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10952156-RR-212 | 368 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old man with altered mental status and hypoxia and left
arm weakness, on xarelto, s/p fall 1 month ago. Known prior CVAs, meningiomas,
afib and CAD// ischemia or hemorrhage
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 7.0 s, 14.2 cm; CTDIvol = 49.3 mGy (Head) DLP =
702.4 mGy-cm.
3) Sequenced Acquisition 5.0 s, 10.2 cm; CTDIvol = 49.3 mGy (Head) DLP =
501.7 mGy-cm.
4) Sequenced Acquisition 12.0 s, 12.2 cm; CTDIvol = 49.3 mGy (Head) DLP =
602.1 mGy-cm.
Total DLP (Head) = 2,609 mGy-cm.
## FINDINGS:
There is no evidence of acute hemorrhage. Again seen are calcified
meningiomas along the right frontal convexity measuring 3.4 cm in largest
dimension (previously 3.4 cm) and in the left posterior fossa along the
tentorium measuring 6 mm (previously measuring 6 mm). There is hypodensity in
the right frontal lobe adjacent to the right frontal meningioma, similar since
at least CT.
There is unchanged areas of encephalomalacia in the right occipital and
posteromedial temporal lobes as well as in the medial left cerebellar
hemisphere, consistent with chronic infarctions, similar in appearance to . There is periventricular, subcortical, and deep open, which is
nonspecific, but likely sequela of chronic microvascular ischemic disease.
Additionally, there is global parenchymal volume loss with prominent
ventricles and sulci consistent with global atrophy.
There is complete opacification of the visualized maxillary sinus with mucosal
thickening of the anterior ethmoid air cells, bilateral mastoid air cells, and
the right middle ear cavity. There is no acute fracture. Patient is status
post left eye lens replacement. The right orbit is unremarkable.
## IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Unchanged large right frontal calcified meningioma and small left
paratentorial calcified meningioma.
3. Unchanged chronic infarctions of the right posterior cerebral artery
territory and in the medial aspect of the left cerebellar hemisphere.
4. Again seen are periventricular, subcortical, and deep white matter
hypodensities, which are nonspecific, but likely sequela of chronic
microvascular ischemic disease.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10952156", "visit_id": "26929743", "time": "2149-08-20 21:08:00"} |
12074610-DS-13 | 1,582 | ## HISTORY OF PRESENT ILLNESS:
year old with history of prostate cancer, hypertension and
hyperlipidemia presenting with acute onset chest pain.
Pt reports that early this morning he had an iced coffee to
drink and noticed a gradual onset discomfort in the middle of
his chest. He states that the pain progressed requiring him to
lay down. Once he was supine, he reports developed full body
sweats unlike anything he has experienced before. He estimated
that the pain and diaphoresis peaked after 15 minutes and began
to subside. EMS was called, and by the time they had arrive his
symptoms were improving. He was given ASA and SL nitro in the
field, and he states that on the EMS ride to the ED, his
symptoms continued to improve.
In the ED, initial vital signs were: 97.6 91 127/86 18 100% RA
- Labs were notable for: WBC 7.0, H/H 15.7/45.9, plts 190, Na
141, BUN/Cr , normal LFTs, troponin 0.01 -> 0.52
- Serum tox screen negative
- UA unremarkable
- Imaging: CXR normal
- The patient was given:
15:38 SL Nitroglycerin SL .3 mg
15:38 IVF 1000 mL NS
00:09 IV Heparin 4000 UNIT
00:09 IV Heparin
00:09 PO/NG Atorvastatin 80 mg
- Consults: Cardiology was consulted as part of an initial Code
STEMI, however they did not think this represented a STEMI and
pt was placed in observation for two sets and a stress. Once
second troponin returned elevated, decision was made to admit
for possible cardiac cath.
## PAST MEDICAL HISTORY:
LBP and sciatica
Positive PPD
HYPERCHOLESTEROLEMIA
HYPERTHYROIDISM - resolved
PROSTATIC HYPERTROPHY - BENIGN
HEARING LOSS - SENSORINEURAL, UNSPEC
HYPERTENSION - ESSENTIAL, UNSPEC
Achilles Tendinitis
Benign neoplasm of tongue
Colonic adenoma
Prostate cancer s/p XRT and hormone therapy years ago
S/P cholecystectomy
NS (nuclear sclerosis)
PSC (posterior subcapsular cataract)
PVD (posterior vitreous detachment)
Basal cell carcinoma of cheek
Erectile dysfunction
## FAMILY HISTORY:
Mother - aneurysm, CVA
## PHYSICAL EXAM:
==========================
ADMISSION PHYSICAL EXAM
==========================
## GENERAL:
Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA.
## CARDIAC:
RRR, normal S1/S2, no murmurs rubs or gallops.
## PULMONARY:
Clear to auscultation bilaterally, without wheezes or
rhonchi.
## ABDOMEN:
Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
## EXTREMITIES:
Warm, well-perfused, no cyanosis, clubbing or
edema.
## GENERAL:
Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA.
## NECK:
Supple, JVP at 9cm
## CARDIAC:
RRR, normal S1/S2, no murmurs rubs or gallops.
## PULMONARY:
Clear to auscultation bilaterally, without wheezes or
rhonchi.
## ABDOMEN:
Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
## EXTREMITIES:
Warm, well-perfused, no cyanosis, clubbing or
edema.
## PERTINENT RESULTS:
=================
ADMISSION LABS
=================
01:00PM BLOOD WBC-7.0 RBC-5.10 Hgb-15.7 Hct-45.9 MCV-90
MCH-30.8 MCHC-34.2 RDW-13.5 RDWSD-44.3 Plt
01:00PM BLOOD Plt
01:00PM BLOOD UreaN-22* Creat-1.0
01:15PM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-141
K-4.2 Cl-103 HCO3-29 AnGap-13
01:15PM BLOOD ALT-20 AST-20 CK(CPK)-81 AlkPhos-83
TotBili-0.6
08:25AM BLOOD CK(CPK)-1249*
03:10PM BLOOD CK(CPK)-926*
01:00PM BLOOD Lipase-44
01:15PM BLOOD cTropnT-0.01
01:15PM BLOOD CK-MB-7
09:05PM BLOOD CK-MB-130* cTropnT-0.52*
08:25AM BLOOD CK-MB-201* MB Indx-16.1* cTropnT-4.23*
03:10PM BLOOD CK-MB-124* MB Indx-13.4* cTropnT-3.85*
01:15PM BLOOD Albumin-3.8
12:09PM BLOOD %HbA1c-5.4 eAG-108
08:25AM BLOOD Triglyc-90 HDL-56 CHOL/HD-2.9 LDLcalc-87
01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
10:42PM URINE Color-Yellow Appear-Clear Sp
10:42PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG
10:42PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
10:42PM URINE Mucous-RARE
===================
OTHER PERTINENT/DISCHARGE LABS
===================
05:30AM BLOOD WBC-8.2 RBC-4.90 Hgb-15.1 Hct-43.9 MCV-90
MCH-30.8 MCHC-34.4 RDW-13.8 RDWSD-44.5 Plt
07:45AM BLOOD PTT-60.2*
05:30AM BLOOD Glucose-101* UreaN-11 Creat-0.8 Na-139
K-3.7 Cl-105 HCO3-22 AnGap-16
05:30AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1
===================
IMAGING/STUDIES
===================
++CXR PA/Lateral -
No acute cardiopulmonary process.
++TTE -
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are mildly thickened (?#). There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Mild to moderate
( ) aortic regurgitation is seen. The aortic regurgitation
jet is eccentric, directed toward the anterior mitral leaflet.
The mitral valve leaflets are mildly thickened. Mild to moderate
( ) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
## IMPRESSION:
Mild symmetric left ventricular hypertrophy with
hypokinesis of the basal and mid anterolateral segments.
Globally preserved biventricular systolic function. Mildly
dilated ascending aorta. Mild aortic stenosis with mild to
moderate aortic regurgitation. Mild to moderate mitral and
tricuspid regurgitation. Mild pulmonary artery systolic
hypertension.
Cardiac catherization
2 vessel CAD. Successful PTCA/stent of OM2 and LAD. Latter c/b
distal embolization into transapical segment.
## BRIEF HOSPITAL COURSE:
year old with history of prostate cancer, hypertension and
hyperlipidemia presenting with acute onset chest pain, found to
have troponin elevation and admitted for NSTEMI.
## # NSTEMI:
Patient developed chest pain at home associated with
diaphoresis while at rest. He has no known history of CAD. He
presented to ED, and initial trop was negative without EKG
changes. trop was elevated to .52 and CK-MB 130, and patient
was started on a heparin gtt and admitted for NSTEMI management.
trop uptrended to 4.23 and CK-MB was 201. Patient remained
chest pain free throughout. EKG was obtained at this point which
again did not show any ST changes. He was treated with
atorvastatin, and baby ASA in addition to heparin gtt.
Metoprolol was not started due to heart rate in . TTE
revealed mild hypokinesis in basal and mid anterolateral
segment. Due to lack of EKG findings, relatively normal TTE, and
patient remaining asymptomatic, he was not taken urgently to
cath at that time. He was taken to cath non-urgently on
which showed 2 vessel coronary artery disease. Successful
PTCA/stent of OM2 and LAD. Latter c/b distal embolization into
transapical segment. No post-cath complications and patient was
chest-pain free. Converted HCTZ to losartan, started low dose
beta blocker, increased statin to atorvastatin 80mg, started
aspirin (lifelong), initiated on clopidogrel which he will need
for the next year.
## # HYPERLIPIDEMIA:
he was converted to atorvastatin 80mg daily
## # HYPERTENSION:
hydrochlorothiazide was held on admission.
Converted to losaratan after cardiac cath as per above.
TRANSITIONAL ISSUES
# two DES placed, needs ongoing ASA, clopidogrel for one year
# home HCTZ stopped
# started on metoprolol and losartan
# home simavastatin replaced with atorvastatin
# Discharge wt: 83.8kg
# CODE: FULL CODE
# CONTACT: (wife)
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 10 mg PO QPM
2. sildenafil 60 mg oral PRN Sex
3. Hydrochlorothiazide 25 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
## REFILLS:
*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
## TABLET REFILLS:
*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
## TABLET REFILLS:
*2
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet
## REFILLS:
*0
5. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
## DISCHARGE DIAGNOSIS:
PRIMARY DIAGNOSIS
- Non ST-Elevation Myocardial Infarction
## DISCHARGE INSTRUCTIONS:
Dear
was a pleasure taking care of you at the
.
You were admitted because you had a heart attack. You underwent
cardiac catheterization on which revealed narrowing of
two coronary arteries, mid RCA and proximal LAD. You had 2
drug-eluting stents placed.
It is very important to take all of your heart healthy
medications.
You are now on aspirin. You need to take aspirin everyday. If
you stop taking aspirin, you risk the stent clotting and death.
Do not stop taking aspirin unless you are told by your
cardiologist. No other doctor can tell you to stop taking this
medication.
You are now on Plavix (also known as clopidogrel). This
medication helps keep your stent open. Do not stop taking plavix
unless you are told by your cardiologist. No other doctor can
tell you to stop taking this medication.
You are being started on two new medications, Toprol (metoprolol
XL) 25mg daily, and losartan 25mg daily. This replaces your
hydrochlorothiazide which you no longer need to take.
We wish you all the best,
Your Cardiology team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12074610", "visit_id": "29569287", "time": "2137-08-30 00:00:00"} |
19273599-RR-132 | 197 | ## INDICATION:
year old man with history of PET avid focus involving the
right eleventh costochondral junction with no definite sclerotic or lytic
lesion visualized in the previous chest CT.
## FINDINGS:
Study is severely degraded by motion despite repeating sequences.
There is no definite lesion visualized at the right eleventh costochondral
junction corresponding to the increased SUV uptake in the previous PET-CT.
Noting that there is motion artifact.
The evaluation of the intra-abdominal structures are significantly limited due
to severe motion artifact. There are multiple high T2 lesions in the liver
with no internal enhancement poorly characterized at the current study likely
representing previously described cysts and better assessed on the dedicated
prior liver MRI studies..
There are also bilateral renal high T2 lesions obscured by the significant
motion artifact with grossly no internal enhancement likely representing the
previously described cysts. There are severe degenerative changes and
scoliosis throughout the thoracolumbar spine.
There bilateral trace pleural effusion. There is small ascites visualized.
## IMPRESSION:
No definite lesion visualized at the right eleventh costochondral junction
corresponding to the increased SUV uptake in the previous PET-CT. Noting that
significantly limited evaluation due to severe motion artifact.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19273599", "visit_id": "N/A", "time": "2200-08-30 15:19:00"} |
17641105-RR-24 | 111 | RADIOGRAPHS OF THE RIGHT FOOT
## HISTORY:
Known chronic pressure ulceration along the right lateral fifth
metatarsal. Question osteomyelitis.
## FINDINGS:
At the site of clinical concern along the lateral side of the foot
near the fifth metatarsal, there is very similar slight irregularity to the
metatarsal as well as overlying soft tissue irregularity and probably
ulceration. Small bony fragments are in the vicinity. There is pes planus
and a similar dysmorphic appearance of the navicular with prominent medial
spurring. Second through fifth hammertoes are noted. Mild-to-moderate
degenerative changes are also similar along the first metatarsophalangeal
joint. The bones appear demineralized.
## IMPRESSION:
Similar irregularity and fragmentation suggesting osteomyelitis,
perhaps chronic.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17641105", "visit_id": "24870135", "time": "2176-08-22 18:16:00"} |
18011109-DS-11 | 1,364 | ## HISTORY OF PRESENT ILLNESS:
This is an male with posttraumatic epilepsy,
depression, and progressive cognitive decline presenting with
generalized weakness for one day.
The morning of admission, wife called into PCP office concerned
that she was unable to get her husband up and his hands were
noted to be shaking. She was concerned that he was having a
stroke -- she was advised to call and patient was
subsequently brought into ED by EMS.
Upon further history from wife/patient, patient reports 1 day of
generalized weakness. He stated that yesterday around 6 pm, he
was unable to stand up from a chair. His wife noted that he
appeared extremely lethargic and unable to even hold a spoon to
eat his dinner. His eyes remained half closed most of the
evening. He noted no improvement in symptoms after sleeping
overnight. Wife has also noted poor appetite and decreased po
intake/fluids over the same time period. Wife denies that
patient has had any recent travel or sick contacts.
Of note, patient recently underwent digital arthroplasty for
hammertoe repair of second toe of right foot ( ) for which he
was started on Keflex TID X 7 days, as a
precautionary measure given that he was barefoot in a shower
with new incisions.
Review of systems is otherwise negative for fever, chills,
cough, shortness of breath, abdominal pain, dysuria. He denies
neck stiffness but has noted headache which is similar to
chronic headaches.
In the ED, initial vitals:
09:17 0 101.4 73 125/60 18 97% RA
- Exam notable for: Low frequency tremor vs ? myoclonus x 4
extremities; myoclonus when supporting himself with arms; no
focal neuro deficit
- Labs notable for: creat 1.4 (baseline , lactate 2.6,
flu swab positivee
- Imaging was notable for portable CXR with streaky left basilar
opacity most likely atelectasis but otherwise clear lungs.
- Pt given: 1g Tylenol, 1L NS, 1gm ceftriaxone for CAP, and 30mg
tamiflu
- Vitals prior to transfer:
Today 13:46 0 66 109/53 15 98% RA
On arrival to the floor, pt reports, that he feels better but
does have mild headache.
## ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
## PAST MEDICAL HISTORY:
Temporal lobe epilepsy s/p vagal nerve stimular (VNS); partial
seizures thought to be due to TBI
Depression
Posttraumatic stress disorder.
Progressive cognitive decline/dementia. Memory difficulty,
particularly with verbal memory, progressive over multiple
years.
Diabetes, type II.
Hypertension.
Hyperlipidemia.
Severe headaches, left sided, electric shock over the left
occipital region..
Bladder tumor, status post transurethral resection .
Gastroesophageal reflux disease.
Lumbosacral spondylosis.
Squamous cell carcinoma of skin.
Testicular hypofunction.
Osteoarthritis.
Erectile dysfunction.
Peroneal nerve palsy.
Digital arthroplasty of left foot, second toe
## FAMILY HISTORY:
Family history is significant for his father having died in his
early from a heart attack, while his mother died at age
but without significant medical problems.
## GENERAL:
Alert, oriented to self and hospital (not to month or
year), no acute distress
## HEENT:
Sclerae anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
decreased air movement in the setting of poor effort, no
w/r/r
## CV:
RRR, Nl S1, S2, No MRG
## ABDOMEN:
soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
## EXT:
warm, well perfused, 2+ pulses, 1+ pitting edema in b/l
ankles; R foot second toe with mild erythema with overlying
sutures in place - no purulence expressed; mild ttp
## NEURO:
CN2-12 intact, no focal deficits
DISCHARGE PHYSICAL EXAM
## GENERAL:
Alert, oriented to self and hospital (not to month or
year), no acute distress
## HEENT:
Sclerae anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
decreased air movement in the setting of poor effort, no
w/r/r
## CV:
RRR, Nl S1, S2, No MRG
## ABDOMEN:
soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
## EXT:
warm, well perfused, 2+ pulses, 1+ pitting edema in b/l
ankles; R foot second toe with mild erythema with overlying
sutures in place - no purulence expressed; mild ttp
## NEURO:
CN2-12 intact, no focal deficits
## BRIEF HOSPITAL COURSE:
This is an male with PMH posttraumatic epilepsy,
depression, and progressive cognitive decline presenting with
generalized weakness for one day found to be flu positive.
## # INFLUENZA:
Found to be influenza positive on admission in the
setting of increased fatigue and decreased po intake over the
last 48 hours. Patient was placed on Tamiflu X 5 days (day 1:
, last dose . His lethargy dramatically improved over
the first 12 hours of admission. On hospital day #2 he developed
mild leukopenia attributed to viral infection, will need f/u as
outpt to confirm resolution. On discharge, patient's wife and
son, who is immunocompromised and lives with pt, were given
prescriptions for Tamiflu prophylaxis to be taken over 10 days.
# R foot, second digit cellulitis s/p second digit arthroplasty
for hammertoe repair ( ): Site with mild erythema though no
purulence expressed from suture sites. Patient had been started
on Keflex by outpatient podiatrist and this was continued during
admission (Keflex TID X 7 days ( ).
## # :
Likely prerenal in etiology. Creatinine on admission 1.4
(baseline : in the setting of influenza and decreased po
intake. Creatinine to 1.1 with IVF and lisinopril was restarted
on discharge.
# Diabetes, type II. Home metformin was held while patient was
hospitalized and patient was placed on HISS. Metformin was
restarted on discharge.
## CHRONIC ISSUES
# "COGNITIVE DECLINE"/DEMENTIA:
Continued home donepezil.
Patient did require two extra doses of Seroquel 12.5mg for
escalation in anger though not noted to be physically abusive.
# PTSD/depression: Continued quetiapine.
# Hx epilepsy: Continue home lamotrigine.
# Chronic headaches: Continue PRN Tylenol.
# Hypertension: Continued home atenolol. Lisinopril was held
while hospitalized in the setting of . This was restarted on
discharge with resolution of .
# Hyperlipidemia. Continue home atorvastatin.
TRANSITIONAL ISSUES
- Last dose Tamiflu
- Patient's wife and son should complete 10 day course of
Tamiflu prophylaxis
- Complete 7 day course of Keflex TID X 7 days ( )
prescribed by podiatrist for ?cellulitis of right foot, second
digit arthroplasty
- Patient should have repeat CBC on given findings of
leukopenia WBC 2.9
- Patient should be evaluated by a geriatric psychiatrist in the
outpatient setting given intermittent escalations in anger
- Patient was discharged home with pt and services. Further
home services or admission to a day program should be considered
given wife's feelings of being overwhelmed by his care
# CODE STATUS: FULL CODE
# CONTACT: Wife, home
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 500 mg PO Q8H
2. Lisinopril 10 mg PO DAILY
3. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
4. QUEtiapine Fumarate 12.5 mg PO BID
5. Donepezil 5 mg PO QHS
6. Atorvastatin 40 mg PO QPM
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Atenolol 50 mg PO DAILY
9. lamoTRIgine 200 mg oral DAILY
## DISCHARGE MEDICATIONS:
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Cephalexin 500 mg PO Q8H
Last dose
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*4 Capsule Refills:*0
4. Donepezil 5 mg PO QHS
5. QUEtiapine Fumarate 12.5 mg PO BID
6. lamoTRIgine 200 mg oral DAILY
7. OSELTAMivir 30 mg PO Q12H
Last dose
RX *oseltamivir [Tamiflu] 30 mg 1 capsule(s) by mouth twice
daily Disp #*7 Capsule Refills:*0
8. Lisinopril 10 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
11. Outpatient Lab Work
J11.1 Influenza
Please obtain CBC and fax results to:
, MD PCP
:
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
You were admitted with generalized weakness and you were found
to have the flu. You were treated with 5 days of Tamiflu. Please
get repeat bloodwork on to monitor your blood counts. We
wish you all the best in your recovery.
Sincerely,
Your team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18011109", "visit_id": "27628901", "time": "2132-01-20 00:00:00"} |
17273012-RR-66 | 179 | ## EXAMINATION:
ABDOMEN US (COMPLETE STUDY)
## INDICATION:
year old woman with LLQ pain // etiology
## LIVER:
The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD measures 3 mm.
## GALLBLADDER:
Single shadowing stone in the gallbladder which is otherwise
normal without wall thickening or pericholecystic fluid
## PANCREAS:
Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
## SPLEEN:
Normal echogenicity, measuring 9.6 cm.
## KIDNEYS:
The right kidney measures 9.3 cm. The left kidney measures 8.8 cm.
There is no evidence of masses, stones or hydronephrosis in the kidneys. A
simple cyst in the interpolar region of the right kidney measures 10 mm.
## RETROPERITONEUM:
Visualized portions of aorta and IVC are within normal
limits.
## IMPRESSION:
1. Cholelithiasis.
2. No findings to account for patient's left lower quadrant pain.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17273012", "visit_id": "N/A", "time": "2203-01-21 12:49:00"} |
14032407-DS-17 | 1,646 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## ATTENDING:
Complaint:
Found down at home
## HISTORY OF PRESENT ILLNESS:
h/o IDDM, h/o NSTEMI and 3 vessel disease being managed
medically, HTN, HLD found down, presenting initially with
hypoglycemia who subsequently became bradycardic.
.
The patient was in-house recently for a right ankle fracture
with 36 units NPH this morning (usual), missed snack/lunch,
found down by neighbor who called EMS, BS 13 at scene, s/p
thiamine, D50, next remembers waking up in ambulance. Repeat BS
in the ED was 100. Recent NPH changes while at rehab (L ankle
injury). ROS otherwise negative for chest pain, shortness of
breath, fever, abd pain. Exam unremarkable.
.
Patient reportsdoesn't remember whether he passed out before
eating or didn't eat because he passed out.
.
Pt neighbors found him with sugar of 13. EMS called
and got line and 100mg thiamine and 1 amp D50. Later stated he
has been having labile sugars s/p ankle fx with stay at rehab.
Thinks he didn't have his morning snack or lunch. No other
complaints. Repeat BS patient was found to have HR 48 without symptoms.
Has been on NPH, Glargine for a long time
Went to rehab 1 mo ago for ankle fracture, had medications
adjusted at that time.
In the ED, initial VS: 98.6 72 165/91 18 98%
ASA 325
Atropine
Trop 0.01 -> 0.04
- EKG: SR, RBBB, AVB, TWI/F in V-3, o/w NSST changes
- CXR - no acute
- UA - neg
- labs, trop, CK - neg
- PO carbs
- 2 sets, obs overnight to monitor blood glucose
## ADMISSION VITALS:
- 68 147/69 20 100%
Spoke to cardiology fellow, looks like complete heart block, but
difficult to tell and felt this may be 2:1 block. EP will see
the patient in the morning. Bradycardic to 29 on EKG for unknown
amount of time, no BP reading but mentating well with that heart
rate. Subsequently HR increased to 54 by the time the patient
was placed back on a monitor, BP 130's/70's at that. Atropine at
bedside, pacer pads in place. CE's were likely after this
episode.
.
No symptoms.
Got ASA 325 at home.
CCB and BB at home. Cr 1.3 at baseline.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema apart from post-fracture pain, palpitations, syncope
or presyncope.
## PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS:
(+)Diabetes (Type 1, pt), (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- NSTEMI
- Unstable Angina, cath : diffusely diseased LAD with an 80%
stenosis in its mid portion, as well as a 70% stenosis in the
proximal portion of the left circumflex. The first OM branch had
an 80% stenosis. The RCA had mild luminal irregularities. The
posterolateral branch had a 50% stenosis. His ejection fraction
was normal. Because his anatomy presented poor options for both
surgical revascularization and percutaneous intervention, Mr.
was treated medically.
Stress echo images revealed more marked regional WMA
particularly with septal, apical, and anterior hypokinesis.
.
- CHF: EF 50% per stress TTE , previous TTEs showed
concentric LVH and trace MR, aortic sclerosis
.
3. OTHER PAST MEDICAL HISTORY:
- GERD
- Glaucoma and reintopathy s/p laser treatment
## FAMILY HISTORY:
Parents deceased father had DM. 2 siblings (1 brother, 1
sister) both alive and well. No history of premature coronary
disease. Paternal aunts and father with diabetes.
## GENERAL:
Alert, interactive, appropriate, pleasant, NAD.
## HEENT:
Pupils equal and round. R-sided ptosis (chronic). MMM.
## NECK:
Supple with JVP ~9cm.
## CARDIAC:
RRR with occasional pause, GII systolic murmer at .
No heaves, thrills, lifts. No S3 or S4.
## LUNGS:
CTAB, no crackles, wheezes, rhonchi.
## ABDOMEN:
Soft, NTND. No HSM or tenderness.
## EXTREMITIES:
No c/c. 2+ pitting edema of RLE with mild erythema
c/w mild stasis dermatitis.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## CXR :
PA AND LATERAL VIEWS OF THE CHEST:
The heart size is normal. The
mediastinal and hilar contours are unremarkable. The lungs are
clear and the pulmonary vascularity is normal. No pleural
effusion or pneumothorax is identified. No acute osseous
findings are present. Mild degenerative changes are noted in the
thoracic spine.
## IMPRESSION:
No acute cardiopulmonary abnormality.
.
## CARDIAC ELECTROPHYSIOLOGY :
1. Normal sinus node function
2. Impaired AV nodal condution
3. Normal His Purkinje system at baseline and after
pharmacological stress challenge with atropine and procainamide
4. No inducibility of bundle-branch reentry
## BRIEF HOSPITAL COURSE:
with multivessel CAD, currently presenting after a
hypoglycemic episode with asymptomatic bradycardia.
.
# RHYTHM: Bradycardic rhythm with evidence of PR elongation
(Weinkebach), dropped beats, and occassional complete AV nodal
dissociation while sleeping. He underwent an electrophysiology
study which showed impaired AV nodal conduction but normal
His-Purkinje system. Pacemaker was not indicated. Cause of
bradycardia attributed to beta-blockade. After discussion with
outpatient cardiologist, decision was made to stop metoprolol
and discharge patient on until his cardiology
followup. Patient was asymptomatic throughout the
hospitalization.
.
# PUMP: Echocardiogram showed 65% LVEF with trace mitral
regurgitation. Patient has chronic lower extremity edema, right
greater than left, which is his baseline. He was discharged on
home regimen of furosemide and lisinopril.
.
# Acute kidney injury: Creatinine initially increased to 1.6
(admission 1.3), but returned to 1.2 prior to discharge. He was
placed back on home regimen of furosemide and lisinopril.
.
# Hypoglycemia: Patient was found down with finger stick of 15
on admission. He has previously had good glycemic control prior
to his recent right ankle fracture. Since then, his antiglycemic
control was changed at rehab due to hyper/hypoglycemia. Here,
his ranged from 47 - 180 on insulin sliding scale and 30
units of Lantus. He was asymptomatic throughout. Patient will
schedule close follow-up with his outpatient endocrinologist at
. He was discharged on home (prior to
ankle fracture) NPH/regular insulin regimen. Patient is
well-educated about insulin medications and titration. He will
skip regular insulin if his finger sticks blood sugar,
which was the instruction of his endocrinologist.
.
# Glaucoma: Patient was kept on home regimen of Brimonidine
Tartrate and Latanoprost eye drops. He complained of eye redness
and crusting in the mornings consistent with blepharitis.
Patient instructed to apply warm compresses twice a day and to
follow-up with his ophthalmologist.
## MEDICATIONS ON ADMISSION:
CRESTOR - 10MG Tablet - ONE TABLET BY MOUTH EVERY DAY
FUROSEMIDE - 40MG Tablet - ONE BY MOUTH EVERY DAY FOR FLUID AND
HEART
ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr -
1
Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
NIFEDIPINE [NIFEDICAL XL] - 30 mg Tablet Extended Rel 24 hr - 4
Tab(s) by mouth take 3 tabs in the morning, one in the evening
POTASSIUM CHLORIDE - 600 MG Capsule, Extended Release - ONE BY
MOUTH EVERY DAY
TRIAMCINOLONE ACETONIDE - 0.1% Cream - APPLY TO AFFECTED SKIN
TWICE A DAY
ZESTRIL - 40MG Tablet - ONE BY MOUTH QD, 3 MO SUPPLY
ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth once a day
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
## DISCHARGE MEDICATIONS:
1. rosuvastatin 5 mg Tablet
## SIG:
Two (2) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl Topical
BID (2 times a day).
5. nifedipine 60 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO DAILY (Daily).
6. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
## SIG:
One (1) Tablet Extended Release 24 hr PO once a day.
11. Micro-K 8 mEq Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day: Equivalent to 600 mg
which was patient's admission home medication. .
12. Humulin N 100 unit/mL Suspension Sig: See below
Subcutaneous see below: Please take BEFORE
##
32 UNITS & BEFORE DINNER:
14 units.
13. Humulin R 100 unit/mL Solution Sig: see below Injection see
below: Please take BEFORE breakfast: 10 units & BEFORE dinner 6
units. .
## DISCHARGE DIAGNOSIS:
Bradycardia
Atrioventricular Conduction Defect
Coronary Artery Disease
Hypertension
Glaucoma
## DISCHARGE INSTRUCTIONS:
Dear Mr ,
You were admitted to the after being found down in your
home. As it turns out you were very hypoglycemic, and after you
received some glucose you felt better. However, during your
evaluation by the EMT's and the emergency room, your heart rate
was found to be very slow. We watched you very closely in the
hospital over the weekend. On you underwent a study
with the electrophysiologists to determine whether your heart
was afflicted with a potentially fatal arrhythmia. They did not
find abnormality in the main conduction fibers of your heart.
Instead, the slow heart rate was most likely due to the
metoprolol that you were taking. You should stop taking it. We
are also going to give you a heart moniter which you should wear
everyday until you see your cardiologist Dr.
listed below). It will document and notify doctors
develop any dangerous abnormal heart rhythms.
## REMOVED:
Metoprolol succinate 50 mg by mouth per day
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14032407", "visit_id": "20994409", "time": "2150-08-01 00:00:00"} |
19073967-RR-36 | 72 | ## INDICATION:
Thickened endometrium demonstrated on recent CT.
## FINDINGS:
The uterus is anteverted and measures 8.0 x 4.3 x 6.0 cm. The endometrium is
heterogenous with cystic spaces and measures 9 mm. Vascularity is
demonstrated within the endometrial cavity.
The ovaries are normal. There is no free fluid.
## IMPRESSION:
1. Heterogenous endometrium demonstrating cystic spaces and vascularity.
Differential diagnosis includes endometrial polyp, neoplasm, or hyperplasia.
2. Normal ovaries.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19073967", "visit_id": "N/A", "time": "2136-11-17 15:14:00"} |
11920350-RR-29 | 106 | ## FINDINGS:
Two frontal upright and two frontal supine radiographs obtained of
the abdomen. Images reveal multiple air-filled loops of large bowel. A
paucity of gas is seen over the rectum and should be correlated to possible
impaction. The moderate volume of stool seen on the radiograph from one day
ago is no longer present. There is no free gas or pneumatosis. Pneumobilia
is redemonstrated, unchanged from that seen on recent MRCP. Clips are
visualized at the right upper quadrant, as are multiple sternotomy wires.
Atherosclerotic calcification is noted along the course of the abdominal
aorta. Multilevel degenerative change is seen throughout the spine.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11920350", "visit_id": "28387210", "time": "2156-11-17 09:24:00"} |
16027364-RR-38 | 406 | ## EXAMINATION:
CTA CHEST WITH CONTRAST
## HISTORY:
with a malignancy, history of prior PE setting with
acute onset pleuritic chest pain and dyspnea. // Assess for pulmonary
embolism as well as pneumonia, metastatic disease to the lung.
## DOSE:
Acquisition sequence:
1) Stationary Acquisition 12.0 s, 0.5 cm; CTDIvol = 72.9 mGy (Body) DLP =
36.4 mGy-cm.
2) Spiral Acquisition 3.0 s, 23.3 cm; CTDIvol = 16.9 mGy (Body) DLP = 394.2
mGy-cm.
Total DLP (Body) = 431 mGy-cm.
## FINDINGS:
The study is limited due to patient body habitus, contrast timing, and
respiratory motion. Within these limitations:
## HEART AND VASCULATURE:
Pulmonary vasculature is well opacified to the
segmental 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 appears mildly enlarged, however this is
likely due to low lung volumes. There are no atherosclerotic calcifications
of the coronary vessels are aorta. The pericardium and great vessels are
within normal limits. No pericardial effusion is seen. A left chest wall port
with tip terminating in the right atrium is partially visualized.
## AXILLA, HILA, AND MEDIASTINUM:
No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass. There is a small hiatal
hernia.
## PLEURAL SPACES:
No pleural effusion or pneumothorax.
## LUNGS/AIRWAYS:
Evaluation of fine parenchymal details is significantly limited
due to respiratory motion, phase of respiration, and photon starvation
artifact. The previously seen subpleural pulmonary nodule in the left lower
lobe is not visualized. No new large pulmonary nodules are identified within
the visualized lung fields, which of note excludes the apices. The airways
are patent to the level of the segmental bronchi bilaterally.
## BASE OF NECK:
Visualized portions of the base of the neck show no abnormality.
## ABDOMEN:
Included portion of the upper abdomen is notable for a diffusely
hypoattenuating liver, suggestive of the hepatic steatosis.
## BONES:
No suspicious osseous abnormality is seen.? There is no acute fracture.
## IMPRESSION:
1. Evaluation of the subsegmental pulmonary arteries is limited due to
contrast timing, respiratory motion and photon starvation. Within this
limitation, no evidence of pulmonary embolism to the segmental branches or
acute aortic abnormality.
2. Limited evaluation of the lung parenchyma reveals no large focal
consolidation or new pulmonary nodule. Previously seen left lower lobe
pulmonary nodule is not definitively visualized. Please note the lung apices
are excluded from the field of view for reduced radiation exposure.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16027364", "visit_id": "29310941", "time": "2147-03-04 20:13:00"} |
15496609-RR-146 | 205 | ## EXAMINATION:
CT PELVIS ORTHO WITHOUT CONTRAST
## INDICATION:
unable to ambulate, left hip pain// ?left hip fracture
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 7.7 s, 38.1 cm; CTDIvol = 17.9 mGy (Body) DLP = 681.2
mGy-cm.
Total DLP (Body) = 681 mGy-cm.
## FINDINGS:
Streak artifact from left hip prosthesis limits study.
## BONES:
No acute fracture or dislocation. Patient is status post left hip
hemiarthroplasty. A small area of lucency and a small focus of air is seen in
between the distal tip of the prosthesis and the intramedullary cement, of
indeterminate clinical significance. This area of lucency has been unchanged
over multiple prior studies going back to . There is no other evidence of
hardware related complication.
Extensive heterotopic ossification is noted about the left proximal femur.
Linear lucencies are noted within the areas of heterotopic calcification,
however the borders are well-corticated. Mild-to-moderate degenerative
changes are seen involving the right femoroacetabular joint.
## SOFT TISSUES:
The bladder and reproductive organs are unremarkable. No free
fluid in the pelvis. No appreciable soft tissue edema or hematoma.
## IMPRESSION:
1. No acute fracture or dislocation.
2. Status post left hip total arthroplasty, with stable area lucency at the
distal tip of the prosthesis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15496609", "visit_id": "20635042", "time": "2163-08-01 21:25:00"} |
19623993-RR-29 | 67 | ## INDICATION:
IV access needed for antibiotics.
## RADIOLOGIST:
Dr. , (resident) and Dr. ,
(fellow) performed the procedure. Dr. (attending) was present
and supervised the entire procedure.
## IMPRESSION:
Uncomplicated ultrasound and fluoroscopically guided double lumen
power PICC line placement via the right brachial venous approach. Final
internal length is 37 cm, with the tip positioned in region of the cavo-atrial
junction. The line is ready to use.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19623993", "visit_id": "20069776", "time": "2139-06-30 11:23:00"} |
19330916-RR-21 | 76 | ARTHROGRAM OF THE RIGHT HIP FOR MR EVALUATION AS WELL AS INTRARTICULAR STEROID
INJECTION.
## HISTORY:
woman with right groin pain, evaluation for labral tear.
## FINDINGS:
1. Right hip demonstrates a grossly normal fluoroscopic appearance.
2. Small amount of water-soluble contrast within the right hip confirming
intra-articular position of the needle tip.
## IMPRESSION:
1. Successful fluoroscopic-guided right hip arthrogram for MR evaluation.
2. Successful intra-articular administration of steroid within the right hip.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19330916", "visit_id": "N/A", "time": "2181-01-19 10:27:00"} |
11009443-RR-27 | 638 | ## EXAMINATION:
CT abdomen and pelvis with IV and oral contrast.
## INDICATION:
year old woman with hemoperitoneum now stable, evaluate with
PO/IV contrast for extraluminal colonic v meseteric mass // PO/IV contrast -
please time appropriately for PO contrast to traverse colon.
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
## IV CONTRAST:
130 mL Omnipaque.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
##
ACQUISITION SEQUENCE:
1) CT Localizer Radiograph 2) CT Localizer
Radiograph 3) Spiral Acquisition 1.0 s, 4.1 cm; CTDIvol = 27.3 mGy (Body) DLP
= 112.5 mGy-cm. 4) Spiral Acquisition 1.0 s, 4.1 cm; CTDIvol = 28.7 mGy (Body)
DLP = 118.4 mGy-cm. 5) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 57.8
mGy (Body) DLP = 28.9 mGy-cm. 6) Spiral Acquisition 5.1 s, 56.4 cm; CTDIvol =
16.9 mGy (Body) DLP = 955.7 mGy-cm. Total DLP (Body) = 1,215 mGy-cm.
## LOWER CHEST:
There are small bilateral pleural effusions with compressive
atelectasis, which is new in comparison to the prior examination. There is no
evidence of pericardial effusion.
## HEPATOBILIARY:
There is a subcentimeter hypodensity within the liver adjacent
to the left portal vein, which is too small to characterize, but likely
represents a cyst or biliary hamartoma. Otherwise, the liver demonstrates
homogenous attenuation throughout. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
There is a tiny hypodensity within the upper pole of the left kidney
that is too small to characterize but likely represents a cyst. Otherwise,
kidneys are of normal and symmetric size with normal nephrogram. There is no
evidence of hydronephrosis. There is no perinephric abnormality.
## GASTROINTESTINAL:
Again visualized is the homogeneous soft tissue density in
the region of the transverse colon. The largest component measures
approximately 5.5 x 5.5 cm and is more homogeneous in comparison to the prior
examination, consistent with organizing hematoma. There has been no interval
enlargement in the size of the hematoma, and no definite intraluminal or
extraluminal mass is visualized. The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and enhancement throughout.
The appendix is normal.
## PELVIS:
Again visualized is the free fluid within the pelvis with an average
Hounsfield density of 40, which is unchanged in size in comparison to the
prior examination and is consistent with blood products. There is a Foley in
the bladder with an expected amount of intraluminal air. Otherwise, the
urinary bladder and distal ureters are unremarkable.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
There are mild-to-moderate degenerative changes within the thoracolumbar
spine. There is a small sclerotic focus within the sacrum that likely
represents a bone island.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. Homogeneous appearance of the hematoma in the region of the transverse
colon, which is stable in size.
2. Stable free fluid in the pelvis consistent with blood products
3. Small bilateral pleural effusions.
## RECOMMENDATION(S):
If the clinical concern for a colonic mass persists,
repeat CT in one month after resolution of the hematoma is recommended. The
current follow-up interval is too short to see any interval chnages.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11009443", "visit_id": "22335949", "time": "2184-05-02 14:21:00"} |
14191782-RR-75 | 179 | ## HISTORY:
Fell, paresthesias, question subluxation.
CERVICAL SPINE, FOUR VIEWS INCLUDING FLEXION, EXTENSION.
The patient's head is tilted and there is right convex curvature of the
cervical spine, which could be positional. No prevertebral soft tissue
swelling is identified. On the neutral lateral view, C1 through lower
portion of T1 is demonstrated. There is moderately severe multilevel
degenerative change, most pronounced from C4 through T1. There is also grade
1 anterolisthesis of C4 on C5. There is facet arthrosis most pronounced in
the mid spine on both sides. Carotid artery calcification, presumed pacemaker
lead, sternotomy clips and wires are noted.
On flexion-extension views, there is good range of motion. In flexion, the
C4-5 anterolisthesis measures slightly greater than on the neutral view (6.2
mm versus 3.8 mm) and it reduces (3.4 mm) in extension.
## IMPRESSION:
1. Moderately severe multilevel degenerative changes, worst at C4 through T1
with grade 1 anterolisthesis at C4/5.
2. Change in the degree of listhesis on flexion and extension views. No other
evidence of instability is detected.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14191782", "visit_id": "N/A", "time": "2140-09-20 13:39:00"} |
12458131-RR-14 | 102 | ## REASON FOR EXAMINATION:
Evaluation of the patient with aspiration pneumonia
and central line placement.
Portable AP radiograph of the chest was reviewed in comparison to .
The central venous line has been inserted with its tip in the right atrium and
should be pulled back for approximately 2 cm. The feeding tube has been
inserted with its tip in the stomach. The ET tube tip is 5 cm above the
carina.
There is no change in currently moderate-to-severe pulmonary edema. Left
lower lobe atelectasis and pleural effusion are redemonstrated. No
appreciable pneumothorax is seen. Bilateral pleural effusions are unchanged.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12458131", "visit_id": "20353775", "time": "2185-04-29 20:39:00"} |
16177748-RR-37 | 81 | ## EXAMINATION:
BILATERAL DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM
INTERPRETED WITH CAD
## INDICATION:
History of left breast cancer treated with left breast
lumpectomy, chemotherapy, and radiation therapy presents for her annual exam.
## TISSUE DENSITY:
B - There are scattered areas of fibroglandular density.
Left breast post treatment changes are stable. There is no suspicious
dominant mass, unexplained architectural distortion or suspicious grouped
calcifications.
## IMPRESSION:
No evidence for malignancy.
## NOTIFICATION:
Findings reviewed with the patient at the completion of the
study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16177748", "visit_id": "N/A", "time": "2142-03-11 10:13:00"} |
15395594-RR-93 | 128 | ## INDICATION:
Evaluation of patient with right hand and arm pain after fall.
## FINDINGS:
Two views of the right forearm were obtained. There is a
minimally-displaced transversely oriented fracture through the right radial
neck with extension into the radial head. Small joint effusion is visualized
in the right elbow. Otherwise, no other acute fractures or dislocations are
noted. An ossified focus adjacent to the medial epicondyle of the humerus is
likely the sequela of prior medial epicondylitis and appears well corticated.
No suspicious lytic or sclerotic lesions. No radiopaque foreign bodies.
## IMPRESSION:
Minimally-displaced transversely-oriented radial neck fracture
with extension into radial head and an associated joint effusion.
These findings were submitted to the radiology critical dashboard by Dr.
at 2:30 p.m. on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15395594", "visit_id": "N/A", "time": "2189-12-24 09:59:00"} |
11113889-RR-24 | 326 | ## HISTORY:
male with history of metastatic melanoma. Evaluation
for disease progression.
## CT THORAX:
The thyroid is unchanged, again demonstrating multiple
subcentimeter hypodense lesions in the right lobe, unchanged dating back to
contrast-enhanced CT of the chest from . There is no
supraclavicular, axillary, mediastinal or hilar lymphadenopathy. The
intrathoracic aorta is of normal caliber throughout, with no evidence of
dissection, intramural hematoma or aneurysmal formation. The pulmonary
arteries are well opacified centrally, with no evidence of central pulmonary
embolism, and are also of normal caliber. No pleural or pericardial effusion
is identified. The esophagus is filled with enteric contrast material along
its mid segment(4:75), but is otherwise unremarkable. The patient is status
post CABG.
Lung windows demonstrate multiple lung nodules consistent with metastases
which have intervally increased in size, for example, a reference lesion in
the right middle lobe (4:120) now measures 24 x 31 mm, previously measuring 22
x 26 mm on prior CTA of the chest from . A second reference
lesion in the superior segment of the left lower lobe has also intervally
increased in size since the prior study (4:89), now measuring 21 x 14 mm,
previously measuring 19 x 13 mm. No new pulmonary nodules are identified.
There is persistent scarring within the left lingula (4:140), unchanged. The
previously seen ground-glass opacities surrounding a right lower lobe
pulmonary nodule has intervally resolved. There is trace dependent bibasilar
atelectasis. The airways are patent to the subsegmental level.
Although the study is not designed for evaluation of subdiaphragmatic
structures, the bilateral kidneys demonstrate simple cysts, better
characterized on concurrent CT of the abdomen and pelvis.
## OSSEOUS STRUCTURES:
There has been a prior median sternotomy. No lytic or
blastic lesion suspicious for malignancy is identified within the thorax.
## IMPRESSION:
1. Interval increase in size of known pulmonary metastases, with no new
pulmonary nodules identified.
2. Subcentimeter hypodensities in the right lobe of the thyroid appear
unchanged since .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11113889", "visit_id": "29547164", "time": "2155-04-25 08:04:00"} |
11789573-DS-14 | 1,689 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Upper endoscopy
Variceal banding
## HISTORY OF PRESENT ILLNESS:
Patient is a yo man with history
of NASH, thrombcytopenia and asthma who presents with a week
long history of hematemesis.
.
Patient was in his usual state of health until last night when
he had an episode of vomiting productive for a large volume of
bright red liquid blood. He had a similar episode 1 week ago
with liquid vomit with few clots mixed in. Patient denies any
orthostasis, chest pain, abd pain, nausea, or blood per rectum.
He denies any recent alcohol or NSAID intake. In of this
year patient underwent upper endoscopy and found to 3 cords of
grade III varices.
.
In the ED, initial vs were: 97 87 130/64 18 99% ra. Initial labs
were significant for a Hct down to 32 from 40 in .
Patient was seen by GI who directly admitted the patient to the
endoscopy suite. In endoscopy patinet was found to have 3 cords
of grade III varices that were seen starting at 40 cm from the
incisors in the lower third of the esophagus with stigmata of
recent bleeding.
.
On the floor, patient was stable vitals were 98.7, 141/73, 76,
18, 96 RA. Patient was not complaining of any dizziness,
abdominal pain, nausea or vomiting or chest pain.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
## PAST MEDICAL HISTORY:
-thrombocytopenia
-iron deficiency anemia
-asthma
-hypertension
-hypercholesterolemia
-obesity
-nonalcoholic
-steatohepatitis secondary to diabetes and hyperlipidemia
-diabetes
-mild renal insufficiency
-possible prior TB exposure.
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
ronchi
## CV:
Regular rate and rhythm, normal S1 + S2, holosystolic
apical murmur, rubs, gallops
## ABDOMEN:
soft, non-tender, non-distended. + bowel sounds. no
rebound or guarding.
## EXT:
warm, well-perfused. no cyanosis, clubbing, or edema.
## NEURO:
CN II-XII intact. Strength throughout. motor
function grossly normal
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear with upper
dentures
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
ronchi
## CV:
Regular rate and rhythm, normal S1 + S2, holosystolic
apical murmur, rubs, gallops
## ABDOMEN:
soft, non-tender, non-distended. + bowel sounds. no
rebound or guarding.
## EXT:
warm, well-perfused. no cyanosis, clubbing, or edema.
## NEURO:
CN II-XII intact. Strength throughout. motor
function grossly normal
## EKG:
Normal sinus rhythm. Leftward axis. Compared to the previous
tracing
of changes are similar to those seen at that time.
## FINDINGS:
Portable AP erect radiograph of the chest was
obtained. There is
no free air seen under either hemidiaphragm. There is moderately
low lung
volume with associated bronchovascular crowding. There is a
right lower lung opacity which may be related to atelectasis.
Otherwise, the lungs are clear with no evidence of nodules,
effusions, or consolidation. The
cardiomediastinal silhouette and hilar silhouettes are
unremarkable. The
aorta is moderately calcified at the arch.
## IMPRESSION:
No acute intrathoracic process.
## PROCEDURES:
3 bands were successfully placed in the 3 cords of
grade III varices in lower third of the esophagus.
## IMPRESSION:
Varices at the lower third of the esophagus, banded
successfully. Mosaic appearance, erythema and granularity in the
antrum compatible with Portal gastropathy Normal mucosa in the
duodenum
Otherwise normal EGD to third part of the duodenum
## RECOMMENDATIONS:
Follow-up EGD in weeks to evaluate varices.
Continue Octreotide drip for 48 hours.
Continue Protonix drip. Change to IV PPI BID tomorrow.
Soft diet for 2 days.
Carafate slurry 1 gm QID.
Start Ceftriaxone for SBP prophylaxis in the setting of GI
bleed.
## ASSESSMENT AND PLAN:
yo man w/ history of NASH with known
grade III esophageal varices, presents with a day long history
of hematemasis.
.
## HEMATEMASIS:
This patient has a known history of esophageal
varices NASH cirrhosis, visulaized on EGD in in setting
of anemia work-up. No evidence of active bleed at that time.
Patient presented to the ED with a week of hematemasis initially
positive for large clots now increasing frequency and without
clots. Patient was taken to endocoscopy where 3 large varices
were seen and banded, while evidence of recent bleed was seen no
active site was visualized. Patient was placed on a
pantoprazole drip, and octreotide drip for 48 hours. Serial
HCTs were collected and were stable not requiring transfusion.
Patient was discharged on pantoprazole mg BID, sucralfate 1
g BID for three weeks, and ciprofloxacin for 3 additional days
for SBP prophylaxis. Patient has follow up with his
hepatologist and repeat upper endoscopy in 3 weeks to revaluate
varices. Patient was not started on nadolol given his history
of asthma prior to discharge.
.
## NASH:
Chronic condition for this patient worked up on previous
admissions and outpatient setting. LFTs were within patient's
baseline. Patient was placed on IV ceftriaxone and discharged on
PO cipro to complete a 5 day course for SBP prophilaxis.
Patient continued to recieve his ezetimibe-simvastain 10 mg/
10mg.
Patient was not started on nadolol given his history of asthma
prior to discharge.
.
## THROMBOCYTOPENIA:
Chronic issue likely from patient's liver
disease and splenic platelet sequestration. Patient's platelet
count currently at 114K, which is well within his normal range.
Will trend count and given recent bleed with transfuse to a goal
of 80K if necessary.
- transfusion goal < 80 if evidence of active bleed
- tren cbc
.
## IRON DEFICENCY ANEMIA:
Patient followed by hematology with
chronic anemia high TIBC and low ferritin consistent with iron
deficency. Will hold his iron sulfate for now given acute bleed
and recent banding. Intention to restart prior to discharge.
- hold iron sulfate for now
- restart iron on d/c
.
## HYPERTENSION:
Patient not on any beta blockade. Will continue
home medications of HCTZ 12.5 mg, imdur 30 mg daily and
valsartan 80 mg daily.
.
## ASTHMA:
Patient's symptoms have been well controlled on home
regimen, followed by Dr. . Most reccent PFTs from
FVC 300 (76%), FEV1 1.31 (65%) and FEV/FVC 58 (81%). Not
currently an active issue will continue home, pulmicort,
albuterol, montelukast, salmeterol and tiopium bromide.
- continue home regimen
.
## DIABETES:
On oral agents with most reccent A1c 6.5%, will hold
metformin while in house and put on Insulin sliding scale with
QACHS finger sticks.
- continue home regimen
.
## RENAL INSUFFICENCY:
patient's creatine at 1.1 which is within
his normal range.
.
## FEN:
No IVF, replete electrolytes, clears and softs
## MEDICATIONS ON ADMISSION:
-albuterol sulfate 2 puffs PRN
-Budesonide (pulmicort) puffs BID
-ezetimibe-simvastatin 10mg/10mg daily
-glipizide 10 mg BID
-HCTZ 12.5 mg daily
-Isosorbide mononitrate 30 mg daily
-Metformin 500 mg QID
-Montelukast 10 mg daily
-Prilosec 20 mg BID
-pentoxifylline 400 mg TID
-Salmeterol 50 mcg QAM
-Tiotropium bromide 18 mcg daily
-Valsartan 80 mg daily
-Ascorbic acid mg BID
-Ferrous sulfate 325 mg BID
## DISCHARGE MEDICATIONS:
1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO twice a day
for 3 weeks.
Disp:*42 Tablet(s)* Refills:*0*
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. isosorbide mononitrate 10 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 * Refills:*2*
## 9. EZETIMIBE-SIMVASTATIN MG TABLET SIG:
One (1) Tablet PO
once a day.
10. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
12. ascorbic acid mg Tablet Sig: One (1) Tablet PO twice a
day.
13. pentoxifylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day.
14. metformin 500 mg Tablet Sig: One (1) Tablet PO four times a
day.
15. glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
## SECONDARY:
-thrombocytopenia
-iron deficiency anemia
-asthma
-hypertension
-hypercholesterolemia
-obesity
-nonalcoholic steatohepatitis secondary to diabetes and
hyperlipidemia
-diabetes
-mild renal insufficiency
## DISCHARGE INSTRUCTIONS:
Mr. ,
It was a pleasure taking care of you while you were in the
hospital. You were admitted for coughing up blood and seen by
our gastroenterologists who preformed an endoscopy. During this
procedure they saw the blood vessels around your esophagus were
very enlarged and bleeding. You underwent a procedure called
variceal banding which stopped the bleeding. You will need to
have a repeat procedure in 3 weeks to reassess the status of
these blood vessels.
The following changes have been made to your medications:
-START Ciprofloxacin 500 mg daily for 3 days
-START Sucralfate 1 gm twice daily for 3 weeks
-START Pantoprazole 40 mg daily
-START Advair (fluticasone/salmeterol) 250/50 mcg 1 puff twice
daily
-DECREASE Pentoxifylline 400 mg three times a day to twice daily
-STOP Salmeterol diskus 50 mcg 1 inhalation Q12H
-STOP Fluticasone propionate 110 mcg 2 puffs twice daily
-CONTINUE Glipizide 10 mg twice daily
-CONTINUE Metformin 500 mg four times a day
-CONTINUE Albuterol puffs every 4 hours as needed
-CONTINUE Ezetimibe 10 mg daily
-CONTINUE Hydrochlorathiazide 12.5 mg daily
-CONTINUE Isosorbide Mononitrate 30 mg daily
-CONTINUE Montelukast 10 mg daily
-CONTINUE Simvastatin 10 mg daily
-CONTINUE tiotropium 1 cap daily
-CONTINUE Valsartan 80 mg daily
-CONTINUE Ferrous Sulfate 325 mg twice daily
-CONTINUE Ascorbic acid mg twice daily
Please return to the hospital immediately if you experience an
more coughing of blood.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11789573", "visit_id": "20167936", "time": "2119-07-06 00:00:00"} |
16450721-DS-6 | 1,732 | ## ALLERGIES:
Aspirin / Motrin / Advil / Penicillins / Amoxicillin
## HISTORY OF PRESENT ILLNESS:
Ms. is a pleasant year old female with past medical
history of cirrhosis and scleroderma who presents with coffee
ground emesis. On , she vomited 500cc dark brown material
with several clots on a car ride from . She denies
wrenching and bright red blood.
.
Prior to this event, she denies any recent history of
nausea/vomiting, dysphagia or GERD. She denies NSAID use and
other anticoagulation medications. She does report melanotic
stools the past week and occasional BRBPR which she attributes
to her external hemorrhoids. She denies any episodes of syncope
or dizziness. She has felt weak the last few weeks, but
attributed this to her worsening scleroderma and cirrhosis
(unknown etiology).
.
Of note, her symptoms of ascites began in . Since
, she has had two paracentesis since for removal of
fluid. Per her report, neither have demonstrated evidence of
infection. Her most recent paracentesis was roughly two weeks
ago, at which time her daughter reports 5 liters were removed.
She reports worsening lower extremity edema. She was seen in
liver clinic by Dr. .
.
She presented to , where she was initiated on
octreotide and pantoprazole drips. During her time there,
reported to be hypotensive (unknown how low BP was), for which
she received 2 liters of IVF. She was then transferred to
for further management.
.
In the ED, initial vtial signs were: temperature of 97.6,
blood pressure 111/86, heart rate 10, respiratory rate of 16,
and oxygen saturation of 100%. NG lavage was completed and
notable for dark coffee ground material that did not clear;
there was no bright red blood. Pantoprazole and octreotide drips
were continued.
.
She was transfered to the MICU where she received 2U pRBC (Hct
22.9-currently stable at 35.1) and started on ciprofloxacin. She
was evaluated for upper GI bleed via NGL and EGD. On EGD showed
no signs of active bleeding, 2 cords of non-bleeding grade I
varices, gastritis, and severe esophagitis. She was started on
sucralafate. RUQ ultrasound showed evidence of cholelithiasis
with no evidence of cholecystitis, but no portal vein
thrombosis. She was note to have a leukocytosis to 23 which was
attributed to steriods, stress response, and possible infection.
CXR showed no consolidations and diagnostic paracentesis showed
no signs of infection.
.
On the floor, she appears comfortable, although complains of
sharp lower extremity and lower back pain. Of note, her bed
sheets are soaked around her abdomen which could be due to
recent paracentesis. She denies any recent episodes of vomiting,
diarrhea, (has been NPO), dysuria.
.
Review of systems:
(+) Per HPI. + Abdominal distension, + lower extremity and back
pain
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies constipation, abdominal pain, dysphagia. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
## PAST MEDICAL HISTORY:
- Scleroderma
- Cirrhosis of unknown etiology: Status-post two paracentesis,
last one several weeks ago, with 5L fluid withdrawal. No
episodes of SBP, encephalopathy, or bleeding. She saw Dr.
for the first time. Liver biopsy has not been
completed. History of positive 1:640
- Hypothyroidism
- Anemia of chronic disease
- Coagulopathy
- Cellulitis (multiple infections in lower extremities)
- Sinus tachycardia
- Mitral regurgitation (patient unaware)
- External hemorrhoids
- 'Heart burn' but no diagnosis of GERD
.
## FAMILY HISTORY:
No family history of liver disease, auto-immune disease. Lung
cancer history related to smoking, grandmother with type two
diabetes mellitus.
## GENERAL:
Alert, oriented, pleasant, no acute distress,
cachectic.
## HEENT:
Sclera anicteric, PERRL, EOMI. MMM and oropharnyx clear,
## NECK:
Flat neck veins. No lymphadenopathy.
## LUNGS:
scant bibasilar inspiratory crackles, no wheeze.
## CV:
Tachycardic. RR. Normal S1 + S2. No murmurs, rubs, or
gallops,
## ABDOMEN:
Soft, distended, no fluid wave. tympanic to percussion
in LLQ, non-tender w/o rebound or guarding.
## EXT:
Warm, well perfused, 2+ pulses. 2+ pitting edema to upper
shin.
## NEURO:
CN II-XII intact. Upper and lower extremity sensation
intact bilaterally
## SKIN:
Per nurses report, patient has two 1-2cm lesions on
gluteus
## IMPRESSION:
1. Massive ascites, with the largest collection marked in the
right lower
quadrant.
2. Shrunken cirrhotic liver.
3. 4 mm hypoechoic hepatic lesion within segment VI. In the
absence of any
available comparison studies at , a three month followup is
recommended.
4. Cholelithiasis with no evidence of cholecystitis.
5. Patent portal veins, hepatic veins, and hepatic arteries,
with appropriate
flow directions and waveforms.
## US IMPRESSION:
1. Massive ascites, with the largest collection marked in the
right lower
quadrant.
2. Shrunken cirrhotic liver.
3. 4 mm hypoechoic hepatic lesion within segment VI. In the
absence of any
available comparison studies at , a three month followup is
recommended.
4. Cholelithiasis with no evidence of cholecystitis.
5. Patent portal veins, hepatic veins, and hepatic arteries,
with appropriate flow directions and waveforms.
Therapeutic/diagnostic paracentesis:
GRAM STAIN (Final :
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
## MICU :
Patient is a female with past medical
history of cirrhosis and scleroderma who presents with coffee
ground emesis
## -HEMATEMESIS:
Coffee ground emesis secondary to likely upper GI
bleed. Upper endoscopy performed on day of admission notable
for old blood in stomach/small intestine, but no active
bleeding; non-bleeding grade I varices were seen. Severe
esophagitis and gastritis were observed. Sucralafate and PPI
were started. Pt had stable H/H. Liver team provided further
recommendations, including investigating possible hepatic
process, however, this was ruled out by abdominal US which
demonstrated patent portal veins, hepatic veins, and hepatic
arteries, with appropriate
flow directions and waveforms.
.
-Cirrhosis: Per report, unknown etiology. Unlikely alcohol
related given history. No clear offending medications on initial
review of her home list, though per yesterday's liver note,
prior use of minocycline (for scleroderma) is a consideration.
Ciprofloxacin was started as prophylaxis in setting of acute
ascites with plan for 5days of treatment. Diagnostic and
therapeutic paracentesis (3L) revealed no SBP, and
patient was given 25g albumin. GRAM STAIN (Final
POLYMORPHONUCLEAR LEUKOCYTES SEEN, NO MICROORGANISMS SEEN. Fluid
culture with no growth. The paracentisis site continued to drain
ascitic fluid. Ostomy care was provided. Liver Team saw patient
prior to discharge and reported that bag could be left in place
to drain ascitic fluid at time of discharge. Spironolactone was
continued to aid in diuresis. Lasix was discontinued secondary
to side effect of persistent diarrhea.
.
-Hypoechoic lesion in liver: Seen on RUQ US, and may
represent HCC vs other process. AFP was 3.0. Plan to follow-up
lesion as out-patient.
.
-Leukocytosis: Marked increase at admission that was normalizing
without intervention. Possible stress response secondary to
bleed as no obvious source of infection. No localizing symptoms.
No vital sign instability. However, blood and urine cx ordered
with results pending; paracentesis did not reveal source of
infection.
.
-Scleroderma: Followed by Dr. in rheumatology, but not
currently on tx. Minocycline was discontinued while in house and
at time of discharge due to concern that it may have contributed
to cirrhosis.
.
-Hypothyroidism: Continued home dose of levothyroxine
## MEDICATIONS ON ADMISSION:
- Calcium with vitamin D
- Nyastatin swish and swallow BID (currently not taking)
- Acetaminophen 500 mg BID
- Calan SR 60 mg daily (Verapamil)
- Levothyroxine 50 mcg daily
- Fluconazole 200 mg Q72 hr (currently not taking)
- Acidophilus 500 million cell BID
- Millipred 10 mg daily (prednisolone)- Stopped
- Hydrocodone 1 tab q6-8 hours
- Lactulose -- prescribed
- Spironolactone 50 mg -- prescribed
- Furosemide -- prescribed
## DISCHARGE MEDICATIONS:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
## 4. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Verapamil 40 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Hold for sedation, RR<12, SBP<95. Do
not take when driving or when operating heavy machinery.
11. Lactulose 10 gram/15 mL Solution Sig: Three (3) ML PO TID (3
times a day) as needed for prn for confusion: Take if patient
becomes confused, unsteady.
## FACILITY:
Diagnosis:
Primary diagnosis:
Gastritis
Esophagitis
Blood loss anemia secondary to upper GI bleed
Malnutrition
Cryptogenic cirrhosis
.
Secondary diagnosis:
Scleroderma
Tachycardia
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
You presented to the hospital after vomiting blood. You were
admitted to the intensive care unit (ICU) and monitored
overnight and received two units of blood. You underwent
endoscopy which revealed inflammation of your esophagus and
stomach. This inflammation was likely due to your underlying
scleroderma and your recent use of steroids. Your steroids were
discontinued and you were started on medications to help protect
your stomach. You had been collected fluid in your belly and a
procedure was performed to both help your symptoms as well as
test the fluid for any sign of infection. You were started on
antibiotics to cover for any intra-abdominal infections. Your
bleeding resolved and were transferred to the medicine floor. On
the medicine floor your blood counts remained stable. Physical
Therapy saw you and thought it would be beneficial to discharge
to a facility prior to returning home.
.
The following changes were made to your home medications:
STOP minocycline
STOP prednisone
START Ciprofloxicin 500mg taken by mouth once in the morning,
once at night - to be taken through .
START Pantoprazole 40mg taken by mouth once in the morning, once
at night
START Sucralfate 1gm taken by mouth four times a day.
START Oxycodone 2.5mg every four hours as needed for pain
management. Do not take this medication if driving or operating
heavy machinery as it has the potential for sedation.
START Lactulose 30ml as needed three times a day for increasing
confusion, unsteadiness.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16450721", "visit_id": "29622279", "time": "2132-05-06 00:00:00"} |
15194382-RR-19 | 132 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
with LOC, neck pain s/p assault// Please evaluate for
intracranial hemorrhage, cervical fracture
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
## FINDINGS:
There is no evidence of large territorial infarction,hemorrhage,edema,or mass
effect. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. Few benign appearing small
well-circumscribed calvarial lesions, stable since , likely represent
hemangiomas. Trace mucosal thickening paranasal sinuses. Otherwise, the
visualized portion of the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
## IMPRESSION:
No acute intracranial abnormality.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15194382", "visit_id": "N/A", "time": "2162-05-28 01:49:00"} |
19798988-RR-45 | 100 | ## EXAMINATION:
BILATERAL DIGITAL 2D SCREENING MAMMOGRAM, SYNTHESIZED 2D VIEWS,
AND 3D DIGITAL BREAST TOMOSYNTHESIS; INTERPRETED WITH CAD
## TISSUE DENSITY:
C- The breast tissue is heterogeneously dense which may
obscure detection of small masses.
A cardiac pacing device partially limits evaluation of the left upper breast
and axilla. There is no suspicious dominant mass, unexplained architectural
distortion or suspicious grouped microcalcifications. There are multiple
stable benign-appearing calcifications. There is no significant change.
## IMPRESSION:
No specific evidence of malignancy.
## RECOMMENDATION(S):
Age and risk appropriate screening.
## NOTIFICATION:
A summary letter will be sent to the patient with this result.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19798988", "visit_id": "N/A", "time": "2193-12-30 14:27:00"} |
15237286-RR-15 | 476 | ## INDICATION:
w IDDM, HTN s/p LRRT p/w in setting obstructive
hydronephrosis seen on ultrasound without evidence of stones.
## OPERATORS:
Dr. radiology fellow) and
Dr. radiology attending) performed the procedure. The
attending, Dr. supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings
## ANESTHESIA:
4 mg of midazolam was administered throughout the total
intra-service time of 35 min during which the patient's hemodynamic parameters
were continuously monitored by an independent trained radiology nurse. 1%
lidocaine was injected in the skin and subcutaneous tissues overlying the
access site.
## CONTRAST:
20 ml of Optiray contrast.
## PROCEDURE:
1. U ltrasound guided transplant renal collecting system access.
2. Antegrade transplant nephrostogram.
3. 8 percutaneous nephrostomy tube placement in a transplant kidney in
the left lower quadrant.
## PROCEDURE DETAILS:
Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per
protocol. The left lower quadrant was prepped and draped in the usual sterile
fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left renal collecting system was accessed through a dilated interpolar
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast outlined a
dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire
was advanced into the renal collecting system. After a skin , the needle
was exchanged for an Accustick sheath. One the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner dilator and
metallic stiffener. The wire and inner dilator were then removed and diluted
contrast was injected into the collecting system as a diagnostic antegrade
nephrostogram. A wire was advanced through the sheath and coiled in the
collecting system. The sheath was then removed and a 8 nephrostomy tube
was advanced into the renal collecting system. The wire was then removed and
the pigtail was formed in the collecting system. Contrast injection confirmed
appropriate positioning. The catheter was then flushed, 0 silk stay sutures
applied and the catheter was secured with a Stat Lock device and sterile
dressings. The catheter was attached to a bag.
The patient tolerated the procedure and transferred to the floor in stable
condition.
## FINDINGS:
1. Antegrade nephrostogram shows a moderate, 2 cm long, distal ureteral
stricture however contrast flows into the bladder.
2. Successful placement of a 8 percutaneous nephrostomy into the left
lower quadrant transplant kidney.
## IMPRESSION:
Moderate transplant kidney hydronephrosis related to a 2 cm distal ureteric
stricture, successfully drained with an 8 percutaneous nephrostomy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15237286", "visit_id": "21326173", "time": "2163-10-02 12:48:00"} |
10039708-DS-14 | 4,233 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HYPOTENSION
REASON FOR MICU TRANSFER:
Refractory hypotension, severe anemia
## INTUBATION:
Sigmoidoscopy
EGD
Tunneled hemodialysis line placement
Colonoscopy
## HISTORY OF PRESENT ILLNESS:
with a PMH of EtOH abuse, liver disease, hypothyroidism, and
hypertension who presents with hypotension and severe anemia.
The patient was seen at her PCPs office today for a a few days
of fatigue and weakness. There she was found to be hypotensive
to the 64/34, pulse 93. She was sent to by ambulance. She
has also been having diarrhea for the past few days with normal
stool color. She denies CP, SOB, Abd pain, N/V, dysuria. No hx
of GIB. No previous EGDs or colonoscopies.
Of note, the patient had a recent admission to
for dizziness and hypotension that responded to IVF. At that
time her H/H was 9.9/29, cr 1.3.
In the ED, initial vitals: 97.8 90 70/42 18 100% RA.
She was hypothermic in the ED to 34 degrees C after getting 3L
IVF; was given a bear hugger.
Labs were notable for: H/H 4.3/14.4 with MCV 107, PTT 140 with
INR 1.1, transaminitis with AST 168 and ALT 89, Tbili 0.7, alb
2.3, creatinine 2.9->2.5 (baseline 0.9), bicarb 8->11, VBG
7.25/33/40/15, lactate 2.1-> 1.5, neg UA.
Exam was significant for normal mentation and brown, guaiac
negative stool.
CXR was without acute findings, and CTA abd/pelvis was without
source of bleed, but showed hepatic steatosis, colitis versus
portal colopathy, and heterogenous kidneys.
A cordis was placed in the R femoral vein for resuscitation.
The patient was given:
13:12 IVF 1000 mL NS 1000 mL
13:53 IVF 1000 mL NS 1000 mL
15:23 IVF 1000 mL NS 1000 mL
15:34 IV Piperacillin-Tazobactam 4.5 g
15:34 PO Acetaminophen 1000 mg
15:34 IV BOLUS Pantoprazole 80 mg
16:16 IVF 1000 mL NS 1000 mL
16:16 IV Vancomycin 1000 mg
16:30 IV DRIP Pantoprazole Started 8 mg/hr
4 units pRBCs.
On arrival to the MICU, the patient's vitals were 97.8 77 81/43
18 99% on RA. She was persistently hypotensive to . She
was mentating well. She was given a total of 4L IVF and started
on levophed without blood pressure response. A-line was placed.
## PAST MEDICAL HISTORY:
'S ENCEPHELOPATHY
ASTHMA
TOBACCO DEPENDENCE
ALCOHOL DEPENDENCE
HYPOTHYROIDISM
HYPERTENSION
S/P BARIATRIC SURGERY
H/O ALCOHOLIC HEPATITIS
GOUT
## FAMILY HISTORY:
Family history significant for T2DM, HTN, hypothyroidism and
asthma.
## GENERAL:
Alert, oriented, no acute distress.
## NECK:
supple, JVP not elevated
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
## ABD:
soft, mildly distended, no tenderness to palpation.
## LINES:
right femoral CVL, right PIV, foley in place
## GENERAL:
NAD, ill appearing, awake and interactive
## HEENT:
AT/NC, MMM, NGT in place
## CHEST:
R anterior chest wall improved tenderness at tunneled HD
site. without erythema or fluctance.
## CARDIAC:
RRR, S1/S2, no murmurs, gallops, or rubs
## LUNG:
CTA in anterior and axillary fields
## ABDOMEN:
scaphoid. +BS, minimal tenderness diffusely
## EXTREMITIES:
RLE edema present 1+ to around mid thigh
asymmetrically w/ LLE with no edema.
## SKIN:
warm, DP 2+ b/l
## BNP:
12:04AM BLOOD
05:32AM BLOOD Ret Aut-6.0* Abs Ret-0.16*
04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217*
TotBili-1.0
04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8*
TRF-80*
03:06AM BLOOD Ferritn-2632*
11:10AM BLOOD %HbA1c-5.6 eAG-114
02:30PM BLOOD Triglyc-59
05:08PM BLOOD Osmolal-308
07:30PM BLOOD TSH-0.82
05:25AM BLOOD Cortsol-13.8
05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE
03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
02:39PM BLOOD ANCA-NEGATIVE B
05:41AM BLOOD AMA-NEGATIVE
05:41AM BLOOD
05:45AM BLOOD C3-88* C4-27
07:30PM BLOOD HIV Ab-Negative
05:27PM BLOOD ANTI-PLATELET ANTIBODY-Test
Test Flag Result Unit
Reference Value
-----
-----
-----
-----
-----
Platelet Ab, S Positive
Not Applicable
Comment
Antibody reacts with glycoprotein to HLA Class I, probable
alloimmunization due to pregnancy/transplant/transfusion.
12:00AM BLOOD COPPER (SERUM)-Test
Test Result Reference
Range/Units
COPPER 91 70-175 mcg/dL
12:00AM BLOOD ZINC-Test
Test Result Reference
Range/Units
ZINC 48 L 60-130 mcg/dL
11:55PM BLOOD VITAMIN B1-WHOLE BLOOD-Test
Test Result Reference
Range/Units
VITAMIN B1 (THIAMINE), 1118 H 78-185 nmol/L
BLOOD, LC/MS/MS
11:55PM BLOOD VITAMIN C-Test
Test Result Reference
Range/Units
VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL
09:10PM BLOOD SELENIUM-Test
Test Result Reference
Range/Units
SELENIUM 29 L 63-160 mcg/L
09:10PM BLOOD COPPER (SERUM)-Test
Test Result Reference
Range/Units
COPPER 34 L 70-175 mcg/dL
09:10PM BLOOD ZINC-Test
Test Result Reference
Range/Units
ZINC 32 L 60-130 mcg/dL
ZINC
Test Result Reference
Range/Units
ZINC (repeat on 27 L 60-130 mcg/dL
09:10PM BLOOD VITAMIN C-Test
Test Result Reference
Range/Units
VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL
09:10PM BLOOD CERULOPLASMIN-Test
Test Result Reference
Range/Units
CERULOPLASMIN 14 L mg/dL
06:35PM BLOOD VITAMIN B1-WHOLE BLOOD-Test
Test Result Reference
Range/Units
VITAMIN B1 (THIAMINE), >1200 H 78-185 nmol/L
BLOOD, LC/MS/MS
01:17PM BLOOD HEPARIN DEPENDENT ANTIBODIES-TEST
TEST RESULTS REFERENCE RANGE
UNITS
PF4 Heparin Antibody .10 0.00 - 0.39
01:17PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
10:28AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG &
IGM)-Test
Test Result Reference
Range/Units
PARVOVIRUS B19 ANTIBODY 8.48 H
(IGG)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
IgG persists for years and provides life-long immunity.
To diagnose current infection, consider Parvovirus
B19 DNA, PCR.
Test Result Reference
Range/Units
PARVOVIRUS B19 ANTIBODY <0.9
(IGM)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
Results from any one IgM assay should not be used as a
sole determinant of a current or recent infection.
Because IgM tests can yield false positive results and
low levels of IgM antibody may persist for months post
infection, reliance on a single test result could be
misleading. If an acute infection is suspected, consider
obtaining a new specimen and submit for both IgG and IgM
testing in two or more weeks. To diagnose current
infection, consider parvovirus B19 DNA,PCR.
11:56AM BLOOD T4, FREE, DIRECT DIALYSIS-Test
Test Result Reference
Range/Units
T4, FREE, DIRECT DIALYSIS 3.3 H 0.8-2.7 ng/dL
Urine studies:
09:33AM URINE Color-Yellow Appear-Cloudy Sp
09:33AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
10:39PM URINE RBC-151* WBC->182* Bacteri-FEW Yeast-NONE
Epi-2 TransE-1
01:20PM URINE AmorphX-FEW
09:33AM URINE Hours-RANDOM UreaN-332 Creat-101 Na-41
K-43 Cl-12 TotProt-171 Prot/Cr-1.7* Albumin-36.1 Alb/Cre-357.4*
## MICROBIOLOGY:
=============
11:53 pm STOOL CONSISTENCY: NOT APPLICABLE
## SOURCE:
Stool.
**FINAL REPORT
C. difficile DNA amplification assay (Final :
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
1:29 pm URINE Source: Catheter.
**FINAL REPORT
URINE CULTURE (Final :
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
9:07 am BLOOD CULTURE Source: Line-hd line.
## BLOOD CULTURE, ROUTINE (PENDING):
9:07 am BLOOD CULTURE Source: Line-aline 1 OF 2.
## BLOOD CULTURE, ROUTINE (PENDING):
3:39 pm Mini-BAL
GRAM STAIN (Final :
3+ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final :
YEAST. ~3000/ML.
## LEGIONELLA CULTURE (PRELIMINARY):
NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
## :
NEGATIVE for Pneumocystis jirovecii
(carinii).
## NOCARDIA CULTURE (PRELIMINARY):
NO NOCARDIA ISOLATED.
1:39 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final :
3+ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final :
Commensal Respiratory Flora Absent.
YEAST. ~3000/ML.
## FUNGAL CULTURE (PRELIMINARY):
YEAST.
ACID FAST SMEAR (Final :
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
## ACID FAST CULTURE (PRELIMINARY):
Negative results:
URINE URINE CULTURE-FINAL INPATIENT
Immunology (CMV) CMV Viral Load-FINAL
INPATIENT
SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
SWAB Chlamydia trachomatis, Nucleic Acid
Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC),
NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT
URINE Chlamydia trachomatis, Nucleic Acid
Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC),
NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT
STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL CULTURE -
R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL
INPATIENT
BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
URINE URINE CULTURE-FINAL INPATIENT
STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
**FINAL REPORT
C. difficile DNA amplification assay (Final :
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
- urine cultures x2
URINE CULTURE (Final :
YEAST. 10,000-100,000 ORGANISMS/ML..
URINE CULTURE (Final :
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
- blood cultures x2 - no growth
## FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
Chain sutures are noted in the left upper quadrant of the
abdomen.
## IMPRESSION:
No acute cardiopulmonary abnormality
## IMPRESSION:
1. No active extravasation of contrast to suggest active GI
bleeding at this time.
2. Profound hepatic steatosis. Enlarged periportal lymph nodes
with hazy
mesentery and retroperitoneum likely reflect underlying liver
disease.
3. Colonic and rectal wall thickening which may reflect colitis
versus portal colopathy.
4. Heterogeneous appearance of the kidneys with possible
striated nephrograms. Correlate with urinalysis to exclude
pyelonephritis.
TTE:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF = 65%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
The mitral valve leaflets are mildly myxomatous. Frank mitral
valve prolapse is not seen but cannot be excluded with
certainty. An eccentric, posteriorly directed jet of moderate
(2+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
## IMPRESSION:
1. Occlusive thrombus of all right lower extremity deep veins
from the common femoral vein down to the calf veins.
2. Patent left lower extremity veins.
ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears depressed (LVEF = 40%)
secondary to hypokinesis of the basal two-thirds of the left
ventricle. The apical one-third of the left ventricle is
hyperdynamic. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. The pulmonary artery is not well visualized.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of ,
left ventricular systolic dysfunction is now present. Findings
suggestive of stress cardiomyopathy with inverse Takotsubo
pattern of left ventricular contractile dysfunction.
## IMPRESSION:
1. There is mild progression of global cerebral atrophy since
the prior
examination of , greater than would be expected
for the
patient's age.
2. No intracranial hemorrhage or territorial infarct.
## IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
2. Trace ascites and small right pleural effusion.
## FINDINGS:
1. Patent normal sized, non-duplicated IVC with no evidence of
a IVC
thrombus. A small circumaortic renal vein originating from the
IVC just above the bifurcation was noted however is very small
in caliber and likely of no clinical significance.
2. Successful deployment of an infra-renal retrievable IVC
filter.
## IMPRESSION:
Successful deployment of an infra-renal removable IVC filter.
ECHO:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
## IMPRESSION:
Normal biventricular cavity sizes with preserved
regional and low normal global biventricular systolic function.
No valvular pathology or pathologic flow identified. Trivial
pericardial effusion.
Unilateral RLE veins
## IMPRESSION:
Extensive deep venous thrombosis involving the wall of the right
lower
extremity veins, overall similar to , but now with
perhaps minimal flow in the distal right SFV.
Video oropharyngeal swallow study
Aspiration with thin liquid consistency.
Portable abdomen x-ray
Patient is post gastric bypass surgery. The Dobbhoff tube ends
in the
proximal jejunum.
Renal ultrasound
No evidence of hydronephrosis. Increased renal echogenicity
consistent with diffuse parenchymal renal disease.
Small bilateral effusions and small to moderate volume ascites.
- EGD
Duodenum was not examined. Small gastric pouch consistent with
Roux en y anatomy the blind limb and jejunal limb were both
visualized. No varices. Otherwise normal EGD to the jejunum.
## BRIEF HOSPITAL COURSE:
hx gastric bypass surgery, alcohol abuse complicated by
Wernicke's encephalopathy, concern for autonomic insufficiency,
presented originally with hypotension, anemia and academia. Her
course in the MICU was complicated by severe nutritional
deficiency, volume overload, renal failure, cardiomyopathy,
hypoxemia and hypoxemic respiratory failure, and deep vein
thrombosis.
# Hypotension:
# Cardiomyopathy:
# Presumed alcoholic liver disease:
Patient was given 4u PRBCs in the ED prior to FICU admission;
her Hgb was stable for days afterward, and there was low
suspicion for active GIB initially in her MICU course. She was
empirically antiobiosed for concern of sepsis, but no source was
found, and these antibiotics were held until a series of
presumed aspiration events that will be discussed below. Morning
cortisol was within normal limits twice; TSH was also within
normal limits. She underwent several echocardiograms to explain
her persistent hypotension with pressor requirement that showed
in sequence: mitral regurgitation with eccentric jet; inverse
Takutsubo's cardiomyopathy; and then resolution of these issues.
Of note, the resolution occurred after initiation of high-dose
thiamine repletion, which may suggest an element of wet
beriberbi from severe nutritional deficiency in the setting of
gastric bypass and alcoholism. There was also strong suspicion
of cirrhosis given her imaging and alcohol abuse history, for
which she was started on midodrine. With these measures, she was
successfully weaned from pressors. Unresolved at the time of her
MICU discharge was a question of autonomic insufficiency raised
in her last Discharge Summary of where it was thought her
alcohol abuse could be contributing to baseline systolic
pressures in the . This in part resolved on the floor as the
patient was weaned off midodrine and maintained systolic blood
pressure in the 100s.
# Anemia:
-Unexplained, possible GI source with lack of erythropoietin in
the setting of subacute renal failure . Patient had decreasing
pRBC transfusion requirements over the course of her stay,
ultimately needing 1U pRBC every 4 days. She was evaluated by
Hem/Onc who felt there was no evidence of significant hemolysis
or malignancy and felt that there was an element of anemia of
chronic inflammation, as well as decreased erythropoietin in the
setting of subacute renal failure. She was evaluated by GI who
found no source of bleed on sigmoidoscopy early in her course
and no varices or bleeding on EGD. She had an episode of guaiac
positive stool but had no significant bleeding on colonoscopy.
Patient may benefit from outpatient capsule study if bleeding is
ongoing.
# Thrombocytopenia:
There was no evidence of active bleed on presentation (stool
normal color, not tachycardic, no clinical or radiographic
evidence of extravasation into a compartment). Surgery and GI
were consulted early in her MICU course for concern of ischemic
gut in the setting of rising lactate, but flexible sigmoidoscopy
was negative for this and lactate resolved with fluid
resuscitation. Hematology consulted, and believe her
anemia and thrombocytopenia are likely a combination of
alcoholic bone marrow suppression, malnutrition and critical
illness. She may benefit from a bone marrow biopsy when more
stable; additionally, given her renal failure, she may have a
developing EPO deficiency. She was transfused by ED prior to
MICU admission and did not require further blood products until
(gradually dropping Hct attributed to anemia of chronic
illness/inflammation/underproduction; she held her Hct each time
after transfusion).
# Diarrhea:
Negative c. diff, improved over the course of the hospital stay.
Possibly related to tube feeding formulas as this improved with
changing to a higher fiber formula and with the addition of
banana flakes. Recommend continued loperamide as needed and
optimization of tube feeds in patient s/p gastric bypass.
# Renal Failure (Addressed Separately Below):
Presented with serum bicarbonate of 8 of unclear etiology. She
manifested diarrhea in the early part of her ICU stay (C diff
assay negative, thought related to either alcohol abuse or early
course of antibiotics administered empirically for presumed
sepsis, resolved); her renal function markers may also have been
under-estimates of her true GFR given her nutritionally
deficient state. Acidemia corrected with bicarbonate drip, but
recurrence remains in a concern in the setting of her renal
failure with poor UOP. CRRT was started in the setting of volume
overload in the ICU as described above, though she was noted to
have ATN by muddy brown casts in her urine as well as
persistently poor UOP. At time of FICU discharge she is being
trialed off CRRT, though with her poor UOP she may need to be
initiated on standing dialysis. Upon transfer to the floor, her
renal function did not improve and she remained oliguric. She
was evaluated by nephrology who felt that ATN without renal
recovery was the most likely diagnosis based on her urine
sediment and history. A renal biopsy was considered, but
nephrology felt that the risks of the biopsy on a patient
already requiring heparin for DVT would outweigh the benefits
with the suspicion of ATN being high already. Urine output
remained low prior to discharge, and tunneled HD line was placed
for longer-term access.
# Respiratory Failure:
Patient developed progressive hypoxemia from volume overload
eventually requiring CRRT with resolution of the same. However,
on she had an unexplained hypoxemic respiratory episode
with persistent SpO2 measurements in the despite NRB and NC;
she was intubated with of continued O2 saturations in
the before resolution not attributable to any particular
intervention (nebs, suction, etc). This first hypoxemic episode
was attributed to aspiration though subsequent CXR and
bronchoscopy were not impressive for evidence of the same. She
was extubated within 24hrs, but then reintubated in the setting
of a break in her CRRT line that caused acute hypotension from
blood loss (trapped in the CRRT circuit) and then hypoxemia.
After restoration of hemodynamic stability and passing her RSBI,
she was again extubated, but re-intubated for nearly the same
exact sequence of events that evening(break in the CRRT circuit
due to equipment failure; this has been reported and is being
investigated). She was finally extubated on and remains
off supplemental O2 at time of MICU discharge. Antibiotics were
empirically started in the setting of possible aspiration with
leukocytosis (that could have been a stress reaction to
aspiration pneumonitis or intubations/exbuations); these will
finish on . She completed her course of antibiotics and
remained afebrile and without respiratory distress the rest of
her hospitalization.
# Alcohol Abuse:
Patient endorses heavy alcohol use. She was seen by social work
who gave resources, though patient is not interested in
counseling.
# Severe Nutritional Deficiency:
Nutritional deficiencies including zinc and selenium requiring
significant repletion. Repeat testing of zinc showed continued
need for repletion. Caloric needs and repletion addressed below.
## # SEVERE MALNUTRITION:
likely contributor to pancytopenia
resulting from bone marrow suppression. Required tube feeding
tube feed which was continued at discharge in order to meet her
caloric needs. She was initially found to aspirate thin liquids
by a speech and swallow evaluation, however on reevaluation
after receiving tube feeds for some time, she was able to
tolerate a regular diet and thin liquids. Her caloric intake by
mouth was not sufficient to decrease tube feeds.
# Hx Wernicke's Encephalopathy:
Patient had waxing/waning mental status for much of her early
hospital course which was initially attributed to delirium;
however, for history of Wernicke's she was started on high-dose
thiamine that seemed to improve her mental status. Nutrition was
consulted, and nutrition labs were sent that were all markedly
low. She was supplemented through her TFs and will need to
remain on standing thiamine.
# Deep Vein Thrombosis:
Patient arrived to MICU with L femoral CVL; shortly thereafter,
asymmetric R > L lower extremity swelling was noticed for which
was obtained - this showed extensive venous clot burden in
the R lower extremity. IV heparin was started. Because of
persistent thrombocytopenia, an IVC filter was placed, though
because of her high clot risk IV heparin was continued. She
should have interval follow-up of her DVTs after discharge, as
well as scheduled follow-up with for filter removal. She was
maintained on a heparin drip and should be bridged to Coumadin
to follow up with hematology/oncology as an outpatient.
# Concern for Gastrointestinal Bleed:
As described above, GI and Surgery were consulted early in her
MICU stay for rising lactate and concern of gut ischemia in the
setting of her hypotension; flexible sigmoidoscopy was
unimpressive and lactate improved with pressors and IVF. Near
the end of her FICU stay she had fresh blood coating a stool
which raised concern for GIB; however, her Hct was stable, she
was HD stable, and guaiacs of subsequent stools were negative
prior to MICU discharge. She underwent evaluation by Hepatology
and EGD which showed no varices, negative colonoscopy. Capsule
study failed, but patient's H/H stabilized and hepatology felt
the study could be done as an outpatient if necessary.
**Transitional:**
## TRANSITIONAL ISSUES:
-Patient will need daily assessment for hemodialysis needs, EPO
with HD given renal failure
-Reassess nutritional status and continued need for tube
feeding, potential need for G-tube
-Daily electrolytes and every other day CBC to evaluate need for
blood transfusion
-Patient on heparin gtt for DVT. Recommend bridge to coumadin
-Needs appointment with OBGYN for Mirena IUD removal. Pt states
this was places at least years ago.
-encourage smoking/alcohol cessation
-f/u for potential IVC filter removal in the future
-Outpatient hepatology f/u, consider outpatient capsule study
-Outpatient Hematology f/u with Dr.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 2.5 mg PO DAILY
3. Albuterol Inhaler PUFF IH Q4H:PRN shortness of breath
4. Levothyroxine Sodium 50 mcg PO DAILY
## DISCHARGE MEDICATIONS:
1. Cyanocobalamin 50 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO BID
4. Albuterol Inhaler PUFF IH Q4H:PRN shortness of breath
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Heparin IV per Weight-Based Dosing Guidelines
## TARGET PTT:
60 - 100 seconds
7. Nephrocaps 1 CAP PO DAILY
8. Warfarin 5 mg PO DAILY16
first dose
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Sarna Lotion 1 Appl TP PRN itching
## PRIMARY:
acute oliguric renal failure, deep vein thrombosis,
anemia, thrombocytopenia, hypothyroidism
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure caring for you at the
. You were hospitalized with low blood pressure
and low blood counts. You were treated with blood transfusions,
kidney replacement therapy, and antibiotics. You were found to
have a blood clot in your leg and are being treated with blood
thinning medications. Your platelets were low but these
recovered. Your kidney function has not recovered prior to
leaving the hospital and you will be discharged with a
hemodialysis line. You were evaluated for GI bleeds, and these
studies were reassuring. If you continue to bleed, you may
benefit from a capsule study as an outpatient.
Best wishes,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10039708", "visit_id": "28258130", "time": "2140-02-26 00:00:00"} |
12752192-RR-12 | 336 | ## HISTORY:
female with epigastric pain, prelim report from
read as gastric volvulus with area of incarceration.
## FINDINGS:
The heart is normal in size. There is atelectasis noted at the
lung bases bilaterally.
There is mesenteroaxial volvulus of the stomach with the gastric antrum and
pylorus located within the chest. The intraabdominal stomach is dilated and
contains oral contrast material. No oral contrast is seen within the
intrathoracic portion of the stomach or small bowel, and findings are
consistent with outlet obstruction. The stomach wall enhances normally with no
evidence of pneumatosis or perforation. There is a small amount of free fluid
adjacent to intrathoracic portion of the stomach. The small and large bowel is
normal in appearance. The patient is status post cholecystectomy. The liver,
spleen, and pancreas are normal in appearance. There is a bilateral striated
nephrograph appearance of the kidneys. There is no free fluid or free air
within the abdomen. There is atherosclerotic disease of the descending aorta.
## CT PELVIS:
There are no pelvic masses or lymphadenopathy. There is
diverticulosis of the sigmoid colon without evidence of diverticulitis. There
is a 2.4-cm left adnexal cyst and a small amount of free fluid within the
endometrial canal of the uterus. The bladder is normal in appearance.
## CT BONE WINDOWS:
No suspicious lytic or sclerotic lesions are noted. There
is degenerative change noted throughout the spine.
## IMPRESSION:
Mesenteroaxial gastric volvulus with intrathoracic location of the gastric
antrum and pylorus. Dilatation of the abdominal portion of the stomach and
absence of oral contrast within the small bowel are worrisome for gastric
outlet obstruction. No evidence of perforation or strangulation.
Striated appearance of the bilateral kidneys, which is nonspecific but can be
seen with pyelonephritis. Correlation with UA is recommended.
2.4-cm left adnexal cyst and fluid in the endometrial canal, the latter of
which may be due to cervical stenosis. A followup pelvic ultrasound is
recommended in three months.
These findings were communicated to Dr. on at 10:30 a.m.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12752192", "visit_id": "26096850", "time": "2182-10-29 09:05:00"} |
12200987-RR-76 | 166 | ## INDICATION:
year old woman with history of IVDU and right buttock
abscesses
## FINDINGS:
Ultrasound examination in the area of concern within the right lateral buttock
demonstrates a 1.8 x 0.9 x 2.2 cm ill-defined complex appearing fluid
collection. This appears increased when compared to prior study. There is a
0.6 cm hyperechoic focus adjacent to the collection, previously present, and
thought to reflect a calcified injection granuloma. New since prior
examination, there is a 1.8 x 1.1 x 1.4 cm cystic structure. Overlying edema
appears decreased when compared to prior examination. Hypoechoic tracts are
identified coursing for the skin surface.
## IMPRESSION:
Ultrasound examination in the right lateral buttock demonstrates two focal
fluid pockets the largest 2.2 cm in dimension, thought to reflect prior fluid
pockets, increased in size. Another smaller pocket within the right posterior
lower back is additionally identified, not visualized on prior study. If
indicated, an MR can be performed for better evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12200987", "visit_id": "22919285", "time": "2132-09-12 11:56:00"} |
13496199-RR-11 | 141 | ## EXAMINATION:
EARLY OB US <14WEEKS
## INDICATION:
year old woman with no IUP on u/s but slow rising HCG// r/o
ectopic
## FINDINGS:
No intrauterine pregnancy is visualized. The uterus is anteverted and
measures 8.5 x 3.5 x 5.7 cm. Again seen is heterogeneous debris within the
C-section scar, however there is increased echogenicity with internal color
Doppler vascularity within it concerning for retained vascularized products of
conception related to a C-section scar ectopic. The vascularized portion
measures 1.8 cm. The peak velocity 16 centimeters/second. The subjacent
myometrium measures 3 mm in thickness.
The ovaries are unremarkable with a corpus luteum on the right. There is no
free fluid.
## IMPRESSION:
Vascularized retained products of conception within the C-section scar
compatible with an ectopic pregnancy. The vascularized portion measures 1.8
cm.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13496199", "visit_id": "N/A", "time": "2142-06-27 10:04:00"} |
15777665-RR-10 | 154 | ## EXAMINATION:
ABDOMEN US (COMPLETE STUDY)
## INDICATION:
year old woman with right abdominal and adnexal pain //
evaluate abdomen and right ovary
## LIVER:
The hepatic parenchyma appears within normal limits.The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD measures 4 mm.
## GALLBLADDER:
There is no evidence of stones or gallbladder wall thickening.
## PANCREAS:
The pancreas is mostly obscured by overlying bowel gas.
## SPLEEN:
Normal echogenicity, measuring 7.1 cm.
## KIDNEYS:
The right kidney measures 11.7 cm. The left kidney measures 11.9 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones or hydronephrosis in the
kidneys.
## RETROPERITONEUM:
Visualized portions of aorta and IVC are within normal
limits.
## IMPRESSION:
The pancreas is not seen. Otherwise unremarkable abdominal ultrasound.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15777665", "visit_id": "N/A", "time": "2129-04-28 12:25:00"} |
19901341-RR-57 | 89 | ## EXAMINATION:
Knee (AP, lateral, oblique) bilateral
## INDICATION:
year old woman with fall and knee pain // concern for fx
## LEFT KNEE:
No acute fracture or dislocation. There is diffuse osteopenia.
No significant degenerative changes. There is extreme diffuse muscle atrophy.
Vascular calcifications are noted. No suprapatellar joint effusion.
Right knee:No acute fracture or dislocation. There is diffuse osteopenia. No
significant degenerative changes. There is extreme diffuse muscle atrophy.
Vascular calcifications are noted. No suprapatellar joint effusion.
## IMPRESSION:
Diffuse osseous demineralization muscle wasting. No acute fracture or
dislocation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19901341", "visit_id": "24115002", "time": "2168-04-12 17:41:00"} |
16712364-DS-21 | 2,034 | ## ALLERGIES:
aspirin / NSAIDS / Haldol / Seroquel
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Left medial knee skin biopsy
## HISTORY OF PRESENT ILLNESS:
h/o schizophrenia, DM2, COPD, HTN, , and sinus
tachycardia p/w rash x 5 days and hyponatremia (Na 119) x 1 day.
1) Hyponatremia - Na 119 incidentally discovered at outpatient
cardiology appointment 1 day PTA. She was also found to have BP
of 80/50. Of note, she was prescribed lasix 40mg BID (from 40mg
daily) on and lost her several weeks ago. Last Na 141
on , never hyponatremic in past per our records.
2) Rash - patient states her arms and legs have been become
progressively covered in non-pruritic but tender erythematous
skin lesions for the past 4 days. She states her apartment was
"exterminated" 1 month ago, but that she was sleeping at
friend's house for several days around the time when the
lesion's over , and does not know if her friend has
bed bugs. She denies being biten by bugs, recent travel, or
being out in the woods. She states she has had dermatitis in the
past usually worsened by detergents that has been similar in
presentation. She reports seeing a dermatologist in before
and using topical treatments as well as special detergent that
she has been unable to obtain recently because of cost.
In the ED, her initial vitals were stable. Chem7/CBC/UA/urine
lytes were obtained. She was fluid restricted and sent to the
floor with stable vitals on transfer.
On the floor, reports some lightheadedness when rising quickly
from bed and mild chronic headache slightly worsened by the
light, but denies confusion, lethargy, or change of her baseline
mental status. Reports baseline neck pain, back pain, and cough.
## PAST MEDICAL HISTORY:
-COPD, exacerbation
-Schizophrenia
-Diabetes mellitus type 2
-Overactive bladder
-HTN
-Marijuana/Tobacco abuse
-bilateral ureteritis
-s/p fall
-right hand numbness
-resting tachycardia of unclear source
## FAMILY HISTORY:
Mother, aged , no reported medical conditions
Sister, aged , no reported medical conditions
Sister, aged , no reported medical conditions
Sister, aged , no reported medical conditions
Sister, aged , no reported medical conditions
Patient reports not knowing her father, one son died aged of
heroin overdose, other son in with no known medical
conditions.
## GEN:
Alert, oriented, lying in bed on her L side in no acute
distress, pleasant, appropriate, somewhat odd affect
## HEENT:
NCAT, dry mucus membranes, EOMI, sclera anicteric, OC/OP
clear
## NECK:
supple, no JVD, no LAD
## CV:
RRR, normal S1/S2, no m/r/g
## ABD:
soft, NT/ND, normoactive bowel sounds, no rebound or
guarding
## EXT:
WWP, 2+ pulses palpable bilaterally, no c/c/e
## NEURO:
CN II-XII intact, motor function grossly normal
## SKIN:
taut skin on hands, several homogenously erythematous
patches with distinct borders distributed along flexor and
extensor surfaces of arms and legs, mildly tender to palpation
but not pruritic
## GENERAL:
Alert, orientedx3, cooperative, in no acute distress
## HEENT:
NC AT, PERRLA, EOMI, dry mucus membranes, anicteric
sclerae, oropharynx clear
## NECK:
supple, no JVD, no palpable lymphadenopathy, thyromegaly
or palpable thyroid nodules
## PULM:
Coarse expiratory breath sounds throughout, mild wheezes
bilaterally, no accessory muscle use
## COR:
RRR, normal S1,S2, no MRG
## ABDOMEN:
soft, non-tender, non-distended, no rebound or
guarding, no palpable hepatosplenomegaly, +BS
## EXTREMITIES:
WWP, 2+ radial, posterior tibial, and dorsalis
pedis pulses bilaterally, no C/C/E
## SKIN:
Several erythematous, non-pruritic, well demarcated
patches along both flexor and extensor surfaces over arms and
legs, mildy tender to palpation. Numerous pruritic chronic
papules in arms and legs that have been scratched. New rash
appears less erythematous and is tender to palpation than
yesterday.
## BRIEF HOSPITAL COURSE:
with a history of schizophrenia, DM2, COPD, HTN, dCHF, and
sinus tachycardia who presents with rash of 5 days duration and
hyponatremia (Na 119) discovered after a routine outpatient
electrolyte panel one day PTA.
#Hyponatremia
Serum sodium was 119 on day prior to admission, 120 in ED on day
of admission. In years of our records, her serum sodium had
previously been normal. Given urine lytes showing low sodium,
## FENA:
0.2, BUN/creat>20, physical exam with dry mucus membranes,
her BP of 80/50 at cardiology clinic, SBP in in ED, recent
increase in lasix dose to 40mg BID, and recent loss of her ,
this is most consistent with hypovolemic hyponatremia. She
remained asymptomatic throughout her hospitalization without
confusion, seizures, change in mental status or signs of
hyponatremia. Her serum sodium was gently normalized with normal
saline.
#Rash
She presented with scattered excoriated papules on the legs and
distal arms, which she reports are pruritic and gets every year
close to time, and has had for ~1 month this year. She
was concerned regarding a second, acute onset rash consisting of
several erythematous, non-pruritic, indurated, well demarcated
patches along both flexor and extensor surfaces over arms and
legs, mildy tender to palpation. Dermatology was consulted and
punch biopsy of rash was performed, which on preliminary
interpretation were consistent with erythema nodosum. Work-up of
erythema nodosum so far has led to normal LFTs, Tbili, AlkPhos,
lipase, and negative ASO titers, negative throat for strep. CXR
revealed mild-to-moderate interstitial pulmonary edema, but not
evidence of pneumonia, mycobacterial, or fungal infection.
Though she cannot take NSAIDs for treatment given allergic
reaction with throat swelling, potassium iodide is an
alternative therapy. However, given she is asymptomatic and
improving, it was decided to begin treatment only if she becomes
symptomatic. She will follow-up with dermatology two weeks after
discharge.
## #RESPIRATORY DISTRESS:
On , she became acutely dyspneic,
tachypneic, tachycardic, hypertensive, and hypoxic (79% RA), was
given nebulizers and oxygen and eventually nonrebreather, lung
exam with poor airflow, ABG was 7.49/41/65 on NRB, CXR showed
diffuse pulmonary edema, lasix 40mg given. EKG showed no
evidence of ischemia. She was transferred to the MICU for
further management of hypoxia, but was quickly stabilized on
BiPap and Lasix and was back on the floor the following day,
satting well on room air since the day before. Lisinopril 10mg
PO daily was restarted, furosemide was restarted at a lower dose
of 20mg PO daily, and blood pressures, respiratory rate, and
O2sat remained stable. This episode was most likely due to flash
pulmonary edema, since x-ray findings were consistent with
development of interval moderate pulmonary edema, furosemide had
been held and several liters of fluid had been given to her over
the previous several days, and her blood pressure was elevated
at 150/90 (compared to baseline SBPs . Continuous
oxygen monitoring revealed oxygen saturations in the when
sleeping, and she may need a sleep study to potentially diagnose
obstructive sleep apnea.
#CHF acute on chronic diastolic
She sleeps on four pillows at home. She sleeps on two pillows in
the hospital and raises the head of the bed. Denied PND,
orthopnea, but reports both occur if she sleeps flat. During her
hospitalization, she was placed on 2g sodium heart healthy diet,
and remained euvolemic throughout. She was discharged on
furosemide 20 mg PO daily and will follow-up with her PCP within
one week.
## #FEVER:
On during episode of respiratory distress
likely caused by flash pulmonary edema, she spiked a temperature
to 102.8. She had previously been afebrile since admission.
Etiologies considered include pulmonary infection, rash, urinary
tract infection, as well as non-infectious causes. No overt
cause was identified. Remained afebrile for the remainder of
hospitalization. Blood cultures pending at time of discharge.
#COPD
Her COPD remained at baseline throughout her hospital course.
She reported baseline SOB and cough. She has an episode of
severe respiratory distress on likely caused by flash
pulmonary edema for which she was transferred to the MICU for
one day. Her COPD symptoms improved as all her home meds were
continued including albuterol, advair, and spiriva. CXR while in
house was consistent with mild to moderate pulmonary edema.
# DM2
Glyburide was held and she was switched to humalog insulin
sliding scale while in house. %HbA1c was 6.9, eAG
151. Blood glucose was well controlled during hospitalization.
She was discharged on off her home dose of glyburide 10mg bid,
and will follow-up with her PCP regarding restarting.
# Schizophrenia
Her schizophrenia was well-controlled while in-house. She denied
delusions, hallucinations, suicidal ideation, homicidal
ideation, and other symptoms throughout her hospitalization. We
continued all her home meds including risperdal, mirtazepine,
fluoxetine, clonazepam, buspirone, and zolpidem.
# Back Pain
Back pain was at baseline and well controlled throughout
hospitalization with home meds including vicodin, gabapentin,
baclofen, and lidoderm patch.
# Hypertension
Her blood pressure remained stable, and well-controlled
throughout most of her hospitalization. She had a blood pressure
of 80/50 in cardiology clinic on the day prior to admission, SBP
in in ED. Her lisinopril 10mg daily was held given
hypotension on down to SBP 88. On in
setting of tachypnea, tachycardia and likely flash pulmonary
edema, she became hypertensive to 165/98, and was transferred to
MICU and given 40mg IV lasix and 5mg IV metoprolol. Her blood
pressure quickly stabilized. She was transferred back to
medicine floor on with SBPs stabilized on for
the remainder of her hospitalization. She was discharged on her
home dose of lisinopril 10mg daily and a lower dose of
furosemide of 20mg PO daily.
TRANSITIONAL ISSUES
#Follow up final left medial knee biopsy results
#Follow-up with dermatology regarding final pathology results
and possible treatment with potassium iodide (NSAIDs
contraindicated given allergy). However, rash has improved
significantly since admission, she is not symptomatic and rash
is no longer erythematous or tender to palpation. We decided not
to treat with potassium iodide in house since lesions
significantly resolving and not symptomatic
#Follow up blood cultures x4, MRSA screen
#Restart glyburide 10mg bid as appropriate
#Follow-up serum electrolytes including sodium
#Follow-up with cardiology regarding furosemide dose. Currently
on furosemide 20 mg PO daily
#Consider sleep study given oxygen desaturations at night
#Follow-up
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea, wheezing, cough
2. Baclofen 20 mg PO TID
3. BusPIRone 30 mg PO BID
4. Clonazepam 1 mg PO QID
5. Fluoxetine 80 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Furosemide 40 mg PO BID
8. Gabapentin 900 mg PO TID
9. GlyBURIDE 10 mg PO BID
10. Hydrocodone-Acetaminophen (5mg-500mg) 1.5 TAB PO Q6H:PRN
pain
11. HydrOXYzine 10 mg PO Q6H:PRN itch, anxiety
12. Lidocaine 5% Patch 1 PTCH TD DAILY
13. Lisinopril 10 mg PO DAILY
14. Mirtazapine 30 mg PO HS
15. Risperidone 1 mg PO BID
16. Tiotropium Bromide 1 CAP IH DAILY
17. Zolpidem Tartrate 10 mg PO HS
## DISCHARGE MEDICATIONS:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea, wheezing, cough
2. Baclofen 20 mg PO TID
3. BusPIRone 30 mg PO BID
4. Clonazepam 1 mg PO QID
5. Fluoxetine 80 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Gabapentin 900 mg PO TID
8. Hydrocodone-Acetaminophen (5mg-500mg) 1.5 TAB PO Q6H:PRN pain
9. HydrOXYzine 10 mg PO Q6H:PRN itch, anxiety
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Mirtazapine 30 mg PO HS
12. Risperidone 1 mg PO BID
13. Tiotropium Bromide 1 CAP IH DAILY
14. Zolpidem Tartrate 10 mg PO HS
15. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
## REFILLS:
*0
16. Lisinopril 10 mg PO DAILY
## DISCHARGE DIAGNOSIS:
hypovolemic hyponatremia, erythema nodosum, flash pulmonary
edema, acute on chronic diastolic heart failure
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure participating in your care at . You were
diagnosed with low sodium in your blood, which we corrected by
carefully giving you intravenous fluids. Your rash was biopsied
by our dermatologists and was found to be "erythema nodosum,"
which is a non-specific finding that should be (and already is)
resolving without need for treatment. You also had an episode
of fluid in your lungs ("pulmonary edema") that was corrected in
our intensive care unit.
You should follow-up with your primamry care physician on
, our dermatologists on , and our
cardiologists on .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16712364", "visit_id": "28195894", "time": "2171-06-27 00:00:00"} |
11887824-RR-13 | 198 | ## INDICATION:
History of cholecystectomy, sphincterotomy, and biliary duct
stent for sphincter of Oddi dysfunction. Presenting with three weeks of right
lower quadrant and lower back pain.
## CT ABDOMEN:
The lung bases are clear. The visualized portions of the heart
and pericardium are unremarkable. The liver enhances homogenously and there
is no focal liver lesion. The hepatic and portal veins are patent.
Cholecystostomy clips are noted in the gallbladder fossa. The pancreas,
spleen, and adrenals are normal. The kidneys enhance symmetrically and
excrete contrast without evidence of hydronephrosis or mass. The stomach and
small bowel are unremarkable. There is no portacaval, mesenteric, or
retroperitoneal lymphadenopathy. There is no free air or free fluid.
## CT PELVIS:
The appendix is normal (602B:33). Surgical clip is noted in the
right lower quadrant (2:61). The colon, rectum, uterus, and adnexae are
unremarkable. There is no pelvic lymphadenopathy or free fluid.
## OSSEOUS STRUCTURES:
The iliac side of the left SI joint is mostly sclerotic
(2:70) and may be degenerative. There is no osseous lytic or blastic lesion
worrisome for malignancy.
## IMPRESSION:
1. No CT findings to explain patient's abdominal pain.
2. Degenerative changes of the left SI joint.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11887824", "visit_id": "N/A", "time": "2121-02-14 21:08:00"} |
10374990-RR-109 | 314 | ## INDICATION:
Prior radiation therapy for Hodgkin's disease in mantle,
para-aortic, and splenic ports. Patient now having exudation of yellowish
fluid from the skin but with no open wound. New pleural effusion identified
on recent chest radiograph.
## FINDINGS:
Small dependent right pleural effusion is new. Numerous areas of
subpleural scarring are consistent with prior radiation to multiple ports
(including splenic). These are particularly noticeable in the bilateral
apices, the lingula, and in the left lower lobe. Within an area of
post-radiation fibrosis in the right apex medially, a 9mm X 5 mm solid nodular
opacity has developed along a site of a previous linearly oriented area of
scarring (4:54). Numerous pulmonary nodules measuring up to 7 mm are all
stable since (4:41,112,117,149).
Absence of the right internal jugular vein is described in concurrent CT neck
report. Dilated, air-filled esophagus has been present since and again
likely represents dysmotility. The heart and great vessels are noteworthy
only for coronary, mitral annular, and aortic calcifications. Though not
tailored for subdiaphragmatic evaluation, the imaged portions of the upper
abdomen are noteworthy for surgical material near the head of the pancreas.
## OSSEOUS STRUCTURES:
Collapse of the superior endplate of T6 is stable since
. There is no lytic or blastic lesion worrisome for malignancy.
## IMPRESSION:
1. New small non-hemorrhagic right pleural effusion
2. Please correlate with concurrent CT-Neck in regards to absence of the
right interal jugular vein.
3. New 9 mm focal area of nodularity contiguous with an area of linear
scarring at the right apex medially at a site of radiation fibrosis. Consider
short term follow up CT in 3 months or PET-CT to exclude a small lung cancer
developing in a site of previous radiation treatment.
4. Multiple stable pulmonary nodules dating back to .
5. Stable dilated air-filled esophagus suggestive of dysmotility.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10374990", "visit_id": "N/A", "time": "2185-09-11 07:28:00"} |
14361933-RR-128 | 154 | ## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN)
## INDICATION:
evidence of portal vein thrombosis?
## LIVER:
The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass.There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation.
## GALLBLADDER:
The patient is status post cholecystectomy.
## PANCREAS:
The pancreas is not well visualized, largely obscured by overlying
bowel gas.
## KIDNEYS:
Limited views of the kidneys show no hydronephrosis.
## RETROPERITONEUM:
Visualized portions of IVC are within normal limits. The
aorta is not well evaluated.
## DOPPLER EVALUATION:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 26 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
## IMPRESSION:
Patent hepatic vasculature. No evidence of portal vein thrombosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14361933", "visit_id": "N/A", "time": "2162-07-29 08:14:00"} |
15627304-RR-10 | 100 | ## HISTORY:
male with suspicion for overdose and change of mental
status. Status post seizure, now intubated. Assess for acute intracranial
injury.
## FINDINGS:
There is no acute intracranial hemorrhage, mass effect, edema,
major vascular territorial infarct. The ventricles and sulci are normal in
size and appearance. There is periventricular white matter hypodensity, more
prominent in the parietal region, likely secondary to chronic microvascular
ischemia. There is no acute fracture. There is minimal mucosal thickening in
the paranasal sinuses, with scattered opacification of ethmoid air cells. The
mastoids air cells are clear bilaterally.
## IMPRESSION:
No acute intracranial hemorrhage or fracture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15627304", "visit_id": "22400980", "time": "2167-04-20 07:28:00"} |
19594599-RR-14 | 101 | ## INDICATION:
female with upper abdominal pain and fever. Evaluate
for pneumonia.
## CHEST, PA AND LATERAL VIEWS:
There is opacity in the right middle lobe and
left mid lung consistent with infection. There is no pleural effusion or
pneumothorax. The heart size is normal. Mediastinal silhouette, hilar
contours and pulmonary vasculature are unremarkable.
## IMPRESSION:
Right middle lobe pneumonia and possible second focus of
infection in the left mid lung. Recommend radiographic follow up 4 to 6 weeks
after therapy to ensure resolution.
Findings discussed with at 7:40 AM at which time the patient was
discharged, but treated for pneumonia.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19594599", "visit_id": "N/A", "time": "2195-01-01 01:46:00"} |
19420422-RR-29 | 257 | ## INDICATION:
Lower abdominal pain and chills, assess for appendicitis.
## CT ABDOMEN WITH CONTRAST:
Imaged lung bases are clear without focal opacity,
pleural or pericardial effusion.
Hypodensity is again demonstrated in segment II of the liver (2:14), unchanged
from prior study and too small to be characterized. There is no intra- or
extra-hepatic biliary ductal dilatation. The portal veins are patent with
minimal periportal edema. The gallbladder, pancreas, spleen, and bilateral
adrenal glands are unremarkable. The kidneys enhance and excrete contrast
symmetrically without hydronephrosis. The stomach is somewhat decompressed.
The small bowel is unremarkable. The appendix is seen and is normal. The
proximal colon is unremarkable.
There is mild apparent wall thickening in the transverse and descending colon
which likely reflects underdistension, however, mild colitis cannot be
excluded. The sigmoid colon is redundant and stool-filled, but otherwise
unremarkable. There is no free air or free fluid in the abdomen. There is no
mesenteric or retroperitoneal adenopathy. The aorta and major branches appear
patent.
## CT PELVIS WITH CONTRAST:
The bladder, uterus, adnexa and rectum are
unremarkable. There is no free pelvic fluid. There is no pelvic or inguinal
adenopathy.
## OSSEOUS STRUCTURES:
There is no lytic or sclerotic bony lesion concerning for
osseous malignant process. The previously demonstrated nerve stimulator device
has been removed.
## IMPRESSION:
1. Normal appendix.
2. Mild apparent wall thickening of the transverse colon likely related to
underdistension. However, in the appropriate clinical a mild colitis is not
excluded. Etiologies would most likely be infectious or inflammatory with
ischemic much less likely.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19420422", "visit_id": "N/A", "time": "2193-02-07 18:17:00"} |
11313297-DS-5 | 997 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
Unstaged low-grade serous neoplasm of GYN origin
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Total laparoscopic hysterectomy, omentectomy, peritoneal
biopsies
## HISTORY OF PRESENT ILLNESS:
woman who was found to have fullness on her pelvic
exam in . She was advised to undergo imaging for
further evaluation; however, delayed doing this. In , a repeat exam again confirmed pelvic fullness and she
underwent an ultrasound on , which revealed a
right-sided ovarian complex cyst measuring 10 cm and a left
complex mass measuring 6 cm. The CA-125 was normal at 14.5.
On , she underwent a laparoscopic bilateral
salpingo-oophorectomy and washings with lysis of adhesions.
Findings were notable for smooth peritoneal surfaces with no
obvious abnormalities in the upper abdomen. In the pelvis, both
ovaries were replaced by multicystic nodular masses grossly
consistent with cystadenofibromas. The right ovary was dominant
and measured about approximately 12 cm. It was densely adherent
to the posterior pelvic peritoneum as well as the uterosacral
ligament. The left ovary was slightly smaller, but also solid
and cystic in nature. The uterus itself was small and normal in
appearance. Grossly, the left ovary was sent for frozen section
and was without worrisome features.
Microscopic evaluation and final pathology revealed a low-grade
serous neoplasia involving the left fallopian tube as well as
the right ovary and fallopian tube. Of note, tumor was composed
of small papillae of mildly atypical serous epithelium with
surrounding stromal reaction, with prominent psammomatous
calcification. The tumor was negative for p53 and the
morphology was consistent with a low-grade neoplasia consistent
either with a borderline tumor or a low-grade carcinoma.
Invasion was
difficult to characterize, but low-grade serous carcinoma was
favored. Tumor was also seen on concurrent pelvic washing
cytology. The origin of the neoplasm was uncertain.
Gynecologic origin was confirmed by PAX8 expression. The tumor
may have arisen in the right serous cystadenoma with auto
implants and spread to the pelvic peritoneum or possibly arising
along the peritoneum and foci of endosalpingiosis. Given the
tumor in both tubes, an endometrial primary could not be
entirely excluded.
She was advised to have further surgery for staging. Prior to
proposed surgery, she a had an endometrial biopsy to evaluate
for endometrial origin. Biopsy showed atrophic endometrium and
an endocervical polyp. She also had a CT torso which showed:
1. Multiple hypodensities in the liver, 1 of which is likely a
cyst, 1 of which is too small to characterize definitively, and
a 1.6 cm segment IV a lesion is likely benign
2. Status post bilateral salpingo oophorectomy. No evidence of
local recurrence.
## PAST MEDICAL HISTORY:
AVM with the intracerebral bleed and
seizure activity, hypercholesterolemia. Her health maintenance
is notable for a normal mammogram in . She has never
undergone colonoscopy.
## PAST SURGICAL HISTORY:
back surgery at in .
## OB HISTORY:
She is a G2 P2 with normal spontaneous vaginal
deliveries in and .
## GYNECOLOGIC HISTORY:
Her last menstrual period was in .
She denied any postmenopausal bleeding. Her last Pap smear was
in , which was normal and she has never had an
abnormal Pap smear. She did undergo surgical tubal ligation.
She denies any hormone replacement use. She denies any
significant gynecologic infections or issues in the past or
present.
## FAMILY HISTORY:
Family history is negative for any breast, ovarian, uterine or
colon cancers.
## PHYSICAL EXAM:
On day of discharge:
Afebrile, vitals stable
No acute distress
## CV:
regular rate and rhythm
## PULM:
clear to auscultation bilaterally
## ABD:
soft, appropriately tender, nondistended, incisions
clean/dry/intact, no rebound/guarding
## GU:
pad with minimal staining
## BRIEF HOSPITAL COURSE:
Ms. was admitted to the gynecologic oncology service after
undergoing Total laparoscopic hysterectomy, omentectomy,
peritoneal biopsies for staging. Please see the operative report
for full details.
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with IV Toradol + PO
Tylenol/oxycodone prn. Her diet was advanced without difficulty
and she was transitioned to ibuprofen once tolerating PO. On
post-operative day #1, her urine output was adequate so her
Foley catheter was removed and she voided spontaneously.
For her seizure disorder, she was continued on her
phenobarbitol. Her blood pressure remained within normal limits
throughout her hospitalization.
By post-operative day 1, 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:
1. PHENObarbital 32.4 mg PO TID
## DISCHARGE MEDICATIONS:
1. Acetaminophen mg PO Q6H:PRN Pain - Mild
Do not take more than 4000mg a day
RX *acetaminophen 500 mg tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice per day
Disp #*60 Tablet Refills:*1
3. Ibuprofen 600 mg PO Q6H:PRN Pain
Please take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*1
4. OxyCODONE (Immediate Release) mg PO Q4H:PRN Pain -
Moderate
cause sedation. Do not take with alcohol or while driving
RX *oxycodone 5 mg tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
5. PHENObarbital 32.4 mg PO TID
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
Laparoscopic instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* 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.
* Nothing in the vagina (no tampons, no douching, no sex) for
weeks.
* No heavy lifting of objects >10 lbs for 4 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11313297", "visit_id": "24740380", "time": "2158-08-22 00:00:00"} |
19245855-DS-6 | 1,910 | ## ALLERGIES:
Compazine / Droperidol / Desipramine / Zoloft / Influenza Virus
Vaccine / Celexa / Maxalt-MLT / Trazodone
## HISTORY OF PRESENT ILLNESS:
F with one week of sharp LLQ pain that is progressively
getting worse. Initially began in LLQ and has progressed such
that it now radiates to the groin and low back. Pain is constant
and not associated with food. She was seen at last th
where she was diagnosed with diverticulitis based on clinical
exam and was started on cipro/flagyl. Pain has failed to improve
despite abx therapy. She denies vomiting, diarrhea, vaginal
bleeding/discharge, bloody stools, dysuria, chills, recent
weight loss, recent sexual intercourse, sick contacts, recent
travel. Has one prior episode of diverticulitis in the past
years ago with similar symptoms. Also with hx of bilateral hip
fractures secondary to osteoperosis, requiring replacement on
the left and placement of pins in the right. Reports that her
groin pain feels very much like her previous hip fracture.
Denies any recent trauma or strenous exercise. No skin rashes.
In the ED, initial VS were: 98.3 71 146/78 16 100%. Labs were
notable for HCT of 33 (consistent with prior), but were
otherwise unremarkable. CT of the abdomen and pelvis showed no
inflammatory or acute process. Bedside US showed no evidence of
hydronephrosis, no gallstones, mild gallbladder sludge. Patient
was given 1L NS, dilaudid and morphine for pain and admitted for
further management. Vitals on transfer were 98.3 71 146/78 16
100%.
On arrival to the floor, patient reports that her abdominal and
groin pain is , and has improved with dilaudid. Notes HA
consistent with prior migraines with associated photophobia and
some mild nausea.
## REVIEW OF SYSTEMS:
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
## PAST MEDICAL HISTORY:
-migraines
-asthma
-GERD
-HL
-LBP
-uterine fibroids
-osteoporosis at years old, menapause at . Refused to take
reclast due to potential side effects. Stopped taking Forteo
because of side effects (neck pain).
-sleep apnea
-depression
-spondylolisthesis
-H/O in - not related to swine flu vaccine.
Reports being clumpsy with difficulty with balance since
-Ruptured R ovarian cyst in requiring laparoscopic repair
-Fractured L wrist requiring several surgeries
-Total L hip replacement in due to a fall during a
blizzard. L hip had to be revised again in
because had trouble walking. Has intermittent groin pain that
goes away. Saw his orthopedics last year (Dr. .
-R hip needed 3 pins in due to avascular necrosis during
pregnancy. Had surgery while 6 months pregnant.
## FAMILY HISTORY:
Sister with breast cancer, father with CHF and lymphoma
## PHYSICAL EXAM:
ADMISSION PHYSICAL EXAM
VS - Temp 98.3F, BP 151/90 , HR 58 , R18 , O2-sat 100% RA
GENERAL - unconfortable appearing female
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
## BACK:
no CVA or spinal tenderness
ABDOMEN - NABS, soft/ND, mild ttp in LLQ, no rebound, no
guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Full range of motion of L hip (as allowed by her
prosthesis). Full range of motion of R hip
## L HIP:
bruise underlying L hip
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM
VS - Temp 98.1F, BP 108/76 , HR 70 , R16, O2-sat 100% RA
GENERAL - slightly uncomfortable appearing female
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
## BACK:
no spinal tenderness
ABDOMEN - NABS, soft/ND, mild ttp in LLQ and epigastric area, no
rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses. Full range of
motion of L hip (as allowed by her prosthesis). Full range of
motion of R hip
## L HIP:
healing bruise underlying L hip
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, sensation to soft touch and pinprick
intact throughout
## PERTINENT RESULTS:
ADMISSION LABS
05:23PM BLOOD WBC-4.3# RBC-3.65*# Hgb-11.7*# Hct-33.4*#
MCV-92 MCH-31.9 MCHC-34.9 RDW-12.9 Plt
05:23PM BLOOD Neuts-46.4* Lymphs-43.9* Monos-7.2
Eos-1.6 Baso-0.9
05:23PM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-141 K-3.5
Cl-108 HCO3-26 AnGap-11
05:23PM BLOOD ALT-14 AST-17 AlkPhos-61 TotBili-0.3
05:23PM BLOOD Lipase-13
05:23PM BLOOD Albumin-4.2
05:23PM BLOOD CRP-1.4
06:15AM BLOOD ESR-5
05:27PM BLOOD Lactate-0.6
DISCHARGE LABS
06:30AM BLOOD WBC-4.2 RBC-3.72* Hgb-12.0 Hct-33.7*
MCV-91 MCH-32.2* MCHC-35.5* RDW-12.6 Plt
06:30AM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-139
K-3.5 Cl-101 HCO3-29 AnGap-13
06:30AM BLOOD Calcium-9.3 Phos-5.0* Mg-1.8
URINE
02:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MICRO
BLOOD CULTURE - PENDING
BLOOD CULTURE - PENDING
BLOOD CULTURE - PENDING
URINE URINE CULTURE- NO GROWTH
IMAGING
CT ABDOMEN AND PELVIS WITH CONTRAST
Mild pleural thickening is noted posteriorly in the bilateral
lung
bases, unchanged compared to . No concerning lung nodule
identified.
Mild periportal edema noted, likely related to resuscitative
efforts. Stable hypodense lesions in hepatic segments I and VI
demonstrate peripheral puddling of contrast consistent with
hemangiomas. No intrahepatic biliary ductal dilatation. The
common bile duct is slightly prominent but tapers smoothly to
the level of the pancreatic head, unchanged compared to .
No gallstones are identified. The pancreas is atrophic with
interdigitating fat. No large lesion identified. The spleen
and bilateral adrenal glands are normal. The bilateral kidneys
are without masses or hydronephrosis. No hydroureter
identified. The bladder is minimally distended but grossly
normal. The uterus is retroverted but otherwise normal. Adnexa
are normal. Deep pelvic
structures are somewhat limited due to artifact from a left
total hip
replacement, but no large abnormalities are identified. Trace
free fluid
identified within the pelvis (2:55).
The stomach and small bowel are unremarkable. The appendix is
visualized and normal. Scattered diverticula are noted without
inflammatory change to suggest diverticulitis. Large fecal load
identified.
The aorta is of normal caliber throughout. The hepatic and
portal veins are patent. No lymphadenopathy identified.
No suspicious lytic or blastic lesions identified. Bialteral
pars defects noted with Grade I anterolisthesis of L5 on S1.
## IMPRESSION:
1. Diverticulosis without diverticulitis. Appendix is normal.
No evidence of cholecystitis. No cause of patient's acute
abdominal pain identified.
2. Mild periportal edema, likely reflecting resuscitative
efforts.
3. Bilateral pars defects with Grade 1 anterolisthesis of L5 on
S1.
## BRIEF HOSPITAL COURSE:
yo female with a hx of diverticulitis and L hip replacement
who presents with LLQ abdominal pain x 1 week radiating to lower
back and groin.
# LLQ abdominal pain - Unclear etiology. No clear pathology seen
on CT - no nephrolithiasis, hip prosthesis misalignment,
inflammatory/infectious process, ischemia, fracture, ovarian
pathology, or nerve compression. Pt afebrile without
leukocytosis, CRP and ESR not elevated, UA negative. Prosthesis
appears well placed on CT and patient is able to walk without
problems, which rules out a hip etiology. LFTs wnl. No rashes to
suggest zoster. Bimanual pelvic exam negative for masses or
cervical tenderness. Patient has a history of spondylothesis and
CT noted Grade 1 anterolisthesis of L5 on S1. However, pain is
mostly in L1 region with no neuro deficits/tingling/numbness to
suggest a neuropathic pain. Per PCP, patient had several
complaints of abdominal pain with multiple negative workup in
the past. She was first started on IV dilaudid and switched to
oxycodone, but with only very mild improvement. CT noted large
fecal load, and patient was given stool softeners and enemas to
attempt bowel movements. Reported no improvement in her pain
after several bowel movements. CT also showed some trace free
fluid in the pelvis, which was thought to be a result of
possible diverticulitis that was beginning to resolve as patient
had already completed 4 days of antibiotics before arriving to
the hospital. She was continued on cipro and flagyl with plan to
complete a 10 days course for diverticulitis treatment. She will
follow up with her PCP next week.
# Migraine- patient with symptoms c/o prior migraines. No
concerning findings on neuro exam. She was continued on home
fioricet as needed and on home verapamil.
# Osteoporosis- she was continued on vitamin D while
hospitlized, but stated that she is no longer taking it at home.
Has refused to take reclast in the past due to possible side
effects. Was previously on Forteo but stopped due to side
effects.
# Anemia- Hct remained at baseline, without evidence of bleeding
# Asthma - controlled and not on any medications
# GERD- controlled and has not needed medication for several
years
## # TRANSITIONAL:
-PCP:
please follow up with results of blood cultures and
continue to monitor abdominal pain
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 180 mg PO Q 12H
hold for SBP < 100
2. Acetaminophen-Caff-Butalbital 1 TAB PO TID:PRN pain
3. Vitamin D 1200 UNIT PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
6. Clonazepam 0.5 mg PO QHS:PRN insomnia
hold for oversedation
## DISCHARGE MEDICATIONS:
1. Acetaminophen-Caff-Butalbital 1 TAB PO TID:PRN pain
2. Ciprofloxacin HCl 500 mg PO Q12H
Please take for a total of 10 days (last day on
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Twice a
day Disp #*10 Tablet Refills:*0
3. Clonazepam 0.5 mg PO QHS:PRN insomnia
hold for oversedation
4. MetRONIDAZOLE (FLagyl) 500 mg PO TID
Please take for a total of 10 days (last day on
RX *metronidazole 500 mg 1 tablet(s) by mouth Three times a day
Disp #*15 Tablet Refills:*0
5. Vitamin D 1200 UNIT PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
## DURATION:
1 Doses
please hold for oversedation
RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours as needed
for pain Disp #*15 Tablet Refills:*0
7. Verapamil SR 180 mg PO Q 12H
hold for SBP < 100
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
## DISCHARGE DIAGNOSIS:
Primary Diagnosis
Abdominal pain
Hip pain
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
It was a pleasure taking care of you during your hospitalization
at . You were admitted to
the hospital becasue of left lower quadrant abdominal pain
radiating to your groin and back. A CT scan of your abdomen was
done which did not show any abnormalities with your colon,
ovaries, kidneys, uterus, hip bones, hip prosthesis, or spine.
It is possible that you had diverticulitis and it is beginning
to resolve. Please continue with your antibiotics for a total of
10 days (last day on .
You are scheduled to see your primary care physician next week
(please see below).
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19245855", "visit_id": "25102462", "time": "2156-11-07 00:00:00"} |
19809073-RR-112 | 388 | ## EXAMINATION:
MRI BRAIN AND ORBITS
## INDICATION:
hx of AML with relapsed sarcoma past avidity of left facial and
inferior orbital nerve. Pt with recurrent facial numbness. Please evaluate //
hx of AML with relapsed sarcoma past avidity of left facial and inferior
orbital nerve. Pt with recurrent facial numbness. Please evaluate
## FINDINGS:
There is enlargement and abnormal enhancement involving the inferior orbital
nerve along its visualized course along the left orbital floor posteriorly to
the pterygopalatine fossa. There is abnormal enlargement of the foramen
rotundum on the left when compared to the right (07:20). Enhancement is less
obvious given artifact from adjacent sphenoid sinus, regardless, the finding
is worrisome for perineural tumor extension. Evaluation for interval changes
also difficult given lack of high-resolution on the prior exam.
In addition, there is abnormal enhancement and enlargement of the mandibular
division of the trigeminal nerve at the level of the foramen ovale. Abnormal
enhancement is also seen to involve Meckel's cave on the left (12:5).
Findings are worrisome for all perineural tumor spread. There is no apparent
involvement of the cisternal portion of the trigeminal nerve.
In addition, there is a T2 hyperintense enhancing nodule overlying the left
masseter (11:2 and 13:15) which measures 1.1 x 0.8 cm which was not clearly
present on most recent prior exam. There had however been abnormal enhancing
tissue in this region on older prior exams including exam from .
In addition, linear enhancement is seen along the course of the left facial
nerve at its intra parotid course suspicious for perineural tumor spread.
Scattered subcortical and periventricular FLAIR hyperintense foci in the
subcortical white matter are visualized without associated enhancement. These
are nonspecific, commonly due to chronic small vessel disease. Scattered
opacified mastoid air cells are noted.
## IMPRESSION:
1. Evidence of perineural tumor spread along the left infraorbital nerve,
extending in a retrograde fashion along the second division of the trigeminal
nerve to the level of Meckel's cave.
2. Additional involvement of the third division of the left trigeminal nerve
from Meckel's cave through foramen ovale.
3. Abnormal enhancement overlying the left masseter, new since prior and not
as extensive as on previous exams from . Linear enhancement
extending back along the course of the left facial nerve also worrisome for
perineural tumor spread.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19809073", "visit_id": "N/A", "time": "2199-04-05 16:26:00"} |
15731682-RR-154 | 140 | ## LEFT KNEE:
No acute fractures or dislocations are seen.There is
chondrocalcinosis suggestive of CPPD arthropathy. There is moderate medial
and lateral joint space narrowing. There is severe patellofemoral joint space
narrowing. There is been resolution of the knee joint effusion since the
study. There is mild demineralization.There are vascular
calcifications.
## RIGHT KNEE:
No acute fractures or dislocations are seen.There has been
interval development of a very large knee joint effusion since the prior
study. There is a 2.6 x 1.3 cm ossific density behind the patella, likely a
loose body. There is some remodeling of the anterior cortex of the distal
femur.There is chondrocalcinosis suggestive of CPPD arthropathy. There is
moderate joint space narrowing medially and laterally. There are small spurs
within the three compartments. There are vascular calcifications.
## IMPRESSION:
As above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15731682", "visit_id": "N/A", "time": "2151-12-10 10:14:00"} |
19239322-RR-38 | 101 | ## FINDINGS:
The right costophrenic angle is not fully included on the image. Given this,
there is opacity at the left costophrenic angle with lateral left base opacity
which may be due to pleural effusion with atelectasis and/or pleural
thickening. No definite focal consolidation is seen. The cardiac and
mediastinal silhouettes are stable. There may also be a trace right pleural
effusion/pleural thickening. No pneumothorax is seen.
## IMPRESSION:
Left costophrenic angle not fully included on the image. Opacity at the
peripheral bilateral lung bases, left greater than right, may be due to
pleural effusions and/or pleural thickening.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19239322", "visit_id": "29917781", "time": "2138-06-09 10:34:00"} |
12161795-RR-19 | 325 | ## HISTORY:
Multifocal hepatocellular carcinoma with tumor thrombus extending
into pulmonary system, on chemotherapy.
## FINDINGS:
Known pulmonary embolism in right lower lobe pulmonary arterial branches (7:17
and 220) appear unchanged. A small embolus in the right upper lobe is no
longer apparent. No new filling defects are appreciated.
The extent of enhancing thrombus in the right atrium has mild-to-moderately
decreased with a more conspicuous cap of hypodense material that may represent
a focus of bland thrombus. Compared to previous axial of the tumor
thrombus, which were 32 x 29 mm immediately above the superior vena cava, the
comparable measurement on this examination is 29 x 23 mm. The heart is
borderline in size.
Mildly prominent right hilar lymph nodes appear unchanged. There is no
mediastinal lymphadenopathy. No enlarged lymph nodes are identified in the
supraclavicular or axillary regions. There is no pleural or pericardial
effusion.
There is again a calcified granuloma in the right upper lobe (6:43). An
irregular opacity in the right upper lobe, measuring 13 x 11 mm (6:48), is
unchanged. A mixed attenuation bronchovascular nodule in the left upper lobe
(7:180) is unchanged at 4-5 mm.
Scattered ground glass nodules, predominantly involving the upper lobes and
generally measuring about 6-8 mm in diameter, appear unchanged. These may be
due to sequela of small distal emboli versus other causes such as respiratory
bronchiolitis that can be seen commonly in smokers, if applicable, but is not
suggestive of parenchymal metastatic disease and these appear stable.
Please see the separate report for findings regarding the abdomen and pelvis
from the same day.
There are no suspicious lytic or blastic bone lesions.
## IMPRESSION:
1. Decreased size of tumor thrombus in the right atrium.
2. Stable pulmonary findings including pulmonary emboli in the right lower
lobe, few small nodules, and scattered ill-defined ground-glass nodules in the
upper lobes, the latter probably inflammatory or vascular in etiology.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12161795", "visit_id": "N/A", "time": "2130-08-09 11:13:00"} |
15443439-RR-52 | 485 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
year old woman with bloody drain output, h/o complex abdominal
surgery including open sigmoidectomy, LOA, right oophorectomy, SBR, end
diverting colostomy // please evaluate for acute intraabdominal process given
bloody drain output, acute drop hct
## SINGLE PHASE SPLIT BOLUS CONTRAST:
MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
## IV CONTRAST:
130 mL Omnipaque.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
## LOWER CHEST:
There are moderate bilateral pleural effusions, larger on the
right than on the left, with associated compressive atelectasis. Effusions
have decreased in size slightly since the recent examination. The heart is
mildly enlarged. Small free abdominal and pelvic fluid is noted.
## HEPATOBILIARY:
The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains gallstones and
shows minimal gallbladder wall edema, which is likely reactive in nature. The
gallbladder wall thickness at the fundus is normal.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
## GASTROINTESTINAL:
A transesophageal tube terminates in the stomach. Slightly
increased fluid is seen in the parent gastric region in comparison to the most
recent study. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. Contrast material is seen within the small bowel.
No extraluminal contrast is identified. The patient is status post
sigmoidectomy and and colostomy. The appendix is not visualized.
## PELVIS:
The bladder is decompressed with Foley catheter. Again noted is small
to moderate free pelvic fluid, is not significantly increased since recent
comparison. The majority of the fluid is a low-density. Two pelvic drains
are seen, one terminating in the right lower quadrant, and one terminating in
the midline.
## REPRODUCTIVE ORGANS:
The uterus is surgically absent. There are no adnexal
masses.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
## BONES:
There is no evidence of worrisome osseous lesions or acute fracture.
## SOFT TISSUES:
A large subcutaneous defect is noted along the anterior
abdominal wall, related to recent laparotomy. Packing material is seen within
the anterior abdominal wound. There is significant, generalized body wall
edema. No drainable subcutaneous fluid collection is noted.
## IMPRESSION:
1. No abdominal or pelvic hematoma or other CT findings to explain patient's
drain output.
2. Overall similar examination to with slightly increased
fluid in the upper abdomen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15443439", "visit_id": "22088878", "time": "2156-08-14 12:25:00"} |
18626202-DS-10 | 662 | ## CHIEF COMPLAINT:
Left thyroid nodule with cytology suspicious for malignancy.
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Total thyroidectomy, parathyroid autotransplantation,
intraoperative nerve monitoring.
## HISTORY OF PRESENT ILLNESS:
The patient is a man with a previous medical history
significant for obesity,status post gastric bypass years
ago. The patient also has paroxysmal atrial fibrillation, for
which he is on Coumadin. The patient now presents with a
large,approximately 6 cm, left-sided thyroid nodule from which a
recent ultrasound-guided fine-needle aspiration biopsy yielded
cytology that was suspicious for malignancy, and the
differential diagnosis includes a papillary carcinoma versus
follicular neoplasm. After discussion of different management
options for the large left-sided thyroid nodule,the patient
presents today for total thyroidectomy. Risks and benefits
associated with the procedure have been discussed in great
detail, and the consent form has been signed.
## PAST MEDICAL HISTORY:
afib, Gastric bypass years ago
## GENERAL:
well appearing, NAD, clear phonation
## HEENT:
no hematoma, dressing C/D/I, no neck fullness
## ABDOMEN:
soft,nontender, nondistended, normoactive bowel sounds
## BRIEF HOSPITAL COURSE:
Mr. is a year old male who is status post total
thyroidectomy. Patient tolerated the procedure well and after a
brief stay in the PACU,was admitted overnight to the inpatient
general surgery unit. Patient postoperative course was stable.
Patient had no perioral or lower extremity tingling or numbness.
Patient had good pain control and was transition to oral pain
medication. POD 1, Calcium level was checked which was 7.9 and
he received calcium and vitamin D supplement. His diet was
advanced to regular as tolerated. Patient was voiding without
difficulty and ambulating independently. Patient was discharged
home in good condition and will follow-up with in
clinic.
## MEDICATIONS ON ADMISSION:
simvastatin 20 mg PO daily,omeprazole 20 mg PO daily,sertraline
250 mg PO daily,coumadin 2 mg PO daily.
## DISCHARGE DIAGNOSIS:
Left thyroid nodule with cytology suspicious for malignancy.
## DISCHARGE INSTRUCTIONS:
You have adequate pain control and have tolerated a regular diet
and may return home to continue your recovery. You will be
discharged home on thyroid medication levothyroxine, take 112
mcg daily. You will also need to take calcium (tums) and vitamin
D supplement(calcitriol),please take as prescribed. Please
monitor for signs and symptoms of low Calcium (hypocalcemia)
which include tingling or numbness especially around the mouth
and in the fingers and feet,and muscle cramps. If you experience
any of these signs or symptoms you may take an extra dose of
Tums, however if symptoms continue please call Dr.
and call the office or go to emergency room for severe
symptoms. Please have your Calcium level drawn on . Your blood work can be drawn at on the
floor (you do not have to wait for the results). Your follow-up
visit with Dr. is scheduled for
as listed below.
Please resume all regular home medications, unless specifically
advised not to take a particular medication and take any new
medications as prescribed. Please restart your Coumadin today
and follow-up with your provider for monitoring of your
INR level and Coumadin dosing. You will be given a prescription
for narcotic pain medication, take as prescribed. It is
recommended that you take a stool softner such as Colace while
taking oral narcotic pain medication to prevent constipation.
You may also take acetaminophen (Tylenol) as directed, but do
not exceed 4000 mg in one day. Please get plenty of rest,
continue to walk several times per day, and drink adequate
amounts of fluids.
Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site. You may shower and wash incisions with a mild
soap and warm water.Avoid swimming and baths until cleared by
your surgeon.Gently pat the area dry.You have a neck incision
with steri-strips in place, do not remove, they will fall off on
their own.
Thank you for allowing us to participate in your care!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18626202", "visit_id": "28646380", "time": "2139-11-29 00:00:00"} |
13747594-RR-48 | 52 | ## INDICATION:
Faint punctate radiopaque densities seen in the upper posterior
right breast on one of the MLO projections on the screening mammogram of
.
## IMPRESSION:
No mammographic evidence of malignancy in the right breast.
Patient can resume annual screening mammography, and this was explained to the
patient.
BI-RADS 1 -negative.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13747594", "visit_id": "N/A", "time": "2148-07-19 15:19:00"} |
17049363-RR-56 | 203 | ## HISTORY:
man with alcoholic cirrhosis.
## FINDINGS:
Note is made that this is a limited ultrasound due to patient's
body habitus. No focal liver lesion is identified. No biliary dilatation is
seen and the common duct measures 0.4 cm. The portal vein is patent with
hepatopetal flow. Small gravel-like gallstones are again seen within the
gallbladder. The pancreas and midline structures, including the aorta, are
obscured from view by overlying bowel gas. The IVC is unremarkable, but is
only minimally visualized. The spleen is at the upper limits of normal,
measuring 12.4 cm. No hydronephrosis is seen. The right kidney measures 10.9
cm and the left kidney measures 11.7 cm. There is a small amount of ascites
seen in the right upper quadrant. No ascites is seen in the lower quadrants.
Incidentally there is layering echogenic material noted within the urinary
bladder.
## IMPRESSION:
1. Small amount of ascites seen only in the right upper quadrant.
2. No focal liver lesion is identified. Note is made that visualization of
the liver is limited due to patient's body habitus.
3. Cholelithiasis.
4. Layering echogenic material incidentally noted within the urinary bladder,
which could be blood or sediment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17049363", "visit_id": "22170148", "time": "2138-10-13 08:31:00"} |
16078217-RR-7 | 112 | CHEST RADIOGRAPH PERFORMED ON
Compared with prior study from .
## CLINICAL HISTORY:
man with no past medical history, with coughing
for two weeks.
## FINDINGS:
PA and lateral views of the chest are obtained. The lungs remain
clear bilaterally demonstrating no evidence of pneumonia. As previously
noted, within the left lung apex, a thin-walled cystic structure is again
noted which abuts the pleura and measures approximately 3 cm. There is no
pneumothorax. The cardiomediastinal silhouette is unremarkable. The
visualized osseous structures are intact.
## IMPRESSION:
1. No acute intrathoracic process.
2. Thin-walled cystic structure in the left lung apex, likely a bulla or
cyst. CT corrlation may be obtained to further evaluate.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16078217", "visit_id": "N/A", "time": "2154-05-02 17:46:00"} |
16807878-DS-6 | 1,293 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Robotic sigmoid colectomy, left Laparoscopic
Salpingo-oophrectomy, with drainage of pelvic abscess
## HISTORY OF PRESENT ILLNESS:
recently diagnosed with sigmoid diverticultis w/ phlegmon
extending to left adnexa in after she presented with
LLQ pain. She as admitted for 3 days, and completed a course of
augmentin for 10days. Her symptoms improved, until , she
began having copius vaginal discharge. She went to the ER, a
repeat CTAP was done and showed mild improvement. She was
discharged with 10day course of levaquin and flagyl.
She presents now for elective sigmoid resection.
## PMHX:
Peptic Ulcer s/p Billroth II w Dr.
Acute necrotizing esophagus, "black esophagus"
Diverticulosis
GERD
Anemia of chronic disease
Hyperlipidemia
Essential hypertension
Gastroesophageal reflux disease
## PSHX:
Billroth II w Dr.
Colonoscopy multiple diverticuli
Remote ex-lap LOA for endometriosis
## FAMILY HISTORY:
Significant family hx of breast cancer: sister died of breast
cancer and nieces with diagnoses, however, patient
negative for mutation; dad with peptic ulcers; and no hx of
colon cancer.
## GENERAL:
in no acute distress
## HEENT:
no facial swelling or plethora. mucus membranes moist
## CHEST:
mild SC emphysema, resolving
## ABD:
incisions healing well. JP removed, stitch left in place.
appropriately tender to palpation
## BRIEF HOSPITAL COURSE:
The patient was admitted to the colorectal surgery after an
elective robotic sigmoid resection, left salpingo-oophorectomy
and drainage of a pelvic abscess. The patient tolerated the
procedure well.
## NEURO:
Post-operatively, the patient received Dilaudid PCA with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
## CV:
The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
## PULMONARY:
The patient developed a moderate amount of
subcutaneous emphysema and was extubated in the PACU with normal
end-tidal CO2. The patient was stable from a pulmonary
standpoint; vital signs were routinely monitored.
## GI/GU:
Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced from sips to
clears on POD#1, which she tolerated well; this was eventually
advanced to a regular diet after return of flatus. Her foley was
removed on POD#1. Intake and output were closely monitored. Her
JP was removed prior to discharge.
## ID:
Post-operatively, the patient was started on zosyn given her
pelvic abscess. Cultures were sent off, with gram stain showing
gram negative rods with negative anaerobic cultures. The
patient was discharged on a course of Augmentin. The patient's
temperature was closely watched for signs of infection.
## PROPHYLAXIS:
The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#2, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO QHS
2. Calcium Carbonate 500 mg PO TID GERD
3. zoledronic acid-mannitol-water 5 mg/100 mL injection Yearly
4. Simvastatin 20 mg PO QPM
5. Metoclopramide 20 mg PO QHS
6. Pantoprazole 40 mg PO Q12H
7. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
8. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
## DISCHARGE MEDICATIONS:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Do not drive or drink alcohol while taking this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
2. Simvastatin 20 mg PO QHS
3. Amoxicillin-Clavulanic Acid mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 Tablet by mouth
Twice Daily Disp #*20 Tablet Refills:*0
4. Calcium Carbonate 500 mg PO TID GERD
5. Lisinopril 5 mg PO QHS
6. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
7. zoledronic acid-mannitol-water 5 mg/100 mL injection Yearly
8. Metoclopramide 20 mg PO QHS
9. Pantoprazole 40 mg PO Q12H
## DISCHARGE DIAGNOSIS:
Complicated sigmoid diverticulitis with pelvic abscess
## DISCHARGE INSTRUCTIONS:
Robotic Sigmoid Colectomy
You were admitted to the hospital after a Robotic Sigmoid
Colectomy with LSO and drainage of a pelvic abscess for surgical
management of your complicated sigmoid diverticulitis with
pelvic abscess. You have recovered from this procedure well and
you are now ready to return home. Samples from your colon were
taken and this tissue has been sent to the pathology department
for analysis. You will receive these pathology results at your
follow-up appointment. If there is an urgent need for the
surgeon to contact you regarding these results they will contact
you before this time. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You have laparoscopic surgical incisions on your abdomen
which are closed with internal sutures and a skin glue called
Dermabond. These are healing well however it is important that
you monitor these areas for signs and symptoms of infection
including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Additionally there is a suture was placed
after the drain was removed. This suture will be removed at
your follow-up appointment. Please call the office if you
develop any of these symptoms or a fever. You may go to the
emergency room if your symptoms are severe.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips) instead of
Dermabond, these will fall off over time, please do not remove
them. Please no baths or swimming for 6 weeks after surgery
unless told otherwise by Dr. Dr. .
You will be prescribed a small amount of the pain medication
called Oxycodone. Please take this medication exactly as
prescribed. You may take Tylenol as recommended for pain. Please
do not take more than 4000mg of Tylenol daily. Do not drink
alcohol while taking narcotic pain medication or Tylenol. Please
do not drive a car while taking narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. Dr.
.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16807878", "visit_id": "21048685", "time": "2143-11-04 00:00:00"} |
19912119-RR-40 | 192 | ## TYPE OF EXAMINATION:
Chest PA and lateral.
## INDICATION:
male patient status post ascending aortic aneurysm
replacement, evaluate for pleural effusion.
## FINDINGS:
PA and lateral chest views were obtained with patient in upright
position. Comparison is made with the next preceding AP and lateral chest
examination of . Status post sternotomy and aortic vascular
repair as before. Appearance of superior mediastinal structures has not
changed during the latest interval, and no pneumothorax has developed. Heart
size remains unchanged and no pulmonary vascular congestive pattern is
identified. Comparing the frontal views with the previous examination
demonstrates that a right-sided pleural effusion has developed which mildly
blunts the lateral pleural sinus. Also slight increase of left-sided lateral
pleural sinus blunting is noted. When comparing the findings on the lateral
views, the previously present pulmonary parenchymal infiltrate with
atelectatic component in the posterior segment of the left lower lobe has
disappeared. There remains evidence of small pleural effusions extending into
both posterior pleural sinuses. No pneumothorax can be identified on the
frontal view in the apical area.
## IMPRESSION:
The amount of bilateral pleural effusion matches that found on
most recent chest CT of .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19912119", "visit_id": "21782531", "time": "2140-03-19 11:49:00"} |
16256226-RR-20 | 296 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
Ms. is a right-handed woman with
historynotable for SLE (on hydroxychloroquine and mycophenolatemofetil),
migraines with aura, hyperthyroidism s/p ablation nowon levothyroxine, and
seizure disorder (on levetiracetam) transferred from after
presenting with leftface, arm, and leg weakness, found on initial imaging to
have aright external capsule ischemic infarct. Follow-up MRI demonstrated
multifocal ischemic infarcts concerning for a cardioembolic etiology, ?due to
PFO or hypercoagulability from malignancy in light of newly discovered
## 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:
Focal ill-defined hypodensities are seen in the right mid brain (02:10), and
in the right putamen extending into the right corona radiata (2:15, 16, 17,
and 18), corresponding to areas of restricted diffusion seen on prior MRI
brain of , consistent with evolving infarctions. Known smaller
infarcts in the left cerebral hemisphere described on prior MRI is beyond the
resolution of CT study. Elsewhere, there is no evidence of a new superimposed
acute intracranial process including new large vascular territorial
infarction, acute intracranial hemorrhage, new focus of edema, or mass effect.
Ventricles and sulci are within expected limits in caliber and configuration.
No evidence of fracture. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are well pneumatized and clear. The globes and bony
orbits are intact and unremarkable. Pipeline device is noted in the left
supraclinoid ICA.
## IMPRESSION:
Evolving right mid brain and right putaminal/corona radiata infarctions, as
seen on prior MRI. Known smaller left cerebral hemisphere infarcts are beyond
the resolution of CT study. No evidence of hemorrhage or new superimposed
acute intracranial process elsewhere.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16256226", "visit_id": "29686559", "time": "2151-09-12 23:37:00"} |
17145022-RR-23 | 102 | ## HISTORY:
Wegener's granulomatosis status post steroid therapy, presents for
renal biopsy.
## ULTRASOUND-GUIDED RENAL BIOPSY:
Sonographic guidance was provided for the nephrology service during
acquisition of two 16-gauge core biopsies through the lower pole of the native
left kidney. The patient tolerated the procedure well with no immediate
postprocedural complications.
Moderate sedation was provided by administering divided doses of 100 mcg of
fentanyl and 2.5 mg of Versed throughout the total intraservice time of 20
minutes during which time the patient's hemodynamic parameters were
continuously monitored.
## IMPRESSION:
Sonographic guidance provided for left kidney lower pole biopsy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17145022", "visit_id": "29680045", "time": "2160-04-13 13:01:00"} |
11049412-RR-48 | 252 | ## INDICATION:
year old woman with autoimmune hepatitis and liver failure s/p
OLT here w/ L sided facial droop. ear pain, on acyclovir, now w/
ALT/AST bump // eval for liver damage
## FINDINGS:
Liver echotexture is normal. There is no evidence of focal liver lesions or
biliary dilatation. The common hepatic duct measures 0.9 cm. There is no
ascites, right pleural effusion, or sub- or fluid
collections/hematomas.
The spleen measures 11.8 cm and has normal echotexture.
## DOPPLER:
The main hepatic arterial waveform is within normal limits, with
prompt systolic upstrokes and continuous antegrade diastolic flow. Peak
systolic velocity in the main hepatic artery is 41 cm/s. Appropriate arterial
waveforms are seen in the right hepatic artery and the left hepatic artery
with resistive indices of 0.58, and 0.62, respectively. The main portal vein
and the right and left portal veins are patent with hepatopetal flow and
normal waveform. Appropriate flow is seen in the hepatic veins. There is
turbulent flow between the right portal vein and a branch of the right hepatic
vein in the right lobe.
## IMPRESSION:
1. Unremarkable ultrasound appearance of the transplant liver. Patent hepatic
vasculature with appropriate waveforms.
2. Turbulent flow between the right portal vein and a branch of the right
hepatic vein raises the possibility of a fistula. If definitive
diagnosis is required, multiphasic contrast enhanced CT of the abdomen can be
considered, although it is doubtful whether a vascular fistula would cause an
increase in ALT/AST.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11049412", "visit_id": "23413658", "time": "2131-01-11 18:22:00"} |
14856613-RR-50 | 94 | This report is for reference only, generated by M2S.
( ), (Age AAA
## DATE OF SERVICE:
Physician , MD,
Current Status
was last scanned on and is a pre-operative AAA
patient. Ms. was previously scanned at Pre-op on . Her AAA
volume, now 62.6cc, has increased by 15.1% since her last scan and increased
by 15.1% since the first surveillance scan. Her AAA diameter, now 4.9cm, has
increased by 0.5cm since the last scan and increased by 0.5cm since the first
surveillance scan.
## NB:
This note was automatically generated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14856613", "visit_id": "N/A", "time": "2134-06-25 14:20:00"} |
18213817-RR-14 | 91 | ## INDICATION:
year old man with pneumothorax. Evaluate for interval change.
## FINDINGS:
No change in the positioning of the left-sided chest tube. Re demonstration
of fractures of the fifth and sixth left posterior ribs. A pleural line is
not present on the current study. Residual left lung atelectasis is present.
The right lung is clear. Heart size is normal. No focal consolidation.
## IMPRESSION:
No pleural line is detected to indicate residual left pneumothorax. Left
lower lobe atelectasis persists, in the setting of possible splinting given
the posterior rib fractures.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18213817", "visit_id": "25520222", "time": "2146-07-15 07:21:00"} |
12433579-RR-27 | 619 | ## INDICATION:
man with metastatic squamous cell carcinoma, here for
evaluation of possible tracheostomy. Study to evaluate extent of malignancy
and soft tissue distortion.
## NECK CT WITH CONTRAST:
Patient has known squamous cell carcinoma with osseous
metastasis. A dominant right chest wall mass is partially visualized today
(2, 1), but better demonstrated on prior chest CTA. Also partially visualized
are an endotracheal tube and a nasogastric tube, both in expected locations. A
left approach subclavian central venous catheter enters the SVC with the tip
outside scope of current study.
The nasopharynx, oropharynx, and lateral piriform sinuses appear patent.
Thyroid and cricoid cartilage appear unremarkable. Infraglottic space appears
within normal limits. Airway is largely patent with endotracheal tube in
place. There is minimal thickening at the level of cricoid and thyroid
cartilage, which most likely represents the vocal cords. Further evaluation
in this region is limited due to presence of the endotracheal tube. Also
noted is an ill-defined area of density anterior to the endotracheal tube
below the level of the vocal cords (301B, 70), which may represent synechia or
scarring or secretion.
More superiorly, the cervical soft tissue demonstrates asymmetry, with strap
muscles partially removed on the left and metallic clips within left submental
region. Soft tissue thickening and stranding within the fat planes in the
left neck may be related to prior surgery and radiation therapy in this
region.
Prevertebral soft tissue evaluation is limited by presence of the endotracheal
tube. Multilevel degenerative disease is most prominent at C4-5, C5-6, C6-7.
Areas of heterogeneous lucency within the vertebral bodies may represent a
mixture of degenerative changes and metastasis, which cannot be excluded.
Lytic metastatic changes are present in the upper thoracic spine, most
pronounced in T4 vertebral body. Additional irregular lytic changes are also
present in bilateral medial clavicles and multiple upper ribs. The alveolar
ridge demonstrates some irregularity, incompletely evaluated. Asymmetric
expansile appearance of the left anterior zygoma may be related to prior
trauma and known zygomatic arch reconstruction, but underlying metastasis
cannot be excluded.
Visualized portions of the neck demonstrate no lymphadenopathy by CT size
criteria. Arch vessels are patent. Atherosclerotic calcifications are noted
in vertebral arteries, left greater than right, near the take off from the
subclavian arteries. There is also calcification in bilateral common carotid
arteries near bifurcation, extending into their branches. Intracranially,
carotid siphon calcification is also noted.
A subcentimeter well-circumscribed hypoattenuating lesion within the left lobe
of thyroid is an incidental finding and may be evaluated on non-emergent basis
as clinically indicated by ultrasound. Within limitation of respiratory
motion artifacts, partially visualized lung apices are clear, with the
exception of previously described right chest wall mass.
## IMPRESSION:
1. Patent airway with endotracheal tube in place. Minimal soft tissue
thickening at the level of cricoid and thyroid cartilage likely represents
vocal cords, although further evaluation in this region is limited due to
presence of the tube. A small area of ill-defined density anterior to the
endotracheal tube just below the level of vocal cord (301B, 70) may represent
synechia or scar tissue or secretion.
2. Left cervical soft tissue thickening with adjacent fat stranding may
represent post-surgical and radiation therapy change in this region. Partial
strap muscle resection and submental surgical clips evident on the left.
3. Partial visualization of a large right chest wall mass extending into
right lung with multifocal osseous metastasis.
4. Multilevel degenerative disease in the cervical spine, concurrent
metastasis cannot be excluded.
5. Subcentimeter left thyroid nodule may be further evaluated by ultrasound
on non-emergent basis as clinically indicated.
6. Partially visualized endotracheal tube, nasogastric tube, and left
approach central venous catheter appear to be in expected locations.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12433579", "visit_id": "20206763", "time": "2112-07-27 09:20:00"} |
16887864-RR-107 | 236 | ## INDICATION:
year old man with metastatic lung cancer; restarted
osimertinib.// Evaluate interval change on osimertinib
## DOSE:
DLP: Given in abdominal CT report.
## FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. The precarinal and pretracheal lymph nodes (2, 15)
Are stable. The right hilar lymph node, moderately enlarged (2, 24) is also
stable. Stable mildly enlarged subcarinal lymph node (2, 28). The stable
mild coronary calcifications. The posterior mediastinum is unremarkable. The
right lower hilar lesion (2, 41) Has decreased in size, from previously 19 to
currently 13 mm in diameter (2, 41). Multiple hypodense liver lesions and
other abdominal findings are reported in detail in the dedicated abdominal CT
report. Better seen than on the previous examination but not more extensive
in number or severity are the pre-existing predominantly sclerotic bony
metastasis.
Some of the innumerable pulmonary metastasis might have minimally increased in
size. The overall profusion of the metastatic parenchymal disease is stable.
In addition to the metastatic nodules, small foci of ground-glass opacities
have newly appeared (3, 66). They might represent local reaction such as
local edema or bleeding, or infectious foci. No pleural effusions.
## IMPRESSION:
Stable mild mediastinal and hilar lymphadenopathy. Decrease of a right lower
perihilar lesion. Minimal increase in size of some of the innumerable
pulmonary metastasis. New small ground-glass opacities likely reflect a local
reaction to the metastatic burden. No pleural effusions.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16887864", "visit_id": "N/A", "time": "2174-08-23 08:16:00"} |
16025133-RR-29 | 164 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
man with seizure, right forehead abrasion. Assess for
ICH/Fracture.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 8.0 s, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
## FINDINGS:
There is no evidence of large territorial infarction,acute intracranial
hemorrhage,edema,or mass effect. There is prominence of the ventricles and
sulci which appears advanced for the patient's age.
There is soft tissue swelling associated with a small hematoma in the right
frontal scalp. There is no evidence of acute fracture. There is near
complete opacification of the right maxillary sinus as well as partial
opacification of a right ethmoidal air cell. Otherwise, the visualized
portion of the remainder of the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear.
## IMPRESSION:
1. Small right frontal scalp hematoma. No acute intracranial process or acute
fracture.
2. Sinus disease, as above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16025133", "visit_id": "N/A", "time": "2192-01-29 10:01:00"} |
18146176-RR-17 | 334 | ## EXAMINATION:
Right internal carotid artery angiogram.
Right vertebral artery angiogram.
Left vertebral artery angiogram.
Internal carotid artery angiogram.
Right common femoral artery angiogram.
## INDICATION:
year old woman with known aneurysm. // Please evaluate
aneurysm.
## ANESTHESIA:
Conscious sedation with local analgesia, please see
separate sheets for medications and dosing.
## RIGHT INTERNAL CAROTID ARTERY:
The distal right ICA, proximal and distal MCA
and ACA branches are well-visualized. Vessel caliber smooth and tapering.
Normal arterial, capillary, and venous phase . No vascular abnormalities
identified .
Right vertebral artery , right , basilar artery, right AICA, bilateral SCA
and bilateral PCAs are well-visualized. Dysplastic appearance of the cervical
portion of the right vertebral artery. The left is branching off from
the AICA (left . No cross-filling to the contralateral left
vertebral artery. No vascular abnormalities identified, vessel caliber smooth
and tapering. Arterial, capillary, venous phases were normal .
Left vertebral artery is smaller when compared to the contralateral side with
very faint contribution to the basilar system, a 4 x 5 mm aneurysm was
identified in the intracranial portion with a 1.5 mm neck with a smaller
tapering inflow when compared to the outflow artery. Large posterior
meningeal branch.
## LEFT INTERNAL CAROTID ARTERY:
Distal left ICA, proximal and distal MCA and
ACA branches are well-visualized. Vessel caliber smooth and tapering. Normal
arterial, capillary, and venous phase . No vascular abnormalities identified .
## RIGHT COMMON FEMORAL ARTERY:
Well-visualized with a good caliber size for
closure device.
I, , participated in the procedure. I, ,
was present for the entirety of the procedure and supervised all critical
steps.
I, , have reviewed the report and agree with the fellow's
findings.
## IMPRESSION:
1. Dysplastic appearance of the cervical portion of the right vertebral
artery. The left is branching off from the AICA (left .
2. 4 x 5 mm left V4 aneurysm with a 1.5 mm neck and a smaller tapering inflow
when compared to the outflow artery.
## RECOMMENDATION(S):
1. These findings will be discussed at the cerebrovascular conference and
recommendations will follow.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18146176", "visit_id": "N/A", "time": "2138-11-14 07:05:00"} |
19046107-DS-11 | 1,279 | ## ALLERGIES:
Atenolol / Lopressor / Zestril / Verapamil / isosorbide / Diovan
/ Clonidine / Norvasc / Celexa / Paxil / Candesartan /
Doxycycline / Felodipine / Caffeine / kiwi / kiwi
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Bilateral Percutaneous Nephrostomy Tube Placement
Right Percutaneous Nephrostomy Tube Exchange
attach
## IMPRESSION:
1. Dislodged right percutaneous nephrostomy tube with unchanged
moderate right hydroureteronephrosis secondary to a obstructing
0.8 cm right UVJ stone. Additional nonobstructing right kidney
stones and numerous bladder stones are unchanged.
2. Appropriate position of the left percutaneous nephrostomy
tube with
resolution of left hydronephrosis. Obstructing stones measuring
1.9 cm in
aggregate in the left UPJ are unchanged.
3. Massive left inguinal hernia extending to the scrotum
containing
nonobstructed small and large bowel loops and mesentery.
4. Worsening bilateral small right and trace left pleural
effusions.
PLMT NEPHROSTOMY CATHETER ( )
1. Completely dislodged right nephrostomy tube. Moderate right
hydronephrosis.
2. Retracted indwelling left nephrostomy tube.
## SUMMARY:
=====================
year old gentleman with Hx of CAD s/p PCI (4 stents in ,
HTN, HLD, HFpEF (EF 50%), A fib on coumadin, s/p PPM, and
urinary retention with multiple UTIs requiring extended foley
placement, severe pulmonary HTN, CKD III, panic disorder,
prostatitis, morbid obesity, depression who was transferred for
worsening on CKD with findings of bl obstructing renal
stones, bl hydronephrosis s/p bl PCN tube placement with
improvement in kidney function to prior baseline and
stabilization of electrolytes.
TRANSITIONAL ISSUES
====================
[] Follow up with Urology for management of kidney stones,
chronic foley management
[] Plan for pending Urology - has
appointment scheduled for for tube exchange in case
needed
[] Follow up with Dr. discharge (nephrology)
[] PO vanc taper (125mg q48h) until
[] Home diuretics (torsemide, spironolactone) were held during
admission and at time of discharge as patient was autodiuresing.
Caution with initiating spironolactone as patient continued to
have high/normal potassium despite improved kidney function.
[] Plan for daily weights with and close PCP to
determine safe timing to restart diuretics
[] Patient endorses difficulty with transportation to
appointments - have reached out to PCP and CRS at to assist
with transportation and provided pt with information for 'The
Ride' services
[] Continue warfarin with goal for afib
[] Consider if can liberalize K in diet as creatinine continues
to improve
## ACUTE PROBLEMS:
====================
on CKD III
#Bilateral hydronephrosis s/p bl PCN tubes
#Obstructive kidney stones
#Hyperkalemia
#Hyperphosphatemia
Patient initially presented with a creatinine of 2, up to 8.07
on admission. Initially was felt to be pre-renal etiology iso
diuresis. However, even with holding diuretics and giving IV
fluids, creatinine did not improve. Renal ultrasound on
showed bilateral hydronephrosis and CT urogram showed
moderate bilateral hydro with 8mm obstructing stones on each
side. It was felt that a large driver of his kidney failure was
from obstructive uropathy and resultant hydronephrosis, however
ATN and pre-renal failure remained on the differential. Had bl
PCN placement , with slow improvement in kidney
function and electrolyte abnormalities. Cr eventually improved
to prior baseline. Recommended to continue low K diet upon
discharge.
#Chronic diastolic HF
#Scrotal enlargement
Patient is usually on Spironolactone 25 mg daily as well as
torsemide 20mg QOD. Notes that he had reduced his torsemide dose
to 10mg qod, and then stopped taking it altogether due to
concerns of urinary retention. He presented to on
for scrotal edema, and received IV diuresis. Pt lost
about 20 kg with diuresis, however developed worsening kidney
function, and diuretics were stopped on . Diuretics were
held throughout admission at and were held at time of
discharge as patient continued to autodiurese after PCN
placement. Pt was continued on home coreg dosing.
#Asymptomatic Bacteruria
Initial UA at was suggestive of UTI, started on
vanc/CTX, then discontinued when culture had no growth. After
transfer to , a repeat UCx grew 50-100K CFU VRE. Repeat
UA/UCx at were negative. Pt was asymptomatic, however
foley in place. Given negative repeat UCx in the absence of
appropriate treatment, this was unlikely to represent a true
urinary infection. Pt was initially treated with ampicillin,
however discontinued. Pt remained afebrile and without signs or
symptoms of infection.
#Coagulopathy
INR on admission 2.9, s/p IV vit K reversal prior to PCN
placement. INR remained elevated at 1.9-2s despite holding AC,
so nutritional Vit K deficiency was considered. INR then became
subtherapeutic and warfarin was restarted.
#Hx Recurrent C. difficile colitis
Pt was placed on oral vancomycin qid while on antibiotics, then
transitioned back to home vancomycin qod taper, to be continued
until per OMR.
#Anemia, normocytic
Hgb stable in the range during admission, which
appears to be his recent baseline. Possible etiologies include
chronic kidney disease and/or inflammation. Hgb slightly
decreased s/p procedure and 2L IVF , then stabilized
without overt signs of bleeding.
## CHRONIC ISSUES:
===============
#Atrial fibrillation
Continued on home coreg per above. Warfarin per above.
#CAD, HTN, HLD
Continued on home Lipitor. His home aspirin had been held at
in preparation for procedure and was held during this
admission, restarted at time of discharge.
>30 minutes spent on patient care and coordination on day of
discharge.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. CARVedilol 6.25 mg PO Q600
4. CARVedilol 6.25 mg PO Q1800
5. CARVedilol 12.5 mg PO Q2400
6. CARVedilol 12.5 mg PO Q1200
7. Vitamin D 1000 UNIT PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Vancomycin Oral Liquid mg PO Q48H
11. Warfarin 5 mg PO 6X/WEEK ( )
12. Warfarin 6.25 mg PO 1X/WEEK (MO)
13. Torsemide 10 mg PO EVERY OTHER DAY
14. Align (Bifidobacterium infantis) 4 mg oral DAILY
## DISCHARGE MEDICATIONS:
1. Align (Bifidobacterium infantis) 4 mg oral DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. CARVedilol 6.25 mg PO Q600
5. CARVedilol 6.25 mg PO Q1800
6. CARVedilol 12.5 mg PO Q2400
7. CARVedilol 12.5 mg PO Q1200
8. Tamsulosin 0.4 mg PO QHS
9. Vancomycin Oral Liquid mg PO Q48H
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 5 mg PO 6X/WEEK ( )
12. Warfarin 6.25 mg PO 1X/WEEK (MO)
13. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until you see your doctor
cause elevated levels of potassium)
14. HELD- Torsemide 10 mg PO EVERY OTHER DAY This medication
was held. Do not restart Torsemide until you see your doctor
## 15.OUTPATIENT LAB WORK
ICD 10:
N18. 9, Z79.01
Please draw Chemistry panel and INR on
Fax results to Dr. ( )
## PRIMARY DIAGNOSIS:
Bilateral Renal Stones
Obstructive Uropathy
Hydronephrosis
## SECONDARY DIAGNOSIS:
Acute Renal Failure
Hyperkalemia
Hyperphosphatemia
Coagulopathy
History of Recurrent Clostridium Difficile
colitis
Chronic Diastolic Heart Failure
Scrotal Enlargement
Asymptomatic Bacteruria
Normocytic Anemia
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a privilege caring for you at .
WHY WAS I IN THE HOSPITAL?
- You were transferred to from with acute
renal failure
WHAT HAPPENED TO ME IN THE HOSPITAL?
- It was felt that your kidney failure was a result of stones
that were blocking the passage of urine. As a result, urine was
backing up into the kidneys
- You had tubes placed in your kidneys to drain the urine
- Your kidney function improved to your previous baseline and
your electrolyte abnormalities normalized.
- You improved and were ready to leave the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and
with your appointments as listed below.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Sincerely,
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19046107", "visit_id": "20977532", "time": "2144-02-05 00:00:00"} |
13137357-DS-13 | 904 | ## ALLERGIES:
No Drug Allergy Information on File
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Staples to right scalp laceration
## HISTORY OF PRESENT ILLNESS:
yo M without significant past medical history presents after
alcohol intoxication with persistent tachycardia. Pt reports
being at a party in , drinking champagne,
more than usual but does not remember amount. Denies any other
ingestions or injections. Last remembers 1am at party, next
remembers waking up on unknown fire escape in with
laceration on read, covered in blood. Does not remember any
trauma, fights, falls. When awoke, felt drunk, headache. Called
taxi to take him home, from there friend brought him to the ED,
where his vitals were T 100, HR 120s-140s (sinus), BP 110s/60s.
He receive 3.5L IVF and no medications. Labs were significant
for etoh level of 245 and tox screen otherwise negative.
.
ROS otherwise neg - no nausea/vomiting, mild headache, no CP, no
SOB.
## GENERAL:
Awake, alert, NAD, pleasant, appropriate, cooperative.
## HEENT:
NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP, stapled laceration of right posterior head, dried
blood in hair and on left side of face
## NECK:
supple, no significant JVD or carotid bruits appreciated
## PULMONARY:
Lungs CTA bilaterally, no wheezes, ronchi or rales
## CARDIAC:
RR, nl S1 S2, no murmurs, rubs or gallops appreciated
## ABDOMEN:
soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
## EXTREMITIES:
No edema, 2+ radial, DP pulses b/l
## LYMPHATICS:
No cervical lymphadenopathy noted
## SKIN:
Multiple areas of skin abrasions, dried blood
## NEUROLOGIC:
Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor.
## PERTINENT RESULTS:
06:00AM BLOOD WBC-19.0* RBC-5.39 Hgb-16.7 Hct-45.1
MCV-84 MCH-31.0 MCHC-37.0* RDW-13.1 Plt
07:08AM BLOOD WBC-7.9# RBC-4.41* Hgb-13.9* Hct-37.9*
MCV-86 MCH-31.6 MCHC-36.8* RDW-13.0 Plt
06:00AM BLOOD Neuts-87.2* Lymphs-9.7* Monos-2.7 Eos-0.2
Baso-0.2
06:00AM BLOOD PTT-25.6
07:08AM BLOOD Glucose-78 UreaN-9 Creat-1.0 Na-142 K-4.3
Cl-107 HCO3-28 AnGap-11
06:00AM BLOOD Glucose-98 UreaN-9 Creat-1.1 Na-147*
K-3.5 Cl-106 HCO3-27 AnGap-18
07:08AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
06:00AM BLOOD TSH-1.2
06:00AM BLOOD ASA-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
09:20AM URINE Color-Yellow Appear-Clear Sp
09:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
09:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Urine culture neg.
HEAD CT - No evidence of acute intracranial hemorrhage or mass
effect.
ABD/PEL CT - No evidence of traumatic injury to the torso.
C-SPINE - 1. No fracture.
2. Slightly asymmetric distances between the dense and the
laterla masses of C1, most likely related to head rotation.
Please correlate whether the patient has pain upon turning his
head to exclude rotatory atlantoaxial subluxation.
SHOULDER - No evidence of acute fracture or dislocation.
ELBOW - No elbow effusion is appreciated. No cortical
irregularities are identified to suggest acute fracture. No
radiopaque foreign bodies are detected within the soft tissues.
## EKG:
sinus tachy at 98, NA, PR widened, otherwise NI, TW
flattening/inversion in inferior leads.
## BRIEF HOSPITAL COURSE:
yo M with no PMH presents after intoxicated black out, with
persistent tachycardia.
## Sinus tachycardia: Pt with persistent sinus tachycardia
after receiving 3.5 L of IVF in the ED. He reported prior
history of sinus tachycardia during hospitalization for
tonsillectomy attributed to anxiety and also tachycardia in his
father during hospital admission. He received another 1L bolus
of NS given slight hypernatremia and was monitored on
telemtry. He was also monitored on the CIWA scale without
requiring any benzodiazepines. Heart rate improved with time and
during sleep and at time of discharge was .
## ## ETOH INTOX:
On admission alcohol level was 245, with urine
and serum tox screen negative for any other drugs. He was
monitored on the CIWA scale but did not show signs of withdrawal
and did not require any diazepam. Pt was maintained on a regular
diet without additional supplementation of thiamine/folate/MVI.
Pt counselled about alcohol abuse and responsible drinking. He
showed no signs of alcohol dependence.
## DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6
hours) as needed for fever or pain.
Disp:*50 Tablet(s)* Refills:*0*
## DISCHARGE INSTRUCTIONS:
You were admitted with alcohol intoxication and a fast heart
rate. We watched you overnight to make sure you did not withdraw
and to monitor your heart rate. We believe that your heart rate
was fast due to dehydration and a component of anxiety. With
some fluids and sleep your heart rate decreased to normal.
We have not started you on any new medications. Obviously we
recommend that you be careful when drinking alcohol and don't
drink in excess.
Please call your doctor or return to the hospital if you have
any chest pain, palpitations, shortness of breath, any loss of
consciousness or any other concerning symptoms.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13137357", "visit_id": "22218886", "time": "2164-09-24 00:00:00"} |
18331815-RR-16 | 64 | ## IMPRESSION:
1. Minimally displaced left distal clavicular comminuted fracture and left
sixth posterior rib fracture.
2. Loss of height of mid and lower thoracic vertebral bodies compatible with
compression deformities, age indeterminate.
3. Degenerative changes in both shoulders with narrowing of the
acromiohumeral interval suggestive of rotator cuff tendinopathy. There is
superior subluxation of the left humeral head relative to the glenoid.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18331815", "visit_id": "25165084", "time": "2112-10-08 19:37:00"} |
16798076-RR-61 | 89 | ## FINDINGS:
The height of vertebral bodies of the C-spine is preserved. No
acute fracture or malalignment. There is intervertebral disc disease at
C5/C6 with small posterior disc-osteophyte complex, but only mild narrowing of
the spinal canal. There are mild atherosclerotic calcification of the right
vertebral artery and the left carotid bifurcation. There is no prevertebral
soft tissue swelling and no large neck hematoma. There is severe emphysema
seen at the lung apices.
## IMPRESSION:
No acute fracture or malalignment. Moderate degenerative changes
at C5/C6.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16798076", "visit_id": "27940271", "time": "2144-12-14 16:00:00"} |
19988493-RR-20 | 90 | ## INDICATION:
HIV and CNS toxoplasmosis, please assess for interval change.
## CT HEAD WITHOUT IV CONTRAST:
There is no acute intracranial hemorrhage or
acute large vascular territory infarcts. There is again demonstrated
irregular vasogenic edema in the left inferior frontal lobe, left internal and
external capsules, left basal ganglia, with mass effect on the left lateral
ventricle, essentially unchanged from prior with an approximate 3-4 mm
rightward shift. Again demonstrated is a left frontal burr hole and a
decreased amount of pneumocephalus.
## IMPRESSION:
Essentially unchanged CT picture from .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19988493", "visit_id": "25600709", "time": "2116-10-10 14:49:00"} |
19711968-RR-13 | 463 | ## EXAMINATION:
CTA CHEST WITH CONTRAST
## INDICATION:
with shortness of breath. Evaluate for pulmonary embolism.
## FINDINGS:
Included portions of the thyroid gland enhance homogeneously. No
supraclavicular, axillary or mediastinal lymphadenopathy by size criteria.
Scattered mediastinal lymph nodes measure up to 7 mm in the left prevascular
station. There is a 14 mm hilar lymph node on the right (3:99), likely
reactive.
Heart is normal in size, without a pericardial effusion. Left ventricular
myocardium appears thickened. Coronary calcifications are noted. Thoracic
aorta is normal in course and caliber with no evidence for dissection or
intramural hematoma. Main pulmonary trunk is dilated, measuring up to 3.9 cm
in diameter (3:78), suggestive of pulmonary arterial hypertension. There are
extensive segmental and subsegmental pulmonary emboli involving all pulmonary
arterial branches. On the left, there is central extension of clot burden
into the left main pulmonary artery (3:80). There is no evidence of right
heart strain.
Airways are patent to the segmental bronchi bilaterally. Scattered
parenchymal abnormalities are noted. Several wedge-shaped peripheral
opacities in the right lower lobe and left lower lobe likely represent small
pulmonary infarcts (02:59, 74, 79). There is a 5 mm mixed attenuation nodule
in the right middle lobe (3:88). Several additional opacities are nonspecific
and may represent an underlying inflammatory process ; for instance, there is
a lobulated 1.1 x 0.8 cm perifissural opacity in the inferior right upper lobe
(3:99) and an additional 0.7 cm nodular opacity in the posterior segment of
the right upper lobe (3:67).
Small pleural effusion on the left. No pleural effusion on the right. No
pneumothorax.
Limited images of the upper abdomen reveals a diffusely hypoattenuating liver,
suggestive of hepatic steatosis.
No fractures are identified. Degenerative changes throughout the thoracic
spine. There is a 1.4 cm skin lesion extending into the subcutaneous fat
along the central upper back (3:61), which may represent a sebaceous cyst.
## IMPRESSION:
1. Extensive bilateral segmental and subsegmental pulmonary emboli, with
central extension into the left main pulmonary artery.
2. Dilatation of the main pulmonary artery however no evidence of right heart
strain.
3. Bilateral scattered wedge-shaped peripheral parenchymal opacities,
suspicious for pulmonary infarcts. Additional parenchymal opacities in the
right upper lobe are of unclear etiology and may represent nonspecific
inflammation. A follow-up chest CT in 3 months is recommended to evaluate
resolution.
4. 5 mm mixed attenuation nodule in the right middle lobe, which could also be
re-evaluated at time of follow-up.
5. Prominent right hilar lymph node is likely reactive.
6. Small left pleural effusion.
7. Hepatic steatosis.
8. 1.4 cm superficial skin/subcutaneous lesion along the central upper back,
may represent a sebaceous cyst.
## RECOMMENDATION(S):
Chest CT in 3 months.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19711968", "visit_id": "21018022", "time": "2152-11-30 19:51:00"} |
19961286-RR-4 | 137 | ## INDICATION:
woman status post fall.
## FINDINGS:
No acute intracranial hemorrhage is detected. There is no evidence
of edema or midline shift. The gray-white matter differentiation is well
preserved. The ventricles and sulci are normal. The basal cisterns are
widely patent.
There is a fracture of the medial wall of the right orbit, with herniation of
the medial rectus muscle and intraorbital fat. Extensive subcutaneous
emphysema is noted along the right lateral temporal region and anterior to the
right orbit and the nose. The emphysema also extends in the right orbit in
the intraconal space. There is mild proptosis of the right globe. The right
globe is intact and the intraocular lens is in place.
## IMPRESSION:
1. No acute intracranial hemorrhage identified.
2. Right orbital fracture with extensive subcutaneous and intraorbital
emphysema as described above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19961286", "visit_id": "N/A", "time": "2111-06-08 18:49:00"} |
16466389-RR-35 | 101 | ## INDICATION:
year old woman with excellent health. // patient with known
IUD and now more heavy and frequent bleeding accompanied by left lower
quadrant pain of unclear origin (gyne vs GI). ?IUD placement okay ?fibroids
?left ovarian issue
## FINDINGS:
The uterus is anteverted and measures 7.1 x 4.1 x 3.9 cm. The endometrium is
homogenous and measures 4 mm. The IUD was demonstrated within the endometrial
cavity. The IUD appears satisfactorily placed.
The ovaries are normal. There are no adnexal masses. There is nofree fluid.
## IMPRESSION:
1. IUD is satisfactorily positioned.
2. Normal ovaries. No adnexal masses.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16466389", "visit_id": "N/A", "time": "2199-03-01 15:45:00"} |
11271927-DS-21 | 692 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
This is s/p mechanical AVR/MVR on
and was discharged on . Readmitted with
subtherapeudic INR for heparin infusion them D/C'd .
She was doing well but said she was having palpitations and was
lethargic. Upon presentation she was in rapid atrial
fibrillation
and after an initial dose of lopressor converted back to a sinus
rhythym
## PAST MEDICAL HISTORY:
1. Rheumatic valvular heart disease with:
- moderate-to-severe aortic stenosis
- mild-to-moderate aortic regurgitation
- moderate mitral stenosis
- mild mitral regurgitation.
- s/p AVR/MVR ( mechanical valves)
2. Mild secondary pulmonary hypertension
3. Breast Fibroma
4. Childhood Asthma
5. s/p Cesarean Section
## NECK:
Supple [x] Full ROM [x]
## CHEST:
Lungs clear bilaterally []occ. rhonchi bilat.
Chest incision: healing well, sternum stable
## HEART:
RRR [x] Irregular [] Murmur crisp valve sounds
## EXTREMITIES:
Warm [x], well-perfused [x] Edema Varicosities:
None []
## UNDERLYING MEDICAL CONDITION:
year old woman s/p AVR/MVR
## REASON FOR THIS EXAMINATION:
eval for pleural effusions
## WED 11:
ilateral pleural effusions.
Preliminary Report !! !!
Trace bilateral pleural effusions.
.
entered: WED 11:10 AM
Imaging Lab
## BRIEF HOSPITAL COURSE:
year old female well known to the cardiac surgical service
due to her recent Mechanical Aortic and Mitral Valve replacement
on with . Please refer to the discharge
summary for further details. She was readmitted on for a
subtherapeutic INR for Heparin infusion and discharged on .
She presented to the ED complaining of chest pain and cough
associated with a rapid heart rate. ECG showed rapid Atrial
Fibrillation 130s. She was admitted to the step down unit for
further observation, rate control and anticoagulation.
Beta-blockers were optimized and Amiodarone was initiated. Her
rhythm converted back to normal sinus. Heparin drip was titrated
for therapeutic PTT and anticoagulation with Coumadin was
continued for a therapeutic INR goal of 2.5-3.5. On HD #2 she
was cleared by discharge to home. All follow up
appointments were advised. First blood draw by is tomorrow
with results to be called or faxed to clinic as
per discharge instructions.
## MEDICATIONS ON ADMISSION:
ASA 81 mg PO daily
Zantac 150 mg PO BID
Colace 100 mg PO BID
Dilaudid mg PO q hours PRN pain
Toprol XL 50 mg PO daily
Lasix 20 mg PO BID for 7 days
KCl 20 mEq PO BID for 7 days
Coumadin 2.5 mg PO daily
## DISCHARGE MEDICATIONS:
1. Docusate Sodium 100 mg Capsule
## SIG:
One (1) Capsule PO BID (2
times a day) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
3. Hydromorphone 2 mg Tablet Sig: Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
4. Coumadin 2.5 mg Tablet Sig: daily dosing per PCP PO
once a day: 2 tablets today (5 mg); then daily dosing per
provider for target INR 2.5 -3.5.
Disp:*60 Tablet(s)* Refills:*1*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
MDI* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: 400 mg BID until , then 200 mg BID
, then 200 mg daily ongoing .
Disp:*60 Tablet(s)* Refills:*1*
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*1*
## DISCHARGE DIAGNOSIS:
new onset postop Atrial Fibrillation
s/p mechanical AVR/MVR on
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 8 weeks
Please call with any questions or concerns
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11271927", "visit_id": "25928963", "time": "2161-03-11 00:00:00"} |
11483803-RR-6 | 149 | ## INDICATION:
with abdominal pain. recent CT showed large left ovarian
mass. OBGYN recommended US to evaluate for ovarian blood flow // flow to
ovaries ?
## FINDINGS:
The uterus is anteverted and measures 15.7 x 9.1 x 10.3 cm. Multiple masses
are consistent with fibroids. The largest is posterior fundal and measures
5.6 x 5.1 cm. The endometrium is homogeneous and measures 9 mm.
The ovaries are not visualized. A large cystic lesion with tubular components
and low level internal echoes corresponds to the finding on same-day CT of the
abdomen and pelvis, where its are better characterized.
## IMPRESSION:
1. The ovaries are not visualized.
2. Large cystic lesion in the pelvis. While this could represent endometrioma
or hematosalpinx, cystic ovarian neoplasm remains in the differential. MRI is
suggested for further characterization.
3. Fibroid uterus.
## RECOMMENDATION(S):
MRI pelvis is suggested for further characterization.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11483803", "visit_id": "N/A", "time": "2122-05-19 16:22:00"} |
15124376-RR-47 | 64 | ## INDICATION:
year old woman with pelvic pain.// Please evaluate pelvic
anatomy
## FINDINGS:
The uterus is retroflexed and measures 8.1 x 5.0 x 4.6 cm. The endometrium is
homogenous and measures 5 mm.
The ovaries are normal. Color and spectral Doppler of the ovaries
demonstrates normal arterial and venous flow bilaterally. There is no free
fluid.
## IMPRESSION:
Normal pelvic ultrasound.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15124376", "visit_id": "N/A", "time": "2147-07-04 08:01:00"} |
17396354-RR-72 | 236 | MR EXAMINATION OF THE BRAIN WITHOUT CONTRAST .
## HISTORY:
female with longstanding DM and HTN, now with left arm
numbness x weeks, found to have left hemibody numbness; evaluate for
subacute right thalamic infarction.
## FINDINGS:
The study is compared with NECT of . The DWI sequence is
completely unremarkable, with no focus of slow diffusion to suggest acute
infarction. There are a few scattered small FLAIR-hyperintense foci in
bihemispheric subcortical white matter, nonspecific, which may represent
sequelae of chronic microvascular ischemia (particularly given the patient's
risk factors). There is no acute intra- or extra-axial hemorrhage, the
midline structures are in the midline and the ventricles and cisterns are
unchanged in size and contour. There is a single punctate focus of blooming
"susceptibility artifact" superficially located in the left frontal opercular
cortex (6:10); while this is nonspecific, it may represent a "microbleed"
related to the patient's history of hypertension. The principal intracranial
vascular flow voids, including those of the dural venous sinuses, are
preserved. There is no space-occupying lesion, and the sella, parasellar
region and orbits are unremarkable. There is minor mucosal thickening
involving the anterior ethmoidal air cells, bilaterally and the left petrous
apex is poorly pneumatized with evidence of previous extensive partial
mastoidectomy as on the CT.
## IMPRESSION:
1. No acute intracranial abnormality; specifically, there is no evidence of
right thalamic or other acute infarction.
2. No space-occupying lesion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17396354", "visit_id": "N/A", "time": "2180-10-01 17:14:00"} |
18902426-RR-13 | 228 | ## INDICATION:
year old woman with right temporal headaches but also
infrequently on the left// ?focal lesion
## FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction.
There are scattered T2/FLAIR hyperintensities in the cerebral hemispheres
bilaterally, predominantly in the bilateral frontal lobes which could
represent migraine related white matter changes or early small vessel ischemic
changes/microangiopathic changes. Alternatively, these white matter lesions
could represent at an autoimmune/inflammatory process. Distribution pattern
of the white matter lesions does not suggest an underlying demyelinating
condition.
The ventricles and sulci are normal in caliber and configuration.
Major vascular flow voids are preserved.
There are mucous retention cysts in the bilateral maxillary sinuses, left
greater than right. Mucosal thickening is also seen in the left frontal
sinus, along the anterior ethmoid air cells and in the left maxillary sinus.
The mastoid air cells are clear. The orbits appear unremarkable.
## IMPRESSION:
1. Nonspecific white matter lesions in the cerebral hemispheres bilaterally
but predominantly in the bilateral frontal lobes which could be migraine
related or may represent early microangiopathic changes. Alternatively they
could represent an autoimmune/inflammatory process. The distribution of the
white matter lesions does not suggest an underlying demyelinating condition.
2. Otherwise unremarkable MRI of the head. No evidence of acute infarction,
intracranial hemorrhage or mass.
3. Paranasal sinus disease as detailed above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18902426", "visit_id": "N/A", "time": "2139-09-03 12:54:00"} |
19036201-RR-24 | 130 | ## HISTORY:
female with fall, rule out fracture.
No prior studies are available for comparison.
AP PELVIS, WITH TWO ADDITIONAL VIEWS OF THE RIGHT HIP:
No acute fracture or
dislocation is identified. There is, however, severe osteoarthritis of the
right hip, with near complete loss of joint space, large femoral head
osteophyte, and subchondral sclerosis. Additionally, slight heterotopic
calcification is evident lateral to the right femoral neck. Mild-to-moderate
degenerative changes are also noted within the left hip, with moderate loss of
joint space. Degenerative changes are also noted in the visualized lumbar
spine. No focal lytic or sclerotic lesion is identified. There is no
radiopaque foreign body.
## IMPRESSION:
1. No fracture or dislocation.
2. Severe osteoarthritis of the right hip, with moderate osteoarthritis of
the left hip.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19036201", "visit_id": "26067364", "time": "2183-05-02 21:19:00"} |
16899049-RR-93 | 178 | ## INDICATION:
history of SDH, now with cavernoma // year f/u, eval against
prior images
## FINDINGS:
The round 5 mm lesion in the left frontal lobe on 09:18 is centrally T2
hyperintense with a T2 hypointense rim. This lesion demonstrates
susceptibility and is unchanged in size and appearance from the prior
examinations. This lesion is also associated with a developmental venous
anomaly.
There is no evidence of acute hemorrhage, edema, masses, mass effect, midline
shift or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration. Patchy T2/FLAIR hyperintensities in the periventricular,
subcortical, and deep white matter are nonspecific, but may represent the
sequela chronic small vessel ischemic disease.
The right maxillary sinus contains a moderate mucous retention cyst. There is
mild mucosal thickening in the bilateral ethmoid sinuses. The orbits are
unremarkable.
A few right mastoid air cells are opacified.
The major intracranial flow voids are preserved.
## IMPRESSION:
1. Stable, small left frontal cavernoma with an associated developmental
venous anomaly.
2. No acute intracranial abnormality.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16899049", "visit_id": "N/A", "time": "2132-03-02 13:14:00"} |
11581456-DS-6 | 1,420 | ## CHIEF COMPLAINT:
transfer from surgery - edema, abdominal girth, cholecystitis
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Ultrasound guided paracentesis with 8L fluid removed
ERCP with biliary stent removal
## HISTORY OF PRESENT ILLNESS:
y/o M h/o Etoh abuse, cholelithiasis, HTN, gout, obesity and
depression who was recently admitted for cholecystitis and
volume overload. Patient was treated with a short course of
antibiotics but the primary cause for his gall bladder edema was
thought to be his anisarca. He has an 8liter paracentesis, and
his anisarca was treated with diuretics. Patient was discharged
to home with lasix and spironolactone. After discharge patient
is adamant that he filled his prescriptions (even remembers the
costs of each one). Says he was compliant as best as he could be
with a low salt although he admits to eating one store
pizza on night prior to admission. Around this
time, patient developed a recurrent nose bleed which did not
resolve with pressure. The following day he presented to his
rheumatologist's office with ongoing bleeding. He was referred
to for evaluation, who then referred him to
. Patient reports increased abdominal girth, but improved
edema since discharge.
.
On arrival to the ED, initial VS were T98.7, BP154/86, HR 73, RR
20, O2 99%. On exam, he was noted to have b/l edema, Labs
notable for T. bili of 11.3 (baseline , INR 2.5, Na 129,
and Cr 0.8. Given RUQ pain in ED has USD that showed no
significant change from prior. Patient was admitted to the
surgery service for management of cholecystitis. Overnight he
was treated with cipro/flagyl. He is now transferred to the
medicine service as he is not an operative candidate, and has
worsening volume overload.
.
At time of tranfser, VS were T96.8, Bp 132/79, HR 88, RR 18, O2
97% RA.
## PAST MEDICAL HISTORY:
- Etoh Cirrhosis c/b grade I varices with recent UGIB,
hemorrhoids, ascites, epistaxis, and anisarca
- Alcoholic hepatitis - not treated with steroids given UGIB.
- Alcohol abuse
- hypertension
- cholelithiasis
- gout
- obesity
- depression
## GEN:
adult male, obese, in NAD
## HEENT:
(+) scleral icterus, EOMI, MMM, oropharynx clear, PERRL
## CV:
RRR, early systolic murmur best heard at apex radiating
to axilla, no gallops or rubs, distant heart sounds
## LUNGS:
decreased breath sounds at right base, bronchial breath
sounds, otherwise no wheezing or ronchi.
## ABDOMEN:
soft, distended, +BS, ascites by percussion, stretch
marks prevelant, +pain to deep palpation in RUQ and RLQ,
improved from prior exams
## EXTREMITIES:
edema in bilateral over shins, radial
pulses palpable bilaterally
## NEURO:
Alert, oriented x 3, no asterexis, CN II-XII intact
## ABDOMINAL U/S :
1. No significant change in appearance to gallbladder which
contains sludge
and stones. No gallbladder wall thickening. Extensive amount of
ascites and
small amount of pericholecystic fluid. No intrahepatic biliary
dilatation.
2. Common bile duct not definitively visualized.
3. Reversal flow within the portal vein.
4. Nodules within the liver adjacent to the gallbladder, not
significantly
changed.
5. Ascites.
.
CXR PA and LAT :
## IMPRESSION:
PA and lateral chest compared to :
Right hemidiaphragm is markedly elevated, presumably due to
subphrenic
abnormality. There may be a very small right pleural effusion.
Lungs are
clear. Heart size is normal and there is no evidence of central
adenopathy.
## BRIEF HOSPITAL COURSE:
The patient is a year old male with history of cirrhosis
secondary to alcohol use complicated by varices and ascites,
with a recent history of GI bleed and alcoholic hepatitis who
now presents with worsening edema, abdominal girth, and possible
superimposed cholecystitis.
.
# Etoh Hepatitis and Cirrhosis: The patient has a history of
EtOH hepatitis and cirrhosis, with his liver function
essentially stable since his prior discharge one week ago.
Increasing ascites since discharge is likely secondary to his
chronic liver dysfunction and is expected. Patient reports
compliance with outpatient medications, but only partial
adherence to low sodium diet, which could also be contributing
to his increased edema. He was continued on home dose of
diuretics, and underwent an ultrasound guided paracentesis, with
8 L of fluid removed on with albumin replacement.
Peritoneal fluid negative for SBP. The patient was discharged
with a plan to follow up at the liver clinic in one week.
.
# Cholecystitis: Patient was transferred from outside hospital
with abdominal pain and worsening edema. RUQ ultrasound was
unchanged from prior, which showed gallbladder sludge and
pericholecystic fluid that could be consistent with
cholecystitis or anisarca from volume overload. He was
initially admitted to the surgical service, but was not
considered to be a surgical candidate given his decompensated
liver disease. He was started on Cipro and Flagyl for a total
bdominal pain resolved with antibiotics and
diuresis, and the patient remained afebrile and hemodynamically
stable throughout his admission. Patient to follow-up as
outpatient for possible elective cholecystectomy.
.
# Epistaxis - Patient reported recurrent episodes of epistaxis
prior to admission. He had no significant episodes of nasal
bleeding while inpatient and remained hemodynamically stable
throughout. He was monitored with serial hematocrits and
treated with afrin nasal spray prn.
.
# Cirrhosis - Secondary to alcohol use, with his last drink
about 4 weeks ago. Esophogeal varices seen on EGD during prior
hospitalization. No history of SBP. INR and bilirubin elevated
and unchanged from prior admission. He was treated with lasix,
aldactone, 2L/day fluid restriction and a low sodium diet.
Additionally, he was continued on multivitamin, thiamine and
folate, and provided with extensive nutritional counseling.
.
# Hyperbilirubinemia - Pt underwent ERCP with biliary stent
placement at prior admission, with no improvement in
hyperbilirubinemia. Biliary stent removal via ERCP was perfomed
on .
.
# Hypertension - Conitnued on home dose Toprol XL.
.
# Gout - Continued on home allopurinol.
## MEDICATIONS ON ADMISSION:
1. Allopurinol mg Tablet
## SIG:
One (1) Tablet PO DAILY
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
## SIG:
Two (2) Tablet Sustained Release 24 hr PO DAILY
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
## 4. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
## DISCHARGE MEDICATIONS:
1. Allopurinol mg Tablet
## SIG:
One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
## SIG:
Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 12 days.
Disp:*36 Tablet(s)* Refills:*0*
## 5. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
6. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
9. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
BID (2 times a day) as needed for nosebleeds.
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
## DIAGNOSES:
1. Acute Cholecystitis
2. Epistaxis
3. Cirrhosis
4. Alcoholic Hepatitis
## DISCHARGE CONDITION:
Good; afebrile. hemodynamically stable and improved.
## DISCHARGE INSTRUCTIONS:
You have a diagnosis of cirrhosis and were admitted to the
hospital with abdominal pain and increased abdominal ascites.
You were treated with antibiotics for a possible gallbladder
infection. Additionally, you underwent a paracentesis with 8L
of fluid removed, and an endoscopy where your biliary stent was
removed.
.
We have started you on two antibiotics, flagyl and cirpro.
Please take these medications for another 12 days. Take all of
your other medications as prescribed and do your best to adhere
to a 2 gram sodium diet daily. You should also weigh yourself
daily, and if your weight increases by >3 lbs, you should call
your liver doctor, at .
.
If you develop fever > 101, worsening abdominal pain, nausea or
vomiting, vomiting blood, blood in your stool, black tarry
stools, chest pain, shortness of breath, decreased urine output,
worsening yellowing of your skin or eyes, confusion or any other
symptom that concerns you, please contact your primary care
physician or go to the nearest emergency room for evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11581456", "visit_id": "20692707", "time": "2183-11-02 00:00:00"} |
10026263-DS-10 | 1,305 | ## HISTORY OF PRESENT ILLNESS:
with h/o CAD s/p stents x2 in , on ASA + Plavix, who
presents with one week of lightheadedness, fatigue, right
shoulder pain, and shortness of breath (SOB). He reports that
the fatigue/SOB occurs after 1 flight of stairs, which is
abnormal for him. He also had symptoms with lifting boxes at
work. In regards to the shoulder discomfort, he describes it as
a "hollow feeling" in his right shoulder without frank pain,
with some extension into the right arm. His symptoms improve
with SL nitro. There is no particular pattern with exertion, but
sometimes it wakes him up at night. He also reports some
intermittent epigastric pain which he reports is how his prior
MI presented, but currently not associated with activity. He
denies any peripheral edema. He has had sclerotherapy recently
for ganglion cyst in his leg and held Plavix about 1 month ago
for that.
In the ED, initial vitals were T 97.6 HR 78 BP 125/70 RR 16 SaO2
99% on RA. Labs and imaging significant for normal CBC, Chem 10,
and troponin. EKG: NSR at 67 bpm with Q waves in III and aVF,
similar to baseline.
Vitals on transfer were T 98.2 BP 160/87 HR 87 RR 18 SaO2 98% on
RA. On arrival to the floor, patient reports some epigastric
discomfort and right arm discomfort similar to before.
## REVIEW OF SYSTEMS:
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is as above.
## 2. CARDIAC HISTORY:
-CABG:
None
-PERCUTANEOUS CORONARY INTERVENTIONS: 2 drug eluting stents:
proximal and mid LAD ( )
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-cluster headache (no terrible headaches for years)
-Left leg tibial/fibula ganglion cyst
-BPH
## FAMILY HISTORY:
No family history of cancer, arrhythmia, cardiomyopathies, or
sudden cardiac death. His uncle and cousin died of MIs in their
.
## GENERAL:
WDWN in NAD.Oriented x3. Mood, affect appropriate.
## HEENT:
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
## NECK:
Supple without elevation of JVP cm.
## CARDIAC:
RRR, no murmurs, rubs or gallops.
## ABDOMEN:
Soft, non-tender, not distended. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominial bruits.
## EXTREMITIES:
No clubbing, cyanosis or edema. 2+ pulses
## NEURO:
CN II-XII grossly intact, moving all extremeties,
sensation grossly normal. Gait not tested.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge
## NECK:
Supple without elevation of JVP cm.
## CARDIAC:
RRR; no murmurs, rubs or gallops.
## EXTREMITIES:
No clubbing, cyanosis or edema. 2+ pulses
## PERTINENT RESULTS:
12:00PM WBC-4.7 RBC-4.58* HGB-14.6 HCT-44.2 MCV-97
MCH-31.8 MCHC-32.9 RDW-13.8
12:00PM NEUTS-62.6 MONOS-6.2 EOS-4.3*
BASOS-0.5
12:00PM PLT COUNT-184
12:00PM PTT-28.6
05:57AM WBC-4.9 RBC-4.55* Hgb-14.2 Hct-43.5 MCV-96
MCH-31.3 MCHC-32.7 RDW-13.6 Plt
12:00PM GLUCOSE-93 UREA N-21* CREAT-0.9 SODIUM-140
05:57AM Glucose-95 UreaN-17 Creat-0.9 Na-140 K-4.6
Cl-103 05:57AM Calcium-9.3 Phos-3.2 Mg-2.2
HCO3-28 AnGap-14
12:00PM cTropnT-<0.01
06:50PM CK(CPK)-80 CK-MB-3 cTropnT-<0.01
05:57AM CK(CPK)-81 CK-MB-2 cTropnT-<0.01
ECG 11:05:56 AM
Sinus rhythm. Prior inferior myocardial infarction. Compared to
the previous tracing of no diagnostic interim change.
CHEST (PA & LAT) 2:10
The cardiomediastinal, pleural and pulmonary structures are
unremarkable. There is no pleural effusion or pneumothorax. No
focal airspace consolidation is seen to suggest pneumonia. Heart
size is normal. There are mild degenerative changes of thoracic
spine, with anterior osteophytosis.
Cardiac catheterization
1. Selective coronary angiography of this left dominant system
demonstrated no angiographically apparent, flow-limiting
coronary artery disease. The LMCA was normal in appearence. The
LAD stents were widely patent with no significant flowing
limiting lesions. The dominant LCx had no significant lesions.
The RCA was small, non-dominant with no significant luminal
narrowing.
2. Limited resting hemodynamics revealed normal left
ventricular filling pressures, with an LVEDP of 5mmHg. The was
no transvalvular gradient to suggest aortic stenosis. The was
normal systemic blood pressure, with a central aortic pressure
of 113/72 mmHg.
## BRIEF HOSPITAL COURSE:
yo man with history of CAD s/p drug-eluting stenting of
proximal and mid LAD in , now presenting with right arm
discomfort, epigastric pain, fatigue, and shortness of breath
with exertion.
## # ARM DISCOMFORT, FATIGUE, DYSPNEA:
Symptoms were concerning for
unstable angina given new onset over past week, though symptoms
were predominantly on exertion and resolve with rest. Of note,
he does have some epigastric discomfort which is a similar
presentation to his prior MI. However, troponins were negative
and EKG unchanged. Coronary angiography revealed no
flow-limiting lesions and in particular no in-stent restenosis
or thrombosis. Unclear what was causing his shortness of breath
with right arm discomfort, but small vessel ischemia or
diastolic dysfunction could not be excluded; he was already on
dual anti-platelet therapy, ACE-I, and a calcium channel
blocker. We continued his Plavix (although not clear he needs
this years S/P DES). Atorvastatin was begun to avoid drug-drug
interactions with simvastatin. He would also benefit from a
beta-blocker for post-infarct secondary prevention given prior
NSTEMI in , but we deferred substitution of his veramapil
for a beta-blocker to his outpatient cardiologist.
## # HYPERTENSION:
continued on ACE-I and verapamil
## # BPH:
Continued on alfuzosin
# CODE: full
# EMERGENCY CONTACT: wife number:
Cell phone:
Transitions of care:
-follow up with outpatient cardiology.
## MEDICATIONS ON ADMISSION:
alfuzosin 10 mg po daily
Plavix 75 mg daily
cyclobenzaprine 10 mg TID PRN
lisinopril 5 mg daily
ranitidine 300 mg po daily
simvastatin 80 mg po daily
verapamil 240 mg ER daily
aspirin 325 mg daily
MVI
Omega 3/vitamin E
## DISCHARGE MEDICATIONS:
1. alfuzosin 10 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO daily ().
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for muscle spasm.
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a
day.
6. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
## 8. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
9. Omega 3 Oral
10. vitamin E Oral
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Chest pain without biomarker evidence of myonecrosis
Coronary artery disease with prior myocardial infarction
Hypertension
Benign prostatic hypertrophy
## DISCHARGE INSTRUCTIONS:
It was a pleasure participating in your care at . You were
admitted to the hospital for chest pain. Cardiac catheterization
was re-assuring that there was no blockage in your coronary
arteries.
REGARDING YOUR MEDICATIONS...
Medications STARTED that you should continue:
atorvastatin
Medications STOPPED this admission:
simvastatin
Medication DOSES CHANGED that you should follow:
NONE
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Please followup with your primary care physician
days regarding the course of this hospitalization.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10026263", "visit_id": "26565360", "time": "2139-11-29 00:00:00"} |
15794450-RR-64 | 85 | ## INDICATION:
History of stroke and recent mental status decline, question of
acute abnormality.
## FINDINGS:
There is no intracranial hemorrhage. There is a large area of
encephalomalacia involving the right frontoparietotemporal lobes, the degree
of which is unchanged from the previous study. Associated with this is mild
ex vacuo dilation of the ipsilateral lateral ventricle. Otherwise, ventricles
and sulci are normal in size and in configuration. There is no fracture.
Mastoid air cells are clear.
## IMPRESSION:
Remote right-sided infarctions. No acute intracranial
abnormality.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15794450", "visit_id": "21555782", "time": "2157-01-04 15:25:00"} |
14499848-RR-4 | 121 | ## FINDINGS:
The heart is normal in size. The mediastinal and hilar contours
appear within normal limits. Lung markings are coarse with irregular
architecture, suggestive of underlying lung disease. This appearance could be
seen with obstructive pulmonary disease, interstitial lung disease or a
mixture of both. The prominence of the interstitium makes it difficult to
exclude more acute etiologies, however, such as mild vascular congestion,
airway inflammation or atypical infection. There is no definite pleural
effusion. Diaphragms are flattened, however, so subpulmonic effusions are not
excluded, although the finding may relate to hyperinflation.
## IMPRESSION:
Coarse irregular lung architecture suggesting underlying lung
disease. No definite superimposed process, but vascular congestion, airway
inflammation or atypical infection may be involved with this appearance.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14499848", "visit_id": "27724284", "time": "2147-06-26 09:48:00"} |
12569899-RR-25 | 99 | ## FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, proximal femoral, mid femoral, distal femoral and popliteal veins.
Right and left posterior tibial veins demonstrate normal compressibility.
Normal color flow and compressibility is seen in the right peroneal veins.
Normal color flow is seen in the left peroneal veins. There is normal
respiratory variation of the common femoral veins bilaterally.
Patient is status post right femoral to popliteal bypass graft which appears
occluded.
## IMPRESSION:
No evidence of deep vein thrombosis. Occluded right femoral to popliteal
bypass graft, not fully assessed on this exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12569899", "visit_id": "24917863", "time": "2126-01-18 18:22:00"} |
15018622-DS-18 | 280 | ## ALLERGIES:
No Drug Allergy Information on File
## HISTORY OF PRESENT ILLNESS:
year-old M presents as transfer from OSH for hematemesis
and EGD findings consistent with ischemic stomach and esophagus.
Patient has history of gastric CA and underwent chemo/XRT/stent
placement . He had been doing well. He underwent CCY and L
inguinal hernia repair in 2 weeks ago and had subsequent ERCP
with sphincterotomy 1 week later. He recovered normally and
yesterday started having severe vomiting. Vomiting became
bloody
late last night and into this morning. He was transferred to OSH
and was transfused with pRBCs and FFP for coagulopathy. EGD
showed blood in esophagus as well as distal esophageal and
gastric necrosis. Patient then became septic and oliguric as the
course of the day went on. He was transferred to for
evaluation as to whether there was an operation that could
salvage him. At current time, he is intubated and sedated on 2
pressors.
## PAST MEDICAL HISTORY:
?adenoCA of stomach - s/p stent at 40-50 cm,
gallstones, A Fib, DM, DVT/PE, neuropathy, SCCA L ear, thyroid
nodule
## LUNGS:
Coarse B/L, decreased at based
## ABD:
distended, firm, no guarding, no rebound, no hernias
## EXT:
cool, slightly mottled B/L
## BRIEF HOSPITAL COURSE:
Patient was admitted to surgical ICU. He was intbutated, on 2
pressors, and in septic shock. CXR showed free air under
patient's hemidiaphragn. After extensive discussion with Dr.
, in which the severity of the patient's condition was
carefully discussed to the patient's family, the patient's
family decided to make him CMO. Patient expired 3 hrs after
admission.
## MEDICATIONS ON ADMISSION:
Coumadin, Lopressor, Amitriptyline, Gaviscon, Protonix 40 mg bid
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15018622", "visit_id": "27176984", "time": "2179-09-04 00:00:00"} |
10188231-RR-81 | 426 | ## INDICATION:
Patient status post Morgagni hernia repair on , who now
presents with right-sided chest pain.
## CT CHEST:
Partially imaged thyroid gland is unremarkable. There are no
pathologically enlarged axillary lymph nodes. Aorta appears normal in
caliber. Pulmonary arteries are unremarkable. Heart is normal in size, with
trace pericardial effusion. Great vessels are unremarkable. There are no
pathologically enlarged mediastinal or hilar lymph nodes. The
tracheobronchial tree is patent to subsegmental levels. Linear opacities in
the lung bases likely represent atelectasis. Centrilobular emphysema
involving the upper lobes is mild. The esophagus appears slightly patulous
and contains layering enteric contrast throughout its course possible due to
reflux. Elevation of the right hemidiaphragm is noted. There is an anterior
mediatinal fluid collection at the site of prior Morgagni hernia measuring 8.1
ML x 6.2 AP x 7.2 CC (2:31, 400b:15). This fluid collection measures 13
Hounsfield units in attenuation, however, there is a dense fluid level likel
representing layering blood products (401b:31).
## CT OF THE ABDOMEN:
Evaluation of visceral organs is limited due to lack of
intravenous contrast. There is an intra-abdominal fluid collection
immediately just deep to the mesh abutting the anterior abdominal wall, which
measures 13 (ML) x 5 (AP) x 12.6 (CC) cm (2:59, 400b:15). This fluid
collection measures 10 Hounsfield units without a hematocrit level. There is
no clear communication with the supradiaphragmatic collection. The
gallbladder is incompletely distended. There is no gallbladder wall edema or
pericholecystic fluid collection to suggest acute inflammation. There are no
calcified gallstones within its lumen. Spleen is unremarkable. Pancreas is
of homogeneous attenuation without ductal dilatation or peripancreatic fluid
collection. Adrenal glands appear normal. Visualized kidneys are
unremarkable. There is no hydronephrosis. A 4.2 x 3.7 cm hypodense lesion
arising from the right kidney measures 8 Hounsfield units density in
attenuation, compatible with a cyst. There is no free air within abdomen.
Soft tissue induration and stranding of the anterior abdominal wall is likely
post-surgical (2:74).
## OSSEOUS STRUCTURES:
No suspicious lytic or sclerotic lesion is seen.
## IMPRESSION:
1. Large supra and infradiaphragmatic fluid collections along the mesh in the
anterior body wall at the site of recent Morgagni hernia repair. No clear
communication between these collection. Small hematocrit level in the
supradiaphragmatic collection. The above findings most likely represent
post-surgical seroma/hematomas. Superimposed infection cannot be entirely
excluded.
2. Slightly dilated and patulous esophagus with layering contrast material
within its lumen, which may predispose patient to aspiration.
3. Right renal cyst.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10188231", "visit_id": "29806145", "time": "2127-10-16 17:20:00"} |
18267137-RR-13 | 99 | ## INDICATION:
year old woman with back and right leg pain // please
evaluate lumbar nerve roots please evaluate lumbar nerve roots
## FINDINGS:
Lumbar alignment is anatomic. Vertebral body heights are preserved. There is
no suspicious marrow signal. Disc signal and heights are preserved. The
conus medullaris terminates at the L1 vertebral level, within expected limits.
There is no signal abnormality of the visualized cord, conus medullaris or
cauda equina.
There is no neural foraminal or spinal canal narrowing.
Prevertebral and paraspinal soft tissues are unremarkable.
## IMPRESSION:
1. Unremarkable MRI lumbar spine without spinal canal or neural foraminal
narrowing.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18267137", "visit_id": "N/A", "time": "2171-12-15 08:03:00"} |
13008336-RR-17 | 426 | ## HISTORY:
woman with L1 burst fracture with significant loss of
height and retropulsion on CT. Evaluate for spinal cord injury.
## L-SPINE:
Sagittal T1, sagittal STIR, sagittal T2, axial T2 upper and lower.
## CERVICAL SPINE:
Sagittal T2, sagittal T1, sagittal STIR, axial gradient echo
from C1-T1, sagittal T2 and axial gradient echo C1-T1.
## :
C1 through T4 are visualized. There is no acute fracture or
malalignment. There is no prevertebral soft tissue swelling. Multilevel
spondylosis including disc osteophyte complexes indenting the thecal sac at
C5-C6 and C6-C7. The signal within the spinal cord is preserved with no
abnormality in the signal.
## LUMBAR SPINE:
There is a burst fracture of L1 vertebral body with around 80%
loss of height. There is extensive retropulsion into the spinal canal with
moderate-to-severe spinal canal narrowing. There is sagittal fracture between
the lamina of L1 extending into the spinous process.
There is a small anterior prevertebral hematoma. There is a hematoma in the
spinal canal, extending poster to vertebral bodies from L2-L4, 4:12. There is
irregularity of the posterior wall of thecal sac at level L2 suggestive of
small hematoma.
There is compression of the conus, at L1 level, but no edema in conus seen.
There is a suggestion of a horizontal line at the fracture level, L1 level,
inferior to L1 lamina and spinous process with suggestion of a widening
between spinous processes at this level, suggestive of ligamentous injury, but
not clear. There is a disruption of anterior longitudinal ligament at this
level, at 3:11. Additionally, there is a suggestion of a defect in the
ligamentum flavum at 4:12. There is a suggestion of a discontinuity of
posterior longitudinal ligament at level L1.
There is a grade 1 anterolisthesis of L4 on L5 with facet arthropathy. At L4-
L5, there is bulged disc with anterior impingement of the thecal sac. There
is end-plate spondylosis at L5-S1. There is suggestion of a hemangioma at L3
vertebral body.
## CERVICAL SPINE:
Mild degenerative changes in the cervical spine. Normal
signal in spinal cord.
## LUMBAR SPINE:
Burst fracture of L1 posterior element involvement.
Retropulsion into the spinal canal with moderate-to-severe canal stenosis.
Compression on conus at this level, but no edema in conus. Disruption of
anterior longitudinal ligament, posterior longitudinal ligament, and
ligamentum flavum, with suggestion of ligamentous injury at the posterior
elements at this level.
Hematoma within the spinal canal extending anteriorly to the thecal sac from
L2-L4, and posteriorly to thecal sac at level L2.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13008336", "visit_id": "26919600", "time": "2186-04-14 11:33:00"} |
18722792-RR-42 | 248 | ## EXAMINATION:
CT right femur without contrast
## INDICATION:
year old woman with past history of breast cancer, now under
treatment for marginal zone lymphoma/ 's macroglobulinemia, s/p
traumatic sacral ala insufficiency fractures, with incidental finding on
sclerotic lesion of R femur.
## FINDINGS:
In the proximal the of the right femoral diaphysis, there is a
well-circumscribed 8 x 6 mm ovoid sclerotic lesion in intramedullary location
without surrounding cortical thickening or periosteal reaction. Given the
lack of suspicious features, this most likely represents a bone island. No
other bony lesion is identified. There is no fracture or dislocation. There
is mild degenerative narrowing of the right hip. There is mild degenerative
spurring in the right knee there is a small osteochondral defect in the load
bearing surface of the right lateral femoral condyle, anterior portion. A
unusual lymph node in the popliteal fossa measures up to 20 x 9 mm in axial
(4:210). There is a well ossified loose body posterior to the
right lateral femoral condyle.
## IMPRESSION:
1. Well-circumscribed 8 x 6 mm sclerotic lesion in the right femur lacks
suspicious features and most likely represents bone island. Given the history
of breast cancer, follow-up radiographs or bone scan could be considered but
the lesion has a very low probability of malignancy.
2. Small OCD in the load bearing surface of the anterior right lateral femoral
condyle.
3. Prominent popliteal lymph node which may be related to the history of
lymphoproliferative malignancy.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18722792", "visit_id": "24909395", "time": "2200-10-02 13:45:00"} |
10104308-RR-81 | 109 | ## INDICATION:
man with abdominal pain, to evaluate for pneumonia or
free air.
## FINDINGS:
The cardiomediastinal contours are unremarkable except for mild
cardiomegaly. The lung volumes are slightly low, but no focal consolidation
is detected. No pneumothorax is evident. The right pleural effusion has
significantly decreased since the earlier study of with only a trace
amount of pleural fluid present. There is mild cephalization of the pulmonary
vascular markings without overt pulmonary edema. Nasogastric tube courses
through the stomach and out of view. No free intraabdominal air is noted under
the diaphragms.
## IMPRESSION:
Trace right pleural effusion. No other acute cardiopulmonary
pathology. No free air under the diaphragms.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10104308", "visit_id": "25947152", "time": "2159-12-22 09:31:00"} |
18338026-DS-10 | 1,667 | ## ALLERGIES:
No Allergies/ADRs on File
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
intubation
intubation
chest tube insertion
intubation
paracentesis:
## HISTORY OF PRESENT ILLNESS:
Ms. is a y/o female with a history of alcohol use
disorder, ADHD, depression and anxiety who presents as an OSH
transfer from for alcoholic hepatitis c/b
acute hypoxic respiratory failure, acute renal failure requiring
RRT, and persistently leukocytosis/transaminitis.
The patient was admitted to on
following one week of abdominal pain/distention, vomiting and
jaundice. She initially presented to but was
transferred to given concern for
choledocholithiasis
(dilated CBD to 7mm, Tbili 10.1, AST 288, ALT 37, Alk phos 620,
lactate 5.1). MRCP on admission showed borderline prominent CBD
without evidence of choledocholithiasis, gallbladder sludge w/o
cholecystitis and moderate ascites. She underwent paracentesis
that revealed a low SAAG and was negative for SBP. She was noted
to have MDF of 74 and was started on prednisolone, which was
later held due to concern for infection. During her
hospitalization, CXR was concerning for multifocal pneumonia,
prompting initiation of vanc/cefepime on . Despite
antibiotics, she became increasingly hypoxic requiring ICU
transfer and then intubation on .
Her ICU course was complicated by hypotension require pressors,
and broad spectrum antibiotics (vanc/cefepime/azithro ->
as well as acute renal failure felt to be
ATN from hypotension. She was started on CVVH and TTE done for
hypotension showed normal EF 65%. She was also given IV vitamin
K
and 1u FFP for coagulopathy and noted to have macrocytic anemia
felt to be likely from nutritional deficiency as well as from
intermittent rectal bleeding. She was found to have a rectal
prolapse, evaluated by colorectal surgery who felt that there
was
nothing to be done currently. She was eventually extubated and
transitioned from CVVH to iHD on .
She was transferred to the step-down unit on . She
continued HD, last on and was started on midodrine 5mg
TID for borderline low blood pressures in the 80-90s. She was
also noted to be febrile on with ongoing leukocytosis.
Repeat cultures, CXR, RUQ ultrasound, and CT abd/pelvis were
overall unrevealing. Aspergillus, c.diff PCR, RPR, urine
legionella, HIV Ab and cryptococcal ag were also negative. She
has remained on vancomycin since and meropenem since .
Reportedly afebrile over the last few days. Her course was
further complicated by ongoing BRBPR, felt possibly from the
prolapse. She was given 1u pRBC on for Hgb around 6.5. She
also had intermittent runs of NSVT and then a sustained run of
VT
for 31 seconds during HD before converting back without
intervention. She has had persistent confusion and paranoia,
though remained oriented. It was felt to be HE and delirium
but also prompted concern for Wernicke's encephalopathy, treated
with high dose IV thiamine.
Upon arrival to the floor, the patient triggered for hypotension
with SBP in the 70-80s. The patient was unwilling to provide
further history. She would not speak with the interviewer. Using
headnods, she denied chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, melena, hematochezia, fever,
chills, or confusion.
## PAST MEDICAL HISTORY:
ADHD
Anxiety
Depression
Alcohol use disorder
Psoriasis
## FAMILY HISTORY:
Per OSH report, patient's father has a history of cancer.
## VS:
Temp 98.2F BP 85/40 HR 90 RR 20 88% on RA
## GENERAL:
Acutely ill appearing, young female in NAD. Appeared
anxious and scared.
## HEENT:
AT/NC,PERRL sclera anicteric, pink conjunctiva, MMM
## HEART:
RRR with normal S1/S2, I/VI systolic murmur at RUSB/LUSB.
No rubs or gallops.
## LUNGS:
Normal respiratory effort. CTAB without wheezes, rales or
rhonchi over anterior chest.
## ABDOMEN:
Soft, minimal distended, non-tender. No guarding or
masses.
## EXTREMITIES:
Warm, well perfused. pitting edema up to mid
shins bilaterally (R>L). No erythema.
## NEURO:
Alert and interactive, though not willing to answer
orientation questions. CN II-XII grossly intact. Moves all
extremities. No willing to participate in asterixis exam.
## SKIN:
warm, dry. Multiple erythematous 2-3 mm lesions over her
chest.
## MOOD:
Answering questions though unwilling to communicate.
Scared
affect.
DISCHARGE EXAM
==================
expired
## PERTINENT RESULTS:
RELEVANT STUDIES
==================
EGD:
Grade B esophagitis in the distal esophagus. Esophageal ulcer.
Varices in the distal esophagus. Congestion, petechiae, and
mosaic mucosal pattern in the stomach fundus and stomach body
compatible with portal hypertensive gastropathy. Hematin was
noted in the stomach. No evidence of gastric varices. Normal
mucosa in the whole examined duodenum.
## DUPLEX DOPP ABD/PEL PORT:
1. Patent hepatic vasculature, but with reversal of flow within
the main,
right and left portal veins.
2. Mildly dilated common bile duct with probable sludge, but no
shadowing
stones seen. No intrahepatic biliary ductal dilatation.
Recommend clinical correlation with bilirubin. If there is
concern for choledocholithiasis consider MRCP or ERCP for
further evaluation.
3. Echogenic, coarsened nodular consistent cirrhosis or
intrinsic liver
disease.
4. Splenomegaly.
TTE:
Normal left ventricular wall thickness and biventricular cavity
sizes and regional/global biventricular systolic function. Mild
aortic and mitral regurgitation. Moderate tricuspid
regurgitation. Borderline pulmonary hypertension. High cardiac
output, c/w known liver disease.
CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS:
1. Necrotizing pancreatitis involving the body and tail.
2. Large quantity ascites.
3. No biliary dilatation.
4. Multiple finding suggesting severe portal hypertension.
5. Anasarca.
6. Bilateral pleural effusions.
7. Uterine fibroid.
## PORTAL VENOGRAPHY:
1. Large portosystemic shunt between the IMV to IVC.
2. Large rectal varices arising from the IMV shunt.
3. Successful STS/lipiodol sclerosis of large predominantly
left-sided rectal varices arising from the IMV.
4. Successful coil and Gelfoam embolization of left-sided and
right-sided
pelvic varices arising from the IMV.
5. Post embolization inferior mesenteric shunt venogram without
evidence of flow to the rectal varices and persistent flow from
the IMV to the IVC.
6. Approximately 3 L non-bloody of ascites drained.
## CT HEAD W/O CONTRAST:
1. No acute intracranial abnormality.
2. Partial opacification of the bilateral mastoid air cells is
nonspecific, and may be related to chronic dependent positioning
or intubation.
MICROBIOLOGY
=================
9:34 am BLOOD CULTURE Source: Venipuncture.
## BLOOD CULTURE, ROUTINE (PENDING):
No growth to date.
4:25 pm BLOOD CULTURE Source: Venipuncture.
## BLOOD CULTURE, ROUTINE (PENDING):
No growth to date.
8:56 am BLOOD CULTURE Source: Venipuncture.
## BLOOD CULTURE, ROUTINE (PENDING):
No growth to date.
4:19 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT
Fluid Culture in Bottles (Final : NO GROWTH.
4:19 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT
GRAM STAIN (Final :
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
## ANAEROBIC CULTURE (FINAL :
NO GROWTH.
11:41 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final :
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
## FUNGAL CULTURE (PRELIMINARY):
NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final :
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
## 3:42 AM URINE SOURCE:
.
**FINAL REPORT
REFLEX URINE CULTURE (Final :
YEAST. >100,000 CFU/mL.
9:55 pm BLOOD CULTURE Source: Venipuncture X 1.
**FINAL REPORT
## BLOOD CULTURE, ROUTINE (FINAL :
NO GROWTH.
7:34 pm SPUTUM Source: Endotracheal.
**FINAL REPORT
GRAM STAIN (Final :
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final :
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
Time Taken Not Noted Log-In Date/Time:
7:25 pm
BLOOD CULTURE
**FINAL REPORT
## BLOOD CULTURE, ROUTINE (FINAL :
NO GROWTH.
11:04 pm BLOOD CULTURE Source: Line-PICC 1 OF 2.
**FINAL REPORT
## BLOOD CULTURE, ROUTINE (FINAL :
NO GROWTH.
11:04 pm BLOOD CULTURE
## SOURCE:
Line-trialysis HD line 2 OF 2.
**FINAL REPORT
## BRIEF HOSPITAL COURSE:
Ms. was a year old woman with alcohol use disorder,
ADHD, depression and anxiety who presented to on
as an OSH transfer from for alcoholic
hepatitis c/b acute hypoxic respiratory failure, acute renal
failure requiring RRT, and persistent
leukocytosis/transaminitis. She immediately triggered upon
arrival to ET for hypotension and ongoing melena requiring ICU
transfer.
Upon arrival to the ICU she was intubated and initiated on
vasopressors for cardiocirculatory collapse, and received 3
units of pRBCs with EGD on with banding of a single varix
in the distal esophagus. She also had an episode of vaginal
bleeding for which she received 1 unit of pRBCs and 2 units of
FFP. She was extubated on but developed a worsening
vasopressor requirement and had recurrent bouts of abdominal
pain for which a lipase was found to be elevated in the 600s
with CT A/P showing necrotizing pancreatitis for which she was
continued on meropenem and started on tube feeds. However, on
she developed a massive bleed for a rectal varix for which
she was re-intubated and started on a massive transfusion
protocol requiring 4 units of pRBCs, 2 units of FFP, and 1 unit
of platelets, and a bleeding rectal vessel was oversown by
Colorectal Surgery at the bedside. This was followed by
sclerosis/coil/embolization of left and right rectal varices
arising from IMV done by . Surgical service was consulted for
the management of her sacral wound, and performed a bedside
debridement. In addition, the surgical service declined drainage
of the pancreatic cyst.
There was discussion of trach but it was not performed as the
patients clinical status was too tenuous. Palliative Care was
involved in the care of this patient and in facilitating
discussion with the family. She was continued on CRRT to aid in
volume removal and in management of her electrolytes. Liver
service declined her candidacy for liver transplantation given
her multiple comorbidities. Ultimately, in the setting of her
worsening overall clinical picture, the decision was made to
transition her care to comfort-focused care. She was extubated
on . On , Ms. died at 11:42 with her
family at the bedside. Her family expressed appreciation and
thanks for the care she had received during her hospitalization.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine XR 10 mg PO DAILY
2. LORazepam 0.5 mg PO Q8H:PRN anxiety
## DISCHARGE DIAGNOSIS:
cirrhosis
renal failure
gastrointestinal bleeding
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18338026", "visit_id": "28683074", "time": "2186-11-27 00:00:00"} |
17785621-DS-11 | 988 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
year old female with no significant history, transferred from
, presents with right upper quadrant pain.
She reports this being present since the night before admission,
located in the right upper quadrant, , radiated to her left
shoulder blade and mid back associated with one episode of
non-bilious vomiting. She also had some chills and hot flashes.
She denies any diarrhea or fever or headache. She denies any
changes of stool or urine color. She has no skin rash or
itching. She had a cholecystectomy at the age of . Outside
labs showed AST 172, ALT 101, normal alkaline phosphatase, total
bilirubin 2.1, normal lipase
In the ED, initial vitals were 97.1 74 103/64 16 99% RA. She
had RUQ tenderness and positive sign on abdominal
exam.. Labs showed ALT 99, AST 79, AP 51, Tbili 1.8, hemoglobin
9.7, WBC 6.2K. Outside hospital abdominal ultrasound showed CBD
dilation to 8 mm concerning for choledocholithiasis. She
received morphine sulfate 4 mg IV x 1 and 1 liter NS.
Currently, the patient reports no abdominal pain or nausea or
vomiting.
Review of systems:
10 pt ROS negative other than noted
## FAMILY HISTORY:
Father with diabetes
grandmother with diabetes
## GEN:
Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
## HEENT:
NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
## SUPPLE, NO JVD
LYMPH NODES:
No cervical, supraclavicular LAD.
## CV:
S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
## RESP:
Good air movement bilaterally, no rhonchi or wheezing.
## ABD:
Soft, non-tender, non-distended, + bowel sounds.
## EXTR:
No lower leg edema
## HEENT:
Anicteric, eyes conjugate, MM dry, no JVD
## CARDIOVASCULAR:
RRR no MRG, nl. S1 and S2
## PULMONARY:
Lung fields clear to auscultation throughout
## GASTROINESTINAL:
Soft, mild ttp in midline in lower quadrants
without rebound, negative
## SKIN:
No rashes or ulcerations evident
## NEUROLOGICAL:
Alert, interactive, speech fluent, face symmetric,
moving all extremities
## ERCP :
Limited exam of the esophagus was normal
Limited exam of the stomach was normal
Limited exam of the duodenum was normal
The scout film was normal.
The major papilla appeared normal.
The CBD was successfully cannulated with the CleverCut 3V
sphincterotome preloaded with a 0.025in guidewire.
The guidewire was advanced into the intrahepatic biliary tree.
Contrast injection revealed a normal CBD of approximately 7mm
in diameter and a small filling defect consistent with a stone
in the distal CBD.
The intrahepatic biliary tree appeared unremarkable.
A sphincterotomy was successfully performed at the 12 o'clock
position. No post sphincterotomy bleeding was noted.
The CBD was swept several times with successful removal of one
small spiculated stone.
No further filling defects noted.
here was excellent spontaneous drainage of bile and contrast at
the end of the procedure.
The PD was not injected or cannulated.
## RUQ ULTRASOUND (OSH):
1. Cholelithiasis without specific evidence for acute
cholecystitis.
2. Mildly prominent extrahepatic duct at the porta measuring 8
mm, withmore distal obscuration due to overlying bowel gas. No
intrahepatic biliary ductal dilatation. If there is concern for
choledocholithiasis, MRCP should be considered.
## DISCHARGE LABS:
================
06:00AM BLOOD WBC-5.2 RBC-4.98 Hgb-9.4* Hct-31.9*
MCV-64* MCH-18.9* MCHC-29.5* RDW-17.0* RDWSD-38.3 Plt
06:00AM BLOOD Glucose-78 UreaN-11 Creat-0.6 Na-139
K-4.4 Cl-106 HCO3-26 AnGap-11
06:00AM BLOOD ALT-83* AST-50* LD(LDH)-208 AlkPhos-50
TotBili-1.8*
06:00AM BLOOD Calcium-8.1* Phos-3.6 Mg-2. year old female with history of knee osteoarthritis,
transferred from with abdominal pain found
to have choledocholithiasis s/p ERCP
# Choledocholithiasis
# Abdominal pain
Patient initially presented with abdominal pain, n/v found to
have choledocholithiasis. She underwent ERCP and sphinterotomy
on with improved symptoms and slowly improving LFTs. She
was started on ciprofloxacin 500mg PO BID for 5 days for
infection prophylaxis. On , diet was slowly advanced with
minimal abdominal pain. Ms. was seen by
surgery and Dr. was consented for cholecystectomy to
take place on .
## # MICROCYTIC ANEMIA:
Patient with unknown baseline hemoglobin
and hematocrit. On admission, her hemoglobin and hematocrit were
low with low MCV. H/H stable overnight. She will need
of her anemia with iron studies and work-up as outpatient.
## TRANSITIONAL ISSUES:
=====================
[]Plan for cholecystectomy
[]Please repeat LFTs on at PCP to ensure
continued improvement.
[]Please repeat CBC and consider iron studies and anemia work-up
as outpatient
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. TraMADol 50 mg PO Frequency is Unknown
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*8 Tablet Refills:*0
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to the hospital with abdominal pain and
vomiting. You were found to have a stone in your bile duct. You
underwent an ERCP with removal of the stone from your bile duct.
Following the procedure, you were started on a medication called
ciprofloxacin (an antibiotic) to prevent infection. You will
take this medication through .
Because of your gallbladder disease, the recommendation is for
you to have your gallbladder removed. You were seen by the
surgery team and will plan for a cholecystectomy on .
Following the procedure, you should refrain from taking any
blood thinners including aspirin for at least 5 days.
Please call your doctor or return to the Emergency room if you
have worsening abdominal pain, nausea, vomiting, bloody or black
stool, fever >100.4 or any other symptoms that concern you.
It was a pleasure taking care of you,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17785621", "visit_id": "27190632", "time": "2145-02-03 00:00:00"} |
13882437-DS-15 | 1,721 | ## CHIEF COMPLAINT:
cc: lower extremity swelling
## HPI:
The patient is an year old male with h/o CHF EF = 25%, atrial
fibrillation not on coumadin secondary to large GIB, peripheral
neuroppathy, chronic venostasis and peripheral edema who
presents
with L foot pain x months along with xerosis of the skin
with
ulcers and then developed increased lower extremity swelling and
redness over the past two weeks. He went to where he was
found to have a left lower extremity DVT. His last car trip was
end of /early when he drove 100 miles to
-
. No other travel. No long plane rides. He has not
been laying around in bed but has been performing his usual
routine consisting of going out to dinner with his wife and
going
shopping with his wife.
He has chronic shortness of breath and there has not been any
worsening. He does not report chest pain. He has a chronic cough
of clear phlegm and this has not changed recently. No shortness
of breath at rest since his was changed.
He originally presented to where he was given clindamycin
and his US demonstrated LLE DVT
.
## PAIN SCALE:
pain in the L leg
## PAST MEDICAL HISTORY:
## H/o Vtach s/p bi-V pacer in
## Originally s/p SENSIA SESR01 S/N
implanted for AF with slow ventricular response
## History of lower GI bleed with recurrent diverticular bleed.
## Atrial fibrillation off Coumadin.
## CKD stage III.
## Hypothyroid.
## Hyperlipidemia.
## COPD.
## Chronic venostasis.
## Gout.
## Hypertension.
## BPH.
## Prostate cancer.
## CHF with an EF of 25%.
## Status post appendectomy.
## Glaucoma.
## Bilateral neuropathy from leg edema.
## History of gastric polyp.
## Schatzki ring.
## FAMILY HISTORY:
His father died of heart disease in his . His mother died of
cancer in her . He thinks it was breast cancer.
## GENERAL:
Elderly male laying in bed. NAD
## MENTATION:
Alert speaks in full sentences
## 2. EYES:
[] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [X] WNL
[X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD
cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [+] Systolic Murmur ,
## LOCATION:
holosystolic blowing murmur with radiation to the
axilla
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
## LOCATION:
[X] Edema RLE 2+ with erythema and chronic venous stasis
[X] Edema LLE 3+- 4+ with + ulcer on lateral mallelus with
intense surrounding erythema, tender to the touch. Could not
express pus. + skin break down with scratches which ooze blood.
[X] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
Diminshed breath sounds throughout but clear
6. Gastrointestinal [X] WNL
[X] Soft/firm
[X] Non distended [] distended [] bowel sounds Yes/No [X]
guiac: negative- brown stool
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [X]Upper extremity strength and symmetrical [
]Other:
B/l dorsi flexion which patient states is chronic secondary
to
8. Neurological [] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [X ]
CN II-XII intact [ X] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument:
+ b/l bleeding superficial ulcers on feet. B/l lower extremity
erythema and edema L > R
[ ] Cool [] Moist [] Mottled [] Ulcer:
## NONE/DECUBITUS/SACRAL/HEEL:
Right/Left
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [ ]WNL
[X] No cervical [] No axillary [] No supraclavicular
[] No inguinal [] Thyroid WNL [] Other:
##
97.3 BP:
96/55 HR: 70 R: 18 O2: 97% RA
Laying in bed in NAD, pleasant and conversant
## LUNGS:
Clear B/L on auscultation
## :
RRR, S1, S2 present, distant heart sounds
## EXT:
B/L lower extremity edema L>R. red excoriations on left
middle malleolus. tender to touch with surrounding
erythema. Small +papular rash on dorsum of foot and anterior
knee.
## NEURO:
AAOx3, pleasant and conversant
## EKG:
IVCD, 72 bpm, non -s pecific lateral ST changes
.
## LAST ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. A mass is seen in the right atrium. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. Overall left ventricular systolic
function is severely depressed (LVEF= secondary to
severe
global hypokinesis. The right ventricular cavity is dilated with
mild global free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild to moderate ( ) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
small mobile filamentous echodensity noted in proximity of an RA
catheter tip (clips 38-39). Although this echodensity is likely
part of Chiari's network (normal RA embryologic variant), a
vegetation cannot be excluded. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial
effusion
.
Admission LEUS at :
Below the knee, images are notable for visible subcutaneous
edema and, on physical exam there was obvious pitting edema and
discoloration in the left lower extremity.Beginning just below
the level of the mid lower leg, in the region of the posterior
tibial vein, this vein becomes noncompressible and colorsignal
is
only intermittently evident. Although the findings suggest
thrombotic occlusion, this is likely partial and poorly imaged.
.
## IMPRESSION:
ULTRASOUND SHOWING PROBABLE PARTIAL THROMBOTIC VENOUS OCCLUSION
OF THE DISTAL TIBIAL VEINS. FOLLOW-UP SONOGRAPHIC EXAM WHEN
EDEMA HAS DECREASED MAY BE INFORMATIVE. CURENT IMAGES ALSO
NOTABLE FOR PROMINENT SUBCUTANEOUS EDEMA
## FINDINGS:
The right common femoral vein demonstrates normal color Doppler
flow, waveform
and augmentation.
There is normal compressibility, flow and augmentation of the
left common
femoral, superficial femoral, and popliteal veins. The posterior
tibial and
peroneal veins are now compressible and demonstrate normal color
flow and
augmentation.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa ( ) cyst.
## IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Posterior tibial and peroneal veins are now completely
compressible, with no
evidence of thrombosis.
The study and the report were reviewed by the staff radiologist.
Xray left foot
## IMPRESSION:
No signs for acute bony injury or radiographic evidence for
acute
osteomyelitis. If there is high concern, MRI could be
performed.
## ASSESSMENT/PLAN:
This is an year old male with h/o severe ischemic
cardiomyopathy with EF = 25%, severe TR ,hypothyroidism, atrial
fibrillation off Coumadin given history of GI bleed who presents
with LLE swelling pain and erythema due to cellulitis
#Cellulitis
#Chronic venous stasis changes
Patient with longstanding lower extremity edema and venous
stasis. Patient may have superimposed cellulitis, although
difficult to determine if these are actually just venous stasis
changes. CRP is 32 making osteomyelitis less likely in addition,
Xray of ankle without signs of osteomyelitis. Can not get MRI
given pacemaker. The patient was treated with clindamycin with
some improvement in his erythema. He was also seen by wound care
and by vascular surgery. Wound care left recommendations for
protective barrier and curlex dressings. Vascular surgery
recommended ACE wraps and leg elevation. The patient has follow
up scheduled in vascular surgery clinic. He was discharged on
Clindamycin to complete a oncern for DVT
The patient was transferred to given concerns for DVT on
ultrasound at . Repeat ultrasound at did not show
lower extremity clot.
#Chronic systolic CHF
Patient presented with chronic shortness of breath which he says
is unchanged from baseline but given his edema there was some
concern that he was in decompensated systolic CHF. HE was given
Lasix 80mg IV x2. Weight on discharge was 194lbs. The patient
was noted to have asymptomatic hypotension on the day of
discharge. He was therefore advised to hold his lasix until seen
by . If blood pressure is greater than 110 systolic, then
furosemide should be resumed at 40mg daily. The patient has
follow up scheduled with his cardiologist the week following
discharge.
#Hypertension, Benign
The patient was noted to have SBP in the systolic. The
patient is asymptomatic. Discussed with PCP and patient has had
low blood pressures in the past. Advised to have check SBP
tomorrow and take lasix if SBP >110. Remainder of cardiac
medications were continued.
Chronic issues:
# Chronic kidney disease- stage III.
The patent has Baseline Cr = 1.8- 2.0. Creatinine was 1.9 on
discharge
#Hyperlipidemia
Continued Statin and baby ASA
#GOUT:
Continued allopurinol
# HYPOTHYROIDISM:
Continued levothyroxine
# Vitamin B12 deficiency:
Continued Vitamin B12.
Transitional issues:
- Blood pressure 90-100s systolic on discharge. will have
check blood pressure tomorrow
- Needs to follow up with vascular surgery 2 weeks after
discharge, appointment arranged
- Will be discharged on antibioitcs to complete a 7 day course
- Weight on discharge: 194lbs
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Allopurinol mg PO DAILY
2. Furosemide 40 mg PO BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Pravastatin 20 mg PO DAILY
7. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
8. Aspirin 81 mg PO DAILY
9. Cyanocobalamin mcg PO DAILY
## DISCHARGE MEDICATIONS:
1. Allopurinol mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin mcg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pravastatin 20 mg PO DAILY
8. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
9. Clindamycin 450 mg PO Q8H
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth Q8hrs Disp #*15
## DISCHARGE DIAGNOSIS:
Cellulitis
Venous stasis ulcers
Congestive heart failure
Chronic kidney disease
## DISCHARGE INSTRUCTIONS:
It was a pleasure taking care of you during your recent
admission to . You were admitted with leg swelling and
concerns you have a blood clot in your leg. You had an
ultrasound which did not show a clot in your leg. You were
treated with antibiotics for a possible infection. You were also
seen by the vascular surgeons who recommended you elevate your
legs and use ACE
Your blood pressure is low, but you have no symptoms of low
blood pressure. A visiting nurse come to your house
tomorrow to check your blood pressure. Please do not take your
Lasix (furosemide) until you see your doctor next week.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13882437", "visit_id": "25932701", "time": "2149-07-03 00:00:00"} |
11340968-DS-8 | 1,837 | ## CHIEF COMPLAINT:
Dyspnea on exertion, lower extremity edema
## HISTORY OF PRESENT ILLNESS:
is an with a history of advanced dementia,
CKD, and aortic stenosis who presents from her SNF with dyspnea.
Due to dementia that patient is unable to provide significant
history, consequently much of the history is taken from the
medical record. She was diagnosed with a pneumonia in and
with recurrent pneumonia weeks ago, treated with
antibiotics.
Per the admission note, "her son reports that she began
needing oxygen about a month or 2 ago, but was always told that
her oxygen saturations were good on low amount of oxygen he
reports that a week ago, she had an echocardiogram which she was
told showed aortic stenosis with a
aortic valve area of 1.0 cm². He was not aware of a diagnosis
of
heart failure."
She was initially admitted to the where a TTE was done
showing normal LVEF with diastolic dysfunction, elevated wedge
pressure (18 mmHg), severe pHTN, and RVH with normal RV function
and chamber size. She was given 10 of IV Lasix followed by
another 20 of IV Lasix with a total of 775 UOP (although some
incontinence as well). She was negative about 435 cc and had
some
symptomatic improvement.
On the floor, the patient reports improvement in her SOB but
does
not feel at her baseline. She has a cough productive of clear
sputum. No congestion, rhinorrhea, fevers, myalgias, CP, calf
pain, n/v/d.
## PAST MEDICAL HISTORY:
CKD
dementia
Aortic stenosis
HFpEF
GERD
## FAMILY HISTORY:
No premature CVD. Her 3 children do not have CVD.
## HEENT:
AT/NC, anicteric sclerae, MMM
## NECK:
JVP of the way to jaw at 45 degrees
## HEART:
RRR, systolic murmur radiating to carotids
## LUNGS:
bilateral crackles halfway up lung fields
## ABDOMEN:
nondistended, nontender in all quadrants, no
rebound/guarding
## EXTREMITIES:
R calf > L calf, 1+ pitting edema
## NEURO:
Alert and oriented to self, "hospital," not date, moving
all 4 extremities with purpose
## GENERAL:
Elderly female, remains alert and interactive
## HEENT:
NC/AT, EOMI, no JVD, neck supple
## LUNGS:
Normalized respiratory rate, no accessory muscle usage.
Bilateral rales improved relative to prior.
## HEART:
systolic murmur appreciated throughout the
precordium. No radiation to carotids. RRR.
## ABDOMEN:
Soft, nontender, nondistended. NABS
## EXTREMITIES:
No lower extremity edema.
## SKIN:
No rashes or lesions noted.
## SOURCE:
Stool.
**FINAL REPORT
C. difficile DNA amplification assay (Final :
Reported to and read back by @ 0708 ON
- .
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
Urine culture
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
## SENSITIVITIES:
MIC expressed in
MCG/ML
ESCHERICHIA COLI
|
AMPICILLIN
-----
16 I
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN
-----
<=4 S
CEFEPIME
-----
<=1 S
CEFTAZIDIME
-----
<=1 S
CEFTRIAXONE
-----
<=1 S
CIPROFLOXACIN
-----
<=0.25 S
GENTAMICIN
-----
<=1 S
MEROPENEM
-----
<=0.25 S
NITROFURANTOIN
-----
32 S
PIPERACILLIN/TAZO
-----
<=4 S
TOBRAMYCIN
-----
<=1 S
TRIMETHOPRIM/SULFA
-----
<=1 S
MRSA Screen
Blood cultures
STUDIES
-----
Echocardiogram
Conclusions
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF = 80%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Doppler parameters are most consistent
with Grade II (moderate) left ventricular diastolic dysfunction.
The right ventricular free wall is hypertrophied. Right
ventricular chamber size is normal with normal free wall
contractility. The ascending aorta is mildly dilated. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is severe
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Renal US . no hydronephrosis.
2. simple parapelvic cyst is stable in the right renal hilum.
3. Anatomic variant of the right kidney which is seen in the
pelvic midline.
## U/S:
No evidence of deep venous thrombosis in the
left lower extremity veins.
## IMPRESSION:
Compared to chest radiographs through .
Mild pulmonary edema has worsened. More severe abnormality in
the left
midlung suggest concurrent pneumonia. Heart size normal. No
appreciable
pleural effusion. Mild cardiomegaly stable. Extremely severe
calcification
of the mitral annulus is noted, a condition often associated
with mitral
regurgitation.
## BRIEF HOSPITAL COURSE:
year old female with advanced dementia, CKD, HTN,
hypothyroidism, and aortic stenosis presented with dyspnea and
hypoxia with echo concerning for acute diastolic heart failure.
## #CORONARIES:
None recorded
#PUMP: EF 80%
#RHYTHM: NSR
## ACTIVE ISSUES:
=================================
# AoCKD:
# CKD IV:
Not on dialysis. Baseline Cr unknown, but appears to be ~2.4-2.5
recently. Creatinine uptrended with diuresis, remains elevated.
FEurea 15.5%, indicating prerenal etiology -- likely represents
cardiorenal syndrome compounded by difficulty with diuresis vs.
ATN. Urine output has markedly decreased. Per family meeting on
, HD is likely not within the patient's goals of care, nor
does it likely provide a viable long term option. Per renal:
Prognosis hard to predict, however, given on O2, inability to
effectively diurese and lack of HD, expectancy on the order of
weeks to months with greater likelihood in the months.
Palliative meeting held , with family on board for
further care at "her home" , unless hospitalization is needed
for comfort. Transitioned to DNR/DNI. Will plan for
transitioning care to SNF. contacted with case management to
ensure 3 things: Capability to treat C diff with PO vanc,
capacity to provide palliative care, and documentation to ensure
son is official HCP given his signature on her behalf for
goals of care. Avoided nephrotoxic agents.
# Acute diastolic heart failure exacerbation
The patient intially presented to the CDAC with volume overload
and was unsuccessfully diuresed. She was admitted for ongoing
diuresis and respiratory disress in the setting of aortic
stenosis. Per echocardiogram done at , her EF was 80% with
increased filling pressures. Patient was diuresed with IV Lasix.
Urine lytes and a renal ultrasound showed no concern for
hydronephrosis. The patient was continued on her metoprolol. IV
diuresis was continued to provided respiratory benefit given she
triggered for hypoxia and tachypnea on . This has
subsequently provided significant respiratory benefit and she
has since not experienced dyspnea.
## #RESPIRATORY DISTRESS:
Resolved
Patient was tachypneic into the with increased work of
breathing and accessory muscle use. The etiology of this was
uncertain, as the patient was volume overloaded but also grossly
aspirating per nursing report. She was treated with zosyn
( ) and azithromycin ( ) for suspected
aspiration pneumonia with significant improvement in her
respiratory status. A formal speech and swallow study
recommended moist ground/extra sauces, thin liquids with
caution, meds who in apples . 1:1 assist. Triggered for
hypoxia and tachypnea on . Further diuresis with BID
Lasix if tolerated chemically subsequently provided significant
respiratory benefit and she has since not experienced dyspnea.
# C diff
Patient tested positive for C diff toxin. She was started on PO
vancomycin, and will complete a course ending 2 weeks after last
dose of systemic antibiotics, which was Zosyn on .
Therefore, she should continue oral vanc until .
# Positive urinalysis
UA notable for large , negative nitrites, 72 WBC, and mod
bacteria. It was uncertain if patient was symptomatic given she
is a poor historian. Urine culture showed 10,000-100,000 cfu of
E. coli. The E. coli was sensitive to zosyn, which the patient
was already on as above.
## =================================
#HYPOTHYROIDISM:
Pt had low TSH (0.25) and elevated free T4
(2.0). Continued decreased levothyroxine 125mg daily
# Aortic stenosis: Not severe per TTE. be contributing to HF
exacerbation. Management of HFpEF as above.
# Advanced dementia: Continued aripiprazole, duloxetine and
mirtazapine. Held home trazodone
# Pain: unclear where pain is, but patient currently not
complaining of pain. Thus, held pregabalin, tramadol, and
lidocaine patch
# GERD: continued omeprazole
## TRANSITIONAL ISSUES:
==================================
[]Please d/c foley once in rehab if ok to, following voiding
trial
[]Discharged with torsemide 60mg daily. If appears volume
overloaded, weight is creasing, or respiratory status worsens,
increase to BID.
[]End date PO vancomycin is
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 1 mg PO DAILY
2. DULoxetine 60 mg PO DAILY
3. Levothyroxine Sodium 137 mcg PO DAILY
4. Metoprolol Tartrate 25 mg PO TID
5. Mirtazapine 15 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. TraMADol 25 mg PO BID
8. TraZODone 25 mg PO QHS
9. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
10. Aspirin 81 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Simethicone 40-80 mg PO TID W/MEALS
13. TraMADol 25 mg PO DAILY:PRN Pain - Moderate
14. Torsemide 10 mg PO DAILY
15. Sodium Bicarbonate 650 mg PO BID
16. Senna 17.2 mg PO QHS
## DISCHARGE MEDICATIONS:
1. Vancomycin Oral Liquid mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six hours Disp
#*40 Capsule Refills:*0
2. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth once a day in the
morning Disp #*30
## TABLET REFILLS:
*0
3. Metoprolol Tartrate 25 mg PO Q6H
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth every six
hours Disp #*120 Tablet Refills:*0
4. Torsemide 60 mg PO DAILY
re-dose once up daily up to BID if symptomatic with dyspnea
RX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. ARIPiprazole 1 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. DULoxetine 60 mg PO DAILY
9. Mirtazapine 15 mg PO QHS
10. Omeprazole 20 mg PO DAILY
11. Senna 17.2 mg PO QHS
12. Simethicone 40-80 mg PO TID W/MEALS
13. Sodium Bicarbonate 650 mg PO BID
14. TraZODone 25 mg PO QHS
15. Vitamin D 1000 UNIT PO DAILY
## DISCHARGE DIAGNOSIS:
Primary Diagnosis
-----
Acute HFpEF exacerbation
Aspiration pneumonia
Acute on chronic kidney disease
Severe C. difficile colitis
Secondary diagonosis
Advanced dementia
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Ms. ,
You were admitted to from .
WHY WAS I ADMITTED?
- You were admitted with shortness of breath.
WHAT HAPPENED WHILE I WAS ADMITTED?
- We gave you medications to remove the extra fluid from your
body.
- We also gave you antibiotics to treat pneumonia, as we thought
this may have been contributing to your shortness of breath.
- You developed worsening of your kidney function, which we
monitored closely.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- You should take all of your medications as prescribed.
- You should follow up with your physicians as below.
- You should weigh yourself every day, and if your weight
changes by more than 3lbs you should call your doctor.
It was a pleasure caring for you!
Sincerely,
Your team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11340968", "visit_id": "29873880", "time": "2179-08-28 00:00:00"} |
12547682-RR-80 | 213 | ## INDICATION:
1.3 cm left breast cyst 2:30 o'clock, 11 cm from the nipple.
Request for aspiration.
LEFT BREAST ULTRASOUND-GUIDED CYST ASPIRATION WITH POST-PROCEDURE MAMMOGRAM:
The procedure, risks and benefits were explained to the patient who gave
verbal and written informed consent. We discussed the need for post-procedure
mammogram to determine if the ultrasound finding and the mammogram finding are
one and the same. Pre-procedure timeout was performed with two patient
identifiers and confirmation of side and site. The patient's medication list
and history of allergies were reviewed.
Using ultrasound guidance, aseptic technique and 4 to 6 cc of 1% lidocaine for
local anesthetic, an 18-gauge needle was placed into the 1.3 cm left breast
cyst from the lateral approach and cc of clear cyst fluid was aspirated.
The cyst was aspirated to resolution. The needle was removed and hemostasis
was achieved. The fluid was discarded due to lack of suspicion.
## LEFT BREAST POST-PROCEDURE MAMMOGRAM:
Left breast CC projection was obtained,
which demonstrated resolution of the previously described mass in the lateral
posterior breast. This is consistent with aspiration of the cyst.
## IMPRESSION:
No evidence of malignancy. Aspirated left breast cyst.
Annual screening mammography is recommended.
BI-RADS 2 - benign findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12547682", "visit_id": "N/A", "time": "2183-02-12 14:01:00"} |
15932127-RR-20 | 275 | ## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN)
## INDICATION:
year old woman with chronic hepatitis B- evaluate for
Hepatocellular carcinoma, cirrhosis. Check WITH DOPPLER TOO // RUQ with
doppler. Pt with chronic hep B, any HCC? any cirhossis?
## LIVER:
The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is A 0.7 X 0.6 BY 0.9 CM HYPER ARE ECHOIC LESION IN
SEGMENT 4 A OF THE LIVER. THIS DOES NOT DEMONSTRATE COLOR FLOW. Main portal
vein is patent with hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD measures 3 mm.
## GALLBLADDER:
There is no evidence of stones or gallbladder wall thickening.
## PANCREAS:
Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
## SPLEEN:
Normal echogenicity, measuring 7.3 cm.
## KIDNEYS:
The right kidney measures 11.5 cm. The left kidney measures 10.6 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones or hydronephrosis in the
kidneys.
## RETROPERITONEUM:
Visualized portions of aorta and IVC are within normal
limits.
## DOPPLER ULTRASOUND:
The main portal vein, right and left portal vein, main
hepatic artery and hepatic veins are patent and demonstrate appropriate
waveforms and direction of flow.
## IMPRESSION:
Sub cm hyper echoic liver lesion is most consistent with a hemangioma.
Comparison with prior outside studies is needed to evaluate for stability of
this finding as hepatocellular carcinoma can rarely be hyperechoic as well. If
prior outside studies are unavailable this could be further evaluated with
MRI.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15932127", "visit_id": "N/A", "time": "2136-05-29 08:06:00"} |
17163986-RR-12 | 100 | ## INDICATION:
woman with 28 weeks pregnant with abdominal pain.
History of abruption.
## LMP:
.
There is a single live intrauterine pregnancy in the breech position. The
placenta is posterior and appears normal. There is no evidence of abruption
or previa. The heart rate is 140 beats per minute. Please note that a
dedicated fetal survey was not performed. The following biometric data was
obtained.
## FL:
28 weeks 2 days.
The age by ultrasound is 27 weeks 6 days.
The age by dates is 28 weeks 2 days.
## IMPRESSION:
Size equals dates with no evidence of placental abruption or previa.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17163986", "visit_id": "N/A", "time": "2177-11-03 18:21:00"} |
12881887-RR-62 | 310 | ## TYPE OF THE PROCEDURE:
Percutaneous radiofrequency ablation of a segment VIII
HCC.
REASON FOR THE PROCEDURE AND MEDICAL HISTORY:
gentleman with
biopsy-proven segment VIII HCC. Status post orthotopic liver transplant.
## PROCEDURE:
The procedure, risks, benefits and alternatives were discussed with the
patient by the attending physician written informed consent was
obtained. A preprocedure timeout was performed discussing the planned
procedure, confirming the patient's identity with three identifiers, and
reviewing a checklist per protocol.
Preprocedure, a limited non-contrast CT of the upper abdomen was obtained
which demonstrates again a segment VIII HCC with minimal mass effect on the
right hepatic vein. Under ultrasound guidance, the entrance site was selected
and the skin was draped and prepped in the usual sterile fashion. A cluster
RFA electrode was advanced into the right hepatic lobe under ultrasound
guidance via a right lateral intercostal approach.
12-minute sessions of RFA were administered initially in the most medial and
inferior aspect of the mass and a second round after the probe was
repositioned slightly, within the superior and lateral aspect.
General anesthesia was provided by the anesthesia team on site.
Post-procedure CT scan in the arterial and portal vein phase demonstrates a
large ablation zone, approximately 4 cm, which includes the segment VIII HCC.
No gross nodular enhancement to indicate viable tissue at this point.
There is again seen a large arterial portal fistula with marked portal
hypertension and presence of perigastric and periesophageal varicose.
The amount of ascites is slightly increased from the prior CT.
The patient was extubated in the CT suite and was transferred to PACU in good
condition. Estimated blood loss was less than 2 mL.
Dr. attending radiologist, was present throughout the entire
procedure. Post-procedure instructions were written in the medical
record.
## IMPRESSION:
Ultrasound and CT-guided radiofrequency ablation of a segment VIII
HCC.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12881887", "visit_id": "N/A", "time": "2167-01-12 06:02:00"} |
16573705-RR-335 | 90 | ## INDICATION:
year old man with quadriplegia and fatigue // R/o PNA
## FINDINGS:
The patient is moderately rotated to the left side. An implantable loop
recorder device projects over the left cardiac apex.
There is persistent retrocardiac opacification, which likely represents
persistent atelectasis. Superimposed infection, and a small left pleural
effusion are not out ruled. The right lung is clear, without consolidation or
pulmonary edema. Heart size is and mediastinal contours are normal.
## IMPRESSION:
Persistent left basal atelectasis. Superimposed infection and a small left
pleural effusion are not excluded.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16573705", "visit_id": "N/A", "time": "2212-11-13 13:56:00"} |
18068179-RR-52 | 376 | ## EXAMINATION:
CT CHEST W/O CONTRAST
## INDICATION:
with IDDM, bipolar, HTN, asthma presents with dyspnea,
tachycardia, and new RBBB on EKG (compared / EKG). CXR unremarkable,
lung exams CTAB with ?faint crackles at bases. 20pack yr smoking history, quit
. Would like to evaluate for ?PE or other lung parenchymal processes not
visualized on CXR. Unforunately has allergy to iodine.// ?PE, parenchymal
process
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 20.3 mGy (Body) DLP = 765.1
mGy-cm.
Total DLP (Body) = 765 mGy-cm.
## FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL:
There are no thyroid lesions that
warrant further imaging.
No lymphadenopathy in the thoracic inlet.
Bilateral gynecomastia.
No atherosclerosis in head and neck vessels.
## UPPER ABDOMEN:
The limited sections of the upper abdomen show no significant
abnormal findings. No adrenal lesions.
## MEDIASTINUM:
Esophagus is unremarkable. Small mediastinal lymph nodes, none
pathologically enlarged by size criteria, measuring up to 5 mm. No apparent
hilar lymphadenopathy.
## HEART AND PERICARDIUM:
Heart is normal in size. No pericardial effusion. No
atherosclerotic calcifications in thoracic aorta and coronary arteries.
## 1. PARENCHYMA:
Azygos fissure (normal variant). Subtle ground-glass opacity
in the left apex ( ) measuring 1.2 x 0.8 cm. Micronodule in the right
lower lobe (302:100).
## 2. AIRWAYS:
Bronchiectasis in the lower lobes with diffuse mild bronchial
wall thickening.
## 3. VESSELS:
Pulmonary arteries are not enlarged.
## CHEST CAGE:
No acute fractures. No suspicious lytic or sclerotic lesions.
## IMPRESSION:
No evidence of inflammatory/infectious processes to correlate with crackles
found on physical examination, nor interstitial disease for that matter.
Without injection of IV contrast, evaluation for pulmonary embolism is not
possible or reliable. However, no signs of pulmonary infarcts are seen.
Pulmonary nodules, one ground-glass and one tiny solid. Comparison to study
of is not possible due to a difference in protocol and slice thickness.
## RECOMMENDATION(S):
For an incidentally detected single part-solid nodule
bigger than 6mm, CT follow-up in 6 to 12 months is recommended to confirm
persistence. If the nodule is unchanged and the solid component remains
smaller than 6 mm, annual CT follow-up is recommended for years.
See the Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18068179", "visit_id": "23178513", "time": "2157-05-15 00:42:00"} |
11546816-RR-20 | 483 | ## EXAMINATION:
CT of the abdomen and pelvis
## INDICATION:
year old man with hematuria// also renal insufficient. Recent
Cr 1.8. Please do without contrast
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 9.4 s, 60.9 cm; CTDIvol = 3.4 mGy (Body) DLP = 204.8
mGy-cm.
Total DLP (Body) = 205 mGy-cm.
## LOWER CHEST:
Limited evaluation of the lung bases shows a 4 mm right lower
lobe lung nodule (03:11). Moderate coronary calcifications are noted.
## HEPATOBILIARY:
There is a 4.1 cm lesion involving segments 1 and 5 of the
liver suggestive of a cyst. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
## PANCREAS:
The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
## SPLEEN:
The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
## ADRENALS:
The right and left adrenal glands are normal in size and shape.
## URINARY:
The kidneys are of normal and symmetric size. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
## GASTROINTESTINAL:
The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits.
## PELVIS:
There is a moderate size diverticulum arising from the bladder dome
(06:42) with mild nonspecific wall thickening along the dome. there is no
free fluid in the pelvis.
## LYMPH NODES:
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
## VASCULAR:
There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
## BONES:
There are mild to moderate degenerative changes throughout the lumbar
spine. There is a compression fracture within the superior endplate of L1
vertebral body with approximately 40% of height loss.
## SOFT TISSUES:
The abdominal and pelvic wall is within normal limits.
## IMPRESSION:
1. No evidence of nephrolithiasis or hydronephrosis. Absence of IV contrast
limits the evaluation for solid lesions.
2. Moderate-sized bladder diverticulum with nonspecific mild wall thickening
along the bladder dome. This could be further evaluated with an ultrasound.
3. 4 mm right lower lobe lung nodule. Please see recommendations below.
## RECOMMENDATION(S):
1. the society pulmonary nodule
recommendations are intended as guidelines for follow-up and management of
newly incidentally detected pulmonary nodules smaller than 8 mm, in patients
years of age or older. Low risk patients have minimal or absent history of
smoking or other known risk factors for primary lung neoplasm. High risk
patients have a history of smoking or other known risk factors for primary
lung neoplasm.
In the case of nodule size <= 4 mm: No follow-up needed in low-risk patients.
For high risk patients, recommend follow-up at 12 months and if no change, no
further imaging needed.
2. Renal ultrasound is recommended for further evaluation as mentioned above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11546816", "visit_id": "N/A", "time": "2150-08-14 13:36:00"} |
17194019-RR-23 | 129 | ## HISTORY:
man status post CABG/AVR, status post chest tube
removal.
## CHEST AP:
The postoperative cardiac, mediastinal, and hilar contours are
unchanged. There has been normalization of the pulmonary vasculature. Right
lower lobe atelectasis is improved. The multiple lines and tubes have been
removed. There is a small right pneumothorax which is not significantly
changed from prior exam. Small residual bilateral pleural effusions are
noted. There is a thin lucency along the superior aspect of the median
sternotomy, measuring up to 2 mm. The sternal wires are intact.
## IMPRESSION:
1. Small right pneumothorax, not significantly changed from prior exam.
2. 2-mm lucency along the superior margin of the median sternotomy. Continued
followup of this finding is recommended to exclude dehiscence.
3. Improving pulmonary edema and atelectasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17194019", "visit_id": "27666531", "time": "2167-02-03 15:00:00"} |
19915652-DS-17 | 2,198 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Incision and drainage of left axillary abcess
## HISTORY OF PRESENT ILLNESS:
This is a F PMhx morbid obesity, NIDDM, HTN, chronic pain,
presenting with right-sided abdominal pain, nausea, fevers,
chills, and right-sided axillary boils. She has a history of
MRSA, and has developed boils like this previously the groin
area, approximately years ago. Patient reports that about 2
weeks she noticed the first bump her left axilla with white
head. She used alcohol and paper towl to sterilize it. She then
took a shower and noted it drained, but continued to use the
same towel. She later noticied smaller bums develping on right
arm and reate, on middle finger, and then breast. She also
endorses left ear pain, and states that she feels like she has
"a bump there". Patient reports that 4d prior to
presentation, she developed abdominal pain, localizing to her
RUQ, unrelated to eating, position, or breathing. She denies any
diarrhea or vomitting before presenting to the ED. She also
had chills for about 2 days before presenting to the ED. She
reports some associated nausea, but denies any vomitting,
diarrhea, constipation. 2 days prior to presentation, she
noticed several painful nodules her R axilla. The day of her
presentation to the ED she reported "feeling miserable". She
took her temperature twice it was initially 101 and then 102,
chills, as well as worsening nausea. She denies cough,
rhinorrhea or SOB.
Of note, the patient tested positive for MRSA on screening
.
the ED initial vitals were notable for 102.7 110 100/85 20
96%RA. Labs were notable for WBC 17.9 (N86%), Hct 44.5, Cr 0.8,
lactate 1.3, UA w 2 WBC, 0 bacteria. Exam was notable for boils
her R axilla, RUQ tenderness. RUQ u/s and CT abd/pelvis
without any obvious cause for vague abd pain. US of boils showed
erythema underlying the largest area on the posterior chest
wall, with multiple small complex fluid pockets the bilateral
axilla. ACS service was consulted to evaluate abscesses, felt
these most likely represented MRSA abscess and aspirated fluid
from L axilary nodule for culture to confirm MRSA, recommended
treating with vanc/ceftriaxone. Patient was given PO tylenol
x2, IV morphine 5mg x1, IV zofran 2mg x1, CTX 1g x1,
vancomycin 1g x1. ED course was also notable for becoming a red
R, signed out to medicine resident, otherwise
unremarkable. Vitals prior to transfer 100.0 95 135/91 18 96%.
On arrival to the medicine floor, intial vitals were VS: T99.0
BP 87/40 HR 81 RR 20 POx 96% RA. Patient reports she is tender
where the indurations are. She notes continued nausea. She
reports throbbing headache at base of neck that radiates to
temples. Reports poor sleep and poor apetite. Endorses
fevers/chills. Endorses mild RLQ pain. Does not endorse any
recent gynecological symptoms of spotting or cramping, she is
currently post-menopausal. She notes that within the past year,
she had vaginal spotting which was followed up by a biopsy that
was found to be benign.
States BM were intially loose with 3 BM yesterday but today
had single formed stool. Remainder of ROS negative.
## REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies,night sweats, recent weight loss or gain. Denies
sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies, vomiting,or constipation. No dysuria.
Denies arthralgias or myalgias.
## PAST MEDICAL HISTORY:
morbid obesity
NIDDM
HTN
chronic pain
Depression
Anxiety
Hepatitis C
history of MRSA
Insomnia
Headaches
## FAMILY HISTORY:
Multiple family members with gallstones. Father with throat
cancer and diabetes. Mother with diabetes. ADHD (brother).
Depression (brother) (sister) (both parents) Lung
CA.
## GENERAL:
Morbidly obese female lying bed cooperative and
pleasant
## HEENT:
NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM,
erythematous tender papule noted right ear canal.
## NECK:
supple, obese, no JVD
## LUNGS:
CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
## HEART:
RRR, no MRG, nl S1-S2
## ABDOMEN:
normal bowel sounds, obese, soft, mild-tenderness to
light and deep palpation RLQ, non-distended, no rebound or
guarding, no masses
## SKIN:
One indurated nodule with large area of swelling and pain
noted around right arm and breast measuring at least 15x8cm. One
indurated, non-tender nodule with a white head on both right and
left axilla. One indurated erythematous, non-tender nodule on
the right breast. One erythematous, tender indurated nodule
with surrounding erythema. No rashes the groin. All areas
were demarcated with purple pen
## EXTREMITIES:
no edema, 2+ pulses radial and dp
## NEURO:
awake, A&Ox3, CNs II-XII grossly intact, muscle strength
throughout, sensation grossly intact throughout, DTRs and
gait deferred
## GENERAL:
Morbidly obese female lying bed cooperative and
pleasant,
## HEENT:
NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, erythematous
tender papule noted right ear canal.
## NECK:
supple, obese, no JVD
## LUNGS:
CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
## HEART:
RRR, no MRG, nl S1-S2
## ABDOMEN:
normal bowel sounds, obese, soft, mild-tenderness to
light and deep palpation RLQ, non-distended, no rebound or
guarding, no masses
## SKIN:
One indurated nodule with large area of swelling and pain
noted around right arm and breast measuring at least 12x8cm
receding from marked regions. One indurated, non-tender nodule
both right and left axilla improved from prior. One
indurated erythematous, tender nodule on the right breast
receding from marked region. One erythematous, tender indurated
nodule with surrounding erythema improved from yesterday. No
rashes the groin. All areas were demarcated with purple pen
## EXTREMITIES:
no edema, 2+ pulses radial and dp
## NEURO:
awake, A&Ox3, CNs II-XII grossly intact, muscle strength
throughout, sensation grossly intact throughout, DTRs and
gait deferred
## 12:59 AM SWAB SOURCE:
left axilla.
GRAM STAIN (Final :
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ per 1000X FIELD): GRAM POSITIVE COCCI.
PAIRS AND CLUSTERS.
WOUND CULTURE (Final :
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
## SENSITIVITIES:
MIC expressed
MCG/ML
STAPH AUREUS COAG +
|
CLINDAMYCIN
-----
<=0.25 S
ERYTHROMYCIN
-----
<=0.25 S
GENTAMICIN
-----
<=0.5 S
LEVOFLOXACIN
-----
0.25 S
OXACILLIN
-----
0.5 S
TETRACYCLINE
-----
=>16 R
TRIMETHOPRIM/SULFA
-----
<=0.5 S
## ANAEROBIC CULTURE (PRELIMINARY):
NO ANAEROBES ISOLATED.
BLOOD CULTURE x2
## BLOOD CULTURE, ROUTINE (PENDING):
No growth to date
## IMPRESSION:
1. No evidence of acute cholecystitis or cholelithiasis.
2. Slightly echogenic liver suggestive of mild fatty
deposition. Other forms of more severe liver disease including
hepatic fibrosis/cirrhosis is not excluded on this exam
## IMPRESSION:
Areas of concern the axilla bilaterally correspond to focal
regions of subcutaneous edema, inflammation, and tiny amounts of
fluid. No drainable fluid collections noted.
## IMPRESSION:
1. No findings to explain patient's symptoms.
2. Fibroid uterus.
3. Asymmetric sclerosis of the bilateral sacroiliac joints,
right greater
than left, likely degenerative nature.
4. Enlarged, nodular left adrenal gland suggesting nodular
hyperplasia.
## EKG :
Baseline artifact. Sinus rhythm. Minor non-specific
repolarization
abnormalities. Compared to the previous tracing of the
findings are
similar.
## BRIEF HOSPITAL COURSE:
F PMhx morbid obesity, NIDDM, HTN, chronic pain, presenting
with right-sided abdominal pain, nausea, fevers, chills, and
right-sided axillary boils.
## # SEVERE CELLULITIS/ABSCESS/LEUKOCYTOSIS:
Given her past
colonization with MRSA, leukocytosis, fevers, chills, nausea and
inflammed nodules with surrounding cellulitis presentation
concerning for severe cellulitis. No focal regions of fluid
collections noted on ultrasound. Fluctulant area was noted
left axilla and surgery was consulted to drain abscess. Culture
from drainage site grew out MSSA, however given history and
degree of cellulitis concern for MRSA as present. Cellultis
involved right axillary and back region, right breast, left
axilla, and left ear canal. Patient was started on
vancomycin/ceftriaxone intially to cover for staph/strep
species. WBC was noted to trend down and on HD#2 patient was
transitioned to PO bactrim/keflex with continued improvement
cellulitis and WBC. She was afebrile for duration of hospital
course. Patient to complete 10 day course of antibiotics (end
date . Please note that patient has a large area of
induration without fluculance below her right axilla/lateral
breast. During the admission, there was no abscess identified,
however, there is a possiblity that this area may organize into
an abscess over time. Please monitor this site for ertyhema,
warmth, and fluctulance over time. I suspect that the area will
remain indurated for quite some time despite response to
antibiotics.
# Constipation/RLQ pain - RLQ pain setting of constipation as
patient had reported liquid stools then hard stool over 4 days.
Last normal BM had been week prior to admission. CT imaging did
not reveal any concerning features of infection and nothing to
explain patient's symptoms. Patient was started on bowel regimen
and had BM prior to discharge. Would recommend outpatient work
if RLQ pain persists despite resolution of constipation.
## #TENSION HEADACHES:
patient reports sleep difficulties and pain
at base of neck that radiates to temples, most c/w tension
headache. Patient experienced photopobia on HD2 but did not have
phonophobia. She was treated with fiorocet prn with improvement
headache.
## #NIDDM:
glucose readings and Hba1c have been great for the past
4 months and metformin was renctly discontinued. Patient was
placed on gentle ISS and remained relatively euglycemic during
hospital course with FSBG ranging from 140-180.
# HTN blood perssures soft on admission: Patient was given IVF,
and lisinopril and hydrochlorothiazide were initially held but
restarted on dishcarge.
## # CHRONIC BACK/KNEE PAIN:
Patient was continued on home
oxycodone, celebrex, tylenol, and voltaren/diclofenac.
## # ADD:
continued on methylphenidate and nuvigil
## TRANSITIONAL ISSUES:
[ ]PO bactrim/keflex with continued improvement cellulitis.
Patient to complete 10 day course of antibiotics (end date
.
[ ]Would recommend outpatient work if RLQ pain persists.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY Start: am
3. Multivitamins 1 TAB PO DAILY
4. CeleBREX *NF* (celecoxib) 200 mg Oral daily arthirits/pain
5. Cyanocobalamin 100 mcg PO DAILY
6. ketorolac *NF* 10 mg Oral q8hrs
7. Sertraline 100 mg PO DAILY
8. Gabapentin 400 mg PO TID
9. Nuvigil *NF* (armodafinil) 300 mg Oral daily ADD
10. Voltaren *NF* (diclofenac sodium) 1 % Topical QID joint
pain
11. Aspirin EC 325 mg PO DAILY
12. Methylphenidate SR 10 mg PO DAILY Start: am
13. Diclofenac Sodium 75 mg PO BID
14. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
15. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral daily
## DISCHARGE MEDICATIONS:
1. Aspirin EC 325 mg PO DAILY
2. CeleBREX *NF* (celecoxib) 200 mg Oral daily arthirits/pain
3. Cyanocobalamin 100 mcg PO DAILY
4. Diclofenac Sodium 75 mg PO BID
5. Gabapentin 400 mg PO TID
6. Multivitamins 1 TAB PO DAILY
7. Nuvigil *NF* (armodafinil) 300 mg Oral daily ADD
8. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
9. Sertraline 100 mg PO DAILY
10. Cephalexin 500 mg PO Q6H cellulitis
RX *cephalexin 500 mg 1 tablet(s) by mouth Q6hrs Disp #*34
## TABLET REFILLS:
*0
11. Docusate Sodium 100 mg PO DAILY constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 packet by mouth
Daily Disp #*30 Packet Refills:*0
13. Senna 1 TAB PO BID constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
14. Sulfameth/Trimethoprim DS 2 TAB PO BID cellulitis
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*34 Tablet Refills:*0
15. Voltaren *NF* (diclofenac sodium) 1 % TOPICAL QID joint
pain
16. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral daily
17. Hydrochlorothiazide 12.5 mg PO DAILY
18. Ketorolac *NF* 10 mg ORAL Q8HRS
19. Lisinopril 5 mg PO DAILY
20. Methylphenidate SR 10 mg PO DAILY
## DISCHARGE DIAGNOSIS:
1. Cellulitis
2. RLQ pain/constipation
## DEAR MS. :
It was a pleasure taking care of you during your hospitalization
at . You had come because you were experiencing fevers,
increased skin pain and swelling, and nausea. We evaluated you
and found that you had significant skin infection caused by
bacteria. Surgery drained your abcess your left armpit. We
started you on IV antibiotics and your infection began to
improve. We transitioned you to oral antibiotics. Regarding your
right sided belly pain, this is likely due to constipation, and
we are recommeding you continue taking stool softeners and try
to walk as much as possible.
We have made the following changes to your medication list:
Please START taking Bactrim 2 tabs twice a day for the next 8
days (end date
Please START taking Keflex 1 tab every 6 hours for the next 8
days.
Pleast CONTINUE taking the rest of your medications as
prescribed.
Please follow up with your appointments as outlined below.
Thank you,
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19915652", "visit_id": "20145546", "time": "2151-03-09 00:00:00"} |
18045287-RR-20 | 103 | ## INDICATION:
woman with open tib-fib on outside hospital films.
PLAIN FILMS RIGHT TIBIA FIBULA, TWO VIEWS: There is a
spiral fracture of the distal right tibia with anterolateral displacement of
the proximal fragment. A triangular fragment appears to remain aligned with
the distal fragment. There is an oblique fracture through the distal fibula
at the same level. This is minimally displaced, although angulated with the
apex lateral. Bones are diffusely osteopenic. No sclerotic or lytic lesion
is demonstrated. There is no abnormal soft tissue calcification or radiopaque
foreign body.
## IMPRESSION:
Fractures of the distal tibia and fibula as described above.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18045287", "visit_id": "29513762", "time": "2174-04-08 01:40:00"} |
10390179-RR-21 | 233 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## HISTORY:
with hx of ICH per patient. Today with sudden onset
headache// ?bleed
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
## FINDINGS:
There is a mixed density extra-axial fluid collection overlying the left
anterior, anterolateral frontal lobe mildly extending over the anterior left
parietal lobe at the vertex, measuring 6 mm maximum thickness. There is trace
hyperdense fluid layering over the left frontal lobe (601:26), may represent
acute on subacute component. There is mild mass effect upon the underlying
cortex. This probably reflects a subacute subdural hematoma. No additional
intracranial hemorrhage is identified. There is no evidence of an acute,
large territorial infarct, mass or edema. No midline shift.
Probably chronic fracture right medial orbital wall, no stranding in the
adjacent orbital fat, no adjacent opacification of the ethmoid air cells. The
there is mucosal thickening of the right greater than left ethmoid air cells.
The remainder of the paranasal sinuses, mastoid air cells and middle ear
cavities are clear.. The visualized portion of the orbits are unremarkable.
## IMPRESSION:
Findings most consistent with small subacute left frontoparietal subdural
hematoma. There may be small frontal component of acute on subacute subdural
bleed.
Fracture of the medial right orbital wall, likely chronic.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10390179", "visit_id": "22908150", "time": "2116-07-21 02:57:00"} |
Subsets and Splits