. MR can be considered if not CI.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17018658", "visit_id": "N/A", "time": "2125-06-29 00:58:00"} |
14395112-DS-11 | 1,110 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
Patient is a male with PMHx significant for hypertension,
hyperlipidemia, and TIAs admitted for diarrhea and hypotension
(70/50s). He reports symptoms began this morning while he was
at work. He works as a at
. Around 10AM he had just finished some work and went
back to his office. He felt "funny" so he went to the bathroom
and had a large, watery BM described as yellow with no blood.
Afterwards he had cold sweats and felt like "blacking out". He
denies any loss of consciousness, blurry vision or headache at
that time. Mentions his memory was a little bit blurry though.
An ambulance was called and he was brought to . He says
this type of episode (diarrhea, hypotension) has occurred two
other times in the last year- but has never been admitted to the
hospital. He has never had a colonoscopy before.
In the ED, he was hypotensive to 88/48. HR was 62. He
complained of weakness and dizziness. He received 3L NS with
good response (BP up to 122/51). Labs notable for ARF (Cr 2.5
from 2.9 on admission). UA was negative. Guaiac also negative.
Normal Lactate. CXR unremarkable. Abdomen benign- no blood or
mucous noted in stool. Cultures sent. Got single doses of
vancomycin and zosyn IV. His symptoms improved. He continued
to have diarrhea on transfer to floor. Once on floor, patient
felt better. Denied weakness or dizziness but still had watery
diarrhea. BP up to 127/68.
.
Review of systems is otherwise negative. Denies fevers, chills,
nausea, vomiting, chest pain, shortness of breath, palpitations,
headache, blurry vision. Reports some abdominal discomfort and
diarrhea.
## FAMILY HISTORY:
Heart disease and HTN in unspecified family members
## GENERAL:
Pleasant, well appearing male in NAD
## HEENT:
Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
## CARDIAC:
Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs or . JVP not elevated
## LUNGS:
CTAB, good respiratory effort
## ABDOMEN:
NABS. Soft, NT, ND. No HSM
## EXTREMITIES:
No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
## NEURO:
A&Ox3. Appropriate. CN grossly intact. Preserved
sensation throughout. strength throughout. reflexes,
equal . Normal coordination. Gait assessment deferred
## PSYCH:
Listens and responds to questions appropriately, pleasant
## CHEST X-RAY ( )- IMPRESSION:
No acute intrathoracic process.
EKG ( )- Normal sinus rhythm.
## BRIEF HOSPITAL COURSE:
#. Hypotension- Patient presented with recent onset of severe
watery diarrhea. This is the most likely cause of his low blood
pressure of 88/48. This is also supported by the fact that he
responded so well to the 3L NS he received in the emergency
department. His pressure on the floor was 127/68. He was
started on maintenance fluids of NS at 100mls/hr. His home
blood pressure medications of
amlodipine/hctz/lisinopril/metoprolol were held on admission due
to low BP. Vital signs (including I/O's) were monitored
closely. Upon discharge, patient's BP was within normal limits.
Patient was not orthostatic. He said he felt back to baseline
and denied any concerning symptoms. He was told to hold his
home BP medications and to follow-up with his PCP for
blood pressure check and to determine when to restart his blood
pressure medications.
#. Diarrhea- The etiology of the patient's diarrhea unclear but
is probably infectious given acute onset. There is no blood or
mucous in stool so it was unlikely to be colitis (also no recent
antibiotic use). He received single doses of cipro and flagyl
while in the ED. Blood cultures were negative. Patient
remained afebrile and his diarrhea resolved during his stay in
the hospital. We recommended that the patient get an outpatient
colonoscopy given that he has never had one before.
#. Acute kidney injury- Creatinine was elevated to 2.9 on
admission (baseline 1.4-1.7 per PCP). This is most likely
secondary to hypovolemia. After receiving IV fluids his Cr
trended down (2.9--> 2.5--> 2.2). He continued to have good UOP
with no concerning symptoms. He was placed on a renal diet
while in-house.
#. HTN- We held patient's home medications while in-house given
his hypotension. He was told to go to PCP's office to check BP
on and then follow-up with PCP to determine when/how to
restart his BP regimen.
# Gout- We held the patient's allopurinol given acute kidney
injury. He wasn't restarted it upon discharge- he will see PCP
weeks to determine plan to restart his allopurinol.
#. Leukocytosis- count on elevation was up to 14.4. CXR and
UA clear were negative as were blood cultures x 2. He received
one dose each of vanc and zosyn in ED. WBC was 6.6 on day of
discharge. He remained afebrile and denied any
chills/nausea/vomiting.
## MEDICATIONS ON ADMISSION:
1. Allopurinol- daily
2. Amlodipine- 10mg
3. Folic acid- 1mg daily
4. HCTZ- 12.5mg
5. Lisinopril- 40mg daily
6. Metoprolol- 100mg daily
7. Tricor- 145mg daily
8. Vytorin- daily
## DISCHARGE MEDICATIONS:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Outpatient Lab Work
Please get your blood pressure checked at your primary care
physician's office before
3. Medication
Please restart your home cholesterol medications- vytorin,
tricor
## DISCHARGE DIAGNOSIS:
Primary diagnosis: Hypotension- resolved
## DISCHARGE CONDITION:
Good, vital signs stable. Hypotension resolved. Doing well.
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital for diarrhea and subsequent
low blood pressure. While in the hospital you got intravenous
fluids and your blood pressure responded very well. You denied
any symptoms of dizziness, fever, nausea, vomiting, headache,
blurry vision or loss of consciousness. You did not have any
other episodes of diarrhea while in the hospital and remained
afebrile. You were able to tolerate a regular diet well. You
were found to have an elevated creatinine (measure of your
kidney function). We contacted Dr. informed us
that you have some mild chronic kidney disease. Your creatinine
numbers continued to trend down towards your baseline. Upon
discharge, you were stable and symptom free.
The following changes were made to your medications:
1. Please hold all of your home blood pressure medications-
amlodipine, hydrocholrothiazide, lisinopril and metoprolol.
2. Please hold your allopurinol until your creatinine returns
to baseline (ask your primary care physician about this)
3. Please resume your other regular home medications as you had
been taking them
If you experience any fevers, chills, uncontrollable
nausea/vomiting, chest pain, shortness of breath or any other
concerning medical symptoms, please contact your primary care
physician or go to the emergency department.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14395112", "visit_id": "25907218", "time": "2161-05-27 00:00:00"} |
14238836-RR-94 | 156 | ## INDICATION:
year old woman with cognitive decline in setting of HTN, DM,
h/o breast CA// rule out atrphy, rule out small vessel disease, rule out space
occupying lesions
## FINDINGS:
Study is limited by motion degradation.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. There is no evidence of slow diffusion. Periventricular and
subcortical white matter T2 FLAIR hyperintense foci are nonspecific but likely
represent sequelae of small vessel ischemic disease. There is no abnormal
enhancement after contrast administration. Major intracranial vessels are
normal. Dural venous sinuses are patent.
There is mucosal thickening in the bilateral ethmoid air cells. Remaining
paranasal sinuses are patent. Mastoid air cells and middle ear cavities are
patent. Globes are unremarkable.
## IMPRESSION:
1. Subcortical and periventricular white matter FLAIR hyperintense foci are
nonspecific but can represent sequelae of early small vessel ischemic disease.
2. No space occupying lesion. No other acute intracranial abnormality.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14238836", "visit_id": "N/A", "time": "2138-05-09 08:15:00"} |
19184983-RR-21 | 108 | ## HISTORY:
An female with altered mental status.
## FINDINGS:
PA and lateral views of the chest were obtained. The heart is top
normal in size. There is atherosclerotic disease of the aortic knob. There is
a linear interstitial opacity in the right upper lobe, likely representing
atelectasis. The lungs are clear bilaterally. There are no pleural effusions
or pneumothorax. Multilevel degenerative changes are noted throughout the
thoracic spine in addition to loss of height of a lower thoracic vertebral
body of indeterminate chronicity.
## IMPRESSION:
Linear interstitial opacity in the right upper lobe likely representing
atelectasis.
Loss of height involving a lower thoracic vertebral body of indeterminate
chronicity.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19184983", "visit_id": "27599437", "time": "2146-12-15 16:54:00"} |
16626016-RR-41 | 90 | ## HISTORY:
male with left facial droop for three days. On
Coumadin.
## FINDINGS:
There is no acute intra-axial or extra-axial hemorrhage, mass, midline shift,
or territorial infarct. Ventricles and sulci are symmetric and appropriate
for age. The gray-white matter differentiation is preserved. Dense
atherosclerotic calcifications seen within the intracranial and ICAs and
vertebral arteries bilaterally.
The mastoids and included paranasal sinuses are essentially clear noting some
mucosal thickening in the right maxillary sinus. The skull and extracranial
soft tissues are unremarkable.
## IMPRESSION:
No acute intracranial process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16626016", "visit_id": "N/A", "time": "2132-06-14 19:51:00"} |
19545860-RR-43 | 916 | ## EXAMINATION:
CT MYELOGRAM OF THE CERVICVAL AND LUMBAR SPINE WITH INTRATHECAL
CONTRAST. NO INTRAVENOUS CONTRAST. Q331; Q311 CT SPINE
## INDICATION:
year old man with numbness on his left side; arm and leg.
Also, has a foot drop and has neck pain // Please evaluate C-spine and
L-spine with Myelogram Please evaluate C-spine and L-spine with Myelogram
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 3.9 s, 30.9 cm; CTDIvol = 27.2 mGy (Body) DLP = 839.2
mGy-cm.
Total DLP (Body) = 839 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 5.1 s, 20.2 cm; CTDIvol = 25.1 mGy (Body) DLP = 505.9
mGy-cm.
Total DLP (Body) = 506 mGy-cm.
## CERVICAL SPINE:
The exam is moderately degraded below the C4 level due to beam
hardening artifact related to fusion hardware and patient body habitus.
There postoperative changes for anterior cervical discectomy and fusion at
C4-5 and C5-6. There is solid osseous fusion across the C4-5 and C5-6 disc
spaces. Cervical vertebral body height and alignment appear preserved.
There is significant artifact in the ventral spinal canal from C4 through C7.
At C2-3, there is no spinal canal or neural foraminal narrowing.
At C3-4, a the disc osteophyte complex, shallow broad-based disc bulge results
in moderate central canal narrowing, there is mild cord flattening, without
complete effacement of CSF about cord, findings are less severe compared with
MRI . There is probably mild bilateral foraminal narrowing,
similar to prior.
At C4-5, there is no significant spinal canal or neural foraminal narrowing.
At C5-6, there is suggestion of right paramedian, ventral osteophyte which
indents ventral margin of the cord and contributes to probably moderate
narrowing of the right side of the canal, and there is mild narrowing left
margin of the canal, with well preserved CSF dorsally. This is best seen on
series 2, image 45 end is also suggested on MRI exam series 2 image 25
sagittal T2 weighted images from with correlate on axial T2
weighted image series 6, image 19. Other areas of artifact in the ventral
canal are fairly fuzzy appearing, and this appears well-circumscribed, is
probably real abnormality. There is mild-to-moderate
right and moderate left neural foraminal narrowing.
At C6-7, analysis poorly seen, there is probably disc osteophyte complex
contributing to moderate central canal narrowing, also seen on prior. There
may be small component of broad-based shallow disc protrusion, difficult to be
certain given artifact.
Findings may be worse from the MRI. There is mild left neural
foraminal narrowing. There is no right neural foraminal narrowing.
At C7-T1, there is no spinal canal or neural foraminal narrowing.
There is a 15 mm nodule within the right lobe of the thyroid gland with thick
calcification. There is a mildly enlarged level 1B lymph node (series 301,
image 24). The prevertebral and paraspinal soft tissues are otherwise
unremarkable. The imaged lung apices are clear.
Lumbar spine:
The exam is mildly degraded due to patient body habitus.
Lumbar vertebral body height and alignment are preserved. There are mild
degenerative endplate changes at T12-L1, L1-2, and L5-S1 with few endplate
Schmorl's nodes, endplate hypertrophic changes. Lower lumbar facet arthritis
is most prominent at L4-5, L5-S1 levels..
The conus medullaris terminates at the L1-2 level.
At T11-12, a right paracentral disc protrusion contacting and minimally
effacing ventral cord, results in mild spinal canal narrowing. There is no
neural foraminal narrowing.
At T12-L1, right paracentral disc protrusion results in mild spinal canal
narrowing, minimal effacement of the ventral cord, similar to prior. There is
no neural foraminal narrowing.
At L1-2, there is minimal spinal canal narrowing, similar to prior. No neural
foraminal narrowing.
At L2-3, there is no spinal canal or neural foraminal narrowing.
At L3-4, there is no spinal canal or neural foraminal narrowing.
At L4-5, minimal central canal, minimal foraminal narrowing.
At L5-S1, there is prominent endplate disc osteophyte complex and probable
partially calcified disc protrusion, which does not indent thecal sac, and is
better seen on the prior MRI. There is mild-to-moderate right and moderate
left neural foraminal narrowing.
Increased attenuation within the posterior paraspinal soft tissues at the L3-4
level may reflect edema. The prevertebral and paraspinal soft tissues are
otherwise unremarkable.
## IMPRESSION:
1. C4-6 ACDF, with solid osseous fusion across the C4-5 and C5-6
intervertebral disc spaces. There is no evidence for hardware complication.
2. Images in the cervical spine are compromised at the operated level.
3. Probably moderate central canal narrowing at C5-C6 level.
4. Probably moderate spinal canal narrowing at C6-7, likely worse from the MRI.
5. Lumbar spine degenerative changes.
6. Mild spinal canal narrowing at T11-12 and T12-L1 due to small disc
protrusions.
7. Bilateral L5-S1 foraminal narrowing.
8. A 1.5 cm calcified thyroid nodule, recommendations below.
## 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 , 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": "19545860", "visit_id": "28786902", "time": "2113-02-20 12:13:00"} |
15768970-DS-28 | 940 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
: Right toe debridement and closure
## HISTORY OF PRESENT ILLNESS:
s/p extensive PMH including DM c/b neuropathy, extensive
cardiac and vascular history, recently s/p right toe
amputation by Dr. presents to clinic with infected
right toe x 1 week. He noticed blood on his sock at rehab
about 1 week ago, but did not think anything of it. Someone at
rehab then recommended he f/u in clinic. Denies purulent
drainage, denies n/v/f/c/sob/cp.
## PAST MEDICAL HISTORY:
CAD s/p CABG LIMA to LAD, SVG to OM & Diag after Cypher
stent to RCA
CHF - diastolic, Echo w/ LVEF >55%
Secundum ASD
PVD - chronic ulcers of the heel and mid foot
HTN
Hypercholesterolemia
Post-op AFib - after CABG in , resolved
IDDM - HbA1C 7.1
CRI
h/o Hyperkalemia
Neuropathy
GERD
Prostate nodules
Hemorrhoids
Anemia
Chronic lymphocytic lymphoma
Mild coginitive impairment
OSA
Restless leg syndrome
Depression
.
## PAST SURGICAL HISTORY:
CABG - LIMA to LAD, SVG to OM after Cypher stent to RCA,
Multiple bilateral angioplasties - most recently with
R-BK popliteal/peroneal ballon angioplasty, and L
tibioperoneal trunk stenting by Dr. partial third toe amputation ( )
R metatarsal head resection
R total hip replacement
R knee surgery
R ankle repair
R inguinal hernia repair
R VATS with pleural biopsy
R digit amputation
Bilateral cataract surgery
## FAMILY HISTORY:
Significant for mother with diabetes and father with CAD.
## PULM:
CTAB, no wheezes or rhonchi noted
## ABD:
Soft, NT, ND, +BS
## :
Bandage c/d/i to right foot. CFT brisk to digits, right
foot. Passive and active ROM intact to right digits. Sensation
grossly diminished to touch, right foot. No gross abnormalities
appreciated.
## FOOT XRAY :
Erosions noted to distal phalanx, right
digit, concerning for osteomyelitis.
## CHEST XRAY :
No acute intrathoracic processes.
## FOOT XRAY :
S/p distal phalangectomy, right digit
## BRIEF HOSPITAL COURSE:
Briefly, Mr. was admitted to the podiatric surgery
service on as a direct admission from Dr.
for a right toe infection. He was started on IV
antibiotics, and cultures were taken from the toe ulceration.
He was hemodynamically stable, afebrile with VSS and
neurovascular status intact to his right foot. Local wound care
was continued. His pre-operative workup consisted of labs, foot
xray, chest xray, all of which were unremarkable. He had no
acute events overnight, and surgical intervention was scheduled
for .
On HD#1 he remained afebrile with VSS, hemodynamically stable.
IV antibiotics were continued. His foot wound appeared stable.
He was taken to the operating room, where a distal
phalangectomy was performed under monitored anesthesia care. OR
cultures were taken. Of note, he tolerated the procedure well
with no apparant complications. For full details of the
operation, please refer to the operative note in OMR. He had an
uneventful stay in the PACU and was transfered back to the
floor. Pain was well controlled postoperatively on PO pain
medication. Physical therapy evaluated Mr. and deemed
him safe for partial weight-bearing to his right heel in a
surgical shoe.
On POD#1 he remained afebrile with VSS and neurovascular
status intact to his right foot. His incision site was well
coapted with sutures intact. Both initial and OR cultures
showed no growth to date. He was discharged back to his rehab
facility/extended care facility. Prior to discharge, all
discharge instructions were discussed in detail with the
patient, including strict partial weight-bearing in surgical
shoe to right heel with elevation at all times possible. He is
to keep his dressing clean, dry and intact. Nursing will change
his dressing. New prescriptions and instructions were discussed
with the patient. He will resume all pre-admission medications
at normal frequency and dosage. He will follow-up with Dr.
in clinic in 1 week. All questions were answered prior
to Mr. being discharged.
## MEDICATIONS ON ADMISSION:
amlodipine 10', ASA 325', atorvasatin 40', cymbalta 120', detrol
LA 4 qam, folic acic 1', glipizide 7.5mg po bid, lantus 13U qam,
lasix 20', lopressor 25'', omeprazole 20', provigil 200',
VITB12, NTG 0.4mg SL prn
## DISCHARGE MEDICATIONS:
1. Amlodipine 10 mg PO DAILY
hold for sbp<100
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcium Carbonate 500 mg PO TID
5. Furosemide 20 mg PO DAILY
6. Glargine 13 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. Metoprolol Tartrate 25 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
if administering hold if sbp <100
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
11. Vitamin D 800 UNIT PO DAILY
12. Amoxicillin-Clavulanic Acid mg PO Q12H Duration: 10 Days
Please take until finished.
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tab by mouth
twice a day Disp #*20 Tablet Refills:*0
## DISCHARGE INSTRUCTIONS:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
.
You can be partial weight-bearing to your right heel in a
surgical shoe. Physical therapy may continue to work with you
while you are at your extended care facility.
.
Keep your dressing clean, dry and intact. Nursing will change
your dressing daily with betadine.
.
Please keep all follow-up appointments.
.
You will be given new prescriptions for pain medication, as well
as for antibiotics. Please take these as instructed. Also,
please resume all of your normal at-home medications at the same
dosage and frequency.
.
Call the office or return to the emergency department
immediately if you notice any of the following: increased pain,
redness, swelling, pain in your calf muscle, nausea, vomitting,
fever >101, chills or any other symptoms that concern you.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15768970", "visit_id": "29732507", "time": "2150-01-25 00:00:00"} |
12891356-RR-34 | 292 | ## HISTORY:
male with multiple surgeries, now with nausea and dry
heaving abdominal pain.
## CT ABDOMEN WITH IV CONTRAST:
Aside from mild bibasilar atelectasis/scar, lung
bases are clear. There is no pleural effusion or pericardial effusion. There
is fluid in the distal esophagus. Nasogastric tube terminates in the stomach.
Small locules of gas at the GE junction (2:18) are likely intraluminal. The
small bowel is dilated up to 4.7 cm, with distally decompressed loops. There
is a probable transition point in the pelvis to the right of midline
(2:60-61). There is no pneumatosis or free intraperitoneal air. The colon
contains fecal material to the splenic flexure. The descending and sigmoid
colon are decompressed.
Coronary artery vascular calcifications are noted. The liver shows no focal
abnormalities. The gallbladder is nondistended. The adrenals are
unremarkable. A left upper pole renal cyst measures 5.4 cm and contains a
single septation. Additional hypodensities of the kidneys are too small to
characterize. There is no hydronephrosis. The pancreas is unremarkable. A
hypodense splenic lesion is incompletely characterized, and measures 1 cm
(2:20). There are no enlarged mesenteric, or retroperitoneal lymph nodes.
The abdominal aorta is normal in caliber. The proximal celiac, superior
mesenteric and inferior mesenteric arteries are patent. The portal, splenic
and superior mesenteric veins are patent.
## CT PELVIS WITH IV CONTRAST:
The urinary bladder and prostate are
unremarkable. There are no enlarged pelvic or inguinal lymph nodes.
## BONE WINDOWS:
The patient is status post L3 through S1 fusion. There are no
concerning osseous lesions.
## IMPRESSION:
1. Small-bowel obstruction, with probable transition point in the pelvis to
the right of midline (2:60).
2. Fluid in the distal esophagus.
3. Incompletely characterized hypoattenuating splenic and renal lesions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12891356", "visit_id": "26748840", "time": "2152-05-28 13:29:00"} |
14066173-RR-20 | 343 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
year old woman with leukocytosis, abdominal pain after total
abdominal colectomy // Please eval for abscess, pneumonia.
## CHEST:
Please see the separate dedicated chest CT report dictated by the
cardiothoracic imaging section.
## ABDOMEN:
The liver is normal in appearance and without focal suspicious abnormality. A
2.5 cm hypodense lesion within segment VIII of the liver (4:36) is stable from
the prior examination and most likely represents a simple hepatic cyst.
Redemonstrated is a completely thrombosed right anterior portal vein
(4:49-52). A minimal degree of thrombus seen within the posterior branch of
the right portal vein has nearly completely resolved as compared to the prior
examination. There is no evidence of intrahepatic or extrahepatic biliary
dilatation.
The gallbladder surgically absent. The pancreas, spleen, and bilateral adrenal
glands are normal. The kidneys enhance symmetrically and are without
suspicious solid mass. Multiple, stable, bilateral renal cysts are noted, the
largest of which measures 3.3 cm in the left lower pole (4:72).
The patient is status post total abdominal colectomy with ileorectal
anastomosis. There is surgical suture material seen at the anastomotic site
within the pelvis (4:98), and there is no free abdominal fluid to suggest a
leak. Again seen are diffuse loops of dilated small bowel, compatible with
continued postoperative ileus.
There is no retroperitoneal lymphadenopathy by CT size criteria. There is no
free abdominal fluid or pneumoperitoneum. The aorta and iliac branches are
normal in course and caliber. The celiac trunk and SMA are grossly patent.
## PELVIS:
The bladder is grossly unremarkable. There is no pelvic side-wall or inguinal
lymphadenopathy by CT size criteria. No free pelvic fluid is identified.
## OSSEOUS STRUCTURES:
No focal lytic or sclerotic lesion concerning for
malignancy.
## IMPRESSION:
1. Persistent, diffusely dilated loops of small bowel. Findings are most
compatible with continued postoperative ileus.
2. Stable thrombosis of the anterior branch of the right portal vein.
3. Status post total abdominal colectomy with ileorectal anastomosis. No
evidence of free intraperitoneal fluid or anastomotic leak.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14066173", "visit_id": "28911439", "time": "2144-04-04 14:13:00"} |
14638111-RR-15 | 78 | ## EXAMINATION:
CT cervical spine without contrast.
## INDICATION:
Agitation and back pain status post fall on to train tracks.
## FINDINGS:
The cervical vertebral body heights and alignment are well maintained without
fracture or malalignment. The prevertebral soft tissue is unremarkable. There
is no significant degenerative change. The thecal sac contours are well
preserved. Neural foramina appear grossly patent. The thyroid is normal.
Right-sided pneumothorax is better evaluated on CT.
## IMPRESSION:
No cervical spine fracture or malalignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14638111", "visit_id": "27704719", "time": "2150-03-23 13:00:00"} |
17804385-RR-17 | 232 | ## HISTORY:
female patient with stage IV mantle cell lymphoma status
post 3 cycles of chemotherapy. For restaging.
## DOSE:
DLP of 769.76 mGy-cm
## ABDOMEN:
Mild bibasilar atelectasis is identified. Please refer to the CT chest report
from the same day for complete details on thoracic findings.
The liver demonstrates normal enhancement. No focal lesions are identified.
The hepatic veins and portal veins are patent. No ascites. No intrahepatic
or extrahepatic biliary ductal dilatation. The gallbladder, pancreas, adrenal
glands, spleen and kidneys are unremarkable. Spleen is now normal in size
measuring 8.5 cm. Kidneys demonstrate symmetric normal enhancement and
excretion. No hydronephrosis. Previously identified soft tissue mass in the
portal caval region demonstrates complete interval resolution. No significant
mesenteric or retroperitoneal lymphadenopathy. Caliber of small and large
bowel is within normal limits.
## PELVIS:
Partially distended urinary bladder is unremarkable. Multifibroid uterus is
again noted. No inguinal or pelvic lymphadenopathy. Mild sigmoid
diverticulosis is identified, however no diverticulitis.
## OSSEOUS STRUCTURES:
No suspicious focal lytic or blastic osseous lesions are identified. Mild
disk degenerative changes at the L5-S1 level are identified.
## IMPRESSION:
1. Interval resolution of the prominent soft tissue mass in the portal caval
region, in keeping with excellent response to therapy. Interval improvement
of mesenteric, retroperitoneal, pelvic and inguinal lymphadenopathy.
2. Spleen is now normal in size.
3. Mild sigmoid diverticulosis with no diverticulitis.
4. Multi fibroid uterus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17804385", "visit_id": "N/A", "time": "2176-07-09 15:27:00"} |
10079231-RR-18 | 117 | ## STUDY:
ERCP cholangiogram biliary and pancreas by GI unit.
## INDICATION:
female with abnormal LFTs and abdominal pain.
## FINDINGS:
12 fluoroscopic images are available for review obtained without a
radiologist present. Scout image demonstrates no surgical clips within the
right upper quadrant. Cholangiogram demonstrates rounded filling defect
within the distal common bile duct consistent with a stone. No biliary
strictures or dilatation is demonstrated involving the common bile duct. The
left intrahepatic biliary radicles appear within normal limits with the right
not well evaluated possibly secondary to under filling.
## IMPRESSION:
Choledocholithiasis with distal common bile duct stones
subsequently removed. Of note the cystic duct did not opacify during the
examination and thus patency cannot be evaluated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10079231", "visit_id": "22388681", "time": "2159-02-24 20:38:00"} |
12119271-DS-22 | 2,572 | ## ALLERGIES:
Bactrim DS / Dicloxacillin / coxycycline / Cephalosporins
## CHIEF COMPLAINT:
Open right distal femur fracture s/p mechanical fall.
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Irrigation and debridement, open reduction internal fixation of
open right distal femur fracture on by Dr. .
## HISTORY OF PRESENT ILLNESS:
year old female with history of peripheral vascular disease
s/p right below knee amputation, left transmetatarsal
amputation, chronic kidney disease, insulin dependent diabetes,
ulcerative colitis, and chronic back pain who presented to the
Emergency Department as a transfer from with an open
right distal femur fracture as a result of a mechanical fall.
She was walking between her kitchen and her living room and
tripped on the ground, causing her to fall on her right leg. She
denies any head strike or loss of consciousness. She was brought
to a hospital in and subsequently transferred to
for further management.
## PAST MEDICAL HISTORY:
DM type 1 w/ gastroparesis and neuropathy
Nephrolithiasis
PVD
CKD
UC
Anemia
HLD
HTN
OSA
obesity
frequent UTI
Stroke - years ago, lacunar
R BKA, L TMA
lap distal pancreatectomy -(neuroendocrine tumor)
R eye vitrectomy
Aspiration pna
C diff colitis
## FAMILY HISTORY:
Father - stroke
Mother - died of hypokalemia, med related
## RESP:
Normal work of breathing, symmetric chest rise.
## CV:
Extremities warm and well perfused.
Right lower extremity:
Thigh and leg compartments soft and compressible.
In knee immobilizer.
Dressing clean, dry, and intact.
Sensation intact to light touch throughout right thigh.
## VS:
1145 Temp: 98.2 AdultAxillary BP: 153/75 L Sitting
## HEENT:
JVP unable to assess, R chest wall tunneled line site
with
mild tenderness, no overlying erythema or drainage.
## HEART:
RRR, S1/S2, systolic murmur best heard at the RUSB,
no
rubs or gallops.
## LUNGS:
CTAB, no wheezes or ronchi. No increased work of
breathing.
## ABDOMEN:
Obese, nondistended, nontender in all quadrants.
## EXTREMITIES:
No edema. RL BKA with sutures, clean/dry/in tact,
mild swelling but no erythema or drainage.
## LEFT KNEE:
L knee with tenderness to palpation on medial aspect.
No swelling or erythema or warmth.
## NEURO:
AAOx3, CN grossly intact, moving all extremities.
## MICROBIOLOGY
============
URINE CULTURE (FINAL :
NO GROWTH.
URINE CULTURE (Final : NO GROWTH.
Blood Culture x3, Routine (Final : NO GROWTH.
MRSA SCREEN (Final : No MRSA isolated.
URINE CULTURE (Final : NO GROWTH.
URINE CULTURE (Final :
YEAST. 10,000-100,000 CFU/mL.
Blood Culture x2, Routine (Final : NO GROWTH
REPORTS
=======
CHEST (PRE-OP AP ONLY) Study Date of 9:24
No acute intrathoracic process.
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT Study Date of
9:24
AP view of the pelvis and AP and lateral views of the right hip
provided.
Underpenetration limits evaluation. Allowing for this, the bony
pelvic ring appears intact. Both hips align normally though
there is mild bilateral hip osteoarthritis with mild loss of
joint space and mild acetabular spurring. Vascular calcification
noted. Femoral necks appear intact bilaterally.
CHEST (PORTABLE AP) Study Date of 3:24
New bilateral consolidations, left greater than right concerning
for pneumonia given the provided clinical history.
Alternatively asymmetric pulmonary edema could also be
considered.
RENAL U.S. Study Date of 9:55 AM
1. Bilateral echogenic kidneys with loss of the normal
corticomedullary
differentiation is compatible with medical renal disease.
2. No hydronephrosis.
TTE
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/
color Doppler. The estimated right atrial pressure is mmHg.
There is mild symmetric left ventricular
hypertrophy with a normal cavity size. The relative wall
thickness is increased with increased wall
thickness, most c/w concentric hypertrophy. There is normal
regional left ventricular systolic function.
Quantitative 3D volumetric left ventricular ejection fraction is
57 %. There is no resting left ventricular
outflow tract gradient. Tissue Doppler suggests an increased
left ventricular filling pressure (PCWP
greater than 18mmHg). Normal right ventricular cavity size with
normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch
diameter is normal. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) are
mildly thickened. There is mild aortic valve stenosis (valve
area 1.5-1.9 cm2). There is mild [1+] aortic
regurgitation. The mitral leaflets appear structurally normal
with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is moderate pulmonary artery
systolic hypertension. There is a trivial
pericardial effusion.
## IMPRESSION:
Suboptimal image quality. Mild aortic valve
stenosis. Mild symmetric left ventricular
hypertrophy with normal cavity size, and regional/global
systolic function. Increased PCWP. Mild aortic
regurgitation. Mild tricuspid regurgitation. Moderate pulmonary
artery systolic hypertension.
Compared with the prior TTE (images reviewed) of , the
findings are similar.
KNEE (AP, LAT & OBLIQUE) RIGHT Study Date of 10:42 AM
1. Interval placement of a lateral fixation plate and screws
transfixing a comminuted fracture of the distal femoral
metadiaphysis. No evidence of
hardware related complication.
2. 1.2 cm sclerotic lesion in the right acetabulum appears
slightly larger compared to . In the absence of a known
malignancy, this likely represents a bone island. However as
malignancy cannot be excluded, a nuclear medicine bone scan is
recommended to evaluate for metabolic activity, malignant
potential, and possible other sites of disease.
3. Mild hip osteoarthritis, similar to prior.
CT PELVIS W/O CONTRAST Study Date of 10:34 AM
1. Interval increase in size of a spiculated sclerotic lesion in
the right
acetabulum now measuring 1.5 x 1 cm. This measured only 6 mm in
size in . Morphologically, this appearance is most
consistent with a bone island however the degree of growth is
unusual. Growth can be seen with bone islands in adult
patients, however recommend a nuclear medicine bone scan to
exclude additional bone lesions/bony metastatic disease.
2. Extensive vascular calcification.
## BRIEF HOSPITAL COURSE:
Ms. is a year old woman with history of T1DM
complicated by non-adherence, HTN, Stage IV Chronic Kidney
Disease (baseline Cr ~3.0), s/p multiple amputations who
presented s/p fall complicated by right femoral fracture s/p I&D
and ORIF by Dr. ( ) and a hospital
course complicated by HAP (s/p meropenem) and on CKD
secondary to hypotension, and subsequent initiation of HD.
## ORTHOPEDIC SURGERY HOSPITAL COURSE:
Patient admitted to the Orthopaedic Surgery service on
for open right distal femur fracture and went to OR on
with Dr. right distal femur irrigation and
debridement and open reduction internal fixation. Patient was
taken to the operating room on for irrigation and
debridement, open reduction internal fixation of right distal
femur by Dr. . Patient worked with Physical Therapy on
post-operative day 1, who felt upon discharge patient would
benefit from admission to rehab. Patient remained non-weight
bearing of the right lower extremity but could engage in range
of motion as tolerated. On patient was hyperkalemic
(5.9) and given Kayexalate. On patient was transferred
to the Medicine service for management of comorbidities.
## MEDICINE SERVICE HOSPITAL COURSE:
Once transferred to medicine, she was diuresed until her O2
saturations were >92% on room air. Additionally, treatment for
HAP was continued with meropenem for a 7 day course until .
Her renal function intially continued to improve with post-ATN
diuresis, though she did develop further hyperkalemia which was
managed with further diuresis, insulin, and another dose of
kayexelate. Pain was well controlled, requiring minimal amounts
of oxycodone for control. However, her creatinine did not
continue to improve beyond 5, and the discussion to start
dialysis was started on . Eventually, the patient decided to
do dialysis, and a tunneled line was placed and HD was
initiated.
on CKD - Cr peaked at 6.3 and the patient was started on
hemodialysis. Tolerated HD initiation well ( ) and to
have outpatient HD arranged. PPD negative. Likely
hypoperfusion during operation. See by renal and HD was
initiated. Discharged with torsemide 80mg on non-HD days. Should
follow up as an outpatient with nephrologist Dr. , as may
not need long term HD.
#Hypervolemia and hypoxia, acute on chronic diastolic heart
failure - Improved with IV Lasix, torsemide, and dialysis.
Likely has component of HFpEF, and should follow up with
cardiology for this. She will continue on torsemide on her
non-HD days.
#Hospital acquired PNA - S/p meropenem (completed on .
#Urinary retention - S/p foley replacement on by urology
given urinary retention and significant anasarca and labial
edema. UA with small and positive bacteria, so started on
ciprofloxacin, but this was discontinued due to rash. Urine
culture was negative. She failed a voiding trial on and
had foley catheter replaced with 500cc UOP retained.
#Distal femur fracture - S/P I&D and ORIF by Dr. on .
Needs follow up with Dr. 2 weeks from operation ( ).
NWB RLE, ROMAT. Heparin SC for DVT PPX. Pain control with
acetaminophen/oxycodone. Continue physical therapy.
#R acetabular lesion
-increased in size on plain film compared to
-Likely bone island, but patient should have bone scan to
evaluate for malignancy
#Anemia - labs consistent with ACD. Required 4U pRBC on this
admission.
#Pruritis - patient experienced rash and pruritis after being
treated with ciprofloxacin. This was discontinued and she is
being treated with fexofenadine with improvement and sarna
lotion and PRN Benadryl for breakthrough pruritis. These
antihistamines were discontinued on discharge.
CHRONIC ISSUES
#T1DM - Insulin managed by as an inpatient.
#HTN - amlodipine continued on non-HD days
#OSA - CPAP
#UC - patient was to be on prednisone taper reduced by 1mg per
month, was on 10mg here, follow up with GI as an outpatient to
further determine her steroid course
#Cardiac risk - continued on ASA and atorvastatin
#Depression - continued on citalopram
## - DISCHARGE WEIGHT:
90.7kg (post-HD on
- DISCHARGE CREATININE: 4.6 (on hemodialysis)
[ ] New HD initiation schedule: TuThSat
[ ] Trend ins/outs and adjust HD as needed.
[ ] FYI, she may eventually be able to come off of HD. Her
primary nephrologist is Dr. .
[ ] Follow up: ortho in 1 month with films, cardiology (HFpEF),
GI (on steroid taper for ulcerative colitis), urology for
urinary retention.
[ ] Patient to continue on DVT prophylaxis for two additional
weeks with subQ heparin
[ ] Needs follow up with Dr. 2 weeks from operation
( ).
[ ] Void trial: failed
[ ] Needs hep B vaccination series, ordered first one here
[ ] Follow with serial X-rays: "1.2 cm sclerotic lesion in the
right acetabulum appears slightly larger compared to . In
the absence of a known malignancy, this likely represents a bone
island. However as malignancy cannot be excluded, a nuclear
medicine bone scan is recommended to evaluate for metabolic
activity and
malignant potential. Needs repeat X-ray as an outpatient with
ortho.
[ ] Recommend bone scan for further evaluation of acetabular
lesion
[ ] Supposed to be on steroid taper to drop by 1mg each month
(currently on 10 here) pending outpatient GI follow-up and
further recommendations
[ ] Would consider PFTs as an outpatient to assess for
underlying COPD given smoking history and slow recovery of O2
requirement
[ ] SPEP/UPEP was sent here for work up of . No
proteins were found but faint monoclonal IgG bands were seen on
both SPEP and UPEP. Would follow up repeat testing and consider
a heme/onc referral if worsening.
[ ] , Relationship: brother, Phone number:
, Cell phone:
[ ] presumed Full Code
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. balsalazide 750 mg oral BID
4. Citalopram 40 mg PO DAILY
5. Diphenoxylate-Atropine 2 TAB PO BID
6. Furosemide 40 mg PO DAILY
7. Gabapentin 100 mg PO BID
8. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
23 subcutaneous QHS
9. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL
units subcutaneous TID
10. PredniSONE 10 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Fenofibrate 145 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Heparin 5000 UNIT SC BID Duration: 2 Weeks
7. Glargine 21 Units Bedtime
Humalog 10 Units Breakfast
Humalog 12 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Nephrocaps 1 CAP PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*12
## TABLET REFILLS:
*0
10. Psyllium Wafer 1 WAF PO DAILY
11. Sarna Lotion 1 Appl TP DAILY:PRN itchiness
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. sevelamer CARBONATE 1600 mg PO TID W/MEALS
14. Torsemide 80 mg PO DAILY
15. amLODIPine 10 mg PO DAILY
16. Atorvastatin 80 mg PO QPM
17. balsalazide 750 mg oral BID
18. Citalopram 40 mg PO DAILY
19. Diphenoxylate-Atropine 2 TAB PO BID
20. PredniSONE 10 mg PO DAILY
## DISCHARGE DIAGNOSIS:
Open right distal femur fracture
Acute kidney injury on chronic kidney disease
acquired pneumonia
Volume overload
Urinary tract infection
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to after a fall and hip
fracture.
## WHILE YOU WERE HERE:
- You had kidney dysfunction and were seen by the kidney
doctors. discussed dialysis with you and together, you
decided to wait and see how things went before starting
dialysis.
- You were given water pills (torsemide) to help take fluid off.
- You were treated with antibiotics for a pneumonia.
- You were started on dialysis.
## WHEN YOU GO TO REHAB:
- Your medications and follow up appointments are below.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
## INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
## - RIGHT LOWER EXTREMITY:
Non-weight bearing. Range of motion as
tolerated.
## MEDICATIONS:
1) Take Tylenol every 6 hours around the clock. This is
an over the counter medication.
2) Do not stop the Tylenol until you are off of narcotic
medications, or are told to stop by your physician.
3) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
4) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
5) Please take all medications as prescribed by your
physicians at discharge.
6) Continue all home medications unless specifically
instructed to stop by your physician.
## ANTICOAGULATION:
- Please take Lovenox 40 mg daily for 4 weeks post-operatively
(until
.
## WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks
post-op.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
## FOLLOW UP:
Please follow up with Dr. in the Trauma
Clinic in one month for evaluation. Please call if
you need to change your appointment. Xrays will be taken in the
office during that appointment.
Please follow up with your primary care doctor regarding this
admission within weeks and for and any new
medications/refills.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12119271", "visit_id": "23149747", "time": "2153-06-01 00:00:00"} |
17953004-DS-18 | 1,421 | ## ALLERGIES:
Penicillins / Coumadin / morphine
## CHIEF COMPLAINT:
Chronic PE's not taking lovenox as prescribed
## HISTORY OF PRESENT ILLNESS:
past medical history of Crohn's disease, adenoma of colon,
Hodgkin's disease never treated from age , nephrolithiasis,
migraines, iron deficiency, and unprovoked pulmonary emboli on
lifetime a/c in who was sent in after being sent
in by his hematologist for recurrent pulmonary embolism.
.
Unfortunately the patient is allergic to coumadin and requires
Lovenox. In , he lost access to a program which had given
him free Lovenox for several months. It is currently costing him
$600/mo. which is of his income.
.
He has not been noticing any increasing symptoms from his
pulmonary embolism, but was complaining to his hematologist
about the cost of the Lovenox, so the hematologist got a
screening CT scan? to see if they could discontinue the
anticoagulation entirely. A CT scan which was done this morning
at apparently showed multiple small
pulmonary emboli on both sides, and so the patient was called
into the emergency department for admission.
In the ED intial vitals were recorded as 99.2 85 141/75 16 98%
ra. EKG was unconcering. The patient admited to the ED team that
he had been trying to "space out" the Lovenox by taking it one
out of every days to reduce the cost. Heparin drip was
started and vitals prior to transfer were 98.7, 86, 12, 132/69,
98% RA.
.
Currently, he is asymptomatic.
.
## REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
## PAST MEDICAL HISTORY:
Chronic back pain multiple spinal fusions starting in
requiring steroid injections q10 weeks
Recent admission to with a "viral illness"
Migraines no ppx, imitrex prn
Hodgkins dx at , no tx
Crohn's in remission
GERD
## FAMILY HISTORY:
NO FH of PE.
## ADMISSION PHYSICAL EXAM:
VS - Temp 97.9 F, 140/2 BP , 84 HR , 16 R , O2-sat 96% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
## DISCHARGE PHYSICAL EXAM:
VS - 98, 130/78, 70, 15, 96% on RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD, no carotid bruits
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/e, Toes are cool to touch and had mild
delay in capillary refil. 2+ pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
throughout, sensation grossly intact throughout, intact,
steady gait
## EKG ON :
Artifact is present. Sinus rhythm. Probably normal tracing. No
previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 198 50 -24 34
CXRAY PA & LAT ON :
## FINDINGS:
The heart is normal in size. The aortic arch is
partly calcified. The mediastinal and hilar contours are
otherwise unremarkable. The lungs appear clear. There are no
pleural effusions or pneumothorax. There is slight loss in a
lower thoracic vertebral body height, possibly T9 and likely
chronic. Small osteophytes are noted along the thoracic spine.
## IMPRESSION:
No evidence of acute disease. Mild loss in
vertebral body height along a lower thoracic vertebral body.
## BRIEF HOSPITAL COURSE:
Mr. is a year old man with a history of untreated
Hodgkins disease since age of , migraines, Crohn's disease,
colonic adenoma, Fe deficiency anemia, nephrolithiasis, and
degenerative disc disease who presented with evidence of
chronic/recurrent PEs on outpatient CT scan in the context of a
lapse in lovenox administration due to inability to pay for his
Lovenox prescription.
## # PES:
Pt has recurrent PE in the setting of only taking his
lovenox intermittently due to cost. He is currently symptoms
free, HD stable and sating in the upper . Treatment will
likely be difficult since ? if patient makes too much to qualify
to have free-care/mass health; however paying for his lovenox is
a financial burden to him of his monthly income). We
discussed possible IVC filter, although this is not a current
indication for IVC filter since he did not fail therapy. In
addition, he would like benefit from anticoagulation in addition
to having IVC filter. However, this should be further discussed
with his hematologist given his financial difficulties and very
high risk for developing PEs which could be fatal. I called the
insurance company today asked for appeal of his coverage which
was denied. He will need to have a letter of necessity sent from
his PCP/hematologist for review and possible decreasing his
insurance copay. Currently he has a insurance gap of $4,700 so
he would have to cover his first $4,700 prior to the insurance
taking over his coverage. His lovenox for the month would
cost $792 and the following month $1,600 which is more than his
monthly income. We also discussed other treatment options such
as fundapurinox which would have an even higher co-pay of $1489.
We also discussed other medications such as Rivaroxaban which
was just approved for the use of PE, but it not available in the
pharmacies. It will cost ~$300/ month (Oral Rivaroxaban for the
Treatment of Symptomatic Pulmonary Embolism, The
Investigators . Dabigatran is not approved for
the tx of PE. Another option would be heparin SQ (2.5mg/Kg) BID,
however he would need close PTT monitoring. For now we were able
to get him 2 weeks supply via free-care pharmacy, and he has
another 2 week supply at home. I also spoke to the nurse from
his Hematologist office who wil be able to supply another month.
So he will have the total of 2months supply of lovenox while he
discuss his options with his hematologist.
- lovenox in house, treatment dose of 1mg/kg BID (80mg).Once d/c
he was given a prescription for 1.5mg/Kg 120mg daily
.
# Migraine HA: pt states that this is a going problem and he is
now having then with more frequency. He was previously on
Topamax which was prescribed by his neurologist and had
significantly decresed the frequency of his migraine HA. He then
stopped taking this med since someone told him it could cause
kidney stones and he had 2 stones in years. He had 2 doses of
Imitrex while inpatient which helped. He is now headache free.
- Will discuss possibly restarting on Topamax 50mg Qhs with his
neurologist
- Cont on Imitrex PRN
.
# Back pain: Currently back pain free, continue vicodin prn
.
# GERD: continue nexium
.
# FEN: No IVFs / replete lytes prn / regular diet
# PPX: on thereapeutic lovenox
# ACCESS: PIV
# CODE: confirmed full
# CONTACT: wife
# DISPO: HOME
.
## MEDICATIONS ON ADMISSION:
Immitrex PRN migraine
Lovenox BID
Nexium daily
Extra Strength vicodin prn back pain
## DISCHARGE MEDICATIONS:
1. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous once a day: Daily .
Disp:*30 injections* Refills:*1*
2. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
ONCE MR1 (Once and may repeat 1 time) for 1 doses.
3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
## 4. HYDROCODONE-ACETAMINOPHEN MG TABLET SIG:
Tablets PO
every six (6) hours.
## PRIMARY:
- Recurrent Pulmonary embolism
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to for recurrent pulmonary embolism in
the setting of not taking your lovenox daily. You were restarted
on a therapeutic dose of Lovenox daily. It is EXTREMELY
important that you continue to take this medication to help you
prevent further pulmonary embolism. Please inform your doctor
immediately if you can not pay for this medication or if you
have any other problems obtaining your medication, since missing
any doses could lead to other pulmonary embolism and even death.
We have made the following changes:
- Increase your Lovenox to 120mg daily
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17953004", "visit_id": "22613749", "time": "2141-02-20 00:00:00"} |
12989532-RR-23 | 193 | ## INDICATION:
female with right-sided abdominal pain and nausea for
one day. History of appendectomy and cholecystectomy as well as total
abdominal hysterectomy.
## CT ABDOMEN WITH CONTRAST:
The lung bases are clear, and there is no
pericardial or pleural effusion.
Overall evaluation of the abdomen is limited by respiratory motion. No focal
hepatic lesion is identified and there is no intra- or extra- hepatic biliary
ductal dilatation. The patient is status post cholecystectomy. The pancreas,
spleen, and adrenal glands appear normal. The kidneys enhance symmetrically
and excrete contrast normally without hydronephrosis or hydroureter. Intra-
abdominal loops of large and small bowel are of normal caliber, and there is
no pneumoperitoneum or free fluid. The abdominal aorta is of normal caliber.
The portal venous system is patent. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are identified.
## CT PELVIS:
The rectum, sigmoid colon, bladder, and adnexa are unremarkable.
The patient is status post hysterectomy. There is no free pelvic fluid or
pathologically enlarged pelvic or inguinal lymph nodes.
There are no bone findings of malignancy. Scoliosis is associated with mild
lumbar spondylosis and degenerative disease.
## IMPRESSION:
No acute abdominal or pelvic pathology.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12989532", "visit_id": "N/A", "time": "2153-06-23 21:43:00"} |
13242540-RR-8 | 131 | ## INDICATION:
The patient is a male with known C2 fractures.
Evaluate for vascular injury. In addition, evaluate for cord injury.
## EXAMINATION:
MRA of the neck with and without intravenous contrast.
## FINDINGS:
Axial T1 weighted fat suppressed images demonstrate no evidence of intramural
hematoma in the vertebral arteries. On the gadolinium-enhanced MRA, the
carotid and vertebral arteries are visualized from their origins to their
intracranial courses, without evidence of irregularity to suggest dissection,
and without evidence of a hemodynamically significant stenosis. There is a
three vessel aortic arch. The origin of the left vertebral artery is slightly
tortuous.
A cervical spine MRI was not ordered and, therefore, not performed.
## CONCLUSION:
No evidence of cervical arterial dissection, stenosis or occlusion.
Findings were discussed with at 3:30 p.m. on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13242540", "visit_id": "28804692", "time": "2142-12-15 13:43:00"} |
11505655-RR-39 | 857 | ## :
Cardiology Staff: , MD
## GENDER:
Male Radiology Staff: , MD
## RACE:
Other Technologist: , RT
## STATUS:
Outpatient Nursing Support: , RN
## WEIGHT (LBS):
256 Injection Site: right forearm vein
## RHYTHM:
Sinus rhythm Creatinine (mg/dl): 0.9
## INDICATION:
Left ventricular function. Myocardial viability.
## CMR MEASUREMENTS:
Measurement Normal Range
Left Ventricle
LV End-Diastolic Dimension (mm) *62 <62
LV End-Diastolic Dimension Index (mm/m2) 26 <32
LV End-Systolic Dimension (mm) 44
LV End-Diastolic Volume (ml) ***280 <196
LV End-Diastolic Volume Index (ml/m2) **116 <95
LV End-Systolic Volume (ml) 113
LV Stroke Volume (ml) 167
LV Stroke Volume Index (ml/m2) 69
LV Ejection Fraction (%) 60 >=54
LV Mass (g) 164
LV Mass Index (g/m2) 68 <80
Basal wall thickness (mm) 10 <12
Basal infero-lateral wall thickness (mm) 8 <11
Q-Flow Aortic Net Forward Stroke Volume (ml) 159
Q-Flow Aortic Total Stroke Volume (ml) 163
Q-Flow Aortic Cardiac Output (l/min) 11.9
Q-Flow Aortic Cardiac Index (l/min/m2) 5
LV Effective Forward Ejection Fraction (%) 58 >=54
Right Ventricle
RV End-Diastolic Volume (ml) 237
RV End-Diastolic Volume Index (ml/m2) 98 58-114
RV End-Systolic Volume (ml) 67
RV Stroke Volume (ml) 170
RV Stroke Volume Index (ml/m2) 71
RV Ejection Fraction (%) 72 >=46
Q-Flow Pulmonary Net Forward
Stroke Volume (ml) 167
Q-Flow Pulmonary Total Stroke Volume (ml) 168
Qp/Qs 1.05 0.8-1.2
Atria
Left Atrial Dimension (Axial) (mm) *49 <40
Left Atrial Length (4-Chamber) (mm) **67 <52
Left Atrial Length (2-Chamber) (mm) 53
Right Atrial Dimension (4-Chamber) (mm) **61 <50
Coronary Sinus Diameter (mm) 13 <15
Great Vessels
Ascending Aorta Diameter (mm) 36 <39
Ascending Aorta Diameter Index (mm/m2) 15 <20
Transverse Aorta Diameter (mm) 26
Transverse Aorta Diameter Index (mm/m2) 11
Descending Aorta Diameter (mm) 26 <28
Descending Aorta Index (mm/m2) 11 <14
Abdominal Aorta Diameter (mm) 26
Abdominal Aorta Diameter Index (mm/m2) 11
Main Pulmonary Artery Diameter (mm) 27 <29
Main Pulmonary Artery Diameter Index (mm/m2) 11 <15
Coronary Artery Origins Normal
Pulmonary Veins
Number of Left Pulmonary Veins 2
Number of Right Pulmonary Veins 2
Valves
Aortic Valve Morphology Trileaflet
Aortic Valve Excursion Normal
Aortic Valve Area (cm2) 3.4 >=2
Aortic Valve Area Index (cm2/m2) 1.4
Aortic Valve Regurgitation (Visual) None present
Aortic Valve Regurgitant Volume (ml) 4
Aortic Valve Regurgitant Fraction (%) 2 <5
Mitral Valve Regurgitation (Visual) Present
Mitral Valve Regurgitant Volume (ml) 4
Mitral Valve Regurgitant Fraction (%) 2 <5
Pulmonary Valve Regurgitant Volume (ml) 1
Pulmonary Valve Regurgitant Fraction (%) 1 <5
Tricuspid Valve Regurgitation (Visual) Present
Tricuspid Valve Regurgitant Volume (ml) 2
Tricuspid Valve Regurgitant Fraction (%) 1 <5
Pericardium
Pericardial Effusion None present
* Mildly abnormal | ** Moderately abnormal | *** Severely abnormal
## STRUCTURE
" T1-WEIGHTED (BLACK BLOOD):
Dual-inversion T1-weighted fast spin echo images
were acquired in 5-mm contiguous axial slices to evaluate cardiac and vascular
anatomy.
## FUNCTION
" CINE SSFP:
Breath-hold SSFP cine images were acquired in 8-mm slices in the
4-chamber, 3-chamber, 2-chamber, and short axis orientations.
" Cine SSFP (Additional Aortic Valve Views): A short-axis series was acquired
at the level of the aortic valve.
## FLOW
" AORTIC VALVE FLOW:
Phase-contrast cine images were acquired transverse to
the proximal ascending aorta to quantify through-plane flow.
" Pulmonary Valve Flow: Phase-contrast cine images were acquired transverse
to the main pulmonary artery to quantify through-plane flow.
##
VIABILITY
" LGE (3D PSIR):
Late gadolinium enhancement (LGE) images were acquired using
a navigator-gated 3D phase sensitive inversion-recovery (PSIR) sequence with
spectral fat saturation pre-pulses 15 minutes after injection of a total of
0.1 mmol/kg (21 mL) Gd-BOPTA (Multihance).
## MRA
" MRA:
First-pass magnetic resonance angiography (MRA) images were acquired
after administration of a bolus of 0.1 mmol/kg (21 mL) Gd-BOPTA (Multihance).
Multiplanar reconstructions were generated and analyzed on a workstation.
## LEFT VENTRICLE
" LV CAVITY SIZE:
Moderately increased
" LV ejection fraction: Normal
" LV mass: Normal
## RIGHT VENTRICLE
" RV CAVITY SIZE:
Normal
" RV ejection fraction: Normal
" Intra-cardiac shunt: None present
## ATRIA
" LA SIZE:
Moderately enlarged
" RA size: Moderately enlarged
## GREAT VESSELS
" ASCENDING AORTIC DIAMETER:
Normal
" Main pulmonary artery diameter: Normal
Pulmonary Veins
" Number of Left Pulmonary Veins: 2
" Number of Right Pulmonary Veins: 2
## VALVES
" AORTIC VALVE MORPHOLOGY:
Trileaflet
" Aortic stenosis: No
" Aortic regurgitation jet: None present
" Mitral regurgitation jet: Present
" Tricuspid regurgitation jet: Present
## ADDITIONAL INFORMATION/FINDINGS:
None.
## NON-CARDIAC FINDINGS:
Splenomegaly, 17.7 cm, cirrhosis better seen on prior ultrasound and CT
imaging.
## IMPRESSION:
Moderate biatrial enlargement. Moderately increased left ventricular cavity
size with normal systolic function. Normal left ventricular wall thickness
and mass. No left ventricular late gadolinium enhancement, consistent with
the absence of fibrosis or scar. Normal right ventricular cavity size and
systolic function. Normal ascending aorta, descending aorta, aortic arch,
and main pulmonary artery sizes. Trace mitral regurgitation. No pericardial
effusion.
## CONCLUSION:
Moderately increased left ventricular cavity size with normal systolic
function, consistent with a high output state. Normal right ventricular size
and function. No late gadolinium enhancement, consistent with the absence of
fibrosis/scar.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11505655", "visit_id": "N/A", "time": "2112-04-26 09:20:00"} |
18908042-RR-22 | 298 | ## REASON FOR THE EXAMINATION:
This is a patient with stroke of
undetermined etiology. The request is to rule out malignancy.
## FINDINGS:
The thyroid is within normal limits. The heart is within normal
limits regarding size and configuration.
The airways are of normal caliber and patent. Lung fields are unremarkable.
No overt filling defect is seen within the pulmonary arteries (though this
examination is not tailored for the detection of PE). No mediastinal, hilar,
or axillary lymphadenopathy is seen.
## ABDOMEN:
The liver and gallbladder are unremarkable. There is no intra- or
extra-hepatic biliary duct dilation. The spleen, pancreas and both adrenals
are within normal limits. Both kidneys enhance and excrete symmetrically.
Parapelvic cyst is seen in the left kidney. The visualized portions of the
ureters are within normal limits.
There is no mesenteric or retroperitoneal lymphadenopathy. No free fluid or
free air is seen within the abdomen.
The nasogastric tube is seen with its tip located in the stomach. Small
umbilical hernia is seen. Mild diverticulosis of the sigmoid colon with no
evidence of diverticulitis.
## PELVIS:
Foley catheter is seen within the urinary bladder. The prostate is
mildly enlarged. No lymphadenopathy or free fluid is seen within the pelvis.
Mild atherosclerotic changes are seen along the course of the aorta, which is
otherwise patent and of normal caliber. The portal vein and its branches, the
splenic vein and SMV are within normal limits. The vena cava and its branches
are within normal limits.
Note is made of fat stranding in proximity to the right common femoral vessels
most probably secondary to catheterization of the right common femoral artery.
## OSSEOUS STRUCTURES:
No lytic or osteoblastic lesions are seen.
## IMPRESSION:
1. No evidence of malignancy.
2. Diverticulosis of the sigmoid colon without evidence of diverticulitis.
3. Mild BPH.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18908042", "visit_id": "20381307", "time": "2179-03-05 16:56:00"} |
11230966-RR-22 | 103 | ## EXAMINATION:
FOOT AP,LAT AND OBL RIGHT
## HISTORY:
with R ankle/foot pain following jump from a 6ft
fence. // Please assess films while weight bearing if possible, for evidence
of fracture/bony injury.
## FINDINGS:
The patient was unable to weightbear. Subtle lucency projecting over the
medial calcaneus on the AP view, not well substantiated on the oblique or
lateral views may be artifactual but a nondisplaced fractures not excluded. No
acute fracture is seen elsewhere.
## IMPRESSION:
Per the radiology technologist, the patient was unable to weightbear. Linear
lucency projecting over the medial calcaneus on one view, query artifact
versus nondisplaced fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11230966", "visit_id": "N/A", "time": "2172-09-27 10:18:00"} |
16552738-RR-52 | 102 | ## EXAMINATION:
CHEST (PA AND LAT)
## HISTORY:
with fever/cough x 2 weeks and hx of CLL // ?
pneumonia
## FINDINGS:
Right infrahilar fullness, new since prior exam, may represent mass or
adenopathy. CT chest recommended for further evaluation. Probable benign
calcified granuloma right upper lung medially. There is a shallow inspiration
the lateral radiograph. No definite infiltrates. No pleural effusions.
Normal heart size, pulmonary vascularity. Mid thoracic curve convex to the
right, stable. Chest otherwise normal.
## IMPRESSION:
Asymmetric new right infrahilar fullness, mass or adenopathy should be
excluded. CT chest recommended in further evaluation.
## RECOMMENDATION(S):
CT chest recommended in further evaluation
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16552738", "visit_id": "N/A", "time": "2190-05-19 13:44:00"} |
10605700-DS-11 | 737 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
ORIF L distal radius fracture
## HISTORY OF PRESENT ILLNESS:
Today, I had the pleasure of seeing your patient,
in consultation. As you know, he is a right-handed gentleman
who
is presenting here with a history of left wrist pain.
The patient was walking on a slippery condition on on
, when he slipped and fell on an outstretched left
hand. He experienced immediate onset of left wrist pain and
swelling and presented to the Emergency Department where he
was diagnosed with a comminuted left distal radius fracture. He
was told to follow up with a hand surgeon as an outpatient for
likely surgical management. He presents here today complaining
of persistent pain, which involves the entirety of the
wrist. It is worsened with any sort of direct impact or
activity. Additionally, the patient is complaining of the
associated symptoms of numbness and tingling involving the first
three digits, which he says has been intermittent represent
since
the time of injury. He has taken oxycodone and ibuprofen for
pain control with minimal relief. He denies any other
associated
symptoms or modifying factors.
## PAST MEDICAL HISTORY:
-Depression
-GERD
-Schwannoma, s/p L3-L4 lumbar laminectomies on . C/b
spinal fluid leak.
## BRIEF HOSPITAL COURSE:
Patient was admitted post-operatively to the orthopedic service
for pain control. He was started on a dilaudid PCA on POD0 that
was eventually d/ced on POD1. At the time of discharge on POD1,
the patient's pain was well-controlled on oral pain
medications. Additionally he was voiding independently,
tolerating a regular diet, and had been afebrile.
Of note, patient presented pre-operatively with a systolic BP of
156. Throughout the hospitalization he remained hypertensive
and required multiple IV doses of anti-hypertensives. He has
been started on a low-dose beta blocker and encouraged to follow
up with his PCP for further management of his blood pressure.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a Disp #*30 Tablet Refills:*0
4. Milk of Magnesia 30 ml PO BID:PRN Constipation
5. Senna 1 TAB PO BID
6. Citalopram 20 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) mg PO Q4H:PRN Pain
RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours
Disp #*75 Tablet Refills:*0
## DISCHARGE DIAGNOSIS:
L distal radius fracture
## DISCHARGE INSTRUCTIONS:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower upon discharge,
but please ensure to keep your splint clean and dry.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
8. Your blood pressure was elevated throughout this
hospitalization and you have been discharged on a low-dose
anti-hypertensive. Please follow up with your PCP regarding
this issue within the next days.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10605700", "visit_id": "22629653", "time": "2171-08-14 00:00:00"} |
15274423-RR-67 | 548 | ## EXAMINATION:
CT abdomen pelvis with contrast
## INDICATION:
year old man with DVT/PE , lifelong Coumadin, IVC filter),
CAD s/p cardiac stent ( ), p/w RUQ pain c/f hemoperitoneum// Assess
drainages to consider removal
## LOWER CHEST:
A loculated right pleural effusion, including a loculation in the
fissure has increased since (for example 2:1). A small left
pleural effusion is unchanged. There is bibasilar atelectasis. There is
extensive coronary artery calcification. A central line terminates at the
cavoatrial junction. There is no pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is surgically absent.
A collection containing gas and hyperdense material with a single percutaneous
pigtail catheter in the largest component has decreased in size significantly
in comparison with , now measuring 11 x 4.5 cm, previously 14 x 5.4
cm (02:24). There remains a subdiaphragmatic component measuring 5.5 x 1.4
cm, which is not being actively drained (602:51). A second anterior approach
pigtail catheter has been removed.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The spleen remains mildly enlarged measuring up to 14 cm. There are
no focal splenic lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized.
## PELVIS:
The bladder is decompressed and contains a Foley catheter with a
locule of air. There is no free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate and seminal vesicles are unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
An IVC filter is in place inferior to the renal veins. The left
common iliac vein remains occluded to the left common femoral vein. There are
extensive venous collaterals. The there is no abdominal aortic aneurysm.
Mild atherosclerotic disease is noted.
## BONES:
Destruction and extensive sclerotic change of the left hemipelvis and
proximal femur with joint effusion and surrounding stranding may be related to
prior trauma, however superimposed osteomyelitis cannot be excluded (for
example 2:96). Healed right eleventh posterior rib fracture.
## SOFT TISSUES:
A subcutaneous soft tissue swelling adjacent to the right
inferior chest wall is probably related to a recently removed drain (02:14).
There is soft tissue edema about the bilateral flanks.
## IMPRESSION:
1. Interval decrease in the size of the perihepatic fluid collection drained
by an anterior approach pigtail catheter. The subdiaphragmatic component of
the fluid collection decreased in size.
2. Loculated right pleural effusion with a loculation in the fissure has
increased in comparison with .
3. Small left pleural effusion is unchanged.
4. Stable extensive deformity of the left hemipelvis and proximal femur with
large joint effusion and stranding. Superimposed osteomyelitis cannot be
excluded.
5. Chronic thrombosis of the left common iliac vein with extensive venous
collaterals along the anterior left pelvic wall.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15274423", "visit_id": "20224665", "time": "2168-08-19 15:38:00"} |
15371038-RR-27 | 91 | ## INDICATION:
year old man with gout and pain in second MCP joint// eval for
evidence of gout
## FINDINGS:
No fracture or dislocation is seen. There is mild soft tissue swelling
adjacent to the MCP joint. No erosions or evidence of tophi. Minimal
insertional degenerative cystic changes at the DIP joint. No suspicious lytic
or sclerotic lesion is identified. No soft tissue calcification or
radio-opaque foreign bodies are detected.
## IMPRESSION:
1. No fracture or dislocation.
2. Mild soft tissue swelling adjacent to the MCP joint without erosions or
tophi.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15371038", "visit_id": "N/A", "time": "2191-12-07 17:13:00"} |
12536436-RR-18 | 227 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## HISTORY:
with head injury. Evaluate for hemorrhage or mass
effect.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 8.0 s, 16.4 cm; CTDIvol = 49.0 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 1.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
3) Sequenced Acquisition 2.0 s, 4.1 cm; CTDIvol = 49.0 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
## FINDINGS:
The study is severely degraded by motion even though some of the images were
repeated. Evaluation for subarachnoid hemorrhage is particularly limited.
Otherwise, there is no evidence for acute hemorrhage or mass effect.
Hypodensities in the right putamen/corona radiata, left putamen/internal
capsule, and left corona radiata likely represent chronic small vessel
infarcts. Ill-defined confluent periventricular and deep white matter
hypodensity is nonspecific but likely secondary to chronic small vessel
ischemic disease in this age group. Ventricles and sulci are prominent,
congruent with global age-related parenchymal volume loss.
No fracture is seen on substantially motion limited evaluation. Partially
visualized paranasal sinuses and mastoid air cells are grossly well-aerated.
The patient appears to be status post scleral banding.
## IMPRESSION:
Severely motion limited exam, with particularly limited evaluation for
subarachnoid hemorrhage or calvarial fracture. No definite acute
abnormalities identified.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12536436", "visit_id": "28222332", "time": "2170-02-06 01:54:00"} |
17215556-RR-21 | 249 | The examination was performed on this gentleman for randomization
into the TINSAL-CV trial, research account . The examination includes
abdomen for liver fat, body fat and coronary artery study for measurement of
calcified and noncalcified plaque. Imaging was performed using the Aquilion
ONE CT scanner.
## ABDOMEN:
The liver was imaged using 80 and 135 kVP. At 80 kVP, the
attenuation value of the liver was 60 and the right 53. Using 135 kVP, the
evaluation of the left lobe was 53 and the right 51. Note is made of a 1 cm
cyst in the left lobe that has not changed from the previous MR examination of
the other small cysts reported in the MRI study cannot be resolved on a
non-contrast scan. The gallbladder, adrenals, spleen and kidneys are all
within normal limits. There is minimal calcification in the iliac arteries
and there are degenerative changes in the dorsal spine.
## CHEST:
A long stent is noted in the left anterior descending coronary artery.
Degenerative changes are noted in the spine. The mediastinum, pulmonary
arteries, aorta, and lung parenchyma are all within normal limits.
The cardiac images were acquired in a prospective gated fashion at75% of the
RR interval covering the heart in one beat. Metoprolol was not needed for
heart rate control and nitroglycerin 0.4 mg was given to produce maximal
coronary artery dilatation. The cardiac images will be reported directly to
the cardiologist and not in the medical record because of its research nature.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17215556", "visit_id": "N/A", "time": "2113-07-15 09:35:00"} |
12364966-DS-14 | 1,558 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
This is an yo man with h/o gstric ulcer requiring surgery
remotely who p/w 7 days of abdominal pain, located
periumbilical, worse with movement, described as feeling
muscular, with no other associated symptoms, at it's peak was
, currently . He also noted constipation for 3 days,
prior to that was having melenic stools for 2 days, with no
gross blood in his stools. He notes wt loss (unable to quantify
'not much') since which he attributed to poor po intake in
the setting of dentures that dont fit and therefore he can't use
them. He denies fevers, chills, or night sweats. He notes
dizziness on standing but states this is chronic for which he
periodically takes meclizine. He denies ha, visual change, sore
throat, cough, sob, doe, cp, palpitations, dysuria, hematuria,
leg swelling. He notes 3 weeks ago right hip pain after he
stepped on his right foot and 'was not careful' but this
improved with an ointment from Dr. . He denies any growth
or swelling in his right groin.
## IN THE ED:
VS: 99.2 55 140/59 20 99% on ra. He was guaiac +.
Surgery and GI consulted. He was given 2 L NS, pantoprazole 40mg
iv. Hct decreased 9 points since . NG lavage negative.
## ROS:
10 point review of systems negative except as noted above.
## HEPATITIS C:
previously followed by Dr. seen ,
genotype I, Biopsy grade II, stage I ( )
gastric ulcer s/p unknown surgery
HTN
hyperlipidemia
renal cysts
CAD, s/p cath , no itervention
glaucoma
.
## PSH:
unknown peptic ulcer operation ago
R inguinal hernia repair
## FAMILY HISTORY:
jaw cancer (mother), CAD (sister)
## GEN:
Well appearing elderly man in NAD
## EYE:
extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
## ENT:
mucus membranes moist, no ulcerations or exudates
## NECK:
no thyromegally, JVD: flat
## CARDIOVASCULAR:
regular rate and rhythm, normal s1, s2, II/VI
HSM at the apex, no rubs or gallops
## RESPIRATORY:
Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
## ABD:
Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present, no appreciable right inguinal mass or LAD
## EXTREMITIES:
No cyanosis, clubbing, edema, joint swelling
## NEUROLOGICAL:
Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, speech fluent
## INTEGUMENT:
Warm, moist, no rash or ulceration
## PSYCHIATRIC:
appropriate, pleasant, not anxious
## HEMATOLOGIC:
no cervical or supraclavicular LAD
## MUCOSA:
Erythema of the mucosa was noted in the stomach. These findings
are compatible with gastritis. Cold forceps biopsies were
performed for histology at the stomach antrum.
## DUODENUM:
Excavated Lesions
A single cratered clean-based non-bleeding 20 mm ulcer was found
in the duodenal bulb.
Other findings:
Evidence of likely prior Bilroth I was seen (no pylorus
identified).
## IMPRESSION:
Erythema in the stomach compatible with gastritis (biopsy)
Ulcer in the duodenal bulb
Evidence of likely prior Bilroth I was seen (no pylorus
identified).
Otherwise normal EGD to third part of the duodenum
## RECOMMENDATIONS:
Routine post procedure orders.
Will inform patient of biopsy results and direct treatment
accordingly.
Proceed to colonoscopy.
.
.
COLONOSCOPY:
## CONTENTS:
Stool was found in the whole colon.
Other Unable to intubate terminal ileum due to the amount of
stool throughout.
## IMPRESSION:
Stool in the whole colon
Unable to intubate terminal ileum due to the amount of stool
throughout.
Otherwise normal colonoscopy to cecum
## RECOMMENDATIONS:
Routine post procedure orders.
Further plan per GI inpatient team.
.
.
Cardiology ReportECGStudy Date of 7:08:38
Sinus bradycardia. Consider prior inferior (question posterior)
myocardial
infarction. Since the previous tracing of sinus
bradycardia rate is
faster. Otherwise, there is probably no significant change.
.
.
CT ABD/PELVIS:
## IMPRESSION:
1. Inflammatory changes surrounding the proximal duodenum, with
mucosal
hyperenhancement in the second segment of the duodenum. Findings
are
consistent with duodenitis. Cannot exclude underlying ulcer or
underlying
lesion. Recommend further evaluation with endoscopy.
2. 3.2 x 6.2 cm heterogeneous right pelvic soft tissue mass,
concerning for
malignant process, either metastatic or primary. Recommend
correlation with
colonoscopy and any known history of malignancy. If no primary
process
identified, this mass is amenable to percutaneous, CT-guided
biopsy.
3. Large bilateral renal cysts and smaller renal hypodensities,
too small to characterize.
.
.
## PATHOLOGY REPORTTISSUE:
GI BX ( 1 JAR)Study Date of
Report not finalized.
Assigned Pathologist .
Please contact the pathology department,
PATHOLOGY #
GI BX ( 1 JAR).
.
.
CT PELVIS W/O CONTRAST:
## IMPRESSION:
Redemonstration of heterogeneous mass in the right
hemipelvis.
Hyperdense components suggest a hemorrhagic component. Overall,
considerations include a hematoma, though an underlying lesion
with secondary hemorrhage is not excluded. Assess evolution with
follow up studies.
.
.
## MICROBIOLOGY:
6:40 am SEROLOGY/BLOOD
**FINAL REPORT
HELICOBACTER PYLORI ANTIBODY TEST (Final :
NEGATIVE BY EIA.
(Reference Range-Negative)
.
.
## BRIEF HOSPITAL COURSE:
yo man with abdominal pain, acute blood loss anemia and
orthostasis.
.
# abdominal pain, melena - upon arrival to the medical service,
pt's abdominal pain had resolved. he was seen by the GI and
surgical service. CT ABDOMEN raised concern for duodenitis and
right pelvic mass.
.
pt underwent EGD and colonoscopy on . EGD revealed an
ulcer in the duodenal bulb. pt was started on PPI BID. h
pylori serology was negative. while limited by poor prep, no
frank mass or source of bleeding.
.
given presence of possible right side pelvic mass, CT guided
biopsy was arranged. however, upon further discussion with
radiology, right pelvic mass was felt to possibly represent
hematoma only. repeat non-contrast CT PELVIS was obtained which
was compatible with hematoma only, though could not definitively
exclude a contained mass.
.
given resolution of his abdominal pain, stable HCT, pt was
discharged home with close follow-up with his PCP , with
instructions to:
- plan for repeat CT in weeks to ensure hematoma is
resolving, and to discuss utility of further biopsy.
- pt instructed to call to schedule f/u in GI clinic with Dr.
.
- above plan discussed with patient's son who confirmed his
understanding.
- continue to hold plavix until repeat CBC with PCP.
.
.
# acute blood loss anemia: normocytic - HCT stable ~30 from
, and then trended down to 30->26.5->26.5 on .
His stools were no longer melenotic. "hematoma" size was stable
on repeat CT. HCT decline was felt possibly due to phlebotomy.
Iron studies revealed ferritin 150s, but Fe/TIBC ratio
consistent with some iron deficiency.
.
given that his VSS, and his preference to be discharged home, he
was discharged home off of his plavix, with instructions to f/u
with his PCP for repeat CBC and to discuss restarting
plavix as needed.
.
.
# benign hypertension: BP meds initially held given ?GIB, but
then resumed (imdur, enalapril) except atenolol, which was held
due to asymptomatic sinus bradycardia (40s).
.
# CAD, native vessel: no recent stent placement, given bleeding,
plavix was held as above. he was continued on ACE, imdur.
unclear why he is not on aspirin at home.
.
# hyperlipidemia: at home on welchol, which was continued.
.
# hepatitis C - lost to follow up in GI clinic, unclear why.
LFTs WNL. no stigmata of liver disease on exam. he will f/u
with PCP and GI clinic as needed.
.
# Glaucoma: confirmed eyedrops with pharmacy, and continued.
.
# CODE - Full code, confirmed via interpreter.
# DISPO - above plan discussed with pt's son, who was in
agreement.
## MEDICATIONS ON ADMISSION:
confirmed with pt's pharmacy:
plavix 75mg daily
atenolol 25mg po qdaily
nifedipime xl 30mg bid
enalapril 20mg po bid
welchol 3 tabs bid ( )
eye drops (2 kinds)
meclizine 12.5mg po tid
nitroglycerin 0.4mg prn chest pain
imdur 60mg po qdaily
xalatan 0.005% 1 drop both eyes qhs
.
pharmacy is , , no answer
overnight
.
## DISCHARGE MEDICATIONS:
1. Enalapril Maleate 10 mg Tablet
## SIG:
Two (2) Tablet PO BID (2
times a day).
2. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Outpatient Lab Work
please have a CBC on . please have the results sent to
Dr. . please call
his office to confirm it has been received, and determine if you
need a blood transfusion. your HCT at the time of discharge is
26.5.
## DISCHARGE DIAGNOSIS:
primary:
gastric ulcer.
right pelvic mass vs hematoma
## DISCHARGE INSTRUCTIONS:
you were admitted to the hospital with bleeding and abdominal
pain. you underwent EGD and COLONOSCOPY which revealed a
gastric ulcer, but no colonic source of bleeding (though the
prep was not ideal).
.
A CT scan showed a question of right side pelvic mass, however,
on further review, this appeared to be a hematoma. Biopsy was
not recommended. You should have a repeat CT scan in 2 weeks to
ensure that this is not changing in size. You will need to
follow-up with Dr. to discuss what to do next.
.
the following changes were made to your medications:
1. your plavix was held because of your bleeding.
2. your atenolol was held because of your heart rate was 38-48.
3. you were started on a medicine called pantoprazole because of
your stomach ulcer.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12364966", "visit_id": "23119505", "time": "2132-10-20 00:00:00"} |
15004141-RR-13 | 138 | ## HISTORY:
with fall. Left-sided chest and sacral pain.
FILMS OF THE PELVIS AND STANDING VIEWS OF THE LS SPINE (FOUR IMAGES):
There
is remote posterior fusion of L4-S1 with corresponding pedicle screws,
vertical posterior rods, and laminectomies which extend more proximally
probably to T12. There is narrowing of all disc levels with associated
calcifications from L3-S1. There is anterior widening of L2-3 disc anteriorly
with slight angular scoliosis at this level. Poorly visualized probable old
T12 body fracture. Scoliosis. Bone detail obscured by considerable overlying
bowel gas and colonic stool. I doubt the presence of acute fracture and the
hips and suboptimally visualized SI joints are WNL. Lower lungs normally
aerated. Aortic calcifications. No comparison exams at this facility.
## IMPRESSION:
Extensive spinal disease and posterior fusion. No acute fracture
or bone destruction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15004141", "visit_id": "21942145", "time": "2126-04-18 06:33:00"} |
18269072-DS-3 | 2,445 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Left knee washout
Left knee debridement
## HISTORY OF PRESENT ILLNESS:
with HepC, h/o IVDU, HTN, s/p splenectomy, who presents from
an OSH with MRSA osteomyelitis of the left knee and persistent
fevers.
He initially presented to in with
fevers and left knee pain. He was found to have MRSA bacteremia
and septic arthritis of the left knee, synovial fluid also grew
MRSA. He had a lengthy 19 day hospital stay and was started on
daptoymcin, unclear if he also initially received gentamycin. He
reportedly had a TTE and TEE there which was negative for
endocarditis, but the reports were not available at the time of
transfer. He also underwent joint washout x3. He was discharged
to rehab with the plan to continue daptomycin through .
At rehab, he subsequently developed worsening left knee pain and
swelling and was febrile for 3 days, so he was readmitted to
on . He underwent an MRI which showed
osteomyelitis and myositis/fasciitis of the left knee. On ,
he went to the OR for washout and debridement. Per report, pus
was aspirated from the proximal tibia and aspirate grew MRSA.
ESR was greater than assay. ID was following and on his
antibiotics were changed from daptomycin to vancomycin/rifampin.
He continued to be febrile to . Per report, his
admission leukocytosis "resolved" but lab values were not sent.
He also reportedly developed with Cr 1.0->1.7. LFTs were
found to be elevated and a HCV VL was sent.
On arrival to , the patient reported left knee pain.
He denied any other complaints. Last IVDU was early .
He denied any trauma prior to the initial episode of septic
arthritis.
Review of sytems:
(+) Per HPI
(-) Denied night sweats, recent weight loss or gain. Denied
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Ten point review of systems is otherwise negative.
## PAST MEDICAL HISTORY:
-HepC
-?Chronic HepB (per OSH records)--he states it is resolved
-Substance abuse and IVDU--last used in
-H/o MRSA bacteremia
-HTN--he denies, in OSH records
-Osteoarthritis of the knees
-Peripheral neuropathy
-Depression
-PTSD (from multiple stab wounds)
-splenectomy from ?MVA vs stab wounds
## FAMILY HISTORY:
No siblings
Lives with wife who is trying to go to rehab for her own IVDU
Parents both alcoholics, now deceased
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
ronchi
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
+BS, soft, non-tender, non-distended. Midline and RUQ
scar, well healed.
## EXT:
L knee is markedly swollen and TTP, pain with passive and
active movement. 1+ LLE edema, trace RLE edema at the ankle. 2+
DP pulses bilat. No stigmata of endocarditis. L PICC line in
place.
## NEURO:
A&Ox3, CN II-XII intact, no focal weakness. Sensation
intact in the LLE, motor function in LLE is intact but limited
by pain.
## GENERAL:
Lying in bed in NAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
+BS, soft, non-tender, non-distended. Midline and RUQ
scar, well healed.
## EXT:
L knee swollen, muscle wasting evident in thigh. 2+ BP
pulses bilaterally. Postoperative scar with in
place. Wound site c/d/i. No bleeding or discharge. Site
nontender, except for small area of erythema and point
tenderness in lateral knee, unchanged in size from .
## BUTTOCKS:
Confluent light erythematous rash in the midline fold,
small non-confluent lightly erythematous macules on left.
Left arm PICC line in place.
## NEURO:
AxO x3, sensation grossly intact in LLE, motor function
intact but limited by pain
## PERTINENT RESULTS:
12:29AM BLOOD WBC-16.9* RBC-2.79* Hgb-8.6* Hct-25.9*
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.5 Plt
12:29AM BLOOD Neuts-49.5* Monos-11.3*
Eos-1.8 Baso-0.5
12:29AM BLOOD PTT-23.9*
12:29AM BLOOD ESR-131*
12:29AM BLOOD Glucose-106* UreaN-23* Creat-1.2 Na-134
K-4.3 Cl-101 HCO3-25 AnGap-12
12:29AM BLOOD ALT-52* AST-69* LD(LDH)-206 AlkPhos-62
TotBili-0.4
06:59AM BLOOD ALT-45* AST-60* LD(LDH)-172 AlkPhos-61
TotBili-0.6
12:29AM BLOOD CRP-123.8*
12:29AM BLOOD Albumin-2.1* Calcium-8.3* Phos-3.2 Mg-1.9
06:59AM BLOOD HIV Ab-NEGATIVE 06:59AM BLOOD
Vanco-21.1*
Urine culture : No growth
Blood culture x2 : No growth
Tissue Culture x4 : Gram stain negative, tissue culture
negative, anaerobic culture negative
Blood culture x2 : No growth
Blood culture x2 : No growth
Urine culture : No growth
Blood culture x2 : No growth
PICC tip culture : No growth
Knee joint aspirate: Gram stain negative, fluid culture no
growth, fungal culture PENDING, Acid fast smear negative, acid
fast culture PENDING
## IMAGING:
OSH TEE
all valves structurally normal
no evidence of vegetations
OSH ECHOCARDIOGRAM
LV size and wall thickness are normal
LV systolic function is low normal
LV EF 50%
No diastolic dysfunction
Insufficient TR to estimate PA systolic pressure.
OSH X-RAY KNEE , comparison
Significantly worsened moderate to severe joint space narrowing
of the medial compartment of the left knee joint with new
heterogeneity and periosteal reaction of the tibia highly
suspicious for osetomyelitis with septic arthritis. Increased
large joint effusion.
OSH U/S
Thickened urinary bladder wall likely related to chronic outlet
obstruction. 123cc post void residual. Enlarged prostate. No
hydronephrosis.
Knee XR
## FINDINGS:
No previous images are available. There is a
moderate
suprapatellar effusion with gas in soft tissues, consistent with
infectious process. In the proximal tibia, there is a large
area of lucency, which may represent a previous biopsy site. The
permeative pattern of opacification in the proximal tibia is
certainly consistent with the clinical diagnosis of
osteomyelitis.
Knee MRI
1. Moderate residual joint effusion.
2. Extensive marrow signal abnormality in the proximal tibia
consistent with osteomyelitis, please see dedicated MR for
further details.
3. Destruction of the body of the medial meniscus.
4. Possible popliteal vein thrombus. Consider ultrasound.
Calf MRI
1. Extensive changes of osteomyelitis involving the proximal
one-third of the tibia as described.
2. An intramedullary abscess penetrates the cortex and extends
into the
anterior tibialis muscle, in total the abscess measures 4.1 x
1.4 x 7 cm.
3. Edema and hyperenhancement of the tibialis anterior and
soleus muscles.
4. Two tubular T1 and T2 hyperintense structures are of unclear
etiology, may represent clot in occluded soleus veins.
Consider an ultrasound study to further evaluate.
## US :
1. Deep vein thrombosis seen within the left popliteal vein and
also within the peroneal and posterior tibial veins of the left
calf.
2. No DVT identified within the right leg.
## KNEE CT :
1. Status post washout for MRSA osteomyelitis with post-surgical
changes at the proximal lateral tibia.
2. Heterogeneous attenuation within the tibialis anterior and
soleus muscles, consistent with edema, better seen on MRI
examination.
3. Filling defect within the popliteal vein consistent with
venous
thrombosis.
Knee CT
1. Persistence of intraosseous abscess with cortical
breakthrough adjacent to a 3.7 x 1.3 cm rim enhancing fluid
collection.
2. Further demineralization of the tibial plateau consistent
with progressive osteomyelitis. 3. Moderate suprapatellar joint
effusion. 4. Thrombus within the left popliteal vein.
CXR s/p PICC line placement
AP radiograph of the chest was reviewed in comparison to .
The left PICC line tip is at the level of cavoatrial junction.
Heart size and mediastinum are unremarkable. Bibasal
interstitial opacities predominantly in the lower lungs are
redemonstrated. No appreciable pleural effusion or pneumothorax
seen.
## BRIEF HOSPITAL COURSE:
with HepC, h/o IVDU, s/p splenectomy from , who presents
from with recent MRSA bactermia and MRSA
septic arthritis which evolved into MRSA osteomyelitis/myositis
and faciitis of the left knee.
## ACTIVE ISSUES:
# MRSA Left knee osteomyelitis/fasciitis - Mr. continued
to have significant fevers on vanc/rifampin, s/p multiple
washouts at OSH. It may have been that he was not adequately
covered or may not have achieved source control. Abx coverage
switched to only vanc on . He has been maintained on
Vancomycin 1g - 1250 g BID daily with trough goal of ,
though aiming for close to 20. He has had intermittent fevers
concerning for poor source control, though on discharge has been
afebrile with the last fever (low grade) on at 11
pm. Blood cultures have been no growth from , and
. Ortho took patient for washout on and repeat I+D
on . He was evaluated by ortho multiple times who
determined that repeat I+D was not necessary. Cultures from the
tissue were negative x4. He had post-operative sutures and
staples in place with a tender area of erythema over the lateral
left knee unchanged in size on discharge since . This
was assessed by orthopedics to be a hematoma, but was
nevertheless drained and gram stain and cultures have been
negative. Sutures and staples removed by orthopedics on
.
- PICC replaced on
- Discharging patient on Vancomycin for a minimum of 6 week
course (Day 1 at OSH was to end on at the
earliest. Patient to follow up with clinic prior to ending
Vancomycin.
- Pain controlled with PO Oxycontin and PO Dilaudid. Tylenol was
avoided to assess if patient was having fevers.
# Recent MRSA bacteremia - During first OSH stay, TTE and TEE
negative for endocarditis. Blood cultures reportedly negative
during more recent admission to OSH, on antibiotics for
osteomyelitis. Repeat blood cultures from , and
were negative. Patient was having intermittent low grade
fevers throughout the hospital stay concerning for poor source
control, though on discharge has been afebrile for several days
with the last fever (low grade) 100.0 on at 11
pm.
# Hepatitis C--Patient denies treatment for hepatitis C in the
past. Denies history of jaundice, encephalopathy or ascites. No
stigmata of cirrhosis on exam. LFTs mildly elevated on
admission, most likely secondary to rifampin use. LFTs
subsequently normalized with discontinuation of Rifampin. Per
OSH Hep C viral load: Quant 869,905 HCV bDNA 5.94. No genotype
available.
- Patient will need outpatient hepatology follow up for further
management
##
# IVDU:
Mainly uses heroin although sometimes cocaine as well.
Active within past months and is likely precipitant for his MRSA
bacteremia. Reports sharing needles and only using water to
clean needles. Has never attempted rehab. HIV test on
negative. SW was consulted and patient expressed desire to go to
rehabilitation for IVDU. Patient expressed sincere desire to
remain sober.
# ARF: Cr elevated to 1.7 per reports at OSH. Repeat Cr here
1.2 on admission. returned to baseline of 1.0-1.2 throughout the
rest of the hospital stay.
## # HTN:
Per patient's chart, he has a history of HTN although
denies knowledge of this diagnosis. Held off on starting any
medication while in-house and patient was normotensive
throughout the hospital stay
## # NEUROPATHY:
Patient's home gabapentin 800 mg TID continued.
## TRANSITIONAL ISSUES:
- Patient will be discharged on Lovenox and Warfarin and will
need daily INR. Can discontinue Lovenox once INR >2.
-Patient will need hepatology follow up to discuss further
management of hepatitis C
-Pt should have follow up with ortho on at 11:40.
-Per ID recs, patient should be on Vancomycin for a minimum of 6
weeks- at least until
-Patient to follow up with ID
-Please obtain vanc troph prior to evening dose on and
adjust for goal of (close to the 20 range).
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Pyridoxine 50 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Vitamin D UNIT PO DAILY
5. Gabapentin 800 mg PO TID
6. Mirtazapine 15 mg PO HS
7. Multivitamins 1 TAB PO DAILY
8. Morphine SR (MS 15 mg PO Q12H
9. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN knee pain
10. Propantheline Bromide 30 mg PO TID
11. Daptomycin 8 mg IV Q24H
12. Ibuprofen 800 mg PO Q8H:PRN pain
13. Naproxen 500 mg PO Q12H
## DISCHARGE MEDICATIONS:
1. Docusate Sodium 100 mg PO BID
2. Gabapentin 800 mg PO TID
3. Mirtazapine 15 mg PO HS
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Vitamin D UNIT PO DAILY
8. Miconazole Powder 2% 1 Appl TP TID Duration: 10 Days
9. Vancomycin 1000 mg IV Q 12H
Plan for at least 6 week course per ID, D1 = through at
least .
10. Warfarin 10 mg PO DAILY16
11. Enoxaparin Sodium 70 mg SC Q12H
Please continue until INR is > 2
12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg one tablet extended release 12
hr(s) by mouth Q 12 hours Disp #*10 Tablet Refills:*0
13. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
14. HYDROmorphone (Dilaudid) mg PO Q6H:PRN pain
RX *hydromorphone 2 mg tablet(s) by mouth every 6 hours Disp
#*24 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 1 TAB PO BID
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were transferred from for an infection in
your left knee. While you were here, we kept you on antibiotics
to help control your infection. The orthopedic surgeons took you
to the operating room to washout your knee on and to
further clean your knee from the source of infection on .
You developed a collection of blood near one of the suture sites
after the procedure, which was drained and has not grown any
bacteria. You have had intermittent fevers during your hospital
stay and we were concerned for poor control of the source of
these fevers. However, your blood cultures, PICC, and tissue
taken from your knee has not grown any bacteria. You have not
had any fevers since pm on and this is reassuring.
We will discharge you to rehabilitation for physical therapy to
increase your strength. We will set up appointments for you to
follow up with the orthopedic and infectious disease teams.
You expressed an interest in going to rehabilitation for your
drug use and we all sincerely hope that you will do this. You
are at high risk of developing a serious infection again and
avoiding intravenous drug use will significantly help to
decrease the chance of a serious infection in the future.
It was a pleasure to take care of you while you were in the
hospital!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18269072", "visit_id": "29609860", "time": "2146-04-02 00:00:00"} |
13219522-DS-20 | 845 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
"I'm pregnant, a dirty nasty whore."
## HISTORY OF PRESENT ILLNESS:
y/o AAF with reported h/o chronic psychotic illness,
extensive history of ER visits and psychiatric hospitalizations
(per ), BIB Police after she presented to their
station apparently looking for a "safe bed" but appearing to be
disorganized and psychotic. Patient also claims she is months
pregnant,
endorses recent illicit substance abuse (urine tox was positive
for cocaine).
On interview, is grossly disorganized, denies delusions, denies
AH/VH and SI/HI. Agrees that she went to station,
approached them to ensure that her baby was safe and confirm the
pregnancy, asking for a shelter. Reports being homeless since
age , spends her days panhandling in . Endorses recent
cocaine use "and partying". Denies current medications. States
she was last well year ago "when I got murdered, my house was
on fire, I died three times over and came back as my mother in
the clouds." Is worried about "the , and out
to murder her. Also concerned that she might be asked to work
for the record company of (the rap artist), who
is "a good friend of mine and of the family." Denies feeling
unsafe/threatened in hsopital, "but I hope I make my life."
Despite disorganization, denies psychotic, manic, anxious or
depressive symptoms. BEST indicates that the pt was recently
hospitalized at (late for a similar presentation.
## PAST MEDICAL HISTORY:
- Reports being "misdiagnosed" with schizophrenia and BPAD
- Multiple med trials, "none of them worked", rattles off a list
including: Luvox, Effexor, Ativan, Seroquel, Depakote, Lithium,
Haldol, Cogentin, Wellbutrin, Abilify, Celexa
- Denies current medications
- Denies suicidality, but "I get crazy when I'm not on
medications"
## PHYSICAL EXAM:
Per ED physician the patient had a clear medical exam. OB
consult showed gravid female with about 8 week IU pregnancy
## APPEARANCE & FACIAL EXPRESSION:
Young AAF, disheveled hair
but wearing appropriate jewelery, under blanket in ED gurney.
Wrist lacerations notable.
## ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE):
Cooperative,
provocative, intrusive.
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC,
## ETC.):
Normal volume, increased rate/rhythm
## MOOD:
"Pretty stable"
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.):
Expansive, full range.
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
## NOTABLE FOR
EVIDENCE OF THOUGHT DISORDER:
loose associations, tangential,
flight of ideas, derailment, neologisms.
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS,
## DELUSIONS, ETC.):
Preoccupied with her pregnancy, 50 cent rap
artist. No evidence of internal stimuli.
## ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS):
Denies
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP,
## ORIENTATION:
x 3
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): DOTWB
## PROVERB INTERPRETATION:
grass is greener = "Wrong
question to ask someone who was mistreated by the government".
## PERTINENT RESULTS:
AVSS
CBC notable for RBC 3.83, HCT 34.8, HGB 11.6
BMP unremarkable
bHCG 112,701
Stox negative
Utox +cocaine
## BRIEF HOSPITAL COURSE:
1) Psychiatric:
The patient was admitted on . She was initially less
disorganized than upon admisison to the ED. She did not endorse
any paranoia however did endorse tactile hallucinations of bugs
crawling on her skin and people throwing bugs on her while
outside the hospital. The patient was able to report that she
feels safe in the hospital and had none of those sensations
while inpatient. However this caused concern for other illicit
substances besides cocaine in her system. The patient was
started on zyprexa 10 mg PO Dialy for psychosis. This was
switched to QHS as patient complained of daytime drowsiness. The
patient showed rapid clearing of her psychosis and was able to
respond linearly by day 3 of her hospital stay. This suggested
that her psychosis was primarily secondary to cocaine use.
2) Psychosocial:
The patient met with SW and elected to return to the
Transitional housing services rather than attempting follow up
with a drug rehabillitation program or out patient psychiatric
services. The patient was unaware of the name of her OB/GYn
provider. An attempt was made to determine the source of OB care
by calling the primary care physician listed on . This
treater had no record of the patient therefore this was
unsuccessful. The patient was provided information for planned
parenthood. An attempt will be made to obtain DMH services for
her.
## 3) LEGAL:
4) Medical:
Apart from patient's pregnancy, no acute medical issues were
appreciated on this admission.
## DISCHARGE MEDICATIONS:
1. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
## AXIS I:
Psychosis not otherwise specified
rule out substance-induced psychosis
rule out post-traumatic stress disorder
## AXIS IV:
severe psychosocial stressors appreciated
## APPEARANCE:
Dressed in pajamas, looks younger than stated age,
NAD
## ATTITUDE:
Cooperative, Good behavioral control
## COGNITION:
alert and fully oriented
## SPEECH:
no aphasia, no dysarthria, staccato sentences, extremely
rapid rate, volume, prosody
## MOOD:
'good' / Affect: more euthymic today
## PROCESS:
linear and goal directed
## SAFETY:
No active SI or HI reported
Abnormal perceptions: none reported no evidence of such in
behavior.
## DISCHARGE INSTRUCTIONS:
Please take your medications as prescribed
Please follow up with your appointments as instructed
Please go to the nearest ED or call if you feel unsafe or
overwhelmed.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13219522", "visit_id": "26231022", "time": "2136-05-09 00:00:00"} |
17339765-RR-115 | 378 | ## INDICATION:
man with biphenotypic leukemia and pleural effusion.
For further evaluation.
## AIRWAYS AND LUNGS:
Airways are patent to subsegment bronchi. Since the largest loculated collection in the right lower lung with enhancing
visceral pleura, concerning for empyema has decreased in size, following
recent thoracocentesis (PER OMR). Few air locules in this collection, which
are new is simply explained by thoracocentesis, but could represent infection.
Adjacent lung consolidation in the right lower lung is consistent with
pneumonia. Since previously most of the right lower lung was passively
collapsed secondary to large loculated effusion, it is difficult to make a
comparison for interval progression of pneumonia. In comparison to , the loculated collection along the right paramediastinal aspect has
increased. For example the maximum width of this collection measuring 2.9 cm
today at the corresponding location previously was 1.4 cm. Overall, the
multiloculated collection on the left side is unchanged in distribution and
extent, except near the left lung apex, where it appears smaller today than it
was previously. Subjected to motion artifacts, assessment of lung parenchyma
for fine details was limited.
## MEDIASTINUM:
Small and borderline sized mediastinal lymph nodes in the upper
and lower paratracheal and precarinal regions are unchanged. For example, a
11 mm precarinal lymph node (2:21) was previously 11 mm (2:23). Heart size is
mildly enlarged and unchanged. There is no pericardial abnormality.
## ABDOMEN:
The study is not designed for assessment of subdiaphragmatic
pathology; however, limited views were remarkable for splenomegaly. Both
adrenal glands are normal. A exophytic hypoattenuating lesion in the left
upper renal pole is measuring 35 x 25 mm is mostly cyst and stable.
## BONES:
There is no bone lesion concerning for malignancy or infection.
## IMPRESSION:
1. Multiloculated, bilateral, pleural effusion, with the largest individual
collection in the right lower lung with enhancing visceral pleura which is
concerning for empyema. This largest collection has decreased in size since
and may be related to prior thoracocentesis (PER OMR). Second
largest loculated collection on right side along the paramediastinal aspect
has increased, while on the left side is overall unchanged, except in the left
lung apex where it shows minimal interval decrease.
2. Right lower lung pneumonia.
3. Borderline sized and other smaller mediastinal lymph nodes, unchanged
since .
4. Splenomegaly
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17339765", "visit_id": "20517149", "time": "2143-11-20 16:46:00"} |
17342204-RR-26 | 542 | ## DISCUSSED TODAY WITH :
y/o M with PMH of
HTN, HLD, pancreatitis, recent diagnosis of unresectable hilar
cholangiocarcinoma, prior ERCP and for sphincterotomy and
plastic stent, now with obstructive jaundice in the setting of increased tumor
burden, s/p ERCP : ERCP was notable for removal of bilateral plastic
stents and placement of a metal stent into the left side. ERCP was notable for
fluid drainage from the right side, which they were able to cannulate, but
unable to pass a stent. Since procedure, pt.s bilirubin remains elevated, he
is clinically stable,
## PROCEDURE:
1. Transabdominal ultrasound.
2. Ultrasound guided right percutaneous transhepatic bile duct access.
3. Right cholangiogram
4. right biliary drain.
## PROCEDURE DETAILS:
Following the discussion of the risks, benefits, and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per protocol. The right abdomen
was prepped and draped in the usual sterile fashion.
Under ultrasound fluoroscopic guidance, a micropuncture needle was advanced
through the right lower abdominal wall into a pocket of ascites. The
micropuncture needle was exchanged for the sheath and the wire was
advanced into the right upper quadrant of the abdomen. The sheath was removed
and a Omni Flush catheter was advanced under fluoroscopic guidance. This
catheter was attached to external drainage and 3 L of clear ascites were
drained.
Under Ultrasound guidance, a 21G Cook needle was advanced into leftbiliary
system. Images of the access were stored on PACS. Once return of bilious fluid
was identified, a wire was advanced under fluoroscopic guidance into the
proximal left bile duct. A skin was made over the needle and the needle
was removed over the wire. An Accustick set was advanced over the wire and the
inner stiffener was withdrawn. A contrast injection was performed to confirm
biliary anatomy. The wire was exchanged for a Glidewire which was placed into
the common bile duct using a Kumpe catheter.A sheath was advanced over the
wire into the biliary system. Attempts to cross into the small bowel
alongside the previously placed metal stent were unsuccessful. The glidewire
was exchanged for wire. A 10 anchor drain with additional
sideholes was advanced over the wire into the left biliary system. Contrast
injection confirmed appropriate position. The catheter was flushed with
saline, secured with stay sutures to the skin and sterile dressings were
applied. The catheter was attached to a bag.
The paracentesis catheter was removed and fluoroscopic guidance and sterile
dressings were applied.
The patient tolerated the procedure well. There were no immediate
complications.
## FINDINGS:
Initial fluoroscopic image of the abdomen demonstrates the presence of
previously placed metal stent into the right posterior biliary system.
Cholangiogram demonstrates intrahepatic dilatation of the left biliary system.
The left biliary system communicates with the metal stent and there is free
passage of contrast through the stent into the small bowel.
External percutaneous biliary drain in the left biliary system in good
position.
## IMPRESSION:
Uncomplicated placement of a external cutaneous biliary drain through the left
biliary system. The catheter is attached to a bag for external drainage.
3 L of clear ascites were drained throughout the procedure.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17342204", "visit_id": "28760030", "time": "2122-11-19 13:08:00"} |
18521744-RR-21 | 101 | ## EXAM:
CT of the head.
## CLINICAL INFORMATION:
Patient with left MCA infarct.
## FINDINGS:
Since the previous study, there has been further evolution of the
left MCA territory infarct. There remains hyperdense left middle cerebral
artery as visualized previously. There is no hemorrhage seen. Mild mass
effect on the left lateral ventricle seen. There is no uncal herniation. No
new hypodensity is seen. Mild brain atrophy is identified.
## IMPRESSION:
Further evolution of left middle cerebral artery infarct with
minimal increased mass effect and edema and secondary indentation on the left
lateral ventricle. No hemorrhage. Persistent hyperdense left middle cerebral
artery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18521744", "visit_id": "24097294", "time": "2136-09-23 13:00:00"} |
13241762-RR-16 | 240 | ## EXAM:
MRI of the brain.
## CLINICAL INFORMATION:
Patient with left cerebellar mass for further
evaluation.
## FINDINGS:
There is a left cerebellar mass identified with focal areas of low
signal on gradient echo images with mass effect on the left side of the
lateral ventricle. The mass measures approximately 4 cm. An additional mass
is identified in the right cerebellar hemisphere measuring approximately 1 cm.
Additional low-signal gradient echo abnormality measuring 2 cm is seen in the
left parietal convexity region. This mass could be in extra-axial location
and is incompletely evaluated.
There is moderate ventriculomegaly seen with prominence of temporal horns
which could be due to combination of obstructive hydrocephalus from deformity
of the fourth ventricle and cerebral atrophy. Diffuse periventricular
hyperintensities are seen on FLAIR images which are incompletely evaluated and
could be secondary to small vessel disease and/or subependymal CSF flow.
## IMPRESSION:
1. 4 cm left cerebellar and 1 cm right cerebellar masses which are partially
calcified on CT images. This could be secondary to metastasis such as a
colloid carcinoma of colon or due to hemangioblastoma as clinically suspected.
2. Left parietal extra-axial appearing mass is incompletely evaluated and
could be due to an additional metastasis in the cortical surface or due to a
meningioma. Further evaluation with repeat gadolinium-enhanced study is
recommended. The gadolinium-enhanced study could not be obtained during this
examination as patient was unable to continue.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13241762", "visit_id": "29090401", "time": "2161-10-11 04:04:00"} |
12554828-DS-5 | 1,235 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Mitral Valve Replacement( 27 mm porcine)/
Coronary Artery Bypass Graft x 3 (Left internal mammary artery
to Left Anterior Descending artery, Saphenous Vein Graft to
Diagonal, Saphenous Vein Graft to Posterior Descending Artery)
## HISTORY OF PRESENT ILLNESS:
yo male with history of MR/AS and possible childhood
rheumatic fever. Serial echos show worsening MR with moderate
MS, and increasing pulm. pressures. now notices DOE. Seen
originally earlier this month for surgical eval.
## PAST MEDICAL HISTORY:
coronary artery disease
mitral regurgitation/ stenosis
hypertension
? rheumatic heart disease
hyperlipidemia
osteoarthritis in hips
mild chronic obstructive pulmonary disease
obesity
amaurosis fugax
prostate cancer/radiation therapy
non-insulin dependent diabetes mellitus
cataracts
spinal stenosis
constipation
vertigo
## FAMILY HISTORY:
father died of MI at ; mother died of heart disease at
## PHYSICAL EXAM:
70" 190#
HR 72 reg right 125/71 left 123/82 99% RA sat.
NAD
skin unremarkable
PERRLA, EOMI, anicteric sclera, OP unremarkable
neck supple, full ROM, no JVD
murmur transmits to carotids
CTAB
RRR systolic murmur throughout precordium to carotids
soft, NT, ND, + BS; no HSM/CVA tenderness
warm, well-perfused, no edema
right leg superficial varicosities with dilated GSV; RLE GSV
suitable
gait slow, and somewhat unsteady; MAE strengths
2+ bil.
## ECHO:
PRE BYPASS The left atrium is markedly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
The fright ventricle is only very poorly seen. The mid free wall
of the right ventricle appears to function well. The ascending
aorta is mildly dilated. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets are moderately thickened. There
is no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are severely thickened/deformed. There
is severe mitral annular calcification. There is moderate
valvular mitral stenosis (area 1.5cm2). The mitral regurgitation
vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is
seen. Significant pulmonic regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Dr. was
notified in person of the results in the operating room at the
time of the study. POST BYPASS: The right ventricle is poorly
seen but the mid portion of the free wall appears to function
normally. The left ventricle displays normal systolic function.
There is a bioprosthesis in the mitral position that appears
well seated. The leaflets appear to function normally. There is
no obvious mitral regurgitation seen. The maximum gradient
across the mitral valve prosthesis is about 11 mm Hg with a mean
gradient of 4 mm Hg at a cardiac output of about 4.2 liters per
minute. The thoracic aorta appears intact.
## HEAD CT:
Normal CTA of the head with no evidence of
infarction on CT.
Carotid U/S: Scattered calcific plaque involving both
carotid systems, no significant ICA or CCA stenosis, however.
M
3:10
CHEST (PA & LAT) Clip #
Final Report
TWO VIEW CHEST, .
## INDICATION:
Status post coronary artery bypass surgery.
Stable postoperative widening of the cardiomediastinal contours.
No
substantial pneumothorax.
## FINDINGS:
Improving bibasilar atelectasis and small bilateral
pleural
effusions. Retrosternal gas in the lateral projection may be a
normal
postoperative finding, but correlation with clinical findings is
suggested to exclude the possibility of mediastinal infection.
Dilated loops of gas-filled bowel in upper abdomen are
incompletely evaluated on this chest radiograph exam.
.
## BRIEF HOSPITAL COURSE:
Mr. was a same day admit after undergoing pre-op
work-up prior to admission. On was brought to the
operating room where underwent a coronary artery bypass graft
x 3 and mitral valve replacement. His bypass time was 150
minutes with a crossclamp time of 129 minutes. Please see
operative report for surgical details. Following surgery was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one was
noted to have word finding difficulties and neurology was
consulted and was brought for a head CT. Was ruled out for a
stroke but neurology felt it was possibly TIA do to
hypoperfusion. His symptoms of word finding difficulties
eventually resolved. remained in the CVICU for another day
for observation and on post-op day two was transferred to the
telemetry floor for further care. was started on Bblockers
and diuretics, his chest tubes and epicardial pacing wires were
removed per protocol. Over the next several days his activity
level was advanced with the assistance of nursing and physical
therapy. was noted to have post-op atrial fibrillation that
was treated with Amiodarone and Bblockers and subsequently
converted to sinus rhythm. The remainder of his post operative
course as uneventful. On POD 7 was discharged home with
visiting nurses. is to return to wound clinic in 2 weeks and
to see Dr in 4 weeks.
## MEDICATIONS ON ADMISSION:
allopurinol mg daily, metformin 500 mg BID, atenolol 25 mg
daily, lisinopril 40 mg daily, amlodipine 5 mg daily, crestor 40
mg daily, ASA 81 mg ( stopped last week on his own), naproxen
500 mg prn pain, viagra 50-75 mg prn, MVI daily, polyethylene
glycol 1 oz. daily
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
## 4. ALLOPURINOL MG TABLET SIG:
One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg QD x 7 days then 200mg QD.
Disp:*60 Tablet(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
## DISCHARGE DIAGNOSIS:
S/P coronary artery bypass graft x3/mitral valve repair
## PMH:
coronary artery disease
mitral regurgitation/ stenosis
hypertension
? rheumatic heart disease
hyperlipidemia
osteoarthritis in hips
mild chronic obstructive pulmonary disease
obesity
amaurosis fugax
prostate cancer/radiation therapy
non-insulin dependent diabetes mellitus
cataracts
spinal stenosis
constipation
vertigo
## DISCHARGE INSTRUCTIONS:
no driving for one month
no lifting greater than 10 pounds for 10 weeks
no lotions, creams or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage, weight
gain of 2 pounds in 2 days or 5 pounds in 1 week
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12554828", "visit_id": "24302523", "time": "2133-03-22 00:00:00"} |
15562436-RR-92 | 232 | ## INDICATION:
female with right upper quadrant pain, positive
sign and elevated bilirubin.
## LIVER/GALLBLADDER ULTRASOUND:
The gallbladder is neither distended nor
relaxed. Layering sludge and several small shadowing stones are seen within
the gallbladder lumen. The gallbladder wall measures 2.6 mm and is not
thickened. There is a small amount of pericholecystic fluid. The common bile
duct measures 6 mm. No sonographic sign is demonstrated. Numerous
thin- walled cysts are seen within the hepatic parenchyma. A cyst in the liver
dome measures 2.6 x 2.2 x 2.5 cm. A 1.9 x 1.7 x 2.1 cm cyst with a single
internal septation is seen within the left lobe, stable in appearance from the
prior study. A 1-cm cyst slightly inferior also appears unchanged. There is
no intrahepatic biliary ductal dilatation. The pancreas appears unremarkable.
There is no ascites in the abdomen. The main portal vein is patent with
pulsatile flow. Neither kidney demonstrates evidence for hydronephrosis. A
thin-walled 2.4-cm cyst is seen in the mid right kidney.
## IMPRESSION:
1. Cholelithiasis and a small amount of pericholecystic fluid without
other evidence of acute cholecystitis. If clinical concern persists, HIDA scan
can be obtained for further evaluation.
2. Numerous thin-walled hepatic cysts, some containing single septations,
stable from the prior study.
3. 2.5-cm simple cyst in the right kidney.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15562436", "visit_id": "N/A", "time": "2167-01-19 08:00:00"} |
13191315-RR-13 | 204 | ## INDICATION:
Right jaw pain status post fall from a horse. Cannot open the
jaw more than 1.5 cm.
## FINDINGS:
There is no evidence of a mandibular fracture. The temporomandibular joints
are normally aligned.
There is evidence of a comminuted right temporal bone fracture, anterior to
the mastoid portion of the temporal bone, status post surgical fixation.
Slightly depressed fracture fragments are unchanged. Gas is again seen in the
overlying soft tissues.
The previously described fracture of the right sphenoid sinus floor, which
extends into the right carotid canal, is unchanged. Fracture fragments are
again seen within the right sphenoid sinus, which is filled with blood and
contains a focus of gas.
There is new mild mucosal thickening in the right middle and posterior, and in
the left posterior ethmoid air cells. There is unchanged mild mucosal
thickening in the anterior left sphenoid sinus. The frontal and maxillary
sinuses are normally aerated. The orbits appear unremarkable.
## IMPRESSION:
1. No evidence of mandibular fracture. Normal alignment of the
temporomandibular joints.
2. Fracture of the right temporal bone status post surgical fixation, with
depressed fracture fragments, as before.
3. Unchanged fracture of the right sphenoid sinus floor, which extends into
the right carotid canal.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13191315", "visit_id": "29718774", "time": "2133-03-20 10:45:00"} |
11731363-RR-17 | 59 | ## HISTORY:
Recent procedure for perforated diverticulitis with
extensive intrapelvic abscess formation with persistent leukocytosis and
rim-enhancing fluid collection, presents for CT-guided abscess drainage.
## IMPRESSION:
Successful 8 pigtail catheter placement into persistent pelvic abscess
using left transgluteal approach.
The findings were discussed with covering resident in the surgical ICU for
placement of post-procedural drain orders.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11731363", "visit_id": "24706741", "time": "2162-01-19 11:33:00"} |
12191398-RR-3 | 342 | ## EXAMINATION:
CT L-SPINE W/O CONTRAST Q331 CT SPINE.
## INDICATION:
year old man with metastatic prostate cancer // Bony lesions?
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 3.9 s, 30.9 cm; CTDIvol = 27.2 mGy (Body) DLP = 839.3
mGy-cm.
Total DLP (Body) = 839 mGy-cm.
## FINDINGS:
No lumbar spine malalignment. Multilevel degenerative changes are again
demonstrated and unchanged from the prior MRI. Height loss with superior and
inferior endplate Schmorl's nodes is again noted at L2 with adjacent soft
tissue findings better characterized on the recent MRI. Redemonstration of a
lytic and sclerotic lesion within the T11 vertebral body better characterized
on the prior MRI and same day thoracic spine CT. Again seen is a 7 mm L1
vertebral body sclerotic focus (series 2, image 25). There is sclerosis along
the posterolateral right L2 vertebral body extending into the lamina and
involving the right pedicle. There is soft tissue again demonstrated at the
L1/L2 and L2/L3 neural foramina, which is better characterized on the recent
MRI in extent but does extend to the central canal (series 301, image 41).
The soft tissue involves the superior insertion of the psoas muscle.
Sclerosis at L5/S1 posteriorly is associated with subcortical cystic change in
is most likely degenerative.
Partial visualization of an infrarenal IVC filter. Again seen is a large left
renal simple cyst. Partial visualization of common biliary ductal dilatation
to 9 mm.
There are degenerative changes at the bilateral sacroiliac joints. Focal and
asymmetric sclerosis is noted at the left relative to the right however soft
tissue and marrow are better characterized on the recent MRI.
## IMPRESSION:
1. Redemonstration of multiple osseous lesions concerning for metastases
within T11, L1 and L2 as well as soft tissue changes at the L1/L2 and L2/L3
right-sided neural foramina, which are better characterized on the recent MRI
and are described above.
2. Common biliary ductal dilatation to 9 mm of unclear etiology. If deemed
clinically appropriate, a nonurgent MRCP could be performed for further
evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12191398", "visit_id": "25776232", "time": "2116-10-14 09:49:00"} |
14386841-RR-25 | 177 | ## EXAMINATION:
MRI OF THE LUMBAR SPINE
## INDICATION:
Bilateral L5 had surgery in in has 2 laterally placed
scars ??Had surgery in in - has 2 laterally placed scars?? // ?
cauda
## FINDINGS:
There is mild scoliosis of lumbar spine. From T11-L1 through L5-S1 level disk
degenerative changes identified with mild bulging. There is no spinal stenosis
seen. Mild right-sided foraminal narrowing is identified and L3-4 and L4-5
levels and moderate to severe left foraminal narrowing is seen at L4-5 level.
The spinal canal remain patent. There is no definite laminectomy identified. A
small linear scar is identified at L4-5 level on the subcutaneous fat without
extension to the deeper tissues.
The distal spinal cord and paraspinal soft tissues are unremarkable.
## IMPRESSION:
Mild scoliosis of lumbar spine and multilevel degenerative changes without
spinal stenosis. Moderate to severe left foraminal narrowing with deformity of
the exiting left L4 nerve root is seen at L4-5 level. No central canal
stenosis is seen. No focal disk herniation is identified. No signs of
laminectomy seen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14386841", "visit_id": "N/A", "time": "2155-04-10 11:08:00"} |
13611758-RR-62 | 274 | ## INDICATION:
year old woman with known AVM> // Please evaluate AVM post
op. *Dr. Please start around 10am, post op angio.
## OPERATORS:
Dr. MD, attending neurosurgeon performed the
procedure. Dr. MD personally supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
## ANESTHESIA:
General anesthetic was administered via the anesthetic team
The patient was transferred from the operating suite to the angio suite and
placed on the angio table. The groins were prepped and draped bilaterally in
a sterile fashion and a team time-out was performed. The right common femoral
artery was accessed under ultrasound guidance in a single pass utilizing
Seldinger technique and a micropuncture kit. A barium stay in 2 diagnostic
catheter was used to access the left common carotid artery. The left internal
carotid artery was then entered under roadmap guidance. AP, lateral and
oblique views were then obtained. At the conclusion of the procedure the
diagnostic catheter was removed. A right common femoral arteriogram was then
performed. The right common femoral puncture site was then closed with a
Angio-Seal.
## DEVICES:
Berenstein 2, 0.038 hydrophilic while
## PROCEDURE:
1. Left internal carotid angiogram
## LEFT COMMON CAROTID:
The left common carotid bifurcation show some mild
atherosclerotic disease without any stenosis. The internal carotid artery
reveal no atherosclerosis or stenosis. The middle cerebral artery and
anterior cerebral arteries were well visualized. The onyx material from
previous embolization treatment could be identified. The previous
arteriovenous malformation feeders arising from the left anterior cerebral
artery were obliterated. No AVM filling could be detected.
## IMPRESSION:
Complete obliteration of the left frontal arteriovenous malformation
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13611758", "visit_id": "21416367", "time": "2151-07-28 09:33:00"} |
12658056-RR-84 | 298 | ## EXAMINATION:
MRI OF THE LUMBAR SPINE
## INDICATION:
year old woman with ongoing low back pain in upper lumbar
spine with mild weakness on the right and uncoordinated gait. Prior L4/L5
laminectomy and fusion in // Please evaluate for central canal stenosis,
neural foraminal stenosis or disc herniations. Known surgical history.
## FINDINGS:
From T10-T11 to T12-L1 disc degenerative changes are seen without significant
bulging.
At L1-2 level, disc bulging and mild retrolisthesis seen with mild narrowing
of the spinal canal unchanged from the prior study. There is progression of
endplate degenerative changes at this level.
At L2-3 level, disc and facet degenerative changes are identified. There is
moderate-to-severe spinal stenosis seen progressed from the previous MRI
study. There is moderate to severe bilateral foraminal narrowing seen also
progressed from the previous study.
At L3-4 mild degenerative disc disease seen.
At L4-5 level, the patient has undergone spinal fusion with pedicle screws.
There is laminectomy. There is no recurrent spinal stenosis. There is no
evidence of high-grade foraminal narrowing.
At L5-S1 level, degenerative disc disease and mild bulging seen with mild
narrowing of the foramina.
The distal spinal cord shows normal signal intensities. Disc bulging contacts
the conus at L2-3 level but no increased signal is identified. Paraspinal
soft tissues are unremarkable. No abnormal enhancement is seen. A simple
appearing cyst is seen in the left kidney.
## IMPRESSION:
1. Progression of degenerative changes and spinal canal stenosis at L2-3 level
where there is moderate-to-severe spinal stenosis and bilateral foraminal
narrowing identified increased from the previous MRI study.
2. Multilevel degenerative changes are identified at other levels including
spinal fusion with stable appearances except for progression of endplate
degenerative changes at L1-2 level.
3.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12658056", "visit_id": "N/A", "time": "2162-05-21 12:54:00"} |
15906911-RR-27 | 95 | LEFT KNEE, TWO VIEWS
## INDICATION:
Left patellar fracture, assess fracture.
## FINDINGS:
There is a transversely orientated fracture through the left patella. The
fracture is transfixed by two lag screws and cerclage wires. The fragments
are in near anatomic alignment. There is no evidence of hardware
complication. The fracture line remains clearly visible without obvious
bridging callus. The distal femur, proximal tibia and proximal fibula appear
normal. Mild anterior soft tissue thickening compatible with recent surgery
is seen in addition anterior skin staples.
## IMPRESSION:
Patellar fracture with hardware in situ. No evidence of hardware
complication.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15906911", "visit_id": "N/A", "time": "2159-05-25 11:04:00"} |
14624686-RR-8 | 288 | ## INDICATION:
male with question of CVA, evaluate for stroke.
## NON-CONTRAST HEAD CT:
Again seen is the hypodense region in the right pons
from prior infarct. There is no evidence of hemorrhage, edema, mass, or mass
effect. No definite evidence of acute infarction is seen. The ventricles and
sulci are normal in size and configuration. The basal cisterns are patent.
Visualized paranasal sinuses and mastoid air cells are well aerated. There is
bilateral maxillary sinus and ethmoid air cell mild mucosal thickening.
## CTA OF THE HEAD:
There is a new occlusion of the V3 and V4 segments of the
left vertebral artery compared with CTA on . There are no
other areas of occlusion identified. Again seen is calcified and
non-calcified plaque in the cavernous portions of bilateral carotid arteries,
more severe on the right, with mild-to-moderate narrowing. Again seen is
irregularity in the middle cerebral arteries bilaterally with multiple
moderately narrowed segments. There is no aneurysm greater than 3 mm
visualized. The V4 segment of the right vertebral artery is hypoplastic.
Multiple short segments of the basilar artery are again moderately narrowed
secondary to atherosclerotic plaques. There is no evidence of occlusion
within the basilar artery.
## IMPRESSION:
1. New occlusion of the V3 and V4 segments of the left vertebral artery
compared with CTA on .
2. Unchanged atherosclerotic disease of the basilar artery with several short
moderately narrowed segments.
3. Unchanged moderate narrowing in the middle cerebral arteries bilaterally.
4. Unchanged hard and soft plaques in the cavernous portions of the bilateral
cavernous carotid arteries with mild-to-moderate narrowing on the right.
5. No evidence of aneurysm.
These findings were discussed with Dr. at 3 o'clock p.m. on by telephone.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14624686", "visit_id": "23740259", "time": "2186-05-20 13:31:00"} |
14786014-RR-44 | 120 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
with slurred speech for past month worse within the past
week. Evaluate for for stroke.
## FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. Prominence of
ventricles and sulci is indicative of mild age related cortical atrophy.
Periventricular and subcortical white matter hypodensities are nonspecific but
likely represent sequelae of chronic small vessel ischemic disease.
There is no evidence of fracture. There is a mucous retention cyst in the
right sphenoid sinus. There is mild mucosal thickening of the right ethmoid
air cells. The mastoid air cells and middle ear cavities appear clear. The
visualized portion of the orbits are unremarkable.
## IMPRESSION:
No acute intracranial process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14786014", "visit_id": "N/A", "time": "2133-08-24 12:44:00"} |
15235072-DS-17 | 2,274 | ## ALLERGIES:
itraconazole / azithromycin / lisinopril
## CHIEF COMPLAINT:
Urinary Retention, Fecal Incontinence
## HISTORY OF PRESENT ILLNESS:
Mr. is a male with bladder cancer and
metastatic lung cancer to the spine s/p chemoradiation who
presents with acute onset urinary retention, fecal incontinence.
Patient recently completed course of radiation to T5-T6 for the
intramedullary mass. On , he received his first CyberKnife
treatment to progressive disease involving the T2-T3 neural
foramen. On he then developed acute onset of urinary
retention and fecal incontinence. He notess right lower
extremity paresthesias that radiates up into his
groin which has been going on for several weeks. He denies any
weakness. He denies trauma.
He initially presented to . A foley was
placed
and 1L of urine was immediately drained. An MRI of the whole
spine was obtained. He was transferred to for further
evaluation.
On arrival to the ED, initial vitals were 97.0 61 97/52 16 96%
RA. Exam was notable for intact strength/sensation but absent
rectal tone. Labs were notable for WBC 3.5, H/H 10.8/33.6, Plt
76, INR 1.0, Na 142, K 4.9, BUN/Cr 48/1.3, and UA negative. CXR
did not show acute process. MRI L-spine was negative for cord
compression. Spine and Neurosurgery were consulted and
recommended no surgical intervention. Patient was given 4mg PO
ativan. Prior to transfer vitals were 98.3 59 121/58 16 97% 2L.
On arrival to the floor, patient reports
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
## PAST ONCOLOGIC HISTORY:
Mr. is a year old man with a history of bladder
cancer,
who was originally diagnosed with lung cancer in after
presenting with cough and shortness of breath. In
the patient noted a persistent cough and shortness of breath at
which time a chest x-ray revealed a right upper lobe lung
nodule.
A chest CT revealed 2 right lung masses (1.7 cm RUL &
4.8
cm RLL). A PET CT ( ) revealed the 2 right lung masses were
intensely FDG avid no evidence of metastatic disease. He was
seen
by Dr. at in and underwent a
mediastinoscopy with negative lymph nodes. He then underwent a
right thoracotomy with an extrapleural lower lobectomy and
limited right upper lobe mass resection as well as mediastinal
lymph node dissection ( ). Both lung nodules revealed
squamous cell carcinoma. Lymph nodes were again negative. He was
staged as pT4N0.
A follow-up CT scan revealed no evidence of recurrent
disease, however CT scan revealed a new soft tissue
mass
in the right upper posterior mediastinum measuring 3.4 x 2.2 cm,
with evidence of erosion of the right rib medially. FDG-PET/CT
scan ( ) revealed an avid right apical mass abutting the
thoracic spine associated with erosion of the posterior second
and third ribs. There was no avid lymph nodes or other
metastases
noted. He was evaluated by Dr. , there was no
role for surgical resection. An MRI of the upper spine
( ) revealed a 3.3 x 2.4 x 4.0 cm superior medial right
lung mass extending into the right T2-T3 foramen, posterior
medial right second and third ribs, and was associated with loss
of sharp cortical margin of the right lateral T2 vertebral body.
A CT-guided biopsy of the right lung mass ( ) revealed
necrotic carcinoma, felt to be either metastatic urothelial
carcinoma or possible squamous cell of the lung.
A cystoscopy ( ) revealed no evidence of cancer within the
bladder. As such it was felt this was likely lung cancer. He was
treated with concurrent chemoradiation from to
(60 Gy/30fx + weekly . He was re-evaluate
by thoracic surgery and still felt not to be a surgical
candidate.
Follow-up imaging PET/CT) revealed improvement of
the
disease. An MRI of the spine revealed overall stable
size of the mass. A PET/CT again revealed overall
stable disease and he chose to forgo an MRI as he was feeling
quite well.
In mid/late he developed pins/needle sensation down
his right leg. He ultimately had a head MR as well as a cervical
and thoracic MR . The spine MR showed increase in the
size of the paraspinal tumor at the level of T2 as well as a new
intramedullary mass at T5-T6. He was started on dexamethasone
, but did not feel a difference in his symptoms.
He is currently undergoing a course of palliative radiation to
T5-T6 for the intramedullary mass. He is receiving 10 fractions.
============================
## ============================
- :
Cough & SOB
- : CXR: 2 RUL lung nodules
- : CT Chest: 2 R lung masses (1.7 cm RUL & 4.8 cm RLL)
- : PET/CT: 2 R lung masses intensely FDG avid, no mets
- : Mediastinoscopy (Dr. ): negative LNs
- : Right thoracotomy w/ extrapleural RLL lobectomy,
limited RUL mass resection, mediastinal LND --> pathology: both
lung nodules: SCC; NL negative. (Stage pT4N0).
- : CT Chest: no evidence recurrence disease
- : CT chest: soft tissue mass in RUL post
mediastinum(3.4 x 2.2 cm), w/ erosion of R rib medially.
- : FDG-PET/CT: Avid right apical mass abutting the
thoracic spine associated with erosion of the posterior second
and third ribs. No LN or mets
- : MR Spine: 3.3 x 2.4 x 4.0 cm superior medial R lung
mass extending into R T2-T3 foramen, posterior medial R &
3rd
ribs, & assoc w/ loss of sharp cortical margin of R lat T2
vertebral body.
- : CT guided biopsy --> necrotic carcinoma, felt to be
either metastatic urothelial carcinoma or possible squamous cell
of the lung (after neg cystoscopy, below, felt to be lung)
- : Cystoscopy: no evidence disease
- - : Concurrent chemoRT (60 Gy/30fx + weekly
- : FDG-PET/CT: improvement of the disease.
- : MR spine; stable size of the mass
- : FDG-PET/CT: overall stable disease
- : pins/needle sensation down his right leg
- : MR head: negative
- : MR spine: increased size of paraspinal tumor at T2,
& new intramedullary mass at T5-T6
- : Started dex
- : Started pall RT to T5-T6 (Dr.
## PAST MEDICAL HISTORY:
- Bladder Cancer
- Lung Cancer
- Hypertension
- Hyperlipidemia
- COPD
- CKD
- PMR
- Paroxysmal Atrial Fibrillation
- Hyperparathyroidism
- Skin Cancers
- Gout
- s/p cataract surgery
- s/p tonsillectomy
- s/p lumbar laminectomy
- s/p hernia repair
- s/p Dupuytren's contracture release surgery
## FAMILY HISTORY:
No family history of malignancy.
## GENERAL:
Pleasant man, in no distress, lying in bed comfortably.
## HEENT:
Anicteric, PERLL, OP clear.
## CARDIAC:
RRR, normal s1/s2, no m/r/g.
## LUNG:
Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
## ABD:
Soft, non-tender, non-distended, normal bowel sounds
## EXT:
Warm, well perfused, no lower extremity edema, erythema or
tenderness.
## NEURO:
A&Ox3, good attention and linear thought, strength in
lower extremities bilaterally at the hip with flexion, ankles
flexors with strength bilaterally
## CARDIAC:
RRR, normal s1/s2, no m/r/g.
## LUNG:
clear to auscultation bilaterally, no crackles, wheezes,
or
rhonchi.
## ABD:
Soft, non-tender, non-distended, normal bowel sounds
## EXT:
Warm, well perfused, slight pitting edema in b/l lower
extremities.
## NEURO:
A&Ox3, strength LUE, 4+/5 strength right shoulder
abduction; 4+ to strength left hip flexor, strength
right
hip flexor.
## SKIN:
hematoma over left thigh, soft, nontender
## PERTINENT RESULTS:
ADMISSION
09:30PM BLOOD WBC-3.5* RBC-3.40* Hgb-10.8* Hct-33.6*
MCV-99* MCH-31.8 MCHC-32.1 RDW-15.5 RDWSD-54.9* Plt Ct-76*
09:30PM BLOOD Neuts-82.6* Lymphs-7.1* Monos-5.4
Eos-0.3* Baso-0.3 Im AbsNeut-2.91 AbsLymp-0.25*
AbsMono-0.19* AbsEos-0.01* AbsBaso-0.01
09:30PM BLOOD PTT-22.6*
09:30PM BLOOD Glucose-114* UreaN-48* Creat-1.3* Na-142
K-4.9 Cl-108 HCO3-22 AnGap-12
06:53AM BLOOD ALT-33 AST-20 AlkPhos-53 TotBili-0.6
09:30PM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
REPORTS
L-SPINE W & W/O CONT
1. No evidence for osseous, epidural, or intrathecal metastatic
disease in the
lumbar spine.
2. Multilevel lumbar degenerative disease. Moderate narrowing
of the thecal
sac with only minimal intrathecal nerve root crowding at L4-L5.
Mild
narrowing of the thecal sac at L3-L4 and L2-L3 without mass
effect on the
intrathecal nerve roots.
3. Status post left L5 laminotomy. Enhancing granulation tissue
in the left
anterior/lateral epidural space at L5-S1, encasing the
traversing left S1
nerve root, without significant mass effect on the thecal sac.
4. Degenerative disease causes mass effect on multiple
traversing and exiting
nerve roots in the narrowed subarticular zones and neural
foramina, as
detailed above.
## NOTIFICATION:
Electronic preliminary report by Dr.
was
provided at 23:55 on :
Cord or cauda equina compression: no
Cord signal abnormality: no
Epidural collection: no
## BRIEF HOSPITAL COURSE:
Mr. is a male with bladder cancer and
metastatic lung cancer to the spine s/p chemoradiation who
presents with acute onset urinary retention, fecal incontinence
after receiving spinal radiation therapy on .
TRANSITIONAL ISSUES
===================
[] decreased home metoprolol from 50mg daily of succinate to
12.5mg tartrate BID given his soft blood pressure, rates were
controlled. Please convert to 25mg succinate and follow up heart
rates
[] TTE demonstrated grade 1 diastolic dysfunction, euvolemic on
exam on day of discharge, may need diuresis started as an
outpatient
[] Patient discharged with a foley catheter. Please exchange the
catheter once per week. Will continue with Foley until further
instructed by radiation oncology or is able to void after a
voiding trial.
[] Patient discharged on prolonged steroid course. Please ensure
appropriate prophylaxis (Vitamin D, Calcium, PPI, Bactrim for
PJP prevention).
[] Please obtain outpatient echocardiogram to evaluate for
potential causes of hypotension (valvular pathology or
pericardial effusion)
[] Discharged on dexamethasone 4mg Q6H. Taper to be decided by
radiation oncology in coordination with primary oncologist Dr.
at .
## ACUTE ISSUES:
=============
# Urinary Retention:
# Fecal Incontinence:
# Spinal edema:
Possibly due to inflammation/swelling from recent radiation
treatment. Also on differential included leptomeningeal
carcinomatosis. No evidence of cord compression or cauda equina
compression on imaging. No plan for surgery per ortho spine and
neurosurgery consults. Completed 5 fractions of XRT to spine.
Increased dexamethasone to 4mg q6h and continued on this dose
upon discharge (subsequent taper to be decided by radiation
oncology). Started on PPI and Bactrim ppx prior to discharge.
Had neurochecks Q8 hours while inpatient. Failed 2 voiding
trials while inpatient. Discharged with foley catheter given his
ongoing urinary retention which is most likely due to neurologic
dysfunction.
# Intermittent Hypotension:
Patient with baseline SBP , per patient has always had
low BPs. Noted to have SBP as low as 80, but asymptomatic. No
evidence of infection. Possibly neurogenic given intramedullary
and paraspinal metastases with radiation therapy. Decreased
metoprolol to 12.5 mg BID. Monitored on tele with no events.
# Left Lower Extremity Hematoma:
Patient with signs of ecchymosis and discoloration of lower
extremity. Overlying skin is not tense, tender and pulses
intact.
## CHRONIC ISSUES:
===============
# Lung Cancer:
He is s/p chemoradation however now with pression of paraspinal
tumor at T2 and new intramedullary mass at T5-T6.
# Paroxysmal Atrial Fibrillation:
Continued home apixaban. Metoprolol decreased to BID (as above).
# COPD:
Continued home inhalers.
# Hyperlipidemia:
Continued home statin.
## :
sister
Phone number:
on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation BID
4. Dexamethasone 3 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Tiotropium Bromide 1 CAP IH DAILY
7. Omeprazole 20 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
## DISCHARGE MEDICATIONS:
1. Calcium Carbonate 500 mg PO DAILY
2. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK ( )
3. Vitamin D 800 UNIT PO DAILY
4. Dexamethasone 4 mg PO Q6H
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation BID
7. Apixaban 5 mg PO BID
8. Atorvastatin 20 mg PO QPM
9. Cyanocobalamin 1000 mcg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Omeprazole 20 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
## DISCHARGE DIAGNOSIS:
PRIMARY
=======
- Bowel and bladder incontinence
- Intramedullary and paraspinal bladder cancer metastases
SECONDARY
=========
- Bladder cancer
- Hypotension
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You came into the hospital because you were having difficulty
with urination and bowel movements. This was likely due to
inflammation and swelling of your spinal cord. You had a foley
catheter placed to collect urine. You were treated with steroids
(dexamethasone) to reduce inflammation. You continued to receive
your Cyberknife therapy while in the hospital.
When you leave the hospital you should:
- Take all of your medications as prescribed.
- Attend all scheduled clinic appointments.
- Watch for signs of swelling of the brain that sometimes occur
after CyberKnife treatment. The symptoms that may occur are:
- headache
- unsteadiness when walking
- numbness/tingling
- nausea or vomiting
- return of presenting symptoms
- seizures
- changes in vision/hearing
- worsening of presenting symptoms
- changes in speech
- fatigue (general radiation side effect, not due to swelling)
If you develop any of the above symptoms please contact your
CyberKnife nurse or call the emergency number(s) listed below.
- To reach a nurse or doctor if you have any questions or
concerns:
-Weekdays-7 am to 5 pm-call CyberKnife Nurse
Coordinator.
-After hours, holidays or weekends call for
the Department of Radiation Oncology and follow the
prompts.
It was a pleasure taking care of you,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15235072", "visit_id": "20740490", "time": "2150-10-14 00:00:00"} |
10349029-RR-57 | 288 | CT OF THE ABDOMEN AND PELVIS WITH CONTRAST
## INDICATION:
Abdominal pain and diarrhea. Question diverticulitis.
## ABDOMEN:
The lung bases are clear.
There is mild intrahepatic biliary dilatation involving both right and left
lobes. The common bile duct is also distended, measuring up to 1.3 cm in
diameter. No definite obstructing lesion or stone is identified. There are
no focal liver lesions. The spleen, adrenals, pancreas are normal in
appearance. There is a stable hypoattenuating lesion within the left kidney
which is unchanged since . The kidneys are otherwise unremarkable.
The abdominal bowel loops are normal in caliber throughout. The abdominal
aorta is normal in caliber. There is no abdominal lymphadenopathy.
## PELVIS:
There is extensive sigmoid diverticulosis. The sigmoid is thickened, however,
there is no adjacent fluid collection or intramural abscess. There is
prominence of vessels supplying the sigmoid, suggesting hyperemia. Therefore,
nonspecific colitis is favored over diverticulitis.
Note is made of gas within the bladder. This may be related to recent
instrumentation. Clinical correlation is suggested. There are subcentimeter
pelvic lymph nodes. There is no lymphadenopathy by size criteria.
## OSSEOUS STRUCTURES:
There is diffuse osteopenia. There are degenerative
changes of the lower lumbar spine. There is no suspicious osteolytic or
osteoblastic lesion.
## IMPRESSION:
1. Intra- and extra-hepatic biliary dilatation, without identified cause. If
the patient has symptoms referable to the biliary system, consider right upper
quadrant ultrasound or MRCP for further evaluation.
2. Gas within the bladder, suggestive of recent catheterization. Clinical
correlation suggested. If the patient has not been recently catheterized, this
could represent infection, and correlation with UA is suggested.
3. Sigmoid thickening and hyperemia, suggestive of colitis.
There is diverticulosis, however the appearance does not favor acute
diverticulitis. Consider colonoscopy for further evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10349029", "visit_id": "N/A", "time": "2171-11-15 10:58:00"} |
11942207-RR-57 | 191 | ## HISTORY:
Ascites and new pelvic mass concerning for ovarian cancer.
?Spontaneous bacterial peritonitis.
## PREPROCEDURE IMAGING AND FINDINGS:
There is a small amount of ascites within the peritoneal cavity. A pocket in
the left lower quadrant was targeted for drainage.
## PROCEDURE:
Ultrasound-guided paracentesis.
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure timeout was performed discussing the planned procedure,
confirming the patient's identity with three identifiers and reviewing a
checklist per protocol.
Under US guidance, an entrance site was selected in the left lower quadrant
and the skin was prepped and draped in the usual sterile fashion. 1%
lidocaine was instilled for local anesthesia.
A 5 catheter was advanced into the ascites in the left lower
quadrant under direct ultrasound guidance. 230 cc of clear straw-colored
fluid was aspirated. Samples were sent for cell count, cytology and
microbiology analysis as per the team's orders.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr attending radiologist, was present throughout the critical
portions of the procedure.
## IMPRESSION:
Technically successful US-guided paracentesis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11942207", "visit_id": "29828373", "time": "2186-06-12 14:21:00"} |
17943379-DS-3 | 1,280 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Ir guided percutaneous nephrostomy tube placement
## HISTORY OF PRESENT ILLNESS:
y/o M HTN, HLD, recent diagnosis of breast ca s/p left
mastectomy with lymph node dissection on who presented
to for left lower quadrant and flank pain
associated with fever. This LLQ /flank pain has been ongoing
since surgery but today became concerned because he had a fever,
nausea, and vomiting. Patient had previously attributed the pain
with constipation and had been treating it with laxatives and
enemas with little improvement in symptoms. Today at showed hematuria and CT scan showed an obstructive stone in
the distal left ureter with associated hydronephrosis. Concerned
for pyelonephritis and patient was hypotensive with systolic
, so patient was transferred to for
urologic evaluation and possible intervention. Received
ceftriaxone prior to transfer.
## IN THE ED, INITIAL VITALS:
97.6 92 109/71 20 91%
Exam/labs were notable for WBC 15 with 74% neuts, Cr 1.4
(unknown baseline)
Imaging (CT scan) showed an obstructive stone in the distal left
ureter with associated hydronephrosis
Patient was given ceftriaxone, morphine, zofran and IV fluid
On transfer, vitals were: 81 125/75 19 100% RA
On arrival to the MICU, patient is alert and speaking in full
sentences.
## PAST MEDICAL HISTORY:
THN, HLD, breast cancer s/p mastectomy
## FAMILY HISTORY:
Father has "heart problems". Otherwise, is non-contributory
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
## ABD:
soft, obese, TTP in LLQ and left flank, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## NEURO:
CN III-XII intact, UE and strength and
intact
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
Thick, unable to assess JVP.
## LUNGS:
Lungs CTAB, no wheezes or rhonchi noted
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
soft, protuberant, mild TTP at LLQ/Left flank, bowel
sounds present, no rebound tenderness or guarding; perc
nephrostomy tube in place with yellow drainage, JP tube in place
with serosanguinous drainage
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; left chest with surgical scar from mastectomy, no
drainage, non-tender to palpation
## SKIN:
no rashes or excoriations noted
## NEURO:
Speech fluent, moving all extremities.
## IMAGING:
==========
Left percutaneous nephrostomy tube placement :
## FINDINGS:
1. Mild left hydronephrosis.
2. Distal ureteric filling defect consistent with known stone
and minimal
passage of contrast beyond the distal ureter on a limited
antegrade
nephrostogram.
## IMPRESSION:
Uncomplicated left percutaneous nephrostomy with an 8
nephrostomy tube
performed for stone related ureteric obsctruction.
## MICRO:
==========
5:27 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT
## MRSA SCREEN (FINAL :
No MRSA isolated.
7:20 am URINE
SPECIMEN CONFIRMED AS URINE. TEST FOR GST UCU AUTHORIZED
BY
@ 0840. LEFT PERCUTANEOUS NEPHROSTOMY.
**FINAL REPORT
URINE-GRAM STAIN - UNSPUN (Final :
GRAM STAIN PERFORMED ON UNSPUN SPECIMEN.
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
## DISCHARGE LABS:
=================
10:20AM BLOOD WBC-8.9 RBC-3.81* Hgb-12.3* Hct-37.5*
MCV-98 MCH-32.2* MCHC-32.8 RDW-12.6 Plt
10:20AM BLOOD Glucose-97 UreaN-15 Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-30 AnGap-10
10:20AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.1
02:09AM URINE Color-Yellow Appear-Clear Sp
02:09AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
02:09AM URINE RBC-75* WBC-<1 Bacteri-FEW Yeast-NONE
Epi- yo M with LLQ and flank pain found to have obstructive stone
in the distal left ureter with associated hydronephrosis.
Patient hypotensive in the setting of likely pyelonephritis
versus sepsis.
## ACTIVE ISSUES:
===============
#Obstructing Nephrolithiasis- Patient has an obstructing
nephrolithiasis which explains his pain and presenting symptoms.
Patient was evaluated by urology who recommended guided
placement of percutaneous nephrostomy tubes. After arrival to
the MICU, he underwent percutaneous nephrostomy tubes. Patient
will follow up with Dr. with urology, is scheduled for
lithotripsy on . Nephrostomy tube to be removed by
nephrology after definitive treatment of stone. Patient
discharged on oxycodone for pain control.
#Leukocytosis- Resolved. Patient's mild leukocytosis was likely
secondary to pyelonephritis in the setting of an obstructing
stone. He was treated with IV ceftriaxone initially. Cultures
were obtained after initiation of antibiotics and were negative,
thus difficult to ascertain accuracy of culture results.
Patient was discharged on PO ciprofloxacin to complete treatment
for presumptive pyelonephritis.
## #HYPOTENSION:
Most likely etiology is sepsis given leukocytosis
with a urinary source. He reportedly was hypotensive in the
emergency room and received fluids, but was fluid responsive. He
was hemodynamically stable at time of admission and remained so
throughout remainder of hospitalization. He was continued on
ceftriaxone and converted to cipro on discharge.
## # HLD:
continued on home simvastatin
## # HTN:
continued on home lisinopril
## # ANXIETY:
continued on home citalopram
## =====================
# URETERAL AND KIDNEY STONES:
recommended that patient follow up
with Dr. at from urology for definitive treatement
of his stone. Plan for lithotripsy on .
## # PYELONEPHRITIS:
secondary to ureteral obstruction from stone.
was treated with ceftriaxone empirically. will dc on 7 day
course of ciprofloxacin.
## # S/P PERC-NEPHROSTOMY TUBE:
Per interventional radiology, tube
would stay in until there is definitive tx of stone, to be
removed by urology. from interventional radiology
has scheduled a follow up appt for him in if needed, and
will t/b with patient in 6 weeks to confirm nephrostomy tube has
been removed. phone number in case there are any issues
with the perc neph tube: .
## # BREAST CANCER:
s/p mastectomy. Has scheduled follow up with
his oncologist for chemotherapy initiation. JP drain to be
removed by surgeon on .
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H
3. Citalopram 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Citalopram 20 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg capsule(s) by mouth every four (4) hours
Disp #*30 Capsule Refills:*0
5. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*15 Tablet Refills:*0
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
7. Acetaminophen 1000 mg PO Q8H:PRN pain/fever
## DISCHARGE DIAGNOSIS:
Left obstructive ureteral stone
Nephrolithiasis
Pyelonephritis
## DISCHARGE INSTRUCTIONS:
Mr. ,
It was a pleasure caring for you during your admission to
. You were admitted for
management of a kidney infection caused by a stone in your left
ureter. A nephrostomy tube was placed to relieve the
obstruction and you were started on antibiotics for your
infection. It was determined you were safe to be discharged to
home. You are scheduled for lithotripsy on
for treatment of your kidney stone with Dr. call
for any questions).
Please care for your nephrostomy tube as instructed and take
your medications as prescribed. Your percocet is being replaced
with oxycodone, you should not take both these medications.
Should you develop fevers, nausea/vomiting, or increasing
abdominal pain, please seek evaluation at a medical facility or
at your nearest emergency department.
- Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17943379", "visit_id": "26274014", "time": "2184-08-16 00:00:00"} |
13467921-DS-7 | 1,163 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Bone marrow biopsy
Port-a-cath placement
## HISTORY OF PRESENT ILLNESS:
year old man with a h/o HTN and atrial fibrillation, recent
cdif(on po vanc), w/ recently diagnosed AML (normal karyotype,
NPM1+, s/p induction w/ 7+3 ( ) BM at recovery
morphologically ablated, on vaccine trial, active chemo last s/p
cycle last week, presenting for severe diffuse bone pains.
Patient has been otherwise in his normal state of health since
receiving the chemotherapy and has had a normal appetite, no
fevers or chills, no URI, UTI, rash, neurological, or abdominal
symptoms since his last cycle. Of note, he has described
palpitations, that he feels are consistent with his prior atrial
fibrillation with RVR. He was to be evaluated for this several
days ago, but he left the ED waiting room prior to evaluation.
However, early the morning of he has had a progressively
developing bony aching pain with occasional radiation down
either leg, proceeding to migrate throughout the day into his
chest, arms, and remainder of his legs. Pain is migratory,
described as deep and aching without any associated sympotms of
fever, chills, NV, abdominal pain, myalgias, joint swelling,
rash, heat cold intolerance. At time of ED evaluation. The pain
is migratory at one point even left his lower back.
In the ED, initial vitals:
2 97.7 91 144/77 18 100% RA
Labs showed:
WBC 0.6 with 1 % neutrophils 12 %blasts HGB/HCT 7.8/ .1 PLT 39
BUN 27 Cr 1.1
CK 96
Uric Acid 4.8
Fibrinogen 368
Ca/Mg/Phos 9.9/3.5/2/0
Lipase 39
Coags normal
Transaminases were normal
Lactate 2.5
Blood and urine culture obtained and pending
Haptoglobin pending
Chest Xray showed: No acute cardiopulmonary process
He was given:
-Acetaminophen 500 mg PO/NG ONCE
-Morphine Sulfate 5 mg IV ONCE
-1000 mL NS x 2
-PO Oxycodone 5 mg x 1
-PO Acetaminophen 650 mg x nd in no apparent distress on arrival to .
Pain in low back has slowly started to recur, very effective
treatment with oxycodone previously.
## PAST ONCOLOGIC HISTORY
-AML:
recently diagnosed, normal karyotype, NPM1+, s/p induction
w/ 7+3 ( ) BM at recovery morphologically ablated, on
vaccine trial
## FAMILY HISTORY:
heart disease in father
mother lived until age of
no history of any cancers including hematologic
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
## ABD:
soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## GEN:
Pleasant, calm, AAOx3 in no acute distress
## HEENT:
No conjunctival pallor. No icterus. MMM. OP clear.
## NECK:
No JVD. Normal carotid upstroke without bruits.
## LYMPH:
No cervical or supraclav LAD
## CV:
regular rate, irregular rhythm. No MRG.
## LUNGS:
No increased WOB. CTAB. No wheezes, rales, or rhonchi.
## ABD:
NABS. Soft, NT, ND.
## EXT:
Warm, well perfused, 2+ peripheral pulses
## NEURO:
CN III-XII intact, no gross motor or sensory deficits.
## CHEST XRAY :
with no evidence of consolidation, normal
mediastinal contours, no effusions, no vascular congestion.
US
No evidence of deep venous thrombosis in the right lower
extremity veins.
## SUMMARY:
Y/O MALE with AML on s/p 7+3 and HiDAC regimen (C1/D1 on
who presented with acute back and joint pain. Was
given IVF and started on Cefepime due to concern for possible
infection. Infectious work up (UA, CXR, and blood Cx) showed no
signs of infection and cefepime was stopped, however peripheral
smear showed blasts. Flow cytometry was sent and a repeat bone
marrow biopsy was performed. This showed stable recovering bone
marrow. His blood counts continued to improve over the next few
days and peripheral blast percentage was downtrending. He was
discharged in good condition with close follow up to ensure
continued count recovery.
## ACUTE ISSUES:
# MIGRATORY ARTHRALGIAS:
No acute precipitating event other than
his known neutropenia from HiDAC 2 weeks prior to presentation.
Pain was not reproducible on exam and has no joint symptoms of
neurologic defecits. CXR and UA were negative. Antibiotics were
discontinued and pain improved with rest and occasional
oxycodone.
## # PANCYTOPENIA:
absolute Neutropenia S/P HiDAC . Was
transfused for HCT <21 and PLT <10 during admission.
# AML S/P CYCLE 1 HIDAC: Blasts found on peripheral smear and
concerning for recovery vs sign of infection vs refractory
disease. Repeat bone marrow biopsy showed stable marrow
with 5% blasts. Counts then continued to recover with decreasing
blast percentage. S/p port-a-cath placement on . Continued
on Acyclovir and fluconazole ppx and will follow up with
outpatient oncology to ensure counts continue to recover.
## # DEPRESSION:
Denies any SI/HI, stable on home regimen.
Continued home Amitriptyline 10mg PO QHS.
## # ATRIAL FIBRILLATION:
INR appropriate, rate controlled with
metoprolol. Continued home dose Metoprolol Succ. XL 75mg PO
daily.
## TRANSITIONAL ISSUES:
=====================
1. He was prescribed fluconazole 400mg daily for prophylaxis.
2. He was set up with outpatient oncology follow up in Dr.
to have blood counts rechecked on .
## # COMMUNICATION:
Name of health care proxy:
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 10 mg PO QHS
2. Metoprolol Succinate XL 75 mg PO DAILY
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. LOPERamide mg PO QID:PRN diarrhea
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Acyclovir 400 mg PO Q8H
## DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg PO Q8H
2. Amitriptyline 10 mg PO QHS
3. Metoprolol Succinate XL 75 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth daily Disp #*30
## TABLET REFILLS:
*0
7. LOPERamide mg PO QID:PRN diarrhea
8. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily
prn Disp #*10 Tablet Refills:*0
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*20 Tablet Refills:*0
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to for
acute back pain. You were given opioid medication with good
effect. Given your neutropenia, there was concern for infection
and were started on antibiotics. Culture results showed no
infection and antibiotics were able to be stopped. Blast cells
were found on your peripheral smear, so a repeat bone marrow
biopsy was done which showed recovering bone marrow. Please
follow up with your outpatient oncologist to ensure your counts
continue to recover.
It was a pleasure taking care of your at . If you have any
questions about the care you received, please do not hesitate to
ask.
Sincerely,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13467921", "visit_id": "20438746", "time": "2157-08-30 00:00:00"} |
17854623-DS-14 | 1,067 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
is a man s/p pacemaker placement who
fell the morning of admission while on his way to the
course. He felt sweaty all morning due to the heat, but
otherwise was feeling at his baseline. He fell while walking out
a door and hit his upper lip, right upper chest, and both knees.
The pt himself reports that he "does not feel like he passed
out", but his wife who was not present believes that he did.
Immediately after realizing he had fallen, he reports feeling
well other than the injuries he sustained.
He had two prior episodes of syncope last year that were similar
and led to pacemaker placement.
.
He denies any fever, nausea, cough, CP, SOB, dizziness, or
palpitations. He at a full breakfast the morning of admission.
.
In the ED, VS were T 97.9 BP 172/95 HR 97 RR 17 O2Sat 96% RA.
Head CT was negative. CXR showed anterior wedging of upper
thoracic vertebral body with <25% loss of vertebral body height,
no acute processes. EKG unchanged from prior one on .
He was given motrin 400mg PO and his superficial wounds were
treated.
## PAST MEDICAL HISTORY:
- s/p bilateral knee replacement
- hiatal hernia
- htn
- bph
- hyperlipidemia
- overactive bladder, taking Tolterodine ( )
- s/p Adapta dual chamber pacemaker placement
for sinus bradycardia
## FAMILY HISTORY:
No history of sudden death. Father had DMT2 and cirrhosis.
Mother died at age and had history of "difficult to
diagnosis" arrythmia. She also had a history of syncope. His
sister has had colon cancer.
## VITALS:
T 96.5 HR 90 BP 159/101 O2 Sat 98 on RA Wt
200.4lb
## GEN:
awake, alert, in no acute distress, mentating very slowly,
superficial lacerations on both knees
## HEENT:
NC/AT, PERRL, EOMI, no oropharynx lesions, MMM
## CARDIAC:
has pacemaker, RRR, nl S1/2, I/VI systolic murmur heard
at the RUS border
## ABD:
not distended, positive bowel sounds, not tender, no
masses, no hepatosplenomegally
## EXT:
no clubbing/ cyanosis/ edema
## SKIN:
no rashes or lesions, numerous seborrheic keratosis on the
back and trunk
## NEUROLOGIC:
CN's II-XII intact, strenth throughout, moving
all lert and oriented to the examiners.
Speech very slow. Rapid alternating hand movements intact, but
slowed. Finger-nose-finger demonstrated bilateral tremor worse
when approaching the finger. Reflexes equal bilateraly, 1+
throughout. Toes downgoing bilaterally.
## FINDINGS:
There is no intra- or extra-axial hemorrhage, edema,
mass effect, shift of normally midline structures, or acute
major vascular territorial infarction. The ventricles and sulci
are slightly prominent, likely reflecting age-related
involutional changes. Visualized paranasal sinuses and mastoid
air cells are clear. There is no evidence of fracture.
## IMPRESSION:
No acute intracranial process.
.
CXR
PA AND LATERAL VIEWS OF THE CHEST:
A dual-lead pacemaker
overlies the left hemithorax with leads terminating in the right
atrium and right ventricle. Lungs are clear without
consolidation or pleural effusion. There is no pneumothorax. The
heart is slightly enlarged, stable from prior studies. There is
no mediastinal or hilar enlargement.
There is very minimal anterior wedging of an upper thoracic
vertebral body (approximately T3), with loss of less than 25% of
anterior vertebral body height. This is new since , but
may be chronic. Soft tissues and other bony structures are
otherwise unremarkable.
## IMPRESSION:
No acute cardiopulmonary abnormalities. Minimal anterior wedging
of upper thoracic vertebral body with loss of less than 25% of
vertebral body height, new since , acuity is otherwise
unknown.
## BRIEF HOSPITAL COURSE:
M with hx of pacemaker placement for BBB presents after
questionable syncopal episode.
*) Questionable syncope: Uncertain hx of syncope vs. mechanical
fall. Pt has hx of previous syncopal episodes and is s/p
pacemaker placement for RBBB and arrhythmia. Given the lack of
prodromal sx, cardiogenic syncope is definitely a possibility.
On the other hand, given pt's recent increase in gait
unsteadiness and short term memory loss, a mechanical fall with
lack of realization of circumstances is also possible. Seizure
and hypoglycemia are less likely given lack of postictal state
and hx of consuming breakfast. EKG unchanged from previous.
Cardiac enzymes negative x 2. Other labs within nl limits. Pt
was placed on continuous telemetry and monitored overnight. On
HD#2, electrophysiology did a pacemaker interrogation which did
not reveal any abnormal heart rhythm.
.
*) Sinus tachycardia: Pt with sinus tachycardia throughout
admission. On pacer interrogation, sinus tach noted approx 20%
of the time since . No obvious cause for elevated heart
rate, such as infection, pulmonary embolism, or decreased
circulating volume. As this is a chronic issue, will have pt
follow up with PCP to decide if further evaluation is warranted.
.
*) Tremor: Pt states he has had sx of tremor, shuffling gait,
memory loss over past few months. PCP has appt with
neurology . DDx includes disease, Alzheimer's
dementia, normal pressure hydrocephalus. Curbsided neurology,
who would not recommend inpatient evaluation of sx. Would
consider MRI head as outpatient.
.
*) Upper thoracic stress fx: Started on calcium, vit D. Consider
further evaluation for osteopenia as outpatient with PCP.
.
*) HTN: BPs elevated upon admission. Lisinopril increased to
20mg daily.
.
*) Diaphoresis: Pt states he has felt increasingly sweaty since
the day of the fall. Denies any other associated sx. TSH 1.5.
Encouraged pt to f/u with PCP if continues.
.
*) Hyperlipidemia: Continued zocor.
.
*) BPH: Continued .
.
*) Dispo: Pt was discharged home on HD#2 in stable condition to
follow up with PCP, , and neurology as outpatient.
## MEDICATIONS ON ADMISSION:
cymbalta 60mg PO daily, lisinopril 10mg po daily, lipitor 20mg
po daily, nexium,
Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule,
Delayed Release(E.C.)(s)
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17854623", "visit_id": "27875452", "time": "2156-02-24 00:00:00"} |
16071629-DS-4 | 708 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
Patient admitted with left upper quadrant abdominal pain status
post Laparoscopic cholecystectomy on
## HISTORY OF PRESENT ILLNESS:
s/p lap chole on . Now presents w LUQ pain that
started early this AM. Patient states pain is a cramping pain
that is in the LUQ does not radiate. States this is
different from his usual low grade burning pain that he usuallly
feels over this area. Now pain is associated with reflux
feeling
in his throat. He denies N/V, +flatus, +BM. Had been eating
well since surgery. No fevers or chills. Denies CP, SOB.
## PAST MEDICAL HISTORY:
Depression, GERD with esophagus, Sleep apnea on
CPAP.
## COMFORTABLE
HEAD / EYES:
Normocephalic, atraumatic, Pupils
equal, round
reactive to light,
Extraocular
## MUSCLES INTACT
ENT / NECK:
Oropharynx within normal limits
## CARDIOVASCULAR:
Regular Rate Rhythm, Normal
first
heart sounds
GI / Abdominal: Soft, Nondistended, mild LUQ &
epigastric pain
## GU/FLANK:
No costovertebral angle
tenderness
## MUSC/EXTR/BACK:
No cyanosis, clubbing or edema
## SKIN:
No rash, Warm dry
## PSYCH:
Normal mood, Normal mentation
## BRIEF HOSPITAL COURSE:
Patient admitted underwent a CT scan that showed findings
consistent with abscess. MRCP done which confirmed no biliary
obstruction. Patient started on antibiotics monitored. White
count initially 11 decreased to 7. Abdominal pain resolved.
Tolerating a regular diet now. Will discharge today with follow
up with Dr. in 2 weeks with one more week of antibiotics
po.
## DISCHARGE MEDICATIONS:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
## 3. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours):
Please continue for one week.
Disp:*21 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Abscess s/p laparoscopic Chole.
## DISCHARGE INSTRUCTIONS:
Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
## DIET:
Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
## MEDICATION INSTRUCTIONS:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals once a day. No gummy vitamins.
3. You will be taking Zantac liquid mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin
Naproxen. These agents will cause bleeding ulcers in your
digestive system.
## ACTIVITY:
No heavy lifting of items pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
## WOUND CARE:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16071629", "visit_id": "27293348", "time": "2167-08-28 00:00:00"} |
10816667-RR-18 | 120 | NUCHAL TRANSLUCENCY AND FIRST TRIMESTER SONOGRAM,
## HISTORY:
Advanced maternal age, diabetes, and hypertension complicating
pregnancy.
## FINDINGS:
There is a single live intrauterine gestation. The uterus is
slightly retroflexed and due to the fetal position, we were unable to obtain
an adequate nuchal translucency measurement. The crown-rump length is 47.5 mm
corresponding to gestational age of 11 weeks 4 days. This corresponds
satisfactorily to the age by dates of 11 weeks 5 days. The uterus and ovaries
are normal.
## IMPRESSION:
Size equal to dates. Unable to obtain nuchal translucency. It
is still relatively early in gestation. Therefore, followup is recommended in
one week. A report with these findings was sent with the patient to her
appointment with Dr. .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10816667", "visit_id": "N/A", "time": "2139-10-03 13:42:00"} |
15749437-DS-8 | 2,332 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
IABP
Swan ganz x2
Cardiac catheterization
## HISTORY OF PRESENT ILLNESS:
male with history of obesity, OSA, and depression who p/w
increasing SOB x5d. 5d ago he noted DOE while climbing flight of
stairs. It was sudden onset and not a/w nausea, CP, diaphoresis.
SOB persisted throughout day and was worse with lying flat. He
also reports significant bilat lower ex and abd edema and approx
5 lb weight gain in 2d. SOB persisted and was worsened with any
physical activity. He said he could "talk it down" until day of
admit when it worsened. He denies any cough, chills, fevers, or
chest pain. He has no hx of CAD, CHF and no new meds.
.
In the ED, 96.8 16 100% RA. Promptly went into HR of
130s with aflutter and SBP 120s. Exam showed cool extremities
and bibasilar rales. He was given Dilt 20 IV and 30 PO with HR
improvement to 110 and SBP 130 -> 80s. He needed 600 IVF. Neo
given intermittently with no improvement in HR. EKG aflutter
with NA, NI and ventricular rate of 130 w delayed RWP. Labs
showed Trop 0.02, CK 187, MB 10. INR 1.7, WBC 15.8, ARF (Cr 2.4)
and transaminitis (ALT and AST 736). Anion gap 17 and
lactate 3.4. CXR w pulm congestion. CT abd showed cirrhotic
liver with small ascites w small/mod bilateral pleural
effusions. He was given 325. ECHO in ED showed
mod MR so patient admitted to CCU for cardiogenic shock.
.
Currently, he is thirsty. On full ROS, he denies any dizziness,
HA, LH, nausea, CP, SOB. he reports increasing abdominal girth
and leg swelling over last several days. Denies any fevers,
chills, cough, sputum.
## 2. CARDIAC HISTORY:
-CABG:
none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: no
3. OTHER PAST MEDICAL HISTORY:
Obesity
OSA
Depression
OCD
## FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
## GENERAL APPEARANCE:
Overweight / Obese, Anxious
## HEAD, EARS, NOSE, THROAT:
Normocephalic, Oropharynx clear
without erythema, MMM
## (S1:
Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic), tachycardic, regular, no murmur
appreciated. distant S1 and S2 without split. no heaves
appreciated.
## (RIGHT RADIAL PULSE:
Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
## NO(T) CLEAR:
, Crackles: bilat bases. )
## ABDOMINAL:
Distended, protuberant, dullness, no shifting
dullness. No organomeg appreciated. No rebound or guarding.
mild tenderness throughout.
## RIGHT:
4+ pitting edema, Left: 4+ pitting edema,
cool extremities
## NEUROLOGIC:
Attentive, Oriented x 3, Follows simple commands,
Responds to: vocal stimuli, Movement: Purposeful, Tone: Normal,
not increased
## PERTINENT RESULTS:
==========
Labs
==========
On admission -
05:25PM BLOOD WBC-15.8*# RBC-4.62 Hgb-14.3 Hct-41.5
MCV-90 MCH-31.0 MCHC-34.5 RDW-13.7 Plt
05:25PM BLOOD Neuts-75* Bands-1 Lymphs-14* Monos-10
Eos-0 Baso-0 Myelos-0
05:25PM BLOOD PTT-25.1
05:25PM BLOOD Glucose-121* UreaN-86* Creat-2.4*#
Na-129* K-4.8 Cl-91* HCO3-21* AnGap-22
05:25PM BLOOD AST-736* CK(CPK)-187*
AlkPhos-178* TotBili-1.2
.
On discharge -
06:45AM BLOOD WBC-10.9 RBC-4.22* Hgb-12.7* Hct-37.5*
MCV-89 MCH-30.0 MCHC-33.8 RDW-16.1* Plt
07:20AM BLOOD WBC-11.2* RBC-4.48* Hgb-13.0* Hct-40.1
MCV-90 MCH-28.9 MCHC-32.3 RDW-15.3 Plt
06:45AM BLOOD Glucose-85 UreaN-15 Creat-1.1 Na-142
K-3.6 Cl-106 HCO3-26 AnGap-14
05:12PM BLOOD Glucose-97 UreaN-19 Creat-1.3* Na-141
K-5.2* Cl-105 HCO3-29 AnGap-12
04:07AM BLOOD ALT-412* AST-86* AlkPhos-86 TotBili-1.0
06:45AM BLOOD Digoxin-0.7*
==========
Radiology
==========
CT Abd/Pelvis
1. Findings suggestive of fluid overload, with small-to-moderate
bilateral
pleural effusions, with hilar fullness in the visualized lung
bases.
2. Nodular contour of the liver, which can be seen with
cirrhosis, with a
small amount of ascites.
3. Rounded hypodensities in the right lobe of the liver are
incompletely
characterized without intravenous contrast.
4. Cystic structure inferior to the third portion of the
duodenum. This is
of uncertain etiology with differential diagnostic
considerations including a fluid-filled normal bowel loop,
duplication cyst, and duodenal diverticulum.
.
===========
Cardiology
===========
C. Cath
1. Selective coronary angiography of this right dominant system
revealed
no angiographically apparent CAD.
2. An 30cc intra-aortic balloon pump was inserted via a
right common
femoral artery with good diastolic augmentation and systolic
unloading.
## FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Cardiogenic shock.
3. Insertion of IABP.
.
TTE
Mild . LV wall thicknesses normal. LV mildly dilated.
There is severe global left ventricular hypokinesis (LVEF =
%). Restrictive left ventricular filling pattern
suggestive of severe diastolic dysfunction. RV is dilated with
moderate global free wall hypokinesis. Normal aortic valve. 3 +
MR. PA htn.
.
TTE
## ON IABP:
There is severe global left ventricular hypokinesis
(LVEF = 20 %). RV with moderate global free wall hypokinesis.
Moderate (2+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Off IABP: Overall LV
systolic function remains severely depressed with some subtle
increased systolic thickening of the anterior and lateral LV
segments (LVEF . The degree of mitral regurgitation
increased to moderate to severe (3+). Compared with the prior
study (images reviewed) of , overall LV systolic
function appears slightly improved and the degree of MR less
## # CARDIOGENIC SHOCK:
Patient admitted with cardiogenic shock.
Work up for causes was unremarkable, including Cath revealing
clean coronaries, HIV, Iron studies, RF, and TSH. EF is
depressed globally without regional wall motion abnls and
improved on IABP. TTE showed mild . LV wall thicknesses
normal. LV mildly dilated. There is severe global left
ventricular hypokinesis (LVEF = %). Restrictive left
ventricular filling pattern suggestive of severe diastolic
dysfunction. RV is dilated with moderate global free wall
hypokinesis. Normal aortic valve. Mild PA htn. TTE also showed
3+ MR, but it was unknown how much this complicated patient's
Cardiogenic shock picture. A repeat TTE on showed minimal
improvement in EF on IABP and unchanged MR. addition, patient
was admitted in A flutter and it was felt that this rhythm
disturbance on top of an already compromised EF caused the
patient to go into cardiogenic shock. Patient was initially
managed on Milrinone and Dopamine, but an IABP was placed during
patient's cardiac catheterization. Milrinone was eventually
weaned off and replaced by afterload reduction by ace
inhibitors, which were slowly titrated up and eventually, the
patient's IABP was able to be removed on . He was also
re-started on B-blocker therapy given his stable hemodynamics
after removal of the IABP. Given his massive total body volume
overload, the patient was agressively diuresed with a lasix drip
while in the CCU and managed to diurese several liters, however,
after less than 24 hours on the lasix drip the patient developed
a total body pruritic maculopapular rash concerning for a drug
rash. Given that lasix had been recently increased, it was
suspected that lasix was related to the rash and was
discontinued. The patient was switched to oral Ethacrynic acid
instead, as it contains no sulfa moiety in case this was
contributing to the patient's rash. The patient responded well
to oral Ethacrynic acid, and was able to be volume net negative
on 50mg daily.
.
# Coronaries: Cardiac biomarkers were flat when cycled. Cardiac
catheterization revealed clean coronaries. Patient was continued
on while in house.
.
# Cardiac Rhythm: On admission, the patient was in atrial
flutter. Per the patient, he had no prior history of AFib or
Flutter. During his hospitalization, he was transiently in
sinus rhythm after cardioversion in the OR on HD #2, but sinus
rhythm was not maintained throughout the hospitalization.
Patient was given a bolus of Amiodarone and eventually started
on Digoxin for rate control. In addition, after recovery from
cardiogenic shock, the patient was placed on a beta-blocker, but
despite this remained in paroxysmal atrial flutter throughout
this hospitalization. The patient was started on
anti-coagulation with coumadin and heparin during this
hospitalization given his paroxysmal AF, and PVD, as below.
.
# PVD: While in the CCU with an IABP the patient was noted to
have bilateral cool lower extremeties that appeared somewhat
cyanotic and mottled appearing. The patient's circulation to
his lower extremeties improved after removal of the IABP.
Vascular surgery was consulted and felt that the patient may
have been showering emboli given his significant PVD, and would
most likely benefit from being on anti-coagulation with coumadin
for at least the next few months.
.
# Respiratory failure: On HD#2, patient was intubated via nasal
airway in the setting of planned cardioversion. He
self-extubated on and did not require re-intubation with
no further episodes of respiratory distress this
hospitalization.
.
# Acute renal failure: Felt to be due to ATN in the setting of
shock. Cr gradually improved back to 1.1 at time of discharge
while on a stable diuretic regimen.
.
# ID: Patient spiked multiple fevers over the course of his
first week in the hospital. He was initially covered broadly
with vancomycin and zosyn given initial concern for sepsis.
Culture data remained negative and lines were removed without
growth of bacteria. Antibiotics were stopped on and
patient did not respike a temperature. In the setting of Tube
feeds, patient had some diarrhea but initial C diff toxins were
negative. On patient's stool was positive for C Diff and
he was started on a 14 day course of Metronidazole for
treatment.
.
# Rash: The patient developed a total body rash as described
above, felt to be a drug rash with lasix as the likely offending
agent. He recieved Benadryl, Sarna lotion, and topical
hydrocortisone cream with some improvement in his pruritis. The
rash stopped progressing after discontinuation of the lasix and
switching to ethacrynic acid as above.
.
# Depression: The patient's home dose of Seroquel and
Fluvoxamine were continued throughout his hospitalization.
.
# Transaminitis: Suspect most likely due to shock liver in the
setting of cardiogenic shock. The patient's transaminases
improved without intervention. A liver consult was initially
requested in case a heart transplant was necessary, and it was
deemed that the patient does not have cirrhosis advanced enough
to interfere with such a procedure should it become necessary.
## DISCHARGE MEDICATIONS:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Fluvoxamine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Ethacrynic Acid 25 mg Tablet Sig: Two (2) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*1*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
.
Disp:*30 Tablet(s)* Refills:*1*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
8. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash/ puritis.
Disp:*1 Tube* Refills:*0*
9. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*1*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritus.
Disp:*1 bottle* Refills:*0*
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Quetiapine 150 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO QHS (once a day (at
bedtime)).
## PRIMARY:
cardiogenic shock
Acute Systolic Congestive Heart Failure.
## DISCHARGE INSTRUCTIONS:
You presented to the hospital with shortness of breath. You
were found to have profoud low blood pressure from your heart's
inability to squeeze. You were started on strong medications to
improve your heart's pump function. You transiently required a
balloon pump to help augment your heart's forward flow. Your
balloon pump was removed on and you are being discharged
on several new medications including: Ethacrynic acid,
Lisinopril and Carvedilol to help improve your heart's squeeze
potential. You are also being sent home on Amiodarone,
Digoxin, and Coumadin for your irregular heart beat.
Metronidazole, an antibiotic, is being prescribed for your
diarrhea, and you should take this for the next 8 days. Please
discuss with Dr. setting up lung, liver and thyroid
testing now that you are on the amiodarone.
.
You were started on Coumadin, a powerful blood thinner to
prevent blood clots because of your atrial fibrillation. You
will need to check a coumadin level or INR frequently until the
level is between 2 and 3. You will see Dr. in 2 days and
can check your INR then at the clinic. Please
call Dr. away if you notice dark or bloody stools, a
nosebleed that won't stop, or vomiting blood.
.
Your home dose of Provigil was discontinued during this
hospitalization due to your critical illness. Please consult
with your primary care physician before restarting this
medication. You should continue taking all your other home
medications as before.
Please seek immediate medical attention if you experience chest
pain, shortness of breath, abdominal pain, nauasea,
palpitations, or any change in your baseline health status.
.
Please weigh yourself daily at home before breakfast. Call Dr.
is you have a weight gain or more than 3 pounds in 1 day
or 6 pounds in 3 days.
Please follow a low sodium diet.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15749437", "visit_id": "27295640", "time": "2173-07-20 00:00:00"} |
12433541-RR-20 | 404 | ## CLINICAL HISTORY:
Right femur lesion, assess for other lesions.
## CT CHEST:
Thoracic aorta is normal in course and caliber without evidence of
dissection or intramural hematoma. The study is not optimized to assess for
pulmonary embolism, but there is no large central PE. A right hilar lymph node
conglomerate measures 2.5 x 3.1 cm (3:22). A subcarinal lymph node measures
1.4 cm. No axillary or left hilar lymphadenopathy. The heart, pericardium
and great vessels are otherwise within normal limits. No pleural effusion.
Thyroid is unremarkable without nodules.
Lung window images demonstrate a spiculated 0.9 x 0.9 cm right upper lobe
nodule. A second 0.7-cm RUL nodule (3:17) is just inferior to spiculated
nodule. No other nodules are seen.
## CT ABDOMEN:
A 1.8 cm hypodensity is seen within segment VIII of the liver.
Two other small hypodensities (3:56) are too small to characterize but are
concerning for metastases in the setting of the lung nodules and bone lesions.
The gallbladder, spleen, pancreas, and bilateral adrenal glands are normal.
The kidneys enhance symmetrically and excrete contrast promptly. The small
and large bowel are normal in course and caliber. There is no free fluid and
no free air. Mild atherosclerotic calcifications are seen in the aorta without
aneurysmal dilatation. No mesenteric or retroperitoneal lymphadenopathy.
## CT PELVIS:
The rectum, bladder and prostate are normal. Diverticula are seen
throughout the sigmoid colon without inflammatory changes. No pelvic or
inguinal lymphadenopathy and no free fluid.
## BONE WINDOWS:
The lytic lesion in the proximal right femur is better assessed
on MRI and CT . A lytic lesion in the vertebral body of L2
is new from , suspicious for metastasis. An old rib fracture of the right
posterior eleventh rib is seen. Partial compression deformity of the T11
vertebral body is of indeterminate age and etiology and may be due to trauma
given the old rib fracture.
## IMPRESSION:
1. 9mm spiculated and 7-mm right upper lobe nodules are concerning for
malignancy with associated with right hilar and subcarinal lymphadenopathy.
2. Liver hypodensities are concerning for metastases.
3. L2 vertebral body lytic lesion is suspicious for metastasis.
4. Partial compression deformity of T11 vertebral body is of indeterminate
age and etiology and may be due to trauma given an old posterior right
rib fracture. However, metastasis cannot be excluded.
5. Right femur lesion is better assessed on CT and MRI.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12433541", "visit_id": "21847831", "time": "2140-10-02 11:53:00"} |
13976080-RR-32 | 382 | ## CLINICAL INDICATION:
man with decompensated HCV cirrhosis and
upper gastrointestinal bleeding of unknown origin, requiring 10 units of PRBC,
6 units of FFP and 2 units of cryo in less than 12 hours. Evaluate for source
of bleeding and administer treatment as indicated by angiographic findings.
## PHYSICIANS:
Dr. , attending physician and Dr. ,
fellow.
## PROCEDURE:
1. Celiac arteriogram.
2. Superior mesenteric artery angiogram.
3. Selective gastroduodenal artery angiogram.
4. Selective left gastric artery angiogram.
## ANESTHESIA:
General.
Witnessed informed consent was obtained from the patient's wife after risks,
potential complications and potential benefits had been discussed. The
patient was placed on the angiographic table in supine position. Skin of the
right inguinal region was prepped and draped in a sterile fashion.
The right common femoral artery was accessed using 21-gauge micropuncture
needle. Over a 0.018 guidewire, the needle was exchanged for a 4
sheath followed by placement of 0.035 guidewire. Selective
catheterization of the celiac trunk and superior mesenteric artery was
expedient using a 5 catheter. A endovascular sheath in
the right common femoral artery was used for arterial access. Formation of a
catheter in the infrarenal abdominal aorta was facilitated by
placement of a Glidewire across the bifurcation over a 5.0 C2 Cobra catheter.
## FINDINGS:
Diffusely attenuated appearance of the first, second, third and
fourth order branches of the celiac trunk is demonstrated with no perceptible
arterial extravasation. Using a Renegade microcatheter, selective
catheterization of the gastroduodenal artery and of the left gastric artery
through the catheter was performed efficiently. Selective
injections of the gastroduodenal artery demonstrated normal anatomical
findings with no arterial extravasation from the gastroduodenal artery or its
branches. Selective catheterization of the left gastric artery demonstrated
normal findings. Examination was concluded following selective
catheterization of the superior mesenteric artery, which demonstrated normal
arterial anatomy with no active arterial extravasation. At the conclusion of
the visceral abdominal angiograms, the patient was transported to the
interventional neuroradiology suite for arteriography and embolization for
manifest bilateral epistaxis. A 5 endovascular sheath remained in the
right common femoral artery for interventional neuroradiology procedure
access.
## CONCLUSION:
1. Normal celiac artery angiogram with selective catheterization of the
gastroduodenal artery and left gastric artery.
2. Normal superior mesenteric artery angiogram.
3. No active arterial extravasation from the visceral aortic branches.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13976080", "visit_id": "22818855", "time": "2144-09-06 08:52:00"} |
17354782-RR-50 | 388 | ## EXAMINATION:
CT C-SPINE W/O CONTRAST Q311 CT SPINE
## HISTORY:
with fall on elliquis // evaluate for fracture
evaluate for fracture
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.5 s, 21.5 cm; CTDIvol = 22.9 mGy (Body) DLP = 493.6
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 13.2 mGy (Body) DLP =
26.5 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 13.2 mGy (Body) DLP =
26.5 mGy-cm.
Total DLP (Body) = 547 mGy-cm.
## FINDINGS:
There is minimal anterolisthesis of C3 on C4 and C4 on C5. Otherwise,
sagittal alignment is maintained. There are multilevel degenerative changes
including loss of intervertebral disc height, endplate osteophyte formation,
and endplate sclerosis. Partially calcified retro odontoid pannus is noted
which can reflect degenerative change and/or CPPD. Multilevel facet
arthropathy and uncovertebral joint osteophyte formation is present, causing
at least moderate bilateral neural foraminal stenosis at C4-C5 and C5-C6,
mild-to-moderate neural foraminal stenosis at C6-C7 and C7-T1.
mild-to-moderate spinal canal narrowing at C5-C6. No fractures are
identified. There is no prevertebral soft tissue swelling.
There is no evidence of infection or neoplasm. Fluid and aerosolized
secretions are noted in the nasopharynx, with some hyperdense material likely
reflecting blood in the context of the nasal bone and nasal septum fracture
described on the separate head CT.
5 mm left apex pulmonary nodule.
## IMPRESSION:
1. No cervical spine fracture. MRI is more sensitive for ligamentous injury
if this is of concern.
2. Multilevel degenerative changes of the cervical spine as described.
3. Fluid in the nasopharynx as well as blood, likely related to the nasal
septum and nasal bone fracture as seen on the CT of the head.
## PREVALENCE:
Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
Jarvik, et all. Spine 26(10):1158-1166
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over years old
, et al, Spine Journal 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17354782", "visit_id": "N/A", "time": "2170-07-21 10:40:00"} |
14711846-RR-71 | 178 | ## EXAMINATION:
ELBOW, AP AND LAT VIEWS LEFT
## INDICATION:
year old woman with L olecranon fx // asses fx asses
fx
## FINDINGS:
As demonstrated on the prior examination still fixation hardware is re-
demonstrated with some screws within the distal humerus as well as at the
level of the proximal ulna. Compared to the prior examination the comminuted
fracture of the olecranon is re- demonstrated. There is anterior dislocation
of the radius with respect to the capitellum as well as anterior shift of the
ulna with respect to the distal humerus. Small osseous fragments are seen
posterior aspect of the elbow as well as abutting the proximal radius. Due to
overlap of the radius and ulna assessment for radial head fracture is severely
limited. There are small displaced fractures posterior to the distal humerus.
There appears to be ulnar shaft of the radius with respect to the humerus.
## IMPRESSION:
Significant worsening in alignment with anterior subluxation of the radius and
ulna with respect to the distal humerus.
## NOTIFICATION:
Findings reported to referring clinician via internal
departmental notification system.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14711846", "visit_id": "N/A", "time": "2193-12-05 12:41:00"} |
14572141-DS-7 | 2,387 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Left internal carotid artery angiogram with embolectomy
tPA
## HISTORY OF PRESENT ILLNESS:
Neurology Resident Stroke Admission Note
Neurology at bedside for evaluation after code stroke activation
within: <1> minutes
Time/Date the patient was last known well:
Pre-stroke mRS social history for description):
t-PA Administration
[x] Yes - Time given: 2200
[] No - Reason t-PA was not given/considered:
## ENDOVASCULAR INTERVENTION:
[x]Yes []No
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
Stroke Scale - Total [18]
1a. Level of Consciousness - 0
1b. LOC Questions - 2
1c. LOC Commands - 2
2. Best Gaze - 1
3. Visual Fields - 2
4. Facial Palsy - 1
5a. Motor arm, left - 0
5b. Motor arm, right - 3
6a. Motor leg, left - 0
6b. Motor leg, right - 3
7. Limb Ataxia - UN
8. Sensory - 1
9. Language - 3
10. Dysarthria - UN
11. Extinction and Neglect - 0
## HPI:
EU Critical , AKA , is a woman
with
past medical history notable for atrial fibrillation not on
Coumadin for unclear reasons who presents as a transfer from an
outside hospital status post TPA for suspected left MCA
syndrome.
The history is limited and obtained from EMS reports as the
patient is unable to provide meaningful history on her own.
Reportedly, she was last known normal at , and was
apparently
with her husband at the time. She rose up out of the chair to
go
to the bathroom. He apparently did not hear from her for about
minutes and when he went to check up on her, he found her
on the bathroom floor supine and unresponsive. EMS was called.
By the time they arrived, she was noted to have a left gaze
preference and not responsive. She was taken to an outside
hospital, initial stroke scale was 19, and CT was negative
for hemorrhage, aspect score 9. She received TPA at 2200. Of
note, during this time, she was noted to have heart rates in the
120s, in A. fib, with blood pressures sustaining to 110-120
systolic. She received 500 cc of normal saline prior to
transfer
for consideration of embolectomy.
On arrival, she was noted to be spontaneously moving her right
foot, though not antigravity. She remained globally aphasic.
Of
note, her right arm was withdrawing in the plane of the bed,
whereas prior she was flaccid. She was stabilized and taken
for
CTA, which revealed a proximal M2 signal cut off. She was taken
to suite for further management.
## VITALS:
T: HR: 120 BP: 124/76 RR: SaO2: 99% RA
## GENERAL:
NAD, eyes open, looking around the room
## HEENT:
NCAT, no oropharyngeal lesions, neck supple
## PULMONARY:
Breathing comfortably on room air
## ABDOMEN:
Soft, NT, ND, +BS, no guarding
## - MENTAL STATUS:
The patient was awake, alert, tracking the
examiner. Globally a phasic. Did not follow commands.
## - CRANIAL NERVES:
PERRL 3->2 brisk. Left gaze preference,
crossed
midline with VOR. No clear blink to threat on the right,
briskly
blink to threat on the left. No ptosis. Right facial droop.
## - SENSORIMOTOR:
The patient was able to withdraw in the plane of
the bed to noxious the right upper extremity. Left upper
extremity she was able to maintain antigravity for 10 seconds.
Left lower extremity antigravity. Right lower extremity moves
spontaneously within the plane of the bed.
- Reflexes:
[Bic] [Tri] [ ] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response upgoing on the right
============================================
DISCHARGE PHYSICAL EXAM
## GENERAL:
Awake, laying comfortably in bed
## HEENT:
NC/AT, no scleral icterus noted, MMM
## PULMONARY:
Chest clear to auscultation bilaterally, breathing
comfortably, no tachypnea nor increased WOB
## CARDIAC:
irregularly irregular rhythm, skin warm, well-perfused.
## ABDOMEN:
round, soft, non-distended and non-tender
## -MENTAL STATUS:
Alert and attentive to conversation. Aphasic and
unable to repeats words thought can vocalize most words when
singing. Able to follow midline command to stick out her tongue
and appendicular command to wiggle her toes but unable to follow
appendicular commands or two step commands.
## -CRANIAL NERVES:
PERRLA. EOMI without nystagmus. R NLFF. Palate
elevates symmetrically. Tongue
protrudes in midline. strength in trapezii bilaterally.
-Motor:
Delt Bic Tri WrE WrF FEx FFx IP Quad Ham
L 5 5 5 5 5 5 5 5 5 5
R 5- 5 5 5 5 5 5 5 5 5
## - COORDINATION:
no ataxia on FNF
## =============================================
CTA HEAD/NECK:
1. There is subtle loss of gray-white
differentiation in the insula and left frontal lobe consistent
with acute infarction. No evidence of intracranial hemorrhage.
2. There is an occlusion of the proximal dominant M2 segment,
just distal to the M1 bifurcation.
3. The major vessels of the neck, circle of , and their
principal
intracranial branches appear normal without stenosis, occlusion,
or aneurysm formation. Incidental terminus
right vertebral artery.
4. Incidental 3 mm left apical micro nodule. For incidentally
detected single solid pulmonary nodule smaller than 6 mm, no CT
follow-up is recommended in a low-risk patient, and an optional
CT in 12 months is recommended in a high-risk patient.
Final read pending 3D and curved reformats.
## NEUROINTERVENTION:
LEFT INTERNAL CAROTID ARTERY:
Distal left ICA, proximal and
distal ACA
branches are well-visualized. Distal M1 occlusion was
identified. Post
thrombectomy (2 passes), successful recannulization of the MCA
territory
compatible with TICI 3 score. Otherwise vessel caliber smooth
and tapering.
Normal arterial, capillary, and venous phase . No vascular
abnormalities
identified .
Right common femoral artery: Well-visualized with a good caliber
size for
closure device.
TTE:
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is mmHg. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>65%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(?#) appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
## IMPRESSION:
Normal global biventricular systolic function. No
pathologic valvular flow. No left atrial mass/thrombus. TEE
needed to rule out left atrial appendage thrombus if it would
change clinical management.
BRAIN:
There is a large acute infarction in the left MCA territory,
involving the the left insula, left frontal lobe, and to lesser
extent left parietal lobe and superior left temporal lobe. The
left caudate and lentiform nuclei are also involved. Few
additional punctate foci of subcortical white matter acute
infarction are present within the left occipital lobe and
bilateral frontal lobes. There is no shift of midline
structures and no evidence for ventricular effacement. No
evidence for intracranial blood products.
The major intracranial vascular flow voids are maintained.
There is mild
global parenchymal volume loss with prominent ventricles and
sulci.
There are bilateral lens replacements.
## MRA BRAIN:
Images are limited by motion artifact. There has been interim
recanalization of the previously occluded superior left MCA M2
segment, which demonstrates narrowing at its proximal aspect
(2:82, 85) with reconstitution of normal caliber within the
sylvian fissure. There is also narrowing of the left inferior
M2 branch as it traverses the sylvian fissure (2:92, 87).
termination of the non dominant right vertebral artery is again
noted. No evidence for new flow-limiting stenosis or aneurysm.
## IMPRESSION:
1. Large acute infarction in the left MCA territory. Additional
punctate
acute infarcts in the subcortical white matter of the left
occipital and
bilateral frontal lobes.
2. No shift of midline structures.
3. Interval reperfusion of the previously occluded superior left
MCA M2
segment, which demonstrates narrowing at its proximal aspect
with
reconstitution of normal caliber within the sylvian fissure.
Narrowing of the left inferior M2 branch is also seen as it
traverses the sylvian fissure.
## BRIEF HOSPITAL COURSE:
Ms. is a year old woman with a history of atrial
fibrillation not on anticoagulation (for unclear reasons), who
was admitted to the Stroke service after as a transfer from an
outside hospital status post tPA (at 2200 on for left MCA
syndrome. CTA showed a left M2 cutoff; she therefore underwent
thrombectomy, with TICI 3 reperfusion. Soon after thrombectomy,
R hemibody strength improved to in upper motor neuron
pattern and she began to follow some very simple commands, but
remained mute. She was monitored per post-tPA protocol, and was
transferred to the step down unit and then the floor. Upon
discharge, her exam had greatly improved to where she has a
right lower facial droop, right pronator drift. She continues to
have trouble speaking but can follow simple commands and can say
a few words. Able to repeat single words at times, able to sing
Happy Birthday, able to say some automatic speech.
Her stroke was most likely secondary to cardio-embolus from
atrial fibrillation. Other stroke risk factors include
intracranial atherosclerosis, hyperlipidemia, and obesity. An
echocardiogram did not show a PFO on bubble study, or any
thrombus that could have propagated. She will continue rehab at
a rehab center.
## OTHER HOSPITAL ISSUES INCLUDED:
#DYSPHAGIA:
She had persistent dysphagia requiring placement of
an NG tube. A video swallow study on showed recurrent
penetration with silent aspiration of thin liquids. However, her
swallowing gradually improved and she was able to tolerate a
dysphagia diet. NG tube was removed on . Diet will continue
to be upgraded at rehab facility.
## #URINARY TRACT INFECTION:
Noted on to have foul smelling
urine. UA was grossly positive. She was treated with a 3 day
course of Ceftriaxone.
## TRANSITIONAL ISSUES:
-Convert Metoprolol and Diltiazem to long-acting formulations
once able to swallow large pills
#Left MCA CVA secondary to cardioembolism from atrial
fibrillation status post tPA and left M2 thrombectomy
- start apixaban 5mg BID on (got aspirin 81mg prior
to discharge)
- continue atorvastatin 40mg
- Goal normotension, euglycemia
- speech therapy, , OT; advance diet as tolerated
- follow up in stroke neurology clinic in months
#Atrial fibrillation
- Continue diltiazem 90mg every 6 hours, please transition to
extended release 360mg daily once patient is able to swallow the
larger extended release pill as this cannot be crushed
- Continue Metoprolol tartrate 6.25mg every 6 hours, please
transition to extended release 25mg daily once patient is able
to swallow the larger extended release pill as this cannot be
crushed
#Hypertension
- Continue home Lisinopril 40mg PO/NG and amlodipine 5mg
- home HCTZ was stoppe in the hospital given the addition of
diltiazem
## #UTI:
s/p 3 days of CTX while inpatient
#DVT prophylaxis
- SCD
- please mobilize pt
=======================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 82) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - () N/A
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Lisinopril 40 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. amLODIPine 5 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Apixaban 5 mg PO BID
Start
2. Artificial Tears DROP BOTH EYES TID
3. Atorvastatin 40 mg PO QPM
4. Diltiazem 90 mg PO Q6H
5. Metoprolol Tartrate 6.25 mg PO Q6H
6. amLODIPine 5 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
## DISCHARGE DIAGNOSIS:
Acute ischemic stroke to the Left MCA
## DISCHARGE INSTRUCTIONS:
Dear Ms ,
You were hospitalized due to symptoms of difficulty speaking
and right sided weakness resulting from an ACUTE ISCHEMIC
STROKE, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Atrial fibrillation
High blood pressure
High cholesterol
We are changing your medications as follows:
- diltiazem 90mg every 6 hours
- metoprolol 6.25mg every 6 hours
- apixaban 5mg twice per day STARTING TOMORROW,
- lisinopril 40mg daily
- amlodipine 5mg daily
- atorvastatin 40mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below. Please call the neurology department at
to schedule an appointment with Dr.
in months.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your Neurology Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14572141", "visit_id": "25818757", "time": "2147-02-20 00:00:00"} |
18214845-RR-13 | 117 | ## INDICATION:
year old woman with 3 months of pain over the metatarsal head
of left second toe, with swelling; no injury // eval abnormalities metatarsal
head left second toe
## IMPRESSION:
No acute fractures or dislocations are seen. In particular, the second
metatarsal head appears intact. However, there is some slight sclerosis of the
second metatarsal head. This is nonspecific and likely within normal limits.
However early avascular necrosis could have a similar appearance. If there is
high clinical concern, this could be further evaluated with MRI imaging. There
is mild hallux valgus metatarsus varus at the first MTP joint with minimal
degenerative changes. There is congenital fusion of the fifth DIP joint.
Calcaneal spur is seen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18214845", "visit_id": "N/A", "time": "2177-11-17 15:47:00"} |
15768973-DS-3 | 1,420 | ## ATTENDING:
Complaint:
Mucocele of the appendix
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
: Laparoscopic right colectomy
## HISTORY OF PRESENT ILLNESS:
Mrs. is a generally healthy woman
whose only significant medical problem is anxiety for which she
is on a few medications. She has a family history of colorectal
cancer with her mother having cancer in her . Her mother's
brother had esophageal cancer in his and her mother's
brother's son had gastric cancer somewhere in his older age as
well. For this reason, she has had a number of colonoscopies
since she turned , the last of which was years ago and
was normal. On the most recent colonoscopy again she had no
polyps or cancers identified, but there was an extrinsic mass
pressing into the lumen of the cecum. Biopsies demonstrated
normal mucosa, according to the patient. She underwent follow up
CT scan, which demonstrated a large mucocele of her appendix.
## PAST MEDICAL HISTORY:
1) Anxiety
2) Constipation
3) Asthma
4) Right hydronephrosis (UPJ partial obstruction)
5) Chronic interstitial cystitis
6) Lymphomatoid papulosis
## PAST SURGICAL HISTORY:
1) Exploratory laparoscopy for question of endometriosis, which
was negative ( )
2) Ureteroscopy ( )
## FAMILY HISTORY:
She has a family history of colorectal cancer with her mother
having cancer in her . Her mother's brother had esophageal
cancer in his and her mother's brother's son had gastric
cancer somewhere in his older age as well.
## VITALS:
Temp 97.8, HR 54, BP 108/62, RR 16, SpO2 97% on room air
## GEN:
Pleasant lady in no acute distress, alert and oriented
## CV:
Regular rate and rhythm
## LUNGS:
Clear to auscultation bilaterally, no respiratory
distress
## ABD:
Soft, non-distended, non-tender to palpation. Steri-strips
in place on laparoscopic incisions, no surrounding erythema or
drainage
## EXT:
Warm and well-perfused without edema
## BRIEF HOSPITAL COURSE:
The patient presented to pre-op on . She was evaluated
by anesthesia and taken to the operating room for her scheduled
laparoscopic right colectomy. There were no adverse events in
the operating room; please see the operative note for details.
She was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
## NEURO:
The patient was alert and oriented throughout
hospitalization; pain was initially managed with a dilaudid PCA,
then switched to intermittent IV morphine. She was then
transitioned to oral oxycodone once tolerating a diet.
## 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/HEME:
The patient's diet was advanced sequentially to
a regular diet, which was well-tolerated. Patient's intake and
output were closely monitored. The patient passed a few loose
dark stools post-operatively, thus her blood counts were closely
watched for signs of bleeding, of which there were none. Her
dark stools had resolved by the time of discharge.
## ID:
The patient's fever curves were closely watched for signs of
infection, of which there were none.
## PROPHYLAXIS:
The patient received subcutaneous heparin and
venodyne boots were used during this stay. She was encouraged to
get up and ambulate as early as possible.
At the time of discharge on POD #3, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a 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. Zovirax Ointment 5% 1 APPL OTHER PRN cold sore outbreak
2. Citalopram 7.5 mg PO DAILY
3. ClonazePAM 1 mg PO BID
4. LaMOTrigine 12.5 mg PO BID
5. Xopenex HFA (levalbuterol tartrate) 45 mcg/actuation
inhalation PRN shortness of breath or wheezing
6. Pantoprazole 40 mg PO Q24H
7. Sucralfate 2 tsp PO PRN reflux
8. Vitamin D 1000 UNIT PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
do not take more than 3000mg of tylenol in 24 hrs or drink
alcohol while taking
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*45 Tablet Refills:*0
2. Citalopram 7.5 mg PO BID
3. ClonazePAM 0.5 mg PO BID
4. LaMOTrigine 12.5 mg PO BID
5. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
do not take at same time as clonazepam. do not drink alcohol or
drive a car while taking.
RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
7. Sucralfate 2 tsp PO PRN reflux
8. Zovirax Ointment 5% 1 APPL OTHER PRN cold sore outbreak
9. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*6 Tablet Refills:*0
10. Xopenex HFA (levalbuterol tartrate) 45 mcg/actuation
inhalation PRN shortness of breath or wheezing
11. Vitamin D 1000 UNIT PO DAILY
## DISCHARGE DIAGNOSIS:
Mucocele of the appendix
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital after a laparoscopic right
colectomy for surgical management of your appendiceal mucocele.
You have recovered from this procedure well and you are now
ready to return home. Samples from your 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, are
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 passage 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 are 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 laparoscopic surgical incisions on your abdomen
which are closed with internal sutures and are dressed with
steri-strips. They are healing well, however it is important
that you monitor these areas for signs and symptoms of infection
including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please call the office if you develop any
of these symptoms or a fever. You may go to the emergency room
if your symptoms are severe.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. The
steri-strips will fall off over time, please do not remove them.
Please no baths or swimming for 6 weeks after surgery unless
told otherwise by your surgical team.
You will be prescribed a small amount of the pain medication
Oxycodone. 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.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. .
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": "15768973", "visit_id": "25165123", "time": "2141-02-17 00:00:00"} |
10178581-RR-57 | 105 | ## INDICATION:
CHF, now with shortness of breath and lower extremity edema.
Evaluate for pulmonary edema or other acute process.
PA AND LATERAL CHEST RADIOGRAPH. There is indistinctness of the pulmonary
vasculature, more pronounced at the right base, and progressed since . No definite pleural effusions are noted. Tenting of the right
hemidiaphragm is stable from , likely related to scarring. Slight opacity
at the right base appears somewhat worse than and may indicate early
developing infection. Surgical sutures are seen in the right upper chest.
Heart size is mildly enlarged. The aorta is slightly calcified and tortuous.
## IMPRESSION:
Findings compatible with CHF. No pleural effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10178581", "visit_id": "25617137", "time": "2160-04-03 13:32:00"} |
10274866-RR-64 | 307 | ## EXAMINATION:
ABDOMEN US (COMPLETE STUDY)
## INDICATION:
with intermittent right and left upper quadrant pain. s/p
distant cholecystectomy at outside hospital// RUQ abnormality?
## LIVER:
The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CHD measures 5 mm.
## GALLBLADDER:
The gallbladder is surgically absent.
## PANCREAS:
The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
## SPLEEN:
Normal echogenicity, measuring 9.2 cm.
## KIDNEYS:
The right kidney measures 10.5 cm. The left kidney measures 12.2 cm.
A cyst with single, thin, avascular septation in the lower pole of the left
kidney measures 3.1 x 2.0 x 3.2 cm, previously up to 2.7 cm. Normal cortical
echogenicity and corticomedullary differentiation is seen bilaterally. There
is no shadowing calculus or hydronephrosis in the kidneys.
## RETROPERITONEUM:
The visualized portions of aorta and IVC are within normal
limits.
The patient complains of pain in the midline upper abdomen which corresponds
with a colonic loop which may demonstrate mild inflammation. This could
represent an area of diverticulitis.
## IMPRESSION:
1. Point of patient's maximum tenderness appears to correspond with a colonic
loop which may demonstrate mild inflammation and could represent an area of
diverticulitis.
2. Septated left renal cyst which is almost certainly benign given minimal
change when compared with prior CT.
## RECOMMENDATION(S):
1. A CT could be performed in order to better evaluate the region of the
patient's discomfort which appears to correspond with a colonic loop with mild
inflammation.
2. The mildly complex left renal cyst can be reassessed in year with renal
ultrasound.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10274866", "visit_id": "N/A", "time": "2170-04-15 09:39:00"} |
15456164-RR-34 | 104 | ## EXAMINATION:
CHEST PORT. LINE PLACEMENT
## INDICATION:
year old man with line placement// line placement Contact
name: RESIDENT, :
## IMPRESSION:
In comparison with the study of , the right PICC line is been removed
and replaced with a right IJ catheter that extends to the midportion of the
SVC. No evidence of post procedure pneumothorax.
Increasing bilateral pulmonary opacifications most likely represent pulmonary
edema. However, more coalescent areas at the left mid and lower zone could be
a manifestation of superimposed aspiration/pneumonia in the appropriate
clinical setting.
Hemidiaphragms are not sharply seen, consistent with small bilateral pleural
effusions and compressive atelectasis at the bases.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15456164", "visit_id": "22871916", "time": "2132-12-14 23:42:00"} |
17135436-RR-13 | 614 | ## PREOPERATIVE DIAGNOSIS:
Right hemispheric stroke with symptomatic right
internal carotid artery stenosis.
## PROCEDURES PERFORMED:
Right common carotid artery arteriogram, right internal
carotid artery arteriogram, right middle cerebral artery arteriogram, left
common carotid artery arteriogram, right common femoral artery arteriogram.
## INTERVENTIONAL PROCEDURE PERFORMED:
Right internal carotid artery stenting
with Protege stent, intracranial thrombolysis of intracranial right
internal carotid artery and right middle cerebral artery with Solitaire 6 x 30
mm stent retriever.
## INDICATION:
The patient presented with significant left-sided hemiparesis and
was given TPA at an outside hospital. She did not improve substantially and
was transferred here. A noncontrast CT scan did not show any significant
infarct. Therefore, we decided to intervene.
The patient was brought to the angiography suite. Following this, both groins
were prepped and draped in a sterile fashion. Access was gained to the right
common femoral artery using a Seldinger technique. The right common carotid
artery was catheterized with 2 catheter. A road map was done. This
showed that the right internal carotid artery had a very tight stenosis,
measuring with near total occlusion. There was no filling of the right middle
cerebral artery and distal internal carotid. At this point, we placed a
Shuttle sheath in the right common carotid artery and a 4-mm Spider protection
device was placed in the distal right internal carotid artery in the cervical
portion. Following this, a Protege stent was deployed from the
right common carotid artery into the internal carotid artery. No pre- or
post-stent angioplasty was done and the vessel was seen to be patent. At this
point, right internal carotid artery arteriogram was done which showed that
the right internal carotid artery was occluded just beyond the clinoid. We
now took out the Shuttle sheath and 8 catheter was placed in
the internal carotid artery. We now catheterized the distal MCA with Marksman
catheter and a Synchro wire. Following this, Solitaire 6 x 30 mm stent
retriever was deployed in the right middle cerebral artery extending into the
right supraclinoid carotid artery. This was left in place for 5 minutes and
then withdrawn. At this point, the posterior right internal carotid artery
arteriogram demonstrated that the entire cranial circulation was now open
including the right middle cerebral artery and anterior cerebral artery.
Left common carotid artery arteriogram was done and a right common femoral
artery arteriogram was done. Since the right common femoral artery was
diminutive, the sheath was left in place.
## FINDINGS:
Right common carotid artery arteriogram shows near total occlusion
of the right internal carotid artery just beyond the bifurcation, with no flow
seen in the distal right internal carotid artery intracranially and the right
middle cerebral artery.
Right common carotid artery arteriogram status post stenting shows that the
internal carotid artery bifurcation is completely patent. There is no filling
in the distal supraclinoid carotid and the right MCA and ACA are not
visualized.
Right middle cerebral artery arteriogram demonstrates that there is distal
filling of the right middle cerebral artery at the level of the M2.
Right internal carotid artery arteriogram status post embolectomy with a
Solitaire device shows that the right internal carotid artery is now fully
patent, with both anterior and middle cerebral arteries seen well.
Left common carotid artery arteriogram shows that the left MCA fills well and
the left A1 is dominant. There is no significant stenosis in the common
carotid or intracranially.
Right common femoral artery arteriogram shows that the right common femoral
artery is very diminutive.
underwent cerebral angiography followed by right internal carotid
artery stenting and Solitaire stent retriever 6 x 30 mm thrombectomy of the
distal internal carotid artery and the right middle cerebral artery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17135436", "visit_id": "27464467", "time": "2167-08-16 20:18:00"} |
15273463-RR-37 | 105 | ## INDICATION:
Fall two weeks prior. Rule out bleed.
## FINDINGS:
There is no intra- or extra-axial hemorrhage, masses, mass effect,
or shift of normally midline structures. The ventricles and sulci are
moderately prominent and may reflect age-associated involutionary changes.
There is bilateral periventricular white matter hypoattenuation, suggestive of
chronic microvascular ischemic change. There is a mucous retention cyst in
the left sphenoid air cell. There is left maxillary sinus mucosal thickening.
The osseous and soft tissue structures are unremarkable.
## IMPRESSION:
1. No acute intracranial process. Specifically, there is no evidence of
intracranial traumatic injury.
2. Periventricular white matter chronic microvascular ischemic changes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15273463", "visit_id": "N/A", "time": "2162-08-08 17:39:00"} |
13250600-RR-15 | 129 | ## INDICATION:
female full fetal survey.
## PREVIOUS SCAN DATE:
None.
There is a single live intrauterine gestation. There is no evidence of
previa. The fetus is in cephalic position. The placenta is anterior in
location. Amniotic fluid volume is normal. No fetal morphologic
abnormalities are detected. Views of the head, face, heart, outflow tracts,
stomach, kidneys, cord insertion site, bladder, spine and extremities are
normal.
There is a 2.9 x 3 x 3.9 cm intramural fibroid within the anterior lower
uterine segment. There is a second fibroid located intramurally and
anteriorly measuring 2.3 x 3.1 x 1.4 cm. No adnexal abnormalities are seen.
The following biometric data were obtained.
## IMPRESSION:
1. Sizes equals dates.
2. There are two anterior fibroids within the uterus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13250600", "visit_id": "N/A", "time": "2136-04-18 14:41:00"} |
19982183-RR-51 | 395 | ## INDICATION:
year old woman with pleomorphic sarcoma with enlarging right
sacral mass and pain. For cryoablation. and // Right sacral
mass
## ANESTHESIA:
The procedure was performed with general anesthesia.
## MEDICATIONS:
For full details please refer to anesthesiology notes.
## CONTRAST:
0 ml of Optiray contrast.
## RADIATION DOSE:
Acquisition sequence:
1) Spiral Acquisition 7.1 s, 21.6 cm; CTDIvol = 16.2 mGy (Body) DLP = 329.8
mGy-cm.
2) Stationary Acquisition 5.4 s, 1.4 cm; CTDIvol = 56.0 mGy (Body) DLP =
80.7 mGy-cm.
3) Spiral Acquisition 18.6 s, 19.0 cm; CTDIvol = 48.4 mGy (Body) DLP =
868.6 mGy-cm.
4) Spiral Acquisition 6.2 s, 19.0 cm; CTDIvol = 16.0 mGy (Body) DLP = 284.0
mGy-cm.
5) Spiral Acquisition 6.2 s, 19.0 cm; CTDIvol = 16.1 mGy (Body) DLP = 285.6
mGy-cm.
Total DLP (Body) = 1,857 mGy-cm.
## PROCEDURE:
CT-guided cryoablation of right sacral mass
## PROCEDURE DETAILS:
Following explanation of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the computed tomography suite and general anesthesia was
induced by the anesthesiologist. The patient was then placed prone on the
imaging table. Following scout imaging, the skin was marked and draped in the
usual sterile fashion.
Under CT fluoroscopy, three separate 2.1 mm IceForce cryoprobes were placed in
sequential fashion, parallel and approximately 1 cm apart. Non-contrast CT
was performed confirming good positions of the probes. Cryoablation was
performed for 11 minutes freezing (with intermittent CT of the area every 3
minutes to evaluate the iceball, followed by an 8 min passive thaw cycle, and
a repeat 11 minute freeze cycle (at 70%). Following this, each probe was
carefully removed. The skin was then cleaned and a dry sterile dressing was
applied. The patient was awakened from general anesthesia without incident and
there were no immediate post-procedure complications. The patient was
transferred to the post-anesthesia care unit
for further monitoring.
## FINDINGS:
Again seen is a soft tissue mass eroding the right sacrum. Given the
patient's symptoms, the lateral aspect of the lesion was ablated, with care
taken to avoid the effaced right S1 neural foramen.
## IMPRESSION:
Technically-successful cryoablation of the lateral aspect of the right sacral
mass. Follow-up cementoplasty / fixation is planned.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19982183", "visit_id": "N/A", "time": "2170-12-02 15:26:00"} |
12335304-DS-10 | 1,261 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## :
Coronary artery bypass grafting x 4 with
the left internal mammary artery to left anterior descending
artery and reverse saphenous vein graft to the ramus
intermedius artery and sequential reverse saphenous vein graft
to the right posterior descending artery and a posterolateral
branch artery.
## HISTORY OF PRESENT ILLNESS:
Mr. is a year old man with a history of
esophagus, hyperlipidemia, obstructive sleep apnea, and seizure
disorder. He has noted episodes of throat tightness while
walking his dog. His symptoms resolved with rest. He reported
his symptoms to Dr. referred him for a stress test
which was positive for ischemia. A cardiac catheterization
demonstrated
severe multivessel coronary artery disease with preserved left
ventricular function. He was referred to Dr. surgical
revascularization.
He stated that he first noted onset of throat tightness with
exertion about six weeks ago. His denied any associated
symptoms. His throat tightness resolved with rest. He denied
syncope, dizziness, lightheadedness, shortness of breath,
dyspnea on exertion, palpitations, orthopnea, paroxysmal
nocturnal dyspnea,
or lower extremity edema.
## PAST MEDICAL HISTORY:
Esophagus
Coronary Artery Disease
Diverticulitis
Esophageal Stricture
Gastroesophageal Reflux Disease
Hernia
Hyperlipidemia
Obstructive Sleep Apnea, not on CPAP
Seizure Disorder
Tinnitus
## FAMILY HISTORY:
No known premature history of coronary artery disease
Mother - died at age
Father - estranged
Grandmother - died of brain aneurysm
Grandfather - died of cancer
## ADMISSION EXAM:
Vital Signs sheet entries for :
## GENERAL:
Pleasant man, WDWN, NAD
## HEENT:
NCAT, PERRLA, EOMI, OP benign
## HEART:
Bradycardia, regular rhythm, no murmur appreciated
## ABDOMEN:
Normal BS, soft, non-tender, non-distended
## EXTREMITIES:
Warm, well-perfused, trace edema
## T:
98.1 HR: 56-61 SR BP: 114-137/88 RRL Sats: 95% RA
## GENERAL:
AA & O x 3 walks independently
## RESP:
clear breath sounds throughout
## EXTR:
warm 2 + edema lower extremities
## STERNAL:
clean dry intact. LLE clean dry intact. no erythema
sternum stable
## PRE-OPERATIVE STATE:
Pre-bypass assessment. Sinus rhythm.
Left Atrium (LA)/Pulmonary Veins: Dilated LA.
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
Normal RA size. Normal interatrial septum. No atrial septal
defect by 2D/color flow Doppler.
## LEFT VENTRICLE (LV):
Mild symmetric hypertrophy. Normal cavity
size. Normal regional & global systolic function
## RIGHT VENTRICLE (RV):
Normal free wall motion.
## AORTA:
Normal sinus diameter. Normal ascending diameter. No
dissection.
## AORTIC VALVE:
Thin/mobile (3) leaflets. No stenosis. No
regurgitation.
## MITRAL VALVE:
Mildly thickened leaflets. No stenosis. Trace
regurgitation.
## TRICUSPID VALVE:
Normal leaflets. Trace regurgitation.
## POST-OP STATE:
The post-bypass TEE was performed at 11:14:00.
Atrial paced rhythm.
## LEFT VENTRICLE:
Similar to preoperative findings. Similar
regional function. Global ejection fraction is normal.
## AORTIC VALVE:
No change in aortic valve morphology from
preoperative state. No change in aortic regurgitation.
## MITRAL VALVE:
No change in mitral valve morphology from
preoperative state. Mild [1+] valvular regurgitation.
## PERICARDIUM:
No effusion.
Electronically signed by MD on
at 12:37:57
## CXR:
Patient is status post coronary artery bypass graft surgery.
Cardiac,
mediastinal and hilar contours appear stable. Small pleural
effusions are
likely unchanged with minor associated atelectasis at each
posterior basilar lower lobe. No pneumothorax. Platelike left
midlung opacity is resolved. Right internal jugular catheter
was removed.
## BRIEF HOSPITAL COURSE:
Mr was brought to the Operating Room on where the
patient underwent coronary artery bypass grafting x4. For
details see operative report, in summary he had: Coronary artery
bypass grafting x4 with the left internal mammary artery to left
anterior descending artery and reverse saphenous vein graft to
the ramus
intermedius artery and sequential reverse saphenous vein graft
to the right posterior descending artery and a posterolateral
branch artery. He tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He extubated
within several hours of arrival in . POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, he weaned off his pressor support and later in the day
transferred to the step down floor. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. All tubes, lines and pacing wires were discontinued per
cardiac surgery protocol without complication. Once on the step
down floor the patient worked with nursing and was evaluated by
the Physical Therapy service for assistance with strength and
mobility. He did have post-operative atrial fibrillation that
was treated with Metoprolol and Amiodarone after which he
converted back to sinus rhythm. The remainder of his hospital
course was uneventful. By the time of discharge on POD 5 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to home in good condition with appropriate follow up
instructions.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fenofibrate 54 mg PO DAILY
3. LevETIRAcetam 500 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 40 mg PO QPM
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q6H
2. Amiodarone 400 mg PO BID
BID x5 days then
400mg daily x7 days then
200mg daily
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*60
## TABLET REFILLS:
*1
3. Furosemide 40 mg PO DAILY Duration: 10 Days
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*10
## TABLET REFILLS:
*1
4. Metoprolol Tartrate 12.5 mg PO BID
hold for HR < 55, SBP < 100
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
every twelve (12) hours Disp #*30 Tablet Refills:*2
5. Polyethylene Glycol 17 g PO DAILY
6. Potassium Chloride 10 mEq PO DAILY Duration: 10 Days
RX *potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth
once a day Disp #*10 Tablet Refills:*1
7. Senna 17.2 mg PO DAILY
8. TraMADol mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*5 Tablet Refills:*0
9. Simvastatin 20 mg PO QPM
10. Aspirin 81 mg PO DAILY
11. Fenofibrate 54 mg PO DAILY
12. LevETIRAcetam 500 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Omeprazole 20 mg PO DAILY
## PRIMARY:
Coronary Artery Disease s/p CABGx4(Lima->LAD, SVG->PDA seq RCA,
OM)
Post-op Atrial fibrillation
## SECONDARY:
Esophagus, Diverticulitis, Esophageal Stricture,
Gastroesophageal Reflux Disease, Hernia, Hyperlipidemia,
Obstructive Sleep Apnea, not on CPAP, Seizure Disorder, Tinnitus
## DISCHARGE CONDITION:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
## DISCHARGE INSTRUCTIONS:
1. Shower daily -wash incisions gently with mild soap,
2. No baths or swimming, look at your incisions daily
3. NO lotion, cream, powder or ointment to incisions
## 4. DAILY WEIGHTS:
keep a log. Call with a weight gain of
pounds over 5 days
5. Monitor your incision for signs of infection: fever > 101.5,
redness, drainage or increased pain. Should you have any of
these symptoms please call the office immediately
6. No driving for one month or while taking narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
7. No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns . Answering service will contact on call
person during off hours**
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12335304", "visit_id": "27491520", "time": "2142-05-20 00:00:00"} |
12457519-DS-21 | 1,865 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
dyspnea, Mitral Clip evaluation
## HISTORY OF PRESENT ILLNESS:
Mr. is a male with past medical history
significant for CKD III, HFpEF (EF57% Class III) renal
cancer s/p right partial Nephrectomy, PPM/ICD, AFIB previously
on Coumadin, COPD, pulmonary HTN, with severe mitral
regurgitation with multiple hospitalizations over the past six
months for CHF exacerbations, transferred to for further
management of HFpEF and evaluation for mitral valve
regurgitation.
Of note, last admission in and
discharged to extended care facility on . Hospital course
notable for exacerbation of HF requiring IV diuresis, flash
pulmonary edema thought to be secondary to HF and severe MRI,
, aspiration pneumonia and an abdominal rectus sheath
hematoma requiring transfusion. Given mod-severe MR,
evaluated by structural heart team, and an extensive discussion
was had with and wife given the many medical
co-morbidities. Acute intervention was deferred at that time
with plan to re-evaluate.
Most recently, was admitted to on from
home (from rehab x 6 days) with c/o of SOB, weight up 5 lbs,
increased edema, increased falls and difficulty ambulation.
32003 on admission to OSH. CXR with persistent recurrent
pulmonary edema, CT negative for intracranial hemorrhage or
fracture or infarction. CT cervical spine with no acute findings
and hypodensity in the left thyroid lobe. US negative for DVT.
EKG with afib/flutter and V pacing. Started on Lasix drip at
20mg/hr and given Metalazone x 1. He diuresed well and weight is
down 5 lbs since admit. Lasix decreased today to 10mg/hr as he
has met his daily goal liter negative for today.
transferred to to to reevaluate for Mitraclip and further
CHF mgt.
On arrival to the floor reports he was at home following
his recent discharge and he became increasingly dyspneic. He has
also has had multiple falls at home. reports he is aware
of when he is going to fall and notices that his legs give out
and he has visual changes. On arrival denies chest pain,
denies dyspnea but notes that he can hear himself breathing.
## PAST MEDICAL HISTORY:
-HTN, HLD, Persistent Afib on Coumadin, complete heart block s/p
PPM , CKD III, HFpEF hypertensive heart disease (
Class III), Pulmonary HTN, COPD, Renal Cell Carcinoma s/p right
partial nephrectomy, Hx colonic polyps, Diverticulosis
-Hx recurrent dizziness/falls -> long standing exertional
dizziness included extensive cardiac evaluation in the past,
negative adenosine MIBI , TTE
## FAMILY HISTORY:
Father with disease.
Sister possibly with disease.
## DRY WEIGHT:
84.5kg at time of discharge
## GENERAL:
frail appearing mail in NAD. Oriented to person and
, slowed in responses. Mood, affect appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. poor dentition
## NECK:
Supple with JVD appreciable to angle of mandible at 90
degrees
## CARDIAC:
PMI located in intercostal space, midclavicular
line. irregular rate, systolic murmur heard at apex .
## LUNGS:
Minimal inspiratory effort, decreased breath sounds
bilaterally. No crackles, wheezes or rhonchi.
## ABDOMEN:
Soft, NTND. Normoactive bowel sounds
## EXTREMITIES:
Warm, well perfused. No edema on exam. Significant
bruising on hands bilaterally.
## PULSES:
Distal pulses palpable and symmetric
## NEURO:
No CN2-12 defects, oriented to person and . slow to
answers, able to count backwards from . ABle to lift all
extremities against gravity.
DISCHARGE PHYSICAL
=================
## GENERAL:
awake and alert to person and time. NAD.
Sitting
up in chair.
## HEENT:
sclera non-icteric, pink conjunctiva, poor dentition, JVP
non elevated sitting straight up in chair
## CV:
systolic murmur heard throughout but best at the apex.
## RESP:
Breathing comfortable, lungs clear to auscultation. No
wheezes.
## GI:
large palpable superficial mass LLQ, nonpainful to
palpation,
Normoactive bowel sounds throughout, abdomen soft and
non-distended, non-tender to palpation throughout.
## SKIN:
Warm and well perfused. Significant erythema, few ulcers
and skin breakdown on his RLE at baseline. Ecchymosees on hands
bilaterally.
## NEURO:
AOx2, able to say days of week backwards and months of
years backwards, no focal neuro deficits. Has a resting tremor
in
both arms.
## CT HEAD :
1. No evidence of acute intracranial hemorrhage or acute
infarction. No
evidence of calvarial fracture.
2. Area of hyperdensity in the region of the left frontal lobe
with associated unchanged vasogenic edema, measuring
approximately 2 x 2 cm. Evaluation of this structure is
somewhat limited secondary to motion, however apparently is
extra-axial. The appearance of this region is unchanged in
comparison to the CT head dated .
3. Stable appearance of chronic right basal ganglia lacunar
infarct and right parietal lobe encephalomalacia.
## CXR :
Compared to chest radiographs through one.
Moderate right pleural effusion is smaller. Pulmonary vascular
congestion has improved. Moderate cardiomegaly stable. No
pneumothorax.
## BRIEF HOSPITAL COURSE:
Summary for Admission:
===============================
Mr. is a male with past medical history
significant for CKD III, HFpEF (EF57% Class III) renal
cancer s/p right partial Nephrectomy, PPM/ICD, AFIB previously
on Coumadin, COPD, pulmonary HTN, with severe mitral
regurgitation with multiple hospitalizations over the past six
months for CHF exacerbations, transferred to for further
management of HFpEF and evaluation for mitral valve
regurgitation. While inpatient, was initially placed on
a lasix gtt. However given his laboratory values and exam
suggested euvolemia, was transitioned to oral Torsemide
60mg BID on . His home Metoprolol was continued. He was
evaluated by the Structural Heart Team who, given the
overall poor prognosis and current deconditioning, did not feel
Mr. was a suitable candidate. Additionally blood pressure
was noted to fluctuate in the setting of positive orthostatics.
His blood pressure improved with restarting his home Midodrine.
noted to have recurrent falls while inpatient, but
repeat NCHCT was negative for acute changes. Physical therapy
evaluated the and recommended rehab. Palliative Care and
Geriatrics were also involved in the care of this .
## ACUTE ISSUES ADDRESSED:
========================
# Acute on chronic diastolic CHF, with preserved EF (57%)
class III: recently admitted to for CHF
exacerbation and re-presented to with evidence
of dyspnea and weight gain. was placed on a lasix gtt at
the outside hospital with approximate decrease in 5lbs.
transferred to for further volume management. On
admission, Na was uptrending as well as bicarbonate.
His JVD was elevated but felt to be likely in the setting of
known TR. As a result transitioned to oral Torsemide on
at 60mg BID. He continued his home Metoprolol Succinate
25mg, fractionated while inpatient. Given his overall
deconditioning and poor prognosis, Palliative Care was
consulted. In discussion with our team and palliative care,
and wife decided to pursue rehab and remained
full code but with a limited trial of life-sustaining
interventions.
## # SEVERE RHEUMATIC MITRAL REGURGITATION:
Last ECHO completed
which was notably for moderate to severe MR.
previously evaluated by cardiac surgery and deemed to be
of high risk for conventional surgical mitral valve replacement.
was re-evalauted by the structural heart team who did
not feel Mr. was a candidate for mitral clip procedure.
## # FREQUENT FALLS:
Initially presented to T Head and CT C spine were negative for acute
process. Falls likely in the setting of deconditioning and
orthostatic hypotension. Physical therapy evaluated the
and recommended rehab. While inpatient, fell out of bed,
despite a bed alarm. Non contrast head CT was without acute
abnormality. Home midodrine was restarted for management of
blood pressure.
## # ATRIAL FIBRILLATION:
Continued home Metoprolol Succinate 25mg
for rate control. No anticoagulation given frequent falls.
## # TYPE II NSTEMI:
EKG without obvious ischemia on admission,
troponins elevated to 0.073, and trended to 0.078, 0.090.
Elevation was felt to be in the setting of demand and worsened
by decreased clearance secondary to his renal function.
## # HYPERNATREMIA:
Na 150 on admission, sodium monitored during
admission and corrected with D5W.
## ==========================
# ON CKD STAGE IV:
Baseline Sr Cr 2.7-2.9. Sr Cr was
monitored during admission and improved with diuresis. At time
of discharge 2.9.
## # MENTAL STATUS:
Concern at outside hospital for acute on
chronic encephalopathy. While at , mental status noted to
wax and wane. without acute neurologic changes and a
normal neurologic exam. Geriatrics was consulted who recommended
potential outpatient Neurology evaluation for Body
Dementia.
## # COPD:
was given duonebs and remained stable on room
air.
## # ORTHOSTATIC HYPOTENSION:
Holding home Midodrine currently.
## # MACROCYTIC ANEMIA:
Hemoglobin was at baseline during
admission and was trended for acute changes.
## MEDICATIONS CHANGED:
Torsemide 40mg PO BID -> 60mg PO BID
[] Please check chem-10 within days of discharge
[] PCP should refer to Neurology for dementia evaluation, some
concern for body dementia
[] is at high risk of falls
[] Per most recent S&S eval, should be on soft solid diet with
thin liquids
[] at one point made DNR/DNI during this hospitalization
by his wife. to full code as his condition improved.
Would continue to engage her in conversations about his code
status and potential hospice as his heart failure appears to be
end stage.
# CODE: Full code with limited trial of life sustaining
measures, please contact HCP immediately if any sudden change in
clinical status
# CONTACT/HCP: Wife,
on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen mg PO Q8H:PRN Pain - Mild
2. Atorvastatin 20 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Midodrine 5 mg PO BID
5. Senna 17.2 mg PO BID:PRN constipation
6. Torsemide 40 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM right rib pain
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Vitamin D UNIT PO DAILY
## DISCHARGE MEDICATIONS:
1. Hydrocerin 1 Appl TP TID:PRN dry skin
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheezing
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Torsemide 60 mg PO BID
5. Acetaminophen mg PO Q8H:PRN Pain - Mild
6. Atorvastatin 20 mg PO QPM
7. Docusate Sodium 100 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD QAM right rib pain
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Midodrine 5 mg PO BID
11. Senna 17.2 mg PO BID:PRN constipation
12. Vitamin D UNIT PO DAILY
## PRIMARY DIAGNOSIS:
===================
Acute exacerbation of diastolic heart failure
Severe Mitral Regurgitation
Orthostatic Hypotension
Recurrent Mechanical Falls
Pulmonary Hypertension
## SECONDARY DIAGNOSIS:
=====================
COPD
Chronic Kidney Disease Stage III
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
Thank you for choosing as
your site of care!
Why was I admitted to the hospital?
-You were having trouble breathing and gaining weight at home.
-You were transferred to for evaluation of your mitral
valve.
What was done for me while I was in the hospital?
-You were given water pills to help get water off of your lungs.
-We monitored your blood pressure closely.
-We had our structural heart team evaluate you. Because of your
overall health, we did not think that replacing your heart valve
would be beneficial to your health.
-You fell multiple times during your admission, a repeat image
of your head did not show acute changes or bleeding.
-Our physical therapy team evaluated you. They recommended you
go to a rehab facility to get stronger.
What should I do when I go home?
-Please continue taking all of your medications as prescribed.
-Follow up with your providers as detailed below.
-Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
-If you notice more difficulty breathing, please call your
doctor.
We wish you the best!
Your treatment team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12457519", "visit_id": "24915292", "time": "2141-07-09 00:00:00"} |
18837589-RR-38 | 437 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
year old man s/p robotic RLL wedge // Evaluate for
interval change in RLL effusion
## HEART AND VASCULATURE:
The thoracic aorta is normal in caliber. The heart,
pericardium, and great vessels are within normal limits based on an unenhanced
scan. No pericardial effusion is seen. Coronary artery and thoracic aortic
calcifications are moderate to severe.
## AXILLA, HILA, AND MEDIASTINUM:
No axillary, supraclavicular, or hilar
lymphadenopathy. Enlarged right upper paratracheal lymph nodes appear similar
to prior. The previously described enlarged soft tissue density in the right
lower paratracheal station (4:88) appears similar to slightly decreased in
size, and again likely represents an enlarged lymph node versus postoperative
hematoma if there is a history of prior mediastinoscopy.
## PLEURAL SPACES:
Slight interval decrease in size of the loculated portion of
the right pleural effusion. A dependently layering component of the right
pleural effusion appears to have increased in size over the interval, and is
now moderate to large, but measures simple density.
## LUNGS/AIRWAYS:
Airway patency has improved significantly over the interval.
No secretions are seen within the central airways. Patient is status post
prior right lower lobe wedge resection. Remaining right lower lobe
demonstrates interval improvement in the degree of aeration, although the
majorty of the lobe remains consolidated with air bronchograms. Furthermore,
there has been interval improvement in the degree of aeration of the right
upper lobe, which also demonstrates a large area of persistent consolidation.
Dependent compressive atelectasis of the left lower lobe is also improved. A
5 mm nodule in the right middle lobe is stable.
## BASE OF NECK:
Visualized portions of the base of the neck show no abnormality.
## ABDOMEN:
Included portion of the unenhanced upper abdomen is noted are
multiple radiodense pills within the gastric fundus.
## BONES:
No suspicious osseous abnormality is seen.? There is no acute fracture.
## IMPRESSION:
1. Interval improvement in the degree of aeration of the right lower lobe,
right upper lobe, and left lower lobe. Persistent areas of consolidation,
particularly within the right lower lobe, are concerning for pneumonia.
2. Improved patency of the airways. No secretions seen within the central
airways.
3. Slight interval decrease in size of the loculated portion of the right
pleural effusion. The dependently layering component of the right pleural
effusion appears to have increased in size over the interval, and is now
moderate to large, but measures simple density.
4. Persistently enlarged mediastinal lymphadenopathy, similar to prior.
## NOTIFICATION:
Updated findings point 1 was discussed with Dr. , by
, M.D. on the telephone on at 10:11 AM, 30 minutes after
discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18837589", "visit_id": "27022736", "time": "2117-09-29 21:04:00"} |
19899252-RR-14 | 217 | ## INDICATION:
Right upper lobe opacification noted on recent chest radiograph
in addition to extracardiac opacity.
## FINDINGS:
The abnormality identified on the radiograph represents tortuosity
of the proximal right subclavian artery, though characterization of this is
limited without IV contrast (601B:24). There is no focal consolidation or
pleural effusion. However, there are several incidental pulmonary nodules,
none of which measure more than 4 mm in the right upper lobe and left upper
lobe (4:65, 73, 98). The lungs are otherwise clear. The ascending aorta is
mildly ectatic, measures 43mm. Stent is noted in the left anterior descending
artery. The aortic valve is calcified. There are scant mitral annular
calcifications.
Though not tailored for subdiaphragmatic evaluation, the included portions of
the upper abdomen are notable for cholecystectomy clips. There may be a few
diverticula around the hepatic flexure (2:58). There is no osseous lytic or
blastic lesion worrisome for malignancy.
## IMPRESSION:
1. Opacity medial to the right upper mediastinum on radiograph corresponds to
tortuosity of the right subclavian artery. There is no abnormality in the
adjacent lung.
2. Several incidental pulmonary nodules as described above, none of which are
more than 4 mm. In the absence of risk factors, no additional followup is
required.
3. Probable colonic diverticulosis, incompletely imaged.
4. Aortic valve calcifications.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19899252", "visit_id": "N/A", "time": "2112-02-22 14:55:00"} |
15407766-DS-7 | 846 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
ERCP with stent removal, sphincterotomy, extraction of multiple
stones and sludge
## HPI:
Ms. is a female with HTN, atrial
fibrillation on apixaban, CVA with mild residual left sided
weakness, GERD, and a recent ICU admission with sepsis
from
cholangitis during which she underwent ERCP with stent placement
but did not have sphincterotomy at the time due to chronic
anticoagulation who presents for observation after repeat ERCP.
Patient underwent ERCP with stent removal, sphincterotomy, and
removal of stones and sludge. She is doing well after the
procedure and has no acute complaints. She is not experiencing
pain, nausea, or shortness of breath. She is afebrile and a
little hypertensive.
## ROS:
Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
## PAST MEDICAL HISTORY:
Afib
Glaucoma
OA
HTN
GERD
CVA with residual L-sided weakness
## VITALS:
Afebrile and vital signs stable (see eFlowsheet)
## GENERAL:
Alert and in no apparent distress
## ENT:
Ears and nose without visible erythema, masses, or trauma.
## CV:
Heart regular, systolic murmur
## RESP:
Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
## GI:
Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
## MSK:
Neck supple, moves all extremities
## SKIN:
No new rashes noted
## NEURO:
Alert, oriented, speech fluent
## GENERAL:
Alert and in no apparent distress, sitting in chair
## ENT:
Ears and nose without visible erythema, masses, or trauma.
## CV:
Heart regular, systolic murmur. Trace edema.
## RESP:
Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
## GI:
Obese abdomen. Abdomen soft, non-distended, non-tender to
palpation. Bowel
sounds present.
## MSK:
Neck supple, moves all extremities
## SKIN:
No new rashes noted
## NEURO:
Alert, oriented, speech fluent. Answers appropriately.
## ERCP:
sphincterotomy with removal of stent, sludge, stones
HIDA Scan
Tracer enters the small intestine at 12 minutes. An oblong
structure along the
right hepatic lobe demonstrated mild tracer uptake. At repeat
images 2 hours
after the initial injection, the gallbladder was visualized.
## IMPRESSION:
Normal visualization of the gallbladder. No
cholecystitis.
## BRIEF HOSPITAL COURSE:
Ms. is a female with HTN,
atrial fibrillation on apixaban, CVA with mild residual left
sided weakness, GERD, and a recent ICU admission with
sepsis from cholangitis during which she underwent ERCP with
stent placement but did not have sphincterotomy at the time due
to chronic anticoagulation who presents for observation after
repeat ERCP for stent removal. She tolerated the procedure well.
She was seen by general surgery but was deferred for gallbladder
removal.
## # CHOLEDOCHOLITHIASIS
# PREVIOUS CHOLANGITIS:
Underwent repeat ERCP with
sphincterotomy
with removal of stones, sludge, and previous stent. She
tolerated the procedure well with no or post procedure
complications. Her diet was advanced without complications. Her
apxiaban was restarted 72 hours post-procedure without
complication.
She was seen by ACS for consideration of a CCY and underwent a
HIDA scan on which was negative for evidence of active GB
infection. Given her age and comorbidities, it was felt that the
benefits of a gall bladder removal were outweighed by the
potential risk and the surgery was deferred. Pt notably was open
to the consideration of surgery if she felt it would be safe and
beneficial.
#Anemia
Patient with anemia, improved from recent admission. No signs of
active bleeding. H/H remained stable.
## #AFIB:
Rate controlled on metoprolol 25mg BID. We held apixaban
for 72 hours as above and was restarted without complication.
## #HTN:
Continue amlodipine. BPs were stable on the day of
discharge.
## #PRIOR CVA:
Continue home atorvastatin
#Glaucoma: continue home eye drops
Transitional issues:
[ ] Monitor clinically for evidence of recurrent infection;
fever, abdominal pain
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Metoprolol Tartrate 25 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Omeprazole 20 mg PO DAILY
8. amLODIPine 5 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. amLODIPine 5 mg PO DAILY
5. Apixaban 5 mg PO BID
6. Atorvastatin 20 mg PO QPM
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Metoprolol Tartrate 25 mg PO BID
11. Omeprazole 20 mg PO DAILY
## DISCHARGE INSTRUCTIONS:
Ms. ,
It was a pleasure taking care of you during your admission to
. You were admitted for a planned ERCP to have the stent in
your bile duct removed. This procedure went well; the stent was
removed and you also had a procedure called a sphincterotomy.
He was seen by the surgery team who felt the potential benefits
of a gallbladder removal were outweighed by the risks, and so
this procedure was deferred.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15407766", "visit_id": "26877336", "time": "2157-10-24 00:00:00"} |
18833064-RR-35 | 298 | ## INDICATION:
female with epigastric pain. Question colitis.
## CT ABDOMEN:
With the exception of bibasilar dependent atelectasis, the lung
bases are clear. There is no pleural effusion. The heart is normal in size
without pericardial effusion.
The liver demonstrates no focal lesion. There is however suggestion of
nodularity along the liver margin anteriorly, raising question of cirrhosis.
A tiny hyperdense lesion along the anterior liver margin is incompletely
characterized. There is mild intrahepatic biliary dilatation and prominent
CBD measuring up to 15 mm, at least in part related to post-cholecystectomy
state. The pancreatic duct is not dilated. The pancreas, gallbladder, right
adrenal gland, and kidneys appear unremarkable. There is mild thickening of
the left adrenal gland with adjacent coarse calcification, nonspecific. Small
and large bowel loops are normal in caliber. There is no free air or free
fluid within the abdomen. No intra-abdominal lymphadenopathy. Great vessels
are patent.
## CT PELVIS:
The bladder, uterus, adnexa, and rectum appear within normal
limits. Mild colonic diverticulosis without diverticulitis. No pelvic
lymphadenopathy. No free fluid within the pelvis.
## BONE WINDOW:
There is diffuse demineralization of osseous structures. There
is grade 1 anterolisthesis of L3 on L4 and L4 on L5. Additional multilevel
thoracolumbar spondylosis and facet arthropathy are present.
## IMPRESSION:
1. No evidence of acute intraabdominal or intrapelvic process such as
colitis.
2. Status post cholecystectomy with minimal intrahepatic biliary dilatation
and prominent CBD, nonspecific. If there is continued clinical concern,
non-emergent MRCP may be considered for further evaluation.
3. Nodular liver contour suggestive of cirrhosis. Tiny peripheral hyperdense
lesion along anterior left liver margin is incompletely characterized.
Nonemergent MRI could be performed for further evaluation.
4. Diverticulosis without diverticulitis.
Final impressions were posted on communications dashboard on evening of
to be directly communicated to the ordering physician.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18833064", "visit_id": "N/A", "time": "2199-09-24 16:38:00"} |
14792389-RR-58 | 362 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
year old man with resected metastatic colon cancer now s/p 6
cycles of FOLFIRI. // Please evaluate for recurrent colon cancer.
## DOSE:
DLP: 1339.60 mGy-cm (abdomen and pelvis.
## LOWER CHEST:
Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
## HEPATOBILIARY:
The patient is status post resection of hepatic metastases in
segments V and VIII. A 1.1 cm hypodensity in segment II (series 3, image 50)
appears grossly unchanged from . There is no evidence of focal
lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits, without stones or
gallbladder wall thickening.
## SPLEEN:
The spleen is enlarged measuring 15.0 cm, however homogeneous in
attenuation without evidence of focal lesions.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation.
## ADRENALS:
The right and left adrenal glands are normal.
## URINARY:
The kidneys show no evidence of hydronephrosis or stones. A 1.8 cm
left renal cyst (series 3, image 77) appears unchanged from .
## GASTROINTESTINAL:
The patient is status post sigmoid colon resection without
evidence of complication. Colon and rectum are within normal limits. Appendix
has normal caliber without evidence of fat stranding.
## MESENTERY AND RETROPERITONEUM:
There is an unchanged prominent left common
iliac lymph node measuring 9 mm in short axis (series 3, image 96). A
perirenal lymph node measures is 8 mm in short axis, unchanged from .
There is no free air.
## VASCULAR:
There is no abdominal aortic aneurysm. There is no calcium burden in
the abdominal aorta and great abdominal arteries. There is no evidence of clot
within the main portal vein, splenic vein and SMV.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. Reproductive
organs are within normal limits
## BONES AND SOFT TISSUES:
No bone finding suspicious for infection or malignancy
is seen. Abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. No evidence of recurrent disease within the abdomen and pelvis.
2. The patient is status post partial colectomy and multiple hepatic
resections without evidence of complication.
3. Stable moderate splenomegaly.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14792389", "visit_id": "N/A", "time": "2174-06-26 10:28:00"} |
13130904-RR-166 | 107 | ## INDICATION:
Pain and swelling of the right second MCP.
## FINDINGS:
No fracture or dislocation is seen. Extensive degenerative change
is seen at the first interphalangeal joint with slight subluxation. No
degenerative change or other bony abnormality is seen at the second MCP.
Degenerative disease at the second distal interphalangeal joint is moderately
severe. Chondrocalcinosis is noted in the region of the TFC. Nonspecific
periarticular calcification is seen adjacent to the third PIP. Soft tissues
are unremarkable. There is diffuse demineralization seen.
## IMPRESSION:
Degenerative changes as described above, most pronounced at the
interphalangeal joint of the thumb and the distal interphalangeal joint of the
second digit.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13130904", "visit_id": "N/A", "time": "2152-03-18 10:23:00"} |
12235296-RR-78 | 140 | ## HISTORY:
woman status post left thoracotomy and left lower lobe
subsegmental resection.
## FINDINGS:
A chest tube is now seen entering the left hemithorax, in adequate
position. There is a right-sided IJ catheter with its tip in the right
atrium. The lung volumes are low with atelectatic changes at both lung bases.
There is no focal consolidation to suggest pneumonia. No effusion is
appreciated. In the mediastinum, at the left mediastinal border, there is a
small linear lucency, which could represent a small medial pneumothorax.
Median sternotomy wires are stable with no evidence of fracture.
## IMPRESSION:
1. Right-sided IJ catheter with tip in the right atrium. This should be
withdrawn by several centimeters.
2. Volume loss in both lungs with basilar atelectasis.
3. Small area of linear lucency at the left mediastinal border, possibly a
medial pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12235296", "visit_id": "28435507", "time": "2175-10-13 14:28:00"} |
16917373-RR-81 | 134 | ## INDICATION:
year old woman with cardiac arrest. ETT confirmation.
## FINDINGS:
The tip of the endotracheal tube projects over 6 cm above the level of carina.
There is a small to moderate left pleural effusion. Diffuse hazy opacity and
decreased volume of the left lung probably reflecting a combination of
atelectasis and effusion. Small right pleural effusion with compressive
atelectatic changes. Probable old right-sided rib fractures. Calcifications
are noted in the arch of the aorta. The cardiomediastinal silhouette is
slightly shifted to the left. Degenerative changes of the right shoulder
joint and acromioclavicular joints.
## IMPRESSION:
1. Tip of endotracheal tube projects probably 6 cm above the level of carina.
Recommend repeat radiographs for assessment of the ETT position..
2. Small to moderate left and small right pleural effusion with compressive
atelectatic changes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16917373", "visit_id": "N/A", "time": "2204-09-03 10:59:00"} |
13153967-RR-42 | 170 | ## INDICATION:
Further evaluation of a thyroid nodule seen on recent CT chest.
## THE RIGHT LOBE MEASURES:
(transverse) 1.4 x (anterior-posterior) 1.5 x
(craniocaudal) 5.3 cm.
The left lobe measures: (transverse) 2.4 x (anterior-posterior) 2.3 x
(craniocaudal) 4.4 cm.
Isthmus anterior-posterior diameter is 0.3 cm.
Thyroid parenchyma is homogenous and has normal vascularity. A slightly
hypoechoic nodule in the lower pole of the right lobe measures 0.5 x 0.4 x 0.3
cm. A cystic nodule in the upper pole of the left lobe measures 1.6 x 1.3 x
1.9 cm and demonstrates rim calcification. A hypoechoic nodule in the left
lower pole measures 0.7 x 0.6 x 0.5 cm. There appears to be an adjacent
colloid cyst.
## IMPRESSION:
Bilateral subcentimeter thyroid nodules, as well as the large rim-calcified
nodule in the left upper pole measuring up to 1.9 cm. year followup
ultrasound can be obtained, as clinically indicated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13153967", "visit_id": "N/A", "time": "2161-03-30 12:01:00"} |
12764979-RR-13 | 217 | ## CLINICAL HISTORY:
Status post fall from 30 feet.
## FINDINGS:
A subdural hemorrhage is seen along the left cerebral convexity
measuring approximately 4 mm. Small intraparenchymal hemorrhages in the right
temporal region and left inferior frontal region are likely contusions. There
is 6 mm rightward shift of normally midline structures with left lateral
ventricle effacement.
There is diffuse sulcal effacement and mild effacement of the suprasellar
cistern, concerning for mild diffuse early edema.
The visualized paranasal sinuses and mastoid air cells are clear. Bilateral
occipital subgaleal hematomas are present. A fracture is seen in the left
occipital bone extending superiorly to the right parietal bone. The fracture
extends inferiorly to the left occipital condyle adjacent to the carotid canal
and close to the path of the left vertebral artery. There is a tiny amount of
pneumocephalus within the posterior fossa. Bilateral occipital subgaleal
hematomas are noted.
## IMPRESSION:
1. Small left cerebral subdural hemorrhage with 6-mm rightward shift of
midline structures.
2. Two small foci of hemorrhagic contusion.
3. Left occipital skull fracture extending to the left occipital condyle.
Vertebral artery compromise cannot be excluded.
4. Diffuse sulcal effacement and mild effacement of the suprasellar cistern,
concerning for mild cerebral edema.
Finding discussed with Dr. surgery attending) and the trauma
surgical team at time of interpretation .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12764979", "visit_id": "28308842", "time": "2148-04-11 14:09:00"} |
12867993-RR-18 | 94 | ## HISTORY:
Unresectable pancreatic cancer with bile duct dilatation.
## IMPRESSION:
ERCP performed without presence of a radiologist. Moderate
diffuse dilatation of the main duct, common hepatitic duct, left main hepatic
duct, right main hepatic duct, left intrahepatic biliary branches and right
intrahepatic biliary branches. Biliary stent was placed. A single irregular
stricture 10 mm long seen at the lower third of the common bile duct. There
was no post- obstructive dilatation. These findings are compatible with
extrinsic compression.
For more details on the procedure, refer to GI endoscopy report in the medical
record.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12867993", "visit_id": "27511222", "time": "2112-03-04 13:51:00"} |
10554954-RR-79 | 167 | ## CLINICAL INDICATION:
female status post renal transplant with C.
diff, now with abdominal pain and nausea, now status post EGD with Dobbhoff
placement and sigmoidoscopy, subsequently with severe abdominal pain.
Evaluate for free air.
## FINDINGS:
There is no free air. There is no pneumatosis. There is a dilated
loop of colon without wall thickening or thumbprinting, consistent with
post-instillation of air for sigmoidoscopy. There are no dilated loops of
small bowel or air-fluid levels on the decubitus view.
The Dobbhoff tube is curled in the stomach and the tip is likely in the
antrum.
Bony structures are not well evaluated on this study, but are grossly
unremarkable. Vascular calcification is seen.
## IMPRESSION:
1. No evidence for free air.
2. Dilated colon without wall thickening, consistent with post-sigmoidoscopy
instillation of air.
3. Tube with tip in the stomach. If post-pyloric placement is desired,
advancing the tube is recommended.
These findings were discussed in person with Dr. at 3:30 p.m. on
.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10554954", "visit_id": "22630997", "time": "2119-02-18 13:37:00"} |
16425465-RR-45 | 128 | ## INDICATION:
yo F ESRD on HD, COPD, Afib s/p L groin cutdown, CFA endart
w/vein patch angioplasty and SFA stent ( ) and left AT angioplasty
( ) returns w/ L toe gangrene // perfusion?
## FINDINGS:
On the right side, monophasic Doppler waveforms are seen in the right femoral,
superficial femoral, popliteal, posterior tibial and dorsalis pedis arteries.
The right ABI could not be obtained due to calcified noncompressible arteries.
On the left side, monophasic Doppler waveforms are seen at the left femoral,
superficial femoral, popliteal, posterior tibial and dorsalis pedis arteries.
The left ABI could not be obtained due to calcified the noncompressible
arteries.
Pulse volume recordings showed symmetrically decreased amplitudes bilaterally,
at all levels.
## IMPRESSION:
Severe inflow and outflow peripheral arterial disease in the bilateral lower
extremities.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16425465", "visit_id": "20950224", "time": "2204-07-16 10:40:00"} |
14244969-RR-45 | 213 | ## INDICATION:
man with GBM. Please assess for change.
## FINDINGS:
The left frontal-parietal enhancing portion of the lesion has slightly
decreased in size compared to , currently measuring 1.3 x 0.9 x 0.7 cm
from previously 1.5 x 1.2 x 0.7 cm, with a decrease of the central necrotic
part. Unchanged T1 hyperintense foci centrally in the lesion areconsistent
with mineralization and corresponding to the decreased signal on the the T2*
GRE sequence.
No new suspicious enhancing lesions are identified.
There are no areas of infarction, no large edema or mass effect and no
diffusion abnormalities. T2 FALRI seq. is not available.
A mucous retention cyst in the right maxillary sinus is unchanged from prior
exams. The remainder of the paranasal sinuses and mastoids are clear.
## ASL AND MR PERFUSION:
There is mild increase in the blood volume and
blood flow in the left frontal-parietal lesion compared to the contralateral
parenchyma ; however, not very strikingly different.
## IMPRESSION:
1. Slight decrease in size of the enhancing portion of the left
frontal-parietal lesion. Mild increase in the cerebral blood volume and blood
flow compared to the contralateral parenchyma; however, not very strikingly
different- of equivocal sigf/related to tumor- attention on followup.
2. No new lesions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14244969", "visit_id": "N/A", "time": "2184-12-24 09:58:00"} |
13150244-DS-14 | 1,601 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
Chest pain
Admitted for pre-catheterization hydration
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Cardiac catheterization without stenting
## HISTORY OF PRESENT ILLNESS:
Ms. is a y/o speaking woman with
known CAD and prior LAD stenting presents with for scheduled
catheterization. Patient is known to Dr. . Per verbal
report from Dr. has symptoms and + ETT showing
inferior and lateral ischemia with LVEF of 50%. Interview was
conducted with translator. Patient reports multiple small chest
discomfort with and without exertion every day. There is no
radiation. These are accompanied with dizziness, diaphoresis,
and shortness of breath. Patient had recently been hospitalized
at and for fluid overload in
and per family. She reports that her physical
activity tolerance is slightly better than a few months ago.
## PAST MEDICAL HISTORY:
1.CAD with three vessel disease, with exercise stress testing
positive by report , s/p cardiac catheterization- DES in LAD
, Echo with EF 60%, LVH
2. hypertension
3. hyperlipidemia
## FAMILY HISTORY:
There is no known family history of premature coronary artery
disease or sudden death.
## PHYSICAL EXAM:
Physical Exam on Admission
## GEN:
elderly female in NAD. Oriented x3. Mood, affect
appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
## NECK:
Supple. Unable to assess JVP due to position.
## CV:
PMI located in intercostal space, midclavicular line.
Distant heart sound. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
## CHEST:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB. no w/c/r.
## ABD:
Soft, NTND. No HSM or tenderness.
## EXT:
warm to touch. no edema.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## RIGHT:
DP 1+ 1+; Left: DP 1+ 1+
Physical Exam on Discharge
## VS:
T97, HR 56(56-72), BP 141/56 (127-220/23-96. SBP 220
occurred on . Today's SBP range is slightly
better than yesterday which was 146-186/58-86), RR , O2Sat
96-100% RA, BG 87, I/O: -/500 today, yesterday.
## GEN:
awake & oriented 3x, walking with cane
## HEENT:
NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
## NECK:
Supple. Unable to assess JVP due to position.
## CV:
PMI located in intercostal space, midclavicular line.
Distant heart sound. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
## CHEST:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Fine crackles at the
right lower lobe. No wheeze or rhonchi.
## ABD:
Soft, NTND. No HSM or tenderness.
## EXT:
Warm to touch. No edema. Right femoral cath site dressing
c/d/i, no redness, induration, or bruits.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## PULSES:
1+ bilaterally at DP and
## PERTINENT RESULTS:
11:20PM GLUCOSE-154* UREA N-41* CREAT-3.0*# SODIUM-138
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-28
11:20PM CK(CPK)-110 CK-MB-3 cTropnT-0.02*
11:20PM CALCIUM-9.3 PHOSPHATE-4.0 MAGNESIUM-2.2
11:20PM WBC-7.8 RBC-3.41* HGB-10.0* HCT-29.4* PLT
COUNT-148*
11:20PM PTT-29.1
CK 73, troponin 0.03*, Crt 2.6.
Echo
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no systolic
anterior motion of the mitral valve leaflets. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
- IMPRESSION: Moderate symmetric left ventricular hypertrophy
with hyperdyanmic systolic function. Moderate moderate mitral
regurgitation.
Cardiac catheterization (preliminary- verbal report.
pending final report.)
- No change in coronary artery disease. No stent was placed.
- Assessment of the renal arteries showed wide patency
bilaterally.
## BRIEF HOSPITAL COURSE:
Ms. is a y/o speaking woman with
known CAD and prior LAD stenting was hospitalized for scheduled
catheterization. Her hospital course was without complication.
1. CAD. She has history of DES in LAD and frequent symptoms of
unstable angina. Most recent ETT per her cardiologist was
positive, showing inferior and lateral ischemia and LVEF of 50%.
She was placed on ASA 325 mg and heparin drip. Carvedilol was
increased to 25 mg BID, and she continued with her niacin and
Crestor 40 mg. While preparing for catheterization, lasix was
held, and she had gentle pre-cath hydration for renal protection
given history of fluid overload and elevated creatinine. Her
catheterization demonstrated no change in coronary artery
disease as compared to her prior study in . No stenting was
done during the procedure. Medications were adjusted mostly for
hypertension (see below for details). Her LDL was 75 and HgA1C
was 6.0. Carotid ultrasound is to be done at Dr.
clinic.
2. Pump. A new echocardiogram was done during this
hospitalization which showed moderate symmetric LVH, LV filling
pressure > 18 mmHg, moderate mitral regurgitation, and
hyperdynamic systolic function (LVEF >75%). Patient also had
elevated LV filling pressure on catheterization. It was thought
that she is fluid overloaded, but diuresis was held given her
creatinine level. Her creatinine elevated mildly post
catheterization to 2.6 which was her pre-cath creatinine level.
The plan is to have patient restart her home furosemide 80 mg a
couple days after discharge to allow renal recovery from the dye
load from catheterization. She is to be followed by Dr. on
outpatient basis for further medication adjustment.
3. Rhythm. She maintained normal sinus rhythm throughout the
length of the stay with occasional PVC. She was monitored on
telemetry throughout the hospital course.
4. Hypertension. Her blood pressure was labile while in the
hospital. Her carvedilol was increased to 25 mg BID from 12.5
mg BID at admission. Amlodipine 10 mg was added. Her SBP
ranged from 130-250s. It prevented her from getting
catheterized initially, and nitroglycerin drip were administered
at the time. During the second attempt of catheterization, her
renal arteries were found to be patent without stenosis. Imdur
was increased to 90 mg daily, and clonidine 0.1 mg BID was added
to her blood pressure regimen. Her BP at discharge was better
controlled. She is to continue the changes in her blood
pressure medication and is to be followed by Dr. PCP
in outpatient clinic.
5. Type 2 DM. Her home glipizide was held during the hospital
course. She was on insulin sliding scale. Her HgA1C was found
to be 6.0 in this hospital.
## MEDICATIONS ON ADMISSION:
glipizide XL 10 mg QD
carvedilol 12.5 mg BID
isosorbide mononitrate 30 mg QD
niaspan 500 mg ER QD
crestor 40 mg QD
furosemide 80 mg QD
tylenol mg PRN
## DISCHARGE MEDICATIONS:
1. Carvedilol 25 mg Tablet
## SIG:
One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed for back pain.
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
## SIG:
Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day:
Please RESUME this on . Please do not take
this medication until the recommended date. .
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
## PRIMARY DIAGNOSIS:
- Coronary artery disease
## SECONDARY DIAGNOSIS:
- Hypertension
- Hyperlipidemia
- Type 2 Diabetes Mellitus
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were hospitalized for evaluation of coronary artery disease.
You received a cardiac catheterization but no stent was placed
this time.
Please take note of the following changes in your medication:
- Please START aspirin 81 mg, 1 tab, take by mouth, once daily
- Please START Norvasc (amlodipine) 10 mg, 1 tab, take by mouth,
once daily
- Please START clonidine 0.1 mg, 1 tab, take by mouth, twice
daily
- Please INCREASE carvedilol to 25 mg, 1 tab, take by mouth,
twice daily
- Please INCREASE isosorbide mononitrate to 90 mg, take by
mouth, once daily.
- Please DO NOT take furosemide 80 mg, 1 tab, take by mouth,
once daily UNTIL , . This is to protect your
kidney.
- Please RESUME niaspan 500 mg ER, 1 tab, take by mouth, once
daily
- Please RESUME Crestor 40 mg, 1 tab, take by mouth, once daily.
- Please RESUME glipizide XL 10 mg, 1 tab, take by mouth, once
daily.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13150244", "visit_id": "22481765", "time": "2143-04-02 00:00:00"} |
19937947-RR-18 | 320 | ## INDICATION:
Right lower quadrant abdominal pain, evaluate for appendicitis.
## LOWER CHEST:
There is mild dependent atelectasis. The visualized portions of
the heart and pericardium are unremarkable. There is no pleural effusion.
## LIVER:
The liver enhances homogeneously, with no focal lesions or
intrahepatic biliary duct dilatation. The gallbladder is unremarkable and the
portal vein is patent.
## PANCREAS:
The pancreas does not demonstrate focal lesions or peripancreatic
stranding or fluid collection.
SPLEEN The spleen is homogeneous and normal in size.
## ADRENALS:
The adrenal glands are unremarkable.
## KIDNEYS:
The kidneys do not show solid or cystic lesions and demonstrate
symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation
or perinephric abnormalities are present.
## GI TRACT:
The stomach, duodenum, and small bowel are within normal limits,
without evidence of wall thickening or obstruction. The colon is non-dilated
without obstructive lesions. The appendix is fluid-filled and dilated
measuring up to 1 cm, and demonstrates hyperemia ( ). There is mild
surrounding fat stranding. There is no evidence of perforation or focal
abscess formation.
## VASCULAR:
The aorta is normal in caliber without aneurysmal dilatation. The
origins of the celiac axis, SMA, bilateral renal arteries, and are patent.
## RETROPERITONEUM AND ABDOMEN:
There is no retroperitoneal or mesenteric lymph
node enlargement. No ascites, free air, or abdominal wall hernias are noted.
## PELVIC CT:
The urinary bladder and distal ureters are unremarkable. No
pelvic wall or inguinal lymph node enlargement is seen. There is no pelvic
free fluid. The uterus is retroverted. There is a 2.2 cm right adnexal cyst
likely physiologic. Note is made of prominent left gonadal vessels.
## OSSEOUS STRUCTURES:
No blastic or lytic lesions suspicious for malignancy is
present.
## IMPRESSION:
1. Acute appendicitis. No evidence of perforation or abscess formation.
2. Prominent left gonadal vessels which have been described in the setting of
pelvic congestion syndrome. Clinically correlate.
## NOTIFICATION:
Findings were discussed with by in person at
3:30am on , immediately following exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19937947", "visit_id": "26344241", "time": "2150-08-04 02:27:00"} |
11681918-RR-54 | 196 | ## INDICATION:
year old man s/p left pneumonectomy// interval change
## FINDINGS:
Compared with the prior study, hazy opacity of the left lung has increased,
now extending superiorly to roughly the level of the aortic knob. (Although
the films are labeled differently regarding position, positioning of the 2
films appears similar.) Residual lucency is seen at the left upper zone and
small locules of lucency are noted in left mid zone. Multiple left-sided rib
fractures again noted. As before, there is gaseous distension underneath the
left hemidiaphragm, which is considerably elevated.
Suspected slight rightward shift of the mediastinum is similar to the prior
study, allowing for patient rotation. On the right, no focal consolidation or
gross effusion. Mild prominence of markings in the right lung is unchanged
and may represent a combination of prominent vessels and background
interstitial scarring.
Curvilinear density again seen overlying the mediastinum is thought to
represent an epidural catheter, best correlated clinically.
## IMPRESSION:
Interval increase in fluid within the left post-pneumonectomy space. Right
lung remains grossly clear, as detailed above.
Mild rightward shift of mediastinum, likely similar to prior, allowing for
patient rotation.
Persistent gaseous distention of the stomach.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11681918", "visit_id": "24571357", "time": "2191-03-01 04:09:00"} |
18010960-RR-20 | 185 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
year old man s/p endovascular clot retrieval// 5PM interval
scan
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP =
746.1 mGy-cm.
Total DLP (Head) = 761 mGy-cm.
## FINDINGS:
Compared with CTA head and neck performed earlier on same day, patient has
undergone interval mechanical thrombectomy of a basilar tip occlusion.
Previously seen hyperdensity in the basilar tip is less prominent compared
with prior. There is no evidence of infarction, hemorrhage, edema,or mass
effect. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is mucosal thickening in the right
maxillary sinus and ethmoid air cells. The visualized portion of the
remainder of paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
## IMPRESSION:
No evidence of acute large territorial infarction or intracranial hemorrhage
status post mechanical thrombectomy of a basilar tip occlusion. Please note
MRI of the brain is more sensitive for the detection of acute infarct.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18010960", "visit_id": "21782431", "time": "2167-04-26 17:43:00"} |
19083070-RR-32 | 108 | ## INDICATION:
Fibroid uterus. Early pregnancy.
## FINDINGS:
Transabdominal and transvaginal examinations were performed, the
latter for better visualization of the endometrial cavity. There is a fibroid
uterus with the largest fibroid in the fundus measuring 4.2 x 3.6 x 3.7 cm.
There is a single live intrauterine gestation with a crown-rump length of 10.1
mm corresponding to a gestational age of seven weeks two days. This
corresponds satisfactorily with the menstrual dates of seven weeks and zero
days. The ovaries are normal. There is no free fluid in the pelvis.
## IMPRESSION:
1. Single live intrauterine gestation. Size equals dates.
2. Fibroid uterus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19083070", "visit_id": "N/A", "time": "2174-03-20 15:12:00"} |
13367318-DS-6 | 334 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
presented with rupture of membranes
## HISTORY OF PRESENT ILLNESS:
G5P0 @ presents with spontaneous rupture of
membranes at 5pm with a gush of clear fluid and continued
leaking
since that time. No fever/chills, no vaginal bleeding or
abdominal pain. +AFM. Not feeling any more contractions than
when
she was discharged 2 days ago.
## G5P0
-G1:
, TAB
-G2: , SAB, 13wks
-G3: , SAB at 19wks after abruption from MVA
-G4: SAB
-G5 current
## PGYNHX:
h/o gonorrhea at age , denies history of LEEP or other
cervical procedure
## PMHX:
pituitary macroadenoma diagnosed , followed by Dr.
@ : open myomectomy of 4 fibroids (during removal of fundal
fibroid, near full-thickness of myometrium so patient advised to
have c-section), HSC/PPY, wisdom teeth
## ABDOMEN:
soft, no fundal tenderness
## EXT:
no edema, no calf tenderness
## SVE:
deferred, grossly ruptured with clear fluid
## FHT:
135, mod var, +accels, no decels
## TOCO:
q2-7min (pt not feeling all of them)
## BRIEF HOSPITAL COURSE:
Patient admitted for monitoring given preterm premature rupture
of membranes.
She remained afebrile with good glycemic control.
On hospital day 6 at 33 patient began to experience
contractions and vaginal bleeding. Given history of previous
myomectomy through the contractile portion of the myometrium-
decision was made to proceed to primary cesarean section.
patient delivered male APGAR 7 at 1 min and 9 at 5 min
Ms had an uncomplicated course postpartum course- on day
of discharge she noted painful urination and was begun on
MACROBID.
## DISCHARGE MEDICATIONS:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7
Days
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth q12hrs Disp #*14 Capsule
## REFILLS:
*0
2. Ibuprofen 600 mg PO Q6H:PRN Pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hr Disp #*40 Tablet
Refills:*0
3. Oxycodone-Acetaminophen (5mg-325mg) TAB PO Q4H:PRN Pain
RX *oxycodone-acetaminophen 2.5 mg-325 mg tablet(s) by mouth
q4 Disp #*20 Tablet Refills:*0
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13367318", "visit_id": "21741758", "time": "2189-12-05 00:00:00"} |
17048441-RR-20 | 93 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
w/garbled speech. Please eval for CVA, bleed.
## FINDINGS:
There is no evidence of large territorial infarction, acute intracranial
hemorrhage edema, or large mass. The ventricles and sulci are normal in size
and configuration. Mild periventricular white matter hypodensities are
nonspecific, but likely sequela of chronic small vessel ischemic disease.
There is no acute fracture. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
## IMPRESSION:
No acute intracranial process.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17048441", "visit_id": "22825162", "time": "2114-06-19 16:18:00"} |
13503962-DS-10 | 2,309 | ## ALLERGIES:
Shellfish Derived / Enalapril
## HISTORY OF PRESENT ILLNESS:
male history of diabetes, CAD with stents on aspirin
Plavix, COPD, difficult to control hypertension on 4 agents plus
Lasix who presents with chest pain. Patient reports left-sided
chest pain that started this evening. He had finished dinner and
was sitting on couch watching TV when she had acute onset
chest pain, without associated symptoms. No shortness of breath,
orthopnea, nausea, diaphoresis. Pain was constant dull,
squeezing, nonradiating. Lasted from 7pm - 2am, with minimal
release with Nitro and baby ASA. Pt finally subsided about an
hour after being in the ED. He denies shortness of breath,
cough, abdominal pain. He has lower extremity swelling but this
is stable. He reports an episode of similar chest pain yesterday
that resolved after minutes. He has known reversible defect
on recent nuclear imaging.
Of note, pt has a long history of HTN and is on myltipled
medications. BPs at home are usually 150s- 160s, however on
he had vitrectomy for DM vitreous hemorrhage and since then he's
had higher BPs in 180s - 200s. He saw his PCP for HTN,
who added Minoxidil. At this time he was not having any
neurological complaints or chest pain.
In the ED, initial vitals were 97.6 214/98 -> 116/53 HR 91
98% RA.
## EKG:
RRR. RBBB. No ST elevation or depression.
##
LABS/STUDIES NOTABLE FOR:
Trop 0.04 -> 0.21. Na 134, K (green)
4.1, BUN 43, Cr 2.1 (baseline 2.1-2.9), Glu 411, WBC 10.1, Hgb
10.4, Hct 32, Plt 236.
Patient was given:
Heparin IV per Weight-Based Dosing Protocol
Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Minoxidil 10 mg PO DAILY Start: Today
Isosorbide Dinitrate ER 60 mg PO DAILY
HydrALAZINE 100 mg PO/NG BID Start: Today
Clopidogrel 75 mg PO/NG DAILY Start: Today
Carvedilol 25 mg PO/NG BID Start: Today
Allopurinol mg PO/NG DAILY
Aspirin 243 mg PO ONCE
1000 mL NS Continuous x 2
On the floor 98.2 84 20 97% RA. Pt denies
chest pain, SOB, orthopnea, abdominal pain, changes in bowel
movements, fevers, chills, sweats, headache, changes in vision,
trouble with speech. UOP is at his baseline.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. +Pedal edema present x
several months, slightly worse now.
## PAST MEDICAL HISTORY:
ADULT ONSET DIABETES MELLITUS
CORONARY ARTERY DISEASE
DEPRESSION
HYPERTENSION
COLONIC ADENOMA
? HYPERLIPIDEMIA
DIABETIC RETINOPATHY
CHRONIC RENAL FAILURE
## GENERAL:
WDWN, obese in NAD. Oriented x3. Mood, affect
appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
## NECK:
JVP midneck at 45 degrees.
## CARDIAC:
PMI located in intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral pulmonary
crackles.
## ABDOMEN:
Soft, NTND. No HSM or tenderness.
## EXTREMITIES:
Warm well perfused. 2+ pitting edema. No femoral
bruits.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## PULSES:
Distal pulses palpable and symmetric
DISCHARGE EXAM
====================
## GENERAL:
WDWN, obese in NAD. Oriented x3. Mood, affect
appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
## NECK:
JVP midneck at 45 degrees.
## CARDIAC:
PMI located in intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles to mid lungs
bilaterally.
## ABDOMEN:
Soft, NTND. No HSM or tenderness.
## EXTREMITIES:
Warm well perfused. 2+ pitting edema. No femoral
bruits.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## PULSES:
Distal pulses palpable and symmetric
## ECG:
RRR. No ST elevations, depressions. Diffuse T wave
flattening. T wave inversions in I, Avr, AvL.
## IMPRESSION:
No acute intrathoracic process.
Cardiac Cath:
Coronary Anatomy
## DOMINANCE:
Right
* Left Main Coronary Artery
The LMCA has no significant stenosis.
* Left Anterior Descending
The LAD has origin 60-70% stenosis and mid 60% stenosis between
prior stent. The distal vessel is small
but may be a reasonable target for graft.
The Diagonal is occluded.
* Circumflex
The Circumflex has origin 95% followed by 90% in-stent
restenosis and then sub total occlusioin before
OM bifurcation..
The Marginal is.
* Right Coronary Artery
The RCA has distal 60% stenosis.
## IMPRESSIONS:
1. 3 vessel CAD. If LAD can be grafted then CABG is a better
option with grafts to LAD, OM, and distal
RCA. If not, then repeat stenting of circumflex is an option but
given high risk for recurrent restenosis it is
not optimal.
Recommendations
1. CSURG consult.
## ECHO :
Conclusions
The left atrium is mildly dilated. The left atrial volume index
is moderately increased. No atrial septal defect is seen by 2D
or color Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%).
Diastolic function could not be assessed. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests impaired
relaxation. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
## IMPRESSION:
Moderate concentric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. Dilated thoracic aorta. Mild mitral regurgitation.
## # NSTEMI:
Patient with squeezing chest pain at rest
lasting several hours (7pm - 2am) with mild relief with Nitro
and ASA 81mg. Trop leak 0.04 -> 0.21 -> 0.31 -> 0.44. EKG
without change from prior or evidence of ischemia. Patient
presented with hypertension, SBPs in 210s. Patient had been
hypertensive for several days, since a recent vitrectomy on
. Had recently started on Monoxidil 10mg daily on by his
PCP for HTN. However, had acute chest pain and so came to the
ED. Differential was Type II NSTEMI, however given his strong
CAD history and previous stents, patient underwent cardiac
catheterization on . Cath showed 95% stenosis on origin of
circumflex, followed by 90% in-stent restenosis. The LAD had
60-70% stenosis. It was felt that if LAD could be grafted then
CABG is a better option with grafts to LAD, OM, and distal RCA.
If not, then repeat stenting of circumflex is an option but
given high risk for recurrent restenosis it is
not optimal. Medically, patient was treated with Heparin gtt x
48 hours and Atorva 80mg, ASA 81mg daily, Carvedilol BID,
isosorbide mononitrate 60mg daily and Plavix were continued.
Plavix was stopped for two days for potential CABG while
inpatient, however restarted on discharge. On day of discharge,
patient with BPs 170s, therefore Carvedilol was increased to
50mg BID.
## # HYPERTENSION EMERGENCY:
Patient on multiple medications as
outpatient including: Carvedilol 25mg BID, Hydralazine 100mg
BID, Clonidine 0.3 mg/24H patch , and Minoxidil 10mg
daily. However patient still presented to ED with SBP 215. His
underlying hypertension may have been exacerbated by pain and
also recent vitrectomy medications (Atropine eye drops). Patient
was hypervolemic on exam on physical exam, and so potentially
this could have increased his blood pressure as well. Patient
given IV Lasix 40mg x 1 on , with good effect. Patient was
normotensive during hospitalization (SBPs 120s-130s) after
diuresis and relief of pain. Continued home Clonidine ,
Hydralazine, Minoxidil. Carvedilol was increased to 50mg BID for
better BP control.
## # RECENT VITRECTOMY ON :
Patient had vitrectomy for diabetic
vitreous hemorrhage in RIGHT eye. Continued his eye drops:
Atropine, Erythromycin, and prednisolone eye drops. Patient seen
by Opthalmology while inpatient and after examination, Atropine
and Erythromycin were stopped. Prednisolone eye drops to be
continued for another 14 days.
## # DM:
Patient on Glargine 38 units BID at home and also on NPH
10 units x 1 PRN fingerstick glucose > 200. Patient and wife
note that patient's blood sugars at home can be as high as 300s.
However during hospitalization patient had several FSGs in -
50s. Patient slightly symptomatic with flushing. Likely in
setting of being NPO for catheterization. Home insulin regimen
was restarted.
## # ANEMIA:
Patient at baseline, likely from CKD.
# CKD: Patient with CKD since , baseline 2.1-2.8. Patient's
Creatinine remained at baseline. Used less dye during
catheterization on and also pre-treated pt with 500cc HCO3
infusion prior to cath per his outpatient Nephrologist Dr.
. Per outpatient nephrologist, based on his score,
his post CABG dialysis risk will be around 10%, and it is quite
likely that he may leave the table with a worse new renal
baseline. However, without CABG, his dialysis risk over the
years (natural course of his CKD in light of age, GFR,
proteinuria etc) is ~40%, and taking into account his poorly
controlled HTN, and DM, his prognosis may be even worse.
Therefore, dialysis is in his near term future. Patient's family
counseled on this. Creatinine remained baseline on day of
discharge.
## # GOUT:
Continued allopurinol.
TRANSITIONAL ISSUES
==============================
-Last dose of Plavix should be on (5 day wash out prior
to CABG on .
-Carvedilol increased to 50mg BID for better blood pressure
control.
-Mupirocin Ointment x 5 days ( ): Using a q-tip/cotton
swab squeeze a pea size amount of the 2% Mupirocin ointment on
the tip and apply it to one nostril. Repeat this process in the
other nostril using another clean q-tip/cotton swab. Pinch both
nostrils and massage x 60 seconds
-Follow up with Ophthalmology TWO weeks after discharge.
-Follow up with Nephrology, Cardiology.
-DISCHARGE WEIGHT: 81.4kg
# LANGUAGE SPOKEN:
# CODE: Full Code, confirmed
# CONTACT: Patient, Wife: (speaks
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheeze
2. Allopurinol mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 25 mg PO BID
5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN
6. Clopidogrel 75 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. HydrALAZINE 100 mg PO BID
9. Glargine 38 Units Breakfast
Glargine 38 Units Bedtime
10. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using NPH Insulin
11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Omeprazole 40 mg PO DAILY
14. Ascorbic Acid mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Vitamin D UNIT PO DAILY
17. Ferrous Sulfate 325 mg PO DAILY
18. Minoxidil 10 mg PO DAILY
19. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
20. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QAM
21. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
## DISCHARGE MEDICATIONS:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheeze
2. Allopurinol mg PO DAILY
3. Ascorbic Acid mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN
7. Ferrous Sulfate 325 mg PO DAILY
8. HydrALAZINE 100 mg PO BID
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Minoxidil 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Vitamin D UNIT PO DAILY
13. Furosemide 40 mg PO DAILY
14. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using NPH Insulin
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Carvedilol 50 mg PO BID
RX *carvedilol 25 mg 2 tablet(s) by mouth twice a day Disp #*60
## TABLET REFILLS:
*0
17. Glargine 38 Units Breakfast
Glargine 38 Units Bedtime
18. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
## DURATION:
14 Days
19. Clopidogrel 75 mg PO DAILY
## DISCHARGE DIAGNOSIS:
PRIMARY DIAGNOSIS
=====================
-Non-ST elevation myocardial infarction
-Hypertensive Emergency
SECONDARY DIAGNOSIS
=========================
INSULIN DEPENDENT DIABETES MELLITUS
CORONARY ARTERY DISEASE
DEPRESSION
HYPERTENSION
DIABETIC RETINOPATHY
CHRONIC RENAL FAILURE
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure to care for you at . You came to our
hospital after having chest pain and also very high blood
pressures. Upon further evaluation, we confirmed that you were
having a heart attack. We controlled you blood pressures, and we
also did a cardiac catheterization procedure to take a look at
your coronary (heart) vessels. We were able to see that there
were multiple blockages and given that you are a good surgical
candidate, the Cardiology team felt you would benefit most from
open heart surgery to fix some of the diseased vessels.
While here, we started the general work up for surgery so that
you do not have to worry about it later. We also treated you
with medicines to best help your heart recover from the heart
attack.
## ***REMEMBER*** ON :
STOP taking your Plavix (clopidogrel)
since you must be off of this medication for 5 days prior to
your surgery on . (Your last dose of Plavix will be taken
on . On : start using the Mupirocin ointment
that your nurse gave you on discharge day. Using a q-tip/cotton
swab squeeze a pea size amount of the 2% Mupirocin ointment on
the tip and apply it to one nostril. Repeat this process in the
other nostril using another clean q-tip/cotton swab. Pinch both
nostrils and massage x 60 seconds. DO THIS FOR FIVE DAYS
starting on - .
Please refer to the showering instructions for the night before
surgery in your discharge packet and use the soap the nurse
provided for you.
Please follow up with you cardiologist, your nephrologist, and
primary care doctor.
We wish you the very best,
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13503962", "visit_id": "20445540", "time": "2199-01-14 00:00:00"} |
11204500-RR-43 | 253 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
History: with multiple falls, headstrike.// Bleed? Fracture?
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 1.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
## FINDINGS:
Small volume hyperdensity with curvilinear morphology on the coronal images
(Series 400, image 41) within the sulci of the left frontal lobe is consistent
acute subarachnoid hemorrhage. Thin bilateral subdural hypodense fluid
collections overlying the frontoparietal lobes, likely subdural hygromas or
chronic subdural hematomas, result in symmetric mass effect without shift of
normally midline structures. The subdural collections measure up to 10 mm
bilaterally. There is no evidence of large territory infarction, edema,or
mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. Mild periventricular and subcortical white matter
hypodensities are nonspecific, but likely reflect the sequela of chronic
microvascular infarction. Mild atherosclerotic calcifications of the
cavernous carotid arteries are seen.
There is no evidence of fracture. There is mild mucosal thickening of the
ethmoid air cells bilaterally. The remaining paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The patient is status post left
lens replacement.
## IMPRESSION:
1. Small volume acute left frontal lobe subarachnoid hemorrhage.
2. Small bilateral subdural hypodense fluid collections, either subdural
hygromas or chronic subdural hematomas, which exert mild symmetric mass
effect.
3. No fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11204500", "visit_id": "22013333", "time": "2134-11-02 16:02:00"} |
10668956-RR-2 | 296 | ## INDICATION:
woman with history of ovarian cyst on the right
measuring 5.8 x 5.4 x 4.8 cm. Right adnexal pain for four days, now worse for
two days and increasing pain and colicky nature for the past two hours.
PELVIC ULTRASOUND.
## FINDINGS:
LMP .
Transabdominal and transvaginal examinations were performed, the latter for
better evaluation of the endometrium and adnexa. The uterus measures 9.2 x
3.3 x 6.5 cm. There is a 1 cm posterior fibroid. The endometrium is normal
in echotexture measuring 12 mm.
Arising off the right ovary is 5.9 cm cyst which is anechoic with good through
transmission and no solid echogenic components. The right ovary in total
measures 5.9 x 5.8 x 4.9 cm. Venous and arterial waveforms could be
identified within the right ovary.
The left ovary, which by report has previously undergone torsion, measures 3.8
x 2.7 x 3 cm. Follicles are present within the left ovary. However, neither
venous, nor arterial waveforms could be identified within the left ovary. This
may be technical as the left ovary was positioned deep in the pelvis posterior
to the uterus. Trace fluid is present in the pelvis. The patient was tender
in both the right and left adnexa, but was more tender in the right adnexa.
## IMPRESSION:
1. Enlarged right adnexal cyst measuring 5.9 cm. Although flow was present
in the right ovary, torsion is not excluded as this correlated to the site of
patient's pain.
2. Normal-sized left ovary, however, neither venous nor arterial waveforms
could be identified. This lack of flow may be positional, but given the
history of previous torsion in this ovary torsion is not entirely excluded.
3. Fibroid uterus. Normal endometrium.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10668956", "visit_id": "24358414", "time": "2125-01-26 03:49:00"} |
15491552-RR-35 | 135 | ## INDICATION:
woman with pain and mild gallbladder wall edema seen
on the prior CT.
## FINDINGS:
A 9-mm echogenic avascular lesion in the left hepatic lobe likely
represents a hemangioma. There is no intra- or extra-hepatic biliary
dilatation. The common bile duct is normal measuring 3 mm. The gallbladder
has multiple mobile gallstones. There is mild gallbladder wall edema, but
there is no significant gallbladder wall thickening or pericholecystic fluid.
sign was not reliable as the patient had tenderness throughout the
abdomen.
## IMPRESSION:
1. Mild gallbladder wall edema, is non-specific and can be seen in the
setting of hepatitis, liver disease, volume overload, heart failure.
Cholelithiasis. No signs specific for acute cholecystitis are seen. If
clinical symptoms perist repeat ultrasound can be considered.
2. Small left hepatic lobe lesion, likely hemangioma.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15491552", "visit_id": "N/A", "time": "2124-02-05 01:32:00"} |
16013806-RR-22 | 90 | ## INDICATION:
year old man with new DHT // NEW DHT , discharge pending
thanks
## FINDINGS:
An enteric tube terminates in the distal stomach. There are no abnormally
dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
Bilateral pleural effusions, greater on the right, and pulmonary edema have
increased since .
## IMPRESSION:
1. Enteric tube terminates in the distal stomach.
2. Bilateral pleural effusions, greater on the right, and pulmonary edema,
increased since .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16013806", "visit_id": "21731461", "time": "2161-11-08 15:51:00"} |
13369123-RR-103 | 267 | ## EXAMINATION:
LEFT DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM
INTERPRETED WITH CAD AND LEFT BREAST ULTRASOUND
## INDICATION:
woman who presents for a six-month follow-up of a
probably benign left breast intramammary lymph node.
## TISSUE DENSITY:
B- There are scattered areas of fibroglandular density.
There is interval decreased size of a left upper outer breast mass, likely
intramammary lymph node, since , although it is still larger than
more remote mammograms. This now measures 8-9 mm, and measured 11 mm in . There is no unexplained architectural distortion or suspicious grouped
microcalcifications.
## BREAST ULTRASOUND:
Targeted ultrasound of the left breast at 2 o'clock 10 cm
from the nipple demonstrated interval decreased size of an intramammary lymph
node which measures 0.6 x 0.5 x 0.7 cm with a cortical thickness of 0.2 cm.
Previously this lymph node measured 0.8 x 0.7 x 0.7 cm.
## IMPRESSION:
There is interval decreased size of a left probably benign intramammary lymph
node since , although this is larger from more remote exams. This
could be due to an infectious/inflammatory/reactive process.
## RECOMMENDATION(S):
The patient is due for bilateral mammography in .
A repeat left breast ultrasound can also be performed at that time to further
reassess the probably benign intramammary lymph node. Both exams will be
scheduled as diagnostic studies.
## NOTIFICATION:
Findings and recommendation were reviewed with the patient who
agrees with the plan. She was given information to schedule her follow-up.
The findings were also discussed with , N.P. by , M.D.
on the telephone on at 12:00 pm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13369123", "visit_id": "N/A", "time": "2199-03-12 10:22:00"} |
11532808-RR-74 | 119 | ## HISTORY:
male with history of non-Hodgkin's lymphoma, now with
numbness in the right anterior and lateral thigh, constipation, and ? urinary
retention.
## MR :
The exam is essentially unchanged from the study of .
Multilevel degenerative disc and facet joint abnormalities are again seen;
please refer to the report from for further details. Tiny left
posterolateral extrusion of the L2-L3 disc is unchanged. Moderate bilateral
foraminal stenosis at the L4-5 level and moderate left-sided foraminal
stenosis at the L5-S1 level are unchanged. The visualized distal spinal cord,
conus medullaris, and cauda equina demonstrate no signal abnormality. The
paravertebral soft tissues are unremarkable.
## IMPRESSION:
Multilevel degenerative disc and facet joint abnormalities are
unchanged compared to .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11532808", "visit_id": "27670582", "time": "2167-02-24 21:15:00"} |
Subsets and Splits