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19123001-RR-84 | 84 | ## HISTORY:
Fall and head injury.
## FINDINGS:
No acute fracture or vertebral malalignment is seen. There is no
prevertebral soft tissue swelling. There is exaggeration of the normal
cervical lordosis, similar to prior exam. Multilevel degenerative changes are
seen throughout the C-spine, with facet joint and uncovertebral joint
hypertrophy, similar to prior exam. The vertebral body and disc heights are
maintained. No lymphadenopathy is present by CT size criteria. The
visualized lung apices are clear.
## IMPRESSION:
No acute fracture or vertebral malalignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19123001", "visit_id": "N/A", "time": "2148-05-08 17:58:00"} |
15682570-DS-20 | 2,054 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
y/o M with CAD, chronic L. hip pain presents after fall this
morning. Patient reports dizziness (room spinning)
intermittently with standing x4 days, resolved with sitting down
and drinking water. This morning, got out of bed to go to the
bathroom. He states that after a few steps, he felt the room
began to spin. He reached out looking for something to hold
himself up, but was unable to find anything to grab hold of. He
fell to the floor on his right side and struck his head on the
floor. Denies LOC, CP, SOB, headache, visual changes. The
patient has chronic right-sided hip pain and was unable to stand
after the fall.
.
In the ED, initial vs: 97.2 68 174/98 18 99% RA. The patient
underwent CT Sinus/Mandible/Maxillofacial W/O Contrast that
showed non-displaced fracture of the right lamina paprycea. He
was evaluated by facial plastics, who felt that the fracture
repair is non-urgent, as there is no evidence of extraoccular
muscle entrapment. Facial laceration repaired. He was
recommended for outpatient followup in days for
reevaluation after swelling has resolved. He was also found to
have a clavicle fracture. CT head and C. spine negative for
acute change. For fall workup, the patient underwent
orthostatics: laying 151/71, sitting 139/76, standing 141/77.
## EKG:
V-paced at 60bpm, unchanged since . Troponin x 2 <
0.01. The patient was evaluated by physical therapy, who felt
he was safe to discharge home. However, given fall hard/sudden
enough for facial fracture, the patient was admitted to medicine
for further syncope workup.
.
Currently, the patient feels well. He complains of chronic
right hip pain (did not have time to put on daily lidocaine
patch today due to fall). Has mild pain at site of right
clavicular fracture.
.
## ROS:
+ diarrhea x 4 days - , no N/V/abd pain/bloody
stool.
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, dysuria, hematuria.
## PAST MEDICAL HISTORY:
- CAD s/p MI/CABG ( : LIMA-LAD, SVG-D1, SVG-RI; EF
40-45%)
- POBA LCx .
- Current tobacco and alcohol abuse. ppd cigarettes.
- Mobitz II AV block s/p Sigma dual-chamber PPM .
- 3+ MR
- Dyslipidemia
3. OTHER PAST MEDICAL HISTORY:
- prostate cancer s/p retropubic prostatectomy
- bladder neck contracture s/p incision and dilation
- chronic left hip pain
- CERVICAL RADICULOPATHY (right hand)
- s/p slipped disc repair in
- s/p right hand surgery in (remove glass)
## FAMILY HISTORY:
Parents with CAD in and . Brother with CAD in .
Sister with stroke and diabetes, deceased.
## ADMISSION PHYSICAL EXAM:
VS - Temp 99.1 F, BP 149/80, HR 88, R 20, O2-sat 95% RA
GENERAL - elderly man with edema around right eye; comfortable,
appropriate
HEENT - PERRLA, EOMI, boggy edema in right inferior eyelid;
bandage above right eye; sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh
HEART - 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 - evidence of macular chronic rash on back
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
throughout, sensation grossly intact throughout
.
## VS:
T98.8 138/62 58 18 100%RA
GENERAL - elderly man; comfortable, appropriate
HEENT - PERRLA, EOMI, ecchymosis surrounding right eye with mild
crusting around eyelid; bandage above right eye; sclerae
anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh
HEART - bradycardic, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - bilateral hips mildly tender to palpation, ext
WWP, no edema, 2+ peripheral pulses (radials, DPs)
SKIN - evidence of macular chronic rash on back
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
throughout, sensation grossly intact throughout
## IMAGING:
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT:
There is a
non-displaced fracture of the distal right clavicle. The
glenohumeral joint is within normal anatomic alignment. A
left-sided
pacer and sternotomy wires are noted.
.
## CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST:
1. Medial blowout
fracture of the right orbital wall with the right medial rectus
muscle abutting a fracture fragment.
2. Hematoma overlying right zygoma without underlying fracture.
.
## CT C-SPINE WITHOUT CONTRAST:
There is no acute fracture or
subluxation. There has been reversal of the normal cervical
lordosis. There are multilevel degenerative changes marked by
anterior osteophytosis and facet arthropathy, most pronounced at
C4-5 through C5-6. Spinal canal is grossly patent. There is no
pre vertebral soft tissue swelling. There is minimal apical
scarring seen within the left lung. Calcifications are seen at
the carotid bifurcations.
.
## CT HEAD WITHOUT CONTRAST:
There is no acute hemorrhage, edema
or shift of normally midline structures. Slight prominence of
the ventricles and sulci is compatible with age-related atrophy.
A cavum septum pellucidum et vergae is noted. Hypodensities
seen with the right caudate are likely prior lacunar infarcts.
There is no fracture. There is mild ethmoidal mucosal
thickening, otherwise, the visualized paranasal sinuses and
mastoid air cells are well aerated. A soft tissue hematoma is
seen overlying the right zygoma and occipital bone without
underlying fracture. Facial bones are better evaluated on
concurrent sinus CT.
## BRIEF HOSPITAL COURSE:
year old man with history of coronary artery disease and
chronic left hip pain admitted for syncope workup after fall
resulting in facial and clavicular fracture.
.
# s/p fall: Patient presented with a fall resulting in facial
and clavicular fracture. He denies loss of consciousness, but
was unable to catch himself on time to break fall. Orthostatics
were negative. CT head negative for acute process. EKG with
ventricular paced rhythm, unchanged from baseline. Telemetry
without evidence of tachyarrhythmia. During episodes of
dizziness, patient did have sensation of room spinning, making
vertigo possible source of fall. The patient was evaluated by
physical therapy in the emergency department, who cleared him
for discharge home. He will undergo a home safety evaluation
with on discharge.
.
# Facial fracture: Patient seen by facial plastic surgery in the
emergency department for blowout fracture of right lamina
papyracea. In the ED, he underwent superficial wound repair to
a laceration superior to his right eye. Per plastic surgery,
patient does not require acute fracture repair given absence of
ocular involvement and degree of edema. He will follow up with
plastic surgery (Chief Resident Dr. as an
outpatient 1 week following discharge.
.
# Right clavicular fracture - Patient noted on imaging to
sustain a right clavicular fracture during his fall. He was
recommended for non-operative management. The patient should
continue to use a sling for arm support while healing. He will
be provided home occupational therapy given decreased mobility
of right arm.
.
# history of CAD: Known CAD s/p MI/CABG and POBA
LCx . Last cath showed 50% distal LMCA,
90% proximal LAD, 90% serial stenoses in ostial and mid LCx, 90%
RCA. LIMA - LAD graft is patent. SVG - OM - diag graft is
patent. The patient was ruled out for myocardial infarction on
admission. No evidence of tachyarrhythmia on telemetry. The
patient was continued on home ASA, statin, metoprolol,
lisinopril throughout admission.
.
# Chronic systolic CHF: Known chronic systolic heart failure,
EF 40-45% with 3+ mitral regurgitation at last TTE . No
sign of volume overload on exam. The patient was continued on
home cardiac medications as above.
.
# Arrhythmia: Patient has pacemaker due to history of Mobitz II
AV block that progressed to complete heart block. Now
Ventricular-paced since , without acute events on telemetry
throughout admission. EKG unchanged from baseline.
.
# Hip pain: Chronic. Per primary care notes and X-rays likely
chronic osteoarthritis combined with musculoskeletal pain. The
patient was continued on home lidocaine patches and
acetaminophen as needed for breakthrough pain.
.
# Cervical radiculopathy: Chronic. The patient was continued
on home gabapentin.
.
# GERD: Chronic. Continued home omeprazole.
.
# COPD: Chronic. Continued home ipratropium nebs.
.
# Social issues: Patient with poor self-care per daughter. Has
housekeeper that comes to clean 1x per week. Meals cooked by
elder services, but patient does not eat them. Patient will no
longer have prescription insurance as of , as daughter called
to cancel it due to dissatisfaction. The patient was evaluated
by social work on admission. He was discharged to home with
physical therapy and occupational therapy. He will have a home
safety evaluation on discharge. The patient was also
recommended to follow up with cognitive neurology on discharge,
as he has difficulty with calculations. The patient's daughter
was provided resources to obtain new insurance.
.
# CODE: Full code (confirmed)
.
# CONTACT: Patient, daughter ( )
===============================
## TRANSITIONAL ISSUES:
# Patient to follow up with plastic surgery 1 week following
discharge
## MEDICATIONS ON ADMISSION:
- gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
- ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours.
- lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
- metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
- nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual Q5min as needed for chest pain: 1 tab every 5 minutes
until chest pain resolves, up to 3 tabs.
- omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
- simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
- aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
## DISCHARGE MEDICATIONS:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
2. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
Disp:*2 inhaler* Refills:*0*
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed for as needed for pain.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily):
apply
to hips bilaterally.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5 minutes x 3 as needed for chest pain: use 1 every
5 minutes for 3 doses as needed for chest pain.
Disp:*12 tablets* Refills:*0*
10. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
## PRIMARY DIAGNOSIS:
Fall, lamina paprycea fracture, right
clavicular fracture
secondary diagnosis: history of coronary artery disease,
chronic systolic heart failure
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (cane).
## DISCHARGE INSTRUCTIONS:
Mr. ,
.
You were admitted to the hospital after a fall. During the fall
you broke a bone around your eye, and the right side of your
collar bone. You were seen by plastic surgery, who sewed your
wound. You should follow up with plastic surgery as below.
During your hospitalization, you were evaluated for causes of a
fall. You likely have vertigo, as you felt the room spinning
prior to your fall.
.
You were also evaluated for home services during your
hospitalization. You were cleared by physical therapy. You
were seen by the occupational therapists and by social work.
Occupational therapy found you safe to return home. However,
they recommended outpatient follow-up with a cognitive
neurologist as you have some difficulty performing calculations.
You will undergo a home safety evaluation with .
.
You were discharged to home. Weigh yourself every morning, call
MD if weight goes up more than 3 lbs.
.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15682570", "visit_id": "29441729", "time": "2154-05-07 00:00:00"} |
10858943-RR-21 | 130 | ## EXAMINATION:
CHEST PORT. LINE PLACEMENT
## INDICATION:
year old man s/p AVR/CABG// Fast track early extubation
cardiac surgery.
## FINDINGS:
Endotracheal tube terminates approximately 5 cm above the level of the carina.
Right IJ Swan-Ganz catheter coils within the pulmonary artery and terminates
within the left pulmonary artery. Left-sided chest tube projects over the
left hemithorax. Mediastinal drains are in appropriate position. Sternal
cerclage wires are intact and aligned. Aortic valve repair devices in
appropriate position. Surgical clips are seen projecting over the left
hemithorax. Lung volumes are decreased. Cardiomediastinal silhouette is
unchanged. No acute focal consolidation. Small left pleural effusion with
associated basilar atelectasis. No pneumothorax.
## IMPRESSION:
1. Stable postoperative changes with intact support lines and tubes.
2. Small left pleural effusion with associated atelectasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10858943", "visit_id": "23401687", "time": "2165-06-22 14:10:00"} |
14584438-RR-33 | 348 | ## PROCEDURE:
CT chest with contrast.
## REASON FOR EXAM:
, intubated on ventilator. Evaluate for mass
progression.
## FINDINGS:
The right paramediastinum soft tissue mass which extends into the
central mediastinum is grossly unchanged in size and is difficult to
accurately measure due to adjacent collapse of the right upper lobe. The
overall including the collapsed right upper lobe and soft tissue
component are 63 x 49 mm at the upper border of the thoracic aorta which is
unchanged allowing for technical differences. The mass extends inferiorly
circumferentially encases the right main stem bronchus from the carina and the
right main pulmonary artery and veins.
A new stent in the right main pulmonary artery is 1 cm distal to the ostium.
The ostium of the right main stem bronchus is slightly narrowed at 4.4 mm
Compression of the superior vena cava has increased since the previous study
and is now slit- like which contains a central venous catheter. Also new is
diffuse extensive thrombus within the central veins which is discontinuous and
extends along the subclavian veins bilaterally with near complete occlusion of
the brachiocephalic veins. Extensive venous collateralization via the
subcutaneous tissues of the breast, periscapular and azygous system.
A large right pleural effusion is unchanged with compressive atelectasis in
the right lower lobe.
There is new near-complete collapse of the left lower lobe. Sub-2-mm nodules
in the left upper lobe are unchanged since the previous study and mild
centrilobular emphysema is stable. Limited view of the upper abdomen is
unremarkable.
Severe thoracolumbar scoliosis unchanged. No new destructive or sclerotic
bone lesions.
## IMPRESSION:
1. No overall change in size of the mediastinal and paramediastinal soft
tissue mass.
2. New stent in the right main stem bronchus with mild narrowing of the
unstented proximal first centimeter from the ostium.
3. Stable large right pleural effusion and right upper lobe collapse.
4. New left lower lobe collapse.
5. Increased mass effect on the SVC which is slit-like and new central venous
thrombosis which extends along the subclavian veins bilaterally.
The case was discussed with Dr. .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14584438", "visit_id": "25918253", "time": "2111-01-15 12:45:00"} |
14975731-RR-12 | 107 | ## INDICATION:
man with large thyroid gland.
## FINDINGS:
The right thyroid measures 4.8 x 2.1 x 2.2 cm. The left thyroid
measures 1.5 x 1.7 x 4.4 cm. The gland is homogeneous with two small nodules.
One heterogeneous somewhat cystic nodule in the right lobe measures 1.3 x 0.8
x 1.2 cm. A tiny hypoechoic nodule is seen in the left lobe, which measures
0.3 x 0.4 x 0.4 cm.
## IMPRESSION:
Two small thyroid nodules, the largest of which is 1.3 cm in the
right lobe. Followup ultrasound in one year is recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14975731", "visit_id": "N/A", "time": "2121-10-24 08:26:00"} |
12189596-RR-18 | 461 | ## INDICATION:
, with low back pain, left leg pain and numbness,to
evaluate for cord compression.
## FINDINGS:
The numbering used for the present study is shown on series 2, image 8 for the
thoracic spine and series 9, image 10 for the lumbar spine.
## MR OF THE THORACIC SPINE:
On the count series, multilevel mild disc desiccation is noted in the cervical
spine.
The thoracic vertebral bodies are normal in height, signal intensity and
alignment.
Small anterior osteophytes are noted at T3-T4 level. Minimal endplate changes
are noted at T10 level.
Mild ligamentum flavum thickening and facet degenerative changes are noted at
multiple levels, indenting the posterior aspect of the thecal sac.
Disc desiccation is noted at multiple levels. No disc herniation into the
spinal canal is noted.
No compression on the cord.
## MR OF THE LUMBAR SPINE:
Lumbar vertebral bodies are normal in height, signal intensity and alignment.
Endplate irregularity and disc desiccation is noted at multiple levels.
At L1-2, mild diffuse bulge along with ligamentum flavum thickening and facet
changes are noted, indenting the posterior aspect of the thecal sac and the
nerves in the thecal sac.
## AT L2-L3:
Mild diffuse disc bulge along with a small focal annular tear, no
canal or foraminal stenosis.
## AT L3-L4:
Narrowing of the disc space, disc desiccation, diffuse disc bulge
along with a small focal left paracentral protrusion indenting the thecal sac.
Facet degenerative changes are also noted on both sides, with mild foraminal
narrowing. Minimal type 1 changes are noted at L3 posteroinferiorly.
## AT L4-5:
Narrowing of the disc space, disc desiccation and diffuse disc bulge
along with bilateral facet degenerative changes seen to result in moderate
foraminal narrowing with the facet osteophytes abutting the L4 nerves. The
disc protrusion is seen to abut the left L4 nerve at the root entry zone.
## AT L5-S1:
Degenerative changes in the discs and facets, with moderate
foraminal narrowing on both sides with deformity on the L5 nerves.
The spinal cord ends at L1 level. The nerves in the thecal sac are
unremarkable.
No pre- or para-vertebral soft tissue swelling or masses are noted.
## IMPRESSION:
1. Multilevel, multifactorial degenerative changes in the cervical, thoracic,
and lumbar spine as described above. No cord compression.
2. Multilevel facet degenerative changes.
## AT L3-4:
Diffuse disc bulge along with a focal left paracentral disc
protrusion with endplate changes seen indenting the ventral thecal sac and
abutting the left L4 nerve with mild deformity. Foraminal narrowing at
multiple levels in the lower lumbar spine as described above, abutting the
nerves in the foramina. Other details as above.
Osseous details can be better assessed with PXR/CT if necessary.
Wet read was entered on the ED dashboard, soon after the study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12189596", "visit_id": "20409718", "time": "2149-12-13 13:17:00"} |
11580750-RR-22 | 301 | CT CHEST WITHOUT CONTRAST
## INDICATION:
male with febrile neutropenia. Please evaluate for
infectious/fungal pneumonia.
## FINDINGS:
The right subclavian Port-A-Cath terminates in the distal SVC.
## MEDIASTINUM:
The thyroid gland demonstrates homogeneous attenuation without
focal lesions. No supraclavicular or axillary lymphadenopathy. No
mediastinal or retrocrural lymphadenopathy. Small mediastinal lymph nodes do
not meet CT criteria for pathologic enlargement. The largest of these
measures 5 mm on short axis. Evaluation of hilar lymph nodes is limited due
to absence of IV contrast. Heart size is within normal limits. There is mild
hypoattenuation of the blood pool in the ventricular chambers relative to the
ventricular muscular wall and septum, raising the consideration for anemia.
Coronary artery stents are noted. The thoracic aorta is normal caliber
without significant atherosclerosis. There is a small hiatal hernia.
## LUNGS AND PLEURA:
Minimal patchy bibasilar and lingular subsegmental
atelectasis. Previously described patchy consolidation in the left upper lobe
has resolved. No pulmonary nodule, mass, or confluent consolidation. No
pleural effusions or pneumothorax.
## ABDOMEN:
Small hiatal hernia. Hypodensity in the right hepatic lobe is
stable since the exam of and most likely represents a cyst,
however, is too small to characterize. A larger hypodensity in the segment VI
of the right hepatic lobe measures fluid attenuation and is most compatible
with a cyst. Hyperattenuation within the gallbladder may represent sludge. The
remaining visible upper abdominal organs are normal.
## BONES AND SOFT TISSUES:
Degenerative arthrosis of the acromioclavicular
joints. No acute fracture or destructive osseous process. Soft tissues of
the chest are normal.
## IMPRESSION:
1. Interval resolution of the left upper lobe consolidation. No new
consolidation, pulmonary nodule, or mass is identified.
2. No mediastinal lymphadenopathy.
3. Small hiatal hernia.
4. Hypodense hepatic lesions most likely represent cysts.
5. Sludge within the gallbladder.
6. Findings suggestive of anemia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11580750", "visit_id": "23362356", "time": "2143-09-11 11:53:00"} |
13604162-RR-40 | 141 | ## TYPE OF EXAMINATION:
Chest AP portable single view.
## INDICATION:
female patient with ischemic bowel and new central
line. Contact name: .
## FINDINGS:
AP single view of the chest has been obtained with patient in
semi-upright position (20 degrees up). Comparison is made with the next
preceding similar study obtained eight hours earlier during the same day. The
patient remains intubated, the ETT is in unchanged position. A right-sided
internal jugular approach central venous line is noted, seen to terminate in
the right mediastinal structures 4 cm below the level of the carina. This is
identical with the position of a line existed already on the earlier
examination. It is unclear whether lines have been exchanged. No
pneumothorax has developed. Before, there is moderate cardiac enlargement but
no evidence of pulmonary vascular congestion and no pleural effusions are
seen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13604162", "visit_id": "29670276", "time": "2177-02-28 12:28:00"} |
17856950-RR-24 | 216 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old woman with AVM s/p embolization// assess for
re-bleed; PLEASE PERFORM AT 0500!!!!!!!!!!
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
## FINDINGS:
Patient is status post embolization of a large right parietal arteriovenous
malformation. Streak artifact related to the embolization coils somewhat
limits evaluation of the region. Within this limitation there is no definite
large volume intraparenchymal hemorrhage. Region of adjacent subcortical
white matter hypodensity is similar dating back to prior. Cortical
hyperdensity along the sylvian fissure corresponds to a draining vein on the
MR dated . No evidence of acute large territorial infarct.
Morphology of the ventricular system is unchanged with continued effacement of
the atrium and occipital horn of the right lateral ventricle. No evidence of
subarachnoid blood.
No evidence of fracture. No significant paranasal sinus thickening. The
middle ear cavities and mastoid air cells are clear. Orbits are unremarkable.
## IMPRESSION:
Patient is status post embolization of a large right parietal arteriovenous
malformation. No evidence of intraparenchymal hemorrhage or subarachnoid
blood however please note that evaluation in the region of the AVM is limited
secondary to embolization coil streak artifact.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17856950", "visit_id": "26474516", "time": "2134-05-08 04:42:00"} |
19513478-DS-13 | 1,300 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
Mr. is a y/o left handed man with a hx of metastatic
melanoma with known L parietal brain met, s/p resection and
cyberknife, who presents with R hand numbness, who we are
consulted re: an area of hemorrhage found on Head CT in the L
parietal area.
He reports that he woke up in his USOH this morning, but at 8:30
all of the sudden developed numbness in his left hand. He
describes 2 distinct sensations. First of all, he has a pins
and needles sensation in his right hand that is more pronounced
when something touches the skin there. He's never had this
feeling before. Second, he has the same "motor-neural
coordination problem" that he had when he first presented in
, and was found to have the L parietal met (which had
resolved after radiation and resection, then recurred today).
He describes having to concentrate to perform fine finger
movements with his right hand (cannot touch type for instance
unless he stares at his fingers) He's been dropping things
(dropped the soap in the shower), and feels clumsy with using
the hand. He's not noticed any obvious weakness in the hand or
arm (or elsewhere in his body). On ROS he denies headache,
facial droop, dysarthria, dysphagia, slurred speech, word
finding problems or trouble comprehending speech, or any
episodes of staring, change in consciousness, or loss of
consciousness (the symptoms have been stable and since they
started at 8:30).
## METASTATIC MELANOMA:
Onc History, per Dr. note:
(1) surgical resection of the hemorrhagic brain metastasis by
Dr. on
(2) s/p Cyberknife radiosurgery to the resection cavity by Dr
on to 1,800 cGy.
His oncological problem started in when he noted a mole in
the left chest. Due to a variety of personal reasons, this mole
was not removed until at .
Staging evaluation of axillary lymph nodes was negative for
melanoma. He was lost to follow up there. On most recent
follow
up with Oncology he had a 3 mm nodule in the RUL of the lung
which was being monitored.
His neurological problem started on when he experienced
difficulty typing with his right hand. His family physician
arranged him for have a head CT and then a head MRI here at . He did not have headache,
nausea, vomiting, seizure, imbalance, or fall, though he had a
hard time staying awake at work. A head MRI at , performed on , showed a
hemorrhagic mass in the left parietal brain. The blood and mass
was resected by , M.D., Ph.D. on . He is
doing well after surgery without sequela.
## - BIPOLAR DISORDER:
past psychiatric admissions in and
. He has been treated with Lexapro, Zoloft,
Lamictal,
Zyprexa, and Seroquel. He is not currently on any psychiatric
medication.
- s/p multiple eye surgeries w/ multiple bilateral detachments,
poor L visual acuity, s/p left lensectomy and vitrectomy
## FAMILY HISTORY:
The patient's mother had bipolar disorder and died of a drowning
suicide when the patient was years old. The patient has a
history of bladder cancer and stomach cancer in two of his
paternal great aunts. Both of these cancers occurred at older
ages. There is a question of a maternal aunt with
mesothelioma diagnosed in her .
## GEN:
Lying in bed, NAD
## HEENT:
NC/AT, moist oral mucosa
## NECK:
No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
## BACK:
No point tenderness or erythema
## CV:
RRR, Nl S1 and S2, no murmurs/gallops/rubs
## CLEAR TO AUSCULTATION BILATERALLY
ABD:
+BS soft, nontender
ext: no edema
## NEUROLOGIC EXAMINATION:
MENTAL STATUS:
Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. Reading intact.
Registers , recalls in 5 minutes. No right left
confusion. No evidence of apraxia or neglect. Interprets cookie
jar picture well, no visual neglect. Calculations intact. No
finger agnosia.
## CRANIAL NERVES:
Pupil 5 -> 3 on R, 4 mm, min reactive on L (pt. has been told
his
pupils were unequal before eye surgeries in the past). No
papilledema bilaterally. Visual fields are full to
confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Sensation
intact V1- V3. Facial movement symmetric. Hearing intact to
finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
## MOTOR:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. R hand drifts up.
Del Tri Bi WF WE FE FF IP H Q DF PF TE TF
R 5 5
L 5 5
## SENSATION:
Some hyperesthesia to pinprick in R hand. +
agraphesthesia in R hand, able to name numbers draw in his
hand
on the L. Some difficulty with autotopagnosia tasks with R hand
(does not touch the spot that I touch exactly, though he can
tell
if I trace my finger down/up on the skin) Intact to light
touch,
pinprick, vibration and proprioception throughout. No extinction
to DSS.
## REFLEXES:
+2 and symmetric throughout.
Toes downgoing bilaterally
## COORDINATION:
finger-nose-finger normal, heel to shin normal,
RAMs normal.
## HEAD CT:
A 1.3 x 2.5 cm intraparenchymal hemorrhage is seen within the
left frontoparietal lobe with surrounding edema and subarachnoid
blood. No focus of hemorrhage is identified elsewhere. No major
vascular or territorial infarct or hydrocephalus is appreciated.
The gray-white matter differentiation is preserved. Patient is
status post left parietal craniotomy. Visualized paranasal
sinuses and mastoid air cells remain normally aerated.
## IMPRESSION:
Intraparenchymal hemorrhage with surrounding edema
and subarachnoid blood. Patient is status post left parietal
craniotomy.
<BR>
## FINDINGS:
There is a large left frontal hematoma that appears
similar to that seen on the head CT scan of the same date. This
is associated with surrounding edema. This appears to extend
superiorly from the region of the metastasis identified on the
MR. presumably represents hemorrhage into
the tumor bed. No other hemorrhages are noted. The post-contrast
images demonstrate no other abnormalities. The diffusion images
demonstrate the hemorrhage, but no evidence of infarction.
The MRA examination appears normal.
## CONCLUSION:
Hemorrhage, presumably into the bed of the
previously radiated tumor. There is edema and local mass effect.
## BRIEF HOSPITAL COURSE:
Mr. was admitted to the neurology floor service for
management of his intracerebral hemorrhage. MRI was obtained
that showed some new enhancement in the old tumor bed, which is
presumably the cause of his bleed. His blood pressure remained
in a normal range without pharmacologic intervention. His Keppra
dose was increased back up to a therapeutic level for the
possibility that his transient episodes of numbness represent
seizures triggered by the hemorrhage. He did well, although the
numbness continues to wax and wane. He was discharged to home
with follow-up in clinic with Dr. .
## MEDICATIONS ON ADMISSION:
Keppra 250 mg po twice daily (slowly being weaned off)
## DISCHARGE MEDICATIONS:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 doses.
Disp:*3 Tablet(s)* Refills:*0*
2. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day: Begin on , after finishing 500 mg dosage.
Disp:*60 Tablet(s)* Refills:*2*
## PRIMARY:
1. Left parietal intraparenchymal hemorrhage
## DISCHARGE CONDITION:
Good condition, numbness over right hand, otherwise
neurologically intact.
## DISCHARGE INSTRUCTIONS:
You have been evaluated for right hand numbness and were found
to have had a bleed in your brain. You were started on Keppra to
prevent seizures. Please take all medications as directed and
keep all follow-up appointments.
If you have any weakness, worsened numbness, double vision,
dizziness, difficulty speaking, difficulty swallowing, or any
other symptom that is concerning to you, please call your PCP or
your neurologist or go to the nearest hospital emergency
department.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19513478", "visit_id": "22742241", "time": "2157-08-26 00:00:00"} |
13816338-DS-4 | 1,178 | ## :
Open reduction internal fixation right parasymphysis
fracture.
## HISTORY OF PRESENT ILLNESS:
Mr. is a man, transferred from
under police custody, who presents with right-sided jaw pain and
occipital scalp laceration in the setting of an altercation and
assault while intoxicated.
The patient reports drinking cups of vodka today and does
not
remember the events of the altercation. Per police report, he
was
struck on the face and fell hitting his head on the pavement. He
was found unconscious by EMS. He reports mandibular pain with
movement and numbness. He also reports occipital headache around
the site of laceration, intermittent nausea, no vomiting. He
denies blurry vision or double vision. Denies CP, SOB, abdominal
pain, neck or back pain. He denies other history of falls or
black-outs.
At head which was notable for left mandibular
fracture. Scalp laceration was repaired with surgical staples
and
the patient was given 1 dose of IV unasyn.
## GEN:
No acute distress, alert and oriented, breath with alcohol
odor, slurred speech likely limited by pain
## HEENT:
Occipital scalp laceration, approximately 3cm in length,
stapled, slight surrounding erythema with minimal sanguinous
drainage on pillow cover. Edentulous. L mandibular tenderness to
palpation with superficial skin lacerations, no hematoma
appreciated. No neck tenderness to palpation, normal ROM.
## CV:
RRR, normal S1 and S2
## PULM:
Normal work of breathing, clear to auscultation anteriorly
## ABD:
Nontender, nondistended, no rebound or guarding
## EXT:
No edema or lacerations
## MSK:
No tenderness to palpation along spine or paraspinal
musculature
## GEN:
A&O, sitting up in bed eating, conversant, in no distress
## HEAD:
atraumatic and normocephalic except for repaired 2 cm
laceration on the posterior scalp.
## EYES:
EOM Intact, PERRL, vision grossly normal
## EARS:
right ear normal, left ear normal, no external
deformities
and gross hearing intact
## NOSE:
straight nose, non-tender, no epistaxis
## EOE:
no soft tissue swelling,
## TMJ:
guarding to 30 mm, left TMJ, no pain right TMJ
## NEUROLOGY:
cranial nerves II-XII grossly intact, except for
bilateral V3 paraesthesia of the anterior mandible
## NECK:
normal range of motion, supple, no JVD, and no
lymphadenopathy
## IOE:
Crest of maxillary and mandibular ridges with slight
leukoplakia that does not easily rub off, oropharynx clear, no
dysphagia, no odynophagia, no lymphadenopathy, FOM soft
non-elevated. patient is edentulous. buccal and sublingual
ecchymosis in area of tooth , area is tender to palpation.
Sutures are clean and intact, wound is hemostatic and no
dehiscence appreciated.
## CT HEAD & NECK:
1. There is no evidence of acute intracranial hemorrhage, an
acute skull fracture, a large acute territorial infarction, or
an
intracranial mass.
2. There is an acute appearing oblique fracture involving the
base of the left mandibular neck. There is minimal displacement.
3. Complete right middle ear and mastoid opacification with
encasement of the middle ear ossicles. The scutum is grossly
intact.
## CT CERVICAL SPINE:
1. Chronic degenerative and/or post traumatic changes in the
cervical spine with superimposed chronic postsurgical change.
There is no acute fracture or acute spondylolisthesis.
2. Note is again made of the right middle ear and right mastoid
opacification and of the acute left mandible fracture.
## BRIEF HOSPITAL COURSE:
man presenting with scalp laceration s/p stapled in OSH,
and left mandibular fracture in the setting of assault and fall
while intoxicated. CT head is without evidence of ICH and
patient remains hemodynamically stable. was consulted and
the patient was taken to the OR on for Open reduction
internal fixation right parasymphysis fracture, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating liquids, on IV fluids,
and oral narcotics for pain control. The patient was
hemodynamically stable.
.
Pain was well controlled. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
.
At the time of discharge on POD0, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
full liquid no-chew diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. He would
follow-up in the clinic and maintain a no-chew diet until
then.
## MEDICATIONS ON ADMISSION:
Lisinopril 5mg QD
Duloxetine 30mg QD
Quetiapine 50mg QD
Albuterol PRN
## DISCHARGE MEDICATIONS:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 650 mg/20.3 mL 650 mg by mouth every six (6)
hours Disp #*500 Milliliter Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % 15mL rinse and spit twice a
day Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. OxyCODONE (Immediate Release) mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. Lisinopril 5 mg PO DAILY
7. QUEtiapine Fumarate 50 mg PO QHS
## DISCHARGE DIAGNOSIS:
Left mandibular fracture
Scalp laceration
## DISCHARGE INSTRUCTIONS:
You were transferred to after an assault. CT scan of your
head was notable for a left jaw fracture and a scalp laceration,
which was repaired with surgical staples in the ED. The Oral
Maxillary Facial Surgeons ( ) was consulted and took you to
the operating room for repair of the jaw fracture. You tolerated
this procedure well and are now medically cleared for discharge
home. Please continue with the full liquid diet until your
follow-up appointment.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13816338", "visit_id": "29197310", "time": "2176-01-09 00:00:00"} |
11654318-RR-36 | 146 | RIGHT HUMERUS AND WRIST
## INDICATION:
man with fall on right arm, pain, evaluate fracture.
RIGHT HUMERUS AND WRIST, SIX VIEWS
## RIGHT HUMERUS, TWO VIEWS:
There is deformity of the humeral head and some
cortical thinning along the head and the metaphysis consistent with an old
fracture.
## RIGHT ELBOW, TWO VIEWS:
The elbow is depicted on the AP view of the humerus;
however, the lateral view is not optimized for evaluation of the radial head.
There is no definite fracture.
## RIGHT WRIST, THREE VIEWS:
There is demineralization of the depicted osseous
structures. There is no fracture or dislocation on the provided views. There
are extensive vascular calcifications.
## IMPRESSION:
1. No evidence for acute fracture. Please note that the lateral film of the
elbow is not optimized for evaluation of a radial head fracture. If there is
clinical concern, this could be repeated.
2. Healed humeral fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11654318", "visit_id": "22583593", "time": "2140-11-08 12:54:00"} |
18394695-RR-152 | 137 | ## EXAMINATION:
CHEST (AP AND LATERAL)
## FINDINGS:
Assessment is somewhat limited due to patient rotation. Heart size appears
mildly enlarged, increased compared to the previous exam. The aorta is
diffusely calcified. Bronchiectasis with architectural distortion, scarring,
and calcifications involving the right apex and left mid lung field as well as
superior retraction of the right hila are again noted along with calcified
mediastinal and right hilar lymph nodes, findings compatible with the sequela
of prior granulomatous infection. New mild pulmonary edema is present. No
pleural effusion or pneumothorax is identified. Multiple punctate radiopaque
densities again are seen overlying the left superior chest. No acute osseous
abnormality is detected. Calcifications in the right upper quadrant of the
abdomen are compatible with gallstones.
## IMPRESSION:
1. Interval development of mild pulmonary edema.
2. Findings compatible with prior granulomatous infection.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18394695", "visit_id": "N/A", "time": "2168-06-26 21:49:00"} |
13537167-RR-24 | 324 | ## INDICATION:
year old man with abdominal pain and and history of coronary
artery disease. Evaluate for mesenteric ischemia.
## CHEST:
Visualized portions of the lungs and pericardium are unremarkable.
Limited images demonstrates and enlarged heart.
## ABDOMEN:
The liver demonstrates homogeneous attenuation throughout without
evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is unremarkable without
stones or gallbladder wall thickening. There is extensive opacification of the
pancreatic tail without evidence of focal lesions or pancreatic ductal
dilatation. The spleen is normal in size and attenuation throughout.
Incidental note is made of a splenule. The adrenal glands are unremarkable
bilaterally. The right kidney is without focal lesions. The left kidney
demonstrates a 1.2 cm simple cyst in the lower pole. There is no evidence of
stones or hydronephrosis. The kidneys demonstrate symmetric nephrograms and
excretion of contrast.
The stomach, duodenum, small bowel are unremarkable. Mild diverticular disease
is seen within the sigmoid colon without evidence of diverticulitis.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
## OSSEOUS STRUCTURES:
There is no evidence of suspicious lesions.
## CTA:
The descending aorta appears patent without aneurysmal dilatation. There
is moderate atherosclerotic disease predominantly infrarenal and extending
into bilateral common iliac arteries. The celiac artery supplies a patent
splenic gastric and left hepatic artery. The superior mesenteric artery
supplies the right hepatic artery. The superior and inferior mesenteric
arteries are patent. The portal vein and mesenteric veins are additionally
patent. Incidental note is made of a prominent left gonadal vein with venous
flow into the left renal vein.
## IMPRESSION:
1. Simple left renal cyst within the lower pole.
2. Diverticular disease without diverticulitis.
3. Patent abdominal vasculature with moderate atherosclerotic disease of the
infrarenal abdominal aorta into bilateral common iliac arteries. No evidence
of bowel wall thickening or ischemia to suggest mesenteric ischemia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13537167", "visit_id": "N/A", "time": "2171-05-21 07:03:00"} |
10431522-RR-52 | 104 | LEFT HIP AND KNEE
## FINDINGS:
No interval change in the alignment of the dynamic hip screw.
Stable minimal degenerative changes within the left femoroacetabular joint,
with some progression of joint space narrowing medially. There is a loose
body at the lateral aspect of the joint. There is no evidence of
periprosthetic loosening or fracture.
There has been no interval change in the lateral plate and screw fixation of
the left distal femur fracture with multiple cortical and cancellous screws.
There is solid osseous across the obliquely oriented metaphyseal
fracture with stable mild deformity. No evidence of periprosthetic lucency or
fracture. No new fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10431522", "visit_id": "N/A", "time": "2146-11-25 11:42:00"} |
17207188-DS-9 | 1,336 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## CHIEF COMPLAINT:
Right hand/arm pain with decreased pulses
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Right brachial/axillary thromboembolectomy and primary
repair of brachial artery.
## HISTORY OF PRESENT ILLNESS:
, well known to Dr her chronic vasculitis
problems, PVD, and asymptomatic carotid stenoses presents today
with acute onset of shooting pain from her right shoulder down
to hand, comes and goes, and well as some coolness in her
fingertips. Denies any weakness. Not worse with movement. Was
not doing anything out of the ordinary when this first
happenned. Also states some confusion today. Denies any
CP/SOB/ab pain/HA/n/v/d/c. No numbness or tingling. Was started
on a heparin gtt at and to
## PAST MEDICAL HISTORY:
Afib, CAD s/p MIx2, h/o CVA & TIAs, vasculitis type
unclear, HTN, AS, dementia, depression, B12 deficiency, s/p
right fem-pop embolectomy, PVD, and remote ab surgery, CRI,
gout,
asymptomatic b/l 70-79% carotid stenoses, NIDDM
## GEN:
Appropriate and pleasant elderly, NAD.
## EXTREMITIES:
no c/c/e stength throughout, FROM. right
fingertips slighlty cooler than left, no pain with movement,
slightly decreased but present capillary refill
## PERTINENT RESULTS:
12:00AM PTT-34.1
12:00AM URINE COLOR-Straw APPEAR-Clear SP
12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
05:30PM GLUCOSE-355* UREA N-16 CREAT-1.0 SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-13
05:30PM estGFR-Using this
3:11 US EXTREMITY NONVASCULAR RIGHT IMPRESSION: No
pseudoaneurysm and no AV fistula identified in the right upper
arm.
## ECG:
Atrial fibrillation. Compared to the previous
tracing of probably no significant change.
## BRIEF HOSPITAL COURSE:
This is an , well known to Dr her chronic
vasculitis
problems, PVD, and asymptomatic carotid stenoses presents to
hospital on
with acute onset of shooting pain from her right shoulder down
to hand, comes and goes, and well as some coolness in her
fingertips. Denies any weakness. Not worse with movement. Was
not doing anything out of the ordinary when this first
happenned.
Also states some confusion today. Denies any CP/SOB/ab
pain/HA/n/v/d/c. No numbness or tingling. Was started on a
heparin gtt at and to had a weak
brachial pulse and Doppler signals in her wrist. Patient did not
regain pulses with Heparin therapy so Dr. decided to take
her to the operating room.
patient was taken to the OR for Right brachial/axillary
thromboembolectomy and
primary repair of brachial artery. Pre-operatively, patient had
bouts of confusion that improved over her hospitalization stay.
Currently alert and oriented x 3.
Post-operatively, she recovered well and transferred to 5
VICU then to floor. Resumed Coumadin with eventually on
bridge. INR is currently 2.3, Lovenox will be
discontinued. Patient developed RUE hematoma, distal pulses
present, currently stable. Patient's diet was advanced. Physical
therapy were consulted, activities were resumed with no issues.
Patient's vital signs were stable during her hospital stay.
Blood sugars were elevated throughout her hospital stay.
consulted-recommended increasing Glipizide to
10mg QD and changing slinding scale, continued to throughout
hospital stay and outpatient. Spoke to Dr.
re: disccharge meds, he recommends to stay on Glipizide 10
mg qd until patient is seen by him in . He also suggested for
patient to be seen by the Diabetes Nurse in
on at 2:30 pm. Patient's daughter is
aware of this plan.
Her labs were checked routinely, electrolytes repleted.
Doppler no pseudoaneurysm and no AV fistula identified
in the right upper arm. Two hematomas are identified as
described.
## MEDICATIONS ON ADMISSION:
pravastatin 40, folic acid 1, allopurinol , glipizide,
lexapro 10, boniva, prednisone 1, lopressor 50"
## DISCHARGE MEDICATIONS:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
## 4. ALLOPURINOL MG TABLET SIG:
Two (2) Tablet PO DAILY
(Daily).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
## Q12 HOURS ():
Continue until INR >2.0 .
Disp:*10 1* Refills:*1*
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once
Daily at 16): Continue as Goal INR 2.0-3.0
directed by Dr. . fax
.
14. Outpatient Lab Work
Have INR drawn 2x per week and prn
Continue as directed by Dr. . phone
fax
Goal INR 2.0-3.0 (INR must not go less than 2.0)
## DISCHARGE DIAGNOSIS:
s/p right brachial embolectomy
Afib
CAD s/p MIx2
h/o CVA & TIAs
vasculitis type unclear
HTN
AS
dementia
depression
B12 deficiency
s/p right fem-pop embolectomy
PVD
and remote ab surgery
CRI
gout
asymptomatic b/l 70-79% carotid stenoses
NIDDM
## INR:
Continue Lovenox 60mg Q12 until INR is >2.0
INR should be drawn 2x per week with results sent to Dr.
fax
## DISCHARGE INSTRUCTIONS:
Division of Vascular and Endovascular Surgery
Discharge Instructions
## MEDICATIONS:
Take Aspirin 325mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of your Right arm
Elevate your arm above the level of your heart (use
pillows or a recliner) every hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
arm elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow arm puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
Call and schedule an appointment to be seen in weeks for
post procedure check and ultrasound
What to report to office:
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from arm puncture site or worsening bleeding of your
right arm
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office . If bleeding does not stop, call
for transfer to closest Emergency Room.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17207188", "visit_id": "29288198", "time": "2120-09-21 00:00:00"} |
15718617-RR-11 | 103 | ## STUDY:
AP pelvis and frog leg views of the hips .
## HISTORY:
Patient with right hip pain.
## FINDINGS:
Comparison is made to prior study from .
There are degenerative changes seen of both hips, left side worse than right.
On the left side, there is bone-on-bone appearance of superolateral aspect of
the joint space worst in the study. On the right side, there is
moderate to severe narrowing of the joint space with subchondral cyst and
spurring, however, the appearance appears stable since study. There are
no signs for acute fractures. Mild degenerative changes of the lower lumbar
spine is seen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15718617", "visit_id": "N/A", "time": "2122-04-16 10:47:00"} |
18437750-RR-125 | 98 | ## HISTORY:
male status post thoracic surgery. Now with fever.
Please examine for signs of pneumonia.
## STUDY:
Upright portable AP chest radiograph.
## FINDINGS:
There has been interval placement of hardware consistent with
spinal fusion. The corresponding soft tissue staple line is also noted.
Cardiac and mediastinal contours appear normal and unchanged from previous
study. The hila are normal appearing bilaterally. The lung fields appear
clear with no evidence of focal or lobar consolidation. There is decreased
visibility of the left costophrenic sinus, although there is no evidence for
pneumothorax or pleural effusion.
## IMPRESSION:
No evidence for pneumonia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18437750", "visit_id": "21993288", "time": "2157-12-06 08:26:00"} |
14581359-DS-11 | 1,533 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
yo M w/ PMH of RA and chronic alcoholism p/w fall and
jaundice. Pt. had been feeling well until about 2 weeks ago when
he began feeling decreased energy decreased appetite and
increasing chronic abdominal pain. He started noticing that his
skin was becoming yellow about 4 days ago. He presented to OSH
w/ a fall and on admission was found to have jaundice w/
elevated LFT's and negative Etoh on tox screen. He was
transferred to for further management. He reports that he
had decreased his drinking from chonic level of beers/day
to / day over the last 8 weeks and that his last drink was on
.
.
On ROS he denies fevers, chills, NS, CP, SOB, cough, melena,
diarrhea, hematemesis, hematuria, dysuria.
.
## PAST MEDICAL HISTORY:
Etoh abuse
HTN
Anxiety
Rheumatoid Arthritis
Hiatal hernia
## FAMILY HISTORY:
RA in his father and several siblings. No history of liver
disease or cancers.
.
## HEENT:
Scleral icterus, No JVD
## ABD:
Soft, NT, mildly distended w/ fluid wave, no HSM, BS+, no
caput medusae.
## EXT:
1+ lower extremity edema. Pedal pulses 2+.
## NEURO:
No asterixis, able to name presidential and vice
presidential candidates. Able to answer difference between a pit
bull and a hockey mom. intact. Gait hunched forward and
shuffling.
## PERTINENT RESULTS:
CT sinus
There is a minimally displaced fracture of the left outer table
of
the frontal sinus. There is overlying soft tissue stranding and
subcutaneous
locules of free air. No other fracture is identified. The
paranasal sinuses
and mastoid air cells are well aerated. The ostiomeatal units
are patent.
The anterior clinoid processes are pneumatized. The nasal septum
is deviated
to the right.
## IMPRESSION:
Minimally displaced fracture of the outer table of
the frontal
sinus.
abd u/s
This is a severely limited study secondary to body habitus. CT
or
MR can better assess focal hepatic abnormalities as clinically
indicated.
1) Diffusely echogenic and coarse liver that is consistent with
fatty
infiltration. Other forms of liver disease and more advanced
liver disease
including significant hepatic fibrosis/cirrhosis cannot be
excluded on this
study.
2) Ascites.
3) Mild splenomegaly.
07:20PM BLOOD WBC-8.4 RBC-2.80* Hgb-10.4* Hct-28.8*
MCV-103* MCH-37.1* MCHC-36.1* RDW-15.1 Plt Ct-81*
05:30AM BLOOD WBC-12.9* RBC-2.46* Hgb-9.8* Hct-27.4*
MCV-111* MCH-39.9* MCHC-35.8* RDW-15.9* Plt
07:20PM BLOOD Neuts-82.4* Bands-0 Lymphs-8.0* Monos-9.1
Eos-0.3 Baso-0.1
07:20PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-3+ Microcy-NORMAL Polychr-NORMAL
07:20PM BLOOD PTT-60.9*
05:30AM BLOOD PTT-49.7*
07:20PM BLOOD Glucose-91 UreaN-12 Creat-0.8 Na-119*
K-3.4 Cl-85* HCO3-23 AnGap-14
05:30AM BLOOD Glucose-78 UreaN-15 Creat-0.8 Na-134
K-4.0 Cl-102 HCO3-22 AnGap-14
07:00PM BLOOD calTIBC-107* VitB12-GREATER TH
Ferritn-GREATER TH TRF-82*
07:20PM BLOOD Osmolal-248*
03:15PM BLOOD Osmolal-261*
05:30AM BLOOD Cortsol-24.4*
05:30AM BLOOD PTH-169*
05:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
05:30AM BLOOD AFP-2.5
02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
05:15AM BLOOD HCV Ab-NEGATIVE
## BRIEF HOSPITAL COURSE:
# Acute on chronic liver failure: Patient reports no history of
known liver disease, though he states he has not seen his doctor
in year. Appeared that he had acute alcoholic hepatitis in the
setting of chronic liver failure w/ his jaundice, coagulopathy,
hypoalbuminemia, asterixis and ascites. His hepatitis serologies
were negative. Tox screen was negative. Pt. was started on
pentoxyfilline for treatment of the hepatitis. His mild
asterixis resolved after several days of lactulose, but his
bilirubin/INR/LFTs remained fairly stable even with addition of
PO vitamin K.
.
# Liver mass: Pt. had question HCC vs. fatty infiltrate on CT
liver his liver u/s at showed only fatty infiltration.
.
# Hyponatremia: Per pt.s PCP his baseline is in the low 130s but
when pt. presented his Na was 114, his K, phos and Ca were also
significantly lower than normal. All of his electrolyte
abnormalities improved with aggressive repletion and his Na
improved w/ fluid restriction. His abnormalities appeared to be
secondary to poor nutrition.
.
# Sinus fracture on prelim CT read: Secondary to recent fall.
Non operative. Pt. was seen by plastics who put him on
prophylactic Abx and sutured the overlying skin laceration.
.
# Alcohol abuse: Per the patient, no recent alcohol for 3 days
prior to admission, and he had recently cut back substantially
from to 1-2/day and he could not say why. Pt. was seen
by social work for abstinence counseling. He was also counseled
by the physician staff that further alcohol intake could lead to
his death.
.
## # RHEUMATOID ARTHRITIS:
Unclear how long patient had been off
his prednisone prior to admission. He was restarted on his
prednisone but we held his enbrel secondary to evidence that
infliximab caused worse outcomes in pt.s w/ alcoholic hepatitis.
## .
#MACROCYTIC ANEMIA:
Pt. had iron and vitamin B12 deficiency. He
recieved iron, B!2, folate and thiamine supplementation while
admitted and was discharged w/ same.
.
## MEDICATIONS ON ADMISSION:
Medications (he reports he has been out of his medications for
at least 2 weeks):
Lisinopril-Hctz daily
Atenolol 25 mg daily
Omeprazole 40-80 mg prn
Ativan 0.5 mg q6H
Tizanidine
Enbrel 50mg/mL weekly
Prednisone 5 mg daily
Lidoderm patch 5% prn
## DISCHARGE MEDICATIONS:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 gram/15 mL Solution Sig: Packets PO three
times a day.
Disp:*180 packets* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
## 4. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO three times a day for 4 weeks.
Disp:*84 Tablet Sustained Release(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. B-12 DOTS 500 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Phytonadione 5 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium & Sodium Phosphates mg Powder in
## PACKET SIG:
One (1) Powder in Packet PO once a day.
Disp:*30 Powder in Packet(s)* Refills:*0*
11. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK ( ) for 8 weeks.
Disp:*56 Capsule(s)* Refills:*0*
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Every 6 hours
as needed as needed for pain for 10 doses.
Disp:*10 Tablet(s)* Refills:*0*
13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*2*
14. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig:
Capsule, Delayed Release(E.C.)s PO once a day.
15. Calcium 500 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*2*
16. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
## DISCHARGE DIAGNOSIS:
Primary
Cirrhosis
Alcoholic hepatitis
Secondary
Etoh abuse
HTN
Anxiety
Rheumatoid Arthritis
Hiatal hernia
## DISCHARGE INSTRUCTIONS:
You have been diagnosed with cirrhosis and alcoholic hepatitis.
You should not drink any more alcohol. You should also avoid
acetaminophen (Tylenol) as well as Ibuprofen (motrin, advil) and
Naproxen (aleve).
## WE HAVE CHANGED YOUR MEDICATIONS:
You will need to take
lactulose every day to avoid confusion unless you are told to
stop by a liver specialist. You will need to take your atenolol
and omeprazole to avoid bleeding in your esophagus. You should
continue to take vitamin supplements. Take the vitamin K
10mg/day until . You should continue taking the
thiamine, folate, multivitamin, calcium and B12 supplements
indefinitely. You should continue the spironolactone to prevent
fluid from accumulating in your abdomen. You should continue
taking the Ursodiol ( ) because it helps bile flow through
your liver. You should take the pentoxyfilline until the liver
doctor tells you to stop taking it, it decreases inflammation in
the liver. We stopped your Lisinopril-HCTZ because your blood
pressure was low. We stopped your ativan because this can cause
extreme confusion in people with cirrhosis. We did not give you
your enbrel while you were here because there is some evidence
that medicines like enbrel can cause harm to people with active
liver inflammation.
If you have any chest pain, confusion, shortness of breath,
fevers, chills, nightsweats, abdominal pain, bleeding, severe
vomiting or any other concerning symptoms call your doctor
immediately or return to the emergency department.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14581359", "visit_id": "28341905", "time": "2120-01-10 00:00:00"} |
12271042-RR-25 | 94 | ## CHEST:
Frontal and lateral views
## INDICATION:
History: with dyspnea// evaluate for pneumonia
## FINDINGS:
Increased interstitial markings are re-demonstrated diffusely bilaterally in
this patient with history of chronic lung disease, possibly slightly increased
compared to the prior study. No lobar consolidation is seen. No pleural
effusion or pneumothorax is seen. The cardiac silhouette is borderline to
mildly enlarged. Mediastinal contours are stable.
## IMPRESSION:
Re-demonstrated prominence of the interstitial markings diffusely bilaterally
in this patient with history of chronic lung disease, possibly slightly
increased compared to the prior study. No lobar consolidation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12271042", "visit_id": "28850931", "time": "2121-09-20 14:29:00"} |
18302268-RR-37 | 103 | ## EXAMINATION:
DX HAND AND WRIST
## INDICATION:
year old man with r hand pain// r hand pain
## FINDINGS:
No fracture or dislocation seen. There are moderate degenerative changes at
the index and long finger metacarpophalangeal joints, similar in appearance to
the prior study. Degenerative changes noted also at the long finger proximal
interphalangeal joint. No destructive lytic or sclerotic bone lesions seen,
sclerotic lesion in the distal ulna is consistent with a bone island. No
radiopaque foreign body seen. Alignment of the carpal bones is within normal
limits.
## IMPRESSION:
Degenerative changes as described, similar in appearance when compared to the
prior study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18302268", "visit_id": "N/A", "time": "2143-11-13 12:38:00"} |
12427936-RR-22 | 256 | ## EXAMINATION:
AVF/DUPLEX HEMO/DIAL ACCESS
CLINICAL HISTORY year old man with history of renal transplant and prior
HD. Now s/p aor arch replacement on CVVH.// access patency of AVF for use
access patency of AVF for use
## FINDINGS:
Difficult study due to multiple previous surgical interventions of the left
upper extremity.
Duplex arterial assessment was performed of an established left upper
extremity brachiocephalic AV fistula.
Occluded cephalic vein is seen in the left upper extremity. No other venous
outflow could be identified.
The native axillary artery is somewhat dilated with velocity of 218 cm/second.
There is a more normal appearing brachial artery in the upper arm. There is a
second dilated and slightly tortuous vessel with triphasic waveforms and a
normal arterial resistance. Diameters of this segment range from 13-15 mm.
Low velocities seen in the segment are likely a function of its diameter and
range from 21-69 cm/second. The visualized portions of the ulnar and radial
arteries are patent with velocities of 29 cm/second and 21 cm/second
respectively.
## IMPRESSION:
The cephalic vein fistula is occluded. The anatomy difficult to sort out
because of the multiple previous surgeries. The dilated vessel with triphasic
waveforms coursing down the course of the upper arm is most consistent with a
hypertrophied brachial artery (? duplicate brachial) that use to feed a
high-flow fistula and now that the official is occluded it has reverted to
normal arterial waveform with larger than normal diameters.
Consider alternative imaging (CTA) if clinically indicated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12427936", "visit_id": "28035197", "time": "2135-08-31 12:54:00"} |
17289872-RR-22 | 146 | ## EXAMINATION:
CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK
## INDICATION:
year old man with sensation of a foreign body after eating
chicken. // eval for foreign body
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 4.0 s, 31.6 cm; CTDIvol = 15.7 mGy (Body) DLP = 497.3
mGy-cm.
Total DLP (Body) = 497 mGy-cm.
## FINDINGS:
Evaluation of the aerodigestive tract demonstrates no large mass, and no areas
of focal mass effect.
The salivary glands are without mass or adjacent fat stranding. The thyroid
gland appears normal. There is no lymphadenopathy by CT criteria. Soft tissue
density in the anterior mediastinum, ikely thymus tissue, is similar to .
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions. There is mild mucosal
thickening in the right maxillary sinus.
## IMPRESSION:
No radiopaque foreign body.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17289872", "visit_id": "N/A", "time": "2186-07-27 00:13:00"} |
17780747-RR-39 | 139 | ## EXAMINATION:
SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
## INDICATION:
year old man with s/p fall today, c/o worsening L shoulder
pain, hx of L rotator cuff tear and OA // r/o fracture or dislocation
ACUTE LEFT SHOULDER PAIN S/P FALL TODAY ONTO OUTSTRETCHED ARM/JAMMING SHOULDER
HX RTC TEAR YRS AGO PER R/O FX,DJD,OA
## FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
There are mild degenerative changes of the glenohumeral and acromioclavicular
joints with mild spurring of the glenoid and narrowing and subchondral
sclerosis within the acromioclavicular joint unchanged compared to the prior
exam. No suspicious lytic or sclerotic lesion is identified. No periarticular
calcification or radio-opaque foreign body is seen.
## IMPRESSION:
1. No acute abnormality detected.
2. Mild acromioclavicular and glenohumeral joint degenerative changes.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17780747", "visit_id": "N/A", "time": "2172-02-01 14:20:00"} |
10987086-DS-16 | 1,399 | ## ALLERGIES:
Actos / Sulfa (Sulfonamide Antibiotics) / primidone / Celebrex /
Betadine / adhesive / Soma / albuterol
## HISTORY OF PRESENT ILLNESS:
w/ hx of lupus, RA, fibromyalgia presents w/ LUQ abd pain
and neck spasms. Pt reports a history of issues with
recurrent LUQ pain. She reports last flare was approximately 6mo
ago. She was seen at an OSH in the last week for this as
well. She reports no trigger for onset of pain, not related to
foods or anything else she can identify. She reports pain
started again last night. She describes the pain as a pressure
and "twisting from the inside", radiating up to her L chest. She
reports past similar episodes thought gastroparesis or
"splenic flexure syndrome", which she reports are the diagnoses
from her PCP. Pt reports she usually gets her symptoms treated
with reglan, pain meds (IV dilaudid) and antiemetics. She
reports last night she did have some nausea without emesis. She
reports a couple days of mild diarrhea (a couple episodes of
loose stool daily) last week. No dysuria or urinary frequency
but does feel she strains to urinate. No fevers. SOB only when
LUQ pain occurs. She also reports "neck spasm" which she reports
is like a tight band in the front of her neck, also something
she has had many times before of unclear etiology. She reports
ativan helps with this discomfort.
Per report: Pt had worsening of pain today, seen at ,
and transferred here for teriary level care. Dr. was
documented as her rheumatologist at ( had no beds for
her). Had neg abd CT at last week.
## DOCUMENTATION:
Pt given 1mg IV dilaudid, 10mg
PO reglan, 50mg PO benadryl, 1mg PO ativan. Pt noted to have
increased tone in anterior SCMs. No CT abd report included.
In the ED intial vitals were: 97.4 77 116/66 16 96% ra. Labs
were black. CXR done. Patient was given: 1mg PO ativan. Pt had
already received reglan and ativan at OSH. Pt reports Morphine
does not help her and this pain has been thought
gastroparesis so ativan and reglan help most. She did say that
while morphine does not help, IV dilaudid does. Vitals on
transfer:97.8 59 131/72 16 96% RA.
On arrival to the floor, pt reports LUQ pain that is now
worse after moving around to go to the bathroom. Denies nausea.
Pt tells me her rheumatologist is Dr at ,
not a Dr. at .
## PAST MEDICAL HISTORY:
- SLE - dx at age
- RA
- Fibromyalgia
- IDDM
## - FATHER:
rheumatism
- aunts x3 with SLE
- Mother: OA
- : RA
## PHYSICAL EXAM:
ADMISSION
Vitals- 97.5, 132/91, 69, 18, 97% RA
General- obese, white female, in NAD
Neck- supple, no significant tenderness, full ROM
CV- RRR, no mumurs
Lungs- Clear to auscultation bilaterally, breathing comfortably
Abdomen- soft, obese, mild LUQ tenderness, ND, +BS, no rebound
or guarding
Back- no significant CVAT
Ext- warm, well perfused, no edema
## GENERAL:
Appears comfortable with sad affect but in NAD
## HEENT:
Sclera anicteric, dry MM, oropharynx clear
## NECK:
supple, full ROM, no LAD, no muscle spasm
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
soft, obese, tender but distractable on exam,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## SKIN:
Mild erythema throughout face
## NEURO:
CN II - XII intact
## BRIEF HOSPITAL COURSE:
w/ hx of lupus presents w/ recurrent LUQ abd pain.
# LUQ pain: recurrent issue for yrs previously thought
gastroparesis, which would be atypicals as that usually
manifests with inability to tolerate POs as opposed to pain. Pt
had a CT abd at the OSH per report which was unremarkable for an
alternative cause of her pain and no other explanation has been
found that pt can report. Her GI workup includes normal EGD and
colonoscopy in . She does have a complex history of pain
and significant polypharmacy. Fibromyalgia or other pain
syndrome could be contributing. The DDx for recurrent LUQ pain
would include PUD/gastritis/dyspepsia (pt already on a PPI),
pancreatitis (not evident based on description of pain and
normal lipase), a splenic process (infarcts can cause this type
of pain but it would be atypical for recurrence over yrs).
Pt's EKG is without ischemic changes, trop was negative and
description is not c/w cardiac pain. She does not have pulmonary
symptoms to suggest this is a recurrent pulmonary process or
PNA. Patient was admitted but tolerated PO well and used her PO
oxycodone for pain control She did not require inpatient care
was discharged for outpatient further workup with her previously
established specialists.
# Neck discomfort: No current evidence of muscle spasm. Pt notes
band of tightness across her anterior neck. She describes the
feeling like food would become stuck if she swallowed it, but
when she eats the food does not get stuck. Potentially globus
vs. manifestation of fibromyalgia. No evidence of thrush on
mouth exam and patient taking POs. No muscle spasm or evidence
of dystonia. Further workup deferred to outpatient.
# SLE/RA: Pt reports history of both SLE and RA, which is quite
atypical. We do not have records here of this and pt reports she
gets her rheum care at .
- continued plaquenil
# IDDM:
- SSI, lantus
- cont cymbalta, gabapentin
# GERD:
- cont PPI
## TRANSITIONAL ISSUES:
- consider further workup of abdominal pain as outpt
- consider workup of abnormal throat sensation as outpatient
- clarify autoimmune diagnosis, rare to have both SLE and RA
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Ambien CR (zolpidem) 12.5 mg oral QHS
2. Amitriptyline 10 mg PO PRN pain
3. Aspirin 81 mg PO DAILY
4. Baclofen 10 mg PO TID
5. Duloxetine 120 mg PO DAILY
6. Estradiol 2 mg PO DAILY
7. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
8. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain
9. Hydroxychloroquine Sulfate 400 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Savella (milnacipran) 100 mg oral BID
12. Tizanidine 4 mg PO TID
13. Vitamin D 1000 UNIT PO DAILY
14. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
15. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous Weekly
on FRI
16. Metoclopramide 10 mg PO QIDACHS
17. diclofenac sodium Dose is Unknown topical PRN pain
18. Sumatriptan Succinate 6 mg SC X1:PRN migraine
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN
21. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
22. Lidocaine Viscous (lidocaine HCl) 2 % mucous membrane PRN
23. Loratadine 10 mg PO PRN allergies
24. Propantheline Bromide Dose is Unknown PO Frequency is
Unknown
25. Gabapentin 400 mg PO TID
26. Gabapentin 400 mg PO HS
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
2. Baclofen 10 mg PO TID
3. Duloxetine 120 mg PO DAILY
4. Gabapentin 400 mg PO TID
5. Gabapentin 400 mg PO HS
6. Hydroxychloroquine Sulfate 400 mg PO DAILY
7. Glargine 20 Units Breakfast
8. Metoclopramide 10 mg PO QIDACHS
9. Omeprazole 20 mg PO DAILY
10. Tizanidine 4 mg PO TID
11. Vitamin D 1000 UNIT PO DAILY
12. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
13. Ambien CR (zolpidem) 12.5 mg oral QHS
14. Amitriptyline 10 mg PO PRN pain
15. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous Weekly
on FRI
16. Estradiol 2 mg PO DAILY
17. Lidocaine Viscous (lidocaine HCl) 2 % mucous membrane PRN
18. Loratadine 10 mg PO PRN allergies
19. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
20. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain
21. ProAir HFA (albuterol sulfate) 90 mcg INHALATION PRN SOB
22. Savella (milnacipran) 100 mg oral BID
23. Sumatriptan Succinate 6 mg SC X1:PRN migraine
## SECONDARY DIAGNOSES:
Chronic pain
Fibromyalgia
IDDM
RA
SLE
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted after being transferred from
for abdominal pain. While hospitalized you were given oral pain
medications and you were able to eat and drink. We did not
identify a cause of your abdominal pain while you were
hospitalized here, but it does not appear to be acutely life
threatening. You can continue with a planned outpatient workup
for the cause of your pain.
It was a pleasure taking care of you here at !
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10987086", "visit_id": "29364332", "time": "2178-03-30 00:00:00"} |
15220151-RR-42 | 62 | ## INDICATION:
Prior C-section, evaluate fetal weight.
## :
.
There is a single live intrauterine fetus in cephalic position. Placenta is
anterior without previa. Amniotic fluid volume is normal. Views of the fetal
head, face, kidneys, bladder, stomach were normal. The following biometric
data were obtained:
## ESTIMATED FETAL WEIGHT:
1469 grams, percentile based on LMP.
## IMPRESSION:
Size 13 days less than dates.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15220151", "visit_id": "N/A", "time": "2183-08-16 08:50:00"} |
17856161-RR-34 | 100 | ## HISTORY:
Right knee pain. Evaluate for fracture or degenerative change.
## FINDINGS:
AP view of the bilateral knees and 2 additional views of the right knee
demonstrate no acute fracture, dislocation, or effusion. There is moderate
tricompartmental osteoarthritis on the right, most prominent in the lateral
compartment. There is a minimal to no right joint effusion. A bipartite
patella on the right is redemonstrated. There are mild degenerative changes
of the left knee on the single AP view. There is no focal lytic or sclerotic
## IMPRESSION:
Tricompartmental osteoarthritic changes of the right knee with minimal to no
joint effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17856161", "visit_id": "N/A", "time": "2168-01-13 13:43:00"} |
12501777-RR-29 | 301 | ## INDICATION:
year old woman with myeloma on lenalidomide abdominal pain
constipation and diarrhea, evaluate for SB Crohn's or tethering from adhesions
## MR ENTEROGRAPHY:
There is an approximately 9 cm segment of mid ileum which demonstrates mural
edema, mucosal hyperenhancement on the early phase and transmural enhancement
on the delayed phase, with associated engorgement of the mesenteric vessels
and prominent adjacent mesenteric lymph nodes, compatible with moderate acute
on chronic inflammation (13: 33, 47; 10:38). This segment demonstrates normal
motion on the dynamic images. There is also hyperenhancement of the terminal
ileum. There is no obstruction, fistula, or extraluminal fluid collection.
There is mild sigmoid diverticulosis without evidence of diverticulitis.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Limited images of the lung bases demonstrate no pleural effusion. There is
unchanged mild intrahepatic and moderate extrahepatic ductal dilatation with
smooth tapering of the CBD near the ampulla, within expected limits post
cholecystectomy. Imaged portions of the inferior liver are unremarkable. The
spleen is normal in size without focal lesion. The adrenal glands are
unremarkable. Simple cysts are seen within the kidneys. There is no
hydronephrosis. The pancreas is normal in signal intensity and morphology
without lesion or ductal dilatation.
There is no lymphadenopathy. There is no abdominal aortic aneurysm. Major
mesenteric branch vessels are patent.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The uterus is not visualized. There is no adnexal abnormality. There is no
free fluid pelvis.
Numerous enhancing lesions throughout the visualized bones are consistent with
known multiple myeloma.
## IMPRESSION:
1. Moderate acute on chronic inflammation of a 9 cm segment of the mid ileum,
as well as inflammation of the terminal ileum. Taken together, findings are
most consistent with Crohn's disease.
2. Numerous enhancing osseous lesions, consistent with known multiple myeloma.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12501777", "visit_id": "N/A", "time": "2181-12-17 14:50:00"} |
16523736-RR-18 | 104 | ## INDICATION:
male with right upper quadrant pain and tenderness to
palpation after eating. Evaluate for cholelithiasis or cholecystitis.
## RIGHT UPPER QUADRANT ULTRASOUND:
The liver demonstrates diffusely increased
echotexture, consistent with fatty infiltration. No focal mass lesion is
identified in the liver. There is no intra- or extra-hepatic biliary ductal
dilatation and the common bile duct measures 4 mm. The main portal vein is
patent with hepatopetal flow. The gallbladder is normal. There is no
ascites.
## IMPRESSION:
1. Normal gallbladder without cholelithiasis.
2. Hepatic steatosis. Please note that more advanced forms of liver disease
such as cirrhosis or fibrosis are not excluded.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16523736", "visit_id": "29507262", "time": "2111-01-31 14:49:00"} |
15729075-DS-6 | 619 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
year old male with PMH of colon cancer s/p resection and
chemotherapy in and nephrolithiasis s/p right ureteral
stent 1 week prior in presenting with 1 day of fevers,
chills, sweats, mild right flank pain, nausea and vomiting. He
lives in and was visiting friends in the area.
He presented initially to , was febrile up to 103,
leukocytosis of 15.8, creatinine 1.2, blood cultures were sent
(no urinalysis or urine culture sent), he was started on Zosyn
and transferred to . In the ED he had a CT A/P which
showed appropriately positioned stent, mild right
hydronephrosis, fat stranding possibly consistent with
pyelonephritis, small amount of R pericolic gutter fluid raising
possibility of forniceal rupture and non-obstructive stones
bilaterally. Urology was consulted and recommend admission to
medicine. He was given Zosyn.
Currently he reports feeling well aside from mild flushing. He
denies any prior history of urinary tract infections or other
infections.
## ROS:
as above, ten point ROS otherwise negative.
## PAST MEDICAL HISTORY:
colon cancer s/p resection and chemotherapy in
nephrolithiasis s/p right ureteral stent
## FAMILY HISTORY:
Father died of prostate cancer, mother died of breast cancer.
## GEN:
NAD, flushed appearing, lying comfortably in bed
## HEENT:
EOMI, PERRLA, MMM, OP Clear
## CV:
RRR nl s1s2 no m/r/g
## ABD:
soft, NT, ND +BS
## NEURO:
CN II-XII intact, strength throughout
## SKIN:
warm, dry no rashes
On Discharge, stable vitals.
He is a thin, elderly male, extremely pleasant, walking with
ease, NAD
Face - + erythema on nose, nasolabial fold -? rosacea
Lung CTA B
CV RRR
## EXT:
No edema
No flank tenderness
## IMPRESSION:
A double-J ureteral stent is proximally coiled within the right
renal pelvis and distally coiled within the urinary bladder with
mild right hydroureter. There is significant fat stranding
adjacent to the right kidney which may reflect pyelonephritis in
the appropriate clinical setting. Small amount of fluid within
the adjacent right pericolic gutter raises the possibility
forniceal rupture. Nonobstructive nephrolithiasis is bilateral.
## IMPRESSION:
No signs of pneumonia. Lucent hyperinflated lungs suggest
emphysema.
Abnormal contour of the posterior left hemidiaphragm, question
hernia or
eventration
## BRIEF HOSPITAL COURSE:
year old male with PMH of colon cancer s/p resection and
chemotherapy in and nephrolithiasis s/p right ureteral
stent 1 week prior in presenting with 1 day of fevers,
chills, sweats, mild right flank pain, nausea and vomiting found
to have likely complicated pyelonephritis.
#Sepsis due to
#Pyelonephritis, complicated UTI
#Nephrolithiasis s/p stent
Complicated UTI given recent stent placement and question of
forniceal rupture on CT scan. He gets his care in but
denies any prior history of infections. Unfortunately received
antibiotics prior to cultures being sent - so as a result, all
cultures negative.
He was originally started on cefepime while awaiting culture
data and he defervesced within 36 hours. All blood and urine
cultures (2 sets blood, 1 set urine) were negative, however.
He was switched to oral ciprofloxacin and remained afebrile. He
will take an additional 11 days of medication to complete a 2
week course. He has been instructed to f/u with his doctors in
regarding timing of removal of stent.
# Anemia - patient with mild, stable anemia. Unknown baseline.
Should f/u with PCP
## # THROMBOCYTOPENIA:
due to infection, improved over the course
of admission.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
## DISCHARGE DIAGNOSIS:
1. Pyelonephritis causing sepsis
## DISCHARGE INSTRUCTIONS:
You were admitted with high fevers, and evidence of kidney
infection. You improved substantially with antibiotics, and are
ready for discharge. Please follow up with your doctors in
regarding removal of the stent.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15729075", "visit_id": "26306380", "time": "2148-06-19 00:00:00"} |
10730236-RR-21 | 135 | ## INDICATION:
yo with strong family history of breast and ovarian cancer,
assess ovaries.
## FINDINGS:
The uterus is anteverted and measures 9.7 cm x 4.4 cm x 5.0 cm. The
endometrium is homogenous and measures 6 mm. There is an intrauterine device
within the endometrial cavity in appropriate position.
There is redemonstration of a complex right intra-ovarian cystic structure
with low level internal echoes measuring 4.3 x 2.9 x 3.6 cm, previously
measuring 1.7 x 1.7 x 0.6 cm. The left ovary is normal. There is no free
fluid.
## IMPRESSION:
1. Slight interval enlargement of a complex right intra-ovarian cystic
structure measuring 4.3 cm, which given persistence over multiple prior exams
likely represents an endometrioma.
2. Intrauterine device is in appropriate position.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10730236", "visit_id": "N/A", "time": "2173-09-29 13:27:00"} |
10851337-DS-19 | 981 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Mr. is a man with HTN, adenocarcinoma of
the colon s/p R colectomy, and DM2 who presents with HTN and
confusion. He has been in for the last years, but
there has been a question of elder abuse where his daughter was
withholding medications from him so he has not been taking
medications. A friend found out and moved him up to . She
noticed there was something wrong and had him see a PCP .
During the visit, the PCP found him to be confused with SBP to
180 so sent him to the ED for BP management.
On arrival, SBP in the 130s. He reports feeling dizzy when
standing that started a little while ago. He is unable to give
specific dates, and he was a very poor historian.
Denies headache currently. Endorses some tingling in his feet.
Feel once last year and once months ago from standing
because he was feeling dizzy. Unable to give more history than
this.
Feels like his memory is starting to go, very stressed about the
whole situation with his daughter.
## PAST MEDICAL HISTORY:
-Colectomy for Adenocarcinoma
- Diabetes
- Hypertension
- cervical radiculopathy
- spinal stenosis
- Cholecystectomy
## FAMILY HISTORY:
Pt states he has no idea about medical family history. Both his
parents passed away but he is unclear what this is from. He has
2 brothers and 1 sister who are older than he. He has 3 sons and
daughters who he sees irregularly. He is divorced.
## HEENT:
NCAT, no oropharyngeal lesions, neck supple
## PULMONARY:
breathing comfortably on RA
## - MENTAL STATUS:
Awake, alert, oriented to self only, does not
know place or date/year. Unable to relate history. Inattentive,
unable to name backward without difficulty. Speech is fluent
with full sentences, intact repetition, and intact verbal
comprehension. Naming intact to high frequency objects only.
Does not know how to read. No paraphasias. No dysarthria.
Normal prosody. Able to follow both midline and appendicular
commands.
## - CRANIAL NERVES:
PERRL 3->2 brisk. VF full to number counting.
Does not bury sclerae bilaterally. No nystagmus. V1-V3 without
deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength bilaterally.
Tongue midline.
## - SENSORY:
No deficits to light touch throughout
## - COORDINATION:
No dysmetria with finger to nose testing
bilaterally.
## IMPRESSION:
No acute intrathoracic process.
CT head
## IMPRESSION:
Subtle hyperdensity in the left thalamus is indeterminate though
appearance is
inconsistent with acute hemorrhage. No significant surrounding
edema or mass
effect. MRI is recommended for further characterization.
EEg
## IMPRESSION:
This telemetry captured no pushbutton activations.
It showed some
mildly disorganized background but normal frequencies in all
areas. There were
no areas of prominent focal slowing, and there were no
epileptiform features
or electrographic seizures.
MRI brain
## IMPRESSION:
This telemetry captured no pushbutton activations.
It showed some
mildly disorganized background but normal frequencies in all
areas. There were
no areas of prominent focal slowing, and there were no
epileptiform features
or electrographic seizures.
CTA head and neck
## IMPRESSION:
1. Hyperdensity at the left posterior thalamus in the region of
a
developmental venous anomaly is not thought to represent
hemorrhage and is
unchanged in comparison with CT head from .
2. Developmental venous anomaly in the left posterior thalamus.
3. Otherwise unremarkable CTA head and neck.
## BRIEF HOSPITAL COURSE:
man with colon adenocarcinoma s/p R colectomy, HTN, and DM
presents with confusion and hypertension. The duration of
confusion/cognitive decline is uncertain. He underwent an MRI
brain w/o contrast which showed developmental left thalamic
venous anomaly. cEEG was negative for seizure. labs were notable
for low B12, for which he was started on B12 repletion, HIV was
negative, RPR****
He was noted to have evidence of uncontrolled moderate
hypertension for which he was started on amlodipine 5mg which
was eventually increased to amlodipine 10mg daily and HCTZ 25 mg
daily.
His Tele was noted to have episodes of multifocal atrial
tachycardia. He underwent a TTE which showed mild global
hypokinesis and LVH, with a mildly decreased EF of 40%.
Cardiology was consulted and recommended initiation of verapamil
and outpatient follow up.
He has a complex social hx, recently moved to from
where he lived with his daughter. There was concern for
elderly abuse for which social work was consulted and
recommended discharge to home to live with his good friend
.
He was seen by OT who recommended discharge home. He will
follow-up with his PCP, and Neurology.
## TRANSITIONS OF CARE ISSUES:
1. Please follow up with your primary care physician 1
week
2. Please call the number listed on the discharge worksheet to
follow up with Cardiology, please state that you were
seen by Dr. in the hospital and need a follow up.
3. Ask your PCP to set you up with outpatient neurology follow
up
4. Please take all of your medications as prescribed including
vitamin B12, Verapamil and for HCTZ.
## DISCHARGE MEDICATIONS:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Verapamil SR 240 mg PO Q24H
## MENTAL STATUS:
Confused - at times
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to after you were noted to have
difficulty with feeling dizzy, confused, and were found to have
high blood pressure. Your blood pressure was slowly decreased
down which helped with your symptoms. You also had an extensive
cardiac work up as we noted your heart rate to be beating very
rapidly. Cardiology evaluated you and we put you on a new
medication called verapamil to control your heart rate.
It is very important that you continue to take your medications
to control your blood pressure as we already see some mild
changes in your heart due to high blood pressure. We wish you
the best !
Sincerely,
Your Neurology Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10851337", "visit_id": "24139599", "time": "2192-08-16 00:00:00"} |
12567079-RR-18 | 117 | ## INDICATION:
h/o ovarian cyst presents with right flank pain// r/o ovarian
cyst rutpure
## FINDINGS:
The uterus is anteverted and measures 7.2 cm x 3.2 cm x 4.7 cm. The
endometrium is homogenous and measures 5 mm.
The right ovary contains a hypoechoic lesion measuring 1.4 x 1.6 x 2.0 cm
which may represent a collapsing hemorrhagic cyst or endometrioma. The left
ovary is normal. There is no free fluid.
## IMPRESSION:
Right ovarian hypoechoic lesion may represent a hemorrhagic cyst or
endometrioma. Follow-up pelvic ultrasound in weeks is recommended given
patient's reported history of right lower quadrant pain.
## RECOMMENDATION(S):
Follow-up pelvic ultrasound in weeks.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12567079", "visit_id": "N/A", "time": "2191-10-19 12:53:00"} |
19458735-RR-27 | 170 | ## INDICATION:
with heavy periods, rule out mass.
No prior examinations.
## PELVIC ULTRASOUND:
Transabdominal and transvaginal ultrasound were performed,
the latter for better delineation of the uterus, ovaries and endometrium. The
uterus measures 10.2 x 3.7 x 6.6 cm and is anteverted. The endometrial stripe
measures 8 mm. The endometrium is slightly heterogeneous, with ill-
defined echogenic foci in the superior and inferior aspects which distort the
endometrial stripe. These may represent impression on the endometrial stripe
by fibroids, or small polyps. There is a left fundal fibroid measuring 5.5 x
5.3 x 6.5 cm. There are several other small fibroids within the myometrium.
The ovaries are normal with a 24-mm follicle noted within the left ovary.
There is no free fluid or hydronephrosis.
## IMPRESSION:
1. Heterogeneous endometrium with two ill defined echogenic foci which may
represent impression by submucosal fibroids or polyps. A sonohysterogram or
biopsy are recommended for further evaluation.
2. Left fundal fibroid, measuring up to 6.5 cm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19458735", "visit_id": "N/A", "time": "2117-04-10 09:47:00"} |
17290113-DS-26 | 1,115 | ## CHIEF COMPLAINT:
left leg radidular pain
## HISTORY OF PRESENT ILLNESS:
A year old female with pain in the left lower extremity.
Pain is posterior to the heel to the whole foot. It has never
been that bad or debilitating. She is not able to walk more than
a block. No weakness. No bowel or bladder problems.
## PAST MEDICAL HISTORY:
Composite lymphoma
IDDM years
CAD s/p stents in
HLD
Asthma
Hypercholesterolemia
Hypertension
Hypothyroidism
Pneumonitis
GERD
Laparoscopic cholecystectomy
Tonsillectomy.
Cesarean delivery x2.
Laparotomy and retroperitoneal lymphadenectomy.
TAH/BSO
Back surgeries
## FAMILY HISTORY:
Father died of lymphoma, Mother died of heart disease, T2DM,
Grandmother- breast cancer, Sister passed from sudden death at
, ? stroke vs. heart disease, No ovarian, uterine, or colon
cancer in the family
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, poor dentition, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
ronchi
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
soft, non-tender, non-distended, bowel sounds present,
scar midline
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## HEENT:
Pupils: 3->2 b/l EOMs
## EXTREM:
Warm and well-perfused. No C/C/E.
## SKIN:
bruise over R forehead.
## MENTAL STATUS:
Awake and alert, cooperative with exam, normal
affect.
## ORIENTATION:
Oriented to person, place, and date.
## LANGUAGE:
Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
## II:
Pupils equally round and reactive to light, to
mm bilaterally (3->2mm). Visual fields are full to
confrontation.
## III, IV, VI:
Extraocular movements intact bilaterally without
nystagmus.
## V, VII:
Facial strength and sensation intact and symmetric.
## VIII:
Hearing intact to finger rub bilaterally.
## XI:
Sternocleidomastoid and trapezius normal bilaterally.
## XII:
Tongue midline without fasciculations.
## MOTOR:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength: in LUE shoulder pain. Otherwise full
power throughout. No pronator drift
## SENSATION:
decreased over lateral aspect of LLE. otherwise SILT.
## BRIEF HOSPITAL COURSE:
The patient was admitted to the Neurosurgery Service for
decompression of her lumbar stenosis. The patient tolerated the
procedure without complications and was transferred to the PACU
in stable condition. Please see operative report for details.
Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs.
She was seen and evaluated by physical therapy who felt that she
would benefit from acute rehab. She was screened for rehab and
on was offered a bed which was accepted. She was deemed fit
for discharge on the afternoon of and was discharged to
rehab with instructions for follow-up. At the time of discharge
she is tolerating a regular diet and afebrile with stable vital
signs.
## MEDICATIONS ON ADMISSION:
1. Atorvastatin 40 mg Tablet QHS
2. Toprol XL 50 mg QD.
3. Levothyroxine 100 mcg PO QD
4. Multivitamin
5. Aspirin 81 mg Tablet QD
6. Omeprazole 20 mg Capsule QD
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen PRN pain/headache.
9. Senna PRN constipation.
10. Docusate sodium 100 mg PRN constipation
11. Bisacodyl 5 mg Tablet, PRN Constipation
12. Nitroglycerin 0.3 mg SL PRN
13. insulin glargine 100 SC QD
14. insulin aspart 100 unit/mL SS
## DISCHARGE MEDICATIONS:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/headache.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may repeat x 3 doses if chest pain is unrelieved, 15 minutes
apart as long as SBP is > 90.
## 10. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
Tablets PO
Q4H (every 4 hours) as needed for pain.
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
## FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17290113", "visit_id": "26004125", "time": "2189-01-03 00:00:00"} |
12035507-RR-43 | 637 | ## INDICATION:
male with metastatic small cell lung cancer presents
with constipation, abdominal pain, nausea and vomiting for 4 days. Please
evaluate for bowel obstruction versus constipation versus abdominal
metastasis.
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## LOWER CHEST:
Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is an ill-defined hypodense lesion in segment VII, compatible with
metastasis and better delineated on the recent staging CT 12 days prior
(series 2: Image 20). A previously noted caudate lobe lesion is not seen on
this exam. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits. The hepatic and portal
veins are patent.
## 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:
There are innumerable ill-defined hypodense lesions throughout the
bilateral kidneys compatible with metastasis including a dominant 2.5 x 2.7 cm
left interpolar lesion and a 2.4 x 2.0 cm right interpolar lesion (series
2:image 30, 25). These appear relatively similar in number, size and
distribution from the prior CT (series 601b:image 44) There is no
hydronephrosis.
## GASTROINTESTINAL:
The stomach is fluid-filled and distended. There are
dilated fluid-filled bowel loops measuring up to 4.2 cm in diameter. There is
a transition point noted along the left lower abdomen/pelvis (series 2:image
60, 57). The distal small bowel with is collapsed. The colon and rectum are
within normal limits The appendix is normal.
## PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The prostate and seminal vesicles are normal.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy.
Minimally prominent left periaortic retroperitoneal lymph nodes are not
pathologically enlarged by CT size criteria. There is no pelvic or inguinal
lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. The abdominal aorta and its major branches are patent.
## BONES:
A 1.6 x 1.0 cm lytic lesion in the right iliac bone is similar to
prior exam(series 2:image 66). A sclerotic posterior left ninth rib lesion is
also stable (series 2:image 11). A 2.1 cm lytic lesion involving the right
T11 pedicle and posterior elements is again noted (series 2: Image 15). No
acute fracture is noted.
## SOFT TISSUES:
There is a 2.5 x 1.9 cm peripherally enhancing lesion along the
right anterolateral abdominal wall, minimally changed from prior exam when it
measured 2.1 x 1.7 cm (series 2:image 40). Adjacent surgical clips are noted.
There is also a partially imaged 1.6 x 1.3 cm right paraspinal enhancing mass
(series 2:image 1). A 1.7 x 1.7 cm enhancing right upper vastus lateralis
lesion is unchanged (series 2:image 70).
## IMPRESSION:
1. Dilated fluid-filled stomach and small bowel loops measuring up to 4.2 cm
with a transition point noted along the left lower abdomen reflective of a
small bowel obstruction.
2. Similar innumerable renal masses and right hepatic lesion reflective of
intra-abdominal metastasis.
3. Similar osseous metastatic disease involving the right T11 posterior
elements, right iliac bone and posterior left ninth rib.
4. Similar soft tissue metastasis along the right anterolateral abdominal
wall, right paraspinal musculature and right upper vastus lateralis muscle.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12035507", "visit_id": "27000661", "time": "2182-12-30 20:25:00"} |
17537741-RR-26 | 414 | ## EXAMINATION:
CTA NECK WANDW/OC AND RECONS Q25 CT NECK
## INDICATION:
year old woman with pathologic c6 fracture from metastatic
small cell lung cancer// Visualize the osseous structures and vertebral
arteries and plan a safe route for access for kypho/vertebroplasty as
requested by and , . OSH images did not have
sagital reconstruction
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 16.1 mGy (Head) DLP = 3.2
mGy-cm.
2) Stationary Acquisition 2.1 s, 0.2 cm; CTDIvol = 37.7 mGy (Head) DLP =
7.5 mGy-cm.
3) Spiral Acquisition 3.9 s, 25.6 cm; CTDIvol = 35.9 mGy (Head) DLP = 896.3
mGy-cm.
Total DLP (Head) = 907 mGy-cm.
## FINDINGS:
Seen again is a pathologic C6 compression fracture with associated soft tissue
mass extending into the epidural and paraspinal space. The right vertebral
artery is noted to pass through the right paraspinal component of this soft
tissue mass, with mild attenuation of the vessel caliber. However, the vessel
does remain patent.
The remainder of the right vertebral artery, left vertebral artery, and
bilateral common carotid arteries also remain patent.
Partially calcified atherosclerotic disease is seen at the right carotid bulb.
However, there is no evidence of internal carotid artery stenosis by NASCET
criteria seen bilaterally.
The imaged lung apices demonstrate extensive fibrotic changes, right greater
than left, in addition to numerous bilateral pulmonary nodules.. Partially
imaged mediastinal and bilateral hilar lymphadenopathy is noted with extension
into the thoracic inlet. Multiple prominent bilateral cervical lymph nodes
are also seen, although not technically pathologically enlarged by CT size
criteria.
A large heterogeneous nodule within the right thyroid lobe measures 2.5 x 1.5
cm demonstrates indistinct borders. Multiple additional smaller,
subcentimeter thyroid nodules are also seen bilaterally.
## IMPRESSION:
1. Known soft tissue mass centered around the C6 vertebral body with
involvement of the paraspinal and epidural space and associated C6 vertebral
body compression fracture.
2. The right vertebral artery is completely encased by tumor at the level of
C6, with mild attenuation of the vessel caliber.
3. Allowing for this, the cervical vasculature remains patent throughout
without high-grade stenosis or vessel occlusion.
4. Dominant right thyroid nodule measuring up to 2.5 cm, with numerous smaller
nodules seen bilaterally. Recommend follow-up with nonurgent thyroid
ultrasound.
5. Partially imaged sequelae of known small cell lung cancer, including
mediastinal and hilar lymphadenopathy, with numerous pulmonary nodules and
fibrotic changes seen at the lung apices.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17537741", "visit_id": "20841337", "time": "2154-08-13 14:16:00"} |
15593032-RR-55 | 486 | ## INDICATION:
year old woman with fistulizing Crohn's disease. // Assess
for fistula/abscess.
## MR ENTEROGRAPHY:
Patient is status post right hemicolectomy and procedure with left
lower quadrant colostomy. There is a small pericolonic fistula arising from
the colonic loop at the colostomy site (series 15, image 7 and series 19,
image 58) extending inferiorly to the periphery of the parastomal hernia
inferiorly where there is a small fluid collection that appears to have
improved in size when compared to prior CT of the abdomen dated . There is also linear tract of inflammatory disease that appears to
tether a small bowel loop crossing adjacent to the colostomy site (series 19,
image 54). The remainder small bowel loops appear within normal limits with
no evidence of small bowel wall thickening, submucosal edema or mucosal
hyperenhancement to suggest active inflammatory disease. The neoterminal
ileum is within normal limits. The anastomosis site is patent. There is no
evidence of small bowel stricturing or proximal small bowel dilatation. No
intraperitoneal abscess collections.
The distal transverse and descending colon appear ahaustral related to chronic
inflammatory disease with multiple enhancing inflammatory pseudopolyps (series
1801, image 46).
There is a small hiatal hernia.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Liver demonstrates normal contours. There is slightly ill-defined T2
hyperintense lesion within segment VII (series 11, image 10) that demonstrates
enhancement on the postcontrast images that progresses on the more delayed
phases, without worrisome features and is stable from prior MRI in , most likely a hemangioma. Patient is status post cholecystectomy.
There is no intrahepatic or extrahepatic biliary duct dilatation. No biliary
duct wall irregularity or beading to suggest primary sclerosing cholangitis.
The common bile duct tapers normally towards the ampulla without obstructing
filling defects.
The spleen is normal in size and signal characteristics. It enhances
homogeneously without suspicious mass lesion. The pancreas and adrenal glands
are normal bilaterally. There are bilateral simple renal cortical cysts. The
kidneys are otherwise normal without suspicious renal masses or
hydronephrosis.
There are no suspicious mesenteric or retroperitoneal lymphadenopathy by size
criteria. No ascites.
Left parastomal hernia through an anterior fascial defect measuring 8.2 cm in
transverse dimension.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
Anteverted uterus. No adnexal mass lesions. No free fluid in the pelvis. No
pelvic lymphadenopathy. No suspicious osseous or soft tissue mass lesions.
## IMPRESSION:
1. Small pericolonic fistula arising from the colonic loop at the colostomy
site extending inferiorly to the periphery of the parastomal hernia inferiorly
with a small fluid collection that appears to have decreased in size when
compared to prior CT of the abdomen dated .
2. The small bowel loops, including the neoterminal ileum are within normal
limits with no evidence of active inflammatory disease. No bowel stricturing
or proximal bowel dilatation. No intraperitoneal abscess collections.
3. Ahaustral distal transverse and descending colon with multiple
inflammatory pseudopolyps related to chronic inflammatory disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15593032", "visit_id": "N/A", "time": "2196-06-13 07:20:00"} |
17112471-RR-24 | 266 | ## HISTORY:
man with history of stone and elevated white count.
Assess for stone.
## CT ABDOMEN WITHOUT CONTRAST:
The visualized lung bases are clear without
pleural effusion. A tiny calcific granuloma is noted in the left lower lobe.
The absence of IV contrast limits evaluation of intra-abdominal parenchymal
organs. Allowing for the limitation, the borderline fatty liver is without
focal lesions. The spleen, gallbladder, pancreas, adrenal glands are normal.
The stomach, duodenum and loops of small bowel are unremarkable.
In the right kidney, a punctate non-obstructing stone is noted in the mid
calyx (image 2:35). There is no right-sided hydroureteronephrosis.
In the left kidney, there are multiple renal stones, with the largest one in
the right UPJ, measuring up to 13 mm. The second largest one is noted in the
mid calyx, measuring 7 mm. There is also a tiny punctate stone in the lower
calyx (image 2:45). Mild left-sided hydronephrosis is noted, but without
left-sided hydroureter. Left perinephric stranding is noted. There is no
evidence of perinephric fluid collection.
There is no free fluid, air or lymphadenopathy in the intra-abdominal cavity.
## CT PELVIS WITHOUT CONTRAST:
The urinary bladder is normally distended without
focal abnormalities. The colon is noted with diverticulosis without acute
diverticulitis. There is no free fluid, air or lymphadenopathy in the pelvis.
## BONE WINDOW:
There are no suspicious lytic or sclerotic lesions. Multilevel
degenerative changes are mild-to-moderate at the thoracolumbar junction.
## IMPRESSION:
12 mm obstructing left UPJ stone resulting mild left-sided hydronephrosis and
perinephric fat stranding. Additional nonobstructing bilsteral renal stones.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17112471", "visit_id": "N/A", "time": "2161-08-22 02:27:00"} |
15571472-RR-62 | 75 | ## INDICATION:
woman with fall, on warfarin.
## FINDINGS:
No acute intracranial hemorrhage, large vascular territory infarct, shift of
midline structures or mass effect is present. The ventricles and sulci are
prominent consistent with age-related involutional changes. There is mild
periventricular white matter hypoattenuation consistent with sequelae of small
vessel ischemic disease. The visible paranasal sinuses and mastoid air cells
are well aerated. No fractures are present.
## IMPRESSION:
No acute intracranial process or fractures.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15571472", "visit_id": "N/A", "time": "2137-07-09 13:00:00"} |
15007980-RR-26 | 94 | ## INDICATION:
man with intermittent dizziness, evaluate for
intracranial hemorrhage or mass.
## FINDINGS:
There is no intracranial hemorrhage, infarct in major vascular
territory, mass, mass effect or edema. Ventricles, sulci and cisterns are of
normal configuration and size for age. There are prominent bi-frontal extra-
axial low density collections that may represent subdural hygromas versus
chronic, evolved subdural hematomas.
There is no fracture. Mastoid air cells and visualized paranasal sinuses are
clear.
## IMPRESSION:
1. No acute intracranial process.
2. No mass detected; MR is more sensitive for the detection of small masses.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15007980", "visit_id": "N/A", "time": "2200-03-14 15:30:00"} |
19405153-RR-29 | 108 | ## HISTORY:
Patient status post redo sternotomy, mitral valve repair, evaluate
for effusion.
## FINDINGS:
Frontal and lateral chest radiographs were obtained.
There is interval improvement in bilateral pleural effusions and associated
bibasilar atelectasis. There is an apparently new retrosternal lucency, which
is difficult to assess due to suboptimal positioning on the lateral view. No
focal consolidation, pneumothorax, or pulmonary edema is seen. Postoperative
cardiomediastinal silhouette and hilar contours are stable.
## IMPRESSION:
1. Interval improvement in bilateral pleural effusions and adjacent
atelectasis.
2. Retrosternal lucency, possibly related to postoperative gas collection
versus pre-existing bullae. Repeat lateral CXR with improved positioning may
be helpful for initial further evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19405153", "visit_id": "28401269", "time": "2120-06-27 10:47:00"} |
13833942-RR-30 | 105 | PA AND LATERAL CHEST
## HISTORY:
Pericardiectomy. Check interval change.
## IMPRESSION:
AP chest compared to postoperative chest radiographs since
:
The bulge in the apparent left heart contour which developed between and is still present. Whether this is herniation of left
ventricle through the operative pericardial defect, a fluid collection along
the heart or mediastinum, or a left ventricular aneurysm or hematoma is
entirely indistinguishable by conventional radiographs. There is much better
aeration in the left lower lobe and only a small amount of pleural fluid on
either side of the chest. The right lung is clear. NP covering for
was paged to report these findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13833942", "visit_id": "25150613", "time": "2140-05-04 10:19:00"} |
17589576-DS-8 | 2,127 | ## HISTORY OF PRESENT ILLNESS:
Mr. is a year old male with a PMH of obesity s/p
gastric bypass, chronic diastolic heart failure, chronic pain
syndrome, and recent admissions for recurrent left lower
extremity cellulitis, who presents with worsening left lower
extremity erythema.
Patient is a somewhat difficult historian - he will quickly
"zone
out" in the middle of sentences and requires frequent
re-orientation. He reports that he has been on antibiotics for
his cellulitis, but over the past few days has had increasing
swelling and redness that has gone past the previous line that
was drawn to mark the border. He has not had any fevers or
chills. This has also been associated with worsening pain.
Therefore he presented to the ED.
Per review of records, patient was first admitted at
from with strep pyogenes A bacteremia and cellulitis.
He was initially started on vanc/zosyn, and narrowed to
ceftriaxone. A TTE showed no vegetation. He completed a two week
course of ceftriaxone.
Around 4 days after antibiotics were completed, he was found by
his wound care nurse to have a worsening infection. Therefore,
he
re-presented to and was admitted on . He was
again followed by the ID service. Blood cultures at this time
were negative, and superficial wound cultures showed
coagulase-negative staph. He went for a CT of the left leg which
did not show a drainable fluid collection. Surgery was
consulted,
but were unable to intervene. Patient was treated with
ceftriaxone ( ), IV ancef ( ), and ultimately
discharged on PO Keflex for a seven day course. However, since
discharge his leg has again worsened with increased erythema,
spreading past previously marked borders. No fevers or chills.
He
was referred back to the ED.
Regarding his "spells" where he zones out - patient reports that
these first started when he was hospitalized in , and
have been associated with memory loss. He never falls and never
has incontinent episodes. His wife has not reported any
seizure-like activity.
Regarding his depression, he states that he takes wellbutrin and
citalopram. He is not sure why he is listed as having an allergy
to wellbutrin.
Regarding his pain, states that he has chronic pain in his neck,
shoulders, back and hips. He reports that he takes vicodin "4
pills 4 times a day" and morphine at least once a day to try to
help him sleep. He also takes gabapentin three times a day. He
notes that "that stuff turns me into gumby", and notes that they
tried different medications while at , but is not sure
what these were.
## IN THE ED:
Initial vital signs were notable for: T 97.6, HR 69, BP 126/67,
RR 18, 99% RA
## EXAM NOTABLE FOR:
Left lower extremity erythema, induration,
swelling with central punctate wound. Erythema extends beyond
previously demarcated borders.
## STUDIES PERFORMED INCLUDE:
LLE plain films with no evidence of
gas
## PATIENT WAS GIVEN:
1L NS, ceftriaxone, vancomycin
## VITALS ON TRANSFER:
T 98.4, HR 66, BP 107/56, RR 18, 99% RA
Upon arrival to the floor, he recounts the story as above.
## PAST MEDICAL HISTORY:
- chronic diastolic heart failure
- diabetes
- OSA
- Obesity s/p gastric bypass
- chronic pain syndrome
- iron deficiency anemia
- irritable bowel syndrome
- essential hypertension
- depression/anxiety
- two toes on right foot amputated via lawnmower accident
## FAMILY HISTORY:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
## GENERAL:
Alert and in no apparent distress. Requires frequent
redirecting. Will often stop talking in the middle of a
sentence,
appearing to fall asleep. Responds immediately to voice or touch
during these episodes
## EYES:
Anicteric, pupils equally round
## ENT:
Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
## CV:
Heart regular, no murmur, no S3, no S4. No JVD.
## RESP:
Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
## GI:
Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
## GU:
No suprapubic fullness or tenderness to palpation
## MSK:
Left lower extremity with 5x3 raised area of induration on
medial aspect with surrounding erythema outside of original
demarcation demarcation made in ED, which this does not
extend beyond). Painful to palpation. Left and toe
amputation
## SKIN:
Left lower extremity erythema as noted above
## NEURO:
Alert, oriented, face symmetric, gaze conjugate with
EOMI,
rightward jerk nystagmus, speech fluent other than pauses as
noted above, strength exam somewhat limited by pain, but with
encouragement is in distal and proximal muscle groups in
upper and lower extremities, sensation to light touch grossly
intact throughout
## GENERAL:
Patient appears overall fine and robust. He is seated
on
edge of bed with his grooming tools ready to clean up. He seems
more alert, and clear in his thinking today.
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
Neck supple with full range of movement without pain.
Tender to palpation over upper back and neck muscles. C3 step
off
noted which likely corresponds with C3 on C4 anterolisthesis.
strength in upper extremities. JVP low, no LAD appreciated
## LUNGS:
Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
## CV:
Regular rate and rhythm, S1 and S2 clear and of good
quality,
no murmurs, rubs or gallops appreciated
## ABDOMEN:
soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
## EXT:
Erythema deep purple in color, and induration over left
medial, anterior distal , erythema significantly receded from
marked borders. Areas of raised oval shaped lesions without
fluctuance
## NEURO:
CN2-12 grossly in tact, motor and sensory function
grossly
intact in bilateral UE and , symmetric
## ADMISSION LABS:
05:04PM BLOOD WBC-6.8 RBC-3.03* Hgb-9.5* Hct-31.0*
MCV-102* MCH-31.4 MCHC-30.6* RDW-15.6* RDWSD-58.4* Plt
05:04PM BLOOD Neuts-57.0 Lymphs-18.9* Monos-10.1
Eos-12.3* Baso-1.3* Im AbsNeut-3.90 AbsLymp-1.29
AbsMono-0.69 AbsEos-0.84* AbsBaso-0.09*
05:04PM BLOOD PTT-28.9
05:04PM BLOOD Glucose-90 UreaN-23* Creat-0.8 Na-139
K-5.7* Cl-104 HCO3-26 AnGap-9*
05:45AM BLOOD ALT-14 AST-21 CK(CPK)-66 AlkPhos-85
TotBili-0.3
05:45AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.3
03:50AM BLOOD VitB12-508 Folate-18
05:04PM BLOOD CRP-12.3*
03:50AM BLOOD Vanco-9.9*
05:08PM BLOOD Lactate-0.8 K-5. . Minimal anterolisthesis of C3 on C4 with irregular cortical
changes and mild enhancement involving the bilateral facet
joints at C3-C4. The findings are nonspecific and may reflect
facet joint infection, inflammatory arthropathy, or degenerative
changes. No peripherally enhancing fluid collection to suggest
abscess formation at this time. Consider correlation with lab
values and blood cultures.
2. No focal epidural fluid collections.
3. Multilevel multifactorial cervical spondylosis, most
pronounced at C3-C4 with moderate spinal canal narrowing,
progressed from prior exam.
## CXR:
1. Left upper extremity PICC line with tip projecting near the
cavoatrial junction.
2. 8 mm nodular opacity projecting over the right lung field.
Recommend non-urgent CT of the chest for further
characterization.
## RECOMMENDATION(S):
Non urgent CT of the chest for further
evaluation of 8 mm nodular opacity projecting over the right
lung base.
## BRIEF HOSPITAL COURSE:
Mr. is a year old man with a PMH of obesity s/p gastric
bypass, chronic diastolic heart failure, chronic pain syndrome,
and recent admissions for recurrent left lower extremity
cellulitis, who presented with worsening left lower extremity
erythema and neck pain.
# Left lower extremity cellulitis
Patient presented with recurrence of left lower extremity
cellulitis despite cephalexin. Suspected to be from strep A
given
association with bacteremia during initial hospitalization
CRP 12, ESR 36.
#Neck pain:
# Left lower extremity cellulitis
# Cervical Facet joint osteomyelitis
Patient presented with recurrence of left lower extremity
cellulitis despite cephalexin. Likely GAS given recent blood
stream infection during prior admission. Initially treated with
Vancomycin for possible resistance, however no cultures returned
positive, so unlikely. LLE ultrasound and CT scan showed no
fluid
collection to be drained, but extensive subcutaneous edema. ID
was consulted and recommended IV vancomycin/ceftriaxone (day 1 =
which was ultimately transitioned to Ceftriaxone on
discharge. He was also complaining of neck pain. Cervical X-ray
showed C3 on C4 anterolisthesis and CT scan showed mild
anterolisthesis of C3 on C4 new compared to with new
destructive changes at the bilateral facet joints at C3-C4,
raising concern for facet joint infection or inflammatory
arthropathy. MRI showed anterolisthesis of C3 on C4 with
irregular cortical changes and mild enhancement involving the
bilateral facet joints at C3-C4 which were non-specific
findings. After further discussion with ID, favoring treatment
for possible osteomyelitis of cervical facet joint given recent
blood stream infection and prior cervical spine injections.
Ultimately, decision was made to treat with 6 weeks of IV
Cefriaxone.
# Spells of inattention
# Memory loss
# Delirium
Reports that he had episodes of inattention during
hospitalization in , when patient was in septic shock
from strep bacteremia and that they worsen when he is infected
and improve when he is treated with IV antibiotics. Occurred a
couple times during admission, likely mild delirium, which
improved on antibiotics during admission.
## CHRONIC/STABLE PROBLEMS:
# Chronic diastolic heart failure - no signs of exacerbation.
Lasix was held since /
# Diabetes
Chronic, stable, continued HISS while in house, held home
acarbose
# Anxiety/depression/ADHD
Continued home methylphenidate (MassPMP reviewed), concerta not
on formulary, was held during admission, continued also
citalopram, continued home bupropion
#Macrocytic anemia:
MCV elevated to 102 this admission, last was in the mid-90s.
Unclear etiology and has prior history of chronic iron
deficiency anemia. Per patient has been sober for years.
Folate and vitamin B12 normal. Can consider eval for liver
disease versus MDS as outpatient.
# Chronic iron deficiency anemia - Receives outpatient iron
transfusions. baseline . Hgb 9.5 on admission, stable
during admit, monitored
# Chronic pain syndrome - Patient is on vicodin and morphine, in
addition to gabapentin as an outpatient. As vicodin appears to
be his main source of pain relief so was continued while
morphine was held. MassPMP reviewed and placed in chart. We also
continued gabapentin 800mg TID. Separated medications into
constituent parts- acetaminophen 1g q6h + oxycodone +
morphine for moderate to severe pain (as
opposed to vicodine with morphine) and added cyclobenzaprine prn
for neck spasm
# GERD
Continued home omeprazole
## TRANSITIONAL ISSUE:
- On day of discharge a CXR for placement revealed an "8 mm
nodular opacity projecting over the right lung base." Radiology
recommended performing non-urgent chest CT to further evaluate.
I discussed this with patient prior to discharge and he elected
to have a CT done as an outpatient instead of inpatient since he
was being discharged in the afternoon.
- 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.
- CefTRIAXone 2 gm IV Q24H Projected End Date: (6
weeks)
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Acarbose 25 mg PO TID
2. Allopurinol mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65
mg oral BID:PRN
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Celecoxib 100 mg oral DAILY
7. Citalopram 20 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Gabapentin 800 mg PO TID
10. MethylPHENIDATE (Ritalin) 5 mg PO BID
11. Concerta (methylphenidate HCl) 36 mg oral DAILY
12. Morphine Sulfate 30 mg PO Q8H:PRN Pain - Moderate
13. Omeprazole 40 mg PO DAILY
14. HYDROcodone-acetaminophen mg oral QID:PRN
## DISCHARGE MEDICATIONS:
1. CefTRIAXone 2 gm IV Q24H
Ceftriaxone 2 g every 24 hours
## WEEKLY:
CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS, CRP
## DISCHARGE DIAGNOSIS:
Recurrent left leg cellulitis
C3-C4 anterolisthesis
Cervical vertebral osteomyelitis
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to for left leg cellulitis. You also had
evaluation of your neck pain with an X-ray, CT scan, and MRI.
The MRI was concerning for osteomyelitis. You were seen by
infectious disease specialists who recommended that you complete
a 6 week course of IV Ceftriaxone.
## PLEASE NOTE:
on the day of discharge you had a chest x-ray
performed which revealed an "8 mm nodular opacity projecting
over the right lung base." Radiology recommended you have a
non-urgent CT scan of your chest to further evaluate it. Please
be sure to discuss this with your primary care doctor.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17589576", "visit_id": "21416585", "time": "2138-01-22 00:00:00"} |
15306180-RR-40 | 174 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old woman with SDH of unclear chronicity. Follow-up on
SDH seen on previous CT head
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 856 mGy-cm.
## FINDINGS:
There is redemonstration of a stable 13 mm mixed density collection along the
right convexity overlying the frontoparietal lobes. There is minimal
effacement of sulci in the frontal parietal lobe. Slight deformity of the
right lateral ventricle that appears stable from prior exam. There is mild
local mass effect. There is diffuse brain for parenchymal atrophy.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
## IMPRESSION:
1. Re-demonstration of moderate acute on chronic subdural hematoma measuring
up to 13 mm with mild mass effect and minimal midline shift that is unchanged
from prior exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15306180", "visit_id": "25074295", "time": "2156-02-14 15:13:00"} |
16420745-RR-60 | 126 | ## INDICATION:
Placement of Dobhoff tube, ET tube, and left pleural tube.
A single AP view of the chest is obtained on at 1515 hours and
compared with the prior radiograph performed approximately three hours
previously. The patient has had placement of a left side pleural tube.
Moderate amount of subcutaneous air is present. This tube appears to be just
above the superior extent of the large left pleural effusion. The Dobhoff
tube has been placed and its tip just crosses the area of the diaphragm and
needs to be advanced. The ET tube is present and is essentially unchanged in
position and needs to be advanced approximately 6 cm.
## IMPRESSION:
Tubes and lines as described. was paged at 1710 hours and the
findings discussed.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16420745", "visit_id": "N/A", "time": "2180-12-26 15:02:00"} |
12522208-DS-5 | 1,488 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
with IDDM, stage IV kidney disease, hypertension, CVA, OSA,
HLD presented to ER with persistent hypoglycemia.
The night prior he presented to ED with headaches, nausea,
chills and was found to have low BG 55. At that time he was
treated with D5W. BG improved to 115. All other symptoms have
resolved. He was evaluated by who decreased his insulin
regimen (Lantus 45 to 36 unit daily).
Patient states he ate a piece of toast and a hot dog since being
home yesterday. 46 this morning by EMS and patient was
confused per family in the early morning yelling. Family states
he does not eat consistent meals. He gets a HA when his sugar
drops. Denies any complaints right now.
Patient was given juice and oral glucose by EMS with repeat
57. In ED patient was intially visibly tremulous, states feeling
less lightheaded and shakey than before and repeat FSBS showed
132. Pt denies CP/SOB, denies n/v/d, denies recent illness, no
fevers. Pt states he administers his own insulin and checks his
blood sugar /once twice daily. He eats irregularly, and most
days eats one big meal a day in the evening. He does not count
carbs. EKG showed sinus at 76, old Q in III c/w prior.
## COMPLICATIONS:
stage IV renal disease--recently saw Dr.
(?) at . Not on dialysis. Last eye exam was one
month ago--according to patient it was negative. He reports
occasional numbness and tingling to the feet.
Was also found to have infiltrate vs lung mass on CXR yesterday
so was started on a zpack and told to f/u with pcp for repeat
CXR and further workup of this finding. Renal function was
worsening yesterday.
In the ED, initial vs were T 97.6 HR 92 BP 183/94 RR 16 Sat 100%
RA.
On arrival to the floor, patient reports feeling a small
"headache" or head fullness feeling and BS 103. Pt has not eaten
anything today at 1000, and got lantus 36U yesterday at bed
time.
## 1. HYPERTENSION:
poorly controlled on multiple meds
2. stage IV renal disease
## 3. HYPOTHYROIDISM:
s/p total thyroidectomy for unclear cause.
Now takes LT4 188 mcg a day
4. HLD
5. sleep apnea on cpap
6. stroke in
## FAMILY HISTORY:
no other diabetes. Several people have thyroid disease and
hypertension. One child died at age from coronary artery
disease.
## PHYSICAL EXAM:
ADMISSION EXAM
VS 98.7 176/85 (not taken AM medications) HR 82 RR 16 99RA
GEN Alert, oriented, no acute distress, laying in bed
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, edema bilaterally
at ankles, no c/c
NEURO intact, motor function grossly normal
SKIN no ulcers or lesions
## FINGERSTICKS:
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP, edema bilaterally at ankles
NEURO motor function grossly normal
SKIN no ulcers or lesions
## PERTINENT RESULTS:
ADMISSION
08:10AM BLOOD
Plt
08:10AM BLOOD
08:10AM BLOOD
08:20AM BLOOD
12:18PM BLOOD
10:08AM URINE
IMAGING
## CXR ( ):
1. Pulmonary vascular congestion without overt pulmonary edema.
2. Right upper paramediastinal opacity could be due to tortuous
vessels, but CT is recommended for further evaluation.
## CT CHEST ( ):
1. No CT correlate for right upper paramediastinal opacity seen
on chest
radiograph
2. Clear lungs without consolidation or pulmonary edema
3. >4 mm left upper lobe pulmonary nodule. Recommend followup
chest CT in 12 months as recommended per
guidelines.
4. Mild bibasilar bronchiectasis
5. Small hiatal hernia with a thick walled patulous distal
esophagus, likely secondary to gastroesophageal reflux
6. Possible subcentimeter splenic arterial aneurysm or venous
varix.
## BRIEF HOSPITAL COURSE:
HOSPITAL COURSE
years of man with multiple medical problems particularly ESRD
is being admitted for hypoglycemia. Pt's low blood sugars not
to changes in DM medications, as pt has been taking same
medications for years. consulted and feels this may be
due to advancing CKD leading to decreased clearance of insulin.
Over course of admission, Lantus was downtitrated to 14 units in
AM. Lisinopril and Lasix were held for creatinine to 3.5 over
baseline of 3.2. Creatinine recovered with small boluses and pt
was d/c'd with Cr. 3.2
## ACTIVE ISSUES
# HYPOGLYCEMIA/DIABETES:
Pt's low blood sugars not to
changes in DM medications, as pt has been taking same
medications for years. The lantus was recently decreased
yesterday from 45 to 36 hypoglycemic episode and ED
visit. Pt reports poor PO intake since moving from to
in to personal issues). Patient has issue
with self care re: diabetes and complications management.
Initially, Lantus was reduced by from 45 to 36u daily
with novolog/humalog 5unit before each meal. He was advised to
divide the big meal into 3 smaller meals a day along with FSBG
at least 4 times a day. ///bs meter from pt reveals
AM blood sugars, and 110 later
in day, and 70, . Pt checks
typically in AM. Clearly has majority of reads <100s and near
believes. this is poor renal clearance of insulin
contributing to hypoglycemia. Over course of admission, Lantus
was downtitrated to 14 units in AM with HISS. Lisinopril and
Lasix were held.
## # PARAMEDIASTINAL OPACITY:
Found incidentally on last admission
on CXR. Initially treated with Azithromycin in ED, but given
lack of PNA symptoms this was discontinued. CT Chest to better
characterize showed no correlate but did find a 4mm RUL lesion
to be followed up in 6 months.
## INACTIVE ISSUES
# HYPERTENSION:
On this admission continued on lasix and
lisinopril were held due to creatinine bump. This may be
restarted in the outpatient setting of creatinine remains
stable.
##
# CKD:
Per renal note recently patient's prior Cr have been 1.7, ,
. Cr of 3.1 is within the range of the Cr
2.8.
## # ANEMIA:
might be to CKD. No iron deficiency. Normal
B12/Folate.
# hypothyroidism: stable and continued on home meds: 188mcg
levothyroxine
## # HLD:
stable. cont simvastatin and ASA 325mg
## # SLEEP APNEA ON CPAP:
stable. CPAP continued.
TRANSITIONAL ISSUES
# Will require continued diabetic education on ,
carb counting and insulin administration.
# f/u 12 month CT for 4mm RUL lesion discovered incidentally
# f/u o/p chem 7 to be drawn or
( )
#monitoring of creatinine and consideration of restarting
ACEI/lasix prn
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine CR 30 mg PO DAILY
hold for SBP<100 and HR<60
2. Furosemide 40 mg PO BID
hold for SBP<100 and HR<60
3. HydrALAzine 50 mg PO BID
hold for SBP<100 and HR<60
4. Levothyroxine Sodium 188 mcg PO DAILY
5. Lisinopril 20 mg PO DAILY
hold for SBP<100 and HR<60
6. Glargine 36 Units Bedtime
aspart 5 Units Breakfast
aspart 5 Units Lunch
aspart 5 Units Dinner
7. Simvastatin 40 mg PO DAILY
8. Aspirin 325 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Aspirin 325 mg PO DAILY
2. HydrALAzine 50 mg PO BID
hold for SBP<100 and HR<60
3. Levothyroxine Sodium 188 mcg PO DAILY
4. NIFEdipine CR 30 mg PO DAILY
hold for SBP<100 and HR<60
5. Simvastatin 40 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Vitamin D 50,000 UNIT PO 1X/WEEK ( )
8. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL 14 Units before BKFT;
Disp #*1 Vial Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL Up to 13 Units per
sliding scale four times a day Disp #*1 Cartridge Refills:*0
9. Outpatient Lab Work
Please collect Chem7 and fax results to Dr. at
.
## SECONDARY DIAGNOSES:
End stage renal disease
Diabetes
Hypertension
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
Thank you for choosing us for your care. You were admitted
because your blood sugar levels are persistently low. Due to
your kidney disease, it is likely that your body is not clearing
insulin as quickly as it used to. During this admission we
adjusted your insulin to keep your sugars at a stable level.
Please follow the following insulin regimen:
14 units insulin glargine (Lantus) in AM before breakfast
Please check your blood sugars after your meal(s) and at bedtime
and use the sliding scale we have provided.
Please note the following changes to your home meds:
- STOP lisinopril until you followup with your PCP
- STOP lasix until you followup with your PCP
get your labs checked this or
before your appointment with Dr. on
.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12522208", "visit_id": "28724844", "time": "2150-02-13 00:00:00"} |
10012062-RR-7 | 106 | RIGHT ANKLE AND RIGHT FOOT FILMS:
## HISTORY:
male with ankle swelling and fifth MT pain after
inversion of ankle.
## RIGHT ANKLE:
AP, lateral, and oblique views of the right ankle. No prior.
There is no visualized fracture or acute osseous abnormality. Ankle mortise
and other visualized joint spaces are preserved. Inferior calcaneal spur is
identified. Soft tissue swelling is seen adjacent to the lateral malleolus.
## RIGHT FOOT:
AP, lateral and oblique views of the right foot. No prior.
There is no visualized acute fracture. Joint spaces are preserved. Soft
tissues are unremarkable.
## IMPRESSION:
Soft tissue swelling adjacent to the lateral malleolus. No
evidence of fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10012062", "visit_id": "N/A", "time": "2180-06-24 11:48:00"} |
12956096-RR-66 | 56 | ## INDICATION:
AV fistula of the left radial artery and renal failure.
## IMPRESSION:
1. Soft tissue swelling about the left wrist may reflect known AV fistula.
If further evaluation of the AV fistula is required, consider ultrasound.
2. SLAC wrist.
3. Volar angulation of the lunate most consistent with VISI. Orthopedic
consultation could be considered.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12956096", "visit_id": "N/A", "time": "2202-09-20 16:43:00"} |
18216436-RR-57 | 395 | ## CLINICAL HISTORY:
woman with multiple falls and bilateral hip and
pelvis pain. No definite fracture is seen on plain films. Assess for occult
fracture.
## CT CHEST:
The right thyroid lobe is markedly heterogeneous with nodules,
better seen on CT C-spine. There is no evidence of acute intramural or
mediastinal hematoma. There is no axillary or mediastinal lymphadenopathy.
Evaluation for hilar lymphadenopathy is limited without IV contrast. There
are moderate coronary artery calcifications. No pleural or pericardial
effusion. There is a small hematoma in the right pectoralis minor measuring
1.5 x 1.5cm with muscular enlargement and adjacent stranding. Small hiatal
hernia.
Lung window images demonstrate a 2 mm right middle lobe nodule (2:24). There
is mild bibasilar dependent atelectasis. Atelectasis adjacent to the tortuous
aorta is seen. There is no worrisome consolidation or mass.
## CT ABDOMEN:
Evaluation of the intra-abdominal organs is limited without IV
contrast. The unenhanced liver, gallbladder, spleen, pancreas and bilateral
adrenal glands are normal. There is no hydronephrosis, renal stone or contour
altering renal mass. The small and large bowel are normal in course and
caliber without obstruction. There is no free fluid and no free air. The
abdominal aorta is focally aneurysmally dilated at the level of the diaphragm
to 3 cm. The remainder of the aorta is of normal caliber with dense
atherosclerotic calcifications. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are identified. Fat containing umbilical hernia.
## CT PELVIS:
The rectum is normal. Suture material is seen in the rectum status
post sigmoidectomy. The bladder is decompressed with a Foley catheter in
place. Numerous calcifications in the uterus are likely related to fibroids.
No adnexal mass is seen. There is no free fluid and no pelvic or inguinal
lymphadenopathy.
## BONE WINDOWS:
No bone finding suspicious for infection or malignancy is seen.
No acute fracture is identified. There is multilevel degenerative change with
mild retrolisthesis of L3 on L4, unchanged since at least . Soft tissue
stranding in the right flank subcutaneous tissues may be related to mild
contusion.
## IMPRESSION:
1. No fracture identified. No evidence of injury in the chest, abdomen or
pelvis within the limitation of IV contrast. Small hematoma in the right
pectoralis minor.
2. Focal ectasia of the abdominal aorta to 3 cm.
3. 2 mm right middle lobe pulmonary nodule.
4. Thoracic aorta better seen on subsequent CTA chest.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18216436", "visit_id": "N/A", "time": "2172-12-08 15:51:00"} |
12492737-RR-50 | 115 | ## INDICATION:
Fluid overload, evaluation of interval changes.
## FINDINGS:
As compared to the previous examination, the monitoring and support
devices are unchanged, except for the nasogastric tube that has been removed
in the interval and the removal of the left-sided central venous access line.
The lung volumes are slightly decreased. There is increased evidence of
bilateral basal opacities and increase in extent of the retrocardiac opacity.
The potentially pre-existing small bilateral pleural effusions have also
increased in extent. The increase in overall pulmonary density is likely to
be caused by a combination of pulmonary edema and infection.
There is no evidence of pneumothorax. The overall size of the cardiac
silhouette is unchanged.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12492737", "visit_id": "27261448", "time": "2156-09-16 07:54:00"} |
18187859-RR-14 | 113 | ## HISTORY:
Recurrent giant cell tumor.
RIGHT KNEE, TWO VIEWS.
Compared with , the patient has undergone curettage and packing along
the lateral aspect of the right femur. The previously seen area of lucency is
now more dense and surrounding heterotopic ossification or calcification
projects lateral to the distal plate. Morselized bone graft is also now seen
in the previously identified lucent area along the distal femur anteriorly.
The plate itself unchanged (proximal edge beyond field of view in these
images). No fracture or malalignment is detected about the joint. No joint
effusion. Mild soft tissue swelling present.
## IMPRESSION:
S/p curretage and packing. No fracture, suspicious lytic area, or
hardware loosening detected.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18187859", "visit_id": "N/A", "time": "2127-05-29 10:14:00"} |
14230528-RR-33 | 101 | ## INDICATION:
with IDDM, HFpEF, CKD, recurrent scrotal swelling transferred
from OSH for concern of scrotal cellulitis, found to be grossly fluid
overloaded with difficulty in diuresis, and cirrhosis seen on imaging. Now
with SBO vs ileus, and new hypoxia. // reason for new hypoxia
## IMPRESSION:
The left-sided PICC line is unchanged in position within the distal tip in the
mid right atrium. This could be pulled back 2-3 cm as recommended previously.
Heart size is prominent but stable. There are bilateral pleural effusions and
a left retrocardiac opacity. There is moderate pulmonary edema, stable.
There are no pneumothoraces.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14230528", "visit_id": "22010195", "time": "2182-12-04 12:47:00"} |
19129599-RR-5 | 148 | ## EXAMINATION:
DX THORACIC AND LUMBAR SPINES
## FINDINGS:
Exam is severely limited by bony demineralization. Moderate rotary
dextroscoliosis of the thoracolumbar at the thoracolumbar
junction with compensatory curve at the lower lumbar spine. Severe
compression deformity of the T12 vertebral body is re- demonstrated. Severe
compression deformity of the L1 vertebral body with greater than 50% height
loss is new since prior study. Evaluation of the remainder of the thoracic
vertebral body heights is suboptimal given severe osteopenia. Imaged portion
of the lungs are clear. Bilateral hip joint spaces appear grossly preserved.
## IMPRESSION:
1. New severe compression deformity of the L1 vertebral body.
2. Severe compression deformity of the T12 vertebral body, unchanged.
3. Evaluation of the thoracic vertebral body heights is limited given gross
osteopenia and if there is continued concern, CT evaluation is recommended.
## NOTIFICATION:
Email was sent to Dr. by Dr. at 15:03 .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19129599", "visit_id": "N/A", "time": "2171-12-31 14:01:00"} |
17071904-RR-104 | 133 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
eval for cause of confusion year old man s/p liver txp x 2
who presents with FTT, mental status changes and pain. // eval for cause of
confusion
## FINDINGS:
There is no evidence of acute large vascular territory infarction, hemorrhage,
edema, mass effect, midline shift, or mass. The ventricles and sulci are
prominent consistent with parenchymal volume loss. Confluent periventricular
and subcortical white matter hypodensities likely represent the sequela of
chronic small vessel ischemic disease. The cavernous portions of the internal
carotid arteries are calcified.
No acute fractures seen. There is minimal mucosal thickening in the paranasal
sinuses. The mastoid air cells, and middle ear cavities are clear. The orbits
are intact
## IMPRESSION:
No acute intracranial process. Chronic findings including parenchymal volume
loss, atrophy
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17071904", "visit_id": "21870053", "time": "2153-07-24 16:52:00"} |
13143465-DS-12 | 533 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## ILEAL RESECTION
:
1. Hepatic Segment 6 resection.
2. Wedge resection of lesion in segment 4A.
3. Wedge resection of lesion in segment 8.
## PER DR. NOTE AS FOLLOWS:
Mr. is a
gentleman with neuroendocrine tumor in the ileocecal area who
has 3 hypervascular lesions
in the liver, in segments 6, 4A, and 8 on recent MR.
presents for combined ileocecectomy and metastasectomy.
## PAST MEDICAL HISTORY:
hypertension, hyperlipidemia, bowel obstructions and gastric
ulcer disease.
Prior surgeries include sphincterotomy for anal fissure and
bilateral inguinal hernia repairs.
## FAMILY HISTORY:
Both parents have coronary artery disease.
## BRIEF HOSPITAL COURSE:
On , underwent ileal resection by Dr. and
hepatic Segment 6 resection with wedge resection of lesion in
segment 4A and wedge resection of lesion in segment 8 by Dr.
for metastatic carcinoid tumor. Please refer to
operative notes for complete details.
did well postop. Pain was initially managed with a PCA that
was switched to oxycodone on postop day 2 when was tolerating
a clear diet. Oxycodone was later switched to Dilaudid with
improvement pain control. disliked the way oxycodone made him
feel-"out of it".
Incision was initially intact with without redness/bleeding.
However, on , the incision appeared erythematous on the
lateral side and Keflex was started with improvement. The JP was
non-bilious and was removed on postop day 2 when output was 170
cc on postop day 1. LFTs initially increased then decreased on
subsequent days.
was out of bed and ambulating independently by postop day 2.
Urine catheter was removed and voided without problems.
Diet was slow to advance until passed flatus and had a BM on
and .
felt well on and was discharged to home in stable
condition. was given a script for Keflex for 3 days to
complete a total of 5 days for the incision erythema.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. lisinopril-hydrochlorothiazide mg oral DAILY
5. Omeprazole 5 mg PO DAILY:PRN indigestion
6. tadalafil 20 mg oral DAILY:PRN
## DISCHARGE MEDICATIONS:
1. HYDROmorphone (Dilaudid) mg PO Q4H:PRN pain
RX *hydromorphone 2 mg tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*12 Capsule Refills:*0
5. lisinopril-hydrochlorothiazide mg oral DAILY
6. Aspirin 81 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
## DISCHARGE DIAGNOSIS:
carcinoid tumor of ileum with hepatic metastasis
incision redness
## DISCHARGE INSTRUCTIONS:
Please call Dr. if you have any of
the following: fever (temperature of 101 or greater), chills,
nausea, vomiting, increased incision or abdominal pain, incision
redness/bleeding/drainage, constipation, diarrhea or bloody
bowel movements
You may shower with soap and water, rinse, pat incision dry
No tub baths or swimming
Do not apply powder/lotion/ointment to incision
No driving while taking narcotic pain medication and until
cleared by your surgeon
Do not lift anything heavier than 10 pounds
No straining
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13143465", "visit_id": "26171927", "time": "2137-04-08 00:00:00"} |
19181791-RR-56 | 684 | ## EXAMINATION:
CTA chest abdomen pelvis with and without contrast.
## INDICATION:
year old woman with mesenteric ischemia, now with vomiting and
rising lactate.// eval for bowel perf, new ischemia
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 17.5 s, 67.1 cm; CTDIvol = 4.7 mGy (Body) DLP = 306.4
mGy-cm.
2) Spiral Acquisition 17.5 s, 67.1 cm; CTDIvol = 11.9 mGy (Body) DLP =
779.6 mGy-cm.
Total DLP (Body) = 1,113 mGy-cm.
## HEART AND VASCULATURE:
The right-sided central line with the tip at the
cavoatrial junction. Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
## AXILLA, HILA, AND MEDIASTINUM:
No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
## PLEURAL SPACES:
No pleural effusion or pneumothorax.
## LUNGS/AIRWAYS:
Minimal biapical scarring. Moderate upper lobe predominant
centrilobular and paraseptal emphysema. Small left and trace right pleural
effusions. There is an enhancing left lower lobe opacity with air
bronchograms compatible with atelectasis however superimposed infection cannot
be excluded in the proper clinical context. Minimal right lower lobe
atelectasis. The airways are patent to the level of the segmental bronchi
bilaterally.
## BASE OF NECK:
Visualized portions of the base of the neck show no abnormality.
## HEPATOBILIARY:
There is extensive portal venous gas. Again seen multiple
hypodense lesions throughout the liver, likely represent cysts or biliary
hamartomas. A peripherally calcified lesion within the left hepatic lobe is
stable. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is not visualized.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The splenic parenchyma is hypoattenuating, consistent with infarct,
unchanged.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
Interval improvement of previously seen bilateral renal infarcts.
The kidneys are of normal and symmetric size with normal nephrogram. No
hydronephrosis. There is no perinephric abnormality. Bilateral renal cysts
are present, largest of which measures 24 mm arising from the lower pole the
right kidney.
## GASTROINTESTINAL:
Enteric tube is present with the tip in the stomach. The
esophagus and stomach are fluid filled and dilated. Extensive pneumatosis
intestinalis involving the small bowel and colon with mild mural thickening
and mesenteric fat stranding. There is diffuse dilation of multiple loops of
small bowel and colon. Several loops of small bowel and the transverse colon
lack wall enhancement.
## PELVIS:
A Foley catheter is contained within a decompressed urinary bladder.
There is a moderate amount of free fluid in the lower pelvis and perihepatic
ascites.
## REPRODUCTIVE ORGANS:
The reproductive organs are unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
The celiac trunk is not well opacified. The splenic artery and
common hepatic artery are not well visualized. There is an accessory left
hepatic artery and replaced right hepatic artery, both of which were seen on
the CTA of however not definitively identified on the current
study. Patient is status post SMA stenting with unchanged narrowing of the
proximal SMA but patency distally. The is not opacified.
Extensive gas is noted within the mesenteric vessels
## BONES AND SOFT TISSUES:
There is no evidence of worrisome osseous lesions or
acute fracture. Diffuse anasarca. Multiple surgical staples overlie the
anterior abdominal wall.
## IMPRESSION:
1. Extensive pneumatosis intestinalis, heterogeneous bowel wall enhancement
patterns, portal venous and mesenteric venous gas and free fluid in the lower
pelvis. Given celiac trunk and occlusion, constellation of findings are
compatible with acute mesenteric ischemia.
2. Post SMA stenting, with proximal narrowing but distal opacification of the
SMA.
3. Left lower lobe consolidation, likely atelectasis but mild heterogeneity
in the enhancement pattern suggests an element of pneumonia. Small left
pleural effusion.
4. Mild upper lobe predominant emphysematous changes.
5. Stable splenic infarct.
## NOTIFICATION:
The findings and recommendations were communicated to Dr.
via telephone,at 6:30pm on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19181791", "visit_id": "23819522", "time": "2142-01-21 17:57:00"} |
18625719-AR-50 | 171 | ## "DIAGNOSIS:
A) Breast, right posterior, core needle biopsy (A-F):
1.Usual ductal hyperplasia.
2.Small incidental radial scar.
3.Calcifications associated with columnar cell change.
B) Breast, right mid, core needle biopsy (G-J):
1.Two small incidental radial scars.
2.Usual ductal hyperplasia.
3.Adenosis.
4.Apocrine metaplasia.
C) Breast, left central, core needle biopsy (K-P):
1.Ductal carcinoma in-situ, high nuclear grade with microinvasion (4 cells
on slide L level 1), solid pattern with comedo necrosis."
The results are concordant with the imaging findings. The right breast
findings of small incidental radial scars were discussed with Dr. in
pathology and do not require excision. In the left breast, the 2 biopsy marker
clips with biopsy proven DCIS are approximately 8 cm apart in the upper outer
left breast with corresponding enhancement on the MRI measuring 8.5 cm in AP
dimension. Dr. will be discussing these results with Ms. on
. Additionally, a chest CT has been scheduled to evaluate the
previously identified mediastinal node.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18625719", "visit_id": "N/A", "time": "2131-10-30 07:23:00"} |
17347036-RR-34 | 249 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
year old woman with SLE and new fevers and tachycardia.
Possible consolidation on CXR // ?PNA
## DOSE:
DLP: Total exam DLP: 241 mGy.cm
## FINDINGS:
Limited diagnostic assessment of the vascular structures and mediastinum due
to lack of intravenous contrast.
No axillary, supraclavicular, mediastinal or hilar lymphadenopathy.
The heart size is normal. There is a moderate sized low attenuating
pericardial effusion. No aneurysmal dilatation of the pulmonary arteries or
thoracic aorta.
Small bilateral pleural effusions.
Trachea and central airways are patent. Some of the peripheral airways within
the left lower lobe are plugged with material. Band like opacity seen within
the left lower lobe which likely reflects atelectasis. 4 mm nodule is seen
within the right middle lobe (series 3, image 24). No pulmonary mass lesions
are identified otherwise.
Limited assessment of the upper abdomen due to lack of intravenous contrast
and limited visualization. No gross abnormalities are identified.
No acute or aggressive osseous lesions are demonstrated.
## IMPRESSION:
Peripheral mucous plugging seen within the left lower lobe with adjacent
bandlike opacification which likely reflects atelectasis.
Small bilateral pleural effusions and moderate-sized pericardial effusion (low
attenuating).
4 mm ground-glass attenuating nodule within the right middle lobe. According
to the criteria, if the patient is at low risk for lung malignancy
then a follow-up low-dose unenhanced CT scan the chest in 12 months is
recommended. If at high risk, then initial follow up CT at 6 months is
recommended.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17347036", "visit_id": "20500762", "time": "2148-06-18 15:36:00"} |
19891671-DS-22 | 1,700 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Altered mental status question seizure
## HISTORY OF PRESENT ILLNESS:
Ms. is a year-old right-handed woman with a history
of
hypertension and COPD (on 2L supplemental O2 at baseline) and
recent admission for IPH from to who presents
with change in mental status. She is presenting as a transfer
from from a transfer from a rehab . While in
rehab, she has been treated for a UTI which she ended up in
microbiology to be MRSA. So she was initially treated with
vancomycin and changed to tetracycline as it was sensitive to
tetracycline. The family members said that for the past week
she
has been having increased lethargy and fatigue. Also they have
noticed that she has a prolonged time to respond to questions.
There was also question of Jerking in "one arm." This jerking
could be either the left or the right. However, she was
responsive during these "jerks." She answers questions taking a
longer time than she was doing. They said interestingly that she
had those symptoms after her stroke but the amount of time that
it takes her to answer questions now is longer. She has no
acute
focal weakness, numbness or tingling. No seizure or
incontinence. No complaints of chest pain or abdominal pain,
nausea, vomiting or flank pain. No bleeding from any source,
and
she does not have any acute trauma. In the emergency department
at she was noticed to have a very mildly positive
UA,
very slightly positive. Her white blood cell count was only 8.
She has a low slight acute renal failure with a BUN of 33 and a
creatinine 1.1. Her albumin is low. Lactic acid was only 1.5.
Her EKG showed right bundle branch block with Q-waves in the
inferior leads. She had a CT scan also and the CT scan showed
improvement of the swelling in her right intraparenchymal
hemorrhage area with less edema. There was no sign of acute
bleed. Chest x-ray showed chronic left lower low markings that
were there last year.
Because of her altered mental status and the fact that she has
still signs of a UTI, it was decided to admit her for IV
antibiotics. However, with the continued confusion and
inability
to get an EEG at , she was transferred back to for further management.
.
Of note Ms , was Admitted on for a
right
frontal intraparenchymal hemorrhage associated with about 9 mm
of midline shift. Initial neurological examination was notable
for dysarthria, pupillary asymmetry (L pupil 0.5 mm > R pupil),
failure to blink to threat from the left, incomplete horizontal
movement of eyes into extreme left lateral gaze, left facial
droop, left hemiparesis ( ), increased tone in the left
upper extremity, left extensor response, and extinction of left
visual and tactile stimuli with double simultaneous stimulation.
Repeat imaging demonstrated stability of the lesion.
Investigatory studies were unrevealing. The location is
suspicious for underlying mass or vascular malformation. A CTA
was done which
did not demonstrate any large vascular malformation at the site
of the IPH. There were small saccular dilatations at the site of
right posterior communicating artery and anterior communicating
artery, to which aneurysm can't fully be ruled out. She was
transferred to the wards for further management. On the wards
she was placed once again on mannitol given lethargy and a
repeat CT head concerning for increased mass effect. She was
taken off mannitol on and was followed with serial blood
osmolality checks after improving clinically. She had a G-Tube
placed on for nutritional support. She was on continuous
oxygen by NC throughout her stay on the wards.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies new focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats, has had some recent weight loss since
the last admission, however difficult to quantify. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
## PAST MEDICAL HISTORY:
- COPD, on 2L suppl O2 at baseline
- Hypertension
- Hypothyroidism
- Right rotator cuff injury
- Depression
- Right intraparenchymal hemorrhage
## FAMILY HISTORY:
- positive for abdominal aortic aneurysm (mother)
- negative for known neurological conditions including cerebral
aneurysm, stroke, seizure
## GENERAL:
resting with eyes closed, easily arousable to voice
## HEENT:
Normocepahlic, no scleral icterus noted. Mucus membranes
moist, no lesions noted in oropharynx. Dysarthric
## CARDIAC:
Regular rate, normal S1 and S2.
## PULMONARY:
Lungs clear to auscultation bilaterally.
## ABDOMEN:
Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
## SKIN:
no rashes or concerning lesions noted.
## MENTAL STATUS:
A Cognitive Assessment was done and she
scored an 8 out of 30.
* Degree of Alertness: Easily arousable to voice. Able to
relate
basic history.
* Orientation: Oriented to person, place, month, year, but not
to
date or day
* Attention: inattentive, unable to do a digit span forward of 5
or backwards of 3. was unable to preform serial subtraction or
tapping with the letter A on letter list.
* Language: Language is sparse but fluent without evidence of
paraphasic errors. Repetition is intact. Comprehension appears
intact; pt able to correctly follow midline and appendicular
commands. Prosody is normal.
Pt able to name , and camel) not Rhino
* Neglect: Evidence of sensory (extinguishes on left with double
simultaneous stimulation) neglect. Neglects left side of image
and neglects the left side with line bisection
Memory - was able to 3 out of 5 and recall 1 out of 5
at
5 minutes
## * I:
Olfaction not evaluated.
* II: L 4--> 2, R 3.5 --> 2mm and brisk. Does not blink to
threat from left
* III, IV, VI: EOMI
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: Left Facial droop.
* VIII: Hearing intact to finger-rub bilaterally.
* IX, X: Palate elevates symmetrically.
* XI: strength in trapezii bilaterally.
* XII: Tongue protrudes in midline.
## * TONE:
Increased in left upper and lower extremity
* Adventitious Movements: No tremor or asterixis noted.
## * BABINSKI:
extensor left, mute on right but contraction of the
tensor fascia
## SENSATION:
No deficits to light touch, pinprick, vibratory sense.
Coordination
RAM intact.
## IMPRESSION:
Large right frontal intraparenchymal hematoma
relatively
unchanged since the prior examinations with less mass effect
towards the left.
Few scattered foci of restricted diffusion, possibly related
with subacute
ischemic changes and thromboembolic in nature, please correlate
clinically.
Mild mass effect towards the left with approximately 2 mm of
shifting is
demonstrated. Foci of magnetic susceptibility are noted in both
cerebral
hemispheres, likely consistent with chronic microbleeds.
Followup
examinations are recommended for etiology of the right frontal
hematoma as
clinically warranted.
## BRIEF HOSPITAL COURSE:
Ms. was admitted to the neurology service after an
deterioration in her mental status. She was found to have
evidence of a urinary tract infection and was treated with IV
vancomycin. Her mental status improved following antibiotic
therapy and it was thought that her change in mental status was
secondary to her infection. Subsequent urine culture from
showed no growth of bacteria and the vancomycin was
discontinued on . She was also evaluated with a repeat
brain MRI and her prior intraparenchymal hemorrhage was stable.
She also had a repeat EEG which on preliminary read showed no
evidence of seizures. She was re-evaluated by physical therapy
who recommended continued therapy at her nursing facility for
help with balance and ambulation. Her Keppra was increased to
1000mg BID and her Celexa was increased to 30mg daily as she
appeared depressed during the hospitalization. She will follow
up with Dr. as scheduled outpatient.
## MEDICATIONS ON ADMISSION:
1. Doxycycline 100 mg p.o. b.i.d.
2. Advair 250/50 one puff twice per day.
3. Spiriva 18 mcg per day.
4. Colace 100 mg twice per day.
5. famotadine 20 mg twice per day.
6. Keppra 750 mg twice per day.
7. Celexa 20 mg daily.
8. Senna 2 tabs nightly.
9. Levothyroxine 100 mcg per day.
10. Trazodone 25 mg a night.
11. ProAir 2 puffs every 6 hours as needed.
12. Sorbitol 70% solution, 30 mL daily as needed.
## DISCHARGE MEDICATIONS:
1. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stools.
2. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
## DISCHARGE DIAGNOSIS:
Altered Mental Status
Urinary Tract Infection
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Ms. you were admitted to the hospital with a change in
mental status and concern for possible seizures. You were
treated for a urinary tract infection and your mental status
improved. Your EEG showed no seizure activity. Your Keppra was
increased to 1000mg twice daily and you should continue this
dose. Your Celexa was increased to 30mg daily for your
depression and should remain on this dose. You should continue
physical therapy at your nursing facility at the .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19891671", "visit_id": "28764537", "time": "2170-12-06 00:00:00"} |
11940715-RR-10 | 157 | ## HISTORY:
Status post fall, assess instrumentation.
LUMBAR SPINE, TWO VIEWS
There is a probable transitional level. Levels are assigned for the purposes
of this report only. The first non-rib-bearing vertebral body is designated
L1.
There is a laminectomy at L4/5, with marked disc space narrowing and grade 1
anterolisthesis at L4/5 and L5/S1. The patient is status post fusion
procedure with bilateral pedicle screws at L4 and L5 and an anterosuperior
screw with graft along the anterosuperior corner of L5.
Compared with , there is a new fracture involving the right L5 screw. No
hardware loosening or change in bony alignment is detected. The bony
fragments at the L4/5 disc space are less distinct, suggesting interval callus
formation but essentially unchanged in alignment.
Aortic calcification noted.
## IMPRESSION:
1) Transitional level - levels assigned for this report only.
2) Interval fracture of right L5 screw. No change in bone or hardware
alignment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11940715", "visit_id": "N/A", "time": "2152-09-23 16:56:00"} |
16946566-RR-100 | 157 | CHEST RADIOGRAPH PERFORMED ON .
Comparison with prior study from .
## CLINICAL HISTORY:
woman with fever, cough, shortness of breath,
and history of right malignant pleural effusion, evaluate for pneumonia or
change in effusion.
## FINDINGS:
PA and lateral views of the chest are obtained. Midline sternotomy
wires are again noted along with mediastinal clips. A focus of pleural
nodularity is again noted along the lateral aspect of the right mid-lung,
measuring approximately 1.8 cm. Right-sided pleural-based opacity is similar
to that seen previously and may represent pleural thickening and pleural
effusion. Radiation-related changes noted along the medial aspect of the
right lung are stable. The left lung remains clear. Heart size is within
normal limits. No evidence of pneumonia or CHF. Visualized osseous
structures are stable.
## IMPRESSION:
Pleural-based nodule in the right upper lung appears stable. Right lower lung
pleural thickening and effusion is also stable. No evidence of pneumonia or
CHF.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16946566", "visit_id": "24363243", "time": "2114-12-03 11:25:00"} |
14749081-RR-30 | 428 | ## HISTORY:
male with portal biliopathy secondary to portal
hypertension. Interval placement of bilateral ERCP stents. Cholangiogram
requested to evaluate ERCP stent patency.
## OPERATORS:
Dr. and (atending physician) and Dr.
(fellow). The attending physician was present throughout the entirety of the
procedure.
## ANESTHESIA:
Moderate sedation was provided by administering divided doses of
fentanyl throughout the total intra service time of 40 min. The patients
hemodynamic parameters were continuously monitored by an independent party
nurse. A total dose of 200mcg of fentanyl were used. 1% lidocaine was also
used for local anesthesia.
## FLUORO:
9.2 min
Contrast 20cc Optiray
## PROCEDURE:
1. Bilateral over-the-wire cholangiograms.
2. Exchange of internal /external biliary catheters over the wire with
placement of bilateral 8 external only anchor drains.
## FINDINGS:
The procedure was discussed in detail with the patient and risks and benefits
emphasized. Informed written consent was obtained.
When the patient arrived in the angiography suite they were placed supine on
the procedure table. A pre-procedure timeout was performed as per
protocol. The region of the left and right biliary drains was prepped and
draped in usual sterile fashion. 1% local lidocaine was used for anesthesia
along the access tracts.
The scout film demonstrated proper positioning of two internal/external
biliary drains and two ERCP plastic stents. Injection of contrast through
internal/external drains demonstrated patency. The right biliary catheter was
cut and wire passed through the catheter, coiling distally in the
duodenum. The old catheter was removed over the wire and a 7 sheath
was placed under fluoroscopic guidance. A wire was then placed
through the left-sided internal external drain, the drain removed and a 7
sheath placed.
Care was taken not to displace the plastic stents.
Bilateral cholangiograms demonstrated brisk flow of contrast through the right
ductal system and right ERCP drain. Left-sided cholangiogram demonstrated
somewhat sluggish flow of contrast through the left the ERCP stent. There is
appreciable residual contrast in the left ductal system and dilatation of the
central left ductal system despite the presence of the plastic ERCP stent.
At this time, bilateral capped 8 external Anchor drains were placed to
maintain access only and allow a clinical trial of drainage. The biliary
catheters were sutured to the skin and dressed according to protocol. The
patient left the department in stable condition. No complications.
## IMPRESSION:
Cholangiogram demonstrating brisk flow of contrast through right ERCP drain
with minimal/sluggish flow of contrast through the left ERCP drain.
Bilateral capped 8 Anchor drains placed to maintain access and allow a
trial of physiological internal drainage.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14749081", "visit_id": "27434898", "time": "2113-10-22 14:31:00"} |
19177306-RR-94 | 99 | ## INDICATION:
Preoperative screening study in a patient with planned right
inguinal herniorrhaphy.
.
PA AND LATERAL VIEWS OF THE CHEST:
The trachea is notable for a focal
narrowing near the level of the clavicular heads. A moderate left pleural
effusion is redemonstrated, similar to that seen in and having
increased since . Note is made of expected overlying
subsegmental atelectasis. The patient is status post coronary arterial bypass
grafting. Median sternotomy wires are intact. The cardiac, mediastinal and
hilar contours reveal a tortuous aorta. There is no focal consolidation or
pneumothorax. The lungs are hyperinflated, suggesting obstructive lung
disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19177306", "visit_id": "N/A", "time": "2124-10-03 08:47:00"} |
13820650-RR-19 | 219 | ## INDICATION:
male with newly diagnosed prostate cancer. Evaluate
for metastatic disease.
## DOSE:
As per CT abdomen/pelvis.
## FINDINGS:
A 4 mm hypodense right thyroid lobe nodule is stable. There are no
pathologically enlarged supraclavicular, mediastinal, hilar or axillary lymph
nodes.
Heart size is top-normal with no pericardial effusion. Coronary artery
calcifications are mild. The main pulmonary artery and thoracic aorta are
normal caliber. No incidental central pulmonary embolus is identified.
The majority of pre-existing pulmonary nodules measuring up to 5 mm in the
right lower lobe are stable (5: 83, 89, 97, 100, 101, 110, 114, 116, 128, 135,
139, 140, 144, 146, 157, 158, 163, 169, 203, 245). A single right lower lobe
metastasis has slightly increased from 6 mm to 8 mm (5, 178). A calcified
right upper lobe nodule is stable (5, 79). No endobronchial lesion or pleural
effusion is present.
For a detailed discussion of the upper abdomen, please refer to the separate
report from the CT abdomen/pelvis performed concurrently.
Mild bilateral symmetric gynecomastia is present.
There are no bone lesions in the thorax worrisome for infection or malignancy.
## IMPRESSION:
Interval stability of the majority of pre-existing pulmonary metastases as
compared to . There has been only slight interval growth of the
largest right lower lobe metastasis as described above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13820650", "visit_id": "N/A", "time": "2136-09-10 14:27:00"} |
15020653-RR-128 | 209 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
female with a history of ESRD s/p LRKT in ,
pancreas after kidney transplant in and subsequent renal graft failure
and LRKT in with recent admission from with atypical
pneumonia and readmission for RUQ pain, presenting with N/V and HA, course c/b
refractory HA's, profound orthostatic hypotension, and intermittent AMS. Now
with LP showing EBV encephalitis, now with dizziness, plan on repeat LP on
// please perform after 9 on . eval for space occupying lesions as
we are planning on repeat LP
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 931 mGy-cm.
## FINDINGS:
There is no evidence of large territorial infarction, hemorrhage, edema, or
mass effect. There is mild prominence of the ventricles and sulci, compatible
with age-related involutional changes. The basilar cisterns are patent.
Vascular calcifications noted in the carotid siphons and bilateral vertebral
arteries.
No osseous abnormalities seen. There are tiny mucous retention cysts in the
floors of the bilateral maxillary sinuses. The remainder of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are
unremarkable.
## IMPRESSION:
1. No acute intracranial abnormality.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15020653", "visit_id": "21065227", "time": "2188-01-29 21:11:00"} |
13925935-DS-11 | 1,349 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
year old woman with Afib on coumadin, severe aortic stenosis,
hypothyroidism, left breast mastectomy presented with dizziness.
Patient was in her usual state of health until morning of
admission, had her medications and breakfast and then had a
bowel movement. Following the bowel movement she felt dizzy so
she sat down and symptoms resolved in 10 minutes. no LOC or head
trauma. No nausea or vomiting. She endorses feeling a fluttering
sensation but denies CP or SOB. She was feeling anxious the same
day in the morning about visiting her husband at rehab. She had
episodes of syncope previously; last episode several years ago.
No further after this episode of dizziness. Not orthostatic.
Sometimes walks with a walker and sometimes does not.
There was a recent admission to for pneumonia
and found to be in Afib with RVR and mild degree of heart
failure with a BNP of 358. On that admission she was diuresed
and treated with antibiotics and rate controlled. In that
admission, echo was done and showed LV EF of 55-60%, severe
aortic stenosis with a peak forward flow velocity of 4.5 meters
per second and a peak gradient of 83 mmHg and a calculated valve
area of 0.7 cm2. Her pulmonary artery systolic pressure was also
moderately elevated on the echo at 46-65 mmHg.
## INITIAL VITALS WERE:
T 97.5 HR 110 BP 154/117 RR 20 Sat 98% 4L
NC. Orthostatics were negative in the ED. UA was overall
unremarkable. Labs were remarkable for INR of 1.7, plt 125, BUN
21 and Cr 1. EKG showed Afib at rate of 59, with TWF in III and
aVF. Vitals on transfer were: T97.5, BP 157/64, HR 61, RR 16,
Sat%99RA.
.
On the floor, she denied lightheadedness, palpitation, chest
pain or shortness of breath but endorses some anxiety about her
general condition.
## PAST MEDICAL HISTORY:
1. Atrial fibrillation which is chronic on Coumadin.
2. Hypertension.
3. Hyperlipidemia.
4. Hypothyroidism.
5. Breast cancer status post left mastectomy and radiation
therapy.
6. Former smoker quit at the age of .
7. Chronic Diastolic heart failure
8. Aortic stenosis (valve area 0.7)
9. Pneumonia
## FAMILY HISTORY:
mother died of heart attack in her , father died in his
, Brother died at age of due to heart attack, 2 sisters
passed away in and .
## GENERAL:
elderly woman, pleasant, sitting in bed comfortably in
NAD, but seems getting anxious on minor things
## HEENT:
MM moist, EOMI, no conjuctival pallor
## NECK:
No jugular venous distention, carotids with a slightly
delayed upstroke bilaterally. ESM transmitted murmur heard.
## CARDIAC:
hyperdynamic apex, not displaced, ESM, normal S1
S2. No rubs or gallop.
## CHEST:
Exam is clear to auscultation bilaterally, no rub wheeze
or gallop
## ABDOMEN:
Soft and nontender. There is no hepatosplenomegaly.
bowel sounds present
## EXTREMITIES:
No edema. She is warm and well perfused, pulses
palpable distally +2
## NEUROLOGIC:
Gait is slow but normal. Power bilaterally in
both upper limbs and lower limbs. Romberg sign negative.
.
Discharge physical exam:
## VITAL SIGNS:
T 97.8 BP 142/84 (120-150/50-80) HR 103 (60-100 on
tele, 2 brief episodes of 120's), RR 13 Sat 100%RA
## GENERAL:
elderly woman, pleasant, laying in bed comfortably in
NAD
## HEENT:
MM moist, EOMI, no conjuctival pallor
## NECK:
No jugular venous distention, carotids with a slightly
delayed upstroke bilaterally. ESM transmitted murmur heard.
## CARDIAC:
hyperdynamic apex, not displaced, ESM, normal S1
S2. No rubs or gallop.
## CHEST:
Exam is clear to auscultation bilaterally, no rub wheeze
or gallop
## ABDOMEN:
Soft and nontender. There is no hepatosplenomegaly.
bowel sounds present
## EXTREMITIES:
No edema. She is warm and well perfused, pulses
palpable distally +2
## NEUROLOGIC:
Gait is slow but normal. Power bilaterally in
both upper limbs and lower limbs. Romberg sign negative.
## IMPRESSION:
1. No focal consolidation.
2. Moderate cardiomegaly.
.
EKG
Atrial fibrillation with a controlled ventricular response and
ventricular
premature beats or aberrant ventricular conduction. Delayed R
wave progression
in the anterior precordial leads. Non-specific inferior and
lateral ST-T wave
changes. Compared to tracing #1 an R wave is no longer present
in lead V3 which
is likely secondary to lead positioning. The ventricular
response is still
controlled but slightly faster.
## BRIEF HOSPITAL COURSE:
year old woman with Afib on coumadin, severe aortic stenosis,
chronic diastolic heart failure, hypothyroidism, left breast
mastectomy presented with dizziness.
.
# Dizziness: Multifactorial. Could be Afib with rapid
ventricular rate in setting of chronic diastolic heart failure
and severe AS with valve area of 0.7. Another possibility would
be increased vagal tone (She reports having a bowel movement
which was followed by dizziness) in the setting of her
underlying heart condition. Anxiety is apparently contributing
as well. Negative orthostasis in the ED. We did not make changes
in her medication list. Her HR remained most of the time 60-100.
## .
# AFIB:
Chronic, on rate control and coumadin. INR 1.6 and
subtherapeutic. CHADS-2 score 3 (Age,CHF,HTN). We increased her
coumadin dose to 3 mg daily rather than 3x5days and 1.5x2days.
She will have INR's checked and faxed to
.
.
# Hypertension: We continued amlodipine 10 mg daily and
metoprolol tartrate 25 mg twice daily. Discussed with Dr
was covering Dr agreed to currently continue the
same medications since she is scheduled for follow up echo in 2
weeks time which would be followed by a follow up visit to
cardiology clinic.
.
# Hyperlipidemia: We continued home simvastatin.
.
# Hypothyroidism: We continued home levothyroxine 50 mg daily.
.
#Transitional Issues:
-follow up with PCP weeks
-follow up with Cardiologist weeks
-outpatient TTE in weeks
-have INR checked and and have results sent to
Anti-Coagulation Clinic at
## MEDICATIONS ON ADMISSION:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet
-
1 Tablet(s) by mouth daily
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 1.5
Tablet(s) by mouth on and , 3 tablets other days
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 WITH VITAMIN D3] -
(Prescribed by Other Provider) - 600 mg calcium (1,500 mg)-400
unit Tablet, Chewable - 1 Tablet(s) by mouth daily
## DISCHARGE MEDICATIONS:
1. Outpatient Lab Work
Please draw blood for coumadin level (INR) on and
. Please fax to Anti-Coagulation Clinic
at .
2. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
.
Disp:*60 Tablet(s)* Refills:*2*
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
## CAPSULE SIG:
One (1) Capsule PO once a day.
## PRIMARY DIAGNOSES:
Dizziness
Atrial fibrillation
Severe Aortic Stenosis
Chronic Diastolic Heart Failure
## ACTIVITY STATUS:
Ambulatory - Independent, sometimes uses walker
## DISCHARGE INSTRUCTIONS:
Dear Ms ,
It was a pleasure taking care of you as your doctor. As you know
you were admitted for brief episode of dizziness. We think this
is secondary to straining during bowel movement leading to poor
forward flow in the setting the narrow valve.
Recently you met the cardiologist in the clinic and spoke with
your regarding your narrow valve. You will have a repeat ECHO as
scheduled on which will be followed by your follow up
appointment with the cardiologist.
We did the following changes in your medication list.
- Please TAKE coumadin 3 mg DAILY
Please continue taking the rest of your home medications the way
you were taking them at home prior to admission.
Please draw blood lab for coumadin level (INR) on and
and get results faxed to
Anti-Coagulation Clinic at (reachable at
Please follow with your appointments as illustrated below.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13925935", "visit_id": "26877716", "time": "2135-01-17 00:00:00"} |
14143688-DS-30 | 2,391 | ## HISTORY OF PRESENT ILLNESS:
Ms. is a woman with multiple medical
problems including bipolar disorder, polysubstance use,
cardiomyopathy due hypertension and cocaine use (EF 55-60%
, cerebral aneurysms, untreated hepatitis C, presenting
for evaluation of left knee pain after a fall and admitted due
to
concern for rhabdomyolysis. History was obtained directly from
the patient but was limited by tangential thought process and
poor memory.
Patient was drinking alcohol at a friend's house a pint of
vodka; she denies intoxication) the night prior to presentation
( ) and fell from her friend's bed onto the floor
when
she was reaching down to tie her shoes. She fell onto her knees
first and then onto her elbows. No headstrike or loss of
consciousness. She fell around 5pm and wasn't able to get off
the
floor until 1pm the following day. She reports the floor was
slippery and full of garbage which made it impossible for her to
get enough traction to push herself off the floor. When she
finally managed to get up, she felt diffusely weak, tremulous,
and achey and was unable to walk, and she decided to call EMS.
She denies ever losing consciousness during the entirety of the
night. No headache, vision changes, dysarthria, ataxia,
unilateral weakness, or paresthesias. No tonic-clonic movements,
incontinence, or confusion. No chest pain or pressure,
palpitations, diaphoresis, or nausea. She denies using any other
substances besides alcohol and tobacco and denies intoxication.
In the ED:
- Initial vital signs were: T 97.7 BP 195/115 HR 114 RR 18 O2
99%
on RA
- Exam was notable for point tenderness over her entire spine,
intact strength and rectal tone.
- Labs were notable for: CK 6055, Cr 1.9
- CT Head, CT C/T/L Spine, and right knee and elbow X-rays were
all negative for fracture or other acute pathology.
- Patient was given sodium bicarbonate 100 mEq and 1L NS and
admitted for further management.
On admission, the patient reports she feels overall much better.
She has ongoing mild-moderate pain in both knees but her
weakness
has resolved. No myalgias. No chest pain/pressure, palpitations,
dyspnea, or nausea.
## PAST MEDICAL HISTORY:
-Bipolar Disorder
-Chrons colitis
-hep C
-HTN
-Spondyloarthopathy
-Restrictive lung disease
-CKD
-Barretts esophagus
-History of R frontotemporal lobe encephalomalacia (h/o 2
cerebral aneurysm repairs , b/l aneurysm clips in Sylvian
cisterns)
-Hx of cardiomyopathy (LVEF 50%)
## HOSPITALIZATIONS:
many, unclear when last one was
Current treaters and treatment:
- Dr. at
Medication and ECT trials:
- Current: Seroquel, benztropine
- Previous: previously rx Prozac, Risperdal,
Depakote, Ability, and Klonopin but could not describe her
response to any of the medications. Denies ever being
prescribed/taken lithium or Lamictal.
## DENIES
HARM TO OTHERS:
denies
Access to weapons: denies
## FAMILY HISTORY:
alcohol abuse in family
Aunt has mental health issues
## VITALS:
Reviewed, afebrile and stable
## GENERAL:
Obese older woman in NAD.
## HEENT:
No evidence of head trauma. No icterus or injection. OP
dry.
## CV:
Tachycardic, regular, normal S1/S2, no audible murmurs.
## RESP:
Normal work of breathing. CTAB.
## GI:
Distended, non-tender, tympanitic. No palpable HSM (limited
by obesity).
## GU:
No suprapubic or CVA tenderness.
## MSK:
Diffuse tenderness to palpation over both thighs. No
tenderness over calves, upper extremities, or trunk muscles.
Abrasions on both knees. No lower extremity edema.
## SKIN:
No rashes or lesions.
## NEURO:
Alert, oriented, attentive though speech tangential.
PERRL, EOMI, no nystagmus. CN intact. Strength and
symmetric throughout upper and lower extremities.
## PSYCH:
Euthymic mood and affect. Thought process tangential. No
evidence of AVH or delusions.
DISCHARE EXAM
==================
## 0713 TEMP:
98.2 PO BP: 153/83 L Lying HR: 81 RR: 18 O2
sat: 93% O2 delivery: Ra FSBG: 240
## GENERAL:
Obese older woman in NAD.
## HEENT:
MMM. No icterus or injection.
## CV:
Regular rate and rhythm, normal S1/S2, no audible murmurs.
## RESP:
Normal work of breathing. CTAB.
## GI:
Soft, non-tender, nondistended. No palpable HSM
## GU:
No suprapubic or CVA tenderness.
## MSK:
Nontender thighs to palpation. Abrasions on both
knees/elbows.
## NEURO:
Alert, oriented, attentive though speech tangential. CN
grossly intact. Moving all extremities equally.
## CXR IMPRESSION:
No acute intrathoracic process.
## CT HEAD IMPRESSION:
No acute intracranial process.
## CT C-SPINE IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Degenerative changes and fusion of multiple facet joints.
## CT T-SPINE IMPRESSION:
1. No fracture or malalignment.
2. Multilevel ossification of the ligamentum flavum resulting in
up to
moderate to severe canal narrowing, worse at the T10-T11 level,
as above.
3. Diffuse increased sclerosis of the T7 vertebral body and at
the T5 inferior endplate which is new since . Findings
raise possibility of metastatic disease. Findings are not
diagnostic of hemangioma based on appearance. Consider MRI
especially in light of patient's symptoms.
## CT L-SPINE IMPRESSION:
No acute fracture or traumatic malalignment.
## RUQUS IMPRESSION:
Coarsened and heterogeneous hepatic parenchyma limiting
evaluation for focal mass. Liver contour is mildly nodular,
consistent with cirrhotic morphology. No splenomegaly or
ascites. No intra or extrahepatic biliary dilation.
DISCHARGE LABS
==================
09:23AM BLOOD WBC-9.1 RBC-4.42 Hgb-11.5 Hct-37.8 MCV-86
MCH-26.0 MCHC-30.4* RDW-16.8* RDWSD-52.3* Plt
09:23AM BLOOD Glucose-248* UreaN-15 Creat-0.9 Na-143
K-4.0 Cl-104 HCO3-25 AnGap-14
06:02AM BLOOD ALT-90* AST-86* CK(CPK)-513* AlkPhos-111*
TotBili-0.4
09:23AM BLOOD CK(CPK)-224*
02:38AM BLOOD %HbA1c-13.5* eAG-341*
## BRIEF HOSPITAL COURSE:
with h/o bipolar disorder, polysubstance use, cardiomyopathy
due to HTN and cocaine use (EF 55-60%), untreated HCV, admitted
for markedly elevated CK and renal failure concerning for
rhabdomyolysis found to have new diagnosis of diabetes with A1C
13%.
# possibly secondary to RHABDOMYOLYSIS:
Patient presented s/p fall with unknown down time in addition to
. Creatinine was 1.0 last checked in . As her CK was
6600, it is possible rhabdomyolysis was the underlying cause (if
CK had actually been higher prior to presentation). Other
features included blood on UA (likely myoglobin) and diffuse
muscle tenderness. Cocaine use (patient denies using but tox
screen positive) may have contributed in addition to fall with
patient unable to get up off the floor. DDx included
alcohol-induced myopathy (though patient reports consuming only
a small amount). No evidence for NMS given patient's very large
antipsychotic doses. No fevers to suggest infectious myositis.
Patient was treated with IVF resuscitation with normal saline.
resolved, and CK downtrended to 500s on discharge. Of note,
with acute kidney injury in the past but no clear history of
CKD. Hyperglycemia-induced osmotic diuresis may have also
contributed to her this admission.
# TYPE 2 DIABETES MELLITUS, newly diagnosed:
No prior diagnosis of diabetes, last A1c 6.0% in , but high
risk for insulin resistance and undiagnosed DM2 due to obesity
and long-term antipsychotic use. On admission, patient noted to
ne markedly hyperglycemic to 500s. No exam or lab evidence for
DKA or HHS (not acidemic, AG 20 but better explained by ,
urine with only trace ketones). A1C on admission 13.5%.
was consulted for assistance in new diabetes management. Patient
was started on lantus QD and humalog with meals. Given patient's
difficulties managing meds at home, decision was made to
simplify insulin regimen. Patient was discharged with once daily
Tresiba injections, glipizide ER 10mg QD, with plan to start
dulaglutide once weekly as an outpatient. Per recs, not
started on metformin due to recurrent history of , but would
consider starting as outpatient.
# POLYSUBSTANCE ABUSE:
Patient denies any recent cocaine use but tox screen positive.
Also reported ETOH use and hx of substance abuse. No other
positive tox screen findings. Monitored and no evidence of
withdrawal during admission.
# TRANSAMINITIS:
Patient was noted to have persistent mild AST, ALT elevation
during admission. This was felt likely due to ETOH injury (acute
on chronic). Possibly also due to hx HCV untreated and hepatic
steatosis vs NASH/ETOH cirrhosis given poorly controlled
diabetes. Transaminitis was stable and not concerning for severe
drug-induced liver injury. HCV viral load repeated during
admission. RUQUS showed coarsened hepatic parenchyma consistent
with cirrhosis. Patient will need full hepatology work up as an
outpatient.
# MECHANICAL FALL:
Patient reported she was at a friends house when she fell and
could not get up. Occurred in the setting of substance use
(cocaine and ETOH) with unclear amount of time down. Patient
denies syncope/presyncope. No findings to suggest arrhythmia,
ACS, stroke, seizure, or other non-mechanical etiology. No
evidence of fractures on extensive imaging in ED. Patient was
ambulating well without assistance with no need for consult.
# BACK PAIN:
# IBD-RELATED SPONDYLOARTHROPATHY:
# T-SPINE SCLEROSIS:
Patient reporting back pain in the setting of mechanical fall on
admission. No exam or imaging evidence of cord compression or
infection. Symptoms resolved with supportive care and were
likely related to musculoskeletal strain and her known
IBD-related spondyloarthropathy. Of note, CT T-spine did show:
"Diffuse increased sclerosis of the T7 vertebral body and at the
T5 inferior endplate which is new since . Findings raise
possibility of metastatic disease. Findings are not diagnostic
of hemangioma based on appearance. Consider MRI especially in
light of patient's symptoms." MRI not pursued given resolution
of back pain. Consider as outpatient pending patient's symptoms.
## ==================
# HYPERTENSION:
Patient was markedly hypertensive to 190s on
arrival to ED, likely due to recent cocaine use as well as
missed meds. BP improved over admission after restarting home
meds. Continued on home amlodipine, lisinopril, labetalol.
## # CARDIOMYOPATHY (EF 55-60%):
No clinical evidence of heart
failure or volume overload despite marked hypertension on
arrival and ongoing substance use. No active issues.
## # BIPOLAR DISORDER:
On large doses of antipsychotic medications.
Managed by outside provider. Continued home quetiapine,
risperidone, benztropine, clonazepam. QTc 445 during admission.
## # UNTREATED HEPATITIS C:
HCV antibody positive. HCV viral load
repeated and pending at discharge.
## # RESTRICTIVE LUNG DISEASE:
Presumably related to Crohn's. No
acute symptoms. Continue home inhalers.
## TRANSITIONAL ISSUES:
========================
[ ] Follow up A1C and blood sugars on Tresiba, glipizide,
dulaglutide. (only able to fill 2 week supply of dulaglutide;
pharmacy will work on prior auth to continue med).
[ ] Recommend repeat BUN/Cr at outpatient follow up given hx
labile renal function. If renal function stable, consider
initiation of metformin for additional diabetes control.
[ ] If kidney function stable, consider initiation of metformin
for on-going diabetes control.
[ ] Recommend HBV vaccine for patient given known HCV.
[ ] Needs hepatology appointment and consideration of treatment
for HCV and work up of RUQUS consistent with cirrhosis.
[ ] Consider outpatient MRI T-spine given CT T-spine finding of
"Diffuse increased sclerosis of the T7 vertebral body and at the
T5 inferior endplate which is new since . Findings raise
possibility of metastatic disease. Findings are not diagnostic
of hemangioma based on appearance. Consider MRI especially in
light of patient's symptoms." No back pain at discharge and no
other findings concerning for metastatic disease/malignancy.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Benztropine Mesylate 0.5 mg PO QHS
3. QUEtiapine Fumarate 50 mg PO DAILY:PRN agitation
4. QUEtiapine Fumarate 700 mg PO QHS
5. RisperiDONE 2 mg PO QHS
6. ClonazePAM 1 mg PO BID
7. Labetalol 300 mg PO BID
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
10. amLODIPine 10 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Albuterol Inhaler PUFF IH Q4H:PRN shortness of breath
13. FoLIC Acid 1 mg PO DAILY
14. Artificial Tears DROP BOTH EYES PRN dry eyes
15. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
## DISCHARGE MEDICATIONS:
1. GlipiZIDE XL 10 mg PO DAILY
RX *glipizide 10 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
## REFILLS:
*0
2. Glargine 40 Units Breakfast
RX *blood sugar diagnostic [FreeStyle Lite Strips] Use with
glucometer as directed. DAILY and PRN Disp #*100 Strip
## REFILLS:
*0
RX *insulin degludec [Tresiba FlexTouch U-100] 100 unit/mL (3
mL) AS DIR 40 Units before BKFT; Disp #*3 Syringe Refills:*0
RX *blood-glucose meter [FreeStyle Freedom Lite] AS DIRECTED
DAILY AND PRN Disp #*1 Kit Refills:*0
RX *lancets [FreeStyle Lancets] 28 gauge AS DIRECTED DAILY AND
PRN Disp #*100 Each Refills:*0
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine]
31 gauge X AS DIRECTED DAILY Disp #*90 Syringe Refills:*0
3. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
This has been filled at your in , .
4. Albuterol Inhaler PUFF IH Q4H:PRN shortness of breath
5. amLODIPine 10 mg PO DAILY
6. Artificial Tears DROP BOTH EYES PRN dry eyes
7. Benztropine Mesylate 0.5 mg PO QHS
8. ClonazePAM 1 mg PO BID
9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
10. FoLIC Acid 1 mg PO DAILY
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
12. Labetalol 300 mg PO BID
13. Lisinopril 20 mg PO DAILY
14. Omeprazole 20 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
17. QUEtiapine Fumarate 700 mg PO QHS
18. QUEtiapine Fumarate 50 mg PO DAILY:PRN agitation
19. RisperiDONE 2 mg PO QHS
## PRIMARY DIAGNOSIS:
===================
Rhabdomyolysis
Acute Kidney Injury
Hyperglycemia due to newly-diagnosed Type 2 Diabetes Mellitus
## SECONDARY DIAGNOSIS:
=====================
Polysubstance Abuse
Bipolar Disorder
Transaminitis
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to .
WHY YOU WERE ADMITTED TO THE HOSPITAL:
=======================================
- You fell and could not get up.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
=============================================
- Your blood work showed an elevated protein from muscle
breakdown that can hurt your kidneys. You were given fluids in
your IV and this got better.
- Your blood sugars were very high, and you started new
medicines including insulin to treat diabetes.
WHAT YOU NEED TO DO WHEN YOU GO HOME:
=====================================
- It is very important you follow up with your primary care
doctor within the next days to check your blood sugars.
- You are being discharged with new medicines for your diabetes.
It is very important you take all your medicines as prescribed.
It was a pleasure taking care of you!
Sincerely,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14143688", "visit_id": "28011648", "time": "2198-07-11 00:00:00"} |
14653003-RR-60 | 93 | ## EXAMINATION:
DX HAND, WRIST AND FOREARM
## INDICATION:
with bruised wrist evaluate for fracture
## LEFT HAND:
No fractures or dislocations. There is mild first MCP degenerative
change. Deformity of the left fifth metacarpal suggests prior healed
fracture.
Left wrist: No definite fractures or dislocations. If there is clinical
concern for scaphoid fracture.
Left forearm, no fractures or dislocations.
There is chronic deformity of the fifth metacarpal, likely sequela of remote
injury.
## IMPRESSION:
No definite fractures or dislocations.
If there is clinical concern for scaphoid fracture, recommend splinting and
repeat imaging in days.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14653003", "visit_id": "21413680", "time": "2194-10-27 12:28:00"} |
15673635-RR-33 | 102 | ## INDICATION:
year old man with hx Left epididymitis // confirmation
## THE RIGHT TESTICLE MEASURES:
4.3 x 3.2 x 2.1 cm.
The left testicle measures: 3.6 x 2.7 x 3.1 cm.
The testicular echogenicity is normal, without focal abnormalities. There is
ectasia of the rete testes bilaterally. There is a 10 mm simple right
epididymal head cyst. Otherwise, the epididymides are normal bilaterally.
Vascularity is normal and symmetric in the testes and epididymides. Bilateral
varicoceles are present.
## IMPRESSION:
1. Ectasia of the rete testes bilaterally.
2. Bilateral varicoceles.
3. 10 mm simple right epididymal head cyst.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15673635", "visit_id": "N/A", "time": "2195-09-16 14:01:00"} |
17538312-DS-18 | 680 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HPI:
year old DM male presents to clinic with an ulceration
on
his right hallux. He presents from his home in from which he
flew into last night. He states it started as a blister
approximately a week ago. It progressively became red. He
presented to a hospital in where he was told he may need an
amputation. He presents today for a second opinion. He was
placed
on oral Clinda/Cipro.
## PMHX:
DM c/b neuropathy, HTN
## FAMILY HISTORY:
Mother had stroke in early
## ABDOMEN:
Soft, NT/ND, (+)BS
VASCULAR
## PEDAL PULSES:
[x] Non-palpable, no dp, palp pt
## BRIEF HOSPITAL COURSE:
was admitted Right hallux ulcer. He agreed
to have an elective surgery. Pre-operatively, he was consented.
A CXR, EKG, UA, CBC, Electrolytes, T/S -were obtained, all
other preperations were made.
It was decided that he would undergo;
## PROCEDURES AND DIAGNOSES:
1. Abdominal aortogram.
2. Right lower extremity angiogram.
3. Catheterization contralateral third order.
4. Balloon angioplasty of tibial disease of posterior
tibialis.
He was prepped, and brought down to the endo suite room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, transferred to the PACU for further
stabilization and monitoring.
His sheath was pulled wihtout sequele.
He was then transferred to the VICU for further recovery. While
in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. When he was stabalized from the
acute setting of post operative care, he was transfered to floor
status
On the floor, he remained hemodynamically stable with his pain
controlled. He continues to make steady progress without any
incidents. He was discharged home in stable condition.
He did recieve preoperative hydration. On DC his creatinine is
stable. He is to go home on PO AB.
## MEDICATIONS ON ADMISSION:
Avandamet, lisinopril, fish oil
## DISCHARGE MEDICATIONS:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): Do not take for first 48 hours after discharge from
hospital. Then resume normal dosage.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
## 5. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
9. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
## DAILY (DAILY):
apply to foot daily.
Disp:*1 tube* Refills:*1*
## DISCHARGE CONDITION:
Vital signs stable. good condition
## DISCHARGE INSTRUCTIONS:
Please resume all pre-admission medications. You were given new
prescriptions, please take as directed.
.
Do not take your metformin for 48 hours after discharge from the
hospital. Then resume your normal daily dosage
.
Keep your R foot dressing clean and dry at all times. You will
need to change your dressing with santyl ointment and dry
dressing daily.
.
You are to remain PARTIAL WEIGHT BEARING on your R foot in a
surgical shoe at all times. Keep your R foot elevated to
prevent swelling.
.
Call your doctor or go to the ED for any increase in R foot
redness, swelling or purulent drainage from your wound, for any
nausea, vomiting, fevers greater than 101.5, chills, night
sweats or any worsening symptoms
.
You may remove the tegaderm dressing to your angioplasty site
tonight and shower. Will will need to take Plavix for 30 days as
prescribed.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17538312", "visit_id": "20118184", "time": "2189-11-30 00:00:00"} |
11402251-RR-35 | 174 | ## EXAMINATION:
ELBOW (AP, LAT AND OBLIQUE) LEFT
## INDICATION:
year old woman with fall on knee, reports hx replacement in
// trauma
## FINDINGS:
There are multifocal small spurs including spurring along the coronoid
process. Lateral view suggests presence of a loose body in the olecranon
fossa. There is a borderline small joint effusion, better appreciated on this
elbow radiograph than on the forearm radiograph. No acute fracture or
dislocation is identified. Minimal narrowing of the ulnar trochlear joint
cannot be excluded, but joint spaces are otherwise grossly preserved.
## IMPRESSION:
Degenerative changes with spurring and probable olecranon fossa loose body.
Borderline elbow joint effusion. No obvious evidence for fracture on the
current examination and the joint effusion is relatively small. However, if
there is a history of recent trauma to the elbow, then the possibility of an
occult intra-articular fracture cannot be entirely excluded.
Please see separate report of left forearm radiographs obtained the same day.
## RECOMMENDATION(S):
If symptoms persist, consider followup radiographs in
days to assess for possible occult intra-articular fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11402251", "visit_id": "23927937", "time": "2156-08-17 09:00:00"} |
15874013-DS-13 | 1,168 | ## ALLERGIES:
Aspirin / Wellbutrin / Nsaids
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Coronary artery bypass graft x2, left internal mammary
artery to left anterior descending artery and saphenous vein
graft to the obtuse marginal artery
## HISTORY OF PRESENT ILLNESS:
Angina for yrs after RT to LT breast for infiltrating ductal
carcinoma. Managed medically after cath revealed minimal disease
w/ 30% LM only, this thought to be secondary to RT. Over last
few weeks has had increasing frequency of angina (back
pain),including at rest, relieved w/ sl NTG. EST positive for
anterior ischemia. Cath today to show 50-60%left main w/o
significant subsequent disease. LV preserved at 65%.Referred for
CABG.
## PAST MEDICAL HISTORY:
Obesity
Chonic obstructive pulmonary disease
Pneumonia
s/p Left VATS/wedge for eosinophilic granulomatous dz .
Right lumpectomy &RT . Left lumpectomy/chemo/RT (inf.
ductal bilat)
## GENERAL:
WDWN, obese WF in NAD
## NECK:
Supple [x] Full ROM [x]
## CHEST:
Lungs clear bilaterally [x]
## HEART:
RRR [x] Irregular [] Murmur n
## EXTREMITIES:
Warm [x], well-perfused [x] Edema Varicosities:
None [x]
## MRN:
TEE (Complete)
Done at 9:48:17 AM PRELIMINARY
Referring Physician
of Cardiothoracic Surg
## INDICATION:
CABG, Chest pain. Coronary artery disease. Shortness
of breath.
## TYPE:
TEE (Complete) Sonographer: , MD
## DOPPLER:
Full Doppler and color Doppler Location:
Anesthesia West OR cardiac
## NONE TECH QUALITY:
Adequate
Tape #: -0:00 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.4 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
## LEFT VENTRICLE - DIASTOLIC DIMENSION:
4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.1 cm
Left Ventricle - Fractional Shortening: 0.51 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.13 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.13
Mitral Valve - E Wave deceleration time: 229 ms 140-250 ms
Findings
## LEFT ATRIUM:
Normal LA size. No spontaneous echo contrast is
seen in the . Good (>20 cm/s) ejection velocity.
## RIGHT ATRIUM/INTERATRIAL SEPTUM:
No spontaneous echo contrast in
the body of the RA. A catheter or pacing wire is seen in the RA.
Good RAA ejection velocity (>20cm/s). No thrombus in the RAA.
## LEFT VENTRICLE:
Normal LV wall thickness and cavity size. Normal
LV cavity size. Overall normal LVEF (>55%). Transmitral Doppler
E>A and TDI E/e' <8 suggesting normal diastolic function, and
normal LV filling pressure (PCWP<12mmHg). Doppler parameters are
most consistent with normal LV diastolic function.
## RIGHT VENTRICLE:
Normal RV chamber size and free wall motion.
## AORTA:
Normal ascending aorta diameter. Simple atheroma in
descending aorta.
## AORTIC VALVE:
Normal aortic valve leaflets (3). No AS. No AR.
## MITRAL VALVE:
Mildly thickened mitral valve leaflets. Trivial
MR.
## VALVE:
Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
## GENERAL COMMENTS:
A TEE was performed in the location listed
above. I certify I was present in compliance with
regulations. The was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The appears to be in sinus rhythm.
Conclusions
## PRE-CPB:
The left atrium is normal in size. . No spontaneous echo
contrast is seen in the body of the right atrium. Right atrial
appendage ejection velocity is good (>20 cm/s). No thrombus is
seen in the right atrial appendage
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter.
No thoracic aortic dissection is seen.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
## POST-CPB:
I certify that I was present for this procedure in compliance
with regulations.
Interpretation assigned to , MD,
physician
© . All rights reserved.
## BRIEF HOSPITAL COURSE:
Mrs. was transferred from outside hospital with left
main coronary disease. She was appropriately worked up for
bypass surgery and on she was brought to the operating room
where she underwent a coronary artery bypass graft x 2. Please
see operative report for surgical details. Following surgery she
was transferred to the CVICU for invasive monitoring. Within 24
hours she was weaned from sedation, awoke neurologically intact
and extubated without difficulty. Beta-blocker/Aspirin/Statin
and diuresis was initiated. All lines and drains were
discontinued in a timely fashion, without complication. POD#1
she continued to progress and was transferred to the step down
unit for further monitoring. Physical therapy was consulted for
strength and mobility evaluation. The remainder of her
postoperative course was essentially uneventful. Due to her
underlying respiratory history of eosinophilic granulomatous
disease, postoperatively she was unable to be completely weaned
off nasal oxygen. O2 Saturation would drop into the with
ambulation. Therefore arrangements for oxygen home therapy were
initiated. POD# 5 she was cleared for discharge to home. All
follow up appointments were advised.
## MEDICATIONS ON ADMISSION:
Toprol XL 50 mg daily,Crestor 20mg daily, Albuterol 2P BID,
Advair 250/50 BID,Vits.Bactrim DS for UTI at HF,but no data w/
pt.
## FACILITY:
Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
Past medical history:
Obesity
Chonic obstructive pulmonary disease
Pneumonia
s/p Left VATS/wedge for eosinophilic granulomatous dz .
Right lumpectomy &RT . Left lumpectomy/chemo/RT (inf.
ductal bilat)
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
## INCISIONS:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
## FEMALES:
Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns . Answering service will contact on call
person during off hours**
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15874013", "visit_id": "25374074", "time": "2175-11-16 00:00:00"} |
16305773-RR-54 | 85 | ## INDICATION:
year old woman with right total hip arthroplasty.
## FINDINGS:
Since prior, there has been interval placement of a right total hip
arthroplasty without evidence of early hardware complication. Post surgical
changes are present including lateral staple line and soft tissue air, as
expected. No acute fracture or dislocation is detected. There are
degenerative changes of the lower lumbar spine. A limited view of the left
hip is unremarkable.
## IMPRESSION:
Expected post surgical changes after right total hip arthroplasty. No
periarticular fracture detected.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16305773", "visit_id": "26517123", "time": "2153-10-15 09:06:00"} |
13512738-RR-43 | 82 | ## FINDINGS:
Patient is rotated to her right, further distorting right hular and
mediastinal contours. Pleural effusion if any, is minimal on the right. There
could be a new right upper lobe nodule partially obscured by the right first
rib. Heart is moderately enlarged. A large hiatal hernia is chronic.
Partially imaged upper abdomen is unremarkable.
## IMPRESSION:
1. Possible right upper lobe lesion. Lordotic view recommended. ,
, MD and discussed these findings by telephone, 2:15pm .
2. Stable cardiomegaly and hiatal hernia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13512738", "visit_id": "22342764", "time": "2175-01-27 06:36:00"} |
18361609-DS-16 | 1,383 | ## ALLERGIES:
Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
: debridement and screw removal R Foot
## HISTORY OF PRESENT ILLNESS:
y/o M with PMH of DM, HTN who presented to the ED after being
seen by Dr. in his Clinic. He was started on PO
abx last week after calling with the complaint of an infection
to the R foot. The patient was seen in clinic again on and
he was noted to have an ulcer with drainage to his right heel as
well as the lateral aspect of his foot. The pt stated he had not
seen his pcp since when his insurance changed. He
stated that he hasn't been taking his HTN meds either. Patient
denies f/c/n/v/sob/cp. Denies any further pedal complaints
## PAST MEDICAL HISTORY:
Remarkable for diabetes of years' duration, complicated by
neuropathy.
HTN
R charcot reconstruction
## CV:
RRR, Distal extremities well perfused
## RESP:
respiratory distress. Breathing comfortably on room air
## ABD:
Soft, NT, ND, obese
## GENERAL:
NAD,A&Ox3
RLE focused exam:
DP and pulses palpable edema. There is a wound to the
plantar aspect of the R heel with + tracking and + PTB. There is
purulence noted. There a wound on the lateral aspect of the
foot with localized erythema and edema. There is a wound to the
medial aspect of the midfoot with erythema and sanguineous
discharge. The is a discoloration noted to the dorsal aspect of
the R ankle. pain to palpation of any of the ulcer sites
noted.
## CV:
RRR, Distal extremities well perfused
## RESP:
respiratory distress. Breathing comfortably on room air
## ABD:
Soft, NT, ND, obese
## NAD,A&OX3
RLE FOCUSED EXAM:
fiberglass cast in place. patient able to move
toes. cap refill less than 3 seconds. light touch sensation
diminished to the feet b/l.
## IMPRESSION:
Appearance of the osseous structures and hardware
along with Charcot arthropathy grossly similar compared to the
prior study from . Difficult to exclude focal
subtle ulceration or superficial soft tissue gas overlying the
lateral midfoot, on the AP view of the right midfoot. Soft
tissue swelling. Likely ankle joint effusion which may have
increased since the prior study.
## WET READ:
focal enhancing collection is identified
## BRIEF HOSPITAL COURSE:
The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have R foot infection and was admitted to the podiatric
surgery service. He was started on broad spectrum IV
antibiotics. The patient was taken to the operating room on
for debridement and screw removal, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with who determined that discharge home was appropriate.
diabetes service was consulted for recommendations.
Infectious disease was consulted and they recommended going home
with a picc line and IV antibiotics for likely 6 weeks. The
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, he had a
fiberglass cast applied prior to discharge, and the patient was
voiding/moving bowels spontaneously. The patient is non
weightbearing in the right lower extremity. The patient will
follow up with Dr. 1 week postop. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
## MEDICATIONS ON ADMISSION:
-Humalog KwikPen 100 unit/mL subcutaneous
-Lantus 100 unit/mL subcutaneous solution
40 units at bedtime
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*80
## TABLET REFILLS:
*0
3. Docusate Sodium 100 mg PO BID
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*120 Tablet Refills:*0
5. OneTouch Ultra Test (blood sugar diagnostic) use times
per day OR as directed miscellaneous as directed
RX *blood sugar diagnostic [OneTouch Ultra Test] use times
per day OR as directed as directed Disp #*150 Strip Refills:*1
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg tablet(s) by mouth q 4 hours Disp #*30
Tablet Refills:*0
7. Rifampin 300 mg PO Q12H
RX *rifampin 300 mg 1 capsule(s) by mouth twice a day Disp #*80
## CAPSULE REFILLS:
*0
8. Senna 8.6 mg PO BID:PRN Constipation
9. Sodium Chloride 0.9% Flush mL IV DAILY and PRN, line
flush
10. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 750 mg 1500 mg IV every twelve (12) hours Disp
#*168 Vial Refills:*0
11. Glargine 36 Units Bedtime
Humalog 6 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 36 Units before
BED Disp #*1 Vial Refills:*0
12.Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
## WEEKLY:
CBC w/ diff, BUN, Cr, Vancomycin trough
7 DAYS POST DISCHARGE: AST, ALT, TB, ALK PHOS
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Mr. ,
It was a pleasure taking care of you at . You were admitted
to the Podiatric Surgery service after your right foot surgery.
You were given IV antibiotics while here. You are being
discharged home with the following instructions:
## ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
## EXERCISE:
Limit strenuous activity for 6 weeks.
heavy lifting greater than 20 pounds for the next days.
Try to keep leg elevated when able.
## BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
## MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
## DIET:
There are special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
## FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are
through .
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18361609", "visit_id": "21354059", "time": "2144-09-09 00:00:00"} |
19518966-RR-97 | 289 | ## INDICATION:
male with history of colon cancer and Crohn's
disease. Assess for recurrence.
## CHEST:
The visualized portion of the thyroid is unremarkable. No axillary, hilar,
supraclavicular, or mediastinal lymphadenopathy. The great vessels are
unremarkable. Prominent costophrenic recesses are noted. The heart is
otherwise unremarkable. The pericardium is intact without effusion.
The airways are patent to subsegmental levels. The lungs are clear without
nodule, consolidation, or pneumothorax. Small bibasilar dependent
atelectasis. The pleura is intact without effusion.
## ABDOMEN:
The liver is normal without focal or diffuse abnormality. The gallbladder,
intra- and extra-hepatic bile ducts, pancreas, spleen, and bilateral adrenal
glands are normal. Bilateral kidneys enhance symmetrically and excrete
contrast promptly. Bilateral ureters are normal in course and caliber.
The esophagus and stomach are normal. The patient is status post total
colectomy with right lower quadrant end ileostomy. The remaining distal ileum
is thickened but demonstrates no abnormal enhancement or adjacent fat
stranding. An enteroenteric anastomotic suture line in the left mid abdomen
(2:74) appears intact. The anal remnant appears unremarkable, similar to
prior.
No retroperitoneal or mesenteric lymphadenopathy. No free abdominal fluid,
organized abdominal collection, pneumoperitoneum, or abdominal wall hernia.
The portal and intra-abdominal systemic vasculature is unremarkable.
## PELVIS:
The bladder and terminal ureters are unremarkable. The prostate
gland and seminal vessels are unremarkable. No pelvic sidewall or inguinal
lymphadenopathy. No free pelvic fluid or inguinal hernia. Bilateral
vasectomy clips.
## OSSEOUS STRUCTURES:
No focal lytic or sclerotic lesion concerning for
malignancy.
## IMPRESSION:
Status post total colectomy with end ileostomy. The remaining
distal ileum demonstrates wall-thickening, compatible with known Crohn's
disease, but no abnormal enhancement or adjacent fat stranding. The anal
remnant is unremarkable. No evidence of locally recurrent or distant
metastatic malignancy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19518966", "visit_id": "N/A", "time": "2184-10-24 10:28:00"} |
11052060-RR-114 | 526 | ## EXAMINATION:
CTA HEAD AND CTA NECK
## INDICATION:
male with history of vertebral artery stroke, now
with lightheadedness worse with head movements. Evaluate for dissection.
## DOSE:
DLP: 2364.98 mGy-cm; CTDI: 156.71 mGy
## HEAD CT:
There is no evidence of hemorrhage, edema, masses, mass effect, or
acute infarction. There are chronic appearing hypodensities in the
periventricular white matter and external capsules, unchanged from CT on . There is commensurate prominence of the ventricles, sulci, and
cisterns consistent with mild generalized parenchymal volume loss. No
fractures are identified. The paranasal sinuses mastoid air cells are
preserved. The orbits are normal.
## HEAD CTA:
There is calcification of the V4 segments of the vertebral
arteries. The V4 segment of the right vertebral artery is occluded unchanged
from prior CTA on . This is occlusion rather than hypoplasia as a
patent flow void was present in the V4 segment of the right vertebral artery
on MRI from . The basilar artery and superior cerebellar arteries
are normal. The right posterior cerebral artery is fetal origin. The left
posterior cerebral artery has conventional anatomy. The posterior cerebral
arteries demonstrate normal patency.
There is marked calcification of the cavernous carotid arteries. The M1
segment of the left middle cerebral artery is smaller in caliber and slightly
irregular compared to the right, suggesting atherosclerotic disease. This is
unchanged from prior CTA on . The right middle cerebral artery is
normal. The anterior cerebral arteries and anterior communicating artery are
normal.
No aneurysm is identified.
The major dural venous sinuses are patent.
## NECK CTA:
There is mild calcification of the aortic arch. There is 3 vessel
aortic arch anatomy.
The left subclavian artery is normal. The cervical left vertebral artery is
normal.
There is mild calcification of the brachiocephalic artery. The right
subclavian artery is normal. The right vertebral artery is diminutive in
caliber but is patent throughout its cervical course.
The left common carotid artery is normal. There is atherosclerotic
calcification and atherosclerotic plaque of the carotid bifurcation but no
stenosis by NASCET criteria. The left external carotid artery is normal.
The right common carotid artery is normal. There is mild calcification and
atherosclerotic plaque at the carotid bifurcation but no stenosis by NASCET
criteria. The cervical internal carotid artery is otherwise normal. The right
external carotid artery is normal. The visualized portion the lungs
demonstrate emphysematous changes. There is suggested heterogeneity of the
thyroid gland. The visualized osseous structures demonstrate extensive
degenerative changes.
## IMPRESSION:
1. No intracranial hemorrhage or evidence of an acute infarct. Moderate
chronic small vessel ischemic disease of the white matter, unchanged from CT
on .
2. Unchanged occlusion of the V4 segment of the right vertebral artery and
mild atherosclerosis of the M1 segment of the left middle cerebral artery
compared to prior CTA from . Otherwise unremarkable CTA of the
head.
3. Atherosclerotic plaque in the carotid bifurcations bilaterally but no
stenosis by NASCET criteria. Otherwise unremarkable CTA of the neck.
4. Visualized portion lung suggest emphysematous changes. Recommend clinical
correlation. If clinically indicated, consider correlation with dedicated
chest imaging.
5. Suggested heterogeneity of thyroid gland. Recommend clinical correlation.
If clinically indicated, thyroid ultrasound can be obtained for further
evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11052060", "visit_id": "N/A", "time": "2146-10-05 16:11:00"} |
10979891-RR-39 | 288 | ## EXAMINATION:
CT C-SPINE W/O CONTRAST Q311 CT SPINE
## INDICATION:
History: with trauma, facial injury trauma
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.3 cm; CTDIvol = 46.4 mGy (Head) DLP =
802.7 mGy-cm.
2) Spiral Acquisition 6.0 s, 23.5 cm; CTDIvol = 22.8 mGy (Body) DLP = 536.0
mGy-cm.
Total DLP (Body) = 536 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
## FINDINGS:
There is widening of the left C3/4 facet joint with adjacent sclerosis (601
image 25). No significant soft tissue stranding or other evidence of
traumatic subluxation is present. There is mild anterolisthesis of C3 over
C4, most likely degenerative in nature. No acute fractures. Degenerative
changes include intervertebral disc height loss, osteophytosis and subchondral
sclerosis most prominent at C5/6. Mild central canal and bilateral neural
foraminal narrowing at C5-6 is present due to posterior osteophyte and
uncovertebral spurring. There is no prevertebral soft tissue swelling. There
is no evidence of infection or neoplasm.
Visualized lung apices demonstrate smooth septal thickening and mild
paraseptal emphysema. The visualized thyroid is unremarkable.
## IMPRESSION:
1. Abnormal widening of the left C3/C4 facet joint with adjacent sclerosis,
but no soft tissue stranding. Findings are of unclear chronicity, but if
there is concern for acute injury based on physical exam and clinical
symptoms, MRI of the cervical spine could be obtained for further assessment.
2. No acute fracture. Moderate cervical spondylosis with mild C3 on C4
anterolisthesis, likely degenerative in etiology. No prevertebral soft tissue
swelling.
3. Mild fluid overload within the lung apices.
## RECOMMENDATION(S):
MRI of the cervical spine could be obtained for further
assessment of etiology of the left C3-4 facet joint widening.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10979891", "visit_id": "N/A", "time": "2122-07-15 12:44:00"} |
15472717-DS-21 | 599 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
endoscopic suppracellar mass resection
## HISTORY OF PRESENT ILLNESS:
y/o M presents for elective resection of suprasellar mass.
## PAST MEDICAL HISTORY:
-T6 mass on MRI
-Nephrolithiasis s/p lithotripsy
-BPH s/p holmium laser ablation of prostate
-Renal cyst
-Penile codylomata
-Appendectomy
## FAMILY HISTORY:
Father had lung disease secondary to smoking, mother with
parkinsons'. NO family history of hematologic malignancies.
## ON DISCHARGE:
A&Ox3
PERRL
EOMs intact
no visual field deficit
No pronator drift
## MOTOR:
throughout
Nasal packing in place, no oozing
## PERTINENT RESULTS:
CT HEAD W/O CONTRAST prelim
Expected postsurgical changes from transsphenoidal approach
suprasellar/clivus mass resection
MRI head
Postsurgical changes from transsphenoidal sellar mass resection
with residual enhancing intrasellar components
## BRIEF HOSPITAL COURSE:
y/o M who presents for elective resection of suprasellar
mass. Patient was taken to the OR on with no
intraoperative complications. Patient was extuabted post
operatively and transferred to the PACU for recovery. Post op,
patient remained stable on exam. Head CT performed showed
expected post operative changes. He was trasnferred to the step
unit in stable condition. His R lower abdominal incision was
c/d/i.
On , patient remained intact on exam. MRI pituitary was
performed. His foley was removed. He was ambulating
independently and voided appropriately. He was discharged home
in stable condition.
## MEDICATIONS ON ADMISSION:
acyclovir, lidocaine, lorazepam, oxycodone, potassium,
venlafaine,cyanocobakamin
## DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg PO/NG Q8H
2. Cephalexin 500 mg PO Q12H
RX *cephalexin 500 mg 1 capsule(s) by mouth twice a day Disp
#*12 Capsule Refills:*0
3. Cyanocobalamin 100 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Venlafaxine XR 75 mg PO DAILY
7. Lorazepam 1 mg PO Q6H:PRN anxiety
8. Lidocaine 5% Patch 1 PTCH TD QAM pain
9. Klor-Con 10 (potassium chloride) 10 mEq oral BID
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
## DISCHARGE INSTRUCTIONS:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
It is normal for feel nasal fullness for a few days after
surgery, but if you begin to experience drainage or salty taste
at the back of your throat, that resembles a dripping
sensation, or persistent, clear fluid that drains from your nose
that was not present when you were sent home, please call.
Fever greater than or equal to 101° F.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15472717", "visit_id": "28335513", "time": "2183-04-20 00:00:00"} |
14535212-RR-96 | 101 | ## EXAMINATION:
CHEST (PA AND LAT)
## HISTORY:
with alcoholic cirrhosis and immunodeficiency now
presents with nausea and vomiting // Please assess for possible pneumonia
## FINDINGS:
Heart size appears mildly enlarged, but decreased from the prior study.
Mediastinal and hilar contours are within normal limits. Pulmonary
vasculature is not engorged. Minimal patchy opacities are noted in the lung
bases, improved compared the prior study, colon likely reflective of
atelectasis. No focal consolidation, pleural effusion or pneumothorax is
present. Osseous structures are diffusely demineralized.
## IMPRESSION:
Minimal patchy opacities in the lung bases, improved compared to the prior
study, and likely reflective of atelectasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14535212", "visit_id": "29008085", "time": "2159-11-04 16:05:00"} |
19152893-DS-10 | 1,321 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
1. Mitral valve repair with an 28mm annuloplasty ring.
# . Model # .
2. Drainage of large right pleural effusion.
3. Ligation of left atrial appendage with Atriclip.
## HISTORY OF PRESENT ILLNESS:
year old female with history of AFIB (on Xarelto) s/p
unsuccessful cardioversion, SSS s/p pacemaker in , HTN, high
cholesterol and severe mitral regurgitation who presents today
for evaluation for MVR. She reports dyspnea with walking <15 ft
on flat ground. She report worsening edema and a dry, non
productive cough. The patient also reports orthopnea and
palpitations at night. She denies lightheadedness, syncope,
chest pain.
## PAST MEDICAL HISTORY:
Afib
SSS s/p pacemaker
Htn
Hypercholesterolemia
Tonsillectom
hypothyroid
## FAMILY HISTORY:
Family history of heart disease. Mother died at of HTN,
father died at of MI. Sister with cardiac stent.
## GENERAL:
Alert, and oriented elderly woman in in NAD.
## SKIN:
+CSM. Turgor fair, skin warm and dry.
## HEENT:
Normocephalic, anicteric, wearing glasses, moist mucous
membranes
## NECK:
Supple, trachea midline, carotid bruit vs. referred murmur
## HEART:
RRR, murmur RSB, radiating
## ABDOMEN:
+BSx4. Soft, non-tender, non-distended
## EXTREMITIES:
Absent right hand, 1+ edema bilaterally, skin
red, taut, gait steady
## NEURO:
Alert and oriented, asking questions appropriately
## PERTINENT RESULTS:
Intra-op TEE
Conclusions
The left atrium is moderately dilated. No mass/thrombus is seen
in the left atrium or left atrial appendage. No spontaneous echo
contrast is seen in the left atrial appendage. The right atrium
is moderately dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is
moderately depressed (LVEF= 40). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. Trace aortic regurgitation is seen. Severe (4+) mitral
regurgitation is seen. The regurgitatant jet is central mitral
annulus is dilated with poor mitral leaflet coaptation.The
mitral leaflet and supporting structures are normal Moderate to
severe [3+] tricuspid regurgitation is seen. There is no
pericardial effusion. There is a large right sided pleural
effusion.
The findings were discussed with Dr
Bypass
LVEF is 45-50% .The right ventricular function is normal.There
is minimal mitral regurgitation.The transmitral gradient is
within normal limits.The thoracic aorta is intact.The right
pleural effusion was drained.The rest of the exam is unchanged
.
05:31AM BLOOD WBC-8.7 RBC-3.54* Hgb-10.0* Hct-32.5*
MCV-92 MCH-28.2 MCHC-30.8* RDW-17.5* RDWSD-58.5* Plt
03:08AM BLOOD WBC-14.9* RBC-3.70* Hgb-10.4* Hct-34.1
MCV-92 MCH-28.1 MCHC-30.5* RDW-17.7* RDWSD-58.8* Plt
12:25PM BLOOD WBC-15.4*# RBC-2.74*# Hgb-7.8*#
Hct-24.9*# MCV-91 MCH-28.5 MCHC-31.3* RDW-16.8* RDWSD-55.3* Plt
04:22AM BLOOD
05:31AM BLOOD
05:18AM BLOOD
04:00PM BLOOD
03:08AM BLOOD PTT-38.3*
10:54AM BLOOD
07:31AM BLOOD PTT-30.6
01:48PM BLOOD PTT-29.0
12:25PM BLOOD PTT-29.5
04:22AM BLOOD Glucose-95 UreaN-30* Creat-0.9 Na-138
K-4.6 Cl-99 HCO3-30 AnGap-14
05:31AM BLOOD Glucose-98 UreaN-34* Creat-1.0 Na-137
K-3.5 Cl-97 HCO3-33* AnGap-11
05:18AM BLOOD Glucose-119* UreaN-36* Creat-1.0 Na-138
K-4.6 Cl-99 HCO3-32 AnGap-12
04:22AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.2
## BRIEF HOSPITAL COURSE:
The patient was brought to the Operating Room on where
the patient underwent Mitral Valve repair and left atrial
appendage ligation via Atriclip with Dr. . She was noted to
have a moderate sized right pleural effusion on pre-op CXR.
This was drained for 1.2L intra-operatively. Overall the
patient tolerated the procedure well and was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Warfarin was started for AFib. INR
rose quickly and became supratherapeutic at 6 with just 3mg
Coumadin. Vitamin K was administered and INR came down.
Coumadin was slowly titrated thereafter. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. PPM interrogated by EP and assisted with
setting changes as needed. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 6 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home with in good condition with appropriate follow up
instructions.
Anti-coagulation will be achieved with Warfarin for at least 30
days. PCP/Cardiology may elect to resume Xarelto following this
time period.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Rivaroxaban 20 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Vitamin D UNIT PO DAILY
## DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg PO DAILY
2. Furosemide 40 mg PO BID
40mg bid x 7 days, then resume 40mg daily
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*37
## TABLET REFILLS:
*0
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Omeprazole 20 mg PO BID
5. Vitamin D UNIT PO DAILY
6. Warfarin 1 mg PO DAILY16
dose to change daily per Dr. goal INR
RX *warfarin 1 mg 1 tablet(s) by mouth daily as directed Disp
#*60 Tablet
## REFILLS:
*0
7. TraMADOL (Ultram) 25 mg PO Q4H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*60 Tablet
## REFILLS:
*0
8. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
11. Docusate Sodium 100 mg PO BID
hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
12. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
## FACILITY:
Diagnosis:
Afib
SSS s/p pacemaker
Htn
Hypercholesterolemia
Tonsillectom
hypothyroid
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
**Please call cardiac surgery office with any questions or
concerns . Answering service will contact on call
person during off hours**
## FEMALES:
Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19152893", "visit_id": "29108521", "time": "2173-06-01 00:00:00"} |
18326209-RR-20 | 151 | ## INDICATION OF STUDY:
female with leukocytosis, elevated LFT.
Concern for occult malignancy.
## BONE WINDOWS:
There is soft tissue density at the upper sacrum (series 3
image 82) and represent dural ectasia. Old fractures of left superior and
inferior pubic rami are seen with callus formation. Bilateral femoral head
sclerosis and surrounding osteopenia is also noted.
Multiplanar reformats were essential in delineating the findings described
above.
## IMPRESSION:
1. Predominant central and dependent pulmonary ground-glass opacities with
underlying fissural thickening which is more consistent with edema. Diffuse
infectious process is also possible.
2. Perihepatic ascites and periportal edema, could be due to underlying CHF.
3. Old renal infarcts and narrowing of bilateral renal artery at origin,
concern for renal artery stenosis.
4. Multiple bilateral renal hypodense lesions, most likely renal cysts
5. Unhealed old fractures of the left superior and inferior pubic ramus.
6. Osteopenia. Degenerative changes of bilateral hips.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18326209", "visit_id": "24649779", "time": "2188-08-01 13:35:00"} |
10459793-RR-42 | 349 | ## EXAMINATION:
CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
## INDICATION:
year old man with left parotid mass. Concern for neoplasm,
assess for malignancy.// Left parotid mass. Concern for neoplasm, assess for
malignancy.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.1 s, 32.9 cm; CTDIvol = 7.1 mGy (Body) DLP = 227.6
mGy-cm.
2) Spiral Acquisition 2.2 s, 3.7 cm; CTDIvol = 9.3 mGy (Body) DLP = 30.8
mGy-cm.
3) Spiral Acquisition 2.2 s, 3.7 cm; CTDIvol = 9.3 mGy (Body) DLP = 30.8
mGy-cm.
Total DLP (Body) = 289 mGy-cm.
## FINDINGS:
There is well-circumscribed low-density intra parotid mass involving superior
in mid aspect of the superficial lobe left parotid gland. Suggestion of
punctate focus of calcification. Mass is measuring 2.7 cm x 2.2 cm x 3.5 cm
today.
On it measured 2.6 cm x 2.0 cm x 3.4 cm.
On it measures 2.4 cm x 1.8 cm 2.7 cm.
There is no extension through the styloid mandibular left tunnel. Left
stylomastoid foramen fat pad about seventh cranial nerve is preserved, no
abnormal seventh cranial nerve enhancement. Mildly expanded left foramina
ovale,, stable since , no abnormal enhancement at the foramina ovale fat
pad or along V3 distribution.
7 mm short axis level 1A lymph node, similar on it measured
2.6 cm x 2.0 cm x 3.4 cm.
Few tiny subcentimeter neck lymph nodes. No adenopathy.
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
The thyroid gland appears normal..The neck vessels are patent.
Paraseptal emphysema in the upper lungs. There are no osseous lesions.
Moderate paranasal sinus disease, opacified ethmoid sinus, moderate
opacification of the left maxillary sinus, with secretions in the sphenoid and
left maxillary, small volume right maxillary, sinuses. Findings suggest acute
paranasal sinusitis.
## IMPRESSION:
1. Indeterminate 3.5 cm left parotid mass, appearance is most suggestive of
pleomorphic adenoma. There is slow growth over time.
2. No adenopathy.
3. Findings consistent with acute paranasal sinusitis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10459793", "visit_id": "N/A", "time": "2144-11-04 14:56:00"} |
11250458-RR-71 | 417 | ## EXAMINATION:
CTU ABDOMEN/PELVIS WITH AND WITHOUT CONTRAST
## INDICATION:
year old woman with microscopic hematuria// eval GU
malignancy.
## CTU:
Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
supine position. The non-contrast scan was done with low radiation dose
technique. After that, contrast was injected obtaining a late arterial/portal
venous phase and a 3 minutes delayed phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 7.8 s, 50.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 169.4
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
3) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 13.6 mGy (Body) DLP =
2.7 mGy-cm.
4) Spiral Acquisition 7.8 s, 50.8 cm; CTDIvol = 13.1 mGy (Body) DLP = 655.6
mGy-cm.
5) Spiral Acquisition 6.8 s, 43.9 cm; CTDIvol = 3.4 mGy (Body) DLP = 147.0
mGy-cm.
Total DLP (Body) = 977 mGy-cm.
## LOWER CHEST:
Lung bases are clear.
## HEPATOBILIARY:
There is diffuse hypoattenuation of the liver, consistent with
hepatic steatosis. Portal vein and hepatic veins are patent. There are no
suspicious hepatic masses. There is no biliary ductal dilatation.
Gallbladder is unremarkable.
## PANCREAS:
Pancreatic contours are unremarkable with no pancreatic ductal
dilatation or suspicious masses.
## URINARY:
There is no hydronephrosis or nephrolithiasis. There are
subcentimeter interpolar renal cortical hypodensities, likely representing
cysts. There are no suspicious masses identified. The right ureter is well
opacified and appears unremarkable. The left ureter is not opacified however,
there are no suspicious masses along its course. Urinary bladder is
unremarkable.
## GASTROINTESTINAL:
There is a small hiatal hernia. Stomach is under distended.
Small bowel loops are not dilated. There are scattered colonic diverticulosis
without diverticulitis.
## PERITONEUM:
There is no free air or free fluid. There is no peritoneal
stranding.
## LYMPH NODES:
There is no abdominopelvic adenopathy.
## VASCULAR:
Abdominal aorta is normal in caliber with moderate atherosclerotic
calcifications.
## PELVIS:
Uterus is retroverted. There is a vaginal pessary identified. There
are no adnexal masses. There are no pelvic adenopathy.
## BONES:
There is a L3 superior endplate compression deformity appearing chronic
with at least loss of vertebral body height. There is a T8 spine
hemangioma.
## SOFT TISSUES:
Soft tissues are unremarkable.
## IMPRESSION:
1. No suspicious masses along the urinary system.
2. Hepatic steatosis.
3. Small hiatal hernia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11250458", "visit_id": "N/A", "time": "2190-06-06 14:33:00"} |
18217356-RR-20 | 117 | ## INDICATION:
with shortness of breath // acute process?
## FINDINGS:
When compared to prior, there has been interval progression of diffuse
bilateral parenchymal opacities most confluent in the left upper lung and
right mid lung. There is no large pleural effusion. There is prominence of
the mediastinum on the right including leftward deviation of the trachea at
the thoracic inlet. Hila are not well assessed on the current study due to
parenchymal opacities but are known to have bilateral enlarged lymph nodes by
prior CT. No acute osseous abnormalities.
## IMPRESSION:
Progression of bilateral parenchymal opacities which may represent pneumonia
in the proper clinical setting. Given findings of hilar and mediastinal
adenopathy, underlying malignancy would also be possible.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18217356", "visit_id": "N/A", "time": "2135-04-28 17:11:00"} |
16902261-RR-6 | 59 | ## INDICATION:
Melanoma and history of frontal metastasis, status post resection
and XRT. Please evaluate for brain lesions.
## IMPRESSION:
1. Focal area of encephalomalacia in the right anterior frontal lobe,
presumably the region of the patient's surgical site with overlying presumed
reactive leptomeningeal and dural enhancement. No other lesions are
identified.
2. Evidence of small vessel disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16902261", "visit_id": "N/A", "time": "2160-05-12 13:38:00"} |
10781312-RR-44 | 136 | ## INDICATION:
man with plaque.
No studies available for comparison.
## FINDINGS:
There is a mild atherosclerotic plaque in the bilateral internal
carotid arteries. The peak systolic velocity in the right internal carotid
artery ranges from 72 to 110 cm/sec and in the left internal carotid artery
from 60 to 118 cm/sec. The peak systolic velocity in the right common carotid
artery is 70 cm/sec and in the left common carotid artery is 73 cm/sec.
Bilateral external carotid arteries are patent. There is antegrade flow in
the bilateral vertebral arteries. The ICA/CCA ratio on the right is 1.6 and
on the left is 1.6.
## IMPRESSION:
1. No evidence of significant carotid artery stenosis bilaterally.
2. Bilateral mild calcified atherosclerotic plaque in the common carotid and
proximal internal carotid arteries.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10781312", "visit_id": "N/A", "time": "2131-07-03 09:12:00"} |
17967161-DS-25 | 1,367 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Non healing right toe ulcers
## :
Diagnostic right lower extremity angiogram via left
groin access
## :
Right lower extremity third digit amputation
## HISTORY OF PRESENT ILLNESS:
This is a year old gentleman who has multiple vascular
issues. In , he had a massive iliofemoral DVT that was
treated with thrombolysis and stenting. He has also had
angioplasty of his tibioperoneal trunk and peroneal artery in
. An ultrasound about three months ago showed
mild-to-moderate tibial occlusive disease. He has also had
non-healing ulcer to his right third toe, which he states had
some purulent drainage days ago. He is now scheduled for a
right lower extremity angiogram and is being admitted for
pre-contrast IV hydration. As instructed, he has been on Lovenox
bridge from coumadin given history of iliofemoral DVT.
## PMH:
DM, HLD, HTN, DVT, CVA , cocaine/EtoH abuse
## PSH:
IVC filter placement , thrombectomy right iliac/femoral
veins and stenting of rt EI vein , I&D LLE abscess
## FAMILY HISTORY:
Sister died from myocardial infarction, otherwise non
contributory
## GEN:
Well appearing, in no distress
## CV:
RRR, normal S1 and S2. No murmurs, rubs or gallops
## LUNGS:
Clear to auscultation bilaterally
## EXT:
Chronically edematous RLE. Amputated R third toe, with
sterile OR dressing. Otherwise pulse exam as follows:
Fem Pop DP
Right palp dopp dopp dopp
Left palp dopp dopp dopp
## PERTINENT RESULTS:
01:37AM BLOOD WBC-8.0 RBC-4.88 Hgb-13.2* Hct-43.3
MCV-89 MCH-27.0 MCHC-30.4* RDW-17.3* Plt
01:37AM BLOOD PTT-30.0
01:37AM BLOOD Plt
01:37AM BLOOD Glucose-183* UreaN-41* Creat-1.8* Na-139
K-4.9 Cl-105 HCO3-27 AnGap-12
01:37AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0
Foot X-ray:
Interval increase in soft tissue swelling with new osseous
fragmentation about the base of the terminal phalanx of the
third toe consistent with osteomyelitis.
## BRIEF HOSPITAL COURSE:
Mr presented to the pre-op holding area at on
for a scheduled diagnostic angiogram. His
intraoperative course was unremarkable. For full details, please
see the operative report. After a brief and uneventful PACU
course, he was transferred to the floor where he remained for
the remainder of his hospitalization.
Post-operatively, he did well without any groin swelling and no
evidence of hemodynamic instability. On , the patient
underwent a RLE toe amupation by podiatry. He tolerated the
procedure well. Post-operatively he was restarted on his home
dose of lovenox and warfarin. His WBC was initially slightly
elevated but was coming down upon discharge. On POD he was
deemed ready for discharge, and was given the appropriate
discharge and follow-up instructions. At the time of discharge,
he was doing well, afebrile with stable vital signs. He was
tolerating a regular diet, ambulating, voiding without
assistance, and his pain was well controlled on oral medications
with intermittent IV for breakthrough. He was discharged on a
lovenox to coumadin bridge to his rehab center.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. ammonium lactate 12 % topical BID
2. Atorvastatin 80 mg PO QPM
3. CarBAMazepine 100 mg PO DAILY
4. Carvedilol 3.125 mg PO BID
5. Diclofenac Sodium 1 % PO Q6H:PRN pain
6. Finasteride 5 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. NovoLOG (insulin aspart) unknown subcutaneous Q8H
9. Levemir (insulin detemir) 18 units subcutaneous QAM
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Pancrelipase 5000 1 CAP PO TID W/MEALS
12. Lisinopril 2.5 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. solifenacin 10 mg oral DAILY
16. Torsemide 20 mg PO DAILY
17. TraMADOL (Ultram) 50 mg PO Q8H
18. MD to order daily dose PO DAILY16
19. Acetaminophen 1000 mg PO Q8H
20. Aspirin 81 mg PO DAILY
21. Docusate Sodium 100 mg PO BID
22. Multivitamins 1 TAB PO DAILY
23. Senna 17.2 mg PO DAILY
24. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 3.125 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 17.2 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO Q8H
11. ammonium lactate 12 % topical BID
12. CarBAMazepine 100 mg PO DAILY
13. Diclofenac Sodium 1 % PO Q6H:PRN pain
14. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
15. Levemir (insulin detemir) 18 units SUBCUTANEOUS QAM
16. Lidocaine 5% Patch 1 PTCH TD DAILY
17. Lisinopril 2.5 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. NovoLOG (insulin aspart) 0 unknown SUBCUTANEOUS Q8H
20. Pancrelipase 5000 1 CAP PO TID W/MEALS
21. Polyethylene Glycol 17 g PO DAILY
22. solifenacin 10 mg oral DAILY
23. Torsemide 20 mg PO DAILY
24. MD to order daily dose PO DAILY16
25. Warfarin 6 mg PO ONCE Duration: 1 Dose
26. Enoxaparin Sodium 30 mg SC Q12H
## TODAY - , FIRST DOSE:
Next Routine Administration
Time
27. Gabapentin 300 mg PO TID
28. HYDROmorphone (Dilaudid) 0.5 mg IV Q3H:PRN breakthrough pain
RX *hydromorphone 2 mg/mL (1 mL) 0.25 mL IV Q3 hours Disp #*10
## SYRINGE REFILLS:
*0
29. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth Q 3 hours Disp #*40
## DISCHARGE DIAGNOSIS:
Peripheral Vascular Disease (One vessel run off via Peroneal
which then reconstitutes the DP and at ankle)
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted to the Vascular Surgery service after your
angiogram. You also underwent a right third toe amputation. Your
procedures went well without complications and you are
recovering well. At this time, you are eating normally, able to
use the restroom without difficulty and have been restarted on
all of your home medications. You are now ready to continue your
recovery at rehab, with the following instructions.
## MEDICATION:
Take Aspirin 81mg (enteric coated) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
## WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
## ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
## CALL THE OFFICE AT FOR:
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (at the groin puncture
site):
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office at .
If bleeding does not stop, call for transfer to the
nearest Emergency Room
Thank you,
Your Vascular Surgery Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17967161", "visit_id": "24321649", "time": "2178-08-31 00:00:00"} |
10989799-DS-16 | 1,877 | ## CHIEF COMPLAINT:
Bright red blood in bowel movement
Melena
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Cordis placement to right groin
Colonoscopy-
Esophagastroduodenoscopy -
## HISTORY OF PRESENT ILLNESS:
Ms. is a year old female with a history of mestastic
pancreatic cancer s/p in who is currently enrolled
in a study in adults with advanced solid tumors who is
presenting after having an episode of BRBPR at home. For the
past two days she has felt like her legs are "rubbery" and weak
but she denies having had any lightheadedness/dizziness/SOB.
She does report having darker brown stools earlier this weekend.
Since starting the study medication, she has had chronic
diarrhea. She had called in to clinic yesterday to
report these episodes of dark brown stool. At that time she
denied any melena or BRBPR. She was advised to watch out for
any dark black stool or bright red blood. Today, the patient
called again noting that she had bright red blood in the toilet
bowl and on the toilet paper. She was advised to hold the study
drug and to come to the ED for evaluation.
## IN THE ED, INITIAL VITALS:
98.8 67 117/61 18 98%. On
presentation, she was hemodynamically stable. Subsequently she
had another episode of BRBPR that was almost entirely blood.
Her blood pressure at that time began to decrease to the high
, low systolic. She had an NG tube placed and with
lavage was noted to have some pink tinged liquid in return. She
was given initially 2L IVF for resuscitation and then a total of
4u pRBCs. A femoral line was placed for additional access. She
underwent CTA which showed high density fluid in the jejunum and
proximal ileum concerning for hemorrhage in the mid small bowel.
She was given Protonix 40mg IV x1. At the time of CTA, no
active extravasation was identified so did not think there
was anything to intervene upon.
On transfer, vitals were: 98.1 88 135/50 16 96% RA.
On arrival to the MICU, the patient denied any abdominal pain
currently but notes that she was having some LLQ pain in the
emergency room. She says that her last bowel movement was right
before transport to the ICU and that she was told it was "less
than before" in terms of quantity of blood. She was feeling
"woozy" earlier and a little bit nauseated but she has had no
emesis. Her appetite at home has been fine and she ate a full
breakfast this morning. She does note, however, that she has
had about a 4lb weight loss in the past few weeks because she
just doesn't eat as much as she used to.
On further review of systems, she says she had a sore throat a
few weeks ago to the point where it was painful to even swallow
water. Since then she has had an intermittently dry and
productive cough. Her sputum is clear and she denies
hemoptysis.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
## PAST MEDICAL HISTORY:
1. Hypertension.
2. Glucose intolerance, diet controlled.
3. Hypercholesterolemia.
4. Status post appendectomy at age .
5. Status post Whipple's pancreaticoduodenectomy as below.
6. Postoperative DVT diagnosed on completed six
months enoxaparin.
PERTINENT ONCOLOGICAL HISTORY (per recent oncology notes)
Pertinent Oncologic history (include past therapies, surgeries,
etc):
-diagnosed with pancreatic adenocarcinoma in
-underwent Whipple's pancreaticoduodenectomy for
lymph nodes were involved.
-treated on the control arm of protocol with adjuvant
gemcitabine as well as continuous infusion fluorouracil with
concurrent radiation. off study on for recurrent
disease.
-remained off therapy until , at which time disease
progression was identified, and she resumed treatment with
gemcitabine.
- : she initiated treatment with capecitabine
and
oxaliplatin.
- : treated with gemcitabine/nab-paclitaxel. She
underwent
a course of CyberKnife radiation to an isolated liver metastasis
on and then began oxaliplatin and irinotecan on
.
-CT showed disease progression in her lungs. She
signed
consent for participation in clinical trial , a phase 1
study BBI503 in adults with advanced solid tumors on
and initiated treatment on .
## FAMILY HISTORY:
The patient's sister suffers from osteoarthritis. Her mother
died at with congestive heart failure. Her father died at
with diabetes mellitus and kidney disease, an uncle was treated
for renal cell carcinoma and aunt for brain cancer and an aunt
for breast cancer and two cousins for breast cancer.
## GENERAL:
Alert, oriented, no acute distress, pleasant, appears
younger than stated age
## HEENT:
Sclera anicteric, MMM, no thrush, oropharynx clear, NG
tube in place
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
bilateral dry crackles to mid lung fields R>L. Otherwise
clear to auscultation. Dry cough on exam. Good air movement.
## CV:
Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
## ABD:
+ NABS, well healed scar and RLQ scar. Soft,
non-tender, non-distended, no rebound tenderness or guarding, no
organomegaly appreciated.
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## SKIN:
no lesions, ulcers or rashes noted
## NEURO:
A&Ox3, CN II-XII grossly intact, strength
throughout. Sensation intact to light touch.
##
98.8/99.5 HR 97 (84-110) BP:
133/55(123-140/50-65) RR
18 93% on 1L (Weaned off and is at 96% on RA after removing nail
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Clear to auscultation bilaterally with minor crackles at
lung bases, R>L, no wheezes, rales, ronchi
CV- Regular rate and rhythm, normal S1 + S2, 1-II/VI systolic
murmur, no rubs, gallops
Abdomen- surgical incision lines (from whipple and appendectomy)
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
## IMPRESSION:
1. In comparison to the CT torso, significant interval
progression of metastatic disease characterized by innumerable
pulmonary metastases, new bilateral pleural effusions, moderate
amount of intra-abdominal ascites, and enlarged retroperitoneal
lymph nodes.
2. No definitive active extravasation is identified, however as
detailed
above, post-contrast images demonstrate higher density in a loop
of distal jejunum. This is likely in part due to enhancing
normal valvulae conniventes although possibility of hemorrhage
or contrast is difficult to exclude. Abnormal adjacent
vasculature raises the suspicion of this being the region of GI
bleeding. The location would suggest a branch of the superior
mesenteric artery.
## FINDINGS:
Increased interstitial markings seen throughout the lungs which
when
correlated to CT is in part due to significantly increased
burden of
metastatic disease. There are small bilateral effusions. The
cardiomediastinal silhouette is within normal limits. Right
chest wall port is again seen. Enteric tube tip within the
gastric body. There is no free air below the diaphragm.
## BRIEF HOSPITAL COURSE:
Ms. is a year old female with metastatic pancreatic
cancer admitted after several episodes of bright red blood per
rectum, hematocrit drop and hypotension in the ED leading to
MICU admission for close monitoring.
## ACTIVE ISSUES:
# Acute blood loss anemia from GI Bleed: Patient presented with
BRBPR and left lower abdominal pain. She was initially stable
in the ED but then had subsequent episodes of BRBPR with drop in
her systolic blood pressures. Pantoprazole was started. CTA
did not show any active extravasation of blood. She received 2L
IVF and a total of 4u pRBCs. Repeat NG Lavage in the ICU showed
clear return. The GI team performed for EGD and colonoscopy
which showed a 2 cm gastric jejunal junction ulcer. There was
also a Sigmoid mass at 20 cm, mucosal biopsies:- Fragments of
adenomatous mucosa with prominent villous architecture and low
grade dysplasia; no carcinoma seen in these biopsy samples (her
oncology team was forwarded these results). She will continue
PPI therapy.
## # COAGULOPATHY:
INR elevated to 1.4-1.6 on admission. Patient
has not been on any anticoagulation prior to this admission.
Platelet count additionally noted to be low. Her hemodynamics
stabilized as above and her coags were monitored closely. There
was some concern for coagulopathy in the setting of metastatic
malignancy vs. consumptive from receiving multiple transfusions
without any additional clotting factors. Additionally, she has
known liver metastases which might be interfering with synthetic
liver function, and her oral intake was down (Vit K deficiency).
## # METASTATIC PANCREATIC CANCER:
Patient was enrolled in Phase 1
clinical trial of BI in adult patients with advanced solid
tumors. The study drug was held per Dr. by
. Onc team came to see her and speak to her.
## # HTN:
Normotensive at time of admission to MICU and on floor.
Beta blocker was held without significant elevation of blood
pressures, except minor tachycardia. Restarted at a minor dose
using extended beta blocker.
## # METASTATIC PANCREATIC CANCER:
progressed according to CT. Will
need follow up with oncologist.
# HTN: Patient was normotensive during admission. Her beta
blocker was held in the setting of GI bleed and changed to long
acting at a lower dose
## TRANSITIONAL ISSUES
- Needs crit check in one week to ensure she isn't bleeding
- GI will follow up with her about path results. (***Sigmoid
mass at 20 cm, mucosal biopsies:- Fragments of adenomatous
mucosa with prominent villous architecture and low grade
dysplasia; no carcinoma seen in these biopsy samples)
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. Pancrelipase 5000 2 CAP PO TID W/MEALS
3. Pyridoxine Dose is Unknown PO DAILY
4. Cyanocobalamin Dose is Unknown PO DAILY
5. Ascorbic Acid Dose is Unknown PO DAILY
## DISCHARGE MEDICATIONS:
1. Ascorbic Acid 0 mg PO DAILY
2. Cyanocobalamin 0 mcg PO DAILY
3. Pancrelipase 5000 2 CAP PO TID W/MEALS
4. Pyridoxine 0 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*30
## CAPSULE REFILLS:
*1
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*1
## FACILITY:
Diagnosis:
Primary
Acute blood loss due to GI bleed
Secondary
Pancreatic cancer
## DISCHARGE INSTRUCTIONS:
Miss ,
It was a pleasure taking part in your care. You were admitted
due to gastrointestinal bleed for which you were given some
blood. An EGD and a colonoscopy showed this was most likely due
to an ulcer. A polyp was also seen in the colonoscopy and a
biopsy was taken. GI team will follow up with you about the
biopsy results. You were treated with a proton pump inhibitor
(PPI). Your bleeding resolved by discharge and your blood count
was not dropping and you had bowel movement with no blood.
Please continue taking the PPI, omeprazole.
Due to the gastrointestinal bleed, the test medication for
pancreatic cancer you were on has been stopped. Your oncologists
will follow up with you on that.
You were also not hypertensive while in the hospital and we
changed and reduced your dose of metoprolol tartrate to long
acting -, metoprolol succinate XL 25mg daily.
It was a pleasure taking part in your care.
Your team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10989799", "visit_id": "26041835", "time": "2181-12-06 00:00:00"} |
17449583-RR-58 | 399 | ## EXAMINATION:
CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
## INDICATION:
year old woman with metastatic pancreatic neuroendocrine tumor
now presents with subacute worsening of hoarseness, concerning for metastates
impinging on recurrent laryngeal nerve. Is there external compression of the
recurrent laryngeal nerve by metastases?
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 3.3 s, 26.1 cm; CTDIvol = 12.4 mGy (Body) DLP = 323.6
mGy-cm.
Total DLP (Body) = 324 mGy-cm.
## FINDINGS:
Evaluation of the aerodigestive tract demonstrates no evidence for an
exophytic mucosal mass. The left palatine tonsil, which was inflamed with
abscess formation in , is larger than the left, but without
evidence for inflammatory change or mass. The vocal cords appears symmetric.
The salivary glands appear unremarkable.
The thyroid gland appears unremarkable.
Bilateral nonenlarged level 2, 3, 4, and 5 lymph nodes are unusually numerous
for age, but the their number is similar to the neck CT from .
Previously noted left level 2 and 3 lymph node enlargement has resolved; it
was likely reactive in the setting of left tonsillar inflammation.
Common origin of the innominate and left common carotid arteries is noted, a
normal variant. There is mild calcified plaque at bilateral internal carotid
artery origins. Bilateral internal jugular veins appear patent.
Concurrent CT chest is reported separately.
This exam is not technically optimized for evaluation of the included
intracranial contents. Partially visualized posterior fossa appears
unremarkable.
There are mucous retention cysts and mucosal thickening in bilateral partially
visualized maxillary sinuses. There is a large periapical lucency associated
with the 7 and 8, with dehiscence of the buccal and lingual cortices.
7 demonstrates caries.
There is partial moderate left mastoid air cell opacification and mild debris
in the left middle ear cavity, without osseous destruction, similar to CT head
from .
No suspicious lytic or sclerotic bone lesion is seen. There are degenerative
changes in the cervical spine.
## IMPRESSION:
1. No evidence for metastatic disease in the neck. The vocal cords appear
symmetric, and no lesions are seen along the cervical courses of bilateral
vagus and recurrent laryngeal nerves.
2. Large periapical lucency associated with the 7 and 8, with dehiscence
of the buccal and lingual cortices. 7. Please correlate
clinically whether active dental inflammation may be present.
3. Partial moderate left mastoid cell opacification and mild debris in the
left middle ear cavity, without osseous destruction. Please correlate with
any associated symptoms.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17449583", "visit_id": "24693473", "time": "2189-10-17 13:10:00"} |
16639111-RR-12 | 143 | ## INDICATION:
in patients with nonenhanced plus CECT initially interpreted as
inconclusive
## PROCEDURE:
Ultrasound-guided left calf aspiration.
## OPERATORS:
Dr. , radiology trainee and Dr. ,
attending radiologist. Dr. personally supervised the trainee
during the key components of the procedure and reviewed and agrees with the
trainee's findings.
## FINDINGS:
Extensive soft tissue edema and swelling is seen in the anterior left calf.
## IMPRESSION:
Extensive soft tissue edema and swelling in the anterior left calf. Attempt
was made to aspirate in two of the more confluent areas of apparent fluid;
however, only 2 drops of blood-tinged fluid were obtained. No organized fluid
collections. No drainable fluid collections. Sample was sent for
microbiology with results pending.
## NOTIFICATION:
The findings and impression were discussed with ,
M.D. by , M.D. on the telephone on at 3:20 pm, 2
minutes after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16639111", "visit_id": "21823856", "time": "2189-08-22 14:12:00"} |
11557742-RR-50 | 170 | ## FINDINGS:
Direct comparison is made to prior examination dated .
There is a 2-mm nodule identified within the right lower lobe on image #2 of
series one. This area is not covered on prior CT scan. If the patient has a
history of smoking, one-year followup is recommended to ensure stability. The
patient has a history of primary malignancy, three-month followup is
recommended to ensure stability. If the patient has no history of smoking or
primary malignancy, no further followup is recommended.
The liver, spleen, adrenal glands, pancreas appear grossly unremarkable. The
patient is status post cholecystectomy. Small, hypoattenuating focus seen
within the left kidney which is too small to characterize but likely represent
simple cysts. The right kidney is grossly unremarkable.
The bowel is grossly unremarkable. Right-sided ovarian cyst incidentally
noted. Pelvic structures are otherwise grossly unremarkable.
No suspicious lytic or blastic bony lesions are identified.
## IMPRESSION:
1. No acute abnormality identified.
2. Right lower lobe pulmonary nodule identified with followup recommendations
detailed above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11557742", "visit_id": "N/A", "time": "2167-11-04 16:46:00"} |
19792938-DS-19 | 689 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
exploratory laparotomy, right ovarian cystectomy
## HISTORY OF PRESENT ILLNESS:
The patient is a , G0, who developed right-sided
pelvic pain approximately 2 days prior to presentation. The
pain worsened over the ensuing 2 days. She was seen at the
office and found to have rebound tenderness on the right side.
The patient has a history of ovarian cyst formation and a
history of 2 prior laparoscopies. In the emergency room an
ultrasound was obtained, which revealed a 6 cm complex right
ovarian cyst and no blood flow noted to the ovary on the right
side. There was concern for probable torsion of the adnexa. The
findings were discussed with the patient and the necessity of
operative intervention was discussed. The risks, benefits, and
alternatives to laparoscopic exploration followed by addressing
the adnexal findings were discussed with the patient. The
patient was aware that a possible laparotomy might be needed.
## GYNHX:
history of infertility currently being followed by HMVA
REI, h/o chlamydia infection years ago, denies history of
other
STDs or PID, h/o R ovarian cyst s/p cystectomy in at
## PSH:
LSC right ovarian cystectomy, done at , per pt path was
"complex cyst"
## GEN:
NAD, A&O x 3
## RESP:
no acute respiratory distress
## ABD:
soft, appropriately tender, no rebound/guarding, incision
c/d/i
## BRIEF HOSPITAL COURSE:
On , Ms. was admitted to the gynecology service
after undergoing laparoscopy converted to exploratory laparotomy
with right ovarian cystectomy. Please see the operative report
for full details. Estimated blood loss during surgery was 750mL.
Immediately post-op, patient's blood pressures decreased to
70/50s, but normalized after 1 liter fluid bolus. Vital signs
otherwise remained stable throughout hospital course. Hematocrit
decreased from 37.9 pre-op to 26.2 post-op, but urine output,
heart rate, and pressures remained normal. Her pain was
controlled immediately post-operatively on dilaudid/toradol. On
post-operative day 2, her urine output was adequate and she was
able to ambulate so her foley was removed and she voided
spontaneously. Her diet was advanced without difficulty and she
was transitioned to PO
oxycodone/ibuprofen/acetaminophen/gabapentin. By post-operative
day 2, she was tolerating a regular diet, voiding spontaneously,
ambulating independently, and pain was controlled with oral
medications. She was then discharged home in stable condition
with outpatient follow-up scheduled.
## MEDICATIONS ON ADMISSION:
tizanidine 2mg TID prn spasm, pantoprazole 40mg, levothyroxine
50mcg qd, cetirizine 10mg qd, fluticasone 2sprays qnostril qday
albuterol 2 pufs prn wheeze, tramadol, gabapentin
## DISCHARGE MEDICATIONS:
1. Levothyroxine Sodium 50 mcg PO DAILY hypothyroid
2. NexIUM (esomeprazole magnesium) 40 mg oral BID gerd
## DISCHARGE DIAGNOSIS:
Hemorrhagic right ovarian cyst
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. office
with any questions or concerns. Please follow the instructions
below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
* If you have staples, they will be removed at your follow-up
visit.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19792938", "visit_id": "27535944", "time": "2165-11-10 00:00:00"} |
10658377-RR-40 | 100 | ## INDICATION:
Multinodular goiter. Rule out change.
## FINDINGS:
The right lobe measures 2.1 x 1.8 x 4.5 cm. The left lobe measures
1.5 x 1.2 x 3.7 cm. Both lobes are homogenous in echogenicity and
echotexture.
Bilateral nodules in the mid portions of their respective lobes unchanged
since :
Left 0.9 x 0.8 x 1.2 cm nodule previously measured 0.8 x 0.9 x 1.2 cm
Right 1.1 x 1 x 1.5 cm nodule previously measured 1 x 1 x 1.4 cm
## IMPRESSION:
Stable thyroid nodules.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10658377", "visit_id": "N/A", "time": "2196-07-29 13:19:00"} |
18911760-RR-20 | 250 | ## INDICATION:
year old woman with recent accidental finding of aorta ulcer ;
AOX3// please eval thoracic aorta ulcer.
## HEART AND VASCULATURE:
Pulmonary vasculature is well opacified to the
subsegmental level. Again demonstrated, is a stable penetrating ulcer with
irregular walls along the left aspect of the aortic arch spanning
approximately 4.8 cm in AP dimension with the most posterior aspect
demonstrating a stable small focal ulcer (03:23). The ascending aorta is
stable in size measuring approximately 3.3 cm in diameter.
## AXILLA, HILA, AND MEDIASTINUM:
No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
## PLEURAL SPACES:
No pleural effusion or pneumothorax.
## LUNGS/AIRWAYS:
Scattered atelectasis and regions of air trapping are noted.
## BASE OF NECK:
The thyroid gland is not visualized.
## HEPATOBILIARY:
Liver is unremarkable. Gallbladder is unremarkable.
## URINARY:
Kidneys are unremarkable. No hydronephrosis.
## GASTROINTESTINAL:
No evidence of bowel obstruction. The appendix is
unremarkable.
## PELVIS:
There is no free fluid in the pelvis.The uterus and bilateral adnexae
are within normal limits.
## LYMPH NODES:
There is no abdominal or pelvic lymphadenopathy.
## VASCULAR:
The abdominal aorta is torturous both out evidence of aneurysm.
Mild atherosclerotic disease is noted. The celiac axis, SMA, , renal and
iliac arteries and their major proximal branches are patent.
## BONES:
There is no evidence of worrisome osseous lesions.
## SOFT TISSUES:
There is a scar along the anterior abdominal soft tissues from
prior percutaneous gastrostomy tube.
## IMPRESSION:
No change in thoracic aorta penetrating atherosclerotic ulcer. No abdominal
aortic aneurysm.
Additional findings as above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18911760", "visit_id": "N/A", "time": "2122-08-15 14:58:00"} |
18271001-RR-13 | 178 | ## INDICATION:
male with metastatic prostate cancer and spinal cord
compression. New paraplegia.
## FINDINGS:
There are innumerable foci of abnormal signal and enhancement
within all of the osseous structures in the cervical spine, as well as the
clivus. There is epidural extension at the T1 level, as described on the
prior MRI of the thoracic spine. No definite epidural extension is seen in
the cervical region. There is no signal abnormality within the cervical cord
nor any abnormal enhancement after gadolinium.
There is no high-grade canal or foraminal stenosis in the cervical spine.
There is no disc herniation.
There appears to be some enhancing paraspinal soft tissue at the C2 level
anteriorly.
## IMPRESSION:
1. Innumerable foci of bony metastatic disease in the cervical spine as well
as the clivus. Paraspinal extension at the C2 level. No epidural involvement
in the cervical spine, although, as described in the recent MRI of the
thoracic spine there is epidural extension at the T1 level and below.
2. No cervical cord signal abnormality or high-grade canal or foraminal
stenosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18271001", "visit_id": "23774767", "time": "2137-05-25 20:23:00"} |
17398573-RR-47 | 249 | ## NO PO CONTRAST; HISTORY:
with epigastric pain and LLQ
TTPNO PO contrast // R/O diveritculitis
## FINDINGS:
The heart is mildly enlarged. No pericardial effusion. Bibasilar atelectasis.
No pleural effusion.
## ABDOMEN:
Pneumobilia is consistent with history of sphincterotomy. The liver and bile
ducts are otherwise unremarkable. The patient is status post cholecystectomy.
The pancreas, spleen, and adrenal glands are normal. Bilateral cystic renal
structures are too small to characterize. The kidneys otherwise enhance
homogeneously without hydronephrosis.
Small hiatal hernia. The stomach is otherwise unremarkable. The small and
large bowel enhance homogeneously without evidence of obstruction. Colonic
diverticulosis without evidence of diverticulitis. The appendix is normal.
No retroperitoneal or mesenteric lymphadenopathy. Small fat containing
periumbilical hernia. The portal and intra-abdominal systemic vasculature are
normal. No pneumoperitoneum, or free abdominal fluid.
## PELVIS:
There is severe 3 compartment pelvic floor dysfunction. The bladder
is otherwise normal. There is a small amount of fluid within the endometrial
canal and a 4 mm polyp. No pelvic side-wall or inguinal lymphadenopathy. No
free pelvic fluid or inguinal hernia.
## OSSEOUS STRUCTURES:
No focal lytic or sclerotic lesion concerning for
malignancy. Calcifications scattered in the posterior soft tissues are similar
to prior.
## IMPRESSION:
1. No acute intra-abdominal process. Diverticulosis without diverticulitis.
Normal appendix.
2. Severe three compartment pelvic floor dysfunction.
3. Small amount of fluid within the endometrial canal with a 4 mm enhancing
endometrial polyp. Pelvic ultrasound is recommended for further evaluation.
## NOTIFICATION:
Final impression was emailed to the ED QA nurse.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17398573", "visit_id": "N/A", "time": "2186-06-11 23:04:00"} |
14253818-RR-131 | 147 | ## EXAMINATION:
MR FOOT CONTRAST LEFT
## INDICATION:
year old woman with pain over midfoot, particularly over
extensor tendon complex and over joints of mid-foot // r/o abnormalities
## FINDINGS:
There is increased bone marrow edema involving the head of the first
metatarsal, likely secondary to edema from degenerative changes related to its
articulation with the tibial sesamoid.
Underlying the skin marker along the dorsal lateral aspect of the midfoot,
there is no definite abnormality. No other bone marrow abnormalities are
identified.
Mild degenerative changes are seen at the tibiotalar articulation, with
subchondral cyst formation.
The extensor and flexor tendons are grossly unremarkable. No muscle edema is
seen.
## IMPRESSION:
1. Degenerative changes at the articulation of the tibial sesamoid with the
first MTP joint. There is prominent marrow edema within the first metatarsal
head.
2. No abnormalities are seen underlying the skin marker along the lateral
midfoot.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14253818", "visit_id": "N/A", "time": "2129-01-22 17:05:00"} |
15036963-RR-7 | 315 | ## REASON FOR EXAM:
female with history of fall and intracranial
hemorrhage. Clinical concern for aneurysm.
## FINDINGS:
There is no displacement or contrast extravasation of the transverse
sinus. A right frontal developmental venous anomoly is seen. Bilateral
vertebral artery, basilar artery and their proximal branches demonstrate no
evidence of flow-limiting stenosis or aneurysm. The visualized portions of
bilateral carotid arteries demonstrate atherosclerotic calcifications in the
cavernous portion with no aneurysmal dilatation or flow-limiting stenosis.
Bilateral anterior cerebral arteries, middle cerebral arteries and the
anterior communicating artery are patent with no aneurysm or flow-limiting
stenosis. Elevation of the right MCA is secondary to right temporal lobe
hemorrhage and edema. The left posterior communicating artery is well seen.
The right posterior communicating artery is not well seen. Again noted is
right frontal inferior temporal lobe parenchymal and subarachnoid and subdural
intracranial hemorrhage. Other foci of hemorrhage seen on prior non-contrast
CT are not well seen due to limitations of contrast CT. Mild opacification of
the left middle ear and some of the mastoid air cells is seen. There is also
almost complete opacification of the sphenoid sinus and mild mucosal
thickening in the ethmoid sinus air cells and left maxillary sinus. The
patient is likely status post left maxillary sinus enterostomy. There is left
occipital subgaleal hematoma and subcutaneous air and left occipital skull
fracture extending to the left occipital condyle as well as the clivus
traversing through the left hypoglossal canal, better seen on bone algorithms
on prior CT. The remaining visualized soft tissues including the orbits are
grossly unremarkable.
## IMPRESSION:
1. No evidence of aneurysm or flow-limiting stenosis.
2. Right frontal DVA.
3. Intracranial hemorrhage, mass effect, and skull fracture as described above
and described on prior CT.
4. Opacification of the left middle ear. Dedicated temporal bone CT can be
obtained for further evaluation and to exclude fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15036963", "visit_id": "N/A", "time": "2174-06-26 19:24:00"} |
Subsets and Splits