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15596114-RR-21 | 171 | ## INDICATION:
Right upper quadrant pain with tenderness. Please assess for
cholecystitis.
## FINDINGS:
The liver is normal in echotexture. There is no intrahepatic
biliary ductal dilatation. Doppler assessment of main portal vein shows
patency and hepatopetal flow. The gallbladder contains a large 1.2 x 0.9 x
1.1 cm non-obstructing non-shadowing mobile mass likely reflecting a
sludgeball. No gallbladder wall edema or pericholecystic fluid to indicate
cholecystitis noted. A small 0.3 x 0.4 cm gallbladder polyp is identified.
The common bile duct is not dilated measuring 0.4 cm. The distal pancreatic
tail is excluded due to overlying bowel gas; however, the visualized portions
of the pancreas are unremarkable. The spleen is not enlarged, measuring 9 cm.
The visualized portions of the right kidney, aorta, and inferior vena cava are
unremarkable.
## IMPRESSION:
1. Large mobile non-obstructing sludge ball, without evidence of
cholecystitis.
2. Small 0.4 cm gallbladder polyp.
2. Doppler assessment of main portal vein shows patency and appropriate
directionality of flow.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15596114", "visit_id": "N/A", "time": "2115-05-31 11:39:00"} |
18265370-RR-5 | 123 | ## CLINICAL HISTORY:
Late registrant from , full fetal low risk
ultrasound.
## LMP:
.
A single fetus is present with a cephalic position. The placenta lies
anteriorly without evidence of previa. The measurements are:
## DATES BY LMP:
29 weeks 5 days.
The weight is estimated at 1282 grams which lies in the 36 percentile.
The head, spine, heart, abdomen normal. The lower limbs were satisfactorily
visualized and appear normal. Limited visualization of the upper limbs could
be achieved. Face was pointing downwards and nose and lips was not obtainable
and given the size of the fetus we are unlikely to achieve this prior to
delivery.
The amount of fluid was normal.
## IMPRESSION:
Marginally limited survey but appears normal, size one week less
than dates.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18265370", "visit_id": "N/A", "time": "2188-10-01 13:17:00"} |
15021710-RR-65 | 207 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
Renal cell cancer, assessment of disease
## FINDINGS:
Substantial interval progression of widespread metastatic disease is
demonstrated seen as increase in size in the left upper lobe mass, from 19 x
13 mm to 20 x 17 mm at its inferior portion and from 17 x 12 mm to 17 x 22 mm
at its inferior portion with obstruction of the segmental bronchus, series 3,
image 24, as well as substantial increase in mediastinal lymphadenopathy and
multiple pulmonary nodules in the right upper lobe, series 3, image 34, 10
instead of 7 mm, right lower lobe nodule, series 3, image 50, 14 instead of 10
mm, series 3, image 56, 27 instead of 20 mm as well as substantial progression
of lymphangitic spread in the lower lobes with innumerable amount of pulmonary
nodules. Right pleural effusion has increased, moderate
There is also progression in the metastatic lesion involving the right fourth
rib laterally, series 3, image 18 with lytic lesion associated with soft
tissue component, currently 31 x 25 mm as compared to 20 x 25 mm previously.
Central airways are patent.
Image portion of the upper abdomen will be reviewed separately.
## IMPRESSION:
Substantial progression of intrathoracic metastatic disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15021710", "visit_id": "N/A", "time": "2169-07-29 12:11:00"} |
14759339-RR-8 | 99 | CHEST RADIOGRAPH FOLLOWING PORTABLE LINE PLACEMENT.
## HISTORY:
man with PICC placement. Evaluate for tip position.
## FINDINGS:
There is a right-sided PICC catheter whose tip terminates in the
mid SVC. There is no pneumothorax. There is a nasogastric tube which courses
through the esophagus and the tip is in the stomach in appropriate position.
The cardiac silhouette is normal in size. The aorta is mildly tortuous but
unchanged. There is bibasilar atelectasis. Otherwise, the lungs are clear.
There is no pneumothorax. There are no pleural effusions.
## IMPRESSION:
Right-sided PICC catheter with tip in mid SVC. No pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14759339", "visit_id": "20750010", "time": "2111-03-19 10:10:00"} |
16163611-RR-22 | 179 | ## EXAMINATION:
MR KNEE W/O CONTRAST LEFT
## INDICATION:
year old woman with weakness and limited ROM after fall on
// please evaluate for intra-articular injury left knee, fall on
, now with Limited ROM
## MEDIAL MENISCUS:
There are mild degenerative changes in the posterior horn of
the medial meniscus without a discrete tear.
Lateral meniscus: Normal.
## ANTERIOR CRUCIATE LIGAMENT:
Normal.
Posterior cruciate ligament: There is mildly increased T2 signal within the
posterior cruciate ligament (04:17), suggestive of a low grade sprain.
## MEDIAL COLLATERAL LIGAMENT:
Normal.
Lateral collateral ligamentous complex: Normal.
## EXTENSOR MECHANISM:
The quadriceps and patellar tendons are intact. There is
trace fluid within the infrapatellar bursa (05:10). The patellar tendon
appears slightly shortened with an ratio of approximately 0.8.
## CYST:
There is a cyst.
Joint effusion: There is no significant joint effusion.
Articular cartilage
## PATELLOFEMORAL:
Evaluation is limited secondary to patient motion, however, no
large defects are seen.
## BONE MARROW:
There is no focal bone marrow signal abnormality.
## IMPRESSION:
1. Low-grade sprain of the posterior cruciate ligament.
2. Mild patella baja.
3. cyst.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16163611", "visit_id": "N/A", "time": "2146-08-22 07:10:00"} |
18573443-RR-115 | 439 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
PMH ESRD DM on HD since via LUE AVF,
HTN,multiple toe amputations, PVD s/p right BKA p/w chest pressure.Admittedin
SICU with intraabdominal abcess// intraabdominal abcessPlease give both IV and
oral (through NG tube) contrast
## SINGLE PHASE CONTRAST:
MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 7.6 s, 60.1 cm; CTDIvol = 27.8 mGy (Body) DLP =
1,669.6 mGy-cm.
Total DLP (Body) = 1,670 mGy-cm.
## LOWER CHEST:
Atelectasis of the right left posterior basal segments of the
lungs are still present. Visualized lung fields are within normal limits.
There is no evidence of pleural or pericardial effusion.
## ABDOMEN:
The fluid collection along the right mid abdomen in which a drainage catheter
tip terminates has been fully drained. Several small punctate gas collections
are noted along the anterior peritoneal recesses. A small fluid collection is
noted adjacent to loops of bowel deep to the anterior abdominal wall incision.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout. The
rounded low attenuation area within segment 6 laterally remains stable in size
and appearance.. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder has previously 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 shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The visualized reproductive organs are unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. The right abdominal fluid collection into which a catheter was recent
inserted has been drained. A smaller fluid collection remains present deep to
the incision site along with several small punctate echo collections.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18573443", "visit_id": "28015626", "time": "2141-02-10 00:46:00"} |
14520070-AR-20 | 116 | CT OF BILATERAL KNEES
## INDICATION:
Recurrent right patellar dislocation. Assess tibial tubercle to
trochlear groove distance. Question patella .
## FINDINGS:
The tibial tubercle-trochlear groove distance on the right and left
is 1.1 cm, with the tibial tubercle lying 1.1 cm lateral with respect to the
trochlear groove on each side.
Lateral projections of a 3D volumetric reconstruction demonstrates that the
ratio is 1.28. This is slightly above the limits of normal,
compatible with mild patella . On the right, the ratio is
1.24. This is also slightly above the normal limits, compatible with mild
patella .
## IMPRESSION:
1. Bilateral mild patella .
2. The tibial tubercle-trochlear groove distance bilaterally is 1.1 cm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14520070", "visit_id": "N/A", "time": "2153-07-08 08:10:00"} |
17337167-RR-31 | 95 | ## INDICATION:
year old man with possible stroke // likely stroke. assess
size of stroke
## FINDINGS:
There are multiple small areas of acute/ subacute infarcts seen involving the
right frontal and parietal cortex, both occipital lobes and left cerebellar
hemisphere. Mild brain atrophy seen. Mild changes of small vessel disease
noted. There is no mass effect, midline shift or hydrocephalus. Soft tissue
changes are seen in the sphenoid sinus probably related to intubation.
## IMPRESSION:
Multiple small areas of acute/ subacute infarcts are identified. No mass
effect or hydrocephalus. No evidence of acute or chronic hemorrhage.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17337167", "visit_id": "26067060", "time": "2132-11-04 02:27:00"} |
16909817-RR-148 | 114 | ## INDICATION:
year old woman with anorexia, G-J tube placement with partial
displacement, leaking at the tube site, now with worsening abdominal
pain// localization of the tube
## FINDINGS:
Persistent contrast from the prior study is seen in the small and large bowel.
Positioning of the GJ tube is unchanged from exam dating .
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air.
Osseous structures are unremarkable. Surgical clips are seen projecting over
the mid abdomen. Small atrophic calcified kidneys are seen bilaterally.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
## IMPRESSION:
Unchanged positioning of GJ tube in comparison to imaging dated .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16909817", "visit_id": "25007673", "time": "2192-12-31 04:39:00"} |
15270331-RR-48 | 105 | ## EXAMINATION:
CHEST (PA AND LAT)
## HISTORY:
with clear cell adenocarcinoma with lung metastases
presents with acute pleuritic chest pain and vomiting.
## FINDINGS:
Right-sided Port-A-Cath tip terminates at the junction of the SVC and right
atrium. The cardiac silhouette size is normal. Mediastinal and hilar
contours are unchanged. Multiple masses compatible with the metastatic
disease are decreased in size and number compared to the previous study. No
focal consolidation, pleural effusion or pneumothorax is identified. No acute
osseous abnormalities are detected.
## IMPRESSION:
Re- demonstration of multiple pulmonary metastases, decreased in size and
number from the previous study. No new focal consolidation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15270331", "visit_id": "26190867", "time": "2156-05-09 14:57:00"} |
11751512-RR-10 | 146 | ## INDICATION:
Alcoholic hepatitis, respiratory failure, now intubated, please
evaluate for ETT positioning.
SEMI-UPRIGHT FRONTAL RADIOGRAPH OF THE CHEST:
ET tube is terminating just
below the thoracic inlet, 6 cm above the carina.
There is improving pulmonary edema with mild residual. There are bibasilar
consolidations, right great than left, which could be a combination of
atelectasis and effusion; however, superimposed pneumonia is not excluded.
There is new plate-like right upper lobe atelectasis. Dobbhoff tube is seen
with the tip projecting upwards towards the gastric fundus. There is a left
PICC with the tip terminating in the upper-to-mid SVC.
## IMPRESSION:
1. Worsening atelectasis, predominantly in the right upper lobe.
2. ET tube 6 cm above the carina, just at the level of thoracic inlet.
3. Improving pulmonary edema with mild residual.
4. Bibasilar consolidations and bilateral pleural effusions, right more than
left.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11751512", "visit_id": "21126489", "time": "2185-07-09 09:32:00"} |
10235987-RR-27 | 360 | ## INDICATION:
woman with acute abdominal pain status post ERCP.
## CT ABDOMEN WITHOUT IV CONTRAST:
Lung bases are clear without consolidation or
pleural effusion. The heart is normal in size, without pericardial effusion.
In the abdomen, evaluation of solid organs is slightly limited in the absence
of IV contrast.
Oral contrast material fills the stomach, duodenum, and much of the small
bowel. There is no definite extravasation of contrast outside the bowel
lumen. There is equivocal wall thickening of the gastric pylorus. There is
no extraluminal fluid collection or air that would suggest perforation. In
this region, near the head of the pancreas, there is equivocal inflammatory
fat stranding which could reflect post-procedure change, versus development of
pancreatitis.
The patient is post-cholecystectomy. There is no intra- or extra-hepatic
biliary ductal dilatation. The liver is grossly normal. The pancreatic tail,
spleen, adrenal glands, and stomach are within normal limits. Kidneys are
symmetric in size without hydronephrosis or renal calculus. At the upper pole
of the left kidney, there is a vague region of hyperdensity, corresponding to
the location of a hypodense lesion on a prior contrast-enhanced CT ( ).
This could represent a hyperdense cyst.
The abdominal aorta is normal in caliber. There is no free air or free fluid
in the abdomen. There is no mesenteric or retroperitoneal lymphadenopathy by
size criteria.
## CT PELVIS WITHOUT IV CONTRAST:
Loops of large and small bowel are
unremarkable. The uterus, adnexa, urinary bladder and rectum are
unremarkable. A surgical clip is located posterior to the uterus. A
physiological amount of free fluid is seen in the cul-de-sac. There is no
pelvic or inguinal lymphadenopathy by size criteria.
## OSSEOUS STRUCTURES:
There is no fracture or worsened bony lesion. Soft
tissues are unremarkable.
## IMPRESSION:
1. No extraluminal air or fluid collection in the right upper quadrant that
would suggest perforation. No extravasation of oral contrast outside the
bowel lumen.
2. Mild inflammatory changes surrounding the duodenum and pancreas, which
could be related to the recent procedure. However, this could also reflect
developing pancreatitis. Correlate with labs.
3. Left renal upper pole lesion unchanged in size since , possibly
representing hyperdense cyst.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10235987", "visit_id": "23549609", "time": "2144-09-29 04:42:00"} |
19162571-RR-20 | 76 | ## FINDINGS:
Left-sided Port-A-Cath catheter is again seen, terminating in the distal
SVC/cavoatrial junction. Again seen are bilateral pleural effusions, large on
the right, moderate on the left, with overlying atelectasis, underlying
consolidation cannot be excluded. Cardiac and mediastinal silhouettes are
stable.
## IMPRESSION:
Large right and moderate left pleural effusions, grossly similar collected
possibly slightly increased, as compared to earlier this same date, with
overlying atelectasis, underlying consolidation cannot be excluded.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19162571", "visit_id": "27866141", "time": "2143-08-27 17:29:00"} |
13437845-RR-24 | 133 | ## EXAMINATION:
PA and lateral chest radiographs
## INDICATION:
year old man with POC for cancer treatment. Unable to get
blood return.// check port
## FINDINGS:
Compared to the prior chest radiograph dated .
Tip of left chest infusion port catheter terminates in the lower SVC in
unchanged position. There is no apparent kink in the tubing although complete
evaluation of the catheter apex is difficult due to projecting tissues.
The lungs remain well inflated and clear. No pleural effusions or
pneumothoraces. The cardiac silhouette is normal in size and stable. The
mediastinal and hilar contours are unremarkable.
## IMPRESSION:
Tip of left chest infusion port in the lower SVC. Unable to fully evaluate
for catheter kinking due to technique. consider evaluation with left and
right anterior shallow obliques. Otherwise, no clear explanation for catheter
malfunction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13437845", "visit_id": "N/A", "time": "2146-04-12 09:54:00"} |
12408912-RR-111 | 433 | ## INDICATION:
man with a history of non-small-cell lung carcinoma.
Status post bronchial stents. He presents with persistent sinus tachycardia
that is not fluid responsive. Evaluate for pulmonary emboli, stent patency
and mucous plugging.
## DOSE:
This study involved 5 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary
Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8 mGy-cm. 4)
Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm. 5) Spiral Acquisition 3.6 s, 28.1 cm; CTDIvol = 7.9 mGy (Body) DLP =
222.9 mGy-cm. Total DLP (Body) = 227 mGy-cm.
## FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
A small pericardial effusion and possible pericardial thickening appear stable
compared to the prior CT chest of . There is no pleural effusion.
Evaluation of pulmonary parenchyma of limited due to respiratory motion.
Emphysema is severe. A large mass centered in the left hilus is not
appreciably changed since the chest CT performed 3 days prior. A stent in the
distal main stem bronchus is patent but contains some secretions.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Mild compression deformities in the lower thoracic spine are similar to the chest CT.
## IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. A stent in the distal left mainstem bronchus is patent but contains some
secretions.
3. Large left hilar mass is relatively unchanged compared to the CT performed
3 days prior.
## RECOMMENDATION(S):
Close clinical followup of the contrast infiltration in
the left lower extremity.
## NOTIFICATION:
The findings on the images as well as contrast infiltration
through the left lower arm IV were discussed by Dr. with Dr. on
the telephone on at 5:08 , 10 minutes after discovery of the
findings. Specifically the need for close clinical followup of the left lower
arm infiltration site including elevation, icing and periodic physical
examination until resolution was discussed.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12408912", "visit_id": "20240142", "time": "2147-11-04 16:12:00"} |
18134115-RR-15 | 103 | ## EXAMINATION:
CHEST (PA AND LAT)
## INDICATION:
with neuro deficit// ?infiltrate, pna
## FINDINGS:
There is a right mediastinal partially calcified mass, better (though only
partially) visualized on same day CTA head and neck and measuring
approximately 5.3 x 4.6 cm. Cardiac silhouette is otherwise within normal
limits. Mild left basilar atelectasis is seen. No acute focal consolidation.
No pneumothorax or pleural effusion. No pulmonary edema.
## IMPRESSION:
1. Right mediastinal ed mass measuring approximately 5.3 x 4.6 cm on same day
CTA head and neck.
2. No evidence of pneumonia.
## RECOMMENDATION(S):
Clinical workup for pulmonary mass is recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18134115", "visit_id": "21206803", "time": "2142-08-29 10:45:00"} |
18176683-RR-98 | 550 | ## HISTORY:
male with hepatitis C cirrhosis with increasing AFP.
Patient recently admitted with chest pain and shortness of breath. Assess for
pulmonary embolism and hepatocellular carcinoma.
## CT CHEST WITH INTRAVENOUS CONTRAST:
The thyroid gland is homogeneous without
focal nodule. No supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy is identified. The thoracic aorta is non-aneurysmal and
grossly patent. No pulmonary embolism is identified. The heart size is
normal, and there is no pericardial effusion. There are large bilateral
pleural effusions, right greater than left, with associated lower lobe
atelectasis. No pulmonary consolidation is identified. The tracheobronchial
tree is patent to subsegmental level, without bronchial wall thickening or
bronchiectasis. There is moderate apical predominant centrilobular emphysema.
A 3 mm right-sided perifissural nodule is stable and likely represents a small
lymph node (6:42). No new suspicious pulmonary nodule or mass is evident.
CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST:
The patient has a history
of hepatitis C cirrhosis. The liver is extremely nodular and shrunken. A
wedge-shaped area of arterial enhancement within the anterior right lobe of
the liver (segments VIII/VII) appears similar in distribution compared to
prior MRI examination. However, delayed phase imaging suggests washout of
contrast from this lesion which is highly suspicious for hepatocellular
carcinoma (9:11). There are multiple additional foci of arterial enhancement
within the liver particularly within the left lobe (9:14, 13). Some are
stable and others are new compared to prior MRI examination. No clear washout
correlate is identified on delayed phase imaging. Hepatic veins and portal
venous system are grossly patent. There is evidence of portal hypertension
including moderate-to-severe ascites, splenomegaly measuring 14 cm,
splenorenal varices, and a recanalized umbilical vein.
Mild right-sided intrahepatic biliary ductal dilatation is stable. Mild
dilatation of the common bile duct measuring up to 11 mm is stable.
Additionally, dilatation of the pancreatic duct up to 7 mm is unchanged.
Findings continue to reflect possible ampullary stenosis. The pancreatic
parenchyma is atrophic and has multiple hypodense lesions within it. Per
prior MRI, findings are consistent with chronic pancreatitis. No suspicious
pancreatic mass is identified. The gallbladder is normal. Adrenal glands
are symmetric without focal nodule. Kidneys enhance symmetrically without
focal lesion. There is no hydronephrosis. Subcentimeter hypodensity within
the interpolar region of the left kidney is stable and corresponds to a cyst
seen on prior MR ( ). The abdominal aorta and branch vessels are densely
calcified though non-aneurysmal and patent. Imaged loops of small and large
bowel are unremarkable. There is no obstruction or inflammation. The stomach
is within normal limits. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are identified.
## BONES AND SOFT TISSUES:
No bone destructive lesion or acute fracture is
identified.
## IMPRESSION:
1. Large wedge-shaped area of arterial enhancement in the anterior right lobe
of the liver (segment VII/VIII) appears to demonstrate washout on delayed
phase imaging and raises concern for hepatocellular carcinoma.
2. Additional foci of arterial enhancement throughout the liver have no clear
correlate on delayed phase imaging and may represent perfusion anomalies.
Attention on followup is recommended.
3. Evidence of decompensated portal hypertension including moderate-to-severe
ascites, pleural effusions, splenorenal varices, splenomegaly.
4. Stable pancreatic and biliary ductal dilatation, possibly related to
ampullary stenosis.
5. Chronic pancreatitis
6. No pulmonary embolism
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18176683", "visit_id": "24150651", "time": "2134-07-14 10:56:00"} |
19172342-DS-7 | 1,645 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
PMH of HTN, HLD, DM2, and 40py tobacco use presenting with 2
weeks of exertional, non-radiating substernal chest pressure and
DOE associated with nausea and relieved with min of rest. Pt
is only able to walk 100ft with sob and 200ft without cp. Never
had pain like this before. No f/c/cough/ abdominalpain/diarrhea/
vomiting/ brbpr. No orthopnea and pnd. Currently CP free. Last
chest pain episode yesterday night. Patient saw his PCP this
morning and was referred to the ED for the concerning history.
In the ED, initial vitals were 12:14 0 97.5 86 147/85 18 99% RA.
On exam: Lungs CTAB, no edema, no jvd. Initial trop: 0.26. A
## CBC:
leukocytosis with left shift. Patient was guiac negative.
An EKG showed inferolateral st depression, NSR. Prelim, a CXR
showed left lower infiltrate vs atelectasis obscuring left heart
border. Patient was given asa y report and
given as well as metroprolol 12.5 and atorva 80 given, and a hep
gtt started.
On review of systems, he reports occasional cramping in his
calfs that has improved since he stopped smoking. He denies any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
## 2. CARDIAC HISTORY:
-CABG:
None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Rectal bleeding
- Obesity
- Candidal balanitis
- Left leg surgery following motocycle accident: repair to
tibia/fibula
## FAMILY HISTORY:
Sister with a stent at . Mother with some valvular disaese
later in life. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
## GENERAL:
WDWN M 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:
Supple with JVP of 7 cm.
## CARDIAC:
PMI located in intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, trace crackles at
bases. No wheezes or rhonchi.
## ABDOMEN:
Obese, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
## EXTREMITIES:
No c/c/e. No femoral bruits.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## GENERAL:
WDWN M 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:
Supple with JVP of 7 cm.
## CARDIAC:
PMI located in intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
## LUNGS:
Resp were unlabored, no accessory muscle use. CTAB, trace
crackles at bases. No wheezes or rhonchi.
## ABDOMEN:
Obese, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
## EXTREMITIES:
No c/c/e. No femoral bruits.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## DISCHARGE:
06:59AM BLOOD Hct-37.5* Plt
06:59AM BLOOD UreaN-14 Creat-0.9 Na-140 K-4.3 Cl-102
12:57PM BLOOD cTropnT-0.26*
08:45PM BLOOD CK-MB-4 cTropnT-0.17*
05:30AM BLOOD CK-MB-4 cTropnT-0.28*
01:23PM BLOOD CK-MB-3 cTropnT-0.27*
03:40PM BLOOD cTropnT-0.37*
06:59AM BLOOD cTropnT-0.22*
CHEST (PA & LAT) Study Date of 1:56
The lungs are well expanded and clear. There is no pleural
effusion or
pneumothorax. The heart is normal in size with mediastinal and
hilar
contours.
## IMPRESSION:
No acute intrathoracic process.
## HEMODYNAMICS (SEE ABOVE):
Coronary angiography: right dominant
## LMCA:
No angiographically apparent CAD
## LCX:
Mild disease. Large bore collateral fills the RCA to a
total occlusion mid vessel.
## RCA:
Totally occluded mid vessel. Serial 40% lesions in the
proximal vessel.
Interventional details
Change for 6 AL-1. Crossed with ChoICE XS wire.
Confirmed intraluminal position in the PDA. Changed for
Prowater
wire. Predilated with a 2.0 mm balloon. Deployed a 3.5 x 18 mm
Resolute stent and a more proximal overlapping 3.5 x 20 mm
Resolute stent. Postdilated with a 3.5 mm balloon. Final
angiography revealed normal flow, no dissection and 0% residual
stenosis.
Assessment & Recommendations
1.Secondary prevention CAD
2.Plavix 75 mg PO QD
3.Smoking cessation counseling given to patient.
Portable TTE (Complete) Done
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is an anterior
space which most likely represents a prominent fat pad.
## IMPRESSION:
Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild mitral
regurgitation with normal valve morphology. Dilated ascending
aorta.
## BRIEF HOSPITAL COURSE:
h/o Htn, HL, DM presented with NSTEMI based on EKG and
troponins now s/p 2 DES to RCA.
## # NON-ST ELEVATION MYOCARDIAL INFARCTION:
Patient presented with
angina. TIMII Risk score of 5 placing him in high risk. Patient
plavix loaded with 300 mg and started on heparin drip on
admission with plan for cardiac catheterization. EKG with ST
depression in II, III, aVF and V3-V6 of approximately 1mm.
Troponin initially downtrending from 0.28 to 0.17, but then back
up to 0.26, likely secondary to epidoses of chest pain. CK-MB
remained at 4. Patient was initially started on home nifedipine,
but this was later discontinued. He was also started on aspirin
325 mg, metoprolol 50 mg BID and atorvastatin 80 mg daily.
Patient was taken to cath lab which showed RCA that had
serial 40% lesions proximal and total occlusion mid vessel, 2
DES placed. Patient discharged on plavix 75 mg daily.
## # LEUKOCYTOSIS:
Patient had a leukocytosis on presentation. He
was recently started on prednisone 40mg qd x2 days. CXR was
clear and no signs of infection.
## # DIABETES:
Most resent A1C 7.5%. Metformin held and
patient placed on insulin sliding scale while in hospital.
Patient continued on lisinopril 40 mg daily.
# Mild intermittent intrinsic asthma- Patient started on
Flovent and albuterol nebulizers with improvement in symptoms.
Recent pneumonia treated with doxycycline 100 mg twice a
day for seven days, and prednisone 30 mg daily for 10 days. CXR
here reassuring.
## # SMOKING CESSATION:
Patient counseled with regards to health
risks of smoking and encouraged to quit. He was started on the
nicotine patch 21mg daily and discharged with a prescription for
this.
## # DYSLIPIDEMIA:
LDL 93, HDL 36 from . Was on Simvastatin 20
mg PO QHS
- Atorvastatin 80mg qd.
# Transitional Issues:
- smoking cessation
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
HOld for SBP<100
2. MetFORMIN (Glucophage) 1000 mg PO QAM
3. MetFORMIN (Glucophage) 500 mg PO QPM
4. NIFEdipine CR 60 mg PO DAILY
5. Simvastatin 20 mg PO QHS
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Aspirin 81 mg PO DAILY
8. albuterol sulfate *NF* 2.5 mg /3 mL (0.083 %) Inhalation q4h
wheeze/ dyspnea
9. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID
dyspnea/ wheeze
10. ipratropium-albuterol *NF* mcg/actuation Inhalation
q4h wheeze/ dyspnea
## DISCHARGE MEDICATIONS:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*1
3. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch every 24 hours Disp #*14
## TRANSDERMAL PATCH REFILLS:
*0
5. albuterol sulfate *NF* 2.5 mg /3 mL (0.083 %) Inhalation q4h
wheeze/ dyspnea
6. albuterol sulfate *NF* 90 mcg/actuation INHALATION QID
dyspnea/ wheeze
7. ipratropium-albuterol *NF* mcg/actuation Inhalation
q4h wheeze/ dyspnea
8. MetFORMIN (Glucophage) 1000 mg PO QAM
9. MetFORMIN (Glucophage) 500 mg PO QPM
10. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
## TABLET REFILLS:
*0
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Lisinopril 40 mg PO DAILY
## PRIMARY:
Coronary artery disease, NSTEMI
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was our pleasure to care for you at . You were admitted
for chest pain and found to have a heart attack by EKG and blood
tests. We treated you with a cardiac catheterization which
showed blockage in your right coronary artery. A drug eluting
stent was placed. You were started on a medication called
clopidogrel. You cannot stop this for any reason unless told to
do so by your cardiologist.
Medication changes:
START metoprolol 50 mg twice per day
START clopidogrel 75 mg daily ** DO NOT stop unless told to do
so by your cardiologist**
START aspirin 325 mg daily
START atorvastatin
START nicotine patch 21 mg daily and follow up with your PCP
STOP diltiazem
STOP simvastatin
Please start taking your metformin again starting on
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19172342", "visit_id": "25521069", "time": "2165-06-16 00:00:00"} |
16094141-RR-44 | 422 | ## INDICATION:
female with left upper quadrant pain and severe
tenderness. The patient has a history of partial gastrectomy for ectopic
pancreas, complicated by duodenal stump leak.
## FINDINGS:
There is atelectasis at the lung bases, without definite evidence of
pneumonia.
The liver is again noted to contain multiple small hypodense lesions, too
small to characterize on this study, though stable from .
There is no new or concerning liver lesions identified. Calcified granuloma
is seen posteriorly in the right lobe. Gallbladder is unremarkable. There is
mild central intrahepatic ductal prominence, also stable from prior study.
There is no cholelithiasis or CT evidence of acute cholecystitis. The spleen
is normal. Pancreatic body and tail demonstrates homogeneous enhancement, and
are without focal lesions. There is minimal prominence of the pancreatic duct
at the pancreatic head. Duodenal stump appears unremarkable without focal
fluid or air adjacent. A small focus of air adjacent to the pancreatic head
is within a duodenal diverticulum, as seen on multiple prior studies.
The stomach contains contrast. A gastrojejunostomy is widely patent, with
contrast passing into the Roux limb. There is an ill-defined fluid collection
again seen insinuating in the epigastric region, which is little changed in
size, but does track slightly further to the left and demonstrates increased
conspicuity of a thin enhancing rim, compatible with degree of organization.
There is no air to definitively suggest superinfection, though this cannot be
excluded by imaging and clinical correlation is advised. Adjacent prominent
nodes are likely reactive, stable from prior study. There is no
retroperitoneal adenopathy. The aorta is normal in caliber.
The remainder of the small bowel is normal in caliber and configuration. The
colon is unremarkable. The anterior abdominal wall is notable for
post-surgical changes, with multiple uncomplicated fat-containing ventral
hernias again present.
## CT PELVIS:
Rectum and sigmoid colon are unremarkable. The distal ureters and
bladder are normal. The uterus and adnexa are normal. There are no adnexal
masses. There is no free pelvic fluid, and there is no pelvic or inguinal
adenopathy.
## BONE WINDOWS:
No suspicious lytic or sclerotic osseous lesions are
identified.
## IMPRESSION:
1. Grossly stable size of anterior epigastric fluid collection, insinuating
about the gastrojejunostomy and left lobe of the liver, with increased
conspicuity of peripheral enhancing rim, compatible with a degree of interval
organization. No air is seen to definitively suggest superinfection, though
this cannot be excluded by imaging.
2. Patent gastrojejunostomy, with contrast seen passing into the Roux limb.
No extraluminal contrast is identified.
3. Multiple small uncomplicated fat-containing ventral hernias.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16094141", "visit_id": "21389240", "time": "2156-12-31 00:12:00"} |
19096027-RR-14 | 104 | ## REASON FOR EXAMINATION:
Respiratory failure.
Portable AP chest radiograph compared to the previous study from obtained at 2:19 p.m.
No significant change in bilateral opacities is demonstrated, although note is
made that current radiograph represent more confluent opacities with less
patchy appearance compared to the previous study, thus may be attributable to
combination of pulmonary edema/volume overload with underlying infectious
process. The ET tube tip is 4 cm above the carina. The right internal
jugular line tip terminates at the cavoatrial junction. The NG tube tip is in
proximal stomach. The cardiomediastinal silhouette is unchanged with no
significant enlargement.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19096027", "visit_id": "20057926", "time": "2129-08-03 03:12:00"} |
14177761-RR-22 | 140 | ## INDICATIONS:
woman with solid left thyroid nodule. Biopsy
requested.
## PROCEDURE:
After discussion of the risks and benefits of the procedure with
the patient, informed consent was obtained from the patient in writing. A
pre-procedure timeout was performed to verify the patient identity and the
procedure to be performed.
Initial ultrasound imaging again demonstrated a solid heterogeneous nodule
along the posterior portion of the mid-to-lower pole of the left lobe of the
thyroid, measuring 9 mm in diameter.
Under direct ultrasound visualization and using standard aseptic technique,
three 25-gauge fine-needle aspiration biopsy samples were obtained and sent to
pathology. The patient tolerated the procedure well. There were no immediate
complications, Dr. attending radiologist, was present and
supervising throughout the procedure.
## IMPRESSION:
Technically successful fine-needle aspiration biopsy of the
dominant left lobe thyroid nodule.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14177761", "visit_id": "N/A", "time": "2176-07-21 13:28:00"} |
13113026-RR-23 | 222 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old woman s/p right occipital craniotomy and resection of
tumor. Post-operative head CT without contrast to evaluate for post-operative
hemorrhage. // Post-operative head CT without contrast to evaluate for
post-operative hemorrhage. Please perform at .
## DOSE:
Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.4 cm; CTDIvol = 54.8 mGy (Head) DLP =
897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
## FINDINGS:
The patient is status post right posterior approach craniotomy and tumor
resection with expected postoperative changes, including pneumocephalus and
hyperdense material layering along the resection cavity. Mild surrounding
edema is noted in the white matter of the right parieto-occipital lobe. There
is no evidence of appreciable intracranial hemorrhage or large vascular
territorial infarction.
The ventricles and sulci are normal in size and configuration.
Periventricular and subcortical white matter hypodensities are noted, likely
the sequelae of chronic small vessel ischemic disease. The basal cisterns
remain patent.
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:
Expected postoperative appearance status post right posterior approach
craniotomy and tumor resection. No evidence for acute intracranial hemorrhage
or large vascular territorial infarction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13113026", "visit_id": "24591654", "time": "2155-10-28 19:46:00"} |
17671435-DS-16 | 2,439 | ## ALLERGIES:
Penicillins / Dilaudid / Chlorhexidine
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Electrophysiology Study for attempted Ventricular Tachycardia
Ablation
Cardiac Catheterization
## HISTORY OF PRESENT ILLNESS:
year old male with a PMH of a-fib, OSA, PVD secondary to a
gunshot wound to his right lower leg, and non-ischemic
cardiomyopathy with a reported EF of in the past and a
recent EF of 40%. He had an AICD placed in , and he has had
4 episodes of syncope in the past 2 months. He has been shocked
8x in total, with one episode shocking him four times
consecutively. His history of cardiomyopathy (best attributed
to a possible viral illness, per patient report), dates back
years. He has also had long standing a-fib, and it is unclear
whether he had the cardiomyopathy or a-fib first as he has never
been symptomatic until .
.
He has had 3 hospitalizations for syncope since . The
first of which was , when his wife reports
witnessing him lose consciousness for a few seconds and falling
out of a chair. He was evaluated at , was
found to have VT, and had an AICD placed on .
.
0n he woke up from sleep, his AICD fired and 15 minutes
later it fired again. He was asymptomatic at the time, he was
then taken to and transferred to
. He was given a loading dose of amiodarone, and
converted to lower dose because of dizziness. He was discharged
home and on , he was feeding his horses and felt dizzy and
lightheaded, fell to the ground had a jerking motion, his family
again witnessed the event. He didn't feel like he was shocked,
and had no palpitations at the time. He lost consciousness and
his wife was able to get him into the car and take him to the
hospital. He was initially treated for what was thought to be
ischemic chest pain. At they gave him dilaudid
for chest discomfort which caused him to flush and have
diaphoresis. He was transferred to and they gave him
nitroglycerin, which caused his blood pressure to drop. This
entire course he was kept on amiodarone of 400mg BID. He had
several beat runs of NSVT while there and on he
was intially increased to 400mg TID of amio, then due to
persistent episodes of NSVT he was put on IV amio at 1mg/min and
transitioned today to 0.5mg/min.
.
His outpatient cardiologist was concerned for AICD lead
migration and on he was taken to the cath lab for lead
replacement. Subsequently he developed 20 beats of VT, at which
time the aforementioned amio drip was started at 1mg/minute.
Since that time his EKG and tele has shown paced beats and
ectopy.
.
Of note at the OSH his creatinine was 1.1, CE negative x 3,
electrolytes WNL, Vanc ppx for lead placement, Coreg was
decreased to 25 BID, Coumadin was held, mag oxide added to keep
a-fib better controlled. He was continued on digoxin and
lisinopril. BPs ranged 86-126/46-60.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for syncope, orthopnea
(chronic), and lower extremity edema right greater than left, as
well as absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, palpitations.
.
On the floor, initial vitals were T: 96.5, BP: 98/72, HR: 93,
## RR:
23, SaO2 95% on RA, resting comfortably in bed, asymptomatic
with his wife and son at the bedside.
.
## 1. CARDIAC RISK FACTORS:
None
2. CARDIAC HISTORY:
Ventricular tachycardia
Chronic a-fib
nonischemic cardiomyopathy with (?)EF of
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: AICD placed in
3. OTHER PAST MEDICAL HISTORY:
. OSA on nasal CPAP
. PVD secondary to gunshot wound at
. Colecystectomy
## FAMILY HISTORY:
2 sisters died from acute myocardial infarction. One sister was
at the time of her death, and his other sister was when
she died of myocardial infarction. He states they don't know
what caused the heart attacks.
## GENERAL:
Well appearing man in NAD. Oriented x3. Mood, affect
appropriate. Appears his stated age.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. No pallor or
cyanosis of the oral mucosa.
## NECK:
Supple with JVP of ~7cm.
## CARDIAC:
Irregular rate with frequent extra beats, normal S1,
S2. No m/r/g.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Sparse end inspiratory
wheezes, but in all lung fields. Mild scattered expiratory
rhonchi.
## ABDOMEN:
Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Scar on the
umbilicus from prior cholecystectomy.
## EXTREMITIES:
No c/c/e. Well healed scar, and considerable
indentation close to the medial tibial plateau with scar vs skin
graft well healed x many years on the right lower extremity
## SKIN:
No stasis dermatitis, ulcers, or scars.
## GENERAL:
Well appearing man in NAD.
## CARDIAC:
irregular rate, normal S1, S2. No m/r/g.
## LUNGS:
Resp were unlabored, no accessory muscle use. Wheezes
posteriorly. No cough.
## ABDOMEN:
Soft, NTND. No HSM or tenderness.
## EXTREMITIES:
No c/c/e. Right groin sites with minimal ecchymosis
and no hematoma.
## SKIN:
Rash improving, few patchy areas around pacer site, none
on neck now. Has peeling skin on left hand only, pt states this
is chronic.
## ECHO:
The left atrium is moderately dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function appears severely depressed (LVEF= %) but is
difficult to assess due to poor image quality and frequent
ventricular ectopy. Relative preservation of basal inferolateral
wall function. There is considerable beat-to-beat variability of
the left ventricular ejection fraction due to an irregular
rhythm/premature beats. The right ventricular cavity is
moderately dilated with depressed free wall contractility. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a prominent fat pad.
.
## IMPRESSION:
Suboptimal image quality. Dilated left ventricle
with severe systolic dysfunction. Right ventricular dilation and
dysfunction.
.
Cardiac Cath Study Date of
## COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated no
angiongraphically apparent disease. The LMCA, LAD, LCx and RCA
had no
evidence of angiographically apparent disease.
2. Resting hemodyanamics revealed slightly elevated right sided
filling
pressures with RVEDP of 15mmHg. Cardiac output was preserved at
7
l/min.
## FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal ventricular function.
.
TTE (Complete) Done
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is moderate global left ventricular
hypokinesis (LVEF = . The estimated cardiac index is
normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of ,
biventricular systolic cavity sizes are smaller and systolic
function is slightly improved.
.
## BRIEF HOSPITAL COURSE:
year old with a PMH significant for non-ischemic
cardiomyopathy, chronic a-fib, and ventricullar tachycardia s/p
AICD placement on , that was transferred from
in for treatment of ventricular tachycardia with
ablation.
.
# Ventricular tachycardia/dialated cardiomyopathy: Mr. has
ventricular tachycardia in the setting of non-ischemic
cardiomyopathy. These episodes of ventricular tachycardia
started in , he is s/p AICD placement and has had
several instances recently of firing of his AICD. Etiology of
his v-tach is likely cardiomyopathy resulting in ectopy. An
initial echo was done the morning after admission and showed
dilated left ventricle with severe systolic dysfunction, also
right ventricular dilation and dysfunction. Hemodynamically
stable and asymptomatic. He was conitnued on an amiodarone drip
of 0.5mg/min until he was taken for EP procedure on .
During the study, they were beginning to warm a site for
ablation, and he went into fast VT, so the study was aborted.
He converted back to his normal rhythm. His amiodarone was
converted to 200mg PO TID and he still had VT with walking
minimal distances, therefore loading dose was increased to 400mg
BID, with plan to transition to 200mg PO BID in one week
(starting . Now currently undergoing workup for heart
transplant. CT chest completed which showed multifocal small
ground-glass nodules predominantly involving the upper lobes,
requiring a follow up repeat CT in weeks as an outpatient.
CT abd/pelvis showed hypoattenuating left upper pole renal
lesion, most likely benign, but a renal US could be considered
as an outpatient. Hepatitis A,B,C, CMV and HIV serologies were
negative.
While on the floor and he had increased runs of
VTach resulting in AICD firing. The device fired once on
at 9:30 in the morning when he was walking with the EP team to
reproduce symptoms. On the , he was washing his hair sitting
at the sink and he became symptomatic with lightheadedness and
flushing. He had 2 runs of VTach that both resulted in ICD
firings at 8:09 and 8:10 in the morning. He was taken to cath
immediately following, and then he was taken to the EP lab for
readjustment of his leads. The lead wires were adjusted to
remove slack from the wires. He tolerated the procedure well
and has been without any runs of VTach since.
He received a TTE on when compared with the prior study
(images reviewed) of , biventricular systolic cavity
sizes are smaller and systolic function is slightly improved to
. A right/left heart cardiac catheterization that showed:
right dominant system that demonstrated no angiongraphically
apparent disease. The LMCA, LAD, LCx and RCA had no evidence of
angiographically apparent disease. Resting hemodyanamics
revealed slightly elevated right sided filling pressures with
RVEDP of 15mmHg. Cardiac output was preserved at 7 l/min. His
volume status was medically managed and he was transitioned back
to his home PO Lasix of 20mg daily.
.
# Contact dermatitis/cellulitis: He developed a likely contact
dermatitis after lead replacement at OSH. The contact
dermatitis may have been from the chlorhexadine prep during the
procedure as the patient reported that this happened in the past
during a prior cath. The contact dermatitis likely became
super-infected and he developed erispelas which was treated
successfully with doxycyline for 7 days last dose .
.
# Atrial fibrillation: His atrial fibrillation was rate
controlled and medically managed. His coumadin was held
secondary to need for cardiac catheterization and he was placed
on a heparin drip throughout his admission.
.
# Sleep apnea: His sleep apnea was medically managed with his
CPAP mask at night without complications.
.
The patient was full code for this admission. Pt was discharged
home with further outpt follow-up planned.
## MEDICATIONS ON ADMISSION:
On Transfer from OSH:
. Coumadin last dose for a-fib
. Digoxin 0.25mg PO Q24
. Lisinopril 40mg PO Q24
. Coreg 25mg PO Q12
. Mag Oxide 400mg PO Q24
. Lovastatin 20mg PO Q24
. Aldactone 12.5mg PO Q24
. Amiodarone 0.5mg/min IV
## DISCHARGE DIAGNOSIS:
Ventricular Tachycardia
Non-ischemic Cardiomyopathy
Acute Renal Failure
## DISCHARGE CONDITION:
Alert and Oriented x3
Independent Ambulation
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were initially admitted to the hospital for loss of
consciousness, and were found to have an abnormal heart rhythm
called ventricular tachycardia. You were transferred to
for further management of your ventricular tachycardia and
evaluation for potential ablation. Unfortunately, the site of
the abnormal heart rhythm could not be localized for ablation on
this attempt. Your pacemaker/defibrillator settings were
adjusted to optimize your own normal heart rhythm and
conduction. You felt significantly improved following the
adjustment, and it was decided that your irregular heart rhythm
would be controlled with medications. We required you to stay in
the hospital for a few days to best optimize your medications
for rhythm control.
During this hospitalization, we also began the evaluation for a
heart transplant in case this is something that might benefit
you in the future.
Other issues on this hospitalization included a rash involving
your chest, shoulders and neck. It was believed to be related
to contact allergy to "chlorhexidine", a cleaning agent we
commonly use before procedures. We also believe this skin rash
became secondarily infected, for which we treated you with
antibiotics.
The following changes were made to your home medications:
- Amiodarone was continued at 400mg TWICE daily for 3 more days,
then decrease to 400 mg once daily on . Please continue
that dose until you see Dr. .
- Start Metoprolol Succinate to control your ventricular
tachycardia
- STOP taking Carvedilol, Magnesium and Digoxin
- DECREASE the dose of Warfarin to 4mg daily. Please check your
INR on with results to Dr. .
- Start taking clindamycin, an antibiotic, to prevent infection
at the site
- Start taking Tylenol as needed for pain at the ICD site
- Start taking Lorazepam if you need for anxiety or sleep.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Check your INR at Dr. office on . You should
have the INR followed closely now that you are on amiodarone.
Please be sure to have your blood drawn at your doctor's office
in months to check your thyroid and liver function tests
because amiodarone can sometimes affect these with time. You
will also need to have pulmonary function tests done to make
sure the amiodarone is not affecting your lungs.
Your initial CT scan of your chest here showed that you have
some non-specific nodules that may be due to an infection,
inflammatory disease, or even cancer. Please talk to your
primary care doctor and cardiologist regarding ordering a follow
up CT of your chest in weeks to evaluate whether there is
any change.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17671435", "visit_id": "28094865", "time": "2157-08-04 00:00:00"} |
15638043-RR-70 | 470 | CT TORSO WITH CONTRAST
## INDICATION:
male with metastatic melanoma. Please evaluate for
disease progression.
## FINDINGS:
There is no supraclavicular or axillary lymphadenopathy. The
thyroid gland demonstrates homogeneous attenuation without focal lesions. No
mediastinal or hilar lymphadenopathy. Small mediastinal lymph nodes do not
meet criteria for pathologic enlargement. Changes of left axillary lymph node
dissection. Heart size is within normal limits without pericardial effusion.
Normal caliber thoracic aorta and pulmonary trunk.
Stable linear opacities in the lung apices, compatible with scarring. Stable
calcified granuloma in the right lung apex. No pulmonary mass or confluent
consolidation. The tracheobronchial tree is normal without endoluminal
lesion. No pleural effusions or pneumothorax.
## ABDOMEN:
The liver demonstrates homogeneous attenuation without focal
lesions. Spleen demonstrates homogeneous enhancement without focal lesions.
Pancreas enhances homogeneously without focal lesions. No pancreatic ductal
dilatation. Adrenal glands are normal without nodularity. Although the 1.7 x
1.3 cm hypodense right renal lesion is stable, it does not fulfill the
Hounsfield units criteria for a simple cyst. Kidneys otherwise demonstrate
symmetric enhancement and excretion. No hydronephrosis or hydroureter.
Enteric contrast reaches the level of the cecum. Small hiatal hernia. Bowel
loops are normal caliber, with minimal scattered diverticulosis without
diverticulitis. Normal caliber appendix and terminal ileum. No mesenteric or
retroperitoneal lymphadenopathy.
Abdominal aorta is normal caliber with moderate atherosclerotic
calcifications. The mesenteric arteries are grossly patent. Portal vein and
mesenteric venous structures are grossly patent.
## PELVIS:
The urinary bladder is well distended without wall thickening.
Prostate gland is within normal limits. Seminal vesicles are symmetric.
There is no pelvic lymphadenopathy or fluid collection.
## BONES AND SOFT TISSUES:
Moderate multilevel degenerative disc disease. No
acute fracture or destructive osseous process. Soft tissues of the chest and
abdominal wall are normal.
## IMPRESSION:
1. No evidence of recurrent or metastatic disease.
2. Normal caliber bowel loops and appendix.
3. Stable hypodense right renal lesion most compatible with a cyst.
4. Stable 1.7 x 1.3 cm hypodense right renal lesion does not fulfill the
Hounsfield units criteria for a simple cyst. Attention to this finding on
follow up imaging.
5. Stable biapical linear fibrosis.
## NOTE:
There was IV infiltration of approximately 30 cc of contrast into the
right forarm. The patient was urgency examined. Mr. denied pain or
parasthesias in the right upper extremeity. Although the overlying skin was
erythematous, there was no significant discoloration. Radial and ulnar pulses
were intact. Sensation and motor stregnth were intact. His right arm was
elevated and ice pack was applied. Mr. had an appointment with Dr.
in clinic follow the CT scan. The incident of the IV
infiltration was directly comminicated to Dr. telephone for
further assessment on his arrival to clinic. The patient was monitored shortly
in the CT suite and remained stable without pain or symptoms. Pt was dischared
with instructions and ice pack.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15638043", "visit_id": "N/A", "time": "2115-11-01 12:10:00"} |
19038331-RR-52 | 170 | ## INDICATION:
female with a remote history of breast cancer,
presenting with multifocal strokes secondary to venous thrombosis. Assess for
evidence of malignancy.
## OSSEOUS STRUCTURES:
There are no suspicious lytic or blastic lesions. A
severe wedge deformity of the T12 vertebral body appears grossly unchanged
in size but less dense compared to the examination of . There is
multilevel degenerative disease. There has been mild interval increase in
terms of height loss of the mid portion of the L2 vertebral body.
## IMPRESSION:
1. No evidence of primary or metastatic disease.
2. Stable appearance of radiation changes within the lungs.
3. Left adrenal adenoma.
4. Cardiomegaly and enlarged pulmonary artery, suspicious for underlying
pulmonary hypertension.
5. Stable mediastinal and right hilar lymphadenopathy compared to CT of
.
6. Extensive atheromatous calcific disease involving the abdominal and
thoracic aorta and its branches.
7. New, small amount of fluid noted within the right inguinal canal.
8. Cholithiasis.
9. Increased loss of height of the L2 vertebral body. Relatively unchanged
appearance of T12 wedge deformity.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19038331", "visit_id": "24102248", "time": "2175-01-27 18:16:00"} |
19776126-RR-5 | 84 | ## INDICATION:
woman with renal insufficiency concerning for
Wegeners.
## FINDINGS:
There is increased echogenicity of the renal cortex bilaterally.
The right kidney measures 10.1, the left kidney measures 11.3 cm without
evidence of hydronephrosis, stones, masses or hematoma.
The arterial waveforms of both kidneys are normal; however, the RIs are
slightly elevated bilaterally, ranging between 0.80 and 0.88. The urinary
bladder is normal.
## IMPRESSION:
1. Increased renal cortex echogenicity consistent with medical renal disease.
2. Moderately increased resistive indices.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19776126", "visit_id": "20550940", "time": "2184-03-20 09:15:00"} |
15251571-DS-16 | 1,017 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
year old man with no PMHx who presents s/p 2 syncopal
episodes. He was in the grocery store
earlier today with his wife when he reports the sudden onset of
a "pulse" like pain in his epigastrium. He then felt dizzy for a
second but this was self limited. Five minutes later he felt
dizzy again while waiting in line and sat down. He feels as if
he would have blacked out otherwise. EMS arrived and he reports
he was able to climb up into the ambulance. Once at
, he fainted when someone asked him to sit up on the
stretcher so they could apply telemetry. His wife reports his
potassium was 3.2. At the OSH, they gave him aspirin, a beta
blocker, and two potassium pills per the patients report but
they did not send over any records. His heart rate then went
from 130 to 70 and stablized. He feels that it has been stable
ever since. Per report from our ED from the OSH, he was noted to
be bradycardic to 10, then went into afib, then bradycardic to
40, and returned to sinus. Troponin was negative. Strips that
they sent over appear to be afib in the 110's to 120's with
PVC's. There is also one with progressive PR prolongation.
Of note, he reports an episode of dizziness in . Labs done
at that time in were normal. He reports this resolved
with increased hydration and decreased stress. Since moving to
one year ago, he notes that he had a period of time where
he craved salt. He would eat very salty food including eating
salt alone. His diet has normalized since then. He has had a
particularly stressful week at work with high stress, increased
caffeine intake and decreased hydration. He feels dehydrated
overall. He also recently started swimming the past two weeks
for exercise. Drank a glass of red wine last night.
In the ED initial VS were 99.5, 99, 102/61, 18, 99% RA. Labs
notable for WBC 13.2, neg trop. Vitals prior to transfer: 84
108/49 15 97% on RA.
Currently, he is anxious but otherwise denies any symptoms.
## REVIEW OF SYSTEMS:
Nevative unless noted above.
## PAST MEDICAL HISTORY:
- Paroxysmal atrial fibrillation (brief episode
- Vasovagal syncope
## FAMILY HISTORY:
Sister was diagnosed with a heart condition at a young age which
involves her valves or septum but he is unsure of how to
translate this condition into .
## GENERAL:
young thin male in NAD, mildly anxious
## HEENT:
NCAT, sclera anicteric, PERRL, EOMI, MM dry without
lesions
## NECK:
supple, no LAD, no thyromegaly
## ABDOMEN:
+BS, soft, NT, ND
## EXT:
wwp, no edema, DP 2+ bilaterally
## NEURO:
A&Ox3, CN intact, symmetric strength
## EKG:
NSR at 90, NA, RSR' in V2, QRS nl duration, QTC
425, no ST-T wave changes
TTE:
The left atrium is normal in size. The interatrial septum is
aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 65%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
## BRIEF HOSPITAL COURSE:
yo male with no prior sig PMH presented with syncope.
# Syncope: Most likely a vasovagal event given prodrome of
warmth, nausea, diaphoresis and his pale appearance. He was
noted to be bradycardic at that time which would be consistent
with this picture. Transient episode of atrial fibrillation at a
rate in the 110s, which resolved spontaneously. Unclear
precipitant, though he noted many stressors recently, which may
be contributing. He was ruled out for ACS with normal ECG and
negative troponins. He was monitored on telemetry overnight
without malignant rhythm or recurrence of atrial fibrillation.
Orthostatics were normal in the morning, though this was
post-hydration. TTE was performed that was reassuring without
structural or valvular disease and no LVOT was seen. Patient was
reassured and given instructions to follow up with PCP within
one week of discharge.
# Atrial fibrillation: Transient in the setting of his vasovagal
episode. He has never noted palpitations or chest pain. He
remained in sinus rhythm throughout his hospitalization. TSH low
normal. He has been drinking excessive amounts of coffee and has
been stressed recently with work and recent death of his father,
which may have resulted in increased sympathetic tone and
precipitated atrial fibrillation. CHADS2 of zero. Started on
aspirin 81 mg daily. He was instructed to decrease caffeine
intake and to seek a therapist to help manage stress.
# Transitional issues:
- Code status: Full (confirmed)
- Contact: (wife)
- Patient has multiple stressors which may have contributed to
atrial fibrillation, he was amenable to seeking out therapist
for strategies on managing stress.
- New onset transient paroxysmal atrial fibrillation. CHADS2 of
0, started on aspirin 81 mg daily.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
## DISCHARGE DIAGNOSIS:
Primary diagnoses:
- Vasovagal syncope
- New onset paroxysmal atrial fibrillation
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure taking care of you at the . You were
admitted to the hospital because you passed out once and nearly
passed out at another time. You heart rate was noted to be slow
then very fast in a rhythm called atrial fibrillation. We
belive your heart rate was slow because you had a fainting
episode after some abdominal pain (vasovagal syncope). The
atrial fibrillation was transient and you did not have any
additional episodes while in the hospital. This was most likely
due to the excessive caffeine and stress you have been
experiencing lately. We would recommend that you cut back on
coffee and see your PCP or therapist for strategies to reduce
and manage the stress in your life.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15251571", "visit_id": "21415287", "time": "2110-10-11 00:00:00"} |
14549906-RR-40 | 115 | ## INDICATION:
History of L5/S1 herniation status post discectomy with fall and
lumbar spine pain.
## LUMBAR SPINE, TWO VIEWS:
Five non-rib-bearing lumbar-type vertebral bodies
are present. No fracture or subluxation is present. Degenerative changes are
seen, most pronounced at L4/5 with intervertebral disc space narrowing,
osteophyte formation and subchondral sclerosis. Milder degenerative changes
are also noted at L5/S1. There is mild associated facet hypertrophy at these
levels. Findings are unchanged from prior. Sacroiliac joints are preserved.
The sacrum is intact. Scattered phleboliths are noted within the pelvis.
Cholecystectomy clips are seen within the right upper quadrant of the abdomen.
## IMPRESSION:
No fracture, subluxation, or change from prior study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14549906", "visit_id": "N/A", "time": "2152-01-02 21:12:00"} |
11022710-RR-23 | 103 | ## STUDY:
CT head without contrast.
## FINDINGS:
No evidence of acute intracranial hemorrhage, mass lesion, shift of
normally midline structures, hydrocephalus, or acute major territorial
infarct. The normal gray-white matter differentiation is preserved. The
major intracranial cisterns are preserved.
The extracalvarial soft tissues appear within normal limits. Oropharyngeal
secretions likely relate to intubation. Mild ethmoid sinus opacification.
The mastoid air cells are clear. A small amount of mucosal thickening within
the left lateral wall of the left sphenoid sinus.
## IMPRESSION:
No evidence of acute intracranial hemorrhage or major territorial
infarct detected. MRI is more sensitive for the detection of acute ischemia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11022710", "visit_id": "22136801", "time": "2112-03-03 11:32:00"} |
13421348-RR-22 | 102 | ## HISTORY:
man with painless right supraclavicular swelling.
## FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues in the
right supraclavicular region. At the site of the patient's swelling there is
an oval heterogeneous hypoechoic avascular soft tissue mass. This mass
measures 6.8 x 3.6 x 7.1 cm. This mass is just deep to the subcutaneous
plane. While this could represent a lipoma, ultrasound is not able to
accurately characterize this mass.
## IMPRESSION:
Soft tissue mass in the right supraclavicular region which cannot be
characterized with ultrasound. An MRI could be performed for further
characterization.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13421348", "visit_id": "N/A", "time": "2148-01-26 13:55:00"} |
16388630-RR-49 | 134 | ## EXAMINATION:
CHEST PORT. LINE PLACEMENT
## INDICATION:
year old woman with PICC. Pt had a L PICC,50cm
Contact name: :
## FINDINGS:
Compared with the prior study, the left subclavian PICC line now extends to at
least the cavoatrial junction or upper right atrium. A right-sided PICC line
is difficult to visualize, but appears to terminate in the mid SVC. An NG tube
terminates in the stomach. The tracheostomy is in place. There has been no
change in the large bilateral pleural effusions and bibasilar consolidations.
## IMPRESSION:
1. Interval repositioning of the left subclavian PICC line, which now extends
to at least the cavoatrial junction and possibly into the upper right atrium.
## NOTIFICATION:
The above findings were communicated via telephone by Dr.
to (IV RN) at 13:59 on , 5 min
after discovery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16388630", "visit_id": "25599518", "time": "2117-09-30 11:38:00"} |
12666037-RR-8 | 167 | ## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN)
## HISTORY:
with no known liver disease presents for evaluation
of CT showing intra-abdominal fluid and cirrhosis. Eval for portal vein
thrombosis.
## LIVER:
The hepatic parenchyma appears heterogeneous and coarsened in
echotexture. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is a massive amount of ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD is poorly
visualized, however it appears to measure 5 mm (image 35).
## GALLBLADDER:
There is a 1.0 cm shadowing gallstone. Gallbladder wall
thickening to 5 mm is thought to reflect edema and third-spacing. The
gallbladder is not markedly distended.
## KIDNEYS:
Limited single view of the right kidney demonstrates normal
echogenicity and a size of 12.1 cm (image 18).
This study was not designed to evaluate the kidneys, spleen, pancreas, or
retroperitoneum.
## IMPRESSION:
1. The main portal vein appears patent with hepatopetal flow.
2. Cirrhosis with massive amount of intra-abdominal ascites.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12666037", "visit_id": "21899068", "time": "2150-12-16 09:04:00"} |
11163532-RR-23 | 97 | ## INDICATION:
year old woman with b/l knee pain for years // eval severity
eval severity
## IMPRESSION:
On the right, comparison is made with the study of , there is
continued tricompartmental hypertrophic spurring with substantial narrowing
predominantly involving the medial and patellofemoral compartments. No
evidence of joint effusion.
On the left, comparison is made with the study of . There is
tricompartmental hypertrophic spurring with substantial narrowing medially
that is much more prominent than on the previous study. The degree of
patellofemoral narrowing is unchanged and there is no evidence of joint
effusion.
Chondrocalcinosis is seen bilaterally.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11163532", "visit_id": "N/A", "time": "2132-01-21 14:35:00"} |
19570901-RR-73 | 350 | ## INDICATION:
woman with low-grade lymphoma.
.
## CT CHEST WITH IV CONTRAST:
Axillary lymphadenopathy is unchanged from the
prior study. The size and number of axillary lymph nodes is stable. A left
axillary lymph node designated target 1 (4:24) measures 15 x 8 mm, previously
13 x 9 mm. There is no appreciable mediastinal or hilar lymphadenopathy. The
heart is normal in size without pericardial effusion. The great vessels are
unremarkable. The tracheobronchial tree is patent to subsegmental levels.
Lungs are clear without consolidation or pleural effusion. There is mild
dependent atelectasis. No new nodules or masses are identified.
## CT ABDOMEN WITH IV CONTRAST:
A small hypodensity at the inferior margin of
the right lobe of the liver (4:77), measuring 7 mm, is unchanged. No other
focal liver lesions are seen. The gallbladder, spleen, pancreas, adrenal
glands, stomach and duodenum are unremarkable. The kidneys enhance and
excrete contrast symmetrically without hydronephrosis or renal masses.
Abdominal vascularity is normal. There is no free air or free fluid in the
abdomen. There is no appreciable mesenteric or retroperitoneal
lymphadenopathy by size criteria, or in number.
## CT PELVIS WITH IV CONTRAST:
Multiple loops of large and small bowel are
unremarkable. Iliac chain and pelvic side wall lymph nodes are stably
enlarged. A right pelvic side wall lymph node designated target 3 (4:101)
measures 18 x 9 mm, previously 20 x 7 mm. Prominent inguinal lymph nodes are
noted bilaterally, without interval change. Target lesion 2, a left iliac
lymph node (4:108) measures 16 x 8 mm, previously 16 x 11 mm.
The uterus is absent. The urinary bladder and distal ureters are
unremarkable. There are no adnexal masses. There is no free fluid in the
pelvis.
## OSSEOUS STRUCTURES:
There is no fracture or worrisome lytic or sclerotic bony
lesion. Soft tissues again demonstrate multiple calcified nodules within the
subcutaneous tissues of the buttocks and proximal anterior thighs, and the
anterior abdominal wall, consistent with calcified granulomas related to
injection.
## IMPRESSION:
1. Stable axillary, pelvic, and inguinal lymphadenopathy. No new lesions.
2. Oncology table has been updated in CareWeb.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19570901", "visit_id": "N/A", "time": "2155-04-16 12:02:00"} |
11111901-DS-15 | 355 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
Lightheadedness, fatigues and weakness
## HISTORY OF PRESENT ILLNESS:
year old male with 6 month 30 pound weight loss presented to
OSH with possible ?RV mass with tachycardia.
## PAST MEDICAL HISTORY:
Nephrolithiasis
Right ventricular tumor
Anemia
Renal insufficiency
## FAMILY HISTORY:
Older brother with arrythmia
## IMPRESSION:
1. Soft tissue masses within the ventricles, involving the
myocardium and
extending into the interatrial septum.
2. Multiple pulmonary nodules and bilateral pleural effusions,
and
pericardial effsuion.
3. Large bilateral adrenal masses and diffuse soft tissue masses
involving
both kidneys, with a rind around the left kidney. Small amount
of intra-
abdominal free fluid.
## BRIEF HOSPITAL COURSE:
Mr. was admitted to the for further evaluation. The
EP service was consulted for evaluation of his atrial
tachycardia. A CT scan was obtained given the echo findings of a
right ventricular mass. This revealed soft tissue masses within
the ventricles, involving the myocardium and extending into the
interatrial septum, multiple pulmonary nodules and bilateral
pleural effusions, and pericardial effusion and large bilateral
adrenal masses and diffuse soft tissue masses involving both
kidneys, with a rind around the left kidney. There was a small
amount of intra-abdominal free fluid. Mr. requested to be
discharged so that he could attend his son's wedding this
weekend. He was discharged with the request to not take any
aspirin or NSAIDS with the understanding that he would return
for readmission on morning for a cardiac MRI and CT
guided biopsy of his right adrenal mass on .
## DISCHARGE MEDICATIONS:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: for urinary tract infection.
Disp:*8 Tablet(s)* Refills:*0*
3. Phytonadione 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 doses.
Disp:*2 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Bilateral Cardiac Ventricular Tumor
History of Nephrolithiasis
Renal insufficiency
Anemia
## DISCHARGE INSTRUCTIONS:
Please return for readmission on to 6 at 7:30.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11111901", "visit_id": "27986601", "time": "2163-08-17 00:00:00"} |
16497723-DS-14 | 1,416 | ## HISTORY OF PRESENT ILLNESS:
with hx of HTN, ESRD on HD, T2DM, recurrent UTIs and R
shoulder dislocation who presents from HD with SOB/wheezing,
tachycardia and hypoxemia. Patient unable to recall why he came
into hospital, reports he was brought in.
## IN THE ED, INITIAL VITALS:
100.0 120 165/90 18 O2 sats 87-90% on
RA, was put on 4L NC. ECG showed sinus tachycardia, no
ischemia. Spiked temp to 102.0. Patient was treated for COPD
exacerbation with nebs, 125 mg IV methylpred. CXR c/f LUL
pneumonia. Pt given 1g vanc/2g cefepime/500mg azithromycin and
tylenol for fever. Patient was initially going to floor, however
per report pt became agitated, was repeatedly pulling off nasal
cannula and mask for nebs, was given Haldol 1mg IV and became
somnolent. Subsequently placed on NIV, CPAP/PSV 40%. ABG
showed pH 7.42, PCO2 45, PaO2 124. Other labs: H/H 12.3/36.6,
WBC 8.0, BUN/Cr .
On arrival to the MICU, 98.2, RR 21, HR 99 116/59, 99% on Bipap
40% PEEP 5. Patient initially somonolent on arrival,
subsequently became more alert. ROS obtained with interpreter -
denies SOB, fevers, chest pain, abd pain, dysuria. A&Ox2.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
## PAST MEDICAL HISTORY:
CAD
Mild COPD
Hypertension
Hyperlipidemia
CKD stage IV
GERD
BPH s/p TURP x2
DM2
R shoulder dislocation
Recurrent UTI
Peritonitis from intestinal perforation of ? etiology, now s/p
colostomy
## PER OMR:
The patient's mother has asthma.
## GENERAL:
A&Ox2, in NAD, speaking.
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Diffuse wheezes throughout all lung fields.
## 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; colostomy bag with gas at left
abdomen
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## NEURO:
A&Ox2, answers questions, moving all extremities, follows
commands
.
## GENERAL:
A&Ox2, in NAD, speaking.
## HEENT:
HD line in place with clean surrounding skin
## LUNGS:
expiratory wheezing and Coarse breath sounds bilaterally
## ABD:
soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding; colostomy bag with gas at left
abdomen
## EXT:
Warm, well perfused, no edema
## NEURO:
A&Ox2, heard of hearing, answers questions, moving all
extremities, follows commands
## ADMISSION:
12:10PM BLOOD WBC-8.0 RBC-3.71* Hgb-12.3* Hct-36.6*
MCV-99* MCH-33.2* MCHC-33.7 RDW-16.3* Plt
12:10PM BLOOD PTT-26.6
12:10PM BLOOD Glucose-120* UreaN-16 Creat-5.0* Na-141
K-4.7 Cl-98 HCO3-30 AnGap-18
04:26AM BLOOD Calcium-8.3* Phos-5.2*# Mg-2.2
06:57PM BLOOD Type-ART pO2-124* pCO2-45 pH-7.42
calTCO2-30 Base XS-4 Intubat-NOT INTUBA
12:26PM BLOOD Lactate-1.8
.
>> MICRO:
- bl cx pending (NGTD)
.
>> IMAGING:
- CXR : Nodular opacities in the left upper lobe are
concerning for infectious process.
.
>> Discharge meds:
05:37AM BLOOD WBC-11.0 RBC-3.06* Hgb-9.8* Hct-30.1*
MCV-98 MCH-32.1* MCHC-32.7 RDW-16.3* Plt
05:37AM BLOOD Glucose-136* UreaN-80* Creat-11.0*#
Na-139 K-5.7* Cl-96 HCO3-20* AnGap-29*
05:37AM BLOOD Albumin-3.2* Calcium-7.0* Phos-6.6*
Mg-2. with hx of HTN, ESRD on HD, T2DM who presents from HD with
SOB/wheezing, tachycardia and hypoxemia found to have a LUL
pneumonia and sepsis.
.
# Sepsis HCAP: On admission patient met SIRS criteria
(tachycardia, tachypnea, fever) with suspected source being
pulmonary based on LUL opacity on CXR and cough with dyspnea. Pt
initially on vanc/cefepime/azithro and quickly improved so
narrowed to PO levofloxacin on with plan for total of 8d
course to end . Flu swab neg. Pt does not make urine so UTI
unlikely.
.
# Dyspnea/Hypoxia, COPD exacerbation: Unclear if acute event at
HD. Pt put on NIPPV transiently in the setting of somnolence
from sedatives in ED. Pt initially on steroids but stopped in
MICU when exacerbation not felt obvious. Prednisone restarted on
given significant wheezing with plan for 5d burst to end
. Pt to continue standing nebs that should be continued
for days and then transitioned to PRN. Pt wheezing on exam
at time of discharge but moving good air and with good O2 sats.
.
>> Chronic issues:
# ESRD on HD: Pt continued on HD. Renal followed pt in house
.
# CAD: continue home simvastatin and ASA
.
# DM: No outpt meds at rehab prior to admission. Discharged on
SSI given steroid burst
.
# BPH: continue home finasteride
.
# GERD: continue home prilosec
.
# Anemia: Stable, likely related to ESRD. On Aranesp as
outpatient with HD.
.
# Gout: continue colchicine 0.3 QOD
.
>> Transitional issues:
# Full code per SNF
# Continue HD
# Prednisone 40mg daily for 5d to end
# 8d course of ABX for HCAP to end
# C Diff studies pending at discharge
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. dalteparin (porcine) 5,000 anti-Xa unit/0.2 mL subcutaneous
Daily
5. HydrOXYzine 10 mg PO QAM
6. HydrOXYzine 25 mg PO QPM
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Simvastatin 20 mg PO QPM
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. Nephplex Rx (vit B cmplex ox)
mg-mg-mcg-mg oral Daily
11. Polyethylene Glycol 17 g PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Colchicine 0.3 mg PO EVERY OTHER DAY
14. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 40
mcg/mL injection HD
15. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
16. Acetaminophen 650 mg PO Q8H:PRN pain
17. Simethicone 80 mg PO Q12H:PRN bloating
18. Senna 17.2 mg PO BID:PRN constipation
19. TraZODone 25 mg PO Q6H:PRN agitation
20. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
21. Fleet Enema AILY:PRN constipation
22. Bisacodyl AILY:PRN constipation
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Colchicine 0.3 mg PO EVERY OTHER DAY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Senna 17.2 mg PO BID:PRN constipation
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. Simvastatin 20 mg PO QPM
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Change to PRN after days.
12. Levofloxacin 500 mg PO Q48H
Last day: .
13. PredniSONE 40 mg PO DAILY
Last day .
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
15. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 40
mcg/mL injection HD
16. Bisacodyl AILY:PRN constipation
17. Fleet Enema AILY:PRN constipation
18. Nephplex Rx (vit B cmplex ox)
mg-mg-mcg-mg oral Daily
19. Polyethylene Glycol 17 g PO DAILY
20. Simethicone 80 mg PO Q12H:PRN bloating
21. TraMADOL (Ultram) 50 mg PO BID:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth twice daily Disp #*10
## TABLET REFILLS:
*0
22. TraZODone 25 mg PO Q6H:PRN agitation
23. Heparin 5000 UNIT SC TID
24. Ipratropium Bromide Neb 1 NEB IH Q6H
Change to PRN in days.
25. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
## PRIMARY DIAGNOSIS:
sepsis secondary to HCAP, COPD exacerbation
## SECONDARY DIAGNOSIS:
end stage renal disease, HTN, diabetes
## MENTAL STATUS:
Clear and coherent. speaking)
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure taking care of you in the hospital. You were
brought in for shortness of breath and found to have a
pneumonia. You spent a brief time in the intensive care unit but
improved quickly. You will continue oral antibiotics after
discharge to treat your pneumonia. You were also treated for an
exacerbation of your COPD.
Please see the attached list of medications for updates.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16497723", "visit_id": "29114833", "time": "2126-08-12 00:00:00"} |
14430169-DS-3 | 1,372 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
Persistent nausea and vomiting in setting of pregnancy
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Cesarian Section
lap band removal
## HISTORY OF PRESENT ILLNESS:
Ms. is a year old female with a PMH signifcant for
mild asthma not on home inhalers admitted to OB service on
for nausea/vomiting x1 month and hypertension
accompanied by decreased PO intake x1 month. She was noted to
have transaminitis, proteinuria, and BP of 140s/90s, with
concern by for preeclampsia.
## PAST MEDICAL HISTORY:
* Mild asthma (not on inhalers)
* s/p laparascopic banding in (in with resultant 25
kg weight loss, never injected with saline
## FAMILY HISTORY:
Denies any medical problems in immediate family members.
family h/o pre-eclampsia or complicated pregnany in her mother.
## PHYSICAL EXAM:
Upon discharge:
Alert and Oriented, NAD
98.5 138/80 98 20 98% RA
## HEENT:
Perrl, sclerae anicteric, MMM, ETT in place
## PULM:
Course breath sounds throughout, expiratory wheezes
bilaterally
## CV:
Tachy S1+S2, systolic murmur at LSB.
## ABD:
soft, NT/ND + BS incisions c/d/i
## EXT:
2+ DP b/l 1+ pitting pedal edema b/l
## CTAP W/O CONTRAST:
1. Slipped gastric band which now surrounds the lower body of
the stomach.
2. Unusual positioning of the fundus of the stomach, a portion
of which is more inferior to the grastric band, and now contains
a large, 5-cm bezoar. There is hold up at his level with no
contrast passing into the distal stomach / duodenum.
3. Right mild-to-moderate renal hydronephrosis.
4. Free intra-abdominal air compatible with history of recent
caesarean section.
5. 1-cm right lobe of the liver low-attenuation lesion, too
small to
characterize, likely representing a simple cyst.
6. Splenomegaly.
.
UGI series w/ KUB:
Slippage of gastric band to the lower stomach with soem hold up
at this level, proximal stomach shows dilation and rention of
contrast. Cross- sectional imaging is recommended to further
evaluate this finding.
.
## RENAL U/S:
Mild right hydronephrosis. The bladder was contracted
and could not be evaluated. Otherwise normal study.
.
## CXR:
No prior radiographs for comparison. Ring-like dense
structure in projection over the stomach. Several ECG leads in
place. Bilateral
subdiaphragmatic air collections. Low lung volumes, borderline
size of the cardiac silhouette. No evidence of focal parenchymal
opacities suggestive of pneumonia, no pleural effusions, no
nodules or masses.
## ECHO:
normal LV, RV function, trivial MR; dilated RA,
LA; nl EFx 65%, nl LV function, trivial MR, abnormal septal
motion, borderline pulm arterial systolic htn, physiologic
effusion
##
1. ATYPICAL PREECLAMPSIA:
The patient was noted to be
hypertensive to the 140s with proteinuria, oliguria, and
transaminitis concerning for preeclampsia. She thus underwent
cesarian LTCS on without complications. Her oliguria
resolved postoperatively. Her blood pressure has improved
postoperatively but does remain in the systolic 130s.
2. Laparoscopic gastric band prolapse with intragastric bezoar:
THe patient has a history of a lap band placement in in
that she had tolerated relatively well. One month prior to
admission, however, she developed multiple daily bouts of nausea
and vomiting with intolerance to PO intake that failed to
resolve following her LTCS, even though her transaminases
post-op trended down.
Ultrasound exam revealed the band to have slipped to the lower
stomach with proximal gastric dilatation and retention of
contrast. CT demonstrated a 5 cm bezoar in the fundus with hold
up in contrast passing into the distal stomach.
She thus underwent gastric lap-band and port removal on .
The procedure was also complicated by gastrostomy with leakage
of NGT contents into the peritoneal cavity.
##
3. ASPIRATION PNEUMONIA:
The initial intubation on was
complicated by aspiration leading to hypotension, hypoxia, and
tachycardia; the patient received 3.5 liters IVF
perioperatively. Post-operatively, the patient was
transferred to the FICU for further monitoring. She was kept
intubated and monitored in the ICU. She was empirically placed
on unasyn and vancoymcin; these were later discontinued as blood
and sputum cultures were negative. On she was weaned off
the vent without difficulty, and was eventually weaned to room
air by . She did require prn nebulizers for her history of
asthma in the setting of chemical pneumonitis.
##
4. SINUS TACHYCARDIA:
Postoperatively the patient was noted to
be tachycardic to 140s; this occurred most likely in setting of
chemical pneumonitis and acute blood loss anemia. Her
tachycardia did improve to the low 100s but did not completely
resolve prior to admission, likely secondary to the above
reasons. An echocardiogram on revealed normal
biventricular wall thickness and function with trivial MR, and
then revealed a dilated RA, LA, nl EFx 65%, nl LV function,
trivial MR, abnormal septal motion of RV, borderline pulm
arterial systolic htn. The septal motion is most likely
secondary to postpartum state (not concerning for PE), and the
RA and LA actually normal sized for her weight (as per
cardiology). If the patient's tachycardia persists following
resolution of her anemia then she should be worked up as an
outpatient for an alternate etiology.
##
5. ACUTE BLOOD LOSS ANEMIA:
The patient was noted to become
anemic during her hospitalization, most likely secondary to
acute blood loss anemia. Her hematocrit on was 25.5 down
from 32.2 on admission. Her anemia should be followed as an
outpatient, and she should be started on iron and folate
supplementation.
The remainder of her stay was uneventful. Her diet was advance
to regular, which she tolerated well. She was seen by
nutrition, who recommended a regular diet. She was kept on
heparin for DVT PPx and ambulated well. She breastfed
throughout her hospitalization and was pumped by nursing and her
husband while intubated.
## DISCHARGE MEDICATIONS:
1. Hydromorphone 2 mg Tablet
## SIG:
One (1) Tablet PO Q4H (every 4
hours) as needed: Hold for altered mental status, hold for
sedation.
Disp:*20 Tablet(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*2*
4. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Inhalation
three times a day as needed.
Disp:*1 inhaler* Refills:*2*
5. Slow Fe/Folic Acid mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*5*
6. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a day
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Preeclampsia
Laparoscopic Gastric Band Prolapse causing intragastric bezoar
Aspiration Pneumonitis secondary to intraoperative aspiration
from bezoar
Sinus tachycardia secondary to the above
Acute blood loss anemia
Pmx
asthma
## 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:
as tolerated. Go slowly given your recent surgery.
## MEDICATION INSTRUCTIONS:
Resume your home medications.
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 and
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 Flintstones chewable complete
multivitamin. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
## 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": "14430169", "visit_id": "24242475", "time": "2172-08-23 00:00:00"} |
15407803-DS-21 | 1,244 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
CT scan
Bubble Echo
Cardiac stress
## HISTORY OF PRESENT ILLNESS:
This is a hx of Hep C cirrhosis and s/p DDLT on
of this year with a post-operative course complicated
by, renal failure, infected hydrocele requiring right
orchiectomy, and seizure who was discharged on to rehab and
presents today for evaluation of dypsnea on exertion. Patient
reports that his recovery was going well until two weeks ago
when
developed profound dyspnea with even slight exertion. He cannot
walk more than several steps. He denies any chest pain at first
development of DOE or with exertion currently. He denies any
cough. He does not feel SOB while at rest nor at night while
lying down. He denies any edema. He has not had any fevers or
chills. He did have lab work that showed anemia with a
hematocrit
of 23. He also had a V/Q scan which was negative and an echo
that
was unremarkable. He is otherwise doing well. He is tolerating a
diet. He does have occasional nausea following meals. His
post-pyloric feeding tube came out several days ago and he has
been eating without it. He reports that he has been able to put
on 3 pounds in recent weeks. He is having bowel movements. He is
voiding without difficulty or pain. He does report some
persistent neck pain for which he had an MRI today. He has not
had any recent seizures, headaches, weakness, numbness,
difficulty swallowing, abdominal pain, nausea or vomiting. He
did
have his right tunneled HD line removed.
## PAST MEDICAL HISTORY:
DDLT , right orchiectomy . Surgery for pyloric
stenosis as child, Umbilical hernia repair with mesh ,
shunt - removed
.
-surgery for pyloric stenosis as child
-Hepatitis C genotype 1a diagnosed in
-Hep C likely cirrhosis on biopsy in
-EGD grade 1 esophageal varices
-liver ultrasound - splenomegaly and no
focal liver lesions
-AFP: Peak value 41.6
## FAMILY HISTORY:
Father had dementia, melanoma, died of CHF at . Mother CAD,
died during valve replacement surgery. Brother, age , with
whom he is not in touch.
## GEN:
resting comfortably in wheelchair
## HEENT:
anicteric, no lymphadenopathy, right chest tunneled HD
line removal site c/d/i. no hematoma.
## ABD:
well healed incision incision, soft non tender, non
distended
## GU:
s/p right orchiectomy, non tender, no edema,
## EXT:
no edema
Weight on Admission 71 kg
## BRIEF HOSPITAL COURSE:
y/o male s/p liver transplant with protracted hospital
course and just completing rehab admission who presents with new
shortness of breath of about 2 weeks duration.
Of note VQ scan done while at rehab was not concerning for PE.
On admission, CT of the chest was performed that showed no
evidence of pneumonia, there is minimal septal thickening,
compatible with mild interstitial edema and he has severe
coronary artery calcifications.
Last hematocrit documented at rehab was 23.3% During this
hospitalization he received a total of 3 units of RBCs.
Hematocrit at discharge was 26.7%. He has also been scheduled
with the outpatient clinic.
On a bubble echo was done showing no echocardiographic
evidence of ASD/PFO or intrapulmonary shunting.
On several occasions the patient was ambulated in the hallway,
and on room air at rest he is in the high , but once he
ambulated about 20 feet, the O2 sats drop to 88%. Once he is
back at rest, the O2 readings are again in the high 90's. He
reports feeling short of breath, denies chest pain.
He has had the feeding tube removed, weight is 71 kg, and he
does appear frail.
In planning for discharge to home, he will have as well as
home . Home Oxygen was also ordered as needed.
On HD 3 ( ) the patient had a cardiac perfusion study which
revealed
"Normal ventricular size, normal perfusion, and normal function
with an LVEF of 47%."
The patient will be discharged to home with full services for
nursing, , and home O2. He is scheduled to return on
for labs as well as a pulmonary function test which has
already been scheduled.
He is tolerating a regular diet, abdomen appears well healed, he
walks with assistance and medications for home were arranged to
be sent home with him. Home immunosuppression will be Tacro 4 mg
BID with goal level and MMF 500 mg BID.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
4. LeVETiracetam 500 mg PO BID
5. Mycophenolate Mofetil 500 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. ValGANCIclovir 450 mg PO Q24H
9. Tacrolimus 4 mg PO Q12H
10. Acetaminophen 325 mg PO Q6H:PRN pain
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
4. LeVETiracetam 500 mg PO BID
5. Mycophenolate Mofetil 500 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Acetaminophen 325 mg PO Q6H:PRN pain
9. Sodium Polystyrene Sulfonate 15 gm PO ASDIR
Take only as directed by transplant clinic
RX *sodium polystyrene sulfonate [Kionex] 15 grams by mouth As
## DIRECTED REFILLS:
*0
10. Multivitamins 1 TAB PO DAILY
11. Tacrolimus 4 mg PO Q12H
## DISCHARGE DIAGNOSIS:
s/p liver transplant with extended hospitalization
Dyspnea on Exertion
Anemia
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Please call the transplant clinic at for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, yellowing of skin or
eyes, increased abdominal pain, incisional redness, drainage or
bleeding, dizziness or weakness, decreased urine output or dark,
cloudy urine, swelling of abdomen or ankles, or any other
concerning symptoms.
You will have labwork drawn every and as
arranged by the transplant clinic, with results to the
transplant clinic (Fax . CBC, Chem 10, AST, ALT,
Alk Phos, T Bili, Trough Tacro level.
On the days you have your labs drawn, do not take your Tacro
until your labs are drawn. Bring your Tacro with you so you may
take your medication as soon as your labwork has been drawn.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air.
No tub baths or swimming
No driving if taking narcotic pain medications
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
Drink enough fluids to keep your urine light in color. Your
appetite will return with time. Eat small frequent meals, and
supplement with things like carnation instant breakfast or
Ensure.
Check blood pressure at home. Report consistently elevated
values to the transplant clinic
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at . There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15407803", "visit_id": "22792234", "time": "2122-05-19 00:00:00"} |
11560612-DS-11 | 1,000 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Surgical excisional lymph node biopsy (groin)
## HISTORY OF PRESENT ILLNESS:
Mr is a with HL and nephrolithiasis who is admitted
for further workup of incidental findings after presenting with
back pain.
He says that over 1 month ago he had some knee pain and mild
sewlling which caused him to limp around a bit. About 1 month
ago this resolved, but he then began to experience worsening
back pain. He didn't think much of it initially, but it became
nagging and progressively worse. He says it comes and goes.
There is no radiation, it is fixed mostly in his lower back. It
is worse with going up stairs and worse with sitting for long
periods. There have been times when it is bothersome at night
but this is not a major pattern. He has had some associated
night sweats, chills, and low grade fevers, but he has not had
any bowel or bladder symptoms, no paresthesias or dysesthesias.
It has gotten to the point where he has had some interference
with his life. He thought he might be having recurrence of
kidney stones, and so he went to his PCP .
His PCP referred him to the ED at . There, he
had a noncontrast abdominal CT (to look for stones) that showed
some bulky lymphadenopathy (within limitations of noncontrast
study). He was for some reason transferred to for further
evaluation. In the ED here, initial vital signs were 98 114
137/89 16 97%. Labs were significant for anemmia (HGB 10.5) and
elevated LDH 482. Heme-onc was consulted and recommended
admission to medicine for work-up including surgery consult for
biopsy. He was then admitted to my service for further
evaluation of this lymphadenopathy, anemia, and back pain.
## ROS:
A 10-point ROS is otherwise negative except as above.
## PAST MEDICAL HISTORY:
- HL
- Nephrolithiasis last bout years ago
Surgical history
- Rhinoplasty x2
## FAMILY HISTORY:
Mother had breast cancer. Father and maternal grandfather were
smokers and had lung cancer. No reported history of other heart
or lung disease.
## PHYSICAL EXAM:
Admission and discharge exam (unchanged)
Vitals- AVSS
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated; some inguinal LAD appreciable
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
## CHEST CT I+:
Multifocal lymphadenopathy in the chest, most
pronounced in the bilateral axilla, with splenomegaly. This is
compatible with lymphoma or other lymphoproliferative process
such as CLL.
## ABD CT I+:
1. Bulky, confluent retroperitoneal, pelvic sidewall, and
inguinal lymphadenopathy. Additional lymphadenopathy noted in
the porta hepatis, peripancreatic region, and root of the
mesenteries.
2. Moderate right-sided hydronephrosis, with areas of urothelial
thickening in the proximal and mid right ureter and a small
amount of thickening and surrounding stranding involving the mid
left ureter. These areas are presumed to represent urothelial
thickening in response adjacent adenopathy, however correlation
with urine cytology is recommended.
3. Splenomegaly.
## EKG:
sinus tachycardia @ with HL and nephrolithiasis who presented with back pain and
some B symptoms and is admitted for further workup of
incidentally discovered lymphadenopathy and anemia. His back
pain was controlled with oxycodone and acetaminophen. He was
given IVF and allopurinol and closely monitored for tumor lysis.
His labs remained stable to improved and he was liberated from
the IVF. He underwent surgical lymph node biopsy (of groin lymph
node). Pathology returned preliminarily consistent with
follicular lymphoma. He was seen by the oncology team and they
recommended discharge with outpatient oncology followup.
## # LYMPHADENOPATHY:
Follicular lymphoma preliminarily.
# Anemia: Anemia of chronic disease by laboratories.
# Back pain: Absence of spine tenderness, fever or leukocytosis,
or concerning neurologic exam findings was reassuring against an
infectious process. No signs of spinal tumor or fracture on
torso CT. There was some lymphadenopathy in the anterior
paraspinal areas that could potentially have caused some local
symptoms, and certainly a bone marrow infiltrative process could
lead to back pain.
# Hyperurecemia and hyperphosphatemia, resolved with IVF; could
be dehydration related but would certainly be concerning for
higher grade tumor with possibility of TLS.
# Right sided hydronephrosis, no apparent effect on renal
function or UOP
## TRANSITIONAL:
- He will be contacted by oncology to arrange followup
- I spoke with him about setting up an appointment with his CHA
PCP. He said he would call the office on . He told me he
did not rember the person's name and had it written down at
home.
## BILLING:
>30 minutes spent coordinating discharge from hospital
## DISCHARGE MEDICATIONS:
1. Acetaminophen 325-650 mg PO Q4H:PRN Pain and/or fever
RX *acetaminophen 325 mg tablet(s) by mouth every 4 hours
Disp #*90
## TABLET REFILLS:
*3
2. Allopurinol mg PO DAILY
RX *allopurinol mg 1.5 tablet(s) by mouth daily Disp #*90
Tablet Refills:*3
3. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth every 4 hours Disp
#*120 Tablet Refills:*0
4. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tab by mouth twice daily Disp
#*240 Tablet Refills:*3
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*180 Capsule Refills:*3
## DISCHARGE DIAGNOSIS:
Likely follicular lymphoma
Lymphadenopathy
Back pain
B symptoms
Hydronephrosis
## DISCHARGE INSTRUCTIONS:
You were admitted with back pain and low grade fevers and
sweats. You had lymphadenopathy on imaging studies and physical
exam, and you underwent a lymph node biopsy. The preliminary
results are a follicular lymphoma, which is the likely cause of
your symptoms. You were seen by Oncology and you will see them
in followup for further evaluation and treatment.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11560612", "visit_id": "26359931", "time": "2146-07-25 00:00:00"} |
12883763-RR-70 | 377 | ## EXAMINATION:
MRI of the Abdomen
## INDICATION:
w/ metastatic ampullary adenocarcinoma (s/p
pylorus-preserving Whipple and portal vein reconstruction on c/b
takeback for retroperitoneal bleed, previously on gem/abraxane), Cholangitis,
T2DM, PE (s/p IVC filter), now w/ new gpc bacteremia// please compare to
recent mrcp and eval for any enlarged abscesses or drainable focus
## LOWER THORAX:
There is no pleural effusion.
## LIVER:
There has been interval improvement of multiple subcentimeter rim
enhancing lesions throughout the liver, mainly the left hepatic lobe, thought
to represent micro abscesses. However, there has been interval enlargement of
the single largest lesion in segment 6 which currently measures 3.4 cm
compared to 2.3 cm on the CT and 1.5 cm on the previous MRI. This is
multiloculated centrally nonenhancing with a rim of hyper enhancement
consistent with an abscess. The T2 signal intensity is mildly hyperintense.
There are perfusional changes surrounding all of the these lesions.
## BILIARY:
Status post Whipple with hepaticojejunostomy. There is unchanged
mild central intrahepatic biliary ductal dilatation. Some of the biliary
ducts demonstrate mild mural enhancement consistent with cholangitis.
## PANCREAS:
Status post Whipple. The focal nodular area at the pancreatic tail
has not significantly changed in appearance compared to the prior images.
Remaining of the pancreatic parenchyma demonstrates unchanged low T1
hypointense signal. The main pancreatic duct remains mildly prominent, and
unchanged.
## SPLEEN:
There is no splenomegaly.
## ADRENAL GLANDS:
Adrenal glands are unremarkable.
## KIDNEYS:
There is no hydronephrosis or suspicious renal masses.
## GASTROINTESTINAL TRACT:
There is no bowel obstruction.
## VASCULATURE:
Abdominal aorta is normal in caliber with patent intra-abdominal
branches. There is conventional hepatic arteriogram. Portal vein and hepatic
veins are patent.
## OSSEOUS AND SOFT TISSUE STRUCTURES:
There are no acute osseous abnormalities.
Soft tissues are unremarkable.
## IMPRESSION:
1. Interval improvement of multiple hepatic micro abscesses throughout the
liver, main the left hepatic lobe.
2. However, there has been continued interval increase in size of a right
hepatic lobe (segment 6) multiloculated abscess measuring 3.4 cm.
3. Unchanged mild central intrahepatic biliary ductal dilatation with mural
enhancement consistent with cholangitis.
4. Unchanged pancreatic tail collection.
5. Postsurgical changes related to Whipple's procedure.
## RECOMMENDATION(S):
The right hepatic lobe abscess may be amenable for
drainage. Consider ultrasound feasibility scan.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12883763", "visit_id": "21218608", "time": "2150-01-03 16:36:00"} |
14420733-RR-27 | 170 | ## EXAMINATION:
FETAL BPP WITH MEASUREMENTS
## INDICATION:
woman with advanced maternal age. Presents for fetal
BPP with measurements.
## FINDINGS:
The fetus is in cephalic position. The placenta is posterior. There is no
evidence of previa. There is a normal amount of amniotic fluid with an
amniotic fluid index of 12.4 cm. No fetal morphologic abnormalities are
detected. The uterus is normal. No adnexal masses are seen.
The following biometric data were obtained:
BPD 8.99 mm, 36 weeks 3 days, 55%
HC 32.23 mm, 36 weeks 3 days, 17%
AC 32.59 mm, 36 weeks 4 days, 57%
FL 7.16 mm, 36 weeks 5 days, 47%
## AGE BY US:
36 weeks 4 days.
Age by Dates: 36 weeks 5 days.
EFW 2962 g, 52% (based on LMP)
Compared to the prior exam there has been appropriate interval growth.
A biophysical profile was performed. There were 2 points each for breathing,
motion, tone, and fluid for a total score of .
## IMPRESSION:
Normal biophysical profile. Size equals dates.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14420733", "visit_id": "N/A", "time": "2130-06-06 12:54:00"} |
17347760-DS-2 | 2,916 | ## CHIEF COMPLAINT:
dyspnea, fatigue, and lower extremity swelling
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Chest tube placement and removal
## HISTORY OF PRESENT ILLNESS:
Ms. is a year old female with PMH of CHF EF 55% in
, CAD s/p stent in at (unclear anatomy),
non-valvular atrial fibrillation on Coumadin, recent fall w/ rib
fx and Alzheimer's Dementia who presents as a transfer from
with worsening dyspnea, fatigue, and lower extremity
swelling over the past couple of days.
Of note, the patient states that she has experienced worsening
dyspnea, orthopnea, and fatigue for the past months. She
reports that her cardiologist took her off of her digoxin due to
bradycardia.
On , she was admitted to after sustaining a
mechanical fall. She states that the power was out and she was
walking to the bathroom and tripped on the rug. She sustained
four lower left rib fractures but no other significant injury.
During her course, she was diagnosed with
hypovolemic shock which resolved with aggressive IVF
administration, left lower extremity cellulitis for which she
completed a full course of doxycycline, acute blood loss anemia
thought to be rib fractures, and Afib with RVR thought to be
due to holding BBs in setting of shock. She was restarted on her
previous digoxin dose.
She was discharged to rehab on , and states that she was not
at her baseline at time of hospital discharge. On , her
dyspnea worsened and she developed BLE edema so she presented to
. She was found to have bradycardia to the and a
large left pleural effusion felt to be hemorrhagic, and an INR
of 4. She was transferred to for further management.
In the ED, she was seen by ACS due to the new large pleural
effusion concerning for hemorrhage, and she underwent a CT chest
which showed a large non-hemorrhagic left pleural effusion, left
rib fractures of , and possible pulmonary artery
hypertension. ACS felt no surgical treatment was necessary. She
was bradycardic to the and was given atropine which improved
her rates. Because of her rib pain, she was given morphine and
fentanyl after which her blood pressure fell to the
systolic. She was placed on norepinephrine for concern for
shock, although she was mentating well and her lactate was 1.8.
A bedside TTE showed no evidence of right heart strain. She was
given Zosyn to cover in case of septic shock. She also underwent
a CT abdomen non-con to evaluate for RP bleed, but this was
negative for hemorrhage.
Given her hypotension and pressor requirement, she was admitted
to the CCU for further management.
In the ED initial vitals were: 97.3 50 112/56 24 94% RA
## EKG:
sinus bradycardia, low voltage in precordial leads, ST
depression in I, II, aVL, and V2-V6
## CT CHEST W/O CONTRAST:
1. Mildly displaced posterolateral left rib fractures.
2. Large non-hemorhagic pleural effusion.
3. Cholelithiasis.
4. Mild dilation of the pulmonary artery may reflect pulmonary
arterial hypertension.
## CT ABDOMEN NON-CON:
1. No retroperitoneal hematoma or evidence of hemorrhage in the
abdomen or pelvis.
2. Cholelithiasis.
3. Left posterolateral rib fractures. Associated left
pleural
effusion.
Patient was given:
morphine 4 mg
fentanyl 50 mcg
atropine 0.5 mg
norepinephrine
Piperacillin/tazobactam 4.5g
## VITALS ON TRANSFER:
Afebrile, HR 52, BP 108/69, 15, 97% nasal
cannula
On arrival to the CCU: The patient reports being SOB with DOE,
orthopnea, PND two weeks ago, left flank pain at her rib
fracture sites, increased urinary frequency, and itchy lesions
scattered on her left arm and bilateral legs.
## REVIEW OF SYSTEMS:
Positive per HPI.
All other systems negative in a 12-system ROS
## PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
Atrial fibrillation
CAD
CHF
2. CARDIAC HISTORY
- CAD with stent years ago at , unclear anatomy. Reported
chest pain prior to that stent.
3. OTHER PAST MEDICAL HISTORY
History of chest pain
History of syncope
Chronic back pain
Anxiety
Alzheimer's dementia
GERD
## FAMILY HISTORY:
Father died of MI, otherwise no pertinent family medical history
## GENERAL:
Appears stated age, increased WOB, lying in bed
## HEENT:
PERRL, EOMI, sclera anicteric, MMM, oropharynx clear
## NECK:
Supple. JVP to earlobe at 45 degrees
## CARDIAC:
RRR, normal S1 S2, no murmurs, rubs, or gallops
## LUNGS:
Diminished breath sounds on left, mild bibasilar
crackles, no wheezing or rhonchi
## ABDOMEN:
Mildly distended, mild tenderness to LUQ near ribs,
otherwise NT, no organomegaly
## EXTREMITIES:
1+ pitting edema BLE, warm, palpable pulses
distally
## SKIN:
White scaly patches on left arm, scabbing lesions on
anterior legs bilaterally, mild erythema on left anterior shin
## PULSES:
Distal pulses palpable and symmetric.
## TELE:
sinus brady, normal sinus and intermittent irregular
irregular rhythm
## HEENT:
PERRL, EOMI, sclera anicteric, MMM, oropharynx clear
## NECK:
Supple. JVP 6 at 45 degrees
## CARDIAC:
RRR, normal S1 S2, no murmurs, rubs, or gallops. Left
chest wall tenderness to palpation
## LUNGS:
Diminished breath sounds on left, no wheezing or rhonchi
## ABDOMEN:
Mildly distended, mod tenderness to LUQ near ribs,
otherwise NT, no organomegaly
## EXTREMITIES:
no pitting edema BLE, warm, palpable pulses
distally
## SKIN:
White scaly patches on left arm, scabbing lesions on
anterior legs bilaterally, mild erythema on left anterior shin
## PULSES:
Distal pulses palpable and symmetric.
## STUDIES:
=====================
+ CT chest
1. Mildly displaced posterolateral left rib fractures.
2. Large non-hemorrhagic pleural effusion.
3. Cholelithiasis.
4. Mild dilation of the pulmonary artery may reflect pulmonary
arterial
hypertension.
+ CT ABDPELIVS
1. No retroperitoneal hematoma or evidence of hemorrhage in the
abdomen or pelvis.
2. Left posterolateral rib fractures. Associated left
pleural effusion.
3. Cholelithiasis.
+ ECHO
The left atrium is mildly dilated. 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%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size is normal with moderate global free
wall hypokinesis. The aortic valve leaflets are mildly thickened
(?#). 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.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
## IMPRESSION:
Suboptimal image quality. Preserved left ventricular
systolic function. Increased left ventricular filling pressure.
Moderately depressed right ventricular systolic function. Mild
pulmonary artery systolic hypertension.
+ CXR
1. No pneumothorax status post left chest tube removal.
2. Mild pulmonary interstitial edema, new since , is
improved slightly.
3. Unchanged left basilar atelectasis.
+ CXR
Greater opacification at base of the left lung has increased
since could be due in part to pleural effusion or
consolidation left lower lobe, most likely atelectasis but
including possible pneumonia. The right lung is clear.
Moderate enlargement of the cardiac silhouette is long-standing.
There is no pulmonary vascular engorgement or other evidence of
cardiac decompensation. No pneumothorax.
+ PLEURAL FLUID CYTOLOGY
## PLEURAL FLUID, LATERALITY NOT SPECIFIED:
ATYPICAL. Atypical epithelioid cells, favor reactive mesothelial
cells; lymphocytes, histiocytes, and red blood cells.
Immunohistochemical studies on cell block preparation shows the
atypical cells to be focally positive for calretinin and WT-1
(mesothelial markers) and negative for and B72.3
(epithelial markers).
## BRIEF HOSPITAL COURSE:
year old female with PMH of CHF (EF 65%), CAD s/p stent in
at (unknown anatomy), non-valvular atrial fibrillation
on Coumadin, and Alzheimer's Dementia who presents as a transfer
from . She initially presented there after a fall
during which she sustained rib fractures. The fall was likely
secondary to hypotension for which she was aggressively fluid
resuscitated. They also found cellulitis and treated her
with doxycycline and discharged her to rehab. She re-presented
to shortly there after with worsening dyspnea, fatigue,
and lower extremity swelling. She was transferred to ED
for possible cardiogenic shock and was found to be hypotensive
and bradycardic (sinus in the . She was started on levophed
and admitted to the CCU.
In the CCU her hypotension resolved with holding her extra pain
meds and she was quickly weaned off levophed. However, she
became bradycardic to the thought to be due to digoxin
(restarted at , which was held and her bradycardia
resolved. She was also found to have a unilateral pleural
effusion on CXR for which thoracics performed a thoracostomy
(removed after 24 hours) and drained a serosanguenous exudative
fluid. Given the findings the fluid was sent for cytology and a
chest CT was ordered to assess for malignancy. She was otherwise
diuresed with 40 IV Lasix. She was transferred to the floor,
where she remained hemodynamically stable. Her floor course was
complicated by left chest wall pain, reproducible on palpation
and located near rib fractures, poor PO intake, hyponatremia and
dementia.
## =======================
# HYPOTENSION:
Likely medication effect given temporal
relationship to medication administration. Less likely
cardiogenic versus infection versus hemorrhagic. Received zosyn
empirically until fluid results without microorg and prelim
culture were negative. Blood pressures remained SBP 100-110s
throughout course. At times, patient had SBP in high to
shortly after receiving opiates for rib pain. Medication
adjustments were made in consultation with palliative care and
the chronic pain team to ensure appropriate pain control as well
as normotensive state.
## # HYPOXEMIC RESPIRATORY FAILURE:
Likely secondary to
hypoventilation from splinting from rib fractures as well as
pleural effusion and pulmonary edema. Dyspnea and O2 saturations
improved with pain control, diuresis and drainage of pleural
effusion. Patient was encouraged to use incentive spirometer.
Patient had a stable O2 requirement of throughout her
hospital course.
## # RIB FRACTURES:
fall, required oxycontin 20 mg BID with
oxycodone breakthrough at prior hospitalization. Initially the
pain had a multi-modal approach including Tylenol, tramadol,
oxycodone and a lidocaine patch. However, patient required
increasing doses of pain medication and palliative care and
chronic pain service were consulted. Gabapentin was added with
good pain control.
## # CHEST PAIN:
patient reported left chest pain at times, which
was reproducible with palpation of the left chest wall. EKG were
stable and troponins were not elevated. This was thought to be
due to rib fractures and pain was managed as above.
## # ACUTE ON CHRONIC CHF:
EF 65%. On admission was grossly volume
overloaded. Improved with intermittent diuresis. Metoprolol was
initially held in the setting of bradycardia, but was resumed
when patient had atrial fibrillation with RVR.
# Pleural effusion: Large left pleural effusion which could have
been from trauma from rib fractures vs. malignancy. Initial
effusion exudative, but thought this could represent resolving
hemothorax. CT chest showed non-layering pleural effusion but
otherwise clear of masses or areas of parenchymal opacification.
Thoracostomy placed for 24 hours by surgery. Cytology revealed
atypical epithelioid cells, favor reactive mesothelial cells;
lymphocytes, histiocytes, and red blood cells.
Immunohistochemical studies on cell block preparation shows the
atypical cells to be focally positive for calretinin. The
recommendation was to have a CT with contrast to continue
possible malignancy work-up for effusion; however, the family
expressed that further work-up did not align with the goals of
care for the patient.
# Sinus bradycardia: Held digoxin and metoprolol. Resumed
metoprolol when she developed atrial fibrillation with RVR.
Patient continued to have intermittent sinus bradycardia with
rates 50-60s but was asymptomatic during these episodes.
## # ALZHEIMER'S DEMENTIA:
On combo pill of memantine and
donepezil. These were continued throughout hospital course.
Patient had frequent agitation thought to be related to dementia
and pain from rib fractures. She improved greatly when family
visited during the day. Patient was frequently re-oriented and
blinds were open during the day to aid sleep-wake cycle.
## # HYPO-OSMOTIC HYPONATREMIA:
Multiple etiologies possible
including ADH, SIADH, AI and poor solute intake. Patient had
initial fluid restriction in the setting of CHF, which did not
improve hyponatremia. Work-up for adrenal insufficiency was
completed with appropriate cosyntropin stimulation result.
Increased solute intake was recommended with supplementation
with Ensure.
## # MALNUTRITION:
Patient had poor PO intake throughout her
course. Her devoted husband brought in her favorite food nearly
daily. Even with this, patient did not have much of an appetite.
Diet was supplemented with Ensure.
## ========================
# ATRIAL FIBRILLATION:
(CHADS-VASC 3) Given bradycardia, held
metoprolol and digoxin initially. INR was initially
supratherapeutic, requiring IV vitamin K for thoracentesis but
was restarted after thoracostomy. Patient was bridged with
heparin, but then the decision was made to transition the
patient to home with hospice. The family and the patient did not
wish to continue INR monitoring, so the decision was made to
start rivaroxaban.
# Anemia: Baseline 9 per records (although only two
values). At , initial concern for acute blood loss
anemia from recent trauma. CT thorax did now show evidence of
hemorrhagic process. MCV borderline elevated. Fe tudies show
acute iron deficiency anemia on top of anemia of chronic
inflammation.
# Fall: Mechanical in setting of a power outage and tripping
over a rug. Seen by who recommended rehabilitation. Family
felt that this was not within the goals of care or wishes of the
patient. The patient expressed that she would not want to work
with physical therapy.
## # GERD/DYSPEPSIA:
Continue home omeprazole 40 mg daily.
Simethicone was added because patient had frequent episodes of
belching.
## TRANSITIONAL ISSUES:
====================
[] Will need f/u by PCP be facilitated through
hospice)
[] Consider simplification of medical management as outpatient
[] Based on exudative pleural effusion, recommended CT with
contrast for malignancy work- up, but family expressed that
further malignancy work-up is not within the goals of care of
the patient.
[] patient started on rivaroxaban for stroke prevention in
setting non-valvular atrial fibrillation, need for this
medication should be reassessed as an outpatient and goals of
care should be taken into consideration
[] patient had Na of 128 please continue to evaluate within
goals of care
[] Discharge weight: 79.8 kg ( )
# CONTACT/HCP: , Husband, / ,
daughter
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 20 mg PO QPM
2. Potassium Chloride 40 mEq PO DAILY
3. Omeprazole 40 mg PO DAILY
4. FLUoxetine 60 mg PO DAILY
5. Warfarin 1 mg PO DAILY16
6. Furosemide 20 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Namzaric (memantine-donepezil) mg oral DAILY
9. Aspirin 81 mg PO DAILY
10. Simethicone 80 mg PO QID:PRN discomfort
11. Metoprolol Succinate XL 100 mg PO QAM
12. Loratadine 5 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO QPM
14. Digoxin 0.125 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 100 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Gabapentin 400 mg PO BID
RX *gabapentin 400 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch each morning Disp #*30
## PATCH REFILLS:
*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H pain
RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
daily Refills:*0
8. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
9. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*30 Tablet Refills:*0
10. Torsemide 40 mg PO ONCE:PRN weight gain of > 3 lbs
associated with difficulty breathing or lower extremity edema
## DURATION:
1 Dose
RX *torsemide 20 mg 2 tablet(s) by mouth ONCE: PRN Disp #*10
## TABLET REFILLS:
*0
11. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
## REFILLS:
*0
12. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. Aspirin 81 mg PO DAILY
14. FLUoxetine 60 mg PO DAILY
15. Loratadine 5 mg PO DAILY
16. Namzaric (memantine-donepezil) mg oral DAILY
17. Omeprazole 40 mg PO DAILY
18. Simethicone 80 mg PO QID:PRN discomfort
## PRIMARY DIAGNOSIS:
Hypotension, medication side effect
Heart failure with preserved ejection fracture
Hypoxemic respiratory failure
Pleural Effusion
## SECONDARY DIAGNOSIS:
Rib fractures
Alzheimer's Dementia
Atrial fibrillation
Delirium
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Mrs. ,
were in the hospital because developed problems
breathing and swelling in your legs. This is thought to be due
to fluid on your lungs from your recent fall, as well as your
heart failure. Your blood pressure was also found to be very
low. This was thought to be due to pain medications used to
treat your rib fractures.
What happened while I was in the hospital?
==========================================
- were in the cardiac intesive care unit and had fluid taken
out of your body through medication
- had a tube placed in your chest to the fluid on your
lungs
- were given medicine to help with your rib pain
What should I do now that I am leaving the hospital?
====================================================
- will be cared for at home by who will
help take your medicines.
Thank for allowing us to participate in your care!
-Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17347760", "visit_id": "23962907", "time": "2132-10-16 00:00:00"} |
19120080-RR-129 | 328 | ## HISTORY:
Left rib pain. Evaluate for fracture.
## FINDINGS:
The thyroid is normal. A 1 cm left axillary lymph node was 9 mm
(2: 21) and a 9 mm retromammary node was 5 mm (2:9). Mediastinal lymph nodes
have also minimally increased in size, ranging up to 12 mm in long axis at the
pretracheal station, previously 10 mm (2:19). A left breast nodule has also
increased in size, now measuring 12 x 9 mm and previously had 10 x 7 mm. The
heart is normal size and there is no pericardial effusion. The main pulmonary
artery and aorta are normal caliber.
The trachea is normal caliber. The airways are patent through the
subsegmental level. There is no bronchial wall thickening or bronchiectasis.
No pleural effusion or pneumothorax. Moderate changes of centrilobular
emphysema are evident. No concerning lung nodules or masses. A millimetric
nodule is seen in the left upper lobe (4:81). No pleural effusion or
pneumothorax.
There are no lytic or blastic osseous lesions within the chest. A
nondisplaced fracture through the left 7th rib is noted (102:125). An older
appearing left anterior 8th rib fracture is also present.
There is cholelithiasis without cholecystitis. A 2.6 cm left adrenal adenoma
is unchanged in size from . The left kidney appears heterogeneous in
attenuation, possibly representing cysts. A cortical defect seen posteriorly
may relate to prior infection. Views of the unenhanced liver are
unremarkable.
## IMPRESSION:
1. Acute left and chronic left 8th rib fractures.
2. Increasing left retromammary, axillary and mediastinal lymph node size in
the setting of an enlarging left breast nodule. Further evaluation with
mammography and breast ultrasound is recommended. Depending on the results of
these studies, a repeat CT chest should be considered to assess the stability
of lymph nodes.
3. Left renal hypodensities with posterior cortical thinning could be better
evaluated by ultrasound.
4. Moderate emphysema.
5. Unchanged left adrenal adenoma.
Findings placed in the critical results dashboard on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19120080", "visit_id": "N/A", "time": "2197-04-04 16:10:00"} |
15997065-DS-16 | 1,945 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
fever and chills with headache
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Colonscopy
Transjugular liver biopsy
Bone marrow biopsy
Lumbar puncture
## HISTORY OF PRESENT ILLNESS:
Mr. is a gentleman with a history of multiple
myeloma nonsecretory type with free light chain disease, kappa
predominating, who came to ED because of fever, chills.
He is now s/p a matched cord blood nonmyeloablative
transplant(about 50 days ago) with conditioning regimen of ATG,
Fludarabine, Melphalan, and methylprednisolone.
.
When he was hospitalized for allogeneic transplant in this ,
his hospital course was complicated by fever, with positive
blood cultures with Staph, coag(-)from his hickman. He was
initially treated with Vancomycin, Cefepime and Flagyl and was
discharged home on Vancomycin which completed on . He
also had diarrhea in the hospital, which was C diff negative.
This resolved when his counts recovered and he has had no signs
of GVHD. His immune suppression is FK-506 and CellCept. He
recently has been noted for a positive EBV viral load and BK
virus in the urine.
He has been having intermittent fever, chills over several weeks
and has been followed by oncology as outpatient for those
problem. He recently has been noted for a positive EBV viral
load and BK virus in the urine. Given his increased EBV viral
load, he was started on Valcyte 50 mg twice per day.
Last night, he developed fever up to 101.6F. He came to ED.
.
In ED,VS T 100.6, BP 145/88, HR 135, RR 20, O2 sat 100% on RA.
ED staff decided to admit him to service for possible line
infection. He received IV vanc and IV cipro in ED.
.
On the floor, he stated feeling okay. reported frequency for few
weeks, denied HA, cough, sore throat, runny nose, diarrhea.
## ONCOLOGIC TREATMENT HISTORY:
1. Diagnosed in with non-secretory multiple myeloma with
vertebral collapse and rod placement. Surgery complicated by
DVT, treated with Coumadin for 18 months. Bone marrow biopsy
showed ~ 40% plasma cells and the presence of a
hypogammaglobulinemia. He was also found to be mildly anemic
with hematocrit of between 35 and 40. His beta-2 microglobulin
was 2.3. He was initially treated with melphalan and prednisone
8 cycles, dexamethasone and thalidomide.
2. Received intermittent doses of Cytoxan followed by high-dose
Cytoxan on with stem cell mobilization and collection
and status post high-dose chemotherapy with autologous stem cell
transplant in .
3. Noted for disease progression on BM bx in and was
treated on the multiple myeloma/dendritic cell vaccine trial in
and taken off study due to progression of disease.
4. Increasing back pain during this time but noted for new
herniated disc and underwent surgery in .
5. Begin Revlimid with dexamethasone but developed a rash at
higher doses of 25 mg daily, then restarted a three-week cycle
with increasing doses as of . His usual dose has been
15 mg daily for 21 days with dexamethasone on six days of the
cycle. He is status post 13 cycles with his last cycle completed
on .
6. Noted for disease progression/persistence with bone marrow
aspirate and biopsy revealing approximately 80% plasma cells.
7. Status post one cycle of Cytoxan, Velcade and Decadron
initiated on . Second Cycle on , Day 11
Velcade held due to low counts. Third cycle on with
Day 11 Velcade held due to low counts.
8. Bone marrow aspirate and biopsy from : Normocellular
erythroid dominant marrow with persistent involvement by
patient's known plasma cell myeloma. The plasma cells comprise
7% of aspirate differential and of the bone marrow core
biopsy by immunohistochemical staining and are kappa
restricted.
9. Completed Decadron 20 mg daily for two days in ,
repeated weekly x 2 in order to temporize his disease prior to
his transplant.
10. Bone marrow aspirate and biopsy from shows a
normocellular erythroid dominant bone marrow with trilineage
ematopoiesis with persistent involvement by known plasma cell
myeloma. Plasma cell distribution is variable on the aspirate
smear ranging from 10% to focally as high as 30%), with
cytologically typical forms. By immunohistochemistry, CD138
positive plasma cells ccount for of marrow cellularity,
and are kappa restricted by kappa and lambda light chain
staining.
## 11. THIS :
matched cord blood nonmyeloablative transplant
with conditioning regimen of ATG, Fludarabine, elphalan, and
methylprednisolone.
.
## PAST MEDICAL HISTORY:
1. Multiple myeloma as outlined above
2. History of Rosacea
3. Question seizure history dating back to with 2 syncopal
episodes. However most consistent with vaso vagal reaction. The
patient insisted on continuing the neurontin as a "security". He
was
initially started on Dilantin but this was tapered and
discontinued in and he was put on Neurontin. He was
thoroughly evaluated and there was no evidence for seizures on
EEG. His Neurontin was tapered to 100 mg three times per day
with no evidence for any seizure activity. This was discontinued
at the beginning of this year.
4. Spinal surgery with rod placement in at time of
diagnosis. Recent surgery for herniated disc in .
5. H/O DVT in the setting of initial spinal surgery.
6. Hypogammaglobulinemia, treated with IVIG.
7. Left inguinal hernia repair.
.
## FAMILY HISTORY:
No clear history of lymphoma, leukemia, or myeloma in the
family.
Vague history of cancer on father's side
## GEN:
well nourished comfortable man in NAD
## HEENT:
anicteric eyes, OP clear with no lesions, no cervical or
axillary : CTA b/l
## ABDOMEN:
soft, NT, ND +BS
## NEURO:
A+Ox3 CNs intact. strength UE and b/l, gait
intact, romberg negative, FTN intact
## SPECIMEN:
BONE MARROW ASPIRATE AND CORE BIOPSY:
## DIAGNOSIS:
1. Involvement by lambda-restricted plasma cell dyscrasia,
immunoreactive, worrisome for post-transplant
lymphoproliferative disorder (Note: Immunohistochemical stains
show increased CD138-immunoreactive plasma cells, singly and in
small clusters, occupying of marrow cellularity. By
immunoglobulin light chain staining these are lambda restricted.
Of note, the patient's prior marrows showed kappa restricted
plasma cells. The differential diagnosis includes
post-transplant lymphoproliferative disorder versus recurrence
of his myeloma with the phenomenon of isotype switch.Given the
increased numbers Virus encoded RNA ( )
positive cells in this patients marrow, the former is favored.
Additionally, scattered histiocytes with ingested hematopoietic
precursors are also seen (hemophagocytic histiocytes). Please
correlate with clinical and other laboratory findings).
2. Hypercellular bone marrow for age with dyserythropoiesis and
dysmegakaryopoiesis.
## BRIEF HOSPITAL COURSE:
year old gentleman with a history of multiple myeloma
nonsecretory type with free light chain disease, kappa
predominating who is s/p a matched unrelated double cord blood
nonmyeloablative transplant with conditioning regimen of ATG,
Fludarabine, Melphalan, and methylprednisolone. He presented
with with fever, chills, and headache. An LP was performed and
was WNL. Peripheral smear was notable for blasts and plasma
cells, and a bone marrow biopsy was performed which showed
involvement by lambda-restricted plasma cell dyscrasia,
immunoreactive, worrisome for post-transplant
lymphoproliferative disorder and hypercellular bone marrow.
.
1. Anemia/thromocytopenia.
- Hct decreased during admission and was difficult to maintain
with transfusions. Chimer studies showed the presence of both
cord blood lines as well as the patient's own cells. The anemia
was thought to be due to low grade bleeding from
thrombocytopenia, melena that pt experienced later during the
admission, and some hemolysis. Haptoglobin was WNL early in the
hospital stay but quickly dropped and Coombs test was negative.
There is a possibility that the anemia and thrombocytopenia are
due to PTLD / hemophagocytic lymphohistiocytosis.
.
## 2. DIARRHEA:
Etiologies unclear. Colonoscopy was benign. Cdiff
was negative. GvHD remained a possibility, but was unlikely
given colonoscopy results. It was felt to be at least in part
due to pt's low platelets and liver dysfunction leading to
bleeding diathesis. Tube feeds were begun for nutritional
support, but stopped as pt began to have frankly melanotic
stools. Pt's hematocrit trended down as the frequency of
melanotic stools increased.
.
## 3. ACUTE RENAL FAILURE:
Etiology unclear. Pt was admitted in
renal failure which responded to fluids. He was then imaged with
hydration and bicarb plus NAC before and after the contrast.
Nevertheless he went into ARF. It is possible - and even likely,
that there was a combination of contrast nephropathy, MM,
pre-renal, hepato-renal, and possibly even direct involvement by
BK, EBV, or PTLD. Pt became anasarcic, anuric and required
intermittent hemodialysis for fluid removal. This volume
overload was thought to be contributing to his respiratory
failure. However, with intermitten hemodialysis pt could not
tolerate the abrupt shifts of fluid and electrolytes and became
very tachycardic (HR 130-170s) and hypertensive, often reaching
into the 180s and 190s systolic. He was placed on CVVH which he
tolerated better, and effectively removed the extra fluid volume
and helped to reverse his metabolic acidosis.
.
## 4. ACUTE HEPATITIS:
Biopsy showed diffuse involvement by large B
cells consistent with PTLD. Liver enzymes continued to rise and
pt became very thrombocytopenic/coagulopathic. Pt showed signs
of low-grade bleeding. Gums were oozing blood and small amounts
of dark blood was suctioned from the trachea. Pt was transfused
supportively to maintain Plt>30 and INR<1.4-1.7.
.
5. PTLD. Related to very high titers of EBV. Treated with
multidrug regimen. Liver involvement was confirmed by biopsy.
Had questionable response to the drugs. clinically, the lymph
nodes in the neck decreased in size however his liver enzymes
continued to rise. Spleen was also enlarged by CT and U/S.
.
6. Increasing O2 demand and respiratory failure: Pt had
increasing O2 demand in the context of bilateral infiltrates on
CT and diffuse infiltrates. Bronchoscopy showed lambda
restricted B cells believed to be consistent with pulmonary
involvement by PTLD. The situation is complicated by ARF and
fluid overload. Pt was intubated and transferred to ICU on
Assist-Control. Pt was placed on intermittent hemodialysis, then
on CVVH for fluid removal. Pt had lactic acidosis and
compensatory respiratory alkalosis. Pt improved from respiratory
perspective enough to be placed on Pressure support however was
not extubated due to concerns for what to do should
re-intubation be necessary.
.
7. BK cystitis. Admitted with very high titers of BK in the
urine with severe urinary urgency. The urinary urgency was
treated only barely effectively with oxybutinin. This was
discontinued and a Foley was placed to facilitate intravesicular
cidofavir. The procedure was tolerated well.
.
Given questionable response of PTLD to numerous drug regimens,
and pt's poor prognosis, a consensus was reached between pt's
oncologist, healthcare proxy, and the rest of the care team to
make patient CMO. He was extubated and expired in the presence
of family.
## MEDICATIONS ON ADMISSION:
CLONAZEPAM 1 mg Tablet(s) at bedtime as needed for insomnia
CLOTRIMAZOLE - 10 mg Troche po four times a day as needed
for thrush
FLUCONAZOLE - 200 mg Tablet Q 12H
FOLIC ACID - 1 mg Tablet DAILY
HEPARIN FLUSH - 10 unit/mL Kit - Kit(s) Q day and PRN To
each lumen daily and PRN
MYCOPHENOLATE MOFETIL 500 mg 2 Tablet(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tablet once a day. increase to
twice a day as needed.
OXYCODONE - 5 mg Tablet(s) every four hours as needed for
pain
PANTOPRAZOLE - 40 mg Tablet daily
PENTAMIDINE - 300 mg Recon Soln - 1 inhaled once a month
PROCHLORPERAZINE MALEATE - 10 mg Tablet every six hours as
needed for nausea
TACROLIMUS - 0.5 mg Capsule one q am and one tab q pm
TRIAMCINOLONE ACETONIDE - 0.025 % Cream - apply to affected area
twice a day
URSODIOL - 300 mg Capsule - Capsule(s) twice a day 1 tablet
in the AM, 2 tablets in the
VALGANCICLOVIR - 450 mg Tablet - 1 (One) Tablet(s) twice a day
## DISCHARGE DIAGNOSIS:
Post-transplant Lymphoproliferative Disorder
History of multiple myeloma
Multi-organ failure
Cardiopulmonary arrest
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15997065", "visit_id": "26206486", "time": "2164-06-20 00:00:00"} |
18619829-RR-26 | 181 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
man with increased subdural hematoma on outside
hospital images after fall. Evaluate for interval change.
## DOSE:
DLP: 891.93 mGy-cm. CTDIvol: 53.31 mGy.
## FINDINGS:
There are bilateral mixed density subdural hematomas, with a small amount of
layering hyperdense material consistent with acute hemorrhage noted
bilaterally (2:22, 13). Overall findings are unchanged from the outside
hospital exam performed earlier today. However, compared to , the
right collection appears slightly smaller and the left is larger. Mass effect
on the cerebral hemispheres is fairly balanced with diffuse sulcal effacement
and without significant shift of midline structures or downward herniation.
Ventricles are stable and within normal limits of size. Gray-white matter
differentiation is preserved.
There is no fracture. The imaged paranasal sinuses, mastoid air cells, and
middle ear cavities are clear.
## IMPRESSION:
Bilateral mixed density cerebral subdural hematomas with small acute component
noted bilaterally, right greater than left, which appears larger than on . No 's of fall seen or downward herniation, though significant
sulcal effacement is noted bilaterally. Neurosurgical consultation is
recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18619829", "visit_id": "23676241", "time": "2156-10-28 22:04:00"} |
15432041-RR-13 | 156 | ## INDICATION:
Knee pain, assess for cruciate or ligamentous tear.
## MR RIGHT KNEE:
There is prominent edema about the lateral aspect of the
femoral condyle and to a lesser degree edema about the medial aspect of the
patella consistent with transient patellar dislocation. The medial
retinaculum appears completely torn with extensive soft tissue edema adjacent.
No cartilage defect is appreciated. There is a moderate joint effusion.
The ACL and PCL are intact. The MCL and LCL complexes are suboptimally
evaluated without coronal images but appear intact on the axial images. The
extensor mechanism is within normal limits. The regional soft tissues are
otherwise within normal limits. There appears to be moderate tendinosis of
the semimembranosus tendon.
## IMPRESSION:
1. Findings consistent with transient patellar dislocation with corresponding
contusion patterns with evidence of tear of the medial retinaculum. No
cartilage defect appreciated.
2. No evidence of cruciate or meniscal injury.
3. Small joint effusion.
4. Semimembranosus tendinosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15432041", "visit_id": "N/A", "time": "2187-10-01 19:32:00"} |
14474710-RR-24 | 224 | ## INDICATION:
woman with a colloid cyst.
## FINDINGS:
Postsurgical changes from prior right frontal craniotomy to drain colloid
cysts and places ventricular drain are demonstrated with residual mild
T2/FLAIR signal prolongation surrounding the prior drain tract and residual
old blood products on susceptibility images.
No evidence of new hemorrhage, edema, midline shift or infarction.
A T1-hyperintense and T2-hypointense mass in the anterior aspect of the third
ventricle at the level of the foramen is overall unchanged from the
prior MRI when accounting for differences in measurement technique, now
measuring up to 6 mm (Series 12, image 13; series 9, image 13). Associated
areas of enhancement are likely from displaced cortical vessels, unchanged
(e.g., series 13, image 105).
The ventricles and sulci are overall similar in caliber and configuration
compared to the prior head CT. No associated signal abnormality to suggest
transependymal flow.
The major intracranial vascular flow voids appear preserved.
The frontal sinuses are underpneumatized. Mucosal thickening in the bilateral
ethmoidal air cells is mild. The remaining imaged paranasal sinuses are
clear. The mastoid air cells are clear. The orbits are unremarkable.
## IMPRESSION:
1. Stable MRI appearance of a 6-mm colloid cyst in the anterior third
ventricle at the formation of .
2. Stable configuration and size of the ventricles.
3. Post-surgical changes in the right frontal lobe.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14474710", "visit_id": "N/A", "time": "2181-10-04 17:31:00"} |
18476198-RR-20 | 93 | ## INDICATION:
Malignant right pleural effusion
## FINDINGS:
Normal heart size with tortuosity of the aorta. Small bilateral pleural
effusions. Multiple nodular opacities including a approximately 17 mm nodule
in the left upper lobe and multiple smaller nodules in the right lung
concerning for malignancy.
## IMPRESSION:
Small bilateral pleural effusions and multiple bilateral nodules concerning
for malignancy. If not previously done, recommend further evaluation with CT
## NOTIFICATION:
The impression above was entered by Dr. on
at 15:46 into the Department of Radiology critical communications
system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18476198", "visit_id": "N/A", "time": "2148-12-15 13:31:00"} |
19510335-RR-24 | 97 | ## INDICATION:
year old man with new line // new left PICC 42
Contact name: : new left PICC 42
## IMPRESSION:
New left PIC line ends in the low SVC. Large region of consolidation at the
base of the right lung has worsened again since previous improvement on
. This could be atelectasis alone but is concerning for either
pneumonia or pulmonary hemorrhage, particularly since accompanied by
increasing moderate right pleural effusion. Left lung is grossly clear.
Heart size is normal.
## NOTIFICATION:
Dr. reported the findings to by telephone
on at 1:05 , minutes after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19510335", "visit_id": "26878786", "time": "2157-10-18 12:21:00"} |
11395120-RR-21 | 103 | ## EXAMINATION:
HIP UNILAT MIN 2 VIEWS LEFT
## INDICATION:
year old man with cellulitis s/p left iliac crest bone graft
donor site // osteo osteo
## FINDINGS:
Patient is status post left iliac crest donor bone graft, with a bony defect
in the expected location in the left iliac crest. Surgical packing material
is noted adjacent to the left iliac crest. No definite periostitis. No
suspicious osseous lesions. No acute fracture or dislocation.
## IMPRESSION:
Patient is status post left iliac crest donor bone graft, with a bony defect
in the expected location in the left iliac crest. No convincing radiographic
evidence of osteomyelitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11395120", "visit_id": "28667787", "time": "2186-12-05 17:37:00"} |
12510466-DS-11 | 1,292 | ## ALLERGIES:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Prednisone
## HISTORY OF PRESENT ILLNESS:
**Note extensively uses prior fellow note from clinic apt this
am. All information was confirmed with pt and my own history has
also been included:
is a man being treated for pancreatic
cancer metastatic to the liver, admitted with dehydration and
acute renal failure. Over the last week, Mr. has
developed progressive nausea and vomiting, and he is only able
to keep down minimal amounts of fluid." His last chemo was
oxiliplatin on and xeloda x2 weeks (last day , now on
his week off of xeloda. "Additionally, he has noted an increased
volume of green colored ostomy output with occasional bloody
output, and epigastric pain and burning. He also has developed
violaceous discoloration and dryness on his hands with areas of
pain and numbness, consistent with reaction to capecitabine." Pt
seen in clinic and noted to also have c Cr of 1.8 up
from baseline of ~ 1.2.
##
PAST ONC HISOTRY:
Mr. was initially diagnosed with
pancreatic cancer in when he presented with intermittent
left flank pain. CT at that time demonstrated a 4.2-cm
spiculated mass in the pancreatic tail, and biopsy by FNA was
positive for malignant adenocarcinoma. On he
underwent distal pancreatectomy, splenectomy, segmental
colectomy with colostomy, left adrenalectomy, and left
nephrectomy. Pathology demonstrated a 4-cm poorly differentiated
ductal adenocarcinoma invading the splenic hilar fat, external
muscularis propria of the transverse colon, and perinephric fat.
Zero of four lymph nodes were involved, and margins were
negative. He was diagnosed with T3N0 stage IIA pancreatic cancer
and was started on adjuvant gemcitabine. On he
underwent surveillance imaging studies, which showed a new 5.1 x
3.4 cm low attenuating mass in segment VI of the right hepatic
lobe. Biopsy of this on confirmed adenocarcinoma
consistent with pancreatic origin. He began second line
chemotherapy with capecitabine/oxaliplatin on . Today
is day 18 of cycle 2.
.
## PAST MEDICAL HISTORY:
1. Hypercoagulable state with left lower extremity superficial
phlebitis.
2. Thrombocytosis secondary to splenectomy.
3. Anxiety and depression.
4. History of migraine headaches.
5. Nephrolithiasis status post lithotripsy in , and
.
6. GERD.
7. Hypertension.
8. Vestibular dysfunction.
9. s/p left nephrectomy
## FAMILY HISTORY:
The patient's father died of lung cancer in his , but had a
prior history of stroke at age . His mother is alive at age
with hypertension and anxiety. His brother has no health
concerns.
## GEN:
anxious, alert and oriented x3
## HEENT:
PERRL, anicteric, conjunctiva pink, MMM
## LYMPH:
no anterior/posterior cervical or supraclavicular
adenopathy
## CARDIOVASCULAR:
tachycardic (~100), regular without murmurs,
rubs, or gallops
## LUNGS:
clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
## ABDOMEN:
ostomy with green liquid stool output. abdomen is soft,
tender to palpation in epigastric region, no
rebounding/guarding, no
hepatosplenomegaly by percussion or palpation
## EXTREMITIES:
no clubbing, cyanosis, or edema
## DIARRHEA:
Given time course of onset of diarrhea after
chemotherapy and infectious etiologies ruled out, this was felt
to be secondary to chemotherapy induced diarrhea. Stool anion
gap elevated at >100 which would be c/w malabsorptive process.
However his stool fat content was normal. Once infectious
etiologies were ruled out, patient was started on scheduled
loperamide, lomotil and tinctured opium. He was continued on a
diet and his ostomy output eventually improved. He was
advanced to a regular diet and patient no longer experienced
diarrhea. His I/O's were closely monitored and he no longer
required IVFs to maintain a net even picture. He was also
empirically started on creon as this may help with any
malabsorption.
## ABDOMINAL PAIN:
Patient complained of epigastric burning worse
upon eating. He was Started on protonix with mild improvement.
Lipase moderately elevated, however, pt not requiring pain
medications and wanting to eat. This was felt to be unlikely
pancreatitis, and more likely GERD. This should be further
managed in the outpatient.
## :
Likely related to profuse diarrhea, improved c volume
repletion.
## PANCREATIC CA:
Treatment deferred to primary oncology team.
wnl at 31. CT scan for restaging showed two new
subcentimeter lesions possibly representing metastases in the
liver. Further management will be deferred with his outpatient
oncologist.
## SINUS TACHYCARDIA/HYPOTENSION:
Noted upon admission. Improved c
IVF. Likely related to volume depletion.
## ANXIETY:
Continued home klonopin and added ativan prn for
anxiety and/or nausea in place of home xanax.
## MEDICATIONS ON ADMISSION:
1. Xanax 1 mg p.r.n. anxiety.
2. Fioricet p.r.n. headache. (has not needed recently)
3. Klonopin 1.5 mg b.i.d.
4. Lovenox 40 mg daily.
5. Vitamin D3 1000 units daily. (has not been taking)
6. Vitamin B12 2500 mcg daily. (has not been taking)
7. Vitamin B6 50 to 100 mg daily. (has not been taking)
8. Zofran 8 mg q.8h. p.r.n. nausea/vomiting.
9. Xeloda (this is his week off currently)
## DELAYED RELEASE(E.C.) SIG:
Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*180 Cap(s)* Refills:*2*
2. Clonazepam 1 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
3. Cyanocobalamin 500 mcg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
4. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Injection
Subcutaneous once a day.
6. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
7. Xanax 1 mg Tablet Sig: One (1) Tablet PO as needed for
anxiety.
8. Butalbital-Acetaminophen-Caff 50-325-40 mg Capsule Sig: One
(1) Capsule PO as needed for headache.
9. 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*
10. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
11. Loperamide 2 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for diarrhea.
12. Simethicone 40 mg Strip Sig: PO four times a day as
needed for Hiccups/Bloating.
13. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every
hours as needed for diarrhea.
Disp:*20 Tablet(s)* Refills:*0*
## PRIMARY:
Chemotherapy induced Diarrhea, GERD
## DISCHARGE INSTRUCTIONS:
You were admitted with diarrhea. We ruled out infection and felt
this was likely from your chemotherapy. We gave you medication
to slow down your bowel movements. With time, your bowel
movements slowed down and you were able to eat a normal diet.
You should continue to take these medications only if you
continue to have loose stools.
You also complained of abdominal pain that was worse after you
ate food. This may be related to gastro-esophageal reflux
disease. You were started on a medication to decrease the acid
in your stomach called Protonix. You should continue to take
this medication and follow up with your doctor further for this.
You also had significant hiccups while you were in the hospital.
We gave you medications to help with this.
## YOUR NEW MEDICATIONS INCLUDE:
1. Loperamide 2 mg every hours as needed for diarrhea. This
is an over the counter medication.
2. Lomotil 1 tablet every 6 hours as needed for diarrhea. You
should take this medication if loperamide is not effective.
***If you continue to have diarrhea after taking loperamide and
lomotil, you should call your doctor.***
3. Simethecone as needed for hiccups/bloating. This is also an
over the counter medication.
4. Pantoprazole 40 mg twice a day for heartburn/acid reflux
5. Creon (pancreatic enzymes) to be taken three times a day with
your meals. This may also help your diarrhea.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12510466", "visit_id": "20842435", "time": "2181-10-18 00:00:00"} |
15909117-RR-124 | 209 | ## EXAM:
Bilateral knees, three views of each.
## CLINICAL INFORMATION:
female with history of hypotension, slurred
speech, multiple falls and bruises.
## RIGHT KNEE:
Only lateral view of the right knee was able to be obtained due
to patient positioning and contracture, per radiology technologist. On the
lateral view, the patella appears slightly low lying. No definite
suprapatellar joint effusion is seen. No large obvious fracture is seen,
although evaluation is suboptimal with only this single lateral view.
Vascular calcifications are seen.
## LEFT KNEE:
AP and lateral views of the left knee were obtained. No evidence
of acute fracture or dislocation is seen. Chondrocalcinosis is seen in the
knee joint. There is mild narrowing of the medial and lateral knee joint
compartments. A 0.5 cm rounded density projecting over the soft tissue
lateral to the proximal femur may represent vascular calcification.
Additional vascular calcifications are seen.
## IMPRESSION:
1. No evidence of acute fracture or dislocation of the left knee. Left knee
chondrocalcinosis.
2. Suboptimal evaluation of the right knee as only a lateral view was
obtained. The patella appears slightly low lying. No obvious fracture is
seen, although evaluation is suboptimal. If clinical concern for right knee
fracture persists, suggest attempt at repeat imaging or cross-sectional
imaging.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15909117", "visit_id": "26623254", "time": "2143-02-10 14:10:00"} |
13720578-RR-33 | 155 | ## INDICATION:
year old man with worsening hypoxemia after fluids, as well as
need for MRI but family cannot complete checklist// Concern for pulmonary
edema, and additionally needs full body XR for pre-MRI screening
## AP AND LATERAL SKULL:
No radiopaque foreign densities are seen. Orbital
contours are preserved. The left frontal sinus is hypoplastic. Bony
structures are intact.
## AP CERVICAL SPINE:
No radiopaque foreign densities are seen. The dens and the
lateral masses are intact. Lung apices are grossly clear.
## AP CHEST:
Heart size is within normal limits. There is scoliosis of the
thoracic aorta. There is atelectasis at the lung bases. There is no focal
consolidation. No radiopaque foreign densities are seen.
## AP ABDOMEN:
There are no radiopaque foreign densities. Bowel gas pattern is
within normal limits without obstruction. There is scoliosis of the lumbar
spine with convexity to the left side centered at L2/3. Hip joint spaces are
relatively preserved.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13720578", "visit_id": "25133492", "time": "2184-06-03 10:36:00"} |
11726187-RR-10 | 357 | ## INDICATION:
Osteogenesis imperfecta. Tracheostomy insertion after seizure in
, subsequent respiratory distress in residental care. Bronchoscopy
performed prior to CT today confirmed tracheostomy occlusion by granulation
tissue which was relieved by repositioning. Evaluate for
tracheobronchomalacia.
## FINDINGS:
The tracheostomy tube tip is 2.4 cm from the carina and the lower
trachea is patent, the balloon is deflated. A vascular device arising from
the left arm enters a left-sided SVC and its distal tip is coiled in the
coronary sinus. The gastrostomy tube is also in satisfactory position with an
inflated balloon lying in the lumen of the stomach.
Bronchial nodules are scattered throughout the right upper lobe and to a
lesser extent in the left lower and right lower lobes. Marked thoracic spine
deformity causes bilateral lower lobe atelectasis, associated bilateral
pleural effusions are small.
Assessment of the airways is limited by the presence of a tracheostomy tube.
The trachea is angulated at the carina with mild narrowing of the proximal
right main bronchus due to scoliosis (400b, 34). The anteroposterior diameter
of the lower trachea decreases on expiration from 10 mm at inspiration to 8.5
mm on expiratory images; the cross-sectional area decreases from 114.7 mm3 to
96.9 mm3 indicating mild airway collapse. A small volume of debris is in the
proximal right main bronchus.
The cardiac chambers are normal in size. There is no pathologic enlargement
of the mediastinal, axillary, or supraclavicular nodes.
Generalized osteopaenia and thoracic spine scoliosis are severe. Healed
fractures of the right humeral head and shaft and bilateral posterior ribs are
identified.
## IMPRESSION:
1. Multifocal consolidation, worst in the right upper lobe, most likely
represents aspiration.
2. Marked bilateral lower lobe atelectasis, worse on the left, secondary to
the patient's severe scoliosis.
3. Incidental finding of left-sided SVC and malposition of kinked central
venous catheter in the coronary sinus. If retracted by approximately 7 cm,
this may result in straightening of the catheter tip in the coronary sinus.
Dr informed at 5 pm on
4. Mild collapsibility of the lower trachea, although the presence of a
tracheostomy tube limits evaluation of the airway.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11726187", "visit_id": "27202460", "time": "2125-12-20 14:45:00"} |
15113058-RR-41 | 140 | ## EXAMINATION:
HIP UNILAT MIN 2 VIEWS RIGHT
## INDICATION:
year old man with r hip fx// r hip fx
## FINDINGS:
Status post right total hip arthroplasty. Alignment appears preserved. There
appears to be cortical thinning of the lateral subtrochanteric femur involving
greater than 50% of the cortex thickness and measuring approximately 6 cm
craniocaudal. While this appears slightly increased from several prior exams,
it is likely similar compared to pre total hip revision on x-ray . This should be followed on subsequent exams. No fracture.
## IMPRESSION:
Status post right total hip revision arthroplasty. There is cortical thinning
of the lateral subtrochanteric femur involving greater than 50% of the cortex
thickness. While this appears slightly increased from several prior exams, it
is likely similar compared to pre total hip revision x-ray on . This should be followed on subsequent exams.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15113058", "visit_id": "N/A", "time": "2158-06-12 08:13:00"} |
12868753-DS-20 | 1,226 | ## ALLERGIES:
Sulfa (Sulfonamide Antibiotics) / Wellbutrin
## HISTORY OF PRESENT ILLNESS:
year old male with history of HIV/AIDS (last CD4 count of
130, not sure of recent viral load; history of PCP per patient)
presenting with fever. Patient fell 1.5 weeks ago while riding a
scooter. Saw his PCP afterward and had CXR that showed left
sided rib fractures. Started taking 800 mg ibuprofen TID and
Tylenol #3 for pain. Noted development of cough productive of
"disgusting mucous" over the last 2 days with fever of 99.7 and
100.4F which promoted his presentation to the ED today. He
denies SOB but endorses rhinorrhea and wheezing. Denies
abdominal pain, nausea, vomiting, and diarrhea though has had
frequency without dysuria. He has missed many of his medications
over the last week including his HIV meds due to pain and
inability to get up. He also has not been taking good PO. He
also uses crystal meth, mostly via inhalation, but did inject
intravenously last week.
Initial vital signs were: 98.2, HR 116, BP 147/86, RR 12, SpO2
904% RA.
Exam was notable for productive cough, poor air movement and
pitting edema in bilateral lower extremities. Injection site was
in right antecubital fossae. No stigmata of endocarditis
detected.
Labs showed: WBC 10.6 no left shift, Hgb 13.6, platelets 191. Na
131, glucose 361, Cr 0.8. Lactate 1.8. UA with trace protein,
1000 glucose, no bacteria. Flu swab negative.
CXR showed: No acute cardiopulmonary abnormality. Left seventh
rib fracture is minimally displaced.
Patient was given 1g vancomcyin, 2g cefepime, 500mg IV
azithromycin, 1L NS and 100mg Tylenol.
## PAST MEDICAL HISTORY:
HIV/AIDS--CD4 130, history of PCP per patient
HTN
GERD
Depression
COPD not on inhalers
DM II
Crystal Meth PO and IV
## FAMILY HISTORY:
father with heart disease died at age
## GEN:
obese gentleman sleeping in the bed with his gown strewn
about, snoring loudly, awakens easily to voice
## CARDIAC:
RRR, normal S1 and S2, no MRG
## EXT:
warm, well-perfused; IV injection sites with mild
surrounding erythema but no purulence or drainage
DISCHARGE EXAM
==============
## HEENT:
anicteric sclera, EOMI, MOM, OP clear
## :
NLB on RA, CTAB, slightly diminished air movement without
wheeze
## CARDIAC:
RRR, normal S1 and S2, no MRG
## GI:
BS+, soft, nondistended, nontender, no rebound/guarding
## EXT:
warm, well-perfused; IV injection sites on UE with mild
surrounding erythema but no purulence or drainage; no lower
extremity edema; and DP pulses strong, symmetrical. No
lesions or splinter hems.
## NEURO:
AOx3, grossly non focal
## CXR ( ):
1. No acute cardiopulmonary abnormality.
2. Left posterior seventh rib fracture is minimally displaced.
## SPUTUM CULTURE:
GRAM STAIN: OROPHARYNGEAL FLORA
## BLOOD CULTURE:
pending
DISCHARGE LABS
==============
05:25AM BLOOD WBC-9.4 RBC-4.50* Hgb-12.4* Hct-36.9*
MCV-82 MCH-27.6 MCHC-33.6 RDW-13.2 RDWSD-39.2 Plt
05:25AM BLOOD Glucose-230* UreaN-16 Creat-0.7 Na-133
K-4.3 Cl-98 HCO3-25 AnGap-14
05:25AM BLOOD Calcium-9.6 Phos-3.7 Mg-2. w/hx of HIV/AIDS (CD4 130, PCP poor HAART
compliance, IVDU, COPD, T2DM, presenting with mild fever and
productive cough s/p recent rib fracture. Pt endorsed recent
IVDU, no stigmata of endocarditis, monitored BCx, which were
negative at time of discharge. Pt had mild leukocytosis, on
broad spectrum ABx in ED, transitioned to levaquin and
prednisone x5d for possible COPD exacerbation. Given pain
control for rib fracture w/improved breathing.
# COPD exacerbation: Presented with tachycardia, mildly elevated
WBC and subjective fevers with concern for pulmonary source in
the setting of poor HIV medication adherence and known low CD4
count with initial concern in the ED for sepsis. CXR revealed no
signs of infiltrate or atelectasis. Poor air movement with
wheezing more consistent with a COPD exacerbation. Patient was
given vancomycin, cefepime, azithromycin in the ED, transitioned
to Levaquin and prednisone for COPD exacerbation and possible
PNA 5d course total. Combivent prescription also given to
patient given good response to duonebs.
# Rib Fracture: pt w/continued rib pain, known rib fx in the
setting of a traumatic fall, confirmed on CXR, was on pain
control at home. Controlled with oxycodone while inpatient, not
continued on discharge.
# Hyponatremia: pseudohyponatremia with concurrent hyperglycemia
though poor PO intake may be contributing factor, resolved on
discharge.
CHRONIC ISSUES
-----
## # HIV ON HAART THERAPY:
last CD4 count 130s. Followed at .
Continued home HIV meds. Planned to start azithromycin for mac
ppx 1 wk after antibiotic course, first dose
TRANSITIONAL ISSUES
===================
-5d of prednisone and levaquin to finish on
-please start azithromycin qweekly for MAC ppx starting on
-pt stated he would continue taking HAART upon DC
-Rx for Combivent given to patient for good response to duonebs
#Contact: Name of health care proxy:
## SISTER
PHONE NUMBER:
#Code: full, would not want feeding tube
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. RiTONAvir 100 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Raltegravir 400 mg PO BID
5. Darunavir 800 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Ibuprofen 800 mg PO Q8H:PRN pain
10. Acetaminophen w/Codeine 1 TAB PO TID:PRN pain
11. Azithromycin 1200 mg PO ONCE WEEKLY
## DISCHARGE MEDICATIONS:
1. Darunavir 800 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Ibuprofen 800 mg PO Q8H:PRN pain
4. Lisinopril 40 mg PO DAILY
5. Raltegravir 400 mg PO BID
6. RiTONAvir 100 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Azithromycin 1200 mg PO ONCE WEEKLY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Levofloxacin 750 mg PO DAILY Duration: 5 Doses
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
## TABLET REFILLS:
*0
12. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*6
## TABLET REFILLS:
*0
13. Acetaminophen w/Codeine 1 TAB PO TID:PRN pain
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
RX *ipratropium-albuterol [Combivent Respimat] 20 mcg-100
mcg/actuation 1 spray inhaled every six (6) hours Disp #*1
## SECONDARY:
DM2
HTN
HIV on HAART
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to after you had a fever
at home and were found to have an elevated white blood cell
count. Your chest xray was negative, and we were less concerned
about you having pneumonia. However, we were concerned you might
be having a COPD exacerbation, we started you on some
medications to help with this. It is also vital that you
continue taking your HAART medications at home.
For you weekly azithromycin, please start this medication after
your antibiotics are finished, first dose should be .
You are being sent home with antibiotics and steroids to
continue treatment of your COPD flare. We have also prescribed a
new inhaler which you can use up to 4 times per day (6 hours
apart) for shortness of breath.
If you develop fevers, chills, shortness of breath, worsening
cough, please contact your doctor or return to the hospital
immediately.
It was a pleasure taking care of you!
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12868753", "visit_id": "20476678", "time": "2178-08-14 00:00:00"} |
16573000-DS-20 | 1,646 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Posteroir nasal packing and removal
## HISTORY OF PRESENT ILLNESS:
year old female with PMHx of dilated cardiomyopathy,
obstructive sleep apnea and ? asthma and substance abuse who
presents with epistaxis. Of note, patient has had 2 recent
discharges from the ED for repeated epistaxis with previous
anterior nasal packing and bleed felt to be secondary to URI and
started on keflex. Patient now presents with new bleeding which
began yesterday evening at 6 pm. Patient is unable to quantify
exactly how much she bled but states that she had to use an
entire roll of papertoilets to clean herself up. Patient
represented to ED this AM and underwent posterior nasal packing.
On exam in the ED patient was noted to have an ulceration on the
posterior aspect of nasal cavity. Patient denies previous
history of nosebleeds prior to these episodes. Patient reports
frequent cocaine use, roughly times per month. Last cocaine
use was about 2 weeks ago. Patient denies any other bleeding
from her pharynx, ears or eyes. Patient denies cough, fevers,
change in voice quality. Denies blurry vision. Denies dysuria
or change in bowel or bladder habits. Patient does endorse some
headaches as well as sinus congestion and rhinorrhea.
.
In the ED ENT was consulted. Patient was noted to have normal
coags with stable crit. Patient being admitted to medicine for
observation with concern for possible bradycardia with posterior
packing.
.
In the emergency department, last set of vital signs were:
Temp 98.1, P 79, Bp 126/89, R 18, 96% on RA
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies 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. Denied
arthralgias or myalgias.
## PAST MEDICAL HISTORY:
Dilated cardiomyopathy EF 30%, most likely secondary to alcohol
and cocaine
Cocaine use
Marijuana use
Alcohol abuse
Asthma
Restrictive lung disease?
OSA on cpap @ 16
Obesity
## FAMILY HISTORY:
Family history is significant for HTN and death due to
"aneurysm" in her mother and twin sister.
## VS:
Temp 98.1, P 79, BP 126/89, R 18, 96% on RA
## GEN:
Hispanic female, nasal packing in place
## HEENT:
EOMI, PERRL, sclera anicteric, conjunctivae clear, +
nasal septal perforation
## CV:
Reg rate, normal S1, S2. No m/r/g.
## CHEST:
clear without rales, rhonchi or wheezing
## ABD:
Obese, Soft, NT, ND, no HSM
## EXT:
1+ lower extremity edema to ankesl, No c/c
## SKIN:
evidence of small lesions over bilateral forearms which
patient is itchying
## NEURO:
A&O x3, moves all 4 extremities
## PERTINENT RESULTS:
03:45PM BLOOD WBC-9.8 RBC-4.51 Hgb-13.3 Hct-41.1 MCV-91
MCH-29.5 MCHC-32.3 RDW-13.8 Plt
07:15AM BLOOD WBC-10.4 RBC-4.35 Hgb-13.0 Hct-40.0
MCV-92 MCH-30.0 MCHC-32.6 RDW-13.4 Plt
03:45PM BLOOD Neuts-69.6 Monos-2.6 Eos-1.8
Baso-0.7
03:45PM BLOOD PTT-23.4
03:45PM BLOOD Plt
03:45PM BLOOD Glucose-131* UreaN-14 Creat-0.8 Na-139
K-4.3 Cl-98 HCO3-31 AnGap-14
07:15AM BLOOD Glucose-146* UreaN-19 Creat-0.9 Na-139
K-4.6 Cl-97 HCO3-35* AnGap-12
07:35AM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-139
K-4.1 Cl-98 HCO3-32 AnGap-13
07:35AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
07:15AM BLOOD %HbA1c-7.1*
.
EKG - Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy with secondary repolarization abnormalities.
Compared to the previous tracing of multiple
abnormalities as noted persist without major change.
.
EKG - Normal sinus rhythm. Left atrial abnormality. Left
ventricular hypertrophy with secondary ST-T wave changes in
leads I, aVL and V5-V6. Axis is 0 degrees. Compared to the
previous tracing of no diagnostic interval change.
## BRIEF HOSPITAL COURSE:
year old Hispanic female with PMHx of diabetes,
cardiomyopathy now presents with frequent nosebleeds in the ED.
Most recent nosebleed on day of admission required posterior
packing. Patient admitted for observation on telemetry while
posterior packing in place.
.
# Nosebleed - patient with history of multiple nosebleeds with
recent ED admissions. Apparently patient has had packing for
anterior nasal bleeding however on day of admission had
posterior nasal bleed. Patient also per ED report had a small
posterior ulcer and on ENT evaluation on the floor there is
evidence of septal perforation. Nose was packed and there has
been no furthur bleeding since packing. Apparently needs to be
admitted for telemetry monitoring for posterior nassal packing.
No evidence of furthur bleeding since admission. There were no
evidence of events on telemetry. Packing was discontinued
without event. Patient told to follow up with ENT on discharge.
Patient discharged on nasal meds as per ENT.
.
# Mild Restrictive Pulmonary Disease - Patient with a history of
? asthma however PFTs from demonstrate mild restrictive
ventilatory defect with preserved DLCO which is suggestive of
extraparenchymal etiology. The reduced FRC is likely secondary
to obesity. The reduced distance attained during the 6-minute
walk suggests a mild exercise limitation. Patient was continued
outpatient pulmonary meds.
.
# Substance abuse - patient with known history of substance
abuse. Admits to cocaine use in the past month. Utox on
admission positive for cocaine. SW consulted for substance
abuse. Please see note in OMR for details of consult.
.
# PUMP- Pt with known cardiomyopathy with most recent EF 30%,
most likely due to cocaine and alcohol use. No signs of acute
heart failure on exam. Patient maintained on digoxin, ACE
, spironolactone, statin, lasix as outpatient which
were continued as inpatient.
.
# Hypertension - patient with history of HTN. She is maintained
on lisinopril, spironolactone with apparently adequate
outpatient control. BP ranging mostly 100-120 systolic. Patient
continued on lisinopril, spironolactone at outpatient dose
.
# OSA- patient takes CPAP at home @ 16, however given nasal
packing patient will be unable to use in house.
.
# New Onset Type II Diabetes- patient with previous history of
prednisone induced diabetes, however fingersticks have been
mildly elevated in house 140-200s yesterday. Suspect that given
obesity and HTN that may have borderline diabetes. Patient had
multiple random fingersticks > 200 and AM > 126 confirming a
diagnosis of diabetes. A1c was checked. Patient was started on
glipizide on discharge. Did not start Metformin given CHF.
.
# FEN: cardiac diet, diabetic diet, replete lytes PRN
.
# Access: PIV
.
# PPx: heparin SC, PPI, bowel regimen
.
# Code: FULL code
## MEDICATIONS ON ADMISSION:
Albuterol 90 mcg/Actuation q 4 hour PRN chest tightness
Clobetasol 0.05% ointment
Flovent 220 2 puffs inhaled daily
Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
Omeprazole 20 mg Po daily
Simvastatin 20 mg Po daily
Digoxin 250 mcg PO daily
Furosemide 80 mg PO daily
Tylenol mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for fever or pain.
## DISCHARGE MEDICATIONS:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Digoxin 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Ocean Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal
four times a day for 10 days.
Disp:*1 bottle* Refills:*0*
11. Afrin 0.05 % Aerosol, Spray Sig: One (1) spray Nasal once a
day as needed for nose bleeding.
Disp:*1 bottle* Refills:*0*
## 12. VASELINE GEL SIG:
small amount to nose Topical twice a
day for 5 days.
Disp:*1 bottle* Refills:*0*
## PRIMARY:
nosebleed
cocaine abuse
new onset type II diabetes
## SECONDARY:
Dilated cardiomyopathy EF 30%, most likely secondary to alcohol
and cocaine
Cocaine use
Marijuana use
Alcohol abuse
Restrictive lung disease
OSA on cpap @ 16
Obesity
## DISCHARGE CONDITION:
afebrile, vital signs stable, no furthur episodes of nasal
bleeding
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with nosebleed. You underwent
nasal packing in the ED with stabilization of your nosebleeds.
You were evaluated by ENT and nasal packing was placed. You were
monitored on telemetry while your packing was in place.
.
You shoujld continue nose bleed precautions for 7 days which
include no heavy lifting and no nose bleeding. You can use
Ocean Nasal spray four times a day for 10 days and Afrin if
there is any bleeding. You should also use vaseline to your nose
- small amount to nose twice a day for 5 days. You should follow
up in clinic as schecduled below.
.
In addition, you were noted to have high sugars in the hospital.
You were started on a medication for diabetes called glipizide.
You should follow up with your primary care doctor in couple
weeks regarding this new medication. Your dose of lisinopril was
lowered as you were noted to have somewhat low blood pressures
while in the hospital.
.
You should return to the ED if you experience any chest pain,
shortness of breath, abdominal pain or uncontrolled nasal
bleeding. It has been a pleasure taking care of you at
.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16573000", "visit_id": "25576960", "time": "2127-04-25 00:00:00"} |
15193493-RR-5 | 176 | ## INDICATION:
Patient is a female status post methotrexate
treatment yesterday for likely ectopic pregnancy per serial HCGs. Now
worsening abdominal pain and increasing vaginal bleeding. Evaluate for
interval change.
## FINDINGS:
Transabdominal and transvaginal ultrasound examinations were
performed. Transvaginal ultrasound examination was performed for improved
visualization of the endometrium and bilateral adnexa.
The uterus measures approximately 7.5cm in sagittal dimension. There is
stable appearance of a 2-mm round anechoic structure located in the cervix,
most likely represents a nabothian cyst. The left ovary measures 3.2 x 1.4 x
1.8 cm. The right ovary measures 2.9 x 1.5 x 2.4 cm. Both ovaries are normal
in appearance. Doppler examination of both ovaries demonstrates symmetric
arterial and venous waveforms. The endometrium is homogenous, measuring up to
13 mm. There is a small amount of pelvic free fluid that tracks along the left
adnexa. There is no evidence of hydronephrosis.
## IMPRESSION:
No evidence of an intrauterine pregnancy. Small amount of pelvic
free fluid tracking along the left adnexa. Normal ovaries.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15193493", "visit_id": "N/A", "time": "2111-03-25 11:58:00"} |
10888124-DS-17 | 990 | ## HISTORY OF PRESENT ILLNESS:
y.o. female with h.o CAD, s/p CABG (LIMA to LAD, SVG
to OM1, SVG to PDA) who presented to OSH with chest pain. The
patient was in her usual state of health until 1 p.m. yesterday
, when she developed chest/epigastric
pain/pressure, with radiation to the jaw and neck but not the
arms. There was nausea but no vomiting. No shortness of breath.
Overnight, the patient had some chills and diaphoresis, and this
morning, she was noted by her daughter to be pale.
.
The patient called her primary care doctor this morning, who
told her to call . She was brought to an outside hospital by
EMS and was found to have elevations in the inferior leads. She
was transferred to where she was given, plavix 300mg,
metoprolol, heparin IV, asa 81mgx4, and integrillin.
.
Vitals in the emergency department were T 97.1 HR 47 BP 122/61
RR 14 Sat 100%
.
Pt was taken to the cath lab, where 99% stenosis of the SVG to
PDA was noted, and a drug-eluting stent was placed.
.
On arrival to the floor, the patient was completely
asymptomatic.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is as above, with the following
additions. No dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, or ankle edema.
## 2. CARDIAC HISTORY:
-CABG:
Coronary Artery Bypass Graft x 3 (Left internal
mammary artery to left anterior descending, Saphenous vein graft
to obtuse marginal, saphenous vein graft to posterior descending
artery)
-PERCUTANEOUS CORONARY INTERVENTIONS: .
-PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
Gastroesophageal Reflux Disease
## FAMILY HISTORY:
Father with history of MI at age . Father also had CVA.
## GENERAL:
NAD. Oriented x3. Mood, affect appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI.
## NECK:
Could not assess JVP as patient needed to be lying flat.
## CARDIAC:
RRR, normal S1, S2. No m/r/g.
## LUNGS:
Exam limited by requirement that patient lie flat
post-cath. Resp were unlabored, no accessory muscle use. CTAB,
no crackles, wheezes or rhonchi.
## ABDOMEN:
Soft, NTND. No HSM or tenderness.
## EXTREMITIES:
No c/c/e. Right groin site with dressing C/D/I.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## LEFT:
Radial 2+ Popliteal 2+ DP 2+ 2+
Discharge exam:
BP 120/69 pulse 78 temp 98.4 rr 18 sat 96%
## OTHER LABS:
07:30AM Cholest-141 Triglyc-205* HDL-25 CHOL/HD-5.6
LDLcalc- y.o female with h.o CAD s/p CABGx3, hypertension,
hyperlipidemia who initially presented with chest pain, was
found to have a STEMI, and is now s/p CATH with .
.
# CORONARIES/STEMI: The patient is s/p CABGx3 (LIMA-LAD,
SVG-OM1, SVG-RPDA) . She presented with chest pain and
was found to have an inferior STEMI. Cardiac catheterization was
notable for 99% stenosis of the SVG-RPDA graft. In addition,
catheterization showed LMCA 30%, LAD 70%, LCX 90%, RCA 90%,
SVG-OM1 30%, LIMA-LAD not injected but filled retrograde. The
patient underwent successful stenting of SVG-RPDA. Following
catheterization, she was treated with aspirin, Plavix,
metoprolol, losartan, and pravastatin. Omeprazole was changed to
ranitidine. Echocardiogram showed no regional wall motion
abnormalities and preserved EF of 55% (prelim read).
.
# PUMP: Following catheterization, the patient was noted to have
basilar rales. Her last echocardiogram from showed
normal ejection fraction. Repeat echocardiogram showed results
as above. The patient was discharged on losartan and
metoprolol.
.
# RHYTHM: The patient was monitored on telemetry, which showed
sinus bradycardia with some venticular ectopy, including a
9-beat run of NSVT. Telemetry in 24hours prior to discharge
showed no arrhytmias.
.
# Hypertension: Continued metoprolol and losartan.
.
# Hyperlipidemia: Increased pravastatin at maximum dose. Lipid
panel showed total cholesterol 141, triglycerides 205, HDL 25,
LDL 75.
.
# GERD: Changed omeprazole to ranitidine.
.
# Code status: FULL CODE, confirmed with patient.
## MEDICATIONS ON ADMISSION:
Cozaar 75 mg daily
Pravastatin 20 mg daily
Metoprolol succinate 50 mg BID
Omeprazole 20 mg daily
Aspirin 81 mg daily
## DISCHARGE MEDICATIONS:
1. Clopidogrel 75 mg Tablet
## SIG:
One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Losartan 50 mg Tablet Sig: 1.5 Tablets PO once a day: 75mg
daily.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO at bedtime.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
## MAJOR:
chest pain due to ST elevation myocardial infaction
coronary artery disease
hypertension
hyperlipidemia
GERD
## DISCHARGE INSTRUCTIONS:
You were admitted with chest pain and were found to have a heart
attack. You were taken to the cardiac catheterization lab, where
a blockage was found in one of your bypass vein grafts. A stent
was placed to open this graft.
.
You must take 325mg of aspirin and 75mg of plavix every day
until you are instructed otherwise. It is very important that
you do not miss any doses.
.
You medication changes include:
Changed pravastatin to atorvastatin 80mg
Increased dose of aspirin to 325mg daily
Start plavix at 75mg daily
Your metoprolol was changed to a long acting form, 50mg a day.
Please take this once a day before bedtime.
Your omeprazole was STOPPED. Please start taking ranitidine
150mg twice a day instead.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10888124", "visit_id": "20194264", "time": "2165-12-20 00:00:00"} |
12325327-DS-30 | 1,755 | ## HISTORY OF PRESENT ILLNESS:
Mr is a w/hx of HCV cirrhosis, HCC, s/p liver
transplant years ago, c/b graft dysfunction with
cholangiopathy and recurrent HCV cirrhosis now presenting at
request of PCP due to abnormal labs. Patient states he is
feeling fine, w/o complaints, says has been compliant with his
medications, notes new jaundice. Otherwise, denies abd pain,
n/v/d/c, dysuria, f/c/ns, cough, sob, new rash, chest pain, GIB.
In the ED, initial vitals: T98.1 56 133/63 18 100% RA
Exam sig for: Awake O x 3, scleral icterus, no asterixis, no
clonus, abdomen benign
Labs sig for: Na 138, Cr 1.0, TBili 4.0, DBili 2.9, Hb 10.4,
WBC 1.3, INR 1.4, UA few bacteria/neg leuk+nit, lac 1.2
## IMAGING:
CXR w/small Rt pleural effusion, RUQ U/S w/patent
TIPS, no ascites
Pt was given: 0.5mg Tacro
Transplant Hepatology was consulted, recommended admission for
infectious w/u as RUQ U/S with dopplers non concerning
Vital before transfer: T97.9 51 146/78 18 100% RA
On the floor, pt was w/o complaints, wanted to go to sleep
## PAST MEDICAL HISTORY:
# Cirrhosis (HCC, HCV)
- s/p liver transplant in by Dr.
hepaticojejunostomy, portal vein thrombectomy, splenic artery
jump graft, arterial conduit
- grade II esophageal and GE junction varices ( )
- non-occlusive PVT and splenic vein thromboses
- Recurrent HCV - on ribaviran and sofosbuvir
# Pancytopenia - followed by heme-onc; suspected secondary to
massive splenomegaly, direct myelopoietic suppression from his
HCV, and med effect from anti-virals
# Osteopenia
# S/p cholecystectomy
# Opioid addiction - on methadone
## FAMILY HISTORY:
Father and brother both with CAD.
## PHYSICAL EXAM:
ADMISSION PHYSICAL EXAM
=======================
## GENERAL:
NAD, AOx3
HEENT - + scleral icterus. normocephalic, atraumatic, PERRLA,
EOMI
## CARDIAC:
RRR, normal S1/S2, no murmurs rubs or gallops.
## PULMONARY:
Clear to auscultation bilaterally, without wheezes or
rhonchi.
## ABDOMEN:
mildly distended, but soft, nontender, no fluid wave,
no organomegaly, no rebound or guarding.
## EXTREMITIES:
Warm, well-perfused, no cyanosis, clubbing or
edema.
## SKIN:
+ jaundice, no spider angiomata noted
## NEUROLOGIC:
no asterixis. A&Ox3, CN II-XII grossly normal,
normal sensation, with strength throughout.
DISCHARGE PHYSICAL EXAM
=======================
## GENERAL:
NAD, AOx3
HEENT - + scleral icterus. normocephalic, atraumatic, PERRLA,
EOMI
## CARDIAC:
RRR, normal S1/S2, no murmurs rubs or gallops.
## PULMONARY:
Clear to auscultation bilaterally, without wheezes or
rhonchi.
## ABDOMEN:
mildly distended, but soft, nontender, no fluid wave,
no organomegaly, no rebound or guarding.
## EXTREMITIES:
Warm, well-perfused, no cyanosis, clubbing or
edema.
## SKIN:
+ jaundice, no spider angiomata noted
## NEUROLOGIC:
no asterixis. A&Ox3, CN II-XII grossly normal,
normal sensation, with strength throughout.
## PERTINENT RESULTS:
ADMISSION LABS
==============
10:18AM BLOOD WBC-1.0* RBC-2.91* Hgb-9.1* Hct-28.6*
MCV-98 MCH-31.3 MCHC-31.8* RDW-17.0* RDWSD-61.1* Plt Ct-42*
10:18AM BLOOD Neuts-66 Bands-4 Monos-6 Eos-2
Baso-2* Myelos-0 AbsNeut-0.70* AbsLymp-0.20*
AbsMono-0.06* AbsEos-0.02* AbsBaso-0.02
10:18AM BLOOD Plt Smr-VERY LOW Plt Ct-42*
10:18AM BLOOD UreaN-9 Creat-0.9 Na-131* K-4.2 Cl-98
HCO3-25 AnGap-12
10:18AM BLOOD ALT-16 AST-29 AlkPhos-583* TotBili-4.0*
10:18AM BLOOD Lipase-53
10:18AM BLOOD Albumin-3.0*
10:18AM BLOOD tacroFK-3.9*
06:16PM BLOOD Lactate-1.2
08:35PM URINE Color-Yellow Appear-Hazy Sp
08:35PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG
08:35PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
MICRO
=====
BLOOD CX x2, URINE CX - NEGATIVE GROWTH
HCV VL - UNDETECTABLE
IMAGING
=======
ABDOMINAL US
1. Patent visualized hepatic vasculature, and patent TIPS, as
described above.
2. Nonvisualization of left portal vein, as before.
3. Reversal of flow within the anterior right portal vein.
4. Cirrhosis.
5. Massive splenomegaly.
MRCP
1. Essentially stable appearance of post transplant liver with
TIPS and
posterior right hepatic lobe fibrosis.
2. Slightly increased intrahepatic biliary ductal dilatation
with poor
visualization of the common hepatic duct and the
hepaticojejunostomy. This
could represent a stricture at that level.
3. Focal narrowing of the otherwise enlarged main portal vein
demonstrating
patency distally.
4. Unchanged severe splenomegaly with evidence of Gamma Gandy
bodies.
5. Slight increase in the size of the right-sided pleural
effusion.
DISCHARGE LABS
==============
06:27AM BLOOD WBC-0.9* RBC-2.66* Hgb-8.3* Hct-26.2*
MCV-99* MCH-31.2 MCHC-31.7* RDW-17.5* RDWSD-63.4* Plt Ct-40*
05:46AM BLOOD Neuts-49 Bands-0 Monos-9 Eos-5
Baso-0 Myelos-0 AbsNeut-0.39* AbsLymp-0.30*
AbsMono-0.07* AbsEos-0.04 AbsBaso-0.00*
06:27AM BLOOD Plt Ct-40*
06:27AM BLOOD PTT-36.2
06:27AM BLOOD Glucose-206* UreaN-16 Creat-1.0 Na-139
K-3.6 Cl-103 HCO3-27 AnGap-13
06:27AM BLOOD ALT-17 AST-34 AlkPhos-579* TotBili-2.3*
06:27AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.5 Mg-1.7
06:27AM BLOOD tacroFK-3.3*
## BRIEF HOSPITAL COURSE:
year old male with HCV cirrhosis, HCC, s/p liver transplant
years ago, c/b graft dysfunction with cholangiopathy and
recurrent HCV cirrhosis s/p HCV irradication now presenting at
request of PCP for new onset jaundice concerning for liver
transplant rejection.
## # HYPERBILIRUBINEMIA, ELEVATED ALK PHOS:
Pt with elevated Tbili
and Dbili, of unknown etiology. RUQ U/S was wnl. Concern was
that this represents transplant rejection vs progression of
liver disease. Infectious w/u negative, CMV and EBV viral loads
undetectable. MRCP demonstrated mild unchanged intrahepatic
biliary ductal dilatation without evidence of stricture or
abnormal enhancement. Otherwise, MRCP demonstrated patent
vasculature and stable appearance of right lobe fibrosis. We
contemplated doing liver bx, but LFTs downtrended during
admission so decided it would not provide benefit.
# Cirrhosis: Pt with MELD 15. He has a chronic Portal vein
thrombosis, for which he is s/p TIPS and portal vein
thrombectomy/tPA thrombolysis. He was on Coumadin, but that was
d/c'd last month given concern about correct administration
since wife, who is primary caregiver and coordinates
administration, is out of the country for the next few months.
Also w/hx of hepatic encephalopathy. RUQ U/S was unremarkable
for acute changes in vasculature in the ED.
- Continue home rifaxamin, furosemide, lactulose, nadolol,
ursodiol, omeprazole
# Pancytopenia:
Relatively stable, but with severe neutropenia attributed to
marrow suppression from immunosuppression and splenomegaly.
Current in low 400s. Considered Neulasta v Neupogen however
decided risks of splenic rupture outweigh benefits. Prescribed
ciprofloxacin 500mg BID for prophylaxis instead.
CHRONIC ISSUES
==============
# S/P Liver transplant: goal tacro , monitored tacro
levels, increased tacro to 1mg bid
# History of Opioid Dependence: Continued methadone 55 mg daily
# DM2: held home glipizide, HISS while inpatient
# Depression: Continued citalopram
TRANSITIONAL ISSUES
===================
GENERAL
[ ] Weight at time of discharge 62.6kg
[ ] Creatinine at time of discharge 1.0
[ ] Restart Coumadin as soon as felt reliable and safe (when
wife returns versus son managing medications).
HYPERBILIRUBINEMIA
[ ] please trend LFTs as outpatient, specifically T bili and alk
phos
PANCYTOPENIA
[ ] placed on ciprofloxacin 500mg BID for infection prophylaxis
given ANC < 500
[ ] Decision to defer Neupogen based on collaboration with
primary hematologist Dr. who felt risk of
splenic rupture too high.
S/P LIVER TRANSPLANT
[ ] increased tacro dose to 1mg BID w/goal trough
OTHER
[ ] QTc at time of d/c 420, but patient on methadone and
recently started on cipro, so please recheck EKG for QTc
prolongation given addition of new med
## # CODE:
Full Code
# CONTACT: Wife (pronounced ) :
separated and not living with pt) cell
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Citalopram 20 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Lactulose 30 mL PO Q6H
5. Methadone 55 mg PO DAILY
6. Nadolol 20 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Tacrolimus 0.5 mg PO BID
10. Ursodiol 300 mg PO BID
11. GlipiZIDE 5 mg PO BID
## DISCHARGE MEDICATIONS:
1. Ciprofloxacin HCl 500 mg PO Q12H
take unless otherwise instructed by your hepatologist or
hematologist
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Tacrolimus 1 mg PO BID
RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60
## CAPSULE REFILLS:
*0
3. Citalopram 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. GlipiZIDE 5 mg PO BID
7. Lactulose 30 mL PO Q6H
8. Methadone 55 mg PO DAILY
9. Nadolol 20 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Rifaximin 550 mg PO BID
12. Ursodiol 300 mg PO BID
## DISCHARGE DIAGNOSIS:
PRIMARY DIAGNOSIS
=================
Recurrent HCV cirrhosis s/p liver transplant c/b graft
cholangiopathy
Pancytopenia w/ severe neutropenia
SECONDARY DIAGNOSIS
===================
history of Opioid Dependence
Diabetes Mellitus Type II
Major Depression
## DISCHARGE INSTRUCTIONS:
Hi Mr. ,
It was a pleasure taking care of you at
.
Why were you admitted to the hospital?
You were admitted after you were found to have jaundice
(yellowing of skin and eyes) and your liver labs were elevated
concerning for rejection of your transplanted liver.
What did we do for you while you were here?
We ruled out infection as the cause of your elevated labs. We
then took a picture of your liver (called MRCP) to look for
changes and found no changes concerning for rejection. We
considered doing a biopsy of your liver, but since your labs
started to come down and your jaundice improved on its own, we
decided against it.
Given the fact that your white blood cells (cells that fight
infection) are low, we started you on a antibiotic called
ciprofloxacin which you will take twice per day to prevent
infections. We also increased your tacrolimus dose to 1mg twice
per day.
What should you do once you leave the hospital?
Please note the medication changes I described above, and take
all medications as prescribed. Please follow up with your
doctor appointments as scheduled. Let us know and come in right
away if you notice worsening jaundice.
IF YOU OR YOUR SON OR BROTHER HAVE ANY DIFFICULTLY WITH YOUR
MEDICATIONS PLEASE CALL THE (NUMBER BELOW).
We wish you the best of health,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12325327", "visit_id": "24346459", "time": "2172-12-15 00:00:00"} |
18422749-DS-17 | 900 | ## ALLERGIES:
Lipitor / Yellow Dye
## HISTORY OF PRESENT ILLNESS:
Ms. is a year-old woman presenting with abdominal
pain.
Seven months prior to admission ( ) the patient was
sexual assaulted. Per her report there was "damage to her
schincter and left ovary" and since that time she has been
incontinent of stool and urine and requires diapers.
Now presents with one day of left CVA tenderness and urinary
frequency. Given concern for UTI she started augmentin on her
own on the day priot to admission. She then noted more CVA
tenderness, constant, severe ( ) and throbbing in nature
with radiation around to the abdomen. Then noted RLQ pain which
was . Noted "peritoneal signs" with rebound so she
presented.
## ROS:
(-) fevers
(+) shaking chills and sweats
(+) easy bruising
(+) nausea and vomiting (day prior to admission; compazine
helps)
(+) anorexia
(-) diarrhea
(+) rash (hives along site of cipro infusion; tolerating oral
cipro well)
ROS otherwise negative.
Pain (flanks and abdomen)
## PAST MEDICAL HISTORY:
1. Coronary artery disease s/p PCI
2. Diabetes
3. Dyslipidemia
4. Hypertension
5. Partial lipodystrophy; congenital/mitochondrial myopathy
- when symptomatic (weak legs), avoids fatty foods
- has had steroid treatment in past
6. Right hand injury w/ surgical repair
7. Fractured left shoulder s/p surgery
8. Uteropexy x2
9. Sexual assualt on ARV prophylaxis
## MOTHER:
PPD/? bipolar. Deceased in her
## FATHER:
dystrophy, lymphoma, depression. Deceased
in his
Brother with myopathy, alive and well
## PHYSICAL EXAM:
Vitals - Afebrile, BP 120/62, HR 86, 96% on room air
General - Lying in bed, sleeping. Easily awoken. No distres
Eyes - No pallor; EOMI
CV - Regular; no murmurs
Pulm - Clear; comfortable
Abdomen - Soft; tenderness in multiple locations
(LLQ/RLQ/epigastrum); no HSM
Ext - Warm; no edema
Neuro - Alert and oriented
Psych - Appropriate and calm
Skin - Warm; no rashes
Back - CVA tenderness on left
MSK - Strength full in all four extremities
## CT ABD/PELVIS (PRELIM):
1. thickening of the left proximal ureter and renal pelvis with
contrast
enhancement, resulting in filling defect of excreted contrast,
concerning for an obstructive mass such as transitional cell
carcninoma. A blood or fungal clot can also be considered.
2. No hydronephrosis.
3. Severe atherosclerotic disease of the abdominal aorta with
intramural
thrombus and a tiny focus of dissection (3:52).
## BRIEF HOSPITAL COURSE:
# Urinary tract infection / Pyelonephritis. UTI based on
symptoms and UA; whether this constitutes pyelo is less clear
given that CT did not show this and there is no documented
fever. She was treated with Ceftriaxone IV initially, and after
observed to be stable for 24 hours this was changed to po
levofloxacin. A Urine culture was negative, as were her blood
cultures. She did take a dose of augmentin 24 hours prior to
presentation, which may affect these results. she had clear
improvement in her symptoms on ceftriaxone.
# Thickening of left proximal ureter with hematuria. It is not
clear what this constitutes. Urology was consulted and
recommended outpatient cystoscopy. Urine cytology was sent and
is pending at the time of discharge
# Intramural aortic thrombus with dissection. Vascular was
consulted in the ED and recommended ASA and blood pressure
control, and follow up as an outpatient (she is already followed
by this group), this was scheduled prior to discharge.
4. Diabetes. As an inpatient, she was managed on sliding scale
insulin alone;
5. Hypertension, hyperlipidemia. Controlled at this time;
continue home regimen(s).
6. CAD, native vessel. Continue ASA/clopidogrel, metoprolol,
statin
7. Anemia. Patient had a decrease in her hematocrit as an
inpatient from 40 to 34 to 31. She was asymptomatic and had had
no further bleeding. She has a baseline hct in the low ,
suspect that initial drop was related to hemoconcentration and
second one may have been related to hematuria itself. These
results were discussed with the patient and given her
hemodynamic stability, HCT was not rechecked and can be repeated
as an outpatient.
## MEDICATIONS ON ADMISSION:
1. Clopidogrel 75 mg daily
2. Aspirin 325 mg daily
3. Metoprolol 25 mg daily
4. Lisinopril 5 mg daily
5. Niaspan 500 mg daily
6. Lorazepam 0.5 mg Q6H as needed for anxiety
7. Red Yeast Rice Extract mg daily
8. Insulin sliding scale
9. Venlafaxine 75 mg Extended Rel daily
10. Seroquel SR 100 AM; 200 HS
## DISCHARGE MEDICATIONS:
1. clopidogrel 75 mg Tablet
## SIG:
One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
8. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
## DISCHARGE CONDITION:
improved abdominal pain.
Ambulatory
## DISCHARGE INSTRUCTIONS:
You were admitted with abdominal pain and CVA tenderness. A CT
showed a thickened left ureter and atherosclerosis of the
abdominal aorta with blood clot. You were seen by vascular
surgery who recommended aspirin and blood pressure management,
and urology, who recommended outpatient cystoscopy. You
received empiric antibiotics for the possibility of
pyelonephritis.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18422749", "visit_id": "20155729", "time": "2131-03-18 00:00:00"} |
19575582-RR-132 | 146 | ## EXAMINATION:
ELBOW (AP, LAT AND OBLIQUE) RIGHT
## INDICATION:
year old man with traumatic fall, now w/ R elbow pain //
?fracture ?fracture
## FINDINGS:
No acute fracture or dislocation are seen. Corticated ossific densities
adjacent to the lateral epicondyle suggest remote injury or chronic
epicondylitis. Similarly, corticated osseous density with slight sclerosis
abutting the medial epicondyle suggests chronic epicondylitis. Mild
degenerative changes of the ulnar trochlear articulation. Small enthesophyte
off the olecranon with tiny adjacent ossific fragment. Substantial soft
tissue edema posterior to the elbow. Small joint effusion.
## IMPRESSION:
1. No fracture or dislocation visualized.
2. Small joint effusion could be reactive from underlying degenerative
changes. If there is persistent concern for occult fracture, repeat
radiographs in days could be obtained.
3. Soft tissue edema posterior to the elbow may suggest contusion or olecranon
bursitis.
4. Sequela of chronic bilateral epicondylitis or prior lateral epicondyle
injury.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19575582", "visit_id": "N/A", "time": "2139-09-06 15:54:00"} |
16687656-RR-13 | 103 | ## EXAMINATION:
ABDOMEN (SUPINE AND ERECT)
## INDICATION:
found down here with RP bleed, duo hematoma, // eval
movement of contrast, leak, do upright
## FINDINGS:
The bowel gas pattern is nonspecific and nonobstructive. There are no
abnormally dilated loops of small or large bowel. Residual oral contrast
material is seen from the cecum to the rectum. There is no evidence of
pneumatosis or pneumoperitoneum. Degenerative changes in the spine, Foley
catheter, and pelvic phleboliths are again seen. Imaged lung bases are clear.
## IMPRESSION:
Residual oral contrast material is seen from the cecum to the rectum. No
evidence of oral contrast extravasation from the bowel.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16687656", "visit_id": "25229519", "time": "2178-01-28 13:59:00"} |
19800242-RR-39 | 294 | ## EXAMINATION:
BILATERAL DIGITAL DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD AND
RIGHT BREAST ULTRASOUND
## INDICATION:
Workup of a palpable mass in the right breast at 6 o'clock,
family history of breast cancer.
## TISSUE DENSITY:
C- The breast tissue is heterogeneously dense which may
obscure detection of small masses.
In the 6 o'clock position of the right breast underlying the palpable marker
there is an asymmetry measuring 35 mm in greatest dimension. There are few
punctate calcifications within the asymmetry, however they are not grouped.
There is no architectural distortion or spiculated mass seen in the left
breast.
## BREAST ULTRASOUND:
Targeted ultrasound of the right breast in the area
palpable concern as indicated by the patient at 6 o'clock, 3 cm from the
nipple demonstrates an ill-defined hypoechoic mass which is heterogeneous and
difficult to determine exact margins. Best attempts at measurement
demonstrates an area measuring 23 mm x 10 mm by 18 mm. Ultrasound-guided core
biopsy is recommended. Additionally, there are numerous cysts seen in the
right breast. The largest simple cyst is at 9 o'clock, 1 cm from the nipple
measuring 6 mm x 4 mm by 9 mm and a larger cyst with layering debris at 9
o'clock 1 cm from the nipple measuring 8 mm by 8 mm x 8 mm.
## IMPRESSION:
Ill-defined hypoechoic mass corresponding to the palpable area of concern in
the right breast for which ultrasound-guided core biopsy is recommended.
## RECOMMENDATION(S):
Ultrasound-guided core biopsy right breast.
## NOTIFICATION:
Findings reviewed with the patient at the completion of the
study. Results recommendations were called to the patient's primary care
physician, , MD at 14:44. The patient underwent same-day biopsy.
## BI-RADS:
4C Suspicious - high suspicion for malignancy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19800242", "visit_id": "N/A", "time": "2128-11-07 13:06:00"} |
18772921-RR-21 | 96 | ## FINDINGS:
There is an extensive left-sided subdural hematoma that is
unchanged in size and appearance compared to prior CT examinations. Left
frontal intraparenchymal hemorrhage is also unchanged in size and appearance
compared to prior CT examinations. There is a trace amount of
intraventricular blood which layers dependently in bilateral occipital horns.
There is no significant midline shift or hydrocephalus. The ventricles and
sulci are normal in caliber and configuration. There is no fracture
identified.
## IMPRESSION:
No interval change in left subdural hematoma and left
intraparenchymal hemorrhage. No new areas of hemorrhage are identified.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18772921", "visit_id": "27848929", "time": "2157-04-17 08:39:00"} |
14471216-RR-59 | 334 | ## EXAMINATION:
MR CERVICAL SPINE W/O CONTRAST MR SPINE
## INDICATION:
year old man with L arm pain, weakness and numbness. //
?worsening spinal stenosis/L C5,6 nerve root compression ?worsening
spinal stenosis/L C5,6 nerve root compression
## FINDINGS:
2 mm anterolisthesis of C4 on C5 and C5 on C6 is similar to prior examination.
Cervical alignment is otherwise anatomic. Vertebral body heights are
preserved. There is no suspicious marrow signal. Disc heights are preserved.
The visualized posterior fossa is unremarkable. There is no cord signal
abnormality.
## C2-C3:
No significant spinal canal or neural foraminal narrowing.
## C3-C4:
A central protrusion with thickening of the ligamentum flavum results
in moderate spinal canal narrowing, minimally remodeling the ventral aspect of
the cord. Uncovertebral and facet arthropathy results in severe bilateral
neural foraminal narrowing. The degenerative changes have slightly progressed
from prior examination.
## C4-C5:
A central protrusion results in mild spinal canal narrowing.
Uncovertebral and facet arthropathy results in moderate to severe bilateral
neural foraminal narrowing slightly worse on the left, similar in appearance
to prior exam.
## C5-C6:
A central protrusion results in mild spinal canal narrowing.
Uncovertebral and facet arthropathy results in moderate to severe left and
moderate right neural foraminal narrowing, is unchanged from prior exam.
## C6-C7:
Central protrusion with thickening of the ligamentum flavum results in
moderate spinal canal narrowing. Uncovertebral and facet arthropathy results
in moderate bilateral neural foraminal narrowing.
## C7-T1:
A central protrusion results in mild spinal canal narrowing. There is
mild bilateral neural foraminal narrowing.
Visualize prevertebral and paraspinal soft tissues are unremarkable.
## IMPRESSION:
1. Multilevel multifactorial cervical spondylosis, most prominent at C3-C4
where there is moderate spinal canal narrowing and severe bilateral neural
foraminal narrowing, slightly progressed from prior examination.
2. At C4-C5, there is moderate to severe bilateral neural foraminal narrowing,
worse on the left, similar appearance to prior exam termination. At C5-C6
there is severe left and moderate right neural foraminal narrowing, similar to
the prior exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14471216", "visit_id": "N/A", "time": "2186-09-23 10:07:00"} |
16221099-RR-21 | 204 | ## HISTORY:
female with left knee pain.
## FINDINGS:
Within the medial compartment, there is abnormal signal within the
posterior horn of the medial meniscus extending to the articular surface
consistent with a tear. Subjacent to this area within the medial femoral
condyle, there is irregularity of the cortical margin with subchondral edema
and a focal cartilage defect. This area involves approximately 9 mm of the
articular surface and is consistent with an osteochondral defect.
Within the lateral compartment, the lateral meniscus is normal in signal
intensity and morphology. There is a focal cartilage defect along the lateral
femoral condyle with underlying subchondral marrow edema involving
approximately 12 mm of the articular surface.
Within the patellofemoral compartment, there is cartilage thinning and
abnormal signal within the lateral patellar facet. There is no underlying
subchondral marrow edema.
There is a small amount of fluid within the popliteal bursa. The extensor
mechanism is intact.
The ACL, PCL, MCL and LCL are intact and within normal limits in signal
intensity and morphology.
## IMPRESSION:
1. Bilateral osteochondral defects within the medial and lateral femoral
condyles as described above.
2. Tear of the posterior horn of the medial meniscus (4, 7).
3. Mild degenerative changes in the patellofemoral compartment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16221099", "visit_id": "N/A", "time": "2126-06-25 10:55:00"} |
16329742-DS-4 | 2,486 | ## CHIEF COMPLAINT:
Diarrhea and orthostatic hypotension
## HISTORY OF PRESENT ILLNESS:
This is a yo F with a past medical history of pancreatic
cancer, stage IIb, s/p gemcitabine -> cyberknife then chemo/rads
with xyloda but self d/c'd it several weeks ago secondary to
cytopenias and electrolyte abnormalities. Admitted to OSH for
n/v/diarrhea suspected to be xyloda and treated for
hypovolemia and electrolyte abnormalities. Pt was d/c w/o
improvement in her sx. She directed to ED from
her radiation oncology visit where she was noted to have
orthostatic hypotension (SBP in and complaints of diarrhea,
n/v. At that time she was hypokalemic/magnasemic. She was
hydrated and electrolytes repleted. Her BCx on admission grew
Peptostreptococcus preotii and she completed a course of
vancomycin. A CT scan done there did not show any recurrence of
cancer or source of infection. She is currently on Flagyl,
despite reported C.Diff Cx x3. Checking . Orthostatic
mainly, but BP stable when sitting/laying. BP meds held. She is
now being transferred from for further
management.
On arrival, the patient is stable with a blood pressure of
110/68 and a hr of 78. On ROS, she admits to recurrent diarrhea
since starting xyloda and with prior chemo. The episodes are
associated with N/V especially during food intake. The are
watery and clear, she reports greasy/oily stools and denies
bloody, mucous like stools. Reports occasional abdominal
cramping. Loperamide has had no effect. Pt also reports pedal
edema developed during hospitalization and a fall during
hospitalization. Per pt. no fracture documented on XR.
Otherwise, ROS is negative in detail. She has not started any
new medications w/ exception of vancomycin and flagyl.
.
ONCOLOGIC HISTORY (taken from Dr. OMR note):
Pancreatic cancer, Stage IIB - : The patient presented
with gingival bleeding and coffee-ground emesis. She was noted
to be profoundly jaundiced with a total bilirubin of 17.8, a
direct bilirubin 14.6, alkaline phosphatase 1600, and AST/ALT
599/543. Her INR was markedly elevated, and it was noted that
she was taking levofloxacin for a urinary tract infection. A CT
scan at that time demonstrated a possible pancreatic mass. In
addition, her CA was elevated at 627. Per the patient, an
upper endoscopy was performed(report unavailable). With
discontinuation of warfarin she had no further gastrointestinal
bleeding and underwent an ERCP/endoscopic ultrasound. The study
demonstrated a mass in the head of the pancreas with dilated
pancreatic and biliary ducts, not amenable to biopsy.
- : She was transferred to , where ERCP showed
duodenal edema, congestion, and probable infiltration by the
pancreatic mass. It was impossible to cannulate the bile ducts.
A CT scan performed here demonstrated a pancreatic head mass
seen along the pancreaticoduodenal groove, causing significant
intra and extra-hepatic biliary as well as pancreatic ductal
dilatation. No vascular involvement was noted, and only tiny
lymph nodes were seen near the pancreas. There was no evidence
of metastatic disease. The endometrium was thickened, and pelvic
ultrasound was recommended for further evaluation. A
percutaneous transhepatic cholangiogram catheter was placed in
the right ductal system for relief of her biliary obstruction.
- : Laparoscopic staging evaluation with intrahepatic
ultrasound demonstrated a likely resectable pancreatic head mass
with no clear evidence of metastatic disease.
Pancreaticoduodenectomy was performed, with pathology
demonstrating a 4.5 x 4 x 2 cm adenocarcinoma (T3). It was grade
2 with lymph nodes containing metastatic disease. Margins
were involved by invasive carcinoma included the posterior
retroperitoneal radial margin, including the posterior surface
of the pancreas. Venous/lymphatic invasion and perineural
invasion were present.
- : The patient began gemcitabine chemotherapy at
1000mg/m2 weekly for weeks, completing two cycles on .
- : Cyberknife therapy to the pancreatic bed.
## PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Microscopic colitis.
4. History of rheumatic fever.
5. Hyperlipidemia.
6. Atrial fibrillation, for which she is anticoagulated.
7. Osteoporosis.
8. History of benign cyst on left leg, status post removal.
9. Status post cholecystectomy in .
## FAMILY HISTORY:
Mother with HTN, father died from aneurysm, no history of
cancer
## GENERAL APPEARANCE:
NAD, pleasant, sitting in bed.
## HEENT:
sclera anicteric, MMM, No lesions/ulcers.
## NODES:
No cerrival, femoral, axillary nodes.
## PULM:
CTA b/l, nl effort.
## ABDOMEN:
obese, surgical scar, diffusely tender to palpation,
mild rebound tenderness.
## EXTREMITIES:
1+ edema b/l to knees. Pulses non-palpable due to
edema, but warm and dry. Point tenterness over sacral area, no
ulceration. Full ROM at hip.
## NEUROLOGIC:
A&O x3. CNs intact. strength b/l .
Sensation grossly intact. FTN intact. DTRs 1+ throughout.
## CXR :
As compared to the previous examination, the right-sided PICC
line
has been removed. Otherwise, there are no relevant changes. The
lung volumes are relatively low, the size of the cardiac
silhouette is minimally increased. There is moderate tortuosity
of the thoracic aorta. No focal parenchymal opacity suggestive
of pneumonia are detected. There is no pneumothorax and no
evidence of pleural effusion. Moderate thoracic scoliosis leads
to assymetry of the rib cage.
## BRIEF HOSPITAL COURSE:
Patient was admitted for treatment of intractable diarrhea
complicated with history of hypotension, hyporkalemia and
hypomagnasemia.
Recurrent diarrhea - patient was started on IVF at 125cc/hr for
hydration, liquid diet advanced as tolerated and restarted on
her enzyme replacements, opium tincture, cholestyramine and
lomotil. Xeloda was held. DDx included neutropenic coilitis,
radiation coilitis, loss of activity or the remainder of the
exocrine tissue, infectious, xyloda treatment as well as
inadequate dosing of the enzyme replacement therapy. Patient's
ANC was 1632, radiation treatment and xyloda were less likely as
they were not temporally associated. All previous Cx and
investigations of infectious causes have been negative to date
(see HPI and Labs). Through further history it was determined
that patient was taking the enzyme replacement sporadically for
the past several months. Patient was educated regarding the
importance of enzyme replacement and barriers to adherence were
discussed. The enzyme replacement uptitrated as well and by
HD#5, the stool frequency decreased to per day, with
semiformed quality and patient was able to tolerate a regular
diet. Her weakness improved and there were no hypotensive
episodes.
FEN/Nutrition - patient had episodes of hypophosphatemia down to
1.0, which were replaced. This was attributed to poor
nutritional status at admission as well as supplementation of
calcium for hypocalcemia on presentation. The values normalized
by HD#5 and on d/c Ca, Phosphate and Magnesium were 8.0, 2.1 and
1.4. Patient tolerated regular diet well and continued on
Megace started at .
Pancreatic cancer - No evidence of recurrence/metastasis on CT
done at outside hospital. Pt. can not tolerate radiation/chemo
diarrhea. on was 153, on was 203. ANC
- 1632. Xeloda was held during admission and a decision was
made to hold it for another 4wks post admission until f/u with
primary oncologist.
Chronically elevated LFTs - elevated since diagnosis and
treatment for pancreatic cancer. Most likely due to disease of
the biliary/pancreatic/duodenal systems and radiation. Although
abnormal on admission (see above), these values are
significantly decreased since diagnosis and treatment for Ca.
Hypotension - there were no episodes of hypotension during the
hospital stay. However, patients antiHTN medications were held
due to SBPs of 110 or less throughout the admission. Her HCTZ
was reintroduced as it was reported to help with edema by the
patient. Upon discharge the SBPs ranged 108 - 114 with HCTZ
25mg PO qd. Cardura, diovan and toprol were held. Patient was
arranged with a cardiology f/u upon discharge for cardiac risk
stratification and management.
Atrial fibrillation - patient was changed from Warfarin to
Lovenox prior to this hospitalization. She tolerated Lovenox
throughout the stay. HR was 70 - 100 throughout the stay and
regular. No ECG was obtained during admission.
Pedal edema - patient reported new onset pedal edema 2mo prior
to hospitalization. On admission exam edema was noted as 1+,
b/l, pitting. Patient denied any SOB, orthopnea, PND, CP, chest
tightness. Etiologies included a most likely nutritional based
on low albumin (1.9) and cardiac (CXR - size of the cardiac
silhouette is minimally increased, no evidence of pleural
effusion/edema), there was no JVD. Patient's EF or Pulmonary
Artery pressures are unknown. TSH was 2.2. edema improved
significantly (1+ to trace) with s/p Lasix 20mg PO x 1 and
reinstitution of HCTZ. Patient was arranged for outpatient
cardiology f/u.
DM - was well managed with ISS, occasionally requiring minimal
doses of regular insulin.
HTN - patient was continued on atorvastatin.
Depression vs. adjustment disorder - patient appeared anhedonic
and with decreased mood. No suicidal ideation. A psychiatry
consultation was arranged and an increase in celexa to 20mg PO
QD was reccommended. Patient refused the increase at the time
of the hospitalization. Outpatient follow up was recommended.
Osteoporosis - patient was started on Ca/Vit D. Treatment with
bisphosphonate was deferred to outpatient setting.
Prophylaxis - patient was continued on lovenox and received
pentoprazole throughout her hospital stay.
On discharge, the physical exam changes were remarkable for no
tenderness to palpation over the abdomen throughout, and
significantly decreased pedal edema (now trace).
## LABS AT DISCHARGE:
see above.
Patient was discharged home in a hemodynamically stable
condition and with improved diarrhea. Appropriate follow up was
arranged (see below)
## MEDICATIONS ON ADMISSION:
Home MEDICATIONS (Please see below for medications on
admission):
AMYLASE-LIPASE-PROTEASE [CREON 10] - 249 mg (33,200 unit-10,000
unit-37,500 unit) Capsule, Delayed Release(E.C.) - 4 Capsule(s)
by mouth three times a day ALSO TAKE TWO TABS WITH SNACKS
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 0.5 Tablet(s) by mouth
once a day
CAPECITABINE [XELODA] - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day TAKE 7 DAYS WEEKLY WHILE UNDERGOING RADIATION
CARDURA - 1MG Tablet - one Tablet(s) by mouth once a day
CITALOPRAM - 10 mg Tablet - 1 Tablet(s) by mouth once a day
DIOVAN - 320MG Tablet - ONE TABLET BY MOUTH EVERY DAY
HYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet(s) by mouth once
a day on hold for low bp per endocrine
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - two puffs twice a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - 1
Tablet(s) by mouth Q8hr as needed for NAUSEA
TOPROL XL - 200 mg Tablet Sustained Release 24 hr - one
Tablet(s) by mouth once a day
WARFARIN - (Prescribed by Other Provider) - 3 mg Tablet - one
Tablet(s) by mouth daily
WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - one
Tablet(s) by mouth daily
WARFARIN - 2.5 mg Tablet - one Tablet(s) by mouth daily
## CURRENT MEDICATIONS (ON ADMISSSION):
AMYLASE-LIPASE-PROTEASE [CREON 10] - 249 mg (33,200 unit-10,000
unit-37,500 unit) Capsule, Delayed Release(E.C.) - 4 Capsule(s)
by mouth three times a day ALSO TAKE TWO TABS WITH SNACKS
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 0.5 Tablet(s) by mouth
once a day
CITALOPRAM - 10 mg Tablet - 1 Tablet(s) by mouth once a day
Cholestyramine one packet bid
Lomitil prn
Lovenox mg sc QD
Lidoderm patch 5% 12hrs
megace 800mg qd
Flagyl 500 q6h
zopran prn
percocet prn
Protonix 40mg daily.
NS 100cc/hr w/ 20meq of K.
Mg 2g IV
## DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
Take tablet by mouth once daily.
Disp:*30 Tablet(s)* Refills:*2*
2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed.
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
4. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed: for loose bowel
movements/diarrhea.
Disp:*30 Tablet(s)* Refills:*0*
5. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
## SUBCUTANEOUS QD ():
100mg subcutaneous injection once daily.
Disp:*30 syringe* Refills:*2*
6. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
Disp:*60 Packet(s)* Refills:*2*
7. Megestrol 400 mg/10 mL Suspension Sig: One (1) PO BID (2
times a day) as needed for anorexia.
Disp:*60 tablets* Refills:*2*
8. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for LBP.
Disp:*30 Tablet(s)* Refills:*0*
9. Omeprazole 20 mg Capsule,
## DELAYED RELEASE(E.C.) SIG:
One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pains.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
11. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO
Q2-6HRS () as needed for diarrhea.
Disp:*100 100* Refills:*0*
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
14. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
## DELAYED RELEASE(E.C.) SIG:
Seven (7) Cap PO three times a day:
Please take with meals.
Disp:*300 Cap(s)* Refills:*2*
15. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Cap PO BID (2 times a day)
as needed for with snacks.
Disp:*120 Cap(s)* Refills:*0*
## 16. COMBIVENT MCG/ACTUATION AEROSOL SIG:
Two (2) puffs
Inhalation twice a day.
17. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day.
## SECONDARY:
Pancreatic cancer, hypertension, depression
## DISCHARGE INSTRUCTIONS:
You were admitted to with a diagnosis of intractable
diarrhea and dehydration secondary to having received
chemotherapy and insufficient use of pancreatic replacement
enzymes which you require because of your pancreatic cancer.
During your hospital stay your blood pressure medications were
withheld due to low blood pressure. Your blood pressures
normalized and you were eventually restarted on some of you
blood pressure medications (Hydrochlorothiazide). Because your
blood pressures were low normal, we did not restart you on
Cardura, Diovan, or Toprol XL.
You were treated with intravenous fluids and electrolytes for
dehydration and pancreatic enzyme replacement (creon), immodium
and tincture of opium for diarrhea. Your diarrhea improved and
you were able to tolerate a regular diet. You were well
hydrated and your appetite improved. We also started a
medication called megace which helped your appetite. You were
able to tolerate a regular diet.
Please go to the nearest emergency department or contact your
primary care physician if you experience any of the following
symptoms: fever greater than , exacerbation in your
diarrhea, dizziness, weakness, fatigue, new pain, nausea,
vomiting, difficulty breathing, chest pain or any other symptoms
that are disturbing to you.
## FOLLOW UP INSTRUCTIONS:
Please follow up with Dr.
or Dr. the next week (see below for appointment
information). You should also follow up with your cardiology
provider, (Please see below).
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16329742", "visit_id": "26709829", "time": "2115-10-15 00:00:00"} |
11652547-RR-18 | 185 | ## INDICATION:
male status post MVC.
## CT CHEST WITH IV CONTRAST:
There is no pneumothorax. The lungs are clear
without nodule, mass or pleural effusion. The airways are patent to the
subsegmental level. The heart and great vessels are unremarkable without
pericardial effusion. There is no axillary, mediastinal or hilar
lymphadenopathy meeting CT criteria for pathologic enlargement.
## CT ABDOMEN WITH IV CONTRAST:
The liver, gallbladder, pancreas, spleen and
adrenal glands are unremarkable. The kidneys enhance and excrete contrast
symmetrically without evidence of hydronephrosis or hydroureter. Incidentally
noted is an accessory right renal artery. The non-opacified stomach and
intra-abdominal loops of bowel are unremarkable. There is no free air or
fluid in the abdomen. The aorta is of normal caliber throughout.
## CT PELVIS WITH IV CONTRAST:
The urinary bladder, distal ureters, seminal
vesicles, and prostate, sigmoid colon and rectum are unremarkable. There is
no free fluid in the pelvis. No pelvic or inguinal lymphadenopathy meeting CT
criteria for pathological enlargement is noted.
## BONE WINDOWS:
No suspicious lytic or sclerotic osseous lesion is identified.
## IMPRESSION:
No evidence of acute intrathoracic, abdominal or pelvic injury.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11652547", "visit_id": "N/A", "time": "2181-02-24 16:42:00"} |
12821893-RR-19 | 103 | ## INDICATION:
Car versus bicycle, evaluate for head injury.
## CT HEAD:
Axial imaging was performed through the brain without contrast.
Sagittal and coronal reformats were performed.
## FINDINGS:
No hemorrhage, edema, mass effect, or evidence for acute vascular
territorial infarction is present. There is no shift of normally midline
structures and gray-white matter differentiation appears well preserved.
Osseous structures are intact. The globes and orbits are intact. There is
mucosal thickening within the ethmoid air cells bilaterally, more on the
right. There are aerosolized secretions within the left sphenoid sinus.
## IMPRESSION:
1. No traumatic injury to the brain.
2. Mild sinus opacification.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12821893", "visit_id": "N/A", "time": "2123-03-04 21:48:00"} |
11882188-RR-50 | 539 | RIGHT NU STENT CHECK AND CHANGE, AND IVC GRAM AND IVC FILTER PLACEMENT
## INDICATION:
man with metastatic prostate CA, with migrated right
NU stent. Also has lower extremity DVT, unable to anticoagulate.
## OPERATORS:
Drs. (fellow) and (attending
physician). Dr. was present in the room throughout the procedure.
## CONTRAST:
Sterile 6 mL Visipaque 320 in the right urinary system and 24 mL
Visipaque 320 in the IVC.
## RIGHT NU STENT:
Consent was obtained from patient after explaining the
benefits, risks and alternatives. Patient was placed prone on the imaging
table in the interventional suite. Timeout was performed as per
protocol.
Initial scout fluoroscopic image demonstrated indwelling right NU stent.
Under aseptic conditions, the catheter was cut close to the hub. After
reducing the proximal pigtail loop, a 0.035 wire was advanced through
the cut end of the catheter and eventually coiled within the urinary bladder.
Catheter remnant was removed to place a new 8 24 cm NU stent. Wire was
removed. Distal pigtail loop was placed in the bladder and the proximal loop
in the renal pelvis. A small amount of sterile contrast material was injected
to confirm position. There was free flow of contrast to the bladder. String
was withdrawn, locked and trimmed. Catheter was connected to an external bag,
and secured by 0 silk sutures and Flexi-Trak. Site was dressed appropriately.
Patient tolerated the procedure well and no immediate post-procedure
complication was seen.
## IVC GRAM AND FILTER PLACEMENT:
Consent was obtained from patient after
explaining the benefits, risks and alternatives. Patient was placed supine on
the imaging table in the interventional suite. Timeout was performed as per
protocol.
Under aseptic conditions, sonographic guidance, and after infiltrating the
skin and subcutaneous tissues with adequate amounts of 1% lidocaine, a 19
gauge needle was placed in the right common femoral vein at the level of mid
femoral head. A 0.018 wire was advanced through the needle and into the IVC.
After making an incision at the access site, the needle was removed to place a
5 Omniflush catheter in the lower IVC. After removing the wire,
catheter tip was placed at the bifurcation to perform an IVC gram. It
demonstrated -
1. Single patent IVC.
2. Renal vein confluence at lower L1 level.
3. Infrarenal IVC diameter of 20 mm.
Based on these findings, we proceeded to place an Eclipse retrievable filter.
After removing the Omniflush catheter over the wire, the 7
sheath (package along with the kit) was placed over the wire and advanced to
the upper IVC. After removing the inner cannula, the sidearm was aspirated
and flushed. The Eclipse retrievable filter was then carefully advanced into
the sheath to place it tip-to-tip. After retracting the system to the
infrarenal IVC, the filter was deployed by unsheathing. Filter delivery
system and sheath were then removed. Firm pressure was applied to the
venotomy site for 7 minutes to achieve complete hemostasis. Site was dressed
in a sterile fashion. Patient tolerated the procedure well and no immediate
post-procedure complication was seen.
## IMPRESSION:
1. Uncomplicated replacement of old right 8 x22 cm NU stent with a new
8 x24 cm NU stent.
2. Uncomplicated IVC gram followed by infrarenal IVC filter (retrievable,
Eclipse) placement.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11882188", "visit_id": "20573586", "time": "2112-10-06 16:01:00"} |
14718684-DS-21 | 1,226 | ## CHIEF COMPLAINT:
Mechanical fall w/o LOC
## HISTORY OF PRESENT ILLNESS:
w/ hx of mechanical fall requiring previous hospitalization
x1, osteoporosis, HTN, R posterior fossa meningioma and R
cavernous sinus meningioma (dx'd in s/p surg/XRT in
who presents after a mechanical fall while ambulating with a
walker to answer the door. She did not strike her head and did
not have any LOC. Of note, patient has been previously admitted
from following a mechanical fall when not using
her cane.
.
In ED VS were 98.5 92 137/70 12 98%. CT head w/o contrast was
unremarkable and AP XR of pelvis showed no fracture, but XR of
L-spine indicated a possible new L1 compression fracture. A UA
showed mod leuks, WBCs, few bacteria, neg nitrite, trace
protein, and epithelial cells. She received cefriaxone for
UTI. Chem10 remarkable for Ca of 10.4 and P of 2.5. She had a
leukocytosis to 15.6, with 80% PMNs. Lactate was 1.5. She failed
evaluation. She received oxycodone 2.5 mg po x1 prior to
transfer. On transfer to floor, vitals were: 98.5 92 137/70 12
98%.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies 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.
## PAST MEDICAL HISTORY:
1. Hypertension
2. Hearing impairment
3. Osteoporosis
4. B12 deficiency
5. Hyperlipidemia
6. Mild cognitive impairment
7. Shingles
8. Cataracts
9. Osteoarthritis
10. Meningioma (R posterior fossa meningioma and R
cavernous sinus meningioma initially diagnosed in s/p
surgery/XRT)
11. H/O Tinnitus
## FAMILY HISTORY:
Mother had heart disease and high cholesterol. No history of
diabetes, stroke, renal disease.
## GA:
Elderly female, very hard of hearing, AOx3, NAD
## HEENT:
PERRLA. MMM. no LAD. no JVD. neck supple.
## CARDS:
RRR S1/S2 heard. no murmurs/gallops/rubs.
## PULM:
CTAB at ant/ mid lungs; mild crackles at bilateral bases
## ABD:
soft, NT, +BS. no g/rt. neg HSM. neg sign.
## EXTREMITIES:
wwp, no edema. DPs, PTs 2+.
## SKIN:
mild bruise over L flank
## NEURO/PSYCH:
CNs II-XII intact (except diminished hearing in
VII). strength in U/L extremities.
## GA:
Elderly female, hard of hearing, AOx3, NAD
## HEENT:
PERRLA. MMM. no LAD. no JVD. neck supple.
## CARDS:
RRR S1/S2 heard. no murmurs/gallops/rubs.
## PULM:
mild crackles at bilateral bases, otherwise clear, no
wheezes
## ABD:
soft, NT, +BS. no g/rt. neg HSM. neg sign.
## EXTREMITIES:
wwp, no edema. DPs, PTs 2+.
## SKIN:
mild bruise over L flank
## NEURO/PSYCH:
CNs II-XII intact (except diminished hearing in
VII). strength in U/L extremities, sensation to light touch
intact
## CXR:
No acute cardiopulmonary findings.
## LUMBOSACRAL SPINE XRAY:
Since there is new compression deformity of the L1
vertebral body. Evaluation of L5 is limited due to severe
osteopenia. If neurologic symptoms are present, MRI should be
performed to better evaluate.
## XRAY PELVIS:
Moderate degenerative changes in both hips. No
fracture or dislocation.
## CT HEAD W/O CONTRAST:
1. No acute intracranial abnormality.
2. No recent change in the appearance of right tentorial and
cavernous
meningiomas.
## BRIEF HOSPITAL COURSE:
w/ hx of mechanical fall requiring hospitalization x1,
osteoporosis, HTN, R posterior fossa meningioma and R cavernous
sinus meningioma (dx'd in s/p surg/XRT in who
presents after a mechanical fall at home.
.
#s/p mechanical fall w/ possible underlying gait abnormality:
One of many falls that the patient has had in the last few
months, per daughter. No evidence of PNA on CXR, no evidence of
UTI WBC and bacteria on UA likely asymptomatic
bacteriuria). Patient currently uses a walker, however still
feels unsteady. Evaluated by who recommended home with
physical therapy. She does have back pain s/p fall, likely
related to both musculoskeletal strain and L1 compression fx,
new since prior study. For this, she was treated with PRN
oxycodone and standing tylenol. She will restart fosamax on
discharge, which she was on for several years and was dc'ed in
, as well as start nasal calcitonin. She will follow up in
clinic on .
.
#Osteoporosis: new L1 compression fx. Was on fosamax for
several years, however stoppped in by PCP. Restarted
fosamax on discharge considering compression fx s/p fall.
Increased home vitamin D to 800 mg daily and continued home
calcium supplementation
.
#asymptomatic bacteriuria: initially concerning for UTI, however
only WBC, asymptomatic, and no growth on culture. Received
one dose of ceftriaxone in ED, this was discontinued on arrival
to floor. Was afebrile and leukocytosis improved.
## #LEUKOCYTOSIS:
improved from 15 to 11. Likely trauma and
not infection, no localizing sx and UA more suggestive of
asymptomatic bacteriuria, no infiltrate on CXR.
.
#Hyperlipidemia: Stable, continued atorvastatin
.
#Hypertension: mildly elevated initially, possibly related to
pain. Improved overnight. Continued home HCTZ.
## MEDICATIONS ON ADMISSION:
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 (One) Tablet(s) by
mouth daily
HYDROCHLOROTHIAZIDE - 12.5 mg Capsule - 1 (One) Capsule(s) by
mouth daily
Medications - OTC
CALCIUM 500 WITH VITAMIN D - 500-125 mg-unit Tablet - 1 (One)
Tablet(s) by mouth three times a day
CARBAMIDE PEROXIDE - 6.5 % Drops - 3 (Three) qtt topically both
ears at bedtime once per month
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1,000 mcg Tablet
-
1 (One) Tablet(s) by mouth weekly
MULTIPLE VITAMIN - Tablet - 1 (One) Tablet(s) by mouth once a
week
## DISCHARGE MEDICATIONS:
1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day.
5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
## 7. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
week.
9. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Disp:*4 Tablet(s)* Refills:*2*
10. calcitonin (salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily): 1 spray in one nostril daily.
Alternate nostrils each day.
Disp:*1 spray* Refills:*0*
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You were seen in the hospital for a fall, which was most likely
due to unsteadiness. For this, the physical therapy team here
recommended getting physical therapy at home in order to get
stronger. You were also found to have a small fracture in your
back on x-ray, which is likely from osteoporosis. Because of
this, we increased your vitamin D dose and restarted your
fosamax. We also prescribed a calcitonin nasal spray which
should help the back pain as well.
Changes to your medications:
INCREASE vitamin D to 800 mg daily
START taking fosamax 70 mg once a week
START taking calcitonin nasal spray. Use one spray in one
nostril daily, alternate nostril each day
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14718684", "visit_id": "28850256", "time": "2198-08-15 00:00:00"} |
15871582-DS-6 | 1,234 | ## ALLERGIES:
Penicillins / Clindamycin / Amoxicillin / Warfarin / Lisinopril
/ Pradaxa
## HISTORY OF PRESENT ILLNESS:
Ms. is an woman with PMH of AF
on Pradaxa, CHF, diverticular disease, presenting with painless
BRBPR. It began at 2am this morning, when she had pressure
indicating she felt like she had to have a BM. She then passed
bright red blood without stool that filled the toilet bowl. She
had a subsequent episode at and an hour later. Each
time, bright red blood filled the toilet bowl. While in the ER,
at about 1pm, she had a fourth episode, this time mixed with
stool. She notes that after some of the episodes, she had a bit
of pressure/cramping after the BM in a band-like distribution
infraumbilically. She denies any fevers or chills, no nausea or
vomiting, anorexia. Doesn't feel lightheaded. No SOB or chest
pain.
She had a similar episode in , at which time she was in
. There she had BRBPR and presented with Hct 22.
Colonoscopy showed diverticulosis, hemorrhoids, rectal polyp s/p
polypectomy (tubular adenoma). Pradaxa was held at the time of
that episode. After she returned to the , had ongoing anemia,
at which time she was admitted here in . She subsequently
underwent EGD (unremarkable) and repeat colonoscopy. Colonoscopy
again showed diverticulosis, hemorrhoids, and this time an
adenoma in the cecum was also found. She has otherwise been on
her Pradaxa without incident since .
## IN THE ED, INITIAL VITALS:
99.3 68 118/60 18 97% RA. On labs,
Hct was noted to have dropped 7 points: 32.7 from previous 39.
Creatinine was 1.5 (stable for recent baseline). The GI team
consulted in the ED reviewed previous colonoscopies showing
diverticuli in they recommended holding Pradaxa,
transfusing for Hct < 25, and maintaining large bore IV access.
They would consider performing coloscopy on vs. as an
outpatient. Vitals prior to transfer were: 98.1 69 109/50 16
95%.
Currently, patient has mild, cramping, lower abdominal pain.
Last episode of BRBPR was in the ED, and was a small amount.
She had an episode of transient, minimal, sharp chest pain at
her pacemaker site last night (which happens intermittently).
## ROS:
per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
## PAST MEDICAL HISTORY:
1. Hypertension
2. Hyperlipidemia
3. Obstructive sleep apnea-not using CPAP
4. Diastolic heart failure
5. Tachy-brady syndrome status post pacemaker
6. Atrial fibrillation
7. Chronic kidney disease
## ADMISSION PHYSICAL EXAM:
VS - Temp 98.1, BP 127/58, HR 92, R 18, O2-sat 96% RA
GENERAL - Older Asian woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, irregularly irregular, 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, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength
throughout, sensation grossly intact throughout, gait not
assessed
## I/O:
140/600+
GENERAL - Older Asian woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
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, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, no focal deficits
## BRIEF HOSPITAL COURSE:
Ms. is an female with history of AF on pradexa,
CHF, diverticular disease presenting with painless BRBPR, likely
diverticular bleed.
#. BRBPR. Likely lower GI source as patient has known
diverticuli. She had two large bore IVs placed, was typed and
screened and transfused 1 unit of PRBCs for a hematocrit of
25.7. Her hematocrits were trended and she was monitored for
further episodes of rectal bleeding. On she had a bowel
movement that was non-bloody. She was not orthostatic and was
not complaining of any abdominal pain. She was seen by GI in
consultation and it was not felt that she needed any additional
imaging at this time. Her anticoagulation was held in the
setting of an acute bleed, as discussed below. She will follow
up with her PCP in 1 week.
# Atrial fibrillation. CHADS3. On Pradaxa as an outpatient. Her
Pradaxa was held in the setting of acute bleed. She will need to
follow up with her PCP and cardiologist as this is her third
bleed, first while on Pradaxa, and the risks and benefits of
anticoagulation vs. stroke prophylaxis will need to be discussed
with the patient and family. Her diltiazem, amiodarone and
carvedilol were continued.
## # CONGESTIVE HEART FAILURE:
diastolic with preserved EF. Cardiac
medications were continued as indicated above. Additionally, her
aspriin was continued.
## # DMII. HGA1C:
6.8. She was placed on an insulin sliding scale
while hospitalized.
# Hyperlipidemia. She was conntinued on her statin
# Hypertension. Continued on diltiazem, carvedilol
# Renal insufficiency. Creatinine on admission 1.5, stable.
# Severe sleep apnea. Does not wear CPAP, only home O2, will
maintain sats >92% while inpatient. Did not require supplemental
oxygen while inpatient.
# Hypothyroidism
- Continue home dose of levothyroxine
## TRANSITIONAL ISSUES:
- Will require follow up of her anticoagulation
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
hold for SBP < 100
2. Aspirin 81 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
Hold for SBP<90 or HR<50
4. Dabigatran Etexilate 75 mg PO BID
5. Diltiazem Extended-Release 240 mg PO DAILY Start: In am
hold for SBP < 100 or HR < 60
6. Diltiazem Extended-Release 120 mg PO QPM
hold for SBP < 100 or HR < 60
7. Ferrous Sulfate 325 mg PO DAILY Start: In am
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Simvastatin 10 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Acetaminophen 650 mg PO Q6H:PRN fever, pain
## DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg PO DAILY
hold for SBP < 100
2. Aspirin 81 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
Hold for SBP<90 or HR<50
4. Diltiazem Extended-Release 240 mg PO DAILY
hold for SBP < 100 or HR < 60
5. Diltiazem Extended-Release 120 mg PO QPM
hold for SBP < 100 or HR < 60
6. Ferrous Sulfate 325 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Simvastatin 10 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN fever, pain
## DISCHARGE DIAGNOSIS:
1. Diverticular bleed
2. Atrial fibrillation
3. diabetes
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It a pleasure taking care of you during your hospitalization
at . You were admitted with rectal bleeding likely from
diverticular disease. You were given a unit of blood and your
blood counts were watched. You did not have any further episodes
of bleeding and your blood counts remained stable. You should
not take your Pradaxa and will follow up with at Dr.
next week to discuss further medication changes.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15871582", "visit_id": "29365913", "time": "2137-11-05 00:00:00"} |
19599760-DS-14 | 1,813 | ## HISTORY OF PRESENT ILLNESS:
year old male with chief complaint of left buttock and groin
pain - s/p recent initiation of chemo for CLL early (Day
#26 of Bendamustine cycle). He was seen f/u and with WBC
total down but no neutrophils. He stopped Acyclovir and
Allopurinol on . There were noted buttock/perianal painful
lesions , which grew worse over the weekend. The patient now
reports very severe pain of burning quality over buttocks and
also penis. He has pain with urinating but he believes that this
is secondary to the surface pain on the skin rather than
infection the urine. No urgency/frequency or foul-smelling
urine, no hematuria.
Patient was given IV acyclovir and IV morphine for pain control
the ED.
## REVIEW OF SYSTEMS:
No fevers, chills or night sweats. Has lost
60 lbs over the course of the past year due to poor appetite.
Appetite remains poor but unchanged. Had loose stool x 2 days
just over one week prior to admission, then a firm bowel
movement ~4 days ago and none since. No blood the stool or
dark/tarry stool. No myalgia or arthralgia. No numbness or
tingling or other neurological deficits. Otherwise negative.
## PAST MEDICAL HISTORY:
- CLL diagnosed (see history below)
- Hypertension
- GERD
- BPH
.
## SUMMARY OF CLL HISTORY:
(1) Rai stage 1 CLL was detected as an incidental finding
following evaluation of traumatic work injury. On ,
peripheral blood cytogenetics by FISH showed: (1) a single
hybridization signal with the ATM probe at 11q22.3 100/100
nuclei, which exceeds the normal range (up to 5% monosomy) for
this probe our laboratory; and (2) a single hybridization
signal with the probe at 13q14.3 100/100 nuclei,
which
exceeds the normal range (up to 5% monosomy) for this probe
our laboratory.
(2) , he developed progressive anemia, increased fatigue
at work with persistent "achy, stiff" back pain and headaches.
Torso CT scan documented multiple enlarged lymph nodes.
(3) Received first cycle of fludarabine and cyclophosphamide
. Rituximab was added for cycle 2
.
(4) Received only 2 out of 3 days of C3 FCR on and
with Neulasta support d/t low WBC.
(5) Received cycle 4 of weekly rituximab .
(6) late , neutropenia while on Bactrim resolved on
stopping Bactrim and administering Neulasta
## PHYSICAL EXAM:
GENERAL - ill-appearing man NAD, somewhat uncomfortable with
repositioning, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - Bibasilar rales up the lung fields, resp unlabored,
no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - Multiple clustered finely vesicular erythematous lesions,
most with central necrosis/graying of the skin, a ~dermatomal
distribution over S1-S2 on the left portion of the buttocks and
left and mid-shaft of the penis and left aspect of scrotum.
addition, the patient has two .75 cm nodular erythematous
lesions overlying the pubic bone, which appear different than
the other lesions and are less tender to palpation.
LYMPH - Palpable LAD most pronounced left groin (multiple
enlarged nodes, non-tender, per patient decreased size from
recent past)
NEURO - awake, A&Ox3, muscle strength throughout, sensation
grossly intact throughout
## MICROBIOLOGY:
- Blood cultures x 2 - No growth
- DFA negative for HSV1 and HSV2, positive for VZV
- Blood culture x 2 - No growth
- Urine culture - No growth
- Sputum :
GRAM STAIN (Final :
>25 PMNs and <10 epithelial cells/100X field.
2+ per 1000X FIELD): GRAM POSITIVE COCCI.
PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final :
MODERATE GROWTH Commensal Respiratory Flora.
- Urine culture - No growth
- Blood culture - PENDING at the time of discharge
- Blood cultures x 2 - PENDING at the time of discharge
- Urine culture - Negative for Legionella antigen
- Sputum :
GRAM STAIN (Final :
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final :
SPARSE GROWTH Commensal Respiratory Flora.
ACID FAST SMEAR (Final :
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
## ACID FAST CULTURE (PRELIMINARY):
PENDING at the time of
discharge
- Blood cultures x 2 - PENDING at the time of discharge
- Urine culture - No growth
## FINDINGS:
comparison with the study of , the
areas of increased opacification at the left base and left mid
lung zone have been virtually cleared. However, there is an area
of suspicious opacification at the right base that could
represent a developing pneumonia. B lines are seen at the
bases, raising the possibility of some elevated pulmonary venous
pressure. No evidence of pleural effusion.
## FINDINGS:
As compared to the previous examination,
the pre-existing subtle right basal opacity has increased
extent and density. At the bases of the left lung, subtle
opacities of similar morphology have newly occurred. Overall,
the progression of these findings and their morphology are
strongly suggesting pneumonia. Otherwise, there is no relevant
change. Moderate mediastinal widening. Normal size of the
cardiac silhouette, no evidence of pleural effusions. Small
scar at the bases of the left lung.
## BRIEF HOSPITAL COURSE:
man h/o CLL s/p recent induction chemotherapy (Day
#26 of bendamustine cycle #1) who presents with a painful,
burning rash roughly dermatomal distribution to the
buttocks/penis.
## # HERPES ZOSTER:
Lesions follow a rough dermatomal distribution
of S1-S3 (penis, scrotum and perianal region on the left).
Lesions were clustered and vesicular; several appeared centrally
necrotic. Skin scrapings were positive for VZV by DFA. The
patient was evaluated by infectious disease consult service and
started on IV acyclovir for 7-day course, then converted to
valacyclovir. Treatment course will be determined by duration of
lesions (plan is to convert to prophylactic dosing once lesions
have largely healed over). Pain control was an issue; the
patient was initially on oxycodone and morphine, but morphine
was discontinued when the patient developed urinary retention.
Gabapentin was initiated to help with neuralgia pain.
## # FEVERS, ? PNEUMONIA:
Patient was initially afebrile but spiked
temperatures to > F from to . All blood and
urine cultures were negative (or pending at time of discharge).
Respiratory viral paneal was negative. Clinical lung exam was
significant for bilateral rales (present on admission), although
the patient had good O2 sats on room air throughout this
admission and did not feel subjectively short of breath. He had
no cough. CXR showed initial LLL opacity concerning for early
PNA, and repeat CXR after onset of fever was read as consistent
with bilateral PNA. The patient was therefore treated
with cefepime (cipro was added for enhanced gram negative
coverage on and discharged with plan to complete a 10-day
course with levofloxacin (last day . However, levofloxacin
was not covered by the patient's insurance, so moxifloxacin was
substituted.
# Urinary retention. Developed several days into this
hospitalization - the patient initially had difficulty
initiating flow and was eventually unable to void. Foley was
placed to relieve retention (> 800 cc). Patient initially failed
voiding trial on but was able to void successfully on
. Etiology of retention likely multifactorial - most
likely largely related to high doses of narcotic pain
medication, but also augmented by underlying BPH. Urinary
retention with sacral Zoster has been reported, but is rare.
# CLL. Patient is s/p cycle of treatment with bendamustine
(admission = Day #26). WBC count has trended down significantly
from > 200 early , but ranged during this
admission. He was visited by NP from heme-onc during
this admission who made recommendations for pain control (stop
morphine, increase oxycodone PRN). He will follow up with the
clinic after discharge to discuss resuming
chemotherapy.
# GERD. The patient was continued on Prevacid during this
admission.
# BPH. The patient was continued on Flomax during this
admission.
# Hypertension. The patient was continued on amlodipine during
this admission. BPs ran the low-normal range likely
secondary to increased doses of narcotic pain medication.
## # COMMUNICATION:
Patient
# Contact: (nephew) is HCP: (H);
(C)
# Code status: Confirmed full
## MEDICATIONS ON ADMISSION:
- Amlodipine 5 mg
- Flomax 0.8 mg
- Oxycodone 5 mg Q4-6H PRN pain
- Compazine 10 mg PRN (prescribed, but patient has not
needed)
- Prevacid 15 mg (recently changed from pantoprazole 40
mg
- Bentamustine 170 mg (on and also received 10 mg IV
dexamethasone those days) - now day #26 of 4-week cycle
## DISCHARGE MEDICATIONS:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr HS (at bedtime).
2. Gabapentin 300 mg Capsule Sig: As directed Capsule three
times a day: Take 300 mg the morning, 300 mg the
afternoon, and 600 mg before bed. Once the pain from your rash
subsides, you no longer need this medication.
Disp:*120 Capsule(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet .
4. Compazine 10 mg Tablet Sig: One (1) Tablet every six (6)
hours as needed for nausea.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, Sig: 0.5
Tablet,Rapid Dissolve, .
6. Oxycodone 5 mg Tablet Sig: Tablets every four (4)
hours as needed for pain: Please do not drive or operate
machinery while taking this medication.
Disp:*100 Tablet(s)* Refills:*0*
7. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet Q8H (every
8 hours): Please follow up with your PCP regarding your rash.
Once it has healed, you should change to a prophylactic dose.
Disp:*180 Tablet(s)* Refills:*2*
8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet once a day
for 5 days: First dose
Last dose .
Disp:*5 Tablet(s)* Refills:*0*
## PRIMARY:
- Herpes zoster, left S2 dermatomal distribution
- pneumonia
- Urinary retention
## SECONDAY:
- Chronic lymphocytic leukemia
- Benign prostatic hypreplasia
- Hypertension
- Gastroesophageal reflux disorder
## DISCHARGE INSTRUCTIONS:
You were admitted to with a
burning, painful rash. Lab tests showed that this rash is caused
by Herpes Zoster ("shingles"). You were treated with IV
acyclovir and then changed to oral valacyclovir after 7 days.
You received oxycodone and morphine for the pain. This regimen
was changed to oxycodone only because you were having problems
with urinary retention.
You were also noted to have some congestion your lungs on
your exam and on your chest x-ray. Because you were also having
fevers, you received additional antibiotics to treat a possible
pneumonia. You will continue to take oral anitbiotics to
complete a 10-day course.
We have made the following changes to your medication regimen:
- BEGIN TAKING valacyclovir 1000 mg by mouth three times
until your rash has healed; you will then be changed to a
preventative dose
- BEGIN TAKING levofloxacin 750 mg by mouth (last day
- BEGIN TAKING gabapentin 300 mg by mouth the morning, 300 mg
the afternoon, and 600 mg before bed to help with the Herpes
Zoster pain
- INCREASE DOSE of oxycodone as needed to control pain (please
try to use only as much of this medication as you need for pain
control, as too much pain medication can cause confusion and
also contribute to urinary retention)
Please follow up with your doctors as below.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19599760", "visit_id": "27669840", "time": "2187-07-05 00:00:00"} |
14688870-RR-60 | 343 | ## EXAMINATION:
MRI brain and MRA head/neck without contrast.
## HISTORY:
female with an episode of aphasia, to evaluate for
stroke.
## MRI BRAIN:
Multiplanar MRI of the brain was performed without intravenous
gadolinium administration.
## MRA HEAD/NECK:
Multiplanar MRA of the head and neck was performed without
intravenous gadolinium administration. Additional 3D reconstructed images
were obtained.
## MRI HEAD:
There is a stable focus of susceptibility artifact in the right
cerebellar hemisphere medially on gradient echo images which likely represents
a focus of prior hemorrhage. No new foci of susceptibility artifact are
identified to suggest new hemorrhage since the prior study of . Again
identified is diffuse T2/FLAIR signal hyperintensity in the periventricular
and deep subcortical white matter. There is no evidence of hydrocephalus,
mass effect, or shift of the normally midline structures. The ventricles and
cortical sulci are prominent in keeping with the patient's age of years.
There is no evidence of restricted diffusion to suggest acute ischemia.
## MRA HEAD:
The vertebrobasliar system is patent without evidence of stenosis or
occlusion. The internal carotid, anterior, middle, and posterior cerebral
arteries are normal in course and caliber without evidence of stenosis,
occlusion, aneurysm, or arteriovenous malfomation.
## MRA NECK:
The extracranial vertebral arteries are normal in course and caliber
without evidence of stenosis. There is atherosclerotic irregularity at the
bifurcation of the left common carotid artery extending into the proximal left
internal carotid artery. The exact degree of stenosis is likely less than
50%, but is difficult to determine on this noncontrast study. The right
common, internal, and external carotid are patent without evidence of
stenosis or occlusion.
## IMPRESSION:
1. Stable old focus of hemorrhage in the medial right cerebellar hemisphere.
No new hemorrhage or infarction.
2. Atherosclerotic irregularity at the bifurcation of the left common carotid
artery extending into the proximal left internal carotid artery. The exact
degree of stenosis is likely less than 50%, but is difficult to determine on
this noncontrast study. MRA of the neck with contrast may be obtained for
further evaluation.
3. Microangiopathic ischemic white matter disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14688870", "visit_id": "25539253", "time": "2111-09-08 16:49:00"} |
10501162-RR-90 | 267 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
Evaluate for change in lymphadenopathy. man with CML and CLL.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 10.5 s, 67.9 cm; CTDIvol = 16.3 mGy (Body) DLP =
1,094.5 mGy-cm.
Total DLP (Body) = 1,095 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS W/O CONTRAST)
## THORACIC INLET:
The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes.
## BREAST AND AXILLA:
There are no enlarged axillary lymph nodes. There are
multiple small bilateral axillary nodes.
## MEDIASTINUM:
Small mediastinal nodes are also unchanged. These are not
enlarged by size criteria. There is a pre-vascular node measuring 4 mm.
Heart size is normal. There is atherosclerotic calcification involving the
aorta. There is moderate coronary artery calcification. There is moderate
aortic annulus calcification. There is no pericardial effusion. There is
moderate cardiomegaly.
## PLEURA:
There is no pleural effusion.
## LUNG:
There is subsegmental atelectasis in both lung bases. A consolidative
opacity in the left lower lobe (3, 51) is new and could represent atelectasis
however pneumonia cannot be excluded. Subsegmental atelectasis is seen in the
right lung base.
## BONES AND CHEST WALL:
Review of bones shows degenerative changes involving
the thoracic spine.
## UPPER ABDOMEN:
Limited sections through the upper abdomenshows small l
retroperitoneal ymph nodes.
## IMPRESSION:
Stable small mediastinal bilateral axillary lymph nodes.
New patchy parenchymal opacity in both lung bases left greater than right
could represent subsegmental atelectasis however new left lung base pneumonia
cannot be excluded.
Please refer to dedicated report on abdomen which has been dictated
separately.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10501162", "visit_id": "N/A", "time": "2190-06-02 13:51:00"} |
19712454-RR-58 | 93 | ## EXAMINATION:
HAND (PA,LAT AND OBLIQUE) RIGHT
## INDICATION:
year old man with R hand pain // R hand pain
## FINDINGS:
There is marked flexion of the middle and ring finger, most pronounced at the
PIP joints, with milder flexion also seen at the MCP and DIP joints of the
same fingers. There is osteoarthritis involving all the PIP and DIP joints as
well as the first CMC and IP joint of the thumb. No obvious bony ankylosis is
identified. No soft tissue calcification or radiopaque foreign body is
detected.
## IMPRESSION:
As above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19712454", "visit_id": "N/A", "time": "2154-08-22 07:24:00"} |
16477441-RR-54 | 249 | ## EXAMINATION:
HUMERUS (AP AND LAT) LEFT
## INDICATION:
year old woman with cortical beaking L femur associated with
bisphosphonate use// ? left arm pain
## FINDINGS:
There is possible diffuse osteopenia involving the left humerus. No discrete
fracture line is identified. Longitudinal lucency along the lateral for shaft
near the junction of the mid and distal third likely represents a nutrient
foramen. At the extreme the distal edge of these images, there is a linear
lucency with surrounding cortical thickening in the proximal ulna which could
represent a stress fracture, not fully evaluated on this examination..
Assessment of the shoulder is limited, the CT which shows mild degenerative
change. Assessment of the elbow joint is limited, but is otherwise within
normal limits for age.
## IMPRESSION:
Linear lucency in the proximal left ulna with surrounding cortical thickening,
seen at the edge of these films, suggestive of a stress fracture. Recommend
further assessment with dedicated left forearm radiographs.
No fracture detected involving the left humerus. If there is ongoing concern
for radiographically occult bone or soft tissue abnormality in the left upper
arm, then MRI could help further assessment.
## RECOMMENDATION(S):
Left forearm radiograph to further assess suspected
fracture in the proximal left ulna.
If there is ongoing concern for radiographically occult bone or soft tissue
abnormality, then MRI could help further assessment.
## NOTIFICATION:
The impression and recommendation above was entered by Dr.
on at 10:03 into the Department of Radiology critical
communications system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16477441", "visit_id": "N/A", "time": "2184-12-07 08:49:00"} |
10222191-RR-68 | 119 | ## INDICATION:
man with newly placed left IJ catheter, assess for
position.
## FINDINGS:
New left internal jugular venous catheter terminates in the left
brachiocephalic vein. Right IJ catheter, tracheostomy tube and nasogastric
tube are unchanged in appearance. Low lung volumes with bibasilar left
greater than right pleural effusions and atelectasis are unchanged aside from
slight improved aeration at the left base. Otherwise, no pneumothorax is seen
with unchanged mediastinal and cardiac silhouette.
## IMPRESSION:
Left IJ catheter terminating in the left brachiocephalic vein.
Left greater than right effusions and atelectasis, with slight improved
aeration at the left base.
Line related finding was discussed with Dr. by Dr. at 1450 by
phone after discovery and page at 14:35 on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10222191", "visit_id": "27488620", "time": "2185-07-20 13:37:00"} |
12640988-RR-74 | 313 | ## INDICATION:
year old man with obstructive uropathy BPH/prostatitis s/p
urinary diversion bilat with PCNUs. Pt now with leakage around his right sided
drain. Please assess, replace if needed.// Assess for right PCNU migration
## OPERATORS:
Dr. ,
performed the procedure.
## CONTRAST:
5 ml of Optiray contrast.
## PROCEDURE:
1. Right diagnostic antegrade nephrostogram.
2. Right 8 nephroureterostomy exchange for new 10 modified
nephroureterostomy tube.
## 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 prone
on the exam table. A pre-procedure time-out was performed per protocol.
The right flank was prepped and draped in the usual sterile fashion.
The existing right-sided nephroureterostomy tube was pulled back to the skin
with pigtail outside the skin. The image was stored on PACS. Local anesthesia
was administered with instillation of lidocaine jelly and 1% subcutaneous
lidocaine injection. The catheter was cut. A wire was advanced into
the right nephrostomy tube and advanced into the distal ureter. The stay
sutures were cut and the catheter was removed over the wire. A new modified 10
nephroureterostomy catheter was flushed and advanced with its plastic
stiffener over the wire into appropriate position. The wire and stiffener were
removed and the pigtail was formed. Contrast injection confirmed appropriate
positioning. The final image was saved. The catheter was then flushed, stay
sutures applied and the catheter was secured with a flexi track and sterile
dressings. The catheter was attached to a bag for drainage.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
## FINDINGS:
1. Initial right-sided to pulled back to skin
2. New 10 nephroureterostomy tube (modified to cut the distal pigtail)
placed into the collecting system and ureter.
## IMPRESSION:
Technically successful Right modified nephroureterostomy stent exchange.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12640988", "visit_id": "N/A", "time": "2185-09-04 15:52:00"} |
14067046-RR-22 | 97 | ## HISTORY:
male with fall, concern for fracture or pneumothorax.
## FINDINGS:
A single frontal supine view of the chest was obtained with patient
in collar. Chronic deformity of the fifth through seventh right ribs, and
slight rightward curvature of the spine are again noted. No evidence of acute
fracture is seen. There is no supine evidence of pneumothorax or large
pleural effusion. The heart size remains normal and the thoracic aorta
tortuous. Allowing for decreased lung volumes, the lungs appear grossly
clear.
## IMPRESSION:
Chronic deformity of several right ribs. No evidence of acute
fracture or pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14067046", "visit_id": "28234812", "time": "2130-01-22 08:07:00"} |
16546124-RR-19 | 242 | ## INDICATION:
Status post fall with altered mental status and back pain.
## CHEST:
There is no axillary, mediastinal, or hilar lymphadenopathy. The
heart and great vessels are unremarkable. There is no pericardial effusion.
The lungs are clear without consolidations or nodules. There is no pleural
effusion or pneumothorax. There is mild bibasilar atelectasis.
## ABDOMEN:
The liver is normal in shape and contour. There are no focal
masses. There is no intra- or extra-hepatic biliary ductal dilation. The
portal veins are patent. The gallbladder, spleen, pancreas, and adrenal
glands are unremarkable. In the right kidney, there is a 3.9 x 2.4 cm
hypodense round lesion most consistent with an uncomplicated cyst. The
kidneys are otherwise unremarkable without masses or hydronephrosis. The
small bowel is unremarkable. There is no mesenteric stranding or
lymphadenopathy. The abdominal vasculature is normal in course and caliber.
## PELVIS:
There is mild diverticulosis of the sigmoid colon without evidence of
diverticulitis. The colon is otherwise unremarkable. The appendix is
visualized and normal. There is a left inguinal hernia containing a portion
of the sigmoid colon, but there is no evidence of obstruction. Bladder and
prostate are unremarkable. There is no lymphadenopathy.
## OSSEOUS STRUCTURES:
No fracture is identified. There are no significant
degenerative changes of the spine.
## IMPRESSION:
1. Left inguinal hernia containing a small portion of the sigmoid colon, but
no evidence of obstruction.
2. Uncomplicated right renal cyst.
3. No evidence of acute traumatic injury.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16546124", "visit_id": "27752991", "time": "2156-09-13 09:58:00"} |
16359089-DS-5 | 1,431 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
year old male who is being transferred from for
reported acute onset right sided sensory motor changes, right
visual
field cut.
He recently underwent left inguinal hernia repair w/ small bowel
resection on for strangulated hernia who was readmitted
to with small bowel obstruction and left pelvic
hematoma. He underwent laparoscopy converted to open LOA with
seprafilm placement and wound vac on developed acute
right sided sensory and motor changes, right homonymous
hemianopia w/ NIHS of 8. CTH and CTA at with left
distal P2 cut off, so patient was transferred to for
possible thrombectomy. LNK 8AM on . NIHSS on arrival of 13.
Vitals notable for Temp 103, HR 135 sinus, SBP 162, FBG 165,
satting 97% on RA. Repeat imaging at showed more proximal
P2 cut off and 55 cc mismatch on CT perfusion. Not tPA candidate
due to recent surgery. CT abd/pelvis ordered due to fever and
recent surgery. He was started empirically on vanc/zosyn.
He underwent thrombectomy which was technically complicated and
resulted in ~10 minutes of basilar thrombosis with subsequent
R-PCA occlusion at P1, L-PCA at P2 w/ TICI 2a reperfusion, R-SCA
thrombus, and occluded Left vert. IA tPA was given during the
procedure to attempt to re-perfuse past these vessels. On
arrival to the NICU, the patient was intubated, off sedation,
and not following commands.
During his time in the ICU his exam unfortunately did not
improve significantly, and his family decided to pursue comfort
directed goals of care. He was made DNR/DNI, placed on CMO, and
kept comfortable throughout the remainder of his hospitalization
## PAST MEDICAL HISTORY:
HTN
BPH
Recent incarcerated inguinal hernia s/p resection
## FAMILY HISTORY:
Father had a stroke in his .
## LUNGS:
Intubated, coarse breath sounds b/l
## ABDOMEN:
Midline and inguinal surgical scarring with wound vac
in place
## EXT:
Pulses 2+ b/l, no edema
## NEURO:
MS- No EO to DNS. Does not follow commands, grimaces to pain.
CN- Pupils , round and reactive to light. Left eye is
dysconjugate with a downward positioning. No corneal on the
left. VORs are not robust b/l. +cough, +gag.
Sensory/Motor-
## RUE:
plegic to noxious, facial grimacing
## LUE:
plegic to noxious, facial grimacing
## RLE:
TF to DNS, some purposeful movement seen
## LLE:
TF to DNS, some purposeful movement seen
-Sensory: unable to assess
Plantar response toes down bilaterally
## DISCHARGE EXAM:
Lying comfortably in bed
## IMPRESSION:
1. There is evidence of left P2 segment occlusion with a
moderate to large
infarct in the left PCA distribution, involving the medial left
temporal lobe,
inferior left occipital lobe, and small infarct of the left
thalamus (22:40
, 53). Of note, the OLEA data significantly underestimates
the true
extent of the area of infarct.
2. There is an opacity of the right lower lobe of the lung,
likely
representing atelectasis versus pneumonia.
MRIStudy Date of 10:29
## IMPRESSION:
1. Acute/subacute infarcts involving the multiple portions of
the posterior
circulation.
2. Left vertebral artery occlusion with distal reconstitution
TTE
Suboptimal image quality. Right to left passage of agitated
saline at rest c/w atrial
septal defect or stretched foramen. Mild symmetric left
ventricular hypertrophy with normal cavity
size and regional/global biventricular systolic function.
Dilated aortic root. No valvular pathology
or pathologic flow identified. High normal pulmonary artery
systolic pressure.
DUP EXTEXT BIL (MAP/DVT) Study Date of 4:00
1. Nonocclusive deep vein thrombosis of the right posterior
tibial and
peroneal veins.
2. No evidence of deep vein thrombosis in the left lower
extremity.
CTH w/o contrast . Redemonstration of multiple areas of
hypodensity involving the upper cervical spinal cord, brainstem,
bilateral cerebellar hemispheres, medial left occipital lobe,
bilateral temporal lobes, bilateral thalami, corresponding to
evolution of acute multiple infarcts, better seen on recent MRI.
2. 2 small foci of hyperdensity in the left cerebellar
hemisphere could
represent tiny foci of hemorrhage transformation.
3. Stable protrusion of bilateral cerebellar peduncles through
the foramen
magnum and increased mass effect on the pons. No further mass
effect.
CTH w/o contrast . Evolving acute to subacute infarcts
involving multiple areas of the brain
and spinal cord as described above.
2. There is worsening compression of the aqueduct and fourth
ventricle
progressive hydrocephalus.
## BRIEF HOSPITAL COURSE:
year old left-handed man with history of HTN, BPH, and recent
incarcerated inguinal hernia s/p small bowel resection 2 weeks
ago c/b infection and SBO w/readmission to s/p ex
lap on w/wound vac in place. Transferred from for
acute onset right sided sensory motor changes, right visual
field cut. NIHSS was 12 on arrival. CTA w/ proximal P2 cut off.
55 cc mismatch on CT perfusion. He was not a tPA candidate due
to recent intraabdominal surgery. He was taken for thrombectomy.
Underwent thrombectomy, notable for confirmation of left-P2
occlusion and complicated by ~10 minutes of basilar thrombosis
with subsequent R-PCA occlusion at P1, L-PCA at P2 w/ TICI 2a
reperfusion, R-SCA thrombus, and occluded Left vert. IA tPA was
given during the procedure to attempt to re-perfuse past these
vessels. MRI following his thrombectomy showed infarcts of
multiple areas in the posterior circulation, most notably
significant involvement of b/l cerebellum, bilateral occipital
lobes, and L-thalamus. Further workup showed a resting ASD and a
RLE DVT, which seemed a plausible etiology of his infarct.
Family then decided to transition him to comfort measures only
on . He is being discharged to inpatient hospice .
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - () Not confirmed (x) No. If no, reason why: n/a, patient
comatose until CMO
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 31) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician (physician/APN/PA) or pharmacist
[x] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
() non-smoker - (x) 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 in written
form? () Yes - (x) No - CMO
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No. If no, why not? (I.e. patient at baseline
functional status) - CMO
9. Discharged on statin therapy? () Yes - (x) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician (physician/APN/PA) or pharmacist
[x] LDL-c less than 70 mg/dL - also CMO
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. Tamsulosin 0.4 mg PO QHS
## DISCHARGE MEDICATIONS:
1. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
2. LORazepam 0.5-2 mg IV Q4H:PRN anxiety
3. Metoprolol Tartrate 2.5-5 mg IV Q6H:PRN HR>130
4. Morphine Infusion Comfort Care Guidelines mg/hr IV
DRIP INFUSION
5. Morphine Sulfate mg IV Q15MIN:PRN moderate-severe pain
or respiratory distress
6. Scopolamine Patch 1 PTCH TD Q72H Duration: 72 Hours
## LEVEL OF CONSCIOUSNESS:
Lethargic and not arousable.
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You came to after having a stroke. We performed a
procedure to attempt to remove the blood clot causing your
stroke. Unfortunately, your symptoms worsened. Your family
decided that the best decision would be to make you comfortable.
Sincerely,
Your Neurology Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16359089", "visit_id": "23982922", "time": "2123-03-17 00:00:00"} |
11189676-RR-41 | 107 | ## INDICATION:
female with renal insufficiency, recent episode of
pulmonary edema, with persistent fever. Evaluate for pneumonia.
## FINDINGS:
Compared to most recent prior, there has been improvement in
pulmonary edema and decreased vascular congestion. Heart size is top normal.
Small bilateral pleural effusions are seen. There is a retrocardiac density
which may represent atelectasis, but could also be pneumonia. No pneumothorax
is seen.
## IMPRESSION:
1. Left basal atelectasis or pneumonia. Lateral view may be helpful to
better localize and evaluate this opacity.
2. Small bilateral pleural effusions and improved pulmonary edema.
These findings were reported to by Dr. by telephone at
11:45 a.m. on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11189676", "visit_id": "24260857", "time": "2137-01-20 10:39:00"} |
12440135-RR-33 | 120 | ## INDICATION:
man with fall on head. Trauma. Evaluate for
fracture.
## C-SPINE WITHOUT CONTRAST:
Cervical spine is visualized from the skull base
through T1. There is no pre-vertebral soft tissue swelling. No acute
fracture or dislocation is seen. There is posterior non-fusion of C1 which is
congenital. Again noted are multilevel degenerative changes, mostly between C4
through C6 and at the atlantodental interval. There are anterior osteophytes
at C4 through C6, without posterior osteophytes. There is straightening of
the cervical lordosis which could be a combination of degenerative changes,
muscle spasm and/or positional factors. The surrounding soft tissue
structures appear unremarkable. Carotid calcification is noted.
## IMPRESSION:
1. No fracture or malalignment.
2. Multilevel degenerative changes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12440135", "visit_id": "27443603", "time": "2171-03-08 17:54:00"} |
19713100-RR-315 | 731 | ## HISTORY:
Four days of epigastric pain, altered mental status.
## CTA OF THE CHEST:
There is no evidence of pulmonary embolism. Scattered
mediastinal lymphadenopathy such as a 12 mm subcarinal node (4A:54) and a 10
mm right paratracheal node (4A:33) are relatively unchanged. There is no
axillary or hilar lymphadenopathy by CT criteria. Thyroid gland appears
relatively unremarkable. The tracheobronchial tree is patent centrally.
There are small bilateral pleural effusions. There is also partial collapse
of left lower lobe. Scattered subsegmental atelectasis is noted on the right.
Respiratory motion contributes to scattered, non-specific ground-glass
opacities however there are no worrisome pulmonary opacities for infection.
The patient is status post CABG with an unchanged partially thrombosed
dilatation of a right bypass graft (4A:66), up to 1.8 cm. The graft, however,
is widely patent to its distal aspect. There is also an area of contrast
extending past the normal contours of the normal myocardium in the apex of the
left ventricle (4A:77). This represents thinning of the myocardium in this
area and suggests prior myocardial infarction, unchanged from the prior exam.
There are calcifications of the aortic valve as well as the native coronary
arteries.
## CTA OF THE AORTA:
While there are diffuse moderate to severe atherosclerotic
calcifications throughout the aorta and iliac arteries, there is no evidence
of aneurysmal dilatation. The ostia of the , SMA, celiac and renal
arteries demonstate atherosclerotic calcifications, but there is no evidence
of high grade flow-limiting stenosis. Mild to moderate narrowing at the take
off of the common hepatic artery is noted from the celiac.
## CT OF THE ABDOMEN:
The liver enhances homogeneously and there are no focal
liver lesions. The main portal vein is patent. The gallbladder contains
numerous hyperdense stones consistent with cholelithiasis, but there is no
evidence of pericholecystic fluid or gallbladder wall edema to suggest
cholecystitis. The pancreas is fatty replaced. Bilateral adrenal glands are
unremarkable. The spleen appears normal. The splenic vein is widely patent.
Once again demonstrated is a right upper pole 3.5 x 3.2 x 4.1 cm enhancing
renal mass, which is grossly unchanged in size since . A
hypodensity at the lower pole of the right kidney is compatible with a
previously ruptured cyst. The left kidney contains hypodensities compatible
with simple cysts but no worrisome lesions or evidence of hydronephrosis.
There are scattered mesenteric lymph nodes, but none which meet CT criteria
for enlargement.
There is no free fluid in the abdomen, nor free air. The small and large
bowel are normal in course and caliber. There are scattered minimal
diverticula but no evidence of diverticulosis.
## CT OF THE PELVIS:
The bladder wall is circumferentially thickened and
irregular and there is adjacent stranding (image 403), moreso than on the
prior exam. In addition, there is dilatation and urothelial thickening and
enhancement of the distal right ureter (377), new from prior and there is
evidence of periureteral stranding. The prostate remains enlarged.
The rectum itself is unremarkable. Presacral stranding is non-specific and
unchanged. The seminal vesicles appear unremarkable. There is no pelvic free
fluid or lymphadenopathy. Bilateral fat containing inguinal hernias, left
greater than right are noted.
## BONES:
There are no lytic or sclerotic lesions to suggest osseous metastases.
Multilevel degenerative changes are once again seen throughout the lumbar
spine with height loss of the L1 vertebral body. Grade I anterolisthesis of
L4 on L5 is similar to the prior studies. The patient is status post
laminectomy of the L3 to L5 levels.
## IMPRESSION:
1. Thick-walled and trabeculated bladder with surrounding inflammatory
changes as well as an enhancing thick-walled dilated right distal ureter.
These findings are consistent with an acute infection superimposed on the
chronic obstructive uropathy.
2. Small bilateral pleural effusions and partial collapse of the left lower
lobe.
3. Unchanged right upper pole renal mass concerning for a renal cell
carcinoma.
4. Status post CABG with unchanged aneurysmal dilatation and partial
thrombosis of a right bypass graft, but widely patent flow throughout the
graft. There is also evidence of left ventricular apical myocardial thinning
suggesting a prior myocardial infarction.
5. Diffuse aortic atherosclerotic calcifications but patent SMA, and
celiac arteries centrally. Mild to moderate narrowing at the take off of the
common hepatic artery, which is otherwise patent. No evidence of mesenteric
ischemia.
6. Cholelithiasis without evidence of cholecystitis.
7. No pulmonary embolism.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19713100", "visit_id": "24658213", "time": "2179-02-19 20:57:00"} |
17185904-RR-71 | 125 | ## HISTORY:
female with chronic pancreatitis and pseudocyst status
post subtotal pancreatectomy and Roux-en-Y jejunostomy, now with three days of
nausea and vomiting.
## STUDY:
Upright and supine abdominal radiographs.
## FINDINGS:
There is no free air. An air-fluid level in the stomach is noted.
On the supine view, an ovoid lucency likely represents that same gas in the
stomach supine. There are no dilated loops of bowel or air-fluid levels in
small bowel. Stool is noted throughout the right colon. The transverse colon
is distended with gas to the mid descending colon. Gas is seen in the rectum.
The lung bases are clear. The bones are unremarkable.
## IMPRESSION:
Nonspecific bowel gas pattern -- if clinical concern for
obstruction is high, recommend CT.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17185904", "visit_id": "N/A", "time": "2161-10-18 21:29:00"} |
12163533-RR-51 | 437 | ## EXAMINATION:
BILATERAL DIAGNOSTIC BREAST MRI WITH AND WITHOUT INTRAVENOUS
CONTRAST
## INDICATION:
woman diagnosed with grade 3 invasive ductal
carcinoma right breast with metastatic disease to right axillary lymph node
. Benign MR guided biopsy of non mass enhancement left breast . Patient is currently undergoing neoadjuvant chemotherapy and
presents for preoperative evaluation.
## RIGHT:
A T2 hyperintense HydroMARK clips is again seen within the upper outer
right breast mid depth (series 4, image 31) corresponding to biopsy proven
malignancy. There has been significant interval improvement in the previously
described irregular spiculated mass (series 100, image 131 and series 201,
image 195) currently measuring approximately 4.2 x 3.7 x 2.1 cm where
previously it measured 6.4 x 4.6 x 2.9 cm. It is overall less confluent than
on the prior examination. Previous identified spiculations extending toward
the skin have resolved. Previous distance between the anterior margin of the
mass in the nipple was approximately 1 cm and currently is 2.4 cm.
There has been significant interval improvement in right axillary
lymphadenopathy largest lymph node currently measuring 1.9 x 0.9 cm (series
200, image 190) where previously measured 2.4 x 1.3 cm. Biopsy clips again
seen along the anterior margin of this lymph node compatible with biopsy
proven metastatic disease. No significant residual infraclavicular or
internal mammary lymphadenopathy is present.
No new suspicious abnormalities identified in the right breast. Additional
scattered foci of enhancement and cysts are seen.
## LEFT:
Again seen is a 0.7 x 0.5 cm enhancing mass within the slightly upper
outer left breast posterior depth (series 200, image 91) which again appears
to have a fatty hilum on non fat saturation T1 weighted imaging suggestive of
a benign intramammary lymph node. Previously identified linear non mass
enhancement within the inner central posterior right breast is less prominent
on today's study (series 200, image 86). Artifact from biopsy clip seen
lateral to its anterior margin consistent with recent benign MR guided biopsy.
Additional scattered foci of enhancement in cysts are seen in the left breast.
There is no new suspicious enhancing mass, non-mass enhancement, unexplained
architectural distortion, nipple retraction or skin thickening. No axillary
or internal mammary lymphadenopathy is present.
## NON-BREAST:
Left chest wall port is noted within the upper inner left
breast/chest wall.
## IMPRESSION:
Significant interval improvement of biopsy proven right invasive ductal
carcinoma and right axillary lymphadenopathy as detailed above. No obvious
residual internal mammary or infraclavicular lymphadenopathy is identified.
## RECOMMENDATION(S):
Appropriate clinical management for patient's known
malignancy..
## FINAL ASSESSMENT BI-RADS:
6 Known Biopsy-Proven Malignancy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12163533", "visit_id": "N/A", "time": "2152-01-15 15:27:00"} |
14360487-RR-20 | 146 | ## HISTORY:
Recent cerebellar infarction, now presenting with right sensory
neglect and inability to ambulate.
## FINDINGS:
There is a new area of acute infarction involving the body of left caudate,
left putamen and posterior limb of left internal capsule. Multiple bilateral
subacute cerebellar infarcts involving the territory with a few foci of
susceptibility artifacts in the right cerebellum, suggesting possible
microhemorrhage are demonstrated. Bifrontal cystic encephalomalacia possibly
from prior contusions are demonstrated. Multiple foci of FLAIR
hyperintensities in the cerebral white matter, with confluent appearance in
the periventricular region suggesting moderate microangiopathic small vessel
disease is unchanged. Ventricles and sulcal configuration are prominent and
age-appropriate.
## IMPRESSION:
New acute infarction in the left body of caudate, putamen and posterior limb
of left internal capsular since the recent MR study from .
Multiple bilateral subacute infarcts in both cerebellum. Background of
moderate severe microangiopathic small vessel disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14360487", "visit_id": "22902129", "time": "2157-02-18 22:03:00"} |
19011714-RR-31 | 189 | RIGHT FOOT THREE VIEWS, AT 1757 HOURS.
## HISTORY:
Apparent left lower extremity vascular surgery and toe amputations,
now presenting with increased pain in right foot.
## FINDINGS:
There is marked soft tissue irregularity involving the distal first
and second digits and to a lesser severity the third digit. There is no
significant soft tissue covering the distal tuft of the second distal phalanx.
The overall appearance is concerning for gangrenous toe. There may be an
element of gangrene also involving the soft tissues of the distal great toe
and possibly the third digit as well. Focal osteopenia is seen along the
lateral aspect of the first distal tuft. No definite cortical disruption is
seen. No periosteal reaction noted. There are no underlying fractures. Mild
degenerative changes are seen at the first metatarsophalangeal joint.
Extensive vascular calcifications are seen. There is a prominent inferior
plantar spur.
## IMPRESSION:
Focal osteopenia in the lateral aspect of the first distal tuft.
Otherwise, no definite osteomyelitis. There are soft tissue findings
suggestive of gangrene involving the second toe and possibly the first and
third digits as well. Of note, no subcutaneous gas is evident.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19011714", "visit_id": "21207204", "time": "2117-04-15 17:55:00"} |
13744836-RR-19 | 101 | ## EXAMINATION:
ANKLE (AP, MORTISE AND LAT) RIGHT
## INDICATION:
year old woman with fall and ankle fracture// ? reduction. AP,
lateral and mortise views please ? reduction. AP, lateral and mortise
views please
## FINDINGS:
Overlying cast material limits evaluation. There is a Weber type B comminuted
distal fibular fracture with mild posterior displacement of the distal
fracture fragment. There is also mildly displaced fracture of the medial
malleolus and minimally displaced fracture of the posterior malleolus. No
priors are available to assess for interval change post reduction.
## IMPRESSION:
Trimalleolar fracture as described above. No priors available to assess for
changes after reduction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13744836", "visit_id": "26108048", "time": "2148-05-21 04:41:00"} |
16269826-RR-13 | 99 | ## EXAMINATION:
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
## INDICATION:
male status post fall. Evaluate for fractures.
## FINDINGS:
There is a comminuted nasal bone fracture (series 2:image 47, 40). There is
also bifrontal, left preorbital, left premaxillary and nasal soft tissue
swelling. The pterygoid plates are intact. There is no mandibular fracture,
and the temporomandibular joints are anatomically aligned. The orbits are
intact. The globes and extra-ocular muscles are unremarkable. There is no
retrobulbar hematoma. There is mild maxillary mucosal thickening.
## IMPRESSION:
Comminuted nasal bone fracture with bifrontal, left preorbital, premaxillary
and nasal soft tissue swelling.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16269826", "visit_id": "23825402", "time": "2131-11-26 17:15:00"} |
12615486-RR-25 | 97 | ## INDICATION:
Status post PICC removal. Please assess for retained PICC tip
and left central venous catheter.
## FINDINGS:
There is a central venous catheter projected over the left subclavian vein and
brachiocephalic vein, the tip of which is at the junction of the SVC and left
brachiocephalic veins. There is a nasogastric tube in situ. The right
central venous catheter has now been removed. No visualized residual
material related to the right PICC line is evident.
There is mild bibasilar atelectasis.
## IMPRESSION:
Left subclavian catheter in situ. No residual material related
to previous catheter is evident.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12615486", "visit_id": "22971263", "time": "2124-08-02 17:31:00"} |
14752184-RR-148 | 345 | ## INDICATION:
woman with pancreatic cancer, one month after
CyberKnife therapy.
## DOSAGE:
TOTAL DLP will be noted in the separate report of the CT of the
abdomen and pelvis performed concurrently.mGy-cm
## FINDINGS:
Supraclavicular and axillary lymph nodes are not pathologically enlarged.
Excluding the breasts, which require mammography for evaluation, there are no
soft tissue abnormalities in the chest wall suspicious for malignancy. A
central venous infusion port catheter ends in the low SVC, free of thrombosis
and the left pectoral soft tissue around the reservoir is normal.
Thyroid is unremarkable. Atherosclerotic calcification in head and neck
vessels is mild, but scattered in all the major coronaries. Aorta and
pulmonary arteries are normal size and aortic valve is free of calcification.
Pericardium is physiologic.
12 x 16 mm lymph node in the aortopulmonic window, probably bridging the
prevascular and lower paratracheal stations, 11: 118, was 14 x 18 mm in
. No other mediastinal lymph nodes are pathologically enlarged and
there is no diaphragmatic or retro crural adenopathy. 15 x 17 mm right hilar
nodal cluster is probably no larger than it was in . There could be
enlargement of the esophagus just above the gastroesophageal junction, 11:256,
or this could be enlarged lymph nodes surrounding the esophagus or even a
collapsed small hiatus hernia.
Wall thickening of peripheral bronchi in the lower lobes and some mucoid
impactions, most obvious in the posterior basal segment of the right lower
lobe, 11:232, and posterior and anterolateral basal segments of the left,
11:192 - 234, are new.
Punctate nodule right upper lobe, 11:73, is no larger than it was in .
There are no lung nodules concerning for metastasis.
There are no bone lesions in the chest cage suspicious for malignancy.
## IMPRESSION:
Mediastinal lymph node enlargement, limited to just the aortopulmonic window
is mild and unchanged, unlikely to be the site of solitary nodal metastasis in
the chest.
No pulmonary metastases.
New bibasilar bronchial inflammation could be infectious or allergic.
Possible the distal esophageal mass or periesophageal adenopathy. CT scanning
with oral contrast agent recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14752184", "visit_id": "N/A", "time": "2149-08-01 10:32:00"} |
13736287-DS-40 | 1,432 | ## CHIEF COMPLAINT:
chest pain and shortness of breath
## HISTORY OF PRESENT ILLNESS:
This is a year-old male with a history of atrial
fibrillation, hypertension, CHF (EF50%)obesity who presents for
increasing shortness of breath, lower extremity edema, and chest
pain starting last night. The chest pain occured at approx
prior to admission while the patient was laying down. The
patient describes pain as sharp, , L-sided, radiating to
left arm, and associated with numbness in the upper L arm and
pain in the lower L arm and hand. Not worsened/relieved with
anything and is constant. Was not relieved by any medications in
the ED. No nausea, dizziness or diaphoresis. The patient has
noted that over the last weeks he has felt increasingly
tired and weak. He has felt more short of breath during this
time period as well. He frequently falls asleep or maybe 'passes
out' according to his partner. On one occasion 2 months ago the
patient had a syncopal episode which he cannot recall clearly
(he refused medical treatment). He hit his R arm and R abdomen
but does not recall hitting his head. He doesnt remember having
any palpitations, dizziness prior to the fall. The patient has
also noted a decrease in his ability to be intimate with his
partner, because he is always tired. He also reports burning
with urination, on and off, for about 2 weeks (has not taken
anything for it). His appetite has been poor for the last 3
days, with some intermittent vomiting after he eats. Patient
took additional 80mg PO lasix at home without effect, which
usually works for his 'CHF flares'. He has not been getting
regular medical care last months; his PCP passed away and he
has not followed-up with anyone else.
At home he uses a walker to get around his small apartment and
uses a wheelchair for further distances. His usual weight is
220lbs but he feels he has gained weight, although his diet and
medications have not changed (he is compliant with a low salt
diet and no red meat).
.
In the ED, initial vitals were T: HR: 80-130s BP: RR:
## O2SAT:
98.2, 88 - 95, 132/76, 94% on 4L. Patient received 2 SL
NTG, ASA, 80mg lasix IV (put out up to 5L), 8mg morphine, 1mg
dilaudid and was admitted for further evaluation and management.
With NTG breathing improved but CP persisted. Given po
metoprolol and 10mg IV diltiazem with HR improving to .
## CV:
-CHF (LVEF>47% by mibi
-normal coronaries on cath
-Chronic AF
obesity
HTN
Pulmonary HTN
Schizotypal Personality Disorder
H/O LGIB
Impotence
OSA
Venous stasis
S/P Appy (Age
Depression
H/O Domestic Abuse
Hyperlipidemia
Iron Deficiency Anemia
Eczema
## FAMILY HISTORY:
Mother died age from CHF. Father died at age from prostate
cancer.
## GEN:
Obese male in NAD, appearing fatigued. Oriented x3.
## HEENT:
NCAT. Sclera anicteric. ?exophthalmos, pupils equal but
pinpoint and sluggish, EOMI. Conjunctiva were pink. No
xanthalesma.
## NECK:
Supple, no LAD, JVD not appreciated (JVP ~8cm).
## CV:
Irreg rhythm w/rate in on palp, distant heart sounds,
m/r/g not appreciated, No thrills, lifts. No carotid bruits.
## CHEST:
Scant wheezes bilaterally, good air movement with no
crackles, rhonchi.
## ABD:
Obese but soft,slightly TTP over suprapubic area. Small
ecchymoses in RLQ. No HSM or tenderness.
## EXT:
Chronic venous and arterial stasis changes. 1+dp pulses
bilaterally. Nonpitting bipedal edema.
## SKIN:
4cm lipoma on posterior neck, moveable. Small scab on
medial R lower leg.
## #. CAD:
3 sets of cardiac enzymes were at baseline and EKG was
unchanged from previous on admission. His home regimen of
metoprolol, aspirin and lisinopril were continued. Initially he
continued to have chest pain despite interventions with NTG,
morphine, toradol, and ativan. However they subsided by the end
of his admission, without further intervention.
.
#. Pump: 80mg IV lasix in the ED yielded approximately 6L of
urine output which improved the patients dyspnea. He was
diuresed with IV lasix and put on fluid restriction and low
sodium diet. Work-up for infectious cause of CHF exacerbation
was negative. It is likely the patient's dyspnea is a
multifactorial process, including underlying pulmonary
hypertension, obstructive sleep apnea, deconditioning and fluid
overload. The patient's symptoms improved with diuresis, however
he still experienced shortness of breath with activity (he was
92-93%RA per evaluation). The patient was sent home with
bumex, in hopes that this would lead to better absorption of
diuretic (given home lasix was not working for some time).
with cardiology was scheduled for further management
of his heart failure and an outpatient sleep study was
scheduled.
.
#. Rhythm: Atrial fibrillation was controlled with metoprolol
which was increased from the patient's home dose with good
response. Coumadin was held on admission given INR of 5.0 and
restarted at 2.5mg once INR was below 3. will be set up to
assist with INR checks and clinic if needed.
.
#. Abdominal pain: Final CT A/P report was negative for any
active process or pathology. UA,GC/chlamydia, hepatitis, HIV
tests were all negative. The etiology of the pain was still
unclear at the time of discharge, at which point the discomfort
had subsided without any intervention. also expressed
interest in seeing if anything should be done about his
umbilical hernia, once he is discharged home. He felt this may
be the cause of his pain.
.
#Weakness/Fatigue: Endocrine labs were ordered to rule out
hypothyroidism, , hypogonadism, iron and B12
deficiency. Testosterone was very low and FSH slightly increased
indicating hypogonadism. Testosterone therapy was not initiated
during this admission given patient's dyspnea, and OSA being a
contraindicated for testosterone therapy due to respiratory
depression. Endocrine was scheduled to further work-up
of his fatigue and low testosterone levels and initiate therapy
when appropriate.
.
#Social: Patient expressed issues with his partner which has
caused him a great deal of distress. He denied physical abuse
but did acknowledge financial and emotional abuse. Social work
was consulted for support and to offer resources for the
patient.
.
:
- clinic for CHF
- clinic for low testosterone
-HCA number was offered for scheduling PCP services, home
## MEDICATIONS ON ADMISSION:
Lasix 80mg po bid
ASA EC 325mg po qd
Iron 325mg po tid
Metoprolol 25mg po bid
lisinopril 10mg po qd
lipitor 40mg po qd
coumadin 7.5mg po qhs
Potassium 20mEq bid
## DISCHARGE MEDICATIONS:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Bumex 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Bumex 1 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1
doses.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*1*
## DISCHARGE DIAGNOSIS:
heart failure
obstructive sleep apnea
atrial fibrillation
hypertension
## DISCHARGE INSTRUCTIONS:
You were admitted for chest pain and weakness. Your cardiac
enzymes were negative indicating you did not have a heart
attack. You were treated with lasix for your heart failure. You
were also in atrial fibrillation (abnormal heart rhythm)which
was treated with metoprolol and diltiazem.
You were found to have low testosterone levels and have been
scheduled for in clinic. You also have
been scheduled for a sleep study to evaluate for obstructive
sleep apnea. Additionally, please call the HCA number to
schedule an appointment with a primary care provider.
Please weigh yourself every morning and call your doctor if you
have gained more than > 3 lbs.
Please try to limit your salt intake to 2 gm of sodium a day,
and your fluid intake to 1.5L a day.
If you experience increasing chest pain, shortness of breath,
dizziness, lightheadedness, fainting, increasing weakness or
fatigue, please contact your doctor or return to the emergency
room.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13736287", "visit_id": "21383011", "time": "2131-06-28 00:00:00"} |
15054299-RR-28 | 371 | ## HISTORY:
Recent lithotripsy, now with fever and right-sided flank pain.
Previously seen perinephric hematoma.
## FINDINGS:
Heart size is top normal with trace physiologic pericardial fluid.
There is a small right pleural effusion with adjacent linear atelectasis.
## CT ABDOMEN WITHOUT CONTRAST:
Evaluation of the solid organs is limited on
this non-contrast study. The liver, spleen, pancreas and adrenal glands are
grossly unremarkable. The gallbladder is absent with surgical clips in place.
A 13.9 x 13.6 cm retroperitoneal perinephric hematoma is overall not
significantly changed in size compared to exam from three days prior and the
hematoma again displaces the kidney anteriorly. Hematoma once again extends
across the midline and has minimally evolved in appearance. Overall, the only
significant change compared to prior study is that hyperdense blood product is
no longer seen within the right-sided renal collecting system. Again several
residual stones are seen in the right-sided collecting system measuring up to
7 mm. A tiny 3-mm calculus within the right proximal ureter remains.
Double-J ureteral stent remains in place with the exception of a 6.5 cm left
interpolar renal cyst, the left kidney is grossly unremarkable.
The stomach, small and large bowel is grossly unremarkable, without evidence
of obstruction. Few diverticula are seen particularly along the sigmoid
colon.
The abdominal aorta is normal in caliber. There is no mesenteric or
retroperitoneal lymphadenopathy. There is no pneumoperitoneum.
## CT PELVIS WITHOUT CONTRAST:
The bladder, prostate and rectum are grossly
unremarkable. Upper portion of the left testicle is seen within the left
inguinal canal. There is no free pelvic fluid or air. There is no inguinal
or pelvic sidewall adenopathy by CT size criterion.
## OSSEOUS STRUCTURES:
There are no focal blastic or lytic lesions in the
visualized osseous structures concerning for malignancy. There are mild
multilevel degenerative changes of the lumbar spine.
## IMPRESSION:
1. A 13.9 x 13.6 cm right-sided perinephric hematoma is unchanged in size
compared to . The only significant change is that blood and air within
the right-sided collecting system has resolved.
2. Residual calculi within the right collecting system measuring up to 7 mm
as well as a 3-mm residual stone within the proximal ureter.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15054299", "visit_id": "20473679", "time": "2112-10-22 07:58:00"} |
15152711-RR-34 | 96 | ## EXAMINATION:
CHEST (PA AND LAT)
## INDICATION:
F Childs B-C alcohol cirrhosis c/b refractory ascites s/p
TIPS , SPB, HE, varices, and likely hepatopulmonary syndrome, Budd
Chiari on Coumadin, recent discharge after admission with hepatic
hydrothorax, who is being transferred from with hypercalcemia //
Eval for edema, consolidation
## FINDINGS:
Chronic right rib fractures. Small right pleural effusion is new. There is
minimal right basilar atelectasis. Heart size, pulmonary vascularity at the
upper limits of normal, more prominent. No edema. Left lung is clear. No
pneumothorax.
## IMPRESSION:
Small right pleural effusion, minimal right basilar atelectasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15152711", "visit_id": "26366755", "time": "2118-07-21 17:06:00"} |
12053638-RR-85 | 180 | ## HISTORY:
Left lower quadrant pain.
## LMP:
The uterus measures 9.0 x 4.0 x 5.8 cm. A fundal fibroid is noted, measuring
2.7 x 2.7 x 2.8 cm, increased in size from prior exam. The endometrium is
homogeneous and measures 7 mm. The right ovary measures 3.7 x 1.4 x 1.7 cm
and the left ovary measures 4.1 x 3.0 x 3.2 cm. There is a rounded lesion in
the left ovary measuring 3.0 x 3.0 x 3.0 cm, with intermediate internal
echogenicity but demonstrates no internal vascularity, likely representing a
hemorrhagic corpus luteum or possibly an endometrioma. Arterial and venous
waveforms are seen in the bilateral ovaries. There is no free fluid.
## IMPRESSION:
1. Normal ovarian size and arterial and venous blood flow bilaterally. No
sonographic evidence of torsion.
2. Rounded intermediate-echogenicity lesion in the left ovary, likely
representing a collapsed/hemorrhagic corpus luteum, less likely an
endometrioma. Repeat ultrasound in 6 weeks could be performed to ensure
resolution.
3. Fibroid uterus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12053638", "visit_id": "N/A", "time": "2160-07-21 12:02:00"} |
14006414-RR-34 | 389 | ## EXAMINATION:
CTA HEAD AND CTA NECK Q16 CT NECK
## INDICATION:
year old woman with high grade SAH// evaluate for vasospasm
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 4.8 s, 37.5 cm; CTDIvol = 11.4 mGy (Body) DLP = 426.6
mGy-cm.
3) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.7 mGy (Body) DLP =
6.4 mGy-cm.
Total DLP (Body) = 433 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
## CT HEAD WITHOUT CONTRAST:
There has been expected evolution of diffuse subarachnoid hemorrhage. There
has been interval enlargement of the lateral ventricles as well as the third
ventricle suggestive of obstructive hydrocephalus. Blood is again seen
layering in the occipital horns of bilateral lateral ventricles. A right
frontal ventriculostomy catheter terminates in the right lateral ventricle.
There is no evidence of new hemorrhage. There is fluid layering in the
sphenoid sinus, similar to prior. Otherwise the visualized paranasal sinuses
and mastoid air cells are clear.
## CTA HEAD:
Status post coiling of a right aneurysm. There is increased narrowing of
the basilar artery and bilateral intracranial vertebral arteries, moderate to
severe in severity and worse compared to prior exam. Otherwise, there is
mild-to-moderate diffuse narrowing of the remaining intracranial vessels and
the vessels of the circle of suggestive of diffuse vasospasm, similar
to prior exam. There is no evidence of occlusion. The dural venous sinuses
appear patent.
## CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
## OTHER:
There are new patchy ground-glass opacities particularly in the superior
imaged portion of the left lower lobe... The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
## IMPRESSION:
1. Interval enlargement of the lateral and third pedicle suggestive of
obstructive hydrocephalus.
2. Interval increased narrowing of the basilar artery suggestive of worsening
vasospasm. Otherwise, stable mild to moderate diffuse narrowing of the
intracranial vessels again suggesting diffuse vasospasm.
3.
## NOTIFICATION:
The findings were discussed with , N.P. by
, M.D. on the telephone on at 4:00 pm, 10 minutes after
discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14006414", "visit_id": "23638506", "time": "2187-03-31 13:45:00"} |
16573603-RR-49 | 93 | ## INDICATION:
year old man with new picc// right basilic 48cm picc, ? tip
position Contact name: :
## FINDINGS:
Interval placement of a right PICC line, the tip projecting over the distal
SVC. Two right-sided chest tubes are again noted.
Persisting, but decreased opacification of the right hemithorax. A small
right hydropneumothorax is likely present. The left lung is clear. The
appearance of the cardiac silhouette is unchanged.
## IMPRESSION:
Interval placement of a right PICC line whose tip projects over the distal
SVC. Probable small right hydropneumothorax with two chest tubes in place.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16573603", "visit_id": "27576354", "time": "2119-04-21 17:57:00"} |
Subsets and Splits